Ya CY2003

V)�
\‹.°
L L MAR - 5 2003
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Q
North Carolina - Department of Environment and *lahual Resources_ ..... .i,
WELL CONTRACTOR (INDIVIDUAL) NAME (print) B I l I �J A s k. CERTIFICATION a 21 t
WELL CONTRACTOR COMPANY NAME_PHONERF.USEN CALDWELL DRILLING, INC:. Q48 )254-3581
STATE WELL CONSTRUCTION PERMIT/ U) 9 O 1060 LJ ASSOCIATED WQ PERMIT/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
8731
WELL CONSTRUC �NhREC
i-FO)fpund
2. WELL LOCAT N:
N .restTown:M65U((t t- County 7t%Jt!t1
iL- ( ` . _ eatz )urPpfto f,
(Street Name, Numbers, Community, Subdivision, la No., Zip Code)
3. OWNER: At A.- (La
in Jnt r&..
L i
Address' Q_O 19 p 3
I—'
I
(Street or Route No.)
130 Ri1/43e1/45/lit° AY' a B 7 r X-
City orTown State Zip Code
d f'2.t)- !oR:•- °'Hz
CX Area code- Phone number
4. DATE DRILLED a'(3/� 3
— 5. TOTAL DEPTH: 4;5 6-
...". 6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
d 7. STATIC WATER LEVEL Below Top of Casing: 7-2 FT.
(User if Above Top of Cuing)
8. TOP OF CASING IS 1 . FT. Above Land Surface•
*Top of cuing terminated st/or below lad surface requires a
variance to accordance with ISA NCAC IC.0III.
r/ 9. YIELD (gpm)g,ao - itt METHOD OF TEST I?AA ta}iiir
10. WATER ZONES (depth): Lc, - l.17/ '
11. DISINFECTION: Types 4e 7, Amount Z.,C- L8
12. CASING: . ' Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From__To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 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.
16. REMARKS:
ter Section
Topographic/Land setting
❑Ridge ❑Slope OvAlfey ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreeem buta/secoads)
Latitude/longitude source:❑GPS❑Topographic map
(chock box)
DEPTH DRILLING LOG
From To Formation Description
hotL r0 P "
a�M 1S7r To Cosr
Ja3ir[ !1.[P R if Err
1—e67-
40 -- R��
LOCATION SKETCR
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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
%2 2?,
SIGNATURE OF PERS CONSTRUCTING THE WELL Di
67o3
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

273378
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) 1AO DK '1 {1�-`JYA,_1QY p� CERTIFICATION # a4=tc
•
FT
VI.1.CONTRAC-EOR COMPANY NAME V"i,IXti� ' - —n W"a14PHONE # ($28) 2oS )boa.
STA E VVELL CONSTRUCTION PERMIT# LLI! ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential M Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELLLOCATIQN:
Nearest Town: ..-et-IS L \\ - County $40..Le /
(Street Nai.'Numb�. Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ueocre h :Stxn n-oM&\�
Address !So U
(Street or Route No.)
LuC!`C
FL Yecir3 /6i2_
774 ity or -I own State Zip Code
Z) 8-2 90`}WI
Arc: code- Phone number
4. DATE DRILLED 313 I o3
5. TOTAL DEPTH: 30.5
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O
7. STATIC WATER LEVEL Below Top of Casing: 3a FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD (gpm): 15 METHOD OF TEST 9-sfAa5
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge NSlope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude souree:OGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
'-1- 1 in '7-7 eh)? +(t' {2)ceAov'O
77 1 n 3o5 Crrc.:.„„,)`:-_
11. DISINFECTION: Type (21;' 1\..5 Amount 8
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _.=/ To 77 Ft. L- il=a1 ,( 0C' ,531:
From To Ft.
From To Ft.
13- GROUT: Depth Material Method
From(_ To �f0 Ft. Co raierJ� c /1k4
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 Fl.
From To FI.
6.REMARKS:
n
cr )
LOCATION SKETCH 1..i_,.., Show direction and distance in miles fraat (easttwo State Roads or County Roads. Inclthc'ro
numbers and common road names. OW-: 0
Y �n
•'> _ I> a
9 as m `
= N.7
- ma
O —I
- 0
z
go[LLE !CEIT
ONSTRUCTIONS
AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
tDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
313 to,
DATE
S ,NATURE OP PERSON CONSTRUCTING THE WELL
GROSliM'riitEthcEsr t to th
ASRE1(1444ijiopj uJforra (919
Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
733-3221, within 30 days. GW-I REV. 07/2001

275759
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resoufces - Division
DELL CO VP AC Olt (INDIVIDUAL) NAME (pilaf)
o EL I. CON Ii4 CTOR COMPANY NAME ± S
STATEELI. CONSTRUCTION PERMIT/
lit applicable)
kr 9uuaa�1 - Groundwater Sectip
7
LSYr yyi) 1a 5 CERTIFICATION
VJi.ya
PHONE IL telit talibiltit
3
ASSOCIATED WO PERM!
(if7plicable)
I. WELL USE (Check Applicable Box): Residential IY Municipal/Public 0 Industrial 0 Agricultural CI
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL2. LOCATI�1
Nearcs�tl'own, j�f(/1$VI �� County ariPF
Ryrc kC( raWt) Q
S:ruat Naves. Numbers. Community Subdivision, Lot No. Zip Code)
3 OWNER:
Address YnQr'\ z -1 (`!rl�N t
ISncet P.i No.)
___61ai1s1 49 S a o
(try or Town Sr m hip Code
$43) _s't.)— a 90
area cod . Phone number V
4. DATE DRILLED (o— I o-o 3
5 TOTAL DEPTH: an 5
6 DOES WELL REPLACE EXISTING WELL? YES 0 NO clo
7. STATIC WATER LEVEL Below Top of Casing:'.jn O _FT.
I Ube "f" if Above Top of Canna)
S. TOP OF CASING IS li FT. Above Land Surface•
•lop of eating terminated at/or below lad artier regstra a
variance In accordance with ISA NCAC IC .0118. //f� • 11 ` -`
9 YIELD tgpm)' a,' METHOD OF TESTc1. CQY'a443
10 WATER ZONES(depth): I ---- LOCATION SKETCH ••
1 I DISINFECTION. Type Tab 14,..4 Amount •L _ _ Show direction and distance in miles from at% st
12. CASING. Wall Thickness two State Roads or County Roads. Include th?road
/1 Depth Diarneler
Homy) -To_7r Ft. r/ j 9
From To Ft. 1•_ 11qq
Fiom To Ft� ac.�.S C��C�IL.
.. GROUT- Depth Material Method
) rem To Ft. P1�.i'� 1441 ic.- 8, ( IYLI -QJ �"•J
Frurn To Ft.
1.1 SCREEN: Depth Diameter Slot Si rc Matenal ig,),yt \- by ncl
Frurn__To Ft. _in. _ in.
Frurn _ To___ Ft. _ in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Topogz hlc!Land setting
DRidge &lope ❑Valley ❑Flat
(heck oppropnarc boa t
Latitude/longitude of well location
teleran/minutes/seconds)
Latitudeiiongnude source',OGPSOTopographlc map
[check boil
pRILLING LOG
Formation Description
From To
CD
co
_ m
r— -(
From, To Ft
From _ To Ft.
or Weight/Ft. Material numbers and common road names.
1. 3 Il'A-Q
OYt,
!n REMARKS'
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
rtblTiit Hie original to the DIw[gtoa of Water Quality, Groundwater Section, I06 Mail Service Center - Raleigh, NC
-,2ye9'++836-R1w1+c'vu.f9l>733A24tl, within 30 days.
GW-1 REV.07/20U1
J C 11
icjd
1
.rig.. ... .. —�

From ( To 5r Ft.
From To Ft.
From To Ft.
13. GROUT: Depth — Material n
From 0 To ` h Ft. ,t,-,F �-
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.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAh1E3W
272536
atural Resources - Division of Water Quality - Groundwater Section
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
r (��
el CERTIFICATION
x � 1
iecs
ASSOCIATED WQ PERMIT#
(if applicable)
PHONE #f)-%33� .�
WELL USE (Check Applicable Box): Residential Q' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: County
c>i'c CR )c—// AA
(Street Name, Nurnber ( Community, Subdivision, Lot No., Zip Code)
/
3. OWNER: YA jn( Q setuj p,
Address ! IS L2 ,/V' ,
(Street oute No.] _
City or Town j5tatg / y1 Zip Code
(`C3)- '7 V 1 - -� I <do t o},r �cr`
Area code- Phone number
4. DATE DRILLED i2 &b--<%r�
5. TOTAL DEPTH: 3ao
6. DOES WELL REPLACE EXISTING WELL? YES 0,11O E<
7. STATIC WATER LEVEL Below Top of Casing: 15 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 lth ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST M t..
10. WATER ZONES (depth): 7t' ?60
I1. DISINFECTION: Type n'\`a(Z;ic_Amount .cz
12. CASING: Wall Thickness
Depth Di eter or Wei hVFt. Mate al
� ( ,lam 3 y,
Method
16. REMARKS:
Topogic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To ormation Description
C .— '36 re C
-C /
c
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.
0
/9T---
t _�l C?» 1
rr -K; V erg
T
9+rN uS ' 1)r tt THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
allearycite).-, <
ubmit the original to th
GNATURE OF PERSON CONSTRUCTING THE WELL
DATE
27.099+tiO4h iRe.''., ri,;
f r_S..iPIAL OFFICE
Divis on of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
33-3:21, within 30 days. GW-I REV. 07/2001

2. WELL LOCATION:
Nearest County k o
(Street Name, Numbers, mmunity, Subdivision, Lot No., Zip Code)
3. OWNER:
Address G9) (,V'opdv
(Street or Rou FFt No.)
6gQe J /Mtn 'IY{Ll 8)- G1-
City or Town 5—JState77C Zip Code
Area code- Phone number
4. DATE DRILLED 3 °l -c3 -
5. TOTAL DEPTH: y'ao -
6. DOES WELL REPLACE EXIS ING WELL? YES ❑ NO Er
7. STATIC WATER LEVEL Below Top of Casing: Win FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS e 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): YR METHOD TEST 4-•C
10. WATER ZONES (depth): SO
11. DISINFECTION: Type c-110 Ioie---.
272528
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) K .vf,•,� soOLe yoc) CERTIFICATION
IS -7Q
WELL CONTRACTOR COMPANY NAME `254 -C1I L'11 �'./j�I�aii PHONE SS(g q 55—`byc*R
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential D ' Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
110
Amount `iac;
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From C7 To r�u Ft. 64). 50Ra -PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method(
From 0 To 'CD Ft. Ce/.tc�ec nr-' ,,. .p
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.
(REMARKS: it • ! -�
HEREBY CERTIFY THAT
INSTRUCTION STANT/ARQ;
Su®fi4ikS i
Ltippographic/Land setting
Idge DSlope DValley DFlat
(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
0-- i f ,-t, _ t
12 - 30 it S <uw
30- +cam cN& 34
Go— 1147
I2L9- I I -I O
Ho- vat,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the5ad
numbers and common road names. W 0
ornn
- C cm
DO
a 'ems
• Crl�
cry
m3)
at --i
0f o
I I:t WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
raa THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
f •I 3-_5"-
SIG ATURE OF PERSON CONSTRUCTING THE WELL DATE
of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

272519
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ResourcesDivision of Water Quality - Groundwater Section
WELL CO\TRu ACTOR (INDIVIDUAL) NAME (print) Lte)• y., 1.,t"44y#—' CERTIFICATION
?SIC)
C)
WELL CO\ l RACI'OR COMPANY NAME bb sle1( D"�,t( .LiZ.' I PHONE # wig )7 -
STATE WELL CO\STI urrioN PERMIT#
(if applicable)
ASSOCIATED \VPERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: 1 �%
Nearest ct (�/ems— _((('''qunty Ji7• r.A 1
(Sircm Name. Numbers, Co tmunity, Subdivision, Lo-NiNto., Zip Code)
3 OWNER: 91.4P ?CP
A s �i"'.t\ j
Address i j jey -j—UQK ?O
^° (Cireet or Rou �) )
r e ic- )i
� `1
Zip Code
City or Town State
( )-
Area code- phone numb
4. DATE DRILLEDKt' 0
5. TOTAL DEPTH: ••� `
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C
7. STATIC WATER LEVEL Below Top of Casing: FT.
/ (Use"+" if Above Top of Casing)
l
8. TOP OF CASING IS
FT. Above Land Surface*
`'fop of casing terminated at/or below land surface requires a
variance in accordance w' 0 15A NCAC 2C .0118.
9. YIELD (gpm): 50 METHOD OF TESL'. �SsY'L
10. WATER ZONES (depth):
Topogr c/Land setting
❑Ridge 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 To Formation Description
0 - 3•'
35-7C-
63
Ci 3"G�u
a za
I I. DISINFECTION: Typecitig _Amount 6 0 t,
12. CASING: Wall Thickness
Depth Diameter or ei A t/Ft. Ma erial
From 0To 'ice Ft. 0 �j"
From To Ft.
From To_ Ft.
13. GROUT: Depth Material Method
From � To �Q F[.
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
16 REMARKS
rl' S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Ft.
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. a
O :E
W
co rn
�
Za
zr
m
rn—
a
3 =a
tnz
ma
01 '--1
Vn o
z
a/O
I3b HERFSci CL/RT
I� Si-RUCTIOa TAND
'flr kfwo --�9% &'I
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/7-c33
NATURE OF PERSON CONSTRUCTING THE WELL
DATE
Su nitlt}te':dirT„iia95birh?eVivisiof Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
, within 30 days. GW-1 REV. 07/2001
2 699-1636 Phone 141I (9(46-434,

WELL CONSTRUCTION RECORD 27 8 2 9 2
North Carolina - Department of Environment and Natural�Resourcest�- Division of Water Quality - Groundwater Section
n
WELL CONTRACTOR (INDIVIDUAL) NAME (print) vent 1' •'US49Cg CERTIFICATION�.y�•�N G 1�6
WELL CONTRACTOR COMPANY NAME �tt'rCi WF�2.P PHONE #!''�) 70 I/��/7 %��
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(i f applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Q/ Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: /p� �r,l� p�,'
Nearest Town:,�5�W OC FW Atl County �.4•�--(
// att ,(�/Ji�y � elect I
(Street Name Number*, Community, Subdivision, Lot No., Zip Code)
3. OWNER: TgNie - '& C 3Ofl
Address lr,c5\ix t'tvc'
(Street or Route No.)
\V RO\tC\ ([vC to-a.
y or Town Since Zip Code
Topographic/Land s ' g
❑Ridge CISlope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number b -- Z
4. DATE DRILLED tp`26" 03 2. G
5. TOTAL DEPTH: •
6. DOES WELL REPLACESTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 4 ' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. if
9. YIELD (gpm): // M�yTHOD OF TEST .7i
t0. WATER ZONES/ (depth): 1 C ,A.47 AI 7ite Y
I . DISINFECTION:Typeeto/?/NC Amount BOZ 6%2
12. Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft.
From 0 To Z. FL tz ye !'{-
From at) To al:2 Ft. 6 t79 r // *? 0,am
13. GROUT: Depth
From To 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
Material Method
CASING:
From
From To Ft.
Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT T
CONSTRUCTION STANDARDS,
I DWELL WAS CONSTRU
D THAT A .Alta
SIGNATU
C fo- 3YS'
Afack
Qrnoec-
&d tti /—e
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.
4II
8
UN ACCORDANCE WITH 15A
CORD HAS BEEN PROVIDEI
E 0 rLl7 RSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundw
27699-1636 Phone No. [phone], within 30 days.
DATE
L
AC 2C, WELL
TO THE WELL OWNER
'7 mite ✓etece
en, ),636-Mad ServicK
leigh, NC
V. 07/2001
r

281823
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andResource., - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)NAI.•�E(print) 0NIV /C fi 19 LL- CERTIFICATION #2 77
WELL CONTRACTOR COMPANY NAMEy14445 w 2A./ 1 .3.0 " .-(tliL1 PHONE # g wr G v9-OS'r2)
STATE WELL CONSTRUC71ON PERMIT#_�Z C ASSOCIATE- D WQ PERMIT# Ain
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential at Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO�1N:
Nearest Town: 4Ld6 CountyV/�/2g .I %/
(Street Name, rs, Community, Subdivision, Lot No., Zip Code)
3. OWNER:»tr
Address JJ,2 N �Q -
(Street or Route No.)
& adatai.her�. n„r�ty
try or j' % S %S` Zip Code
(p 8 9—
Area code- Phone numt�
4. DATE DRILLED V/f / O 3
5. TOTAL DEPTH: / ' T'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 27
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / S FT. Above Land Surface'
'Top of cuing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /0 METHOD OF TEST -Ern v
10. WATER ZONES (depth): $S'
11. DISINFECTION: Type
12. CASING:
Depth
From_ To SO
From To
From To
Amount to el -
Wall Thickness
ameter or Weight/Ft. Material
Ft �'� #e2 / ®U L
Ft.
Ft.
13. GROUT: Depth AA _Material Method ,
From O To e2 0 FL (rn - L.>,/4- /
From To Ft. /
14. SCREEN: Depth Diameter Slot Size Material
Froni
-To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Material
From To
Fro To Ft.
Size
Ft.
16. REMARKS:
Topographic/Land setting
[Midge aSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILI4ING LOG
From To Formatio Pe
LOCATION SKETCH
LETU-U
Show direction and distance in miles from at least
two State Roads or County Roads. Include the ro
numbers and common road names.
CO
0
N
+—
I DO HEREBY CERTIFY THAT THIS WM T WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a
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

'Wo,ltibi ct aalul::dns - L)epietme nt of Ena'ent_nultlmn1116it)wu1118uy`atli)' lh
eihR0.La AM'%Ia lIIOK UNUIVIOC LJI NIMBI I001t— ll/��y�ICY*f-`-'W1�
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%I 1'I r. is YI I. CONS Rl C 11U1S rt.KDlrfa. ___....—.._--____ _—
(; Res- :..il • a0anerc'ipal-Publtc D ineusfrial SJ A_ran uhutat G
WELL CONSTRUCTION RECORD
mtainVuuarglitrittM.._ iiii tomb rAimttium
aIFIKOLIFICC 1APtC
ASSOCTtfatYamI tp
f ,�:;<xb'.ca
IP1ta1HE x
283055
v.,-, e =. St eC wck Applicable Dux 1: List C:Sc._--. ___— —_.
\;;•,�"sa�:nm 0 Itcco\ery ❑ Heat PumpWater In :'lion 0 Diller 0 11 Other,
• Topogra) ic;Lantisettinutly'1
f ❑Kidgl: ON Ovalley
l !check anpannll: box'
Latitudellongtito of se '4 lL
Lalitudo longitude lour c:II ' +?Ik'lilhlua!utpi'
t. her tncu.
OEP riii rt.O. LIvii
Igrlrrnan
E rvin T n ______
wL1.1 Locnnt>Ny �.,, f12 r;:ounly'
V.:J:Ca TUun il. I.`—.—.. .Vcu Sv
zs9 5{� F' No
[sp..,Naas:,.{\^i h t'rromv, Vy. SOb�dIVI IVn. Lot No Lip Cua )
—cam g.:wa'an Z F yL--
. ..Nc1,6V11\k_e_.-�'l'__._c '
4. UA I E DKILLED_.__1.1- 3 0,-D
--- t
(. TOTAL DEPTH:__._5�-�____
6 DOES WELL REPLACE EXISTING WELL' VES ❑ NO T
7. STATIC WATER LEVEL Below Top of Casing: _4eU__F _____
t tea: .r ♦ho,c Tap of Casing• .__
8. 1 UP OF CAti1NG I‘)4 ___ F . Above Land Surface' _
rtYYlr:a a
A ETH DOF 11.,E__—___LE-
IS',h1FTHODOFTEST�b'i' �b�-'—�--
a. 19. 1 C 1 h;
—, ---. $ho.v circlion and distan,: m In:l:s ln.,m al Iz
lmbel s and common
•lop ut cavae terminated atbr below lad sorbet
verlao<e in accordion: wl' l ISA
.4YIELD tepmY_L.
t(• WATER ZONES (du
If DISINFECTION Type
1'_. CASING- Diantctn or N'c1ghCF:. \lalrr',-1
Depth
F«xn ""O_ Fn_ 11.,___.-_ _--- ._.____.
To iFt. ___
To------- IFn.- ..
'r nn'.I _... n1ttu.:
Lye 1 h ntawn
�Cjri
ntaterra
1{ j('Rl t\- Urp,h Uumclnl S. o; �.'.
Ft ._ __In. In. ____
Amount -- two Stare Roads or Coon,. Roads. I
ws11 'Thickness n road names
15 SANE) 4RAA'EI. PACK.- Sin Material
Depth
---- O V=
E
1 UO -i li b!31 Cti:TIF' - AT IRIS U'ELI. WAS CONSTRUCTED IN ACC (1RpA\'CE WITH i `5, `CAL 'i tiLLW F
CON I sil<! t.'l ON LANDAR S AND THAT A COPY OF THIS RECORD HAS BEEN PROS IDED 1 O 1H WELL l<`
Al.-.
`_.I"—o3 --
--- )� sic,: ATL:RE CIF PERSON CONSTIisCTING THE WELL.
Quality, DAM
er Greundw ater Section. In36 detail Servicr Centel
I RaitigEV h.,NCIU!
Submit the oione ao to t9e 33 3221 v.i hint 30 da) s.
2?A`>')�tb)6 I'hon: Wo. 141U) "
cces
0
0
0
0
0

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (LND1VIDUAL) NAME, (print)
WELL CONTRACTOR COMPANY NAM
STATE WELL CONSTRUCTION PERMIT#/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
283375
Resources - Division of Water Quality - Groundwater Section
t0A/n//c BAILS
CERTIFICATION 41)77
PHONE a (fli Ly9-Iy8?)
NH
1. WELL USE (Check Applicable Box): Residential Pa Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI f, .
Nearest To �,:� `�L . _ _ County
(Street Name,
,NGf�
Numbers,�Community, Subdivision, Lot No., Zip Code)
3. OWNER(2
Address
Sweet or Route Ness.).
43 2/y
City or Town State Zip Code
(` Area code- Phone number
4. DATE DRILLED /D/aa //D-3
5. TOTAL DEPTH: .Z /VS'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0?
7. STATIC WATER LEVEL Below Top of Casing: I/ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / S FT Above Land Surface'
'Top of casing terminated atfor below land surface requires a
vivisect Le accordance with ISA NCAC 2C .011S.
9. YIELD (gpm): S- NJ TROD OF TEST_ /eGisr,L
10. WATER ZONES (depth):
1 1. DISINFECTION: Typet Amount
12. CASING: Wall Thiclmess
Diameter or Weight Ft. Material
From__% To .SD Ft�i_ *a/ Pat
Depth
From To
From To
13. GROUT: Depth
From tQ To ea 0
From To Ft.
Ft >Vi�
Ft.
Method \U
Ft. e fw 1 Nuy ��4�Q�C
h
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.From /To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From/ To Ft.
From To Ft.
16. REMARKS.
7LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads Include the road
numbers and common road names.
0
co` ga
Topographic/Land setting
DRidge %S1ope ❑Valley ❑Flat
(check appropriate box`
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To
L OG
Formation !• sc
ous L
porn#1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRULtlrD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
p3
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-1 REV. 07/2001
0.1

283374
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
/- Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAM (print / >• i i > i L CERTIFICATION nag?//
WELL CONTRACTOR COMPANY NAME . .�� 'N% r' /CJ.C4 4-IF r�Y/ PRONE # (�dlt' 4ry Oy
ra
STATE WELL CONSTRUCTION PERMIT# N J7 ASSOCIATED �WQ PERMITV # 4 /,4
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential g Municipal/Public D Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLLOCATI
Nearest Toy�n W � County e V._
(Street Nam; Numbers, Community, Subdivision, Lot No., Zip Code)
(S fo.)or Rowe N
�.�.fir 2ny
City or Town State Zip Code
( )
Area code- Phone number
4. DATE DRILLED /D/aa. /D 3
5. TOTAL DEPTH: 'aaS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO J:if
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+- if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of cuing terminated atior below land surface requires e
variance in accordant with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OFTESTT�Lnre
10. WATER ZONES (depth): /901
11. DISINFECTION: Type Amount iv( BL
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From /2 ToS_Ft. _tole /i+2/
From To Ft.
From To Ft.
13. GROUT: Depth �Materiall
From_/ To 2fl_ FL_6t..rt
From To FL
14. SCREEN: Depth Diameter Slot Size
From o Ft in. in.
From To Ft. in. in.
15. SAN /GRAVEL PACK:
th Size Material
From / ro Ft.
From To Ft.
16. REMARKS:
Material
®Jr
Topographic/Land setting
DRidge ❑Slope ❑Valley ❑Fiat
(check apprgtriatc box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To
f--
t
Show direction and distance in miles from at Least
two State Roads or County Roads. include the road
numbers and common road names.
Method
U hod , Iv)
Material iU
LOCATIONSKETCH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUUIED IN ACCORDANCE WITH 15A NCAC 2C, WELL.
CONSTRUCTION STANDARDS, AND THE - COPY OF THIS RECORD 1-IAS BEEN PROVIDED TO THE WELL OWNER
TURE 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-1 REV. 07/2001

283373
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (LNDI VIDUAL) NAM (print
WELL. CONTRACTOR COMPANY NAM
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
yin
tural Resources - Division of Water Quality - Groundwater Section �1
CERTIFICATION itie/ 7
�.t1 �442ceyta� PHONE a
ASSOCIATED WQ P' RMIT4
(if applicable)
Al/de
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI is
aNea st Town: County
s vy
(Street Name, Numbers, Community, Subdivision, Lot No., Tip Code)
($ t or Route No.)
G tiN C, 7/1/
City or Taw State
Zip Code
Arca code- Phone number
4. DATE DRILLED 44,C2.3/03
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO !
7. STATIC WATER LEVEL Below Top of Casing: 66 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / .'i FT. Above Land Surface'
*Top of casing terminated attar below land surface requires a
variance In accordance with ISA NCAC 2C .011S.
9. YIELD (gpm): 3 !D METHOD OF TEST
10. WATER ZONES (depth): /lpv�r .2OO 1
11. DISINFECTION: Type___ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0 To o2O Ft_ki__ ,*J/ ®dG
From To Ft. _
From To Ft.
13. GROUT: Depth Material Method ,
From 0 To 020 Ft. i___ _Lf1d�a t
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From /To Ft. _—in. in.
From / To Ft. in. in.
15. SAND/GRAVEL PACK:
16.REMARKS:
9°i
Size Material
Topographic/Land setting
ORidge I$S1ope OValley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPSOTopographic map
(check box)
DEPTH ARILI NC-LL1fi
From To FomtationDescripti3e _l
OC S CH
Show direction and ' stance in miles .om a
two State Roads or aunty Roads. Include the road
numbers and co on road names.
o „
0)
0
CD
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COJY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRULIING THE WELL
/40/.2 8/6 3
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

283372
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N
WELL CONTRACTOR (INDIVIDUAL) NAM (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
Resources - Division of Water Quality - Groundwater Section
CERTIFICATION 4;077
L41. thl ®.rN+. p n l PRONE # �S� oSfB�d
(if applicable)
_ASSOCIATED WQ PERMIT.
1. WELL USE (Check Applicable Box): Residential LI Mttnicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI
Nearest Town: It/J o C ty 7/41
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address ?, S9 'j 4a *- - -' Gad
(Street or Route No.)
IY• C•
City or Town State
Area code- Phone number,
4. DATE DRILLED �D/�r.2 9/0 3
5. TOTAL DEPTH: .L 1DS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /9 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / J6 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): O MnHOD Of TEST-1;;n0
''JJ
10. WATER ZONES (depth): /
11. DISINFECTION: Type 92 t - Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
To % Ft. ©VC
To Ft.
-I87/
Zip Code
From_f0
From
From To Ft.
13. GROUT: Depth Material Method
From D To�� Ft. %+xv�Q! �, • y�f vN•"-Y,
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To _ Ft. in. in.
From /To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From /To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope XVailey ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(dbeck box)
DEPTH PRILLING LOG
From To Formatirl rrptin
LOCATION SKETCH m
Show direction and distance in miles from at 1tt
two State Roads or County Roads. Include the road
numbers and common road names. o
fo
rn
rn
n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THPy"t) A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
t9flh 6/P/e.2y/d3
SIGNATURE OF PERSON CONSTRUCTING THE WFI I 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

ill. PG WELL
cO lit auCTION P ilT
'� �� f
WELL CONSTRUCTION RECORD
Norris 04rolin2 - Dcpsrmunr or Environment and
1\ ELL CONTR;CCOR (iNU11'IDU.a1ni1' ) N.a(print)
wcLL CU,�'1'I:a�t'JIi COD' PANY NwDI le re P'Q4..SOSIS // (/ hkilp//,/Ni
Co '
ASSOCIATCO \YQ P41t IIT,, _
(if'.IppliCablEl
29871.E
r Qualiry - Groundwater Section jj
CERTIFIC:>.T1ON R3JL
PHONE WQaIIS alSd'- 4.,
I. WELL USE LChccic Applicable Bo>4 Pesids nti' ❑ iViuniGipa th[] Iheni0 .4
&(°°haring 0 RcaoveryWater Hear Pump atcr Injection 0 OOtherer 0 ]IOrher. r, Lis[t Llse snculntral Q
2. 11E121 LOCATION:
Neyex To W11:,AfIr..ink ✓, !/c
Counq• 7✓•n tt
LSoen Rm'�c ry n0 oc re, Comnw nay, Subai vision, Lot No., Zip Code)
r-3. 011 NER_ T h r✓ I�io__- U1 e \
.a.t:as __ ✓ O � 1
tv,ccI Rourc No.)
o r Yri� M Cang7V0
-n 83--aOtFO '—'pCode
1JJc- Phdnc ItwTpn'
4. DATE DU- /0-2`2-Q3
3. TOTAL DEPTH: o— —/
o. DOES WELL REPLACE YES 0 NO L7
7. STATIC WATER LEVEL Below Top of Casing: Gi, FT
(U tc ". "'if .♦bare Top of Cu, i ns)
3. TOP OF CASING 1SFT. Above Land
Surface"
'Top oRa,mi Iurinmacq floor bclur Illnd su rate rcqulrea:< w a;coroawith nec 15A NCAC 2C.b11.
d. YIELD (,pnt): 7/C h'IETHOD OF TEST r . 9
Iu. WATER ZONES (depth):
11. DISINFEC
12. C :SING:
From 0
Fmm_
Fmm
3. GROUT:
Frun,,p
ral Resources - Division of Ware
1 '
TION: Type
Amount /'/ c55
Well Thickness
Ucprh DiamdIdi or WeighUFI. bee/trial
To--_Z Ft. & LY /�✓L
To Fr.
To Fr.
Depth Mama]
Tom. Ft. C'ON_�
From 'To Fr.
14. SCREEN. Depth
From__ To
From__ 'To--
li. SAND/GRAVEL PACK:
Dcpih
U
From
From To
Io. REMARKS:
Diameter
F[ in.
F[. n.
Fr.
Fr.
Slot Size
in.
Size Material
LA w s 4eaNC L N
N1en,oa �r e e rg info/ ' ,l C
irlalcrial
cis
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH lSA NCAC 2' WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(
SIGNAMGTHE WELL DATETURE OF PERSON CONSTRUCT / E 03
E
Submit inc, original ro DIYIslon Of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh NC
27699-1o3o Pltnnc No. [phone], within 30 days.
GW-1 REV, 07/2001
Topographic/Lan)serling
❑Ridge ❑Slope Malley o OFlar
(check appropriate box)
Lurirude/lon'inlde of well location
3r-' ) S. a)7 r' port" tit j) r'
(degree;minutc{ss� cconds)
Letirude/longitude source: anPSOTopographic map
DEPTH (check: bog)
DRILLrN3 LOC
From To Formation Description
/ 7 - Lz
c
0
LOCATION SKETCH
Show direction and distance in miles fromieas*o
nvo State Roads or County Roads. Include rite roq---
numbers and common read names 3 -o
COrn
i
m�
--I
Cr

298677
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) %Y%ar-,k 411aAn. CERTIFICATION „3a?6
WELL CONTRACTOR COMPANY NAME r 1„ Sn n W 42-1 r f'U PHONE wc4 l /.S'? -91fp
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITt
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential h'YMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water lnjection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Toev�,i: %3urnrv, lIt
/lLr bh; f /dek ,t d,
(Street Name, Numbers, Comm try, Subdivision, Lot No., Zip Code)
3. OWNER Jecr't IA]; )n
County yAnCtr
i
rl
Address ' "t /ca-L7 h, t flap 1e
Cr or Route No.)
Spruce nc ae-777
City or Town State Zip Code
(621)- 76 5 — ;Sea
Area code- Phone number
4. DATE DRILLED �% - tin - C 3
5. TOTAL DEPTH: a c r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: QC 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 ith ISA NCAC 2C .0118.
9. YIELD (gpm): Y METHOD OF TEST m5
10. WATER ZONES (depth): /
11. DISINFECTION: Type //DI/
12. CASING:
Depth
From 0 To a S
From To Ft.
Amount tie —
Wall Thickness
Diameter or Weight/Ft. Material
FL i is / 5'b' 51-ed
From To Ft.
13. GROUT: Depth Material
From 0 To :9O FL COntcta/e
From To Ft.
[4. SCREEN: Depth Diameter
From To Ft. in.
From To Ft in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft.
From To Fr.
Method
�p rtd
Slot Size Material
in.
in.
Topographic/Land setting.
❑Ridge ❑Slope ❑Valley 124Fl i
(check appropriate box)
Latitude/longitude of well Iocatio
ar�yq�7,r — Df�.�i,F fV? w
(egrees/minutes/sec nds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D a0 Gray .-I
.;7/ rag (-7 an 5/ate
1l9 a9' fllac. (-ran,.fQ
0
c O
n
cm
Sm
LOCATION SKETCH IV o<
o
Show direction and distance in miles from at least ��
two State Roads or County Roads. Roads. Include the r'
m
numbers and common road names. wa-
rs.) ma-
Al 0 p Ltd. J s
a l/ 6, /tie bbi
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Gt/
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
North Carolina - Department of Environment and Natural//y��Resources - Division of Water Quality -
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Mark A)/p.11
/ Cc3 lna LJe(I —Dr i1I.:1
d ASSOCIATED WG PERMIT#
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(i f applicable) (if applicable)
298631
Groundwater Section p�//
CERTIFICATION #.31f9orG
PHONESM'7a 4.4•3-99#9
1. WELL USE (Check Applicable Box): Residential f7Y 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: W-nSV,//e
Nearest Town:
Inc (22
County tzlane4-51
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ?AV r IAyhlor
Address 7 a _ c2 7 *t— ., t'e c/ tv Lu
G 0/
Zip Code
( - L7- I
Area code- Phone number
4. DATE DRILLED 7 *30 —03
5. TOTAL DEPTH: ,205'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO '
7. STATIC WATER LEVEL Below Top of Casing: 2 `i 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 15A NCAC 2C .0118.
9. YIELD (gpm)• 30 METHOD OF TEST R, j
10. WATER ZONES (depth): / (.0
(Street or Route No.)
cite
City or Town State
II. DISINFECTION: Type
Amount r' Ar
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From b To a / Ft. G fy Sat( At(`.
From To Ft.
From To Ft.
13. GROUT: ., Depth Material ��;;gg Method
From To ?0 Ft. (coCre pdet c-I
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.
Cc
Topographic/Land setting
❑Ridge O8lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: nel5S❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O /O` n Jha f1.
// at r `Ictt ra coy\ 4Lf
LOCATION SKETCH
Show direction and distance in miles from at leaf
two State Roads or County Roads. Include the roi
numbers and common road names. d5
UOe C.�aMt-
t.l / /✓5U, ��•'
1 C
16. REMARKS:
! DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC 1ED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.2 GG�� 7 -3o —63
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
- r m_
Ovzt
--
rJ z n
%
M�

298630
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section /
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �rAr k .'4/A 1I CERTIFICATION # ��t4.
r ` I a
WELL CONTRACTOR COMPANYNAME frcart_Asof �z t 1llino CO. PHONEgt,Pil 6?3-Ir/rj
STATE WELL CONSTRUCTION PERMIT# J ASSOCIATED W . ERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Lli.erpt vii/i'
Nearest Town:
County P3(T
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER.0 7,4 n/I-/ 4drne tdt.t] jdrfs
Address IZ 4!I •14- EF Fr-S 4-
(Street or Route No.)
ret rvi ems./ YlC at73o
Ciry or Town State Zip Code
(ta5- 4D-9-44Y`I
Area code- Phone number
4. DATE DRILLED y -C 03
5. TOTAL DEPTH: ✓o O j t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO m�
7. STATIC WATER LEVEL Below Top of Casing: YS 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 15A NCAC 2C .0118.
9. YIELD (gpm): ! METHOD OFTEST�, -y
l0. WATER ZONES (depth): //iS
11. DISINFECTION: TypeD// Amount ,on.—
l2. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To if Ft. «-7 5D1 4.W rVe
From To Ft.
From To Ft.
13. GROUT: Depth„Material Method
From Q To ,c7L) Ft. �°.7C'reje a'e-c
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.
Topographic/Land setting
❑Ridge E St'dpe ❑Valley '❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o ; v 5wn d — 2'o t74
rfD �e 5174A
)a (r•rnn
0
LOCATION SKETCH
o
or en
rho
— N P
Show direction and distance in miles from at least c.p...-
two State Roads or County Roads. Include the road 0
numbers and common road names.
l refr-un d
T r, �.eS•C..rVc.
Catw1�
�u r N su jIct h •C
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAR S, 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 Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

293629
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalatJResources -/Division of Water Quality - Groundwater Section (� /
WELL CONTRACTOR (INDIVIDUAL) NAME ( rint) / Zf- k fyy'lle ✓^)'� ) CERTIFICATION # .Kd//lp
WELL CONTRACTOR COMPANY NAME r7Le con LLl-Gl/ (/r, ill:7S PHONE fa/ Irfor7.��J'l
STATE WELL CONSTRUCTION PERMIT# j ASSOCIATED WQ PERRMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential - Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest To County YQ'7c4V
CiS43 opalnf ce tKd_
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:'az? bit" ., /1rt2
Address SS/3 r4i a r V'e (moo[
(Streetor Route No.)
( Yf' p-fl WI -rV . )Y C 2-fi70Ea
City or Town State Zip Code
(Xa8)- GWO- 3s97
Area code- Phone number
4. DATE DRILLED 9 ,7-/- 03
5. TOTAL DEPTH: ,2 r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [R-
7. STATIC WATER LEVEL Below Top of Casing: 120 FT.
(Use "+" i f Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
*Top of casing terminated a or below land surface requires a
variance in accordance wit I5A NCAC 2C .0118.
9. YIELD (gpm): (C METHOD OF TEST R,'4
10. WATER ZONES (depth): 449e,
$� t
Topographic/Land setting
❑Ridge CA3tope ❑Valley ❑Flat
(check appropriate box)
Latitude/lo gitude of wel location
3L/o�.�9A1n01� d Oau/
( egrees/minutes/ cos)
Latitude/longitude source: IFISFSOTopographic map
(check box)
DEPTH DRILLING LOG
From To etszFormayiot�ion
e �iD 2� e
�
Yi /A7 Rh -re Sha}
11. DISINFECTION: Type D# Amount �7Z
12. CASING: Wall Thickness
Depth
From 0 To It Ft
From •»2 To //D Ft
From To Ft
13. GROUT: Depth
From 0 To aZC:1• Ft.
Diameter or Weight/Ft. aterial
4DK21
/k'Y 57fe. c/
Material
COnC..fe3Q
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.
Method
Ul
Slot Size Material
in.
in.
f7
Y
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.
re • nQ.
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
/7 03
SIGNATURE OF PERSON CONSTRUCTING TIIE 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

From To
13. GROUT: Depth Material Method
,From0To ."t6 Ft. Can eretr 7otre.d
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.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /MAAU, / HerL
WELL CONTRACTOR COMPANY NAME /cccju. iorl UJeULrtl/j1
`o-
CERTIFIICATION ot3Q9 b
PHONE yw'yl.6JP: "?AP
STATE WELL CONSTRUCTION PERMIT# ASSOCIXTED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Burn IP Countyt /4fl
cic`S Crr—et Zrl
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: SC , -C-(.•Jooj fy/
Address /$O/ ler/rcS C'Cr.a_k., %Pc{
(Street or Route No.)
�u(td‘,. Ott ITC 114
City or Town State Zip Code
(Sax)- NA -
Area code- Phone number
4. DATE DRILLED SI - /3 -o'
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top,of Casing: So FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
"Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 9 METHOD OF TEST 7/5
10. WATER ZONES (depth): aR61 �,50'
11. DISINFECTION: Type kb /-`
12. CASING:
Depth Diameter
From 0 To (D I Ft. ion
From To Ft.
Ft.
Amount S 0 •
Wall Thickness
or Weight/Ft. Material
SR.T) *PVC
Topographic/Land setting
EIRtige OSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3SjS14 s nr—Ora/aU6 1-14,
(degrees/minutes/seconds)
Latitude/longitude source: Qf3irS❑Top ographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
— r!o
U/- STC
JrLn - c
_6a-roc
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.
Jam,) erc ei
riszi/Ie /✓C.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAAND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G` g
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
Ica C/
Pen
s y
t- G.-tO
tJ %'-
-o rc
3 r,
CP

298627
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /'7ork Allen CERTIFICATION p3R1la
WELLCONTRACTOR COMPANYNAME --X-Pt-G(4.A'On LA../1 Dtri 1%t'nra' CO. PHONE �fWP{E V3 - 9W9
STATE WELL CONSTRUCTION PERMIT# tJ ASSOCIATED/WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IY Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Burnsv. Ile. Countypll(',y
(Street Name, Numbers, Community, Subdivision, Lit No., Zip Code)
3. OWNER: (%• C. l.JooJ
Address l' Al TaLck s,Cra.-rL72$.
(Street or Route No.)
u-rn,sp:llr r\C_ 1101(-1
City or Town State Zip Code
A44-
Area code- Phone number
4. DATE DRILLED g -- e - d 3
5. TOTAL DEPTH: 4<C-
6. DOES WELL REPLACE EXISTING WELL? YES/0 NO fie
7. STATIC WATER LEVEL Below Toppf Casing. ZO _FT.
(Use"+" iT Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated a or below land surface requires a
variance in accordance witp 15A NCAC 2C .0118.
9. YIELD (gpm): / / METH�O,D�)F TEST 7.
WATER ZONES (de [h): A /1
10.
p
J
II. DISINFECTION: Type ND 14
12. CASING:
Depth Diameter
0 To 6O5 Ft. is,—y
To Ft.
To Ft.
13
14
15
From
From
From
GROUT:
From
From
Amount 4 OZ
Wall Thickness
or Weight/Ft. __4/laterial
Si7I�a� t' vG
Depth Material I Methoci
To cX Ft. Go/ICY e72 /3pf
To Ft.
SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ftin. in.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
DiRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
a zLsG IaG AIy PaJ 34T1J
(d grees/� minutesiseconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH
From
To
()
ea
DRILLING LOG
Formation'Description
e� C/ /�aJ
81'c t6iymi e
0
n
tr ?O
--O 1$1°'
� Y
(ram G
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.
J5 Crt••K l�
- ctrl-sUtlle 13.0 C.
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
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

293622
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural I'%ResourqIGr- ••�t
Resources - Division of Water Quality - Groundwater Section
� /
WELL CONTRACTOR (INDIVIDUAL) NAME (print) a n t H1CERTIFICATION q �p8.G
WELL CONTRACTOR COMPANY NAME FcoPtS i (.) II T)-JIin, 2. PHONE OW) 6K3 -/yfr
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential al, 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: n i____ __ County y4nt(y
„Jo/��rT�
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: G 17 C 5
Address At) #Vags•/d; t /QnS-'
(Street a✓Route No.)
/p,v t.ce%1•Ae /Vc. )5r797
City or Town State Zip Code
(SSG)- 6 73--g-/07
Area code- Phone number
4. DATE DRILLED S' — / g -03
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 6'
7. STATIC WATER LEVEL Below Top of Casing: 3 o 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,Rh l5A NCAC 2C .0118.
9. YIELD (gpm): / % METHOD OF TEST 41 `/
10. WATER ZONES (depth): /%/
1 I. DISINFECTION: Type / .DD/ Amount 3 02.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Adrenal
From aTo 3S Ft. /e3Y 5R)a/ f kt
From To Ft.
From To Ft.
13. GROUT: Depth Material //
From 0 To ad Ft. (oncre, 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.
Method
'Betz ci
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3r/s`3/ce-2,I-�-�-0/ c?/o/ w
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From Fot [ioni Description
le
3C
O_
LOCATION SKETCH
Show direction and distance in miles from at least-0
two State Roads or County Roads. Include the road
numbers and common road names. ^?
Crobtree. -eye r
Smutty? ?Ave nc.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL....
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
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

From
13. GROUT: Depth
From d To a 0 Ft.
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.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section /
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /77 -k ry %lyt CERTIFICATION U
WELL CONTRACTOR COMPANY NAME ten Lf Sn.O L✓ P// ( r V,Alc (o PHONE fit )(os3-5W,
STATE WELL CONSTRUCTION PERMIT# cJ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
298621
1. WELL USE (Check Applicable Box): Residential e/ MunicipaUPublic 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: 13brnsti!l.fu County
Fa,- ?air— ,es
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 301 netv j /1�sS
Address Pea Da. / e id .
(Streer or Route No.)
%u ENS v,'/le /✓c-
City or Town State
y4nc e 9/
.ZY7/ V
Zip Code
Area code- Phone number
4. DATE DRILLED rQ—/?'- O 3
5. TOTAL DEPTH: /CC
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cfl/
7. STATIC WATER LEVEL Below Top of Casing: /S FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD (gpm): 25 METHOD OF TEST
10. WATER ZONES (depth): %O
11. DISINFECTION: Type /'/ MP Amount / 07..
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To e2 1 FL 6 y SJ7 e,?( PVC
From To Ft.
To Ft.
Material
(,oOCde/Q
Method
Slot Size Material
in.
in.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Bi't3t"
(check appropriate box)
Latitude/longitude of well location
3Vs47ati M-nva/ov/54,w
( egrees/minutes/seco ds)
Latitude/longitude source: 136PS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
0 i d D/./t/
/n
L.Jh,te spar
i
O_
3 '
A - r
LOCATION SKETCH fr -
Show direction and distance in miles from at letsb mC
two State Roads or County Roads. Include the rCig
numbers and common road names. tV o,
cs
�D
G
Mew Dale - .CZ
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
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
North Carolina - Department of Environment and Natural Resourc/es - Division of Water Quality -
WELL CONTRACTOR (INDIVIDUAL)NANIE (print) (fl k Alb
WELL CONTRACTOR COMPANY NAME /CcrjLt fon (a1.P// 3.)r,'/ rei.2 CO.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED Wrf PERMIT#
(if applicable) (if applicable)
298620
Groundwater Section //
CERTIFICATION # kt�
PHONE OO2,) 683-fl99
1. WELL USE (Check Applicable Box): Residential eMunicipal/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. )i..srns' it 11If
F0.1er $ a W- Ilk RcL.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
//, ff
3. OWNER: n62�rA1 4 Ca. arl h' e- L?ccon
Address ,WC) i uc> rSrr/P j4- Pm-
(Sl�etorR7 g) e9r iK
13c1rnslr, lr t//
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED Y -aa _ 03
5. TOTAL DEPTH: 354S-..
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top,of Casing: VC ' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/ r below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm)• 8 METHOD Off' TEST /�f)
10. WATER ZONES (depth): S
County 1/417C Ey
11. DISINFECTION: Type ND jl' Amount 302_
12. CASING: Wall Thickness
Depth /�Diyneter or Weight/Ft. Material
From 0 To / Ft. V-t ,55Epd./ PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
L/
From 0 To go Ft. wcre tp Borec
From To Ft.
14. SCREEN: Depth
From
Diameter Slot Size Material
To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
!dge 0Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well locati n
33-fry/aPH-oYsja/G w
(degrees/minutes/seconds)
Latitude/longitude source: S6PS❑Topographic map
(check box)
DEPTH DRILLING LOG
From y'♦T�o Formatign Description
, V Ii / 7,
sg/H 54)/]o
5-hole
ilWac 6rnn2Jc
O_ P
cn
A lm
rJ
t� JJ
LOCATION SKETCH -v me
Show direction and distance in miles from at teas¢
two State Roads or County Roads. Include the ro 3
numbers and common road names. cr
10
jam.,'rs.S
Uflit Y'C-
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THA A OPY 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 Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001