Cl CY2004

WELL CONSTRUCTION RECORD
298340
North Carolina - Department of Environment and Na
?y,f��e-
oral Resources - Division of Water Quality - Groundwater Section
A ,
\YELL CONTRACTOR (INDIVIDUAL) NAME (print) 5�
i/%0- LIP I ( I lY 1�i r
\YELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMITS/
if applicable
CERTIFICATION M o 3
PIIONE is fPY)'37-2997
ASSOCIATED \VQ PERMITH
if nnnlicablc
1. WELL USE (Check Applicable Box): Residential B Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: /7(7e--'o,a(e-
kA%eJon Cove "J.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. .SDe
Address tin rlC\t\CS.k. P -- —
(Street or Route No.) �eQ
at�iVPwAV wC Zip Code
OliA
City or Town State I
( )-
Area code- none number
4. DATE DRILLED °y
s TOTAL DEPTH: ,262o
County Clay
6. DOES WELL REPLACE EXISTING WELL? YES Cl NO 8"---
7. STATIC WATER LEVEL Below Top of Casing: /r° IT.
/ (Use "✓' if Above'fop of Casing)
8. TOP OF CASING IS / EF. Above Land Surface•
•Top or rising terminated at/or below land .':dace requires a
v.riunee In accordance with ISA NCAC 2C .0119.
9. YIELDrPnr„1 __/S ME'iunn(IF TTiSI /`ir
10. WATER ZONES (depth): z70
I I. DISINFECTION: Type //77/71
12. CASING:
Depth
From 0 To
Front %3' To
From To
13. GROUT: Depth
From
To .2-
Diameter
Ft.
Amount Itc-
Wall Thickness
or Weight/IT Material
SD�zf /VG
Ft.
Ft. _
Ft. tMatf al �1etbod
i-r/N4d GS/4-�C
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.
Slut Size Material
in.
in.
Material
Topographic/Land setting
DRidge ❑Slope OValley ❑Plat
(check appropriate box) '
Latitude/longitude of well location
Ns3tOb'4.0"Wc67 V9'941-)
(degrees/minutes/seconds)
Latitude/longitude source:UUPS❑Topographic map
(check bor)
PEPTI( pI_ILLINQLI,JG
From TO nnrnation Dcsaiptioil
—/5—
�s -orb
4. CH- .t, ,Lc_
O
0
}
om
LOCATIONiKH -;Et-
Show direction arid 0;gtance in mites f ] at1Psst
two State Roads or County Roams. `'•"O e tlg=ad
numbers and common road names. r'a''
t o
16. REMARKS:
1 DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WI111 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF 1111S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�=c�— Z z 6 a 9
SR NA RE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceentµerl Ralclgh, C
276g9-1636 Flame No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater S2ti4 r,
,n CERTIFICATION li i/'I"8
wFLL CON TRACTOR (INDIVIDUAL) NAME (print) j(}yVt P.s`
WELL CONTRACTOR COMPANY NAME IM l>'\.O�\( C 11,/1
ASSOCIATED WI) PERNITLIS
STATE WELL CONSTRUCTION 1't:RAtITB if in dicablc)
if sl plic9blc)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: ){A‘)Q Str S i t t County Cie A
�r 1, E t-ro\ ; COUP
(Sure Name. Numbers. Community. Subdivision. Lot No., Zip Code)
3. OWNERC (aCt
Address es e-Uslat} n&
(Street or Route No.) nLgQ
PyrarskewN QC2 402
City or Town Stale Zip Code
( )-
Alta code- Phone number -
4. DATE DRILLED —S-OC1
5. TOTAL DEPTH: f - ----
6. DOES WELL REPLACE EXISTING WELL? YES El NO ❑
7. STATIC WATER LEVEL Below Top of Casing: SO ` FT.
(Use "r" if Above Top of Caning)
8. TOP OF CASING IS I FT. Above Land Surface•
•Top or using terminated oVor below land surface requites ■
..rl.nre in accordance with ISA NCAC 2C.011R.
9. YIELD (gptnl _. S _ METHOD OP i PST A g_
10. WATER ZONES (depth):
PHONE II ft`7^) -2 ;7
Topographic/Land setting
❑Ridge ❑SlopeIley ❑Plat
(check appropriate box)•
Latitude/longitude of well location
A135°2' get) 1283C37'17 e
(degtees/minutet/second,)
Latilude/longitudc source:UGPSC_ITopographic map
(check bo t)
rn-r1-I PRILLINQIOG
Tl4• .
Front To Fnmiaticnr Dc cri nion
l �
II. DISINFECTION: TypeViSr-i'1 `01\9\-t
12. CASING:
Depth`� Diameter
I
Front PD To ' fC 1 Ft. LD, h
From To Ft.
From To Ft.
13. GROUT: Depth Ma(9ial Method
}l b—t-rrssu✓ p
Front r> To ,DF1 Ft. c, Q 3- 1..+: —•»-
From To Ft.
14. SCREEN: Depth Diameter Slut Size Material
Front To Ft. in. m.
Front To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount L1
Wall Thickness
or Weight/Et. Matctial
0
N
fV
tzt
ry-
LOCATIQNSISa11
Show direction niid distance in mites tR"Rist
two Slate Roads or County Roads. I:'rdc tcctoad
numbers and common road names.
16. REMARKS:
I DO I IFREI3Y CERTIFY THAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WH71 ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF 'FIBS RECORD I IAS BEEN PROVIDED TO TILE WELL OWNER
j— 5_��_
DATE
(2-2, Y7fiztA
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Uh Isloo of Water Quality, Groundwater Section, 1636 Mail Service Center REV- gh, C
27699-1616 Phone Nu. [phone], within 30 days.

299103
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LARRY F. JONES CERTIFICATION N 3295
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT', ASSOCIATED WQ PERMIT',
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ea Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE County CLAY
LANCE COVE RD TO COUNTRY SIDE LN
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: TOM GOTTLIEB
Address 116 SUNFLOWER CIRCLE
(Street or Route No.)
ROYAL PALM BEAt FL 33411
City or Town State Zip Code
( 561 ). 236-9351
Area code- Phone number
4. DATE DRILLED 07-01-2004
5. TOTAL DEPTH: 625'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: ISS' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface`
*Top of casing terminated aUor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 10 METHOD OF TEST AIR
10. WATER ZONES (depth): 590'
I I. DISINFECTION: Type CHLORINE
Amount 100 PPM
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 150 Ft. 6 1/8' SDR 21 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 20 Ft. CEMENT
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
Method
GRAVITY
Topographic/Land setting
]Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3503.902N/8350.810W
(degrees/minutes/seconds)
Latitude/longitude source:KlGPSOTopographic map
(check box)
DEPTH DRILLING LOO - From To Formation Description
0' TO 80' SAND
80' TO 100' RED CLAY
100' TO 120' BLACK DIRT
120' TO 150' GRANITE
150' TO 625' GRANITE
Slot Size Material
in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
C-
LOCATION SKETCH Show direction and distance in miles from atr e' st =
two State Roads or County Roads. Include the road -
numbers and common road names.
L,rwce caDVE fLp
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT • COPY OF T tS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�.. ! 7-i-D
SIGN 'URE v' PERSO COt, CTING 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- I 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)8NZ were)? CERTIFICATION #.3J
(7Y
WELL CONTRACTOR COMPANY NAME �J'r/4Sa/Ptt L)R/CL//✓6 ZINC. PHONE If IZ 7y -- 66
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT%
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er-Municipal/Public [7 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: LU9RNE County CI
//R wAire oA ic DR. t-C'RNC- NC 775
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:Dr7V//D MILLER
Address /52 //17W. kNo(_ I g u
(Street or Route No.)
evARAlc 28909'
City or Town State
(22)- 359-9364'
Area code- Phone number
4. DATE DRILLED 7-13 -Cie/
5. TOTAL DEPTH: 3 2 S r
Zip Code
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: (S FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 02 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in aeardaase with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TESTIP
10. WATER ZONES (depth): /40
11. DISINFECTION: Type Td
12. CASING:
Amount 7 E
Wall Mites!
3 opographic/Land setting
£rdge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
fia4Cn 967 wo P3 St 77/
(degredminutet/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From - Tq AFoSO CD8 lion
Pe;9-Bien&.d CLAY °'/.wits
Erg ✓ Rae* 60/Ator/e/C/C4
c2J, iE Xgcft ArAi/C2
coo T-C/7P c-k
"/A/Jn as/@v %?,ak
ices— o a s
5 ---- n?tC
aS-.2-2S
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
7 Depth Dice � orWight/Ft ;ten: numbers and common road names.
From To 35 Ftt " t"
Fro .3.5" To f7 Ft <; %Y ,C'D/?2?T.S pvC
From To Ft
13. GROUT: Depth Material
From ` 2 To C9 Ft CC-PVC-w r-
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
OROWi'
16. REMARKS:_ -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST S. AND THAT A COP THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
'�` 41- �
SIGNATURE OF PERSON CONSTRUCTING THE WELL
7- /3 - Dq
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) LARRY F. JONES CERTIFICATION f 3295
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMAPNY, INC. PHONE S [phone]-
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
299646
1. WELL USE (Check Applicable Box): Residential El MunicipaVPublic ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE
MCCLURE POINT
County CLAY
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DARRELL LAIL
Address 1342 BEECH CREEK RD
(Street or Route No.)
ROBBINSVILLE NC 28771
City or Town State Zip Code
( 828 )_ 479-8028
Area code- Phone number
4. DATE DRILLED 07-13-2004
5. TOTAL DEPTH: 585
6. DOES WELL REPLACE EXISTING WELL? YES O NO El
7. STATIC WATER LEVEL Below Top of Casing: 120 FT.
(Use "N if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Top or casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 20 METHOD OF TEST AIR
10. WATER ZONES (depth): 540'
I I. DISINFECTION: Type CHLORINE
12. CASING:
Depth
From 0 To 70 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 20 Ft. CEMENT
Amount 100 PPM
Wall Thickness
Diameter or Weight/Ft. Material
6 1/8" SDR 21 PVC
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Method
GRAVITY
Slot Size Material
in
in. p
Material y
Topographic/Land setting
®Ridge ['Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3511.835N/8407.472W
(degrees/minutes/seconds)
Latitude/longitude source:RIGPSOTopograp c map
(check box) --_.-
DEPTH DRILLING LOG
From To Formation Description
0' TO 40' RED CLAY/SAND
40' TO 70' RED CLAY/GRANITE
70' TO 585' GRANITE
(-v
HARD GRANITE
LOCATION SKETCH '='
Show direction and distance in miles from at-1•east
two State Roads or County Roads. Include throad, --
numbers and common road names. tv -'
CO o
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT Al PY OF THIS/TORE) S BEEN PROVIDED TO THE WELL OWNER
SIGNA !'' OFPr e
N CO
ST
713_011
NG TILE 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-I REV. 07/2001

NC V UHNEN
MWO
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nnlllgyal Reesour s - Division of Water Quality
WELL CONTRACfOII (INDIVIDUAL) NAME/((pprrint)r
Ellie/ _ eCL
WELL CONTRACI.Ott COMPANY NAME /! / //a'%
299704-
- Groundwater Section
CEn IIFICATION W �jti-5>
ruone e ( Y.37 -(`/C7
STATE WELL CONSTRUCTION rERMI rM ASSOCIATED WO ramie
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential LB' M1luuicipal/Public ❑ Industrial ❑ Agricultural 17
Monitoring ❑ Recovery ❑ tienl Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: (--1-)4/1' E
(surd Name, Numbed. Community, Subdivision, Lot No., Zip Code)
County
3. OWNER: C! a,"Eva/ il(C7--
Address Pc. /336
(Street or bottle Ho.)
! (AYFSV/LtE Nc. .28964
City or Town Stale Zip Code
Area role- rlrone number
4. DATE DRILLED %"/C-cr
5. TOTALO1-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 8
7. STATIC WATER LEVEL Below Top of Casing: _5-0 FT.
(Use "+" If Above Tap of Casino)
8. TOI' OF CASING IS / IT. Above Land Sul face•
•Top of wine lennin•lea •Vor below land our lore requites •
valance In •ccordsnce with ISA NCAC IC .011a.
9. YIELD (gpm): /2- METHOD OF TEST /?- -
10.1VA"1'ER ZONES (depth): /`l3
1I. DISINFECTION: Type /iT1/21
12. CASING:
' Depth Diameter
From L To //7/ Ft. 625—
Prom To Ft.
From To Ft.
13. GROUT: Depth .0ated
From C
Amount kyi.p
Wall 'I hickness
or Weight/It Material
.S.t / /� C.
1'o n . Ft. t2/ / •,r9Gl
//kilted
FNom To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. hi. hi.
Croat _ To Ft. in. in.
IS. SAND/GRAVEL PACK:
Depth Size Material
From To Et.
Front To Ft.
16. REMARKS:
Topographic/Land setting
Midge ❑Slope ❑Valley ❑Flat
(check ippropdnte box)
Latitude/longitude of well location
N39° 59 ',3S-reooP3° n CE-x
(dev entin lnute✓eecond e)
Latitude/longitude source:❑CPS❑Topographic map
(check box)
PEPTll PA! LIIIQLQ2
From To Formation Description
C -/C2 C7t
a-
/n ,p2d L Gti7
LQCAT + sETc)1
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and coiunon road names.
CD
I DO HEREBY CERTIFYTIIATIIIIS WELL WAS CONSTIWCfED IN ACCORDANCE WI711 ISA NCAC 2C, WELL
CONSTIIUCI ION STANDARDS, AND TIIAJ;A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
SIC tIATUItE OI' PERSON CONSTRUCTING TIIE WELL DATE
Submit the nI Iginal to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center- Raleigh, NC
27699-1636 Flame No. (9191733Jill, wRhin JO days. OW -I REV. U7/2001

NC NOR EN
NWO
WELL CONSTRUCTION RECORD 299760
North Carolina - Department of Environment and Nalyral Resouttf es - Division of Water Quality - Groundwater Section
WELL CONTRACIOit (INDIVIDUAL) NAME (mint) f?T,/ /eecC
WELL CONTRACT Olt COMPANY NAME
CERTIFICAIION0 onei-
PIIONE N IaUd'l S92-25S)
STATE WELL CONS f RUCTION PERMITM ASSOCIATED WI) PF.RMI IN
(if applicable) (If applicable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ ►teat Pump Water Injection ❑ Other ❑ If Other, List Usc
2. WELL LOCATION:
Nearest Town: 7� e✓�; %E County
/SC/y
ALT / �-C �..
(Sunet Name, Number, Community,Subdivlelun, Lot No., Zip Code)
3. OWNER: /1%f1
Address ca $uo w I N/ ' 44' 7-2 )(sot
(Sheet or Route No.)
m,9alnr4,36(4/41
City or Iown Slate Zip Code
( )-
Atra rode- Phone number
4. DATE DRILLED 7 -' 7- 05'
5. TOTAL DEPTII: tc' '
6. DOES WELL REPLACE EXISTING WELL? YES U NO 1-
7. STATIC WATER LEVEL Below Top of Casing: / D FT.
(Ore "+" If Above 'lop of Coxing)
8. TOP OF CASING IS / rt. Above Laud Sus face
•Ibp or mini terminated annr briar Rand outface requiter a
inn lance In accordance wilt ISA NCAC 1C .RI IR.
9. YIELD (grit,): 025` METHOD OF TEST /%,"L-
ID. WATER ZONES (depth): .2 3 0
11. DISINFECTION: Type 4/77/
12. CASING:
From h
Mont 7Sl
Front
GROUT:
Front 0
Front 12
SCREEN:
From_
Amount l`f C-4.-
Wall Thickness
or Weight/Ft. Material
,/8'S' .S/ee /
13. Material ewod
Ft. /rJY� )�/ lie.sr��
To PE, Ft. �??7`c'71: /— // csc yr -e.
14. Depth Diameter Slot Size Material
.ro Ft. in. In.
From 'To Ft. in. in.
15. SAND/GRAVER. PACK:
Depth Size Male,m l
Front To Fl.
Depth Diameter
To 7-5— FL
To /9/ Ft. 100
To FL
Depth
To /'2.
Front To Fl.
16. REMARKS:
Topographic/Land selling
❑Ridge ❑Slope ❑Volley ❑Fla(
(check appropriate box)
Latitude/longitude of well location 7 ,
,U35°O0 .3b'-8' icy' Oil D9, 9'2%
(deareex/mInuln reconda)
Latitude/longitude sourcc:❑OPS❑Topographic map
(check box)
PEP Tll 1211JLL1N0I,OQ
From To Formation Description
0 — /C c-/4 y
C)
LOCATION SKCTCIi--
Show direction and distance in miler?ronl idcast
two State Roads or County Roads. Ini;ludellic road
numbers and common road names.
I DO IIFRFBY CERTIFY TUAT'111IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TITANA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
nj
SIGNATUIU1 OF PERSON CONSTRUCTING TIRE WELL DATE
Submit the or Iglnal to the Division of Water Qunllly, Groundwater Section,16)6 hall Service Center - Raleigh, NC
77e00_I616 Phone No I919I7),I-]2Il. within )U dnvs. OW -I REV. 07/2001

WELL CONSTRUCTION RECORD
a0e014
North Carolina Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pilot) CHRISTOPHER L DICKEY CERTIFICATION 5 2261
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC. PRONE 5 [phone]
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential I MunicipaVPublic ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE
BROOKS COVE
County CLAY
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ROBERT BOND
Address 1995 COPPER CREEK RD
(Street or Route No.)
MURPHY, NC 28906
City or Town State Zip Code
( 706 )- 898-1880
Area code- Phone number
4. DATE DRILLED 08-24-2004
5. TOTAL DEPTH: 225'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 25 FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top of casing terminated al/or below land surface requires •
variance In accordance with 15A NCAC 2C .0115.
9. YIELD (gpm): 50 METHOD OF TEST AIR
10. WATER ZONES (depth): 200'
II. DISINFECTION: Type CHLORINE
12. CASING:
Depth
From 0 To 178
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 20 Ft. CEMENT
Amount 100 PPM
Wall Thickness
Diameter or Weight/Ft. Material
Ft. 6 1/r SDR 21 PVC
Method
GRAVITY
Topographic/Land setting
❑Ridge ❑Slope ®Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0' TO 20' SANDSTONE
20'TO 100' BROWN SAND
100' TO 140' SAND/SOFT SLATE
140' TO 180' DARK BLUE SLATE
160' TO 178' DARK BLUE SLATE
178' TO 225' SLATE
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:
LOCATION SKETCH -O
Show direction and distance in miles from atrleas(
two State Roads or County Roads. Include t1 oad
numbers and common road names., /'�
I DO HEREBY CERTIFY THAT THIS WELL -IV --
CONSTRUCTION STANDARDS, AND $AT A C
SIG
ATU
CONSTRUCTEIN ACCORDANCE WITH 15
CORD ....:. l EEN PJJ V ID
F ' ERS St CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Ma
27699-1636 Phone No. [phone], within 30 days.
NCAC 2C, WELL
TO THE WELL OWNER
DATE
lee Center - Raleigh, NC
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD C\-)2 3 0 2 3 3 2
North Carolina - Department of Environment and Natural Resources - Divi io of Water Quality - Groundwater Section 3 0 S�5
WELL CONTRACTOR (INDIVIDUAL) NAME `(print) / r l rat / / CERTIFICATION #
WELL CONTRACTOR COMPANY NAME c/ Ck. in,n�M, f I/V 'CCl/ /!. rr /� PHONE # id)7ij 3782
STATE WELL CONSTRUCTION PERMIT# r1Y A ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential C] MunicipalPublic ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIONKatie
• /
Nearest Town: r--(a es✓r`lI be County G
a94 Ma hcs6ri Cave Reit
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: o 1in
Address klOn
treet or out No.)
esvo/fe 1�.�
or Town 'State
gt5
c a`fzip code
( )-
Area code- Phone number
4. DATE DRILLED II L/ _ c. V
5. TOTAL DEPTH: / € 7
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ei
7. STATIC WATER LEVEL Below Top of Casing: 3 C) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS j . Q FT. Above Land Surface*
*Top of casing terminated at/or below bad surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3 0 METHOD OF TEST 14 tR
10. WATER ZONES (depth): / 7 C
I I. DISINFECTION: Type Cy Amount
12. CASING: Wall Thickness
Depth„in iameter or Weight/Ft.
From a To i5 ?1 Ft. GrY( 5aiAI
From To Ft.
From To Ft.
Material
pt/*e
13. GROUT: Depth Material ,Method
From 0 To D.,b Ft.v air/
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 OSlope Walley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formytion Description
DEPTH
From To
d� �s
/r- V s-
t!�- 7
t17 —
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.
n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR�TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER j
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, N
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2(101

V HIT /
In IIU
WELL CONSTRUCTION RECORD 3 0 C " ;; e,'
North Catalina - Department of Etivitomment and Malutal Resoutces - Division of Water Quality - Groundwater Section
WELL CON I RACfOR(INDIVIDUAL)NAar,EE 7
(piing nth S `r, Strpn CERTIFICATION) 2jOV
WELL CON IItACI OR CUanrANY NAME i�li l�C•C C.L. VA RCi1)1✓15 PHONE a $J&)Sri
STATE WELL CONS I R UCI ION rum I s ASSOCIATED WQ PERMIT,
(if nl'lrlicnblc) (if lipidicnble)
I. WELL USE (Check Applicable Box): Residential LTV Municipal/Public ° hldusnial ° Agricultural
Mmlitoriug ❑ Recovery LT heat pump Water Injection 0 Other ° If Other, List Use
2. WELL LOCATION:
Nearest Town: IPSV:i/P County Clan
(SuedNV 1) - le.„ 1 1
(Sweet Name, Umbels, Community, unity, Suhl nlar, Lou No., Zip Code)
3. OWNER:)4611 V,telt'\OPr c�
Address I3�D.I�j
(Simi a Houle No.)
{�C1/4_1Y1r7FG'1 Cif?
City or loon Stale Zip Code
C )"
Area cede- rhnne number
4. DATE DRILLED 12-D3-D*I
5. TO [AL DEPTH: aoS'
6. DOES WELL REPLACE EXISTING WELL/ YES LT NO M
7. STATIC WATER LEVEL Below Top or Casing: (°f") Fr.
(Dee "4- If Above Top of Cooing)
8. TOP OF CASING IS L IT. Above Lend StuFace
•1 re nl c solo/ Iertnlnated Minn below land outface requh ee a
e Wince In accordance with ISA NCAC 1C MIN.
9. YIELD (gpnl): ' METIIOD OE TEST A
IU. WATER ZONES (depth):
II. DISINFECTION: TypeWt\ri,PQy)Pk Amount IS
12. CASING: Wall 'thickness
Depth Diameter or Weight/Ft. Material
Ftolt C To 555' FL (:,,J sOr QV C
rum
Erma To Ft.
13. GRUUf: Depth Material Method
From 0 To aC) ' Ft. por;-lair‘c� k fvsSt tClo
hum To It.
14. SCREEN: Depth Diameter Slot Size Material
Ftont To Ft. in. in.
Front To Ft. in. in.
IS. SAND/GRAVEL PACK:
Depth Size Mnletial
lions 'fo Ft.
Front To Ft.
Topographic/Lend setting
°Ridge G13tbpe [Walley UFlat
(check apprnpdale boo)
Latitude/longitude of well location
Nz D'7" f•)83o '//'
(dearees/mlmri arrecnml•I
Latitude/longitude source:°OPS°Topogiaphic neap
(check boo)
llR1LL1N(L_LUC
'orn)ation Description
Dim
From To
Io
Jo - to'
'w - a05
^r
%a air"
ccn
LOCATION SKh:LC11
Show direction and distance in miles from a1'ast
two State Roads or County Roads. Include ELeyosd7
numbers and common road names. w o
ry
*9
16. REMARKS:
1 DO I IFREDY CERTIFY THAT MIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS1 RUCI ION STANDARDS, AND THAT A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
SIGNATURE OF I'L'ItSON CONSTRUCTING 771E WELL
.3-6Y
DATE
Summit the m Iglnal to the Ulrblon of Water Quality, Groundwater Section, 1636 Mall Sernlce Center - Raleigh, NC
17699-1636 Plume No. [phone], 111h1n 30 tiny I. OW -I REV. 07/2001

V
11VNF.R
WELL CONSTRUCTION RECORD
North Carolina - Department of Euvirornitent and Natural Resources - Division of Water
WELL CONTRACTOR (INDIVIDUAL) NAaIE (print)Cr) V1V 5 IS. (.): \ Co el
WELL CON IRACI OR COMPANY NAME Ifif1, I) t2( Iot7i( dtlil:rt
STATE WELL CONSTRUCTION PERDtITH
(if applicable)
Quality -OtoundwaterSeUiWi ?
roe -
CERTIFICATION Il..24JV(/
PHONE a Jilt) `s-57—Z`)`17
ASSOCIATED WC) PERMIT"
(If applicable)
1. WELL USE (Check Applicable Dux): Residential IJ— Municipal/Public U Industial U Agricultural U
Monitoring U Recovery D Item Pump Water Injection U Other U If Other, List Use
2. WELL LOCATIN: n/
Nearest Town: I-11-1IP<v; tie County
(Sued Name, Numb it. Community. Subdivision. Lot No., Zip Code)
3. OWNER:R4y it/70.S AP,C
Address v -i' 43J Pir)QXj
(Shed or Route No.)
L'
City or 'Wan Stale Zip Code
Airs code- Mnne number
4. DATE DRILLED 1- 30 - C> l
5. TOTAL DEPTIh aq5'
6. DOES WELL REPLACE EXISTINO WELL/ YES U NO LT-
7. STATIC WATER LEVEL ()clew Top ofCnsing: $0FT.
(We"+"If MUM lop of Ching)
8. TOP OF CASINO IS I FT. Above Land Sur face*
•Top of wing ter mingled st/or beiuw land art fact regale to a
valance In accordance with ISA NCAC 1C .011a. pp
9. YIELD (gpnt): 5 METIIOU OF TEST 1-t R-
IU. WATER ZONES (depth):
I I. DISINFECTION: Type1nii‘ Ntl(Arc
12. CASINO:
Depth
From 0 To n15'
Front To
From To
13. GROUI: Depth
From b To 21)'
From To
14. SCREEN: Depth Diameter Slot Size Material
Ftonr To Ftin. in.
Front To_ Ft. in. in.
15. SAND/6'I3AVEl. PACK:
Depth Size Material
Diameter
Ft. ( a5
Ft.
Ft.
Arnomlt 1S
Wall 'I Irick:less
or Weight/Ft. Material
SDI21 Ng"
Material
FL irtc‘-lo r,nd.
Method
Ft.
Front To Ft.
Front 'to Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT 11115 WELL WAS CONS 'TRUCIED IN ACCORDANCE WITH ISA NCAC 2C, WILL
CON RUC3 ION STANDARDS. AND TIIAT A COPY OF TINS RECORD IIAS BEEN PROVIDED TO TILE WELL OWNER
„AA/LA, � % 3o i_ -e?" _
SIGNATURE OF PERSON CONS.' RUCTINO THE WELL DATE
Submit the a,lglnal to the Division of Water Quality, Groundwater Section,163611LII Service Center -Raleigh, NC
17699-1636 Plume Nu. [phone], Wlthhl 30 dap. OW-1 REV. 07/2001
Topographic/Lnnd setting
DRidge gaggpe °Valley Uflat
(check appropriate bat)
Latitude/longitude of well location
nl Sc° I ' 23 `t war 991S'74'
(deareeafminntea/aecondi)
Latitude/longitude source:DOPSOTopographic imp
(check boa)
J2RJLLIA GLVQ
or4ration Description
PJ:L UI
Flow To
D — its'
I d - Qs�rytS�''
Yc)t — rrr"tS '
Cr a
C r' 9
vs Arn
LOCATION SKELC11
t �O
J cfiZ
err
Show direction and distance in miles from atiast
two State Roads or County Roads. Include We roar
numbers and common road names.
,,,drt

WELL, CONS'l'ItUC'UON RECORD
300',"55
IJof1 11 Cm ldil, ntll I /rpllctlt of IijtviIIiiiiilcIuI unit Notion' Itraotlices - Division of Wale! tlunlily - (hoailwnlcl Srctinn
Mini CI II III ICA X,,24/04
SCi
ttFl.l, ClrNllUl.l OltCllnl l'AN1'IJAPII[ M .L1 Q{�Jt'1` t�-�7 --' PIIUNF. X �� 7-294?
A5a(IC'IAl VD WI) I'E.IU111X -
1YF1.1.lI1NIIlACIUII (INIrIlI11UA1,)NAME (plug JGYY\Cc.6 �• L^
71p ('ode
2. \\' P I itI.t'CA I It Ii : \\
I lenlrsl lo,vn'��)Q(4Q
.0tA V\wsrz Rd P,..t. krn,
(Strrrl tbiue,[[ii ('rnnnn e',. Sunn Stagily 'nI . I •n Iin , 71p 1'.Ir)
AIIItres _-t.t.l3 a IJI I\l-
(Slirrl n, Ilnnle )1t,)
c)!'a S s-+O(_f1t
r it) rn Ia'.n $Inie
Arr. r.-I. I loll. mmolr,
NM I I I i:l I I_`_%°LA___-__.__.
S. WI Al nrrin' _30;1_
6. Nor: will. J;,:rl.Al'll I'XIS IHID W1:I.I.1 PISS IL NO Its
7. S I A I IC \\'AI EIt I IiVEL NcIuw 1. (thr ill A:r.rlinl n10I;,,pl l' 1
8 l01' Of t'ASIIJI I IS i _ 1-1 Alnive I and .Mince'
•I r p rl r•,l.p In min•I d.U.,l 1t•Inn lend .nll.re writ.*
In loon I,, *nonfinite n111115/I NUM'
i',IIJIIl I'.:.1 A\A
Ill. AVA 1 PIt 70116S (arlllb) — --- ------ —
SIAIF.\\EI.1.l'ONSI lt11-11014 1'EI1n11 innpplivnhlr
if npplit nidr)
I. \\'PI 11ISP ICbruk Applicnlilr Nosy Itrsidrnihii ijVl,luoiripal/Public U holunllinl I 1 Agliatllutnl Ell.'
htonitnliug Li Rrcuvuly 1_I 11ra1 fumy %Vairl lijccliun U Odin L) IPUlhcl, List Use
4J1t__—
'fopogltil,hidl.;uld sl'lliuj�:.
1idµe I [Slur, 1.1vnilry Liim l
Clerk Igqn,.p life Lo.)
ntiluddlongitude of well Inrnlinn
I I. PISIN ITU I Iltil: Tvpc n� � �E Aliii'llol 15
12. l'Atil I Jt is \\'nil l hirkurc+
I) -pill Uinmrlrl trt \Vriphlifl. hlnlciinl
Ilom___0__ to _Ica 1t _(ps?$___
Il pill In — It
Dom I It.
11. (HMO I: Peril' bloirlinl Method
Ilrni__,) to .2DI It. pnf_iCtnn't?( El+S[J cc
Prom ii H. —
I4. SCItpuIJ: Ilrplh Uinmrtel Slot Sin" hinirtinl
Flinn( 'l o I.I. III. III . _
Mont--- - Iii it in. . in. IS. SAKI)/(IItAVPI. l'ACF.:
Ivplh
II,'III I I' _ It
Flom(,_ Io_ II.
e3! st' Sir , LA sr s'_23''
pleprerdullnut.agr•nn,l. )
LnliluddItnlgilude soutcc:LII;I'S11I min); npbic
tdle<k Mn) - - -
1)):1_Ill CIVIL All i I.I II)
Mom 'Jo �I'tit lnalion Ncsciirlioo
- lb'
_v' R0'
GD - 30c,'
Sivc Lbdrl inn
SE
0 La
rn
Cr. sd
rr'
—'V "O
LUCA 1014_5F,Ii>_I l'l l 3 I;
Show dilection and distance In miles lionl�ylcn�
Iwo Stole Roads or County Pond,. Inc lodge loS
nulubeli and commonroad Itniltca. N Z
PO I II' I'.PII'i CP It 111 }' 11IAI Jill:: Will. \VAS I't INS I ill ICI M) IN ACCOI(I )ANCII W 1111 1 SA NCAC IC,
CONS I RUC I ION SI AIJUNtDS, AND'I I IA I' A COPY or 'I in:; I(ECOI(U IIAS BEEN i'I(UVIUL)U'►U'II IC WELL OWl IIill
.,Y__ 4 vy
SIR;NA ILIM!OIIVEItSONCONSIIWCNNOIIIEWELL DMI!
Submit the nl ll;lual to the NI Non or \Vole' f)onihpi Giowltlienler Section, 16.16 Mill Service tenter
lining?, is
11 REV.
1;(a9 tor, Phone No.t7IQ) 71111,nitlibi IIIda)4.

IIIIIII li row)
WELL CONSTRUCTION RECORD
300882
IVFI.I, CON IRACIlnt(NNlVIDUAL)NAME lrrinll 3CYIi61S Ift (A;;:ASO( .
W FI.I, CON! ItAC! OE COME/SOY NAME k1��C (.i,C IL �f''t�IvA5
North Carolina - Department of Environment and Natural Resources - Uivisiun of Water Quality - (hound wnter Section
CF.R I IF ICA' ON -401(
rlltNE N Ish-1 Yi 7- 2(;5 7
S I A I F IN I.1. ((MS I IRA ION rF hail l N ASSOCIAl El) IVO rERatl1 N
(if null( slide _ (ifn licnblrl
I. !II,'MU
I. R'i i 1. (ISI: (Cbrck Applicnbie itii )' Ite idrnlinl 111- Municipal/I'nblic U Induntlinl I Agricultural U
Monitoring LI Rcruvety U I lent Pump Water Injection U Other U If Oilier, List Use
1. Avil.1.IucAiR)IJ:
Ne1al cs11t 1 trwi )41,4QSbl� ('uunly-(iftl4
`11
(Sltrrt N.M., Numbr,r, Crnun nn ill. Sulvli, irlom, 1,n Ito, i il, heir)
1. (I\VtJER � (f 2 Terra F'trntAin j
Addhres JB 92 CSh nit S.-__g d.._
(. litrl
-_1+ uucSSzx _ _DEL—__3C546_- --
v' If, Sint.lip('ode
Aar, r,-I.. F I'-n• number
•1. PAIFPull .IFI)5'-17-G�(
5. lmint Prprn. y)5:
6. POPS Wrl.l. PFI't.n(11 rsls t intI wi i I.? YES U NO U-
7. S I A 1 I I: NYA I Tilt I (EVIL Below "fop of t'asiup, (p'..
tut. "t" If Abinv i iqr ar Un.inpl
8 111I' 1lr l',\SIIJi I IS _ i - I'l. Alice hull 5urfacc•
• Ip of r.iit'r tnn'I,,.lyd .Om hrinn WO 'nitre nyn6 to
t, lour. In sun; June .till, ICA NI'A(' rl' Itl Ip.
V. 1IN P (rpm)' _ _ hlplllt)U LIE IESI 14Iif
(I. \VA I Pit LUNE. ; (arplh):
11. PISIIIITCIION:1)reL;1,-\ `t`qPJs nnu'tlnt 15
12. CASH l is Wall thickness
I ''-pull 1)innieirr or \1'cight/FI. Mnlcrial
hum C• lu 1(Y' FL(c,JS SDC7L OvC
rloln"Io It.
Ilom to Ft. - _--- —
13. UI(Ut)I: Drplh t,WeIliat Method
From ( ' .far .)(1_ It Prsi 11tt.,1ri .?.if•'cSc
Elvin 'I o Ft.
14. SC'duel: Urplh Diameter Slot Size Mnlcrinl
Horn In It in. in.
Ilonl__-- _-- •ko Et. in. --_- in.
IS. SAIJP/DRAW' (.PACE.:
I'rpill Sin. Mnlri nl
From li' 1rt.
limn to It.
Ili. REMARKS:
'fopuprnphit/Land'rlli ig
Ultidge LkHtgtr [_'Valley Ullal
(rlirrk 'rn 'nnln'r ha.)
Latitude/longitude of well locnlirrrt
(ilrptrWmhn'vt'...nn?) toot. -..
Lotilude/longitude sourcc:U(11'51J I upltgrapt lie 'il.p
(clrck Mr)
J11:111j1 VR11_L111131,1
From To Formation Description
fl - I t l'H d C. 4
10 - cif -Scot C 5 ( , E-
r
cr.
jrrl_UA[lUL�1;I;:LL') cGi
Show dlrerlion and disiaiice in miles Il ows I Ir z4.,
two Stale Roads or County Roads. IncludfWe via
-0 Cc
O
Z
numbers and common toad unmet'.
E1�E N
tV
r
0,
I PO I li RI'IIY CFR I UY 111A1 111111 WELL WAS CONS I ItUC1 FD IN ACCORDANCE WIl 1115A NCAC 2C, WEI L
CONS I RUC I ION 5IANDAI(PS, AND 111A f A COPY OF l HIS ItECUIW HAS BEEN PROVIDED.' U 111E WELL UWN[R
5-- /'7-1,c/
SIUNA I lull! UI' l'FItSON CONS IRUCI INU 1111.1 WELL VA I It
Submit the or 10111 to the DIrivinn of Water Quality, Groundwater Section, 1616 Mall Service Center - Ilnlrlkb, NU
VW'? 1611. I'hnnr Tin. (QIel'1J1.1221, oltldn 30 dad,, (1W-1 REV. 07/21101

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CHRISTOPHER L. DICKEY CERTIFICATION If 2261
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT!!
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential EII 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: HAYESVILLE
FIRES CREEK
County CLAY
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: WENDELL BARLOW
Address P.O. BOX 615
(Street or Route No.)
ANDREWS, NC 28901
City or Town State Zip Code
( 828 )- 321-5872
Area code- Phone number
4. DATE DRILLED 07-26-2004
5. TOTAL DEPTH: 345'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "*" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of easing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 2 METHOD OF TEST AIR
10. WATER ZONES (depth):
I I. DISINFECTION: Type CHLORINE
Amount 100 PPM
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 21 Ft. 6 114" .188 STEEL
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT GRAVITY
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ®Flat
(check appropriate box)
Latitude/longitude of well location
300131
(degrees/minutes/seconds)
Latitude/longitude source:OGPS0Topographic map
(check box)
DEPTH DRILLING LOG
From To FormationDescription
0' TO 15' SAND 8 GRAVEL
15' TO 345' GRANITE
0 O
t ?m
Cs% L
i LOCATION SKETCH -A—
Show direction and distance in miles from at least'Z� rn' ram"
two State Roads or County Roads. Include the road n'
numbers and common road names. r`
0 2
I DO HEREBY CERTIFY THAT THIS W L WAS CONSTRUCTED IN ACCORDANCE WI
CONSTRUCTION STANDARDS, r a TACOY Oe rills RECOO HAS BEEN PR(rIDED TO THE WELL OWNER
7 a6-t L/
tit
GNATURE 0 ' ERSON COPISTRUCTI • G THE W
II I5A NCAC 2C, 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 ► ECtl►tU 301201
Nall, Unlvlina - Derailment of 1!nvimnmeot and Natural Rewwccn - Division of W nlcr duality - Lln,undwntct Section
S,An,C�S
Will. Cl/rJ 11lAC1 UII (IN 0I PIIIIIAL)nnnlrpl hrV a-W;iCC4/1 cr,tllrlcA I Cagac
tt rLL CON I ItACI Olt COMIAN V NAMGyg�Q,.[_.-1-�--\� dr1,t`:‘A5
SIAIE R E1,r (11NS I ;MCI ION 1'EItM11 N ASSIIC'IA I Ell WI) rEllnll I N
it n • dicnldc
if n dicnbirl
I. W1;1 I, IISI' (Chuck Appliculle Ilan)' Itr^.idrntinl I V htaulcipnl/public Cl Indunhinl I l Ap•liculhnnl U
t�hmiiuling U Itccovcly L1 Ilcnl Pomp Wale' Injection U Utltei U 110liter, List Use
2, A1'p.Ll. I tUCA li431.1:
Ijcnl esl l own[_(L2S,_1n,Zh_._
_Ol-._.l�auuly-[,1�}�,
.�� broncin Rcr - ---
(Corr! thistle. Nmnl•rn, l ammw�il ). `•r�LJir idol,.l1l nl Ili•, fir 1'r.ir)
). u11 Nr•It _k;Charj.-_JVVI_C 1C)(a\d__
nlhuicss 9 o eic2A, t -
(Snret in Voile No.)
_Ara sstow_n_ A/c_ Z590a_
(ii)' or Im'n Solt, lip (bdr
/urn r.•Ir. IL�.iv timber
d. IIAIFDIM .l1:1
5. II)FAl. UPI'1II:- 9Q1.. ._
6. DUES 1VP1.1, 111,1'IAl'II.IIXIS IINU wi.i Id YES U NO h.1-
7. SIAIIC11'AllitI.LVISLliclo(vopofl•:aingt(vO_11.
(the " r'• II ALnvr l op nl I'n.inp)
P. IOI' OI" (-r1SINU IS _ 1 _. El. Above I nod Bodice'
• I op of r.,lnp In min.ItJ al/v. below Inn; .ml.rr rrgnk,..
.nlurrr In monism, 15A NI'AI' H'. Ill III.
V. YIN 11(PPM)• 1 _._611•.1IIUI)in, 1Fsl.tAr jj
11. 11'n I FR /LINES (depot): -__--
rumor. N tt2 1411--i'r
Lupogrnphicll,and rrltinl:
Liltidge I re IT Valley Lillat
(clink .ppngnlnle hn•)
1 nliluddloogilullc of well Ivcnlirnl
035-62-1ZS- t 85'S "I(c
Lnliludefloagilude soulcc:l7Ut'SUT olnq;lnphic Illnll
(chuck I -in)
I)):L1111 UitILi,11)t)L(II)
plum 'fo rioimation I)csaipliuu
V
a - 10' C;l.
__11c) - QD ' .SOns- I A
GO - S 10' (1,revA, e-
II. DISIrInCIIUN:T)pc• il >o11g15 Alll'olu(_l-h
12. CASIN(;: Wall lbirknrss
Drplll i l)iniocicl tic 1Vrigbl/11. tvintnial
nom p To- tO I _ Fluty, si7.c2L ,1)\I(
floor Iv H. now I o 11. _ _-- --- --
I). liRt1UI: Iteplll tIfF11nl Method
Ruin (2 To o1Q' I I. QI j ckvi - 4(.C3$at .
Plow to Pt. - ---. —c
14. SCREED: I)rpdn Diameter Ski Size Matelinl
Plin___.I.a1:1 in. -- - in.
Plum_—_--- I a__. It _in. io.
15. SANU/titAVPI, l'AUL:
Nrpnl Size Mainint
hum
I,' It.
Mont Ta Pt.
16. REMARKS: _—__
j iI FE 1:;) FE I I4) [
I1UIlikIII'i Liltlll'1'111A'l h itSWELLWA,(OI qL ILDINACCURDANLPI(q I5ANCAC2C,WELL
cUNsIRUCNUNSIANDAIU)S,AND II1ATACOPY 1II11SIt&EBtwUIIA52QtNED'luhillWELL UWNPR
II l7- 0Cj
LUCAIIVI4_Sk L.IC)t
Show dircelion and distance in miles hunt nl Iract
two Stale I(oads or County Ron Is. Include the tend
timidity; and communion(' lino es. c
C C
"oy cl y �r�-rn
a�� o rn
c
qO gc
r1
s �rn
x
- m�
IX o
IUNAIIMP, DEITltttfll ,7ti14101/4.01:l sVftLL
DAZE
not the I};lnal to the Illrhlun of Wafer I)unlily, lll.ndVYitter Section, 16361NNl S(nice CU1Vr1 REV. 27r? 16161'hour rlo.(91e)7J112ZI,n1(hh1111d:1)c,

NC ✓
1)11N / /I
2. WELT I OCAIJUI'J:
lien; csriSVi ("ounl), C1Cni
tslrrrl Nninr, thunlar+, t'ununnnllp, 5u1•Ji+i+loq I nl l in_ 711r
3.
Addlres __t99 1/erS R�------
(Slirelu, Ilmrle Inn l
Rayewi1Le_ Ncz ±1PE.t
lip
l Jy o, In,vn Code
Slate
Ain rr4- !Ingle unnd•rr C
4. I)AI P. UI111.1 IW3 9n_
5. lUfALNp.P1Fit.
_1
(. (DUES %VEIT.ItP.I'l Alt FXISIINU \VEI.1:/ YES 13-1-110LI-
7. SIAlICWATERLEVELIlclow Top ofl'nsinp,t._50:
II Above lip nt t'n.inp)
A. l III' (IF CASINO IS I jr!. Above I and lace'
r I rI• rl t •dnp 1,,,,,1n.Iril allot hrinn loin got l.rt t eolith r. •
• ul.nrt In •rt,n du+tt nitlr I+A NUAI' It: ,III In.
v. 1WI I) from): _ ._N11111101)11E IESI_fl[k.—_—
Itt. WATER ZONES (dcplit):--------
j��
II. 111$INI'P.0 IIUIJ:'f}'pc "`"'1`f-' SJ_-eS Amount Will "I hickncss
12. CASINO:
I lrpllt Uimncict of \Vriyld/PI. hlnlcl ial
honk1oil Q 1'1 C¢ _SS c,01
PnnOM_ _ill__—_ I1.__—----
flunl To _-1'1.
r hlglrrti9l Method
I), lillUll f: 1 o (� -j l
Role _ _f1.
14. SCREEN: 4: Irrplll Uimucter Slot Size Welild
ly, fl. __iu. __ in.
fo_.- - I1"-- in. -----
15. SAIJU/611AVll. 'TACK:prp:iile Idnlrt inn
fnrlI% To It_
Ili. ltLNlAItl:S: --
I PO 111JRf11Y CH fIVY I IIAI IIII S WIl1.L 1V
CUNSI RUCI W Id S I ANUAIN/S, ANU l 11A
Lg�'
�� o , ( 4p�1 .EWfrn IsnwcnC2C•WELl.
lI' u II?I It 14
UM}' OM -FUG Ill II, AS 1Ian MOVIULU10111E WWELLOWIICII
J U
-G r JI �e III! WLLLh UAII!
sItnNAWUIll )1'I'III�SUEKVIs113941tflj
w►;►,►, (;UNstRucrION ►t► Ct)itu 301202
Notlh 0uohm' - I)rpaloncnl of P.nvilouurcul and Nulwal Ilenomccs- Uivisiun of Wale, Qualify - Uhonudwnlcl Section
\\ cenllrlcnllurl�� DLO �
VIEl.()CON IµACtllit (INIiJVttlUUAI.) NAME (p,ho1�J-On2N.S--- Sam runny. s Allt
rM' 1,S. u -- —
u
FIE, CUNntnClOlt CtInIPAfJYNAn1E. _ 1 C_ ��I1 of
ASSUCIA I PIl WI) I*ERI1tl11 N
S rhlF.v\F.LL hUNSI old( IIICI ION I'F.IN111M ---- ifn rrlicnble
if n • lilt
k A 1' I I rn) Ilrridrulinl I I luuieilnd/Iuhlic IJ /ndunllinl IJ Ayliculuunl Ll
I.
\\'1'I.I, IISP. (Cher pp ten r e II
,
Plonitol lug LI Recovety 1_I I lean rump \Vnlrl Injection U Other LI If Other, Lisl Usc
Topolpnphiell.nmd rettilig
IJlthlge IL!fgre LiVolley (JEW
(rhrrlt •ppnnnlnlr hn•)
I nliluddlu .Bole of well localimi
y w $3° v_4' 2S
>tz(_er r l ...
(d!p+ernJndnnlyd..rnmi+)
Latitude/luuµiludc nowcc:DI II'SF.I fupu);Inphic ul,p
(chrcb hot)
Patti UKILLII!U TOO
Pouf To Pmurativu Ucsaiption
nt
i
1-L :1212r
p o
m —
iden11u1l_SKILI.cl reCte
Show ditecliun nod distance iu miles Ii%nl
Iwo Stale hoods or County Bond+. Iticitu�! the
numbers and common road nnnlcs.
riD
Plae
Oen✓C
c.11vrch
Submit the el Ipinnl to Ilse I)hislun ul 11'nl'r I)unlily, GI oundlrrlfer Section, 1636 Mali Service Center, P hrIgh , nu I
2767? 16.11 floors No. (911/) 7Jy 1221, ulllllu all da}+.

NC
l II II) li
cUNSTKuc'1'ION ItEctntu 3 0 4 0 2 6
14,4 tit Cnudina - Derailment railment of Puvinruulcnl and Datum' Itesoutees - Division of V/nler Quality lhuuudwnlct Section
11E1,1,CONI ItACI011 IINNII%'IUVAI.J NAME. (plug 1GwiHr ?. t Ar)I\F )in CEIIIII ICA I ION 11020VU
WELL CON I MCI flit COnil'AN1 NAME Lvate_ ' Cy')�(1 C1 r,11`�h j r11omlr, ! j9-r6) S'S 7-0)997
SIAIE WELL CANS I IONA ION FERMI IN ASSOCIAI E.11 WI) l EIIMI III
l if nl'iiicihlr) --_ (Ifnppiicnlrk)
I. \Vlii-I, USL' (Chrrk Applicable Ilu,t) Residential ILVPluniripnl/i'ublic U Jodunuinl 1:1 Aguicuhtnnl Ll
hlouiluting Ll Itecovriy LI Hell I'Inup \\ier Injection U 011ie! U If Other, Lisl Use
2. \\'FLl, I DCAIIUN:
Hem est.1own:fLayPe-,\L, 1e Comtq•Clf(i
S%'tOke_cI5e. . .. -_-..
ISitrr1 Nnnir, Nand n•, l'onummily, 1$rlLJivielon, I o(I ln_ lip ('wlr)
1, l t 1V 111.11:� 12y1n( _Styr. LYE
Addles% Si Lz fuseul Ofu2L
(SI,rr1 in IOntle No-)
E}nyllz tiC z$ao(f -
Cil)'u, Ina, $lair lip I'oil,
Arta r,-In I Iwo, nmul r,
.1. DM I r. NW l 11. HUD _" CA:Qy5. IDFA1. NISI'TII: 30.5-
6. DOES \\'PLI, RI!I'LACI! PAS \Viil.1.7 YES L I Nu Id-
7. SIAIIC \\'AIIi1( I.EVFL, Delon, Top of ('using
(II.e"1- If Above -lop of Potion)
8. I I II' OI° ('ASINU IS j _ -_ " 1 I. Above I nod SwIhce'
• 1rp of •.,Inr trnnln.Ird nl/o, Lrinn Iu,J .m I.re •rqule• n
•.,Nunn h• .crmdnrte null, I5A NCAI' IC.111 In.
N. YIIU I)Moo). _t5.---_AIRIIIOI)(Ip'IESI'Aia_
Ill. \VAI Lit ZONES (drplh): - —
I I. 1'ISIMJEP.(: IIUD: I wArl\144 rx(10 JS Amount \S
11. CASINO: Wall Iltidurs,
Irplh Diameter or WcighUl'l. f 1nletial
flout p lu gO ` fl.L2ia' S%C,ZL ii)_vC
flnm 'fo II.
1"tom Tu 1'l.
II. URUUI': Depth Material �..
flom� To.�v It psis -(or.� -_--
I'1(1,11 Io El. _--
14. SCREEN: DepthDintncter .•Iv1.,ve Mu nfenl
1-toot 'l o I i. Hi.
Mot___—_--- •fo ---__ IT in.
15. SAND/uitAVl i.l'ACF.:
irplli Sire
floe(-__ Iil _I'1.__
Vrot❑ To II.
---Nicurntl
_ �; Psa,ts<
— wloke_
iu.
blr,Irtinl
16. I(LiIAIIKS:
'fupogtnphidl and ?cllinJ;
Ultidge 1.ISIope 10-17-nllry 1_)flnl
(rii rk pgn,gnln4 bm)
Lniilude/luugilude of well location
( lap,ern/nJnuln'noennd•)
Lnlihole/longitudc soutce:L P 11'SUTopn(pnplic asap
(clerk Mon)
ultlu.uu; LOU
fvtlnalion I./en-14,1km
MULL
I,o111 In
c) - lb'
�(n 7 - )1 q �ckklbL Sf3 n e
o' - 3 0 S' C=r�,z
Lue/vfI.VIt_sI:ELIII o u
Show di,cclion nod distance in miles lium al Ict t' C)
two Slate Ronda or Comity Roods. Include the ton'I
Itlllnh,ci nod CO111111011 load newel.
mo,+-11: so2,
m
IDUIII'I(PII1'uritlIflIIIAI7illSW11.1,WAS CODS TR(ICIPI)INACCUI(DANCEWIlll I5A NCAC2C,WELI.
CONS-1IWCI ION SEAWARDS, AND I IIAT A CUP 1' UP 'IBIS I(ECURD IIAS BEEN I'RIUVIDED'I U 111E WELL OWNER
/0 - py-D9
SIUNAI 11111! OF RUCIINU Tut: WELL DM I!
Submit the tit I);luni to the 1)11 Non of 1Cnter Quality, Groundwater Section, 1636 pill Service Center - Vain gh, tIC
••r • „I,,. ,.9rinut

VVE1.1, CON I I(ACI OIL(INUIVIIIUAL) NAME (pt INN f lr✓ K-
VVE I,I. CON ILIA C I On UI rnI FAN V NAME a%//er
e CC e,
.A0'On
WELL CONS'I'RUC'I'!UN ItECUItU
NotCnndina - Nepal Intent of Euvinnuneul and lit Jai Itcnogcen - DIVISION of Wnler Quality - Olouidwnlct Section
CFRl a tutlhurt Nit Yet?
rilulir N lgel--?SSJ
S I A I E %%ELI, CONS I IIIICI ION FERMI IN ASSOC'IAl F.I) WI) PERM! IN
it n • diuddrl .E..r-...., r, (if nppliotlrlr)
I. \l'ELI, 11SE (Cheek Applicable Ilea): Ilesidrnlinl 1-✓f`luniripnl/l'ulrlie U Indunitlel C1 Agtieuhutnl L1
t t'uitllning U Itccuvely U Ileaf l'uugr Wald Injection LI Ulllcr U If Other, Linl Use
2. A' f I,I, I OCAI It ',III.
I lrni co iownt._, n4, f.ce/#1 e ('t,unty der l/
(Gnrrl Uncut. Number•. Ilnnnuv,il), Subdi,i+lnn. loll In ,) ip 1'r.dr)
ponoT)f7
()W\'IJUlt hh'' f• iei fir'
Atlticcs ..3J�' OoUrn 0A5S _-CrK. R.&
(Sllrrl it Ilonle flu)
_ E aysSJt11t ALL- z%xi 0
(-it) 'of iv, n Slnle Tr ('ode
( )-
nrrn r dr. anon- an„ihrr
4. I)AIL•.InuuED 5 a7-°I
5. I(lIAl.1)1'1'1l1.__-722._--_.__
6. DOES WELL HEN ACI! I!XI511111I WEl 1.7 YES Li NO 1-1'
7. S I A FIG WA! lilt LEVEL Ucluw'l i p of racing. 2 0 _I
(I.hr•l• Ir/onor 'hpof I'n,inpl
8. l I )1' (II' CASING IS I'"1'. Above I nod Sullhce•
• Irp nl r.•Inr !null I .Ihn hrinn 1.11111 tors• trgulrn.
,.rbnn In .rem donut nIth 15A NUM IC irlin.
v. YIN I)(ppm): _ME.111uunf'l:r:f//,'r
10. WA I LIt ZUNJIS (depth): /75
II. ItiSltdhf.CIlull: -I pc /fTir— Amnon( tkl'r;,/0'
12. CASIIIli: Wilt'Ihick,esN
1)rpllt Uinuhef r co Wright/Ft.hlnted:II
from 0 To c2' fl. 6-2S 10421 wG
floor 'Ib I'1.
I1 o m---
1J. (;IUJUF:
Ilout__()
loon l o I'I.
'Iitpngnyrbic/l .and 'clliuL
Ultidgc I.ISlnpc IIIVnllry I_Il lal
(' Irek .pp,nprl.o- hn.)
l.nlitude/lougitude of well Inrnlian /
N3S ° 0 4/'0 y . / ' " w o�3 N tt(S/ Y S/ a
(drillerdndnnl t'r-"mtIt
LIIIII111IC/IVIIg11111Ie notlicC:Llt i l'SUI I opuglnphic nlnp
(rheck Im.)
DIALED. DIM.1,UIt) Litt.;
flour tO rotulntiottIJcscliplinn
O—0 C`:. —
eZ0.-/ZL
1.1.2.CA11014 KI I C7I
Show direction nod dislance in miles limo al Icn'l
Iwo Stale Roods or Comity Ronds. Include Ills Fond
numbers nod cmumtml toad motel.
O
' I L f 1. rr --o
I lerili h Orlin iclbud CD :)
-00
c1rl -0(--.
r ;r`_,
3 CC,
W
O to 0
C)
14. SCREEN: I Ir1t h Uinturlet Slot Sire htnledal
flout to II. iii. in.
I'n,ul_-- __--. To -,--- fl. in. in.
IS. SAt1D/UItAV FT 1'AC1::
Urrlll Site hhurlinl
flow_ fo IT
flort_ Tu fl.
I (i, IU!hlr\ILLS:
DU IIERf11Y CER I IN* 11IAT 11115 WELT, WAS NUCLEI ICI ED 114 ACCORDANCE WflIl I5A NCAC 2C, WELL
CONS IRUCIION SIANUAIU)S,ANDMATACUI'YUP . ItliCUIWIIASBEEN I'ItOVIDED101IIE WELLUWIIER
7 D /
SitUTAIlllll!UfPERSON CUNSIDUCI1t1U11IL'WELL 1JA11!
Submit the of it:Ina! to the I)It Moo of \}'tiler IJul1I11), (:ruuitdlroter Section, 1636 Moll Sendce Center- H1111, gh, (I(.

roc
11 ll rr I It
I4n/)
WELL CONSTRUCTION JECvItu 304030
Notch Carolina - Department of Environment and Natural ►tenouu/lccs - Division of Willer Quality - Uurundwaler Section
WELL CONI IUCIOIn (INDIVIDUAL) NAME (rho /'"Cfy jleec e- CFIIIIEICA-I ION N 2903
moue N LC2n 83)-•ii9?
W ELL CON I ItACI Olt COMPANY NAME
S ITl E WELL CONS I RUCIION PERN11 N ASSOCIAI Ft) WO 'PERDU IN
if nrmikuble) -_. (ifnpplienbld
%%7<//.er
I. WELL USE (Cheek Applicable lion): Residential I tthuticipal/Public U Indunitinl U Agticultulal U
Mount.' ing LI Recovery LI heat Pump \Valet Injection U Other LJ If Other, List Use
2. W I I.L L( )CAI -ION:
Near cst lown. /G S0//e County C-4
�ne Of Give /e
(Sure! Nnnte, 1'IomLm, l mmnunny, Snhdininlun, lnl Ito., 71p Grlr)
3. ()WNNIt: Le07Y°/'l ,Lwr/e
Address 15444 }}err)`iS Aikgiill
(Sneer or haute No)
y(2(t_nq arri&A- .305g2-
City m own Slnle Zip Code
( _)-
Arrn rode- fhmm number
d. DAIEDRILL El) /0'"o7-aV
5. IDFAL I)F1'llL___
6. DOES WELL REPLACE EXISTINU WELL? YES U NO N'
7. STATIC WA! LIt LEVEL Below Top of Casing: _Sv_.__FI'.
(Ow "re If Above l rap .it ('n,'1p)
A. T(11' OE CASINO IS / IT. Above I.nod Sullace•
•l rp e1 fining In minnled ill/nr below Iuul ran lore requites •
alone In accordance nllh 1SA NCAC 1(17.IIt IN.
9. Y 1) (gone): _._ . hIE111UD OF IFS 1
Ill. \VAl ER ZONES (depth): 390
I I. DISINEFUHUN: Type fi7-f%
12. CASINO:
I halt Dinn,elcr
Aunt v To lip Et. 6-:?s'
floral /510 To .26y FL5c4to PUL
Flom r769' 'Iu .ZS'3" IL 'it, nee!
13. URUUI: Depth Material Method
Amount g46ry9
Wall l Ilickness
or Weight/IT Millen:!
S404,2I �vr,
From To It.
It pm
14. SCREEN: Depth Diameter Slot Sire Matelinl
Fronk To Ft.
Iron( lo It.
IS. SAND/URAVE.I. PACE:_
Depth Size Material
ill. _ hi.
111. Ill.
Fumy Ta
From To
16. REMARKS:
El.
It.
"Iopogtnphic/Land setting
Ultidge USlupe [IValiey Ur bit
(rhen, nppr(pllnle bar)
Lntitudcflongilude of well loca)ion
,v3y°55'Sl-S" wo83° SY /0.1 •
(drineen/ndnutrthernndt)
Latiludellongitude source:[) il'SU Itipuginpllic map
(check Ion)
J)lill11 VItIl UUQL.U�;
Pwnl 'lu 1'otnalimlllescription
O-02So G!
2/6- ¥as' Ufay 4e-
L LCAilULSIsG1_C)
Show diteclion and distance in miles horn at least
two Stale (toads or County Roads. Include the toad
numbers and comma road mica.
I DO I IE WINY CER HEY 11IA'I'I111S WELL WAS ('ONS11tUC1 El) IN ACCORDANCE WITI1 ISA NCAC 2C. WELL
CONSI ItUCI ION S IANDAItDS, AND II IAT A COPY OF THIS IIS RECORD HAS DEEM I'ItOVIDED'10 TI IE WELL OWNER
A
etcp
<0 -07-aii
SIGMAILIItE OF PERSON CONSTRUCTINU'[IIL WELL
DAIS
Submit Ilse III Ightal lu the Division of %Paler ()tidily, Grutmdnaler Section, 1636 lloin SenIce Center - Raleigh, NC
-- - -...-. _. ,... _. t, n.I-- ,I• .r...._ (1W_I lot V (17/)1I01

//c
II II 111 li
vVEL,A, Ct)NST1(UCl'ION atECuttt) 304025
Nut Ih Cnullina - Drpallnmid of Ilnviluunicul and IJnlulal ltesulnccs - Division of Wnlcr Ilunlily - Ulouudwnlcl Scctiou
WEI.I, CON I ItAC I VIt OWN VINUAL) HAM: (p.lot)-3nvieLe s IS , Lo \ 4Gl('1 CFIt I If ICAUVN N a ybb<i
MI W ELI, CON I IUCI UII CII'AN1• NAIIF j[Y1i1�( \x�1 �1L J I r11ONF s j4141 cc 7- 2d)!7'
S I A I F. wELI, CONS I PIMA ION I'ElUti111/
lif nrldir tt Ir) _— (if npplicnlrlr
ASSOCIA IFNI WI) 1'EItMI II
I. \VI:I.I, IISF (Cbrck Applicable II,.,Q Itesi,lrtitlnl Aµticulhunl LI
Itlouilming LI Itetawety IJ heal Pinup l\'nlet Injection U Ulllci lJ IfUlher, Lim Use
2. WH I. I (ICA I )11:
Nral csl l ow.r�nkjg SVI\'l,o Couuty..�G11_____—_
SMOke_ RiSG'I i
(Bird Name. Nanil rl t, tomnnwiq, Sublli.initm. I nl I In„ 71p Cwle)
3. ll\V(Jlll: -Sc(Irigs Srti.11'l
Adlhess 3?' ke Liu e(ft) _vim
(Sn eel or Rotor Nn)
;ll Rare s 'f ALL_ 2 `10(y
I —
('ily of I omit $Inge 71p Cud.
( )
Arr. r .l• I'hnnr number
4. UA l F. Until Pi )JQ�1 - t'11 - o�\
5. 1 I) FAL. Nii' i i l:__ 2D 5.'__
6. IJUES \VIII, Ill?rl.Acli. EXIS1'1NU WEI.1:i YES LI NU N1-1-
7. SFAlIC\\'A1EltLEVELIlelowI'ot.ofC:•ing:._SO'.._ ._I
(11•e "I"Ir Above lop of I'n•inR)
B. 1 I)I' OI' l'ASllfli IS __ 1_ -_-__ 1 1'. Above I and Sullilcc•
• I rp nl t•dtr Ito nln•Ird .I/.r brion tuna nn l•rr ergolrn
•.,ln,er h. octet dente ”Ill; 1SA NCAC )/'ill In.
V. 1 INI l)(11'1l1): _i5_h1E111U1)U1:1I;,`iI •ti�
I(I. \VA I bat 7. )IJI'.S (tieplll):
II. IiISINFECIION: 'fype 'h P iictS Alumna lO
12. CASINO: Wall Illirknc.^.7
Nrplh Dinulricr of \\'cigbllll, h1nlclial
Dr?L P)/c
Mont Q 'I-o -ter I'I.__Cpr
o___ I'I.
hum 'Iv PL_... ._.
13. liRoilI': Prigll bbuclial
1-1lull 0 'fu ' i't. PoL la9>d.- _
I'Ilull lo'
14. SCREEN: Ucpih Diameter Slot Sire
lion(_
IlomfuI I.
IS. SAIJU/UIIAVNI.PACK:
Nrplh
Bonk fn fl.
Elton
It,. (REMARKS:
Melted
4 t c ctLc_
M1lnlrlinl
111, ill.
hi. in.
Stir t~lnirlinl
fopai,riglhic/I,:vld sclliu);
Ulli lge LWlopc LiVallry LII Int
(rherk ggvoprinl. Imo
Lnliluddlungilutle of well Iocnlinn
( Itgi reed mini lrt', rand.) -_-
Loliludellougiludc mitec:Ll1 )I'SU I-(rpuglnphic neap
(check han)
111tKLI.UIt; LOU
� i'onnal�iunIlcscripliun
i_1' -6
MILL LI
Bout 'lu
ID'
101 — 3 h
3b (— 9rr,S
'
acf..)
rr
Ll2CA1:wf S .iuiut $e�
Show i itcclion and (isiauce in ulilrs livia
Iwo Slate Roods or County Roots. Include lI.€ road
uuudrem and cominon wad nauirs.
l
I DO 111'lll:all' LEE l it Y I I IAT'1111S WEI.I, WAS CONS i ItU 1IJ.0 III ACCORDANCE WIII 115A NCAC 2C,1'JELL
CONS I RUC' ION 5IANUARDS, AIJU'111A r ACM or RECUT W IIAS BEEN I'IIUVIUEU 1 U'fl THE WELL UWIIER
1 ✓ \ 11 A ),r ni-2,I Z
I SniNA l01(1! OE PERSON GUNS I RUCIINU'11W WELL
//, / -, c7
DAI II
Submit the of IgInnl to the Division of 1Ynle% I)mllhy, GI oulldtrater Section, 1616IA*11 Stoke Center - Itnlrlgh, NC
•r.., I not% owino%

II IIIII It
WELL CONSTRUCTION RECOltl)
Notlh Cat olina - Depal talent of liuv it oiutent and flu lat nl Resout ccs - Division of Water Quality - (h ound watcl Section 3
,,,x /etc. CellIIriCAIION 290%
lVrl.l.CON urnclrllpmnculunl,)NnaIF (pi !MI terix �,� $;1)-.?yy7
ll puma: nrt.l,amnRAC loncunlrnnrNnnlr . �L'
nSSOCIA Iran wQ I'ERMI.1$
Slnlr,wrLl,CONS Iable (11VI'F.IlMllp ifn1likable
if n , Jlicuble ..... - .
I. WELL USE (Chick Applicable Box): Residential El—Municipal/Public U Industrial U Agticultulal U
ftioniloting U Itecuvety O Iteat I'mup Water Injection U Oilier U If Other, List Use
2. W ELL I.()CATIOJ ' Topographiclmnd selling
Nuatestfawn: iYeyTTe.Ifiil/e ('ounl) G/!"/—_—_ Ultidge Mimic I_IValley UIlat
� GsDW J . _. __. -. __ ._ (drcrk .pproprl.le bn))
A(' - -- Latitude/lon itude ofwell location
($Ireri IJanrt, Numbs+ l onunnrlily, Sal rhrinlon, loll , Zip Cade) 'Vi? D3 //. � �� Gd08.3o u7�r� f(,(
(Ylrprce ✓nJ nulyda.rn m l+�)
1. OWNI:It:_/�//en ®4i✓n / — —
5620._LA0 di (Irk DL— Lntiludenutlgilude!murcc:U(11'SOTupoglnpl,icunp
nddlcss J (clink brtn)
fleeto. Route Na) u1tILL11lh-I,UIi
Pa(_m �i- El 3'-i-990---._ Rasa.
.Fiona '1.o Formation Descnptiun
City m 1 or. rt Sl,le Zip Code
(.. DOES WFLI. REPLACE EXISTING WEI,1,7 YES LI NO Ha
7. SIATIC1VA1lilt LEVEL Below Top ol'Casing: _ Q_ _ —I'1' —
(Oar -1-II Above lap of mainµ)
A. 1 UP Cl' CASING IS _ f____._- ET. Above I.nnJ Sur lace•
• 1 up of min, In tolneleil nl/ne brio., land nu lore lrsnit vs a
1.111nre In *eon dane ”Ill. 154 RCA(' rI RI IL
Q. YIN 1(rpm): _-,J__-_h1E111012OFTFSI_di/ —_ -
nl. WA TER ZONES (depth): ° -- -- -- LUCIVilDN_Sr,Llcat
Type 7» Amount _Z��C"/ 511ow dhectioll and distance in lades limn al lead
1 I. DISH,' N?CI"IUN: /� all •I Maness two Stale Roads or County Roods. Include the toad
12. CASING: RhWeigh/Et.
Oepl1, Diameter or Wciglll/Il. htntcl ial INIIIhe19 and common load names.
hoot__ 0 To X Ft. a,.?s= SO/ld1 pv
IrlC
tI'l. )
nn �ro -- r r��-;
Flom_- Tn rt. — — p `'.:_
Method 'G 0CD
17. IiRUUh: Drp(I, bdctinl l
z / Ft. /r)`�u-- o-
/'r�Ja. �- cis -=',
I'mm O To — r�°.
1'nnn 'fo It --- -v 0-i i
14. SCREEN: Depth Diameter Slot Sire Mntetinl r,r_',
in. G? -:*
lit oin
From_
u__ Ft'— in. in. Jr l
15. SAND/URAVEI. I'ACIC: Mulct inl
Drplir Sire
V0034
floatto Fl.
Ftom To 1'1.
16. REMARKS:
I DO I IFRFRY CERTIFY MAT 1111 S WELL WAS CUNSNtNC2ED IN ACCORDANCE WIIIt I5A NCAC 2C, WELL
CONSI ItUCI ION S [AWARDS, AND 1IIAT ACOPY OF THIS IUiCUI(U HAS 131.104 PROVIDED'fl1 HE WELL OWNER
le
SIGN/Cl ORE OF I'FRSON CONSIRUCIINO THE WELL DM E
Subunit the of Igiunl to the division of Water Quality, Groundwater Section, 1636 Mill Service Cent
er1 ItLIVgh, NC

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcess- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) FR2/JZ T• VtcreR CERTIFICATION #31 75
WELL CONTRACTOR COMPANY NAME B9013 Lit Cad— D QJCLIUA =KC. PHONE # )74'S-14 4a
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential B Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCH ON:
Nearest Townayc-SViu.e County 0-$.9
Voi LekFmutate:- ,Z P99 1
(Street Name, Numbers, Cammtmity, Subdivision, Lot No., Zip Code)
3. OWNER: 1/450,9 irga3ORE--
Address Vo( LQkcsfrkeac .D12
(Sant or_ 1Moute No.) 2 7 961/
site y�(.cf NC
City or Town State Zip Code
MO- (MO —sal o
Area code- Phone number
4. DATE DRILLED /0 .4-1- O
6. DOES WELL REPLAC EXISTING WELL? YES 0 NO
5. TOTAL DEPTH:
IS — Z.9
cr— 37
7
ctq 641
7. STATIC WATER LEVEL Below Top of Casing: GO FT. 69 L 65
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS -(- 2. FT. Above Land Surface' %- Z 2 Z O
'Top of casing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0118.
9. YIELD(gpm): l METH() OFTEST `8i&
10. WATER ZONES (depth): v{
11. DISINFECTION: Type NMI Amount (7 O Z.
12. CASING: Wall Thickness
Depth Diameter or Weight/Pt Material
From 76 To C. S Ft Lit • / St STEC-c.
Front (pS To 4.1 S Ft (a t/ S' SDR ?( PVC
From q S To+2 Ft. Co r/4 SOR 2 Z5 PVC
13. GROUT: Depth Material Method
From 2.0 To C) Ft Cf 4 ad,vrs. C,2.iv711
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
Topo d setting
ORidge ®S)ope OValley ❑Flat
(check appropriate box)
Latitude/longitude pf well location
N.y°K�_SS5 w 0$3 4b.SZ2
()
Latitude/longitude source: PS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o ) 5 Btmoa Ct,ar
tuu)TE
tic 225
0225 - Z6.5
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.
RECEIVED I DENR } DWQ
AQUIFER PROTECT ICNSECTION
OCT 2 6 ;'.,H
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUE IED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRtrf ION STAND.9)tDS, „THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ARttri
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

ere V
/ 2' 0'
SIGNATURE OF PERSON CONSIRUCI INU Tile WELL D '1B
Submit the original to the Division of Water Quality, Groundwater Sectlon,1636 Mall Service Coder- Raleigh, NC
27699-1636 Phone No. 019) 733 3221, is Man 30 days. OW -I REV. 07/2001
WELL CONSTRUCTION RECORD
Tenn
45112
Nottlr Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CON TRACTOR (INDIVIDUAL) NAME (print) A- &N tA)i (SO \1 CER77FICA7ION 0
WELL CONTRACTOR COMPANY NAME (ylrll er kiC it pf, i(rNS
1110NE P f )
STATE WELL CONSTRUCTION PERMTI II ASSOCIATED WI) PERMIT0
(if nppliemhte (if nmdicnble)
I. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Indushial ❑ Agricultural ❑
Mrnriloring ❑ Recovery ❑ Iteat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: tte . C.5-V, I I C- County_[ %Q/
Di
Fa_ 1._
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Rt.CKI QC
Address a.3 F; r1_Crk etc\
(Sheet or Route No.)
Uc y-eso Ile .()(.- g90_9:
City or 7-own Stale Zip Code
Area cote- Phone number
4. DATE DRILLED I V MAL)
5. TOTAL DEPIT1. ' A. y5 '
6. DOES WELL REPLACE EXISTING WELL? YES U NO ILY
7. STATIC WATER LEVEL Below Top of Casing: 30' )-)',
(Vre "r" if Above Top of Casing)
8. TOI' OF CASINO IS _1 IT. Above Land Surface•
• Jop of taring letndnaled Mier below land tan fare requli ea a
variance In ■ccorduae with ISA NCAC IC.01111
9. YIELD(gprn): f METHOD OF TEST
10. WATER ZONES (depth): — . 30'
I I. DISINFECTION: Type -14 b).et Amount R
12. CASING: Wall-IMekness
Depth Diaijieter or WeiµhUEL Material
Fr oar 6 To /JS'O' Ili, /Cf sae 2 / `J✓L
Front To II
Front To Ft.
13. GROUT: Depth Material Method
Front D To 76
1/4
EL Por-1-4,-cd PvnV)
From To Ft.
14. SCREEN: Depth Diameter Slot Size Matetinl
Nos r To Ft. in. in.
Flom To Ft. in. in.
15. SAND/GRAVE1. PACK:
Depth Size Molehill
Front To Ft.
Front To Ft.
Topogrn .e/Land setting
❑Ridge ttI Lope ['Valley UFla1
(check appropriate boa)
Latitude) longitude of well location
N 3 r°0 3'tt6" W83'43'tt8"
(degrees/ndn uteyreen ads)
Latitudefloogitude source:❑OPSOTopograpbic neap
(check boa)
attILLIN LOQ
PEP Tll
From To
6 %�'
I -- J60'
/'(cr 2i/Sr
Form ption Description
LOCATION SEETCIL
Show direction and distance in miles from at least
two Slate Roads or County Roads. Include the toad
numbers and CO11n1100 road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT TIIIS WELL WAS CONSTRUCIED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ND TI IA'f A COPY OF TI ITS RECORD 11AS BEEN PROVIDED TO TILE WELL OWNER
e
up)

V
I, II I/I /f
WELL CONSTRUCTION RECORD
C12.v
zoill
/I
Not lit ('aiolina - Department of Envinnnneut and Nnttl�d Resume-5s- Division of Water Quality - Oloundwalcl Section
1VELI, CON IIORCI Olt (INI'IVIm7AL) NAM E (win() jam) q// .4," c—c i-J- Celli IEICAlIION n �/6.f
1VEI.I. CON IItACIOi( COSIrANII NAME > '/'-`/c7' ruoNH n 15.&1?.?7-255)
S IATE \VELI. CONS I III CI ION FERMI I t/ ASSOCIA 1-EI/ WI) FEIth11TM
if nl'plicntde)__ - (if nnulicnblc)
I. \VI'1 I. (ISE. (('her( Applicable Ifos): Residential Itt—Municipal/Public Ll Industrial El A)picultuial O
AlonilnrMg ❑ Recovery IJ Iteal I'mnp Wald Injection Ll Other Ii IU011icr, List Use
2. WEI I.I ()CATION: /
I ear est Town: nets v,.//t County
($hrrl Nmne Numl•rl,, l'nnnnunily. Sul'lns Binh. I of lb,. /iv ('our)
3. OW1WItj-C)'e 2%i'ur�•,I
A(Mr uss 12,0-- `�-%t)r1`Py-C, 1/.f \A__.._._
(Snrrl or Huuir Ns )
thi v e_s Li )e_tiL �>10-
ti-
n!) m t o n Slur Sir ( ...te — -_-_-
I- -) _-------------_..--
Arrn i Ir- rhonr mmnbr,
•t. DAII'.DPII.Irt'//y1_ o _—_--
5. IVIAL NfI'lll:____
(. liMES Wft.l, RI:rt Aril E\IS1-RJ(; WEll.7 }'Ifs 11 NO 1
7. S FA 11C \VAITtt I EVEI. Below Top of('asiug: /1S-TfT.
Mgr "" ' If Ahove liar of Cn+ing)
8. 'FOP Of ('ASINI; IS /- _ FT Above lam! Stufilcc•
•'Ire or roving In,ulnnled nl/nr Wow tutu nr, leer (mils re
v e,leure In .rent dent Ith 15,1 NCA(' IC.911n.
9. YIFAA) (ppm): _/ y _MEIIIODOFTESL criPti
W. WA Hilt ZONES (depth): i/0
!SEAM RSA I 1G11
Show direction and distance in unites flow al Ic .I
Iwo Slate Roads or County Roads. Include the road
numbers and common road ❑amen.
Topographic/Land scllinl;
L]Itidge [ISIope OValley IJFIaI
(rlirrk nppmrr int.: tun)
Latitude/longitude of well localion
NisOf'06•/' 6Vdr/:57 i6.,Z
(drgrrrs/mimdre's.rnndi )
LnlihulrlluugiluJe source:CJGPSOI upogiaphic snap
(check Mu)
)2�I'Ill P-WI-1,I11U LU(;
from "fo founation I/escriplinn
(} —
II. DISII1lECIION: 'fypc_,'i'J Amount%-frr,
12. CASING: Wall'Ihic(ncss
Depth Diameter or Weight/El Mntclial
from (Z To s'S Pt. -!u SDr7)✓C
Flom To II.
Ft oar --- TO Pt.
13. (ROD I : Depth Meth! Method
I'nnnfo r/L" fl. rGr` 4;/r7 se -PS -role,
How 'Io 11. _
14. SCREL'11: Depth I)imncicr
from To ft. io.
Ilnr__--_ Ill __--- It in.
15. SANN/UitAVIil. PACK:
1 irplh Sire
lion' In fl.
Boar To fl.
16. REM ARES:
skit Silr Malcl inn
in.
in.
Mata inn
6Ty
0
t
1110 IlpRpltV (TR11FV l ilA ['I IIIS WELL WAS ('(INS7)(I1Ul lii) IN ACCORDANCE WWI 15A NCAC 2C, WEIA.
CONS I RUCI ION S IANDARDS, AND I I IAT A COPY Uf'11)IS RECORD 11AS BEEN PROVIDED TO TI IR WELL OWNER
'�✓�Ja� �!%�.� // /S -0 J/
SIGNAI11111i(IfI'PItS(INCOWL Itt)CllugIIIL'WELL DAIR
C.
Bohan( the nl Iglual to the IOil a u111'nter Quality, Crurnnllynter Section, 1636 kln11 Service Center- Raleigh, N(;
27677 Inc Phone No. (71ti) 733-3221, nlllrhi II) (In . OW -I REV. 07/2001

7It' v
IIII /II II
WELL CONSTRUCTION ItEco►tu 3 0 5 le 8
No11h Cal Mina - Drparinu•ul of kiivituunlcnl and Natural Resources - Division of Wain- Quality - (houmhvntcr Section
VPEl.1, CON I WWI Olt (Nun'runnI.) r+An1E (prhrr) G eS
VvL P..—th.i15�1q cennrlcnlluNx<'_yDy
I% EL(. CON I I(ACI Olt COairANS NAME ;U@s- t Ajell Efictn9 mad1_�1-z ty
roue+E x q�
_ASS(ICIA I El/ WI) i'ERpli lx
tAle WELL CONS nun.HHONrF.nnnrx_
If n liadde tQ is r
r..a. -wn...nil fa,........`.-, ... . ,n1
I. \V1:.1.1, I ISE. (Check Applicable !tux)! Residential I1/R111tnicipal/Public U Industrial Ll Aglimilluial L1
ttouitoririg U Recovery U I teat Pump 1Vatcr Injection Ll Other U If ()filet, List Use
2. WPIT I OCA-IIOIJ:
Nelr est To n'n:-J-IY1.Er5��Lc.�e ('molly CS Ca/
��r_ . :Ur- +fat
(Suer! Noma, Nmohel, Cnmulnnily, Subdivision, 1 of (Jo., 7i1 ('tole)
r
3. (nVNt:lt:___(
C- ._ _— H00U11
Addiess (nf lne tal Lle net e.1,V
(.
(Slrrrl or Poole. No)
113 FPS ter_ si_ (U_UleLo 6 4 3 0.53
City co Iron Slntr 7.ip 1,}nlc
1_ )-
Aron r.an I'h,•na nnmbrt
•I. PAff'. PRn I 110_11:_
5.-I(IIAl.1)1;1'1.11! 0 ,226~
6. DONS WI'1 I, REPLACE EXIS1l14(1 W'E1.1.7 YES I.) NO I_1
7. S lA IIC WAlllt I EVEI. Below'fnp orCasinp:
(11m"1"IFA1.ove Imp n1 Posing)
8. ll)1' OF ('ASINI; IS I I"I'. Above Lurid Surfrcc•
•Top of redng Inndnnlyd el/or orlon Nod lot lore If galr et
vn [nice In Irrol dnae nllll 15,1 NCAC IC All In.
9. I'ililI)(pplll):.___flIII111(11) T:Sf-Alk
Ill. WA FI It ZONES (depth):
II. UISIIJPI
12. CASING:
From D
how
From
13. OitCU I':
front-d
from
14. SCREEN:
hum
Ilom
15. SANP/Cl(
I'mnl_
faun
l l)pograpllic/1 mnd selling
LJitidge LISIopc WA/alley LJflat
(check oppuanlnte has)
Laiiluddlon ilude of well location
A/35°0i 16" UJS3`'i4'52 °
(deg enhiii natrdcr.ronds)
Latitude/longitude source: LIU PS❑ fopogra ph is map
(check MIs)
n.LL' lll UrtILLlr_,c L0 3
from 'DI formation Description
0 -- (Q'
1 1_I 1 s'
_ 0705,
CI IUN: Lilei14.11.1;Cd _3 Aunmul __LS_
VralI 'I hie towns
(Tilt I(inlnrlrr of WrighL'I I. Itinlerial
'1 i 1 Ka I L�os.�-`>7---sD.[21 pyc
To It.
_&..nj a a
IT!
Show ditcelion and distance ill miles flow at least
two Slate Roads or County Roads. Include the road
numbers and co111111o11 road 11annICs.
To 1'I
Perth Material Method
I u :v_i_ I C Ui Ch n _Vare S3_ r _
fo LI.
Depth Diameter Slot Size Material
Io H. _-- in. ---- iii
fo I. in. --- in.
AVI'I. PACK.: ---
Drplll Sire f.lnktinl
16. Itlil TAltKS;
To fl.
To 1'l.
J
DO IIfRpll'i (FP, I IFV I11AI 71115 WRLI, WAS (1)IISIRIIC(PI) IN ACCORDANCE WI711 I5A IJCAC 2C, WEI,I.
CONS I R(JC1 IONS IANNARDS, AND 'I IIA u A COPY Of'11115 ItECUIW 11AS BEEN PROVIDED 'IO11I11 WELL O'rVNER
n
SIGMA IIMF (II: I I.It;ONCONSIRUCI1t4U111p WEI,I, DAZE
Sullnli( the of IRIuvI to the PhIrian of Water Quality, Groundwater Section, 1636 Mall Service Center- Italel(;II, NC
17GT; I(11, Ptnnlc No. (rlin)i11 3221 ullhhl III da)1.
1:1V_I IrUI/ 111+vuu

NC lJ OIt1l I?
N3
WELL CONSTRUCTION RECORD 306462
North Carolina - Department of Envitotimeut and Habitat Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME Quint) (imps 2
11., II.�.\SOYA CERTIFICATION S.2
WELL CONTRACTOR COMPANY NAME FINI1i Qf 1n)Q.1( C7f111,/15 PHONE#fk7c)S7-244i
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential I.U-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: N-14yt'SV County (Jo/
S7r'.ent4Pt( set) .., D-, .t .i,Nc' r'Ceel:ll
(Street Name; Numbers, Community. Subdiviitlat, Lot No., zip Code)
3. OWNER: WIN s) \--\op\G\r%h
Address 5550 NE .tnfe ISA )2 I
(Street or Route No.)
Wtllt$f04 Ft 326/6
City or Town State Zip Code
( )-
Area code- (hone number
4. DATE DRILLED Q- I6-pt\
5. TOTAL DEI'Tll:
6. DOES WELL REPLACE EXISTING WELL') YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: hG
(Use "+" If Above'rnp or Casing)
8. TOP OF CASING IS IT. Above Land Surface'
•Top of casing terminated stror below land sot face requites •
entente In accordance with ISA NCAC IC .at IS.
9. YIELD (gpm): IC) METHOD OF TEST 4 ,2
30. WATER ZONES (depth):
II. DISINFECTION: Type V1414 he�llriks Amount 16
12. CASING: I Wall Thickness
Depth Diameter or Weight/Ft. Material
Front To Ft.
From To Ft.
Front To FL
13. GROUT: Depth Material Method
Front 0 To ,aO' Ft. QDI'Nrnss ?TeSSure_
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Frotn To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Front To Ft.
Topogniphic/Land setting
❑Ridge ['Slope laValley ❑Flatz'i:;
(check approptiate box)
Latitude/longitude of well location
(degieea/minulesfseconds)
Latitude/longitude source:❑GPS❑Topogtaphic map
(check boy
PEPTl; I21U1,LINO LD_Q
Front To Formation Description
P> - /U
0
r
—1
cV U
1.In
Show direction and distance in miles fromit lease`;
f
two Stale Roads or County Roads. Includrtl e road&
numbers : nd common road names.
✓e
1 GCATION SKRTctt -�
Docorm•/r9
creel('
e`luslr re
.ffnM e ✓
CDyp
16. REMARKS:
1 DO JIFREBY CERTIFYTIIAT1111S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
/-2_/5 -ot/
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division or Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
OW -I REV. 07/2001

305101
WELL CONSTRUCTION RECORD
North Carolina - Drpat Intent of Environment and Habitat Resources - Division of Water Quality - Groundwater Section
WELL CONI RACI.Oit (INDIVIDUAL) NAME (pint) , cry. cece CEnI !PICA-1ION Nay
PHONE N (8J%-2551..
WELL CON I HACI Olt COMPANY NAME
STATE WELL CONS FNMA ION MIMI I// ASSOCIA'I El) WI) rE1tMrIN
irn t 'fleshly (if allicnblc)
\VELL USE (Check Applicable Box): Residential 13"—Municipal/Public U Industrial ❑ Agricultural
Monitoring U Recovery U I teal Pump Water Injection ❑ Other CI If Other, List Use
2. WELL LOCATION:
Nearest Town: efV://e-- Comity
(Sheet Name, Numbera. Community, Subdivision, Lot No., lip Cale)
3. OWNlIt: D4°t 4/*-ro4,T
Address SO i 5evgrd lvs-
(Street or Route No.)
___C ealr wa Ee c EL- 337Lt
City or loon State Zip Code
( )'
Ate% code- Phone number - O
4. DATE DRILLD,ZED //-
5, TO FAL I)EI'TI I: /Z2
6. DOES WELL REPLACE EXISTING WELL'? YES U NO 11"..
7. STATIC WATER LEVEL Below Top of Casing: 3 Ef.
(We "+" If Above lop or teeing)
8. TOP OF CASING IS / FT. Above Land Sur lace'
•Top of Casing lennlnated alter beton land tot tare ieq oh es a
violence in accordance nith RSA NCAC IC .011N.
9. YIELD(gpul): /2. METIRID OF'fEST
10. WATER ZONES (depth): _7.2
I I. DISINFECTION: Type
12. CASING:
From 0
From
I tom
13. CROUP
Utom 0
T'opographie/Land setting
❑Itidge USlope OValley UFlat
(check appropriate boa)
Latitude/longitude of well location ,
4)3C°0V 06:'O -wd off' VI
(degteea/minutea/aecnnda)
Latitude/longitude sourcc:UGPSUTopograplic neap
(check box)
F4PT71 FRILLING LOU
From '1'u Formation Description
O -f %t"r'e, /
I troll
To a_ I rt.
To Ft.
To Ft.
Deptho. f1ntc)c4
To � FL C d
Diameter
G-
Al tiottlil C9a
Wall iltickitess
or Weight/Ft G,terial
ee/
/crehvd
I1Gre-
From To F1.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FI. in. _ in.
15. SAND/GRAV El. PACK:
Depth Size Material
Front To It.
From To Ft.
LacMj41 CI=1S31
Show direction and distance in miles Gout at least
Iwo State Roads or County Roads. Include the toad
numbers and common road names.
0
O
Er'
C)
0
16. REMARKS:
11)0 HEREBY CERTIFY THAT THIS WELL WAS CONSIRUCI I I) IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONS1 RUCI ION STANDARDS, AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO TI LE WELL OWNER
//—Uz-o4'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DALE
Subunit Ilse on Iglu al to the Division of Water Quality, Groundwater Sectiot1,1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. (vl9) 733-3211, within 30 days. OW-1 REV. 07/2001

11/
WE'LL CONSTRUCTION RECORD)
305107
Not di ('ntolina - I )cpnl linen! of linvilumncul nod Ihaw ;II Hest -fluxes - Division of %Valet ()'onlily - CoolnehvaIer Srdinn
WEI.I.. CON IIL(cl Olt (INUII'IUIIAL) NAMI. (puhd).....,.L�W(fls Pt L Arlon, CFI(nrll'A null N:%`/Uqi
Rri.l. CUN I I(ACI(Pit CONr,tNI' NAME fro T LA3L\A cjuA tli--) rit(INEMLl=J�15J_2t/li
SIATE R'ELI, ('ONSI IIII('1111N FFatMIIfASSOCIA'IEU WI) r r.Itr111/I
lif:I tiClld) ...,. (ifngiIknblcl
I. W EI I. USE (Check Applicable Ilox) Itraidential I(yMonicipal/Public Ll Lldloshinl ❑ Ag'icollutal LI
Mouiloting LI Fennel), L I Heal Pomp AVair( Injeelinn ❑ Oilier IA Ifolflcr, List Ilse
2. AV1:I I,1OI-AIIOR
N('alcc( Ill van:lqq
_tk.PSS'Lue,.. st/rGY>l 1'ounly C_I01-
I$bvl I Imur, t: vn1//1•^1., CIo'Imnnmilly. ,^•uldi, i.ion, I n1_I in lip I'..dr)
3. I\ I I: I c J f 1- !IL'()_(
AdtI,).` ICI. t1:1,0._I: �I P F)- C-1`11C
1.r11 et or Prnlr I1 )
ii 3 fesfe, 31Lett Lnrnel,(, 6,1-_°5 ;1
rn, . r I. •'11 Slut, tip Cod, -
Ayr,' r.. I' l l
d NAIL DPW I I D-it-
5. TOIAI I'I:I'I11: 1LDS1 _
6. UIIPS N'Fr I, P1:11.A('I' lf.Alsl IN(i \VMI.I.7 'ITS II NO nil.
7. SI'i\TIC1CAICltIF1'I!I.!Iclaw1opof(':Trial:: (pD( I:E.
(I ... -I" it -Alpine hp Of (nail•c)
F I' 'I' (It' ('ASI I(I IS I I I. Abu%r l.gild .r,fit nicer
•lrp nlr•.h,p te, etI,ntr,I n('•n Mlnn InnJ ..n lvr'
I •t lance In !urn! clanre nlih IC .v NC A/' le Ill In.
v.'liF1.D(ppt1l):_.30.__MEIIIODOf•1PNIjN.;4 __.
10. IVA I I It it )NFS Werth).
1I. NISIDITCI1(1N:l,prj\A-\ _yd_\eAtwood )5
12. ('ASIIJLi: W01 tin
I)r rill UimurIei m C; ri);bl'I1. Mnirli: l
Fiom U.. "fo 1_/.D2/�' II. 6,, 75 _S/ 2.. 10I;'_C __-
horn ./.Qci' .Io__C 3Q_I II.lp._-Q . :../,.5.(- _c_ske_f
him, fo Pt
13. (MOO I : 1'7111 plliclinl Method
I-i ntll—_-C�---- III_ _ 0 - 11_pC(.1<_ Cf7'/1'I :IN eSri( Ile___
now _ Io 1t-
I I. S('It F.FII- Ilriok Dinnlrlrr SII•i Mir. iir VInlrlin]
Item 'In Ii. in. in.
flew "In It. in. in.
IS. ,SArIUr'l;ItA\'1:1.I',\('I:•
I'rl,lh r,irr r.bdri inn
I tow ll• II.
Iioii, To 1.1.
16. It l' i.l r\ R I; S:
Topoginphic/Larld selling
LIRinge LISIorr ELPt<lloy Mkt
(cheek npprnprin4 luau)
L.alilvdc/Ioug 11tle of neIl location „
W 5.3°9. 12
(drpICrdt a n11r� od')
LatiludcllougiluJc sonice:LJf IPSEt11gnI)aapllic map
(rhrck I"n)
Inil_Ul 1JRILLlIJL1 U)I i
From "In Formation Ur.liplinn
-C) I O Lag, - -
La — l/c5'
LQC-AIION_S.ICIICI( C.
Show tin ecliun and distance in miles flow et len
tw) Stale Roads or County Ronda. Include line wild
IIIII fibers and common load I)aineg.
I DU I II:I.1:II'i (l:R I II:Y -I IIAT'11113 R'FI.I, WAS ('I ll ls I It1ICI CI) IN ACCORDANCE Will! I SA IJCAC 2C, WEI1,
CONS I ROdI II )N S lAIJPAIWS, AND 111A f A COPY OF'11115 RECORD HAS BEEN PROVIDED 10 'HIE WELL OP:I IEP
S
5\
SIGMA Ult.l? I A: I'FItsi IN C YNS IRUI_'I IN(i 1111! Wlil.l,
DAl It
Submit (hr 1✓1 (gival to the Ph islnn of \roll' I)ualilt', l:rutuutwidcr Seclluu, 1636 Mail Service Center-
27t,,,., Ic• •'II .;.I. r., ("I")711"21, 9,li bill 'p,l..,'. • 1 UN. 1

11 11 1/ 1 11
WELL CONSTRUCTION RECORD
Notts Carolina - Depadmenl of Enviioumen! and Natural Resources - Division of Water Quality - (itoundwaler Section
WELL CON I RACI'O It (Inn I VI OVAL) NAM E (pr hot) iQwI CS \ 1 cL C Elt TIFICA LION pstNQy
WELT. CON I ItAGIOlt COMPANY NAME _Mai e_c \A54..\] C, 11 r hq PIIl1NP. p f -.ifd 5t 37- 97
STATE WELT. CONS I HOC! ION PERMI IV ASSOCIATED WQ mom p
if nlgdicnble) 'if n »licable
I. WELL (1511 (Check Applicable Do.): Residential li.l--"-Municipal/Public O Industrial C1 Agricultural U
Monitoring LI !tecovcly U I!cat Pump \Nader Injection ❑ Other U If Other, List Use
2. WELL IOCAIION:
Neat est'Uin 45\/t')P- County�-1Q1I
(Sheet triune, dumber,. Community, mnnoity, SuhdivNon. lot 110., lip ('ode)
3. O\V Nlit: yyy)LI r) Qin
Add:ccss �1> 2-_Ghatr_ A
(Snerl or Route Nod
�s(ii)ke NC, ZS390y-
City rr I own Store lip Cole
( )-
Arro ride- Thane number
4. DATE DRILL(a - f>r-i
5. TOEAI. DEP IL'-2gs-------__
6. DOLES WELL REPLACE EXISTING WELL/ YES LI NO U
7. STATIC WATER LEVEL IlclowTop of Casing: ____ ► 1',
in
(tier '4"If Above lap of Citing)
B. TOP CIE CASING IS ]1 E. Above Loud Slit face
•1 op or IrnnlnMed nt/or hrlon hind ins lore reinter, it
valence In aerordnrze nllh 15A NCAC IC .MIe.
9. YIELD (gpm):_5_-ME111000F ESTA;e
to. WATER ZONES (depth): —�
I. DISINIECIION:Type,n�-1nYp-t(0tSAmount lc)
12. CASING: Wall Thickness
I)rptll Diameter or -\Vciglit/Ft. Mntcl sal
rnnn E7 To got rt. (.QScatc al 4liir
Itom To 1:1
Flom To
Topographic/Land selling
Ultidge Ed -Slope OVallcy lJflat
(check npproprinle hoe)
Latitude/longitude of well location
51/ 35°OF09"J1V.33r3 i lv
(deg ren/nr i mrlr dsecond+)
Latitude/longitude soulce:OGPSO fupographic map
(check box)
1JLCU1 NULLING LO(
from '1'o ,i'ornlalion Description
- I el
lb- 'is'
7'6- ausr
r
LW /111 1_SY4LGII
Show direction and distance in miles limn al least
Iwo Slate Roads or County Roads. Include the road
numbers and couu loii toad names.
13. GROUT': I)rpth Mnlctiat Method
I'mm b To 9 rh.�o rt .rynL � 7t-P5<are
Prom— To
I t. f
14. SCREEN: Depth Diameter Slot Size Maletinl
trout_ To Et. in. in.
Prom___-- .II) _._.. El. in. ------ ill. —
15. SAND/GRAVEL PACK:
Depll, Size Male, inn
trout To EI.
Rout To Et.
16. REMARKS:
coO V
lfcjc+
0-
I
DO IJEREliV CERTIFY IIIAT 11IIS WELL WAS (1NS11tIICIF.D IN ACCORDANCE WI11I ISA NCAC 2C, \VEI.I,
CONS] RLIC1 ION STANDARDS, AND TIIAI' A COPY OP'II ITS RECORD IIAS BEEN PROVIDED '10111E WEI.L OWIIER
�_.'` I mil,
/f
�f
IIU
305100_
1/- i& - o y
SIUNAI IIItw, t )1' I'EItSUN CONS I farm WELL DA11!
SnIIIIIIt the ut Iglual Ill the Ills ilk!' of Water Quality, Groundwalet Section,1636 Mall Service Center- Raleigh, NC
27699 I616 Plume Na. (910) 731"1221, w Ithbl 111 days. GW-1 REV. 01/2001
112
•

afth
lc. WI Al DUI'I -IC /0,'----
6. I)01:S VVFI1. It!:I'I A('R I:NI S1lNO VVI.I.I1 ITC;
i I II t( 1-1'
7. S I A IIC WAAI!It I.EVGI_ Ileloly'fop of ('acing: ___ p l'•
(11e•'1•'i rAbmr Hp or rn-Imp)-
8. WI' (tf ('ASINt1 IS / ri-. Above I.nnd ,glints
• 1 r•p rf r.dnp Irr ni bnlril nlL,r Mon Iona •ntl.rr Iequhn •
c•, 6nrr In Afro, diner Hill, IRA NCAI' jl•,III IR.
V. VINI.D(yowl _/.1,__MII111012(JIJSI. % —__
III . \VAII It ✓.01JI[S (tl. plli): _ 0 _ -_- _- -
II. DISU11 FL I ION1vpe/5'7 Alurnaii %yc /2
12. CASUAL Wall II,i-I'nrss
I) -pa, Dinn,clrt or Wrighl,'Ft. ALllrriail
Front 9 To �+i i'i ,.ZJ - ,SeN,Z I p2dC
I tom 'fo fl - - -
Fr ni _-- fo I:!
11. 131101/I: Itrplli hlnlcllill b)rlhnd
Ploni_Q o II 0ll/%'i/ 1;ef ✓i
Irwinto IrI.
IA_ S(-ItNf•N: Irplll I)innmier SlotSi,-c M1lairtinl
Flom To I -I. in. iu. .-__---
Ioot Iit 1`I...___-__.. in _... in.
IS. SANI>,:OILAvlll.l'A(K
I trl lh Si,r Mainha
Ilnm I o PI.
Er,ru l t' Il.
16. RI:AtAItl.S:
\YELL CONS I7tUC'r1ON ►tE COtti1 305105
Thoth ('alnlirt:1 - I )ry,aiIr cii! of Nnvirsnuncut and Nnl n:d Itesontcr.a - Division of WW1 Quality - (honndanler Srclion
{PE1.1, CON II(M.1011 (INUll'l l)11,V 1.)NAalf (pilot)7rx _/(14c e- I: EIt11L ICAMill MR ti °.1
WPri.l, CON I itAl'1 Olt CnalrAN V NAME /1_11;77er 1•IIONC n4,1,7? fr2-zf5;2
S I Al 'PELF. ('I!NS IIfIll.I ICON I'F:ItaM11N __ _ .___-.---_AS.SOC:__._M ED WI) i'ERPII'Ill
i,111,hc al Jt1 pi,04211:11c21;lcl .'
I. \VI:I I, IJSE (Chick Applicable Hot): Residential U iMtrriicip:d/Public LI Guhisnial I I Agticullutal CI
l.Ioniloring I..I Recovery LI Ileat Pump Walri Injection LJ nutlet 1.1 If011ict, List Ilse
2. Wit I I It('AIlo ll' // //
Ilea: cc( Town: a/elv i/le_-._.__ ('ounly C /
,J _ Topoprnpliic/Land srllinp
------ Llltidgc 1-!.Slope LlVallr
fret Cree c.
(tfimk flitter hie bo.)
($lirr111•inr Ihonirit Cl nmuuuih', S"I kin% o I Ili, Tip I he) I- rttililddloilgtllltle of well location
C/ Al35°aq i I g ' WS3`30'll r,
1. ( )1CtJt It �7e�
�
G �n T�I veito/1
• (drgrrrdm nlin.c'(•rnn l.)
Addre s 1.30 A _ / / G LnliludcJlouy,ilude sumce:(J(71'SCl l opo)napllic rnap
( br Im I!rulr Nn)
(cLrck Lr<)
lL -yt2 5).LIli,(.'[ _2 'J CLj _ ))EClJI URILLlt11 L(11;
ril¢,,r lr-.tn smlr ry, Lod?. Errnn To Formation llrs-notion
1 )-
Air, n•dr nnmba 0
•1. 11AII:DI'.11II:I) /l c»-0Y &, xiZ CTr"`/
LQCM IV t SY.I 1_C7l
Show direction and distance in miles Gum nt least
two Stale Roads or County Ronda. Include the mad
nuu tieiq and common road names.
IP(tIIEEFH'i(TR11f1'111AI11(ls\VI'II,\\'AS('ONSlltill,'IFDIflACCORDANCE 1v1111ISAIJCAC2(',INN I.
CONS I RU('l 1OIJ S I AIJIARDS, AND'1IIA I. A COP'! OF 171IS RECORD IIAS BEEN PROVIDED 70'111E WELL OW11EP..
/4Cc
itJAl llONOpI'I'RSON(:ONNI'MCI It4(i11I11 WIULI, DAIS
Submit Ile or ig11191 Io the I)Itislim or \Vote' Oualily, (:touudn'aler Section, 1(1( Mall Sex dce Criifrr- Itnh9)'h, tic
,,, ,: tcir. rb tut, r:o. (m In) 711Am. nibin 10 d„•;s' (il'r-1 REV. 111/211111

1?'LLI, (()NSIILU(,'IIUN itII,WItU
Howl Unrnlin:, - Dept linen! of Hnvilumnent and Daiwa! Resumers - Division of Water Quality - (Jionndwate: Section
1VELI. CON I ICACl Olt (INl)ICl m1AL) NAME (print)— G/7 eec
tVEl.i• CON I It.\CI nit (' nnrrANE NAME-- //J Wet-
Celt I IFI('Al 11/N
more n ff'4i fJ)-Z r2
SIAJE tc EI.I, CONS 111,CIION VERMIN
------------- ASS(1CIA1F.1l WI) PERM! IN
if nr ,Iic:Jdc if r dicalt)
%YrI I. IISI? (('bock Applicable Jinx)' Residential LI—'Atunicipnl/Public LI bldusltial 17 Ayricullural LI
Monitoring L.I Itecnvcry I_I lien! Primp \Valet Injection LI Oilier Ii 1FO11ier, List Use
2. Wrl I. I I nA(l01/1:/
Denied Tn wit /1/yet (/e //
5411) yet teat;
(Slirrl Ilenir, Ih ml r,. l'nnunnn hfilibulilkion, lot Ito. Tp
3. (I\\'rII R Ty Geed
Adtltecs _37(10 Nt✓
tr.', fir hand flu )
.
Cif) PI Il'' IT SW, ---
l'nnnly Z v
Llr I'ni .
)-
A,rn ri.a._ rh„n. lin,nl Tl
d. It;1Il:. NRII.I fit //-o -'0y
5.-fllf,'\I,1)1:1'Hi:
('. NT.'S \\'1:11. RCN A('B I:SIS NIJ( Wll l.7 Yl.'; H Nu I-I---
7. S FA HU 1.1'A1lilt I FVF1. Pelee: 'l p of (':r:it;p _. d _I' F.
(Ibr"I•' If Ahmt 1, s. of I'noinp)
H. 'II II' OF ('AS111(; IS; / FT. Alwyn] and Sulfate*
'a rp or rndnp In ndnairnn ni/,. hrinn Intl Tut l.rr, Ie,ril,r, n
.nl.nrr In lirrmrinurc ollh I!.\ N('AC IU.nl In.
Q. YIN!) (rpm): _/•S1___N1E1HOD DI' 'IEST /SZ'
Id1. \1'A'l'IR 2,011 :S dr,h i -----
I I. NISIIJI'IY:.1II)N: 1\pc j%/7 Aneroid ��(c� Show direction and distance in miles Goon nt Ica;t
12. CASINO: Wall IhitLoess Iwo Siale Roads or County (toads. Include the toad
Ilrpllt Diameter or Weight/Ft. ?Amnia; numbets and coi111r1u,n toad !Mlles.
limn D Tn)§�ffG._..2J� a_ea-r wG
funit__---_ To Il.
hart__--- fnrl._ _
13. GROU I: I lrplll Iart-ij l „Method
horn -..-0 .Io02a__._ I'I. /'1mil ci --ell(rc^_e—
•foiroprnphie/land rrrl!inh
L'Ridge LISlopc CIVnlley IJil:d
It boric nisnolaino- boy)
Ltdilude/Iungiludc of well location
/✓35°D3' 4-7,r W 83°'t7'22
(I leg ire dm i n i o n' a m n n,. h)
Lalilodcllouyiludc sourcc:LlOPM hiprlprnpllic map
(check M,.)
R41_T11 DRILI.IIJ( ; Lou
from 'RI Lot nedirm Ncseriplion
(11
305104
_CZ
0
r
horn in _ I'I.
I.1. S(RF):IJ: North Dinn,clrr Slot Si:- tUalrtinl
slow '1n I, in. in.
ern Ta FI. i
I
n.
IS. SANNL(;RAVi:LI \(f::
Ir rth Si,c k hoer in!
from 10 _-- It.
Flom ---------_--
To II
16. IINTA111:S:
1dtQAi 1QL1_rfU (I (
1-
I
II) I I I:R1-11'i ('hit I IFy 111AT'I 1 ris Wpt I. WAS i •OIJS IIN ICI79) RI ACCORDANCE Will( I SA IJCAC 2C, WEI CONS I RUCI INN STANDARDS, AND 111A [ A COI'Y 01:'111IS RECORD HAS BEEN PROVIDED"! 01111i WELL OWNER
SRUJAI(IRENEI''ESN 4CONSf1(NcntJolue WELL DAIF
Subulif the nt Iphnnl to tar VII Blau of \Valor I )unMi1E, GI oondtvater Section, 1636!,fnll Service Cenlcr- RnielpIm, N(: 27h7" Ini, 1'Ir,ur lfr. ("In) 7t3 )_'.`i, a ttain !II 0(,:,-
()IV I rrnv litrn,r,I

/4 tl'D
WELL CONSTRUCTION RECORD
Not tlr Carolina - Dcpatmneut of Envirmune,t turd Nattual Resources - Division of Water Quality - Grou water 1 io
WELL CONTRA CI011 (INUIVIUVAL) NAME (pilot)Section
WELL CON IREn
ACI Olt COairANY NAMI`1 aaC___ `tea
SPATE WELL CONS IItNCI ION IERMIUN rnone "Igo) g7`+'
-�9)
if n + ilicnble ASSOCIATED WO PERM] IN
'fat riicnble
I. WELL USE (Check Applicable Box): Residential fieMunicipal/Public U Indust' inl ElAgilcuilulal ElMonitoring ElRecovery LiHeat Pump Water Injection Li Other ElIf Other, List Use
2. WELL LOCATION:
Vlettitce_Nio
Nearest 'fown:�yrall ___ nuttily_
(Skeet Nine, Number; Conununisy Subdivision, lot No., Zip Code)
3, 0 WNlUt:,3_Qe_lautC I
Address �2_0 S tLln v ± 2,,±C
(� (Skeel (It Rowe tJo.) "
----- krAry2_SSLI I /( 7 $ (Q E/1 City to I owes Slate Zip Code---
Art, rode. Phone nnuiber
4. DATE DRILLED
5. TOTAL DEI'TIL_3' -
6. DOES 1VE1I. REPLACE EXISTING WELL? YES U NO k]-
7. STATIC WATER LEVEL Below Top of Casing: _SCpl )rl
8. TOP OPCASING IS (ore "4--IrAbove lop of Coxing)
IT ove Len
•'i'np oft, rliR lei oiln,trd id/or below hind int bite requli eor • Sol theevulture In ,crordance will, 16A NCAC ICAIM
9. YIELD (grim):jO METIIOD OF TEST 11412
10. WATERZONES (depth):
II. DISINFECTION: Typc}4w Ifl Alumna_LS __ 12. CASING:
Wail Thickness
Depth Diameter or Weight/ELWeight/ELMntetial
To_l�9! ELleI25 <1)c 1 pllr
Front Q
1'1011To
11.
From To Ft._
13. GItOUIt Depth Anterial
Fronr-�__ To_a i FI.
Front_ To Et.
14. SCREEN: Depth Diameter Slot Size
Fiorit To NJaicrinl
Ft. in. in.
Hoot To Ft. in.
15. SAND/GRAVEL PACK: in.
Depth Size Material
From To Ft.
Front To It.
16. RENtARKS:
CERIIFICALIONN_^%i�oj✓
Topographic/Land setting
Ultidge 11a31ope ❑Valley UFIat
(check spproptinle box)
Latitude/longitude of well location
" r t o 4:
(deven/minniex/reconds)
Latituddlongitude source:CIGPSUTopogiaphic map
(check box)
MI, NQ LUV
Formation Pesciiptiun
)J1<1'_1.1
1
Flom To
JALCAIIDnucil
Show direction and distance in miles flow at leas
two Slate Roads or County Roads. Include the road
numbers and common road navies.
I DO HEREBY Y CERTIFY MAT 1111S WELL WAS CONS 1'I UCI ED IN ACCOIWANCE WITH I5A NCAC 2C, WELL
CONKS I RUCCIION S FAANNDDAA1JWSS AANDD THAT A COPY OF MIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
6 Ste^ SIUNA') ORE (11'ITItsou CONS'1'RULSINC) TILE WELL
UA'1Lr
Submit the of lulnal to the Division of Warr Quality, Groundwater Section, 16J6 Mall Service Center -Raleigh, NC
27649-1636 Phone No. [phone], nIIhilt 31) daps,
OW-1 REV. 07/2001

NC
IN1li
WELL CONSTRUCTION RECORD
Neil' Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION H
WELL CON TRACTOR (INDIVIDUAL.) NAME (print) MICR/ wu (SON
WELL CONTRACTOR COMPANY NAME 1ll.11ef tniCu.,<5
ASSOCIATED WI) PERMIT/I
STATE WELL CONSTRUCTIUN PERMIT (Tapp l;cal le)
(if npplicnbte)
carmsmimmw
//II I)
3�5112
PHONE M I )
I. WELL USE (Check Applicable Box): Residential II'Municipal/Public 0 Industrial D Agricultural D
Monitoring ❑ Recovery U Heat Pump Water Injection U Other U If Other, List Use
2. WELL LOCATION:
Nearest Town: Het>/&I-VIl I C County_[lQ'/
Ci K4 r r
(Sheet Name, Number., Community. Subdivision. Lot No., Zip Ciwle)
3. OWNER• KrL(C./ 2f C
Address .2:3 �{_ F; t"e-$C-rk RA
(Sit eel or Route No.)
k�ct1-e.,t Ile AJC-_2_S`It'`i
City or Town State Zip Code
Aura code- Nome number
4. DATE DRILLED I(/z3/o1-1
5. TOTAL DEPTH: _-2-95' /
6. DOES WELL REPLACE EXISTING WELL? YES U,NO I
7. STATIC WATER LEVEL Below Top of Casing: 10-f' t
(the "I- if Above Top of Gating)
8. TOP OF CASING IS _ L FT. Above I.nnd SinFace
flop of rasing ter min aced atleer below land rot lace requites a
vatlance In accordance with ISA NCAC 1C .at IR.
9. YIELD (gpm): 1X ME I OD OF TEST !! r
10. WATER ZONES (depth): `LW — ). 70'
tropogrnykitiLand setting
DRidge lope UVallcy OFlal
(check appropriate box)
Latitude/longitude of well location
N35'b3'46"WS3`43'#
(degreeJm inutei/aeconde)
Latitude/longitude sourcc:DGPSOTopograpbic map
(check box)
12jtJLL1NU_LOSI
Form lion Description
II. DISINFECTION: Type
12. CASING:
From 6
Depth
To
bier Amount IR
Wall 'thickness
Dinr peter or WcighUFL Material
Ft. ( SD.2 21 _pv(i
From To Fl.
Front
13. GROUT:
From a
To
Depth \
To 2b
Ft.
Material Method
I:. Pori- pore
From To El.
14. SCREEN: Depth Diameter
Frorn To Ft. in.
From To FL in.
15. SAND/GRAV El. PACK:
From
Eforn To Ft
Depth
To Ft.
Slot Size Material
in.
in.
Size t,tntetial
PEPU1
From To
6 Iris
Ion - Ifo'
/, t 2 L/6'
LOCATION ZEE' �1
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY 11IAT TIES WELL WAS CONST'IUICIED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, /AND THAT A COPY`O� CORD IIAS BEEN PROVIDED TO TILE WELL OWNER
C� / z
SIGNATURE OF PERSON CONSTRUCTING TTIE WELL D IL
Submit the orlehrnl to the Division of Water Quality, Groundwater Section, 1636 Mall Service Cnwf t Ita'Vg07 N001

//C 1/
II IIIII It
WELL CONSTRUCTION JtECOH1)
zo5ttt
No(Ih ('aiolina - I)epallinen! of Fnviloulneid and Natu's! Renourc5s - Division of Water (lunlily - (iloundwnlei Section
V
WELL CONIILYCIOIt (INDIVIDUAL) NAME (p.Ln)Carr ✓1 eC (2ERIIEICA1ION ft
WELL CON I RAC' (IIt COnrrANY NAME 0/7/4/7 - rumor, M ospvi-Rif)
S FATE WYELI. CONS I MICA ION PERM! I U ASSOCIA I F.n WQ FF.Ithii I N
II n'plicnble `�I cnblcl -
I. 1YP1 I. USE (Check Applicable Box): Residential 1 I'Atunicipal/Public ❑ Indusllial IA Apr indium! U
Monihning ❑ Itecoveiy LI heal Pump W:der Injection ❑ Other O Il Other• List Use
2. AV Ft I. I OCAIIUN://
Ideal est IInvu• [7 e3 v, 4:- Comity C
f /e5 C/ , . /C2
(Sltrrl 7111111P, Nnmbret, Community, SnhJirittinu, I nl Il(1.• rip ( n Ir)
O e ",,o
Addles 12.9.5 t.11 4i,,._IIEJ'\c1.__..
(Slrtrl I thoot. No )/
t+nv2S)11)P /VC_ z(16-1c' — ---
Cily nl 1o,.(n Stmt. lip Coat
t )-
Arn r(ver- I'honr immbet
4. uAfl'.mot I1'U_//'/Z_ 0V
5.-IOIAI, i)III'LII:—
6. 1OFS WRLI, REM MT EXISIINO WEI.1.7 YE; 1
7. SFA1ICWAIER. IEVEILBelow Topof Casing: - /_G3.T._P1.
(lhr "I" If Ahoyof ('n:iup)
5. TOE Of ('ASINO IS _--/___ F1'. Above Land Smthcc•
•'I 'p of r•dne Iry minntt,l •t/nr Inlnn Innd nit Inre ninth rr •
n•1 l Hoct In Ham dmre with 1SA NCAC IC 111111.
Q.'CI F!!)(ppmmm):/_-MIiTNOUOF IESI _i__r —
10. WATER ZONES (depth): 9 /0
II. uhslulE.CTIUN:T}pe /7TH Antonia -1/-ft.79
Wall 'thickness
or WcighUPI. Material
12. CASING:
Neplli Diameter
From C To ,S'S 1'l. -i-(
Prom To
Flom to
13. (WOW': Depth
Flom _To
Prone fo
14. SCRIilifl: Drpth Uimncler
Mom To __PI. iu.
Plnitl-----_-- To 1't._
15. SANILGItAVPI,PACK:
I trpth Sive
Horn In H.
1'r111❑
16. Itlit.lARKS:
Method
_esfv.r
Slot );ire Male in!
h lamclint
'Popogrnpltic/I"attd setting
C1Ridge LISIope CIValley IJllai
(rhrrk nppl nprinte hot)
Lnliludellongilude of well location
4)isec;06•/ wegJ'`S/'3.,c
(rirprere/mintnedsP:nnd. )
Laliluddloupiludc source:LIGPSLlropogiaphic map
(check hos)
Plitt
U_BILI"ILC LO i-
from To Founalion Dcscliptinn
—� CT�
_mac- R*0 _Crecy,-ie-
L4CA1 I9t15Y,li:I (�;�1I�������
Show di'ectton and distance in miles front at iea•1;l
two Stale Roads or County Roads. Include the road
numbers and couunou road names.
I DO I IERF NY CLR I IFY 111A I.it IIS WIl I. WAS t nh+SI RI ICI P.D 111 ACCORDANCE WITH ISA NCAC 2C, WELL
CONS I RUd1 ION S IANDAIRDS, AND 111A F A COPYOPOf lilts hIS RECORD IIAS BEEN PROVIDED 10 T11E WELL OWNER
..��r'012/7 1�L`L `,C' C/'/iv0 Ji
SIur1AlUlt1(II'PI'ItS(INCOIJSIHUCIIND11111WELL DAIS
Submit the of IgInal to the 1)IYWon of Witter Duality, GIoandsvnler Section, 1636 Mall Service Center- Raleigh, NC.:
-- ..-. .-.. (1W_I it it (11/70(11

1111II / li
WELL CONST1tUC'I'ION ui+:couu 3 0 510 8
Noi lit ('atolina - Nepal nicul of him itunwenl mid NnluLd Itesonrccs - I)ivi.^.iou of Water ((utility - Otonudwaler Section '
\\'Ft.LC(ON I I(ACI ORI)NIiI CI1rPAi.) NAME (p,ln) c&V\,CeS �1' l,�i,��Sy�l CEIIIIricAI tort xjioY
\V FI,l, CON MAC' OR COMPANY NAME )-(/t,c1eC l +^)(L1 ciclho r11UNr, M pug)
S 1-A I F. \\'ELI, CONS 11il'C I ION I'F.1151I I N ASSoCIAI EI) WI) 1'1..10111 M
lif n�•Irlicnbl n icatic
I. IA' El I, III (('heck Applicable Ilea) Residential It1/Rtunicipal/Public Ll Agiiculnual U
Rloniroi ing LI Recovety U Heat I'unu, (Valet Injection U Oilier U If Other, List We
2 WELI, I OCAIIOII:
"cal ect fown:_Oy\lQS 131.e_ ('nnnly-C caj ___-
t1 r_ 'cL,00t__ lad,
1
IS (ler? N+nr, Nurnl•rrt, (lmmmnily, Sntidivi^inn• I nl Ili, , 7ir ('our)
I ' D 1
1.I,arar•R: C�li_f--- — f tic
Adult CSC i.nr )1€ It ( e'lep Ce Tit C.
(Snrrl m Polk. No.)
ll3 Fps Eer 51 S. Ccrk,_eL' a f,-A 3 053 I
City or loran Slnlr Zip ('ode
Aim r•.I rlr•.nr 'HMI tier
4. PA IT Intl] I ff)1L_JCt_- O(4
5. I OFAT . PEl'I II:0-.2U67..
6. NOES VVlI I, ItEI'I.A('R. EXIST II4O W111.1.7 YES LI NO U
7. SIAlIL WW1 fitI1VRI,IlclotvTop or(*acing
(Vie "I"If Al,ove I rip of rmleg)
R. l OP OF l'ASIN17 IS ) 1 1'. Ahlna• I.nnd Smtncc'
• Iop of toiler Inndnnlyd elfin triton Tend nnlnrr Irrinlrel I
rn lento In error dance (dill 15A N('A(' IC 11118.
9. YN?ll)(Jl)1):_3U _Ru:nRn)OFTEST iC
10. WATER U_1NES (depth):
II. UISINII;CTIOrd: 1)1,01{11 Hie Amount 1 S
12. CASING: Wall Ihi( korai
1 \rplh tyionrclrr of \YcighUfl. hlaletial
1sum Q-_I., i_KO I't.-iD,25_SDI 21 ,?YYC.
nom To Ft
Ptnm To 1`I. 13. (Ut(IUI.: Prpth Rlnlclial MethodI roll( 0To a� f(.Gif1a,h_�--y�Y=�i(r�-
Flom 'In ft.
H. SCltfft1: Prpth Diameter Slur Si;e R1alctial
Pt tint To It. iu. ill.
it'.
Topographic/Land selling,
Ultidge LlSlopc IlPfallry Lillnl
((heck erprnpriehe hot)
Latitude/longitude of well location
A/35`OI'I6tt W83`44'52"
(dkgrrrdwinuirt'trcnich)
Latintde/loigitudc source:UOl'SU I opographic m:qi
(check NIT)
PEl1.Ul UItiLl,11_I(J-L Uti
Flom To Emulation Nest riplinu
Q - -to'
(0'r_I(61
/s - t7o$
1tom To 1.1. in
IS. SAND/GItAVEI. I'ACL:
Pr pill
Mont 'Io
Ftnun To
16. RF IAIZLS: -
Sir r•itiri In]
Il.
It.
LQQAtIU(J
Show direction and distance in miles lions al least
two Stale Roads or County Roads. Include the toad
numbers and common load names.
I PC I IFRFIll' CI:R I1EV "I I IAI. l I llS WEl 1, WAS COI IS I RIICI liu IN ACCOIWANCE WI11I I5A NCAC 2C, Wil.l,
CONS I ItOCI ION S I Ar,nnRDS, AND l IIAI' A CI 11'S OR l l llS IlECOIt) IIAS BEEN PROVIDED TO'r1IR WELL O('.'t 1ER
- LA L QD ` /7- /9- DC/
SIt;NAIMtn IIF1'lE:;ONCONS IRUCIIN0'lilt!WELT NAIlt
Snhnritlhe in 'gloat to Ihe•IN\idlon of Orator-Op;dily, Gt-oundn•nler Section, 1616 AlallService Center -1talei0, NC
(!1,1 I rri(V 11-/nflnl

l!l' IIII NI H
\VELE CONS't'RUC'J [ON RECORD
North (':nMimi - 1 )cpar horn! of PIivitoiiiiwllt unit N;lllitlll Rcao cen - Nivl.ritlll of \Vatei (tunliiy - ( irlrrrnrdwalct ;r.ii ill
\ \ 111
wELI, CON 11(ACI011 iINPIVIDIIAL)NAn1E. (piing JS,A\ryla5 \L w.31,1.{L — cennrlcnln)IIn_I{vU-
vvELL CON lnoel Olt (-nnlrnnvN,lnu.1'V��\_\at-Lti).a._5IV A \)iC-----
riuNr n Lis-) ii57___�6_7
slArt;wel,!.IIINsnn in oNrr:unuln____ __.__.—.—__--
AssociAl En wl) i EItMI t n ----
cif n)•Idicd,lr) Of nyrlicnble
\\'I:I I. 1ISP (llrrrk AI lic:IiIr Ilox): ItreidrNinl ILL—Municipal/Public LI biluntlial 1.1 Aw,ricullula! L1
Monitor ing E. I Rrcovely II I leaf Pinup \V:det Injection LI Oilier 1..1 If Other, List Use___-"
2. WI:II"ItnA-I1011: E7! '
Iteheel!ln•rn:1�Atiosy it.Et_.SCGrarPCourtl' Cia9.
l .tier! ttrittit., 11und ^r., l unuuih, .rr I li i<ion, I ,III , 7ie 1'odr)
Adds.'. C011,1c ll4 . lG.11. f P t'_.l�o J-- u[_.
(^Teri! is Ilntlr 110 )
JI s ceI,ct (.•,i
('ih r 10,11
Slur ;III t n.lr
I )-
.114\IP Dltil 1 PD I1- Icl-QC1 ...__._
s. li_HAl plI'1II• 1iscit-
6. l'ImES \VI'1 I. null ACP P.\ISI lNU wt i.l'1 'i I! S I I lit) ILL,
7. S I A IIt' \Yr\ Il'It I.I.VP.L Rclow I op of (':error: jar)(.._ El'.
(U.r"1"if Al,,,vr I, q, rl 1'n<irn)
IL l I rp (11- CASINI; IS 1 __. LI. Abner I and Sutlncc'
• Irp 11 (-r.lny Innr hrntrd nt''n Irrlon Inn l mt Inc trgrd<n n
Ftlnnrr In errnldurrr nllh IL\ N('AC it' 11110.
V. l'IP1.11(1'Pnr): _. Q__—h1EI11000P'lESI 1�
Ill. WA l IT 7.11NPS
)0531
TupI' rapllic/Land sclting
I IKidgc 1_I>lopn 19 ny 1II'lti
(clmrk Al rn pt iir lin!)
Lalilut(dloi,ilidc of will lncalion „
3_5 °OI11A1 3c4I 32
(dr r l er<hui nn lr v'<rOnl d.)
Lalitidc/IouYiludc soulce:ti(II'S❑ I (portaPbic nngr
(clock N..)
I)E11ill ultILIJIat1IIh1
hom 'flr Ponunlinn Ur liplirnl
1(_ lls
/
_345.5/01E
�jcr — _
O
rn
jr
LUCA IION_51 I IS) t
i \\`\ c ete.i� \iri nut 1 S Show dileclion and d1s(nnce In miles horn nl Ica
1 I . ('A l(11'C I Ion: I . 'r tw1Stale Roads or County Itnnds. Iidud^ Ills to. 1
12. l'ASRIU Wall l,4.knran
in�plb Di:nurtct of \,ril�hr'Ph P.tntclial um rhos and communion(' nnnlcs.
I-how__�%_--- I-"_�./D�I! _F. L_ir,dS _SA .,?/- _,42k'-G----
nom_j0c%_'In_CSD:Fl.f2,_D _ !OS_ _3%U'C-_/
Ilan) to IL----_ --- ---- _-----._
13. NMI I: !'rplll rInlrlinl Method
now fn_.mac_--Irl.-f"cl_f_.(Cre_JJ_ .:ix e sccIF'_
fllgrr In II. 14. S( RII'N: Urj'lli I Iinnrctrr SI1,1 Sinn MalrlinI
horn •I 11 - --- I t. in in.
Ilan) 'It, I'I.___.___ in. ___.. in.
I:_ S,Atl) IRAA'PI.I'A('I::
I lrplll ,r:i:r Minn I'd
Ilanla
Ilo11I II' I -I.
16. Rft.tAltl:S: _ ----- —
11)O I11 1U 11'i l'PR I II'Y 111;\l '11115 R'1'I I. WAS ('t 111S I RI ICI EI) IN ACCOIMAl10E \Vllll I $A NCAC 2C, W EI I.
CONS I ItUCI I1111 S I-A111)AR )S, AND l IIA I' A COPY VI' MIS RECORD 1IAS BEEN PROVIUED'IO'fill? WELL OP:1II:l!
SIGMA1111W UI:PEIit; I r11 COFt IlUll'IINU llli? WELL UAII.
Submit the m 1),III'll lu the Ill) idiot of W:ttet 1)inl((r, Groom! titer Section, 1636 Blnll Scrcice Cvnlrr- Itn11,1101, TIC
(iAV-1 It P.V.I1woo
1

-fir `V
I/ II i1/II
305106
WELL CONSTRUCTION ItECOI4I)
North Carolina - Dcpal Intent of I nvitomncul and Natural Itesoutces - Division of Water Quality - Groundwater Secliun
WELL CON I ItACI Olt (INDIVIDUAL.) NAM E (pr arp jy,rrrr Kam._— ^'G)-`� CFR11E1CAI ION n,02gQ �f
WELL CON IRACtOlt COMPANY NAME 1Z1a12C \ •')4jI Arl,\,n� Forme, a 1V1/1It/ 97
STATE. SVELI, CONSI InICI ION I'EIID11Tp ASSOCIATE,(( WI) 1'ERAIIU
rrdn dicnldc tin n dicablc
I. \VEIT. USE (Check Applicable Nos): Residential 1i.1---Monicipal/Public O Industrial ❑ Agricultural LI
Monitor Mg LI Recovei y U Ileat Pump Water Injection O Other LI It -Other, List Use
2. W'EL1. LOCATION: Nearest Town: 10 SV I1leer ComityCr�a( `
eixessi
(Sneer Nmnq Jlnnba,, Crnnnuniiy, SubJivirion, lot Na., Yip Crole)
3. OV; NI It 12-r
Add;css A6,2-L C-im & y A,-
(Sir eel or Poole No
_Jt yCSt2111e tiC- 2$g9y-
City < I l eon Stale Yip Code
At en code- Phone number
4. DALE. VitnIEl'ii- k(a -ntI
5. TOFAL DEPFIE_ y5'----__..---
6. DOES WELL REPLACE EXISTING \VEI.1.7 YES U NO Li
7. STATIC WATER LEVEL Below Top of Caring: -_-Q.___FT.
(Vile "+" If Above lop of ('ring)
8. TOP 01' CASING IS -__I __ Ff. Above Land Surface
•l rp of tnrinr Irnninnled nl/or brinn land rn,Ieee I enukes t
rnimte In •ceordulte n1111 ISA NCAC 1C .111 In.
9. YIELD (gpm): —5 ME IIOD OF TEST_
IU. WATER ZONES (depth):
11. DISINITCTION:'1ypeSisl�at5 Amount L'
12. CASING: Wall 'thickness
Depth Dinutcler or Weigle ft. Material
From 0 To qO' Ft. (o a:6 SXQt _ )vc
from To FI.
ftoltl To It.
13. GROG I: Depth Material Method
Flom b To ao' PL 1ayiI ?re Sure
Flom ToFt. --- -.--
14. SCREEN: Depth Diameter Slot Size Material
Flom To Ft. in. _-__—_ ill.
in. in. ------
'fopograpiir/land selling
❑Ridge filSltpe OVaIIey Ullat
(drtrk ippropriale bo t)
Lntitu(cllongiludo of veil Inca lion
,'i/35"01'!79"11533"51 S
(dryer/to innirt rrnm),)
Latitude/longitude sour ce:OGPSOI opoglythic map
(check hex)
PIULLI11U.LU(
)fIu1
From 'fo
- tot
Ib - 'i5t
- aus'
irony------- Fo-_---ft.
I5. SAND/GRAVEl. PACK:
Drplh
Flory Tyr Ft.
From To Ft.
16. REMARKS:
Size Material
'urn alum Description
Li/QUINN Si_claciI
Show direction mld distance in miles from nt least
Iwo Slate Roads or County (toads. Include the road
numbers and cone Ion road names.
I DO IIWItl'II( CFR
CONS) RUCI ION S
TIEY'I11AT 1111S WELL WAS CONSFR(ICI ED IN ACCORDANCE WIIII 15A NCAC 2C, WELL.
TANUARDS, AND TITAT A COPY OF "I111S RECORD IIAS BEEN PROVIDED TOTIIE WELL OWNER
i.
SIUNAI1IItl? Of ITRS(IN CONS IRUCIINGTIIII WELL
//- /6D=OS
DA111
Subunit the of iglus► to the Dhision of Water Quality, Groundwater Section, 1636 Mail Service Critter - Raleigh, NC
nt.:..In.r..,.. GW-I REV.02/21)01

II II !! t /i
WELL :ONS'E7RUCTION RUi:COR((1 305105
Notth l':nnlina - 11r(,atlmrnl of F111411rinnrul 1111t' Iii1311:11 Ite5o111Cr3 - Divikiu11 of Wahl (1nnlily - (ilonud ,vnlel Srclion
\I'Fl.1, CON I IIArlU1t (INIIIPIIi1/Al) NAP11: (pi lid) feat Rk-C- CF.I I II ICA 111)11 Hill0-�
R'FI.I, FUN I ItAt-1 Ott Cl tnlr.triv NAM1II! /E( r` //er ruutr n fy22I fn-rzcs-2
SI Al F: WELL CONS11114rtloN mum Ito
it nl•rlic able) - �ifn�jtlicn6lc
ASSUCIA.1rn W1) I'F.It111Iln
I. \Vh1 111SIi ((:heck Applicable Iloa): lte idrwial 1 1hluniripal/I`ublic 1.I Indnslli:d I 1 Apiicullulal CI
Itlouilu!iiR I I Itrcoveiy l_I Heal Pomp \V;Ari Injection LI UII1ei I1 Ifonic', List Use
2. AA'PI I oCAIIOII'
_. /(�.---. (nnnh. (-/4 /..
Idralcsl only aye) '
-V.//-
Fret Cree/c
(�Irrrt 1:oi ir, IJm u4r.., t u nnwnily. I li.irirn, I I Of,. i Ir 1'(4r)
3 nWtll'R .__./7ulcieih TL'ry'✓1J6/1
Adhes. _ 6/in0A f11--.—_--
(Snrrl n1 11n11r Iln.)
I Hre -2 �,I 10 _,('i 2_1). r L j
t'in` at In'nn Stmr 7ipCode
1 )
Arrn ri•dr- I'Iv.nr ninnbrt
•1. NAIl'. DPW I'n/7v C.
C. lnhAl.111'1'1
C. DOES \\ IT1. It1'1 I \('F. 1:A1;1IfIU \V1'I I.7 YES 1-I IJU I-1�
7. S VATIC \VA I Fit l.FVFI. Uelin; 'hp of U:ring: PT.
(1 I.r"1"if Abo.r 1(ir of Poring)
(',ASING IS _ / FT. Above I-nud Sinlacc'
. 1rp i tnthn beton Innil an lure rraui rr
anlnnrr ht Arrni dour n`11, 15A NCAI' 21'.111 In.
Q. YIFID(Ipm) 11 NI I11000I Il ,T- ,./ --_--
111. \VAll1P i ONES (depth):
'Fopogrnphic/I.:u1d sctliult
LlRitige I.ISlupe LIValley 1 II h1
(clink nrinopiinir hn')
Lnliludc/luogiludc of well n
4,35°04' IS u1133`50'll hurtful,
(driver dminulrr rnmd.)
LntiluJcllungiludc soutcc:L1(d'S11 fupo)tlaplii: Map
(chrtIt Mn)
J)FV(Jn Nunn I(i1J)II
Flom To Fonnalion I )cscIiptinll
0 Cleo
- _
as
as
LQGA:LIVIJ-SKIL:l01
I I. UISINII (' I ION Tcpe_- Annnnil !y� /J Show dileclion and distance in miles flout nl lenI
12. CASIN(_i: W; ll lbickncss Iwo Stale Roads or County Roads. Include the load
Di tali Nianlctrl or weight/At. f.hdriial numlrets and common toad names.
Ftuni D To yC Ft. ..2J� Sii1/1.21_ ".././"G
flow To Il..----------
Ffont To Ft
13. GR11II I:/� I1rl•�lllt nlrtial b)othn i
1 toni_ ui2,/� I I. / nc u�Plcui,
lloltt lh It.
14. S('RI'IiIJ: Nrplh Nianicicr Slot Sire Rlatrli:il
Flom Tn Etin. ill.
I'ifm I 171..----_--Ill. -.- in.
15. SANI)itiltA\'fl. PACE:
llrrih Sire binlri inl
How 1 v _-- I I.
Ili. RLRJARI;S:
0
-171
1110IIPI'ftti cfR1IfV111A1 II11SWIT 1,WAS COI ItiIRIJCIEs)IllACCORDAIHC1iWlll1I5ANCAC2(',WEl 1.
CONS I RUCI ION S 1A1II1AIt1)S, AND'I l IA t' A CUI'Y OF 11115 RECORD IRS IIEEN PROVIDED'10111E Val 1, OWI IfiP.
1/—'O/JO
t ICIIn it Ifni. t I'fIC;UN ('OIlS I ItUCJIN(;'I1111 WI?LI, 1Al11
Submit the in 10111l to the 1)l ;slim of 1Vnlr1 t )unlilp, Citnnitla'nter Section, 1636 Mall Service Lenin' - 1!nlrlph, NC
_ . -. _.._. _...... ftW-I I11W. 117/20'11

nr
N II IlI I?
Min
vYEI,a, CONS'L'JtUC ION itECoxu
I4otth Carolina - Itermlinen! of Environment and // uurNaturalItcsomccs- Divinion of Water Quality - 0ounduntcr Section
11ElI. CON I RAC( OR (INn1VInIfAt.) NAME. (pi Inn •e co CFI(Itrlcn ION II „2L1�,
wF I.I. toll I II WI Olt COMrAN V NAME i`i 7 //er ruorlr n 1f.*) Pj7-Zyf1
5 IA I F \V ELI, (fcNS I PVC I IUN 1'F.RMI IN ASSUCIAlEI' V't) EF.IIMI IN
if nitlicablcl OEa;'i titan Ic.... «, 1 .. ....... J,,,,............ ...._ ....
I. \YEI 1. 11SE (Check Applicable Bus): Residential LYAfunicipal/Public LI Industrial I J Agricultural Ll
\louiloiing LI Recovery 1_I (led Pump Water Injection LI Other U If Olhcr, List We
2. NV I: I. 1 I)(. -,A NIOI/!
canecl lown:/ _.-. T‘fIm✓Ui L/e
StilavVPl Wove. /lei
(stir,I lane, I11(nlhr,'. Crnnnnmrh-, Snbditi inn', I in I ii , lip twit)
c%/
3051p4
'I'npogrnpllit/Land sctlinl;
Llltidge 1.!Slope IT 'Valley 11i lat
(tlrrrk np rrrgninv hnn.)
Latitude/longitude of well location
/ �j /✓ 5°03' 1+7 W 83 11722 „
1, OWNER- y / y/�.te`� (ilegvJmmnl.afs•nal+)
AddlccS _37 (0 OW %/ WO ' , -- _--- I nliludciloupihulc ounce CI(JPSLJIupn)nap ur: map
pr orrt or Poole Ina ) (dirk ho.)
( ,l r lion, L_1
tii) rloon 711t o„I'fn Formation Ut.clipliun'
4. I).\IF..I)RIII1°I)/r'0.2 07._._ 7U-- lZ- _�r/_G3s! �
5 MIA!.!WNW_ /L.2-_'
tr. IMPS \\ II.I, WTI 1('I' I'.\I S I.111(i WTI 7 VP; I.I I1O I-f--
7. SIAIle. WAlPRIP,VI'LIlclm)'fopof( r nnp,l_ o .-I''. ---- 0rn
R
W., -I " If Ab,i. r hill rl t'n•inpl
N. IMI' (IF ('ASIINI L: -l- I' I.Abner I. mil Sin lice"
•rp rf rn.lrrp In n(onlnl Mint briny. land *intone If ln1reaa-------- —_--_Q
7
.nloo(r In *urn (hone tnth l5A N1'AC lC.M IR. 0
1-).'IINI1)(p1,111): `,—lll'11101)UI' IR.1:IAlt _______
II). \VAl Pant LOIJFS (depth): _5-0
I.SZCla:l-IULJ skis C.
II. rusirrfl'CaION: NIe 7E7 AMO1ltit rp/c"/ Show direction and distance in miles Gone at least
\Wall'Ihicknrv! IWO Slate Roads or County Roads. Include the road
12. C'ASIIJt': Wirth Diameter i:rn�lcl/cr or Weight/Ft. rhLPI. Material numbers and common road names.
From 0_._ Ih �/pp
Q__.— -- Ft h
.2J fOF'ree?1 nvc
f10111 _._ f0 It.
11m1n Tn_ I1 --
13. (lltOUI: Ikplh VInertial lethal
I1om-- O. 1.0_02Q,-_- It. /14 117<an 1 Acel(Vi'_Q
Irtout b u Et. _ -
14. SCREEN: 1)rpllr Diameter Slid Si:, Material
items-- --- I0 El in. -- ---- iu. __-------
rem TO _ fl.. -_in. __. in.
15. SAMtlerRAVP.I. PACK:
I)rluh .'lire Material
hnrnn Ti'
Plant to fl.
County
vie v, ff .e 2� d X
Pr,
IG. RIIGiARKS:
I In) IIPCPR'i CIrRI IPl' "IIIA F iIIIS WI l L W AS 'VI IS lltl/CIEl) IN ACCOIWANCR wall I5A NCAC 2C, WEI l.
CONS I RUC( ION STANDARDS, AND'(( IAf A COPY OP'I711S RECORD HAS BEEN PROVIDED 701111? WELL OWNER
„os
SICNAI Iltl'.OF l' .IRSONCUIJSTR000NUlllEWELL UA1L1
Subunit the nl !phial to the I)irislon of \ranter Quality, (;nnmtlrvaler Section, 1636 Mall Service Center- Raleigh, NC
... (RV -I 1! F.V. 1)712Hul

11117✓l If
NWO
WELL CONSTRUCTION RECORD CA
305102
North Carolina - Department of Environment and Natural Resoutcesf�- Division of Water Quality - Groundwater Section
WELL CON1RACTOR (INV!VIiLAL) NAME (prim) `_ttWiNG VA Lei, \ iw1 CERIIFICAI ION ez,t/Oc
WELL CON I RACI OR COMPANY NAME M1\L t- W eM CA c ; Woric3mom r IRO S S7-299I
SLATE WELL CONS IRUC17ON PERM! Iu ASSOCIATED WI) FERMI 1H
(if applicable (if applicable)
I. WELL USE (Check Applicable Box): Residential ILL- Municipal/Public IJ Induslial O Agricultural ❑
Monitoring El Recovery LJ I Teat Tung, Water Injection O Other Ll If Other, List Use
2. WELL LOCATION:
Neatest 1own:iiAvp\k Counly_{'iry�p
vteguce_
(Sneel Name, Nurnberg, Community, Subdivision, Inc Ian., Zip Coale)
3. OWNI1I10 W(vJ(-
Address f Z.d 3 5 frr�l'il
h--rtiesuifl'e AR /7 B?O4
City kir town State Zip Code
(Siren or Houle No.)
Area rode- Phone number
4. DATE DRILLED 11- O. -04
5. TOTAL DEPTH: 305
6. DOES WELL. REPLACE EXISTING WELL/ YES LI NO ILl-
7. STATIC WATER LEVEL Below Top of Casing:
(Use "f" if Above 'lop of Casing)
8. TOP OF CASING IS L FT. Above Land Sur Face•
•'fop of erring ter coinnled at/or below bind mutate r mirth n a
variance In accordance with I5A NCAC IC .0118.
9. YIELD (gprn): lfl MA TIIOU OF TEs'F 1112
10. WATER ZONES (depth):
Topographic/Land setting
Ultidge 613lope LlValley UFlat
(check Appropriate box)
Latitude/longitude of well location
(degr een/m inutrs/recon ds)
Latitudellongilude source:OGPSOTopographic map
(check box)
DRILLING LOU
Formation Description
From To
0 - IOr
)0'— ;r5
36— SOS'
II. DISINFECTION: Type\-r-tw 9_dJ1Q1-S Amount \S
12. CASING: Wall 'thickness
or Weight/Ft. Material
Front e s43(2) p✓�
From
From
13. GROUP: Material Method
Flom E FL 11Da\c,vt r1, PrPSSure
From Ft.
14. SCREEN: Diameter Slut Size Material
Non r To Ft. in. in.
horn _ To Et in. in.
15. SAND/GRAVEL, PACK:
Depth Size
From To It.
Front To Ft.
Depth Diameter
To (.W I1 Ft. (01.15
To El.
To Ft.
Depth
To
'To
Depth
Mnlet inl
16. REN1ARKS:
LOCATION SKETGIS
Show direction and distance in miles from at leas
two Stale Roads or County Roads. Include the road
numbers and common road names.
•reset(
ipc4
r-Iayesv2lie
islicchnald let
I DO I I FRFD Y CERTIFY THAT 1 i IIS WELL WAS COIJSIRUCIL'D IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND'111AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO DIE WELL OWNER
lz 1ornn
SIUNA1UItL' OF PERSON CONSTRUCTING TILE WELL
1/Na -Oct
BATE
Suluuib the or Iginal to the Division of Willer Quality, Groundwater Section, 1636 Mall Service Center- Raleigh, NC
27609-I616 filmic No. (919 73.1 3221, n!thin 30 days. GWI REV. 07/2001

nr v nllr l l;
alga
WELL IONS ItU( LION HECOltU
Nolth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Ounntdwnter Section
%VELLCON I I(ACIOtt(INI/IV1ntIAl.) NAME (`p`ritr) 'J G1'vl(`'S\ fj 1�, CPU IricA I ION N-7I/04
CCEI.i, CON I RACI CUMrANY NAME tr11`e�%�,l,C (j],ctelC morn, N fb)il_` 1_t2Pi`1
514I E \\'EI.I, CONS I HOC' ION rEItMI IN ASSOCIA IEll \VI) I'EItIII'IN
If n +plicnble)
(if nurlicnhle
305910
I. \\'Pfl. tISE (Check Applicable Ilu.$): Residential ld- Municipal/Public Li Industrial LI Agricultural ❑
Monito' ing LI Recovery LI Heal Pump Water Injection LI Ober CI If Other, list Use
2. WELL I OCA.f 011:
Nearest Efown: SS Comity L �1_----__
CEP-C1 Lout p11
(Churl Nam,. Numl•t. Community. Sol li%isian, I ot Ni.. 7ip Oulu)
3. OAVNIER: f-a:'
Address pc acx. 4 yQ,-
(Street or Route No.)
_-- lira s s bjAh% rn_ Z15-9'02
Oily yr I own Stale 7ip Carle
( )-
Arun unlit-- flume mmther
(. DATE•. IRN,i ED 11- IrK -OR
5. TOrAI.Dlil'TII:
6. DOES \\'ELI. 11I?1'I.ACII !EXISTING WI'1.1 7 YES LI140 1.1
7. STATIC WATL'IL LIEVEEL Below Tip of radio,: JO'ET.
(Hue "I-" it Ahm r'I ul+ nl Opting)
8. TOP UE l'ASIN(7 IS __. Fr. Above Lnnd SurIhce'
•'r rl. rr reilt p Irt u+hunlyd el(or belay Inn) rat her teulvint
n*donut IN +wrtndn¢e nil, 15A NCAC 2C .III IR. ""��
9. YIELD (ppm): 5 MEl IIOD OF TES FAT ----_-----
I(1. \VATI It ZONES (depth):
II. DISINFECIION:'fypc_ hp k_ Amount 1,,S
12. CASING: Wall -thickness
Ucplh Diameter or Weight/Ft. Material
From 0 Tn _11>' It iI SDCZt
Enan fo Et.
From "to Ft.
11. (iROtl f: lrpth Alnlclial`` rietinal
From O To ,)p t Frsp[''C] -..__ y.V e sui:
From do It ___ -_____—
Id. SCREEN: Depth Diameter Slot Site Material
From Ti rt, in -_.--- in.
from_.--- 'co rt. ill
.
15. SAND/GRAVEI. PACK:
Drpih Site r.burr inl
.PyL
Er ear 'fi 1:1
From To fl.
16. RI.rIARLS:
'lopogrnpllie/l.nnd satin);
[Ridge ClSlope l h'allrry IJl blt
(check npryrgoint Iws)
Latitude/longitude of well location
5°[717..' nn,k1 8 3 ° OS. 6
Our redul inntrds^cruh)
Latiludc/longitude source:D(i1'SOTopngtvide map
(check boa) --'
1tGLCII ultlt.urit _[.uu
From 'rn Formation Description
_ LID'
LIP' - r/5
1j5' — (93(-1'
2
rJ
0 c f'
-s-,0-+—
Luctamrsr,u (.7
Show direction and distance in miles hum at least
two Stale Roads or County Roads. Include the road
ambers and common road anima.
VoS
r'e7C)
•
tc,;
I DO I IER Ent' CIF MY TIIAT 11IIS WEl.I. AVAS ('(INSI Rue. -I ED IN ACCORDANCE W lllt I SA NCAC 2C, W1E1.1.
CONSI RUCI10N S FANDARDS, AND THAT A COPY OF 1IIIS luiCOIW IIAS BEEN PROVIDED101IIe WEILOWI IER
;wt., __ /`?'OrJ
SIGNAI(MR IIF PERSON CONS IROGUING TRR WELL DATE'
Submit the nr ightal to the Ph islon of Water Quality, (;intindwater Section, 1636111all Service Center - Raleigh, NC
21G"2•I621, Plume t+. (^ 1,)"}}t_21,,--,won )11 drys. OW-1 IIUV,U7/20UI

NC
1)11'N!_I? _
MUU
305906
WELL CONSTRUCTION RECORD
Nottlt Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACT Olt (INDIVIDUAL) NAME (print) '3CtPv(PS Yam, l„l.` Cn CERTIFICATION 0 r-24I0(.(
WELL CONTRACT OR COMPANY NAME x2x1 t .i)P(( rlr:ISin
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMUTE
(if applicable) (if applicable)
PITONS N ff2X-)kST-:24S`(__
I. WELL USE (Check Applicable Don): Residential La- Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest
Town: la mel sU;
xKI4
(Stmett b 19, I P Comnumity, Subdivision, Lot No., Zip Code)
3. OWNER: Ni1P 1 ; Ssq h): vt'CS
Address 77_70-SE1k;v'k 0r Nu.)
(Sheet or Route No.)
41,141I-4 &d 3 o �zZ
City or Town State Zip Code
( )
Ares code- Phone number
4. DATE DRILLED ID - OJ.-Ocl
5. TOTAL DEPTH: lac'
6. DOES WELL REPLACE EXISTING WELL? YES LI NO LIL
7. STATIC WATER LEVEL Below Top of Casing: _go.)' FI'.
(Use "+" If Above Top or Casing)
8. TOP OF CASING IS I rt. Above Land Sur face*
*Top of casing Iermlneled st/or below land indite requiter a
valiance In accordance with 1SA NCAC IC .01111
9. YIELD (gpm): I METIIODOFTEST 1AI2
10. WATER ZONES (depth):
County Clot)
IL. DISINFECTION: Type L\-kpQJt(1<kS Amount IS
12. CASING: Wall Thickness
Depth Diameter or Weight/Et. Material
Front 0 To (6 1 Ft. (o.P5 SV)r.'( pU(
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
Front D To .20' Ft. poi" -Want DCP45ute
From To F1.
14. SCREEN: Depth Diameter Slot Size Material
Front To Ft. in. in.
Front To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Eton To Ft.
16. REMARKS:
Topographic/Land setting
❑ILidge ❑Slope ET -Valley OFlat
(check appmprisle box)
Latitude/longitude of well location
fl/ 34 `5q' 3l" t J 83 `SB'
(degrees/minutes/recondx)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
I211.1 O 1
omtation Description
p'PTi
Front To
�7 I F1 t
(,n _ f,
G>FJr — A'G
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include r
numbers and conunon road names.
I DO HEREBY CERTIFY THAT Tills WELL WAS CONSTRUCIED IN ACCORDANCE WITII ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS IS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
io- a oq(
SIGNATURE OF PERSON CONSTRUCTING TILE WELL DATE
Submit the et Iginal to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center- Raleigh, NC
27699-1;26 Mont Na. (71q) 713-3221, ttktdn 79 t!='.y+ OW -I REV. 07/2001

NC ✓
I)IVNLIf T It
WELL CONSTRUCTION RECORD 306911
North Carolina - Dept intent of Envirmuneut and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Ct nit zS Qt (A ` Con CERTIFICATION 0-7z/0N
WELL CONTRACTOR COMPANYNAME r>1 11 e.� v)r,l1.,45 PItONEajY)`�S7'��'`'y
STATE WELL CONSTRUCTION FERMITM ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential f Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: lii41,2sV;\le. County clay
AriwyPC COUC'-
(Sheet Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DQI)Lie C�1�oSen
Address 13 D W i p I 1 3 &n.e
(Sheet or Route No.) oFJ >i
I-1;awassee GA
City or Town Stale Zip Code
( )-
Arts code- Phone number
4. DATE DRILLEDla-
a3-oy
5. TOTAL DEPTH: I
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ID-
7. STATIC WATER LEVEL Below Top of Casing: .5D_Fr.
(Use"+" if Above Top of Curling)
8. TOP OF CASING IS I FT. Above Land Surface*
'Top of cuing terminated aUnr below Land surface requites a
variance In accordance with ISA NCAC IC .aM la.
9. YIELD (gpm): (s METHOD OF TEST LA ate
10. WATER ZONES (depth):
II. DISINFECTION:Type/ peileis
12. CASING:
Depth Diameter
Front D To I3S' Ft. (07S
From To Ft.
Front To Ft.
13. GROUT: Depth
Front O To .20
From To Ft.
Amount IS"
Wall Thickness
or\Veight/Ft. Material
S I2C 2 L P ✓C
Material PnfFl( ad_
14. SCREEN: Depth Diameter
Front To Ft. itt.
gist'' To Ft. in.
15. SAND/GRAVEL PACK:
Depth
Front To Ft.
From To Ft.
Method
clre°«u f e
Slot Size Material
ill.
in.
Size Material
16. REMARKS:
Topographic/Land setting
❑Ridge l3slope Malley Mat
(check appropriate box)
Latitude/longitude of well location
/L/ 3500}' 5- 1(IR7'4S'O7
(degreedm inutesbeconds )
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH, DRILLING Loci
From To AFoymation Description
O- ID'
)n' - IdO'
I DD - 1555r
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and conunor(road names.
N
CO
O
CJI
ad'
r
I DO I IEREBY CERTIFY TIIATTIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITS 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TItlS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
SIUNA'IURE or PERSON CONSTRUCTING TILE WELL
IZ -.2 S-OC/
DATE
OC
CD
CD
C
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

NC UWII trt _ I4WU
307481
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pant) AUY,\I tiO: )go \1 CERTIFICATION II 2378
WELL CONTRACTOR COMPANY NAME /' of ( oil n!:)! At) �7' rums
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITN
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential E rvluuicipal/Public ❑ Industrial 0 Agricultural
El
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Usc
2. WELL LOCATION:
Nearest Town: fraye5ulll-e. County Cietr
H-ob l� o u s t d l
(Surer Name. Numbers, Continually, Subdivision, Lot Ho., Zip Code)
3. OWNER: kik I n 14 ddc3C S
Address 7343 Sea breeae Dr
(Street or Route No)
Lakewnd-dt FL- 33,467
City or Town Stine Zip Code
Ares code- Phone number
4 DATE DRILLED I (,
.36/0 '-1
S. TOTALDEPTHl: Z 5
6. DOES WELL REPLACE EXISTING WELL? YES O NO YY
7. STATIC WATER LEVEL Below Top of Casing: 30 Fr.
(Use" t" If Above Top or Casing)
8. TOP OF CASING IS I /->, Fr. Above Land Sur face*
*Top or mini tertnlnaled Mier below land lurks. regnh es a
variance In accordant with 1
YIELD m : METHOD OF 7
Topographic/Land setting
❑Ridge OSlope ❑Valley OFlat
(check appropriate box)
Latitude/longitude of well location it
(darter/irritators/seconds)
Latitude/longitude source:OGPSOTopogiaphic map
(check box)
pRILLIN_G_10S
Formation Description
flu .�
G-let✓el
Cr /A N•fe_
DEPTH
From To
<6 76
SA NCAC IC ellfl
9. (gp ) 'EST- 4 c
10. WATER ZONES (depth): 120
I I. DISINFECTION: Type 4 I e t Amount 6
12. CASING: Wall Thickness
Depth Dimmneler or W�eiehUFI. Material
Front To_ Ft. G AE SVJ.EZ l G
Front To Ft. ■
From To FL
13. GROUT: Depth Material �/ Method
n
From 0 To 26 Ft. for 'I- I ei'vd p✓ ^r /'
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Front To Ft. in. in.
Front To Ft in. in.
15. SAND/GRAVEI. PACK:
Depth Size
Fronk To Ft.
Front_ T o Ft.
Maim inl
7G 205
LOCATION SKETCH
Show direction and distance in miles [torn at least
two Slate Roads or County Roads. Include the road
numbers and conunon road names.
0
r�
16. REMARKS:
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIIAT A✓C9PY OF THIS RECORD IS BEEN PROVIDED TO TILE WELL OWNER
/736/cCl
SIGNA7 URE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Wafer Quality, Groundwater Section, 1636 Mall Service Center- Raleigh, NC
,"re,.,,,,,t .,ur,r.,in.I,.:, OW -I REV. 07/2001

29591,
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) TARRY F. JONES
CERTIFICATION # 3293
WE1.1. CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY. INC. PHONE # I828) 837-8008
STATE WELL CONSTRICTION PERMIT#
nRrRa
(if applicable)
ASSOCIATED WO PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential El Municipal/Public ❑ Industrial ❑ Agricultural O
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 I [Giber, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE County CLAY
SNEAKING CREEK -
(Street Name, Numbers. Cnnmumity, Subdivision, tat No., Zip Cade)
{, OWNER: DAVID HUDSON
Address 549 SNEAKING CREEK DR
(Street or Route No.)
HAYESVILLE, NC
City m Town State
( 828 )- 389-3453
Area Gale- Phone numhnr
4. DATE DRILLED 05-11-2004
28904
Zip Code
5. TOTAL DEPTH: 205'
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: 80' FT.
(Use "I" if Above Top of Cn solo
3. TOP OF CASING IS 1 FT. Above Land Surf•Ice`
*Top of eating terminated odor below land surface requires a
variance In accordance with ISA NCAC 2C.011K
9. YIELD (gpm): 15 METHOD OF TEST AIR_____
In. WATER ZONES (depth): 160'
II. DISINFECTION: Type CHLORINE
12. CASING:
Depth
Fronk To 98 Ft.
From To Ft.
Front_ To Ft.
Amount 100 PPM
Wall Thickness
Diameter or WeighlTI. Material
61/8" SDR 21 PVC
13. (Amur: Depth Materal
rront_0 To 20 Ft. CEMENT
From To Ft.
I4. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL I'ACK:
Depth Sirc
Front To Ft.
From To Ft.
Method
GRAVITY
Slot Size Material
in.
Material
16. REMARKS:
Topographic/Land setting ,
El Ridge ()Slope ❑Valley ®Flat
(check appropriate box)
Lalituddlongitude ofwell location
I degrees/mintier/scamds)
al it ode' !ono i l ode so tree:OC PSOTopographic map
(check box) ;.._._.
f)I?IT[I[ DRILLING LOG
Front To Formation Descr ption
O' TO 60' RED CLAY
60' tO 80' SAND
80' TO 9ff GRANITE
SS' TO 205 GRANITE
� G
LOCATION SKETCH I =i
Show di reef ion and disi once in miles from at least
two State Roads or County Roads. Include th—droaef i G;
numbers and common road names. n'
1 DO HEREBY CERTIFY TI[AT TI11S WELL WAS CONSTRUCTED IN ACCORDANCE Willi MA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND MAT A CRPY OF THIS RECOIL IAS BEEN PROVIDED TO TILE WELL OWNER
SIGNA14IRE OF p, SON CONSI' iCriN(i TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 ;Mall Service Center- Raleigh, NC
27699-1616I'hone No. (91.9) 733-3221, within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 293454
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LARRY F. JONES CERTIFICATION # 3295
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC. PHONE,/ [phone]
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMITS/
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential El MunicipalPublic 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE
SNEAKING CREEK
County CLAY
(Street Name. Numbers, Community, Subdivision, lot No., Zip Code)
3. OWNER: MERLE SINGER
Address P.O. BOX 697
(Street or Route No.)
HIAWASSEE, GA
30546
City or Town Slate Zip Code
( 706 ). 835-5492
Area code- Phone number
4. DATE DRILLED 02-19-2004
5. TOTAL DEPTH: 505'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing: 21 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
`Top of easing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 2 METHOD OF TEST AIR
10. WATER ZONES (depth): 160'
IL DISINFECTION: Type CHLORINE
12. CASING:
13.
From 0
From
From
GROUT:
From 0
Depth
To 100
To
To
Depth
To 20
Diameter
FL 6 1/8"
Ft.
Ft.
Ft.
Material
CEMENT
Amount 100 PPM
Wall Thickness
or Weight/Et. Material
SDR 21 PVC
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
Method
GRAVITY
Slot Size Material
in.
in.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ®Valley ❑Flat;,_
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) i '{
Latitude/longitude sourcc:OGPSOTopographic:map
(check box)
DEPTH DRILLINGIjLOG
From To Formation Desbription
0' TO 40' RED CLAY
40' TO 70' BROWN DIRT
70' TO 100' GRANITE
100' TO 505' GRANITE
c
O
r
Tax
Q
c'^
LOCATION SKETCH
Show direction and distance in miles from afeast o
two State Roads or County Roads. Include tFroaiz
numbers and common road names. �'-\ c'
v.)-) a
z
z
x1
±.";ITi
[V rm
AC1
N
SNeHKI IG LRi
r1Lb 1-1+41.
Dc
l DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE. Wfftl I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT t OPY OF TIIISJ2EC9i 1) HAS BEEN PROVIDED TO THE WELL OWNER
c1-
TING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall SenIce Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

6.
7. STATIC WATER LEVEL Below Top of Casing: teL) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): MT I? OF TEST
10, WATER ZONES (depth): S.
11. DISINFECTION: Type py w tIl Amount
12. CASING: Wall Thickness
Depth Enrrir(ter Weigh tJFt, at 'al
From 0 To tk Ft. (04-
From To Ft.
From To Ft.
13. GROUT: Depth tFnal
From b To` b Ft.
of v
293343
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�pp��� R�eesouu/rllces(�- DDiiivii�/sijoJn�of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 2-4P-L-S a. 't • "24t1L CERTIFICATION ## 9-"N
WELL CONTRACTOR COMPANY NAME WICKCV iL t U`5�-u-12t�-('( ' PHONE # i t) SC9— 1i SC
r,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential l7 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nearest T
(Street Name
3. OWNER:% ;seaLl
Address � i --
City o; own State Zip Code
4
Area code- Phone number �—, II
4. DATE DRILLED k\Sb o`
5. TOTAL DEPTH: #5 4
DOES WELL REPLACE EXISTING WELL? YES ❑ NO 7
Topo c/Land setting
Midge lope ❑Valley OFla
(check appropriate box)
Latitude/longitude of well location =_
(degrees/minutes/seconds) r^ t_
Latitude/longitude source:❑GPS❑Topograpjiic map
(check box)
DEPTH
Frb To
IS' 43'
43' Sa-4 '
From To Ft. i
14. SCREEN: Depth Diameter Slot Sae 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:
DRILLING LOG
Format 1pn D¢$cnptlon
3C
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.
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 WEL I\
OWNER
�fd jet 4.1-C<
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

2. WELL LOCATI
Neare
(Street Na
3. OWNER:
Address
u n, Comm u ;, ubdivision, Lot No., Zip Code)
(S`.or Router •.)�
City or To
State Zip Code
Area code- Phone number ©�
4. DATE DRILLED
5. TOTAL DEPTH: • 1
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: ‘bO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface•
`Top of casing terminated at/or below land surface requires a
variance In accordan with 1SA NCAC 2C .0118.
9. YIELD (gpm): METHOD pF TEST
10. WATER ZONES (depth): Z%
11. DISINFECTION: Type 1tli Amount
Wall Thickness
Depth,Diameter orWei�t/Ft.Material
From b To `I FL 4e
- 4h 16o
From To Ft.
12. CASING:
13
14
15
From To
GROUT: Depth
From 0 To 9ri
Ft.
MatMal
Ft. E
From To Ft.
SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in
From To Ft. in. in.
SAND/GRAVEL PACK:
Size Material
Depth
From To Ft.
From To Ft.
16. REMARKS:
293333
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and �Natural `Resource
3�- ivision ofWaterQuality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)(p�`) ` ")"_s CERTIFICATION
rp ,O� t`u I_
WELL CONTRACTOR COMPANY NAME P'YYi6Zi(l) I k. L l (�` tC.-tl L1I06) PHONE p tj7/6)�7D ``l(G
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMIT®
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I"Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topo c/Land setting I
❑Ridge CdSlope OValley ❑Flat '
(check appropriate box)
Latitude/longitude of well location 2 _ .
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topogr
(check box)
:LD ILLIN
Fr6m To Fo
.90
at 99' ,
qq i `lbn
phic map L(..
OG
O
C
b
c
O
G7�
OT
crn
1 rt
cc
4 r-.
LOCATION SKETCH a no
Show direction and distance in miles from at33st ao
two State Roads o Coun Roads. Include toadm z
la
numbers . . )•• on road. y
G
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, LL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE 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

293338
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource ivision of Water Quality - Groundwater Section�
-�[]
ILA CERTIFICATION itAial
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L/t tS a
WELL CONTRACTOR COMPANY -teeAf.
Ili.W t—�
PHONE ,/ i:' )3g1 _fib
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT,/
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 19 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LO
Nearest
(Street Na
3. OWNER -
Address 9b
County ('�
Subdivil'on, Lot No., Zip Code) Li
(St a or Route N9.))
City oq Ti\wn Stae
)-
Zip Code
4. DATE DRILLEDt4,
6. DOES WELL REPLACE EXIST NG WELL? YES ip NO Q
7. STATIC WATER LEVEL Below Top of Casing: FT.
_ (Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface•
*Top of casing terminated at/or below land surface requires a
variance in accordance wit SA NCAC 2C 0115
9. YIELD (gpm): t
Area code- Phone number
5. TOTAL DEPTH: ,da S
METH p OF TEST Q
10. WATER ZONES (depth):
1 I. DISINFECTION: Type
12. CASING:
Topographic/Land setting
❑Ridge OSlope ❑Valley OFla
(check appropriate box)
Latitude/longitude of well location in-
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topogra
(cheek box)
DEPTH P'ILLIN
From To
0 S"
I
r
Amount
Wall Thickness
Depth D)ja9eT,er ct(We pry
From D To Jb Ft. (a ci �-CO
From To Ft.
From To Ft.
13. GROUT: Depth Mlial .
From b To Ft.
From To Ft. 1
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
Slot Size
in.
in.
Material
Size Material
Tl
I
cription
O
-a
c
N2
Show direction and distance in miles from gleas 2
two State Roads or County Roads. I lude fhb ro
numbers and common road names. • 'AV' z
LOCATION SKETCH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, LaL
CONSTRUCTION STfjNDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T L
eDA-fc l�aL c C
SIGNATURE OF PERSON CONSTRUCTING THE WELL D
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 �tResourc ivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
- (print) l�1�N�-fir.-k7 /`i CERTIFICATION #
WELL CONTRACTOR COMPANY NAME\Vk Y .(E"stf USE/_\2.U✓(V3G) PHONE i 194 3 91SC
STATE WELL CONSTRUCTION PERMIT'S ASSOCIATED WQ PERMIT'S
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential le/Municipal/Public 0 Industrial 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LO
Nearest tToWn'
(Street N
3. OWNER:
Address
4
5
6
7
Number. Co
City or own State
Area code- Phone number
DATE DRILLED
Ptct
TOTAL DEPTH:
DOES WELL REPLACE EXISTING WELL? YES 0 NO
STATIC WATER LEVEL Below Top of Casing:) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance In accordsaccordaingth 15A NCAC 2C .0118. QA-h.-
9. YIELD (gpm): U U M THOi� OF TEST
0 WATER ZONES (depth): ���
t ttoC
11. DISINFECTION: Type Wl-k
12. CASING:
13. Ma pal
Ft. e
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From 0 To 1a Ft. II?latngter
From To Ft. b���.
From To Ft.
GROUT: Depth
From C) To rla
Amount
Wall Thickness
29333
Agricultural
✓ 4 r
Topohic/Land settin
DRidge CgSlope ❑Valley
(check appropriate box)
Latitude/longitude of well 1oc4(lon-;
�`., —
(degrees/minutes/seconds) rrt., L------____
Latitude/longitude source:❑GPS❑Top graphic milk— —
(check box)
DEPTH
From To
t�I 1st
qa ass'
r Wetght/Ft. M feria]
.��
16. REMARKS:
RILL
Format'
G
lion
c
3
cry
r-
r—
'"o
LOCATION SKETCH b mo
Show direction and distance in miles from east=
a
two State Roads or County Roads. Include rog'�
numbers and common road names. Ca) -4
_) a
z
(4
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND�RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT L 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

293335
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and /Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) IJT LUS a1 •
' _kt t1‘.71 CERTIFICATION�y# 691737
WELL CONTRACTOR COMPANY NAME W n t N1 PHONE Stf ) 31a -9 GC -
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) —/ , (if applicable)
1. WELL USE (Check Applicable Box): Residential H MunicipatfPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCA
tat,
3. OWNER.
ts
City or Town
014- to — -I
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: %• I /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO (3
7. STATIC WATER LEVEL Below Top of Casing: ub 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. n `
9. YIELD (gpm): 2t7 METHOD OF TEST ll.
10. WATER ZONES (depth):
Zip Code
II. DISINFECTION: Type V-TTrl Amount
12. CASING: Wall Thickness
oj3 Dyh nt/Ft. vtat6e�ial
Depth
From C) To Ib3 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Ma nal
From I To la3 FLS`4.h
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Di eter
t ft%
From To Ft.
From To Ft.
16. REMARKS:
Material
Topo ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map...
(check box)
DEPTH DRILLING LOG
To t Form n Description
35
�b31
From
'3S
ID3'
210
12, r
I c-
<r
vo
a �rn
LOCATION SKETCH o ma
Show direction and distance in miles from gjeash
two State Roads or County Roads. IncludeM ro4
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION 5,TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T WE L OWNER
o/'SC 44lcl 10 62
SIGNATURE OF PERSON CONSTRUCTING THE WELL D TE
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
--11__I
1 r ;;

WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural )R`ees urc s`
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME
293334
ivisionvio� ff Water Quality - Groundwater Section
t tC---F-Gr___ CERTIFICATION
NA PHONE # f*) MMISC
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 LO AT
Nearest To
cg.C6S
(Stye
3. OWNER:
Address
Coun
asg84
City or .wn State Zip Code
—)-
Area code- Phone number n o
4. DATE DRILLED pig
5. TOTAL DEPTH: I 2'
6. DOES WELL REPLACE EXISTING WELL? YES.1110 NO II
7. STATIC WATER LEVEL Below Top of Casing: n 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 accordanJJ{{,,,with ISA NCAC 2C .0118. �1L
9. YIELD (gpm): 0 METHOD OF TEST
10. WATER ZONES (depth): ob
Topographic/Lsetting
❑Ridge OSlope ' Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location:,-
(degrees/minutes/seconds) ��`
Latitude/longitude source:❑GPS❑Topogra 1iic r{iap _ _-__
(check box)
DEPTH LLIN
From To Forma on res ption
0 l5'
1s' n`+'
rYt' 143'
11. DISINFECTION: Type 1-k l
12. CASING: Depthrm DiameIn Ft.(0'X'ter C
From 0 To •
From To Ft.
From To Ft.
13. GROUT: Depth M tgria_I
From D To TI Ft. c
From To Ft. t
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Amount
Wall Thickness
Wei UFt. at 'a]
Slot Size
in.
in.
Material
Material
NZ
LOCATION SKETCH o r"
Show direction and distance in miles fromWleasc
two State Roads or County Roads. Include the rota
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T WE L OWNER
rC6A5 c / ,57l fry L tC
SIGNATURE OF PERSON CONSTRUCTING THE WELL D TE
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 - Divisionvi1of Water Quality - Groundwater Section
�j
WELL CONTRACTOR (INDIVIDUAL) NAME A(prin�t)0 (.� eke1 �c2 .� 1 ,�'�'e-,v CERTIFICATION a, CO
WELL CONTRACTOR COMPANY NAME WIVE Ckk-1—g wLW CbQ..sL L'34 PHONE'S
STATE WELL CONSTRUCTION PERMIT'S ASSOCIATED WQ PERMIT'S
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ('Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
293333
2. WELL LOCAT
Ne
(Street Name, Numbe
3. OWNER:
Address
City o Town State Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1E
7. STATIC WATER LEVEL Below Top of Casing: 100 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
9. YIELD (gpm): 1 METHOD OIF TEST OtXX.
variance In accordance with ISA NCAC 2C .0118.
10. WATER ZONES (depth):11 �
,,R o
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Dept;Diateter or��Weight/Ft. aterial
From 0 To a Ft. Co yb `�3�
From To Ft.
From To Ft.
13. GROUT: Depth M e(tai
From 0 To 63a Ft.a.4,4st t
From To Ft. 1
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To
To
Slot Size
in
in.
Material
From Ft.
From Ft.
16. REMARKS:
Topo Inc/Land setting
❑Ridge MSlope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic
(check box)
DEPTHDRILLING 0
From Teo t Format!
(1
Coal .(V
C� at
Map L7__
ption
c
3 r"'
LOCATION SKETCH a rn
Show direction and distance in miles from UC.ttyj � lea
two State Roads or County Road ssr Includeayle
numbers and common road na
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST.9r1DARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T WELL 0'
C64s� c 96
IGNATURE OF PERSON CONSTRUCTING THE WELL D TE
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�ur�Reesourcess-Diiviissio)n offWater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
p (�priint) C2' [JJ11 GeCt '� ' •'-'v""'� CERTIFICATION
toy`/✓(
WELL CONTRACTOR COMPANY NAME WflTESyt LSELL- 12-1U-di PHONE /. OM ODl /SS'
STATE WELL CONSTRUCTION PERMIT/0 ASSOCIATED WQ PERMIT/.
(if applicable) (if applicable)
293331
1. WELL USE (Check Applicable Box): Residential ET Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
NearestT
(Street Name, Numbers
3. OWNER:
Address
try oL `-C, ' \DS
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: om' `'�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: St> FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated et/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
Zip Code
d4
9. YIELD (gpm): METHOD OF TEST Q33\'
10. WATER ZONES (depth):
Vie-6 1
opographic/Land setting
dge ❑Slope ❑Valley ❑Flat-i
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic: map --
(cheek box)
DLUNG
Format on Idsc'ption
DEPTH
From To ,
0 l5
t P9b'
11. DISINFECTION: Type ,'C &k Amount
12. CASING: pi�p�er
Wall Thickness
e
From b Depth, I Ft /n or�Weight/Ft.� aterial
To
From To Ft.
From To Ft.
13. GROUT: Depth M tenal
From D To il9 Ft
t
From To Ft. (
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Material
c
0
Zr L7_
7l rl
c C)
Fri
LOCATION SKETCH —
nc
Show direction and distance in miles froGaet le4-
two State Roads or County Roads. Incluo
numbers and common road names. ••
Cd
rV
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE7ELL'"
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
Q.�{Q
WELL CONTRACTOR (INDIVIDUAL) NAMEp((prrin2t)` Iw\t^-OVIN` 5.�.�j VIA./S� CERTIFICATION ft O'f` S
WELL CONTRACTOR COMPANY NAME *f€5'itU.t L %SEU _ .ate^��f�"t 1I rmaiti —qts
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMITH
(if applicable)
(if applicable)
292710
PHONE
I. WELL USE (Check Applicable Box): Residential Di/Municipal/Public 0 Industrial 0
Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
1
2. WELL LOCATI
Nearest Towtr5
County
(Street Name, N
3. OWNER:
Address
hers, Comrnw(sity, Subdivision, Lot No., Zip Code)
co o� �tl;.,
-•J
mit��i` 1 t `�
City or
( )- -
1.'L
n
ID
t or
Sta
o.)
�I
er • I
Zip Code
Area cede- Phone number 1
4. DATE DRILLED
5. TOTAL DEPTH: ' /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO H
7. STATIC WATER LEVEL Below Top of Casing: 40 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 accordar)5� with ISA NCAC 2C .0118.
9. YIELD (gpm): 1 /a.. METHOD, OF TEST 'R--
10. WATER ZONES (depth): \tog
a.
11. DISINFECTION: Type 1/4.-14 Amount
12. CASING: Wall Thickness
Depth pipmit r Sr eight/Ft. M�Ee[ial
From 0 To %% Ft. 16% lip aI (,, F'Y lJ
From To Ft.
From To Ft.
13. GROUT: Depth i Mate al
From ID To �e6 Ft. `a' i
From To Ft.
14. SCREEN: Depth
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size
in.
in.
Material
16. REMARKS:
Diameter
opographic/Land setting
Ridge ❑Slope ❑Valley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
To Forma ionDescription
DEPTH
From n
11
&
3Lc'
0
r
LOCATION SKETCH -TT el_
Show direction and distance in miles from ant ast cm
two State Roads or County Roads. Include t roag,r
numbers and common road na es. v o
-yam
mo
�m
tit z
to
ma
c7
--1
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRU_ CZ ON ST ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT WE L 04r
ThrO I to bi--
SIGNATURE OF PERSON CONSTRUCTING THE WELL D TE
O
N
rn
r
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 Sectioon(' Q
WELL CONTRACTOR (INDIVIDUAL) NAME (print),�\AU-A.'9'\w S • S-\ CERTIFICAATTIION # b138
WELL CONTRACTOR COMPANY NAME A'( �\11 w€� 1t&U-k 6 PHONE # IU76)�' I��S
292'70Q
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
/
l . WELL USE (Check Applicable Box): Residential C�' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOC
Ne. st To County
r-1,, L.�,Is.-1-
AT
(Street Name, Numbers, Com
3. OWNER
Address
u
(Street o Rqut
I' _
, Subdivision, Lot No., Zip Code)
City
i as
Area code- Phone number _
4. DATE DRILLED \1�5
5. TOTAL DEPTH: 5 5 r /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I3
7. STATIC WATER LEVEL Below Top of Casing: (00 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 ce with I5A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 1k112—.
10. WATER ZONES (depth): I-1�ri t
No.)
aOlc (p
Zip Code
11. DISINFECTION: Type �Tki
12. CASING:
Depth /Diameter
From b To (oD Ft. l�'41t
From To Ft.
From To Ft.
13. GROUT: Depth Mayt�nal
From bTo SOD Ftu
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Amount
Wall Thickness
o_ Wei t. Kee
From To Ft.
From To Ft.
16. REMARKS:
Material
�opographic/Land setting
Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
To Formatign Description
DEPTH
From
bti
et 'Met'
31.1 t .ai
363t 3C'�
Sit 4 '
LOCATION SKETCH .. 70
Show direction and distance in miles from aast
two State Roads or County Roads. Include the road
numbers and common road names.
I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
CONSTRRUU TION,STANDA, AND THAT A COPY OF THIS RE
A
n;a
ACCORDANCE WITH I5A NCAC 2C, WELL
HASBEEN-PROVIDED -TO THE LL J R
SIGNATURE OF PERSON CONS 'I 1i1C�'(,'iNG THE WELL
�� ;i
Submit the original to the Division of Water Quality, Groun(giwat r Section, 1636 Mail Service;Sit
27699-1636 Phone No. [phone], within 30 days.
r - Raleigh, NC
-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division ofWaterQuality - Groundwater Sectionio
WELL CONTRACTOR (INDIVIDUAL) NAMES ((pr(print)W\�\ `�k-Ark
-lb'on` Ce-to `� CERTIFICATION N: 1Q
�+ �
WELL CONTRACTOR COMPANY NAME filet AIE PHONE it fi 3g`t gj55
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT',
(if applicable)
(if applicable)
292707
1. WELL USE (Check Applicable Box): Residential L[f Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI
Neares o
Topographic/Lan setting
❑Ridge ❑Slope gValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address C2 E ) t sc"r• 1� .Q� Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
FormatiAn Description
p� /City o
1.1 o)-
Area code- Phone number
4. DATE DRILLED a-k
5. TOTAL DEPTH: k4,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: PO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. ,1Z
9. YIELD (gpm): a'C MET OD OF TEST
10. WATER ZONES (depth):
Ps'
11. DISINFECTION: Type TN Amount
12. CASING: Wall Thickness
Depth 2� enQr eter W- eight/Ft. to 'a1
From b.To_' _ Ft. (.,74st �DQ„ i IL.
From To Ft.
From To Ft.
13. GROUT: Dept I1�Serial
From_h To b 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.
16. REMARKS:
OCATION SKETCH o Ni
Show direction and distance in miles from at leas0
two State Roads or County Roads. Include roaG
numbers and common ro d vammes.
Ca.au W...
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUE I ED IN ACCORDANCE WITH I5A NCAC 2C, WE
CONSTR ION TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE YELL R
Agai
SIGNATUREOFPERSONCONST14OCT1NgTHEWELL. , _QA1`—
Submit the original to the Division of Water Quality, Groundtya4 I$ect[on;T636Mail Se nth -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. 1J i'! I REV. 07/2001
i i �
IIII

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural1Resourc Division��/of Water Quality - Groundwater SectiononJ
WELL CONTRACTOR (INDIVIDUAL) NAME (print) c1-us ei • ' • `-"�� CERTIFICATION # 39
WELL CONTRACTOR COMPANY NAME FkPC( 4JLLLc i Nsacer u_wc„) PHONE M CMS O s— 115S
STATE WELL CONSTRUCTION PERMIT',
292705
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential /Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
NearestTo
.\ 3.
(Street Name, Numbers
3. OWNER:
Address
C�)ACity orrTTo Sta
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
Subdivision, Lot No., ip Code)
ate$
Zip Code
6. DOES WELL REPLACE EXISTING WELLS YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing: t 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 with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOp OF TEST
10. WATER ZONES (depth): `'aq
11. DISINFECTION: Type
12. CASING:
Depth
From C) To sa
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To ei01,.. 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.
16. REMARKS:
Topogr3lihic/Land setting
❑Ridge m Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH D LLIN OG
From To Formatio(l scnption
b
Set kc6,41
LOCATION SKETCH o
Amount Show direction and distance in miles from at]�rast NZ
Wall Thickness two State Roads or County Roads. Include the road 73
eter or Weight/Ft. ate al nurt�rets and common road names. J o
Ft. It � �� x
t•rl 1Em
-t
Sat rn-,
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I 5A NCAC 2C, WELL
CONSTRUCTION STANQA���AND THAT A COPY GNATURE OF PERSONONSIS ETROU�ING T�HAS E`NELL PROVIDED TO TH>3 W»l L gWNER
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`'yyI���� �RR+esourceess-- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)Arie PAS s t s'-P-"� 1., CERTIFICATION # a�sii
WELL CONTRACTOR COMPANY NAME .Jk* �v(u� �ELLIE LL.C-L i'�C2 PHONE # jp�) aStI" (�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) -.:.
(if applicable)
I. WELL USE(Check Applicable Box): Residential L7 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCAT
Near4st To U-Xi (\ County
n, Lot No., Zip Code)
3. OWNER:
Address
(06\ -Poi- fiEs ZiF
Area code- Phone number
4. DATE DRILLED Al
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 13
7. STATIC WATER LEVEL Below Top of Casing: 470 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): I 0 METHOD OF TEST
10. WATER ZONES (depth): V3-6
11. DISINFECTION: Type *T14 Amount
12. CASING: Wall Thickness
Depth
From D To
cis Ft.
ie
From To Ft.
From To Ft.
13. GROUT: Depth M elial
From 0 To 1. 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.
5. TOTAL DEPTH:
Ca tg—
29 703
Topogrptfc/Land setting
DRidge �v 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
ion
F
-rl
rn
co
f
U7
QW1 j12'
LOCATION SKETCH 9 ma
Show direction and distance in miles from tttleast�
two State Roads or County Roads. Include/ roa�
Diameter r Weight/Ft. ate,nal numbers and common road names.
roD i4�� 'S
Slot Size
in.
in.
Material
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC ItD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANL}ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T WE L 0
24 e
(SIGNATURE OF PERSON CONS'yRUCTING THE WELL I Ali D TE I
Submit the original to the Division of Water Quality, Gto hhdµ'ater Section, 1636 Maid I' g Center -Raleigh, NC
L
27699-1636 Phone No. [phone], within 30 days. l' I, GW-1 REV. 07/2001
I 4

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
/Natural
11Resources - ivistrvlsio�n(off Water Quality - Groundwater Section �p
WELL CONTRACTOR (INDIVIDUAL) NAME
EEy((print) `l i ens Ck, t t 1LF+GF� p CERTIFICATION II 5/ /
WELL CONTRACTOR COMPANY NAME s^n��4\L L L5'au k.`u-t. D3('t PHONE p fiU15 1-9155
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMIT,/
(if applicable) — / (if applicable)
1. WELL USE (Check Applicable Box): Residential 13" MunicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Nea st ,
0
ounty
(Street N
3. OWNER
Address
Numbers, Cow ni , Subdivis •n Lot No., Zip Cade)
Li 41 . ` (j.
beet or '
— --s I. 1 r k
City o C . ' State Zip Code
sista
Area code- Phone number
4. DATE DRILLED tS
5. TOTAL DEPTH: i= /
6. DOES WELL REPLACE EXISTING WELL? YES ,U4 NO I
7. STATIC WATER LEVEL Below Top of Casing: t4b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS k FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accords��ryrycce with ISA NCAC 2C .0118.
9. YIELD (gpm): `td METHOD OF TEST
10. WATER ZONES (depth): \a� t
II. DISINFECTION: Type `art{
12. CASING:
Depth Diameter
From C To kb-3 Ft. 1Q4
From To Ft.
From To Ft.
13. GROUT: Depth,
From Z) To t"3 Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Amount
Wall Thickness
or Weiglit/Ft. ate al
1 Q
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
29270 2
I
Top ographic/Lan'setting
DRidge DSlope l 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 Fprmatlpt{Description
0 15'
15' tb3'
IDS aD5'
'o
A
oC
cf2 >> 0
A
7C aom
LOCATION SKETCH a cnz
Show direction and distance in miles from�t'leasty�
two State Roads or County Roads Inclu --,
numbers and common road names. a 5 r—f
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUW ED IN ACCORDANCE WITH I5A NCAC 2C, WEL
CONSTRUCTION STANDA$DS, ANDD `'T
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE frALL R
6SIGNATURE OF PERSON CONSTRUCTING THE WELL BATE
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

n^i 14 M Fr, `� =_.tt to
2. WELL LOCATION:'
Nearest Town: BRASS TOWN - County CLAY
OLD HWY64-BRASSTOWN
h f
i a I 292510I
i WELL COIVSTRIJCTION R1tORD I
'3
North Carolina - Department of Environment and N1atural Rdsrfurces + Division of *ater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prWt) LARRY F. JONES , ' r,Ii i l i 1 CERTIFICATION 0 3295
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INE. PHONE a (828) 831A008
I I ASSOCIATED WQ IIPERMIT# '
STATE WELL CONSTRUCTION PERMIT,/'
(if applicable) 1 I, (If applieabl) - I
Y
I. WELL USE (Check Applicable Box): Residential ® Municipalh'ublic O , 1ri ustnal ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Infection ❑ Other CI If other, List Use
ITopographic/Landsetting
LIRidge ®Slope ❑ValleyOHM
' (check appropriate box)
(Street Name, Numbers, Cowntmity, Subdivision, Lot No., Zip Code) Latitude/longitude of well location
3. OWNER: DON DECKER
Address 642 MCCOMBS RD
(Strut or Route No.)
MURPHY, NC
City or Town Stale
( 828 )- 837-5420
Area code- Phone number
4. DATE DRILLED 1-18-2004
5. TOTAL DEPTH: 807'
28906
Zip Code ,
6. DOES WELL REPLACE EXISTING WELL? YES O NO El
7. STATIC WATER LEVEL Below Top of Casing: 180' FT.
(Use "+" If Above Top of Casing)
8. TOP.QF CASING IS 1 FT. Above Land Surface*
*Top of ening terminated ■uor below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gum): 1/2 METHOD OF TEST AIR
10. WATER ZONES (depth):
II. DISINFECTION: Type CLORINE
12. CASING:
Depth
From 0 To 90 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 20 Ft. CEMENT
Diameter
8 1/8"
From To Ft.
Amount 100 PPM
Wall Thickness
or Weight/Ft. Material
5DR 21 PVC
14. SCREEN: Depth Diameter
From_______To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK: '
Depth Site Material
' From To Ft.
From To Ft.
Slot Size
in.
iIL
Method
GRAVITY
16. REMARKS:
I (degrees/minutes/seconds) -I
Latitude/longitude source:OGPSOTopograpbic'map L,
I (check box) I II
DEPTH 1 DRILLING LOG ,
From "To Formation Description
0'TO20'I' '' BROWN DIRT II I '
20'TO801 I':' SAND
GRANITE
80 TO 807' `. I I GRANITE ,
60TO80 U
I b ll
i !I
r_'
_ I ? rfl
LOCATION SKETCH { ! ''-'a'
Show direction and distance in miles from teeasea,
two State Roads or County Roads. Included rote
numbers and common road names.
ria
_C�a5y'CR
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL i
CONSTRUCTION STANDARDS, AND TIJ4t)j. COPY OF THIS RECORI? HAS BEtEN PROVIDED TO THE WELL OWNER
], I 9—/6 -0Y SI ATU PERSOPiC01�5fKUCIINC THE WELL ' DATE
Submit the original to the Division of Water Quality, Groundwater Sectiod,16J$ Mall Service
27699-1636 Phone No. [phone], within 30 days. i ' "' F
ens
GROUNDWATE
ASHEVILLE REGj

WELL CONSTRUCTION RECORD 2 9 31 n 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) •DGW1 Q-S,`` L\, LC), I.scn CERTIFrF#,QATIONOU
1Y
WELL CONTRACTOR COMPANY NAME i� ��� Ia70.ki art
STATE WELL, CONSTRUCTION PERMIT$ ASSOCIATED WQ PERMITN
(ifaplicable) (if applicable)
PHONE N fs;251 5.1C 7-27i 7
1. WELL USE (Check Applicable Box): Residential 0---Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: u rat) e S V i t i v County C
Dna," &✓Vet
(Street Name. Numbers, Lomnm,•: ;, S• hdivicion. Lot No.. Zip Code)
3. OWNER. Ron (MI corP
Address PC) PCY 152
(Street or Route No.) n 3n _ ^
City or Town State
Area code- Phone number
4. DATE DRILLED I - no
5. TOTAL DEPTH: .-Sag
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1➢--
7. STATIC WATER LEVEL Below Top of Casing: 1`., FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
'Top or casing terminated at/or below land surface requires a
variance In accordance with 1SA NCAC 2C .0118.
9. YIELD (gpm): U METHOD OF TEST A. R.
10. WATER ZONES (depth):
Zip Code
II. DISINFECTION: TypeV\\-k c`ietia-s Amount \ri
12. CASING: Wall Thickness
Depth Diameter/or Weight/Ft. Material
a From f? To � YO' Ft. (G r cl-5 6 0i2 1 ,ot/r
From To Ft.
From To Ft.
13. GROUT: Depth Material / Method
From h To &L" Ft. porAICcI1 d pr'Cret/'
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 f
❑Ridge ❑Slope Ivlley ❑Efat:, � '1 "
(check appropriate box)
1 atitnrlefinngitude of well Iocattom '! `-' ( C
(degrees/minutes/seconds)
• •dt cnurce:UliPSOTopo raphic ma��'--- j t
Latituddlon .a.._ j
tci,::<Mxl
y ;ITII PRILLINtr 1,013.
From To t n lion Description
o �
C)
rm
zm
-=
t' �rn
LOCATION SKETCH, -o mo
Show direction and distance in miles f rt af11bZ t
two State Roads or County Roads. IncfQbe thread
numbers and common road names. o 0
iftty cS Ville
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI! 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF 7111S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I��t f/v cL /_ Sri-D</
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
uu1
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. (919) lei -Hill, wa;i:: day:. GW-1 REV. 07/2001

/nf wTPTT i r!rTTll r\T TT /r/i^^
re1_._, a.a'11011\Vli11V1\ nJEA.AJKUJ
29310.E
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) \)cWv1ES \S. .2 1Snr1 CLATIFICATION a'24/04
WELL CONTRACTOR COMPANY NAME ni I\P - kA a) f)f.ILn(3
STATE WELL CONSTRUCTION PERMIT,/
PHONE,/ J41k) `537-)'Yi7
ASSOCIATED WQ PERMIT,/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Q- Municipal/Public 0 Industrial 0 Agricultural 0 .
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use -
2. WELL LOCATION:
Nearest Town: uA9 SC; ( I
MokieclCY'race11I
(Street Name, Numben, Community. Subdivision, Lot No., Zip Code)
3. OWNER. RDk{E NIr_ks
Address -30 Z Z A/C 661
County r \Ceq
(Street or Route No.)
ay-esuilIC NL ZS1Ct+
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED / - a)- tt7y
5. TOTAL DEPTH: S/0'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO CD-
7. STATIC WATER LEVEL Below Top of Casing: //7f7' FT.
(Use "+" if Above Top of Cuing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): (o METHOD OF TEST di le
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge W&tope ❑Valley tFlat
(check appropriate box)
Latitude/longitude of well local on-
(degrees/minutes/seconds)
Latitude/longitude source:CIUPS❑Topog aphic m p —)
(check box)
yu?TH
From To
- /F)r
11. DISINFECTION: Type%i-h Pelle71 Amount /i
12. CASING: Wall Thickness
Depth Diameter or WeighUFt. Material
From h To 02O' Ft. (o(.)S 5D1a/ pY-
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From__O___ To olU r Ft. p7sf /-/Gi9 rJ P(PSSUr e
From To Ft.
14. SCREEN. Depth Diameter Slot Size Material
From To : i. .... in.
From To Ft. in.
Size Material
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
DRILLING7UG.
Fnrmatiou Description
P
O
r-
c
rn
LOCATION SKETCH _ m�
C
Show direction and distance in miles Croft at vr-
two State Roads or County Roads. Include x (Rd
numbers and common road names. F
V i71(5
(jjr
u
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
z (ti /iin YGcm) / -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
293104
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print, l)QYVIQ 5 . L,Jikn(1 CERTIFICATION M02Y,/
QU
WELL CONTRACTOR COMPANY NAME 6Y)i\)P c L.DP (\ d fI(`r. nCD PHONE 8 {8I18) 537-2`kg 7
STATE WELL CONSTRUCTION PERMITS/ ASSOCIATED WQ PERMITS/
(if applicable) (if applicable)
br Be.): Residential D Municioal/Public 0 Industrial f_i
1. WELL USE (Check Aoohca.,,c .._.-,. _
Monitoring 0 Recovery ❑ Heat Pump Water injectiotI ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: IAAgPSv Ik
LeDry ic,(P
County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. .75 GIMES SrvAh
Address -61 \,Belle 33 \TC
N ke_ (Street or Route No.) 2�nO�
` t3C. `i
or Town State Zip Code
Area code- Phone number
4. DATE DRILLED i-4-2 c/
5. TOTAL DEPTH: 3L/S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0--
7. STATIC WATER LEVEL Below Top of Casing: 00 r FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118. n
9. YIELD (gpm): 15 METHOD OF TEST IJ‘72
10. WATER ZONES (depth):
11. DISINFECTION: Type) --Pa c)eSI al-S Amount \ 5`
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
4Fromt 1-)To 115t Ft.'tc„ b � ,<f21 pW-
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From Q To D()' Ft. 4)tS-\invic'1 0CeSCItCe
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:
n
Agricultural
I-- 1
)1 f9
I--�
LEA 1
Topog h . and sea:dig:
❑Ridge SlopeOValley ht _—
(check appropriate box) - rt-
Latitude/longitude of well loc"cjtiott !;
- ,, LEI.I1
(degrees/minutes/seconds) Fri
Latitudc/longitude source:❑GPS❑To ographic
(check box)
DRILLING I,OQ
Fnrmation Description
DEPTH
From To
- ID CIGV
19Ft
I CJEIt — 3L1S'
m �m
Cc
LOCATION SKETCH -o '�
Show direction and distance in miles fret& at
two S to Roads or Coun Roads. Inch* thf0(§)d
numb rs on road names. -- 2
I.- G
VI
DO HEREBY CERTIFY THAT 'Ft IS WELL ?JAL: w::sTPWtrrED ixr,.CCOI ANCE WITH i.5ANCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TI IE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
U
M'
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 n 3 3 1 0 3
North Carolina - Department of Environment and Natu Resources Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
e ece CERTIFICATION M24d3
WELL CONTRACTOR COMPANY NAME 5 ?-%/v' LUPI 1 el PRONE # ea)) sy7-2n 2
STATE WELL CONSTRUCTION PERMIT" ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0--"Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION,: / /
/7le-J6: l!,'- County
Nearest [ Town: a/ / C`
Cree
Name, umbers,
(Street
Community,
ity, Subdivision, Lot No.,dZip Code)
3. OWNER. %7ec'el/ pL/e744 ,4 %z5
Address 1=2-13 13?\uCC ems- S+
(Street or Route No.)
kap. FL- �`lrl 12
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED /-023 C) V
5. TOTAL DEPTH: `SOD
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO O."'
7. STATIC WATER LEVEL Below Top of Casing: ?O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires ■
variance In accordance with 1 SA NCAC 2C .0118.
9. YIELD (gpm): / C METHOD OF TEST t'
10. WATER ZONES (depth): 3 b
11. DISINFECTION: Typo / f! Amount 47C
12. CASING: wail ihicknc6s
Depth Diameter or WeighuFt
From To G 7 FL 6- -
From 6 % To e Ft. 6-25-
fviat ria!
, e9f) Sfe-e/
From To Ft.
13. GROUT: Depth ,ten I Method
From %) To Ft. // e 744 fte_crkle e
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
.tvjs `D>Z 3 > ' wr83 jY o25; 6 '
(degrees/minutes/seconds)
Latitude/longitude source:LJGPS❑Topographic map
(check box)
NEPTH DRILLING 1.OG
From To F,nrmatiou Description
C -Jo c7ul
r o
CO C
0 {
LOCATION SKETCH -a
Show direction and distance in miles frt7m at Rzgi
two State Roads or County Roads. Inch* thp' -Od
numbers and common road names. o 2
a
I DO HEREBY CERTIFY THAT TILLS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIiAT A C )PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/-2.3-O`/
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
_ Ts
e i
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

tla
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and �NtJ
Natural Resources
v
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Il l'•`�(1•(
M1/4f��—..
WELL CONTRACTOR COMPANY NAME
296223
\\\��i�\]]]\\\\]����ivision of Water Quality - Groundwater Section
p
11 11 II -. CERTIFICATION p# (2M�—s�
l...t_.t PHONE f/UisIP07'97
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMIT,/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ll3 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
es To �a�a.Lis� . t runty
(Street Name, V mbers, Community, Subdivision, Lot No., ode)
City or �o:et - tale
ti
ArA code- Phone number ��i�
4. DATE DRILLED I
5. TOTAL DEPTH: -/
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO f�
7. STATIC WATER LEVEL Below Top of Casing: LCD FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. Ql.i1.
9. YIELD (gpm): 30 ME HOD OF TEST
10. WATER ZONES (depth): -eV
3. OWNER:
Address-`-�-
• S eet or u of
vi
Zip Code
11. DISINFECTION: Type
12. CASING:
Dep Diameter
From D To "C i Ft. tot(�
From To Ft.
From To Ft.
13. GROUT: Tp�LkM tfria1 11 �Metho
FromOb Too`Y. ( 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
To Ft.
To Ft.
Amount
Wall Thickness
qr Weigh �t 'a t. al
From
From
16. REMARKS:
Topo c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG- -- -
From To t Fodription
LOCATION SKETCH
Show direction and distance in miles from atu,;'_
two State Roads or County Roads. Include t tl a roa -'
numbers and common road names. �l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STAND S, AND THAT A COPY OF/EE THIS RECORD HAS BEEN PROVIDED TO THW&LL n
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceentteer' Raleigh,
lREeig, 07/2001
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andNatural Resources Division of Water Quality - Groundwater Section
WELL ` v\
CONTRACTOR (INDIVIDUAL) NAME (print) `t
29I., 4,
#IY\S. ,AS CERTIFICATION#V
(C. Gr/`!13
WELL CONTRACTOR COMPANY NAME Oxfik,lkl..L6G ,u3,L.A. �C4
STATE WELL CONSTRUCTION PERMITS/
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential Ili"/Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
PHONE
0g9-9/SS
2. WELL LOCAT
Nearest T;A3
3. OWNER:
Address
City oJown
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6 DOES WELL REPLACE EXISTING WELL? YES 0 NO
ASSOCIATED WQ PERMIT#
7. STATIC WATER LEVEL Below Top of Casing: OS FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordancf�pps�{{th I5A NCAC 2C .01I8.
9. YIELD (gpm): �_ MEAHQD OF TEST \--
10. WATER ZONES (depth): MC)
11. DISINFECTION: Type TS l{ E Amount
12. CASING: Wall Thickness
Depthp u eter r Weight/Ft. yb�la rial
From To lJ Ft. bY`ft' •� Tx�
From To Ft.
From To Ft.
13. GROUT: Depth
From b To Q-L.31 Ft
From To Ft.
Slot Size
14. SCREEN: Depth Diameter
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:
Material
Topogra�c/Land setting
❑Ridge QSlope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box) I
DEPTH DRILLING LOG------
From To_ , Format'pn Description
ry
-r
LOCATION SKETCH o
Show direction and distance in miles from at lea
two State Roads or County Roads. Include the rgaa
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
\ 49 t 4
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
C
C
0

296221
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - DivisionYof Water Quality - Groundwater Section
, -/fin
WELL CONTRACTOR (INDIVIDUAL) NAME
(print)(W I I-U b W\ S. :TT -EMS CERTIFICATION k/J`ia?
WELL CONTRACTOR COMPANY NAME Ys A E5,1(1-I.F (..,Sec TbQjLU
ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT#
PHONE a a
Of applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential M Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT 0
Nearest Town:
(Street Name Numbers,
unty -6 Q..
ubdivision, Lot No., Zip Code)
3. OWNER:
Address
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO M
7. STATIC WATER LEVEL Below Top of Casing: r0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface•
'Top of casing terminated at/or below land surface requires a
variance in accord•# e lestut, 15A NCAC 2C .0118.•
l- 9. YIELD (gpm); l METHOD OF TEST
10. WATER ZONES (depth): q.ri
1lttt
Zip Code
11. DISINFECTION: Type F (-i Amount
12. CASING: Wall Thickness
Depth Diameter or Wei t/Ft.
From ii To 9C Ft. L VLF" •(0
From To Ft.
From To Ft.
13. GROUT: Depth M eQ al
From b To5 Ft(t 1/E(
From _ To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Lan setting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topograp)lic map.
(check box)
DEPTH DRILLING LOG
Frpm t Forma anon Description
r0� LId- lSlaaA/
O 1 Sb'
i5br W-I
0
LOCATION SKETCH -‹ c
Show direction and distance in miles fromast --
two State Roads or County Roads. Include the roai
numbers and common road names. 7we
r
taq-
p
a
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
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

296219
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
.Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDMDUAL)NAM (Prr�i/n/t) Vv`\,U_\WC �S.. - t€EENINS CERTIFICATION �M,�j
IVs
WELL CONTRACTOR COMPANY NAMET�I��A V�.�Z+w�i.71LlU..IrW-) PHONE 8) D t-�...
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMITA
(if applicable) / (if applicable)
1. WELL USE (Check Applicable Box): Residential I9 MunicipaUPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL L
Ne.rst
(Street Name
3. OWN
ddre
City or Town
ers, Community, Subdivision, Lot No., Zip Code)
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /a_ /
6. DOES WELL REPLACE EXISTING WELL? YES I,] NO 63
7. STATIC WATER LEVEL Below Top of Casing: / FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordsn� w,�ith ISA NCAC 2C .01t8. n; ^
9. YIELD (gpm): 01} MEN 9D OF TEST l.<v-.
10. WATER ZONES (depth): \
%ct
11. DISINFECTION: Type -Tk
12. CASING:
From b
From
From
13. GROUT:
From
From
Depth peter
To Ft. f `i "
To Ft.
To Ft.
Dep M t a1
To ¶J Ft.C'AWIa4 C
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
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
Material
16. REMARKS:
Topo c/Land setting
❑Ridge lope ❑Valley ❑Fiat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Format Description
o n4
c L 91:>5 '
O
LOCATION SKETCH
Show direction and distance in miles from at IE @t
two State Roads or County Roads. Include the wad
numbers and common road names.
0
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 T WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Ism
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

296j9
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME �E,�((�i
(print) V' \u1 -kt'm b.t WI"\ CERTIFICATION # d�on7 1
WELL CONTRACTOR COMPANY NAME W RG?V/1 \X -. USEtU 121 LLA. �`
STATE WELL CONSTRUCTION PERMIT#
PHONE # 669bt3c69-9GS-
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential la Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
(Street Name, Numb
((
3. OWNER: `U`
Address 012::. l •:
eet or ". to o.)
County
unity, Subdivision, Lot No., Zip Code)
9,D
ity or own Sin
Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: VD-`
6. DOES WELL REPLACE EXISTING WELL? YESQ NO
7. STATIC WATER LEVEL Below Top of Casing: tQ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordance with I5A NCAC 2C .0118. n
9. YIELD (gpm): 90 METHO? OF TEST LA.1.-+^
\-
10. WATER ZONES (depth): 1 \ (DSS
11. DISINFECTION: Type Amount
12. CASING:
From (]
From
Wall Thickness
Diameter or Weight/Ft. Material
Ft. Ce'/-k" �fni•lp 17V:.
Ft.
From To Ft.
13. GROUT: Depth M�ter�ial1
From D To Lt-a, Ft. c
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
16. REMARKS:
Topo phic/Land setting
❑Ridge GdSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Form1(tion Description
DEPTH
From To
0 \Lc'
l4` ,2a51
C
LOCATION SKETCH -yc r_"
Show direction and distance in miles from atr ast
two State Roads or County Roads. Include the roadE
numbers and common road names. I 3:30 rn
co
0
IV
O
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 ILI.OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA 1 I 54
C Ya')'I-f2o 1 ,LciAGIA
r;
—�
CD
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
296180
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (wino TARRY F. JONES
CERTIFICATION # 3293
WE!.!. CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY, INC. PHONE # [phone]
STATE. WELL CONSTRUCTION PERMIT# ASSOCIATED WI) PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ® Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection 0 Other 0 I f Other, List Use
2. WELL LOCATION:
Nearest Town: HAYESVILLE County CLAY
HWY 69 - WINDY RIDGE
(Street Name, Numbers, Community, Subdivision, let No., lip Code)
3. OWNER: MIKE 8 JEAN GORA
Address 203 14TH ST., NE
(Specs or Route No.)
ATLANTA, GA
30309
City or Town Stale
( 828). 361-0873
Area code- Phone number
4. DATE DRILLED 0S-10-2004
Zip Code
5. TOTAL DEPTH: 485'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO KI
7. STATIC WATER LEVEL Below Top of Casing: 120 FT.
(use "r" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Tnp of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .011a.
9. YIELD (gent): 39METHOD OF TEST AIR
10. WATER ZONES (depth): 475'
II. DISINFECTION: Type CHLORINE Amount 100 PPM__
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 107 FL 81/8— SDR 21 PVC
From To
Fromm To
13. GROUT: Depth
From 0 To 20
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From _ To Ft.
Ft.
Ft.
Material Method
Ft. CEMENT GRAVITY
Ft.
Diameter
FL in.
FL in.
16. REMARKS:
Slot Size Material
in.
in.
Material
Topographic/Land setting
K)Ridge ❑Slope #Valley ❑Flat
Ichcck appropriate box)
Latitude/longitude of well location
3459.725N/8349.833W
(dcgrcedmi ntites/seennds )
Lai itudc/longitude source:K]GPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description`
0' TO 60' RED CLAY/FIL BOULD
60' TO 90' BLACK DIRT
90' TO 107' GRANITE
107' TO 485' GRANITE
c
n c
LOCATION SKETCH
Show direction and distance in miles from at4east1=
two Slate Roads or County Roads. Include road-�.
numbers and common road names. "r
'O r"t r
t/I=
C)Cej
C,
11K) HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A SJ/JPY OF T I US RECORD-t1AS BEEN PROVIDED TO TF IF. WELL OWNER
`--
2_ SAD Y —a
SIGN/TIURE OF,13$RSON Z'ONS'VRUG LING TI IF WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Servke Center - Raleigh, NC
27699.1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

94 , .�
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and` Natural Resources/�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) it 1A r t v S • Tat S/� CERTIFICATION
NNpit DiSS
WELL CONTRACTOR COMPANY NAME w ESVI L.E t.uS€�. b12l U.( AiG) PHONE # 1/1vo)2 9I -'- ---
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 13/Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELLLOCA IN:
Nearest 1L County S.
(Street Name, Numbe. -• ity, Subdivision, Lot No., Zip Code)
3. O ' R:
Addr
•
u e No. 31ba3
City or own State Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: er1- /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO [H
7. STATIC WATER LEVEL Below Top of Casing: a0 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 .01I8.
9. YIELD (gpm): `fib METHQD OF TEST W k
10. WATER ZONES (depth): d6S
11. DISINFECTION: Type \AT4
12. CASING:
Depth Dia
From h To,9 Ft. 61
From To Ft.
From To Ft.
GROUT: Depth
From 1) To Cad-- Ft.
From _ To Ft.
tfi
Amount
Wall Thickness
or Wei`�t'/Ft. eri
(2
SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Lansetting
❑Ridge ❑Slope Walley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic trap
(check box)
DEPTH DRILLING LOG
To Forma on Description
fit
LOCATION SKETCH
Show direction and distance in miles from
two State Roads or County Roads. Include
numbers and common road names.
at least
the sad
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2 , W
CONSTRUCTION S ANDARDS,��/��,�
�AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE L
SIGNATURE OF PERSON CONSTRUCTING THE WELL A']
ER
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

294" 50
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
\N,,atturral' Resoourccees - Division
�o—ffWater Quality - Groundwater Section �(f
WELL CONTRACTOR (INDIVIDUAL) NAME (print)`'CA WAVY
,v \ S • \ �•-�.•�fy\S CERTIFICATION # �/7
WELL CONTRACTOR COMPANY NAME \+r`T Ems. VIL.LF I.�C ( i d I'. PHONE #
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
( 3e7-I5S—
I, WELL USE (Check Applicable Box): Residential M"Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LO
Neare t To
(Street Name, Numbers, Com'vision, Lot No., Zip Code)
3. OWNER:
Address
(S
or Route No.)
4-tos3
or Town.
14 Si A. I Zip Code
Area code- Phone number �,,I
4. DATE DRILLED 0 a "'C
5. TOTAL DEPTH: °i}O9'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13
7. STATIC WATER LEVEL Below Top of Casing: `.7 , FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): I b METHOD OF TEST Q'�
10. WATER ZONES (depth): L I
11. DISINFECTION: Type ViCR-k
12. CASING:
From 0
Amount
Wall Thickness
Dep pjaineter or Wei t/Ft.
To Ft. L074" bly . (p
From To Ft.
From To Ft.
13. GROUT: Dept
From 0 To 1- Ft.
From To Ft.
14. SCREEN:
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size
in.
in.
Material
Depth Diameter
Topographic/Lan setting
❑Ridge ❑Slope lBValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLIN
DEPTH
From To ,
D t5
rl ,' 9651
Fo, atio D. , ton
`1� a s.
• lam_ • 1
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.
, ftt
O`
SJ
t.2,
Z r�%
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2Cr WE
CONSTl1CTION STANDARDS, A ID THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

294749
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourceses- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)\\\LIAAVY\ 5J. T/EE ,\S CERTIFICATION
#U739
WELL CONTRACTOR COMPANY NAME Y3v1I�-E W€LLZ 'Qjj PHONE p ;RN) 3 SS
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential le/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LO
Near t To
County
(Street Name, Numbers, Community, SubdivisioneLot No., Zip Code)
3. OWNER:
Address `1bD
treet or ute No.)
City o Town
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: ct
State
Zip Code
4
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1�J
7. STATIC WATER LEVEL Below Top of Casing: `2 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 'I FT. Above Land Surfaces
*Top of cuing terminated at/or below land surface requires a
variance In accordance with I5A NCAC 2C .0118. •
9. YIELD (gpm): l D METHOD OF TEST (alit
10. WATER ZONES (depth):3/rib3/rib'
II. DISINFECTION: Type \\TA
12. CASING:
De S� 1I D' ever
From b To OTT Ft. �d�
From To Ft.
From To Ft.
13. GROUT: Depth ,t M tFria
From To C Ft.
From To Ft. l
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
rii tetghVFt.
9 Uo
Material
Topo ic/Land setting'
❑Ridge Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box) DRILLING LOG
Forma Description
DEPTH
From To
0 I �t
l -t
O
LOCATION SKETCH .� tl
Show direction and distance in miles from at least cn
two State Roads or County Roads. Include the road CR cn
d� Z
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC I bD M ACCORDANCE WITH 15A NCAC 2C, WE
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE »'EL
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

294748
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural R�esouu�rces - Division - Doff Water Quality - Groundwater Section
��,[(�
WELL CONTRACTOR (INDIVIDUAL) NAME (prriint)) W1I 1-YAS-Ts� Y"S CERTIFICATION #O 0
WELL CONTRACTOR COMPANY NAME 11 7���-�-�% i,SEU.- I I U✓IOOS PHONE # IDPDI 3ft 9(sC
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential El MunicipalPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI,
Neazest
0
County Cr0\
(Street N; Numbers, a rn ity, Subdivision Lot o. Zip Code)/
3. OWNER. .__ Li %_
Address
et or Ro
t-wx) ca4_3q.
�
Zip Code
ry
Area code- Phone numbe
4. DATE DRILLED
5. TOTAL DEPTH:
S
a
• i I �
6. DOES WELL REPLACE EXISTING WELL? YES ID NO El/
7. STATIC WATER LEVEL Below Top of Casing: it) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance In accordan ith ISA NCAC 2C .OI IS.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): q4-
11. DISINFECTION: Type TcTN Amount
12. CASING: Wall Thickness
Depth/'2 'Diameter
or W ''ght/Ft. �NL{,-teria7il
From To l0?) Ft. \O. t(-1i �_ .1,4 , M E E V
From To Ft
From To Ft.
13. GROUT: Depth Ma 'a] Qt A .M et,o
From C) To G ?) , Ft. Qy� N
From To Ft. 1
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size
in.
in.
Material
16. REMARKS:
Topographic/Lanetting
❑Ridge ❑Slope [BValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) _
Latitude/longitude source:❑GPS❑Topoglaphic map -
(check box)
DEPTH DRILLING LOG _ - -
From Tq . Form ion Description
0
141
l ‘-5-
r
53 dA
6
0 O
LOCATION SKETCH 9 i
Show direction and distance in miles from at leas�j ,
C
two State Roads or County Roads. Include the road-•
numbers and common road names. G
i
1
6-
46,
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC1ED IN ACCORDANCE WITH 15A NCAC 2C, WE
CONSTRUCTION ST ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE L
ynAc
SIGNATURE OF PERSON CONSTRUCTING THE WELL A
•
t,
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

294744
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �(%
WELL CONTRACTOR (INDIVIDUAL) NAMEt��,,((priJrint)kTW�'`i-31- � `S • k�vN'"t xs �p CERTIFICATION Mcp99C�u
WELL CONTRACTOR COMPANY NAME CNvv t€5dtlLC >���� �Ki LL.Lr�Aa PHONE,/ ( ) 3Dl— 165
STATE WELL CONSTRUCTION PERMIT,/
ASSOCIATED WQ PERMIT,/
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential I' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use "-- — �"-"
77.
2. WELL LOCAT
Neatest To
(
County Qi a_
ity, Subdivision, Lot No., Zip Code)
Topo tc/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNE (degrees/minutes/seconds)
Addres 0�4�. Latitude/longitude source:❑GPS❑Topographic map
(check box)
note l` XS t
w rl SUle -
Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: e
6. DOES WELL REPLACE EXISTING WELL? YES p NO d
7. STATIC WATER LEVEL Below Top of Casing: 440 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS j FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance In accord.eel rith ISA NCAC 1C .0118. •
9. YIELD (gpm): �.''1 Mi5TI-I�Op OF TEST ��•
10. WATER ZONES (depth):
11. DISINFECTION: Type Wilk Amount
12. CASING: Wall Thickness
Depth 99t�" toter or W� QigQ. toht/Ft. l
From fi To t Ft. (Pro �3�Y
From To Ft.
From To Ft.
13. GROUT: Depth r.SE. oisaLµ-
From TOSS Ft.C9� ►a s�Q
From To Ft. MaL
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Slot Size
in.
in.
Material
Material
16. REMARKS:
DEPTH DRILLING LOG
From To, i Format* n Description
f
(�,� aoS
»sS ' 4 •
0
O
LOCATION SKETCH
C�
Show direction and distance in miles from at least =.'o
two Stag Roads or County Roads. Include the ro.v1
nm
numbers . nd common road names. ^
i
czq
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2 WE
CONSTRUCTIO STANDARDS,�AT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT VIER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

294'743
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and, Natural -\ Resources - Division of Water Quality - Groundwater Section
j �Q
WELL CONTRACTOR (INDIVIDUAL) NAME (print) V '.L MCt� S' --rEC' S„ v� CERTIFICATION
##9 '�`]c_
WELL CONTRACTOR COMPANY NAME Wa" J\LLE ��Wtc-tl i r") PHONE # f )UD `�-1I` S
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential /Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use I,-
2. WELL LOCAT
Neaccst To
(Street
3. OWNE
Address
City
( tr
ounty
Numbers, Community, Subdivision, Lot No., Zip Code)
elfr
Area code- Phone number
4. DATE DRILLED 3
5. TOTAL DEPTH: i.
6. DOES WELL REPLACE EX ST NG WELL? YES C) NO EV
7. STATIC WATER LEVEL Below Top of Casing: �j� FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordanyq Ith 1SA NCAC 2C.0118.
9. YIELD (gpm): 1 �a- M THQp OF TEST am'-"
10. WATER ZONES (depth): pCZ'
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
From U
Depth [2 p{neter or Wet t/Ft. Mate r} I
To (.0i Ft. � (4'rQatIp
From To Ft.
From To Ft.
13. GROUT: Dept4 ^ M�tetial
From 0 To ton Ft.epy+t cIJ+JI)
From To Ft. t
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.
Zip Code
Slot Size
in.
in.
Material
Ir.
Topographic/Lan setting `,
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To
O NI
t
L4'
bb' l0`1'
tV1' Lab'
1b ' •Set59'
DRILLING LOG
Formatipn Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the*
numbers and common road names. l�.
(w�
cr
yi
tota
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WEL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE yIELL
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

294741
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
' 'Resources rL'vision
of��Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
s�,,(spaarrrint) C`( , t'\ IIC.ILELL� CERTIFICATIIONN 09739
qC
WELL CONTRACTOR COMPANY NAME * R 1cs\ALLC LLU'3Gt PHONE q j(.V O) ag i - I (5v
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential El/MunicipatPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Near
(Stre
County
me, Numbers, Community, Subdivision, Lot No., Zip Code)
Topographic/L.agtsetting
❑Ridge ❑Slope pB'VValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNE (degrees/minutes/seconds)
Address Jai ... Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
City •r To n ` 1 bS1tat Zip Code From Toss Forma tiop scri [ on
k Li ' 144S'
orRuq lq Np.) C_/K�C
_9
Area code- Phone number
4. DATE DRILLED ..]J
5. TOTAL DEPTH: kLit J
6. DOES WELL REPLACE EXISTING WELL? YES IGIL NO IFI
7. STATIC WATER LEVEL Below Top of Casing 14r) FT.
(Use "+" if Above Top of Casing) O
8. TOP OF CASING IS l FT. Above Land Surface' - 3
'Top of casing terminated at/or below land surface requires a n_ -9
variance In accordagce w ISA NCAC 2C .0118. . r.
9. YIELD (gpm): ` ME,TirIOL1 OF TEST r"
10. WATER ZONES (depth): \3,-<<-
LOCATION SKETCH tv ,—
Show direction and distance in miles from at least o
two State Roads or County Roads. Include the roads u,
numbers and co on road names. Q ,
11. DISINFECTION: Type * (Fit Amount
12. CASING: Wall Thickness
p pramcter or W= , t/Ft. ate 'al
From b Tot Ft. b Kt (i 1Lta•
From To Ft.
From To Ft.
13. GROUT: Depth M serial \t .
From d To S( Ft. it h�.L
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:
fQ
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WEL
CONSTRUCTION STANDARDS, AND THAT_AGCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE f7✓ELL
f¢3r4r /MGF{A--
d SIGNATURE OF PERSON CONSTRUCTING THE WELL (DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mill Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV-07/200I!

WELL CONSTRUCTION RECORD
294046
North Carolina - Department of Environment and Natural Resoutces - Division of Water Quality - Groundwater Section
pp
WELL CONTRACTOR (INDIVIDUAL) NAIVE (print),'Qvr''P 5 'h, I tTh 1S(Trn CERI'IFICAt ION M 94O
WELL CONTRACTOR COMPANY NAME VYI1WWO ( LOP -a dT.11. ri✓lg PHONE M Jr)a$17-29%
STATE WELL CONSTRUCTION I'E.R.IIT/I ASSOCIATED WQ PP.IIarITM
if applicable) if nplicnble�
�acrerwmusmamM�elrsaear mmI eea�traml
I. WELL USE (Check Applicable Box): Residential El--"Municipal/Public D Industrial 0 }Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use I
2. WELL LOCATION:
Nearest Town: .\IAv1€ S V; )) Q County C/at/
/'„6✓ &a a L/ Ant Lei
/
(Street Name, Numbers, Connouoity. Subdivision, Lot No.. Zip Code)
3. OWNER. Draw:, s 0'1 BOLL\aY1
Address
(Street or Moore No.)
City or Town State Zip Code
( )-
Arer code- Phone number
4. DATE DRILLED 3- X o DC4
5. TOTAL DEPTH: 34S'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO itv
7. STATIC WATER LEVEL Below Top of Casing: /922__hf.
(Use "✓' if Move of Casing)
8. TOP OF CASING IS t FT. Above Land Surface'.
•'top of using terminated attor below !and s':r face req tilt en a
v.rl.nre In accordance with ISA NCAC 2C .0118.
9. YIELD (Eon,): _- 3 METHOD DETEST 4: IC
10. WATER ZONES (depth):
I I. DISINFECTION: TypetA t pt? IIP*S Amount IS
12. CASING: Wall 'thickness
Depth Diameter or Weight/Ft. Material
J From 0 To Ito' Ft. (p,.?S SOV2l DVr
From To Ft.
From To Ft.
13. GROUT: Depth Material
From Q To ID' Ft. pOf+inn d
Front To Ft.
14. SCREEN: Depth Diameter Slut Size Maletial
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To
Method
Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ©elope ❑Valley ❑Feat
(check appropriate box)'
Latitude/longitude of well location
N .5°leII r^7&'tt'22H
(degrees/minutes/seconds)
Latitude/longitude source:LIG1'SOTopogtaphhc map
(check bo :)
Yyn rll 1.1i;ILLI NQI OQ
Front To r'arntatiun .;c;aiption
C — /O' G/oy
/Do' JCS'''. Grow .' e•
c_
LOCATIQNSKF>"fRJ az
Show direction eitd diciance in zniies fr9ra atr`ars
two State (toads or County Roads. I:" * c the road
numbers and common road names.
CL?//
S41 ch
I DO HEREBY CERTIFY THAT 1711S WELL WAS CONSTRUCTED IN ACCORDANCE WI111 I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF 11115 RECORD HAS BEEN PROVIDED TO THE WELL OWNER
3-.76-oy
(,LZC-e
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ens,
Submit the original to the DI%Islon of Water Quality, Groundwater Section, 1636 Mail Service Ceenterl Raleigh,
NC
N001
276'19-1636 Phone No. [phone], within 30 day.

ASSOCIATED WQ PERMITN
WELL CONSTRUCTION 1tECORU
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pr6d)
�inW1 Q.7 (� D, �i`jpn CER TIFICAT ION N?4104
437-
WELL CONTRACTOR COMPANY NAa1F,��l1\o I� , P)I_ (1r V1: �PHONE N filed a`�c+7
STATE
WELL CONSTRUCTION PERAtITN Aif dicnbic)
if applicable) wol01 �1A0la���a
294086-
I. WELL
USE (Check Applicable Box): Residential Ca Municipal/Public ❑ Industrial 0. /(g icultural 0
WELL
Monitoring ❑ Recovery ❑ hs i
eat Pump Water Injection 0 Other 0 If Other, List U,`\
2. WELL LOCATION:
Nearest Town: 1-1 A� e Sv i I1?fee e
(Street Nam e,�urnbera, Crnnnwni4Y. Subdivision, Lot No., Zip Code)
County C1ar{___
\v 3. OWNER ken
Address
ctvenzr
(Street or Route No.)
City or Town State Zip Code
( )'
Area code- Phone number
4. DATE DRILLED 3- IC -cU
5. TOTAL DEPTH: (64'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0-
7. STATIC WATER LEVEL Below Top of Casing: in r FT.
(Use "✓' if Above Top of Caing)
8. TOP OF CASING IS ) FT. Above Land Surface'
•Top of casing terminated aVnr below laud Ira face requlsef a
..rt.nre In accordance with ISA NCAC 2C .01IP.9.
YIELD (gpt10' j00 M; ruOD OF TTSF ,; 2
I0. WATER ZONES (depth):
II. DISINFECTION: Type\1-\A 1)0\4 ''
t�
12. CASING:
Depth Diameter
From 0 To ,3& ' Ft. 6', Lri
From To Ft.
Front To Ft. _
13. GROUT: Depth Material Method
From C To , /2' FL url/anel pce;ci/, ro
From To Ft. / 14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Front To Ftin. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Amount
Wall Thickness
or WeighUfl. NI 'alai numbers and common road names.
/ifs
Topograpl \c/Laldsttttttr:
❑Ridge ❑Slop_
(check opp opnattbnu)
Latitude/longitu a of well location
&esi'33"1WB °?A'o"
(degree s/ u u n u tad sec o n d e)
Latitude/longitude sourcc:U01'S❑Topographic map
(check Ito :)
f;yn 11I )=));1LLINt�I JQ
Front To 1'nnnatiou Description
- ' 4%
— '
2•6114, CTITaI_�,_
=o
Front To
From To
Ft.
Ft.
LOCA'f'IQN isaci1 a ;;:-4
,-
Show direction di:rr (.'::lance in miIes fr. dt#eglt
two State Roads or County 1t00d3. L• c tl)'ta tjad
Pen 4tnc/s.
s/tee c
16. REMARKS:
I DO IIEItEBY CERTIFY TIIAT 'DES WELL WAS CONSTRUCITD IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TT IE WELL OWNER
,S 0 • n'�
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
2709-I6361'honc No. (919) 7t1-3111, within 39 days.
GW-I REV. 07/2001
L

294917
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso s - Division ofWaterQuality - Groundwater Section
WELL cONTRACTOR (INDIVIDUAL) NAME (print) T' Halm. _ v(1 G() t 2 CERTIFICATION $ 3) 7 5j
WELL CONTRACTOR COMPANY NAME �(4 €722 W Ec. LE (CC(14CD -L NG PHONE I VC») 7 . -Z/G6
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
if appBashi*
(If ropllcable)
1. WELL USE (Check Applicable Box); Residential 63" Municipal/Publie ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection C Other 0 If Other, List Use
WELL LOCATI,
Nearest Town:I-66u NI County
DOG SRaNe l D. 35 2 ce d 2_
'Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
),ANER: \) C6 n(/ r ' o c f?
Address ?410i )ne ?,wrs-[ RD
(Stint or Route No.)
< 2ar ,tun( NC, 7 8902
"VTitres-(A0 Zip Code
Area code. Phone number
4. DATE DRILLED_ 3—Zc- -o'/
5. TOTAL DEPTH. ( SSA
6. DOES WELL REPLACE EXISTING WELL? YES ' NO ❑
7. STATIC WATER LEVEL Below Top of Casing;
(Use "+" If Above Top of Culrta)
S. TOP OF CASING IS ? FT Above Land Surface`
*Top of colon terminated ,blur below laud surface requires a
vadeoes In noontime with ISA NCAC 2C .011a.:
9. YIELD (gpm); -;(J METHOD OF TESTA 1('
10. WATER ZONES (depth): I75
11. DISINFECTION: Type ii
12, CASING:
Depth Diameter
FromI00 To Ft
Fromh2& To4-P Ft,
From_ To_, Ft,
Amount - it o7
Wall Thickness
or W eight/Ft. torial
VC
+41?27 PVC
13. GROUT: Depth Material
From % ('J To 0 Ft rnitnP717
From To Ft.
14. SCREEN: Depth Diameter
From, To Ft.__In.
From______, To Ft.,__,jn
15. SAND/GRAVEL PACK:
From
From
Dcptb Size
To Ft.
To Ft.
Method
Slot Size Material
in.
in
Material
Topographic/Land setting 7
CIRidge °Slope OValley Mat
i (check appropriate box)
Latitude/longitdde of well location
N3S2,2.366 CO to 83°510 394
(degnei/miauu�ei oads)
Latitude/longitude source:t . QPSQTopographicmap
(theca box)
DEPTH DRILLING LOG
From To Formation Description
0 t SAr
1 - <L.
— %5
$5- 95
9S - /85
R6CCPV
YC[ww c-r-a v
aeotud oJe.s NHtC-L) ,?ors.
(c2^L,v<T
LOCATION SKEZCIj
Show direction and distance in miles from at least
two State Roads or County Roads. Include the_oad
numbers and common -mad -names.
O P
v. G+-
N rr
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRU }ON STAND AND AND THA'f,4COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
3- 2- cif
SIGNATURE OP PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 clays. OW-1 REV. 07/2001

WELL (ZONSTRUCfON RECORD
North Carolina - Department of Environment and Natural ResourcAs - Division of Water Quality - Groundwater Section
w1tLL coNTRACToit 02ND1VWDVAL) NAME (print) FR e A(z_ P. V/cc-o2
WELL CONTRACTOR COMPANY NAME 13 warts W ELL— Dig(LL(N(ro TMC,
CERTIFICATION a !'75
STATE WELL CONSTRUCTION PERMTr#
ifapplicablel ASSOCIATED WQ PERMITS,
4_(if applicable)
PHONE a` lid 7yS-T/66
1. WELL USE (Check Applicable Box): Residential el/Municipal/Public C Iitdustria) ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Igiection Cl Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: if e� VtLLE County CA -2 t1
S+ic q-(G µ ro Cer-c c _.
(Steer Name, Numbers, Community, Subdivision, tot No., Zip Code)
3. OWNER; EM'R€ £S4ELMaw
Topographic/Land setting
DRidga Ballope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitdde of well location
A/3562 `.399 W 0834:37.r/yl
Address //62lieu67E .L ‘ :( a!minu—wssiecoads)
'/ (streetnrRouteNo.) LailNde/Iongitudesouroe:20PSOTopographic.mao
1taYCS Ir/I_ F /v/c 7 POFir/ ?check box)
City or Town Stets Zip fie— � DIMLING LOG
C82�- 38or— 26we From i To "tie
Description
Area code. Phone eumM. i 0 G /J/re(Jie aY41reree Rack
1 WATER ZONES (depth).
6. DOES WELL REPLACE EXISTING WELL? YES C NO p' /So ----Lac__ 7. STATIC WATER LEVEL Below Top of Casing; C33 �rT 3s 3 SO
n (vie Nell Above
Top of Casing)' 4 pp - ..52(
S. TOP OF CASINO IS ___ . _ FT Above Land Surface
*Top of cuing terminated aver below land suefaee requires a
variance In accordance will; ISA NCAC SC.011a,:
9. YIELD (gpm): t METHODOF TBST e R,_
O.�
11. DISINFECTION:
12, CASING:
Depth
From 7U To C, 5 Ft.
pOmL -To Ft 15
Tot ? , Ft.
13. GROUT: Depth
FroO To C) Ft.
Ft
14, SCREEN; Depth Diameter
From. To
From.__�-To
15, SAND/GRAVEL PACK:
Depth: Size
From To Ft,
From To Ft.__
Type
From To ZVST`
16. REMARKS:
/— a Amount. -
Wall Thickness
Diameter or Wel t/Ft, Material
STEC-L
01/k 5.1221 Pvc
G Vet SD R 77.5 Pvc-
Material Method
C "tn1G—!v'T' QR
Slot Size Material
in,
in,
Material
294915
Ga /lock w/y2
Sceck Rock
DAke or1 __
flank ao ✓ c* ,ex,,,s%
.CCtzeac r?.ck
Da ec azaYr7 c/r W ,ewer
• �— — 0 o
LOCATION SKI
Show direction and distance in miles from a9east.er
two:State Roads or County Roads, Include the aE? .
numbers and common road names. C- CI
-o (no
f ( rn
r
N n"
J u
I DO HERSBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OP TT.(IS 11ECORD HAS BEEN PROVIDED TO TEE WELL await-
- - Oy
SIGNATURH OP PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], Within 30 days,
OW-1 REV. 07/2001