Cl CY2001

WELL CONSTRUCTION RECORD 2 4 7 2 6 2
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
—ceElitt
}
WELL CONTRACTOR (INDIVIDUAL) NAME}(print) Wk.LLV& �..7 . S (; CERTIFICATION
WELL CONTRACTOR COMPANY NAME'1llE(�tes ltsU I ti ��L "� ^I U.-A NIA- PHONE :�-') SC61 -91SC
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 037/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT
est T
(Street Name,
3. OWNER:
ddress
,,pp++��pp//c�ity o own S
_ r
Zip Code
Area code- Phone number
4. DATE DRILLED 12-\ l ��
5. TOTAL DEPTH: ��'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ed
7. STATIC WATER LEVEL Below Top of Casing: `f 5b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS \ FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 5� M THOD1OF TEST
10. WATER ZONES (depth): OS
Topographic/Land setting
ORidge Mlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fo on Description
D cr
1b('
\bl' 144'
11. DISINFECTION: Type 1- A
12. CASING: II
From PfiTwo \U4' Ft. ( ier
From To Ft. ��}
From To Ft..
13. GROUT: Dep
From_ To_
FromTo Ft.
I
Amount
Wall Thickness
0r Wa�� . at 'al
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1. ki
I DO HEREBY CERTIFY THAT THIS WELL WAS CON
CONSTRUCTION STANDARDS, AND_THAT A COPY
—aa4 l40
SIGNATURE OF PERS
Submit the original to the Division of Water Qualit$', Gr
27699-1636 Phone No. [phone], within 30 days.
C4D IASI BE
$STRUCTING JHE WE
ojxndwater Section, 1636 Mail Se
GROUNDWATER SECTION
ASHE` ILLE REGIONAL OFFICE
NCAC 2C, WELL
TO THE WEL 0
2//6 /
DA
ce Center - Raleigh, NC
GW-1 REV. 07/2001

2. WELL LOCATION:
Nearest Town:
Z-i nL L CZO? \
244$08
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
g2p
�(Z.�. CERTIFICATION # O'ty I
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (� q
WELL CONTRACTOR COMPANY NAME k& tE 111 1.1— I.J E' 'L-L U. M.`j PHONE # ON) - isc
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential El Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topo hic/Land setting
❑Ridge Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
County CA -Pa
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: L4159:rniac 0-\\ 1. L52._
Address ci ' aCyr P
(Street or Route No.) o n ' 1
GA
City or Town Stn�te Zip Code
( - ?7i�''rl 't " '0h
Area code- Phone number' U l
4. DATE DRILLED J
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO lei
7. STATIC WATER LEVEL Below Top of Casing: (oU FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C .0I18.
9. YIELD (gpm): Y METHOD pF TEST La---
10. WATER ZONES (depth):Lc
11. DISINFECTION: Type Wilk
12. CASING:
C
From
From
From
13. GROUT:
From
From
Depth/
To (p(e Ft.
To Ft.
To Ft.
Depth Ma al
To�C Ft. Q0_h4, &`t'
To Ft.
Amount
Wall Thickness
Diameter Q _ 't. Material
14. SCREEN: Depth Diameter
From To Ft. in.
From_ To Ft. in.
15. SAND/GRAVEL PACK:
Depth
To Ft.
To t.
Slot Size
in.
in.
Material
From
From
Size Material
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DLUNG
Fo aio, D tion
pEPTH
From To
b ‘51
ry
C
C)
rn CD
c� c_
LOCATION SKETCH $ 7
Show direction and distance in miles from at least ,
two State Roads or County Roads. Include the maad c)
numbers and common road names. 43p"_ 3{ow
le
cv-crA m1/441/2
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A CQEY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL 0'
r' t /4 P C
SGN TURE OF PERSON CONSTRUCTING THE WELL
DA
GROUNDWgERSECTION
ASHEVP_LE REGIONAL OFFICE
u nut the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
2

IDO
CON
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and \Natural Resources - Division
noo{fyWater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) - rW\Ui. lt\'\ S. �r/-r1-I�t� CERTIFICATION
�pcp'Per3g
WELL CONTRACTOR COMPANY NAME ES Skt--LEw) 2 (t-a--L-. NSCl PHONE # SD `-_` f cc -
STATE WELL CONSTRUCTION PERMIT./ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
244803
1. WELL USE (Check Applicable Box): Residential L9" Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest Town:
3. OWNER:
Address
(Street or Route No.)
City or Town State
Area code- Phone number
4. DATE DRILLED \�\c& DI
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO le
7. STATIC WATER LEVEL Below Top of Casing: '-ice FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 1C .0118.
9. YIELD (gpm): as) METHOD QF TEST Wta--
10. WATER ZONES (depth): \ 5S
11. DISINFECTION: Type WTAA Amount
12. CASING: Wall Thickness
Depth titer or Weight/Ft. 'at al
From 0 To � Ft. ld `t .c t9 v "�
From To Ft.
From To Ft.
13. GROUT: Depth
From (7 To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
nevi,
I
L',
Zip Code
FE
16. mi/mcS:
ERE1 Y CERTIFY THAT THIS LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Material
Material
Top° c/Land setting
❑Ridge Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fo ion Description
DEPTH
From Toni
SeeU64-'
IV
LOCATION SKETCH S
Show direction and distance in miles from at ]pest
two State Roads or County Roads. Include theimad
numbers and common road names. •f
...ICC-C(5X E
.64 ' EEftStiN
Imo_:S `',J. f ._.i F ;c
TRUCtfje?J-,,S A {BARD$;, AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL 0
Sty ( s/�S�o I
SIGNATURE OF PERSON CONSTRU HE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

244805
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
`� Resources'��- vi��siionnn of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CLK 7 (r
WELL CONTRACTOR COMPANY NAME
` \ ` L-I _- IC . 1 f CERTIFICATION/�# d l J I
_VO �� IRA L� 4cs,HONE #Iyr-ot 9155
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nea t Town: t(L�t County 0—UR"(
r u E �WUI✓
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: €Y'r\ N s\cm
Address 'AND C.?7DX Sly
(Street or ute No.)
�Pc`i�11uk
b
cCity or Town State Zip Code
fl%l
)" CC ~
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: ..,
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO lEr/
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordan with ISA NCAC 2C .0118.
9. YIELD (gpm): METH D OO TEST \ci1V1..—
10. WATER ZONES (depth): Boto
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth Di peter 'AR-et/
Weight/Ft.,,�/Material
From O To . Ft. '-1 `t AR-e t/• P 9 '
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To Ft
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Slot Size Material
in.
in.
From To Ft.
From To Ft.
,1 I
I''
TopogrOhic/Land setting
❑Ridge BS1ope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To Formati
LOCATION SKETCH F
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
-Jsxf 1(yC
I
HEREBY CERTIFY THAT TijIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Ii NIR11CTION SP((J{b S{ THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEI.F.0
Can V // i �/(P
SIGNATURE OF PERSON CONSTRUCTING THE WELL
GROUNDWATER SECTION
ASHEVILLE REGIONAL OFFICE
sunmlt the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
r1nWN111r ON

244.806
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectiono�j
WELL CONTRACTOR (INDIVIDUAL) NAME,, (print) \fJ LLI14-EV\ EKED CERTIFICATION # Yin
WELL CONTRACTOR COMPANY NAME k - Vl u-E \ JEU-1Q LU--L L1L PHONE # (TO) c1.93 —II SS —
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential HV Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIOON%��`L��.
Neares� Town: County
'll)tt< LbtT�
CLict•f
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER: K ( QM
Address " C,Q \\ Mt? Q)*b
(Street or Route No.)
`t€ AuaJ ii� c sc
City or Town_ is.StateZip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES II NO El"
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of cuing terminated at/or below land surface requires a
variance hi accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): aS METHOD OF TESTl'2-
10. WATER ZONES (depth): 11,1
11. DISINFECTION: Type V Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. �M1 nal
From D ToAS_ Ft. %14" S'l\LFZZ.t9 VU(
From To Ft.
From To Ft.
13. GROUT: Depth
From I To Licsio Fts`o
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Matfrial Metho
Slot Size
in.
in.
Material
From To Ft.
From To Ft.
r)`'I;L
OO HEREBY LER'111.TMTTITH)6 WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ONSTRUCTION STANDARDS, sit1`(D THAT A COPY OF THIS REC RD HAS BEEN PROVIDED TO THE L 0 R
�dAl
7001 12) S � jan,,,® /� /- D/
SIGNATURE OF PERSON CONS G THE WELL D TE
Topographic/Land setting
❑Ridge ❑Slope IB4alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH WILLING LOG
From To , Fo ion Description
rJ/ t
c
c7
0
fV
LOCATION SKETCH
Show direction and distance in miles from at lest
two State Roads or County Roads. Include'theffd
numbers and common road names. !
GRQUNCWPJER SECTION
*Wilt Shp 61EinattotheDivision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
c-
-17 c.3
cn.
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0

North Carolina • Department of Environment and Natural Resource - Division of Water Duality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] /� / A I7- (1'$
WELL CONSTRUCTION RECORD WELL CONTRACTOR- ( )IP OK4Q Lue.l1 j Rit�►14.:
WELL CONTRACTOR CERTIFICATION It: ). G S� J
STATE WELL CONSTRUCTION PERMIT":
1. WELL USE (Check Applicable Box): Residential [31 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other D If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: BRASS Tb Let n% County
(-Pea Gee k
(Road Name and Numbers ommun/ily, or Subdivision and Lot No.)
3. OWNER FAMES ! Qa..1E SE)I.I S
Copy
Address i 9 (a(jp�¢S" Gap12k RD
""(`S�reel or Ro e l
BR4SSTok7nl /J C 239o2
City or Town / _ State Zip Code
4. DATE DRILLED < 2 -5 -0
5. TOTAL DEPTH •• Y l '
6. CUTTINGS COLLECTED YES NOD--
7. DOES WELL REPLACE EXISTING WELL? YES n NOET
6. STATIC WATER LEVEL Below Top of Casing: t7' FT.
(Use •+ It Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top or casing terminated sUor below land surface requires s variance In accor-
dance with 1SA NCAC 2C .9118
10. YIELD (gpm): b METHOD pF TEST /%' lei
11. WATER ZONES (depth): `2 0C -2/o'
DRILLING LOG DEPTH
From To Formation Description
. D ' J.. 5c7 C93•'D
)ZV .7y2• 19-7e_
12. CHLORINATION: Type /777/y Amount 4- G v/ If additional space Is needed use back of lorm
13. CASING:
Depth Diameter
From d To 23- Ft 6i
From To Ft.
From To Ft
14. GROUT:
Wall Thickness
or Welyht. Material
vc
Depth Material Method
From C To •\D' Ft
From 1.0 To / kC Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft in In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
I DO HEII4B
CONSTR
FOR OFFItEilSE ONLY
Ouad No:
Serial No
Size
FI
Ft
Material
Material
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
CER ,j rr;
TOY T4ATI4HISwatt I 10 ONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
bN STANDARDS, AND THAT A C r PY a THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3-
CONSTRUCTING THE WELL DATE
Wit aurally, Oroundwawr Section within 30 days
OW -I REV. 12/99

I 1 Envlronmani and Ilatur nl Pesourco, - (11vIelorl of Waler Duality • (bound cantor Section
WELL C011NIAC1OTI `%/'h��BQa_-���/
WELL CON MAC 1011 CEI111FICA11O11 11: U9
sTAT E WELL CONS1IIUCTION pEDMIIII!
Indushlal U Agrlculwral U
1. WELL USE (check Applicable noel: 11osldonllallll Municipal UII Olher, std Use:
rlecovory rl Heal Pump Water 'l ocllo', Li U
2. WELL LOCATION: (Show skolch of Iho locallun below')) nty. ��G`
Itearesl lawn: ar PS'
----- -----
ploaA Ilmne end Mohan. Couv14 n^ay, or Subdivision and Lai Ito
a OWNED
Address
North Carolina
- e Centrnen o -
1636 Mail Service Carver - naleigb, N.C. 2 T699.1636 r'hona (919) 733.322
1
WELL CONSTRUCTION RECORD
1
ISIiii131 noula 1161
— S
COy nr low++ lab;
4. DA' E OnIL1.ED 1224� �f
5. 1OIALDEP111 U7`J
6. CUTTINGS COLLECTED YVS 1—I 1101:4- __
I10
7, DOES WELL nEPV\CE EXISTING WELL? YES II-1 __
B. STATIC WA1 Ell LEVEL Dolow Top ol Casing: _-5p'__,.El.
(Use '•• 11 Above lop al Ce sh'01
g. TOP or CASING IS__-__-
I'L. Above Land Sutlace•
•lnp of cednp terminated it/or below land surface requires a valance In accor-
dance will' ISA IICAC 2C .0110
10. YIELD (gpr11): —L- MEI HOD OF TEST 122
11. WAIEn ZONES (depth):
12. CI ILOflINAI ION: l ypo
13. CASING:
S. Arnow II
Depth Ulamelor
HOW _2io 1.2":2--f rL
Prom 780 lO— rl.
From 113 FI.---
1E. CHOW:
\'hell llddnees
or Welghurt. Maledal
Depth
nodal
Flom To - -r-rl. n rf7r*
now lO PI. — —
15. SCnEEII:
rlolil 10
Ilom To
Flom To
16. SANDIOfAVEL
Depth Ulaniolor Slol Size
In _— In.
D
Front
Ftorn
17. F1EMALKS:
117011E11E0Y CE IIPY $
cousinucllotl. • -
IF0110FPICE USE ONLY
Quad Ito:
rt
p(.-___ In. In. -
II. In. ____- In. -
it
rt. lit
-
PA oil ad
IA: todal
dal
_MILLING LOG
Elam to
244815
IAonllorirg U
D=7111_
// ronr,:nr Oe'srripon-
1B r �l
agr
272p / _a
II additional S,^a ee is tneerf rat irse Irac: of If+n
LOCAI10NSKEICH Stall
direction gild distance Iran 21 Ina leo
Floods, or other relen:Ce Polon`
'Br r uclED III ACCOrnontcm With isA rlcnC r. vita
Ills DECOr10 11AS DEEP' PfovlcED 10111E 7I_e L OW EP.
SOW ME or rrn9011 c(XlSiIItY.IVIo U c vv El I.
oa -:
suts1111 odflml to Divldon of Wale pudliy oneurx.vo. &eeen wiU do YJ Ga y 1
tn.' Fig V. I`11
It]

Department of Environment and tiaiurel Ilesourcne • Mlvl+Ion of Wain( Mutiny • (luoundwatnr Section
WELL CONSTRUCTION RECORD
North Cement •
1636 I.Iafl Service Censer • nalelph, N.C. 27699.1636.I'hono [phone]
WELL CON IIAC101I: ��-
WELL Coll MAC Ion CEI1TIrnCAlloll
SIAlE WELL CONS11,1IC110I1 PEIIIAIin
btduorlal I-1 Agricultural U
1, WELL USE (Chuck Applicable PDX» Nesldenllal ft Municipal U
flecovory Ft fleas Puny Water Injection ❑ Other [I II Oilier, List Use:
2. WELL LOCATION: (Show sketch of Via location belo(�ulny.
Ilearesl Town:
(00,d!Wrier and numbers. Convnunliy. orSubdivision on and Lul Ilu
3. OwttEn ;
Address
244814
City or 7ow+t
4. DATE UnhLLE(..2--D/
5. 1O1Al. DEPTII Z-
tSi
5. CUTTINGS COLLECTED YVSLTA fi0u[— IlU _
7, DOES WELL nEPLACE EXISTING WELL? YES l_I CI I_ --
O. STAT ICWA]Eli LEVEL Below Top ofCnsing: __'j2__.
IUse •t' II Above Top of Caslnp)
1"r. Above Land Sullaco'
9. 10P OF CASING IS �— ___
•7op of eating blndndad uUor below land tudece requital a valance In actor•
dance with ISA IICAC 2C.011e h1CTN0U OF TEST ,a,�/�
10. YIELD (9Pr'I): -�--
11. WAl En ZONES (depth):
Zip Code
(MILLING LUG
from In
15tie"ororM5ult 1W,
Slate
12. CIII.ONINA1ION: Typo
13. CASING:
Ammo ni
\7all IlarLnest
Depth Ularnetor or WelphWrt. Material
Et ow _—To --- ri.lv�J - �_
to rt.
Ft.
From
From to
14. GrIOUi: Material Method
DepthFlom_ To 020 ri.�af1
Front To rt.—_------ ----
15. SCREEII: 1A;,lodal
Ulamolot 13101 Size
In. In.
From
In.
Rein
Eton'
16. SANDIG
Flom
Flom
17. nEh1Ar1kr. i iELI
N7WP7EH SzCTION
DO IIEOIEO]'--L II ' naitiA9 (`(1riSI11UCito RI ACCorn:ismE vont ISA r cn.c rt. ii
CON51nUC110N STANDAUDS. AND 11IAT A COPY OF 1111S IIECOUD 11AS UEEII rn0NCEM 101ile-'7� =L ChnEF.
Volt OFFICE USE ONLY
Quid tie:
Depth
10
To
rl
El.
In.
In.
Malarial
IAonllortcg li
?III__.
for ru:tlr Ur stripy, -
II additional Brace 1s neeer l us., back of l irn
LOCH I ION SKc I C11_
(Show direction and dYs'anre l'arl zl Inat::-o `U111
floods, or other n<7 reletuce porno!
pill Size
To rt.
O_
0
rn
c)
-J
-s
r
J
o=off- 0-�
oe � t
f SIOIIAIUIIE or PrnrOli CoflSI11U '1110 t,c wtl (.
Submit oiI Inil to Divlilon of WValer Ouallty. grovnd.ettl stan rviAlln Y) C-a y5 t: tt
n.I FiE Y. I

Northonment and
636 a I Services Cenlere Rniel911,1iN.e. 2T699.1f 636 r1''1tonn ol
° [phone]
1H
WELL CONSTRUCTION RECORD wri L CUIIIIIAU
1. WELL USE (check
recovery ❑
2. WELL LOCA110N:
Nearest town:
plead II1
I
3. OWPIEll
Address ___/
Wain' Duality - (bound now Section
1 oil: _�/i_li�/el1__, e////
Ton cEI111FICA1101I fl:
sIAIE WELL CONS1IltJCTIOII PEW
Induslilal El A9
pen
IIculWral [� tAonlimicg U
leaf utlip ): Water
irij nlliollal Li p11 opal UII Other, List Use:
leaf pump Water In)ocllon L_I Li
244811
(Show skolch of the locallon below)
County
trolly, or Su idly lion end Lot I l0 1
_- -or - y�3D
(5haorn ul--Ito`.)
•
Zip Coda
Clly of town
Stale
4. DAlEUnILLEo/2_t:27Q/
5. 101ALDEP111-/
6. CUTTINGS COLLEC1 ED Y S L_I HOLLY __
7. DOES WELL nEPLACE EXIS I NO WELL? ? YES
IA 11017 --
B. STA1IC WA1 En LEVEL Dolow Top el Cnslog: _50__.171.
(U+e •I' II Above lop ol Cs sin)
P. lOP Or CASING IS_ 1_ rr. Above mead SUIIPCe'
'Top al casino i,rodn.led it/or below land suffice requires erv.d.nce In accor-
10. YIELD (gum): �- . ME I HOD OF TEST dance with 151( IlCAC 2C .011E
11. WAIEn ZONES (depth):
12. CI ILOnINA] ION: 1 ypo
13. CASING:
Amount
wall 1 lilt- ;Me II
Ueplll
Ulametor or We< V�. 1.1ale'lal
Flom �To�`—�r1.LR� �
From
to FI.
Flelli
to FL —
14. GITOUT: Mal dal t.lulhod
Depth r n �/ l
rlorn To rt. P--
lo Ft.
rowl _
15. SC lEEII:
From
Flom
horn
horn
16. SANDIOI
Depth
To_
To.
From
From
17. fEMAUKS.
1 DO I IEItES
cONSinuc
IFUII OFFICE USE ONLY
Oued Ito:
Diameter
Ft _—
Fl. __—
0
In.
In.
5101 Site IA:lloltal
_ In.
In.
IAalollal
UfIILLING LUG
(nom 9la
A11n
__MEP II ---
romp, Ue2c dpfin'
II nddldonal scare is or rrr7 es -sr list's ol lvrn
-- LOGA)IOIJ SK E ICI1_
(Show direction Cr'] des-:nrlse ban El Ina:: ieo
Mood'. or other n2p relert rC2 points!
ca
CEI�1 Tf1:116W
) s111UC1EUIII ACCOn07ice nlsA PICK y �L
iTUATIDSAIJU1HAT A COPY or IIS f1ECOf1D IIAS OEEN pHOME O 10 1OI1tiEF..
7 SIOIIA1UnE or ocoo6I111Y=IIIIO11t-ryl.,lddn!OG�ys
Sub1Jl o'I lnel to Uivhlan of haler Oudlry, 0•oun fie er
SeanFIEv. t_n
i
O
P1
N
J
-D
3G
r
J
•

I Environment end (Jaime! nesourcns • Divlelon of Water Quality • Ground Miter Section
00
WELL CONSTRUCTION RECORD 1 TIIT1inCTOm %7
EII
Ilorlh Carolina - De enter N o N.C.1636 Mail Service Center • nalelph, .C, 27699.1636 Phone [phone]
writ. C( • --- "WELL 00111IIAC I Oil CEI11 IFiCAl1011 tr: -f
SIAlEWELL. CONSINUC11011P I.4111N __ ----
Induslrlall I A9
icuhural U I4onllortrg U
I, WELL USE (chick Aporlcebie nor)' NesldonllallYY �dton opal UII Other, I_Isl Use:
hecovory U I teal Pump Water InIecilon U l l
II blw)
2.
WELL LOCAT I N: (f how sketch of Illo to ° County. e -._ --
Nea'est Town:
--
NULLING LOG I l r;v';
nnto ponud i
IgFIEcred Italic and Duo on. Convnu rhy, or SuhdlvlsloJn end lit No I -- non ��rory rr e /
3. OWNER ----
Address _--j� ---
(5iiiof of rl"olio Ito.)
—'— -----Stale
City cr Town
A. UALE DRILLED 3 O
5. 101AL DEPTI I /�.L.
6. DOES WGUI-TINOS CREPLACE EXIS I •iG Ill v sU llO1j
7, DOES WELL Casing: •0
b. STA71C WATER LEVEL Below -(e°I ell Above lep el Catlnol
9.
TOP OF CASING rf. Above Lend Sutinco'
'lop of eaahip br min algid aVor below land audeee requires �rvnle ice Iv acorn. --
dance with ISA IICAC 2C A11a
10. YIELD Wont— MEI HOD OF TEST
11. WATER ZOI IES (dep111):
12. CIILOnlNA1ION: typo
13. CASING:
14
from
From
15. SCIIEEII:
from
Rom
r tom
16. SAND/Olin
ROM
From
17. REMARKS:
-- ul II ndn
deloal race is mire d rrse bit of Iv+n
A1110l1111 � --'— -- --
-- LOCA.IIONSKE IEli
(Slow direcilon end dts'ance h:rn al Inatibieo
Donde. or aver rr 2 relent -tee poL,u!
Depthh1nturial ldulloti
__C-'—To �—
110 II
Ulamolnr Slot Site IAalodal
Depth 61.
to FI In.
rt._ Ill.__-—•'�n.._—
To In. n.
Size .. ' I�ialorinl
244825
t}EE
Tf1ND11
STANDARDS, AND 11IAT A COPY or 11115 IIECOrID I IAS bEEI
nil C(NISIIIl/CiIIlO Ut w %�
FOR OFFICE USE DNLY SIOIIAriAIE or TEit %-�dh b�Wrlde.ele' Saprn wldlln'.'J C v�
Omdllo: IJI e�I Ind IO Uivirion el Water Ou y Fn,i ft��
I DO IIEREOY
CONS1UUC11011
From-
Fronl.
From
GI10UT:
—_ 1 o ie22/ F--I.--
to Fl.
10 Ft.
\'tall Ihtrineee 1lalt dal
Depth Diameter or .wf 4u�ri. ,1_•',l
rt
r-1.
r1.
.LL 9 CONS I NUCIEU RI ACCONONICi With
isA U 710 Cr..'''�LQ1 n/
C
0
rt
Jn
zm
Cr_
>c
rn
mC
<Am
rnz
rrl
I — I I n
SuW p

1 Environment rind flakes?Ilesoorcns - Division of Water Ounlily - Ground writer Section
North Cnlollna - Department o
1636 Mail Service Center - Naielph, N.C. 27699.1636 Phone (919) 731'9221
WELL CONSTRUCTION RECORD WELL Cori (mown!
L Coll MAC IOil cEllTlrrcATlollI!:,
SI'AlE WELL CONS1Nl1011011 PENIAt19:
(nduslllal ❑ Agricultural U Monllorirg U
1, WELL USE (Check Ae al rump
p e Injectal or, Li municipal l I II Oilier, List Use:
flecovory ❑ Heal rump Water Injection LI LJ
2. WELL LOCATION: (Show sketch of the location belo`')piiiilY.
Nearest lawn:
mead Igme and !lumber,. Coles malty, or Subdivision and lot lin I
3. oWNEll -
Address
244827
(Sliest oT rlouln Ito`.(
Cnda
Slate
4, DATE [MILLED 1I002
5. 1OTALDEP111 ___
6. CU(TIIIOS COLLECTED YI'S _ i 1ICU 7. DOES WELL REPLACE EXISI IWG WEI L7 YES
_
D. SLA110 WAl EN LEVEL Below Top of Cnsing: ��
luse's' li Above lop of Casino} 9. TOP OF CASING IS L_ rr. Above Lond Stelaca' —
•Top of casino brndnalnd atror below land surface requires I variance In actor-
dance with ISA IICAC 2C .0115
10. YIELD (gpm): - MEI110D OF TEST --- —
1 1. WAl ED Z01lES (depth):
//
(MILLI! IG LOG DF.7111_
on-A:en Lie scriptln
r torn 10
—_S
r— a� —
City or lows
12. CI IL0711NA1 ION: 11'pe
13. CASINO:
Antolini
Wall Ihlrirress
Depth Ulan'olor, or W1 h0/rt. Material
/ �_ 7 Fl✓
Flent�—Te n.
flour
to VI. —
Elvin to Ft.
14. G110U1: Ma dal tdullmd
e,et
norm, To .8�-FI.
From _L2—
From _ 1v rt. _ ______
15. SCFIEEII: Maloilal
Depot Diameter Slot Slro
From To_Ft_ In — In.
�_
r"Ivm 10- 10C—L. II.
i
I n.
From ��.�--fit. 'III_.— j \�!1
16. SANDIGHA l PACT.-- I Slre;. , �J alorlal
noun
Front To rr_
SL iION
17. REtdADI<S: C�' ip .'�`II
L 1 iEll
CONS1 NUC110t1 SIAM/ADDS, AND MAT A COPY OF 11115 TIECor1D I IAS PEEN PNOVICEO 70111E WELL (>0E11
I DOIIEPEDY CEHIIrY MAT 1111S WELL WAS COtISIr1UCIEOIII ACCOr10A710E WITH isA I CAC -. /
II additional SraC t is rscoCri is -se bac; of Ic nr
LOC.AIIOIJ_SY,=-iCl
(Slow direclion and destance tram art Inav!wo c?,nie
Ilondl. or other rr27 teieleree points'
O
O
rn
PO
J
0
v
CD
0<
Do
rnG
rn
�z
m�
-1
0
IF011DFPICEUSEUNLY
De
SIUIIAIUnEorPE117011carsttt tlt10u<'rftl-
ova()No: SubiJl odQAtil to Division?' 5Vtler Gullet O'°vn`7"etel Sacco wlUdn :0 C%rYd r11.1 Fie V. 1`T1

Depth
North Cer Service • 0Cenlment of o BEnvironment an tNeat Phone t (tacn • Di1vision of Water Quality • (boundvnolnr Section
1636
er
21
WELL CONSTRUCTION FIECORU Wl!LLCON111AC10f10Elltlrl lorin:,
s[All WELL CONS]IIUCTI011 PEI1M11/I:
1. WELL USE (Check
flecovory ❑
2. WELL LOCATIOf1:
Nearest lawn:
Applicable e°*)° Nesldanllal Ek_ Municipal it Other, List Use: UInJustdal U
Flaal Pump Water In)acllon L I rU
(Show sketch of Ilse locallon below) Countya/
'Flood Ilene enriddor 3
. n anvun0y _ Of SuUJlvlsron Our Lul Un 1
3. OWPIER
Address
City 0 Town
4. DATE DRILLED //-%- _-
F. CUTTINGS COLLECTED Y{'S El IIOIW__ FIOP .—
7. DOES WELL REPLACE EXISIING WELL'? YES e; Ff. _
D. S TAT IC WAl ER LEVEL Below I(Useobop l lve, lop of Ca 'In01
g. lOP OF CASINO IS_1"f. Above Land Surlaco'
__1_--
I et/or below land eudece requite+. vul.nce In eccor
ZIP Cudn
'Tort of too
dance with 1Se IICAC 2C .011E
IU.YIELD (gprn): l5 _ MEI HOD or TEST
11. WATER ZONES (depth):
/ y - Amount .
12. CIILORINAIIvrJ: 1YPe
13. CASING:
ISIieal of I1o`u1n IIo`.(
Stale
Wall Idcsneu
Depth ValuatorlGGar °rWer b1a
ienni
glom—fl—lo.l2L— F
rrom To--- 11. —
From 10 Ft.---- -
14. GROUC Malotl,_al MomoJ
I)oplb '��_
Prom _s'L To fl.t - —
Plom 10 _____rl / -- .
15. SCf1EE11:
Diameter Slot 51zo Malallal
To _— El _-- In. In. -
rlolll fill _T.—T-�.�
1"tom --- To _��- i P^v�
Th I"i.�-' III --h
I'IOfll -1r
t.
16. SANDIGRAVEL P t
1
D
!!IASize fhli 1.I
clam 1po[: ( L: f
I
rt. 1 —
non T° � , SEC � i‘''
17. REMAnus: 1 rEll
�CACrr fill Er.
I COIISIRUC110N SIWY 111AT TAN DARDS IAND 11IAT 11S WELL A COPY lorS I lII IIS RECORO IIIOC I EC It I ns DEE11 PROVIL O ! 01IIE -.'/
Ovid OOPICE USE ONLY SIONATUIIE or rrns011 C(xlS111110111101 rv'ElI
Qved No:Submit odVlnr Io Civilian of Winer thorny, Urowdr+ru Seem riltin:0 CS YE Ce 1 FIE V. I: n
Ul11LLIIiG LOG
tram to
Agilcullural Li
822
)nonllork g I__I
11E7111_ ..__
r onFsior Uesc^ptirc
II additional watts Is needed trss back of 1 ire
LOCATION SKE I CI I
(Slow dlrecllon end d>stance Lan al to as:.wo �'n I
floods, or other r, 2 relererr> poled!
0
0
r*1
C)
IV
-J
"o
7C
J

Wall IlJrsoees aAatedat
Deplli °leerier or Welphll t.
rime
to rl.
r tom to rl.---
14. UMW: Material t+iulhod
Depth
From —'To ri.740-1"-e' --
1a _--rlDepth . — —_
ITIatrIelor Slot Size Malarial
to
Fl
ICI(:
lot FI.
To
In.
tu
J
P. SEGTI0
North Cer tine - oCenlerent of Environm oil en 1fGraaiul i e (u:ce • Div221n ol Water Duality • MLoundtinier S,tiion
Ser
e
•
ok N.C.
WELL CONSTRUCTION RECORD WELL COIII11AC10110E1111riCAlloll fl: 24f21:_LL
slAIE WELL. CONsititiC1loll PERMIT/! _____ ----_____
.244823
1 WELL USE (cheek Applicable
B ) N_I� Municipalesldenllal(U
Indus!' la! ❑ A9
lcuiiural U IAonliorirg U
oa
flilea'
ecovory U Heal Pump Water In)oclloli Li oilier 1-1 II Other, List Use:
2. WELL LOCAL IQj4: (Show skolch of Pio locallun below) n/l��
flearesl Town: ' L
LLB ,
Woad llama end howbeit Canvuunny, or SubIri vision end Lnl Ito i rio�n l o
3. OWNEn ��v - r.,.�.-y Oy-' S
Address
_ ©r
Q
Oral oi n-oulo Ilo`.I
-----Sills
City or Town
4, DA1E (NULLED
5. TOTAL DEP111 aim+ 6. CUTTINGS COLLEC1ED Y( ;S I I IJO 1__ IIU _
7, DOES WELL nEPLACE EXISIIIJG WELL? YES I —I r 1-1L '--
B. STATIC WATEU LEVEL Below Top of Closing: __S�1__,.
(Use •s' It Above lop ol Caslnul
g. 1 OP or CASING IS _ �— rr. Abovo Lnnd Sullnco'
top ol cm bop 'motivated eVer below land audaca requires I violence In ceaer-
danee with 15A IICAC 2C .011E
10. YIELD (gPf11): ME1110D or TEST A+Z---- .
11. WAI EU ZOIIES (depth): 12. CIILORINA1ION: 15po------
13. CASING:
UIIILLIIJG LUG
---Zip curio
15
rtom
SCHEEII:
rigor
1 Ig111
Flom
16. SANDIGUAV
room
From �r IIIVJ
17. REMIAUK5:
1 D011E11EBY CEnitrY MAT 1111S WELL WAS I:0115111UC1EU IN ACCONONICE YJ111115A NCAC r_.
COI ISInUCI oti STANDADUS, AND MAT A COPY or 1I ITS IlEC011D IlAS DEEII PnoVICED 10111E 71 at' L Ow:rEE
IP D. `
lie:
ICE USE ONLY
stollA1U1iE or rpn6011 carstl; win u< VV'E
Quad Ho: 1 Suborn oilglnil to Uivldon of Wider oudhr, Orounoratel 5.a^ yillliin '_J CY1
.n.IY. Ltt
�I JIIl
A tonal
DEPIII _----
roma:ul Vesalplin-
II nddelonal e:^ace is t rreed ors^ bar of Ivm
LOCAI ION_SK-.(CI1-
(Show direction sod d s trice ban a1 loas•!+ro Flab!
Bonds. or other ri 7 relerrze points'
-o
.4
J
•

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater�eSection
W
WELL CONTRACTOR (INDIVIDUAL) NAME (print) l�(�m 1'U� .T M � PeTh HONE #CIA ION fOcl
—5 35�
WELL CONTRACTOR COMPANY NAME r-t-fF 1uC -`t 2—
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential C' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
p�\'� ftS-\JICounty
(Street Name, Nu naers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: a' kSC'- ((bl\J —
Address &55- C-T`r E L>��5
(Street or Route No.)
ppC��rTity or — State Zip Code
en
Area code- Phone number 1 `'
4. DATE DRILLED 1\ , t- O 1
5. TOTAL DEPTH: \ '
6 DOES WELL REPLACE EXISTING WELL? YES 0 NO Ei
Topographic/Laa'''n'',settin
4 g
❑Ridge ❑Slope MValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/Minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
`l'
lb'
?apt ln`b'
(off' 1 tk'5'
7. STATIC WATER LEVEL Below Top of Casing: b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 15- METHOD OF TEST WM-
10. WATER ZONES (depth): 1 Zi
11. DISINFECTION: Type \--VOA
12. CASING:
Depth
Fro % To nt l 11
From To
From To
13. GROUT: Depth
From C> To n
Di eter
Ft.
Ft.
Ft.
Mat al
Ft.Q.
DEPTH
From
n'
lb'
244807
rri o
tV r
J rrc
cnz
Amount
Show direction and distance in miles from at€ast
Wall Thickness
two State Roads or County Roads. Include thRoad
o r Vygght/Ft. t_tteria(... numbers and commonroad names. J z
�i401f
Method
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
rr,
A(St
Size Material
LOCATION SKETCH
Pan, I
CJ Ca
N
HEREBY CER11FY THAT
TRUQTIQN STANDS,
LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL 0'
OF PERSON CONST/ZUCTING THE WELL
DA'
r
`it -the origlnattothe- MUT-Oh
27699-1636 Phone No. [phone],
orWater Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 2 4 4 8 0 4
North Carolina - Department of Environment and Natural Resources - Divisionof
oof Water Quality - Groundwater Section �j
WELL CONTRACTOR (INDIVIDUAL) NAME(mint)\.Wu�..1141\1' S . l �-��� ,S CERTIFICATION # NO
WELL CONTRACTOR COMPANY NAME l \ nriR�LuCSv c W ELF— LL—I. IIC., PHONE # ) mJ�'c�1 1SC
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential lEMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Neare t Town: iE t 1 t County 0-UM
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: E -'611E.
Address -V7 •X aS
Zet(GS.11 (r n ue Street ))-%C(�
City or own State Zip Code
( - --19Uo(e
Area coda Phone number
4. DATE DRILLED 1�15 D1
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO H
7. STATIC WATER LEVEL Below Top of Casing: ' b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ` FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 1 METHOD OF TEST 1419..
10. WATER ZONES (depth): Cg 0 /
5. TOTAL DEPTH: \ rl
11. DISINFECTION: Type
12. CASING:
Di eter
From 0 To �a). Ft. 10 L("
From To Ft.
From
13. GROUT:
From U
From
To Ft.
Depth Mat nal
To 6D, Ft
To Ft.
Depth
Amount
Wall Thickness
or Weigbt/Ft. Material
"Sian-7 4, VVC .
14. SCREEN: Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Ht.RLBY t,EK I fFY
NSTRUCTION STANDARL 8
‘11';- 7 2002
SIG
/T'opographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Forma on Description
15
lS' Sl'
Sit k VA'
O
0
171
n
or'
LOCATIONSKETC$
rrl
• Cr: It
• m :o
Show direction and distance in miles from atteast
two State Roads or County Roads. Include thTioad2
numbers and common road names. S 1
WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
ATURE OF PERSON CONSTRUCTING THE WELL
DA
S GRO JD Vq lac TTlltn�vision of Water Quality,Groundwater Section,1636MallServiceCenter-Ralei h, NC
R4 i 4togT104E� g
27699-1636 Phone No. (919)7JrJ111, within 30 days. GW-1 REV. 07/2001

From
14. GROUT:
From
From
15. SCREEN
Front
From
From
16. SAND/GRA
From
From
17. REMARKS
North Ceroprle • Department of Environment and Natural Ilesourcee . Division of Water Quality Oround tinter Section
1636 Mail Service Center • Floleiph, N.C. 27699.1636-Pho a [phone]
WELL CONSTRUCTION RECORD WELL CONTNACTOII! l EnTirFf Sn i IJ ttt P, C/o 1: n�
STAKE WELL CONSTIIUCTIOII PERMITIN
1. WELL USE (Check Applicable Boa): Resldenllal (a.-- Municipal ❑ Industrial ❑
Recovory ❑ Heat Pump Water Injection ❑ Oihor El II Oilier, List Use:
2. WELL LOCAT14N:
Nearest lawn:
3.
(Show sketch of the location below) I I
County: CIe(\
i noad !lime l/ e'�e suntan. C unwell y or dlvlslpn end Lot Ilu.)
' %D i J
OWNER �,
Address
jSli-eof of Boula Noo
City or "(oval �, �� ��Sttate
A DATE DRILLED re_R � O
101ALDEPTII
5 !J
IIJGS COLLECTED VIES Cl NOD
Zip Coda
DRILLING LOG
From To
2421301
Agrlcuiiural ❑ IAonitorirg El
6. CUTT
7 DOGS WELL REPUSCE EXISTING WELL? YES I I FWI
6. STAIIC WAT ER LEVEL Below Top of Casing:
(Use II Above lop of Casing)
9. TOP OF CASING IS _ FT. Above t.mld Surinco•
'Top of cm shop lerminaled ,Uor below land eurlace requires a variance In actor
dance wlih ISA MAC 2C.0116
10. YIELD (gpm):— METHOD OF TEST : IZ
I I. WATER ZONES (deplll):
12. CIILOf11NATION: TypoAmount
cd
13. CASING:
\Nall lhtrlmees
Depth Diameter or WalphUrt. Material
r
Flom_-�2---To R. �.Q'—. �."—
From 10 Ft
10 Ft.
Depth Material ) Method
To _g_1(2±PL
10 FI
Depth Ulanlelor Slot She Material
To ____ Ft in. _— in.
To -- Ft.
DEPTH
ronr.roi BexripGn-
qll' n ITS
II additional srrace is needed r_-se bad of lvrn --
LOCH!
(Show direction gird distance ban 21 Inas• ho S'-oie
O
Ponds, or other relervOe Points) C:, Cr.)
C7 277.1
I 2r2
Cr
n
a
Cn (n
n�
-y
w s
GROUNO\ •/', `TONAL OFFICE
IDOSRECY A
CI
"' • .e STFIUEDiHACCORDAMICEWITH 1SA rJencr.,v/ELL
CONSTRUC110N STNDANOS, ANQ TI TAT A 'OPY or 1111S RECORD I IAS BEER PRONGED 10 THE YI' _L. � �P..
F011 OFFICE USE WILY
Clued Ito:
SIONATUIIE PE116011COISSIIIIY:11110ii yv'EIL
SubnJl odpinal to Division of Water Quality, oround.relu S.ccn within Y) C%ry's
Vie.)Fig v. iT1
CA TF
Serial Ilo.

North Carolina • Department o1 Environment and Natural Ilesource, - Division of Waler Quality • 0roundr.alor Section
1636 Mail Service Center • Elalelph, N.C. 27699-1636T'hone (919) 731 322 I � o 4 /1 O 2 8
WELL CONSTRUCTION RECORD wr:LLCoNTnAC1oil: \A>e\\ c r; v'g
t.•
WELL cONTnACTOn cEnTlrlcAllorl If: a-Uoc(
STATE WELL CONSTRUCTION PERMIT/:
1. WELL USE (Check Applicable Boa): Flesldentlal I Municipal ❑ Industrial ❑ Agricultural CI Monhorieg Li
Recovery ❑ Beal Pump Water Injection LI Other ❑ II Other, List Use:
2. WELL LOCATION: N: (Show ketch of the location below)
Nearest Town: '14\IL'SV I�l�' County C.-1C.4v
fin[_\` ,a \I.S(?) Cite_
Woad Itante and Minims. Community, or Subdivision end Lol Ito )
3. OWNER gPvl Ihr lanai
Address 777 �� //ce/d
jSireoi or RouTa Ro.) /d�t
City or Town Stale Zip Curie
4. DATE DRILL ED 11.9 -r2L/ Ol
5. TOTAL DEPTH ins
6. CUrTINGSCOLLECTED Y`SC1 Noa__ _
7. DOES WELL REPLACE EXISTING WELL? YES 1 1 r1Gf J-
0. STATIC WATER LEVEL Below Top oI CesIng: _ rr.
(Use'r' II Above lop of Casing)
9. TOP OF CASING IS \ Fr. Above Land Surface'
'lop of cosine terminated pVor below land eudece requires a variance In actor•
dance with ISA PICAC 2C .011E
10. YIELD (open)• tic METHOD OF TEST A i Q
I I. WATER ZONES (depth).
(MULLING LUG
horn to
am — /os'
DEMIII
Font, sOescriptio-
.0 eicd- (Crr,,.Q /
12. CIILORINATION: Type in\--V). I21.ekAtnount
6
II additional space h needri t_-s-e bats el Ivrn
13. CASING:
LOCATION SK_lCH_
Wall lhir r,ess
Depth Diameter or WolphVrt. Material (Show direction end ds'hnce Iran al leas: two gate
From F) To SOI Ft /o• O t / 41-ee7 Roads, or other rrra7 reiettrce paints!
Rent to Fl
Front To Fl
14. GROUT:
Depth Material Method
From O To al9 ` rt per- again
From 10 Ft.
15. SCREEN:
Depth Diameter Slot Site Material
Flom 10 Ft In .It_ --''hi.
From _r� j ,I i�
From bj�i f'L �= 11, In' L Illl,•
16. SANDIGnAVEUP K:— i �
Size it a gnat
From Orb `- rl
From !To rt.
17. REMARKS:
1
I DO IIEREBY CERTIFY THAT MI5 WELL WAS CONSTTIUCTED IH ACCOnDAlICE WITH ISA MAC 7:. WELL
CONSTRUCT loll STANDARDS, AND 1IIAT A COPY OF 1111S IIECORD I IAS DEED PROvicED 10111E V,_'1 0W'EP.
rot' OFFICE USE ONLY
Quad No:
Serial Ito.
MOAT ME OF rFIn30N COLISIIILY.T1110 tic vv.ELL Or 'E
submit origin", to Divltion p1 'Miler Duchy.Oroundi.ater S.ccn wiUrin !r) Lit -ye cn_1 pIE V. 1:11
S

Ulamotor Slot Site Moloch!
Ft to. III
El. 11!
---
WTI OFFICE USE DULY
Dad Ile:
North Colollna • Deparhnenl of Environment and Nolan! flesaer cne • Uivl+Ion of Water On nllty • (bound orator Sec lion
1636 Nail Service Center - nnielph, N.C. 27699. 1636t'itone (919) 73a-322i
WELL CONSTFIUCTION RECORD WWELL L `OIIIIIC Alort r,El r1i n lea it: 2�/o t.1:/j
S IA1 E WELLCONS111UC11O61 PEW/111H:
214337
1. WELL USE (Check Applicable Floe)! DesldenllalEa Municipal U Industrial U Agrlcullural Li Monitoring U
(lecovory ❑ Beal Pump Walor In)ocllon L) Other CI II Oilier, List Use:
2. WELL LOCATION: (Show sketch .ol the locallon below)
Deafest Town: N ✓'t I f 5V County
yy
p1onA I me and Ilunb on. onnnity,
of
Subdivision and tut Iln )
3. owNEn tt e!.2;€:$ rnienne fl^ ()ono dory
Address
(Sheol or Multi Ito.(
City or ion Stale
NULLING LUG
r loin to
�5 - 10< (
Zip Lotto
4. DATE unlLI.ED 1D-De)-CA
5. 101ALDEPTH IbS
6, CUrTINOS COLLECTED YpS I_I IluL- 7. DOES WELL nEPLACE EXISTING WELL? YES I___I rHutu
n. STATIC WAIEn LEVEL Below Top of Casing: __riot _. LI.
(Use •r• II Ahovn lop of Cn Opp)
9. 1 OP Or CASING IS 1 __ Fr. Above Lind Stir taco'
•top of whip Iarminaled i /or below land notate requires a v.rl.nce lit error•
dance with 15A IICAC 2C.011E ..�n
10. YIELD (gouty� METHOD OF TEST Aid
11. WATEll ZONES (depth)•
DEPTH
roof—nooescripon'
may,/a(efsE,4 give/
/s>tsrl • Le_
12. C111011INA1ION: Typo 1411'1--d7ie7t4 Amount
13. CASING:
Ftorn
From
From to
14. unour:
Flom 0
Ftonl
15. SCI1EEIl:
( To 3S r
36 ' to 31'
wall Ihlrfness
Depth Ulamotor or Weipburl. I.laiedal
rl 4- r /
rt 6-as 3b/z1 pv�
Fl
Depth Material 14uthod
To rQ.O v FI ro-?'/ecnel
10 rl. —
Depth
now to
Horn To
Ftom _—T�•S �1-I1 � �(t l�
16. SAND/cnnvEL Ail r--
i'
Delplhl'',. S17v
FIo01 jot, 'I —FI•—
From To rt.
17. 11ElAAFKS:
"('2
-
' 7-TSTSITTUCIEUIII ACCor1Uu10EY/nui5A r+cACY'•YrEt1.
IUOIIEnEOYCnsTA 1)lATt1 ND111A AC
CONS1 nUCl iOtl STANDAnUS, AND 11IAT A COPY or 11 IFS IIECOr1D I IAS UFEH rnovwEO 10111E Watt. O"NEP
Wl� 70 — a s — o_,(___
Sim IAIUIIE or f'EFIS011 coilsntiY•n110lie. WEll D.
Sub.rJl orI roil la Uivldon al Wier Ouallty, oround.-elor Sr-ccn witiiln Y) G3 ys C'sJ PE v. l `N
II nddidonnl sr Cr! is rue pr r1 u-se Lac: of Ivrn
LOCAI lollSKEE.I_CII_
(Show Jlredlon end rJ noce ban al lone two Etaiq
Floods, or otter n�7 relemee points`
C
0
CD
a"-
c, 4
C`rri
g r:s
-4�
(If _+-
C,;4a
—I
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. Qte t'4 C k2 // .Q.)14N;
WELL CONTRACTOR CERTIFICATION k: 2-.J G
STATE WELL CONSTRUCTION PERMITN:
241030
1. WELL USE (check Applicable Box): Residential I t' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El II Other, List Use:
2. WELL LOCATION: AW Z C—
(Show ketch of the location below) /-1�
Nearest Town: S ✓/d-LCounty-
i/iie -s Cti L (eb
(Road Name and Numbers, Community, or and Lot No.) DRILLING LOG DEPTH
3. OWNER 47/l< E 4-01,77_13 From To Formation Description
Address a$ /»TU P A,v q0 SO' /�e 7 Ciy Sr,
1 reel or Route No.) / e 'kO ) ' r9 7!
City Town State Zip Code
4. DATE DRILLED/9 - )- 0 /
5. TOTAL DEPTH Din c
6. CUTTINGS COLLECTED YES n NO[� 7. DOES WELL REPLACE EXISTING WELL? YES D NO.
rl '� o a
8. STATIC WATER LEVEL Below Top of Casing: - Tom' FT. 0 n em
(Use'+' II Above Top or Casing) ""'I am
9. TOP OF CASING IS / FT. Above Land Surface' 1�0 . 0<
'Top of casing terminated uVor below land surface requires a variance In accor- 22.0
dance with ISA NCAC 2C,01111 ✓ ) ▪ ma10. YIELD (gpm): 1 METTHODQF pTEST / 9' d` & ^'m
11.WATER ZONES (depth):% �O (3 Gen' /S.S Spots\ o rrt-n
✓
12. CHLORINATION: Type /'T' N Amount z Cf-1 it additional space Is needed use back of lorm — z
13. CASING:
Wall Thickness LOCATION SKETCH
^� Depth D meler orr WeigghtFt. /MDatterial (Show direction and distance from at least two Slate
From 1 To C7✓ Ft - `' 5/7 Q / r c c- Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Dept rMated Method
F1
From Fl To 9 Ft
From _L.P___ To_92.__—Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft
From To Ft
From To Ft
16. SAND/GRAVEL P
From
From
17. REMARKS:
I DO HEREB CER �■IGI-v
CONSTRUCT ON STAY lt0Sf)A�11
ASHEVILLE REGI
FOR OFFICE ONLY
Quad No:
Serial No.
In In
In
In
In
In
ate dal
ON
PY O
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
�D- 3- O
SIGNATURE I�ERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality. Groundwater Section within 30 days
GW-I REV. 12/99

2401127
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone] i'tAkeF-at. W ELL
' LL I • "r
WELL CONSTRUCTION RECORD
1.
WELL CONTRACTOR •"' ""'�' `•" "' ""'
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
.act3c1
1. WELL USE (Cheek Applicable Sox): Residential [t' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ED If Other, List Use:
2. WELL Le • TION: A - ow sketc' -1 he location below)
Nearest T• !trsae' • as I / 6 county
(Road Na /. �;}+,!Remo
3. OWNER y_ /�... i s
Address Arne
jt
No.)
City or Town 21p Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOOK
B. STATIC WATER LEVEL Below Top of Casing: FT.
7. DOES WELL REPLACE EXISTING WELL? YES NOEr
(Use •s• II Above Top Casing)
9. TOP OF CASING IS 1 FT Above Land Surface*
'Top of casing terminated odor below lend surface requires a variance In accor-
dance with 15A NCAC 2C 9118
10.YIELD (gpm)• In METHQD TEST (t.CZ,
11. WATER ZONES (depth)• E[/8
DRILLING LOG
From To
4 -/S'7'
/37 — / 73
/73'- was'
State
/' O/
i!_e
12. CHLORINATION: Type fl'n/"
13. CASING:
From DToth/ Ra Ft nry /.� r
From To FL
From To Ft
14. GROUT:
Amount
Wail TNCknssa 0A
orP t
Depth Ma dal
From (% To / �� Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in In
From To _ Ft . In In
From To _ Ft. In _ In
16. SAND/GRAVEL PACK:
Depth Size Material
To Ft
To Ft
From _
From _
17. REMARKS:
DEPTH
Format' acrtption
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
0
I DO HEREBY C'1TTIFv THAT THIS WFJ j WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO113TAN Ilt1gITINpT+pCOPK�)F THIS R CORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE U V I��,� /
Quad No: IAu C 9 LOUD !.or
Sedtl No.
NATURE RSON CONSTRUCTING THE WELL DA
Divblon or Water orailty, Groundwater Section within 30 days
OW-1 REv. 12199
Groundwater Section
AheviiP Regiennl Office

240626
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
Wker L(\ WELL )2tLk, I -
WELL CONSTRUCTION RECORD WELL CONTRACTOR- ` S-1WVc-YMS
Ai3cz,
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appal* Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other El If Other, List Use:
2. WELL LOCATION: ( o sketch of th . r anon below)
Nearest T• A% .rarata.,
, A. !% Count':
me . N ,'^.l:/7JTfF,. •._ bdlWsion and Lot No.)
ii
(Road
3. OWNER
Address
Of
4. DATE D- LED
5. TOTAL DEPTH
6, CUTTINGS COLLECTED YES Q NO3'
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: (aJ FT.
(use •: a Above Top of Cuing)
9. TOP OF CASING IS�_ FT Above Land Surface'
'Top of casino terminated at/or below lend surface requires a variance In moon
dance with 1SA NCAC 2C Bits
10. YIELD (gpm): �O METH991 Of TEST Ott
11. WATER ZONES (depth)• /70
Stale
DRILLING LOG DEPTH
From To Formal)
Formal) Description
7 /
?rl / ?r7
'7' ems'
12. CHLORINATION: Type 7 /rT Amount
13. CASING:
�pp�1 Wall mamas
Depth , rlaptrH o w n �.
From To 90 Ft G� r
From To Ft
From To Ft
14. GROUT:
Depth Mat I
From _.1),_ To Ft S�t�
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in In
From To _ Ft _ In _ In.
From _ To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
F�✓C�
From To Ft
17. REMARKS:
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY
CONSTRUCT!
If T119 HLT-A. ONOF THIS RECORD HORS BpEENEPRIOV15A NCAC 2C, WELL
IDED TH TO THE WELL OWNER
STRUCED IN
FOR OFFICE
Quad No:
GNATURF,P"PERSON CONSTRUCTING THE WELL DATE
'toss )dglne to Division of Water Quality, Groundwater Section within 30 days
Groundwater Section Gw•t REV.12/99
AMA* Regional Office
LYJAN
2 9 2002'
Swill No.

North Carolina • Department of Environment and Natural Resources • Division of Water Quality• Groundwater Section le `.[ 0I 1
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone] t �� W at-
12-.t LL
Yek(F 1 D
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
WELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PERMITM:
a13s
1. WELL USE (Check Applicable Bob): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATIO
Nears
' (• how sketbh
.. I, 1
location below) C County Y�,
3. OWNER
(Road Name +d Numbers, Co ni
►� 7 ____ d Lot No.)
%L `
Ad • rasa
Ciy OTo Stale Zlp Coda
4. DATE DRIL- a tb i
5. TOTAL DEPTH iu
6. CUTTINGS COLLECTED YES E] NO[Er
7. DOES WELL REPLACE EXISTING WELL? YES NO Fr
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -a• II Above Top of Cuing)
9. TOP OF CASING IS 1 FT Above Land Surface'
'Top of casing terminated odor below lend surface requires • variance In accor-
dance with 15A NCAC 2C .
10. YIELD (gpm)• 1e
METJ OD OF;EST
11. WATER ZONES (depth)• I `
3� a�. Gem
12. CHLORINATION: Type Amount It additional apace Is needed use back of form
13. CASING:
DRIL G LOG DEPTH
From To
b r1l
rj' (431
Format Description
Wall Thickness
Depth 'I1 lart( o eI� VFI.
From0To 1 Ft t 4 1 laic
From To Ft.
From To Ft
14. GROUT:
From O To
Depth terl I Method
Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft _ In In
From To _ Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
I DO HERE
CONSTRU
FOR OFFIC
Quad No:
SeMI No.
LOCATION SKETCH
(Show direction and distance Irons at least two Stale
Roads, or other map reference points)
r F 'IJ1l
DNLY
JAN
9 2002
L
T
ter Section
Ik Revonal Office
As
0
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
PY OF THIS R ORD HAS BEEN PROVIDED TO THE WELL OWNER.
• /
SIGNATURE RSON CONSTRUCTING THE WELL DyrE
to Division of Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR'
WELL CONTRACTOR CERTIFICATION I:
STATE WELL CONSTRUCTION PERM-Ti:
240351
WELL USE (Check Applicable Box): Residential LIB Municipal ❑ industrial ❑ Agricultural ElMonitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /1
Nearest Town: 1-���S 1/ILLB County: Chkg-y
02-P Riot 6V
(Road Name and Numbers, ommunity, or Subdivision and Lot No.) /h1_�a/' {[/� DRILLING LOG
3. OWNER SNF2 PPr4D ` UMW,71AN.) PI-l/41LI J' From To
Address ? U 7Cai or L dI Jf� ! (/P ' �/ 5 r
NaC 2 4?Ci / 5
tv
City or T wn Slats Zip Code
4. DATE DRILLED /0- 0 I
5. TOTAL DEPTH 2 t17'
6. CUTTINGS COLLECTED YES NOE-
7. DOES WELL REPLACE EXISTING WELL? YES NOf
8. STATIC WATER LEVEL Below Top of Casing: Jr FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated suor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): '2 S METHOD OF TEST A9" d?
11. WATER ZONES (depth)- A Q."
12. CHLORINATION: Type //j-N Amount 3' CL/P
13. CASING:
DEPTH
Formation Description
5c
6 eV '7 C-
II additional apace Is needed use back of form
Wall TNckneas LOCATION SKETCH
Depth Diameter or Weighl/FI. irks' (Show direction and distance from at least two Stale
From O To is Ft �— SJ q 9C II Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:
Depth / MateriiV Method
From 0 To I c Ft
From -. V ' To 9c. Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
CD
I DO HEREBY CERT FY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STenlnean9 AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7-3-e1
9 R PERSQ2ONSTRUCT1NG THE WELL DATE
NSulxnll dgl sion of Water Duality, Groundwater Section within 30 days
�; GW-I REV. i2/99
FOR OFFICE USE
Quad No:
Serial No
Ira 101
�tc
Groundwater Section
Asheville Regional Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR- CAea.-,koe Well bK;
WELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PERMITS:
240352
1.
WELL USE (Check Applicable fox): ResidentialtJd' MunIcipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other If Other, Ust Use:
2. WELL LOCATION; (Show sketch of the location below) CAM/
Nearest Town: // Fes✓/ 1 h. 1 11 /� County
Cul2v L-, 6F2W-- h Q D
(Road Name and Numbers. Community, or Subdivision and tel No.)
3. OWNER OR. I), JO3t0AL_b
Address ' rL' UPr L �QnsJcl Rio
/✓ tsreilor oue o) aq
Gayerwn✓ I I I Q State 2 0 / o GZip Code
4. DATE DRILLED JD- J (i, D
5. TOTAL DEPTH t/
6. CUTTINGS COLLECTED YES NO0.-
7. DOES WELL REPLACE EXISTING WELL? YES O NOri
8. STATIC WATER LEVEL Below Top of Casing: Oo FT.
(Use '+' N Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated stlor below land surface requires a variance In accor-
dance with 15A NCAC 2C..g7J1111
From To
C C
o v>'
10. YIELD (gpm): m) : METHOD OF TEST /9' di
11. WATER ZONES (depth)• 3 Vo We'
12. CHLORINATION: Type
13. CASING:
From
From
Depth
To 0
To
From To
14. GROUT:
Depth
From 0 To 9
From :L.1C To 9d
/77-//
Amount C
Wall Thickness
Dliunir or WeighVFt. Material
Ft PP SUPl1
Ft.
Ft
Material Method
FI C01n,
Ft ti/..<j
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To
17. REMARKS:
Ft
DRILLING LOG DEPTH
Formation Description
C 57 C47 •
/V12,7e J ✓Eli Thr
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOtiAF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U
Quad No:
Serial No.
`'nn
SON CONSTRUCTING THE WELL DATE
of Water Quality. Groundwater Section within 30 days
DWI REV. 12/99

North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR- ,-2e0+1Ke.2
WELL CONTRACTOR CERTIFICATION Is:
STATE WELL CONSTRUCTION PERMITN:
?10355
LT-/( L l/2i �lI A1Q
5 6 S l
1. WELL USE (Check Applicable Box): Residential Municipal El Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other O II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 1447P 5 I/ IL/ e County /
TAl-b..EQsfAY QlMe
(Road Name and Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ThONf.45 Qiasse i i
Address
_ /a9 ?sw 9✓c
77��(Street or Route No.)
s P n ro.J F'— 3 r-1 3f/
City or Town State Zip Code
4. DATE DRILLED /O' .G C/
5. TOTAL DEPTH PC
6. CUTTINGS COLLECTED YES NOD-
7. DOES WELL REPLACE EXISTING WELL? YES n NOET
8. STATIC WATER LEVEL Below Top of Casing: /,y' o' FT.
(Use'.' II Above Top of Casing)
9. TOP OF CASING IS / FT Above Land Sur -lace'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gpm)• /rtn-f METHOD OF TEST / ve
11. WATER ZONES (depth): 77C
From To F rmation Description
Cron,7„J
•
12. CHLORINATION: Type /79/7
13. CASING:
Depth Diameter
From C9 To LE— C Ft 0 'Cr
From
From
14. GROUT:
To Ft
To Ft
Depth
From (✓) To vl d Ft
From ,) a To /l- C Ft
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
From
From
17. REMARKS:
Amount -A C%cif'
Wall Thickness
'tor We eclat
Diameter Slot Size
Ft _ In In
Ft In In
Ft In In
Material
Size
Ft
Ft
Material
If additional space Is needed use beck of lorm
LOCATION SKETCH
(Show direction and distance from at least Iwo Stale
Roads, or other map reference points)
-o
O
50
I DO HEREBY C
CONSTRUCTIO
TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/D
IA
Division
F
ter
ON
STRUCTING THE WELL DATE
ly. Groundwater Section within 30 days
GW-I REV. 12/99

1Slieor6TRoulo 1Jo1
((��� Stale Zip Code
4. DATE DRILLED -y- i a -O
5. 1 OTAL DEP11I LDS
6. CUTTINGS COLLECTED Y(S CI N0�1�
7. DOES WELL REPLACE EXISTING WELL? YES ( I NOL1
D. STATIC WATER LEVEL Below Top of Casing: by `
I (Use'.' Ii Above lop al Cesinpl
_
9. TOP OF CASING IS_ Er. Above Land SuiInca'
'Top of casino ler mingled Nor below land surface requital I valence In Iccor-
1n. YIELD Wm):MEI HOD OF TEST i r
11. WATER ZONES (depth):
Address
or
City Town
dance with 15A PICAC
2c fills
I E I i d Natural Ilesources - DivIalon of Waled Quality • (lround valor Section
1636 Man Service Center • s a p i.
North Carolina
• Department o nv martian nn A rl O n tee
R I I I 11.C. 27699 1636d'hono [phone] `3 ( O .7 /
WELL CONSTRUCTION RECORD WELL CONTRAG]
RACTOR ccn iF1cA► ofrn �a�lo1( 0�
STA1 E WELL CONS1f1UCTIOII PERMITP:
1. WELL USE (check Applicable Boa): Nesldonllai Municipal U Industrial El Agricultural ❑ Monllorirg ❑
Recovery ❑ Heal Pump Water Injection ❑ Oilier ❑ II Oilier, List Use:
2. WELL LOCAT ON: (Show sketch of Ilse location below)
\
nearest town: AA of -A, yll Q— County.
J.xld-cd- L(____ a.
?load Flame nd Nun Lars Community, or Subdivision�siand tel Ito )
W
3. oNEn . erc�a�1 PnvMo air
C\vt
12. ClLORINATION: Typo
13. CASING:
From
From
Front
14. GROUT:
Amount 6
Was Ihlclncss
Depth Diameter or Wean n 'I
Mar
To F1
10 F1.
Depth h1 mlal
Fi.
From _�-- To .�sz_
Frolic To El.
15. SCREEN:
Fr
From
From
16. SANDIGIIAVEL PACK:
Depth
From —CPT.
From
17. REMARKS:
Depth
To _ Ft
To FI.
ToFl.
1 DOIIEREDY CE
COIJS7nuC1 ION •TAN
FOB( OFFICE USE NLTY "I
Quad Ile:
Dlanieler Slot Size
hi hi.
In. In
Ili, In
Size
T IAflIUS WELL WAS CO
AnuS, AND TI FAT A C
Method
Material
Material
1 i• 'I'I
DI -TILLING LOG
r,om le
s,_ qs
L/s r
DEPTH_
nDons Descdvan-
`I
eks,
ShG/e
II additional race is ncedr9 use bac: of (ire
LOCA.!ION SK_1CR_
(Show direction end d lane bun al toast !no 5".ate
Roads. or other rr22 relere ce points`
.FIE or rEItSON calsrn(Y:Rna 1st wttl.
Submit •dpkial to Vrvlsion of Water Duality, Ground"eleI SW,/ within c. y3
C4.1 Fte v. 1`71
r
rs
0
CJI
IJCTE0RIACCORDANCE WIN; 15A NCAC7:.WELL
OF 1115 RECORD lips DEEM PROVICEO 10111E WEi T- Oii'.EP_
JJJJJJ _ /a
Da
Serial lie.

240624
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] \
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• 1ilh
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITS:
,c13s
1. WELL USE (Check Applicable Box): Residential 1� Municipal 0 Industrial 0
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL L
Nearest
TIO how sketch f e location below)
County
0
Agricultural ❑ Monitoring ❑
(Road Na
3. OWp' ER
Add ass
an Nu rs, Convunity, or Si division and tel No.)
set Of
City or Town
4. DATE DRILLEi
5. TOTAL DEPTH
\ 11
Stale
(DL
Zip Code
DRILNNG LOG DEPTH
From To
b a
rig'
nLI motor
6. CUTTINGS COLLECTED YES 0 NOCEr
7. DOES WELL REPLACE EXISTING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Casing: r-,U FT.
(Use'+' II Above Top of Cuing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below lend surface requires a variance In actor•
dance with 15A NCAC 2C .0118
10. YIELD (gpm): � METHOD O. FFITEST`�
11. WATER ZONES (depth)• C 34-
12. CHLORINATION: Type \ rk-i Amount
13. CASING:
From
From
From
14. GROUT:
DepttD
From d To 7'7
From To
15. SCREEN:
Depth
From To Ft
From _ To Ft
From To Ft
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
b l Thickness
Dth�/ r ToFt "II( °u41en Li
To Ft
To Ft
Diameter Slot Size
in
In
In
Size
Ft.
Ft
Material
In
In
In
Material
Forma Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY C
CONSTRUCTIO
FOR OFFICE U
Quad No:
Fetal No.
V" -TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
T LC 0 N. IFTHI�DHAS BEEN PROVIDED TOTHE WELL OWNER.
nr� n I'NATURE OFP N CONSTRUCTING THE WELL TE
2 9 [v rNt oi&r . DMalon of Water Quality, Groundwater Section within 30 days
�r1NAldwate. Section
Ashevi le Regional office
OWI REV. 12/99

WELL CONSTRUCTION RECORD WELL CONTRACTOR -
WELL CONTRACTOR CERTIFICATION a:
STATE WELL CONSTRUCTION PERMITU:
North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]VtakerathU_E 12._,1 i..(..I M4
a93c1
1. WELL USE (Check Applicable lox): Residential Q Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL L ATIO (.howVsketch��.
o . ; atlon below)
C I
Nearest Town: 7� . •. County
•`1 \ flea k _ �1
(Road Name bdivlmon and Lot No.)
3. OWNER ...;) __t. '�`V �I
A•.• ress a,
at
C40fi23
DRILILING LOG DEPTH
From To Forman Description
b 3'
-2>' k-1'
City own Slate
0 r �,
T•
Zlp COM �W
4. DATE ... ' LED b 1 ea'
5. TOTAL DEPTHMr
6. CUTTINGS COLLECTED YES 0 NO�
7. DOES WELL REPLACE EXISTING WELL? YES a NOED'
8. STATIC WATER LEVEL Below Top of Casing: f FT.
(Use 'ill Above Top of Cuing)
9. TOP OF CASING IS 1 FT Above Land Surface'
-Top of casing terminated actor below lend surface requires a variance In accor-
dance with 1 SA NCAC 2C Aye
10. YIELD (gpm)• ` i METHOD QF TEST S
11. WATER ZONES (depth)• sv`t
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
ppp LOCATION SKETCH
O Depth 9Ia e$$lr o T i. (Show direction and distance from at least two State
From To Y' Ft —1�'G_ l Roads, or other map reference points)
From To FL
From To Ft
14. GROUT:
Depth),"recta Method
From 0 To 'T•) , Ft 0
From To Ft j
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in _ In
From To _ Ft In In
From To Ft In In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To
17. REMARKS:
Ft
C
O
I DO HEREBY
CONSTRUCTI
FOR OFFICE U
Quad No:
Settsl No.
ttAt TT)
LY
N
9 2002ii0rrie
TRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
9/ia/o/
NATURE • .S- SON CONSTRUCTING THE WELL OAtE '
o Division of Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99
Cron, dy„r
Ashw..;'

1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR•
WELL CONTRACTOR CERTIFICATION I:
STATE WELL CONSTRUCTION PERMITS:
240621
North Carolina • Department of Environment and Natural Resources • Division of Water (Duality • Groundwater Section
W VP-s-k \Ll E W El I. 2(LL NCB —
ans
1. WELL USE (Check Applicable Bo■): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection O Other El If Other, List Use:
2. WELL LO ATIO
Nearest Towrr.
ation below)
Codpty
(Road Name umbere, Co fifty G- bdl si• and WI No.)
3. OWNER
Address
rs0 or • .- •r��,
11-06
City or Town slate zlp Cods
4. DATE DRILLED 9 -9I DI
5. TOTAL DEPTH (.
6. CUTTINGS COLLECTED YES NOD'
7. DOES WELL REPLACE EXISTING WELL? YES C no Ea
8. STATIC WATER LEVEL Below Top of Casing: , FT.
(Use 'ell Above Top of Casing)
9. TOP OF CASING IS I FT Above Land Surface'
'Top of casing terminated st/or below lend surrace requires a variance in actor•
dance with 15A NCAC 2Cdjga_ Q��
10. YIELD (gpm): 1`METHOD OF TEST
11. WATER ZONES (depth). (L-I)
12. CHLORINATION: Type «R
13. CASING:
Amount
If additional space Is needed use back of form
Wall Thickness LOCATION SKETCH
Depthc.� Deennrr11eerr it or �/ l7L�1. (Show direction and distance from at least two Stale
From To Ft Roads, or other map reference points)
From To Ft.
From C
To Ft
14. GROUT: . — o
From
From _
15. SCREEN:
Depth
To 5 (3,_ Ft
To Ft
Depth
From To _ Ft _ In
From To Ft In
From To Ft In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To
Diameter Slot Size Material
In
In
In
Ft
O
17. REMARKS:
I DO HEREB
CONSTRUCT
FOR OFFICE I
Quad No:
NLY
AN 2
ii 2002 J; IGNATURE OF P N CONSTRUCTING THE WELL
Stint • rlge% to Division of ter Duality. Groundwater Section within 30 days
( I I A?QCNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
• - S / OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tio
ATE
Sen.
r —water Section
Asheviiie Re tigrei
ow•t REV. 12/99

From To Ft
From To Ft
14. GROUT:
Dept?
From 0 To .6l Ft
From To Ft
15. SCREEN:
240f120
d Lot No.)
Depth Diameter Slot Size Materiel
From To Ft In In
From To Ft In In
From To _ Ft In _ In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
(Road Name
3. OWNER
A
4. DATE DRIL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOQ�
7. DOES WELL REPLACE EXISTING WELL? YES N0�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •.• II Above Top of Cuing)
9. TOP OF CASING IS� FT Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2c,
10. YIELD (gpm)- 1T METHg9pOt; TEST 333
11. WATER ZONES (depth) .`�
12. CHLORINATION: Type �l fl Amount II additional space Is needed use back of form
13. CASING:
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699- 1636-Phone [phone]
HkllESU1LLE LJOA--1VA L.1M6s —
WELL CONSTRUCTION RECORD WELL CONTRACTOR:--14"-1/41463/46es--Gt/akaCt
WELL CONTRACTOR CERTIFICATION #: aQ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boxy Residential [ Municipal El Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection Other El If Other, List Use:
2. WELL La. ATI..- t how ketct t-e location below)
-. s To•i�a:�► ••• •\ I
IWO Ita a I& .._ .. 9 •
4r1 yt�a,. _i,A,_ts,
• • re 8 11117111VPANIMIIIIIII
MalliedraC
lya7. _ _O Stale
Zip Code
DRI NG LOG
From To
al
Lc? h05
DEPTH
Form
ptlon
Wall TNcknesa LOCATION SKETCH
//�� Depth Mar c°�Wnai1- "patesat (Show direction and distance from at least two Stale
From —12— To �^ ` Ft 1t"'r' +�'Q`t•/NNNU�-' Roads, or other map reference points)
2
I DO HEREBY C :p IF7IIS�N�L gAS
CONSTRUCTIC lag Y1 A US, A I NAt A
FOR OFFICE U i Nr"i1 . 9 2002
Quad No:
SI
Sufrtt.o$gfnal
STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RECORD HAS BEEN/PROVIDED TO THE WELL OWNEER.
rt�7r�ae /"f�/1/lrQ
9 16 /b!
;NATURE OF PERSON CONSTRUCTING THE WELL DATE
o Division of Water Quality, Groundwater Secion within 30 days
Udall No.
GW1 REV. 12/99

240619
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
i-MiESUILLE W0.L�RIlll0`)6% —
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 011�-� c 9 C�
WELL CONTRACTOR CERTIFICATION f: aci
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential In/Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI o (Show skate • the location below)
Near- t : - rd. �'� k WangialliallaM
City or T. ^ ©Q �j a zip Code
4. DATE DRIL s t
(Road Name
3. OWNER
A r ss
5. TOTAL DEPTH
DRILL Th LOG DEPTH
From To
C•
143
6. CUTTINGS COLLECTED YES El NOE
7. DOES WELL REPLACE EXISTING WELL? YES CD NOE(
8. STATIC WATER LEVEL Below Top of Casing: ( y,q,ET,
9. TOP OF CASING IS 1 (Use •: If Above Top of Casing)
FT Above Land Surface'
-Top of casing terminated Wor below land surface requires a variance In actor.
dance with ISA NCAC 2C.1413
10. YIELD (gpm): METHOD19F TEST
11. WATER ZONES (depth)- 13'T
12. CHLORINATION: Type
13. CASING:
Amount If additional space is needed use back of lorm
Fo lion Description
LOCATION SKETCH
Depth /D1 "�1ar or t, al (Show direction and distance from at least two State
From To �' Ft `�"1" 1 "tit Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth
From h To � l Ft
From To Ft
15. SCREEN:
Wall Thickness
Depth Diameter Slot Size Material
From To _ Ft . In
From To _ Ft _ In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
In
From
From
17. REMARKS:
To Ft
To
Ft
I DO HEREBY CERTI
CONSTRUCTION STD
A
FOR OFFICE USE ON.. I
Quad No: `• ' JO 2 S bNl c-d`vinaSliI
0,4
Sass) No.
Gc /vex
le OF PERSON CONSTRUCTING THE WELL
Divisl n of Water Ouality, Groundwater Section within 30 days
ED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
IS RECORD HAS1 EN PROVIDED TO THE WELL OWNER
9/s/c i
DATE
GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
240615
Wlk EY.)tLLE La at_ 1121U.1 -
1. WELL USE (Check Applicable Boa): Residential Lb Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LO TION:, ow sketch of . location below)
stTo n_�►`G.�a%-_- �'r� 1
'� County
'O JAWS
2h
('oad Name tl umbers, mm Il�r bdivlslon and Lot No.)
3. OWNER
Address
ree
City or Town Stale 21p Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[
8. STATIC WATER LEVEL Below Top of Casing: .y) FT.
(Use'.' If Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
'Top of casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C M18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth)I
LUNG LOG DEPTH
From To
6 Do'
12. CHLORINATION: Type
13. CASING:
Amount
Fonn.lf•n •
rt as
ai g- it. •
sbdptl
If additional space is needed use back of form
De th Wall Thickness LOCATION SKETCH
P
From O To 5-0 Ft &%�
DI4rr�tep, or igh7-I. Ft. •(ue ia_' t(Show direction and distance from at least two State
y�(%( Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth
From d To CO Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To . Ft _ In in
From To _ Ft In In
From _ To Ft _ in In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
ern' TRAT@HIRwifuevAR
ars
CONSTRUCTION IONI torn Alan 1AV A 0-0C�1�D
oA1.Y
l A'h0 2 9 2002
Submit odgi to o
FOR OFFICE USE
Quad No:
Sedal No.
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LYlf01'L`c /�t1iniceic
TURE OF PERSYN CONSTRUCTING THE WELL
vision of Water Duality, Groundwater Section within 30 days
ATE
p.c.:,'1
Ash Ville n�
GW-1 REV. 12/99

WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
/Municipal
STTATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery Haat Pump Water Injection Other El If Other, List Use:
240G.1.4
North Carolina - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
JetMESUtt_t_E LJE\l..121u-t—
2. WELL LOCATI
Nearest To
e' : Show sketch •1 et location below
?alliAa Ee1M 1 •fie •
sue • i ikai Subdlvislon and Lot No.)
awsiti
City or T State zip
4. DATED •
� is D
5. TOTAL DEPTH icy
(Road Name an
3. OWNER/
A ress
A9?f�
nty:
DR LING LOG
From To
O La
17,1
aur
6. CUTTINGS COLLECTED YES Q NOE✓J
7. DOES WELL REPLACE EXISTING WELL? YES NOD'
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use •'• If Above Top of Casing)
FT Above Land Surface'
`Top of casing terminated aVor below land surface requires a variance in accor-
dance with ISA NCAC 2 to
10. YIELD (gpm): i �l) , METHOD OFITEST�
11. WATER ZONES (depth)•
12. CHLORINATION: Type
13. CASING:
7� Depth ern°
From V To �� Ft
From To Ft
From To Ft.
14. GROUT:
From 0 To FS Ft
From To Ft
15. SCREEN:
Amount
Wall Thickness
Depth Diameter Slot Size Material
From To Ft in in
From To Ft In In
From _ To Ft. In In
16. SAND/GRAVEL PACK:
Depth Size Metedsi
To Ft
To Ft
From _
From
17. REMARKS:
DEPTH
F rmatl Desc lion
If additional space Is needed use beck of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CE=
CONSTRUCTION
"HAT THIS WELL WAS Q
DARDS, AND.THAT A CO!
FOR OFFICE USE
Quad No:
Y
- L a W002.
@� undwate
Ashf vhir
'N STRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
OF HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF P RSON CONSTRUCTING THE WELL
//U
ATE
Medal No
original to )ivislon of Water Duality. Groundwater Section within 30 days
OW-1 REV. 12A9

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section r Q O 5A 8
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '7 `i
WELL CONSTRUCTION RECORD
WELL CONTRACTOR. C hecokee tcJel/ 2),2i/4Zt
WELL CONTRACTOR CERTIFICATION 0: 2'SC; S
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential L►', Municipal ❑ Industrial El Agricultural El Monitoring El
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: H47'PSJr Li co County.
saes C2eek C tJC
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER :TOE: 73itokER
Address
On/
//G70 P^'e Homnork cite_
f Street or Route No.)
F /rl e,e s- FL .33 9/ 9 p
City or To / State Zip Code
4. DATE DRILLED S' 9 ' 0 / y
5. TOT.A,LDEPTH /b2' �l
6. CUINGS COLLECTED YES Ell NOD-
7. DOES WELL REPLACE EXISTING WELL? YES in NOn
8. STATIC WATER LEVEL Below Top of Casing: a p FT.
(Use'+ If Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In accor-
dance with 18A NCAC 2C .0118° METHOD ,/1 r�
10. YIELD (gpm)• 2 MD OF TEST TY
11. WATER ZONES (depth)i rap
DRILLING LOG DEPTH
From To Formation Description
0 a9' 3c7 C--,Ps.3
as D' 4-te9 idler_
,O ,>, es ref( 9 6e»
a Hen Vie 41es-1-
I (o7 t O-''nor'ie ,
12. CHLORINATION: Type /1/ 7 4 Amount 't" GD
13. CASING:
Wall Thickness
Depth DCmeer or5gh I. M arial
v i v
From To Ft. From To Ft
From To Ft
14. GROUT:
Depth Mated Method
From 0 To 'LC_ Ft e
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To Ft. In In.
16. SAND/GRAVEL PACK:
Depth Size Material
From
From
17. REMARKS:
To Ft
To Ft.
zm
O 3'c rn
a. m�
m
%se Fn=
c)
C ti
II additional space Is needed use back of lorm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
9 %n„ SIGNATURE OF PERSON CONSTRUCTING THE WELL
S1 original to Division of Water Duality. Groundwater Section within 30 days
FOR OFFICE USE ONLY
Ouad No: r-
DATE
GW-1 REV. 12/99
Sedal No.

From —
From 14. GROUT:
From
Ftom
15. SCIIEEN
From
From
Flom
242878
North
11ar ling - D parirn net
Environment
vI on m ent ind 1 Ba8nol Resources
• Dlla221 yialot of Water Quality • Groundwatnr Section
enter
N.
27
WELL CONSTRUCTION RECORD WELLCONTl1AC1OR: _L111' nil J
WELL COINIIACTOR CERTIFICATIOiI
SLATE WELL CONSTRUCTION PERMITN:
—1� rlal ❑ Agricultural D Monllorirg U
1, WELL USE (Chick APpueebl. Box): Residential Fr Municipal U Indusl
Recovery ❑ Heal Pump Water Injection U Other [] II Other, Llst Use:
p. WELL LOCATI N: (Show skch of the location below)
!fewest Town. n l
end lmbers. Cohiy.
pro d flame Plumbers. Community. or Subdivision and Lot Ito
3. OWNER
Address
51i"oat o`r Iloulo Na`.1
City or Town Slate
4. DATE DRILLED C -OI'
5. IOTAL DEP1I I fir' IJO
6. CUTTINGS COLLECTED Y S CI ILI—
7. DOES WELL REPLACE EXIS1ING WELL? YES 110
B. S TAT IC WATER LEVEL Below Top of Casing: 501 El.
(Use '+• N Above Top of Casing)
9. lOP OF CASING IS 4-- FT. AbOVe Land Swlaco'
'Top of culnp ill minded a for below land surface regulate *violence In accor-
dance with ISA IICAC 2C.011e
10. YIELD (gprn)• .E-- METHOD OF TEST 't-2-------
Courtly:
1 I. WATER ZONES (depth):
_S1_---
12. CIILOFlBJATION: typo Y1 Arrl0nt11
f�T-°"��'S-
13. CASING:
Zlp Coda
Wall p,Iclme el
Depth biamolar or Weight/Q. Mater?OE
Jai: -From 0 To 1�FI. -�-.
To VI.
To FI.
Depth Medal (Author)
_12___ To __ II. P 1 1
1 o Ft. __------ --
Depth Diameter Slot Size Malarial
To PI In. _— In.
To FL In.
To —Ft.. J14-=---
16. SAND/GRAVEL PACK:
Depth
Ta To
From
From _
17. REMARKS:
In.
Slit tiM&ITa1
rt.' ,
_
100 NENEBY CERTIFY 1I1AT 11119 WE1:l'WA9 CONSIJIl1CTE0111 A.0
CONsi RUc1I0N STANDARDS, AND 11 IAT
DRILLING LOG
r iom to
Iaor_
Jai
DEPt11___
FonrJxr Dewrip1
II additional space is needrd 1-'se back of f nn
LOCA I ION SK 1 CF1
(Show direction erd dunce Ir;rn z7 lnas! two 5'tale
Hoods, or other n- P relertr a point!)
FOR OFFICE USE ONLY
Curd No:
COPY or
O
O
crn-)
1
W
-11
Cll
O
CA
rf10A110E Willi ISA /JCAc r..'//ECL
AS BEEN PROVILED 10111E
ti
c Da TE
( SIOr1ATUHIE or PE11'SON C 1 11110 e^ wlUdn'r7 L�Y2
SubtdlodpinalIoDivldonciWitirOs1 y. 0rouEH.IFie v.isn
e
0
CJmr
or
0—
Yro
rno
as
CO z
C)
0
Serial lio.

North Carolina • Department ol Environment end Natural Flesources • Division of Waler Ouality • Groundwater Section
1636 Nail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION nLL CONTRACTOR: 01:‘10( Q`t bu014
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable Boa): Residential issd- Municipal ❑ Industrial ❑ Agricultural EllMonitoring El
Recovery ❑ Heal Pump Waler Injection ❑ Other 1] It Other, List Use:
2. WELL LOCATION: (Show skQIch of the location below) Nearest Town: CAN
I \ Ie. County:
r>) (M, SS'OX, &cS
(Road Name and Numbers. Corrvnunliy, or Sub elvlslo and id No.)
3. OWNER L TI\GEC
Address
SireeFETRFtilii Io.).
City or Town
Slate Zip Coda
4. DATE DRILLED 5- -O (
5. TOTAL DEPTH 390 r
6. CUTTINGS COLLECTED YIEs ❑ NO fiY _
7. DOES WELL REPLACE EXISTING WELL? YES I_I NOI .-f
B. STATIC WATER LEVEL Below Top of Casing:
FT.
(Use'+ ll Above Top of Casino)
9. 10P OF CASING IS I FT. Above Land Swine'
'Top ol casino terminated Nor below land surface requires a vrtlence In accor-
dance with 15A 11CAC 2C .01115
10. YIELD (gpm)• _-.._ METHOD OF TEST t i fl
11. WATER ZONES (depth):
Di -TILLING LOG
From To Fonrvoi Descripto-.
(n - 5 '
5 - 10'
j0 - Gran
12. CHLORINATION: Type
}V eAc Amount S II additional space is needed i.S-e bath of Icrn
Waal
LOCATION SKETCH
Weight/Ft.
Depth �lamelor or Weight/Ft. Material u
(Show direction and dnce fren al least Inu` ^'o "a e
From
To �._ FI. '— S •Sj) ' pile' Roads. or other rrra7 refer/rte.
From To- Ft
From To FL
14. GROUT:
Depth Malarial Method
From 0 To 22 FI. --
From To FT.
15. SCREEN:
Depth Diameter Siol Site Material
From To _ FI ____- In In.
From To Ft.._ In. In.
From _ To FI. In. In
13. CASING:
242885
DEPTH
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
I DO HEREBY CERTIF TFIA
CONSTRUCTION STANDAR
FOR OFFICE USE ONL
Ovid No:
Serialtlo.
1 Ft.
SO :S Wd £- 33010
TFIIS WELL WAS CONTT 111S CT.DECOR° HAS DEEM PROOFED 10 THE 71aL Oi1�ER.
?#ATE I - —�
, i E,2; UI--FILE �J ISA
�sLCe�� iEO.
SIOHATUr1E or PERSON CONSTf W:TI1101 t WELL or'E
Sub1tdl odpinal to Division of Water Quality. Orovn6.ealer Secon within Y) c 1y2
NA pt& v. 12 tt
e

WELL CONSTRUCTION RECORD
240611
North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] \
i-k ESALLE LJO.I.. 12"u I 14G, -
WELL CONTRACTOR•
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
a9 t
1. WELL USE (check Applicable Boa): Residential Er Municipal ❑ Industrial ❑
Recovery El Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCAT(Show sketc
Neare tvown:
U r
the location below)
� County:
(Road Name d u srs, Cornmun�(v o�Subdlvislon and Lot No.)
3. OWNER
�)Q.�
Address
r
Cltor Town Sue -
4. DATE `'ILLED kat
5. TOTAL DEPTH S '
6. CUTTINGS COLLECTED YES NO�
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing:
rl
Zip Code
Agricultural El
Monitoring ❑
DRILLING LOG
From To
h 2l
NO ][-
FT.
I (Use'+ if Above Top of Casing)
9. TOP OF CASING IS
FT Above Land Surface'
'Top of casing terminated or below land surface requires a variance In aoeer-
dance with 1SA NCAC 2C 18
10. YIELD (gpm): METH/ OT TEST
11. WATER ZONES (depth)• 'It .o
12. CHLORINATION: Type
13. CASING:
Depth
From C) To
From To
From To
14. GROUT:
Dep Mu te(lel
From • To Ft'. c
From To Ft
15. SCREEN:
Depth
From To
From To _
From To
16. SAND/GRAVEL PACK:
Depth
To.
To Ft
From _
From
17. REMARKS:
Amount
Method
Diameter Slot Size Materiel
Ft In In
Ft _ In In
Ft In In
Size Material
Ft
I DO HEREB'
CONSTRUC-
FOR OFFICE .
Clued No:
T Ir1Al In1Wttr
TANDARGS4ND THAT s
VAX
DEPTH
Forman., De alp
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
r+1
Zr ▪ '-I
Sc
Ca
rn
mZ
CO
at --
0
Z
A�C
DNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
'Y OF Tx,1IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
eC t s c, `�i9 h�CP rC
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
Soda' No.
Grngridwate` Se.ditakdt odglrai to Division of Water Quality, Groundwater Section within 30 days
?eni2r3 Office
Asheville
GW-I REV. 12/99

(Road N
3. OWNER
Address
238817
North Carolina • Department of Environment and Natural Resources • Division of Water 'Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]NA-W (\U_E WEIL
WELL CONSTRUCTION RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITN:
a9SS
1. WELL USE (chock Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: I h.wsketch oft e anon below)
Newts 7 :: _ ��al Willa \ 1 County.
itt and Lot No.)
City or T _State Zip Code
4. DATE DRILL a
5. TOTAL DEPTH - 1
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES NOE
8. STATIC WATER LEVEL Below Top of Casing: FT.
cute *cif Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
-Top or casing terminated actor below land surface requires a variance In actor -
dance with 15A NCAC 2C .0118
10. YIELD (gpm)- 4.-1� MET��+(1D OF TEST
11. WATER ZONES (depth)• rxatD I
DRILVIING LOG DEPTH
From To
b l;0i
1�O' &31
a3' a'
'Ydt•r a%.1
Forma on Description
12. CHLORINATION: Type 1 4 Amount If additional space is needed use back of form
13. CASING:
WYI TNekrNas LOCATION SKETCH
Depth �aa•�m�wr or VFt, �►►uWWrrw-..d�T1� (Show direction and distance from at least two Stale
From To taS Ft `� T ..L1dY��. Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT: a _
o_ o
cis �p,
rn
in 0
rn
_ zrn
o�
(V pc
�0
a rno
3 rn
9 vs
_ cs
to o
From
From
15. SCREEN:
Dep\_ Ma d
To "cdS Ft
To Ft
Depth Diameter Slot Slze
From To Ft
From To _ Ft
From To Ft
16. SAND/GRAVEL PACK:
Depth
From To
From To Ft
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE USE
Clued No:
WY No.
Material
in In
In _ In
In in
Size
Ft.
Material
ARDS, AND THAT A C
U.
7RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
-SAL Vii
SIG TURF RSON CONSTRUCTING THE WELL D TE
( oundwate, AsWna to aeon, at Quality, Groundwater Section within 30 days
C-ou'th tie*innal ice GW1 REV. 12/99
6/

Show stele 1 ',If the location below)
Ittamismenri
r ` .Idslon and Lot No.)
`
inatagaithi fin
-a a `_'_ ry tall �Za
Slate
0�
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR•
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
238809
North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section \
t-HC`(E�)tLLE I.JEN-L �RUU..I 4 —
1. WELL USE (check Applicable Box): Residential 10 Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATIO
Near l T
(Road Na
3. OWNER
Address
City or T
4, DATE DRILL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOc
7, DOES WELL REPLACE EXISTING WELL? YES NO (
8. STATIC WATER LEVEL Below Top of Casing: I OD Fr.
16%
Agricultural ❑ Monitoring ❑
Countyy-�`�-•�-�,
DRILL NG LOG DEPTH
From To Forman
o-2o'
2-0 W '
Zip Code
(Use -.' N Above Top of Casing)
9. TOP OF CASING IS ` FT. Above Land Surface'
'Top of using terminated sVor below lend surface requires a variance In aceor-
dmee with 15A NCAC 2C .g11a
10. YIELD (gpm)• t METESD qF TEST 03.34_
11. WATER ZONES (depth)•0-a
12. CHLORINATION: Type ` .1a.�` 1 R
13. CASING:
/� Depth,
From _,S.L_ To
From To
From To
14. GROUT:
Ft
Ft
Amount
Wall
Thickness
�t`6 7 Ma
al
From To Ft
From To Ft 1
15. SCREEN:
Depth
From To _ Ft In
From To Ft In
From To Ft In
16. SAND/GRAVEL PACK:
Depth
From To.
From To
17. REMARKS:
Size
Ft
Ft
Diameter Slot Size Material
In
In
in
Matedal
It additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY C
CONSTRUCTION'j3DARDS, AND THAT A C
FOR OFFICE US
Quad No: L....,(
off ire'rL
SIGIjATIJRE OF PERSON CONSTRUCTING THE WELL
rlgInal to ivision of Water Quality. Groundwater Section within 30 days
ice
O
t0
0
0
C)
7:7CD
O rn
z-C
0rn
m-
rn
rn
u,z
rn3
c)
O
TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
1/C /
QF THIS RECORDASON PROVIDED TO THE WELL OWNER.
D E
GW1 REV. 12/99

110r111 Carolina • Deparimeni of Environment and Natural flesourcoe • Dlvielon of Water Duality - Oround water Section
1636 Mal Sarvlce Censer - (Weigh, N.C. 27699-1636-F'hone [phone]
WELL CONSTRUCTION RECORD WEILCOr norcron IIACTOtI: f' FI,nCTfo ns
SEAT E WELL CONS'flUCTION FEf1FAIT1f:
242864
aUaU
WELL USE (Check Applicable Do.): Resldentlal L2.-- Municipal El Induslrlal D Agrlcuilural ❑ Monlloricg ❑
Recovery ❑ Iloal Pump Water Infection U Oilier LI II Other, List Use:
2. WELL LOCATION:sk
(Show etch of the Iacono') below)
Nearest Town. P,Ip\keSJ , 1 E) County- n `- o
R
woad llama and Humber!. onvugyilly, or Subdivision and Lot No
3. OWNER V «--\LL flG N
Address J
(5lioot m Iloilo No.T
Cliy or Town Slate
A. DATE DRILLED 7- I3-Ok
5. lO1ALDEP71I L-)SO' _
6. CUTTINGS COLLECTED YFSL-_I NO[a..-_
7. DOES WELL REPLACE EXISTING WELL? YES L I MU
U. STAl IC WATEn LEVEL Below lop of Casing: _Asp, rt.
use •e• II Above Top of Casing)
9. LOP OF CASING IS__j__—_ FT. Above Land Surface'
-Top of C. terminated .Vor below land surface requite I a variance In accor-
dance with ISA IICAC 2C.0118 METHOD OF TEST Q iA
10. YIELD (gent) 1L
11. WATER ZONES (depth):
Zip Code
12. CHLORINATION: 11po�l Arriooril ..
13. CASING:
Flom 0
Flora
Rom
14. GIIOU1
Flom
From
15. SCREEN:
\Vail I hiclore as
Depth Ulaniolor or Weight/ft. Fdaledal
To. ri. io2 DColt
To FI
To Ft
Depth Malarial Method
_Q__ To
riv
to Fl.
Depth Dlanrelor Slot She
From To Fl In In.
From To — Fl.
Flom _10 FL.-
16. SAND/GRAVEL PACT(. (I 71
Depth I' 41--Stza---
Flom
From
17. REMARKS:
To
To
l
1 DO)IENEDY CEn1IFY TI!
cot's]nuci log STANDA
FOn OFFICE USE ONLY
wad Ito:
SedalIle,
In.
)
In.
In
Material
tta rral I! 1'�
I•
I)l
DRILLING LOG _DE. IH__
riom to Fonr.ax' De . ripfio-
r/1 r_ 1
/ ©_ 6/0 ' nrV Qv? ro
r
If additional Brace is nereel r_ze bar of item
LOCAL ION SKETCH
(Slow direction and distance ban 21 In:W fen Sate
floods, or Other r-r rap releterc'e point)
'O
Cu
O
01
AT 10 WELL WAS cons tFWUC1EU DI ACCOnDA)ICE WIIFI t51, IICAC r.
t4D'
io 1IiAT ACOPYOFThTITITECOFIO HAS DEEII PNOVICED 70111E viaL Ott•`EF.
V` 017E
siotlnTurIE OF PErlSOFI CONSTFI Y.-TIII01✓c Yv'RL
Submit original to Division of Water oilallly, 0round.rater Seccn willdn Y) Cell V. 1:11
Col Fig
a

O I I f Envbonmenl and Natural Itesourcns - Division of Wain! Duality - Ground Nato r Section
�16
WELL CONSTRUCTION RECORDWELL COJIIIACTOR CERTIFICATION It:
SI'AlE WELL CONSIRILUCTION PEI1MITII:
1. WELL USE (Check Applicable Do.): Residential Municipal ❑
industrial ElAgricultural ❑ MonitoringU
hecovery ❑ Heal Pump Water Injection ❑ Olhor ❑ II Oilier, List Use:
2. WELL LOCAT N: (Show sketch of the locallon below)
Nearest Town: 4 County.
3esCleU.Le 2:1lG-- —
(road llama and liunbnrs. Convnurt iy. or Subdivision and Lot tin
3. OWNER
North Carolina -sparmen o
1636 Mail Service Center - Raleigh, N.C. 276g9-1636 Phone [phone]
Address
C
Slia'oi or SrIto.
City or Town Stale
4. DATE DRILLyED / "
5. TOTAL DEP11I O. CUTTINGS COLLECTED Y` IJOS L,I f1'r' LIOa
7. DOES WELL REPLACE EXISTING WELL? YES .
6. STAUC WATER LEVEL Below Top ol Casing: Also( . El.
(Use'+' II Above Top of Casing)
g. TOP OF CASING IS
Er. Above Land Surface'
'Top ol co slop terminated atfor below land surface requires a variance in accor-
dance uAlrn) 2C
In.
10. YIELD (opt)' METHOD OF TEST
T 1. WATER ZOIJES (depth):-----
12. CIILDRINATION: 'typo
13. CASING:
UIIILLING LOG
nom To
- SD
6CLL 34L
zip code
Amount ----
Wall Thickness MaterialDepth r Ulamotor or Wef rr pS
Flom --- To —L=n—
From—
From 14. GROUT: Lit dal
Depth
_0--To 2Q—FI.
to___—_-------
FTOM
From
15. SCREEN:
now
Frein
From
To rI.
To Fl.
Depth
To
_To.
To.
16. SANDIORAVEL PA
Depth
Flom To
From To u
17. REMARKS:
DO IIEREBY CEflIIF 111A rW17U1-L WA`3`CO(iS''TR11C1
CONSIRUC110N STA OAmDS,ANU I ITAT li PYOF_-tins
pI TE
SIONATUf1E OF PERSON COIIS TR11a11 IO1 <vv'ELL
SubIJl odglnal to Division of Wirier Ouelhy. Et,rnpenlar Seccn vwiUdn YJ a )" tit, FIE V. 1: T7
I
Dlantolor Slot Sba
Fl
FL
Ft.
1.tothud
Moiedal
DE?rll___
Fonr.axn oescriplio-
II additional space is needed ¢se back at kiln
LOCATION SK- ICH
(Show direclion and d'a=ante Ica( z1 leas: :,qo E.'-ale
Road,. or other n—..a2 relen rot points)
0
0
n
n
1
W
Eon OFFICE USE OilLY
Ouad No:
_ lit -- In.
In. In.
In. In.
Size Mal
El.
car
0
C►
DIIIACCORDANCE WITRISA IIJCAC%.WELL
ECORD IIAS 6EE11 PROVICED 101IIE'I!'—_'-L Ow'ER
Serial llo.

North Carolina • Deparirnenl of Envlronmenl and Haturol flesourcoe - Division oI Water Duality - (bound orator Seclion
1636 !.Mail Service Cooler • Raleigh, N.C. 27699-1636-Phone [phone]I
WELL CONSTRUCTION RECORD WELLcow TIACTOII' Gl AASt ck-19U,drA\1n(1)
WELL CDI1111ACTOn CERTIFICATION if aL/Oq
STATE WELT. CONSTRUCTION PERMITIt:
242861
1, WELL USE (check Applicable nor): Residential Municipal LJ Indusldal El Agricultural ❑ Monitoring El
(lecovery ❑ Ilea! Pump Water In)ecllon ❑ Other ❑ II Other, List Use:
2. WELL LOCAJ yN: (Show sketch of the locallon below) /-) (Gl'
Neatest town: AlesU71�P County:
hloed Name and Nunbou, Convnunlly. or SubdlvIslon and tot Ito.)` DI IILLIIJG LOG
¶
3. OWNER t3tl�Cl ex\ji S LID(,G (P i )OcA \Talk )4tA on 10
KS 1 6,25'
Address
(Siin61o711ou1a Ra.)
Cllyorlovm Stale
4. DATE DRILLED 17-11.-
5. 1OTALDEPTH _S
6. CUTTINGS COLLECTED YI•SCI NoLLY__
7. DOES WELL REPLACE EXISTING WELL? YES I I NOVI
6. STATIC WATER LEVEL Below Top of Casing: '_ El.
(Use'.• II Above lop of Casl.w)
9. TOP OF CASING IS 1 FT. Above Land Surlaco'
'Sop of cm sing lermin sled Nor below land surface tequlres s variance In accor-
dance wllh ISA IICAC 2C .011E
10. YIELD (gpm): 16 METHOD OF TEST 4r (?
11. WATER ZONES (depth)• ' \1
I2. CI ILORINATION: typo 3 c %2i i'S Amount
13. CASING:
Dep111�/ 1 Ulanlolor
1s�
From (1) To..- Ft.
'.�5
From
From
14. GROUT:
Prom
I'IOW
15. SCREEN
To PI
10 Ft
Depth
() to �� -FI.
10 Ft.
From
From
From
Depth
To
To Ft.
To PI.
Zip Coda
--
Wall 1ldcknees
or WelphVH. Maledal
' or, I jOur
Method
Diameter Slot Size Malarial
In. In.
In III
In. In
16. SAND/GRAVEL PACK:
1
{ iSlze
^i I From --'T—
From
17. REMARKS:
I I
1 DOIIEREMY CFM FY THAT .. WAS CON
collslnuC1
IStAHW111o:SYAND 1ft 9l1,C9PY
FUR OFFICE USE ONLY
ousd Ito:
VFW
ronrj%ID Desuipllo-
/s''a_n��d� 4on L
( 7r f7a
II additional srrace is needed cse beer of Ivrn
LOCATION SKI 1 CH
(Show dlrecllon erd dunce Iran zl loos: ten S'ale
Roads, or other srr.p relererce points)
O
0
rn
cD
CO
s
01
O
al
IRl1CIE0III ACCORDANCE WITII ISA 11ICAC to. vita
F 1111511EC0WO HAS 6EE11 PROvicEo 7O HIE '77_"_L Ott-,EP..
C
C
rti
Cr
0< am
rn
rn
�rn
m onrnz
rn
0
SlorlAt UfIE or PERSON cot-sfrllk llll01✓c'/v"Ell. pelf
Submit original In Divldon al %Yeler Ouellly, 0roenO..aleI Srr_cn snllidn Y) Cr y s CIA
FnE Y. 1:11
Serial tlo

4. DATE GRILLE
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOT/
7. DOES WELL REPLACE EXISTING WELL? YES C NOrEr
8. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use': a Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface'
Top of casing terminated sVor below land surface requires a variance In *CCOr.
dance with 15A NCAC 2C Ala
a
10. YIELD (gpm)• L N METHOD OF TEST
11. WATER ZONES (depth)• agai
238816
North Carolina • Department of Environment and Natural Resources • Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] WE,e-L(1LLE W EU- D Q.t (..L I �t
WELL CONSTRUCTION RECORD WELL CONTRACTOR• l]t
WELL CONTRACTOR CERTIFICATION S:
STATE WELL CONSTRUCTION PERMITS:
a9Sci
1. WELL USE (check Applicable Box): Residential Q Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO e location below)
Ne
(Road N
3. OWNER
Addre
City or Town 0
fats
Nu
Holm
It
Count'
21p Cods
12. CHLORINATION: Type ickl1-k Amount
13. CASING:
From
From
From
14. GROUT:
From h
From
15. SCREEN:
Dppth T,,
To
To
wall TNcknsu
Ft e`t{,l r *Kt r.11
Ft
Ft
To b3 Ft
To Ft
Depth Diameter Slot Size Material
From To Ft in In
From To _ Ft In In
From To Ft._ in _ In
18. SAND/GRAVEL PACK:
Depth Size Material
From
From
17. REMARKS:
To Ft.
To Ft
If additional apace Is needed use back of form
LOCATION $KETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
O_
rn
Pt
'C
N
0
4.0
0
0
C,CD
cm
0M
Do
m0
tom
NZ
0
z
I DO HEREBY CE
CONSTRUCTION
oundwa,.
ye
UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RE ORD HAS BEEN PROVIDED TO THE WELL OWNER.
TUBE r C,' SON CONSTRUCTING THE WELL OAT
aeon of Water Quality, Groundwater Section within 30 days
OWI REV. 12A19

238815
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]YekY tuE W Eth \ )12-1 Lis (f'I6
WELL CONSTRUCTION RECORD WELL CONTRACTOR- j
WELL CONTRACTOR CERTIFICATION 11:
STATE WELL CONSTRUCTION PERMITa:
.ra13S
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO how sketc •I t e location below)
Neat tT• " '=�S4r - County
(Road Na
3. OWNER
Ad
n• Nymbers
on 1�+�71A Dr�IL�.ING LOG
From To
O Gat
City or Town Sin Zip Code
4. DATE DRILLED '1 II I) I
5. TOTAL DEPTH �`(i�. t
6. CUTTINGS COLLECTED YES NOOK
7. DOES WELL REPLACE EXISTING WELL? YES NO(
B. STATIC WATER LEVEL Below Top of Casing: (,,0 FT.
(Use 'a" if Above Top of Cuing)
9. TOP OF CASING IS t FT. Above Land Surface'
'Top of casing terminated et/or below lend surface requires a variance in aceor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm)• 1DD METtQ,D Cr TEST
11. WATER ZONES (depth)• \ SS
12. CHLORINATION: Type
13. CASING:
-2)bs`tta 131
113 I%SC'
Amount
DEPTH
II additional space is needed use back of form
Wall Thickness LOCATION SKETCH
nn Dept /Fiart`/w, r �°-�We°�ht.t. c—,u�S.t�.1,1rI (Show direction and distance from at least two State
From V To 5 Ft �^ "*tt -o�•(e T " v Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth M t dN
From To T15 Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in In
From To _ Ft In In
From _ To _ Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To
17. REMARKS:
Ft
I DO HEREBY CEP'
CONSTRUCTION S
tfiSI/4L'WAS' O 1STAUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
, nit tr1ATA•CORY OF: IS RECORD BEEN PROVIDED TO THE WELL OWNER.
sub vdt od
rourdwater Section
hevilie Resionai Orifice e_
E •,�: RSON CONSTRUCTING THE WELL DATE
alon of liar Quality, Groundwater Section within 30 days
OW -I REV. 12.199

238812
North Carolina • Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-1636-Phone [phone] iES\ t LE W QL..'b2(LLt —%
WELL CONSTRUCTION RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION fl:
STATE WELL CONSTRUCTION PERMITS:
at5t
1. WELL USE (Check Applicable Box): Residential Q Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATIO (Show sketch • the location below)
Qat
minnowirt
eares
(Road N
3. OWNER
A••ress
Agricultural ❑ Monitoring ❑
County
Na)
City or Town 13O State Zip Code
4. DATE DRILL
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOQ—
7. DOES WELL REPLACE EXISTING WELL? YES DU NO (
8. STATIC WATER LEVEL Below Top of Casing: Gait FT.
(Use'Above Top of Casing)
9. TOP OF CASING IS 1 : if FT Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2CA1111 l
10. YIELD (gpm): MET OF TEST
11. WATER ZONES (depth)•
DRI G LOG DEPTH
From To
D `tI
91.s1
st' 4V
12. CHLORINATION: Type
13. CASING:
Amount
ppII�M Wall
•rhhiclineae '�'(�
From D Depth
51 Ft. 1v}4 rr �11Yd 1. (� T`( I <
From 'To Ft
From To Ft
14. GROUT:
Depth :tat
From h To RI Ft 00C
From To Ft
15. SCREEN:
From
From
From To Ft
16. SAND/GRAVEL PACK:
Depth
To
To
Depth
To
To
From _
From
17. REMARKS:
Diameter
Ft
Ft
In
In
In
Slot Size Material
In
In
In
Size Material
Ft
Ft
F rrnall De ption
If additional space Is needed use back of lorm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
3�C
0
1n
0
a
C,a
om
o�
crn
_
01
>0
rn
"D0
rn
Ja
rnz
-y
0
z
I DO HEREBY C
CONSTRUCTED
1 ti WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
D=Y H}Airr A COPY OF THIS RECORD HAS BEEV PROVIDED TO THE WELL OWNER.
4041C. %�i4/Z/LE2 c3D/Qi
DATE
/ /J
; SIO TORE OF PERSON CONSTRUCTING THE WELL
Subrnli o.1g4nal to slon of Water Quality, Groundwater Section within 30 days
undwate- Section
Asheville Reclonal t'?i._ .p.
GW-1 REV. 12/99

FOR OFFICE E OilLY
Clued No: N,,,,,,,.'....E,
Grou
Serial No.
238808
North Carolina • Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
\-MiEYJtLLE LJQI llRllllWC1 —
WELL CONTRACTOR CERTIFICATION a: AGt
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check App4lcabl. lox): Residential Municipal❑ Industrial Agricultural El Monitoring El
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCAT a : (Show skit \ 1 ; the location below)
Ne . r at T. County 8,,au
—er ---
(Road Na - .iT*s ity,
3. OWNER • t
Address \caDo
sion a j
DFiSI NG LOG
From To
Eat
City or Town State zip Code 1 ` 1 �Eac
1
4. DATE DRILLED n 13 D
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES EI NO© —
7. DOES WELL REPLACE EXISTING WELL? YES NOG
8. STATIC WATER LEVEL Below Top of Casing: t'a. FT.
(Use': N Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires • variance In accor-
dance with 15A NCAC 2C d 1e
10. YIELD (gpm)- METHOD OF TEST °kilt
11. WATER ZONES (depth). ``--�EIL��
12. CHLORINATION: Type
13. CASINO:
Amount
gamy Wall Thickness
From b DToth Ft (Qr`irt (v�•ls_/, al
From To Ft �L3
From To Ft
14. GROUT:
Depth M t de I\E .
From --fa—To " 1 Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To _ Ft. In In
18. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To
17. REMARKS
Material
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least Iwo Stale
Roads, or other map reference points)
Ft
it
IC; ri
IL
I DO HEREBY blitFY THAT THIS WELL W4LSc TE 1STRUCD IN ACCORDANCE WITH 15A NCAC 2C, WELL
h'
CONSTRUCT' .STA D 'D THAT bf1Y OF THI RECORD HAS MEN PROVIDED TO THE WELL OWNER.
L.1 alter a_ &t. 71/S
NATURE OF PERSON CONSTRUCTING THE WELL
o Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99
fwP-s AI 81*Safe• Section
orl

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR•
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT":
235408
(%t kee_ LOA bpJ /, o 1
5-6 3
"
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town. pit -yes tie County.
/r-1 S4 a l rree %AuRe.-1--
(Road Name and Numbers, Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER AM e 1-,9.I/AA/ From To Formation Descripfon
Address Cj7�1 e 5/,,ae DR O 7(� 2-' ...5 C.- 7 f i.-fa
ISkeel or Route o /u 1- 'kG7' U r477r' Ti-
zip Code
NO
B. STATIC WATER LEVEL B I C I S- FT.
(Use'+ II Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Sudace•
'Top of casing terminated el/or below land surface requires a variance In accor-
dance with ISA NCAC 2C .OJ18 10. YIELD (gpm): 2 S METHOD OF TEST /V/
11. WATER ZONES (depth). "Z it d
CL4-/
City or Town I State
4. DATE DRILLED T {�`V
5. TOTAL DEPTH ') 6 ) '
6. CUTTINGS COLLECTED YES n NO1 r
7. DOES WELL REPLACE EXISTING WELL? YES (l
Below Top ofCasing: -o
12. CHLORINATION: Type
13. CASING:
Amount L C tigIf additional space Is needed use back of form
Wall Thickness
Depth Diameter r Wel hVFI. Material
From 0 To 0 J Ft (7 `Lii I !-`��
From To Ft.
From To Ft
14. GROUT:
From 0
From 20
15. SCREEN:
Depth Material Method
To )..O Ft a..
To /u t- i Ft
Depth Diameter Slot Size Material
From To Ft in _ In
From To Ft in In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance Irons at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STj4NOAJOS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
rTh ,o A 7 . /� .. p
J�wY
SIGNATURE PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
FOR OFFICE VS 'ONLY
Quad No:
Serial No.
OCT
- 27101

North Carolina • Department ol Environment and Natural rlesourcos - Division of WaterOuality - Groundwater Section 242858
1636 (.tail Service Genies - Flelelph, N.C, 27699-1636'Phmto [phone] �� /I// II //�/ri
I
Y /ft
WELL CONSTRUCTION RECORD WELL coil -Howl -On CERTIFICATION H: 13gg
STAKE WELL CONSTRUCTION PEFHMITIN
1. WELL USE (Check Applicable Sox): Residontlal L
Municipal D Industrial ❑ Agricultural ❑ Monitorirg CI
Recovery ❑ Neal Pump Water In)eclIon ❑ Oilier ❑ II Other, List Use:
2. WELL LOCATION: (Show skoich of lli location below)
DRILLING LOG DEPTH
now to FonrJxnDescripfo-
2 brawl
Woad flame end Numbers. Convnnnity. orSubdivisionand lot Flo )
3. OWNER TeCr 11 Ma }--es0tt
Address
+Sheol or rloula Noa
City or low" Slate
4. GATE DRILI ED Clan/0l
5. TOTAL DEPT11 Ti, _
O. CUTTINGS COLLECTED Y�SLI No L_
7. DOES WELL REPLACE EXISTING WELL? YES N0V7
B. STATIC WATER LEVEL Below Top of Casing: FT.
'Use ..-14 Above lop of Casino)
B. TOP OF CASING ISFT. Above Land Surince'
lop ol co slap terminated et/or below land surface requires a violence In eccor-
dines with ISA !ICAO 2C .011a l
10. YIELD Wpm): 30_ METH OF TEST 1
11. WATER ZONES (depth):
Zlp Code
12. CHLORINATION: Typo 1;0918-71:s Amount
13. CASING:
II additional space is needed t-se back of I>rn
LOCATION SKc l CH
Wall ip? Bess
Dep11 Dlamelpr„ or w iol vn. Mate�sl (Show direction erd dance Te n al I ats! Es-ate
To .-!�•- Ft /`t E' �_' Rooth, or other rr27 relertnce Po
Frorn v
From To - Ft.
From 1b Ft
14. GROUT: Method
Depll,hyyh � Mated IU-�
From CJ To ._L_�-FI. ri-I C r H 5
from To El -
15. SCREEN:
Depth Diameter Slot Size Malarial
From To _ FI ht In
Ft. In In
From __To_-
From _ To ___ PI. In. _ In.
IS. SAND/ORAV ' 'h5�
�t :S Sized iL I I Ibtorial
FL I ,
From
From
17. REMARKS:
I DOIIEREBY
coNSIRUClt
EnTI L. TTWT[11M WEtt'WAS CONS FIUCTEO Ill ACCORONICE WITH isA {JCAC to. YELL
NSTANDARDS, MDTITAT A- COPY 0.fill nECORDIIASDEE/IP ON[EO"10T1ff. '71'%LL0w,EE.
slorUTUr1E or PEIISON CONsr111Y:/1f 101✓'HELL
pa.E
Submit ollpinal to Division of Water OUelily.OrWnp.eater S,ccn within :'J c*ys V. I: N
6a.1 FIE
FOR OFFICE USE ONLY
Ovid No:
Serial Ito

Moil Carolina Deparhnenl of Envhonmanl and Malmo,Resources - Division of Water Duality • (lroundwalar Section j�
16361.lai1 Service Center • Raleigh, N.C. 276994636-Phono [phone]
WELL CONSTRUCTION RECORD
242856
WELL CONTIIACT011:
WELL COFIJ Rncron CERTIFICATION In 99.F214 3
STATE WELL CONSTRUCTION PERMIT :
1, WELL USE (Check Applicable Bar): Residential Pr Municipal L..]
Industrial ❑ Agricultural U Monllorir g U
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION;, (Show skald' of the locallon below)
ounty
Nearest Town: Ali/ ll
rose of StG e -- ---
Gnd --
MeadItame end Hurlbut Community, or Subdivision end Lol No )
3. OWNER O;!( 51 //D01
Address
Sli"e"ei or Iloulo lad
City or Town Stale
4. DATE DRILLED 2O-C/
5. TOTAL DEP1I I ;Cr 6. CUTTINGS COLLECTED YFSLi Nog—
7. DOES WELL REPLACE EXIS1ING WELL? YES I'tOLJ.
O. STAI IC WATER LEVEL Below Top of Casing:
r-- l .
fuse'.' p Above lop of Caetnpl
9. 1OP OF CASING IS _ FT. Above Land Surlaco'
'Top of casing lerminaled eVor below land surface requires a variance In accor-
dance with lsAIICAC2C.0118 f'r
10. YIELD (gpm): HOD OF TEST /
�� —
I I. WATER ZONES (depth): 33'0
iirf Arnoufll L9
12. CHLORINATION: Typo �
13. CASING:
c/7
Flom
Flom /0 7
Depth
Q 10 f0 7 I.
To /.26' FI.
Frorn le Fl
14. GROW:
zip cods
flail 111icbne se
Ulamolor or Welphtrt. Material
2s_
SOO / /00c
Depth a Mal dal Method
T.oP20 rt 7 `id n e...crve-
From
From to Ft
15. SCREEN:
From
From
From
Depth
To
To
lo-
Ft
Fl.
FI.
Dianmtor Slol Slzo Malorial
In In
In.
In
16. SAND/GRAVEL PA6k:-
DePiI C�e
Floni
From
17. REMARKS:
I OOIIEREBY CER IrY ll
COIISIRUCIION S ANON
FOR OFFICE USE ONLY
Wad Ho:
Serial Ito.
PI.
IT.
DRILLING LOG
Foil to
DE2111
ronr.xn OexriP6o'
a/o c%y_
/,2o- 3G� .
LsJ
c
,ANIONA7Acbb ry.orr-'Ilt
If additional space is needed r_ze bac: of kern
LOCAl101J SKETCH
(Show direcllon end d6"ance b✓n za Ioae:ro Sale
Roods. or other rrrc7 reference polnu!
lE0 Ul ACCOROffCE WI1111sA pWCAC%, YrELI
S RECORD I IAS DEER FROVICEO 30111E Yr==-L OW EP
S1011 Tur1E OF PEI16011 COtrSIMPCl11101 c'h''EILL
SubrJl original la Divldon of Water Ouditr, Ground.ealer Seeen within 0 5 Ee 1 GtE Y, t: ti
e
O
rn
C,
co
rf
O
CT
C
0
c+•n
•
- I
o<.-
em
DC
"in
m
vim
C)
rst�
0
z
Oa E

North 1636 Mail Carolina
• DCentereni oleE vironmen Gas- Natural Re
ne (ulce - Division
iivt lof l of Water Quality • Oround water Section
Ser
e
•
WELL CONSTRUCTION RECORD
WELL CONT[TACT011:
WELL cm -melon CEnTIFICnMION R:
STATE WELL CONSTRUCTION PER141111:
1, WELL USE (check Applicable Inj ctIo L Nlur then l LJ
Industrial ❑ Agricultural ❑ Monllorirg ❑
Recovery ❑ Heal Pump Water Inlecllon ❑ Othor ❑ 11 Other, List Use:
242782
2. WELL LOCATIPN: (Show sketch of Ilse locallois below)
rrlb\\e_Syt County
: CI
Nearest Town:---e--�
,ass
Moat; flame,Jnd IJu lbels. Community. or Subdivision and Lol Iiol
3. OWNER
Address
City or Town �� �y ,-, �
4. DATE DRILLED .S.D__12-
5. TOTAL DEPTII
6. CUTTINGS COLLECTED YTSLI NoL 7. DOES WELL REPLACE EXISTING WELL? YES — I 110 R-
O. STATIC WATER LEVEL Below Top of Casing: _G 'rt.
9 (Use •s• II Above Top on Casino)
g. TOP OF CASINO IS J.______- F T. Above Land Surface'
'Top of chino lerminsted etior below land surface requires a variance In accor-
dance Elh 15A IJCAC tC A11! METHOD OF TEST ra --
10. YIELD (gpm): ��
11. WATER ZONES (deplli):
12. CIILOFlINATION: typo Antounl
13. CASING:
Zip Code
From 14. GROUT: alotlal Method
F torn _�— to D� II.
riot» to FI.
15. SCREEN:
Sli"eoi or F1o`uln 1Jo`.)
Stale
Walt thickness
Depth Diameter or Weiohvfl. Material
From. --To _FL_(.a,2,i -Sal
From to FI
To Fl.
rrom
From
From
Depth
To
To.
To,
16. SAND/GRAVE ),ACT(:
—
T.O rt.
To rt.
Prom
From
17. REMARKS:
I DOIIEREBY CERTIFY T11AT T`<t43,VVtLL WAS .CONS 7 1UC1ED Iti ACCORDAnce WITH 15A IIJCAC r. WELL
couuslnucllort SIANDAROS`r Md131)IAT A C PY or1iIts RECORD HAS DEEII PROVICED 1011t. ?rat- Ow'EF._
DP
Diameter Slot S11.a
Ft
rt.
Ft.
In
In.
In
In.
In.
In.
Material
Ilal
DIIILLING LOG
riot» To
r
DEPI-H_
ronra)os Descriptio-
II additional space is neede-d trse boric! kern
IOCAl ION SK_ ICR
(Show direction and ds'ance hen 21 leas temp Sale
Meade, or other n<7 telererce points!
O_
0
rn
n
s
W
s
U7
03
C
z
a
C)
an
cn
zrn
0-oc
>n
mrn
cn
VsZrrl
0
FOR OFFICE USE ONLY
Quad No:
SIOIIATUNE OF PErisoll constnhlY.Tlll01 1v'ELL
Sub it original to Division of Water Ouallly, Orparderater Seem within `0 C.SYs C„.1 ptE V. 12 T1
a
Serial llo.

north tore Mail r Carolina
- DepC arirnennofe nvi onmenl en 16at .Pal
Ile
a (urco y37ly)3ion of Wnler Quality • Oround Name Section
nter
Ser
e
7
21
WELL CONSTRUCTION RECORD wowr'nNrHAC1011:
STATE WELL CONSTRUCTION PERMITS,:
Appnc.bl. Boy: Resldonliala— Municipal U
Indushial El Agricultural ❑ Monhotirg U
teal Pump Water InJecllon ❑ Other 1-1 II Other, List Use:
(Show sketch of the location below)
lP County:
Fton1—
From 14. GROUT:
Fun
Ftoln
15. SCREEN:
1. WELL USE (Cluck
Recovery ❑ I
2. WELL LOCAT- N:
Nearest Town:
Woad flame
3. OWNER
Address
!lumbers. Colt
WELL CONTRACT on CERTIFICATION
molly, or Subdivision and Lot I la )
Sheet or 11o`liI5 N0.1
Coy or Town State
4. DATE DRILLED ,,S� HOt
5. TOTAL DEPTH riopj—_ _
6. CUTTINOSCOLLECTED VIES CI
7. DOES WELL REPLACE EXISTING WELL? YES LJr El.
IIOH-
B. STATIC WATER LEVEL Below Top of Casing: Q_
(Use'+• II Above Top of Cattily)
9. TOP OF CASING IS
Fr. Above Land Surlaco•
'Top of es slop larmlosied sVor below land audice requires�a variance In sccor-
10.ce YIELDwith 1 (g rn): . ol�le- METHOD OF TEST �J.t6----
10. (gprtl):
1 I. WATER ZONES (deplh):
12. CHLORINATION: Typo
13. CASING:
zip —coda
Amount _-�---
Wall 1111CWness
Depth °lanloler or INelojivrt. Ida
terial
Flom __O-- l o ��-- I' I. \
To FI.
10 FI.
Depth IA lorlal
Ft. �-
To .rz12—
lo PI.
Malhod
Depth Dlantelor Slol Site Malmlal
FI __._.- Ill _ In.
From 10--
rI.
111.--_h1•-
From __. To __-- _--- kl.l�,�
)ir. I
From To Y"�fT ` I,1
16. SAND/GRAVEL Pt�GK -
Depilj,t 1�. size IA i rib
From 10 \ 1 I FL._�—r .'
From
17. REMARKS:
IOOliEREBYCERTIF T it
CONSI nuci ioN STANDARDS, AND 1I TAT A
D u rt.
FOR OFFICE USE ONLY
Quad No:
24 284 w
DRILLING LOG _ DE7f_fl__
ronra xis Desuipoo-
Norn 10
II additional space is nerdr4 t_-se back of 1c/rn
LOCATION SKE I CR
(Show direction and dIr ance Iran s1 !oast two Salo
(loads, or other rr27 releitrc4 points!
-n
0
0
OFFICE
CONS fRUC1EDIII ACCORDANCE W111115A NCACY.'/✓ELL
OPY OF This RECORD I IAS BEEN PROVICED 10111E WE"-1— QW'EF..
sroNATUnE or PE113011 cOflsfflintilio 1✓ WELL
submit originalio Division ol Water lausiliy. OrOcind..tlit Seczn
ubi ioriginaltoDivisionciWaterOuallly,Droond,.tlarSec-cn wlUlinJr)csys
C
C
n
0
cm
Cc
orn
VVa
ac
fnO
cores
C)
—4
0
31—
Da E
Serial Ilo.
Col pig V. 1:/1

232504
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]WIXttLLE U3Q.L.. Ital.(
WELL CONSTRUCTION RECORD WELL CONTRACTOR-
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITS:
a9Vt
1. WELL USE (Check Applicable cox): Residential ( ' Municipal ❑ Industrial 0 Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO ( • w sketch •, e location below)
Neares T. :• ‘ II:J•. I
w� � Wan.
(Roa• Name
3. OWNER .a.�L� •:.
Ad re- a v," O ozwilimmi,
4. DATE DRIL • ® Cityor own slam
N
5. TOTAL DEPTH iinlT�
6. CUTTINGS COLLECTED YES NOES
7. DOES WELL REPLACE EXISTING WELL? YES [
8. STATIC WATER LEVEL Below Top of Casing:
County
DRILLWG LOG DEPTH
From To
a act
gal
NOE
FT.
(Use': if Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance In actor.
dance with 1 SA NCAC 2C .01
10. YIELD (gpm): \m METHOD OF TEST nil-
11. WATER ZONES (depth): `
12. CHLORINATION: Type 4' Th Amount
13. CASING:
Fo au• De
kit!
6!nA-
--
`c
07
t21
'Tr -\
3
N mz
W
If additional space Is needed use back of form
Wall Teams* LOCATION SKETCH
Depth Cl f1 /playellar w�eh+�huR rp1W�a/d.(1� (Show direction and distance from at least Iwo Stale
From To 1 1 Ft ?Sit it `w'w�•� , " ` Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT: (\
De
From D T. n Ft
From To Ft
15. SCREEN:
Mat al
Depth Diameter Slot Size
From To Ft In In
From To _ Ft _ In in
From To Ft In In
18. SAND/GRAVEL PACK:
Depth Slze Material
To Ft
From
From
17. REMARKS:
Materiel
I DO HEREB
CONSTRUC
lellVi
FY THAT THIS WELL
ANSORDS, kNQQrj/AT
FOR OFFICE OSE NLY
r
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Y OF THIS REC RD HAS BE )NPROVIDED TO THE WELL OWNER.
di
206 �XlSDI
� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Remised Marra oil to Division of Water Quality, Groundwater Section within 30 days
Quad No: Grou
Aslmtilk
&Mal No.
Seders
GW-1 REV. 12/99

232503
North Caroline - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ' E t ,LE I.��QI .i
WELL CONSTRUCTION RECORD WELL CONTRACTOR -
WELL CONTRACTOR CERTIFICATION #: aQ .54
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (cheek Applicable cos): Residential [ET Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (• how sketch . - location below)
��,es 1.� � Count
`_
114M . �'��1 1,
'area
(Road ��!� ''';���`��e1�yy� He,) DRI_ NG LOG DEPTH
3. OWNER ;etT��-`.t1+iii '.� ,,
Address -1 A - �i S111/ 13
__ City or Town T!�, State W •Coda sal �l� l
4, DATE DRILLED %•. D1
5. TOTAL DEPTH Vii
6. CUTTINGS COLLECTED YES O NOQ"--
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOE"
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' a Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of easing terminated at/or below land surface requires • variance In accor-
dance withISANCAC 2C. /a n`
10. YIELD (gpm): r METHMI Or TEST `^-"1•
11. WATER ZONES (depth). V II
12. CHLORINATION: Type Amount
13. CASING:
From To
r, 12-'
Forma on • -script
0
O o
CD
C c "
a c,
CO zr
ar.
—Co rn
IV .mom
N./ --I
If additional apace Is needed use back of form
Wall Thickness LOCATION SKETCH
Depth • Cxw\ecwsn'uFt./ • II (Show direction and distance from at least two Stele
From —di —To SO Ft t`:'`G `TM "`�'�ro " Roads, or other map reference points)
From To
From To
14. GROUT:
Ft.
Ft
Depth M tedal Method
From To Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ In In
From To _ Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth
From To
From
17. REMARKS:
I DO HERE
CONSTRU
FOR OFFIC
Quad No:
SMe No.
Ft
To Ft
Size
STANDARDS. AND THA
ONLY
Material
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. y/
Ge
SIGNATURE OF PERSON0
CONSTRUCTINGTHE WELL 0 TE /
sl to Divisional Water Quality, Groundwater Section within 30 days
GW-1 REV. 12A9

232498
North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] \ ^I��
W:'A`(FZL(CLUE WELL p(2lU,I'", --
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• - \-
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
gactss
1. WELL USE (Check Applicable Sex): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL L
Nearest Town.
(Road Name
3. OWNER
At-ress
TIO , how sketch • the location below)
Al l t County:
City or Town
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQi
7. DOES WELL REPLACE EXISTING WELL? YES j j NO ✓C7
8. STATIC WATER LEVEL Below Top of Casing: LJ. FT.
9. TOP OF CASING IS
sion and Lot No.)
DRThLING LOG
From To
b bS l
12s' 12-'
561
Slate
Zip Code
(UN '+' II Above Top of Casing)
FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a varlane In accor-
dance with 1SANCAC 2C. 111 n` w
10. YIELD (gpm)• METI 9_p�9F TEST ""�' 1.
11. WATER ZONES (depth): �0LL�f}}
12. CHLORINATION: Type VM# Amount
13. CASING:
DEPTH
Format' Descrptlon
n
co
C)
o
D
CO Nrn
IV rn
IV
14 —.
If additional space Is needed use back of form 2
Wall ThicknessLOCATION SKETCH
Depth carp"(W hVFt. 1 (Show direction and distance from at least two State
From To �S Ft ✓ r•['o Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth Me{IN Method
From t) . To Cs Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ In In.
From To Ft In In
From To _ Ft In In
16. SAND/GRAVEL PACK:
Depth
To_
From
From
17. REMARKS:
To
I DO HEREBY CE
CONSTRUCTION
FOR OFFICE US
Quad No:
6edal No.
Size
Ft
Ft
ATTH
AR , AND THAT A C
?rill
Material
Ashville Rea.,"
Nr
SIOhATUREVF PERSON CONSTRUCTING THE WELL D E
undwater • • to )Mahn of Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99
'RUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
“,—;to

232510
North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR -
WELL CONTRACTOR CERTIFICATION'S:
STATE WELL CONSTRUCTION PERMIT'S:
1. WELL USE (check Applicable Box)! Residential LYJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other II Other, List Use:
2. WELL LOCATION: (dhow sketch 91 the location below)
Nearest Town: Ha JL Or ar County
(Road Name and Numbers. Community. or Subdivision and Lot No.)
3. OWNER fdCK SRC a
Address ;- .2 '/dtor_ /.33-/
(Street or R to No.)
City or Town Stale
5. TOTAL DEPTH P-0 )
6. TTCOLLECTED [] NO[
NO
7. DOES
CUINGS WELL REPLACE EXIYESSTING WELL4 YES n E{--
8. STATIC WATER LEVEL Below Top of Casing: i FT.
City
DRILLING LOG
From To
S6
zd)
DATE DRILLED
Zip Code
(Use •i II Above Top of Casing)
9. TOP OF CASING IS / FT Above Land Surface'
'Top or casing terminated et/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): METHOD OF TEST /9' J/
11. WATER ZONES (depth)• I fir
•
12. CHLORINATION: Type 4 4'
13. CASING:
Depth
From To S
From To
From To
14. GROUT:
From1,2
From as
15. SCREEN:
Ft
Ft
Ft
Diameter
Gy
Amount
Wall Thickness
or WeightFi. Material
YJ7' at e-
Depth Material Method
To `Z" Ft Cels,X
To _LC_ rt
Depth
From - To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
I DO HEREBY CER-
CONSTRUCTION S
FOR OFFICE USE C
Quad No:
Serial No.
Diameter
Ft
Ft
Ft
In
In
In
Size
FI
Ft
Slot Size Material
In
In
In
Material
DEPTH
Formation Description
Se7 c ,t5'
C
0
0
3
W
a -)
If additional space Is needed use back of formCO i
LOCATION SKETCH
(Show direction and distance (tom at least two Stale
Roads, or other map reference points)
arrester Secbos
k,hevitk Retetff
0:l "UCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Sr-
-3/-p/
i 7 riE OFIjS N CONSTRUCTING THE WELL DATE
to • IsIn Waler Duality, Groundwater Section within 30 days
GW t REV. 12/99

North Carolina • Department of Environ m:nil and Nalurnl Ilesoorces • Division of Wolof Ounlity • Groundwater Section
1636 Mail Service Center - Relelph, N.C. 27690•1636.Phone (9I9) 733-3221
WELL CONSTRUCTION RECOFIIJ WELL WELL ^�
STATE WELL CONSIRUCTIOIJ PEDMITA: —
Indusitlal ❑ A9
rlcullural ❑ Monlloriry
RU
1, WELLUSE (shack r
Heal Pump WaleInjecllal a- tion 0 Municipal
J II Oilier. List Use:
ecovery
p, WELL LOCATION: (Show sketch of the location below) %/��
a County: `-I�
Nearest lawn:
I_o �A,,� __—_-- DRILLING LOG
Irioa ame end Number. Cemnunity, or Subdivision and Col tin .) Fan
To
3. OWNER
Address
5971;111 Noula N0.
City or Town ' f '�, ,, Stale
4. DATE DRILLED �-{- lO,-mr
5. 1OTALDEP11i____?t ---
6. CUTTINGS COLLECTED YES 0 N0Li IJO
7. DOES WELL REPLACE EXISTING WELL? YES U I
B. STATIC WATER LEVEL Below Top of Ca slug: Sa.21 FT•
(use -f- II Above lop of Casing)
g. TOP OF CASING ISFT. Above Land Surloco* --- — "—
b-- --
-Top of tut op IlCAC led shot below land eurlace requires a variance In ■sear•
--
dace ebb ISA MAC 2C.0110
10. YIELD (ppm): 11— METHOD OF TEST gig---
_�-
1 I. WATER ZONES (deplii):
----'---'---s II additional space a needed use back of Inn
12. CIILORINATION: 1y'po
Amount
13. CASING:
LOCAL ION SK=I CH
Wall elpheThickneof
Depth olametor or WeIphUEr. ,pM��al�alal _ (Show direction
loot other n� relnceerr� point!
sen al leas! � Etate
Frorn�—.To FI.eata-5-- L_ 7 e
From To FI. —
Flom
lb F1.
14. GROUT: tit, I rlal Method
Depth
From _a___ 10 ao r F-I.
From to PI. __ ----
15. SCf1EEL1: Malarial
Depth Diameter Slot Slzo
PI In. _— In.
from To -- In. _ In.
From _-To—Ft.._.--
R. In. __--- In.
From ___. To __-
16. SANDIORFlyEL p% f SI o_ I'} atonal
Ftom _i1 6
From
41 ate-- Fi.
17. REMAFlK51 �;,
i
I DO HEREB}' CFRttrr Jir'T SWELLWA9 COtts!DUCT EU IN ACCORDANCE WITH ISA NCAC 21. WELL
CoilsinUCtION STANDARlbS. AND 111AT A COII'Y br 11115 FlECOFID IIAS BEEN PROVICEO 10 NE N_.1 Ois1EFDa TE
242776
DEPIfi__
Fonupr oescdplk'
ZI , Cod;
SIoliATURE or PEtISOU Colui1111Y.T1110 1Y wED.
Submit odVlnil Io Division of IVe1er OUalliy. orparWraUr Srccn Yf
Fa.) EIS V. 1:11
a
FOR OFFICE USE ONLY
Cued No:
Serial Ito.

From —
14. GROUT:
North Carolina - Departmental Environment end Natural Resources - Division of Water Duality - Omundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636.Pbone [phone] `�
ari
WELL CONSTRUCTION RECORD WELL cow rowr ELL CONIRACTOIT cEniF CATION tit cog
STATE WELL CONSTRUCTION PERMITS:
El Agricultural ❑
1, WELL USE (Chick Applicable Solt Residential En Municipal D Industrial ---_
Recovery ❑ Ilea! Pump Water Injection ❑ Oilier El II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
County:
Nearest•
_eTown: p�°LS—�
/fI`P'
u� -- )
treed name end Nunbe s. Community, or Subdivision enJ lot tlo
3. OWNER
Address
Slieetm Ro`ula No.)
city or Town
4. DATE DRILLED -Dia-
5. 1OTALDEPT1I y 6. CUTTINGS COLLECTED YES CI HOLY __
7. DOES WELL REPLACE EXISTING WELL? YES Fr.
110 0
B. STATIC WATER LEVEL Below Top of Casing:
(use •-•• II Above lop of Casing)
9. TOP OE CASING IS FT. Above Lend Surface'
"Top of cosine ler minuted eVor below land surlecs requires a violence In eccor-
e YIELD
(gpm): J METHOD OF TEST p 10. YIELD (get»):
11. WATER ZONES (depth):
I?. CIILORINATION: 'typo 2 Amount
13. CASING:
Walt lhlrimess
Depth _sy�Diameter or
orINeighvrt. Male
Flom __t2---
To --- ET�,<nr92/
From, To FI.
To Ft.
Pep ill
noun -to-20—FI.
Flom to Ft.
15.SCREEN:
Depth
Prom
Rain To
Flom —__ To
16. SANDIGRAVEL PACK:
Depth
From lo
From To_-
17. REMARKS:
FI
FI.
Fl.
Material Method
Diameter Slol Size Malarial
In. In.
Th,
j 1 .-J 2e FfaToirl
1 DO 11E11E0Y CERTIFY 111AT tills WELL WAS CUNSITLUOTE61NtI A
COIISIRUCT ION STANDARDS, ANDMAT A CQPY OF 11IIS nECOR
[Quid
On OFFICE USE ONLY
Ito:
eriil lo.
DIIILLIIJG LOG
non 10
242805
Monllorirg O
Foncapn oescriv1io
ionalspace Fs needed tze bat' of I1*nS-
(Slow direction erd dante Icon al leas two "-ate
Roads, or oear n7 relenrce Point'
d
C
C-)wc1
0
CO
COROAIICE WRIT 15A r+CAC
I IAS BEEN PROVICED -To TIE '71--L DssiEP..
SlortA1urE or rErISON COuSTltJCtSub glnel Io Division of Weler Ouellly,BrpgndrslerSean within Yr Csy7 Ce Ip t: V. Cn
e

North Carolina • Department of Environment and Holum! Ilesourcas - Dlvl+Ion of Water Quality - Oround avator Section
1636 Mail Service Center - Fleleich, N.C. 27699-1636d'hone [phone]
WELL CONSTRUCTION RECORD WELLcotlll%ACTORCERTIFICATION 11: quo
STATE WELL CONSTRUCTION PERMITS!:
Applicable Sot): l 0 Industrial El1, WeUSE (Check Heal Pump Water In) clllon D MloilieraL I II Other, List Use:
Recovery ❑
111 location below)
2.
WELL LOCATION: (Showsketch
°le Nearest Town: courtly If�ifpGUIIO
Ifload llama end N nber s. Community. or Subdlvlslon and Lol tin )
3. OWNER f-rn
Address
City or Town
14. GROUT:
Slieni or TIEPIN 1161
Slate
4. DATE DRILLED
5. TOTAL DEPIII75' _
6. CUTTINGS COLLECTED YrS Li NOL
7. DOES WELL REPLACE EXISTING WELL? YES T10(�-
U rt.
STATIC WATER LEVEL Below Top of Casing: tp
(use •-e I( Above Top of Casino)
FT. Above Land Sur lace'
9. TOP OF CASING IS d amists requires a variance In actor -
'lop of casino lerminsled avor
dance with 15A IICAC 20.011E
10. YIELD (gpnt): _2-- METHOD OF TEST ✓)
11. WATER ZONES (depth):
' Amounl
II tt__�—.--
12. CHLORINATION: type Yl�--
13. CASING:
Zip Coda
Wall lhlc4nes1 Material
Diameter or We
From -_°---To __94-l. FI. 10-22C-__
From To Fl.
From 10 Ft.
Depth M tonal Method
From _a___
D I F I.>?L) —
From l-° Ft.
15. SCREEN:
From
From
From
Depth
To
To-
1o.
16. SANDIGRAVEL PACK:
Depth
now 10
FromTo
17. REMARKS:
Diameter
Ft
Ft.
Fl. __—_-
r
In.
In.
In. In.
Slot Site Matmlal
In.
MIti1e4a1 '- - ` j
I DO 11E11E9Y CEn1IFY 11IAT 11119 WELL WAS CONSTRUCTED 111 AC
constnUCTion STANDARDS AND MAT AC T'Y-4r-711(-RECOnU
Fon OFFICE USE ONLY
Cued Ito:
NULLING LOG
From to
Agricultural ❑
242804
Monitoring
DEPr1I__
r con x" oescriplio-
II additional space is needed use bed al krm
LOCAL ION SKI i CN
(Show direction erd dance htn al leas' two Sate
Dyads, or other rr<7 telereoce points)
"O
CJ1
O
CO
;ORDMICEWITIIIsA OJCAC?+.YltLL
l IAS DEED PROOFED 10111E 71==-L of ,EE.
SIDIIATUItE OF PERSON CONS1f11Y'11110 1Y ',AU.
OS E
Submit original to Division oI Water Duality, 0rourdwatar S.ccn widdn Y) C9YE Eel
FIE V. Lai
5,110 Do.

229233
North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] ESL(\U_E WELL
' 3I2-1
� I
WELL CONSTRUCTION RECORD WELL CONTRACTOR* kk-t`ftM SlYkkS
WELL CONTRACTOR CERTIFICATION .: 29 N
STATE WELL CONSTRUCTION PERMIT.:
1. WELL USE (Cheek Appleable Po■): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other El If Other, List Use:
Nearest
�Tlown• ,�� Cry, �(
(Road Name Numbers. �*•^ y, or Subdivision and Lot No.) ILLING LOG
3. OWNER a
From To
b Est
2. WELL LOCATTII a \ Show sR - ,of the location below)
1s' I
Oily • T. State Zip Code 5c3' la-5
4. DATE DRILL . O\
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES C NO
7. DOES WELL REPLACE EXISTING WELL? YES Ell NO[j
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' If Above Top of Cuing)
9. TOP OF CASING IS 1 FT Above Land Surface'
'Top or casino terminated atlor below land surface requires a variance In aeeer-
dance with 1SA NCAC 2C,.411L1a
10. YIELD (gem)* otU METI1OR OF TEST able
11. WATER ZONES (depth)* \'t
12. CHLORINATION: Type kink
13. CASING:
Amount
DEPTH
t1 additional space Is needed use back of form
LOCATION SKETCH
b Depth �-X•� glyppyr ,yyadat (Show direction and distance from at least two State
From To D� Ft to ( rt. Roads, or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Wall Thickness
� C!>n► dal Method k
From 13 1_. Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Skit Material
From To Ft in. _ In
From To Ft In In
From To Ft. In _ In
UI CawIVf3Favri PACK-
Depth Size Matedal
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT,THIS WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THATIA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1/4,..STuifig —URA-KO
FOR OFFICE USE ONLY
Quad No:
SIONA PERSON CONSTRUCTING THE WELL
SUSI oipinwl to Division of Water Quality, Groundwater Section within 30 days
tNMI No.
0W-I REV. MN

230143
North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27669-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' Cli-kce k9e11 1)12.�1/
WELL CONTRACTOR CERTIFICATION N: 9 b C S
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable Pox): Reeldeneal li Municipal ❑ IndUbtrlal ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heal Pump Water Injection ❑ Other II Other, List Use:
2. WELL LOCATION: (Show sketch pl the locallon below)
Nearest Town: i44/ES ✓ I I i e County.
kiZCS C&eek—
(Road Name end Hunterrs,, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER SO)% G-46-ti=01`-) From To Palmation Description
Address 11 I Li Ri'.hityicto 2D 0 2 0 ' &T C �V (Sheet or Route o. ` 0 6p7' (�-T/9h-"7�
YiIsitncK'e Ft_. - 3oI
City or Town ' State Zip code 4. DATE DRILLED y` 2 Di rJ
5. TOTAL DEPTH 607
V o {
6. CUTTINGS COLLECTED YES NO[a—
7. DOES WELL REPLACE EXISTING WELL? YES in NOn- . n
8. STATIC WATER LEVEL Below Top of Casing: FT. cr
9. TOP OF CASING IS / FT. Above Land Surface'
H
'Top of cuing terminated egor below land Surface require. a variance In actor-rico
dance with 15A NCAC 2C .0116 10. YIELD Wpm). METHOD OF TEST /2 'e•(As N Lrn�
(L/s4 II Above Top of Casing) f
m
If. WATER ZONES (depth)• o "
'w
0
12. CHLORINATION: Type /7/7 /7 Amount 2 C.‘19-
II additional apace Is needed tree beck of form
13. CASING:
Well ThicknessLOCATION SKETCH
C) Dept 0 , DIp ter or W !gyp. ,Material (Show direction and distance from at least two Stale
From To" FI b r.l /- ° e- Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth atedal` Method
From f) To Ft .LmtJ/
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To FI In In
From To Ft In In
From To FI In in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY <, /
Qun: 1J
Mad No: .1t, t ..U,,,•I' SIGNATURE 0 PE CON9TRUCTINO IRE WELL DATE
IdjN7 r 1 tSub ,,;;
odghlal to Division of * er Duality, Groundwater Section within 30 days
Serial No. OW -I REV. 12799

North Carolina - Department al Environment end Natural Resources - Division of Water Quality - Groundwater Section 2 3 `J 1 4 9
1636 Mail Service Center - Raleigh, N.C. 27899-1838-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' ChIl-E-c-
WELL CONTRACTOR CERtIPICATION 0: 2-3-6 a --
STATE WELL CONSTRUCTION PERMf -o: •
WELL USE (check Applicable boa): Residentiallif Municipal ❑ Indualdat ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r�%i-✓ES1/I County l.Lv;rY
1 RCS/ C -E
(Road Name and Numbers, Community, or SubdivisionandLet No.) DRILLING LOG DEPTH
3. OWNER 6-e fQ From To Fomullon DesedpUon
Address �X ,> s Sc 7 cJApp
er Route r�.) �,A /JsS / i_/
ite
City or own 'Stale Zip Cods
4. DATE DRILLED 7" .2 0.. 0 1
5. TOTAL DEPTH /9') "
a
6. CUTTINGS COLLECTED YES f] NOf}-
a
7. DOES WELL REPLACE EXISTING WELL? YES n N0rr
8. STATIC WATER LEVEL Below Top of Casing: )..a FT. =
Tar prfl
WOO**. If Above Top of Casing) .-< 9m
9. TOP OF CASING IS / FT. Above Land Surface' T o
'Top of easing terminated sVor below land eudsce Squirt* a variant* In actor- >0 `
dance with ISA NCAC 2C .0118 ,,,D 10
ID. YIELD (gpm)• S`J METHOD OF TEST /9
11. WATER ZONES (depth): %J P'
12. CHLORINATION: Type /7' % Z9 Amount T
13. CASING:
C4,60
Wall Thickness
Depth _ D�ntelr Of yaighVFt. Material
From To ° 5 Ft !k)091 4-'
From To Ft.
From To Ft
14. GROUT:
Depth O Material____ Method
From 0 To 2-51 Ft L .f nt/
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To FI In In
From To Ft In. In
From To Ft In In
18. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To Ft
17. REMARKS:
� c74:
0 --r
tl additional space is needed use beck of form =
LOCATION SKETCH
(Show direction and distance from at leas) two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
`. Sicouvruni &1F PERSON CONSTRUCTING THE WELL DATE
Submit odgt N to Division or Water Quality, Groundwater Section within 30 days
- „.:.. GWI REV. 17199
ti •

North Carolina - Department of Environment and Natural Roseate's • Division of Water Quality - Groundwater Section
r Ha�tF9Jt L�� LAaL law-1 uG -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ^
WELL CONTRACTOR CERTIFICATION S: 0A9
STATE WELL CONSTRUCTION PERMITS:
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
(Road Name
3. OWNER
A as
229230
1. WELL USE (Check Applicable Box): Residential Ll Municipal 0 Industrial 0 Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATIO t - how sketch • the location below)
Nearest Town: - - '4't = - - - •_ County 1�
1e — `.. CHIT
Numbers, j��yy'Ryl, , er Subdivision and tel No.)
gra ' 4:
CityorT Stale Zip 4, DATE DRILL- r D
5. TOTAL DEPTH —.A-
DRILLING LOG DEPTH
From To
b tn1
=.! ask.'
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES NOD
8. STATIC WATER LEVEL Below Top of Casing: 5b FT.
(Use •.• a Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance M war -
dance with 15A NCAC 2C .p 16 -
10. YIELD (gpmp t METH OF TEST 11. WATER ZONES (depth)•
12. CHLORINATION: Type
13. CASING:
F lion Des
Amount If additional space Is needed use back of form
Depth � Wan Thickness LOCATION SKETCH
From�TO tr`�1 Fttiti MwMI (Show direction and distance from at least Iwo State
From To Ft.
t'u Roads, or other map reference points)
From To Ft
14. GROUT:
73 From To Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft In _ in
From To _ Ft. In In.
From _ To _ Ft In. In
+a tanmrnaeye' earte.-
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORDA HAS PROVIDED TO THE WELL OWNER.
2frL /�A?J1at.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Sohn* o lgMY to Division of Water Quality, Groundwater Section within 30 days
0W-1 REV. 12AM
s
Bedal No.

1 oilli lair Carolina
-cDepartme t of Raleigh,Environment
and
- 16a6-I hone (urco919) - Division
2 to of Water Quality • Ground water Section
636
Sery
e Center
WELL CONSTRUCTION RECORD WELL cop-DonAci w-ton c n 1r,10N II:
STATE WELL CONSTIIUCTION PERMITN:
1, WELL
eCo USE (Chick Applicable Boa): Water
Injection
Municipal 0
Indust:lai ❑ Agricultural ❑ Monitoring 0
Recovery O !teal Pump Water Injection ❑ Other ❑ It 011teh LIM Use:
2. WELL LOCATI N: (Show' sketch of Ike location below)
- I)I,p _ County:
Nearest lawn:
Imo ad a and Humbert Community. or i uomvislon �dlotI� 3: OWNER �.ien �
Address 3Cc swu'f 9
1,pin Flo.
ityr / Town
Slate ._-- Zip Cora
City r Town
4. DATE DRILLED
5. 10TAL DEPTH isa r
6. CDTENOSCOLLECTED YTSLI Nop-
7. DOES WELL REPLACE EXISTINGFto4-
WELL? YES i—J Ft.
STATIC WATER LEVEL Below Top of Casing:
(Use •.• II Above Top of Casino)
9. LOP OF CASING IS - FT. Above Land Sur lace*
•Top or casino terminated sVor below land turf ace requital a variance ht actor
dance with ISA ncAc 2C.one METHOD OF TEST _ Q ---- —
10. YIELD Wpm): _AD
11. WATER ZONES (depth):
12. CIILOFlINATION: TypoAmount
13. CASING:
Depth
Frorn_�--10 '9O
Flom To El.
From —
14. GROUT:
L/
Wall l,dcine ss
Diann:dor ors�ght/TI. Material
n.-
To Pl.
Depth h Medal Method
—
From __L2l0 �� rl• n � _
ROM 10 rt..-_-------__- —
15. SCREEN:
Depth Diameter Slot Size Material
Ft
1 o _
From __ In.
To El. In. _—
From _— In.
Flom __ To •---
FL__— In. .--
16. SANDl i/E P (.I. m, �li Si
To
Fro
l 10 FI.
From ITS ?off —' FA,
17. REMARKS:
I DO H REBY GEC1JfEY,"T1tP
L WA
CotIS nueROWS t NnAnosA0hWAC AT A'
FOR OFFICE USE ONLY
Du ad Ho:
Material
MILLING LOG
From To
aaUoc,
242765
DPW
P orrr.a xn De scriptio-
11 additional race h needed t_ze bad of 4lrn
LOCATION SK= I CH
(Show direction and d's-'ante barn al lnas! t,eo Slate
Roads, or other n27 releorce potnn`
CONSTRUCIE091 ACCOROMICE WITH 11A NCAC
OPY Or 11115 RECORD HAS BEEN PROVICED 10111E W OwIEF O
pelf
SIOIIATUfE or POISONcoti SIfllJC tNt'n' OT 'ELL
Sub' dl original to Division of Waler Quality. 00Nrldrtlu S.ccn Within Yl csy5
Ee•I FIE V. I:T1
a
Serial 110.

1lorth CaI Itna • D r n,erenlol o a Environment
nodINatured
at rof He OM a 7- tiM,l 1 i of Water Quality • Ol ound neinr Section
636
WELL CONSTRUCTION RECORD WELL
ELL COtnl1AC10ncc lncn 1011 Ili
SIAlr WELL CONS' IIIICTION PEDIAITH:
��, Industrial ❑ A9
rlcullural 1� MonitoringU
neco 1, 1USE (Check eal Pump Wa erslrnjection LI r^IOili Ira j II Other, Usl Use:
ecovery [J h
2. WELL LOCATION: (Show sketch of the location belownry: ) /, I
Dearest lows: ouL a
( e or (mood lame uW.1lumbers. Community. or Subdtvlslon end Lol tla 1
3. OWNED JCS - C-0��t
Address
DIIILLING LUG
roan Flo
JSli eel UMW, rlo.) _ �A ,_
_____ ----'- --_- 71p Code (� s,'
Stale
CllDnitt,r Li
4. Unl E UUILLEU 3-L9' D!:
5. 101AL DEPI l l 6 -
6. CUITItIGSCOLLECTEU Y` SI_ I IJU ITh -- IJU
7. DOES WELL UEPLACEEXISTINGWEL17 ESSLi iioL4
D. STAI IC WAl E11 LEVEL Below l op of Cosine: ve lop of Casing) •
g. l0 P OF CASING IS 1 _ Ft. Above Lend SurInce'
,lop of ceglop lnrnin,lnd ,Vor blow land ,enlace tequila, s vnlu,ce In actor
dance with 15a TIC*C 20.011a
I
10. YIELD (pm): -�- MEI I IOU or TEST ---
1 I. WATEU ZONES (depth): wasp h necCed tze ba v of Ivtn
II additional s.
12. CI ;IODINATION: 11,e� -- LOCAI IOIJ SK_ I CN
13. CASING:
DWan jiklooese Sod's:anca b:rn al l0 at:lro Sale
Diameter or WelphVfl. I.laleolal (Slow direction andpoints!
Depth C floods. or other Tr-...L.-7 relenrc=
Fwm _Il V
non
To FI. -
From'n
to PI.
14. Gn0U1: Material
Ueplh
�- l e .�rt
— . R_.."— --
Ft ore From
lo II.
Depth Ulantelor Slot Ski 15. SCflEEIJ: Mnlodel
lo_—Ft-_— In. In.
FloFrom In. In.
16. SANDIGNAV 0� CK -- Sl7e iOlollal
1
--
r,om 'I'i, ,.
,,, rt:/,
now 7b_',._-Ft.— --
17. DENIAF11(Si 1_ tons'
I OI SIn ci oilst amnos.AN MAWAcyor111C1rOlIIIl0IIM EEII IO1C€ lull E.v I
COII51 nUC110N STANUAl105, AND MAT cony OF 11113 fIrCO� U I InS UEEN PIIOVIEEU O 111' 71:1-1-altiEE.
oe TE
ae
242799
Pill l----
fonrJx, Desuiptio-
SIOnnTtloeorrrn9011cossos/CI 'Decec' Ell. 97c3Y�
Sub, Jl 01101111110 Uivldm, el Tiller p ldtr, Oround cis" FIE v. I: n
OR OFFICE USE ONLY
0uad Ho:

North Carolina • Department of Envlronmanl end Nalurd flesoorcae • Dlvlelon or Water Ouaiiiy • Oroundwaior Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION ION RECORD WELL CORII%ACTOR cErIrlcATiot4 a: ay0
STATE WELL CONSTRUCTION PERMITIO
1. WELL USE (Check Appnceble Boxy ResidentialQ-----Muntclpal ❑
Industrial D Agrlcuiwral ❑ Monlloriry LJ
Recovery ❑ Ideal Pump Water lu(ocllon U Oilier U II Other, List Use:
2. WELL LOCATIQN: (Showsketchof the location below)
County:
Nearest 1 own:
P.l Il __
(noa ame end Hurlbut Community or $ybdlvlslon and Lot Ito)
3. OWNER •S.1-
Address
j5beol or Rorila Vol
'-'------ —Stale
City or Town
4. DATE DRILLED
5. TOTALDEPII!
6. CUTTINGS COLLECTED Y(SCi iJoLU-
7. DOES WELL REPLACE EXISIIIJG WELl7 YES U
IJOO_
B. STAI IC WATER LEVEL Below Top of Cesium 616140 PI
(Use •s• 0 Above Top of Casu'0)
9. TOP OF CASING IS
FT. Above Land Swine*
*lop of to stop trtmineted ,Vor below land eurlace requires a vnimice In eccor•
dance with 15A IICAC 2C .011E
10. YIELD (gum): _�4-- METHOD OF TEST
1 I. WATER ZONES (depth):
Zip Coda
��,��-�-�,�,k��� Amount __----
12. CIILORINATION: 1}'po r-�� -�-`�
13. CASING:
Wall thickness
Depth Ulamalor or WelQ �a��+l
Flom -To �`=— r-I. SR�—
Flom To rt.
From 10 Ft.
14. GROUT:
From 0
From to Ft.
15. SCREEN:
From
From
Depth M�Idal Method
To Q—FI..Qv / /U�2.�L- L
Depth
To
To.
From To
16. SAND/GRAVEL PACK: Size
Dept'�'\
rl0m
l o ,
glom To;l- rt.
17. REMARKS:
I MC
IDOHEREBYCERTI YTII�1111SWET:1,t't% O Q.TIII
CONSIRUC110NST NDATIDS,,AND l�i1l�`�,Pr 1:F,-,rE
F1
rt.
PI.
Dtamotor Slot She Malarial
In.
In.
hi.
In.
In.
In.
FOR OFFICE USEONLY
Clued No:
DRILLING LOG
Fwm 10
242812
DE71H_
F onuxn DescripGo-
II additional trace is needed use ban of lcfrn
LOCAL ION SKETCH
(Show direction erd d'a'.ance Irzwn a, loan two Slate
floods, or other rr<2 relererce Point')
O
O
rn
03
C
0
CI -
onr_r
;yC
rn
m
cnz
rra
CT
0
EON ACCOROAHCE WITH i5A IIICAC C. Y%ELL
RECORD 11AS BEEN PRONGED 10 T11L '7/E. -L ow'E
02
SmiATUNE or PC1e011 CotSTi1Y.v°c
Da'F
Sutl i original ie Divlllan of1VHer 0ue1117,Brovnd;Sr<^IUIn :fiYT
6 n,l pie v, 0. T1
e
Serial lie.

229231
North Carolina • Department of Environment and Natural Resources • Division of Water Qualify • Groundwater Section
1636 Mail Service Center • Raleigh. N.C. 27699.1636•Phone [phone]
* (MA l E W EU— )69--t U, I NC; —
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION I: saCtSS
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (clack Applicable Soo): Residential Er Municipal 0 industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL LOCATI a . (Show ak6 , I the location below) n
Neatest T•'-.,_-\C4�v..•1.\_11 \` Q
eaS 0ai�1
(Road Na - •�°�n�,,I on and Lou No )
3. OWNER ..r�j\�
ti la A • • as can 'ice•,
Sin
pT
4. DATE DRIL r i70
Zip Code
DRILLING LOG
From To
b 4k'
—LS
a
5. TOTAL DEPTH EL rl V R2,
6. CUTTINGS COLLECTED YES EI NO2r 111 )
�
r
7. DOES WELL REPLACE EXISTING WELL? YES NOE( I-h I
6. STATIC WATER LEVEL Below Top of Casing: rat FT. )�� �r
(Use •.• I Above Top el Casing)
9. TOP OF CASING IS. I FT. Above Land Surface'
'Top of casing terminated evor below lend surface requires a variance In tweer-
dance with 15A NCAC 2C .011a
10. YIELD (gpm)• 1 O METH ¢Fi TEST �-k
11. WATER ZONES (depth): `J
12. CHLORINATION: Type +11# Amount
13. CASING:
From —CI —To th• t , ( Ft 'a 4 V-n t
From To
From To
14. GROUT:
thai
From C) , To 'tic
From To
15. SCREEN:
Depth
From To
Ft
Ft
Ft.
Ft
Wall Thickness
Diameter Slot Size Material
Ft in. __ In
From To Ft. In In,
From To Ft. in In
16. SAND/GRAVEL PACK:
Depth Size Matadi"'
From _
From
17. REMARKS:
To Ft
To Ft
DEPTH
Fermiliry) Description
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at but two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS Wets
CONSTRUCTION STANDARDS. AND _,.
FOR OFFICE USE ONLY
Quad No:
CyONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Y'OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1JOiyu
$IONATUnE PER!#ON CONSTRUCTING THE WELL
Nubmg Olga to OMalen of Water Quality, Groundwater Section within 30 days
Radar No
OWI REV. 12/a1

3. OWNER
Address
229228
North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center. Raleigh, N.C. 27699.1636-Phone [phone] `i)t `LE WQt-' Q1U-1 „6
WELL CONSTRUCTION RECORD WELL CONTRACTOR si°"e e rbArt—
WELL CONTRACTOR CERTIFICATION I:
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Applicable aoa): Residential I/ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO - how eke `of the location below)
Nearest T. s-�`-1._, . I Cotmly
ame ` ^1�' �„^�'t-fi or Subdivision and Let No.) DRIYLING LOG
City or Town _ 1 1 state
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ'
7. DOES WELL REPLACE EXISTING WELL? YES fl NO�
8. STATIC WATER LEVEL Below Top of Casing: JRj FT.
(Use'.' ft Above Top of Casing)
9. TOP OF CASING IS \ FT Above Land Surface'
'Top of casing terminated auor below land surface requires a variance In accor-
dance with 15A NCAC 2C .Qys
10. YIELD (gpm): 1\ METH�,q,,Of TEST 6331-
11. WATER ZONES (depth).
Zlp Code
From To
w.' 5131
ats'
12. CHLORINATION: Type 'i'E Amount
13. CASING:
��1, Q ►� wo�aaftvVTehhJips�a1�wYas
From b DTo h Ft �)led7.i, _
From To Ft.
From To FL
14. GROUT:
From O To l_ Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft In _ In
From To _ Ft In In
From To _ Ft In In
DEPTH
F t De
If additional space is needed use back of lorm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference paints)
4a e..C! Oery
....,...._rn Armlet a�W_..... Depth
..
Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL
gubmtarykw b Division of Water Quality, Groundwater Section within 30 days
DA
01P/6 /
WY No.
GW.1 REV. 17/95

229229
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
tt+`itu-E I.JQI_ It2-tw I4 —
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION I: c
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable sox): Residential (B Munkapal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery Q Heat Pump Water Injection Ej Other If Other, List Use:
2. WELL L • ON w ekeloh • location below)
Nearest .:.. .. h�_� \ i�1
r County
woeT• State 21p
4, DATE DRILL 0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOCEr
7. DOES WELL REPLACE EXISTING WELL? YES NOE(
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use.' II Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface'
'Top of casing terminated Wor below land surrace requires a variance In accor-
dance with 15A NCAC 2C Fin
10. YIELD (gpm): to METIIQDQF TEST /A-
11. WATER ZONES (depth). ��lh�}}
12. CHLORINATION: Type
13. CASING:
Amount
It additional apace Is needed use back of form
QQII-- �}� WaeTleekrrsa LOCATION SKETCH
From DepthTo Ft are a1 d r t 1t L. (Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft.
From
14. GROUT:
To Ft
From C) To Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft In
From To Ft In
Frdm To _ Ft. In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
In
In.
In
0
v
a °"3
70
17. REMARKS:
I DO HEREBY CERTIFYLIWO T$IS IfEII4 WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS: 0eCtIWAT A:COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE or PERSON CONSTRUCTING THE WELL DATE
tbe. original to Division of Water Ouallly. Groundwater Section within 30 days
OW1 REV. 12/91
FOR OFFICE USE ONLY
Clued No:
Serfs. No.

North Carolina • Department of Environment and Natural Resotaoee • Division of Water Quality • Groundwater Section
t-1iViESJLLLE LJaL 1121t_t_t NCB —
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t 144 - E I A\ J
WELL CONTRACTOR CERTIFICATION e: oaq
STATE WELL CONSTRUCTION PERMIT.:
1636 Mail Service Center. Raleigh. N.C. 27699.1636-Phone [phone]
FOR
Quad No:
Serial No
229225
1. WELL USE (Check Applicable Sea): Residential Q Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO \ •
m
Nearest Town? 'Vs 1`,• ••\
(Road Name v,{�� '�*'^—!t+
3.
NER Lti•� .,�visk
• ¶fit.
ten ati �� � I•
w sketdh f'r . location below)
Canty �1
CIy or T
4. DATE DR 0 b
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES.)
7. DOES WELL REPLACE EXISTING WELL? YES'D NOE-
8. STATIC WATER LEVEL Below Top of Casing: LFT.
Abo
ve Top of Caektg)
9. TOP OF CASING IS. I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires s "dance Ni actor -
dunce with 1SA NCAC 2C 11a
:cub/10. YIELD (gpm):cub/9 METH F TEST �.+��•-��
11. WATER ZONES (depth).
Lot No.)
State Zip
b
DRILLING LOG DEPTH
From To
o abi
104) ILP:
12. CHLORINATION: Type * Amount
13. CASING:
S4�_.
Depth'' ,, II
From_ �_To .
From To
From To
14. GROUT:
till
Wall TNdWeu
Ft. Tf ro`t'`+ T
Ft
Ft
From To � . Ft.
From To Ft
15. SCREEN:
From
From
From
Depth
To
To
To
Diameter Slot Size Matedal
Ft hi
Ft In
Ft. In
In
hi.
In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft
Forma on
If additional space is needed use back of lorm
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
0
-o
vt
440
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS/..BEEN PROVIDED TO THE WELL OWNER.
OFFICE USE ONLY 0e-cvz Cam. /'i}�C.4rx. /6 b/
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
SubrrA Manila Division of Water Quality, Groundwater Section within 30 days
Ow•I REV. 12191

North Carolina - Department of Environment and Nalurol Resources • Division of Water Quality • Oroundnater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636 Phone [phone]
WELL CONSTRUCTION RECORD WELLCOII1f1ACTOf10Ef1TiFIC TION p: o?C7o�/ r11t�_J
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (chuck Appllceblt Poa): Residentiala— Municipal ❑ Indusirlal ❑ Agricultural ❑
Recovery ❑ Heal Pump Water Injection LJ Other ❑ II Other, List Use: _—
WELL LOCATION: (Show sketch of 11 location below)
e ����
2• 4 la County:
Nearest Town.
I 2Ooi--11--- of llo
(nand llama end numbers. Conalunt�jv1. or Subdivlslon end Lot ito )
OWNER t I� \'C IIPL�>o1
Address
5lieo1or Ilo`ulo
City or Town Slate
4. DATE DRILLED 01-a3-O/'
5. TOTAL DEPTI IC- S '
6. CUTTINGS
COLLECTED `ITS I �— ILO0-
7. DOES WELL REPLACE EXISTING WELL? YES
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+• II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surlace'
--- ---••has a variance In actor"
-Top of whip terminated ettor below '/� n
Banc ewith I (gCA Ir ): 2C .0118 MET HOD OF TEST L-.g.----
10. YIELD (gpnl):
11. WATER ZONES (depth):
12. CIILORINATION: Typo
13. CASING:
Deplli Ulametar
r-rom__._—To
To Ft
To Ft.
From —
From —
14. GROUT: p1 toilet
Depth To . 9(0 PI.
Zlp C«la
Amount
Walt lhickness
or Weight/Ft. Material
From
From to Fl.
15. SCREEN:
From
From
From
16. SAND/GRAVE
Depth
To
To.
To.
From
From
17, REMARKS:
I DO I IEREBY CE
CONSTRUC110N
roll OFFICE USE ONLY
Quad No:
Seriil Ilo.
Diameter Slot Slzn
Ft
Ft
Fi.
Method
Material
DRILLING LOG
Fwm To
SJ 5`
5r //'
242791
Monllorirg ❑
UE7f11_
Fonn>m Descriptio-
)iQ
II additional trace is needed use back of Iclsn
LOCAL ION SKc I CH
(Show direction sod dance barn 21 lees' tr'o "-ale
floods. or other rr ap relererca point!
O
0
1
CO
3
cn
J
TIFY,T1/TTLr.rfNS 1L
5:-ANrcrTr,v7-00'YU-rfilRECORD IIAS BEEN POViCEO io in is vat-
an
/ 51UNAtUnE OF PE11S011COn51111Y.111f01>t'rv'E oar E
Submit original to Division o1 Wider Ouillry around.raltr 6accn wild iln Y) ct ys Ca•I ptE V. I a1
a
C
0
crn
m
Do
'-
ma
�m
cnz
m�
t-4
0

North Carolina -sparoanp rl 1 of Envlronmenl and Hahn& rlesourcos - Division or Water Duality - Oroundwam, Section
242825
11�, rkPAIN/
1
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phmre (919) 733.322
WELL CONSTRUCTION,RECORD
WELL CONTnncToil:
WELL CONTRACT on cERTIrlcnlloN II:
SPATE WELL CONSTRUCTION PERMITM:
1. WELL USE (check Applicable nos): Resldonllal❑ Municipal U Industrial ❑ Agricultural 0 I4onllorin9 ❑
hecovery ❑ Heal Pump Water Hearth ❑ Other Lf II Oilier, List Use:
2. WELL LOCAT RN: (Show sketch of the location below) ���
Nearest sown:
I •o S r ') / County: — 1---
J4)7j:•
head rlam
3. OWNER
Address
unb�Com�olly, gr Subdivision and lot I lo.)
SlieelTi ()FA no
---------Suit
Clly or Towne Slfle
4. DATE DRILLEO2 —
5. TOTAL I)EPTII 159/e r
6. CUTTINGS COLLECTED Yfs Nog--170
7. DOES WELL REPLACE EXISTING WELL? YES �r HOU
6. STATIC WATER LEVEL Below lop of Casing: p
r.
(Use '4' 11 Above Top of Casing)
g, TOP OF CASING IS_1-__-
FT. Above Land Smlaco'
'Top of wimp lerminaled aVor below land surface ;squire'sna variance In accor-
10. YIELDe with ISA (wpm):
2C,011e MEI HOD OF TEST ,�i1.i -----
10. (gpnl): -�-2--
11. WATER ZONES (depth):
�--
12. CHLORINATION: Type Amount
13. CASING:
Zlp code
Wolf lhlckness
Depth ulanrelor or WelghUFI. Material
p�.
From.--Ta
From To Fl.
Rom To Ft.
14. GROUT: MedalMethod
f
To _2 rt.
1 o FL
_------
From
From
From
15. SCREEN:
Ffanl
Flom
Flom
Depth
to
To
To
16. SAND/GRAVEL PACK:
Depth
From To
FromTo
17. REMARKS:
Diameter Slot Site
Ft ._— In —_ In.
Fi. __ In.
Fl.-- $l:
I DO HEREBY CERTIFY 11IAT T
conslnucTION STANDARDS.
FOn OFFICE USE ONLY
Cued No:
Material
yq wrT1 WAtxdotisJnUCTETY1Fl AC
AND 1 i TAT A pQPY or I I ITS new
[MULLING LOG
From
b
To
C r
DEPTH_
Formaxn Descriptio-
II additional space Is neede4 l_Ke bats of tcirrs
LOCAL ION SK= I CIA
(Show direcllon erd do'ance Irrn al Inas::r,o Stale
Roods, or other rr22 relent -co polars!
OnDANCE WITH ISA AJCAC r. WELL
IAS BEEN PRONGED 701IIE 7fSti_ OIa-EP.
2. 05-0,
SIOrIATUf1E OF pEr1SON CONSTIItY.111101Y WELL
Of E
Submit original Io DIvldon of We1er Quality. Brodno-till' Srccn witllin !C r%sys
CIA prEV. I_it
e
Serial llo,

229226
North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
¥k ES1J%LLE LJEL b12.L L-11Y>, -
WELL CONSTRUCTION RECORD WELL CONTRACTOR: - - 2 O5 1C -1'^^"""
WELL CONTRACTOR CERTIFICATION e: r�9.7'1
STATE WELL CONSTRUCTION PERMIT&:
1636 Mail Service Center. Raleigh. N.C. 27699-1636-Phone [phone]
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other Ej If Other, List Use:
2. WELL LOCATION: S • sketch the location below)
Nearest T
or own
4. DATE DRILL 0
5. TOTAL DEPTH
ains
DRILLING LOG DEPTH
From To
e94.6t
6. CUTTINGS COLLECTED YES ❑ NO3—
7. DOES WELL REPLACE EXISTING WELL? YES NO[i�
8. STATIC WATER LEVEL Below Top of Casing: \ t FT.
(Use ••• a Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
*Top or easing terminated eVer Slow land surface requires a variance in moor -
dance with 15A NCAC 2C4t,111
10. YIELD(gpm)• .'S(] METI, G0_QFTEST
11. WATER ZONES (depth)
12. CHLORINATION: Type Amount
13. CASING:
Depth
From To
Wae TNdmoss
Ft. tent?' ti% 3"S/C..,
From To Ft.
From To Ft.
14. GROUT:
From To L.— Ft
From To Ft.
15. SCREEN:
Depth Diameter Slot SIzti Material
From To Ft M In
From To _ Ft In. In.
From To _ FL In In
16. SANO/ORAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
omyllon Description
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
•0
'V
rn
--0
cm
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCTION STANDARDS. AND
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quid No:
Se4Y No.
«ci
a�7co �.ae a .
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit enplliaI to Division of Water Oually, Groundwater Section within 30 days
t p E' m c - SecEi)tJ Own REV. 12/N
nttsl 0-!:_ ..

229227
North Carolina • Department of Environment and Natural Resources • Division of Water Oualiy • Groundwater Section
tt1�1�ESJtutr 'Zak— Da-"u(►r,, -
WELL CONSTRUCTION RECORD WELL CONTRACTOR•
WELL CONTRACTOR CERTIFICATION It: -
STATE WELL CONSTRUCTION PERMITS:
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone]
From
From
15. SCREEN:
Depth
To
To
4a eantrvnesuet e&PIC.
Depth
From To
From To Ft.
1. WELL USE (Check Applicable Soa): Residential Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other Ej If Other, List Use:
2. WELL LOCATION: , • sketch • e location below)
Nearest T
y or Town
4. DATE DRILLE
5. TOTAL DEPTH
LLING LOG DEPTH
From To
6 15'
15 4.0
(act a>6'
6. CUTTINGS COLLECTED YES ❑ NO [Er
7. DOES WELL REPLACE EXISTING WELL? YES NO[f
8. STATIC WATER LEVEL Below Top of Casing: SD FT.
(Use •.• If Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated War below land surface requires a variance In mica -
dance with 15A NCAC 2C
10. YIELD (gpm)• METRO tOF TEST a.K-
11. WATER ZONES (depth).
12. CHLORINATION: Type t't"
13. CASING:
Forma De
Amount If additional space Is needed use back of form
Wall ThicknessLOCATION SKETCH
//�� Depth 6S g1MMtlr Ink �k1y4U (Show direction and distance from at but two State
From�LLTo Ft. 1sr4T . Ttl� Roads. or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
DepthTo,
65 Ft
To . Ft
Diameter Slot Size Materiel
From _ Ft In _ In.
From _ Ft M In
From _ To _ Ft. in In
She Material
FL
or
C 2:
ri
c)
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
£%tW C.., A.00Chet /o/
SIGMAYURE OF PERSON CONSTRUCTING THE WELL DA E
*An edginS to Division of Water Duality, Groundwater Section within 30 days
OW1 REV. 12M
FOR OFFICE USE ONLY
Clued No:
Sethi No

229195
North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699-1636-Phone [phone]EU1LLE W az_ 'Qt L.I., I V! a
WELL CONSTRUCTION RECORD WELL CONTRACTOR �-1
WELL CONTRACTOR CERTIFICATION e:
STATE WELL CONSTRUCTION PERMITS:
2iSS
1. WELL USE (Check Applicable Box): Residential Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL
Nea
L
T
All
(Show sketc
the location below)
(R d Na
a--
_R ► i
3. OWNER ►'�s.�i�_� \�t_►�
• ea •
sIE ., a
a '*nali�
IT
Town State Zip Code
4. DATELLED ), bat5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO 9 10bl Iat f
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD' 1 -I I etS Sr
8. STATIC WATER LEVEL Below Top of Casing: I t-) & FT.
DPFFLLING LOG DEPTH
From To
h as'
(Use •.• a Above Top of Cuing)
9. TOP OF CASING IS FT. Above Land Surface'
Top of casing terminated stir below lend surface requires a variance In actor -
dance with 16A NCAC 2C h,. 1,s
10. YIELD (gpm)• bo MET OD OF TEST Q'
11. WATER ZONES (depth): VAbt
Am-, 403'
S �3' Lbai
t bah
lr 4l
12. CHLORINATION: Type kl Amount
13. CASING:
F• y• Description
It additional space is needed use back of lorm
WadThlNtmww LOCATION SKETCH
Depth P T •tt r a W hVFtl mW (Show direction and distance from at least two State
From--.0—.To--.0—ToSPS Ft. in P G Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Dept¢ Ma I
From D To bs Ft t .••
From To Ft
15. SCREEN:
Method
Depth Diameter Slot Size Material
From To Ft In In.
From To Ft. In in.
From To _ FL In _ In
16. SAND/GRAVEL PACK:
uepm atze matdnm
From To Ft.
From To Ft
17. REMARKS:
O
a
-u
IV
a
3
0
Cn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RE" RD HAS BEEN PROVIDED TO THE WELL OWNER.
\So 61 d/
SIGNATURE R N CONSTRUCTING THE WELL i Zilr
OAT
Submit anginal to Division Ater Quality, Groundwater Section within 30 days
OW-1 REV. 12199
FOR OFFICE USE ONLY
Quad No:
Serial No.

229194
North Carolina . Department of Environment and Natural Resources • Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] W(VESI`UE W r De-1,
vC� QJ Us' f 1,�
WELL CONSTRUCTION RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION e:
STATE WELL CONSTRUCTION PERMIT#:
a`t3�
1. WELL USE (chick Applicable Sox): Residential al Municipal 0 Industrial 0 Agricultural 0 Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI • : .ow sketch of the location below) n
Ne - rest T•to ; 4—L� County `
talk
(Road Name - • Numbers, • • • , a`bdfvlaion and Lot No.) DR LING LOG DEPTH
3. OWNER "t�f_ �11 . �w►`,aVl k ! _ —a
Address Se `..��„!1yR1SM
Ilks
City ar • 1 1 I
State Zip Code c�
4. DATE DRI LED -� O / 1 ,
5. TOTAL DEPTH ✓qk' 2&P p` --t
6. CUTTINGS COLLECTED YES ❑ NO[
7. DOES WELL REPLACE EXISTING WELL? YES j❑ NOL 1
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.' Il Above Top of Casing)
9. TOP OF CASING IS t FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance in accor-
dance with ISA NCAC 2cc,l�..,,0,, �$s
10. YIELD (gpm): r=J-LJ METI1O • (IF TEST all,
11. WATER ZONES (depth)* \ _�} ll I
From To
O Di
c
Fonna Description
12. CHLORINATION: Type 1rt1 tt Amount If additional spare Ls needed use back of form
13. CASING:
Depth
_� d�/ �y r w� I
From�_To �9_ Ft � .S�
From To Ft.
From To Ft
14. GROUT:
Deptpe[
From b To o Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In in
From To _ Ft In In
From _ To FL In. _ In
16. SAND/GRAVEL PACK:
14 II_.n J-,I
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS $EEN PROVIDED TO THE WELL OWNER_
FOR OFFICE USE ONLY
Ouad No:
SIGNATURE RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Groundwater Seaton within 30 days
Ow REV. 12A9
Serial No.

ttl llFwtLLE SL Dau 1 A1SiWELL CONSTRUCTION RECORD WELL CONTRACTOR• EA�1 t�cK 1C
WELL CONTRACTOR CERTIFICATION I: sag '
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATION. .. sketch • f
Nearest Town:
rJS
(Road Na
3. OWNER
a
229201
North Carolina • Department of Environment and Natural Resources • Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
e location below)
11��� County:
or Sub:viator and lot No. DRIL'QING LOG
ow or T. Stale Zip �^ 14I
4. DATE D - 0 a-e 14�- .oS •
5. TOTAL DEPTH -ice
8. CUTTINGS COLLECTED YES NOf
7. DOES WELL REPLACE EXISTING WELL? YES (� NOE(
8. STATIC WATER LEVEL Below Top of Casing: L� FT.
fuss Y' II Above Top or Casing)
9. TOP OF CASING IS ` FT. Above Land Surface*
'Tap of casing terminsled aloe below land surface requires a variance In seeor-
dance with 1SA NCAC 2 gyte
10. YIELD (gpm)• ab METH 9F TEST
11. WATER ZONES (depth). k�t
From To
h 151
ISt 55
12. CHLORINATION: Type
13. CASING:
Depth ffin�
Prom—n—To —L.1. Ft.
From To Ft.
From To FL
14. GROUT:
Amount
0��r wiles
�1�I�
l.,'t4' 1 JawD. ,T t
Depth 1p'� o
From 0 To 1�� Ft.Cgl"`°'TEI �E�-a.t-� 2 o
From To Ft 1 si c'
v
15. SCREEN: 70 c_ n
Depth Diameter Slot Size Matedal N 'Cis .7-
From To _ Ft in _ In. -
From To Ft In In3 o
From _ To _ FL In. _ In o n A
16. SAND/GRAVEL PACK: _ n
Depth Size Material Li o
From To Ft. Z
From To Ft
17. REMARKS:
DEPTH
II additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4)/2�R/L/C•erL c) D/
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Duality, Groundwater Section within 30 days
GW1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Becht No.

229200
North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
tk ESALLE 0ELLuG WELL CONSTRUCTION RECORD WELL CONTRACTOR: E_l►�_Y�•
WELL CONTRACTOR CERTIFICATION e: aC .!{
STATE WELL CONSTRUCTION PERMIT-:
1. WELL USE (Check Applicable Pox): Residential (g Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0
Recovery CD Heat Pump Water Infection Other El If Other, List Use:
2. WELL LOCATIO how sketch •• 4 location below) rn A
Nearest T
County -
(Road Name
3. OWNER
MSS
.. or SubdW `No.)
• tLl.l.� r
DRILLING LOG DEPTH
From
a
To
actcl
Sb'
CNy or Town State rep Cede Mc'
4. DATE DRILL- • - e
5. TOTAL DEPTH `T
6. CUTTINGS COLLECTED YES � NOLvJ�
7. DOES WELL REPLACE EXISTING WELL? YES NOEr
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •.• a Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated War below land surface requires a variance In eater -
dance with ISA NCAC 2C,,pPp�1a '
10. YIELD (gpm): �1 MElligg TEST -
11. WATER ZONES (depth)' JJ
12. CHLORINATION: Type FA--Th Amount
13. CASING:
/y WaN Thicitneu
From�aTpoth N FL qt r _yv.f __
From - To Ft. �a 6y�
From To Ft.
14. GROUT:
From
From
15. SCREEN:
0
Depth M t Method
To a (o Ft V
t
To Ft.
Forma on • crfptIon
If additional apace Is needed use beck of form
LOCATION SKETCH
(Show direction and distance from al least two State
Roads, or other map reference points)
0
0 0
Ss. L-.
1
Depth Diameter Slot Size Material o �
n,
0
From To _ Ft In _ In N = rti
From To _ Ft In In s m
From _ To _ FL In In
o N�
101 CANnmQ AVM PAr1K-
Depth Size Material a1
From To Ft.
From To Ft.
17. REMARKS:
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORDD,IAS B$EN PROVIDED TO THE WELL OWNS
11 P_ 7 /cam& 16/01
SIGNATURE OF PERSON CONSTRUCTING THE WELL OAT
Saba* original to Division of Water Quality, Groundwater Section within 30 days
OWI REV. 12/91
FOR OFFICE USE ONLY,
Ouad No:
Serial No.

Address P • �OX '1g�
(Sheet orRue o.)
/7'yes /� C �B9v
Cft r Town / State 21p Code
4. DATE DRILLED o? -0 /
5. TOTAL DEPTH /67
6. CUTTINGS COLLECTED YES n NOM"'
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOI
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS - / FT. Above Land Sudace'
'Top of cuing terminated Wor below land surface require• a variance In accor-
dance with ISA NCAC 2C pie
10. YIELD (gpm): 7 METHOD OF TEST 4/1..
11. WATER ZONES (depth): /CO r /'y7
North Carolina - Department of Environment end Natural Resources • Division of Water (Duality • Groundwater Section L. ? J 7
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] I ll "
WELL CONSTRUCTION RECORD WELL CONTRACTOR• C/1P.RoACC %1.a//
�5105
WELL CONTRACTOR CERTIFICATION H:
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery El Heat Pump Water Injection ❑ Other O If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 114,vGS ✓/ LLQ County oijci
vvr.vQi s CRee_k
(Road Name and Numbd(s. Community, or SSubdivlslo and Lol No.) DRILLING LOG DEPTH
OWNER kC VI i7 kc b FOP_D From To Formallon Description
Sex cRski6-
90'
O' - /27'
427'—/C,7'
GPp,--/ re-
U
TI
rr -
Co c
C2
co c,
12. CHLORINATION: Type /-i rti Amount $/ Cc4 If additional space Is needed use back of form
13. CASING: II
Wall Thickness LOCATION SKETCH
Depth Diem1gtern or Weight/Ft. Material (Show direction and distance from at least two State
From O To 90 Ft SOS -3 ' 2) PVC . Roads, or other map reference points)
From To Ft
From To Fl
14. GROUT:
Depth
From 0 To )O Ft
From O To 7o Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft In. In
From To Ft In In
From To Ft. In in
16. SAND/GRAVEL PACK:
Depth Size Material
Material
From To Ft
From To Ft
17. REMARKS:
DO HEREBY CERTIFX T#AT1i11 3,V/ a. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT! STAND/00 At iq F •A CQ1Ry OF THJ.S.CECORD HAS B - PROVIDED TO THE WELL OWNER.
10.1! Cif
E OF PE rj.STRUCTINO THE WELL DATE
vision of Water Duality, Groundwater Section within 30 days
GW-I REV. 12/99
�`�2-0

North Carolina • Deparlmenl of Envlronmeni end Natural Resources - Division of Water Duality - Groundwater Se^_lion
1636 Mail Service Center • Raleigh, N.C. 27699-1636.Phone [phone]
•
WELL CONSTRUCTION RECORD WELL CONTRACTOR CERTIFICATION 0: (I OG/r c�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Appllc.bl. Box): Resldenllal GA.4'f Municipal ❑
Industrial El Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Infection ❑ Other r] H Other, List Use:
2. WELL LOCATION: (Show sketch of Ike location below)
Nearest Town: �' 1G\\
\AV-10 S'J t \\€ County:
end Lot tlo.)
'flood name
rnM �I-eC-S 3. OWNER From To
Pnle I � �yrf1— 0
Address r V& I
DRILLING LOG
City or Town Slate
4. DATE DRILLED 1' 12-3 1
5. TOTAL DEPTH ((05 r
6. CUTTINGS COLLECTED YFS ❑ NOI 7. DOES WELL REPLACE EXISTING WELL? YES [J NOW
B. STATIC WATER LEVEL Below Top of Casing: Lie.
r.
(Use 'i 6 Above Top of Casino)
9. TOP OF CASING IS I FT. Above Land Surface'
'Top of cueing lerminaled ,Vor below land surface requires a voidance In accor-
dance with 15A NCAC 2C.olla METHOD OF TEST r g
10. YIELD (gpm): �—
11. WATER ZONES (depth):
12. CHLORINATION: Typo Amount
13. CASING:
From D
Flom To Ft
Flom To Ft.
14. GROUT:
Zlp Code
Wall ThIckne el
Depth Diameter or Weloht/F-t. Material
To —51121 Ft _ s/1C—
Depth M lariat hlolhod
From 0 To ... & -.FI - _d—
From To FI.._----
15. SCREEN:
Depth
From To _
From To — Ft.
From To --Ft.
16. SAND/GRAVEL PACK:
Depth
To
To
Flom
From
17. REMARKS:
Diameter Slot Size Material
FI _ In. _ In.
In. In
In. In.
"70 - /6<'
Malarial
236195
DErili_
Font-axn Descdpuo'
04 I/
(rode. /e_
II additional svace is needed use back of Icnn
LOCATION SKETCH
(Show direction and dunce Irm al leas: two Sale
Roads, or other rr<p rely -trice polna1
63:8 WV 9-s11n 10
1 DO HEREBY CERTIFY THAT TIryIIS WELL WAS CONSTRUCTED Ifl ACCORDANCE WITH 1SA IJCAC?r. se/ELL
CONSTRUCTION STANDPIPE/S.-AND INAT A.COPY OF 7111S RECORD HAS BEER PROViCED 10 THE yi J- Os REF..
cn
C)
�i
0
DI.E
FOR OFFICE USE ONLY
Ouad No:
Serial No.
SIONATUnE OF PERSON CONsrnucritts ore Yv'ELL
Submit original to Division of Waist Ouality.Oround.falai Seem wit)tin 79 csyS Ce.t prE V. I211
a

North Carolina - Deparimenl of Environment and Natural Resources - Division of Water Oualiy • Groundwater Section 236196
1636 IAaa Service Center - Raleigh, N.C. 27699.1636.Phone [phone]
•
WELL CONSTRUCTION RECORD WELL WELL CONTRACTOR CERTIFICATION IS: -C/ �U 111 ten
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE (Check Applicable Box): Residential ly Municipal ❑ Industrial ❑ Agricultural ❑ Monlloring ❑
Recovery ❑ Heal Pump Waler Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch or the locallon below)
Nearest Town: LOCATION:
eSUI FIE County tO
ail l tA:rt
(Road If me end Numoers. Convnunlly, or ubdivlslon end Lot Flo.)
3. OWNER UI(OrIV1A �1Gvv &�'Anp
Address J
s- cz
,Ftou a .
ZSrel
ry or Town Slate Zip Code
4. DATE DRILLED 1' j (' 1
5. TOTAL DEPTH 226
6. CUTTINGS COLLECTED YFS ❑ NO(LI-
7. DOES WELL REPLACE EXISTING WELL? YES I I NOU
B. STAI IC WATER LEVEL Below Top of Casing: /„at FT.
lose'+• if Above Top of Casing)
9. TOP OF CASING IS____ FT. Above Land Surface'
-Top of caslnp terminated at/or below land surface requital* variance ht accor-
dance wish ISA MAC 2C .otie
10. YIELD (gpm): .`i METHOD OF TEST )Q,
11. WATER ZONES (depth)•
12. CHLORINATION: Type h}h +01012--s Amount y
13. CASING:
DRILLING LOG
From To
yr� S 2,,o2 C/a/
's.'- j6n �/
/gyp - - .2,?.‹' nm.yTro
DEPTH
f onra>to Des: riptio-
II additional soece is needed t_-s-e back of form
Wall Thick neee
LOCATION SK=TCH
eigbV
Depth Diameter or Weight/Ft. Material (Show direction erd dunce hcrrt al leas:1 era Slate
From —a —To
ILA Ft._ 'S' -a
— r�'i °A3 Roads. or otherrrlelererrspoints)
From To Ft
From To Fl
14. GROUT:
Depth ��M� �te�r.,la�l 1� Method
From n To 2U —FI. C
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malarial
From To Ft __ In. In
From _ To _ Ft. _ In. In.
From To FI. In In.
16. SAND/GRAVEL PACK:
Depth Size
From To FI. From To Ft. —
Material
17. REMARKS:
I O HEREBY CERTIFY THAT . ANDIO WAC. Y OF THIS RECORD HAS HEN PROVICED 10 THE vial INNER
ONSTRUCTED AcCOnonicE WITH ISA eicAc r:, WELL
CONSTRUCTION STANDARDS. htJdd H�YT i
FOR OFFICE USE ONLY
Ouad No:
Serial 11o.
SIGNATURE OF PERSON CONSTRtf.T1t1D ttt WELL DI E
Submll original to division of Wafer OVallly, OrounO•raler sec -en within h to- ys Ce•I plE y. I:?t
e

• TIO' (.how sketch fL
(Road Name �'1ri� or Su• - on and Lot No.)
3. OWNER � 1aN�,_ lilt 4` �4 .1p ���
Add ; ss y.4E a7\`11tat�1�1]% 1 ' S:TJ\
1 _n.L.
Town
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR -
WELL CONTRACTOR CERTIFICATION A:
STATE WELL CONSTRUCTION PERMITH:
229198
JtW OEN' . WOc'ts
gain
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELLL
Neares T
location below) oi
County
DRILLING LOG
From
42,'
To
cI
I l,'
11n' It4g'
4. DATE DRILLED a 1-5{1 144
5. TOTAL DEPTH —_T. 1UG'
5. CUTTINGS COLLECTED YES
7. DOES WELL REPLACE EXISTING WELL? YES O NOd
8. STATIC WATER LEVEL Below Top of Casing: ]� FT.
(Use •+• 9 Above Top n Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated sUor below land surface requires a variance In accor-
dance with 15A NCAC 2p .011e
10. YIELD (gpm): 1 bO METV,O%r TEST
11. WATER ZONES (depth). pCifth
State Zip Code
12. CHLORINATION: Type 4-1-4 Amount
13. CASING:
From 0
From
From
14. GROUT:
From
From _
15. SCREEN:
DEPTH
Fo Son Des lion
If additional apace is needed use back of form
Wd Tiwsuwes LOCATION SKETCH
Depth MO fir W hVFt. !�arial (Show direction and distance from at least two State
To Ft �p �1�� Roads, or other map reference points)
To Ft.
To Ft.
Depth
To at Ft
To Ft
Depth Diameter Slot Slzi Material
From To Ft In _ In.
From To Ft. in In
From To _ Ft. In _ In
16. SAND/GRAVEL PACK:
From To Ft.
From To Ft
17. REMARKS:
O
—o
v
70
N
Ito
O
Q1
I DO HEREBY CERTIFY THAT THIS. WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS HECORDBEEN PROVIDED TO THE WELL OWNER.
_r
SIONATUR PERSON CONSTRUCTING THE WELL GATE
Bubnh original to Division of Wafer Quality, Groundwater Ssctlon within 30 days
ow.' REV. 1S/99
FOR OFFICE USE ONLY
Ouad No:
Serial No
0

229197
North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]YekY,LLE W - Q( ��' a i/!l -
WELL CONSTRUCTION RECORD WELL CONTRACTOR -CONTRACTOR -
WELL CONTRACTOR CERTIFICATION IS: 213S
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (check AppllcabM Box): Residential Er/Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection 0 Other El If Other, List Use:
2. WELL LOCATIO ' •how akelo Qj the location below)
Nearest T• �a ►� lI 0 ,tM �-r
(Road Name
3. OWNER `Tv
A 1dress art
\>{\
and Lot No.)
City or T�
se o
izWoCo
' to Zip Code y
4. DATE DRILLED n D I r
5. TOTAL DEPTH ^'r
6. CUTTINGS COLLECTED YES ❑ NO[r
7. DOES WELL REPLACE EXISTING WELL? YES D NO[vr
8. STATIC WATER LEVEL Below Top of Casing: p I FT.
(Use •a• a Above Top of Casing)
9. TOP OF CASING IS k FT Above Land Surface'
'Top of easing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C .0115
10. YIELD (gpm)• METHOC3
D 9F TEST .h�
11. WATER ZONES (depth): °Ann
CDRILLING LOG DEPTH
From To
b sr
S! l
?0-I rib r
12. CHLORINATION: Type i+T[h Amount
13. CASING:
From
Depth q�r
Togs Ft
From To Ft
From To Ft.
14. GROUT:
Depth
From _0-- To `IC Ft. r0
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft in _ in.
From _ To _ Ft. In In
From To FL In In
18. SAND/GRAVEL PACK:
Wall Thickness
i S29bvFr.
Ma
Fwrry,lion Description
If additional space is needed use back of form
LOCATION SKETCH
writ♦) (Show direction and distance born at least two State
,�� Roads, or other map reference points)
aM
From To Ft. . a' 6
x
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIONA PERSON CONSTRUCTING THE WELL AT
Submit original to Division of Water Quality. Oroundwater Section within 30 days
ow•t REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.
0

229196
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] WAttAL E EU 21LL 1 NIC -
WELL CONSTRUCTION RECORD WELL CONTRACTOR �f
a`13�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal 0 Industrial ❑ Agricultural 0 Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOC
Nearest Town
(Road Name
3. OWNER
,dress .� e. lrenki
City or T• stale Zip
4. DATE ORi' : 0
5. TOTAL DEPTH L
6. CUTTINGS COLLECTED YES ❑ NOE
7. DOES WELL REPLACE EXISTING WELL? YES NOGE'
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use +' 11 Above Top of Cuing)
9. TOP OF CASING IS I FT Above Land Surface*
Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C,,QQ11_e
10. YIELD (gpm): 2:4-0 METHOD OF TEST (1\k-
11. WATER ZONES (depth).
TIO
Show sketc
WELL CONTRACTOR CERTIFICATION #:
‘: t..1
mWrsll TALGokLoi No.)eft
the location below)
County
DRIIILING LOG
From To
t-tcl
nD' 1{3'
DEPTH
Forma Description
12. CHLORINATION: Type Amount If additional space Is needed use back of form
13. CASING:
Depth ,
From To 1
From
From —
14. GROUT:
To
To
Ft. trr
ial
FL
Ft.
From b Topt'iS Ft
From To Ft
15. SCREEN:
Wall Thickness
ortVgilt vFt.
Depth Diameter Slot Size Material
From To _ Ft in . In
From To _ Ft. In In
From To _ FL In _ In
16. SAND/GRAVEL PACK:
veyuI
To Ft.
_ To. Ft.
From
From
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OFFICE USE ONLY \<\U TOQ -0 /9/
D /
SIGNATURE R90N CONSTRUCTING THE WELL DAT
Submit original to Division of Water Quality, Groundwater Section within 30 days
Ow-1 REV. t2/99
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
FOR
Quad No:
Serial No.

North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
'--"-al1 90
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone] `iE J LE 1-6BA- \ 2, 1���1-„y�.�
WELL CONSTRUCTION RECORD WELL CONTRACTOR- - C'A bQ.G,C 1"r (*Ire
WELL CONTRACTOR CERTIFICATION #: oidl
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential [11 Municipal 0 Industrial 0 Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other D If Other, List Use:
2. WELL LOCATIO
Nearest Tow
(Road Name an
3. OWNER
Add : ss
how tch 4 ice
tkirlatienlir
unity. or Su..
. ,. 1 Sim.-
or Town
ocation below)
County:
4. DATE GRILLE
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES El NOnv r
7. DOES WELL REPLACE EXISTING WELL? YES NO '
8. STATIC WATER LEVEL Below Top of Casing: '(D FT.
9. TOP OF CASING IS I (Use. II Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated attor below land surface requires a variance In scow -
'vision and Lot No.)
O tate
e
Zip Code
dance with 15A NCAC 2Q-pM�
10. YIELD (gpm)• �5(J METHOD PF TEST UL`-l-
11. WATER ZONES (depth) �O
12. CHLORINATION: Type Amount
13. CASING:
D'IQ ING LOG DEPTH
From To
GII
- Si'
-
Formal •n Dnotion
c_
CZf
If additional space Is needed use back of lord "c-
T �
m�
LOCATION SKETCH c.a.) y
O Depth (g7eter rWe 7 t.� lajgdal (Show direction and distance from at least two ate a
From To Ft �� �� �' �� ' Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth M-te(ial I ethod
From 0 To iZ Ft
From To Ft
15. SCREEN:
Wall Thickness
Depth Diameter Slot Size Material
From To _ Ft In In
From To Ft In in
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U4 ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. Groundwater Section within 30 days
ATE
Sedal No. f tw
y},e�f!Yit;p
GW1 REV. 12/99

1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR -
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
Vel\1ESIALLE— WE\l..U-.1 —
aclt
1. WELL USE (Check Applicable Box): Residential Er" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI (Show sk
Nearest own:
ASu
of the location below)
County:
(Road Na
m a mbors, mmunlly, or S
3. OWNER C
dress
• 315 \ Dq
(S reel or Route No.)
.1 _ e
City or Town State Zip Code
4. DATE DRILLED 3 01
5. TOTAL DEPTH Sf
6. CUTTINGS COLLECTED YES E NO©r
7. DOES WELL REPLACE EXISTING WELL? YES n NO I�
8. STATIC WATER LEVEL Below Top of Casing: �.-p FT.
(Use'-. If Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface*
'Top of casing terminated ator below land surface requires a variance In !moor -
dance with 15A NCAC 2C,,pq11e
10. YIELD (gpm): -L�, METHOD OF TEST-
11. WATER ZONES (depth): \Dsl
rb
'skin nd Lot No.)
ILLING LOG
From To
(h' - 1st
49,1 - 23gi
DEPTH
Format on D scription
0
—+7 ^,
m c i
CC/ <
,
r1n o_
> -0
4- .�1 r.9
t..
12. CHLORINATION: Type \ kT� \ Amount it additional space Is needed use back of tow E'y
13. CASING:
LOCATION SKETCH
Depth , `(ry pater �L !el (Show direction and distance from at least two State
From To tom Ft b (P Roads, or other map reference points)
Wall Thickness
From To Ft
From To Ft
14. GROUT:
Dept M.tad.l ethod
From ci To Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In in
From To Ft In In
From _ To Ft In In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL: WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD,HAS BEEN PROVIDED TO THE WELL OWNER.
CJ?)A C /iix4ec
FOR OFFICE. USE ONLY
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
tMpyral to Division or Water Quality, Groundwater Section within 30 days
GW1 REV. 12/99
0/
Quad No:
Serial No.
Su
z.uorlat'ate: Secaon
nTh2vil e. Roden?l Offir yn

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] iFC3J LLE IZIEL' �(�( I `Y�.
WELL CONSTRUCTION RECORD WELL CONTRACTOR• f osE ll a
WELL CONTRACTOR CERTIFICATION ff:
STATE WELL CONSTRUCTION PERMIT@:
a�
1. WELL USE (Check Applicable Box): Residential QV Municipal El Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATIO
Nearest T
(Road Na
3. OWNER
Adress
Numb rs, Corrrun
City or To State
4. DATE DRILL e eu t2L
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE(
7. DOES WELL REPLACE EXISTING WELL? YES NO((
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top or Casing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2Cal
10. YIELD (gpm): <d.Q) METHOD OF TEST
11. WATER ZONES (depth). \t
Show skate
the location below)
County.-�""^-i'\
DRILLING LOG
Zip Code
From To
- poi
Ib t - SD'
fat -'
12. CHLORINATION: Type kTi-i Amount
13. CASING:
-
DEPTH
Formation De notion
c
T
o
w Lnr-:
m n
If additional space Is needed use back of Io¢aa --I
Wall ThicknessLOCATION SKETCH
Depth .� Dlarneter, �_scw lvFt, Sat el (Show direction and distance from at least two State
From To G b Ft. 6y`+t -" �•Co Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:
Depth M te4al Method
From 0 To Ft �a •
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft ,
From To Ft
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRLCTIONSTANDARDS, AND THAT A COPY OF THIS RECORD/J HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIC}F^t' E OILLY
Quad No: iJLl Prot~
),'/ro&S c /!/Z/ P/i✓ l/�"�
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouality. Groundwater Section within 30 days
DATE
Serial No.
e.Inin
Rs, �ev!I e Ne
GW-1 REV. 12/99

02 ti
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699-I636-Phone [phone] `(E4t LL E L. E\.L \ �(u-(
WELL CONSTRUCTION RECORD WELL CONTRACTOR• 4-4 — C t�€R 1?1° !U -
WELL CONTRACTOR CERTIFICATION I: A9.J'1
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Check Applicable eon): Residential LJ Municipal ❑ Industrial ❑
Recovery 0 Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATI e : (Show sketci e location below)
Nearest To 1`• a/ 1.,_I 1 Is
(Flo
3. OWNER
A.
City or ® Stale
4.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO.
7. DOES WELL REPLACE EXISTING WELL? YES O NO (
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. FT Above Land Surface'
1/s
ry
Agricultural ❑ Monitoring El
County.
on and tel No.)
dress inevilipantwi
4
own
DATED ED
FOR OFFIcHalSEOLY
Ouad No: J J i11 l{ I
Bads No. I
I
Zip
'Top of casing terminated atfor below lend surface requires a variance In accor-
dance with 15A NCAC 2Cj11e
10. YIELD (gpm): r>n METHOD OF TEST a
11. WATER ZONES (depth)• \ O S l
12. CHLORINATION: Type Amount
13. CASING:
Depth i ametsr
From To rig Ft. y�
From To Ft.
From To Ft
14. GROUT:
Wall Thickness
etc act:C—
-trll
From O To Ft Q- .mc� O,1
From To Ft I
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From __ To _ Ft _ In In
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
Ta
DRftLING LOG
From To
&o'
3sb` rlB'
DEPTH
Formats. De
NO
Cdptlen
C
Cs
W c•
o
''I
g•;7 ry:
C)
If additional space Is needed use back of 1 ~
LOCATION SKETCH
e)!.I (Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HERESY CERTr THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
coNsrpitotooi4 DA
S ANR S,'AND THAT A COPY OF THIS RECO9 HAS BEEN PROVIDED TO THE WELL OWNER
•
72-( S C / 1/2kri 1 1 /9 6
SIGNATURE OF PERSON CONSTRUCTING THE WELL 0 E
Submit original to Division of Water Duality, Groundwater Section within 30 days
GWl REV. 12A9
,dtedr SPC,t rii
Asheville Regional 0 ss n
TOP OF CASING IS

(Road Lme
5203
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
�kW�i�)tl.LE OaL_- \ �LL (( „,.
WELL CONSTRUCTION RECORD WELL CONTRACTORi« r L��
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
aqt
i
1. WELL USE (Check Applicable Box): Residential L�J Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other El if Other, List Use:
2. WELL LOCATIO
N:: rest Tow
`'how sketch 1 ith' location below)
Coun,Fy f n
3.
t en and Lot No) DRILL G LOG
l-4, From To
Adsress 1 ���i��t. t C _ �DI
�i►n2_ _
•
1if1�+tY1. `t
City or To
4. DATE DRIL. a 1
5. TOTAL DEPTH ,CAN
State
0
6. CUTTINGS COLLECTED YES NOrW
7. DOES WELL REPLACE EXISTING WELL? YES NOr- = o
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 154 NCAC 2C .0118
10. YIELD (gpm): METHQQQ�fEST 3
11. WATER ZONES (depth): OS I
Zip C
• br - !+
DEPTH
12. CHLORINATION: Type kA Amount
13. CASING:
From
Wall Thickness
Dept
Torn , . Ft bear Vt-.0 YVIi
From To Ft
From To Ft.
14. GROUT:
Depth M t rial Method
From 0To -9D Ft Q Drro r
From To Ft
15. SCREEN:
0
n
C7 r.1
a-rrtr,O
C)
If additional space Is needed use back of loran o
LOCATION SKETCH
(Show direction end distance from at least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material
From To Ft In in
From To _ Ft In In
From To _ Ft In in
18. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCT(ON STANDARDS, AND THAT A COPY QF THIS RECORQ HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICEj1IL9E ONLY , , (Ice--hn. ce /4 ec/L /
'
Quad No: : 1
"s SIGNATURE OF PERSON CONSTRUCTING THE WELL DAT°
.,,,e„SyirNl original to Division of Water Oualiry, Groundwater Section within 30 days
+c!OIIO 'ha °S CAt:iial3
Serial No. a..ti_..:,�_ „ 1 GW1 REV. 12/99

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ke-j1�� W eu_ '. Q-( LL (r I ^
WELL CONSTRUCTION RECORD WELL CONTRACTOR• dVttlAPK �p p 5
WELL CONTRACTOR CERTIFICATION #: �C 13
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE neck Applicable eox): Residential021 Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection EI Other II Other, List Use:
2. WELL LOCATIO how sketc f the location below)
Nearest T
Cou
•
(Road Name an umbers, C
a OWNER 9 p
Address
Skeet Or R
unl , or Subd ion and Lot
City or Town State
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOo
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
9. TOP OF CASING IS \ FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C� 0^118
10. YIELD (gpm): Iry METHOD O F TESTRVI
a)
D'ILLING LOG
�` ;(��� From To
UA, b - qs
SSS -S'
11. WATER ZONES (depth):
?,01 D l
Zip Code
12. CHLORINATION: Type k-riti Amount
13. CASING:
DEPTH
grmation1D script n''
I a
> mo
W
II additional space is needed use back of lora)
Cr,
I,-
c7
Wall Thickness LOCATION SKETCH
Depth From h To 9
b L)lalt)etq( o Weight/Ft. ,---April (Show direction and distance from at least two State
Ft (b� YY S Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:
Dept. M tpdet- Method
From 0 To D Ft
From To - Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in
From To Ft In
From _ To _ Ft _ In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
In
In
In
i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO$-S ANQARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I /
7� !S�;IQNA OF PERSON CONSTRUCTING THE WELL DA E
Submit o$1 4 Division of Water Quality, Groundwater Section within 30 days
-�S GW1 REV. 12199

' ti
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center -Raleigh, N.C. 27699.1636-Phone [phone] kYrx& LLE k D
12.—( LL I
WELL CONSTRUCTION RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicabla Box): Residential lEr Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WEL eCATI
Nearest Town.
(Road Name
3. OWNER
Address
Agricultural ❑ Monitoring ❑
the location below)
County:
Subdivlsjon and Lot No.)
ree or -our:L o f
City or To State i.. .- iOc-71 I
4. DATE DRI
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [] NO(a
7. DOES WELL REPLACE EXISTING WELL? YES Q NOV
8. STATIC WATER LEVEL Below Top of Casing: ) FT.
(Use'✓ If Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface
'Top of casing terminated at/or below land surface requires ■ variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): `�ti METHVD OF TEST
11. WATER ZONES (depth)• rx7d)
From To
O IS
I SI c9f
12. CHLORINATION: Type t
13. CASING:
Amount
▪ c.;
- _01
r
cM
o r-rt
W ^n
If additional space is needed use back of form
LOCATION SKETCH
Depth2 Derr( o elgnt/Ft. ��Maa�sfd/a•t (Show direction and distance from at least two State
From To s2� Ft v 7� ��• a—"� G Roads, or other map reference points)
From To Ft.
From To - Ft
14. GROUT:
Dept M t al Method
From a To Ft r!___
From To Ft k 1
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft in _ In
From To _ Ft In In
From _ To . Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
Wall Thickness
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR J6TiO L•STAN=RDS »JD.THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR uncle USE ONLY ) 1 (z14..
�a��
Quad No: • SIONATUR F PERSON CONSTRUCTING THE WELL DA E
dnl4 !Stibmg original to Division of Water Quality, Groundwater Section within 30 days
Serial No. OW-1 REV. 12/99
Croundwate; Section
Asheville Rational

cue
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] keFr-L(tU_E W y Q-t UL I ^ I^
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
WELL CONTRACTOR CERTIFICATION'S:
STATE WELL CONSTRUCTION PERMIT'S:
i3c1
1. WELL USE (Check Applicable Box): Resldential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring El
Recovery ❑ Heat Pump Water Injection Other Ej It Other, List Use:
2.
WELL LOCATION (,how sketch
Nearest To
(Road Name . ra
3. OWNER
Astres
location below)
County
umbers, Comm or Subdivision and Lot No.)
,c22)1b7
Zip Code
4. DATE DRILL
5. TOTAL DEPTH h21 /
6. CUTTINGS COLLECTED YES NOM.--
7. DOES WELL REPLACE EXISTING WELL? YES Q NOE(
8. STATIC WATER LEVEL Below Top of Casing: L FT.
(Use'.' II Above Top of Casino)
9. TOP OF CASING IS \ FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In steer -
dance with 15A NCAC 2C 0118
10. YIELD (gpm)• MET OD OF TEST -
11. WATER ZONES (depth):
12. CHLORINATION: Type ' 1 t"T Amount
13. CASING:
From DToth 30 Ft bfPr
From To Ft.
From To Ft
14. GROUT:
Depth M t rial Method
From 3 To m Ft (`O rrc �t1
Wall Thickness
or Nt.51l(F}. at
From To - Ft
15. SCREEN:
Depth Diameter Slot Size
From . To _ Ft In
From To Ft in
From _ To _ Ft In.
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From
17. REMARKS:
I DO HEREB
CONSTRUC
To
Ft
Material
in
In
In
Material
DRILLING LOG
From To
- c) t
-
1`1' - 103'
DEPTH
Fo anon Description
rn
n ,-
Ph
ft-
m
If additional space is needed use back of form rJ
V..i
rn
C)
LOCATION SKETCH C"
(Show directbn and distance from at least two State
Roads, or other map reference points)
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU3E OF PERSON CONSTRUCTING THE WELL DATE
rW to Division of Water Quality, Groundwater Section within 30 days
OW-1 REV. 12/99

1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR -
North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
WrW1 f�QE W CU iQJ L I —
}1 t1AM1 S t gtk TEET4
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Chick Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LO
Near
(Road Name
3. OWNER
Address
TIO ,: Show skel
he location below)
County:
umbfl, C•^'° _or Subdivision and Lot No.)
ee or o
City • Town I State Zip Code
4. DATE DRILLED 11� D
5. TOTAL DEPTH I
6. CUTTINGS COLLECTED YES O NOir
7, DOES WELL REPLACE EXISTING WELL? YES 0 NOE(
8. STATIC WATER LEVEL Below Top of Casing: I (ym FT.
(Use II Above Top of Casing)
9. TOP OF CASING IS \ FT Above Land Surface'
'Top of casing terminated ,Nor below land surface requires a variance In accor-
dance with 15A NCAC 2Ccil8
10. YIELD (gpm): � METF{OD OF TEST 01/4:01-
11. WATER ZONES (depth)- S
DRILLING LOG
From To
3l'
12. CHLORINATION: Type Amount
13. CASING:
Wall Thickness
Depth ?titer o r Weight/Ft. �V
From U To �g Ft � WaC--
9�W
From To Ft.
From To Ft
14. GROUT:
Dept
From a To S' Ft
From To Ft
15. SCREEN:
M tgdel . Meet
Depth Diameter Slot Size
From To Ft in
From To _ Ft In
From To Ft In
16. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft
17. REMARKS:
Material
In
In
In
Material
--t c>-_,
CO c >:
I E
Cr'
-s2 r'
3 .73r-0
If additional space is needed use back of form c
u1 p
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIF``�y. TmAT THIS WELL AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST&IIOAl3DSEAND i}iA ,A ?pcY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
RSON CONSTRUCTING THE WELL
ater Quality, Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
Submit,
01741
SIGNATURE OF
nil to Division om 15
DA
do/
Serial No:+=
GW-t REV. 12/99

North Carolina - Department of Environment and Natural rle5ourcns • Cllvblon of Water Quality • Dromnd++alor Section
242840
1636 MailService Center - naleloh, N.C. 27699.1636.Phone [phone]✓ �C�� `/I I�r
WELL CONSTRUCTION RECORD WELL coil-Inncion: -(G �J "� Z9.a2)
WELL coil-In/Nei-on CERTIFICATION If: f
STATE WELL CONS111UCTION PETIMITM:
1, WELL USE (Chock Appllcpbb Ooa): FlesldenllalL�AlJnlctpal El
Industrial ❑ Agricultural ❑ (Aonllorirq 0
hecovery ❑ Heal Pump Water Injection 0 Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
.✓o ot17 County:
Nearest Towre
lanai frame and Cumbers. Community. or Subdivision and Lot flu j
3. OWNED
Address
5lieei or FI'ou1 IJ5-)
City or Town Stale
A. DATE DRILLED
22-0/
5. 1 OTAL DEP11I 7 fo
6. CUTTINGS COLLECTED YES7. DOES WELL nErLAcE [_I NO� UOu
B. STTAI IC WATER LEVEL BelowiNG Casing:
lop of D rt.—
(Use -+- If Above Top of Casinpl
9. 1 OP OF CASING IS FT. Above Land Sur loco•
'Top of casino terminated .Vor below land purled. requires a variance bi accor-
dance with ISA IICAC 2C .011E
10. YIELD (gpm):__ METHOD OF TEST' C
,2
11. WATER ZONES (depth): 5
(
/1 %[7
cA
12. CHLORINATION: Type
13. CASING: LOCATION SY_ RCN
Wall Thickness
Uiamelor or Wei hurt. f laledai (Show direction end ds'ance Irvrn z1 least two Sate
Depth - SDgZ t l%-- Monde, or otherR<7 telererce polnh`
r-tong.—Te � rt.6'23
zip Code
DRILLING LOG
Flom To
s s' ife2 .
DEPII I_
Fonr.asn Oescripeo'
prom To Ft.
From To Ft.
14. GnoUT:
Depth
Flom _.C2 -- To zD
From to —
15. SCnEEN:
Ptom
From —
From 16. SANDIGR
Depth
To_
To.
10.
--�
Amount 4'Gu It additional space is needri t_se back of ice-*n
a�lo)�lal M Ilod
7`(a fid /'etlt./'t
rI. O/
Ft._ ---
Dlan,elor Slot She Material
Ft In In.
Ft. ___-- In. hi.
In. _ — In.
Fl.
4J -
morn pp . rl. II\
From u Yb rt.
17. fEMANI(S:I ye -El DO DEFIED Crnhlr( nJiA�TT11t5*t» WNAS CO1 STNUCIEU III ACCOnDAlICE WITH ISA NCAC re. Y
a • IlECOFlD I IAS DEEM PROVItED 10111E'n:_L DinEF..
COrISIHUG ION„._. AnQg;nND1t1A1"Jk P 11115A
roil OFFICE USE ONLY
Quid no:
alerlal
pat E
SIONAT t1E OF POISON commmniCtlf I hvc'MELL
Submit original to Divlelon of Water oudily, Groundwater Sean rilUdn Y) csys E^.I PI V. 1211
S
Serial Ile.

1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR•
238810
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
Hj1'ESUtt. Lr L. aL 1b2tU_I 0`)61 —
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
aq-5t
1. WELL USE (Check Applicable Box): Residential [3 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATIO
Neprest Town
(Road Name
3. OWNER
Adresa �rLEI 7
the location below) �y
County l`
City or Town
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES E3 NOQ--
7. DOES WELL REPLACE EXISTING WELL? YES rj NO (
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •• If Above Top of Casing)
9. TOP OF CASING IS ' �
FT. Above Land Surface'
'Top of casing terminated actor below land surface requires a variance In accor-
dance with 1SA NCAC 2QJ11a
10. YIELD (gpm): METHq�,D,,v,OF TEST
11. WATER ZONES (depth)• Oct
12. CHLORINATION: Type ‘-k(" Amount
13. CASING:
State
on and Lot No.)
a$q 34-
Zip Code
DRILLING LOG
From To
b 401
lob'
(nob' (1%'
I L1cat
If additional space Is needed use back of form
LOCATION SKETCH
Q Dept(t, v gamebr teptlFto 'Tlwee� (Show direction and distance from at least two State
From TO ., `o Ft lo.�({ ?J' 'k'V Roads, or other map reference points)
From To Ft.
From To Ft
14. GROUT:
From 0 To Ft
From To Ft
15. SCREEN:
Wall Thickness
Depth Diameter Slot Size Material
From To Ft In In
From To . Ft In _ In
From To _ Ft In _ In
18. SAND/GRAVEL PACK:
Depth Size Materiel
From To Ft
From To Ft.
17. REMARKS:
I DO HEREBY CE
CONSTRUCTION
T •Ii W LL\ALIC
&:CQNSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
I1140 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNERtalr0/21c P9121fre-A— 7/7 0/
SIGNTORE OF PERSON CONSTRUCTING THE WELL
Submlto$gkW to D dston of Water Duality. Groundwater Section within 30 days
Sec.ion
onal (Jica
ATE
GW-1 REV. 12/99