Hy CY2004

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
l- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
r� (print) q e_r JJUV O it CERTIFICATION # J 3�S-�
WELL. CONTRACTOR COMPANY NAME S//>rttj)P. J PHONE # (® LVZ'2/9d
STATE WELL CONSTRUCTION PERMIT# / 17`0� ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELI. USE (Check Applicable Box): Residential)6 Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Neafjest Town: 'yyt",,;�,,C] t p Va�/el? County b)kd
/4 / /{ � d gO r 77
(Street Name, Numbers, Comicknity, Subdivision, Lot No., Zip Code)
3. OWNER: / / /3 o
Address /4I 2 '.Th / tio4 %ad -
Lc./
(StreetorJtoute No. fl7d 6 ilC
Cry Town State Zip Code
( )
Area code- Phone number
4. DATE DRILLED / - 2 S -041
5. TOTAL DEPTH: //051
-6. 1)Uf s 9.11,1.1. REPLACE IIX!S! in"U. WELL? YES L II NO d
7. STATIC WATER LEVEL Below Top of Casing: /&LD FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. 9. YIELD (gpm): �3 METHOD OF TEST a ti I-
10. WATER ZONES (depth): 2./5 r - q//. en
8zs' -.� `p,r,,,
DISINFECTION: Type )--tri ! Amo'Unt /1. /i//s
CASING: Wall Thickness
Depth,,//// t Diameter or Weight/Ft.
From ep To i4 Ft. 6 a
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To ,QD Ft. -r..pl4,
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.
11.
12.
Material
PG'Gl
16. REMARKS:
Method
oei
308933
Topographic/Land setting
Ridge ❑Slope (]Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0GPSDTopographic map
(check box)
DEPTH DRILLING LOG
From T9y Formation Description
4/6 r / /e15 / YJM..+� <, ,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO I UEREBY 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
02_ AWL
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

308706 H
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N al Res urces - Division of Water Quality - Groundwater Section ) ,
WELL CONTRACTOR (INDIVIDUAL) NAME(print)
Gr CERTIFICATION #y' /
WELL CONTRACTOR COMPANY NAME AA 4'�7 /17 /04.95-1 PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: N restown,• J1 e 19s I it,. County
7 iUi - `- Tt'i n-25UiI
(Street Nam , Numbers, Community, Subdivision,' of No, Zip Code)
3. OWNER:
Address� V ��L
(Street or oute No.)
(..00. n 4-svt- I , l� C2S7Ve,
City to Town Stat Zip Code
(K li 73tit tr
Area code- Phone number • /
4. DATE DRILLED / 1—/ to - 0 y
5. TOTAL DEPTH: L4/ 0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1�C
7. STATIC WATER LEVEL Below Top of Casing: KO 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
varlance In accordance with ISA NCAC 2C .0118. 9. YIELD (gpm): 7 • METHOD OF TEST A. / r
10. WATER ZONES (depth): 330
Topographic/Land setting
C e, 'Ridge ❑Slope ['Valley❑Flat
.2 7SI,. (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
p -- g re
3 S 33
� w
73 NI2
Q/ / LOCATION SKETCH
11. DISINFECTION: Type 1—F-` — Amount J!d'(!) e 2 Show direction and distance in miles fro�t lea
12. CASING: Wall Thickness two State Roads or County Roads. Include the r
or Weight/Ft. Material numbers and common road names.
From 0 To C Ft.- 141 5PL2.1 .-pUUr_,_
From To Ft.
From To Ft.
13. GROUT„„: Depth Material
From '7To__„Ft.
To Ft.
. -A
From c_
14. SCREEN: Depth Diameter Slot Size ib aterial
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
Depth Diameter
From
From
16. REMARKS:
Li)« „ya
Z24r ;14 £ I &vt.
I DO HEREBY CERTIFY THAT THIS WELL -WAS CONS 1 RUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION ST .ARDS,'ANDTHAT A COPY OF THIS -RECORD -HAS BEEN PROVIDEDTO THE WELL OWR T T
c5
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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE

1
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From
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o
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5 IC l kr. L PI-[ ELL I2 PL CEEXISTING 1\iELLr YEE ❑ II J L�
rJ,I,
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larcnal
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_... v�:. + EL P.-.C1_
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Fr.
frJnl
Ft.
_T-,_TIC. 4,:•.lgt; LE\EL Bdow Top . r'CaSLH : 7a � �
FT
I �,o r" Sr Boa,:'I'Jp ur C.am;-
,
TOP Ji: C-Lt: .S3 13 FT.
� dI( 4e L.anJ Satiate'
Ir49 I 1 rlrn \T ll bcl , I - 1 a'u rrA eC r.il antes
} 11�1 U-rr,IR: 19n .v1-C nL .W 15.
I. iIETHOD oh' IEST ,� 3
' 1 1. NE3 ..apulp:—RAC/OO —
DISiNFECIIO\
I11uullt /_—
_ ti+ In llil lal�3, r';rin LI , .ylale Roads or Counry Roads. Include the road
(WO
41
hPF1'. IvlJrar:l uuwhers and COmm011 rand Haines.
Fr.
opogral;hieiLant1 scmng
• l-JYSv:Jgc ❑SILpo ❑Valley ❑Flat
(Chtilc JpimpnJrc bJi)
Lurlludeilo1lSlfllde pf 5cl' locacLurl
Wcyr rnmw mac vnd,)
sollrcc. 'SOTupoaraphic H1a
IiIIc i box)
DRILLINNG LOG_,
Formation Do>Clip l' W n
`hs (SrQnlx
F:.
I41crn Ja
tour'2__-_
Jr:101[Ie- Slaf SI2C i11a G.tI4
Pc. In.
111.
FI. In.
tin it[ri ]I
LOCATION SKETCH
Show dicterion and distance in mires from a[ Ica>r
i D r & C Bl CERTilii1"1113.irTHIS WELL W A.9 CONSTRUCTED IN ACCOkDANCL WITH liA NCAC 2(2, WELL
NSi Uc1i cviv v1 _,ND-I'Ds. AND THAT a COPY OF THIS l'.FOOPL) HAs BEEN PROVIDED TO THE WELL OWNER
v fUN : Jct. 0 .I t`UCTIIYGELL
Su -ua1 [n: aR final [0 rile 011 iiiU li of 11'a[cr Quahr
y 'o io ?horn: �yi. yl ), Gruen dlvn rcr See [nun, 163o Ni Ail Strviee CoI ter- Raleigh,
l ) i3icion %virllin 3o LAys. 6 NC. —
GW-I REV. 07/200V
Me-
as S 5'-3 q'9
p
i

WELL CONSTRUCTION RECORD
30Z48�
North Carolina - Department of Environment and l Resources - Division of Water Qualii - Groundwater Section
t
WFI.I. CONTRACTOR (INDIVIDUAL) NAME I print) ,QD / CERTIFICSIION ff s�T/6
\\EI.I. CONTRACTOR CONIP:ANV NAME �Y l.l e ::+).fit "') �u^"'j') rRONE N LW? 9 S 9 g - 3 / I `,
EA l'E WELL (O.NS [RUCTION PE.RMI l#
3102
ASSOCIATED WQ PERMIT#
(if upplieahlcl lif npplieah e
1. \VI(i.l. USE- (('heck Applicable 13ox): Residential lt Municipal Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Ileat Pump Water Injection 0 Other 0 If Other. List Ike
'_. WE1.1.1.0('AllO
Nearest Town: pdVta TSA. IIL County_ i-4 ,.
ettetri
Fork$ 0 =V(
(Street Same. Numhy(s, ('oimmunity, Subtlifiston. Lot No.. Lip Cutlet
3. OWNER:
Address r
(Street or Rome No
Cin or limn State
Area code- ('hone number
4. DATE DRILLED 5 -1 1- d'{
5. TOTAI. DEPTH: (Q 5+
I. DOES WIiLI- REPLACE EXISTING WVE1.L° YES 0 NO
7. SlAIIC\VAl'ERLEVEL Below Top ofCasing: - iOD_FT.
I l'sr `"il Ahute Fop of casing)
S. TOP OF CASING 1S / TT. Above Land Surfhce*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA N(A(' 2C .0118.
9. YIELD lgpm): 3 METHOD OP f11SF hr-S
10. WATER ZONES (depth): __34,s+ -'
SnS' I+�:_ypm (etS'-lipr. I(K•:\rtONSt,ETcn
1 1. DISIN ITC Ill )N: Type--_)-/7 . Amount _i7_3_#4, 4,5_.- Shots direction and distance in miles from at least
12. CASING: wall Thickness t\VO Slate Roads or County Roads. include the road
Diameter or \\e [gilt Ft. Material numbers and common road names.
2g7 tg
Ap 1ode
Topographic/Land setting
❑Ridge OSlope ❑Valley jHj'lat
i check appropriate host
LatimdeJonpitude of )Veil location
dcac., uunnie, secnudsI
Latitudesouree:❑GPS❑'fopographie map
(cheek hoer)
DI I) DRILLING I. l)li
From m I t Formation Description
Depth
From _p To at) Et. /a t l
From ,Fo Et.
From To Ft.
- _Wes_
13. (iROI)T: Depth /r Material Method
Front t To QD Pt.
front--_ .. To
Id. SCREEN: Depth Diameter Slot Sim \Iaterial
Front To Pt. in. in_
From_.. To FL in. ---- in.
15. SAND .'GI( AVI':1- PACK:
Depth Size Material
From
From To Pt.
16. REMARKS:
SS:6 WV 9Z130h0
-or=
ar
Oss
rht
m
--ice
`emu
r
0
1 DO IIh:R1.lil ( 1::R'IIrY TIIAr 'nits Rb:LI. \\AS CONS'IRL('I ED IN :\('CORI)ANCI\\Tfl I 15 \ NtA(' 1(', \V1.I.1.
('ONS IRL ft'TION ti fAN )ARDS, AND II Iry I' A t OI'l' Or -Il ' 'COI(D I IAS Iil-IN PEW A-IDIiD 10 THE AAlil.l. UAANH(
SI(iNA'fORb (IF I'PRS()N CO NSIRLC'I'ING(III \\tl I. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163o Mail Ser' ice ('ewer - Raleigh. N('
27699-1636 Phone No. [phone], within 31) days. G W-1 REV. (17 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division �of Water ()Wilk
WELL. CONTRACTOR (INDIVIDUAL) NAME (prior) —R0 -- t'J(' ,. t1.V AJ JL,
WEI.I. CONTRACTOR COMPANY NAME.IJ" racv,e. 17rttJ . Wttt 4 FP"- it' �`r'C.
STATE WELL. CONSTRUCTION PERMIT# __ ' 70 a ASSOCIATED \\Q PERMIT#
l it applicable) (if applicable)
30348'7
- Groundwater Section )
CERTIFICATION # 3/ 3 347
PuovE: #
f0� �o Sig 3) 7 c7
I. WELL tISli (Check Applicable Bow): Residential Municipal Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ I Icat Pump Water Injection 0 Other ❑ If Other, List l isc
3. WFLI. I OCAIION:
Nearest on it Count)' Alkyaect
Iso tNam._ Numbers 'onmlUI1I1, Sub.iviim. t au No /1p (ndcl
1. (BA NFR: EC.._ o 7"1
Address /621 C.5.�es� ('rexk_
I,Slrcel or Route No.l
�/�J/OJT plc a27 2 /--- -
( 0' 11 fo n Slate hp( odr
:\Tea code- Phone number
4. Ds\FE DRILLED T - / 9 -4
5. TOTAL DI1'Tl1: 3/n5 E /
C. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Fop of Casing: n FT.
/ IISc-' d'Abocc Top of Casing) a'ft
J
S. TOP OP CASING IS F'I'. Above Land Surface*
`Tao of casing terminated at/or below land surface requires a
variance in accordance with ISA N('A(' 2(' MI Th.
9. YIELD (gpm): au MerlIOD OF TEST _.12__hrs
10. WATER ZONES (depth):
I1. DISINLECILION: :Type_
12. CASING:
From 0
Iron)_
From To
Topo iraphicrl_and setting
❑Ridge $iSlopc ❑)alley ❑Plat
'check appropriate box)
Lalitudclongitude of well location
IJc.ir.:. nunucx sccond,,i
Latitude. lomiitu(IC ;puree:❑GPS❑Topoemphic map
!chick hoe)
DRILLING I.
Formation Description
Dh Plll
Iron I
D 3z'
S 2 ' 3C>5-
5-6 - STif • - 21) y p
IAK' :AI'IUN SKETC11
{-I'Tf [ :Amount 4,1}_L)h. .Sbow dironiun and distance in miles from at !cast
\1;d1 l hickness nvo State Roads or County Roads. Include the road
Depth Diamcicr or Weight Et- A-latcrial numbers and common road names.
To J R Ft. /a (i ---- ��Lr._
I . (iR0(I T: Depth Material \iethud
Iron) D I0_-4:20_.. Ft.fAtm-tµ _ 1e
from_ i-o Pt.
11. St'RI (I:N: Depth Diameter Slot Sizc Material
From To Pt. in. in.
From To PI in. ___ in. _.
15. SAND4RA\'E.L PACK:
Ncpth Size '.\latcrial
Front To Ft.
From 'To Pt -_—_
. _._
IG. REMARKS:
1D
cn
1 DU IIERI:RY (Ii12IIFY 'I I IAI 1I lIS WEI.I. ACAS CONS 1RLCII':D IN A('('0RI).ANCI : Av 11l I5.1 Nt. V( _C, WLLI.
(ONSIRL('IION STAND RDS, AND IIFHA FrV COPY OF II Ill 12FCDI2I) IIAS BFFN PROA IDFD l 1) Illli Wlll.l. (Wt NI -It
/D- .2e-eV
SI(iNAFURF OF PERSON ('NNSII2 l....N(i'llll AAl I I. - - _-� _ Dahl
Submit the original to the Division of Rater Qualit\, Grounclnater Section, Ib30 Mall Seriee Center- Raleigh, \('
27699-1636 Phone No. [phone], within 311 da)s. (iW-I RI:\ . 1)7 200 I

WELL CONSTRUCTION RECORD
307883
North Carolina - Department of Environment and /N�at�ural Resources - Division of Water Quality - Groundwater Section
WEI.LC'ONTR.A("I'OR(INDIVIDUAL) NAME (print) t_�Js.t1c=5—L� S.n ,�J(-LA CERTIFICATION #.a y/g
WELT CONTRACTOR COMPANY NAME ttene., /3roS. //.30 pi f uM� �C•PHON F, # fP.9� G `f S- 317D
STAIN: WELL CONSTRUCTION PERMIT# / 4102 ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
I . WELL USE (('heck Applicable Box): Residential FJ Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. W ELI• I.00'ATION:
Nearest Town: i) �a 1 ' b- County {-/� ittzel
/3 Y On k I l czJ
(Street Name, Numbers, Community, Subdivision, tot No., Zip Code)
3. OWNER: raj<E 7-1
Address 854 S' Yctmt't•.,.x Yr(y uvui 4-30
(Street or Route No.)
CTra Sri Pt 34Q3(
('ity or Town State Zip ('ade
( )-
Area code- Phone number
4. GATE - Co - O 4-
5. TOTAL DEPTH: I S pri' �/
fi rvtuc i.sri t�i 1.1 t ou(,Lnr 1, NH rw_(; wl.l vn i ,, l.c Ui o) 6
7. STATIC WATER LEVEL Below Top of Casing: 1 a DO FT.
I (Use "s" ifAbove Top of Casing)
R. TOP OF CASING 1S I FT. Above Land Surface*
Topographic/Land setting -
❑Ridge'Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
at)
an) /.54C'
*'fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): IIS METHOD OF TEST c r5
10. WATER ZONES (depth): gF85 -JJ>0.i' - 'l X ran
11. DISINFECTION: Type Amount �nrl-
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To ,.D Ft. (/ '1
From _ To Ft.
From To Ft.
13. GROUT: Depth Material
From n To a Ft.___Cp .v.Ln_m t
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVELPAC'K_
Depth Size Material
From To Ft.
Material
('.)
!tom,
LOCATION SKETCH
)-d l3s Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
CO 0
c11 crrt
• nt2
.Drn
1 =v
fl o
✓ 0
• ram
Method
Material
CO
From To Ft.
Ib. REMARKS:
I DO I IER EI3Y ('E.R FIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI1 15A NCAC 2C, WELL
CONS'IRI)C'TION S'I'ANLZARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

30308
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N- ural Res011reeS - Div Mon of Water QuaIn) - Groundwater Section
O Ell. CONTRACTOR (INDIVIDUAL) NAN1E (print) ail • a
WELL CONTRACTOR CONIPANI• NAM!: A-0.224.0.-. tic° /h&j_ i&Alp
STATE AHA. CONSTRUCTION PERMED 4/152. _ASSOCIATED WQ PERMITO
(if appltcahlc t if tipplieahlo
CERTIFICATION # 29 /
cif, 3/ les
[must: 4 (VP
I. WELLUSE (Check Applicable Box): Residential It Municipal Public 0 Industrial 0 Agricultural 0
Nlonitoring 0 Recovery 1:1 I teat Pump Water Injection 0 Other 0 I.ist 1 se
2. WELL LOCATION-
Neare. County
Street Name. N»iht4s. Community. Sitliolw loon. Lot Nii tido
3. OWNER:
Address
1„‘ltifltl Staw
7In-
q t es Ls -
Bonet or Route NItti)
ES Vali ALC
hip Code
Arca ode- Phone number
4. DATE DRILLED - tar 04
5. D1.1311 I: .5-4
L. DOHS WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WAFER LEVEL Below fop of Casing: / 00 ET.
, (Use -E" ii..moN," Top ult.:IsnotI
8. TOP OF CASING IS / ET. Above Land Suritice*
*Top or casing terminated at/or below land surface requires a
ariance in accordance with 15A MAC 2( Al
9. YIELD (grin: e.DO METHOD Of TEST .22 A r5 •
io. WAFER ZONES (depth): SS'S' o
Topot.;raphic./Land setting
0Ridge '.Slope ON'alley plat
(ciwck appropriate Fox)
Latitude longitude of well location
&eice,. minute:. seconds
LatilLitle Ionittude souree:OGPSOTopographic map
!elle& hir.1
1)1 PII DR11.1.IN6 LOG
from ro formation 1)escript ion
o g3 Ct-6-44 •
83 ' 545' .2:1gAzumed,
rocA HUN sicrrcii
Dismmc FR*: r _ 1-17H ,thlootti 41/1.s_ Show direction and distance in miles Bum at IC:LSI
12. CASING: Wal I 1 hicknet.o. ot, o State Roads or County Roads. Include the road
I tepth Diameter eleht. FtI:aerial Mullikin,' and common road names.
from 0 lo / 3 Ft. I t
l'o
From l'o
13. GR011 I': Depth MaterialMethod
Erom 0 ToZ/L.
front To
14. SCREEN: Depth Diameter Slot NIA: laterial
front TO It. 11. tl.
TO
15. SAND GRAVEL PACK:
I hipth size NI:nen:11
From to Ft.
Front _
P VC
16. RENIARKS.
CT1
cn
rrt
7
I no iii•uin chit rin"rilAT Wit' WAS coNsTRUCI I.D IN Ac(()RI) \ WITII I \C
CONSMilt-BON SIANDARDS, AND IIACOPY ol. 'I Ills oRI) II. PRO \ 11)1-1) 10 Fill WI( OW NI:It
',Li.) 3 ,,tiotiA-t,_t.
S1GNA ft RE DI: Pill(SuN CoNS FR. i 1111 ‘‘. I I 1. DAIL
Submit the original to the Division ol Water Quality. Groundwater Section. I 6.30 Mail Sen ice Center - Raleigh. Nt
27699-1636 !'hone No. [phone]. within 30 days. OW -I REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource
VAT:1.1. (ON'IRA( 'TOR (IN DIVIDUALt N:AOE (print,
6 r 9 c .aJr
N ELI. CONTRACTOR COMPANY NAME sresin Rytr� . W
styli,. \\t].1. CONSTRUCTION PERMED( / ` °4
lit applicable)
s - Division of \Cuter Oualit\
�p yy IJ r LLe,
4_30_ *t PK MP)
\SSO('IA lED \\'Q PER\IIT#
(if applicable,
3434g9
- Groundwater Section
( ERTIFIC \ LION # 30 4 /
PHONE # San p 311"
1. WELL (Check Applicable Box): Residential % Municipal Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump AA ater Injection 0 Other 0 I(Other, List ltse -
? . WELL LO('AIION:
Nearest Town: ___'1f county/
(Street Name. Numbers, Community. Staub INiun. II..oi No.Jip Code,
3 OWNER:
Address 'tl ► D,..e .•.. t a
/� !Streit or Route No.l
L al/ , $-t 2872/
Cat or l'ovi State hip ( lode
Area code- Phone number
T. DATE DRILLED 6-/6 -6 cti
5_ "[MTAI. DEPTH:.
C. DOES WELL REPLACE EXISTING WELL:.' NTTS 0 NO
7. STAIR' WATER LEVEL Below "Lop of Casing: an ET.
(Use"" ir,Ahocc hap at Casing,
S. TOP OFCASING ISFL. Above Land Surface`
Top o1 casing terminated at/or below land surface requires a
variance in accordance with 15A N(A(' 2(' .0118.
9. YIELD (gpm): 20 METHOD OF TEST .2 hrs
10. WA II:12 ZONES (depth): -.2VS
11. DISINIH. ItON:'I'ype %-/Thl Amount._LLQ.J-A/)
12. CASING: Wall Thickness
I)epth Diameter or Weight, I t. \Y ucrial
Itronm Q To /$y
Prom
From I\) 1-t"
13- ( ORO(J'1: Depth Material
from ."- 0 It)___42P_ _ Ft" µ
From._ To Pt
I-0. SCREEN: Depth Diameter Slot Size
From To ht. in.
Erum 'fo PL in. in.
15. S\NI) GRAVEL PACK:
_ -----
Depth Size
Imam In Pt"
From 10. ----- Ft.
Nicthhood
T--
16. REMARKS:
latcr,al
lateri al
Topographic/Land setting
❑Ridge dope ❑Valley OF tat
(check appropriate box)
I.alitude. longitude of well location
Nettox, mmines..econds)
Latitude. longitude sotnce:❑(IPS❑Topographic map
I heck boil
DI-.Pl11 DRILLING I
From fo Formation Description
/541• ' 3Gs''
LOC:AIION SKEI(I I
Sho\\ , I Feetion and distance in miles from at least
MO State Roads or ( "aunty Roads. Include the ruin
numbers and common road names.
O
m°
N O-
a' �tr
Xs,twirl
---
CI
to
11)0 11LRI:B\ (ER lIn' "I IlA'r'IIIIS \\EL.l. \\,\S CoNSIRC("IIID IN At (oRD.\ti(I! tvl IIl 15'. \CAC 22C, \VI-LI.
('ONS'I'R1.1C1ION STANDARDS, ANI) fll:A l':A COI'\ OF IIIIS ItL'(-()RI) II AS 13II N I'ROA II)lll) 10IIIIi WFI 1. (AA'NIt
SIGN:VIER)- OP PERSON CONS IRL CIIN(i 1111- AAII L I)111:
Submit the original to the Division of Water Qualitw. Groundwater Section, 163o Wail sin -vice Center - Raleigh. NC
27699-1636 Phone No. [phone]. within 30 days. (i1V-1 REV. 0? 2001

Depth Diameter
From _-L_To HHO Ft. /r R
From To Ft.
Frc,m _ To Ft.
13 GROUT: Depth Material
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
WELT (ONTRACI OR (INDIVIDUAL) NAMF:,(print)/2t I/(La £,'ELL S p
wit',CONTRACTOR COMPANY NAME (LffdaC u,bJ-//��d7�7,�{({
S'I'.AIE WEI,I, CONSTRUCTION PERMIT# _ _/So a ASSOCIATED WQ PERMTI'#
(if applicable) (if applicable)
305717
- Groundwater Section ' /
CERTIFICATION # .11i1/11
PHONE # (�,'7�/a 7 8_- 3/ 7O
1. WELL USE (Check Applicable Box): Residentia Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water njection ❑ Other O If Other, List Use
2. WELL LOCATION: ' 1
Nearest Town: fl rcac�cgd'' 4_0_12., County h-k 1 yacri
'xF -
1j-yitt f c __ 1
(Street Name, Numbers, xn bers, Community, Subdivision, INo., Zip Code)
3. OWNER: l `ttr d 2LP VP -FASCIA
Address _g730
r Route No.)
S rtt
Cd)+1,ri{'own State Zip Code
AI ea axle- Phone number
4. DATE DRILLED 5- /. -0 4/
5. TOTAL DEPTII: c /p S 1 .
(NHlC 1V1.11 PEP! ..*.(1- N!CYES 9/EL!? LI I I
7. STATIC WATER LEVEL Below Top of Casing: go FT.
Oise "4' if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C .0118. r�
9. YIELD (gpm): SO METHOD OF TEST �c Ars
I0. WATER ZONES (depth): .q Q.'I - �)�S )
Top o raphic/Land setting
❑Ridge Slope OValley OFlat
(((check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
a_Alai �Cf4 ,�
A t
) l01 g/eS
LOCATION SKETCH
1 I . DISINFECTION: Type /-7L'7/ I Amount t/r2 //�/,L ,Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. M'tee dal , numbers and common road names.
From U To c O Ft. CeAr„ e "Y.
Frotn To Ft.
I S('R FEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Front - To Ft. in. in.
15. SAND/;RAVEL PACK:
Depth Size Material
From Ft.
From ..--- To_
ht.
ethod
Ib. REMARKS:
I DO fIEREBY CERTIFY THAT
CONSrRU(TfON STAND
TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI 115A NCAC 2C', WELL
AlpEIS RECORD IlAS BEEN PROVIDED TO TIIE WELL OWNER I/- Vie "h - s /
AND THAT A COPY OF T1
SIGNAT'IJRE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_. [t V 4 / / '/
/^1 CERTIFICATION#_.,3.5 it/ CONTRACTOR COMPANY NAME i Y rec ne , YAS, Zh'.Il q'- oo .1{�(</r� � �hS' PHONE # (Soled" 44 - 3 / 7 o
STATE WELL CONSTRUCTION PERMIT# .7 / a _ ASSOCIATED WQ PERMIT#
(if applicable) _—
(if applicable)
1. WELL USE (Check Applicable Box): Residential $ Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Ileat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearrc,st 'Gown: n - �, //[ County
{
(Street Name, Numbers, Community, Subdivision. Lot No.. Zip (ode)
3. OWNER: //_� ,
Address _ / 5 57 n Lz J p Az,
� et all de so rc (degrees/minutes/seconds) -.
(Street or Route No.) /- P r"'7S - Latitudeilongimdc source:❑GPS❑Topographic map
�/iPSV/J�er /�/�' ��'7g� DEPTH (check box)
( ity o town State Zip Code DRILLING LOG
(_ )_ From To Formation Description...
Al co code- Phone number j 4g. /D I'
4. DATE DRILLED //-5-D tf S'/./b T45.14.) -it.
5. TOTAL DEPTH: 5.,a5 1
r Iv11. S 9.' it! 1 REPLACE CVICIIN(; W!-I I9 YES I 1 NO
7. STATIC' WATER LEVEL Below Top of Casing: _ / , FT.
(Use "+" if Above Top of Casing)
R. TOP OE 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): METHOD OF TEST
10. WATER ZONES (depth): �5 / - �1,pa�' r5
Ot
1I. DISINFECTION: Type %j Amount
12. CASING:
! 4-1,l'}5 .
Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To I a Ft. (p.i
From _ _ To- -��t`—
Ft.
_
From .... __— To F't.
13. GROUT: Depth Material
Prom Method
From _ To
Ft.
14. SCREEN: Depth Diameter Slot Size
m_ Material
Fro
in To_._. Ff--- in. in.
From . To - Ft. in.
15. SAND/GRAVEL PACK: in.
Depth Size Material
From_'_ To Ft.
Erom To Ft.
16.REMARKS
305724
Topographic/Land setting - -
idge ❑Slope ❑Valley ❑Flat:
(check appropriate box)
Latitude/longitude of well location
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 IIERE[3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STAN ARDS, AND INAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
Yip:% y�Lc
SIGNA'URE 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

305719
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
sot:l.I, ('1 N FRACTOR (INDIVIDUAL) NAME (print) Cw2r/P .S �r.-�x / A
<-lbIri 1? d>-�yz CER"fIFICA'f10N#�2i1e
WELL CONTRACTOR COMPANY NAME ✓2 j., eris_- _
t1_ PHONF, # yQ.2f,)1 / .4g" 3/ %n
STATE WELL CONSTRUCTION PERMIT# / tit .Z
(if applicable) — --ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (('heck Applicable Box): Residential. Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WILL LOCATION:
Nearest Town:_et,u Le u 1 1 I r County
YrrtrlL TF�r-.14-k ` I..n c ,1
(Street Name_ Numbers, Community, Subdivision, IAA No.. hip ('ode)
. OW NIiR:[�orce I oL
Address P p - �n�-
�aY 5�(j
(Street or Route No.)
.1/:Iw/rleSV i TIP ).i(� r2 CO
('ityu 'roam State
Zip Code
I I. DISINFECTION: Type
12. CASING:
Depth Diameter
From .Q_._To .R Ft. In ) t
loom__ To
From To
13. GRO(fr Depth
Frnm_-Q-_
From To
Area code- Phone member
4. DATE DRILLED (} - a a -b
5. TOTAL DEPTH: I PC' 5 I
1,0HIC WET! REPLACE A('I. t v te"I IAI(: WELT? ? VIL 1 1 NO p11
7. STATIC WATER LEVEL Below Top of Casing: FT.--
(llse `4" if Above Top of Casing)
H. TOP OF CASING IS / FT. Above Land Surface*
*'fop of casing terminated at/or below land surface requires a —
variance in accordance with 15A NCAC 2C .0118. 1 -- -----
9. YIELD (gpm): METHOD OF TEST h rc
I O. WATER ZONES (depth): rl (a 5 I — g 45 I (c m
�
LOCATION SKETCH
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographicmap
(check box)
DEPTH DRILLING LOG
From To Formation Description
S8/ �
Amount I ft'a-k_H},i
Wall 'Thickness
or Weight/Ft. Material
PAC
Ft.
Pt,
Material Method
Ft
Ft.
14. SCREEN: Depth Diameter Slot Size Material
From_... To Et
n. in.
From i
To Ft n.
U. SAND/GRAVEL PACK: - ----- in.
Depth Size Material
From ... _To Ft
Front _ To
Hi. REMARKS:
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I Ex) I IER EI3Y CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C', WELL
('ONSTRUC[ION S IANRDS, AND 'ft IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUC
//-30-aV
IND 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

in. in.
From To Ft. in.
I5. SAND/GRAVF:LPACK: in
Depth Size Material
From To E;t.
Front. ToFt.
Topographic/Land setting
❑Ridge °72SIope OValley ❑F7af.
(check appropriate box) _
Latitude/longitude of well location
(degreeshninutes/seconds)
Latitude/longitude source:OGPSOTopographic map..
(check box)
DRILLING LOG
Forma ion Description
A(2a.e{c.
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or County Roads. include the road
numbers and common road names.
Ib.REMARKS:
I DO I fEl(EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC'C'ORDANC'E WITI 115A NCAC 2C', WELL
RUC"t1UN S"I'ANDAR S, ANU'TEIAT
O N)
eJj..
COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
�
//- 3a - D �F /
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
A
SIGNATURE OF PERSON CONSTRUCTING DIE WELL
305720
WELL CONSTRUCTION RECORD
North ('arnlina - Department of Environment and /Neattural Resources- - Division of Water Quality - Groundwater Section
WEI,!,(CONTRACTOR (INDIVIDUAL) NAME
1� (print) C__f .r�1ti-pL_i)..y1- La pi, rL CERTIFICATION#�y/Q
WELL (CONTRACTOR COMPANY NAME (_,y�p EEnC I /` OS�.tt y
�la mtfg__ PRONE # (gin fo'f' 3 i 7
STA7�K WELL CONSTRUCTION PERMIT,/_
(if applicable) _ -- , ,, ASSOCIATED WO PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential py, Municipal/Public O Industrial ❑ Agricultural O
Monitoring ❑ Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. W'FI,f, LOCATION:
Nearest Town:__LJ( ne`_Yl1 le_ County 14a-�.(y)C
,fi! rt- I re. - ec` Duct tC_is..
IStreet Name. Numbers, (Community, Subdivision, Int No., Zip (lode)
3. OWNER:LL_ri. Tkc
in_
Address ,�(y egna al ' ,!N
as 1.'_rvavrl.
(Street .r Route No,)
m4 �,� p �jn a N eco s l
y •n .o.nl State a zip ('ode
Area axle- Phone number
4. DATE DRILLED 1 0_- I c} -p
5. TOTAL DEPTH: 8a5 1
�.. 1)!l)!t; 11'lll 1 REP.-8/'1. EY:18;I INI. \A/EL Et YES I I NYI III
7. STATIC WATER LEVEL Below Top of Casing: 1 toe) FT.
(U.se"4" if Above Top of casing) --
R. 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 2(' .0118. --_-
9. YIELD (gpm): (p METHOD OF TEST 6,2 in rc
10. WATER ZONES (depth):
DEPTH
From To
_6 �
_ S
8rte!c,
11. DISINFECTION: Type %}—f'� Amount
12. (CASING: tan 1"j)J.
Wall Thickness
Depth /� Diameter or Weight/Ft. Material
From C)._ To In,_t Ft. (e I l
From_ To Ft — s5/�e�
From To Ft.
13. (TROUT: Depth Material
From Method
From To FL -_IF:L____
14. SCREEN: Depth Diameter Slot Size
From_ Material
To Ft

STATE WELL CONSTRUCTION PERMED/ ___ /,11/>
(ifa licable --` ASSOCIATED WO PERMIT#
(ifa licable
1. WELL (1SE (('heck Applicable Box): Residential Municipal/Public❑
Agricultural 0
305718
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME/� (print)_ CERTIFICATIONp ci �� WELL CONTRACTOR COMPANY NAME Oreent 8r05,
r!/�i� d Y. war i.._PHONEX e��_6Vg"3/r7o
Monitoring 0 Recovery ❑ Heat Pump Water Injectio❑h then, List 0
J Other 0 If Other, List Use
2 Wfd.l. LOCATION:
Nearest Town:
tS Vim_ Count
(Street Nana, N'umhers, Community, Subdivision, Lot No., 'p (Ede)
3. OW'NfiR
Address _lt�4t�
(y� r (Street orRouteNn.)
City or Cuwn / .SWt�
Zip (.lace
Area code- Plume number
4. DATE 1)RILLIif) %
5. TOTAL DEPTH:__-____V 7
(, fY S W1.L.. R1.P1. A( L ES:!s.lh,l: 1'/ LC N!I ly
7. STATIC' l Vv 1.1 L!
... V'f^
WATER LEVEL Below Top of Casing:,-__(,01LFT.
R. -MP OF CASING IS FT. Above Land Surface*
*Top of easing terminated at/or below land surface requires a
variance in accordance ith 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST r< 0. WATER ZONES (depth): 2 ry - / _
(Use "4" if Above Top of C'asingl
Amoun
Wall "thickness
or Weight/Ft. Material
_in. in.
From To Ft in._ _._
15. SAND/GRAVEL PACK: --- In' —_
Depth Size Material
From _ ..-_To Ft.
From To Ft _-
1 I . DISINFECTION: Type__
12. CASING:
Depth Diameter
From 6— To__7
I'torn_ "ro Ft.
From _ To
Ft._
13. GROUT: Depth
-
aterial Method
From a Tot Pt.
From To Ft.--.-L_r'-
14. SCREEN: Depth ---
P Diameter Slot Size Material
From._ - To Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
FormatiDescription
DEPTH
From To
72)'
'7L> `— ya r
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO I IEREBy CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C', WELI.
( 0NN'IRU(TION .Sl'A�C..q ARDS, AND lI IAT A COPY OF uar•ORD IIAS BEEN PROVIDED TO THE WELL OWNER
�1- 3d—es
SIGNATURF OF PERSON CONSTRUCTING TIIETIIE--- E WELL -_
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NNatturall�Resources� - Division of Water (?ua lily
WELL ('ONIRACTOR (INDIVIDUAL) N.%ME I print} ' l 6 b 1 �('1 WALL,
/� 0 1 "''.I`1'
\ctn.L(uxrR:u-rolx(oNtP:\Ni N:\wt:GrGZNt .ovGS. l.O,aAl V I
STATE \VEL.l. CONSTRUCTION PERMI I# ) ij 0 a -------Asso(L [El \yQ PERMIT#
lif applicable} (it applicable)
PHONE N I esS t/ g
I. W'1'.1.1. LSE (Check Applicable Box): Residential ) Municipal Public 0 Industrial 0 :Agricuhural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List 1 ise
2. W 1i1.1. LOCATION:
////
Nearest 1(.n: /4.. (/ ounty p(
IStreet Name, Numb/Ts. Community, Suhdiv1slon. 1 ut No.. Lip Code)
3. OWNER:
Address Ise P S FJ ivo De (aril- t# 5
'Street or Route No.}
l❑ or t I State hip tide
/-
Area code- Phone number
1. D:VfF DRII.111) 9 - -
5. lOTAI. DEPTH: CO 2_S_'
(.. DOES WELL REPLACE EXISTING WE1,IJ YES 0 NO )4,
7. STATIC WAIP.R LEVEL Below Top of Casing: --70 __FT.
y ICse--(- it Abate lop of ('as111 1
8. TOP OF CASING IS / FT. Above Land Surface*
*Top or casing terminated at/or below land surface requires a
variance in accordance with 15A NUM' 2(..0118.
9_ YIELD Igpn): _i._ METHOD OF TEST & rS
W. WA /ONES (depth): _ 3 a51 - ' li cj p ono - --
1I. DISINFF:(I'ION: Type_ HTr. .\mount Arts.
12. CASING: Wall thickness
W
cisI la Material
y/
Ucpth Diameter or
IFrom/�, t o S 9 Ft. Co I r P V C.
From ..__. t U__
From to FL
13. (iR01!T: Depth nnNRnerial ,� Method
Front p To. aD._.. Ft. 1 .. _.-i1r0j--
From To
14. SCRI HN: Depth Diameter Slot Size Material
From l'o Pt. in. in.
From To __--- Et. in. -___ in. _.
15. SAND (IRAVI',l. PACK:
Depth Size \ Iatermal
1 __ to Et. ____- —._
From —1 o_
Topotraphie/Land setting
❑Ridge ❑Slope ❑Valley'Lu
cheek appropriate hoc)
Latitude longitude of ell location
ul. nunnes,_ ndsl
I. Milli& Ionaitude st ulce ❑(01'S❑lopog aphis neap
(check bof
1)I•PTII DRILI.IN(i LOG
rout To ( Formation Description
59' [0oSt 1 ,1.._
16. REMARKS:
I t)(':Af1ON SKI:TC'lt
Shoes direction and distance in miles ti'om at least
two Sntte Roads or County Roads. Include the road
numbers and common road names.
SS:6 NV 93130h0
1 DO IIFRLIiV (1:1211PY T11A r iiiis AAlil.l. WAS (ONSFRI.I("HID IN AC(ORD AN( F. 1/4W1111 15 A N( .-A( 2( . Wl..1.1_
('ONS'IRL'(TION STANDARDS, AND IIIA i' A l Oh TIIIS RE( URD II:AS 131 LK I'ROA IDI-.I)'1O 111E WLI.I. t)AA NI.R
/o' x /-
DA I1
�_-
SIGNATURE' OFF PERSON CONSTRUCTING T111- Qll 1
- Groundwater Section
( ER'l'IEIC.yrtON # 2 4/ g
3 i'70
_
rnrrt
y7
ca rt
cart
ca
cea
c')
Submit the original to the Division of Water Quality, Groundwater Section, 163o Mail Ser. ice ('enter - Raleigh. N(
27699-1636 Phone No. [phone], within 30 days. (AV-1 RI -A'. 07 2001

9.
It).
303419
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and(INV u_rall Resources
1j{)i' ISIOu of Water Quality - Groundwater Section
\\EI.I.CONTRACTOR (INDIVIDUAL) NAME (print)V� �Oq�L\��LA,Y- J�1�.���aI • p ('F:R"rII IC.\'I'II0N #,/a ,/ 31
WEI.1.(ONTR\('TOR COMPANY N.(\IE>.r.4l.t-S�"-"'+• K2--- "V ramrs" l'IIOVF # (xri l✓T O
SIAFE \\ELL CONSTRUCTION PERNII'r# -_- % 4°1Q .. _ ASSO('I.\'tEl) \CQ PERNIII# --- -
lifapplicahleI (ifapplicable1
1. \k 111.1. t 1S11 (Cheek Applicable 13ox): Residential W. Municipal Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 11 Other. List t Esc
�- W I:LI. LOCATE() 11 '' A
Nearest'l-own: Devi i�Countyit-L.{ 0
___ SLl\L4ge L.Y]-. - - __1'77�/1 -___-
!Street Name. titrtubers, Community. Subdicismn. Lot Nu_ Lip )Feet
3. OWNIIR: a Dae4.-7 .l_CILL 4 xoU-.---. -
Address C4(1) -1 -4-vaa --4 -- -
Streel u
/2 ' '9, IJ, Mitt i a.. tsv, l lc MC int Ili
.t i
t in ut loan State ip List: l fort) Ili
I _) _
Area code- Thane number q
-1. DATE DRILLED aa( - I -o 4
5. TOTAI. DEPTH: Ci to '-_.-.--
L. DOHS WELL REPI.AC'E EXISTING WALL? PITS 0 NO
7. STATIC WATER LEVEE. Below 'Fop ofCasing: i1a1!) FT.
(ilk "t- ifAbut-elop of Rasing)
Si TOP OF CASING IS ) PT. Above Land Surface"
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCA(' 2(' .0118.
\IP.LD lupin): 4.1) METHOD OF TItST_ rs --
WA 111112 ZONES (depth): 6 y-5 ' - 9.-0 9 jN m
II. DISINFECTION:'I'ypc.
1_.
('ASING:
Depth Diameter
From _JO To a 5 R. Io I t
From co Ft.
From to Ft.
Topogral) 11ICl Land setting
❑Ridge ❑Slope ❑Valley rat
talkie appropriate box)
1 aiitudelongitude of well location
&La a, nunut.s. seconds' —_
latitude longitude source:❑(iPS❑Topographic map
whcek box)
DRILLING LOG
Formation Description
S
' 0,10,5' dataa, to
1 OC \ IION SKETCH
1-1 zN \mount 12k +1,i Fs , ',how direeiion and tlistance in miles Irons al least
\Call !Meknes"( two State Roads or County Roads. Include the road
or \\ eight Pt_ Alateriul numbers and common road names.
PVC -
13. ( ikOUT: Depth Marco;rl Niethod
From._Q lb__QQ_ Ft. -
Front Tu
14. S('RIiFIN: Depth Diameter Slot Size \I:uerial
From To Ft. in. - in. From . To Ili in. in.
15. S:\NI): GRAVEL PACK:
Depth Site NI atenal
I rom Tu
From 1'0
lb. RF:NIARIKS:
I DO III -RHO ('1LRHEN' THAT 1111S \CIIi I WAS CONS IREC II1I) IN ACCORD \NIT. \\l'I 11 I5.\ Nt \( 2(. \\l.LI.
( ONS IRE( l ION SIA DARDS, AND 11I n l A t A- or- I I ITS ICI (ORD I I S ill TIN PRO A IDIID TO l 111 AAlfl.I, uWNILR
ZC)
SIONAOF PERSON CONSI RCC I INt l l 111 AAl0 L U AT6
Submit the original to the Division of w ater Quality, Groundwater Section, 1636 Nail Serx lee Center - Raleigh. S(
27699-1636 Phone No. [phone]. within 30 days. (iAV-I RFti. 1)7 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division or Water Quality- - Groundwater Section
WEl.l.CONTRACTOR (INDIVIDUAL)NAME (print) —Rifler J7tt att (ERTIFI(.Vl )Nif 5354 To
WELL ('ONTRAC)Y)R COMPANY NAME &re.e_ne eras, i. )" 6 6 4 • Dwnis, a ,Rag /_ 4�
SPATE wilt CONSTRUCTION PERMIT#
\SSO(.IA FED \\ Q PERMIT#
1 i( applicable) ( if applicable)
I. WI(1.1. USE ((heck Applicable Box): Residential Municipal. Public ❑ Industrial ❑ :Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ Il'Othcr, List I Isc
2. WELL LOCATION: '
Nearest lown:Yri/i.�i(n 1�IL�i .!Count
—tDtJoaFfsl.ez/ Pi
191mct Name, Numlxrs, (, Oommnnily, Subdn ),,rose. Lot So.. / (ode 1
3. OWNER:
Address
• Sued 1' Rothe No.1 r./.,_/,/
Al ea code- Phone number
-I. DATE: DRILLED 9 - 2 -o 4/
>. 101.A1 Dllrrll:
St5'
✓
E. DOES WELT REPLACE EXISTING W1:I1' YES ❑ NU ,
7. SIAII(' WATER LEVEL I3clowTop ofCasing: _ a/pP FT.
Itt,.-r'i Allow imp of casing)
3. TOP OF CASING IS FT. Above Land Surface*
*Top or casing terminated at/or below land surface requires a
variance in accordance with 15A N('A(' 2C .11118.
9. YII I) (epni): ifL__. METHOD OF'FEST a A rs •
10. WATER ZONES (depth): _. 4'45_ r 85.'
11. DISINPI`.l"1'ION:'rypc N :Amount 92 14/4._
12. C:\SING: \kal( Thickness
1)epth Diameter or Weight. Ft. Material
From 0 to a)_Ft. _6_, PVC.
Front To Ft.
From _ To Pt.
Rot it: Depth Alstcri.d Nldhoti
From ,n -I o_�.. Pt. Ju 1
Prom_ To It._
Id. SCREEN: Depth Diameter Slut Sim \laierial
Erum to Pt. in.
in.
n. in.
I. SAND tilt:\VE1.l'A(K:
Depth Site \ l(terial
From _ Fo 1
From to _ 1
16. REMARKS:
,,/, Topographic 'Land setting
t.Riduc DSlope ❑Valley 0Flat
(:heck .t1 propriatc box)
I.:1111 de. longitude of well location
iticiircc. uunur.,.mtcolitisi
I.:mitudc. loncitudc topographic map
',heck boa)
DI- I'TI 1 DRILLING Luc,
From fo Formation Description
�Da a/
SO ' f14 a.wf.
IA lc: ITON SKETCI1
Show direction and distance in miles I}ont at leas'
two State Roads or County Roads. Include the road
numbs rs and common road names.
I Do III'RIWY cut Fin( Tjtivr rills WEE I_ AAAS ('ONSTRU(lYD IN ACCORD -ANTI VA rut l I -A N(AC 2C. Witt].
CONS FRRI i(TION SFAND..A DS, AND ILIA I \ (OPT' OF THIS I(L(ORD I I.\S 13I FN PROVIDED TO THE WELL OWNER
SI(iNAll PRE OF PERSON CONS ILECIINT'I'I II. AAlilt DA'IL
Submit the original to the Division of Rater Quality, Groundwater Section. 163i, 9lai1 Son ice (enter - Raleigh, N(
27699-1636 Phone No. [phone]. within 31) days. (iW-1 REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N il Resources - y 111Un of APater Qualitc - Groundwater Section
\\'Fit CON FRA('TOR (INDIVIDUAL) N:(MI::: (print) VJj\ Ors •-F-(-4, ('F:RTIFI('.\'1l)N a 335.11
WEI.I. (ON IRACTOR COMPANY NAMMFkktt/� /NKa°° . [c%L-�- 0 Plait • ' ' PHONE # 6a2 4 €/ $ • 3 I I D
SI':VIE\\ELL (CO.NSFRUCIION PERMIT# _._ �y' Pa__\SSO(IA FED I'ERNII'I#
(if applicable) (if applicable)
1. A4'I:LI. l ISI� (Check Applicable I3oc1: Residential)4 Municipal Public 0 Industrial ❑ :Agricultural 0
Monitoring ❑ Recovery 0 heat Pump Water Injection 0 Other ❑ I (Other. I.ist l isc
2. W III.1. I.(K A (ION: � Topo"raphicLand setting
' sle Nearestw: n.� hu -- County Alto / tzdh )ee ❑Ridge *Slope ❑balev ❑Flat
-- e- .�..-�� r_N1 ._ 1..11.....1. appropriate hox1
(Street Name. Numbers, Community. Suhdn Lunn. lot No_ Lip (a.del Latitude longitude of well location
3. OWNER: t T� ic ce:O seconds)
Address �[� P.J jy �1 ,�.g__ C.� • Latil uda. lel�itud� .'once:❑GPS❑-fupoct.lphir nlap
/ 1 !Stitc11W Route No.i / (cheek box)
W pfc✓1 (le AI _ 41 T'9t. DEPTII DRILLING LOG
( nc ii, lo,.n Smlc --r lip Cod.) IMoil) Fo Formation Description
at -
Area cwlc-Panne number ,/ 79 i � i £ t
4. DATE DRILLED $ - / U - 45 (1
5. TOTAL DEPTH: 1£lS•
IX)ES WELL REPLACE EXISTING WELL? YES 0 NO ei
7. SI,\7I(' WATER LEVEI. I3elow lop ofC'asinu:
:se :thine Top of easing)
S- TOP Of CASING IS FT. Above Land Surl:Icc*
*Top of casing terminated at/or below land surface requires a
t ari:mee in accordance with 15A N('A(' 2(' A1IS.
9. YIELD (gpm): _426 _METIIODOI:TLSi a ti.S •
10. WAII.R ZONES (depth): 1 55- 0 F _
Lu..\ FAUN S61CCilt
1 I UISINI 1 ( Ill )N: Type (--r•-[}-i. Amount za - ,14: ;huo .lircction anJ distance in milts from at IL ixi
12. CASING: Wall thickness
I)epth I)i;uncter or \\ eight Ft. Material it Withers and common road names.
Front h Il)_ '1 rj Pt. Co It .__.__. - L__ O _
lion' I'o _ Ft. C ...
FromIn 11. O R?trn
13. (iRoinu:: Depth Material Method —I
firctI.J
bruit) n I O_�Q . It. �yyty_,y -_- _ _ ON cr--
p•a
From__._. to _._._Pt..—_.._ _ —?C)
14. SCREEN: Depth Diameter Slot Size \ laterial oTa
MC
--i;:]
Front To Ft. in. in. _ N ��
Front 'lo Ft.in. in.
L.; SAND GRAVEL PACK. C�JI r u
Depth Size Material Ch
From
From To It.
16. REMARKS
two State Roads or County Roads. Include the road
1 DO llEltI131 (I'.RIIPY 1l1A11IlIS N1-1.I_AV:AS CONS IRUC Ill)INACCORD ANCI VAIIlI IS\1(\C:'(', W1.LI.
CONS IRF(-LION SIANDARUS. AND TI IA .A COP}- 01 11115 RI (()RI) 1I.AS 131 I N PROA WI I) 10I I II NA III OAANIR
LU iS A D It D i�CJ �D � 2 � - a SI
SI(iNA I;RI 012 PI.RSON ('(11CSIR I'CllN0'llll AVFI 1. DAll.
Submit the original to the Division of Water Quality. Groundwater Section, I63o Mail SCIM ice ('enter - Raleigh, \('
27699-1636 Phone No. [phone]. within 30 days. GW-I REV. 1)7 200 I

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Seel ion
N TI.I. CO.NIRA('TOR (INDIVIDUAL) N.WIE (print) bQQ-'f' -D t->-V C.-� ` CERTIFI(:\ 17ON N 3 3 54
WELL CONTRACTOR COMPANY NAMEC r ctnt ��'t{/o1CS . 1.e).a1.A- ) "" r11oNF'. n 22 L g -.3 1-7
STATE WELT. CONSTRUCTION PERMIT# __ / • D.2 _ tSSOCI:\ FED \\Q PER\II Trt
( it' applicable) (if applicable)
1. WELL t ISI': (Check Applicable Bost: Residential Municipal Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ID Heal Pump Water nlcclion ❑ Other ❑ Ifl)thcr. List ('isc
2. WE1.1. LOCATION: . L l Topu_}}-aphidl-and setting
DRidge O(*Slope ❑Valley ❑flat
(check appropriate box)
I Street Name. Numbers, Community, Subdicisum, I. No.. Lip C�KL- I -�-esizrentC, 1.al etudelongitude of Well h1Ce(1011
OWNFR- - - -. ni minute.seconds)
Address Re '')t.palp -. _-_- l.atimdclongitude souce:❑OPY:Topoglaphic map
1$nlYl nl' Rome No.l
(cheek box)
Nearest tint n: ,t County
Li%)e Eas i TOr IC c1
cnin a.
1 nc III ION II Slate ) LiP f'odr
Area coJ.- ('hone number
4. DATE DRILLED 4 -Imo- n�----------
5. 'I(TFAl. DEPTH: 1 SS ' - _ .
L. DOES WELL REPLACE EXISTING WELL'. YES ❑ NO
7- STATIC WA I ER LEVEI. I3clow Top of Casing: -2,/5 PI-.
(i)IC i( : Abocc Top of Casing)
S. TOP OF CASING IS J ET. Above Land Surf:lee*
*Top or casing terminated alior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. Y111 D I METHOD OF TEST 0211 rS__
10. WA TER ZONES (depth): 1 to 5 t - 7 dpm .. __.
1 I. DISINPH(' IION: Type_ 14TR
12. CASING:
Depth Diameter
From Q ro _S Pt. it
From _-- P°-
From To Ft.
\mount_33_}bl�s -.
\\"all l hickncss
or Ayeight Pt. Material
P\! c
13. (TROUT: Depth btaterial Method
Front n To aD Ft. r _. _.—
From--_ 'ro Et.
14. S('RIIEN: Depth Diameter Slot Size \ latcrial
from 'to Et. in. in.
From— _ to __ Et. . in. in.
15. SAND (iRAVIil, PACK:
Depth Site Material
Iiou1_ — to Ft.
From To Ft.
lh. RF.\(.ARKS:
DI Pell
From la j
35
3s' /4f5'
DRILLING LOG
Purmappli�otn I)eescripuoil
LO('_ALION SKEI('ll
Sho\v direction and distance in miles from at least
Mt) State Roads or Ca unty Roads. Include the road
numbers and common road names.
SS :6 kV 93 130 h0
1 DO TIER(. BY ( )'Bunn' TIIAr its Wlill. N':\S (ORt;CI El) IN ACCORD AN(l \\I I11 I S.\ .N( \(• 2(', tt,iti .
('ONSIRut- LION S[AN )ARDS. ANDTIL\I:\ COPY U1: 1111S ITT( ()RI) II.\S 131.1N PRO\ I1)I.D-I0 tin, Wh1-I. O\\'N
- .2 / V
SI(iNAr(II21- 01 PlI{SON tuNStR GCTINtl T111- AAlit l- DATE
R
Submit the original to the Division of %\ ater Quality, Grounds% ater Section. 163o Mail Ser. ice ('enter - Raleigh. \('
27699-1636 Phone No. [phone]. within 31) days.
11W-1 REV. (17 200I

k 4fl
WELL CONSTRUCTION RECORD
North Carolina - Department el Environment and ral Resources - Di\ ision of \\'titer Quality - (iroun(lwater Section
N'F:1,1. ( O.NTRACEOR(INDIVIDUAL) NAME (print) 021..1:44-' le._)-e_ L L ( HUE I('.%HO.N # a rye-/ 9
Creep Ian- ()wrap , �-- . t
vcELr('oN�rR.u`roeco�lrnNv�N,yaut arc/5. � PHONE # (�g1�/8- 3>7
SI'Art: N' ELI. (ONSFRU(TION PERMIT# -_ )41D4___(SSO('1:\ FED WQ 1'F.R\II're _._._.._
l it' applicable, (it applicable)
I. WELL t ISI: (Check Applicable Box): Residential, Municipal Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ heat Pump Water Injection ❑ Other ❑ I (Other, I.ist Ise
2. WELL Id/LATIO : , +
Nearc�sjt Town: I 1 Ili County 14 /tJo
G - L3tt1
dlot
Street Nano. Numbers, (omnnmsubdisiuon l u(t Ni. hip ( into
3. OWNI':k:.
Address _ ?jg �'�,po�_ f_ -
TopographiciLand setting
[Midge 0Slope ❑Valley tSlidat
(cheek appropriate box 1
Lill lt(ak IJllgiltlde nt 'sell location
Idn•re. nuntne. sceoudsl
1.;titudc longitude ;otu'cc❑GPS❑Topographie neap
!Street to Rome No 1 I rhet 1, h. x )
Nei_.— 8.78(- 1)1-Pll1 DRILLING I.Ot
Ic of nsn tilutc lipCode
Area code- phone number
4. DATE DRILLED - 3-014
5. IT)TAI.DEPTII: ) OLIS I
(.. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEE, I3elow'lop of Casing: loci FT.
I I ise - r.. if Alois e 'top of Casing
8. 'FOP OF CASING IS _ _� FT. Above land Surface'*
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A N('A(' 2(..0118.
9. YIELD terms: a METHOD OF 11Sr r2 h rS
10. WATIfkZONI`.S(depth): (Qp$t - q,m_.
II. DISINEII(''ION: Type H7-t_i_ :Amount
12. CASING: Wall Thickness
Depth Diameter or Weight. Pr Material
Prom_,. co lv _-_ Ft. to tl Pole..
From I n
From To PI.
13. (IR( IT: Depth / Niethod
From 12 To aa)_.. Ft.(o _PLC_
Front To Pt.
14. S(RIEI'.N: Depth Diameter Slot Site Material
From To 1'1. in. in.
From_. . To F(_ in. in. -.
15. SAND: (RAVEL PACK:
Depth Size Material
From ro Pt.
From . l o -- Pt.
16, REMARKS:
Material
It
1 'rom l'o Formation Description
4 tie
t41 t /64
l OC:AIION SKETCII
Shove .Ineel ion ;ld distance in stiles front at least
two Stine Roads or t aunty Roads. Include the road
numbers and common road names.
9S:6 WV 9Z130h0
I DO HEREBY ( lFRIIFY MAT TIIIS Vhim. AAiAS ('ONS'l'I(I (' ETD IN :ACL ORI) AN(T \41111 I SA N('.W 2(', Nl'.I.I.
('ONSIRU(TION STAND RDS, AND111.AT .A ( OF ll ORU II:AS 131-I N PROVIDED U 1'O loll) AA'lil.l. OAA'NI:R
sr(iNATI:RF OF 1'F.RSON (l)NSIRI!('TINt i11I1 \\P.1 I. D:\11,
Submit the original to the Division of Rater Quality, Groundwater Section. 163o Mail Ser' ice ('enter - Raleigh. N('
27699-1636 Phone No. [phone]. within 31) days. (IW-1 REV. 07 '001

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment :ld Natural Resources - Di i51u1) oI Water ( )ualitc - Groundwater Section
\FF:1.1. CONTRACTOR (INDIVIDUAL) NAME (print)' Rt6) /`M d 4- ('ER'IIFICSI'ION tt e7�/8
tens 3in) . (s%. .j et PL1n') •-F' *PHONE p )p�/.1p p V8 • 311E
/4/0 2 __-__ASSOCIATED \YQ PERM) lit
l ifapplicable) - (itapplicable) - -�-
1. W. ELI. t!SE (('heck Applicable Box): Residential' Municipal Public 0 Industrial 0 :Agriadtural 0
Monitoring ❑ Recovery 0 heat Pump Water Injection 0 Other 0 II Other, List 1'se
Wlil.l. CONTRACTOR COMPANY NAME.
STATE WELL. CONSTRUCTION PERM l'1'k
2. WELL 1(R'AIIO
N st "Town:
!Sueci Name. Numbers, (
3. OWNER:
Address
flt.SV/ /./a County ALA
�e v - kit D
owing Suhtbnsnm. Lul Nu_ hip (ndc)
Y 3 9 IA: I . coct.
I Street or Rome No.
1t.s.v+!/t /t/r. at7gL
Stat.' Tip Cot).'
)-
:\rca code- Phone number /
4. DATE DRILLED 8dd —de
5. El HAL DI -]''II l: //1/
E. DOHS WELL. REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Bclow!lop of Casing: 400 FT.
Il se"it:Abo.c lop of Casings
S. TOP OF CASINO IS I FT. Above Land Surface*
*Top of casing Terminated at/or below land surface requires a
variance in accordance with 15A Sit A(' 2(' .11118. �1 /
9. YIELD(gpno: 1 I METHOD OF lllSl' y7 AYS
1(1. WATER ZONES (depth): 1 1 as -�1 r� __
Topographic/Land setting
❑Ridge (,Slope ❑Valley ❑Plat
L:hcck appropriate Kos)
Latitude. longitude or well location
IJhv<:. nunumaccand>I
Latitude. Ion,gitu(le source:❑(iPS❑Topographic clap
Icheck box)
1)1 Plll DRILLING LOG
Front fo F I ormation Dcscriplion
5/
S/) %/VS"'
Loc.A l R)N SKy i ('I I
11. DISINI'F('II ( aN: l}!pc_J-/T - :\mount D_'? 413.16 Show direction and distance in miles ('rum at It Nt
12. ( ASINII: Wall Thickness two State Roads or County Roads. Include the road
Diameter or We i_ghl. Pt. Nlaterial nIII)bc rS and Chills 11Ull road names.
PVC
I kin!)
From _Q "10 6 /
Drum To
From ---- To
Pt. 4 Id
13. (IROt11!: Depth Material Nlcthud
From_Q -Po ao
From 'Fe Ft
Id. SCREEN: Depth Diameter Slot Size Niwcrial
From TO Ft. in. in.
From loI'I.__. its. _.._._— in.
15. SAND .GRAVEL PACK:
Depth Size 1 )arenas
From TO Ft.
From_. 'lo
16. REMARKS:
9S:6 WV 9Z130110
I DO I IE:RP.BI CILRTIpy II IA'r THIS WELL W:AS CONSTRUCTED IN ACCORD.A.NCI svIII 115.A N(':AC 2l', AA t.l.l-
('UNSIRt'T{'(ION STANDR S, AND FIT:\I' :\ COPY Uf! TI IIS RIE("URI) IL\S BHA I'RO\ IDEI) la) 11II1 Will I. OWNER
SIGNArCRI OP 1'IRstN COINS I R1 C I!Ktl l lll- AA 1'.l I.
/o _20-Dc/
DA it
Submit the original to the Division of Rater Quality. Grounthyater Section. a hto Mail Ser. ice ('enter - Raleigh. SC
27699-1636 Phone No. [phone], within 30 days. (IW-I REV. 07 2001

WELL CONSTRUCTION RECORD
North ('arolina - Department of Environment and Natural Resources -Die ision illWater (duality - Groundwater Section 1
\\ ELI, CONTRACTOR (INDIVIDUAL) NAME (print) ��D3t c DLLy G-1 cT:RTIFICA1lON N 335"}
WWELLCONIRACTM�r
ORCOPAN\ NA%IE Gr
Y1t _.JJ1'G3 . i.t)a�l. M Via-rs .pr t`� PHONE N (Swig 4.M S
STATE WEI-t. CONSTRUCTION PERMIT/4 _-- 14 D a.... ASSO('IA TE.D \\Q I'F:RMI T#
l it applicable) (it applicable} - --"
1. WI111. t ISt. ((•heck Applicable 13oc1: Residential Municipal public ❑ Industrial 0 Agricultural 0
;Monitoring 0 Recovery ❑ I1eat Pump Water injection 0 Other ❑ Ill/titer, List l Ise
22. Wad IOC A PION
Nearest Town: ylgyy t / /L county_
( Sera Name. Sat ntw(s, r'on Subdn rxiun. Lni \'o.. /ip (od,)
to �CY�
3 OWNI[R:M'{n__ Yr♦?i...)84.4414
Address 3SM 1 ccL -.&. _..--
y- I (Street or Route No.� ry
In1,J eL_t .. Q %
Iona
tlrcr lotto Slaty /ip l'ndr
)-
Area code- Phone number
.t. I)AIEDRILLED q- 3 -Dq
5. .I.UT A I. l) I PT11: 1 2D5 1 �,,/
P. 1)OI:S WI-:LI_ REPLACE EXISTING WELL' YES ❑ NO CC
7. STATIC W'.ATER LEVEL I3etow Top of ('asinu: 3D PT.
t Cue " " i t \hot e Top of Casing 1
S. TOP OF CASING 1S i IT. Above Lund Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A RCA(' 2(' .0118.
0. YIELD(gpui): Jn MET11ODUPT[S'I
10. W":AT'lIR ZONES (depth):. 1 36 I - 145 ' - LI.`d pen
1C)1oS= 1 4S5 4 c p Y`
I I. DISINFI`(I ION: Type__. 1-HI_N. Amount _18_ +k 1t .
12. CASING: \Vali Thickness
Depth Diameter or \\eight. Ft. :\laterial
From to W'S_.t_ Pt.- fo 11 Pye_
Prom To Ft.
From
13. GROW.:
Prom©
Front
1.1. St At
Tu Pt.
1)epth Material \I elh�od
To_ Q Ft. �v ALL. } I'
To
Depth Diameter Slot SR: Material
From 10 Ft. in. in.
From To Pt in. in.
5. SAND GRAVEL PACK:
Depth Size \taterial
From Ib Ft.
From lFt) Ft
16. Rli\IARKS:
mTopographic:Land setting
idge ❑Slope ❑Valley ❑flat
'acct. appropriate box)
Latitude- longitude of well location
-. I r !UMW:, SCCOIlliNi
L:niwd:.loneitrale none:❑('PS❑Topographic uwp
I c ha k httm
DI' PH DRILLING LOG
Isom Fu formation Description
0 851
$5a /.20Y'
I.O( :Al't1N SKL It 1I
shim. direction and distance in miles from :it least
two State Roads or ('twiny Roads. Include the road
numbers and common road names,
9S:6 WV 93l00h0
1 DO 11ERIi13Y (IRIIPY ll1AI'-IllIS WEIJ. WAS ('DNS 1'RUCII:DIN ACCORD.\NCI. 1\ ITII I5.\ NCA\C '('- WFI.I.
CONS TRF('I ION STAN�DD RDS, AND TIRE ;A CDI'Y Uh Till. CORD 11 AS 131.1 N PROA IDEA) ll) lllf WELL 1)WN11R
`Cl11/42 �e1,42Fe� /6.sa-GV
SI(iNATGRF (nPIERS( CI)NVrg[( 11N(i-1111 AATI I- D.
Submit the original to the Division of Water Qualit). Groundwater Section, 1636 Mail Sers ice ('enter - Raleigh, Nt
27699-1636 Phone No. [phone], within 30 (laps. (IW-1 REV. 07 11)01

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME/+(print) R{�C)6�1 n W (t CERTIFICATIONTp# 1S
WELL CONTRACTOR COMPANY NAME(-s ref. rig, t3roS L.%J t Q - PI, r•tt .11t, . PHONE # 44 e,Stg - 3 / 7n
STATE WELL CONSTRUCTION PERMIT# ) S¥o.. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water njection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Neare To 1:• .� . .•�. County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: la et_AA C'0-44.'Aam...1,
Address Zo ant SS g
(StreetorRoute No.)
/1 nest[ t Nc io2e7ged
City Town State / Zip Code
( )-
Area code- Phone number . / ' -
4. DATE DRILLED /)( v
5. TOTAL DEPTH: 4 D
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO i.
7. STATIC WATER LEVEL Below Top of Casing: fo 0 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.
9. YIELD (gpm): / % METHOD OF TEST a) r
10. WATER ZONES (depth): airS
11. DISINFECTION: Type i-1'TN
12. CASING:
Depth Diameter
From__ To rl to FL to t t PUS,
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
Fromm To , f) Ft. CO.IA.o.t. f
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
Topographic/Land setting
❑Ridge ❑Slope ❑ValleyFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
D 16'
']/a t 4b5
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
LS:6 WV 9Z13010
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
RD CONSTRUCTION STANDARDS, AND THAT A COPY OF T�ECOHAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ResourccIe�s,,- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Q 1 n LL.LDJ .l CERTIFICATION�/If�# .7 SI/ SI
PHONE # (aolY 64/8 - ' D
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# / `'f U . - ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
WELL USE (Check Applicable Box): Residential) Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION�I:
Nearest Town: Luati nPSiftlIt County ttnoX
LD 4 1 Z 5tzi��e a-s j elr�t,tZ.
(Street Name, Numbers Community, Subdivision, Lot No., Zip L de)
3. OWNER:
Address
tiktne5ut1lP, Mc ag�8le
City or To State Zip Code
31 -C • .I at.) 23
( )-
Area code- Phone umber
4. DATE DRILLED 1 '- 1 S-D4
(Street d0'
5. TOTAL DEPTH: ''1 DS I a-,l
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Y2
7. STATIC WATER LEVEL Below Top of Casing: '4 0 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): 4 METHOD OF TEST d h r
10. WATER ZONES (depth): 5g S ' ' 4 ci r
Topographic/Land setting.
❑Ridge ❑Slope ❑Valley MFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From ToJFormatjon Description
1 E
52iIDS ' atil to
LOCATION SKETCH
11. DISINFECTION: Type 14- T k Amount 12 -1 +1.I4 , Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Inclycde the ?Ad
Diameter or Weight/Ft. Material numbers and common road names. i
to't PVC.
Depth
From L) To CA. Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0To OD Ft CD o 44..} 4sp
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LtJJ „EhJJ4,1 /G-/s -a4.1
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources 1- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1/ �O 6,.n (1)�� CERTIFICATIONAry(# Z 4 / Si
WELL CONTRACTOR COMPANY NAME C7h13.s,1 I3 PS Ij_1aJ) 4 �R,r.. fL .1Kt .PHONE # tar q Lin -.3 1 92.)
STATE WELL CONSTRUCTION PERMIT/4 / sip 2 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nvirest Town: CoAunAty, -:-)
CW Cr?S _ Yr7 is /F.1C Irt
(Street Name, Numbers, Community, Subdivision, t o., Zip Code)
3. OWNER: Cr Rap
Address 3 4 ( D14
(Street or Route No.)
L CL%/?€svrlle MC, aS7844
City or vm State I Zip Code
(—)-
nqa)
f IWr
Area code- Phone number
4. DATE DRILLED 1-IL - D c-
5. TOTAL DEPTH: 1 8!S /
6. DOES WELL REPLACE EXISTING WELLS YES 0 NO $[
7. STATIC WATER LEVEL Below Top of Casing: 30 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top °leasing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): $ METHOD OF TEST of rS •
10. WATER ZONES (depth): ILcS r - Sc3Prn
I I. DISINFECTION: Type )4 -1-1 Amount 33 t),) 4,,
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 3D Ft. 1p `' PVC.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 2D Ft it c.ry a.rt -ft-p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/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 Formation Description
D 3bl CL
1IS' rj21ASS +e
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
O
0
—I
N
0'
•
C,ft
;:j c-a
n1
-ar.r
�C
en
0
co
trio-
rt
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
YE) i -tuL.
/6 l.s- a Z"
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

0
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME(print) R )� i , (1ti CERTIFICATION # 42 / 8
WELL CONTRACTOR COMPANY NAME &r a ene. ens . %/V e, 1 I -t 9-K NT Zo..e. PHONE # (FOR G VS ' 3 / 7
STATE WELL CONSTRUCTION PERMIT# / 5/0 -2 ASSOCIATED WQ 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 ❑ If Other, List Use
2. WELL LOCATION: ,1 ``
Nearest Town:Lt „eSv, 11e_ County i-1 t.O# ad
ri0 1. a QA.) i4 4%. 11
(Street Name, Numbers, Community, Subdivision, No., Zip Coot)
3. OWNER: rvN Pt SSE l Y12, -
Address I t n C) Li S Sit.. E
(Street or Route No.)
5+. flwL s+ne 1 FL .3ab%Zo
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED '15 - b `f-
5. TOTAL DEPTH: .1' L/S'
6. DOES WELL REPLACE EXISTING WELLS YES 0 NO M
7. STATIC WATER LEVEL Below Top of Casing: i CO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ) FT Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3Ci METHOD OF TEST 1, r 5 .
10. WATER ZONES (depth): a f 5 a - 3 a wn__
LOCATION SKETCH
11. DISINFECTION: Type t—i T H Amount as +1.) J. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
Topographic/Land setting
❑Ridge ❑Slope OValley 'flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
© Ib
tan aS G-nAAbe
Depth
From n To 1 Ft.
From To Ft.
From To Ft.
Diameter
(p tt
13. GROUT: Depth Material
From_ To 40 Ft. CS,wr.o
From To Ft.
PVC,
Method
atc r:
n mil r:
--1 «
14. SCREEN: Depth Diameter tv -0n
From To Ft. in. tT X7 0
From To Ft. in. a --tt
n."
lG --t"=�
Crl Tc
v rrtt �
c2
16. REMARKS:
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDAR S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
`id j ycJnteuc l6 - /S-a �f
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

306328
WELL CONSTRUCTION RECORD
North ('andina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)Chft /,fie Eijie '/ �t.J/ �`-- � �' `e- CERTIFICATION itai �
W ELL CONTRACTOR COMPANY NAME�I„Jh l. *• �/4 • IA 1 r �, PM
... CS %,, l/.rp '/
STATE WELL CONSTRUCTION PERMIT#- —1 T.a.� /' , P �— PHONF, # (c{.{a y� •.3� �fd
(ifa licable _ASSOCIATED WQ PERMIT# --
(ifa licable
1. WELL. USE (Check Applicable Box): Residential S Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearestt/ �Town: t,5 j County_da.
S—.? Wig___
(Street Name. Numbc Community, .Subdivision, Lot No., Zip C'cdc)
. 1
Area code- Phone number —_--
4. DATE DRILLED_--7 3
S. TOTAL f)EPTH: t
I 1c! A ;"I IAII; \Ai 1.1 I9 YES. LI s,0
7. STATIC WATER LEVEL Below Top of Casing:
(Use "4" if Above Top of( FT.
X. TOP OF CASING IS FT. Above Lnd S*'fop of casing terminated at/or below land surface requires
urfaCC*
variance in accordance with ISA NCAC 2C .0118
9. YIELD (gpm): �__— METHOD OF TEST___
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge ❑Slope [Walley lat
(check appropriate box)
Latitude/longitude of' well location
3.-OWNER:_
Address ,3_ ,tJA /. I / � (degrees/minutes/seconds)
/ ' /1 gC
(Street or Dote No) Latitude/longitude source:OGPSOTopographie map
LUL1•�I heS 1/ / p N(✓ ..r 21796 (check box)
t} or Town State Zip
C>de DEPTH DRILLING LOG
)- From To Formatiiop Description
1 1 . DISINFECTION: Type__t TN
12. CASING:
© Depth Diameter
From To-_n__ Ft. ll
From - To Ft.
From ---.--
13. GROUT: Depth �� ----
FromO—. TO---��! Ft.
Fro pm _.. To Ft._
14. S('R EEN: Depth Diameter
From_- To Ft.
FromIn
To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From ToFt.
From --_fo rt—
Ib. REMARKS:
I DO I (EREBY CERTIFY THAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE Wall ISA NCAC 2C', WELI.
('ONSTRl1C flON ,STANDARDS, AND '17IAT A COPY OF THIS RECORD 11AS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE PERSON— ( RUC'TING THE WELL /'2 - 3'/ — a
Submit the original to the Division of Water Quality, DATE
27699-1636 Phone No. 919 733_ ualit Groundwater Section, 1636 Mail Service Center -Raleigh, NC
( ) 3221, within 30 days.
GW-I REV. 07/2001
aterial
LOCATION SKETCH
Amount _6._JA/45. Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names
Siot Size
in.
._ in.
Method
�
Material
Material
Ui
0
rA

- North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: rQJ 1442` 1,70
306363
WELL
STATE ION RTACTOR CERTIFICATION ":,4"kk%, tioec
CONSTRUCTION PERMIT".
1. WELL USE (Check Applicant. Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketc of the location below)
Nearest Town: tr17Nv4th /. - 7 County: hlc7/7
(Road Nam/e,/a�d Nu ens, o unity or Subdivision and Lot No.)
3. OWNER i is%t_5c%n9-{ r
Address 363 S V s5
rrei &
1P�SliY . a (Sued or Rour I o..) vio !'/W-
ai yr
I�Y or Town ((
�'vs_ Vsny_ WA, Zip Code
4. DATE DRILLED
5. TOTAL DEPTH _
6. CUTTINGS COLLECTED YES Q NOD
7. DOES WELL REPLACE EXISTING WELL? YENO
S
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': if Above To of Casing)
9. TOP OF CASING IS 02 FT Above Land Surface'
'Top of cuing terminated Wor below and surface requires a variance In accor-
dance with 15A NCAC 2C A}1e !J W. YIELD (gpm): . 7 METHOD OF TEST nit"
11. WATER ZONES (depth): �1
12. CHLORINATION: Type fry/ Amount
13. CASING: -
Depth/r� D}ametp� Wall Thickness
�� To W / Ft /.SU or Weionl/FL terial i
From Di / eiaN
From To Ft.
From To Ft
14. GROUT:
Depth . /7 Material Method
From To 0 Ft( Ole,/
From TO Ft
15. SCREEN:
Depth Diameter Slot Size Material
From - To Ft in in
From _ To Ft in in
From _ To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
Monitoring ❑
it additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
14J/73
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
tiP ./,ci f
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE "7
Submit original to Division of Water Duality, Groundwater Section within 30 days
GWI REV. 12/99
FOR OFFICE USE ONLY
Ouad No:
SenatNo
:,1

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalResources- Division of Water Quality - Groundwater Section ti WELL CONTRACTOR (INDIVIDUAL) NAME (print) —RC))- s n WeJ b CERTIFICATION # a is
WELL CONTRACTOR COMPANY NAME Ci r CP vs. C aro 4 Purist -, PHONE # ( ( j q & ` 3 )11'
STATE WELL CONSTRUCTION PERMIT# I 44-0 a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): ResidentialI Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: County OC
Ca.�f ► v — r +l a rt� Pat .
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ti an, IQ ou)a-kota)5 k .
Address 'a in 3 a Trsv. l n.._. C nP h al .
. `` (Street or Route No.)
( 2hSyf Jh. MC�fl724i
City ddd own State ' Zip Code
Area code- Phone number
4. DATE DRILLED Co -1 ] - D 4
5. TOTAL DEPTH: 3/l5
6. DOES WELL REPLACE EXISTING WELL? YES O NO IS
7. STATIC WATER LEVEL Below Top of Casing: 4D FT.
(Use'+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): ) 2, METHOD OF TEST . kv-5 .
10. WATER ZONES (depth): 1 R 5' - 1 a i3prrN
11. DISINFECTION: Type HT N Amount St.» 441 is
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To L) 0 Ft. (u a' PVC.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To QD Ft. C.otiv.e.a 1
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope OValley 'J1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
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.
LS:6 WV 93100 h0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Ltd
ia-is--o4
SIGNATURE OF PERSON COAS IkUCTING THE WELL DATE
Cr
r_
-or;
fir=
Cir- ri
- t
a
rstr
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

a()-1°
303444
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resou111--es -- Division
of Water( )uality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NANIP (print) to W1...t.a/&CL ('t:N'I'Itl(':\IIOVC 3354
WELL CONTRACTOR COMPANY NANIECr ee.lie. SII . LeJ.,_ LL d AAu-4-P , - mow:a (g42$ 4Q x' 3 / 7 t
STATE WELL. CONSTRUCTION PERMIT# __. / delit.'2 _.._—\SSOCIATED \\Q PtR\trrA
(ifapplicablel
(itapplicablel
1. WEI.I. 1ISE (Check Applicable 13ox): Residential pt, Municipal. Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ !beat Pump Water Injection 0 Other ❑ If Other, List l lse
2. WELL LOCA.'ID :
Nearest Town: lLey,' �r ��L/�ey^('ounty_
I MANI Name. Numbers. community. Subdivision. I all No.. hip ( 'ode
''
Pia /8ad-_ --
Cin (inn Slat.• , 7ip rode
3. OWNER:
Address
:\rca code- Phonc number
it DATE DRILLED $- / %=d_yr
S I'OTAI. DEPTH: ,_./
F. DOES WELL REPLACE EXISTING WELL? YIPS 0 NO ot,
7. STATIC WATER LEVEL. Below Top of Casing: 3OP FT.
I I's • " i" iI'Abocc'l op of basing)
8. TOP OF ('ASIN(', 1S / ET. Above Land Surface*
*Top of easing terminated at/or below land surface requires a
variance in accordance with 15A N('AC 2(' .0118.
9. YIELD ()wink METHOD OFTESF_Jrs
ID. WAFERZONES (depd): 685' - ?q pmi 905'yp,,,
9,?S' — /.2 /° "' LO(:\ IIUN SKL'I CI I
1'IUN: "rypp f-/7 J Amount J_2 thi }5 Share direction and distance in miles from at (cast
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or AYcight. I t. Material numbers and common road names.
Topographic/Land setting
❑Ridge 14:Slope ❑Val lcv ❑Plat
I h cA apprapriatc hoc)
I.al itude longitude of well location
(lerrc:. nt iawc). socandsI
latitude. longitude source❑(il'S❑Topographic map
(check ha.)
DII'III DRILLING LOti
FornrtiJn D.cscript ionPmFt)
� — 3Dy_ Zz
II. DISINI`F.(
12. CASING:
From , Fo 30 Ft L 11
From_
From
13. GROUT' Depth Material Vlethod
Groin 0 To
From__ To
14. SCREEN. Depth Diameter Slot Size \Literial
From Fo Ft. in. in.
Boob_- .- Ft) It. in. in. - ---.--
15. S:\NI) GR:\\ LL PACK:
Depth Size AItnenal
E(1111 Lo L't.
I'o _ _ Ft.
fo Pt.
PVC,
16. REMARKS:
9S ;6 WV 97130h0
1 D) IIPIU Ii\" ('FRIIFY'II IA T THIS WEI.1. Vt. ;\S (l )NS IRCII LI) IN At t'ORD:\NCI( \\ITII \ N( AC '('. \YI.LI.
CONS 'IR1n I R)N STANDARDS, AND 1lIA"I ;A COPY t)I: 1I11S ILE( ORD 11.AS 13I'I N NIL()A'IUIIU Ir) 'THE WEI.1. OWNER
1.9
1 io..26 -gel
sl(iNATt Rtl' OF PERSON ('ONSIRI(.'IIN(i"rn1 WFI L D.Yn.
Submit the prig - 1 to the Division of Water Qualit). Groundwater Section, 163o NI ail Vert ice Center - Raleigh. N('
27699-1636 Phone No. [phone]. within 30 days. (1W-1 REV. 07 2001

303176
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and �41attural Resourc - Division of Water Quality - Groundwater Section
//�
WELL CONTRACTOR (INDIVIDUAL) NAM (print) �.RR I'3' I� We l / 5 CERTIFICATIONQ�# Oil#CJ
WELL CONTRACTOR COMPANY NAME ff /Ach; VV 0l1 i/ll N q PHONE # ( A &Ea' 9A
STATE WELL CONSTRUCTION PERMIT#
(if applicable) (if applicable)
ASSOCIATED WQ PERMIT#
1. WELL USE (Check Applicable Box): Residential /Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Towt
(SbtetName, Numbers, Commuoi
n'C.o/u,,n'ty' WOO
Subdivision, Lot No., Zip Code)
3. OWNER: i '1 cUt7epC . Address 14� -Th(t0(�)
)CAN--oN( NBC Nn) a 7-/6
City or Town State Zip Code
Ara code- Phone number
4. DATE DRILLED 7- r� 7 - D 5
5. TOTAL DEPTH: LIS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 6
7. STATIC WATER LEVEL Below Top of Casing: /OO 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
Topo d setting
❑Ridge 08lope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrea/minutes/aeconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in aetord et wit615A NCAC 2C .0118. // �,,/,, r'
9. YIELD (gpm): THOD F TESTCA • ry lALVer
0. WATER ZONES � r3�o
1 (depth): --�
11. DISINFECTION: Type-TP ICI ViE Amount
12. CASING: DeP�j
From 0 To (0 7 Ft.
From.... To Ft
Front__To Ft
13. GROUT: Depth Material
From To FCterck
Wall Thickness
Diameter or Weight/Ft Material
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
tax
Slot Size
in.
in.
Material
Material
o m
r.--;
r yV
LOCATION SKETCI-Z
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad names.
TDLci-e,h Cove, I�� .
a(,3L --{ol(o&J
rn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS.UCTION ST a • a S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
SIGN
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

ilk'
WELL CONSTRUCTION RECORD
North (:arolina - Department of Environment andNaturalResources - Division of Water Quality - Groundwater Section""��
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_(2 /4.s 4i LittX _ CERTIFICATION#ay/S
WELL CON" -.
CONTRACTOR COMPANY NA67F, t"�retne. ZroS Vt/Gtt -t P4n1� , alp,c_ PHONE # (ge (o qk-a/70
SPATE WELL CONSTRUCTION PERMIT#,_.._ _ / 4,6
(if applicable) - - 1' —ASSOCIATED WO PERMIT#
(if applicable)
WELL. USE (Check Applicable Box): Residential! Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATION:
Near sl Towu:_)�.as County.
�,�) De Ln"
(Street Nam
t9�a3-be.bisa,
e. N
umber. , Coin mnity, Subdivision, lot No., Zip ( ode)
3. OWNER:
Address _I_14 3 p t`tij 'R
(Slrttt or Route No.)
N C �Y% ( t
City or Iowa State Lip ('ode
Area code- Phone number
4. DATE DRILLED j[j-- 8
5. TOTAL DEPTH:
58
(:. ! OE!.; IUIII I R,' P1 A('I. I:XIS*! (i WELL., VI,C 1Li *it r(d
7. STATIC WATER LEVEL Below Top of Casing: �00 FT.
(Use "1" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): (e-n METHOD OF TEST___p 1,
10. WATER ZONES (depth): . Sit SI-_j, 9 pm.--------
Topographic/Land setting,,,('
ORidge ❑Slope ❑Valley Ilyr'lat
(check appropriate box)
Latitude/longitude of well location
( degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From
/)
To
µat
585'
11. DISINFECTION: Type_ LOCATION SKETCH
12- CASING: ��— Amount Ion }W-� , Show direction and distance in miles from at lease--
Wall Thickness two State Roads or County Roads. Includt�he road
3-73
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_D To__ � Ft. n crl cy
From To -_Py�_ r_ �'rn
Ft.
Ennn To Ft.
13. GROUT: -_..-Depth Material ----
From 6,ju / 6 J Method
_.�__- To-_-o2� Ft. 15
ko
14. SCREEN: Depth Diameter Slot
r—
Slot Size Material
From To Ft. —._in.
Fromm.
To -Ft in. in.
15. SANU/(;RAVEI.PAC'K: --
Depth Size Material
From To Ft.
From ..---f o —.— Ft. —
16.REMARKS:
I DO I IERELW CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WJTI I I5A NCAC 2C, WELL.
(UNS'rRUCTIUN STANDARDS T1 IAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
`et) J .cs[p//lh, . AND
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 Na [phone], within 30 days.
GW-1 REV. 07/2001
306329

4. DATE DRILLED 9- 3 —O
5. 101AI.DEP111: 4tL '
t. IR)l S WELL REPLA(.'E EXISTING WELL? YES ❑ NO tit
7. SGCII(' WAFER LEVEL Below Top of Casing: 40 PT. - ---- ---.
N. TOP (II: CASING IS 1,1 if ITop ofCasing)it se"
a Above Land Surface*
"Top of casing terminated at/or below land surface requires a -
variance in accordance with 15A N('A(' 2( 0118.
9. YIELD((_pin) J 1/9. MtrlloD01:1 .Sr ,�
'l/ h/is _.
10. WA I ER /ONES (depth):. 2/2 — YQ.S ' IJ Z _OS '
-'_ .._._..-
_ I ,s05_ Tot.\IRON sKET(-11
I I. DISINFP(" II(N:' typo._ Hy pi Amount 10. fb J}5 Iirection and distance in miles from at least
12. CASINO: Wall Thickness two State Roads of ('ouflty Roads. Include the road
Depth Diwnctcr or Weight Fi. lituerial numbers and common road name;.
From D to 7e Pt. 6't Pv�
From
From To Ft. -
13. (iR( )lIR: Depth -hlaterial Vlathod p
Front.._Q To ,.1/Z_.. _ FLyKpµ� C'7
ro vt*i
IT S+(J
rrI c
t'tin:
in in. � c7..,..
tD OCD
Cn
NC
rat
-
From To_
1.1. St 'RI Depth Diameter Slot Size Material
Front To 1't. in.
from_... _ To _ PL _._--
I5. SAND .tGR.\\lEli PACK:
Depth Site \ lateral
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and I': oral Resources - Division of Water (duality - Groundwater Section
('EkflIll'.\IION # 241 /8
LJGAID/� p
\\'Eit.('ONIKA('lORCOMIPAN\' NAME GYeGI9t_-/3ros.�2.�R- `I Yea rate,\ . I'l1ONF:#1 6 L d8 -3i v0
4o.Z__--_-.\SSOCIA l'F I) \v( PER\MI'I'p -.... _
(if applicable)
\HELL. (ONTRACTOR (INDIVIDll AL) N NMI: (print)
STATE E WELL (ONSI RUC iON PERMEI'N
lit applicable)
1. WELL l�Sli (('heck Applicable 13os): Residential I]x. Municipal Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Ileac Pump Water Injection 0 Other 0 It' Other, List l sr
2. W I;LI, LO(-A I'LON: "
Nearest l own: LL(u /, 4../4i (onnty
(((reel Name, Nu ers.(('ol,lulunin-. Suhti,ismn. I of Na_ Lip yodel -_-
3. OWNL12:
Address /.SD
rn
1,1) r IDO
.-Area code- Phunc number
cr r, Yla2 Y. 'Sore Cn.5
n Route No
A/C al 7S- /
Slate p zip Cod:
Toput'Iaphic-Land setting
❑Ridge j,Slope ❑Valley ❑Elat
(cheek appropriate box)
Latitude_ longitude or wall location
decree, nunutes.seonds
Latitude. loneiwde .Source:❑UPS❑Topographic map
(check bets)
DI-.P TII DRILLING 1.0(i
Twill To Fonnation Description
0 74
74 ' 4.5' ,Zti+�At M•.�i
From -To Ft.
From.
16. REMARKS:
DO 111121i1(1 (IiRTRV 'CI IA'I''IlI1S \kT.11- \VAS CONS IRI It I) IN ACCORD .\N(h \\Rll l I>.\ N(.\( "_`(', Wt'..I.I.
CONS 112U(TION STANDARDS. AND 111A 1 .A (()I'); t )I II II,S,Rht ORI) I IAS RF.1 N I'RDAIIMD la) II II. RTI.I. t)AVNI IL
SI(iN,V Ft 1121- OF PF12SUN ('t)NSfRI'.0 I IN( i lIII -AAP.1 I_ D.AII.
Submit the original to the Division of Rater Quality, Groundwater Section. 163n .\Tail Ser\ ice ('enter - Raleigh. NC
27699-1636 Phone No. [phone]. within 30 days. (iW-1 REV. 07 2001

(
Area code- Phone number �//
4. DATE DRILLED S - �D `aY-
5. TOTAL DFPTII: 3 t/SI
AIH I'�AILa ln,;'I A(1,I.vIIINI(:u,I..11') b'LSLI h'I)bd
7. STATIC WATER LEVEL Below Top of Casing: a D FT.
(Use "+" if Above Top of Casing)
R. 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): 3D METIIODO_FTEST d hrS .
10. WATER ZONES (depth): 3DS r - _3.251
3034'71
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na al Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME. (print) C ..q.%L, D U V R L o CERTIFICATION # ../.351/
WELL CONTRACTOR COMPANY NAME Grre_ ne.y Nasal
- (,Dail -I Pumps IRC.P1IONE # fR-tl aTg.'3/1
45
STATE: WKIA, CONSTRUCTION PERMIT# ) 4 02 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WEI.I. USE (Check Applicable Box): Residential 11. Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Beat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATJ'IO11.''.
Nearc,T�o n:LJJ( 2FS v I / /t County
i'G I) n r►C T-6-4 d - /34 IS
(Street Name, Numhyts, Community, Subdivision, Lot No.. Zip Code)
3. OWNER:__
Address I4'S %amrltk-t..l 12tLLQQ.
(Street or,Route No.) e �� !b�
te ne,vl /le, I'J
('ity or �Iwn
eState Zip Code
1 I. DISINFECTION: Type /-f 'T'/
12. CASING:
Depth Diameter
From CO To 1 09 Ft. Lc ' I
From To Ft.
From To Ft.
13. ()KOUT: Depth Material Method
From 0 To-.20 Ft eoannn.„c' jt�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount (v3 +hj}5
Wall Thickness
or Weight/Ft. Material
PVC
I6.REMARKS:
Topographic/Land settin
❑Ridge ❑Slope ❑Valley
(check appropriate box)
Latitude/longitude of well location
la
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
r� Ib9' CPA .
I D9345'
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
IS:6 WV 92 130 h0
I DO 11ERE13Y CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A C`LrF' OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
� J J YBitcl .A /D - 2 / - 4
SIGNATURE OF PERSON CONSTRUCTING TILE 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

9
10. WATER ZONES (depth): 736' - ,8 a pen,
tti5
�a4
11. DISINFECTION: Type HTH
12. CASING:
Depth Diameter
From__-Q_ To aG Ft. /,, It
From To Ft.
From To Ft.
13. GROUT: Depth Material
From__ a _ To_ Ft, ltrapALI-
From To Ft.
14. S('It EEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To - Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalatResourcesyy.- Division,/�of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME � (print) S�1 at CLAJC R.A.LL CERTIFICATION #.36p`1
wtu.1. CONTRACTOR COMPANY NAME &Lt'_ent/ /a♦rts /I JI Y 1. a _. PHONE # (g g L g- 3 1 7 0
STATE WELT. CONSTRUCTION PERMED/ L 4404 ASSOCIATED WQ PERMIT#
(if applicable) (ifapplicable)
303472
1
WE.1.l. USE (Check Applicable Box): Residential g Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Ileat Purnp Water Injection ❑ Other 0 If Other, List Use
2. WELL, LOCATION.
Near 'st To _. ./l County
iladrnoetet
rs, Community, Subdi
3. OWNER: t tlf
Address
nn -rStreet or Route No.) / /
`✓ C .28 7 / C.
City or Town Stute Zip Code
( 1 _
Aura code- Phone number
4. DATE DRILLED 4- /6 -�
5. TOTAL, DEPTH: 74S
:)Ot-..; 11/I..t l RiiP! Ar'P HY. N. 11 nlr: UAgH1,1 o YL:S 1 1 '1') S.
7. STATIC WATER LEVEL Below Top of Casing: /20 FT.
(Use "+" if Above Top of Casing)
5. TOP OF CASING IS / FT. Above Land Surface'
*'I op of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
YIELD (MIDI _�_ METHOD OF TEST Q{ A r5
Topo aphic/Land setting
❑Ridge ,&$lope DValley ❑Flat
cheek appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
.94 . Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
aZ.
a� 74 5'
LOCATION SKETCH
Amount J 3 g -- ti 14s Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
,thod
From To Ft.
From To Ft.
16. REMARKS:
'IS:6 WV 9Z130h0
I DO IIERF.BY CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
('ONSSTR(1(I ION STANDARDS, AND THAT A COP OF THIS RECORD I{AS BEEN PROVIDED TO THE WELL OWNER
kee-A2__ze
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural \\ElI. Resources- Division ul Water Quality
(CONTRACTOR (INDIVIDUAL) NAME (print) ' l0 i 1`1 r/'.) Ea
13
\\ELI. CONTRACTOR COMPANY N:\MIarcene arGS. 1 et bb_ 4 PUNT% .
STATE w'EI.t. CONSTRUCTION PE.RM1'1'N _/4,L)2 ASSO('I:V11:D WO PER\Itrk
lit applicable) _ ( ifapplicahle)
- liroundwater Section
t ERI'IEI( _VI'ION t? a Ai/ g
r1u)NE S��8 ice
_V 7
C
1. WALL l ISE'. (Check Applicable Box): Residcutial)k Vmicipal. Puhlie 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Eleat Pump Water Injection 0 Other ❑ II Other, List Ilse
Topographic/Land setting
❑Ridge 4Slope CB/alley ❑flat
Khed approprium box)
Latitude longitude of well location
2. WELL LO('AllO
e est'1't) tI _ ('aunty
(bocci Nome. Nun ors. Community. Subdn imon. Lot No.. tip
3. OWNER: L%/ 'I!.
V
Address 8 « c
_ (Street or Rifat ( In uil 'Stale llp I. ode (O
:\rca code- Pheat number
4. DAt E DRILLED 81-PP -0 V
5. T(rrAL. DEPTH: ADC '
::. DUES WELL REPLACE EXISTING WELL' YES 0 NO 4.
7. ST:AIIC WAFER LEVEL. Below Fop of Casing: Lib ET.
1I Sc -' - If :thine loop of Casing,
8_ TOP OE CASING IS ET. Above Land Surface*
"moot' rasing terminated at/or below land surface requires a
variance in accordancewith 15A N('A(' 2C .0118.
9. Y'ILI.D(gpm): 46 METIIODOF1'ES1 J r4
10. WATER ZONES (depth): Q 85 ' y0 9 prn _.
I1_ DISINEP.('IION:'Ivpe__4T� :Amount Sfr+blh-
12_. CASING: Wall Thickness
/� Depth
Diameter or Weight. R_ Material
Beal _�/ to `Y' let. �n 't - -- —��
lium . _._ To_
Front To Et.
13. GRUNT: Depth Material Aiehod
From D To Dr) H. — _t--
Prom _ To Pt._
14. 5(REl-.N1 Depth Diameter Slot Site \laierial
From To let. _ in. in.
From _ to Ft.__. in. _ ____ in.
15. SAND (GRAVEL. PACK:
Uopth Site \laterial
Trent 'TO Pt.
From---_ _Io
idcprces minutes sccnnds)
Latitude. longitude source:❑(IPS❑Topographic map
(cheek hurl
DI-. PTt1 DRILLING 1.00
from 1'4) Formation
r
Q 413 )
4f3' 10_5'
LOl'_AIION SKI::EC'11
Shovy direction and distance in miles from at least
t\co Sidle Roads or l 'ouity Roads. Include the road
numbers and common road mantes. _.
tS:6 HY 9Z130h0
16. RIAIARKS:
1 DO I IE.RP.BY CE:RIIFA' THAT II Its \AT.LI. WAS ('UNS FRUITED IN AC C URD AMoll AVI ITII I -_A Nl A( 2C. AVI.I.I.
CONS'IRI!CIION SIA 'DARDS. AND I IIA'1 PA OF nits RFACURD TEAS Bf I'N PROA IDI:I) TIIE WELL OWNER
) ,% /tl -.z/ - a 1
S IONAEYRF(u' PERSON CONS I REV' PSG nu \ EI 1. DYtll
Submit Ile Original to the Division of Water Qualit\, Groundwater Section, 1630 .Nail St r' ice Center OW -I RCA eig. ls '_0O I
27699-1636 Phone No. [phone]. within 31) da)s.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural)Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL) NAME (print) PSLu D P,r l J 4.11CERTIFICATION# 33.3 ci
WELL CONTRACTOR COMPANY NAME 13.X.!_zy. 1Zr'� E L.ai,ait .4- Punp Apc. ,PHONE # (OAR 6, dig- 5 J r%
STATE WELL CONSTRUCTION PERMIT# 14 b a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential . Municipal/Public O Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest.TownL� k County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
Topa phic/Land setting
❑Ridge Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
3. OWNER:S -eV, vMr ck'/ r -» a aus:I0.p cc O r ia NC (degrees/minutes/seconds)
Address 3cr.p p r i 1--No 11 v-43 Rci . Latitude/longitude source:OGPSOTopographic map
(Street or Roue o.) (check box)
CL A (�' i G % 1 a DEPTH DRILLING LOG
City or Town sate Zip Code From To Formation Description
( )- n 7 I 'Area code- Phone number
4. DATE DRILLED 1 - a `b - b q
5. TOTAL DEPTH: 1 Lc _Ta r
6. DOES WELL REPLACE EXISTING WELL? YES O NO it
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): ,21) METHOD OF TEST .2 krc .
10. WATER ZONES (depth): i 25 1 - 130 `
'1 1
i Lo s' tiYsn a. s Y L
LOCATION SKETCH
11. DISINFECTION: Type 1-1 T i-1 Amount blq +61 }S Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From b To 71 Ft. % II Pk/(`L
From To Ft.
From To Ft. O a'`_
13. GROUT: Depth Material Method o -nrr
From To 'Q D Ft. CittAn va_ 'a-p.p -4 XL
From To Ft. r .eni
14. SCREEN: Depth Diameter Slot Size Material Ol =
From To Ft. in. in. Oc
rnri
From To Ft. in. in. 3 c-3_w:
15. SAND/GRAVEL PACK: ~^
a
Depth Size Material mcw
From To Ft. g22,
From To Ft. c-:
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION ST NDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and /ryNlatural Resources` - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME0� (print) l r ern 1 mil` , J 1 Z.f(ixnc)t-nQ+ CERTIFICATION #3 iga.
WELL CONTRACTOR COMPANY NAME J6rdrtR➢ ara 1 rt-S J i...111 v1 lkWw.p Le PHONE # eat Lo
STATE WELL CONSTRUCTION PERMIT# j T ha ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable)
1. WELL USE (Check Applicable Box): Residentiath Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: C .ru.So County
I-1 �rlto �!'��
(Street Name, Numbberrs,`Rommunity, Subdivision, Lot No., Zip Code)
3. OWNER: S orra k (Yl t r, k. 0i1
Address 4 2 ToL,c, t n .
(Street or Route No.)
(1 (1. A-t-k 1 N C of %') to
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 8 - 1 e] - D ti-
5. TOTAL DEPTH: .34 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO tit
7. STATIC WATER LEVEL Below Top of Casing: 2b 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 ith 15A NCAC 2C .0118.
9. YIELD (gpm)• METHOD OF TEST a2 Ls
10. WATER ZONES (depth):
3aS 1- 4ciprr,
11. DISINFECTION: Type f-} T 4-1
12. CASING:
Depth
From 0 To 414 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From. To go Ft. iov
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
Diameter
L0 it
Topographic/Land setting
DRidge ['Slope OValley '%Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
44' 34s,
LOCATION SKETCH
Amount (0 3 +61 f. Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
PVr.
From To Ft.
From To Ft.
LS:6 WV 9Z13o110
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/d-/3=d41
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-1Division of Water Quality - Groundwater Section`' C'
WELL CONTRACTOR (INDIVIDUAL) NAMEn(print)—RI, L rx P.1� O I� A CERTIFICATION /# 2 9 / b
WELL CONTRACTOR COMPANY NAME Sc 1'*P rte. NYCfv , I l �i y YwN4 �yl+C PHONE # (fin ,iq - 3 7D
STATE WELL CONSTRUCTION PERMIT# J 'U e Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential* Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
NearpstTown: /Da,,j frW�5V11 fPCounty�. Od
C� retn V n 4 D_e ," 2�
(Street Name, Numbers, Community, S1�t6a1,ivision, Lot No., Zip1Code)
3. OWNER: M0. r Har+5 Il
Address 1 09 S u-, 41ts �v s IM -
(Street or Route No.) _ t
LJ Casa ne,svt')P Nc. sari86
City own State t Zip Code
( )-
Area code- Phone number
4. DATE DRILLED '% - / 5i - D11
5. TOTAL DEPTH: 3842,5
6. DOES WELL REPLACE EXISTING WELLS YES 0 NO of
7. STATIC WATER LEVEL Below Top of Casing: 'VC) FT
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): .5- METHOD OF TEST a k rs •
10. WATER ZONES (depth): 3+/S ' � .5-2PM
Topographic/Land setting
❑Ridge ❑Slope OValley'Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
o 4/a '
3L5 1 Jc t1 ,✓
11. DISINFECTION: Type 147j-I Amount J.,ry 44.14s
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To 14 a Ft b i t
From To Ft.
From To Ft.
13. GROUT: Depth Material
From C3 To in Ft. CG,v,...0.4
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.
Pyr.
Method
t5
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAN]�DARDS, AND THAT A COPY OF THI�„),tECORD HAS BEEN PROVIDED TO THE WELL OWNER
/S
./
/O - o `i
DATE
Y) J )'1kLLttt
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) -RD U I n L . D IN N, CERTIFICATION # a Li /t'
a
WELL CONTRACTOR COMPANY NAMEG rep rl.-1Krc:,- LZ)Lll `1 itlry p.%Ste . PHONE#( In-lr -a 111:5
STATE WELL CONSTRUCTION PERMIT# 1 4b a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATown: II
Near t Town: Countyt=%C.
A.L. of
(Street Name, Numbers, Comnignity, Subdivision, Lot No., Zip Code)
3. OWNER: 8 6 Lei LtJt 16 a,tl
Address 3.-'1 -Da; s )-i-t 1 1 PA .
(Street or Route No.)
en. NC 02%1 an
City or Town Star& Zip Code
( )-
Area code- Phone number
4. DATE DRILLED $ -, q -04
5. TOTAL DEPTH: 1 2 5 '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /AO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accord ace with ISA NCAC 2C .0118. ^ LL
9 YIELD (gpm): 15 METHOD OF TEST oC n rS
10. WATER ZONES (depth): I OS L 1 `i it pr..
11. DISINFECTION: Type I-4 -n-1 Amount 2 +1.1;s
12. CASING:
Depth
From To 11) Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
Fromm To aD Ft. -4-cry.
From From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Diameter
tf
Topographic/Land setting
❑Ridge ❑Slope OValley Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
n n -
DEPTH
From To
D '7Df
71>1
LOCATION SKETCH
Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
P 1/C
LS:6 WV 9Z130hQ
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DJ
.it L--
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

From To Ft 4 /30t� /
From To Ft
14. GROUT:
Depth .1 Material Method
From n To 020 Ft J o^'aB^'t—
From Tb Ft
15. SCREEN:
Depth Diameter Slot Size Material
From - To Ft in in
From To Ft __._ in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
North Carolina • Department ol Environment and Natural Resources . Division of Water Oualiry . Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone] D//
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JA�"CP w'e///Q viye'/�
WELL CONTRACTOR CERTIFICATION ft: e,y/I L/� 1 y.
STATE WELL CONSTRUCTION PERMIT'S:
306364
1. WELL USE (Check Applicable Box): Residential L"J Municipal ❑ Industrial ❑ Recovery ❑ Heat Pump Water Injection
❑ Other ❑ II Other, List Use:
2. WELL LOCATIO(S ow ske( of the location below) `/ %
Nearest Town: C- M4SV e County: j'Lrd,OpO�
WTq ���yj�,(
(Road me :and tub^er�s Community of Su vision and Lot Nu) DRILLING LOG
3 . OWNER /V AT -/ ' en n /,V&
Address `/ iin n i e2f C- From To
1:I li (Shoot o Ar oM
try or Town �-1 Stat Vg- -Va—;rZip Code - OC
4, DATE DRILLED CR-c2 -O .,,,/
5. TOT-. ---- .
6. CUTTINGS COLLECTED YES[1 NOD
7. DOES WELL REPLACE EXISTING WELL? YES ED NO
8. STATIC WATER LEVEL Below Top of Casing: 9 3 FT.
9. TOP OF CASING IS a (Use': i1 Above Top ol Casing)
FT Above Land Surface'
'Top of casing terminated aUor below land surface requires a variance In accor-
d
ance with I5A NCAC 2C le
10. YIELD (gpm): 0 METHOD OF TEST /4// __
11. WATER ZONES (depth):
12. CHLORINATION: Type /777/ Amount
13. CASING:
Agricultural ❑
Monitoring ❑
DEPTH
II additional sgace is needed use back of form
Depth 'ff Wall Thickness LOCATION SKETCH
From 'fa To �� Ft
/QJai y or Weight/FL nal (Show direction and distance from at leas) two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
Serial No.

AgD
�eAY
Town:
ame Nurnow. Community?,or Subdivision and Lot No.)
3. OWNER eat/ r eq/er
Address 7a ? : i) f 0� p- ;d .
reel o ri of
Ev c " /(n
From Tb Ft
15. SCREEN:
C4A1 o4
CiN w Town Stq�y�. C1,_ 4 • C C IL f BP Code
4. DATE DRILLED (" "s
5. TOTAL DEPTH
6. CUTTINGS COLLECTED- YES 9 NO
7. DOES WELL REPLACE EXISTING WELL? YES o NOE1
B. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use •: 'Above Top of Casing)
9. TOP OF CASING IS 0( FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires • valance In accor-
dance with 1SA NCAC 2C 41111
10. YIELD (gpm): 0l0 METHOD OF TEST /t}+r (31
11. WATER ZONES (depth): 12. CHLORINATION: ,Type Aire/ Amount
13. CASING: -
- North Carolina • Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Schnee Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. Pr (.. LOP lig ��rI'�O•
WELL CONTRACTOR CERTIFICATION Si: , ry k,s4i ,/e_ # rjr
STATE WELL CONSTRUCTION PERMITS:
306366
1. WELL USE (Check Applicable Boa): Residential Er Municipal 0 Industrial ❑
Recovery 0 Heat Pump Water Injection ❑ Other CI If Other, List Use:
2. WELL LOCATIOp: (Show sketch of the Location below) /
trifle County:04.2/2 ✓
Agricultural 0 Monitoring 0
DRILLING LOG
' From To
DEPTH
If additional space is needed use backot form
Way Thickness LOCATION SKETCH
f Depth �' r or W t. kta dal (Show direction and distance from al least two Stale
From To Ft h ' ' v- vYCt/ Roads, or other map reference points)
From To Ft
From To Ft ' .31$ r1
(A
14. GROUT: r_
0 Depth., Material Method
From To FL /pi stair jL
ci
Depth Diameter Slot Size Material
From To Ft _ in. _ in.
From To _ Ft In in
From _ To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DieWon of Water Ouamy. Groundwater Section within 30 days
GWt REV. 12r99
FOfi OFFICE USE ONLY
Ouad No:
Sedal'No.

fv
North Carolina • Depanmenl of Environment and Natural Resources • Division of Water Oualiy - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1976P Wee 9f/4` ric,
WELL CONTRACTOR CERTIFICATION #:4.' >t i414VrayQ r 61,
STATE WELL CONSTRUCTION PERMIT#:
306367
1. WELL USE (Check Applicable Box): Residential t Municipal ❑ Industrial ❑•
Agricultural 0 Monitoring CIRecove
Recovery 0 Heal Pump Water Injection 0 Other 0 If Other, List Use:
2. WELL LOCATIQy: (Show sketch of the location below) /
Nearest Town•(-1,Y County: '9y�f%OF-,I/
arre//s Cr 3ve- 227
(Road Name a rs, ommuniy, or Subdivision and Lot No.)
3. OWNER 1_ r (e•
Address sD//�
DRILLING LOG
, From To
v
Clyne (tractor aid a�. 02f?a)
City wILLE Town // ? /.'9f-7 Zip Coda
4, DATE DRILLED car t�'77''
5. TOTAL DEPTH
6. CUTTINGS COLLECTED- YES O NOD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE(
8. STATIC WATER LEVEL Below Top of Casing: /S— FT.
(Use •. MOWS• MOWSTop of Casing) -
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C .011S
10. YIELD (gpm): .. f METHOD OF TEST / 1)-
11. WATER ZONES (depth).
t2. CHLORINATION: .Type /i7 Amount
13. CASING: -
•
From /�
From
From
14. GROUT:
From 0
From
15. SCREEN:
Depth rD
To
To
To
Ft.
Ft.
Ft
Was Thickness
y or wggpigt.371;joial
Depth Material Method
To °ZD Ft C F^r� ✓T
7b Ft.
Depth Diameter Slot Size Material
From To Ft _ in. in.
From To _ Ft.— in. in
From To Ft.in. in.
16. SAND/GRAVEL PACK:
Depth
To
From Ft
From To Ft.
17. REMARKS:
Size Material
DEPTH
11 additional space is needed use back of form -
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads. or other map reference points)
4/513
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Ia
e.
SIGNATURE
SOF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water ouallty. Groom:W ater Section within 30 days
GW 1 REV. 12/99
FOfi OFFICE USE ONLY
quad No:
Serial No.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and atura Resources - Division or Water Quality - Groundwater Section
-_-- /*WELTCONRACIQlt(INDIVIDUAL) NAME rho)) IhLAI_ u,ape- CERTIFICATION aJl/WELL (ONIIu r)a COMPANY NAME /ce..//^,'eI('c %imp PHONE it SAp•ry,g3yig
srA•re we(.i, caNs'ruccrloN retMrra
I ifapplicablc) _-
A,S.ioc,,vrEn WQ PARMI•re
era 'cable)
3'05509
I. WELL USE (Check Applicable Box): Residential Fi Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring 0 Recovery 0 Heal Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATl_ C)}l:
V�/
west 'fouat:1L
/‘)GM/.N
(Street Nanic. Numbers. Community. Subdivision, tan No.. Zip Code,
3. OWNER:
Address
County
rl'oqrroll
ISin:et a ltouw No., -7 e&once/ 4/, Ag733
City, awn talc Zip Code
Arca code- Phone number/
4. DATE DRILLED // -741 OY
5. TOTAL DEPTH: 5.05 4--}
6. DOES WELL REI'LACE EXISTING WELL? YES Q NO
7. STATIC WATER LEVEL Below Top of Casing: 3 IT.
^'1 (usc'v" if Above'npr of Casing)
R. TOP OF CASING IS OC IT. Above Land Surface*
*Top M easing terminated at/er below laud surface requires a
variance in aceordan jewith I SA NCAC 2C .0118.
9. YIELD (gout): 11L METHOD OF TEST it, r
10. WATER ZONES (depth):
Topographic/Land setting
tdge OSlope ❑Valley Dial
(check appropriate box)
I.at iludc/longitude or well location
(dcgrecs/ttnutes/snalluka
La(itude/longilutic source:❑GI'S❑Topographic map
(check box)
DEPTH . DRILLING LOG
i.(alio Description
v
rn
I I. DISINFECTION: Type
Amount Show f% LOCATION SKETCH pp
T direction and distance in miles from ;am
12. CASING: Wall Thickness . two State Roads or County Roads. Include the road
From tt. Ihplh Dian rie or Wei t it/FI. "renal nun bers and common road names.
Front To Ft.
Prom To • FL old 11- 2 3
13. OROUT- Depth Material( Method
From 0 To ` (0 I•'t.C[' ' e
From To FL
14. SCREEN: Depth Diameter Slot Size Material
From___ To PI in. in.
nom To Fi. in. ;IL
15. SAND/GRAVEL PACK:
Depth Sire Material
From To I .
From To Ft.
In. REMARKS:
I DO HERL•'13Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TI-IAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
I -10 (kl
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. 07/200I

WELL CONSTRUCTION RECORD
North Carolina - Department of Euvironnient and Natural Rcso fees - ivision oT Water Quality - Groundwater Section
7
WELL CON'i R.ACfOR (INDIVIDUAL.) NAME Nut A7tt,/ �J
CERTIFICATION a¢,,/6�
/
%%
)''�� "// I:1.1. CON RACrOR (COMPANY NA\1E /�.Q Wr.47-� //--�� --_—__ 1'l1ONE a L T�[7 VSS
stATE wyt.t. coNSTnrc Tios mini ra
ASSOCIATED w(? reRau7 a
(if applirihiel (if applicable)
I. WELL USE (Check Applicable Box): Residential li Municipal/public 0 Industrial ❑ Agricultural Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
N tress To)vn: ✓re County,
lStreet Name. Nundh rs. ('ommmmily. Subdivision, lad No.. %Jp C,del
3. OWNER:
Address
'�,,.�/�t
t,,Srceet tyf�ltouiteN,o.J
a `'//(� .�y,J, , 1 ,s
Topographic/Land l@Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
blegnros/minutes/seconds)
Latitude/longitude sourer.❑GPS❑Topographic map
(check box)
DEPTH . DRILLING LOG
Coy m'rox•ns MateI Zip Cock :
From To F' m ltot escription
Aren code- Pbone ntmlha .
4. DATE DRILLEu 9-O
5. TOTAL DEPTH: / 2,fi
6. DOES WELL REPLACE EXISTING WELL? YES El NO
7. STATIC WATER I.EVEJ. Below Top creasing: rr.
Oise "t" if Above Top of Casing)
8. TOI' OF CASING IS C--7 ET. Above Land Surfaces
*Top of easing terminated at/or below land surface requires a
variance in nceurdanepg.ytiDi 15A NCAC 2C All It
9. YIELD (pm): ,,,;:eu METHOD OF TEST Jg' f
10. WATER ZONES (depth):
/ram Y
1e
I I. DISINFECTION: Type TT LOCATION SKETCH
YI Amount • Show direction and distance in miles from at least
12. CASING: - Wall Thickness . two State Roads or County Roads. Include the road
'] Depth
From hoc '1'o„ _ Iiariy lyr orW it/Ft. M Icrial/ numbers and common road names.
FL (9'/y /
From From To FL _ ' ? /31 To Ft. �'j
13. GROUT: Depa Material. Method '
from TO Ft.LC("zhw,t
From To Et. p G1
Id. SCREEN: Depth Diameter SI Si a
1
From To Irl. in. in.
F9-1
From To F1 in. ill.
15. SAND/GRAVEL FACK: O F:
Depth Size Material
From To Ft. DEC 2 k' .2V4t
From To Ft.
apc
305541
16. REMARKS:
1 IX) HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sulmdl the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Censer - Raleigh, NC
27699-1 ,36 I'hnne No. [phone], within 30 days.
GW-1 REV.07/2001

- North Carohna • Depanment of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh. N.C. 27699.1636-Plane [phone] .gn /J
WELL CONSTRUCTION RECORD WELL CONTRACTOR: / �r WP/( i�aI'f'%,//O•, 'f
WELL CONTRACTOR CERTIFICATION %: K['r� J 4 eter2 a
STATE WELL CONSTRUCTION PERMIT%:
1. WELL USE (Check Appik:abla Bong Residential tr1 Municipal ❑ Industrial ❑ ' Agricultural ❑ Monitori•
ng 0
Recovery 0 Heat Pump Water Injection Other El If Other, List Use:
/
2. WELL LOCATIO
N/e�ar1st Town: �J
Fes' i�N S PP_
(Road Name Numbers. mmuniry, or SubdMsian and Lot No.) DRILLING LOG
3. OWNER Name
tofos
Address From To
i7 1 /if 49vt✓ n /O
e pw ,i, ' d�Ta, ,� 3
Iy o Town yd—ate gdg- 647..0 °
5. TOTALDATA DEPTDa` � ,
4.551
5. DEPTH
6. CUTTINGS COLLECTED- YES 0 NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOE
8. STATIC WATER LEVEL Below Top of Casing: 6,3 FT.
„AN (Llse 't*il Above Top al 9. TOP OF CASING 1S FT. Above Land Surface')
'Top of casing terminated et/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C .o)1a
10. YIELD (gpm) / METHOD OF TEST 4!�
11. WATER ZONES (depth):
12. CHLORINATION: ,Type r Amount It additional space is needed use back of lorm
13. CASING: -
vesketch o1 the location below) /
H County: L*o17'
-51
305591
DEPTH
•
5-
. WM Thickness LOCATION SKETCH
From �� Depth
p! % or Weight/FL {// lerfal . (Show direction and distance from at least Iwo State
F. ` j/� - Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depth, /, Material Method
From 0 To !� Ft: J Z'•MPev7L
From To Fi
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in in.
From .__ To Ft. in. in.
From _ To Ft..__ in in.
16. SAND/GRAVEL PACK:
Depth
From To
From To Ft
17. REMARKS:
Size Material
Ft
e
rn
c»
8
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No:
Senat'No.
ls
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division ot water Maley. Groundwater Section within 30 days
GWI REV. 12/99

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/atResources - /D/]iivision of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL) NAME (print) !2LhLtLu1 /.�+ttl Li CERTIFICATION # .3U �//
WELL CONTRACTOR COMPANY NAME Ala £kt41 aka 91 Paint_ 4Ae . PHONE # 9-2q I, SAS(- 3
STATE WELL CONSTRUCTION PERMIT# /di 6 s- ASSOCIATED WQ PERMIT#
(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
2. WELL LOCATION :
Nearest Town: b n e.ii. / /c. County
(Street Name, Numbers, Commum , Subdivision, Lot No., Zip Code)
3. OWNER: m41,, Trnher S+r 4ti-ts, t,..l,C
Address J 630 E. ubf+3 n
(Street or Route No.)
ta vA r ,'cleff ITN 3 ill a
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED tp - a 3 -04
5. TOTAL DEPTH: qDSI
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: .3 DO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 9 METHOD OF TEST c2 h rs
10. WATER ZONES (depth): 251 - ij 20 pm
11. DISINFECTION: Type
12. CASING:
Topographic/Land setting
Midge ❑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
37 ' /4a.e4
37 90s1 .,... t..
$35 ' - / , 4 Pen $L'" - Q p n' LOCATION SKETCH
I-1 TN Amount a Show direction and distance in miles from at least
Depth
From 0 To 3 7 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From o To SO
Ft.
Material
C
Wall Thickness two State Roads or County Roads. Include the road
Diameter or Weight/Ft. Material numbers and common road names.
1 f P UC,
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
4p
Slot Size Material
in.
in.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ted
a..L
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

(Sheet Nanieeumbers, Community, Suhdirlson. Let No.. Lip Code)
3. OWN P.I(: cZ I \--�7 __._
AddressJ.:if -.. sze-kppyr _ Crt.
(Street of Route No-) p J
Vic( [ tys�d (J�taR /(!P op ( e St �o
tll_ ,I lotin State/ Lip(\+de
:\rca code- 'Inc(onnumber
4. DAI'E. DRILLED 4"-a') - °C/
5. TOTAI. DIVA(: 05'
E. DUES WELL REPLACE EXISTING Veld.. ! YES 0 NO
7. Sl;\ll('WA[ER LEVEL 13elove Top of('asine: ,b FT.
((Ise- ir,Abo e top id Casingl
S. TOP OI: (ASING IS _ _�. E'I'. Above Land Surfitce`*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A N('A(' 2C .0118.
9- YIELD (gpui: ! 0/2 METHOD OF TrsT y7 ArS
10. WATER ZONES (depth): - 4d5 '
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME (print) Gerald_ St Le rpm. rt ^ CERTIFICATION 3...///�� a
\\'F:LL('ON'IR.\('l'OR ('O\IA\NVN:\\IFaSr c-c y)t �ros - �e9 ► 4Pa,F�p, PIIONE # ( )
SI'A'1'E\\'E1.1. CONSTRUCTION FERMI'('# 1 tDZ ASSOCIATED 1\O PERMIT# -
(if applicable)
(if applicable)
303493
1. WELL l ISI` (Check Applicable Boil: Residential 15"Municipal Public 0 Industrial 0 \grieultural 0
Monitoring 0 Recovery ❑ Hem Pump Water Injection 0 Other 0 If Other, List t Ise
2. WIIL1. LOCATION: Topuu-aphiciLand setting
Nearest 'down! nesi Llc.---County_ jaz ❑Rid_e 'lope ❑Valley ❑llat
(check approprmle bo\)
I.alitudelongitude of 'yell location
fie. rS _.1 I QIiicd. nuuute mdst
Jab latin, k longitude sv a ce:❑( iPS❑Topographic nap
ch k host
DE .PI'(I DRILLING 1 l)G
From 1 o Fot)r� tyyn) Description
0 / 2 / ' �cl Q_
8/ ' Sa 5'
— _.. l Jn pricey- .
I,OC:A II(N SKI `IYl1
1 I . DI 11'll 1 CTION: Type_ 1'1 :Amount 9_2 fh/%Nhou direction and Jislmcc in miles from at head
12- CASING: \\"all I hickncss two State (toads or bounty Roads. Include the road
Depth l)i;uneter or Weight Pt- \I: serial numbers and common road names.
From__ to I 8 1 Ft. 4 it35
„ D
Front— ---- f°-- --- - ht"
From To Ft. _ o o-:.:
r c«,
13. (iRU( IT: Depth Material Method
tram a to QC I-t.�„yhmr,.t, 10 r ;acti From To -_. I't._ _ r N -
Ll. S('RI'-. EN: Depth Diameter Slot Site --- V lateri;d O'1 w
O�
From To Pt. in. in. --(.—
Mill
nm_
-t-o
o--,
z0
n0
rm
t7
From_.. I oFt. in. -
in.
15 SAND GIL:\V[I, PACK: --
Depth Site Material
Franc I)
Prop)..
Iv. RI[\IARKS:
99:6
I I)O I1FRIi1DY CFR I!FY 1'IIAI"IIIIS \\liLL- \V \S ('t)NRERC'CITII IN ACCORDANCE: \\I'll( I5.\ N('AC 2C. Wl.l.l.
C(>NS 1 RhlCIION S lANI)ARDS, AND TIIA'f :A COPY OFFI IIS [CELL A D I I:AS BFPN PROVIDED In — DE WEI.1. OAA NFR
GC /31.2_
SIJNATtIRI-OE PFI&St)N l't)NSll(1(lINtl 11 II-AAI[I I. D.A'II.
!o-..2.L
Submit the original to the Division of Water Quality, Groundwater Section, 1630 Mail Sem ice ('enter - Raleigh. NC
27699-1636 Phone No. (9191733-3221. within 30 days. (iW-1 REV. 07 21)111

STA•rE wag, CONSTRUCTION PERMrrt ASSOCIATED WQ PERiMIT#
- t ilapplicahlel (Ltpplicable)
WELL CONSTRUCTION RECORD 3 0 5 514
North Carolina - Depannlent of El wironmcnt and N• tu`rrallReso)urce; - ivision oT Water Quality - Groundwater Section
WELT. ('O.\'I RACTOR (INDIVIDUAL) NAME print) A, .. Ir L. LQ Q '//�
WE!.LCON'i'I(A(TOR (Y)\I PAM' NAM?:J19 co WeUct-Arry CERTIFICATION/!-.�J�C,'�
PHONE 0 i17/X
I. WELL USE (Check Applicable 13ox): Residential M7 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heal Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
N st Telly
heap 1
r
(Street one. Numbers. l'onlmuniiy. Subdivision, tan No.. Zip Cak)
3. OWNFlt' Y) Eit"
e'ua/Fr a4/
Cay or town Slate Zip Cale
(
Area c dc- Phone mmnhc
4. DATE DRILLED // ' 0
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL'' YES ,NO EV
7. STATIC' WATER LEVEL Below Top ofCasinc: -, J 7 Fr.(Usc ••+" if Above Top of Casing)
S. TOP OF CASING IS � Ff. Above Land Surface'
'Top of easing terminated at/or hdow land surlier requires a
variance in accords et with ISA NCAC 2C .011a.
9. YIELD (ppm): J METHOD OF TEST .C%./r
10. WATER ZONES (depth):
11. DISINFECTION: Type #7.-- Amount
12. CASING: Wall 'thickness .
Fnnn�IkMI>r_ lehUFL �tcoal
To FLrx . `ire l
Nom To Ft.
From '1'o FI.
13. GROUT' Depth Matcria) Method
From To r10 Ft ake si
From To Ft.
14. SCREEN: Depth Diameter Slot Sims: Material
From 9b Ft. in. in.
From '1'o Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From '1'o Ft.
From -fo Ft.
16. REMARKS:
�7 opographie/Land setting
tidgc OSlopc DVallcy OFlat
(check appropriate hox)
Latitude/longitude of well location
(degreeshniout xJsecunds) -
Latitude/longitude source:OGPSOTopographic map
(check hos)
DEPTH . DRILLING LOG
Front ' ry it1(yr Description
020
4.-
LOCATION SKETCH o ,
Show direction and distance in miles fronr least
Iwo Slate Roads or County Roads. Include the to;
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCI1NG THE WELL DATE
Submit the original to the Division of Wider Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV.07/200I

- North Carolina • Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Rateigb, N.C. 27699.1636-Prone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t%(
WELL CONTRACTOR CERTIFICATION E: 44,ih I00/per ,2+'67
STATE WELL CONSTRUCTION PERMUTE:
r
305513
1. WELL USE (Check Applicable arm): Residential t2 Municipal 0 Industrial ❑
Recovery 0 Heat Pump Water Injection ❑ Other I1 Other, List Use:
2. WELL LOCATION:
Nearest -town:
Cail
(Road and Ni�ls.
3. OWNER (h .4y'/j
how skekr t� of the location below) County: F1�L )0er.//
Address /37
YN)4y
City or T,(vn,
4. DATE DRILLED
5. TOTAL DEPTH _
6. CUTTINGS COLLECTED- YES O NO0
Of HOW0
ion and Lot No.)
ov
w Ec
/
stay
rip
a ��lr Ced.
7. DOES WELL REPLACE EXISTING WELL? YES E3 NOEI
B.
STATIC WATER LEVEL Below Top of Casing: (400 FT.
9. TOP OF CASING IS DC(use "t it Ab0Ye Top of Casing)
FT. Above Land Surface'
-Top or using terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C .011e
10. YIELD (Qom). / METHOD OF TEST 47r
11. WATER ZONES (depth).
12. CHLORINATION: -Type 1/7/7-
13. CASING: -
•
Amount
Agricultural ❑ Monitoring ❑
DRILLING LOG
From To Fo - tiof Description
0 /0
DEPTH
n
?ot-
a S-
O
n
It additional space is needed use back of form
Wa11Thickness LOCATION SKETCH
Depth Diameter
m
. eter or Weight/FL erfal ,r (Stow direction and distance Irom at least two Stale
From To Ft in //V t.
From To Ft.
From To Ft.
14. GROUT:
From
From
15. SCREEN:
Depth
From To Ft
From To Ft.
From _ To Ft.
16. SAND/GRAVEL PACK:
Depth
•
0
Depth]�
To
Tb
Material Method
Ft: ( P^1C "t
F1
Diameter Slot Size Material
in __ in.
in in
in in
From To Ft.
From To Ft.
17. REMARKS:
Size Material
Roads, or other map reference points)
1 DO HEREBY CLFITIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF iSON CONSTRUCTING THE WELL DATE
Submit original to division or water Ovary. Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
Sedai No.
GW1 REV. 12/99

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resour - s - Di, ision of` Water Quality
WE1.1. (ON RA('TOR (INDIVIDUAL) NAME (print! �e GAP LAN.LAN.c ``
W E I.!. CONTRACTOR COMPANY NAMEar e_rre,_ MrOS . l4.l�l -N 9( yi )4"`-
Sl'n'I'E: \V ELL CONSTRUCTION PERMI r# ____ i q O . __----.\SS(U I. I ED WQ rl:RNII ttt
(if applicable} (it appbcabiel
- Groundwater Section
CERTIFIC.\[ION N 33.5 )
i'IlONE N 8QW 4 Le t - 3) 1 b
I. WI'.L1, 11 SIi (('heck Applicable Box): Residential Al Munieipal Public 0 Industrial 0 \gricultural ❑
Monitoring 0 Recovery ❑ heat Pump Water Injection 0 Other 0 If Other, List t se
2. WELL I. I O(':A7ION.
�� ` ,
Nearest Town:��/C14� dC Vitt County N ,.{� .
Lo+ l b1 U i. bt1 _ 1ago4_,
!sue. 'Name. Nuothers. mununity. Subdin 1,nnl in No. 'yodel
3. OWNER:
Address
-1
5
7
Street ,r Route No.l
mkt_ .7s1
, vu Sate ' Zq, Cade
DATE DRILLED 9- -04
TOTAI. DEPTH: // 415 ) �./l-
DOES WELLWELLREPLACE EXISTING WELL' YI:S 0 NO Ll
STATIC WATER LEVEI. 13eluw'lop of Casing: 5819 I'T.
1Ilsc..,.. it Abe e lop or Casing!
$. TOP OP CASING IS IT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance sjj'ith 15A N('A(' 2C .0118.
9 YIEI.D(gpnf: )/4 METHOD OF IESr r/Jjrs —
10- WATE:R ZONES (depth):
Topogl phic; Land setting
tide ❑Slope ❑V llev ❑Flat
! h k"i propria! box)
Latitude longitude of tvell location
I Jerre:. Inuut... ssund .I
Latitude. loneimde source: ❑(il'SD topographic map
'check hoxi
0E.I'l.11 DRII.I.IN(i LOG
Prom To , formation Description
D 514
At ea code- Phone number
.. 12 '
tl. DISINI:I:c lU )N:"rvpc__ 1-, 7 /-j Amount 614s
12. l �1SINli: Nall liminessDepth Diameter or Weigh: Ft. Material
Prom l'o _ El.__
From To
13. (i R( )l I'1'. Depth Material Method
Prop) To
From 4 l'o
• 14. SCREEN: Depth Diameter Slot Site \ I.ncrial
From To Ft. in. in
_
1?. Si\NI). GRAVE.!. I'AC'R:
Depth Site \ laterial
Front _--_ ro Ft.
From
10. RI':MARKS:
LO('AlION SKI:r('ll
Shoo direction and di,taner ill miles from to (east
ta, State Roads or County Roads, Include the road
numbers and common road manes,
I DO 11E:RH»r (ERIIFA" lllAl' rills \411I. AV:AS ('ONSIRCCTED IN ACCORD. ANCI' VATill 15.A N(
CONS'IR l!l-IION SIANDA DS, AND III l V COPY Ol )) Isis RFt ()RI) II AS 13h.1-N' PROA IDIiD "I ()
La.) .07
SIGNALER'. of PERSON CONSIR I C I ING 1111 AAl'I 1.
Submit the original to the Division of Water Quality, Groundwater Section. 163o Mali Service
27699-1636 Phone No. [phone]. Within 30 days.
9S:6 UV 93130h0
-ur
n
-urn
=o
U
33
U+
C
cis
rrl_
\(' 'C \VI..LI
l'IIF \VFI.I. OW NH(
D.\11. -
Censer - Raleigh, NC
(iAV-I REV. 1)7 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - I)i\ ision or Water Quality - Groundwater Section
w la.l. CONTRA(' I )R (INDIVIDUAL) N.%NtE (print, OCI: R'I'IFIC.\'1'IUN #3 3
WELL CONTRACTOR COMPAN\NAltr:re-e-rl t1�0`� i., 1 PLA-N p> pIioNF: k iga z to dig - 3 1 i C
STATE WELL CONSTRUCTION PERMIT)* ___ 1 4"d a __ASSOC I:%TED \vQ PER\IITii (if applicable) lif applicable) - _--
I. WELL. 11SI.. (('heck Applicable l3o\): Residential itl, Municipal Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Ileat Pump Water Injection 0 Other 0 II Other, List t 'se
3
WALL I OCA LION:
Nearest Town: CD 4 n r . County
CcaLs,_.—.._.
Street Name, Numbers. ( bnmouup'. Subilo lawn. tan No.. Zip (oat
WNER:
OAddress J )4:
7. SFA"I'I('W.Art:RLEVEl.l3elowTop
I Use .. � " i I . Ahkne Top of "Sing)
('ASING IS ( I'T. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NUM. 2C All IN.
9. YIELD (gpm): l _ METHOD OF TEST ,'O kr*.
1(1. WA Fit I2 /ONES (depth):
IS cat or Route No.)
t 7ot}5 a
In nr Ibsro State lip Gale
— _ -
:\I t t Ir- Phan number
-4. DA 11,DRILtED '3-Il,e-o4
5. "MI AI DP.I''III:
DOIIS WEL.t. REPLACE EXISTING WELL? YPS 0 No
of Casing: - 530F t .
aLISr_-aLs•
1I_ DISINlTh'ION:l)pe HT Amount Lg3 �-��
I
12. (':\SIN(i: Wall Ihiekness
Depth I)iwneter or \\-eight Ft. \iateria l
Prom_Q_ ho 33 Pt. /„ It PVC—_
From ro
Prom To
13. (,ROUT: Depth Material Vlethott
Prom_ Tom Pt. _,. Sn,., a ► -- tyr
Prom___ ro Ft. II
14. S(RF:I:N: Depth Diameter Slot Size AIaierial
From To Pt. in. in.
From ) _ It. in. in.
15. S:1NI) (iR:1VL'I- PACK:
Ucpth Size \lateral
from To Pt.
From ro It.
16. REMARKS:
Topographie/Land setting
�1{idge ❑Slope ❑Val Icy plat
'cheek appropriate hex)
Lalii u e longitude of well locution
itheue, outlaws .ceunast
Latiun1 Ion_ritude sourer:❑lips❑'ropoeraphic map
I eheeL box}
)r.PI I I DRILLING LO(i
I7om lb Formation Description
b 33
33' Laos
I OC:AIION SKI:l'Cll — _.--
Show direction and distance in smiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO 11E12E111 ('Ii1111F11 TIIAT 1111S \b1L1 W AS ('ONSIRV( I FI) IN :AI CottO.ANCI WPlli I5.A NCAC 2(-. WEt.1
('ONSII( ('IION StANDARDS, AND ll[XI .ACt)I'1"I)FllIISRP(ORD II . -AS 111I'N1'I(oAIDI:D't0 THE AFlilI. OAANF.R
SI(iNATt:RF lh PI4RSt)N CONSFR t('IlNtl l'1 II AAI'I 1. l)AIF.
Submit the original to the Division of Water Quality, Groundwater Section, I630 \tail Syr ice ('enter- Raleigh, N('
27699-1636 Phone No. [phone]. within 30 dams. OW-1 REV. 117 2001

0349�
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources- Division ofW Ater Oualitc -Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) N:v.vJ� Iprhu^
). T„c� r r t) (tenFI(.%II(.N p 24 / 9
WEI.I. CONTRACTOR COMPANY NAMIt re_e-nc. I3ros 4).4At a Pt...,r,P) J'- rrloNE s (g.25 Lo tit- 31,e
STATE \wl:l.l. CONSTRUCTION PERMIT# / W D a- __ASSOCIATED ED \cQ rERMl r#
d if applicablc) rd.applicable) - _- -
I. Wl[I.l. I ISI: (Check Applicable Box): Residential 45... Nlunicipnl Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump I\ Vater Injection 0 Other 0 I (Other, List 1Ise
NearAt Tow t: / ! County
Sired Nantes Numbers, ('ontnnmitg, Subdn 1e1011. Lu1 No /ip (odc 1
3. OWNI:R: ac_AID V
ISO I-iat-ki rr., -
Ln-.-----
Street of Ku its No.1 -
nrsvIJIt Ai --a726
Address
It)
Ill en Stale 71p Cole
1 1- _
:\rca node- Phone numbed'
T. DAnT: DRILLED l ! -
5. TO FAT. DEPTH:
From _0__
From
From
13. (iROIIT:
Irom__Q
From
Lt. SCREEN:
"7DS'
L. DOES WELL. REPLACE EXISTING AkEI.l:' YES ❑ NO NI
7. S CAll(' WATER LEVEL Below "Fop of Casing: 4-0 ET.
(Ilse".-. ((AKA 'Fop of Casing)
S. 'CUP OF CASING IS FT. Above Land Surface*
*top or easing terminated at/or below land surface requires a
variance in accordance with 15A N('AC 2(' .0118.
9. YICI.D(_pn)I _w3 _METIIU1OFTEST a Ars ,
ID. WAI l:-t /ONI(s (depth): U io5' - 3 R pr",
I I. UISINI`1 C FIoN: l'ype_... /-+ -r_124 Amount 1_2q_}Lits
12. ( ASINIi: Wall Thickness
Depth Diameter or R"ei^ht. I t. :Material
Q ht.
Il
1'0____—_.-ht'--
1 )epth Material
ro Ft '%
To It
Depth Diameter Slot Site NI aterial
Penn I o It in.
From_.. . To It. in.
15. SAND GRAVEL PACK:
Depth Site
lnuu
16. RENIARKS
in.
in.
Nlatenal
DI l I I
Prom Co
D 'f.?
sz. ' 76S'
TopographidLand setting
❑Ridge ❑Slope ❑Valley gIFlat
I. hrd urpropriate box 1
Latitude. longitude of well location
1 do_uc.. minutes . lmds1
ttillnle longitude source:❑(iPS❑Topoaiaphic oral.
l dmdc bo.s.1 -
DRILLING Ll)(i
Formation Description
LOCH LION SKETCH
I!
Show direction and distance in miles tronl at least
two State Roads or County Roads. Include the road
numbers and common road names.
h
11)0111:RIi13V ('ER'IIFY 'lIlA'I T1115 W Ill AV AS CONS Rl'(. I I I) IN :ACCORD ANCIi \ATlll I5_1 NI AC 2l', AA1(1.1
CONS RIn-IION (S IANDARDS, '1 II IA 1 . COPS 0I 1 111S RH ORD I I.NS Iil 1.N PRHMI) WI) I0lIIF Ai'IEL1. OWN1.12
3 ib y o _ C li
---- -� —_ sl(iN:\ I-l)RP OF PI::RSON CUNSI"Rl l'IIN(i Illy \\1-.1 1. U:\Il—
Submit the original to the Division of Water Qualit\, Groundwater Section, 163o \Tail See) ice ('enter- Raleigh. \('
27699-1636 Phone No. [phone], within 31) (lays. OW -I RI:V. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcces - Di\ ision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL.) N.UIw E (print) �rt0 C-r .y la t1 1 CERTIFICATION73351-
WELL. CONTRACTOR COMPANYNAMIgrt-tf•
c_ Oros. Lt)v 1► Pw p,'A-+'c '1'11ONt: tt i8i bq$ 3I
SI'A E\\ El.l. CONSTRUCTION PERMED* 14 b a _ASSOCIATED \\Q PERM I'ftt _
lit applicable) (it applicable) - - -
L WELL. 115E (('heck Applicable Box): RcsidcntialQ Municipal Public 0 Industrial 0 ,Agricultural 0
Monitoring 0 Recovery ❑ Item Pump Water Injection 0 Other 0 If Other, I.ist list;
'_. WELL LOCA TIO
Nearest Town:
Lok 11
[Street Name. Numbers
3. OWNER:
Address _ _3aq_
(Street or Route No.;
3 � Tope I[Slopc a\' scyine
('ounty Pr ORidYe '�1.Slope ❑Valley ❑Plat
[check appropriate box)
I.ot No.. hip (, �dc; Latittule longitude of well location
shill-
Cktt,CC�
.2272-1
tln, hip(
:\rea code- ['hone number
4. DA1EDRILLED 5-.25-04
5. TO'IiAI. U1:P7'11: ,35t—S2 r�
L. DOIIS WELL REPLACE EXISTING WELL'? YES 0 N() fey-
7. S IAII(' WATER LEVEL Below Top of ('asing: Leo FT.
Nt'
,rint�[[
I'SC " _ l,Ahucc Top ofl astuei
S. 'TOP ()I: CASING IS J 1`C. Ahocc I.and Surthce*
`Fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2(' .0118.
9. YIELD Igpin): j METIiOU OFIl ST Jrs
rldpr:C, nu nu[d. sccnnJ> 1
Latilud.: loncitude source:❑(iPS❑l opographic map
(check box)
1)I-.I'I'I1 DRILLING LOIi
From To Formation Description
o 4 D f — C�.LA4-,
(00 ' 3ASt cJh^
IC. WATER ZONES (depth): — 345.- .3 S '_--
LOC ArIUN SKETCH
11. UISINPI'.(Ili IN: -0ypc__ )-i T__rl :Amount 2l..%)Jis ,Show direction and distunee in miles front at (cost
12. CASINO: AV alI Thickness two State Roads or ('ounty Roads. Include the road
I)cpth Diameter or weight: Pr :NIaucrLd numbers and common road moos.
Front n lo.�(� Et. /Ott __--_-- _PVi -
1-ront _.-- [Tu
Front To Pt.
I.; GROI IT: Depth \lutcria l Method
From 0 to '02 D Pt. _C?A.t, n—a. }-.. _j OIL_
Prune [To 1 t.— ---
14. SCREEN- Depth Diameter Slot Size A(decrial
From To 1't. in. in
Front_ ro_____ I`t.__ in. _____ in.
15- SAND lil(AVNI. PACK:
Depth Size \(atonal
Prom 1'o Ft.
From -_ To Pt.
Ib_ RFVIARKS:
9S:6 WV 9?130h0
1 DO TIER[.RY CE:RIII:Y lllAl THIS WELL WAS CONSTRUCTED IN ACCORDANCE: 1ATlll 15. \ N([.-AC '-(. AkF.l.l.
CONSI12t7(IION S FAN})ARUS, AND 11IA r .A COPY t )P TI I1S 12Ft [ORD I I.AS 131-1-N PROVIDE')l1) ll Ili WELL. UAkNILR
YlJ �hi-.r-t-_ Imo, �6 V
SI(iN:ATl iID 01- PIiI(SUN ((INN' RI C'llEst i l I11 AA 111. 1.):11 I.
r[t) )
- Wt-
ntct
o�
—+ram
rnrrt
--tttrd
's
ND
m
ca
Submit the original to the Division of Water Quality, Groundwater Section, 163n Mail Set-) ice ('enter - Raleigh. \('
27699-1636 Phone No. [phone]. within 30 days. (iW-I REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment a ral Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NA/M' (print) n ] 1 <✓ oLNC� CERTIFICATION # 24//g
WELL CONTRACTOR COMPANY NAME IT P.PJ,L IT� /JR3S - GI /.8�� PHONE # 16Gs{a V if -.�/ l
STATE WELL CONSTRUCTION PERMIT# / 6 2 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town: County_khrthriet
(Street Nam umbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address so airy
(Suet or Route No.)
City or To tate
encitnlena
Zip Code
( )- Area code- Phone number
4. DATE DRILLED 7- 2 h- 6 4
5. TOTAL DEPTH: Sl6S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO E.
7. STATIC WATER LEVEL Below Top of Casing: / 1)0 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): .. 5 METHOD OF TEST c7 Li rS
10. WATER ZONES (depth): 345 t - flrvx
4' D S- ' - 1 al d j rti LOCATION SKETCH
11. DISINFECTION: Type /477-/ Amount '7ti +b 1 }-s Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Topographic/Land setting
❑Ridge l 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
D r 4
89 4as'
12. CASING:
Depth
From 0 To 14 Ft.
From To Ft.
From To Ft.
Wall Thickness
Diameter or Weight/Ft. Mn�ateriaall
f� ' Pt/C
13. GROUT: Depth Material Method
From0 To 20 Ft. &*k..QaL� it
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
in. in.
From To Ft.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
9S :6 WV 93100 h0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCTION STAND IDS, AND THAT A COPY OF THIS REC HAS BEEN PROVIDED TO THE WELL OWNER
htZki- ,c-/I— °�
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

4. DATE DRILLED i 1 - I% - D 44
5. TOTAL DEPTH: 1 LDS I
.-. ..r)I k; `AL! t REP! Art: t.Vlgt Inu; sfrvl ' 7 YES L] NO 4
7. STATIC WATER LEVEL Below Top of Casing: 4 b FT.
use "+" if Above Top of Casing)
11. TOT' OF CASING IS / FT. Above Land Surface*
*'lop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 4 D METHOD OF TEST rs •
10. WATER ZONES (depth): I S' - 4b %?a ,
t LOCATION SKETCH
I 1. DISINFECTION: Type._ 11.1 Amount 0 -1-1s h }S _ Show direction and distance in miles from at (cast
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Fromd To a 3 Ft. 10 I' P12 C,
From To Ft. C)
FromTo Et. 0
13. GROUT: Depth //�M'aterial Method n .�
From Q To .a20 Ft._e,yxwg ______Vp— NIFrom To Ft. O
14. SCREEN: Depth Diameter Slot Size Material r„t
From To Ft. in. in. .
From To _ Ft. in. in.
15. SAND/GRAVELPACK: N
Depth Size Material rJ
805727
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section w ELL('ON'IRACTOR(INDIVIDUA1.) NAME
� (print)-O'Ztr'1 LJ bb CERTIFICATION#.gq
4/b
WELT, CONTRA(' TOR COMPANY NAME (71 ✓'ePY/)EIBTDS. 1t.1n Qk 4 PLL1riD
STA'rI: WELL CONSTRUCTION PERMIT# [ 'r/ U.?
PHONE SS 4ys"319h
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residentiand, Municipal/Public ❑ Industrial D Agricultural 0
Monitoring 0 Recovery 0 heat Pump Water Injection ❑ Other 0 If Other, List Use
7
WELL. LOCATION: 1
Nearest Town: / t �.y ❑es) I 1 1t County n
R,,.t 501. - s C i
(Street NAmc, Numbers, Community, Subdivision, Lot No.. Zip Code)
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 'Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNER: IM`V).1_ r� ! J7 )A (degrees/minutes/seconds)
Address P O "rF 1 1 S Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No) (check box)
t-t! S V r I 1 P 1 M c 0$ 7 8 Le DEPTH DRILLING LOG
City or 'Fol.vn State Zip Ctle From To Formation Description
( 1- 0 23 '
Area aide' Phone number .2 a / / G .5 (n �,L
From To Ft.
From To Ft.
16. REMARKS:
1 DO I IERFBY C ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I5A NCAC 2C, WELL
('ONSfRU("110N STAN'ARDS, AND "THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
VC) r) . d -
SIGNA'f(110E 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

305728
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
�t'e%-W
WELL CONTRACTOR (INDIVIDUAL) NAME. (print)_tty-Ly„T_
wit!. CON'1 RA("1(1R COM PANY NAME C-scent., 1'. �C&. �JQ_11 y LAn124
STATE WELT. CONSTRUCTION PERMIT# 1 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
Groundwater Section
CERTIFICATION # %g
.PHONE # gat. (a k-
1. WELL (1SE (Check Applicable Box): Residential It Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2_ WELL LOCATION:
Nearest Town: Li)c....y rw s v 1 1(e Coun/tyy f
V • 1lttr(e4 o4' Pt ti L,,n +
(Street Na MC, N dmhcu, Community, Subdivision, Lot No., Zip C'ode)
3. OWNER: Dc..bbie
Address 3t7 k
(Street or Route No_)
rCYI act-LAr-,-. esr CAI e 4 4 T
City or Town State Zip Code
( )-
Area code- Phnne number
4. DATE DRILLED 1 1 - a - d ti
5. TOTAL DEPTH: (n a. I
I" "4 \A,l..l l Ill:pl A/'1; I: YTS! !NC \VFI,I ,1 Y!.' I 1 N )
7. STATIC WATER LEVEL Below Top of Casing: $Lb 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
sariance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): (p METHOD OF TEST ., h re.
1(1.WATER ZONES (depth): 4DS'— 3 op1t`n
DISINFECTION: Type 14 }— Amount-1-1,145 Show direction and distance in miles from at least
CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From D To Lp'1 Ft. Lit
11.
12.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley (Flat
(check appropriate box)
Latitude/longitude of well location.
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographicmap
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
d
to l
Lot) ' 1p 7 5 '
PVC,
From To Ft.
From _ To Ft.
13. GROUT: Depth Material y Method
From a.___. To D Ft. C„ ..t.s-t .--4o P
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
I5.SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
I DO IIEREt3Y CERTIFY "THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
('ONSFRRU.0IIION STAND R ', AND T11AT A COPY OF THIS RECO S BEEN PROVIDED TO TILE WELL OWNER
F
SIGNATURE OF PERSON C'ONSTRUCfING 'HIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV, 07/2001

WELL CONSTRUCTION RECORD
North ( tarotina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACMIC (INDIVIDUAL) NAM/Ill (print) /32- 5.Ar ± CERTIFICATION ..304i WELL CONTRACTOR COMPANY NAME (sree_f2e_ rAS • 1ilik/29pr1/441-CHIONE tt 12t6,_Vg 31 70
STATE WELL CONSTRUCTION PERMITS/
(if applicable)
(if applicable)
I . WELL USE (Check Applicable I3ox): Residential unicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. W1,1,1, 1,0CATION:
Nearest Town:
Lt_ County kiatft,tzoci
Mao
LC? 3 2 A ocm F IS
(Street Milne, Numbers, Community, Subdivision, lan No., Zip ('ode)
3. OWINTI,R: rw_v ta„Gstrn_
Address P ,
Rho
ffl
(Sir et or•Rpute. No.)
cing`e._ \la Un Li ,NC t
gySt Finvn State Zip Code
(. .)-...
Area code- Phone number
4. DATE DRILLED $ ) b - 4
5. TOTAL DEPTH: 3 '
f)311'.N PFP!AL!' !AN.) !Nit i WEIL? YES LI NO
7. STATI(' WATER LEVEL Below Top of Casing: _ an FT.
, Oise "3" if Above Top of Casing)
8. TOP OF CASING IS / _ FT. Above Land Surface*
*Top of casing terminated abor below land surface requires a
variance in accordance with 154 NCAC 2C .0118.
YIELD (gpm): 3D METHOD OF TEST tri? A r-5 •
WATER ZONES (depth): - a 45
1. DISINFECTION: Type 1-/ Amount 58 {Ill -4
12. CASINO:-
Wall Thickness
Depth Diameter or Weight/Ft. Materiikl
From , C.> T o Ft. LO II
To Ft.
From To Ft.
I O.
14/6a ASSOCIATED WQ PERMIT
13. GROUT: Depth Material Method
From
From_ 4°_,_ To_gc°3 Ft. eitme,,ILL
To Ft.
13. SCREEN: Depth Diameter Slot Size Material
1' 'ton 'to Ft in. in.
From To Ft. in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From ,, To Ft
From To
1 h. REMARKS:
305716
Topographic/Land setting
ORidge Slope OValley Onat '
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Forma ion Descri tion
onv±4_,.
DEPTH
From To
gi) I 345'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO I f ER El3Y CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI1 I5A NCAC 2C, WELL
( 'ONSTR 1CTION STANDARDS, AND TI1AT A COPY OF' THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
//- St e
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW- I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Dcparoncnt of Environment and ryalural/Rcsoo ccs - Division oT Water Quality
\CELL (•O\ I ItAtIIJI4 (INDIVIDUAL) NAME
i
WELL ('ON IR.\(•roRrow'.ANv NAME/dee' %f/e1 L��p
sIAtEWELL CONSTRUCTION PERM rr ASSOCIATED WQPERM ITa
lira lineable) (if applicable)
305512
- Groundwater Sectionp1�,/v
CERTIFICATION d oRY67
PHONE d asZa1-rissys
I. WELL USE (Check Applicable 13ox): Residential f'Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 IMINN, List Use
2. WELL LOCATION :
N 'oust Towne
Jf�/1-W be
(SIrp9 Name. Numin.
3. OWNER:
Address
o my /j"O(J
Community. Subdivision, Ina No.. Yip Cue)
rt
,f//yy w ,ae,th
sype
Town
Zip Code
Arca soak- tame none r
4. DATE DRILLED/ a,3 -O
5. TOTAL DurrH: dS SZF
6. DOES WELL REPLACE EXISTING WELL? YES NO V
7. STATIC WATER LEVEJ. Below Top of Casing: FT.
^, (Usc 'v' il'Ahove'lop of Casing)
S. TOI' OF CASING IS OC P'G Above Land Surface*
`Top of casing Irrndnaled al/or below land surface requires a
variance in accordan r with ISA NCAC 2C .01 I&
9. YIELD (gpm): Q METHOD OF TEST ,041-4--
I0. WATER ZONES (depth):
opographic/Land setting
Idgc ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
ion
Ittegre&l;linuIWatonds)
L.alilude/longitude source:❑GPS❑Topographic map
(chock host
DIEPTH . DRILLING LOG
From To i`(ition Description
t� ri20
11. DISINFECTION: Type
12. CASING:
7f-0?
Depth 1 'at eh.
From To Ft.
From To Fi.
From To 11.
13. GROUT: Depth �i. Material , Method
From D To. El. C`Ena trig —
From
To Et.
14. SCREEN: Depth Diameter Slat Size Material
From To Ft. in. in.
From To I. in. in.
15. SAND/GRAVEL PACK:
Sire Material
1
O
rn
LOCATION SKETCH
•
Amount - Show direction and distance in miles from mast
Wall'lllickness . two State Roads or County Roads. Include the ma
or WcighUpt.oM eriai, numbers and common road names.
I)pih
From To Ft.
From To Ft.
I6. REMARKS:
I DU HEREI)Y CERTIFY TFIAT Tilts WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
°lam'& I c-a3-0 y
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1634 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
Natural Resources - Divisiontof Water Quality - Groundwater Section
WELL ('ONTRAC"fOR(INDIVIDUAI.) NAME (print) j"�U �ey) bads. CERTIFICATION #a41/f(
WELT, CONTRACTOR COMPANY NAME ,Ja6014,/ �_. �Lx&t, ).4 }'(.LrhTL, .PHONE # fig.7si/o t$ -3/ 70
STATE WELL CONSTRUCTION PERMIT# / 7 D-2 _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:
(Street Name, Numbers,'t'ommunity, Subdivision, lot No., Zip ('ode
County 14a... fi yinA
3. OWNER: �c -- ---1--)0_\ t�
Address }D D Ian / 1 `i
(Street or Route No.)
C9y�afNr a % 7 a 1
('ity or Town State Zip Code
( )-
Area cede- ('hone number
4. DATE DRILLED q - a D - n c1
S. TOTAL DEPTH: 5451
%1 UI:UI Al'I. LYIetItit. \Ai LY 1'' VLI II NI1
7. STATIC WATER LEVEL Below Top of Casing: ((6 FT.
(t )se "4" if Above Top of Casing)
S. TOP OF CASINO IS I FT. Above Land Surface*
*'fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpni : 60 METHOD OF TEST Q kr.S
10. WATER ZONES (depth): 3D 5 ' - 3/4 p r*i
5,0_5 ' - 59'14 �P
1 1. DISINFECTION: Type ITN Amount R 1
12. CASING: Wall Thickness
Depth
From D To 4 oS Ft
From To Ft
From To Ft
Diameter
(�ti
or Weight/Ft. Material
PVC
13. GROUT: Depth Material Method
From_ n To ZO Ft. [to
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From ___.. To Ft. in. in.
From To Ft. in
15. SAND/GRAVEL PACK:
Depth Size Material
Irom _ To It.
From To Ft.
in.
In. REMARKS:
apt
305715
Topographic/Land setting
❑Ridge ❑Slope ❑Valley $F'lat
(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
`/c ' 5i/5 ' rltp#nze_
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO I IER EBY CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
('UNS'rRUCHON STANNARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
(
YiJ J //-36 -6
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME
(print)
WELL CONTRACTOR COMPANY NAME G r G
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
al Resources -
0
140
304"
ivision of Water Quality - Groundwater Section '/
CERTIFICATION # 3.3 Jr2
HONE # ($.�i if L 4 - 3) 1 D
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residentiall4 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO `
Neare Town: nrat t 1 1e. County i L r + J r,r,(7-
(Street Name, Numbers,QCommunity, Subdi/iision, Lot No., Zip Code)
3. OWNER: .X..1 A1..ry
60-44)
Address n w ,-,4 not)
(Street or Rop o.) /+ y -7
/ A/✓ A o0
City or T State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED IC- 6 - d41
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO yes
7. STATIC WATER LEVEL Below Top of Casing: I (a .i 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): / METHOD OF TEST a b rs
10. WATER ZONES (depth): l 1 S- 6 4S
Topographic/Land setting
GIZIRidge ❑Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
FormationDescription
DEPTH
From To r
Sf 1
2i� /n CI L)
LOCATION SKETCH
11. DISINFECTION: Type /4 'rH Amount I 2 4 44, 1 k Show direction and distance in miles from at least
Wall Thickness
12. CASING:
Depth Diameter
From 0 To t%ti Ft. In' I
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From Q To 20 Ft. Cernp.k," 4 0
From To Ft. V
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.
or Weight/Ft. Material
Pur.
two State Roads or County Roads. Include the road
numbers and common road names.
LS:6 WV 9?130fit)
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
`& .7 des - / P -
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) � NAM/E*v (print) ear A \I AA1 tt CERTIFICATION # 335
WELL CONTRACTOR COMPANY NAME lY C e.@-Yl� gi'iX, : WAIL_ '4 k 4 V1 D-. PHONE # (S 1 brf f: 31 it
STATE WELL CONSTRUCTION PERMIT# I trt U 2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential DK-Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
iii '' //
Nearest Town: ./J(( .v.. County Haa.yl .iza')�
.ar DU
(Street Name, Numbers, Community, Subdivision,+Lot No., Zip Code)
3. OWNER: Je.nnne . G34``rtcrk-t^ t
Address 1 fl AS ' e rtsr'A CnV V.RA
C(Street or Route No.)
p, dI A/C4.2%7 J
City or Tovtt State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED fo - .2 9 - o 4
5, TOTAL DEPTH: <f di5 '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 111"..
7. STATIC WATER LEVEL Below Top of Casing: Co U FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. /�
9. YIELD (gpm): / 0 METHOD OF TEST oS
10. WATER ZONES (depth): a b 5'- .2 IS
11. DISINFECTION: Type 14 TF-I Amount g j }L j h .
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From b To ,ri 14 Ft. La 't A VC
From To Ft.
From To Ft.
13. GROUT: Depth pMaterial Method
From 0 To a® Ft. l.?.nja 16 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.
Topographic/Land setting
Midge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To , Formation Description
sg
'
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.
LS :6 WV 92 130 10
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
`4J j 7EJiuc-4•4•�K* /o - /5-64
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

nv
307640
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resott,(�\esc- Division of Water Quality - Groundwater Sectionon+��
WELL CONTRACTOR (INDIVIDUAL) NAME (print) `.ARIZ`�(' /WE 15 CERTIFICATIONeFAL130
WELL CONTRACTOR COMPANY NAME PtMAtAChi Ah[ lb1L}1. �1 lUncj PRONE 0 firii)�ODU-7aa
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential B" Municipa1/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATMI:
Nearest Tow 1. Nfl'�OC� C.oupty K�
i% R(1b Ec $. 14Y.
(Street Name, Numbers, Community, Subdivision, Lot No., Tap Code)
bytil
3. OWNE ` al Cr tt Addreess04)
I��jt 1 �/ /`
C0 1•1 (SUeet No.) AgT�W
City or Town State Zip Code
4. DATE DRILLED i �ag'o
Am coda Phone number. ll-
5. TOTAL DEPTH: fr ' /
6. DOES WELL REPLACE EXISTING WELL? YF 0 NO I9
7. STATIC WATER LEVEL Below Top of Casing: /}Q 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 acard1SA NCAC 2C .0I18. /��
9. YIELD (gpm): P±S� OD OF TES1l7G1'C o%1)(?K
10. WATER ZONES (depth): ' 10
Topoc/Land setting
❑Ridge lope ❑Valley ❑F1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DRILLING LOG
Formation Description
DEPTH
From To
11. DISINFECTION: Type 1
12. CASING: Depr�
From c.J To Coo Ft.
From To Ft.
From To Ft
13. GROUT: Depth
From To
From To
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
Amount o{ Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Diameter or Weight/Ft. Material numbers and common road names.
16. REMARKS'
co
tt0
Fee3r3nch Thz,.
9
rn
W
CO
0
CJI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON ION STAND ' a S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA
OF PERSON CONSTRUCTING THE WELL
ICJ
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Marl Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
34n
North Carolina - Department of Environment and /Nattural Resources - /Division of1Water ? Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME+ (print) ( .h n I /E s -- o Aim {ship . b h CERTIFICATION # "a SO k
WELL. CONTRACTOR COMPANY NAME (-rret.b)r-,BChs. lc>r 1/ `- PP m�^x, J. ex c.• PIIONE # (RR�Yg-3/ 7G
STATE WELL CONSTRUCTION PERMIT# / 2 U al ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WE.LI. USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: I
Nearest Town: W 21ne SV t i le County Nicu{ tsTC�
re. — at, uDhip nr6 n
(Street Name, Numb&rs, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
Tier
© Lri l
(St eet or Route No.)
e �a llt_ti ,I-1G a`X'7 S1
Coy ter Town State Zip Code
( r
Area axle- Phone number
4. DATE DRILLED ID -Du - O `E
5. TOTAL DEPTH: a SS '
DUES WELL REPLACE L:vLST! niri WELL? ,r YES Lit NO
7. STATIC WATER LEVEL Below Top of Casing: g0 FT.
(Use •'+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
`'fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): Cob METHOD OF TEST a h rs
O. WATER ZONES (depth): ,Q 4_5 ' - (o C p
1 1. DISINFECTION: Type ]-1 T1-1
12. CASING:
Depth
Frum 0 To 5D Ft.
From To Ft.
From To
13. GROUT: Depth
From /nTo c 0
From
Diameter
Amount 5) +is )4-s
Wall Thickness
or Weight/Ft. Material
Ft.
Material Method
Ft. (ro. t at ib--e
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
Frum To Ft.
From ___ To Ft.
16. REMARKS:
Topographic/Land setting,
ORidge ❑Slope ❑Valley Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 fa I
fir/
rU
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 TI11S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
-zl-as
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. (919) 733-322I, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
308,931
North Carolina - Department of Environment and Natural Resourc--e(s'�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMEE(print) 01P r V Ls ya_1 ] CERTIFICATION It33.54
WELL CONTRACTOR COMPANY NAME Ye Lrie._Sroc, ilk)) sj Pan . Ift PHONE # L`Ig- 3/7b
STATE WELL CONSTRUCTION PERMIT# / stay, ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 1e1. Municipal/Public ❑ Industrial O Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: d, to - Countyhzt-t,+-, r:,,c�
b lorDet x-nzs a. , . 11 A It
( Street Name, Numbers, Community, Subdivision. Lot No.,//Zip
//�Code)
3. OWNER: tau t c-� PenkbiPer
Address P [3 Cirt I r 1 (r
�� (Street or Route No.)
f a te. ' /: i it.t k)C en)C ryS
City n State ZipCode
)-
Area code- Phone number ,/
4. DATE DRILLED ib,- -y-
5. TOTAL DEPTH: .S,Q g I
6. D.M-.s 9.'E LREPLACE EX! ST IN}(7 WELL? YES V NO 91
7. STATIC WATER LEVEL Below Top of Casing: 4G FT.
(Use "+" if Above Top of Casing)
H. 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): 4 METHOD OF TEST h PS •
10. WATER ZONES (depth): ,5"a .$' ' - 4
Topographic/Land setting
ORidge eaSlope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
SO 1
SD' S.*5"r
'I
LOCATION SKETCH
11. DISINFECTION: Type /-17-N Amount go ihi 36 Show direction and distance in miles from at least
t 2. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From.._..Q_ To 5-6 Ft. I I P ll fit.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 1) To a() Ft. „ / hie
To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To - Ft. in. in.
15.SAND/GRAVEL PACK:
Depth Size Material
From___ To Ft.
From_. _ To Ft.
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU('.TION STn NARDS, AND THAT A COPY OF THIS $FCORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�JResources '-1Division of ]] Water Quality - Groundwater Section
�1
WELL CONTRACTOR (INDIVIDUAL) NAME (print) plex�.I if V dLC CERTIFICATION #
(; 3.4Sy
WELL CONTRACTOR COMPANY NAMEretry, Q,/ r04. 4JfF// W Pun, •. PHONE#f /y$-3/76
STATE WELL CONSTRUCTION PERMIT# / 7 L} 2 ASSOCIATED WQ PERMIT#
(if applicable) _ (if applicable)
I . WELL USE (Check Applicable Box): Residential )] Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery O Heat Pump Water Injection 0 Other E If Other, List Use
2. WIiLL LOCATION:
Nearest Town: I"(mu.,,:str, to Vc J )e County F-1� ��pra
i'n ntlC-✓L rip —Oar r .
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: t'Cr -r )anise, l I a_Ac
Address L. 4-i-a rLLhntr/t, rt rr 4".4 Dr,
(Street or Route No.)
neWtilt NC .W1SCD
Cuy o r own State Zip Code
Area code- Phone number
4. DATE DRILLED - I D -& 4-
5. TOTAL DEPTH: 3D5
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS % FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 1 5 METHOD OF TEST oV rS
10. WATER ZONES (depth): Q g S' - 1 G a p m
DOLS NrELL REPLACE l.vlSTItNr WELL? Y„S U NO IA
11. DISINFECTION: Type /—f 7%-/ Amount 5ID4-b!4S.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_._Q__To ?i(a Ft. (Q t! 1:71/P,
From To Ft.
From To Ft.
13. GROUT: Depth Material .L Method
From O To ,,,,,0 Ft. C& -a_i, .0 44—aa
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.
I6. REMARKS:
MTopographic/Land setting
idge ❑Slope OValley OFIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/secunds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To r Formation Description
O PQ
gG ' 305,
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.
3
W
0
I DO I IEREBY CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
•
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
L J
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
308929
North Carolina - Department of Environment and Natural Resour es - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM/E� (print)ri/r� j- 0 �/)� Li, CERTIFICATION # ,�///
WELL CONTRACTOR COMPANY NAME cr err YID 2rOS . /�C // � &mp, inc- PHONE # (FI4 4 rii(' 3 /'7 a
STATE WELL CONSTRUCTION PERMIT# /5/01 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
WELL. USE (Check Applicable Box): Residential l' Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
1
WELL LOCATIOtN
Nearest Town: () „ha ne 6 Vt /%P County/��t�,l,,���
&t3 Iinr�{ /Srhi) — fe.eki <r.t�ve
(Street Name, Numbers,.Qommunity, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
( t�n inrv) I l of
A/C 8'7 S
city orffown State Zip Code
( )-
Area code- Phone number //
4. DATE DRILLED t -1 6 _b'/
5. TOTAL DEPTH: of q Tj I
i)ULS WELL REPI.^fl. IX!SJ NG WELL! YES t I NO ra
7. STATIC WATER LEVEL Below Top of Casing: too 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��ywith ISA NCAC 2C .0118.
9. YIELD (gpm): `i' METHOD OF TEST AYS
10. WATER ZONES (depth): 3D S z _
11. DISINFECTION: Type f-1iH Amount gI 4h14S
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_ 1) To 9 1 Ft. _-U
From To Ft.
From __ To Ft.
13. GROUT: Depth Material
From D To af> Ft. r i.-1-
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To - Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From_ __ To Ft.
16. REMARKS:
Method
% P
Topo phic/Land setting
❑Ridge l $jope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To I
91
C�/t
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
C'ONSCRUCTION S/TANDARDS), AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TITE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) —,
//�� .. ``
CERTIFICATION #33 S I
WELL CONTRACTOR COMPANY NAME P fr_P ye.. G Laat a ni3 PHONE # (g,2 j & t4 $ - 3) 'i 6
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential Xi. 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: C 6.4t4a County , .
zzi
(if applicable)
Shn,4 r.l 06beta
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:Me_ R ► c eLd T'Q,
Address 4 Li-q 01.4
(Streetor Route o.) •
Fsvl )Ir AlG o18' 8
) n
N' G
City or tiDwn State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED el - to p 4
5. TOTAL DEPTH: Lt fls
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
lit
7. STATIC WATER LEVEL Below Top of Casing: Lite) 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.
9. YIELD (gpm): METHOD OF TEST i1 rC
10. WATER ZONES (depth): I$S'- aCS 2gp„r.,x
J
I I. DISINFECTION: Type
12. CASING:
300518
Topographic/Land setting
ORidge Slope DValley OFIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From o e To Formation Description
A f
t' )oDS1
H T1-1
Depth
From b To S 2 Ft
From To Ft
From To Ft
13. GROUT: Depth Material Method
From G To .QD Ft. ('(� P
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in.
From To Ft in, in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Diameter
(ctt
Amount 1 DR' -i
Wall Thickness
or Weight/Ft. Material
PVC,
16. REMARKS:
•
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
o o▪ o
• c,
a A:4,,
c
0
PO
o or
�r
y�c
Z Xm
O en-
cn
G7t
ON i
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STAN RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1J1%II 011/
SIGNATURE OF PERSON CONSTRUCTING THE WELL / E �,
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 300515
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME(print) —ROT'.r Thu_Un IL CERTIFICATION# 335
WELL CONTRACTOR COMPANY NAME &rrt np. arcf.) - t J) M Purim) t , .POONE # L, 4 $ - 3 l 7 0
STATE WELL CONSTRUCTION PERMIT# 1 'I' CZ ASSOCIATED WQ PERMIT#
1
(if applicable)
(if applicable)
WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO. N:
Nearest Town.) L p YIP 5 V 1/ it County lLJoc
(Street ty, division, Lot No., Zip Code)
m.k, . Rd.
Name. Numbers, Co muni SS
3. OWNER: i eryvt KFs •-nlets-
Address ILy Fr c.�.0 AS{. u.ry 12c/ .
(Street or Route No.)
nes✓, lle AEC .287 4t`0
City Town State r Zip Code
( )
Area code- Phone number
4. DATE DRILLED Lo • 3
5. TOTAL DEPTH: 4 4 5 t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO g.
7. STATIC WATER LEVEL Below Top of Casing: a O FT.
(Use "*' if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): (131 METHOD OF TEST a
10. WATER ZONES (depth): 4 10 s- y 1 S t - Lb t
I1. DISINFECTION: Type
12. CASING:
Depth
From c^) To r] cj
From To
From To
13. GROUT: Depth
From C To aC
From T
Diameter
Ft.
Ft.
Material
Ft. CD Aat..-.t
Amount']' 4h1
-bc
Wall Thickness
or Weight/Ft. Material
PVC
o Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
Method
*710p
Slot Size Material
in.
in.
16. REMARKS:
Agricultural 0
Topographic/Land setting
$Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
nn_
DEPTH
From To
-ICIt
��J t 41 TS
CLAIain-
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
O o
C -671
N C-
p Lr
)s-c
r"c
a r.,
m?)
O
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 TO THE WELL OWNER
kit.)J ilL.LLAkL- 7-3/—o lii
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

N011038 831VMONf102iO-0M0 •
3013301VN01031:1 3111A932100I4 2.92665
WELL CONSTRUCTION RECORD
Nort PP4R1Nitt1 -Waruucnl of Environment and Natural Ttje%purees-_JDivii..ion of Water Quality - Groundwater Sectioon�//
wE:1.l. CONTRACTOR (INDIVIDUAL) NAME/print)/ e. +TV"ft CER•i1FIC11101Y.'^. �9
11, EL1 ClIaM tC 1NV NAME ir/cC t4 1/i'1 f 11IIONE a (gni bwc/-/o
S308(10S3H ni N ONY
1N14/102 ,FI3101 0110N PER as; (SSocIATt:D WQ PF.Ii\ItTq
tic• ,liclblc) (fray I icablel
WELL USE (Cheek Applicable Box): Resident till Munikipal/I'ubltc 0 Industrial ❑ Agricultural ❑/
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 IrOthcr, List Use
2. WELL 1.
NaTown: Ut
aresl Town:
County
o(/e DI4 77-C OVF
!Slice; Maim. Nnmheri. Caaonnmilyl Subdivision. ton No.. Zip Code)
;. (1WNIiR:
Addles%
thirect or Route No.) 9:
Zip Code
(52g )- 6.2 i-Qg
Area code. I'himc another
.t. DATE DR 1LLI:D1- 0 os�
5. TGTAI. l)EI'TII: 44,-C- F-f- - m5 7C'O
t,. DUES WELL REPLACE EXISTING WELL? YES NO E.".
7. STATIC WATER LEVEL Below Top ofCasiIa,: �0 Fr.
(use "+" if Above Top °raising;
S. TOP OF CASING IS a FT. Above Land Surface"
••loin of easing Icrulhlaird al/or below land surface requires a
variance In accordance with ISA NCAC 2C AI18.
'I- YIELD(gpm): METHOD OFTEST ,G'r
I0. FVA•riiR ZONES (depth):
Topographic/Lan erring
°Midge ❑Slope alley ❑Flat
(Check appropriate box)
Latitude/longitude or well location
uv or To,rn
I I . DISINFECTION: NFECIION: Type
12. CASINC.i:
Depth__
From 1-02 To_Yi) Ft -
From _ To___._, I'I.
From_--_- I•o�--__ 1.I-
13. GROAT: Ocpih �fNL•neri;l _
.From._ O _To 9 1'1- r Pr^e/n
nom To
SCRI(IiN: Depth Diameter
F1,,,,, -_. To
Fro01----._--- To _.... 1•I -_..—.in.
15. SANI)/Gl(AV1i1-PACK:
Depth Size
Front - To El.
I tom_-__.---- Fll_..__.FI.
( dcgrccsminuWsseeomts)
Latitude/longilucic sotirce:OGPS❑Topographic map
kheck b,%)
1)1PTI( . DRILLING 1.OG
Penn Tti Fgr{nirlion nDescription
LOCATION SKETC'tl
AinmMIL Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Vg�w7 t. Material numbers and common wudta nacs:
l�7ee
Ib. REMARKS:
p-lcthod
Slot Size Material
in.
Material
1 Ix) I I iltEIBY CERTIFY THAT THIS WELL WASCONSTRUCTED IN ACCORDANCE WITI I ISA NCAC 2C, WELL
CONS FRUC I )N STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I-l3-OBI
SIGNATURE OF PERSON CONSTRUCTING T11E WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
2709-1616 Phone No. [phone], within 30 days. • CM -I REV. 07/2001

S30eings cj 'vci u.vn uri %
1N3WNpiIANd;tji kLd3Qr NcrroN PERM tr#
tB'a +iicable)
NOII03S 2131b'MONf1021J�M0
3013301VN01J321311IAS32100IN
WELL CONSTRUCTION RECORD
twozmint c 7��
mirth ut lir : Deparuuent or Environment and Natural R snurcf: - Divisi n of Water Quality - Groundwater Section /
KEI.I. CM:MA(-r01i (INDIVIDUAL) NAME Oa) C;'th f\A'i`U� to CER'riFIC\TIONa 6249
�� I )\II'ANV NAME_ ./. fC& atilt 4 PHONE a 00,34 697-S
VI
ASSOCIATED WQ PERMITtl
or a 6 livable)
292668
I WEI.I. USLi (Check Applicable I3ox): Residential 12KolunicipaUI'ublic 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 II'Other, Lis( Use
2. WELL. LOCATION:
ire c e€ C54-reJ O <J7%dXioarart
/
f tiowet Nail . NNamhe+s. (laonnmi y. Suhdivixion, Lim No.. Zip Code)
; . OWNEI(: 12 C)
Addicss 7 $J (',' rd,5 f �a c
37,74/
we%(Sired or Route No.)
FA.
ny o I wn tit ne Zip Cu.k
ts6f;- 7913- o967
:\ree c,nk. I'Ixme a,wer h
.1. DATEDRILLED/—
a- o
b. DUES WELL REPLACE EXISTING WELL? YES ❑ NO Hre
7. STATIC WATER LEVEL BelowTop ol'Casino: 6 r2 FT.
Oise "+" il'Ahove Top Praising)S. TO1' OP CASING IS ET. Above I.and Surface*
*'fail of casing Ivrmla:lied odor below land surrate requires a
variance in accordantf with 15A NCAC 2C 9118.
v. YIELD tom):METHOD OFTEST pr/—
O. WATER ZONES (depth): ,L
I I. DISINFECTION: Type /%!7 Amount
12. CASING: Wall rhickaess.
�apy C or\\eight/FI M I
Depteo
Fromt2. Tn•S I . Ft.
From To 1.1.
From__ _'ro Et.
13. (31(C)11T: Depth /n/ Material L Method
. Frolit_D Tn_� Fil .eMeft,
`Frm To Ft.
I-1. SCREEN: Depth Diameter Slot size Material
From, To PI. in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To Ft.
to Ft.
16. RIiNlA1(ICS:
�Topngraphic/Land setting
(Midge ❑Slope ❑Valley ❑flat
tcheck appnriate boK I
Latitude/longitude pawed! location
t degawshn inu0.Wsccomis I
Latitude/longitude source:❑GPS❑Topographic map
tel,cck box)
)
DEPTH . DRILLING 1.00
From TO P,r 'tit 1 Description
LOCATION SKETCH
Show direction and distance in miles From as least
two State Roads or County (toads. Include the road
na numbers and common road names.
Mlfr
tgg
r—... 1
O
0
0
CI73
4-41
_-
o<
qo
-o mCl
3 Cl
N ma
n
w z
1 In 1IIEItE.BY CERTIFY THATTI'IIS WELL WASCONSTRUCTED IN ACCORDANCE WITI I ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I (9D—o
SIGNATURE OF PERSON CONSTRUCTING THE WtiLL DATE
Submit the original to the Division of Water Qualify, Groundwater Section, 1636 Mail Semite Center - Raleigh, NC
27699-1636 Phone Nu. [phone], within 30 days. GW-I REV. 07/2001

NO11038 2131VMONn089-OMO
3013301VN0103213111AS3M0OW
29.2667
you s ti inr
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natoral //R��eso
NvEl.L CV0.I9EWhit7INDIVImCAl,) NAIU: ring) Ii°,Tl-'-
s3Uanos3a1vanlvN aNv �\ \\Ib ���,
11VBNNowi1 ?Yfl'lcEI3'VM t-
ces - Division or Water Quality - Groundwater Section
,4'� -\ 1 )�r� CER7IFIC \'r10V
r/iy" PRONE a ,,4, 497-8ni
s l l K: WELL CONSTRUCTION PERM ITN ASSOCIATED WQ PERM ITN
lira .licahle) lira ytlivable)
WELL USE (Check Applicable Box): Rcsiden:ial Lid" Municipal/Public 0 Industrial 0 Agricultural q
Ioniloring 0 Recovery ❑ - Beat Pump \Valet Injection ❑ Other 0 If Other, List Use
2. WELL L.00ATIIONN/
Newest Town:
tc
t Snot Name. NNoodle's, Coosmonity. Sulnlivisinn, Can No.. Zip C1771e1
3. UWNI:It:/ r?1 ! 4.61
:W(1icss tic
tract or Route No.)
,ice i
xo
Lt K
nv „r'1'urcu rate ' Zip C'rk
1�P
County. //'Ty
Area r,xte• Phone nntnher,
.1. DATE DRILLED
/
5. TOTAI.
O. DUES WELL REPLACE EXISTING WELL? YES CI NO t -
7. STATIC \VATER LEVEL Below Top of Casino: . kQ Fr.
(use •+ • if Above Top or Casing)
S. TOP OF CASING IS a FT. Above Land Surface`
'Tnj, or casing terminated at/or WON/ luml surface requires a
variance in urtIulanee with 15A NCAC 2C AIM
'1, YIELD(gpnt): /0 METHOD OFTEST4'r
10. WATER ZONES (depth):
II. DISINFECT
12. CASING:
ION: Type /lig
Depth Q� . Diameter
Front To FL n
Front — To— Ft. _--_--
rn,m___Mull____ Ft.
13. (i1LOU : Depth q Material Method
st . Fro__ . I'nc)0 FIce....2n.r±
now To Pt.
1-1. SCREEN: Depth Diameter Slot Size Material
Frn:tt ..... To _.._ I'I•... _.._In. in.
From_ ._.__To FL in. _ in.
15. SAND/GRAVEL I'AC'K:
Depth Size Material
From To 1:1.
tom To 1'I.
Ih. Itli;\L'\RKS:
Topogra c/Land setting
❑Ridge .'tope [Nutley ❑fl:u
teheck appn'priate hox )
Lalitudc/longitude of well location
C degrees/ntinutcs/sceomisl
Latitude/longitude source:❑GPS❑Topogrtpltic map
• kited: Nix)
DEPTH . DRILLING I.OG
From Tip Fyrlyatiyn Description
szo
LOCATION SKETCH
Amount .. Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or v yylu/FI. lain numbers and common road names.
cn
-D
—a
cs
0
+a
1 I)O I 1 ER kin. C'ERTI FY THHAT TH IS WELL WAS CONSTRUCTED IN ACCORDANCE W ITI I ISA NCAC 2C, WELL
C'ONs RucTioNSTANDARDS,ANDTHATACOPYOETHISRLECOILD1-IASBEENPROVIDEDTOTHEWELLOWNER
"'41
' SIGNATURE OF PERSON CONSTRUCTING TliE WELL DATE
Submit the original to the Division or Water Quality, Groundwater Section, 1636 Mail Senvice Center- Raleigh, NC
27699-1636 Phone No. (9191 733-3221, within 30 days. OW-1 REV. 07/2001

N011033 831VMQN110219-oM0
301dd011/N01038 3111AS380011
292666
WELL CONSTRUCTION RECORD
tiooz g g inr
North Carolina - Department or Environment and Nat iriral R/es rc s - D' isiu of Water Quality - Groimdwatcr Sectio�nn i lc
wELidiAI�i.�. lot panVIUUAL)NAME Wog /4 IY� i.a /PP CERTIFIC\TION#Ot3
167
S3(Q»f10U681Ji JiniripmQ41I'A'V'%NIE , �Ce G✓j0 vn, PHONE, r fgc s..6_22:::&07
1N3WNgL�`/�t1� 4Q i R:2440N rERMrra •%SSOCIATEt WQ PERMIT#
sr,\IF. )..
t il'a likable)
(ifs L+l icable)
I WELL USE (Check Applicable 13ox): Residential ErclunicipaliPublic D Industrial 0 Agricultural El
Monitoring 0 Recovery Q Heat Pump Water Injection ❑ Other 0 II'Othcr, List Use
2. WELL LOCATIO I:_,[l
Nearesl'Fowl); '; _ Al Couni\ IW00_-
t Sieet Name. Nundx, .Community, Subdivision, Lol No.. Zip Code)
3. OWNER: g
Address 1 cr-
(Street or Route No.)
(llv nr)bwn Slab:
.2p7/(lam
Zip Code
:\rea code. ( un a namhcf /t� •Y/'
.1. DATE pit I1.1.kt_ i_
s. I'(yrAt.1)IW II: '✓05-ft-
o. DUES WELL REPLACE EXISTING WELL? YESp NO er--
7. STATIC WATER LEVEL I3elowTop u&Casing: bO FT.
p)se -:" it Ann.. Top or Casing)
S. TOP OF CASING IS ov FT. Above (.and Surface*
`Toil of casing rernrinated atlnr below land surfute requires a
variance In acc,Nlnnc ritl, ISA NCAC 2C 9118.
YIELD(gpn0:O METHOD OF TEST A--/-
IO. WATER ZONES (depth):
II. DISINFECTION: Type Amcunt ..
12. C'ASINCE Wall "Iltickness.
Revd) Di:{It cIcr or \%eight/FI. Magri:d,..,
From in 5 Fl. 1/L� 7)Y
From_ -_._ _To FL-
13. cRtd.,, Depth cyea( .vl�
.Frntn._—� _•rat o20 r•1.
Prm...._ ,._. To•_--__ Ft.
I-1. SCREEN: Depth Diameter Slut Size ?lateriul
From. Ta._..._. _.._ Ft. in. in.
From...__.._To _ 14.. in. _ iu.
15. SANI)iGRAVELPACK:
Depth Size biatcri:d
Method
From
I Toni To 1'1.
I(p. RE%IARKS:
Topographic/Land setting
pItidge ❑Slolx: ❑Valley ❑Ilai
(cheek appnrriale We 1
Ltdilud✓longitude of well location
1degaro9nintilU /Secmuin)
Latitude/longitude source:❑GPS❑Topographic map
kixv:k bo, I
DEPTH . DRILLING LOG
From TTo.ttit I Description
O o� 4
c?0 cCg
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.
#/ob7'
-1,
2
L
Inn!
fit
0
-1
rat
to
-t
N
rs
I Lx 1 IIEItNIY CERTIFY THAT THIS WELL WAS -CONSTRUCTED IN ACCORDANCE WITI I ISA NCAC 2C, WELL
c oNti i'RUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I-N-
0
0
o�
0 ornr*i
rn
Om
-4O
rn
�rn
<ri z
cm'x)
0
SIGNATURE OF PERSON CONSTRUCTING THE WIiLL
DATE
Stilrlilil Hie original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 (Mom No. [phone], within 31) days, • OW -I REV. 07/2001

WELL CONSTRUCTION RECORD ((��
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwatersettikjn' 1
WELL CONTRACTOR (INDIVIDUAL) NAME (print) . • a • • li. IsCERTIFICATION # a i I 0
WELL CONTRACTOR COMPANY NAMER re P Y1L' arts La, II a 11tl w pHoNE # 0$.M 4 4/$ - 3/ g°
STATE WELL CONSTRUCTION PERMIT# / 40 aZ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential` Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: e Ile.y County . , ty, c
(Street Name. Numbers, Community. Subdivision. Lot No.. Zip Code)
3. OWNER: 5 r•r 'flu r r\/xent,
Address P G ran( 4 a 5
(Street or Route No.)
YYl&qui p \I t 1 � e.y N C B 7$ I
City ol4Fortso State t Zip Code
( )-
Area code- Phone number
4. DATE DRILLED In - ,? $ - U 4
5. TOTAL DEPTH: q 05 I
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO-
7. STATIC WATER LEVEL Below Top of Casing: 1 Pt) ET.
(Lse "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm)• LD METHOD OF TEST _D h rs
10. WATER ZONES (depth): 3 l< 5 ' - (.o rs fy"
Topographic/Land setting
❑Ridge ❑Slope DValley `Q
(check appropriate box)
Latitude/longitude of well location
a
(degrees/minutes/seconds)
Latitude/longitude source:OGPSDTopographic map
(check box)
DRILLING LOG
Formation Description
L.
DEPTH
From To
G RIoI
' 405'
1I. DISINFECTION: Type I-4T i--i
12. CASING:
Depth Diameter
From Cj To 2 it Ft. (c I I
From To Ft.
From To Ft.
13. GROUT: Depth
From D To at: Ft.
From To Ft.
Amount 5.4 4-L1t
Wall Thickness
or Weight/Ft. Material
Material
c9 xrv.,_ L.1
14. SCREEN• Depth Diameter
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK:
Pvc
Method
Slot Size Material
in. in.
in. in.
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
a An Li/
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
o s
r
C c
Cr-
IV 0<
p
y0
"-tom
m0
i am
O mw
Cn O
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
iL7- /-04
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
300513
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) N'A (print)RD 6) n 14)& /J CERTIFICATION#?4/8
WELL CONTRACTOR COMPANY' NAME( 7(PP y 0$ /1.2aL V Punt) 'J31 PHONE # 1942cd /o z/lt • 3 / 70
STATE WELL CONSTRUCTION PERMIT# / go a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential % Municipal/Public ❑ Industrial O Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other ❑ If Other, List Use
2. WELL LOCATION: ` 1
Nearest TT/oYwn: iYkl it a I Iw County
as 1.1
(Street Name, Numbers, Community. Subdi ision, Lot No., Zip Code)
3. OWNER: S%e_t) s Pt-1-9.ar5e-v\
Address 15 a also w.
y (Street or Route No.)
P1L moise FL 3 4 Li- L
City or Town State Zip Code
( )-
.Area code- Phone number
4. DATE DRILLED (o -'.{ 3 - b 4
5. TOTAL DEPTH: 185
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 'fib
7. STATIC WATER LEVEL Below Top of Casing: ft FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at)or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 3D METHOD OF TEST 2 H r S
10. WATER ZONES (depth): I l0 5 ' - 3D Q tr
11. DISINFECTION: Type 4yi-4
12. CASING:
Depth
From /D To oil Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To_,,V)Ft. ins ...ft 4trp
From To Ft. j-'
Diameter
11
Topographic/Land setting
❑Ridge ❑Slope OValley AFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To , Forma don Description
0 a '7 (?`v./ _
.i%' dv ' .C7Mw.I.
LOCATION SKETCH
Amount q 4 -►b (-s Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
2ue
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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
L OWNER
SIGNATURE OF PERSON CONSTRUCTING ELL 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
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL

WELL CONSTRUCTION RECORD 300512
North Carolina - Department of Environment and Natural Resources (- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME/I rr
(print) K e, 6t M /PILL EA CERTIFICATION #.1.41/S
WELL CONTRACTOR COMPANY NAME (:7reee1/ ISM:. iD / qt Pa w,i 'J&t-PHONE # rya 6 Sir -.3/2°
STATE WELL CONSTRUCTION PERMIT# /,7 d.Z ASSOCIATED WQ PERMIT#
(if applicable) (ifapplieable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: _
T`i///Neare$t Townountyllarri
/U1NI- Ji-baz n LsYld
(Street Name, Numbers, Community. Subdivision, Lot No.. Zip Code)
3. OWNER: (Lit, qt rn Liana
Address Sil q j 1gCLt/4 S4.-st?�2
(Street or P e No.)
%Ctoit P2. 346 to
City or Town Staie Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 5 -- / % - C't
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL') YES 0 NO 11.
7. STATIC WATER LEVEL Below Top of Casing: I CO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): S METHOD OF TEST c2 lrS
10. WATER ZONES (depth): 585 I - ,$ pprn
1 I. DISINFECTION: Type 1-1T (-1
12. CASING:
Amount it,
Wall Thickness
Depth Diameter or Weight -Ft. Material
From ,O To .,�t Ft. 6 I t P V e
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From O To ,0 0 Ft. r Dyill ,y j -}-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:
Topographic/Land setting`
❑Ridge ❑Slope OValley ¥Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formatjlon Description
DEPTH
From To
o ac '
ao' �25'
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 STAN DS, AND THAT A COPY OF THIS RECORD ^HAS BEEN PROVIDED TO THE WELL OWNER
tli),%iLe eJ 7- 3/- a V
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
rn

WELL CONSTRUCTION RECORD
300511
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 8h.L./QA...±. ) !S&LL (L. CERTIFICATION # 31:4I
WELL CONTRACTOR COMPANY NAME Grep rtt art . Lit_ 4 Pianp, IEC PHONE # gii.Zii /e di Y ' 31 7t
STATE WELL CONSTRUCTION PERMIT# / %' da ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
WELL USE (Check Applicable Box): Residential* Municipal/Public 0 Industrial O Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: , /
Ne�ar•est Town: Witt, nt s V l / I t County HT
oa_c ol,
(Street Name. Numbers, Community, Subdivision. Lot No.. Zip Code)
3. OWNER: T1 m Cds-V er
Address 3 Si+ Fir Tr, p
(Street or Route No.)
maeadsx;t �Ir.1L NC' a r?
M City 11 n State 1 Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 5 - 3 - D
5. TOTAL DEPTH: cP&.5 '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO'S
7. STATIC WATER LEVEL Below Top of Casing: —3 6- FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): c- METHOD OF TEST a rs
10. WATER ZONES (depth):
Topographic/Land setting
ORidge nSlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
a is o 1 0 �J L
1D1 .2Co51 /��L/.w.v ..
I1. DISINFECTION: Type H Ti-) Amount 4 q -F-) 1+s
12. CASING: Wall Thickness
Depth Diameter or Weight;Ft. Material
From t To LP Ft. 4 /1 put
From To Ft.
From To Ft.
13. GROUT: Depth {�tatertal Method
From Q To . L) Ft. (,wc J ` h
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the pad
numbers and common road names.
9 cam:
-'
f
0 y4rn
N N
O
CA 7
QY 2
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST AN DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Ih (Q�t t-
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

WELL CONTRACTOR COMPANY NAM
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N. tural Resources - D' ision of Water Quality - Groundwater Section ' /
WELL CONTRACTOR (INDIVIDUAL) NA E (print) ' � CERTIFICATION #J(2)4
AL PHONE # (ga yi"3/71>
ASSOCIATED WQ PERMIT#
(if applicable)
/yv�
3005] 0
1. WELL USE (Check Applicable Box): Residential. Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
OWNER:
2. WELL LOCATION
Nearest Town: County
►�c3�k C-vej
(Street Name. Numbers, Community. Subdivision, Lot No.. Zip Code)
3. IJ
Dr 15
Address t'19 5 Rt l ei v�
(Street or Route No.)
He a x 776
Cm oil own State z Zip Code
( )-
Area code- Phone number
4. DATE DRILLED -3 - 15 — D 4
5. TOTAL DEPTH: 305'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO WI.
7. STATIC WATER LEVEL Below Top of Casing: 1 b FT.
(Lse "*" if Above Top of Casing)
8. TOP OF CASING IS
I I. DISINFECTION: Type
12. CASING:
FT. Above Land Surface*
*Top of casing terminated at'or below land surface requires a
sariance in accordance with 15A NCAC 2C .0118. pp
9. YIELD (gpm): L 0 METHOD OF TEST Tim.. .
10. WATER ZONES (depth): 3%5' - at\O
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
Depth numbers and common road names.
From 0 To S7 Ft.
From To Ft. t �'
From To Ft 9
ct—
G
m C.
ri
rn
6
l
Topo aphic/Land setting
❑Ridge iSlope ❑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� Formatitxt Description
o 552 ' 3D 5' 8�
14 T }f
Diameter
(c
13. GROUT: Depth Material
From Ci To OD Ft. e u_Aiv L_Ad
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND:GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount 55 +b l }y
Wall Thickness
or Weight/Ft. Material
MIL
Method
C
eft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEE ty',p�2OV IDED TO THE WELL OWNER
T�i ( 7-5/-as/
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. 07/401_

302924
\VEITL CONSTRUCTION RECORD
North Carolina - I )epnnlnenl of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION N `N /a
\t I':I.i. CON I(A("I1)R II\tIV IUI.: %I) \ \III' (prinnII)�1�}e,/4-4 �y ,Q�6 L'
\YI:LI. CON 112.\( Il)It ((1111'A\l UI I, 1( _'.".e! F -Uf_ 1 _- — - _---- ---- PI IONE 11 fr0[61 ,7
si.' i is WTI.!. ()Ns lRI t I I0\ 1'I(101Ira assO(:I VITT) Il'Q I'EI(BII Iq
1 if applicable
_ire -
(it applicable)
WELL USE (('heck Applicable 13o.$): Residential "EY cumicipalipublic ❑ Industrial ❑ Agricultural 0
Nlouitttring 0 Recovery ❑ Beat Pump Water Injection 0 Other ❑ I[Othcr, List Use
2. WELL LOCATIpiN:
Neayst To cn: 0'. NeS✓isle County
VA/ es
1 Street Name. booth
3. OWNER:
Address
Svcs in Rul ; No.'.
Pit 7o 9
( Jo, nr-I o,.n Stale Lip Code
1 )-
it}. Stlhiloim 11 I as No.. /to e'ode
'C 114,1111
Area code- ('hone inn
4. DATE DRILLED Jr' oVi
j(opographic/Land setting
iidgc ❑Slope ❑Valley ❑Flat
I check apprupriale boil
I :Itimdc/longitude of well lucalion
I decrees/minutes/seconds)
Lit i l udeilungil ucle source:❑GPSOTopograph is map
(check box)
DEPTH DRILLING LOG
From To F .n alion cscription
U
5. TOTAL DEPTH: ,3C5- -/
6. DOES WELL REPLACE EXISTING WELL? YLS Q NO !1G
7. STATIC WATER I.I.N'I11. Below Top of Casing: ? __—FT.
-, (use '1' o Aboec 1 op of lasing)
S. TOE' OF CASING IS ae FT. Above Land Surface'
'Tun nr rasing Iermiu,I tI al/or Lelosv land surface requires a
variance in accordance oilh 15.X NCAC 1C .01111.
9. YIELD (gpm): Ic METIIODOFTEST eh
10. WATER ZONES It epth):
LOCATION SKETCH
I I. DISINFECTION- Type #2.-/l/ Amount Show direction and distance in miles from at least
12. CASING: Wall 'thickness Iwo Slate Roads or County Roads. Include the road 7 U
�1� Depth � Diomo e ur Al' •i.lu/FI. Iclial cumbers ;old common road names. 0 '�-i
2 ��i� ¢( //
From Tc� To Pia FL6%� , _ / / o fv'i_
From lrr I Oil iq 3 �1 .pr-+
From Tn_-- fl. 1 ��
13- GROUT: Uepth Material .Method ��
/� m "'
From (,' To =��/ PL `rle 3 c"(a
--
From To 1'. 0 00
Id. SCREEN: Depth Diameter Sint Size Material
From To .._ I"L in. in. N ( �
c4
From To I -I. in.
15.SANDK RAVELPACK:
Depth .Size M;uerial
Prom To fl.
From To FI.
16- RFN'LARKS:
I DO HERI.'131' CERTIFY TI IAT THIS WEI.I. WAS CONSTRUCTED IN ACCORDANCE WITH ESA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND Il IAT A COPY OF THIS RECORD HAS BEEN I'RovlDED TO THE WELL OWNER
S-`=-o�i
Ct SIGNATURE OF PERSON CONSTRUCTING IIIE WELL DATE
Submit the original to the Division of Water Quality, Grounds\ filer Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 I'hnnc No. (919) 733-322I. within 30 days. GW-I REV. 07/2091, ,) ) i

302923
WELL CONSTRUCTION RECORD
North Carolina - Departincnl of Environment and Natural I}es urceti<- Division oT Water Quality - Groundwater Section
WELL CON•I n.%(-I'Olt I INDIVIIIUAI.) NAME print) Ka
//,{ , ' ` �J CERTIFICCA7T'IONN$$ V
WEI.l CONTRACTOR (Yl\I PAN 1' NANIE( rtP w..i/ X PlAvil PHONE it f o)&O
STATE: WELL CONS•IRUCrIoN PERM ITN ASSOCINrEI WQ PERMITN
tirapplit:ahlcl ___.. litapplicahlc)
I. WELL USE (Check Applicable 13ox): Residential 42" MunicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Item Pump Water Injection 0 Other 0 ITOther, List Use
2. WELL LOCATI N: j
Near 51 Town: Nj`2/✓
f NSod (7✓e
(tilM•I Name. N
County
b�rx, ('.nnmuniry. SuhJlrisi.al, Lul No.. Zip Conk)
3. OWNER:_ i tor
Address _ 3 _w� •
(SIrtvl or Rnale No.) G
CAeJ ryl N.( - (9� ? 16
(uy r 'rpm_ SIa1' Zip CMk
Arra cork- Phone neon /
4. DATE DRILLED 'C 09
5. TOTAL DEPTH: /07
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVE1. Below Top of Casing:
ttJzc "t' if Aloe Tap of Casing)
8. TOP OF CASING IS FT. Above Land Surfaces
'Top of rasing terminatcJ atiur below land surface requires a
variance In arrordanwill. ISA NCAC IC .011/1. �I
9. YIELD(gpm): D METHOD OF TESTJYr
10. WATER ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from al Least
two State Roads or County Roads. Include the road
numbers and common road names.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Mt
(check apprupriate box;
Latitude/longitude of well location
I(kgnvs/minmes/seconds)
Lali ode/longitude source:❑GPS❑Topographic map
Ido:ck box)
DEPTH . DRILLING LOG
From To F. ty(tio Description
0 o?a
11. DISINFECTION: Type
12. CASING:
T4'
O ❑
FT.
__1 Depth )I)t•r aflet
I=roin lac( To 36 Ft. (0 `��y
From To Ft.
From To • FI.
13. GROUT: Depth Material Method
From 0 To 19-0 FLf1v'riciA/11'
From To Ft.
14. SCREEN: Depth Diameter Slot Sin Material
Prom___ To Ft. in. in.
From To Ft. in. in.
15. SAND/CIRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall 'Thickness
or Wciolp/Fi. atcri:IJ ,f� i0`/1 yJ
97 O
r
Q
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL \VAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED l'O THE WELL OWNER
%L�-cat g as (pH
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 Pbnnc No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Etiviionmcnl and Na u aj Resyurciivision oT Water Quality - Groundwater Sect'pn
�/ k ,v1J
\\'FI-LI'O\"1121('I'U1t (INDIVIDUAL) NAND: ring '��
WEI.I. CI1N'FKACF11R ('Il3I1'ANY NAME C.t
sTATr: WELL ('ONSI Kt CI'ION I'F:R%trrx
din pnl ieahle)
CERTIFICATION
)
PHONE a llr_eJr7e5 j3�
ASSOCIATED WQ PERMIT#
(if: ilicahlel
I. WELL USE (Check Applicable 13os): Residential IiMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ileat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELI. LOC:ATIO
Nc:)nst'fu cn: �}
County �✓r'C'
IS rest Name. N Cwnnuutity, Snhd)visi.rt. ! to o.. Zip Carle)
3. OWNER:
Address
'Street or It
ArY r 1 /Yr
f p
7. STATIC WATER LEVEL Below Top ofCasing: / ' FT.
fuse ••+" it Ahove Top of Casing)
II. TOI' OF CASING IS PT. Above Land Surface"
••lop of rasing terminated st/or hclow land surface requires a
variance in acrordancc tlh ISA NCAC 2C.0118.
A�1
9. YIELD (gpm): ' METHOD OF TESTA/C
10. WATER ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
Topographic/Land setting
❑Ridge ❑Slope alley ❑Flat
(check appropriate hex)
I.: tiiuddlongilude of well location
Idegrees/Inininwsec nnks)
Latitude/longitude sourec:❑GI'S❑Topographic map
'dick hoe)
DEPTH . DRILLING LOCI
Fran To I -4:al Description
7/
City or Tonto Slat •• 'Lip Cork
(g)- a35 .
Area code- Phone hs
4. DATE DRILLED �—ot/ -0
5. TOTAL DEPTH: �*17 bS 41 -
6. DOES WELL REPLACE EXISTING WELL? YES O NO
11. DISINFECTION: Type
12. CASING:
FIhryh y
mm�� To 'IS FL
From To FI.
From To - Ft.
13. GROUT:, Depth r Material
Prom ( l-o 9 »
From To FI.
Amount
Wall'fhickness
lr t /Ft. } tcriatr
164,442 74,
Method
14. SCREEN: Depth Diameter Slot Size Material
From_-- To Ft. in. in.
From '1'o H. in. in.
15. SAND/GRAVEL I'ACK:
Depth Size Material
From To Ft.
From l'o Ft.
e
CO _AO
/miy
— nth
• �L
O o
N CD
N es
16. REMARKS:
I DO FIEREI)Y CERTIFY THAT TFIIS 1VELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COl'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
q-av
DATE
Submit the original In the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Ratcigh, NC
27699-1616 ''hone No. [phone], within 30 clays. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of lit wironlncnt and Natural,1/�Csoutres -/Divv'lion oT Water Quality - Groundwater Scebon
O'EI.1. COST ltACTI 1 I INDIVIDI:Al.) NAME rim) N� �/ y7��� A7U/� e CERTIFIC,�AT,eItONN #
\Vt:I.L ('ON't um -mu C I)\II'ANY N,\ Mt: (. l tail / U.'" PHONE, N t6�u)C0c7gt-72
sT ATE \\'t:1.1. CONS-MI:CIION PERM art
l ifapplicahtel _
AssoC)ATED WQ PERMIT/
Ufa Heal -del
1. WELL USE (Check Applicable 13ox): Residential Fa—Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ileal Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N:
Nyar •st Tun! • • N "V County
4440 de if
(Surd Na, •. Numbers. C'rmuuunily, Suhrbviu,si, LuI No.. Zip Code)
3. OWNER:�//li 2
Address _T - Aryl
Topogra ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude ofwell fixation
(degrccs/minuies/secontts)
_ Latitude/longitude source:❑GPS❑Topographic map
(Sired ru Rowe No.) (check box)
(7 -•-u9o4f 444 L.. 0275 7/6 DEPTH . . DRILLING LOG
nv yr n t star • Zip ctak From Tq ter ltio Description
Area code- flume num1 „0,./4. DATE DRILLED-ayO- sY
5. TOTAL DEPTH: &CS-4-F -
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO fl
7. STATIC WATER LEVEL Below Top of Casing: /.r FT.
�-I lust-4- it Above Top of Casing)
8. TOT' OF CASING IS DC FT. Above Land Surfaces
-mu or rasing irrMnatcd al/ur below land surface requires a
variance in areordanre with 15A NCAC 2C in 1a.
9. YIELD (gpm): rQn METHOD OF TEST /4/f
10. WATER ZONES (depth):
,L LOCATION SKETCH
11. D%i/ISINFECTION: Type .) Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness IWo Shut Roads or County Roads. include the road
Dcprh_ I9iai le or \'g it/Fi.-tcri:d numbers and common road names.
From -f-� To /'y FL t %f/ 6etej p
From To FI. .,!•i✓ !bog' ....
Tl P -r,
Prom '1'0 _ I't. r' :--11?
13. GROUT: Depth /v Material Method 0 r'+—
Fram 17 To d0 Ft.r riei'/ -'( -Orr'
l d
CO � n
corn
a c;^-
VC --1
c
C.? =-
N cn 0)
N e-j
Frain To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From I Fa. in. in.
Front To Ft. ill. in.
15. SAND/GRAVEL PACK:
Depth Sim Material
From To 1-1.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY TI IAT'ruis WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS ANDARDS,ANDTHATACOPYOFTHISRECORDHASBEENPROVIDEDl'OTHEWELLOWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original In the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 PI • No. [phone], within 31) days. GW-I REV. 07/2001

302921
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and/N�•uural I�csoo i�rces-pivvision oT Walcr Quality - Groundwater Section
//�J
WELL COST It.1(TOR (INDIVIDUAL) NAME rini)pAe'�/ I"'•r.+"7l�///�e7 CERTIFIC�A�TIIOjN q-�(�'1ps��/z�
WEI.I. CONTRACTOR COMPANY NA Al Pr/7 (ei/ 9- Pi�fJ PHONE a etz7)(2,27—e �
STATE. WELL CONSTRUCTION PEIC%UT# ASSOCIATED WQ IT:RMIT®
I if anplicaMcl fir. licable)
1. WELL USE (Check Applicable Box): Residential CJ Mlmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
.494NearesTywy;
4
(Slrect Name. Northers, Community. Suhdreis
3. OWNER: / tVh1r
Address 57 in/ t
County
W0oo'
iat. 1.01 Na. ZIP rake)
/ ' n/sYrJG '
✓ li
r/ yµe i Of R.nne Nn.1 iS_7S f
( ny or Town ale Zip Code
(&.t$ )- 9—. 00 3
Area code- Phone north ,
4. DATE DRILLED 7`/ c
5. TOTAL DEPTH: /90S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC' WATER LEVEL Below Top or Casing: er0 I•'T.
(Ilse "+" if Above Top of Casing)
S. TOP OF CASING IS IFT. Above Land Surface*
*Top of casing terminated at/or below laud surface requires a
variance in accordance with ISA NCAC IC All It
9. YIELD (gpm): Ja METHOD OF TEST Air
I0. WATER ZONES (depth): 1
I I. DISINFECTION: Type -T/ J,
,„„TopographicfLand setting
Midge ❑Slope ❑Valley ❑Plat
(check appropriate box)
I .al itude/longiludc of well Meation
Wegrees/minwcNsceonds)
Latitude/longitude source:❑GPS❑Topographic map
(check hozl
. DRILLING LOG
F atio Description
DEPTH
From To
LOCATION SKETCH
Amount - Show direction and distance in miles from at least
12. CASING: Wall Thickness . two State Roads or County Roads. Include the road
Deptl )i�lmct •r or yV'u 'ht/Ih. WOW/numbers and common road names.
From +02 To Di FL /2525 ,,�{
From To Ft. 7J Sig
From To Ft.
13. GROUT: Depth Material Method
From 0 To OZ6 FtCo" e-S"
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Fi. in. in.
From To Id. in. in.
15. SAND/C;RAVEL l'ACK:
Depth Sitc Material
Prom To Ft.
From To Ft.
Coc ( ;
r r"enro -
n ;o <=
—4 -cirri
1 0—
a C7
rail
A Csx
p o.0
tV t^c)
tV 0
16. REMARKS:
11)O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
V.G.- q--o(
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 )'I • No. [phone]. wilhin 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
302920
North Carolina - Department of Environment and N• tu�r�al5Rcs[our�ceess - Division oT Water Quality - Groundwater Section
�
wit]. I'ON'I RACI'OR (INDIVIDUAL) NAM oat),,e�./'�, // h4, j%/p� CERTIFICATION pp716/
WEI.L ('ON'rR.l(-1'Ou COMPANY NAME/ 1el�..9".. 'vrf) PHONE a(gx996a?>Ss`:
ASSOCIATED WQ PERiIITO
%TATE Nlil.l. ('ONSIR(`CIION ri:w%,Fret
li in ilk:able)
HT applicahle)
I. WELL USE (('heck Applicable I3ox): Residential l3" Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nearest Town: f i4e'VYZ7n/ County
ante %l
(Strcci Name. Numbers. Co moony. Subdivision. I..1 No.. Zip Cook)
3. OWNER
Address
Or;Rome Na.)
1
Zip Cock
Area code- Phone
4 DATE DRII 1 PD
0V
5. TOTAL DEPTH: r f
6. DOES WELL REI'LACE EXISTING WELL? YE 0 NO i�
7. S'M'I'ICWA'f14RLliV11-IiclowTop ol'Casing: i� FT.
IlJsc -4" if Above Top of Casing)
R. 'f01' OF CASING IS Fr. Above Land Surface*
*Top of casing irrminaleS atlor below land surface requires a
variance in ocrnrdanr ••}'ilh ISA NCAC 2C .0118.
9. YIELD (gotta:}r METHOD OF TEST f}".
10. WATER ZONES (depth):
11. DISINFECTION: Type ,4/j'l�
12. CASING:
13. GROUT: Dept, Material From G To r- 1'1. a-xPN/
To Ft.
14. SCREEN: Depth Diameter
From To
From To FI. in.
15. SAND/GRAVEL I'ACK:
Depth Size Material
Prom To Pt.
From To Ft.
bpographic/Land setting
idgc ❑Slope ❑Valley ❑FIat
(check appropriate hox)
1 .al itrRle/Iongilndc of well location
Idegrecsiminutearsecondx)
l.al lode/longitude source:❑GPS❑Topographic map
ldreck box)
DI:PTFl . DRILLING LOG
Front To
LOCATION SKETCH
Amount Show direction and distance in miles from at leasi
Wall Thickness . two Slate Roads or County Roads. Include the roadg
c-i :.
,,`` Dcptl�j�y I i:1p, •I •r nr Weight/Ft.trial- numbersand common mad names. 0a_;
Frnm702 'fo •'J25 Ft., - p rn
mtl
From To FI. / M /s1/7
..d �v"=
-'"
From To - H. i ,0`
Method Co pot
vii
� ta
0
cs
ra in
N cn
Front
Slot Size
in.
in.
Material
16. REMARKS:
I DU HEREI3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI(iNAlUltl? OF PERSON CONSTRUCTING THE WELL DATE
Submit the original In the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 PI • No. [phone], within 30 days. GW-I REV. 07/2001

\',,ELL CON ri)_,c foil CU,NIPANY Nt.11E
Sv rii'\Y ELL. CONSTRUCTION ?ERN11Ta
WELL CONSTRUCTION RECORD 302840
..oral Oafolulti - Dcparrlllenr of Env lronmen[ and
O OLL CONTI vcro1: i INDIVIDU.AL)N ANIL i p rot) //,'' Coi.50/✓.$ /i e// DP/t��l/YQ c. PHONE sRaKust-ytj%.
ASSOCIATED WQ PERA11Tu
lit nppl idablci
Jy;yurul Resources - Divis)ion of W uter Qualiry - Groundwarer Section 2
.JUC R.litM . (l�ip✓C5 CCRTIFI L':1T1ON ».J/
I. 1Y ELL LISE tChcol: Applicable Box): Residential LZ 1vi unicipoU'Public 0 Industrial 0 Agricultural ❑
i\.lommnng ❑ Rcoovery ❑ Heat Pump AVoter Injection ❑ Other 0 ]1 Other, List Use
2. WELL LGCATI
Nearest Town. F Cret
An Hee &c,c 4
County
,S0cn N aax, Numbers, Community, Subdivision, Lot No., Zip Codc)
3 OWNER. _
.:arcs_ (D010 AShevl Ile
t5 nett or Route No.)
He ie s vide nC
"p er Twin Swte
,825, r-$1'74
a1 tbdc- Pnnc namDcr
DATE DRILLED 3-4, -04
Zip Cone
TOTAL DEPTH: 3 4S'
o. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Cssine:/ZO FT.
/ IU;t "r' )(Above Top of Caning)
3_ TOP OF CASINO IS FT. Above Land Surface^'
`Top or tarn rerrn n [s0 sour below land surisce requires a
va Mande 111 ecaoreance with ISA NCAC 2C.011a.
YIELD lepn^,1: 30 METHOD OF TEST BbW4y -K•q
O. WATER ZONES (depth): 3 ZD ` 752,?n J .J
Topo�gr�a hic!Land setting
ORidge L7Slope ❑Valley ❑Flan
(cheek appropriate box)
Latitude/longinlde of well location
par 39. etc' tdV rz' J r. 8 r'
(degrees;mimnec�i seconds)
Laurudeilongirude source: Fd"GPS❑Topographic mop
(check bus)
DEPTH DRILLING LOG
From To
-br
Formation Description
Ioy- 73 Sk!l
73 - vs .Stich - Cr..*
ll. DISINFECTION: TypeC/O JL,.ve. Amount /7 jefj
NI. CASINO:
D,pm
From 0 To 73 Ft.
mn To Fr.
From To Fr.
Wall Thickness
Dlatncrtt or WcighiiFI. N' aterial
L.lb - Jolt/ �Vc.
13- OROUT: Dvpat Nlamnal Mcmod
from Q To at Fr. OHeele Qa,,.�,q
From To Ft.
I . SC1'REEN. Ocprn Diamncr ERR izc i Iorcriul
Front Fs, Fr. in. m.
From To Fr. in. in.
IS. SANDr0RHVELP.ACK:
Depth Soso Material
From To Fr
From To Fr
Id. REMARKS.
0▪ /• 0
0 Cill
pG
LOCATION SKETCH -01'I
o�
Show direction and distance in miles from at Icatat p _yO
(WO State Roads or County Roads. Include the road n�
numbers and common road names. -.a
Op
O ��
im ./ :�.rl _-.
Pan -icier 13 ran c .
�r'rles Creek,rtc
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, .AND THAT .A COPY OF THIS PRECORD HAS BEEN PROVIDED TO THE WELL OWNER
' N
3-/D �y
SIGNATURE OF PERSON CONSTRUCTFNG THE WELL
DATE
Saonlir the original (o the Division of Water Quality, Groundwater Secrion, 1636 :L.—eV Yu:2 Center - RaleigE, NC
37699-1o5o Phone No. (919) 733d:21, within 3U days.
GW-1 REV. 07/2001

9
1(1. WATER ZONES (depth): 4f(!S/- q&5,
11. DISINFECTION: Type HT�
12. CASING:
Depth
From Q Tom Ft._je' -
From $ To 4 5 Ft. L. "
From To Ft.
13. GROEIT: Depth atcna T
Prom-Q TooJD Et.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount 79 161-1_
Wall Thickness
Diameter or Wcight/Ft. Material
5+1
PVC' 4_
16. REMARKS:
CC�vHi-V�
804205
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources �- Division of Water Quality - Groundwater Section , l
H ELL CON'TRACTOR(INDIVIDUAL) NAME/�(print) po ar L LLV&t1 CERTIFICATION# 3-3
weft CONTRACTOR COMPANY NAMEL. rttYSt, TBFd> . F l 4 Pt&r. P1 .PHONE # (2'jg_Ijt Q__.. 3 1 7 b
STATE WELL CONSTRUCTION PERMIT# I µb ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
I . WELL USE (Check Applicable Box): Residential`fl Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: County
(Street Name, Numbers. Community. Subdivision, Lot No.. Zip Code)
3. OWNER: RP
Address aiof a.e e r Tr'0:4-4
(Street or Route No.)
CI -PA -AA A- - Q. `I rZ I G
C ity Town Slaw
( )-
Area code- Phone number
DATE DRILLED $ - aD—b -
4
Zip Code
TOTAL DEPTH: 4 8 6 '
DI 1LS 1A,)..I REP A/'I, I. Y!S! Ifllr_ \Ail-1 1') VI:t LJ hill 4
7. STATIC WATER LEVEL Below Top of Casing 4b FT.
((Jse "+ _ if Ahove Top of Casing)
8. TOP OF CASING IS % FT. Above Land Surface*
*lop of easing terminated at/or below land surface requires a
variance in accordance with 1SA NCAC 2C .0118.
YIELD (gpm): tp0 METHOD OF TEST a Ars .
Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreesiminutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Form tipn Description
DEPTH
From To
f> 4/5
'/5' ASS
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
O
I DO HEREBY CERTIFY THAT TI I IS WELL WAS CONS I RUT TED IN ACCORDANCE WITII I SA NCAC 2C, WELL
CONSTRUCTION STANDAR S, AND TI TAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/0-3_.6V
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Qual
%%EId, CONTRACTOR (INDIVIDUAL) NAME (print) Ko 1 AA
304204
Groundwater Section
rr�� ((�� CERTIFICATION#y/ $
WELT. CONTRACTOR COMPANY NAME G__ee_rat_ a3 roc L0e..11 Pusvvp tinPIIONE # (&f_(ei/b.1_3I 70
STATE WELL CONSTRUCTION PERMIT# / yI' S ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WEI.I. USE (Check Applicable Box): Residential 5 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOC'ATIONA
Nears t •town: �p.�y�c-^ 1
Nearly:
tt1
(Street Name, Numbers. ('ommun ity. Subdivision, Lot No_ Zip Code)
3. OWNER:
Address
(Street o, Route No.)
`A)ekc�e.o.l)( 1)f /!C—2�'72t
(lty or'f con State / Zip Code
( )-
.Ama code- Phone number
4. DATE DRILLED I - 5- - 6-3
5. TOTAL DEPTH: 3 a S I
•/)!C Uli.l l UL:P) (.t• L VIYI IN/: AA h.;I I'r Y ht; ( N'.!
7. STATIC WATER LEVEL Below Top of Casing: I pp FT.
(Use "+" if Above Top of Casing)
R. TOP OF CASING IS FT. Above Land Surface*
*lop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. 9. YIELD (gpm): '7 METHOD OF TEST o2 h rS
ID. WATERZONES(depth): 3'ts — r7 tf?m
I1. DISINFECTION: Type
12. CASING:
Depth Diameter
From O. To $t3 Ft. (c 1 1
From To Ft.
H- 14_ Amount !07 +1r1+
Wall Thickness
or Weight/Ft. Material
t�VC
From _ To Ft.
13. GROUT: Depth Material Method
Frorn_Q_ 'to ,Q/) Ft.___CLAc o sti
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
F'rom_ t. _To F
From _. To Ft.
16.REMARKS:
County WI/1 Y0d
y
Topographic/Land setting
❑Ridge *lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
)214. • Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forme Description
DEPTH
From To 1
b 80
ZAr its'
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.
W
On
I DO 1JEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONSfRUCIION STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
is-si—a1
SIGNA'I EIRE 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

Depth
Frotn_ 0 To I hb Ft.
From To Ft.
From--- To Ft.
13. GROUT: Depth Material
From_.F0 &/9 Ft From To To Ft.
9
10
304202
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/+Resources - Division of Water Quality - Groundwater Section
WN;LI. CONTRACTOR (INDIVIDUAL) NAME (print) (9-P rad SIT.r-Try DrP CERTIFICATION 1/ 3,2
WELL CONTRACTOR COMPANY NAME re,_,.�/jl-pl , vv I1 w- t�Unip . /tr -PRONE # &tto «t. i 3 70
STATE WELT. CONSTRUCTION PERMIT# jilt t 2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential` Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 0,2 r..
(Street N((mC, NAmbers. ('ommunity, Subdivision, Lan No.. Zip Code)
County_L • t jacoct
3. OWNER: l in t
Address '14 C,r, pa PaX
(Street or koute No.)
!t/r e_SVi )lel
( ity or .rostin State Zip Code
( )-
NC t? 78Cn
Area code- Phone number
4. DATE DRILLED g -a'i -CI 4"1--
5
TOTAL DEPTH: I 5 i
tit t l 1t,Y.I I 1)1.1)1 Aa9. V Il, 1n,(. U'L:( I Y V Ll Li sil,
7. STATIC WATER LEVEL Below Top of Casing: a 0 FT.
f ((ise "+" if Above Top of Casing(
X. 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. YIELD (gpm): 30 METHOD OF TEST ,2 b rc
WATER ZONES (depth): I ri 5 I
Topographic/Land setting
DRidge *hope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:f7GPSDTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
C7 b (I�D,,.Ir..r1
IbbI IddSI .d„•.. : O
LOCATION SKETCH
11 . DISINFECTION: Type /—/ TH Amount 3 3 }b 1 ts Show direction and distance in miles from at (east
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
PVC,
Diameter
r t
Method
14. SCREEN: Depth Diameter Slot Size Material
From _ To Ft. in. in.
Prom___ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To_ Ft.
From To Ft.
16.REMARKS:
W
LSI
I DO IIEREBY CERTIFY TIIAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSMULLION STAND RDS, AND TI TAT A COPY OF THIS RECORD 11AS BEEN PROVIDED TO THE WELL OWNER
• /1)- 3/ --6c7
SIGNA I URE OF PERSON C ONSTRUC"I ING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

304201
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources-DDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) -PQn�Cff t_r `I pJ t.L'qC` I
CONTRACTOR CONTRATOR COMPANY NAME s5(_P�k1E , S [,I .04., sal�Vy.,
1�D
(if applicable) (if applicable)
S'IA'FE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
CERTIFICATION #3.35.`l
PHONE # ( L K
I. WELL. USE (Check Applicable Box): Residential it Municipal/Public D Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water njection ❑ Other 0 If Other, List Use
2. WELLLOC'ATION'
Nearest Town: O._In,w County
v eJ oaks U) r
(Street Nairn:, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: �iJ peiri .k
Address I I E- pna I 1 (C)Cr<ICS
(; truer or Route No.)
City or Town Stale Zip Code
Area code- Phone number
4. DATE DRILLED t D - QS-64
5. TOTAL DEPTH: 3Cfl 5 t
IVN-,' AV 1.41 REP! x!'L I.V1V'1 INl; 1 AJVt. 1') V1t'11 N'tt
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
R_ TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): R METHOD OF TEST 1-5
10. WATER ZONES (depth): 3 q S
II. DISINFECTION: Type— -17li— Amount to / -Os /Is_
12. CASING: Wall Thickness
(� Depth Diameter or Weight/FT. Material
I'roln D To 81/ Ft. (o l r _ PVC
From To Ft.
FromTo Ft.
13. GROUT: Depth Material Method
From To a 0 Ft. Ce .. t rj.)
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Prom__...__ To Ft. in. in.
From _ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
TopoPraphic/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
Di a 3 G, 5 '
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and cominon road names.
I DO IIERFI3Y CERTIFY THAT THIS WELL WAS CONS ERUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONS Min ION STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
C
/b-3/-a�
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

304200
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and-2, Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL.) NAME (print) to .4 $)-CERTIFICATIION# 304)
WELL CONTRACTOR COMPANY NAME gment_ lros , LOa &t -a PtLyst PHONE # 163).1p412...B' ) b
STATE WELL CONSTRUCTION PERMIT# ) 4-02 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (('heck Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOC'AT1O j•
(Street Name, Numbers, Community. Subdivision. Lot No., yip Code)
Nearest oCounty) "
wrl;
3. OWNER:
Address c jt Qi
(Street orJoute No.)n n
u.t.CErL.CjtVE �[T'
City or Town Slate Lip Rile
( )-
.Atea gale- Phone number
T. DATE DRILLED S.-ab, -Uc4.
5. TOTAL DEPTH: SD $ '
{)OaC 1t; 1.1 t elan A!'I LYK116:C U;t-I t v YILS LI ��O
7. STATIC' WATER LEVEL Below Top of Casing: 45 FT.
(Use "+' if Above Top of Casing)
R. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated allor below land surface requires a
'ariance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 'a METHOD OF TEST a hrs .
10.WATER ZONES (depth): opI - 3�S
310 Cam► 2
1 I. DISINFECTION: Type 1- T-H
12. CASING:
Depth
Fromb To £ Ft.
From _-- To Ft.
From To Et.
I3. GROUT: Depth Material
From(] To a DFt. e_ o i
From To Ft.
I . SCREEN: Depth Diameter Slot Size Material
From _ To Ft. in. in.
From _ To - Ft. in. in
15. SAND/GRAVEL PACK:
Depth Size Material
Fiona _ To Ft.
From To Ft.
Diameter
Amount q 44,
Wall Thickness
or Weight/Ft. Material
PveL
Method
16. REMARKS:
Ili c ff 7s l
Topographic/Land setting
❑Ridge klope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
58
68' S�Sf
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.
Di]
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACC'ORDANC'E WITII 15A NCAC 2C, WELL
('ONS {RUC! ION STANDARDS, AND THAT A COOP OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
et-, 1`�%LQ�h / ail l J - 3 / - O , %
SIGNA"LURE OFP •RSON CONSTRUCTING TILE 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

3041'09
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section .. /I
WELI, CONTRACTOR (INDIVIDUAL) NAME (print) 13 � tr �i211A J' CERTIFICATION # 3 S'-F
WEI.I.CONTRA(:TOR COMPANY NAME(-ey)e ti1. •f ?Limp• t,. . PHONE #rati94,C%2.3 I%D
STATE WELL CONSTRUCTION PERMIT# I ij14.___ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2
WELL LOCATION:��
Ncuresl Town:
3. OWNER:
Zip Code
( )-
Area code- Phone number
4. DATE DRILLED /p-4"-1141
5. TOTAL DEPTH: /S)
[ I /I. e 1LI 1 UI:o1.A( I l YlltN,( 9)/E! I') Vl.s II) `L
iit
7. STATIC WATER LEVEL Below Top of Casing: 410 FT.
(tlse "4- if Above Top of Casing)
R. TOI' OF CASING IS / FT. Above Land Surface*
mop of casing terminated at/or below land surface requires a
variance in accordance with ISA N(:AC 2C .0118.
9. YIELD (gpm): L. 6 METHOD OF TEST
10. WATER ZONES (depth): 1 �6 )
I
12
1 2
a.
(Street Name, Nbbeers, Community, Subdivision, Lot No„ Zip Code)
Q
Address S3 a-,r.r va .
Street or Route No.)
(ND,.,, - A/c aft7.1.- l
City or'frlwn i State
DISINFECTION: Type
CASINO:
Depth
From_ To 9 .2
From To
County_142Zerd
tip.
rI Tat_ Amount ,Q s +b 11�
Wall Thickness
Diameter or Weight/Ft. Material
Et. Lo " PVP.
Ft.
From To Ft.
13. GROUT: Depth Material
From_6 To ht. C �1e o „
From To Ft.
Method
P
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From__.. To Ft. in. in.
15. SAND/GRAVELPACK:
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
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 9A
9a' /4/5' 6-
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.
'-r
tr
0
c2fl
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONS.1RUCTED IN ACCORDANCE WITI I I5A NCAC 2C, WELL
(ONS FRCCI ION STANDARDS, AND TI IAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
A / -
V.
SIGNATURE OF PER 6N CONSTRUCTING .111E WELL
/0-31-6`Y
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

304198
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectionoq
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �D�1 CERTIFICATION #-gj2
WELL CONTRACTOR COMPANY NAME Grpey e. '/j'rcz- . 3talk "4 t m�] IA( . PHONE # �g.73 L. 41 g - 31 7°
ST7ATE WELL CONSTRUCTION PERMIT# / 0„2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential $1 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL, LOCATION:
Nearest own: G V I ) h. County
L n. (-eta k
i Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER. ank,),L, 14 I
/V ° tcDLYocL
Address tYl.p rneAthy J3r .
(Street of Route IVo.)
I.1 ntsv l Ile_) NC a 8 7 81n
City or Tiwn State Zip Code
Area code- Phone number
4. DATE DRILLED 16— 1 - b�
5. TOTAL DEPTH: 05
nOL`; 4t1'I . Rl:l ACE I: v iS,!N(i'ul_ity Y(.S Li NJO
7. STATIC WATER LEVEL Below Top of Casing: 1 Q FT.
Rise "+" if Above Top of Casing)
R.TOP OE CASING IS l FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 1 3 METHOD OF TEST
10. WATER ZONES (depth): 1 451 — 11 i p•rn
a Ars
t I. DISINFECTION: Type j-{ tkL_ Amount 3 Lo 4-I,145
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From0 To a 5" FL _ " PVC.
From _ To Ft.
From __--To Ft.
13. GROUT: Depth Material Method
From n To d D Ft. C_parn_¢.ua ..j_„-.,
From To Ft. 1
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:
Slot Size Material
in.
in.
Material
Topographic/Land setting,,,�`
❑Ridge ❑Slope ❑Valley tatlat
((heck appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
D 5'
aS' a0s'
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
I DO I IEREBY CERTIFY THAT'CIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
('ONS'IRUCT1ON ST ANpARDS, AND "CHAT A C PY OF THIS RECORD IlAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING 'HIE WELL
/6-3/—d<F-
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

Cif
3e4ig4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�Resources - Division of Water Quality - Groundwater Section
W' ELL( ONTRACTOR (INDIVIDUAL) NAME (print) t��JJS irk ri LIAILkJ . CERTIFICATION #,
WELL (:ONTRACTOR COMPANY NAME ,st f3&tp , Li-t'Q-L 4 nap, , PRONE # .(a S♦ g -31 ' b
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Mb, Municipal/Public ❑ Industrial ❑ Agricultural 0
2
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
WELL LOCATION: / ,f
Nearest jown: LLlnyi7ESVr /IL County y'"741(wcOc>L
(Sire Ninne Nur%M;rs, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
L31oz
e-tts
erti�ibl'li�.
(Street or Route No_)
LLewrlt5Vr l it. &t 7kr7 gL
City or Tr n State Zip Code
Arai code- Phone number
4. DATE DRILLED 9- al - b q
5. TOTAL DEPTH: / 2 5
I., IVAIti U/LI I mt.)! Act F VICI INI, U141 I') Y!i5Ij1 !1r1 1�
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 accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): / b METHOD OF TEST Arc •
10. WATER ZONES (depth): /05' — /0 9f4M
Topographic/Land setting
❑Ridge ❑Slope ❑Valley la
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek hox )
DEPTH DRILLING LOG
From To Form l/tionlDescription
0 S/ '
5//.2s'
LOCATION SKETCH
11 DISINFECTION: Type H T/'H Amount 2 'Flubs Show direction and distance in miles from at least
12_ CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_.QTo 6/ Ft. to I! Pert
From _ To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To a0 Ft. ow,.. ,f
From To Ft.
14. SCREEN: Depth Diameter
Iron _._ To Ft. in.
From 'to Ft. in.
15. SAND/GRAVEL PACK:
Depth
From _To
From To
Size
Ft.
Ft.
Method
Slot Size Material
in.
in.
Material
16.REMARKS:
I DU IIEREBY CERTIFY TIIAT THIS WELL WAS CONS'fR UClED IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONS I RUCTION STANIdd1P/DS, AND'FI IAT A COPY OF T111S RECORD ITAS BEEN PROVIDED TO THE WELL OWNER
-3/-0T /
ONSTRUCTING THE WELL DATE
J
Taal
SIGNATURE OF PERSO
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh,: NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalResources - Division of Water Quality
l. WEl(T)NTRA(IOR (INDIVIDUAL) NAME (print). _ tuRC1) Pa n � ,,,p -
WELL ('ON1 RA("I OR COMPANY NAME )C X44-...&&4 . ��4 ---T �
SATE WELL (ONS I'RLJCl ION PERMITS _ l dr 0 a.._ ASSO('L\TED \\Q IWRMIT#
(if applicable) it applicable/
03480
- Groundwater Section
'/
(ER'rIFIC.\ IION# 2T/a
u(iNE: # (SWS-3/70
AV [LI. US11 (Check Applicable Box): Residential 0, Municipal Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water injection 0 Other 0 If Other, List t'ise
2. WELL LOCALION: Topographic/Land sett ittiNea�glown:�('ounty_Watteat. ❑Ridge ❑Slope ❑Valley at
lchceA appropriate box
Street Name. NundWrs. Community. Subdi, rutin. Iaa No.. hip t ode) L2111(Idelongitude of well location
3. ()WNFit: ale r4Jrllf-QJLJ
Address P 6 alit /.,3 g
Street
Route No.l q
l llc at luv n Slm/Whip
Area code- Phone number
.l. DATE DRILLED 6 - 3.0 -6
(,
.2AV/t3
L. DOES WELL REPLACE I EXISTING WELLY l't=.S ❑ NO R(
7. S'I A'I'I(' WAI'GR LEVEI. Below Top of Casing: ►O _FT.
Itha"I" iI .Ahme Tap or Casing)
K. TOP OF CASINGIS_---2 FT. Above Land Surihce*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2(' .a118. �7
9. YIELD Igpnt): �b METHOD OF I EST en /'ors
10. W ALI-.R ZONES (depth): j 05 ' - OD tp CYA _ ..
I L DISINF1lC f 11)N: Type- NZN -- --Amount 2,1+11 45..
C. CASING: Wall Thickness
)cpth Diameter or Weight Ft. Material
Prom 0 ro n Et. le ' 1
From _--.f"---__Ft.__.
Prom To Ft.
13. (iROL(T: Depth V-taterlal 1
From D To Q/J Ft.
From-_._ To_
I-l. S( REI`-N: Depth
NIethod
Diameter Slot Size Material
From To Ft. in. in.
From I) _--._ PL in. in.
15. SAND: (iRAVLL PACK:
Depth Sim \ latcrial
Front To Pt. ____. -_..._
From to
16. REMARKS:
�Jcuri a. uunule.. s.cnnds)
l.atit LOC. loneitude source:❑(iPS❑Topographic Iitap
(cheek hox
Di-P 111 DRILLING LO( i
Iron l'o Punn:ttio_ I Description
20• ' ias'- l%' <_ o
LO('.AIION SKE'FCli
Shove direction and distance in miles Gomm least
two State Roads or l'twiny Roads. Ines z the r(�d_._:
numbers and Conuuon road names. r
0
-or;
▪ =ci
cr+ cs-
—ten
Ric -1
• cox
-aa
LO o"
Lis N,__
r� (✓,
I DO IIE14Ii131- (ERIIFY TI IAI lIIlS \ATI-1. \V.\S ('DNS IRtiCFED IN At MI) \NCP. \\Till 15.\ Nt \ C 2C. \l1d.1.
l'oNSIRI:("rloN S IANI)ARDS, AND TlirVVCtT7111 (/1 IIIIS RIuORD 11:As I3l 1 N PROA I1)I.1) 101Ill: NA EH OWNI'_R
/0 -Z1 - 0 V
DA rF
Ltd Ainut
siGNAIFRI- OP PI'RSON CONS1ICLC"IINll 1111 AAIII I_
Submit the original to the Division of Water Quality, Groundwater Section, 1631. Mail Sec\ ice ('enter - Raleigh. N('
27699-1636 Phone No. [phone]. within 30 clays. OW -I REV. 07 2001

3p3481
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) N:AAI (print) (0 � / n
g
WELL CONTRACTOR COMPANY NAME _/ae�lh I'd�Ji4C ('ERIIPICA1ION a a�/ '• ! t ' PHONE. it)d fg 4ta 3 i �,e
stilt WELL CONSTRUCTION PF,RMI'1'H _4Y __. / O.,2.__-- Assoct A TED WQ PERMIT# _.... _
(if applicable) (if applicable)
1. WIILI. t1S11 ICheck Applicable Rae): Residential i Municipal. Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 I Other. List I ise
2. WELL I I OC',Vfi) : J% . 1_
Nearest town: (ountyglipr 9001
{Street Name. Numbers. (omntunity. Suben won. Lot No.. lip (o del
3. OWN1:12:
Address U PPS Lies__./475 .._-
�'Nr, t IS+Feet or Rome No_I
( in mn State ApC--
dma CAR' Phone numhcr
4. DA IT DRILLED g -�5 -lit
5. TOTAL DEPTH: 305
E. DOES WT.I.L REPLACE EXISTING WELL? YES ❑ NO
7. SEAIIC WAFER LEVEI. Below lop of Casing:
(Use 'r" if .Above l op of (:maim
S. TOP OF CASING IS _ _-/ FT. Abine Land Surfocc*
*Top or casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .e118.
9. YIELD(gptn): 32/) METIlot) OIa rksT hr5
10. WA VER ZONE'S (depth): / 86/5 n-7 _.
�1 .3p7�_ -_fir fern
1 L DISINff.0 {ION: Type I't• 1 :Amount j t4 /-lS-
12. ('ASIN(i: Wall Thickness
Depth Diameter or Weigh. Ft. \l:teria l
From _. T0_q_ Pt. l.o It ?A!C
From to Ft.
From To Ft.
17. (iROL 1l': Depth ,. Material } Nlethod
Front r_ To
iron) T°--___it.__._..
14. S(' 12.11EN: Depth Diameter Slot Size VIaterial
From __. l o
iron)_.. To
IS. SANI) GRAVE{. PACK:
Depth Size \laterial
Front l o Ft.
From — to
16. REMARKS:
Topogrphidl.and set1ni
❑Ridge OSlopc [Walley %lot
(cheek appropriar b m 1
Latitude longitude ol well location
I derc., nunucN second 1
�- Latitudelongitude source:❑ iPS❑Topographic mays
{check host
I)RILLIN�(,iLO( i
Formation l,
7Q�V�=sip`ion
Di-.P111
rom 43'
43 ' 30_61
LC )C',A flt)N SKETCH
Show direction and distanee in miles from at least
two Smtte Roads or County Roads. include the road
num1hers and common road nameS.
SS:6 WV 9310010
I DU I IERIillY CER'Ilil' MAT THIS WIiLI. WAS CONSIRLIC IIiI) IN .AC CURD:AN('I- V 111 I 15 \ NC VC 22C, UI.I.1_
('ONS'IRI i(IION STANDARD$, AND III:A f -A COI'(" OF_lIIIS RI'CO121) II_AS 1311-N PI-UAIDILI) TU lllli Wlil.l. OAA'NF.12
/p-.1/-OSI
SI(INAI't:RF 01-I'PRSUN CUNsfRt:r'TING ll1l-AAllI. I)Allf
Submit the original to the Division of N ater Quality, Groundwater Section. 163o \I ail Sen ice Center - Raleigh. N('
27699-1636 Phone No. [phone]. within 30 days. (iW-I REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N. tural $csources - Di ision oT Water Quality - Groundwater Section
\VELL('ON'I It.\('I'OR (INDIVIDUAL) NAME riot)Af ;1"
WEI.I. CONTRA( TOR ('(E%I l'AN V NA31 E _
SATE WELL CONSTRUCTION IlON PERMfig
if applicable)
4J0 /t :re CEKTIFICATION 044
!(. !_ ElIONE !tafq ' / D
ASSOCIATED WQ PERM ITN
Ora dicable)
I. WELL USE (Check Applicable 13ox): Residential S"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:
Ne)ijjcs(Town: l/Yolfres,�"y'/lf; County „l
7'CCr✓ /1%!' ✓•
(Sir Name, Notobers. onlmunily, Suluhvision. lad No.. Zip Cak)
3. OWNltR:Z7 rt,Cc
Address - 342
(La- `5$.Q -7/i9
•
Area code- Phone nailer
4. DATE DRILLED/P.(, V5' o
V.
5. TOTAL DEPTH: o(Ei " 4 t
6. DOES WELL REPLACE EXISTING WELL? YES I7NO 0
7. STATIC" WATER LEVEJ.13elowTop ofCasing: ? rr.
(Use "4" if Above lop of Casing)
R. TOP OF CASING IS FT. Above Land Surface'
*Top of rasing terminated at/or below land surface requires a
variance in accordancewith ISA KCAL 2C .011A.
9. YIELD (gpm): /0 METHOD OF TEST ,- /
10. WATER Z.ON S (depth):
ny m nwrn
(Slr or Route Nn.) (A/ )/ ,/
A1G
Stale Zip Code
11. DISINFECTION: Type 4/ , Amount
12. CASING: Wall 'Meknes
Depth Diameter or er Wci'ht/Ft
From t04• To RS- Ft.6 4/ / J3
From To FL
From To 11.
Topographic/Land setting
IH4£idgc ❑Slope ❑Valley ❑Flat
(check appropriate box)
L't iluddlongilude of wet I location
Wcgrecs/minulcdseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
. DRILLING LOG
lextir)p Description
DEPTH
From • To
1J /e
LOCATION
Show direction and distance in miles from at (cast
s . two State Roads or County Roads. Include the road
S7<�N Ntocriat/ numbers and common road names.
)/7j/ , %(
13. GROUT: Depth s Material Method
From t To &n Ft. eiE"dew,—
I-•rom To Ft.
14. SCREEN: Depth Diameter Slot Sin Material
From To Ft. in. in.
From To FI. in. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To FL
From To Ft.
16. REMARKS:
11)O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Pho1c No. [phone]. within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
504182
North Carolina - Department of Environment and Natural `Reso recs.- Division oT Water Quality - Groundwater Sccltioonn'/> /y-
\\'ELL('ONIIt,\("I'Unll\UI\'IUUALI NAME (print) tile/let
joy ' CERTIFICATION #G^ t'
W1:1.I. CON'IRA(TOIK C(fIPANYNA?lE f'6e -V ./l et tip PHONE It C'
sExrE wit,. (-ONKtiturnoN PERMril ASSOCIATED WQ PERMIT#
( irapol icahlcl (if, secable)
I. WELL USE (Check Applicable Box): Residential IF Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 (Recovery. 0 Neat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO :
Nearest Tpwn: I
•. Te4(Alert
(SOW Naunc. NI Is. Community.
3. OWNER:
Address
County
E
Sohlhvisimt Ian No.. Zip C ode)
eihert
(S rl , Roe No.
!4Ve7 N4usysi mw('. ..2K1V6_
City as Town Stale Zip Code
(V. )- 6017- 97n
Area ark- flame number
4. DATE DRILLED IS::/-2
5. TOTAL DEPTH: (1.5S
6. DOES WELL REI'LACE EXISTING WELL? YES Q,NO
7. STATIC WATER LEVEL I.IielowTopofCasing: &2 FT.
(Ilse "+" if Above Top of Casing)
S. TOI' OF CASING IS t 1•T. Above Land Surfaces
•Top of casing terminated at/or below land surface requires a
variance in acrnrdurc with ISA NCAC 2C .01111.
9. YIELD (grin):JO METHOD OF TEST »'r
10. WATER ZONES {depth):
1 I. DISINFECTION: Type _ 7-27
12. CASING:
Ixpt a '% r
�� Frmn , To T1 H. lD
From To rt.
From •ro • Ft.
13. GROUT:: Depth
From 0 To.f� Ft.
Topoggraa ie./Land setting
❑Ridge I2Slope ❑Valley ❑Flat
(check appropriate box)
I ai ilu(Ic/tongiiude of well fixation
tdegrees/minules/sceonds)
Latitude/longitude source:❑GPS❑Topographic map
lcheck box)
DEPTH . DRILLING LOG
From • To Fhrynapin Description
vOY
f0.Sa,+4.S4/tC
LOCATION SKETCI-1
Amount - Show direction and distance in miles from al least
Wall Thickness . two State Roads or County Roads. Include the road
or Wright/Et. M• serial numbers and common mad names.
Material(
Ateivr
From To Ft.
Method
0
J'
14. SCREEN: Depth Diameter Slot Size Material a
From To Ft. in. in. o
Front 'ro FI. in. iu. 1
15. SAND/GRAVEL I'ACK: to
lhpIh Size Material . as
From To Et. Zt
Front -fit Et. to
16. REMARKS: CD
I IX.) HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
to la- oL P
DATE
Submit the original ill the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636I'hone No. [phone], within 31) days. GW-I REV. 07/2001

oLF 3034"
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and / u al 1 esources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR COMPANY NAM
WELL CONTRACTOR (INDIVIDUAL.) NA E (print) /
CERTIFICATION #07 NI $
_-Gc%t�L� / ....i ). _ PHONE # ve- 3 / 7d
STATE WELL CONSTRUCTION PERMIT# Liio.2 "�"'---
ASSOCIATED WQ pF.RMIT#
7
(if applicable)
(if applicable
WEI.1- USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATION -
Near Town: s - County /` Y//
(Street Name: Numbers. Community, Subdivision, Lot No.. lip C xle)
3. OWNER:
Address
(SVeet or Route N
City or Town r
-State Lip Code
.Area code- Phone number
4. DATE DRILLED g - /- t
5. TOTAL DEPTH:g _..__ i)��` ///
OLS \U:.:. 1. U1:nl A/'l; FVIl H( a/1:1 I9 YES1a1 Ivr\
7. STATIC' WATER LEVEL Below Top of Casing: __Qfj FT.
K- Top OF CASING IS (Use '' if Above Top of Casing)
FT. Above Land Surface*
`top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): � Q METHOD OF TEST____,_ rt 10. WATER ZONES (depth): gla ., _ - 6 1
11. DISINFECTION: Type ____
122. CASING:
__/-� Tja Amount�L:F.-i,�'�.
Wall Thickness
® Depth Diameter or Weight/Ft. Material
From_ To J g__ Ft. /a II
From -.. .._ To Ft.
From To Ft._
13. GROUT: Depth Material
FromO To
_e2Q_
Prism _ To Ft.
14. SCREEN: Depth Diameter
Slot Size Material
From To Ft.
From To FL_—_-
15. SAND/GRAVEL PACK: __
Depth
in.
Depth
From To
From To
P TEFL
Method
16.REMARKS:
Size
Ft.__
Ft.
Material
Topographic/Land setting
...///
❑Ridge ❑Slope ❑Valleylat
(check appropriate box)
Latitude/longitude of well location
(degrees:minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
DEPTH (check box)
From DRILLING LOG
To Formation
rmation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
hS:6 WV 9?130h0
I DO IlERF13Y CERTIFY TIIA7-THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
('ONSTRUCTION STANDARDS, AND TIIAT A COPY OFFF TTHIS RECORD 11AS BEEN PROVIDED TO THE WELL OWNER
SIGNAL URF 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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat al
WEL.I. CONTRACTOR (INDIVIDUAL) NA%IE (prim) /%p�j Ob)
WELT. CONTRACTOR COMPANY NANwGreene erxdt
l4- 6
S'1 ATE WELL CONSTRUCTION PERMED(
I if applicable)
z03` 15
esotlrccs - Dii\-isioo Il uli.Water ( lualily - (nound\4 atcf �ldetlon'/ Q
n Lt _))` t_I? ... CERTIFI(.VlIION{ff /g�(7J� V
\SSoctAI'P.D \\Q I'ERNIIT# --__--
(if applicable}
1. W'I.1.1. 1iSli (('heck Applicable l3ox1: Residential)6 Municipal Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ I leat Pump Water Injection 0 Other 0 if Other. List l'de
'- I WELL U('AI'10 - Ne � E
Neat e\t'I Town: 1i�E�S rV�I /�L- ('ounty
ara
enS O-1 mil.
ISuur Halm. tiumhers. Cumnlunirc. SubrIn ”rot tot hip ( „del
OWNER:
Address -__tat. -Sep�
(Street or Route No.) a O (% J
(lno I uli State hip Lode
Area toile- Phone aumher
T. DATF. DRII.LI[D _U.) 04
5. -fO'lAl DEPTH: 1105
DOES WP! 1 RI'.PILA('E EXISTING WF:I.1.? YES 0 NO
Eta.__ T J
7. SINIICW.AIERLEVEL Below lopofCasing: t'i'D F"l.
Il Ise it Top ot(antl
N_ TOI' OI (ASING IS _-J- ET. Above Lund Surface*
*Top of casing terminated at/or below land surface requires a
arianee in accordance with 15A NCA(' 2(' .0118.
9. YIEI.l)tgpm): g%% .-METIIODOI—FI T_-7_13rS •.
1U.AVATFRZONES (depth):.__5 — RQ�Qm..-
Topugaphic;Land setting
❑Ridge IN -Slope ❑Valley ❑Flat
cheek vpprupriale box)
Latitude. Ion iitude of wc1F location
Wcpr.,'> nnuute> second.)
Latitude longitude souree:DliPSO'ibpogrtphic nap
I:heek hog)
DLPlll DRILLING Li A i
From 1'o I Formation Description
3`1' ILo5' iSa-.te•
1 I. DISINFF(' IION: Type_.. }-}-Z1-1_. An„,,„„Aft_ . s-.
12. CASINO: \Val1 Thickness
I)cpth Diameter or \\bi^_ht. It I\iatcrial
From I" 1'o 3C( Pt. to it -- —PVC__
From .__'lo__.._—..
Front To
13. GROt I"l: Depth
From D_ To_ab
Prom _ To_
td. S(RFEN: Depth
From _ lu_
From To
15. SAND 014 AVFL PACK:
Depth
Front---- to
From To
16. REMARKS:
ptamrial Method
Diameter Slot Size \ Laeria
I1. in. ______ in.
Size \lateral
It.
Ft.
LOU, AIION SIC IYII
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
nuulbcn and eomunon road names
hS:6 WV 931301)
I 1)1) HEREBY CERTIFY TIiAT TIIIS WEI.1. \VAS ('t)NSIRucn l) IN ACCORD \NCI \\l'l11 I5.\ MAC 2C. WELL
CQNSI R1 !CIION STANDARDS, AND II IA T A COPl OF THIS I(li(-ORD IIAS BI fN PROA ID! !) TO IIIII WRIT. t)WNF(
/D-sz/-e�1
) til(iNAl'1121-OP P0N Ct)NSIRI'C I'INtil'I ll-\\'1-.11. U:\I'1.
Submit the original to the Division of Water Quality. Groundwater Section. I63o Mail Nersice ('enter - Raleigh,UI11N
27699-1636 Phone No. [phone]. within 30 days. G\V-I REV. D

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources\- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)6 )_Yn ,Id`�P,bl b CERTIFICpATIpON�#27 6
WELL CONTRACTOR COMPANY NAME Grc_ TI'Ct, 2 n-C`u L�P✓1-A PRONE # (Laic Qt- 3 i 7b
STATE WELL CONSTRUCTION PERMIT# I'Y� e'2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential $L Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT/IO. :
Nearest Town: L6 /Z//L1 County
'Jtrt'-e M 1-) - Leathtruann.li
tAffid-
I Street Name, Numbers, Community..rnLL�
Subdivision. Lot No.. Zip Code)
3. OWNER: £ n'q Brrnr
Address i •4D9i Pr m.v Irlelnr» g - sotLa
4�(Street or Route No.) LQ�I �e asi'7 A
City or Town State Zip Cole
( )-
Area ode- Phone number
4. DATE DRILLED Lo - j 1 D 4
5, TOTAL DEPTH: 5 Q5 '
,. Irl ri.e µll.l 1 UGPI A!'I, I. VIC'I INII: 1A%LI 1 .1 VI. 11"Nill
7. STATIC WATER LEVEL Below Top of Casing: V'T FT.
(Use"-4 if Above Top of Casing)
K. 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.
9. YIELD (gpm): % METHOD OF TEST clhr5 -
10. WATER ZONES (depth): � � S - 641 ern
-5 6. - '/2. pt
I1. DISINFECTION: Type rkI Amount 9�.
}{-'.,+b14s
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From b To 3(o Ft. /n It
From To -_ Ft.
From _ To Et.
13_ GROUT: Depth Material Method
From__To ab Ft. ice..
From To
14. SCREEN: --- Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From _To Ft.
From To Ft.
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Material
DEPTH
From
Rlo t
Topographic/Land setting
DRidge DSlope ❑Valley 'Tat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
tude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
To� t Format ipn Description
SaS' 11A Aszis.
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
hS:6 WV 9Z190h0
n;:
Pa St T�
"Dw
- (.
C:
o0
-ac
Rir
-t is
=CI
rno
rnp
0
16. REMARKS:
I DO HEREBY CERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS' OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
e ei/-eV
J %.2 A
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Dip)
- Uicisiu!1of Water Quality - Groundwater Section �!5'
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ��jjDP) n }e`+V C'ERI'IFl('.\IIppON#aij/"
WELT. CONTRACTOR COMPANY N:(NIFvrGe-inks L�f GS . Wei -4 A(A.>;r\�J1 PHONE # 3o�'9 JO'kg - 31 -7
S'1':\I'E WE I.I. CONSTRUCTION PERMED( __. //b ._.._.__ASSOCIATED WQ PERM IT#
I it applicable) (it applicablcl
I. WE:I.I. USE (('heck Applicable Box): Residential, Municipal. Public 0 Industrial 0 :Agricultural 0
Monitoring 0 Recovery ❑ 1 (cat I'ump Winer Injection 0 Other ❑ If Other, I.ist l Ise
2. WELL I,O('A1.ION: I I
Nearest
lfowm: )/—tl tZta/ Cot.unty/ ]f ck
ity
Ai
(Street Monte. Nmnbcrs, (( immunity. Subdn Isom. Lot No.. /ilt`l ode
3. OWNER: 3-1 re%
ti
Address P -]
'Street or Rotile No.
:CYla I ey at.1 C--- 1
l 11' UII Slate ) /in (
:\rite COLIC- Thom. number
-4. DATE. DRILLED $ —sI-0S
>_ ToTAI. DI':PT11: 405'
(. DUES WEI.1- REPLACE EXISTING WELL? YES 0 NO EL
7. STAIR( V.\ TER LEVEL Below Top of Casing:. 5«0 _FT.
'Lea ..t.. il:Vwcc top or Casing/
S. TOP OF CASING 1S � IT. Above Land Surt;tcc*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A N('AC 2C .0118.
9. YIE':f.D(gpnl): /5 METHOD OFILST o�Lr5
10. WA IIIR ZONES (depth): ' ,2D5' -J5 q ism.
II. DISINFII(IION:'fypeI
1^L.1s7 \{
12. CASING:
Front D
From
From
13. (ikoltT:
From©
From
L1. SCREEN:
Deptli Diameter
To_aFt.
To
To
Depth
\mount _7_4
Wall Thickness
or Weight. Id. Material
�(" PVC
/t "Material 1ethod
ro_c20
To It.
99°—
Depth Diameter Slot Site Alace ial
'bunt To El. in. In.
From To Pt. ia. in.
5. SAND :(i12:1VIII_ PACK:
I/epth Site
Front ho Ft
From --- -.fo Pt.
16. REMARKS:
latcrial
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 'lllat
I cheek appropriate box/
Latitude. longitude of nell location
l dccrc:. nunalcs sce ,ii 4,1
Latitude- Iongitude Source:❑(iPS❑Topographic neap
'cheek ho>I
DI'.I'lll DR11.1.I1N(i L.U(i
From fry I'Up1Cltit111 Description
jai
a
3. 5'
LOC.\ ''ION SKI :T('ll
Show direction and distance in miles from at least
two State Roads or (aunty Roads. Include the road
number. and common road names.
SS:6 WV 9Z13O10
I DO IIERIiR\ ('I1 Rl1PY TIIAr THIS WELL WAS ( '1)Ns'1RUCll!D IN :\(CORD-\N(F: WTlll I5:\ N('AC ('. \\ 1JL1.
CONS IIft 'ION STANDARDS, ANI) TIIAI A (UI'Y OI l IlIS Rh( ORI) I1.AS 19FIN I'120A 11)1 I) 10 1111: WI -I 1. t)WNP.(
e2) e zi—a
SI(iNAIURF- (I*YfRSON (ONSIRI'tt !NG II JF AATl 1. D.AII':
Submit the original to the Division of Water Quality. Groundwater Section, 163o Mail Sea ice ('enter- Raleigh, \('
27699-I636 Phone No. [phone], within 31) days. (iW-I REV. 07 21)111

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section // p
WEL1. CONTRACTOR (INDIVIDUAL) NAME (print) 1't (J b 1 r1 Lip a �s..�, (' ERTIFICATION# a 1` �o
WELL CONTRACTOR COMPANY' NAME S'7 t'te-Ile_ a(' CS. 1 r_) p3D N 0-rAil I'HO\F: # (!).(1(> rP qt- 3/ q
Lir/D�
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal: Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 110t1er, List Use
2. WELL. LOCATION;
(Street Name. Numbers. community. Subdivision. Ian No.. Lip ('odes
3. OWNER: (I t4T 1 ' MIc
Address 1 D scq -t l d u).atlu
(Street or Route No.) Nc ol g) L ^/, )
nesvr //e ,(/`U U/
State /
29822E
STATE WELL CONSTRUCTION PERMIT#
hp( ode
1 Area code- Phone number L` I�
4. DATE DRILLED I - 1 3 - Dy-
ASSOCIATED WQ PERMIT#
Topographic/Land setting
❑Ridge ❑Slope [Walley ighlat
I check appropriate box;
Latitude. longitude of well location
Ile?ma nunutcssecond>I
Latitude longitude source:❑GPS❑Topographic ntap
(check host
DI.I'Tll DRII-LING LOG
Front l o 1 Formation Description
4 r 95 t
5. TOTAI. DEPTH: Li- a s 1 ..
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO _
7. STATIC WATER LEVEL Below Top of Casing.: 1 Da FT.
(Usc"t" It Abe veTop of Casing)
8. 'TOP OF CASING IS I FT. Above Land Surface* -
*Top of casing terminated at/or below land surface requires a —
variance in accordance with 15A NCA(' 2C .0118.
9. YIELD (gpm): Y 50 ( METHOD OF TEST_ ps i1 Ys
10. WATER ZONES (depth): I-1 D - I So l p m
11. DISINFECTION: Type 47-i:-1 Amount /r,n ±UU%S
12. CASING: Wall Thickness
Depth ,,// Diameter or Weight Et. Material
From 0 To 9 `F' Ft. (o rt P VC,
Front To Ft.
From To Ft.
13. GROUT: Depth Mater_ ial t Method
From 0 To a C) Ft. ���,Yt4lw� +b-R
From To Ft.
14. SCREEN: Depth Diameter Slat Size ,Material
From 'To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Nlatcrial
From To Ft.
From To Ft.
16. REMARKS:
L,OGALION SKEICH -
Sliow direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. c ..
o
Y
CJ7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wllll I5A NCAC 22C. WELL
CONSTRUCTION STANDARDS, AND 'MAT A COPS OE llIIS RECORD IlAS KEN PROVIDED T0'11IE WELL OWNER
SIGNATURE UP PERSON CUNSTRUC II- . WEEI I. DATE.
Submit the original to the Division of Water Quality, Groundwater Section, 163i Mail Secs ice Censer - Raleigh, :SC
27699-1636 Phone No. [phone], within 31) days. (i\\ -I REV. 07. 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION # 3, $2
PHONE # Faie (pT -31
WELL CONTRACTOR (INDIVIDUAL)NAMIE (print) &__era L4J._ vI-�LC nc--a.-- -
WEI.LCONTRACTOR COMPANY NAME' >t,p a,_/. tc3t-oS . /p) u `F PLL_J77p
STATE. WELL CONSTRUCTION PERMIT# / Y D R ASSOCIATED \%Q PERMIT#
(if applicable) I if applicable)
I. WELL USE (Check Applicable 13ox): Residential Municipal. Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 IfOther, List (Ise
2. WELL LOCATIO
Nearest Town- 1 County
P ity-in A In
(Street Name. Numbers. Community, Subdivision. Lot No. . Lip lodcl
3. OWNER: of 4-Pr V I LD& kb LJS
Address / �U ,� r
(Street or Route No.)
a- /Mua�J, / /P t) I✓ a
( ity o iewn State Zip ( ode
1 )-
Arca code- Phone number
4. DATE DRILLED I JI/3 - b
tit
5. TOTAL DEPTH: T c2 S'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO tit
7. STATIC WATER LEVEL Below Top of Casing: / FT.
0?8788
(use if.Abave Top of Casinel
S. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/ur helot land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gptn): 2D 4- METHOD OF'lES'L P 1- rs
10. WATER ZONES (depth):
Topographic/Land setting
Lge ❑Slope ❑Valley ❑Rat
(check appropriate box)
Latitude longitude of well location
tdeprees nu auto. seconds)
Latitude lon_itu(Ie source:❑GPS❑Topographic trap
(cheek huxl
DI.01.11 DRILLINCi I O(i
From To Formation Description
LOC'A'HION SKETCH
I I. DISINFECTION: Type -f -% ,Amount 4_h14& She' direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include theaoad
Depth '/ Diameter or Weight Et. Material numbers and common road names.
From f) To In el Et. &, t i P V C.
Front To Ft.
From To Ft.
13. GROUT: Depth /Material Method
From dO To c & H. CD /bT
From To Ft.
14. SCREEN: Depth Diameter Slot Size \iatcri:d
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Svc Material
From 'To Ft.
From To Ft.
16. REMARKS: - -
1 DO IIEREI3Y CERTIFY TIIAT TIIIS WELL. WAS CONSTRUCTED IN ACCORDANCE WFIT1 I5:\ NCAC 2C. WELL
CONSTRUCTION STAND RLDSS, AND THAT A COPY OFTIIIS RECORD I II,A,SS BEEN PROVIDED TO TIIE WELL OWNER ,
ei 11 1 c�c�('�-r... l i -= i- b `(/ /
SIGNATURE OE PERSON (UNSTRIiCTi t5 T11- Wlil L DATE.
Submit the original to the Division of Water Quality, Groundwater Section. 163a Mail Ser, ice Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 day. (AV-1 REV. 07: 2001
298225
'70

WELL CONSTRUCTION RECORD 298221
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectionfj
WELL CONTRACTOR (INDIVIDUAL) NAM print)__ Dip/n _—_W���-^ /�'�' ��'� CERTIFIC.Vf1ON ka4t / ,/g
WELL CONTRACTOR COMPANYNAMEj �2-Qh tiiQ_ Faros O// PHONE it 4)S ry T-3/ 9C
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
.sSSOCIATED WO PERMIT#
(if applicable)
I. WELI. USE (Check Applicable Box): Residential K'. Municipals Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ ICOther, List Use
2. WELL LOCATIO
Near To
County_ n�0(�,
(Street Name. Numbers. Community. Subdivision. Lot No Zip C oriel
3. OWNER:
Address
(Street or Route No.)
)� lGa
City or Tomlt State
(
Pi' II •
Yip (,�IC 010 6
Area code- Phone numhe 41.
4. DATE DRILLED I - �l -
Topographic/Land setting
❑Ridge ❑Slope ❑Valleyat
'check appropriate hox)
.at itude,longitude of\veil location
(degree,. minutes. s conde)
Latitude lom_itu(Ie source:❑(iPSOTopographic map
(cheek box)
DI P1!! DRILL.w(i LOG
From ha Formation Description
t3'6,t t
Rip
5. TOTAL DEPTH: 9 9i) r ,,.,(
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: $O FT.
(Use•.. i f Ahovc Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2(' .0118.
9. YIELD (gpm): f ',1O -I- METHOD OF'I EST pQ ArS •
ID. WATER ZONES (depth): (i 9D l - / 2[D lern- _
LOCATION SKETCH
11. DISINFECTION: Type
12. CASING:
HT/-/
Depth
From © To S' % Et.
From To Ft.
From 'Fa Ft.
13. (TROUT: Depth
From e To .2
Amount % S 6I-1-s Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Diameter or Weight Ft. Material numbers and common road names.
P V (1,
� t(
Material Ntetbod
i-V�YY(YJ/2-C
Ft. , 7_o-0
From To Ft.
l4. SCREEN: Depth Diameter
From '1'o Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size :Material
From To Ft.
Slot Size A'Iatefl91
in.
in.
From To Ft.
0
0
CS7)
nra
-c
o-c
frn
vo
rn
con
NZ
frl
16. REMARKS:
1 DO I IEREBY CERTIFY TIIAT THIS WELI. WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C. WELL
CONSTRUCTION STANDANRD-S,,//�Y�NI) .II IA I A COPY OF TT IIS RECORD I I�\S.FiJ;[.N PROV IDED TO TI IE WEI.I. OWNER
_A w a- 0' g_ 13 9
W SIGNATURE OF PERSON CONSTRUCTING TRI. TI I. DATE.
J2
Submit the original to the Division of Water Quality, Groundwater Section, 163o Mail tiers ice Center - Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. OW-1 REV. 07 200I

WELL CONSTRUCTION RECORD
Noah i to!ur., . Jepanment rf Fn' Iromncnt and Nau)ra1 Resoufces - Dis
\\)11.1 I1A 11(1('I ON11\VI\IU1 AI.1\\SWE (print)__.at\sr
N1(-IUt(OUP \' t5.1E 115I b-j
11' YI I' \1 El I. ( ins 1 Nl ( I10\ Pf.RMIIs - ___
I u f JPl
298102
of Water Quality • Groundwater Section
CERTIFICATION aZI
PHONE -M
ASSOC! \ I V.n 'Q PERMIT/
l(appLcablr)
1l ELL USE tl'h::k .\ppteable Hox1. Residential 1.2 Stunicipal-Public ❑ InJustrial ❑ Acrieultural O
.'onil.iiin g 0 Reco e,c O Heat Pump Water Inaction 0 Other ❑ If Othc, List Lis:
..
2 N ii;.L LOCATItcn— ----.
i\t'JR,.t Tll1.n .. C11111itV
Loin _..i4-_ _(>xv Et _N.
.S. e:: N enc. \.4 rh. rs. ('om; ri.i: ). Subdiviiioe. Let \a L., C ode)
\„I:R a.Lg � Y
km un piatc Zip Code
I 1-
00#7opogra is Land setting
1 ( ORiJgc lope O\'alley �t blur
`1 V !check a:Trunnaa Mrr
Latitudelongitude or well location
S. L'AI t DRILLED.._/? 14-- C
TOTAL. DEPTH._ 71, ----
6. DC)hS WELL REPLACE EXIS1 ING WELL." YES 0 NO F
' ST:\ I IC WATER LEVEL Bciow Top ofCasing: _fa 0_..FT.
11icy; "•"i(Abo,. for. or C asmg,
? TOI' Or CASING IS ._ ___I__-_, _ FT Abort Land Surface•
ii7Ly n( casing terminated actor heluw land surface requires a
, arianee in accordance with 15A NC' \C It .011N. __ __
9. YIELD Lprnl:_a•� ti1ETFIODOFTEST __e.f• //11 Ci1Cit1El�• .-- __—_.
'U \VA i ER ZONES (depth). _._-1 t� _s - ------ -----AT}ON SKETCt1--- ...--
LOS
!I I)IS1.\FEC T`h
TION. Type \ _t- _jr— Amount .—_ -----
__ -. Show c it Ilion and d. tar c in miles from at ica.m
12 CASING' Wall Thickncs Iw:a Slat; Roads or County Roads. Include tea road
Depth D.amercr or Waleh,'Fr Mutest uarnbet s and conmwrr-rpad names.
From _Q__ fn. g,„ Ft _____
rom •-o R.
nNgr.'el q:n,..'; s. seconds:
Lul IUIJ: ItineitliJe .souls-OCiPSOTopotra, hic roan
hos)
FRILLING LIKE
Formation Dea: ripllon
Ut l_TN.
From To
13 ( ;RCJL.1 Ok nth y ,t Mchor:
twin__,— Ft.gQ1.et.e4
L: l_ RF I.N i.%Tih __.._ Diamete- s.•o \ae \131er z;
Erma. _.__...__. 'To .... _..— FI. in.
Fr.uc To Ft -.. _ in
15 SAND ciRA \' EL PACK
Ficp'a S -e \larcrial
I1171'1---__1".-.Ft-----
!r RF'.I+.RK\: _
1 v (mil
zog
-�
tS K�=
CO Frri-,3
YO
r•lx
I')O Hi RIb', IS\('ELL WAS C' )NSIRLCFE[) IN At. WIZ DA\( E WI'[H 15A CAC?C WILL•• �S
(DNS fR t'f;i) S NDARDS. ND_r7flT A COPY OF INS RECORD HAS BEE\ PROVIDED TO 11ifi WELL OWN LTIzJ
2
.\IGNATL'RL OF PLIRSON CONSTRI.C'TINCi THE \4fLL DATL
Submit the original to the Di\ ision of S%ater Quality. Uroundn ater Section. 1636 Mail Scr\1ce ( enter - Raleigh. \C
77644-tale Phone No. [phone]• within 30 da\a (ON -I REV. 072001
0
Z

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Ih ision or Water (ivalith
\%E:LL CONTRACTOR (INDIVIDUAL) NAME (Priori --/ � t Q.� A4-2A
WELL CONTRACTOR COMPANY NAME. GYCt_hE •6•Kb 5 . LL/ 4 /'/ �1 PHONE
STATE \vEI.l. CONSTRUCTION PERMIT# _-.. /VC) Assoc [ATE() \yQ PERMIT,*
lit applicable) - (if applicab lei
299082
(i roundwater Section
('ERl IF I('.U'ION # Joel/
1. WELL. II SE ((_heck Applicable Bus): Residential, \lunicipal Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Ileat I'untp Water Injection ❑ Other ❑ ICOther. List Elm:
2. \\'I:I.L LOCA I lO�
Nsaccst loam
/�Q.j J(1/k (ounly //
�L/Lc/JOG( L
il! .1 +P.r111 T(/. 'V ��kyed t�" !"JD lit Cie a
unyl�cn, Cummunib. Su6dinnnm. Lot N . G i (od •
J(.W anI
lstreel r:amo. N %% I U
Address .. 47 7 2.Le s`•'0A .1.) iU- _ata •
_r I lrcct ulRif _ANO.//f ag3/
Gl]� L E NG
(n fowl Scnc !qi (nth'
Area vatic- Phone number
I. D:AI E DRILLED - /
5. 1OTAI. DEPTH: _Ct US_.!
b. DOLS \YEI.I. REPLACE EXISTING W'ELI:' YFS NO
7. S'TA1IC WATER LEVEL Below Top of Casing: 0 Fr.
use - 1 if Above 1op oi( a,olpl
8. TOP OF CAS[NG IS f IT. Above Land Surface"
*Top of casing terminated ator below land surface requires a
variance in accordance with 15A NCAC 2(' .011K.
9. YIELD (gym): _ METHOD OF TE:s r�ypJ
•
ID. \VAIT':R ZONES (depth): _6D'_.- SRC
11. DISINII.CI ION: Type f'f %/"/ Amount /Q$_Jiffs,
12. (ASIN(i: wall lhiekne„
I)cpth Diameter of Weight Ft. Material
Prom. 1 "To 4/7 Ft. , )/_ Pye_
I-roni .— Io _--Ft.--. __.__..-..
From To
13. (ROVE 1 Depth /l Materi�al �J Method
From (� 'ro_�'Q,.. Ft 4-4_Qj
Prom ,,_.Io -_ Et._
14. SCREEN. Depth Dtanteter Slot Svc \lateral
From.._ To Ft. _ in, _ in.
From ru Ft._ _ in.
13. SAND GRAVLI. PACK:
Depth Svc Material
-tom_ ru_ Ft.
Front ._-ru
16. RLNI:ARKS.
Topographic:'Land setting
❑Ridge 'Slope ❑\•'alley ❑plat
check appropriate box)
Lai nude longitude of vyell location
i deetvc nnnmee,eeandn l _.
I.atiuule loro_Itlnle source:❑(iPS❑ ropographlc mall
(cheek boa
DRILLIN(i Ll)(i
Formation Description
1)1.P111
1 ronl ro /
O
¥Y t GS
_
LOC. \(IONSKIfrclt --
Shms direct on and distance in miles from :u leasi
two State (toads or ("ounty Roads. Include the, road
numbers and common road names. o
1 D1) I IEkF[il' (l:R1IIY TIIA I-11115 WELL \VAS CONS I RU(-I hD IN At ('tkDANCI \\III I I s.\ N( A( 2(. N'Eli
('UNSTRUCTION STAN ARDS, AND "II LA'I rA CI)PY DE II IIS I(F(t ASI{LEKPROVIDED 1OIIiF:AA'1.11 ()A4'NtI(
st(iNAInRF uF Pt.RSUN ( l)NSrRI t l IN(i El l WI 1 1. D.VI I
Submit the original to the Division of Water Quality. Groundwater Section. 1636 Mail set" 'lee (enter - Raleigh. N(
27699-1636 Phone No. [phone], within 30 days. G\V-I REV. (ET 2ui I

299081
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section,/
WELL CONTRACTOR (INDIVIDUAL) N ANIIL (print) i/pO tip n'' Lit,/
n (t:KIIFH"AIIONu ai/2
WELL CONTRACTOR COMPANY NAME ! �e /,)YOS . L(/t�// 4- Pt np, �A-r PHONE a 1Se2m 44,9 -3 /'»
-_ / 41 C .2 ASSOCIATED \VQ PERMrra -- -.
STATE \VEIL. CONSTRUCTION PERM(ra
(it applicable)
(if applicable)
I. WELL USE (Check Applicable 13os): Residential Municipal Public 0 industrial ElAgricultural 0
Monitoring 0 Recovery 0 [Teat Pump Water njcction ❑ Other 0 If Other. List I ec - -.__-
2. \\"E1.1. LU('ACION. Nearest 'Town:SeI SuCC(Mane. Numbers:Conununity. Subd4„tiountyl-ja_yttkerl
n. I of Nu.. /.q+( Ode
.3. OWNER:
Address . --
'.etiv��a
(Street or R uutc Nd 1
L), t_ rIC o2 S' gee-
„, l ur toss n Slate % lip t line
:\rca code- Phone number ' /
4. DA"1 E DRILLED Zi — 1- - U 4f
5. TOTAL. DI:PTI-I:. - 9 1lS
6. DOES WELL. REPLACE. EXISTING WELL? YES 0 NO
7. STAII( WATER LEVEL Below Top of Casing: 8S1) -
.......... Abu":. 1 up of (
S. '1-OP OF CASING 1S
L
FT. Above Land SurISces
*lop of casing terminated at/or below land surface requires a
variance in accordan e with I SA NCAC 2(' .0118.
9. YIELD (gpnl): MMETHOD Of T[ST ram/) ACC
10. WATER ZONES (depth): 3DS-ADS - 'AY Jpr,',
II. DISINFECTION: Type -)177-1/ Amount [je.4_-i1a./13
12. CASING: Wall (hickiie_v,
Depth Diameter or Weight l-t. Nlatcrial
front To_&QPt
from
/t
F rum__- Tn El.
l i. GROa"r: Depth Material
From 0. -.. r0_d D_. Faft µ2t(_r
From_ 'l n 1-1.
II. SCREEN: Depth Diameter
From To fl. in
Front Tu It. _ in
1 i. S:\ND. (iRAVI-L PACK:
Ucpth Size
Dlow _-. fog I t._
1-rom To
16. RIM:\RKS:
Slot Sire
in.
in.
Material
M ettu,t
Nlaterlal
Topographic Land setting
❑Ridge ❑Slope ❑Valley rildat
i s heck alumnaiaic Nisi
Lantude longitude of well location
seeiiikki
Latitude Tun zitudc soured:❑(,PS❑Topographic map
(chock bonl
1)1.1)III IRII.I.IN(i Loa
I row Co Fotmaaon Description
2) at>
ate' 91/7-5
1O(ADON SKETCH
Show direction and distance in stiles from at least
two State Roads or County Roads. Include the road
numbers ;ui I common road names. o „:
l DU I Ilil(PI3V (T.RTIFY 111A1TI Its \\'E1.1. WAS CONS I RI)t' I ED IN Al CORD:\Nut \\TII I I5.\ Na. At 2(-. WEI.I
('ONSIRUCTION S T.ANDAI )S, AND MAT A COPY OF I111S R1i('013.F4'6(AS 131 EN PRO\IDItl) It) 1111i WEI.I U\\'PLR
-so -a/
SIGNAIURL OI I'ILRSON (1 NSrRI-(i1M, Till U111. D;\II
Submit the original to the Division of \\ ater Quality, Groundwater Section. 163o Mail Stirs ice (-enter - Raleigh. \C
27699-1636 Phone No. [phone], within 30 dais. OW -I REV. 07 2001

WELL CONSTRUCTION RECORD
North Caruliva - Department of Environment and Natural ResourJces,- Division orWater Quahh
WELL CONTRACTOR (INDIVIDUAL) NAME (printl
Lt
bp
WELL CONTRACTOR COMPANY NA MECI-Pe J1Z £Dot 11 P �4t ->
STATE WI.1,I. CONSTRUCTION PERMIT# fT b. ASSOCIATED \\O PERMITg
(if applicable) (if applicable)
299080
- Groundwater Sectl
CER'1'IFI('.CI'ION a a 7 /6
`PnoNF. a 18�?� 6,/B -.3/ 7C
I. \VELI. USE (('heck Applicable Bus): Residential Municipal Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ heat Pump Water Injection ❑ Other ❑ I(Other. List Ilse
2. \\I!Ll.LOCArto
Nearest 'I own: J ae5i)l1 r/� County ��Q-. ,za Y�
PI: P. Set._D't TI11�`1—L t /3 I (J. >
(Street Nana. Numbers. community. Subdivision. I.ot No.. tip ( ode)
i�YL`! / 3. OWNER:. /tL.JG) ---
Address 41 3 5 f)Aa 41 err k- b r .
ISlry"� ur Ro to Nu.l �6 %`/
,v2e._/1�JllG J
Ia,vu Slate hip 111(Ic
\rca cotk• Phone number
d. DAl E DRILLED 6 - 7-
5. rarAL DEPTH: B S )
DOL.s \VEL). REPLACE EXISTING WELL'' YES ❑ NO tjif
7. STATIC WATER LEVEL Below Top of Casing: .20 FT.
Itise -t.. d:Aburc lop of ( aangl
ti. TOP OF CASING IS FT. Above Land Surface'
'lop or casing terminated at/or below land surface requires a
variance in accoed7e with 15A NCAC 2(.31118.
9. YIELD (gpm),:; /Jf'METHOD OF TEST .� A rt
lo. WATER ZONES Idcnll(1:-
II. 1./ISINFI-.(.1I0N: Type f-JY/1 :Amount
12. CASING: Wall Ihickuc.,
Depth Diameter or \\eight ft. llatcnal
From a_. -To_, 3 Et. t) pVe
From - To _ I=t.
I- rom__'ro PI
13. (iRO(IF: Depth (Material Method
From tQ
From ._ To ._ _.. Ft.__
14. SCREEN. Depth Diameter Slot Siic Material
F rum lb It. in.
From _ To. _ in. in.
15. SAND GRAVEL PACK:
Depth Site Material
How__.to Ft.
From _ _ To ......._ _ Ft.
Eh_ Rl M.\RKS:
Tupo,traphic and setting
❑Ri.lgc ❑Slope ❑Valley XInt
!check appropnatc buy I
Lauutde longitude of well location
Latitude luu_itudc source:❑(iPS❑Topographic
(check Kw(
DFI' fII DRILLING LOU
Co Formation Description
O (C .3 1 � {
I l)C.AIION SKLTUll
Sho\\ ,lirection and dist:utcc in ntik> Got, at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
0
1
C
;v
J
I1)OIlIRI.[31'(l-.R11F1'TIIAr THIS WELL \VAS CUNSI RUt I tD IN A( ('URDANCI \\'IT'I I5.\NIA( 2( . WEI.I
('DNS FREECT10N S I1A 'D RDS, AND THAT A CUP( OF 'I11(, (1 FN (1)1(D IRS (31 PRO\'IUF.II TI()ll Ili W1,11. U\\'%6R
_1�C/� (� Q!`� 4- SoOe/,
SI(iNA 1 URD UI- PIfRSUN ( DNS IRI -( 'l iNt V Fill \\I I I. I >.\ I1.
Submit the original to the Division of \\ ater Quality, Groundwater Section. 163o Mail sec. ice ('enter - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. 07 2001

WELI. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources^.�f_- Division of Water Quality
WEI,1. CONTRACTOR (INDIVIDUAL) NAME tprintl epa / [(M'±'.. ll �•fA,.�
WELL CONTRACTOR COMPANY NAMEG, Yeeht SJ1YOS. W r
STATE \CE1,I. CONSTRUCTION PERMIT# / /v� ASSOCIATED N Q I'ERMI r#
tit applicable) ( if applicable)
299079
- ( ,round"ater Section
CERTIFICATION* 3b 1
PIIONI,#bc2 (ove-a/9
I. WELL USE ((heck Applicable Box): Residential \lunicipal Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ II Other. List Ilse
2. WELL LOCATION:
Ne Town: fF_.Sys //e Count)
fW1J4tC/L III R,14 ) _.
Street Nave. Number', Community. Sub rvv. um. IA1 Nu.. hip ( ode)
Address E
3. OWNER: �ver..t ,��.h �_
sLrf- k ! .
(Street or Roust Nu.l
-. Gc}u�tiP� /1t, kJ a 279es _
( nt ,r 1 II State /tit 1 not
1 .1-_.
\rca code Phone number
J. DAlEDRILLED /c -14 _611
5. TOTAI. DEPTH: —.'3 , )
6. DOLS WhI.1. REPLACE EXISTING WELL? YES 0 NO S-
7. Si Al I( WATER LEVEL l3elow Top of Casing: 2/0 FT.
arse - l" it -Nitrite lip of ( none)
S. TOP OF CASING IS I FT. Abuse Land Surthce*
*lop of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2(..0118.
9. YIELD (gpm): / 0 _ METHOD OF TEST r2 /\ r.S
!0. WATER ZONES (depth): . _ a271h_= a 65
11. DISINI-I-.(II(N: Type /-{TI-1 :Amnon 55744its
12. CASING: \\'all Ihickneos
Depth Diameter mmeter ar \Vclght Ft.
From 0 _ to / /I
Front _To ____ FL
From__ To _ Pt
13. (iROIil: Depth Material
From e Ft s4cE-„
From t_-
14. SCREEN: Depth Diameter
From To
Front _ To. _ Ft._
15. SAND (UR:AVI;. PACK:
Depth Size Mate;
loom_. _ To I. t_
From To
IF REMARKS:
Slot Svc
in.
in
Material
,Method
'Lup.o,y_,f�:'tpine. Land setting
❑Ridge *Slope ❑Valley ❑Plat
tchce1, appropnalc 110\1
Lal nude longitude of well location
t J. pct.. nu nata. sccuida. ..
Latitude louaitude source:❑(iPSIJTopographic map
teh«I: hia
DI PTII DRILLING LOCI
EotlntttIpI1tDe5c pt
— LOLA tON SKIrC'II ... 1
Show direction and distance in stiles from at (east
mu State Roads or ('aunty Roads. In le dui road
numbers and common road names.
INS
1 DO HEREBY CLIC.I WY TIIr11 THIS WELI. WAS CONS(RU( l lI) IN e\l CURD:\NCI Win I5.\ N( AC 2C. WTI.I
CONSTRUCTION SEAND4RDS, AND IILAT A COPY Oh HITS RL.(
_ Yz) L2
SIONAItJRI UP PI.RSUN ()Ns tRI (-IIN( i 1111
)IRS BE I N PRO\IDI 11) 1lIF. wT.I.I. UwNlI(
6-30_ oY
\\ I1 I. BAH
Submit the original to the Division of \\ ater QualitA, Grounds ater Section, 163o Mail Syr\ ice Center - Raleigh. St'
27699-1636 Phone No. [phone], within 30 da\s. OW-1 RI'.V. 07 2991

299078
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division ()I' Water Quality - Groundwater Section
WE LI. CONTRACTOR (INDIVIDUAL) NANIE 111690 £t ai.._Vec_ i i CERTIFICATION #
WELL CONTRACTOR COMPANY NAME aree_kte., le tss . Ladd_ 9- PLA-hvp,1/4-12-e- PHONE # fla 6, q g --3 1'7 e
STATE WELL CONSTRUCTION PERMIT*/ _ / _ . tit ..2 ASSOC (ATE() MO PERMIT#
_
(if applicable)
(if applicable)
WELL USE (Check Applicable Dux): Residential* Municipal Public
Monitoring 0 Recovery 0 I leat Pump Water Injection 0 Other 0 It -Other. List 1l).e
WELL LOCATIOlt
w) Nearest on:./>06-2a/2.1_th,„ County/
- nna..d-e.- 1=-LeP
(Street Nall1C. Numbers, Community. Stlildl =NO . LIP ( Ode
3. OWNER:
Address
LtAta, lin
i5r tr._ 93 '7
(Street ktoute
ign .1 111-it.a, I F 2 314-
( its or 1(mn State ftp t «tic
)-
Area code- Phone ((anther
4. DA1 E DRILLED 1.0 -0
5. 101 Al. _ a 4.5 I ...
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
7. S'ENTIC WATER LEVEL I3e1ow 1 op of Casing: to 6 FT.
_J (us, ifAbuve lop to ( a \ met
K. -1-01\ ()1: CASING IS _ FT. Above Land Surdace*
ap of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2(.9118.
9. YIELD (gpm): 2D ME-1-1101) OFFEST <2 A r.s
10. WATER ZONES (depth): I - c'S
I 1. DISINI El I ION: Type
12 t'ASING-
Depth
1-kni Amount 404b/1-5
Er0111 , FE (40
From _
1- runt__ - -do Ft
13. 012011-1 : Depth Method
Material
From 0 _ ,
From _
l4. SCREEN: Depth Diameter Slot Size Material
Froin„ I o It. . in.
I tom _ 'Do Ft._ _ in. in.
15. SAND GRAVIA. PACK:
Depth
I I otn- to I t
Front Itt
16. REN1ARKS:
Wall l'hicknes),
Diameter oi \A -eight Et. Nlaterial
Sze
Staten:it
Industrial 0 gricultural 0
Topographici_and setting
Oltidge *Slope OS -alley OF I at
at)Pronttale NA)
Latitude longitude of well location
. . .
ItLIe.IIiiittcs •0:011(k)
10112111.iliC smiree:OOPSOTopographic map
wheel: hN
DI- LI I DRILLING 1_01i
From I o Formation Description
/zD g 5-7S-
Itreff4-1--Haets._
Loc-A noN sKErci t
Show direction and distance in miles front at least
two State Roads or t.-outity Roads. Include the road
numbers and common road names.
Do Rd.u. (1-.1(IfFy 111AI IUS wadi, \VAS coNN-11((a ILI) IN A( (a)RD:\ NcE wal 15.
CONS -I !DICTION STANDARDS, AND IA I- r). COPY ()1 Ilus )(WI S IN PROVIDFD
•
SItiNA11113.1 PI.RNGN ( ()Ns I ID I IN( I I \ )) I 11.
. WEI
It) IHI I GWNI It
D.\ II
Submit the original to the Division of SS ater ()malt). Groundw ater Section. I 63o Mail lsers ice Center - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. 07 2001

299076
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and /Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
'�(print) `�a1�4_('� S' L&s-ncre_ et:RIIFl('.\7l0Nit 3.ka
WELL CONTRACTOR ('OVIPAN\'N,\VIE .(„T/2wse aro's . /t).Q)...L Y 1 LLrnP I PHONE a isQg V 8 - ?O
STATE WELL CONSTRUCTION PERMIT # _-_) IG' .\tiSO(IAlEI) wQ PERM(Ta ...
(if applicable) (if applicable)
WELL USE (Check Applicable 13ox): Residential{ , I\l unicipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 !Scat Pump Water Injection 0 Other 0 I:)char. List l he
2. \VI[LI. LOCATION-
Nearest .Fox n:
- der
3
4
b
{Street Nam. Numbers, Cumuli
OWNER: 1. ( 5
Address 7 l VF rV('tit) �r
�a-iVe2
. Subt tit it i_ Lut No_. /ip (vac(
I Street ur Route NO. )
lt�n.esy)ilP Alt a287f6
( I' or I\)en Stale Jq)( udc
Area code- Phone - number ' _ D
DAI E DRILLED 6`f-
101 A[. I)LPT41: --LBO '._
DOLS WELL. REPLACE EXISTING WI'.I.1.:' YES ❑ NO
Nf:Vl I(' WATER LEVEL Below lop of Casing: '12/1 FT.
lush)" if Abuse r( op ut( asmgl
S_ TOP or ('ASING is L FT. Above Land Surface"
*)I op of casing terminated at/or below land surface requires a
variance in accordanj$e w'th ISA NCAC 2(' .0118.
9. YIELD l��pin f (p METHOD OF TLSI r� Ars '-
Jo. WATER ZONES (depth):_ /.4/5' -(p6 pin
t
11. DISINFLl LION: Type H %r/ :\mount 3.4_#6)is. •
12. CASING: Wall Ihicknc-,s
I >epth Diameter of Weight It. Material
From 0 _-To eQb Ft. Ip 'I Pva_
From To Ft.
.1.O --1_t_. ._.
13. ( iRl)I 1 Depth A Ntaterial
From � _ To__ Q P, IL C_O�t-svi
From lb Pt._-
14. SCREEN. Depth Diameter
From _ To Pt. in.
Irunl Tu. 1-t. in.
13. SAND ((RAVht. PACK:
Depth Site
Flom Tu I-t_
1-rom
I6. RENT \RKS:
Slot Stitt
Mat al
Nlethod
Material
Topographic {_and setting
❑Itidge ❑Slope ❑Valley [Flat
appropriate haV
Latitude longitude of vall location
)de rea. minute. comb).
Latitude Innsitude source:❑(jPS❑Topugraphle map
{check buvl
DI -.I' 111 Iltlt.l.IN( Too
from I u Formation Descnplion
v asa /}
.2U 1�i.3--'.. - „tA
LO('.A LION SKETCH
Shoes direction and distance in ratites from at Ica${
Imo Stab: Roads or County Roads. Include the road
numbers and common road names.
11)U I IERFEY CI.RTIFY IIIAT THIS Will WAS CONS( RU( I IA) IN At ('t)RI):\N(E \V Ill I I>.\ N(
('ONSIILIA IRON STANDARDS, AND 'IDAI ACOPY 01 IIIIS RL(ORD I[ AS 0IN PROVIDED It)
���tr1J (7iU - .
SIGN:VI Ultl. Uh I'I RSL)N ( UNSI RI t"lINtV 1111 \\ Ill
.
Subunit the original to the Division of \\ ater Quality, Groundwater Section. 163o :gall Sery ice
27699-1636 Phone No. [phone], within 30 (lays.
o =
L
C)
C
.\( _'(. \VI.I.I
1111f \\LL1. a\VNI.R
I >AI I
Center - Raleigh. NC
(iW-I RI!V. 07 2001

2990'7 5
WELL. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
/- Division of Water Quality - Groundwater Section
wT:1.1. CONTRACTOR (INDIVIDUAL) NAME (print) '`-' r'- c - (—� r e-e- n t. CLRI IOC .\ II()N a a 2 g
WELL CONTRACTOR (OMPANYNAME Crre_e-v\e l3rsr, . LLD._ O FPt\.t.�p1 L PHONE a(82g(,VW- 6
(4ca
STATE WFI.l. CONSTRUCTION PE.R\ITTM
\SSOCLCIEI) \yO rERtlIT#
applicable) (if applicable)
I. \VELI. USE ((.heck Applicable 13us): ResidentialMunicipal Public 0 Industrial 0 Agricultural 0
Monitoring Recovery 0 I leat Pump Water Injection Other 1 (Other. List l ise
2. WELL. LOCATION: 1
Nearest 'town: CGt_-(.t_4-treti-.
IL c.
Street Nantcc'.'Nummber... Community. S/ubbdn own. 1.ot No.. hip ( tide(
3. OWNER: DCUIt'cR. U-r -�-- --..-.
Address l to .Q _ .- c_c_w/ e _ cRA
J W; i--
(Street or Route Ni.)
County 1-1 cs=ai-(JD_oA_
. e. 4nt.Sya ll� _ � g�
nTy. t-Stale
Area code- Phone nuather
4. DAI El DRILLED le-R1-
5. ROYAL. DEPTH: 4 t5 '
O. DOES WEL.I. REPLACE`. EXISTING W'EL1.7 YES 0 NO lal.
7 SI AIIC WATER LEVEL }3clow Top of Casing: 3 (i ET.
IUse If:Abore Top ot(:sing)
S. TOP OF CASLN(i 1S I E.E. Above Land Sur[.rce*
'fop of casing terminated at/or below land Surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELDOr):(): 1' MF 11{(D Of T[[S1 ra h rS
to. WATER/ONES(depth):_L_g5'._.- 177tkp.vy ---
Lo0'-i1.'%Z ppa, LOC'.\FI(1NSLKE:TCH
I I. DISINFECTION: "Type !71_TkI Amount j, . hus , Shot direction and distance in miles from at I':ut
12. CASING: Wall Thickness two State Roads or ( ounty Roads. Include the road
Depth t)tanteter of Weight I•t. Itlatenal numbers and mnames. eontttn road es.
From £ l o. '7 a Ft. /a " P I/C-
Protn r o _ ..__ Ft.-
----
I-- rtn__-•Ttt Et.
13. ( rROlfh: Depth Slatertal \lethod
From p..._ iu_
From _ _ to
14. SCREEN: Depth 1)iunietcr Slot Sue
From To _ Ft. ._in. in.
From) _
15. SAN D•GRAVF.I. PACK:
)Depth Site \tatertal
I•runt --- fu__...._ it.-
1-rost(
I upographiu'Laud setting
❑Ridge ❑Slope 'allay ❑flat
icheck appropriate hues
Latitude longitude of well location
id minute.. aiud,l" ..
Latitude Milliards source:❑(,PS❑I Opugraphic map
(cheek b,w
Di PIII
Iloin I
6 7-2_..- L' ee •
I)RII.LIN(i Ll1(i
Formation Description
16. RI:NI:\RKS:
1latenal
0
r—
�v
CO
0
I DU I[ERPff\" Ch.R11F1" 11IA1 11115 \\hLI. \VAS (ONSII(Lt-[I'.I) IN At COItD:\Nei CIII I>.\ N( At 2(. \\'I:I.I
('UNSTRIICTION.S'IANDARI)S, AND 11IAT A CO1'Y 01. TIIIS Rh( Olt!) _S(31 iN I'ROATOEDlt) 111F. \VI:L I. OWN"(
Sl(INA'I:RI UI I'l(RSUN Ct)NS IRI-(.11Nti IIII Ul1I. 1).111.
Submit the original to the Division of \\ ater Qualitc. Groundwater Section. I63o ?tail Ser.ice Censer - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. OW -I REV. 07 200

299074
WELL. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Sectnnt
CERTIFICATION a 3 3VT/
PHONE a f s'.)g 4, Lie -3 / '71
WELL CONTRACTOR (INDIVIDUAL) NAME/� (print)
WELL CONTRACTOR COMPANY NAME (yiBPJ+o-a
SPATE. WELL CONSTRUCTION PERMIT#
tQaC.
(if applicable)
b ( Ti-Dia_(.L
ASM)CIATEm WO PERMIT#
Of applicable)
E. WEI.I. IJSE (('heck Applicable Box): Residential W Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Reci)very 0 heat I'ump Water Injection 0 Other D I Other. List 1iNe
2 WELL LOCATION:
Nearest Town: 1c V_q ucounty O r.)l ODA
tal
•X-YI' .4--itk. _ Ili
(Street Name. Numberr:, unun unuy. Subdn otnn. I.ott No...hip ( oriel
3. OWNE12:._ Q1�.9 -(ti.� Ev4 0..../ lrc,.-,,9�_Address .._ 9t'icNile_
l CL Rd..
ISlrcct or gomc No I
I //'t i(C �Sr7 cs'�o
Mate r lip („d:
Area code- Phone number
4. DAI F. DRILLED (o - / -� (7/
5. TOTAL DEPTH: _. S3 5 _
b. DOILS WELL. REPLACE EXISTING WELLY YILS ❑ N()
7 SI tkTIC WATER LEVEL Below -Top of Casing: 4U-._FT.
(use "."it:mooclop of ( axing)
S. TOP OF CASIN(i IS / FT. Above Land Surface*
*Top of casing terminated ateur below land surface requires a
variance in accordance with ISA NCAC 2C .01Ia. I
9. VIELD (gpm): 1� MET74{i0U ()I: TISI 'L)/S_.
IU.\WA"TF:RZONIIS(depth): CO0 - Re'
11. DISIN ELUTION: Type N / F-/
12. CASING:
Depth� Diameter
From _ .-To_.is Ft. Co 1 (
From To Ft.
Front 'To
nntoum s� 1:4 I+S
Wall Fhicknc.o
of \Yacht 1.1
\I}t lal
13. (i1Ol11 Depth 5taterial Nlothod
FroTo To aL . FL_ eQ.mL &_± 7711i'p
From .._ l o
14. St'REEN: Depth Diameter Slot Sue \latcnal
From... To Ft. _ in. in.
Fr1nl _ To. ___. Ft.___ in. _
15. SAND GRAVEL PA('K:
Depth Siva \latcrtal
From _ To I-t.
From _Ft'--
16. REMARKS:
Topographic: Land setting
❑Ridge rithilopc ❑Valley ❑Plat
IahecL aiprapnat: box
.allude longitude of well location
depra� Iinlia� .c(vlldxl
Latitude longitude :curet:❑(iPS❑ I opographic map
Rhea, bout
ur.t' 111 DRILLING Loa
From 3.� ) I.ormatiun Description
fi
3 5 ' _a -' _Lys
LO(AnciN SKEIY'll
Sho,v ,Iirection and distance in miles lio(n�s at I iSt
o twState Roads or County Roads. Incltufa tl)arsiad
numbers and common road names. C
r--
.t3a-a-t,.t-��
c,
1 1)O HIRE i3Y (LRTIPV TILWI Ti us \\F.LI. WAS ( ()Ns.i Rut -ll'.D IN Al CURD,\NCI- \Will 115.\ N( At 2C. \\l:l.1
CONS 'RUCTION SP> ANDt RUS, AND THAT A COPY UI 11115 RF.It)RD I1:\S 131 I N PROVIDED I()1111i \\lit. 1. OWNER
SIliNAl Ual. . ()I- I'I:RSUN ( UNSIRI.111N(I Il II \Vt l 1. I).\l F.
Submit the original to the Division of Water Qualit), Groundwater Section. I63o ?tail Sen ice (-enter - Raleigh. N(
27699-1636 Phone No. [phone], within 30 days. (i\\'-I RLV. U 7 ?I)U I

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources I- Division of water Quality
N-ELI. CONTRAU1OR (INDIVIDUAL) NAMEE:/ (print) 7 o b £L_)���•-e�'/''',l r,
N'h;LL CONTRACTOR COSlPAN\ N:1D1F, i!_ �' 0 /j a 4�,4 . jc^� T " "--0-
STATE; WELL CONSTRUCTION PERMIT# I i) a .(StiO(TATED NQ PERMIT#
(if applicable) - (if applicable)
2990'73
Groundwater Section
c r;R1iFl( cr HON # a q/ $
I'IIONE x PS V?-317°
1. WEI.1. II SE (Check Applicable Box): Residential Municipal Public ❑ Industrial ❑ Agricultural ❑
NIonitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ 1I Other. List l !x
2. WELL LOCATION.
Nearest Town:.
\
�e s��/g (,ttmy 41id°
�
Sued Nnmt Nunihcys, 1 onmmunfm. Subdivision. Lot o.. ftp ( ode)
Address .`�.. '% b� df�-<.-(. �! .
(Street or ?outNo.l
// / V C 2' 7 R' 6
( Ili or t en State /ip t ode
3OWNER:.
1
\rce anlc- Phone number
4. DA I E DRILLED 5- at &-U S�
5. TOTAL DEPTH: __ /1�5�.
b. DOES WELL. REPLACE EXISTING WELT.:' YES ❑ NO Ve
7. STATIC w'A tER LEVEL I3clow lop of Casing 9.50 FT.
IUse"I' if Abus. I op o1( a+nrvl
S. TOP OF CASING IS / _ EC. Above Land Surface*
*too or casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .I)118.
9. YIELD (gpm): �1�1 METIi(D OE TL5 t /i t: .
t0. WAIT:R ZONES (depth): tsoa — Goa 1/2?
Topographic: Land setting
❑Ridge ❑Slope ❑Valley *tat
I: hc.k appropnalc boll
Latitude longitude of well location
mlinnee.cComl.i.--
Latiuula longitude source:❑(,PS❑Topographic nap
t cheek hml
UI.PIII DRILLING LUG
Fromtt FormationDescription
,,� 11 9P^° I.00.\ 1I ON SKE.TCII
11. DISINILCI ION: -type K//T� \mount ,,/Do +b i+5 . Shots direction and distance in miles from at leas)
12. CASING: \Vall thickness two State Roads or County Roads. Include the road
Depth Diameter of Weight lit. Material numbers and common road names.
From To c2� Ft. to " P vL O
Prom _ ..___To _ _Ft._------. .... ---____ L
r_
( runt :-
To P1.
(iR(>1 1: Depth Material ;v)ethotl tV
From
From
SCREEN:
Front._
-cool
Depth Diameter Slot Site \Iatenal
To It. _ in. __ in.
To Et. --
in. In.
SANDURAvll. PACK:
Depth Site Mate( ai
[tom_ to It.
From
lb. RIfNI ARKS.
•
I DU I lLRE.IIY (I.IZTIFY l l l/V1- 1111S WELL WAS CUNSI RUC..1LI) IN
('UNSIRUCTION STAND 121.2S, AND 'lI SAT :\ (OI'l lit .1111S REC
Cedj
SIGNAL 1:1ZE. UE PERSON ( 1N5I
\l CORD. \NCI NTII I 1 5.\ N( A( 2(. NI:I.I
) IL\S 141.1-N PROVIDED lu 1111[ P'I.I.I U\' N'I It
/-3Z7" 0
IINt• 1111 \\I1I. D.\Il
Submit the original to the Division of Water Quality. Groundv)ater Section. 163o Mail Sers ice Center - Raleigh. N('
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. 07 2001

2990'; 2
WELL CONSTRUCTION RECORD
North Carolina - Deportment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
\YELL CONTRACTOR (INDIVIDUAL) NAME (print) ' `O��
99 �r I"���`It
WELL CONTRACTOR COMPANY NAME Graeae, �1'2)s. Le�F�-�- PrnpI('f:R'1TF I('.�f1UV n �' 3'J�
";"•I'IIONE'. # fan to VO 3I 96
SLATE WE:l.l. CONSTRUCTION PERMIT# _ / Le 0 .\SSOC1:\ rE.D \\Q PE.R\IITe
(if applicable) (if applicable)
I. \VE1.1. USE (Check Applicable 13ox)-. Residential" Municipal Public 0 Industrial ❑ \gricultural 0
Monitoring 0 Recovery 0 )seat Pump Water Injection 0 Other ❑ 11 Other. list l'oe
2. WI:I.I.LU(AIION
Nearest Town: neSyCo011lyA/atu000
t st-rve_s
Street Nana. Numbers, Community. Stibdt mwn. Lost No.. hip1( talc)
3. UWNLR: F r /zJ�}
Address. 35 0-.4.4COK tLJ.I...
I Street or out• n.)
.(r)i��.—j� c __ ( tiq, 7 5/
( u. or 4 tigil State I /q) Cade
:\rea coda- Phone number
d. DAIEDRII.I.ED 5-aU-Oct
5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO bi-
7. STATIC WATER LEVEL Below Top of Casing: lib FT.
It$se "1- d.A6ve l op of t eam:l
S. TOP OF CASING IS FT. Above Land Surface*
*'top or casing terminated at/or below land surface requires a
variance in accordwe with 15A NCAC 2(- .011h.
9. YIELD (spat):_'l(fry)2G ME:rtlODOrT11;I
ID. WATER ZONES idep(n):_.._ 4_Vs'_7 6' 5'
I.OTAI. I)EPTII: _ 1/Jj$" (__.
I opo�_ia�phic:Land setting
❑Ridge h4.Slope ❑Valley ❑Flat
I cheek appropriate hove
Latitude longitude orvvett location
Iae_re:. minute:-e<uI1dH _.
Lai ituda longitude source:❑(iPS❑Topographic neap
Lei eek hn i
DRILLING LUG
FOn1I Ijl0!1 Description
1)1.Pr11
Iron) Ili
38 ' L/ VC
LOC.A PION SR:L'. I( It
11. DISINFL( TIUN: Type Uri/ Amount Jew _-f -I Shoo .Iissom and distance in tulles front at bast
12. CASING: Wall Thickne s Iwo State Roads or County Roads. Include the road
Depth Uii ureter or Weight Et. \Iyt�al numbers and common road names.
Front. /)....To.:Jb Ft. (O Lf PV
From "Fo Et.
I. rout _.1.
_.--o —_. __— Ft. -
13. (iR0111: I)epthgq [�llatcn;d ,y
Front t .to do 1" Ft -a�.e�n�e
From _ To __ .. Ft._
14. SCREEN: Depth Diameter slot Size Material
From _ To Ft. in. in.
From 10 l:t is -- - in.
15. SAND•(iR:\\I.I. PACK:-
Depth Site Maternal
Front__ To
1`ront To
U,. RIINIARKS:
F t.
Et.
Method
-%x
0
0
r—
ry
3
(
C) _
Ca.)
[DU HEREBY Chitral- -DIAL THIS WELL WAS CONS.' RUC -I 1!; IN Al CURI)AN(F \1lTI1 15.\ N( :\( 2(. \\I:I.I
CUNSTRt1CTION STANDARDS, AND 'II IAT A COPY ( )1.1 WS 1(1 (01(D ItAS RI. FN PROVIDED It) 111F. \'ail 1 OWNER
_crD - Oti,/
SRINArt'IItl•.OF Ph.RstN (1)NsrR1 ('rlNti rut W1I I. D,\IT.
Submit (he original to the Division of Water Quality. Groundwater Section. 1636 Mail Service (enter - Raleigh. N('
27699-1636 Phone No. [phone], within 30 days. (i\\'-I RI`V. 07 2001

2990'71
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and oral Resources - Division of WaterQuality - Urouudwater SectionWEI.I. CONTRACTOR (INDIVIDUAL) NAME/ (print) / A-e-A-4-'t' 41 ° (' ERI IF IC.% 1TON# 5//8
CONTRACTOR COMPANY NANIF '/n t�
. .S( &L4$6 °1"�' PHONE. #! 6qg'-3/'?
STATE \\'El.I. CONSTRUCTION PE.R\FIT# Y(') 2 ASSOCIATED WO PERMIT# -...
if applicable) (if applicable)
I. WELLUSE (Check Applicable Box): Residential Municipal Public 0 Industrial 0 Agricultural 0
co Monitoring 0 Revery 0 heat Pump Water tgection ❑ (titer ❑ I( Other_ List l:,e
2. \\'EL.l. LOCAI )Tr: ',
Nearest Tov �r' t [. t E5UJ/A_ County4//(e. L
(Street Name. wi hers. Rm)numin•. Subdivision, Lot No. Lip ( otcl t
i. O\\'NER:,j y^� �nt-Puit �ezid. pr::. minutes sewiwi.l
Address ..3.G _teilyt..L. Latitude loneu ude source:❑(IPS❑Topographic map
(cheek btnl
1)I.1'TIi DRII.I.IN(i Lori
From Iu ) I unnatio 1 l)csenpt iuo
.,23'aS' Atd�a�
i opographic. Land setting
❑Ridge ❑Slope ❑Valley yjhlat
t eh::A appropnaIt box I
Latitude longitude of well location
(Sir 9el ar Route No.I /
A/C- .2{t 72
( . ill Toxin_State
n/tp (nil:
Area code• Phuuc number
4. DAIE DRILLED ..5"-/1-6 f!
5. TOTAI. DEPTIL ___ 4/65'
6. DOES WELLREPLACE EXISTING WELL? YES 0 NO 44
7 SI:V FI(' WATER LEVEL Below Top of Casing: r26 FT.
I(lse-t.,.1 A6uve lop tit (.time)
S. TOP OF CASING IS / FT. Above Land Snrlaee*
• I•op of casing terminated at/or below land surface requires a
variance in accordan a with ISA NC:\(" 2C .0118. — ---- - -
9. YIELD (gpml: MF1110I) OF _.. `. TESL �/-
10. WATER ZONES (depth): � gid.L- ayPM ._
IOC.\ -
LION SKIT I (I I
1. DISINII-a;IIUN: Type �'>/%// :\axxlnt / lhovv tliroetion and distance in miles from ;It least
12. CASING: Wall Thieknc.o two State (Loads or County Roads. IncIt tltei'cdatl
Depth q Diameter of Weight I t. Material numbers and common road names.
From. a. l o . oZtu7 Ft. 6"1 /J c� `- _
r—
Prom To Et., -.---,I,O _... `--!_t. -
Prom.V
1..1 ORO1lit: Depth Material , Ietltud -y -'
From Q _ To_�Q __ Pt.__ .p-hr.P�xj . _
Iron, To ht. _ r'• .
11. SCREEN: Depth Diameter Slot Site \Iatenal r 2
From_— To - It. ._.____in. -_ in. Ca
Drum 'litFt. in. in.
13. SAND GRAVEL PACK: --- - - -
Depth Site \latcrml
front.__ _. lo I-t_ _.- -J
I - ton) __ilk) Et
16. RI:\'1:\RKS:
DU IIERI BY CI:R lIFY 111AC'11I1S \\Ell. \\':\S CONSI RU(."11..D IN Al (t)RI):\1(I III 1>.\ N(:\( 2( . \VLI.1
( ONSIILL( IIUN STANDARDS. AND 'llIAI A COP\" O1 1111s Rh(-( ) II \S lit I-N PROnuLD I t) -IllE. \\T.1:I. D\\NP.R
_ o Sl
SR INAIUR!.. 01 Pi RSUN ( ONs R1 t IN( I rat \VI I I. DAM.. __. ....
Submit the original to the Division of Water Quality. Groundwater Section. 163h \tail Sersiee Center - Raleigh. N('
27699-1636 Phone No. [phone], within 30 days. (AW-1 RIA'. U % 2111)1

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and tural Resources - `Division of Water Qualit.
WEII.CONTRACTOR (INDIVIDUAL) NAMEE� (print) (�"pie,
1Q.+ 5( Len tt �l
WELL CONTRACTOR COMPANY NAME; Gseehe- i ros , Al p L cj Paint
STATE WELL CONSTRUCTION PERMIT# / Cz ✓c _ASSOCIATED \\Q PERMIrtrt
(it' applicable) lit applicable)
299070
r - (iroundwatcr Section
CERTIFICATION ;3)
0
•PHONE# • 4/g7 3/70
1. WELL USE (Check Applicable Box): Residential% Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 ((Other. List [hc
2. WELL LOCATION
Newts Town:
County 711-(f&Oa"
IStree Name. Numbers, C' nnnmity. Subdivi^m. Lot No_, lip ( ode
3. OWNER: _
Address 4i Nir a ui %�C't/
n /) �IStttta or RoutetN( gY.2
(llx Town State hp (
Area code- Phone number
4. DATE DRILLED S-1, -b�
5. TOTAL DEPTH: alp S /
6. DOES WIi1.1. REPLACE EXISTING WELL? YES 0 NO 1,
7. STATIC WATER LEVEL Below Top of Casing: 6 FT.
((fie "1" ifAbo'c Top ot(11smU
8. TOP OF CASING IS PT. Above Land Surface*
'Top of casing terminated at/ur below land surface requires a
variance in accordance with ISA NCA(' 2C .0118.
9. YIELD (gpm): LiS METHOD OF TEST r5 .
10. WATER ZONES (depth):
I1. DISINFECTION: Type kril
12. CASING:
Depth Diameter
From To 4 a Ft. ie /t
From To Ft.
From To FL - ---...
13. GROUT: Depth Material N cthoxt
From — to ,./0 Pt. ! nD .✓rt o s_± _
From To H.
l4. SCREEN: Depth Diameter Slot Size Material
From if() Ft. in. in.
From To Fa. in. in.
15. SAND•GRAVEL PACK: ---..
Depth Sizc Material
From To Ft.
From To Ft.
Topographic/Laud setting
❑Ridge *Slope ❑Valley ❑liar
(cheek appropriate hoc 1
Latitude longitude of\\'ell location
the rrc, minutes 5econtkI
Latitude longitu(Ic sourcc:❑(.iPS❑Topographic nmp
Ichcek bail
1)1 P ll DRILLING LOG
Pon) To Formation Description
4�
QGS'
//�� LOCATION SKETCH
,Mount (/ ? �6 /15 Shore direction and distance in miles from at IcasI c-
Wall Thicknes two State R,lads or Chanty Roads. Include maxi;
or Weight Pt. Material numbers and common road names. L e-_
P //C
16.REMARKS:
l DO II ERELiY CEICTIF1' TIIAT 1111S WELL WAS CUN.s'TRUCTED IN A(CORUANCF WI'll 15.A NCAC 2C. AA'E1.1.
CONSTRUCTION STANDARDS. AND .II1AIT rA COPY UP '111Ls ILICURD ILAS I3I1-N PROVIDED It) TIIP. Wh1.1. OWNER
SIGN ATU R E: OF PERSON (
SIRCCTI Nt 11l II UT.t.L
DAII.
Submit the original to the Division of N\ ater Qualitc, Groundwater Section, I63o Mail Scnicc (enter - Raleigh, N(
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. (17 2001

2990C9
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Ut. ision of Water Quality - (iroundwater Section
WELL CONTRAUFOR (INDIVIDUAL) Nu�t}t�. //print) CCv e D L �' �tU,(P ��`� rCERTIFICATION
ERTE # AT Ir (o `/� - 3/'�0
WELL. CONTRACTOR COMPANY NAM t:J�d�[ f �e
SI'A'( E WELL CONSTRUCTION PERMIT#
I it applicable)
i_41_a 2
ASSOCIATED WQ PERMru
1 it applicable)
I. WELL USE (Check Applicable 13ox): Residential', Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 I Mther. List t''oe
2. WELL I(XA IO :
ec ))%le. count
,street N aft'e. 4<untbens Community. Suhdis(shin. Lot No. . /Ip ( ode(
3- OWNER: \ 0/a/Let. I' `ti
Address 1 3 1T HC-tL.lc-tY
��. (Street 11r Route -No.1 1-4 /7 0�
( r foa n Slate) tip t ode
Nearest !rown:
Arca code- Phone number /
4. DAl N DRILLED LIL
itekeril
5. LOlAl. DEEPT41: 16 5"
o. DOES WELL REPLACE EXISTING WELL:' YES 0 NO 15/
7 5!AII(' WATER LEVEL Below Top of Casing: .
Il)sc "I" d Aboc Top oft a.mLJ
S. TOP OF CASING 1S / ET. Above Land Surface"
"Top of casing terminated atfor betow land surface requires a
variance in accordanchwith 15A N('AC 2(' .0118.
v. yILLD Igpm): MLTI[OD ()FrF.S r I) KS
'_ )
IU. N�AI r.K ZONES (depth): l n..r.C._...
1. DISINI LCTION Type LL_T/-% :Amount (.3. S_ _f-6] .i
12. CAS EN(i: \\'all I hickne,
Depth Diameter of Weight Pt. Material
From- JD _[. IC_ Et. Le )I
From To Et.
Front
13. OR(ll ll Depth f/,� Material
From Toa(i' "(Jai
From - 're
_.._ t-1. S('RE-:EN: Depth Diameter
Front _ _ Tu Ft. in
From Ib Ft. in
I5. SAND GRAVEL PACK:
Depth Size Material
I a tom To I t.
Ltom lb Et.
16. RIAIARKS:
Slot Stec
in.
in.
Material
Topo_ aphid Land setting
❑Ridge i�,Slope ❑Valle} ❑flat
I Check appropriate hose
Lantude longitude of vvell locution
n11,_I e nunutev .econd.l
l.:uitutLloci itudesource:❑(iPS❑lopouraphicmap
t check box 1
pit lll UKILLIN(i LO(i
I rout I o hot -illation Description
6 _ Eeui
_.. _._.- O -
C t
v _
LO(.A IION SKETCH
Show Direction and distance in miles friTial at [,'ur
Iwo State Roods or Count} Roads. Incline the roe l
numbers and common road names. e.) r
I D(/ I IE.ILIttiY ('I.1211PY T I IA I 'rlll5 WEL1. \VAS ("ONSIRUC TIE IN A( CURI)AN('r. \\'r1I l 15.\ N(':\C 2C. \\'LEI.
(ONSTR11CrION STANDARDS, ANU 111Ar A COPY Ol• TIIIS IRPCURD IRS I31•FN PROVIDED IU Tlll. W'I.LL OWNER
S l(iNAI'URP. UP I'1.RSUN ( UNS'1121 ("I INt l II II- 0T.1 1
D.111.
Submit (he original to the Division of \\ ater (lux[it . Groundvv ater Section, 163h \I ail Sets ice Center - Raleigh. N(
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. 1)7 2001

299068
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NCB- ral Resources - )iv isio/hn of Water Quality - Groundwater Section
wiLI. CONTRACTOR (INDIVIDUAL) NAJ (print) V_l i Z / n e , a b ,l /��c/� - CERTIFICpAT�I/ON a /2/Yp' /
WEI.I.(-ONTRACTOR('OMPANYNAME jam'/✓CS.IJLLL I ' / I PlIONE#UK6)4Vg.3/Qc
STATE WE.LI. CONSTRUCTION PERMIT# -- L Y d . ASSOCIATED WQ PERMITS --- -
iifapplicable) _. (if applicable)
1. \YELL. USE (('heck Applicable l3ox): Residential l Municipal Public ❑ industrial 0 Agricultural 0
Monitorutg 0 ROiFoVery 0 Ileat Pump Water Injection 0 Other 0 II' Other. List list.:
2. WE:l.l. LOCATION:
Nearest •tuvcn:�/ _gnes5i?iJ/e (ounty'(`/&y
TicFP.�Z'
_ . LtJl 111 /
'Street Name. Numbers. ('unmuunity. Subdiv'.uun. Lot Nu.- ftp ( ode)
OWNER:
Address .5-h
-(/ 1Street ur Route
— !Lc_
( it) nr lann State
_)-_ ---
Area u+de- Phone number
4. DATE DRILLED -.0
TOTAL. DEPTH: 72 S
a .l4I l!1 (. -&u O ✓rt
0t
2 £ / /6.
(,tdc
b. DOES W'111.I. REPLACE EXISTING WELL? Y`ES 0 NO lid
7. STATIC WAFER LEVEL I3elow lop of Casing: '`%Q __FT.
(Usc "' ` if Above Top of ( asuigl
S. 'FOP OF CASING 1S /__ ET. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C' .0118.
9. YIELD (gpnt): (s _ METHOD OF Ttsr J irs .
t0. WATER ZONES Idepth): .6es' .M Coy pv,._, -- ...
i i. DISINFECTION: Type H' rli Amount /31__ .6.0 5
122. CASING: Wall thickness
Depth. /// D/iiameter of Weight Ft. N1aterial
Front. O _. To 4 4 Ft. /)
From . _ To _ __ Ft._-
I- rune, - :Fu
13. ORO(II,: - Depth qq Material Method
From 0 T o_ab Et. C.QX/r2t�- _
Front ..... Tb Ft.
l4. SCREEN: Depth Diameter Slot Sire Material
From
10 Ft. „ in. __ . in.
From To Ft. in. in.
Li. SAND (GRAVEL. PACK:
Depth Size
i-rum Fu Ft.
Front _Io ____ Ft.
t6. RLMARKS:
Ntatertat
Topu t aphle Land setting
❑Ridge Hope ❑Valley ❑Flat
'cheek appropriate ho<1
Latitude longitude of\yell location
'deer:c. mutates peetat\i.1 _..
l.atiuub: Iunzitude source:❑(iPS❑Fupo raphie mal
tcheek hos i
DENT DRILLING 10G
How Fu Formation
Description
0
FIUN SKETY'l1 ; ,)
Show direction and distance in miles from at 4&iist
mu State Roads or County Roads. 1ni:1=tde ib nwd
numbers and common road names.
I DO IIERI-ISY (I.RTIFY TIIAI 'EMS \\'EL1. WAS GUNS IRIX 1 LD IN A( CORD :\N(k \l"CI'll S.\ Nl A(' 2C. WIa.I.
CONSTRUCTION STANDARDS, AND I LAT ,\ CUPY OF II itSJ21'.CURD I IAS BF hN PROVIDED 1 U'1I1P. WEL.l.U\VNI-.R
�11 ,
SI(iNA I IIPI Or PERSON (. 0
IRt:CTIN(i I1IF \\Teel
Submit the original to the Division of Water Quaid). Groundwater Section. 163t, NI ail Seri ice (enter - Raleigh. N(' '
27699-1636 Phone No. (9l9) 733-3221, within 30 days. (iW-I REV. 07 2220111

North Catalina Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section WELL CONTRACTOR(1NDI VIDUAL)NA>lE (print) !'t7 (-L7
— L � CERTIFICATIONS o2/0(QJ%
WELL CONTRACTOR COMPANY NAME reetlei N•/r7rI' PHONE S ( )
STATE WELL CONSTRUCTION PERMIT:: ASSOCIATED WQ PERIT.:
• (ifipplicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential. Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ IffOther, List Use
2. WELL LOCATION: Topoo aphic/Land set[ino
Nearest Town: AA) 4 nPsuitie- County 064, ❑Ridge ❑Slope ❑Valley r4Fla:
'Marti ers ©r arri, L/JAtoe Ile AKC.21?7
AA j7 i6 /long rude of:well)
(S:r::t Nome, Numbers, Community, SaS..i•,isior., L [ No., Zip Cede) / Latitude/longitude of well location
3. OWNER: Sm/eLLC /fOOPSI<
Address a.f6 62}-(S:reet or j�a_rri ]/fir
City or To 'r State Zip Cede
tU/ n f a X 1k 10
WELL CONSTRUCTION RECORD 299246
(Q1&- A<0q — o g7Y
Arta cove. Phone number
4. DATE DRILLED S y — D
5. TOTAL DEPTH: 02O0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J'
7. STATIC WATER LEVEL Below Top of Casing.: 3 0 FT.
t (Us: Abo.s Top o.`Casinr)
S. TOP OF CASING IS I �2- FT. Above Land Surface'
'Top orcasin2 terminated at'or below land surface requires 2
variance In accordance with ISA NCAC 2C MI IS. 0 '
9. YIELD (epm): a • METRO�pOF TEST i y'
0. WATEP, ZONES
�t'�
(depth):
I
11. DISINFECTION: Type ktTH
12. CASING:
Dep:h
From O To / 0SS Ft.
From To Ft.
From To Ft.
13. GROUT' Depth
From O To .16S Ft.
From To Ft.
14. SCREEN: Depth Diar.c _:
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Sze Ma:cis!
From To Ft.
(decre:;.'mind:tes:cords)
Latitudelongirude saurce:❑GPS❑Topographic map
(ch:c bps)
DEPTH DRILLING LOG
From To Formation Description
- / yto
/44.2. -Zo0
//,�
LOCATION SKETCH
Amount q OZ_ Show direction and distance in miles from: least
Wall Thickness te.o State Roads or County Roads. I nclude'the rozd-t
IDia: :c cr 1l eiz :T:, f r • ,,cambers and common road camel. _ _
S:o: Size
i%
Ma.erial
in.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH 16A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO?Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0 XER-
•`-0 - /'h LUrrt:\ 7 0;ri-c4
SIGNATURE OF PERSON CONS 'CTixG THE WELL DATE
of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
within 30 days. GW-1 REV. 07/2001
sus

North Carolina - I)eparintent of Environment and Natural l csources - Di isiou oT Water Quality -
\FL1. (()51 R\"Il t (INDIVIDUAL)\\\E�print) [C't"4'
VEI1(ON'I RA( iU( (OM I'AN\' NAME
/LCP WCJ/
STATE: WE1.1. CONSTRUCTION 1'4:1CM1'1'N
lifapplicable)
=OS®a
I. \VliLI_ USE (Cheek Applicable I3ox): IZcsidcmial �hmicipal/Publle ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ peat Pump Water Injection 0 Other ❑ 11 Other, List Use
WELL CONSTRUCTION RECORD 2 9 9 8 8 i
Groundwater Section
CERTIFICATION {rXij6/
IIONE U (ra5))6
ASSOCIATED \\'Q PERMIT#
(if aphlicahlc)
2. WELL LOCATION:
Ne, rest "Town.
County
(Street Name. Numbers. Community. Subdivision. Lot No.. Zip Cute)
3. OWNAddress 167— ' 'I'
Address 1� /I/i r o
t (S feet or Coum Na.)
l4✓� N(. V6
Coy or 'loan tit Zip Cade
3.,_ )-6V/0- ?49.
Area code- Phone number_,„
4. DATE DRILLED /9-0V
5. TOTAL DEPTH: 020c5—
G. DOES WELL IZGI'LACE EXISTING WELL? YL'Sp NO l�
i�
7. STATIC WATER LEVEL BelowTop ofCasing: £" 0 ET.
( Use "a" i f Ahuve lip of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
"fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .01111
9. YIELD (gpm): 3 METHOD OF TEST fI"-7—
10. WATER ZONES (depth):
Topographic/Land setting
tidge ❑slope ❑Valley ❑Plat
(check appropriate bolt
I.atilude/longitude of well location
(degrees/in inures/seconds)
I_at it u(le/Iungi hole source:❑GPS❑Topographic map
(check box)
DEPTH . DRII.I.ING LOG
From • To F( n, iliot Description
0
-
I I. DISINFECTION: Type TX Amount
12. CASING: Wall 'Thickness •
Depth Dia,ieter of
Pnn�� 'Tu 7 H.
From To
From
13. GROUT: Depth Ntmerial�/
From 0 To ;90 Id. (WxBNr
Frou, To Pt.
Method
14. SCRENN: Depth Diaincter Slot Size Material
From_ To FI. in. in.
Front — To :I, in. in.
15. SAND/GRAVEL PACK:
Depth Size Materiel
From To Ft.
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
0G
16. REMARKS:
11)O HEREBY CLIO IFY TI IAT THIS \VEl1. WAS CONSTRUCTED IN ACCORDANCE WITII I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND PRAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER.
I ' IG -Oci
SIGNATURE OF PERSON CONSTRUCTING TI IE WELL DATE
Submit the original to the Division of NValer Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Thane Nu. [phone], within 30 days. GW-I REV. 07/201.

WELL CONSTRUCTION RECORD
299886
North Carolina - I)ep;urintent of Environment and NI -Huai I//I��eso rccs/- Division oT Water Quality - Groundwater Sectionn. //G
\\ EI.l. CO.\'l IUC"IUR (INOIvIltAI.) NAME (prim)/ % / r'\ )4JO/�9 CERTIFICATION ♦024
I'IIONE it 016r(7.773
\e l:l.l. (ON l ROTOR COMPANY NAME:free._fge/�_Y'
s I A FF: VICt.t. ('CNSIRt:('Tl(1N I'r:KNI I'l #
I if ;I t 1Ge;lle)
Limp
ASSOCIATE) WO PERM mg
(if. tlictblc)
I. WELL USE (Cheek Applicable Box): Residential NJ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL. LOCATIO
Near •st Tonic County
-her-be-Cs rT \i C
ISIr Name. Numbers. ('i�nuu1unily. SuL,Lvisiw Lot No. lip Code) C3. OWNI:R:FAA‹�- L /Pw( S
Address /?C.( oils..-')ors's 77-
/J / . (Sired or Rome No.l
C/Z.0_e_
nv or rm„i
sue
Zip Code
Area code- Phone number
4. DATE DRILLED 7 l -6
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELI.? YES ❑ NO Er"
7. STATIC WATF.I( I.EV1;1. Below Top or casing: yt 11.
(Ilse "a•'if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surl ice*
•'fop of casing terminated at/or below land snrfure requires a
variance in accordance with ISA NCAC 2C MI In. c
9. \'IELD(gpnt): t� METHOD OFTEST/¢/-
10. WATER ZONES (depth):
II. DISINFECTION:'lypc2/fi Amount
12. CASING: Wall Thickness •
topographic/Land setting
Ridge ❑Slope ❑Valley OHM
(check appropriate box)
I.alitude/longitude oI'wdl location
(degrees/mi les/scennds)
L.:nitude/longitude source:❑G PS❑Topographic map(check box)
. DRILLING LAG
DEPTH
From
Font uiot. Description
ce
/-4. t/>t
LOCATION SKETCH
Show direction and distance in nu les Gat;4t$ ocast-r.
Iwo Stale Roads or County Roads. Include the road, ..
ll Depth„ �r or Weight/H.Weight/H./M )r , numbers and cannon road names.
From OS- Toi` J Ft. '' /
From To
Front To
13. (iROUT: Depth Material 74. Method
Front 0 "fo a(J I'I. 6' ' E'/✓
From To Ft.
W. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From to II. in. in.
15. SAND/GRAVEI. PACK:
Depth Size M;ncrial
Front To Fl.
From To H.
16. REMARKS:
11)0 FIEREI3Y CERTIFY TIIAT THIS \VELt. WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL'-=
CONSTRUCTION STANDARDS. AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOl FIE WELL OWNEIt
IGNAIURIi OF PERSON CONSTRUCTING -111E WELL DATE
Suhnlil 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
J
0

STATE: WELL CONSTRUCTION I'ERNIrfN
l it -applicable)
Nen
I. WELL USE (Check Applicable Bus): Residential Er-Municipal/Public ❑
Monitoring ❑ Recovery ❑ I teal Pump Water Injection ❑ Other 0 1
WELL CONSTRUCTION RECORD 299883
North Carolina - 1)cparlmcn( of Environment and It tura Rcourccs - Division oT Water Quality - Groundwatcr Se:tion//(,
\\-EI.1. ('ON'I It.\('TOIt (INDIVIDUAL.) NANI print) / J L A�) �I f � CERTIFICATION Nl2J67
\VEIL CON'1 RAC "FOR Cl/NH.4NV \,.IF f« �e11 �� /i) 1'DoNI: N g_7, .3a
Assocl:l'El) \iQ PERM ITN
(ifa ,licahlc)
2. WELL LOCATION:
N •;tres('I'uwm a � County
�> �� i
(Slrcel Name. Numbers. Community. Suhdnisiwl, Iul Nu.. Zip Clare)
3. OWNER: % A
Address /w bo4 rr -' --
�, / Unr' "Na.l
Cite or -fu v 1 Star •• Zip Code
6,_ nvR o/aL
Area code. ('hone number
4. DATE DRILLED / -7-0
5. TOTAL_ DEPTH: 2 05
6. DOISS WELL REPLACE EXISTING WELL? YES 0
7. STATIC WATER (.IEVIiI. Below Top of C asing: /.r F1.
(lust "+" if Allow Top or Cluing)
8. 'TOP OF CASING IS Q FT. Above Land Surface'
*Top of cuing 1erm ina led at/ur below (and Stir -face requires u
vuriauce in acrllrrlanc• vtlh 15A NCAC 2C .11118.
9. YIELD (gpm): METHOD OF TEST 4'
10. WATER ZONES (depth):
Industrial ❑ Agricultural 0
father, List Use
Topoggraa) oc/Land setting
❑Ridge lope ❑Valley ❑Plat
(check appropriate box)
I .atiludc/Iongilullc of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DKH,L.ING I.OG
Fum �To F 1 lio) Description
�37
NO Et' 35—
;.o
LOCATION SKETCH
I I DISINFECTION: Type grit/ Amount Show direction and distance in miles from -TO least`-•
12. CASING: Wall Thickness two State Roads or County Roads. Inclut (f�. Ile mail:
From 7Dia�ccr or Wci do/P. c;r
To `(/�
Frmtl
Depth
From _ To _ H.
13. GROUT: Depth //rrMatcn l Method
From 0 To 90 Ft. (,PrteN?I—
From "10 Pt.
14. SCREEN: Depth Diameter Slot Size Material
Front_ To Ft. in. in.
From To ht. in. in.
15. SAND/GRAVEL PACK:
Depth Sire Material
From To
limn To
16. Rlil\IARKS:
numbers and common road names.
J c
11)0 FIE14E13Y CERTIFY II IAT THIS \YELL. WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTNN STANDARDS. AND THAT A COPY ON THIS RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
'IONA'I'UItti 01: PERSON CONSTRUCTING 'TIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-I636 I'houc No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resoures- Division of Water Quality - Groundwater Section
\\ EI.1- ('O\ IRAC'I OR (INDIVIDUAL) \.AME1 (print:'tisYY(t.�,,
WEI.I. ('ON' IR AC IOR COMPANY "'sale: I/li • ktQ
SI %IE \\ Et. L CO\SfRL:C PI ON PERMITS
l it anpha.ble)
6
ASSOCIATED \VQ PERMITS
(if applicable)
299917
CERTIFICAA1ION Z.46
PHONE X OLDI • r%d.���a3
WELL USE iCheck Applicable Box): Residential VMunictpal/PubIlC 0 Industrial 0 Agricultural ❑
:Monitoring 0 Rccovcry 0 Heat Pump Water Injection 0 Other 0 If Other. List Use
2 WELL LOCATIC N;
Nca •st Tuwn.
IStreot Name, Nu ,hers. Conunun it Suhdivu:un, Lot Nn.. ZiTiotied
3. OWNER: fZ-e
.\d:u' s 4
St ct
�a5�1
Cov er'itiwn
( )-
Area node- Phoi e o.mrher
4. TOTAL DEPTH: �j If
6. DOES WELL- REPLACE EXISTING WELL? YES 0 '0 B.
7. STATIC WATER LEVEL Below Top of Casing: / ___FT.
I Use'4-" d Above Top M Casing)
R. TOP OF CASING IS _-_ t FT. Above Land Surface'
"'Fop of casing terminated ailor below land surface requires a
variance in accordance with I5A N'C.AC 2C .0118. /�
9. YIELD(gprn): CDO METHODOFTESTCNL Yon&
State
reel (d
Zip Code
Topographic'Land setting
DRidge ❑Slope 0Valley rlat
(check appropriate hwo
Latitude/longitude of well location
I degrees% ini nnies stcoOJj l
Latitude:longitude souree:l7GPSDTopoarupiiic map
i chee b.,v
DRILLING LOG
Formation UeFipTion
DEPTEi
From To
10. WATER ZONES (depth): I 6.4 d
i . DISINFECTION: Typc Id R1L_ Amount 2-.
12. CASING: Wall Thickness
Depth Diameter or \Voight:Et. Material
Front_ v _ To_laS EI.
From --- — To It.
Front To Ft.
13. CIROLIT'. Depth //j� Alatcrial �/� ��, �s Method
From _ To_ --_ Ft._lQ Cr tit
From To Ft
14 SCREEN. Depth Di....meter Slot Size Material
FrontTo Ft. in. In.
From To Et. _in. --- in.
15. SAND/GRAVEL. PACK:
Depth Size Material
Hon To Ft.
From To Ft.
ca
LOCATION SKETCH ?
Show direction and distance in miles from at leastN.1T
two State Roads or County Roads. Include the road
numbers and common road names.
ilD
*''l'l '0(D
Td\ic ticiu3 cat
16 REMARKS: ____-- ---------- -- -"---
I DO HEREBY CERTIFY 1 HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC. 2C, WELL
C'ONST1tutTl0NfyAND TFj\T A COPY Oh THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
C - ll-0
SIC;NATLRE. OF PERSON CONSTRUCTING THE WELL DATE
Submit tlw original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27h90-1636 Phone No. (9(9) 733-3221, within 30 days. GW-I REV. 07'2001

\ortl•. Cot - Dep.irt.nertt of Environment and Natural Resourc-
1 (ls\ I At I OR it'.UH'IDt %LI NAME (piton 1..atYY .-&
\, let l 1 ONIK,'-ION ('p\IMA\\ s4ai F
l l U]SrN(('llll] 1'ENNITI _.__. _.._
I ay hcaF!uI
V. h'.. L L ):-. ithockApplicable Box). Rcsidenual \!unittpe1%Ptibltc 0 Industrial 0 Agricultural 0
\Iou:t,:rl•,g 0 Rcco\cry 0 Heat Pump Water Injutlon 0 DiSei 0 If Other List
Topugra is Land setting
GRtdgc ope C\'alley OFtar,..
'check vrrr:.cna:c
Latitude luneitud- of well lo?a'i :In._
WELL. CONSTRUCTION RECOR
• DiVnndl of Water Quality - CiroundHaier Section
`
299916
CERTIFIC T FIUr a Lob
- Nila'E
?. WEI.I. LOC ATI).
Neatest Tijmso
.1-
\dtI C' (&25_
g
N
or I...n :.•.u,(
\ Ic%itt, y::,r 'twit h,t
i D\ It-. DRILLED_-- 1. _
5 TOTAL DEPTH- _.� ---
6. DOES WELL REPLACE EXISTING WELL? YES 0 thO --- -.-- -_
ST:\CWATER. LEVEL Helms Top aCasing`opt,
.90__FI (lse "`-if .AN.tuy .''avm F,
8 TVI' ('E CASING IS . `_ FT. Above Land Sur!a as -
�Cu nl)
Scho,t gym. Lot \o Lip )));gri -.
tdgre :!ina:es td`.
La'.:.tee . m;tm,.e our .en(IP\OT.,pe „aping tram
yao)d
i_ ?rCQ
\SSW I OLD WO PERMIT,
tit anl,l:cablc)
IJF,fljt
1.0
: ch,..'x hes'
DR1l I INCi LC) i
Formati.,,l
• I y oi Cabin, lersmnnled al:ar be,OM Ind surface re'luire
ronanee in aunrdance Milli 154 \C4C 2C .ri118. _, -_. ___
4 \IELDlgpmt. aQ. METHOD FTEST d. ��-.- — \ ._
31 -- -
Ill W \TER ZONESlde; th} — - - (L )C.4 Il(i1 SkFI
r Tact
r -- Shc , JIrecli)rl ant djstan_c t. miles . ,: al ["
:2 (\SIN-F:CTI(.)N-T+pc__ 1ato��T Amoutcknt sS — iv. oSii,tcRoads or -eu;kRoads Include Mad
CASING Wtr Weight
I-1
piameler or WciFht H. Mara:al numbers and tomnr mod names
Depth • \
1'ro:,'- lc) lit -- - _-----
I j CittOL. L T {1th �th
F rtnn _-_.__._
Ftl, --- --- , n
IS iCRLF^ Ugtlit Diameter Slot Sit: blaf:na,al
. C/}1W.
III — Irt _ .....
r_
I S. ti,\Nn-GRAVEL PA( K
LX-ptii
iori To
FI
sse note ;al
Ft--
- F t - ------- --
L�
I DO nk'CCBS CliR I i F\THAT HIS W ELL \\A>CONSTRUCTED IF At 1. OP.DANCF V. II H 1' A NC\C 2i. WEL. 1.
(iNSTKtt'fl NDAR - AND HAfACDPYel- 1HISRECORD HA:loanPKOVIDED1VTHE WELLUWOE
/a II nn 4- 1
SI'.I\ Alt RE Of PEi:S(Js. Cla\ IRLC)' TM:. W I\U TM:. EI.I. DATE
'submit the original It. the Di%iiion u( W a ter Quality. (.ruund„ater Section. In3b Mill Serutr Center - Ralrigh, NC
Y04 I:,Sb Phone Na. (919) /33-3221, 14 ithin 30 da,s. OW-i REV 0

WELL CONSTRUCTION RECORD 30 i 7 F 3
North Carolina - Department of Eitvironntcnt and our I Resources - Division oT Water Quality - Groundwater Section
wiLL (' I RA(-r(JR (INDIVIDUAL.) NAME (prim),« 44 �A (- CERTIFtCATIONra'5��1
rwit!.coxru.(-run COMPANY NAME g-T CC. (CA)E I PHONE a Ke)622 8"-
ASSOCIATED WQPERau•ra _.....
S'r,TE wr:l.t. coNSTRu:C II(N PEKMrra
i ira 11Se: hle)
(if applicahiel
I. WELL USE (Check Applicable Box): Residential I'Y Mrmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ilcal Pump Water Injection ❑ Other 0 1IOther, List Use
2. WELL LOCATI N:
Nearest Town:
b1J)(h VC`
(Sired Nanw. Numbers. frxnnronily, Subdivision, Lnl No.. Zip ('ale)
3. Adt7s
ISnen ullirun.• N 1.1 ^2 /)
Zip Cate!
L �y
(vrim-y r12/—r3aCor03.
Area rode- Plume number
�/
4. DATEDRILLEDV--o24"O
5. TOTAL DEPTH: cco
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO B--
7. STATIC WATER I.EVIi . Below Top of Casing: /et FT.
(Use "a.. if Alcove Top of Casing)
8. TOP OF CASING IS FI'. Above Land Surface"
'Top of easing ierminaled anor below land surface requires a
variance 1n accordance with 15A NCAC 2C .0111i
9. YIELD(gpm): a0 METHOD OFTEST/Qr%
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
pot
From 'fa DTeo � 6
From To
From To • F1.
13. GROUT: Depth Material
From 0 To (20 Ft(P^'PAIT
From To I't.
Topogr� nc/Land setting
❑Ridge l3Slope ❑Valley ❑Flat
(check appropriate tmxl
I .atituddlongi(ude of well location
idcgrecs/minulcs/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
. DRILLING -LOG -
fr ma 'on Description
DEPTH
From •
To
d
C
LOCATION SKETCH
Amount • Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
to I • rr Weight/Ft. + trial numbers and common road names.
H.
1 5%
FI.
14. SCREEN: Depth Diameter
From To F1. in.
From To Ft.
15. SAND/GRAVELI'ACK:
Depth
From
From I'o
16. REMARKS:
Method
Slot Size Material
in.
in.
Sire Material
Ft.
11)0 HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
pl' , Gl
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Sen'ice Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CON
STRUCTION RECORD 301116
North Carolina - 17epaninenl of Environment and N:
CONT R.KcrU1t (INDIVIDUAL) NAS1F (Print)
WEl.l. COMTRAC 'TOR CO?I I'AN\' NASIE
SPATE. wEI.I. COy\T-RUCTION 1'E it NI ITN
if applicable/
�.—a- . m k.
tural $csourj:cs - Division eT Water Quality - Groundwater Sections
,/ CERTIFICATION
rnt
le// FYzit RHHONE 11 h5o(g) 7.f�in
'v {{i ASSOCIATED WQ I'ERMITN
(if apfl icahlc)V
I. WIiLL USE (Check Applicable 13us): Residential L9- Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT Q
Nearest Town: De -
Count
(Street Name 'ti/mbers, l-tmtnamity. Subdivision. 1 nt No.. Zip flak)
3. OWNlilig:h1 ,
,Street ar Ro`.e No.)
/ti44U%//f� /�/•`
nv or Town Sr le
Ana r.dc- 1'hnnc numlxx' 04,51
4. DATE DRILLED \5
5. TOTAL DEPTH: ni0-5— i�-�
6 DOES WELL REPLACE EXISTING WELL? YES 0 NO tm
Address P'TUf.3P
7. STATIC WATER LEVI.U. Below Top of Casing: 7 � ire.
Disc "+" if Above Top of Casing)
S. 'fO1' OF CASING IS
7fS
zip Oulu
FT. Above Land Surface'
*Top of easing terminated atlor below land surface requires a
variance in accordance with ISA NCAC 2C .0111k
9. YIELD (gpm): /0 METHOD OF TEST .4/
10. WATER ZONES (depth):
1 I. DISINFECTION: Type
12. CASING:
-frog
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Off;
(check appropriate box)
I.atitudc/longitude or well location
Idegrecs/minulcs/sccontls)
Lati$ude/ongitudc source:❑GI'S❑Topographic map
DEPTH
From To
0
7
Depth Diameter
From T0/ Et. 2 F7 /..,
From To Ft
13. From To - F1.
13. GROUP: Depthaa Material _L
From z2 To (-C Ft. re.""erVT
From To Ft.
14. SCREEN: Depth Diameter Slot Sin Material
From To FI. in. in.
front To II. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To ht.
From To Et.
Amount
Wall Thickness
or Weight/Ft.
iefiai
Method
Material
I6. REMARKS:
(check box)
. DRILLING TAG
F. Mot Description
LOCATIONSKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
tIse
ieCEe
�Be
ci PLO
cb 2jp
ot
oy
I DO HEREBY CERTIFY TIIAT fills WELL \VAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
'%'-cam' 1;
SIGNATUItI? OF PERSON CONSTRUCTING THE WELL
,8-14-e Li
DATE
Submit the original to the Division or Water Quality, Groundwater Section, 1636 Mail Service Ccntcr- Raleigh, NC
27699-1636 Phone No. [phone]. Within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N• / rural gyesour�
WELL(•ONY RA(-1'OR (INDIVIDUAL) NAMEj,primp/ i'✓t t(
WELL CONTRA(' wait ('O\II'ANV N.\\lt: f Jt� V'- ilL/`
STATE Wf:1.1. CONSTRUCTION PI:WOLIN
Iifapp icahlel
Noce -
'es i rviision oT Water Quality - Groundwater Section 6,
• ‘J ii. e CERTIFICATION M '7
i<alf PHONE N Wfq) ,7$
ASSOCIATED WQ PERM ITN
(if applicable)
I. WELL USE (Check Applicable Bus): Residential a i4unicipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, list Use
2. WELL LOCATIO
Nearest /own.
(Street Name. Numbers. (,minnmity. SuhJi •ision, 1.01 NO.. Zip Code)
3. OWNER:
Address
vie-
5'0Z
(Si eel or me Ne.1
p/3 Cily pi Town SLOW 7b t 7 Zip cook
Area node. (game numlw�y
4. DATE DRILLED 75' 7-0 4/
s TOTAL DEPTH: � 4 ZJC -(-�
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO er
7. STATIC WATER LEVEL Below Top of Casing: n( Fr.
(Ilse "$•' if Above Top of Casing)
S. TOP OF CASING 1S 1T. Above Land Surface'
`Tap of rasing terminated al/or below land surface requires a
variance in accordant with ISA NCAC 2C OWL
/f/ /
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type 7 /
,41
12. CASING:
Dept
// /Dian C'c/r
Front �i� Top( Ft. 1p �J7
From To
Frunr To 1'1.
opographic/Land setting
dgc ❑Slope ❑Valley ❑Flat
(check appropriate box)
I. Brute/Iongilude of well Meat ion
tdegrccs/minulcsiscconds)
Lai source:❑GPS❑Topographic map
(cheek box)
I)IEI'TH . DRILLING LOG
From xo F.•rt alit. t Description
0
4o
rx
LOCATION SKF.TCII
Amount Show direction and distance in miles from al least
Wall Thickness . two State Roads or County Roads. Include the road
tr W_ cig it/Ft. ateria numbers and
common road names.
13. GROUP: Depth Material � // Method
From b To dQ n. rie-i/T
From To Ft.
14. SCREEN: Depth Diameter Slot Sizc Material
prom To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 'to Ft.
From To Ft.
16. REMARKS:
1 DO HEREI3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COI'Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
oC-I
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-I636 Phone No. [phone], within 30 days. GW-I (REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and alura Re'oure •s - iv`iysion ol'Water Quality - Groundwater Sections
�f �re CERTIFICATION rrp:'r'))
WELL COS" RACTOR(I.NDIVIDUAL) NAME olio /' 4 !aer
wE1.t. CosrRAc-rl)R COMPANY N:v>u: i'_
"M rIIONE u V'r'g)67-325".
STATE: WELL ('ONS.RCCr1ON I'F.R?II'I #
(i f a s ilic:ihIt
il��fOQI®'
Ass0C IATEn w'Q 1'i• it'i rra
(i f apple icable)
I. WELL USE (Cheek Applicable 13os): Residential frMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Near • I Town: Wn
(SiresI :Inc. Nwithers. C,nnnnaiily, Subdivision, IA No.. /id Code)
3. OWNER
Address
Topographic/Land setting
Cage ❑Slope ❑Valley ❑Plat
(Check appraprialc boa)
I alit ode/long il ude of well luealion
(tlegrces/minmes/secondal
L:Il i I uck/l oncilude source:❑G PS❑Topographic map
ISlur Ito nir No.) / ,,they,le+sl
}� b DEPTH .DRILLING LOG
' yor.fawn Slade . • Lip Cnae Prom • To Font lli a Description
)- 515-4 S`°y 1-
D
4. DATE DRILLED ¶-vO ��
5. TOTAL DEPTH: 34-3-' 9-3,�'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 2 '
7. STATIC' WATER LEVEL 13clowTop ofCasing: CS) FT.
t Use -4" if Above "fop orcasino
8. TOP OE CASING IS PT. Above Land Surface*
*Top of casing lenninaled at/ur below' land surface requires a
variance to acrordauc^c with 15A NC AC 2C .1/I IS.
9. YIELD (gpm): rx j METHOD OF TESTShf
10. WATER ZONES (depth):
301773
Area cola- I hunt number
LOCATION SKETCH
I I. DISINFECTION. Type 7- Amount Show direction and distance in miles from at least
12. CASING: Wall 'Thickness • two Stale Roads or County Roads. Include the road
Depth > 1)iap pr o1r4�;iy;ht/FL -erial - numbers and common road names.
From �� 'I'o�/ FL (�!y,py/Q
From To Ft. /'A"
Prom To H. 9P ',"
13. GROUT: Depth Material y Method GFF9 FG
Front_ Tt O Ft. ce''vteA/ A e
From To Ft. CP lb!/�tC
14. SCREEN: Depth Diameter Slot Sizc Material e j " <91,jO��
From "1'u Fh in. in. �Q tf+� Q
Prom To PI. in. in. O
15. SAND/GRAVEL PACK:
Depth Size Material
Front To Ft.
From To Et.
e.
16. REMARKS:
I DO HEREBY CERTIFY TIIAT THIS \YELL. WAS CONSTRUCTED IN ACCORDANCE Wfrli I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND il-IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Imo_.
10-a
SI(,NATUIt IS OF PERSON CONSTRUCTING "I'I3E \VCLL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 l'honc No. [phone]. within 30 days. GW- I REV. 07/2001

WELL CONSTRUCTION RECORD
301772
North Carolina - Department of Environment and Nd• tur'�"�// allU,)J°sources- Division oT Water Quality - Groundwater Section Q
WELI.CONI lt.\Cr(lt (INIIIVlnt:Al.) NAME ((print) I. 4)T& L4 , UJ(ice CERTIFICATION /
WELL CONTRACTOR CONIPANS NAME f? j( f wed / -,•'Z/2 PRONE a i)60-95.1S
STATE I E \\tI.1. ('I INSTRUCTION I'EgMrra Assoc/mat \%'Q I'ERbliTti
I it aplrlicaMe) (if applicable)
,tom -. ,..h..w i..,,,,. - „ 4.- _,v.,,„, .,--sass-
I. - r
WELL USE (('heck Applicable I3ox): Residential Er Municipal/Public 0 Industrial 0 Agricullural 0
blouitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
/
4vbQ /J Topographic/Land setting
CountyA Midge ❑Slope ❑Valley ❑Flat
(check appropriate has)
I .at ituddlongitode of well location
2. WELL LOCA•rl
Nearest Town:
(Street Name, Numbers. Coni t tity, Subdivision, lad No.. Zip (-,de)
3. OWNER:
Address
( /0e._ (Street la hoot..
('ny or Town 51 to Zip Coale
• Area c,dc-Titone number /
4. DATE DRILLED ?/` ti rig -
5. TOTAL DEPTH: . '.Y, c- -
6. DOES WELL REPLACE EXISTING WELL? YES RI NO e'
7. STATIC' WATER LEVEL Below Top of Casing: /0(0 FT.
(Use -4- if Above Top of Casing)
S. TOP OF CASING IS vr. Above Land Surfaces
*Top of casing terminated a1/ur below land surface requires a
variance in avnrda,ee with ISA NCAC 2C _out /� /
9. YIELD(gpmr / METHOD OF TEST / -'
10. WATER ZONES (depth):
11. DISINFECTION; Type 171 7'4Amount
12. CASING: Wall Thickness
, 7 Depth •7 Dialpcicr or Weight/Ft.
Prow 7 oC. 'fo vc(�C ,:i
From To 1st.
From To •_ Et.
13. GROUT': Depth Maicrial
From To (9'D FI.Cyevt6,,71`
From To Ft.
14. SCR( IiN: Depth Diameter Slot Sivi Material
From1•o FI. in. in.
Front To PI. in. in.
15. SAND/GRAVEL l'ACK:
Depth Size Material
From '1'o 1'1.
i degrees/m inulcs/atonds)
Laiitude/loneimdc source:❑GPS❑Topographic map
(cl eck host
DEPTH . DRILLING LOG
From -/ o Fhjp ion cscription
o C.
/0 :'ry
2y S'
LOCATION SKETCH
Show direction and distance in miles from al (east
two Slate Roads or County Roads. Include the road
M crial numbers and common road moles.
� IMQ /7- (93
From
l'o FI.
Method
147
pel O
ofr
16. REMARKS:
1130 HEREBY CERTIFY TIIAT 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
d-Leeee ,a e-w-O�-�-
SIGNATURIi OF PERSON CONSTRUCTING THE WELL DATE
Submil the original to Ibe Division of Water Quality. Groundwater Seelion, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

301Q92
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
- Division of Water Quality - Groundwater Sector
WELL CONTRACTOR (INDIVIDUAL) NAM�E^` (print) /'C Q.%%T�7/ Lo t. S .Ant / CERTIFICATION ri
WELL CONTRACTOR COMPANY NAME S't )eeTW•J _ Lt ✓l. rl Tw/r �6�7
� t-�J-tT-�-ss—� PHONE N �GY 1 og 8O
STATE WELL CONSTRUCTION PERMIT* /U/.. ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
1- WELL USE (Check Applicable Box): Residential CB"Municipal/Public ❑ industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nest Town:
(Shutt Name, Number, C
3. OWNER;. AU.IQ
Address q Y S(Sheeett or RRo.& No.
C41r/o , rvG
City or own State Zip Code
(28)- Sys- y3s3
Area code- Phone number
4. DATE DRILLED `.3 O y
5. TOTAL DEPTH: Z
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L"'
7. STATIC WATER LEVEL Below Top of Casing: .30 F.T.
p e. (Use"+^ if Above Top ofCasingl
8. TOP OF CASING IS J O FT. Above Land Surface'
'Top of casing terminated aUor below land surface requires a
variance in accordance witb 15A NCAC 2C .011S. r /
9. YIELD (gpm): 2 0 METHOD OF TEST //tatted
10. WATER ZONES (depth): %0 '
11. DISINFECTION: Type C•jl/RAmount » et.
12. CASING; Wall Thickness
Depth feu or Weight/Ft Material
Front__--� To 70 Ft spg z / ['tic
From To Ft.
13
14
From
GROUT
From
From
SCREEN:
From
From
SAND/G V
Topog>hic/Land setting -
❑Ridge I Slope ❑Valley ❑F1at
(check appropriate box)
Latitude/longitude of well location
ua (deo;mraeat)
Latitude/longitude source:❑GPSOTopographic map
(check box)
DEPTU DRILLING LOG
From To Formation Description
To Ft. Dnth
T 2s2 Fepth It AMaterial
f /se tt le
To Ft
Depth Diameter Slot Size
o Ft in. in
To Ft. in. in.
Material
15. EL PACK:
Depth Size Material
From / To Ft.
From / To Ft.
16- REMARKS.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or Co r . Include the road
numbers and co r /it r eS
CC
19Ke /oy vti Rd
H
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC I Ell IN ACCORDANCE WITH 15A NCAC 2C. WF( 1
CONSTRUCTIOI7ANDARDS, AND THAT A a'Y OF r.;, RECORD HAS BEEN PROVIDED TO THE WEII OWNER
4-3/-ey
SIGNATURE •F PERSO CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMITS
(if applicable)
301815
tural Resources - Division of Water Quality - Groundwater Secti�o1n�j�
CERTIFICATION ty[_%
ASSOCIATED WQ PERMITS
(if applicable)
HONE S S& e4-44gO3f 12)
N/q
1. WELL USE (Check Applicable Box): Residential lit Mttnicipat/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATIO
Nearest Town:.
2so
(Street Name, Numbers, 'immunity, Subdivision, Lot No., Zip Code)
.. t
3. OWNER:AtmQ S it-4d-LGLCJ
Address _ �i. S/� %i. [ g .o &d
Countyyl��A'.titu0ay
Ord .1>s'�.2 /
or Tout State Zip Code
e.n }_ 1'47- y384'
Area code- Phone camber
4. DATE DRILLED 7/.2 �/D r
5. TOTAL DEPTH: /f
6. DOES WELL REPLACt EXISTING WELL? YES 0 NO 2
7. STATIC WATER LEVEL Below Top of Casing: —7
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS J. Ft. Above Land Surface'
'Top of wing terminated at/or below land surface requires a
variance hi accordance with ISA NCAC 2C .0118.
9. YIELD (gpm)' 'C o METHOD OF TEST —rant o
10. WATER ZONES (depth): 7o' /1 D'
11. DISINFECTION: Type C.
12. CASING:
Depth Diameter
From_ To ,5.2 Ft. h
From To Ft
From To Ft.
13. GROUT: Depth,
From 0 To of 0 Ft
From To Ft
14. SCREEN: Depth Diameter
Fro To Ft in.
From_ To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From o Ft.
From To Ft
/1. f% Amount -4.5. et
Wall Thickness
or Weight/Ft Material
�✓ tPdc
fef7P..cY WV' My
Slot Size Material
in.
in.
16. REMARKS:
Topographic/Land setting;;
l$Ridge 0Slope ❑Valley PFlat
(check appropriate boa)
Latitude/longitude of well location ' r
c
(degxsimimrseslsamb)
Latitude/longitude source:❑GPS❑Topogiaphic map
(teckbox) -.'*, --- -.
PRJLLIk.G LOG
Formation Desatiption--
9ee
0r�
DEPTH
From To
LOCATION SKETCH
Show direction and distance in miles from . east
two State Roads or County Roads. Incl . e the road
numbers and common road names
0
b
1 DO HEREBY CERTIFY THAT THIS WEI ( WAS CONSTRUC 1El) IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD$, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
tge 7/2 % 9
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

WELL; CONSTRUCTION RECTOW 300780
KA( ••• OR grimyInc 4L) NritM
tlejtaruite rt. of I- nvIrunrnerd and ' Rea.,111ce.. - iThvg.11,Fi attr Quaint nount-h_ jr- - St:c fl,
•••• • • • •:_0", !cc( (13( COMP 4.NIN 'NAM' 4,./4.fil
ft•rist n.AJAJ
kJ- • Hi'. 4/22
LUNSTxt CA ION PLIthlio
app ,cahr
N/4
vigeidt.ip zieci sira4,9-en
ASSOCIATED Wy PERAII
Of 8A-dal-tie
Si: f ( heck Apphcable Box i Residenna.! Municipal/Public 0 Industria fl Apy-L.1,..
M,•:-..!.Eurn: El Recovery 0 Hea Pump Water Injection 9 Other' D 11 Other Lit
V•I• •AY;A.Tnto
Topograplii, Lar.d
Nt••• c.i 0%41. -14.0)- 'lilt\
- - • Diudgr It; pc
.. _
'.Lit:' "%tr.' ..C7 • COITIR4Uralrl CitOXIIV r Lot !.4c ZIT JN-- Lantude',..mir-inr.
AA ' ‘.. Eh "tit Ir ,01.4,4....3
-Aer . „Ciesti —4:.it.di..,-.,t.' , 1,--v-nr_:nraz
r Li,
a/9/0 44
.2.3-
c,
r
• irk
-A-
-en°
rT1
/VD I /9_5-1fl -Da erz
_C • _il.. N. isectut ' SaS 2-, Shcv inc:11:T anc: rl...d.b ... ..
IN3 -- -
V. a:
o 99S• 6te pita./ ei)c
o D ' animas/ taitg ALA/
r.
- Tr•AT. 'THIS WIT;1 WAS CONES"F.k.'t•CIED .Ait-,f WiTh
.42CL).1h.01, A COPY (.1i- BEENR tTet •
sa499 6/31/051
1)11,...ir:, ‘.i.ro•Jadvi.3ttr torstf, t:“

WELL CONSTRUCTION RECORD
300494
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L»jt CSC.% a':t0.41. twat<S CERTIFICATION# aw$V
WELL CONTRACTOR COMPANY NAME _thde S4W<CS 4'be 1att •�,p t PHONE # &(it) terns -tone
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 ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: rSsatttte�V: tit County lire!
2q CeeNJA. Lent_ 23984,
(Street Nacre. Numbers. Community. Subdivision, Lot No., Zip Code)
3. OWNER: Sharman. Plaa.s
Address A9 eery i an.
(Street%r Route No-)
tJaaenit t to ►tt air! 66
City or Town State Zip Code
($3S-)- 456- 4R59
Arca code- Phone number
4. DATE DRILLED i• I) •OM
5. -TOTAL DEPTH: 645 it /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cf
7. STATIC WATER LEVEL Below Top of Casing: 6e FT.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): A METHOD OF TEST il:q
10. WATER ZONES (depth):
1 I. DISINFECTION: Type pats
12. CASING:
Depth
From 1.1 To 115 Ft.
From To Ft.
From To Ft.
13. GROUT. Depth
From 0 To 2e Ft.
Amount
Wall Thickness
Diameter or Weight/Ft. Material
t� ttzl _past.
Material
C.Qaie as
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.
Method
?Out ea.
Slot Size Material
in.
in.
Material
16. REMARKS:
Topographie/Land setting
❑Ridge ❑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
s
115 an, i%.waa..
its Sit 6cenl+re
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
D annia ltsaa6,
7-la?•o4
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

300520
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
'� (print) h 9 t-r" {JIJ V& L t A CERTIFICATION # 7 3 4 y
WELL CONTRACTOR COMPANY NAME t-e re -Pane ne UrvS Lai4J J1 4 j'(� t x r.iy u... PHONE # 012 $ - .3 / %
STATE WELL CONSTRUCTION PERMIT# / 41 D a ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential*. Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: Nearest Town: la) gvyrt S ut / /e _ County/I'' k
izt
rY) i'an,Q A 1-
(Street Name, Numberskommunity, Subdivision, Lot No., Zip Code)
3. OWNER: �ci-4" tidy ti-�GA.tll�r,
Address PD. /'rs/a
(Street orote No.)
et,,d, x c 2%7i1
City or liown / State Zip Code
( )-
Area code- Phone number , /
4. DATE DRILLED 7- .i2 - 6y-
5. TOTAL DEPTH: 4 45- /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1I4-
7. STATIC WATER LEVEL Below Top of Casing: 416 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .D[ 18.
9. YIELD (gpm): /.,'/ METHOD OF TEST e r5
10. WATER ZONES (depth): 3/S r - 3.23- '
11. DISINFECTION: Type 1-4 T-J
12. CASING:
Depth
From /) To /•/a Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material"� Method
From 6To .�ti Ft. CD IG 1
From To Ft. 1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Diameter
G
Amount 1/. 4/,i
Wall Thickness
or Weight/Ft. Material
PVc
Topographic/Land setting
❑Ridge ❑Slope OValley 'Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From /o For gn Description
iyf 34/S
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I:"t fl—
c €n
16. REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STA DARDS, AND THAT A COPY OF THIS RECORD HN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING 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

300519
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
t (print) �i lD��t CERTIFICATION # .2y /
WELL CONTRACTOR COMPANY NAMENAMEV-rE.r4r. I.l- Ccra . 1_0.,�AL 4�-RHONE # (g'p' 4,4/P' 3,I '
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery O Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Ina n it, ve 11 County !-)cw t )o Ot&
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: C70 hiy C_CCJr re-vu
Address P Li r )f 11 4-4
(Street or Route No.) (� r� ry
& YIPS s/ r I I c. Ad C -? C ( 0
City ottown State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED L - 3 C —o 4
5. TOTAL DEPTH: S S S '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO a
7. STATIC WATER LEVEL Below Top of Casing: Ile D FT.
(Use if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 4 METHOD OF TEST 3 r%•
10. WATER ZONES (depth): 545 ' — 'i 4 Qen
11. DISINFECTION: Type +.{T)-)
12. CASING:
Depth Diameter
From C To D 1 - Ft, tc ''
From To Ft.
From To Ft.
13. GROUT: Depth � Material 11 Method
From Il To D Ft. 4Gwv. .a—th \-., V,
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount 1 S( +1.1 fs
Wall Thickness
or Weight/Ft. Material
PVL'
Topographic/Land setting,
[Ridge ❑Slope [Valley pdtlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
D 3L
-2lc' SSS'
ter r��-yy
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STA?"DARDS, AND THAT A COPY OF THIS RECORDIL.S BEEN PROVIDED TO THE WELL OWNER
7-3/-.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
LL' 1. (do:,

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WEI.I. CONTRACTOR (INDIVIDUAL) NAME (print) _ (3r� ter (���C-=-_. - CF.RTlFI(AFION/+(� �6
WELL CONTRACTOR COMPANYNAME a Ve_ is II: S. O5 .. )u) OA r"�WI4K PHONE M (, WrG (Ig '�/
STATE WELL CONSTRUCTION PERMIT# /i()oC ASSOCIATED WQ PERM1'[K
HI applicable) lit applicable)
1. WELL USE (Check Applicable I3ox): Residential Municipal Public ❑ Industrial 0 .Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other. List Use —
2. WELL LOC'APIO
Nearest gown:
cSmok
I Street Name. Num
.�t County ily/Le_eCZ
�J CI.w.0 •kt t o rt _•
-
Community. Sahib vo ion. Lot No.. lip ( ndep
3. OWNER: TI tvvv vioAtvs/ AA1IClP.r&
Address ] 4 Q- .'S,' 41--r t r o c a CI rile.
I Street or Route No.1
USv t lit nj(, <28 7 %CL
( in or roan State Gp (ode
( )-
Area axle- Phouc number r /
4. DATE DRILLED_�D _U if-
5. -TOTAL DEPTH: Ions t
6, DOES WELL REPLACE EXISTING WELL'? YES 0 NO t
7. STATIC WATER LEVEL Below Top of Casing: LIRO FT.
(Ilse "1- it Above Top of('auine)
S. TOP OF CASING IS 1 FT. Above Land Surface*
*'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .II118.
9. YIELD (gpm): I/ 4 METHOD OP TEST 02 A Y.
W.WATER ZONES ldepth): 1RD' - /9C
I I. DISINFECTION: Tvpe /J77--7Amount / 2 a 01S
12. CASING: Walll'hiekness
Depth Diameter or Weight Tt. Material
From a. To d—% Et. to /l _ Ate
From To Ft.
From To Ft
13. GROUT: Depth /� MaterialMethod
From I)To,0 Ft. C-e.4'riQ,b-t _ 7
From -lb Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Et. 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 pl.Slope ❑Valley ❑Plat
Icheek appropriate 1)0<1
Latitude longitude ofvcell Iocation
1 d:,,c�� uunute. s cond*1
Latitude longcitude souiee:DGPS❑Topographic nap
tcheck ho I
DI. Fri DRILLING LOG
From To I ttii m ion Deeserri��lion
2TT __te.!
LOC:A I ION SKI: T(I l
Show direction and distance In nolcshront at Icast -
Us o State Roads or C Dunn Road: Inc kale thc,und
numbers and common road name -__. ...
`o
I DUIIERERYC TRTIFY THAT THIS WP.I.I. WAS CONS TRUC TED IN AC CORI)ANCE VMITI 15:A St .AC'_C. W EI]_
CONS FRUC'TION S'T ANDdARDS, AND Il IA T A COP1 OF- G ITS RFC ORD I :AS I3I:EN 1'RDA'IDI-I) l D CUE WET-1 _ OWNER
kzeii
t0 ,
SIGNATURE OF PERSON CoNS'TRULFINU TI II-. WLI I_ DATE
Submit the original to the Division of Water Quality, Groundwater Section. 1636 Mail Sec) ice (-enter- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. (IAA. -I RI --A. (1' 2(00l
293713

294665
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/tuResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAN E print) J2 —eaM. `�, L-�e'' ,CE:R"iI FI('A Ft0N # .3 � � 8
WELL CONTRACTOR COMPANY NAM LCL /rrbc to (- ' '-1 l'IION E # �(,9' L ' * 3 J 2 °
STATE WEL1. CONSTRUCTION PERMIT/ /} 0,2
1 it'applicable) Of applicable)
ASSOCIATED \VQ PER)lIru
I. WELL USE (Check Applicable Box): Residential`, Municipal Public ❑ Industrial 0 ,Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 110ther. List Use
2. WELL LOCATION'
Net l�ejTown:,J6 ne51/t /�t,county
X J 7 n,.J iP
I Street Name N(4'hers. Community, Subdivision. Lot No.. Zip Code
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ttr LIat
Ichccb appropriate hurl
Latitude longitude or well location
3. OWNER: dceres nil Lauds seconds
Address Latitude lom_ittn.le unnce:❑(iPS❑TopograpMai)ic Mai)
(Street ni Ruutryt check bust
fQ DI-.PTII DRILLINGLOGCity or on Sine /'p (-ode 1 loon To Formation Description
NE 22721 -L) /! 2
Area code- Phone number /J 7
4. DATE DRILLED •• - c2 2 -6 41.
5. TOTAL DEPTH: / AS"
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Fop of Casing: 3D ET.
(Use"r' ir.4bncc Top or Casing
3. TOP OF CASING 1S FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): a n METHOD OF TES t oC Ars -
10. WATER ZONES (depth):
I E. DISINFECTION: Type
12. CASING:
Depth
From cO 'To 1/'7 Ft
From To Ft
From To Et
13. GROUT: Depth
From D To c20
From To
//o5/ - 01' h-'
/--I--77T Amount a7 +Albs
\\'ul I Thickness
Diameter or Weight. Ft.
1\tatcrial
14. SCREEN: Depth Diameter
From To Ft. in.
From To
15.SANPC RAVELPACK:
Depth Site
Tu Ft.
To Ft.
From
From
Material
PICA
Method
�
Slot Sin V1aterial
in
Vlaterial
LOC:A(TON SKETCH
Show direction and distance in miles from to
two State R.mds or County Roads, Include the nail
0
numbers and common road names.
l6. REMARKS:
1 DO IIERLDY C ERTIFY TIIA'l THIS WEI.I. WAS CONSTTLUCTED IN ACCORDANCE WITH 15.V NCAC 2CC. WEI.I.
CONSTRUCTION STANDARDS AND TTIAT A COPY OF TTIIS RECORD II:AS 131.E.N PROAIDLD TO T1IE WE.I.I. OWNER
SIGNATURE OI' PERSON (ONSTRL("FIN( i TI II W III I. DAII-.
Submit the original to the Division of Water Quality. Groundwater Section. 163o \)ail Sen ice (enter - Raleigh; !NC
27699-1636 Phone No. [phone], within 3U days. (.i\F-I REV. 071201)I

WELL CONSTRUCTION RECORD 297681
8
North Carolina - Department of Environment and Natural Resources - Division of Water (?utility - Groundwater Sectiogn Q
WE.l.L CONTRACTOR (INDIVIDUAL) NA\I)��:}print) �_ /�17)I� /V C,.G-/jtJ-�J.iA ('t:RTlFl('.Ttp()N # r'� I 0
win. CONTRACTOR COMPANYNANIL ___i.f �.Id4LQ—w.A." 9 / ��NIONE it (p?64 /k '3/ 76
STATE WELL CONSTRUCTION PERMIT( / 4 O ASSOCIATED N'Q PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Dcat Pump Water ejection 0 Other 0 110ther. List Use
2. WELL LOCATION•
NearestTown:
SNCrYV\�Z tS (1A _ (chink appropriate box
(Street Name. Numbers, Community. Subdivinwn. Lid No.. Zip ( ode) Latitude longitude of well location
3. OWNER:
Topographic/Land setting
County MA ❑Ki.lge ❑Slope ❑Valley
v llc� Mea.."Pova_
Address 3 3 S n�rrvSn.w'S Zi Ux�
n trecl :Route No.
a�i NC '1 1 Li
Cn) or Tosco Mute hip Code
( )-
.Arco code- Phone number
4. DATE DRILLED S."' '7 - b
5. TOTAL DEPTH: a OS a !,(
6. DOES WELL REPLACE EXISTING WELL:' YES ❑ NOV.
7. STATIC WATER LEVEL Below Top of Casing: 60 ET.
(Use I- it Above mpg( Casing(
S. T'0P OF CASING IS FT. Above Land Surface*
`lop nl' casing terminated at/or below land surface requires a
)deerce. nmne'seetud,)
Latitude loci tuck source:❑CiPS❑Topographic (nap
(cheek h0x1
I)I.PT I I DRILLING LOG
From To E my t. n Description
o _SG'
tget
variance in accords ce with 15A NCAC 2C .0118.
9. YIELD (gpm): 7 METHOD OF TESTS-s
10, WATER ZONES (depth):
155 ' - Lu rn-
II. DISENPECION:Type_ kn./_
12. CASING:
Deptht- Diameter
From in 'To SA. Ft. %o )1
From To Ft.
From To Ft.
13. GROUT: '� Depth
//� Material I-- 'Iethod
From C To G//Fite)�}
Vl F_sr •�
From "I'o Ft.
l4. SCREEN: Depth Diameter Slot Sim Material
From To Pt. in. in.
From To Ft. in, in.
15. SAND GRAVEL PACK:
Depth Sitt Nlatertal
LOCATION SKLT('li
_Arno"! oS +61425 Shove direction and distance in miles from at least
Wall thickness two State Roads or County Roads. Include the ro(fd -
or AVcieht It, AIater)a( numbers and common road names.
AVC
From '10 Ft.
From _ .co Ft.
16.REMARKS:
—o
O
1 DO IIEREOY CERTIFY TIIATTIIIS WELL WAS CONSTRUCTED IN ACCORI
CONSTRUCTION STANDARDS, AND 11IAT A COPY OP T111S I(I[CURD II
` j ,Llh . -
SIGNATURE. OF PERSON C ONSTRCC TIN(
\N('II WIC II I5.\ Is( ACC 2C. Vt EI.I.
EN PROVIDED TO TIIP. 'El.L OWNER
ems-=3i-a�
\\ 111. D:\ Il.
Submit the original to the Division of Water Quality, Groundwater Section, 163e Mail SerN ice ('enter - Raleigh, NC'
27699-1636 Phone No. [phone], within 30 days. (iAV-I l(EV. 07 2001

297r(9g
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources//- Division of Water (Quality - Groundwater Section
WELI.CONTRACTOR (INDIVIDUAL) NAN E (print) �7 J /\/ /I-) CERTIFICATION aall /2
WELL CONTRACTOR COMPANY NAME) .Lt CJUI-•N�.L7�o • ({ evict te..Pll(NE # (D.t D 6 die J'�/ 94
STATE WELL CONSTRUCTION PERMIT/ / 42/d it - _ _ _,ASSOCIATED \CO PERM FOP
Of applicable) Of applicable)
1. WELL USE (Check Applicable Box): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 heat Pump Water Injection 0 Other 0 I (Other. List Use
2. WEI.!, LocATlo
Nearest Toycn:
_i t/U
tStrecl Nance. Numbers. Cu munity. Subdni,ion. Lot No., Lip ( ode(
3 OWNER:��
_ �-CJ
Address
atek(Street or Raub; No.l
kr ..1)/ / /e ilo2.2o2s
( UN or llnm Slate Lip ( ode
)
Arca code- Phone number
4. DATE DRILLED 5 - i) -O
5. TOTAL. DEPTH: ,5-8 C
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO 4_
7 STATIC WATER LEVEL Below Top of Casing: 160 FT.
(Use -Li. it .Aborc Top or Lasing)
6. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCA(' 2(' .l)118.
9. YIELD (gpm): 41D METLLOD of TEST ID r$
10. WATER ZONES (depth): 6(o 5 a - l{. C A Fr20
( onnty_ 2 J
l
2
13
14
l5
Topographie/Land setting
❑(tidge i Slope ❑Valley ❑Plat
I eek appropriate boxl
Latitude longitude of %yell location
• ) ideate.. uunutc. seeond.1
_ J� 5- ex./7 Latitude Ionittule source:❑(iPS❑Topographic neap
(check hNAL
DRILLING 1 ( )(
Funnatio t Description
DEPTH
from To
_s0_9
ea9' sgS'
•
LOC'ATLON SKETc'11
DISINFECTION: Type F- r E4 .Amount 29 44i . Shore direction and distance in miles prompt limo— _
CASING: Wall Thickness two State Roads or County Roads. Include the road 1 '
Depth 9 Diameter or Weight Et. \l:uerial numbers and common road names. rry
From 'Co /n Ft. �o ) t /V
From to Ft.
From to Ft.
GROUT: Depth
From 0 T. Q 0
From To Pt.
SCREEN: Depth Diameter Slot Site
From "lo It. in. in.
From To Ft. in. In.
SAND,GRAVFL PACK:
Depth Sin Material
I•ront To _ Ft.
From To Ft.
Method
16. REMARKS:
��tt ''Material
Ft.�.y:t 1 n•_
\latcnal
s
—
C
1 DO IIEREBY CERTIFY II IA[ 11115 WELI" \\'AS CONSTRCCILO IN ACCORDANCE-. WI'III 15.\ N ('AC' 2C. WEI.I.
CONSTRUCTION SIAN ARDS, AND '[IIA[ ,\ COPE' OI- I1I15 RECORD I-.I-N PROA'IDED"fi) TIIP WELL OWNER
t2 oa 5'-3/- 6V
SIGN.ATEILE Uf PERSON C ONsIRL(TlN(t!HIE ACIa I.
D:\Ill
Submit the original to the Division of W ater Quality, Groundwater Section, 163o Mail Sem ice ('enter - Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. GW-1 RI-.V_ 07 2001

297689
WELI. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of \\:titer Quality - Oround\catcr Section
/0
WELL('ONTRA( TOR (INDIVIDUAL) NAM print) o I IV n �, 7C
WELL CONTRACTOR COMPANY NAME. �Cf5 -. I[.�-e-eZ �` /fY° NF: it (gag ��t
STATE WELL CONSTRUCTION PERMIT# ._/174D
(if applicable) (if applicable)
/j ' / ) ) ) CERTIFICATION #
httt�
ASSOC L\TED MO PERNI IT#
1. WE1.1. 11SE ((heck Applicable Box): Residential*. Municipal Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump \\ater Injection ❑ Other ❑ 1 Other. List Ike
_). Near). LFinn:. v _ _ _/
Nearest 'Finn: (TK., County�/�((,%2'1'rC
Bitted aS
Street Nanic. Numb . Community. Suhdn 'stun. Lot No.. Lqp ( ode )
Address .44_ '�
refit yktr ,C NorL L3 2 7 its or Ion State 7 tip no:
)-
Arcu cuac- P6unc number
4. DAI E DRILLED S—.3 —b LI
5. TOTAL. DEPTH: _ 51515 '
b- DOES WELI. REPLACE EXISTING WELL? IVES ❑ NO 4.
7. SEATIC WAFER LEVEL 13elowlop ofCasing: ET.
Illse".` r Above l up (it Uv+m}I
S. "TOP OF CASING IS I F.F. Above ).and Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance !kph 15A NCAC 2C .011S. �1
9. l"IELD(gpm): `T�_.METIIODOFTEST h rs -
10. WATER ZONES (depth):--3QS'— 41/0P "I-
1 1. DISINhI'.CIIUN: 1'ypc HTt--F Amount . --_.. /p/713.
12. CASING: \\'all II1 ickness
Depth Diameter or Weight I t. Material
From. D -- fo 4/ % Ft. (o )r
From
from To Ft.-- 13. ORO(rr: Depth Na:ucr.al
From D "rug.. �--. rt.__
From t o Ft. _
14. SCREEN: Depth Diameter
From._ To Et. __in
Prone - l o_ ___ Ft. _ in
15. SANDYiR:\VIA. PACK:
Depth Sicc Ntatcrml
I- win_ 1 U It. _
From to Ft.
1 O. RI'.NIARKS:
Slot Si/C
in
in
Pve
Method
\I ncrlal
t opographie:'I.mtd setting
❑Ridge ❑Slope ❑Valley ,81at
l steel. appropriate bus )
l.:unude longitude of \cell location
mina sccnuas)...
ttitude lom_itudc snurcc:❑(JPS❑Topo_rtphi_ map
DL.PHI
I ruin I u
o
(chccL Nisi
DRILLING Lou
1 orntatiu 1 I )cscnpiioo
LOC. \UIONSKL1Cli
Shoo (lircction and distance in miles from at I&r)
two State Roads or County Roads. Include the road
numbers and common road names.
C)
r^`
0
Q) G
i
r
I Do I IL(I l3' ch.R l IFY 7nAl Tits WEI.l. \\ As r-oNs t Ito( let) tN At coRD:\Nt T \crrt l 15.\ Nc A( 2(. \\Seel
CONSTRUCTION STANDARDS AND 'ritAT A COPY OI' 1II1S R1'.( ORRD IL\S 131_I'N PROVIDED I u I1l1:. \\ 1.1 I. OWNER
I
S—sr
SR;NAIUlt.( of PI':RSl)N (uNsrR1 (1IN(, I \\r1 I. D:\rt'.
Submit the original to the Division of Water Quality. Grounds ater Section. 163n Mail Ner. ice (enter - Raleigh. N(
27699-1636 Phone No. [phone], Within 30 days. OW-1 REV. 07 1)01

WELI, CONSTRUCTION RECORD
North Carolina - Department of Environment and N• aural Resources
- Division of Water Qualit - - Groundwatef Section CERTIFIC.VIIONer `3dq/
WELL CONTRACTOR COMPANYNAME G reP//r\Gr^r` '1 f._ e a Pr.—_. ..-....07P c.:./_ ,--3
scat: W E.LI. CONSTRUCTION PERMITS ,t/ -- !. Y" D _
(if applicable)
297688
W EI.t. CONTRACTOR (INDIVIDUAL.) NAME Ipr(nn
ASSOCIATED WO PER?Off#
(if applicable)
I. WP.I.1. USE (Check Applicable Rua): Residential Municipal Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Beat Pump Water Injection ❑ Other 0 1( Other. List 1 .,c
2- WE:1.1. LOCATION: �
Nears: Town: ni4 (,t Vat(etf omup
0.
(Street Name. Numbers, Community. Sundt mum. I.ot Nag hip (odel
3. OWNER: _ A l S aQQ,,tt�� � �
Address _ _- nQ.D�& -Lai RA•
(Street or Route No.l i
°eSyi_tltrN� �S7$�o
(n. to n Stale•/gttbJ:
1
6
I )-
Area code- Phony number
DAI Et DRILLED 5' 3 —o 4-
lOTAl.DEPTII: _ as5I
DOLTS WELL REPLACE EXISTING WELL! YES ❑ NO V
7. STATIC WATER LEVEL Below Top ofCasing: aac _PT.
I U>C',.. if Abnv< 1 op of ( aging)
8. TOP Of CASING IS / _ FT. Above Lund Surface`
'Tap of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. .. _.-
9. YIELD (gpnl): I a METHOD OF TEST c2 1, rs _ ...... ___ .- _--. -.
11). WA1 t.R ZONES (depth): _.. (�I-S l - L %S i --- - . ..
' 1 __ //LOC. \[IONSKEICIt
11. DISINIL.CTION: Type i""7 I H r\nnntt „57 _.4/./ Shots direction and distance in miles from at !eau
12. CASING: Wall Thi:kiic,s two State Roads or ('ounty Roads. Ijtclude the road
Depth Uuunetet 01 \\eight It. \Iatcrlal numbers and common road names. 1
From. D TO Q3 Ft. l0 11 PVG to— fir..._
Froln _ ill) --- Ft._ c— --
From_- To — —
Ft. - -i
13. (iRO(IT: Depth (n pMatetial o-
Front Q . __ 10_ .. I L''""'" r _ :
la. SCREEN: Depth Diameter N:;:i
Frcnn To Ft. _.. _ill. -�
From _ l o,. _--- Ft.__ in. p .-'-.
15. SAND GRAVEL PACK: - 137
Tupu'a tphic 1_and setting
❑ILi.lge 't` `lope ❑Valley ❑flat
has:cis appropriate pox'
Lantude longitude of well location
mimeos sec.piabo
I.atitocla Ion-_itudc source:❑(iPS❑Topographic map
Icheek bnnl
ur.P fn
I ruin To
D
413' --c2OS'
DRILLING Loa
I onuation l)cscri pkion
Depth Sloe
111)01 10 IL
From--- Tu Ft.
t6. REMARKS:
Slot Size
n.
M.
\ Latertal
NIethod
\t tertal
1 DO I IF.RLBY ( LIMEY l IIA1 TI[IS WLLI. WAS CONS.' RU(11:1) IN A( CORD:\N(l- \ti I1lI I8.\ N( Al 2C. WI.LI
(ONtifI{li( fl(1N 11-ANDARUS, AND THAT A COPY OF 11115 Rh( into II:\S BI. IN PROVIDED 10llll. Will 1. O\\'NI,R
SI(INA1 t 11(1 (/I 19.RsoN ( t)NSI Itt (rINI
—0V
Submit the original to the Division of Water Quality. Groundwater Section. 163u Mail sett\ ice ('enter- Raleigh. N("
27699-1636 Phone No. [phone], within 30 days. (.i\\-I REV. 07 2901

WELL CONSTRUCTION RECORD
North ("arulina - Department of Environment and Natural Resou
WEt.l. (ONTRA(IQR (INDIVIDUAL) NAME -1C (print) 6 ) /0� 1n
\\ ELI. CONTRACTOR ('OJMPANY NA\IE) #. �.). [ - 1
SI' \Tt: WELL CONSTRUCTION PERMIT# - _ _ / I7 D er
(if applicable)
297687
roes - Division of Water Quality - (Groundwater Section
(..J_t_t_ - d rl`'���d`eloNE t8,2g 648-31
.\S50('IAl11) wQ PERMED(
l if applicable)
I. \WE1.1. USE ((heck Applicable Box): Residential' Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I leat Pump Water Injection 0 Other ❑ Ir Other, List se
\\'[.I.I. L(X'A110 I
Nearest.ro)Gowti: �_K- -77 _
I Street Name. Number', Chnifuottity. Subdi'l n)n. Ian Nt... hip ( nth:
(ounty_
3. O\WNIA(
:
Address ZOO sag0.4 �
(Street or Rowe Nn.l Vi.
( n. or I oss n State hap Cott:
:\tea code- Phone number
-. DA E.DRII.F.ED 41-024 -a
;. "101Al.1)EPTII: Sn$!_—
h. DOIiS WELL RLPLACI. EXISTING WL1.1.1 11.S 0 NO
7. STAIR' WA 1,R LEVEL Betel?, 1 op of Casino I et) I
r Illse"i"d Abt cop ut(vampI
S. TOP OF CASING IS Above Land Surface*
*Top of casing terminated al/or below land surface requires a
variance in accordance with ISA NCA(' 2(' .0118.
YIELD (gpltu: L .O METHOD IHOD OE TEST Ars- .
\\ATF:R7ON1.S(depth): .ygS1- 419pre'., l
DISINFECTION: "1%pe HTH Amount % 3 4-i) Show direction and distwt e in miles Itunt' t least
12. LASING: wall l hlcMe„ two Slate Roads or County Roads Include thei�tiud ..
Depth O Diameter err Weight Ft. 5 - terpd numbers and common road names. I
Ft to i
VC
Frtnn __-_ To Ft.
( iR011"1: Depth Material Method
From .0 To_.. a o ut._ ._.fo
From 'Fa -_ rt. P -
14. S(RE:EN. Depth Diameter Sloi Siie -._ \l.ncrial.
Front__. To
9
11)
11
in. _ _ in.
I runt _ To_ ___ Ft._-_- in. in.
15. SAKI)-(ilt.•\VI-.1. PACK:
Depth Size
1-Punt . ,-__lo Ft.
Iopu_raphie%Land setting
❑Ridge,lope ❑Valley 0I1lat
checA apprupnale hu\ I
Latitude longitude of hell location
id-'r SLCOIldpl..-
I.atitutI longitude source:❑(iPS❑Topographic map
ltxk Iona
DI Pl11 DRILLING LOU
From f0 )
83'--SDS'
Fonuatiot Description
I (t. RI\IARKS.
Material
O
0)
1 DO lIt RF13V (I.Rrll'\- TAXI TI US \\Iil.l. WAS (DNS "I RUC "i ED IN A( (ORD;\N(I \1/41II1 I5.\ N(:\( 2C. \\'t:I.I
(ONSTRU(TION STAND DS, AND IIIAl A (0PY OF -11IIS Intuit S tIr FN PROVIDED lei I III: \\LI.I OWN( I(
SIGN:WIERE uF PERSON (UNSIRt.1 IN(
nl \\ I 1 1. DAI I.
Submit the original to the Division of \\-ater Quality, Groundwater Section, 163o Mail Sersice ('enter- Raleigh. M.
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. fi7 _'UU I

29 '; n3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environs lent and Natural Resources - Division of Water Quality - Grouhdwater Section
Derr'(_ Y1Qe('�\` +GewN - CERTIFICATION
a4-Sto
WELL CONTRACTOR (INDIVIDUAL)NAML (Print)_---- � PHONE�_-# r.2A faS -L7022
WELL CONTRACTOR COMPANY NAME t\` Q iW'tO C� `Son F1El\C' �_..rp--- _
ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT('_ (if applical=e_
(if applicable) -
1. WELL USE (Check Applicable Box). Residential IS Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat I ump Water Injection 0 Other 0 If Cther, List Use
2. WELL LOCATION:
Nearest Town: :..)G• neSK\te _ County____ ?(udE CieeK
(Street Name. Numbers. Community. Subdrvts on, Lot No.. Zip Code)
3. OWNER: (iobeet Mes-iv-r
Address t3`. fcwn ^x
(Street or Route o.)
City or Town State Zip Code
()- ioa1-S53.1 —
Area code- Phone number
4. DATE DRILLED b- ltii-.D4 --
5. TOTAL DEPTH: Sv6 —
6. DOES WELL REPLACE EXISTING WELL? YES ng: ONO rid
7. STATIC WATER LEVEL -Belo (Use Top
ro fAbof ve Top of
8. TOP OF CASING IS 1 FT. Above Land Surface`
'Top of casing terminated at/or below land surface requires a
MELD accordance with 15 METHOL OFCAC 2C $TEST�_6__ ---
9. YIELD (epm):
10. WATER ZONES (depth): LOCATION SKETC=i
Show direction and distance in miles from at least
11. DISINFECTION: Type v\s _Amount 12. CASING: Wall Thicknesstwo State Roads orCounty Roads. Include the road
Depth
Diamet sr or Weight/Ft.
t. Material numbers snd common road names.
412\ O\m - --
From 1- i To i X\ Ft.__ f�.�
From To Ft.
From To Ft- - Method o `"
13. GROUT: Depth Mat .vial �� a ,
From 0To QC) Ft C¢en -2+
From To Ft. _
14. SCREEN: Depth Diameter Slot Size Material
From
To Ft. ia. in.
in.
From To Ft.
15. SAND/GRAVELRACIK: Size
Material
Depth
From To Ft. _
From To FL —
Topographic/Land setting
❑Ridge tlope ❑Valley ❑Flat
(check appropriate boo.)
Latitude/longitude of well. location
(degrees/minutes/seconds)
Latitude/Icngitude source:OGPSO Tdlpographic map
(cheek boz)
DEP—H DRIL -._ -
From To Fomsution Description
—�, \ -o 12% Cvz' a�¢Ldon
2 y�� Gcwe:te
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELI . WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THA T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THEE WELL, OWNER
SIGNATUF E OF P :SON CONSTRUCTING THE WELL DATE
GWr1 REV.h,NC
Submit the original to the Division
WiVv thnL30Qdays'ty, Groundwater Section, 1636 Mail Service Center - Raleigh, N
____2Z69y 1636flonv_a .1219-17

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR(INDIVIDUAL) NAME (print) DCc`C:($ 'AtQth CERTIFICATION if 24-1G
WELL CONTRACTOR COMPANY NAME -\'jQ .SQW+�v C7a`5 3 C PHONE#r�S1A
STATE WELL CONSTRUCTION PERMIT# "" - ASSOCIATED WQ PERMIT# _
(if applicable) (if applicable)aisrammisma -"
I. WELL USE (Check Applicable Box). Residential IN Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery, 0 Heat I ump Water Injection 0 Other 0 If Giber, List Use
2. WELL LOCATION:
Nearest Town: r yhesv:t.e County liaytuocil
z'i\(o Rmc1 an*
(Street Name, Numbers. Community. Subdivis an, Lot No., Zip Code)
3. OWNER: ape
Address 3'Ito }levy. pW tt Road
(Street or Route No.)
\.y) Y: \1Q IOC n isGi&
City or Town State Zip Code
( - t€rtt
Area code- Phone number
4. DATE DRILLED -55 - is-
5. TOTAL DEPTH: a.,*
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO It
7. STATIC WATER LEVEL -Below Top of Casing: SD 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 . t18-
9. YIELD(gpm): \5 METHOL OFTEST R:�
I0. WATER ZONES (depth):
11. DISINFECTION: Type et.-0._____ — Amount 1O-
12. CASING: Wall Thickness
Depth DiJamet :r
or Weight/Ft. Material
From t-1 To Ca Ft cp y ktL _ => Qv-1
To Ft.
To Ft.
Depth Mat trial Method
To :CO Ft. Ca -nano Po'.`v"d_
To Ft.
Dcpth Diameter Slot Size Material
From To Ft. ia. in.
From To Ft. 1. in.
15_ SAND/GRAVEL PACK:
Depth Size Material
From To Ft. _ _---
From To Ft.
From
From
13. GROUT:
From Q
From
14. SCREEN:
Topogiyphic/Land setting
❑Ridge SA Slope ❑Valley ❑Flat
(check appropriate bo-)
Latitude/longitude of well. location
(degrees/minutes/seconis)
Latitude/Icngitude source:OGPS❑Topographicmtp
(check box)
DEPTH DRILLINCLOG . ,_
From To Fomtation Descnphon
}\ -;o 92 CV 2.- %tcdora
92 To aos C>.cwt: te.
LOCATION SKETC1
Show direction and distance in mi ;es from at least
two State Roads orCounty Roads. Include the road
numbers and common road names.
c
c.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCEWITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THP T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
5•is. -OM
D,Qn�+FK "Hl �l SIGNATUF E OFFPEPg ` ON C NSTRUCTING THE WELL DATE
Submit the original to the Division of \later Quality, Groundwater Section, 1636 Mail Service Ceenter' ] aeigh, C
27699-1636 Phone No. [phone], with 30 days.

- North Carolina • Depanment of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Servicu Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR• rice v/eJ/,Jv- rG»/
WELL CONTRACTOR CERTIFICATION #:r99 9 lee/f-/ 44714 `
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential LV] Municipal ❑ Industrial D.
Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 11 Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
County
FOR OFFICE USE ONLY
Quad No:
SenalNo.
Neares}) Town:
:cede v' V �•%ll
(Road NameNytmbe Co unity, or Subdivision and Lot No.)
3. OWNER c)0 /h✓V 0C5)At
Address &M0 /S trrb-
ore-f
Sireel or q o.
,0 r� (r�. 4, � JD
dyor own S Ie237•..5-7*".////zip Code
L
4. DATE DRILLED /".d.- VV"T
5. TOTAL DEPTH `S DC-C:t
B. CUTTINGS COLLECTED YES n NOrl
7. DOES WELL REPLACE EXISTING WELL? YES n NOVI
8. STATIC WATER LEVEL Below Top of Casing: (-)7 FT.
(Use 'i if Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated error below land surface requires a variance In accor-
dance with 15A NCAC 2C.0116 .-
10. YIELD (gpm)• .5/0 METHOD OF TEST /9 17-
WATER ZONES (depth)•
/ eri/iJnry
296625
12. CHLORINATION: Type/off Amount
13. CASING: -
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
,1- DepthQ Deng or Weight/Ft tr1aleria) (Show direction and distance from at least two State
From / "2 To /J 1 Ft w ���/ 7451 rL. Roads, or other map reference points)
From To Ft /
From — To Ft
14. GROUT:
`11/.5 cJ
Depth //+�Material Method
From 0 To ,.%r7 Fi
From To Ft
15. SCREEN:
Depth Diameter Slot Sizo Material
From - To Ft . in in
From To Ft in in
From To _ Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
CT) --
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF P RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV. 12)99
i

. Nonh Carolina • Depanmenl of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. the 14ki�` ue%1e
WELL CONTRACTOR CERTIFICATION # c23'6e/ ,ee/ill 1 44',ne
STATE WELL CONSTRUCTION PERMIT#:
296624
1. WELL USE (Check Applicable Box): Residential LJ Municipal ❑ Industrial D.
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2. WELL LOCATION: (Show sketchthe location below)
Nearest Town: VA' Y'�E�.SVfI/%ti' County : Ai/tl0 f)/
(Road Name d t u ens. ommunity, or Sy ivision and Lot No.)
3. OWNER / ram'-/ 0( From From To Fo alio. Description
Address / G7ree.'.1 C.E1 AN.
( reel or outs )
Li 5�;/lamZeli, os
Cn or Town // itef rs— 92- % / Zip Code
4. DATE DRILLE0�7"U7 CC-- 71'5—
5. TOTAL DEPTH 30 i
6. CUTTINGS COLLECTED YES n NOn
7. DOES WELL REPLACE EXISTING WELL? YES 4 NOV
8. STATIC WATER LEVEL Below Top of Casing: 33 FT.
(Uso'.' it Above Top of Casing)
9. TOP OF CASING IS 04, FT. Above Land Surface'
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C. 119
10. YIELD (gpm): V METHOD OF TEST. *!
11. WATER ZONES (depth)
Agricultural ❑
Monitoring ❑
DRILLING LOG DEPTH
,76731(
12. CHLORINATION: Type%-1/ Amount
13. CASING:
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
t] Depths Damp/e.Ja or WeightFt. anal.- (Show direction and distance from at least two State
FrOm70' To r? 1-- Ft 122' / Roads, or other map reference points)
From To Ft
From — To Ft
14. GROUT:
Depth
From To Ft
From Tb FI
15. SCREEN:
Material
Method
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
J'1
SIGNATURE OF PERSON CONSTRUCTING THE WELL GATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GWt REV. 17199
0
r
--c
0
0
FOR OFFICE USE ONLY
Quad No:
Senal No.

- North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR• nice Wegq" uMf p.
WELL CONTRACTOR CERTIFICATION #: r y49 I * ��, 6 4'4re
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eos): Residential Kr —Municipal ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch/ the location below)
Nearest Town: %/✓��/i1/t-'5 sketch/
County: /l'a�GL00O"
?Il %7AI fJord
(Road Name and //Nu er
3. OWNER ,�ji/7
Comrfunily. or Su ision and Lot No.)
"rth•arf 17 ✓C. / Address 4rj 6 �NA>LJ n! (3 ,e'i
(Sireel or oulo N9.)
✓e5. �,e /1/ f. 62e7'S
iiy (%1or Town State-L/Qc•' 7c,c3Zip Code
4. DATE DRILLED Y'8-0`J
5. TOTAL DEPTH r OeC
6. CUTTINGS COLLECTED YES (—I NO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use': it Above Top of Casing)
9. TOP OF CASING IS ° FT. Above Land Surface'
'Top of casing terminated alor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm)• r2 METHOD OF TEST A-ir -
11. WATER ZONES (depth)•
•
296623
Monitoring ❑
DRILLING LOG
From
To0- a
/OS c'7
12. CHLORINATION: Type J1/%f% Amount
13. CASING:
Depth //�1 D' etor
From �� To ('' / Ft r �/y
From To Ft.
From — To Ft
14. GROUT:
Depth11 nn Material / Method
From 0 To c % Ft ( e-^'E'i✓7
DEPTH
Fo atie • Description
II additional space is needed use back of form
Wall Thickness
or WeighUFt, enal .,
fi f,-
From To Ft
15.SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
Diameter
Ft in
Ft in
Ft in
Size
FI
Ft
Slot Size
in
in
in.
Material
Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
63
^
—5.
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
sr u-Spre-I
SIGNATURE OF PERSdN CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
/ce �l/v y z'
GW-I REV. 12r99
SenalNo.

29VVn
- North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. / CIC 1teJJ 4-PJV,7f
WELL CONTRACTOR CERTIFICATION #:Qvh'y Xedilh 4;ee
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery n Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Showsketch of the location below)
Nearest Town (/.� YAP, County f}' /Vont/
(Road Nameme Numper ommun y. or Subdivision and Lot No.)
3. OWNER - 7/ /lbegJja-rtf / From To Formation D scnplion
Address yc- 6 [ �TrJeic,,,, (red( 0
`; 1'Suecl or Houto N .
LW e Jame 7/r t j
y or Town �St e - l„7(�-3tt,.3Zip Code
4. TOTAL
DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NOE
7. DOES WELL REPLACE EXISTING WELL? YES N0r-q---
8. STATIC WATER LEVEL Below Top of Casing: Kt- „,2, FT.
(Use': it Above Top ol Casing)
9. TOP OF CASING ISFT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance wllh 15A NCAC 2C Na
10. YIELD (gpm) uUJ METHOD OF TEST Air
11. WATER ZONES (depth)•
DRILLING LOG DEPTH
rQ
12. CHLORINATION: Type j7 Amount It additional space is needed use back of form
13. CASING: -
Wall Thickness LOCATION SKETCH
I-� Depth s Dyay or Weight/Ft.ria6l (Show direction and distance from at least two State
From To -J Ft �� / - Roads, or other map relerence points)
From To Ft
From — To . Ft
14. GROUT:
Depth ,),, /nf Material Method
From n To � Ft l � e--N-k
From To FI
15. SCREEN:
Depth-- Diameter Slot Size Material
From To Ft in in /
From To Ft . in in /!/
From To Ft in in
16. SAND/GRAVEL PACK: I____
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division ol Water Quality. Groundwater Section within 30 days G W t REV. 12/99
FOR OFFICE USE ONLY
Quad No:
CD
G
SenarNo.

_ North Carolina • Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone] ,y/� , . /�
WELL CONSTRUCTION RECORD WELL CONTRACTOR' ` `r(N rye/A' e/PH, WELL CONTRACTOR CERTIFICATION #:0W67 /4"' / J¢74i4/c
STATE WELL CONSTRUCTION PERMIT#:
296671
1. WELL USE (Check Applicable Box): Residential ErMunicipal n Industrial D.
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other. List Use:
2. WELL LOCATION: (S ow sketch of the location below)
Nearysl Town: A-Ne.S(�o%L'- County
(Aoad Na e ate` Numbers. m ily, or Subdivision and Lot No.)
3. OWNER 7•l- v'T// 1�er
Address a3yQVeeN rove a. •
( ueot or HoutyNo.) ...,�,/ p �2 TNT
to*l i6v4.1 2 . 6ViL• 98 /15(C.1 r7D - ENO ✓e
ity or Town Sitr q Wig.-�2 I?SIzip Code
4. DATE DRILLED 97/ rJ / 77 1
5. TOTAL DEPTH O
6. CUTTINGS COLLECTED YESQ NOD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use'it Above Top of Casing)
9. TOP OF CASING IS :FT. Above Land Surface'
•Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C4119
10. YIELD (gpm)• , 0 METHOD OF TEST FF/ir
11. WATER ZONES (depth)'
=fyGt`UOd
Agricultural ❑
Monitoring ❑
12. CHLORINATION:
13. CASING:
Type #7771 Amount
It additional space is needed use back of Corm
Wall Thickness LOCATION SKETCH
Depth / Oarrpe %a or W+1ei jI/FI. rd le_riial �- (Show direction and distance from at least two Stale
/
From `x To 2 / Ft ,(J /r o /n ,'7TCN/ Roads, or other map relerence points)
From To Ft
From — To Ft.
14. GROUT:
Depth // Material Method
From 0 To 040 Ft ` es' e"' 7L
From To
15.SCREEN:
FI
Depth Diameter Slol Sizo Material
From To Ft in in
From _ To Ft _,__ in In
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
0
—c
0
0
Cl01 -_
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAL''2'C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PE CSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwaler Section within 30 days GW1 REV. 12/99
Serial'No.

296620
- Nonh Carolina • Depanmeni of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] ' . /
WELL CONSTRUCTION RECORD WELL CONTRACTOR* PriceVu4J/ -E',p
WELL CONTRACTOR CERTIFICATION The-WekeisY4 t .' i///
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Er Municipal ❑ Industrial ❑
Recovery El Heat Pump Water Injection ❑ Other D If Other, List Use:
Agricultural ❑ Monitoring ❑
2. WELL LOCATIO )Sow sketch of the location below) ��I
Nearest Town: �- County-4-1 14/
0 Cc)• •
i< 3. OWNER we
Nutt;
-
(Road Name "rya Nurpbws. Conununii or Subdjyisign and Lot No.) DRILLING LOG
C_ i fir S from
0
Address 53161
7rAButrue a ,
CiYr
(Su el or e
7a I
City or Town p Code
'�
4. DATE DRILLED /1/
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOrl
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOIV(
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use• '+ i1 Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface
'Top of casing terminated actor below land surface requires a variance In accor-
dance with 15A NCAC 2C .o 18
10. YIELD (gpm)• ca. METHOD OF TEST A•
11. WATER ZONES (depth).
To
o2J
12. CHLORINATION: Type Amount
13. CASING: -
From' L
From
From _
14. GROUT:
DEPTH
FonnaG• n Description
v
II additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth i � D�'n��r or Weight/FLtedal - (Show direction and distance from at least two State
To (� Ft �: 'C Roads, or other map reference points)
To Ft
To Ft
/'\ Dept Material T
Frorn iJ To �% Ft Ce2r'u C''�
From TO Ft
15. SCREEN:
Depth Diameter
From To Ft in
From To Ft in
From . To _ FI in
16. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft
17. REMARKS:
Method
Slot Size Material
in
in
in
Size Material
1I/w (Roc(
0
—mac
0
0
I DO HEREBY Ct'RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A GOP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
`-1
SIGNATURE OF POISON CONSTRUCTING THE WELL 1 DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days GW 1 REV. 12/99
FOFI OFFICE USE ONLY
Quad No:
Senal'No.
i

_ Nonh Carolina • Depanmenl of Environment and Natural Resources • Division of Water (DuaLry -Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. /TC-C' 1 '//,z//p /J
WELL CONTRACTOR CERTIFICATION #: -')7'% A/et)/1 L 414r
STATE WELL CONSTRUCTION PERMIT#:
•
1. WELL USE (check Applicable aox): Residential Eriunicipal ❑ Industrial El Agricultural ❑ Monitoring ❑
Recovery [I Heat Pump Water Injection ❑ Other 0 II Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Towr): .4 N'�z'-/� County' � 1 LV -
v//CI in n r
(Road Name an lumbers. Community, or Subdivision and Lot No.)
3. OWNER /Piy) .9 �(/ e
Address {/'7
�4>tc-�
City or Town -3 Stat �;!S -egg —id ei Zip Code ' �,J j c . J �'
4. DATE DRILLED % eg,"C gi i/C.S
5. TOTAL DEPTH •f,S
6. CUTTINGS COLLECTED YES (l NOE
7. DOES WELL REPLACE EXISTING WELL? YES NO(l
B. STATIC WATER LEVEL Below Top of Casing: f FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
-Top of casing terminated .Vor below land surface requires a variance In eccor•
dance with 15A NCAC 2C .0318
10. YIELD (gorily / METHOD OF TEST Al r
DRILLING LOG DEPTH
From o Fp aeon r•escnpton
0 o') N
tor o.A`)/(Street or auto o.}
11. WATER ZONES (depth)•
12. CHLORINATION: Type
13. CASING: -
Ti
Amount If additional space is needed use back of form
WallThickness LOCATION SKETCH
Depth /pra / e or Weight/Ft. Ma nal (Show direction and distance from at least two State
'3 From ` To / Ft `e'' �' �L� ..L� Roads, or other map reference points)
From To Ft
From — To Ft
14. GROUT:
Dept Malarial Method
From 0 To C� Ft ('& —'e`V*
From
15. SCREEN:
To
Ft
Depth-- Diameter Slot Size Material
From To Ft - in in
From To Ft in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
C
r \ /
l
AUg
4 200
4
1
CD _
o - =
o
- 0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
9 fiizsci DATE
SIGNATURE OF PER ON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Senal'No.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and natural Resources - Division oT Water Quality - Groundwater Sectiion f7
wh:I.LCON'I RACTolt (INDIVIDUAL) NAND: ((prriint)) e),,t J'4,„,..4%, tie CERTIFICATION tA9V /.-Qc
NVE1.1. ('(ICI HA(TOR CO.I I'ANN' NAND': JI et Vve/J Q-/ ✓✓N, I•IIONE N ) 62T$S /.D
SI .\'rf. Nvr:l.1. ('t )NSF RCC'r ION 1'ER.Irr#
29R1318
ASSOCIA'I EI) WQ I'EItMl'1'k
lira likable) (if a .IICable)
I. WELL USE (Cheek Applicable Box): Residential m' municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ I lent Pump Water Injection ❑ Other 0 If Olhcr, List Use
2. WELL LOCATION:
tit ei/v C
r f<�C7y code
Street N:I 4• Nmnhcrs
Community.
I SubIIIVISiun. 1.01 Na. Zip Code)
3. OW N1'.R:M#' itr. 1(y✓ (degrees/ininifes/seconds)
Address./ /1/erk 1:_(rn)d Or Latitude/longitude sourcc:OGPS❑Topographic map
(Street w Ro)ae No.) (clieck box)
.� /�%r 1- � �� 2 DLPI'H . DRILLING LOCI
coy or Town stale Zip Ciotti: From , To FN 1 ratio Description
( D)-1'ODOf (J /0 4-1
Area late- Phone mmihy/ JCj
5. TOTAL DEPTH: 47 —/ SY
6. DOES WELI-REPLACE EXISTING WELL? YES 0 NO lX
7. STATIC' WATER I.EVIU. Below Top olCasing: /-2. PT.
(the "+" it Above Top of Casing)
8. TOP OF CASING IS - FT. Above Land Surface"
•l'np of cuing lerininated al/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpin): / MLTIlOD oFTEST %9,'
10. WATER ZONES (depth):
'Topographic/Land setting
LSRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
I :aliluddlongitude or well location
gro R"rJ
'V/
/L LOCATION SI<ETCI I
11. DISINFLCIION: Type /7 Amount Show direction and distance in miles lion at (east
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth I lay I • or Weight/Ft. ly1 trial . , numbers and common road manes.
From' -cc To(;) Pt. (0�i �ff:5 1 /'//
From To PI. '4 /SC /
Prone
13. Ci ROUT:: Depth Material Method
0Fron) TO aO rl.r(e.'(+e^t z
From To Pt.
14. SCREEN: Depth Diameter Slot Size Matcriot
From To PI. in. in.
Front To PI. in. in.
15. SAND/GItAVI7,PACK
Depth
From
Frain 1t1
Size Material
16. REMARKS:
0
0
1130 HEREBY CERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCil€„9, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
o
/ SIGNATURE Or PERSON CONSTRUCTING TI IE WELL
e
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636I'hone No. [phone], within 30 (lays. GW-1 REV. 07/2001

296617
- North Carolina • Depanmeni of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] ,�%
WELL CONSTRUCTION RECORD WELL CONTRACTOR' #FC2 ©r�
WELL CONTRACTOR CERTIFICATION #: as' A-8 1-3'% ire.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Dos): Residential Lr Municipal ❑ Industrial ❑ - Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2. WELL LOCATION how sketch of the location below) /
Nearest7/own. C'/D e County-4A/PC70
/l -7rr/ _ /'
(Road Name an Numbers. Communit ,/e/ Su vision and Lot No.) DRILLING LOG DEPTH
3. OWNER r/tt/ea. ` - eJ From To Fo alio Description
Address %4 /'/A / 9✓' i9
/a7feC K. (Sueef/uCo Po.I <����� �N� ,Yp
City or Town -6.97• r7� 7.R zip Codo /
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES n NO En
7. DOES WELL REPLACE EXISTING WELL? YES NOE
8. STATIC WATER LEVEL Below Top of Casing: •�_�j FT.
Q (Use '.' it Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surace requires ■ variance In accor-
dance with 1SA NCAC 2C:y94..�18
10. YIELD (gpm)40 METHOD OF TEST /`i/ r-
11. WATER ZONES (depth)•
12. CHLORINATION: Type
13. CASING: -
74- Dep
From cA To
From To
From — To
14. GROUT:
%%
Amount
Wall Thickness
9iarit,2 , or WeighUFt. teriaL
Ft (� �C� . r
Ft
Ft
Dept . Material j Method
From 0 To c(J .Ft �P^^�^'
From To Ft
15. SCREEN:
Depih Diameter Slot Size Material
From To Ft - in in
From ____ To Ft . in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�� GAT- E ODATE
SIGNATURE OFF PE PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days GW t REV. 12/99
II additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Sae
Roads, or other map reference points)
3
0
FOR OFFICE USE ONLY
Quad No:
Senal'No.

297649
North Carolina - Department of Environment and Natural Resourc
\\E:I.1- CON IR \C'I OR I I\t1IVIDL.ALI NAME (print) LtstrY -
\\'E.L.I CON 1R. CLOR CO\IPANAN AMP. Apptch,' 1b
SI %IF:\\ ELL ('O\tifR1.('1ION I'ERNIIT# _—__.—
r:f anpIcablel
WELL USE (Check Applicable Box): Residential /MunicipalPublic 0 Industrial 0 Agricultural 0
\lonitoring 0 Recovery El Heat Pump Water Injection 0 Other 0 11C/tiler, List Use —
WELL CONSTRUCTION RECORD
s - Division of Water Quality - Groundwater Section
CERTIFICATION ft ZCiO
(__�iLI1l kg CitVitaias,
ASSOCIATED WC)PERMIT#
-- (if applicable)
PIIONE
2, WELL LOCATION'.
Nearest To,v'n S.re: Name. Numbers.
(umbers.rrC om moiety, Suhui'
3. OWNER
:Addicss (Q 3 —
CO or Taxn Slate
1
A:ca and:- Faun: number
4. DATE DRILLED la
5. TOTAL DEPTH: .3L5
6. DOES WELL REPLACE EXISTING WELL.? YES 0 NO iera
7 STAITC WATER LEVEL Below Top ofCasing: eQ _FT.
(Use if A'aove Top o� Casing)
8 TOP OE CASING IS t ET. Above Land Surface'
`fop of casing terminated adur below land surface requires a
Co'mty L111 80 V
n, Lot F. Zv%i
Z b de)
I
Zip Code
variance in aecordanre with 1SA \CAC 2C .0118.
9. YIELDtgprn): 30 METHOD FTEST L
10. WATER ZONES (depth):
11. DISINFECTION: T ypc_ 14 E1C T Amount
12. CASING: Waal Thickness
Depth air Diameter or Wcight'Ft. Material
Fowl v To13 Ft.
From_. To __. Ft.
From lb Ft.
13. GROO f: Depth p):Alaicrial
FromTo_ --
From To Ft._
14. SCR EbN'. Depth
Diameter
From Tu.--. Ft. in.
From To litin.
l5. SAND'GRA'VLiL PACK.
Depth S
Float To Ft.
From.._.To , Et —
I(. REMARKS: ----- —
Method
Topoggrap)iic:Land setting
❑Ridge pe ❑\Talley DFlat
(check appn.pnme bons
Latitude longitud, of well location
(degrees. mmutestseconds,
La;i nide.longitude source:DGPSOTopographs map
i dirk bcv I
DF PTF;, DRILLING LOG
From To Formation Description
Sint Size Material
in.
in
Maier
_ LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or Cctmty Roads. Include the road
numbers and cumin road names.
....c.
w`t,s64iC Cage
3
'Mt rn
en S_
1 1)0 IIEREUY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT! ND.AR NDAJH T A COPY OF THIS RECORD HAS BEEN PROVIDED 10 THEWELL E
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 Pliant No. [phone], within 30 days.
GW-t REV. 07/260:..'.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
WELLCONTRACTOR (INDIVIDUAL) N:\\IE(print) "Rob I N 0tIlb
WELL CONTRACTOR COMPANY NAME &fl.thc. Bra_3_A . tt ,t_w._ u V13.%".cot
WELLSPATWELLCONSTRUCTION PER\IITP _ _J cQ)C ASSOCIATED MO PE.R\IITtt
(if applicable) (if applicable)
297693
- Groundwater Section
CERTIFR.\rtooNa '.L2 4i/e
HONEs pil0 4Tg. 3/ %a
I. W EI.L IISE ((Meek Applicable Box): ResidcntialX Municipal Public 0 Industrial 0 :Agricultural 0
Monitoring 0 Recovery ❑ Ileat Pump Water Injection 0 Other ❑ If Other. List Use
2. WELL LOCATION:
Nearest Town:
1-I La .
County__ HQ,ya0D001
(Street Nana. Ni Merit. Community. Subdivision. Ian No hip C odcl
3. OWNER: 5+
Address ��l rpS r (-1�7' !Q
ME
(Strict or Route Mr,.)
Cop or lo,cn State lip llnlc
Area code- Phone number
4. DATE DRILLED 5"-I3 -b4
5. TOTAL DEPTH: 36S I ,�/
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO pt.
7. STATIC WATER LEVEL Below 'Fop of Casing: 440 1'T.
(e "t" i(Aboce Tap of Came)
S. TOP OF CASING IS IIlsFT. Above (.and Surface* -
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2(: .0118.
9. YIELD (gptn): /S METHOD OF TESTrS
10. WATER ZONES (depth): (g D I — /,5-5 jaT.n
11. DISINFECTION: Type J4774
12. ('AS IN(i: Walt Thickness
Depth Diameter or AAeight. Fi. Material
From-__O "fo 31 Ft. 6 /I p11
From
TopouraphiciLand settinu
❑Ridge OSlope ❑Valley
(check appropriate 6oS)
Latitude longitude of well location
I (iiiaciis minute. Annual,'
Latitude ion_itudc source:❑(iPS❑Topographic map
id leek poll
DI-.PIll DRILLING LOG
From To t Formation Description
D 32_.•
3 7 '_Q�'
I OC AIIUN SKGTC[1
Amuunt y5 4.shis Show direction and distance in miles From at least
tn-o State Roads or County Roads. Include tlicroad
numbers and cununon road names. f __
From CD
0
13. (TROUT: Depth Material Method L
Fromel To aA Et. CeeatakL +o p
From To Ft. —
14. SCREEN: Depth Diameter Slot Sin Material
From To Ft. _in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Nlatenal
From 'fo Ft.
From lb Ft.
16.REMARKS:
To Ft.
To Ft.
r
0
CO
1 DO I IEREDl' CERTIFY il[AI. 1111S WELL \VAS CONS IR CTED IN ACCORDANCE: Will l 15.\ NCAC 2C. \WEI.I.
C'ONS'IRUCTION STAND ARDS, AND 'THAT \ (OPT OF 11115 RECORD HAS 1 PROVIDED TO TI IF: WELL OWNER
Y.IJ� S-.I( -G _
SIGNATURE uF PERSON (ONS IRLCTINti -El II NT.I I. DAI 1:
Submit the original to the Division of Water Qualit, Groundwater Section, 163o ,Mail Str ice Center - Raleigh, M'
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. (17 2001

297692
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources - Division of WaterQuality - Groundwater Section
CONTRACTOR ONTRACPOR (INDIVIDUAL) N:AIMIIE,�(print) rE
,,,,L�JJ// G.h'i . raL.CA_ . _ (ERTIFICATIUN # .30�
M1
WELL CONTRACTOR COMPANY NAME &P&e t QYo _ W..// 4Ip "3/ 7a
��[[ Pt�1Jxp,T.aac .Plu)NE. #
SLATE WELL CONSTRUCTION PERMIT# /TeD :ySSOCI:\lEI) \Q PERMEEa
(if applicable) (if applicable)
I. WELL t1SE (C'heck Applicable Box): Residential Municipal Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 heat Pump Water n)cction 0 Other 0 I Other. List Use
2 WELL LOC'ALION-
Nearest town' u /� 11Va 1 )e County
0
0 0-k) : fir ? u
(Street Name. Numbers. Community_ Subdir isms. Lot No.. lip ( ode)
3. OWNER: So G • .'� r
I Street ir Route No.)
I tar( Mn
n olcn State
Lip Code
I )-
Area code- Phone number
4. DATE DRILLED .6 -13 - D
5. TOTAL DEPTI-I: /513.
6. DOES WELL REPLACE EXISTING WELL.? YES ,❑ NO l�l,
7. STATIC WATER LEVEL l3clowTop ofCasing: /O ET.
(Use..)" irAbove Top ut ( asine)
5. 'FOP OF CASING IS FT. Above Land Surface*
`Top or casing terminated at/or below land surface requires a
variance in accordance with 15A NCA(' 2C .0118.
9. YIELD(gpm): nit METHOD OFTEST a ) rs •
l0. WATER ZONES (depth): «51 --
I I DISINFECTION: TypeL-171-`
12. CASING:
Depth
From 6 To o(o Ft.
From 'To Ft.
FrontTo H.
13. GROUT:
From O
From To
14. SCREEN: Depth
From To
From To
15. SANDUURAV E.L PACK:
Depth
From To
From To
Topographic/Land setting
❑Ridge iClopc ❑Valley ❑Plat
(cheek appropriate buy l
Latitude longitude of well location
I degrees m mutes seconds )
Latitude lom_itu(le source:❑(il'S❑Topographic map
(chock box)
DRILLING LOG
Formation Description
DI.I't'11
:11)I11 I U a
CS
ao' IKS(
Amount as + b1 43
Nall Thickness
Djamcter or Weight Pt. !Material
L I
Depth A Material Method
' o ,Q Ft (a,, t _moo
ht
16. REMARKS:
Diameter Slot Size AI atonal
Ft. it). _ in.
Ft. III. Ilt
Size Material
Pt.
Ft.
LOCI\ (ION SKETCH
Show direction and distance in stiles Front at least
*Show
State Roads or County Roads. Include the had
tnnnbers and common road names.
c - 1-
--.
5
—o n_ =.
co
n
G
I DU I I FRE1 Y CERTIFY TIIA C 1Ills WELL WAS ('ONS . Rt; CT ED IN ACCORD.AS('(- AAITI 115.A eNCA( 2C. WEI.I.
CONSTRUCTION STANDARDS, AND TIRE COPY UP 1T115 RECORD IRS N PROVIDED O THE WELL OWNER
`
SIGNATURE UP PERSON C ONSTRCCTING I11I AA hl E. 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. (iW-I REV. 07 21101

WELL CONSTRUCTION RECORD
North Carolina - Department rtment of Environment and Natural est urccs - D vision oT Water Quality - Groundwater Section
//
CERTIFICATION A>(/
WELL CON "IU.t 101i (INDIVIDUAL) NA\Ir (print) e
w f /1 'Q')Uj �(`
l:l I N' COI D AC I'OR(' O\IPAN\ \;%ME r ___...._...__( 11-/r,�n
7.- ,_.
STATE \Vt:i.l. ('O\Sf DECIDES Ph:R\I rl'0
li(ap tlieah
II�li
mIltal�l�rl SAlliiRi
296847
LE Lee Un PHONE e 12/6 4,271{.s91%
ASSOCIATED \VQ PERM FI'q
(if aj czthlel
I. \VIiLI- USE (C Beek Applicable Box): Residential B"cdunicipal/Public 0 Industrial 0 Agricultural D
Monitoring 0 Recovery 0 Ileat Pump Water Injection ❑ Other ❑ ICOther, List Use
2. WELL LOCAT ON:
Near 'tit TO\'n:
County
I Slrcel Name. Nm ns:is_ ( ononunily, Subdivision, Lot No.. Zip Code)
(sheet r Mute No.)
(Al-CAA/2_n/ looGy�
Cale a'own Slate Zip Code
(773) 701- naet .
Area cotle- Phone nwnhe ,/
4. DATE DRILI.ED —�a -O�"
5. TOTAL DEPTH: (.2a.,5 - /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO i l
7. STATIC WA"IIUt LEVEL BcIow Top of Cs asing: 3� H.
(Dsc •'t.. i f Above Top of Casing)
8. 'f01' OF CASING IS ET. Above Lad Surface`
*Top of rasing terminated allor bvlon land surface requires a
variance in accordance will) ISA NCAC 2C .Dl 11.
9. YIELD (gpm): l5 METHOD OF TESTR'
ID. WATER ZONES (depth):
����Topographic/Land setting
hirki lge ❑Slope ❑Valley ❑Flat
(check appropriate box)
I.alui is/longitude ul' well location
(degrees/in inmeiiseeonds)
Latitude/longitude source:❑GI'S❑ Topographic map
Icheck box)
DEPTH
Prom - To
. DRILLING LOG
F. t ali Description
�L LOCATION SKETCH
I
11. DISINFECTION: Type fifil Amount Show direction and distance in miles from al least
12. CASING: Wall Thickness two Stale Roads or County Roads. Include the roatb
l Depth/ /( ?oiler or Wcighl/PI. ��\\.. atcri:Cd numbers and common road names. _
From Ia To 7J Ft. to /9 f 459ic J 4/3 e—
From To PI. _
From 'fo • Ft.
13. GROUT: Depth
From 0 To _0 _ FI.
FromTo 1'I.
14. SCREI'.N: Depth Diameter Slot Size Material
From Tii Ft. in. in.
Front To PI. in. in.
15. SAND/GRAVEL PACK:
Depth Site Material
Method tD
From To
I:r(ll) I0
16. ItL(hIARKS:
1 1)0 HEREBY CERTIFY TI IAT THIS \VELL. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, \VELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TFIE WELL OWNER
-as-oaf
_aeae.
SIGNATURE OF PERSON CONSTRUCTING "HIE WELL DATE
Suhmil the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone Nu. [phone], within 31) clays. GW-I REV. 07/200I

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and /NN tural Rcso trees - I/�7 ivision oT Water Quality - Groundwater Section
WKI.1. COYI IIACI OR (INDIVIDUAL) N,WME (prior) 42/ F/U//(G CERTIFICATION td3.0
\EI.I.CONTRACTnR ('O\IPAN\' NAMup/'/Ca- 11.)e_nee- jMP PHONE uG45)674.1:578
SFAIT. WE1.1, ('o\S'rRCCr1ON 111:It511Te
I1 nPphcahlcl
ASSOCU'rEI w•Q I'ERi1ITN
(if a t11111c)hle)
I. \VELI- USE (Check Applicable liox): Residential lMunicipal/Public 0 Industrial ❑ Agricultural 0
Nloniloring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ 110thcr, List Use
2. WELL. LOCATI )N:
N'ies1T wm .•N in/
I51 rn:el Name. !Niwdrers, ( 'onmmmi
3, OWNI:R:/''/'AN��A� j''
Address &J:'/Gni -/"/i�..
4.
5,
6.
(Sired urRuulc Nu.l
A• ('
Coy nr I o ii \tale•
g)Ja?35 gi�D
County a 14001
Ihdlvisiun, Lot No.. /.in Cade)
oc07 K3
Zip Cade
Area e xle- Phone number, �/ O /
DATE DRILIAil) (o' y
TOTAL DEPTH: r30v -.
DOGS WELL REPLACE EXISTING WELL? YES ❑ NO flr-
7. STATIC WATNRI.EVIi1.Below Top ofCasing: / C FT.
IUse "+" il'Abu ve 'top of Casing)
8. TOP OE CASING IS h'"I'. Above Land Surface*
*Tap of rasing terminated at/or below laud surface requires a
variance in accordance will, 15A NCAC 2C .0118.
9. YIELD(gpm): / METHOD DETEST /1.7-
10. WA"TIiR ZONES (depth):
1I. DISINITC'TION:Type f/T/Y Amount
12. CASING: Wall'fhickncss
Depth I hytyel •r or Weight/Ft. M' serial, numbers and common road mantes.
From 1-� To 7,) Ft. s, p >t,< /-lyv' a7�
Front To FI.
From Tn 1'1.
I . C;ROU'T: Depth Material Method
From 0 To PI. (7674,e,''7�
From To Et.
14. SCREEN: Depth Diameter Slot Size Material
From
From To Pt. in. in.
15. SAND/GRAVIil. PACK:
Depth Size Material
296845
Topographic/Land setting
❑Ridge ❑Slope ❑Valley
(check appropriate box)
Lalilu(Ic/Iongitu(le of well location
(degrees/minalestsccontls)
L.alilu(le/longitude source:❑GPS❑topographic map
(clwck hoc)
DEPI li . DRILLING LOG
From - To F -tadgn Description
From 'to
From To
16. Rl\I:\RKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
1 DO HEREBY CERTIFY TI IAT THIS \VEIL. 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
SI ;NATURE OF PERSON CONSTRUCTING "HIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163E Mail Service Ceder- Raleigh, NC
27699-1636 Plume Nu. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
296844
North Carolina - Department of Environment and Nalu./r�a/yIy Resources j Division oT Water Quality - Groundwater Sectio�n`'/
WELL ('OMRACIOR(INDIVIDUAL)NA:\lE (prinOHe/T/t Z J0Jpe CERTIFICATIONgrX7C'9
WELL (ONI RACIOR (U.\l PANT ,,,II: Pi, _L421 f%- REM") PRONE it 6 78' S
Sr AI'h: w'I':1.1. ('(INSI R C('IIUS 1'vic ii rN AssociATEi UY21'l:RNIIT#
Cif applicable) (ifapplicablcl
I. WELL USE (Check Applicable Box): Residential D 1[1unicipal/Public 0 Industrial ❑ Agricultural 0
Monitoring O Recovery O I teal Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIC N:
Neat (t Town: </',N o/%
County
(Sege) Name. Numlcrs. Common° . SUIRIIVisiou. I i,t No.. Zip Code)
I:R 3. OWN:�ene6 fe rpert
,rjAddress L3 ,/ s¢Ue
(slrcel r Rome No.)
oft,(
J/ Zip Code
L )
Cwor ,.,I Stale.
-7 — S38
Area code- Phone nomhcr
4. DATE DRILLED y7
5. TOTAL DEPTH: �346— 1//0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
,. opographic/Lurid setting
ertidgc ❑Slope ❑Valley ❑flat
(check appropriate box)
I.:uiludedongiWdc of wclI location
( degrees/ntinmca/seeouds)
I.atinlde/longitude sourcc:OGPSOTopographic map
(clack Nisi
DEPTH . DRILLING LOG
From - To Fo'ma ion Description
c20 'a
7. STATIC' WATEKLIi\'EI.Below Top oFCasing: Pr.
Use "*" if Above 'rap of Casing)
8. 'f01' OF CASING IS FT. Above Land Surface*
'Tap or casing terminated at/or below laud surface requires a
variance in accordance will) ISA NCAC 2C .0118. _
9. YIELD (wank3o IMGII IOD OF TEST/ i
10. WATER ZONES (depth):
1I. DISINFEC"LION
12. CASING:
ii. Depth I i;il cicr or \\'eight/Irt. M' trial numbers and common road names
From OC to IS I'I iy %,r.
From To PI. * /00 /7
From l o rl.
13. GROUT: Depth Material L Method
From 0 To_c20 FL MCAT
From To Pt.
//o
Amount Show direction and distance in miles From al least
/[ , [, LOCATION SKETCH
lYpe 7/r/
Wall Thickness Iwo Stine Roads or County Roads. Include the road
Id. SCRIiNN: Depth Diameter
Tram "ro
From To II. in.
15. SAND/C;R.AVEI_ PACK:
Depth Size
From To PI.
From To PI.
Slot Size Material
in.
in.
M:acrial
16. REMARKS:
I DO HEREBY CERTIFY TI TAT TI-ITS \VELI. WAS CONSTRUCTED IN ACCORDANCE WITH I5A
CONSTRUCTION STANDARDS. AND I11AT A COPS' OF THIS RECORD HAS BEEN PROVIDED
cNATURE OF PERSON CONSTRUCTING TIIE WELL
NCAC 2C, WELL
TO THE WELL OWNER
DAIti
Subnlil the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 I'honc No. [phone], within 30 days. GW-I REV. 07/2001

296848
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N. tural
WELL CO.\ ItACTOlt/INDIVIDUAL)NAnt (print)
('(IN" 112A( "Wit ("O\I I':\NY .\:DIE:
sixty. \\ EI.1. ('()\S't RUC( ION 1'4:12\II"IN
tit ;I Ilicahlel
'Lc Wei
csources - Division oT Water Quality - Groundwater �Section / e CERTIFICAIIONISaSln/
L// (�
onAp PIIONE u 123.29) d:8SYS"
ASSOCIATED \\'O I'I IV U r#
ti.lan slicable)
I. \\'I:LI- USE (Check Applicable i3os): Residential LN' N4unicipal/Public O Industrial ❑ Agricultural 0
Moni tering O Recovery O Cleat Pump Water Injection 0 Other 0 If Other, List Use
2. \VELL LOCATI )N: /
Ncj esI my i::%ANYG N
{Pee/&vQ 41(
County
(Street Name. Numhcrs. Community. Suhdrcisiun, I.ul Nil .. Zip Code)
3. OWNER.
�Vu
Address , N'�I ..
(S t or Route_ No.)
�
�4 e4tJ4Ie N.0 .
City n'town Stale
`d77ti(p
Zip Code
11/5(0(IC
Area note- Phone ntmhet
4. DATE DRILLED 6-, ` 0
5. TOTAL DEPTH: �s/S /
6. DOES WELT. REPLACE EXISTING WELL? YES 0 NO IN
7. STATIC WATER (.EVEl. Below Top ()leasing: E'1'.
(use "+•' if Above Top of Casing)
S. Top OE CAS INC IS FT. Above Land Surface*
+Top of casing terminated allon 61:low land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpin): `7 METHOD or TEST
10. WATER ZONES (depth):
Topogra iic/Land setting
OR )(Igo. )iriSlope ❑Valley ❑Plat
(check appropriate box)
Latitude/longitude of well location
(degrces/miuules/scamdsl
Latitticle/lonei(ude sourcc:DGPSOTopographic map
Icltcck box)
. 1312I L L I NCI LOCI
DEPTH
Prom - To For nati 0 Description
44
11. DISINFFC'IION:'Type Tp% Amount
12. CASING: \Vall'fhickncss
Irro_ I0�� �I t. I fonder or '1yi)(111/FI. Malcr1
,`DJ "} e��Dd
Front To P1. -- From To . I t.
13. GROUT: Depth F Malcrial Method
From 0 To /J20 1'I. up-m Ent
Prom To _ 1 t.
14. SCREEN: Depth Diameter
From To I't. in.
From To 1 I. in.
15. SAND/GRAVEL PACK:
Depth
From to
Slot Size Material
in.
in.
Size Material
s r.
ita
°Pie
LOCATION SKETCI
Show direction and distance in miles rronl al leas)
two State Roads or County Roads. Include the road
numbers and common road names.
)gas
From To
16. REMARKS:
11)O HEREBY CERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
t(r,-a-0�I
SIGNATURE OF PERSON CONSTRUCTING -HIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone Nu. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and Na oral R
a
WELL CON'I It.\("I()It(INDIVII)L (INDIVIDUAL) (riot) �w�1 /I,
\cf:1.I.CON .(I'OHo\ ItCu'AN\ N:\\IE i /;ce_/e/ 4/.
SI ATE: wt.:Li. CONSI RLCI'ION I'EI(\IIIN Assoc:Tv: m WQ I'eualrra
lirapnlicable)
296842
sources - Division oT Water Quality - Groundwater Section//
CERTIFICATION
PHONE # $r6a
tit applicable)
I. \NELI- USE (Check Applicable Box): Residential I A'1unicipal/Public 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0
WELL LOCATIO �,/ ��
Nearest Town: / ' GAY/ ' County
�r4 fi/r(
(Sl reel N:une. Kuilbe's, Community. Subdivision, Lot No.. Zip Cale)
3 OWNER:
Address r eiiy_N f'Or F
INA
// Street it IttIIIIe No.)
g g
((�i cr Q/, �
(Soy or Tome stole Zip Cade from
gQ$)- Vef\' /5// •
4
r l/tec
6. DOES WELL REPLACE EXISTING WELL? YES g NO M
7. STATIC \VA'IIiRLEVEL Below Top ofCasing: ye ET.
(UM:•' I" i I Above Tip Or Cuing)
S. TOP OP CASING IS Ff. Above Land Surface*
Industrial ❑ Agricultural 0
1fOtlier, List Use
topographic/Land setting
Ri(Ige ❑Slope ❑Valley ❑Plat
(check appropriate box)
I.aliludc/longitude of well location
Itlegrccshuinilcs/sccolals)
lalilud✓longilude source:❑GPSI]Topographic neap
(check bos)
DEPTI-1 DRILLING LOG
• To F. olio Description
a.2r✓
Arca code- Plume number, , /
DATE DRII.I.IiD _/fi'(?Y
TOTAL DEPTH: .Rr2S
*Top of casing terminate,' al/or below Enna surface requires a
variance in ateor.ancc w' h 15A NCAC 2C .0118.
9. YIELI) (upin): MCTIIODoFTEST A%
10. WATER ZONES (depth):
I I. DISINFE(TION: Typo_` Amount
12. CASING: Wall Thickness
Ucplh (�
Front% To 77 Ft
From To F1.
was
SIM
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include die road
Dia ceder or Weight/Ft. M; /trial._ numbers and common road names.
From To • Ft.
13, GI2OUf/:��� Ucpth Maceri;d Nlcthod
Cf
From To ,-i20 FL (,fg^' e/✓/
From _ ToFL
14, SCRENN: Depth I)i;micler Slut Size Material
Prom _ To P(. in. in.
From To IT in. in.
15. SANU/GRAVEL. PACK:
Depth Size Material
From fo
From To
16. (REMARKS:
I DO HEREBY CERTIFY TI TAT THIS \VELI. WAS CONSTRUCTED IN ACCORDANCE WITH l 15A NCAC 2C, \VELL -
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of \\rater Quality, Groundwater Section, 163E Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/200I

w/EL,L CONSTRUCTION RECORD
North Caiolin.i - I )eparunent of Et and at oral esourcc\ Division oT Water Quality - Groundwater Section
l M ELI. (OM I(\(I'OR (INDIVIDUAL) NAME pryyint)), �% 11 /r� CERTIFICATION g�Y7v
WELL(1NI (\( Olt COMPANY NAME Lei0- Limp PHONE vas) /47o47
f
STATE \VEI.I. CONSTRUCTION I'EI(U rl'#
I i fa'llie;thlc•1
�tslnll+niria
296841
ASSOCIATED \VQ I'ERpl1T#
Biteable)
applieable)
I. WIiLI. USE (('heck Applicable 13os): Residential LY I\lunicipal/Public 0 Industrial ❑ Agricultural 0
ilouiloring 0 Recovery ❑ I leaf Pump Water Injection 0 Other 0 Ir Other, List Use
2. WELL. LOCATION: _ Ncan: resl T( vA,ic5V) //e County \ 14lp/
cao p'
lJ l' uA)/a
(Street Name. Numbers. ('omnwnins.yy.. Suhd1rcieion. of No.. Zip ('odel
\V 3. ONER:Z1�I`�5170V er
Add less /O ti
(S cn i�r Koutc Nu.)
t4/% A2 (-
Ir or Town tit le) Zip Code
)- S�r'a 766 .
.Area cute- Phone munebc[
T. DATE DRILLED /
H) (041/
5
6. DOES WELL REPLACE EXISTING WELL? YE�/S/ [17 NO
7. STATIC WATER I.EVIL.13clowTop olCasing: /3 PT.
((Jsc "+" i t Above Top of Casing)
8. TOP Of CASING IS PT. Above Land Surface*
"top or easing terminated al/or below land surface requires a
variance in accordance with ISA NCAC 2C .1)118.
9. YIELD (gpm): 3 METHOD OF TESTerr
10. WATER ZONES (depth):
LOCATION SKETCI I
I I. DISINFECTION: Type } jT.# Amount Show direction and distance in miles from �CasP-
7-7
12. CASING: Wall Thickness two Slate Roads or County Roads. Include yeti road -
From �-2
Depth . DWeight/Ft.i; ncic or Weight/Ft. serial numbers and common road naes.
'I'o �i�' fL �(((Vs/��5�-((- nl 1
From To FI.
TOTAL DEPTH: /nA-
566 .mrs--
tIopographic/Land setting
dge ❑Slope [Walley ❑Plat
(check appropriate box)
I .ate lu(Idlongitudc ul'\vcll location
1 tlegrees/minwcs/.seconds1
I.alilutle/Ioneilutle source:❑GPS❑Topographic map
(check box)
DEPr31 . DRILLING LOG
From l v To F ritj n Description
0 02(141
52 05/ C.
.afnSNff671-
y
qN2?e
from
13. Ci ROUT: I)cpdi Malarial Nicthud
Front 12 l o 010 I-I.1eplen '
From To I't.
Id. S(l(ENN: Depth Di,ncicr Slot Sizc Material
Prone____ To I t. in. in.
From To fl. in. in.
15. SAND/GRAVEI. PACK:
Depth Sizc Material
from To I'I.
front To ft. -...
16. RI'.MARKS:
d 1)0 HERE13V CERTIFY THAT IAT THIS \YELL. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, \VELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE Of PERSON CONSTRUCTING •liIE WELL DAIS
Submit the original to the Division of Wafer Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, INC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

Sf A'1Y: \vi:i.l. CONS 11(UC'I'il)N I'r:K\I I'!-t/
WELL CONSTRUCTION RECORD
296840
North Carolina - Department or Environment and N. tural Resoylr s Division oT Water Quality - Groundwater Scetion
A V/
\\'I:LL('U,\'let.\("Il OR (INDIVIDUAL) L\:\\II! (print) C' �liP� CERTIFICATION N�)a/�9
WELL CON RAC ORCOMPANY NAME�7-, Ce tde/% AP-110 PHONE # gcYv)sr-s�t%-g3I8
,SSOCtA'I'EI/ \Yr) I'EItin in
1. WELL USE (('heck Applicable Box): Residential u Municipal/Public 0 Industrial 0 Agricultural 0
Iilonitoring 0 Recovery 0 Ileat Pump Water Injection 0 Other ❑ IIOthcr, List Use
2. WELL LOCATION
Nearest/
Town
e
(Slreei Name. Nualhers. Loon
3. OWNER:(G&r Q
Address
J r
unity. Subdivision, tad No.. Zip Code)
,4 v. e /s
AL k
I ISlreal or Hume Na.) 7f
A NI/ clit C
C'ily or To,v. Seel : Zip Code
S,2$ j ,3 /6 'b
Arc.,I'hooc oum0Cr
A. DATE DRILLED
5. TOTAL DEPTH: c2
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO '
7. S'I'A'I'IC WATER I.EVEI. Below Top ol'C'asing: - Pf.
I use -(" if Above Ton of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing Ierniin3terl at/or below l:uul surface requires a
variance in accordance wins 15.\ NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST At
10. WATER ZONES Idcpth):
LOCATION SKETCH
Topographic/Land setting
❑Ridge DSlopc ❑valleys
(check appropriate hole
I.atilude lougiludc or well i0Cal n
l degrees/luinnlce/secuudsl
L:oiludellongilude source:❑GPS❑Topographic mop
(check kw)
1)EETI-I . DRILLING LOCI
From • To rmr'p;uimyIcscripl ion
7
C,C) ,. r-t/2
I I. DISINFEC'TION:'lypeAmount
12. CASING: Wall Thickness
Depth Ditiycicrr or \VcighUl9. nM Icrial,
From to II
Prom "lei El
13. (iROU'f: Ucpth Material N'lcthod
From 0 To ,.Z 0 _ Et. ep,E.'Uf
From To PI.
la. SCREEN: Depth Diameter Slot Size Material
From To I'I, in. in.
From To FI. in. in.
15. SAND/GR(AVEI- PACK:
Dcplh Size Material
Faun To I't.
From To Pt.
Show direction and distance in miles from al lead
two State Roads or County Roads. Includ die rd;RI
numbers and common road manes.
c_
16. Itl'.M:\RKS:
I DO HEREBY CERTIFY TI IAT -'FIN WELL. WAS CONSTRUCTED IN ACCORDANCE WITFI 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF TNIS RECORD HAS BEEN PROVIDED-I'O TFIE WELL OWNER
IGNATURL Olr I'EI{SON CONSIRucrlNG IIIE 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 (la)s. GW-1 REV. 07/2001

296849
s I A'r E: \\lii.l. ('ONs I Itt('IION 1'k:I \IEra
\WELL CONSTRUCTION RECORD
North Carolina - I )eparlment of Environment and Natural Resources - Division or Water Quality - Groundwater Scclion
well. Cusnt.\c'ruu (INDIVIDUAL) NAME p,rh10 Pld(. 1 44 1 �CERTIFICATION xS/
WtWELLCONI RAC TOR C(nll'ANC NAME (I Ce_ U) 1�1.- UepM7 l'IIONE x (i.'g) 6/7-SSY
ASSOCIATED \\'Q l'E12\IrIT0
lira>slieable} (ifa rlieablc)
I. WELL, USE (Check Applicable I3ox): Residential 6 Municipal/Public 0 Industrial ❑ Agricullual 0
I\louilorinu ❑ Recover)' 0 Ileat Pump Water Injection ❑ Other ❑ If Other, List Use
2. \VELL LOCATION: ' 1-1/ ,//
Nearest'rown: C County,
61neepPA-sue_ » '
I tit reel Nei n•. Nmubcrs. ('anununil V. Suhdn isiun. 1ul Nn.. Zip Cute)
inc
3. OWNER: q'."Address. cp re lyJ ",
t rcei of Km to Nn.)
AiesvJe A C' ?gb
Pe;pographic/Land setting
❑Slope ❑Valley ❑Pku
(cheek appropriate box)
Latitude/longitude of well location
(tlegrccs/minulca/secondsI
Latiluddluneiludc source:❑GPS❑Topographic map
(check box)
Dlil'l I-1 . DRILLING LOG
nr ;ion"' State Zip code From To F n Ilio Description
(Sig )- a 775 2. 0 Jc
Area code- Phone number. 1v c-i? er )
4. DATE DRILLED 6 -a3-off �� low giOswa �e
5. TOTAL DEPTH: /YS 6c- /Yc
6. DOGS WELL REPLACE EXISTING WELL? YES 0 NO Id
7. STATIC' \VATlil( Lli\'1iJ. Below Top of Casing: - 3t2 FT.
( Use "i" if Above Top of Lasing)
8. TOP OF CASING IS FT. Above Land Surface"
"l'op of casing Ierulivatcd a/or nelow I31111 surface requires a
variance in uccordmic • will, I5,\ NCAC 2C .0118.
9. YIELD (gpm): t-0 METHOD OF TEST .9r-
10. WATER ZONES (depth):
LOCATION SKETCH
11. DISINFI.C'TION: Type /IT, Amount Show direction and distance in miles from al (cast
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Disnut}'•r or \l'cight/Pf trial, numbers and common road names.
Prot»t2 To �b PI. [i //`1 /�i-7r//L ���,/ �GC�
Prom To _ Pt. V Q
Prom "rn 19. `
r
13. Ci ROUT: Depth Material Method
nn
From V To 920 I'1. 1.6neN � I
from 'Io Pt. �0
la. SCR1iliN: Depth I>i:uncler Slot Size Nlalerinl
Prom To I i. in. in.
Prone To PI. in. in.
15. SAND/GRAVELI'ACK:
Depth Size Material
From To I'(.
From To
16. REMARKS:
ram;
1 DO HEREBY CERTIFY TI IAT THIS \VELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TT IB WELL
DATE
Submit the original to the Division of 'Water Qualify, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW- I (REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N nal Resources - Division of Water Quality - Groundwater Section r�
WELL CONTRACTOR (INDIVIDUAL) NAM((FF��//,,(pa�in�t> pNA/1 r 8 QLL CutrsrlCAT10N #et' 8%/
WELL CONTRACTOR COMPANY NAME 4 2-rcLrl /..i.24,10,20,acy PHONE # WIGyy—D9$p
STATE WELL CONSTRUCTION PERMIT# 17747 ASSOCIATED WQ PERMIT'S I/It
(if applicable) (if applicable)
298864
I. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION.]
emest
County
N.C)Q T o 9Wntp at
el ea tIS D28'�%/(j
(Street Name, Nymbets, Community, Subdivision, Lot No., Zip Code)
3. OWNER: A,.r cy
Address #4DQ // /lns2 "DYd.
! �L (Street or Route No.)
/I/. la. .Z $ 7Jc
$2 )City— or /eflTqwn yosl Zip Cock
Area code. Phone number
4. DATE DRILLED .Z/ t/e5 y
5. TOTAL DEPTH: yQ ,S
6. DOES WELL REPLACE EXISTING WFI I ? YEJ1 NO ,6)
7. STATIC WATER LEVEL Below Top of Casing: i� FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS �.S FT. Above Land Surface*
`Top of wing terminated at/or below land surface requires a
variance In accordance with 1SA NCAC 2C .0118.
9. YIELD (gpm): 7 METHOD OF ZTES rent- v
10. WATER ZONES (depth):
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 d
Topographic/Land setting
❑Ridge ❑Slope ®Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degteesfmimms/seoonds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH L&G
From To
11. DISINFECTION: Type /P- f1. // Amount /y at
12. CASING: Wall Thickness
Depth or Wei t/Ft
From_To Air Ft 4 #.2ffiapl:
From To Ft
From To Ft.
13. GROUT: Depth a Material Method -
From 0 To a j> Ft r isso,_...` l .tl»l' rl/w 4,
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:
Formation -Ph on
a
70
E2
11.
to
Ite
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL i1;U IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON ONSTRU G THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

( )-
Area code- Phone number
4. DATE DRII.LED a- / ' -D
5. TOTAI. DEPTH: s3 S ( ,,_/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q1..
7. STATIC WATER LEVEL Below Top of Casing: irA FT.
(Useif Above 'Fop of Casing)
S. TOP OF CASING IS % FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCA(' 2C.OI18.
9. YIELD Igpm): / METHOD OF TEST 0.1 h rS
10. WATER ZONES (depth): a& .S' - S4pm
32' - Jo e3 prn LOCATION SKETCH
11. DISINFECTION: Type /4 7 FT Amount 4,, A,(, j3-5 Sho)) direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
numbers and common road names.
298233
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N' aural Resources - DivvAion of Water Quality - Groundwater Sectionb� /
WELL CONTRACTOR (INDIVIDUAL) NAM ' (print) Nfr- _/ _'trZ) ra 1 e �Q _ CERTIFICATION d
yet Lf/P.j. 4 _ /..an9floNF a G fId'"33!7e
YYELL CONTRACTOR COMPANY NAME �%Qi.I''%//�. /� �5 a
STATE WELL CONSTRUCTION PERMIT/ _._ / `2`6 a ASSOCIATED WV PER)IIT#
(if applicable)
1.
2,
(if applicable)
WELL USE (Check Applicable I3ox): Residential*. Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATION::
Nearest Ta'yen: d%/Ct4G/ � '�tTounty gy 4%MGt
//.
)
(Street Name. Numbers, immunity. Subdivision. Lot No., Zip (-odes
3. 0
Topol' aphic/Land sett
❑Ridge ` Slope ❑Valley ❑Plat
(check appropriate box)
Latitu(lelongitude of well location
OWNER.: id<grcc. co Imes. secondsi
Address D�L�dr }_ _-.uu7 /UK -.a .a.&t.r} atitude Iom_itu(Ie source:❑GPS❑Topographic neap
:tree( or lR9g7t��—t� lchccR hall
J. /i`"-� DP.PItI DRILI.IN(ilO(i
ch ,r Fm'.1 Slate Zip cone Eront To Format sn !)eScriptirm
I(
___T-O
12. CASING:
Depth
From _Q To -CO Ft.
Diameter
it
or W'eieht Ft. Material
PUa-
From_ To Ft.
From To Ft.
13. GROUT: Depth }hMaterial �� Method
From To ab Et. (. 7-a
From To Ft. V
14. SCREEN: Depth Diameter Slot Sive Material
From 'io Ft. in. in.
From To Ft. in. in.
15. SAND/(IRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size \iarerial
16.REMARKS:
I DO IIEREUY CERTIFY TIIAT TIIIS WELL. \VAS CONSTRUCTED IN ACCORDANCE WETII I5A NCAC 2C. WEI.I.
CONSTRUCTION SFANDADSJAND THAT A COPY OF TIIIS RECORD I IA .4+44; 1 PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRtJCTIN(
ri II W'liI I.
DAi F:
Submit the original to the Division of Water Quality, Groundwater Section, 163o Mail Service ('enter - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. (iW-I REV. 1)7 2001 _

298231
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM ' print) s ri 0l )..)C1-'fin--_ _ CERTIFICATION # •2 I/ / SA
' Al-p-14. - ler4S - tJJ[2ti 4 /'[.LY.7 p PHONE # (gr21�' �o �• IS 3 / '70
WELL CONTRACTOR COMPANY NA)1F. '/ _.
STATE WELL CONSTRUCTION PERMIT# / i L) a ASSOCIATED MI) PERMIT#
l if applicable) iifapplicable)
1. WELL USE (Check Applicable liox): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: ' / ___y
Nca st Town: Li, LWritsvi / �e County H__ DOcY-
(9-adS N-l3
(Street Name. Numliers. Community. Subdirislon.Lot No.. Zip Code)
3. OWNER: P
Address 3 2 1 1 -De
(Street or Route No.)
oecv[ //t NC. Vi l gl�
City or Fowl State hip Code
Area code- Phone number
4. DATE DRILLED Q - 1 to - bLtd
5. TOTAL DEPTH: 1 S /
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casiry : (o 3 FT.
fuse"!" it Ahoce Top of Casing)
8. TOP OF CASING IS 1 ET. Above Land Surface*
*Top of casing terminated at/ur below land surface requires a
variance in accordance with ISA NCA(' 2C .11118.
9. YIELD (rpm): 1'1 METHOD ()I 'TEST r2 iir.S
10. WATER ZONES (depth): / OS 1 - I ri Tpm
11 DISINFECTION: Type N TH
12. CASING:
Depth
From D _ To % a
From To
From To
13. GROUT: Depth
From D To QC)
From To
14. SCREEN: Depth
From l o
From To
15. SAND/GRAVEL PACK:
Depth
From Ill Ft.
I rmn l o Ft.
Ft.
Ft.
Ft.
Diameter
/I
Amount 1 2 4kif5 •
Wall Thickness
or Weight. Ft. Material
:Material
Ft.y�l,..
Ft.
PVC
Method
4'90
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size 'Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley *kit
(check appropriate has(
Latitude. longitude of well location
(degrees minutes seconds)
Latitude lon_itude source:❑GPS❑Topographic map
'cheek host
DF.PTI I DRILLIN(i LUG
From To Formation Description
D Z4_ I
'7a' /a5'
LOCATION rION SKETCH
Shoo direction and distance in miles from at least
Iwo State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
0
a
01
a
CD
U1
c
0
m
cr
Z rrl
-c
rn
>o
m —
cnm
cn
rat
-1
G
I DO HEREBY CERTIFY TI IAT THIS WELI. WAS CONSTRUCTED IN ACCORDANCE WIT -II 15:\ NCAC 2C. WELL
CONSTRUCTION STAN ARDS, AND TTIAT A COPY OF Ti its RECORD IIAS 13FE:N PROVIDED TO'I I1E WELL OWNER
L/-d t°-29-0`>L
SIGNATURE OF PERSON CONSTRI)('TIN(i TI 11- AVEI I. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163h Mail Nen ice Center - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. OW -I REV. 072001

298230
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
(print) 13--/Ci-A._± CERTIFICATION # 34
/�T.u�In�/'--- -
0
IIros . bid) U e # r ll YYs P
STATE WF.1.1. CONSTRUCTION PERMIT# / a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL CONTRACTOR (INDFVIDUAL) NAME
WELL CONTRACTOR COMPANY NAME
PHONE # (842$ ✓0 1/ ¥ -3 ) '7 0
1. WELL USE (Check Applicable 13ox): Residential`- Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 other 0 II Other, List lice
2. WELL LOCATION:
Near,.yt Town: Iles % Cuunty_ildiado_oet
_zysi
(Street same. Numbers. Community, Sahlivisiun- I nt No-. Zip (.11de)
3 OWNER: Y i I..QJ-z4e- t-J
as 7 V1+ Ret.
Address
(Street ortoutc No
/`f c d Ci 76 o
('uy Town State - Zip C odc
)-
.Area code- Phone number
4. DATE DRILLED / - a 9 -o
5. TOTAI. DEPTH: 9 S '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO S.
7. STATIC WATER LEVEL Below Top of C'asintz: (03 FT.
(Use ''t.. ifAhose lop of (Msioog)
S. "POP OF LASING IS ( FT. Above Land Surface*
*Top of casing terminated at/ur below land surface requires a
variance in accordance with ISA NCA(' 2C.0118.
9. YIELD (gpin): It METHOD OF TEST o2 r S -
10. WATER ZONES (depth): l SD t — '/z, eAf'vn
I I. DISINFECTION: Type
12. CASING:
Depth
30
Prom© 'i'
From To
From'to
13. GROUT: Depth
From . To a D
From To
14. SCREEN: Depth
From - To
From To Ft. in
15. SAND/GRAVEL. PACK:
Depth Size
From To
From To
Ft.
Ft.
Tupog aphiciLand setting
❑RidgeSlope ❑Valley ❑Flat
taco, appropriate box)
I.at i Lucie. longitude of well location
dearces al inures. seconds)
Latitude lunsitude source:❑(iPS❑l opographic map
(check box)
DP.PTI I DRILLING LOG
From I Formation Description
_0 ,30
34)' 2'f5 '
Q n n 1 - p ineN Lot H'IION SKETCH
1-I%1-Amount I 6-3.rLi5 "Short direction and distance in miles from at (east
Wall Thickness two State Roads or County Roads. Include the =id
or Weight Ft. Material numbers and common road names.
Pike_
Diameter
Ft. 6 I(
Ft.
Ft.
Material Method �r
Ft. C..P...vrNa_n_ -}-o-�
Ft.
Diameter Slot Size Material
Ft. in. in.
IIt.
Material
16. REMARKS: -
1 DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE will' I SA NCAC 22C, WELL
CONSTRUCTION S 1 AN ARDS, AND II IAT A COPY OF I'1115 4; 'ORD I IAS BEEN PROVIDED TO 'HIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING ll Il -AAlil 1. DATE
Submit the original to the Division of Rater Quality, Groundwater Section, 163 , .\(ail Sen ice ('enter - Raleigh, SC
27699-1636 Phone No. [phone], within 30 days, CIW-I REV. 07:2001

298229
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and 'Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) _ _ D &) n CERTIFICATION #q 4 /E
8
/� s-,_LIJ.e}I- It Pump PRONE # (2((o -s/ 96
WELL CONTRACTOR COMPANY'NAMF re-P /�I L. /oJC.eL- --
/yoA
STAFF: WELL CONSTRUCTION PERMIT#
(if applicable)
SSO('IATF,D WO PERNIIT#
( it applicable)
1. WELL USE (Cheek Applicable 13ox): Residential$._ Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATLO��.
Nearest T n: / / /C, County_��
( .-Lia / a, Doc%
(Street Nano. Numbers. Community. Subdivision. Lot NO.. Lip Code
TopographiciLand setting` //
❑Ridge ❑Shope ❑Valley ltitklat
(ched appropriate box)
Lai itude.longitude of well location
3. OWNER: C tdcurcen minutes seconds)
Address Latitude loinditude source:❑GPS❑Topographic map
b h (Suet or Rou}y�- No.) /y rn Idtcck bust
9 °,1 /�e/S lCb �2 �/(. UI PIII DRILLING LUG
t ny of r srn ne zip node 3 o4-1f.rem To / Formation Description
_6_8A lc, rhr
Area code- Manic number
4. DATE DRILLED I - to -°4
C,C .
5. TOTAL DEPTH: 125
6. DOES WELL REPLACE EXISTING WELL'' YES 0 NO
7. STATIC WATER LEVEL Below Top of Casino: c O FT.
(Use Alain fop of Casing) _
R. 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.
9. YIELD (gpm): I '� METHOD OF rE.Sr cQ h /'S
I0. WATER ZONES (depth): 1 to 5' - l a .3p rv--x
LOCATION SKETCH
11. DISINFECTION: Type ./-{ 7-t1 Amount .c] -1-_13145-Shoo direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
or Weight Ft. Ivtaterial numbers and common road names.
PVC
From 0
From To
From To
13. GROUT: Depth
From_ To aD
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From Fo
From
Depth
Fu to W Ft.
FL
FL
Diameter
Ft.
Material Method
Material
--es p
Diameter Slot Sire Material
Ft. in, in.
Fi. in. in.
Size Material
Ft.
To Ft.
0
0
a "rn
p rn
77 Crn
mrn
3 am
• c-)
at O
In. REMARKS:
1 DO IIEREBY CERTIFY THAT THIS WELI. WAS CONSTRUCTED IN ACCORDAN('L WI'II 115 \ NCAC 2C. WELL
C'ONSTRU(TION STAND (DS, AND .111AF A COPY GE lI IIS RI:(ORD 1!. 31h1 N PROVIDED TO TIIE VWELT. OWNEI(
p) a-a9 - 0 V
SIGNATURE OF PERSON CONSrMUTIN( nu—v,Ei I.
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1634 Mail Seri ice Center - Raleigh, S('
27699-1636 Phone No. [phone], within 30 days. (i\V-I REV. 07 2001

3. OWNER: (matt, gal
Address ?i bS_ rcL
Street or Route No.)
YYIC 3nJ
1J!
City. orfawnState Zip ( ode
l )-
Area code -Phone number '/
DATE DRILLED / - D -6 Y'
10. WATER ZONES (depth):
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N),T.tral Resourcesr- Diivision of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (-De-raj. e—rQL Off. i t to-VT\Or P.-
WELL CONTRACTOR COMPANY NAME G r?ros•l�tJ-3- 4 PCLM4
STATE WELL CONSTRUCTION PERMIT# j Q D 2- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
298228
- (iroundwater Section
CERTIFICATION # -38
PHONE. # (8-n ��! . -31'7°
1. WELL USE (Check Applicable Laos): Residential', Municipal Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: CO'(012-1.-(dt, ounty
` t n 'i LP r [.JDOGC e f7 .
(Street Name. Numbers. Community. Suhdi vision. Lot No.. Zip Code)
4
5. TOTAL DEPTH: S n0
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC' WATER LEVEL Below Top of Casing: in 0 FT.
(Use'' '' if Above Top of Casing)
R. Top OF CASING 1S 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. II
9. YIELD (gpm): io METHOD OF TEST h rS
3�5 I - i�cn��rvY,
Topographic/Land setting
❑Ridge ❑Slope A/alley ❑Flat
Idrecl. appropriate host
Latitude.longitude of well location
i dcpree. nunum.sseeunds l
Latitude longitude source:O(iPSOTopogrtphie map
(cheek host
UI.I'fl 1 DRILLING LOG
From to r Formation Description
(aO' �i
tf�
LOCATION SKETCH
11 DISINFECTION: 'type /47-7 / .Amount 5?/-3 -IDI}S Shovr direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight Ft. Material n umhe rs and common road names.
From D To a o Ft. PI/
Front To - Ft.
From To Ft.
13. GROUT: Depths Material .�y. Meihoa
From o To a0 Ft. ( 6.✓ECv_4T-I.
From To Et.
14. SCREEN: Depth Diameter Slat Size '.Material
From "I o Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 'fo Ft.
From To Ft.
v �
16. REMARKS: -
I DO HEREBY CERTIFY THAT TIIIS WELI. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C'. WELI-
C'ONSIRUCTION STTANARDS, AND TIIAf A COPY OF TIIIS RECORD IIAS BEEN PROVIDE) 'R) TIIE WELI. OWNER.
SIGNATURE OF PERSON CONSTRUCTING TIR WIII I. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163tr Mail Sen ice Center- Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. CiW-1 REV, 07. 2_001
00.E -b; NC aq

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divi -ion of Water Quality - Groundwater Section //
WELL CONTRACTOR (INDIVIDUAL) NAME ( rind
W ELI. CONTRACTOR CONIPANY'NANiE n - CERTIFICATION 3GY'/
�, W-21-4 V Tit_h7pPIION F.#(82864g-3/r7D
- --
ASSOCIATED WO PERNIIT#
STATE WELL CONSTRUCTION PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential $1.1. Municipal Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Usc
2. WELL LOCATIO
Ner.,est Town:
(Street Name. Number
3. OWNER:
Address
4.
5.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WAFER LEVEL Below Top ofCasintz: Q© ET.
(llsc" 1" iLAhure Top of Casing) 1
A. 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 2(: .0118.
9. YIELD (gpm): , 5 METHOD OE TEST
1s). WATER ZONES (depth): 3105' - 4. C p.r.-,
Coun
Community. Subdivision. Lot Nu. . Lip Cadcl
�r/
(Street or Route a.)
4�on- C
City. or Tun
Area code- Phone manlier
DATE DRILLED / - Flo -D
TO"rAI.DEPTH:
State
Dr•
Topographic/Laud setting
DRidge 'Slope ❑Valley ❑Flat
'check appropriate box)
Latitude. longitude of well location
t degree. minutes. seconds 1
Latitude longitude source:❑GPS❑Topographic map
(cheek hurl
DI-PTII DRILLING LOG
From To Fomlatjon Description
6 a
_3a ' �b S ' Ai L2S
11. DISINFECTION: Type HTI-{
12. CASING:
Depth Diameter
From e To 3 Ft. Li ( )
From To Ft.
From To Ft.
LOC'AIION SKETCH
Amount Q/ / 4-1„61G ,Show direction and distance in miles from at (east
Wall Thickness two State Roads or County Roads. Include the road
or Weight Ft. Material numbers and common road names. o
0
PUG o 0
- n�
c
rn
XI
n
XI C-m
`VC
"' D o
—I -
- tin
3 ar_,
lD Prt70
▪ C)
O 1 —a
(T G
z
13. GROUT: Depth Material Method
From 0 To c2b Ft. Ch-A-v-e-wk_ I o p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From "To Ft.
16. REMARKS:
1 DU I IEREBY CERTIFY TIIAT Tins WELL WAS CONSTRUCTED IN ACCORDANCE writ' 15A NCAC 2C, WELL
CONSTRUCTION STANDA (DS, AND TIIA'r A COPY OF 'THIS RI:COI ILAS BEEN PROVIDED TO 'TIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI II AAT1 I. DATE.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Sen ice Center - Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. OW-1 REV. 07 200I

- North Carolina • Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR•nCe tUeI%/wr1P
WELL CONTRACTOR CERTIFICATION #: RJ479 414 29YW'joe
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable eon): Residential Er Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection 111 Other 0 If Other, List Use:
2. WELL LOCATION: ('Show sketch I the location below) / /
Nearest Town: !'U&i yAk°SWJi//l" Counly �y fir + XY
4A°c S r�nt//e a. /
(Road Name edgy Nupbers ommunjty, or Subdivision and Lot No.) DRILLING LOG
3. OWNER // 5e -'f' q/•.11"/ vrte From
Address ,4/--/ 5/ ,T N4//u9N / t.?p/ ,C27 • 0
4,
5.
6.
7.
8.
(Jueet or Houto o.
w�a ,S;> >2R 785-
ss-
DATE DRILLED 02- 0 r`SS
or Town slat 7c�a+ - /b -J�Jip Code
TOTAL DEPTH "?37
CUTTINGS COLLECTED YES (l NOQ
DOES WELL REPLACE EXISTING WELL? YES n NOj17(
STATIC WATER LEVEL Below Top of Casing: /0 FT.
(Use': a Above Top of Casing)
9. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C .0118
10. YIELD (gpm): .'if) METHOD OF TEST t4 r r
11. WATER ZONES (depth):
Agricultural ❑
293374
Monitoring ❑
To
1
/02.S
12. CHLORINATION:
13. CASING:
TYPe /zT//
Amount
DEPTH
eV, Description
a /D
II additional space is needed use back of form
Wall Thickness LOCATION SKETCH
f Depth[- Dia � or W iighVF1. eria� (Show direction and distance from at feast two Slate I -
From To . J 3 Ft 12 SS� Roads, or other map reference points)
From To Ft.
From — To Ft
14. GROUT:
yf 736
Depthl) Material Method
From 0 To �'✓ Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Sizo Material
From To Ft in in
From To _ Ft in in
From _ To Ft _ in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
0
N
Ib
0
0z
crn
cm
o.<
be
cram
m�
zm
rn o
G
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
11it!/_. a s c< I
SIGNATURE OF PER9ON CONSTRUCTING THE WELL GATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GWl REV. 12199
Senal No.

sr ttrF: WF.l.L CONSTRUCTION PERMrr# ASSOCIATED WQ rr.RJUTX
Or( (irappl icahle)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - I ision or Water Quality - Groundwater Section
} �JAl CFRrIRiG\TIOYX���C
WELL CONTRA(TOR(INDIVIDUAL) NAME
f%'HT. (o.IUt-rimcum 'ANVNAND.:�"ikeItie//0"r�pvro, rnONFXI-)'32
743
y
r
1
lVILI. USE (Cheek Applicable Box): Residenral Ll A•Lunicipai!I'ublic 0 Industrial 0 Agricultural 0 '
Monitoring 0 Recovery 0 Beat Pump Water Injection ❑ Other 0 I [Other, List Use
2. WELL. LOCATI %�/
Nc.II',est'f„fvn:, ...CO
(7
Colon; St to
t Sireel Name. Numbos. (leunnu,ity. Subdivision, LI No.. Zip CIde)
3. UWNGR:QCIIIILS�(A7'Fid �C
Yddless-WILl > Qn bh J Lc( u c -
tNI co: or Row,: Na.)
Coy or Slate'.
( i-
d. ado- Plume number
.t. DATE DRILLIiD'" 22'-
5. Itrr, t.1)I rr(I: _2705'
n. DOES WIiLL REPLACE EXISTING WELL? YES 0 NO ILT
7. S I'A'1'IC WATER LEVEL Below Top oreasing: 92 rr.
Rao "+- if Ahovc Top or Casing)
S. TOP OF CASING IS rr. Above (.and Surfaces
yin].) of casing Ivminatcd attar below tuna surface requires a
arluner, in urmriluvith ISA NCAC 2C Mt IX.
'1. YIELD(epnv: rL METHOD OFmsr Alf-.
w. WATER ZONES (depth):
LOCATION SKETCFI
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and coininon road names.
Zip Code
°pngraphic/ and setting 1
1( tee ❑Slope ❑Valley aqijakI
(cheek appropriate box,
Latitutl✓longitude ol'well local u
I
ttegncs:ninuhWuro:ntsl St
do source:❑GPS❑Togo m
Lalimde/langitu
phie mak-C_
DEPTH .
From Ti020
11. DISINFECTION: Type ffr/Y" Amount
12. CASING: Wall Thickness
'Y ,) Depth S._ Diaptyt •r or V. eichnTt. tv tonal
From �Tuy 7 I t. �-' � SY/C
From _ To FL
From_ ---_--
From—__.To __E
13 GROUT: Depth blalerial L Method
FnV )III_—_ To -9(;Et. rignred>
Trout To I I.
(•I. SCI(EliN: Depth Diameter Slot Size Material
From. . I .._.._.. _.._ PL..-_.._.iu. _..._.._ in.
From_o PI.
I1ul)1 TO I't.
IL. IT10.1ARKS'
293373
reiteck
,x)
DRILLING LOG
rrp;u, ym Description
H /Scs
in. iu. a
15. SANIY(GRAVIi1. PACK:
Depth Size ivlaicrial 00
From To FI.
CO
I Ix) HEREBY CERTIFY TI IATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WIT( 115A NCAC 2C, WELL
C'UNS'I'RUC'1'ION STANDARDS. AND TFIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- t/
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Qu:;lity, Groundwater Section, 1636111ai1 Service Center - Raleigh, NC
27699-1636 ('hone Pin. [phone], within 3(I days. • GW-I REV. 07/2001

- North Carolina • Department or Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' nice We//fj?,7
WELL CONTRACTOR CERTIFICATION rr:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentialia' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Ell Heat Pump Water Injection ❑ Other El)1 Other, List Use:
2. WELL LOCATION. (Sqow sketchy the location below)
2,4 lire/ /2i7 .
Nearest Town: IVA 4tc 111 6 County.
(R
i od] Name and Numbers. Co%q'unity. or Subdivision and Lot No.)
3. OWNER 7,--0 44/ /SA.t •
Address
• 4-•
City or Town Stale
4. DATE DRILLED ?I
5. TOTAL DEPTH r L):i -1.'
6. CUTTINGS COLLECTED YES ❑ NOD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOE(
8. STATIC WATER LEVEL Below Top of Casing: r;" 7 FT.
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of cuing terminated at/or below land surface requires a variance In actor•
dance with 15A NCAC 2C .4.IJa
10. YIELD (gpm): / METHOD OF TEST Air
11. WATER ZONES (depth):
0tot/
DRILLING LOG
DEPTH
From To Fo, a'onD scription
(J �2o bPy
5-9
o6
3z�
4
12. CHLORINATION: Type Ak7f7 Amount II additional space is needed use back of for
13. CASING: -
Depth Diameto�S or Weight/Ft. en I (Show direction and distance from at least two Slam �-.
From �� To •S7 Ft (9 7�H ll1 �_ Roads, or other map reference points) CD `n
From To Ft. 2 i �m
From — To Ft /33 sw
cn
m
14. GROUT: I oc
y� Depth Materialy Method ma >o
From [J To .Q10_FI /rett€' / --tc
rnc
From _ Tb Ft en2
me
Zip Code
Wall Thickness LOCATION SKETCH
293371
15.SCREEN:
Depth Diameter Slot Sizo Material
From To _ Ft _ in in
From To Ft in In
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
3
0,
CO
0
-1
G
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality. Groundwater Section within 30 days GWt REV. 12M9
FOR OFFICE USE ONLY
Quad No:
Senal No.

WELL CONSTRUCTION RECORD
North C teittLt - Department et E.mirunnrnt and Natural Resuuicgs
wIL.L('oslN\clot( ( U)iP\U\Sla,F♦1F rapioph .t
\u \v:IL (U"Sj RI( I ION 14%101II* ASSOCIATE WO PF.RNITd
] u'uppb: ahlc ] nfappl:cable)
293088
Div 'on
of Water Quality - Groundwater Section
CFRT(FICATION ILZ
1 111k,P� PHONE M
\1 F L!. LSE I L?: ck ,\pp6cable Laos;. Residential Er/ !\I unicrpal-Public ❑ htJustria! ❑ Aaricultural 0
'�: t"r••rnh! 0 Ro.ocer>. 0 Heat Pump Water Injection 0 C)thet 0 It Other. List Use
NF;.L. LOC\TIO!
Ne,l.
ilc( Lot a ' I&4 g`�SCooRl,be
Tupograp Land setting
opt: ,\'alley OFl❑
lank 4:Trum. •ti bia:
:S.'ta `t.1.e. \. bers. cnr,:rurry. Subdttd;ion. La !\n Zio Codcl ! atiludc 1ontptudt. H %Len location
ll t Rk NTR 1 �/y�(-,l(( ___ I degree's �.nc,:,s. seconds]
`—"" _1='—ctSve LJoitted, Lmemle sut.terDGPSDTopogra;shic reap
I.Sncn r Ru�e�' ] Ar
L%7� UEPTI!
-neck bus]
i ( _ DRILLING LOC,:
.S- Lp dude Frain Tb Formation D. ripuon
-4. I`'slLDRII.LED_ z 9-0
TOT:\1. DEPTH
A. DOES WELL REPLACE EXIS1 INC WELL' YES
ST.A I IC WATER LEV'FL LTciov Tup al&slug: _Z.
tun..,.. it A1•01: Fop of( •stngt
TOP Or CASING IS _ ET. _ ET. Above Land Surface"
•lop ea' casing roanInared attot below land sunccr requires a
s arisaee :n uerordance wt:h 13A NC':\C 2( 0118. /)
YIFLD!ytpmi: z,(7 a Q OF TEST h f. ent41LV- _ -
u WA r ER ZONES (depth): -AY )L fX
!1 DISINFECTION. TypeA't:Zt A)nount.._Z—
i2 CASING' Wall Thickness
/� Depth D:amcior or W,:ght'Ft Matertii
F ru:]n ._Q _ To_ 1_I _ Ft _—__.—
arant .`o H.
Front _...___..To Ft.
i5 (.68,01'1 Lhpth Malcn•y
rrunt TO COAXI< S
Tu+c, TO Ft
1.: 'CkCEN i.kplit Dl.ain:lcr S.n .1zc
Fr Ha _ .rt F't _._._ in. _ to
to
Frin— To at -...___in m
15 SAND'ORAVELPACK:
Ucpt:t 5 -e Material
In RF::.\i \Rks:
")rt HFRrb'YC
co
Ti, _..--- FI ---_._
N
Mat
LOCATION SKFTCII <_
Show (iiraet ion and dater.:: in miles from ai ,ea..t
two Stare Reads or County Roads. Include tht: roaJ
nnrnhcI s and cooinlOn road flames.
C weh Opic, die(
111F) T THIS WELL WAS C()NSTRL'CFED IN ACCORDANT E W1TH 15A NCAC 2C. \\ELL.
SAND lF' T A COPY OF FHB RECORD HAS BEEN PROVIDED TO'IH@ \WELL O\4NE I.,
)1 (fJ4'
SI(.INATLII(h Oh PERSON (. OiNSTI(L(TINL, TH[ \\LLL DATL
Submit the original iu the His isinn or Water Qunliis , (,round, ater Section. Ioi6 Mall Semler ( cuter - Raleigh. N((7I'
77b99-Inin l'Io.nc\o (919)'33-3221. within 30da\e, (.AV -I REV 07 '('OEI
Ps,
U
Ind
�Sc
771

293068
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural IResources\- Division of Water Quality - Groundwater Section r,
\HELL (ONRACIOR (INDIVIDUAL) NAME%' (print) CRO f-3 \ Yl � • (-ERIIF t('A"ff lOON a / a
VVE:1.1.( ON IRA(' TOR COMPANY NAV1EGY�e � i&ti5 . Lj�y.\ � * • PHONEk fp)dm 4/ �3 ) 110
STATE WELL CONSTRUCTION PERsIIT#
(if applicahlc) lit applicable)
(Ito 11U(l\IY.U\VIJPERM Eta
I. WFI.I. USE (Check Applicable Box): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ilea! Pump Water Injection 0 Other 0 IF Other. List 1 ise
2. WELL LOCH:
Nearest Town: C'ounty_4�_1f70CCI
I&C`),
le ve�
IS'.ccl Name. Numbers. (imm lity, Suhdivann. Ian No.. hip Cudcl
3. OWNI R.
Address r t- J t e-4-0
/y Succt ur,Routet Nu.0 l l G
town .Slate 71p(aak
Aral d'- ',bun, iliamhcr
4. DAL E DRILLED 1— 1 - b 4
5. TOTAL DEPTH: I L S
6. DOES WELL. REPLACE EXISTING WELL:' YES ❑ NO
7. STATIC WATER LEVEL- Below Top or Casing: _gip ET.
(Osc •.. I -Ahacc Top of t using)
8. TOT' OF CASING IS 1 ET. Above Lund Surface*
*Top of casing terminated at/or helots land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD Igpm): 1-1-D METHOD OP'l'LST r S •
Io. WATER ZONES (depth): I L-151 — 1-}fav en_
DISINI LC] ION:' I-vpc_ _14 1 }--_ Amount LIi -14-1 .
12. CASING: Wall [Meknes,
Depth
front L' To % a
Fromfrom To
13. ( [ROUT: Depth
From 0 To �17
From l o
14. S( RI.EN: N Depth
Diameter or \\'eight Pt. \iatcri'al
PVC_
ft._
It.
Material Method
Ft. r F * +et
Diameter Slot Site
\late rial
Front Tug-- Ft. in. In.
From To Ft. in. in.
15. SAND (TRAVEL PACK: -
I)cpth Site %I:aerial
Front To Ft.
From To Pt.
16. R.ENIARKS:
fopographic»Lund setting
❑Ridge ❑Slope ❑\'alley 'Ins
(cried, appropriate hot)
Latitude longitude of well location
I ti;gre. minute, see lnd,l
Latitude longitude source:D( iPSDTopographic That
,heck bnc)
DRILLIN(i Lu(i
Formation Description
Dh1I11
From Tu
.14 1LsI
LOCATIONSKETCH
Shots direction and distance in miles from at lout
turn State Roads or County Roads. Include the road
numbers and con(intlnT(md+rtime8-. ...
m
(n�
m�
—Icr —I
C.l7 0
I DU I IERY.If1' (ER lIF'i 111AI 11I1S W11I. WAS C ONS I RUC'II.D IN ACCORD AN(F V:ITII I S.A NCA( '_C. WELL
(.'ONS1Rt1C"IION STANDARD. AND I I IAF A COI'Y OP THIS RE( ORI) I jti I31 FAN I'ROA IDI.D 11) TI If. WELT. 09s Nh.R
3/-6 V—
D
Ill
SI(iNA'F UItL ()I- 1'1[I2SON ( ()Ns IRLCI IN(I f111 AA'1.1 I.
Submit the original to the Division of by ater Quality. Grounds\ ater Section. 1630 NI ail SCE ice Center - Raleigh. N(
27699-1636 Phone No.19191733-3221, within 30 day. (iA''-I RI-V. 07 29111

WELL CONSTRUCTION RECORD 2 9 3 0 6 7
North Carolina - Department of Environment and Natural Resoo�urr�ce¢ss - Division or Water Oualiiy - Groundwater Section , I
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (ate r((..{1 L-1,./)'(l-l_, `ia r D'C- (� ( ERTIF I(�.\ ttlp0N/p 464 I
WELL CONTRACTOR COMPANY NANIE.G-re-e '�L arD . C-✓4-1-1- � khiD4r-C .I'RONF. a awl (n 9 g -3 / 9 O
STATE WELL CONSTRUCTION PE.R,MIT# __ _ / Ile � .(SSOCIA t E:D AN() etio ITp-----
(it-unplicahle) i llapplicable)
I. WFI.t. USE (Check Applicable Box): Residential 7Y. Municipal Public 0 Industrial 0 \griculttral 0
Monitoring 0 Recovery 0 Heat I'untp Water Injection 0 Other 0 If Other. List Use_
2. WELL LOCATION:
Nearest Town: �.
t t'Y IG
County
gaAtt_JDoet
(Street Name Nunthcrn. (lunnamit Suhdi,taam, I of No /ip Codcl
3. OWNER: G�r frx, PP,
Address � � _ /�� '/ r •_.-
0,R.nnc 'vu;l
C 4 8 / ,j
(l1, nr 10111 Sot! N hip
Area code- Phone n0olher
4. DATE: DRILLED I - i l - b
5. TOTAL DEFILE q o'-)
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. SFA IIC WATER LEVL[. Below Top of Casing: i''
f(isc it Ahocc The of ( :eine)
R. TOP OF CASING IS FT. Above Land Surface`
`'Iop of casing terminated at/ur below land surface requires a
variance in accordance with ISA NCAC 2( .01 IN.
9. YIELD(gpm): 30 METHOD OF TEST 'E))
ID. WATER ZONES (depth): I qS ' - 1 -- --
3IPS' - 1 qq_�rn Lacy! ION SKETCH
I I. DISINI EC-1 ION: I ypc I—I-TE-. Amour 1n '7 i )ts .Show direction anti disEmcc in miles Gorr at Ieasl
12. CASING: Wall Thickness mu State Roads or County Roads. Include the road .
ropooraphic;Land setting
❑Ridge '.tilapo ❑Valley D19m
(cheek a1propriac hex)
Latitude longitude or well location
1d r inutao,,:,1.1..1
I.utilude. longitude -t urcc:❑(lPS❑ I opographic (nap
W heck her
1)1-. PI11 DRILLING LO(i
Format s(;i,I)csc ri phon
1-r011l to
D �3
g3
tC,
INTO Diameter or Weight Pt. A(Renal
From C) To 93 Pt. L II Ryes
From ro Ft. . _
From To Ft.
13. ((ROUT: Depth Material Nlethed
From D To a0 Ft.�.vtio t,4- I13 P
From To Et.
14. SCREEN: Depth Diameter Slot Site Material
From To Ft_ in. ill.
From To Ft. in. in.
15. SAND:GRAVEL PACK:
Depth Site Alatenal
hhon1 It) Ft.
From To
16. REMARES:
numbers ;Ind common road names.
i
O F
x
I DO I IL:Itk.BI ( LKIIFV TI IA'[ 11115 WELT. WAS (. ONS'( RUC II'.I) IN ACCORD:ANC I- AA fl II I5.A V. 2( . ACF.IA.
C'ONST RUCION STAND, RI S. AND I IIACOPY Of I A TI IIS RE( I( ORD II A. OA IDF.I) TO 1111. WI.I.1. OWNI.Ii
rc%,? �tt "— /—al-6 V
SIGNATt II(L 01 PERSON ((7N IRI IINti 1111VAIII_
D,\ I 1:
Submit the original to the Division of Water Quality. Groundwater Section. 1030 Mail Sen ice Center - Raleigh. N(
27699-1616 Phone No. [phone], within 31) days. GW-I REV. 07 2001

WELL CONSTRUCTION RECORD
295494
North Carolina - Dcparuncnl of Environment and Natural Resources - Division oT Water Quality - Groundwater Section
w Eli ('l1.\'l lt.\("1'Ult (INDIVIDUAL) N,\:ME (print) A e., �� L.P,4-0 )' f'e CERTIFICATION WY/it/
%%ET.i. CON-rfr( ('O]IPAN,' NAME f'fTWv-
C�! 1 c_ Alp I, IIONE # ') JYyJ� /q
X
STATE (vl:I.l. CONS RI'C'I'ION rER\I Era ASSOCIATED w'O PERM I I #
I:Ipplicablel
(if applicable)
I. \VIiI_I. USE (('heck Applicable Box): Residential ❑ Municipal/Public ❑
I\louiloring ❑ Recovery 0 Heat Pump Water Injection ❑
WELL LOCATIO
Nc, rest "'own: �Q
(tiireel Name. N , nl,crs. Community, Solidii%isioon, I of No.. Zip (\xle)
3, OWNER: • )5/2 Ce(2I.11.-5-A Cl of
Address
743
('nvurTown Slue Zip Code
4. DATE DRILLED .5 /9-Oy
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER 1.EA'l;l. Below Top of Casing: �/ PI'.
(Use "a" i f Above 'Flop of Casing)
S. 'FOP OF CASING IS FT. Above Land Surfaces
'Top of casing ter minaled at/or below land surface requires a
variance in accordance wills 15:\ NCAC 2C .11118.
9. YIELD(gpm): ./.5- METHOD OFTEST /r.
Nne<I or 1 me No.)
Arca c,xlc- Phone number ---
From 'fo
14. SCREEN: Depth Diameter
From To
From To P( in.
15. SAND/CHtAVEI.I'ACK:
Depth Size
Industrial ❑ A'ricultur 1 ❑
Other II'Other, List Use C iTh
10. WATER ZONIiS (depth):
1 I. WSJ NFN( i'ION: Type i/72%f% Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.Icri:d.
From 7"02 'fo ,13/
Prom To
From "ro PI.
13. GROUT: Depth M:gerial
From 0 "fl PLt e'„✓(,,tte
From To
From To
16. ItEAIAI{KS:
"-Topographic/Land setting
Midge ❑Slope ❑Valley ❑Plat
(check appropriate box)
i al iludc/longiludc of well location
(degrecshninutcMscconds)
1.atitode/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH (cheek
DRILLING LOG
From To F r wino Description
ai 44-
Method
1Jm/
Slot Size Nl:ua dal
in.
in.
Alalerial
LOCATION SKETCH
Show direction and distance in stiles front al least
two Slate Roads or County Roads. Include the road
numbers and common road names.
I DO HER EI3Y CERTIFY TIIAT THIS \VELI. WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED To THE WELL OWNER
niteide
re -
SIGMA-1'Ultli OF I'ERSON CONSTRUCTING TI IE WELL DATE
Submil the original to the Division of Water Qualify, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 flays. GW-1 REV. 07/200I
j 1,

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural csourccs - Divis' n oT Willer Quality - Groundwater Sectiono[,
✓ri/' �� CERTIFICATION pQ9�7
vEi.i. (ON'nt.u'aun (INDIVIDUAL) NAiIF print)
WELL CON l I4A(-r(m ('O]tl'AN,' NAME
s'I'A'rh: WP:i.I. CONSTRUCTION PERMIT,/
1 it a t tlicahle)
,k h lv%/ e
�nee to ei/c i44 7 rnONE is
ASSOCIATED \YO PERMIT#
(i fa tlicablc)
295493
I. WELL USE ((.•heck Applicable Box): Residential EMunicipal/Public 0 Industrial 0 Agricultural 0
IMloniloring 0 Recovery ❑ I leat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOC'ATIQN: //
Nearest Town: rr./5/O
—rn — i - G
County 01/000
Ircrl N:m Nijnl a'rrs ('oniniunhlly. Subdivision. Lod No.. Zip Code)
3. OWNER: C"-(f /9
Address / &&or .0
ISuccl or SS'.l [//7sc
City or Town Slat Zip Cute
mac) V7?- 3421-3
.Area code- Phone number
4. DATE DRILLED S 0
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER I.IiVI.U. Below Top of Casing:
I Usc "3" it Above Top of Casing)
8. TOP OF CASING IS FT. Above land Surface*
crap or casing termini ded at/or be lam I:utd surface requires a
variance in accordance widb I5.% NCAC 2C .0118.
9. YIELD (gpm): 3 METI IOD OF TEST 4-1-
10. WATER ZONE'S (depth):
11. DISINFECTION: Type //./7 Amount
12. CASING: Wall Thickness
Depth Diayneler or Wcighl/Pt.
I 'o n ToJ/ FI.4-�/
Topographic/Land setting
❑Ridge ❑Slope PIley '❑Flat
(cheek appropriate box)
Lalitu(IL/longit udc of well location
( do grces/m i n u l a/sccoa ds 1
l.al ittide/longitude source:❑GPS❑Topographic neap
(check box)
DEPTH . DRILLING LOG
Pre n To F• rn oil) Description
0)0 73
N06� / •
From To Ft.
From To II.
13. CiR()UT: Depth Material Method
From D Too2r) Fi.!�o tt,j/
Front To Ft.
14. SCREEN: Depth Di;uneter Slot Sire Material
From To PI. in, in.
Front To Pt. in, in.
15. SAND/GI(AVF.I.l'ACK:
Depth Size Material
LOCATION SKETCI I
Show direction and distance in miles from at least
two Slate Roads or County Roads. Include the road
Ag4, numbers and common road names.
From 1'o
front To
16. ILENIARKS:
I DO HEREBY CERTIFY TIIAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND 1'IL\T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�Lrc/fr i J—:cbo'Ott .
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of \\•rater Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC.`:
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07X 1101L,_,__.

\\/ELL CONSTRUCTION RECORD
Noah carotinu - Department orlatvironntcnt and Natural Resources - Division oT Water Quality - Groundwater Section
\vI:I.i.('O\'Ilt.\(-rfl((INDIVIDUAL) N.4.'IF: (prim)A/ •
a
\VEI.I. CONI AcJOi COMPANY N.UR�: ,'ce `7
STATE\VI I.l. CONY! It CC" flON PF:IcIITN
l i l a+ tl irahlr l
CERIIFICATION s�i�j5�
e �V- P PIIONI+. N (K�{j)(')Q/' R.S/d
,sssouvrEn PENSIVE/1
cif a it icabk)
I. WELL USE (('heck Applicable Box): Residential c Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recover' 0 I lcat Pump Water Injection ❑ Other ❑ II' Other, List Use
2. WELL LOCATION:
Net rest 'I'u\cn:
(Strut Name. N'wnhcrs, ('nntuuunilV. Suhdt
3. OWNER:
y/ / ion. lot No lip Cute)
Address y (�I�( >l r�fL 5
(Street or Roam No.)
WA/,vc.5'J'i II e AJ'C.
Zip Caste
)- C'W8-;> �.
Area 'axle- Phone number
4. DATE DRILLED S=/ 0
5. TOTAL DEPTH: y33-
h. DOES WELT. REPLACE EXISTING WELL? YES.C,7 NO
7. STA'ITC WATER I.IEVEl. 13clow Top ofCasing: y3
(use "t" if Above Top orCasing)
S. TOP' OF CASING IS F'I'. Above Laud Surlacc*
rho) np nr casing terminated at/or below Enid surface requires a
variance to accordatrrc�e with I5:\ NCAC 2C
9. YIELD (pm): c�(O METHOD OF TEST tar
I0. WATER ZONES (depth):
L47-Ij PF
('oyor Town Stale
II. DISINFIi( PION: T'ypc
12. CASING:
Depth
Fruntt� To.03
Frmtl To
From To
13. GROUT': Depth
Prom f) to:�V
From To
14. SCREIiN: Ucplh
From To
From To
15. SAND/GRAVEI..l'ACK:
Depth
From To
From To
16. REMARKS:
295495
Topo�gr��'TLuc/Land setting
❑Ridge 63SIope ❑Valley briar
(check appropriate box) '
I .alilu(ic/longiludc ol'wcll location
(ticgrec)/nti nu Ies/secol tls)
I.: anode/longitude source:❑GPS❑Topogr phic map F '.._.
(check (loc)
DITTH . DRILLING LOG
From To Fort alio Description
<9
O fc�
/ns ,y75-
FT.
//Y' Anwuut
Wall Thickness
Diync •r or Wcicl t/Ft. tcria
Fls�,// ;/
Material of
'I. CC-2-1e�.17
M •lh 1
Diameter Slot Size Nlaterial
n. n.
Size Material
Are
to N'
LOCATION SKETCH
Show direction and distance in Writes from at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
-a
O
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TT)AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4%4;7:e 13-U-1
SIGNATuRIi Oh PERSON CONSTI(UCfING -NW WELL DATE
Submit the original lu the Division of Water Quality, Groundwater Seel ion, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

295'498
\YELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Mine/al[�2csources - Division oT Water Quality - Groundwater Section
\\-h:1.L ('llSlli.\("I 1112(1.\'Ill\'IDCAL)\':\DI F' (priul) e%jr'/1 l,Q�„1Pe dy�y
"� /y. ity CERTIFICATION p
wELL(oNl RACTOR ('O.%IP..tNV .i\\IP:_9)(C. t4f?//9 Ijn1!i r11ONP:F
STATE: WELL ('1 INS'I RI COON PERMIT(' F
ASSOCIATED \\'Q 1'F:It,\IITp
l it :q+plicahK•) (ifa +licablc)
1. W'ELI- USE (Check Applicable Box): Residential !J A•lunicipal/public 0 Industrial 0 Agricultural 0
tNIonitoring 0 Recovery 0 Heat Pump Water Injection ❑ Oilier 0 IFOther, List Use
2. WELL LOCATIC_ )9i:
Near •st "town: ,t4-
(Street Name. Nmul,, us ConuuuNty Suhdnisinn l td No.. Zip (late)
3. OWNE1214)1) 1 // 1' •-•( �----�
A LIdress Z� (,LN Leis /�{y•
u//e
/n� V p ISuea nr Rnjme No.) yj J
1 / z7 ` /(IC rQ@ /e�/
Coy ur 10 cu Slat Zip Cute
(s)- (27- 5/7g
.Area tole- flume numbs
4. DATE "NULLED
5. TOTAL DEPTH: 3C_r
Topo_g}ryl�p��hie/Land setting
OR kip tlSlope ❑Valley OFIat
(check appropriate hoc)
iluddlongil tide of well loauiun
(degrees/minute../seconds)
LalinRle/longitude sourcc:OGPSOTopographic map
(check laud
DEPTH . DRILLING LOG
From • To Ffr atif. Description
D
6. DOES WELL REPLACE EXISTING WELL? YES,0 NO
7. STATIC WATER LEVEL Below Top ofC'asing: & h'('.
(use "t" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Laud Surlacc*
'Top of rasing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C:.0118.
9. YIELD (gpnl): 'O METHOD OF TEST ff'f
ID. / WA-IIiI(ZONES (depth):�,L
I I. UISINI'EC'TION: Type l/ ///7 Amount
12. CASING: Wall Thickness
Depth Irrom'oZ To 73 -> Diyineier or Weight/Ft. M: IcrS/ial
:Lin /1 y/J i e_
From To
From
13. GROUT: Depth di Material Method
From 0 To ,-))1) 1'I. CF7-v-LE id
From
14. SCREEN: Depth Diameter Material
frontto
From To fL in.
15. SAND/G1CA V Iil. PACK
Depth Size Material
From To Pt.
From fo R
16. RENIAItKS:
Slot Size
in.
in.
LOCATION SKETCH
Show direction and distance in miles from al least
Iwo Stale Roads or County Roads. Include the road
numbers and common road names.
I DO IIEI2EEY CERTIFY TIIAITTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND TEAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING ITI IE WELL
DATE
Suhmil the original la the Division of Willer Qualify, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 flays. (i\V-I REV. 07/2(I0I -

WELL 1. '. I It.0 TOR ('(1.\II'ANl' N.\III.: %- // �e
elp
s'rxri: \vra.t. ('ONSIItUCTION PERNUTif ASSOCIA I ED W
i fapplicablel Q 1'F:Rdll'I'q
(if; \�Iicable)
L NVEL,CONSTRUCTION RECORD
North Carolina - Department or Environment and Natural Resources
esources - Division oT Water Quality - Groundwater Setion/
\F:LLOM It.\(TOR (INDIVIDUAL) NAIIF: print) 4'//2A 4`fr/4'7t CERTIFICATION NtW(7/
9.
V PHONE # fvn) /�7—in
1
WELL USE ((.'heck Applicable Box): Residential Ig' Municipal/public 0 IndusIrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. \VEI.L LOCATION Nearest Town 7r�/.✓
Street
eke
Street Name. Noulhers. ('anwlmdrty. Subdivision. I.ol No.. Zip Cale)
3 O\VNER: / r.L� .2'c/4-74r
Address 77, 0_,
IArcei or Rowe Nu.l
v% izd/ /12 o)K7�Sfo
r 1
„I.
y��
IIya�Slave Zip Code
(Si)- (O -SR37.
Cotiniy44/utttt
DEPTH
From
Arca code- I'bonc number _
4. DATE DRILLED 5 =///- o �e' /7
5. TOTAL DEPTH: $3/C c‘17`r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 17
7. STATIC WATER LEV Id. Below Top of Casing: f0£ rr.
(Ilse "i" if Above Top of Casing)
8. TOP OF CASING IS "'Z FT. Above Land Surhlce*
•Tap of casing terminated al/or below land so Hare requires a
variance in accordance with ISA NCAC 2C .II118. dd..
9. YIELD /gpll). S METHOD OF TEST q/r
10. WATER ZONES (depth):
Topo_g�r�aphic/Land setting
❑Ridge I11Slope ❑Valley DFlat
(check appropriate box)
Lalilude/lungiludc of well location
-0
(dcgrees/Ininules/secmnlsi
Lat it udc/longitude source:❑G PSOTopogrl ph is map
(check hose .: l.....
. DRILLING IiAG
• To Fo inalion )escriplion
I I. DISINI'Ix IION. Type /% 7.41
12. CASING:
From-1,Z
Depth Diayuler
To 179 i:i W
From to FI.
AMMO)!
%Vail'I'hickness
or Weight/Pt. M Icri:d
From
13. GROUT: Depth ��iilalerial Mclhod
Fran, V To 026 FI. r-e a.✓7
from To Pl.
Id. SCREEN: Depth Diameter Slot Size Material
From To PI. in. in.
Front To PI. in. in.
15. SAND/GRAVEI. PACK:
Dcpol Site Material
To Pl.
To FI.
From
Prune
16. ItEMAI:KS:
LOCATION SKETCII
Show direction and distance in miles from at (cast
two Stale Roads or County Roads. Include the road
numbers and common road names.
dyki 02>rs
1 DO HERLI3Y CERTIFY TI TAT tills \YELL. WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND 'IIIAT A COI'Y OI' THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
- .tt>*a S—it—ocl
SIGNATURE OF PERSON CONSTRUCTING TIIE WIELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 flail Service Center - Raleigh, NC
27699-16361'hone No. (919)733-32?I, within 30 days' GW- I REV. 07/2001
496

_ North Carolina • Department ol Environment and Natural Resources - Division of Water Oualiry - Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ACE2 °OP) /(4- Pth•ly°
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑
Recovery El Heat Pump Water Injection ❑ Other II Other, List Use:
2. WELL LOCAT�ION�: (Show sketch 9 the location below) /
Nearest Town: VV4 &c3SUr 7/9 County.
/ G✓flo
wr4Jue_r
(Roa Name an Numbers. Co unit or Subdivi i n and Lot No.) DRILLING LOG DEPTH
3. OWNER '.5 live ki c,"i.-rq e/1j From To Fo alion aescripoon
Address / �� bicde r /J_/ 0 �✓
J ISueclor uloFlo.) •CtJ /' 0 4'0 �N4
Si ea it e Vp497�C� cif/feel �� ��4J /$
Ci or Town �I �Cotle J(J'� tr •4v0 .vE'
4. DATE DRILLED 4: -42 -0 � - �/SG-Eb/ /�/?/ SJ'PS �v^ -�vr�C'
5. TOTAL DEPTH r
6. CUTTINGS COLLECTED YES n NOD
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOP(
8. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use': it Above Top ol Casing)
9. TOP OF CASING IS 2 FT. Above Land Surface'
'Top o1 using terminated alor below land swine requires a variance In accor-
dance with 15A NCAC 2C .0118 A
10. YIELD (gpm): / G METHOD OF TEST /v'
11. WATER ZONES (depth): /`
12. CHLORINATION: Type /`1 / /Y Amount II additional space is needed use back of form
13. CASING: -
296626
Monitoring ❑
Wall Thickness LOCATION SKETCH
From Y` `
Depths �Q Diameter or wee UFt. Maledal/ (Show direction and distance from at least two Sate "
To f r> Ft �{' //T : is5 Roads, or other map reference points) I - " -"-
From To Ft.
From _ To Ft *I //57
14. GROUT:
Depth.) Material Method
From U To 00 Ft Cefy%e'vr
O
From To Ft
15. SCREEN:
Depth.. Diameter Slot Sizo Material
From To Ft in in
From To Ft - in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
r
c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2G, WELL
CONSTRUCTION STANDARDS, AND THAT A CO�PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GWI REV. 12r99
FOR OFFICE USE ONLY
Quad No:
Senal•No

WELL CONSTRUCTION RECORD
2 96080
North Carolina - Department of Environment and I tural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM (prtot),
WELL CONTRACTOR COMPANY NAME ) .tt /
STATE WELL CONSTRUCTION PERMIT# AI/4 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
P R ,2L L CERTIFICATION K7 (
sLRc-✓PHONE # (fSi/if 1 / yy D V�D
1. WELL USE (Check Applicable Box): Residential ta Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO
Neare Town: �?!/L2vC. County
trkE rl e<�� t. 09.k'7//
(S t Name, NNumbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address , h va.ee..ceLc..,Ce t.t .
(.1 (S t or Route No.)
City or Town State Zip Code
Area code- Phone mmtber
4. DATE DRILLED i/h'/
5. TOTAL DEPTH: oZ G
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: JFf.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / S FT. Above Land Surface*
'Top of casing terminated at/or below land surface requira a
variance to accordau a with ISA NCAC 2C .0118. •
9. YIELD (gpm): Cl METHOD OF TESTTarP
10. WATER ZONES (depth): ,/v.2- cI o2 fl t">'
11. DISINFECTION: Type (.�
12. CASING:
From 0To C Ft
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To .15 Ft
From To Ft.
Amount 52., io
Wall Thickness oor7i t p'tyttc
er
(,Mn Method
14. SCREEN: Depth Diameter
FrocTo Ft.
From Z." To Ft.
15. SAND/GRAVEL PACK:
16. REMARKS:
Slot Size Material
in. in.
in in.
Size Material
Ft.
Ft.
Topographic/Land setting
❑Ridge 14S1ope ❑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
`7
rn
0
--+ C,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. ' clude the
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WEI I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
ATURE PERSON CONS
TRUCTING ) OF PE
STRUCTING 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 Natur 1 Resources - Division of Water Quality - Groundwater Section
WFI I CONTRACTOR (INDIVIDUAL) NAM : 1prinn
r
293714
Q p ('�—%1— — CERTIFICATIONk 3b't
WELL CONTRACTOR COMPANY NAND: _ trit ' /8rp Ltl..00-'-_•t_17iji.tinp,`Q-I`c - PIIONE. # '.�� Z. `, �' - �/ 7
SLATE WELL CONSTRUCTION PERM ITO /`2`).,1 _kSS0((AFEl) WO PEk tIf
(if applicable) (it applicable)
WELL USE. (Check Applicable Box): Residential Y1 Municipal Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Puntp Water Injection ❑ Other ❑ 11 Other, List 1) e
2. WELL L LO(ATTO /
Nearest Town: Yl F'S )////f. County <.Y�
�OI_A_C as y (4
(suet Name. Nutit -a, Community, Subdivision. Cut No.. Lip (oi
3. OWNI[R: r Thri JALejS
Address ) 14-4 nathortek C rel_t.
L1 (Street or Route Nu)
4J/LLInaSvlllc t NC a(a°]$t,0
r itq or lob n State Lip ( ode
)-
Area code- Phone number
4, DATE DRILLED -3-3D -Ott
5. TOTAL DEPTH: 9nS
6. DOES WELL. REPLACE EXISTING WELL? YES ❑ NO 1.
7. STATIC' WATER LEVEL Below Top of Casing: 7D PT
(0se"1 * irAbove The ut Casing)
K. TOP OF CASING IS / ET. Above Land Surface"
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TES Ij�L S •
10. WATER ZONES (depth): 7L) - %5 )
I I. DISINFECTION: Type jr. ra-
12. CASING:
Depth
From 40 To ..5 Ft.
['roll) to Ft.
From •To Ft.
13. GROUT: Depth a�Ma�ter�ial
From D To • FL_L-gf-L.�
From To Ft.
Diameter
/D it
Amount /aa+4/ 1z/5
Wall Thickness
or Weight It. \Iaterial
Nlet hod
t4. SC RI -IN: Depth Diameter Slot Si/e
From To Ft.
From "" To Ft. in. in.
15. SANDJ(1RAVL1_ PACK:
Depth Site Material
From To Ft.
Froth l0 Ft.
16. REMARKS: -
latertul
Topographic/Land setting -
❑Ridge Dint
LhecA appmprrn hose
Latitude longitude or well lucatiim
d.in s. minute. sceond>I
l,atintde lonitude source❑(iPS❑ Topographic )nuµ
Iehcck hos.)
DI-PIII DRILLING -I -
1to/m� IS / Format o t Description
sg ' qn L
LOCrA1l(N SKF.TC'11
Shiny slirectiun and distance in stiles From at least
two State Roads or County Roads. Include the road
numbers and common road names.
IiIJ. O
I DO IIEREB1 Y CERTIFY IIAI THIS WELL WAS CONS [RUC LLD IN A(CORDANCF WITH I5.A N(-A( 2C. AA�-.-
CONSTRUCTION S I AN A DS, AND IIIAI. A COPY OF I HIS RE( ORD II AS RI EN PROVIDEDI()TI(E WELL OWNER
SIGNATURE OP PERSON CONSTRUCTING IIIF. AA I:I L DATE
Submit the original to the Division of Water Quality, Groundwater Section. 163o Mail sersive (enter- Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. GAb-I RIiV. 07 201)1

WELL CONSTRUCTION RECORD
293715
North Carolina Department of Environment and Natural Resources - Division at Water Quality - Groundwater Section
CERTIFICATION # di `/ / 9
cis 70
WEII. CONTRACTOR COMPANY NANIE /rOS. &AB a Panipi PHONE. N ig22 (O
STATE WELLCONSTRUCTION PERMIT# / �' Q at :\SSOC(A I ED \\Q Pt.R?I I f#(if applicable) I if applicable)
WELL CONTRACTOR (INDIVIDUAL) NAM . (print) A./ t / Ae4
WELL USE (Check Applicable Box): Residential Municipal Public ❑ Industrial ❑ Agricultural ❑'
Monitoring ❑ Recovery ❑ heat Pump Water Injection ❑ Other ❑ I10ther. List l Ise _
2. WELL. LOCAiIOI
Nearest Totin L(k�yt,� 67Li County/Y CttXn
(Street Name. Numbers. Community. Subdiciawn. Lot No.. hip ( octet
3. OWNER:
Address
(ip
Topographic/Land setting
❑Ridge Slope ❑Valley ❑Plat
t dtcck appropriate bogi
Latitude longitude of well location
F[/err fiL )C%
J'7 a 1 Al 'ro-rtk let Latitude lon_it ud .-uurce:OOPS❑Topographic mp...
(Street or Route No ( h k host . L,16rtpsi FL. 3c DTP ILI DRILLING LOG
Sestet /ip ( ode From To ) Format. Description
,,
Y//E2%
y7( /n1t/
Area code- Phone number
4. DATE DRILLED 3 -aq -off
5. TOTAL DEPTH: 1 b SS 1
6. DOES WEL1. REPLACE EXISTING WELL! YES ❑ NO
7. STATIC' WATER LEVEL Below Top of Casing: I QC) ET.
(Ilse -I- if Abort Top of Cm rie)
I. TOP OF CASING 1S 1 ET. Above Land Sur -lace
*Top of casing terminated at/or below land surface requires a
variance in accordant with 15A NCAU 2(' .0118.
9. YIELD (grim): METHOD OF TEST- krS
10. WATER ZONES (depth): 4bS / - 1 5 }> ors
to ES I — I r tOLAI[ONSKETCH
11. DISINIIICIION: Type H%{-�__. Amount [ ,. ',,, - Show rlircLIion Zffill distance in miles from at least
12. CASING: Wall Thickness taro S6tte Roads or County Roads. Include the road
Depth Diameter or Weight Ft. Alateriat numbers and common load names.
From 6 To 41 7 Ft. 6 11
From To Et.
From To Fi.
13. GROUT: Depth Material NI et
From 6 to O Ft. t_p.V129-1c-
From _ To Pt.
14. SCREEN: Depth Diameter Slot Si,c Alateiial
From l o Ft. in. in.
In. n.
Pvc�
From -. to Ft.
15. SAND:GRAVEL PACK:
Depth Sire Material
From To Ft.
From Io Ft.
16. REMARKS:
0
r.c
I DO IIERLUY(C ERTIFY THAT IIIIS WELL WAS CONS FRUCFED IN ACCORDANCE_ AAII11 I5.A1N( \C 2C. A\'EI.1.
CONSTRUCTION STANDARDS, AND 'lIIAF A COPY OF IIIIS RECORD II: lE EN PROVIDED IO TIIli AWELL. OWNER
St(INArtuRP. oh PIiRSON CONS'IRLCTIN(I- -- —
1111- \VItI I. DAIF:
Submit the original to the Division of N ater Quality, Groundwater Section. 163o Mail Sen ire C enter - Raleigh, NC
27699-1636 Phone No. [phone], within 31) days. OW-1 REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Div isi in of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (/�C,/,J(.�C�/--r0n� _ CERTIFICATION 1• � � / �
�4 Lc . d h)Jrlp PIIONE. a L'&'G4� 3! 7
WELL CONTRACTOR COMPANY NAME /_'1, q /
STATE WELL CONSTRUCTION PE.R\IIT# / -J V of ASSO(l \ l L D \yQ PERNII'IC _-
(if applicable) (if applicable) _---
294673
I. WELL IJSE (Check Applicable Box): Residential) Municipal Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 heat Pump Water Injection 0 Other 0 II Other. List Use
2. WEI.I. LOCATE()
Nearest
mtY-//J1)2.Mo,L
(Street Naas. Ntunber.s. Cunununilil 5ubdiei>ion, Lot No.. Zip l oce)
3. OWNER: ='1_,v'-440e.
Address I u^ 9 0
4
Street or Route No V 'J
C an / I
( it) or Teas State Zip ( ode
)-
Area code- Phone number '' //
4. DATE. DRILLED a -2 -0 `f'
5. TOTAL DEPTH: I S S '
6. DOES WEI.I. REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of('asing: /off) FT.
((lsc"t' if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .011X.
9. YIELD (gpm): R METHOD OF TEST iZrs
10. WAFER ZONES (depth):
IL DISINFECTION: Type /-1-7-1-1 Amount a +6Hs
12. CASING: Wall Thickness
Depth Diameter or weight it. Ntatcrial
From i l0 78 Et. 6'I _Pile
From lo Et.
From to Ft.
13. GROUT: Depth Material Method
From & to aD Ft._C .ae�i—1-0—(3
From To Ft.
lT. SCREEN: Depth Diameter Slot S'va Material
From To Et. in. in... _---....
From To Ft. in. in.
15. SAND'(iRAVIL PACK:
Depth Sim Nlatcrial
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge tI1Slopc ❑Valley ❑Plat
(cluck apprapriaic has
Latitude longitude of well location
I&gch uunuts see° adsI
1.atitutic longitude -source:0(1PS❑ topographic (nap-
(cheek buxl -
DI.1'ItI DRILLING LOG
From To Formation Description
_ 1_. _..'` J
22 ' 21 2� �Il A:lea
LOCA I ION SKETC'll
Shoo direction and distance in stiles tress at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO IIEREBY CERTIFY TIIAT TTIIS WP.1.L WAS CONSTRUCTED IN AC CORI):ANCH WF111 15:A NCAC 2C. Wkl.l.
CONSTRIi(('TION STANDARD,
AND TIIAF A COPY OF TTITS RECORD IlAS BEEN PROVIDED I 0 TICE WELL OWNER
(
Lz �J/taec(L, -3/-67
SIGNATURE. it: PERSON CONS FRL(ON( i II II- wEL L .VFI:
Subunit the original to the Division of Water Quality. Groundwater Section. 163o ?fail Sen ice Center - Raleigh. Nt
27699-1636 Phone No. [phone], within 30 days. OW-1 (HA.. 07 2001
L\

3. OWNER:
Address
(Streit Ro n• No.( itze,
n
Cit o Ibtsn State /ip t ode
Area code- Phone number a - _ (�--
4. DATE DRILLED
5. TOTAL DEPTH: Ce a5
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO )4
7. STATIC WATER LEVEL Below Top of Casing: Ea I:T•
fuse"(.. it Above Top orCastng(
8. TOP OF (•ASLNG IS 1 FT. Above Land Surface*
*lop or casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. )
9. YIELD (gpn,): '�, 6 METHOD OF TEST , t.5 •
10. WATER ZONES (depth): _AD
294R72
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
_j-_Div Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (Print) QM �C /J�r 1 1 C�l� - CERTIFICATION
/ gt -3/
7 0
WELL CONTRACTOR COMPANY NAME �. k-441_ —Wak 4 P..(-(-t. .ylLxe 'PHONE N "(
STATE WE1.I. CONSTRUCTION PERMIT# /V tO -ASSOCIATED \\Q PER\II Pi
(if applicable) tit applicable)
I. W EI.L USE (Check Applicable Box): Residential K. Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 other 0 If Other. List Use
?. WELL. LOCATION:
Nearest Town: rY1ni;o4 e. /ttl Lit County i-letikbsk
(Street Name. Numbers. Community. Subdivision. Lot No_ Lip ( ode)
//2///e3' SDI)
l 1. DISINFECTION: Type
12. CASING,:
Topog'aphis/Laud settiiig
❑Ridge ,Slope ❑Valley ❑Plat
(cheek apprnpr'ime host
Latitude longitude of moll location
tdrQ¢ea nun1.11Cs eaud,.
Latitude loneftudd source:0(6PS❑l opographic man
(cheek box)
DI PFII DRILLING LOG --
From TI ti ) Formation Description
7 yj 1
zLCK'AI'ION SKETCH
ItA -Ealn Os ow Shdirection and distance in mile
l-f Amount s From at (east
Depth
From I) To Et.
From To Ft.
From To Ft.
13. GROUT: Depth �j "Maternal
From 40 To ab FL
From To PTo Pt.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.-
From-- _-- Tu_. Ft. in.
15. SANDLIRAVEL PACK:
Depth Size Material
Prom To Ft.
Diameter
11
Wall Thieknes_s Iwo State Roads or County Roads. Include the road
or Weight H. Material uuntbers. an common ' to rand ❑'tines.
Method
FYotn To Ft.
16. REMARKS:
nnnu � .
cr 15
cn
7 :) rn
"d r
(J L�
0
Vy �
O
0 %
1 1)O I IEREL3Y CERTIFY TI IA'T THIS IIS WET. WAS CONSTRUCTED IN ACCORDANCE ATT 11 I5A M'AC 2C. WELL
CONSTRUCTION STAND RDS, ANDFIIA'I- A COPY OETIIIS RECORD 11 LEN PROVIDED To THE WELL (WNER
I
SIGNATURE OF PERSON CONtiTRCC TIN(i nu. . WEI L DATE.
Submit the original to the Division of Water Quality. Groundwater Section. 163o :gait Sererice Center - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. OW -I REV. 07 2001

294671
WELL CONSTRUCTION RECORD
North C'arolina - Department of Environment a Loral Resource: - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME. (prim) Da/m�ns. ttg 2 p _ _ . CE:RTIFIC.\/TtIu))N/#,2 /s"
WELL CONTRACTOR COMPANY NAME __reale Aixri4, We —II eJ ! !f ktp ('HONE # f�p(d7 ( y'8 -3 / 9 d
/ 4/.0,P
( it applicable) I if applicable)
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED \V O PE: R]I IF#
1. WELL USE (Check Applicable Box): Residentialit Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Beat Pump Water Injection 0 Other ❑ [(Other, List Use
2. WELL LOCATIO
Ncarcyt 'Town'
(Street Name. Numbers, (.'unanmtit'. Subdiv ,sum. Lot No.. hip Code[
3. OWNER:
Address ) !7O F [ try / Y) •
( Street or RogueNo., n /
C ��L/C0
( hay or I own State hip ( Ole
I )-
Arca code- Phone number ' /
4. DATE DRILLED & -/ /- D `t`
5. 'TOTAL DEPTH: / 8S '
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NOV,
7. STATIC' WATER LEVEL Below 'Fop of ('using: (p/) ET.
(Urn -I` i a Aims Top or amagi
R. TOP OF CASING IS f FT. Above Land Surtacc*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD(gpnl): /eZ METHOD OFTESI 02 /ir5 •
I0. WATER ZONES (depth): 1/o S t - / 4 m
Topographic/Land setting
❑Ridge OSlopc ❑Valley flat
check appropriate hurl
Latitude longitude of well location
,deem, minutes seconds,
Latitude longitude source:❑(JPSOTupographic nap'
check hum .-
DET11 DRILLINGLD(i
From To Forma Mil I)escriWion
-6 7a
7,1
LCKAIION SKETCH
11. DISINLECI ION: 'Type /-/T4 Amount a 2 had )t{s Show,Iirectiun and distance in miles from at leas'
12. CASING. Wall Thickness two State Roads or County Roads. Include the ruS
Depth Diameter or Weight Ft. Material numbers and common road names. C
t c-77)
,n
CG
r^�
F r.
t.. 0
cfi
CP Z
From () To 7A Ft. to /
Frolll To Ft.
From To Ft.
Pam.
13. (,ROUT: Depth q� Material ,�- )tethod
Eronl� To_p9� Ft.
from 'IQ Et.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. -_- —.
From To Ft. in. in.
15. SAND-(iRAVEL PACK: Depth Size Site Material
From 'fo It.
From To Ft.
16. REMARKS:
1 DU I[FREI3Y CERTIFY TI IA'F'1'111S WELL WAS CONSTRUCTED IN ACT'ORD:ANCF. Willi 15.A NEAT. 2C. WEI.I.
CONSTRUCTION S TA D RDS, AND 'II IA'I A COPY OP 1II1S RECORD IIAS 131-FN PROVIDED To 111E WELT OWNER
SIGNATURE OP PERSON LONSTRLETIMi 111 VAI-I 1. D:A I I.
Subunit the original to the Division of Water Quality, Groundwater Section. 1636 Mail Senice Center - Raleigh. N('
27699-1636 Phone No. [phone], within 30 days. OW -I REV. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na al Resources - Division or \vaterQualit
WELL CONTRACTOR (INDIVIDUAL) NAME. ( intl _ `-/C.(�G��/
WE i.t. CONTRACTOR COMPANY NAME -k� 7d-+� Y ! 1
PM
STATE WELL CONSTRUCTION PERMIT
(if applicable)
ASSOCIATED \\Q PERMIrr#
lif applicable)
294670
- Groundwater Section,/7/g
CF:RTIFI('AffIIOjN/# [/�i )Qb
PHONE: # go< 0 ! o _3/
I. WELL USE (Check Applicable Bol): Residential Municipal Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ II Other. List li,so
2. WELL LOCATION:
Nearest Town: �./..10PSV1 ) )e
(Street Name. Nunthers, Community. We Idivisit
3. OWNER
Address
'Street or Route No
L
Cilq or Tot State
N o.. /qp( octet
.Area cads- Phone numher
4. DATE DRILLED
p ( ncte
Topographic/Land setting
❑Ridge ❑Slope ❑Valleyjlat
I cheek appmprimc huxl
.al itude longitude %veil location
(tIet [.e. minutcaceouds1
Latitude lomlitudc source:❑(iPS❑lopugraphie wap
Icheek host
DI-.I'TII DRILLING LOG
rrom Tu ( Funnariptiau
/Jo' /5'S' -t_ie-
5. TOTAL DEPTH: / b'S
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO pl
7. STATIC WATER LEVEL Below 'Fop of Casio_: L/) FT. --
(Use -.-.IAbove Top of(asinel
S. TOP OF CASING IS / FT. Abuvc Land Surface* -
*Top of casing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST Y�—•
l0. WATER ZONES (depth): / /0 5 ' — ((�
1.
12.
13.
14
15
LOCATION SKETCH
DISINFECTION: Type 7I721' Amount _g2_ilt {5 Slum direction and distance in miles rrom at least
CASING: Wall Thickness two State Roads or County Roads. Include the real
Depth Diameter or Weight Pt. Nl aterial numbers and common road names.
From /j 'To //6 Ft. / u
From to Ft.
From To Ft.
GROUT: Depth Material N. hod
From I) To a!' Et :re r .,.
From To Pt.
SCREEN: Depth Diameter Slot Site Material
From To Et. in. in.
From 'To Ft. in. in.
SAND/GRAVEL PACK:
Depth Site Alateri:d
From To _ Ft.
From l.o Ft.
l
VC
16. REMARKS:
I DO IIE.REBY C'E:RTIPY THAT THIS WEI.I. WAS C ONS. ROUTED IN ACCORDANCE. A61I I1 15.A N(A( 2C. AVEI.I-
C'ONSTRUCrLON STANDA , AND THAT A COP( OE TIIIS RE I I:AS BEEN PROVIDED TO l IIF Vst.I.I OWN
E.
11 A Q P AU— _ --
SIGNATURE OF PERSON C ONS'IRLCTIN(I' 1111- AA I Lt. DA'IT.
Submit the original to the Division of N ater Qualit), Groundwater Section, 1630 \Iai1 Sen ice ('enter - Raleigh. S('
27699-1636 Phone No.[phone], within 31) days. (i\V-I RI.V. 07 2001

2946f:9
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - 1) v is of of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NANI- (print)__-!-/�J,Q+-//�i� 7�INpe p • C F.RTIFI(:AIUN aTa
\VELI. CONTRACTOR COMPANY NAME _attic_/..Ir�S . f,I/.PL I tUt),k, ' I'IIONE
(if applicable) (It applicable)
STATE WELL CONSTRUCTION PERMIT# :\SSO(TATED \\Q PERMI Fa
2
cis ..3/'76
I. WELL (1SE (Check Applicable Box): Residential irk. Municipal Public ❑ Industrial 0 Agricultural ❑'
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ (!Other. List Use
W'LLI. LOCATION -
Nearest Town: �O.44--TD71-, County F7I? L
cN31-4_a-a.r-o_-ram 2e/
Sunni Nenic. Numhcts. Cunvn unity. Subdici.,iun. Lot No Lip ( tnlcl
3. OWNER:
Address R. 7L- p. L24
Stmct nf) Ruutc No.l
+--`2-v-+vt A
Unit State
Lip t ode
Arca code- Phone number
4. DATE DRILLED / - / V - V•
5. TOTAL DEPTH: - q%> S'
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO
7. STATIC' WATER LEVEL Below Top of Casing: /i 6 FT.
(Ilse "l'1 if Above Top at Casing)
S. TOP OF CASING IS ET. Above Land Surface`
Topographic/Land setting
❑RiJge 4l.Slopc ❑Valley ❑Plat
I dnvk tlpprapriale hos I
Latitude longitude of well location
I (le_ulV S Ill nlatcS>Koodsl
Latitude longitude source:❑(,PS❑Topographic map
(check haxl
DP.PIII DRIL.LIIkI(i"1.O i---
Formation Description
Iron I
27,WS'
"Top of casing terminated at/ur below land surface requires a
variance in accordan9a with ISA NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TEST "1 Tic - W. WATER ZONES (depth): -28C / i p-cej -
deaf--- — —
LOCH ['ION SKETCH
I I. DISINFECTION: Type %-/7 /-/ Amount 31a -4-1,J--t _show Direction and distance in stiles from at lead
12. CASING: wall Thickness two State Roads or County Roads. Include the i tI
Depth Diameter or Weight Pt. Material nuntbers and common road names.
From (°) To 57 Ft. 6 '1
From To Ft.
From To Ft.
At
13. GROUT: Depth /:Materia NI thud
From n To 9/'J Ft. l.
From To FL
I4. SCREEN: Depth Diameter Slot Size Material
From To _ Ft. in. in. _ From To Ft. in. in.
15. SAND:(iRAVLI PACK:
Depth Sizc Material
From Ib Ft.
From Ib Ft.
16.REMARKS:
I DU I IEREBY CEICHFY TIIAI'Ill1S WEI.I. WAS CONSTRUCTED IN ACCORDANCE. IATIII 15.A NC:AC 2C. WELL
CONSTRUCTION STANDAI)DS, AND ILIA l A COPY OF THIS RECORD IIAS BEEN PROVIDED I()'r1IF WEI.1. OWNER
3/_dy
c )d
SIGNATURE. OF PERSON C ON.S'TRIiCI INt i II11- AATT L
D.
Submit the original to the Division of Water Quality, Groundwater Section. 163a Nail Sen ice Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days, (i\$-I RI.V. 07 2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
WELLCONTRACTOR (INDIVIDUAL) NAME (print) genie"- .6) L ,
WELL CONTRACTOR COMPANY NAME tree—t,�,// Los r..V.1..F_.�. `t ILF�mf )
STATE WELL CONSTRUCTION PERMIT# / `/ 0 •2 \SSO(tA IF.D WO PERMI r#
(it' applicable) fit applicable)
294667
- ( iroundwater Section
CERTIFIC !ION n 3 a 2 a
I'IIONE It {9 2cf ie_'. a / 7
I. WELL USE (Check Applicable Bus): Residential $I. Municipal Public 0 Industrial 0 A_gricultural 0 -'
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 I Other. List lkse
2. WE[.l. LOCATION
Nearest F) tn:
b / 0--
(Sonia Name. Numbers. Community. Subdivision. I.ut No. . hip I.
3. OWNER: / / 1 k f
�is 1
Address ``% l ,“ale I t`C 1/1-1
(Streit( or Ron: No.
/
d(Le n P C tf , l h , )1/4.) C cQ & Lt
( it1t barn Slate hip ( ode
I )-_
Area aide- Phone number
4. DATE DRILLED I — a 3 —b�
5. TOTAL DEPTH: 9CO
6. DOES WELL. REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top ofCasing.: aZO FT.
/ (Use''(" if Ahocc'coo of Casingl
3. TOP OF CASING IS 1 PT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCA(' 2C .0118.
9. YIELD (gpm): /I S METHOD OF TEST a 7 CS W. WATER ZONES (depth): ziv U — /' S
Topographic/Land setting_
County '$Ridge ❑Slope ❑Valley ❑Plat
I check appropnate box I
Latitude longitude of well location
I dCpICC, minutc. >econda
Latitude lon_itudc so irce:❑Gips❑Tupu_rraphrc map _
(check boss -
OFPI[1 DRILLING LOG
From to Formation Description
T
`f7_' 9b0`
) LOCIA f ION SICETCIi
11. DISINFECTION: Type /—/7-/—C Amount i 23 4- I, J is .Shots direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include thead
Depth Diameter or Weight H. Material numbers and common road names. O O
Frotn_Q To 4 % Et. 6
From To Ft.
From -- To Ft.
13. GROUT:
From D
From
14. SCREEN:
From
From
PVC
Depth NIaterial Method
To ab
To Ft.
Depth Diameter Slot Size Nlaterial
To Ft. in. in.
To Ft. in. in.
15. SANDi(iRAVEI. PACK:
Depth Size Material
From To Ft.
From To Et.
16.REMARKS:
1 DU IIEREBY CERTIFY TIIAF TIIIS WEI.I. WAS CONSTRUCTED IN ACCORDANCE \\TFII I5.\ N('AC 2C. WELL
CONSTRUCTION STANDARDS. AND 'l IlAI. rA COP( ()I: 11115 RECORD II AS BEEN PROVIDED ID TIII. WELL OWNER
SIGNATURE OF PERSON CONS I RITTING 1111- AVII I. DATE
Submit the original to the Division of Water Quality. Groundwater Section. 163o ?tail Service Center- Raleigh. NC
27699-1636 Phone No. [phone]. within 30 days. OW -I REV. 07 201i1

294666
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - (Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMk: (print) _/ at�h_ A . + Ivr - - - - CF:R'IIFl(':\rIOV# 36�
t�/7
Wr:EI.CONTRACTOR co�IPAN\N\AtEGt-«nt _-_graLs�• eus.- QtuMf )�Qru PHONE # -3 0
-. �
STATE WELL CONSTRUCTION PERMIT# /_4D a. ASSOCIATED WQ PERMI'ru _—
(if applicable) (if applicable)
1 WELL USE (Check Applicable Box): Residential, Municipal Public 0 Industrial 0 :Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 I(Other. List Use
2. WELL LOCATIO Near
'�.
Ncu'Cpw'n: o-�xJ) County
Strcct Name Numbcrs. 4 (immunity. Subdici.,iop. Lot No-. 7ip C ode)
3. OWNER:
Address
(Street or Route No -I Ci g g /
( it> ui('on Slate
hp lode
.Area cede- Phone number
4. DATE DRILLED - / _ d
5. TOTAL DEPTH: a.2 S / �./
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1yt
7. STATIC WATER LEVEL Below Top of Casing: LAO ET.
(Ilse"-" if .Above Top or C :uag)
3. TOP OF CASING IS I FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0I18.
9. YIELD (gpm): METHOD OF TEST C -
10. WATER ZONES (depth): / SS / -
11. DISINFECTION: Type dr_L- Amount 3 71 }b 1-
12. CASING: Wall Thickness
Depth Diameter or Weight Ft \-latcrial
From 0 to /5/ Ft. 6 /1 ___ S o A
From To Et.
From Co Et.
13. GROUT: Depth Material Method
From 17 To aD Ft. o.(.,+o w.. t ±b�p
From _ To Ft. 1
14. SCREEN: Depth Diameter Slot Size Nlatcrial
Front To Ft. in. in.
Front To Ft. in. in.
15. SAND/GRAVEL PACK
Depth
From I o
From To
Size Material
Et.
Et.
Tupo,t 'aphic/Land setting
:Midge 'lope ❑Valley ❑flat
'cheek uppropriwc boil
Latitude longitude of well location
ulce r. a. nunutt. _wens 6
Latitude lonsitudc source:❑(iPS❑Topographic nap
l dmck ho .I
DE.PTII DRILLING LOG
I ruin To ) For t4at'on Descriplitm -
o /5/ _
�-5// gas
L(CATI(N SKETCH
Show direction and distance in stiles tkom at Ie l
two State Roads or County Roads. Inclutthe t~Qd
numbors anti contntoa road names. 5** cl
- C
rixn
j7 0
5^
tv o
C (Li°
(/ =
1 ? n7j
al -4
CD Z
M. REMARKS:
I DO I IEREBY CERTIFY TIIAI 'lI 1IS WEI.L WAS CONSTRUCTED IN ACCORDANCE Mill 1 5.A NCAC 2C. WELL
C'ONSTRUCION STANDAR AND TIRE A COPY OF II IIS REC ( S BEEN PROVIDED It) THE WELL OWNER
SIGNATURE UP PERSON C. ONS 1121 - i III- AA hl E. DA'TI'.
Submit the original to the Division of Water Quality, Groundwater Section, 163o Mail Sen ice Center - Raleigh. \('
27699-1636 Phone No. [phone], within 30 days. OW -I REV. (17 20111

293718
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - (,roundwater Section
!,(` //�^��( tERTificA ioN/# //3(6l �/
l f�+ 1 ,—, •PHONE # 1Q2 4, 7 6 -.3/
WELL CONTRACTOR COMPANY NAMErtem E. r05.,._LSl `�_. /.�l,Lnya
ASSO( LATER WI) PERMIT#
l it applicable)
WE1.I. CONTRACTOR (INDIVIDUAL) NAM ( (nrintl
Y
arva.t`: , &L_
STATE WELL CONSTRUCTION PERMIT# / `i iC).
(if applicable)
I. WELL USE (Cheek Applicable Box): Residential. Municipal Public 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 f (eat Pump Water Injection ❑ Other 0 If Other. List 1.) e
2. WELL LOCA Cl N:
Nearer own: County
Psucci Name. Numbers. onmtuniiv. Subdivision. I it No_. Zip Code(
3. OWNER:
Address Y D I3R'X
4Street or Runty; No.l
/�1u99J! L4)e ,NC I25)
( ITV or lb n State .1 !Ip (-ode
1 )-
Area code- Phone number 1 A 1 ,
4. DATE DRILLED
S .1.0TAL DEPTH:
Loosed
6. DOES WEL.I. REPLACE EXISTING WELL? YES ❑ NOL
7. STATIC WATER LEVEL Below Top of Casing: _QQ ET
/ (Use "t" If Above Top oFCasino
H. "I -OP OP CASING IS ET. Above Land Surface'"
`Lop of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /S METHOD 01= TEST r hrs to. WATER ZONES (depth): ,3D$ — /.JQ pre
I I. DISINFECTION: Type /4 rl-f
1?_ CASIN(i:
Depth Diameter
/�
From � To /a / Ft. t 'i l,
Prom To Ft.
From To
[3. GROUT: Depth
n/�-�Materl�a�l � Method
Frum�'lo RI! FLS .Qdtx �er-P
From T o Pt.
14. SCREEN'. Depth Diameter Slot Size Alaterial
From I0 . Pt. in.
from - To It. in. --__-_ in. __ ---
15. SAND -GRAVEL PACK:
Depth Size Material
From To Ft.
Prop) To Et.
Topog aphiciand settit
❑Ridge nSlope ❑Valley i
I cheek appropriac hurl
Latitude longitude of well lo�
rtl r-es mmut ends, k Cj
Latitude lom_itud source:❑GPS❑ T( I3.? I1hic Tip
(check lo,o 5
DI-.PTI I DR11 P7FN
rout To t Forma
D �a1
la / -' 445'
I OC,A T ION SKETC1(
Amount 4,7 4d�, Show direction and distance in miles from at least
Wall Thieknes-s lotto State Roads or County Roads. Include the road
or weight I t I ierial numbers and common road names.
e_e
16. REMARKS:
IV
I DO IIERLt3Y CI:RTIPI" TIIAT HITS WELL WAS CONS. RIX TED IN ACCORDANCE VAfill 15 A N( AC uC ANETT.
CONSTRUCTION ST NDARDS. AND II IAT A (TRY OP'I111S RI t ORD I L-AS lit FN I'ROA IDID TO Hilt II Hilt IT L OAVNL.R
41-3i -
SI(iNATtJREO1.PERSONCONSIRCCTI i 11. AWEI I- DATE
0
Submit the original to the Division of Water Quality, Groundwater Section. 1636 Mail Scn ice Center - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. (OW -I REV. 07 2001

WELL CONSTRUCTION RECORD 293717
North Carolina - Department of Environment and Natural Resources - Division of
WELL. CONTRACTOR (INDIVIDUAL) NAME (print) _ D 17 1 YT i 1 % C'- U
WELL CONTRACTOR COMPANY NAME l re_e_I L_.Qr'OS.
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
olaa
'Water Quality - (iroundwater Senior
cERTIPlc,\TIONz a-V/8
uvv\? IIONI. # (ve b k - 3 ! 70
ASSOCI.A I El) A\ Q FERMI T#
(if applicable)
I. WELL_ USE (Check Applicable Box): Residential 10 Municipal Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 I-Icat Pump Water Injection 0 Other 0 I ['Other. List Use
2. WELI. LOCA.
Ncare: 'Town:
(Street Name. Nun
3. OWNER:
Address
No.7/1 C ca2 R 7 /
('ray or loon Stan
1 )-
Area code- Phone number —
4. DATE DRILLED —�
County 75-10l/112
n. Inl no.. hip (o Icll
hip ('pile
5. TOTAL DEPTH: 3-? S '
6. DOES WEL1. REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /FO FT.
(Use" " i (.Ahose Top of casing)
S. TOP OF CASING IS I FT. Above Land Surface*
*Lop of casing terminated at%or below land surface requires a
variance in accordance with I5 \ NCA(' 2C .0118.
9. YIELD (gpm)'. „2,6 METHOD OE TES 1
10. WATER ZONES (depth):
3D5' - r-QD cn. p,m
1l. DISINFECLION: Tvpc FITI-1 Amount lab -I -Las
12. CASING: Wall Thicknes.
Depth
�l
From O To 5 9 Pt.
[tom .110 Ft.
Front
To Ft.
13. (iROIJT Depth n�l
From Q ._ Co�2 J _ Ft
From Ib
14. SCREEN: Depth
From T"o Ft.
From -. 'Et)
15. SANDI(1RAVEL PACK:
Depth
Front To
Diameter
to I'
or N eight. I.t. A heal
llaloria1 Nlcthod
Ce�r\� - L
Diameter Slot Size Material
Ft.
From Lo Et.
in.
in.
ut.
in.
Size Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ' iLlat
dn2k appropriate host
Latitude loIIJitude vtell location
I Jc, rc nunutc. >cc ond,l
Latitude lonaitudc source:❑GPS❑Topographic map
I dmek bos 1
DP.PIII DRILLING LO(i
From I ogqq
( 1n11atIol11?sinPI:
Rai
----- — T _,:j ...
(
— - I OCA I ION SKI. I C lk � 1 c3
Shoe direction and distance m lilsf.ctrynl a los'1
two State Roads or County Roads.
numbers and common road names.
16. REMARKS:
1ti:31i(`Ic the road (N'.�
in
J
I DO HERL13V ( Elf l'EFY TIIAI- TIIES WLI1. WAS CONSTRUCTED IN ACCORD ANCI. AWIII 115:A N(AC 2C. AWEI.I.
C'ONS"IRIJC'TION STAND AND TT IA I" A COPY OF Tuts RFCORD I I AS UI• EN PROVIDED TO T i IP. WELL OWNER
)P PERSON' CONSTRLL IN.; 1111- ACLI 1. D. lI-.
J
SIGNAEURI
Submit the original to the Division of Water Quality, Groundwater Section, 1631,,Alail Sen ice ('enter - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. (1W-1 REV. (17 21)111

293'716
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Mural Resources - Division of Watch Quality - Groundwater Section
WEI,I. CONTRACTOR (INDIVIDUAL) NAM (print)
)
STATE WEL1. CONSTRUCTION PER)11Tk
l if applicable)
obi 14)e1)h
(EIt1IFICATION # a 41 /
&OS. 1L/iLL <Iota "'iCC. PHONE k 6212(O in 4../
/_ .
Assoc LWrt:D P'Q I'F:R\I rrx
i t applicable)
I. WELL ELSE (Check Applicable Box): Residential"0 Municipal Public 0 Industrial 0 :Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 It Other, List Use
2. WELT. LOCATION:
Nearest • wn: fly e CV 1 %c County
(/rat i, ,
ISacet Nal te. Numbers, Community. Subdic ision. Lot No., hip ( ode;
3. OWNER: —nit) Yyl < r �4G�
Address 2 J,� ('it t !F I t)D 1 I Jt
(Street or R?utc Nt 1
,C. a 8 7S�
1-p k
(II)oon State V Lip('odc
I )-
.Area code- Phone number
4. DATE DRILLED 3 — `t —D L
5. TOTAL. DEPTH: anS )
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 114
7. STATIC WATER LEVEL Below Top ofCasine: 1G FT.
(Use -1 " i t:Above Top of. Casing
S. TOP OE CASING IS 1 FT. Above (-and Surtitce*
*Top of casing terminated at/or below land surface requires a
variance in accordanncF with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OI: TES T- A rs •
ID. WATER ZONES (depth): LDS) —4D c-rL
I I. DISINFECTION: Type l-1r(-i_.__.Amount 35 4- IN 1h
12. CASING: Wall Thickness
Depth //,� Diameter or Weight It. itc
From_. "To <3 Et. Ir
From To Ft.
From To Ft.
13. GROUT: Depth n Material Nie)hod
From 1 o Ft
From To I t
14. SCREEN: Depth Diameter Slot Site
From l o Ft. III
From 1t1 Ft. __in
15. SAND'GRAVIiL PACK:
Depth Brae Nlatertal
From I o Ft.
From •Fo Ft.
16. REMARKS:
11)
Nlaterntt
Topogriphie:Land setting
❑Ridge Slope ❑Valley DElat
rc tcc . uppropriam box)
I.alnude longitude of well location
J.;r:e, nnnumr second,.)
Lail alda longitude totlrec:D iPSOlopographic map
ietweL host
DEPTH l DRILLING LOG
Ilaiii l I I'onw l Description
93 I _r ,s' � t,
LOCATION SKETCH(
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road mines.
0
0
I DO I IFRLL3A CERTIFY TIIAI'THIS WELL WAS (ONS I R(C TED IN AT ANCL AA IT II 15.A NC AC 2C WELL
I.
CONSTRUCTION STANDARDS, ANDARDS AND TI TAT A COPY OF I I ITS RECORD 1 (AS RI 1-N PROVIDED TO il10. WEE I- OWNER
SIGN.AIIALI OI PI!RSON CONStRLCTINti TIII- AAII 1. I)AFI:
Submit the original to the Division of Water Quality, Groundwater Section. 163o ?tail Ser' ice (.enter - Raleigh. NC
27699-1636 Phone No. [phone], within 30 days. CiAA•-I REV. (17 2001

294942
- North Carolina • Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699.1636-Phone [phone] /J h�(( D
WELL CONSTRUCTION RECORD WELLCONTRACTOR• 71Ce W%/4"/Vmt
WELL CONTRACTOR CERTIFICATION #: 3YL7 /brit, d '/ve
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential IV-
Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection ❑ Other II Other, List Use:
2. WELL LOCATION: (Show skel of he 1• ation below)
Neare I Town: v - -! e- Al County 3441
(Road Name a Nu •ers, �o�••r nity, or Subdivision and Lol No.)
3. OWNER L�O!��, Jet-
�yj (i From To
•►Ji'i
Address n �i`�V,
Ir —
el or •ou • •o. qc'
C or Town ? • Ie ft' - eL /y% ip Coda Y
A. DATE DRILLED)- S- 7 /( .5C5
5. TOTAL DEPTH 305
6. CUTTINGS COLLECTED YES Q NO fl
7. DOES WELL REPLACE EXISTING WELL? YES D NO'
8. STATIC WATER LEVEL Below Top of Casing: r22c' FT.
(Use '+' it Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In accor-
dance with 1SA NCAC 2C. 18 n
10. YIELD (gpm)• 75 METHOD OF TEST /'f • fr
11. WATER ZONES (depth)• /G
12. CHLORINATION: Type Amount
13. CASING: -
Agricultural ❑
Monitoring ❑
DRILLING LOG
DEPTH
inflation aescnption
/4-
eft'
c
o .
o
If additional space is needed use back of lorm a
n^1
Wall Thickness LOCATION SKETCH I
Depth...." Dia ear or We' r t. "Venal/ % ecn
P] rq / (Show direction and distance from at least two State
From t� To 7 r Ft / 4 /_ —nee Roads, or other map relerence points)
From To Ft. �,�
From — To Ft. 7 L.
14. GROUT:
Dept Material Method
From 0 To Ft (F'---e-
From To A.
15. SCREEN:
Depth Diameter Slot Size Material
From - To Ft in in
From To FI. . in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
up CC
rn
t.o c
._ .........
1.
FOR OFFICE USE ONLY
Ouad No:
Serial No.
i
3-F3-oLI
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality. Groundwater Section within 30 days GWI REV. 12/99

North Carolina • Depanment of Environment and Natural Resources - Division ol Water Quality • Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR /c �,4E.;/�
294941
WELL CONTRACTOR CERTIFICATION kr--'? 9 rE I�
STATE WELL CONSTRUCTION PERMITH:
-,
kr.r:,l 9 dc e,
1. WELL USE (Check Applicable Box): Residentialr2 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Sow s Ich of the location below) ,/ 1/
N-eaarrejl Town: ''�T : * County. lA ticrP!�
irAA/5e ✓ A/-ivr OG •
(Road Name and1r/4Number), CJmmunityTor Subdivision and Lot No.)
3. OWNER FretC =.7 meS
Address t G,r f / 77-?
(Street or Houl) O.)
/V • o771
ly or Town Slate V4`6,.7..S7:,S yip Code
4. DATE DRILLED J'JC DV
5. TOTAL DEPTH
6. CUTTINGS COLLECTED Sn NO� YES
7. DOES WELL REPLACE EXIYESTING WELL?
8. STATIC WATER LEVEL Below Top of Casing: ;Po FT.
51_,(Use'i1 Above Top of Casing)
9. TOP OF CASING IS . FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .e 1E
10. YIELD (gpm)• 'C METHOD OF TEST Ac%
11. WATER ZONES (depth):
•
DRILLING LOG
From To
/0
/ 1'25-
pZ 3 rs,�
S26"
NO71."
12. CHLORINATION: Type //%, Amount
13. CASING: -
DEPTH
FO,malio
Description
/n
qN
11 additional space is needed use back ol form
Wall Thickness LOCATION SKETCH
Depth Dia``e a or Weight/FL erial (Show direction and distance from at least IwcLStale
From �� To / Ft L') V 1'M517( Roads, or other map reference points)
From
From —
14. GROUT:
To Ft.
To Ft
Depth Material Method
From D To Depth
Ft (PM rc"^/ ✓
From To Ft
15. SCREEN:
Depth Diameter
From To Ft in
From To Ft in
From To Ft in
16. SAND/GRAVEL PACK:
From
From
17. REMARKS:
Depth
To
To
Size
Ft
Ft.
Slot Sizo Material
in
in
in
Material
4ioo7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
t 3-10-00
SIGNATURE OF PERS CONSTRUCTING THE WELL
Submit original to Division of Water Duality, Groundwater Section within 30 days DATE
GW1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Senal'No.

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section 29.1940
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] '�, /
WELL CONSTRUCTION RECORD WELL CONTRACTOR. !�' '•We 11 t1,41 //
WELL CONTRACTOR CERTIFICATION #: 7f,•y fee'Y'4i HA f v.
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCAT�IOJ: how skerch of the location below) lQ/�
Nearest Town: W4)NC'S t�'- //L County %/" �tkca-1
vW,JL 2;ll4w,
(Road Name and t umoe s. Corrynunity or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 7'%}fit/ (UT.O/7/ � / Rom To nation escdpuon
Address ,�7 (�il,'!�� /C to• 0 a a.t
14-1/4 . / '//� Street or ) NO
y or Town staje v5 4- h/S(,,. eQyl Zip Code
4. DATE DRILLED-3. 7-C
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES0 NOE
7. DOES WELL REPLACE EXISTING WELL? YES
8. STATIC WATER LEVEL Below Top of Casing:
NO(V(
FT.
,-� (Use '+' 11 Above Top of Casing)
9. TOP OF CASING IS c FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance In accor-
dance with 16A NCAC 2C . Pie
10. YIELD (gpm): le METHOD OF TEST /7'r
11. WATER ZONES (depth): /,/
12. CHLORINATION: Type I/�. 7J4 Amount
13. CASING:
7' -7 Depth oiarnftar
From .' To Ft C'
11/
From To Ft.
From To Ft
14. GROUT:
Wall Thickness
or Weight/Ft. , anal -
A.Si�/<_
Depthhi, Material Method
From C To 7C Ft rr- '+FrN'r
From To Ft
15.SCREEN:
Depth Diameter Slot Size Material
From To Ft in in
From To Ft in In
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
r
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State I---- -._...._ _
Roads, or other rnap reference points) ,
0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Alta(�./3-11- 00
SIGNATURE OF PERSON etioNSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.

- Nonh Carolina • Depanment of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center • Raleigh, N.C. 27699-1636•Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: 7i yy//,,��
't'r LUe//3-�A///
WELL CONTRACTOR CERTIFICATION'S:.,2 4 % /444 I4,4/U/row
STATE WELL CONSTRUCTION PERMIT'S:
294939
1. WELL USE (Check Applicable Box): Residential [ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other El 11 Other, List Use:
2. WELL LOCATION: jS ow sketch of the location below)
Ne. rest Town:
A
(Ro. • ``9-ap9d Numbers. Co^n)u ni , or Subdivision and Lol No.)
3. OWNER (/Aie:vC� 7t4eS
County
Address 7••
CA? NTLnI
City or Town Ste
4. DATE DRILLED ,
5. TOTAL DEPTH r 1
6. CUTTINGS COL CTED YES D NOD
7. DOES WELL REPLACE EXISTING WELL? YES
B. STATIC WATER LEVEL Below Top of Casing:
until/ gL 12ei1 ,e_ •
( reel or I o )
:2 7j ;
Zip Code
DRILLING LOG
From To
<af 1/
e9,054%o 5%qe
NO (
FT.
(Use': d Move Top of Casing)
9. TOP OF CASING IS a< FT Above Land Surface'
'Top of casing terminated .Uor below land surface requires a variance In accor-
dance with 1SA NCAC 2C .e 18
•
10. YIELD (gpm): (U METHOD OF TEST f)
11. WATER ZONES (depth):
•
12. CHLORINATION: Type
13. CASING:
4x%
Amount
Wail Thickness
�� Depth Dia �t r or We' r. �^}led I
From To y.3 Ft. (e, "4 ;4r 25 ✓; /
From To Ft.
From _ To Ft
14. GROUT:
Depth. Material I. Method
From 0 To di-2 Ft {fr:ug.Ny
From To FI
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft - in in
From To _ Ft
From To _ Ft
16. SAND/GRAVEL PACK:
Depth
From To
Ft
From To Ft
17. REMARKS:
in
in
in
in
Size Material
DEPTH
l �ation Qescllplion
7 ,ill
r--
11 additional space is needed use back 01 Iorrn
LOCATION SKETCH
(Show direction and distance from at least two State-- —
Roads, or other map reference points)
a
J1
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
✓�..�� =4/44w 3-1
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Groundwater Section within 30 days Gw t REV. 12/99
FOR OFFICE USE ONLY
Ouad No:
Serial No.
i

North Carolina • Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Serwcu Center • Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. - le We ll Y Pn, f
WELL CONTRACTOR CERTIFICATION #:4 /6?AC' Z .A14e
STATE WELL CONSTRUCTION PERMIT#:
2919 '8
1. WELL USE (Check Applicable Box): Residential `LI' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
•
Recovery El Heat Pump Water Injection ❑ Other ED If Other, List Use:
2. WELL LOCATION: (S w sketch of the location below) ,�/
NeaoestTown:(N�41i✓E,.SVi,J/e Counry /"9�d00�
Zahn/lame Name anu Numoers. Con�un y, or S bdivision and Lol No.) DRILLING LOG DEPTH
3. OWNER 4 r pi- From To Form on scription
Address 11 1 , to
JJJ dd
(si t r a So e.) 0 75 �s71
Lt}.0\l/1)c-AuI J1 �+ 7 3 7/ . rr -•ro ,ve
Cil or Town ? Stale �- a p Code `/
4. DATE DRILLED 3-ac3'C `� �� /S— �i �-`> ..1"....." e
5. TOTAL DEPTH /Yr
6. CUTTINGS COLLECTED YES 0 NOE
7. DOES WELL REPLACE EXISTING WELL? YES n NO 1/ r
8. STATIC WATER LEVEL Below Top of Casing: .3 3 FT.
r
(Use'i it Above Top of Casing)
9. TOP OF CASING 1S FT. Above Land Surface'
'Top of cuing terminated et/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0 16
10. YIELD (gpm): METHOD OF TEST Air c
11. WATER ZONES (depth)•
-
12. CHLORINATION: Typo Amount 11 additional space is needed use back of form
13. CASING:
•
Wall Thickness
q_� Depth Di melo or Weight/Ft.
�7 /
From To Ft /
From To Ft.
From To Ft
14. GROUT:
al
LOCATION SKETCH
(Show direction and distance from at least two Stale
Roads, or other map reference points)
Depth -1 �/ Material Method o
From To oC'� FI (- P/'Tr e r e,
From To Ft
15. SCREEN: f'
1 � rrl
Depth Diameter Slot Size Material cr?o—
From To FI in in 'z''
2y -fC
From To Ft in in 3 ao
From To FI in in w m �'
16. SAND/GRAVEL PACK: NI
Depth Size Material o`
From To FI
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL /NNER. C��
� 2 ZZJ O
SIGNATURE OF PERS N CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days DATE
GWt REV. I2/99
FOR OFFICE USE ONLY
Ouad No:
SenalNo.
i

- North Carolina • Depanment of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR* 1-Ce lie/APAt/
WELL CONTRACTOR CERTIFICATION 11: cQ9'6i� ,1L.i%04.44�O
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Boa): Residential Lr Municipal ❑ Industrial ❑
Recovery [J Heat Pump Water Injection ❑ Other 0 If Other. List Use:
2. WELL LOCATION:(S
Ne est Town: rr4
rel Al
w sketch o the location below)
e County:
ad Name anU umber )�Co unity. or Subdivision and Lot No.)
3. OWNER r. pbPA/¢rp,S&_
Address 73 /V✓ rng.& /
eel or Houlo No
(�t/1q �/JV V, �/ Ci
1� stale ��
Agricultural ❑
294937
Monitoring ❑
Gt or Town / �R7� 6 h S
3 s-� Y -ysa7-./0271Zip Code (O
4. DATE DRILLED �VrJ ���
5. TOTAL DEPTH /��
6. CUTTINGS COLLECTED YES(—] NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO[C7
B. STATIC WATER LEVEL Below Top of Casing: $ FT. r
DRILLING LOG
DEPTH
From To
0 /22
5's/
lion Descnplion
(Use'.' it Above Top of Casing)
9. TOP OF CASING IS _ FT. Above Land Surface'
-Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C. 11a
10. YIELD (gpm): r 215 METHOD OF TEST l/T
11. WATER ZONES (depth)•
12. CHLORINATION:
13. CASING:
Type 7--
Amount
If additional space is needed use back of tech'
Wall Thickness LOCATION SKETCH
..y Depth /� O'ar�ne e or WeighVFI. Ma riai _ (Show direction and distance from at least two State
From / a To / Ft. 1p1L �C Roads, or other map reference points)
From To Ft.
From — To Ft 4 // CJ�
14. GROUT:
���� Depth 1. Material / Method
Freom C/ To , v Ft CPA/ eN'' 7-
-From To Ft
15. SCREEN:
Depth
From To Ft
From To Ft
From . To Ft
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
Diameter Slot Sizo Material
in in
in in
in in
Size Material
Ft
Ft
0
b
73
C11
l0i
N
kD
c
CD
GI
GI
;24m
Cn
Trn
orn
m
0
rno
„
n
mS
G
1 DO HEREBY CthTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. p
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GWd REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Senal'No.

294944
. Nonh Carolina • Depanmenl of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] /�
WELL CONSTRUCTION RECORD WELL CONTRACTOR• kite We l�l//- kin
WELL CONTRACTOR CERTIFICATION N:c9# 9 ei;1 h4,&J, e
STATE WELL CONSTRUCTION PERMITN:
•
1. WELL USE (Check Applicable Boa): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATNION: (Show sketch 9ythe location below) %7
N{(efrr stt'yT/own: ` JCounty- "41/00r/
(Road Name and Nu ets. Commynjly, or Subdivis n and Lot No.)
y
3. OWNER )"'Ll f'r or - >rj
Address ,R79 X1w/� .1J, /1
(SIlecl or oulo o.
ty:y or Town _/ Stale -.y 4473-7 Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOKI
6. STATIC WATER LEVEL Below Top of Casing: , .Q FT.
(Use': tl Above Top of Casing)
9. TOP OF CASING ISFT. Above Land Surface'
*Top of casing terminated aUor below land surface requires a variance In accor-
dance with 15A NCAC 2C.Q118
10. YIELD (gpm): IX v METHOD OF TEST A
11. WATER ZONES (depth): 12. CHLORINATION: Type // ,z� r Amount
13. CASING:
DRILLING LOG
DEPTH
escripoon
II additional space is needed use back of form _
LOCATION SKETCH
Wall Thickness I
Depth Di m��I rr or Wpe�o-nUFt. M erial (Show direction and distance Irom at least two Stale!
From `� To 0`"( FL /rn 7 r��`�� 5tee Roads, or other map relerence points)
From To Ft
From — To Ft
14. GROUT:
Depth Material/ Method
From D To OtO Ft Cernyyr-
From Tb Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in
From — To Ft in. in
From _ To Ft in. in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
•li003
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No:
Senal No
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zs orn
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cri orn
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Sim m�
as
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rn
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SIGNATURE OF PERS N CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouaitly, Groundwater Section within 30 days OW4 REV. 12199

291957
WELL CONSTRUCTION RECORD
y )n of H aler ()alms .•Icund\`ater Jesnar -
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.,u111 u.i. Lilhpitide 5Ju((- n(il's0'lbp,4: raph,C nru'•
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294958
rat 144I II l ION INUI\lb%%t l4\a11. print)....
WELL CONS'IRUC LION RECORD
r u,. m ` - ocl:•Jrl.n, II of I- n, `ronnc nl arJ Naiad) Ns•uur `, • ' on
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1111 L)c.PTH
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I t:tiNt ..h rioN Tyrc_.til1.0 Amount'..... ---
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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural /Resources - Division of Water (qua
WELL CONTRACTOR (INDIVIDUAL) NAME:` (print) [Rai)/ A/ ��'-de- -
WELL CONTRACTOR COMPANY NAME J Yire 1)e__ Qr _t_ &al-__ - I 0-'710
STATE WELL CONSTRUCTION PERMIT# /7 DA ASSOCIATED WQ PER?Ifs#
(if applicable) litapplicable)
293710
lily - Groundwater Section
CERTIFICATION #
t'>; -,I IIONE
1. WELLUSE (Check Applicable Box): Residential L Municipal Public ❑ Industrial 0 .Agricultural ❑
Monitoring ❑ Recovery ❑ Ileat Pump Water Injection 0 Other ❑ [(Other. List 1 Ise
2. WELL LOCATION:
Nearl'st Town: `i .6 4.9 P_ (/n / /e3 County ) it tYX
moon rl0 ri - 1
(Street Name, Numbers. Community. Subdivision. Lot No., Lip ( ode)
3. OWNER: r P ari RYOL liN
Address
,Q e1fp arena arV KC •
Street it Rot to No.1
V'YIiL • a2"7s )
t
( its on State / /ip tide
Arca code- Phone number
4. DATE DRILLED q - I % -0 Lk
5. TOTAL DEPTH: R b5
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: tee) LT.
(Use"l" It .Above Top ut Cuing)
8. TOP OI' ('ASING IS / FT. Above Land Surface"
*Top of casing terminated al/or below land surface requires a
variance in accordance with ISA N(A(' 2( .11118.
9. YIELD Igpm): I 0 METHOD OF T ESTrS
H0. WATER ZONES (depth):
I - LD r pm
IL DISINEECIION:'type J-7 -I Amount 344-1sj}S
12. CASING: Mall Thickness
Depth Diameter or Weight Id. Material
To L a Ft. Lo tt
From
From To
From To
13. GROUT:: Depth
From P To .Q
From To
l4. SCREEN: Depth
From To
From To
15. SAND/(TRAVEL PACK:
Depth
From To
From .to
PVG
Ft.
Material 4ecpMethod
Ft.
Diameter Slut Size Material
Ft. in. in.
Et. in. in.
Site
Pt.
Et.
Material
16. REMARKS:
44/g-.3/7‘)
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 0IF1at
(check npproprlate hods
Latitude longitude of well location
Latitude longitude;puree:❑(iPS❑topographic map
tcheck box
DF.PTII DRI1.I.ENG LUG
Train I ( Formation Doscrip(ion
Lv� — —�
LOCH.( ION SKG(CI I
Shots direction and distance in miles IIoniat Iujt_)_
tov State Roads or ( aunty Roads. Include the rond
numbers and common road names.
I DO IIE12E1)Y CERTIFY TIIAF TITS WELL WAS CONSRUCCED IN AC CU12D.ANCL WITH 15.A N(AC 2C'. WELL
CONSTRUCTION STANDhRDS, AND" HAT A COPY OF TITS RLC ORD IIAS PROVIDEDIt) TIIF. AATI_I. OWNER
3n - 6 V
SIGNATURE OI: PERSON
)NSIRL( ZINC Nil AAl1 I.
the original to the Division of Water Quaid), Groundwater Section. 163n Mail Sea ice ( enter - Raleigh. NC
27699-1636 Phone No. [phone], Within 30 days. OW -I REV. 117 22(1111

fl'3'Y11
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
{.�J r £ + /Jrti�— c FRTIrl(:� r1UN �D �/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) v`I\
WELL CONTRACTOR COMPANY NAME & etn C. �f ros- •�'��. of Pin*, n))f?( rte.. PHONE k k N `t` O - 3/
SI'AlE WEI.I. CONSTRUCTION PERMIT# /va? ASSO('IA I'E11 \VO PER\1( t1
Of applicable) tit applicable)
I. WELL IJSE (Check Applicable Box): Residcntialli 'Municipal Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ II Other, List llsc
2. WELL LOCATION:
Nearest Town: Le County______ita XJ
Fo v
(Street Name. Numbers, Community. Subdicisian.lot No.. Zip (odu
3. OWNER: E-11 ) rz,„„,101 � --
Address (I q' Fbc a1 4 Qct .
(Street or ROL MC No.l
Li)(atne-Sm In1C •aS 2gS _
Lay or Iown State lip t ode
)-
.Arca code- I'1o1C number
4. DATE DRILLED (% - I a -
LI-
S. TOTAL DEPTH:
6. DOES WELL. REPLACE EXISTING WELL? YES ❑ NO
7. STATIC' WATER LEVEL Below Top of C'asine: FT.
it Fie if AKA Top otC aims)
S. TOP OP CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordanfe with ISA NCAC 2C .0118. 1
9. YIELD (gpm): II ti- METHOD OF TEST ol n r5 •
W. WATER ZONES (depth):
LOCA LEON SKE[('11
I I . Amount 1 S t i-L I }Show direction and distance in miles: froth at least
12, watt Thickness two State Roads or County Roads. Include Mc road
Diameter or AA'eight. D. Aiamriat numbers and common road names.
Topographic/Land setting
DItidge 0ISlope ❑Valley ❑flat
tc:ecL approprsate boil
Latitude longitude or well location
1 degrees uunum., >enmd,l
Latitude l uu%itu(Ic source:❑(1PS❑ Topographic nap
I Bieck host
l)RILLINti LUG
Formation Description
DIMIMI
From Vo
n ‘2. z
�7 ems'
13
14
IS
DISINFECTION: Tvpc f-i%f-I
CASING:
From
From
From
GROUT:
From(G
From To
SCREEN: Depth
From 'To
Front To
SANK) (GRAVEL PACK:
Depth
From __-11)
From To
Depth
0 To 5 Et.
Et.
Ft.
To
.Fo
Depth
To 30
Ott
^Material Method
A�Cc.Q.4(f
Ft.
Diameter Slot Sire \ hateriul
Ft. in. in.
Ft. in.
Ft.
Et
size .vlaterial
I6. REMARKS:
c
0
I DO IIERELIY CP.RTIPY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORD:ANCI-. WITH I A NCAC 2C'. AVLLI.
CONSTRUCTION STAN)ADS, AND IIIAT A COPY OF NITS RECORD IIAS 13h.EN PROVIDED I O (III! WELL OWNER
y.) N? ,11 �.r�e -3v -
U:\ Il-
St(iNALURP OP PERSON CONS IRE( TING 1(11. FA'Id I.
Submit the original to the Division of \\ ater Quality. Groundwater Section. 163e Plait Sew ice Center- Raleigh. NC
27699-1636 Phone No, [phone], within 30 days. (iAA -I REV. 07 2001

293112
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL. CONTRACTOR CO %IPANY NAME&c n—
S'IA'['E WELL CONSTRUCTION PERMIT#
�11 Resource; - Dit-isiun ofU ater (ivaIIt>
__i�Db/iv /LJel L
13rn5 . ✓)_ -4 P`hni /cC .
-
ASSOCIATED ME) PF:R?Ilia
(if applicable) Of applicable)
- Groundwater Section
CNFu:A &«�/
PHONE/
a
I. WELL ((SE (Cheek Applicable Box): Residential Municipal Public ❑ Industrial ❑ :Agricultural ❑
Monitoring 0 Recovery 0 l scat Pump Water Injection ❑ Other 0 I[Other. List Else
2. WELL LOCATION:
Near kit Town: Lt/Q-tj S U 17 7 E Coun
r1 4C-ik
IStrcot Kwne. Nw hers, Community. Subd)vivan. Int No.. Lip ( ode)
3. OWNER:jo V 1 0.- '`f L..2 f oil ( 1 alA l^(\
Address 131 Za ? 1 .. L ' - .
Street or Route No.1
Yl� t r Ip r);�A �nn2
( ltl or Hove Slate Lp
Area code- Phoac number
4. DATE DRILLED 4 - -DLL
5
6
7. STATIC WATER LEVEL Below Top of Casing: IOC ET.
(Use-.'. II Ahocc Top or( :tong)
3. TOP OF CASING IS 1 FT. Above Land Surface'
*lop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): U ...a- METHOD OF TESL i=2 rS
10. WATER ZONES (depth): (per (I.Z nt p re"
'I O I - (P ry rV\ --
1 I. DISINFECTION: Type ht T7� Amount J C� +bl+s
12. CASING: Wall Thickness
Depth Diameter or Weight Et. \Iateri,d
From To 3 Et. to II --- t'_V
From To Ft.From To Pt.
l3. GROUT-: Depth V1uterial Method
From Q To
aD r p
l-OTALDEPTH:
DOES WELL. REPLACE EXISTING WELL? YES ❑ NO
From To Ft.
14. SC'REEN: Depth Diameter Slot Si<e Materiel
From To Et. in. in.
From - 'To Et. in. _--- in.
15. SAND'(iRAVEL PACK:
Depth Size Material
From To Et.
From ilio Ft.
l6. REMARKS:
Topographic/Land setting
❑Ridge Slope ❑Valle); ❑Teat
(check uppropriu)e howl
Latitude longitude OF well location
deer,°. minute, x•Conda
Monde Ion titudc source:❑GPS❑ topographic map
(check host
DI PHI DIME ENO LO(i
From l o Form tiun Description
E.0(A l ION SKETCH:
Shotv direction and distance in mile); fronSat least
oleo St:nc Roads or ( minty Roads. Iltclude the tt d
numbers and common road mums (
co
C—
a
CPI
r
)
I DO IIERE[IY CPRT[n( TIIAT'CI ITS WELL WAS CONS IRUC"I ED IN AC CORD:ANC11 A TI 15.A NCAC 2C. ANEI.1.
CONSTRUCTION SfAtvD4RDS. AND ll1AT A COPY OI TIIIS ILLC ORD) 11 \ I EN PROVIDED lO Tiff, VVEI.L OUTER
Y `?
S[(iNATtllui 01: PERSON ( ON.S'FRLCI t', rill AVI-I I 1),Vl b
Submit the original to the Division of Water Quality, Groundwater Section. 1630 Mail See ice ('enter - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. OW -I REV. 07 2001