Ma 2 CY2001

244182
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: lil.Pn n r 4t /L/ ) elM a (02 !! 1)v. I I f eAv -,
c
WELL CONTRACTOR CERTIFICATION#: . t-S-9 : /r
/7 ,
STATE WELL CONSTRUCTION PERMIT#:
l!X
1. WELL USE(Check Applicable Box): Residential Munlcipa!❑ industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: ✓24/4-4L' L i4� A/L_ County: ,A14 (etx J
IJ1 d,\t-e C rQ _
(Road Name and Numbers,Community,or Subdivision and Lot No.) DP,!LL!NG LOG DEPTH
3. OWNER 77rn i ('rlr r>'�i From To Formation Description
Address I Cf / LtL/C-P L
i Cc,l ccryc_ p cS
Street or Houle No.
1 ate, !�'I � 1( * •mo d''7 3 V.
City or Town State Zip Code
-
4. DATE DRILLED AP-7 -a /
5. TOTAL DEPTH , 3o c
6. CUTTINGS COLLECTED YES E NO[22--
7. DOES WELL REPLACE EXISTING WELL? YES El NOQ__-
8. STATIC WATER LEVEL Below Top of Casing: �7 FT.
(Use'«'a Above Top of cuing)
9. TOP OF CASING IS / FT.Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In scoot-
dance with 15A NCAC 2C.0115 /�
10. YIELD (gpm): �n METHOD OF TEST f /'/mu m
11. WATER ZONES(depth):j'4}6ej iffhi -, O
12. CHLORINATION: Type /f f/4 Amount 1/4 I>55 If additional space Is needed use back of form
13. CASING: ------- - - - - - ..
Wall Thickness LOCATION SKETCH
Depth ('� Diameter or Weight/FL Material (Show direction and distance from at least two State
From 0 To X// Ft. [a'' r/01 Roads,or other map reference points)
From To Ft. fY-' /
From To Ft.
14. GROUT:
Depth Material Method
From C To r-LN IT !)Ft. O Pi», ,o r /nt r> > CD
From To Ft. I — xo
15. SCREEN: f0
Depth Diameter Slot Size Material c i cart.;
From To_Ft_ In. ___ In. v o:
From To_Ft._ in. _ In. r
From _To Ft. In. _ In. s ` 'c
16. SAND/GRAVEL PACK: rnz
Depth Size Material r
From To Ft. z
z
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAADS,AND THAT'A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 'mm.•r 4 /.hn QAgr,� /,--2 7 -O /
Quad No: i ,SIGNATURE OF PERSON CONSTRUCTING THE WELL. DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW0 REV. 12/99

244181
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: t -Pr:n,5 Ho ) plm a (Oeii �v. if he4
WELL CONTRACTOR CERTIFICATION#: ,r&-Q- cQ/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural D Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town:;4..4 ,✓ ram County: /f" lQ Cerni
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER n Y I Iv r < fe r'-Il�, From To Formation Description
Address ) �s (i t:riYYi of S W��'
( veett or cute o.
City or Town Stale Zp Code •
4. DATE DRILLED /c-7 O/
5. TOTAL DEPTH -hn
6. CUTTINGS COLLECTED YES NOD-
7. DOES WELL REPLACE EXISTING WELL? YES D NOQ-
8. STATIC WATER LEVEL Below Top of Casing: (or FT.
(Use'i 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 scoot-
dance with 18A NCAC 2C.01 8
10. YIELD (gpm): L METHOD OF TEST Hind in (if-
11. WATER ZONES(depth): inn' �.5d ' l
12. CHLORINATION: Type it t H Amount r'/4 /1'55 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To 7"� Ft. <<''' r/kV P r' P • Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To f-(N Ft. Cr Pirn tg17 (1L1/" ,1 . 53
/ O o n
From To Ft. —
15. SCREEN: as
rn °n 1
Depth Diameter Slot Size Material 0 c-r
From To Ft In. in. 0,7.
From To_Ft._ in. In. S,`D
TG
From To Ft. In. — In. xr„
16. SAND/GRAVEL PACK: _ u)
Depth Size Material
J o
From To Ft. x
From To Ft.
17. REMARf3: r -
' I ii I l i
I DO HEREBY,CERTIFY-THATTNIS WELCY(�,SICDNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT AC PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-. )
FOR OFFICE USE ONLY ,I` cainmr G i rlinagOAL /r9 -7 0
Quad No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
- - .: SUbrdll odgirW to Division of Water Duality,Groundwater Section within 30 days
Serial No. �: GW1 REV. 12/99

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 2 4 4 3 8 0
1636 Mail Service Center-Raleigh,N.C.27699.1 636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11-en nr ei l+v Ll e a Weil . I-. /i e4 rn c
WELL CONTRACTOR CERTIFICATION#: c).-,)/'7/,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Infection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION:(Show sketch of the location below)Nearest Town: f P44 ,e1L /-2/ A/C'_ County: /q�r r a ctrr--�
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER pp,. 1 f 2r� From To Formation Description
Address % CIA /a i; /
i—a2)1)l /n.�(Street o`�ohto�`)' r,,)l(73 y
City or Town rW State Zip Code .
4. DATE DRILLED /c9-CI-0/ -
5. TOTAL DEPTH -Co S'
6. CUTTINGS COLLECTED YES D NO1/1 —
7. DOES WELL REPLACE EXISTING WELL? YES Q NOT--
8. STATIC WATER LEVEL Below Top of Casing: ‘,T FT.
(Use'ell Above Top of Cuing)
9. TOP OF CASING IS / FT.Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C,0118 /_
10. YIELD(gpm): In b METHOD OF TEST iN7/Ji?9 ell--
11. WATER ZONES(depth): /7 C' 1�C' t!
12. CHLORINATION: Type r't 1 H Amount VI///5 If additional space is needed use back of form
13. CASING: - - .
Wan Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To F64 Ft. (<' . ,-/ P b" (2 - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To .,LlI\ Ft. 0 en, o.,-T p/rn n ,
From To Ft.
15. SCREEN: c
Depth Diameter Slot Size Material c o
From To_Ft _ In. _ in. rn o, -?
From To Ft. In. _ In - n c
From To_Ft. In. _ In. - o`er
>c 16. SAND/GRAVEL PACK: ,�
Depth Size Material S Ic
From To Ft. w r")=
C
From To Ft. C./1
17. REMARKS: Cl) o
(� r� r� II �'�0 r' Y
I DO HEREBY,RtWYLYAWIIYS W LL! ASL'"r�STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTfiISTANDARDS,AND [HAIAh.'!f1'OF THIS RECORD HAS
//BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICJSI ION R 7 2002 V n1m r A /krn601/2.4 ) /2-4` -'a /
Quad No: —st13NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit riginal,o Division of Water Quality,Groundwater Section within 30 days
Serial No. rani imi ATER SECTION - GW-1 REV. 12/99
AbNLVILLE EGIONAL OFFICE

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 2 4 4 3 8 1
1636 Mall Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JN-Pn,n r g Ih l 1 a (*a r . t I ,n, el. n T
WELL CONTRACTOR CERTIFICATION it: c /7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Llr< Municipal ❑ Industrial D Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO,I• (Show sketch of the location below) y
Nearest Town: 12A-4-/GL (A/ /i /4/r'. County: r Q(-0— )
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (t-<-t-f it"as-c4-e.. U-rcr m+
rf , From To Foation Description
Address 024,/ 7 0Q (!r_ 2 �u
btreel`or Route o.)
IYJ, 1fr //c� ' t n7ay
City or Town Stale Zip Code .
4. DATE DRILLED Lr-41-11 /
5. TOTAL DEPTH /7 S r
6. CUTTINGS COLLECTED YES NO[IIi
7. DOES WELL REPLACE EXISTING WELL? YES NOES
6. 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 15A NCAC 2C,0118
10. YIELD(gpm): ZS METHOD OF TEST h//li/Ji n rr!—
11. WATER ZONES(depth): /.2h r //
12. CHLORINATION: Type if 1`14 Amount f/4 /is3 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth .1 Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To / 0 F . re' . r Med n r' P. Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c
From 0 To ;2¢\ Ft.. ITfl-rn >.,a! _ f)/r>., ,1 , o to
From To Ft t= nT.,3
15. SCREEN: r*1on
n Tm
Depth Diameter Slot Size Material — o�
From To Ft _ in. _ in. — yc
From To Ft._ In. _ In. 3 ��
From _To FL_ In. In. r„
16. SAND/GRAVEL PACK: at y�
Depth Size Material ul o
From To Ft. Z
From Td Ft. �_ A
17. REMARKo DCE J i= -1`
dI , l
I DO HERE Y pRTIFY THAT THIS WELL WA STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
.:::,ISr let qns r2T2AT?;'^ OF TH! I P'HAS PEE"PROVO!ED TO THE wFI,L OWNER.
f ' tiFF+. 1,6SG{,t"'a v )
ta
I ' .se rr. p- - A'+t= tf r .P3Orl r, i1 i.icikr o Twit ad t OA"
GR01 y r5+1 ,t.
a
1 �awE«i 4 ac grr^ • rf . •�.-. ..- ,s�¢.r?.x+` .k�.>w.+zwu5sark,.� it-„"r7'lay:
Ys Y' ...��.. 7 �I • -` - r:`; 12'99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 4 4 3 8 2
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11)-BI'7 rl, 4 Hz,1) A COQ I I f)sr. /I 711 el, '.
WELL CONTRACTOR CERTIFICATION#: ,y-5-'- c-Q/7G,
STATEMu WELL CONSTRUCTION PERMIT#:
t/X
1. WELL USE(Check Applicable Box): Residential nIcipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
- Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of_thro location below) Alearest Town: /�2/71L�CL / /V A/C_ County: / "6 -n J
(Road Name and Numbers,Convnunity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER E n
C- /J,i /l(7/,L/ tF From To Formation Description
Address 707 I/L 6LA nrj_pH_ S
}� (supero to o.
/U1fin014 AVM . c - 61 E r,
City or Town State Zip Code .
4. DATE DRILLED I e-2-0 <-O/
5. TOTAL DEPTH C?'
6. CUTTINGS COLLECTED YES❑ NO[1:1---
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD—
S. STATIC WATER LEVEL Below Top of Casing:eQ on FT.
(Use'.'It Above Top of Casing)
9. .TOP OF CASING IS /r FT.Above Land Surface*
'Top of using terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.011S 10. YIELD (gpm): "S, METHOD OF TEST H/Li/l i Yl 11—
11. WATER ZONES(depth): .�0) 1
12. CHLORINATION: Type /t f H Amount y4 /6 If additional space Is needed use back of form
13. CASING:
Wall „ LOCATION SKETCH
ne
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To I '3 Ft. (c- . "kV OY P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
prom C Te aft Ft, 0 P-r, o-IT 1)In n,i
From To FL o CD
15. SCREEN: m c�^,
Depth Diameter Slot Size Material 0 ` ;;
From To_Ft In. _ In.
ter-:
From To Ft. in. In. . 2-c
w cm
From _To Ft._ in. In. S --m
16. SAND/GRAVEL PACK: w giz
r��
Depth Size Material cn
From To Ft. ow o
z
From To Ft. .
17. REMAR t r_
I DO HER 'knnrY THAT THIS WELL WAS C NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR iiiii
bTPON STANDARDS,AND THAT A CQW OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I , liln _ 7 2.(i'0Z i s _ . • 9
FOR OFFICE USE ONLY �a O5`� /
Quad No: J GNATURE OF PERSON CONSTRUCTING THE WELL DATE
._______.._.----._�_._I od
;iv �VJ 1 FR SECS{b!d 9 10 dvWanof Water Quality,OroundwaterSection Within 30 days
Sedal No. - F�ICiu/l OFFICE DWI REV. 12199

244379
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 \
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c1-en ni g IL I l A (lw U 1)1•. ii 7, >1 wit C-
WELL CONTRACTOR CERTIFICATION#: S. i- . /`76, ti
STATE WELL CONSTRUCTION PERMIT#:
L(X
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) V�
Nearest Torn: if �/-I 4/ C'_ County: / l 1 a L` - —)
LILor 1 ktnml l
(Road Name and Nur bertton/nunity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,To fr1 N (AG-YY- ; S Zrn. , From To Formation Description
Address 6.,7 AI4055 V; e(Li' L a
(tree or Route No.
City or Town State Zip Code •
4. DATE DRILLED I -3 -0 /
5. TOTAL DEPTH Cr-,'
6. CUTTINGS COLLECTED YES 0 NO9i'
7. DOES WELL REPLACE EXISTING WELL? YES Q Non
6. STATIC WATER LEVEL Below Top of Casing: ,.<7.) 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 15A NCAC 2C,0118
10. YIELD(gpm): METHOD OF TEST HP)/1;79 t-
11. WATER ZONES(depth): /So ' /
12. CHLORINATION: Type ft 1`/4 Amount 1/Li if' If additional space Is needed use back of form
13. CASING:
wai Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To 0 Ft. (C'. r/") P b' P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method O
From 0 To .;Li\ Ft. 0 elm 0,-7 (>n7v1 , O o
From To Ft. O c3
r
15. SCREEN: cm) o
Depth Diameter Slot Size Material — z=
0..,,-
From To Ft _ in. _ in. ni✓
From _To Ft._ In. In. $ me
From To_ _Ft._ In. in. C4
16. SAND/GRAVEL PACK:
CJ1 -.4
S(ze � Material to z
From 4 FL__.-1
From Pre— -Ft. li
17. REMARKS J
111 J \pw. Li
I DO HEREBY C RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRYCTIOkI STANDARDS,AND BAT n COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USEQNLY ._ • ` riamm4 p /,17„ai)J/74rfl D- 3 - a- J
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-I REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 4 4 9 5 J
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] •
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lZen car 4 IL!) cam a Weil hL, it 7h>4 Tn
WELL CONTRACTOR CERTIFICATION#: .S41- cQ/7L,
/X Mu
STATE #:WELL CONSTRUCTION PERMIT
1. WELL USE(Check Applicable Box): Residential ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below) ,
Nearest Town: ce4 -���'1 � �/7C County:- /) / (9 ((f U>
<—n'li«'-✓ //ft1rcr�e��dzrz,1.--, �
(Road Name and Numbers,Community,or tubdivIsion and Lot No.) DRILLING LOG DEPTH
3. OWNER IC'(i), /l.�7 ,% /r S From To Formation Description
Address (�, 3`z c
!7 J (1 (t -,L 0 A S
lStreet orR Ite o.,
` 3 9) / .5. k
mr ��r , rc
City or Town Stale Zip Code
4. DATE DRILLED I ;1-I ¶'--O /
5. TOTAL DEPTH .Snc"
6. CUTTINGS COLLECTED YES❑ NOEl-
7. DOES WELL REPLACE EXISTING WELL? YES n NOE---
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 15A NCAC 2C.0118 /_
10. YIELD(gpm): >' METHOD OF TEST %/, !FYI 4h
11. WATER ZONES(depth): /c S
12. CHLORINATION: Type it 1`N Amount VC( 0•9 If additional space is needed use back of form
13. CASING:
Wall LOCATION SKETCH
Depth Diameter or Weight/FR. Material (Show direction and distance from at least two Stale
From D To �7C, Ft. !o• . r IC& P r P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To c-i\ Ft. 0 Pin, 0-Y1/ I MA a--"
From To Ft. 0
15. SCREEN: o
Depth Diameter Slot Size Material orn -c'"7
From To Ft_ in. _ In. n
From To_Ft._ In. _ In. N 'c
CO ter:
From To_Ft._ In. in. c
16. SAND/GRAVEL"• r f \.0 L� _ a,.r
Dep C V Site V rial 4- m
From To Ft. o
From To 1 r rt. - _ ;':;Li 1 o a
17. REMARKS: )__)
i
I DO HEREBY CERTIr d LTh aWEL�I,EYyABcONSTF UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST (p$EA ITHATA)OOPY OF-HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 49MA 0 lefTWVanA , /EP -/k _D /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 244954
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: x -Pfn n, 9 /+r 1) rim A �WOf) fit'. ii n, el, Tl1 C,
-
WELL CONTRACTOR CERTIFICATION#: 1��q- ::;"2/7o, a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential E Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r/1/4. A A/iL L I I/ 4./ ( , County: .A1 (_(-L>n_,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER I i) . Z.- 0 0-y fl2 i C I\ e, C-I From To Formation Description
Address S 7 S in 0 S 61 b ct a-vD Id 41, } e- L. 1�
- (Street or Route No.)
J-tiot (✓ i ,,,_) Aic , „ C73 (
City or Town State Zip Code •
4. DATE DRILLED_ It - lQ 'DI
5. TOTAL DEPTH .E±-;.
6. CUTTINGS COLLECTED YESr] NOD-- -
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOR--
6. STATIC WATER LEVEL Below Top of Casing: (f',0 FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD(gpm): _�METHOD OF TEST G1/N0//,-H 6.1—
11. WATER ZONES(depth): b S / /
12. CHLORINATION: Type /t 1-14 Amount +�4 055 If additional space Is needed use back of form
13. CASING:
wall Thickness LOCATION SKETCH
Depth I . Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0To -sX Ft. Cr". ,/kV n/ P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c
From (.-) To ;i.1t Ft. (I ell-, tvi[ f/rlt /t> C
From _ To Ft. o cC_,
15. SCREEN: n ��'
Depth Diameter Slot Size Material fV .._:
From To Ft in. in. w H.
From To Ft in. in. � _m
From To _a � le,t. -�
16. SAND/G �ACK:E. r '�, A . It'I w ,
� f4=.- '" 31r \ Aaterial lb -0
From '"To Ft.
From 70 1Ar,Fr.-
17. REMARKS:
i
I DO HEREBY ERTIC ItiV TiTJd� CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTI N STANDAgIL1 OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 1i71m✓ e Al-oUUQiren
- I4 - 0 I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

244953
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: cl }F'Cl n t `3 IC I ) 'cm a Leo f I • I I Dt 4 Th <
WELL CONTRACTOR CERTIFICATION#: . - <c/7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential IIX Municipal El Industrial 0 Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONS(Show sketch of the location below) �1
Nearest Town: f'?,4 A,)l L iA/ At"7e - County: ,/t)a (-r�nc -)
L-Jill' e{2 -7 LLlL rv\\h n - —
m(Road Name and Numbers,ComunitlVor Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i I )(v.A (1 ' L)0.1 A? F IL From To Formation Description
Address '"1' �"•
f 5 .), _ 7�t�. /
L, (Street or Route No. _ _ _
City or Town Stale Zip Code
4. DATE DRILLED /02-/</-t' /
5. TOTAL DEPTH 37_5.
6. CUTTINGS COLLECTED YES Q NO[k-
7. DOES WELL REPLACE EXISTING WELL? YES 0 N00---
8. STATIC WATER LEVEL Below Top of Casing: /,r. FT.
(Use'+'II 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 1SA NCAC 2C.0118
10. YIELD (gpm): 3 5 METHOD OF TEST /7//J)/1 r)1 il'jr
11. WATER ZONES (depth): p, s cam' !/
12. CHLORINATION: Type /t t H Amount iI 4 I If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth 6,- Diameter or WeighVFl. Material (Show direction and distance from at least two State
From D To 9 / Ft. ((. . r/0,1 P k P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: -=
Depth Material Method o L.-
From C To ;IN Ft. 0 /3111 m-rl/ n m.f it , 0 `".T
From --- To Ft. _--.— 0 c.c.
15. SCREEN: N ` _-_.
CO ,-
Depth Diameter Slot Size Material
From To Ft In. _ in. "•_
From To Ft. in. in. F " '=
rn .
From To Ft. In. In. o
16. SAND/GR 1 r' \F-, o Z
IEt,r-Dept Ste _:- I l \i atenal
From I To Ft.
From __U To Ft.
17. REMARKS;' , qiI • ')
I DO HEREBY CERTI ,, ;Wf{t1/AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANS I DS.'ANO THAT-A C_`OPY_OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY n ne o Anoeo a---/ o I
.
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

244952
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: than n 1 g ih I) 'cr., A WO li }r. l I T), 4 Th c
WELL CONTRACTOR CERTIFICATION #: .540- , /7(,-,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential D Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: : / A-n.P L/iD /. (_ CounryyM Ce<. ;
(Road Name and/ Numbers,Community,or Subdivision and Lot Na.) DRILLING LOG DEPTH
3. OWNER I-6 ir./rl. /t-P S/ell- From To Formation Description
Address 7/ / c�l�r"" U/r,c; / Qa_C__-,
(Street or outs No.)
/ pit tf; L//fie_ 471/ 3Y9,C:2
City or Town State Zip Code
-
4. DATE DRILLED /P-/ 7-O /
5. TOTAL DEPTH 01 S
6. CUTTINGS COLLECTED YES NODS
7. DOES WELL REPLACE EXISTING WELL? YES Q NOE
8. STATIC WATER LEVEL Below Top of Casing: / ,), FT.
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS I FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118
10. YIELD(gpm): ran METHOD OF TEST NW/r74 f�
11. WATER ZONES(depth): /Q 0 300
12. CHLORINATION: Type /±t El Amount y4 /6 If additional space is needed use back of form
13. CASING:
Wall Trick• LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To /.al O Ft. (c.. r/0/ Pb" P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c
Frm C To (" FL O Grn a0-0 f fl/nn /1. O CD
o
From _ To Ft. r,1 ;;
15. SCREEN: c, c,^
Depth Diameter Slot Size Material
From _To Ft in. in.
\
From To Ft. in. _ in. = El.
From To Ft. In. _ In. r
16. SAND/GRAVEL PACK - o C
Depth = Site _ii dal 0 o
From To Ft. UU 2
From To Ft. ;fX))
17. REMARKS: Mr'
I DO HEREBY CERTIFY , AS•AP,E(d,� (�¢ONST UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDS �ti 4atAiAt AMP(OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY e4ntnir o /1//thQn.A� /n /;) -/ 7-0 /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /R1 r n (1 r
1636 Mall Service Center•Raleigh,N.C.27699.1636-Phone[phone] 4 'f 3 4. J 3
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tb-en ni 4; II I ) nm 6)0 II v. If h iy jr)
WELL CONTRACTOR CERTIFICATION#: 5-50-Q- cQ/7G, U
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential I!X Municipal 0 Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: EPAAYIC L /a/ 47e-- County: M 72. Gcn1 J
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L- 4 /LIZ J t9 e-4'1, P /� From To Formation Description
Address
/7n E C,No.) j Q rn-C D�
/ / veal or Route . , �•7 3
/'i'Qni/Cln 1 4,' 7/
Gty or Town State Zip Zab •
4. DATE DRILLED / )—uI-n1 —
5. TOTAL DEPTH 3 7 S'
6. CUTTINGS COLLECTED YES fl NOD-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE-- c:
8. STATIC WATER LEVEL Below Top of Casing: / FT. N C
(Use Y'II Above Top of Casing) L 17)--
_...—:
9. TOP OF CASING IS / FT.Above Land Surface' = rc
Top of casing terminated aVor below land surface requires a variance In actor- 1 Er
dance with 15A NCAC 2C 115 tD -:_
10. YIELD(gpm): 0/O METHOD OF TEST h/mi Iin l{- >`_,
11. WATER ZONES (depth): .3hn' 1 �"
GO
12. CHLORINATION: Type /f t H Amount r/4 //9 It additional space is needed use backart lorrrf.;
13. CASING: -- - . ----- ----
Wall ss LOCATION SKETCH
Th
Depth o Diameter or Weight/FL. Material (Show direction and distance from at least two State
From 0 To o / Ft. /<' ' '/-' n t" P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To -1\ Ft. 0 Can 0„917 [tflA / -,
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: T
I DO HC OL4�ST D89D9, ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OF kEONLY QQ fmM 4 /�Q01Qnr� /� . iH /-A
Quad No' MAR 1 /8 2002 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Su oriel al to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW1 REV. 12199
GROUNDWATER SECTION
•
PSHF`rIU-F DFrinNAI__riFFICE

s —North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 4 J N 9 t)
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .r-annrg A,I) ,c,-, a (LLI) v. /i >, -4 ri, C-
WELL CONTRACTOR CERTIFICATION#: .c-404t- c /7G, iJ
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El Municipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION;Show sketch of the location below)
Nearest Town: t A-AAL L fy A/C- County: -Al t' «22 ?
(Road Name and Numbers. m Numbers.Com nity,or Subdivision and Lott No.) DRILLING LOG DEPTH
a
3. OWNER ( r t , IC c (rLO cI h �
Ckj FormationQ�yFrom To Description
Address _j ;; __� 11 / .tukQ° A0 kir/A ,-(
(Street or outs No.
City w Town State Zip Code
4. DATE DRILLED ! 'r)S -10 / ,N(s,_ eV t°Z47//icC
5. TOTAL DEPTH h-Sn
6. CUTTINGS COLLECTED YES Q NOES rv, o
7. DOES WELL REPLACE EXISTING WELL? YES El NOn— c - "-
8. STATIC WATER LEVEL Below Top of Casing: / min FT. - ..
(Use-.'II Above Top of Casing) r F`
9. TOP OF CASING IS / FT.Above Land Surface' '
'Top of casing terminated at/or below land surface requires a variance In actor- �U 4
dance with 15A NCAC 2C.0118
10. YIELD(gpm): ?ir. METHOD OF TEST h//Jii/rTi rr — 02 2
11. WATER ZONES(depth): / 6)0 ' / r n
12. CHLORINATION: Type /t El Amount VI/ /6 It additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To Ft. It— . ,/lrfri P i P - Roads,or other map reference points)
From To Ft.
From To FL 3 f) 6 7 r (elf 11
14. GROUT:
Depth Material Method 03°/7 r /t 9 N
From t To .-)-I\ Ft. (r Coa, o.-riT I lot n ,
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: f� ((� T (I M
I DO HEREBY IFETSr S LEL`fl W 11 RUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTS,AND THAT A C THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U LYMAR 1 8 2OO r, g -o l
Quad No: SIGN TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit origi al to ision of water Quality.Groundwater Section within 30 days
Serial No. AiOLI DWr1TER SECTION GW-1 REV. 12/99
ASHEVILI E F`O_F IAL CFFICE •

North Carolina•Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 0 LI n 3 O 3
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] I- A
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JNe1'1 n, `s I!, I) cs (L/o I) N)v I rh ei, 'LI
WELL CONTRACTOR CERTIFICATION #: 5 S'51- •>. /'7o, ii
• STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable sox): Residential tl�� Municipal ❑ Industrial❑ Agricultural D Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below) M
Nearest Town: ') tir7&' icm-) ,A-2.— County: / / rO Ctwi
nc. a � ,' rr .iLCci e
(Road Name nd Numb4s,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /l/t u t r (tt.• I I -, S From To Formation Description
Address 7ti Q f$, A 3 9 ( LO
(Street or Houle No.)
City or Town '-f State • Zip Code •
4. DATE DRILLED 11 -0 1 -/I /
5. TOTAL DEPTH Ssn'
6. CUTTINGS COLLECTED YES n NOlii----
7. DOES WELL REPLACE EXISTING WELL? YES E NOR--
8. STATIC WATER LEVEL Below Top of Casing: 9 45 FT.
(Use'+'11 Above Top of Casing)
9. TOP OF CASING IS G FT.Above Land Surface'
Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 2 F) METHOD OF TEST /711r1/1/-37 �f-
11. WATER ZONES (depth): 1 (i' S ' /(n7r ' I
12. CHLORINATION: Type it t H Amount ''/4 /is3 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To I S Ft. E!. . 'Iffy Pi P . Roads,or other map reference points)
From To Ft.
From To Ft. c
14. GROUT: O a
Depth Material Method z x?
From (7 To „1-t' Ft. /7 rnr, a �T, na)4 1 > cmoC
I C Tm
From _ To Ft. 1 0�
�
15. SCREEN: Cn m-a
Depth Diameter Slot Size Material = =o
From To Ft In. _ in. t m,a
From To Ft. in. In. _ c-'
From To Ft. In. In. 0 o
z
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
CONSTRUCT a. a • srPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
flintinn n
FOROFFIC: TI:7•-Tn flh ! •a 40 /A. 1 it -/ -t7 I
Quad No: L�Ja I� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1111 ., Z�u alto Division of water Quality,Groundwater Section Within 30 days
Serial No. 11,I!I GW-1 REV. 12199
..:�irlt..lriu

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 2 4 0 3 8 4
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: h-er1 n, `+ iic I 1 ck t( c 11 1)F /I n,r' 1 t <
WELL CONTRACTOR CERTIFICATION#: <:r/76,
• STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION jShow sketch of the location below) M
Nearest Town: /Y6 /c 7 In- j/h- County: y /o' Cern_
n
(Road Name and NumberrIs-1✓ Alta
or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER al . I-ro ' la riLLsj From To Formation Description
Address I i S. b- . �e --
(street or Route No.)
l'Y o 1,7 3 'Y�/
c2n�I Y>J A,,,/ oC
City or Town State - Zip Code
4. DATE DRILLED! I - I -o /
5. TOTAL DEPTH /00
6. CUTTINGS COLLECTED YES Q NO0
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
8. STATIC WATER LEVEL Below Top of Casing: it, FT.
(Use':II 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 15A NCAC 2C.0118
10. YIELD(gpm): �_ METHOD OF TEST /7/P)///77 M-
11. WATER ZONES (depth): /
12. CHLORINATION: Type. 1f f/4 Amount r1/1/ I If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To `3 7 Ft. to• . //f& tit-t9`-. Roads,or other map reference points)
From To Ft. 5/te/
From To Ft.
14. GROUT: o
Depth Material Method o 0
From 0 To . ,,Li1 _Ft. - r7 r'on.o.,17" _ n in, - am
r
From To Ft. r zm
15. SCREEN: I o<
Depth Diameter Slot Size Material fl ac
From To Ft _ in. in. S o
From To Ft. in. In. m
,
From To Ft._— In. In. _ __,
y
16. SAND/GRAVEL PACK: O a
Depth Size Material sic
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 • b.0 THATsA COPY OF THIS RECORD HAS BEENBE PROVIDED TO THE WELL OWNER.
FOR OFFICE U - 1 . IT I n p1 L .' (� "r®` I/ -0 i - V 1
Quad No: 4 1.L3NATURE OF PERSON CONSTRUCTING THE WELL DATE
IA .ri n or
'Aril 42 9 to Division of Water Quality,Groundwater Section within 30 days
Serial No. _ J GW-1 REV. 12/99
Grounr...'..-'action
Ashen' nffice _

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 211892
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: li- -ei'nr ' illorl) nM A (02.1) 11. /i 4. ril C
,44 (n
WELL CONTRACTOR CERTIFICATION 0: ' <Q 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: i—/ c'<< L /,2"7 %VC—County: Ma Genes,
(Road Name d Numbers,Community.or Subdivision and Lot Na) DRILLING LOG DEPTH
3. OWNER IG-oh .5 Pi gA11 "eV"( mi
. From To Formation Description
Address 7) 0,/C A�r%�U )
(Street or route No.)
L7/7n//- q/( : --217
City or Town State z$Code •
4. DATE DRILLED /7`G -0
5. TOTAL DEPTH StSn '
6. CUTTINGS COLLECTED YES❑ NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD-
6. STATIC WATER LEVEL Below Top of Casing: C r FT.
6 (Use N.'II Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surfaces
'Top or casing terminated at/or below land surface requires a variance In scoot-
dance with 1SANCAC2C.0118 /,n//in ��. 1 >
10. YIELD(gpm): METHOD OF TEST
11. WATER ZONES(depth): -513e '- - -
12. CHLORINATION: Type /f f H Amount 7�c/I/9 If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 70' Ft. (c.' r/ P Y P, Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: O
Depth Material Method O
From n . To 1-I\ Ft. n Pam ,,,4T n/ni n , z 2�
From To Ft. 7`— �� i \!tl J_ I I 1 �i .0
15. SCREEN: 5 ,I , - --
Depth Diameter Slot Size Material m�
From To_Ft in. in. �02 ;�''I� a zno
FEL B 2 5 a e_
From _ To_Ft._ in. In. ------ es
mA
From To_Fl. in. _ In. 'C-1 —'
16. SAND/GRAVEL PACK: GROUNDWATER SECTION ;
Depth Size Material ASHEVILLE REGIONAL OFFICE � o
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 RECORDI HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
f pryoihnDQQuLi p_co --6 /Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days GW-1 REV.12199
Serial No. -

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 4 13 9 3
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1b-en nr 5 'cI) An' a C0e.I I j ram• i I rhi.� �h <
WELL CONTRACTOR CERTIFICATION#: .�-4- cQ/'7�'n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable 804: Residential Municipal 0 Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: r ✓OA1 fc' 1' / /V /V C County:Al a C4flc
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 13-cht9 i2��j From To Formation Description
Address 53 7 Al SP?krlk t-0C C-
btreet orRoute No.
Fr a i(i/,r /t/C arC7- /
City or Town State zip Code •
4. DATE DRILLED ii--6 -o /
5. TOTAL DEPTH 9,, 5-'
6. CUTTINGS COLLECTED YES❑ NO1/3-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD
8. STATIC WATER LEVEL Below Top of Casing: O) FT.
(Use'+'If Above Top o 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 2C.0118
10. YIELD(gpm): 30 METHOD OF TEST h/07/lift 1—
11. WATER ZONES(depth): /h D /A272 I
12. CHLORINATION: Type if h`/4 Amount 7'/t//t6 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeIgnVFL. Material (Show direction and distance from at least two State
From D To �/ Ft. (t'• ,-/frV O f' P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
c
From To Ft. (1 n.n d 1T n � C o
From To FL D k D E L U i) . c)
15. SCREEN: 2
0 0 ,
74
Depth Diameter Slot Size Material i I l i j II c m
2002 "<
From To Ft in. in. i FEB 2 5 ��'�-' j r nc
From _.To_Ft.— In. — In. I i _ o
From _To_Ft.— In. _ In. h --- m
GROUNDWATER SECTIOU
16. SAND/GRAVEL PACK: ASHEVILLE REGIOPLI- OFFICE__; O rim
Size Material F'
Cr! 0
From To Ft. ES
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.
OPM^+
FOR OFFICE USE ONLY Y GIIL' 1Lnoela4i 'BE (�l/` -O /
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW1 REV.12/99
SerW No.

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ti 411894
1636 Mail Service Center-Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ‘N-e1)tie g i)r l ) nm A L1e I I Li`. /I-fl`>� Tn c
WELL CONTRACTOR CERTIFICATION#: ,c - cQ/-7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 1:/1 Municipai 0 Industrial❑ Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection 0 Other 0 If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
. Nearest Town: /' Q'1‘-'Gfr^.-✓ /✓r^. County: rn OcL"n, ,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ph i it 1 S IC l o( Ic- From To Formation Description
Address j a u, - m a c d>✓ 2 2, (7 h
ILL treetorRo/� . �-g 7 //
�Y am t 3y
City or Town State Zip Code
4. DATE DRILLED /) -s" D I
5. TOTAL DEPTH ,3n
6. CUTTINGS COLLECTED YES❑ NOQ---
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD
8. STATIC WATER LEVEL Below Top of Casing: 9() FT.
(Use's'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 15A NCAC 2C.9118
10. YIELD(gpm): SO METHOD OF TEST /ohnii n ell---
11. WATER ZONES(depth): l a 0) t B p ) l 4 n I
12. CHLORINATION: Type if*I''t Amount r/4/'$ If additional apace Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From ' D To Ft. lc.. r/CV Art"; Roads,or other map reference points)
From To FL 5
tGe1
From To Ft.
14. GROUT:
Depth Material Method o
From n To ., --t' Ft. 0 ern cmT I)fr t n • C `o
From To Ft. I Z a=
15. SCREEN: D s �� C _m
m
Depth Diameter Slot Size Material on
From To Ft in. in. -, I ": cr.
From To_Ft.— In. _ In. _ I F E B 2 5 2002 1:9 3
From _To_Ft. In. — In. 1 rn
o mrn
16. SAND/GRAVEL PACK: I ' --t-t
Depth Size Material GROUNDWATER SECTION as o
ASHEVILLE REGIONAL OFFICE z
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 RECORDBE
HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Y {Qum;o I Leg ade / I I` S - o l
•
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
•
Submit original to Division of Water Quality,Groundwater Section within 30 days
GM
REV.12/99
Serial No.
•

•
North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 j I. 8 9 J
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \NeI'I nr " iLrl) n— a t Oe I I ''. ii 71,>1 751 <
WELL CONTRACTOR CERTIFICATION(I: 4� cQ/76�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO,ff;(Show sketch of the location below)
Nearest Town: re" e I,-,) 4,-(2, County: /Y)a_e'ant ,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER kiG rPF�J Al e Al a-Aaat r From To Formation Description
Address S c a,, 0
tree eree
it o k 9 3 V
7M ill ale Zlp Code .
City or Town Stale
4. DATE DRILLED ij - 2 —0 /
5. TOTAL DEPTH '/n C.
6. CUTTINGS COLLECTED YES❑ NO f —
7. DOES WELL REPLACE EXISTING WELL? YES D NOE-
6. STATIC WATER LEVEL Below Top of Casing: ,O F FT.
(Use Y'U Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface*
-Top of casing terminated ab'or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): / METHOD OF TEST h/Mll i Yl 4—
11. WATER ZONES(depth): 7n ' - CI) . i
12. CHLORINATION: Type /t 14 Amount A I! /6 If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To (v' Ft. in•. r I"V P r P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: O
c
Depth Material Method C..
From 0 To (IN Ft. CI
0 orn
From l cm
15. SCREEN: To Ft. 6 �� i �11 I' j II ,,1 i Sm
Depth Diameter Slot Size Mate IL) I S ), ��
a
From To_—_Ft_ In. In. m DE
From __To_Ft.— In. _ In. F E B 2 5 2002 i i ) o m
From _To Ft. In. — In. I I .— —"
16. SAND/GRAVEL PACK: ON 7E,
GROUNDWATER SECTION z
Depth Size Material ASHEVILLE REGIONAL OFFICE
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 RECORDI HAS/BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY I p im. A /Lneda4/4 l / / `U .2 —0 /
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odpinal to Division of Water Quality,Groundwater Section within 30 days GW-1 REV. 17f99
Serial No. _

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2
41396
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ch-en n, g /61) , , A Lin a fi r._/1 Dt 4 rig C
WELL CONTRACTOR CERTIFICATION 0: .c-S - cQ/7G,
STATE WELL CONSTRUCTION PERMITS:
L!X
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO/N• (Show sketch of the location below) n�
Nearest Town: /rr/Jm 1,--- /n.v �n /4.4'- County: (1 lint J
PiriAle roS4. VIe< J I)2
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER J O i.(C'.'r t, 0 r t(to PC From To Formation Description
Address _P &to roS 4 3 , e-tc.) B 7e
Feet or Route No.
1�1'l�/.i Ir (ram A/c- ,-, A-7 3 V
City or Town State Zlp Code '
4. DATE DRILLED Il- J-O /
5. TOTAL DEPTH ,=.2,5-0/
6. CUTTINGS COLLECTED YES❑ NO❑---
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fl
8. STATIC WATER LEVEL Below Top of Casing: / co FT.
(Use'+'U 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 15A NCAC 2C 0118
10. YIELD(gpm): oer METHOD OF TEST /71/n/1i77 k-
11. WATERZONES(depth): /SO =a-471n
12. CHLORINATION: Type /t t N Amount y4 I'9 II additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth'^b Diameter or Welght/Ft. Material (Show direction and distance from at least two State
From - 0 To./O Ft. h'. r/(r9 ®y' P • Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method 55 ((�� pp
From __L To . -. Ft. _ n c:;' o..1T I n-:r n ` D S lJ E V o_
A
From To Ft. ! Z a7
15. SCREEN: I C cc-'
ni
Depth Diameter Slot Size Material _ F E B 2 5 2002 U _ o
o<
From _To Ft in. in. .c ao
From To_Ft.— In. In. 3 Lit,'
GROUNDWATER SECTION c
From To_Ft._ In. _ In. ASHEVILLE REGIONAL OFFICE riff:,
16. SAND/GRAVEL PACK: FP: y�
Depth Size Material tT o
From To Ft. z
From To Ft.
17. REMARKS: `2ar1/lr .05 5:cr ,
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 y �Q nAnr 4 Ana°/14 BEl 11 — 9 --U/
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GM
REV. Ira
Serial No.

244278
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: t.esa 4 I ) rl Jn
WELL CONTRACTOR CERTIFICATION#l l 1
,� STATE WELL CONSTRUCTION PERMIT#: � — d
1. WELL USE(Check Applicable Box): Residential t/dk Municipal 0 Industrial 0
Recovery 0 Heat Pump Water Injection Agricultural 0 Monitoring ❑
❑ Other (� If Other, Ust Use:
2. WELL LOCATIO • (Show sketch f the location below)
Nearest Town: — k/ ' C -
County:_/ ' ' OA. et
i
(Road Name and umbers,Con, ry,or ubdiwsion and Lol No.)
3. OWNER (t Q, j DRILLING LOG
Address From DEPTH
To Formation Description
a BO Of�s, a � 2a1 port
City or Town Stale Zip Code
4. DATE DRILLED -3 G,
5. TOTAL DEPTH n
6. CUTTINGS COLLECTED YES 0 NO
7. DOES WELL REPLACE EXISTING WELL? YES El NOD
8. STATIC WATER LEVEL Below Top of Casing: _4 FT.
(USe'''II Above Top of Casing)9. TOP OF CASING IS
'Top of casing terminated at/or to d surf requires ove an ariad nt eln actor-
dance with 15A NCAC 2C. 18
10. YIELD(gpm): METHOD OF TEST
11. WATER ZONES(depth):— ( /
12. CHLORINATION: Type It t N
13. CASING: Amount If additional space Is needed use back of form
Depth Wall 9ckneu LOCATION KET H
From P Diameter or Wel ht/FI. Material (Show direction and distance from at least two State
To Ft.._.(E
From To Ft `3 r�-� Roads,or other map reference points)
From To Ft
14. GROUT:
O -
Depth Material Method
From ---� To ,.Z.l\ Ft. n ram_ 0 2 w
From To Ft. Cam') oc,
c
15. SCREEN: qr'1
Depth no
P Diameter Slot Size Material
-o -
From
From To Ft —_ in. in. ) m z
a xm.
To Ft. In. In. Scn
From To Ft. In.
16. SAND/GRAVEL PACK: in.
0
Depth Size —a_,_ _ 2
From To Ft.— ITT • \ ,
From To , 11
17. REMARKS: '
j
it
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY n
Quad No: /- 3 b a
SIGNATURE DF PERSON COONSNS TRUCTING THE WELL—�� Submit original to Division of Water Duality,Groundwater Section within 30 days DATE
Serial No.
OW-1 REV. 12/99

+ �
North Carolina•Department o 7 f Environment and Natural Resources-Division of Water Quality-Groundwater Section y.. >-,2 v 7 2
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 21vn n r g i)u1) An, a (Lk I I . 11. II � Zn C
WELL CONTRACTOR CERTIFICATION#: .55'-S9- /'7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial 0 Agricultural❑ Monitoring D
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ijn 2r, le L 1 •2" /L'e— County: M.r+ Fi+—
f'1Q , Itbc„>- ln,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (.4_' (1 n v m C' Cat l)Cv>tii From To Formation Description
Address/ C , � et ut cj ���
qq �1 ('treat rRoula o.)
/l. 1 1.1 r-n2r ) ta— - c
City or Town Ctata Zip Coda c
cE
4. DATE DRILLED //— 1 Lit—Q ! C
5. TOTAL DEPTH Son i ca,
6. CUTTINGS COLLECTED YES 0 NOEI/ { c'•
7. DOES WELL REPLACE EXISTING WELL? YES NO�/ '7'r"
8. STATIC WATER LEVEL Below Top of Casing: / FT. o c''r�
(Use-+'II Above Top of Casing) asb
9. TOP OF CASING IS / FT.Above Land Surface' yror,
'Top of casing terminated at/or below land surface requires a variance In scow- - 0 cNn a
dance with 15A NCAC 2C.011
10. YIELD(gpm): METHOD OF TEST Mot Fri �f— co —1
11. WATER ZONES(depth): r n- I a z
12. CHLORINATION: Type / 114 Amount 1V 4 /6 It additional space Is needed use back of form
t p
13. CASING:
-
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Fr. Material (Show direction and distance from at least two State
From 0 To Jo 9 Ft. (c r/.L P t P- Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From D To V-lA Ft. n /.m, d-v1 i pl,Te n—,
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 HEREBY CER *AO, 113-$VB WAS�1CO?YSTMUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONSTRUCTION IOF IDS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
brill., �/_/y � o-/
FOR OFFICE USE Y f�+�J � � �n u�
Quad No:
)��''� ' r��uZ S t1•'MTURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW1 REV. 12199
1,11 NOWATER SECTION -
ASHEVILLE REGION [ OFFICE

North Carolina-Department of Environment and Natural Resources•Division of Water Quality Groundwater Section /_ .. ,_ r'
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Jan ni "C 1 tu)) ea,., A LOP I) 1 r. /1 a Al. -Tn C
WELL CONTRACTOR CERTIFICATION#: Q/7/,,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 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: r n 4y/ Az. A / / 4,7 county: Ala Cr.--„_,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /eni {t -e P/7C! ,- /1, From To Formation Description
Address 7 s l L k S e r / /l
Street or Houle No.)
�Erhi� I ; �t2. /L' C.. ` 2 ic7A'k
City or Town State Zip Code •
4. DATE DRILLED //-/.3 —O/ CD n
5. TOTAL DEPTH ?ti I,
6. CUTTINGS COLLECTED YES Q NODS ' �'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO� o or
S. STATIC WATER LEVEL Below Top of Casing: (//m FT. N r,-
(Use'+'If Above Top of Casing) O *r
-ribri
9. TOP OF CASING IS FT.Above Land Surface' cw
'Top of casing terminated at/or below land surface requires a variance In scoot- = m
dance with 16A NCAC 2C.011e
10. YIELD(gpm): /5 METHOD OF TEST h/N2/JI n 61— O 2
11. WATER ZONES(depth): •<( /Co o2•7) / n c
z
12. CHLORINATION: Type It t µ Amount r'/4/6 If additional space Is needed use back of form
13. CASING:
Wall ThicknessLOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From C To Ft. (C• '/kV P k P - Roads,or other map reference points)
From To (([ Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To A, Ft. 0 ern, 0-44 [)/'1.4 it ,
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. REMAR •
int
I DO HE NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST N STANDARDS,AND THAT C Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI
pA R Jn ° / / �/� l
EONL�T Mm" '
Quad No: IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1 origin to Division of Water Duality,Groundwater Section within 30 days
Serial No. GROONOW ER SEC Ild GW4 REV. 12/99
ACYtv'La a GIONAL OFFICE

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section L rR. .2 j ! 4
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: XNr)n m 4i 1wl) nM a (DO I) Av. i I n rkt
WELL CONTRACTOR CERTIFICATION#: —sip- cQ/'76o
STATE WELL CONSTRUCTION PERMITS!:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)r
Nearest Town: / F&"n 4' /,,7J z/G County: /11(I etz'w
(Road Name and Numbers,Community,or Subdivision and tot No.) DRILLING LOG DEPTH
3. OWNER fir) , lL -e (L1c2, -/c )2J, From To Formation Description
Address ,3ct6.. ,il zJ- 1�-C65,,— Ec<
(Street or Route No.)
Ff ail ldiu i/c_ d2j73 V
Gry or Tovm State p Code •
4. DATE DRILLED I/`/ o /
5. TOTAL DEPTH *C"*),-) K
6. CUTTINGS COLLECTED YES E NOD—' p
7. DOES WELL REPLACE EXISTING WELL? YES D NOQ — o
8. STATIC WATER LEVEL Below Top of Casing: Seri FT. z
(use•.•0 Above Tap of Cuing) C `
9. TOP OF CASING IS / FT.Above Land Surface` DO of
'Top of casing terminated at/or below land surface requires a variance in actor- G yo
dance with 15A NCAC 2C.011e t
10. YIELD(gpm): /O METHOD OF TEST h/PJUi n /If - ? rn
11. WATER ZONES(depth): - l its% 1 `.' N�
rg
c,
12. CHLORINATION: Type if f N Amount r�4 053 If additional space is needed use back of OP z
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth C Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 7 / Ft. ("'.' r/C& /I/ e • Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To Z-I\ Ft. . elm >-v1 f I 19A/1 '
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: (� [��� ���p���
IDO HEREBY,Ca IL 4T VfEL4'M'�Ce • RUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIO F r .c , • c:i a' THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
G 11119 4oa� `/.>/ 0 —O
FOR OFFICE U•,: a 1lLY „ DATE
Quad No: •- c '• RE OF PERSON CONSTRUCTING THE WELL
I Submit original to Dwision of Water Quality,Groundwater Section within 30 days
_ _ _ GW1 REV.12/99.
Serial No. , `",- u(n} DINA'ER St' -

n 1 iel ry
North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section ,.. I. 3 ! LI
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cN'l n P r "i 41) flan A NO I I v. /l f<.4 TA (
WELL CONTRACTOR CERTIFICATION#: .tom 5" c2/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:�(Show sketch of the location below)
Nearest Town: Fd2ltit (- l.c� /L'e___ County: 49a cr
470 < 7, 4s"—' 2c't'
(Road Name and�Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /'l Gr r V i h-- /r'`a S it l'7 4, P-/1% From To Fomaaon Description
Address S- S 5/''4 I yrzo ,R-ca
(Street or Houle No.)
/ iQA . Li-,J 71.-/C'_ .. ,f93k
City or Town State Zip Code •
4. DATE DRILLED J�--9-0/ c
5. TOTAL DEPTH &'/'/1 C o
6. CUTTINGS COLLECTED YES❑ NOO- Z a
7. DOES WELL REPLACE EXISTING WELL? YES NOn o a"'
6. STATIC WATER LEVEL Below Top of Casing: l 49 FT. t c,(7,1
(Use es.'g Above Top of Casing) --
9. TOP OF CASING IS 1 FT.Above Land Surface' Y no
-Top of casing terminated at/or below land surface requires a variance In razor- J...,'
0
dance with'SA NCAC 2C.0118 z
10. YIELD(gpm): / METHOD OF TEST h/NvJi n el— o
11. WATER ZONES(depth): /SO f Y ca -'
O o
z
12. CHLORINATION: Type /1 1 Amount r'4/ri If additional apace is needed use back of form
13. CASING:
Well LOCATION SKETCH
Depth Diameter or WeighlFt. Material (Show direction and distance from at least two State
From 0 To.10 S Ft. ie'' .-icc' P v P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From D To ZLN Ft. (7 P-n, lam? J/'JA it ,
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: -7�
I DO HEREBY 10 WEt3 3CDN" UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT' ANDARDS.AND THAT A CCj Y op THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U LYi% AlAG a0Q//M •
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
al to DvWon of Water Oualiry,Groundwater Section within 30 days
Serial No. GRGUi]D ATIR L. v% GM REV.12199
.rUu E REC-3010

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section
'- i..-. 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tl-t1 n i g 1115 I) nn. a (OP I i F>V. /I r>1'4 T)1 ,
WELL CONTRACTOR CERTIFICATION#: S-Sr-ii cQ/7Ga
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring D
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION how sketch of the location below)
Nearest Town: /-1'Cf-IttC 1.a-i 1j (' County: in a r-h`-i2 '
IP! -h\ A C�
(Road Name and Numbers,ComAwnity,or Subdivision and Lot No.) DRILLING LOG DEPTHo .
3. OWNER 5 C e• Y- V tt% LCt'<\-d l O u- IAe- - From To FormauoraaescriAan
Address
it;z-r Sets G"n e2. CZ) e m
/ (Street or Houle No.) �1 0 ,C C r
/'l gin Q: l72 A-/C- • r/ a 7-3 V N o¢
City or Town Stale Zip Code r"ti `T
yo
4. DATE DRILLED_J_,_ - - `710
5. TOTAL DEPTH S°b S Q y=
6. CUTTINGS COLLECTED YES❑ NOD— "'�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD O o
8. STATIC WATER LEVEL Below Top of Casing: FT. r.
(Use'+'u 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 In accor-
dance with 15A NCAC 2CA11s
10. YIELD(gpm): =METHOD OF TEST hlln//n i /--
11. WATER ZONES(depth): i/CC ' /I
12. CHLORINATION: Type if t/-I Amount VI/ / If additional space is needed use back of form
13. CASING:
Wall Thidmess LOCATION SKETCH
Depth r 3 Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From - D To Ft. (c'.. r/Qf/ P v P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From D To .2-(t Ft. P ein, a..,iY p IQ, r1,
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:
rtiI DO HEREBY C is [i it \11 CTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIO ,1 a 4'IS,AND THAT A COPY 0� I IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US a o /Ji4 -4? O l ) -7-0
Quad No: S GNA RE OF PERSON CONSTRUCTING THE WELL DATE
I , Submitod9 to DI on of Water Quality,Groundwater Section within 30 days
Serial No. LLL Gf;,uIJDW,ATER SECTION GW1 REV. 12/99
ASPEVILLE NAL CFFIC;E

242911
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: can n r g 1e U ,i a (I)e a 11 I . / 7k e4 Tr( c, -
WELL CONTRACTOR CERTIFICATION#: Cam?/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential t!X Municipal ❑ Industrial D Agricultural D Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of r the I cation below)
n � o
Nearest Town: rC�2 /�/ / C��� . County: ,/+ 1�1 n J
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �JY/7 . ,in Q C/04_J From To Formation Description
Address c.,Q // R I It B ich e y You L Z-. i
(-tree or Route-go.)
FrOmk) A/c- . g1a y
City or Town State Zip Code
4. DATE DRILLED I)-a7-0/
5. TOTAL DEPTH S 05;
6. CUTTINGS COLLECTED YES NOILI----
7. DOES WELL REPLACE EXISTING WELL? YES Ej NOfl
8. STATIC WATER LEVEL Below Top of Casing: r„0 FT.
(Use'+'it 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 eceor-
dance with 15A NCAC 2C, 18 -10. YIELD(gpm): METHOD OF TEST /O/N0/1i n
11. WATER ZONES(depth): /h/)) /70
12. CHLORINATION: Type /f t H Amount 1/4/ /6 If additional space Is needed use back of form
13. CASING:
Wall LOCATION SKETCH
Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 5 O Ft. (r. . e/kl/ P v P- Roads,or other map reference points)
From To Ft.
From To Ft. o
14. GROUT: air o
Depth Material Method rn o^
From To Ft. 0 r_rT /n.r rim n �_ ;
From To Ft. cI o�
r-
15. SCREEN: - mo
Depth Diameter Slot Size Material = z0
From To Ft In. in. C/i ma
From _To Ft, in. — in. . • O a
From To FL_ In. In. z
z
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMAR
tt,11)
____
I DO HE EBY cEFITIFY THAT t-tS'wEl t \V GDNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST UG1t(JN STANDARDS,AND THAT PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
It
f` 1/ ' 21 b/'
FOR OFFidE USE ONLY - anim4 e / nD /2-
[
Quad No: 1 . I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
I _...Wad*origir(al to Division of Water Quality,Groundwater Section Within 30 days
i
Serial No. ; GM REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
242910
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \Ner1 nr i I ful) rM a (Oeu r II 7t>/i_ Z1 C
WELL CONTRACTOR CERTIFICATION#: ,y-3r-&— : /7(0 v
_ STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection El Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: PP/2n1(c �- I -V 4 7 ei County: /r o L/—it__,
m i A A 1-e he Ll R-Y1 1-h +fru:.,/
Community,Name and Numbers,Conunity,or Sdbdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t l Q A .-e I O (r C-, From To Formation Description
Address I e, / RI, ct(r,-@k OCItsl) t`2- -- —
(Street or ou a No.) U
City or Town State Zip Code •
4. DATE DRILLED f I-1 3 o 6 /
5. TOTAL DEPTH ti-/q r
6. CUTTINGS COLLECTED YES E NOON
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOfl---
8. STATIC WATER LEVEL Below Top of Casing: (tip FT.
(Use'.'II 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 eccor-
dance with 1SA NCAC 2C.0118
10. YIELD(gpm): 3-'j- METHOD OF TEST h/lr7U„1 Bl�-
11. WATER ZONES(depth): 7.t/' (
12. CHLORINATION: Type /t t/4 Amount r/-/ //9 If additional space Is needed use back of form
13. CASING: - -- - --- -
Walt Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To •�/ Ft. (C• r/fr// P t P - Roads,or other map reference points)
From To Ft.
From To Ft. c
14. GROUT: O o
Depth Material Method c
From C' To elf\ Ft. f1 /7,ni d-✓1/ n1o.t /> , n cm
From To __Ft. / 1 0�
15. SCREEN: CO Dc
Depth Diameter Slot Size Material 'v Et,
CI
From To Ft In. _ in. S �m
From To_Ft. In. in. ' cn 7J
From To_Ft. In. _ in. O _,
.r o
16. SAND/GRAVEL PACK: _
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY tFRT•FY THAT-nits WELCWT(iUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION S, ANDARDS,AND THAT A COFf IITHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I ICJ /
FOR OFFICE U�I �YLY v 1` I'i o ��/2 L. ��
Quad No: ..I 4 - I TURE OF PERSON CONSTRUCTING THE WELL DATE
I Submit odgi vision of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
GI-L J.11,,,-,,,,: r ;,IJiJ
ASrI- ILLERL(.il , .I [

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 242915
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: X>f'1 nr" fir I) rM a (On I) . f- 11 ni ,i. -7Dn c
WELL CONTRACTOR CERTIFICATION#: . 'S c l7Ko
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable eox): Residential Ill Municipal El 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:
�r 4 A-lC i • /✓ 7/%__ County: /77 Q 1-1-21_ J
i3Oe) ll. L042.419 Rf;
(Road Name and Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ill 'c✓ 4, -r7f1-,it — From To Formation Description
Address f 'blip j, i La,,,,,_-at1to r4o.)
[Y1241VI 40 /C . � 52 71-
City or Town 'State Zip Code •
4. DATE DRILLED //—.Q,f,/i/
5. TOTAL DEPTH • 5—nfl
6. CUTTINGS COLLECTED YESQ NOEli
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO En
8. STATIC WATER LEVEL Below Top of Casing: 3n FT.
(Use'+U Above Top of Casing)
9. TOP OF CASING IS I FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): 3 METHOD OF TEST h/ni/m i f�
11. WATER ZONES(depth):
12. CHLORINATION: Type h f/4 Amount r'/c'R tS It additional space Is needed use back of form
13. CASING: - --
WalThcknesa LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To '7-� Ft. Ic' . '1kQ P t P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: --
Depth Material Method 0 om
From D To -(I\ Ft. (1 Er» mdi% p/ne it_ n Cc,
i o
From To Ft. W ,.-,
15. SCREEN: 1'c
—U m�
Depth Diameter Slot Size Material c
S ^mm
From To Ft in. In. rs mz
From To Ft. In. In. p
From To Ft. In. In. i
16. SAND/GRAVEL PIS !"—` I
Dep - Size I Mat n
From To Ft. 1 I
KT
From To I
17. REMARKS: I
I DO HEREBY CER FY TNY�T TR(S7-WELLWA!,T tRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION S ANDI)(:dbS ANDTk(PTAQ QE THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY °iA 4 AJ on.,.r._ // _ S -o >
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Quality,Groundwater Section within 30 days
Serial No. GW1 REV. 12199

42913
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: xN-en ni.1 iiv-1) nM A (OP i I lr. t I D, e4 T„ (
WELL CONTRACTOR CERTIFICATION#: .4 cQ/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential ll�� Municipal El Industrial El Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION how sketch of the location below)
Nearest Town: i2 4 L/G L/"L, 7' ( County: li4.c->, .
re) /27,4 ., (4,rhi ji z //
(Road Name A�ngd Community.Corunity.or Subdivision and Lot No.) DRILLING LOG DEPTH
LJ 3. OWNER c C. y r r, ---Ser7k.-12. From To Formation Description
Address •7 7 Ii 12 , SI ,
///' (Street or Route No.)
/1 , SS/in in r°r- f ;T I
City or Town State Zip Code •
4. DATE DRILLED 1/ ` r.,2 6—D /
5. TOTAL DEPTH D `;
6. CUTTINGS COLLECTED YES NOES
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD
8. STATIC WATER LEVEL Below Top of Casing: -3 r FT.
(Use'+'II Above Top of Cuing)
9. TOP OF CASING IS / FT.Above Land Surface'
'Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): METHOD OF TEST hfll7/Brn lh
11. WATER ZONES(depth): 7/0 —°� `U4 I
12. CHLORINATION: Type 1t 1`1 - - Amount VC' // If additional space Is needed use back of form
13. CASING: -- - -- - -- "
Wall ThicknessLOCATION SKETCH
Depth / Diameter or WeighVFt. Material (Show direction and distance from at least two State
7
`'From D To ' Ft. I • ' r 1kV P t P - Roads,or other map reference points)
From To Ft.
From To Ft. a
14. GROUT: 0 o
Depth Material Method t� n�
From C To rIN FL 0 err o.,i7 I /n.l it rn o^
z--
From To Ft. I 0<
15. SCREEN: >o
Depth Diameter Slot Size Material 3
rn
From To Ft in. in. cnz
!1 rn u
From To Ft. In. — in. o y
From To Ft. In. In. 4— o
16. SAN t?fSCK:, 11 F'.'`" i1 Z
ibepth -, Size ,I Material
From " To Ft. i H
From 111'i To Ft, i
17. REM i\,
ISKi"
I DO REB --R u W CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS RUC N _$,i AfyO:Tk,tPT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
a
FOR OFFICE USE ONLY 1Qn'im;o �^"in�C�4A"^` ' l/`E J D
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water(Duality•Groundwater Section 2 4 0 91 6
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: trl-enn, ei IL ) elm rk (00II N5v Iir1,,.,, �)1C
WELL CONTRACTOR CERTIFICATION #: .ct4 Q- .x/7Ga d
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 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: it/ Cl HI LA"N))-54 A/C - County: Ana <{7
(Road Name'and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER .. 1l1/.l In A )t P YI S C f From To Formation Description
Address ,Y, 0, 96 x 5 7 ct
(etreeCorHoule No. /
l Lit 11 f?Y S AA) _
City or Town Stale Zlp Code '
4. DATE DRILLED I 1 - I -O I
5. TOTAL DEPTH 3n S
6. CUTTINGS COLLECTED YES El NOEji
7. DOES WELL REPLACE EXISTING WELL? YES n NO[ I--
6. STATIC WATER LEVEL Below Top of Casing: (op FT.
(Use'i II Above Top oTTCasing)
9. TOP OF CASING IS / FT.Above Land Surface'
-Top of using terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): .-,25 METHOD OF TEST /')//0/lll9 l
11. WATER ZONES(depth): 14h 1 I7 O /
12. CHLORINATION: Type I+t H Amount +'/4 (6 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To Ft. IC r!kV P G P , Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
From C To ;IN Ft. (I Grr, o..vi/ plof n p o
From To Ft. p a—
;.-
15. SCREEN: rrl c'r�
Depth Diameter Slot Size Material t� o<
From To Ft In. in. w ^
From To—Ft. In. In. -n m--
From To Ft. In. _ In. 3 V? m�
arc
16. SAND/GRAVEL PACK: o -�-r
Depth 1 Size —Miffe al 1 r o
From To 11 i 1 h _ rZ
From To_4, Ft.
i
17. REMARKS: • Ill i I
1 ';r -. 'JU/ L_j
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS UCTBD IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAFIDS, 4DTHAT-AC ORY O IS ITEICORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE Ofi----- —-
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-I REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 3 / 0 ) 1
1636 Mall Service Center-Raleigh,N.C.27699-1636-Phone[phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c)1-en n, -r is /),:, A (L'12 I I 1 /I r): a 7 /1 (
WELL CONTRACTOR CERTIFICATION#: . 3-Q- /7(n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential LLd< Municipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) M
Nearest Town: 1I /(k C 4d'6f' ,4/0_— County: / Y 7 t; (m-n-L)
(Road Name and Number]piCommunity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l.P31.11C2 R6rJ91L�)�i'! "•Pr(� S1 ci e n"--- From To Formation Description
Address Ti n, Re,x ) 5
1 (Street or outs o.)
Tifd h OerIAc /VC. c2c7 'Il
City°(/sown State - Zip Code •
4. DATE DRILLED /D._4-0 /
5. TOTAL DEPTH S"sn,
6. CUTTINGS COLLECTED YES NOC.----
7. DOES WELL REPLACE EXISTING WELL? YES n NOH-
B. STATIC WATER LEVEL Below Top of Casing: p FT.
(Use':11 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 In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): - I METHOD OF TEST Hlr1//,71 �!—
11. WATER ZONES(depth): qS / k? I
12. CHLORINATION: Type 11 t µ Amount 'i/4 I r5 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To LS- Ft. Cc '/�T' Pr--f-- Roads,or other map reference points)
From To Ft. 51{Y L
From To Ft. c
14. GROUT: o
Depth Material Method a c.
From (7 To Z-LN Ft. /I Crn c.A( p/').l ,k -, —I ;_
From To FL j, `
15. SCREEN:
—o '4."
Depth Diameter Slot Size Material
From To Ft in. in. r' =
r,»
From To Ft, in. In. C71 o
From To Ft. In. In. —
lc
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(/OP�\ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 7 :'r1i++ .r iin,d0a,r,0 /U- cf - cD /
Quad No: i,� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
� '�-�`�I StIxMt original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 3 3 7 3 4 3
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t lnn, 9 IhIIfin A LL�e11 �v fl n, .� 7)1 r
WELL CONTRACTOR CERTIFICATION #: .�- i3- c /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L(�� Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other O It Other, List Use:
2. WELL LOCATION. (Show sketch of the location below) M
Nearest Town: /71/ C-// L l9-it-',DC �C1i / / /County: & (wan
LLB@ o(0 XYLo-n-in
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 11 rn vo.IA i tt4 e.n a r ci From To Formation Description
Address SO e JR cie S wv, S •S-r
`Street or Houle No.)
a r 1anmctrl r I 3c;g D /
City or Town Stale Zip Code
4. DATE DRILLED f b •-Z -O/
5. TOTAL DEPTH -CO 5-
6. CUTTINGS COLLECTED YES D NOD -
7. DOES WELL REPLACE EXISTING WELL? YES n NOE-
8. STATIC WATER LEVEL Below Top of Casing: ,� r) FT.
(Use'i II 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 15A NCAC 2C.011a
10. YIELD (gpm): /n METHOD OF TEST h/)///!-1 61-
11. WATER ZONES (depth): 025 /
12. CHLORINATION: Type it±/4 Amount '�4 M If additional space is needed use back of torn
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeightFt. Material (Show direction and distance from at least two Slate
From '1 0 To t�/ Ft. (r". . r 7 Pri P f P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o =_
From C' To r-N Ft. Pens, a.,r i p/Q.r ,t., — r'
O C'
From To Ft. c') c,''.'!
15. SCREEN: --`''
f U2
Depth Diameter Slot Size Material LO w;rri
::-c
From To Ft in. in. -0 - c
,
From To Ft. In. In. '-'„
0
From To Ft. In. in. ry r'•:�
`Ul i
16. SAND/GRAVEL PACK: — c>
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 BEENBE PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Yt it/r9/n l D /�l)✓(tn<'��/ /6 - 3 ' U I
Quad No: l w SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subndt original to Division of Water Quality,Groundwater Section within 30 days
Serial No. -. GW•1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 3 7 3 5 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tl et-)n, ct I+c11 rk L* I1 kv-. iI n;,� TnC
WELL CONTRACTOR CERTIFICATION #: -i- ,-;)/7G,
� STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l[�- Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:j.Show sketch of the location below) �-
Nearest Town: ) 71 er/./L .: i1'il-- d /- County: / L1.fr f--9.
(Road Name ang,�umbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 4e,«J r J2 e-r..dy/ n From To Formation Description
d
<} fC-cho r-t<e - ,,- a asp
(Street or Route No.)
,-- Alnf1 72 ( - :7J93y
City or Town State Zip Code
-
4. DATE DRILLED -/b -- -C` /5. TOTAL DEPTH 'in .5-
6. CUTTINGS COLLECTED YES n NOD-
7. DOES WELL REPLACE EXISTING WELL? YES n NOn
6. STATIC WATER LEVEL Below Top of Casing: c2p FT.
(Use':II 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 15A NCAC 2C.0118
10. YIELD(gpm): c20 METHOD OF TEST /O/P7/11-17 r1—
11. WATER ZONES (depth): /
12. CHLORINATION: Type /f f H Amount '/4 ( If additional space is needed use back of form
13. CASING: -- ----- - -- - - -- _._-
Wall Thickness LOCATION SKETCH
Depth Diameter or WeightFt. Material (Show direction and distance from at least two State
From 0 To ,5 Ft. if' - '/kP P I P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To .;2.1A Ft. lr ('ah c-y1i 1)arie 't , c
From To Ft. ru
15. SCREEN: ` O ='--
Depth Diameter Slot Size Material `
From To Ft in. in. `I `-
From To Ft. in. in. _ -
From To Ft. In. in.. `� [' ,=
16. SAND/GRAVEL PACK: t\) r.,
Depth Size Material is .r
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 RECORDI HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ��mm) ,e l ✓Q/JnJ.� /' - �' o /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division dl Water Quality.Groundwater Section within 30 days
Serial No. Fli j GW1 REV. 12/99

7 4 U ( J
Or
Noor6 MahCarolina Service-Depart Ce tmenRa Environme
N.C. nt and N
1 atural Resourc
(ur )es-Divisionv221 of Water Quality•Groundwater Section A. `S
1il
WELL CONSTRUCTION RECORD WELL CONTRACTOR: nri 1 ) ' n
WELL CONTRACTOR CERTIFICATION#:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �
%C� County:
Nearest Town:
DRILLING LOG DEPTFi
(Road Name and Numbers.Community,or Subdivision and Lot No.) From To Formation Description
3. OWNER �'
Address 7S/ cG + ' � /' J_
ee or e e O. k 7
State Zip Cdde
City or ILLSTown . `,
4. DATE DRILLED -
6. TOTAL DEPTH " '—
6. CUTTINGS COLLECTED YES❑ NO11----
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO0
S. STATIC WATER LEVEL Below Top of Casing: �_
(Use•:it Above Top of Cuing)
9. TOP OF CASING IS__Z — FT.Above Land Surface'
'Top of casing terminated aver below land surface requires a variance In actor-
1 with 1(gpm):A NCAC 2C A�6 METHOD OF TEST 1�'
10.1 YIELDZONES
-) , i-�,�v 7/ �7
11. WATER ZONES (depth):
12. CHLORINATION: Type rt t�—Amount
_ II additional space U needed use back of form
13. CASING: LOCATION SKETCH
Wan Thickness Show direction and distance from at least two State
Depth Diameter or WeighVFt. Material ( Roads,or other map reference points)
From �� To ��Ft.—�-- �_
From To— Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To _alit_Ft. _Lf= a1[-- -- sn L. 0 0
n
From To Ft. o o^
16. SCREEN: '� c=m
Depth Diameter Slot Size Material
I c=
To Ft __ in. _ in. CJt 0r
From -0 rn
From _To —Ft.— In. _—. In. >0
From __To__Ft._- In. In. ;II'
16. SAND/GRAVEL PACK: a- m�Depth _ n
Size Material '
o z
From
To Ft. 5
From To Ft.
17. REMARKS:
a r- , . ,-., .erh.TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
I DO HEREBY C r S r,=,i' t(r T C C I • \.F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTIO � �+ a /, ,� _
`act L ,IL .1 u- // r /i. .• DATE
FOR OFFICE U 11�11 9 '- (,QU" u, ATURE OF PERSON CONSTRUCTING THE WELL
Quad No' , y- Submit od: 3 • Division of Water Quality,Groundwater Section within 30 days
GW-I REV. 12/99
Wili
Serial No.

North Carolina-Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section 2 LI
4 0 3 3 0
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tb-en n, g icj ) r,., a We if .>v.. I1 rh e.� zh ci
WELL CONTRACTOR CERTIFICATION #: .4'44L :a/'7/n
STATEMu WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L!X nicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) MM
Nearest Town: f 4•1IC I i .2/ /17C'/ County:int"( <217"LJ
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ;57-117 A-- ,C)ee l7 j*i From To For-ratan Description
Address 6-'02 CJ i C r,E�cJ�J/
(Street or ou a No.)
.57r ra cri C--/ . (/' J .2
City or Town Stale •"Zip Code
4. DATE DRILLED ./. L-/0/
5. TOTAL DEPTH '
6. CUTTINGS COLLECTED YES O NO --
-7. DOES WELL REPLACE EXISTING WELL? YES n NO(
8. STATIC WATER LEVEL Below Top of Casing: _7,r, FT.
(Use'?it 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 15A NCAC 2C.0118 10. YIELD(gpm): / S METHOD OF TEST h/p7/l in 1-
11. WATER ZONES (depth): J-5o r .-DLO n -
12. CHLORINATION: Type /t t/) Amount r/4 05 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth o�� // Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To .-��C.1' Ft. it' ' '/frQ P t e - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method :s-
CI)From C-' To .-)-II\ FL f7 (idol oil,// !)I iii t A -.•• 0
From To Ft. I o o"1
15. SCREEN: aC `=m
Depth Diameter Slot Size Material I s2-
From To Ft in. in. m�
From To Ft. in. _ in. a'
From To Ft. In. In. .r mm<
•16. SAND/GRAVEL PACK: -"-,
Depth Size Material 1D _
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CER a •- • • a a -( • •.1.• -UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION '`(ay• D'j- A • •f• , • IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 11 ill r �G. .1.�I `RE/FPER1)/741 CONSTRUCTING THE WELL L -� DATE
Quad No: �►�I�N ,�
� `bubrNl origin. o •i Ion of Water Quality,Groundwater Section within 30 days
Serial No. IIII GW-1 REV. 12/99
w
f0011. ' i.__.i $tpe

Nonh Carolina-Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section
24- 038 ]_
1636 Mail Service Center-Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ih-Ptl n, `i /)-0 I ) elm ,+ (1±7 I I V . r t ,-�.")) c.
WELL CONTRACTOR CERTIFICATION #: 54 ' �.-/'7o,
,_.,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential IDS Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATIONJShow sketch of the location below)
Nearest Town: tit it k /'i /1,4( - County: 7/2(2 rrin
C v. IG) _hjJ /12 Lv yW1L_i Pc(
(Road Name and Numbers,Con/m/unity.•dr Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L//1•r`Wf GLI:-//i d97/ 4 From To Formation Description
Address c7().73t X 32 . - --
1., (Street or Route No.)
city or Town State / 21p Code
4. DATE DRILLED /r6 - ?-
5. TOTAL DEPTH 4`n n
6. CUTTINGS COLLECTED YES❑ NOEl----
7. DOES WELL REPLACE EXISTING WELL? YES D NOE-
8. STATIC WATER LEVEL Below Top of Casing: 9p FT.
(Use'a'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.0118
10. YIELD(gpm): ___/__C METHOD OF TEST h//t/W1; >t e1--
11. WATER ZONES(depth): -� S`n 1-- -js r1 l
12. CHLORINATION: Type If f H Amount /Q /19 If additional space G needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/R. Material (Show direction and distance from at least two State
From 0 To /i7 3' Ft. rr' . 'W' P I P , Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To , ,IA Ft. (1 &m t 7/ proe n
0
From To Ft. -- a
15. SCREEN: O or.
Depth Diameter Slot Size Material - c"
From To Ft in. — In. jj zm
f31 go m
>O
From To Ft. In. In. -p —+
From To Ft. In. In 3 20�
rV-•,
—• N.Z
16. SAND/GRAVEL PACK: cries
c,
Depth Size Material
0 o
From To Ft. _
From To Ft.
17. REMARKS:
UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
I O HEREBY CERTIFY TN•• I. 1• • IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTIONS •• • C I' �i _j ••
�f1 t �� �� I s c /
FOR OFFICE USE of 1 �. " Ail. •e/ • DATE
t 1i `Z 3 r1U'_ • , r RE OF PERSON CONSTRUCTING THE WELL
Quad No: 1 I Submit origin I. -v Ion of Water Quality,Groundwater Section within 30 dayshill GW i REV. 12/99
Serial No. •
Groundwater Section
Act-mile Recinnm Office

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
2 " OJB/
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Jwn nr g hr i j rim A Well . /I n‘ il
WELL CONTRACTOR CERTIFICATION #: .5-3- :a/-7o
• STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal 0 Industrial❑ Agricultural C Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION; (Show sketch of the location below)
Nearest Town. 7'd11 f/ 1 .ti /(r— County: All i fr^-,.
(Road Name and Nukbers.Coifmuniry,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ill •le >7 it< From To Formation Description
Address
-
- r (Street or Route No.)
City or Town State Zip Code •
4. DATE DRILLED I -3/-0/
5. TOTAL DEPTH 6-ymt+
6. CUTTINGS COLLECTED YES❑ NO0i
7. DOES WELL REPLACE EXISTING WELL? YES 0 N0p'
8. STATIC WATER LEVEL Below Top of Casing: 9,--e'-7 FT.
(Use'r II Move Top of Casing)
9. TOP OF CASING IS I/ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0115
10. YIELD (gpm): METHOD OF TEST h/10/l• 11 11-
11. WATER ZONES (depth): /
12. CHLORINATION: Type 11 f H Amount /4 f f3 If additional space Is needed use back of form
13. CASING: - --
Wall Thickness LOCATION SKETCH
Depth 21'7 Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0To' / Ft. ft. . f/f 1 PI P - Roads,or other map reference points)
From To Ft.
From To Ft. _
1a. GROUT: o 0
Depth Material Method c-�
From C) ToeV' Ft. (I r'�n tr i i _ R74,1 ; __ c
From To Ft. -rn
15. SCREEN: f ��
CA >o
Depth Diameter Slot Size Material m�
From _To_Ft _ In. in. _ nc
From To Ft. In. in. F Ki2Ki^
From To Ft. In. In. 0 a
16. SAND/GRAVEL PACK: z
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: /�Jtr,sue/2/)-2'4 ��
I DO HEREBY C r 1 anyi,I //la We41„W1 1?'TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION �4F CjiF#8T `C F THIS RECORDII HAS BEEN PROVIDED TO THE WELL OWNER.
•FOR OFFICE US YA to . ami .1 /,721/1/(JAZ Io -3/ -C / -
Quad No: %Mil A 'LQUZ; ani 1ATURE OF PERSON CONSTRUCTING THE WELL DATE
1 Submit on nal to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW1 REV. 12/99
Asheville Regional e

North Carolina• Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section !� 3 ,a `) ./ 3
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,I-Po t,, `7 I c I ) r", A (L)2I I t r I n.,ri T11 C
WELL CONTRACTOR CERTIFICATION #: .4'4- :h/'7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO : (Show sketch of the location below) -
Nearest Town: 1n ra' loi I. vi..1 ,A./� County: TY) a (C^,Th�7
(Road Name andNumbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r / Er-h^- fi ant.S€ / From To Formation Description
Address S� k 1 n S ia \ p (e• . - — —
(Street or-outset o5 EC
PYnM le_ I!� A/C ;-n�73 ( -
City or Town / State Zip Code
•
4. DATE DRILLED f -/ 9-c /
5. TOTAL DEPTH cf.")
O S
6. CUTTINGS COLLECTED YES❑ N01:2:1----
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOn
8. STATIC WATER LEVEL Below Top of Casing: in f') FT.
(Use'i it 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 15A NCAC 2C.OU6
10. YIELD(gpm): METHOD OF TEST /o/i ///11 �1--
11. WATER ZONES(depth): 44 Bn 1
12. CHLORINATION: Type /± 'I F/ Amount '/t / II additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth �7 Diameter or Weight/R. Material (Show direction and distance from at least two State
From 0 To /(1/ Ft. (e. '/kle, P r P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From (..') To l"Ft. (r r''*n o.✓t r (> n-i i - , a
/ O
From To Ft. o
15. SCREEN.- _O �a-
Depth Diameter Slot Size Material S - o�
.m
From To Ft in. in. Iw `o.c
From To Ft. in. In. -V' sem
-,ao
From To Ft. in. in. S z�
m
16. SAND/GRAVEL PACK: N=
Depth Size Material - m=
NI -nt
From To Ft. N o
From To Ft. x
17. REMARKS:
,
TH 15A NCAC 2C,
I HEREBY CE T I LL A ,THIS RECORD HAS BEENED IN EPRIOVIDED TO THE WELL L
OWNER.
CONSTRUCTION
FOR OFFICE USE "^I t1 DATE
Quad No: 4TURE OF PERSON CONSTRUCTING THE WELL
Sue„_bout oit to Division of Water Quality,Groundwater Section within 30 days GW 1 REV. 12199
Serial No. i - Section I
_ . i_... n�..�-'»fie

Nonh Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
2396 '72
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cNen nr g hr I ) A,., �k l OP 111)''. I I '' ' T,, C .
WELL CONTRACTOR CERTIFICATION #: c4 4- ca/ 7(� li
' STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal 0 Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below)
Nearest Town: t'o'n 1' ,l/C— County: fil 0 Urn_
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER A if, C /el e. Le nut r L— From To Formation Description
Address 1Le06 A/ ,JAz' c, CIC . IZL _ --
(9treetor•oulo o.)
rta4)leI1%cJ Aye - r_ k73LI
City or Town State Zip Code •
4. DATE DRILLED IIIS -1 n-c' 1
5. TOTAL DEPTH . Sh S
6. CUTTINGS COLLECTED YES Q NOILI---
7. DOES WELL REPLACE EXISTING WELL? YES Ej NOf
B. STATIC WATER LEVEL Below Top of Casing: / tD FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD (gpm): /1 METHOD OF TEST NM//,77 �l-
11. WATER ZONES (depth): /
12. CHLORINATION: Type /±/-/4 Amount '/4 I6 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To Ft t! '/frti' P l 0 - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c
as
From (.2 To ;all_Ft. 0 Gr>, pill 1),I9 1 i o
cisFrom To Ft. 0 om
15,,SCREEN:._ --i z_
Depth Diameter Slot Size Material - N- o<
- * ,
From To Ft in. in. • -cr mo
From To Ft in. in. _ 7:rm
From To Ft. In. in. N Al=
16. SAND/GRAVEL PACK: N '"
Depth Size Material N o
z
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 .a-F!_.ANl THAT A.QMP.y.OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
.rnsE r N5 • v_ jo , Dl
FOR OFFICE U iu � S. ` _ 7ma .r lilo✓'(/Qnft
Quad No: ,f
i4IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
�� Submit kta to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV. 12r99
Serial No. �,,.

Nonh Carolina- Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section 2 3 9 6 7 0
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1-en n, g /lc l) nix, A 102 i i i)v . /I r,r. Tn c
WELL CONTRACTOR CERTIFICATION #: .�rS=+r; • L'7(n ti
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El" Municipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below) -
Nearest Town: l rowl (C I r vJ /a.-- County: in 61- 4r}1 a
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER R1 0 y. /a2Lurt-1 ) From To Formation Description
Address
(Street or Route No.)
!'VointL j,1,J Svc_ c-QR 2 a y`
City or Town State Zip Code
4. DATE DRILLED /6 -/) -e /
5. TOTAL DEPTH -•fin c
6. CUTTINGS COLLECTED YES 7 NO❑---
7. DOES WELL REPLACE EXISTING WELL? YES Q NOM--
8. STATIC WATER LEVEL Below Top of Casing: tT FT.
(Use'+'if 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): 30 METHOD OF TEST h/N7/l 1}7
i
11. WATER ZONES (depth): /
12. CHLORINATION: Type ff 7 N Amount VC, I P3 If additional space Is needed use back of form
13. CASING: - _ - -
Wall Thickness LOCATION SKETCH
Depth r/ Diameter or Weight/Ft, Material (Show direction and distance from at least two State
From 0 To �Q Ft. i7. . I/ P 1 P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o •
Depth • Material Method 0 o
From _C To . ,;L{‘` Ft. (r err, 0,-,17- I)/9.f r1 -' 0 c=
From To Ft. 0 on"--1 cr,:r
15. SCREEN: r3 o:c
Depth Diameter Slot Size Material - �' -Do
From To Ft _ In. in. �\
MC 0
From To Ft. In. In. cnz
From To_Ft. In, In. N y�
16. SAND/GRAVEL PACK: N o
Depth Size Material Z
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY F.; -f >gg1 (.y11�W S48 $STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTI, p: .AB)S« A r rOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U , • LY 4 )-riin.4 i /77060/2er,0 Jo- is -0- I
IL
Quad No: i y t ,,J AATURE OF PERSON CONSTRUCTING THE WELL DATE
,it Subn t o gloat a Division of Water Quality,Groundwater Section within 30 days
Serial No I .-.W--_. GW-1 REV. 12/99
e,'v 3` Section
,01;;ce I

North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 23 9 1.) U 9
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1-ann09 Ms,) Ain ,a (* I) A . ii r,,eii r)t
WELL CONTRACTOR CERTIFICATION #: J.?/7�
STATE WELL CONSTRUCTION PERMITS,:L((X
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below)
Nearest Town: Vann lc f r -kJ X/0_, County: /11 0.Crern
(Road Name an Lot No.)
Numbers,Community,or Subdivision and DRILLING LOG DEPTH
3. OWNER hr4Si c- Qv' 2ti�K � From To
Formation Description
Address sj b 5 0/a G'-j ./( a h !Qin A4 acJ
(Street or Ro�u/a No.
City or Town State Zip Code
4. DATE DRILLED - /7 " O /
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES EJ NODi
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOf
8. STATIC WATER LEVEL Below Top of Casing: tc' FT.
(Use'.'II Above Top of Casing)
9. TOP OF CASING IS r/ FT.Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 154 NCAC 2C.0118
10. YIELD (gpm): 02 0 METHOD OF TEST /9/,wii,}7 D�
11. WATER ZONES (depth): /
12. CHLORINATION: Type It t 14 Amount r1/4 //9 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
0
From To Ft. (C' . r/ft' Pr P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth • Material Method o
From �� To ,-)-l\ - a
Ft. 0 Br>, o.,�% 9 4 ,l -, o
From To Ft. �' O 53a
15. SCREEN: �rR'•
zrt _
- Depth' Diameter Slot Size Material .0 -om<
F
From To Ft In. in. m'
From To Ft. In. in. 3 70,
From To Ft. In, In. N '"z
c,16. SAND/GRAVEL PACK: N y
Depth Size Material N o
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 LV ) il flhin' ,, /,hnfU1/1nr f) I b�- /7 -D /
Quad No: ()4 - IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
u Submi to Division of Water Quality.Groundwater Section within 30 days
Serial No.
GW-1 REV. 12/99
h~
f ,re vale Sadie!
r�oral Of ic6 •

239953
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: J�C1 n, es l iv I ) r,„, rk WO I) 'N)t . 1I n,tie , C2
WELL CONTRACTOR CERTIFICATION #: - .:/ 7/n
- STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION/: (Show sketch of t e loc tion below) ,
Nearest Town: /'r71'n gL i A/( County: /22Q ( -A___J
( /et( /gib c / o l
(Road Name and Numbers.Cordinunniity,.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER -.57 C&z /e) V/ i r e 3 From To Formation Description
Address I CCI 12) f, L 6' , 1. ) la.
I i �), h
(St,� reet or Route`No.0 1
) � 57 /
City or Tin State Ziff Code —'
4. DATE DRILLED /0 -, 5"-/7/
5. TOTAL DEPTH .'3 4.4
6. CUTTINGS COLLECTED YES Q NOn-
7. DOES WELL REPLACE EXISTING WELL? YES in NOQ---
8. STATIC WATER LEVEL Below Top of Casing: (z,T FT.
(Use'+'II 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 15A NCAC 2C.0118
10. YIELD (gpm): METHQD OF TEST b/10/l; 17 ti-
11. WATER ZONES (depth): - 0 /`
12. CHLORINATION: Type /t t N Amount 1/44 /r3 II additional space is needed use back of form
13. CASING: `— _ ---- —__ - ---� ---
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Stale
From 0 To /(,Q ii Ft. le. . r 1i4/ P i co . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: tzp
Depth Material Method 0
From C To ;LIi Ft. n Gas, a.A% fl/w< 1 , p cil�
From To Ft. --1 -'
- 15. SCREEN:_.._ . . N z[72 -
Depth Diameter Slot Size Material Do
From To Ft in. _ in. Mcrn
to
From To Ft in. in. �. ��
From To Ft. In. in. p
16. SAND/GRAVEL PACK: Co --:--/
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WEt I WASnON TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIOP 14F�i S,1$N4ITFNCT 1EC F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE US 2 Y y IS U V l5q
nA .` /eo✓( ()ALL
• /G %� c-o /
Quad No: `� ATURE OF PERSON CONSTRUCTING THE WELL DATE
_ rSu mlt on I Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 1V99
Groundwei:-c^9"140

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 `t 0 9 3 3
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,Nennrci IhI ) r.., rk (f)2a t- nn- ,. -
WELL CONTRACTOR CERTIFICATION #: . 5-Q- .-/-7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential I!� Municipai ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO `(Show sketch of the location below)
Nearest Town: / ?'%. n &l"' ,i/C- County: /Y1 C Cts> c
L L•k' 2'✓ �0 it I-nu-r 1-01-4.
(Road Name andnn Numbers,Community, Subdivision and Lot No.) DRILLING LOG DEPTH
!C 3. OWNER LL L^/ > / }-dYv From To Formation Description
Address 3 cr- 7 bU 0,,A &L k d.
(street or Route .)
-I'a -n te t vt A! r_ .2 h" 73 YY
City or Town State Zip Code
4. DATE DRILLED /D—/6 U /
5. TOTAL DEPTH RS?r,
6. CUTTINGS COLLECTED YES Q NO11---
7. DOES WELL REPLACE EXISTING WELL? YES E NO7 cg
6. STATIC WATER LEVEL Below Top of Casing: FT. 0 A
(Use'i it Move Top of Casing) O cs
9. TOP OF CASING IS FT. Above Land Surface' C 7 or"
'Top of casing terminated at/or below land surface requires a variance In accor- —4 =m
dance with 15A NCAC 2C, 11B
10. YIELD (gpm): METHOD OF TEST MOP, +7 1— CPI Do
11. WATER ZONES (depth): -MO ' / g. �m
f1 in z
12. CHLORINATION: Type U T 14 Amount `�4 /� If additional space is needed use back of Wm 017J
13. CASING: — o
LOCATION SKETCH Z
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 1 62-( Ft. i< '/kY P i P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From �' — To .-)-fi\ Ft. U_122" ,,4 - pm, 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.
From To Ft.
17. REMARK - il i'
1 COLAsCwL 11
I DO HER AT THIS WELL W �S STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU`�1(iON STANDARDS,AND THAT fi Q OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICI:"USE ONLY' r 19 r r /LodlitinrLI% /6 —/ U O / —
Quad No: I I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SVDmtoriginalito Division of Water Quality.Groundwater Section within 30 days
ln 7l ,jV :
Senal No. A H r GW-1 REV. 12/99

North Carolina- Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 4 0 9 3 5
1636 Mail Service Center•Raleigh,N.C.2769g-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cf\an r), 9 ICI ) '1— rk (*I) F)t . /I n'el. -7--/
WELL CONTRACTOR CERTIFICATION#: . 4-Q- / 7G, a
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential(Ld<micipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: ($how sketch of the location below) �l
Nearest Town: r�/ / t A' ti/�h�C:41r County: Al 0 ('r'm
It g h I(a71A (
(Road Name d tubers,Community.or Su ivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ind
12 kp I In Id. 1 Z-1 eQ% From To Formation Description
Address J,97o Tex, h ) Pk'to,,
'Street or Route Cbg
1) a^plla PI --7.--) 7/.71
Cit or Town State Zip Code '
4. DATE DRILLED_/6.,sT-o /
5. TOTAL DEPTH 'S
6. CUTTINGS COLLECTED YES 0 NOQ---
7. DOES WELL REPLACE EXISTING WELL? YES NOQ c.
—
8. STATIC WATER LEVEL Below Top of Casing: /Sr FT. £
(Use'+'if Above Top of Casing) 0 0
9. TOP OF CASING IS / FT.Above Land Surface' p 7,m
'Top of casing terminated at/or below land surface requires■variance In actor• el cm
dance with 15A NCAC 2C.0118 O
10. YIELD (gpm): '3C METHOD OF TEST /7/I77/7, t7 F'{-- cr Val
11. WATER ZONES (depth): SC75 ( '.
.S inn
12. CHLORINATION: Type /./t 14 Amount '/ /6 If additional space is needed use back of Tore cm"r
-55
13. CASING: • _ -- - 7l
LOCATION SKETCH to 2
Wall Thickness
Depth Diameter or WeIghVFt. Material (Show direction and distance from at least two State
C
From 0 To TL 7 Ft. re '/14' n i g . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .1(N Ft. (1 ;^o,), :.n! Hint 1 ,
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 �—
1 17. REMARKS: r "h
11II
I DO HEREB �� 'ref THAT1 THIS
ELL WAS' OfP.. TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT IO TANDARDS,AND THAT A CO YOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE ipISE`(INLY lit, + % IMOd nnr 0 I i c-
Quad No: I _ . .1 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
it 1—�; 'Subrr4(tonginal to Division of Water Duality,Groundwater Section within 30 days
Serial No. GW-t REV. 72199

242914
North Carolina• Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mall Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1 FL9 n, cs I i'I ) n,,, a (L)211 I v. ii n,a4y T" c
WELL CONTRACTOR CERTIFICATION#: 54,-10- :k/7/n 0
_ MuSTATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): ResidentialL( - nicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONF(S how sketch of the location below)
Nearest Town: /—Kilnk-/- / ,'v /(/() County: Al Q (r.+7? )
(Road Name an Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r//%r77— (0 S i i i l i'7 S From To Formation Description
Address @(✓, . C 3 9
Street o ou a --
C'hi'FPI0,, .> Cl <32 /it/-
City or Town State Zip Code '
4. DATE DRILLED /(3 - c 9- n /
5. TOTAL DEPTH 4'+v/o '
6. CUTTINGS COLLECTED YES❑ NO[ —
7. DOES WELL REPLACE EXISTING WELL? YES n NON--'
8. STATIC WATER LEVEL Below Top of Casing: 9%, FT.
(Use'i II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated atior below land surface requires■variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -/' METHOD OF TEST hh' 1,71 r<j
11. WATER ZONES (depth): 4 --Co
12. CHLORINATION: Type /t t H Amount ''c' I If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth ,,7 Diameter or WeignVEL Material (Show direction and distance from at least two State
From 0 To / Ft. <<' r/frV P r P - Roads,or other map reference points)
From To Ft.
From To Ft. -c
14. GROUT: 0 0
Depth Material Method o n�
From (7 To �N Ft. n (3,-Th to/l r)/�).t ,l rn
n o
�-°
rn
From To Ft. I i'j�.
15. SCREEN: ca I>C
Depth Diameter Slot Size Material -o r'-'„�
From To Ft In. in. 3 "c'
NX
From To Ft. in. In. "t
From To Ft. In. In. 0 -I
.6• o
16. SAND/GRAN Z
r ii
4P1 Sze trial
From 1 L;r—F�
From ___ FL i�'} ' I
17. REMARKS: 1 u L' -"1 / H J 1
I DO HEREBY ( ERTIFY THAT-THISWFt I WASCaNSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT! N STANOA}V'C15 AN6ltl AT ACCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
AS1F 'it LE i f . .- C t: _ I� �//1/� /O -
PO Ali ,ll/9 i') <,iA - 9-0/
FOR OFFICE USE ONLY / a
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
OW-1 REV. 12/99
Soria No. .

OrROcc
North Carolina• Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 4-
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: clan n, g /tom I ) A (0)2 I I )- ` i I '-)• '
WELL CONTRACTOR CERTIFICATION#: 54—/7(n r'
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other Ei If Other, List Use:
2. WELL LOCATION:)Show sketch of the location below) /y
Nearest Town: t g 11 f(/`2✓ /�Al - County: / ` 61-�a )
(Road Name and Numbers.Community, LOG DEPTH
,or Subdivision and Lot No.) Formation Description
3. OWNER L 62-a J C4-1i ' From To
Address ,'r � (I!- 4
(Street or Route r�,Y �•� .
7 4-4(.(/ I n, � i r L.1 -` -3
City or Town S ate • Zip ode
4. DATE DRILLED /6-di-90/
5. TOTAL DEPTH r"
6. CUTTINGS COLLECTED YES n NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD„---
6. STATIC WATER LEVEL Below Top of Casing: c-Q FT.
(Use'+'II Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface'
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0111
10. YIELD (gpm): �_. METHOD OF TEST h/H)//;la q-
11. WATER ZONES(depth):
12. CHLORINATION: Type /± ±14 Amount '/t/ irs5 If additional space is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To /4 :)--Ft. ft `/k P d P - Roads,or other map reference points)
From To— Ft.
From To— Ft.
O
14. GROUT: soDepth Material Method
From (;) To ;.1N Ft. 0 P.yr, o.i l rp1+'1
n O ni
From To FL N =`
0
- - 15. SCREEN:-- - CI- Ca
>�
Depth Diameter Slot Size Material To_._.Ft __ n. _ - _ - 3 m I in. a 4
From . �
From TO Ft. In. In. rV rn=
E C E_ I 1f f D N °j�
From _To_Ft._ In. in. D 43
16. SAND/GRAVEL PACK: z
Depth Size Material :I 1 7 oc i
From To Ft.
From To Ft. W�at P -
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 RECORDI HAS BEEN PROVIDED TO THE WELL OWNER.
Y� �mAL a li-miaanxAn /6 --// —O
/
FOR OFFICE USE ONLY DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Quad No:
Submit original to Division of Water Quality,Groundwater Section within 30 days GW 1 REV. 12/99
Se a No.

1.' 39668
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: ll 1YC1 n, / I) ',in, A (._02 f) N)`.. /f `r,e)t J" C,
WELL CONTRACTOR CERTIFICATION #: .4- ,C.-2/ 7(,,
STATE WELL CONSTRUCTION PERMIT#:
•
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATIONJShow sketch of the location below) /y�Q Cam`
Nearest Town: trani V I r" / /t C - County: I "
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l�P /'] kamZr�7` �{-- From To For ation Description
Address 5Or.r1c./,2_ Up )(Screeuts o.)/e- r7 e 7 3 C/
/"Y/.�/rl �l I t e ZipCode J
•
Dry or Town Stale
4. DATE DRILLED /) -u-O /
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES E NOH---
8. STATIC WATER LEVEL Below Top of Casing: yr) FT.
(Use•+'II Above Top of Casing)
9. TOP OF CASING IS P FT.Above Land Surface'
Top of casing terminated at/or below land surlace requires a variance In accor-
dance with 15A NCAC 2C.0115
10. YIELD (gpm): 3 O METHOD OF TEST h//'1//;nor _
11. WATER ZONES (depth): —
12. CHLORINATION: Type /f*N Amount 1/44 I/3 If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth `` 2 Diameter or WeighVFL Material (Show direction and distance from at least two State
From 0 To / Ft. /!' ' (m) P b P . Roads,or other map reference points)
From To Ft.
From To Ft. g
0
14. GROUT: o
Depth Material Method c'z
O �z
From _2__ To ,-L Ft. n Rrn 0.111 01I7.r '\> cn
1 0
z�'
- From .. - -To- Ft. N o.c
• ;ST Sn
15. SCREEN: mC
Depth Diameter Slot Size Material S =m
From To Ft in. in. • (y NA
From To Ft.__ In. In. -'
From To Ft. In. — In. JA� ' y2 O N
16. SAND/GRAVEL PACK: /
Depth Size Material
From To Ft• Soda
From To Ft. �shev lle�R caa 1
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 ONLYt AjA / DATE
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE W ELL
Submit original to Division of Water Quality.Groundwater Section within 30 days GW t REV. 12/99
Sena No.

North Carolina- Department of Environment and Natural Resources•Division of Water Quality 3 9667•Groundwater Section 2
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL
WELL CONTRACTOR C RTIFICATIONN: _ 5.'; �/7�� 16
- STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOVShow sketch of the location below) Ail 0 cr1�
Nearest Town: J r�� h lr'`J �C� County:
(Road Narneckid Numbers.Community,or Subdivision and Lot No.)
DRILLING LOG DEPTH
From To Formation Description
3. OWNER l o h 1�0. I tzlv`.
Address 1 -J O 0
W a_4-. N i �cx.
Street or Rou eNo.) �,
1 1 wrI Ztn.✓ /VCR „ �7 -3 Z
City or Town State Zip Code
4. DATE DRILLED /o —/6 -0/
5. TOTAL DEPTH •`c S
6. CUTTINGS COLLECTED YES n NOG
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE-
6. STATIC WATER LEVEL Below Top of Casing: •5—,p FT.
(Use'i It 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 19A NCAC 2C..0118
10. YIELD (gpm): c3 0 METHOD OF TEST h/N71/fin t-
11. WATER ZONES (depth): /
12. CHLORINATION: Type /t if N Amount 1/4 I II additional space is needed use back of form
13. CASING:
LOCATION SKETCH
wall Thickness
Depth Diameter or WeIghVR. Material (Show direction and distance from at least two State
From 0 To /U 7 Ft i< r/c L P t P ' Roads,or other map reference points)
From To Ft.
From To Ft. c
14. GROUT: o
CS
Depth Material Method c,a
P.'From C To Ft. 0 c'ern o.c'I% r/elf ,l ) �,m
0
From To Ft. I o<
15. SCR EEN: _ _ -Ow
rn
no
Depth Diameter Slot Size Material - ==, _. m'�
In. In. S zP
From To__.Ft _ (AI
ii 1, E. i t`I r es N c2,
a
From To Ft. In. In. D D rV
From To_Ft. In. In. N �
16. SAND/GRAVEL PACK:
Depth Size Material JAN 1 7 2
From To Ft.
From To Ft. Groundwater Section
17. REMARKS: _ Asheville Regional Office 1
•
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 1 .1M, o /174ad/?4,rn /O — /6 - o /Quad No' SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days GW-1 REV. 12199
Serial No. -

/.96 w
39671
Nonh Carolina- Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section �'
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] y\,, �l
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,L�-Pt�nr `s IC f ) ''n a (� Q I I ` `± I I J`e C
WELL CONTRACTOR CERTIFICATION #: .54'— ' `")/ 7(- 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION;(Show sketch of the location below) . Pt m
Nearest Town: le l ye' County:
Sam d `e it 2 aDRILLING LOG DEPTH
(Road Name d Numbers.Community,or Subdivision and IDl No.) DRI RIL To Formation Description
3. OWNER cD0 10 I- !v' e1°A
Address 6,7 y I.1 .c m� ,P a-,- (Yy--
'// (Scree cr/Route No.3 i7 3
C Y2,r1 I I r7c) /�S to Zip Code .
City or Town
4. DATE DRILLED i "n
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOEi----
7. DOES WELL REPLACE EXISTING WELL? YES NOE-
r
6. STATIC WATER LEVEL Below Top of Casing: FT. _17
_
(Use'+'If Above Top of Casing) �y
9. TOP OF CASING ISM_ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C.Ott 8
10. YIELD (gpm): _ `i METHOD OF TEST h/InUiTi �!—
11. WATER ZONES (depth): /
12. CHLORINATION: Type /t H Amount r1/4 I(s If additional space 4s needed use back of form
13. CASING: t nraT1C1N $KETCH
Wall Thickness
Depth Diameter or Weight/FL Material (Show direction and distance from at least two State
�� To EV- Ft (e• • r l °n r P . Roads,or other map reference points)
From �1 ;r
From To— Ft. 2 r0/ O r Q S.3
From To Ft. .h.)n ,t
14. GROUT: �'Je z0 ' j7 c
Depth Material Method C
From f To .�Ft. 0Gan ct,i7 1 MA A > n
a
From To Ft. c7 0
15. SCREEN: . 0e.I em
Depth Diameter Slot Size Material
�' 8m
From To— Ft _ In. _ in. C 'FA
From —To—Ft..— In. In. S am
__From To—Ft.— In. In. !V
16. SAND/GRAVEL PACK: 'C rri
Depth Size Material N o
z
From To Ft. -----
From To Ft.
17. REMARKS:
I DO HEREBY.CFATiF''THAT THIS WFLL WAS CONSTRUCTED IN ACCORDANCE
C OR BEEN P WIITHITH 1 D NTOCAC
C 2 2C,
WELOWNER.
L
S'�
ELL
(-9 _Pau_CONSTRUCTION' At.@Af 1S, p j3) S - 0
15
FOR OFFICE U E LY DATE
.i NATURE OF PERSON CONSTRUCTING THE WELL
Quad No:
Submit olthiaF'19 Division of water Quality,Groundwater Section within 30 days OW-1 REV. 12J99
Serial No. .
i

North Carolina• Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section A 4 5 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cl l-Pf'1 n,'i /lit, I l ,-„ A LL.l(2I 11)v i I ni g4 n C,
WELL CONTRACTOR CERTIFICATION #: - •k/7G, 4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Sox): Residential 0 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: /124 4,k L/ .V �(-- County: /Y)Cr' c+Of
(Road Named Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t -.--bii-vc -3 e -CGt , Llt . From To Formation Description
Address s Li/ .S, 5/C h c!
( «eet or Route No.)
/-712n l�/ni NC- °V 73 y
City or Town State Zip Code •
4. DATE DRILLED 9 iii-C' /
5. TOTAL DEPTH &oS-s
6. CUTTINGS COLLECTED YES NO❑----
7. DOES WELL REPLACE EXISTING WELL? YES In NOM
8. STATIC WATER LEVEL Below Top of Casing: ,Q4_rp FT.
(Use'+•II 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.0118
10. YIELD (gpm): METHOD OF TEST /o//n/f,)1 41—
11. WATER ZONES (depth): 3 90
I
12. CHLORINATION: Type ft it/4 Amount '/4 //53 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Fl. Material (Show direction and distance from at least two State
From (_, To -./C) Ft. It c/kV P t P . Roads,or other map reference points)
From To Ft.
n
From To Ft. O o
14. GROUT: N c-i
Depth Material Method rrt oc"f,
From (-i To ,- t" Ft. f7 r7Tr, ,.,17 )In f I. , "1, c,T
From To Ft. r CA .n
15. SCREEN: OCT2 6 MP ~
a �
Depth Diameter Slot Size Material 3 �rn
rl2
From To Ft in. in. 5n^
From To Ft. in. In. N —I
N ,,
From To Ft. In. in. z
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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OO�WNER.
FOR OFFICE USE ONLY Yc 1�
,-, 1
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW1 REV. 12199

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section
236449
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,, en r1, es IL, I ) :,,, rk (t) I) k1I' i I ,/), r.), /1 C,
WELL CONTRACTOR CERTIFICATION#: .c-5-+QT- cam:'/-7/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential ll� 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: rite 47 C County: m Q (ATIti--)
(Road Name an umbers,Communityhor Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /1 Yf/1r1 (4- .E7 A./ (an )7�II7� 11 From To Formation Description
�
Address 3 e lrt n C
(Street or Flou ao r o.)
Ai-
City or Town //�� State Zip Code •
4. DATE DRILLED "('—/ -9 -0 /
5. TOTAL DEPTH '? SS '
6. CUTTINGS COLLECTED YES NOfl_
7. DOES WELL REPLACE EXISTING WELL? YES Ei NOQ---
8. STATIC WATER LEVEL Below Top of Casing: 4fl FT.
(Use'+'II 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 15A NCAC 2C.0118
10. YIELD(gpm): /0 METHOD OF TEST /IMP] 17 �1--
11. WATER ZONES (depth): • �'G' / 1
12. CHLORINATION: Type /t t}-1 Amount r/ 4 / If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFl. Material (Show direction and distance from at least two Stale
From C` To Ft. It' ' r/k4' P i ? . Roads,or other map reference points)
From To Ft.
From To Ft. C
14. GROUT: C o
Depth Material Method t. I' in `B.z
rn Ern
From C To •�i_ Ft. /1 Grn a-,ai p;i7e 1_, —0 ec,
From
CR To Ft. TT
2 6 MI vy`em
15. SCREEN: 9lif V ac
Depth Diameter Slot Size Material $ ��
From To Ft _ in. in. o �ro
From To Ft in. in. N) -,
c-s
From To Ft. In. in. IN o
z
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�\ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `A n9,u 7 RitadP/2nrii ?/g:2—o
Quad Not SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 dayS
Serial No. GW-1 REV. 12/99

North Carolina• Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section (" " " r 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IL en n, '1 is I) rg a 192I I N)v /I n ,A4 ,t C.
WELL CONTRACTOR CERTIFICATION #: . - ;r/.7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Ili 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: O/` ) /V p County: .7)7)' a c 1
(Road Name and Numbers, (Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0 ICLnrdil S on--1-a4� e I(v From To Formation Description
Addressc.Z 9 Lee,k.t. C X a /.cc Rc!
(Street or Route No.)
r� f2M/r:/ tie c2Y93
City or Town 0 State Zip ode •
4. DATE DRILLED ` — 7-0 /
5. TOTAL DEPTH 3 Q c;
6. CUTTINGS COLLECTED YES In NO®--
7. DOES WELL REPLACE EXISTING WELL? YES n NOFR--
6. STATIC WATER LEVEL Below Top of Casing: "Lip FT.
(Use':it Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' •
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 3 METHOD OF TEST 117/Pi/117 (-
it. WATER ZONES (depth): lc:2/1 '
12. CHLORINATION: Type it f H Amount Vt/ /6 It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth or., Diameter or WeighVFl. Material (Show direction and distance from at least two State
From 0 To `' v Ft. re. . r/fry P 1 P . Roads,or other map reference points)
From To Ft.
From To Ft. o
14. GROUT: O `o
Depth Material Method to o
From ti ToFt. /f /71im o.r1% (1;n4 -tom - '9 1-117 c m
m
From - To _ FL / ,. N o<
15. SCREEN: CFI Dmo
Depth Diameter Slot Size Material OCT 2 6 2fln1 a m:
From To Ft in. in. o mT
From To Ft. in. In. NIy
From To Ft. In, In. P.3 3
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/ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OP
FOR OFFICE USE ONLY ri SniAf; .1 /L�eaA.rt 9:I-7_o I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section 2 2 6 4 4 4
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tNetn n, I I ) /I,., ,j 1L12 II i)t• lI n r,, rl
WELL CONTRACTOR CERTIFICATION #: . 4sl- C:'/.7(n Q
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential(n"- 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: 2 (2- n idih'i /(/(— County: /y),Q. F:en2-
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /Y) , le -e I4- e 0. 8, From To Formation Description
Address 5 3 &,t L vU
bireM or Houle No.)
/�i't2'2le t, A/ C'� <7- g-7 3
City or Town State ' Zip Code
4. DATE DRILLED 9;4 --O/
5. TOTAL DEPTH 4C0 '
6. CUTTINGS COLLECTED YES n NOD-
7. DOES WELL REPLACE EXISTING WELL? YES E NO--R—
6. STATIC WATER LEVEL Below Top of Casing: 3( FT.
(Use':II 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 15A NCAC 2C.0118
10. YIELD (gpm): 1 METHOD OF TEST h/in/l,"n 4-
11. WATER ZONES (depth): 9'0 ' 0
12. CHLORINATION: Type /t t/4 Amount 'Vi /'9 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0To b 7 Ft. ft. . r/k(/ Pi P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
O
o
From 62 To Lf. Ft. n (-t,-) tr-i i f�l'i.t '>> ca �a�
From To _ _Ft. / OCTrn o
15. SCREEN: IW 2 6 2nn1 Z7 cat c,
Depth Diameter Slot Size Material CD,
From To Ft in. in. Dc
From To Ft. in. In. S r4m
From To Ft. In, In, O rn
mZ
16. SAND/GRAVEL PACK: IV -f-t
Depth Size Material iv
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 Yt n1mr ,1 /1IO1504nt.(.") T n-6 -o I
Quad No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subnv't original to Division of Water Quality,Groundwater Section Within 30 days
Serial No. GW.1 REV. 12/99

North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 A l)3 C /1 5
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] J '+ �i
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cI 1Pf-1 n, `t I!/ 11 r. WO I) v a ,Tht g, Tit c
WELL CONTRACTOR CERTIFICATION #: .lam-&-Q- ,a/76' 0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L(X 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: O//i) 4/C , County: a (.-hr2� J
Lake- ('.hones Rr)
(Road Name and Numbers,Community,o Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /- l r4 v,� 2i /�Pe •P ho/?tt 2, From To Formation Descnpuon
Address / c.�b QC-,U y�{+tIt Y ' C
//U isre77,okt o.) 4,,, 76e
City or Town State Zip Code •
4. DATE DRILLED 77-0 /
5. TOTAL DEPTH c �i
6. CUTTINGS COLLECTED YES Q NOD---
7. DOES WELL REPLACE EXISTING WELL? YES El NOn
B. 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 at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.9118
10. YIELD(gpm): / METHOD OF TEST h1/211//,71 l�
11. WATER ZONES(depth): 0,LC'
12. CHLORINATION: Type /t t N Amount `1/4 / It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least Iwo State
From 0To 9 C7 Ft. f!. ' '/ Roads,or other map reference points)
From To Ft. `5 er' �
0
From To Ft. O Q
14. GROUT: Cn ct7.-,/
Depth Material Method m or
From C To .- t' I- Ft. n r'1r e.o9t ]
/ 1 t , ,I n. Cr^..
From To Ft. Crl -rn
15. SCREEN: 2 6 �OI s mo
Depth Diameter Slot Size Material N`
From To Ft in. in. o• 01=
From To Ft. in. In. tV
no o
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 OF THIS RECORD HAS
((BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY chi I�O l/a �' 7 -0 ,
Ouad No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina- Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 3 6 4 4 6
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: d }PCl n, I 11 e-:„„\ (02iI v it n,el r)1 C
WELL CONTRACTOR CERTIFICATION#: :C/-Wm 41
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Ilk<unicipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) /1/1
Nearest Town: ,i. 14'7.V L 1n /�/C- County: ,/ 7 2 a 1 )
(Road Name and Numbers,/ Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 44 vn/4. Lilar5'/-IttZ. From To FomwtionDescription
Address &S e upi Re
( treat or ;Lit)��Yar7k l ;Li C73 9L
_
City or Town State Z,IP Code '
4. DATE DRILLED //(2—O /
5. TOTAL DEPTH t SS `
6. CUTTINGS COLLECTED YES 7 NO[2:1-
7. DOES WELL REPLACE EXISTING WELL? YES IL NOD-
8. STATIC WATER LEVEL Below Top of Casing: 24, FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD(gpm): 020 METHOD OF TEST /7/111/1,71 /1—
11. WATER ZONES (depth): /30 ' I
12. CHLORINATION: Type /t i-/-4 Amount `'/4 I If additional space is needed use back of form
13. CASING: - - --- -
LOCATION SKETCH
Wall Thickness
Depth •�1[i Diameter or WelghVEL Material (Show direction and distance from at least two State
From 0 To /7 Ft. it. r/fry P i P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
From C' To :Sail_Ft. 0 Gan 441 i prim V l O o
From TO t. —F C/) x)a
15. SCREEN: m rn
C cc
Depth Diameter Slot Size Material OCT 2 6 MI dIV CI al
<
From To Ft in. in. ao
From To Ft. In. in. 3 xlo
From To Ft. In. in. rn
m=;
16. SAND/GRAVEL PACK: " co
Depth Size Material PO o
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 Con„rtr •r 1LnUQa"et c)-/,-V /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
I
Submit original to Division of Water Quality,Groundwater Section Within 30 days
GW-1 REV. 12/99
Serial No.

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 3 6 4 4 7
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone [phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c 17 n. 9 'Tt' I ) et (* I) ♦-)v /I ,7,el r)t c
WELL CONTRACTOR CERTIFICATION it: 54-4— c; /7/n d
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other p If Other, List Use:
2. WELL LOCATION: (Showh sketch of the location below)
Neares Town: (7/70 AV d— County: /71 a €,i-n
!' (.G'!? a RE Tess"',ife-C.
(Road Name andGmbbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER .t rI N Q c h 7n From To Formation Description
Address ti7 3 e Y'j(l3, / L ,,,-1 r t'
(Street or ou a o.
L(/Lir,11P et///771 41 n.. ?D ..) /y/ —
City or Town q State Zip'Code
4. DATE DRILLED /.76 "O
5. TOTAL DEPTH c-CC
6. CUTTINGS COLLECTED YES❑ NOD/
7. DOES WELL REPLACE EXISTING WELL? YES 7 NOQ-
8. STATIC WATER LEVEL Below Top of Casing: r FT.
(Use'+'it Above Top of Casing)
9. TOP OF CASING IS S/ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0118
10. YIELD (gpm): ani O METHOD OF TEST h/P>//nr t—
11. WATER ZONES(depth): 3 be / I
12. CHLORINATION: Type U 1-H Amount `! c' /6 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth / Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To '/ Ft. if '/fV P i P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: 1 o
Depth Material Method 1 I" tin I ' i
From C To —Ft. (I Ga» .i o -t% pIne it i �_. V) 2 rT7 0
ni
From To Ft. - 2 6 � Cr
s
N.) of
15. SCREEN: cn --m
Depth Diameter Slot Size Material Do
r
From To Ft in. in. 3 am
From To Ft. In. in. o mz
From To Ft. In. In. IV y
16. SAND/GRAVEL PACK: N a
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.
`A / Lndlin OR OFFICE USE ONLY mint . / / �`/A —QL
Quad
DATE
uaO No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV. 12/99
Soria No.

North Carolina•Department of Environment and Natural Resources-Division of Water Duality-Groundwater Section 2 3 7 3 4 7
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cN'n n, cc III U , a (L)* I I .L.- r 17);,, )t C_,
WELL CONTRACTOR CERTIFICATION#: .c4- - : 1/'-7/,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential ID- Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /1 m IC t t iJ A/ County: in O- tm,.
f_ I,- /Li LLO b)
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER I's:8i 'I &L, k7 ft;ckFormation From To Description
Address (.4_I S I VI_a, )1U1 e-}-)- (r?A
(Street or Rout()No.)
lima )«, IIr= G7, , 30 :13r
City fjr Town c, State Zip Code .
4. DATE DRILLED s1� --;26 --c.' I
1L%
5. TOTAL DEPTH r5
6. CUTTINGS COLLECTED YES Q NOD-
7. DOES WELL REPLACE EXISTING WELL? YES n NO In
8. STATIC WATER LEVEL Below Top of Casing: /Re-, FT.
(Use'+II Above Top of Casing)
9. TOP OF CASING IS if FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118
10. YIELD(gpm): /72 METHOD OF TEST NM/l,?1 �
11. WATER ZONES (depth): I3/' .-,2k O I
12. CHLORINATION: Type /' Y.N Amount '4 /6 If additional space is needed use back of form
13. CASING:
Wan Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To 6^ / Ft. <<. ' r/a' PI P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: c
Depth Material Method S c
From CI To .-)-if\ .Ft. 0 Cn, c.,ai n;o4 1-, co �'.,
From To Ft. / c-� on,
^I cc;.,
15. SCREEN: I --
Depth Diameter Slot Size Material ;=:
From To Ft in. in. - r,i._'
From To Ft. in. in. !'`1 ✓T
nv,=
From To Ft. In. in, u; y,
16. SAND/GRAVEL PACK: -- 5
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 COi✓rmLs / OU(/onr 19 i — :2 h — O 1
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ubmit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. CO�A -- <% - _ GWI REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 3 7 3 4 6
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .l -or, n, es I)r I ).,., 4 1 tL2 a I),c I i rzu,� jr/, < .
-&-y
WELL CONTRACTOR CERTIFICATION #: .5 - a/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential(1X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) M/ ��1
Nearest Town: i/'6291 I�' / Io. ' L.//C__County: //" a Cfilq
ile" // 5 �I_cc
(Road Name and Nu/ ers,Co un/ity,or Sardivision and Lot No.) DRILLING LOG DEPTH
3. OWNER \TC t1 t 'i}..i4-9-' From To Formation Description
Address // II /N ( % Il
Street or Houle o.)
jrwn lr.� „ Cl_ .�-873V
City or Town (// State Zi code
4. DATE DRILLED_!- /- o/
5. TOTAL DEPTH /fz7'
6. CUTTINGS COLLECTED YES In NOITh----
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: c,-pj) FT.
(Use-+'II Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface'
-Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): Sr' METHOD OF TEST /7/I4/I, if 6'I-
11. WATER ZONES (depth): Ia S d a
12. CHLORINATION: Type /t t H Amount /c' /6 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth 7 Diameter or Weight/FR. Material (Show direction and distance from at least Iwo State
From To /C Ft. if. ' '/k` /2 I e . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: r2
i_J
Depth Material Method _
From CI To '- .1 Ft. (I r'o-1, 7T o., le .1 o c —
�' I ;`_;^
From To Ft. -
15. SCREEN: ‘ tf c3-
Depth Diameter Slot Size Malaria' =
From To Ft in. in. - o
From To Ft. in. in. ro (i
From To Ft. in. in. cn -",
16. SAND/GRAVEL PACK: — c.
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 GMin) .1 /1701)Qnnrt J - V- O /
Quad No: Nov 9 ;q' ,. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section el
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
r_ 3 , 0,) 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .b-eL1 n, es III 1 j rt (0•2 I I j) l I r>e� )i C,
WELL CONTRACTOR CERTIFICATION #: 5- - :a j 7o,
STATE WELL CONSTRUCTION PERMIT#:
/X Mu
1. WELL USE(Check Applicable Box): Residential ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the lopation below)
Nearrpjt Town: �Y/7m le, I, r✓I A/(1 -' County: GL Cnn
Kr( k m aA, (t,uv - Cuv'c--e-
(Road Name anA Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 5 t_ea 1-e csi._S 9 f(. L i 1 int J From To Formation Description
Address o,C1-4 o
A
- (Street or outs No.) 2
PI f2,11 v In) A.%C., r 7 3 L/
City or Town Slate Zip Code —'
4. DATE DRILLED 9 ,a,U ( a o
5. TOTAL DEPTH C�h S' O c�
6. CUTTINGS COLLECTED YES El NOD.--— f C7 orn
El I L[a c i�i
7. DOES WELL REPLACE EXISTING WELL? YES NOR-- w v
8. STATIC WATER LEVEL Below Top of Casing: FT. �v`
(Use-.'It Above Top of Cuing) -0 --r
9. TOP OF CASING IS I FT.Above Land Surface' :Z Ac
-Top of casing terminated at/or below land surface requires a variance In actor- r V r
dance with 15A NCAC 2C.0118 m
10. YIELD(gpm): `fo* METHOD OF TEST h/Ifl/I177 RI— N a
11. WATER ZONES (depth): (/ _
12. CHLORINATION: Type 1t t 14 Amount '// 76 II additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From (,� To 44 7 Ft. It' . /Ike' P i Y . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To �-I�\ FL (1r7m c r1 i [)/'H v ,
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPYOP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY x i,14,, i,• �aJU/1At,� - �U .- U /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
y S�Y Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. 8A4 '. GW-1 REV. 12f99

North Carolina• Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 237052
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \Nen flies I Jr ) ) r;,., a Well I r. /l n, Jrn
WELL CONTRACTOR CERTIFICATION#: S 3 :k/'7rn
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): ResidentialD Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: j 2'-ti,:'- L / til AVC— County: Ct-c6 J
/ P k�
(Road Name and Numbers!Conmunity,or Subdivision and Lot Na.) DRILLING LOG DEPTH
3. OWNER WCcyn.a e I. -'-/n1L From To Formation Description
Address (o y (d ; s oYc,
(Street or Route No.)
` ///)IC l n� Al
City or Town State Zip Code
4. DATE DRILLED R-as-o
5. TOTAL DEPTH lf®s''"
6. CUTTINGS COLLECTED YES❑ NOIDi'
O p
7. DOES WELL REPLACE EXISTING WELL? YES (� NOH—
S. STATIC WATER LEVEL Below Top of Casing: ) FT. O
(Use's II Above Top Casing) cryi
c->
9. TOP OF CASING IS l FT.Above Land Surface' f z
o :
Top of casing terminated at/or below land surface requires a variance In accor-
dance
with 15A NCAC 2C.0118 y"
10. YIELD(gpm): METHOD OF TEST h/h7/l,")1 BI-- thj r;lc
11. WATER ZONES (depth): /O� 0N c z
cn�
N
12. CHLORINATION: Type /f t/4 Amount /c' /6 If additional space is needed use back of form z
13. CASING: - - - -
Wall Thickness LOCATION SKETCH
Depth / Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From I-, To Ft. I .. r/V P f P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C' To .ZLIi" Ft. /7Can .0-r1 Pln.r 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.
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.
N
FOR OFFICE USE ONLY ni;nt r din a(nnr.0 / - ,0,5'-0 i
Quad No: . SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
a
S iii)Submit original to Division of Water Duality,Groundwater Section within 30 days
Serial No. „R�. GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Duality-Groundwater Section 2 3 7 0 r 3
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] c/
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lLben n, cs 1 U ,,,, a 1L12 a 1. v I I Tha jr-lt c,
WELL CONTRACTOR CERTIFICATION #: . 4- cQ/7/„
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential E Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other IT: If Other, List Use:
2. WELL LOCATION.;(Show sketch of the location below) ,A�nn
Nearest Town. 0_•4 A//Z L- r Al 4/C' County: /u lO G/ni,p
u A rtM1a- 2 R.
(Road Name and Nubers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
m
3. OWNER Bi // I/f P-bb From To Formation Description
Address -7r,r C /1) ••, evuy , I.
Street or oute No.t• f ieeee /_ ! 3 y 9 <'2
City or Town no State Zip Coda •
-
4. DATE DRILLED / ' —0/
5. TOTAL DEPTH cP0S
6. CUTTINGS COLLECTED YES(l NO El-- 9
7. DOES WELL REPLACE EXISTING WELL? YES n NOES a)
8. STATIC WATER LEVEL Below Top of Casing: fi FT. Q c-,_
(Use':II Above Top of Casing) prn
--r i n
9. TOP OF CASING IS / FT.Above Land Surface' 1
Top of casing terminated at/or below land surface requires a variance In actor- W
dance with 15A NCAC 2C.0118 • rT'�
10. YIELD (gpm): co-{- METHOD OF TEST MOP,-et (I— ryci
11. WATER ZONES (depth): -pi70 I' fV ^z
• m ,
12. CHLORINATION: Type /f*H Amount 4 /6P4
,/ If additional space is needed use back of form rl o
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0To a� Ft fe' r/kV P 1 P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To �L_Ft. (I (1), >.,a, 2 "7e 1 ,
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 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 r n1411 1 /,holth4Ar,0 q Lf —0 /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
401 . Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section t. ' 7 0 19
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] I ��,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tl,-er�n, 9 'f77 I ) elm LL)' II i-?v, /I Ph e,J T)1 c
WELL CONTRACTOR CERTIFICATION#: .:mod- - :k/7/ d
,� STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Il�� Municipal ❑ Industrial D Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)Nearest Town: GP., Ai/K /',e 1v 4 C_ County: in
//Q F-er-r-r
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER -T'/"in/1-7J /Lr Yr Cperi--' From To Formation Description
Address (a„, S w r — .
/ y� �� (Street or Route No.
/ '/ / r flm1A 1= / .3, / 7 _3
City or Town State Zip Code
4. DATE DRILLED 9 -;24 -o /
5. TOTAL DEPTH &7 S
6. CUTTINGS COLLECTED YES NOC---- c
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO©- o o
8. STATIC WATER LEVEL Below Top of Casing: /--, FT. cn_,
(Use-+'II Above Top of Casing) 8
9. TOP OF CASING IS / FT.Above Land Surface* t v`
'Top of casing terminated at/or below land surface requires a variance In accor• c..W
dance with 1SA NCAC 2C. 8 1...,
10. YIELD (gpm): .> METHOD OF TEST'?//4//rt /'I-- Tit mn
11. WATER ZONES (depth): - ree5 - 7%1<- 6 - —d7
N m1-
12. CHLORINATION: Type It t/4 Amount 'Ai /� N a
YP If additional space is needed use back of form �7 o
13. CASING: - -
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 7/ Ft. ( . '/C V P 1 co - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .... Ft. /1 /tat, o.yl% p;n.t .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.
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 /rn/m r .r / O✓'(1Q-u .k./l /- .24 eD /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1 l $toknit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. / . .) GW 1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water(Duality•Groundwater Section 2 38 6 0 6
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: rf-en n, g l r /1 r.'n A CLL2 I I I- /I n,e1 ), C
WELL CONTRACTOR CERTIFICATION e: - cr/.76,
STATE WELL CONSTRUCTION PERMIT/I:
1. WELL USE(Check Applicable Box): Residential L!X Municipal ❑ Industrial D Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:y(Show sketch of the location below)
Nearest Town: /_I-4'21 /Gl✓t✓ .G--CL.- County: ma-e-4-.,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /11 G---IC- Co I I From To Formation Description
Address ) 2 -) L tt k e c,cit. )) /a.>
(Street or Houte o.)
City orT/ fw•- ,�/C, of--73f/
City or Town n Stale Zip Code •
4. DATE DRILLED !1-}5 -o I
5. TOTAL DEPTH *OM '
6. CUTTINGS COLLECTED YES n NOC-
7. DOES WELL REPLACE EXISTING WELL? YES 7 NODS-
8. STATIC WATER LEVEL Below Top of Casing: op FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST h/0/1; 11 (1.—
11. WATER ZONES (depth): -Qbb ' /
12. CHLORINATION: Type Ht t F) Amount /Li /6 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth � Diameter or Weight/Ft. Material (Show direction and distance from at least two State
/
From 0 To 11 ,c Ft. l<. . '/kV P E P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
0
Depth Material Method p
0
From n To �- i Ft. (I r't)-1 P-111" n;n{ > > �,
From To Ft. / nn cc"
15. SCREEN: ^
Depth Diameter Slot Size Material O �r
`no
From To Ft in. in. a r~rt�
From To Ft in. in. = ma
From To Ft. In. in. le
16. SAND/GRAVEL PACK: 0 2
— o
Depth Size Material
From To Ft.
From To FL _
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 Y� QC fit{ ,r /kin{piaAlLl :`J ✓ 0 /
Quad No: 41G� Cti SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
9 •? 1original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

238605
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: cNen n, i /c I ) ,k Weil . r i I n, e4 T1t ci,
WELL CONTRACTOR CERTIFICATION#: - :;.2/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable sox): Residential ll�� Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection E Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: cp -hk/ / ti/.4�t^_County: A4 a (-d )
M)a L-4Z IS 0-• R-._
(Road Name and Numbers,Commu
nity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER tii . ..1 o!
7 • f�o Lelc\O it, From To Formation Description
L� n
Address i.2oX s
(Street or Route No.}�
PUr r- I 3353 0
City or Town State Zip Code •
4. DATE DRILLED 9-5-0y
5. TOTAL DEPTH 'IL, S
6. CUTTINGS COLLECTED YES n NOC-
7. DOES WELL REPLACE EXISTING WELL? YES n NOE
6. STATIC WATER LEVEL Below Top of Casing: ',,/) FT.
(Use'+'If 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 In accor-
dance with 15A NCAC 2C.01 8
10. YIELD (gpm): ` METHOD OF TEST /7/Ir10;12 G�
11. WATER ZONES(depth): /Co ' /
12. CHLORINATION: Type /t f N Amount 1/44 I ts5 It additional space is needed use back of form
13. CASING: - ._Walla sickness LOCATION SKETCH
Depth / Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To -7� Ft. Cr ./kv Pi P . Roads,or other map reference points)
From To Ft.
From To Ft. o
14. GROUT: O
0
Depth Material Method to c-n�
From 0To ,;LIt' .Ft. 17 /'rn o•1/1 r >A;ni rT10 c�
From To Ft. — 0`=1
15. SCREEN: O Do
Depth Diameter Slot Size Material a r"'„-,
From To Ft in. in. =f1
From To Ft. in. in. Ws r^�
From To Ft. In. in. 0 -1
a
16. SAND/GRAVEL PACK: z
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 STAfiDARDSi-AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �r /N/++� e i//072Af,� 9`S-o
Quad No: Mr I 9 2001 , :SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
S1CSubmit onpinal to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina• Department of Environ:nent and Natural Resources-Division of Water Quality-Groundwater Section 7 0 V
1636 Mail Service Center- Raleigh, N.C.2 76 9 9-1 63 6-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: . f, nr `s IJcu ..<, ra (L)Q.n 1)r 1t n,el, ��,
WELL CONTRACTOR CERTIFICATION #: ,ram.--9=. , /-7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box.: Residential L!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketc:. of the location below)
Nearest Town: ' !4 4-A4/ 7 f) S' County: (.-4, Cfr�
fI -/Jqh iaq C' 0
(Road N and Numbers,Comrnun;1,o/r Subdivision� and Lot No.) DRILLING LOG DEPTH
3. OWNER cS C // i V Qom- c,"--, a1-T From To Formation Description
Address .34 i 9 Czc_ `2 cl
street or Rowe No.)
Pi'J4,7 I, 1 J 47 C- `Y 3
e
City or Town Salo Zip Cod u
4. DATE DRILLED / S -c'7 / 'm--
TM
5. TOTAL DEPTH iQ S c--, -:'i
6. CUTTINGS COLLECTED YES I NOD— N /-,-_:
7. DOES WELL REPLACE EXISTlt G WELL? YES 1 I NO(�—
8. STATIC WATER LEVEL Below Top of Casing: g..ipO F7. -o ch,.
(Jse'+'It Above Top of Casing) -e H.
9. TOP OF CASING IS / FT. Above Land Surface'
J n,
Top of casing terminated aOct below hind surface requires a variance In eccor- -�'i dance with 15A NCAC 2C.0118 CJl
n
10. YIELD(gpm): METHOD OF TEST Mu)/l,'N (II-- z
11. WATER ZONES (depth): 9.D/0' r
12. CHLORINATION: Type ' I 'a Amount ''/U /' If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth C-Ft.
orWeightFt. Material (Show direction and distance from at least two State
From 0To `S2 _Ft. �'' r/�4' Pi e . Roads,or other map reference points)
From To F.
From — To Ft.
14. GROUT:
Depth Material Method
From C To Fi. _l i, ,1 i
From To Ft. /
15. SCREEN:
Depth Di ame'.or Slol 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:
I DO HEREBY RATiRY THAT HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC r.• .T C 'an cl,Art •AOJPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L5 U U c n -
FOR OFFICE NLY _ '' /n i/i )nr J / A- -/,-5— `
Quad No: I t d r 1 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. r .__ GW-1 REV. 12/99

235087
North Carolina• Depanment 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: J -en n, -s /it,I 1 ,,, A (G)` I) �-)Y rl hel, -7 11
WELL CONTRACTOR CERTIFICATION #: _y. s,3_ :Q/'7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box;: Residential E Municipal ❑ Industrial D Agricultural❑ Monitoring ❑
Recovery n Heat Pump Water Injection Other
n If Other, List Use:
2. WELL LOCATION: (Show sketct,, of the location below)
Nearest Town: ,fta /C/,7r.) ///1 - County: /72O Grn .1
Al, clraNjacL tack 04- E
(Road Name and umber.Ccmrnun::r,/oorr�Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER JJJ, ll i /ai»� (2g. rr-oI /
Addressq •f� n j�OA ! 9 / (� �/ From To Formation Description
1icvrl lc!I yA) S«eet or 'owe Na.)/ 1O �f 2$ ! c/
N oC
City or Town Stare Zip Cod
4. DATE DRILLED g- /-O /
5. TOTAL DEPTH %/?S'
6. CUTTINGS COLLECTED YES ,7 NOT1i
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO—
8. STATIC WATER LEVEL Below Top of Casing: Fir- FT,
(Use-.-If Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated a'or below land surface requires a variance In accor-
dance with 15A NCAC 2C.011 B
10. YIELD (gpm): / S METHOD OF TEST /7/I1//l10 4-
11. WATER ZONES (depth): 02 75 ' (1
12. CHLORINATION: Type 17 1 'a Amount 'l4 053 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth L,ameter or WeighvFt. Material (Show direction and distance from at least two State
From D To 0 Ft. i" it/14' P i P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
i.;
Depfn Material Method
c_ :�.
From � _ ,:To 2l'' Ft. .7 -,1, .',1/ p "7i 'A ,
n _ -
From To Ft. IN) is •
15. SCREEN: p -- TE
__
Depth Diamelor Slot Size Material -a r;�
From To Ft in. in. -_L.
From To Ft. in. in. N r,=S
fJ1 `-
From To Ft. in. in. tD 5
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THE., W,A3_CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC r STs•NQAR 4TV Q1H OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
f L5 ® Il U 1 ,. �J
FOR OFFICE 1 -'r a -1 , /no,i , - ctiI fA i CP -9/ -© /
Quad No: I�il al'a I ` SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit bnginal to Division of Water Quality,Groundwater Section within 30 days
his
Serial No.
.._,.........____......_.. GW-1 REV. 12/99

North Carolina -Department of Environment and Natural Resources- Division of Water Duality•Groundwater Section J
1636 Mail Service Center-Raleigh, N.C.27 6 9 9-1 636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: db-en n, ei IL) ,-n A (c1e f) 1.-)V II i.),el, �,, ,
WELL CONTRACTOR CERTIFICATION #: ,y.,£:syi :k/.7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box': Residential lri� Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑Recovery D Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Shown sketch. of the location below)
Nearest Town: AP ii/LkL / "7/ //L County: /29C; Gn->1 i
C
(Road Name and N ethers,Cc rnun;1,or ubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r'/�1/2a1 p 9 ,S-nee/e.-
Address q From To Formation De:cdpticr,
o.
'/7(� I O//4 i�;tS reelor iouto ! 3 � -/ 35
Cityor Town 51ace Zip ode
•
4. DATE DRILLED 1�// -0 / ,3/i y
5. TOTAL DEPTH -4L7n c
6. CUTTINGS COLLECTED YES I NOE1i
7. DOES WELL REPLACE EXISTING WELL? YES n NORM
8. STATIC WATER LEVEL Below Top of Casing: 4tp FT.
(Jse'.'II Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface'
Top of casing terminated aVor below lands unlace requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): 40 METHOD OF TEST /'/N7//,}7 et—
11. WATER ZONES (dep:n): qo ' //o ' 3.,25` /
12. CHLORINATION: Type __= i '4 Amount �1/(4 /f If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth D,ameter or WeighVR. Material (Show direction and distance from at least two State
C -
From To Ft. '" ./,“' Pi ? . Roads,or other map reference points) o ; -
From To Ft.
From To FL-
14. GROUT: c-) -c
N
Dep,h Material _ Method
From _To :i i.' Ft. r 1, > 1 71 •1 -p
From To FL _ �FE;
pia
15. SCREEN: N co:-r_
CA ti
Depth Diame:ar Slot Size Materialup
_
From To Ft in. in. o
z
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 CERTIFS THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS •
To.Tv■'. - a _.1.t..„•1S1a HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FORD.. ,' I 11• " -L� ' A !opt• - n7h/! rfl ,' G
Quad No: _ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
•.,. _. n ` / init original to Division or Water Quality.Groundwater Section within 30 days
Serial No. , ,., , -.
W 7E G1 REV. 12/99

North Carolina•Department Of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 Q A 4 4 8
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] "
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cN-en n, es Ir 11 ,t (L)2 I I v /I n,, )1 C
WELL CONTRACTOR CERTIFICATION #: .4-Q- c /'76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential D 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: f fi A .LIt L/qV A/C — County: Q-C.erx .
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Irat / 8 a)r n ( Py From To Formation Description
Address iCb lstre m n to
rN J
et or outs c�.J) OnikIn3 A1/� -S73 ti
City or own �-± State Zip Cod -- —
4. DATE DRILLED d - fr-U I
5. TOTAL DEPTH 400
6. CUTTINGS COLLECTED YES[l NOC-
7. DOES WELL REPLACE EXISTING WELL? YES E NOR-
8. STATIC WATER LEVEL Below Top of Casing: 2r, FT.
(Use'+'II 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 15A NCAC 2C.0118
10. YIELD(gpm): / METHOD OF TEST /Oht7/I, 11 r�1—
11. WATER ZONES (depth): /S() lI
12. CHLORINATION: Type /f t H Amount 1/4//6 If additional space is needed use back of form
13. CASING: - -- -- -- - --- - _ _...
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From (-' To /(l 9 Ft. iL. . r Iid PL P - Roads,or other map reference points)
From To Ft.
0
From To Ft G
o
14. GROUT:
.
N —
Depth Material Method rn om
From To •1:L1 Ft. P Go n o.oa% r�>> "O C C
/ . it . 2m
N o
From To Ft. -. — V7 as Dc
OCT5. SCREEN: —f�
Depth Diameter Slot Size Material l 2 6 TM rnrn
From _To Ft in. in. Q m
sip
From To Ft. in. In. N
From To Ft. in. in. N z
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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Gnam r r /LnU`QQnr-C -9 S -U I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section /.. ..• tI J 0 4
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \Nen n, g Fir t) A We n b v ,I n„} Z-r
WELL CONTRACTOR CERTIFICATION #: ;Q17h G
,� STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Ila<unicipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: I/2,92/CL /..1/ .7(9 County: Al Q Gtrn
(Road Name and.Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,ii//C LC.I)8 - Ai11 CJ 25;;t . From To
/ Formation Description
Address // S f-- J0A0 s C A. Ed
(Street or Route No.)
f-7a l</,k2 /1/ct ,F -S�
City or Town State Zip Code
4. DATE DRILLED c .�//�-rn 7
5. TOTAL DEPTH LSh,n ' - -
6. CUTTINGS COLLECTED YES n NOD--
7. DOES WELL REPLACE EXISTING WELL? YES ElNOI j 77' -
8. STATIC WATER LEVEL Below Top of Casing: FT. i i' I f
( Top Casing) �u DEC 4 2001 tu
Use•✓II Above of
9. TOP OF CASING IS / FT. Above Land Surface'
Top of casing terminated aVor below land surface requires a variance In eccor- —" -
dance with 15A NCAC 2C.0113 re lLLE V/AiER SECTION
10. YIELD (gpm): . -1.- METHOD OF TEST / //)/// /7 OV- GI
11. WATER ZONES (depth): /92<4 / //
12. CHLORINATION: Type /t t N Amount 7r! /1 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To // 7 Ft. fr. • ,/k' P i P . Roads,or other map reference points)
From To Ft.
0
From To Ft. O o
14. GROUT:
N G7_.
Depth Material Mo(:;cd Ill on
From 67 To .-)-(\ Ft. (3 (th a.,rtT pior ,1 . ,,m
�
From To Ft. F �
yo
15. SCREEN: 'O mo
Depth Diameter Slot Size Material 3 =�t
C.4 N.
From To Ft in. in,
�w
From To Ft. in. In. NI —
l0 0
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�\ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Y �.1i M r r /nO✓'(%nn,,0 ,9 67-0 f
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No.
GW1 REV. 12/99

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section ? " r J '
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] /
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cN-Pn n, g At, i l n,,, a Mu br lI ,-> ,., ri1
WELL CONTRACTOR CERTIFICATION #: ,gam ;k/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential IEJ� 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: ll Qi7 4'/A-71 i /Kt- County: P{r-, ,
/f/; L kr:j C.r_li /i d.
(Road Name and Nub, ers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /`j, VV f-4-c.212y- From To
Address ,g 7 7/ _ • - Formation Description
// �vi1.�S Pc?` (Street or Rout.
City or Town rr'�++ State Zip Code •
4. DATE DRILLED d"— �7-0 I
5. TOTAL DEPTH .-2 7Ci
6. CUTTINGS COLLECTED YES n NODS V R l ll nn R 0
7. DOES WELL REPLACE EXISTING WELL? YES (l NO IS (5
8. STATIC WATER LEVEL Below Top of Casing: ii>• FT. Hill
(Use'+if Above Top of Casing) g i rr
9. TOP OF CASING IS / FT. Above Land Surface' ,' NF9 � ll j WNW
'Top of casing terminated at/or below land surface requires a variance In accor- r f
dance with 1SA NCAC 2C.0118 -..,.1
10. YIELD(gpm): JSO METHOD OF TEST h/io/I i 11 Ft
�
Y2
11. WATER ZONES(depth): ' ' e H.S / _,_
12. CHLORINATION: Type /t t/4 Amount / LI 16 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth // Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To T7 Ft. (/'. . ./kV P 1 1 . Roads,or other map reference points)
From To Ft.From To Ft. oo
14. GROUT:
rn Depth Material Method -00 cc-'
m
From _1� To .-)-1\ FL 0it), a.11/ n;1�i t ; 2 oc
From To Ft.
/ n`o
15. SCREEN: 3 z�
rn
Depth Diameter Slot Size Material W ma Nz
From To Ft in. in. IV ---1
From To Ft. in. In. tD o
Y
From To Ft. In. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From T Ft.
17. REMARKS: •,./-)/a < ,Pri. j)l,yp / >.oi
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 `A Ana,/r ihniilr/iAt ,l l
Quad No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No.
GW-t REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Duality•Groundwater Section 0 2 t-/ 4
9 r' A
1636 Mail Service Center-Raleigh,N .27699-1636-Phone[phone] �_ .. ( :) l�
.0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: th-Pn n, g /Li ,1 ) r.,, A WO I . 1." /I )1 el •-2-72 ,
WELL CONTRACTOR CERTIFICATION #: .. ;:;".?/7(.., a
tvtuSTATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential lid- nicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other Ei If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: f-I.O47h-'/,tc/ 47(7 , County: /M (ern(F-
DLIallat.t-T el r1 k.- � -__
(Road Name d Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r i -f'-F lrc- -to rf r/p
From To Formation Description
Address LUQ./11 02 ad-
(Street oar Route No.) n /7
City or Town (.7 Stale Zip Code
4. DATE DRILLED a SAD/
5. TOTAL DEPTH 3 0,S `
6. CUTTINGS COLLECTED YES In NOO— [' p
7. DOES WELL REPLACE EXISTING WELL? YES NOD- 1
6. STATIC WATER LEVEL Below Top of Casing: FT,
(Use'+'ll Above Top o Casing) ' ', k._-;N 4- i;
C
9. TOP OF CASING IS / FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor- 1 _� e
dance with 15A NCAC 2C.0118 ,�-4 !"t z
10. YIELD(gpm): METHOD OF TEST �c/ /lr}p /� cr= �+
11. WATER ZONES(depth): -rD ! - m. a�
ti ai.,
m
12. CHLORINATION: Type [t t/4 Amount '/4 I is3 If additional space is needed use back of fo rF-n --E
rn
13. CASING:
m
Wall Thickness LOCATION SKETCH [3 cn
�,� Depth 9 / Diameter or Weight/Ft. Material (Show direction and distance from at least two Sate rN*1 a`
From To--�}_ Ft. i!' ' ,/ftt' P/ P . Roads,or other map reference points) N.,
t0 0
From To Ft.
x
From To Ft.
14. GROUT:
Depth Material Method
From (7 To .Z)-(\ Ft. (r Gvai o.oa! [/ter-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.
From To Ft.
17. REMARKS: 1P.t/) /0 /-r. C j yj y
/ ) I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY !` '79414 -, 1�o4)11aA, _ F----ei-s--0 1
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No.
GW-1 REV. 12/99

238604
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: 1N-en n, et /4 I A (02I I . 1' iI ,f, eJ T'1 C,
WELL CONTRACTOR CERTIFICATION #: -4= - J::1 7(�
�, STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El-- 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: /d/J 79 ir/1 nui Ate/ County: /Y10 �t
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /7n 0ltha-ci CiitLy/71GLit r From To Formation Description
Address „ ce,leA ,Jfy ke./
Street or Route No.)
City or Town r State Zip Code •
4. DATE DRILLED 6 -31-6 /
5. TOTAL DEPTH S`3S"
6. CUTTINGS COLLECTED YES n NO J-
7, DOES WELL REPLACE EXISTING WELL? YES In NO
8. STATIC WATER LEVEL Below Top of Casing: /go FT.
(Use'+•II Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
-Top of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): SO METHOD OF TEST /7l/rl/1, }1 /I-
11. WATER ZONES (depth): ,3 OSy /
12. CHLORINATION: Type // (4 Amount /4 / If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To /1 Ft. II. ' r/kV P l P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o
Depth Material Method 0o
From C To -Z�� Ft. (1 r'rn 49-G4 % rh9l > to CI
Fn o rn
From To Ft. -o ap
15. SCREEN: — z-
Depth Diameter Slot Size Material 0 --rn
yo
From To Ft in. in.
a
Z z�
From To Ft. in. In. aD ��
From To Ft. in. in. G -I
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY.THAT.THfS WELL.WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AI1D\THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
II
FOR OFFICE USE ONLY �n„m+ , /krnG(/pert g -3/-o /
Quad No: f;;:u r t 9 '?OOI - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 3 8 6) ll 3
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cNe1 n, g 1 I le:— r, I021I \5 h- 1I n. s1 X/1 c.
WELL CONTRACTOR CERTIFICATION #: . 5-9- ,CI/7(�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L!X Municipal 0 Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other D If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FKQn it I"(-' ,c-e- County: m Q ('/k-a't 2,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l • h Y; S Ca ri ct(1-0—) From To Formation Description
Address 7a. 14 P; (,(c s a c c c,Y to,
(Street or Haute No.)
L a k- (nowci iz. I ra t- 7 tit (o
City or Town -State Zip Code '
4. DATE DRILLED y-3 a —0 „
5. TOTAL DEPTH '7(0.c
6. CUTTINGS COLLECTED YES 7 NOC.-
7. DOES WELL REPLACE EXISTING WELL? YES n NOr —
8. STATIC WATER LEVEL Below Top of Casing: ,5- j 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 15A NCAC 2C.0118
10. YIELD (gpm): /b METHOD OF TEST /7//f)/h)7 ml�
11. WATER ZONES (depth): / D - .5'oo' 6 ko' l
12. CHLORINATION: Type N t N Amount `'/4 / If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / Diameter or Weighi/Ft. Material (Show direction and distance from at least two State
(
From 0 To i/ 7 Ft. if 'ixa' n/ P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
From £ To ,-2.1A Ft. (1 ill, 0.r1[ n 1,a-1_ C CD
From To Ft. rr 7 om
15. SCREEN: Zm
Depth Diameter Slot Size Material
or
O ern
From To Ft in. in. -331a
A
From To Ft. In. In. Me am
From To Ft. In. In. to ma
16. SAND/GRAVEL PACK: O --t
Depth Size Material — 5
z
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 ryry ` ��a n• - 4 (4jn� .0
g-3e -o /
Quad No: !A C ,
I 9 ' '' SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ? Y -I- 3 t 1
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JNen n, " 14, I) ntn a Coe II . r-. II ;,- •T)1 c
WELL CONTRACTOR CERTIFICATION#: .sii- ,Q/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal El Industrial El Agricultural El Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:iShow sketch of the location below)
Nearest Town: T Y/2m I-'1 i uJ iir . County: Al O Cl/Pc
P i) eel C 1--0 {'R--
(Road Name and NurTtfers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER m & r, )i YL EL-) h 4 e/N From To Formation Description
Address S3 .7 «k £f e//,- .59 et G r-C
eel or Route o.
U h//lmr-fsl /=l ,3,2k/
City or Town 9 State Zip Code .
4. DATE DRILLED )Y—3 -ol
5. TOTAL DEPTH 4tb_S/
6. CUTTINGS COLLECTED YES NOEl-
7. DOES WELL REPLACE EXISTING WELL? YES n NOR-
8. STATIC WATER LEVEL Below Top of Casing: / FT.
(Use•:if Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' o -
-Top of casing terminated at/or below land surface requires a variance In actor- — •_ _-
dance with 15A NCAC 2C,0118 HM/int
_
10. YIELD(gpm): (,"0 METHOD OF TEST /7/I0/1;711— `
11. WATER ZONES(depth): Op - 3 7.S ' /!
12. CHLORINATION: Type if t 14 Amount 4/�i s =�c
�� If additional space Is needed use back of lens -.-r;,
13. CASING: - - - - _ _ --
LOCATION SKETCH noWall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State o
From 0 To 7d Ft. I.<'. r/f& P l P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 _ To �f\ Ft. _n etn o.,-i _ oft,, ;l ,
)
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 HER �1 `r,E I . TjlS 1JELUN• • INSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR /r •kte.• . _, •e - - e• OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFFIC ONLY 2002 rnlmr n d —3 —0/
I Quad No: II i'EB 3 S NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit nginal o Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12199
GROUND ATER SEGOFFI
ASHEVILE REGIONAL GI-HL

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 1 v A. 4.
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \"-en ni g l it I) A (* I I �V- t I rx,4 -i1
&
WELL CONTRACTOR CERTIFICATION#: S- - cQ/77r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection El Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: rOh7(?/r2rJ 41/2' - County: /y)a ec7
L,
(Road Name and Numbers,Community,or Subdivision and Lot No.) _DRILLING LOG DEPTH
3. OWNER Let re rjL P/� From To Formation Description
Address / 7n efLT rid --4 p/ m /
(St(ee:or Route o.)
�yl �lk-inr i A r - _ -, Z-p3�
City or Town State - Zip Cod .
4. DATE DRILLED ' -G O-7
5. TOTAL DEPTH �n S
6. CUTTINGS COLLECTED YES❑ NOD-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE--
8. STATIC WATER LEVEL Below Top of Casing: rp FT. ci _-
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS V FT.Above Land Surface'
Top of casing terminated et/or below land surface requires a variance In aeccr- C
dance with 15A NCAC 2C.0118
10. YIELD(gpm): oc2 S METHO,g OF TEST /2//0//1"!7 41— c.
11. WATER ZONES(depth): r' /
12. CHLORINATION: Type /t t H Amount ' 4 /6 '==
If additional space is needed useback arm m;;:
13. CASING: r ^a
_o
Wall Thickness LOCATION SKETCH ..-
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To --65/ Ft. iE.. r/kV P i P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From , C _ To ,7/-N Ft. _CILin, <.,l( 11-,.{ 1 ,
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-g
I DO HEREBY CE IF4;1- i}9S WELWAS CO 'RUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT!: ANDARDS,AND THAT A CO'Y F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
II
FOR OFFICE LSE LYFEE j Z 2002 l 4" "1 �415"/1A;l -6 - o
Quad No: NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit wig nal to Division of Water Quality,Groundwater Section within 30 days
Serial No. GGOl1MwATER SECTION GW-1 REV. 12/99
AFNEVILLE FFGIGNAL OFFICE

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 0 n 1 3 t 3 1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cl)-en n' 9 lL' U r. , a (*I) )t-. a 7>1_,, rn C
WELL CONTRACTOR CERTIFICATION#: .c-4=62- cQ/`io,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential tl - Municipal ❑ Industrial D Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION:1Show sketch of the location below)
Nearest Town: /YQm /i/iici /L-(2- County: 7)9a-Gin 1
(Road Name and umbers,Community or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /enn i -e- Ee e i.'t2 5 From To Formation Description
Address /S 74/ �i,-JJle t1 .fn.njy�v�c„ )1L,,l_
Street or oute NO.
/Ti)/1/Vicki AY P. 02 l73
City or Town r State Zip Code .
4. DATE DRILLED d --‘ -0 /
5. TOTAL DEPTH 36 S
6. CUTTINGS COLLECTED YES Q NOD-- o r=
7. DOES WELL REPLACE EXISTING WELL? YES El N0EI a
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 scoot- —
dance with l5A NCAC 2C.0119 - r^
10. YIELD(gpm): ./ S METHOD OF TEST (0/l4/11)7 rr1--- CDc H
11. WATER ZONES(depth): /i S �7 S a 5'0 (! —
N
12. CHLORINATION: Type if t H Amount r�4/6 It additional space Is needed use back of form `
13. CASING: -
Wall Thickness LOCATION SKETCH
Depth , Diameter or WeightFt. Material (Show direction and distance from at least two State
From 0 To /!'O Ft. to. . r/02 P k P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To • ).li\ Ft. 0 r,a1 >.,a% pm r iii
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°y'r'��T' TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU '( NF D A D TWAI C^ DE THIS RECORD HAS BEEN PROVIDED
�TO THE/ WELL OWNER.
FOR OFFICENLY n+ �nn6Q'pn, T w 'O
Quad No: �. -' Silb C��9 i( NATURE OF PERSON CONSTRUCTING THE WELL. DATE
mil o(igl to Division of Water Quality,Groundwater Section within 30 days
Serial No. j GW-I REV. 12/99
GROUND WPIE `r V 1
ASHcVII_LE tVGlD.wL 0r_IGS. ._

North Carolina•Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section l 4 1. 3 4 4
1536 Mail Service Center-Raleigh, N.C.2 76 9 9-1 636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: Clef)cif `5 /)-8,I ) ri,n A (Deft 1)r /I ,7,1,� X) ,
WELL CONTRACTOR CERTIFICATION #: 5.5:s _ :k/7 ,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box : Residential l2:1- Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery [] Heat Pump Water Injection Ej Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketc:, of the location below)
Nearest Town: & 4fzi A' C'.- County: �7a Cn�r -
/,1'.6,/ 2i r/.a r- /2rt
(Road Name and Numbers,Ccmrnun;:/,pr Subdivision and Lot No.) DRILLING LOG
3. OWNER r Tr'SSe S ^ DEPTH
Address �� ,) l R From To Formation Description
��l creec� �f'/ �LJ+'�olt �
(Street or'cute No. 0
r ) //'e - ..--DI76, 3
City or Town (1 State Zip Code
4. DATE DRILLED d - rO /
5. TOTAL DEPTH .ins
6. CUTTINGS COLLECTED YES NO
7. DOES WELL REPLACE EXISTING WELL? YES n NOrr—E
8. STATIC WATER LEVEL Below Top of Casin g' �kn FT. _-
(Use Y'It Above Top of Casing) - '-'
9. TOP OF CASING IS 1 FT. Above Land Surface' 7+ "er
'Top of casing terminated a:bar below land surface requires■variance In actor- C ;''
dance with 15A NCAC 2C.0118 n
10. YIELD (gpm): On METHOD OF TEST /0/E//Ir 11 d — -
11. WATER ZONES (depth): 7 5 ' (I '—
_ra -_
;
12. CHLORINATION: Type %r 1 'a Amount VS/VS/ /� If additionalv r-;space Is needed use back of loan r--)"
13. CASING:
C o
Wall Thickness LOCATION SKETCH Z
Depth G. Cameter or WeignVFi. Material (Show direction and distance from at least two State
From 0 To J Ft. it r/<4' Pi P . Roads,or other map reference points)
From To Ft.
From To Ft. •
—
14. GROUT:
Depth Material Method
From n To _=iN` Ft. r �';), .r rl% ;‘)t;l ,
From To F, /
15. SCREEN:
Depth Diame:or 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:
rr��
I DO HEREB lit, TI4AT'�gIS N d WAS Of�' YRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC , . I C Pre THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE tJLY, 1n2 ICI Va1VI+ •,r - r 1( -� �' _0 /
Quad No: , �.L ,1
-- j SIGN ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit onctal to 4viston of Water Quality,Groundwater Section within 30 days
Serial No.
6HCUNDV,IATE'?, SLCT10I GWd REV. 12/99
Acu�V LLF PFSI 1.'-.),:',,.._
a _--

North Carolina-Department of Em iror,..nent and Natural Resources•Division of Water Quality-Groundwater Section n , + 0 1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] L. f J. .. 4. J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,NpIt n C,, err I ) Kin. a (02I I P 1-. /I ,n- , -Tn
WELL CONTRACTOR CERTIFICATION #: ,c. y9- �7'-7('
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box : Residential ILd- Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump 1 later Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketc: of the location below)
Nearest Town: ) lriD 4/C- County in& ,)
(Red Nreme and Numbers,Ccmmunl(Jor Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER
/�-P_iLA,L-ce—, r 3 ita�y'�)� '{-�
P - From To Formation Description
Address iL Pel��l�p Io 3,-; /2 c4
(oueet or houC No
F all kiO3 i.C r �'73/
'y or Town State Zip Colo -7
4. DATE DRILLED F,7.-n o 17-
5. TOTAL DEPTH .-t2 f1 S _ ]-- c,__
6. CUTTINGS COLLECTED YES 7 NOD-- C c,'-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOI -+— — _
8. STATIC WATER LEVEL Below Tap of Casing: 9p FT. _ -
(Use':It Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface' ,a
'Top of casing terminated a Leto Ind t urface requires a variance In actor- — •'+--
;iar w dance with 15A NCAC 2C.011E u Pl.:-
10. YIELD(gpm): / 2 METRO OF TEST klilf7(1, 11 I(.— ry
F
11. WATER ZONES (c''ep::t):___2e ' (/ r-
12. CHLORINATION: Type r 'l Amount '/(4 /r5 If additional space is needed use back of form
13. CASING:
Walt ThicknessLOCATION SKETCH
Depth L, Lameter or WeighVFt. Material (Show direction and distance from at least two State
From To C' Ft.— '
�,� '' . ,/fV Pi g . Roads,or other map reference points)
From To F:.—
From To Ft.__.
14. GROUT:
Depth Material Method
From To _7)-l'` Ft. __' %-.2, ; rl% p;,74 1.>
From To Ft.
15. SCREEN:
Depth Di❑mcar Slot Size Material
From To Ft . in. in.
From To _ Ft. _._ in. in.
From To Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth EIze Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREB l T 1 l*ATrfl4'.' !.�L �S TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT ILI kJPV;f F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE NLY �L4,,,,r , /�ntk' 4/t 1 7--D /
Quad No: L - l:L tq;NATURE OF PERSON CONSTRUCTING THE WELL DATE
L
J Sutmit ofiglnai t, Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
.ill t .. i... • • :

North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section r- y J- v r-
1636 Mail Service Center• Raleigh, N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tl Pt'L1, .`s / l) r,,,, ,4 Li.) It it- f I ,), ,� "Tv'.f.
WELL CONTRACTOR CERTIFICATION #: , i :k/7/n
STATE WELL CONSTRUCTION PERMIT'S:1. WELL USE(Check Applicable Box:: Residential L(�- plunicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Y/ater Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Show sketch of the location below)/ /�
Nearest Town: 1-1"li.r,lk> 6vit) A/ C - County: .7fl C
(L', n ci✓I L ),�-r-4
(Road Name and N' t ers,Cc rnun:/,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER J e cc `PCC irk S
Address p /� From To Formation Description
( tree or oulo No
ib%hAr.) /i/C- f 17. V
City or Town Sate Zip Code _ -
4. DATE DRILLED rS7--i-O/ -ri
5. TOTAL DEPTH 45-0'
6. CUTTINGS COLLECTED YES 1 j NOfi
7. DOES WELL REPLACE EXISTING WELL? YES n NO[-
8. STATIC WATER LEVEL. Below Tap of Casing: 9' FT.
o
(Use'+'if Above Top of Casing) `-,
9. TOP OF CASING IS FT.Above Land Surface' N
'Top of casing terminated actor below land 5 urface requires a variance in accor-
dance with 1SA NCAC 2C.0118
10. YIELD (gpm): 7 METHOD OF TEST /0/IR//<Yi l-
11. WATER ZONES (depth): CD e 9D , c?-e
12. CHLORINATION: Type /7 1 14 Amount V4 i t5 If additional space Is needed use back of lorm
13. CASING:
Wall Thickness LOCATION SKETCH
,1 Depth Gameter or WeighVFL Material (Show direction and distance from at least two State
`
From To 7/ Ft. .J<4 Pi P . Roads,or other map reference points)
From To F:.
From To Ft.
14. GROUT:
Depth Material Method
From
From To Ft. �''1il
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 {{� (p{ y�yp��Y,�/p]p'� �-
CON HEREBY CE J N[R I1 1.fHATAAg CIF UCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
J O HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE O LY `f, na; r r /,�/7t7(i/2�t f ` � -v-0j /
Quad No: L _,� LOU? £TORE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Div slon of Water Quality.Groundwater Section within 30 days
Serial No. I
GW-1 REV. 12/99
L. / I •

North Carolina• Department of Environment and Natural Resources_Division of Water Quality-Groundwater Section 2 4 . U ri 9
1636 Mail Service Center-Raleigh,N.C.27(93-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cI 1NPr1 n, 9 ihi I ) a (t) I/ i)v. I I n- ei '1;1 ,
WELL CONTRACTOR CERTIFICATION #: .c-4 z- :Q/7G, a
STATETA WELL CONSTRUCTION PERMIT#:
•
1. WELL USE(Check Applicable Box): Res;dentialL(X Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of tie location below)
Nearest Town: S'raIL) Ybl' County: ina- (-cn. )
14 i PA .1 1 U.,,61Ci a (--bidLk
(Road Narna&nd Numbers.Comm nib',or EL nn;vision and Lot No.) DRILLING LOG DEPTH
3. OWNER ini ICE CbPT�hi Ifs, From
From To Formation Description
Address Q �, CD/9l- i rei e. A L '
(Streeter owe No.)
A+1an-1 d 30,3b9
City or To.n State Zip Code • O
4. DATE DRILLED ?.-/4-0/ p 2c
ca
5. TOTAL DEPTH 7'0_5-
A `
6. CUTTINGS COLLECT ED YES I I NO Ea-- r— =ven
e�
7. DOES WELL REPLACE EXISTING N ELL? YES ❑ NOn an cm
8. STATIC WATER LEVEL Below Tcp o: Casing: 6 ey, FT. cc
co -cr.,
(Use','I!Above Top of Casing) w
9. TOP OF CASING IS I FT. Aoove Land Surface* as rMi.--.
_ =a
'Top of casing termica tad_L cr L.>!ca land surface rxqulres a variance In actor- Ncn
2
dance with'SANC.to 2C.M1e CD - nt
10. YIELD(gpm)• 4/ METHOD OF TEST /))li/)i77 f— t11 n
11. WATER ZONES (ca,,:!1):_2On ' _ 1 v z
0
12. CHLORINATION: Type �&t)Y ._.__Amount ''4 f r3 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth oiamet.r or Weight/Ft. Material (Show direction and distance from at least two State
From 0 -To sr Ft. (' ' r/kV Pi P - Roads,or other map reference points)
From - To- Ft.
From To- Ft. _
14. GROUT:
De;rth Materia: Method
From
From To Ft. /
15. SCREEN:
Depth Diameter Sio; Size Material
From To _ Ft in. in.
From To _._._Ft. in. in.
From To —_ __ Ft._ in. in.
16. SAND/GRAN:_L PACK:
Depth Size Material
From _ To_. Ft _
From _ To _ Ft.
17. REMARKS _
rr:. i i 9 LC;
I THEM -H..EL 'AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C ST(1 CTI N STANDARDS,AND TH4 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR oFIt CE L goPG_� . 02 sa q !n,am r .r ,2 pa.,.t i / K)—Na -D l
Quad o: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sub t cdgL,al to Division or Water Quality.Groundwater Section within 30 days
Serial No. OHfli INl1INAl.Eti S:CI ION GW-1 REV. 12/99
r.e71"1E h'iG am.- ' L OFFICE

North Carolina-Department of Environment and Natural Resources-Division of Water Duality-Groundwater Section 2 4 1 6 4 2
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tNPt1 n, i is i 1 A 1*II ir. 11 rh., Z
WELL CONTRACTOR CERTIFICATION #: . ,Q/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 11:1-<nicipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION/• (Show sketch of the location below)
Nearest Town: If•/tr.El L.47XUS y&/ County: _../ 1 a- G4M
G-f..) l d Int)in -4_ •
(Road Name and Numbers,Community,or Subdivision and Lot No.) _DRILLING LOG DEPTH
3. OWNER l .(r P RJfc1, cb-ein-1 F From To Formation Description
Address (006, toyv ,t n . e,.c-� p a
(street or le No.)
If11 �n,n�, VP (N/ ? 7L/
Cl Town State Zip Code
4. DATE RILLED c-`')/-o/
5. TOTAL DEPTH SC S
O aE
6. CUTTINGS COLLECTED YES(l NOD--- o
7. DOES WELL REPLACE EXISTING WELL? YES fa' NOR C— ate,
B. STATIC WATER LEVEL Below Top of Casing: FT. C7 cm
(Use'+'If Above Top of Casing) tV p=
9. TOP OF CASING IS / FT. Above Land Surface' m Yc
Top of casing terminated at/or below land surface requires a variance In accor- ?
dance with 15A NCAC 2C.01 E - Z =p
=
10. YIELD(gpm): METHOD OF TEST /')/NJ//;l7 rt{— 9 cn
11. WATER ZONES (depth): 5 ✓2' rn ` / r^�
N . y
...10
12. CHLORINATION: Type Itt //4 Amount , //3 If additional space Is
needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ? Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To • 7 Ft. If' . r/ P. Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 6-C To 1--2-((\ Ft. /r 1'rrt o,?7 pin)t .1
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: ni ,-1-Q a-e,, L' inn,,.
I DO HERE 3Y-C R�'jIroillklAitl-H a r/L`L u AS STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT lO S-T,b,N1TAR C "OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE(OE ONLY. 9 1 --4/4 u .x i o✓U1nnt,0 &I -'0 1-0 I
W J ad No: ' , - ' - 2002 _:MATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit :riglnal o Division of Water Quality,Groundwater Section within 30 days
Serial No. ( GW-1 REV. 12r99
`n HiciiiON -
_ .. 1
1FICE .

North Carolina-Department of Environment and Natural Resources-DI :n of Water Quality-Groundwater Section 4
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone(919)733-:. 1 11 II
WELL CONSTRUCTION RECORD WELL COI, 1ACT0R: tlen n, 5 iM I ) ei,„ a (L411 ')e. i I 7)1 >y T11 C,
WELL CO: 3ACT0R CERTIFICATION #: ,S.,'- :h/'yo, 4
STATE WI". . CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential t(X fvlunicip: ] Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 1 If Other, List Use:
2. WELL LOCATION:.-(Show sketch of the location below)
Nearest Town: Fla as) <,hJ .eQ r County:- '2O :.+-
(Road Name and Numbers,Comm pity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER CL7.-rn r S Q S r-c� _ From To Formation Description
Address 90/ Lt f/to Oa./Z 5 $l
(Street or Route No.) -
)/ a l r r c�� !_(, r-r36-9�j
City or Town State Zip Code •
4. DATE DRILLED k'-.i3 -o /
5. TOTAL DEPTH sn
6. CUTTINGS COLLECTED YES n NOarzi
—
O 'a
7. DOES WELL REPLACE EXISTING WELL? YES In NO.--- s aa„
8. STATIC WATER LEVEL Below Top of Casing: / dd-o FT. 0 cc r
rn
(Use'+'if Above Top of Casing) rN cc
9. TOP OF CASING IS / FT.Above Land Surface' yo
?op of casing terminated at/or below land surface requires a variance In ac Y Ma
dance with 15A NCAC 2C.0118
10. YIELD(gpm): 440 METHOD OF TEST /0///i//;lv 0.-- usz
11. WATER ZONES(depth): /fp ' r,_ en y—
J o
12. CHLORINATION: Type It I-14 Amount z
��`' - If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WelghVFt. t.1r. (Show direction and distance from at least two State
From C To //3 Ft. <<. ' '/kY P , - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Metho-
From C— To .�LI\ Ft. 0 (lit o.0Y pin
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Mate;:
From To Ft in. in.
From To Ft. in. In. •
From To Ft. In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
17. REMARKS:
I DO HERE f''ORTI THADTI- S WEL( V STRUCTE• 'CORDANCE WITH 15A NCAC 2C,WELL
CONSTRL Tlbj}SYAN9AR OF THIS R 3 HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIcLISEONLY ;-,., C . 1. l/)nr ) ?'i3 -vI
Quad No: ( ;,, L' - ��"` GNATURE C. SON CONSTRUCTING THE WELL DATE
Submit dginal to Division c -)uality,Groundwater Section within 30 days li
Serial No. I :
GW4 REV. 12/99
'Cri

941641
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] II (O
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J i1 n, /fv I ) A n 1)r- i t I. -1
WELL CONTRACTOR CERTIFICATION #: .c—s=43- :k/76,
,� STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential(/ Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 4/e-- /}
//I ,ins IV/ County: .4-)Q-Pn,&J
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L rqcr.( 4
Address �On✓� �/� / From To Formation Description
-/,.7 a ci /2, 717E
(Street or Route No
/ir71i Ar it/ .2�
City or]"�wn Code
wn State Zip C e
4. DATE DRY LED S -.2/ -o /
5. TOTAL DEPTH D S
6. CUTTINGS COLLECTED YES 7 NODS- O
7. DOES WELL REPLACE EXISTING WELL? YES n NOE— O o
8. STATIC WATER LEVEL Below Top of Casing: _ pp_ FT.
a
(Use's if Above Top of Casing) g _tA
9. TOP OF CASING IS J FT.Above Land Surface' r-"
'Top of casing terminated aVor below land surface requires a variance In actor- POx
dance with 15A NCAC 2C.011e w e+t
10. YIELD m : 3'O MET OD OF TEST h/P1/ll>1 rr1— Ao
TAI-
11. WATER ZONES(depth): ' /0b ' r = zr^„
00 1nz
n
s
12. CHLORINATION: Type /t'/14 Amount '/ i/ (1/ If additional space Ls needed use backdatiforma
13. CASING: _— _..—_.._ ._. _- -- -. _.
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To Ft. (C' • r&V 23f.E 1 Roads,or other map reference points)
From To Ft. �
From To Ft.
14. GROUT:
Depth Material Method
From C To ;V\ Ft. (r r'q9, ,.,-ti ?r ,t ,
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.
16. SAND/GRAVEL PACK:
' Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1 C Ili �r
I DO HER BY �t�TIFI' I`I-1A 'TF41S ELL' VAS STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR ($ PISTANDARDS,AND THAT A C "OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ii ,i I
FOR OFFIdErj 1E ONLY' 1 2002 /N-041I .1 /rhniitia,rr,0 2-- /--O /
Cued No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit angina to Division of Water Quality,Groundwater Section Within 30 days
Serial No. I - r 1 r r,, Sr ION GW-1 REV. 12/99
it IFF!CE , •

241640
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: 1--en n, g l it 11 el.„ a (ale a ")t-, II n, >1 Th
WELL CONTRACTOR CERTIFICATION #: 54 C /7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X 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: /-1/!'/Z/ /1-fh S L'-L County /7) 0 C«il..,—>
(Road Name and umbers,Community,or Subdivision//- and Lot No.) DRILLING LOG DEPTH
3. OWNER $j /d/e-ir2 rr2 e/2 From To Formation Description
Address i ` )(' L a.
«eet br oute o.
reh )ar-AS 1/e e297c /
City orrown p State Zip Code •
4. DATE DRILLED O '/' '0 /
SS 5. TOTAL DEPTH 3rt
6. CUTTINGS COLLECTED YES Q NOC— o
7. DOES WELL REPLACE EXISTING WELL? YES Q NOR-- Q o
8. STATIC WATER LEVEL Below Top of Casing: &to FT. s c)
(Use'+'II Above Top of Casing) ac"
9. TOP OF CASING IS / FT.Above Land Surface' 1V o".Z
'Top of casing terminated et/or below land surface requires a variance In actor- CO st dance with 1SA NCAC 2C.0118 Dv
10. YIELD(gpm): S METHOD OF TEST HMV/ i1 ell-- MO rn
11. WATER ZONES(depth): �6n r / en y=
12. CHLORINATION: Type /t t H Amount ` C/ /6 If additional space Ls needed use back of 10nh o
13. CASING: _
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFl. Material (Show direction and distance from at least two State
From 0 To eine ic. Ft. <<' . A/kV Pi P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,-11v Ft. 0 ('-ill 4,.24% r);,74 1—,
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. REMAR
IDOHER lr l 1p
Y ---
Ao NSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C,WELL
CONSTR M STANDARDS,AND THAT OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFIy E USE.ONLY ) 0 2002 .2'r1,r r /Xinti(rnnr.,% ? —/7.O/
Quad Na: I� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
• `_�__._...____ Subm t original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GP Of )VF(ER SECTION GW1 REV. 12/99
/r ' .IL fIf ,,n,itiJ OFFICE

1643 North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 4
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tb-en n, g /+r I 1 d LL)L f I I)V, /I nt>4 T)1
WELL CONTRACTOR CERTIFICATION#: .g- -�i c /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal El Industrial El Agricultural ID Monitoring ElRecovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ii/C N I 4,r M C .T/C-- County: /7)/3 r-.(pi i
PLt( k_ Cit. 12 .
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L_ yyt pj„, L nM_�Q✓ From To Formation Description
Address / l' Pa
�/ treet or oue O.
//ilyiar,.4c 70 -- ,-7,-1t/
City or wn State Zip Code ,
4. DATE DRILLED 2-- * 0/
5. TOTAL DEPTH cBc S a
6. CUTTINGS COLLECTED YES El NOCi' O o
7. DOES WELL REPLACE EXISTING WELL? YES c NOE-- s c>---i
8. STATIC WATER LEVEL Below Top of Casing: i/'"J FT. C xi
(Use'+'if Above Top of Casing) N Z`
9. TOP OF CASING IS / FT.Above Land Surface* CO'Top of casing terminated at/or below land surface requires a variance In eccor- Pit-,
dance with 15A NCAC 2C.0118 b -ice
10. YIELD(gpm): /S METHOD OF TEST h/Nl//,Ft j— S �`�
11. WATER ZONES (depth): /90 ' // ma
n
ton H
J
12. CHLORINATION: Type it t H Amount 1/4/ /6 If additional space is needed use back of form z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two Stale
From 0 To /.'1---Ft. (I. ' /!kV Roads,or other map reference points)
From To Ft. ->'r /
From To Ft.
14. GROUT:
Depth Material Method
From To i:IN Ft. i r Cl 1, a.z'i% n r t rt ,
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 HER Y EFLT'IFi$HRTnits WEL W• INSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR 7
1N STANDARDS,AND THAT O. OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFFICtit1 EONlL\ 1 0 2002 .4 vonaif+ r /170/%0'4,4 f V --a c9 -0 /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
_ _ Subrnil original to Division of Water Quality,Groundwater Section within 30 days
Serial No. ..,r ,IP, LION GW-1 REV. 12/99
___ -rE

234259
North Carolina- Department of Environment and Natural Resources - Division of Water Quality-Groundwater Section
636 Mal Service Center. Raleigh, N.C. 27693-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ] -ef)ni` H /end Nell
♦,WELL CONTRACTOR CERTIFICATION #: 9- 4 s)- a/7L Ji
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L ' Municipal ❑ Industrial❑ Agricultural❑ Monitoring n
Recovery I I Heat Pump Water Injection C Other E If Other, List Use:
2. WELL LOCATION: (_Show sketch of the location below)
Nearest Town. r---YO.n IC I r'ti ill Q County Al A L7nt�
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3 OWNER T0T12i jy� r-4.�j r-K, From To Formation Descrip_on
Address 4-S SOCa
(5tree or oute O.
�Yao,lrlo5 A1� `. �'I3 (f/
uy or Town State Zip Cdde
4 DATE DRILLED 7-a -D I
5 TOTAL DEPTH I 5-5
6. CUTTINGS COLLECTED YES El NO[1-
7. DOES WELL REPLACE EXISTING WELL? YES I I Nont _
8. STATIC WATER LEVEL Below Top of Casing: /a_ FT.
(Use'.'II Above Top of Cas.ng)
9. TOP OF CASING IS / FT. Above Land Surface' •
'Top of casing terminated Wor below land surface requires a variance in accor-
canoe with 15A NCAC 2C.0118
10. YIELD (gpm): In, METHOD OF TEST fl/r"Ur,)' i't_
1 t. WATER ZONES (depth): g.s ' `
2. CHLORINATION: Type it 1 N Amount `/`r I r7 It additional space is needed use back of torus
13. CASING: .__ -- ---
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L To Ft. if : /k<' . , Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
0
Depth Material Method O
From To ' Ft. /r ['16 > , f1 '•
From To Ft C 5`*6
•
15 SCREEN, r cnT
Depth Diameter Slot Size Material C orr
>c
From To Ft in. in. -p n-,
From To Ft in. in.
IV rf>,From To Ft. In. in.
1E. SAND/GRAVEL PACK: = o
Depth Size Material z
From To Ft.
From To Ft.
17. REMARKS:
I GO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
f.,u._.V. PION--STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1 V'' s
7_ a _D
FOR 0 Y � ���,."f �Ftnv(���. 1 / /
Q o a i ii I . SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
fKA7 3 I1 I
1 " ''
A Submit original to Division of Water(Duality,Groundwater Season within 30 days
Serial No. GW•IREV. IZ'99
Groundwater Section
Asheville 8ecional ice

Nonh Carolina • Department of Environment and Natural Resources - Division of Water Quality-Groundwater Section 17 U +
1636 Ma.: Service Center- Raleigh, N.C.27699-1636-Phone (919)73,3-3221
1'JELL CONSTRUCTION RECORD WELL CONTRACTOR: •b-ex, HeII2iiI ulel D
WELL CONTRACTOR CERTIFICATION #: e ' - a/710_
STATE WELL CONSTRUCTION PERMIT#:
I WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery 7 Heat Pump Water Injection ❑ Other n If Other, List Use:
2 WELL LOCATION;_(Show sketch of the location below)
Nearest Town. Fran k I Yt_U IVV County: 41 a Lvh -z
Incaa Name anc Numbers. ¶ommunity,or Subdivision and Lot No.) DRILLING LOG DEPTH _
OWNEP SC US S On'-_-X From To Formation Descno:.on
Andress
(Street or Houle No.)
City or Town ./ State Zip Code
4 /-DATE DRILLED o -D I
5. TOTAL DEPTH cSOCS•
6. CUTTINGS COLLECTED YES[ ) NOT1-----
7. DOES WELL REPLACE EXISTING WELL? YES [ I NO[E-
6 STATIC WATER LEVEL Below Top of Casing: >7/ 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 15A NCAC 2C.0118 •
10. YIELD (gpm)' / METHOD OF TEST / -'r - i' '
11. WATER ZONES (depth): /OD ` o
12. CHLORINATION. Type iir y N Amount '/i-r l r3 It additional space is needed use back of lorm
13 CASING: .__ ____ . .. ... _...
Wall Thic ass LOCATION SKETCH
Depth C/, Diameter or WeignVFt. Material (Show direction and distance from at least two State
From - To !-3 Ft. / /;;.;" i'i 1: Roads,or other map reference points) o
From To Ft. O c
From __To Ft.
14. GROUT: C cam'
Depth Material Method — _Di+'
• G -n
From _L_ To .�,1 _FL I :'9P t n ' (h 'rrr . - 0 — ��
From To Ft. -0 -1mr
15. SCREEN: -m
Depth Diameter Slot Size Material IV m
From To Ft in. in. F '"
00 o
From To Ft. in. in.From To Ft in. in.
16. ShND/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.
---.- -M..,, �. �/
FOR OFFIC cg l- II U 5 il --' ` y. •' ''; . r 'I ' i/'�r. ' / — 02 —6
Ck.a'No r SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1j(p_ ��f1If Su dr inal to Division of Water Quality.Groundwater Section Within 30 days
Ser.3 No. L'^�+ 3 ' CW, t( GWI REV. 12/99
Crotm4water Section

234 5 29
Norn Carolina • Department of Environment and Natural Resources - Division of Water(Duality•Groundwater Section
1636 Mal Service Center- Raleigh, N.C. 2 76 9 9-1 63 6-Phone [phone]
ro WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'inn, , Nr i l ,-. Hk (/)," I I F', rv. -'-
WELL CONTRACTOR CERTIFICATION #: c4-"+-- O(l'7‘, ''�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential❑- Municipal n Industrial ❑ Agricultural ❑ Monitoring fl
Recovery ni Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2 WELL LOCATION:(Show(S' sketch of the location below) /y�
Nearest Town: /`ram-4I In2 4/ C County-_i g z a Cin
(Roac Name and Numbers,Community,or Sued v sion and tot No) DRILLING LOG DEPTH
3 OWNER �Cc (.k I k9Y✓ta_Aj _ From To Formallon Descnp_on
�aress N /' /�, ���, - - -- ---
free or Haute No.)
irThi i /2J A cfc73 %
City or Town Stale Zip Code
4 DATE DRILLED 7—/-o If —
5. TOTAL DEPTH :'3:2,5`
5 CUTTINGS COLLECTED YES I J NO[ —
7. DOES WELL REPLACE EXISTING WELL? YES [ I NOR-
8 STATIC WATER LEVEL Below Top of Casing: 5� FT.
(Use'+'It 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 eccor-
cance w9th 15A NCAC 2C.011s •
10 YIELD (gpm): IS METHOD OF TEST /9/.))I/I, i- 'j--
11 WATER ZONES (dep:n):_ <<!1 e .-,71) ' `)
1..2 CmLORINATION: Type _LI 7 H Amount —L�— it additional space is needed use back of lour,
13 CARING: . ._ _.. _ .
Wall Thickness LOCATION SKETCH
Depth, Diameter or WeighVFI. Material (Show direction and distance from at least two State
F'cm - To lQ/ Ft. i,. / tt"L i r I i Roads,or other map reference points)
O
From To Ft.
O ---
From To Ft.
14, GROUT: C-. c":
r c r
Depth Material Method -
Fr.,m A.
To Ft. (I :-->h : ,t- . r> ''1' ', . CA 0=1
rem . To Ft. I—__— ^"c
15. SCREEN. -- -
Depth Diameter Slot Size Material a rN*1
From To Ft in. in. o --I-I
From To Ft. in. in. CA
From To Ft. in. in.
16. SAND/GRAVEL PACK: •
Depth Size Material
From To Ft.
From Tc Ft.
17. REMARKS'
I CC)HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
N . ' "TION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNERr.
FI._vi �1".Tu7 2111.uq • !/ 't ^ ,.f /'r,^.;P2c-L /
• SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
I s Submit original to Division of Water Quality, Groundwater Section within 30 days
'P .. . Gw-i REV. 12r99
ii i

North Carolina - Depanment of Environment and Natural Resources -Division of Water Quality-Groundwater Section 2245 2 8
1636 Marl Serv,ce Center- Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,H741 n, I�r f ) -z-,. -; L/ I• I)) r ,
WELL CONTRACTOR CERTIFICATION U: .4-'d-- cal 74_
STATE WELL CONSTRUCTION PERMITN:
WELL USE (check Applicable Box): Residential Li- Municipal n Industrial ❑ Agricultural ❑ Monitoring n
Recovery 1 I Heat Pump Water Injection n Other ❑ If Other, List Use:
2. V;E'_'_ LOCATION ( now sketch of the location below)
„eases;Town. ✓a41 k Irt > A.tci Cony m CL (+1Ya
tRoac Lame a--NNumoters, Corvmunity.or Suxivision and Lol No) DRILLING LOG DEPTH
OWNER < DO ti, e PO r 0 C I(AP•O From To Formation Descrip...on
A^c ress S10. r�
i /\ A VFi? P . _ ---- -- . --
Streetor Route o t
rial1Uiki A/ C'_ oZ c7 3 t
City or Town Stale Zip Code
4 DATEDR','_LED rJ -ci_p/
5 TOTAL DEPTH 5.077
E. CUTTINGS COLLECTED YESJ I NO(fl-
7 DOES WELL REPLACE EXISTING WELL? YES I I NOR
E. STATIC WATER LEVEL Below Top of Casing: c/cp FT.
(Use'+'II Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface• _-Top of casing terminated aror below land surface requires a variance In scoot-
came with ISA NCAC 2C.0118
-C. Y:ELD (gpm): METHOD OF TEST /-Y'„" . r• -y_ _.
11. WATER ZONES (depth): il fc-- — — ----
2 CH_ORINATION'. Type 7 ((-5 `v Amount '4 /r-
-. If additional space 'a needed use back of lorro
)3 i:r.S:PiG•
._
LOCATION SKETCH
Wall Thickness
Depth Diameter or weighVFi. Material (Show direction and distance from at least two Stare
From - To — Ft. (II r , " Roads,or otner map reference points)
From To Ft.
From To Ft. o
14. GROUT o 0
Depth Material Method
r-t
) ,�-- C iri
r �rti
Prom To Ft. _ ^.—
15. SCREEN.: CO nEt-.21
Depth Diameter Slot Size Material p,
From To Ft in. in. --'r
cm:::
From To Ft. in. in. rr.::
c,
From To Ft. in. in. 0 -1
rill El--)
16. SAND/GRAVEL PACK: '.c
Depth Size Material
From To Ft.
From To Ft.
17 REMARKS: wS _.
i DO HEREBY CERTIFY THAT THIS WELL WAS ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C T'�,}1 `.•,i y-Nc:'US,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(yl (�2j I1.�r9 C V , 7- '�- O
• ••
� r, ,,,; , /,)"h^I1('t -HP
OFFICE USE ONLY
ar No. 1 rt. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
a ' 1 Submit original to Division of Water Quality. Groundwater Section within 30 days
Set' No. 1 GW-I REV. 12,99
ntlndwate ti r

mj
Nona Caroi:na - Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ?v '-/ 5 4.
1636 Maa Service Center- Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .1 )er)pfi,S Po ll qtn j ( i ) I
WELL CONTRACTOR CERTIFICATION et: =r. =% /7� c. r l
STATE WELL CONSTRUCTION PERMITe: r7
1 WELL USE (Check Appitcable Box): Residential❑"-- Municipal n Industrial n Agricultural E Monitoring ❑
Recovery I 1 Heat Pump Water Injection ❑ Other n If Other, List Use:
2 WELL LOCATIO (Show sketch of the,location below)
Nea:es:Town: P/.2A/k1 /47 A e County: a(A.
i'-,ceo hence a embers.Comununity.or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER Q I7VLta C
e I Lt. From To Fom.a;:on Descnp:.o,n •
Acddr ess ,...ii S/_ r�Q.71-{`i1• /c.� --- -- -
t reel or Route Nal ' /
Cay or Town S ate Zip Code /
4 DATE DRILLED 7-6/6 ---n J"/ --
5 TOTAL DEPTH Snn'
h. CUTTINGS COLLECTED YES 71 NO(/ ...---
. DOES WELL REPLACE EXISTING WELL? YES I I NOI ..4--
6 STATIC WATER LEVEL Below Top of Casing: f3,n FT.
(Use'.'II 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-
Canca Altn 15A NCAC 2C.C118
Y'E'LD (goal): 4C METHOD OF TEST [1/„r/'- r' T
,. WATER ZONES (depth): -she) a -R r `
12 CHLORINATION: Type rr t N Amount `V'-/ r T If additional space is needed use back of Iorrr%
13 CAS:f:G: _
c
LOCATION SKETCH
Wall Tnici ness _inc,_,
Depth Diameter or WeignvFt. Material (Show direction and distance from at least p Staf6
F•orn - To �0 t Ft. r. , %�'C. /1 r , Roads,or other map reference points)—_ ce.o__=-
-
From - To Ft. -. ❑�r-.
From To Ft. Me rn
rt1
14 GROUT: tr,4-0
;,
Depth Material Method n'''
0 --+
Prd a: To Ft. /r - rr _ , ,c- o
Frum 'ripFt. CZ
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
o ftb 2 i.DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
)rI R OFFICE US 'gyp `,� r�.r, - li-r-✓L0'rr.� 7 i6 — D f
!,
(p ^ r. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
l.til •
i i Submit original to Division of Water Quality Grouncn alai Section Within 30 days
rat No. . [ GW 1 REV. 12199
i
t
otn i r'atc-Section
,hai Office

North Carolina - Department of Environment and Natural Resources - Division of Water Quality-Groundwater Section -_ 3 4 5 2 6
:53e 1.10:: Service Center- Raleigh, N.C. 27699.1636-Pnone (919) 7333221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: . 't, 1.r I it i ) -, (. I:' I r
i� , t/� .
WELL CONTRACTOR CERTIFICATION #: ' `.' '2-y-_46— r.
STATE WELL CONSTRUCTION PERMIT#:
I WELL USE (Check Applicable Box): Residential El- Municipal n Industrial❑ Agricultural n Monitoring Li
Recovery L ) Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2 'V E_L LOCATION: Show sketch of tine location below)N'e /1�
ares:Town_ 1�d07 fr � e-i � County. , I Lai Cfrlt
(Roes, Nana arc j Nurrwers,Convr:onity. or Subdivision and Lel No.) DRILLING LOG _ DEPTH
OWNER B. 71 kl-a S a cse, From To Formation Descno:.or
AclCrc55 l) p,- ) ..
, tree:or to No-) --
[-fa,'kire Af� c -tf 3 9/
ody or Town State Zip Code
DATE DRILLED 7_ a^-'�'
5 TCTP._ DEPTH c50 0
6 CUTTINGS COLLECTED YES 171 PLO
7 DOES WELL REPLACE EXISTING WELL? YES 1 I NOf —
b STATIC WATER LEVEL Below Top of Casing: <Qo FT,
(Use'.'II Above Top of Casing)
_. TOPOFF CASING IS / FT. Above Land Surface'
'Top or caning terminated aJor below land surface requires a variance In accor-
canoe with 1SA NCAC 2C.0118 _._
i o r iFD.. (gom its _. METHOD OF TEST 1 "y: i ',-.-____
tat:'"_R ZONES (depth): /of) e _.
12. CriLO:RINATION: Type _ /r 7 f4 Amount . ' /(-3 It additional space Is needed use back of lour
CAS:NG: —
wa;l Thickness LOCATION SKETCH
Depth Diameter or Weigno'Ft. Matena! (Show direction and distance from at least two State
From - To 5- FL i'l ' le i fr'f P Roads,or other map reference points)
From To Ft.
.From To Ft. -t
GROUT: L ^�
C ail:
Deptn Material Metnod r c.,:
From To - ` Ft. _ .f I zt. . '„'r, 2 -- o
CO
crom ..-o Ft. _ _. -ro
SCREEN. "'115. +,•• rn 3 —m'
Depth Diameter Slot Size Material <n`
tD rfl
From To Ft in in. o c,
From To Ft in in. c o
From _To Ft in in.
16. SA,NDIGRAVEL PACK:
Depth Size Material
From _ To Ft _
From To Ft.
REMARKS
C„HEREBY CER T iFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
"C Ea
a- Z, A{RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
~ IsysEa i
7 - d o 7
v ) OH UFFIGt USE UT II
j U..a: Nc. e SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-.71 I ail Subr't original to Division of Water Quality, Groundwater Section within 30 days
} Senal No GW-I REV. 12/99
aii
„erdwaterSection
,?,,..,..lib PooioraI C r:no e

Porn Carolina • Department of Environment and Natural Resources - Division of Water Quality-Groundwater Section ? 3 4 5 2 5
163E Ma:; Service Center- Raleigh, N.C.27699-163E-Pnone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .Nat,n 0 `' l ir, t i -. r, i' �
WELL CONTRACTOR CERTIFICATION #: s+ 5 ,J- c..2i76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal I I Industrial❑ Agricultural I I Monitoring I I
Recovery 1 j Heat Pump Water Injection (T Other n If Other, List Use'.
2 WELL LOCATION: (Show sketch of the location below)
Nearest Town: /—Yam(G 1rf) At- County. ih O GFn-v J
,Road Name and Numbers.Community,or S,:odivision and Lai No.) DRILLING LOG DEPTH
3 OWNER fchh i!eL�x. L- (} roi h (Vrr._ From To Formation Descn;'_or
Address i, n <
(Street or out Ffo.)
—
F r ai,j, (,--o A/c_ k 14-q
Cny or Torn , State Zip Code
4 r/
DATE DRILLED /—/,—Ct /
5 TOTAL DEPTH ri?[hs
—
6. CUTTINGS COLLECTED YES[ 1 NOn---'
7. DOES WELL REPLACE EXISTING WELL? YES I NO t'
? STATIC WATER LEVEL Below Top of Casing: 691 FT.
(Use'+'II Above Top of Casng)
S. TOP OF CASING IS ! FT. Above Land Surface'
'Top or casing terminated sUor below land surface requires a variance In actor• — --
dance wltn 15A NCAC 2C.0118
19. YIELD (gpm): L S. METHOD OF TEST [7r,, - i � _
11. WATER ZONES (deptn):
12 CHLORINATION: Type r' 1 r! Amount —:'__'1 / If additional space is needed use back of lorm
13. CASING: —_
Wall Tnlcrness LOCATION SKETCH
Depth p� Diameter or WeigriVFt. Ma.enal (Snow direction and distance from at least two State
From - To 103 Ft. ' it ; 1r r - Roads,or other map reference points) p
0 'e
From To Ft. _ a
From To Ft. C— `-='-
4. GROUT: r cr
ter,
Depth Material Method — C:'
From To .-Li` Ft. rr ion ,, �A
,i' 'nt. �m
c
°Hein To Ft. - —
tint
15. SCREEN. Lp rcn
Fc-
Depth Diameter Slot S!ze Material CDy
From To Ft in. in. c' o
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 CD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
EO*,€TRUOT4SN-ST•ANOARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i af'-'r�
F e_ • • i vn9 it , lr}„tii rol ' 7 — ,, /
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
W Submit original to Division of Water(Duality.Groundwater Section within 30 days
GW1 REV. I2/99
' Groundwater Section
Y, Asheville Ref<ional Office

North Carolina - Department of Environment and Natural Resources - Divisional Water(Duality-Groundwater Section L. ^-
1536 Ma.l Service Center• Raleigh, N.0 27699-1636-Phcne [phone] y r I I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: • ''' : � M L�e� ' • •/'1-t1e
WELL CONTRACTOR CERTIFICATION #: SC-rr-}� c2 J7y4 ---3
STATE WELL CONSTRUCTION PERMIT#:
I WELL USEA Applicable Box): Residential / / ❑
(Checkpc ❑� Municipal D Industrial❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2 WE_L LOCATION�(Show sketch of the location below)
Neares:Town: KV(7411r (41(3 A/C -) County. in O (cn'l )
iRoac Name and Numbers, Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
O'•V:N'ER ��OptiS f-LL 1 �qyL . From To Formatton Descnpt.on
Ancress . to a 130 K 10
,� (Sre°,or Moots o. Ca t
_ tramsv/AD W C
, E7 L/
(Jay or Town State Zip Code
-
DATE DRILLED 7-/r.—t-71
.. TOTAL DEPTH r-7,S5'
-
CUTTINGS COLLECTED YES[ 1 NO7/
7. DOES WELL REPLACE EXISTING WELL? YES [ J NO[ —
8. STATIC WATER LEVEL Below Top of Casing. j,l 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 actor- -- '-
dance with ISA NCAC 2C.0118
10. YiELD (gpm): /_�7 METHOD OF TEST /)/rnr', . '1-
11. WATER ZONES (depth): f'
:CHLORINATION: Type .'tit 7 N Amount '/t1 /r3 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / Diameter or Weigh/Ft. Material (Snow direction and distance from at leas)two State
Fr on - To Ft. f• r ir.; T I £ Roads,or olner map reference points)
From To Ft. -
From To Ft.
14. GROUT:
Deptn Material Method ht
co
From To To Ft if Iii ,- r '!i. O o
t
_
From To FI. L l...
15. ECREEN. r rr---C'
Depth Diameter Slot Size Material p0 EF rn
From To Ft in. in. z'r'
va -f'3 r
From To Ft. in. in, wn.,
From To Ft. In. in co cr'72:
on
1E. SAND/GRAVEL PACK: 0 . i
Depth Size Material o
From To Ft.
From To Ft.
17. REMARKS:
. :O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
r:'.. STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1 ,."COT' ON- vim` �/�1
I USE ONLY I 'nd ,. , ';r1n, 6�/)�. r /-' (a -�(7/
No: 3 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
EP 9 Kul t f 7 j i Submit original to Division of Water Ouaiity_Groundwater Sacnon within 30 days
__ No GW-I REV. 12199
Groundwater Section
___Asheville Regional Office„_,,,,

235556
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: INe n n r i /) 11 d (1)e I I �t-. I I I> . Tit C
WELL CONTRACTOR CERTIFICATION #: .94 - c /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential I!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)Nearest Town: /)/C4! /.'C - //yy2 County: /2 (7 l'r•a___)
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
l�r 3. OWNER 'I/r /U ,re// From To Formation Description
Address
(Street or Route No.)
® / S- A 3
T/w' -
City orTown State Zip Code •
4. DATE DRILLED 7-/7— in /
5. TOTAL DEPTH l�e'I~ '
6. CUTTINGS COLLECTED YES 7 NODS
7. DOES WELL REPLACE EXISTING WELL? YES n NOD
8. STATIC WATER LEVEL Below Top of Casing: / o, FT.
(Use'+'if Above Top o1 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 2C,8
10. YIELD(gpm): � METHOD OF TEST /Q/I1////7/ F�
11. WATER ZONES (depth): /fin £- 1$7)
12. CHLORINATION: Type hi*/ Amount ''A I/6 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth OO Diameter or WeighvFt. Material (Show direction and distance from at least two Stale
From C To b. S Ft. (�•. r/kV P 1 P - Roads,or other map reference points)
From To Ft. o z-
_
From To Ft. c"
L r-?
14. GROUT: c ;. ,
Depth Material Method
From C To .-1-N Ft. (I t'-m 4,.11/ pm( it
From To Ft.
r.;
15. SCREEN: �0r
o (. ..
Depth Diameter Slot Size Material „-.-
!V P
From To Ft in. _in. �.t __
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 STANDAIRDSANIXTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ,, , C1nl sll .f /X70)(//2nv.� 7-/%-r I
Quad No: l'A':W� — SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. GW1 REV. 12/99

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 2 3 5 5 5 7
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tI'-en n, '' 'fin I ) nm A WO I) F>,-. II ni 4 r11 C
WELL CONTRACTOR CERTIFICATION #: .q- 'sit- > /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable sax): Residential I! l Municipal ❑ Industrial❑ Agricultural D Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIONL(Show sketch of the location below) �t�7
Nearest Town:—fi-rom 4'1i t ) ,/'' C - County:
(Road Name and,cambers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /-i /Jar f/ /AO S d1LJ From To Formation Description
Address 19,9 Ter / /2,J
(Street or Route No.)
P /144 k/n.% Air" .Q,173 V
City or Town State Zip Code •
4. DATE DRILLED_ 7/6 -0/
5. TOTAL DEPTH 1/4'7 O
6. CUTTINGS COLLECTED YES ff NO
7. DOES WELL REPLACE EXISTING WELL? YES n NO(l
8. STATIC WATER LEVEL Below Top of Casing: g fp FT.
(Use'+'II Above Top of Casing)
9. TOP OF CASING IS if FT.Above Land Surface* •
Top of casing termin:a:,_etior below land surface requires a variance In accor-
dance with 15A NCAC 2:.0118
10. YIELD(gpm): ->�_ METHOD OFTEST Hin'frT7 ��
11. WATER ZONES C:pth): /r25 " .3 6, o '
12. CHLORINATION: Type /1 f/4 Amount /4 /" If additional space is needed use back of form
13. CASING:
Walt Thickness LOCATION SKETCH
D. .:h Diameter or WeighvFt. Material (Show direction and distance from at least two State
From D ) r� Ft. <<. ' 'i1"1' P l' P . Roads,or other map reference points)
From To Ft.
From b Ft. o
14. GROUT: o
[:plh Material Method `
From 1 Ft. (f (.-yri a.y71 t n :-",
rS-
From , , Ft. iu
15. SCREEN: cJl ,
Dep:h Diameter Slot Size Material — i.
From To_ Ft in. in. -" -
Fram Tc . Ft in. in. c;
From Tc . _Ft. In. in. N -
tin C
16. SAND/GRAVEL ! •CV: :i
De •th Size Material
From , Ft.
From Ft.
17. REMARKS:
I DO HEREBY CE. -Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTICt,„•_LAANOAROS,ANDTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1,l 1 ,' I
FOR OFFICE U3 ?�{L - C �knOC!l4e / /C 'O /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
Submit original to D>ision of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV.12/99

235558
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: d1--en n, 9 lit, f) rim A (Oc I i �it• r I a e4 T"
WELL CONTRACTOR CERTIFICATION k: . -S 42- c.Q/`74
STATE WELL CONSTRUCTION PERMIT#:
� Mu
1. WELL USE(check Applicable Box): Residential Llnicipal❑ Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: r"/2'12 /' /i) -t 4 ( - County: /in a C rho
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER C P4 L A /2[l wn- - From To Formation Description
Address /97 ' LG!ells R2ya..c-. C_ 0.
(Street or Route No.) T2 g-73 7
1-7 a.,lkl,i
City or Town ,`State Zip Code
4. DATE DRILLED ,-/3 `0 /
5. TOTAL DEPTH R C' C'
6. CUTTINGS COLLECTED YES❑ NOIII/
7. DOES WELL REPLACE EXISTING WELL? YES ED NO(.--
8. STATIC WATER LEVEL Below Top of Casing: 'p FT.
(Use'+'if Above Top of Casing)
9. TOP OF CASING IS t FT.Above Land Surface'
?op of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 �
10. YIELD(gpm): /0 METHOD OF TEST h/u)/fm l
11. WATER ZONES(depth): —,/(-5 ' I
12. CHLORINATION: Type /f f H Amount r/4' / If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth rr__ Diameter or WeighVFl. Material (Show direction and distance from at least two State
From D To (-0y Ft. (c.. '/kV P k P • Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: (._'
Depth Material Method a c3
From C To .;2.\ Ft n e-ni o.ri( ()Ire "i > c. c%-_
From To Ft. 1
r' c
15. SCREEN: c==
Depth Diameter Slot Size Material
From _To_Ft_ In. _ in.
From To Ft. In. _ In. o , ,'
From To Ft. In. in. �
16. SAND/GRAVEL PACK: c
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.
I (Q� l / (2.77 3 -o /
FOR OFFICE USE OMLY p m iknG •
Quad No: s ,l J SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
i C( ( Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-I REV.12/99

23 2 „ 4
� 1
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: than n r l ita l) .,m a Cr)e I) v. �) nt-#4 :i1 c
WELL CONTRACTOR CERTIFICATION#: /76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 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: Sri/✓y /3?71- County: Pia C-t'-
•
(Road Name and Numbers,Community,or Subdivision and Lot No.) _DRILLING LOG DEPTH
3. OWNER 71 et- m Q.rc_h.Q-nck Frcm To Formation Description
Address 3 go r ��1 �r f i t .�
( tree out o.
SCa /rI A/ �S713
City orTp4m State Zip Code •
4. DATE DRILLED (c —`t — D
5. TOTAL DEPTH '7 S"> CS r`
6. CUTTINGS COLLECTED YESQ NOD—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ- G E
B. STATIC WATER LEVEL Below Top of Casing: tin FT. ' -rn
(Use•i If Above Top of Casing) — :9 rn
9. TOP OF CASING IS / FT.Above Land Surface*
-Top of casing terminated st/or below land surface requires a variance In Decor-
dance with 15A NCAC 2C.011E
10. YIELD(gpm): /r2 , METHOD OF TEST b/N)//n? Fj Ca.? n:t
11. WATER ZONES (depth): 43
/
12. CHLORINATION: Type ft t/4 Amount r�1/ /P3 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth I Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To ("`"/ Ft. (c.. "PC PPP - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method •
From D To . 2J' Ft. (1 ern o.✓rY (>m.t i> ,
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 HEREB wa- A?TH LL?W4V NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC r •TIla r !' Le• U •Trjde-YOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
•
FOR OFFICE r NLY t� 'i Airn /r'ad0/)n — + .-n
Quad No: ' IGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
Submit•dgi to Division of Water Quality,Groundwater Section within 30 days
Serial No. —., T", air Section GW-1 REV. 12/99
• Re onal Office -

•
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section C 3 9 5
3 A.
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II
l�
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t n r g eta I 1 elm a (*I1 N.)r. 1I rail, �ii c
WELL CONTRACTOR CERTIFICATION #: .Ft-S-i3- _Q/`7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection D Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of,the location below)
Nearest Town: /'' ' 7//i 7—' 4/C County: 7/2 Q fir >-,
(Road Name an 94
umbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 7/ I' P r 9--
From To Formation Description
Address I( 9j m(� y�r Q Do v
Il 2'rtnLPCS U7(S orRopo.l 3 7ag(/
City or Town State CC�� Zip Code '
4. DATE DRILLED G —/, —T
5. TOTAL DEPTH 2j5 ro
6. CUTTINGS COLLECTED YES E NOD— ' •
7. DOES WELL REPLACE EXISTING WELL? YES E NOQ— t_ `�
8. STATIC WATER LEVEL Below Top of Casing: 900 FT. rr
= p
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' co r
'Top of casing terminated at/or below land surface requires a variance In aeeor- �O —Z
dance with 15A NCAC 2C.0116 s ^'r..
10. YIELD(gpm): METHOD OF TEST h/117//iYr al— ^ -
11. WATER ZONES (depth): 7/15 / r `c-,
—
C`
12. CHLORINATION: Type if*N Amount 1/ 1 I/s If additional space Is needed use back of form Z
13. CASING:
Wall Thickness LOCATION SKETCH
Depth//// Diameter or Welght/Ft. Material (Show direction and distance from at least two State
From D To 7/ Ft. is '/ P l' g- Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To ..1ff\ Ft. t7 Cry, t 1/ pine 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.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON v LLnaon.41f 6 -/ ;2- - O
Quad No: SI RE OF PERSON CONSTRUCTING THE WELL DATE
Subiniti il}tnal t Ion of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
Cro uMs,'ater Section
*,,,Ja at.lonal Office, �_.__

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 I
23. 3296
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 11.etnnr "i Ito I ) n, A ntAl.
WELL CONTRACTOR CERTIFICATION#: S-S'`i- cQ/7(n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential p-- 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: ' Pr&a2 e ji � .4/C- County: /Y7 a 6-0,; .
(Road Name a/od Numbers.Communi or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /(:-; 4'A -c M 6'c_it:a,c. From To Formation Description
Address .S gO"�, f9Q-`11. .1f0- ki n
(She or Route No.F./ P c ('e et �/ 3 4L 9 8'—
City or Town / State Zip Code •
4. DATE DRILLED -/3=0 /" 1 o
5. TOTAL DEPTH (50 " — CD
6. CUTTINGS COLLECTED YES 0 NO[ -
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD---- c- 3,�,
B. STATIC WATER LEVEL Below Top of Casing: 4 ids FT. = cam,
(Use'+'II Above Top of Casing) m O-C
9. TOP OF CASING IS / FT.Above Land Surface' >`.,
?op of casing terminated at/or below land surface requires a variance In aceor- -95 rn o
�. 1
dance with 15A NCAC 2C.e11 a
10. YIELD(gpm): `C METHOD QF TEST h/IJ7//i74 �l r m='
11. WATER ZONES (depth): rwi 4--
C1 0
z
12. CHLORINATION: Type /*t 14 Amount y4 /6 If additional space is needed use back of form
13. CASING:
Wail Thickness LOCATION SKETCH
Depth Diameter or Weight/R. Material (Show direction and distance from at least two State
From 0 To s T7 Ft. Cr' r/ft) P v P - Roads,or other map reference points)
From To Ft.
From To Ft.
-
14. GROUT:
Depth Material Method
r-N From C To Ft. 0 !'.-», 0."1 n
% I Pie n
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 HER- AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR ,.'�10 Trig,VD fjhlP1i COPY OF THIS RECORD HAS//BEE�EN PROVIDED TO THE WELL OWNER.
FOROFFIt�6'$EONLY (� JO/nm; hnDUnnnv l l "`� �'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Wad No: ) ?(elf' Sum I Nina!to Division of Water Duality.Groundwater Section within 30 days
Serial No.
GW-1 REV. 12159
Cr Jundtvate.Section
.. men II Office

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 233297
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: awn rt, g 14,1 ) A WO O 1)F. II ni--.4 ri, c
WELL CONTRACTOR CERTIFICATION#: . cQ/7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential la Municipal El Industrial El Agricultural El Monitoring El
Recovery El Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: c/-aof/r/,,J ,"C County: 7Y1 et Cm'`.._>
(Road Name and Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0)a r"L /Y)Lr 0 a /I u-r- -- From To Formation Description
Address p, o, Box � l :2_5
/J/ (Street o route No.) /
, au
City or Town rd State Zip Code •
4. DATE DRILLED G-/3 -'U/ L'
5. TOTAL DEPTH 30.5 G c
6. CUTTINGS COLLECTED YES 0 NOES
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOS 5 J
8. STATIC WATER LEVEL Below Top of Casing: 4'p FT.
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' c
r. -"_,\
-Top of casing terminated aVor below land surface requires■variance In eeeor- S o
dance with 1SA NCAC 2C.0118 '
10. YIELD(gpm): 3O METHOD OF TEST h/N0/1114 ell-- ry
11. WATER ZONES(depth): /75� /
Vl O
T
12. CHLORINATION: Type ft`t µ Amount 1/1///6 If additional space Is needed use back of form
13. CASING:
Wall ThicknessLOCATION SKETCH
Depth`(/ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
T From D To to Ft. to.. '/ /O P - Roads,or other map reference points)
From To Ft. •
From To Ft.
14. GROUT:
Depth Material Method
From D To riff Ft. P eth calf InA n
From To Ft. l
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,
ANRDTHpATMA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
f- rpFOR OFFICE USE QIY!� U 15 (1i't ;; / 41)/hr.,0 (' -"l3 ` v /
Quad No: 4 C.V TORE OF PERSON CONSTRUCTING THE WELL DATE
Submit prig) C ID Aston of Water Quality,Groundwater Section within 30 days
Sedai No. .,.� ... / Lfj`i? • GW-1 REV.12199
Groundwater Section
Asheville Regional Office._

6.
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 0 J 1. 1,1
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \-an nr g 1)ul) nM a (0<I) . t) -9.. �i1
WELL CONTRACTOR CERTIFICATION#: .y-5- cQ/7(„
STATE WELL CONSTRUCTION PERMIT#: •
1. WELL USE(Check Applicable Box): Residential L(X 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: jr"n k, U / e2 .) County: /Y n_ C-rrA
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L c2 1r IZ 12 57` From To Formation Description
Address C 7 in y P 1 a ( r L a-1, c
(StreerofRoute No.)
F11m( / 1 /(r' 02�`73 Y
—
City or Town Stale Zip Code .
4. DATE DRILLED ��! C ./ c
5. TOTAL DEPTH Cvn S o s
6. CUTTINGS COLLECTED YES❑ NODS ` cl -
7. DOES WELL REPLACE EXISTING WELL? YES o'
8, STATIC WATER LEVEL Below Top of Casing: 6 p FT. N _
(Use'+It Above Top of Cuing) U7
9. TOP OF CASING IS / FT.Above Land Surface*
—13
'Top of casing terminated at/or below land surface requires a variance In accor- 3
dance with 15A NCAC 2C.0118 /_vl
10. YIELD(gpm): S METHOD OF TEST iln/1 i71 A'1— N :
11. WATER ZONES(depth): —2 }? S C U
12. CHLORINATION: Type if 1-H Amount 1'/4/19 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth rn Diameter or Weight/Fl. Material (Show direction and distance from at least two State
From To —d.= Ft. (c.. - r/kV P/" P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To /-Q-N Ft. 0 car, a,r1 i O/oA rt)
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS ANn Hier a r�'r)))Jnnneov OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE t�ID �-. " M
t Q U LS n1J „ /ktnOP/1,.41 l 6 —/ S- o
Quad No: 9GNATURE OF PERSON CONSTRUCTING THE WELL DATE
I. _ I /t 6}(brnhi i s to Division of Water Quality,Groundwater Section Within 30 days
Serlai No. �I ✓ GW-1 REV. 12/99
wills water
r

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 3 3 1' 6 2
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �Nein n t g /w I ) a (OQ I) r. II ;kAti rit
WELL CONTRACTOR CERTIFICATION #: .53- cQl7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below) �
Nearest Town: lid 7)x /v I?!] A/e-- County: / iv 12 C(In
(Road Name and Numbers,Communi or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �f/_�t S�-= /c"6 / s/smolt, From To Formation Description
Address (o Q L /b c'a G2 [� Oct 1)-e 2
(Street or Route No.1 ABC , 173y City or or Town Slate Zip Code .
4. DATE DRILLED C -/4-n/
5. TOTAL DEPTH . O
6. CUTTINGS COLLECTED YES❑ NODS
7. DOES WELL REPLACE EXISTING WELL? YES NOES c _
8. STATIC WATER LEVEL Below Top of Casing: Sp FT. — C'
(Use':II Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface*
'Top of easing terminated at/or below land surface requires a variance In actor- N
dance with 15ANCAC 2C.0118 rn --.r-
10. YIELD(gpm): OA METHOD OF TEST h//fl/m i l(.—
11. WATER ZONES(depth): - '7 1- /A ) ' z:
am-.-.
12. CHLORINATION: Type H Amount r�4 If additional space Is needed use back ofdarm
13. CASING:
Wall Thickness LOCATION SKETCH
Depth . Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From C To --�n Ft. la•. r/kV P k P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _e_ To .1( Ft. n Gill .P.117- f)InA'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.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,_AND THAAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE LISP 9II ' I V 7mip /.Ihdo///LnQ Co -/ / 0/
Quad No: / 11JATURE OF PERSON CONSTRUCTING THE WELL DATE •
�yp�t o• c Division or Water Quality,Groundwater Section within 30 days
Serial No. 7 �(�J(l- GW-I REV.12/99
Groundwater Section
Ashe .)9 Regional Office .,_. •

•
North Carolina-Department of Environment and Natural Resources-Division of Water Quality.-Groundwater Section . 3 1 f)I
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: IN-ar1 n, g 1ho 11 tin, A (1)0 a r. i I a1� i1. (
WELL CONTRACTOR CERTIFICATION#: ,c- - cQ/`7(�
STATE WELL CONSTRUCTION PERMIT#:
_
1. WELL USE(Check Applicable Box): Residentiai Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List We:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: f Y a*t 1-"(,23 //e . County:fri a e ern -
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH;
3. OWNER 1:JQ. (Z p1-ec1 l_ r,A.0 to From To Formation Description
Address S Ii .e CJC3 /1) ; 1 1 -')- /2 c<
(Street or oute No.)
I-1Y0-41 IC !rd /f/C— -. '1 3 V —
City or Town State Zip Code _ '— -
4. DATE DRILLED C- -1 ' - o I
5. TOTAL DEPTH glY0
6. CUTTINGS COLLECTED YES❑ NODi
7. DOES WELL REPLACE EXISTING WELL? YES p NO[ — o
8. STATIC WATER LEVEL Below Top of Casing: ? / FT. o 0
(Use'+'If Above Top of Casing) r �?
9. TOP OF CASING IS / FT.Above Land Surface* 'c, c`:
'Top of casing terminated at/or below land surface requires a variance 1n accor-
dance with 16A NCAC 2C.0118 fl.-
10. YIELD(gpm): /1'2 METHOD OF TEST hflnrn 1— Cr, =_-ii
11. WATER ZONES(depth): 1 = r"
-mot=,
12. CHLORINATION: Type /f t H Amount IP4/r'3 If additional space Is needed use back of rm J
13. CASING: '-_ - _ --- -- - -- " --- �-" CO o
Wall Thickness LOCATION SKETCH z
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To it` �'Ft. Cc'. r tr& P t' P-- Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To (.11 Ft. P &m, o.✓T p tr?A n
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARR®DS ANnD THH�AT A CO Y OF THIS RECORDg HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U!"- 1, 1 ° U 1 rim* 4 /iaJ9e/T-un (-, .. I s - o I
Quad No: rim,
3NATURE OF PERSON CONSTRUCTING THE WELL DATE
AUG ygrNt ) o DivWon of Water Quality,Groundwater Section within 30 days
Serial No. - r!IU; J GW-1 REV. 12/99
Groundwater Section
Asheville RegiondOffia •

233621
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: J>en nt /k I .n, a _We u fir. u n>� r/1 c
WELL CONTRACTOR CERTIFICATION #: ,5- - cQ/7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential IZI- 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: l'I4 // /rtt-' /ft(' - County: -412 C-(:•
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (7G 1-vo/I �i-A7 0 e) I' '-.1From To Formation Description
Address --2/ p cm I'I t rt d G IlcJ
( treet or feria.
it -1' /11 _ � g7 '23 / . .
City or Town tate Zip Code •
4. DATE DRILLED 4-,S-t? l
5. TOTAL DEPTH •c-2-5
6. CUTTINGS COLLECTED YES 0 NOC-
7. DOES WELL REPLACE EXISTING WELL? YES E NOn
6. 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 15A NCAC 2C.0118 •
10. YIELD(gpm): /-5 METHOD OF TEST I7/N2//0t /-
11. WATER ZONES(depth): /nn' /lr./ ' /9,1' l
12. CHLORINATION: Type it+14 Amount r//4 (6 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth cj) Diameter or WeighVFt. Material (Show direction and distance from at least two State
From D To °L' Ft. (C• r/ _ Roads,or other map reference points)
From To Ft. s5 twc.I
From To Ft. v
14. GROUT: o
Depth Material Method L c'--
From _ To (� Ft. n Cn m�T r)/7+ r on
From To Ft. 1 0_.-
15. SCREEN: N c
Depth Diameter Slot Size Material 3 m�
From _To_Ft_ In. _in. to ro :
From To Ft. in. in. c
From To Ft. In. In. Co o
16. SAND/GRAVEL PACK: • z
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C,WELL
CON A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR O. Ali: : e " mma „ AnaQ A i
Quad No SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
1 a I,I I . t original to Division of Water Quality,Groundwater Section within 30 days
Serial No GW-1 REV. 12/99
( Croundwate•Section
AshevrienegionalQice.

c �
North Carolina•Department of Environment and Natural Resources-Division of Water Quality Groundwater Section ? 3 U�.
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c }eii ni fir I) IIm a MI) . v. II l P4 -1D1 ,
WELL CONTRACTOR CERTIFICATION #: .ci-S - cQ/"7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below) /�
Nearest Town: 'rdZot k/nc) /1/C //county: rQE�L.,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0 /2 / /n Ii/L-G%-A'- , From To Formation Description
Address .7/s,77 fly q )O�t,1s /'
��'i ,E'/ (Streett or Hout�.) i73
t2at ter,%
City or Town State Zip Code •
4. DATE DRILLED 6 -• 6 —v I
5. TOTAL DEPTH .-i/l/)
6. CUTTINGS COLLECTED YES Q NODS
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE
8. STATIC WATER LEVEL Below Top of Casing: y..12 FT.
(Use'+'II 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 15A NCAC 2C.0118 •
10. YIELD(gpm): .cziL METHOD OF TEST h/lrnil i-1 rr—
11. WATER ZONES(depth): 1 Q 0 ) 27) r /
12. CHLORINATION: Type If f N Amount VI/I/6 If additional space Is needed use back of form
13. CASING:
Walt ThicknessLOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To �')(-- Ft. it' ' '/141 P k P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
From C To r-li" Ft. 0 P.n, 0,,1 i [P7e rt-, a
0
From To Ft. c_ —
15. SCREEN: r c(-
Depth Diameter Slot Size Material -
1 a.=
From To_ Ft in. In. ,, =r'
'mac
From To Ft. In. In. -a rR—
S —c'
From _To_Ft. In. In. r`
w en_-
16. SAND/GRAVEL PACK: -. rn
Depth Size Material c j o
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 _t s a:e _. a 1_ • A C/OnPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FORD ��e P v.TilRjlV ri dam MA RI0000nr,� ( -' 6 "i5 j
Quad Na `/ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
't■' 't original to Division of Water Quality,Groundwater Section within 30 days
II
Serial No "1 - 4 j I GW1 REV, 12/99
8roundwatet Section
;sheville Regional Office__

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 33
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL C0NTRACT0R: J -ell n t 9 /tv'I) A,,, ,A WO II . 1`. I I ntj '151
WELL CONTRACTOR CERTIFICATION#: 5 S-9i- EQ/7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential l!X Municipal 0 Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
f/ > //�tCi County: An 4 (2*7-L
Nearest Town: Z
(Road Name and Numbers,Com/mnunity,or Subdivision and Lot Na.) DRILLING LOG DEPTH
3. OWNER LE V l l� a 'pc ,7'-i flj From To Formation Description
Address 1 1 0 P. 0 ki cA P_c!_
(Street or oute ) C '7L�
City or Town State Zip Code
4. DATE DRILLED C''- 7-0 /
5. TOTAL DEPTH ..j.>_
6. CUTTINGS COLLECTED YES Q NOC-
7. DOES WELL REPLACE EXISTING WELL? YES D NOQ---
8. STATIC WATER LEVEL Below Top of Casing: 5rl FT.
(Use"a"II 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 15A NCAC 2C.011 a
10. YIELD(gpm): :30 METHOD OF TEST h/N)/l FYI ��
11. WATER ZONES (depth): :5'0S"
12. CHLORINATION: Type h`1`/ Amount r'/4 /6 If additional space Ls needed use back of form
13. CASING: -
Wall Thickness
SKETCH
Depth // Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To (-'"Cj Ft. !a.. r/PP P k P - Roads,or other map reference points)
From To Ft. co
From To Ft. o 0
14. GROUT:
Depth Material Method C 152.
I— CT_•
From 0 To A-(\ Ft. (I can >.n i p/rm it I Erc
From To Ft. IV C"
c
15. SCREEN: v
Depth Diameter Slot Size Material N^:
From ______To—Ft_ in. in. • N ii
From _To Ft. In. In. co 5
From To FL 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
CONSTRUCTIO COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OF aim; d /Lao/) ,,t1 L 6 — 7 7,0
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
L
^1 2 rYYI' original to Division of Water Quality,Groundwater Section within 30 days
Serial No. LW GIN-1 REV. 12/99
i
6roandwate Section
,hov,ife Regional O cg__.}

233624
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: \ e1n n i g l i I) nM a We 1) lv. II ;1, ,� l/1 (
WELL CONTRACTOR CERTIFICATION #: 54' cQ/`7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below) //��
Nearest Town: a-17t 1ilL' A''C- County: / ? ('lt
(Road Name and Numbers,Community` orr Subdivision and Lot No.) DRILLING LOG DEPTH
C
3. OWNER )1 'e re ✓/ i-all'>r-eA 5 From To Formation Description
r
Address D , Gx CE 7 7
(Street or Route No.)
/KG2n k /rhJ A.'?'— k 7 V z
City or Town ff State Zip Cod
4. DATE DRILLED L? -,9 /` O /
5. TOTAL DEPTH 3n-5.:
6. CUTTINGS COLLECTED YES❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES DNOn
6. STATIC WATER LEVEL Below Top of Casing: /t) FT.
(Use'+'if Above Top of Casing)
9. TOP OF CASING IS__L__ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor- .
dance with 15A NCAC 2C.0118 /-
10. YIELD(gpm): .-,7O METHOD OF TEST him/Jim Y 4--
11. WATER ZONES(depth): /7 5--- 3 if e /
12. CHLORINATION: Type it t N Amount +'/t I If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To V- •- Ft. ff.' r/kV PIP - Roads,or other map reference points)
From To Ft. o
From To Ft. o `o
14. GROUT: c_. :3
Depth Material Method moo
I - c
From To -lN Ft. '-' P7e rt o__,From To Ft. pa _r;
D- c:
15. SCREEN: 3 ter,
Depth Diameter Slot Size Material in 7.:
From To Ft In. In. w rr `
From To Ft. In. _ In. •N -1
CJ o
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
�jSTANDARDS,AND THATA COPY OF THIS RECORD�g HAS BEENBE PROVIDED TO THE WELL OWNER.
FOR OFFI:(9uS�eltvl 3 U l5 I/mm.t : ,L,„....E ( • " /- D 1
Quad No: 4 I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1AUGr] ry��srII viral to Division of Water Quality,Groundwater Section within 30 days
Serial No. _L 1 AUG l 2 CUO$ GW1 REV.12/99
t cwoundwater Section
;s , e Regional OffircP

233625
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: .evi n r i I)�l I I rim A (UP iJ j)v. i 1 Dt-ei Zn c
WELL CONTRACTOR CERTIFICATION#: 5-, i3- : /76-
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential I/X 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: ti`ail P/ r2J /d''C- County: m a C-D1(
(Road Name and Numbers,Community,, r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (r S /- A -e✓ .43 ,ICI"' -0 From To Formation Description
Address �) r 3 _ __ _ _
(Street or AcildeNo.)SO' , d -tcg5
F'liiI1, R rc7r�L)
City or Town State Zip Code
4. DATE DRILLED C 4 c -n /
5. TOTAL DEPTH ,-ThC?
6. CUTTINGS COLLECTED YES 0 NOEl --- .
7. DOES WELL REPLACE EXISTING WELL? YES E NO[1--
8. STATIC WATER LEVEL Below Top of Casing: S25 FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS r FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.011a
10. YIELD(gpm): <'0 METHOD OF TEST 1)1/9/Jill 6(—
11. WATER ZONES(depth): 90 / 7 S cQ An/(
12. CHLORINATION: Type h`t H Amount r/ 4 i P3 It additional space is needed use back of form
13. CASING: - - "
Wall Thickness LOCATION SKETCH
Depth Diameter or WeIghVFt. Material (Show direction and distance from at least two State
From D To " -a Ft. (C. '/ P b P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o
Depth Material Method O r3
From 0 To .2l Ft. (f err, o,nT p/n r n c._ C
r From To Ft. I--
15. SCREEN: IV
Depth Diameter Slot Size Material Hi
From To Ft_ In. __in. — c
From To Ft. in. In. W cnrr
From To_Ft. In. In. N _c-,
16. SAND/GRAVEL PACK: t o
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 RECORDI HAS BEEN PROVIDED TO THE WELL OWNER.
atFOR OFFICE USE ONLY atMA p /,hn(/C/nnrt G -- tQ—o I
. Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
Submit cqlginal to Division of Water Quality,Groundwater Section Within 30 days
Serial No. III .0 2 2 200i I l GW1 REV.12199
Groaindwater Section
.:_._u_.. .:_ '.. Office j

North Carolina-Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section `3 4 G v O
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: dill n t 9 / I ) .,,„ A (OP II 1)r. l I ;)-(m
WELL CONTRACTOR CERTIFICATION#: S S,•gil- 02/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L(X Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: if74, koi /VC_ County: /na-C �
(Road Name and Numbers, mnwnity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Tv-i ti- JJ et&girl . From To Formation Description
Address 80 q� I,IG �-Qin L-n ) •
,Street or Rout No•J
a( fr5o, h) ,Ie- ,�, 3a 51
City or Town State • Zip Code •
4. DATE DRILLED 4 -. 9-c /
5. TOTAL DEPTH c 1 S
6. CUTTINGS COLLECTED YES NO❑�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�-
8. STATIC WATER LEVEL Below Top of Casing: fO FT.
(Use Above Top of Casing)
9. TOP OF CASING IS / , FT.Above Land Surface'
Top of easing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): 4f0 METHOD OF TEST b/N7/JiiYf (-•
11. WATER ZONES(depth): /9S '
12. CHLORINATION: Type r4 y I Amount '/4 //53 If additional space Ls needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To ' Ft. (c" r/kir' P v P- Roads,or other map reference points)
From To Ft.
From To Ft. o
14: GROUT: � o
Depth Material Method L 0-'—
From D To .2I Ft. (r Pm, t,47 O m,r r> ,
From To Ft. I — mow:
15. SCREEN: °r
Depth Diameter Slot Size Material m
From _To Ft In. _ In. N
From _To—Ft._ In. _ In. n
From _To_Ft._ In. _ In. co 0
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
CONSTRUC110N 8TANDARDS AN,Q THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7;1? n I
FOR OFFICE U• rat" �-.._y_ `A . ,14,2 A /.hnat 19
I
Wad Na. 'n o SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
a a� 3 I mtiubmit p$9Inal to Division of Water Quality,Groundwater Section within 30 days
Serial No. W (UU( L. GWI REV.12/99
Groundwater Section •
Asheville R__� eaggg�Orytce •

2 31. 25 4 •
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: t-en nt'i /hri) el a (0eil >�� -TA C-
WELL CONTRACTOR CERTIFICATION#: . S-f- 0Q/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): ResidentialMunicipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: ,///a %t<( County: /-10-_r.rn
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (--)/1.; re:J �-7-r From To Formation Description
Address %%iy_ ,� ) r ,•
( treat or 2j
oulle
%-r) /,tee; ,4 '7 & 3
City or Town State Zip Code •
4. DATE DRILLED �`l- ti-'O /
5. TOTAL DEPTH '70
6. CUTTINGS COLLECTED YES Q NOD-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD— e
8. STATIC WATER LEVEL Below Top of Casing: 3,24 1 FT. -- T
(Use'+-0 Above Top of Cuing) _ s-'•.:
9. TOP OF CASING IS / FT.Above Land Surface' 9p. �;
'Top of casing terminated at/or below land surface requires a variance In acorn- o_-
dance with 1SA NCAC 2C.0118 a' t"'
10. YIELD(gpm): METHOD OF TEST H/0/1i79 F� �o
11. WATER ZONES(depth): •ur2' / N5:
12. CHLORINATION: Type /t t N f 4/ _
Amount � If additional space B needed use back of lorreu ='
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Li Diameter or Weight/Pt. Material (Show direction and distance from at least two State
From 0 To Ft. iC•• ,/P2 P( P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To r1N Ft. n eirr, o-1-17-
Prom . To FL15. 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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST:• e• -e • . T _:, IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE D � "� 5
Quad No: S a RE OF PERSON CONSTRUCTING THE WELL DATE
I JUN -Stbl4Jginal • - q on of Water Quality,Groundwater Section within 30 days
Serial No. GM REV.12/99
Groundwater Section
Asheville Regional Office

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 3 0 6 9 3
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: than n, g nil l) rm eS C!)Q I) 1r. lI k,�, X,z c
WELL CONTRACTOR CERTIFICATION#: 5-e 40- c2 7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L(X Municipal 0 Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: U / l-)- L 4-Al'2 ,V( County: l 4 (-in,
(Road Name and Numbers.Co nity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 2..`• T) r< c_ 'L e l--C_ From To Formation Description
Address 02 (l 0 G rI n P r2 S re-1
f
(Street or Rou a No.) el
CI-en ILrhttL- A- C. C-
City or Town Stale Zip Code •
4. DATE DRILLED - / - C' /
5. TOTAL DEPTH (-3 h
6. CUTTINGS COLLECTED YES❑ NOE:1---
7. DOES WELL REPLACE EXISTING WELL? YES E NOD--
8. STATIC WATER LEVEL Below Top of Casing: ,ay-a FT.
(Use'•'If Above Top of Casing)
9. TOP OF CASING IS J FT.Above Land Surface'
'Top of casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0 1a
10. YIELD(gpm): METHOD OF TEST hw7/l Of BI-
11. WATER ZONES(depth): ,5 CO 4 3 co /
12. CHLORINATION: Type /f*/4 Amount 7/4 (ri If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To Ft.._if•, '&2 P d' P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o
Depth Material Method 2 cS
From To (Q-(" Ft. n em+ o.yr7 D nle it 2 0
,A c From To Ft. t mm
15. SCREEN: v• c
Depth Diameter Slot Size Material .c
From To_Ft_ in. _ in. = H m
From To_Ft._ in. _ In. w m
From To_Ft. In. _ In. c'
16. SAND/GRAVEL PACK: UI 5
x
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 STANQARDS;--ANP Trf-COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USENQIITL Mm. p idlad OAAQ S-'I - D I
Quad No: ._. !f I - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
ti no origk(al to Division of Water Quality,Groundwater Section within 30 days
Serial No. �"` GWI REV.12/99
Groundwater Sado 1
Asheville Regional Qthes 1 •

23
North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 0691
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c ti n, 'S hr./ nn, a (!)e a r. ti rk-si T)- G c
WELL CONTRACTOR CERTIFICATION#: .5•-S - cQ/7/,
STATE WELL CONSTRUCTION PERMiTR:
1. WELL USE(Check Applicable Box): Residential El--- Municipal El Industrial❑ Agricultural El Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: 1.4 l 6 /J t .4-4- p S. /L C- County: TY1 e` C-0'N.—)
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER `) t HL,,-, r-)a_n (c,{t i From To Formation Description
Address ye, ?Cc,',fr., J2•es+a tc .,:i
(Street or Route No.
Her,i ii /e2,-+s ,1Jc C7y / --
Cityocjown Stale Zip Code •
4. DATE DRILLED •5-3--0 I
5. TOTAL DEPTH n S
6. CUTTINGS COLLECTED YES O NOES
7. DOES WELL REPLACE EXISTING WELL? YES El NOD
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use'+'if 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 In accor-
dance with 15A NCAC;0.0118
10. YIELD(gpm): METHOD OF TEST h/N7/L-n fit-
0
11. WATER ZONES(depth): 3-0 ��! al) l
12. CHLORINATION: Type /t 1-H Amount +�1//6 If additional space is needed use back of form
13. CASING:
Wei Thickness LOCATION SKETCH
Depth ../ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To ✓"' Ft. (C-- r/kQ P lc P - Roads,or other map reference points)
From To Ft.
From To Ft. o
14. GROUT: 2 o
Depth Material Method a ��
From C To Ft. n ell', a 7 n/oe c1 -e a cm
/From To FLm I o
15. SCREEN: ""4 �c
Depth Diameter Slot Size Material = cc,.
From To_Ft_ In. in. W cn.r.
From _To Ft._ In. _ In. c
From To_Ft._ In. _ In. t!i o
z
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY Cis. UP I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIOiF%' 7AFbS 'NI�TFdid,TA COPY 0F THIS RECORD HAS BEEN PROVIDED T0 THE WELL OWNER.
FOR OFFICE U•'��c�1�, v pMM; /LnOQ/In1.) S ` �� ` o
Quad No: Illtil )�• 'nil SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1LLL.l1 Submit original to Division of Water Quality,Groundwater Section Within 30 days
Sedai No. MI
...- GW-1 REV. 12/99
ndwater Section
.,, nine Re Tonal Office

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 231457
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: I11-ar,n t -i iw i) An, A (0e I f rr. ii ;), -4 ri t
�WELL CONTRACTOR CERTIFICATION#: . i 7 02/ 6,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: �V 441 it' I,v) /✓( - County: /Y) a c r�_ J
(Road Name and plumbers,Community.or Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER / n a c4 ;erne_L if 7 From To Formation Description
Address ,3 co/)
�J a, / ' rt
tree or Routs o.
C City Town i.1J �{/1' .-Q kq3 Li
City or Town State Zip Code — . —'
4. DATE DRILLED S—C/—O
5. TOTAL DEPTH b C
6. CUTTINGS COLLECTED YES❑ NO❑,--
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE1-
8. STATIC WATER LEVEL Below Top of Casing: 61 e, FT.
(Use'+'if Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface'
-Top of casing terminated odor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): oZ A METHOD OF TEST b/Miirii 1--
11. WATER ZONES(depth): /
12. CHLORINATION: Type if t 14 Amount i�4 /6 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To H 7 Ft. it'. r/f�V fir79 : Roads,or other map reference points)
From To Ft. c—e i
From To Ft.
14. GROUT:
Depth Material Method O o
From C To :-IN Ft. 0 els, 0.-07- Hintrl-, 3 c,�
From To Ft. .-c cot
15. SCREEN: 1V o;=
Depth Diameter Slot Size Material --
Dc
From _To_Ft_ In. _in. rn
From _To_Ft. In. In. N `fi-
From To Ft. In. _ in. y
16. SAND/GRAVEL PACK: co 0
Depth Size Material x
From To Ft.
From To Ft.
17. REMARKS: �••
I DO H CONSTRUCT,1�4TsBAi is IRfyr NSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE NL1JN - 6 2001 Mrn",s /J DIJ4., l S— C/ — D J
• Quad No: IGNATURE OF PERSON CONSTRUCTING THE WELL DATE •
Su odgi to Division of Water Quality,Groundwater Section within 30 days
SrNo M1MPu_w.r o
GW-1 REV.12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section - `" 1 4 5 8
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t1an n, ' )1 e:M A (O e 1) 1)t'. II � rh
WELL CONTRACTOR CERTIFICATION It: .9 &'S. ,Q/7/0
STATE WELL CONSTRUCTION PERMITS,:
1. WELL USE(Check Applicable Box): Residential Municipal 0 Industrial 0 Agricultural 0 Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATIOVShow sketch of the location below) M
Nearest Town: /- g4-t-/4/ /4'�� //-/F County: ,/,/( ier
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER CU +{ 7 /0, ) / / qp-f-t S From To Formation Description
Address a ,Q_ jore,rt ec (i e 1Z ' tt14<
Stree or R u o.)
City or Town Stale Zip Coda . -- •
4. DATE DRILLED r ' 9
5. TOTAL DEPTH (,-%O- S
6. CUTTINGS COLLECTED YES NOIII----
7. DOES WELL REPLACE EXISTING WELL? YES n NOD
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 at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.g�8
10. YIELD(gpm): METHOD OF TEST h/P1//i7 �—
11. WATER ZONES(depth):
12. CHLORINATION: Type k t/4 Amount Vie/6 If additional space Is needed use back of lorm
13. CASING:
Wall ss LOCATION SKETCH
Depth 4� Diameter or WeIghVFt. Material (Show direction and distance from at least two State
From D To 47 Ft. te'. ''a' n t P , Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: 0
O
Depth Material Method `p
From D To �N Ft. (I Bn) 070T [P-74 it" b oT
From To Ft. c crn
15. SCREEN: =
-
Depth Diameter Slot Size Material 9c
v —\
From To Ft_ In. _in. s rn
rn
From To_Ft.— in. In. r'. "'rn
From _To Ft._ In. _ In. U I 0
16. SAND/GRAVEL PACK: CO B
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
CONSTRUC` PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
iii
FOR OFFIC 81,1Lifmm r p ILO(/b/1nr 0
• Quad No: 1, J 6 r7n SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
(- ..UN LUOI Sub- a/nal to Division of Water Quality,Groundwater Section within 30 days
✓-Serial No. GW-1 REV. 12199
i I r urdwater Section
erPe ;',;;chat Office 4 •

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 231459
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: xh-en n, 9 I c l) nr, A LOP I) v. II ;kfi� Tit
.y-
WELL CONTRACTOR CERTIFICATION#: �..4L /767
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El" Municipal❑ Industrial❑ Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection D Other ❑ If Other, List Use:
2. WELL LOCATION5r(Show sketch of the location below)
Nearest Town: 0 4- f.1/ /',l> 4 -#(.'- County: .'/ )re (i- t 7
(Road Name an Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L. 6 ✓] t' `L- /U r 7/l dog. A From To Formation Description
Address /(J,-90 ca Or', -'ic- (c'i
(b.reet or Rout No.)
7/747///,2, iL e2F%3 Li
City or Town State Zip C
4. DATE DRILLED . 5 1 V- 0 /
5. TOTAL DEPTH •7 rt c
6. CUTTINGS COLLECTED YES Q NO0----
7. DOES WELL REPLACE EXISTING WELL? YES D NOEI-
8. STATIC WATER LEVEL Below Top of Casing: I-42Lt FT.
(Use'+II 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 15A NCAC 2C.011a
10. YIELD(gpm): c2/' METHOD OF TEST hi1n/Jrn ref-- •
11. WATER ZONES (depth): /YP ' /
12. CHLORINATION: Type ff t/4 Amount VC' /#9 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth _ / Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To •S a% Ft. re' . r/Crli P/ P - Roads,or other map reference points)
From To Ft.
0
From To Ft. o
14. GROUT: '-
Depth Material Method a
or,
From C To l\ Ft. n e 7T pi,14 n _
From To Ft. N a_r
15. SCREEN: -17 me
Depth Diameter Slot Size Material S zro,
CJC
From _To_Ft _ in. in. r n
cl
From _To Ft. in. In. c.rI -'
co
From _To Ft. In. in. z
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
•
From To Ft.
17. REMARKS:
I DO HERE-Y CEPT[FY TNetS/Jto uect l‘Atv ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU ft SttS,fTfT PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE Vi ONLYu �+l
1l '^'. � Q� /Jn' � �-/y -o /
• Quad No: `II UN
6 2001 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
UIN Su g al to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 23 1 4 60
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II 1 `t
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 111-an nr g }L"f) n.,A C1Lf'�U w /l n li
WELL CONTRACTOR CERTIFICATION#: . - Q/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Boa): Residential Il�� Municipal ❑ Industrial El Agricultural El Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) v
Nearest Town: JC7/ i L11 L-h-� A -'-- County: i✓ is C-t-,l
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER roll ,-,,,_ /t`r 7/ 1 c2-tn. .-; From To Formation Description
Address (-,` 7) JL)C-,A 04-reef? (t)C4
(Stree or-oute/No.)
KJCt-71vin, t 4I /( . .1) ,c?4'1-ie
City or Town State Zip Cods
4. DATE DRILLED ,5 L S-0 /
5. TOTAL DEPTH 3 r2.`3-
6. CUTTINGS COLLECTED YES 0 NO[-
7. DOES WELL REPLACE EXISTING WELL? YES n NOn
8. STATIC WATER LEVEL Below Top of Casing: -Jlri FT.
(Use-+'II 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 16A NCAC 2C.0118
10. YIELD(gpm): .5-0 METHOD OF TEST h/ln/I n'i r( •
-
11. WATER ZONES (depth): --47t r '-Q 5 1 6
12. CHLORINATION: Type /f f H Amount 1/(1 /' If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ,-) Diameter or Welght/Ft. Material (Show direction and distance from at least two State
From 0 To Cn Ft. (e. . r tr& P t' (2 - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: 0
Depth Material Method o C
From CI To Ft. 0 e/Yri 441t /ne A ya, o ;
From To Ft. --4 =r"
N c-
15. SCREEN: — j"
Depth Diameter Slot Size Material v m
From _To_Ft In. _in. s a m
•
From To Ft. in. In. f 3
From _To Ft. In. _ In. is
16. SAND/GRAVEL PACK: CO 0z
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C,WELL
C0NSTRUCIT3f4,S Llphlttjl,r ri Y OF THIS REIC�ORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE� NLYLui� 3 , (ai1 m.r o /^-7n0Gnn4� < /S - 0 /
• Quad No: II rt1 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
.III` II 6 2O__ubrr�aral to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV.12/99
Groundwater Woe
Asheville Regional Office

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 231462
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: x11-en n r g /L!) elm A WO I I i V. /17 i 4 T 1
WELL CONTRACTOR CERTIFICATION#: 54'5- < /7/,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 12:1-- Municipal❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: k 0(2-71 it 1 r n✓ it/ C- County: /114 Cs,
(Road N and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER i v )-&. ) e )-C 1' P S 7- From To Formation Description
Address r(�1 es c 7-- ry -
(Street or Route}lo.)
1507m k.l, n) A/C.- ,C2 rc i73
City or Town Stale Zip Code .
4. DATE DRILLED t)! 7-0 /
5. TOTAL DEPTH ,?G
6. CUTTINGS COLLECTED YES❑ NOILI----
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-
B. STATIC WATER LEVEL Below Top of Casing: 7 j 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 15A NCAC 2C.0115
10. YIELD(gpm): • c) METHOD OF TEST HP /1 i71 fr-
11. WATER ZONES(depth):_/3C• , •-2 20 1
12. CHLORINATION: Type if 1-14 Amount Vie i 6 If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To 1,2 3 Ft. IN' r/kf) P t P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: CT)
p s
Depth Material Method — a7
From D To ..2N Ft. 11 enn, Oi,'f [)MI rt ' MC -•
o •
From To FL =m
15. SCREEN: N o
--• �m
Depth Diameter Slot Size Material o m
-
From To Ft _ In. _ in. zm
From To—Ft. In. — In. tv Mi z
From To Ft._ In. _ In. 2
16. SAND/GRAVEL PACK: 03 z
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
CONSTRUCTI a OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r��r. ;.. It .• s_ o
FOR OFFICE U �" " ��/
' NATURE OF PERSON CONSTRUCTING THE WELL DATE
Ouad No: pp''{i @s19ralIi��
K11 - 6 ?Sail•I, a Division of Water Oualiry,Groundwater Section within 30 days
Serial No. G W 1 REV. 12/99
Groundwater Seetlon
Asheville Regional Mfig_�

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section G 3 1 4 6 1
1636 Mail Service Center-Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: XNI1 n t `i 161) AM A (Oo I I jr. /I ;1, >� Tit
WELL CONTRACTOR CERTIFICATION#: .S*-rS�- Q/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial 0 Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION) (Show sketch of the location below) M i
Nearest Town: f e-61'/ L'/1'-> c"(o ;/ r County: G «'n
(Road Name and Numbers,Community,or Subdivision/ and Lot No.) DRILLING LOG DEPTH
3. OWNER 0 h a L1,".. /)O A S l♦ a/2-c J From To Formation Description
Address
3 0 Co. a, (I-)< < is LO
(Street or Route No.)
��e��w co ay i= ) 3 37
City or Town State Zip Codo -
4. DATE DRILLED •5—.// -(` /
5. TOTAL DEPTH c7S`
6. CUTTINGS COLLECTED YES❑ NOE:P--
7. DOES WELL REPLACE EXISTING WELL? YES E3NOD—
B. STATIC WATER LEVEL Below Top of Casing: ,Cr FT.
(Use'r'1f 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 15A NCAC 2C.0118 �(�.
10. YIELD(gpm): •2 5 METHOD OF TEST h/l0/Th !1
11. WATER ZONES(depth): 5'/7' / �•O n
12. CHLORINATION: Type it It H Amount '/Q I It additional space Ls needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To iS i Ft. te'' '/' P it P - Roads,or other map reference points)
0
From To Ft. p 6
From To Ft.
14. GROUT: qc
Depth Material Method �`na LA='
From 0 To L(t" Ft. 0 eri 0-417 fl hie Al_, — --,
From To Ft. -o rn�
15. SCREEN: s ��'
viz
N
Depth Diameter Slot Size Material t7
From _To Ft in. in. CJ1 -.
oa o
From To Ft. in. In- z
From To_Ft. In. — In-
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
FromTo Ft-
17. REMARKS:
I DO HEREBY . - ' STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTI erirs
I,' ',1C 1s • I 's OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U- LY — 6 �ni fIL'/I, m2 o nthia-Q c5— . - C
Quad No: %I 2 , 'TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit o - Division or Water Quality,Groundwater Section within 30 days
GW-1 REV.12/99
Serial Na. _

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 231463
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c f1 n r 'e /M I) c4, A (Oo II i)v. /1 n, el, '1-5
WELL CONTRACTOR CERTIFICATION#: . $'4- Q/`74,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential lik<Atinicipal ❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: P✓/Pm i' I,kJ 2 t- County: ,/)/h? /-re J
(Road Name and�Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /''.1/ Pa rr7 c k - From To Formation Description
Address �� 7 C7 � � ce (?; �r �
(Streetr(
orktute o.
ti12)1li/, /i a k73
City or Town State Zip Coda
4. DATE DRILLED S—1 7-0 /
5. TOTAL DEPTH 02Sn' o
6. CUTTINGS COLLECTED YES❑ NO❑— e o
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD-- — c.
8. STATIC WATER LEVEL Below Top of Casing: ss r FT. 3 �,?
(Use'+'it Above Top of Casing) S m
9. TOP OF CASING IS I FT.Above Land Surface' Iv o<
— ter^
'Top of casing terminated at/or below land surface requires a variance In accor- y C
dance with 15A NCAC 2C.0119 "C —1--
10. YIELD(gpm): r METHOD OF TEST h/in/1i71 F� - n am
11. WATER ZONES (depth): RI' ' 95' N R?
c.tt
12. CHLORINATION: Type /t t H Amount '/4 /9 If additional space is needed use back arm
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 7�' Ft. (c'' r/f& P k t - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,2(t' Ft. 0 Pm, 0,1T pm"(it
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS 1^ t `' lemai A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR O ' I a I - Iran;p /17006/2,4et
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
IUN — 6 '001 ' t original to Division of Water Quality,Groundwater Section Within 30 days
Serial No. GW-I REV.12/99
Asheville le ResionISSIL

231253
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: •I\e1 n, `i hr I ) .:-., ci (()21) J>r if n.,, -2—)
WELL CONTRACTOR CERTIFICATION #: .SR•i•-- 07/ 7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l!X Municipal ❑ Industrial D Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: tit��t7 Y Ir Ni 2it1, County: I7/y�
Ga r,./Y'(
•
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER IQ /,,7 e n"7G I (IC_'� From To Formation Description
Address /P..) the,,,, , O yy 0 cc:-rG✓
( treet or Route No}
P110/-(Y// 1: ) ).C2 3 6/
City or Town late Zip Code
4. DATE DRILLED S- 7- O / o
O o
5. TOTAL DEPTH .3 CLS — ��
6. CUTTINGS COLLECTED YES❑ NO�/ m
AD c
7. DOES WELL REPLACE EXISTING WELL? YES n NOE— —c c_m
8. STATIC WATER LEVEL Below Top of Casing: ,/j FT. -- s�
(Use'r'it Above Top of Casing) Do
9. TOP OF CASING IS / FT. Above Land Surface' S rna
Top of casing terminated at/or below land surface requires a variance In scoot- •-'sr
coZ
dance with 15A NCAC 2C 0118 fV 4-,,--?10. YIELD (gpm): to 0 p METHODH OF TEST MOO,t: rtl— NA —I
11. WATER ZONES(depth): 0 o
z
12. CHLORINATION: Type It t 14 Amount /4 I If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To 2 -Ft. Cr' . (/kv Pi ? . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From (--) To .-)-ih Ft. 0 (Th], n--,a, ),?t 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.
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
CONSTRUCTIC . a I 1 JF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
crm
FOR OFFICE U�`:� S rim; - /hOl2 +/hr,0 7
Quad No: n £NATURE OF PERSON CONSTRUCTING THE WELL DATE
JI` JUN — 126O nt o jai o Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
•
Groundwater Section
Asheville Re¢ional Offer

0 °1771
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: •1 1 n, 5 /tr I) a I 12 a i)1 1 t ;,, r/` r.
WELL CONTRACTOR CERTIFICATION #: . -4-?- . /7/,, c
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El-- 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: Fa 44, V in, 2/'11-- County: n')a Cent ,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
(
3. OWNER r 4.ci 7e h/yr?j2 ,S From To Formation Description
Address 3
I�„treat orRoute o.)
Vein r � / /. 3(4 O r i
City or Town State Zip Code
4. DATE DRILLED S-.:Di 0 /
5. TOTAL DEPTH :2Sc
6. CUTTINGS COLLECTED YES EL NO❑-
7. DOES WELL REPLACE EXISTING WELL? YES El NOn
8. STATIC WATER LEVEL Below Top of Casing: "wry FT.
(Use'.it 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 15A NCAC 2C.0118
10. YIELD(gpm): nzn METHOD OF TEST /O//J1/1/Tr ri
11. WATER ZONES (depth): r�4 S r I'
12. CHLORINATION: Type I t H Amount 'VC' //3 If additional space Ls needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �j}'� Diameter or Weighl/Ft. Material (Show direction and distance from at least two State
From CI To 9 Ft. <<. . //kV h 1 P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method [ C E I V E "'iso
i
o 0
From �� To .0 l\ Ft. 0ron r o-1T
From To Ft. il 3 n__
15. SCREEN: illi . JUN I 3 rr,i ,,,a < ern
Depth Diameter Slot Size Material ca oe=
From To Ft in. _ in. _ c
Groundwater Section
From To Ft. in. _ in. Asheville Regional Office m c
c
From To Ft. In. in. 3 cocn
16. SAND/GRAVEL PACK: La -Pi
m^
Depth Size Material N 5
From To Ft. z
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 X smart r /La✓(' 7A,-0 S-- o2) -0 I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section `) ' 4
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'N-ci ni i / t' /J ?;-,, A (/)a 1) i)tv I l f, 1� -)1
WELL CONTRACTOR CERTIFICATION #: S�•b-s-i1- --:/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential D 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: r(? an /2 l nc/ //✓ County: .n Ot efn--J
(Road Name and Numbers,Community,or Subdivision and Lol No.) DRILLING LOG DEPTH n
3. OWNER ( . ./!'TG r. n A i /YOn1 !.'S From To Formation Description
Address `7 4/(/S h ,„, 12
(street or -ota o. e'er 1 Q /�j
1 V am I r'L v'c—u , t-Q -
City or Town State Zip Cobe •
4. DATE DRILLED S- Lf-D I
5. TOTAL DEPTH .fib `i
6. CUTTINGS COLLECTED YES n NO f-
7. DOES WELL REPLACE EXISTING WELL? YES 7 NOE___
8. STATIC WATER LEVEL Below Top of Casing: ,3 _FT.
(Use'.'it 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.0116
10. YIELD (gpm): 9-7i) METHOD OF TEST NM/1,71 FI-
11. WATER ZONES (depth): 9i) . On ' 0
12. CHLORINATION: Type /t t I-! Amount /c' I(5 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth / Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L, To (c --Ft. fr. . r/frF, P I r° . Roads,or other map reference points)
From To Ft. o
From To Ft. O
O
14. GROUT: 111 I 3 c),.
Depth Material Method
From (2 To .,Lid Ft. (I r:-n, 0-,-1i [)'.); 1 ; c.J o
,ii1/4
From To Ft. - 0 ( `nc
15. SCREEN: -o -
Depth Diameter Slot Size Material SSD° 3 mF,
From To_ Ft in. _ in. - •• r"^'
From _To Ft. In. In. tV o
From To_Ft._ in. in. z
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�\ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Y� st4/=it.; iht7d01nrt S-'—a, uL'--D /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12199

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 ry
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] 3 1 i 7 v
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'N'n 11, e1 I L ) r.,,, A (L)e 1) i r /l r),421
; T"
WELL CONTRACTOR CERTIFICATION#: .--3-41- . /.7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATIONhow sketch of the location below)
Nearest Town: flrara, i /,vi} /L/ram County: M Or G(ti.
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Pn„ i{' c'ii�F/]17.O Ih-ci From - To Formation Description
Address /
(Street or Route No.)
rr49/ (_ _ sir , __ cQ 173 '-
City or Town State Zip Code •
4. DATE DRILLED S- a I
-n
5. TOTAL DEPTH an S
6. CUTTINGS COLLECTED YES n NODS
7. DOES WELL REPLACE EXISTING WELL? YES D NOIC1-
8. STATIC WATER LEVEL Below Top of Casing: c, FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD(gpm): Sh METHOD OF TEST /Oh)/1,77 �1--
11. WATER ZONES (depth): /
12. CHLORINATION: Type /t t 1-4 Amount `'4 I ts5 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth c� Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0To .3 / Ft. t7 . '/ ) Pi r . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method Imo
From P To .L Ft. 0 r7Tr, a.,,i fl:oe 1_,
From To Ft. / O o
a
15. SCREEN: UN f o
LL mil
Depth Diameter Slot Size Material . - � MC P?
From To_ Ft _ in. in. c n
ca
Greundwate'Sectione- -
From To—Ft._ in. In. _ .r:,
i :rr A;Y« e Reg!2nal Office 5c
From To Ft. In. In. - - -- v >_
16. SAND/GRAVEL PACK: 3 ��
Depth Size Material - m:,
From To Ft. w -,
From To Ft. N o2
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 et)(/2+r"t 1 /rhai /lnr,� �-� _
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 231774
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Zennr "i 1!111) elM A Well V. II am Tit
WELL CONTRACTOR CERTIFICATION#: S-e'- 2/'76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential la Municipal El Industrial El Agricultural❑ Monitoring El
Recovery❑ •Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATIONy(Show sketch of the location below) Alarest Town: 77an k/,>� 4/0—. County: / I r a c'(T-yv )
(Road Name an,Q Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
r
3. OWNER G , I P.- )14- YYI /1 nib From To Formation Description
Address ��-5 ,
/ �,� P l�
jStree or ou a O.
617/0 F --,ze
City or Town State Zl
4. DATE DRILLED 5 I "2d( G-
5. TOTAL DEPTH n `-
6. CUTTINGS COLLECTED YES❑ NOO-
7. DOES WELL REPLACE EXISTING WELL? YES ED NOD-
6. STATIC WATER LEVEL Below Top of Casing: Xe) FT.
(Use'.II 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 15A NCAC 2C.0118 1—(
10. YIELD(gpm): 3 METHOD OF TEST h/N)(/i19 !1
11. WATER ZONES (depth): (^ or • �U
12. CHLORINATION: Type h`*H Amount r/4/13 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 6 7 Ft. re. . i•/fQ PY P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: 1 E C f E
Depth Material Method 0
n i a
From __Pe____ To Jai m Ft. (r e- o-ri7 1 Pic n 4 co
o, J —
From To Ft. ii HN I nrli 2 3
15. SCREEN: -c crri
,
x-
Depth Diameter Slot Size Material 03 a-=
Groundwater Section "`
From _To Ft_ in. _ In. Asheville Regional Office -17 —t
From ___To_Ft.— in. In. a,,n
From To_Ft._ In. In — "''
mom:
16. SAND/GRAVEL PACK: CO
Depth Size Material ro z
From To F1.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 75A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.OP
FOR OFFICE USE ONLY Y� !Fnim; 4 448 41t `f- �3 + O /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV.12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2) ) ry J
r) 1 7 C
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] ( 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: tb-en n r "i lir/) em a LOP I) r. t I ,4 ri, C
WELL CONTRACTOR CERTIFICATION#: .ci-ece 1 - Q/`7G,
_ < MuSTATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential I/1nicipal ❑ Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: Yf"7Mr f-'/i it/ i1i('' . County: fill a. C-am
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0. n A c, 01 r Y-P l? n From To Formation Description
Address 7:f L i d/)? ,
treat or Houle No.
Fro„ (1i 4/ � fQ _
City or Town State ZIP •
4. DATE DRILLED S-0a-0 j -
5. TOTAL DEPTH Arts
6. CUTTINGS COLLECTED YES❑ NOD---
7. DOES WELL REPLACE EXISTING WELL? YES El NOn
8. STATIC WATER LEVEL Below Top of Casing: ,P FT.
(Use'+'II Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface*
'Top of easing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.011e
10. YIELD(gpm): r-V7) METHOD OF TEST h/?f7/11 Yl (�
11. WATER ZONES(depth):
12. CHLORINATION: Type 11 t H Amount 1'/4 09 If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
V
From 0 To / Ft. 1C•. r/SrV ®a P- Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method c,
From C To (Q-1\ FL O err, a.✓1% D 1112.4 A "► ( nv El O
From To Ft. I _ V - no
�
15. SCREEN: c)
Depth Diameter Slot Size Material is a41 co
7.=
II;N 'i" ;" m
Ca o
From _To Ft _ In. _in. — T
:Do
From —To_Ft._ In. In. —p —1,-,Groundwater Section rt.,
�r
From To Ft. In. _ In. Asheville Re:ional Office _ t
16. SAND/GRAVEL PACK: rn 3
c�
Depth Size Material CO =`
1O o
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 BEENBE PROVIDED TO THE WELL OWNER.
•FOR OFFICE USE ONLY ygmm�# �kfotiDn,4,r,,L cr'`2 r, _p
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV.12/99

•
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section :232168
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: th-e`-,n. 4 /Iv I) ,, a «ell r. I l n, ,4 r'1 c
WELL CONTRACTOR CERTIFICATION#: .Cr3'S . no,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural El Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL.LOCATION: (Show, sketch of the location below) /Y1
Nearest Town: 0 ' /70 — County: /V r a't'A,
(Road N and Numbers,Comu nity.or Subdivision and lot No.) DRILLING LOG DEPTH
3. OWNERS Ph In i S Ha YYP_/c tinFrom To Formation Description
!!!!!!
Address 8 O x 13 c
(Street or Route o.)
/Inn)iiin3 ,,,e_ rP Tvy
City or Town State Zip Code •
4. DATE DRILLED'5 a 9-- n /
5. TOTAL DEPTH •cn S .
6. CUTTINGS COLLECTED YES NOQ—.-- .
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE--
6. STATIC WATER LEVEL Below Top of Casing: f,' FT.
(Uses♦'U Move Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface'
'Top of using terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C.Ott
10. YIELD(gpm): /• METHOD OF TEST Hill/in/ 4—
11. WATER ZONES(depth):
12. CHLORINATION: Type if f N Amount VI/ I If additional space Is needed use back of form
13. CASING:
Well LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To 7./' Ft. (e.' r/f& P k' P - Roads,or other map reference points)
From To Ft.
From To Ft. 0
o 0
14. GROUT: —
Depth Material Method C— coo
n c Sr-.From C To ..-IN Ft. (1 Pm, r qfT I /n.t A , a ;rc,-,
From To Ft. t 1 orn
15.SCREEN: nc
Depth Diameter Slot Size Material 3 �m
From To_Ft _ in. _in. o t"'
mi
From To_Ft in. in. N o
From . To_Ft._ in. _ In. 02 a-
z
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HE- - - 'm THAT IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST' 0� • -(Fin - "- ' OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFF2,- E.,EONLY D m n M A /� �'a nae449 y `0)
. Quad No: `� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
•
I�!N j %� original to thvlslon of water Quality,Groundwater Section within 30 days
Serial No.
GW-1 REV.12/99
,.roundwater Section
Asheville Reyial Office
s •

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 232169
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: \Non n, 4 lc 11 elm a CDQ i i V. I I nt4 T11 c
WELL CONTRACTOR CERTIFICATION#: .�i-SS- CQ/761
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Sox): Residential L!X Municipal ❑ Industrial❑ Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �/
Nearest Town: F'Cl1yk'1,1 ) 4/r_ County: / r )/D PA-n 1
(Road Name and Hunters,ConvnM,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER in CL421-L &- M a % Ys. S From To Formation Description
Address 04 4_ 7 PF /4 - L G c
r (Street or Aouie o.
. lac(e5ntu.)). rj 3 aao7
City or Town State Zip Code
4. DATE DRILLED 5-3 6 -a,
5. TOTAL DEPTH re-'),;" .
6. CUTTINGS COLLECTED YES❑ NO El--- .
7. DOES WELL REPLACE EXISTING WELL? YES ED NOD-
8. STATIC WATER LEVEL Below Top of Casing: - p 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 15A NCAC 2C.0118
10. YIELD(gpm): / S METHOD OF TEST JOIP)iinl R1—
11. WATER ZONES(depth): q/ r /
12. CHLORINATION: Type if t/4 Amount IL/ in If additional space is needed use back of form
13. CASING: _
Wall Thickness LOCATION SKETCH
Depth G i Diameter or Weight/FR. Material (Show direction and distance from at least two State
From D To // Ft. !e'' r/kV P b' P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method o
From C To ,:l1 Ft. n (.7o-n 0.yf7 1 P1.t A-, p o
From To Ft. 0
15. SCREEN: C o"1
Depth Diameter Slot Size Material T"M
'
I e—
From _To Ft_ in. _in. Q1 n
. >o
From To_Ft._ in. in. a —'
m�
From To_FL_ in. _ in. m
O
16. SAND/GRAVEL PACK: No) y
Depth Size Material co o
From To Ft. _
From To Ft.
17. REMARKS:
I DO HEREBv rr=ariFv THAT THI. WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC M N!AZAW1AI{IryS PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE W ONLY LS V [9 A /I ^ n 5--3 0 o I
Quad No: J11L '; nn,-• ,> SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
r it Su ariyrlinal to Division or Water Quality,Groundwater Section within 30 days
Serial No. GW-I REV. 12/99
::roundwater Section
?eviile Reci H Office

229 699
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: ,,Necl n, 5 /fr I ) c•, J (1)2 D F?v i I n TPI
WELL CONTRACTOR CERTIFICATION #: /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential E Municipal ❑ Industrial D Agricultural El Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Show sketch of thelocation below)
Nearest Town: 17 /"2-L 4't l , Q �-l�' ,County:
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER :1-0,S C /7 / ')Q. O F From To Formation Description
Address tree!oo f L'
r
City or Town State Zip Code
4. DATE DRILLED -J - /7-0 /
5. TOTAL DEPTH Zit C
6. CUTTINGS COLLECTED YES 7 NOEl. — o
7. DOES WELL REPLACE EXISTING WELL? YES El NO�� b.
B. STATIC WATER LEVEL Below Top of Casing: /5 FT. c�
ar.
(Use•.•II Above Top of Casing)
/ IV
9. TOP OF CASING IS FT. Above Land Surface' tso ao
Top of casing terminated actor below land surface requires a variance In mecca-
-0 —i
dance with 15A NCAC 2C.011e 7C �c
10. YIELD(gpm): 4o METHOD OF TEST /7/N7/r, /7 D'!- ,F. (An
11. WATER ZONES (depth): C.l1 yK
F e�
12. CHLORINATION: Type /t t N Amount '4 / If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFI. Material (Show direction and distance from at least two State
From L. To C Ft. if /kV Pi ? - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To . ,-Li Ft. (I P.n, c-,-,7
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 HEREBY CERTIFYIHAT THIS+0E WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANQAAOS,1*&tl1jjT ;COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
t / -
FOR OFFICE USE ONLY �,r1m, .r o�IIQnr �
Quad No: - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GIN-1 REV. 12/99

229700
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: 1.1-en nr `s Iia /) ,,., A OA?I I P) n r- /i n ,3 T
WELL CONTRACTOR CERTIFICATION #: .�S `j .�'-/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential EV Municipal ❑ Industrial❑ Agricultural C Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: /'1/ _ County: girl-fteris
(Road Name andan Numbers,Cor)tvnunity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t I) Q I{ A Cif Ir2 From To Formation Description
Address J7) 0 O Route
c21 7
( creel or No.)
l.� r I l''--
City or Town Stale Zip Code
4. DATE DRILLED <"-/ El-O /
5. TOTAL DEPTH 2r, q
6. CUTTINGS COLLECTED YES 0 NO El.-- C-
7. DOES WELL REPLACE EXISTING WELL? YES 0
� O p ^
8. STATIC WATER LEVEL Below Top of Casing: .� e) FT. -n
(Use'+'it Above Top of Casing) rm
9. TOP OF CASING IS / FT.Above Land Surface' tJ fir„
rn
`roc of casing terminated at/or below land surface requires a variance in scoot-
dance with 15A NCAC 2C.0118 f ruo
10. YIELD (gem): V METHOD OF TEST �/JVP//Ir-17 6� m
11. WATER ZONES (depth): c-a
C../1 -1
12. CHLORINATION: Type /t t` r
yp Amount '�U /� II additional space is needed use back of loan
13. CASING: v- . ..._ --- -- -- -- -- -- -
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To Ft. if /thy P! (o . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From (T To ,- i ' Ft. (I G 1,
From Tc __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 HEREBY CERTIFY THAT THI$.WELLWAtiS-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 n1iu /L ;i)a nt.o . -/ F - C/ /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. - • GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 2 3 0 6 9 4
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c r1 nr 9 /he 11 4 WO I I 1-J r. i 1 nt-ol. -7-)1L
WELL CONTRACTOR CERTIFICATION #: S4i3• m2L7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Munlcipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: how sketch of the location below)
Nearest Town: f I BC L/ / a n h r ,4'- County: Al OL-Pi
(Road Name and umbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER %)e, t" LP-re r(./ lL From To Formation Description
Address zit,,.?7 in ij a r7-is 'r/24i I(Street or or life No.)
9pi-1, +4- 6-4 .3d a 7
City or Town State Zip Code •
4. DATE DRILLED `>-,✓)7--D /
5. TOTAL DEPTH ?n S
6. CUTTINGS COLLECTED YES❑ NOQ-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOR-
8. STATIC WATER LEVEL Below Top of Casing: - 4-0 FT.
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS I FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): c METHOD OF TEST h/N)//%M1 ��
11. WATER ZONES(depth): 5c7m
12. CHLORINATION: Type It+H Amount y4 /6 If additional space Is needed use back of form
13. CASING:
Wall ThicknessLOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To .-2-/ Ft. (e'.. ..yf9 P)'' P - Roads,or other map reference points)
From To Ft.
From To Ft.
0
14. GROUT: 0 o
Depth Material Method 0
From C To ;If\ Ft. lr Bar, o.,�T �loe I a or
From To Ft. _ rn
. ' oti
'15. SCREEN: _ _ -4 -*(--7
Depth Diameter Slot Size Material -0 'mom
From _To_____Ft in. in. 3 a T
From To_Ft. in. _ In. • C'=" r"S
-74
From To Ft._ In. _ In.
r::rt 0
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
'•" • +, .,"•CONSTRUC t AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE I r e • - fPi10'.1 e /.tenth-?AA A 1 -". 7 /
I I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL I if Submit original to Division of Water Quality.Groundwater Section within 30 days DATE
Serial No. railGW-1 REV.12/99
..
Ash ,y;,.,:

230V50
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: 'Vert rt, ei /Jr f ) ,zn, rk ( .la I I N)t- /I r,. ,,� T„
WELL CONTRACTOR CERTIFICATION #: .c-&-'&- .c j'7(,,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 0-- Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) m
Nearest Town: II/ a-1NF Lcc Ic f,"e--- County: f//f (11+41c 1
(Road Name and Numbers,Community.or Subdivision and Lot No.) _DRILLING LOG DEPTH
3. OWNER JC /11') ( '-Ct S { y1 - From To Formation Description
Address Hp/ /�-lr /<'.r �i?,ii Lu.-c—C..�
Street or o o.) r3.� 7 5 /
YnOili •0> �
City or Town ( � Sia: l Zip Ccdo
—
4. DATE DRILLED �F - Lo —O I
5. TOTAL DEPTH 711 Si•
6. CUTTINGS COLLECTED YES Q NOC—
C
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOR— o
8. STATIC WATER LEVEL Below Top of Casing: -390 FT. Z 2�
(Use'+'it Move Top of Casing) dt7
9. TOP OF CASING IS J FT.Above Land Surface' I <°'
o�
Top of casing terminated attor below land surface requires'variance In'odor- — y,,I
dance with 15A NCAC 2C.0118 `i
10. YIELD (gpm): 9 METHOD OF TEST ki/O(h71 i- 3so C To
11. WATER ZONES (depth): C G3 cn- --'
eo -
12. CHLORINATION: Type If t H Amount /4 I P3 If additional space is needed use back Ir rm 2
13. CASING: - _. . .. - -- -- -- ----
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L' To o2 3 Ft. it 'Jfr-c' P i . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To .-LII\ Ft. 0 Gan o rti p'.1i , ,
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN:ARDS,AND THAT A COPY� OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE gSE ONLY X mmr .r lioU(Qnr40 CF _ P-O -- © 9
Quad No: ', ) 1,fi ynv , '+ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
$ ,1 1'il1 Submit gdglnal to Division of Water Quality,Groundwater Section Within 30 days
Serial No. GW-1 REV. 12199

230151
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: .#-Pt,n, 5 I it I lc,— A O1 h i1 I)v ,I n,1„ ,T,
WELL CONTRACTOR CERTIFICATION #: .c4- y1- /.7(,,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentially Municipal ❑ Industrial❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:SSShow sketch of the location below)
Nearest Town: Pi /6-hi I-fl tiE9 m k L-- County: .I fl a r.aw, >
(Road Name�a and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
:I)3. OWNER ) Y - .fie, r lc ci)C.L f,n/� From To Formation Description
U
Address j ; 5 S o co n,n A c !) 0 ,
(Street or RieNo.)
J4 i fn.n..1 e A/C . r- g 7 9 I
City own State Zip Coda •
4. DATE DRILLED 14 -•2 S-0 /
5. TOTAL DEPTH 7-a5'
6. CUTTINGS COLLECTED YES[l NOD--- co
7. DOES WELL REPLACE EXISTING WELL? YES n NOL — CI °
a
6. STATIC WATER LEVEL Below Top of Casing: () FT. co
(Use'+•It Above Topof is
o
9. TOP OF CASING IS 1. FT. Above Land Surface' z
'Top of casing terminated at/or below land surface requires a variance In'coo,. ��
dance with 15A NCAC 2C.0118 '
no
10. YIELD (gpm): /O METHOD OF TEST /7/14(/r-17 ef 'v m�
11. WATER ZONES (depth): (� _ �m
Gia
12. CHLORINATION: Type It t N Amount 4 /� N IbD Es
If additional space Is needed use back of n o
13. CASING: -�
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To r>2/ Ft. fe. r/kTV l21 ;% . Roads,or other map reference points)
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From () To ,-)-i\ Ft. (i r'at, o.,ai >; 1
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 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.
',f?All
FOR OFFICEUSE4W f ,5,1r . /Lode0- rf Lie- 5--° /
Quad No: ` SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
" ? 3�1�,y - Seise*original to Division of Water Quality,Groundwater Section within 30 days
Serial No. I U .- m , . GW I REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Duality-Groundwater Section 2 3 01 .,2
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] /f
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'Nei u115 !rrI ) a (02II F)r II n„4 TI1 <
WELL CONTRACTOR CERTIFICATION #: .¢4--9- :c/-7(n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L(d< 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: N r ('-ld C./�,�/) c /L / r /'L-County: 0 er-t 2-4--1
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 7O tj P P, IC 0.<:"- SOYFor
mation 7 S From To Description
Address ,Q / ('a c•. , 12 a_
(Street or Route o.)
4 f r4 I i-ry- /V C. . rc 7 9 I
City or Trm State Zip Code •
4. DATE DRILLED 4_-_5-0 J —
5. TOTAL DEPTH . c .
6. CUTTINGS COLLECTED YES NOD •
-
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOR-
8. STATIC WATER LEVEL Below Top of Casing: , FT. o
(Use'+'if Above Top of Casing) � o`
9. TOP OF CASING IS l FT.Above Land Surface* Z co-,
'Top of casing terminated at/or below land surface requires■variance In accor- ' S 1
dance with 15ANCAC 2C.0119 < Cn
10. YIELD(gpm): /S> METHOD OF TEST IVN7/IIll (1.--- f o`.
11. WATER ZONES (depth): 7;O ' / n`'o`
v r*i
12. CHLORINATION: Type If t H Amount `/4 /153 11 additional space is needed use back of IGoi
13. CASING: --- --- -- - -- - -. - -- cm -.4
Wan Thickness LOCATION SKETCH IV in
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To -I/ Ft. if f/k'4' P< P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ '' To ;IN Ft. 0 (.701 a z-1T [1'7 i X,
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 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 ' (�/Omt .r /LOAJl1Ar.t C/ - .Q.5•-a'1I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Ael3,1 — i Submit original to Division of Water Quality Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99
f •
>_.," tea. ... .. .....-.

230153
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: •-')-er111, 5 Itr I 1 .,, A (02. I) 1 /I n. , -i,
WELL CONTRACTOR CERTIFICATION #: .4s}- ,CJ!7(.,
, STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Sox): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location
Nearest Town- f•Y t C.:-14- L/-, jj'.C. A,1(1 / County: Ab .(R11 )
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0112,co J`t ft ytr ()OQ.YU`eM )
1 From To Formation Description
Address Ftli ( I � ) .
J 7 5(r6al' r ou e
) 41, IAA, /L�C> .? 6 7 U I
City or wn ! � // State Zip Code
4. DATE DRILLED T— .b—O / o
5. TOTAL DEPTH It -- -
Q 0
6. CUTTINGS COLLECTED YES El NOD-- • 3 c,,:13
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO(-- ..mot c
8. STATIC WATER LEVEL Below Top of Casing: I q'n c
FT. f <{
(Use'i If Above Top of Casing) >o 9. TOP OF CASING IS / FT. Above Land Surface' +�
-Top of casing terminated at/or below land surface requires a variance In accor• Z T`nt
dance with 15A NCAC 2C.0118 r*r
10. YIELD (gpm): �S METHOD OF TEST h//0/,-n 4' Cal
(-)-'1'^�'
11. WATERZONES (depth): t2h0' ( N
12. CHLORINATION: Type /t t/4 Amount '/4 I' If additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/FL. Material (Show direction and distance from at least two State
From L, To •.I Ft. It' . r/kV f)/ ,° - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To ;I \ Ft. (1 G,1i a-uai p'rn, 1_,
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 HEREBY CERTIFY-T#A LLt�.,,WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN(tiAR Df FtAtf AC�O'P\Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY { `A stoi/nr .- /kmkanr. ) L —of —G
Quad No: MI Y 7 ' •I SIGN_ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original io Division of Water Duality,Groundwater Section within 30 days
Serial No.
GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 2 9 2 12
1636 Mail Service Center•Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ')N-er1 n, es Pr I ) ,c , ,1 (02 u .b r r I ;lea ?1
WELL CONTRACTOR CERTIFICATION#: .¢- .,;'/-74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential l/d<unicipal 0 Industrial❑ Agricultural❑ Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION, Show sketch of the location below)
Nearest Town: /- Y/J n ✓<L/r--✓ /A _ County: /)& e-Iti--1
(Road Name and Numbers,CQITV I'ity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER (i-e.trz fit- ('-f-.Q,t4r From To Formation Description
Address 3 77 /F/ r , �Q- Pr)
I `B (Street or cul`No. a If 73
coayCity or Townj r��, State - Zip
4. DATE DRILLED S'--//—o
5. TOTAL DEPTH rh_ o rE
6. CUTTINGS COLLECTED YES 0 NOD •
—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE ,--,
8. STATIC WATER LEVEL Below Top of Casing: �7 FT. ,n
(Use':it Above Top of Casing) �'=
9. TOP OF CASING IS / FT.Above Land Surface' ONym
lop of casing terminated at/or below land surface requires a variance In scoop-
dance with 15A NCAC 2C.0115 + :,i
10. YIELD(gpm): ,20 METHOD OF TEST h/ln//i)1 A1— cacn
m
/ �
11. WATER ZONES(depth): TCri'/1 r l cri —I
. UI so
12. CHLORINATION: Type /t t hi Amount / 4 /�
_ . . ... .. . _ if additional space Is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L To 9 3 Ft.. if' . ,./kV 1 r P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
•
From C To ill)._Ft. /I r',>, .,,-1T , 1
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANQARDS,AND THAT A COPY� OF THIS REIICORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY arm rm r f lehm5MALL1 L..// D /
Ouse No:' CC SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
APR 2 , Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial 06:--:'.rr GWd REV. 12/99
Lam.,: ,......,.,,-..., ,..-

North Carolina•Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section 2 2 9 3 11
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •I Fen n, cs lir 11 ,t,,, A (02I i 1' iI Ih,l
.,�s
WELL CONTRACTOR CERTIFICATION#: .y1- ;Q/74
STATE WELL CONSTRUCTION PERMITS,:
1. WELL USE(Check Applicable Box): Residential La� 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: frnm,P/,b) //(' County: /21(1 fern )
(Road Name and umbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ia..0 h 5 h 4. From To Formation Description
Address 7n pi_L Co�S-f �t,,66 /lob R
/ (Street or Houle No.) rs
1,0c v e5,ic l ( ,. A/C' -R2 cc.°
Cirffr Town State Zap Code
4. DATE DRILLED (f //) —0/ 0
5. TOTAL DEPTH �.S'S' o 0
6. CUTTINGS COLLECTED YES❑ NOD— ' ' _ `—'%%
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO _- Li 6
8. STATIC WATER LEVEL Below Top of Casing: % FT. — EE5
(Use':If Above Top of Casing) '
9. TOP OF CASING IS " �'FT.Above Land Surface* -D
'Top of casing terminated at/or below land surface requires a variance In accor- Y -r'
dance with 15A NCAC 2C.0118 r.1 tnz
10. YIELD(gpm): METHOD OF TEST /0/N7//in el-- c-;�
11. WATER ZONES(depth): / CJ7 a
12. CHLORINATION: Type It t H Amount r1/4 //53 If additional space Is needed use back of form
13. CASING:
WTI LOCATION SKETCH
Depth Diameter or WeignVFt. Material (Show direction and distance from at least two Slate
From L Tor 3n�. Ft. (<' . ,/f4I sr)I P . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To .-)-IN Ft. a Aar, .•r,• t, ,1 ,
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 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.
FOR OFFICE USE ONLY X niin r .r /XOdP/ 4r40 41/Q —a l
Quad APR 2 G 2;,?r! SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
V " Submit original to Division of Water Duality,Groundwater Section within 30 days
Serial No. 3 .
GW1 REV. 12N9
Cc!
,,in9 E rrn{s I l' r
{� _.u..

229310
North Carolina•Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section
1636 Mall Service Center-Raleigh.N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: j\-Pc)n, ds I A (*t 1 i)1- i t ,-><,i _T
WELL CONTRACTOR CERTIFICATION#: .g41- cZ/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential I tvlunicipal ❑ Industrial❑ Agricultural El Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, Ust Use:
2. WELL LOCATION (Show sketch of the location below)
Nearest Town: fr/I,n/GI C'¢t_ ,i'?t• County: 7Y1 Cl_ Cern '
(Road Name anANumbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ken 1 t iu.O Skis hr-/ From To Formation Description
Address ,30 44I2, nee ,', 12,4
(Street or o o.}
l-r4� -z�, le' l, A/C- a&?a V
City or Town State Zip Code
-
4. DATE DRILLED 9-9-0/
5. TOTAL DEPTH (n.673 o
6. CUTTINGS COLLECTED YES El NOEL-- • o o
7. DOES WELL REPLACE EXISTING WELL? YES El NO©---- as G'-
8. STATIC WATER LEVEL Below Top of Casing: (./z FT. -
gr'
(Use'r'g Above Top of Casing) o�
9. TOP OF CASING IS FT.Above Land Surface' a+
Top of casing terminated et/or below land surface requires a variance In,coot- H,c
dance with 15A NCAC 2C.0113
" m^
10. YIELD(gpm): _ / MET OD OF TEST h/lr)/h77 FI m
S � I r Z Co
11. WATER ZONES (depth): • c-)
cri _
UT
12. CHLORINATION: Type /t t H Amount 1/44 /P3 If additional space Ls needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ,-' Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0To /a Ft. (C. . di-1j i"c/ Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .-21\ Ft. 0 (All nsi% )%171 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: 1
1 \.1 « I., =j
I DO HEREEIrCERTIFY TR7tTTWIS1710.1iMPAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TRA A COPY/^� OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE' )SEAONLY PP 2 6 200! - 'A � 14 r .r /kin✓'7nnr,0 L1 %—0 /
Quad No: r SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina-Depanment of Environment and Natural Resources•Division of Water Quality-Groundwater Section "-2 9 3 0 9
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,NPt1 n, cc r1r I) ,c„ ek (0(2 )) i)v /I rh<. 7�,
WELL CONTRACTOR CERTIFICATION # ¢ -5 -: . S• ;mot/^7t,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential L/:� Munlcipal❑ Industrial❑ Agricultural❑ Monitoring 0
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:,(Show sketch of the location below)
Nearest Town: PI4mI' I it., 110/ County: MO_Oh: )
(Road Name d Numbers,Co niry,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER .I•SA Q ca .hwt ci From To Formation Description
Address
nee or ou a
4'ty4 1 Ak/n., ) P c-21yl13
or Town State "Zip CM c
O -
4. DATE DRILLED 9-6 -O 7
5. TOTAL DEPTH .J 7 5 a' a?
6. CUTTINGS COLLECTED YES Q NODS �"
7. DOES WELL REPLACE EXISTING WELL? YES D NOQ _ rn o¢
6. STATIC WATER LEVEL Below Top of Casing: in FT. ::--;cd
(Use•.•II Above Top of Casing) MC m ,
9. TOP OF CASING ISrl FT.Above Land Surface' w
'Top of casing terminated at/or below land surface requires s variance In scoot- 0"
dance with 1SA NCAC 2C.0115 r.n y
10. YIELD(gpm): 1, METHOD OF TEST /C/P7/'i77 R(_- u1 0
6 (I
11. WATER ZONES(depth): r
12. CHLORINATION: Type /t t/4 Amount 04 /
If additional space U needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two Stale
From 0 To - . Ft. /<. . r/Id/ P i P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To .ZLt\ Ft. (I co-» 0_,,,/ ll;1tr 1 -
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _ In. in. _-- ---".
From .To Ft._ In. In. = i?
From __To_Ft. In. In.
16. SAND/GRAVEL PACK: APR 2 6 20.91
Depth Size Material
From To Ft. _
From To Ft. ian
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL •
CONSTRUCTION STANDARDS,AND THAT A C/^OPY, OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY Y �QVltlr .r /XIO✓U/Inr,L) 41 `- 6"6-7
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL. DATE
Submit original to Division or Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

29698
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: •I `Pn n, '' Br I ) rk (C)* I I 1-‘)). f I pi ,, Ti7
WELL CONTRACTOR CERTIFICATION #: .c-a-+}- .• /.7(ii
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential ll�� Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOO L(Show sketcf}of theA location below)
Nearest Town: i7•n 1//✓iC .!`/(1 - County: ,M 11 r .- -1 )
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER <a / 6'e / enl-; From To Formation Description
Address 5 So Cr: 2 yryrsu� P. I I 12 i_
Street dddr Route No.l
/-'li/i Qd le i rr„ ) 4 r ._ 07 i (/
City or Town Stale Zip Code
4. DATE DRILLED 4'—/=7-0 /
5. TOTAL DEPTH .-:•;1,5 1 - CD
6. CUTTINGS COLLECTED YES Q NOEi C n
7. DOES WELL REPLACE EXISTING WELL? YES c NOD---- a -7T
8. STATIC WATER LEVEL Below Top of Casing: qr FT. -111 o�
(Use'+if Above Top of Casing) N frl..2
9. TOP OF CASING IS / FT. Above Land Surface' ca *rn
�c-i
Top of casing terminated at/or below land surface requires a variance In actor- -ID --I
dance with 15A NCAC 2C.e116 �m
10. YIELD (gpm): ,.2- _ METHOD OF TEST /O/P7/1,17 1.—
11. WATER ZONES (depth): ( mpu
0
r o
12. CHLORINATION: Type /t t N Amount V4 /6 If additional space Is needed use back of form r
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To •S 3 Ft. le. ' //ffV P 1 g . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From _ f To .-Li" Ft. 0Gn, ar111 fl,,1i 1 ;
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY/"� OF THIS REICORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY all c /knbU/1/ID S` /,C —f' I _
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
1� r Submit original to Division of Water Quality.Groundwater Section within 30 days
l Serial No. • Yam' GW-1 REV. 12199

228978
North Carolina•Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section
1636 Mal Service Center•Raleigh, N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: • n n, es I+r I ) rs.,, ,a (L)2I I F)r )1 n. ,,) Ti
, }WELL CONTRACTOR CERTIFICATION #: .c- - /76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable eox): Residential L(X Municipal ❑ IndustrIal 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: :-'lJ- 1 ki 1'>-" 4�-c- County: nN a 4r>,-J
(Road Name and Numbers,Cormpynity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 177/.fried /�''rr /4ej, y-e.C. From To Formation Description
Address a (� Wao rip, Ce.h e 2r-d
(atreat or Houle NO./
iu/i21 P/,73 / ') ,2 S.73 V •
City or Town State Zi Code .
4. DATE DRILLED ''-S--n / ,
5. TOTAL DEPTH 46,0
6. CUTTINGS COLLECTED YES El NOC-
7. DOES WELL REPLACE EXISTING WELL? YES Ei NO[11-
8. STATIC WATER LEVEL Below Top of Casing: /on FT.
(Use':II 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 15A NCAC 2C.0118
10. YIELD (gpm): METHOD OF TEST /O//1,/I,T7 �I�
11. WATER ZONES (depth): /7/) ' l
12. CHLORINATION: Type It t N Amount 1/1/ /15 It additional space Is needed use back of form
13. CASING: -- - - - -
Wall Thickness LOCATION SKETCH
Depth , Diameter or WeighVFL, Material (Show direction and distance from at least two State
From 0To m Ft. f r. ' //kti' P t P - Roads,or other map reference points)
From To Ft. O_ --
From To Ft.
14. GROUT:
-v -' .
Depth Material Method — r -1
,,,
IP From P To .Z Ft. 0 /'-in Pilo/ r, 1 ; p x=o
From To Ft. re r-io
15. SCREEN: a mI
Depth Diameter Slot Size Material - y
From To Ft in. In. (.,.) 3
z
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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `/1 �4 n1,i i r IL 1)(1i9 +r19 -S- 0
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. GW-t REV. 12/99

228976
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: then flies 5 / I ) n A LOP I 1 i >e i I n- P.� -f t
-�
WELL CONTRACTOR CERTIFICATION#: - 76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential ria<unicipal❑ Industrial 0 Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other E] If Other, List Use:
2. WELL LOCATIONShow sketch of the location below) �C'�X�
Nearest Town: J ri2'tL U-/'"J j" County:
LOG DEPTH
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLINGFormation Description
3. OWNER .j)cin U'd. t5(as,-e-Li-2,^_d From To
Address 6,(0 (J gr-trjI)t f 6k. tPQ• I2
(Street or Route .) T r1r73
City or Town State Zip Code .
4. DATE DRILLED V- 2.- I
5. TOTAL DEPTH 3",
6. CUTTINGS COLLECTED YES❑ NOD----
7. DOES WELL REPLACE EXISTING WELL? YES El
N
OFM-
B. STATIC WATER LEVEL Below Top of Casing: ,-?,71
(Use'i 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 16A NCAC 2C.0118
10. YIELD(gpm): —2.._METHOD OF TEST /O/N)l I,-Kr �}-
11. WATER ZONES(depth): 60) i
12. CHLORINATION: Type /t t H Amount /Q /6 It additional space is needed use back of form
13. CASING: LOCATION SKETCH
Wall Thickness
Depth �J Diameter or Weight/FL Material (Show direction and distance from at least two State
From 0 To /� FL /( '/C•( P I ` , Roads,or other map reference points)
From To Ft.
0
From To— Ft.
d
14. GROUT: c :-,
Depth Material Method
From �_ To Ft. (1 Cm o.e'11 p/,1t -11 — `•'r�
From To Ft. o =""
15. SCREEN: ?"
Depth Diameter Slot Size Material ..,r„
From To—FI — in. in. p to--
r•,
From _To Ft. in. _.__ in. r --I
coo
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 STANO'M PS„AN\THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(j� yl,n ^(nf �_ D -0 /
FOR OFFICE USE ONLY �` �-rim l dL0nf
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days GW-I REV. 12/9Serial No.

228977
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: c ri r,, ei IC) ) A (1)0 i i . E i l ^
WELL CONTRACTOR CERTIFICATION#: . rr 4—Q- '/7G• 41
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 0' Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: f re R.t1(L 1,2/ Al 0-- County: Al Q. G*1-nJ
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /Y)r4-4-9 7r o 4T From To Formation Description
Address (c q getgie.Date(
(Street or Route No
/ra yl I!_I.n^-) /Lc-- ,Q 8 73 7"
City or Town State Zip Code •
4. DATE DRILLED 4"-4-o
5. TOTAL DEPTH S -
6. CUTTINGS COLLECTED YES❑ NOE:3,-
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD
8. STATIC WATER LEVEL Below Top of Casing: �`® FT.
- (Use'.'if Above Top of Casing)
9. TOP OF CASING IS I FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0115
10. YIELD(gpm): i METHOD OF TEST IOhrvint /-
11. WATER ZONES(depth):
12. CHLORINATION: Type /t t/4 Amount `/~ / If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0To Jr� Ft. /< r! P r P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o --
Depth Material Method
From _12__ To :-.2.... .._Ft. 0 Rv>, o. '1 f O 1i-,1 hl , aJ
From To Ft. I • o '
15. SCREEN: ,,
Depth Diameter Slot Size Material .-in. .:1--i
From To Ft _ in. in. o O)'T_'
From To—Ft. in. In. .. y..:.5
From _To_Ft. In. in w o
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THtT A COPY OF THIS REICORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 1L
n1ar,t XIOJIrnnr.,l / • 4 —4 -- O / —
Quad No: ,,0 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sutxnitdriglnal to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

227 1 2i
North Carolina•Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.27696.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -N.t i t1, , IL.,� -. A (().? a 1,• 117)- el -1 t C ,
WELL CONTRACTOR CERTIFICATION #: ti-4-Q- ./7/0
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Resi:fential❑— Municipal El Industrial ❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection [] Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ti I N L 4i iL Jj E .714n-, County: Ct (/rlt�
(Road Name and Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH dN
3. OWNER �,) r Il n 1,10 c, .e/' ' From To Formation Description
Address •� / (,. 6t (cA a) ( /1 A
A ��� - Street or otno No.J
l—I I jM)1 In��� c il,'I, - /c17. /
City drjTown Stato Zip Coda
4. DATE DRILLED :3- / -O / ..
5. TOTAL DEPTH 0-,5 i 0
6. CUTTINGS COLLECTED YES 0 NOn, _ o 2
7. DOES WELL REPLACE EXISTING WELL? YES J J NO(� �-
8. STATIC WATER LEVEL Below Top of Casing: __pet Fr. a C'—,
(Use'I.'it Above Top of Casing) —
9. TOP OF CASING IS / FT.Above Land Surface* 1 �,
'Top of casing terminated at/or below land surface requires a variance in actor- '•L
dance with 1SA NCAC 2C.0118 ri o\
10. YIELD(gpm): METHOD OF TEST t•-).nir% • l+ < -
11. WATER ZONES (depth): / 1/ C
N o
12. CHLORINATION: Type it t H Amount 1/L, /y"i If additional space is needed use back of form
13. CASING: — —
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To f a. S Ft. if. . ._ r /f 5 e'r." Roads,or other map reference points)
From To Ft.
From To Ft. _
14. GROUT:
Depth Matorial Method
From .
From To Ft. f
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 HEREBY CERTIFY THAT THIS WELL',VAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTIONSTANDARDS,AND THAI A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFI E O _ 1, fi .,-r n ,, n .3_/ _ [n /
Quad No: 5 ZOOI L.,
b k t SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
StfDm.d o'oinal to Division of Water Quality.Groundwater Section withir 31; days
Serial No. GWI REV. 12/99
n.
.nt:n`7•°•ate•Section
1

227912
North Carolina-Department of Environment ar.d Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -h1, ,1, 5 lit' 1 ) 4 019II fit.. /Ifl;el1 ,It ` .
WELL CONTRACTOR CERTIFICATION #: C4-&- j7/�, U
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE(Check Applicable Box): Residential❑— 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: ,40<IN Z ? c 1.) t' 4 _ County: 7) 2 r'n-„
(Road Name and Numbers,Community,or Su:division and Lot No.) DRILLING LOG DEPTH
3. OWNER ('' I) y . 4.- ii e )E
From To Fom;z:ron Description
Address , „Z0 / /); j i(2S A. P d
(Street or Route No.)
14 r C,i, I/n -4 -* 2 /
City otjown State Zip Code
4. DATE DRILLED -' J-r^/
` - )- — ='
5. TOTAL DEPTH -6C '
6. CUTTINGS COLLECTED YES Q NO i . - `, '
7. DOES WELL REPLACE EXISTING WELL? YES I I NOT— _
8. STATIC WATER LEVEL Below Top of Casing: ,Vtj FT. ry
(Use'+'it Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' _ r,;
'Top of casing terminated at/or below land surface requires a variance In accor- -'
dance with 15A NCAC 2C.0118 p ��
10. YIELD(gpm): � O METHOD OF TEST /'ii,"''• i• " - o n
11. WATER ZONES (depth): i4^o ' 'I r-J o
..
12. CHLORINATION: Type /t t/4 Amount '/t- 'F' If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance Iron at least two State
From C To / Ft. /'' .. i /> ' 2: Roads,or other map rc ter:nce points)
From To Ft. ._
From To Ft.
14. GROUT:
Depth Material Method
From r To _.-1ii` Ft. (tin: ,n , I, r't ,
•
From To Ft. 1a
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2::,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT-IE'NELL OWNER.
FOR OFFICE Ubf FkY,` I 1=�I 1 •,- l 3-l.� Chi
Quad No: I ) 14- SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. ( I r,) �.
GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section 27911
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -Nr-i)nr5 Ilz• / ) ,,, . "1 (/),911 �v /( n.,� =litC
4-•,&•-WELL CONTRACTOR CERTIFICATION #: s-71- .(j'y(„
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑- Municipal El Industrial❑ Agricultural ❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: //c (-` Nc . ,rtrk re,% G County: r )--) ch ,
(Road Name and Numbers,Community,or Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER L.c , I 1 c C r o; i-: oL:J From To Formation Description
Address / i•icl tatual ( *h
1,1
(Street or Route No.) -.
City or Town State Zip Code • C
4. DATE DRILLED '" - / - c' / r--1
5. TOTAL DEPTH - 5-7. > ' ^,,
6. CUTTINGS COLLECTED YES n NOI , (—" s ;-;"'
:D3 ci4
7- DOES WELL REPLACE EXISTING WELL? YES n N0�1�� v
8. STATIC WATER LEVEL Below Top of Casing: / 7 FT. -- _
�
(Use'+'it Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' r —�
'Top of casing terminated at/or below land surface requires a variance In actor- Li
dance with 1SA NCAC 2C.0118 _ r
10. YIELD(gpm): -D-'-) METHOD OF TEST />'"r_'; I, 4:- o
11. WATER ZONES (depth): '' -`>r' ' ''%r w o
12. CHLORINATION: Type H '1 14 .__Amount ' /, It additional space is n ter:3d use back of form
13. CASING: - —
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From C To -Sn Ft. i(• • . ri ' i'i Roads,or other map reference points)
From To Ft.
From To Ft. _
14. GROUT:
Depth Material Method
From _Li__ To .;2 L.- Ft. (1 c it, •-• , - ,
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 HEREBYCEATIFYrt{i4TTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION)ST•ANbARDS ,NOTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
af:
FOR OFFICE US1bN14,0 „ h � .,) •:� ; I lit, n�1 .,, .I -3 _9 ' /
Quad No: '_J A+i r - „,i SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SubMit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW I REV. 12r99

North Carolina-Department of Environment and Natural Resources-Division of Water(Duality-Groundwater Section 2 '1 2 7 /� 5 6
1636 Mail Service Center-Raleigh,N.C.2769)-1636-Phone[phone] C. `I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ) / ' 1 I ,. . A /i' l I ,f. ,k -I
WELL CONTRACTOR CERTIFICATION P: . /'-y((,
STATE WELL CONSTRUCTION PERMIT'#:
1. WELL USE(Check Applicable Box): Residential 0 " Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water I-tjection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: / ri ;-i 1� 1,7.,_- /.��— County: .r[)l r'c7y
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER
vr` I' rl `/ J it •`-A From To Formation Description
Address r"i f/ / (
Street or uia a.) ;J� - - "-"
I r.?2/ V/.
City or Town Stale C� '� Zip Co,i,e
4. DATE DRILLED " /
5. TOTAL DEPTH - r ' '; o
6. CUTTINGS COLLECTED YES n] NOn oo
7. DOES WELL REPLACE EXISTING WELL? YES n NO 'z
8. STATIC WATER LEVEL Below Top of Casing: -/3C FT.
(Use'+'d 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 scour- — r' U
dance with 15A NCAC 2C.0118 --L.. -:
10. YIELD(gpm): V:( METHOD OF TEST f' )
N n._
11. WATER ZONES (depth): •-�»C ' '
'""
12. CHLORINATION: Type I,. t H _Amount "c, r It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth _ Diameter or Weigh&Ft. Material (Show direction and distance from at least two State
k From L To / Ft. I' r Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Ma:erial Method
From �' To 'J_`iv� _Ft. R %n- ,
From To Ft.
15. SCREEN:
Depth Diameter Stot 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 CERTIFYTHAXJ1At&.W •RUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDlr iDFAIR' 11111A P THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
•
FOR OFFICE USE ONLY �T jIir ',, , . �,k- 'r:z)-, �, _3— ( — G
Quad No: • 1'^ — n1 (SIdMATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit origiriaFlo'L$vislon of Water Quality,Groundwater Section within 30 days
Serial No. d
.._._ GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwr:er Section Fy /� 7
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone [phone] 7 2 r '-t
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -h=n ,1, cl /),• f ) ,o //!? I) j-- 1' /I ;,. el 7 „
WELL CONTRACTOR CERTIFICATION #: C-4,-4 C/'76-
STATE WELL CONSTRUCTION PERMIT#:
i
1. WELL USE(Check Applicable Box): Residential❑" 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:LOCATION;(Show
r I'/t s�% /t/ L_ county: ,0'7.A c"n7-, ,
(Road Name and Numbers,Community,or Scadivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /-1 c /F;;. (I; l b y,, ,; j-'V From To Formation Description
Address (2-
l dm;a No.)
' 1,
( trees or Routee No.) --
City or Town State /Zip Code -.
4. DATE DRILLED S -9- C / -. o
5. TOTAL DEPTH .--
6. CUTTINGS COLLECTED YES in NO1 ,4.,--- -
•
7. DOES WELL REPLACE EXISTING WELL? YES j NO - (l•r
8. STATIC WATER LEVEL Below Top of Casing: FT.
�� ry =-l(Use'✓7 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 15A NCAC 2C.0118 �%_
rJ tc =:;
10. YIELD(gpm): '/r METHOD OF TEST h ,,,r• I t
F 11. WATER ZONES (depth): .P-:/r — c
12. CHLORINATION: Type It t hi Amount _ // L. It additional space is needed use back of form
13. CASING: ---
Wall Thickness LOCATION SKETCH
Depth c Diameter or WeightFt. Material (Show direction and distance from at least two State
0From To V Ft. I/' ' _ , is - . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From n To ,-2l` Ft. 0 i - , t ra •
From To Ft.
15. SCREEN:
Depth Diameter S;ot 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 CEAT4644M TRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIO "'S?)AI�AI gS, N T T C0�1 , F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE 9{t!_Y r 1
Quad No: .••_ 'Arr`t„ — 9 r 3 `$( NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit oribinal Id Division of Water Duality,Groundwater Section within 30 days
Serial No. i i T
GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 2 7 4 5 8
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .N 1t ll1 e) Iir ) ) k- ll!2I) �, iI 1- ,,� � „ C
C:;
WELL CONTRACTOR CERTIFICATION #: • - C/7/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Resi:iential❑ - 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: /- , . ' ; /.'
County: Al(. '"r.\ a —
(Road Name and Numbers.Community,or Subcivis:on and Lot No.) DRILLING LOG DEPTH
3. OWNER (,l(„ y ri Y.-- 0 ci. ) 1� F 13 From To Formation Description
Address
/ 3 ,,y (, „ b1 tI () t_, Ik
(Street or Houle No.) -- —"— —
.
I- 1 , 1l. ir.,0 ', /LT 1
City or Town State Zip Code
4. DATE DRILLED -)- `:..i` /
5. TOTAL DEPTH <n c;
6. CUTTINGS COLLECTED YES n NO}r 1— o c�
7. DOES WELL REPLACE EXISTING WELL? YES 1 1 NOES •
y r
8. STATIC WATER LEVEL Below Top of Casing: <,,i., FT. ,o ci_),
(Use•+'Jr Above Top of Casing) -- i_
9. TOP OF CASING IS / FT.Above Land Surface' tv __
'Top of casing terminated at/or below land surface requires a variance In accor- 2
dance with 15A NCAC 2C.0118
10. YIELD(gpm): METHOD OF TEST [-/ "'. // _ N �-t--:_-
11. WATER ZONES (depth): It" ' - 4 -I
— o
12. CHLORINATION: Type //- t 14 ._Amount —;�;, /ri _ It additional space is naedr:d use back of form
13. CASING:
Wall Thickness LOCATI Dry SKETCH
Depth Diameter Cr Weight/Pt. Material (Show direction and distance irom at least two State
From L To �� Ft. • / 2, Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
To l" .
From - .fir FL 0 ,'�," - . — n• a-r• t •
From To Ft. r
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 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.
t' / •t /
FOR OFFICE USE Oryf�Y..- ' et •._ L �� . r n - I .3_5 - ("1
Quad No: ;9 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. ?( ` Li
y
GW1 REV. 12r99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 ti 7 4 5 9
1636 Mail Service Center-Raleigh, N.C.27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: it it. , /h• 1 ) ,;. ,, 1/ 1.9;) j-`,c II n r� -;, c
WELL CONTRACTOR CERTIFICATION #: Yam. -9- </.7/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑" Municipal
p ❑ Industrial❑ Agricurtural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other r❑ If Other, List Use:
2. WELL LOCATION,(Show sketch of the location below)
Nearest Town: - .1.Y.LI: 1 r N County' ) )(,-
(Road Name and Numbers,Community,or Suadivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _3 f P• b L (—I
Cc 7 7 :{„ From To Formation Description
Address (17/1jc (.} ) L ? PGtorinrt,-I ��.'.- /4-�--
/ (Street or Home No.)`
City own Scale Zip Code —. C,-,
4. DATE DRILLED :7)-- - C! 5. ^7:
5. TOTAL DEPTH Syr3 ' ' `' _'
6. CUTTINGS COLLECTED YES n NOE CV i.rn
7. DOES WELL REPLACE EXISTING WELL? YES n NO[4- _
8. STATIC WATER LEVEL Below Top of ;;asing: /al`FT, r -
(Use'+'if Above Top of Casing) N (;)
9. TOP OF CASING IS _ r;"''
FT.Abt:ve Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): { (1.'METHOD OF TEST .�' ' ', l'
11. WATER ZONES (depth):
12. CHLORINATION: Type /1 t!a .`Amount.T//-4 ' If additional space is needed use back of form
13. CASING: —.
Wall Thickness LOCATION SKETCH
Depth .- Diameter or Weight/Ft. Ma,erial (Show direction and distance from at least two State
0From To - - Ft. ('' . _ i i. : Sf 7, / Roads,or other map reference points)
From To Ft. _
From To Ft.
14. GROUT:
Depth Material Method
From (' To -21` Ft. /r i.,_ . , _- 1k 'l) •
From To Ft. f
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 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.
I
FOR OFFICE USE ONLY; 'e _( f
Quad No: i4` $fUNATURE OF PERSON CONSTRUCTING THE WELL DATE
e ..,f Submit originalTo"Drvislon of Water Quality,Groundwater Section Within 30 days
Serial No. GW-1 REV. 12/99
. 4.el'+r

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 7 914
1636 Mail Service Center-Raleigh,N.C.2769E-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S M1.' rt W9fl Y11- n n,ea llit
WELL CONTRACTOR CERTIFICATION .:• c-.c..-54- .-C' /„/'y
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑' Municipal ❑ Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ;��'r 2)7 t L / v ,A--L.- County: .41 G. C nx
(Road Name and hunters,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER //f) � / c. 17 ell l l/n.,-, Ld From To Formation Description
Address X (Cr,r (�.J2-LC 14 I f C'4
(Street orRoute No.)
1:1-1,9.11 b let) A C- c J 73 V
City or Town State Zip Code . rp
4. DATE DRILLED --/ Y -0/ —
5. TOTAL DEPTH 1 7 r r ' o
6. CUTTINGS COLLECTED YES�J NO[� __ -�=-
7. DOES WELL REPLACE EXISTING WELL? YES [ I NO[ -� `::
8. STATIC WATER LEVEL Below Top of Casing: , FT. 'v •= --
(use'+'it Above Top of Casing) _;,
9. TOP OF CASING IS I FT. Above Land Surface' ---
'Top of easing terminated at/or below land surface requires a variance In actor- - i
dance with 15A NCAC 2C.0118 CD �'r
10. YIELD(gpm): C-z�a METHOD OF TEST /-v"'). '- II A^ -- _ 2_
11. WATER ZONES (depth): Al C , [It; '' w o
z
12. CHLORINATION: Type /t t/4 Amount ;/t' /'1 It additional space is needed use back of form
13. CASING:
Wall ThicknessLOCATION SKETCH
Depth -., , Diameter or WeighVR. Material (Show direction and distance from at least two State
From C To '-‘)-Th Ft. G.. . ._ /-/> !'f .` Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From f To .-21` Ft. R .,+,
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 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 I.4gONLY 0 ' /,I,- r /, .+, A - S -/ V -al
Quad No: rr . ; ; ' " q SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
F Subm I original to Division of Water Quality,Groundwater Section within 3(i days
Serial No. i il 1 GW-1 REV. 12/99

2 27 911
North Carolina-Department of Environment ar d Natural Resources-Division of Water Duality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] II
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -�-'I t t1r t, /1r i ) r A t i', n I )l n- :� -� )t
WELL CONTRACTOR CERTIFICATION #: C-.S=- - : /'7/„
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑ , Municipal ❑ Industrial❑ Agrice tural C Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)Nearest Town: /7 4 L. County: 1"),'L (OM 7.
(Road Name and Numbers.Community)or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /-1 /I E{) ( 1 )1,-y.r /r 7r;��� From To Formation Description
Address ( C X (f 10 (21
i
(Street or Houle o.
Ltiu , r"l D !3 .7
City brtown U State Zip code .
4. DATE DRILLED 3 -/ Y- c" y
5. TOTAL DEPTH -Pi'
6. CUTTINGS COLLECTED YES Q NOTI v
7. DOES WELL REPLACE EXISTING WELL? YES I NOnc--- —
8. STATIC WATER LEVEL Below Top of Casing: FT. L.
(Use if Above Top o sing) 7-O
9. TOP OF CASING IS / FT.Above Land Surface' ry roc
'Top of casing terminated aVor below land surface requires a variance In acooa —
dance with 15A NCAC 2C.Otte —
10. YIELD (gpm): `Z`i METHOD OF TEST ^ -�" r• -
11. WATER ZONES (depth): C-/ •`> L - a
4 -!
12. CHLORINATION: Type itt}') Amount `'' ''.= It additional space is needed use back of form co o
13. CASING:
Wall Thickness LOCATION SKETCH
0 Depth 7 Diameter or WeightFt. Material (Show direction and distance from at least two State
From To /7 Ft. /"' • ).. Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From P To ,-I(` Ft. It (,»
From To Ft. ) _
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY T}JAT"THIS W€LL-WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDt�RES'-,ACID TRAY A�'OOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE pNL1 'r,+ rJ , r �t ^• r 3)—/9 —o / •
Quad No: ' - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original(o'Divislon of Water Quality,Groundwater Section within 30 days
Serial No. y GW-1 REV. 12199

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
2 $ 452
1636 Mail Service Center-Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,Ner1 is es fir I ) eln, 'a LO`2 I 1 �;v I l f. ;f J /r
WELL CONTRACTOR CERTIFICATION#: 5
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal 0 Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection 0 Other El If Other, List Use:
2. WELL LOCATION. (Show sketch of the location below) /y� C�f>`
Nearest Town:
�r/1�n[i%r�J 2/L' County: / 'i t
DRILLING LOG DEPTH
(Road Name and Numbers,C niry,or S rvision and Lot No.) Formation Description
3. OWNER i ; ✓N Mil2r� From To
Address y e et - hr �"Lr��Rd
i / (Street or Repute Nd.) '1 L���
• rrfi/.ril? I , A/ C , c `/
C ty or Town Slate Zip Code
4. DATE DRILLED -3-.Q 3 -O /
5. TOTAL DEPTH C% `c
6. CUTTINGS COLLECTED YES❑ NO®---
7. DOES WELL REPLACE EXISTING WELL? YES [] N00--- r�
8. STATIC WATER LEVEL Below Top of Casing: _$ (\ FT. - — r-�
(Use'.'II Above Top of Casing)
9. TOP OF CASING IS/ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a verknce In accor- -
dance with 16A NCAC 2C.0118 w
10. YIELD(gpm): -�O 71/METHOD OF TEST � '7/1< Y1 �� _. — _.
11. WATER ZONES(depth): •>-1=�'' 4- '-i'G
N r},.
/t 1 /4 Amount `�4 / If additional space is needed use back of form
12. CHLORINATION: Type s
13. CASING: LOCATION SKETCH =-
Wall Thickness
Depth;H Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From L- To `( _Ft. (e' 'ykfi —`' Roads,or other map reference points)
From To
Ft. 5 f r-<
From To— Ft.
14. GROUT:
Depth Material Method
From To Ft. if (--its o.o-% pirli >>
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 HEREBY CERjTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A GI
OF THIS RECORDI HAS BEEN PROVIDED TO THE WELL
Ouad No: II IV jd l OWNER.
._� _._ " �[I ni 41; ,o /Boar;/)nt� J DATE
FOR OFFICE USE( LY OP. SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality,Groundwater Section within 30 days
Gw.t REV, 12/99
Serial No.

North Carolina•Department of Environment and Natural Resources•Division of Water Quality•Groundwater Section 6 5
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone] r� 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,Zec) Q. es /c I ) r,•1 A �L92�II I1. /I n. ei, -T1t C
WELL CONTRACTOR CERTIFICATION#: . 4-'•T ,>I7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial 0 Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
•
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
j-i'.7--ft 1/ /r 7:J it/Lt.. County: ,41 0- <��• ,
(Road Name and Numbers,Communi ,or Subdivision and Lot No.)
DRILLING LOG DEPTH
3. OWNER Th,hr aid ihl ✓nd,'1'1 '
From To Formation Description
Address 3 if,S � pa, ccrnni-,, by '
� (Street or Route' o.)
A r.le_ 11 . II s. c r.P. 9 73 D
City or Town State Zip Code
•
4. DATE DRILLED 3 --y --0 /
5. TOTAL DEPTH n7(E, C
6. CUTTINGS COLLECTED YES 0 NOD---
7. DOES WELL REPLACE EXISTING WELL? YES EJ NOD-- -
6. STATIC WATER LEVEL Below Top of Casing: 2 /) FT.
(Use'+'II Above Top of Casing) --
9. TOP OF CASING IS � FT.Above Land Surface' =� -
'Top of casing terminated atlor below land surface requires a variance In actor- --
dance with 1 SA NCAC 2C.0118 _
10. YIELD(gpm): Sly METHOD OF TEST /O//')/1, It �� ."�
-
11. WATER ZONES(depth): /9c '
YJ
12. CHLORINATION: Type /t t N Amount V4 / II additional space is needed use back of fw �,
v o
13. CASING: =-
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From I- To /7 Ft. it r ik(' Pi P - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From fl — To _Ft. 0 (1)13,41i p;o t 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.
From To Ft.
17. REMARKS:
I O HEREBY CERTIFY THAT THIS THAWACCOPY OF THIS RECORD HAS BEEN CONSTRUCTED IN E PROVIDED TO THE WELL WITH 15A NCAC C, OWNER.
L
CONSTR 9'��a'~
' , r
tr"I�EE 3
FOR
No. 1 -EON ' SIGNA UR I MO RSON C � DATE
Quad No: '[[(ii. SIGNATURE OF PERSON CONSTRUCTING THE WELL
A s! �(''^�! Submit original to Division of Water Oualily,Groundwater Section Wlthln 30 days GW i REV. 12/99
w4
Serial No. �� r
i
.

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
228064
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ' flni /cI ) ,,, rk (1)21) .)v. /I r>� T11c
WELL CONTRACTOR CERTIFICATION#: C7
1- , / (,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential EF<Inicipal ❑ Industrial 0 Agricultural 0 Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION)(Show sketch of the location below)
Nearest Town: I-X Cl,,,k I : .J County: M Q-Cent '
(Road Name andAlumbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �
/ '0 yl yY, e L VCa i7 S From To Formation Description
Address (,a LQ.ut..¢,l''. La(C..a_ it) t .
/ (Street or Route No.) r� ]
_�'YL]m lc l : � NC .City or Town State Zip
4. DATE DRILLED 3-a/ -0/
5. TOTAL DEPTH -Ste, ci
6. CUTTINGS COLLECTED YES❑ NO®i'
7. DOES WELL REPLACE EXISTING WELL? YES O NOE--
8. STATIC WATER LEVEL Below Top of Casing: / FT.
(Use'+it 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 15A NCAC 2C.9118 _
10. YIELD(gpm): r. METHOD OF TEST NH/1, 17 l�
11. WATER ZONES (depth): /4s1
12. CHLORINATION: Type if t H Amount /4 /3 II additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth r _ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To J L1 Ft. if ./ ' P i t , Roads,or other map reference points)
From To Ft.
From To Ft.
0tr-
14. GROUT: •
'-—
Depth Material Method �_
From ___Cl_ To ;Ll' Ft. 0 Grn O.o-i/ p Pl1 1_, . -
From To Ft. r
15. SCREEN: : -
Depth Diameter Slot Size Material v
From _To Ft in. in. ry i
From To Ft. in. In w o
From , To Ft. In. in. -a o
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. •
17. REMARKS:
I DO HEREBY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC'FI N STANbARbS AN13TI�ATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
l,. _ II J -��/ -0/
o1MAJ kra✓(r/)�rA i
OR OFF 111SE-9 ; :, i tI _i DATE
Quad No: '9 + �'� 11j)R Z I �{{ SIGNATURE OF PERSON CONSTRUCTING THE WELL
1 - ubmi original to Division of Water Quality,Groundwater Section within 30 days Serial No. GW 1 REV, 12/99
C. ............. _. ..._ S ri� ,......»f LY Inl t
dl ��@

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 228063
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,-)-Pi l fir `s fir I i tn, rk (c'? I I `' `I fl e 1/1 c
WELL CONTRACTOR CERTIFICATION #: .5r4-"`r}- . / 76
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Bos): Residential Municipal El Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION4(Show sketch of the location below)
Nearest Town: Fr ciii U 1,,)J ,{ic'� County: hi & .r'�.
•
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER L M m C-, 12 Cc�,_.
From To Formation Description
Address Li 3 9(street t 1 oraFfiou , C t h n'/ I rid
/- V
tfor ram( /t�`� • .73 J, Code '
City or Town Slats p
4. DATE DRILLED -?)S-ri
5. TOTAL DEPTH .7 7 S
6. CUTTINGS COLLECTED YES❑ NOD-
7. DOES WELL REPLACE EXISTING WELL? YES 7 NOQ-
8. STATIC WATER LEVEL Below Top of Casing: ifrri FT.
(use':it Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C. 18
10. YIELD (gpm): METHOD OF TEST NM/i,In Al--
11. WATER ZONES(depth): ��, 5 / (
12. CHLORINATION: Type )II-N Amount r1/t /i If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth�� 4, Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From I-,' To 1-�' ' Ft. i7 '/kV/ P f P . Roads,or other map reference points)
From To Ft.
From To Ft. o
14. GROUT: o c7
Depth Material Method
From C To -/- . Ft. (1 (4 n p4/1% p drri t 1 =' _ _
From To Ft. no
J -
15. SCREEN: —
Depth Diameter Slot Size Material '�
From _To Ft in. in no cn''
From _To Ft. In. in. )
From To Ft. In. In. c1 c
--Io'
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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-a - . 'USE ONLY : DATE
a Not - SIGNATURE OF PERSON CONSTRUCTING THE WELL
'I No.APR I 2 5. 'i " Submit original to Division of Water Duality,Groundwater Section within 30 days GW-1 REV. 12/99
Croundwater Section
Asheville Re',ional Office

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 228062
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i1L'11 Ili 5 I)7 11 r- • -> 1-1 1.) i i �`E /I n: e� 4Jt c.
WELL CONTRACTOR CERTIFICATION #: C%-.:-4 c /7/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential❑- Municipal [I Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �/1
Nearest Town: r)f//l A'C -- County: / l /r? C ci t _ .--
(Road Name and Numbers,Community,or Sube vision and Lot No.) DRILLING LOG DEPTH
3. OWNER /I) ri K in P r1Zd-vl From To Formation Description
Address (/Li 4bItrS /� ,y
^ (Street or oute No.)o. - Y !. Z
City or Town Mate Zip Code -- '
4. DATE DRILLED - --/b -0
5. TOTAL DEPTH 2 TS-r
—
6. CUTTINGS COLLECTED YES n NOf----
7. DOES WELL REPLACE EXISTING WELL? YES n NOQ-
8. STATIC WATER LEVEL Below Top of Casing: 7r FT.
(Use'+'II 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 15A NCAC 2C.0118
10. YIELD(gpm): -5-0 METHOD OF TEST /1/5/1/1. 0 !liH
11. WATER ZONES (depth): `;
12. CHLORINATION: Type /t t /4 ._Amount '�`/+ If additional space is needed use back of form
13. CASING:
Well Thickness
LOCATION SKETCH
Depth p2 Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From. 0 To 4- ) Ft. it ' 4 i P t , Roads,or other map reference points) O .-
From To Ft.
From To Ft.
14. GROUT: IV� =
Depth Material Method - -_-
From (�. To ��` FL /r i;,, c >i;' [ ,'; 1 • ,_
From To FL fU ftc
15. SCREEN: c -,
Depth Diameter Slot Size Material a
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
CONS are E G' • s•• ec �'` A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR 0 `1� �SEONLY a� ll. (1 („�, ;,; / ;'!''7 „ A . /L _Q
Quad No 1.6� !Iselin
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
p !a: 1 original1oDivisionalWaterQuality,GroundwaterSectionwithin 30 days
Sedal N• E GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2 2,6.9 75
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t n n,cs 1 I 1 r.n, ,. (02 II .. v /I :t..ei. T)t
WELL CONTRACTOR CERTIFICATION#: 1- : /76.E
STATE WELL CONSTRUCTION PERMITS!:
1. WELL USE(Check Applicable Box): Residential Municipal❑ Industrial❑ Agricultural El Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Pia_ u�J
Nearest Town: [r2.42 E/r'U L// County:
DEPTH
(Road Name and�}'tubers.Community,or Subdivision and Lot No.) DRILLING LOG Formation Description
3. OWNER /c--e / re_ ��/10 1d From To
Address — , ry i
-10M Or GYta O. 0 7 J
cri2.4own d late
City or Town state Zip Code
4. DATE DRILLED 3-09 '0/
5. TOTAL DEPTH -30 c •
6. CUTTINGS COLLECTED YES❑ NOL —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ----
8. STATIC WATER LEVEL Below Top of Casing: /5 FT.
(Use'i II 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 15A NCAC 2C.0118 10. YIELD(gpm): _I'e�.. METHOD OF TEST /0/u i/I r_Y1 �r
11. WATER ZONES(depth): 72
12. CHLORINATION: Type It t N Amount '/4 /6 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth r Diameter or WeighVFL Material (Show direction and distance from at least two State
From 0 To "L Ft. /t ,/k` /f r . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT: o
Depth Material Method CD• u
From To 11\ Ft. 0 Gmn d.o�l% pp-it a , CD r;�
From To Ft. / ,_
15. SCREEN: r
—
Depth Diameter Slot Size Material o -,;,
_,t
From —To_.Ft _ in. _—in. zzoT
From _To_Ft._ In. in. ^4-i
-
From _To___.Ft._ o rl
In. In. a
16. SAND/GRAVEL PACK: r 2
Depth Size Material W oz
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY T;MA1l{T�HIS L"WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAR_ MD SACOPYOF THIS RECORD HAS/BEEN PROVIDED TO THE WELL OWNER.
h0✓10 L 3 -39_,,,
�'"� ' DATE
FOR OFFICE USE ONLY S / n`
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality,Groundwater Section within 30 days GW 1 REV. 12/99
Serial No.

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section , 1- I
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] 41' sC 0 1 8 9
WELL CONSTRUCTION RECORD WELL CONTRACTOR: :Nt, 1, ti ih• 1 ) -, ,a Lc)2 f f bt- I I a >4 Tn7 c,
WELL CONTRACTOR CERTIFICATION #: - ,Z2/ 7.4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑ Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIOtL(Show sketch of th&location below)
Nearest Town: -I ,i n Y /,/r .' ,: c. County: 2(5l ram.. - -_
(Road Name and Numbers.Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER l r .l C ^ '^+•_ From To Formation Description o
Address k/ LCl5T 6tciiS E_'b-i,J 0 ' ,
(Street or Route No.)
�') (.1)l/'/l� S i S7-'3/ rrn or"
City or Town State Zip Code • C7 :rn
4. DATE DRILLED c-7--D /-6 / I
al cEr,
5. TOTAL DEPTH -05C'
6. CUTTINGS COLLECTED YES NO©— ~3 n'
s �m
7. DOES WELL REPLACE EXISTING WELL? YES D NO© u,-
8. STATIC WATER LEVEL Below Top of Casing: /. FT. w "'
(Use'+'If Above Top of Casing) C.'`7 --+
9. TOP OF CASING IS / FT.Ailove Land Surface' z
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): /1' METHOD OF TEST him/i,at/ S /3P ti i f
11. WATER ZONES(depth): i --
12. CHLORINATION: Type If t N Amount 1A/ //3 If additional space is r e:•ded use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 2- Ft. it ' /1-(' P I ; - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From P To .:2i1" Ft. a i a, e, ,a, pa,'-,
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft ir,. 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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `A !' 11 a+r ; il-tc. (i/9 n,.f �- o /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit,original to Division of Water Quality,Groundwater Section within 30 days
Serial No. t I ..-I 614 • OW1 REV. 12/99
6
Lro mdwat.I Stc
.Anb Rin,lte F,.- 1 l' . .

226338
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.2769:9-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -1111r /Lk r-., ,a Tell i)r, /1 rh,4 -Ti1c,
WELL CONTRACTOR CERTIFICATION if: 4-.S-91- ,-Z/7G
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Q Municipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: C 4 7' ' C- County: A L 0_(P-7t
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER TIT(C;. i I i. is -e_. `t-r 6<'1 $ Ow From To Formation Description
Address /i, g_2 k!-) h 11 ' LLI C^e;c1 I) p
(Streettr Route N
LC . Pa- 11>i ID, , t-- I .3 ),(//7- 563,E.
City or Town State Zip Code - C
4. DATE DRILLED - 5 -r/
5. TOTAL DEPTH K'r, ^ ' rm ':m
L.L.J- — c
6. CUTTINGS COLLECTED YES In NO - rb,-
7. DOES WELL REPLACE EXISTING•W.LL? YES E NOE rrli
8. STATIC WATER LEVEL Below Top of Casing: ?it-Rito FT. .,D-`
(Use'✓it Above Top of Casing) y o
ni
9. TOP OF CASING IS / FT.Above Land Surface'
O ml
'Top of casing terminated at/or below land surface requires a variance In accor- N
dance with 15A NCAC 2C.0118
10. YIELD(gpm): METHOD OF TEST /1/I0/1, P I- `�� r_g,
11. WATER ZONES (depth): /,_-)0 ' '
12. CHLORINATION: Type it t H _Amount ''/rr /6 If additional space is needed use back of form
13. CASING:
walThickness LOCATION SKETCH
Depth _ Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From D To CC-T Ft. Ir • '/1.."f' P 1 Roads,or other map reference points)
From To Ft. -
From To Ft.
14. GROUT:
Depth Material Method
From PTo .->iN Ft. Rr'- „ o ,i/ •p,17t 1
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 HEREBY CERTIFY THAT THIS WELL WA5 CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARD$,AND yF(4T t1' OPYOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY r �^1'%11 r / ni'/`4"' 2 ' `�- s /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WEU. DATE
St omit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

226339
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.2769—1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •.N-PIt n, `i i+r 1) c•., A (* ii I'r- I I ni 4,4 T11 C
WELL CONTRACTOR CERTIFICATION#: c-4-s}- eQ/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential VVl Municipal El Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection El Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: CV/7' ,4l (-- County: /)"7 Ct C/-t
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Vi 01CL -((tfa( A From To Formation Description
Address b. l • L;t2 i fi .. I Jr.' (j Y(t A et
(Street or oule o.
r)th' -4'C_ r rS J ,
City or Town State Zip Code •
4. DATE DRILLED j.. „2-0/
5. TOTAL DEPTH =t 3 n o
6. CUTTINGS COLLECTED YES Q NO©—
7. DOES WELL REPLACE EXISTING WELL? YES n NO 11 m :;m
8. STATIC WATER LEVEL Below Top of Casing: ,) FT. 03 cn
(Use':if Above Tap 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 15A NCAC 2C.0118 rT.
cn
10. YIELD(gpm): 7/' METHOD OF TEST (71/rIl f rat 1-- na
11. WATER ZONES(depth): 4 C c t l N `-4
+- o
s
12. CHLORINATION: Type It t/4 Amount `/L/ (6 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diamet•ir or Weight/Ft. Material (Show direction and distance:rom at least two State
From D To 9 Ft. (1. _ r/s(' P/- Y Roads,or other map eference points)
From To Ft. c5fc-t-•
From To Ft.
14. GROUT:
Depth Material Method
From To .-1" Ft. (d (;,, n nT 1)/91 1. ,
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 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 TC THE WELL OWNER.
FOR OFFICE USE ONLY '' ,+,u �.he,)(ii ,, O - -0
Quad No: 3 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
AK - Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section 2 2 6 3 4 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: dTh-P1 f f1, v /c I ) • a WOO f l 1)v n f e4 .n
WELL CONTRACTOR CERTIFICATION #: .' `.>,- )- :C/7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Res.dential U Municipal ❑ Industrial❑ Agrict tural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the idlocation below)
Nearest Town: f) 4of /�/'�L/ 'C - County: „.4/7
(Road Name and Numbers,Communi ,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /c ; ( /C •J f'/17- ' From To Formation Description
Address 9 4) 5- 0'u C_h it)
or Route o.)
/— /Cl9)Il/ 13 A/C- rQf"7
City or Town State Zip Code
4. DATE DRILLED'—& -0 / -q •.
5. TOTAL DEPTH •3/'`i`
6. CUTTINGS COLLECTED YES D NOM,—
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ- r `r
8. STATIC WATER LEVEL Below Top of Casing: r71t FT. 2 ,
(Use'.'if Above Top of Casing)
9. TOP OF CASING IS / FT.Above Land Surface' o
'Top of casing terminated aVor below land surface requires a variance In accor- N
dance with 15A NCAC 2C.0 18 —
10. YIELD(gpm): Cr METHOD OF TEST /'/nr/4 11 rt� c.�
11. WATER ZONES(depth): /7r'`' ' /
12. CHLORINATION: Type /t fig Amount `'/c, /n If additional space is needed use back of form
13. CASING: '---
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From C To -7er Ft. it ./4 r' Pi i - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From (_ To Ft. /r ('-)),
From To Ft. .
15. SCREEN:
Depth Diameter Slot Size Material
From .ToFt 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 CC 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 '" 'f �� ^✓Cr0^' _ --O
Quad No: a J SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
L '"IScomIt original to Division of Water Quality,Groundwater Section within 30 days
Serial No. G W 1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 226341
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: !NH ilr <S I4,1 ) ,- . 4 (1.)2II i)r /1 ;1,>� rnCi
cZ.&WELL CONTRACTOR CERTIFICATION#: . - :Z/`76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Q Municipal ❑ Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Stow sketch of the location below)
Nearest Town: (f%/TY' •41 /(- County: 4 h r e-0C
(Road Name and Numbers,Community,or Scbdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER .7{ -III' 9 / 49.).9,n- From To Formation Description
Address (.. 6 ,S A ac4a ' ') /2
No.)
City or Town State Zip Code •
4. DATE DRILLED •) -7- c:> /
5. TOTAL DEPTH ? 7 S
c
6. CUTTINGS COLLECTED YES E NODS- v
7. DOES WELL REPLACE EXISTING WELL? YES n N0j 3 — — r'
8. STATIC WATER LEVEL Below Top of Casing: /_5 FT. r� n_,
..i
(Use'+'if Above Top of Casing) ODc
9. TOP OF CASING IS / FT.Above Land Surface' — _-_—
'Top of casing terminated at/or below land surface requires a variance In accor- t—
dance with 15A NCAC 2C.0118
10. YIELD(gpm): _3 METHOD OF TEST FA)?/I If R� x rri—,o
11. WATER ZONES(depth): 3 r%c' ' ` o m
12. CHLORINATION: Type /1' t 14 _Amount `/(4 (r r) It additional space is needed use back of lorr*0 o
13. CASING: ,=,
Wall Thickness LOCA1 OW SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distanco from at least two Slate
From 0 To /t-.S Ft. tr• . r/-4't' P l - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To .1(1 Ft. 0rrn1 . r1( .1) ',if 1 ;
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. In.
From To • FL Ir. 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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY `A .fin^+ f r n��(rf(1.4r-t i -7_ p /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
•. , Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

226342
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.2769P-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c.1-'1'1 ill r tt I (/ c' I I it- /I ni`� Zit CJ
Sr-rs-•WELL CONTRACTOR CERTIFICATION#: . - ,-/7o,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential El'----unicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 1)1 fi' ni Ci County: nr)4.O f-yt t
(Road Nan*. nd Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ; flirt d o Cc • !-F`AC(.4. li - From To Formation Description
Address 39 / Ha 0 it c h 7) 717, /h.{
(Street orr oute No.)
6tit A/e" ,R 874 _',
City or Town State Zip Code
4. DATE DRILLED �—& —It /
5. TOTAL DEPTH (Sc;'02 c
6. CUTTINGS COLLECTED YES n NOQ/ o e'r
7. DOES WELL REPLACE EXISTINGWELL? YES I-I NOQ -r1 2_0
6. STATIC WATER LEVEL Below Top of Casing: /5 FT. fT1 0 L
(Use':it Above Top of Casing) =c
9. TOP OF CASING IS / FT.Above Land Surface' .F-
'Top of casing terminated atior below land surface requires a variance In accor-
dance
with 15A NCAC 2C.0118 =': ter.
10. YIELD(gpm): . 3 METHOD OF TEST kIln/1,Z7l'f— L
11. WATER ZONES(depth): // 5 r .? n-a
IV —t
ea V
12. CHLORINATION: Type /t'fig _Amount 1/4/ (iS It additional space is needed use back of form z
13. CASING:
Walt Thickness LOCA1'iON SKETCH
Depth o _ Diameter or WeighVFL Material (Show direction and distance from at least two State
From To -) Ft. (r '/--.(:--- P i ' - Roads,or other map reverence points)
From To Ft.
From To Ft-14. GROUT:
Depth Material Method
From (' To .-2l" Ft. (-1 G-n, it-r9 i .�1 a
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:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCA::2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICEUSf3UNLY MD2 `,3 ( 1",'%'i • kider/l n' ^ 1 'P`'c-4v
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
`i Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. ". GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 226343
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: -f'- n n' 4i IJZ- I ) - rf (//7 a ))1 /I ;1-,4 -7-11 C,
WELL CONTRACTOR CERTIFICATION #: .S4- ;C/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): ResidenUal 0<ilicnicipal ❑ Industrial❑ Ag lei/aural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: G/Fr, /(%. County: ") 1 G (-Al i
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER re n `J Sf C I 1 )(tA -r f9 From To Formation Description
Address (r 1 7 7(' A "tf 4� )r 2,r r h�a
y // � Street or Route a d Sr 7(3
C I �Ll �[iL_-
City or Town Stale Zip Code '
4. DATE DRILLED •'2--9-. C /
5. TOTAL DEPTH 4i G o
6. CUTTINGS COLLECTED YES Q NO❑— r
7. DOES WELL REPLACE EXISTING Vuau? YES 7 NOrg--- '1
8. STATIC WATER LEVEL Below Top or Casing: / -�jn FT. P
(Use'.'it Above Top of Casing) — n-
9. TOP OF CASING IS / FT.Al:ove Land Surface' -- 7.--.71
'Top of casing terminated at/or below land surtattt requires a variance In actor- a r
dance with 15A NCAC 2C.Otte -- — .,.,a
10. YIELD(gpm): •- 5 METHOD OF TEST /)/.")"I' i1 4— p n+
11. WATER ZONES (depth): `7 t N ~u
W 7
12. CHLORINATION: Type if t/4 Amount 'l 4 /6 It additional space is needed use back of form 'c
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or WeigntFt. Material (Show direction and distance from at least two State
From 0To Ft. (A• 'r;"t• 2 1 Roads,or other map reference points)
From To Ft.From To Ft.14. GROUT:
Depth Material Method
From _a__. To _ .:1)1\ Ft. 0 r",i, e ,7 .r, ,,,, 1 ;
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 HEREBY CERTIFY THAT THIS WEL..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.
�ir,to,,,i : /�n!P�ln,.0 d_ /- rr
FOR OFFICE USE ONLY', -
Quad No: t) `i SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ^ 0 ry 1 9 e,
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] ! 1 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: c r11), `+ /4' )) e1 1 (02 1) 1t'. /1 nt,4 T" C,
WELL CONTRACTOR CERTIFICATION #: .c-4-41- ,-;)/74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential IR 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: r'( 4,,/,--J fC- / i- County: ) ( C-ah i
(Road Name and Numbers,Community,or Subd vision and Lot No.) DRILLING LOG DEPTH
3. OWNER /) 1 ('r it - I`i e /) 12 ul From To Formation Description
Address —�
(Street or Route No.) r
City or Town State Zip Code •
4. DATE DRILLED '2-'/ - •'/
5. TOTAL DEPTH • F-•�'' 06. CUTTINGS COLLECTED YES El NO©— �,
7. DOES WELL REPLACE EXISTING WELL? YES n NOR-
8. STATIC WATER LEVEL Below Top of Casing: / FT. F?
(Use***it Above Top of Casing) .-1
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.0118 '
10. YIELD(gpm): •-L: METHOD OF TEST /')/P1/f,71 (�-- :: '__'�
11. WATER ZONES (depth): Jr( ' /('n ' r N J
12. CHLORINATION: Type /1 t 14 ._Amount `•/u /IS If additional space is needed use back of form _o
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �2.7} Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To Al / Ft. fr• • t 4((U Pi '" . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From C To ,-Z e\ .Ft. (f lilt o •1/ p:iu 't
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To_Ft In. in.
From _To Ft. in. In
To Ft. in. in-
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
FromTo Ft.
17. REMARKS: _.
I DO HE BY crane TI INTTHIC WI WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2:J,WELL
CONST IOES1RICRRIRS,�`J�'H I `COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
II 1
FOR OFFI i4EONLY 7 1i I• init,;,•, ; /,1-inl10A.,,,l l /� -U
Quad No: i 1 APR L Llfl1 j ''` SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
J _ tr
ILL.!!! *writ bripinal to Division of Water Quality,Groundwater Section within 30 days
Serial No. y !. ; GW-1 REV. 12199

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ti R" v J 3-
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t11-'tt n, ills i) IC 1* I I )VV. II ni e4 rn C
WELL CONTRACTOR CERTIFICATION #: 4-4 - C�/WI
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential M Municipal ❑ Industrial❑ Agricultural C Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION• (Show sketch of th)location below)
Nearest Town: /-r/h P /u i /'Ci County: 71?6LAri_.-)
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
an
3. OWNER l /an/7•-rJ 431 et_IC F re From To Formation Description
Address (3 r r)ey_lu1 T L4
(Street or Roula No.)
City or Town Mate Zip Code COi '
4. DATE DRILLED J-/(f�)r m n^
5. TOTAL DEPTH •) b c r'
C7 c;_i
6. CUTTINGS COLLECTED YES fl NO0-
7. DOES WELL REPLACE EXISTING-WELL? YES fl NOD-- vfl `-r''
8. STATIC WATER LEVEL Below Top of Casing: / FT. -p ri—
(Use'.`II Above Top of Casing) --'i=,
9. TOP OF CASING IS FT.Above Land Surface' tv rn7.a
}
'Top of casing terminated at/or below land surface requires a variance In actor- 0-1 —r
dance with 15A NCAC 2CA 15 3
10. YIELD(gpm): 1 1 La METHOD OF TEST /O/lhl/I.77 �t1-
11. WATER ZONES(depth): /•2!' • / % i7 _
12. CHLORINATION: Type if t N ._.Amount '/Li /6 If additional space is -.of-led use back of form
13. CASING: SKETCH
,
Wail Thickness LOCAT:�N
Depth J Diameter or WeightFt. Material (Show direction and distance from at least two State
From 0To ^-) Y Ft. (r. ..— I/S(' P i - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material. Method
From (7 To Z N FL Jq_1_a1 -Tr ,21 r t A ;
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. ir. 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 WEL'_WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS REICORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY . . `A /•, n+%r t r /.LL;ieaAI.i "1- J y -- d /
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
' Submit original to Division of Water Quality.Groundwater Section within 30 days
Serial No. _� 'i m GW-t REV.12/99
n r1 �w

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section - 1 L
1636 Mail Service Center.Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: cj'Wflfl, e5 lCII ) A (* II1)r /1 ;Ae4rnc,
WELL CONTRACTOR CERTIFICATION#: 4-41- .-/76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Municipal 0 Industrial El Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other Ej If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: rI , ma V) In-n ea5 /L i County: /1'1" < L,--‘`.,
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ( -C otik Ct.t &• /L' O I Lc4 From To Formation Description
Address 1:3 c X `1I le
(Street Cr Haute o.)
1-ItrL1A0m d%C Air , . g 7w- I
City or yawn State Zip Code
4. DATE DRILLED ,r-.->2 -L' I
5. TOTAL DEPTH <-crr '
6. CUTTINGS COLLECTED YES n NO[�------
7. DOES WELL REPLACE EXISTING WELL? YES 7 NOrn-
8. STATIC WATER LEVEL Below Top of Casing: 5d•y FT.
(Use-+it 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 15A NCAC 2C.011a
10. YIELD(gpm): /r-` METHOD OF TEST /'I/0)/19-17 n�
.11. WATER ZONES (depth): /1 .5 ` /
12. CHLORINATION: Type /t It H Amount `i/U /6 If additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To #174) Ft. it. . r/kt' P 1 P . Roads,or other map reference points)
From To Ft. 4::,o
From To Ft - — CD
�
14. GROUT: m coo=i
Depth Material Method z cc",
From C To _ .,)a1\ Ft. 0 /M c r / r'l7 1 ; rn o<
From To Ft. -- -cy m�
15. SCREEN: ^' n
Depth Diameter Slot Size Material ry ma
From To Ft in. in. .r o
From To Ft. in. in co o
z
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$TANDARDS,AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY U' yn o+a,r - LIT,di;a A Q /v 0 /
Quad No: i , SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment ai.d Natural Resources-Division of Water Oualiry-Groundwater Section 2 2 4 1 C�
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] O
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'NI»), 9 'k' I) rt', a (112I I })c I ,el, '7)1 C,
WELL CONTRACTOR CERTIFICATION 4:•. 5r4-471- C/7G,
STATE WELL CONSTRUCTION PERMrVf1:
1. WELL USE(Check Applicable Box): Residential❑' Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION, (Show sketc of the location below)
Nearest Town: 7CA, 7,¢-ritllx- County: ) ,'rm 1
(Road Name arLd Numbers,Community,or•Subdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER ( '- G, L. et,,-c�. From To Formation Description
Address Ij 'A / Si i,
veer or ou,a
1�I C? h lrr-�tilc �� CNo.)'� k 7 Cu
City or down State Zip Code —
4. DATE DRILLED I- I --o 0
5. TOTAL DEPTH -Sn S : ,-
6. CUTTINGS COLLECTED YES Q NO 0-- ' cP„
7. DOES WELL REPLACE EXISTING WELL? YES n NO©— —
8. STATIC WATER LEVEL Below Top w Casing: FT. _ al
(Use'+'If Above Top of Casing)
9. TOP OF CASING IS J Fr.Above Land Surface' 3C ��,
'Top of casing terminated aVor below land surface requires a variance In accor- N UT a
dance with 15A NCAC 2C.0118
10. YIELD(gpm): ,--,Ir METH DOF TEST h/Ni/I, f1el/i" --1
11. WATER ZONES(depth):
[` //& e t co z
12. CHLORINATION: Type /t t/-) Amount ill (6 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From 0 To —L
q�/— Ft._JCL_ r ii•(1 n l C . Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From D To -) Ft. .I i„ .' , F im,,,v
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 HEREBY.CERTIEY -44ATTHiS'WEU WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCt(C'SN rAlf S Tf(AT(l COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7t, �� W_ ,
FOR OFFICE U,SB ONLY
I 14,,,,y; r I Alf'r;P?.4f r) / - c' -(..' /
Quad No: I SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW1 REV.12/99
Seria No.

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] 224109
WELL CONSTRUCTION RECORD WELL CONTRACTOR: •Neil n, 41 ih l ) (:-., a (*II )r. I I :h zy T11 c,
WELL CONTRACTOR CERTIFICATION #: .c-4 9- :`/7G, (I
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Box): Residential❑Municipal ❑ Industrial❑ Agricultural❑ Monitoring El
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:` '<-ter(Show sketch o the location below) /y'1
Nearest Town: -- / ��1) /r-rr•i( County: / 16_ Cr�� J(Road Name and Numbers.Community,otSubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER I'r. -). P:-, c` c, it; (-1, c /1 -) From To Formation Description
Address j-- h el c it l_._- L-el--A�.c
(Street or Route of
I )- II( � h o„ 4-.1 r�,3-7,...,q
City or Town . State Zip Code •
4. DATE DRILLED I —9-0/
5. TOTAL DEPTH an c' O
6. CUTTINGS COLLECTED YESEi
NO� O
7. DOES WELL REPLACE EXISTING WELL? YES n NOf r o
8. STATIC WATER LEVEL Below Top o'Casing: 7r '1 Ff. + Ern
rn
(use'i if Above Top of Casing) — p
9. TOP OF CASING IS / Ff. Above Land Surface* Cri ecru
-..--
"Top of casing terminated at/or below land surlace requires a variance In accor- -p -1
dance with 15A NCAC 2C.0119 fi
10. YIELD(gpm): Q5' METHOD OF TEST I)/l'H/I i 11 /— PJ m^
n
rn--
11. WATER ZONES (depth): /' /0C' C _ a— _,
Type t t/4 /t/ /n If additional spacez
13. CHLORINATION: T e —Amount is nee:ded use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weighl/R. Material (Show direction and distance from at least two State
From L To '' 7 Ft. (c '/A't' RI - Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To .'21- Ft. (i /•.an r , 'rIt 1 :
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 HEREBY CEBIIF.Y.,ZHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIC I' TA&7D/OBD At WATAiCO?Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
LLB to L L )V as r
FOR OFFICE USE NLY ���r ' 14 i" % 1 70j'(I n,I' n 7- / - e /
Quad No: - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
3ubmit!Original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section (-. �. r O 1
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] [l 1
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Tf i- n Ili t /4' 1 ) -4 1 c 2 f) ))` II ;1t ei. T/1 C.
WELL CONTRACTOR CERTIFICATION #: c-4--y- ,C/'74
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑,---
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: (-railCh hi free County: ,r,1 Ja C-c-vt
(Road Name and nNumbers.Community,orSubdivision and Lot No.) DRILLING LOG DEPTH K 3. OWNER ed C. Pre _. From To Formation Description
Address S4tit
qtr t or ou ro ran e l in/ a l'_ e Pfl t37
City or Town Zip Code •
4. DATE DRILLED J-f/o -0 1 O
5. TOTAL DEPTH -RnS' .- — _
6. CUTTINGS COLLECTED YES I Not i_f— L-
m
7. DOES WELL REPLACE EXISTING WELL? YES inNOn— S or;1
8. STATIC WATER LEVEL Below Top of Casing: be) FT. Ni =¢
(Use •it Above Top of Casing) N t'=r n
0
9. TOP OF CASING IS / FT.Above Land Surface' -o ,T o
-Top of casing terminated at/or below land surface requires a variance in actor- -y' Si m
dance with 15A NCAC 2C.0118 CO
tor
10. YIELD(gpm): IS METHOD OF TEST 7/-V,»7 I I1 �� O -I11. WATER ZONES (depth): /.37 r d-/96 ' I "- e
12. CHLORINATION: Type /t t/4 Amount '/t/ /6 It additional space is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0To 7 3 Ft.__L! •— ' /."(' Pi i Roads,or other map reference points)
From To Ft.---
From To Ft. —
14. GROUT:
Depth Material Method
From (.n To .^)-1N Ft. (I (on a ,a' .7; z
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 HEREBY CERTIFY THATIH4S.W1 4.L WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN-DA%0S, ,Np ITT 4 COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
"
FOR OFFICE USE-ONLY ''', ' :,i - /L,1''iI�" = /-fe -D I
Quad No: SIGNATURE OF PERSON CONSTRUCTING THE WIiLL DATE
Submit original to Division of Water Quality,Groundwater Section with%n 30 days
GW-1 REV. 12/99
Serial No.

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ; 2 ,} 6 0 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: .NPI>», `S Ij' ) ) r , r° 0)(211 t- /I "`el. 'Tn c'
WELL CONTRACTOR CERTIFICATION #: <4--9 -• /7G,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Sox): Residential a/nicipal El Industrial❑ Agricultural El Monitoring El
Recovery❑ Heat Pump Water injection ❑ Other ED If Other, List Use:
2. WELL LOCATION: Show sketch of a location below)
Nearest Town: /1 s2 re L' l'1`- County: n ) r,41`%+,,, i
(Road Name and Numbers,Community,&Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Pie V A-)r)1 ck. From To Formation Description
Address
0< (Street or Route No.) i7
•
f-1f{ -jH .r,t A/O___ ;71-eF73V
City or Town Stale Zip Code
4. DATE DRILLED / — A---2-/'/
5. TOTAL DEPTH C<5 5.
6. CUTTINGS COLLECTED YES n NOS t 1i
7. DOES WELL REPLACE EXISTING WELL? YES 7 NOH— o
8. STATIC WATER LEVEL Below Top of Casing: - 3 - FT. C.
(Use':if Above Top of Casing) "� o
9. TOP OF CASING IS I Fr. Above Land Surface'
o'er
'Top of casing terminated at/or below land surface requires a variance in actor- .� c;
dance with 15A NCAC 2C.0113 IV `c�,
10. YIELD(gpm): 16 METHOD OF TEST him/I, p Ai. rV -r
�4'c ' r _c
11. WATER ZONES(depth): 3 .0
ft#6J Amount `/c' /h II additional space is needed use back of!?On s7
12. CHLORINATION: Type y
N 13. CASING: O 0
LOCATION SKETCH o
Wall Thickness z
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To ;5 7 Ft. /f r i, t' P i ,,7 Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From — To ....2". Ft. If ill, r , �% • I ' ±
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS tANQTFRAT A COPY OF THIS RECORD HAS/BEEN PROVIDED TO THE WELL OWNER.
�� 117,')f ti-nIC1�, P � -, /=1 —O /
OR OFFICE USE ON Y DATE
Quad No: ;; I fJy L = 'SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality.Groundwater Section within 30 days,.Ini. GW 1 REV.12/99
Serial No. _. N ,. --Sac'`P..-. .

North Carolina-Department of Environment and Natural Resources•Division of Water Quality-Groundwater Section y c Q `^1
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] C. " rz 5 " `�
WELL CONSTRUCTION RECORD WELL ,I. 11 n, `s fir I) r, Aa 11)0 f I I-- i I n, el. r11 e,
WELL CONTRACTOR CERTIFICATION #: <- -- ,-/7/n
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Ul Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 71
Nearest Town: ) r1/01 (t�%n� 4- C - County: ,' / 2 a ( 'i 1
(Road Name and Numbers.Community,orSabdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ni)(ik t I trfl._ ( -/0 UE {?. From To Formation Description
Address V L3 .5-'1 /- tp rs is r
(Street or Rou o.) .,
LinCr/� r .fT, 3 -�t • �3o b .7 —
City or Town State Zip Code •
4. DATE DRILLED 1:iS%-0 /
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES❑ NO fl— O o
7. DOES WELL REPLACE EXISTING WELL? YES NOWT en a
8. STATIC WATER LEVEL Below Top of Casing: �n FT. ?^
(Use'*'if Above Top of Casing) "-' c cm
c'
9. TOP OF CASING IS / Fr.Above Land Surface' r..., 0ti
N m
'Top of casing terminated aVor below land surface requires a variance in eccor- >
dance with 15A NCAC 2C.oiiq -•-1,
10. YIELD(gpm): JV METHOD OF TEST /'/fit'/t r i' 'u--- = ^
coc
11. WATER ZONES(depth): ZS o y
12. CHLORINATION: Type /t t 1-1 Amount ' /r) if additional space is needed use back of form o
VC'
13. CASING:
LOCATION SKETCH
Wall Thickness
Depth Diameter or Weight/Ft. �M-a�te;ri^al (Show direction and dist(ncr from at least two State
From 0 To 701 7 Ft.__ .- 'ik"(' - G� Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To ,.'111 FL (r r'in c ,a% p;i)rt ,
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 HEREBY CERTIFY THATJHtS WELL WASCONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL.
CONSTRUCTION 9 ARD&"iAfi�t THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I
FOR OFFICE USE©��'�y" C ,,+nif r �"7^I,Ln,4, C bis --t
Quad No: yF l SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
r I ,� ' Submit original to Division of Water Quality,Groundwater Section within 30 days
a 1.Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section L ti' J 1 8 6
1636 Mail Service Center-Raleigh,N.C.27699-1536-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C.)\ /1, 5 fir l Lc.-., (I)9 l l 1)r f t n,>4 rn G
WELL CONTRACTOR CERTIFICATION #: .C4."- /76,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential D Municipal El Industrial❑ Agricultural D Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION)(Show sketch of the location below)
Nearest Town: /l'110,K /r)t/ A'e- County: '4/r ("icy?
(Road Name andn Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 73,( IC %- 4.//7 ry From To Formation Description
Address o2[/-c/ Lrtc f_ (l (0 J: -- —
c h (Street or Flute o.
IiCl He On . -3eo Igi
City or Town State Zip Code •
4. DATE DRILLED /-r?.5. 0 /
5. TOTAL DEPTH 7n_S
6. CUTTINGS COLLECTED YES 0 NO©---
7. DOES WELL REPLACE EXISTING WELL? YES n NOra— _.
8. STATIC WATER LEVEL Below Top of Casing: 30.0 FT.
(Ude':if Above Top of Casing)
9. TOP OF CASING IS I FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD(gpm): METHOD OF TEST h/in/l 17 fi�—
11. WATER ZONES(depth): .4.,./.6 ' `
12. CHLORINATION: Type /t f H Amount ill/ /1 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From C.) To •-z/ Ft. (r '/k t' P f ( , Roads,or other map reference points)
From To Ft. _c
From To Ft. o 0
14. GROUT: -*1 - ,.�
Depth Material Method rn a /-,
1,1
From 0 To ./l\ FL 0r'1„ , ,1( rt;,): 1 , 1 (-15:::From To FL ! C..T1 :
15. SCREEN: v r"'\'+
3 z;,t
Depth Diameter Slot Size Material w
rr
From To Ft in. in. W c.O y
From To Ft. in. . In. J a
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 VI AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ETM1PARP. A..M -THAtA.C/OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tiLt sr' �//.].. ��
FOR OFFICE USE 6d�' i 1- I(7 /s k'rb4'�r r /�1Qi)O/JA..i / -.vote/
Quad No: ;d ' SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
i, 7
i , Submt original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV.12r99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwa'er Section r; . - 1 '7 1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
O
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Pfl n, `c i1r f ) S (t)? I I I5 f'. i I Dt,4 r/1 c,
WELL CONTRACTOR CERTIFICATION At: c- - ,C/74,
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑Municipal El Industrial tEl Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: /—/'/2'1 t l'rt1 .4. ci - County: 474. f'H -
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,f1 Or L tL -V R A-,4/A- From To Formation Description
Address / ,. .3 i Ltd; d 4 7, 2.‘ /r-, i 224 LA__
(Streetor Route i4o.)
9
City or Town State Zip Code •
4. DATE DRILLED /- 3 d"— ' /
5. TOTAL DEPTH 4/ S S'
6. CUTTINGS COLLECTED YES IT NO J-
7. DOES WELL REPLACE EXISTING.WELL? YES n NOD--
8. STATIC WATER LEVEL Below Top of Casing: e,./fin 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 19,4 NCAC 2C.0118
10. YIELD(gpm): -s METHOD OF TEST /O/u//fr 1n !-
11. WATER ZONES (depth): �/ 5-1
12. CHLORINATION: Type if t N Amount '/l/ / If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth —7 Diame:ar or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To `7 / Ft. (' '/k"l' P 1 { Roads,or other map reference points)
From To Ft. —
0
From To Ft. — o —
14. GROUT: en_,
Depth Material Method rt i a..''''
From (7 To ;al` Ft, if r's„ i r., .n l'l t 1 .co m
1 1 c-
From To Ft. 01 -
15. SCREEN: -v --j�
Depth Diameter Slot Size Material 3 ` m
From To Ft in. in. (1)DC
C,
From _To Ft in. in. C'`1 ='
*-4 o
From To_Ft in. in. z
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. _
17. REMARKS:
IDO HEREBY'CERTIFY THAT T.IS�„''((E�a�i74, W S:CONSTRUCTEDINACCORDANCEWITHISA NCAC 2C,WELL
CONSTRUCTIIfTN 5'[ANDAR(ZS,ANLl'S:l7, *PY OF T•HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOROFFICEUSEONLY ''d�" 'l�^"1',? , /J7r')P/1"'.fl /_`3j� ,n /
Quad No: f1 f-�:?'.SIGNATURE OF PERSON CONSTRUCTING THE WELI DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GW-1 REV. 12/99

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section r7 I O
1636 Mail Service Center-Raleigh.N.C.27699.1636-Phone[phone] '-• •- . 1 CJ
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4)-0rt no es / I! Al (I.LP I l r- /I ;R<� -h. /1 C,
WELL CONTRACTOR CERTIFICATION 0: -, Z, /7/n
STATE WELL CONSTRUCTION FERMI-4:
1. WELL USE(Check Applicable Box): Residential ll.l- 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: !"Y e 7 nY/rhJ /A'> County: /210 rn,
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH n
3. OWNER /'1 pp, 7--ftTh f 2� lL-h- From To Formation Description
Address 9./ A/-,na/' r� ___
(Street or Rou{{{e No
[1/7nP.IA ) L/ — , 173L/
City or Town State Zip Code •
4. DATE DRILLED 1_61-c /
5. TOTAL DEPTH ,~2 '>
6. CUTTINGS COLLECTED YES C NOLij-i
7. DOES WELL REPLACE EXISTING WELL? YES E NOQ..--
8. STATIC WATER LEVEL Below Top of Casing: .4//,, FT.
(Use'+'it 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 15A NCAC 2C.0118
10. YIELD(gpm): /-- METHOD OF TEST /1/fin/l- Ir 6
11. WATER ZONES (depth): /00_, //C5 II-S5 •)2r t
12. CHLORINATION: Type it*14 Amount `/lr /(3 If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth e, Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To /- Ft. L.'. . r/PC P i Roads,or other map reference points)
From To Ft. — c'
From To Ft. o a
14. GROUT: T `- '
rn
Depth Material Method
From (7 To :1-/I\ Ft. is f.,1, f .:1= .0 ,),_1 : I c:_
I CIl -'-
From To Ft. _
15. SCREEN:
Trn
Depth Diameter Slot Size Material cA `rr
dj
From To Ft in, in. • c'
w -r
From To Ft in. in. • --1 z
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 ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS/BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICEUSEIONLY `/ i' •1';,; - /1-7,,,'(1/24..,( 1 / - 3/ -Y)
Quad No: ) . ' . SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
• 7 t t. S!bmit original to Division of Water Quality,Groundwater Section within 30 days
r{ JI i;
Serial No. . - GW-1 REV. 12/99

I_ L 4899
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: ,N-Pon, 5 Hz, I ) ri,. a 102I 15I . a >1 :)1 c
WELL CONTRACTOR CERTIFICATION #: <-&- - ,Z!'76,
STATE WELL CONSTRUCTION PERMIT#:
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 jShow sketch of thi)location below) /Y�
Nearest Town: /ii 91// /.1^r ///'— County: /'//n-4°/'i,
(Road Name and Numbers,Conxnun�ity,orSubdivision and Lot No.) DRILLING LOG DEPTH
c
3. OWNER (,tn 7` I5. ,7'-JL4211 TIE)-- From To Formation Description
Address .9a.., .° jet lce.._,5 4 ---- --
i (Street or Rout°No.) _
i Id,, f// '1/9-3
City or Town State Zip Code '- • o
4. DATE DRILLED -.Z1 S"✓ a / o 0
5. TOTAL DEPTH -it^ i — C,
6. CUTTINGS COLLECTED YES n NO©— C-- ice;
7. DOES WELL REPLACE EXISTING WELL? YES inNON
8. STATIC WATER LEVEL Below Top of Casing: 4,T FT. . K`,
(Use',- it Above Top of Casing) T-c
9. TOP OF CASING IS ili F ..Above Land Surface' o rn c
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15ANCAC 2C.0118 r:? TI"r
10. YIELD (gpm): !-'i METHOD OF TEST kWh)/f•-17 it(—
c3
11. WATERZONES(depth): 49c' e /44 [ •2t& fir co z
12. CHLORINATION: Type it t N Amount 1/4c' /? If additional space is needed use back of form
13. CASING:
Wail Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 1, To �L Ft. (( • r ik C' P f Roads,or other map reference points)
From To Ft.From To Ft.14. GROUT:
Depth Material Method
From C To �i Ft. _Lill, c-1l �
' n ,7r 1 ,
From To Ft. I
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From —To Ft. ia. 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'ISA N3AC 2C,WELL
CONSTRUCTION STANDARDS,AND TrIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT IE WELL OWNER.
17 /`.
FOR OFFICE USE D 15 L L II . 2vd r'it,e,r - /limit/Anr r S 'd '�
Quad No: i �.yy. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
j Submit original io Division of Water Quality,Groundwater Section within 30 days
Serial No. V 1 Y j( r�Rrr�� GW-1 REV. 12199
-o:l I c`.1i05

North Carolina-Department of Environment and Natural Resources-Division of Water Quality•Groundwater Section L. 6 4 9 10 0
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: f1.Pnn, 5 IJrI) r, A 0)2If P)r /I n-e4 TtlC
WELL CONTRACTOR CERTIFICATION#: C- - ,C/ -/4
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential❑/nicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �y
Nearest Town: '-7r771 P /17, 1 _l'G County: ./ a7 A/O-0�---3 ._
(Road Name and Numbers,Community.onSubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r7)Pl1).711 '7 in? C kat ) From To Formation Description
Address Ci '5 S / ,/,5y_,cr//'�!✓ if1r / __
(Street or-outs No.)
Flitt.,_U fr)J ,f/L— P/3 Y
City or Town State Zip Code •
4. DATE DRILLED ['OS-- n/ c
5. TOTAL DEPTH 57, r1 _
6. CUTTINGS COLLECTED YES E NO©— n
7. DOES WELL REPLACE EXISTING WELL? YES n NOQ/ o 11 I
8. STATIC WATER LEVEL Below Top of Casing: / FT. PJ r
(Use':it Above Top of Casing) tD c=ri
9. TOP OF CASING IS / Fr.Above Land Surface' -x, >�
'Top of casing terminated attor below land surface requires a variance In accor- i=i
dance with 15A NCAC 2C.0118
10. YIELD(gpm): /O.- METHOD OF TEST t)/m/1,7 i 11L- 1 ro
' .:
i co --I-I-r
11. WATER ZONES(depth): CO
`
12. CHLORINATION: Type /t 1-f-I ._Amount 'id in' If additional space is needed use back of form
13. CASING:
Wadi Thickness LOCATION SKETCH
Depth cof Diameter or Weight/Ft. Malarial (Show direction and distance from at least two State
From 0 To ` Ft.—CC.- r if't' P I : - Roads,or other map reference points)
From To Ft.From To Ft. -
14. GROUT:
Depth Material Method
From _ C To a1 Ft. _ 5h e 2'IT--- r I-)fiR, ' ,
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 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTLONLSIANIDA LQL ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE
1, �r , 1n�a,i t ; Idillie/,A1.,l i I r9 S — C I
•
Quad No: ?f r - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
){ yy" - Submit¢rlginal to Division of Water Quality.Groundwater Section within 30 days
Serial No. I'..l �i 1a1/ I ` GW-t REV. 12/99
i Crorindsvalsir Section
Asheville Recri rsl P.":-."

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section : ,:. r3 901
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] /I
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ,.�t1 )11 9 Pr I ) it a (C)''- I I I.
1I nt^4 Z11 C
Z
WELL CONTRACTOR CERTIFICATION#: r1- 7/�/
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential Q Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of tha location below) Cat—)
Nearest Town: Pra�1 v l ''- r(/('� County: "Ma C
(Road Name andNumoers.Coxnunity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER r 1 dL l0 fir i1 'G IL, From
From To Formation Description
3
Address / 33 2 �e -e Ad --
(Street or Route No.)
fr74 t fr.1, 4J .vt 02 873 V
City or Town State Zip Code •
4. DATEDRILLEDI'-Lt- o/
5. TOTAL DEPTH ei o.G ' tti
6. CUTTINGS COLLECTED YES 0 NOQ— 0 4
7. DOES WELL REPLACE EXISTING V.tELL? YES f] NO[ ...4- —
u
8. STATIC WATER LEVEL Below Top of Casing: . j FT. c_ e'_
(Use it Above Top of Casing) Sr?,
9. TOP OF CASING IS / Ff.Move Land Surface' o.n F-<
'Top of casing terminated at/or below land surface requires a variance In accor- o
dance with 15A NCAC 2C.0118 _15 m
10. YIELD(gpm): METHOD OF TEST h/m/I, fix 3 ^`ri
11. WATER ZONES(depth): t N c'
CO —1
co 0
12. CHLORINATION: Type /t I-N Amount ;�t/ / It additional space is needed use back of loan a-
13. CASING: '-T—
LOCATION SKETCH
Walt Thickness
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State
From L, To '13 Ft. fr.. ' (^ ' ./ Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From ._12___ To •(_Ft. __CL:n), : ,17 , O '9, ' ,
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 Sizo 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
CONSTRUCTI• ib.. •• 'e 1`- C YDF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
e C._ l�i i i /_i ere J
FOR OFFICE U`•' ra11LY i ��,tl /1 i/10/7 in
Quad No: 1 t ,; SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
t A`iA I p Submit Odgindylb Division of Water Quality,Groundwater Section within 30 days
Serial No.
GW-1 REV. 12199
-