Bk CY2004

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD
030486
r,�uUUO
• i
WELL CONTRACTOR. Dewey Wright Well Pump Co., Inc.
WELL CONTRACTOR CERTIFICATION it. 2688
STATE WELL CONSTRUCTION PERMIT# Leslie Reece
1. WELL USE (Check Applicable Box): Residential I XI Municipal 0 Industrial 0 Agricultural El Monitoring
Recovery Heat Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MORGANTON County: BURKF
HWY 181
(Road Name and Numbers. Community, or Subdivision and Lot No.)
3. OWNER GEORGE G ANDERSON
Address 5 DEW DROP LOOP ,
NEWLAN6treet or Route No.) NC 28857
City or Town State
Zip Code
DRILLING LOG DEPTH
From To Formation Description
0 85 DIRT
85 103 GRANITE
103 104 SHALE L____
4. DATE DRILLED 4/28/2004 104 197 GRANITE
5. TOTAL DEPTH 245 197 198 QUARTZ
6. CUTTINGS COLLECTED YES 0 NO 0 198 245 GRANITE
7. DOES WELL REPLACE EXISTING WELL? YES El NO 0
8. STATIC WATER LEVEL Below Top of Casing: 50 FT
(Use "." if Above Top of Casing)
9. TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 28.0118
10. YIELD (gpml' 3 METHOD OF TEST Aar
11. WATER ZONES (depth): 1.00 ppm 103-104 2.00ppm 197-198
0.00 ppm 0.o0ppm
J l 1�
FT) DJ
C
12. CHLORINATION: Type HTH Amount 40
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To 88 Ft 6 1/8
From To Ft
From To Ft
14. GROUT:
.350
If additional space is needed use be
:.of
orm
For'
LOCATION SKETCH =
Material \JShow direction and distance from at IeasfZ4vo State
PVC Roads, or other map reference points) rt--- --7
Depth Material Method
From 0 To 20 Ft Cement Gravity Flow
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in in
From To Ft in. in.
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
Cr(1001
0
17. REMARKS•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGN RE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to 'vision of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12.99
FOR OFFICE USE ONLY
Quad No -
'7)
0
Serial No

294782
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) WOW T (WI CERTIFICATION 73/43
WELL CONTRACTOR COMPANY NAME HI(K(7(Y WEi T. TRTT I TN: m PHONE 0 fR2R) '176-CMS
STATE WELL CONSTRUCTION PERMITSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential MunicipaVPublic ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: VALDISE County BURKE
3&z) FIRE PEAK MACE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: RICHARD FETUS
Address 'NM l-lT l4 PEAK TFRR4(Ftreet or RoMe No.)
VALDESE, NC 28690
City or Town State Zip Code
( R7R)- 42R—PLO
Area code- Phone number
4. DATE DRILLED 02-16-O
5. TOTAL DEPTH: 1245
6. DOES WELL REPLACE EXISTING WELL? YES Sd NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 498 FT.
(Use if Above Top of Cuing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
`Top of casing terminated at/or below land surface require a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 5 METHOD OF TESTY AIR TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type THI' TARS
12. CASING:
Depth Diameter
From 0 To 71 Ft 6'
From_ To Ft
From To Ft
13. GROUT: Depth Material
From_ To 70 Ft (RUI TF
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From. To Ft in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Amount 157
Wall Thickness
or Weight/Ft. Material
PVC PLASTIC
Method
IW'i RFT)
Slot Size Material
in.
in.
Material
Topographic/Land setting'
°Ridge °Slope Malley ['Flat
(check appropriate box)
Latitude/longitude of well location
(depwlminutes/eaanda)
Latitude/longitude source:OGPSOTopographic map
(duct box)
DEPTH DRILLING LOQ
From To Formation Description
c
C,
rn
J
.%
LOCATION SKETCH m E.
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road names.
10�� N ::1''/O
fear,. t-
eiN Per
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU
CONSTRUCTION STANDARDS, ANDma A _ / COPY OF
?• I ACCORDANCE WITH ISA NCAC 2C, WELL
.i '.411TrORD HAS BEEN PROVIDED TO THE WELL OWNER
02-25-0'+
SIGNATURE OF PERSON CONSYRIJCTING THE WEI.i
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-1 REV. 07/2001

294781
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) W XNE I ( i CERTIFICATION it 2 43
WELL CONTRACTOR COMPANY NAME HIQKCRY,%E' L Eall C CO. PHONE [phone]-(f5
STATE WELL CONSTRUCTION PERMIT) ASSOCIATED WQ PERMIT/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑( Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: M'lflNTL'N County RIEKE
4775 S1 MAR RACE
(Street Name. Numbers, Community, Subdivision, Int No, Try Code)
3. OWNER: RELIAD) FEV. / HATK & NtNICY HART
Address En Rox
(Street or Rome No.)
Na NC 28655
82 e n-l3E4 state
Area code- Phone number
4. DATE DRILLED 03-03-O
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ®(
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 2 FT. Above Land Surfaces
'Top of cuing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TESTRY AIR TEST
10. WATER ZONES (depth):
LOCATION SKETCH 0 o
Show direction and distance in miles from at least=
two State Roads or County Roads. Include the road
numbers and common road names.
C)i,•,.`t
- /may121v i.0
RrSN0
V4' C,�t��1`
Topographic/Land setting
ORidge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(de a/mimNa/secroad,)
Latitude/longitude source:❑GPS❑Topographic map
( tax)
DEMI pRILLING LOG
From To Formation Description
0 r
3.
0 _
--v
V
63
11. DISINFECTION: Type HTH TARS
12. CASING:
Depth
From O o 88 Ft 61: INC MASTIC
From To
From______ To
13. GROUT: Depth
From_0_ To 70
Amount 54
Wall Thickness
Diameter or Weight/Ft. Material
Ft
Ft
Material
Ft. CR1TT
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft
Method
Size
Material
0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
CONSTRUCTION STANDARDS, AND THAT ACO_PY OF THIS
ORDANCE WITH ISA NCAC 2C, WELL
HAS BEEN PROVIDED TO THE WELL OWNER
Q3-03-C4
SIGNATURE OF PERSON CONSTRUCT R1G 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. OW -I REV. 07/2001

4..Ii4AYI& mint 4.-\suLtcx.
NIORETZ W.ELL r
F
czien
;aims L>!i;;.. �p CMs)
i'Cfn:J[.L ES[,', N cs i.
a: _z
r'xbrio. Ta ^`ca
�J
0
CO
V
CONSTRUCTED 1,cC--t
.:'-� - F II -US 1;7"'Cc' -:1 -:
erC!' al , Grp. -.w -r.�. ,, ..
29691'9
C7-"zL.rc9>?� .SC.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Td !Ties to Camp, Jr CERTIFICATION 21 38
WELL CONTRACTOR COMPANYNAME ramp's Well R Pump Co Tnr PHONE#$78) d5R-7322
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
?9S526i
1. WELL USE (Check Applicable Box): Residential IbMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:
County :c,akX'._9.•
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:(\�(` )(kJ(--
Address t' 0 {nay \YiII
V` ( (Street or v No.)
M q\t�',�
City State
4�� )7t 9 -/o / 9'
Area code- Phone numb
4. DATE DRILLED .3 • 00U"N
S. TOTAL DEPTH: ,g as
6. DOES WELL REPLACE EXISTING WELL? YE$ ❑ NO d
7. STATIC WATER LEVEL Below Top of Casing: bl) 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 cc yirlth 1SA NCAC 2C .0118.
9. YIELD (gpm): U 10. WATERONES (depth): METHOD
0 OF TEST nit
Zip Code
11. DISINFECTION: Type rh l nri rip
12. CASING:
Depth Diameter
From—p To IBC Ft.6 1/4
From_ To Ft.
From To Ft.
13. GROUT: Depth
From_p__ To 30 Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Amount C. U?
Wall Thiclmess
or Weight/Ft. Material
QDR.21 PVC
Material
Neat Cement
Method
IIa
Slot Size Material
_ in.
in.
Material
Topa hic/Land setting
['Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formatipn,pgscription
PFPTIt
From To
0 kI s
wy
CAAv
t'
xD m
- 0
NZ
N �r
LOCATION SKETCH
Show direction and distance in miles from at leapt
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUUIED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c (SI
SIGNA B
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

297155
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) DEAN SHEHAN CERTIFICATION # 2160
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: MORGANTON
BETHEL RD.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: RHONDA RHONEY
Address 1086 BETHEL RD.
(Street or Route No.)
MORGANTON NC 28655
City or Town State Zip Code
(_)-
Area Code Phone number
4. DATE DRILLED 02/10/04
5. TOTAL DEPTH: 325
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 80 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 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): 4 METHOD OF TEST ARD
10. WATER ZONES (depth):
County BURKE
11. DISINFECTION: Type CHLORYTE Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
To 130 Ft.64/4" SDR.21 PVC
To _ Ft.
To Ft.
Depth Material Method
To 20 Ft. OUIKRETE POURED
To Ft.
Depth Diameter
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From 0
From _
From _
13. GROUT:
From 0
From
14.SCREEN:
16. REMARKS
Slot Size Material
in. in.
Material
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #64 K FROM RUTH TO MORGANTON.
TAKE I40 E. TO BETHEL RD. EXIT #106. TURN
LEFT. 1 MILE ON LEFT.
0
r
N
N
ul
1V
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A D-0Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
. %
SIGNATURE OF PERSON CONSTRUCTING THE WELL
-id-ay
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

2998C3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
12u.,,i
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SSe (� CERTIFICATION# 31 y�r•°
WELL CONTRACTOR COAIPANYNAaIE ,qU5fret / /t%GI/ DYa//'ns LNC PHONE # 18) e, 3 D 36Sti
ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# (if applicable) - — --
(if applicable)
1. WELL USE (Check Applicable Box) Residential f8' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
Topographic/Land setting
DRidge DSlope ❑Valley Bfiat'
(check appropriate box)
Latitude/longitude of well location.
2. WELL LOCATION: ,
Nearest Town:
(Street Name, Nu hers, Community, Subdivision, Lot No., Zip Code)
. OWNER:
Address
��" (Street or Route No.)
jd-�cti[yv
m
County 154114tiG-
1j )
a81003
,cgjty or Tow State Zip Code
Area code- Phone number
4. DATE DRILLED 7- 023-04i
5. TOTAL DEPTH: 2/03 '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EZ
7. STATIC WATER LEVEL Below Top of Casing: /e .0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS J y . 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): _4 _ METHOD OF TEST avid
10. WATER ZONES (depth): _ SLOs
(degrees/minutes/seconds)
Latitude/longitude source:❑CPS❑Topogiraphic map
(check box) 1
DEPTH DRILLING
sOtG
From To , Formation pien—- J`7/5I `/05'
r—
C)
LOCATION SKETCH ;;,)
I r +/_ c _ _ _. Show direction and distance in miles from at least
1 I . DISINFECTION: Type- �T�-; Amount---r.-1�--'-uf�'
12two State Roads or County Roads. Inside the road
. CASING: Wall Thickness Depth Diameter or W'eight/Ft. Material number • and common road names. _ r, `-
1l5 Ft. PVC' e
From O �o_
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
FromOO To P.O Ft. 9/)_41-m.7" ' 01
From__ To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. -
16. REMARKS:
I 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
GSfTURE F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenter, R8Vgh, NC
27699-1636 Phone No. [phone], within 30 days.
v
0

302134
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) IFRRY WATKINS CERTIFICATION #2457
WELL CONTRACTOR COMPANY NAME
HIQCRY 41FTI IFIILI CO. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT/ -- (if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential% MunicipaVPublic ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: KYCaAN1U
PERSINNQd ID.
County WPK E
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: AlAN RCUTSCN
Address 1392 WA1(FTEID VAII.FY RD.
(Street or Route No.)
NEW 1,01131CR. MARY1AND 21776
( 410). or Town
63 i-6881 Sias Zip Code
Area code- Phone number
4. DATE DRILLED (XN03-04
5. TOTAL DEPTH: 225
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO g(
7. STATIC WATER LEVEL Below Top of Casing: /d) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
`Top of casing terminated actor below land surface requires a
variance in accordaaa4r1th 1SA NCAC 2C .a115,
9. YIELD (gpm): tbitJ/ METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type H1H M it Amount 1
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 84 Ft 6V' 1'WC PLASTIC
From To Ft.
From To Ft.
13. GROUT: Depth Material
0 From To 20 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.
Frorrt—.—To Ft.
13Y AIR TEST
Method
FaRED
16. REMARKS:
,ocpis
Topographic/Land setting
❑Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check boa)
DEPTH DRILLING LOQ From To Formation Description
00
LOCATION SKETCH C rn
Show direction and distance in miles from at least CO rn
two State Roads or County Roads. Include the road
numbers and common road names.
ek
6
I DO HEREBY CERTIFY THAT THIS WFT.3 WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTtOIiSSANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WFT.1 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

302133
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) IFRITT WA'IKINS CERTIFICATION k 2452
WELL CONTRACTOR COMPANY NAME HT(W1W WFT I urn I TN; co. PHONE s 1 23 '174-(1135
STATE WELL CONSTRUCTION PERMIT./ ASSOCIATED WQ PERMIT$
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): ResidentiaE Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: VAWFSE County FIWK
784 FERMIS RQ SE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 784 JERKINS ID. SE
(Street or Route No)
VATS, IC 28690
LWIGTSUL
City or Town State Zip Code
628 )- 879.8003
Area code- Phone number
4. DATE DRILLED 09-01-{Yt
5. TOTAL DEPTH. VS
6. DOES WELL REPLACE EXISTING WELL? YES (XXNO ❑
7. STATIC WATER LEVEL Below Top of Casing: 62 FT.
Mae "+" if Move Top of Casing)
S. TOP OF CASING IS 2 FT. Above Land Surfaces
•Top of casing terminated actor below land surface requires a
variance in accordance with 1SA NCAC IC .01111.
9. YIELD (gpm): 75 METHOD OF TEST BY AIR TEST
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude sou rce:OGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
11. DISINFECTION: Type HMI TARS
12. CASING:
Tod D,t�t °�
From_0 58 Ft O"4
From_ To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. GMT R1RTn
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 55
Wall Thickness
or Weight/Ft. Material
BC PLASTIC
-o
tJ
Z
LOCATION SKETCH p
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road �p
numbers and common road names.
/V �i,LV
‘-_ yGtoOsE
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCO
CONSTRUCTION S,YP 4DARDS, AND THAT A COPY OF THIS RECORD HA
aid o2s�
SIGNATURE OF PERSON CONSTRUCTEN
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
ANCE WITH 15A NCAC 2C, WELL
PROVIDED TO THE WELL OWNER
/Ve
ATE

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prtnt) Pfl1L PAWIE CERTIFICATION Y 2609
HIOCRY1,11I IRILLEC CD.
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
302132
PHONE a 8) 324-003.5
1. WELL USE (Check Applicable Box): Residential W Municipal/Public 0 industrial O Agricultural O
Monitoring O Recovery 0 Heat Pump Water Injection O Other O If Other, List Use
2. WELT LOCATION:
Nearest Town: ICPBI) County BUI6(E
3040 REEF RD.
(Street Name. Numbers, Community, Subdivision, Lot No, Zip Cade)
3, OWNER: DYE E ERWA4 NIE HILDEBRAN
Address R) Ill( 1W/ ST. 30
Q-ar% 3*1-1007
City or Town Siate
j- 373-4220
Area code- Phone number
4. DATE DRILLED 09.14-C4
5. TOTAL DEPTH: -V-;
6. DOES WELL REPLACE EXISTING WELL? YES 1 NO O
7. STATIC WATER LEVEL Below Top of Casing: 58 FT.
(Sae^+^ if Above Top of Ca®a)
8. TOP OF CASING IS 2 FT. Above Land Surface'
*Top of cuing terminated aelor below laud surface requires a
variance in accordance with ISA NCAC 2C .01111.
9. YIELD (gpm): 10 METHOD OF TESTBY AIR TEST
10. WATER ZONES (depth):
rap Code
Topographic/Land setting
ORidge OSlope CIValley OFlat
(cheek appropriate box)
Latitude/longitude of well location
(degrtechninticalseconds)
Latitude/longitude source:OGPSOTopograpbic map
(cheek boa)
DMA DRILLiNG LOG
From To Formation Description
11. DISINFECTION: Type HIH TABS
12. CASING:
Depth Diameter
From__(_ To Q+ Ft fay'
From_ To Ft
From To FL
13. GROUT: Depth Material
Frotr1_�_ To_22 Ft, OnTr
From_ To FL
14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft._in. in.
From To FL in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From,_ To Ft.
Amount 106
Wall Thickness
or Weight/Ft Material
m1r PI ACM'
16. REMARKS:
Method
Fa RFD
CD o7r
.� `_
N ,
rro
-a rn
iV ,c)0
00
mrvi
LOCATION SKETCH
Show direction and distance in miles from `2._
two State Roads or CountyRoads. Include road 3 --
numbers and common road names. t N o
O rt
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO/ OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
f Of A`dm . i 09=23-Q'f
SIGNATURE OF P%S0 NSTRUCTING 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-1 REV. 07/2001
•

302130
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) BILL UMW LaxITSICATION# 23+7
WELL CONTRACTOR COMPANY NAME t-T C1TRY WF11. rim LIN CO. PHONE # 1Q8) 324-0035
STATE WELL CONSTRUCTION PERMITS —ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residentialf Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION
Nearest Town
1844 KNIA FICPA RD.
County [[WE
(Stint Name, Numbers, Canmrmity, Subdivision, Lot No., Zip Code)
3. OD'>I CLEK
Address 1844 FLNA1 FI RA RD.
,ANC 28761)
Croy et Stele Zip Code
(�- 584-1F114
Area code- Phone number
4. DATE DRILLED 05-28-04
5. TOTAL DEPTH: 400
6. DOES WELL REPLACE EXISTING WELL? YES)121 NO 0
7. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(use 'v^ If Above Top of Cashed
8. TOP OF CASING IS 2 Fr. Above Land Surface`
*rep of awing terminated aaor Mew Ind surface requires a
'arbor: In atardance with ISA NCAC 2C AlIL
9 YIELD (gpm): 5 METHOD OF TE51BY AIR TESL'
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(der«aman mreeeoads)
Latitude/longitude source:❑GPS❑Topographic map
(dtertbox)
REM pRILLING LOCI
From To Formation Description
11. DISINFECTION: Type HTIl TARS
12. CASING:
Depth grster
From 0 To 58 Ft.
From To FL
From To FL
13. GROUT: Depth Material
From_0_ To 20 Ft. Mel TT
Ft.
Diameter Slot Size Material
FL_io. ion.
Ft._in in.
From(_ To
14. SCREEN: Depth
Front To
From To
15. SAND/GRAVEL PACK:
Amount 82
Wall Thickness
a Weight/Ft. Material
(NV. S1FEL
Method
RI RFD
Depth Size Material
From To FL
From To Ft`_
.C-
cif
-0
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include the rol3
numbers and common road names.
t
meetiten,,,
J
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
06-09-C4
SIGNATURE OF PERSON TRUC ING 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. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME Quiet) BILL LAMBERT CERTIFICATION* 2347
WELL CONTRACTOR COMPANY NAME HTCKfPY GIFT T DP TT T TNa CT) PHONE * (823 S74-n035
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
302143
1. WELL USE (Check Applicable Box): Residential fl Municipal/Public ❑ Industrial ° Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water le jecdon ° Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Ton MORGANI'ON
2817 HARDWOOD HILLS DR.
(Street Name. Nwtben. Community, Subdivision, Lot No., Zip Code)
3. OWNER- JASON SMITH
Address 908 DREXEL RD.
(Sweet or Rouse No.)
VAT DFSF., NC 2R690
City«Tam StiesZIP Code
(828 )- 430-7542
Ana code- Phone mwaber 05-17-04
4. DATE DRILLED
5. TOTAL DEPTH. 340
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 4
7. STATIC WATER LEVEL Below Top of Casing: 1 0—FT.
(Use''+" if Above Top of Casing)
B. TOP OF CASING IS 2 FT. Above Land Surfaces
"Top of cuing termiaated at/or below land earfan requires a
variance In accordance with ISA NCAC 2C .0118. BY AIR TEST
9 YIELD (gpm): 100 METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth Diameter
Fromm To 154 Ft 6P"
From To FL
From To FtFL
County BURKE
HTH TABS
Topographic/Land setting
ORidge °Slope OValley °Fiat
(check
appropriate box)
Latitude/longitude of well location
(degnee/mimwalseeoods)
Latitude/longitude source:OGPSOTopographic map
(check box)
p� DRILLING I Ix
From To Formation Description
0
t!f
ry
J
LOCATION SKETCH Q
Amount 42 Show direction and distance in miles from at lead -
Wall 'Meknes* two State Roads or County Roads. Include the mad
or Weight/Ft. Material numbers and common road names.
PVC PTASTTC nl
13. GROUT: Depth Maw
Ft GROUT
Method
From 0 To 20 POURED
From To
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. h i. D� z
From To Ft. --ill. in. liIOi�� i' -
15. SAND/GRAVEL PACK: yt
Depth Size Material
From_ To Ft '�
I.
From._ To Ft- }t! Ill v 5
16. REMARKS:
/7GPtifa
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF PHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/3a/fat / o7 ) n5-7n-n4
SIGNATURE OF PERS CON31RUCfING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Sectlon,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 (INDIVIDUAL) NAME (print) BTT I. ) AMBFRT CERTIFICATION 2'147
WELL CONTRACTOR COMPANY NAME HICKORY WELL DRILLING CO. PHONE N (82$ 324-0035
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
302142
1. WELL USE (Check Applicable Box): Residentialg( Municipal/Public ° Industrial 0 Agricultural 0
Monitoring 0 Recovery ° Heat Pump Water Injection 0 Other ° If Other, List Use
2. WELL LOCATION:
Nearest Town: VALDESE County BURKE
2981 FLAT GAP ROAD
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
TERRY JACUMIN
Address PO BOX 2587
Da rNC I1t3619
City or Town Sie Tip Code
( 828)- 443-6270
Area code- Phone number
-' 7 -r 4. DATE DRILLED 05-17-04
5. TOTAL DEPTH: 405
6. DOES WELL REPLACE EXISTING WELL? YES KK NO 0
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Tap of Ca'ag)
S. TOP OF CASING IS 2 FT. Above Land Surface'
*Top of easing terminated atfor below land surface requires a
variance in accordance with ISA NCAC 2C .011t
9. YIELD (gpm): 1 METHOD OF TEST BY AIR 11 ST
10. WATER ZONES (depth):
Topographic/Land setting
°Ridge °Slope °Valley °Flat
(cheek appropriate box)
Latitude/longitude of well location
(degrees/minutegmeonds)
Latitude/longitude source:°GPS°Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH t
11. DISINFECTION: Type HTH TABS Amount 72 Show direction and distance in miles from at least '"
12 CASING: Wall Thickness two State Roads or County Roads. Include ties; road
Depth Dimmer or Wa Material numbers and common road names.
PVC PLASTIC
From 0 To 68 Ft 64
From To Ft.
From To FL
13. GROUT: Depth Material
From 0 To 20 Ft. GROUT
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
POTiRFT)
4/0 Id vor
gal Ili&
Mot-4 '
5
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS R,CORD HAS BEEN PROVIDED TO THE WELL OWNER
`rr'c'c 05-25-04
SIGNATURE OF PERSON CO U G 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
•
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t?

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMITI)
(if applicable)
Robert Miller
304668
Division of Water Quality - Groundwater Section
SAEDACCO, Inc.
ASSOCIATED WQ PERMIT#
(if applicable)
CERTIFICATION k 2675
PHONE N [phone]
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 121 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest TownJjl ft%k'C' County_fi tAe.Kt/
/NMa1a] a
(Street Name, Numbers,yCommunity, Subdivision, Lot No., Zip Code)
✓
3. OWNER: 'IDtV'/�'a �. Ma_t t•
Address/dd-la a
(Street o
WteN -#t llte rR; )i o.)
City or Tokv Site �•/ Zip Code
( )-
Area code- Phone number
4. DATE DRILLED %c —,ic' Q S
5. TOTAL DEPTH:7,(j'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO>
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ® FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth):
II. DISINFECTION: Type
12. CASING:
Topographic/Land setting
❑RidgeSlope ❑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
7N S' t t S kx1)
Depth
From a To
From To
From To
13. GROUT: Depth
From a Tot? Ft.
From To Ft.
14. SCREEN
From
From
15
From 3' Toalit Ft. 30
From To Ft.
Amount
Wall Thickness
Diameter or Weight/Ft.
Ft. X„ S6il vc
Ft.
Ft.
Material
PV C'
Material Method
POfan jii\ AD(
Depth Diameter Slot Size Material
To Z(Y Ft. 2" in. ) ()IQ in. PV C1
To Ft in
SAND/GRAVEL PACK:
In
Depth Size Material
gi tick _CAP
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.
M(N 5-t*
16. REMARKS: f' Qe a—oN,+'e Sea) V to 3'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. &NS' 11IA7A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
10 - 2),. 04
NATURE OF PERSOyO 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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Robert Miller
WELL CONTRACTOR COMPANY NAME SAEDACCO, Inc.
STATE WELL CONSTRUCTION PERMITq
(if applicable) ASSOCIATED WQ pERMITq
(if applicable)
CERTIFICATION q 2675
PHONE # [phone]
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 3 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N:
Nearest Town: F€N At live, County 1't„'rk-c'
)01 may, s.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ,fty q t S f ArK.T
Address J Ala I,/d S t
cult/ .4cStmore RouNNC, )
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED / Zo-G'
5. TOTAL DEPTH: ID`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
)31
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use " ' if Above Top of Casing)
8. TOP OF CASING IS a 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 OF TEST
10. WATER ZONES (depth):
Topographic/Land setting
❑RidgeyeSlope 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 „°ol Locrnatiya Description
iNJ7(
11. DISINFECTION: Type
12. CASING:
Depth
0
From To1_
Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
Diameter
I
Material
From__ To 21 Ft. Perm ,u)
From To Ft.
14. SCREEN: Depth ` Diameter Slot SizeMaterial
From 5 ' To 10 Ft. 11' in I Ol ® in. FV V
From To Ft. in. in.
15. SAND/GRAVEL PACK:
3 s Depth t Size
From To 2.0 Ft.),So_
o
From To Ft t�---
Amount
Wall Thickness
or Weight/Ft. Material
ST41110. pv c
{Method
pour
Material
C`i. 5.44
304667
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.
0-1,2Ktigt eh,
9 Ci
L
N
16. REMARKS: l gevioN LIe Seal t• -o ? I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD SfAi11Di THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SfUNATURE OF PERRSS7N 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
C71 ('
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J

WELL CONTRACTOR COMPANY NAME SAEDACCO, Inc.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
304666
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Robert Miller 2675
CERTIFICATION #
PHONE # [phone]
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring N Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N: �
Nearest Town: &l Wu 49 »Nt?, County es, ,,ate,,
/aa .fria iA/ J'I,
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: /vtoftddly's sot.
Address %0i - a Jaf sT
(Street or Route No.)
(clew dlipme NCi
City or Tow Site Zip Code
(
Area code- Phone number
4. DATE DRILLED / -,k% ••J 9
5. TOTAL DEPTH: Lici '
6. DOES WELL REPLACE EXISTING WELL YES 0 NOS(
7. STATIC WATER LEVEL Below Top of Casing: 1,{' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS Q 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): METHOD OF TEST
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge X,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 Tn Formation Descripjion
iw
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To Ft. '3 (Gj-J 40
From__!__ TO i • Ft.--WT'' Stf% 4CD f7✓
From To Ft.
13. GROUT: Depth
From O To
From Q To
14. SCREEN: Depth Diameter Slot Size Material
From '-(fj' To LIS" Ft. " in. ,Q llO in. PVC✓
From To Ft. in. in.
15. SAND/GRAVEL PACK:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
erial numbers and common road names.
Material
Ft. rirt3,iid
Ft.
Method
thin
l /nj
Depth Size Material
From C? ' To tic Ft. ,%Z,G4 5/JIYj)
From To Ft.
also Sit,
Nc
fft4tj o
N.�
J J�
tS � -�-.
—a
16. REMARKS: a.; Re»kN//e, Sew 3G. to 38)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, A • T ' COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/0- / Oy
RE OF PERSO 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
J • r.
•

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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME SAEDACCO, Inc.
Robert Miller
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
304665
CERTIFICATION # 2675
PHONE # [phone]
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring El Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest Town:.•: At/N6/CountyJ1 i�ti'.IV�
/Oil'Many S
(Street Name, Numbers, Community, Subdivision Lot No., Zip Code)
3. OWNER: AltA/Ayl'S /'14rr )
Address /0/ Ala N (>�
Street or Route No.)
6teA, 4e INe No
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED /0 - z /—O lY
5. TOTAL DEPTH: AO t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO)51
7. STATIC WATER LEVEL Below Top of Casing: / el) FT.
8. TOP OF CASING IS (Use "+" if Above Top of Casing)
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 OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth I Diameter or Weight/Ft. Material
From 0 To 5 Ft. l" 5 It'1YQ ftC/
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To__/,' FL -nano ecvars
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From S' To?)?' Ft. 7.," in. , ode
in. pt
From
To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 3 i To )...0° Ft. 2Si t ICC!. S440
From To Ft. �`'�
Zip Code
Topographic/Land setting
DRidge lope OValley OFlat
(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
N fiti CCU
2 d'
LOCATION SKETCH
Show direction and distance in miles from at least _
two State Roads or County Roads. Include the road
numbers and c. mon road names.
3
Maui y'1.
16. REMARKS: J' UGNf4Nit°L Sea tO 3'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD i:�0i! I A A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G ATURE OF PERSO CONSTRUCTING THE WELL / DATE A E)11
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 - Dearman of Environment and Natural ivision of Water
to } O � Quality • Ckaaadwater Section
ti.a
wan COlYraACfOL RNLlVIDUA[a IWIaIE
fan r✓1 % rDi4 U ,r
cur>P[cwTroyqa.� y
WELL cor ucroatcouarANtrnnata PRICF WELL °PILLING, INC. mom p2$ 327 0268
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PtiMIT6
Ctf rabk)
1. WELL USE (Check Applicable Boa): Residential g/Mwicipai/Public C Iaduatial O Apiculture! D
Monitoring D Recovery ❑ Hat Pomp Water Nation 0 Other 0 If Other. List Use
_Zrop° � m
Ladoga OSlope DVaIl DFIS)
(clack fppmy,iaeeteees) (
Labmddloogit de of well loadoe"s
(a) sT
Laattiluddlmyimde aomee.OGPSOTopopaphienk urap
t�� 6 D.ECI1I ( pRJLUNG LOG
From To P....pnDaaiption
Of applicable)
I DO HEREBY CERTIFY THATTIES WELL WAS CONSIRUCIED IN ACCORDANCE Wrrx ISA NCAC 2C, WEIL
CONSTR ST AND TACOPY OPTHIS RECORD HAS BEEN PROVIDEDTO MIR WEIL OWNER
SIGNAId1R6 OP PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Seaton, NM Mall Ser4e Cesar - Raleigh
27655-1626 Thew No. [phone], within 30 days. GW-1 REV.
NC
07/2001
2. WELL LOCATLp]R
Nearest Towm /17nr,7 *Ian County at-t a C.
( (Save Nam. (Number. Mean*aSubtsim la Ne. tt Code)
3.OWNE Los/ «ra," i
Address �— � � 1 l/1 ! C-
g19(9 Cogs,
4. DATE DRILLED
S. TOTAL DEPTH:
Rae. No.)
Zip Can
cc)/2 c
Jiaa /r
it
6. DOES WELL REPLACE EXISTING WELL? YES CI NO a; r y i3
7. STATIC WATER LEVEL Below Top of Genius; o p 14q a F i r/ f'
/ (Dar*" if Men Tay dCa
S. TOP OF CASING IS / t PT. Above Land Surface*
RN atadas sannYaad taw Ina had sten rants ■
imbue lb aaerdu *a lM EGAC2C MIL
v. Wit'IgTFIOD OF TEST H/ri 1L0
10. WATER ZONES (depth): 13 safS a''Peri
11. DISINFECTION: Type ,l ate ft ii• Amount in . tA r
12. CASING: Wall Thitaa
From n TDooaFt th ` a Weight/Pc Marcia!
e
From_ To Ft. y
if
Fxtci To Ft
13. GROUT: Depeg1 )duo 1 ,
From C.I To O1� }t (..c acre, e
From To Ft
14. SCREEN: Depth Dimas Slat Sim Manal , /^
Fro_ TO��Ft S. '�h �. C� /"otl�1 s'
Prate.__ To
1S. SAND/GRAVEL PACK:
Depth Sim
Fron`__To Ft_
From To Ft
in.
S.
Maeda!
rec m &.%
OLr t1 n: r
LOCATION SICE70
Show direction and distance in miles from at least
two Sense Roads or Catty Roads. Include the road
numbers and common road tames
\Ate 1 4
Cx``-13 45hL-0r�-17
( " /t u
!Arty
•
16. RncARICS: ea- t-'e. hI cAt-4:4_,,o t1. kr37 I- ea1�! / l3c2-S�repf
/

c /2u
293581
WELL CONSTRUCTION RECORD
Nosh Carolina • Departmatt of Environment and Naabn 1Jtnources ivWaon of Water Quality - Groundwater Section (�
i
WILL CONraACIOa (IINDIVWtit) / /UAL) NAME (PeH/7/" ,r- I coo 1.4 Lam. CERTIFICATION a //1 LJ
watcortrRACTOt coast ANTNAHE PRICF WELL DRILLIN„ INC. 'Borael9p2 Sii' 327 0262
STATE WELL CONSTRUCTIQN ruffian ASSOCIATED WQ FERRI=
(ita,plicable) (ifwvEcabk)
1. WELL USE (Check Applicable Box): Residential BIMuoicipal/Publie 0 Industrial O Agricultural O
Monitoring O Recovery ❑ Heat Pump Water Lpection C Other O If Omer List Use
2. WELL LOCATI
Nearest Toms n<,a/Sa»
Na Neabms. Cotam.A'. SM isita let No. Elp Cab)
3. 0
Address
'19f9 coI-
ran
Pas No.)
Do Coda
4. DATE DRILLED
S. TOTAL DEPTH.
6. DOES WELL REPLACE EXISTING WELL? YES O NO Br-
7. STATIC WATER LEVEL Below Top of Casing: OQ .
t/ ((He•r" ifAban Top otCa,b&
8. TOP OF CASING IS /4 PT. Above Land Surface*
'Tap et maim tendaaaed able Wow bar swim eguIrs a
Magee le aserdu wilt ISA MAC 2C.011L e I
o VIE!!' (spec,): _; D OF TEST As rj) `1C )
10. WATER ZONES (depth): / 3 d.S r 21' ,even
II. DISINFECTION: Type . l 6 /e 4.)-
IL CASING:
From n Toil 6. D Ft r / fr
Fromm To FL
From _ To Ft
13. GROUT: Depth fie itnal
Fron_tTo OI� Pt tiCieJe
Front_ To Ft.
14. SCREEN: Depth Dimmer
Froi_Tn Ft�pL
Frame__, To Ft
1S. SAND/GRAVEL PACK:
Depth Sine
Fro° FL
flwq _To Fe
I
Cam, Arc/L
"TFri
Olidge lop Malleysetting
Nock appmpS beet) I
Latitude/longitude of well location '14
CM t
(der tesmenarnstoo <) C.
Latitude langituda somee•.OGPSDTopographie map
(dr* bra)
gar 33ag )2E[mit DRILLING LOG
From To F Description
0 66
CO l a0
(faOo /' e'7S'
On5.13Olt
lI?s 133 r'
Amount a1 u LA -
Wall Mildness
or Weight/FL Material
pve
Slot Slla Matrix!
io.
in.
Material
I.
/K
/c
rce:r 6
D(�.r r.,:1-
LOCATION SKEI'CI{
Show direction sad distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad names.
Fct )—f3 45 h 't h
f It 0 An
. Grahys
16. REMARKS. ea' t d; tctTL %1 y k)ZPG e t ill/ yv .5 rep JL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WflI.
CONSTR/�J T ARDS AND A COPY OF THIS RECORD HAS BEEN PROVIDED TO7 WELL OWNER
SIGMA. OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, lei Man Service Cass - Raletga, NC
27094636 Mae No. [phone], w8bia 31 day& GPM REV. 07/2001

WELL CONTRACTOR (UIW VIRUAIJNAME
WELL CONSTRUCTION RECORD • 3 0 5 4 9 8
North Carolina - Department of Environment and NMual Resources - Division of War Quality - &mmdrwlc Section
Qv r Rasae_.3c cmuksnon a el(CV)
WELL COA"TRACroR COMPANY NAME S4C 1, VEIL Ari i t :Div Pions s 04 72Y-t.c41P
STATE WELLCOtCraLCTOR mmatrro _ A 4:n'tno WQ scams
Of (iifapptiaSe)
I. WELL USE (Check Applicable Box): Residential iDgdaracipaliPubfic 0 Industrial 0 Agrieulunal O Monitoring[] Recovery 0 Neat Pub Watts -Injection 0 Other 0 If Other, list Use
2. WELL LOCATION: yn�
Nearest Tome 1:16ry k..1/4J txuoly U s rL
tits OLp 14C- 16.r
ModNate. aea1beet.Cao cRA�d tmNe)
a,TipCo
3. OWNER:2(1L-1 (�, 1A/NA/LSEAddress 1`iS eLt4 •Nc iOC
Nela.as t tt; riteNO
Cayaum _mete Np Code
( } R%'&- (Al 3
Ana ads. Nan a ator
4. DATE DRILLED l0 -
5. TOTAL
6. DOES WELL REPLACE EXISTING WELL? YES L8J N0 a
7. STATIC WATER LEVEE. Edow Top o(Cao FT.
ttesiegy
8. TOP OF CASING IS . Above Lade Toe Surface
FT. Above Land Surf aces
a'ra►aa.laaaraamdwar Ards r.i..6.aaapi_.
vaaimtt e 5 .menlawe wi a ISA NCAC 2C .Era
9. YIELD (spar): is METHOD OF TEST A 1 y
10. WATER ZONES (depth* IP q p rvt (o t?
I I. DISINFECTION: Type
12. CASING:
el"
F��°�° �To /�/80L_��-T° v$
FrooLLt'
Topographic/Land setting ."
O alley t
Meek apiaritwaaa)
WitadS1ongimde of well location
MaresAuimoiestecoadO
Lx eRo de soaacm OGPSOTopographic map
tents)
wit DRILLING LOG
From To Formation Description
V- taw
/% -0
/Y 9- - ,'3 t
ik 4'- /tlecile
ire- '1a5 - lrur� Ze
LOCATION SKETCH
it. Lont ry Q Ammo ci 07 7 it %Show direction and distance in miles from at last
Wall7Lidaem two State Radom County Roads, iuslade the mad
wet
pan oemuaraaad aka ruin oases.
�(Q
13. GROUT: Depth Material Method
Fronk_ To FL
rum fl--Ta .4L2 PthiAled
�—
Froml_____To FL ____ AIL
SCREEN:
14. Depth • Slat Sire M awa
From To un
15. SAND/GRAVEL PACK: 16 it
DIM& Size Maerial
FrOIII To Ft-
F_-To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT
CONSTRUCTION ST---- / WELL WAS COICTRUCt$3INACCORDANCE
0
r
/V ateliid f Lei
3
I
AND THAT ACOPY OFTHISRECOED WITH 15ANCAWELL
�IASBF.E)IPROVIDF.DTOTHE WEIL OWNER
Ct
CD
SKGIATLtREpt)Pnivr�r:win..UCTINf'THE WELL DAB tq,y
Subunit the origisul to the Divides of WaterQu�y, Groradwater Section,1636 Mad Service Cana_ Raleigh, NC
27699-1636 Plea Na. ip19) 733 32T1. within30 days.
OW -I REV, 07r100i�

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pMt) WITT. PATSI IF. CERTIFICATION sue_
HE
WELL CONTRACTOR COMPANY NAMEtill MUM C' PHONE it Q) 324-0035
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMTT,
(if applicable) (Ifappliable)
1. WELL USE (Check Applicable Box): Residential SIC
Municipal/Public Cl Induebial C Agricultural O
Monitoring CI Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
NearestTownL.JWINRN County EWE
T)1 .II; WTI cal 'ST
Came Name, Numb tbmmmi4, ssuvwa. tatN0. Zip Cede)
3. OWNERtDMl8ONR RNSFY
Address T)1 .II; WTI ciN Cr
tortM rbC 7I55
City or Ste
(R7R)-
4S491F4
Areaoed..Pbaeamber
4. DATE DRILLED u-O 24
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO lt;K
7. STATIC WATER LEVEL Below Top of Catchup SFr.
Warta SAW,. Tap OMSK*
8. TOP OF CASINO IS 2 FT. Above Land Surface
'Top of coelq ambient akr below led man require a
esthetes la seowdareewab Y3A NCAC 3C Silt
9. YIELD (gpm): 15 METHOD OF TESTS' AIR IPSI
10. WATER ZONES (depth):
TO Code
11. DISINFECTION: Type HIE 'MPS
12. CASING:
Depth
From D _To 155 Ft riff
From_To Ft
Fronk_To ur-
13. GROUT: Depth Material
From 0 To 70 Ft GIMP
Amount 54
WaR ThiBaa
or_W:R. Material
GALT. Sall,
Method
Topographic/Land setting
ORidge OSlope DValle9 °Fiat
She*appropdatebmt)
La6R ielio girndeofwelllocation
(desw Wodamesieeaadr)
Latitudefiongitude source:OGPSCITopoglaphicmap
toxic box)
Dmmi MILLING r41(
From To Formation Description
From_ To Ft
14. SCREEN: Depth Views Slot Sim Material
From__ To_ Ft in. in.
From__ To Ft_n. io.
15. SAND/GRAVEL PACK:
Depth Sire Material
Fromt_To Ft
From_TR Ft
16. REMARKS:
0
vh
r-
w
LOCATION SKETCH -a
Show auction and in miles from at Swat
two State Roads or County Roads. Include thorned
milers and common road names. 0
of N J4ry
Ncuy, /Zb .J
W 7 e
s
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SANCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY Of THIS HAS BEEN PROVIDED TO THE WELL OWNER
SIOt1A1tJRE OP PERSON 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. OW -I REV. 07/2001

300024
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (erns* fiL PARLXI; CEIXrDnent:to it 2609
WELL CONTRACTOR COMPANY NAME I4T(K(RS'tH1. T1 T1T 1N; m non is fa 3744115
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (Iiapplicable)
I. WELL USE (Check Applicable Box) Residential MC MudcipaYPublic 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water bijeudion 0 Other 0 If Other, List Use
2. WELL LOCATION:
NearestToWDLj)Wf (TWIT IF County PURIM
9{RTY MRIFR TY)4T)
(SI NNName, Numbs. tammmay. SebdiS Lot*. Zip Code)
3. OWNER:_ (JFN)4 R 1+TVJN ATTFY
Address Tn P(H F(%17
OnectaSsNA)
Matt, is 28603
Cray arTea Sete Sip Cede
ea.> 495-7416
Ana code- Mena amber
4. DATE DRILLED C9-29-o
5. TOTAL DEPTH: 285
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ear
7. STATIC WATER LEVEL Below Top of Coin' F!1 FT.
mewNAboarT parcme)
8. TOP OF CASING IS 2 FT. Above Land Seam`
'Top of aches terminated atlw below had man neaten a
reduce In accordance with ISA NCAC 2C A13t
9. YIELD (gpm): 100 METHOD OF TEST BY AIR 'TFSr
10. WATER ZONES (depth):
11. DISINFECTION: Type Hill TARS Amount 47
Wd Thebes
D or WeigWPL MMrad
Ft,6T' RC PLASM
itc
12. CASING:
Front 0 TO116
From To
Prom__ To Ft
13. GROUT: Depth Medal Method
From 0 To 20 Pt_grl TT RIPFfl
From To Ft
14. SCREEN: Depth Disaster Slot Size Mmeth
From To Ft io. in.
Front To Ft in. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft
F To Ft
16. REMARKS:
Topographic/Land setting
°Ridge °Slope °Valley °Flat
(duck appropdmebo4
Latitude/longitude of well location
Lath ulollongnude aata OGPSE Topoga_hic map
Net WO
LOG
RUM MILLING
From To Pomade°Dacription
n
%
•
a
en
c.7
Show d'aectian apol rfatence in males tom at least
two State Roads or Caoesay Roads. Include the road
ants and common toad flames.
W
!Y
),81a` SiHA en
oap,
N
0 (cN/eW
S
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WEIL
CONSTRUCTION STANDARDS, AN�D77�LH,A, TA COPY OP
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
u 1.( �I'! rh (�f/ � u (®ificedSIRUCTRI0
SIGNATURE OF
1OM54)+
THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Malt Service Center - Raleigh, NC
01
27699-1636 Phone Na Q19) 733-3221, within 30 days
ece

306623
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) NEEL PAFEUE CERTIFICATION II 2609
WELL CONTRACTOR COMPANY NAME HT(T(CIiY WFI I TYi1T I T r, m
STATE WELL CONSTRUCTION PERMITI ,ASSOCIATED WQ PERMITS
(if applicable) (ifapplicable)
PHONE a (828) 124-(1)15
1. WELL USE (Check Applicable Box): Residentiana Municipal/Public O Industrial O Agricultural 0
Monitoring ❑ Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WEII LOCATION:
Nearedown••__Y County RIEKE
(Street Name, Number, Community, Subdivision, Lot No., Zip Code)
3.OWNBR�C P'tV
Address
(Scutt or RetattNa)
(TPNFTTY SFRTNS, TQ. 28617
City
eer 4 Stile De Code
(82838-9027
Area code- Phone number 10-14-0 i
4. DATE DRILLED
5. TOTAL DEPTH. Gfi5
6. DOES WELL REPLACE EXISTING WELL? YES ggt 6 NO O
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'W' if Move Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface°
*Top of easing terminated abut below lead sedate modem a
variance in atterdauce wish ISA NCAC IC Alta.
9. YIELD (gpm): b METHOD OF TEST BY AIR TEST
10. WATER ZONES (depth):
Topographic/Land setting
ORidge OSlope Walley OF)at
(cheek appropriate box)
Latitude/longitude of well location
(depamfminutedaecomb) ..
Latitude/longitude source:OGPSOTopographie map
(duck boa)
DEEM DRILLING LOG
From To Formation Descnption
11. DISINFECTION: Type I(Idi TARS
12. CASING:
Depth Diameter
From 0 To 1 CA Ft CV'
From__ To Ft
From To Ft
Material
13. GROUT: Depth
From 0 To 20
From To Ft.
Amount //
Wan Thickness
or Weight/Ft. Material
PVTC, FTASTTC
FtGRCUT
14. SCREEN: Depth Diameter
From To
From To Ft._in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
Method
ECLEED
Slot Size Material
in.
in.
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.
oe4
le
� s9'w,6L
5
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
f rid 6zti, r. jJJ 10-21-C)
SIGNATURE OF PERS CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, GroundirS S4ction446 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. OW-1 REV. 07/2001
SE6I rJ7i
u ._

FROM : MORETZ WELL & PUMP
FAX NO. : 7044621322 Jan. 05 2005 10:14AM P4
widow togaerdsau AKAT2C.911/.
YIBI.D (wm) .- L�METHOD OF 1
STATE WELL CONSTRUCTION Itintr a 4aanr•r,2yn WQ mans !!4
(irerft)- fdepelioebtel
WELL CONSTRIMIO Y REC.,QRD
North Carolina • Deveriment of Environment and Natural Resources - Division of Water
WELL cm:macron WmIVSDVAt,) NAME aw1aA AS HLEY T pN Quality.OroonacA11dwater w0Sec_2
WELL 4R rp CRRTLYSCATt462-1.6
CONTRACTOR coMpAivyN,dn:r, MORETZ WELL DRILLING
room a I701r,4 ra 2 -132 2
1 WELL USE (Check Applicable Bonk Residential VMtaieipeVPublie O Industrial 0 Agricultural Cl Monitoring CI Recovery CI Hat pump Water Injection 0 Other D If Other, List UsO
2. WELL LOCATION: •//�� 11
Nearest T unty t Sri rice
a�1 Qry��
(Spew Name. Nowbow, Comma*. &tedthoa, tot No..2Ip Code)
3. OWNER: rpp t-Il i ve_ / s inr
Address x3/ ,�.i 7e- a : n r - r-
isme op _ no co
Jot -
Din Tows Sate zip cede
Ana aa/.Phone amber t 9 7
4. DATE DRILLED �(0
S TOTAL. DEPTH: fl/ 8Z
306109
4/4
Midge C1, v hey setting iat
(tot *PPmpdea nos)
(
Lntituddtongitude setmce: opog mop
DtH Moon bad
ro ARILUNG LOG
Frid/ott
�r OL
6. DOES WELL AEPLACEEXTSTINQ WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing . AQi T.
((he "t+' if Abort Top of Ceeaa)
S. TOP OF CASINO iS I , FT. Above Land Surt'ice"
'WsrofantraI..-'-- Sblowload eormmake e
9 STAr 1f P*
IO. WATER ZONES (depth):
11. DISINFECTION: o
12. CASINO: WAS nicks
Ivi
Emma,Ft. . �`A�% U! .
___- Ft -
From___ __To_ Ft
13. GROUT: t
From ins Toot 0 Fr CA
prom To Ft.
14. SCREEN: Daedr Dimmer
Fro
16. REMARKS•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC2C, WELL
CONSTRUCTION STANDARDS, AND THAT ,p COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
urancausuati
Show direction and fastanat in mike *met at least
two State Roads or County Roads. Include the void
numbers and common road mimes. 7
SR e-
51Tun
breoNsintucinNoT P WELL DATE
t.O
SabSt the original to the Dividon or Water Quality, Groundwater Seedon,1636 Mail Strohm Center -Raleigh, NC
27699-1636 Phone No. (919) 7333221, within 30 days. OW I REV. 07/2001

Nenh Crewe . Dspramnt of Environment and Natural ReseuttYs • Division 01 Warr avidity • Orourdwalar Section
an Mr Oeralae Coder - RS WI, N.C. 27ee11-1435-Phone (Iif) 732.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR.
WELL CONTRACTOR CERTIFICATION S: 2L�S
STATE WELL CONSTRUCTION PERMITS:
Lc),
305573
1. WELL USE ApplieMN trey: Rastdentlal EMuNdP$1 ❑ Industrial 0 Agricultural ❑ monitoring 0
Discovery Heat Pump Water Injection 0 Other Other. Ust Use:
2. WELL LOCH : (Show sketch of Me location below)
NesreeTren: 7S/1»7 Afs/i%ICptpdy; L%/t!'/J e
IRwad Nen relirdiers. Callselly.w8uediMenandLotNa) DRILLING LOG DEPTH
S. OWNER Al Jul Rem 70 FawasiDOOUIPIItel
Adda l23 « I .rr }An
ifr-
44141plaees
�zp
Cede -
4. DATE GRILLE ll,r0
5. TOTAL DEPTH , 2-S/
S. CUTTINGS COLLECTED YES 0 NOETZ
7. DOES WELL REPLACE EXISTING WELL.? YES NOD
B. STATIC WATER LEVEL Bab* Top of Casino: FT.
(fin' ' I MGM Top ei Curd
P. TOP OF CASING IS i# FT. Above Land Sunoco'
'rep et ease IraihMd ever Mimi land swarm Mass a s efeeee le scoot.
p YIELD (ppm): a— METHOD OF TEST !4/r-J1),. Jr
11. WATER ZONES (depth): 20 S
12. CHLORINATION. Type /ALkIP r Amount
13. CASINO: 5/2 '
was 1 flnsu
Depth tawnster rwalp*FL MM "M
Fran_ —To ! FL 4r 1�YC'
From To FL
From To FL
ti. GROUT:
M M Method
Front To Q C FL ,,I ' "�r re
Fran To Ft.
15. SCREEN:
Depth Domeier Slot Ski Material
From To Ft In. In.
From To __ FL in In.
Prom To __ FL_ In. In.
16. SAND/GRAVEL PACK:
Depth Size Material
From , To FI.
From To FL
17. REMARKS:
Depth
"077
a�
LOCATICS4 SKETCH
(Show Sato and fawn Wm a Nag two Ste
Roads. or otter n1a�Sens Oh*
Afireer
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. A O THAT ACOPY OF RECORD HAS BEEN PROVIDED TO THE WEILL Ou1iEP-
Do ICE
FOR OFFICE USE ONLY
Ond Ns:
NONATURE or PERSON CDNSTRUCtvs 1NE »ELL
SubnAOre toW1AbeelWar DWNI.Oroundestutarvdiilt71)GRr3
r