Ya 1 CY2004

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural p Resources�"- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Mar Allen
WELL CONTRACTOR COMPANY NAME
f er/.✓fai✓ VW. jr,7/4-7
302P74
CERTIFICATION # 3e? a
C O. PHONE it ) 647
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential (' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: ataf n t V I.I County 41,91V6 Ey
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: illy )„�tt �PLf✓) I
Address ejl'dl1Q-/'//rIAIYDA VZU,i4 'RTvp
(Street or Route No.)
13oL„sktru nc Qa-,iy
City or Town State Zip Code
)- tWA
Area code- Phone number j
4. DATE DRILLED GSM f a- O 17
5. TOTAL DEPTH: 4.24 S
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: o 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): METHOD OF TEST ?t'9
10. WATER ZONES (depth): hp
11. DISINFECTION: Type // 771 Amount 307
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From Q To 3 (( Ft. 6 iDit3,1 Pkt
From To Ft
From To Ft.
13. GROUT: Depth Material/ ,Method
From b To A)Ft. &,n re r J okra]
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ftin. in,
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
ORidge ❑Slope Lalley ❑Flat
(check appropriate box)
Latitude/longitude of well location
35/Sa/olPI -08 /ays--A w
(degrees/minutes/ conds)
Latitude/longitude source: W PS❑Topographic map
(check box)
DEPTH DRILLING LOG
Fro Formation
9
7-7
Gels[ yty rei
I-, 73
l
—*In
m
n
oCD
LOCATION SKETCH rnrn
Show direction and distance in miles from at Mg▪ t -yt�
two State Roads or County Roads. Include thedyad 2t7
numbers and common road names. N`�
t7
rn CSL9
J'
faA � 1
ce;
11 �-
16. REMARKS:
Tiv Trw CREEK
Bialys vzcce, /YC
r
;g2, s'l
I DO HEREBY CERTIFYY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS A AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4.
SIGNATURE OF PERSON`CONSTRUCTMG THE WELL DATE
/-2 2 oY
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

3p2873
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�(Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) dire- k ,4 //i tl CERTIFICATION k 325%
WELL CONTRACTOR COMPANY NAME re ry r, sr,n W Q II D r, U,n( (7 PHONE y / � c � )6s'9 '%'i�r/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: aurns- vie County }'aptly
1/styp Crrei
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
Rd.
3. OWNER: Jnhn *- Stantiy ln/hi4ehoure
Address /b Shkatit,ra.. %Z. d3 e .Cd
(Street or Route
.) 4 •kin . C, "X9e
City or Town State Zip Code
(ad 3)- (ecj!-990
Area code- Phone number
4. DATE DRILLED - ar-- oS
5.TOTAL DEPTH: a
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing: /,( 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): „2 S METHOD OF TEST /�- ; y
10. WATER ZONES (depth): /6Q'
11. DISINFECTION: Type /1 1 tel Amount p
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_.0 To 3a Ft. 6 1,-. s i.at tDV<
From 33 To 14d Ft. 6'r /8Y atccl kgryty C/t,� �/
From To Ft. I
13. GROUT: Depth Material �yMethod CI at/S 0'1/e In C • !A
From D To ;0 Ft. `.once..-ia TVarued '=_^�
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.
jTopographic/Land setting
tdge 0Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/loyngitude of well location
S TA a el-o8,��ao/a9w
``degreesi minur€s/seco6ds)
Latitude/longitude source: QS❑Topographic map
(check box)
DRILLING LOG
Formation Description
(VAX
Sqq An d S1-nn-c
(Y
3-3 rA ri- 1-e
DEPTH
From To
0 /5-
`t
0 rn n,'(,-
LOCATION SKETCH rj
513.2, Show direction and distance in miles from at least
two State Roads or County Roads. Include the roe*
numbers and common road names.
m
16. REMARKS:
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 F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, INC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
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WELL CONSTRUCTION RECORD
302S'2
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /'Nr a- k A /4 rl
WELL CONTRACTOR COMPANY NAME y (v f2ft • cnn -W Qll l7 r�l�ir,( �C PHONE# 1L"J'/7(
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: -2)LAC n6VI/IQ.
/If?r()WOO .11 trivc,
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: CA kV td1-.'1,thn/
Address ICI Vt21^Q 'on Avenue
weQ,vervi He nc ag787
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED i- to - 60
5. TOTAL DEPTH: .Soc
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO &V-
7. STATIC WATER LEVEL Below Top of Casing: SO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15.A NCAC 2C .0118.
9. YIELD (gpm): 7 METHOD OF TV" /)
10. WATER ZONES (depth):
I
12. CASING:
(Street or Route No.)
DISINFECTION: Type
Depth
From 0 To 7.3 Ft.
From To Ft.
From To Ft
13. GROUT: Depth
From .0 To ra4O
From To
14. SCREEN: Depth
From To
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
County t%q„-y�
CERTIFICATION # _6
Topographic/Land setting
EiRidge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3s`62A.014 - 04al it /V/w
(degrees/minutes/secon )
Latitude/longitude source: 136SOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O 3O
;3 / 3-- fFrr1./ ta<,t-
4b '37 /a/wnl-_
1 9 CYngn , ICJ
O
n
LOCATION SKETCH CO
Aize// /I Amount p `1,1 S/ ✓ehow direction and distance in miles from at leas
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names. Q.
-SYT a.( Pvc-, _
r4 r.
Diam eter
4
b
Material Method NavdUicad -Dr 1 t1L
FL etinCe,4v red 7��/
Ft. Yc iisvIl1f , C
Diameter Slot Size Material
Ft. in. in.
in.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDA tDS, .AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN IRE OF PERSON CONSTRUCTING THE WELL DATE _ U
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
GW-1 REV. 07/2001
27699-1636 Phone No. [phone], within 30 days.
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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /•Nine k A//i„ CERTIFICATION# 3,21'4
WELL CONTRACTOR COMPANY NAME A"-C - , [mit )xJ QI I D r, (It)-t( ( (; PHONE bJ ) � f` � '�~9�/y
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 ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 4c ns -I/ County C
- Ce/0- 9 on JhtC-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER A L_toad�c,
Address A-1-f6N /A;et g l ( ;,r/IQ
(Street or Route No.)
j'C1 1V ✓.)/e it) C aY7'Y
City or Town State Zip Code
c.&- (p 73-- S4sgl
Area code- Phone number
4. DATE DRILLED a - 9- p43
5. TOTAL DEPTH: t[_S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EQ
7. STATIC WATER LEVEL Below Top of Casing: 34' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15.4 NCAC 2C .0118.
9. YIELD (gpm): .50 METHOD OF TFpST 7 d�
10. WATER ZONES (depth): <9,Q$
11. DISINFECTION: Type
12. CASING:
NON
Depth Diameter
From-�.,H To Ft._. -r
From t7 h To 0 Ft. L '-
From To Ft.
13. GROUT: Depth Material � Method
From .0 To ,2O Ft. /3 cer-/0 -r7UnrRC
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
Wall Thickness
or Weight/Ft. Material
Spat ai ?✓c_
80 QrKtiE
From To Ft.
From To Ft.
16. REMARKS:
fir
l
graphic/Land setting
idge ❑Slope OValley ❑Flat
(check appropriate box)
Latitu e/lon itude of well ocajjjion
3f/'.JJN - OeP.t�/�Sg NI
(degrees/minutes/secondsl"
Latitude/longitude source: Ii3QPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
7/ 2/ �aa ci%' v -
90
Amount p : I I saa.Show direction and distance in miles from at let
two State Roads or County Roads. Include the road
0'
numbers and common road names.
�K „svelter C',
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARD , AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r27 & -
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
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LOCATION SKETCHz.▪ ��
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WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section %%//��JJ nt' /.
•
e rT CERTIFICATION # �r) J/tp
1nJe_II1Dr;Ili.-+s Cr PHONE (a 10;12/ in
_ASSOCIATED WQ PERMIT#
(if applicable)
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1 " rc e
WELL CONTRACTOR COMPANY NAME
z fit, cr',n
STATE WELL CONSTRUCTION PERMIT#
(if applicable) V
1. WELL USE (Check Applicable Box): Residential MunicipaUPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
topographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3.57 +{9(070 • OY.7//a cr[W
if% degreesiminu�te_ge�se�conds)
p fY7 �Ro '�" Latitude/longitude source: ht51'a0Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description aCIAif
4- -' Sh n
v—
V_I_ ---
2. WELL LOCATION:
Nearest Town:
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
County ya nCE7
City or Town State Zip Code
Zg)- (oh5-5ag7
Area code- Phone number
4. DATE DRILLED ^�_ - QiL-
5. TOTAL DEPTH: e'en?
6. DOES WELL REPLACE EXISTING WELL? YES 0 NOF❑
7. STATIC WATER LEVEL Below Top of Casing: '
T.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated aiior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): a20'
�• I
/' ry
O
LOCATION SKETCH
H V /1 Amount p
: J P r t%oz,Show direction and distance in miles from at leas]
1 12.. DISINFECTION: TypeWall Thickness two State Roads or County Roads. include the r�l
CASING: numbers and common road names. 7
Depth Diameter or Weight/Ft. Material
0 To r3 Ft. _ R>t a/ Pro O
From 18Q sleek t
From To-�� Ft. /� -Y Patti/ r t 1 I11 Ck e
From To Ft.
Material Method I [ 1/1
13. GROUT: Depth RNA„,,d Bur ns Vl I e r l
From :a To�O F[. �ivac ��-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: Material
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,.ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THWELL ,r/
OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL �x "T
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center' RREV gh, INC
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ''j jV
WELL CONTRACTOR (INDIVIDUAL) NAME (print) / - lac k ,4 I I P n CERTIFICATION # 3 Rht
WELL CONTRACTOR COMPANY NAME F-ecictc MI W e IJ Ddd i h r,S1 PHONE (gYfP) t fA —9,09
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
302832
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public H*- Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:�
ee r Nest Town: p aaSY i i le
Lorol;nR crrl o th
County L%AT]LCv
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: CAS FS
Address /U 6- 4 al GaA- S".
A.3hw,//(e/V$ eetorRoute C) 0.
Ciry or Town State N Zip Code
(46•3a)- zf7—yanggf
Area code- Phone number
4. DATE DRILLED to - /o? -0 V
5. TOTAL DEPTH: S85
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑
7. STATIC WATER LEVEL Below Top of Casing: /Pc FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS o? FT. Above Land Surface*
*Top of casing terminated at/or below and surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): SO METHOD OF TEST R rG
l0. WATER ZONES (depth): !-,%' (p 7 t a -)0
11. DISINFECTION: Type %7/ % hi Amount a2-
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To S a Ft. (a A SDa a( PVC
From To Ft
From To Ft.
13. GROUT: Depth
From O To Set Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Material
Slot Size
in.
in.
Method
jPsaiaszi
Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STAND DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/pographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/Iopgitude of well locatici
S
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
tA
DEPTH
From To
0 /fl
LOCATION SKETCH tp
Show direction and distance in miles from at least
two State Roads or County Roads. Include the root
numbers and common road names
SIGNATUKE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
t1699.1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
0)
m
0

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource /($1-/Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /1A ft k Hlltri ! CERTIFICATION,4"
�#32
WELL CONTRACTOR COMPANY NAME A-ec os0tS � We llr: Uaf� PHONE flap ) 6c�-n400
STATE WELL CONSTRUCTION PERMIT,* WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public IfY Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Near st Town: 34MC vt74e� Co/un/'ntty t1/X-,,"y.., {[/
a rat:,a /+a? f/Il i e growl
,/
(Street Name, Numbers, Community, Subdivision, Lot No.,Zip Code)
3. OWNER: /kTJt¶
Address toA %!//.Goa a
(Street or Route No.)
ea lie rje
aso a.
City or Town State Zip Code
Sa8)-357- 429 y
Area code- Phone number ,/
4. DATE DRILLED 6 -,-- o
5. TOTAL DEPTH: 765
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO I'
7. STATIC WATER LEVEL Below Top of Casing: /SAD FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS a FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordancg with 15A NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TEST 14.3
10. WATER ZONES (depth): Goa '
11. DISINFECTION: Type /41 T# Amount 7 oz.,
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From D To 0.2 Ft. 4 4 5PRaI ?vc
From To Ft.
From To Ft.
13. GROUT: Depth Material / Mrs
From 0 To 9? Ft. �r,nCrG� i��+�d"
From To Ft. 4r1p e4
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 0Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well locati n
.357Sill/ A tir -Dirie /37
(d greesiminutesiseconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
FromO C!
LOCATION SKETCH
Show direction and distance in miles from at leaffC,
two State Roads or County Roads. Include the ro51,
numbers and common road names. -----
cv
C
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS AND T}iAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF'�ERSON 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
302828
North Carolina - Department of Environment and Natural Resource}�{sy���- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) MA1tk Akcrk CERTIFICATION#ta Sh6
WELL CONTRACTOR COMPANY NAME Terra Wed ; PHONE tlignati Ltet-,51,11
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITn
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 113u1-vj //t County 4411 !J'Y
Windy valley LAW e
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER: Vctd4,t VD ri
Adaress 59 Will4. Valle DR.
lwrn5Yd.I.e. e[ C[eNo) a8ny
fCityorTown)-2t4
State
—QRn
Area code- Phone number /
4. DATE DRILLED G _ O ,T
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EY
7. STATIC WATER LEVEL Below Top of Casing: /5 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface"
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): C7O METHOD OF TEST R1•ci,
10. WATER ZONES (depth): 60 e-'/DO
11. DISINFECTION: Type N i/.."
12. CASING:
Depth
From O To «6 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To ,02,0 Ft.
From To Ft.
14. SCREEN: Depth Diameter
Zip Code
Amount of Or,
Wall Thickness
Diameter or Weight/Ft. aterial
spn.I( YY(�
Val telk Dr hit
Material /
o4G/LZ 7 iu�41i l� V.J II lc
l./YYLSV6r
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size Material
in.
in.
16. REMARKS:
Topographic/Landfiattiing
❑Ridge ❑Slope 2Valley ❑Flat
(check appropriate box)
Latitude/longitude of we}'location
ss / 4, 8
degrees/minutes/ cond
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
0 a
O C.
LOCATION SKETCH p m
Show direction and distance in miles from at lest .O
two State Roads or County Roads. Include thectOad o 0
numbers and common road names. rnr•
S
O zz
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED tN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS A COPY OF THIS HAS BEEN PROVIDED TO THE WELL
�n3— /(r
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
From ( To
16. REMARKS:
303801
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andaaaNN��� Resources -I/�ivist/Q_n of WaterlQuality - Groundwater Section @ �/
WELL CONTRACTOR (INDIVIDUAL) NAME (print)9 C gh D dr Snn 0 R.7� CERTIFICATION #27 p 7
WELL CONTRACTOR COMPANY NAME $ tAa CG Lon r W 1:L( 'J I Pot, ..TNL PRONE # eat 4no no
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential R Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATI<)Di
NCatC�/t Timm: 44L11 Countyy
(Street Name, Numbers, Community, Subdi ' j�;•, Lot No., Tap Code)
3. OWNER:
Address /o
City or Town State
�f%/#'
ZIP Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �/
6. DOES WELL REPLACE EXISTING WELL? YES 0 /1O L7
7. STATIC WATER. LEVEL Below Top of Casing: 50 FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS 1a 2 FT. Above Land Surfaces
'Top of casing terminated atior below land surface requires a
variance in accerdaace with ISA NCAC 2C .0118.
9. YIELD (gpm): b 0 METHOD OF IES / m eel
10. WATER ZONES (depth): V O• 3 r
I I. DISINFECTION: Type Is .R. N • Amount JO 0 2.
12. CASING: Wall Thickness
Depth or Weight/Ft. Material
From 91 To_5 Ft ( 50R2( pvc.
From To Ft
From To Ft.
13. GROUT: Depth Material
From To 7.0 FL c S#1CPC J' C.
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
Fro To Ft in. in.
Fro To Ft. in. in.
15. SAND/G. VEL PACK
C
Topographic/Land setting
❑Ridge p lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreWmimama/secmds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek 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.
CA
rTrt :�
c^�
Depth Size Material \L Ft.
Ft. 4‘-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION SJA$DARDS, AND THAT OJY OF S RECOJt HAS BEEN PROVIDED TO THE WFI.f OWNER
SIGMA
/61-oY
IJCTINO THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment card u•ru(r.a��I Re sources:.
Division of Walt, Quality - Groundwater Section
CONTRACTOR COTRACTOR ONDIVIDUAL) NAME throe)) .✓ t i_s-t CsJAtjt4
CERTIFICATION a a7 I
1'HONCY?J8 54-3581
WELLCONTRACTOR COMPANY NAME REUDEN
CALDWELL DRILLING, INC.
STATE WELL CONSTRUCTION PERM(TI ASSOCIATED WQ PERMrrs
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential dMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Hcal Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIDN:
Nearest Town: vRrM J1 t-t-. County L A e C
\0o C.LtAR C(2CetA forC-t G
(Sumo Name, Numbcn, Community, Subdivision, Ia No., Lp Code)
3. OWNER: 'Z 1, V be R%C►C
Address \oe C, "A(_ Cite etc- bR.t1E
(Sine or Rowe No
tgJ�r�SV%"C t%)� a81 ►4
ity or Town s Zip Code
(%' )- tons -t5i 0
Ara coda Pharr number
4. DATE DRILLED et 7a
5. TOTAL DEPTH: 5 "l
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing: FT.
ph. a i(Abon Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface•
•Top of wlog I.rmlested aU.r betow had entice sequlrea.
vsd.om to .card.atel:b ISA NCAC IC .os is.
9. YIELD (gpm): METHOD OF TEST 24G - At R-
10. WATER ZONES (depth): g b 0 ' - ± (', ere-,
11. DISINFECTION: Type kg u{ Ovro Amount 1 it big. .
12. CASING: Wall Thickness
Depth Di car co�r Wetgit/FI. l� aterial
From 4- To 1 5J Ft. 6l8 7sOd( Yd C
Front To Ft.
From To Ft.
13. GROUT: Dept)), Materiel Method
From To 6910 Ft. (e Pdt �bv(LgD
From To Ft.
14. SCREEN: Depth Diameter Slot Sire Materiel
From To FI. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size htarenal
From To Ft.
From To Ft.
16. REMARKS:
"Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
(deneennlmndeeconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH FRILLING LOQ
From t To a Fo do Description
`
4 — . o o (t-f1 v R-613 A3
`lo' - 3b0' GQ_ArJcriF
3b o ' c.R-#Ntc.t 1GPm
GQ4%Nrr
3bo'- 5w'
en r- cr.
t nn
..t
a
J OCATION SKETCH
Show direction and distance in miles from
two State Roads or County Roads. Includ
numbers and common road names.
ft." $ 6 50010
�0 r-
6./4 stiLua Awl
l$ M
atleast
c
Nt
rniTI
h+a
Tp
cn o
cr
c_Arrfie..
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITII ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND T)1gT PY OF TI IS RECORD IL&S BEEN PROVIDED TO aWEL /QO
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-I636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WEI,I, CONSTRUCTION RECORD
North Carolina - Department of Environment surd ”•rrrt(,aT Rc souse es;
Divi`sion of Water Quality - Groundwater Section'
war. CONTRACTOR (INDIVIDUAL) NAM E.(prt.rt__ •✓ t L e-. Cea AC:. 14 C'}RTIqPICATIONS "`1 y 1 I
WELLCONTRACTOR COMPANY NAMC_RFUDEN CALDWELL DRILLING, INC. 1HONEY?(8 )254-3581
STATE WELL CONSTRUCTION PERMIT, ASSOCIATED WO PERMIT,
(ifapplicable) �� (if applicable)
1. WELL USE (Check Applicable Don): Residential CI MunicipsVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLLOCATIQN:
Nearest Town: b y APIS J t L.LC County
Nee c LtsR CR.Ce-, Ott
(Strati Name, Numbers, Community. Subdivision, lot No. Zip Code)
3. OWNER: lR E, X g-L Db Rt C (�
Address ND t C, A R Cg..e tilt. 4 (�t V E
(Street or Rowe No.)
`��I�rJSvlLli NC. a81I4
a rn
ityToS Zip Code
(% )- (r,-\S —* 5 j 0
L
ti
4. DATE DRILLED q 0% 4—
5. TOTAL DEPTI I: S 1 p /
6. DOES WELL REPLACE EXISTING WELL? YES 0
7. STATIC WATER LEVEL Below Top of Casing: gV
cuts -.- if Above Top or Coins)
8. TOP OF CASING IS 3. FT. Above Land Surface•
•Top of cellos Icrroleased War below Ind se/On re Or es
vnlua Is acnrtia.c. *lib 1SA NCAC 2C .011s.
9. YIELD (gpm): & METIIOD OF TEST R+CI - f f
10. WATER ZONES (depth): 1 (9 0 " a GPM
11. DISINFECTION: Type (iFI4 L(Olio Amount I ( d`I -
12. CASING: Wall Thid.nt..
Area coda- ?bona number
From To °ICS a Ft.
From To Ft.
From To Ft.
13. GROUT: Dep
From Too Ft.
From To Ft.
14. SCREEN: Depth
From To Ft.
From To Ft.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
la It& ¶o2Z'i t. (AMaterial
Material Method
C,O M IA ro T ro o left
Diameter Slot Sat
in. in.
in. in.
16. REMARKS:
Sire Mutual
NO (9
FT.
"Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(data appropciese box)
Latitude/longitude of well location
(desrerahoimue✓secands)
Latitude/longitude source:❑GPS❑Topographic map
(cbtck box)
DRILLING LOQ
PEPTH
Fro{n /— 1 1
1-1 — 1 lots '
L6o4
[GO' — 503'
Fo tionescription
0 NJgpRtsto,e-bee
G 2A rot-f(-
C ft-dt c€. - a G('ttn
C,0-a4r3r tg
S
LOCATION SKETCH
Show direction and distance in miles from
two State Roads or County Roads. lnclud
numbers and common road names.
ast Op
0
�5 Mm
tl/ cC Cessa W C
Ir r 6 Sou -to (1-L1
sJILLe. NW
t % M
I DO HEREBY CERTIFY T1LAT THIS WELL WAS CON;1 RUCIED IN ACCORDANCE Wmi 1 SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, TIiAT A COM' )1 17RECORD ItAS DE EN PROVIDED 700 TIRE WEL9 0
r
SIGNATURE OF PLKCSUN CONSTRUCi1 NG 111E WELL /DATE
Submit Ilse original to the Division of Water Quality, Groundwater Sec lion, 1636 Mall Service Center- Ralelgh, NC
27699-1636 Phone No. (919)/33.3221, within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD h 3 i 5 2
North Carolina - Department of Environment and Neural ResourcesC- Division of Water Quality - Groundwater Section t
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Y� �.)V �� tercr117CAT10NA•�l J V
WELL CONTRACTOR COMPANY NAME 10 kAA e C l,lt e LL-- b (. LC !U ni PNONE a
STATE WELL. CONSTRUCTION PERMITY ASSOCIATED WQ PERATe
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I',7%Mlmicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use 0
0 0
r
2. WELL LOCATI9N: / v Topogtaph d setting 77 m
Nearest Town: 1. ww��7't-�x-t' . County k ` 43- 1 ❑Ridge alley Orbit e m
t (cheat appropriate box) N p„
(Strew Name, mbers, Community, Subdivision, Lot No. ET Code) Latitude/longitude of well locati6t? yr'
o
1 C� F u wvue r , 7 7 ficsied 444-
3. OWNER: it wt C
re m�
n
Address j ? of S 4 eC £ nt k )2.d Latitude/longitude source:❑GPS❑Topogi�hicAa
(Streew t or Roe Nu) (cheek box) c�
A ; c lr-,—( NC- Z€(t) 2 DEPTH DRILLIN LO€
Sit), or Town State Zip Code From To Formation DescriptiZn
Area code- Phooe number �'
4. DATE DRILLED 7 - 2. - C'-(
5. TOTAL DEPTH: it 9 C
6. DOES WELL REPLACE EXISTING WELL? YES LYNO ❑
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use"t"if Above TopofCuing)
8. TOP OF CASING IS i FT. Above Land Surface'
`Top of easing tmmiaatd .U*, below land sortie. req.kee a
ndaam m accordance was ISA NCAC 2C All&
9. YIELD (gem): (» METHOD OF TEST (9! k -
10. WATER ZONES (depth): ( 6) 7, rag 6 7 r?J'
11. DISINFECTION: Type D I D j21 �j i. Amount �) D
12. CASING: Wall Thiclm�
Depth Di�j,`,r or weight/Ft. From To _ Ft. f ►'/
From 4zrFt.nV „
,- .
From
13. GROUT:
To
Depth
From To
From a To_2/
14. SCREEN: Depth
From To
From To
15. SAND/GRAVELPACK:
Depth
Ft.
FL
Material Method
p - /0
- /P r0
U ' 7�
7$ = 225—
FL l VP/ _M
Diameter Slot Size Mat al
FL in. in.
Ft. in. in.
Size Material
From To Ft.
From To Ft.
16. REMARKS:
Fi%2P A; c'-
ne.-P feet 14,
i%a r 6444 ,41 e1$Z�
fi
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common ro names.
�I P K
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,
CONSTRUC'gON STANpA[tDS, AUQ T}IATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WFu 0
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center fl, C
27699-1636 Phone No. [phone], within 30 days. GW-I REV: 07/2001
cdoe

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
030510
283025
WELL CONTRACTOR. Dewey Wright Well Pump Co.. Inc
WELL CONTRACTOR CERTIFICATION #- 2687
STATE WELL CONSTRUCTION PERMIT#• Steve Reece
1. WELL USE (Check Applicable Box): Residential
Recovery Heat Pump Water Injection
Municipal 0 Industrial
Other If Other, List Use.
2. WELL LOCATION: (Show sketch of the location below)
Nearest (Town: B}I�IRRNS""r+IuLI Ej ��� y pF County' veANCEiray
ihodd I ammee an Um6ersl.t6�nrhuu ity, ub ivit an�anldY.tt No.)
3. OWNER DAVID GILI ESPW
Address P n BnX 7RR
(Street of Route No.)
MlrAvii P Nr
City or Town State
4. DATE DRILLED 1n/2012MR
5. TOTAL DEPTH 500
6. CUTTINGS COLLECTED YES NO
7. DOES WELL REPLACE EXISTING WELL? YES 1=1 NO
8. STATIC WATER LEVEL Below Top of Casing: do FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm)• 6 5 METHOD OF TEST Air
11. WATER ZONES (depth): 1.00 aom41-44 5 Onnnm 9f1-i3/4
n 5n nnm430-43R 0 Onaom
12. CHLORINATION: Type HTH Amount 93
997 p o5�
de
AgricultRECE dgtB1)ing
►`1.C.Do;t.GPEHl to
DRILLING LOG
From To
fl in
MAY 2 0 2004
c rr1
DEPTH
Formation Description
IIIRT
1n R+-i GRANITP
RF RR SAW -STOMP
13. CASING:
I xl
Wall Thickness
Depth Diameter or Weight/Ft. Material
From n To 21 Ft H 1/d 1RR GAI V
From To Ft
From To Ft
14. GROUT:
4R 41 GRANITE
d1 dd FANnSTON
44 PIO GRANITE
90 94 RR) SHAI F
94 d4n GRANITE
din dRR nl1ART7
411 +-in0 GRANITE
If additional space is needed use back
-z
pro
m
Depth Material Method
From 0 To 20 Ft Clamant Gravity Flow
From To Ft CEMENT GRAVITY FI OW
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
LOCATION SKETCH
l
(Show direction and distance from at least two State )lye
i
Roads, or other map reference points)
ri ;Le
Ul
Cl1
rn c,
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
Quad No'
;¢ K II-67-v3
Serial No
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

296339
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NSA Resotsces - Division of Water Quality - Groimdw®tr Section
WELL CONTRACTOR (INDMDUMJNAME (pr`t) [j-ftk y �oSj��G� II '' cswnPtcwnotva �
WELL CONTRACTOR COMPANY NAME -roc �it Lot° OaY e L(_a t-' PHONE a f ) 72,yt258
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WO Ptand
(if applicable)
rhfapali�le>,
1. WELL USE (Check Applicable Box): Residential O--hMmuapaVPublic O Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pwup Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:•
Nearest Town: �`/w�u�- County
3=d pew dit-ty l-a-1-,'2---
(Seam Name Nembees, Caohwoity, Subdivision, L:3,INo, Zip Coe)
3. OWNER: (.44,vt.C` e W
Address 3 e i .J
or IT No.)t �,�'
a Q`7(`(
Cry or Taw° ate Zia
(—} Co?5Sp
Area code- Moe number
4. DATE DRILLED c- 7 - U
TopographirA.andg
❑Ridge °Slope Walley , ❑Flat
(check appropdn: box)
Latitude/longitude of well location
Latitude/longitude source:❑GPSOTapographic map
reedrbox)
DEPTH
From To
5. TOTAL DEPTH: 7 e f- / {— 7---t us-
6. DOES WELL REPLACE DUSTING WELL? YES O NO
7_ STATIC WATER LEVEL Below Top of Casing /0CJ Ft.
(Uss"F' if Above Top of Gnat
8. TOP OF CASING IS t' FT. Above Laid Surface"
`Tap attain geared arNM Slew load saris rowan a
Mom he atmrdtaQ'�wab 1SA NCAC IC MIR
7
9. YIELD (gpm): i METHOD OF TEST/Hy--hi( -4
W. WATER ZONES (depth): Y7 cip,s, it 70
11. DISINFECTION: Type 2a-e !Amount g 0 Z,
12. CASING:
Depth Disuse;
From To Ft__
From 0 Tot 2
From % 2 To l S/ Ft.
13. GROUT: Depth
From To Ft
Wall Thn9mess
or WeighVFt Maeda!
Method
Fmttt_oL To Z el FL pt&4. aM 2 /
14. SCREEN: Depth Dimmer Ste Size Material
From To Fi._lin. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Sae
To Ft.
From To Ft.
From
Material
DRILLING LOO
Formation Description
6- rz-etr
v
Z n_
fV —
LOCATION SKETCH s
Show direction and distance m miles Nib r at inn
two State Roads or County Roads. Include t g oad
naRrbGa and amtmma road names. --1 pi urZ-
geta
Il Ux, 1,..1061 1r�1
Dom; n "tom-,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS
CONSTRUCTION STANDARDS, A
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
�Jl AT A COPY f(�= THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IGNATURECONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mali Service Center- Raleigp, NC
27699-1636 twat No. (919) 7333221, within 30 days. GW-1 REV. 07/2001

296082
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM (print) D tiyN^ i e 8/�/nn L.CERTIFICATION #,4 9 77
WELL CONTRACTOR COMPANY NAME -4-tt� f-*1 ticu jcl " K .r PHONE # V t) L N9 z'41K2)
STATE WELL CONSTRUCTION PERMIT# A/4 ASSOCIATED WQ PERMIT# /09
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential DI Mtmicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIQN: %��/gy�p
Nearest Town: 2i4-t Lt2C f.' County
(Street Name, Ambers,
Community. Subdivision, Lot No., Zip Code)
3. OWNER:
Address f
c
( A No.)
Bate ,/�C. oz F 7/y
City or Town State
Zip Code
Area code- Phone umber
4. DATE DRILLED 3V9/b y
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELD YES ❑ NO 18
7. STATIC WATER LEVEL Below Top of Casing: FI.
_ (Use "+" if Above Top of Casing)
8. TOP OF CASING IS / . 4i FT. Above Land Surfaces
'Top of caring terminated at/or below land surface requires a
variance in aecordenc with ISA NCAC SC .0118.
9. YIELD (gpm); _ METHOD OF TESTT�Imi
10. WATER ZONES (depth): 1'9%
11. DISINFECTION: Typed./7, /-1. Amount
12. CASING: Wall Thickness
Depth Diameter or Wei t/Ft
From 0 To -Cif) Ft. ,#.
From To Ft
From To Ft.
13. GROUT: Depth
From �J Too:� � Ft. l�2'le��
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Fro TO Ft. in. in.
From_ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From_o Ft.
T
Fro To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge AIS1ope ❑Valley ❑Flat
(check appropriate box)
Latitudellongimde of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Deseription
r
LOCATION SKETCH
Show direction and distance in miles from at Mast
two State Roads or County Roads. Inclur'the road
numbers and common road names
LAyAg
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL IEI) IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, At)D1HAT A COPY OF THIS RE C D HAS BEEN PROVIDED TO TETEWE{ L OWNER
riDATE
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
From JO To .2 /e
From T
From To
13. GROUT: Depth
From_ a_ To •-2fl Ft.
From To Ft
14. SCREEN: Depth
Fro To
Fro To
15. SAND/GRAVEL PACK
Depth
From�To
From / To
WELL CONSTRUCTION RECORD
North Carolina - Department of Enviromnent and Na Resources - Division of Water Quality - Groundwater Section 7
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Na
/i(l / c gp y_ L CERTIFICATIIOON tt Res/ 7
WELL CONTRACTOR COMPANY NAME Y rt, Lt,r:J�s a 1 A�_J Oi • -62.. of PHONE` /M MA k 4 •D t%�
STATE WELL CONSTRUCTION PERMITS( gOCLkflD WQ_P_ERMITS Ay/i7
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential la Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIIQN
NeareATown: tire¢ t� County
n�' Lf1yi�
(Street Name, Numben, Community, Subdivision, Lot No., Zip Code)
3. OWNER:'1 Yl
Address 4 n fi. i / 2 �d
(S or (tome No.)
KaLtte.i4 t2 t AV C. „2� 7/V
CityorTown Stun Zip Code
(k2X)- /cRc2 - 9t &7
Area code- Phone comber /� j
4. DATE DRILLED / f
5. TOTAL DEPTH: .7
6. DOES WELL REPLACE STING WELL? YES 0 NO T8)
7. STATIC WATER LEVEL Below Top of Casing: 7 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS �.J FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance ha accordance with 15A NCAC 2C .011a.
9. YIELD (gpm): /�j M�T$OD OF TEST72n
10. WATER ZONES (depth): / fc C
296079
Topographic/Land setting
❑Ridge taS1ope ❑Valley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map..
(check box)
DRILLING-LO _ -
DEPTH
From To Formation Descrj tjan
N 0
LOCATION SKETCR
11. DISINFECTION: Type /', , //, /-/ Amount / /), j 07— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Ft Diameter 7tar W ght/Ft num • ers and common road 1 •• s.
Z.
o Ft.
Ft.
('vim-n14VI
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
16. REMARKS: f LJae 4/one 'c/' /3 „.Li� 442
0
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU(.1 hD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ n �� /7�/VA y
SIGNATURE OF PERSON CONSTRU 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

294 ;'99
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natual Resources - Division of Water Quality - Groundwater Section
7
WELL CONCONTRACTOR(DIDMDUAIJi't"
NAME
(PrYt) �e`f J �%i,1-:CERTIFICATION 4-2 /Si7
WELL CONTRACTOR COMPANY NAME 3ost-c., W PCC Cr e! ;vtKi PHONE a f F-'—t-a9
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PPERMITS
(if applicable) Binh/able)
I. WELL USE (Check Applicabk Box): Residential IV-MmicipallPublic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Puny Water Injection 0 Oder 0 If Other, List Use
2 WELL LOCATIO :
Nearest Town: dictSU.CCe Countyf//»'cc7
ear S%T/f114 SCisia. l del
/
(Street Name. Numbers, Caammit% Sabdivisim lot Nee., Zip Cade)
3. OWNER: Z(S 1 s �t e✓�
Address &/5 5/hTJ-1cr " .iA-1 ..0 PCj
(Sant or Rome Nat
191If iQf) (Le /U C f 7.5 S
City otTown State Code
(1;'2d). % L NOw
Am cede- Thom =her
4. DATE DRILLED 3/%7.
5. TOTAL DEPTH- rl 25
6. DOES WELL REPLACE EXISTING WELL? YES 0 No re
7. STATIC WATER. LEVEL Below Top of Caaarg.
Mel, if Abowe Tap of Cosine
8. TOP OF CASING IS / FT. Above Lad Surface'
*Tem d are l af.d Mee Mom load swim requiter a
mien In acmrAaam Ida ISA NCAC 2C SIR
9. YIELD (gpm): 4" METHOD OF TEST A / /C
lb. WATER ZONES (depth):
I1. DISINFECTION: Type !'cA'Z' Nc Amin 1-?020,2'
12. CASING: . Wall Thidmess
Depth Diameter or Wd$dIFL Maeda!
From To Ft
From_ To RS FL 6441 90 "be
Froiq, f _To 9 7 Ft. 4 fits / it? S'4 J
13. GROUT: Depth Material Method ,S;o2alG
From To Ft Frotn_e To 7!: Ft ,pa! /» Ave
14. SCREEN: Dept Dieter Slot Size Material
From To Ft in. in.
From To Ft in. in
yTopognphictfand setting
®Ridge ❑Slope °Valey;:OFIat
(cheek appap'um box)
Latitdellongitude of well location
(d aimedsemndt)
Latitude/longitude source:OGPSOTcpographic map
(check box)
DEPTH Rtl 11MIJ.)Q
From To Formation Description
450 Ai/Z.)�
6 - {/D Aix *-E/�J<z
Cfr/2r0 W,h�
O 0
t c s -.
n
c G
LOCATION SKETCH am c
Show direction and distance in miles from at t
(wwo State Roads orCounty Roads. Include thead 27
rarrlbera and carman woad mama.
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Size Material
Ft.
FL
60
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STAND(QRDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
TUREOF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Sectien,1636 Marl Service Center - R >NC !
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 00000
GI3N L OFFICE

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAM (print
WELL CONTRACTOR COMPANY NAM
STATE WELL CONSTRUCTION PERMTTO
(if applicable)
301822
Resources - Division of Water Quality - Groundwater Section
n L— CERTIFICATION ft07 77
E ..wYA� 11ys44-4� PHONE a Sid
ASSOCIATEDVWQ PERMIT. _WA'
(if applicable)
1. WELL USE (Check Applicable Box): Residential till 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:
NearesLTown.
(Street Name, Numbers, Community. Subdivision, let No., Zip Code)
3. OWNER:
Address COX��''l,JQ
(ri2[� /iLEeC OQd
C. tr2 //7
City or Town State Zip Code
Area code- Phone number
(-)-
4. DATE f/�Jp'7
5. TOTAL DEPTH: e2 SP '
6. DOES WELL REPLACE EXISTING WELL? YES ly0 ,®
7. STATIC WATER LEVEL Below Top of Casing: 7FT
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 2..'S FT. Above Land Surfaces
'Top of casing termisated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): S METHOD OF TEST 7 nc.D
10. WATER ZONES (depth): TS'
LOCATION SKEfCIj
11. DISINFECTION: Type (3. ff. N. Amount -� /D CZ— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
From D DJ #t'2-I Ft numbers and common road names.
From /
From
Topographic/Land setting
❑Ridge SSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreestmimdea/seeonds)
Latitude/longitude source:❑GPS❑Topogiapli;..-map-
(check box)
DEPTH DRILLING LOG
From To Formation Description
S Rome No.)
To D
To
To
13. GROUT: Depth
t7 From 0 To
From To
14. SCREEN: Depth
From Cr
From To
15. SAND/GRAVEL PACK:
Depth
From o
From TTo
Ft
Ft.
Ft.
Ft.
L
Ft.
Diameter Slot Size Material
Ft. in in.
Ft in. in.
Size Material
Ft.
Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC 1 tD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD-...ii THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ o7DATE
SIGNA 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

County
27699-1636 Phone No. [phone], Within 30 days.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalttResources - Division of Water Quality - Groundwater Section
/'l
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ark An,"
WELL CONTRACTOR COMPANY NAME 6 JPi1'I �1 r tl li itC
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT##
(if applicable) (if applicable)
302909
CERTIFICATION .3a1
PHONE@ )tan- 515IO'
1. WELL USE (Check Applicable Box): Residential VMunicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: r:t.vrn s V; t Lc
y4nctCe(a
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: / /OW/ 0 i't -�-4
Address )9(t)Swee+ (f ev Lane
'/ ns Vl I I{ (Street or Rout• No.) ;g 714
City or Town State
Z$)- 6,76 - Qy fog
Zip Code
Area code- Phone number //
4. DATE DRILLED / a 0 - O Y
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: '/o FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated atfor below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): it METHOD OF TEST /Zr,
10. WATER ZONES (depth): e2 I
11. DISINFECTION: Type
12. CASING:
Depth
0 To 8O
To
To
13. GROUT: Depth
From D To of J
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
hit /-r Amount 3 a o z-
Wall Thickness
Diameter or Weight/Ft. Material
From Ft. 6 y' iota( P✓G
From Ft.
From Ft.
Material
Ft. Carl a rp/e
Ft.
Method
O re,d
Diameter Slot Size Material
Ft. in. in.
Ftin. in.
Size Material
Ft.
Ft.
Topographic/Land setting
°Rale ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
"i,S /(dd/2)N1 • (Ma ' ArSyk iJ✓
(degrees/minutes/s onds
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
Cn
rn
Ca23<
-or"
0
LOCATION SKETCH 03 to o
Show direction and distance in miles from at 4st t
two State Roads or County Roads. Include thaad --4z
numbers and common road names.
CO 0O
Ce►o
130-nsvi If P,NC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL _
CONSTRUCTION STANDARDS ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU OF PERSON CONSTRUCTING THE WELL
DATE
0
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
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) /Jcar k '414M
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
CERTIFICATION # c3o& VC
I.� e%/ h . t if;gj CO PHONE tel
I. WELL USE (Check Applicable Box): Residential [t' Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: $ornst.;/lc- County L/AncEf/
,Se4.:1-. �8e
(Street Name, Numbers, Community, Subdivision,
Lot No., Zip Code)
3. OWNER: Ca/ Mwr p4 ,
Address
C11icaviIIe(Stree[ArrRCa[eNo.) 08755
City or Town State Zip Code
c6l5— 57y3
Area code- Phone number
4. DATE DRILLED / 0 lC
5. TOTAL DEPTH: 3nO
6. DOES WELL REPLACE EXISTING WELL? YES 4❑ NO m
1/
7. STATIC WATER LEVEL Below Top of Casing: 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 ni.th I5A NCAC 2C .0118.
9. YIELD (gpm): Y METHOD OF TEST R. 4
10. WATER ZONES (depth): /06
11. DISINFECTION: Type N41i
12. CASING:
Depth Diameter
From 0 To 8 Ft. 4 3
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To AO Ft. Cone role,
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.
Amount 7.1(3
Wall Thickness
or Weight/Ft. Material
SaF a/ Pvc
Method
$ore.d
Slot Size Material
in.
in.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope E0Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3t<ter, oi • 01771r�.Av
(degrees/minu s/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 .20 C/Ay
j/ b/ 8gn1 s9a to c
4A L P Graa/4
Q
'tan irk
0
ta—_,
crr
nrn
v� rnrn
LOCATION SKETCH "'I
Show direction and distance in miles from at l6st
two State Roads or County Roads. Include the road
numbers and common road names.
O
IV
O -
Soo-111 The
13vrnsvllle,NC
1 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
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
73G
-gym
0o
o0
rn
n'
m
r
-iA
CA 0
OQ
cm-y_

STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMIT,/
(if applicable)
(if applicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources,/�- Division of Water Quality - Groundwater Section
fry�a
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Aloe k n
4sdn Wo(( 1Dr „)I.�
r CERTIFICATION ��
WELL CONTRACTOR COMPANY NAME itr
9 f CO PHONE (tl ) [ y$ v(rnp
302900
1. WELL USE (Check Applicable Box): Residential Er.' Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: $erns villa, County Ynncey
fryix tC,,v/fr
(Street Name, Numbers, Community, Subdivision//, Lot No., Zip Code)
3. OWNER:ta g, fr eacik,
Address 117
(Street or Route No.)
Piurn6wile NC
City or Town State Zip Code
In- (On—L132.9
4. DATE DRILLED A" --/%'-UV
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /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 ISA NCAC 2C .0118.
9. YIELD(gpm): /00 METHOD OF TEST
10. WATER ZONES (depth): /S6
Area code- Phone number
Depth
From 0 To 10 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From C, To .QQ Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
11. DISINFECTION: Type ,/%r/ Amount
12. CASING: Wall Thickness
Direter or Weight/Ft. Material
tfit/ VP S7�d/
of a z"
Material // ethod
Oancr./e
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ST-tat"
(check appropriate box)
Latitude/longitude of well location
33/6o// ctw - °LI!
( egrees/minutes/ eccnds)
Latitude/longitude source: BPS❑Topographic map
(check box)
DRILLING LOG
Formation Desc,iption
DEPTH
From To
'I
.1 3dU
gran i
grain
LOCATION SKETCH
Show direction and distance in miles from at lest
two State Roads or County Roads. Include thead
numbers and common road names. O
fV
0
€hsacdLo,
13urn6 vi U e, NC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDR THATPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER_ -- -
0.7
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-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)
r (qt �C 4l411 CERTIFICATION 3�,Y(...
WELL CONTRACTOR COMPANY NAME , _ r, u st -a 1.1./ e, / A .. //, Iv PHONE @/a 4 r)'-- Q/Yy
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
302891
1. WELL 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
2. WELL LOCATION: Crearest Town: R..sr o sv, 11 c County / E9/7C..0 y
ids ?ci.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ucr
Address 33O• /�(SbJQ TS(
vyun . or Route No.)
Grew l
City or Town State
$22-(1115- 4( cs
"DX-►yo
Zip Code
Area code- Phone number
4. DATE DRILLED ,W`1- Y-OS/
5. TOTAL DEPTH: Vd S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO l —
7. STATIC WATER LEVEL Below Top of Casing: Vn7 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): J METHOD OF TEST /z r S
10. WATER ZONES (depth): 300 5/a0
11. DISINFECTION: Type
12. CASING:
Depth
From !, To 6i Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To .70 Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
/'l) H Amount
Wall Thickness
Diameter or Weight/Ft. Material
/ '-z= 5-Pk -2( i�✓e
Topographic/Land setting
D4Ldge ❑Slope OValley ❑FIat
(check appropriate box)
Latitude/longitude of well location
JJ/v/off -o2 //./ 4 c✓
Idegrees/minute seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From
0
a�
51,
To
a6
Ennd
LOCATION SKETCH S
Show direction and distance in miles from at lead
two State Roads or County Roads. Include the road.
numbers and common road names. r0
Material Method .F) U(�c i� Q^d
Burnsut:lle, RC
Slot Size
in.
in.
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 STAND RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�` �� / — 2-°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