Ya 2 CY2004

305804
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Matt.ral Rerources ivii - sion of Water Quality - Groundwater Section
ELL N WCONTRACTOR (INDIVIDUAL) NAME (prim) 6 l LLte fJASt1 CERTIPICATION/ alit
-r 11
WELLCONTRACCOR COMPANY NAMERF.UIIEN CALDWELL DRILLING. INC• PHONE[phone]
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 19' MunicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use a*
2. WELL LOCATIQJ4:
Nearest Town: 15010,5Q1 LLB, Count Ar)CE
oc CLtA&I` U tR o2l✓
(Street Name, Number, Cwmmuniry, Subdivision, lot No., Zip Code)
3. OWNER: CLe.A (L CILeug -1 sc{-I
Address 1 0 o GItA 2 Qi.t c K OR(VE
nn (Street Routs No.)
1 J :? A r1S J I LI_ g (J C,_ 34111i-
Ity or Town State Zip Code
(`64 )- 1315 - 451.0
Ain cods Phone Dumber
4. DATE DRILLED 11,/ q / 0 4-
5. TOTAL DEPTH:_ tic
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Et
7. STATIC WATER LEVEL Below Top of Casing: FT.
ANu"+- if Above Top of Cuing)
B. TOP OF CASING IS FT. Above Land Surface'
'Top of cuing tertnlaated Wor below had serrate req ul:u a
variance to accerdaattg Itb ISA NCAC IC.0111.
9. YIELD (gpm): a /a. METHOD OF TEST
I0. WATER ZONES (depth): Vb CI - - t. ,a (7 Pr.
11. DISINFECTION: Type
12. CASING:
+ Depth.,
From .1 To
From To
From To
13. GROUT/ Depth
From To_b
Q-A -AIR-
I -R q brh Amount i j b
Wall Thickness
Diameter or Weight/Ft. Material
Ft. if SORa( i'VC
Ft.
Ft.
Material A Method
Ft. CbMetat VvvRe
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.
Slot Size Material
in.
in.
16. REMARKS:
_ /Topographic/Land setting
l2lUdge ❑Slope ❑Valley ❑FIat:
(duck appropriate boa)
Latitude/longitude of well location.
(depeaM.imster/,ecoada)
Latitude/longitude source:❑GPS❑Topographic map
(cluck box)
DRILLING LO1t
Forljution Description
t bf-4 ✓2o toa
N)
PP.PTfi
From / To
— as
as - 3be'
3bc'
,o'•_ Sr,R'
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.
so SaYffri
11 vv." \
4w1
1 DO HEREBY CERTIFYTIIAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WTDI 13A NCAC 2C. WELL.
CONSTRUCTION STANDARDS, AND T11 A COPY OF TI S RECORD HAS BEEN PROVIDED TO HE 1 L WNER
tI 1a o
SIGNATURE OF PERSON COSTRUCTING THE WELL DA
6Pr t
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD • 3 0 6 8 9 4
North Carotin - Dep aoment of Environment and Nasal Restates - Division of Walx polity -Grouadwrx Section
inn L oo rrwACTaa(swtvwtrrwynsrs opis n �� A; 'S J i c a Qo,crur • ts�
WEt1. CONTRACTOR COMPANY NA ( 1 u&&1-;t C t,..It a yr- ari recess ' 724 -4S fe
stern Wnu aota:rntn:tao►t vaaaarca -f--i UM Pl anent
(ifaEMiable) Gfapnlierbb)
1. WELL USE fleck Applicable Book Reaidslid SZManicipaUFalic O hedonist 0 Agricultural D
Monitoring 0 Recovery 0 &at Paw Waterbjectiot 0 Other 0 Ventre List Use
2. WELL LOCATION: NearestToaa: Mat4i
u'.LLe County 13-).4L"t
Sret{ia*A- 1R1
Mai Ms. taaioti Graft ithavieiae.LeNa.MCadai
3. OWNER: jie?CS} LI_ teke r.SS
Address 104S ifjF.r✓gya:d".etji Dz
Sot co Rode No.) ACZA(q
r�LZa 1A) .7` 91/e(
&cis."egosd Sena $*Cade
Y La15- 1LP
ameed► atea.,e...
4. DATE DRILLED it-3i- 011
5. TOTAL DEPTH: 9cc
6. DOES WEIL REPLACE EXISTING WELL? YE$ 0 ND 6'
7. STATIC WATERIZVEI. B*wTcg afCaeittg;
No"r"ifAdeaTapd Ombe
S. TOP OF CASING IS / FT AboveiadSurface*
*Tap train aer- - -.rgra.1.abedeedY..wae1..a
vagina In amnion.. wis ISA NCAC2C.ttla
9. YIELD (wm) r memo (i ✓l,
1O.WATER ZONES (dap)* i9tat 61/ ,200
1I. DISINFECTION: Type 6 Lon; ,to E Amon % to 23 Y.
12. CASNC . WailMidaas
one Pear arwlatltft, Mold
Fin..._IL
To 7/ t� _
F� %1 To��' M4 c+
Peen"tr To N 7 Et lay l
13. GROUT: Depth Material
From To Ft
Rent 0 SCREEN: To & 3 FL t/ #'1p ptimpid
14. SCR
FCRr Tom Oia ler Slat She Material
F>_JU. ia.
Pram To Ft is in.
15. SAND/GRAVEL PACK:
Depth Ste MMer(al
Frook____To Ft
From To R
16. REMARKS:
Method
Topograpitidtand selling
>
Mak synopsis lox)
lafmadellangialde of nil location
e+eanda+ertecoaso
LNiNddeogitdesoarcel]( SUTepogeaphicmap
1. (dactDRU11110 LOCI
Fro® To FormYian Description
rj'or i7i=rPw :
N)
LOCAITON SKET CF) co
Stow ti etiootaddepotsitariasRomat
two Stale RoodserCanty twat bAGds dyad
aaatal.ga ad common toed norms.
eYl°
9111-6.04
ric
I DO HEREBY CERIIFYTHATTROWEL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC2C, WELL
COus1RucTntSTANDARIQ 'THAT ACOPY OFTEN RECORD OAS BEEN PROVIDED TO THE WELL OWNER
t ,
� SIGMA O�'�OIiA0t67RUCTR101iR:WEL1. DATE
Submit thearigiaaItotht Rivkin ofWake Quaky, GronadwatorSeethe, MGMMaitSarioeCater -Raelnk,NC
2709.1iiiPon No. Inn Mani. wkbhe30dnys. GW-IREY."mow

307693
North Carolina Department of Environment S. Natural Resources
Division of Water Quality - Groundwater Section
1536 Mail Service Center
Raleigh, NC 27699-1636 Phone: [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR: j
CONSTRUCTION
DRILLER CERTIFICATION NUMBER:
��% L SPATE WELL
�- PERM IT NUMBER:
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
La Long. RO. •
Minor Basin
Basin Code
Header Ent GW. I Ent.
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: iety 31.r//e- County: F4
'
.5'O /// fino,�, e 6ut„so;)le
{j
(Road, Community, Pr Subdivision and Lot No.)
2. OWNER r"-Oh aR o5 h e
ADDRESS
(Street or Route No.)
Cite or Town Si c Zip Code
3. DATE DRILLED,If -`J 2 SE OF WELL I h /i
4. TOTAL DEPTH 9 T c
5. CCTTINGS COLLECTED YES 0 NO
6. DOES WELL REPLACE EXISTING WELL" YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casino: / era FT.
(Use + if Above Top of Casing)
8. TOP OF CASING IS'f' 1- FT. Above Land Surface*
`Casing Terminated atior below land surface is illegal unless a variance is issued
in accordance with I5A NCAC 2C .01I8 9. YIELD (gpm): 4 METHOD OF TEST R f Y
10. WATER ZONES (depth): / WG
II. CHLORINATION: Type {i
12. CASING: Amount
Wall Thickness
Depth",
From 1— f To 4e/ 0/ Ft.
From (,C To Ft
From To Ft.
13. GROUT:
!DC , i pe�(r Or i�'c a .t/Ft. `IH t e
De th Materi� ' j�
From fN To � � FL ��''1 ��•"f"f Mo� � f �"
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in
From To Ft in. in
From To Ft. in. in
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
�OFFF1THIS
S RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i!`IVATrtD�f I /) on!`/r10 1n wm
DEPTH
From To
es
.-1 nr-
DRILLING LOG
Formation Description
Cr%f�(�,`/'j;
C gciit.
CO
a
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least twq,Sinai/
Roads, or other map reference points) 1((

307669
North Carolina Department of Environment & Natural Resources
Division of Water Quality - Groundwater Section
1636 Mail Service Center
Raleigh, NC 27699-1636 Phone: [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR:
e//A t ll/` sTC
STATE WELL
CONSTRUCTION f ( /�
DRILLER CERTIFICATION NUMBER: 1.Y7-�) 6 PERMIT NUMBER:
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Las Long. RO.
Minor Basin
Basin Code
Header Ent. GW.I Ent.
1. WELL LOCATION: (Show sketch of the location betf w)
Nearest Town: �t � 4 - -//.e County: vet. A't L e
VAP®tcr /4, ..4 !.- €A )i
(Road, LCommunity, or Subdivision and Lot No.)
2. OWNER ,4" 4 't r° .
ADDRESS
(Street or Route No.)
City or Town $j� ie Zip Code
3. DATE DRILLED( 'SE OF WELL ED
a. TOTAL DEPTH ;7 5
5. CUTTINGS COLLECTED YES El NO Q'
6. DOES WELL REPLACE EXISTING WELL? YES O NO O-
7. STATIC WATER LEVEL Below Top of Casing:4 7 ET.
(Use "+- if Above Top of Casing)
8. TOP OF CASING ISf / FT. Above Land Surface'
'Casing Terminated atior below land surface is illegal unless a variance is issued
in accordance with 15A NCAC 2C_0118
9. YIELD (gpm): 1 67 METHOD OF TEST IS r
ID. WATER ZONES (depth): 2 47c&
11. CASING: �z. CHLORINATION: Type
1_Amount '%t? If additional space is needed use back of form
Wall Thickness
DEPTH
From To
DRILLING LOG
Formation Description
U
r-1
CO
CO
O
Ll1
/I Depth '
From T/ To (1'FL
From To Ft
From To Ft.
ter Or W ItUFLcM,ateria,/
13. GROUT:
Depth., � Materia Method '
From G/ To -7 / Ft. L dT( / )(-
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in in
From To Ft. in. in
From To Ft. in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
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 RAS BEEN PROVIDED TO THE WELL OWNER
r) hr/El p 1-4// ./ry c'
T f
•T
.J
CTC,A TrTO At r`nhrrn A rTAt1 Ao •r•cwm

VYELL CONS•TRUCiiON di .Cor,.D
Plain c1rJkl.i4 p;: rn,cn6 or Env ironmcn, and- rut Resources- IDivision of\\aror uali
Q ry -
:I II" °9 j� • 1�
QCOundva Rr SGChon112.c\1'L+rust `/YG S CGI:TTFILaT1oN A_ L1N oni VANY L. 4Vice rctGCSOn S hie// DP//fVN Cf:, . a2J1 NHON,: mass a57- sty elm.
rcofvsravc.rtorl brad rtTB
.ppow4 a-neLi•,r
fir r.orGr..bldi
LJ E L 1 I:=.pp1'0abls Box): Rcldmu(sl lee _Ndwili‘ipliliPLiblic ❑ AyrieWNrAI
1.3111L01111g ❑ I os cry ❑ Has: PumpVWater lnjccrioc1 0 Other ❑ h'Orier, Lis:Lisa
County tier
"-ne./e ecWei
Comm tinny, Subs:vision, La PW., Zip Coac)
O
Low,
_aacr or doers Na)
JG Zip Cau.
SA,*
L523 _ Ga.e
c Iu,mc wrocr
7. DATE h D tJL D <
FOT DEPrti
o. DOES 1\ ELL REPLACE EXISTING WELL? YES 0 NO OV
STATIC \ . TER LEVEL Below Top of Casing:
2. (use ",-"-if .{oovc Top ar Casing)
TO.P OF CASING Is FT.
Above .TOH O1'"iO: (°rms:l+::a a oor oclu r land iu tryst calairos ufl8tic'"
a= uNSu.c I+itl 15d NC.=-C 2C .0116.
>. YIELD tom). �__- METHOD OF TEST r
J. 1\ ATER ZONES tncp,n): /GD a Jlf
013iNFLCTIO Typts_+ , .
mounL�
1V:dl'fhrClptc53
orm
fma,
:3 .3I:JLT:
A[cfla Ivlclnotl
Fr. C'OrY!'o eS
i'rPub Pa �'_"�„-- Ott. �
from
r 0. 1'.E\lA R CS
Dcpcn DB111 1n' or Wci&u.(Fr. blarcr:ai
l'o /oJ Fr. ,/ ; f d1l
Fa_ FL
Y'o Fr.
Depth n.l..
Fr.
D: tll i--
p Dumcr Or Slot Si2c C1'Itlrcrlal
Fe.
Po Fr.in.
EL PACK: I°.
Dcplh Set
1IArtri Al
To Fr.
To, Fr.
DO HEREBY CERTIFY
coINSTRurnoiN sTAVD
DEPTH
From To
_tire-/D
309256
,„ Topographic/Land sexing
Midge ❑Slope OValley []Fla,
(check nppropriarc box)
Latitude/longin,de of well location
(segrcac'rminu,ec6onds)
Lau,udtflongirude source:2rOPSOTOpOgr4phie mop
Ltnul: out1)
DRILL.CNGG j_ Oar_
Formation Dsscription
LOCATION SKETCH
Show clirccrion and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
m �ya ti�,e-Cc.
7ittagnie WC- NC .
TH., T'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
.&RDS, 4 ND THAT ;DPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
0 '14•- Ott
;aLuar rno urie iliac to me Division or \Vsree Quality, Grewo wirer Ser[iun, 1636 friar Service CoRrer- 1114ai`R,IVC
?a>9-!a.io Phone :Vo' l-"1917J3.3.:1, within 30
6
days.
G\V-I REV. 07/2001

WELL CONSTRUCTION RECORD
iN. n olla L ,Thal11Gn6 Or FM ironnlcnt and Pal !'soul. r
Divi>lon O.
N stet Qualiry - Oroundwatar section
'd L tYLI:: 1 , iln❑11'lUU,1)N.+Ill�t('(,n-rna) -iAN k 1,t ei r
•
,rL r_ ,51., I )i u,,,r•. v1 Y+.,,G f Pi -"' CCI:TIAI C.ATiDN It ,(- d
5tcsoNs //120�/ RagaSYYr/le.
":1 !‘ — CJl I I UeCIOY ['1rN 11 Tn A'—ri/
ssoct.:TGD wQ 1 Rrr11Tli
cii:'.ppl,,abldl ----
1. `,\EL U>_ ,Chcalr Appt,asbit Box)' 12ealga-trial
n, V
4 rpa P
.�.g[icaltu ral El
I
\w:,::o:u:-,❑ Rearpry 0 Hcat PumpWolcr injectionl]Oncdr0J I' Ocher, List Lisa
_. SiL WC.=.1I�0
Nca!-cs T3101)
3 0 i,H F1
CDunly err
.)ubzivtiion, 1.J! No., ZIp :CJJc)
I_a:cr or Rou(c Na.)
— �ceuc h' ivy da7isG
.1 7 St:0c Zip l-ouc
a.) jeS a a
VIlaka cunlocr
Dlv l_L Rfl 5-z-ob!
TOT L)EPTrl /
DOES 1\ ELL REPLACE EXISTING ST[NG WELL'? YES 0 N0 11 S1 H 11O \Y:<TER LEVEL Below Top or'Casing: /1°0 F.T.
101' OF i_(Use 'Y' ii .Above Top of Csnut)
°Cap oF: CASING IS51111 GuIc . FT. Above Lard Surrace-
ac or below 1an4 su rNee requires a
>::aragllco Iriril 13.A NC _C 2C .e) I .
9 YIELD I pnU. S METHOD OF TEST
tO. 1F _TER _ONES racptn)-
3. 0ROUT-
hran1
I-/. OCREEN.
r(On'1
From _
1 _ E4.1I1):GiCs\tELPACK
Dcpta
From Ts
4121411,zget5
DISINFECTION- Type
��._ mount
._. �;._i1iV G: -
Lb'ali Thieluscs
0 1 `pin�,� - Diani;tcr or WeighUFt. bl-tonal
erl— Fr. . 2 SO.1Z/
TO Ft.
Fr.
Daplh material
Ta, .aQ _
Ts
Fr.
D,put
I's
Ji i..kRK_S:
Tu
Diameter
Fr__
in
Ft
Fc
Melnon
Slot Si2p I}larcrlal
in.
in.
Sac Material
309292
Topogr phict/Land sorting
DRidgc Slope [Walley CFlat
(cheek nppropriura box)
Latitude/longin)de of well location
N11f'Ss' /IJd`war .azi'off
(&' recsjmnmttyscconrls)
Lutudeilongirude source: [3GPSDTopographic map
lcncok bo\)
DRILLTN3 LOQ
DEPTH
From To
Frmation Description
LOCATION SKETCH
Show direction and distance in miles from a[ least
two State Roads or County Roads. Include the road
numbers and common rod names. - -
DO t1EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED TN ACCORDANCE WITH l]A NCAC 2
'DNSTRUCTION STAiN.D..;RDS, .AND THAT ,A COPY OF THIS RECORD HAS BE
EN PROVIDED TO THE WELLLL 'VNER
rL• 7
SIGNATURE OF PERSON CGNS'TRUCTMGTHE AT '
usa,:( tat aria Anal mInc llivi3ion ur Water �u� WELL DATE
' Lll1: 63o rhoncwo. l"1-)) 733.32: Quality, Gruundw Water Section, 1636 Mail Service Ccn[cr-Rulei �h,
1, within 3d days. 6 NC
GW-I REV.07/2001

North Carolina - Department of Environment an
WELL CONTRACTOR (INDIVIDUAL) NAME (print
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if ap.licable)
d Natural Resources - Divisionntof Water Quality - Groundwater Section
'.Cy' cn*II T CERTIFICATION#a
ASSOCIATED WQ PERMIT#
1. WELL USE (if a • • linable)
(Check Applicable Box): Residential 0 MunicipaUPublic CI Industrial ❑ Agriculture] ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If0
2. WELL LOCATION: dyer, List Use
Nearest Town: P�urne 'JJt
County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(gP.;y1 G-
PHONE Y7 9yL"9
TJ /'-'
.Area code Phone number i
4. DATE DRILLED
5. TOTAL DEPTH: —3 13a2 —
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L9-
7. STATIC WATER LEVEL Below Top of Casing: FT.
' Above Top of Casing)
UqT
City or Town State
Zip
ode
310822
WELL CONSTRUCTION RECORD
8. TOP OF CASING IS (Use + f
*Top of casing terminated at/°�la d uFT. faeerequirres arface*
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /00 METHOD OF TEST 10. WATER ZONES (depth):
11. DISINFECTION: Type H �/
12. CASING: _7� Amount / 6z.
Depth Wall Thickness
From D or Weight/Ft. Material
From FL son ��
FL�..�
To --��-sL
From To
13. GROUT: Depth Ft.
From
To
From �y— Ft' Ct�nG��
To Ft.
14. SCREEN: Depth
From To Ft
From To Ft.
I5. SAND/GRAVEL PACK
Depth
From To Ft
From To
Ft.
16. REMARKS:
Material
Diameter
in.
in.
Method
Slot Size Material
in.
in.
Size Material
I DO HEREBY CERTIFY THAT ,,,THHHHqqqIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
27699-1636 Phone No. [phone], within 30 days
Submit the original to the Division of Water Quality, Groundwater Section, 1636
Mail Service Center -Raleigh, NC
GW-I REV. 07/2001
Lat
rude/longitude source: OGPS❑Topo
DEPTH �(
From To
(check box)
DRILL�LdG
Formation Description
�San�l_
Topographic/Land setting -
❑Ridge 0i31ope ❑Valley OFIat T '''.
(check appropriate box) i -
Latitude/longitude of well location
3(1E7_ 3d.�ntu/h z' '
(degrees/minutes/seconds) _...
LOCATION SKETCH
gray m.
Show direction and distance miles from at I ast
two State Roads or County Roads. Include the road
numbers and common road names.
?ukx/,rv. //
w
0
0,
t'3
11
0
6
O

North Carolina - Department of Environment and Natural Resources - Division of Water Quality -Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)�_y% �, /t
WELL CONTRACTOR COMPANY NAME —
CERTIFICATION #6
STATE WELL CONSTRUCTION PERMIT*) �' I
PHONE estat _ i r,
ASSOCIATED WQ PERMITM T/t
1. WELL USE (Check Applicable Box): Residential IIK Municipal/Public 0 Industrial ❑
Agricultural ElMonitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: wn N-'A (¢,
"nr// /✓ // ems_ County Lfq nG
(Street N
e, Numbers, Commumry. Subdivision, Lot No., Zip Code)
(if ap.licable)
3. OWNER: WERhJE
WELL CONSTRUCTION RECORD
.Address -'' r - (14 R `'
(Street or Route No.)
Cary orSownL� 8O
State
( L1)-g'4'�'�� ZAP Code
Area code Phone number
4. DATE DRILLED___
5. TOTAL DEPTH: VOD
6. DOES WELL REPLACE EXIST WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: J� Y
(Use'•+" if Above Top of Casing)
8. TOP OF CASING IS
FT. Above
*Tap of casing terminated at/or nd surface requirres arfaCe*
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): e_/ METHOD OF TEST
10. WATER ZONES (depth)::
11. DISINFECTION: Type 7
12. CASING: '— Amount
6z.
Depth y Wall Thickness
From�� De o? I Diameter or Weight/Ft. rMatterial
Sa Q2/ —L� From To Ft.
From To
13. GROUT: Depth Material
From_ To Method
From— Ft. /f �Crdp
14. SCREEN: Depth Ft.—_ --
From Diameter Slot Size Material
To
From Ft. in.To FL in.
15. SAND/GRAVEL PACK
in. in.
Depth Size Material
From To
From Fr.
To Ft. --�'�-
16. REMAR
KS:
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
27699-1636 Phone No. [phone], within 30 dayst
Submit the original to the Division of Water Qy� Groundwater Section, 1636
Mail Service Center - Raleigh, NC
GW-I REV. 07/2001
(if a. placable)
310821
�econda
Latitude/longitude source: l3GPS❑TopodrtpylF map
(check box) �-
Topographic/Landsetting;
Okfrig
e ❑Slope ❑Valley gl3taF.
(check appropriate box) ;?; I
Latitude/longitude of well locatiqu.
3S/cQ/t,r
(degrees/minutes/ 0P2 - 1 s Do
DEPTH
From
To DRILLINd'rfoo
so
Formation Description -."
6 • e.+x•
)," <
"l
,F
W
LOCATION
Show direction and distance in miles from at least "- two State Roads or County Roads. Include the road
numbers and common road names.

or et-y
ST
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -
WELL CONTRACTOR (INDIVIDUAL) NAME Division of Water Quality (print) ; �n ). . ty -Groundwater Section
WELL CONTRACTOR COMPANY NAME ) CERTIFICATION #
PHONE lYiS GPx-9s[yg9
ATE WELL CONSTRUCTION PERMIPERMIT'S(ifap. licable)
ASSOCIATED WQ PERMIT#
(if a.plicable)
1. WELL USE (Check Applicable Box): Residen4. Monitoring 0 Recovery 0 Heat Pump Water Injection Municipal/Public c 67 then, Listi0 Agricultural 0
Other 0 If Other, Use
2. WELL LOCATION:
Nearest Town:22„� v y)
0-----�_Couny �%grc_t_7
o r
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:5a4.�
Address
Ciry or Town State
Csd ZAP e
Area code- Ph
one
number
4. DATE DRILLED_ 1p
5. TOTAL DEPTH: pD
6. DOES WELL REPLACE EXISTING WELL') YES
7.
STATIC WATER LEVEL Below Top of Casing: 0 NO [.
8. TOP OF CASING IS /..(Use + if Above Top of Casing)
*Top of casing terminated at/or below la d surfaceT. erequ Land
arface
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm). �_ METHOD OFT�,$ T
1 U. WATER ZONES (depth): /ff6 2----��
11. DISINFECTION: Type H 7 f/
12. CASING: �— Amount
Wall Thickness
Depth Diameter or Weight/Ft. Material
From__ To
From T Ft-�-�,—/ PvG
Ft.
From To Ft.
13. GROUT: Depth
M
0
SCREEN �1-MOCJti Ne
Diameter Slot Size al i,
Material
-
From�_ To dP E Method
From--`a�.i)_' Ft. fin-`
To
14.
From
Depth
To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope icy ❑Flat
(check appropriate box)
Latitude/longitude of we location
35- , //
(degrees/minutesis conds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING
Formation Description
DEPTH
From To
Ft.
Ft.
Ft.
Ft.
Ft.
in. n.
in. in.
Size Material
LOCATION SKETCH
Show direction and distance miles
two State Roads or County Roads. I
numbers and common road names
7 2005 I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT'ED IN ACCORDANCE WITH 15A NCAC CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EEN PROVIDED TO THE WELLOWNER
2C, WEL{�
a
I
from aast
nclude the road : 3
SIGNATURE OF P SON CONSTRUCTING THE WELL
DATE
27699-1636 Phone No. [phone], within 30 days
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -
Raleigh, NC
GW-1 REV. 07/2001
310820

t'Y Heat Pump101
Water Injection 0 Other 0
ater Quality
ASSOCIATED WQ PERMITR
. WELL
1 Monitoring
(Check Applicable Box): Residential 6] Mun' i UP
g 0 Recove
(i f a..licable)
County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
WELL CONSTRUCTION RECORD ` 1 0 8 1 1
North Carolina - Department of Environment and Natural Resources -
WELL CONTRACTOR (INDIVIDU Division of W
AL) NAME (prin0_
STATE WELL
CONSTRUCTION PERMIT'S
WELL CONTRACTOR COMPANY NAME
(if ap.licable)
2. WELL LOCATION:
Nearest Town thc V)
Z�,, State Z.
Area code Phone mber 9 y-�T'--__.
4. DATE DRILLED
5. TOTAL DEPTH: / 7C .
6. DOES WELL REPLACEE XI
7. STATIC EXISTING WELL?i YES 0 NO L3—
WATER LEVEL Below Top of Casing: p _FT
S. TOP OF CASING IS (Use "+" if Above Top of Casing)
*Top of casing terminated at/or Above Land Surface*
variance in accordance with 15AbNCAC 2C .0land 118. requires a
9. YIELD (gpm): S� METHOD OF TEST 4,
10. WATER ZONES (depth): '%_—
11. DISINFECTION: Type
12. CASING: Amount oz.
Wall Thickness
Depth Diatlieter From�Q_ To_ Ft or Weight/Ft. Material
From To �/ ��
Ft.
pa ublic
From
City or Town
p Code
To
13. GROUT. Depth
From_ To Material
From To — Ft. �.,,,. _ _ 1
14. SCREEN: Ft.
Depth Diameter
From To
From To Ft. in.
15. SAND/GRAVE Ft. in.
SAND/GRAVEL
Depth Size
From To
From To Ft.
Ft.
16. REMARKS:
Ft.
p Method
Slot Size Material
in.
in.
Material
- Groundwater Section
CERTIFICATION F
PHONE Sayan _ r��i /7
t Industrial 0 Agriculturat:[j,.
If Other, List Use
Topographic/Land setting
ORidge OSlopeyi
(check appropriate box)
Latitude/longitude of well Ideation
Latitude/longitude source: ❑GPS❑T
DEPTH
From To
(degrees/minutes/seconds)olati-�-'1-
(check box) ogrdphic [nap
DRILLINGOG ..
Formation Description
r'
0,,
LOCATION SKETCH
Show direction and distance from t st
two State Roads or County Roads. Include the road
m
numbers and common road names.
(Os1Lh �!
c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE IS
CONSTRUCTION STANDARDS, AND THATCOPY OF HIS RECORDL i
A WITH ISA NCA � EL �`�;'
HAS BEEN pnnv.,,,. C -C. W
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section,
27699-1636 Phone No. [phone], within 30 days.
D TO THE WELL
J
c t
1636 Mail S�-.4: 1?
Service Center - Ral. NC
OW -I RE :Cf42001
DATE

Depth Diameter
From_Q To
From —T'- Ft'--rt-k5•L
To Ft.
From To
13. GROUT: Ft.
Depth Material
From_Q To
From To--aL3- Ft.-�/1G r
14. SCREEN: Ft. --
Depth Diameter
From To
From Ft. in.
15. SAND/GRAVELTo Ff
P 1p'
PACK
Depth Size
From To
From Ft.
To Ft.
16. REMARKS:
WELL
I. WELL USE - —� (Check Applicable Box): R
Agricultural le
2. LOCATION:
Nearest To wn: t'i�r Ir���
:2-rn l' rr6 County nCL'y
(Street Name, Numbers, Community, 7
umry, Subdivision, Lot No., Zip Code)
3.OWNER:
Address
( tyy or �
te p Cod
Area code e nu ber
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING(Use "+" if Above Top of Casing)
FT.
IS�f ))-�
*'fop of casing terminated at/or below land surfaceT. erequires Surface*
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST i
10. WATER ZONES (depth): -_
tdc-
11. DISINFECTION: Type /`% 7-¢/
12, CASING: --� Amount y_� z.
Wall Thickness
or Weight/Ft. Material
--b- / ✓c
Slot Size
in.
in.
Material
p Method
ace
r 2005 /!' i l
WELL CONSTRUCTION RECORD
UJ3D 310819
North Carolina - Department of Environment and Natural Resources -
WELL CONTRACTOR (INDIVIDUAL) NAME Division of Water
(print) jY� J Quality -Groundwater Section
WELL CONTRA n
CTOR COMPANY NAME CERTIFICATION #b
STATE WELL -,
ASSOCIATED WQ PERMIT#
(if a. plicable)
Monitoring°X Residential Municipal/Public 0 Industrial 0
0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
CONSTRUCTION PERMIT#
(if applicable)
PHONE f"p`t /ey;_9s[�O
Topographic/Land setting
❑Ridge ❑Slope OValley ❑Flat
(check appropriate box)
Latitud longitud of well location
(degrees minutes/seconds) /
Latitude/longitude source: ❑GPSDTopographic map
DEPTH (check box)
DRILLING G
To Formation Description
-�JL_ Q Sa4n- %1n
a
2 YZ3a i-J
- t73
^:
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.
BY
IDO HERECERTIFY
DO R BY RTATHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
NDARDS, .ANDRECORD HAS BEEN PR
THAT A COPY OF THIS OVI e . _ _
C, DED TO THE WELL OWNER
NATURE OF PERSON 0 �/ - (J'
CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,DATE
Submit Phone Noth 7 iv Groundwater Section, 1636
( ) 3221, within 30 days. Mail Service Center -
Raleigh, NC
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD�-1 1 0 8 '] /
North Carolina - De i " 1 / Department of Environment and Natural Resources -
WELL CONTRACTOR (INDIVIDUAL) NAME Division of Water
WELL CONTRACTOR (Print) Quality - Groundwater Section
RgCTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
s, Communiry, Subdivision, Lot No., Zip Code)
(r'
. Q�.tto-Ceiry or sown `
•� eat iP Code
Area code Phone number
4. DATE DRILLED)o
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING W WELL? YES p NO p-*
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING IS (Use '4" if Above Top of F F'
*Top CA
terminatedFT. Above Land Surface*
at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm):
10. WATER ZONES (depth):
s— NIETHOD OF TEST
I1. DISINFECTION: Type y,y���
12. CASING: —_!L_ Amount�z.
Wall Thickness
Depth
From >>Dia-�mn eter or Weight/Ft. Material
From To— Ft.—�&_ y_—
From Ft'
To ��—
13. GROUT: Depth
Ft.�� �—
Material �— �_ Tom f1 Ft nc (_ ▪ Method_
From To
From
14. SCREEN: F[. .
Depth Diameter
Slot Size
From To
From To Ft. in. in.
15. SAND/GRAVEL PACK:
ACK: in.
Depth Size From To Material
From Ft.
To
Ft._
16. REMARKS:
I DO HEREBY CERTIFY
CONSTRU THAT THIS WELLiWELL
t =�
CTION STANDDAARRDDS, AND THAT A COPY F TH SONSTRUCTRE ED ORD IN HA BEEN pp rTu NCA_ ; r t
VIDED TO THE WELL OWNER
Material
CERTIFICATION #_ b
ASSOCIATED WQ—PHONE fl ' . i3 _9yd /9
(ifa. PERMIT* 3'
I. WELL USE (Check Applicablepiicable)
Monitoring 0 Recovery0 PumpHeatBox)dential �j00 0ipalOieri° Industrial List
0 Agricultural °
Water Injection
2. WELL LOCATION: If Other, List Use
NearestTown:ta
County Li/JnLE
• (Street Name, Num
Topographic/Land setting
°Ridge °Slope OValley appropriate °Fla[
3. OW NER' Lan de/lon I box)) :tyde f well location
Address
(Sn e[ Ao (degrees/minutes/seconds)
degrees/minutes/secon ' '� "''
Latitude/longitude source: ❑GP$ ds)
°Topographic map
DEPTH (check box)
D
From To DRILLING LOG
Formation Description
a7_
-71
rrl
CO
LOCATION SKETCH''
Show direction and distance in miles from at0 `}
County Roads. Include the road
two State Roads or a
numbers and co
moron road names.
%U4auf4L64, de .
SIGNATURE OF PERSON CONSTRUCTING THE WELL
27Submit the original to the Division of Water
Submit
t 636 Ph DATE
Phone No. (919) 733-322 Quality, Groundwater Section,
t, within 30 days. 1636 Mail Service Center
Raleigh, NC
GW-1 REV. 07/2001
- nG
w
0
0
t7

ASSOCIATED WQ PERMIT,/
1 . WELL USE (Check Applicable Box): R
Agricultural
2. WELL LOCATION:
Nearest Town:�L(n
/tom' '�---County �i4�ft�-;�
(Stet Name Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LT
Address
(if a. plicable)
Monitoring ❑ Recoveryox � Residential ❑ Municipal/Public O Industrial O
❑ Heat Pump Water Injection ❑ Other O If Other, List Use
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,
CONSTRUCTION STANDARDS, AND THAT A COPY OF T IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER^
-� C/ —v
Submit the original to the Division of Water Quality, E WELL DATE
Submit
Phone No. (919)h7D- Groundwater Section, 32_1, within 30 days. 1636 Mail Service Center -
Raleigh, NC
GW-1 REV. 07/2001
City or Town e
raze Zip Code
( P--GBa y2 .Area code Phone number
4. DATE DRILLED D - _
5. TOTAL DEPTH:
6. DOES WELL
LEVEL Below Top of Casing: 39
8. TOP OF C (Use "+" if Above Top of Casing)
CASING IS
"Top of casing terminated ator below land surface erequirres arface*
variance in accordant with ISA NCAC 2C .0118.
9. YIELD (gpm):ON‘10 METHOD OF TEST
10. WATER ZONES (depth); I S-
11. DISINFECTION: Type i
12. CASING:
Depth Diamete
From O
From To F.
From To Ft. t a/ Yc
To Ft
13. GROUT: Depth
From Material
From-To�i� Ft %pn
14. SCREEN: Ft.
Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To
From To
16. REMARKS:
p Method
Diameter Slot Size Material
Ft._-min. _
Ft, in.
in. in.
Ft.
Ft.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natura
WE
LL CONTRACTOR (INDIVIDUAL) NAME (print
WELL CONTRACTOR COMPANY NAME -{
STATE WELL CONSTRUCTION PERMIT#
(if ap.licable)
7. STATIC E REPLACE EXISTING WELL? YES O NO IY
WATER
Amount 6Z.
Wall Thiclatess
r or Weight/Ft. Material
Material
2
( egrees/minute seconds}
Latitude/longitude source: ❑GPS❑Topographic map
From To
I/ �U
(check
DEPTH
box)
DRILLING
Formation Description
LOCATION N—H
Show direction and distance in miles from at least
two State Roads or County Roads. include the road
numbers and common road names.
v�vxovil�,we
7 2C"5
�'JJ
SIGNATURE OF PERSON CONSTRUCTING TH
1 Resources - Division of Water Quality - Groundwater Section
vl 4!(
r 1 . Il—�� CERTIFICATION #,y�
PHONE gaa nisi5^�9
310818
Topographic/Land setting
ORidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well loctipn
TS E' LA.,
- 612 / wCC
r

WELL CONTRACTOR COMPANY NAME Farr, sot tA/Gl I �C: H.Y)¢,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
310844
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 14nr k /41i h CERTIFICATION #39Y/p
PHONE fan 693 -9i417
I. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: ]19,46045 V t l e County
c5 + 1aA-KS Cre-e
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Q!'}iy NSAi,/ler
Address 1 r ,» 4C(NW 80 (),l}E%t
(Suev6r Route )
Ciry or Town State Zip Code
kso- G is _.,T
Area code- Phone number
4. DATE DRILLED //- U r
5. TOTAL DEPTH: r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
hrAiricey
Topographic/Landing
❑Ridge ❑Slope 634lley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING I_OG
From To Formation Description
e-- W
V AG
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): %q
Qd METHOD OF TEST R 1
10. WATER ZONES (depth): /O $ f
11. DISINFECTION: Type hi 71/
12. CASING:
xi Depth
From V To 3 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From O To 9n Ft.
Dja)neter
BY
Amount "( OZ.
Wall Thielcness
or Weight/Ft. Material
SPe2/ ?VC,
Material
Cant ro I -I'
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
Poured
Slot Size Material
in.
in.
Material
4h
aC
3 )-
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
i9E
(.tens n j /k Are
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC I'ED [N ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TH92' A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
/l- -3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Rale
27699-1636 Phone No. [phone], within 30 days. GW-1 REV

or
311362
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division�of Water Quality - Groundwater Section �--rr�9/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i v%ra r k' toll t h CERTIFICATION #�Ur �(tp/q
WELL CONTRACTOR COMPANY NAME fj//iu Set a) ih/fl l hri1(.� PHONE Win 6Y3 —9/1
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 1VMunicipal/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: 34rnty. I" County
(Street Name, Numbers, Communnity, Subdivision, Lot No
3. OWNER:n ai42./ p1/L)
�ni
Address O. e� fie
(StreC'Q}�La /NC'r Route ) ov& 09
Ciry or Town State Zip Code
Area code- tone number
ieMS
4. DATE DRILLED 7—ga8—cF
aJ
5. TOTAL DEPTH: !f •
6. DOES WELL REPLACE �ISTING WELL? YES I1'NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): /00
, Zip Code)
11. DISINFECTION: Type f% 7f/ Amount OZ.
12. CASING: Wall Thickness
Depth DiaTeter or Weight/Ft. Material
From U To 3 a Ft. 1 ? ,S 2/ ?VC --
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From D To 9n Ft. eencro 1e POurn]
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:
pographic/Land setting
idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
LatJtude/1 ngitude of well to ation
.36717j v-orva7/a-rw
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o /0 clay
!/ % .SAn<- J'Avna—
.27 3.2 &Gael
33
; k—
W
LOCATION SKETCH T
Show direction and distance in miles from at least t
two State Roads or County Roads. Include the road ;r
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH lii NCA 2C, WELL
CONSTRUCTION STANDARDSE 1
AND THAT A COPY OF THIS RECORD HAS BEiP$OVIDED TO TIME= fl ILL OWNER.:
! —qt."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-I REV. 07/2001

C) 3113 63
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
/4Iit r
WELL CONTRACTOR (INDIVIDUAL) NAME (print) . 4ri r
WELL CONTRACTOR COMPANY NAME �'e ryu Saa) dJtl 1 19rill.'n C,
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
Groundwater Section �--ss ��99��
CERTIFICATION # er__
PHONE failACS -/pT//
ASSOCIATED WQ PERMIT#
(if applicable)
9
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
WELL LOCATION:
Near stTown: B4rn6Vi )IC —County Y,DCe-t
e *hairy tratrt
(Street Name, Numbest; Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
4
5
6
7
mi tes at
�p • r
6 Sg'R3r rRout/.flt
Ett#.4u11L / M? 4't//
City or Town Sate Zip Code
016- 6n Lo/9
Area code- Phone ndmber
DATE DRILLED S `a -o
TOTAL DEPTH: a C t
DOES WELL REPLACE EXISTING WELL? YES 0 NO
STATIC WATER LEVEL Below Top of Casing: 30 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 ISA NCAC 2C .0118.
9. YIELD (gpm): 5 METHOD OF TEST Xh9
10. WATER ZONES (depth): /80
11. DISINFECTION: Type f'/ 7f/
12. CASING:
Depth Diameter
From 6 To .3 D Ft. LT
From , j/ To .3 % Ft.
From To Ft.
Amount 9 bz-
Wall Thickness
or Weight/Ft. Material
seta( T vc,
/&V 51-ee-j
13. GROUT: Depth Material
From O To af) Ft. Concro Ee
From To Ft.
14. SCREEN• Depth Diameter
From To Ft. in.
From To Ft. in.
15.SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
Method)
PAura.O
Slot Size Material
in,
in.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope l .Veti'ey ❑Flat
(check appropriate box)
Latitude/ ongitude of well loc Lion
3s/S i sa tA. D Yz a6 o la.)
degrees/minutes/seconds
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
From To Formation Description
DEPTH
J/ 3d
3G
rrt
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 WITHTSANCAC 2C, WELL
CONSTRUCTIONiTAARDS AND THAT PY OF THIS RECORD HAS BEEN PROVIDED -TO THE WELL 0
Gia/j/ �v0.2• 6 e]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

033 3 064
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division�of Water Quality - Groundwater Section -� -� �q/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) , c 1- /4110 ✓\ CERTIFICATION #y per/ /q
WELL CONTRACTOR COMPANY NAME f-{rY.usoa) IAilll Zlri 1(�n/ PHONE ORO ?3 - 9/1
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential l41 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
7
WELL LOCATION:
Nearest Town: -31.xt AIDA County ll(7 C
e0Xe_S eree E-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER: 3-,254,n wnC43
Address j(e / 4 2Oysb (2 i n (
(Street or Route No.)
YQvtinauiij i,/I/e n,/
City or Town State Zip Code
(tea. 4eV- 02S8
Area code- Atone number
4. DATE DRILLED g'L- -3,- O y
5. TOTAL DEPTH: G sr-
6. DOES WELL REPLACE EXISTING WELL^ YES 0 NO EY-
7. STATIC WATER LEVEL Below Top of Casing: 2 O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance t h 15A NCAC 2C .0118.
9. YIELD (gpm): __ METHOD, TEST . /".
10. WATER ZONES (depth): N%f
11. DISINFECTION: Type %' 7f/
12. CASING:
From 0
From
From
13. GROUT: Depth
From LI To an
From To Ft.
Depth
To YO Ft
To Ft
To Ft
Diameter
Amount /5.
Wall Thickness
or Weight/Ft. Material
StZe2( 2vc
Material
Ft. COnGro t-e
14. SCREEN• Depth Diameter
From To Ft, in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
DZ.
Method
Pauro
Slot Size Material
in.
in.
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
'45-fref l 09a1/470/llw
idegrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o ao Gl�
±za
Cis
Ul
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.
dolco.a. datA
iefidddx,eviat,Ale
w
a
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA' NCAC 2C, WELL
CONSTRUCTION STANDANND 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
3

DASD 311359
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i'!!t r
WELL CONTRACTOR COMPANY NAME FLYyusoal Well I", c- (I,'
/ v,2 PHONE ilasn ‘V3 -9y47
STATE WELL CONSTRUCTION PERMITPERMIT,/ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential el/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
CERTIFICATION #a2X 1,
2. WELL LOCATION:
Nearest Town: 3.4cn I'V v ) le
BlUL FncL Z A ..
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Wes!?0(� irYQ-fliTrC
(Street or ute No.)
`et;AAC4-Lt n
/ LLt .VC '7
City or Town grate tip Code
Address
Areode-Phone number
4. DATE DRILLED 7 - ifs- o st
5. TOTAL DEPTH: 3 ar`
6. DOES WELL REPLACE EXISTING WELL' YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 3(3 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): S- METHOD OF TEST Rep
10. WATER ZONES (depth):
11. DISINFECTION: Type 7.71
12. CASING:
Depth .y Diiameter
From D To 4 L FtJ_7
From__ To i3 Ft._
From To Ft.
13. GROUT: Depth
From (3 To St) Ft.
County '#ANLe f/
Amount )t'p;IJa dir'
Wall Thickness
or Weight/Ft. Material
57?2z l "a✓C_
Material
Cons ro Ee
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
p0c r¢A
Slot Size Material
in.
in.
16. REMARKS:
Topographic/Land setting
DRidge ❑Slope Vley ❑Flat
(check appropriate box)
Latitud,ef/I ngitude of well to tion
3r/r% 33 K • OYli�7 S<G-c.J
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 .9v ern y
d1 Y? diond SFr�r�
Spy 5*3 &nen, 4c-
Ty
0
r-Q
t� -a
LOCATION SKETCH CR '
71
Show direction and distance in miles from at least �9
two State Roads or County Roads. Include the road 1
numbers and common road names.
Ciel4bajZfL Aid
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS ND THAT A C9PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7-/. ......_..
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

311335
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalaResources - Division of Water Quality - Groundwater Section �9�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /'//t r k /416 le; CERTIFICATION # .49ea
WELL CONTRACTOR COMPANY NAME ter/ous,J iu el l ZI r.I(.n� PHONE f in 6 V3 -?}1717
STATE WELL CONSTRUCTION PERMIT# - ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 19 MunicipabPublic ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: 234MSY: le
County Yancey
(Street Name, Numbers, Community, Subdivision, Lot No., Zi
3. OWNER:
Address
(Street or Royte Now
Irritrisr4
Zip Code From To
848 3 3 0 090
p Code)
City or Town vState
t 4/r/5/ DEPTH
Area code- Phone number Q + .3 Sf
4. DATE DRILLED 8 oo /D
5. TOTAL DEPTH: 5-e i 9
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V
7. STATIC WATER LEVEL Below Top of Casing: 6 0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): t METHOD OF TEST 11.O
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
From 0 To Lk
From To
From To
13. GROUT:
From 0
From
14. SCREEN: Depth
From To
From To
l5. SAND/GRAVEL PACK
Depth
From To
From
Depth
To 9/)
To Ft.
H 7f/ Amount 6L.
Wall Thickness
Diameter or Weight/Ft. Material
Ft. In' ,3Th?i 2 VG
Ft.
Ft.
p� Material
FL a1 nC ro FP
Diameter
Ft. in.
Ft in.
16. REMARKS:
Ft.
To Ft.
Method
Po L&CeJ
Slot Size
in.
in.
Material
Size Material
. (7
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/long itude of tie�llt joca%ton
3S/Sb/%7K- Bt7'r/ i / OD W
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPSOTopographic map
(check box)
DRILLING LOG
Fopr)aon Description
t-rrrta.n
en -a
-C
Ca
LOCATION SKETCH N ',n
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road is
numbers and common road names.
I —.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH15A NLAC:g WELL - -
CONSTRUCTION STANDARD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED IU-IHE WELL OWNER
R
P-03^vy'-
SIGNATURE OF'PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section,
27699-1636 Phone No. [phone], within 30 days.
DATE
1636 Mail Service Center- eigh, NC
G - V. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural��IResources - Division�of Water Quality - Groundwater Section gy�pp//
WELL CONTRACTOR (INDIVIDUAL) NAME (print) . rlei r i, Mt vn CERTIFICATION # .d/-(p/p
WELL CONTRACTOR COMPANY NAME Feu//>so J. i,/111 b Ci ll.v ri PHONE 449A'j —9y1/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Q1 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: Zutrtst,,i11 County titan
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Sec vc✓1,p f ./
Address `JYmtlti c+Z wJ LY iB
(Street or Route No.)
.t om; tfie4 f7/V
C�ttry or Town pre S Zip Code
7- !o yr- 5�9/R
Area code- Phone number
4. DATE DRILLED e- t/ —O SL
5. TOTAL DEPTH: ,3 U S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 7 r ' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING I5 / 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 a METHOD OF TEST T c-c, 10. WATER ZONES (depth): / 170 1- —70 rr
0450
11. DISINFECTION: Type f/ 7// Amount /D bz
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 6 V Ft. 4 1-Se 53:7La/ hVC,
From To Ft.
From To Ft.
13. GROUT: Depth Material T, Method
From t) To a/) Ft. eenCra I-e POCAip l
From To Ft.
14. SCREEN• Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge 0Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/lon itude of well location
/r aril- aye//// 3Yal✓
( egrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o c_70
'7 -5 cf
Gla
s'9� 5 F-ti4.
fin.✓7-`--
6'rct sM C2
3
•
-ti:
Gl
LOCATION SKETCH
Show direction and distance in miles from at least 1
two State Roads or County Roads. Include the road
numbers and common road names.
WC.
CFI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A N, 2C, WELL
CONSTRUCTION STANDARDS, AND THAT COPY OF THIS RECORD HAS' BEEN PROVIDED -TO -TN WELL OWNER
SIGNA
E 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 - Depanment of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) / lin r % 41 CERTIFICATION 032 (p �p�
WELL CONTRACTOR COMPANY NAME te..r/iiso a) IAi L.I I 11 C: II(n�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE W f93 -5541
1. WELL USE (Check Applicable Box): Residential 1 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: j3urn,< V (1 I e
�PP,'
County t-/1911Cbid
(Street Name, Numbers, Conhnunity, Subdivision, Lot No., Zip Code)
3. OWNER: pp�
Address 1 Q i l zn. )
/ et = or Rry: No.) tnyv
Ciry or Town State Zip Code
40a - mVO
Area code- Phone number
4. DATE DRILLED 8,.Q5/ O
5. TOTAL DEPTH: / [o $ '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO [Y
7. STATIC WATER LEVEL Below Top of Casing: /1) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS i FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .01 t8.
9. YIELD (gpm)- 30 METHOD OF TEST IR;
l0. WATER ZONES (depth): / (f/1
11. DISINFECTION: Type hi 7 -/
l2. CASING:
Depth Diameter
From 0 To 51 Ft. (u IT
From To Ft.
From To Ft.
13. GROUT: Depth
From (i To a ()
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Amount !o- 7flz.
Wall Thickness
or Weight/Ft. Material
a)R al Pv<
Material Method
Ft. Lbncro Ea PO (Jac]
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
Topographic/Land setting
❑Ridge 0Slope 0Valley anat
(check appropriate box)
Latitude/longitude of well location
35/58/t/7rJ- n8aA2V.10w
(degrees/minutes/seconds)
Latitude/longitude source: Qt3'1fS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
v (20 Clay
a( YSnozcie
h
A
tr
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,
iiatouivaz, , fe
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANgfWITH 15ANCAC 26, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED -TO T-HE WELL OWNER
c
re)
177
SIGNA OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

31137
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ?� --�s ������
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i �%(j r k /416 Yt CERTIFICATION #__ fp
WELL CONTRACTOR COMPANY NAME Fero,o so.) U\9 J61 I 1ri ll:»� PHONE itRel !93— f�1'/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential fJS' 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: --bt..cn.sv Ile County `, #WIC yi
rtnl/'n( AcJ-c, re C f1"a-/-es-
(Street Name, ,umbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 'DOR. Tod LC
Address �Q_ (1 `6Gf% 9i9
rr (Silty douse No.)
,77 . c l►la lb Nn oP/56-
Ciry or Town Sheer Zip Code
1644- Z. if.- OVA,
Area code- Phone number �P
4. DATE DRILLED 7 — -aT
5. TOTAL DEPTH: i2pt-
6. DOES WELL REPLACE EXISTING WELL'? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: ,3(7 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS � FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): R METHOD OF TEST II
10. WATER ZONES (depth): d 6.5
11. DISINFECTION: Type / Tf/ Amount oQ(j OZ.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To LS Ft. G', COIL,/
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To g/i Ft. CYpnCro iv PO to azi
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.
Material
P
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3r/,33//3iJ-0WO QatW
(degrees/minutes/s�e nds)
Latitude/longitude source: € GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
-24 chat,
1 Gs- and the
re- (mC 6+-anT.c.
Oren, 44-
CS
}
W �t
LOCATION SKETCH oo
Show direction and distance in miles from aUaast
two State Roads or County Roads. Include the road a
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL •
CONSTRUCTION STANDARDS, A D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a/' 7-6 -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 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
O 1 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section ��99//
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /Vi/r r 1' 1416 h CERTIFICATION #
Fr/ruson) „Jell br-III;.,, PHONEOW)%Y3-lp Y(pi4/p
ASSOCIATED WQ PERMIT#
(if applicable)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
9
WELL USE (Check Applicable Box): Residential Itl Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATI2ON:
Nearest Town: Zkrns v,"//e. County t/9nc cry
(Street Name, Numbers, Community, Subdivision,s�yyLot No., Zip Code)
3. OWNER: /v1tl'lswh C.rMITF+/ n
aa
Address /VA, 7 Annt. yawed aim.
2 (Sneer or R ute No.) L.4A4A-
4-4rosv,i4- ,Ate .yogi 02,9 r%r/I
City or Town rate Zip Code
(so- Lag- /39
Area code- Phone number
4. DATE DRILLED 9- io -or/
5. TOTAL DEPTH: 5-or"
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing: ,t'O FT.
i (Use '4" 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 R,y
10. WATER ZONES (depth): A//A-
11. DISINFECTION: Type
12. CASING:
Depth
From 0 To a 7 Ft.
From To Ft
From To Ft.
13. GROUT: Depth
From n To a/) Ft.
f/ 7J-/ Amount aV az-
Wall Thickness
Diameter or Weight/Ft. Material
cv .SDR,a1 PVC --
From To Ft.
Material
G'onGro f-e
14. SCREEN' Depth Diameter
From To Ft. in.
From To Ft. in.
Method
Po urea
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well locati9n
167 6V6 7 t3 - Ora/ 17 / /a t,.J
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
/ a ern,/
CranfI
0
t.ft
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
i�uaix tc%l i / /tie
1 D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH '1SA-NCAC2C t; WELL,
CONSTRUCTION STANDARDS,%TAAND HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO-TH$ WELL OWNER
G
y_/o -d;
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

Dp 3113"` 6
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division1of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /4{ Yin i- tih CERTIFICATION # p
WELL CONTRACTOR COMPANY NAME sr so al iA/ C. I ri IIen, PHONE S1/11;1) iYn-/,41p
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential .14-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: 1 t.KYvS Jol I e
'i;hie SWRnp
(Street Name, Numbers, Community, Subdivision,
ubSubdiivision, Lot No., Zip Code)
3. OWNER: A. t2 iCl4/
Address ✓9. 0. oy /dJA
/ (Street or Route No.)
6 wta ant/G x c 4 PiJ/
City 'State Zip Code
sa A IA-
County nLe.
.Area code- Phone number �!
4. DATE DRILLED 9' /3 - 6I
5. TOTAL DEPTH: c>7O C
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO CJ/
7. STATIC WATER LEVEL Below Top of Casing: 0` O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS fl / 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): SO METHOD OF TEST R iy
10. WATER ZONES (depth): 1,25 / si S
11. DISINFECTION: Type j! 7// Amount
12. CASING: Wall Thickness
Depth Diart/eter or Weight/Ft. Material
From C�' To B2 / Ft 0 p s1)2,21 YYC-
From To Ft.
From To Ft.
6z.
13. GROUT: Depth Material Meth
Czo
From (3 To o n Ft. ncro d-e pOtAr
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 laVallertiffat
(check appropriate box)
fwell �/ y'ca
tion
S-VA? 4 - O
(degrees/minutes/seconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 ro ClAy
/ a1
fi
tJ
—c
o a=
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.
fLa/a/o
Autixa1)11,6, K CC"
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDA S, AN 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

311416
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i41r
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
1.
CERTIFICATION#W!Y(p
Fi rr.v $o wl a ell TAc.11,:17 PHONE(#Q ‘Y3-5;3417
ASSOCIATED WQ PERMIT#
(if applicable)
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
WELL LOCATION:
Nearest Town: lanx- r.ik County tuners/
;511C a6 Cfe.k /Za.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:-S e ./7.%n
Address 44 YY s deecl4 /&I
(soxt or Route No.)
AIYAtts Yj nnanoi2 , ee JS7'Sl19
City or Town State Zip Code
( -4 a8- 7a 90
Area code- Phone number
4. DATE DRILLED /0 -d/-
OY
5.TOTAL DEPTH: <2GP
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO t7�
7. STATIC WATER LEVEL Below Top of Casing: 30 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): /0 METHOD OF TEST Pit
10. WATER ZONES (depth):
11. DISINFECTION: Type 9 7f1 Amount /0 Oz.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To a Ft._(e_t___ 5ba2 ( Vyc
From To
From To
13. GROUT: Depth
From 0 To 9C1
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Ft.
Ft.
Material Method
Ft. Cr�nGro1-e PO Lanz)
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Material
Topographic/Land setting
[(Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of/ell location
as/cbVIROW eV �t
(degreesiminutes/secon s)
Latitude/longitude source: IEldPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formatioqn Descr ption
ssicYck s*r,-t
/4 c20 ern lit
to
��G
ar
--c
•
0
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.
#41.140,. 1770otlea4t,, N.C'.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE F 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��tResources - Division�of Water Quality - Groundwater Section �--ss ��99//
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i•fA r k A-11, n CERTIFICATION#3.7Y(p
WELL CONTRACTOR COMPANY NAME ftrr:5oa) U tII Zlr il(enq PHONE Patti Ia S/3-/5471/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 1;11/Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nease„,§tTo}wvn: Ltr 'f County VA/Vet
CUfen
f fGG
(Street Name, Numbers, ommunity, Subdivision, Lot No., Zip Code)
3. OWNER: /a? rink
�etre, j
Address 44.7 in Nl et
a �� al.
eu /..L (Street or RouteNo.) 4 Q 7/9
City or Town State Zip
Zipp Code
(4 - 68. - 9659
Area code- Phone number
4. DATE DRILLED gi " r3 �6
5. TOTAL DEPTH: C�
6. DOES WELL REPLACE EXISTING WELL? YES '❑/ NO F3--
7. STATIC WATER LEVEL Below Top of Casing: VssS 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 T ST �'
10. WATER ZONES (depth): - N/. p
11. DISINFECTION: Type /17N Amount &2 Qz"
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. M�`,�aterial
From 0 To Ft. & v 5,171i.d/ pvC—
From To Ft.
From To Ft.
13. GROUT: Depth
From 6 To 9 Ft.
Material
tonCro I-e
Method
pa ur¢J
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
igiaidge 0Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well loc ion
a /S- 51/AA au/ 1:7 17 VV
( egrees/minutes/second
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
DEPTH
From To
0 iD
For}ttption Description
T
LOCATION SKETCH -.
Show direction anddjstance in miles from at least
two State Roads or CountylRtoads. Include the road
numbers and common road/names.
Samt4.02112, /✓e
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STAND DS, A D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
is a3-6
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

311425
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - (INDIVIDUAL) Division of Water Quality - Groundwater Section -�
WELL CONTRACTOR (INDDUAL) NAME (print) r k 416 el CERTIFICATION #-� �q�
/fp/q
WELL CONTRACTOR COMPANY NAME AcerodLSO al th/PII 11ri1(:ng PHONE Wp�Y) �a V3 -/Tp,i/
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 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 2tnfnc'v,ile County L/A/IGGry
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Er/G Leuo141,4,
Address Tj) 6. Roy 3G S
(Sneer or Route No.)
.ZdanLrOVAL Na -fA7//
City or Town State Zip Code
.Area code- Phone number �/
4. DATE DRILLED /d - 3 " 0/
5. TOTAL DEPTH: V44
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): < �d METHODTEST Rix
10. WATER ZONES (depth): Y VOL)
11. DISINFECTION: Type /% 7f/
12. CASING:
l Depth.._ Di eter
From f/ To (b t Ft._ _
From To Ft.
From To _ Ft.
13. GROUT: Depth
From n To 9f7 Ft.
Amount
Wall Thickness
or Weight/Ft. Material
OZ.
Material
&One ro 1-e
Method
l
Po urea
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
tdge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
ALDO
(degrees/minutetseconds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fortrt}ttion Description
6 t/Q CA'17
/o r Stin / ,S/u.74_
6— 70 5k9'Le-
7/ ? V
G Zc
A
Ca
LOCATION SKETCH
Show direction and distance in miles from at least "a
two State Roads or County Roads. Include the road
numbers and common road names.
d,aitf,ve
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
.722a dfY?( l 02 ` 3 `2V
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 -� �q�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i Via c I",41 t _____ pCERTIFICATION #/q
WELL CONTRACTOR COMPANY NAME Ar�� so a) CQ e 11 ZN c- :II,ng PHONE WV) GV3-/T7/
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
7
WELL USE (Check Applicable Box): Residential e Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
T Zip Code
Area code- Phone number
4. DATE DRILLED 42 — 7 64
5. TOTAL DEPTH: p% V
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 7/) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth)* ner - 0 O
Topographic/Land setting
❑Ridge 0Slope GlVellef ❑Flat
(check appropriate box)
Latitude/longitude of well to ti n
3 7SS. e cbv•O,P�
(degrees/minutes/sec
Latitude/longitude source:
DEPTH
From To
n .2(
WELL LOCATION:
Nearest Town: r County 49-a
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: CU.'nSM9] P'tas�f lac
Address /4LS /i/a t 0629u2laL// JjdaPt
/�UN� a queer oVC No.) 4 d?/7
City or own State O
11
12
DISINFECTION: Type
CASING:
Depth
From O To �o Ft.
From To Ft..
From To Ft.
13. GROUT: Depth
From_a__To 9n Ft.
H 7Amount silo 61.
Wall Thickness
Digmeter or Weight/Ft. Material
(CDR 2( f<--
Material
£X9ncro FP
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
Method
Po LA.rQJ
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
ds)
S❑Topographic map
(check box)
DRILLING LOG
Forttlation Description
4
W
O
(II
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.
yrthinvniate Ale
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTI N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
7-
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

3i1429
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) MCI r %
A-11,. CERTIFICATION#307tep
WELL CONTRACTOR COMPANY NAME Fe%iisaal INeI I b PHONE itge) i9j -9,//7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I9/ Municipal/Publie 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLLOCAT IN:
NearregLt Town: t 1 County �7r
5Clef- 6 r /* " °4. ()ice S / r
(Street Name, Numbers, Confmuniry, Subdivision, No., Zip Code)
3. OWNER: glIVJre.�-' �724,k"��
Address .14V G 1,4n/i/ e)ael
��..//j�� (jStreet or a No.)
)4x1,1ALa n /`e (? 487/9'
Zip Code
(- /o A.? - 410//
Area code- Phone number
City or Town State
4. DATE DRILLED /92 " o
5. TOTAL DEPTH: �C
6. DOES WELL REPLACE EXISTING WELL', YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing: a C 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)
10. WATER ZONES (depth): WOO l /
Amount �% Ot.
11. DISINFECTION: Type W 7 -/
12. CASING:
Depth _ iameter
From 0 To n Ft GP k
From To Ft.
From To Ft.
13. GROUT: Depth
From_ To 9 (} Ft.
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Wall Thickness
or Weight/Ft. Material
s-221 Tvc-
Material I
fbncrote
Method
l
PO urQJ
Ft.
Diameter Slot Size Material
Ft in. in.
Ft. in. in.
Depth Size Material
From To Ft
From T Ft.
Topographic/Land etting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Lan de/longitudeofwell ocation
3S4S6.30?1t • A.Ya' ,Qd.11 QvJ
(degrees/minutes/ - ands)
Latitude/longitude source: r S❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fortpationp escr'ption
JD 5sn'd 6$arlw-
`Ti-�
ra
r1
&If -nerd IFS__ ,l
n
°i
tQJt
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County_Roads.Include the road
numbers and common road narpes;.
o UaCjit
r /C
16. REMARKS: iii
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STAND DS, 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 Natural Resources - Division/l1of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /•fair £ 4r16VA CERTIFICATION a (p�p�
WELL CONTRACTOR COMPANY NAME F/rS, zso a) tQ till -brrlli»� PHONE titan �Y3 '! r/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITit
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential a 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:
Neare tT wn: 8url).SVine County yrlflCC y
tido e rf,s (ree
(Street Name, Numbers, Community, Subdivision.rLot No., Zip Code)
3. OWNER: .TAC4 LIP fit 4 g
Address /0 0 Ygo e 9
(Street or Route NNoo.trite tup We n2 y
City or Town State Zip Code
(8V ir- n3.71
Area code- Phone number
4. DATE DRILLED `/ 30 -0
5. TOTAL DEPTH: /420
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IY
7. STATIC WATER LEVEL Below Top of Casing: Al.) 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 Rift
10. WATER ZONES (depth):
11. DISINFECTION: Type H 7//
12. CASING:
Depthq
From To t / Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From f1 To al) Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Diameter
68
Amount
Wall Thickness
or Wei t/Ft. Materia
Material
£Ancro j'P
7
OZ-
Method
POLikro d
Slot Size Material
in.
in.
Topographic/L ndjs tig
❑Ridge 0Slope aft Iley ❑Flat
(check appropriate box)
Latitude/longitude of we l location
3c/VrJth.II- oaa/' . Pi l.'
(degrees/minutes/seconds)
Latitude/longitude source: atCtSOTopographic reap
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
n (a
bho/e
54%,7c/ ;3a(sr>-cam
CJ
(J1
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: ' ` zz Uiliac , C
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
SIGI URE PERSON CONSTRUCTING THE WELL // 3o v /
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

311
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturalr1�tResources - Division/�1of Water Quality - Groundwater Section �--ss ��99//
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Mai r 1.- 141(o h CERTIFICATION #.Jap/'.,e(
WELL CONTRACTOR COMPANY NAME Fe_rr sot, ll✓GI 1 IN 1-: Ili, PHONE WO %Y3-/Tr/
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 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Bums ✓i �P County�r Yee, el es
s E,ri• /.oinlr-
(Street Name,
bers. Communi{y, Subdivision, Lot No., Zip C de)
3. 7'Q OWNER: min.
_41
Address //(1 �'p!/4�j1� %]f�Of
(Street or Route N6 )
City or Town State Zip Code
(tom 4 IC." S.SZ
Area code- Phone number
4. DATE DRILLED /� g (7 V
5. TOTAL DEPTH: 8,79.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: .30 FT.
/ (Use"+" if Above Top of Casing)
8. TOP OF CASING IS ` FT. Above Land Surface*
'Top of casing terminated atior below land surface requires a
variance in accordance ith ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST /)
10. WATER ZONES (depth): /tr
11. DISINFECTION: Type H 7 f/ Amount aZ'
12. CASING: Wall Thickness
p, Depth 0/ D' [peter or Weight/Ft. Mat
From lJ To (0 Ft. ,I -? �.2-1 3'erG
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
POur¢A[
Fro mt5To 9fl Ft. Conerai-e
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.
WUA-Madste, Ate
16. REMARKS:
Topographic/Land se_aing
❑Ridge ❑Slope te"oney ❑Flat
(check appropriate box)
Latitude/longitude of well location
ar/6:7,967n1- on/13,ova'
(degrees.minutes/s onds)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
G'Grw c1
DEPTH
From To
./ r4nrc
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 ISA NCAC 2C, WELL
CONSTRUC3'ION STANDDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/7-•-•V<°7
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. 07/200I

31"
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural���Resources - Division of Water Quality - Groundwater Section 'q/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) MA r �" A-1 �n ✓l CERTIFICATION # Y(p fj
fe co,45a ») uJLll �t-i l(.nry PHONE M" 1 65/3 —'Y /
ASSOCIATED WQ PERMIT#
(if applicable)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential IEVMunicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: ,
yL
Nearest Town:
/3unsv.-Ile— County
tir9/2eEY
�%C-rJ'1'YV f rt R4'yr / 'M10 SrtUAA
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3.OWNER: I ,CAde/ z0 4s
Address 14Not d nrliA ]e
(Street or Route No.) /
etaww.l t +r 1/z. NC!r 1/ /Y
City or Town State. Zip Code
is- S"95/7
Area code- Phone number (/
4. DATE DRILLED /-/" 7 /0 ' 0
5. TOTAL DEPTH: WC
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
7. STATIC WATER LEVEL Below Top of Casing: in0 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): 7 METHOQ% OF TEST N.
10. WATER ZONES (depth): ??O
11. DISINFECTION: Type fY rill Amount
12. CASING: Wall Thicicness
Depth Diameter or Weight/Ft. Material
0 To 56— FL -• ➢vf
From
From To Ft
d/S oz.
From To Ft.
13. GROUT: Depth Material Method
From_0 To a!) Ft. L`oncro (-e POt ireLl
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.
Mtpographic/Land setting
ge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location ,
35—e t/p-s71ri/osa //.77 �'
(degrees/minCtes/secands)
Latitude/longitude source: ❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D O Clay
-)I er- :Xd Wit✓
L
vJ
zo-
O
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 I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
oV
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