Cl CY2003

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality Groundwater
Section
etin
WELL CONTRACTOR (INDIVIDUAL) NAME (print) PCERS SirATION
WELL CONTRACTOR COMPANY NAME t ,f
SSOCIATED WQ PERMITS/
if applicable)
STATE WELL CONSTRUCTION PERMITS/
(if applicable)
1. WELL USE (Check Applicable Box): Residential fi7-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
Topographic/Land setting
❑Ridge IJStope ❑Valley ❑Flat
(check appropriate box)
La tituddlongitude of well location
(degrees)minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
Formation Dc:-riptiOn
280129
2. WELL LOCATION:
Nearest Town:
CountyC tOi4_.---
(Street Name, Num ere, Community, Subdivisica, Lot No., Zip Code)
3. OWNER:
Address
City or Town
State Zip Code
Area code- Phone number
4. DATE DRILLED °I OS'C
5. TOTAL DEPTH: C e
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Li-
7. STATIC WATER LEVEL Below Top (Use" °fAboveTopofCasing)
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.
METHOD OF TESTY
9. YIELD (gpm): ___4_____
10. WA"fZONESepth):
ER(depth):
11. DISINFECTION: Type t 3 5 Amount \ S
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_ 12_, To. 2LL Ft. 6-- —
From To Ft..
From_____ To Ft. Method
' 1
13. GROUT: Depth Mate n S<CCQ
From To
14. SCREEN: Depth Diameter Slot Size Material
To Ft. in. in.
Frorp From_To Ft. in. in.
15. SAND/GRAVEL PACK: Depth Size Material
From To Ft. -------
From To Ft.
r n?AT1Q.t CKRTCii _
Show direction and distance in milestfriorrli ati�ast
iwO Stale Roads or County Roads. 1 lude the dad._
numbers and comtnui, r^nit names.
0
t7
D
It 1}ttv.i C\Nx
2H
LCK gc� cct tnp C-4 i/)c
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a
Tim
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenteri leigh, NC
27699-1636 Phone No. [phone], within 30 days.

272558
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) `N�-L�� AS • TCEYYS CERTIFICATION SIL: 9' 2 �51)
WELL CONTRACTOR COMPANY NAMECS.1 to I E L1JC�' � L-U # ��• )3`6`1-9) 3
PHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential E Municipa1/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA tsN:
Ne e,�r st To
(Street Name Numbers, Co
3. OWNE
ddress
County
t or Routek
(TO City or T' Q — 9 4te9 . Zip Code
Area code- Phone number
4. DATE DRILLED 3' c a
5. TOTAL DEPTH: 1 I /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing: t- 0 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 accord e with ISA NCAC 2C .0I18. 9. YIELD (gpm): METHOD OF TEST _
10. WATER ZONES (depth): 1M
11. DISINFECTION: Type 1 i
12. CASING:
Depth r�ii �treter
From 0 To �D Ft. ( r4�t
From To Ft.
From To Ft.
13. GROUT:
Dep14% teary l
From To 66 Ft.C�a���
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.
Amount
Wall Thickness
oraUc77.Weight/Ft. „Mottal
I,, FM
1-DO HEREBY CERTI
, 111
L'
GONSTRUCTIONST/
GROW
ASH -''�' LE.
"Topographic/Land setting
QRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fotm*ion Description
DEPTH{
From To ,
iS
15' BS
RS' \go'
LOCATION SKETCH
Show direction and distance in miles from at Ieasb
two State Roads or County Roads. Includeebe tog
numbers and common road names.
.5,a,4
CO
a
—O
Cw)
O
0
S.
\\111(l llr
l tAI1 p,4.tty.0 \ 1 s
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
igma to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

268425
WELL CONSTRUCTION RECORD
North Carolina - Department ofnvironmen an a Resources
Environment d Natural R sources Divisio of Water Quality - Groundwater Section
\ 3
tLE 1 i.121ULA, 1S, # pit() _�tSS
-
WELL CONTRACTOR (INDIVIDUAL) NAME (print) \u-�, 11 , \ lS • V - CERTIFICATION #
PHONE
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Nf Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
(Street
3. 0
Address
City o`ow0, —
Area code- • , e number
4. DATE DRILLED ,
5. TOTAL DEPTH: ,11 /
6. DOES WELL REPLACE EXISTING WELL? YES Q NO fd
7. STATIC WATER LEVEL Below Top of Casing: (d..) 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 accord nee with I5A NCAC 2C .0118. /i
9. YIELD (gpm): M THO? OF TEST l `L
10. WATER ZONES (depth): 1oO
Ilia*
11. DISINFECTION: Type
12. CASING:
thSOmeter
From D To Ft. to 4"
From To Ft.
From To Ft
13. GROUT: Depth
From b To SO
From To
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Topoy • t t'c/Land setting
❑Ridge r Slope OValley ❑Flat
(check appropriate box)
Latitude/ongitude of well location
DEPTH
FromTo
�(r L4
11D3 lbrl
From To Ft.
From To Ft.
16. REMARKS:
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forttt&taon Description
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Wet t/Ft. ter)al numbers and common road names.
MAR - 3 2903 -I
Submit the original to
L. tlrune.N
ASFEVI[LE EEEIO'N/AL OFFICE
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W LL
SIGNATURE OF PERSON CONSTRUCTING THE WELL D'(TE
vision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
-3221, within 30 days. GW-1 REV. 07/2001

268426
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) \i' k• . Ykin` -�y`�� • -Ca S CERTIFICATION #
WELL CONTRACTOR COMPANY NAME*\` 1 'tU� `-'C-•LL' E �Qt "'), PHONE # 8 —ci5c
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) /
1. WELL USE (Check Applicable Box): Residential El Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCA qN:
Nea • ,T
Area code- Phone number
4. DATE DRILLED 1 al D3
5. TOTAL DEPTH: b /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Et
7. STATIC WATER LEVEL Below Top of Casing: DO 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 accordanc1((�� y(th ISA NCAC 2C .0118. 5`
l
9. YIELD (gpm): ME HOD,OF TEST --\--
10. WATER ZONES (depth): \(oa L1Efr
'
11. DISINFECTION: Type \-}� Amount
12. CASING: Wall Thickness
Dep� _ titer Wei 1 t. k'-r1
From t) To L0 Ft. l/o (�
From
From To Ft.
13. GROUT: Depth,
From 0 To 'o FL
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.
From To Ft.
From To Ft.
16. REMARKS:
(if applicable)
opographic/Land setting
Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To , FoDescription
LOCATION SKETCH
Show direction and distance in miles from at lea
two State Roads or County Roads. Include
numbers and common road names
I DO HEREBY CE___ RIIELIk AT
IONST` 1 a': • a
IS
h1 visio
3
mt original
a original to the
27499-1636 Phone No. (919 73 322
GEOL, " cn SECTION
ASHEVILLE RLO:01,AL OFFICE
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE 0 R
D
ATURE OF PERSON CONSTRUCTING THE WELL D
of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
within 30 days. GW-1 REV. 07/2001
VaiL

WELL CONSTRUCTION 1tECOMi
North Carolina - Department of Environment and Natural ResoutceS - Division or Water Quality Groundwater Section
�nl 1S
WELL. CON7MCTOR(INUIT'IUUAL)NAPIE (print)
n ifa PHONE I �'�L )b`� in
N
WELL CONTRACTOR COMPANY NAME //��� / /� ASSOCIATED WQ FERMI IN
STALE WELL CONSTRUCTION PERM! IN WQ FE
(irappreablc)
WELL USE (Check Applicable I3ox): Residential CO--Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Neat l'unip Water Injection ❑ Other ❑ IF Other, List Use
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Mat
(check npprrprlale hoe)
Latitude/longitude of well location
(de gre a e/m l n u I c sts e c n n d s)
Latitude/longitude source:❑OPS❑Topographie mop
(check ban)
DIULLI1ICLLQQ
Formation Description.
2. WELL LOCATION:
Nearest'L own.
Ian}n
(Sheet Name, Number, Commumly, Subdivision, lot No., Zip Code)
3. OWNER:
Address Vn
(Sheet ar Rc.ie No)
iry or Town Stale
(_)-------
Ain code- Phone number
4. DATE DRILLED) Z
5. TOTAL DEPTII:�G----
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO rD1—
7. STATIC WATER LEVEL Below T.
tTose p or Casing:
ve e2ef 2. s)
8. TOP OF CASINO IS _ % FT. Above Laud SurFnce•
•Top or carine err minatrd •Uor below lewd amine requite! a
♦anis" ct In ,ecordanre aellh 1SA NCAC TC .011s.
9. YIELD (grim: — METHOD OF TESTA%; 2
10. WATER ZONES (depth):
.M
il. DISINFECTION: Type
12. CASINO:
Depllt Diatneler
To /41t:.F(.
To rt.
Ft
13. GROUT: Depth
Morn al Method
County
Zlp Code
Front_
Fwm_
From To
Amount S'
Wall thickness
or Weight/FL Material
, D,
From_ To Ft.
From____ To Ft.
14. SCREEN: Depth Diameter
To Ft. in. ill.
Flom -- __ From To rt. in. in.
15. SAND/GRAVEL PACK: Size
Depth
From To FL___
rt._
To
to/
Slot Size Material
Material
268.280
pLP1fl
From To
I K'
LOCA:110A LI
Show direction and distance in miles From at least ,
Iwo Stale Roads or County Roads. Include& to I
numbers and common toad names.
16. REMARKS:
I I WELL WAS CONS DIMMED IN ACCORDANCE WWI I5A NCAC 2C, WELL
I DO I IEREDY RUCTIOCERTIFY S01)1III DS71AND THAT A COPY OF TIt S RECORD 11ASS BEEN PROVIDED TO TIIE WELL OWNER
CONSTRUCTION S iV N j -OS
C._ C.,
,tu Fri
� c
>o
n rH
o cn
m�—
C) C)
J G
SIGNATURE' OF I'ERSON CONSTRUCTING TIIE WELL DATE
liiRllT Nle"oFlRtna Division of Water Quality, Groundwater Secllon,1636 Mall Service Corr' II V�07 2001
I76g9-1636 Phone No. [phone], Withhr 30 days.

f
N rites% I orvlc_y_C__f -0p- 4��_ Cuonly
(Shin Ilnrnq Number., i,+ """hr, snbdi vielon, ynl tio:• 71p C'Je)
3. OWNER!
Add' �� _- \X Q�
gfOSSIDWr'• iSl`nn^rile.)._ One
_-._
CII) Pi IonSloe
I ) -
lip Cole
Atrr ante. rhene mmitel
. •1. PAID DRll.l.l'.0 i _3____
5. I O fAI. UI:I' f 11.___"_%'as---------"-
G. DUES NVEl.l, RI!1'LACIr. EXIS I WO \YE! 1:1 YES U Ho I;
1I'.
7. S I"A11C 1VAiER. LEVEL Below itr of l-.• If(Above lop ill Ci•ing)
// 1 I. Above I. mid Sullirce'
Ir
P. l hl" CASINO IS _ _L-- r--- -
• p of rn•Ine Iru•Ji•d,d dim 1•rlvn land rn,btr rtgnhr� \
•.,loci In atcnnlrinr nllh ISA NCAC IC.n11N.
0. YN'L II(EEloo._ 30 MIDI I�1,t'II L P
III. \VAI ER LONES (depth): _
J+ ,�}. (Q Amount
IC S OION: Type Wall I!da ins
IL CASINO!
: Uimneler orWe WEI. Alnlellnl
DrpllrL—
I"rmit� In�f1.�1- '�
Elmo -Io Ft..
11 Pil1_ 'In_.__ —I I.
13. OROUI. Depth fl
flow._ I n�_
fiom -__._ io...—_ri —
li. SCir jE N: Ucl ill IJinurcici
If. .
I -- - El. -_in
f I mil----_.
1 u _____ 1 I in.
IS. SANU/liltAVl'.I,I'ACK: Sire
Depth
Iron In Et
I(,
WELL CUN5'I'RUC'I'IUN IUsCvi:;T
Nor lb Calulinn - VepahRnud of ISnvlronuteot nod Nututall Resources - Division of Wnlcr quality - 11d Enter I Ntiion
NIELI, CON I RACI OIL IINIIIVIIMAL) NAME, i ccn1
dull ',norm N IAI'or' -Z9r�
IN f.hl. CON I IUCI 01t C(InM INI' NAMErn Iv�hi�ll
SIAIE tr ELL CONS IIIIICI ION &RoiliN_______________
if n r rlicnblc
I. Wlvd,L USE (Chick Applicable
I' i l it ) R__ideldinl is/ Islunic{pal/I'ulrlic U lu Mistrial III Agoicullulal U
ASSOCIA I VI/ WC) EERMI IN
if nlrPlicoblc)_
oa ..
?Avidly! big IL licence,
Ieely I_I IleM I'uugr Wilier lit)ecllou U Oilier LI If Ulher, List Use
'I'r pngtnpllicll,mld selling
UIUJgr, 1ISlopr hiVolley UIInt
(check nppngnlelr boil)
Lnlllude/lougilude of well location
S-1s=00O5 we 3 1GL7_L4-
(ArNr: reJodrnrkJr-^^nd•)
LnliludelIno¢ilude snwce1JOl'SU fopoglaphic III
(check twin;
)1111LLIlJ1J 1,9S1
Ro1111111011 Vcscliplion
270318
now
17. ;REMARKS:
r I no IIEREID' CER111'Y111
CONSIIIUCI ION SIAIIDK
fl.
Mnlci inl Method
1711-`A_L
Slut Sire
lu.
71of&al
Motet's'
Show direction mod distance in miles Goal nil tenet
Iwo Stole Roads or Courtly Roods. Include the road
numbers mod common mond names.
U1
0
-616 (€r IZcI
I I IIS WELL WAS CONS I RUCI ED IN ACCORDANCE WI III I5A IICAC 2C, WILL
n1JU'IIIAI' A CUI'Y UI"IIII5Iu1CUIIU tIA5 BEEN I'iIUVIUL'U lU iltn WELL OWNER
IUNAI Ultl! UE ('Ell. UN CUNS11lUC117111 711E WELL
AIL
)3r035 ta•171
1
C
Snl.uolI the -nrlghoofIn!heti skin of \Vnlrr Quality, Cieoliths filer Section, 1636 Mall Service Center
ICEVgt', N 2171
216ss-1616 Phone No. (919) 7.U-JII1, within 311 days.

WELL CUNS'IN.Uc7',UN Mii,C01:11
ecru IF lcA i rS Section
-lO �l
iiolih Carolina - Urparhucnt of Iiuvhuuulctlt mid Natural Itenouiccs - Division Wnlcr a;H iy - Chound:vn �52c ;on
wE1,Ll'UNIttA C-i lilt (lN Ult'IUIyAI,)NAPI F. tight!)
IN EI,I, CON I ItACI on conirmY NAME Y7l �1 I AS�UC� V,li Rn)PF,RPIIIA��
5 to IE tt El.l,CONS lIubic ION i'EIUI11
itnrdWI) I'
c
it n r rliuiblc
I WELL USE (Chick Applicable Ilos) Itroideidinl V Municipal/l'ulrlic U Iullishinl CI Agiicullmal U
I Water Inf cctiou U Oilier U If tither, List Use
bloniloliug U ttccovciy U Ilea I utul
2. WELL LUCAl'IUN:
J'_ l
Ncmcsl-Iv,cn: Grit'
County
!wily. S,Jivi.lon. 1 ni Iln'., 7Ip C,.le)
lCberi Nome,
q Nunrhrr., C�:""" U
J e Lon —
UWIJI'Il:__ 5te,)
,l
Atldicss �jl)
1 'Spiel or or novle I
SYI� 2$C-1-0A—
slnle 71p Code
c Ph lit,. rl
�--
A,r. ENV th,,nr nnmhet
d. PAW 0101.1.1IDs -----
5. lDIAL l)1:1:111._ID
6. DUES WELL Itl'r.l'LALE L•.nISI IIIO 1VII 11 IFS U NO W-
h.
1. S FMIC WAl ER LEVLEVELIlclor`ttlrrl' of lrlAhnvle lop ofining)
+ _p
f tFL 101' OF CASINO IS 1. Above Loon .^quince
• i.o nl nrbne let oJ,nlr,i olive h.ieIsnJ nit brr iegnL r..
.dente In .rrnrd.dre onto I!,\ NUM'
vi)lesIAA
o. 41CI.fllfpnl):
III. WAIEll LONES(depth):_ --
Amuunt . 20
Wn11'I Idcknres
ni 1Veightl'1.
'*4
II. NISINI'RCIIUN:'lpr
12. CASINO: Mull 'Amuck'
In _ rI.�c 2____
Il ouLQ— .
Tinto _ In Ft __
I n__— It
pima—__ Mold nl
u. tIROUI: Itrplli o Ft%.
Iiom_----It' fI.---- Uifund
1,1. WI'EFN. Itrpllt
in II in
.
Ilonl___.f t, ,
In
-
15. SANNlUItAVUrpPACK: ili Sire
Iloili .1ii II.
Ilvm
To_ 1'I.
16. REMARKS!WELL on 111'R111 CEII_i IIIT IILM 11115WELL I, WAS-LUt IIIIICIIIU IN ACCUIUATICE WI III 15A IICAC 2C,
CONS IItUCIlUNSFM1DMUS,ANU111AfACO'Y'IIIISRECORD HAS fICCIJI'IIUVIULUlU111CWELL OWNER
DM 1.1
—�— 51UNAIUIILOtt I LIlSUN CUN11tUCIINUIII[? TNITA, 1 11C
tl T'.NCU712.0I
Suhndl the nily*4i+nl In the Ulririnn of Wider Quoin •i Clnundtsnlep SecllonOlder i 1636 Mall Service - Itnlelg
11699-1676 ['boor No. )919) 1JJ-J221, t+Ithht JU driy`�. ow-( IU
pbdctltd
270299
fopogrnpl+ldi,nod setting
Ullidge. IlSlnpc I nllcy UI'Inl
(chrok eppnynl.le full)
Lnlitudelluogiludc of well location
l ie p,r rdndmur tit c.flnd.)
Lnlilu:I-'1^Ileilude smuce:UiL1gi
Ioponplits ni
'check
))ILLII u(LILLIrJU i.U-U
Iloln lb Emulation Itesclipliun
I0N St:I:J GI I
Show ditecllon nun distance hi miles how I kid
Iwo Stole hoods or Counly hoods. L Iudctic tond
M1 ntrlinl umbels nod common fond unities. 's , lr
11
Method
Molehill

270293
WELL CONS 1'IIUC'1'lON lU CGiw
(told: C:Ncli::n - Dena]intent of Euvlroumcot niid Nnlural Ilermurces - Division of Wnler Quality - Uro ndwnteIt N tioii
u!!! Inrbnl ��pp (y� I-GL��
,,24/41941
W EI,I, CON I RAC' O n (IN u1 vINN,ti,)" : name:: p fK2.C) b�
i 11P�
w El,l. CON IlUC1 On COWAN ASSVCIAI rut ,('Q -- �--
STATE t1CLLtdCIIl/N I'EIUIIU __— ilnrplicnblc �_---��nm
iftn dirdie tilt
I. WELL USE (Check Applicable Ilox)I (Residential ILr 1 llllllcipal)I'ulrlic U hulusliinl LI Agricuhulal U
plouitol Mg U Recovcly LI Ileal Pomp Wider Inf ccliou U tact LI If Other, Lls1 WC
2. WELL I OCATIUN: '1'opoginpllle/I,mul selling
UlUdge I-ISlnpr UVnllcy Mint
(check nrgnrptlair hot)
L,IltuJdlmigitude of well location
l Irpteed olmiteu't--w,J1)
y. hWNE.R ilk i Lnlitudarhnailudc sotlrce:Ur)I'Sl7 I opoglnpllic mp t
Athhcss i-r-�Or�U`)`t.-- (check Inn)
(Sorele aleNo.) Milli UIlIL1,1110I,(HI
�- �le -- 'to Emulation Dcsclipliun
Z1 p Cole hum
��lno l( Slate I CJ _ / -
11' ll .
�������CuuulyCJ
Neatest -I own:
Jn'C� W�- - SnbJi.i+load l.rrl tin., 71p CMe)
IClr?tl Hanle,Np inhcp., C.�...._. .
A,r. cr.lr (horpe n,,nhrl
..1. DAIRullnLENS —q2nt1. _—
s. I0FAl. PH' Uu l.F. W!!
.—"--- �1
6. DOES WELL lAI COS 1100 ! 17 YES LI ODIN-
7. SEA( IC WATER LEVEL Below T1 I' I.
of rising: .
(ltie ",.. If Above a rp of Cntlop)
g. I Or Of CASINO IS L__ - I' r. Above Lnnd Sul litre'
• frp rl c.d,q Itmin•tril •tlr, bulgy( him( anise (twilit, a
Lnrrin.rrr(rLi,rt nIthl,rn�hlnvC.0hi�llsry
O. Vnu.0 (fr(t)! _CP-- __ �'-------
Ill. WA IEll LUNES (depth): ------
ia , n1ltP alit ticD
ll
I1. DISINI"1!CIION:'fypcY-1>.rs�-�'''i>=-"'WAmo nt 02+p
12. CASINO
Deptht Uimocicr of Wci BI1Uln
f1. h (ell"1
f1on�Q_
pu�_ f 1. (p � s TUS72JL(!—r-�—I —
11. UIIUU I : Depth
hlnlehinl Method
from lti fl.----
now - fit._.rt. _____ - --- '
Uinnlelci sl
ot Siac Mnlctinl
Id. SI:PI:IJ: hcplll ht.
(lout In _ El --ill. --
IT ill. In.
Flom---- I °--
IS. SANDfuiIIAVIll. I'ACK Sire Mnlellnl
Orlin'
I it—
Ilom
II I.JOI l nrnl• cFlt111Ti11Ar n s
culls I noel ION S INWARDS, A 11
IJ
SAUNA
SuhudlII, 00111lInthe P hIitous, Water Quality, GIoundlsnlerSection, 1616Mull Service Center
l IILtVlgli,
11fa11-1616 flame Nn.IC19 711.1111, within 311 tiny,.
OW-
LQCAiJUl� Sil
Show direction and distnnce In miles Flom nl lend
Iwo Stile floods of Cowlly Ronda. Include the tond
nuntbcts and common rund names.
0
C.)
.(
a
0
Ut
'.I.I, WAS CONS I RUC( Itb IN ACCORDANCE WI Ill iSA IICAC 21:, l"!tl t.
IIA f A COPY or'11115 RECORD IIAS DEEM PROVIDED '10l lin WELL OWNER
Ulll! UII I'EtISON CUN5111UC11NU 111D WELL DAI E

. 2'70696
YVELL GUNS J. uk.; UN iu wi:;;
14o1111 Carolina - Department of Environment mud Nnlul al Renoir' cur - I)I(v�isio:: e�f Wider Quality - ouudnIer Sectio
UrHn
I4+ . . _.. nC K (� 1;ISfn t...^I IFICAriv::' 0
t1 ELL CON MAC'
NAME. IRrlolf.� -' r '
wrl,I,CON IPAC! Vf COMrANY NAa1F, %�IiA? ,MK// 1//its
ASSUCIA I CII IV() 1'ERMI I I
SrAIE tt EL1, GUNS IIIIIC IIIIN fEllalll� .--- — it nrdicablc
;In r ilimbic
wri.I, USI? (Cheek Appllcahle lies)' Residential 1 Muuicipnl/l'uLlic U Indushinl f I Agricultural U
?Antrim' Mg U Recovery' U I Ica! Pump IVnlcl Injection U Other CI If Ulllcr, List We
2. Nemcst'Io,vui: 4)N:,
life, County i
W I! LL LOCA
ona
i$he Illemq Nm E � "l' ��_��
_CL
1�_�ti ke,,
nher., Ga::^^ . Pnbdivi.lon, nl Nn:r Zlp G.Ir)
Address
ISnrellorr Route Ito.)
i110s��SQQ__—L�tT— i)p Coil<
— —
Cry or Twin Side
An cc -Jr- thole monber
a. PA'i
S.'IDEAL I)I:I`fll.E?S_.--------
6. DUES WELL RNI'LAC.E. Fir; IlUUU IVF! I YES U bit) fides
1. StAI IC WATER LEVEL Helm,: 'top of ('using: _-c_9L__-_F F.
flirt "r" If Above lop nl C.rirRi
P. 'WI' Ilf CASINO ISi__
I'I'. Above I.nnd .Sul Incc'
• ivy rl night! III,ILJ •Um brlon land n„bn rtquhn
•
rnlnnr In •rcnnIiirte .r llh I5A NCAC IC.Pitt.
O. r lr•LP (rpnl): _1ST. MIs IWO Cr ES L ;
ID. WA I ER ZONES (depth): _
-Li,
II. UISINI EC f ION: I)l'r�} 1Q1 Amount ll lMean)
12. CASINO:
I,rpill yDiiametter or \VrighVfl. Mnlrrinl
fn.nt
1 n Cie f 1. L2 ,_. 5DZ2L A---
from In Li.
From_ 10_ It. _. ___--
Mclhod
•I Ppugnpluic/Lnnd Belting
UIUJge I.1Slopr UVnllry Ullnl
(chrc4 nppngntain hen)
Lntltuddluugilude of well location
I.1r p. a rJminnlr ✓rrnnd.l
Lnliludcrinl,glludc somcca_IUI'SLl I opogl apllic in p
(Med. My
)iEILLIbIti LU_O
Formation Ucsaiptivn
I). OR(lUI: Nrplll Moir ml
Ruin _.IotEl.
Irl.77777_
14. SCI.I:IiNJ: Depth Uinnrelcr
! IL iu
Iloul _
fl.
IS. SANDIIUItAVLI,PALK:
Depth
Rolle— 1I,_PI.
Moil !'
---1C Jti;14A11Y5
Irf+111=rtFR1C1:1111n tifq
CUIISIRUCIION SIAIIUNII
NAIUIUt UI' I'LiIlSUN CONS I ItUC111lU'II1E WELL
Slot Site Mnlelinl
In.
In.
Size Mnlelinl
Flour 'fo
!ci 1 '
LVCAI IUN_SKE)_cll
Show 'lirecllml and dislnnce br ulilr:s Gum al lend
Iwo Slnle Ronds or Counly Rands. Include the rood
numbers nod corunrou rood tomes.
CDTjt
o
P
a
ut
WELL WAS CONS I IICICI I'D IN ACCURUAI ICE t91111 I SA IICAC 2C, WELL
U 1IIA I A COI'? UI' 1111S RECORD IIAS IIEEN PROVIDED 10 -I I IE WELL OWNER
DATE
r,
0
_l
I
Submit lire orIglnnl In ILrHltllh n of 11'nlrr Qunllly, Cloundirnler Secllon, 1636 Mall Service Center- IUi1c1g1', n )01
11699-1616 Minot No. (919)133-31 I, nllldn 311 days.

1VELL GUNS 1 IIUC'1'1UN
tJorlh Cnloliva - Delon intent of Environment nod Natural Itesuuncs - DivisiS of Wnlei Quality
n F.LL CON 11UCIUR (lNUIVIUUAL) NAME tpllnp —C Q-S tC
wILLCON I IIACI011 CUNIEANY NAME
SIAIF, wr1.6 COINS IIIUCIIIIN fEINIII�__ ASSOCIAIEll WI) rrfM11Mif nrdicnblc
ifn�diolblc
WELL USE (Check Applicable IIu3): Residential t trruicipal/I'uhlie U Industrial f 1 Agricultural U
Monitoring U Recover U Ilent fowl' \Valet Infection CI Other U If Oilier, List Use—__-----
Topnginplric/Lnurl'telling
Ullidan 111774:160r UVnllcy UI'lat
(cheek eri ..,IiIn I nU
1_nlllodenuugitude of well location
2. V; EL! I (7rA I II)N:
Ncmcsl-10,, n'
.,nv Sa4Jivi+lun, l.id tin., 71p code)
(Corti Hanle, Ihn„horn i:� ..._.
1. OWNER:
Address in.-_(
loaf—
, —
Sired on Route MO
Con71p CedeSY1oi�--
G Io„„ SlnIe
Aura rrrvirrhrnr n„„Iha d� -
. A NAIl7. UIt11.Li'.0 c�'
5. l U EAl. Phi 1 i i _ca�s-'-------
6. UUES WELL ILEU'LALp. E;(I .1IVO WE! I 7 YES U NO 10—
1. S fAl IC 1VA1-Ell LEVEL Ilclo,`Wt.' °lr°Al„yn. Ioirship D ___I: U.
Cmrl"a)
S. ri I OICASINO•I n-
I. 1. Above I.nod Supine.'•
• Ire, rI rating Irn��Lnpd .Ile, hrlon Ind nu 1•rr rtgvh rr •
• orIn null IS'N11i�I C IC OF^'1 liS rL-niI(q
e-----
Ill. W A I ER ZONES (devil):
JI
I I. UISINrEC ION: 1)pr
12. CASINO:hrl,lh Omelet
b±7-2, Et./ �S`
flour—_ I
flpin II' rt
fo rt
Ftr*1n_
10
13. II U U 1: 7 LJ
Ilom O
floe,---
1A. SC!'- 10:
1 lam_
io--- 11._
15. SANU/ORAVEl. PPACK:[frSire
flmn
Lo rt
rt pin Io
Idrprrrr/ndn, rr•r�„Iq ,IIiC null
Ln1ilu: cI!.,neiludo source' I(ll ., irI tr1" ,gt"I
iil I! l-I!Ni it$7
ponnalion I!csclipliun
► ktiii
pll cIn
r
LOCATION SICEJKII
—�— Sllow• direction and disinnce In mile.' liuur nt lensl
l hickn
Amount _rs.' tiInvo Sink Rcommon rood names.oads of County Ronda. Include the road
uumbcls and
Wall
�
or Wright/EL Mnicl in
S�rl/
270295
l)Inutldwnlel Sscliuu
Ctlt ltt ICA1101I IaUOU
r NONE.. I
7671LIFI- tn- : '
I1701111111V t rnI11r''jl
CUNSIRUCIIUN SIANI.
lhplli bInlctinl
To 11— --- . —
Urplh Uinnlcicl Slid Sire
Ir, rl
ill. hr.
__ --
ir, in.
11.
Mnlcrinl
Method
Mntuinl
tracut
tvre
In
KO•I.I
ch
iditokerc
0 Rd
llDANCE WIIII I5A 1ICAC 2C, WELL
I1115 ll'Ili l,1VAS CON$ I ROLL Eb IN ACLU
ANUIIIAf A COPY UI' 111151 I!COIW IIA5 uruN PROVIDED 10 711E WELL UW11LIl
SIUtJAIUItE OF PERSON CONS IIIUCI INU'I IIE WELL
Er.. n ' Mon nt 11'ntrr ()wilily, Crnuodw'der Section, 1636 Mrlll Service Center
1 6V&', NC 1
11A+ndl6l6 oinorLln, i
11600 16161'hmnNn.(919)7J]-llli,,rii6iil:'!%da)'.'.

2. Neatest
WELL test 10 n:f1ON -ll Counly
Ncmcsl 1 own:
Vireo Nnnre• Numbers, v,:::n o hv, Snbdivieb, IAA Ito:, 71r Clxle)
7.
iY- s
Oiler! in Raule Iln)
‘A d ,AZ9 -
or / ono Stole ZIrCode
—
Air. tr410. Phone nmnbr,
1. PA i F. UNLIT D a4 -_Q:---
6. DONS WELL I(NI'LAC E FXi :IIt!U 1VP! 11 YES U Nu U
P `-�ii L--I• I .
7. 5I-AI IC WA [ER LEVEL Helot',"-°Pcolr Above lop of C•alne)
,iIl E l' CASINO IS I_._.-"--_ I' I. Above I,trrd S,Illllee•
R. .I" ,.011n I,, t nntitt rrgnhe,•
•Ire rlrna ntheme ii11 III r nl1•
aulnrtr In awn theme adrlr l!,\NCA('%�.. pp
U. VIN13(rpI')'_-i5D
----MEIIIUOF1ESFA _ -
Ip. WA I Ell ZONES (drptlu: _
I I . I11S1 NI" Ill; IIUtJ: 1)-pc4_Y"'
Wall -I Whirl,12. CASINO Diameter or WrigliUFt. ttntetinl
Frrnni
linnl 1'1(0�25- s5in/ ..�2YC---
Frnrll _�pr, rl. ______
Flmn-_—_ !o_---FL. _._
i h1
1 41 Dr nlint / Method
I). CIIIOUF: I I1. ni
VIonl_n_.Io— —
e Floor.__-I-o_ F1.--_------
Diameter Slot Site MaterialId. SCREEN: Depth _ in.
in.
I o_---_ It in. ---
floor--- __.
I5. SAND/URAVELPACK: Sire Mnlr,inl
Depth
1It— I'
po FL
ASSOCIA I VO WI) I'F.RDII II
II nnhlicutic)
Flom
hour
Jf
l l' Rf1ri'{ I H tti 5 �1�11
CONS! RUC(Ititl S IA) ID%I
.270293
WELL GUNS ERUC'I'IUN m CORO
Noith Carolina - Derailment of Environment nod Nalulol Resources - Division ofWriter Quality - U,oui dwater I I S2ctiul� i /
lr ran S t2 i��l Z-1
EI,Lconcunt n ncnlpnululuuAl,)NAnIF Unloo -
_n1oNF r ll R' I�I
tv111,1, CON I IUCI Olt COMIMNY MANIC
S to I E c\ FLU CONS I IIIIU l 1IN I'EIUII I I __.----
if n diarblc
R'FLI, USE (Check Applicable 11us)t Residential IULMIII',Cll l/Public U ludushial FI Agricultural U
Monitor lug U (recovery U I (cal Pulp Wilet Injection U Oilier U If Other, List Use
fopu8Inph!c/I,nod selling
Ullidge ILIshFpc UVnlley Uilat
Idrerk nrrynrd ale hm)
LIII!luddlmrgilode of well location
IdrgrcrJndnnlr Jsr^nJQ
dds OWNER: �F'' (`y�ppr��''�-,��(+((�� Lnlilu ki!^lteiludc sontee:LRIESCI1 opogtnpilic n''p
Addres5 C
(check l+ox)
))LL' 111 l/ILILLI)J11 LIH7
I'toul b Ignition Description
u '('Aj IUIL SICli1(;11
Show ditecllon and dislnnce ill miles limn al least
Iwo Stale Roads or County Roods. In line di: toad
uwnbcLs nod couunorl load I`aucs.h
LUS faf 4,01
6
y 6
GI' v :Iu5gU'iie -S
NI
0
0
Cl,
11115 WELL WAS GUNS! RUG! ED IN ACCORDANCE WI III 15A NCAC 2C, WELL
, AND I IIA f A COPY OF 1111S MILORD IIAS BEEN I'IIUVIDED10111E WELL OWNER
SIUNA I URE OF PERSON CONS I blue! lUG'I I IE WELL
! UWr1 Raleigh,
h71211D1
Suhlull Ihritl�+lnnl !Pitts_ Ilion of \1'nler Ilunlll), Crumldlsnitr Section, 1636 pt•II Service Center - IliRh, NC
i{j;ga16)61'IloneNo. (919)7 3-3121,ollhln31Itin)s.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment an
272382
d Natural Resources - Di iei n of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) / / t 4�/C
WELL CONTRACTOR COMPANY NAME S
CERTIFICATION # 7 �/ $
GvN �La. vt r L'i/7i // PHONE # (%(Jr[) o .2 _ 775 -Z
C ?x/`—Yte
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ❑ MunicipaIPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO,N:
Nearest Town: ('Tit -1) vale e County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
S
•5,)/ Address
(Stre� et or Route.N
tit V
ate.llNC.
City or Town State Zip Code
col")- V'0- 30Y0
A90y-
Area code- Phone number 3
4. DATE DRILLED .2 - 6 S - U
5. TOTAL DEPTH: 2 a 7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 'it
7. STATIC WATER LEVEL Below Top of Casing: 6 0 FT.
�r/ (Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): / S METHOD OF TEST
Topographic/Land setting
0idge OSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fo tion Description
0 5 lay
Se/ 7 4
10. WATER ZONES (depth):
Amount 5- ' e reF>
Wall Thickness'
or Weight/Ft. Matey al
11. DISINFECTION: Type )f {- I-/
12. CASING:
Dept
From t/ To
From
From
13. GROUT:
From
From
14. SCREEN:
Diameter
.2 Ft. t fins
To Ft.
To Ft.
Depth J foe. $ateria
To Ft. f r7 ,
To rt.--
Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Method
Slot Size Material
in.
in.
Material
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at Ilgst c
two State Roads or County Roads. Include thcixad
numbers and common road names. -:
I DO HEREBY CERTIFY THAT THI WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STANDS, A D A SPY OF THIS RECORD I-lAS BEEN PROVIDED TO THE WELL OWNER
RE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the otiginal to th i'ision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
GEOL. e i(lT
AS- V Ili
�_ ICE

WELL CUNS'1'iRUCl'IUN RECUi:11
I\l1 odi Ca1
01iva - Ucpnllncnl of
Iinvlluwuncul il niid UntoldLle� otICcs - D
i
vClsion of Wnic1 Quality - cUrrofululrdwnler S_c
rLl. CON I RACIIIII(INDIVInnAL) NAME IRlI _Ntl%rou
_ifDLU
WELL CtrIItACI OR C(n1rAN1NAMr rO1F, • �.�$)lii7 ASSOCIAI rl) WI) rr.RPll 11 ___----
lilnuRlicnblc)
SIAIF or1,1. curlsfilm:1 IIIN rEllMl IN
if n p lirnblc
I. WELL USE (Check Applicable Box): Ilesiteulinl lye hlullicipld/Public U Iudustllnl U Aglicullulnl U
Mnuilnling U Itccovcry l I I teal rump \Vnlu Infection U Olin U If Where List Use___—.---
'fopuglnpllic/I,mIJ selling
UItidge LISlopr UVnliry Urinl
(chrri nPr ")"lnir ho'
nrhuddlmlgitude of well location
272336
2, wFLI, LUI'A IWO: If ��q�I
Neatest lotvu:}iA\_�Q�S.11� S�-- _ i ouulY
__.1.43NIL\ _ ______ ,Irv. Sulnlividon, LC! IL'., Zip Cinle)
rfirel Finn*.
CnU
3. USaNP.II:� Q
A J+hccs
(Surd m Prole IIn.)
S14UL .o-1--7q1 C�le
Ciryym loann sInle smle
Are cede- Phone nnmha
..1, PA( i( I1111LS I'l)y, U— �---
5 101AI. Phi' Iil._ S'_ ------
6. DUNS WPI.L Iti11'LACli. PXISII1!O W!I! I YES U NO lie
I I; I.
_
7. S IA I IC VIA I lilt LEVEL Below op ofI neon! _Sop of Li"e)
9 lUP (if CASINO IS __..-___.__- P r. Above Ibort'nnd ruillnce• -
•1rrrl C•11111Ir,mindta don Luton Lnd'ul late 'code e'•
•ulna? in •rtrtileiite nut 15A NCAC IC MIL.
o. YIP.' N (ppmu): _la_ __ 6111111UU U1'II;Sf1 L— ______
N.WAILitLONE-S(JCplh)---- —
,ra } Amount. \E
11. U!SINf!!CIION:'fypc well .l hirknco
12. CASINO: Perth Uinmete et Wrip.1 Vrh biniciinl
--- rt. ,`Z IC-2L -V�--
nont_-1n 1.1 _
I0 —I'1.--
(IRbldhud
IJ. IIUI: Ucpll' n Ft. i—
rinnl� 11' __ _---
flom-_- _ I)lnmelet Slot Sire Alnluis'
H. sCltl?fN; Ucplh —
'lo1t. PL_in. _-- In.
Ilon'_— _ hi.
in_----
lo.__ _ it in.
15. SAKI lUIIAVPI, PACK!Sire Mutual
Urplh
PL— _ —
II nm—___ l a --
horn fo_—rt._
16. RNA ARKS!
IIt)ILI tfbl5" lit 41'
COtIS RUCIloHS{A
ii
C:S�idlnJl-SIIeMIOri,g‘ olhe
"eI27dlod: 6561'bnuttN6tR919)
(drgi /i inntr Jr•,,m10
Lnliludd(neeflude sow ce:LUUl'SU I-opngl npbic
(check box)
I)I:.LLl1 �iIIILLII!(i I JU
Plum Io Fa 'nation Ucsuipth+
n I
K
SL
l.V_CA7.IUN SK)ii
Show direction mid 1119lnllce h1 miles O nnod lens(
Iwo Stale Romig CI County Itonds. InclutlLtle Ioa(I
umnbusmud common tend names. 77,7
0
cJ
0
T
re tr
3
c.
f Illls WELL \VAS CUBS I Niel PU IN ACCUNUA(ICE WI III I 5A MAC 2C, WELL
)S,ANt)'th AtACOPY Olt 'I111SRECORD IIASREED PROVIDED lol3 WELL OWNER
UAIL
StUNA I Ullll OF 1'PItSUN CONS1 RUC' INU "I I IC WELL
t Scntre Cederl is - I1nIeIRh, NC
i)id,huil Gr \Vglrr Qunllly. ccuund,i'nicr SecU ii, i636 Msii S .ItEVR 07/Zt101
)1J221, tvllhln 111 tiny!.

272133
WELL CONSTRUCTION RECORD
S 1 North Caron- Department of Environment and NntwnlResources - Ui/vi,slon of Water Quality - Oroundwfater Section
WELL CONIMCTUR(INUIVIUUAL)NAME ^prInl) CERTIFICATION c
7
WELL CON1RACI OR COPIFANY NAME PHONE ASSOCIATED WO nanny
fif o) icnble
S to rE WELL CONSTnUCTION i'Eftl•T�
if a licabte -
1. WELL USE (Check Applicable licable Box): Residential I/Municipal/Public L7 Industrial ❑ Agricultural
hlmtiloring ❑ Recovery ❑ heat Pump Water Injection ❑ Other ❑ If Other, List Use_—_._--
2. WELL LOCATION: County
Neatest town: .1.
(Sneer Name, Nnmbus, Community, Subdivision, Lot No., Zip Cale)
3. OWNER:
Address
Cis nr Town Stale
Zip Code
(_)
Nu code- rbnne math r
. 4. DATE DRILLED
5. TOTAL DEPrII: W CI
6. DOES WELL REPLACE EXISTING WELL7 YESI U NO
7. STATIC WATER LEVEL UcIot(U C "I' If Above p of gTop or Casing)
R. TOP crop
of CASING IS.�_--
Pr. Above Land Surface'
•Top ncasing In,nln sled •Unr below land rm tare requites a
verbose In aanrJrhe<nill' Is NMCAC2C .01111.
OD OF TESTQ�� 2---
9. YIELD (WO:JD —
10. WATER ZONES (depth):
4.4
11. DISINFECTION: Type
12. CASING: Depth Diameter
Prnnt 2 To 2eD pL r Ft.
To
Pwnt PI.
Flom To_
13. GROUT: Dept,
From —To
Ft. '
Fr°m—_.10 Uimncicr
14. SCREEN: Depth in.
From I^--FI.___
I1.
from To
15. SAND/GRAVEL PACK:Depth Size
To
To
Mat
From
Fr our
Ir7,�`
I IA)ilel<FDY CCRHI' 11
CONSTRUCTION STAND
Ft
Ft.
Amount IDS
Wall llsickncss
or Weight/Ft. Material
inl
Slot Sim
iu.
Material
Method
Material
•Fopogrnphic/Lnnd selling
❑Ridge ❑Slope CB/alley OFlat
(check npropdale hos)
Latitude/longitude of well location
kg.o011A pB3; 56 0
(degrees/minutes/seconds)
Latitude/longitude source:l7GPSC1Topographic rnnp
(check bon)
p RI LilQLOG
Formation Description
Z-5
pal
From To
v
C�
p K KB c_r
l,SLGl�1—
Show direction and distance in miles Rona leapt
Iwo Slate Roads or County Roads. Include the toad
numbers and conutton toad names.
I' I
AT 1111S WELL WAS CONSTRUCTED IN ACCORDANCE WTI11 I5A NCAC 2C, WELL
U)S, AND TITAT A COPY OF 11115 RECORD IIAS BEEN PROVIDED TO TILE WELL OWNER
SIGNATURE or PERSON CONSTRUCTING TIIB WELL
,t TIDIJounlit Groundwater Section, 1636 Mall Service Center
e7 er- ttalygp NC
17 -l636 Pliant
No. o Ih Division3-3221w 1Valer Quality,
116aq-16J6 No. (919) 7lJ-J211, within 30 days.
C
DATE

WELL CONSTRUCTION lU't- . L'
North Cmulinn - Depathocld of l'a,vhuuurcnl mid 'Animal 'tenuufccs Division o`^Vj�--- nlet Quality
« ELL CON I ItACI(III IINIII vII1(IAL) NAME bi 1'(1 QN
,vri,L CON I MCI On COPIPANV NAME
ASSIICIAI r,h R'rl PF.RMI I It
sIAIF,,vEII,CONS illOC11(InfEI( III _— ifn,dico)lc
if n llicnblc
I. WELL LIST. (Check Applicable Iloay Recidculinl IUMuuicipnl/I'uhlic U ludostrinl LI Agricultural U
Flouiloling U Recovery LI Ilea Pump WVnlcl Injection U Met U If Wirer, Llsl Use
272132
2. WELL LUCA I ION: Cuunl
LJcnreslIownt—
by Soh Ii vidon, l nl tio.• 71p Code)
(Clirel Name. C, ,
1. 0WDEIt
Ju a.O--
Add' css
(Soul tit Milnealk—\J._.--- 2t� � ---
m Il ou, SShiiteShiite71p Code
Air! cr,tr. mine numb?,
. L. 1)AII° null I PN.3— �--
5. 10FALPHA ii.__-aSSS/_ ._, ___ull ! 'iCSU NU Li
G. DUES WELL RPM ACE L•„ (13I •� E- !- I' F.
7. S FM IC WA I ER LEVEL Ilclow'lop of Cooing: _6D_-_
(the • 17 If Above lep of C..I„p)
l UI' Ol` CASINO IS 1 - _-- 1'-I Above I.nnd Surface'
8_ . hip rl until, lr,,,,ln.ird .Pr, lido.. 1.m1 .,,,l.re lupin. •
edam, lnsnot J.V,rr nllL le,\NI;AC IC OIIA. A�—
hu0 iIOl) Ul I1,S P
a YII'LDl!'P"0 �--- --
10. \VAl l'.Il 7.UNL� µ„ I r��,� — � ---
to I Amount _—
II. DISINPISCfION fypc�vNall IldckncnA
IL CASINO: Perth Uimnclrr or weight/E'f. Dhlnnl/clinl
Fr o �(� Li I7I._&_c2 -- ` _ /
Er nll In II__— __
I o____ hL MethodI.
hRU- M
IJ. OROUp: hrpll l. ale inl ����
Dinmcicl Slot Sire hlnlclinl
o Fl. Ill.-
houri
_ --- fllu.
oor—__.
I o— 1 I. W.
15. SAND/UILAVFL PACK: Sf e hLdednl
Ilrplh
Fr ow_ _
To it
Clioutolwnler Section
/ /
CEIII IF ICAI inn F /^
r von A Fnal`y3�-Z9�i'1
'fopo rnphidl-nod srlti°LUflnl
URldgr, IiJRtnpr IlVnllcy
!dark ep rlrpl I,ir bn')
Lnllludcllungilude of well location
(drgrte Jminnlr Jv-e ,dQ
Lnlilud:f!^"giludc sourcca_I(. ll'SL1 I.opnglnphic n:=p
(Alert, In)
►l1_UI-LI(IU I J.
ixruraljon Description
hum Ib
v direction nod distance In miles Boni nl Iensl
Ie Roads or County Ronda. Include the toad
IIUIIYU'CI$ nod coo.,..-. fund 111111,75.
e t,
G
-1w,L
,5
(it
��_ . � pp;41-Y--Lt . -H- rY I tillIS5ELKWAS CONSIRLICIEDIlACCORDANCE WIIII 15AtICAC2C,
WELL CLlIG
lea )
Lm II ' I ,
I�CUNSIILU'DUN SfAN )S, AJD'IIIAT A COPY 01IIII5RECORD IIAS DEEN ILUYIDL
ISIUNAUII! UV 1ltSUN CVNS1lUCIINUIIIL WELL — —��
DIS
p----- �L� awl.W-{ ItLver, ocn1
F'Sylm ,, fh.1,,, n! 0!4_,Llhe .)vision of 11'nlrr I)unlll)', CrClouudtnnler Section, 1636 Mill Service Cooler - ItelelRh, NC
pSHc Q. — --
ao-Ibib Filmic No.191911JJ 111I,,+Ilhhl JII day s.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) rap N.z.. P vi CIO t2 CERTIFICATION a 3 i 7 5
WELL CONTRACTOR COMPANY NAME 8`j C- (7 S (.) eti-- PQ (Lt'"t Nlo PHONE >r 1a1745 -2/66
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if ay limbic if y.licable
1. WELL USE (Check Applicable Box): Residential fl MunicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery Q Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: e� ��a- Y (LUC, County adity
-
4 3 7 ijoa.car Z p IEAZecest/(LLL - Zrt°el
(si-tet `. em., Numbers, Community, S,:bd:viico, tot No., Z;y Cod
3. OWNER; vPd- MdiNik-/S
Address'tCloca (met uJ&.&N) MC„
(Strict or Route No.)
City or Town State
(MO- c3 39 - c Q,S 3
Area code -Phone number r.
4. DATE DRILLED 1- r 0 3
Zip Code
271921
Topogl$ )lic/Land setting
°Ridge L Slope ❑Valley ❑Flat
(check appropriate box)
Latituderlongituue of well location
(dtgreeshninutesraeeends)
Latitude/longitude source:OGPSOTopograpbic map
(check box)
DRILLING LOG
Formation Description
TOP S D/ L
&bcznv „sonic, Lic(rvy
s2cs We" (L'62 7k-+r€W /2a(4,
4?d? eoFecnR=ut-K1 /axe
fj�0✓/-/PRJ Torn-
fi11Ari Sn.=TF2 /20
[toil r0/212eC-r,
CJ Aft re- Race
i./C, /:rGRP Y /ZDCi
Szet G /Z2-V %l+C-k
DEPTH,
From To
0
- 73
5. TOTAL DEPTH. FJ ES � 73 - Yn
7. STATIC WATER LEVEL Below Top of Casing: WO FT ,2 -
4CL_
I+sL LIST
1575- - .3-yo
S �C1 - 7.2i
6.DOES WELL REPLACEEXISTING. WF1s? YESDNO 90 - z(�C7
(/ (Use"+" If Above Top or Casing)
8. TOP OF CASING IS Z FT Above Land Surface"
'Top of cuing terminated atur below land surface requlres a
varlaue! In accords ce wish 15ANCAC 2C .0118..
9. YIELD (gpm): 3/'f METHOD OF TEST
10. WATER ZONES (depth): i ZS
11. DISINFECTION: Type
12. CASING:
Depth
From _To.55.5 Ft iC 6
s S Front_To b
From To�, Ft.
i I (-i- Amount I'�i lb
F'zL' 7hickiiose
Diampte( or Weight/Ft. Material
SDP?! eVC.
Ft. G, %' .S't7R 77 S /IV C
13. GROUT Depth Material
Fron`� To Z U Ft. C ert-t -W'i'
From To Ft.
14, SCREEN: Depth Diameter
From To Ft-,_ in.
From To Ft.42,_jn.
15. SAND/GRAVEL PACK:
Depth. Size Material
From To Ft.
Method
GP-e)V (1-11
Slot Size - Material
in.
in,
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two Statc Roads or Cou.ty Roads, Include the rciad
numbers end common road names.
IdY c: S H / G`i
VI2 •
E
in•
V
�^1 Norl�; ,,
16. REMARKS:
yv
'Sm
C,
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH 1SA NCAC 2C, WELL
AND
CN RIPE, 1; S SIGNATURET 0�0N CONSTRUCTING THE WELLOF THIS RECORD HAS BEEN PVIDEO TO THE
WELL OWNER
MAY submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone N o. [phone], within 30 days. OW-1 REV. 07/2001

274435
WELL CONSTRUCTION KI;COILI)
Matti I-adina - I )rp:n Inlrnl of Fovironment and Natural /Rcsautues -` Division (o lfr \,Haler Quality - Groundwater Seclion
W I It IIl Ill\( -lUn Iro'In\'In1IAll NAME (tnlul) •�Q—Re..'"0 ' l_}. I101HIetz�% to GritrIFICA IION ll3..`��5p•
Wi II I ILNII.\f Itllt(41\ IPAN1'NAN11 j� An(Z L Q1L JQrl(( �/____._ PHONE, II frig) •i7 �o`4
NI \ I I ‘AI I I. (WY:11t1'1' I IUN PE:10111 H _ ASSU('IAI Ell \\l) FERMI I N
III :wilt able) (irap[llicahlc)
I \\I I I. NSI Il he( k Applicable !lox): Residential (1Y nlllnicipal/Pulllic IJ
i•.hnlihn ine I I Ruei eiv ❑ I leal I 'unlp Water Injection ❑ Other O I
1 \VI'II.I(II';\IIt)11
r •. 1: m:w. Nam b••1._l �a.:nu:nily Su 6:licisinn.lrrd1 Nil Zip CoJr1 7__. ..
1)\\atilt• _—_. &CJA/ e. �iM So4—)-.. ..
Ad 11,•.'; _ __. _Po Rog / F C,
to! KtPuie tin )
,n 1, n I 1r / __-- lip Cody
1$11S) Sa/— COO_ C)-----
I. 1)rAI1 1)RI1.1 Pn
s .I) I AI Nl:l' I l l ' /
I)111.0 \VI0.1 1(I I I. A('P [XIS] WIRE? YES LI NV n
) I Ail(• \VA I I.It LPhl. Reluw Top of ('acing. _7:60 _I 1 .
_-- (U.<"I" if Alive loll 01r'0i000
{; 111' OI ('ASIN(i IS / I'r. Above Land Sullaces
-lit pot r:nlnp Irnnln:nril fl/ur halm, land rnrrare require,' II
. : rr 10 nnotJ:lnrr"llh IS,\ N1'AC EC .0118.
u 1 II II I) 1!•pmP. _ (`IE FI IOI) OF iI.ST
In V; A I I[I' /I )MPS ldeplh)-.. _
II. I IISINI I(' III IN: I yc (f4tc2. ti< Amount_/C_v_, Show diroclinn
11 (',Ar INI Wall illicitness Iwo Sl:llc Ita:ul
17rplh 1//)ii�:ml9et or \Veiglil/II. r.iI -n it uuulht i'::oi l r,
C7 ) l i._SU._ _II s��il PVC
Indusllial ❑ Aglicullutal O
I 1 )16c1, List IIse
I (flogin tllic/Land selling
-Rid)a• IJSlopc U\'alley 011:d
brat k fh'PugninIc bra)
I :IIiludo'luagilude or wen location
I rice- 'oil inol<C•ie<nnlltl
Ialinalrhall:in1(1C stmlcct_1(71'SI7 I opogrglhic neap
(:heck h,..)
urr 111 Ulill I,RJu Lou
1 of malign I)cscriplion
II
l i,lll I a I I.
I l„nl 11, ICI'---._._ - --- —
I I Ii01111l Urpal Pluli•lial TT
I:nll 7C) la 8C'1I iI, CLITIT.:J)s
I.1 ':I PI I'll Il..l,ll, I)ianlelci Slul Sin'
0.111 In I I .._ill. in.
uml Ill I I ill ill
I.A11Nl il'.AA'I 11'.A( K'
Ili pill Sipe platen ial
111111 In Il.
lalll I11 I�t.
t( iPIIr�\ifri':`'-
I11r I III I I N 1 1 i P.
I I1N;;Ii I T( 1II11I
GRC " : A,T SEC-HON
ASHEVi LLV; 1v1•_ 0=HEE
t uGnll ,lit ni;phial lu Ihr Division u
nit) IIUi Ilion( Na.(')I9) 711-1221, nilhin 30 da)s.
F. Ir11001 -,/
vi
4t)ryN:ilri .
Ia
0 —.
get. CL-01
c
a o a
)C;A'I ION SKICICII I o`
and dislanec in miles rronicrt? kat o
•: or county Roads. IncludtIc tl
minion road
O n:a
1 I I IA I I IIIS WI'I.I. WAS CONS I 121IC I FP IN At'('Oltlh M A' kl'l I I l 15.A N('A(' 7C.
lt'A\Itl)S, nMr,I IIIAI A COPY Ui--1 11S RI'(l)IiU II 111'IN I'It(l\'ll)I'D 1111:, WELL O\VNI:It
tn.wrr-t �1
or l l ItSUN ('t N4il lilIl I IN(i l ill' W1'I I. [WE
Valet- Quality, (:ruunlh\aler SecHun, I616 I\l:dl SeiIce Ceuta- Rah Iglu, N('
(I\1'-I REV.I)1/201)1

2. W Et I, LUCA I ION:
I( —r,�ai_—
NcnreslIorvn'.� " — County
5.4 /Jos.t
(Sow (lime. Nombn., C.,••• llv. Snbiivirlon, l.d tln., 711( Co,le)
3. OW N l` l l: _f,dL-5C
Addles ke'
N 71p Code
i 7 m m•n Slnle
AU" code.. rbror unmbr, ,2/. ` O z
5. I v fAI, Dry fN._ t _
G. IMPS \VEIL, REI•LACR EXISIIOU 1vE1la YES NO U NO 11111-
7. STATIC \VATLII LRV FL helolE.
(We lr` If Abovr lop of Cndnp)
CASINO S I I'"I', Above Loud SwIi ce'
g. -1 1o' or allot I _ ---_
• lop of r•rhe In vdr,•Ird d'm Triton bid nn Per rt9nh rr
. iJmcr In (itrrdence nllb Is.\ NCAC IC .nllp.
Ylla.p!rpm)' _c2Q. _ _ MIiIIIU OE'IllS1 —
IU. WA PR TON (Jeloir):
WELL CUNS'IIII(Ut;7'IUN IC_El;tiiW
No11h Cnt olina - Urpolhucnl of linvlwnuleul nod IJnlwal Itesuuccs -
dwnter
Division shn fV nlcl Quality IISection
W r. CON I nACOlt INIl1IUVA FIP+I"0 ^ \CFt IIF ICA IIUN
writ• CON! UCIUR COntrANY NAME y'll; room!. oG 2C/C7
mom"
SIAIr1% Fit CONS 11111(,-1 ION r F.lU1 IIl_ __ ifnlASSlIC1A'I F,U rll 1\VtII)
r
if n' dioddc rble
I.
I' I I lion): Itreidrulinl M Municipul/Public U IIuI11sI1in, U Agliculiwnl U
WELL USE
(Check App Ica r c us
M mriloling U Reco1'cly LI Oral Pinup Wntet Infection LI Oilier U If Oilier, LIs1 Use
'lupnl,I nlrllic/Lm111 ' rltluig
Ullidgc I_ISlnpc ElVnllry Ul'lnl
Iclnrk nlgmgnkie Inn)
Lnlhudeilmlgilude of well Iocslion
Ngs:ol;_s cJBs_451,23
Idrptrt/mbntlr0^^^'IQ
Lnliiu c!!^"gilude Sn111ee:U(I1• SCI I-npnglnpllic NI gl
[check l'n)
I)I J ill LIRIM IV O WO
I'Iunl lu �'onnnlion Ucscl)pliwl
274816
,�,1� _ _12
I I. DISINPPCIION: 1)pc .h Wnll lhlAmount r If_
12. CASINO: Plaintiff o1 Wright/Et. Mnlcllnl
(kWhryfy 1 5Q'71 ?�
I'n.n� In—L�PL� 7.5_
Plow I n_ rt._ _
hmo_ 'I_o—_ft.
---_.---
f,lnirtinl Method
Il. OR( WI! ;truth/� I OILS uL- -
Piton 0 TA.d It - _ t ion2 --r
how 10-.._11. __. ___
Uimnelcl Slot She Mnlelinl
Id. SCI'.I:p)J• Ilrpllr III.
hor— In-- _- I'L-- in.
Flom__ ___ Ill______
15. SANV/lURRAVIll. PACK: filth -tint
lrpll, Sire
10 ll__—
flow_
hvlll To 11.-- --
%den
(WI ni
nnt
Show der �'n null nds co Cloudy Runde. Includelr
thetenr
d
Iwo 1ir.
uuurbcts rind common n,n•1 unlurn.
LVCAIION
�r.1-� 1l
L
C
f 1111S WELI, WAS CONS I Il1ICIIID IN ACCORDANCE, WI711 I5A IICAC 2C, WELL
US, AND 1lIAF A COI'Y OF 1111S RECORD IIAS BEEN I'NU/VIDEO10 111E WELL OWNER
SIGN/U ORE OF I'EIISUN CONS111UCIINU "111E WELL
GRGU::'C. 14
ASFC1'i 1= �ilIPkln III Pidgin(' 01\1'nirr ()wilily, Croundlynler Section, 1636 Mill Service C(l1Vrl IILIVRU7l2tUUl
�, l I tUD 11rb PI
•
176110-1616 1$onc 133-3111,1111hhr 311 tiny,.
orn
c:

WELL CONSTI{IJC•I'ION ItECORI)
I I„l 111 r:n Mina - Oepminirnl of Environment and Natural Resources - Division of Wino oualily - (1roundwater Section
\\III IiiNl itflit ion IINml)'1rrAl) NAME (ink!) hVy }tc._ /0 /rf E'kCJ LY__ C Fn IITICAIION H322j
\\III t Ilnlu\t I U O\II'ANl NAME_ _CIaDkee __.LOCI. I___b R..._-ruUNE a ( ,`�3� 't
SI ill \\i-.II,((1.\5 I HP( 'lIONI'EUM1111 ASSO('L\'Ir. II\ct)I'K1t\Iln
01 ;Iq'Iiulblc) or ;ggine:adc)
274436
I. WI -I I I I';I (( hrcl. Applicable Box): Residential ld Nlunicipal/I'llhlir ❑ Inducnial U Apt ❑
minim illy LI Rcroucly ❑ heal I'uwp Waler lujeclinn ❑ (Ube' ❑ II t Niel. List 1Ise
RIII In(.AIICIN
Nrai sl I n:vr Homes ✓/LLE'_ County CLA
I)1-4 L - O-(7 Le �_,,zct. � __1 0�=_ _.2C2.
I Nnnr- tavm .i, I omnumily. Subdivision. I nl No.. Zip (bdcl
1 1 )A1-OLIt
c _. ZA kit S_L./4 K
r- 0 .15 CVC — its
y -
I en•.iI IIIuoue: Ni,
Fin/Ccsk Ie_ AG 4foV
I il, 1uu••ornn Sisk fy 7ipCock
I C)1 _ "1"lLi-- 1J.2J5
totIC !Mato nlnnl.rl
I U\If. 111111.1.11). —��-03
s. lilt Al nLPrll'
6 Iv'S \\ III.1. RI'I'I. Ar'II FRISIINU Will,? YES CI NC)
';I/\II('\\'AIElt I.F\ III. Below Top of('using:_(C1..5 _ _I
(use "," it About,_ 1 op of Crimp'
11)I'I)I ('.'\;Itll; IS If. Above Land Stir line'
• I iq• of rv,bq• IrrrLlal, d al'n, !wino hurl rurlace rnlulret
•:n loom In am odan,r „ Im, IS,\ N('A(' I('. III IN.
Il \ III I, I 1pul):..'... MElIl ))11)CA' IIiST--- fi/R
III \l-,\ I I I' JI IrJFS 1dc pule rX `%Q'
II I'ISp111-( II IN l nc��/7[ctO ,v.'c _ AIIIm1111 /
1'LOC Wall Thickness
]lq,Iannplric/Land setting
❑Ridge I ]Stolle [Walley :Vial
block npplihli:nr bus,
I aliludc/lonpihule of well location
n L•plrr['inin:N•d(ern l lilt)
I.ulilud.vl .i,t'iluik solllce l_I(il'SLl1 opogr phic ml:q,
Irheck hos)
1 )1:1' 1 II URILI.INU LOU
From l o Formation liescriptigqn
C:L y _SA 1"D57&Jt
- 306
C F
C
El_,
LOVA110NSKETCH 2.3 gm
Shove dirrclion :uul distance in miles from n1 least
I vo Sisk hind: or ('ouuly Roads. Include IIrSo' tlT3,57,
I kplh I)ianlclr or Wciglu/I`I_ luhei izl muilbrls and (nlniron road names
m.
1'l _ Ir• //Li Ft *' 5422 PVC.
In'ul to II ._.—
Ili•in In _.. 1-1.__
11 Ilp( )1II- r ptll Natrnd _ -- NItillioil
ono Q ln_20 II C104(E T �F19hny
I non ;a6� I n // 0 I I C'.4 Li7/C^5. .. L'/Cr1L9(_.)/
Id S' I'I Fri I):Idh Iliametei ulSi7e (// NIdinire
//
I unn
I min
IS ';•\rII 1'I il?
1 loin
I will
to
in.
'I'I I'Al K-
I)ridll Size Ni:nclial
11• LI.
Io
I6 III ',IlAItlS)
_-11u)1II 'FII'l Il:It llty iII\ 11111S111I'I.I. WAS CONS I WWI Id) IN AF111111)4119 \\'I11I ISA NCA(-2(. \VIII.I.
-trJ;iltll(_11UN°I,Atll)'(\Rot; I)"IIIAfA(UI'YOE"1ISltllt.' ILUII SIIFIII'ROVIOLI)I(11l1LWELL OWNER
IGNA I UR L I'El SUN toN .1101CA MO 1111. 11 E1 1 UAIII
Submit Ihr ml i4i1tad lu lIlt Division of ll'aler (luallly, Crnumbs:11 r Section, 1616 Nlail SPnire (ruler - Rnlelgh, NC
27699 I6Ili homy Nn.(9I'll71t.1221,k\llhinilldays. (111'-I REV.072111)1

272560
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -- Division �otf Water Quality - Groundwater Section? C7
WELL CONTRACTOR (INDIVIDUAL) NAME (print) l.i� S G •^ �F , -( „ CERTIFICATION #O` t 3 1
WELL CONTRACTOR COMPANY NAME tU E L — 2..(Li-.(I PHONE # (*i 339
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential il3 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCA IN:
Near: t To -�9__ \ 1 '' County
!t1_R��a..
(Street N: e, Numbers, Or uni 1
3. OWNER:
Subdivision, Lot No., Zip Code)
City or Town Stine Zip Code
(
Area code- Phone number , t 1
4. DATE DRILLED `
5. TOTAL DEPTH: 'Dfclo I
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 11/
7. STATIC WATER LEVEL Below Top of Casing: icC 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 accords a ith ISA NCAC 2C .0118. ��
C
9. YIELD (gpm): METHOp OF TEST
10. WATER ZONES (depth): h rI
11. DISINFECTION: Type tttk Amount
12. CASING: Wall Thickness
or Weight/Ft. itigicel
cagbatL
I03
Depth Diameter
From d To `S Ft. bt `i`1
From To Ft.
From To Ft.
13. GROUT: Depth_ M telial
From b To 5 Ft. L
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size
Slot Size
in.
in.
Material
Material
Topo c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
LUNG iG
Forma on'#es.ption
DEPTH
From To
0 201
abi (i s'
r,
LOCATION SKETCH O ,
Show direction and distance in miles fromSt/leastn
two State Roads or County Roads. Include ro4'^
numbers and common road names. w o
>0
gtmtses..Y
16. REMARKS:
1,)3Q HEgtinf': CI;RTI}ri
boteRUCTfbN',.
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL 0
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Div sion of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
2T6994 P36ThlaniiRdi$9 733-4221, within 30 days. GW-1 REV. 07/2001
E REGIONAL OFFICE

, 7 2
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisionsiof Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) W
(pprint) ('�LL-�W` � 5 . `reert 1 CERTIFICATION #
P—L CYWELL CONTRACTOR COMPANY NAME PHONE # ) t'�l -O�isO
.�
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential �Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nea
ounty
(Street Name,
Numbers, Coin
3. OWNER:
Address
ty, Subdivision, Lot No., Zip Code)
s —_ '
\'l) %
aq\C.), o4, .`:�i d i
0
Zip
Code
Area code- Phone number
4. DATE DRILLED J
5. TOTAL DEPTH: IT /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 27 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 accordant ith 15A NCAC IC .OILS. Q--L)1�
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): ��.a\S' 1
11. DISINFECTION: Type Vv tAmount
12. CASING: Wall Thickness
Depth Diameter or Wei t/Ft.
From D To ,41to Ft. Co`{— 13 Xty.
From To Ft.
From To Ft.
13. GROUT• Depth111I
From b To ILK.,0 Ft.
From To Ft.
14. SCREEN: Depth
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
From
From
Depth
To Ft.
To Ft.
D
Diameter
Slot Size
in.
in.
Material
Topographic/Lantj,setting
❑Ridge OSlope &Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fo t.tionD- cri
1LiD' 11
LOCATION SKETCH C
Show direction and distance in miles from Cleast-6
two State Roads or County Roads. Include road-,
numbers and common road names. -0
S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANCjARb�, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
6. jtEIAjeireRK: n f�
12€W IHA
.r4-`Ip N
?EcqpOFPitlte Divsion of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
GW-1 REV. 07/2001
IGNATURE OF PERSON CONSTRUCTING THE WELL
W
O
O
6`Phoue No. (v19) 733- 221, within 30 days.

3. OWNER:
Address
272557
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) " 5'
`` rr WWt `""� � � CERTIFICATION1F
o93gy
WELL CONTRACTOR COMPANY NAME (LJVI t USE-112.I LU IJCI PHONE it
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential m vlunicipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest T.
County ��
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) o114,
or Route NoJ
tip— 9
Cityo T. State, Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �...1
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EV
7. STATIC WATER LEVEL Below Top of Casing: 00 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 I5A NCAC 2C .0118.
9. YIELD (gpm): SC) METHOD OF TEST
10. WATER ZONES (depth): `\a
4
D3
11. DISINFECTION: Type tSPZ Amount
12. CASING: Wall Thickness
Depth Diameter(Wei t/Ft. a al
From b To % Ft. L974'' �Jt.(o
From To Ft.
From To Ft.
13. GROUT' Depth M e 'al
From 0 To% FtC
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.
From To Ft
Slot Size
in.
in.
Material
16 REMARYS
l e ii r Y Fp`3'(Fv' THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAADAR3S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEI/L 0
Top ographic/L 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 Form4ion Description
o D•L1
e-94' ,55'
55' arc-'
LOCATION SKETCH o
Show direction and distance in miles front") leas
two State Roads or County Roads. Includt<'$re rcLacl
numbers and common road names. --D
Xt
v5b'�
Ca)
O
O
.c
Citri
S
F PERSON CONSTRUCTING THE WELL DA
GR Tr('�g���t the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
ASH[
2 9 ri4t5' hnk A`'(�9to) 133-3221, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
1 Natural Resources - Division of Water Quality - Groundwater Section �g
WELL CONTRACTOR (INDIVIDUAL) NAMEI,�A���{,�(prlIint) w1tu--1l'kYN\ `S- • (C—mS CERTIFICATIONlJ^/#fP-7
WELL CONTRACTOR COMPANY NAME tM \t 1 U..E ��u-�Q'�'L-�-(f5 PHONE # f2�6) 3S1 — Il
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
272556
1. WELL USE (Check Applicable Box): Residential li' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI a :
(Street Name, Numbers
3. OWNER:
Address
City o
To
C mm , Subdivision, Lot No., Zip Code)
• 's . 1)W!
(Stmet Route
Zip Code
Area code- Phone number 1 n T rj
4. DATE DRILLED o'1 t 1 b3
5. TOTAL DEPTH: I /
6. DOES WELL REPLACE EXISTING WELL? YES I ] NO t3
7. STATIC WATER LEVEL Below Top of Casing: Lip 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 ISA NCAC 2C .0118. �.v1-ZL
9. YIELD (gpm): 10 METHOD OF TEST
10. WATER ZONES (depth): (0 Dr — 3
11. DISINFECTION: Type F-VI*-i
12. CASING:
From_L_To Ob
From To
From To
13. GROUT: Depth
From O To 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.
Amount
Wall Thickness
�°�W�et�t/Ft. to
�t�tCd t e
Topographic/Lan setting
❑Ridge OSlope alley ❑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 Formati¢p Description
,t
as"' ls1+I
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common fpad names.
�jp, ati,
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 NCAC 2C, WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE w7L 0
/7763
ATURE OF PERSON CONSTRUCTING THE WELL
fib the D vision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
FI,. • 3221, within 30 days. GW-1 REV. 07/2001

272 555
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME �(print)` W*U tottery 5 • t �S CERTIFICATION #
WELL CONTRACTOR COMPANY NAME WFCU(C LEEL -J 1 LUI nirs PHONE # (
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential lt3 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nearest t �s
Co
(Street Name,
Nu rs, Comte ty, Subdivisio Lot No., Zip Code)
e,
3. OWNER: `i`a
Address„al
�`- (Sneetyr,•
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: ei5(O
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1i3i/
7. STATIC WATER LEVEL Below Top of Casing: Ff.
(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 accord h ISA NCAC 2C .0I1S.
9. YIELD (gpm): Iw tMETHOp OF TEST '
10. WATER ZONES (depth):
No.)
State _ Zip Code
11. DISINFECTION: Type t%� Amount
Wall Thickne
Dinler o We iess a rig
numbers and common road names.
Ft. (a (p
12. CASING:
Depth„,
From b To____4,-__
From To Ft.
From To Ft.
13. GROUT: Depth Mae ial
From 0 To 31e, Ft E
From To Ft. t
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Slot Size
in.
in.
Material
From To Ft.
From To Ft.
16. REMARKS:
lopographic/Land setting
e ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From Tot Formation Description
O to
IDt 30i
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include thgoad
c.a.) o
Xto
.Z)
O
I pW H.t r wp,It Yt
C ST�U I a����
'i11°1
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S, AND�HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE
AefiyhiA
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA'
Submit the original to the 1 ivision of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No-(919) 7 3-3221, within 30 days. GW-1 REV. 07/2001
Cry
SGLL

273051
WELL CONSTRUCTION RECORD
Noilli l luuliun - I)ep:utincn( of Environment and Natural Resources - L3'Y�Divisiioonof Walcr Quality - Groundwater Section
%11'.I.1.(11N'I II AI"I Ott (INPI VIDUAL) NAME (riot) DR kat) IL kL'�No IJ CERTIFICATION N2�// pQ
w ii,i.l (MI RACI (lit COMPANY NAME ( 'k'n OR1 I' II bNg,LL/0'�r PHONE N 18 �,3'7-800 V
s LA I I. F1 I:1.1. COr STIII'('l ION pr.NNITN Assoc:IA f FU \PO 1'E10 111 N
l if applicableI (if applicahlc)
1. WI' IA, USE (Check Applicable (lux): Residential IIY Nlunicipal/I'uhlic O Industrial ❑ Agricultural El
Moniloting ❑ Recovery O Ilea( Pump Water Injection ❑ Other El IfOIhcr, List Use
2. WELL I.( IC/ATION:
Neatest To-w^n, %�PAS5/�, 100 County an/
jPASSToU)'') ) Q.S
'Snort mime. Nwnbcis/.�Comniunililyy,, Subdivision. Lot No.. Zip Code)
. OWNHE: KIK.r�r SHeRkv
Address JD?// 4PC 6
SI¢rl nr Ituute No.)
R/1SS Ota(d M C scjn 2
(irym Slav/ Zip Code
¶ 7- Te(-3 C
,An'a code- I'bome number
4. NATE D12II1E12 -29
5. to-rm. DIET( II: .305 ,
6 D)FS l\'I'.LI. REPLACE. EXISTING WELL? YES ❑ NO EIV
7. S 1 AdIC WA] Fli LEVEL Below Top of Casing: .ikQ,_FT.
(Ore "I" if Above Top or Casing)
R 1 (DI OF CASING IS I I']'. Above (.and Surface'
' inn nt rasing lei lole,led Vier below land mince require%
.ni:orce lu ncrurdeotr nllli ISA NCAC 2C .a1la.
Q. VAHD Input): aO _MET(IODOtTI;ST /9/i�,
III. WA IIIIt /.ONES (depth):
Topographic/Land selling
I_lltidge OSlope OValIcy ❑Plat
(check appmpl tale ben)
I.nliltide/lotigiltide of well location
tile Weer hni nil Ic s/secolidt)
I.aliludcliungiluJc suulce:OCiISEi Topogrgtiiic map
(check host
D1i1'1ll DRILLING LOG
Flom Tn� Formation Description/
cs lci/on
Cut
- AIR 141-
I I. I)ISINIIICIION : Iypc 4.uRl'.1e Anunitll J cup
12 CASING : Wall Ihickiies
Depth Dianicler or Weight/FI. R later al
I tom _... _ I.1' %.&__FI. c
11m11 r0 I'I.
114n11 I0 ---- Ft.
Ii. (i ItOI.fl Depth Matclial Method
1 tom_ _0 1 a .�_- Ft l /(4'ne^,i Ari.WEr
I tow de__ - I o 7%•__ FI.__CN-Lf -75 VT
Id SI"REIN: Depth I)ianielcr lSiol Sin VVV Male
I Imo Ta 1'1. in
I I nnI__._ to Ft. iii
IS. S,\ND/(;RAVPI.I'A( K:
Depth Size Make jai
Ilmn To 14
Ilom I
teas) _p✓C
in.
in.
y
CD
Iv )r.C'
n
LOCA'IIUNSKE'ICII No
Shaw dilcclinn: and distance in miles trout al easty,
two Slate Roads or County Roads. Include lift ro:r i"`
numbers and common load names. (�
O
LE' 4.1 n
I fa t of l i In rl'trrtri I I I �•
lUNSI hilt I It IN SIAND AI,
ram)
1111S WELL WAS CONS TRli('1I(I) IN ACCORDANCE WI III I5A NCAC 2C', WELL
AN¢'ITIAT A COPY O''IIIIS Itl ORD IIAS 11l'I'.N PROVIDED iU'fI lE WELL OWNER
;4nt-e71.— 2/-2 9-03
SIGNATURE Op PERSON COMSI IttICI ING 11I1:
DATE
,TER SECIeCIN
/15'.144illlniiED.W0fikilbftlitlf lie I vision of IVater Quallly, (;rotinitualer Seellutt, 16.16 alai' Set lire Center - Raleigh, NC
27699 1616l'Innic Ni'. [phone], trRhin 31) days, (iW-I REV. 07/2001

11'ELL CONS t'ItlJl 1 JUN 1lP t.JO l`I
TIN llt Cmulion - Urpar twill of Environment nod Dolma' Resources - Division of Wnlci 11un1iij (hound it! Section
f u-o crnuncnuuN �4�U
w ELL CON I RACIOlt tINllit'IIIUAL) NAME Ipilioll
rHONE r fiZGISarlf 47
STAICON] IIAL-tOIIl ioNEAN YNnn1E1�-t--E-L AssoiinIVNnvprEunuu �-- —
SIA Ir. Milt CONS I I'M l'EMIIU— it n I rl!cnblc
if n p die ublc
I. \VFI.L USE ((heck Applicable Pox): Itcsidculinl 1 hluuidpnl/I'ulilic U Indialiill I I Agticullural U
FivoilNiug U Itecuvciy LI Ilcal Pont \Viler Infection LI Oilier U If Oilier, List Use
TrilogynpllidLowl selling
2, N'falesl Inw ON: Ullidgc laffiI'c LIVnllry LW hi
_ ('t, a: . Berk n rl" Ln')
Ncmcslloccnt_�;-C�S�Qi�i;Ka- -- (rhea Iq,r�,p
�y _-brsass —' - - - I,nlhuddlou dude of well location Q
_��.I IQL.i r"' ,,iro, SnbJ'¢Jmr Il I Ito., 71p CiwIr) 0.3 •�6 ie of e r. o l
1Cbcel Hanle. IL ,u •, Co::::v" /(/ 35. _ J
Lw IJrprrrJnrLtnlr✓'-'^n,l,!
1. 11WFJN.I(: 531.__S Y-rt-S-9--R--- Lnlitu cn^neiluuc soutce:lll ll'Sf-I I npogrnphic r' in
�� �� p� (check AJJless 19-$s--�Qe0. e''_— — 111-IILLItJC LU_U
(Sheet nr orate re,l 1�LtL' 111
q02- - -- 1'wl❑ Td f`dtmalion tc 1,9_0
__BC_2s5n;.N 71p code
0
La
Cr.
" —) -
Alf! r rlr. Theme n nibet
..1. IIATIE URN I.pUlt2=93--
9 l l2IAL UEt ! ll--__Li1/2:_._--.--- - -
6. IN) ES \VI'.LI, IUPI'I.ACE AXISI IIJU WELL./ YES U NO 16Y
7. S IA1IC W'ATElt LEVEL Ilelow'Pt of Casing: =50----
Wit -r.' It Alinvr I nt, of CnJnp)
R. lOI' vl CAtl,IJ IS __A, —de -
I' I. Abner I.nud SinInce•
• Ire rl t.•hq Ire nd n.l,n .Ito, bete,. tool nn btr tupelo to .
. ulrntt L, ittrtJrme +cIllt ISA NUAC IC .DI Is. 1 '
V. 1'IPLU.
(Itii _S. ---- MEIUUDUI' IESl_LL-- —
to. VVA I Till ZONES (depth): — —
,s,, Amount _ ls ....
II. IIISINNNC1101J:.Fypc \Vnll IIuckucie
12. CASINO: ul'1. Material nuwhcls nod common fond uau,cs.
t, Prod, S -f?1 -f�`— I(
I"ion(_— ! d t lynirlrr (Jr WcipIV
FIii I1. ---
e __
From___ 'IQ_ FL _— -. -_. Melbud
lie uli M1t"I _ j }'°I 1 —
11.--_-- - Flnlciinl
IIuN_ _- __— I u - 12inwdct Slot Sire IA, SCp.rpN Droll in. In.
i-Inu,--- 1 --- ._. I I In
r:.
15. SAIIUIURA\'IL TACK: t.lnlrrinl
Ihpdi Stir
I i' It_ _ --
from_ —
f ton' To_ — II.--
276101
16. REMARKS:
I hO III RI Ill KKR:1111 `y F IIIIS WEI I, WAS COOS IIIICIPI/ III ACCORD/ 1CH W1I11 I5A IICAC 2C . WEL
COtI I-0.L!1 11OtJ SFA112/14)S, AND 111AI A COPY OF MIS RECORD IIAS BEEN VEUVIULU 1U 111E WELL OWNER
1 rot-, 11J„^ ^o the
161( 1r(iollt'f lk(19I9)
03
slurlAI ORE UI' I'ERSUN CUNS IIIUCIIOU IiIll WELL
UlrNon of \voter Qnnllly, Cr000drvnter Sectlo'', 1636 Mill Set vice Center - ItnleIg1', NC
JJ-ylll, ollhhl 311 days.
- -
LUCA HUH S1
-l 1S
Show (Medial' and distance In nil lei Not _
Stele floods of County !fonds. Include the Iona.

276099
111L1 1, CUNS'17tUC' lUN ItEl iii,
tJulllt Cnioliva - Derailment of Iinvlwnlitcut null Nntutal Itenotuce 11vwn of ler Quality - thou11FICAer Se rlio11
u� czlig
I In1 i1T- rlll)Nr. I lb�.� �naS
Si FLI, CONI RAC RAC'
lit( tIM r'IN NAME I..F.(/�(/P�` ��Ip
nl' G,L CON I RAC' O N COMrAN V NAMF. _L -� ^q,pCIAI PI) vv1)I'F.ItP111N ---
$IA IF, t3FL1•IlnnrN lie nl likable
INN I'F.II PI110 ----'
i(n I rlic I) P ��
I. Avoliil,tjug (Cbtec vet
Applicable ;lvn): Ilcsidclin' I�IAtuticilml/Public U Indusltlnl LI ngticullutnl L1
r.Imliloling U Ilcatccly LI Inca 1'ulnl, \Voter Injection f_I Other U If Other, Us( Use__
'fopn(nnlllnic/I,mnl e•rlliul:
��.. //'' n ui I_ of any UI'inl
2. N'rl.L LcnI I0 0 ION: Couul th/ 1 Ullidgn IU?'1 I
1 �l.�a1��
Nr oo_k tvu:� — well location
l Illudcllmtgiludc of
I thnnbrl•.C+'::""^Iro, SuL,Qvitvn,Inl lln, 7lp Ct.lr) 3s'__--
(cbrtn I IIrn4 (drpmeJnJrrllrJt--rnJQ
Q�p� ` � I.nitit: ar!'vlgiludc sotnncc:Cll Wink
'I fnrngtnl,bic n'. p
1. DAVtJFit T
INUI-1 Il-lU 11)tJ
Formation Pescii1itun
Addncss _g1i- k�uieto Dr.—
(Joni of n:.”Lt
SVilc
— }i9 - nlr C ale
1 ler•O slob
ell
Mr. ttvlr. Phone nnurhu
L. DA I F. DIM
5. IVIAI, PIT 111_ ;2,5t
---
c ours\vrI,1,RI+rl.nler•XIS luJU\vIll l:r vlisU Nu r
7, S IM IC WA I -Eli I.rVRL llrloty loll oft Caning.
I. I-
„1„ nd" RI
t�Ir..
I"1 Above l.nnJ .svilnce•
fl. 'I Ir DIt '' Mill lmi."- Int lnpdrn•
• Irp rl t••L�r Irrndn dril .I 15lin LNC . IJ rvr
II IFS NCAC 1C .n1111. n'•n
nlurtt In rttrn rn I-.
rn ll
v. Slrl.D11'I'lll):_.-i� __1\1h111UDU 11'.SIJ
p, WA I li - ` —' — Show tit cclloN not t ns n
l } 1 Amount 15 I Stale Runde or Cuunly hoods. IncludVle rb'i+t
II. UI`;INfpClll \volt Ilur4,lr bclsnudcvnuut
I1.
I)I Clll
Fluor to
IIKAI1UN-5vi i 71 rFi
Il 711tJ1 S (drrll0 I I' I ncc In oaten InnnUd i-
7N: I)Fc vo. ��
I ns common Ioad nnn1C9.
LUI9, 'Anlctini tluul
CnSINII: Dimndcr of \Vclp.
I Ir db�
D .I t I I. (Qz2—S- �F-.-24- -*�'
IlvuL--- a -- --- 1\ --
honl_ In_- I I __ _ . ____
pinlctlnl Method
ELUIoot U1._rut_ _I1 _ _
fII. l�n
VI oll__- _ In_ glut Sire pinla inn
Uimn_Icl
IA, SCnI!I N IJrplln — In.
In Il.___in
Ilom— I I ;n. In.
Ilom Iv__ ___
15. SAND/URAVI 1, I'ACK: pinlrrinl
Drrllt Sire
II_ _ —
Ilcln__I o----
It, __II._ — -
Flew
s 4icKe.
rise,
I f Itl M AltLS
wl
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276864
From 'To
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.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LARRY F. JONES CERTIFICATION (' 3295
WEI,I, CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC PHONE ( [phone]
STATE WELL CONSTRUCTION PERMIT(' ASSOCIATED W'Q PERMIT('
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL. LOCATION:
Nearest Town: HAYESVILLE County CLAY
SADDLE RIDGE
(Sheet Name. Numbers. Ctnnmunity, Subdivision. In No., Zip Code)
3. OWNER: DONALD NAVIT
Address P.O. BOX 888
(Street or Route No. )
HAYESVILLEJ_ NC 28904
City or Town Stale Zip Code
( 828 )- 389-9078
Area code- Phone number
4. DATE DRILLED 07-18-2003
5. TOTAL. DEPTH: 505'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO La
7. STATIC WATER LEVEL Below Top of Casing: SO' FT.
(IJsc'4" if Above Top of Casing)
S. TOP OF CASING 1S 1' FT. Above Land Surface`
*Top of casing terminated al/or below land surface requires a
Variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm):20 METHOD OF TEST AIR
I n. WATER ZONES (depth): 430'
Topographic/Land setting
®Ridge ❑Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(dcgrec minutcs/seconds)
Latitude longitude sourcc:OGPSOTopographic map
tcheck box)
DEPTH DRILLING LOG
From To Formation Description
0' TO 93' RED CLAY
93' TO 505' BLUE SLATE
0
Amount 100 PPM
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0' To 93 FL 6 118" SDR 21 PVC
From To Ft.
From To Ft.
I I. DISINFECTION: Type CHLORINE
I 3, (GROUT: Depth
Material Method
Prom Cr To 20' Ft. CEMENT GRAVITY
Ft.
16. REMARKS:
cn
LOCATION SKETCH -_
Show direction and distance in miles from at telst co
two State Roads or County Roads. Include the=road f?
numbers and common road names.
CD
I IX) Ill.RLRY (1 R HEY 11iPA3 THIS WELL WAS CONSTRUCTED IN ACCORDANCE. WI III I5A NCAC 2C, WELL
� 9t { H4( H{M+S.ANi)AIOS AND TI{,�T A COPY OFT1VLS RI ORI) HAS BEEN PROVIDED 10111E WELL OWNER
1-SIGNAIUR. FPERSON ('( MAT INGTIII.WFLL DA7T.
-- Sul ndt-the erigiina C* lie Dhh'ision of Water Quality, Groundwater Section, 1636 Malt SenIce Center- Raleigh, NC
2'7499 1636 Phone No. (919) 73:-3221, within 30 days. GW-1 REV. 07/2001

276377
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural`'/�Resources t..D v�iissioo�n�of Water�yQuality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) e tA��1 (�Cx� 'k'\,��� KII -V-'Gi L CERTIFICATION # a'/ 7
WELL CONTRACTOR COMPANY NAME v`I Pc��V \.UX W L�lIU ICI (JC PHONE # ffial_a2L-digr.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Q' Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N: /t
Nearest,Town: {r��u County LIA i
(Sa...c)
(Street Name, Numtlers, Community, Subdivision, •t No., Zip Code)
3. OWNER:
Addre s
tT
C
(S ut N•.)
acbcc
City or To
State Zip Code
Area code- Phone number
4. DATE DRILLED kJ [51
5. TOTAL DEPTH: Ida
6. DOES WELL REPLACE EXISTING WELL? YES iNO 0/1
7. STATIC WATER LEVEL Below Top of Casing: "6)(-) 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 ISA NCAC 2C .0118. ��
9. YIELD (gpm): 't METHOD OF TEST
10. WATER ZONES (depth): *J'l`1 l
11. DISINFECTION: Type \*T * Amount
12. CASING: Wall Thickness
Depth Dtt'faprneter o at a Weight/Ft. l
From O To �� Ft. lo7L CbQ2-i.(p
From To Ft.
From To Ft.
13. GROUT: Depth _ Material
From C) To tok
From To Ft.
14. Diameter Slot Size
Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
SCREEN: Depth
From To
16. REMARKS:
Material
opographic/Land setting
tzz
dge ❑Slope OValley ❑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 scription
as' (an
O
r
c_
LOCATION SKETCH
Show direction and distance in miles from arteast -
two State Roads or County Roads. Include theeroad.;: __-
numbers and common road names. -_
DO HEREBY CBRTWY
DNSTRUCTION STAND
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A COPY OF THIS 1>,BCORD HAS BEEN PROVIDED TO THE WE .L IdWNER
s etz ra&�
NATURE OF PERSON CONSTRUCTING THE WELL DA
7/23
Submit the original tq, the Divisic n of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27694-1636 Phone NOJ (910) /33-322d, within 30 days. GW-1 REV. 07/2001

276378
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section C3g
WELL CONTRACTOR (INDIVIDUAL) NAME �(prrint)�� '�mS.-1— VAS CERTIFIC606.3(0
A�TIION#
WELL CONTRACTOR COMPANY NAME W R`-t€S,l1" E ' S XL Q-10-- ( 6V PHONE # b 3 I �7/5
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential a Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATNN:
Nearefft_Tot�.
3. OWNER:
Address
County I
(Street Name, Numbers, CommuRity, Subdivision, Lot No., Zip Code)
Lt
et. 'at
• (Street or Routd, o.)
City or Town � State
(('�77 Olr)- i d ♦ c` c
Area code- Phone number ce
4. DATE DRILLED
5. TOTAL DEPTH: sa • t
6. DOES WELL REPLACE EXISTING WELL? YES )•],NO
7. STATIC WATER LEVEL Below Top of Casing: (pU it
(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 accords ce with ISA NCAC 2C .0118. n ` \
9. YIELD (gpm): ME HOD OF TEST IAJ.JI._
10. WATER ZONES (depth): �, , L\t
11. DISINFECTION: Type Tl
PC
12. CASING:
ccyy
aj!z�np!�,ter
From D DTo"t% Ft. (0 $14
From To Ft.
From To Ft.
13. GROUT: Depth M�t eCe
From b To `b� Ft C4 1
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
From To Ft
From To Ft.
3•S,Y.
Zip Code
Amount
Wall Thickness
or Weight/Ft. ,Matial
YV
Material
16. REMARKS:
Topoc/Land setting
❑Ridge Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To , Formation Description
d1
43'
1�4� IS"l
\1CS'
le6S aco'
n
CA) "
LOCATION SKETCH
Show direction and distance in miles from aQast =_ -_
two State Roads or County Roads. Include tliuoad:y
numbers and common road names. .-o
"' I,DO HEREBY CEAIit 2 -,I-yr" T THIS WELL WAS CONSTRULitD IN ACCORDANCE WITH 15A NCAC 2C, WE L
in
CONSTRUCTION ST S, AND TH T A CJ:21____”( CIF THIS RECORD HAS BEEN PROVIDED TO THE WEL 0'
i I , IGNA OF PERSON CONSTRUCTING THE WELL DA
L L Submit the original to thejfivision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
—_--_ .
".29699-fb36 FIi6o�,,(gpJ(919) p33-3221, within 30 days. GW-I REV07/2001

(
3. OWNER
Address
276379
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesp- Division of Water Quality - Groundwater Section
W
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ".U1.Y1t' S • ��S CERTIFICATION��yyAIu((,W3
E iD
WELL CONTRACTOR COMPANY NAMk� l V (...3 l�M�.i U.PHONE it(ZY3549
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential f Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATN:
Nearest Town:
(Street Nam � S.Q s,nunity, Subdivision, Lot No., ip Code)
t\
W
Costnt3
Il eet or ' . L o.)
��{ jCity or ow J ta%
MO' �� t�
Area code- Phone numbeh
4. DATE DRILLED I I a �3t
5. TOTAL DEPTH: S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO I9
7. STATIC WATER LEVEL Below Top of Casing: LC3 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 1SA NCAC 2C .0118. •
9. YIELD (gpm): N. METHOD OF TEST
10. WATER ZONES (depth): \ to
Zip Code
(if applicable)
opographic/Land setting
Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH pRILLING LOG
From To Form 'on Description
b 1
n' 5a'
St' as'
11. DISINFECTION: Type *MA
12. CASING:
From
From
From
13. GROUT:
From 0
From
14. SCREEN:
Depth
To5 I
To
To
Depth
To 59 Ft. Cfl t oa to L
Amount
Wall Thickness
o Wei t Material
A\J
To Ft. t
Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
Slot Size
in.
in.
Material
Size Material
t^
CO
LOCATION SKETCH °
Show direction and distance in miles from aweast
two State Roads or County Roads. Include theroacC,
numbers and common road names. ry
1 DO HEREBY CERTIFY T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I 5A NCAC 2C, WELL
CONSTRUCTIO'N_STAI Q DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEILL Oj
' SIGNATURE EIs!SON CONSTRUCTING THE WELL
theoriginal Submit inaltd the ivision of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. ( ) 73-3221, within 30 days. GW-I REV. 07/2001
' 919 7

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisionis�ofofWater Quality - Groundwater Sectic1.69
n 3q
WELL CONTRACTOR (INDIVIDUAL) NAME ((pprint) ��/�Y-Nt-5� C71�t "AL�"� `� 1, 1 CERTIFICAATIO-N7## I1 [�
P"v�V�l-IJC. U5E1 _�IU�W, PHONE #)eve)Ml—I(SJ
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) i (if applicable)
276376
1. WELL USE (Check Applicable Box): Residential M Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT "N:
Nearest1T.
County.
(Street N umbers, Community Subdivision, Lot
(`No.,,Zip Code
3. OWNERt1 I 1 C=1,L�^�'"---
Address S i S 7 c'j,;t;Nee Rc
Route
City or T State
(40?)- c - 3Sf 9
Area code- Phone number ����1 h3
4. DATE DRILLED 11111
5. TOTAL DEPTH: ?b 1
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: (en 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 I5A NCAC 2C .0118.
9. YIELD (gpm): 2"D METHOD�rr-9F TEST
10. WATER ZONES (depth): rQci;s
11. DISINFECTION: Type 1 R Amount
12. CASING: Wall Thickness
Depth Diameter ight/Ft. '
From �) To �� Ft. / 1 o Wea7.(P to
From To Ft. n
From To Ft.
13. GROUT: Dept, From D To . Ft.
From To Ft. /
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Zip Code
/
Q
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)
RILLIN OG
Format t? n D } cription
DEPTH
From To
ate' n,
16. REMARKS:
J
LCnhmit the. nriginial to
L.'{ ,406'Plioit0t.`to. (9
Material
C
t_
LOCATION SKETCH
Show direction and distance in miles from at least
two tate Roads or County Roads. Include theiiad
numb rsinnd common road names.
,,a
0
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
)ARDS, AND THAT A COPY OFnT is RECORD HAS BEEN PROVIDED TO THE WE 0'
?Z/S lf�, /"At /`/�` D
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
he Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
GW-1 REV. 07/2001
9) 733-3221, within 30 days.

275015
2. WELL LOCATION:
Nearest Town._ _7 e$v///'e County Cy/ '
,,4RE Ckicctye
,St cct Nine. Nnnthcrs. Community. SuVdivision, Lot No., Zip Code)
3 OWNER : -c)e keyNot^d'S
Address �?)L/ f-i h�,J b
(Shrcct or Route No.)
or Foss State' Zip Code
(71)' ). V37-- o 2.
A rea ode- Phone nom her
4. DATE DRILLED _ '//5Jo3.,
5. 'foTAI. DEPTH: ,3(O. •
6. DOES WELL REPLACE EXISTING WELL? YES El NC)
7. STA 'l IC WATER LEVEE Below Top of Casing: _3_0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS J_ FT. Above Land Surface"
'Tip ill casing terminated at/or below' land surface fequIres 4s
variance in accordance with ISA NCAC 2C:0118.
9. YIELD (gpm): I? METHOD OF TEST
10. WATER ZONES (depth): 1J-O' ' a70
Amount
12. CASING: Wall Thicl:ness
Ucpdr (.I Diameter or Weight/O. Material
From f/To 21 FL
Front To Et.
FromTo Et.
I). GROUT': Depth Material Method
From Ct To 2 j_ i t. k q-F Pourcc
Ilom To Ft. Grv.mni
I -I. St EM. Depth Diameter Slot Size Material
II. DISINFECTION: 13pe
From To Ft. in. in.
From To Ft. in. in.
15. SANI),'GRAVHI PACK:
Depth Size
Et one_.--_ In-----_— Ft.
Froiil TIb- ------ Ft.
Rlil\I:\I{KS:
Material
WELL CONSTRUCTION RECORI)
North t., :militia Department bf finv;ironmeht add Natural Resour es - Division of Water Quality - Groundwater Section
1
\\F I Lc'IrvTlt\CT012 (INDIVIDUAL) NAME:y(print)) is IT'4:' xi,-9K}t, rlj r CERTIFICATION Ii:A '-l-j c-
"F.t. LI:I slit:\(- IoncOMI'ANl' NAME i(B&IC'v+ (...)c i1I Co.. ' ['DONE N f33t0 `{L..il ..(9 1O
s I,\I E U I':Lt. ('ONSI RU('TIONI'ERMFr# ASSOCIATED WQ PERI\11TN
I ifi l4 ;Itt) (if applicable) I
lisr
MS
WELL USE (Check Applicable Box): Residential 12' Municipal/Public ❑ Indusliial 0 Agricultural D
Nlonitoring ❑ Recovery U Heat lump Water Injection ❑ Other CJ If Other. List Use
A'
foliographic/Land setting
❑Ridge' ❑Slope ❑Valley ❑Elul
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude souree_DGPSDTopographic map
(check box)
UEf -fli DRILLING LOG
Frnm To. Formation Description
- /,) 0I
blur G n;A
1 , , 030 s + c�,rlY
a l - 3(,a Soak 6rty Gre„ lk
10.) I cr 6,0Co7
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.
I DU IIERPl3Y CFRT IPY TI TAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I 5A NCAC 2C, WELL
('t INS TR(lcrION STANDARDS, AND THAT A COPY OF T111S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
15-193
'It -.
kJ SIGNATURE I �I Sl: `{3N49'li THE DATE
Subunit the original to the Division of Wate 1 ity, Groundwater Seclio ' Mail Service Center - Raleigh, NC
276))-I6.6' Phone No. I))733-3_21, within GW-I REV. 07/2001
GROUNDWATER SECTION
ASHFVIL LE REGIONAL OFFICE

276014
WELL CONSTUIC'I'1ON itEconI)
pb,l ll ..,„1 11 , - I iclui ii lit ur Environment and Naatnt l ltd:n)uiucs - Division of Valet Quality - (iloundtvaicr Scclion
IN'1V.\( toll IINu(l'IDIIAL) NAME (pilot) ! (�±L/i .CD' oW/\. _ rtitritl('KIION M_LO SG
\ III l i,NIII1( 1(litl iltll•,\NVNAME/4.Dk ^)Cl)I'VC., 1'ItONF, a LPG 1//p�—y'/y0
SI \II \LI I. r(051111( llti' l'k:1tP11IX ASS(kIA l Ell lf'I) I'1!ItMI IM
lit applic ahlcl _ , (il applicable)
I 1 ;1: I( Ertl, .\pplirable Box): Rcsidcnlial, Mlinicipal/Puldic CI huhu:hill U Aglicullutal U
Vlrn,ila inc U Rccot elv CJ Ilyd (lump Water Injcciilnl El Oilier Cl II I Ilhcr• I isi Ilse
BIAS
\\'1 I I I , u'A I It IN 1o1)ilgI gthic/I.mld setting
sl Ii„tm /NI Q$VJ//c.-- Cointly_CL/9 , ,
1�' /,, p � I:Il. Hue Iltilalc CI\:Illcy UPlal
Sia ILO _ ' &I- S. Irl A',II,�,I^inlc l:n�)
I'. rr, • I rlani�. Nm,i l,,,• I �d Iinnnily, Subdivision 10l N. Zip Coilci I :dil,Li, ;'luugilude of well loealinu
93'/i- 75 ?(S 7
/
(t',vliFf: /C.'7 e /i14K50h)
5y(a3 LeJLNeR A41Ve f 'ST
lc:n.110, envie No
Lc',,\,
I �,. Jl'�• Zip('nit
c't."— /od
1.60 -2GO
— ,3 8a '
3 QO ' .-..'t f.Q
I:\ll('\\AIIRIJ[\111. T: JOL) Pl'._-....{U2.--
•
(llvr "I"it At,,rve Top ofr'nstncl
e Inl' UI I\SIN(i IS PT, Above Land Sultan'
' n, r:ninp fer mbr„al flint ',Hog,.
Intel nul:,re regtdrel e - - -
,:ehetrr Lrfly, , d:nv a oh!, I,A NUA(.' H'.III Ia.
In\\\IIU2/ INNS (dcpnl):._ C�1''i`'.�.65_.-
IIIIAI. lijt I II .,C_12__
11I 11 s tc l!LI. LPd'I A('li IANI INC; WE.l.l'1 YES LI NO
n �� P } S 11 I DII•pm1 /O: ME orrrsr /�,.-- �..
_tria
„ u,lyd e'nnds)
alilivb meet e:l J(il SU1Lpographic neap
tilled Lott
1)I-I' I ll DI2ILLINU LJQ
In lint to ( fnnnal%on Ccscription
A"lJ, }liv r44,t{,
Sa k &'t ZrM:t&
�s, A (;rt
_mrt Nutt
I U('A.110N SKEtC11
I II'CIt1I f( I If IN I\1,c C/Ar>n,4,11%//Anunnd --- _ .-(wD5 Show ,lilt rlinn and dishulce in miles From al least
1 \':1 NI Will thickness
Iwo Si do Pius or (wooly Roads. Include the road.—
I ,rI,IL I)i:uncler or Weight/Id. M:nieiial nuulhrn' ii d common load names_ L O c
in q 1'I. 6,/2fff!/1 Gi _Pa(_,_ --
Tn li
lc, Ii
1)-till hlalenil . Nriliril /7 /1
lc, e2 P1. //La#(e•nut .---/4a"+lTav,,cC.
l„
I trl nL
,lull _ I n
Imo I1,
VIJII I;itAA''1 I 1':V K
non
1'1 NIAI'.I,'i
i) i:nncic, SI,I Size IJ:ACI iat
11 In in
Ii. in.
I krill Size M:deri:d
to
I„ It.
I III I III 1'I II', (III II A IIIAI IIIIS W11.1. WAS CONSTRDt Ill) lid A(YUIRD,AIlf lV WI III 15A Nt',A(' 2('. W'lil.l.
1-n1::I1tl4.1111N si,\Nl t1I(US. AND'IIIAI. A con' or lilts RI'( 0121)IIAS Intl l'P(i\'IDIII) IU-I IIIi WELL OWNER
SIGNATVRE (IF I'CItSUN IT.:(- NSA. VI, ii'10 hilt \'J I t 17 IT � iA l l:
LLb' S,° '[
}titer Section, 1(11G Mall S
.JI
Sulimit the al ipiuol to ti c Ilivhiun of \l'aler OII: lIIV, GI
ta9^ I b 14 pI I'll 711-1221, It (thin 111 days.
,i'7J'� -1- W(}
'cuter - Italrl)!h, N('
iW-I REV. 117/21101

STATE WELL CONSTRUCTION PERMIT/I
(if applicable) /
I. WELL USE (Check Applicable Box): Residential Ei Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topo igr c/Land setting
❑Ridge elope OValley ❑Flat
(check appropriate box)
Lattude/lon rude of well location
(Street i
s umbers, Commwiry, ivision, Lot No., Zip Code) Bi
(degrees/minutes/seconds)
Address
3. OWNER: D �l2 Latitude/longitude source:❑GPS❑Topographic map
_ (check box)
DEPTH DRILLING LOG
From To Forma t{on\Des jription
9J-_)l 1 bn t
Area code -
Phone number ' , { h nt ,rvl 1
4. DATE DRILLED �1 ,C 03 ` t'1
5. TOTAL DEPTH: -9 / l/ `� 1r19 t 9 r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: rlb FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS , FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118. Q1.3'l�
9. YIELD (gpm): \5 METI-�4D OF TEST
10. WATER ZONES (depth): k'Sm c3A3 t LOCATION SKETCH
Amount Show direction and distance in miles from at least t -
Wall Thickness two State Roads or County Roads. Include the tad t
fi-
ne • -
u
-a
WELL CONSTRUCTION RECORD 279,2)4
North Carolina - Department of Environment and Natural G Division Quality - Groundwater Section
CERTIFICATION it 71.
`J5
WELL CONTRACTOR COMPANY
NEME .(print) `t a ) 3 1 91
IWp+R`a`�.,"�( PHONE q[fj� 1` �
WELL CONTRACTOR COMPANY NAME
ASSOCIATED WQ PERMITF
(if applicable)
2. WELL LOCAT ON.
N st
11. DISINFECTION: Type T
12. CASING:
From rib DTePt R1 Ft.(p llttter
From To Ft.
From To Ft.
13. GROUT: Depth Mat 'al
From b To \rl1 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: ;
Size Material
Depth
From To Ft.
From To Ft.
og/fright/Ft. at nal numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCA 2C, WELL
CONSTRUCTION STANDARDS, AND THAT 4 COPY OF THIS RECORD HAS BEEN PROVIDED TO T ' E Q R
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
c
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Centerl R leigh, NC 20 ' '
27699-1636 Phone No. [phone], within 30 days.
n

279259
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natt(urral�Resourc - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (,p�rint), C l t S G G. "� CERTIFICATION #p 1
WELL CONTRACTOR COMPANY NAME Ws�C-CS\ ( - "`'"�"1'1'( rC PHONE #Sa) 5
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ili Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAN:
Near4 \9)
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: ,tea
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LE
7. STATIC WATER LEVEL Below Top of Casing: FT.
I (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 #
variance In accordan th ISA NCAC 2C .0118.
9. YIELD (gpm):i METHOD OF TEST-
10. WATER ZONES (depth): 1'14
11. DISINFECTION: Type �}
12. CASING: dt`
From_.Q_Tp `- c Ft. �D tgEer
From To Ft.
From To Ft.
13. GROUT: Depth
From d To� Ft.
From To Ft.
Slot Size
14. SCREEN: Depth Diameter
in.
in.
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK: r
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
&nWeight/Cot.,Material
16. REMARKS:
in.
in.
Material
opographic/Land setting
ra dge OSlope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To i
3bi SZe
`i I g'i
LOCATION SKETCH
Show direction and distance in miles from at least-)
two State Roads or County Roads. Include the ridgt;
numbers and common road names. -II
N
I DO HEREBY CERTIFY THATS
STRUCTED IN ACCORDANCE WITH 1 5A NCAC 2C,
CONSTRUCTION STANDARDS AND THAT IS WELL pCOPY NOF THIS RECORD HAS BEEN PROVIDED TO THE 6V
F027 �9�✓J`—
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2601'
C
C
C
r
c-
c
C
a

WELL CONSTRUCTION RECORD
2792 58
North Carolina - Department of Environment and Natural Resources - ivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (paint)
�(k CERTIFICATION #
WELL CONTRACTOR COMPANY NAME 1v„\�` VILE r—`.A)EU_1 U -k PHONE # )269-91Q-C
STATE WELL CONSTRUCTION PERMIT#
(if applicable) /
1. WELL USE (Check Applicable Box): Residential Ef Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
ASSOCIATED WQ PERMIT#
2. WELL LOCA N:
NearrT
�4City
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO H
7. STATIC WATER LEVEL Below Top of Casing: lop FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .011S. (let9. YIELD (gpm): S� METHQpD OF TEST
10. WATER ZONES (depth): �\3`l-t
11. DISINFECTION: Type 4't 1tt
12. CASING:
Depth Diameter
From O To bs Ft. (o `%'1
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To (oS 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: y
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
gr, ,W,e�ig.h.,t/Ft al
16. REMARKS:
(if applicable)
Topographic/Lanfetting
❑Ridge ❑Slope t Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH iL L
From To
0
S' 15
[S' (Ob'
65' dos
t n r esc ption
•,tea.
LOCATION SKETCIL
Show direction and distance in miles from at lea
two State Roads or County Roads. Include the riai
numbers and common road names. rn
-73
.J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE W�LL OWNER
��� `i�ll�n�
moo, -S C
SIGNATURE OF PERSON CONSTRUCTING THE WELL
C
C
r
V:
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC { ?' c>
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001„'

WELL CONSTRUC IO- RECORD "t � "`' CTION
� � Q l A•��lS��� CERTIFICATION p
North Carolina - Department of Environment and Natural Resources - Division of Water Quality uruL`d"'ater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) P \1 nQ PRONE N I�TI N N
WELL CONTRACTOR COMPANY NAME ASSOCIATED WQ PERMIT?!
WELL CONSTRUCTION PERMITS/ ifa licable
ife licable
I. WELL USE (Check Recovery
Applicable Box): Residential CYMunicipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topographic/Land setting
2. WELL LOCATION: 1l County CiaL ledge ❑Slope OValley ❑Flat
Nearest Town: �) ' ` appropriate box)
R Latitude/longitude(checkappropriate
of well location
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) . it �0 9r '/ , t well
location
ton
(degrees/minutes/seconds) p ra hie
3. OWNER: Q^T�"a Kp�.nr Latitude/longitude source:❑GPS❑To og p map
1 (Street
St wZl1 No.) __—_- (check box)
Address '"'� f G
ptuLL.. •�
(Streeter Route No.) ip Code Formation Dc.=^ption
State Zip �
rear
City or Town
Area code- Phone numb r1G. D
4. DATE DRILLED
5. TOTAL DEPTH: a46
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑'
7. STATIC WATER LEVEL Below tTop of se "+" CapVneg:op orFC
8. TOP OF CASING IS l FT. Above Land Surface"
*Top of caring terminated at/or below land surface requires a
variance in accordance with IS ETHOD OF TEST A tQ
9. YIELD (gpn)
10. WATER ZONES (depth):
Amount
11. DISINFECTION: Type Wall Thickness
Dep12. CASING: Diameter or Weight/Ft. Material
Frnm C Tojl Ft. s2 __ "
From To Ft
a
From To Ft.
13. GROUT: Depth
Material
From To R.
Diameter
14. SCREEN: Depth Ft. in.
From To
From
To Ft. in.
15. SAND/GRAVEL PACK: Size
Depth
From To Ft.
From To FL
16. REMARKS:
) DO HEREBY CERTIFY THAT THIS THAT AACOPY OF TUH S REED pa AC
CORD HOARDSEEN PROVIDED TO THC.
E WE
CONSTRUCTION STANDARDS,
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
SubmGWr1
27R 9,IG3G Phone Not the original t(919) 33 7221, within 30 days. Quality, Groundwater Sectlon,lG3G Mail Service Center -
fin
Method
— l
Slot Size 1.,ateri-
in.
in.
Material
From To
\rl� Vl�t
I O ATION -s5
Show direction and distance in miles
two State Roads or County Roads. In
numbers and ormnon road
i14�.C1
r
s
,Wr! least I'
lude t e
WELL
LL OWNER
0%-03
Raleigh, NC
REV. 07/2001

WELL CONSTRUCTION RECORD 279215
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Imo. ISCXl CERTIFICATION McV(i/pq
WELL CONTRACTOR COMPANY NAME `nil ,)PC t.7 P,Il Ac't11,ng PHONE'S fY2s') k37 --2 9-
STATE WELL CONSTRUCTION PERMIT'S ASSOCIATED WQ PERMIT,/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IY 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: 14` is to <v 1 \ i o County cloy
Dunk, 1nnc
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:c,,,,.i Cl P.Yl, se ,o\ C.r> r,
Address / 17 SS 1341 t ce 5f
4Slayet or Roue No.)
y/ c Zegf04(
C crTewn
State Zip Code
Area code- Phone number
4. DATE DRILLED 5S-1O - c)3
5. TOTAL DEPTH: Ic-IS'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Eli
7. STATIC WATER LEVEL Below Top of Casing: AOFT.
(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 ■
variance In accordance with ISA NCAC IC .0118.
9. YIELD (gpm): % METHOD OF TEST 0 t P
10. WATER ZONES (depth):
tr �1 0 cAlo 1—z Amount I S
11.
DISINFECTION: Type
12. CASING:
Depth
From f) To gin
From_
To
From
13. GROUT: Material
From (7 Ft. perky/ r i
From Ft.
14. SCREEN: Depth Diameter Slot Size
Wall Thickness
or Weight/Ft. Material
�n�71 p✓L
Ft.
Ft.
To Ft.
Depth
To 020'
To
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
Ft.
Ft.
Method
eSSure
Material
in. in.
in. in.
Size Material
Ft.
From To Ft.
16. REMARKS:
Diameter
/o,; 1S
Topographic/Land setting
❑Ridge IHSfpe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(\MC' 5'(a', W $3°So'
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From ToY 0 - IC
LOCATION SKETCH ii IJ
Show direction and distance in miles froin afileast
two State Roads or County Roads. Ingtde fe road
numbers and common road names. cp
1 c
c
mo
rnz
ma
.n-
O
—u
t c�
e
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
r /2 -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
}lalestA'

qq/oa o-)v
WELL CONSTRUCTION RECORD 279 418
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prtnt)irSdN('\R1i.t.' C tiip, A] CERTIFICATION #-7+Z I
WELL CONTRACTOR COMPANY NAME IMC Ccel( raec Rc3 �G' PHONE # ( )
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USl~r (check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultural CI
Monitoring Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT N:
Nearest Town: u ; I CP County C
353a g E
(Street Name, Numbers, Community, Subdivision, Lot No.,.iip Code)
3. OWNER: S 6) T) Coco ea 5-4-owe
Address 35.3 `oi I-(t ).t_s /c,t E
(Street or Route Nol
e5Xi; Ile Nit.,
City'or own State Zip Code
Area code- Phone number
4. DATE DRILLED 5`.ZS/-2
5. TOTAL DEPTH: Vt, c
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:
(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 ISA NCAC 2C .0I18.
9. YIELD (gpm): ' METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
From 0
From f)
From
13. GROUT:
From o
From
Depth Diameter
To as Ft &5i8
To Li I FL a "
To Ft
Depth Material
To 33 Ft. eot-
Amount
Wall Thickness
or WeighQFt. Material
(( ails•
�C_
To Ft
Method
14. SCREEN: Depth Diameter Slot Size t-' erai
From 1I To Lilo Ft P " in. , i) t () in. U C.-
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From 3 - To Li (o Ft. ',3 We I 1 Sow
From To Ft.
Topographic/Land setting
❑Ridge OSlope ❑Valley ' ❑Flat
(check appropriate box)
Latitude/longitode of well location
(degrees/minutes/seconds
Latitude/longitude source:❑GPS❑T� pographi map___
(check box ..
DEPTH D LIN
tan
From
T43 tr
K„
r
Formation Description
Cf lcA'c -e
SC), I
LOCATION SKETCH o
Show direction and distance in miles from eastc,
two State Roads or County Roads. Include ro
numbers and common road names.
Huy GN E
-o
16. REMARKS:
I DO HEREBY CERTIFY
CONS r UCTION ST
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C
S.
WEl l
THAT A COP OF THIS RECORD HAS BEEN PROVIDED TO THE JCVELL OWNER
OF PERS
ONSTRUCTING THE WELL
b3
Submit the original to the Divis on of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

280744
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION 2045
It EL. I. COMIRACTOR COMPANY NAME Redden Brothers Well Drilling, Inc PHONE F ( 828 369-9591
WELL CONTRACTOR (INDIVIDUAL) NAME (print) James B. Brown
STATE. WELL CONSTRUCTION PERMIT.
(if aunlicable)
ASSOCIATED WO PERMITa
(if acnlicable)
WELL USE (Check Applicable Box): Residential 0 MunicipaVPt.'blic 0 Industrial ❑ .Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 li-Other, List Use
3. WELL LOCATION:
Nearest Town Nantahala
Big Choga RD
County Clay
(Street None, N.nnbrsi Community. Svbdnia,v:, Lot No., Zip Code)
3 OWNER' Jerry Hedden
Address PO Box 837
(Street or Route No.)
Andrews, NC 28901
or 'I o'r, Sate
(828)- 321-4377
Area code- P'.vne nu -ter
DATE DRILLED 8-19-03
Zip Code
5, TOTAL DEPTH: 600'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below To: of Casino: 400 FT.
(Use if Above Top of Casing)
S. TOP OF CASING IS 2 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): 3 METHOD OF TEST blow
10. WATER ZONES (death): 275'
I I. DISINFECTION: Type H T H
12. CASING:
13
14
15
Depth
From 0 To 51 Ft
From To 5 Ft
From To Ft
GROUT: Depth Material
From C To 20 Ft.l'ern1te & Le tat
From To Ft.
Diameter
6"
6"
Amount 16 oz
1k'e;l Thickness
or P.'eicht'Ft. Material
pvc
.188 steel
SCREEN: Depth DL;meter
From To Ft. in.
From To Ft. in.
SAND.'GRAVEL PACK
:
Depth Size Material
From To Ft.
Method
Antes
Slot Size Material
In,
in,
From To Ft.
Latitude loncitu
DEPTH
From To
0 53'
53' 600'
Topographic/Land setting
ORidge ❑Slope ❑ValIey ❑Flat
(c'he_k appropriate box)
Latitude longitude of well location
:0GPS❑Toga tic map
oe.re;ktoy) �L.�.-._._
DRILLING LOG
Formation Des,n tion
clay & sane
gr nite
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include the road
numbers and comma on road names.
O
CO
16. REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC ZC, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/9—e_3
SIGNATURE OF Pt`RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07:2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat rah Resources/ - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)/// %e c C' CERTIFICATION p. y O)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
7X/7:'.. 1Jt1l nrt PHONE # MS) 937-z99)
ASSOCIATED WQ PERMIT#
(if applicable)
I. W FI I USE (Check Applicable Box): Residential 9 'Municipal/Public ❑ Industrial ❑
Agricultural ❑
r, ilea' Pump Wnter Injection 0 Other ❑ If Other, List t se
Monitoring n Recoveryu -
2. WELL LOCATION/
Nearest Town: 7(cy'Ef (1t
Fires Creek /CA
(Street Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER: ketlity .r 77,4
Address tR) Qnk\eY t.c ncSa '
(Street or Route No.)
C/AV
City or Town State Zip Code
( )-
Area code- Phone number// `/C _ G 3
4. DATE DRILLED
5. TOTAL DEPTH: /72,0 ' —
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO l-
7. STATIC WATER LEVEL Below Top of Casing: 726 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
•Top of casing terminated aVor below land surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3 & METHOD OF TEST A..,"
10. WATER ZONES (depth): //d%
l I. DISINFECTION: Type h7r57
12. CASING:
Depth
From To elWi
From To
From To
13. GROUT: Depth
From C To,.2C
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. _
From To Ft.
16. REMARKS:
Amount fYc//
Wall Thickness
Diameter or Weight/Ft. Material
Ft. 6.. As SO2R 1 /J42e-
Ft.
Ft.
Avlat rial ,Method
Ft. ,4or1l/// /afore
Topographic/Land setting
DRidge ❑Slope [Walley ❑Flat
(check appropriate box)
Latitude/longitude of well location
I4.35-0y'I`f" trJB 30SD'
(degrees/minutes/seconds)
Latitude/longitude source:LI GPS❑Topographic map
(check box)
pEPTII DRILLING LOG
From To Fnrmation Description
Slot Size Material
in.
in.
C —3°
cAy
c) - /2C 6'c'n. fc
Fri
LOCATION SKETCH o (or:
Show direction and distance in miles from atT ast
two State Roads or County Roads. Incte tlgroad
numbers and common road names.
I DO env CERTIFY THAT 7111S WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC
CONSTRUCTION
THAT I. COPY OF TIES RECORD HAS BEEN pTO T HE
t l�*)CTAbIrlAR17\. ANI/Tiiru aRvvivi:D
CONSTRhC Aq
ld=
�LGbD
GtiL
SIGNATURE OF PERSON CONSTRUCTING THE WELL D
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceen
27699-1636 Phone No. [phone], within 30 days.
County
281371
oG

WELL CONSTRUCTION RECORD 2 813'7 0
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
\�, g
WELL CONTRACTOR (INDIVIDUAL) NAME ((print)%,7YYIQ q5 e. (rk )' Sr) y1 CERTIFICATION N go
WELL CONTRACTOR COMPANY NAME (Y)'A\ C- 1.+9 01) A C r )1;in PHONE N fY2s-I Vc7--247
ASSOCIATED WQ PERMITS
(if applicable)
STATE WELL CONSTRUCTION PERMITS
(if applicable)
1. WELL USE (Check Applicable Box): Residential fir Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
K;l p4r c.ic \ 0:,
Nearest Town' s i;Jo County C 1 H
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER<. A r \cI
Address rL1fl \4RSD\Ck \'`Q-f\ I
(_cr.eor Route No.) ^fin
MCC) CC 'A VJ[
City or Tow Stale Zip Code
Area code- Phone number
4. DATE DRILLED 11 - h O3
5. TOTAL DEPTH: ;-ClOQ
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 174--
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
*Top deluging terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): ICE METHOD OF TESTA R
10. WATER ZONES (depth):
I1. DISINFECTION: Typeim po114s
12. CASING:
Depth Diameter
From C To 9)' FL Co "i
From
From
13. GROUT:
Front CJ
To Ft.
To Ft.
Depth M lerial
To 2,�' 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
Amount 21)
Wall Thickness
or Weight/Ft. Material
SD 1 .I?VC
Method
�f�C U' Y\C�. ()CPsSI 1(e
Topographic/Land setting
❑Ridge ❑'S1 pe ❑Valley OFlat
(check appropriate box)
Latitude/longitude of well location
µdo 1 '12" r LJ B',a `1`f' !o
(degrees/minutes/seconds)
Latitude/longitude source:IJGPSDTopographic map
(check box)
;.� p^RILLINQLOQ
From To Fnrmation D criptiion
C — 12 .lc I--
From To Ft.
Front To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO
o �-
(7 c
LOCATION SKETCH, a r"_
am:.
Sho direction and distance in miles frorjt least..
two `tate Roa s or County Roads. Includta2he r'Ead
numb rs and con on road name,.
ras
oh
t`va
LA
CI
J
2il, WELL
(A(IELL.QWNL-
c-s
1 /_ /7-O<
I-
} f
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service CGWrI
27699-1636 Phone No. [phone], within 30 days.
SIGNATURE OF PERSON CONSTRUCTING THE WELL

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalatResourcesf- Division of Water Quality - Groundwater
Scti nD 3
WELL CONTRACTOR (INDIVIDUAL) NAME (print) / i- fry /C e Cc tCERTIFICATION
WELL CONTRACTOR COMPANY NAME
281368
f211,1eK' We,11 Ori Il try PHONE a fgeMin" -299)
WQ PERMIT#
STATE WELL CONSTRUCTION ASSOCIATEDPERMIT"(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential (_i Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Usc
2. WELL LOCATION.
Nearest Town: %tesvel7E
k:cA
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. 70All Drwwe
Address '< Q i2DirCYI ('Yll tfT
(Street gL$oute No.) 5LC\ 5
City or Town State Zip Code
(
Area code- Phone number 4. DATE d DRILLED /� i 6-)
5. TOTAL DEPTH: /20
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO la'
7. STATIC WATER LEVEL Below Top of Casing: S-D FT.
(Use "'" if Above Top of Casing)
8. TOP OF C SI.NG IS _ / FT. Above Land Surfaces
Top of casing tel ud,,.:.. t'c- bet-- tend •nriace requires •
variance In accordance with ISA NCAC 2C .0116.�`-
9. YIELD (gpm): D METHOD OF TEST
10. WATER ZONES (depth): /e 0 '
County C/cy
II. DISINFECTION: Type
12. CASING:
Depth
From D To g •z
ffj/f
Front To
From To
13. GROUT: Depth
Frotn_12__ To /2-42 Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From-__ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: Depth Size Material
From To Ft.
From To Ft.
Diameter
Ft. 6-,2-3-
Ft.
Ft.
Amount 9c?
Wall Thickness
or Weight/Ft. Material
50R,1
atF9y)al
oier cr>c(
ethod
/r.e$SdiC
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
)3q°OP'Ott" c 083°'19 '31.9'
(degrees/minuteshecon Ls)
Latitude/longitude source:UGPSLjTopographic map
(check box)
w•uTli DRILLING LOG
From To Ern -motion Description
C/4
D 7S 6-rr•71t
75"-iLe
16. REMARKS:
c
0 0
0
rrl
n
LOCATION SKCa.+ y
Show direction and distance in miles frotsat Fast_
two State Roads or County Roads. Includt the'c p*d
numbers and common road names. ry
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
i
SIGNATURE OF PERSON CONSTRUCTING THE WELL, DATE
Submit the original to the Division or Water Quality, Groundwater Section, 1636 Mail Service Ceenterl Raleigh, C
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
281366
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Creme 5 , I C AS nil CERTIFICATION N au fJy
WELL CONTRACTOR COMPANY NAME Ill iIJO4" LC) QJ CA41\V,nc!) PHONE /I f 25) Lir _7°79Y
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) U f. li 11
1. WELL USE (Check Applicable Box): Residential EY-Municipal/Public 0 industriallU-`Agricultural 0
Monitoring 0 Recovery u Heat Pump Water Injection ❑ Other ❑ If Other, List tSe'
2. WELL LOCATION:
Nearest Town: 1-bolt rSVV' /P County 1/4/c
gnri, uYS -6sit
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. t'iornte V� S
Address (()'i- CYtp1-0J4a ) Ytve
(Street or Route No.) ���D'
(i�t IYOi1 pw`` CJ� L2
City or Tos,n Stale Zip Code
( )-
Area code- Phone number
4. DATE DRILLED IDO.3
5. TOTAL DEPTH: o2'S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO la-
7. STATIC WATER LEVEL Below Top of Casing: '75 ' FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS I FT. Above Land Surface'
*Top of casing terminated at/or below land nuface requires a
variance In accordance with ISA NCAC 2C .01IS.
9. YIELD (gpm): C METHOD OF TEST kQ: 2
10. WATER ZONES (depth):
I I. DISINFECTION: Type V t ia(Io Amount \t
12. CASING: Wall Thickness
or Weight/Ft. Material
3121 ft/c
Depth
t From Qi To a(e
From To
From To
13. GROUT: Depth
From Lr) To
Diameter
Ft.
Ft.
Ft.
Topograpititaa,rd ttmg
❑Ridge [ope I]V}Icy ❑Flat
(chck. app'taguataina.} -.
Latitude/longitude. of well Iccatinn
k36'1`31'', t,d83`YS' 2"
(degrees/minutes/seconds)
Latitude/longitude Source:OGPSDTopographic map
(check box)
4orii PRILLINQH,OG
From To F,nmtation Description
�) - /D ' 7761
IK% - / S %id's>"L s'io 1E
7 I�
M terial Method
Ft. SilDYl LeSC-crre-
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
Slot Size Material
in.
in.
17.7
0 0
0
Cri
n
-i
LOCATION SKETCH, pa E
Show direction and distance in miles froptskat
two State Roads or County Roads. Include th 'ctpi'd
nd bers and common road names.
tcsi
Cy'lc
Size Material k, %j ridU/
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
C( ALIPJ C-4---,-- /() - 3l — 03
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Ma:: Service Cenic: -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
G „r-: o FN. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
5�\�1AYl�—
WELL CONTRACTOR (INDIVIDUAL) NAME (print), CERTIFICATION 8���-- PRONE R Ik.]u)��7� 29SY
WELL CONTRACTOR COMPANY NAME Ni 11 Qs \� lr �� P
WQERMITN -
STATE WELL CONSTRUCTION PERMITS ASSOCIATED i(a lWQ
if a. licablc ble
281365
trial
1. WELL USE (Check Applicable B x): Residential Water Injection pa /Public If Odduestrial D e\l/r rt�ultural ❑
Monitoring ❑ Recovery ❑Heat
ep
TopographtdLar LUn
❑Ridge l3Sop ❑V nCy ❑FIaf c
(check aplirnp�''
Latitude/longitude of well location
f 2 5__< °t r2�a". t 830 8, �I if
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
npILLIt TC l_(j(j
Formation Dc7.ription
1
2. WELL LOCATION:
Nearest Town:L�3
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address �2
(Street or Route No
��Statee zip Code
Ct or Town
County
Walla
From To
— 5
Area cafe- Phone nuatbv.
4. DATE DRILLED
5. TOTAL DEPTH: ).555
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C>a-
7. STATIC WATER LEVEL Below
op of
sine ::Tnp o5Casing)
8. TOP OF CASING IS
FT. Above Land Surface•
�—
*Top of casing terminated atlor below land surface requires a
variance In accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 1CO METHOD OF TEST
10. WATER ZONES (depth):
(P 15
11. DISINFECTION: Typ Amount
'Thickness
12. CASING:
Depth Diameter or Weight/Ft.
Fronr_12_—To Is© Ft.
From To Ft.
Froth To
13. GROUT: —' Depth
Material
Fro' am^ --Tom_
From To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
Prom To
From To
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS _ UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TOM WELL OWNER
Ft
Diameter
Ft. in.
Ft. in.
Ft.
Ft.
Size
Slot Size
in.
in.
Material
Material
�Meethho�dd
.Y.-.'
Ce-
Material
jacA ION KE I
Show direction and distance in miles fret at 4aal t
two State Roads or County Roads. Inclwe th Ik ad
numbers and common road names. ry o
1e-^1`stli
r_
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - RaleighGWrI REV. h, NC
, N
27699.1636 Phone No. [phone], within 30 days. d r
DATE

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesp- DivisionTof Water Quality - Groundwater Sectiionnj 2 (�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L-� T t t ' \ S. .. (71� ���� CERTIFICATION ccc# 9 3 D
WELL CONTRACTOR COMPANY NAME E hU sE&U--'yt'--`-`-t_•L P' PHONE N f "4:t 3 fl/SC
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
/
1. WELL USE (Check Applicable Box): Residential l9" Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring D Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAYJiLLE V
Nearest 9 --(: ( Cganty
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER lbhS\"(
Address 4201 T 1trEE r`5
(Street ore o.)
ilk
City qr Town State Zip Code
6431
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES NO l�"
7. STATIC WATER LEVEL Below Top of Casing: 4-D 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 ISA NCAC 2C .0118.
9. YIELD (gpm): 15 METHOD1OF TEST
10. WATER ZONES (depth): \P"5
11. DISINFECTION: Type Amount
12. CASING: Diameter Wall Thickness
b To �� Ft. t,--vi er Qr We.gh (ot Mal
From �dT/.
From To Ft.
From To Ft.
13. GROUT: Depth Mat al
From d To �� Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
281277
Topographi setting
❑Ridge ❑Slope Valley OF
(check appropriate box)
Latitude/longitude of well locatioi
(degrees/minutes/seconds) i
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
To Forth t n Description
DEPTH
From
C6b 1
9-e1
1
C
O
rr,)
P
m Em
C) c_Rt
C.r n
LOCATION SKETCH m---
Show direction and distance in miles from aE%ast a c
two State Roads or County Roads. Include th1roadn
numbers and common road names. CO
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL
JN I/J Qarn'°
ATURE OF PERSON CONSTRUCTING THE WELL
lie 3
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

281176
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and` Natural Resources - Division
�o�f�Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
E((prr-i+nt) \A\\, LA ;r (��\ 5 . t��L t r L� CERTIFICATION #
WELL CONTRACTOR COMPANY NAME ) A 17V I, l.� \,C < l` aft.0 NIS PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 9' Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCH ION:
Nearest Town: `(C'JU 1 Cr County t'
\ ��h 1L��`tb1NT UWE-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:^Z'-v•�1 jai
l
Address Ibt
l l f$t eet orute No.)
i5sD1b1-'
City or Town State Zip Code
4. DATE DRILLED il\ Area code- Phone number
Z�3
5. TOTAL DEPTH: D /
6. DOES WELL REPLACE EXISTING WELL? YESNNO f3
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 laud surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): l b METHOD,OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type ItircIA Amount
12. CASING: Wall Thickness
Depth!lI t Diameter or Wei t/Ft. Material
From_Lb_ To `tP^Ft. L 1/
From To Ft.
From To Ft.
13. GROUT: Depth
From 0To "%(v 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.
Topo� c/Land setting
❑Ridge OSlope ❑Valley ❑Flat
(check appropriate box)
latitude/longitude of well location
(degrees/minutes/seconds)
r- -. --t 7
Latitude/longitude source:❑GPS❑Topograrhic map lL
(check box)
DRILLING LOG
Fonngijon Description
DEPTH
From To
\t,qIt% t
°72a
aS'
l
cn—
LOCATION SKETCH r"
Show direction and distance in miles from at rst -`2(
C
two State Roads or County Roads. Include the mad
numbers and common road names.
16. REMARKS: ❑ _
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL
. �J 'ems it /g76 a
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
OWNER
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

281275
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
`Natural
'Resources - Division�oof,,�Water Quality - Groundwater Section
v
WELL CONTRACTOR (INDIVIDUAL) NAME
E ((print) Imo') `�-'�' `rn . -,1` 1 �p�! CERTIFICATION # 5 3g
WELL CONTRACTOR COMPANY NAME WRtt k U-f U)UU `�_( a, `1"i PHONE # i) 31:1 9155
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT N:
Nearest Town: eSALLE
1-14 123�P
County
(Sate Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 1 ` `fa
Address ti)4 R�]3 £a) �I[� `t'p
�p� erect or Route No.) 69.T14
-
City or
Zip Code
69 Ol"
Area code- Phone number
4. DATE DRILLED 11
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cd�
7. STATIC WATER LEVEL Below Top of Casing: 90 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 accordan with ISA NCAC 2C .0118.�
9. YIELD (gpm): METHOD OF TEST kctl
10. WATER ZONES (depth): \ V 1 t
Topographic/Lan lsetting
❑Ridge ❑Slope EValley ❑Fla
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) _
Latitude/longitude source:❑GPS❑Topograp
(check box)
DEPTH DRILLIN
11. DISINFECTION: Type
12. CASING:
Depth_, Dlipmeter
C
From To ate" Ft. (o//4''
From To Ft.
From To Ft.
13. GROUT: Depth Ma Oa]
To RioFt.
From To Ft.
14. SCREEN: Depth
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To
0
icV
435
Or
)a -a'
Formati
cn
rn
^'m
O v>
LOCATION SKETCH CO
Amount Show direction and distance in miles from at'itrast z
Wall Thickness two State Roads or County Roads. Include the road
or�7ght/ Weight/Ft. a rial numbers and common road names.
Diameter Slot Size
in. in.
in. in.
Material
Size Material
From To Ft.
16. REMARKS:
sihRuLti
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LLPWNER
/6-3
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
i
L�

281273
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andnNatural�11 cResoure - DivisionDvp'of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMEEt,(prtnt)�%\( (2 G . ` , " 'NULL
1 CERTIFICATION # ��
WELL CONTRACTOR COMPANY NAME Wes( 11 �- wt P� PHONE #
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) —/ (if applicable)
1. WELL USE (Check Applicable Box): Residential Ck1 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery El Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCA
Nearest T
N:
County,
(Street Name, N unity, SuLM No., Zip
3. OWNER: `E
Address C) ('c4 in`12,
���\p\��t dr _Rout 0
q —`rael
City or
J-
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: 3i
6. DOES WELL REPLACE EXISTING WELL? YES 4_ NO i
7. STATIC WATER LEVEL Below Top of Casing: L}) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordansq with ISA NCAC TH 2C OF TEST
9. YIELD (gpm):
10. WATER ZONES (depth): \2-
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
b Depth is 1 pk nter Qr Wei t�t. to
From To Ft. 4 �.d- `P
From To Ft.
From To Ft.
13. GROUT: Depth Mat nal
From D To CO FL N t
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
rl
0O(
Zip Code
Depth
To
To
Material
Size Material
From Ft.
From Ft.
16. REMARKS:
Topographic/Lan»etting
ORidge OSlope alley ❑
(check appropriate box)
Latitude/longittide of well locati
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopogrLafth
(check box)
DEPTH D LIN OG
From
D
l at
To
l
(ol I
1431
m
LOCATION SKETCH o c
Show direction and distance in miles from ajjyast y
two State Roads or County Roads. Include the road
numbers and common road names. `-
rriCaltr
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARRDDg, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE
(7tWt
SIGNATURE OF PERSON CONSTRUCTING THE WELL
l
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
l FT

281272
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturalrn�,,R,Ceesourrc^ces - Division�of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME,^,((,prrinntt.)` 0`1 f- J ( - V"yC�-ILEY... CERTIFICATION #d7v7
WELL CONTRACTOR COMPANY NAME i3 kk 1 r C?SLU PHONE # 6.5 ) i
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0MunicipalPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT�IO�NN::,�,tt
Ne stTown: WR(Z4..S•--
County i
Lb3t (A c
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
W�� 1
3. ONER:di`
Address Pb wobk tct3
(Street or ute No.)
33%31
City or State
()- T 5', -\310
Area code- Phone number
4. DATE DRILLED V.
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 27
7. STATIC WATER LEVEL Below Top of Casing: L) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated atfor below land surface requires a
variance in accordant?with ISA NCAC 2C .0118. Wit-
9. YIELD (gpm): , METHQD OF TEST
10. WATER ZONES (depth): 14•%
t
Zip Code
11. DISINFECTION: Type tit't tt' Amount
12. CASING: pprt�pe Wall
_Thiichkness
From D To th 1 Ft. e NI �.DI[or �a7.(P Mal
From To Ft.
From To Ft.
13. GROUT: Depth Ma rial • Method
From To �1 Ft. t
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.
From To Ft.
Slot Size
in.
in.
Material
Topohic/Land setting !
❑Ridge SSlope ❑Valley ❑Flirt` ;
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic-I^ap
(check box)
DEPTH DRILL
From To Formatio III on
b 1?'Ll.• e..}s
)fit �l r :ram _I1t*i -
1
1 CO o
0
n
tJ
A Rj
y O
C1
tie r
LOCATION SKETCH v
Show direction and distance in miles from afidast 7-4
two State Roads or County Roads. Include the roare
numbers and common road names.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WI�L.L WNER
oetscOF PERSON SIGNATURE 0 PERSON CONSTRUCTING THE WELL
l�//s/a3
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�pp� �..Resource//��Division`of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME �(pprrinnt)UC`t Ki'-^�J a . `t , ' ^y1-'I�"�'T CERTIFICATIONyft6 q"' / r
WELL CONTRACTOR COMPANY NAME W r` t `SM W �E 121t-L-tIA
PHONE # IOw )�g� /��`�
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT# r
Jl .1
(if applicable) (if applicable) ,r-
1. WELL USE (Check Applicable Box): Residential I/ Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: n ,
Nearest Town: CountyT
•
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ve-a e-1)N
Address 1-14;T- fbai r rid 427
(Seet or Rout
W. Q t l 1r^ a' r sl FL e No.) &34t t
City or Town ' State Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: uzb /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E
7. STATIC WATER LEVEL Below Top of Casing: Sup 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 accords cc with I5A NCAC 2C .0I18. •
9. YIELD (gpm): METHOD OF TEST-
10. WATER ZONES (depth):U3r
11. DISINFECTION: Type
12. CASING:
Amount
Wall Thickness
Depth Diameter or Weight/Ft. Material
From (] To JzI Ft. fit. �QWito Q��
From To
From To
13. GROUT: Depth
From b To `Jzt Ft
From To Ft.
14. SCREEN: Depth Diameter Slot Sire Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
t MA
16. REMARKS:
/ Topographic/Land setting
dge ❑Slope OValley ❑Flajt
(check appropriate box)
:
Latitude/longitude of well location ; `,
(degrees/minutes/seconds) Ir�'.�
Latitude/longitude source:❑GPS❑Topogra)}hic mlaapp.C�--'1....)
(check box)
DEPTH DRILLING LOG
From Tg , Formatigp Description
d
Al,
late,
281271
O1t
n
a '"=
to-:.
Show direction and distance in miles from aast ='
two State Roads or County Roads. Include theroact
numbers and common road names.
LOCATION SKETCH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND/q/jLDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE EGL O'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
////7/D3
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
r

281269
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisio• n of Quality - Groundwater u Section#
WELL CONTRACTOR (INDIVIDUAL) N"�E((print) w�uAl n r�q
2788
WELL CONTRACTOR COMPANY NAM € Mil LF ���CII2iLL[ PHONE # tI/�i1 �b -9PCC
ASSOCIATED WQ PERMIT#
(if applicable)
i
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box)' Residential 13/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCA
Neare¢t ro
Topographi setting
❑Ridge ❑Slope Valley ❑Fla►
(check appropriate box)
Latitude/longitude of well location
3.OWNER:
_ :�, s► (degrees/minutes/seconds) 4 --
e.� `
Latitude/longitude source:❑GPS❑Topogra�ntc
Add-ss /� ._. (check box)
DEPTH DRY
From To
Formati
f ffOD) �•Q — 3 b la-` —
4. DATE DRILLED
i 1St n.ni
Area code- Phone numbe l 1 St 4ai
b 4a1 1 4-'3,
5. TOTAL DEPTH: \4
6. DOES WELL REPLACE EXISTING WELL? YES NO 21/
FT
7. STATIC WATER LEVEL Below Top of C(Use "+" if b Casing:
of9-0 e Top Casing)
8. TOP OF CASING IS L t FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
.
variance in accordsppce with ISA NCAC 2C .0118. , w
9. YIELD (gpm): J Q— METHOD OF TEST (M".-
10. WATER ZONES (depth): \31D
Zip Code
11. DISINFECTION: Type VklA-i Amount
12. CASING: Wall Thickness
Depth Timer o Wei t/Ft. 'Mali
From C) To 9::) Ft. lino `, 'yvi
From To Ft.
From To Ft.
13. GROUT: Depth Ma
From l] To SID 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.
LOCATION SKETCH
Show direction and distance in miles from
two State Roads or County Roads. Include
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TFIWS
as .4
ATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenterl RRHVgh, NC
27699-1636 Phone No. [phone], within 30 days.

281268
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)WkWlekr cc5 hm� CERTIFICATION II
WELL CONTRACTOR COMPANY NAME \ { E�\I1 r W � htU lU IA PHONE ISOy30}
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 1Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA •N:
Nearest T
Area code- Phon2-[(umber
4. DATE DRILLED
rj
5. TOTAL DEPTH: (pelt
6. DOES WELL REPLACE EXISTING WELL? YES [ , N
7. STATIC WATER LEVEL Below Top of Casing: rip FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
'Top of cuing terminated at/or below land surface requires a
variance in accordancejb 15A NCAC 2C .0118.
9. YIELD (gpm): 1METHOI? OF TEST el -lit
10. WATER ZONES (depth): rCR
03
11. DISINFECTION: Type
12. CASING:
From D
From
From
13. GROUT:
From
From
14. SCREEN: Depth
From To
Depth
TTos�s
To Ft.
To Ft.
Depth Mat
To 91.5Ft.
To Ft.
Diameter Slot Size
Ft.
Topographicetting
❑Ridge ❑Slope ( alley 0
(check appropriate box)
JJ]
Latitude/longitude of well locatioi)=.
-,,
(degrees/minutes/seconds) �7; r
Latitude/longitude source:❑GPS❑TopograI f
(check box)
DRILLING LOG
DEPTH
From To ,
D ID
ID` (51
1st DPI
1.23`
Formatiotj,Desccii 1 on
LOCATION SKETCH
n
r�
c-i
rn
Amount Show direction and distance in miles from a
Wall Thickness two State Roads or County Roads. Include the
Wei t/Ft. at rial numbers and common mad names.
Diameter
Ft. te4t`
Material
in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size Material
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C WEL
CONSTRUCTION STANDARDS, AND THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO TFLL WNER
�(GNATURE OF PERSON CONSTRUCTING THE WELL
43
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INntwDUAL) NAME (print) F'Rtg N Z P, 'i t CTo R CERTIFICATION 13 175
WELL CONTRACTOR COMPANY NAME t3Y&RS WELL 0RICLl['I (o PHONE I pm) 7K$-y(66
STATE WELL CONSTRUCTION FLAM M ASSQCIATF-4 WQ PERMITII
orT (if applicable (Iftunlicahlrl
1. WELL USE (Check Applicable Box): Residential (Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Iglection ❑ Other I7 If Other, List Use
2. WELL LOCATION:
Nearest Town; W 2R N E County CLay
8C'2rt4 Cove RD 22IQQ
(Sreet Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNEmHOG4 NLU-IERD
Address b64 6E?C-1-1 CoV6 RD.
lA )zRNE (Street or Route No.)
t C_
Lati
City or Tow] State Zip Code Fro
($2$)- 3 -3µ90 Fr
Area code. Phone number
4. DATE DRILLED_ /2 —4 -d 3
5. TOTAL DEPTH. (0 e . 79
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO GT PS
7. STATIC WATER LEVEL Be1owTop ofCasing; 137
(Use "+" I7Abovr Top at cuing) . j 4 8. TOP OF CASINO IS a FT Above Land Surface'
'Top of cuma tarmtnatsd attar below land audio requires a 185
variants In accordaac Ith 1SANCAC 2C MIL « polo
9. YIELD (gpm): • 5 METHOD OF TEST 94 I R -zAS
10. WATER ZONES (depth): ? 2S ? a 9/
2 29 04
11. DISINFECTION: Type 4714
12, CASING:
Depth
From-(' % To 2/5 Ft
From To Ft.
From To Ft
13. GROUT: Depth
Frorn _O To 20
Amount - /'7L /6c
Wall Thickness
Diameter or Weight/Ft. Material
fv5/8 .ISB srEe�
Material
Ft, CEMENT
From To Ft.
m
14. SCREEN; Depth Diaeer
From. To 'FL in.
From__ To
15. SAND/GRAVEL PACK:
Depth: Size Material
From To Ft.
Method
CR2v (TY
Slot Size F Material
in,
in.
From To Ft.
16. REMARKS:
281093
Topogr�aphic/Land setting
0Ridge DStope ❑Valley ❑Flat
(enact(appropriate box)
trtude/longittide of well location
N.Vco 39o(Awo83'sv-36,2-
• Ontr.a/nunuteshecondr)
tudefongitude solsce:OGPSOTopographicmao
DEPTH(thed(box)
DRILLING LOG
m To Formation Description
24 Ce p 12ED rlgtd
29 36 R6D Clay
79. 1 o.q Z2rt ctaq
PS 6R2.y-re.t c-L2,5'
13? -rant cc.av
645 lOser4e><reo G421° Reek<
i45 QR2y.c,ne of/PY/1rre. recce;
2/0 G Ree•4 Rock `.VPYRtrL
ZRSA CeRk6Rev-/3cack Rock
- 79 ( L/C-✓fTC-)POY /20c4-
- 30e Deg/?fc a 6C
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.
360 -.3rZ
362 -368
36,- yes
405 - 4/7
94gi-Sit
S/Z. -,SCo
Sea - QS"
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, 'StEL1
CONSTRUCTIONS ARDS, AND THA A FY OF THIS RECORD HAS BEEN PROVIDED TO TICEth4
SIGNATURE OP PERSON CONSTRUCllNO THE WELL DAT$_, I
i
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center = Ra14igh, NC
27699-1636 Phone No. (919) '733-3221, Within 30 days, OW-i
r„
07/2001

WELL CONSTRUCTION RECORD 2 8 2 3 9 6
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater
Section n
to
WELL CONTRACTOR (INDIVIDUAL) NAME (paint) `)0t^�1PS K� �t'Sf flr�ACERTIFICATION g37-2-1
WELL CONTRACTOR COMPANY NAME WI Co('tNt ..Da(I CAc rl l‘lr13 St--
PHONE
ASSOCIATED WQ PERMITN
STATE WELL CONSTRUCTION PERMITS (if applicable)
(if applicable) -
1. WELL USE (Check Applicable Box)' Residential 03---Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topographic/Land setting
DRidge 08+Vpe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNER: � `tfaC k t C
Address r3t-1 r"'1
rn ��• of (Street 1y�or, R City orTown e
( )-
2. WELT LOCATLON:
Nearest Town: 1 )Ufl.SS±Or ryA Co mtyc Art i
OCz TCsant^\ RA,
' tr ZipCode)
Name, Numbers, Community, Subdivision, Lot No.,
i�.114Ci
oivCYvYd.
to No.)
Zip Code
Area code- Phone number
4. DATE DRILLED \6 -fa — CY
5. TOTAL DEPTH: I fl S r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO W-
7. STATIC WATER LEVEL Below Top of Casing: Lb
(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 IS NCAC 2C .0118.
METHOD OF TEST l lL
9. YIELD (gpm): �Q--
10. WATER ZONES (depth):
rJ;5°2-'19`fW $3'S7v elf
Latitude/longitude source:❑GPS❑Topograp' i map
(check box)
r :NO t� tj
pEPTti pK]L,..
From To Forma ion Dcz_r ption
o
- /DS9c072 `e
(degrees/minutes;L<en'iil
11. DISINFECTION: Type 4rtPQSAek Amount IS
12. CASING: Wall Thickness
or Weight/Ft. Material
K(czt
Depth t Diameter
Front D To,____I Ft. la,a.<
From To Ft.
From To Ft.
tonal Method
13. GROUT: Depth Pil'S$U(@
From fD To �Ot 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
From To
From To
Ft.
Ft.
Size Material
CD
i OCATION S FK iCH = r2o`
Show direction and distance in miles Um a(O, east
two State Roads or County Roads. Inc�Ode tWrtbad
numbers and common road names. caa
/a
16. REMARKS:
1 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
/D—Da-5S
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-] REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andNaturalResources - Division of Water Quality - Groundwater Section
\
WELL CONTRACTOR (INDIVIDUAL) NAME (print) w (u-L�� l- a -MS CERTIFICATION�y# G'
WELL CONTRACTOR COMPANY NAME t \5L' Lr ����-�' ` t2)LUi PHONE # tom l- 1ISb
282329
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I3 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: W `ARSJ\ F County
tht3t5T\ . CtaE k. VMk S
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNE'
Address
D
(Sfr t .r RoutA`N`p
City or To . tliLLIV_ $a
Arca code- Phone number (e
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO /
l'J
7. STATIC WATER LEVEL Below Top of Casing: 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 I5A NCAC 2C .0118. 0-0_
9. YIELD (gpm): le M HOD OF TEST
10. WATER ZONES (depth): \kR I
Topographic/Lan etting
l
❑Ridge ❑Slope alley Gnat
(check cppropriate box) n �n
Latitude/longitude of well locatigD_
-r1
(degrees/minutes/seconds) m
(I) Latitude/longitudesource:❑GPS❑Top phicmDdr--:J
(check box) (�--
DRILLI o LOU
Formption Description
Zip Code
�b b
DEPT
From To
0 15'
�Sr c t
r ?9'
11. DISINFECTION: Type W Amount
12. CASING: Wall Thickness
Depth � ter orW,,ei,� t/Ft. Must al
From_ b
To `k0 Ft. r 1 4 m Dl�% -(a
From To Ft.
From To _ Ft.
13. GROUT: Depth, ur_� Mat
From 0 To "ti Ft. ( flj e
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Material
Depth
From To Ft.
Size
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least _
two State Roads or County Roads. Include theirrad
numbers and common road names.
c3 L- k-t t' LA
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WF,LL O'
'vr/J
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
IV
G)
N
0
Cs)
0
0
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0
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(Street
282328
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
11 Natural�Resources - Division of Water Quality - Groundwater Section 3�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) \-3\ •Tt�1' E) CERTIFIC�A.T9ION #U(]9�7
WELL CONTRACTOR COMPANY NAME‘410E V \l 3C, W'�—'IQi w' � PHONE # t0e0) 30-1 '1I SS
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ere-Municipal/Public 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATr ,
Ne rest To •
SS_ IlEira
_Ii
Name, umbers, Comm ity, Subdivision, Lot No., Zip Code)
WNER:A! • 4 7
s l �� melt+ �bbRl�q!
3. O
Addre
City
(`
II
Area code- Phone number
4. DATE DRILLED s
5. TOTAL DEPTH: is.- l N/
6. DOES WELL REPLACE EXISTING WELL? YES I O l3
7. STATIC WATER LEVEL Below Top of Casing: L{-U 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 I5A NCAC 2C .0118.
9. YIELD (gpm): `DU MET OOgv TEST -
10. WATER ZONES (depth):
r To
- •. — State es
L�J
Zip Code
11. DISINFECTION: Type k 1 \A Amount
12. CASING: Wall Thickness
Depth, Di etelr o Weight/Ft.
From 0 To '"tD Ft. (o74-I iP
From To Ft.
From To Ft.
13. GROUT: Depth Mat final
From O To 9 D Ft. L
From To Ft. I
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
C)
z_
Topographi setti
❑Ridge ❑Slope alley lat
(check appropriate box) cm _JD
Latitude/longitude of well loc$ *
o
(degrees/minutes/seconds) 7,12
Latitude/longitude source:❑GPS❑To gr.phir
(check box)
DRIL,.ING LO
Forma ion Description
DEPTH
From
b
To
74
q4' ^`t,st''
9b' 24
t_
N
LOCATION SKETCH =.
Show direction and distance in miles from arfbast
two State Roads or County Roads. Include t1road
numbers and common road names. W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL 0'
SIGNA
F PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
limn
n

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andNatural Resources - Division of Water Quality - Groundwater Section✓7,
WELL CONTRACTOR (INDIVIDUAL) NAME (((print)` w�. M S . �G���S CERTIFICATIONATI# `/g
WELL CONTRACTOR COMPANY NAME W4t, `- uS Cb� �'1 PHONE # FA, 3% c`��hss
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
282327
1. WELL USE (Check Applicable Box): Residential E3 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
estl
�t
County
(Street Name, Num.. rs, Community, Subdivisi Lot No.,
3. OWNERA\to- •
Address
City or `-
`l :�
Area code- Phone number 1
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q
7. STATIC WATER LEVEL Below Top of Casing: IDS 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 accordant with ISA NCAC 2C .011S.
9. YIELD (gpm): 1a METHOD OF TEST Ou--)%
•
10. WATER ZONES (depth): kt-I D I
11. DISINFECTION: Type WT1k Amount
12. CASING: Wall Thickness
Depth grpetcr Weight/Ft.
From b To_____,
4 .(e
From To Ft.
From To Ft.
13. GROUT: Depth Ma
From n To loci Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in
15. SAND/GRAVEL PACK:
Depth Size Material
To
Zip Code
,pographic/Land setting
Cdktdge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
*Latitude/longitude source:❑GPS❑Topographic
(check box)
DEPTH D LLIN 0
To
Slot Size
in.
in.
Material
From Ft.
D3
From To Ft.
16. REMARKS:
From
(0'
c.0
LOCATION SKETCH
Show direction and distance in miles from at feat
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0'
beervto
SIGNATU$'E P PERSON CONSTRUCTING THE WELL
'-o
0
CO
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

North Carolina - Department of Environment and Nafrral Resources - Division
/ V
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ,l y ee e
W ELL CONTRACTOR COMPANY NAME ^ ^
STATE WELL CONSTRUCTION PERMITH
(if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
%J%-ge: 'Nell Drv11\
2. WELLLOCATIOt Y
Nearest Town:
/ori a //i✓ County LA
/v;lhle
ASSOCIATED
(if app
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. TER. - g,ll Mat)xti Rey\\L(
Address PC) hi. rAC1
y (Street or Route No.)
I( 1 l nr\\AM (IC C-4\
City &Town State Zip Code
Area code- Phone numbs,/x,L 3' 63
4. DATE DRILLED
5. TOTAL DEPTH: 3 Yo '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO a"
7. STATIC WATER LEVEL Below Top of Casing: 200 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / v 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): 510 METHOD OF TEST Ay /'
10. WATER ZONES (depth): .?LC
Amount hicc,
11. DISINFECTION: Type be rfr
12. CASING:
Depth
Front c> To 25—
From To Ft.
From To Ft.
13. GROUT: Depth
From To ,2
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To
From To-
16. REMARKS:
Wall Thickness
Diameter or Weight/Ft. Material
FL 6-;25 - >o.,a r Cyc
��Material
Ft. Pc," 7L-4,/il
WELL CONSTRUCTION RECORD 284336
of Water Quality - Groundwater Section(/
CERTIFICATION #Vc 73
PHONE # {Pei 1 —
I23I Zyry 2
WQ PERMIT#
licable)
Topographic/Land setting
ORidge ❑Slope OValley ❑Fiat
(check appropriate box)
Latitude/longitude of well location
N OF 37 rr, f,) nSa r2M„
(degrees/minutes/seconds)
Latitude/longitude source:UGPS❑Topographic map
(check box)
pRILLINQI,OG
Fnrmatiou Dc,sc iption
Method
'zStce.-
From To
6 - (O
60 -19n
Slot Size Material
in.
in.
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles [[q�m aQeast
two State Roads or County Roads. InoiRde tfi,i road
numbers and common road names.
rn
O<
rn
�o
rn�
3[ P3m
uz
o mz
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE4L''
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W3LL OWNER
/,2— 0.3 - c)3
DATE
z
77
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service CGWrl - leigh, C01
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD 2 8 4 3 37
North Carolina - Department of Environment and Naajural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)�9 C/fr/r-'Ec6 e— CERTIFICATION /I e71114S
//i//eD K i*II Dr -II i; irk Pf1ONE/I On ell ''2Y,I)
WELL CONTRACTOR COMPANY NAME
STATE. WELL rnNSTRUCIION PERhtT,/ ASSOCIAYED WQ PERMIT,/
(If applicable:
r'r"^-•fl VI`
I. WELL USE (Check Applicable Box): Residential O'Municipal/Pubiic 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: //ri ,, /le
County (ley
(Street Name, Numbers, Community, Subdivision,
3. OwivER: /a`''S Coo<L
Address 12ic2 1407
(Street or Route No.)
City or Town State
Area code- code- Phone number
4. DATE DRILLED /(-2- D3
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -
7. STATIC WATER LEVEL Below Top of Casing: r 0 FT.
• (Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .011B.
9. YIELD (gpm): (.. METHOD OF TEST /, V
10. WATER ZONES (depth): CO
Lot No., Zip Code)
2DQd `
Zip Code
11. DISINFECTION: Type // 77/
12. CASING:
Depth
From '__ To4
EC
Amount '7/t
Wall Thickness
Diameter or Weight/Ft.
Ft. 6.2S' .i%.741I
From 6 L' To 6 (, Ft. 6 .,25 /5'D'
Front_ To Ft.
13. GROUT:, Depth ;Material
From_ To ✓e, Ft. /'-/"li.!/d
Material
S1/ee /
Me,drod
Topographic/Land setting
❑Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location ,
!1/34- exi' 9/..(/r wC6'.SOS/ ,22-5-
(degrees/minutes/seconds)
Latitude/longitude source:UGPS❑Topographic map
(check box)
pEnTH DRILLINQI,OQ
From To F,nnnation DcscriptiOn
/;d.c -.Z2o
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.
LOCATION SKETCH
Show direction and distance in miles faro aQeast
two State Roads or County Roads. mettle th road
numbers and common road names. x cm
o`
r— >0
>0
rn�
S
w
16. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE 1YIT11 15A NCAC 7C, WELV-, tvER
CONSTRUCTION STANDARDS, AND AT A C�C PY OF THIS RECORD HAS BEEN PROVIDED "1 O T.:_ 'iW 4
,zs-v�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenter' R leigh, NC
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD 284331
North Carolina - Department of Environment and Nat rat Resources - Division of Water Quality - Groundwater Section
�^/ee ec <% CERTIFICATIONS ;Ya 3
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /-l�
WELL CONTRACTOR COMPANY NAME 777- UeI I 06I (t1 �1ED
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
I. WELL USE �., •._.Chec
(k Applicable Box): Residential nunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring u Recuvciy ---Pump
lr_:t Water infection 0 Other u if Other, List Use
2. WELL LOCATION: /
Nearest Town: / �y�G`/le County C/ky
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. J /1l
Address 1Se6 F•0.L8J \ L) 0( '
(Street or Route No.)
IAO u f,\I \e NC.
ity or Town State
( )-
Area code- Phone number
4. DATE DRILLED /2-0 9-0J
5. TOTAL DEPTH: 0 0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO lP
7. STATIC WATER LEVEL Below Top of Casing: 25— ' 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 ISA NCAC 2C .0118.
9. YIELD (gpm): 2.f.- METHOD OF TEST i i i"
10. WATER ZONES (depth): /i0
2gaoU
Zip Code
Topoaraphic/Ltmat setting
❑Ridge OSlope Li+,il-ey ❑Plat
(check appropriate box)
Latitude/longitude of well location
Vas° Oo/6..1' c4.209S° SO 'ir•�. F�•
(degrees/minutes/seconds)
Latitude/longitude source:OGPSCtTopographic map
(check box)
/-)LIPTH DRILLING LOG,
From To Formation Description
6-S'--6,200 (,I' /2. fe
I I. DISINFECTION: Type
12. CASING:
t From
D
From
From,
13. GROUT:
From D
From
14. SCREEN:
From
Depth
To (a'
To
To
Depth
To2
it
To
Depth
To
/f rh`
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Diameter
Ft. CI. -215
Ft.
Ft.
Ft.
Amount '`f c✓/o
Wall Thickness
or Weight/Ft. Material
.Ma pal Method
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
P IION E S of ? -`z r5 7
c
Cr
r
r
L
a
LOCATION SKETCH } -zo
Show direction and distance in miles fr'lrt afljt
two State Roads or County Roads. Incsle tl pad
numbers and common road names. w y
C'
16. REMARKS:
'MAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONO
S
I OHEREBY Cr STr� .TANUniuiS, :.•.
P. COPY OF THIS RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
ni
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenter' R leigh, C
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD 284332
North Carolina - Department of Environment and Natural Resources�
ec
.1/t
WELL CONTRACTOR COMPANY NAME /- Division of Water Quality - Groun after S xtion s
WELL CONTRACTOR (INDIVIDUAL) NAME (print) // ?c° / /L c�G�
�%%/- 1nfe(t nti l`‘•PHONE N JAa1 Si
STATE WELL CONSTRUCTION PERMIT/0ASSOCIATED WQ PERMITN(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Er-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT1ON r�
Nearest Town: �, �"'' e
. 4e "c( C077771
(Street Name, Numbers, Community, Subdivision,
County C//
Lot No., Zip Code)
3. OWNER: 74w/es s,1 f/
Address hate x&eMT N
(Street to L:cc:c Ne t
1.-\pAervk\\e rc- itSCiOy
Zip Code
City or Town Stale
Area code- Phone number
4. DATE DRILLED /� cs-°✓'
5. TOTAL DEPTH: S 6 o '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 9'
7. STATIC WATER LEVEL Below Top of Casing: ia0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
"Top of casing terminated aVor below land surface requires a
variance In accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): .2- METHOD OF TEST
Topographic/Land setting
[Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location ,.
035`oo' 3,0- so/ '
(degrees/minutes/seconds)
Latitude/longitude source:❑GYS❑Topographic map
(check box)
j` %;'TH DRILLING 1,0G
From To F•nrmatiotr Description
Ef'
E k'- 5-6 D
10. WATER ZONES (depth): -'' e'c
Amount KV 6,-,
Wall Thickness
or Weight/Ft. Material
S4rd r Pei‘
11. DISINFECTION: Type grV
12. CASING:
Depth Diameter
d From O Tom Ft. (.25-
From To Ft.
Frotrt— To Ft.
13. GROUT: Depth ,Material Method
To ^A Iv.-e.-
From �' Ft. p'v.-f��✓r� / r
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.
Sy
-gn, f z
Cr
o
r
L
c••,
a r—c)
*ri
LOCATION SKETCH a -rr,�
Fl,
Show direction and distance in miles fen atclt
two State Roads or County Roads. Inc u le tiryo Thad
numbers and common road names.
16. REMARKS:
1 DO HEREBY CERTIFY TIIAT 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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenter' R leigh, NC N001
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat}iral Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME (print) e/ly leee CL CERTIFICATION o .3
PHONE # tb '1"2—:if5'I
WELL CONTRACTOR COMPANY NAME
WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential Q Municipal/Public 0 Industrial 0 Agricultural 0
284328
2'i'//er< tVlelcc)
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: g/ Vas `-'• lie
.Sh"o%tc, / 's
(Street Name, Numbers, Community, Subdivision,
3. OWNER: "'cern es te, t<b
Address 1% Lnyjv\euq 1Y
(Street or Route No.)
tic Cy
Zip Code
City or Town State
Area code- Phone number
4. DATE DRILLED /� '
5. TOTAL DEPTH: "b20
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q-
County G A/
Lot No., Zip Code)
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
4..13> ° 00' 50' 464"
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEP DRILLING LOG
From To Formation Description
c) - /2 o S4,71,- tic e-
/zo—/in 6;u«.74-e-
7. STATIC WATER LEVEL Below Top of Casing: S' O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. /i .�
9. YIELD (gpm): /G0 METHOD OF TEST
10. WATER ZONES (depth): / �s
11. DISINFECTION: Type /7 r/f
12. CASING:
Depth Diameter
From L ' To 7.2 !' FL
From To Ft.
From To
Fr.
13. GROUT: Depth ,Material
From—-L... To 2 0 Ft./2',
Amount (-4,c
Wall Thickness
or Weight/Ft. Material
seine "At
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
ty/Cuiod
yestvrc-
Slot Size Material
in.
in.
From To Ft.
From To Ft.
C,
r
t_
a_
v�u
-c
c
LOCATION SKETCH
Show direction and distance in miles t�m agoast
two State Roads or County Roads. Inetede dee road
numbers and common road names. 2
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCI ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ 1 -/c "03
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center RREVgh, C
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD 2 8 4 3 2 9
North Carolina - Department of Environment and NaSttral Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /'/I lee
� CERTIFICATION # re516 -1
WELL CONTRACTOR COMPANY NAME 07'/�e'r hie _11 Dr ‘l\PHONE # (P-?1) 2-12-n F>
STATE WELL CONSTRUCTION PERMIT" ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential D- TMunicipal/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:
1/ es ti,//c-
S,7c,clit re
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 7 fries Stec/
Address 66 Lo-PV1evo Dr
(Street or Route No.)
t� T11 V1\lam loc
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED /4,2
5. TOTAL DEPTH:;ZOO '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0-
7. STATIC WATER LEVEL Below Top of Casing: 9 & 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
varianceIELDg accordance with IS NCAC 2C .0118.
METHOD OF TEST
9. YIELD (gpm): /7% /
10. WATER ZONES (depth): /ff
County c l`r
(2-:ePtoy
Zip Code
11. DiSirvFEC T ION: Type /71%/5'
12. CASING:
Depth
From L% To 5,1
.1
From To
From To Ft.
13. GROUT: Depth
From C To -.eel
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.
From To Ft.
Ft.
Ft.
Diameter
Amount /fc
Wall Thickness
or Weight -Pt. Material
Material
/ Ft. oC-'1944,-.71
Method
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
N�s'oo'/to" &yewCfl'3Y 3"
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D — y; <
Slot Size Material
in.
in.
c
.c—
c_
c"
o7:-
>r
LOCATION SKETCH ZC am
Show direction and distance in miles ftt atMjt
two Siaie Roads or County Roads. Include tl road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
% l7-lj-di'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-I636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 2 8 4 3 0
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section J3
/f c' e t CERTIFICATION #
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ✓ � r/ ,��� 7 -Z 5 5
WELL CONTRACTOR COMPANY NAME - // �' hJ e I I Ur', 1 I i t 1 PHONE it(b-W)
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential EV Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
Topographic/Land setting
❑Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
/135-' p0 ",?o.s"woe.? SD "9C. 9.,
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
2. WELL LOCATION: ��
Nearest Town: Nate) /% County C
57101Gr // Id con?'
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: fu ncJ Si». IA -
Address -6-6 1-t\`Z-e-J Q\x) 'a(
(Street or Route No.)
City or Town State
(�-3-
Zip Code
Area code- Phone number
4. DATE DRILLED /.l 0
5. TOTAL DEPTH: S 70
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1--
7. STATIC WATER LEVEL Below Top of Casing: 6 '' FT•
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Ter of casing terminated at/or below land surface requires a
variance:...in accordance with :NCAC in lit
-
2
9. YIELD (gpm): ( METHOD OF TEST
10. WATER ZONES (depth): Y'
11. DISINFECTION: Type ////71 Amount iycP,✓
12. CASING: Wall Thickness
Depth
Diameter or Weight/Ft. Material
_
From () To /JY Ft. K.�J .5,42 XLIC
From To Ft.
From_ To
13. GROUT: Depth e
From %� To ) Ft. q
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
Ma gal / �blethod
ir, / i of U;�
o /,2s
/1J - S7e)
Ft.
From Ft.
From To Ft.
(- /7
C
Cr
r
L
s
Trn
LOCP.TTON SKETCH •c- �'m
Show direction and distance in Iu1iC frgtn a iist
two State Roads or County Roads. Inc-irtde tRer`Tad
numbers and common road names. 9 P
co -,
— C
16. 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
/2 /2-Of
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Ceenterl REVgh, C01
27699-1636 Phone No. [phone], within 30 days.

wiI.r. CONSTRUCTION RECORD
284327
From
From
Front
13. GROUT:
From Q
From
14. srPF.EN: Depth
Front._ To
From To
15. SAND/GRAVEL PACK:
Depth
To
To
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)NAME (prini)- ,�t✓I/\[' S V', :A-J i .A-N CCRTIFICATION # f%O q
I WELL CONTRACTOR COMPANY NAME Lr1I1\<-\1- lADP (` C1(--i ki "i PHONE N hss) 857-2997—_ --__-_
ASSOCIATED WQ PERMIT# -
STATE WELL CONSTRUCTION PERMIT# - 1
(if applicable) r--ice--
(if applicable) —� 7
1. WELL USE (Check Applicable Box): Residential i i 1unicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery D Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: \ \ ? County. \Ctl(
-12-:e-CAS CnVf (eel< (anent
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. /c\- p-L t - ((arie
Address '9tI -nuih bf °DCS - (.C\
(Street or Route No.)
�251t11e l�C
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED 1D-11-03
5. TOTAL DEPTH: QCM.'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO D--
7. STATIC WATER LEVEL Below Top of Casing: 1-ic-' 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 ISA NCAC 2C .0118. q
9. YIELD (gpm): :20 METHOD OF TEST 1, : (e
10. WATER ZONES (depth):
2`6ctCY-1-
Zip Code
11. DISINFECTION: Type V)Wh iCAI 4--T(
12. CASING:
Diameter
Ft. ( <-'
Ft.
Ft.
C)
Depth
To
To
To
Depth Material Method
Method
To .20' Ft. �Jt.)CHrIrid �1rMCSnre
To Ft.
Diameter Slot Size Material
P L .... In
Ft. in. in.
Amount 15-.5-
Wall Thickness
or Weight/Ft. Material
«K. i C �(
Topographic/Land setting
DRidge R3Stripe ❑Valley plat
(check appropriate box)
Latitude/longitude of well location
/1/4I &S1"3'11,", w 8ii°37 26
-11
(degrees/minutes/seconds) i
Latitude/longitude source:LJGPS❑Topographis-map----
(check box)
pE; Tfl PRILLINQ i 00
From To Fntmatio" Description
q /(0
.2C1 S` YC?Yl l
Size Material
From Ft. o,11
From Ft.
0
C
- C
2 c_ c?
CG
Do
pa Pier
"le �o
LOCATION SKET;QF o ma
Show directio and distance in miles Rest at4”ast
two State Rods or County toads. Inclade th-Thad
numbers an common road ames.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r/O)--Ai7- ll vX
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-J221, within 30 days.
GW-1 REV. 07/2001

City or Town State
( 828 ). 361-0873
Area code- Phone number
4. DATE DRILLED 12-23-2003
5. TOTAL DEPTH: 305'
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LARRY F. JONES CERTIFICATION # 3295
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC
283803
PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 113l 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: BRASSTOWN
PINE LOG COMMUNITY
County CLAY
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: PAM BOLAND
Address WELLS RD
(Street or Route No.)
MRASSTOWN, NC 28902
Zip Code
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO RI
7. STATIC WATER LEVEL Below Top of Casing: 10 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 aurface require' •
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST AIR
10. WATER ZONES (depth): 260'
I I. DISINFECTION: Type CHLORINE
12. CASING:
Depth Diameter
From 0 To 130 Ft. 61/8"
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT GRAVITY
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount 100 PPM
Wall Thickness
or Weight/Ft. Material
SDR21 PVC
16. REMARKS:
Topographic/Land setting
❑Ridge ®Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3500.793N/8357.446W
(degrees/minutes/seconds)
Latitude/longitude source:KIGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
Front To Formation Description
0' TO 50' SAND
50' TO 80' GRAVEL & RED CLAY
80' TO 110' RED CLAY
110' TO 130' GRANITE
130' TO 305' GRANITE
C
0
C..=a
v Qm
LOCATION SKETCH Z =rn
Show direction and distance in miles from atst o<
two State Roads or County Roads. Include the road `sv
numbers and common road names. _ �o
O�z
/In
c)
\ 1
0
I DO IIFREBY CERTIFY 11IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND �T}�AT A COPY OF THIS 'CORD HAS BEEN PROVIDED TO Ti IE WELL OWNE
/'2 -2.3
Cr
SIGNATURfSTRUCTING THE WELL DATE I'.,a
ii
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Sen lee Center - Raleigh, Nc_'; c:
27699-1636 Phone No. [phone], within 30 days. G W- I REV. 07/200 C

WELL CONSTRUCTION RECORD 2 9 2 7 0 3
North Carolina - Department of Environment and
\Natural Resources
s-- Division of Water Quality - Groundwater Section �7
WELL CONTRACTOR (INDIVIDUAL) NAME
�,(�print) t S"U4 n t4 J . (tE'4S CERTIFICATION # i v21
WELL CONTRACTOR COMPANY NAME 5]ir 16\ u-E �t� �-� � PHONE # t e� )JD ,- `ISC
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I/Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Nest�To
(StreetName
3. OWNER:
Address
ION:
0 NULL
Community, Subdivision, Lot No., Zip Code)
(Street or ou No.)
County
Cll`1�
City Town State Zip Code
9-c 1.:
Area code- Phone number 1
4. DATE DRILLED
5. TOTAL DEPTH: 16.4 /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accords ce with ISA NCAC 2C .01I8.n
9. YIELD (gpm): METHOD OF TEST it.-
10. WATER ZONES (depth): \ \ \ SS
11. DISINFECTION: Type Cc i
12. CASING:
03
Topographic/I.agd'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
Forma 'on Description
DEPTH
From ToS b '
c,
low'
9i I b l
OC
r-,
no
-,o
VOCATION SKETCH O Nt
Amount Show direction and distance in miles from f eas `tn
Wall Thickness two State Roads or County Roads. Inclu a roag
Depth, �; :'( er of Wkggbt/Ft. to numbers and common road names. ,• z
(] From OS Ft .1: • ` 1S Up.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To loc. Ft.CGX-uka
From To Ft.
14. SCREEN: Depth Diameter Slot Size
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 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
CONSTRUCTIO STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE 0
`5��i Milr o 4 - I a�$03
SIGNATURE OF PERSON CONSThY,ll(%INGTHE WELL 1 ;DA">)E
Submit the original to the Division of Water Quality, Ground4lir Section, Mail Service (tepid, -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. i,'', ',Cad� REV. 07/2001
GA
ater
T
o_c,in .. 1ff. 'r'�:E

Area code- Phones umber
4. DATE DRILLED
5. TOTAL DEPTH: We
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I3"
7. STATIC WATER LEVEL Below Top of Casing: 2SD FT.
I (Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordce with ISA NCAC 2C .01IS.
9. YIELD (gpm): ME1 I p OF TEST
10. WATER ZONES (depth): l}
11. DISINFECTION: Type
12. CASING:
Dep Diame er
From b To c& Ft. i Wil
From To Ft.
From To Ft.
13. GROUT: Depth Ma eiial I 1
From d To at Ft. c
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Ate,
Topographic/Lan etting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude solute:❑GPS❑Topographic map
(check box)
IL IN OG
Formati. Lkscrtb on
pEPTH
From To
Qt
�I' l t3'
0
aJ C3
r
i ▪ 0rn
rCI ptl
W �rn
r,
Cn m
v
LOCATION SKETCH a mh..
Amount Show direction and distance in miles from ZeasF'
Wall Thickness two State Roads or County Roads. Include roacdta
orWeight/Ft. ate•,•gqt���,,1 numbers and common road names. I3 —4 so6U _ v o
z
i292.a 04
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
l Resources( ,- DivisionD,�of Water Quality - Groundwater Section
J
WELL CONTRACTOR (INDIVIDUAL) NAME\pp�((pp..r/int) ,,2- S G.� e..111-0? CERTIFICATIONyTIo#r�Frpp✓!
WELL CONTRACTOR COMPANY NAME 7`t t� l v1 � USELL: tMU U-1 l�l PHONE # yv[c )3W-1/
STATE WELL CONSTRUCTION PERMIT# _ _ .ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) r ,:
I. WELL USE (Check Applicable Box): Residential L9 MunicipalPublic ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCA
est To
County
(StreetN
3. OWNE
Address
Numbers
ry,
Su
vision,
V` �1 v•
1•r Rout N..)
�' L-
t No., Zip Code)
WaKki
1
Zip Code
03
16. REMARKS: Tc"
L G-T-I .-WEL-E..-..-.
tto n -;'
SIGNATURE OF PERSON CONS U i
Submit the original to the Division of Water Quality, Grounil ate• Section, 1636 Mail ServicFl IC-ejIt
27699-1636 Phone No. [phone], within 30 days. { J �4 "' " !�u
i
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAN43°S, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO Ty�WEL}�OWNER
�/ih' kt�l1
��KCity or To
r - Raleigh, NC
-1 REV. 07/2001
E's! P. 6E'iION!
i Sr Edl._ K I" lir`.}

WELL CONSTRUCTION RECORD
293111
North Carolina - Department of Environment and ^Natural Resources - Division of Water Quality - Groundwater Section /+�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) MI eft 1,v 11. (.l�i SCd'1 CERTIFICATIONS/ tX2)0
WELL CONTRACTORCOMPANY NAME liVA P C 1A QM (AC,'\. rl9 PHONE 0 fcs.2g1 S3Y-,2it7
STATE WELL CONSTRUCTION PERMIT" ASSOCIATED WQ PERMIT"
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:[�Alecv e_
�45ti ' Sr tn¥
County G0.‘'
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER.norcis)n4 a,G
Address 1o(JW a,C ><
(, X1 y it✓+�
(Street a Route No.)'
VACACiPla 6W, 3co5
City or Town State Zip Code
(.—)-
Area code- Phone number
4. DATE DRILLED/.?-,��-
5. TOTAL DEPTH: 9/D'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [cam
7. STATIC WATER LEVEL Below Top of Casing: /&Q FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS )' FT. Above Land Surfaces
'Top of casing terminated at/or below land surface requires ■
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 7 METHOD OF TEST Ai
10. WATER ZONES (depth):
11. DISINFECTION: Type144k Neils{
12. CASING:
Depth Diameter
Front D To IIC" Ft.. C
From To Ft.
From To Ft.
13. GROUT: Depth
From,_ To „%r0 '
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Amount
Wall Thickness
or Weight/Ft. DMaterial
S21 1 UC
n��a)�crial Method
a prft1�<rT, resscano_
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Size Material
Topographic/Land setting
❑Ridge ®Sipe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:UGPS❑Topographic map
(check box)
j PTt1 DRILLING I,OQ
From To Fnrmatiou Description
- /Ln
�R - /(OS-'
1/9.S ' 9/0 '
LOCATION SKETCR c,
Show direction and distance in miles from ateast
two State Roads or County Roads. Ince tali mad
numbers and common road names. am r,
'=
—c
Ca rrl Ds'
Cr)
IT'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, IbEtt,
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I jrr, I
•
d t'L
)2-2 X -0?
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 293110
North Carolina - Department of Environment and Natural Resources.- Division of Water Quality - Groundwater Section �r
WELL CONTRACT Ws�ese rnrtnn 4/)eft/ t", r5oAV CERfiFICATION N
(iiw:�:H:1:: ).: _--
WELL CONTRACTOR COMPANY NAME /miller I-i ¢) I PHONE N f )63-1-9-Ot4CI
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMIAN
(if applicable) (if applicable) _tranamia
I. WELL USE (Check Applicable Box): Residential f"Municipal/Public ❑ Industrial ❑ Agricultura ❑
Monitoring ❑ Recovery Cl Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: NP)/th✓t l /t- County c
Ins eb4r IA ) ,A.y
(Street Name, /Numbers, Commurfty, Subdivision, Lot No., Zip Code)
3. OWNER. (4114N LJ,ISO )
Address tJ2ber t.'a/
(Street or Route NN'oo )
44 2-5.14. NC -84041
StateCity'or Town
(323)--$A5-7fC'
Area code- Phone number
4. DATE DRILLED fief �6 O 3
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EV
7. STATIC WATER LEVEL Below Top of Casing: CO' FT.
` (Use "+" if Above Top of Casing)
8. TOP OF CASING IS Z lZ FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires ■
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 6 METHOD OF TEST Mr
10. WATER ZONES (depth):
I I. DISINFECTION: Type ahltt I-S Amount %b
12. CASING:
Depth Diameter
From_a_ To 72. Ft. o1/41n SOR 2) pvC.
From To Ft.
Front To Ft.
13. GROUT: Depth Material
From b To 2O Ft. pi) {-}iaNL
From To Ft.
14. SCREEN: Depth Diameter Slot Sizc Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/CRAWL PACK:
DcY sire Material
From To Ft.
From To
Wall Thickness
or Weight/Ft. Material
Method/7
fum
Topographic/Land sett
Qgidge ❑Slope OValley
(check appropriate box) ET,1-',
Latitude/longitude of well Io4 tai�
r i
(degrees/minutes/seconds) c i ,.
Latitude/longitude source:UGPS❑To htc map il�'-`
p ^
(check box) g -1 --_---
�IoTfi L { O C%�!i
From To Fntmatiou "'
O )5. r/4,1
/5 CO iv✓d Sie IN} re
Sr) at P.O (- 4ti:+ e.
C
U o
-Ti —
i•s c�
t�
LOCATION SKETCH, a,
Show direction and distance in miles from atijast
two State Roads or County Roads. Inca° tI ad
numbers and common road namc3.
Moorrky
Ft.
3
ce?
O
r.)
B ydsv Tic
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH{ I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TI{AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
oder, G✓..%, 1. %z67o 3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001