WM0301152_GW-1 records MW-1 through MW-46_20211101

1111'i rurm VA.. w , ,.-.. 1V1 an,gu: au u..uuya.. v..."'
1. Well Contractor Information:
Thomas Whitehead
ZONES
TO
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Infection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
Clndustrial/Commercial
°Irriy&anon
❑Mtn icipallPublic
❑Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
EMonitoring °Recovery
Injection Well:
°Aquifer Recharge
❑Aquifer Storage ttnd Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
°Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/24120 Well ID# MW_1
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility iD# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610872.421 N 1461603.523
6. is (are) the well(s): I3Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or EINo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -wafer supply Is ONLY with the same
submit one fwm.
34.0
n, you can
9. Total well depth below land surface: I� )
For multiple wells list all depths if different (example- 34ay200' and 2(j10o')
10. Static water level below top of casing: 28.20 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 CD•)
12. Well construction method:
Auger
(Lc. auger, rotary, cable, dircct push, etc.)
114. WATE
I Mom,
ft.
t.
•
is. OUTER CASING
t.
ORL1NER
arxtrrla rrtrc_x
( rt. ft. in.
lfa INNER CASING OR TUBING (geothermal closed-!
FROM
TO
m
DIAMETER
_
Tntclinf SS
MATERIAL
€ +3
rt.
19
rt.
'2
in., SO 40
PVC
FROM
TO
DIAMETRR
t
TrtiCitNFSF
MATERIAL _
119
it.
34
ft.
2 m,
.010
Sch 40
{
E
PVC
l
1S. GROUT
OM
0
TO
15 ft•
ATERIAL
Grou
LACEMENT METHOD Sc AMOUNT
Tremie
5 It.
17 n•
entonite
Pour
ft.
19. SAND/GRAVEL PACK (if applicable),
FROM TO MATERIAL
17
10
22
34 ft.
ft.
#2 Sand
tR1LLING LOG (attach additional %keen if ore
1t TO DESCRIPTION trohir, hurzi try iVrue€ t , rr i at;
EMPLACEMENT METHOD
Pour
xl
FL 22.0 ft- Data available from boring log SB-37
34 rc
Dark Gray silty Sand
ft.
ft.
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13b. Disinfecdon type:
Amount:
Form G W-1
ft.
22. Certifieation:
Signature of Certified Well Contractor D
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NOW 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 INSTUCTIONS
24a. BAR : 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 seeding 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 Mall 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 Csmlinn Department of Environment and Natural Resources — Division of Water Resources Revised August 2013
FROM TO

This firm can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Ella -Motion
Non -Water Supply Well:
ElMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
CIRecovery
Injection Well:
DAquifer Rechak;e
❑Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heathy, Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under #21 Remarks) i 0
14. WATER ZONES
FROM TO
ft.
DESCItlIT10N
5. OUTER CASING for multi -cased wells) OR LINER (1f apfalieable)
ROM TO DL METER 1 TILCKNI , MATE1
17. SCREEN
ft.
GROUT
19 tt. 2 In. ? Sch 40
ft.
TOICKNESS__
Sch 40
MATERIAL
PVC
115
ft.
ft.
4. Date Well(s) Completed: 8/25/20 Well ID# MW-2
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld, one lat/long is sufficient)
610823.419 N 1461424.282
6. Is (are) the well(s): li3Permanent or ❑Temporary
7. Is this a repair to an existing well: [Yes or END
If this is a repair, fill nut known well construction information and explain the nature of Me
repair under 021 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water .supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 34' 0 (ft.)
For multiple wells lest all depths if different (example- 3@200' and 2C100)
10. Static water level below top of casing: 2" • 57
limier level is above casing, use "+"
11. Borehole diameter: 8 (In.)
12. Wen construction method: Auger
(i.e. auger, rotary, cable, dircct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type: -.
Amount:
(ft.)
19 ,SAND/GRAVEL PACK (tf ape le.shtel
TO MATERIAL
1
17
e- Grout
ft Bentonite
FROM TO MATERIAL
17
ft.
34
TO
23.5
23.5 ft.
ft.
t. ft.
ft. ft.
ft.
L
22. Certification:
of Certified Well Contactor Date
By signing this form, 1 hereby certify that the wen(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of dais record has been provided in the well owner.
#2 Sand
EMPLACEMENT METHOD & AMOUNT
Tremie
Pour
EMPLACEMENT METHOD
Pour
(rotor, hardnesx apiUrock type.
Brown Sandy Clay
Light Gray Silty Sand
1
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 In'ection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply, & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources —Division of Water Resources Revised August 2013

This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
14. WATER ZONES
FROM TO iik.SCRIPTION
ft,
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lim all applicable well permits (Le. County, State, Variance,
3. Well Use (check well use):
Water Supply Well:
C Agricultural
°Geothermal (Heating/Cooling Supply)
Clndustrial/Commercial
Irrigation
Non -Water Supply Well:
RIMonitoring
Injection Well:
°Aquifer Recharge
DAquifer Stotage and Recovery
°Aquifer Test
I:Experimental Technology
DGeothermal (Closed Loop)
°Geothermal (Heating/Cooline Return)
ft.
I 15, OUTER CASINGITarMultheasell
tiikaTER );14 TO
) OR LINER Of apoRcable)
THICKNESS MATERIAL
ft.
16. INNER CASING OR 1USING (geothermal closed-1mi
FROM TO ntAmETER Tfirctorks's MATERJAL
17
Injection, me)
ft.
DMimicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
°Salinity Barrier
DStorinwater Drainage
°Subsidence Control
°Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 8/25/20 Well la# nAvv-3
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Facility ELM (if applicable)
14511 Huntersvil e-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one latdong is sufficient)
610971.458 N 1461854.757
6. Is (are) the well(s): 2IPermanent or ElTemporary
7. Is this a repair to an existing wen: OYes or No
if this is a repair, fill out known well construction information and explain the nature of the
repair under 821 remarks section or on the buck of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 22.78 (ft.)
limier level is above casing, use
30.0
11. Borehole diameter: 8 (tm)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, ete.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gm) _ Method of test:
13b. Disinfection type: Amount:
It SCREEN
Sch 40
PVC
DIAMETER
117 ft.130 2 in.
1 ft. In.
18. GROUT
t 0
0
ft
scalp SIZETH1K'3 MATERIAL
Sch 40 3 PVC
- —
MATERIAL. ECEM
13 it• " Grout iTremie
Bentonite Pour
, 19. SANS1GRAVEL PACK Of applicabiel _
V
' FROM rib
MATERIAL
i 15 fi• 30 ft. #2 Sand
) _
1 ft. ft.
i
20. DRILLING LOG tattacp additional sheets if nefeSSarY)
DESCRIPT1QN, teolor, hardness, ao41/ k tN e. noolttv, ere.)-4
0 ft. ft Brown Sandy Clay
3 ft. Light Gray Silty Sand
, ELROD & MOIL
FROM
22. Ce
TO
13
30
ft.
Signature of Certified Well Contractor
Pour
Date
•
By signing this form. 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 154 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been pmvidcd 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 AU 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 Wens 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 Su & In'ection Wells:
Also submit onc copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
(It.)
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

This fn.ur can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
4. WATER ZONES
OM
O
12. Well construction method:
(i.e. auger, rotary, cable, direct push, cto.)
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits 0.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Weil:
DAgricultural
DGeothermal (Heating/Cooling Supply)
Dlnd ustriallCommercial
Dl riptation
Non -Water Supply Well:
OMonitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
CExperimental Technology
❑Geothermal (Closed Loop)
D MunicipallPublic
DResidential Water Supply (single)
OResidential Water Supply (shared)
ORecovery
❑Groundwater Remediation
DSalinity Barrier
DStotmwater Drainage
DSubsidence Control
DTracer
DGeotbennal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 8/28/20 weft ID#MiN-4
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
14511 Huntersville-Concord Rd
Facility ID# (if applicable)
Physical Address, City, and Zip
Mecklenburg 01940102
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610775.085 N 1461415.603
6. Is (are) the well(s): lilPermanent or DTemporary
7. Is this a repair to an exisdng well: DYes or I INo
1f this is a repair, fdl out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same coctroo, you can
submit one form.
9. Total well depth below land surface: 40' O
For multiple wells list all depths if dijjerent (example- 3 200' and 2 a1100')
10. Static water level below top of casing:
limier level is above casing, use "+"
3 .32
11. Borehole diameter: 8 (In.)
Auger
(ft.)
•
5. OUTER CASING (for multi -eased wel a) O L1PPlEl3. tit .11eab1e
ROM TO t)t cltf It `rittt;K tp's:
ft. ft. in.
16. INNER CASING OR TUBING (geothermal ctosed-lnom ,mom
PRotd TO DIAMETER TIILCKNESS
17. SCREEN
EROM 1 To
10 f1.140
ft.
i
1$ GROUT
6
ft.
ft.
ft.
2
DI .TER
MAT
Grout
Sch 40
SLOT SIZZ
.010
C
i EMPLA
Tremie
Bentonite i Pour
i 19. SAND/GRAVEL PACK (if applicable) ry
FRtNIi TO MATERIAL
18
10
OR WATER SUPPLY WELLS ONI..Y:
13a. Yield (gpm) _
.... _....
13b.
13b. Disinfection type:
_ Method of test:
40
ft.
14 ft.
22. Certification:
r=.
Signature of Certified Well Contractor
#2 Sand
h addlltaaal sheets if
RIAL
PVC
SS MATERIAL
Sch 40
OD
Pour
PVC
Brown Sandy Clay
Gray Brown to Gray Silty Sand
)°//4/
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to (he well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For MI Welts: 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 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 tltly & 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 OW-1
North Carolina Department of Environment and Natural Resources —Division of Water Resources Revised August 2013

10. Static water level below top of casing:
If water level is above casing,use "+"
11. Borehole diam,u
eter: "'
T hie forth can be used far single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑lrri 3ation
Nan -Water Supply Well:
© Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
C°Experimental Technology
❑Geothermal (Closed Loop)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
°Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/28` 20 Wen DMW-5
5a. Well Location:
Colonial Pipeline
Facility/Owner Namc Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
610997.941 N 1461596.988
6. Is (are) the well(s): Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or EINo
1f this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or an the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the sane construction, you can
submit one form.
9. Total well depth below land surface: 39 " 0
For multiple wells list all depths ifdtjjerent (example- 3(000' and 2®100)
27.04
12. Well construction method:
(1-9)
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
(ft.)
rut Ila.Wit tl3V V1V3✓3.
( 14. WATER ZON
'FROM TV
r 15.OUTER CASING (for m
FROM TO
-16. MIER CAS
FROM TO
I+3
FROM Tt
9 f1• 139
GROUT
OM TO
7
ft.
t.
DESC1UPTION
OR LINER tIf a
IL 4
thee- mat ctosed-toom r
R THICKNESS MATERIAL T'
bl
ATERIAL
L3T1duAL
Grout
Bentonite
Sch 40
RICKNE.SS MATER1AL
Sch 40 PVC
EMYI ACEMENT
Tremie
1 Pour
19. RAND/GRAVEL PACK of applicable)
FRO
t.
' 20. D
0 ft, 22.5
22.5 it.
21. REM
#2 Sand
EMFLACEMEMrMETHO
Pour
b additionat sheets tf aecese`l
Dt 5t'x3it Tl€.rN color. Mode zss vrocl. htaz• Lrai
Brown Sandy Clay
39 lt. Brown to Gray Silty Sand
22. Certification:
Si; %tssrc of Certified Well Contractor
UNT
10/ 16 10)1
Date
By .signing this form, 1 hereby cent* that the well(s) was (were) constructed in accordance
with 154 NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided In 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 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. ater Su t alp & 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 Environment and Natural Resources — Division of Water Resources Revised August 2013

r<< L'LL 1iV11011\V \. 11V11 LP
This faun can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contmetur Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Ind ustrial/Commercial
Cllrri alion
Non -Water Supply Well:
©Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Coolin Return)
❑MrmicipaVPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain
4. Date Well(s) Completed: 8/29/20 Well Mt MW-6
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
14511 Huntersvile-Concord Rd
21 Remarks
Physical Address, City, and Zip
Mecklenburg
County
Facility ID# (if applicable)
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610954.120 N 1461495.917
6. Is (are) the well(s): ftdPermanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
Ohs is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the sane cons
submit one form.
9. Total well depth below land surface: 40
,
For multiple welts list all depths if different (example- 3�00' and 2Q100')
10. Static water level below top teaming:
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
Auger
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
27.04
criart, you can
(R•)
(ft.)
For Internal Use ONLY:
l4. WATER ZONES„
FROM TO
. OUTER CASINGY(for ma
OM
i+3
O
l3.
[9N
d wells) Oa LINER I(f app1icablep
dT&R THICKNESS MATERIAL
i
R CASING OR TUBING (geothermal closed:lo )
.
70 DIAMETER 'THICKNESS
10
2
FMSCREEN
FRO
[10
18. GROUT
EROM TO
0
ft.
DIAMETER
ft. 2 In.
ATERIALf
Sch 40 PVC
SLOT SIZE TRICKNEsi
.010 i Sch 40
MATERIAL
PVC
EMPLACEMENT METHOD &
Grout Tremie
Bentonite Pour
19. SAND/GRAVEL PACK lr a tikabte)
FROM TO MATI:RIAi.
8 ft 40 #2 Sand
2©. D
10
'5.5
113
22.5
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Dislnfecdon type:
Method of test:
Amount:
R.
22. Certification:
EMRNT METHO
Pour
DESCRIPTION eelor, fardaeu. wiVroeY 1',
Brown Silty Sand
Signature of Ccrtified Well Contractor
Gray Sandy Silt
Gray Silty Sand
Gray Sandy Silt _ .___._._..,...
Datc
VI— ':.
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A WCAC 02C.0100 or 15A NCAC 02C ,0200 Well Canstrta:tion 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 NV ells: 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 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
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

VV L' 1JL 1.01.1111.711AV
VL\
17ris form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits 0.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
1'Or Irrtcrnat USC ONLY:
15.OUTER C
DESC
iG #for mul
rt. tn.
R ttff,t2plicaMet
4'tE111
16. INNER CA51NG OR TUBf1YG (geothermal elosedaooltl FROM TO DIAMETER TAfCKNESS
1 +3 ft. 20 n, 2 la
7.SCREEN
Water Supply Well:
DAgricultural
°Geothermal (lleatingiCobling Supply)
°Ind ustriallCommercial
DhTigation
Non -Water Supply Well:
0Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
DGeothermal (Closed Loop)
°Geothermal (Heating'Cooling Return)
OMun.icipallPuble
°Residential Water Supply (single)
°Residential Water Supply (shared)
©Recovery
°Groundwater Remediation
El Salinity Barrier
D Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other ( plain under #21 Remarks
4. Date Well(s) Completed: 8/30/20 Wen ID# MW-7
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
hysical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b, Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/lang is sufficient)
610983.987 N
1462042.726
6. Is (are) the well(s): ®Permanent or DTemporary
7. Is this a repair to an existing well: DYes or EINo
If this is a repair, fill nut known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same coasts
submit one farm.
9. Total well depth below land surface: "'
For multiple wells list all depths if different (example- 3(a'200' and 2®100'
10. Static water level below top of using: 3177
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
Auger
you Can
(f•)
(ft.)
'20
18. GRO
__ ...... ..:
ERCH4i,,.-._..
0 1 f
6
ft.
Sch 40
MATERIAL ��
PVC
DIAMETER
2
lei
LOT SIZE .p
.010
THICKNESS j MATERIAL
Sch 40 i PVC
EMPLAC
Grout Tremie
HOD & AMOUNT,
i9. SANDIGRAVEL PACK Cif aplica. w
FROM r TO MATFHLAi, !?MPLACFMEN r METHOD
18 n• 35 #2 Sand Pour
ft.
0. DRILLING LOG attach adelit'on
al srk
0 rt- 18.5 ft.
8.5
118
FOR WATER SUPPLY WELLS ONLY:
. Yield (gpm)
Method of test:
13b. Disinfection type: __. _,. .,.,._..............._.— Amount:
t.
22. Certification:
Orange Sandy Clay
Brown Clayey Sand
Gray Silty Sand
1;
.�
Sigaiif c. ofCortificd Well Contractor Date
By signing this form, 1 hereby certt& that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTUCTIONS
24a. For AB 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 In(ection 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
constnrction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Wain' Re+oarces
Revised August 2013

For Internal Use Only;
RECEIVED/NCDEQ/DVVR
Industrial/Conuneroial
WELL CONS t Rucrrront RECO D (cup-1)
1, Well Contractor Information:
('a/1o5' Xavier WQrrt �n
Well Contractor Name
i/399�
NC Well Contractor Certification Number
U/a11c�� rl� En Urra Y)e
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, Slate, Variance, elc.)
3, Well Use (check well use):
Water Supply Well:
Agricululral
RZO
Unit CAIRN
trRct; 1 TO
ti' 2 ft,
G
rR,
f
,r
ft,
ft.
P
ET
in,
2021
WQI OS
ESVII_LE REGIONAL,
R (Jf'appltcalile)
CtcNESS MATERIAL
o vC
tI°•ele'sed loop)
Tin
ATER
ft,
ft.
In,
()Municipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Itrrng
njeetlon Well:
aquifer Recharge
Aquifer Storage and Recovery
quifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4, Date Well(s) Completed:
5a. Well Location:
ll l to
Facility/Owner Name lun rSVrft
k
Physical Address, City, and Zip
County
ERecovery
0Groundwater Remediation
Salinity Barrier
Stormwater Drainage
Subsidence Control
r: Tracer
// Other (explain under #21 Remarks
1J'/7/2020 WeUID# %11k'-D9
Facility ID# (If applicable)
Ir aft lyvn1,r1
28Q9
„Qt.! °(02
Parcel Identification No. (Pi.N)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well,field, one lat/long is sufficient)
61100, 713 N 14/62.0,—(2.0`�,
6, Is(are) the well(s)
7, is this a repair to an existing well: Eves or No
If rhea (8 arepo u; fill out known well corrstruefl n, information an explain the nature of the
apart- under 021 remarks section PP on the ba.k of this
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
constnletion, only I C W-1 is needed, Indicate TOTAL NUMBER of wells
drilled:
9, Total well depth below land surface 7tg
For multiple wells list all depths if different (example- 3r,))2?tp' and 2©100 )
10, Static water level below top of easing:
tfivaterlere/ is above caring
I (in.)
P
anent or Temporary
relrote diameter:
12, Well construction method: ' Sonjc
(i.e. auger, rotary, cable, direct push, etc.)
(ft,)
(ft.)'
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Poem GW•I
FROM
TO
n1AMZTEI( 1 5I,01 SIZE
'[BILK E.S,L,
MATERIAL 1
ft,
ft.
In,
ft,
rrn,arr'r'
ft,
In.
4.,51, elGl . S'E.AC K (If:a: , Ito
TtOM MATER/AI
h adiUHnnnl site
DESCn]e'I°Ict's
2i,
27.
Lo ft,
S<RPCfA11KS
SLt&fie St
22, Certification:
uuiurcul.:eltifled kJal1[,'omrn:efor
By aigmr:g this form, 1 hereby certify that Ore 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 welt owner,
23, Site dlagrani 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, iNS`I'RUCTIONS
24a, For All Wells: Submit this form within 30 days of completion of web
construction to the following:
Pt.CJrIv ENT N1t'fIIOD 3c +LiIOI
t:T11OD
a
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Intention 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 web
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
2,4c, For Water Supply Sr. Injection Wells: In addition to sending the form to
the address(cs) 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 onnstntcted,
North Carolina Department of Snviromnental Quality - Division of Water Re.snurces

CONSTRUCTION REC
RD
1, Well Contractor Information:
rr1
Wei! Contractor Name
NC Well Contractor Certification Number
Company Name
2, Well Construction Permit.
List all applicable well construction
3. Well Use (check well use):
Watcr Sttpp1:
Agricultural
Geothermal (Heating/Cooling Supply)
hmdustriallCommercial
� _irrl;a*iorr.
Nott-Water Supply Well:
4,iYlftnittrrirlg
riaauiter Recharge
quifer Storage and Recovery
Aquifer Test
mental Technology
tJtherrn. l (Closed Loop)
Geothemia; (Hears g/Coolin
4, Date Well(s) Completed:
5a. Well Location:
acilty/Owner N»me
!car address, City, and Zip
County
'i.e. UWC, County Slate, V
Variance etc.)
DMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
Groundwater Remcdiation
oSaliuity Barrier
Stormwater Drainage
Subsidence Control
Tracer.
Return) j ther (explain under 1/21 Ruaitar )
Well ID#
Facility ID/I
pplicable)
28G')8
Parcel Identification No. (PLN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if ivii11.field, one latrlong is sutTloimit)
6, Is(are) the well(s)
ent ur IlTemporary
W
7, Is this a repair to au existing well Yes or No
if this is a repair, fill out knorvr! Weil construction information and explain the nature of the
repair under 1111 remarks section or on the b,:;;b pj'thlk,,"rr'ru.
S. For Geoprobe;jp'I' or Closed -Loop Geothermal Wells having the satire
co mstrue:1On, only 1 GW l is needed, indicate TOTAL• N1JMI3);R of wells
drilled:_
9, Total well depth below land surface:
For multiple veils list all depths ifdifferent texamp
10. Static water level below top of casing:
If water level is above casing, use ".p.'_%
11. Borehole diameter: C
12. Well construction method:
(i,e, auger, rotary, cable, direct push,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount;
n,
(ft.)
(ft.)
Fcr Interna} I,tse Only,
RECEIVED/NCDEQ/D
7 SCREEN
FROM
1J ft,
ft.
curr'iioN
MOORE,
inulit =csesetlwetis }RL1NhR Ifaf(l
b£t�ii7'F, Trnc:KVKSS'
In.
eothern atclosed-loop,
Irth£1;'1'T:R TWCKNESS
ntAAI..rift_
TE1tL1L...__.. La4fP
WOROS
ONAL OFFICE
t L\'rARI,
rtnck;ytbss htAtrkL /
iT ll t tt00 ab A 1 S)VN ,
19 SAND/GRAVEL IsAGif (pllcalilc
",MATERIAL
qi1
. —�-- EMPLACE
ttt,r tt:'rNon
" ft.
, ft. Sc `= 1I t
r 20,-CiR1LIANG LtiG irtinch addittunal sheets If nee astir FROM TO °RSCiRii!0 (color hsrdaess �...
ft, �erGtarxt7V y+'al sits
22, Cer, tflcation:
Sig rat e off)artLicr# dell Contractor
By signing this form, I hereby cent. that the wells) was (Were) constructed in accordance
with 15A NCAC 02C.0100 or 15,1 AlC,4C 02C.0200 Well Construction &outlands Mid 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 addi
construction details, You may also attach additional
S UB
24a. For All
constnlction to
TRtJ C'l ONS
Submit this tonn within 30 days of completion of well
ollowing;
well site details or ,welt
es itnecessary.
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, Fur Inlet:tion 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 MaU Service Center, Raleigh; NC 27699-1636
24c. For Water Sri 1 C in echo {fir ►ls: In addition to sending `ho form to
the address(es) above, a,so submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.

VVLLL L Lynn i11U411Uf I KI C
Ibis form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Numb
S&ME Inc
Company Name
KD
2. Well Construction Permit ll:
Lis/ all npplicahle well permits E. County, Stale, Variance,
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
LJGeothennal (Heating/Cooling Supply)
❑ Ind ustrial/Commercial
❑ hrie,ttion
Non -Water Supply Wen:
E Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
CAquifer Test
CExperimental Technology
❑Geothermal (Closed Loop)
etc.)
❑Mtmicipa /Public
t7Residential Water Supply (single)
CIResidential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
0Subsidence Control
©Tracer
CGeothennal (Heating/Cooling Return) ❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: 8/31 /20 Well UV MW�9
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDtt (if applicable)
14511 Huntersvi le -Concord Rd
Physical Address, City, and Zip
Mecklenburg
01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/longis sufficient)
610766.024 N 1461606.198
6. is (are) the well(s): ®Permanent or ❑Temporary
7. Is this a repair to an existing wen: ClYes or ElNo
I(lhis is a repair, fill out known well construction information and explain the nature of the
repair under 121 remarks section or on the back of this form.
S. Number of wells constructed:
F'or multiple injection or non -water supply wells ONLY wi h the same construction, you can
submit one him.
12. Wen construction method:
9. Total well depth below land surface: 34 (ft.
For multiple wells list all depths if different (example- 3(&200' and 2@l00')
10. Static water level below top of casing: 28. 82
If water level is above casing, use "+"
11. Borehole diameter: 8 am.)
Auger
(i.e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _-_� Method of test
t3b. Disinfection type: Amount
(ft.)
4. WATE
FROM
ft.
ft.
(, DESCRIPTION
INC 1for ma]
wens ) OR LINER In a Beat
DIAMt'TFdt IIIICFC,Nif.4 MAT
16. INNER CASING OR TUBING
FROM O DtAME
rt.
17. SCREEN
19
FROM TO
119 ft•
ft.
ff. It.
B. GROUT
ft.
cothermal dosed -too
1I1TCKNESS Lft3ATERIAL
2 t°• Sch 40 PVC
DIAMETE
2
In.
SLOT SIZE
hiCKN&SS„
MA TA
.010 Sch 40 PVC
FROM
TO
MA I'ENiAi EMPL.ACEdNENT
Grout 1 Tremie
Bentonite i Pour
► -KTUOD & AMOUNT
0 ft•
115
_
15 ft•
17 ft•
it•
pUcabiel
19.SAND/GRAVELPACK(ita
RtOM
TO
MATERIAL
EMPLACEMENT METHOD
.17 ft•
34
ft.
....
#2 Sand
Pour
ft.
20. DRILLING
nd�t sets@#eryl
LOG fntch
1
FROM
1
TO
I3t Si"1tW1tq g ( t� baron »rr t t s. rain st x. elt7
1 0 ft•
4 •
Brown Sandy Clay
14 ft•
29.5 ft.
Red Brown to Gray Clayey Sand
29.5 ft.
34 ft•
ft.
ft.
Brown
Silty Sand
ft.
ft.
ft.
ft
ft.
ft
21. REMARKS
22. Certification:
(Certified Well Contractor
Ily .signing this form, l hereby certify that the wets) was (were) constructed in accordance
with ISA NCAC. 02C .0100 or 1 SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
constntction 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 Su P1aIs & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resotuces - Division of Water Resources Revised August 2013

YV L' 14L
This form can be used for single or multiple wells
1. Well Contractor information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor anal non Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance,
3. Well Use (check well use):
1113 .\U1.. 11V1\
njeclion, ere.)
Water Supply Well:
DAgricultural
DGeothennal (Heating/Cooling Supply)
❑ lndustrial/Commercial
OJrrigation
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
©Ivlonituring ❑Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
©Aquifer Test
CExperimental Technology
❑Geothermal (Closed Loop)
DGroundwater Remediation
❑Salinity Barrier
DStomwater Drainage
°Subsidence Control
°Tracer
CGcothemal (Heating Cooling Return) ©Other (explain under #21 Remarks)
4. Date Well(s) Completed: 8/31 /20R,en 1➢# MW-1 a
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility LDtt (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Litngitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lot/long is sufficient)
610518.259 1461415.944
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or I?3No
If this is a repair, fill out knmsn well constructiou information and explain the nature of the
repair under 021 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non-xwlersupply wells ONL
submit one form,
ith the same construction, you can
9. Total well depth below land surface: 25 ,
For muhiple wells list all depths if different (example- 3( CO'2and 2 100)
10. Static water level below top of easing: N(
if water level is above casing,use "+„
11. Borehole diameter: 8 (In.)
Auger
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft-4
(R•)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
For Internal Use ONLY:
pis trrikjcAs1Nt. tt
pBoM TO
lt.
ft.
ni
L 16. INNER CASING OR TUBI_-11NG ( 11-
FROMS TO DtAMETE
E+3 f 10 ft.2
R0M TO DIAMETER
0 • i 25 2 la.
18. GROUT
0
TRIGS§ MATERIAL
Sch 40 PVC
in.
SLOT SIZE jTRICKNE§S MATERTAI
.010 Sch 40 PVC
To !MERLu xM[7,Ac
5 Grout Tremie
8 Bentonite I Pour
SA.NWGRAVEL PACK (I a€
FROM 1 TU
8 fi. 25
o
10 M rt,2.
2 ft. 4.
14.5
20 ft.
ft.l
20 n•
25 rt•
tion:
ATERIAL
#2 Sand
Signature of Certified Well Contractor
T METHOD & AMOUNT
LACEMENT METHOD
Pour
Topsoil Organics
Red Brown Sandy Clay
Red Brown to Gray Clayey Silt
PWR
icy �l rest
Date
By .signing this form, 1 hereby certlb, that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Construction Standards• and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form OW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1, Well Contractor Information:
A1'14./ictlf
Well Contractor Name
(I 8`i /4
NC Well Contractor Certification Number
Company Name
2. \Veil Construction Permit 4;
tiii14'/
List all applicable well construction permits (Le. WC, County, State, Variance, etc)
3. Well Use (check well use):
WaterSupply WeiL
IDAgrieuttural
OGenthertnal (Heating/Cooling Supply)
DindustrialiCommeroial
Non -Water Supply Well:
Monitoring
njeetiun Well:
LJMunicpaVPubIic
Residential Water Supply (single)
Residential Water Supply (shared)
Ditecovery
D Aquifer Recharge Groundwater Remediation
EliAtiutfer Storage and Recovery Salinity Barrier
E]iStormwater Drainage
ubsidenoe Control
DTracer.
Geotionnat (Heating/Cooling Return) EJotliei (explain under #21 Rci arks,
4, Date Well(s) Completed: qii/202c) Well Loll //
DAquifer Test
Experimental Technology
ri Geothermal (Closed Loop)
Sn. Well Location:
Facility/Owner Name
/ 3 C72
Physical Addresa, City, and Zip
dcl r,
County
54, Latitude and Wit gitude In degrees/
(if well livid, one tai/long us.uffieis;id)
6, l(are) the well(s) Permanent
C.
4. WATER ZONES
1/1t011 TO DESCRIFIION
ft.
15,
ft,
WQROS
MOORESVILLE REGIONAL OFFICE
'AS NC for etuld.eased wells OR LINER if a i Ilcable)
it: at IICKIIESS MAl'ERIAI,
in, 1
6: MISER CASIING: It 'PUBIBB;(geatItertnal closed.loop),
. FROM TO
• DIAMETER 'rim:kiwis 1 NIATERIAL
ft. LJ In.
ft,
IT, SCREEN
PROM TO
f t ft.
n,
I..,METKR SLOE 814F; UKN,ESS
ft. ft, ' In,
ft, R.
19, SAND/CRAVE!, PACK Of amillcable)
PROM TO i MATERIAL ENIKACLISILNINIETHOD
riscd7Viijrcilte,!
lAt4KIAL
KI
ft.
2r, DR1LlitNG Loaattach additionel elfeets.lf creetssa
DESCRIPTIOrdifpfor hardness, soilireek ypg grirli, size, sic,
I EMPLACEMENT METHOD& AMOUN
I 811Lrs:ci _62!!L7/:!!!!!
1 k3__:
ft. tit ft. Facility I.D# (if applicable)
)
ft.
ft,
i)...42?_41„, _JAC
C 111-47'
,, t," ll .
I i .
C 0,-al Ne(i ilt.,,,jr.z:coff4 ..) ) ' e "3 5 t 1 it"tt gi:1 d ,..(—:..tte
2,5)02e 141.11 .S.'"' 5-0 C"Alr:l Catt', 5,i/LY
IL ''
0112/2/2_ 111.2 EMARKS
Parcol Identification No, (I'DI)
es/scimitds or decimal degrees;
Yof""
Tcruporary
w
7, is this a repair to an existing well: Ejves or No
/phis is ,r repair, f ill out known well Janxtructlatt infirmation tund explain the nature of the
kepair under fi21 remarks seetian ac on the back of 1/1. pm
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the sarne
construction, only 1 GW-I is needed, Indicate TOTAL NUMBER of welts
drilled:
9. Total well depth below land surface:
For ifitItipie svelis Ifs/ cat depths if different (example- 3@)200' and 2©100')
10. Static water level below top of casing: (0,)
If Wala feWel ls above casing, use '',:.:`
11, Borehole diameter: R • (in.)
12, Well construcHort method: ..50/)1(
(i.e. auger, rotary, cable, direct push, etc.)
OR WATER SUPPLY WFLLS ONLY;
13a. 'Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Cer ' atIon;
/21. 342/1/,,,,
SiFidature of Certified Well Contraotor
8e signing thiqirizo, 1 hereby cerryti, that the WNW ivas (were) consioriirerl in accordance
tvith 15A NCAC 02C 0100 or /54 NCAC 02C .0100 Well Como -notion Standards and that a
copy of this record has been provided te the well °weer
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site (It:tails or wei!
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
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
2'4b. Per Inleetion 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 subtnit one copy of this Miin within 30 days of
completion of well constniction to the county health department of the county
where C011vtructed,

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Usc ONLY:
1. Well Contractor information:
Thomas Whitehead
Well Connector Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit it:
LLvt all applicable well permits (i.e. County, State, Variance, Infer ttan, etc.
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
0.1E11 ition
ter Supply
onitoring
❑Mtmicipal/Public
©Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
a
ection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
©Geothermal (Closed Loop)
❑Groundwater Remedialion
❑Salinity Barrier
❑Stormwater Drainage
°!Subsidence Control
°Tracer
OGeothermal (le i ii,n-Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 8/27/20 Well m# MW-12
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Facility ID# (if applicable)
14511 Huntersviie-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No.
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
35.41455 x,-80.80797
6. Is (are) the well(s): OPernnanent or ©Temporary
7. Is this a repair to an existing wen: ©Yes or 6No
If this is a repair, fdl nut known well construction information and explain the nature of the
repair under #2! remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply
submit one form.
lie ONLY with the same eonsrruetian, you can
9. Total well depth below land surface: 40.94 (t)
For multiple wells list all depths if different (example- 3 00' and 2®100')
10. Static water level below top of casing: N/A go
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
(i.s. auger, rotary, cable, direct push, etc.)
Auger
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: r,.w Amount: _.,
14. WATER
FROM
0
FROM FT() u1AMETEli flirt KNF-SN MATERIAL
DESCRIPTION
p
17. SC
ft.
CASING (for multi -cased weds OE LINERLf applicable)
G OR TUBING (grothermal closed-loopl
TO -1DIAMETER �7Ti1CKNEsS
20 ff. 2 lg Sch 40
FROM t TO
120 ft. 140
18. GROUT
TERiAL
PVC
MATERIAL
PVC
MATERIAL EMPLACEMENT METHOD & _AMOUNT
ft. 17 Grout Tremie
17 Et 18 11. Bentonite Pour
9. SAND/GRAVEL wicks atpti
22. Certillcation:
—s
.Signature of Certified Well Conttacto
ENT METHOD
Pour
se�t� 4f rrY) .
(color, Ito rdaies watch <7Lr
Dark Brown Clay
bight Brown Clay
f)^
.tea 0/4 /t)!
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed irr accordance
with 15A rNCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells Submit this thrill within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall 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.
Form GW-t
North Carolina Department of Environment and Natural Resources —Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD (GW-11
1, Well Contractor Information:
ll/ .�.
-414 , /alter f'fd/Y`+Y1Qlflr)
Well Contractor Name
8 ?
NC Well Contractor Certification Number
G(/c� !/car
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
�( Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
+j Monitoring
Injection Well:
IS:OUTER CASINdlotanta eased Nells)OR LINER (If lip
THICKNESS
4.3 ft.
ft.
I7. SCREEN
DMunicipaUPublic
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
■ Aquifer Recharge Groundwater Remediation
tAquifer Storage and Recovery OSalinity Barrier
Aquifer Test r3Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal (Closed Loop) OTracer
Geothermal (Heating/Cooling Return) rilOther (explain under #21 Remarks)
4. Date Well(s) Completed: (/%/?p20 Well ID# Thu.,- 1.3
5a, Well Location:
(c,/nJ9i4„/ PrelfAe
Facility/Owner Name Facility ID# (if applicable)
/3 ?2 E
Physical Address, City, and Zip
rr e CC le n &4 r c
County . / Parcel Identification No. (PIN)
!% - Can c v, c/ ed,
Z8©'n
019 2/2/Z
5b, Latitude and longitude In degrees/minutesiseconds or decimal degrees:
(if well.fietd, one laJlong is sufficient)
3.. //3/ 28 N (Fa 89-S/ 9 7 w
6. Is(are) the well(s) eN•Permanent or [Temporary
7. Is this a repair to an existing well: DYes or No
if this is a repair, fill out knaxm 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if diffirent (example. 3@200' and 2 a@I00')
10. Static water level below top of casing:
1/water. level is above casing, use " 4"
11. Borehole diameter:
12. Well construction method: -Sdi/'I!L
(i.e, auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13 a, Yield (gpm)
13 b. Disinfection type:
Method of test:
Amount:
TO
FROM I TO
/s ft.
ft.
• 1$:.GROUT
FROM
14. WATER'ZONES
FROM
ft,
ft.
TO
ft.
ft.
DESCRIPTION
WOROS
M()ORESVILLE REGIONAL OFFIC
FROM
ft.
DIAMETER
ft. In.
llcablc)
MATERIAL
16:11NNEItCASING:'OR TURING(geotherniai:ciased-hoop)
FooM TO DIAMETER THICKNESS MATERIAL
l.r ft.
In.
ft. 1 n.
51-/ 4'0 Pv(.
60 ft.
ft.
DIAMETER
In.
In.
SLOT SIZE
s 0/0
THICKNESS MATERLU,
Sch fa Pv�
!1 ft,
® ft,
ft.
TO
/3 ft.
c r ft.
ft.
MATERIAL
Paudis
Cem cn±
19. SAND/GRAVEL PACK (if applicable)
TO
FROM
13 ft.
ft.
6o 1t.
ft,
MATERIAL
EMPLACEMENT METHOD & AMOUNT
Ptai,rtt///-Bit/Gt�
/3-aT1
"fr2 59nd
EMPLACEMENT METHOD
fgcired /V/%fade
20.,131 LEINGIOGtattneh additional sheets if tiecessaty)
To
FROM
Q ft.
rs— f6
ft.
lc ft,
22, ft.
32. S ft.
40 ft.
rt.
DESCRIPTION (color, hardness, toll/rock type, grain size, etc.)
Red Si lfY C/a�y
rri 1 t"41 S( ft'Y a
�
14k , 6/47Gy S11
tr k Gray Self
ft.
ft.
ft.
21. REMARKS'
ft.
22. Certification:
I��pyAA f
Signature of Certified Well Contractor
Date
By signing this form, I hereby certify that the wen(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 1 SA NCAC 02C .0200 Well Construction Standards and Thai 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 weii
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 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 Sr 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:
J ",C5 #All tie
Well Contractor Name lii-f;w l ' '' -L,,_
(3)� �} Nov 0 4 2020 4156�
NC Well Contractor Certification Number
Cascade Drilling, LP WQPO
Company Name MOORESVILLE REGIONAL OI=FiC
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (11C, 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
njection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
'Experimental Technology
Geothermal(Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 9
Ptlt,Far
For lftternal Use Only:
14:�VVA�cTi!Il�ONES ,'. ,
FROM
TO
DESCRIPTION
6 ft.
ft.
ft.
ft.
'15:
t)U `ER C)t
FROM
ft.
TO
FROM
ti(toy;multdcaseij'tveis) B L1Nllitfii6p
THICKNESS MATERIAL
G IIt`2f3HING (geetGerinWeYoaed iiitin)
ft.
1tgA$IN.
TO
DIAMETER
DIAMETER
in
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
5a. Weill Locatio • 1 //
Ceo/v,Tt rife
Facility/Owner Name✓rife
Facility ID# ifapplicable)
%c//d h' m'l?iis 0�� w (O,Jccvei Rd
Municipal/Public
()Residential Water Supply (single)
()Residential Water Supply (shared)
Recovery
Physipal Address, City,
..,tf and Zip leC �It'�! L)tl/Lt9 C
/
14
County i
()Groundwater Remediation
Salinity Barrier
DStormwater Drainage
()Subsidence Control
Tracer
()Other (explain under #21 Remarks))%
Well ID# p t/ �/L¢"
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
W
6. Is(are) the well(s) ermanent or Temporary
7. Is this a repair to an existing well: DYes or No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
/
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3 0'a and 2®100')
10. Static water level below top of casing:
If water level is above casing use "+"
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
cam/,
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
0 ft.
TO
ft.
DIAMETER
in.
SLOT SIZE
THICKNESS
MATERIAL
// ft.
1$:Gltff
ft.
t,. m.
rn/ Z1
4, 'to
PVC
FROM
t) ft.
ft.
TO
) ft.
ft.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
X9:S.
FROM
,4148U PACK#tt lippliCgbag;
7 ft.
ft.
TO
y/ ft.
ft.
MAERIAL
%02 S gr�c
EMPLACEMENT METHOD
Ace" -4/
..2p:DIt1LL11VGi;:fX)Gi fkt�cli:adtTi'lioi'iak:aheef�:if'iiYecerlsarq):;
TO
FROM
ft.
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
OCT 2 6 20
20
Il �farr^,at,
Scc� t on
©Vdf.
22. Certificatio
Signatur
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells. Submit this form within 30 days of completion of well
construction to the following:
Division of 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: 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:
For Internal Use Only:
Well Contractor Name
NC Well Contractor Certification Number
vv`w W. I *
Cotnpany Name
2. Well Construction Permit #:
List ctll applicable n'ell construction permits (i.e. (/IC. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothennal (Ileating/Cooling Supply)
❑ lndustrialfCommcrcial
❑Irrigation
Non -Water Supply Well:
t lonitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑AyutforTca(
❑Experimental Technology
❑Geothennal (Closed Loop)
❑Geothennal (lleating/Cooling Return)
❑Municipal/Puhlic
°Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPI
° Recovery
°Groundwater Reined lotion
°Salinity Barrier
°Slormwater Drainage
°Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed 2/77/ "0 fWell It)
5a, Well Location:/
Facility/Owner Name
Facility 110 (if applicable)
Physical Address, City. and Zip %AvJs ejele .ViiL..
Met -Weil k?to•ty Q\ci-4t --
Coudty Parcel Identification No. (PIN)
5b. i..atitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35,41-116)3 N $d,$oSS-,
W
6. is(are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ItNo
if this iv a repair, fill out known well construction inhumation and explain thy' nature of the
repair under s21 remarks .seetimt nr in) the hack of this, form.
8. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction; only 1 GWV-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below hard surface:
law inalti/tle wells /is/ all depths if (Wren! (example- 3(h)2110' and 2 dV00')
10. Static water level below top of casing: (ft.)
limiter level is above casing, tree "
11. Borehole diameter:tQ,
12. Well construction method: rrpjj0s - Sew, ,,,,tlet9 , v P,o 4.iy
(i.e. auger, rotary, cable, direct push, etc,)
(in.) (•r,St4tc5(t LC_
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
131), Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
itik '' ft.
74; 3 fr.
E frioc4rC .NtatC 44 r
ft.
rt.
15, OUTER CASING (for multi -cased wells) OR I,1NER (if ap
liable)
FROM/�.
TO
DIAMETER
TIHCKNESS
MA'I'ERIAI.
O• tJ�1.
SI% ®ft.
¢ in, 60I. 4v
kii. 40 Pk, L
16, INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
©'.Oft.
/ i0 ft.
Q,
•
/1� in.
L
(-IC h . "ro
r�
1 k . f vim'
rt. ft.
17. SCREEN
FROM
Tou�rr
DIAMETER
SI.O1SIZE
T[IIC'KNESS
MATERiAL
� l f '
;1 �f %" '
2 in,
Q 1 Q 1
Sck. t}O
SC L 419 W
ft.
ft.
in,
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT MFYI'IK)D & AMOUNT
(7 , d ft.
SL Q ft.
�M
4-ye-lu t ?
Q , ©ft.
60 '.Qrt.
6e vt'�r►'�
�or+t.INe. cevtt►i>.
+mew,
19. SAND/GRAVEL PACK (if applicable)
FROM
'1'0
MATERIAL
EMPLACEMENT ME1'IIOD
0 °' 0 ft.
-7 3 ft.
a ,�1 eat in a-
. �t fUos
fr °e. i e._
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
'1'0
DESCRIPTION (color, hnrdncss, soil/rock Ivpe, grain sice. e1c.1
ft.
ft.
See q jet e te.► 4'0_9
it.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft,
ft.
R.
21. REMARKS
22, Certifi
Si 'nature of Certified Well Contractor
By signing this fcn•o, / herehv certify that the well(s) was (were) constracled in accordance with
/5A NOW 02(' .0100 or 1.5,1 NCc9C 02C .0200 flit/l Construction Standards and that a cagy
of this record has been prickled to the well rusher
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over` in Remarks Box). You may also attach additional pages if necessary.
24. SIUBMITTAL. INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells; Original fonn to Division of Water Resources (DWR),
information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For injection Wells: Copy to DWR, Underground Injection Control (IIIC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPI): Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form OW -I
No11t1 Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
Olnd ustrial/Commercial
OIrripation
NonWater Supply
Monitoring
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lkhr all applicable well permits (i.e. County, Stine, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
ClAgricultural OMunicipal/Public
DGeothermal (1-leatingiCooling Supply) DResidential Water Supply (single)
DResidential Water Supply (shared)
Inject -to Well:
OAquifer Recharge
DAquifer Storage and Recovery
0 Aquifer Test
ORecovery
OGroundwater Remediation
OSalinity Barrier
OStommater Drainage
FROM TO MATERIAL EMPLACEMENT METHOD
21 ft. 39 ft- #2 Sand Pour
D & AMOUNT
Tremie
OExperimental Technology 0Subsidence Control —
1 20, DRILLING LOG (attach additional sheets if aecessAryi
DGeothermal (Closed Loop) Carat& molt TO nipoder, tiardarm.„ 1PiL ear t. mi•iir we. ete.
OGeothermal (Heating/Cooling Return) 00ther (explain under #21 Remadcs) ,., : 0 ft. 5 Red Brown Silty Clay
4. Date Well(s) Completed: 9/2/20 Well KW MW-15
5a. Well Location:
Colonial Pipeline
Facility/Owncr Name Facility FD1/(if applicable)
14511 Huntersvil e-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/udnatesiseconds or decimal degrees:
(if well field, one lat/long is sufficient)
610450.293 N 1461470.456
6. Is (are) the well(s): 11Permanent or 3Temporary
7. Is this a repair to an existing well: Dyes or ElNo
If this is a repair, fill nut known well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY wlth ihe sme construction, you can
submit one form.
39
9. Total well depth below land surface:
For multiple well Ilst all depths if different (example- 3@,..)200and 2@100)
10. Static water level below top of easing: 34-79
If water level is above casing, use ''+''
11. Borehole diameter: 8
12. Well construction method:
(in.)
Auger
(i.c. auger, rotary, cable, direct push, etc.)
(ft.)
For Internal Use ONLY:
4. WATER. ZONES__ TO
ROM ir7„Esthup_TioN_
ft.
ft.
ft.
' IL OUTEICASING (for mulft-cased v;_efti) OiLKefilkapiiraltle) _
i raii4 TO DIAMETER T;THICKN FAS MATERIAL
ft, ft. in.
ER CAR-W-49ft TUBIN9.1gt1Mb.erclased-lee 1
1FROM To ----T DIAMETER i TRIOCNESS
I: +3 ff. 24 ft- 2 in' 1 Sch 40
ft.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
.1-- 17. SCREPN
FROM FTo
24 11- 139
ft. ft.
ft.
ft.
DI,,Y.HET194
2 in.
Grout
Benton
tn.
SLOT SIZE THICKNESS MATERIAL
.010 I Sch 40 1 PVC
19.SANDTGIIA,41, pACK Of aPolicable)
SiOutam of Certified Well Contractor
Lcth /
Date
By signing this fonn, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
(ft.) 24a. For AU 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. Fo ection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days at' 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 Stioly & 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 Deparument of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
-J w5 /ra j J�2�
Well Contractor Name i h t' tit i
NC Well Contractor Certification Number
3 ? Y/9 NOV 04 2020
Cascade Drilling, LP VI/CdROS
Company Name
2. Well Construction Permit #:
A/IOORESVILLE REGIONAL OFI ICC
List all applicable well construction permits (i.e. (/IC County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
For Internal Use Only:
475637
14.'VVATFAt'Zt)NFS
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
FROM
i5;;t)U3 Eft ChStNG (for piultt+c sed wells} Dl# tINEf; (if 44/114Iiii
THICKNESS MATERIAL
ING tf'2UBING(eutberraatttosd iiitlji) ; ,
DIAMETER
ft.
TO
]&'::1NNIOICCAS
FROM
ft.
TO
ft.
ft.
DIAMETER
in.
in.
THICKNESS
MATERIAL
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
onitoring
njection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
[3RecoVery
°Groundwater Remediation
°Salinity Barrier
g�fStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: / ro[ 'e20 Well ID# t �(/� JJ
5a. Well Locatio
t CaO/ ei/ Pipe
Facility/Owner Name / Faciility1D# if applicable)
/11id s Ihide'•i),14)— (orticeval RC
Physical Address, City, and Zip //
1. (l6I t('? & .
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 °Temporary
7. Is this a repair to an existing well: OYes or ! No
If 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 of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: i6 (ft.)
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:
(3.
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
csefyilal
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
%17 $CR
ft.
ft.
in.
FROM
p it
TO
ft.
DIAMETER
%1 ft
Z`E eft.
taditflli
FROM
TO
0 ft.
ft.
ft.
ft.
in.
ley in.
SLOT SIZE
THICKNESS
MATERIAL
/n/ a
5c /t 1/0
MATERIAL
IQ�JC
EMPLACEMENT METHOD & AMOUNT
Vfe,'m,
ft.
ft.
: A1VDtGRe><u 7:)N:d €ffdttNticatli
FROM
ft.
ft.
TO
6/4
t.
ft.
MATERIAL
a? Seats{
20' tiItILLi1V(;<, iit7(� #aftacli additldl'iatsheefs`if:ii
FROM
ft.
TO
ft.
EMPLACEMENT METHOD
r
eAri ,tf7
arvl'i. ' ,,,'
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
2I;'it
uL� 6 20
brit.
22. Certificatio :
Signet
ell Contractor
Date
By signing this form, / hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of 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.

WELL CONSTRUCTION RECORD (GW-1)
I. Well Contractor Information:
Vet/i VA whQ-
Well Contractor Name
NC Well Contractor Certification Number
p°IeNa+k 14/0 t
f-
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (1/C, County. State, variance, etc.)
3. Well Use (check well use):
Witter Supply Well:
❑Agricultund
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑Irrigation
Noin-Water Supply Well:
HMonitoring
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental 'Technology
❑Geothermal (Closed Loop)
❑Geothermal (llcating/Cooiing Return)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residen ial Water Supply (shared)
❑Wells> 10 . 00GPD
❑ Recovery
❑Groundwater Remediation
❑Salinity 13arrier
❑Stonnwater Drainage .
❑Subsidence Control
CJ'I'racer
❑other (explain under #21 Remarks)
4. Date Weli(s) Completed: + k/14'/21 Well iD# WA/ ) D
5a. Well Location:
CO(0 ;r4 F;ee.kZ t42.. %ta_
Facility/Owner Name Facility 11)4 Of applicable)
NAktssv.,tc,
Physical Address, City. and Zip i',3iXl.&AXe.
M,PCc16ti1butte:l
County J Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/ntinittes/secouds or decimal degrees:
(if well licld, ono tat/long is sufficient)
'SS,6f )32- Ngo5)
6. Is(are) the well(s): ❑Permanent or ❑'Temporary
7. Is this a repair to an existing well: ❑Yes or el No
if this is a repair•, fill oat known well cvnlsn•reetion n j,rtnanm cord txplrtui the nature (Ohre
repair under '-21 remarks .section or on the buck of this form.
8. For Geoprobe/DP"I' or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: }
9. Total well depth below land surface:
For nn ilnple welly hit all depths ifdiffereat (example- 3 ?200' and xi /100`)
10. Static water level below top of easing: , % (ft)
if water keel is above casing, nse „
W
ILBorehole diameter: 8.'- - 5
(in.)
12. Well construction method: 1401(0w S4e,vv%/� t4o�QV 1
(i.e. auger, rotary, cable, direct push, etc.) a .. V t/ 0'i OiA,"1`
(ft.)
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
I o ft.
130 ft.
> ► ,,Q.
ft.
ft.
15. OUTER CASING (for multi -cased wens) OR LINER (if ap licable)
FROM
TO DIAMETER THICKNESS
MATERIAL
6 0•
7 Grit.
� in. fj' (.1,1.
Sc Li. it(
16. INNER
CASING OR TUBING
(geothermal closed -loop)
MONi
TO
DIAMETER
THICKNESS
MATERIAL
fl.
ft,
in.
r
©`Oft.
!)OAOft.
in.
Z-
sG0
1' '�
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
Tnicr NEss
11 0 ft.
1
1
130 ft.
2... in.
�Gin.
a ©,
�j �,►.� , le
/MAATERIAL
/' :k. ` 'o K
ft. ft.
18. GROUT
FROM
TO
MATERIAL
I.:MPI.ACE\iENT Mta•HOD & AMOUNT
Qr0ft,
...Is ft.
15h
0. 0 "-
13 Oft.
eel►
Pt/ vrT
^YQ bey 1-�_
ft.
ft.
19. SAND/GRAVEL
PACE (if applicable)
FROM
'1.O
N1 TERIAI
ENnv.;u r:Nlr:err �tr,rnon
I 3 /� ft.
`
O(P ft.
(A.tn�%s
b t Nos 1n S
-t-Ie k,! e
ft.
rt.
20. ITRILI,ING
LOG (attach
additional sheets if neeessary)
FROM
TO
DESCRIPTION (calor, liar Inc,,, soil/rockiype. erain sire. etc.)
ft.
ft.
Soe taed Lcl
ft.
R.
ft.
ft.
ft.
h.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certified
Signature ofCertitie, Well Contractor
Date
By.srgu,g this lima,; I hereby eerttfy that the wells) was (were) constructed in accordance with
/ S l V('A(' 03C .0100 or ISA N( `A( 02(' ,0200 WW1 Construction Standard& and that a copy
of this record has pea, provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Ovci in Remarks Box). You may also attach additional pages if necessary.
24. SUI3MI'fTAI. INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original lbnn to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh. NC 27699.1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IIJC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supplv and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC. Raleigh, NC 27699-1611
Form G W-1
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6.6-2(}18

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: y
641//Gry Xv/er� iTali^snGi n
Well Contractor Name
w389A
NC Well Contractor Certification Number
L(/c& Ike( Hi '11 £n uiro,irnr:l l5
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
Infection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Bxperimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
For Internal Use Only:
14. WATER ZONES
FROM
ft.
rt.
TO
RECEIVED
S€=P 2 010711
ft:
ft.
DESCRIPTION
WQROS I
MOORESVILLE REGIONALIOFFICE
15:AVTER CASING:(foi;malt3 cased wells) -DRONER (If an llcablb)
FROM TO DIAMETER I THICKNESS MATERIAL
ft, tn.
ft.
16'INNER: CASING:OR TUBING -(geothermal
FROM I TO DIAMETER THICKNESS MATERIAL
r rt. to st• y tn. 110 Pvc
ft. ft. in.
17. SCREEN
TO
QMunicipalfPublic
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
QGroundwater Remediation
DSalinity Barrier
fStormwater Drainage
Subsidence Control
Tracer
q Other (explain under #21 Remarks)
4, Date Well(s) Completed: /2 /2020 Well ID# / 7w' 12
5a. Well Location: I
(o/n,�i<t/ P17c 11 1e
Facility/Owner Name
L3?26 / -ir c,
Physical Address, City, and Zip
met-kler) hurr
County Parcel Identification No. (PEN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
wa
il eil field, one IaUlong is sufficient)
3S, 41133 2/ N
Facility m# (if applicable)
0172/2/2
t9©.8©9222
W
6. Is(are) the well(s) Permanent or DTemporary
7. Is this a repair to an existing well: DYes or E3No
//this is a repair, fill out knanvr well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form,
8. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same -
construction, only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:1)
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
1 1, Borehole diameter: t7 (in.)
12. Well construction method: S©r'if_'.
(i.e. auger, rotary, cable, direct push, etc.)
fth
(ft.)
(ft,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b, Disinfection type:
Method of test:
Amount:
FROM
to ft.
ft,
18.GROTIT
FROM
b ft,
d
ft.
ft.
ft.
TO
8 ft.
ft.
ft.
DIAMETER
in.
in.
MATERIAL
SLOT SIZE
alkts
19. SAND/DRAYEL`PACK Of applicable)
TO
FROM
8 «,
5-0 ft.
ft, ft.
MATERIAL
..0/0
THICKNESS I
S'ch Ya
MATERIAL
Pvt
EMPLACEMENT METHOD & AMOUNT
Pui.,rct/1/-b't�,
Tr," n1 %e /2-- Cuss
EMPLACEMENT METHOD
Rrlrr-c/ /t/i6trope
20.13RILLING LOG'(atta'ch addltloual sheetsdfnecesdary)
FROM
a ft.
J ft,
ft.
20 ft.
a2, fit.
ft.
TO
ft.
DESCRIPTION (color, dardness, salt/rock type, eraln size, etc,)
ed s, /,-y Gl
8 4t £ hW
r/ s�4��crG�
i7,c.ft.
f
20 ft. S/I y -i4
22 / h SqN. &e
5/D ft,
21rREMA UCS
ft.
�-rty s. f
22. Certification:
Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the welt(s) was (were) constructed in accordance
with 1SA NCAC 02C.0100 or ISM 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 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 & Infecton 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.
0

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
For Internal Use ONLY:
12. Well construction method:
Thomas Whitehead
Well Contractor Nance
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural
OGeothermal (Heating/Cooling Supply)
❑In dustria[/Commercial
Olrri(;ation
Non -Water Supply Well:
©Monitoring
Injection Well:
DAquifer Recharge
OAquifer Storage and Recovery
OAquifer Test
DExperimental Technology
OGeothermal(Closed Loop)
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
ORecovery
OGroundwater Remediation
©Salinity Bather
OStonnwater Drainage
❑Subsidence Control
DTrecer
DCreothermal (Heating/Coolingg Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 9/2/20 Well 1D# MW-1 8
5a. Welt Location:
Colonial Pipeline
Facility/Owner Name
Facility iD# (if applicable)
14511 Huntersvil e-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610817.943 N 1462185.479
6. Is (are) the well(s): c Permanent or OTemporary
7. Is this a repair to an existing well: Oyes or t?INo
If this is a repair, fill ow known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same canstruetiun
submit one furor.
9. Total well depth below land surface:
For multiple wells list ail depths tf tferent (example- 3®200' and 2®10IY)
10. Static water level below top of casing: 39.78
If water level is above casing, use "+"
45
11. Borehole diameter: 8 (lo,
Auger
(Lc. auger, rotary, cable, direct push, etc.)
u can
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
13b. Disinfection type: Amount:
Method of test:
DESCR1PT1ON
15. OUTER CASING tfor
FROM TO
ft. R.
16. INNER CASING OR TUBING [:
we OR LIVER afailcable
MATEtUAL
FROM
TO
13rAMETER
P _.,
l "„, yr
TiIiCSN44
S -e."_.
M4TERiAL
+3
1----
ft'
30
ft.
2
l"- +
Sch 40
PVC
ft,
in,
FROM
I30
18. GROUT
SLOT Sit
.010
Tremi
Pour
2
ft. ft.
9, S4ND/GRAVEi. PACK tlf as s licabie "
RaM TO MATFRiA1..
7 ft. 45 rt. #2 Sand
j 20. DRILLING LOG (attach
VROM 10 Dk>>Sd"rdt£ i t t"t irnir, hardnr, ,?oil reek t}peeraI
0 ft' 6 ft. Red Brown Silty Clay
PVC
& AMOUNT
PLACEMENT METHOD
Pour
6 15
15
ft. 45
ft.
22. Certification:
Red Brown Clayey Silt
Gray Silty Sand
S aturc ofCettified Well Contractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1SA 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 LNSTUCTIONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection_ Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Mso submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Forrn GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1, Well Contractor Information:
f-ctnCI S Xavier Nat'l,nq I�L
o,
Well Contractor Name
41389A
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e, UIC, County, State, Variance, etc)
NC Well Contractor Certification Number .�.
//ccr 1111 /1 £n ulrt7t7 'n 01 /:
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a. Well Location: (�p/niiiJ pr'lrne
Facility/Owner Name I ,,�,�
/3 l2 th./.1 erSU/ l/e
Physical Address, City, and Zip
me klei h c r9
County
DMunicipal/Publie
DResidential Water Supply (single)
Residential Water Supply (shared)
ORecovery
DGroundwater Remediation
Salinity Barrier
.Stormwater Drainage
Subsidence Control
Tracer
Other (explair. under €12l Remarks)
TO Wel1ID# P'!Ur-/9
Facility IDt$ (if applicable)
For Internal Use Only:
RECEIVED/NCDEQ/DW
14. WATER ZONES
FROM
ft.
ft.
TO i DESCRIPTION
ft:
SEP 2 O'7JI11
WORDS
pp��f( Sell l REGIONAL 3 FFICE
dS.OLlTERCASIN�°;(foi:innl6=cased"iveQs)OIiLII(aji ifcabFic)
FROM TO DIAMETER THICKNESS �] MATERIAL
ft. ft. tn.
ft.
f6aNNE11 CASING`OR TUBING (geothecuiakclosed-loop)
FROM TO DIAMETER THICKNESS
2
.13 tit. Y In.
ft.
17. SCREEN
FROM11
16 ft.
ft.
TO 1 DIAMETER
36 ft, (J In.
18;;GROUT.
FROM
rt.
ft.
In.
in.
Sc.4 LID
SLOT SIZE
.•O/t
MATERIAL
Ivt,
THICKNESS
St6 Vo
ISIATER!AL
Poz:
TO
8 ft.
0 rt, 6 ft,
ft, ft.
MATERIAL
PGlldfs
Cememi-
19. SAND/GRAVEL PACK (if aspAcatile)
_ MATERIAL
FROM TO
8 ft, 36 ft,
ft.
20; $RILDING
FROM
0 fL
20 ff.
ft.
ft.
ft.
ft.
EMPLACEMENT METHOD & AMOUNT 1
PV IJrCC/ jl - iJi.t.l4.t: !
Tri tumid f 2-, S
312SaN,/
EMPLACEMENT METHOD
&rcc/ /t'/lhrafe
LOG(a(ta'eh'addltlotial sheetsif neceiin y)
TO DESCRIPTION (color, hardness, sollirock type, grain s@e, elc,)
teed Sl / 4' C a)
6fuy 544/ y
2.2 ft.
36 ft.
ft.
ft.
ft.
t,
ft.
280'7e
O/ 21212.
Parcel Identification No. (PEN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ifwell.ficld
on
e ne laUlong is sufficient)
3S.%1/2 io, N 6o.go6.(36
W
6. Is(are) the well(s) ' Permanent or DTemporary
7. Is this a repair to an existing well: DYes or 4 No
If the is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section ar on the back of the form,
8. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed, Indicate TOTAL NUMBER of wells
drilled: r
9. Total well depth below land surface: ,3 t�
Formulnpte wells list all depths ifdifferent (example- 3@200`and 2@' I00)
I O. Static water level below top of casing:
1f water level is above casing, use "i;
11. Borehole diameter: (in.)
12, Well construction method: of);(
(Le. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
ft
21. REMARKS
ft.
,/2 A, Za
Date
B
orm, I hereby cert15,
the
w(were) constructed i
accordance
wsigning
ithISA NC,1C102C.0100 or 1SA CACt02C 0200)Well Construction Stanarrds and lliw 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 Progrnm,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
22. Certification:
Signature of Certified Well Contractor
16 n.
ft.

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
!For Infernal Use ONLY:
Thomas Whitehead
Well Contractor Namc
2907-A
14. WATER ZON
FROM__4Te 4DSqIFnON
ft.
NC Well Contractor Certjficatjon Number 15. OUTER CASING (for multi -cased was/ 1OR LINER or a pplluitde)
“......*
FROM TO DI A 41 ET EftTWICE t't I SS MATERTAI.
in.
r 145). INNER CASING OR TUBING (geothermal eloseri-hm)
FROM TO R t TRICENESS MATERTAL
2. Well Construction Permit #: +3 ft. 33 rt.
-
ft.
S&ME Inc
Company Namc
Sch 40
Um ail applicable well permits lie County, State, Variance, injection, em.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural
OGeothermal (Heating/Cooling Supply)
Olndustrial/Commercial
DIrrigation
Non -Water Supply Well:
Monitoring
Injection Well:
OAquifer Recharge
ElAquifer Storage and Recovery
Aquifer Test
DExperimental Technology
OGeothermal (Closed Loop)
1 OGeothermal (Heatin Coati R
0Municipal/Public
OResidential Water Supply (single)
OResidential Water Supply (shared)
DRecovery
['Groundwater Remediation
OSalinity Barrier
OStormwater Drainage
Subsidence Control
Tracer
DOther (explain under #21 Remarks
4. Date Well(s) Completed: 9/3 20 MW-20Well TD#
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
610895.751 N 1462288.912
6. Is (are) the well(s): 2IPermanent or DTemporary
7. Is this a repair to an existing (Wes or EINo
If this is a repair, Jill out known well construction information and explain the nature of the
repair under O21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same cons
submit one form.
48 9. Total well depth below land surface: „
For multiple wells list all depths if diffiment (example- 3v00' and 2@1001
10. Static water level below top of casing: 42.25
ifwater level is above casmg, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
Amount:
c • n, you can
(ft.)
(ft.)
17. SCREEN
FR91LJ FO DIAMETER
33 ff. 48 ff, 2 In.
ft.
ft.
2
-V ^
18. GROUT
FROM 10
0 ft. 3
3 ft.31
ft.
PVC
SLOT SIZE THICKNESS ; IVIATERIAL
.010 Sch 40 1 PVC
Grout Tremie
Bentonite Pour
MATERIAL EMMAibEFIENT METHOD & AMODN*Li
ft.
- - ---
19. SAND/GJRAVEL PACK (if. app711 ea hie)
FROM TO MATERIAL
31 ft• 48 . #2 Sand Pour
- - _
ft. ftft.
20, DRILLING LOG iniachildilitionalsheets if neves san)
Mt At '1(1 0k:sem 4. El f.."' (odor, hardness. %Wrack t . a. rain giaa, ate.)
9 ft.
,
0 ft.
-EMPIAcEaforr METHOD
Brown Silty Clay
9 t. 13 ft.
.13 ft. 20 11.
!20 48 fi•
ft.
ft.
1 21. REMARKS
fL
ft.
ft. I
Red Brown Clayey Silt
Gray Sitty Sand
Gray Clayey Silt
22. Certillea n:
) I
)/:
Signature of Certified Well Contractor
67 I
Date
By signing this form, 1 hereby certtfj• that the well(s) was (were) constructed in accordance
with 15A hICAC 02C .0100 or 15A IVCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided lo 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.
suBmarrAL 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 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 Suitt -I,* Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construe -don to the county health department of the county where
constructed.
Form GW-1
Carolina Department of Environment and Natural Resources - Division of Water Rmayinces Revised August 2013

Well Contractor Name
WELL CONSTRUCTION RECORD (GW-1)
1, Well Contractor Information;
IrunC:IS Xavier i7a/Y,nQ to
11 389A
NC Well Contractor Certification Number ,L
L(/cy Ike 1'11 /1 &.,1 ulroa1j ►1I
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i,e, ViC', Cmnty, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
DGeothermal (Heating/Cooling Supply)
0Industrial/Commercial
Irrigation
Non -Water Supply Weil:
ry
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
•Aquifer Test
For Internal Use Only:
RFCEIVEPINCDEOIDWR
SEP 2 0 202
14. WATERZONES
FROM
«,
TO
rt.
DESCRIPTION
WOROS I
MOORESVILLE REGIONAL OFFICE
ft.
ft.
5. OUTLR CASING (for
mulfki sed:wells) OR LINER (If ap
FROM TO DIAMETER
ft.
ft, tn.
THI
16:INNER :CASING `OR'IU R/NG (geot}ieriaial.closed-loop)
FROM TO ¢l
DIAMETER THICKNESS
H. rt.
ft. ft. In.
Heal) e)
MATERIAL
DMunicipaVPubile
DResidential Water Supply (single)
Residential Water Supply (shared)
nitoring D Recovery
J Experimental Technology 0Subsidence Control
DGeothermal (Closed Loop) DTracer
Geothermal (Heating/Cooling Retum) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 7et/2020 Well LD# MU' 2/
5a. Well Location;
Coin/1;u1 /r dine
Facility/Owner Name 1l Facility 1D / (if applicable)
13 ?2 6 No.111-erC tii !it - Cc:n C a J I'I,
Physical Address, City, and Zip Z QG J
1?��Clc�en �ur-ef dlg22/2 q
County �../
Groundwater Remediation
Salinity Barrier
r Stormwater Drainage
Parcel
arcs Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if weft field, one Iar/l©ong issufficient)
3-‹j128j/ N c Ort9Q2©5., vV
6.ls(are)the weli(s)tl'Permanent or DTemporary
7. Is this a repair to an existing well: DYes or ,nNo
If tins 4 a repair, fill out knout well construction information and explain the nature of the
repair under 621 remarks section or an the back of this farm.
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 ifdttferent (example- 3@200' 2(0100)
10, Static water level below top of casing:
f wafer level is above casing, use ' i ;
11. Borehole diameter: ' (in.)
12. Well construction method: .$ai)l4.L
(i.e. auger, rotary, cable, direct push, etc)
So
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpna) Method of test:
13 b, Disinfection type: Amount:
7;SCREEN
FROM
1
ft,
ft.
1L,GROUT
FROrr
1
TO
sob) it,
DIAh1
R
tn.
ft. ! 1n,
SLOT SIZE THICKNE
0/0
Sch
S
a
MATERUAL
Pvc,
ft.
© ft.
t.
TO
1.3
ft.
ft
MATERIAL
CG/►i Gal_/
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
13
t.
ft
so
ft,
EMPLACEMENT NI HOD & AMOUNT
Puvrct/ //- h't,s-l<: k
'Ms" . / 2- & S
#2 Ss»i(J
20,•i)RILL`iNGILOGlettach additional sheets I
FROM TO DESCRIPTION (
ft, 12
12, C ft.
ft.
ft
-S�
ft
ft,
ft.
EMPLACEMENT hMETHOD
necessa
oler, bardness, ioHit
Real St 1•f`1 6
ft`Jwt9 �nasdl
type
grain size, eta.}
ft. ft.
ft.
ft.
ft,
21. REMARKS
ft.
22. Certification:
Signatu a of Certified Well Contractor
Date
By signing this form, / hereby cent.* that the wells) was (were) constructed in accordance
with iSA NCAC O2C .0100 or 1 SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or ~veil
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 wail
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 wed
construction to the following!
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Inlectlon 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
Company Name
2. Well Construction Permit #:
List all applicable well permits (Le. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Healing/Cooling Supply)
Olndustrial/Commercial
Dlrrigation
Non -Water Supply Well:
@Monitoring
'Injection Well:
OAquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
OGeothennal (Closed Loop)
OGeothermal (Heating/Cooling Return)
EMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarksi
9/3/20 MW-22
4. Date 'Well(s) Completed: Well ID#
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Facility 11)4 (if applicable)
Physical Address, City, and Zip
Mecklenburg
County
14. WATER ZO
FROM
DESCREPTION
rt.
1
FROM
R C
TO
ING (jor multi -eased wells) OR LINER (if applicable)
MATERIAL
16. INNER CASING DR TUBING (geothermal
FROM
ETER
THICKNESS
Sch 40
entonite Pour
19. SAND/GRAVEL PACK (tf applicable)
FROM TO MATERIAL
1 17 ft. 34 ft. #2 Sand
1-- —
rt. 11
EMPLACERIENT METROD
Pour
20. DRILLING LOG (a
FROM
0
t.
6
E C
Is
rneettsuryl___
ON ccilor, hardocu. toRfrock , rain war, etc.)
Brown Silty Clay
ft 14 . Red Brown Clayey Silt
4 ft 34 ft• Brown Silty Sand
-- -
ft. ft.
ft. ft.
ft. ft.
ft.
ft.
21. REMARKS
Parcel Identification No. (PIN)
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if wen field, one lat/long is sufficient)
610918.335 N ' 1462111 418
6, Is (are) the well(s): @Permanent or °Temporary
7. Is this a repair to an existing well; °Yes or )No
If this Ls a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or an the buck of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the some construction, you can
submit ane form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3@.200and 2
34
10. Static water level below top of casing:
Ip....ter level i5 above Casing, use
11. Borehole diameter: 8 (in.)
Auger
34.88
12. Well construction method:
(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:
22. Certification:
Signature of Certified Weil Contractor
Date
By signing this fOnn, 1 hereby certif.b that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or ISA AICAC 02C .0100 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 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 27694-1636
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:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Num
S&ME Inc
Company Name
2, Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (HeatingiCooling Supply)
❑Ind u strial/Commercial
❑lrri Ration
Non -Water Supply Well:
E Monitoring
OMtmicipal/Public
° Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
lnjectioo Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remediation
❑Salinity Barrier
OStonnwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under 421 Remar
4. Date Well(s) Completed: 9/3/20 Well 10# MIN-22R
5a. Well Location:
Colonial Pipeline
Facility-IOwner Nam-c Facility ED# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minates/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610918.335 N 1462111.418
6. Is (are) the well(s): ir7Permanent or DTemporary
7. Is this a repair to an existing well: °Yes or l INo
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.
1
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example-- 3@200' and 2®100
10. Static water level below top of casing: 34' 88
34
If water level is above casing: use "+
1I. Borehole diameter: 8 (in,)
12. Well construction method:
Auger
(Ls. auger, rotary, cable, direct push, etc.)
(ft.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
_ Method of test:
13b. Disinfection type: Amount:
or laternal Lase ONLY:
14. WATER ZONES
FROM TO
DESCEiPTION
13. OUTER CASING (,for multi -eased wells OR LIN R (if applicable
FROM TO DIAMETER irrtC' i Sfi MATERIAL
16, INI
( FROM
+3
a
7. SCREEN
ROM TO.
119
la,
G OR TORING (geothermal cloaed-1
DIAMETER i Trvrvm MC SS
2 in. Sch 40
ATLRIAL
Grout
Bentonite
i 19. SAND/GRAVEL PACK of applicable)
FROM TO f M.4"...:_-
17
16
14
rt,
ft.
6 it.
14.ff.
34 ft*
ft.
22. Certifrc;ttlon:
RIAL
PVC
LOT SIz4 THICKNrsa ; MATERIAL
.010 Sch 40 PVC
#2 Sand
Sigirte oftraiied Well Contractor
+ FMPLAe
Tremie
Pour
Th
(n bsdUr4eku>p
Brown Silty Clay
Red Brown Clayey Silt
Brown Silty Sand
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided in 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 t lv & 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 OW-1
North Carolina Department of &Mom' ut and Natural Resources —Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: } J
Itanos f![3f11G'r Wairin4 J','i
Well Contractor Name ,/
Company Name
2. Well Construction Permit #:
List all applicable well consh ruction permits (i,e. UfC, County, State, Variance, etc)
NC Well ContractorfCerti//catio1n Number
boa rceruiroivoc
3. Weil Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply WcU:
r4. Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Recovery
0 Groundwater Remediation
Salinity Barrier
Stormwater Drainage
Subsidence Control
DTracer'
riOther (explain under #21 Remarks)
4. Date Well(s) Completed: q/3/2020 Weil LD# 616// -23
5a. Well Location: Coln,91tl! A/2 /0/1e
Facility/Owner Name ,� Facility tD# (if applicable)
/3cf2.' I1 '1epSvl //c.• Ccncvrd
Physical Address, City, and Zip 28)028
I-n
cow
e t- len t 1,4 0t�`2121,2_
COWry Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall
field, ono lat/long is sufficient)
3 /12 2 2 N 8'0, 6'o `?2
w
6. Is(are) the well(s):Permanent or DTemporary
7. Is this a repair to an existing well: T)Yes or El No
if this Is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or an the back of this form.
8, For GeoprobeiDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW -I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: '�
Far multiple wells list all depths if different (example. 3Q200' and 2Qa 100')
10. Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter: t (in.)
I2. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)'
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13 b, Disinfection type:
Method of test:
Amount:
For Internal Use Only:
4. W>ATER''LONES
FROM
ft,
ft.
TO
ft:
ft.
RECEIVED/NCDEO/DWR
SEP 2 O'201
WC)ROS
nrscRrPTwaniESVILLE FREG1ONAEOFFtC
213 DOTERGASING(for:lath$ cased'ivclls)-:OItLTNER:(lfhp H abil))
FROM TO DIAMETER I THICKNESS MATERIAL
ft. in.
..I NNER:t ASTNG'OR T'UHING=(Reotherutai'closed-loop)
FROM TO DIAMETER MATERIAL
/ ft,
ft.
t3 n,
ft.
17 SOREEN
FROM TO
IS'
ft.
ft.
Ysft.
• =111.GROTIT':
FROM TO
t/ ft.
0 ft.
ft,
ft.
13 fL
/ ft,
ft.
L1 In.
7 In.
THICKNESS
$C 90
DIAMETER SLOT SIZE
I. in.
In,
MATERIAL
llels
CGM Grl'r
1.9..SAND/GRA3!ETi PACK (it.appllcable)
TO
icft.
FROM
l3 ft,
ft.
ft.
MATERIAL
01©
THICKNESS
s c11 4'o
MATERIAL—.
EMPLACEM/ENT METHOD & AMOUNT
rf PO,rt/1"aL' .-
T�•�",�,m;'e /3-$935
EMPLACEMENT METHOD
aired /vlhraf�
20.:DRILDING.I;OG'(sttieh,lidditional'sheets:lf heccsaaiy).
FROM TO DESCRIPTION (color, hardness, salt/rock
ft. 6i�J Ct type, grain size, elc.)
�.t! & 4M l�/5; /4
Cray
20 ft.
3 ( ft.
ft.
ft.
ft.
3 ft,
ft,
ft.
ft,
ft.
ft,
3l
ft.
22, Certiflcalon:
4dI CI,
Signature of Certified Well Contractor
JO /3/2020
Date
By signing this fnrnt, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA 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 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 Infection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c, For Water Supply & Injecton 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 farm can be used for single or multiple wells
1. Well Contractor Information:
For Internal Use ONLY:
Thomas Whitehead
Nell Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Tndustrial/Commercial
['Irrigation
Non -Water Supply Wen:
®Monitoring
Injection Well:
°Aquifer Recharge
['Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
DGeothermal(Heating/Cooling Return)
❑MtmicipallPublic
°Residential Water Supply (single)
❑Residential Water Supply (shared)
DRecov
°Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
°Subsidence Control
❑Tracer
©Other (explain under #21 Remarks
4. Date Well(s) Completed: 9121 /20 Well ID# MW-23R
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
13900 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
9. Total well depth below land surface: 45
For multiple wells list all depths if different (example- 3 it CO' and 2©100)
10. Static water level below top of casing: 'AV'1A
!fwnter level is above casing, use "+"
Facility ION if applicable)
01921204
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long issufficient)
610088.879 N 1461555.526
6. Is (are) the well(s): (1Permanent or DTemporary
7. Is this a repair to an existing weB: ❑Yes or No
If this is a repair, fill out kng,-wn well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form,
S. Number of wells constructed:
For multiple infection or non -water supply wells ONLY with the same construction,
submit one form.
12. Well construction method:
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection .
type Amount:
11. Borehole diameter: 8 (in,)
Auger
can
(ft.)
(ft.)-
+3 ft. 15
17. SCREEN
O
11.
14. WATER ZONES
FROM 1 TO ,._..�.
ft.
S. OUTER CASING far mu1N-cased wells) OR LIPIGIi (If a�heabl
aOMOM TO DIAMETER € dill1CNrSt MATERIAL
ft. ft. In. ,
R CASING OR TTAIINGigent6erma! closed -Waal
OM TO '-1IAMp!ER —THICKNESS
2 In. i Sch 40
Bentonite
THICitNE,SS MATERIAL
.010 Sch 40 1 PVC
I MCLACEMENT METBOD & AMOUNT
Tremie
9. SANDICRAVEL PACK (If aplalica6le)
ROM TO MATF.RJAL
3 ft• 45 rt #2 Sand
10 ft.
22.
TO DESL tiC; seater hardneu. soli/rock r. e, . ain size, ere:
35 ft- Gray Silt and Clay
Grayish Brown Silty Sand
Signature of Certified Well Contractor Date
By signing this farm, l hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 114 WCAC 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 We Is: 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 Inieetion 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 ttply & 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 C W-1
North Carolina Department of Environment and Natural Resources—1Hvisam of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
Ibis form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
rdel l Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List al! applicable well permits (i.e. Couniy, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
©Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
Non -Water Supply
Gs Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
O Experimental Technology
❑Geothermal (Closed Lop)
❑Geothermal (Heating/Cooling Return)
OMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
OStomiwater Drainage
©Subsidence Control
CiTracer
❑Other (explain under It21 Remar
4. Date Well(s) Completed: 9/4/20 Wen
5a. Well Location:
Colonial Pipeline
W-24
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and lip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
610605.100 N 1462116.596
6. Is (are) the welt(s): ®Permanent or ['Temporary
7. Is this a repair to an existing well: OYes or EINo
If this is a repair, fill out knmvn well construction information and explain the nature of the
repair under #21 remarks section or on the buck of this form.
1
8. Number of wens constructed:
For multiple injection or non -canter supply wells ONLY with the sane construction, you can
submit one form.
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
9. Total well depth below land surface: 54
For multiple wells list all depths if different (example- 3(ay200' and 2@100')
46.69
(in.)
Auger
(fr•)
(i.c. auger, rotary, cable, direct push, etc.
FOR WATER SUPPLY WELL
13a. Yield (gpm) _ Method of teat:
13b. Disinfection type:
Amount:
14. WATER ZONES
FROM TO
ft.
FROM
TO
DIAMETER
:mot
CKNESS
MATERSAL
+3
ft.
39
ft•
tt.
2
to
lfl.
Sch 40
PVC
ll
%kTtOM
TO
k IERIAI. RMPLACI ME1VT METHOD & AMOUNT
a ft.
13 ft•
3 rr.
Grout Tremie
37 ft•
tt.
Bentonite l Pour
ft.
19. SANDIGRAVEL
PACK
rib---
Walla'
FROM
MATERIAL E.MPLICEMENT METHOR
137 ft.
54 rt.
#2 Sand Pour
Ew._._.,mw_.
O. DRILLING
LOG (attach tttiditiohal l$ettta it necesaa}
FROM
TO
S tx "ttlPTirt (tutor. haVrack h to in size etc.}
0
9 ft
Red Brown Silty Clay
9 ft
' 20 ft•
20 tt.
Red Brown Clayey Silt
25 ft•
__
Brown Silty Sand
25 ft
3I ft
ft.
34 ft
Brown Sandy Silt
54 ft•
Brown to Gray Silty Sand
R.
22. Certification:
ignature of Certified t c,r Contractor
t
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA 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 INSTUCTIONS
(ft,) 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 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 Se Inieetlon 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 W-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:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Ccrti
S&ME Inc
ation Number
Company Name
2. Well Construction Permit it:
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Industrial/Commercial
°lrri.,ation
Non -Water Supply Well:
tEMonitorirtg
rInjection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
DMunicipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
°Recovery
❑Groundwater R.emedia►ion
°Salinity Barrier
°Stormwater Drainage
❑Subsidence Control
°Tracer
❑Geothermal (Heating/Cooling Return) °Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/4/20 Well 1D# MIN-25
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and zip
Mecklenburg 01940102
County __ ...,....
Parcel Identification No, (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
610724.207 N 1462220.540
6. is (are) the well(s): 21Permanent or DTemporary
7. Is this a repair to an existing well: °Yes or EINo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the buck of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY
submit one form.
9. Total well depth below land surface:
10. Static water level below top of easing:
If water level is above casing use '•+ "
11. Borehole diameter: (in.)
57
the same construction, you can
For multiple wells list all depths if different (example- 3@200' and 2®(Y)10(ft-)
43.52
12. Well construction method:
(le. auger, rotary, cable, direct push, etc.)
Auger
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ._.... .
Method of test:
13b. Disinfection type: . _. Amount:
......_...
For lntcrnal Use ONLY:
15.OUTER
FROM
edweI °HONER 11au=11 blel
Ttin TATC'KNES3 MATT
16. LINER CASING OR TUBING t eoihermal closed-1
i ROM1i TO i}tAMETEn 1 THICKNESS hfA
+3
28 2 Soh 40
28 t. 57 ft.
It. L
Our
25
Grout
• Benton
119. SAND/GRAVEL PACK
FROM TO
25
attach ad
1) ON tear, herdnee, eniVroek i1'7l;rsf 5tt , sus,
Red Brown Silty Clay
our SIZE TRICKNfs5
.010 Sch 40
2 Sand
ets
RMPLACft
Tremie
ATERIAL
PVC
OUNT
Red Brown Clayey Silt
Brown to Gray Silty Sand
!"s e i i 5 1 Dr't
22. Certification:
ign rt of Certified Well Contactor
f f•
Date 16/f
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been pmvided 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. lior Ali 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 In3ection 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 Marl Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Alsosubmitone copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form OW-1
North Carolina Department of Environment and Natural Rm.:orace; — Division of Water Resources
Revised August 2013

I
L CONSTRUCTION REco
1, Well Contractor Information;
Il Cootractor Name
NCI; Coa melon Cennc�atioa ?'lumber
Company Name
2. Well Construction Permit #:
List all applicable well construction permits 74 C//C County, State, I"arianee etc.)
3. Well Use (check well use):
W.
Water Supply W
Agleultutai
Geothermal (Heating/Cooling Supply)
Industtial/C ontmciciel
hTi a[i0t1
Non -Water Supply Well:
Yloulitaring
rjecruon %yell:
Aquifer Recharge
Aquifer Storage and Recovery
{ Aquifer Test
!Experimental Technology
.Geothcmtal (Closed Loop)
Geothermal (Healing/Cooling Reum)
D1viuntoipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Sa, Well Location:
cry
0Groundwater Itemcdiation
°Salinity Barrier
DSterrnwatcr Drainage
°Subsidence Control
°Tracer
4, Date Well(s) Completed; , t JJ/
Count
under N..21
y (Z. Well LD. 4/
Facility
„arcalldeutincat,unNo. (PIN)
5b Latitude and longitude In degrees/minuteslseeonds or decimal degrees:
(if well held, one lat/loug is sufficient)
f
267pq
/t!
6, Is(are) the well(s)
IFOR WATERSUPPLY WELLS ONLY;
113a: Yield (gpm)
Method of test;
113b, Disinfection type,
Amount;
Form i W1
North Carolina Department of B vironmen
(ft.)
manent or jTemporary
7, is this a repair to an c
IJ)hra is r c existing well Yes pair, I111 out known well c' n r nr 111 NU
repro, under 021 ,er,,artt notion oo r 7 (ru,'l,o7, pj rx,tgtran t nr explain the nature aJ'!he
�n turn orr�;kaY'tkfcjcna,
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I OW1 is needed.
cicilted: _ Indicate TOTAL NUMBER--__�__.,,� - of wells
9, Total well depth below land surface;
Forrmdrlple wells list all depths if different flxample.3@200`and
10, Static water level below top of casing•
tfwarer level ip l
Yd
rnnl Use Only'
1_O
ft:
ft.
J5, OVVE=t CAfiOla loj •rpur 1-c'asp FRONT pn
y.3 ft,ntnc'rit
JaB C��
anf to
ft,
ft,
7...SCREE
iV'
FROM yd.
ft,
1B ORQXJT,"
e
FRO
AR
ft
ft.
ft,
ft,
ft.
ft,
4
ft.
ft,
ft,
ft. ft.
t,
22, Certification:
�r slg,j(
v!!G 15.1 VC
copy of rat newt
ft.
ft.
cut
1,1
I)IA:ytETF.R SF OT aft
zg 1 i416�"' t t{ t•S^.--- "_______--<......
In,
In,
RECEIVED/NCDE
TION
MOOR
tn,
In,
! 5e
c. closed -I
rinC1SNg
t®NAh 9EE_
I`iflt,fC�tgg htRTfitttriL�"'---'
tea6f�.,
r
Philfi 11t(7 31'.._i
3 Ntt t 1Cit�iMP.T IRO()
trttnch.tult ttlnnal sheets if nesessar v
l Ui SCnIF t TON coitir isr yrrtnraa rqk ietrp r,E €t j
�
ft.
ft.
ft,
ft. I
tit
tei-eby tali& Mat !i7 r lit win (were) e rs >,ired in accor.,6net
a Ott or ISA NOW 02C 020g 11 to Consn•ucrrcru `tandards and them ,r
Iran'ucenprovided tot/to 6ellowner.
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,
5UR,1TfI 1
AL INS I R C.11ONS
24a• Forells: Submit this form
construction to the following; rrrr wtthu+, 30 day, of completion of we
rtHive casing, use "r
(ft,) Division of Water 12tsow
diameter:•
11. Borehole
12, Well construction method: 24b, For Intcelion kens: In addition to
(re, auger, rotary, cable, direct push, etc.}—" -- — above, also submit one copy
construction to the following:
of This form
wing:
1617 Mail ces, l
lad Service Center,
nforrnatiort Processing Unit,
Raleigh, NC 27699-1617
sending the form to the addres
s in
..4a
within 30 days of completion of well
Division of Water Resources, Underground I
Program,
24c Lor Water ct Su uU' Infection Writs: In addition to sending the fora] to
the address(es) i. live, ulso submit one copy of this form within 30 days of
completion of well constructionto the
where constructed, county health department of tbe county
,. woos
Onali:v - Division of Water Rewoos
Raleigh,
1636 Mail Service Center,lejection Control
NC 27699.1636

12. Well construction method:
37
10. Static water level below top of casing:
If water level it above casing, use "+"
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Ust all applicable well permits (Le. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Contmercial
❑Irrigation
Non -Water Supply Well:
RIMonitoring
Injection Wen:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 9/4
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Physical Address, City, and Zip
Mecklenburg
County
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
/20 Well ID#
-26
Facility ID# (if applicable)
Parcel Identification No. (PIN)
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610924.172 N 1462017.515
6. Is (are) the well(s): ®Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or E)No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same cons Mien, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3Qa 200' and 2@l00')
33.25
11. Borehole diameter: 8 (in.)
Auger
(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:
14. WATER ZONES
FROM f TO t DESCRIPTION
it.
15.OUTER CASING
FROM
ft.
TO
mini! -cased
DIA1tiET
11s OR LINER{if a
•
ble)
THICKNESS l MATERIAL
16. INNER CASING OR TUBING (geothermal clod -loop)
DIAMETER 1 THICKNESS
+3 . 22 ff. 2 Ia. Sch 40
is I
ft.
17. SCREEN
FROM 1 TO
22 ft• ! 37
18. GROUT
FROM
0
TO
ft. 3
ft. 20 _.
FROM
20 ft
DIAMETER
ft, 2 in.
in,
MATERIAL
ft Grout
ft.
SLOT SIZE
.010
PVC
TWICKNESs
Sch 40
MATERIAL
PVC
PLACEMENT METHOD & AMOUR
Tremie
Bentonite Pour
19. SAND/GRAVEL PACK Of applicable)
MATERIAL
#2 Sand
37
TO
ft.
20. DRILLING LOG [attach additional sheeta f
FROM i TO DESCRIPTION tealar, hardana,sell/reek type, Beata stxe. ere.}
0 ft• ! 13 ft. Red Brown Silty Clay
Red Brown Clayey Silt
0 ft 37 ft Gray Silty Sand
ft. 1
ft.
Pour
13 ft•120
ft.
ft. 1 ft.
ft. -
22. Certification:
Signature of Certified Well Contractor
By signing this form, 1 hereby certt& that the nell(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For Ail Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For 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 Injectlon Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su lv & In action Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Weil Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits ()e. County State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
Industrial/Commercial
°Irrigation
Non -Water Supply Well:
®Monitoring
Injection Well;
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
0Mtmicipa1/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remedietion
°Salinity Barrier
OStormwater Drainage
°Subsidence Control
DTracer
°Geothermal (Heating/Cooling Return) i Ocher i x hum z)ra€fvt ' 2I Remarks)
4. Date Well(s) Completed: 9/4/20 Weil L➢ MW-26R
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
arccl Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one IaVlong is sufficient)
610924.172 N 1462017.515
6. Is (are) the weU(s): 121Permanent or ❑Temporary
7. Is this a repair to an existing well: °Yes or ENo
If this is a repair, fill nut known well construction infrtrnawtton and explain the nature of the
repair tender #21 remarks section or on the back of this form,
8. Number of wells constructed
For multiple injection or non -water supply welts ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 37
For multiple wells list all depths ifdifferent(example- 3@200' and 2G100')
10. Static water level below top of casing: 33.25
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(Lc. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)_...___...,..,,.__...,_..:Method of test:
13h. Disinfectlon type Amount:
(ft.)
ft.
ft.
for
For Internal Use ONLY:
0
R
TFR ZO,,�1
fit.
ft.
+3 rt. 22
ft.;
7.SCREEN
it. ft.
19. SAND/GRAVEL. PAC
FROM To
20 37 ft:
20 ft. 37 Gray Silty Sand
alti-essed wells} OR LINER or sEl licabl
et
iii vrr r n Yl[tf KNENS MATERIAL
jo.
staff m 1AL
Grout
Bentonite
#2 Sand
dditiansl sheets
letoCKKN S
Sch 40
THICKNE9,S MATERIAL
010 Sch 40 PVC
EMPLACEMENT METHOD
Tremie
' Pour
22. Certification:
Signature of Certified Well Contractor
Pour
r hardnexs, snWroc7. rs
Red Brown Silty Clay
Red Brown Clayey Sit
1O/'t
Date
ja/
OUNT
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15,1 WCAC 02C.0100 or 154 NCAC 02C.0200 Well Consmrction Standards and that a
copy of this record has been provided to the wed 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.
SLBMTTTAL INSTUCTIONS
24a. Fur AU 'ells Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this fora 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 Su )1 & Iniecton 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 W-1
North Carolina Department of Environment and Natural Resources _Division of Water Resources
Revised August 2013

10. Static water level below top of casing:
If water level is above cuing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(Lc. auger, rotary, cable, direct push, etc)
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit !h
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
❑Auricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑.Irrigation
❑Munieipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
@Monitoring
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Muffling 'Cooling Return)
❑Recovery
❑Groundwater Remediation
°Salinity Barrier
❑ Stormwater Drainage
°Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/5/20 Well Mil MW-27
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility ID# (if applicable)
14511 Huntersvilie-Concord Rd
Physical Address, City, and Zip
Mecklenburg
County
01940102
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrecs/ndnutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610986.312 N 1462085.698
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 nut known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
1
8. Number of wells constructed:
For muleiple injection or non -water supply wells ONLY with the same construction, you can
submit one form
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 300' and 2@1
33.27
42
FOR WATER SUPPLY WELLS ONLY:
a. Yield (gpm) Method of test:
b. Disinfection type: Amount:
14. WATER
NEs
0
. OUTER CASING (for milli -cased wells) OR LINER as cabled
FROM TO tll,��€tt`t'E82
h Ater i:1L,ss MATERIAL
16 INNER CASING OR TUBING
FROM TO
ft.
17. SCREEN
j FROM
27
} ft.
18. GROUT
mat closed-lov}
TAICKNFSS t4fATEtuAL
Sch 40 PVC
SLOT SIZE
.010
ncI Ess
Sch 40
MATERIAL
PVC
FROM
To
vLiTFRIAI ) EMp1 ACEMENT METHOD & AMOUNT
10_..
6 rt
_.
Grout a Tremie
6 rt.
25
Bentonite 1 Pour
ft.
ft.
i
19. SAND/GRAVEL
PACK
To
42 R•
ft.
tl(applkab
FROM
125
M_TERIAL
#2 Sand
EMPLACEMENT METHOD 's
Pour
j ft.
20, D
;
G LOG "a" v.
h adrWir rtal ah is if a
FROM
TO
D€ trIPTICr lrat her t , i, nolVrack c rata -t, etc.)
0
11
Red Brown Clayey Silt
11 f•
114 ft•
t.
14 rr-
42 rL
it.
Gray Brown Sandy Silty Clay
Gray Sandy Silt
it.
21.
ARKS
22. Certtj.atio
tgnaitYre of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 154 NCAC 02C.0100 or 15A WCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the welt owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBM1T"TAL INSTUCPIONS
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 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Su £pt Iv& Injection Wells:
Also submit one copy of this fonn within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form OW-1
North Carolina Department of En
t 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:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (l,e, County, Stale,
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustria1/Commercial
❑Irrigation
Non -Water Supply Well:
RIMonitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
Variance, Infection, etc.)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
4. Date Well(s) Completed: .9/6/20 well ID
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
®Other (explain under #21 Remarks)
MW-28
Facility ID# (if applicable)
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 latllong is sufficient)
610218.934 N 1461369.873
6. Is (are) the well(s): ®Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or l 1No
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.
1
S. Number of wells constructed:
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit maim,.
12. Well eonstruction method:
9. Total well depth below land surface: 40 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 29 ° 37 (ft.)
If water level is above casing, use "+
11. Borehole diameter: (In.)
Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
3a. Yield (gpm)
3b. Disinfectlou type:
Method of test:
Amount:
For Internal Use ONLY:
r 14. WATER ZONES
PROM 1 TO
ft.
15. OUTER CASING
FROM TO
ft.
OM
+3
wells) OR LINER (if applicable)
TBI
in.
R CASING OR TUBING igeotbermal closed loop
TO DIAMETER TNICKN
ft.
ft.
25 ft. 2 in.
t7. SCREEN
140
fr. 1
.GROUT
FROM
0 ft.
ft.
In.
MATERIAL
ra Grout
Bentonite
19 SAND/GRAVEL PACK (if appIlea
OM
TO
23 ft' 40
ft.
20. DRILLING
Sch 40
SLOT SIZE
.010
#2 Sand
MATERIAL
PVC
THICKNESS MATERIA.
Sch 40 II PVC
EMPLACEMENT METRO D & AMOUNT
Tremie
Pour
FROM 1 TO
10 ft• 30
[30 ft. 40
attach additional sheets If trecesaary)'
DESCRIPTION (Mort hardness, aoWreck ttrpe, 5rain tire, eta
ft Red Brown Clayey to Sandy Silt
ft.
fr F
Gray Silty Sand
ft.
ft.
ft.
ft.
ft.
22. Certification:
Signature of Certified Well Contractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I SA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniectioo Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW.1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information:
Well Contractor Name j'
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name
2. Well Construction Permit #:
List all applicable well construction permits
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irritation
Non -Water Supply Well:
onitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal Heating/Coolint Return)
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
°Groundwater Remediation
°Salinity Barrier
Stormwater Drainage
°Subsidence Control
°Tracer
Other (ex lain under #21 Remarks
4. Date Well(s) Completed: r (,�
Well ID#A
5a. Well Locatio
Facility/Owner Name
+'•PS ubf
Physical Address, City, and Zip
County
Facility ID# If applicable)
(o,✓cord 1
Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/Iong is sufficient)
W
6. Is(are) the well(s)
ermanent or °Temporary
7. Is this a repair to an existing well: °Yes or
If this is a repair, fill out known well construction information and explain the nature of the
repair under #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
For multiple wells Its! all depths ifdlerent (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,)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Form GW-1
Method of test:
NG DttLitslkit' a +liiril,1e
TO THICKNESS
DIAMETER
0.-D t'3'UB
DIAMETER
DIAMETER
IIVINM1111 VAX
FROM Tn
MATERIAL
THI
SLOT SIZE
MATERIAL
iad�lii{f'
CKNESS t�
MATERIAL
EMPLACEMENT METHOD AMOUNT
EIMMIN
rfti''i' ticsble r
MATERIAL EMPLACEMENT METHOD
il��r�'y►fiair
'iCli addihot'iaCaheefs :E ", ����
neoessa � ,,
DESCRIPTION color hardness soil/rock e rain size etc.
11111111.111111111111111111111111
Zl 111AR1CS, ��:
22. Certificatio :
Signature1I Co actor
Date
Hy signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or 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 A_ l� Vyeps: 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 IIniecti n eljs: 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 Suy & 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.
North Carolina Department of Environmental Quality - Division of Water Resources
Amount:
(ft.)
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
- J4ie.�. i/ JR.
Well Contractor Name
(32,2 Vi
NC Well Contractor Certification Number
Cascade Drilling; LP
NOV 0 4 2020
Company Name
t/t ! FI U 5
2. Well Construction Permit #: hi1C)0RESVILLF REGIONAL, OF f IC; '
List all applicable wellconstruction permits (i.e. (IIC, County, State, Variance, eta)
3. Well Use (check well use):
Water Supply Well:
'Agricultural
1! Geothermal (Heating/Cooling Supply)
r Industrial/Commercial
rrigation
n-Water Supply Well:
onitoring
Injection Well:
DMunicipal/Public
°i Residential Water Supply (single)
°Residential Water Supply (shared)
Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Groundwater Remediation
Salinity Barrier
OStormwater Drainage
°Subsidence Control
Di Tracer
[_Other (explain under #21 Remarks)
4. Date Well(s) Completed: / I/©f -?C Well ID# /79AALC%
5a. Well.Locatio �1
CCtoyl�ra/ P e
Facility/Owner Name ,/ / Fa_ciilityIID'#f if applicable)
/1f/dg #0/i/ /34— C.f�dcos "c.:l ge
Physical Address, City, and Zip
Jelf C. 064 6
/1/1 C.J
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
IFor Internal Use Only:
I4VVATE
FROM
zoN
TO
475548
DESCRIPTION
ft.
ft.
5,.t nillat A SING (fo ;)nuHtkitied ttiells) 0 t-I ftigit (if ti
FROM TO DIAMETER j THICKNESS
ft. ft. in.
1ti.XNN.�B+�;ASING'iRNE>TfI�ING(�eoihermal�ctt��t! la{iti}';
FROM ( TO DIAMETER
ft.
ft.
17 $ EN
ft.
ft.
THICKNESS
In.
k ble)
MATERIAL
MATERIAL
in.
^A01,
DIAMETER
SLOT SIZE THICKNESS
MATERIAL
1iv
0 ft' ft. in.
pig.,FROM
f:.fL ft in'
st t Ilio
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
ft.
7o
f
/ ,/
�s �/%!/I�/�Gf
ft
ft.
ft. ft.
I4:S'OBJ(0.RAYEL'P CK(ifaitpiieiblei
FROM
/ ft.
ft.
ft.
TO MATERIAL
ft.
203fttaLi • fi?' OCx ist)ac'
FROM
ft.
ft.
TO
ft.
EMPLACEMENT METHOD
ik�dditioy�$l:sh�t9 ifueeessaryi`%, s
DESCRIPTION (color, hardness, soil/rock One, grain size, ete.)�
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
2k>`l>wltilAli10,; n z-:: .
ft.
0(1
2 6 2020
v : ilk
rifia,m3. 00; �� t,on
D`'r
22. Certificatio
N W v
6. Is(are) the well(s) Permanent or QTemporary
7. Is this a repair to an existing well: DYes or Oi, No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2/ remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Welis having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: �1
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 "+"
(in.)
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)
13b. Disinfection type:
Method of test:
Amount:
Signatu
lh
ell Con actor
9,7600
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All 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 Iniection 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 Supply & Iniection Welis: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wens
1. Well Contractor Information:
For Internal Use ONLY:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Ccrtificatjon Number
S&ME Inc
Company Name
2, Well Construction Permit #:
List all applicable well permits (Le County, State, Variance, Injection, e(c.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
OGeothemtal (Heating/Cooling Supply)
° Industrial/Commercial
Irrigation
Non -Water Supply Well:
LE Monitoring
Injection Well:
°Aquifer Recharge
DAquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
14. WATER ZONES
rilt1 kt jTo
DESCRWTION
—
r 15. OUTER CASING (for mialti-;ed vv aigi Of ap licable
r FROM TO FHAMTElii I HICK NFSS rxt Ai
ft. T
! 16. INNER CASING OR TIMM I.
FRoM 1
TO
flIMETER
1 THICKNESS
MATERIAL
+3 rt.
ft—
V. 0,1116, A..,
20 ft.
2
I Sch 40
PVC
ft.
4...—
Mtmicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
°Groundwater Remediation
O Salinity Barrier
DStormwater Drainage
°Subsidence Control
OTracer
5. 5
FROM I TO _ E_R.A_SLOT SUE 1 THICKNESS MATERIAL
. 20 ft' 135 ft2 In-
.010 Sch 40 I PVC
ft. ft.
18. GROUT
FROM TO _ MATE
10 ft• 3 • Grout
.13
EMPLACEM.ENT METIL0p. AMOLINT_
Tremie
ft. 18 11. , Bentonite
Pour
ft.
t.
- i 19. SAND/GRAVEL PACK if etpllcMe_
' 1F—Cloil To
I 18 fl• 35 #2 Sand
ft.
ft.
io. DRILLING
°Geothermal (Heating/Cooling Return 00ther (explain under #21 Rerna
4. Date Well(s) Completed: 9/7/20 Well DM nAvv-30
5a. Well Location:
Colonial Pipeline
FaciLity/Owner Name Facility Oft (if applicable)
14511 Huntersville-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610799.782 N 14615 .298
8. Number of wells constructed:
For multiple injection ar non-waier supply wells ONLY with the same construction, you can
submit- one Atm
6. Is (are) the well(s): @Permanent or lTemporary
7. Is this a repair to an existing well: DYes or fE3No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or an the back of this form.
1
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3®200' and 2@1(10')
10. Static water level below top of easing: 3059
If water level is above casing, use "+"
11. Borehole diameter: 8
12. Well construction method:
35
(in.)
Auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft.
ft.
22. Certification:
athrt*1IrDlbws If Inces
cscRIPTtos Iorbnrta±aek orK 4oilo e etc 1
EMPLACEMENT METHOD
Pour
,
eut
S 'mature of Certified Well Contractor
lo A 42 /
Date
By signing this fnnn, I hereby certify that the well(s) was (were) constructed in accordance
with ISA ATCAC 02C .0100 or ISA ttTC4C 02C .02019 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
1
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 kiection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information: f�
Sri$ ' LS t Wex
Well Cootractor Name
NC Well Contractor Certification Number
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (t.e UIC, Comity, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
IndustriaUCommercial
Irritation
Non -Water Supply WeU:
A Monitoring
Infection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
)experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin. Coolin Return)
4, Date Weli(s) Completed; aa
'f� �U Well II7#
Sa. Well Location:
Facility/Owner Name
Physical Address, City, and Zip
County
Facility ID# (ifapplicable)
or
DMunicipaUPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
0Groundwater Remediatian
Salinity Barrier
Stormwater Drainage
Subsidence Control
Tracer
Other (ex lain under #2 i Remarks)
Parcel Identification No. (PIN)
5b, Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one iatftong is sufficient)
N a 90 '2
6. Is(are) the well(s)Opermanent or OTemporary
7, Is this a repair to an existing well:
If this Is a repair, fill out knows, well construction
formation, and xplain the nature of the
repair under 1121 remarks section or on the back ofthis form.
g. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only l OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple welts list all depths if -different (example. 3©200' an 2
Q1007 (ft,)
10. Static water level below top of casing: 3'0
1f water level Is above casing, use
11. Borehole diameter:
(in.j
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:
W
(ft.)-
For Internal Use Only:
14. WAT'ER1ONE8
FROM 'rn
DESCRIPTION
RECEIVED/NCDEO/DWR
b'Ro T$RGAiSIN forihalsa.casedivel'. �
FROM TO
DIAMETER
1111111111
B':W14EA:GASTNG'O1t,TUB1Nt;a; b'�"
FROM TO fher°riieIcloir
FROM .. DIAMETER �rS±iT:SYr. iaa.�.
DIAMETER
f t.
lS GrRQIJT
EMPLACEMEN
LE REGIONAL
MA1 ERIAt
METHOD & Alt OUN9
EMPLACEMENT METHOD
20.'u i • 'D NG.L0GG h;additlonatttieetsdf aecrsaa
FROM TO DESCRIPTION color hardness, soltlrock 4n
tamer row
rOu, R < e Sc !
rower a
Signature of Certified Well Contractor
aft) size,
By signing this fonn, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C A1100 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 weal
construction details, You may also attach additional pages if necessary,
S MITTAL INSTRUCTIONS
24a. For Ali Wells'
24nstruction to the followinm it this form within 30 days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. oe Infection Wells: In addition to sending the form to the address in 24a
construction to the following;
above, also submit one copy of this form within 30 days of completion of well
Division of Water1636Mali Resources, Underground Injection Control Program,
Service Center, Raleigh, NC 27699-1636
24c, For Water Su 1
the address es above, &In colon Weirs; In addition to sending the form to
completion of) well con tiruction ottheso y of this form within 30 days county
where constructed. county health department of the county

WELL CONSTRUCTION RECORD
This fisnn can he used for single or multiple wells
1. Well Contractor Information:
Kevin White
Welt Contractor Name
2973
NC' Welt Contractor Cer ti ficatiau Number
Parratt-Wolff, Inc.
Company Name
2, Well Construction Permit #:.
ict all applicable well permits (l,e, 011011Y, Stale t itriwwc, htleclion, etc)
3. Weil Use (check well use):
Water Supply Well:
OAgi' cultural
❑Geotllermul (Ileating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
®Monitoring
Tee leIernal Use ONLY:
14
FROM
59
ft.
fi ZONES
70
ft,
Wet
rL
ft.
FROM
To
OIAM E'IF;R
TUIC
MATERIAL
ft.
it.
0
fi
NG Olt TOlithi
TO
55
ft,
DrAsurrr
n.
li
TtIICENFSS
sch40
MATERIAL _
pvc
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loup)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 5-10-21
❑Municipal/Public
OResidential Water Supply (single)
OResidential Water Supply (shared)
0 Recovery
FROM
55 ft.
ft.
To
70 et.
DIAMETER
2
in.
s
uI
IZE
.010
fltDARESS
sch40
NATERIAt.
pvc
❑Groundwater Rcmediat on
OSalinity Barrier
❑Stortnwuter Drainage
JSubsidencc Control
❑Tracer
❑Other (explain under #21 Remarks)
Well 1D# MW-31 D
5a. Weti Location:
Colonial Pipeline Company
Facility/Owner Name Facility IINI (if applicable)
13900 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address, City, and Zip
Mecklenburg
County
4660193695/1921204
Parcel Identification No. (PIN)
5b, Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Iicld, one latlong is sufficient)
35.412004 N -80.807398
6, is (are) the well(s): ©Permanent or LlTemporary
7. is this a repair to an existing well: ❑yes or t?iNo
1/7his is a repair, Jill tart known welt constructlan intonation and expin/n the nature of the
repair under `21 remarks section or an the hark o/`thisibrar.
8. Number of wells constructed: 1
w
For antitank injection or non -water .supply wells ONLY with the .rthere construction, wn, can
:urban' mar /itrnt.
9. Total well depth below land surface: 70 (!t:
/ ar antitank wells list all depths tfili larent (example- 3(d12011' neat 2CtU.100)
10. Static water level below top of rasing: 59 (ft.)
1/ water level is above casing, use " '
11. Borehole diameter: 2
(in.)
12. Well construction method: 6 5/8 HSA @ 2" spoons and 4" and 6" Air Hammer
(i.e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection types._...__._...__...,. Amount:
,................_.._
FROM
TO
\IATERIA.
sMl'I ACK31iN'r.Nk
tt
0
ft.
46
Portland Cem
Tremie
46 fl,
51 it
Bentonite Chii
Tremie
fL
ft.
FROM
TO
A Ktta
TMPI;AC
Erie M
SOD
51
t,
70
t.
#1 Sand
Tremie
ft.
ft.
FROM
ft,
ft.
TO
ft.
ft.
dittanatatter is tttuctaxarvl
DELI tt
k time, ak`al11 ii1' F74.)
ft.
ft.
ft.
t.
ft.
ft.
ft.
ft.
ft.
2 X 2 Pad
8" Flush Cover
22. Certification:
Signature of Certified Well Contractor
Date
Hy .signing this farm, 1 hereby yar l& that the well(s) erns (were) mans'tructed in trccm'rhurce
with 15,1 N('A(' 02(' _0/0U or ISA NC'A(' Qt'.0?00 It'ell t'onstrartiau Swm/arils and that a
cope gf'this record has been prank/ell 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 IN IN ONLY: In addition to sending the turm 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 OW -I
North Carolina
epa tmcnl 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:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lin ail applicable well permits (i.e. County, State, Variance, Inferti
3. Well Use (check well use):
Water Supply Well:
°Agricultural
©Geothermal (Heating/Cooling Supply)
°IndustrialtCommercial
❑irrigation
Non -Water Supply Well:
['Monitoring
injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return) °Other (explain under #21 Remarks
etc.)
❑Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
°Recovery
❑Groundwater Remediation
°Salinity Barrier
❑Stormwater Drainage
°Subsidence Control
❑Tracer
4. Date Well(s) Completed: Well 1D# MW-32
5a. Well Location:
9/6/20
Colonial Pipeline
Facility/Owner Name
14511 Huntersvi
Facility ID# (if applicable)
e-Concord Rd
Physical Address, City, and Zip
Mecklenburg
01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
611207.899 N 1461763.847
6. Is (are) the well(s): ®Permanent or °Temporary
7. Is this a repair to an existing well: ©Yes or ENo
If this is a repair, fill our known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form,
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same eon traction, you can
submit one form,
25
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3(w200' and 2Q100')
10. Static water level below top of casing: 16.19
(ft)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method:
(i.e. auger, mtary, cable, direct push, etc.)
Auger
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
3b. Disinfection type:
Amount
14. WATER ZONES
FROM TO
ft.
I is.o
FROM
ft.
ESCRLPTION
G (tier maid -eased was OR LINER (if a pticabl
TO MASI§" t K TIltC
16. INNER CASING OR TUB
FROM TO
1+3
l Q ft•
ft
t
118. GROUT
ft.
G (teothertua1closed-too
LOT SIZE TnICKNESS
AL
FROM..
T()
6 fr•
S •
M.4TER1AL
Grout
Bentonite
EMPLAC[SNFIVT NIETHUD & AMUUN'i
Tremie
Pour
ft.
ft.
TO
25
21. REMARKR
22. Certif:stion:
Signature of Certified Well Contractor
K (if a plleable)
MATERIAL
#2 Sand
hits if
MP)..4CEMENT METRO
Pour
"RI1'iti3.'ti twist, hardness, eoW vnch . . Ie size, etc.t
Brown Clayey Silt
Gray Sandy Clay
Gray Silty Sand
Gray Brown Silty Sand
Date
ay signing this form, 1 hereby certi.b, that the well(s) was (were) constructed in accordance
with /SA ATCAC 02C.0100 or ISA 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 well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCT1ONS
24a. For Alt 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 & Infection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed,
Form GW-1
North Carolina Department of Environment and Natural Resources —Division of Waesomces Revised August 2013

°Municipal/Publc
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
❑Groundwater Remediation
Salinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
°Other (explain under 21 Remarks)
Facility MN (if applicable)
14511 Huntersvile-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contactor Certification Number
S&ME Inc
Company
2. Well Construction Permit #:
1.131 all applicable well permits (i.e. County, State, variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
DlndustnaliCommercial
OIrri diva
on -Water Supply Wen:
©Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Hc tit g;t ',,)0lirig Return)
4. Date Well(s) Completed: 9/ Well 1D# MW-33
5a. Wen Location:
Colonial Pipeline
Facility/Owner Name
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
611254.113 N 1461864.564
6. Is (are) the well(s): RPermanent or °Temporary
7. Is this a repair to an existing well: DYes or No
If this is a repair, fill am known well construction information and explain the nature of the
repair under 021 remarks section or on the back of This form.
1
W
12. Well construction method:
(i.e. auger, mtary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection tyre:
10. Static water level below top of casing:
;Twofer level is above casing, use "+
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same conshwctlon, you can
submit one form.
9. Total well depth below land surface:25
For multiple wells list all depths ifdiifferent (exam le- ( )
p 3(a�00'and2(a)100�
13.2
11. Borehole diameter: 8 (in.)
Auger
(ft.)
Method of test:
Amount:
For Internal Use ONLY:
14. WATER ZON_
I FROM TO
ft.
ft.
PEsgltIPTIOA _.
15. OITPER EASING ifor at ased wells)"—._.. Et tt s
FROM TO O
ftDtAMETER T€dt> qy
f t i• n, ,
16, INNER CASING OR TUBING { eothe H
napt
FROM .a TO DIAMETER THICKNESS
17. SCREEN
rROM ITC
10 25
18. GROUT
R. 6
2
MATEI
II. Grout
R.
19. & D/CEAYEL PACK
1_ fROM
LOT its
,010 1 Sch 40
ATERMA
PVC
41_EMPLACEMENT METHOD gr AMOUNT
Tremie
Bentonite 1 Pour
14
15
22. Ce
ation:
2 Sand
li
Pour
ram s
Brown Clayey Silt
Gray Sandy Clay
Gray Brown Silty Sand
Gray Sandy Silt
Date
8y signing this form, I hereby certify that the wells) was (were) comma -led in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy clans record has hem 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 Welts 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 S lv & ingestion 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.
Signature of Certifier Well. Contractor
Form GW_1
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
This farm can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well; ...
°Agricultural
©Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
D1rriµation
Non -Water Supply Well:
©Monitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Facility ID# (if applicable)
14511 Huntersville-Concord Rd
or Internal Usc ONLY;
iL
ft.
15. OUTER CASINGy(for ®alti c+�netl well) OR LINER (Jf applicable
mom i Ttl nti.1't►'rp.R Ttitc'{'NFM MATERIAL
"...,. "
ft. ft hi.rAL
DFSCRtPT10N
16.
FR
+3 ft.
❑MunicipaVPublic
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
9/6/20
❑Groundwater Remediation
°Salinity Bonier
DStormwater Drainage
°Subsidence Control
°Tracer
°Other (espl.tin under #21 Rem
MW-34
Well ID#
Physical Address, City, and Zip
Mecklenburg 01940102
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
(if well field, one lavloug is sufficient)
611273.038 N 1461934.811
6.1s (are) the well(s): fiiPermanent or °Temporary
7. Is this a repair to an existing well: Dyes or EINo
if this is a repair, fill out known well construction information and explain Me nature of the
repair under #11 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construe
submit one form.
1
n, you can
9. Total well depth below land surface: 2" (ft.)
For multiple wells list all depths if different (example- 3 j200' and 2©100)
12. Well construction method:
(i.c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WEL[ y ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
10. Static water level below top of casing: 1 0. 89 (f)
1f water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
Auger
ft.
8. GROUT
GGGG CBR 1 i1B1[NCx 3 eotheratal c;tt3ed t°a}9X
DiAiNETER THICKNESS MATERIAL
2 in. Sch 40
.
U
SIZE
.010
Sch 40
TO MATERIAL EMPLACEMENT
Grout ` Tremie
19. SANAIGitA VEL PAC
4
.g
10.5
ft.
ZL Itl
Bentonite ' Pour
w MATERIAL,
20 #2 Sand
ft.
Nf2 l €3i1 attach additlortal ssheets R n
TO
ATERIAL
TkIOD &
tco l° . Lardnes, sod/ruck tc
Brown Clayey Silt
rt. Gray Sandy Silty Clay
10.5 i3, Gray Sandy Clayey Silt
20 f` Gray Silty Sand
22. Certitation:
ro oY l rtificd Well Contractor
E i
Date
By .signing this form, 1 hereby certh, 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 L STUCTIONS
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 In'ection 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 within 30 days of completion of
well construction to the county beahh department of the county where
constructed.
PVC
0 NT
Form G W- I
North Carolina Dcpartmaut of Environment and Natural Recourse —Division of Water Resources
Revived August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Wen Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permit(i.e. County, State, Variance, Injection, ele)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal Bleating/Cooling Supply)
C IndustsiaUComm.ercial
❑hTicstion
Non -Water Supply Well:
©Monitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
ClExperimental Technology
❑Geothermal (Closed Loop)
DMtmicipaUPublic
❑Residential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 9/7/20 Well ID# MW-35
5a. Well Location:
Colonial Pipeline
Facility/Owner Name Facility IDit (if applicable)
14511 Huntersville-Concord Rd
Plrysical Address, City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(Swell field, one lat/long is sufficient)
611009.321 N 1461705.220
01940102
6. Is (are) the well(s): ®Permanent or °Temporary
7. Is this a repair to an existing well: [Yes or EINo
If this is a repair, fill out known well construction information and explain the nature ofthe
repair under 621 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple in/ectinn or non -water supply wills ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths ()Afferent (example- 3@200' and 2n100')
26.78
12. Well construction method:
(i.e. auger, rotary, cable, direct push, ere.)
37
10. Static water level below top of casing: _
If water level is above casing, use "+"
11. Borehole diameter: 8 _. (in.)
Auger
(ft•)
FOR WATER SUPPLY
13a, Yield (gpm)
13b. Disinfection type.
LLS ONLY:
Method of test:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FRght _ TO
ft.
OUTER CASFNG,[[or mnttl ceaed wells► OR
CitA.flltLER
in.
(
16. INNER CASL G ©1INR TUBG "eother'mal closed-l€to
FROM TO�
DIAMETRR THICKNESS
+3 li• 15 ft. 2 Sch 40
17. SCREEN
in._�onf Tc
15 ft. i 37
I8. GROUT
MATERW,
Grout
Bentonite
ATE
SLOT SIZET THICKNESS
.010 Sch 40
19. SAND/GRAVEL PACKAlf applicable)
FROM TO MATERIAL
13 ft• 37
O.
fdttt
0
11 11. 37
22. Certlficaiion:
#2 Sand
CEMENT R1ET1UAD t& AMOUNT_
PVC
TAE.
PVC
Tremie
attach additonal sheets if nerd_
tit R t riO N cek,r, 11arTlnesr, soil/rock . e, ruin
Red Brown to Gray Clayey Silt
' Gray Sandy Silt
t� 10//
Signature of Certified Well Contractor
Date
By .signing this form, I hereby certify 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 in 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 INSTUCTLONS
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
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 form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form OW-1
North Carolina Department o
vimnment and Natural Resotn,ces — Division of Water Resources
Revised August 2013

For multiple wells list all depths if different (example-3 00' and 2Q100')
10. Static water level below top of casing: 28.62
If water level is above casing use "+„
1I. Borehole diameter: 8 (In.)
Auger
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Nei
2907-A
NC Wclt Contractor C
S&ME Inc
Company
fication Nun
2. Well Construction Penult #:
List alt applicable well permits (i.e. County, State, Variance,
3. Well Use (check well use):
Water Supply Well:
GAgricultural
❑Geothermal (Heating/Cooling Supply)
DIndustrial/Commercial
©]rrik;ation
Injection Well:
DAquifer Recharge
CJAquifer Storage and Recovery
OAquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
0Geothermal tHc a ttz'Cooling Return)
;yearn
�Mtnucipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
©Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
DSubsidence Control
❑Tracer
❑Other (explain under #21 R
4. Date Well(s) Completed: '`'I_ `•'!20 Wen
5a. Well Location:
Colonial Pipeline
Facility/Owner Nemo
County Parcel Identification No. (PIN)
5b, Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
610925.672 N 1461745.145
6. Is (are) the weil(s): 17Permanent or DTemporary
7. Is this a repair to an existing well: ❑Yes or E No
If this is a repair, fill out known well construction information and explain the nature ofthe
repair under 1121 remants section or on the back of this form.
& Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 42
ft.)
12. Well construction method:
(Leauger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY;
13a. Yield (gpm)
13b. Disinfection
Facility ID# (if applicable)
e-Concord Rd
01940102
Method of test:
Amount: _
For Internal Use ONLY:
15. oUTEIt CASING far m
ulii�cssed we1R OR LINER h a
FROM
TO DrAnMhTER TmmcKNFss ar!
37SCREEN
FROM TO
27 It 142
18. GROUT
FROM
PAMPER
2 __ . In.
Grout
25
ft.
9. S.4Nii/GRAVEL PACK
ROM TO
osed-iaa
1 _
rfCKNE. S MATERiAL �" __.
Soh 40 PVC
Entrt.r►Ci
Tremie
Pour
PVC
err METHOD
EMPL�cestrr NETBOD
25 ft. 42 ft. #2 Sand
_..__._ Pour
o. DRILC fb1 LOG a .th _e s G ttnch additional sheets.if if aecessa -� xaa ��• It nos color, bandncs-,
0 ft• 27 rt. Red Brown to Gray Clayey to
27 ft 42 Gray Silty Sand
22. Certification:
andy Silt
60,IG 0ai
Signature of Certified Well Contractor
Date r
By signing this firm, I hereby Geri fy that the wehys) nos (were) constructed in accordance
with ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. She diagram or additional well details:
You may use the back oFthis page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
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 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 Su tlply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county heath department of the county where
constructed.
Fomi U W-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD G
1, Well Contractor Information:
U
ell Contractor Name
NC Well Contraetor Certification Number
Company Name
2, Well Construction Permit #:
Lin all appitcable well canstructlon permit
3. Well Use (check well use):
Water Supply Well;
aAgtiersltural
JGeothsrmal (Heating/Cooling Supply)
ldu ttial%Commercia1.
fi2a io
Non -Water Supply Well:
Monitorin0
ell:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Hearin
4, Date Well(s) Completed:
Sa, Well Location;
Facility/Owner
Physics
r�rrr
County
e: UIC, County, State, Yarlanc
DMunicipaVPublic
;Residential Water Supply (single)
Residential Water Supply (shared)
Groundwater Remediatio❑
Salinity Barrier
Stormwater Drainage
.D.r Subsidence Control
JTracer'
Other (explain under #2
Parcel tuentiticat?e�nNo, (PIN)
5b, Latitude and longitude in degrees/minutes/secon.ds or decimal degrees:
(ifwelLfeld, one lat/long is sufficient;
N
6. Is(are) the well(s)-permanent or rTemporaty
7 Is thh a repair to an existing well: J'Pes or
ljdn !s a rep r r Ell out drawn welt construct fief motion rrnrl plain the nature o the
rapalr under r121 eon;arks serener a,•nn OW en4eA-ofdrtsjtst�11
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I OW.l is needed Indicate TOTAL NUMBER of wells
dd l led.__
W
For h-571 l Use Only:
FRO;
ft.
ft,
ft.
ultr
( DESCR1P'I`fOrN'
eotl crow! cluscli-ia
r ftttt THICKNES..
ft.
SC1tRl
-�----- FROmO` DLLPoiErizR SLOT
ft,
ft, I
u,57 TO
ft'
ft'
ft. I ft.
TO
ft,
ft,
P4ATI ltLmL...._ Epq hL CtIalTaA
EN,lh;'fr!OD & OUNT
-#171
I. AG]( {If<appili'tib"
MATERIAL EaIt'LACESretiTri
F_tICE
'2(.,1ijaftimffil: mulish uriattlutiM sheeteArtieceisur, s
FROM TO ng ar.color, hardness, zutUrpeh type, grater size, err) -'—`
0 ft, /® ft, No L
ft.
0 ft. x r
22, Certification:
By l'i iag this Aron, 1 ixCr'i f 010, ,, t/ P lire i' //(; was (were) Ccnstrn !Fd 7n aC"condor, ems
tvrdi /54 NC-1C 02C,Ul0O u+ ISA Nt7,4 tt2C,0200 Well Construction Standards and that rt
copy aphis record has been provided la the well owner,
23, Site diagram or additional well details:
You may use the back of his page to provide additions well site details or well
construction details. You may also attach additional pages if necessary,
9. Total well depth below laud surface: ,� SUBMITTAL INSTRUCTIONS
FOY multiple wells else all depths If different f;-.rample. �Qi2n0r,naL,1U0'1 (ff) consul24a.
or rill Wells: Submit this font; within 30 days of completion of well
t0 Geer ri conshttetiU.n, to the following:
2I / L/.2©2v
water level below top of easing:
vo £tt8lli4*, I,so
I I. Borehole diameter: (in.)
etc,)
( rotary, cable, dizec• push,
12. Well construction method: SC7/11 �•
i:o, auger,
construction to the following;
(ft,)
FOR WATER SUPYLY WELLS ONLY;
13a, Yield (gprn)
Method of test:
13b, Disinfection type:
Amount:
Form GW • i
Date
Division et' Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1 17
24b, For 1tt action Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form ._ _ _
Division of Water Resources, Undergrottud Injection Control Program,
1636 Mail Service Center, Ralclgh, NC 27699-1636
24c. For Wato7 Snntlly ae it: Well.;
to
the address, 7) ahuvee also submi opyho f this forte addition toswithin 30 daysendinthe of
cotnpleno:t of well construction to the county health department of the county
alas re esustruoted,
North Carolina Department of En
oncnemai Quality - Division of Water ReRnurrPq
e

County
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
Lis/ nil applicable well permits (i.e. County, State, Variance, Injection, et
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
D lndustrialiCommercial
❑irri.'ation
Non -Water Supply Well:
ElMonitoring
❑Mtmicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatin, Coolin Retum)
©Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑tither (x..lain under #21 Remark
4. Date Well(s) Completed: 9/8/20 Well ln# MW-37
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
14511 Huntersvi
Facility ID# (if applicable)
le -Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
610847.989 N 1461775.311
6. Is (are) the well(s): @Permanent or ❑Temporary
7. Is this a repair to an existing wen: ❑Yes or ®No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one fwnt.
9. Total well depth below land surface: "" (ft,)
For multiple wells fist all depths if different (example- 3 .00' and 2@10IY)
10. Static water level below tap of casing: 26' 90
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
114. WATER ZONES
FROM TO
ff �._. ft.
5. OUTER CASING
ROM TO
DESCRIPTION
AI
R11N L
A
R CASING OR TUBING (geothermal cio
OM TO DIAMETER Tt11
i +3 • 20 2 In.
R.
0
20 ..1
„35
ft.
GROUT
0
6
1
u
•
&ss
Sch 40
DIAMETER
2 in.
ATERIAT,
PVC
fi MATERLAL
.010 Sch 40 PVC.
MATERIAL € EMPLACEMENT MET1it3D & AMOUNT
Grout Tremie
Bentonite 1, Pour
9. SANDIGRAAVEI. PACK (if applicable}
ROM TO MATERIAL
113
R.
35 #2 Sand
DRILLING LOG (attach additional sheets if
EMYLACEMFIIT METHOD
Pour
rein si,e. ete.i
0 li• 35 ft• Red Brown to Gray Clayey to Sandy Silt
{0,
(,M '10 nt`tiCIIIP11()N (color, hardnesn, wiUrack
ft.
of Certified Well Contactor
Date
By signing this form, I hereby certify that the well(r) was (were) constructed in accordance
with 154 NCAC 02C .0100 or 15,4 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or 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:
Dh'ision 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
24e. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the cotmty health department of the county where
constructed.
Font G W-1
North Carolina Department of Environment and Natural Resources —Division of Water Resources Revised August 2013

2. Well Construction Permit #:
List all applicable well construction permits (l.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
✓lt( iXu5
Water Supply Well:
Agricultural °Municipal/Public
Geothermal (Heating/Cooling Supply) ®Ii Residential Water Supply (single)
Industrial/Commercial r3Residential Water Supply (shared)
Irrigation
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
-N‘j e thit/J'�
Well Contractor Name j l(
NC Well Contractor Certification Number
Cascade Drilling, LP
N O V 0 4 2020
Company Name MOORESVIL_
11; l;EGlUrfEtl r )F=FIC1:`
on -Water Supply Well:
onitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a. Wel(.Locati: „
grg/
COplvtt' ipe
Facility/Owner Name Facility ID# if applicable)
////cog Ade/Stty� �- C©,Jcof't: t
Recovery
Groundwater Remediation
°Salinity Barrier
0Stormwater Drainage
°Subsidence Control
Di Tracer
/ Other (explain under #21 Remarks)
`r Well ID# 112 tt/ —3 tj
Physical Address, City, and Zip
l eat ,�i C.t
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 °Temporary
7. Is this a repair to an existing well: °Yes or ONo
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:
Far 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 "+"
<34
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
5
(in.)
ceptid
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
runt t or
For Internal Use Only:
4A:NAB'l;Ili7ANES41`
.> ; ;? , - t::+ ?',a,=,
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
35 titIVEI2Cil S iG"Oni
nulti sedlvells); akti11Vti( i[ap
litgble)
FROM -
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
1G.':it iN. R
CASJ$G HM .111Nc
(gentheritnalelola?td loop) ... '',' <,,
FROM
TO
-DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
.117i:!SCREJ1N f : ,.. , r %.. ::: : ::.':. ... : z_. ..
. ... E.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft.
ft.
in.
, e) fft.
�o ft.
m
10 / b
sc4, 90
PVC,
lit tt3lll
! St ...n
F OM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
rs-^eft.
0 ft.
7 ✓CyCt-
',7e/y2//2/ eni
ft.
ft.
ft.
ft.
I94410,10tiOE1itiktMit8ppt
Cnble)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
Q' ft.
D
43-0 ft.
S f AQ
�rter,2%7,
ft.
ft.
203)- ti1.04241.041at(icti.addittbtiatsheetaariic4tisarl')
J."st. ` . r '
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.
ft.
ft.
ft.
ft.
ft.
ft.
$$
ft.
ft.
ft.
ft.
1 n�.T 2, 6 ZOZO
ft
ft.l7
, rIg 'J131
21...Ti} Mr1ax fi 41A t{jti
11 irk
22. Certificatio
Signatu
i c.errttibd 'ell Contractor
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of 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 G W-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD GW-1
1. Well Contractor Information;
lit C: / j
Well Contractor Name
t
r a {
NC Well Contractor Certification Number
L
t;
Company Narnc
2. Well Construction Permit #:
List all applicable well construction permits (i.e, UiC, County, State, Variance, a/c.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
r Irritation
Non -Water Supply Well:
. Monitoring
Injection Well:
Aquifer Recharge
ji Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin. Coolin
4. Date We11(s) Completed:
5a. Well Location; /
coi
Facility/Owner Name
Physical Address, City, and Zip
County
DMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
DSalinity Barrier
DIStormwater Drainage
Subsidence Control
Tracer.
Return ; Other (explain under #2l Remarks)
12f7i0. Well ID# - /
Facility ID# (if applicable)
2.80'98
Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield, one latt/long is sufficient)
6. Is(are) the well(s) ,M1Permanent or JlTemporary
7. Is this a repair to an existing well: DYes
or EINo
If this is a repair, fill out known well construction information and plain the nature of the
repair under #21 remarks section or an the back of this form.
8, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only y 1 GW-1 is needed. Indicate TOTAL NUlv1BBR of wells
9. Total well depth below land surface:
For multiple wells list all depths if d(/ferent (example- 3Q200 and 2(]a 100 j
IQ. Static water level below top of casing: .
If water level is above casing, use "+ (ft.}'
I
11. Borehole diameter:
(in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, cue t
FOR WATER SUPPLY WELLS ONLY:
13 a. Yield (gpm)
Method of test:
13 b. Disinfection type:
Amount:
FROM
t.Br-
T. SCREE J
IAMETER
hIA1'ERLAL
ft.
ft,
tn.
18;.GROSUT
FROM
TO
DESCRIPTION
t,
ESVILLE REGION
far mat•:cased webs-ORL3Ng1j ifk..11cabte
DIAMETER—yy_:
ININNIII
3t:CitSING'ORTUBING •'eothei i ial•.closed=loa
For Internal Use Only:
0 '2021
14: WAT1rR`�OiYEB
FROM
ft.
''15, OUT$R CASIN
FROM
f
ft
TO
TO
SLOT SIZE
MATERIAL
THICKNESS
v
Pv•.
wiRIAL Etv1PLMETROD &All?OUN'r
wow
19' S1lioa
1�. , I
FROM TO MATE
turi
4-1
•
e
� 1PLACEMENT METHOD
a to AiNINT
U..i RIUtiIIYG:LOG� afta'ch addttion'pl"sbeeta if accesaa
FROM TO DESCRIPTION color hardntss solUrock p e 'rain stee, et
t r A I Cu.5d lfY C er
FinargararLa r
reic0 C/a S l
AIM ft.
R. ft, /Cat C
ft,
t.
:21. RE
22. Certifteadon:
ft,
Signature of Certified Well Contractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I SA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Weil
construction details. You may also attach additional pages if necessary.
SU$MITTAI INC f R?trTIONS
24a, For All Wells: Submit this form within 30 days of completion of well
construction to the following:
5
ID i0/2c,2Q
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 SunDly & Znlcction 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,
FFICE

12. Wen construction method:
8. Number of wells constructed:
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Contractor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Varionce, Infection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
Non -Water Supply Weli:
©Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Rem
9/9/20
4. Date Well(s) Completed: Well ID
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Physical Address, City, and Zip
Mecklenburg
County
MW-40
Facility
yJ ID# (if applicable)
(It - �6etnCi.,Y.l •t,1
Parcel Identification No. (PiN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one 1st/long is sufficient)
610244.764 N 1461670.079
6. Is (are) the well(s): 1,3Permanent or ❑Temporary
7. Is this a repair to an existing well: [Wes or ElNo
If this is a repair. fill out known well construction information and explain the nature of the
repair under #2! remarks section or on the back of this form.
1
For multiple infection or non -water supply wells ONLY with the same co
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths if different (example- 3Q200' and 2@100')
10. Static water level below top of casing: 33.25
If water level it above casing use "+"
37
11. Borehole diameter: 8 (in.)
Auger
ctian, you can
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm)
13b. Disinfection type:
Method of test:
Amount•.
14. WATER ZONES
FROM 4 TO
ft. I ft
DESCRIPTION
rt. ft.
15. OUTER CASING (for multi -cased wells) OR LINER of ar
FROM TO ( DIAMETER THICKNESS I MATERIAL
ft ft
6. INNER CASING OR TUBING feothermal el foe
ROM TO DIAMETER I THICKNESS
+3
ft.
17. SCREEN
27 fL 2 in. ; Sch 40
FROM TO
27 ft., 37
ft. j if.
18.'GRO
i FROM
0 ft.
6 ft•
i
6
25
n.
MATERIAL
liv „able)
HICKNESS
Sch 40
tPLACEMENT
Grout Tremie
• Bentonite Pour
19. SAND/GRAVEL PACK (if applcable)
FROM TO i MATERIAL
25 ft. 37 fL #2 Sand
ft.i
ft.
20. DRILLING LOG (attach additional sheets if necessra
FROM TO DESCRIPTION {color, hardn
0 ff. 37
ft.
22. Certification:
et.
ft.
1L
Signature of Certified Well Contractor
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15.9 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to Me well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach 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, lnformatlon Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Inlection 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,
TERTAL
PVC
OD & AMOUNT
ENT METHOD
Pour
soltherk tom, 2taia size etc
Red Brown to Gray Clayey Silt
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

�. +. vi•1.1 JAIL) 14'JJ I L'l.Vl(.1J
This fueni can be used for single or tnnitiple wells
1. Well Contractor Information:
Thomas Whitehead
Well Contractor Name
2907-A
NC Well Conteuctor Certification Number
S&ME Inc
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County,Stale, Variance,
3. Well Use (check well use):
Water Supply Well:
CAgricultural
CGeothermal (Heating/Cooling Supply)
Ind ustriaUCommercia1
❑Imation
Non -Water Supply Well:
MMonitoring
njection Well:
❑Aquifer Recharge
CAquifer Storage and Recovery
CAquifer Test
CExperimental Technology
DGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
cunt; etc.)
OMumicipaL/Public
CResidential Water Supply (single)
❑Residential Water Supply (shared)
DRecov
❑Groundwater Remediation
CSaUnity Barrier
DStormwater Drainage
CSubsidence Control
❑Tracer
DOther (e
4. Date Well(s) Completed: 9/9/20 Well ID# M
5a. Well Location:
Colonial Pipeline
Facility/Owner Name
Remarks)
1
Facility ID# (if applicable)
14511 Huntersviile-Concord Rd
Physical Address, City, and Zip
Mecklenburg 01940102
County Parve! Identification No. (PIN)
5b, Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
610493.441 N 1462185.803
W
6. Is (are) the well(s): ®Permanent or CTemporary
7. Is this a repair to an existing well: DYes or EINo
If this is a repair, fill nut known well construction information and explain the nature of the
repair under #1 / remarks section or on the back of this form.
8. Number of wells constructed;
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 65 ( )
For multiple wells list all depths if different (example- 3(ay200' and 2@I00')
10. Static water level below top of casing: 53.40 (fL)
If water level is above casing, use "+"
I1. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(Lc. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
3a. Yield (gpm)
13b. Disinfection tune:
Method of test:
14. WATER ZONE!
FROM o
•
15.OUTER CASLNG (for multi -cased wel
rat•1NI 'H'4`s DIAMETER
t)ESC upTtON
I.
ft.
R
+3 ft• 50
ft. 1
17. SCREEN
FROM TC
50 ft. (65
R LINER i ,$ licable)...
it(`tiSEsti
G OR 'TUBING (geothermal et_
AMSTER
ft.
18. GROUT
FROM
0 ft.
fG
ft.
SLOT .SITE
.010
THICKNESS 1 MATERIAL
Sch 40 PVC
TAMETER
to.
io
Grout Tremie
Bentonite I Pour
ft.
19.3AND%GRAVEL PACK 1
i FROM TO
48
ft
20. DRILLING LOG (attach additional sheet* (f n,..
F RICH TO D} K °RIP ri. (color h.
0 ft. 65 ft, Red Brown to Gray Clayey Silt
r
T METHOD i,AMOUNT ,
METHOD
Pour
22. Certification:
ii
of Certified Well Contractor
By signing this form, 1 hereby cenif5, that the well(1) was (were) constructed in accordance
with 154 NCAC 02C.0100 Or 1SA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well coveter.
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 Merit 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,
Amount:
1636 Mail Service Center, Raleigh, NC 27699-1636
;r Suyiitir Infection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county healthdepartment of the county where
constructed.
Form GW-1
North Camlina Department of Environment and Natural Resources — Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD (GW-1)
1. WelliContractor Information: yy
i.Cane;S. X 411/e Marirt�f Ta"2
Well Contractor Name
(18`
NC Well Contractor Certification Number
1/tar/1
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Infection Well:
Aquifer Recharge
Nr Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
FROM TO DIAMETER
ft. ft, In.
. 16;:11`1F1Elt•GiiSINO`OR TUBINGIgebitierutakelesed-loop)
FROM TO DIAMETER
0Municipai/Public
DResidential Water Supply (single)
ID.'.Residential Water Supply (shared)
Recovery
Groundwater Remediatio❑
Salinity Barrier
DStomtwater Drainage
DSubsidence Control
Geothermal (Closed Loop) QTracer'
Geothermal (Heating/Cooling Return) nOther (explain under #21 Remarks)�}
4, Date Well(s) Completed: cf/0/2(320 Well ID# f)1 , L/2
5a. Well Location:
C'rt�,7t„411 Ape h,1e
Facility/Owner Name Facility ID/4 (if applicable)
13126 1141,,i7LrCQI1/e✓ • ConeGrp1 Rd, iivrfAercibi4
Physical Address, City, and Zip
IreCkdei lour" C�/g212/2.
County Parcel Identification No. (PEN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is autTicient)
33r:'Y/2/2t2 N t?O e033 c/C.
6. Is(are) the well(s) a Permanent or QITemporary
7. Is this a repair to an existing well: DYes or „)No
If this is a repair, fill out known well construction information and explain the nature ojibe
repair under /121 remarks section or on the back of this form,
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW -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- 3(41200' and 2@100`)
10. Static water level below top of casing:
If water level is above casing, use " ,."
11. Borehole diameter: t (in.)
12. Well construction method: -Sal?I(,:
(i.e. auger, rotary, cable, direct push, etc,)
33
(ft.)
(ft.)-
FOR WATER SUPPLY WELLS ONLY:
13a, Yield (gpm) Method of test:
13 b. Disinfection type: Amount:
/4 ft.
(J ft,
if ft,
ft.
17:SGREEN
FROM
1 ft.
ft,
TO
L.J le.
in.
THICKNESS
Se /i yO
For Internal Use Only:
14. WATEit
FROM
ft,
ft,
ZONES
TO
ft:
ft.
RFCEIVFn/NCPrn/nvuR
SEP 2 0' 2021
DESCRIPTION WORM-
MOORESVILLE REGIONAL OF ICE
IS;GUTER CASINGIornitil i cased Wells)iOR L•hYERI(If by licablo)
THICKNESS 1 MATERIAL
MATERIAL
Pvc
S( ft
18. GR0TiT:..:
FROM
.9 ft,
0fL
ft.
TO
ft.
DIAMETER
L7f In,
in.
SLOT SIZE
+(2/O
THICKNESS
Sch S'a
MATERIAL
Pv�
ft.
? ft,
ft.
MATERIAL
Pc 11z f,�
CcM,Gnaf
19..SAND/GRAVEL`PACK Of tappable)
TO
FROM
ft,
ft.
Si ft.
ft.
MATERIAL
EMPLACEMENT METI 0D & AMOUNT
Pvt./rte./if- iat_lcz,7•
7.101.11%e /3 - eays
P'2
Sane/
26:43RILDING:LO G'(tittech Additional
FROM
17,S ft. 3 ( ft'
7
21) ft,
ft.
ft.
ft.
5/ ft,
.21: REMARIeS '
fh
ft,
ft.
EMPLACEMENT METHOD
P(4red /1/i6raAa
heetsdfnecessaiy.).
DESCRIPTION color bardness mlUrack pe •rain
reilm lr7
Car 191own s hill c%
e r (ndu, vl
Grdr dm
y1.
5
22, Certification:
Signature of Certified Well Contractor ISO /2020
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 111 NC/IC 02C.0100 or 154 NC/IC 02C,0200 Well ConsiraciIon Standards and that a
ropy of this record has been provided to the well owner,
23. Site diagram or additional well detalls:
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 Wails: 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 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.

1�
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:
jr Agricultural
Geothermal (Heating/Cooling Supply)
j� Industrial/Commercial
a
ion
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Hearin. Coolie: Return
DMunicipavPublic
DResidential Water Supply (single)
()Residential Water Supply (shared)
Recovery
Groundwater Remediation
()Salinity Barrier
13Stormwater Drainage
()Subsidence Control
Tracer
jl Other (explain under #21 Remarks
4. Date Well(s) Completed: _SZZe/Rj,Lp Well ID# U/--
5a. Well Location:
Facility/Owner Name
Pb r
County
ysicat Address, Ci
and Zip
r
WELL CONSTRUCTION RECORD
1. Well Contractor Information:
e
Well Contractor Name
NC Well Contractor Certification Number
s
GW-1
Facility ID# (if applicable)
Ul
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f/
(if well field, one latilang is sufficient)
3 . 4./I32 Lila N
6. Is(are) the well(s)Permanent or DTemporary
7. Is this a repair to an existing well: OYes or
ONo
If this is a repair, Jill out known well construction information 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: _ Y_2
Far multiple wells list all depths if different (example- 3Q200 and 2@100) (ft,)
10. Static water level below top of casing:q
!/water level is above casing, use "+" (ft.)
11. Borehole diameter. (in.)
12. Well construction method: r L
o e, auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
!! lrtt-t
DIAMETER Ua••IIcablo _.
IS:INNER CASING Ole TUBING • eothei mat closed -too .
FROM TO DIAMETER
+,3 ft. r
For Internal Use Only:
DESCRIPTION
1,
RECEIVED/NCO
w
1S. OUTER CASING or maid -cased wells OR LINER
FROM TO
ft.
ft.
17; SCREEN
FROM
20.-DElL
FROM
111111111111111111111111111111111
TIDCKNESS
IMIETER SLOT SIZE MATERLII
tin. e t
18. GROUT
FRo1f
TO
MATERIAL
IMEIMMENI
a fL EMPLACE MENTMETHOD Sit NT
lirerffita MEW
19. SAND/GRAVEL PACK 11. , licabfe
TO
ft.
/0 ft.
8 ft.
•
rrEMPLACEMENT METROD
11111111111111111111111
ft
ING LOG attach additional sheets if aeceasa
DESCRIPTION color hardneu, sall/rock pe rain size, etc.)
ke
TO
ft. ft
11111111111111111131
111111111111111
ft.
21. REMARKS
22. Certification:
r
//a
ewe
Signature of Certified Well Contractor
Date
By signing this farm, 1 hereby certi6 that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 114 NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 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 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 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells; In in 24a
above, also submit oncopy ff this form within g30 days of completthe form to thetiionsof well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suonly & IniecH 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 well construction to the county health department of the county
where constructed.
t S S� 11
cad s' /ii- cvlft 511
ry / si 6
et,
he Sao
t
H

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Well ContractoroName
(.rscrrC
NC Well Contractor Certification Number
Cascade Drilling, LP
NOV 0 4 2020
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 Weil:
Agricultural °Municipal/Public
It Geothermal (Heating/Cooling Supply) °i Residential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
!fi onitoring °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:
5a. Well.Location`: (
Ca& T q e
°Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°!Tracer
°Other (explain under #21 Remarks)
f / j'Ot I Well ID# mw 7 /
Facility/Owner Name Facility ID# if applicable)
// g //641.St O _
Physical Address, City, and Zip
Alec anap 64)
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 Temporary
7. Is this a repair to an existing well: °Yes or No
If this is a repair, fill out known well construction information and explain the nature oldie
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: r (ft.)
For multiple wells list all depths lfdlerent (example- 3Q200' and 2Q100)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
41
11. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
"C4'/C
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
N
a.
r—r r
FROM
TO
DESCRIPTION
ft.
ft.
ft. ft.
13400 titt:GASTNG (foi4raili
cased`.wellsYtilt t114tI( i€a'ii
liiii 14
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
6 lltitC:AS%NG:1QR
'UNING'(deotbe'lnal
closed loitp)
.
FROM -
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
`.'17MCRE.BN-.{,:r; , t :;:
.•
,rr t. ;:.: ,! , r' a' ..
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
Q
ft.
in.
eft.
/p®�lrJ —1.
, 44rft.
// ,,
if in
�yt %�
,V j `.'
1
SCrlf 90
//�
itiV
!8$. rl'IttlIl
5:? 15
_ .. k•: i .. ., . i
..�.. .. J
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
6 EL
6 ft.
, �7474"
¢TP.4r/4.
ft.
ft.
ft.
ft.
lLe} .. ,,:, 4.
FROM
TO
MTI IASeif
EMPLACEMENT/ OD
�/9:.SAN1.1.600:00,,A'0101Eajttitgit
J t � ft.
3 "\r eft.
isdr
r� ie
�/
/ l�f�%/�%,,,
ft.
ft.
20: 1tILIANOI
C.tn ttacli;addihoriaEtahe titi rieeedsary) .` ...•
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.j
tn ti,
ft.
ft.
ft.
ft
A 2 6 NS
21, sARIts.'t, 41� {
�Dti
Itti.,la;
,; S m,, ;oft
22. Certificatio r :
Signatur
ell Contactor
Date
By signing this form, 1 hereby certify that the well(,) was (were) constructed In accordance
with 1SA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn OW -I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

W
(ft.)
WELL CONSTRUCTION RECORD
1, Weil Contractor Information;
Well Contractor Name
`1_38
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable wall construction permits (i.e. UIC, County, State, Variance, etc.)
3. Welt Use (check
we
ll use):
Water Supply Well:
Cg Agricult'urat
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irri: ation
Non -Water Supply Well:
d Monitoring
Injection Well:
Aquifer Recharge
rt Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heatin • Coolin: Return)
4. Date Well(s) Completed:
5a. Well Location;
Facility/Owner N� m
Physical Address, City, and Zip
rMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
0Groundwater Remediation
°Salinity Barrier
Stormwater Drainage
Subsidence Control
°Tracer'
Other (ex.lain under #21 Remarks)
°°""' �/g2121?
Parcel Identification No, (PIN)
(if well field, one laulong is aufficient)
5b. Latitude and longitude in degrees minutes/seconds or decimal degrees;
gos
6. Is(are) the well(s)
'Permanent
or °Temporary
7. Is this a repair to an existing No
Ijthis is a re g well; Yes or
pair, fill out known well construction information aexplain the nature o
repair under i11I remarks section or on the back of this font.
of the
8. For GeoprobemDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW.2 is needed.
dri llod:t Indicate TOTALNUMBER of wells
9, Total well depth below land surface: ,��+
For multiple welts list all depths iifd�erant (example- 3{rt�2p0 and Xal inn)
(ft.)
10. Static water level below top of casing:
If water level is above casing, use °+
11. Borehole diameter: 6 ,
(in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
.3 b. Disinfection type:
Amount.
For Internal Use Only:
RECEIVED/NCDEQ/DWR
DESCRIPTION
75;OUTPiR`GA'5 IN: f� tiJ :C•
FROM TO .:._asa"we g
1g;"'�nft� IT
MATERIAL
EMPLACEMENTu1lETHOD & AMOUNT
n
a tacfi;addttienat sheer e�� ty� 1, f toe
ON
22. Certification:
Signature of Certified Well Contractor
By signing thisci
feral, I herebyCate
with signing
g this 01C, certify that the well(s) was (were) constructed In accordance
copy of this record has been provided to !e well owner.Well Construction Standards and that a
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 yells; Submit this form construction to the following; within 30 days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-I617
24b, F r In ection Wells:
above, also submit n coIn addition to sending the form to the address in 24a
construction to the following;
Y of this form within 30 days Y of completion of well
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water unnl�
the add er ss es ems 1 & In ectionn?� ells; In addition to sendin r the add es of wabove, also n t ittone he Doan y of this farm
g he farm to
where constructed, county health department
30 days of
pattmenf of the county
as
hardnea

WELL CONSTRUCTION RECORD (GW-1)
1, Well Contractor Information:
XC'st/ter 6Tt/Y'l3?Gj 1G►�7
Name �J
Well Contractor
NC Well Contractor Certification Number
/kep 1-6 11 , a1r,:?4,v2e,1Ia 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:
Agriculiural
Geothermal (Heating/Cooling Supply)
IndustriaUCommercial
Irrigation
Non -Water Supply WeU:
Monitoring
Injection Well:
DMunicipavPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return) �n
4. Date Well(s) Completed: (/t2/%2QPia" WeU ID# a- 4/4.
5a. Well Location:
(0/iivJ f'pc l„ie
Facility/Owner Name ,�
/3 92 r/ y71 rsu
Physical Address, City, and Zip
freckle) ytArc
County
5b. Latitude and longitude In deg
(if well.field, one lat/iong is auffioient)
Groundwater Remediation
Salinity Barrier
Stormwater Drainage
DSubsiderce Control
Tracer'
ri Other (explain under #21 Remarks)
Facility ID# (if applicable)
/ 1 r r • Con Ca'' Rd; i lt,wilt''i a'Ui4
0/7212/ _
Parcel Identification No. (PIN)
rees/minutesfseconds or decimal degrees:
6, Is(are) the well(sPermanent
t�'©• 6:0S /)
or DTemporary
7. Is this a repair to an existing welt: DYes or ,F3No
If this Is a repair, fill out know,, well construction information and explain the nature of Use
repair under #11 remarks section or on the back of this form.
8. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
Construction only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total web depth below land surface: /11E
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: t7 (in.)
12. Well construction method: ,.$cnfli �
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft,).
FOR WATER SUPPLY WELLS ONLY:
13 a. Yield (gpm)
13 b, Disinfection type:
Method of test:
Amount:
For Internal Use Only:
14. WATERZONES
FROM
ft.
ft.
TO
ff.
ft.
RECEIVED/NCDEQ/DWR
SEP' 2 02021
WOROS
REGION
DESCRDESCRIPTIONMOORESVILLE FICE
'15;?01)T);•R C SING,(foe:uidiii cased ivells)it3Ii LTNEIt (U tip Ucablo)
FROM TO DIAMETER THICKNESS MATERIAL
ft.
ft, in.
6:11NNERCASING.pR :TI•IBING,fge oth erutaLelosed-loop)
FROM TO DIAMETER
t3 rt,
ft,
27: SPRE N
FROM
TO
la".
ft.
18hGrRQTIT':
FROM
ft.
0 ft,
ft.
10 II.
ft.
Li©".
TO
ft.
ft.
ft.
ft,
DIAMETER
In,
In.
In,
In.
THICKNESS
Sc 1 YE)
SLO f SIZE
MATERIAL.
a 1104S
CCMGnt
1.9.,SAND/GRAYEL'PACK (iaapplicable)
FROM
12 ft.
ft.
TO
go ft.
ft.
MATERIAL
r))O
MATERIAL
Pv�
THICKNESS
s'ch Ya
MATERIAL
Pk;
1
EMPLACEMENT METI OD & AMOUNT
. Puvrcr� /1- eutk;:*
.77"i-enmie; / 2 - —S
EMPLACEMENT METHOD
gC4rcc1 / Vi ra'fe
20:,,rirkli %LNG IOG:,:(a(tach;additlonal'stieets.if necessary)
FROM TO
1
ft.
ft.
1l� ft,
ft.
26)
ft,
fl. L1 ft,
f1.
ft,
ft.
ft,
DESCRIP7LON (color, hardness, rolVroch type, grain size, etc.)
l/O &toum S; i& /a
fires,. f es,. da Cy 1
G-ra. 5, !g
Dark Groy 5-!f
ft.
ff: REMARB'S"
ft.
22, Certlicatlon:
Signature of Certified Well Contractor" IO/i©" 2v2
Date
By stgning this forms, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 154 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 web 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 web
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 Fragrant,
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.