Ya CY2002

WELL CONSTRUCTION RECORD 2 6 3 4 27
North Carolina - Department of Environment and Natural Resources - DDivision of Water Quality - Groundwater Section ,, //
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ^� YJ �t C ��• CERTIFICATION #�-ng7`� �/
WELL CONTRACTOR COMPANY NAME �! l-e .t)X JR �L•LL f% PHONE,//# ,(K�f/dl_� ti7' d l%p a
N/1
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ec.l J6x1 l L).2CrV ILIf
ASSOCIATED WQ PERMIT
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: 45-1.44-14.444/11-6 County iJ,IP..€41 `j2
Pius A—ey1Gc4' C. O
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
£c i-u4 ° 4/%C, 2,r7
L
City or Town State Zip Code
Area code- Phone number//�/ U
4. DATE DRILLED
5. TOTAL DEPTH: ,2 .1/.S
6. DOES WELL REPLACE EXISTING WELL? YE ❑ NO ,
7. STATIC WATER LEVEL Below Top of Casing: ( FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in aceordyynce with 15A NCAC 2C .0118.
9. YIELD (gpm): /8 METHOD OF TESTTi att
10. WATER ZONES (depth): SO'
11. DISINFECTION: Type__ __ Amount /0 02
12. CASING: Wall Thickness
Depth
,,�� Diameter or Weight/Ft. terial
From 0 Toycc^^er Ft. /#�/
From To Ft.
From To Ft.
13. GROUT:
From D
From
14. SCREEN:
Depth
Tostb_ Ft.
To Ft.
Depth Diameter
From To Ft. in.
Material Method ,
lt�l7'1�� J4.1 44—ty
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size Material
in.
in.
Topographic/Land setting
tii(Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from . east
two State Roads or County Roads. Include the road
numbers and common road names.
JJU 9i:l9HT
giOtAiYi
ut
(A �d
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
STRUCTING THE WELL ATE
n of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
1, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 2 6 3 4 2 8
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectionl7
WELL CONTRACTOR (INDIVIDUAL) NAME (print) I9h /141/ // E /3 ' ;ILL ,/, CERTIFICATION A
WELL CONTRACTOR COMPANY NAMEr-c./J'v .r 4../..4 Ll ()jilt 1J��L��/�J C/ PHONE 8 (034 V7- O tip
STATE WELL CONSTRUCTION PERMIT# V17 _ASSOCIATED WQ PERMIT# /il4
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: at:442/44.4.1 County
(Street Name, Numbers, Community, Lot No., Zip Code)
J /€ tu-
3. OWNERc- 4 GLr ube; in
Address //.:L O [210-4 Q 60 -Hari ✓ id
621-1.—t-t-eteid--e, 4' r, fl7
City or Town State Zip Code
Area code- Phone number., /
4. DATE DRILLED Y
5. TOTAL DEPTH: /1 r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A
7. STATIC WATER LEVEL Below Top of Casing: /D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS i•S FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3 t) METHOD OF TEST? -CacJ
10. WATER ZONES (depth): /Dh
11. DISINFECTION: Type .."2 Amount
12. CASING: v Wall Thickness
Depth, Diameter or Weight/Ft. 1� aterial
From_ D Ft. (s Y JJ 2-/ IYL�r
From To Ft.
(Street or Route No.) /
From To
13. GROUT: Depth
From ,h To &D Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I ]tQ H F>�Y Q R
J
Ft.
Material
lI Per t��Lv�
Topographic/Land setting
❑Ridge ❑Slope NValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Method�A7'
UL�
f THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ai rho .1 6 a�cv
9>/I�/D
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
yimii4 he the D vision of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
ASF'.�� *441 9) 733-3221, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tural 'C. Resources/ - Division of Water Quality - Groundwater Section �{
WELL CONTRACTOR (INDIVIDUAL) NAME (print) & !(// /vi7 � CERTIFICATION to gt/-�
WELL CONTRACTOR COMPANY NAME f'bit<✓)-r/��N -1122,9'1/,/ 74 PHONE # .d%/`J-G�d 9
STATE WELL CONSTRUCTION PERMIT# 1Z/ ASSOCIATED WQ PERMIT# 0111
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Neare Town: 2•11-nettLieg County Yg-.ej
r 7)77-/1/ ..147/11
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 5¶9%/2 eorit) r/ d
(Street or Route No.)
feu Mrs/ N• - ,,2K2/y
City or Town State
Area code- Phone number
4. DATE DRILLED // /61D L
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO PI
7. STATIC WATER LEVEL Below Top of Casing:y
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / 6- FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 5 METHOD OF TESTt—r1
10. WATER ZONES (depth). 4/j' - 2//
Zip Code
11. DISINFECTION: Type Amount
12. CASING: Wall Thiclmess
Depth Diameter or Weight/Ft. Material
FromPJ To �C/
From To Ft /
Ft.
13. Material`1�
,Ft. Cce-p 2t-.fit
From To
GROUT: Depth
From 0 To6-
From To Ft.
Method •
[.e N 12C.v
14. SCREEN: Depth Diameter Slot Size Material
From / To Ft. in. in.
From 7 To Ft. in. in.
15. SAND/GRAVEL PACK:
th Size Material
From To Ft.
From To Ft.
.(LP4 vl,.a
264792
Topographic/Land setting
❑Ridge ❑Slope ❑Valley PIFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH PRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles §bm at least
two State Roads or County Roads. Include the road
numbers and common road names/
ye'./ rtizre,/
r—YH6-ti E84CEK Tf�AT THIS WFI T WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST hRDS, AND THAT A COPY OFT THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/7Jai/ //// /D
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
O
fV
0
rn
0
GR (� A �ER ScC,T10 the Division of Water Quality,Groundwater Section,1636 Mail Service Center -NC
ASHErtrMI9R Raleigh,
./oyy-l.hso Phone No. [phone], within 30 days. GW-1 REV. 07/2001
c_
0

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME(% (p�r�i,nt,), ALL Al t/�1' h/,� d de 5 •�. CERTIFICATION/#//...270.
'/ �
WELL CONTRACTOR COMPANY NAME ,g-OC.Ll't--k-1.•-el e I .l_L/ e/ 7&C•PHONE # yw4ji S ‘ y 9—o4 o l
STATE WELL CONSTRUCTION PERMIT# // ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential t Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
263424
2. WELL LOCATION:
Nearest Town. 2 47././2 County
n.
tatif
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: £ ,%-4- l c O�d
Address
(Syrt or Route No.)
City or Town State
(� 476
Area code- Phone number
4. DATE DRILLED 9///t 1 (') L
5. TOTAL DEPTH: .2 G -'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 95.5— FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / .S' FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .01IS.
9. YIELD (gpm): yes, METHOD OF TEST2Ztir
10. WATER ZONES (depth): 9 S I
Zip Code
11. DISINFECTION: Type
12. CASING: `/
From_ To `h"Y G
From To
From To
13. GROUT: Depth
From © To &D
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From / To Ft.
Diameter
FL
Ft.
Amount ? ° z
Wall Thickness
or Weight/Ft. terial
Ft. (aterial
r 44-2e-rQi
Method ,
w.N-rr
Slot Size Material
in.
in.
From To Ft.
16. REMARKS:
.aa
_1
Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
PEPTH DRILLING LOG
From To Formation Description
JOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
f
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND THAT A COP • - IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7
Sub
a769911'
ASHEVILLE
IGNA
O ON CONS
CT G THE WELL DATE
DIvi:IOn of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
i J i4.41 1-733-
1, within 30 days. GW-1 REV. 07/2001

2582Zn
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesu`- Division of Water Quality Groundwater r Secti# on 36
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
50.V HONE # (479 illI5-119nr
ASSOCIATED WQ PERMIT#
Cif licable)
WELL CONTRACTOR COMPANY NAME)
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential 1 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELLLOCATIOR:
Nearest Town: kt-yy""r)-5 JtO•e_ County t
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
t h IIIM Ini- Nc
City or Town State
a5s�
Area code- Phone number
4. DATE DRILLED —I- ter CZ
5. TOTAL DEPTH: ' . ` 5 ---
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO P
7. STATIC WATER LEVEL Below ( Top of Casing: FT.
if Above Top of Casing) .
8. TOP OF CASING IS 1 FT. Above Land Surface'
'Top or casing terminated at/or below land surface requires a
A
AC 2C
variance ginre,): accordance w, li METHODg9. OFTEST !Zs''at
10 WATER ZONES (depth):
a'e' II
Zip Code
Topographic/Land setting
DRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
3`t
LOCATION SKETCH
a tI Yr, Amount Show direction and distance in miles from at least
1 1. DISINFECTION: Type Wall Thickness two State Roads or County Roads. Include the road
12. CASING: S
Depth Dia etcr or Wei hdFt pM�aterialnumbers and common road names.
,�
From 3,_.— To—� L — Ft._k L_ tL -ice"
From To Ft.
From To Ft.
Material Method
13. GROUT: Depth ^ ew r Po..Ced
From__Q_— To_�d — Pt. t'
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
To Ft. in. in.
From From To Ft. in. in. —
15. SAND/GRAVEL PACK: Material
Depth Size
From To Ft. ------
From To Ft. —"----
16. REMARKS:
_—Submitthe arigitial to I
47p?9L1636 Phone No. (91
0
ry
LI
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-0Z.
SIGNATUR �F PERSJN 0NSTRUCTING THE WELL DATE
NC
he Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenter1 RREVgh, NOl
9) 733-3221, within 30 days.
c

ella. -,4 a /j/C. o2Alfly
City or Town state
Area code- Phone number
4. DATE DRILLED /%/n `L
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Y/ T
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS /,jam FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0118.
9. YIELD (gum):_ METHOD OF TEST
10. WATER ZONES (depth): ijS ' 000 n r
Address frt/± 121-41.? J./ orO- CP
(Street or Route No.)
Zip Code
Topographic/Land setting
WRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
1 I. DISINFECTION: Type sf%.S
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
.7/J
WELL CONTRACTOR (INDIVIDUAL) NAM �fs (print) �p�DA/ 4// r ,(34L1_ CERTIFICATION/[t.Lpd /
WELL CONTRACTOR COMPANY NAME—ee.9_(4JQYy tAJ.t 6 l/1�4j, • PHONE # 6[p�j-Q9Bd
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
26017
4/7,
I. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town County/c,�%
(Street Name, Numbers, Community, Subdt)aon, Lot No., Zip Code)
3. OWNER: /4
7OL
12. CASING. Wall Thickness
n Depth Diameter
From t/ To cX () Ft [P
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To do FL CPityl¢.5` 1 kJ .!- //2€
From To Ft. Y
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Amount
or Weight/Ft. M terial
#-a/
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Size Material
Ft.
Ft.
(kJ -I HrCE¶2TIffy TWA
&ST C ION TA DkR
n
tv
LOCATION SKETCH m o
Show direction and distance in miles from at least:
two State Roads or County Roads. In Iude the road
numbers d common road names. 0 tam
16 WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
NATURE OF PERSON CONSTRUCTING THE WELL DATE
Suitmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
2769@pC6Q(il19ViaENomihi33-3221,within 30days. GW-1 REV. 07/2001
ASN.EVILLE REGIONAL O! FICE

255023
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Cl/ de k 50.t1st7 e^S CERTIFICATION # at"{ Alp
WELL CONTRACTOR COMPANY NAME Nile 0 vs s -21, .S0fl Well rf../Mr _VLC PHONE # (878) a55 nee
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential ET Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: `/
Nearest Town: /)ure5d itf County rant.'/'
(Street Namc. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Reltt Ro1rnse'—
Address PO sox igoo
(Street or Route No.)
A.ds$ 11 /UL 2t754
City or Town State Zip Code
(S24 )- (d . aSao
Area code- Phone number
4. DATE DRILLED S. wet.
5. TOTAL DEPTH: 2205
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I
7. STATIC WATER LEVEL Below Top of Casing: RC) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated aUor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): Zo METHOD OF TEST_ AtR
-
10. WATER ZONES (depth): h
11. DISINFECTION: Type fri%s
12. CASING:
Depth Diameter
From 4-1 To 13o FL
From To Ft.
From To Ft.
13. GROUT: Depth Material
From (7 To ao Ft. Cenent
Amount 7
Wall Thickness
or Weight/Ft. Material
1k21 �l25
i ..
Method
(Jo ore el
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
16 REMARKS'
DC) F/FR7'Tt<
CONSTRUCTI
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
4l ISO Over Aerdnn
1So 325 (rran;te
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Zit
0
(.11
CO
—IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
^ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
se -pi 62
SIG
Cr nH';Cb<ASiibWiitItheloriginal to the Division of Water Quality, Groundwater Section, 1636 Mail Service CGWrI - REVgh, NC
ASHH.L' EEii �44l ni ne Na. [phone], within 30 days.
CONSTRUCTING THE WELL DATE

254762
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural •pl+,, /,rurces - ivision of Water (Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)is.5YItiU-'cj ls��I i�S lC CERTIFICA�TIIOjN# j��`(3�
WELL CONTRACTOR COMPANY NAME ►4o, f kick Y v�..IA %l riJ } IAA a PHONE if fir CP D5 -I z. z-3
ii t+ - 1.1c5
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ FERMI
• (ifa. Iicable) (ifa licable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLLOCAT:
Nearest Town: %A. ")-C CC 1 8
County I,Sa KnC L f
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: )O ?-(-`e I
Address V-OtifiK ) \'C
(Street or Route )
1//lvIc5)))i12 -(1
City or Town State
Zip Code
Topo�gr�a�phic/Landsetting
❑Ridge EJSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
( )-
Area code- Phone number _
4. DATE DRILLED `3 - Z 1 -0 2-
5. TOTAL DEPTH: ZZ.'-I / r"
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO B' L.)�r Lo
7. STATIC WATER LEVEL Below Top of Casing: LvO FT. C.
(use "+•'i(Above Top of Casing)
8. TOP OF CASING IS ) FT. Above Land Surface* ry
*Top or casing terminated at/or below land surface requires a ,
variance in accordance s Rh ISA NCAC 2C .0118. n /Q 1
9. YIELD (gpm): tom METHOD OF tT't,d I • l Ihy
10. WATER ZONES (depth): I ,�7w,)i Z l/
1 I. DISINFECTION: Type Ti f:��.�'•r Amount ?J
12. CASING: Wall Thickness
Depth a,..;; Diameter or WeighUFt. Material
From To 5 k' Ft. ('j
From To Ft. 1 `-( Z
From Toe FL I' l , I
13. GROUT: Depth ,y MatcnaJ /� Met W (_,If I
From To FLC "d1'1 et-Q`t& rfr ^ 1From To Ft. )--I L6 I . I �-(
14. SCREEN: Depth Diameter Slot Size Material '"I 1
From To Ft. in. in. y ,p a
From To Ft. in. in. V- T �.
15. SAND/GRAVEL PACK:
Depth Size Material
0
From To Ft.
From To Ft.
16. REMARKS:
C
mr
Show direction and distance in miles from at law -.-i
two State Roads or County Roads. Include the Ind c
numbers and common road names.
LOCATION SKETCH
v rFRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
Odr SN ST y ' pS IAN AT A CO OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CrAr
S
Sabmit t lc original to the Divisi ir'o�l
21699 1 36 Phone No. (919) 733-32 I, wit
GFC', UPI
ASH t (� FICE
E OF PERSON CONSTRUCTING THE WELL
DATE
'ater Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
in 30 days. GW-I REV. 07/2001

253165
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) el A r' '-},i-i C.E CERTIFICATION # -01/ 5t
WELL CONTRACTOR COMPANY NAME _ 50`d-Icc, t tic DJ br; LC(NIC] PHONE#
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential CV-Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: (30(�('✓/4J3C 114
ny7
(Street Name, Numbers,/CoMln unity, Subdivision, Lot No., Zip Code)
3. OWNER: /(,o(.r2n.il
Address (if.* t5a)c 3?/
(Stint or Route No.)
5/[,)(FP'L't tQC
City or Town State Zip Code
ftg )_ t,75 - 1059
Area code- Phone number
4. DATE DRILLED Li- /
5 TOTAL DEPTH: ' / /^
County 4Gte
4z earl-7
6 DOES WELL REPLACE EXISTING WELL? YES
❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Co_ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 1C .0118.
9. YIELD (gpm): _ METHOD OF TEST ' -
10. WATER ZONES (depth): o"/ / '5
11. DISINFECTION: Type. (e»f rV a WAmount all tknes�i02
12. CASING:
Depth Diameter or Weight/Ft. Material
From_C To _r__Ztr— Ft. V Ya Pi
From t' To_S—Ft• Pie
From'(-. To 14 FL / 9 (4
13. GROUT: Depth
From To Ft.
From Li To Zz
14. SCREEN: Depth
From_ To
From_ To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
I DO HEREBY CER
CONSTRUCTION ST
GROUNDWATER SECTION -
ASh'EVI L- REG,NAL.GFfI E Division ofWater Quality, Groundwater Section, 1636Mail Service Center
IREVg072001
27699-1636 Phone No. [phone], within 30 days.
Material
Ft. 2 sJ
Diameter
Ft. in.
Ft. in.
Size
ethod
Slot Size Material
in.
in.
Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH pRILLING LOG
From To Formation Description
b
I OCATION SKETCH_
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
;gtc.& P?pc
7 ' c #Ica
maid tier'
O
I. THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S, AND THAT A COP DIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ti
S
A OF PERSON CONSTRUCTING THE WELL DATE

255095
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - }Division of Water Quality - Groundwater Section
WR WELL CONTACTOR (INDIVIDUAL) NAME (print)✓^7 A UN f e D f} L 1 CERTIFICATION #? O 77
zatleglahswa
4//^7
WELL CONTRACTOR COMPANY NAME /w.�l� PHONE #
STATE WELL CONSTRUCTION PERMIT# A,f./ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N:
Near st Town: County a'e
(S Name, nbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:J"
Address'/4/ /2t1 2
nAir'-
n,r T ew.ur
62.-p3/
Area code- Phone number
4. DATE DRILLED 'y//G / D t.
5. TOTAL DEPTH: 19 S
6. DOES WELL REPLACE EXISTING WELL? Y S ($ NO 0
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
/
8. TOP OF CASING IS 5 FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .011S.
9. YIELD (gpm): / D METHOD OF TEST kern.,
10. WATER ZONES (depth): 5/$-t
Topographic/Land setting
❑Ridge i�Slope ❑Valley ❑Flat
((check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
(Street or Ro a No.)
ity or Town tote Zip Code
11. DISINFECTION: Type Amount Jf) oZ
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From__ To T. +< Ft. lr .„2/ p yP
From To Ft.
From To Ft.
13. GROUT: DepthMaterial Method
From(_ To 3-5-Ft. L � �2Gais� (1J e m ' y
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the oaa
numbers and common road names.
Pace) dew'
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
t
es
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
ivision of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
3-3221, within 30 days. GW-1 REV. 07/2001
Ho►S'

WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section' e
North Carolina -rep (" CERTIFICATION a `l .sC)
WELL CONTRACTOR (INDIVIDUAL) NAME (print) `� PHONE 8
WELL CONTRACTOR COMPANY NAME ,J U J'f'.ZG V� �" ASSOCIATED Lc
WQ PERMTra
STATE WELL CONSTRUCTION PERMIT* if applicable)
if a Ipp icable /
1. WELL USE (Check Applicable Box): Residential [8 MunicipaI/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: L'
Nearest Town: LLe County 1/TLL
1c)"L.
(Sheet Name, Numbers, Community, Subdivision, tot No., Zip Code)
3. OWNER: godCr e HCR 1' N c
Address 1 °1 tS
(Sheet or Route No.)
v(.aSthLLC fU (--
City or Town State Zip Code
(n75" 5541 3
Area code- Phone number
4. DATE DRILLED i' /' O L
5. TOTAL DEPTH:
6 DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: (, n FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Top or casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.r
9. YIELD (gpm): METHOD OF TEST % /
10. WATER ZONES (depth): Z. c ` .'-' 62' /
11. DISINFECTION: Type U L 0t t a
12. CASING:
Depth Diameter
From To FL----r— —T— �,
.
From 0To W- Ft (OJ G' — /�`Ji (,
From_E To_j Ft— I / TIC'\ GRL
13. GROUT: Depth Material Method
From To FL
From C To ,2 0 Ft. 1 i I
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: Sue MaterialDepth
To FL
To Ft.
Topog ap d setting
❑Ridge Pgrope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRrt r ING t OG
From To Formation Description
Wall Thickness two State Roads or County Roads. .1-
thfload
Inc1
oc
rn�
LOCATIONKET SCH o rnz
Amount $i C 2 C' if el, Show direction and distance in miles from at
or Weight/FL Material numbers and common road names.
From.
From
16. REM
RE C f
CONSTRUCTI
GROUNDWISi8Sh6tdfi✓*'itinal
ASHEVILLE R. ID'u
o Q
f1f6
ISA NCAC 2C, WELL
Y THAR S, AND THAT A COPTHIS WELL WAS Y NOF THIS RECORD HAS BEEN PRSTRUCTED IN ACCORDANCE OVIDED TO THE WELL OWNER
ATURE`
o the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenterl REV. gh, C01
[phone], within 30 days.
251051
SI
PERSON CONSTRUCTING THE WELL DATE

North Carolina - Department of Envimnment and Natural Resources - Division of Water Quality - Groundwater Section
P.O. Box 29578 - Raleigh, N.C. 27626-0578-Pho e (919) 7333221
248724
WELL CONSTRUCTION RECORD DRILLING CONTRACTOR: Ca —a -ri Gveb" 17n f (tr4
1, 2/SV
DRILLER REGISTRATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 171 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection El Other Q If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: P). crtit Li-t County
(Road. Comm N(yian anC I,ot No.)
3. OWNER �/�u, �'
ADDRESS
(Street or Route No.)
Olt.44t/LCt TVO
City orTown State
4. DATE DRILLED .2-i7
5. TOTAL DEPTH l
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES [y NO�
LEVEL Below Tap of Casing. FT.
(Use- LfAbove Tap of Cask*TOPSTATIC OF
WATER CASING IS / FT. Above Land Surface '
• Casing Terminated anon below
w land surface is Begat urdess a variance is issued
10. YIELD ( m): E''67 METHOD OF TEST �
DEPTH
From To
-g2
DRILLING LOG
Formation Description
A;rtfF /2“k S*a
� 9 - ir, s (T�'cilQx )"e�P
Zip Code
S.
r
in accordance vial 15A 2C .a118
9P 0-,
. 11. WATER ZONES (depth): 4, O %P"M s
12 CHLORINATION: Type R 241-t
13. CASING:
Depth. J _ Diamer
From �To 3 w Ft tv lie
m-Z Frok— To 'g T> FL UPI /y
From To Ft
14. GROUT:
Amount Pot e
WaR Thickness
or WeigM1Ft Material
Pit
./4g 84,d
Depth Material Method
From To Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in in
From To Ft. in in
From To Ft. in in
16. SANDIGRAVEL PACK
Depth Size
From To Ft.
From To FL
17. REMARKS:
FOR OFFICE
Quad No.
Serial No:
Material
d NAL OFFICE
..
c
If additional space is needed use b cc.,,)� (r •
of gnn
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
r
(1CTED IN ACCORDANCE WRH 15A NCAC 2C, WELL
F THIS RECORD . S BEEN PROVIDED TO THE WELL OWNER.
CONTRACTOR ORAGFM DATE
Ditislon of Water Quality and copy to well owner.
GW-1 REV. 1198

246113
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) REUBEN CALDWELL CERTIFICATION # 2140
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, IN.
)54-3581
STATE WELL CONSTRUCTION PERMIT# 1537 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential d Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: County `fA;-� L 7
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER:I:/LN..--rne0zc-LhQ
Address t?" r i?re.l !G ti 3
i
(Street or Roue of
City or Town State Zip Code
(g-140- S' 91, - o.i7k
Ara code- Phone number /
4. DATE DRILLED % j / rr / u :Z.
5. TOTAL DEPTH: ' 7 4,-6
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surfaces
*Top of casing terminated at/or below laud surface requires a
variance hi accordance with 1SA NCAC 2C .0118.
9. YIELD (gpm): / ti' METHOD OF TEST ff / L-
10. WATER ZONES (depth): .71-f
11. DISINFECTION: Type f Ili , Amount —
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From i f To 7 I Ft. (o a 7 PC('
From To Ft.
From To Ft.
13. GROUT: Depth Material , ildethod
From ..) To 2-0 Ft. 72.-1//.r/t /
ic:,LLIF
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
D
I DO HEREBY t)ERTIFY'�1 A']
CONSTRUCTION STANDARID
MAR 2 7 2002
sl
GROUNDWATER SECTION
ASQhbm Otero/tig?hatto0e Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
1
crte—
DEPTH
From To
v - /G
/ci - 7--I
9/- 4, (-7
7.C-'1-
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation DeFription
t'n '-i
o____
LOCATION SKETCH r c-
r:v,
Show direction and distance in miles from *Past n `_
two State Roads or County Roads. Include roa6l
numbers and common road names.
N
ac
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
RSON CONSTRUCTING THE WELL
0

North Carollna - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Censer - Raleigh, N.C. 27699-1636-Phone [phone]//,' J
WELL CONSTRUCTION RECORD WELL CONTRACTOR. Xe RinAN 4 • 2A-((,
WELL CONTRACTOR CERTIFICATION #: aCe' 7
STATE WELL CONSTRUCTION PERMIT#:
i
26891'7
1. WELL USE (Check Applicable Box): Residential Q. Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) v
Nearest T wn: V 1 l l? County: 10.V1 C 2.l
_5 kPd. ka,p.s fir a87/n
(Road Name and Numbers. C(ommmunity, or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER Terr 1 ' III le r From To Fonnat!on Description
Address p[�
�6 re er RoAeo) 0 - 14 P R t
ttulrnsyi_I le NC a$11'-1 7 q - a65 Tr-rjl2or k
City or Town Stale Zip Code
4. DATE DRILLED a- I3-Aa,
5. TOTAL DEPTH 205
6. CUTTINGS COLLECTED YES f NO l
7. DOES WELL REPLACE EXISTING WELL? YES in NOM'
8. STATIC WATER LEVEL Below Top or Casing: 90 FT.
(Use's' II Above Top of Casing)
9. TOP OF CASING IS___1_ _ 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): IC- METHOD OF TEST RJ no
11. WATER ZONES (depth): .c-
Ql c,
w
Z
fV
CHLORINATION: Type it TH Amount j3.5 pr/15 If additional space Is needed use back of form
CASING:
From
From
O
From
14. GROUT:
Wall Thickness
Dmeter or WeighVEL Matedal
epth
%� Fr b 25 ,a)t,/ 5 PV65,01 .
To — Ft.
To Ft
Depth Material Method ,
From ii To d. o FI C'aONC�.Ei E �le.a`!1-
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To Ft. In In
16. SAND/GRAVEL PACK:
Depth Size Material
To
From
From
17. REMARKS:
To
FI
Ft
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
�c�cl�s C r ee-k
O
W
17' 1
CO
CO
O
W
I DO HEREBY CER IFY THALTHIS WEI
CONSTRUCTISN NiDAROS, AND THATIA GOP
UCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
PHIS RECORD HAS BEE OVIDED TO THE WELL OWNER.
�� a-ce a I'D-c1a
URE OF PERSON CONSTRUCTING THE WELL DATE
sion of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

North Carolina - Dapertmonl of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1638-Phone [phone]
268916
WELL CONSTRUCTION RECORD WELL CONTRACTOR• 1Yo RmAM Z.
WELL CONTRACTOR CERTIFICATION 0: o?O.3 7
STATE WELL CONSTRUCTION PERMIT":
WELL USE (Check Applicable Boa): Residential I✓I Municipal n Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location
below))
��
serest Town: WA ^ - 'DOOM l�/( 2/60 �
3.
(hoed Name end Number, Community, or Subcrlvlslon and Lot No.) DRILLING LOG DEPTH
OWNER �d y Cry, Urn* Roth", Pno8rC?pl From To Formation Description
Address Qoy � O
Ireo or Roo e o.) 0 - 76 D1'R F
0-y rie
City or Town �1 J
4. DATE DRILLED !
5. TOTAL DEPTH ter_
d. CUTTINGS COLLECTED YES I I NO171-
DOES WELL REPLACE EXISTING WELL? YES J J NO(/
3. STATIC WATER LEVEL Below Top of Casing: Lfrj FT.
i(Use -.- if Above Top of Casing)
2. TOP OF CASING IS FT. Above Land Surface'
'Top of cm sing terminated auor below land surface requires a variance In scoot,
dance with 15A NCAC 2C .011E
10. YIELD (gpm): g METHOD OF TEST �.
i 1. WATER ZONES (depth)
76- 5 Bckgck
/17
Slate
R8427
Zlp Code
0
Cr)
r.,
IV
'-O
12, ^LILORINATION: Type H / ! l Amounl J II additional space Is needed use back of form
3. .SING:
Wall Thickness
Depth Diameter or Weight/FL. Matedal
From 0 To 75 FI 1r •a 5 ,?)&bl PJC.SDR
From To FI,
From To Ft.
4. GROUT:
Oepih Malerlal Methodf1ll. From b To al-° FI i'bf(CPFin
'F �L
From To FI
5, SCREEN:
Depth Dlamelar Slol Size Materiel
From To PI In In.
From To FI In In
From To FI In. In
6. SAND/GRAVEL PACK:
Depth Size Malerlal
From To FI
From To FI
7. REMARKS:
rn c
LOCATION SKETCH
(Show direction and distance from al least Iwo Stale
Roads, or other map reference points)
area) Oa/ Dr; ✓e
OCon C.
I DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION ST • 94R89; At3D1ttAT A Y;fJ - ii L ECORD HAS BEEN PRIDEO TO THE WELL OWNER.
r-.
F OFFICE USE 0
t. No:
Serial No
u L.
siON/j{ n
Submit original to OIL"
F PERSON CONSTRUCTING TIIE WELL DATE
Wale, Duality. Groundwater Section wllhln 30 days
GW.I REV, 12/99

North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section 268901
1638 Mall Service Center - Raleigh, N.C. 27699-1638-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /!'D RMAN • 2, (�,
WELL CONTRACTOR CERTIFICATION #: ..,?De 7
STATE WELL CONSTRUCTION PERMITA':
I. WELL USE (Check Applicable Box): Residential I✓f Municipal n Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2, WELL LOCATi 4 (Show skelc 1 of the location below)
rest Town: KDDi rt5V I County
(noed Name an. Numbers. Community. or Subdlvlslon and Lol No.)
3. OWNER lavc1c5V 5;IV\P s
Address -pc{fix �13
real or Rae No.)
-Uurvlsvi Ile NC,
Clly or Town Stale
I. DATE DRILLED ra"ID- Oa.
TOTAL DEPTH aor,
5. CUTTINGS COLLECTED YESJ l NOI4
DOES WELL REPLACE EXISTING WELL? YES n NOFV(
i. STATIC WATER LEVEL Below Top of Casing: tin FT. p
(Use •+- I1 Above Top of Casing) w
7. TOP OF CASING i5 / FT Above Land Surface'
Top of casing terminated et/or below land surface requires a valiance In actor- -ri
fence wllh 15A NCAC 2C .0118
0. YIELD (gpm): q METHOD OF TEST R : 3 ry
1. WATER ZONES (depth):
DRILLING LOG DEPTH
From To
-$a
410-�J
Formation Descdptlon
ivp
•&LRpcic
2. n'ILORINATION: Type
3 SING:
From
at-114
Zlp Coda
TN
Amount 1 If additional space Is needed use back of form
Wall Thickness LOCATION SKETCH
D �v Depth Diameter or WglpilvFc. Material (Show direction end distance from al least two Slate
IC)
.1*
��5
To Ft T ad� �161�5 A Roads, or other map reference points)
From To Pt.
From To FI
4. GROUT:
Depth Malarial Method
d
From D To vZ0 FI ('vNC3EEiE �
From To FI
5, SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To FI In In
From To Ft In In
6. SAND/GRAVEL PACK:
Depth Size Material
Rom To FI
From To FI
7. REMARKS:
Possum Trot
lap v-ins vale, NC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ;?tANDARD$, AND THAT A COPY 6 N-IS RECORD HAS BEEN PROyDEO TO THE WELL OWNER,
F OFFICE USE eN(:,
1. No: 1
Sedal No
SI
Submit odginal j
A IIJ1E OF PERSON CONSTRUCTING TIIE WELL DALE
bn of Water Duality, Groundwater Section within 30 days
OW- i REV. 12/99
0

North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1630 Mali Serylce Center - Raleigh, N.C. 27699.1636-Phone [phone]
268904
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /1 e RmAN Z . LL.
WELL CONTRACTOR CERTIFICATION F: o7O-9 7
STATE WELL CONSTRUCTION PERMIT#:
1 . WELL USE (Check Applicable Box): Residential ✓I" Municipal n Industrial ❑ Agricultural D Monitoring ❑
Recovery D Heal Pump Water Infection ❑ Other El II Other, List Use:
2. WELL LOCATI• : (Show sketch of the location below)
Near- Town: County' \kilt(Q�
e_ I el
(Floe. Name end Numbers. Commune v. or subdivision and Lol No.)
3. OWNEP, TO—flyer)t\c Martin
Q 4
ree or I ou a No, l
ISU ail Q C
dress
City or Town Stale
4. DATE DRILLED -3- -CCi'
>. TOTAL DEPTH 'oa1-1O
5. CUTTINGS COLLECTED YES I I NO(/
DOES WELL REPLACE EXISTING WELL? YES I J NO(V
?. STATIC WATER LEVEL Below Top of Casing: .?)cj FT,
/ (Use -s• 11 Above Top of Casing)
?. TOP OF CASING IS 1 FT. Above Land Surface•
DRILLING LOG DEPTH
From To
D -
104 -atie
21p Code
Top of casing terminated at/or below land surface requires a verience In scoot-.
lance with 15A #CAC 2C.011E ��77
0. YIELD (gpm)' 1GO METHOD OF TEST
I. WATER ZONES (depth)'
Formation Descdpllon
1)s'R -1'
B&dtQc
CO
2. "LILORINATION: Type r! 7! I Amount `Thfi.ULS If additional space Is needed use back of form
3 .SING:
Depth Diameter
From To (04 FI la • a 5
From To FI.
From To FI
4. GROUT:
Depth
From 0 To xn 0
Wall Thickness
or W ightFt. Material
QI/,J PI/C•SDK
NIatonal
FI (Of1 Cfl t t
From To FI
5.SCREEN:
Me Iliad
inou.e fdw
Depth Diameter Slot Size Material
From To FI In. In
From To Ft In. In
From To Ft In. In
8. SAND/GRAVEL PACK: '..
Depth Size Material
From To FI
From To FI
7. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points)
Too+ e5 C week
he yiev;lle, K -
0
0
Fri
7-0
I DO HEREBY
CONSTRUCT
F OFFICE
I No:
Serial No.
�7 TIfY TttlYHI IJS WELI. WAS • • STRUCTED IN ACCORDANCE WITH 15A #CAC 2C, WELL.
�I "¢ 4ND (IDS, ANC1 THAT 4C� THIS RECORD HAS BEEN PRFl IDED TO THE WELL OWNER.
ONLY
u I'
S
Submit od[.•.. o Division of Wales Ouallly, Groundwater Section within 30 days
ATUfTE OF PERSON CONSTf1UCTINO TIIE WELL DATE
GW1 FIEV. I2/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1630 Mail Service Center- Raleigh, N.C. 27699-1638-Phone [phone]
268895
WELL CONSTRUCTION RECORD WELL CONTRACTOR- /TeRmAN L. 24-Z(.
WELL CONTRACTOR CERTIFICATION 0: c;O.,;
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable sox): Residential ✓I T Municipal (l Induslrlal 0 Agricultural El Monitoring ❑
Recovery in Heal Pump Water injection n Other n II Other, Llsl Use:
2. WELL LOCATION: (Show sketch of the location below)
crest Town: hji din y /e County XIcL" y
(noed Namer—�Ylt�end Number, Commuplly, or Subdivision end Lot No.)
3. OWNER � pa/C
Address R-f. x
ISlreo or l oule Py:Irnqvige j11
City or Town Slate
4. DATE DRILLED 31-15-0a
5. TOTAL DEPTH,
6. CUTTINGS COLLECTED YES ( I N0 4
7. DOES WELL REPLACE EXISTING WELL? YES I I NO71
d. STATIC WATER LEVEL Below Top of Casing: 55 FT.
/ (Use'r' II Above Top of Casino)
9. TOP OF CASING IS J FT. Above Land Surface'
'Top of casing terminated et/or below lend surface requires a vedsnce In accor-
dance wllh 15A NCAC 2C .011E
10. YIELD (gpm): F6" METHOD OF TEST 3
DRILLING LOG
DEPTH
From To Formation Description
11. WATER ZONES (depth):
12. 'HLORINATION: Type
13 SING:
Zip Code
Bz•,d_egck
r�9
7N Amount _hT
II addillonal space Is needed use back of form
iv
LOCATION SKETCH
Deplil Diameter or W}eighVFl. �Maalle�dall (Show dlreciton and distance from al least Iwo Slate
From O To 2— Ft. �s • a 5 �i6 •h5 PI/GSDR Roods, or other map reference polnls)
From To FI
From To FI.
14. GROUT:
From
From
15.SCREEN:
Depth
To
To
To
Wall Thickness
Depth Material Method
hod
vZ
0 re O Ft C'OP-E'F /YCE
To Ft
Diameter Slot Size Materiel
From FI In In.
From FI In In
From FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To FI
17. REMARKS:
so/ ////I
hncey
UT r
—rT
P1
0
tD
-0
C?
0
I DO 1IEREDY
CONSTRUCTION, STIANDAROS, AND THAT A GOTt'9 THIS RECORD HAS BEEN PRO IDED TO THE WELL OWNER.
a
IF( 'TAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F OFFICE UE ONLY
l No:
Submit ono'
I{�TUnE OF PERSON CONSTRUCTING TIIE WELL
rDivision of Water Ouallty, Groundwater Section wllilln 30 days
DATE
GW-I REV. 12/99
cn _'
0

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secuon
1638 Mall Service Center - Raleigh, N.C. 27699-1638.Phone [phone] �//_`
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /`D RYYIAN L. i- C.
268897
WELL CONTRACTOR CERTIFICATION 0: a D,a
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable Box): Residential Iv/ Municipal ❑ Industrial Q Agricultural ❑ Monlloring ❑
Recovery n Heat Pump Water Infection [1 Other n I( Other, List Use:
2. WELL LOCATI N: (Show sketch of the I cation below)
N areriTlj{jw®n: f aunty. 11.
(Road Hame
3. OWNER
Address
slon and Lol No.) DRILLING LOG
L" ...CAA M A l 1A. e a o- ^9 //
'1— ��1p Ate- 5gb
City or Toren Sale 21p Code
4. DATE DRILLED — ' 0 TOTAL
. TODEPTH S n
3. CUTTINGS COLLECTED YES( ] NO1
DOES WELL REPLACE EXISTING WELL? YES n NOW(
3. STATIC WATER LEVEL Below Top of Casing: Q0 FT.
/ (Use -i- II Above Top of Casing)
). TOP OF CASING IS f FT. Above Land Surface'
Top of casing terminated alior below land surface requires a variance In acorn-
1 ante wllh 1SA NCAC 2C ,0118
10. YIELD (gpm): kit— METHOD OF TEST
1. WATER ZONES (depth): ^r3
DEPTH
Formation DescdplIon
eit
B&pack
ON)
2 'LORINATION: Type 1l T Amount '7 b NHS II additional space Is needed use back of form
3. L., USING:
Wall Thickness
Depth CI Diameter or W IghVFl. Material
From 0To 9' Ft 11 .a5 .rif.jj5 PYLLIC
From To Ft.
From To FI
4. GROUT:
Depth i'�MalorI)l Method
From 0 To a�. ° FI nC�tf E_ k
lLc ti
From To FI �_
5. SCREEN:
Depth Diameter Slot Size Material
From To FI In In
From To FI In In
From To FI. In In
5. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To FI.
7. REMARKS:
LOCATION SKETCH
(Show direction and distance from al least Iwo State
Roads, or other map reference Ines)
60,40z C.
0
CO
-T1
m
03
lD
-o
w
0
I DO HEREBY (IVY -THAT THTS-WELLWIWIUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT' Itt STMDAfIDS, AND THAT A CO !THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
DFFICE Ug QNLY
Quad No: 1 1 I
Serial No
TUf E OF PERSON CONSTRUCTING THE WELL
Subrnll odal;ta o D vision of Waler Duality, Groundwater Section Within 30 days
_J
DAIE
GW-I REV, 12199
0
rl cj
ri
cn
rn
G

1. SING:
North Carolina • Darn-nenl of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Censer - Relelgh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR-
26889_(-
is;,QmAA/ Z•
WELL CONTRACTOR CERTIFICATION N: 0vca 7
STATE WELL CONSTRUCTION PERMITN:
. WELL USE (Check Apptic.bl. Box): Residential ICI Municipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery [1 Heat Pump Water Infection ri Other If Other, List Use:
2. WELL LOCATION: (Show sic tcll of the location below)
rest Towcn County y
/tifioadNa S Ap �(BunsandLol Q )
(Flood Name end Numbers. Communhy, a Subdivision end Lot No.) DRILLING LOG DEPTH
I. OWNER Re&,r+ Re) bi()s ) From To
Address 732 I/ryrr pc,„:2 * /�/'
S reo or filou eNo.)
2a na dPQ% F ). ,3lit(
CI& or Town State Zlp Code
DATE DRILLED 33-a2,6 04m
TOTAL DEPTH 3R7r"J
CUTTINGS COLLECTED YES) I NOFA-
DOES WELL REPLACE EXISTING WELL7 YES I I NOW(
STATIC WATER LEVEL Below Top of Casing: 5rj FT.
/ (Use -s- if Above Top of Casing)
TOP OF CASING IS ! FT. Above Land Surface'
op al casing terminated stror below lend surface requires a vnrlance In accor-
mce wllh 15A NCAC 2C .011E
). YIELD (gpm): S- METHOD OF TEST
I. WATER ZONES (deplh)
Fonnelion Description
il:R
Beck
rJT
^LILORINATION: Type H T H Amount 2:5:14,LaS If additional space Is needed use back of form
Wall Thickness
SKETCH
Depth IDlameler or WelelwFt. Matoedal (Show direction and distance from at least Iwo Slate
From 0 To Ft is . 5 07/6.L y?5 f�
Roads, or other map reference points)
From To Ft,
From To Ft
. GROUT:
Depth Material Mollrod .
From D To ss7-0 Ft Owl
�N�'i�ft _.jj�pli Q'-_E-rj„�,�.
From To Ft
SCREEN:
Depth Dlarneler Slot Size Material
From To Ft In In
From To Ft In. In
From To Ft In In
SAND/GRAVEL PACK:
Depth Size Material
From
From
.REMARKS:
To FI
To FI
9nice_s Cr-e�
yQneyeic
I DO FIEREDY TIFY IHAT THIS WELL WAS �NN��TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC LSE
TANDAROS; AND TI3AT AiC�('� qF THIS RECORD HAS BEEN PROylinE TO THE WELL OWNER.
OFFICE USE ONLY
No:
ATUnE OF PERSON CONSTRUCTING THE WELL
olDlvision of Water Ouallly, Omundwaler Secllon Wllhln 30 days
DAT076
GW-i I1EV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1630 Mall Service Center- Raleigh, N.C. 27699-1638-Phone [phone]
268884
WELL CONSTRUCTION RECORD WELL CONTRACTOR- /ID Rn1A'V Z. 2q-((.
WELL CONTRACTOR CERTIFICATION it: .c'?D
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Pox): Residential ✓0 Municipal ❑ Industrial n Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Infection ❑ Other n If Other, List Use:
2. WELL LOCATI N: (Show skelcch of the location below) ry/�/ Pp Nearest Town: U 5 y( ! County' /Y
—_. ....
(need Name r'}d� Number mm Counlly, or Subdivision and Lot No.)
3, OWNER «lr// I ROJI'/peon
Address
eol or Iloule
e
DRILLING LOG
From To
DEPTH
Formation Description
/of 1n[ c� ��a11 v/l -
City or Town 1 Zlp Code
I. DATE DRILLED
TOTAL DEPTH
1. CUTTINGS COLLECTED YES r ] NOrszl- _
DOES WELL REPLACE EXISTING WELL? YES n NOW1 o
STATIC WATER LEVEL Below Top of Casing: 35 FT.
/ (Use'e' II Above Top of Casing)
TOP OF CASING IS / FT. Above Land Surface'
Top of casing terminated aVor below land surface requires a variance in accor-
ence with ISA NCAC 2C,0118
0. YIELD (gpm)• __La__ METHOD OF TEST P C 3
P R `-
t)E-rbe_4ck
1. WATER ZONES (depth):
S ale
2 'LORINATION: Type H 7! ( Amount i141iiS
3. SING:
Depth
From O To
From
From
4. GROUT:
3
l`J
If additional space Is needed use back of form
LOCATION SKETCH
Diameter or Wp_IghVFt. M�uL S l (Show direction and distance from al least Iwo State
Ft b ' a5_ a)" .b5 Roads, or other map relerence points)
To Ft.
To Ft
Depth
From 0 To v1.0
From To
5. SCREEN:
Wail Thickness
Material Method ,
FI C'�% Pi jlDufE_ri.'
FI
Depth Diameter Slot Size Material
Frain To It In. In
From To FI In In
From To FI In in
5. SAND/GRAVEL PACK:
Depth Size Material
From To
From To
7. REMARKS:
FI
FI
(-7/aGreg
/awe/ Co_ 71.6-
I DO HEREBY
CONSTRUCTI
N
tTNd WECLWA$C(
NfJAROS, AND THAT A CLOP
i OFFICE U
L. No:
Serial No
EigNLY
I! I,
UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
HIS RECORD HAS BEEN PQVIDEO TO THE WELL OWNER.
i Uf1E OF PERSON CONSTRUCTING THE WELL
Submit origin t Islon of Wafer (Duality, Groundwater Section wi1111n 30 days
DATE
GW.I REV. 12/99
ram'
G

North Carolina - Department of Environment end Natural Resources - Division of Water Dually - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1636.Phone [phone]�//_'
WELL CONSTRUCTION RECORD WELLCONTRACTOR- /lc RmAM L • 24LL,
268877
WELL CONTRACTOR CERTIFICATION 0: 4,10.9 7
STATE WELL CONSTRUCTION PERMIT":
1. WELL USE (Check Applicable aoa): Residential Lrl Municipal n IndusIrlal El Agricultural ❑ Monitoring El
Recovery n Heat Pump Water Injection n Other n If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 'RVrn Il)e County. Yn)7C 1.1
road Name and Number,. Community, or
Subdivision and Lol No,) DRILLING LOG DEPTH
WNER TtrYp—i Ij lr icct4 e l From To Formation Descdpllon
Address s55J pi1.gv jam.
1SIle or Dula No,
A-5h Zvi 112 I\.( C.
CIIy or Town Stale
DATE DRILLED y J-oa
TOTAL DEPTH LOGj
CUTTINGS COLLECTED YES j NO[4
DOES WELL REPLACE EXISTING WELL? YES I I NO'
STATIC WATER LEVEL Below Top of Casing: \ c- FT.
/ (Use's' II Above Top of Casing)
. TOP OF CASING IS ! FT Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In accor-
fence wllh 15A NCAC 2C .0118
O. YIELD (gpm): (A METHOD OF TEST )\.
:1. WATER ZONES (deplh)-
assoq
Zlp Code
I ' aa nieR
as - alp BE,1tQCk
V
W
N
4-
2. "`ILORINATION: Type H 7! I Amount 41._IS 11 additional space Is needed use back of form
3. 3ING:
Wall Thickness
em Depth Diameter or WelphUal Fl. Maled
From 0 To FI IL•a;J `a7c•/;S p, alR
From To FI.
From To FI
4. GROUT:
Depth Material Method
hod
From 0 To vZ�eN�� � FI 4E
From To FI
5. SCREEN:
Depth Dlarneler Slol Size Material
Frorn To FI In In
From To Ft In In
From To FI In In
a. SAND/GRAVEL PACK:
Deplh Size Material
From To FI
From To Ft
7. REMARKS:
LOCATION SKETCH
(Show direction and distance from al least two State
Roads, or other map reference points)
Sacks Cr.t.ck
-e)urhsvillQ, KC,
SO :£ Vld 6 183J CO
r-
0
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI011 ST NOAFlOSTAND THAT A COPY OE THIS RECORD FIAS BEEN PR IDES TO THE WELL OWNER.
r OFFICE US 'ONLY Ai m.,..• CAvc-_ a .Q y-i i - Qa
C . No: $ QF$TIME OF PERSON CONSTRUCTING TIIE WELL — DATE
Submit odpini U Ii . ston of Water Duality, Groundwater Section within 30 days
Serial No. -...) GWd NEV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ;7
WELL CONSTRUCTION RECORD WELL CONTRACTOR* nm R?AN J 4 L. + /ek (.
WELL CONTRACTOR CERTIFICATION #: orOA 7
2688'70
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Ll Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Wafer injection ❑ Other ❑ II Other, Llst Use:
2. WELL LOCATION: (Show sketch of the location below) e_�IL /u. ntye/C
-e/aresl T/166-
(Road Nam}�nd Nu%hers�7Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /r%- / Il�' 7/�% From To Formallon Description
Address Rif I ri-_X /[/(,1-rr� /7 City or Town -�����Slate Zip Code 3 - �6n
4. DATE DRILLED 0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES In NOV
7. DOES WELL REPLACE EXISTING WELL? YES Ii NOM/
8. STATIC WATER LEVEL Below Top of Casing: MO FT.
(Use'+' 11 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 ISA NCAC 2C .gq11a
10. YIELD (gpm): / METHOD OF TEST 3
11. WATER ZONES (depth):
AIR
BE-ciR2ck.
CHLORINATION: Type Tf TH Amount —_ 1LI.iS it additional space Is needed use back of form
CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. ;TM'alledall (Show direction and distance from at least Iwo Stale
From 0 To 3 Ft. L • e 5 a)l •1;5 PI/L"S02 Roads, or other map reference points)
From To Ft [3,6_From To Ft g3ra/2c )„
14. GROUT: \iahCeY /Orr / U 1 .C.
LG�/� C� 1
Depth Material Method ,
From D To a7.0 PI C1e�NCP.EiE ,�.B�d�._
From To Fl.
15. SCREEN:
Depth Dlarneter 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 1SA NCAC 2C, WELL
CONSTflUCTIO STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PIDED TO THE WELL OWNER.
ROe
FOR OFFICE U EO
Quad No:
Serial No.
URE OF PERSON CONSTRUCTING THE WELL - DATE
Islon of Water Ouallty, Groundwater Section Within 30 days
GW.1 REV. 12/99

OFFICE
1.....d No:
Submit orlgl
Serial No.
North Carolina • Department of Environment and Natural Resources - Division of Water Ouelly - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' /7N R%Y)AN L •4��.
Boa 7
WELL CONTRACTOR CERTIFICATION II:
268867
STATE WELL CONSTRUCTION PERMIT#:
1 . WELL USE (Check Applicable Box): Residential ✓P- Municipal I-1 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other n II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) ``_
N rest Tow ,a � County' X�-nC P tcy
C C'
mood Name :��. Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q+G.di C E o( %Y1.P Sr
Address IS act.4-A
Ireo or oule No.)
r$Drnsvill-e NC.
City or Town Si ale
4. DATE DRILLED
5. TOTAL DEPTH 1{5
8. CUTTINGS COLLECTED YESn NO4
7. DOES WELL REPLACE EXISTING WELL? YES ri NOw
8. STATIC WATER LEVEL Below Top of Casing: (GO FT.
/ (Use 's' II Above Top of Casing) W
9. TOP OF CASING 1S ! FT. Above Land Surface' :
--n.
'Top of casing terminated et/or below land surface requires a variance In actor- :.
dence with 15A NCAC 2C .0118
10. YIELD (gpm): as METHOD OF TEST Q N
11. WATER ZONES (depth): j -a
From To
D -59
5Q - 31-15
Formation Descdptlon
Meld-
l3i-the-QC
Zip Code
12 'LOA:NATION: Type H 71I
13. .SING:
Amount r IIS If additional space Is needed use back of form
IV
c
Wall Thickness LOCATION SKETCH
Depth Diameter or W Ight/Ft. Material (Show direction and distance from at least Iwo State
From To 59 Ft 'e • aZ 5 Roads, or other map relerence points)
From To Ft.
From To FI
14. GROUT:
Depth Material CIMotli it
From b To L�•O FI Ott, i"".p.`�,.`
From To FI
15, SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To FI In In
From To FI In In
16. SANG/GRAVEL PACK:
From
From
17. REMARKS:
Depth
To
To
Size
FI
Ft.
Material
OI.)'n ►3L3 rd mod. •
o r1f/SV i 1 lc tc_
0
0
m
C7
�LJ
0
0
r1
I DO HEREBY Ali? FY THAT THIS WELL WAS—CON‘TIRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION SAt4DARDS, AND THAT A COPE` THIS RECORD FIAS BEEN PRO DEO TO THE WELL OWNER.
Li- a3-o a
ni
TORE OF PERSON CONSTRUCTING TIIE WELL DATE
(vision of Water Quality, Groundwater Section within 30 days
GM NEV. 12/99
Cr

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1630 Mall Service Center- Raleigh, N.C. 27699-1639•Phone [phone] �'
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /INRmAN L. 2,4«.
WELL CONTRACTOR CERTIFICATION if ,71).7
STATE WELL CONSTRUCTION PERMITN:
268859
. WELL USE (Check Applicable Pox): Residential U Municipal n Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch or the I .atrn below)
Nee eat Town: - .4 •a ! 4 - ; County- inC4
(Flood Name An Nu- •ors. Co ^ nay. or Subdivision end Lot No.)
3. OWNER ► q e.���.��►��tai 41
Address
/1-------- or
r.-ue 'o -----�
City or Town
1. DATE DRILLED
TOTAL DEPTH
CUTTINGS COLLECTED YES NO(4]
DOES WELL REPLACE EXISTING WELL? YES NOrvr
STATIC WATER LEVEL Below Top of Casing:''T��-- FT.
(Use -.- II Above Top of Casino)
TOP OF CASING IS FT. Above Land Surface'
Top of casing terminated ettor below land surface require' a verlence In accor-
ance with 15A NCAC 2C ,011a
0. YIELD (gpm): 2 METHOD OF TEST
1. WATER ZONES (depth):
Zip Code
DRILLING LOG DEPTH
From To
Formation Description
/SD- D5 JB&4 Qcic
0
2 'LORINATION: Type H 7!I
3..,,‘SING:
Depth Diam�e1ter
From _To�FIG •saa5
From To FI.
From To Ft
4. GROUT:
ry
Amount iippliLS It additional space Is needed use back of form
Wall Thickness
or Weight/FL Matedal
1\1
Depth Material Method
From 0 To AOFt i'elYCP.EiF 7Q"'"`
From To FI
5. SCREEN:
Depth Dlameler Slot Size Materiel
From To Ft In In.
From To Ft In In
From To FI In In
6. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To FI
7. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points)
cIA&Stile Ci.
SW� r7C
-o
I DO HEREBY Fy THAT THIS WELL WAS C t TlRUCTEO IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT I'N SI ANDA[tQS, AND THAT ACO THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
C 3-�-02--
1 OFFICE U1E rn 4LY
Quad No:
J
Serial No.
TUBE OF PERSON CONSTRUCTING TIIE WELL DATE
vision of Wale( Quality, Groundwater Section within 30 days
OW -I REV. 12/99

i
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 WELLCONTRACTOR'
268858
AVa RmAN L • PLC.
WELL CONTRACTOR CERTIFICATION M:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LCJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:.
Nearest Town:
how sketchnnnbl '''thAAAggg location below)
County
(Road Name a iiprr/)ers, Communlll . or S
3. OWNER `jam --Le
Address
bdlvlsion and
Lot No.)
DRILLING LOG
From To
DEPTH
Formation Description
r ae " / / U'R"®s k
City oown State Zip C
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NO
7. DOES WELL REPLACE EXISTING WELL? YES I L NOI VI
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'i 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 ISA NCAC 2C .9911
10. YIELD (gpm): !' METHOD OF TEST TN 3
11. WATER ZONES (depth):
O
W
ry
CHLORINATION: Type 7ff_ Amount II additional space Is needed use back of loan
CASING:
Wall Thickness
Depth , /, r Diameter or W IghUFL Material
From To-//JL,.i Ft b , a 5 071 �.1.75 PV65OR,
From To Ft.
From To Ft
14. GROUT:
Depth Material Method
From D To atliI C'e7p(C2.Eit s01l,g.✓`d_
From To
15. SCREEN:
Depth Dlarneler 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
Ft.
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points)
ouleni
Biu,s2p10,2 VC.
O
4)
CD
CD
'o
c.o
O
U1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI ANDARDSr a - • • • - • HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE U
Ouad No:
Serial No
Submit oriel
-ICE
URE OF PERSON CONSTRUCTING THE WELL DATE
sion of Water Duality, Groundwater Section within 30 days
GW-I REV. 12r99

North Caroline - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1630 Mall Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
268857
WELL CONSTRUCTION RECORD WELLCONTRACTOR-
iiy;RmAN C. ((.
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITN:
I . WELL USE (Check Applicable Box): Residential ✓n' Municipal n Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other n If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) \,
Nearest Town: &reel art M.ii'1• County einLer1 1
m
JQ7 /2& 4 AA iSa1 � th,tq i9
Mond Name end Numbers, Co rwnunlly,, or Subdivision end lot No.) DRILLING LOG DEPTH
�I' I 3. OWNER I etc C Lury L,( From To Formation Descdpllon
Address '-.-bX
ISitea or Houle No.) e
ClrePn Mkn• ML
Clly or Town Stale
DATE DRILLED d'—I/' Oa
TOTAL DEPTH csjOF1
CUTTINGS COLLECTED YES (l NO[4
DOES WELL REPLACE EXISTING WELL? YES
Zip Code
NOE/
STATIC WATER LEVEL Below Top of Casing: Lo S FT.
/ (Use 'e' II Above Top of Casing)
FT Above Land Surface'
TOP OF CASING IS
mop of casing terminated .Vor below land surface requires a variance In eccor-
ance wish 15A NCAC 2C .0116
0. YIELD (gpm): 4P METHOD OF TEST t, 3
(
1. WATER ZONES (depth):
0 - to n,'R 4-
"70 - 005
BE -die -or i[
0
—14
iJ
2 'LORINATION: Type TH
3 SING:
From 0
From
From
h. GROUT:
Depth
From Q To 020
Amount 1f piiLS
•� Wall Thickness
Depth Diameter
Ft 101a ^ 5 or 0ils Weight/Ft.Material
pyC•saR
From
5. SCREEN:
To
To Ft.
To Ft
Material
FI eivicetf t
Ft
If additional space Is needed use back of form
v
Mothod
laQ1
Depth Diameter Slot Size Material
From To It In In
From To Ft In In
From To Ft In In
3. SAND/GRAVEL PACK
Depth
From To
From To
7. REMARKS:
Size
FI
Ft
Malerlal
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
IQ? 17)0AJcI
Green . , 11fC
0
0
r
rTl
UD
0
0
w
I DO WERE It( RTIFY'tmAtTHIS WPLLI,WA
CONSTRUl 1 OU $TANOAROS, AN&TttA
OFFIC
No: II
Serial No.
SP ONLY
STRUCTEO IN ACCORDANCE WITH 15A NCAC 2C, WELL
0- HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r _e
SIn NATURE OF PERSON CONSTRUCTING THE WELL DALE
Division of Water Duality, Groundwaler Section within 30 days
GW.I REV. I2/99
wr
G

North Carolina - Department of Environment and Natural Resource, - Division of Water Duality - Groundwater Secaon
1636 Mall Service Center • Raleigh, N.C. 27699-1638-Phone [phone],
268856
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION p:
STATE WELL CONSTRUCTION PERMIT":
I. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural n Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nip rest ToCouunttyy- (�
)_ / tea '.^�Z QC"- /i r
Road NA,e tn4 Numbers, Community, or Subdivision and Lol No.)
3. OWNEF
Address
es1 ee .1 • ft�r�.�
Cil
ree many 31.-4 Gr ou e ' l•i- a 6 7 R /
R to - £La 5 &jtgc k
Cly or Town Stale Zip Code
4. DATE DRILLED I _l 5.0 0-
5. TOTAL DEPTH a ip 5
5. CUTTINGS COLLECTED YES ( f NO(Vj
7. DOES WELL REPLACE EXISTING WELL? YES I j NO c
8. STATIC WATER LEVEL Below Top of Casing: _14___ FT. o —
/ (Use'+' II Above Top of Casing)
9. TOP OF CASING IS ! FT Above Land Surface'
'Top of casing tarmineled aUor below land surface requires a variance In actor- _
dance wllh 15A NCAC 2C.0118 rV
10. YIELD (gpm): ._cl.. Q METHOD OF TEST !\.
11. WATER ZONES (depth): _
irk _A kJa1
DRILLING LOG DEPTH
From To Formation Oescdptlon
12. LORINATION: Type _Hitt__ Amouniy'7 pi
)IS
3. CASING:
Wall Thickness
RmAN
Iv
II additional space Is needed use back of lorm
LOCATION SKETCH
Depths Diameter or WeighVFI. �Maarteriall (Show direction and distance from el least two Stale
From O D To / Ft G . a 5 .416.1,5 PY.6,5Pg. Roads, or other map reference points)
From To FI.
From To FI. 44_6( lee/
14. GROUT:
Depth Malarial
From Q To , 0 n el_DNC,2 -tf
From To Ft
15. SCREEN:
MolliodZziAmS 21.61/4 ,
Depth Diameter Slot Size Malerlai
From To FI In In
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
IDOHERESYC�RI? YTkiAt�7HSSWIELLW
CONSTRUCTIQ STAGDAROS AND THAT A CO
I
OFFICE USB_Ot{LY
Ouad No:
IONA
Submit original to DI
O
+1
rn
a
iUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Uf1E OF PERSON CONSTRUCTING THE WELL DAI E
Islon of Water Duality, Groundwater Section Wllllln 30 days
Serial No.
GW.I REV. 12/99

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]
268854 '
WELL CONSTRUCTION RECORD WELL CONTRACTOR'
IYc R m AN L.
�33 (( .
WELL CONTRACTOR CERTIFICATION 0: oTO..3 7
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential ✓I - Municipal ❑ Industrial LI Agricultural' 1 Monlloring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2, WELL LOC •N: (Show sketch of the location below) / 1
earesl Tpwn: k 1 - = a_ County: Q.-+�-Z
4
Floe/,dJQJam d Numbers. Community, orr su ILLING LOG DEPTH
3. OWi`r�H V ,g/L., �.�lekn lM,Qs From To Formation Description
Address D 145'
2,9
D - 7/1 -h,'R i-
76 - Bfe4ck
//2AS 1cL%lg %%(i2k7/Ci
bolvlslon end Lol Not DR
City or T�+n U I� Stale Ztp Code
1. DATE DRILLED I -I (0 -0
TOTAL DEPTH V D 5
S. CUTTINGS COLLECTED YES 1 1 NO WI
DOES WELL REPLACE EXISTING WELL? YES^� [ I NOW(
3. STATIC WATER LEVEL Below Top of Casing: d� n FT.
(Use ' If Above Top of Casing)
3. TOP OF CASING IS ! FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In actor -
fence with ISA NCAC 2C MI le
0. YIELD (gpm): Y METHOD OF TEST R. R
1. WATER ZONES (deplh): 2 LORINATION: Type H T HAmount /oS N H S If additional space Is needed use back of form
3. CASING:
340.5
Depth a (IDlameler
From U To 7`T FLJ' ray
From To FI
From To FI.
4. GROUT:
Wall Thickness
or W IghVFI. MaPv� sDR
al � r1�5
Depth Material Method
From �W, t /� Q To � 1014C.2b4F ;�1n'+„4ao-fu,J+a-
From To FI
5. SCREEN:
Depth Diameter Slol Size Materiel
From To Ft In In
From To FI In In
From To FI In In
6. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To FI
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points)
U Sri
1 DO HEREDY CFJ
CONSTRUCT
FY,,TI-AT TI11S WE l7 W(K
AhoARbS;'AND TI AT KCC
I OFFICE UbE ONLY
Quad No: I i �.'
Li
Serial No
Y
—.9i
Submll od i nal to
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
e THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF PERSON CONSTRUCTING THE WELL DATE
Division of Water Quality, Omundwaler Section Within 30 days
GW-I flEV. 12/99
FS'r. cif
!iV
0E

North Carolina - Department of Environment and Natural Resources - Division of Willer Quality - Groundwater Section 2 6 8 8 5 2
1630 Mall Service Censer - Relelph, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR- Xe tc) m,v L • 7 2 L.
WELL CONTRACTOR CERTIFICATION ": c7Da
STATE WELL CONSTRUCTION PERMIT":
WELL USE (Check Applicable Boa): Residential r✓T Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water In)ecllon ❑ Other n If Other, List Use:
WELL LOCATI N: (Show sketch of the location below)
Nearest To County'
(ks AP.�� 4svzeia n '.071
Inaed Name d Nurtdei s, Co unity, or $u••Melon and I No.) DRILLING LOG DEPTH
OWNER r _ From To Formallon Description
Address
•- � tea o out •o—_ __ `r a O 7/ti �LQ! -
City or Town �s tale Zip Code
DATE DRILLED 3 - D-q•-0 2-
TOTAL DEPTH JIp el
CUTTINGS COLLECTED YES I ( NO4
DOES WELL REPLACE EXISTING WELL? YES O NoM/
STATIC WATER LEVEL Below Top of Casing: �� FT.
i(Use •+' II Above Top of Casing)
. TOP OF CASING IS ET. Above Land Surface'
Fop of casing lermineled sUor below land surface requires a variance In actor•
snce wllh 15A NCAC 2C. ill
O. YIELD (gpm): 6 METHOD OF TEST .
1. WATER ZONES (depth):
Loct AIR a0S B 2�ocJ_
r
r
2 '.ORINATION: Type R TH Amount 7 5' rl )JS II additional space Is needed use back of form
3. LASING:
Depth (� Diameter
From0 To 101 Ft b , a 5
From To Ft
From To FL
T. GROUT:
Wall Thlckness ,r
oral IghUFI. Materia
l
•
Depth Material Mothod
From b To Ple0 FI ( NC.2.k'+E
From To FI
5. SCREEN:
Depth Diameter Slot Size Materiel
From To FI In In
From To FI In In
From To FI In In
3, SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To Ft
7.REMARKS:
LOCATION SKETCH
(Show direction and distance Irom at least Iwo State
Roads, or other map relerence points)
,/ (]wki2Q
Cc�fl5
Lo
I DO HEREBY
CONSTRUCT'
I OFFICE L
Quad No:
Serial No
A$Afjp,rlDr
L
ASHEVL.IL
Submit o
HOE
RUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
TUBE OF PERSON CONSTnUCTINO TIIE WELL DATE
Division of Weber Quality. Groundwater Section Wllhln 30 days
GW-I nEV. 12/99
5

WELL CONSTRUCTION RECORD
269159
` ^ CERTIFICATION #anti%
WELL COAT RACTOIt COMPANY NAME 4I DR 1I � -. PHONE # ez--4T7 SY- 2&ic-Z
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NANIE (print) }!V 132-i2.5C
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 12' Mrmicipal/Public 0 Industrial 0 Agricultural 0
Nlonitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: r�
Nearest Town: s4tr P1-61/4-t County ar✓c.P,/
4 2 )1N -, `3 aFi- CR,
(Street Name.. Nuum s, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Rr1n4- S t1hb 4
Add ,a ll(-4 .30,‘ t`3'Rah
(Street oectoute No.)
City or Town State Zip Code
)-
Area code- Phone number
4. DATE DRILLED i- f5—O
5. TOTAL DEPTH: )0e)k-A
6. DOES WELL REPLACE Er STING WELL? YES 0 NO L�
7. STATIC WATER LEVEL Below Top of Casing: 47 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Tap of casing terminated at/or below land surface requires a
variance in accorda�n.. —�Sti,th 15A NCAC 2C .0118.
9. YIELD (gpm):' METHOD OF TEST AR
10. WATER ZONES (depth): '/61 (CA.
tl. DISINFECTION: Type (htA 9P Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To '1 Ft. 6X ' 2
From 1 To 31 Ft. G 576
From To Ft.
13. GROUP: Depth
From_ To 3D Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
MAR
Submit the original o tlje Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
2499-P-7 161rHHIe Ai. (9l' 733-3221, within 30 days. GW-1 REV. 07/2001
Material p, Method
Ce
Slot Size Material
in.
in.
Material
Topoggraa hic/Land setting
❑Ridge I1Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
To Formation Description
DEPTH
From
(.-2
30- ,co
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
O
CO
rn
CO
—D
O
tit
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
c_
0
rn
to --
r�a
G
z

)
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER Tian OCh
Address )wpm '?� Creek ►�Jd•
(S ree or ou a No.};1) 11
City or Town Stale Zip Code
4. DATE DRILLED n' (P - Da
5. TOTAL DEPTH .2
6. CUTTINGS COLLECTED YES I I NO
7. DOES WELL REPLACE EXISTING WELL? YES [1 NO171
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Usa'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 SSA NCAC 2C .0118
10. YIELD (gpm): %b METHOD OF TEST r 3
11. WATER ZONES (depth):
vrv15vCUR_ NC
1 serial No.
North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1638-Phone [phone] //
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /'e RmAN 4 L. 2Aq((•
WELL CONTRACTOR CERTIFICATION 0: v70.4 7
STATE WELL CONSTRUCTION PERMIT":
270127
1. WELL USE (check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) i0.vlt�f
Ne rest Town:f"ILTV't1S1/J�I,� Ile � /� County'
07 4�e&k / / 1244 -' DRILLING LOG DEPTH
From To Formation Description
9L 'c�r��J BF-th2ock
0
LJ
0
CHLORINATION: Type H 7H Amount .Z_SprilliS II additional space Is needed use back of form
. CASING:
Wall Thickness
Depth Diameter or WeIghVFt. Material
From 0 To N1 Ft G .; 5 all •%,5 PVe-$D4C
From To Ft.
From To FI
14. GROUT:
Depth Material Method
From Q To AO F1 C1mNCEEiE 7.7p►?—E"�C1-.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Materiel
Frorn To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show dlreclion and distance from at least Iwo State
Roads, or other map reference points)
01
=
O Sli n5 Creek TilCii
bunitsviIle, NC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTTtet4STANDARDS,-ANDT AiJ+f.C�X-OF THIS RECORD HAS BEENPROVIDED TO THE WELL OWNER.
FOR OFFICFrUSErONLY
Oiled No: j - NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit b(iglr)IaI o Division or Water Quality, Groundwater Section within 30 clays
L� GW-1 REV. 12/99
ma
0
5-lc-0 �_

270123 I
North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] Are CONSTRUCTION RECORD WELL CONTRACTOR. 7rd RmZ. t' 2 n7L.
WELL CONTRACTOR CERTIFICATION 0: c2D.
STATE WELL CONSTRUCTION PERMITM:
WELL USE (Check Applicable Box): Residential Qi Municipal ❑ industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:(
Neaiapt Town:
w sketch of -hp location below)
11MS.3i13 County —
Agricultural ❑ Monlloring ❑
oad Name an Numbers, Cy5vuunity, or Subdivision and Lot No.) DRILLING LOG
3. OWNER tn6- IC ::: From To
Addressf110 - ))/I )a-ja(pr�-{A-
A1, .suire:Lor ipysp (Jp,) ari Iti
CIIy or Town Shale\ ` Zip Code
4. DATE DRILLED �3-o ..1 1
5. TOTAL DEPTH .
6. CUTTINGS COLLECTED YES n NO[II
7. DOES WELL REPLACE EXISTING WELL? YES O NOj v1
8. STATIC WATER LEVEL Below Top of Casing: FT.
I (Use'✓ II Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
crop of casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0.116 'D;
10. YIELD (gpm): '1 METHOD OF TEST
11. WATER ZONES (depth)•
CHLORINATION: Type H 7ti Amount
CASING:
DEPTH
Formation Description
%n - a-R5 B&cJe ck
h�� Wall Thickness
From
Dept
uv FI.(i1a 5 orb%�I�1?5 Mat
•
From To FI.
From To Ft
14. GROUT:
From b
Depth Material
To 910 Ft t"tJNC2EiE
From To Ft
15. SCREEN:
„ThoilALMethod
Depth Diameter Slot Size
From To Ft In
From To Ft In
From To Ft In
16. SAND/GRAVEL PACK:
Depth Size
From To Ft
From To Ft.
17. REMARKS:
Material
In
In
In
Material
T
II additional space Is needed use back of lorm
LOCATION SKETCH
(Show direction and distance from et least two State
Roads, or other map reference points)
U1
0
/ /poi
.ti
&vtc5 ,1 ,
I DO HEREBY CERTIFY THAT THIS WEtLWASI
CONSTRUCTIONISTANDARDS, AND THAT A COPY
FOR OFFICE USg, ONLY
nuad No:
Sedal No.
SI NA
Submit original
CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
IS RECORD HAS BEEN PR IDEO TO THE WELL WNER. 7-3
%/YYIGLti/ C/J� 'O a
'RE OF PERSON CONSTRUCTING THE WELL DATE
Ion of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

1
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] y//,' /
WELL CONSTRUCTION RECORD WELL CONTRACTOR- /7d RmAN C • 24((.
WELL CONTRACTOR CERTIFICATION #: o?Oa
STATE WELL CONSTRUCTION PERMIT#:
3. OWNER
Address 6 �(
r VI 6 • IS ree OrA oleea.;
1. WELL USE (Check Applicable Sox): Residential ✓❑' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCAT N: (Show sketch of the location below) y
arestTown: OYYISV I I P c County JanCP( {
9 JA,tA,. n.• ( ,� L s WAD—)
J
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
CO I d G., Soh k-LSayL From To Formation Description
City or Town Slate
4. DATE DRILLED a�
5. TOTAL DEPTH r%CJ
6. CUTTINGS COLLECTED YES 1-1 NOIV1
7. DOES WELL REPLACE EXISTING WELL? YES NOJ
8. STATIC WATER LEVEL Below Top of Casing: FT.
I(Use '+' II Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
•Top of casing terminated et/or below land sudace requires a variance In accor-
dance with 15A NCAC 2C .0110
10. YIELD (gpm): IOC METHOD OF TEST
11. WATER ZONES (depth):
a8�1y
Zip Code
270121
yo -3a5 BIltock
It 0
r•O
19. CHLORINATION: Type Tr T H Amount•a. 5s II additional space Is needed use backol form
ASING:
u1
Wall Thickness LOCATION SKETCH
Depth p� Diameter air Wf IghVVFt. ;1Matedal (Show direction and distance from at least Iwo Slate
From.0To `�.5 Ft L • a 5 e-rtst,r?5 PVC'SO4C Roads, or other map reference points)
From To FI. '^ 'PI u n-\ --or,
From To FI.
14. GROUT: V V143 v I I /
I e JpV/`{Q:�
Depth Material Method '"-
From D To AO .FI rpm CPxiE tl,
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
Frorn To Ft In In
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth
To
From
From
17. REMARKS:
To
Size
FI
R
Material
c
I DO HEREBY CERTIFY THAT,THJ.SWEL TRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
F THIS RECORD HAS BEEN PRQVIDED TO THE W�N�R. a'o
CONSTRUC OMSTANDARDS,'AND THAT AC
PR ,�/, J1
! I
FOR OFFICEUSE ONLY (�/l/�'Yli
rluad No: , S) ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit oriel... Jo Division ol Water Quality, Groundwater Section within 30
days
GW-1 REV. 12/99
.rectal No -'

i
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section r
1636 Mall Service Censer - Raleigh, N.C. 27699-1636-Phone [phone] - 270105
WELL CONSTRUCTION RECORD WELLCONTRACTOR• !►a RtnA/✓ 4 • 24•L(.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other If Other, List Use:
2. WELL LOCATION • how sketch of the location below)
Nyprest To Q7��> County
"Rdad Name and Nuor rp�ars. Community, SubdlvIslon Lot 3. OWNER ��1J
Address
sr
51, Et
ree or •ou a 'o
Cliy or Town Slate
/
4. DATE DRILLED '-/7.0a
5. TOTAL DEPTH U. US
6. CUTTINGS COLLECTED YES n NOW1-
7. DOES WELL REPLACE EXISTING WELL? YES n NO
8. STATIC WATER LEVEL Below Top of Casing: ,010 FT.
/ (Use'.' it Above Top of Casing)
9. TOP OF CASING 15 I FT Above Land Surface*
'Top of casing terminated elor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): a METHOD OF TEST R : 11. WATER ZONES (depth):
Zlp Code
DRILLING LOG
From To
- 30
�D -'66
DEPTH
Formation Description
B E-ciItoc k
I'0
CHLORINATION: Type Fi 71-1 Amount /D.4nu II S it additional space Is needed use back of form
CASING:
Depth Diameter
From 0 To a_ Ft L r a 5
From To Ft.
From To Ft
14. GROUT:
Wall Thickness
or W IghVFt. Maledal
Puc.sDC
Depth Material Method
From n To AO FI Ctv/YCP.E4EIDOL1Qa
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In. In
From _ To FI In In
From To FI. In In
16. SAND/GRAVEL PACK:
Depth Size Malarial
From To FI
From To Ft
17. REMARKS:
—J
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS .AND THAT A IS RECORD HAS BEEN PR IDED TO THE_WWELLLLL WNER.
FOR OFFICE USE O(Tt�Y _ / /n/Le-L rCJ ' V G 6 .-/%d .9-
'luad No: _. L 81 A E OF PERSON CONSTRUCTING THE WELL DATE
Submit original lb I if n of Water Quality, Groundwater Secllon within 30 days
1 Serial No J GM REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone] _' p
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /(O p M AN G .�f i4Ct
WELL CONTRACTOR CERTIFICATION #: c O.I
270102
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): ResidentlalE Municipal ❑ Industrial 0 Agricultural El Monitoring ❑
Recovery ❑ Heal Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO (Show sketch o the location below)
DThirest Town: County.
WV/ WWI I
(Road Name ag(jMutnbe
3. OWNER
Address
Commit II o Subdivlsyi rand of
ree or ou
¶t&- ,
City or Town Sip?
4. DATE DRILLED l• G
5. TOTAL DEPTH �3 y�
6. CUTTINGS COLLECTED YES In NO
7. DOES WELL REPLACE EXISTING WELL? YES —� NOI vi
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. 9
10. YIELD (gpm): METHOD OF TEST n , 5
11. WATER ZONES (depth)•
DEPTH
Formation Description
:777 Code 4c -gages j�c12Qck
Zip Code
1/2
CO
tV
-.t
171
CHLORINATION: Type _Ifni_ Amounl.5. i1i)IS If additional space Is needed use back of form
. CASING:
From
From
0
From
14. GROUT:
Depth99 n
To �l
To
To
Wall Thickness
Diameter or W IghVFI. Material
FI b .. 5 alA.JSDS Pve.sx
Ft
Ft.
Depth Material Meshed ,
From D To do FI C',dr(CEE4E .�1�a.�d._
From To FI
15. SCREEN:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Depth Diameter Slot Size Material :Jr
From To Ft In In
From To Ft In In ,a —
From To FI In In 01
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To FI
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 8EENC PROVIDED TO THE WELL OWNER.
SIG T OF PERSON CONSTRUCTING THE WELL DATE
Submit odpina7Toi 1NI1 i of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
FOR OFFICE USE GRLYY
Quad No:
Serial No.
Y

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] - y//_'
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ijD RMAN L • 2/4-7(.
WELL CONTRACTOR CERTIFICATION #: € DA `7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (SI;, sketch of the location below)
Nearest Town
County.
7Ci I�OLMSUJ S9
(R4ed Name and Nu ars. Communit or Su division and Lot No.)
3. OWNER
ztLyi S
�3No. ef7/°Address4sV-R
,T a8.
7,ry
City or Town State Zip Code
4. DATE DRILLED t /o •d �--
5. TOTAL DEPTH to 00
6. CUTTINGS COLLECTED YES 1 I NO VI
7. DOES WELL REPLACE EXISTING WELL? YES [J NOWI/
8. STATIC WATER LEVEL Below Top or Casing: 7S FT.
/ (Use •+' II Above Top of Casing)
9. TOP OF CASING IS l FT Above Land Surface•
*Top of casing terminated oVor below land surface requires a variance in accor-
dance with 1SA NCAC 2C .prga
10. YIELD (gpm): A. METHOD OF TEST
11. WATER ZONES (depth)*
D-45
v3 - taco
DEPTH
Formation Description
o
N
" CHLORINATION: Type rf TH Amount If additional space Is needed use back of form
CASING:
Depth Diameter
From .0To FI t •aZ5
From To FI
From To Ft
14. GROUT:
Wall Thickness
or W IghVFt. Material
n71Ai;s pvtsx
Depth Material Method ,
From D To vi.0 Ft t'mNC2.FiE ���_
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To FI In In
From To FI in In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
;la
42 .5
k s-v- ,
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTIO STANDARDS: -AND -THAT -A COPY
FOR OFFICE USEIOt4d -
uad No:
Serial No
IS RECORD HAS BEEN PR IDED TO THE WELL WNER.
%/1%I GLti CJ C9 "V d - e'L
SIG7�1)RE OF PERSON CONSTRUCTING THE WELL DATE
Submit odpine I D d#Ion of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
270101
-

270099 '
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. )Y RrAN Z •�1 J7 ALL.
WELL CONTRACTOR CERTIFICATION #: c1Oa 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential0- Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATIO
est Town:
Road Name and Nu
3. OWNER
Address /1
how sketch of the location below)
County:
UM SA)1 Q
bets, Communl)y,pr Subd)vision and Lot No.)
c r e o.
Stjl
City or Town
— -4- -e
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NO14
7. DOES WELL REPLACE EXISTING WELL? YES
Zip Code
NO
8. STATIC WATER LEVEL Below Top of Casing: 1>� ET.
(Use'+' II Above Top of Casing)
9. FT Above Land Surface'
*Top of casing terminated et/or below land surface requires a variance In accor-
dance with ISA NCAC 2C,,gq11
10. YIELD (gpm): GY METHOD OF TEST n
11. WATER ZONES (depth):
CHLORINATION: Type nAmount4Z41111..S
CASING:
TOP OF CASING IS
DRILLING LOG
From To
DEPTH
Formation Descdption
ta S ock
,o r
CD
If additional space Is needed use back of form
r r:
Wall Thickness LOCATION SKETCH
Depth 99 0 Diameter or Weight/Ft. ;1Material (Show direction and distance from at least Iwo Slate
From D To Ft L ' a 5 ai 4./25 pve•SDc Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth Material Method ,
From D To LZ• 0 Ft CmNCaf i 7,�]`nr_r'e`.E-'i%�-
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
Frorn To FI In In
From To FI 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 OFFICERUSEIIONLY
'
Ouad No: ' ,. --
Serial No.
Submit olio
Acc(i 4-6-09
ATURE OF PERSON CONSTRUCTING THE WELL
Division al Water Quality, Groundwater Section wllhln 30 days
DATE
GW.1 REV. 12/99

i
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mali Service Center • Raleigh, N.C. 27699-1636-Phone [phone] - 4
yy//jj__'' /
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ) •DR l7AA/ • 2aLL.
270094
WELL CONTRACTOR CERTIFICATION #: 071)A'7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town: U Y V 1$ V 1 I 1 + County' � con C' P L�
C �e \( ' , f, a r� '
�& . 1� 1111%AA 1AY.0 Jc-/
- oad Nam and Numb ra, ommunity, 4or c.Subdivision and Lot No.) DRILLING LOG DEPTH
3. 4 NER n Q V 1 Yl TIL A,a From To Formation Description
Address 'nO(\+eZoYn(fix 'aS3
i Slree orHo 0W&3
City or Town Slate Zip Code
4. DATE DRILLED �—
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NOI11
7. DOES WELL REPLACE EXISTING WELL? YES n NOM/ o
c.
8. STATIC WATER LEVEL Below Top of Casing: cj(e., FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS / FT Above Land Surface*
N
'Top of casing terminated eVor below land surface requires a variance In actor- O
dance with 15A NCAC 20.011e
10. YIELD (gpm): Jf METHOD OF TEST -°
11. WATER ZONES (depth): ' 1 �I "-
I' CHLORINATION: Type 17 ?N Amount1Ls If additional space Is needed use back of form
;ASING:
o - y In
Luc- a<3 13> Izoc_k
azi
a
41 0
Wall Thickness LOCATION SKETCH
Depth Diameter oraW)IphVF�t. ;1Maledal (Show direction and distance from at least two Stale
From To FI 1. . a 5 �l .1i5 PVt S.O.0 Roads, or other map reference points)
From To Ft. r,
From
14. GROUT: Depth Material
FL �UrrL5v I 1 C/ hit:
Material Method
From n To vZ° Ft 0dNCP.fr4E .Jj'%prr'F'.k'i{`_'
N
From To FI
15. SCREEN:
Depth Diameter Slot Size Materiel
From To Ft In In
From To FI In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
0
cn
r D
0 o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS
RECORD HAS BEEN PR I DED�TTO THE /WJELLLLL WNER.
FOR OFFICE USE ORLY , itrir ICJ C.C.-C��-- ��p�O �O�rluad No: SI _ NSTRUCTING THE WELLDATE
Groundwater Section within 30 days
Submit original to D VI
1 aedai No. i
f, GW-I REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality- Groundwater Section 2 7 0 0 8 3
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
FOR OFFICF, US ONLY
quad No: .
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
N;RMAN 1. 247(.
WELL CONTRACTOR CERTIFICATION 0: 49.4 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldenllal2r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI
arest To
-N: (Show slselch of the location below) "la Colin • nc a 1A
(Road Name and Numbers. Community, or Subdivision and DRILLING LOG DEPTH
3. OWNER to CUers Chapel pwy Ciiurck From To Formation Description
Address -hot* 4
s reel or Route No.)
'lat)rnew; Ile. -WC
City or Town Stale
4. DATE DRILLED Q�_
5. TOTAL DEPTH 4
6. CUTTINGS COLLECTED YESn NoI✓I
7. DOES WELL REPLACE EXISTING WELL? YES n NOI1j
8. STATIC WATER LEVEL Below Top of Casing: 33 FT.
(Use'+ If Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
•Top of cuing terminated etror below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): IL15 METHOD OF TEST
11. WATER ZONES (depth): 6T
n -a�
Nit 1-
t7j* R Ck-
Zip Code
rV
19 CHLORINATION: Type I•f 7N Amount a 5 If additional space Is needed use back of form
3ASING:
Wall Thickness LOCATION SKETCH
Depth Dia I VEL Material (Show
Show direction and distance from at least Iwo State
From To Ft. Roads, or other map reference points)
From n To_al. Ft. (A • `a•6 • 1Si S1-e ea .*
From To Ft
14. GROUT:
Depth Material Method ,
From 0 To vZC'�7d � it CEt:iE '1%pt?Eu�-�j_
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To FI In In
From To FI In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To Ft
17. REMARKS:
Cone ivetr o
rrl
v
C1
r
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF THIS RECORD HAS BEEN PRIDED TO THE WELL WNER.
7-II-0a
aerial No. j
NATURE OF PERSON CONSTRUCTING THE WELL DATE
o Division of Water Ouallty, Groundwater Section within 30 days
GW-1 REV. 12J99
J

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section . 7 O 0 J 2
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] /'
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /rDRYYIAN L. 2147(,
WELL CONTRACTOR CERTIFICATION #:
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 LOCIVION:-(S1
NgarestT nd:_
�Na a
sketch oMhe location below)
r Numbers Community, or S•� vision and Lot No.)
3. OWNER pQ Q— !�/athK From To
Address (�y" \L/j�/�//�1 U
(S'Irael or RoulelNrl) - /25
/.5 - 1L2S
uy ar Town Stale
4. DATE DRILLED Q'3' 'd 2
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES I J NOI4
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: D FT.
I (Use 's' If Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
•Top of casing terminated euor below land surface requires a variance In accor-
dance with 15A NCAC 2C .eti
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
Zip Code
13&cbzgck
0
c�
t`J
IN
CHLORINATION: Type N TN Amount Kara& If additional space Is needed use back of form (ft
CASING:
From
0
From
From
14. GROUT:
Wall Thickness LOCATION SKETCH
Depth „ r- Diameter ar Weight/Ft. Material (Show direction and distance from at least Iwo Slate
To /�' S Ft �+ .;5 al'° •�a5 PVe-SD�. Roads, or other map reference points)
To Ft
/N �"""`-' CrI `
To FI. %A .0�Q/t/
Depth Material Method (/`��e,A,,,,,z,,,,
/ //To doF1 etne 4E . poi`p_k_a
To Ft -v
_:
iv
Frorn 0
From
15. SCREEN:
Depth Diameter Slot Size Material
Frorn 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:
a
-71
co
UT
r'l
r" 7-3
cb
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANp IHAT.ACc THIS RECORD HAS BEEN PRO/IDED TO THE WELL WNER.
OON\TORE OF PERSON CONSTRUCTING THE WELL DATE
•Submit Islon of Water Ouallty, Groundwater Section within 30 days
r I GW-I REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.
r _.

I
North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section ? `J `'
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ACV RinAN L • .WAL(.
WELL CONTRACTOR CERTIFICATION 0: c O_i 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential la- Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other (J If Other, List Use:
2. WELL LOCATION: low sketch of the location below)
N rest Tos4
County
Wv/!
( Name end Numbers, Communit or Subdivision and Lot No.)
3. OWNER !n v n -
Address
City orTown
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES f f NO
7. DOES WELL REPLACE EXISTING WELL? YES n NO VI
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •+• 11 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 .0110
10. YIELD (gpm): iE METHOD OF TEST R. J
11. WATER ZONES (depth):
S 1 eOr Halite INo.o.)CiNi c 5 D-814 a
Slate Zip Code
DRILLING LOG DEPTH
From To Formation Description
7) Nit htn - to S 3E•ri�gek
0
0
". CHLORINATION: Type 17H Amount L3pLus 11 additional space Is needed use back of form
CASING:
From
From
Wall Thickness LOCATION SKETCH
Depth Diameter
Diameter or Weight/Ft.. ;1Material (Show direction and distance from at least Iwo Slate
© To 'i) Ft. t/ ' a 5-714.1;5 PVt•SDR. Roads, or other map reference points)
From
14. GROUT:
To
To
Ft,
Ft
Depth Material Method ,__
From D To CFI CImNCEEfE .j1p��t,Q.�Cl
From To Ft
15. SCREEN:
Depth Dlarneter Slot Size Material
Frorn To FI In In
From To FI In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
ea„,,Lo.k
I DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
NARE OF PERSON CONSTRUCTING THE WELL DATE
Submit od01nd too C i(,hien of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

270036
1
DRILLING LOG
From To
l (1C OSS'111- s y - �i-U d
City or Town Sae Zip Ce
4. DATE DRILLED
5. TOTAL DEPTH l'�h
6. CUTTINGS COLLECTED YES n NO1A
7. DOES WELL REPLACE EXISTING WELL? YE$ [� N01
8. STATIC WATER LEVEL Below Top of Casing: / t� 5 FT.
(Use '< II Above Top of Casing)
9. TOP OF CASING IS 1 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): 1 METHOD OF TEST
11. WATER ZONES (depth):
DEPTH
Formation Description
0 - 5 -( AIR t-
B&dQack
CHLORINATION: Type /4 TN Amount ells
. CASING:
Depth I 1
From To S�
Ram To Ft.
From To Ft
14. GROUT:
From 0
From
15. SCREEN:
Depth
To Ft
To FI
Depth
From To
From To
From To
16. SAND/GRAVEL PACK
Depth
To
To
From
From
Ft
FI
FI
3. OWNER
Address
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mali Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. IVe RnIAN L L. 2A-Z(.
WELL CONTRACTOR CERTIFICATION 0: 07.±9A 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCA-JAM:-f &, ow sketch of the location below)
Nearest Town: 1 U'1 L> County•
l��
(P(ord Name end Nu . Community,n and Lot No.)
�a
ca
r-a
If additional space Is needed use back of Iorm
Wall Thickness
Diameter or W IohVFI. Material
Ft.L.5 ?1t.1DS PVt5Die
Material
Method
Diameter Slot Size Material
In In
In In
In In
Size
FI
FI.
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map re erence points)
cows -i.(1)-Q--L,1n tec
r-;
-o
3
N
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND'`ARDS,rAND THAT A COPY F THIS
� RECORD HAS BEEN PR IDED TO THE WELL WNER.
FOR OFFICE US bll `klo -(7-0
Ouad No: l ; [ —II' NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odginai l C Vision of Water Duality, Groundwater Secllon Within 30 days
Serial No. J s_+) GW-I REV. 12/99
2-
or S bdivlsio
�

i
Show sketch of the location below)
&County•
umbers, Community. or Sub •Iv lan and Lot No.)
9
1
i
Of ou
11
.SU I
f'1
From To FI
15. SCREEN:
From
Depth
To Ft
From To Ft
From To Ft
16. SAND/GRAVEL PACK:
Depth
To
To
From
From
17. REMARKS:
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section 2 7 0 0 3
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] //_' J�
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /lei RmAN C L. 2 -(t
WELL CONTRACTOR CERTIFICATION 0: c'.O 'J
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Residential 21 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2, WELL LOCATI
Nea&est Tow
(Road -lame
3. OWNER
Address
tL
),
k
iL_ 4
g 71'9-
City or Town Staalllo Zip Code
4. DATE DRILLED n•L o'a
5. TOTAL DEPTH �h .
6. CUTTINGS COLLECTED YES 1 NOW I
7. DOES WELL REPLACE EXISTING WELL? YES piNO1 v(
8. STATIC WATER LEVEL Below Top of Casing: J S FT.
(Use Y 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 ISA NCAC 2C A 18
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth): -�
etAn
DRILLING LOG
From To
DEPTH
Formation Descdpllon
D - an
0
c,)
-a
0
Ni
1° CHLORINATION: Type n.Amount3AiliAS
CASING:
From
From To Ft
From To FI
14. GROUT:
If additional space Is needed use back of form
Wall Thickness
Depth Diameter Diameter or Weight/Ft. Maledal To _2 CDFI L ..,15alt,/�5 PVC'-SDiC
Depth Material Method
From � TovZ� Ft i1vNCP�fE 7ueE orL
Diameter Slot Size Material
In In
In In
In In
FI
Ft
Size Material
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
ae
rn
ry
s
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PR (){/IDEDD TO THE WELL WNER. lb • I (-O
D
Submit odginel upj
I,J
ARE OF PERSON CONSTRUCTING THE WELL DATE
Ion of Water Duality. Groundwater Section within 30 days
GW.I nEV. 12/99

North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]//_' J�
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /I d RYY)AN L • 2•f4.-�«y.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Z. Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT ((SS`Iilia(-�pj/(ww sketch ol1he location below)
Nealast A ow / \l f. (% (,' County.
(Road Name and Numbers, Comm nl y, or Su division and Lot o.) DRILLING LOG DEPTH
3. OWNER � IVLItl� From To Formation Descdpllon
Address (`(J•.}'�'�'1',,`,,",'
Oa s1�LY.(XHoule o.) �' 0 l0 0 h,'w<2'�'
nc, agws (n y
City or Town Slate Zip Coda y O
4. DATE DRILLED .
5. TOTAL DEPTH 4i.o
6. CUTTINGS COLLECTED YES f NO17
7. DOES WELL REPLACE EXISTING WELL? YES NOl vi
8. 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 actor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): _1__ METHOD OF TEST
11. WATER ZONES (depth):
N
1" CHLORINATION: Type Tn Amount LapilLS If additional space Is needed use back of form
CASING:
Wall Thickness
Depth D Diameter
or W Ight/Ft. Maledal
From 0 To FI er a>7)t,/;s PvtsDR,
From To FI
From To FI
14. GROUT:
Depth Material Method .
From Q To vZ•0 FI C1vJYCPEfE OLI
From To FI.
15. SCREEN:
Depth Diameter Slot Size Material
Frorn To Ft In In
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To FI.
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
1 DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY QF THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
Submit odglna' id
TUBE OF PERSON CONSTRUCTING THE WELL DATE
vision of Water Duality, Groundwater Section within 30 days
GW.1 REV. 12/99
I
270034
0

1
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1638-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR. /farRm4N L. 2A-LL.
WELL CONTRACTOR CERTIFICATION 0: 4Di37
STATE WELL CONSTRUCTION PERMITS,:
270030
1. WELL USE (Check Applicable Box): Residential 2r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ II Other, List Use:
2. WELL LOCAT
Nea1'8st Town:
DSao
(Road Name are
3. OWNER �(11
Address
(ShoQw� sketch D1the location below)
vQ X_PJ1 S'v County:
gd.
aye
aht
umbers`Comm n y, or Su !vista and t/elNe) r ?IdDRILLING LOG DEPTH
From To Formation Description
(S ealor}TouteNo.)rc d-(2777
to , C_o /
Cil)Tor Town State Zlp Code
4. DATE DRILLED 16— I I O
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NO[71
7. DOES WELL REPLACE EXISTING WELL? YES in NOI ti/J
8. STATIC WATER LEVEL Below Top of Casing: 4 rj 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. 118
10. YIELD (gpm): METHOD OF TEST r J
11. WATER ZONES (depth):
pr7 s
3&dRock
•
03 c_.,
1' CHLORINATION: Type FI 774 AmountS a1b; II S 11 additional space Is needed use back of Iorm
CASING:
Wall Thickness
Depth r( Diameter or Weight/Ft. ;1Maledal
From To 5 I Fl.ir•a5 ai&.l,f PVCr-Vie
From To Fl. "�
From To FI.
14. GROUT:
Teeth Material AOMol_ Method r
From Q To � Ft C10NCP�f6 �701tILa�d._
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
Frorn To Ft In In
From To FI In In
From To Ft. In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From
17. REMARKS:
To
Ft
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND COPY THIS RECORD HAS BEEN PRrP/IOED TO THE WELLAWNER.
EIIU S E O N'CY
041402
SIQNATURE OF PERSON CONSTRUCTING THE WELL DATE
dglnal to Division of Water Duality, Groundwater Secllon within 30 days
GW-1 REV. 12/99

i
270027
North Carolina • Depanmont 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.
NARmAN L. 24.1-Z(.
WELL CONTRACTOR CERTIFICATION #: olD� 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentiall Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION Show s - c 1 of the location below)
'Or rest Top `y I 1 County'
(Road Name a u. •Ivlsion and Lot No.)
3. OWNER - - 1 '�
Aedress �
/%' imam 1 ti
City or Town Slate Zip Code
4. DATE DRILLED b• o• 0
5. TOTAL DEPTH >S
6. CUTTINGS COLLECTED YES F 1 NOW
7. DOES WELL REPLACE EXISTING WELL? YES n NOl vl
8. STATIC WATER LEVEL Below Top of Casing: •5 FT.
(Use 'a' if Above Top of Casing)
9. TOP OF CASING IS 1 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): a °METHOD OF TEST R.
11. WATER ZONES (depth)
-
DRILLING LOG DEPTH
From To
Formation Description
51 - aa5 Beck
•
0
N.)
0
O
v
1' CHLORINATION: Type W 71-1 Amount 9l/S If additional space Is needed use back of form
ASING:
Wall Thickness LOCATION SKETCH
D Depth rDiameeter or_ W Ight/FI. ...Material (Show direction and distance from at least Iwo State
From To '7 Ft d/�t�2 R_ Roads, or other map relere points)
From To FI
From To FI. '6-1xr-erg .w.J
tA. GROUT: 11- *1 • �'
Depth Material Method , . t I '
From 0 To aZ0 Pt ��/YCQ.EiE ".jjlpNTeE7{'_
From To Ft. rift
Ca
15. SCREEN: ry
u-1
Depth Diameter Slot Size Material
Frorn To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PR IDED TO THE WELL
WNER,
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit odolne Ia vision of Water Duality. Groundwater Section within 30 clays
GW-I REV. 12/99

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.
2'70023
eRmAN L. Lg'LL.
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Q Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other al II Other, List Use:
2. WELL LOC (Show sketch of the location below)
sNNl@arest Town: County
.SU.)�l:4G1. IX �54j . LJWIh.$LULLQ ,
(Roa ame and umbers. Commuo`u�c,or Subdivision and Lot N(o.)�
3. OWNER Y
Address
O
c aT1L+b
CitorTown State Zip Code
4. DATE DRILLED Iba
5. TOTAL DEPTH �� ��'ii--�S
6. CUTTINGS COLLECTED YES NOly/ 1
7. DOES WELL REPLACE EXISTING WELL? YES in Not
Vi
8. STATIC WATER LEVEL Below Top of Casing: to 5- FT.
J (Use -+' II 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 R;
10. YIELD (gpm): 30 METHOD OF TEST
11. WATER ZONES (depth):
C-J
DRILLING LOG
From To
Iao
DEPTH
Fomreflon Description
Brzpc k
0
rn
1 o CHLORINATION: Type H 7H Amount — If additional space Is needed use back of form
CASING:
Dept Diameter
From 0 To ;,1O Ft. L ' a 5
From To FI.
From To Ft
14. GROUT:
Wall Thickness
or W ight/Ft. Material
alk.»s PvC-sDC
Depth Material Method
From �% To a2 O FI C�O/Y C2Ei E piglet
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
Frorn To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ailjt
�t�1YJY•SJ U I _
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY,pF THIS RECORD HAS BEEN PRIDED TO THE WELL WNER
FOR OFFICE IJSE 1NLY
rluad No: �!
I .,edzl Na.
Tgwn
Submit odgrrlql�
/liLti-."
3
TUBE OF PERSON CONSTRUCTING THE WELL DATE
vision of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
C)

North Carolina • Department of Environment end Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' eRmA/✓ L. 24LC.
WELL CONTRACTOR CERTIFICATION is: aye.; 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential N=1 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT (Show sketch of the location below)
Nearest T wn: r T� �T'e-� Coupty
b.S9 TA,
&ham av,,sLs
(Road Name a ?ers, Comm` ly, pr Subdivision an Lot No.)
3. OWNER 1`t�1,..___- From To
Address 65 9 qm 4 p iCC R4
V�Luwsu;U
(S reet or ou a No.)
Q, hc_ a8itLi-
City or Town Q C, Stale Zip Code
4. DATE DRILLED 1- a'6 '-
5. TOTAL DEPTH TI'} S
6. CUTTINGS COLLECTED YES I I NO
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -r' II Above Top of Casing)
9. TOP OF CASING IS ' FT. Above Land Surface*
'Top of casing terminated attar below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): c D METHOD OF TEST R:
11. WATER ZONES (depth); j
12. CHLORINATION: Type W 7H Amount
1: \SING:
13 F-r1R4
0
CO
r.1
0
_O
IV _
If additional space Is needed use back of form
Wall Thickness
Depth Diameter or W lghVFI. Material
From 0 To 14 t it.a 5 alt.U1 PVC-SD
From To Ft,
From To Ft.
14. GROUT:
Depth Material Method
From b To ,p1 0 Ft C'xNC2.E4E �g'1'n'-r, p�,�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:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
L n
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Quad No ON STANDARDS, AND THAT A COPY QF//THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.(��-1
CONSTRUCTION USE ONLY / (Y///�%'l-�iLtii` .8 / tg - el ; FOR OFFICE .. ... __ Id NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit °dolt 1 to Division of Water Duality, Groundwater Section within 30 days
,I, GW-1 REV. 12J99
J
.al No
270000
0
SLU1 ON
ASHEn.L.E hI ; / L OFFICE

3. O
Address
OWNER
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Censer - Raleigh, N.C. 27699-1636-Phone [phone]//_' J J� //
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /IORMAN C. 24-((.
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
269999
1. WELL USE (Check Applicable Box): Residential ✓Lf Municipal ❑ Industrial Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCA
rest Town:
(Show sketch of the location below)
Llks^SS 9 4
�Counry
4mC_4.4—O
(Road Name an Numbers, Commu Ily, r SubdlvislenLgl Np.)) DRILLING LOG
/ Q ��'tl4-/l .�-`t1-41-Y• From To
WO ar ou e
City or Town Stale
4. DATE DRILLED 9 -11-0 a
5. TOTAL DEPTH 5
6. CUTTINGS COLLECTED YES I I NO WI
7. DOES WELL REPLACE EXISTING WELL? YES NO[71
8. STATIC WATER LEVEL Below Top of Casing: $ FT.
(Use'✓ II Above Top of Casing) r"/
9. TOP OF CASING IS 1 FT Above Land Surface' - .p
•Top or casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): O METHOD OF TEST _ R J
11. WATER ZONES (depth):
Zip Code
DEPTH
Formation Descdptlon
- 57 1>rs t-
aos BE-rLeock
o. c
n
0
12. CHLORINATION: Type _EMI__ AmouniS5 If additional space Is needed use back of form
1. 1SING:
Wall Thickness LOCATION SKETCH
/� Depth i^-Diameeterr• or WplghhVVFt. Matedal (Show direction and distance from at least two State
From —.5-- f o rt 3L-'-ud—art +dd b5 `�'��]�S`R Roads, or other map relerence points)
From 0 To 1 FI (e•�•5 . j g7 sV r'i :A< /�
From To FI
�L.�.r�' S �� /e ld �(_ -
14. GROUT: /� �
N
Depth Material � Mel�ng,t
From To �Ft ilE7/YGe�••iF .r„rr`�"`
From To Ft
15. SCREEN:
Depth Dlarneter 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:
tutA,L -y,.c ucd ( C
N �.
r�
n
0
0
N
1
'D
s
N
w
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU:T1ot STAt4DAFlQs;-fl,NQ4H4r a rnPY
FOR OFFICE US
Quad No:
.al No.
NL-Y
Submit
F THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
9-in a
]NATURE OF PERSON CONSTRUCTING THE WELL DATE
o Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Secllon
1636 Mall Service Center • Raleigh, N.C. 27699-1636-Phone [phone]//_' p
WELL CONSTRUCTION RECORD WELLCONTRACTOR• /1 N rY mAN C . ./ A-Z(.
269994 1
WELL CONTRACTOR CERTIFICATION'S:
STATE WELL CONSTRUCTION PERMIT'S:
I. WELL USE (Check Applicable Box): Residential 121 Municipal ❑ Industrial ❑ Agricultural El Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION Show sketch o t e location below)
Town:
LikSUYv
•^ County
(Road Name and Num ars. Comm glly, o_r-Sub Islonland Lol/No.)
(//��� p-�--
3. OWNER 1111111\` l�U i�'l1t.Au l LUTIAJt5G1-li') From
Address 9b
DRILLING LOG
To
DEPTH
Formation Description
ree or ou e o. 0 ., inn
l�s Rl
)v..Le . G D.S17 7 /Do - 34-s 3E.degck
Ci y or Town Slate Zlp Code
4. DATE DRILLED A -13-b D _
v
5. TOTAL DEPTH -34s C.J
6. CUTTINGS COLLECTED YES J 1 NO[4 T
7. DOES WELL REPLACE EXISTING WELL? YES in NO(( a
8. STATIC WATER LEVEL Below Top of Casing: SLa FT.
(Use': II Above Top of Casing)
9. TOP OF CASING IS / FT Above Land Surface'
•Top of casing terminated eUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): ,- n METHOD OF TEST co,.
11. WATER ZONES (depth): 1 ry
12. CHLORINATION: Type )4 TH C Amount �i.21L.U.S If additional space Is needed use back of form
1. 1SING:
Wall Thickness
Depth Diameter or WplgliVF�I. ;;11Maledal
From To I O FI (� •. S .�1 2 PVe-SO.c
From To Ft.
From To Ft
14. GROUT:
Depth Material aC'mMel_ - From � To � Ft IYCP�-FE .�o_
From To Ft
15. SCREEN: -
Doplh Diameter Slot Size Material
Frorn To Ft In In
From To Ft In In
From To Ft In. In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction end distance from at least Iwo State
Roags, r other map reference points)
CA'N Q(uiv.„
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION -STANDARDS; ANa-TtfAT-ACORY THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
FOR OFFICE USE c1) i'{'Yl.triti.t- 13-o a
Quad No:
al No
SIGN?
Submit odolnapj
URE OF PERSON CONSTRUCTING THE WELL DATE
Won of Water Quality, Groundwater Secllon within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mall Service Censer - Raleigh, N.C. 27699-1636-Phone [phone]////__''
WELL CONSTRUCTION RECORD WELL CONTRACTOR. it Rm AA/ L • ✓JR-LC ,
269992
WELL CONTRACTOR CERTIFICATION #: aye-11
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Resldential U Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other ❑ If Other, List Use:
2. WELL LOCAT46lb1} (Show sketch of the location below)
Nearest Tow% Ty) 1.LnA"-C4Q+0._0-X • County
A {,,
(Road Name and Numbels. Comrrully, or Subdivision and Lot Na,)
3. OWNER J
Address 5
A_Ct
City r Town Slate Zip Code
4. DATE DRILLED a-b a
5. TOTAL DEPTH O (7
6. CUTTINGS COLLECTED YES ( I NO171-
7. DOES WELL REPLACE EXISTING WELL? YES NOI VI
8. STATIC WATER LEVEL Below Top of Casing: b FT.
(Use '+' II Above Top of Casing)
9. TOP OF CASING IS / FT. Above Land Surface•
•Top of casing terminated eUor below land surface requires a variance In accor-
dance wllh 15A NCAC 2C .9111a
10. YIELD (gpm): 'METHOD OF TEST T\ k 4:3
11. WATER ZONES (depth):
5
Of •o
c
'7517
DRILLING LOG DEPTH
From To
- (a_
Formation Oescdptton
�Lc - -Eon BE-ditock
12. CHLORINATION: Type R7 ) Amount10_2_.}11.(1S
1. \SING:
rA
J
V n1=5
0
r 0 c.
If additional space Is needed use back of form
Wall Thickness LOCATION SKETCH
Depth � / Diameter or WplghVFt.t. �M�aalle`dall (Show direction and distance from at least two State
From D To alit Ft (/ • a 5 ads • CJ cff.5D . Roads, or other map reference points)
From To FI. C —�
From To Ft �J • 7C__.
14. GROUT:
Depth
l /� Material Method
From O To DuD FI l i1NCLE4 E JyD014'poyc`,',..,_
From To FI
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 DO HEREBY CERTIFY THAT THIS WELL WA__ $ L1 UCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANITTTiAT A CO THIS RECORD HAS BEEN PR IDED TO THE WELL WNER,
.�d�LY JVI C Y WELL
slot{URE OF PERSON CONSTRUCTING THE WELL GATE
Submit original 10 I ston of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199

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 WELLCONTRACTOR• NARmAN Z. _15A'«•
WELL CONTRACTOR CERTIFICATION N: .OTDS 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential ✓Lf Municipal ❑ Industrial El Agricultural El Monitoring 0
Recovery ❑ Heal Pump Water Injection ❑ Other El II Other, List Use:
2. WELL LOCA Show sketch f the locallon below)
Nearest Town: ' hMs County
Vlinglitte
c1f
oad Name
NER
Address
rlo;r unit or Subdivision and Lot No.)
k!c '
- (Street' r Houle o.)
I Lvr._i l (_ .D2 7 I'-1-
�1
ily or Town Stale Zip Code
4. DATE DRILLED 9-14 -0 T
5. TOTAL DEPTH -2-NL-I- C
6. CUTTINGS COLLECTED YES I I NORI
7. DOES WELL REPLACE EXISTING WELL? YES n NOM'
8. STATIC WATER LEVEL Below Top of Casing: 1.4.O FT.
/ (Use '+ II Above Top of Casing)
9. TOP OF CASING IS I FT Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 4 METHOD OF TEST R.
11. WATER ZONES (depth):
DRILLING LOG
From To
12. CHLORINATION: Type
1' %SING:
4
TH
Amounts R IIS
269982
DEPTH
Formation Descdptlon
0
c -)
rs)
0
-10
!'J
If additional space Is needed use back of farm
N c;
Wail Thickness LOCATION SKETCH
Deptt Diameter or W IghvFt.t. ;%Material (Show direction end distance from at least Iwo State
From O To � Ft
L ' 5 $-r-'Ps/�-L 7Ve_Spie Roads, or other map ref nce points)
From To Ft ^.
From To Ft.
14. GROUT: , t fi S 2/„�,atic
Depth Material Method , /wv�
Xi
From Q To 0?-0 FI i1mN f Phi' t .�4B.I�d_
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In
From To FI In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Malerlal
From To Ft
From To FI
17. REMARKS:
0
C.�
rn
0
N
Cl
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION &ANDARDS, AND.THAT AT A COPY F THIS RECORD HAS BEENPyRq�/IDED TO THE WELL WNER. /
FOR OFFICE USF,ONt)Y''' /�l.liLti/ VPS
9-&-o a'
Quad No: Si( IIJAk4IE OF PERSON CONSTRUCTING THE WELL DATE
Submit original 10101 Ifk on of Water Quality, Groundwater Section within 30 days
L 1 GWd REV. 12/99
.d No

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]y(//%%__''
WELL CONSTRUCTION RECORD WELL CONTRACTOR. XeRmAA/ L • 2.4«.
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE (Check Applicable Box): Resldentlal l o Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other Ej II Other, List Use:
2. WELL LOCATION: (Show sketch t the location below)
t L c
Adella J
Nearest Town:
��7♦ HI
(blree or Houle
) I
City or Town to
4. DATE DRILLED -S-U
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOf4
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing: ! FT.
(Use 't.' II Above Top of Casing)
9. / FT. Above Land Surface'
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2 1e
10. YIELD (gpm): METHOD OF TEST �. 3
11. WATER ZONES (depth): 1 � �--p���g
12. CHLORINATION: Type I -I 7H Amount -
1 \SING:
ount y Q/1'T
21 A eut4AS Utl cz ( C1
Road Name
3. OWNER
Address
Numbers. Community, or Subdivision and Lot No.)
ooh o
TOP OF CASING IS
From
From
From
14. GROUT:
turn`5(5 .dc
c
Depth Diameter
To 5 � Ft. hi 015
To FI
To Ft
From 0
From
15. SCREEN:
Zip Code
NO
DRILLING LOG
From To
DEPTH
Formation Description
sg-3os B Qck
vf
If additional space Is needed use back of form
0
c)
N
0
-Q
0
Wall Thickness
or W Ight/FI. Maledal
�.l�s pvesDC
Depth Material
To a Ft NMIC2k4E
To FI
Method
�11�
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 FI
From To FI
17. REMARKS:
tv
LOCATION SKETCH
(Show direction and distance from al least two State
Roads, or other map reference points)
r}S CIJLLJC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
DS AND THAT A COPY aF THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
FOR OFFICE USE RUSESC�NLY�',,, y ( C.CK�C._-. 6)- 6"'D
Quad No:
al No
SI
Submit original to b(v
U OF PERSON CONSTRUCTING THE WELL DATE
Water Quality, Groundwater Section within 30 days
GW-1 REV. 1Z199
0
c.c.!
(71
r\)
cn
-o
IV
0
269981.
CC-

269978
i
North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mall Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
ARmAN L.24,-«.
WELL CONTRACTOR CERTIFICATION #: a7CA
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential r Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other If Other, List Use:
2. WELL LOCATI
N
arast Town:
tow sketch of th location below)
County
tin ns..sWki
(Road�NaramQan^mod Numbers. Community, or Subdivision and Lot No.)
^J[ •
City or Town slate
4. DATE DRILLED —7) 5-o a
5. TOTAL DEPTH .--a-QS
6. CUTTINGS COLLECTED YES n NO14
7. DOES WELL REPLACE EXISTING WELL? YES n NOI
8, STATIC WATER LEVEL Below Top of Casing: ) b FT.
/ (Use '+' If Above Top of Casing)
9. TOP OF CASING IS ! FT Above Land Surface'
•Top or casing terminated eUor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118 ''11��
10. YIELD (gpm): 100 METHOD OF TEST Yl: 3
11. WATER ZONES (depth)•
12. CHLORINATION: Type 4 7NAmountl
1 \SING:
3. OWNER
Address
DRILLING LOG
From To
1a n
DEPTH
Formation Description
Bs-.irzocic
0
N
If additional space Is needed use back ol form
Wall Thickness
Depth ^ Diameter or W IghUFt. Material
From 0 To_14_LFI L.a5 �1�.PVC-SAC
From To Ft.
From To Ft
14. GROUT:
From 0
From
15. SCREEN
Depth Material
To aZ 0 Ft. i'v1YC2A4 E
To Ft
Method r _
Depth Diameter Slot Size Materiel
From To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Stale
Roads, or other map reference points)
ci3
I DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
13
iiii� • •_ :ND THAT A COPY THIS RECORD HAS BEEN PRE IDED TO THE WELL WNER.
CONSTRUCTIO
FOR OFFICE U
Quad No:
.al No.
RE OF PERSON CONSTRUCTING THE WELL DATE
slon ol Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

i
/%_' J� 2699'7 0
WELL CONSTRUCTION RECORD WELL CONTRACTOR' /TN /PMAN C L. JA'(C..
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 CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Lit Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List Use:
2.
3.
WELL LOCATel: (Show sketch ofthe , location below)
Nearest Town: `(-Th(AhAr\S` County.
Si S US 1gri &BukskuLec,
(Road Name and Numbers. Com uun Cy, or Subdlvislod*and Lot No.)
OWNER %� QFl r✓v C 't i Mnu.., / CUYY1
Address I .
bl ep for oule No
��
City or Town Cl•
Slate
4. DATE DRILLED Jv �- 6 a
5. TOTAL DEPTH 1 (P S
6. CUTTINGS COLLECTED YES n NOIV1
7. DOES WELL REPLACE EXISTING WELL? YES ( J NO
8. STATIC WATER LEVEL Below Top of Casing: ,..;, C 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 2C4I118
10. YIELD (gpm): .- 0 METHOD OF TEST
11. WATER ZONES (depth):
0L\ -ag
Zip Code
a nC
DRILLING LOG
From To
12. CHLORINATION: Type U 7H Amounl3
1 %SING:
DEPTH
Formation 0escription
iR4ck
w
rV
rl
Iv
If additional space Is needed use back of form
Wall Thickness
Depth Diameter or WFIOhVFI. ;1Maledal
From D To a-9 FI,L •01S m'J •j;5 PvtsAC
From To Ft.
From To Ft
14. GROUT:
Depth
From I To a0
Material
FI. C'vIYCP1-FE
From To FI
15. SCREEN:
Method
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 FI
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
Roads, or other map reference points)
ww
)4c4-7 m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CQPY F TH, S RECORD HAS BEEN PR IDEO TO THE WELL
WNER.
FOR OFFICE USE 01I4 (, /{�'l.e�ilti/ ( GL,L'iL.— R- 30 -6 a
• r
Quad No:
al No
SIGN
Submit odglnal 10
Ivls'
J
E OF PERSON CONSTRUCTING THE WELL DATE
n of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
Al; 269960
N
WELL CONSTRUCTION RECORD WELL CONTRACTOR. RmAN G • 24 7.
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITM:
WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other El If Other, List Use:
2. WELL LOCATIO . (Show sketch of the location below)
Nearest Town: CoUnty'
fr-AANS Lath.)
Road Name and umbers. Community, or Subdivision and Lot No.)
WNER LA-LCIfl -)
Address
LL/1'T
4, DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ( NO 1/ I
7. DOES WELL REPLACE EXISTING WELL? YES n NO1 vf
8. STATIC WATER LEVEL Below Top of Casing: )S FT.
I(Use'.' II Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated euor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 3 METHOD OF TEST
11. WATER ZONES (depth)• ..
DRILLING LOG DEPTH
From To Formation Description
-3e5
SSreal orJipule No.)�n 087'1-1
City or Town wlN�- Stale l Zlp Code
3h
'., CHLORINATION: Type ;f 7N Amount Es2+.11s
CASING:
Wall Thickness
Depth Diameter or W°IghVF_I. Matedal
From To Ft
From To n�<% Ft. !r•15 a nn STZ'er
From To FI
14. GROUT:
Depth Material Method
Horn Q To aZ 0 FI f1v1YCP_.E••F E ��.nrri"�„`
From To FI
15. SCREEN:
Depth Diameter Slot Slze 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 FI
From To Ft. _
17. REMARKS:
$; cLRock ow
-r
rsrl
0
rJ
If additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference otnts)
0
W
FT1
w
-9
IV
CO
0
I DO FIEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PR IDEOTTO THE WELLLL WNER.
lR OFFICE WSF'.. I V ' V (�/�/rAGL.ti/ ICJ C.L-Cx--- U
TUnE OF PERSON CONSTRUCTING THE WELL DATE
vision of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Nearest
/(Road N
3. OWNER
Address
North Carolina - Department of Environment and Natural Resources - Division ol Water Quality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] y//�' /
C
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /lev RMAN • 2R-Z(.
WELL CONTRACTOR CERTIFICATION IS: 40A 7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heal Pump Water Injection ❑ Other ❑ II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �/�
own: �rl✓nivii ! County +Vnt y
�`'�Com5 p
rtwfr(II
e n Numbers, y, or Subdivision and Lot No.)
Cia,ecie �mle .-4-414-e25-l1,
as (S(reel or�yfoute ro.) r L ✓ c Rd.
Ournskilho O.r•
City or Town Stale Z
4. DATE DRILLEDana
5. TOTAL DEPTH 2h
6. CUTTINGS COLLECTED YES fl NO[71
7. DOES WELL REPLACE EXISTING WELL? YES n
8. STATIC WATER LEVEL Below Top of Casing: 35'
DRILLING LOG
From To
Ip Code
NOW(
FT.
(Use': II Above Top ol Casing)
9. TOP OF CASING IS / FT Above Land Surface'
'Top or casing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): 8 METHOD OF TEST i2 : 5
11. WATER ZONES (depth)- r.�
10 CHLORINATION: Type )4 7H Amount _p;JiS
CASING:
DEPTH
Formation Description
la•R
Block
rl
c)
rV
If additional space Is needed use back of form
Wall Thickness
Depth aa��11 Diameter or W}IghVFI. ;)Maledal
From D To Oa. FI G.;5 07/4,LPS PVt5D4C
From To FI,
From To Ft
14. GROUT:
Depth
From Q To do Ft
From To FI
15. SCREEN:
Material Method
C71M G2.Ei E "rjlp_u'Q
Depth Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
i&ea &/2/ j ei?4
Gantry tie n .c
--a
N
N
'D
I DO HEREOY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAGD&ANRSHAT A COPY THIS RECORD HAS BEEN PRIDED TO THE WELL WNER.
0/IiYh i r Poff,?C
'ME OF PERSON CONSTRUCTING THE WELL DATE
Islon ol Water Duality, Omundwaler Section within 30 days
GW-1 REV. 12/99
269957
r
--4

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1630 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. RMAN L. 2L}LL.
WELL CONTRACTOR CERTIFICATION 0: ova.;7
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential LJ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI (Show Sv; `( the location below) b IQ� C�P.I
west Town: l t �'}- Coun u+ l
( o d Name and Numbs. Community, r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Ed J�IT Ur� From To Formation Description
A�lddressPQJV T(}J }� Q y
jXli� (e Mire° or ( CuptS Creek
V e 9V f - 606 Ask ►1 4 c - 16� BrT-dr�ac_k
City orrTown G 5 ale Zip Code CO
4. DATE DRILLED U -
5. TOTAL DEPTH _r'7 � i0
6. CUTTINGS COLLECTED YES (l NOIV1
7. DOES WELL REPLACE EXISTING WELL? YES ( ) Noll/ %n
8. STATIC WATER LEVEL Below Top ol Casing: ` p FT.
(Use '' II Above Top ol Casing) - r
9. TOP OF CASING IS '+ FT Above Land Surface' ry
•Top of casing terminated el/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 10. YIELD (gpm)• .--On.--OnMETHOD OF TEST Rs Q __
11. WATER ZONES (depth): j
1 o CHLORINATION: Type 1.1 TN Amount .1141111.5 II additional space is needed use back of (arm
3ASING:
Wall Thickness LOCATION SKETCH
Depth Diameter Of Wetgh.VVF-I. Material (Show direction and distance from at least two Stale
From O To FI G • a1 5 �l4.125 Pl/GSDrC Roads, or other map reference points)
From To Ft. `#
From To FI.
14. GROUT:
Depth Material Method
pZ.
From n To o Ft C1o/YC2.Eib /
From To FI.
15. SCREEN:
Depth Diameter Slot Size Material
Frorn 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:
269952
r,
par %raL915 C
rn
'bUrn3ViIte, a
I DO HEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RDS AND THAT A COPYHIS RECORD HAS BEENNN�IDE� THE W�NER.
CONSTRUCTION TANDA//
E OF PERSON CONSTRUCTING THE WELL DATE
n of Water Quality, Groundwater Section within 30 days
GW-I flEV. 12J99

B&c1RQtk
ry
Amount .21—p- iS If additional space Is needed use back of form
LOCATION SKETCH
Wall Thickness ;T
From 0 Depth
22— FI LDiameter
; 5 j )4I;1 1 PvtsD (Show direction and distnee fromrent epoileast
tstwo State
�. Roads, or other mapreference points)
From To FI ''
From To Ft 14. GROUT: Cane 1 Lv-er
Depth Material Method
Frorn D To � Ft (1CN CR-E4 E , BO,vns v► l i e,
Frorn To Ft co
ry
15. SCREEN: al
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. /IN RmAN 4 • A LL.
WELL CONTRACTOR CERTIFICATION 0:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Er* Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Infection ❑ Other II Other, List Use:
2. WELL LOCH N: (Show sketph Qf the location below) .„4�Cp
Ne )est To V 1 1 1 e. County [G
45CUu-.s ze tt�
(Woad Na end Numbers, Co'mmunll or Subdl'vlislon end Lol No.) DRILLING LOG DEPTH
3. OWNER1 Lab Wl.l From To Formation Descdpllon
Address 311 S e or Dula o -4v .
-Wild r1L fl- a$733
City or Town State Zip Code
4. DATE DRILLED ', C
5. TOTAL DEPTH L F
6. CUTTINGS COLLECTED YES In NOI./4
7. DOES WELL REPLACE EXISTING WELL? YES n NOj 1,4
8. STATIC WATER LEVEL Below Top of Casing: $a- FT.
(Use'i If Above Top of Casing)
9. TOP OF CASING IS ' FT Above Land Surface*
'Top of casing termtnaled at/or below land surface requlrea a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): C METHOD OF TEST r or3
11. WATER ZONES (depth):
D-72
72. lac)
'^ CHLORINATION: Type 1Rf 7H
CASING:
Ooplh Diameter Slot Size Material
From To Ft In In
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI
From To Ft
17. REMARKS:
FOR OFFICE USpr ONLY _'_
quad No: Si(�1�URE OF PERSON CONSTRUCTING THE WELL DATE
Submit original lq D ton of Water Quality, Groundwater Section Within 30 days
"O
3
(V
N
LD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOriSTANDARDS, AND THAT A COP-K. THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
r7
Serial No.
269949
Cr:
n_
G

1
North Caroline • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] i7
WELL. CONSTRUCTION RECORD WELL CONTRACTOR: /Ye RmAN L L. �i A•LL
WELL CONTRACTOR CERTIFICATION #: 4D 7
STATE WELL CONSTRUCTION PERMIT#:
269948
1. WELL USE (Check Applicable Sox): Residential 2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below) �/,,
rest Town: *It County eY
o55a.-e,. /t 1 j314 wit-4 /1 C
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER MOP /and/ Nye oon/ler From To
Address
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES inN01 J
7. DOES WELL REPLACE EXISTING WELL? YES Q NO RI' rV
135 8. STATIC WATER LEVEL Below Top of Casing: FT.
I(Use'i 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 .0116
10. YIELD (gpm): 5 METHOD OF TEST R: 3
11. WATER ZONES (depth)•
+e. CHLORINATION: Type n Amount 1
ilLS
CASING:
(� - 13D
1.9 -3
DEPTH
Formation Description
'!-
13F-cM QC k
w
(Street or Roufe No.) u
Sore cr pipe n.c. a8777
dy or Town I State Zip Code
444:02
Depth
From D To /30 FI
From
From
14. GROUT:
To Ft.
To Ft
1\1
If additional space Is needed use back of form
Wall Thickness
Diameter or W IghVFI. Maledal
G.a5 aItiss PYGsDIC
Depth Material
From b To AO Ft ir.NC 1-16
From To FI
15. SCREEN:
Depth
From To Ft
From To Ft
From To Ft
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
ffidALMelhod
"
Diameter Slot Size Materiel
In In
In In
In In
FI
Ft
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
ee
Fo74rr-
(&ur/70rl/e, /1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PR IDEO TO THE WELL WNER.
FOR OFFICE /KAGLti/
Quad No:
Serial No.
L
Submit odglnal I
L.
TUBE OF PERSON CONSTRUCTING THE WELL DATE
vision of Water Duaiity, Groundwater Section within 30 days
GW-1 REV. 12/99
L^ti' tr
AsHEATILLEh u,vl

1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 269923
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] '
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /rayRn1A/✓ L. 24((.
WELL CONTRACTOR CERTIFICATION S,: C DA
STATE WELL CONSTRUCTION PERMITS,:
1. WELL USE (Check Applicable Box): Residential2 Municipal ❑ Industrial CI Agricultural ❑ Monitoring El
Recovery ❑ Heal Pump Water Infection ❑ Other II Other, List Use:
2. WELL LOCATI c : (Show skelgh QI
own: U�
Roao ame a
—riled
Vim(
(umbers, Commeynyty, or Subdlvle on end Lol No.) DRILLING LOG DEPTH
3. OWNER (��Q-NHS From To Formation Description
4t 9 Cr33 0
(S reel or oule No. r�t� 1
l,tJw\S,,Jal 12 _ Yl C a' a I V` 1'
City or Town State Zlp Code
4. DATE DRILLED Gl +o a
5. TOTAL DEPTH C�
6. CUTTINGS COLLECTED YES n NO WI
7. DOES WELL REPLACE EXISTING WELL? YES n NO Vii
8. STATIC WATER LEVEL Below Top of Casing: ?ZD 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 +—
ID. YIELD (gpm): ___Q_. � METHOD OF TEST ;._�
11. WATER ZONES (depth):
Address
°
- n
aBE-the-ock
w
0
e location below)
T)LAns County.
12. CHLORINATION: Type W TH Amount ilpi S
1 ;SING:
1` ]
II additional space Is needed use back of form
Wall Thickness
D Depth 3 b. Diameter or WpIphUFr. Matedal _
From To FI. �1�./�5 yuc s��
From To FL
From To Ft
14. GROUT:
Depth Material Method ,
From Q To ao FI OD/YCPi-i6 rj1Qr'r'"P_�r%.
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
From To FI In In
From To FI In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
Jims,
-mecum
nC
0
CO
'T
r1
Iv
c;i
I DO FIEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIQNSTANDARDS.AND. THAT A COPY THIS RECORD HAS BEEN PR IDEDD TO THEoWEfLLLLL WNER.
FOR OFFICE USE ¢iLY .. i l4. r 9,44ey�~"� 2
q-�
Quad No: - r S NURE OF PERSON CONSTRUCTING THE WELL DATE
Submil odglnailo Won of Water Quality. Groundwater Section within 30 days
al No. � j i L GWd REV. 12/99
C)

i
North Caroline - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 2 6 9 9 4 2
1636 Mail Service Center - Raleigh,N.C. 27699-1636-Phone [phone] D //_'
WELL CONSTRUCTION RECORD WELL CONTRACTOR• RMAN C .
WELL CONTRACTOR CERTIFICATION A: 4D.a 7
STATE WELLCONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable Boa): ResidentialU Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, Llst Use:
2. WELL LOCATI
Nearest Town:
9Q .-tff�i� KEY 7fl1`ia&
(Road Nam4.bnfi Numbers, ommunJy.,or Subdlvislon ar)h Lot No.)
WNERlJ�Ji\lQJrvC
Address `pi-'14—Sj ,rf "33 Q
.Lyinsm _, (51 ° or Houle N1 "�i— n27I f
City or Town ..1 State �' l Zip Codedlle,
4. DATE DRILLED 9-1+0 a
5. TOTAL DEPTH n• 5
B. CUTTINGS COLLECTED YES n NO[71
7. DOES WELL REPLACE EXISTING WELL? YES in NOW(
B. STATIC WATER LEVEL Below Top of Casing: y.5 FT.
/ (Use'+' II Above Top of Casing)
9. TOP OF CASING IS I FT. Above Land Surface'
•Top of casing terminated al/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 118
10. YIELD (gpm): METHOD OF TEST �. 5
11. WATER ZONES (depth):
Show sketch of ((le location below)
aunty. tI L( A1C
DRILLING LOG
From To
DEPTH
Formation Description
D - 5 7 t�,R tt—
S 7• 3a5 .Ezoo
=D r
0
ry
r
12. CHLORINATION: Type rl T Ti Amount SSpaS If additional space Is needed use back of form
1SING:
Wall Thickness LOCATION SKETCH
To Diameter or Wf IghVVF�I. M�aatte`rial (Show direction and distance from at least Iwo Stale
From D To f Ft le •' a 5 �1�[ez CJCiv2Lvi` Roads, or other map reference points)
From To FI.
From To FI a 14. GROUT: U.j�5 V
Depth Material Method c'� /
Frorn b To pl.0 Ft. OPPECP-EiE l_ i7�
-01A-47
From To FI /[/�)7(j 1. j
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft In In.
From To Ft In In
From To FI In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
0
CO
-q
r-1
_O
ry
I DO FIEREOY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
FOR OFFICE USE{ONQY.
Quad No:
el No.
J
L.
LE R,.,
F THIS RECORD HAS BEEN PR IDED TO THE WELL WNER.
(6. i4,-Aowy ate_ 9 - q- o
SIdNAIL RE OF PERSON CONSTRUCTING THE WELL DATE
Submit original tolDiv on of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

1
North Carolina - Department of Environment and Natural Resources - Division of Water (Duality - Groundwater Section
1636 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR•
�.� 269921
N�RmAN L. LOLL.
WELL CONTRACTOR CERTIFICATION P: c 0.
STATE WELL CONSTRUCTION PERMITS,:
1. WELL USE (Check Applicable Box): Residential la Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El II Other, List Use:
2. WELL LOCAT tow sketch of the location below) �e . �
Neares own: SV.?� < County U
Cl�mtte �a d. ��►t�Lr �1J
(Road Name and _mt�be(rr�s.�C�p4ly�mmunit , r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER t hDi.J . �)nvv+-S From To Formation Description
Addr s JL 9 C�.�N,/
(Stree or Route o.) 3Z� o - el Le_ ni*R t
Gr rYc/ � / (ii� (0� 3Ei�q
�
ty or Town Stale Zip Code
4. DATE DRILLED L0�Z ai
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n No14
7. DOES WELL REPLACE EXISTING WELL? YES NO(vl
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': 11 Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface' 0
'Top of casing terminated at/or below land surface requires a variance In accor-
dance wllh 15A NCAC 2C Al1.8
10. YIELD (gpm)• METHOD OF TEST
11. WATER ZONES (depth)•
CHLORINATION: Type H _h Amount LILZpilLS If additional space Is needed use back of form
,. CASING:
0
w
'\t
"7
IV rn-:
rn _a
Wall Thickness LOCATION SKETCH
Depth Diameter or Wf IghVFt. ;1Material (Show direction and distance from at least Iwo Stale
From 0 To 910- Ft b ...IS ;J'.1,5 f VC'SDC Roads, or other map reference points)
From To Ft
From To FI Sv
14. GROUT:
Depth Material Method
, (b I
D To do F1 C'aNCE&iE4LBkd._ j/�/) e�l) kQ• w
From V 1. rrN ��""' r`'
From To FI ry
15. SCREEN: "'
Depth Diameter Slot Size Material v
From To Ft in. In
From To FI In In IV
From To Ft In In CO
C'I
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THATACOPY - THIS RECORD HAS BEEN PRQ}/IDED TO THE WELL WNER.
4* (=//y as iv -3-62
FOR OFFICE a,
Quad No: S.I TIME OF PERSON CONSTRUCTING THE WELL DATE
Submit original tp Division oI Water Duality, Groundwater Section within 30 days
Serial No. / GW-I REV. 12/99

J
FOR OFFICE U
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mall Service Censer • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR• RmAN L. 2A1L.
WELL CONTRACTOR CERTIFICATION #: e O '7
STATE WELL CONSTRUCTION PERMIT#:
269920
1. WELL USE (Check Applicable Box): Residential 21 Municipal ❑ industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Olher If Other, List Use:
2. WELL LOCATI N: (Show ske ch of the location below) �
Nearest To n: .cit V/�i • County: e y
TO `✓�f»r. i * slai4.
(Road Name and Numbers. Community, Subdivision and Lot No.) DRILLING LOG
3. OWNER Cori 5 lunsforri From To
Address y eeo Rc 5o
Jv jSlre�roule o.
City or own State Zip Code
4. DATE DRILLED
5. TOTAL DEPTH JL ,5
6. CUTTINGS COLLECTED YES NO1✓
7. DOES WELL REPLACE EXISTING WELL? YES Q NO11,4
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' II Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C . 118
10. YIELD (gpm)• METHOD OF TEST R.
11. WATER ZONES (depth):
I
o - 35
s3.5 -1 y 0
1n CHLORINATION: Type 1Er / J--1 Amount Wrist
CASING:
DEPTH
Formation Descdptlon
1i,'R t
13z9cic
O
t,)
='C
N,)
If additional space Is needed use back of form
Wall Thickness
SKETCH
Depth Diameter or W ight/Ft. ;TMaledal (Show direction and distance from at least Iwo State
From 0 To 35 Ft i/ ' a 5 d �.1;5 PI/C•SDC Roads, or other map reference points)
From To Ft
From To Ft.
14. GROUT:
From Q
From To Ft
15. SCREEN:
TMaterial Method
Too AO Et C'v)YCP-EfE .77-0u•E_Er{__
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:
4376
gurrmsv, JM A.C.
I DO FIEREDY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO STANOAflDS,AND IUAT A COPY F THIS RECORD HAS BEEN
`PPR/ /IDEO TO THE WELL WNER. u
'Wad No: �Ij3NP(1URE OF PERSON CONSTRUCTING THE WELL
Submli odgln I Lo flhhllll Islon of Water Quality, Groundwater Section within 30 days DATE
jedal No. GW-1 REV. 12/99

North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mall Service Censer - Raleigh, N.C. 27699-1636-Phone [phone] yy////__'' �J //
WELL CONSTRUCTION RECORD WELL CONTRACTOR. lreRmAN L. T A-Z(.
WELL CONTRACTOR CERTIFICATION 0: .c D..,7
P69917
STATE WELL CONSTRUCTION PERMITM:
WELL USE (Check Applicable Box): ResidentialEr Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) Ya
N�a-r st Town: , yi ty
• Ucn�L<l� CIA 4id -� /lG /.
(Road Name and Numbers. Community, or Subdivision and Lot No.) DRILLING LOG
3. OWNER IYlaCK-Thoir4 From To
Address 'R} rO 1L ''w
1Slree oT Houle No
Green IYMipp"ijn n 01g740
City or Town Stale Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
..Lge
6. CUTTINGS COLLECTED YES (l NO 14
7. DOES WELL REPLACE EXISTING WELL? YES n NOI
B. STATIC WATER LEVEL Below Top of Casing: 7Q FT.
l (Use'*' II Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
*Top of casing terminated Ivor below land surface requires a variance In actor•
dance wllh 15A NCAC 2C .0118 ,
10. YIELD (gpm): 3 METHOD OF TEST
11. WATER ZONES (depth): I
In CHLORINATION: Type >1 •r TN Amount SL.pa.11S
DEPTH
Formation Description
65 3'Z $&c(2oc k
CASING:
4
ram)
u
rV
r
it additional space Is needed use back of form
Wail Thickness
Depth Diameter or Weight/Ft. Matedal
From 0 To __.a----FI 1' 5 2Jt.1.15 PVe SDee
From
From
14. GROUT:
To
To
Ft
Ft
Depth Material
From D To Ft eionC2.f:4E
From To Ft
15. SCREEN:
Depth Dlatneter Slot Size Material
Front To Ft In In
From To Ft In . In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS PECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i �7
Method
LOCATION SKETCH
(Show direction and distance from at least Iwo Slate
or other map reference points)
Ro)
w,s
r
FOR OFFICE USE 0
quad No:
Serial No
G(en rne, ain, a,
0
SIGNATU"1
Submit original to Diylla
F PERSON CONSTRUCTING THE WELL DATE
Water Duality, Groundwater Section within 30 days
GW-I REV. 12/99

North Carolina • Department ol Environment and Natural Resources • Division of Water Quality • Groundwater Section 269915
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] y/jam'
WELL CONSTRUCTION RECORD WELL CONTRACTOR' / eRnAN Z. 2A-Z(.
WELL CONTRACTOR CERTIFICATION U: cqua 7
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE (check Applicable Sox): Residential Q• Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other Ej If Other, List Use:
2. WELL LOCATION: low sketch of the location below) , 441
N rest T n: County'
1 C Clh444S t/
(R d Name and Numbers. Co unity, or Subdivision a• • Lot No.)
3. OWNER
Address
ree or 'oue •o. D - 4/.5
Sat„-51/ asii�`de "15 - as s
City or Town Slate Zip
4. DATE DRILLED 7-1-
5. TOTAL DEPTH -a'
6. CUTTINGS COLLECTED YES n NOIVI
7 DOES WELL REPLACE EXISTING WELL? YES
NOI
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use •.s II Above Top of Casing)
9. TOP OF CASING IS 1 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): 1 METHOD OF TEST . 3
11. WATER ZONES (depth)'
O o
c>
CHLORINATION: Type )4 7n Amount 3_84-WS 11 additional space Is needed use back of form
CASING:
Wall Thickness
Depth/� Diameter or W IghVFI. ;1Material
From Li To T"FI It •a5 rve•SDR'
From To Ft. '"
From To Ft
14. GROUT:
Depth Maledal Method
From D To al-0 FI NiN1�f en- l
From To Fl.
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 FI
From To Ft
17. REMARKS:
I DO HEREOY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND THAT A COPY THIS RECORD HAS BEEN PR DED TO THE WELL S?WNER.
-11
rr.--
c,
o .—{
LOCATION SKETCH
(Show direction and distance from al least two State
Roads, or other map reference points)
0
)w,yls?f.L W
/7
SI
Submit original IQ
I I�
E OF PERSON CONSTRUCTING THE WELL DATE
qn ol Waler Quality, Groundwater Section within 30 days
GW-I REV. 12/99

1
North Carolina - Department of Environment and Natural Resources - Division of Water Duality- Groundwater Section 269912
^'
1638 Mall Service Center - Raleigh, N.C. 27699-1636-Phone [phone] //_'
WELL CONSTRUCTION RECORD WELL CONTRACTOR. A RJAN 2 .�1 25-C� .
WELL CONTRACTOR CERTIFICATION S,: o7O.3 7
STATE WELL CONSTRUCTION PERMITS,:
1. WELL USE (Check Applicable Box): Residential Lrl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other I] II Other, List Use:
2. WELL LOCAT N: (Show sketch1of the location below) y
Nearest Town: vrili fSU i tie �'Countyy: r��dCA C-e t (—
tin ! i /1cr-i . 0 (74-✓ l�.Xouts&fez
(Road Name and Numbers, Commu Ity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER C Qve1 Judd
Address alc) (1eetcr non
S ree or -%j o(f.
Line c c In 1m' C P$ocl a
City or Town Sta a Zip Code
4. DATE DRILLED �Q
5. TOTAL DEPTH �f1 n
6. CUTTINGS COLLECTED YES NO14
I
7. DOES WELL REPLACE EXISTING WELL? YES n NOI A
8. STATIC WATER LEVEL Below Top of Casing: a S FT. 0
(Use -a' If Above Top of Casing)
9. TOP OF CASING IS / Z
FT Above Land Surface' t-
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2r1nita D . O
10. YIELD (gpm): t7,_ METHOD
11. WATER ZONES (depth):
From To Formation Description
O(D5 B2oc k
•
"fir,
17 CHLORINATION: Type PI 7N Amount . llS If additional space Is needed use back of form
BASING:
Wall Thickness
Depth Diameter ofWeight/Ft. Material
From 0 To ao Ft L..25 m?).b5 PVGSDJC
From To Ft
From To Ft
14. GROUT:
Depth Material Method From � To v�-0 Ft itONCe.Ei'F .li%ON'eE,�.
From To Ft
15. SCREEN:
Depth Diameter Slot Slze Material
Frorn To Ft In In
From To Ft In In
From To Ft In In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map ce points)
aCJ
-
Ltit
turnsvilieMC.
lv
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST(ANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PRQ).rIDED TO THE WELL WNER. �1 /�
FOR OFFI �Ej
II O Y _ b I 1b /04i�%%7Le4.�7
i' V GCX�-- C9a v �L
0
Sulan;i o
i
quad No:??, r -- •-•
pedal No
SI NATURE OF PERSON CONSTRUCTING THE WELL DATE
al to Division of Water Duality, Groundwater Section within 30 days
CW.I REV. 12/99

LOCATION SKETCH
11. DISINFECTION: Type 7�i - '. Amount /, DZ Show direction and distance in miles from at least
12. CASING: V Wall Thickness two State Roads or County Roads. Include the road
Depth or Weight/Ft. Material numbers and common road names.
From To J� n
From To
From To
13. GROUT: Depth
From 0 To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From�['o in. in.
From -/ To Ft. in. in.
15. SAND/GRAVEL ACK:
Depth Size Material
From To
From
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and I j4tural Resources - Division of Water Quality - Groundwater Section/7
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) E7 N.V/ e /34.4.2_ ., CERTIFICATION #4 h,77
WELL CONTRACTOR COMPANY NAME -ear .0-et%<.1) (aid L 4....." i 4. PHON�E/ # f�i;%RI h VY I). Yp
STATE WELL CONSTRUCTION PERMIT# N/%7 ASSOCIATED WQ PERMIT# A///7
(if applicable)
(if applicable)
263426
1. WELL USE (Check Applicable Box): Residential( Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI a :
Nearest Town: County
Luyae%tt*' 2b'% /y/
(Street Name, Numbers, Community, Subdivision, Lot No., Zip ode)
3. OWNER: ,2
Address W /itA&22e. gd
(Sheet or Routh No.)
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED /// /7 L-
5. TOTAL DEPTH: s
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: zaS ET.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / .S FT. Above Land Surface'
*Top of wing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0I18.
9. YIELD (gpm): METHOD OF TEST1—r.,r-co
10. WATER ZONES (depth): Lo.s
Topographic/Land setting
❑Ridge ❑Slope ylValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH pRILLING LOG
From To Formation Description
Diameter
Ft. la ,
Ft.
Ft. qqMaterial
� �
txy i
M od ,
/42
t.
rTh
S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
21, within 30 days. GW-1 REV. 07/2001

266273
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
,
WELL CONTRACTOR (INDIVIDUAL) NAME (print) -JCCCSC-K fiP8.846eC+tS CERTIFICATION # ,'1,4 d8#
WELL CONTRACTOR COMPANY NAME Cte, SCA'ar•S3'S2.41/4x\V ae'rr-I -A'K• PHONE # eta) bbS +822..
STATE WEI,L CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential IS Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection D Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: (?)t,.e nay,/ ; tee County e{unt-
Rouee 3 130x 3‘ '2. Q acnsr'.tee nc aZ
(Street Name, Numbers. Community, Subdivision, Lot No., Zip Code)
3. OWNER: Sin1-e,u4y
Address Rem, . 3 951T�.,c 3) 2
(Street or Route No.)
3vcnti.:tee Y\C, aRl04
City or Town State Zip Code
(82S)- toS2- (0452.
Area code- Phone number
4. DATE DRILLED \\- VA-131-
5. TOTAL DEPTH: 3 is
6. DOES WELL REPLACE -EXISTING WELL? YES ❑ NO M
7. STATIC WATER LEVEL Below Top of Casing: a5 FT.
(Use "+" if Above Top of Casing)
8, TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): S METHOD OF TEST v
10. WATER ZONES (depth):
Topographic/Land setting
DRidge aSlope DValley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic ms:p
(check box)
DEPTH DRILLING LOG
From To Formation Descriptior.
at
a`15 bCUn:t�
11. DISINFECTION: Type ?; A`vc Amount '7
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From •i-\ To .,_IX Ft. (ctr+ it ak pta+:c
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 0-0 Ft. Pi.rhent vnuxed
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
IL
+I i I o HEREBYCER.71E ..
`CONSTRUCTION STAND
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. O
Ts
O 52:o
n e C47
N o<
7 s.r^.
pet
me
S cnr,t
O m 17
Ul —+
W a
HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
h 14oz
GNATURE OF ' RSON CONSTRUCTING THE WELL DATE
SUbtnrt the 2'inQ4=iG3G:1'linc:Na.(days. original tbi crDivt "on of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
21, within 30 da s GW-1 REV, 07/2001
_21

North Carolina - Department of Environment and Natural Resources - Division of Water Dually - Groundwater Section
1636 Mali Service Censer - Raleigh, N.C. 27699-1636-Phone [phone]
268885
(noad Name
3. OWNER
Address
WELL CONSTRUCTION RECORD
WELLCONTRACTOR-
eRmAN Z. 2.4.
WELL CONTRACTOR CERTIFICATION If:
STATE WELL CONSTRUCTION PERMITN:
4,70a 7
1. WELL USE (Check Applicable Box): Residential ✓I T Municipal I-1 Industrial n Agricultural ❑
Recovery I1 Heal Pump Water Infection ❑ Other If Other, List Use:
2. WELL LOCATIO ar (Show sketch of the loc%lo
Naasst Town: 1.71.6s-1 AA • tr
�. ' •
R �e� ;A
til
eo•r
�'�
Clly or Town
DATE DRILLED
TOTAL DEPTH
n. Communlly.
tale
a
-oa-
below)
County:.-Q(/YL�C__Q_t2
Monitoring ❑
Subdivision and Lol No.)
hip Co
DRILLING"LOG
From To
tos
D - .5
-
cam•
CUTTINGS COLLECTED YES I I NOI4
DOES WELL REPLACE EXISTING WELL? YES NOW
STATIC WATER LEVEL Below Top of Casing: •�O FT.
/ (Use '+' If Above Top of Casing)
TOP OF CASING IS ( FT Above Land Surface'
fop of casing terminated at/or below land surface requires a verlance In accor-
ence wllh 15A NCAC 2C .0118
0. YIELD (gpm): 3 P METHOD OF TEST
1. WATER ZONES (depth):
2. ORINATION: Type fi 7! 1 Amount '3T
3. LASING:
From
From
From
t. GROUT
Wall Thickness
0 Depth/ Diameter or Weight/Ft. Material
To i2 3 FI 1t , a 5 ,,4 ,i;, Pic,a_L
To FI.
To FI
DapMaterial Method .
FFromD To v2 C�-° FI 'OIYCP�%E 'j�ln`1_r'P.E=,'i%"__
From To Ft
5, SCREEN:
Depth Diameter
From To FI In.
From To FI In
From To Ft In
3. SAND/GRAVEL PACK:
Deplh Size
From To Ft
From To FI
7. REMARKS:
Slol Size Material
In
In
In
Material
DEPTH
Formation Oescdpllon
))aIRt-
Br<dtoc
IV
11 additional space Is needed use back of form
LOCATION SKETCH
(Show direction and distance from al least Iwo Stale
Roads, or other map reference points)
0
t,.J
L sib;nC.
(D
i%O SR�
$p_i336 ro %I N
Pd
I DO WERE CERTIFY THALTRIS WE uv s 6OySTRUCTEO IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU�T,IcI�1$TANDARDS AND THAT,A j Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I
ONATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submlforfpina to Division of Water Ouallly, Groundwater Section Wllliln 30 days
F JFFIC
Ouad No:
Serial No.
USE ONLY
II
v
GW.1 fEV. 12/99
0
0

nh Caroline - Depanmonl of Environment and Nalural Resources - DivisIon of Water quality - Groundwater Secllon
76 Mail Service Center - Raleigh, N.C. 27699-1638.Phone [phone] y//_'
ELL CONSTRUCTION RECORD WELL CONTRACTOR- /7e RrAN L • 24-L•
268913
WELL CONTRACTOR CERTIFICATION I: ,70-;
STATE WELL CONSTRUCTION PERMIT":
WELL USE (Check Applicable Box): Residential fa Municipal El Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ri Heat Pump Water Infection ❑ Other n If Other, List Use:
WELL LOCATI : (Show sketch of the location below)
Nearest Town: 13YK5'•, G,ounty ;IQ.Vt(QC(
Mead Name end Nunta s. Community. or Sub Ivision and Lot No.)
OWNER Cel.o Heal --tom, CQvi+er
Address 1aQG `q vein -(j€
(
S reo or l oule No.) _-7W
Clly or Town Slate zip Code
DATE DRILLEDa—a O—Ca,
TOTAL DEPTH 7CtD �{
CUTTINGS COLLECTED YES NO[ l
DOES WELL REPLACE EXISTING WELL7 YES I I NO
STATIC WATER LEVEL Below Top of Casing: FT.
/ (Use's• if Above Top of Casing)
TOP OF CASING IS ( FT. Above Land Surface'
of easing terminated aVor below land surface requlree a variance In actor•
:e wllh 15A NCAC 2C .011E
YIELD (gpm): In METHOD OF TEST �.
WATER ZONES (depth)
?uvrt5vttle
DRILLING LOG
D - 51-I
�T4 -76?)
Nit
BNlxvc
0
rJ
^HLORINATION: Type _ ii_t1_ Amount _LIB pillaS II additional space Is needed use back of form
, SING:
Wall Thickness
Depth ,t Dlameler or WWIghVFI. M�y� S l --rem O To 511 Ft 1+ • oZ 5 e7)4rl,5
Trom To Ft,
From To Ft
ROUT:
Depth Materiel Mol,ho`tt. �
d ,�
=rem b To 2FI. �'OIYCP.1i E c�
-rim To Ft
SCREEN:
Doplh Diameter Slot Size Material
From To Ft In. In.
From To FI In. In
"rom To Fi In. In
SAND/GRAVEL PACK:
Depth Size Material
From _ To Ft
From To Ft
REMARKS:
LOCATION SKETCH
(Show direction and dislance from al least two Slate
Roads, or other map reference points)
C210
-bbvn. vi Ile, NC
DO IIEREDY C Tl YTHAT TITIS WELL WASLCO CTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO !ST�7DARDS, AND THAT A_0011 HIS RECORD HAS BEE °VIDEO TO THE WELL OWNER.
a - GC) -oa
ri OFFICE UStiIP LY
No:
u L.
'dal No.
nE OF PERSON CONSTRUCTING TIIE WELL DATE
Ion of Water Ouallly, Groundwater Section within 30 days
GW-I NEV. 12/99
c,)
z

261488
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
REUBEN CALDWELL
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CERTIFICATION a 2140
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING,
STATE WELL CONSTRUCTION PERMIT/ '15�7 OCIATED WQ PERMIT/
(if applicable) W ,5 D / eta /. (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT .
Nearest Town: 02S-3 e-- County tiPM><-girl
A t- en Q c —C--
(Street Nurse, Number, CanmuniySubdivision, Lot No., Zip Code)
3. OWNER'kr M PVt.l .SDCJ$tQj 0.3-02
Address �D 13 EA*,. es el
(Street or Rows No.)
[3o1.1451)(1(C— r4 C--
Ciy or Town Sure Zip Code
( )- 4772— — e!`Yt
Area code- Phone number
4. DATE DRILLED 'il/(
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 2T
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of cuing terminated at/or below land surface requires •
variance eordun with ISA NCAC 2C .0111.
9. YIELD gpm)': %eo METHOD OF TEST IQt lr
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check apitvrlats box)
Latitude/longitude of well location
(dope a/mimnes/secoods)
Latitude/longitude source:❑GPS❑Topographic map
(clock boa)
DRILLING LOG
Formation Description
DEPTH
From To
— 2.4:>
;O-.50
jVC
FT. /ice �foq
10. WATER ZONES (depth): / SG r — /S 2— — L.57
11. DISINFECTION: Type #f. fO7,
Front/ / To Z3 Ft.
Fro T_o Ft.
Fromg" DZAUc- mliee_
13. GROUT: Depth MMetric!
From C.To7-re
Ft.Cr�aeAtT & Th k fPesa+Ql�D
From
14. SCREEN: V Depth
From (9 cr , f‘i Ft.
From To Ft.
15. SAND/GRAVEL PACK:
Depth
From Ft.
From To Ft.
12. CASING:
Depth Diameter
fE 0 PN ltJ S.E _1
I DO HEREBY CERT
CONSTRUCTION ST
INC. PHONE4%8 54-3581
r
jr
firratill,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
number and common road names.
Amount rie0/15.
Wall Thickness
or Weight/Ft. Material
L8 4-reel
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
)S, AND THAT A COPY OF THIS RECORD�,H(AS�EE BEEN PROVIDED TO THWELL OWNER
iA
SIGNATURE OF PERSON CONS UTR CTING THE WELL ` DATE
GROUNDWATER SECTION
ASHEVII,thibitinaetatgit1®t to the Division of Water Quality, Groundwater Section, 1636 Mall Servlee Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

D
From
13. GROUT:
From D
From
263429
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na 11R/es/ources - DivisionofWater Quality - Groundwater Section �7�J
WELL CONTRACTOR (INDIVIDUAL) NAM (print) (I IN— N&/ C Dili. L CERTIFICATION 4 % ( p-
WELL CONTRACTOR COMPANY NAME ,-(.2-ti '4 b) U9� PHONE f it % 19 -Dyp D
STATE WELL CONSTRUCTION PERMIT*/ u/(7 ASSOCIATED WQ PERMIT 4/1/49r
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential)if Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: GJ 24-s4tc%l4,' County g t-(v yi
r �d r2317/y
(Street Name, NumbeK, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address fiLes t- 7� d
N:Lllyt zu No.) oC , % /
City or Town State Zip Code
Arca code- Phone number
4. DATE DRILLED 7/13 / b
5. TOTAL DEPTH: / 9.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EA
7. STATIC WATER LEVEL Below Top of Casing: ter FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance In accordance with 1SA NCAC 2C .0118.
9. YIELD (gpm): 9 d METHOD OF TESTI,Ln-60
10. WATER ZONES (depth): yD P I
11. DISINFECTION: Type ea
12. CASING: V
Amount ci b L
Wall Thickness
Depth ameter or Weight/Ft. Material
FromTo�J & Ft. A ter// /YC.
From To Ft.
To Ft.
Depth /1 Material Method .
To_ Ft. lz-rvi_z4>1 W>i t'fity
To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Slot Size Material
in.
in.
From To Ft.
16. REMARKS: *-t-
Th
_�^ 'I nrl (�
_ 150 HER?B'Eh Y T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STABS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7//3/0t
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Topographic/Land setting
❑Ridge ❑Slope Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roaor County Roads. nclude the road
numbers and c • mmon road npmes
GR(SUbM MTtIi 6ii$$iftlill to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
AS HEViy6§96fsk6tiAiQI9lq) 733-3221, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 2 6 3 4 23
North Carolina - Department of Environment and Natural/JResources
%- Division of Water Quality - Groundwater Section
ry
WELL CONTRACTOR (INDIVIDUAL) NAMF(�/) (print).4L-1 C 4! / I At Gn' .c 3 777 CERTIFICATION,/ika 7,4
WELL CONTRACTOR COMPANY NAMEArt-Art-(+:Ti�.l1/l�('� t .1l II J /J ztL PHONE # (-iYl /0V9
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
4//H ASSOCIATED W PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential Of Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest To
County
7
(Street Name, Numbers, Community, Subdivision, /Lot No., Zip Code)
3. OWNER:
cam/
Address emi p-f?Au,,,, A-A'tp
(Street o oute No.)
24c4 t ?& .iCO ,2 Sr 7N
City or own tate Zip Code
Am code- Phone number// D / 0 y
4. DATE DRILLED /`�J C—
5. TOTAL DEPTH:. S r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ,
7. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS /.e,7 F'. Above Land Surface'
*Top of cuing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C .0118. r
9. YIELD (gpm): /LIF) 4- METHODIOF TESTT. GZ C.
10. WATER ZONES (depth): ofrD I / RS'
11. DISINFECTION: Type yYc7
12. CASING:
Depth', Di
From To ?' i) Ft.
From To Ft.
From To Ft.
13. GROUT: Depth ,a Material
From_ To� Ft..y/a`
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
FromTo Ft. in. in.
From / To - Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
er
Amount Cr 6Z
Wall Thickness
or Weight/Ft. gaterial
Topographic/Land setting
❑Ridge fiaBlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
od r
16. REMARKS:
LOCATION SKETCH
Show directi. and distance in miles from at least
two State Road. .r County Roads. Include the road
numbers and co on road names.
CD c2'�'
pz,VNc�tNc
U
u
`HERM\kJCERTIF'Y
I, CONSTRUCTION STAND
IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
AND THAT A COPY OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r
C
IGNATURE OF ' "' ON CO S' UCTING THE WELL 'ATE
Sabt96f Ahe origlialltOlhe Div sion of Water Quality, Groundwater Section,1636 Mail Service Center - Raleigh, NC
221, within 30 days. GW-1 REV. 07/2001
Iti5i
0)

-
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CINde X. 54wlef5 CERTIFICATION# awli/.36
WELL CONTRACTORCOMPANY NAMEJI/tadC sahzvrs tdon {/el/ Pump PHONE # f1Zk') ;SS-7�ng
STATE WELL CONSTRUCTION PERMIT# ! ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
251581
1. WELL USE (Check Applicable Box): Residential2i Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 8uredyrtle
Z.cdon Crer
County Yancey
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 00rea/d Scooter
Address Rot 1-• 3 Igox flo (o
(Street or Route No.)
Bur 43v.'Ne .1/C
City or Town State Zip Code
(8/1)- (oR2- (o4it
Area code- Phone number
4. DATE DRILLED 3- 2-1 -0
5. TOTAL DEPTH: / 26
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 4m FT.
(Use "*" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST /Qfg.
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge (e ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
+1
21
z/
/25
11. DISINFECTION: Type p: //S
12. CASING:
Depth Diameter
From 1-I To 2/ Ft.
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
S?eel
13. GROUT: Depth Material Method /�
From 0 To eo Ft. Ceetea+ f yen,
From To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
c
3r x�
braat't �m
-c
N
W
0
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
r•-) f OtFYEREBY'pE/2/TIFp= 1
iJ NSSRdCTI(3NSMAND
ii u,
I
i_Si2¢mit the original to the Di
2700-1636'Phbnc IYo; J 19) 733
1
wag _ S�
• IGNAF{?RE OF PERSON CONSTRUCTING THE WELL
HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
03
DATE
ision of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
3221, within 30 days.
GW-I REV. 07/2001