Cl CY2005

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality eater Section �
WELL CONTRACTOR(INDIVIDUAL)NAME (print) W��U R'I,\S.\(1r. S 'CATIONN#
WELL CONTRACTOR COMPANY NAMEt3V�L1,� ���
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ff Municipal/Public ❑ Industrial ❑ ,al❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic) 'tting
Nearest Town:
nn, �t'�Jl�- County � ❑Ridge ❑Slope ✓ ,v ❑Flat
(
(iw''ttl-1 y-0-)1Nb - (check apt, )
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitud; I location
3. OWNER: (degrees/mint, is)
Address LatitudcAongitude sotrrce:C ":Topographic trap
��nn������..���� rr (Street or oute Na J e-�d •)
FSVIt_�11LUk. �C _ C/ uct DEPTH ILLING LOG
City or i �h Zip Code From To 'ion Description
� �)- J C) 13t -
Am code,Phone number
4. DATE DRILLED
5. TOTALDEPTH: Qlo,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 52
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing) _
8. TOP OF CASING IS , FT.Above Land Surface'
eTop of cuing terminated allor below land surface requires a -
varlance In accordance with ISA NCAC 2C.0118. -
9. YIELD(gpm):0 METHOD OF TEST _
10.WATER ZONES(depth):
LOCATION -H
11. DISINFECTION:Type Amount Show direction and distan, 'les from at least
12. CASING: Wall Thickness two State Roads or County s.Include a road
Depth l�aftte Weigh/Ft. Idataial numbers and common road S.
Fromm To��Ft. 4 Qa1• ff VC
From To Ft.
From To Ft.
13. GROUT: Mate 'al ethod ` 1
From_SZ To-' FL V-
From To Ft. ( C Y t l
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in.
From To Ft. in. in. (('1 o iP_
15. SAND/GRAVEL PACK: '==-
Depth Sim Material ri
From To Ft.
From To Ft. '
o ca
16. REMARKS: --t)C-X V*X-E `W� <b t��CLOF(LAC. g'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC. WELL
CONSTRUCTION STANDARD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOc 01'�R '
15��A pw-,Y LQ 9 d
SIGNATURE OF PERSON CO
RECEIVED
Submit the original to the Division of Water Quality,Grc andwater Section,1636 Mail Service c Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. FEB 07 2006 ' REV.07/2001
Asheville Regional Office
Aau'rfer Protection

00 J € 5 e3U 7
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources--p `�Division of Water Quality-Groundwater Secti//o��npp
WELL CONTRACTOR(INDMDUAL)NAM`EE(print)�1���\ '�egrz � T�E n s CERTIFICATION 0 2G` (g
WELL CONTRACTOR COMPANY NAME 6�'l ` '�-t �t—� �1�--1 -1�C� PHONE p f4K)2'
STATE WELL CONSTRUCTION PERMrr# ASSOCIATED WQ PERMIT#
ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal./Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopographicAm,&setting
Nearest Town: t�WfSA!u1-_ - CountyLI- ' ❑Ridge ❑Slope alley ❑Flat
\~60 C.6W'] --T K.-c At ) (check appropriate box)
(Street Name,Numbers,Commu
n
ity,Subdivision,Lot No.,Zip Code) Latitude longitude of well location
3. OWNER: (degrees/minuma/seconds)
Address \`3C) T LatitudeAongitude source:❑GPS❑Topographic map
(Street or Route No.) � II (check box)
�EenA\-1E z �q04 DEPTH DRILLING LOG
City or Town tale Zip Code From To Forrnntinn neSCript n
R - a - A(�s n - %t
Arcs code-Phone somber 1� OS — Sa'
4. DATE DRILLED
5. TOTAL DEPTH: aqQ1
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q1 ' ItiSr
7. STATIC WATER LEVEL Below Top of Casing: vZC7 FT. 1,
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of cuing terminated allor below land surface requires a
vulance In acmrd cq with 15A NCAC 2C.0118.
ELD 9. YI (gpm): t� ra METHOD OF TESTQ-
10.WATER ZONES(depth): ��
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dippggter qr V(ejght/Ft. at numbers and common road names.
From To�_Ft. 66 l�
From To Ft. a r
From To Ft. 4
13. GROUT: ep {a�_' _ Metho
From D
D T-' FL�t � D
From To Ft. r\.t
14. SCREEN: Depth Diameter Slot Sim Material O
From To Ft. in. in. CA
From To Ft. in. in. a
15. SAND/GRAVEL PACK-
Depth Sin Material
From To Ft.
From To Ft.
16. REMARKS: lktticsltL 5 H'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WE
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDE7 TO WELL WNER
01 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Rslelgh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 309197
North Carolina-Department of Environment ands Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) W Lw Rim v� S (t:7eyy
�,p-���tnNj CERTIFICcATIcON. S
WELL CONTRACTOR COMPANY NAME W P-CT I U_k %—�—U_10RA L,l"( PHONE
STATE WELL CONSTRUCTION PERMITN_ifslicable ASOCIATED WQ PERMTIN
(if applicable)
-
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOC O
N at own. C un Topogr ie/Land setting
_ ❑Ridge QSlope []Valley []Flat
(Strut Name umben,Con dry,Subdivision, No.,Tip Code) (Check appropriate box)
\ Latitude/longitude of well location
3. OWNER:
Address (degreeslmiautesheconds)
for Latitude/longitude source:❑GPS❑Topographic map
(check box)
i or Town ss�a� �P Code DEPTH RILL
FrO iob r Formation cription
Area code-Phone number (otl?
4. DATE DRILLED
5. TOTAL DEFTH: 1 /
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO [5
7. STATIC WATER LEVEL Below Top of Casing:_{Q-0--FT,
(Use-+-if Above Top of Cuing) r�
8. TOP OF CASING IS_L Fr,Above Land Surfaces a
'Top ofessina laminated at/or below land surface requires a =
varlaoee In acmirclance with 1SA NCAC 2C.0118.
9. YIELD(gpm): OF TEST
-
10.WATER ZONES(depth):
11. DISINFECTION:T e LOCATION SKETCH p
YP Amount Show direction and distance in miles from V)east 12. CASING: Wall Thiclotess two State Roads or County Roads.Include the roa�
Dep D er or Weight/Ft. a�tenal numbers and common road names
Frorr)_�To Ft.Di (e t ` '
From To Ft.
From Tc Ft. ^�
13. GROUT- Depth M e(tal Method Q `"i • I
From 0 Toi- 9—Ft
From To Ft.
14. SCREEN:
Depth Diameterr�
Slot Sim Material
From To 1
From To Ft. in, in. --FW37
Ft. in. in.
15. SAND/GRAVEL PACK
DePth Sim Material
From To Ft,
From To Ft. --
16. REMARKS: Gt1 �F 1 5
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE a
CONSTRUCTION STANDARDS,AND WITH 15A NCAC 2C,WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THHEµPE- t OWNER _
r SIGNATURE OF PERSON CONSTRUCTING THE WELL ElAtE
tr
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh If�F;
276991636 Phone No.[phone],within 30 days.
GW-1 REV.07/2gol

NC _v UITNEII p_C _
1�1lYXy� 3 t e3 I S7
WELL CONSTRUCTION ►UJ' C01m
Not Us Carolina-Dcparhncnl of Enviro meal and Notulal Resoulcc$-Division of Water Quality-Oroundwaler Secliml
WELL CON tRACTOR(INDIVIDUAL)NAME (p lnl) �)Oryl e R �,81r� n CEIIIIFICATIONa-2 O
WELL CON TRACTOR COMPANY NAME, 1')W C \, )pl( Arr' ,VnA rmONE 0 fZU51 Srz7--2WY
STATE WELL CONS MCI ION PERbll IN ASSOCIATED WQ l`ERlsII IRA
(ifnpplicnble) __ ____(Rfopplenblc)
I. WELL USE(Check Applienble 11un), Resideolinl liJ/Municipal/Public U Industrial U Agricultural U
himliloling U Recovery U llcal l'unip Walcr Injection U Other U If OUler,LISI Uae
2. WELL LOCAL UN: 'Fopogrnphic/Lnnd selling
Neatest Town: Couldy UILldge rQSi'1pe Malley Uflal
(ch"It appi mJnie box)
(SSooeeet NLso-ier,,1N•vn+i-bar-e l-ommunhy,Subdirirlpy Lot No.,Zip,Cl-le) Lallludetlu gilude Of well location
►` 3s�o ss'' f w8s°ply' lG`'
3. OWNEIL: rlC (\ (depleedminutr�lecondr)
Address pn B Laliludellongilude source:UCPSUTupagtnpbic nwp
(Sueel a Itoute No.) (°limit box)
s„ 1 Ile NL Pam— MULLINU 4_V_Q
City orlown Ste(e Zip care noel, o F rlilall0l1Ucsmipli011
Air2 cedr-rhnne ninnber
4. DATE DRILLED r7- �O - OS
5. 10TAL DEPTH: yUG'
6. DOES WELL REPLACE GXISTINO WGLL7 YGS U NO La - ?
7. STATIC WATER LEVEL Below•I'op of Cnsiugt--63) _I
(Ire"i-"If Abovc'I np or Ceeinp) C
B. 101, Cl-'CASING IS_�__1r1'. Above Loud Solloce•
.Top°r nrlap Irrndnelyd eUrr Delon lend nn Lce r<quhn• O
♦silence In■ccordsiae wllh ISA NCAC rC.011a. 1
9. YIELD (gpin):'—METHOD OF TEST A; e 0
IU.WATER ZONES(depth): cn
LWAIMMMU
it. DISINFGCIION:'fype Amuuul_1 S Slow direction and distance in miles Eon at IcA
12. CASING: Wall thickness two Slate Roads or County Roads.Include We road
DRAM Dinnteler or WeigilYK Material I'll"' ra and common road names.
Ficin To 2L FL Fora
Aunt To rl.
Front To rl. )ytcCraken
13. GROUT: Dep111 bi icual Mediod BV
riom o To�r_11. o�,elc
I'wm 3 To n'FI.
14. SCREEN: Depth Dialnelcr Slot Size Material ro e-
Flout To Ft. in. 111.
°rout 'f0__ft. in• 10' q�leS
15. SAND/GILAVEI. PACK: b
Drplh Size hlntedal Vr cIJ
1,10111 1'0 FL
Flom To H. �r6
16. RENIAMS: _
I DO I WREBY CGII MY I IIATII IIS WELL WAS CONS I'RUCI HD IN ACCORDANCE WIT11 ISA NCAC M WITL
CONS-111UC110N STANDARDS,AND 111AT ACOPY Or 1111S RECORD HAS BEEN PROVIDED T0711B WELL OWNER
SIUNA'IUIIGUI'PERSON CONSI'1lUCfING Till!WELL DATB
Su1n1111ie nl Iginnl to the Dlvi11011 of Wit let QonIlly,Croundsraler Secllonr 1636 Mall Service Censer-Italelgh,NC
27699-I636 r[to uc No.[phone],ish Ill t 30 days. OW-1 RLIV.07/2UU1

NC _ 11 Pllfll
WELL CONSTRUCTION REI COttU Gi! 306912
North Carolina-Dcparhnent of Environment and Nnlural Resources-Division of Water Quality-Groundwater Section
WELL CON"TRACTOR(INDIVIDUAL)NAME (prhu) )OyKe� Q u--) `-rnyl CERTIFICATION111-2yD4
WELL CONTRACTOR COatrANY NAME M N:ctr V3,uAj HIONE It i&gd S 2997
STATE WELL CONSTRUCTION rERa11TN ASSOCIATED WQ MMtITN
(ifnpplicnbk) (ifepplicnble)
1. WELL USE (Check Applienble Box): Residential 0—Tlurricipal/Public O Industrial❑ Agricultural D
Monitoring ❑ Recovery ❑ Ifeat Pump Water Injection O Other O If Other,List Use
2. WELL LOCATION: Topogrophic/Land setting
NcarestTown: �u oGtl Flo County ❑Ridge Mope OValley DFlal
`
(check appropriate box)
(Stre une,Numbers,Clnmmwntty,Subdivia1w.Lot No.,Zip Code) /t3y e rn�r�e of well location �x
3. OWNER: rr)j ��yxd' ' PCQT ,p f , (drgrcealminuter arcanda)
Address Z S 7 E 4 LliuJcllouiwdo source:OGPSOTopographic"Lip
(Street ra Route o.) (check bos)
4 z- a9Or{ pE1'lIl llBll11N�I�0�
AU-+ —�----- - a
City or low" State Zip Code Frtnn To Fort lion Description
Arrs code-Phone number
4. DATEDRILLED t- '-I-US- �� - IloC,
5. TOTAL DEPTH: \(of.` -
6. DOES WELL R171'LACLI EXISTING WFLL7 YES D NO Gil- r
7. STATIC WATER LEVEL Below Top of Casing: Z[>
(Use"+"If Above Top of Coring) tb
g. TOP OF CASING IS I ET.Above Land Surface" _ b
•Top c nrjoll accordance
Irdance d of/orISb C land .011 S.
r<q atra• Bf�
♦arlance In urnrdance with ISA NCAC IC.OI la. I
9. YIELD(gpnn):J,l_ —METHOD of TEST X le
10.WATER ZONES (dcplb),,: LOCATION SKETCH
11. DISINFECTION:'fype hClnmouul t5 Show direction distance in miles from at least
►2. CASING: Wall Thickness two Slate Roadt Gusty Roads. Include Ore road
Ueptlr Dinunelcr or WcighVFl. Material num and cor�udion road name .
From Q To ' D t Ft.� --
Front To Fl. 6a�
Ftom To FL 5"IW
13. OROUT: Depth Material Mediod
FronLD To ;Dt 1`1194-k ; �(w s y'rP �sf�IK ra
From To Ft.
14. SCREEN: Dcpdi Diameter Slot Size Material o
From 'Ib Ft. in. in. Th,rwpiF� - rr
From Tu Fl. in.
15. SANDIGRAVEL PACK: e
Depth Size I'laletial a u -
Front Tu FL Epoxy-
FrorL To Ft. old tpy
16. REMARKS:
I DO IIEREUY CERTIFYTIIATTIIIS WELL WAS CONSI'RUCfED IN ACCORDANCE WITH ISANCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF TI IIS RECORD HAS BEEN PROVIDED TO TI W WELL OWNER
SIUNAFURF 01:I'llRSON CONS'lRUC17NOTlIE WELL DATE
Sub nit the o11glnal to file DlvisloIt of Wit ter Quality,Grouudlvaler Sectlous 1636 Mail Service Center-Italeigh,NC
I7699-1616 Pltanc No.[phone].111011U 3p dn}'s OW-1 REV.07/2001

NC — — OWNER OP
1
WELL CONSTRUCTION 11CCORD 3 p 6 g 2 0
North Carolina-Dgaarmtent of Environment and Natural Resources-Division Of Water Quality-Groundwater Section -
WELLCON"rRAC-FOR(INmIVIDt1AL)NAAI,E�A(p��rint) . -, h7 5 #
� P, tA�� 1Gty Vl CERTIFICA710N
WELL CON TRACTOR COMPANY NAME 6A_ ,,10 C 'K)OA PIIONE 0 ( I
STATE WELL CONS'FlltICFION PERNIFI'# ASSOCIATED WQ PERMIT#
(if applicable) __ (if applicable)
1. WELL USE(Check Applicable Box): Residcmial 1p- Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoting❑ Recovery ❑ heal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: 7bpographiclLmid setting
Nearest'Townn: a3��C'',S-r( 2 Comdy Midge UJSlope ❑Valley ❑Plat
Ec75LV it-6 (check tpprrgritte box)
(Street Neme,Nu ,ben,Ctnnmuniiy,Subdivirinn,U t No,Zip Crnlr) Latiluddlon$ilude ofwell location
3. OWNFR:,jil/L9 �Gk _ 35`OZ 1I " W83°3q,02 `
(deareedm Imntt/teennd�)
Address I; 1_o U r' Lalitudc/longilude source:❑GPS❑Topographic map
tSn«t m Route Nn.) (check box)
>�-11e 4)( 7.YJ611 1alllll 1?liILGINSzL_04
CityM lbd, $dale lip CnJc
From '1'o Formation Description
Arta Phonemnnbrr,
4. lln-rE DRILLED
G. DOL•S WFLL REPLACE 6YISTING WLI.L'1 1'ES ❑ NO li)-
7. STATIC WATER LEVEL Dclow l'op of Casing:_5 0__F1', {
(Ure"r"if Above Tnp of Ca+inµ) A
8. TOP OF CASING IS_j-_-Ff.Above Lmld Sur Glee'
•Tnp of odor rerminatrd annr Ireton Itnd nrrhtt rtgnlrex a m -
xnitnre In ttrnrden ce nfib 15A NCAC 2C.0119.
9. YIELD(gpm): _NIETI IOD OF T FSI-A'k cn
10. WA Hit ZONES(depth):
_ LOCATIONS F'f ll
11. DISINFFC'TION:Type r_-2 Anrnnd 1j Show direction slid distance in miles from at Icast
12. CASING: Will[ I hickncss two Slate Roads or County Roads. Include life road IJ,41
Dcpnr Diameter or Weil;hUFt. Nlnlctiat numbers and common road names. m /
from
From Tb FL
13. GROUT Drplft Mnielial —_---- Method �a6 PCn lts,tr QLl l�fC ._
From 0_To �n , FI. �= F��+�rs7'-/'rrcy �'`�sc' C:
From To Ft.
14. SCREEN: Depth Dinnreler Slot Sizc Marcrial
From Tn Pr._in. in. _
Front ,10 Fl in. in.
15. SAND/GRAVFLPACK:
Depth Sizc Llalrri:d �= -
From To I-L _----- `
From TO1'r. _-- - .___._ :�$'x
— -
16. REMARKS:
1 DO IIERFRY CER 11FY*11IA1''IIIS W17LL WAS CON7II1,1,JCI111)IN ACCORDANCE Will ISA NCAC 2C,WELL �
CONSTRUCTION STANDARDS,AND TRAT A COPY OF 11IIS RECORD IIAS BEEN PROVIDED TO TIILI WELL OWNER ..
SIONAIUI(E 0171`ERSON CONSIRUCFINO TIIE WELL DATEco
0
Submit (fieoriglnnllnfileBIvtsInnofWaterQuality,GroundwaterSeellon, 1636Mpl[ServiceCenter-Rairigh,NC E'
27699-163F,rhnne No.[phone],vi Ithhr 30 days. OW-I REV.07/2001 ' .

fJC OWNLR ---- ---- (1 MWU
WELL CONSTRUCTION RECORD U 306921
Nolth Carolina-Depalmlent of Iinvimunlcol and Natural Resources-Division of Water Quality-Groundwater Seclion
T
WELL CON RACTOR(IN DIVIDUAL)NAOII�E'q(prh,r)--fit e1PS Y' I L)t`�nl'� CERTIFICATIONa�'����'�
R
WELL CONIACTOR COMPANY NAME.Li�1 1 '`N1� Jf'\l n(1 PIIONE / -Z /-J r•�i �'
f8�1•�>
STAKE WELL CONS I RUCTION PERAII _ ASSOCIA'TF.11 WQ PERMIT#
--rappbcabie)
(if Applicable)
1. WELL USE(Check Applicable Box): Residential IU,-'�,funicipal/Public❑ Industrial ❑ Agricultural❑
Afoniloring❑ Recovery ❑ Heat Ilmnp Waler Injcclion❑ Olher❑ If Olher,List Use
2. WELL LOCATION:
Nearest TO tn:41r� lea y'��t> Cumdy_ Topographic/Land setting
LA - �---- ❑Ridge []Slope ❑vauey ❑rlat
n e ,IICi��___ (check epp opriste boa) -
($beel Nome,Nmnben.Comoemily,SubdiAsion,Lnl Ito.,zip Iinle)
IaliludrrJlongiluJ5 of cllijocalion
/✓350j`pb W 350z3"
3. OWNI;R (de
Qren/minnte✓xecnnds)
AJdress 18 j( fxyCil Laliludc/lougilude source:❑GPS❑Topographic map
(Sorel nr Ronk No.) (check box)
— 1Ls� i�P ti'c z �rfc�r_ u4� =L�v�
City Io,vo stem r;pcoae From To Formation Description
" ,
Arcs rtrlo-Phone nnmbrr r
4. DATE DRILLED�- S' - `��`�' Vic'• ,n -
5. TOTAL DEPTD: .`i>;.`',' -= = --'` �ro.2: tv
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L-1-
7. STATIC WATER LEVEL Bclow"fop of Casing:
(Use"P if Above Top of Casi,jU
8. TOP OF CASING IS FT. Above land Surface• z
•Top orraxinp lerminarrtl infer bdew heed rurf.ce requ6n
""Isere In xvordmre w111;I5A NCAC 2C'0118' -
9. YIELD(gpr„):�3 METHOD OF I STD _ _
10.WATER ZONES(depih): - C
mul LOCATION SKEK11
11. 1)1SINFE-MON:Typed p��p S Arm 1; Show direction and distan m toile,from at Icmt
12. CASING: 1 Wnll'ILi,knesa two State Roads or County Dads.Include the road
Depth Dizmcler or WeiphUi7t. Alnictial numbers and common road names.
Front 0 _1'0 "Li Ft.
1710111 To 17t.
From To 17t.
13. GROUT: Depth r mere I Method
From F, To
From To Fl. _ -(
14. SCREEN: Drptll Diameter SIM Sire I,Iatrllal <`vG� aWr>ll
Front To Ft. in. in.
Ft. in.
15. SAND/GRAVFLPACK:
Deplll Size Malelial
From TD F,. A-
Front To Ft.
I6. REMARKS:
1 DO IIERF.Dti'CER"I1FY 171Af'rl{IS WELL WAS('UNSTRIIC11iD IN ACIX)ILDANCE WI'lll ISANCAC 2C,WELL
CON/S�TRUCT'ION S"I'ANDARDS,AND TI IAT A COPY Or'I I JIS RECORD I IAS BEEN PROVIDED TO TIM WELL OWNEIL :
SIGNATUREOir PERSON CONS IRUC11NG IMWELL cc
DATE
Submit the Original to the llh•ision of\Valor Quality,Croundssaler Section, 1636 Mall Service Center-Raleigh,NC
27699-1fi.m cheer No.[phone],u 11hht 30 days. OW-1 REV, 07/2001

N C ✓ _ OWNER --____-- 3 0 816 5 m""
WELL CONSTRUCTION RECORD
Nor lh Carol iva-Depaitulenl of Etwimintienl nod Natural Resources-Division of Water Quality-Groundwater Section
T WELL CONRACTOR(INDIVIDUAL)NAME (prlel)yrlAvylNt 1t� IAS 'Vtt-1 CERTIFICATION a-2YO-q
%VEIL CON'I RACT(IR COMPANY NAME MA10 C LA'lQ2 llfg,, viG PRONE a th1Y1 $ -TLI- fy
STATE IVELL CONSTRUCTION PF.RMI 10 ASSOCIATED WQ PERMITM
(if applicable) (ifapplicoble) -__-_-
I. WELL USE(Check Applicable Box): Residculial[Municipal/public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ licit Pump Water Injection❑ Other O If Of11er,List Use
a
2. WELL LOCATION: TopograpLic/Land selling ti
Nearest Town: County 1-1CLy 1131tirIge []Slope Valley ❑Flat
JG ci. S_ ___._ (check appropriate box) A
(Sheet Name, umber,,Community,Subdivishm,Lel N,. Zip Csxle) Latiludellongitude of well location ;
315
3. OWNFR:-j _ __ (degsm/minutea/secondr) -
Address Ig 70 .S V(_2 t k t � Laliluddbngifude source:OGPSOTopographic map
(Soeet M Rome Nu.) (ehak box)
nT"of _Be.c(L l---EL---3 :t2-6 Mrw MLUN_4UQQ
City or Tmvn sate zip Cede From To Formation Description
Am rgxie-rhene number Lr�t ..
4. DATE DRILLED �_yi5- }1P1' - ICUs
5. TOTAL DEP'1IL :248' _ ?
6. DOHS WELL RFPLACH EXISTING WELL7 YES O NO hY i
7. STATIC WATER LEVEL Below Top of Casing:_t&q Fr.
(Uge•'V'if Above l ep of Casing) <
8. TOP OF CASING IS I 171'.Above Land Surface"
-Top orcadng terminaltd We,bNaw load nnfaee require,a T
-�r
vadxnee In scrordanre with 15A NCAC 2C.0119. � :3
9. YIELD(gun,): ICA METHOD OFT I'S lu},k _
10.WATER"ZONES(depdt): `^
LOCATION S.IL.TGIi
I1. DISINFECTION:'fype } LLf9Z AmomR_ L5 Show direction and distance in miles from at asf
12. CASING: Wall'llticknrns two Stale Roads or County Roads. Include I e road
Depth Diameter or Wcight/FL Mntetial numbers and common mad names.
Front��_•fob 1_Ft.�,� .54.r. �_ �vc _ •,.,u/ -
rrolrt TD FL
rmm _
13. GROUT: Depth Mntctinl Method
From TD FL—
From `5
From To 171-
14. SCREEN: Dcpol Dimnetcr Slot Site Material S
From To Ft. ill. in.
From To Ft. in. in.
15. SAND/GRAVELPACK:
Depth Size htutcfial ��y
From ro I L 7 I R�
From To FL pctbSr�T�1 I ( 4
i
}
16. REMARKS:
{
DO HEREBY CERTIFY I HA"r i Ris WELL WAS CONS I ROCIED IN ACCORDANCE WIT11 15ANCAC 2C,WELL ? f
CONSTRUCTION STANDARDS,ANDTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOTR WELL OWNER
SIGNATURE OF PERSON CONS RU(71N0 THE WELL DATE
Submit lite orI{;Innl to file Division of Witter Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 phone No.[phone],wifbin 30 days. GW-1 REV,07/2001

oP ..
WELL CONSTRUCTION RECORD 3 0 815 8
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
' IQr- ,^
WELL CONTRACTOR(INDIVIDUAL)NAME (prin0' aQrvtPS �� t CERTIFICATION# ' LaU
WELL CONTRACTOR COMPANY NAME
ffil\I'P CILI)M t�r '11� ✓a4 PHONENfscivl
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential GI Municipal/Public❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other[] If Other,List Use
2. WELL LOCATI N: opographic/Land setting -"
Nearest Town: County ( _ 'I i — 131tidge OSlope OValley []Flat J
(check appropriate box)
Latimd�/lon nude of well location
(Street Name,Numbers,CommuniQ,Subdivision,Lot No.,Zip Code) silt zS � �r/ 1g�p�i Z�
3. OWNER' I�� i`e o "n (degrees/minuteefseconds)
Address Latimde/longitude source:OGPSOTopographicmip
(check box)
(Street or Route No.) DEPTH DRILLING LOG
From To Formation Description
City or Town Slate Zip Code C, 1 0 , e-1 "4 _ _-
Area code-Phone number
4. DATE DRILLED
r�
5. TOTAL DEPTH: Y CI D
6. DOES WELL REPLACE EXISTING WELL? YES[] NO m tP
—
7. STATIC WATER LEVEL Below Top of Casing:_AD(I!_FT.
(Use"+"if Above Top of Casing) 17 1)
8. TOP OF CASING IS FT.Above Land Surface*
-Top of using terminated atlor below land surface requires■
variance in accordance with 15A NCAC 2C.01Is. p Y
9. YIELD(gpm): (ef) METHOD OF TEST d 1 (? A
10.WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type�C , p\(o : AmDmt I Show direction and distance in miles from at least
12. CASING: 1 Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/FL Material numbers and comet road names. �Il
From__jLL._To_L6 Ft. (o,_x__ bZ1I VC--
From To Ft.
From To FL
13. GROUT: Depth Material Method
From D To_,2_j:2_LFt. \7nVkLlaik
From To Ft. \\/\`
14. SCREEN: Depth Diameter Slot Size Material
From Tri Ft. in, in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material e
wv
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
77TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER .
r SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Ceentert Raleigh,
NC 1
27699-1636 Phone No.[phone],within 30 days.

111 N lI Ili)
WELL CONSTRUCTION RECORD 3 G 9 8 9 4
IJolIll C'alolina -Depattolcml of Poviiit o icol and Nnlutal ltcaoulccs-Division of Water Qunlily- Onnuldwalct Section,
1VF.I.LCONIltACIUIt(INP11'IUIIAI.)NAPIE (1'+,,111" )1. 1ow Q-s plia_ tom, 11�$£71�-- +CFIl11rICA110NNLaQ
1%FLL CON I IIACIOlt CUNII-ANY NAME_a'rjl@-..1__�- -_C,.1=r 11 r-lyQ—_—_—_-_1'IIUNC N 11211.-r 7= GG7
51-AIF.OFI,L CItNS I1t N1'III/N I'F:IIa111M-_---------_— _—ASSOCIAMIPIVI)PEI1a117N
if n • rlicaldr if n , dicablc
IT
I. WI°I.1, USF (Chrck Applicnble Ilos): Itc^idrltlinl la—Mlimicipal/Public U Indusllial lJ Agiictdmoal U
Plnnilnl ing U Recovriy LI l lcat 1'tnnp 1Vnlri Injection U O1hct U If Ulhcr,List Ilse __
2. W ILI, I OCA 1101,1: I'opn(trapbi /land xllillg
IJcalrs1Cl"'I owls rl_ �-1`----Counly_�yp�(_--_-- 196)go LlSlupc IMillry UI lat
_ cx:Ji1l1Ct._ C.�Q��C khrrk nr pugnime M1nn)
($arrl Nm e. tal IL,.,Tip 1'rde) l.,llh llld C/1(111g11111IC of well locahnit
1. U1C rJ l'It: L)��'�,�J_1VS.�.—_______— (rkp,erdminno-Nvcnnd•)
Addlcss _..w1A-_ _.. ti_f�SSPI.r�-mod_---- LnliIutledollgifudcsourec:LI(;PSIJfol+uglaplricmap
(Sw,l nt Il(nle fit,I (chrck Iwo)
City of nor, 'SIM, Zip Code Ilum 'I'o Fomunlion hcsaiptiuu
A,rn rrvl.- rannr num(,c,
A. PA IT DRILI 1:1) IL r;9-
5. 1M*ALDITIIL_ags —
G. DOFS WFIA, Rlil'LA(T F.\ISiltJti WF1.17 )'IiS U I40 11— -
7. S fATIC WAlli1C LliVlil. Dclnw'fap of(':,sing:_.1_pp_ _FL
(1 hr"r"If Ahnvr Irgr of 1'n-.inpl at
_ T
R. 'fn1• (117 CASIVNI IS \ I-1'. Above I nod Sulfilce' — � —
•7 r•Ir of rrJnp In ndn nlyd nl/�n'Lrinv In,d rn,lrre Irsluh rr • --- � -r
vnlrnre In perntdu,ce nith 15A NCAC W.111IN. — P3
Q. YIII.D ( rpm): 1\11 fIlOU UF'fFST_�
10. \VA I ER ZUNFs (depill): —_- _—_ ---
' ` LSLGA1�ICrldSKICC')l
sl
I I. DISINI'11.C11OtJ:'fppc �--��- - sltotV dilcclion and disfauce oil miles limn n1 IC!
12. C'r1$IIJI;: 1VaIl'Ihickncss Iwo Slate Roads or County (toads. locludc 111c oad
Drplh Dinmelcr ut Weight/H. h)nlclial numbers and common toad names.
Ilom�_'fo US_ FI. Cv'a5 � 5.21 �VL �c1�
I'nnn 'fo I't. _ {2,,xfc1"5
Flom 'fu I1 --- ---.-_-- c_%,drr
13. OROUI': Drpllt A\lnlrl,i1l INI it tl ____-it
Ilmu Io �J I'I.gcn71)Y T _Qe1��on(��Lf£SSsdf_t
1-1. SCREEN: 11rp1h Dimucicr SlotSi7c Plalclinl
Mont 'fo I711. in. ---
Ilom ---
15, SAND/DRAM(. PACT::
Droll Sim I,Inlclinl
0
16. REMAINKS:— _ _ -
1 DU III:III llY C I:RI If Y II M '1 I IIS WILL WAS('0I1SI'It1ICl FI) Ill ACCORDANCE WITH f 15A IJCAC 217,IVELI,
CAN
L'__
ICDs, D'IIIAI'A COPY OF'1 HIS ItECORD HAS BEEN PROVIDED101[ILI WELL 0WHER
_ _ _ 3-_a 5--0SSIGIIAI111M(WI•IIMINCONSIRUCIlWYJIR!WELL DALE
submit the al Il,ln tl lu the Ilh islon at\Pater IJunlily,(.1 omnlhvliler Sccllon, 1676 pinll Scrvlce Crutcr- Itn)riLit, w
276­n Pr I' 1'!I, Irl(bhl tit (1%V-I VFV. 010Ofll

-- II II Ill li /fill)
309894 - -WELL CONSTRUCTION RECORD
14o1111 Carolina - Drpalintent of lalvinnuncul and Nnlulal Itcsoulces-Division of Wnlct Qunlily-UOIU I'd"'PicI Scc'iun
1%FLI CON-I IIACI Olt(INDIVIVIIAL)NAPIF. IPI lnl) Cv .1S.--I 1»_�1�`��1
ceunru:n'nuN n��/Dq
1%FLL CON I RACIOII C11p11'AN\'NAMIi_ r�� 1L��-/ -�`1.-1Y +- ------1' IONS. M
SI AI F.\PF.I,I,CONS I IIIiCI IUN I'F.I1n111M__.___ - ASSOCIAI RII wl)1pop lIP9
'F.I1h117M
if:i• dirul,lr if n r dicablc
I. 1V1 1.1, USE IChrrk Applicable Il(m) Itcnidrulial ILI,"hl till icilml/Publit: ❑ bnlushial U Agticulluml U
hlouilm ing Ll ltccovrly l._I I le:11 Ptuup 1Vnlrf Injeclion U Ulhcl L1 If 0111cr,list
2. WVI I. I OCA 11101.1: Ibpop'Otphic/Lnnd sciilig
I Jcalccl'I o\vll:p.t Ap$1��_—_-(�oilt11yCAQ1_V____ I�dge LlSlope, LIVnI(ry l_ll'lal
I_1iCll__.__-._.___.—__. (,he,It npprvprinie 6n<)
isurrl Onn.e,tlurnl,rL,(..11111r111111)',SIILIIIVIRI011,Ini Nn.,%Ip llVlr) LIIIIIudC11(III�IIIItIC of well locnllnlll`n
N35" �7
Ir
11 ,,I (drpren/alinnbrhrcnml•)
1. ll\1'lJlilt:_�-t,� OY_�-CEfCTY��---- - ---
a._-.--_.— Lnliludellungillide sutlimE liPSU fupnglnpbic nap
Addrecs 2330 Mirtoh..�_Qj Q----------
( nerl or It Gale IIll.) (check hn)
--��esvill�N� Z 8R It 1>.U_Ul 11BILI I11u Luu
t ilyrr Ic•rn smlt 7ii tldr ----- Flow 'IL pmmnlion l .cril, iuo •.
Arrn r•.le I'h•.nr nund�a __�l�' _ I�1
A. I)AII? DRII1I'i) J-�-s-O�---- Ian
-v
G. I\OI'S 1V191.1, I(I'I'I,AI'I'. I°.,`iISI RM WITI.7 YIS U IJU 11
7. SIAiIC1VAIFRI.FVVI, Dclow-f ill, ofCn^iogt-_,% ..- __I'I- (V—
((bt"V'If Aln•ve'lLq.ofl'n•ina)
fl. fl\I• ()1' CASINIJ IS _.I .-- _--_-- I-1. Abovr Lnud Sul lace'
•I.p rl rrlhlg Irl nd nand al/or Irrinn InnA ran larr n•lnhn a —
carinr<r In nr on dn¢e nli1, 15A NCAC IC 1111 G.
9. 1'Ilil.D (Ppnl): _14-__--h1RIIIUD01' '1FSI'� --
10. WA I ER ZUNI:S(dcptll): —_-.-- LSZCIII IU(J SY\4_L( il
_ Show diieclion Gild distance ill miles from ni Icnst
I I. I IISINI I.CTIUhL'fype Awmml-a S two SI. le Roads or Conuly Roads. hlclude the rond
12. CASING: Wall'Ihi(knc.^s
Drp1l1 Uimncicr or WcighVfl,�hl�nlclial uuwbc mid conuuou road ualucs.
1'l ill it —
Pnvn_
11. (7ROU I': hrplil lair ial [� M1lclbnd //r<se
Ilom�—To_.2r) -1_S. In �SSLjLv aW
hunt_ Car' er
14. SCREEN: D,11111 Uimncicr Slnl Sizc hlalainl o
o_-__-
15. SANDAURAVIT TACK: a e
Drell, Sire hhdclinl ,/ �i " --
Pmul .hI'_.- I.I'- ---------- - -
it_ 00
N
DU I11'Rf 111'(TR FIf l--I I IA f l I ll S WITL WAS C011S I RUCI RD Ill ACCORDANCIi W1111 15A PtAC 2C,WIiI l
CONS 1 RUCI ION S I'Af1DARDS,AIID'lllAl'A CUI'1'UI''I MS RECORD HAS BEEN PROVIDBD'FO7 m, WL'I:LOV 111T,— _ suaanluup.ufrr•.Its(IrlcuNsluu(-rlrulrneweLL un1l'.
.S'Id11111t the ill Ighrll In the 1111 idnu ill 11'11lcr( lmlil)',GI otlud\\•nler Section, 1636 pinll Service Ceulcr-IInIrIVII,tlr
,.r,na I"I( 1'(! nr f li,. ("I 111 711 t !'21,nIIblit IItd,•I.r GW-1IIEV:11101101
�.

��ff"'�` 30� 889 -
AVELL CONSTIMCTION REXOM)
140,ill Carolina •Dcpaltulerl of I?nvirollul(ut and Nntural Rcsoutces-Division of Water Quality-Oruundwalcr Section
R'F.1,4 CON'InACI Olt(INIrl1'llrllAL)NAME IPr InIJy
�'�SE,� cenlfrlcnlfoNn�!�&��
,nelll _ � ��_�Zr rnoNe, ns "_ 17
\\EL1.CON I IIAI'l lilt COW ANY NAME
SI"ATF,\\'F,I,I,CONSIItUC11UN 1'F.INIITN__-__-__— AS506AI EDvVf)1•F.I1all IN
ifn, rlicabic -
if
I. "10.1 USE (Check Applicable BOX): Ites Ytideolial h lunicipal/111b1ic U ludusnial U Agriculhual U
Mouiloliog U Recovcty U I leal 1'ungr water Injection U Olhcr❑ If Other,List Usc
2. NNTILI, LOCAl1( IJ: ""Opormphic/L.and setting
IJcalcsl'ro,vtl ^ _( ovuty�'t�ii�_ Tidge USlope Malley UI lal 00 _
(check npprnprinte Anx)
- Latilude/longitude of well lucal'mn
(Sorel tJmnq Nunilar.,('on,lnnnil),Subdivision U I it,,.71p('wle) r - _
3. OWNER:� (drprerJlninnlydemmnlQ .
Address -10 9-Lm �L_-way_ ,yt-OVA---- LatiludL/lougilude sourcc:U(iPSUI'upogralrhic neap
6 9 (check hu)
(.rnr I or aoole tln >>�eui ul-ULLIRG LUu
1'rnlll
II --
i1A er stme ZiIs�'e- (.— -4�- ----- Palion Description
CVo,Invp Code IU otrn -
A,rn v,ir- rhonr somber
4. DAIPDRI1,1.1?DZ- �U- OS '
a
(. D()Es W'I?L1,R111'I.ACL E.XIS"1ING, W1:1.1,7 ti'I?S U NU LUG
7. S FA"IIC WA I ER LEVEL l)clow"fop of C':Isiug
r'1'.
(U•a"r"K Above l op of Cn-iup 1 �-
N ~,
OI'l'ASIN(7 IS—_1____— I'I'. Above Land Smlacc"
•'1'rp of odnp,Ill nlnnlyd nll"r brinv Inod on lore req ah er• p '�
vIE In %crrn doneeellll I9A [-Il 247.1111 9. — —
v. YIELDuaLlD (hhnr): Cam_nu;ru" ou ur• �n �sr _
10. WrnTGR 7,ONL•S (depth$ LQCALI_Q.(J SKI LS)1
Mnouul_�S Show direction and distance in stiles fionl at least
it. DI51NrEC"PION:"I'}'peh� 1 null two Slate Roads or County Roads. Include the road
12. CASING: Wall'Ihickncss
Depth Dinmelet or 3Vcight/FL �Mnrtclial numbers and couunon road na ties.SDL2( 't vc"
From Ib Il.
1`lool "ro Et.--- --- --- �-
13. GROU r; Deptll M I sal Method
eil
•c Eli
Ilom�'ro�,�I'L — e-C�C�''-- h
171onl__"fo__
14. SCREEN: Depth Dimncler Slot Sim MNtclinl Z
hO----Ft' in.
15. SANDJORAVI?I. PACK:
Depth Sim nintelinl
floor To FL ___----
Fnnit .I -_-
'�;res
I(l. REMARKS: --
D(1 IIERGIt1'CI:I(Tlrl'llln'I"111151VP1.1,WAS('OPISTRUL'IFD IN ACCORDANCE W1111 15A I4CAC 2C,Wl:i.I.
CONS I RU(--I ION S IAM)ARDS,AND-II IA"I'A COPY OF'11IIS IT-CORD HAS BEEN PROVIDED TO TI IL WELL OV,'I lLR
---
SIGNAl(11W()I'PERSONCOI4SIRUC11NG'111LWLLL DATE
Stilnntt IIIe of li;hl11 ht the Ph Won of Water Qualily',GImuldwnlcr Sccllml, 1G36 mall ScnlccC('Nrl RI?IV. 07/2001
27G"^ I( rG 1•11rnr rh.. t9ln)'13 31N,»llldn

till It I it 1111 it
ce 309ti888
WELL CUNSTRUC'110N RECUM
14o1111 Clio Iilia -Dcpalhncnt of I![IV irounicul and Noluml Itcsout�ccs-Diiviiriml of Wnlcr Qunlily- Utoundwnlcr Sccliun
IN FLl,CON-I 1lACI Olt(INDIVIDUAL)NAME (11-1011) ,_IC `1'1PS\ JI]1_b.2.,_\�� �Ce1rI 1r7CnuUN na�/o4
\\'Fill,CON I IIA(.-1(III('0611'ANV NAME J1,j)..e-\�__lA1QdL-C.1rAIL� 1'l1UNE IF
—_.
5 rA IF,\1'ELL CONS I111C11UN 1'EIUII7N
ASSIICIA"1 ED\VIJ PERIMIN _--
01n ' •lirul4c ifn , dicnl,lc _ -
1, WFLI, USI; (Check Applicable Iloa): Iteridrutial ILIll`_Municipal/Public U Indushial ❑ Aglicullulal U b
Monilmiug ❑ Rem cly U I Icat I'ungr Walet Injection LI Ulhcr U If Olhcr,I,isl Usc
2. �VISLI, I OCAI 1ppl: Topoglnpbic/Land nclling -•
LISIo,c I 1(.W"allcy Milt rn
Ncalecl-1o,vc -- }' �LQ LIRid c
(check npprg,ekl•Am) >
tadkLlyv(_�r-�U{ __teS. Cie k (�d, _- _. Lnlitildelloogilude of INCH locatimi
(Snrrl tlnmglJnud�rp,Connnnnil},Sulnlirision ll,/�+l lllKa�.,lip l'rvlc)
3. O W NI'R:_ ��rr�=�is'r-+` (e source: lrrhrrn jfoll--'
Adnc�zs 712.5._�L W_m_\f '�if x, 91�E n�_— Laliludcllungiludesource.Ll(Icktl") q,uglaphicmap
(•".noel nr Itnme Nv) (chrck Mu)
_Lci sS e���_3.2 312 ------ 1)EUj1'f 1>ItILLI)�u_t.u4
Yp I'nae Fenn hu pr nnalian Dc.^.cliplion
('it) All loon $Inlr
Arrn rnlr- Thane nvn,l•rt ,
•i. DA I F DitIL1 261 l M51 p
—
(. 1\hliS 1VI?1.1, RI�PIA('I! EXISIIIJU 1VlSl..l;7 PISS LI 141) IL— _ _-
7. STAIIC NVA I I:It LBVt;l, l)clo,v'fop of('acing _ '._ __t I• —
(Urr"r"Ir ALnrr'I•q•of I'n�inpl
R. I.1)I' (ll' CASIN17 1S--- 1-1'. Above I.nud Sul lbec•
•lrl•el tr Any bnnlnnlyd aU••r Lrinv trod•nrinrr,nlnhn• �
rnrin,re In arcnnlma ntill BA NCAC P:.111IN.
9. a.0(cPl�r): —_l-g-- nualluu ur•rral_t-Q-- —rv---��
10. WATEIt ZONES (dep(b): ----- LQCA�IQId�SYv4CCll p
I I. I)ISINI IiCl1OW:'I'}pc �1$�IL¢#S Amould -15 Sbo S die Roo l and amity I in nrilcs l 1ldc Il a Wj
12. CASINO:
1V:,11'I bickncss hvo Slate Roads or County ILo, la- hlclude Ibe�d
Ueplh Uimncicr or wcighUl'1. binlctial nulllbcls told cunuuou road na Ic s
PN,nr-�_—'ro�.E2�l�t._�2J��z ���1 n✓�--t--- ee(( al�,tt�
17lom 'Ib Il. ---- k l*"
13. OROUF: Drptl, Aillrlinl1— hlclhud
vill
14. SCREEN: Dcptlr Uimncicr Slot Sim Matclinl
in
—_.-
15. SANIVURAVII,PACE:
Ur1,111 Site t,lnlclinl f (;(M" ,
form fo 1'1.--- —.---
16. RIibIAR1;5: ---
I)11111 11111}•(-I:R Nf}'I11Af'I IIIS WITI,WAS CONSI IMCIFI)III ACCORDANCE\VII II 15A PICAC 2C,1VITI,
CpI1S I ILUCI 1014 STANDARDS,AND111A7'A COPY LIFIIIIS RECORD HAS DEEN rikoVIDED TO T11L1 WELL OWI IER
SI(TJA1lIItEU1° I'ISItSUNCUIJSI1tUCI1NU•IIILrWL!LL RAIL
Submit lhr of igpl't1 10 Ibc Ph Won of 11'11trr 011 lily,(;I ouud I'll Alta-Section, 1636 Ainll Scnice C('`VrI R nirigh112"
,.,,m. „,r r•,._..., rl.. ialn\?ll 1•)1 ull lrl„ it1 �1t'1'n. -

IJC ✓` Illl ill li ^ .�Q i 1 is
1141"AA, CONSTRUCTION ION RECORD 309884
Pol III(':IToliin -Prpnlhncl:t of Fovilunmeul and IlMolal Resources- Uivi^ion of AValet Ounlily-Chound,•:ntrr Section
- ]PAT`�` r 1: .n I IIlCA I lot In,
)I'FI.L CUNT II:\C I o It(JNp r F II I n A I,)NAn IF Irr In') UCAY✓e&
IN FI.I.( ON I TACT OR( 1rn11•AN5'
rNltt+r n I`�tS.l f511;JG4'2
$1,11E ISF.I.1.CnNSlltO('IIUN I'LRrd 17P____. -�� - ASSIICIAIP.D R9J rF,l@lllp ___._ ----�--------
il n • dir 114r it n, rlicnblr _
I. R'PI.f, USE Il'hn l: Applicable Ilnsl: Ilrr:idruli.11 INKNjuuiripal/1•ablic LI Indusida O Ap.tic ullw al U
r.lollitonop. LI Rcroccry I Ilyd I'wnp Wnlrl brjccliuu 1.1 0111c1 I.I
I ()CA IIt if 1: 'Iopogl:ipbic/l and sctlinl;
I' �} >?511i��� ('�rnnly LSO\� IJRidge 1 ., upr I Ivnllry 111Inl
.rm rcl'fnv:n' __.
_ (ri,.rk npproprinV h,,•)
n-�,Nn��•.Nvnih- r�inn�n�nu? �d Ih i.i„n. I III,•,%i�1 �+Ir) Lnlihtrldhnrgthulc of v+rll locahnn
T '
I, 111`.IJI'I'.. At4 LG� 1^�e 14"Q1�. L/O IQAY Weiyold (lrµrcrdr iiinrl .v,�n 1•)
Adrhrzs 3�69 _Ga den Oaks. , W - _ .-_-- l 11ilud!Moogilodc soutcc:Ll(r1 SUIvi-Y, phic nrap
(cli rk)-n)
( I I ,, la,.d.Ito.)
IILI'lll 1g,ILI,IIR,_LVIi
�,�. ;i1,, ,,,h prom 'flr fonnntio❑ Ur uiptinn
----1 PIr t I a"n ` 6(
Ann nil IT it ��_--
1. 14\Il• ])III[ i
.1 l U -O _QJ�------_. __ - _ 155' -_—J�S�s7' =CfAd }CJ--
S. l l lrAl. Itl'1'1ll � tJr - ----" -
(i, 1t(tl°S WFT,1, RFPI.A I'll 1'V IS I It M WI;I_I --_--
7" S I AIIC 1VA77{It LI's1'lil, Ilclu,v ---- ---"_-- — -
(11.."t'II AI nr l�qr 11'miuF) __ -
F. ITTO17 CA S II IT; IC _ _. I . At,m,• L and SIIIFICe*
•l rp o(rnlny trrn�h�nhd nU�•r Lrli•n lend nnln�-r rs�pdn.• "----- -_----__—
.•,I•nrrIn <rrn dnnrr n10. 15A NCAC 21" Ill 19- —�----�" -
MRIIIOD ()p1l`•r;1_4; -- —�
11). WAI ER ZOIJGS Oct""): LQCAlIUI�_iY1=1:CI1 0
Sllow direction and distance ill miles "1(1110 Ica
II. IIISINII.CTII)IJ fvpc�]�� l���S A""""'I - ---
W:dI Ihir t ness Imo Slnle Roads or County ltonds. Include the re
12. Cr1:IN(;: ❑ Moberg and couunoll and n1111m
1 h•pllr Ilimucict or Al'ci{;hVpl. PLtict ial
Itvu, Io --- -- - —
l I, GROU1 tlrpth ((�� P.lttmrlyd JJ M1lrlhnd _ _
co -
il��nr y ' _Io. 3Q`) t'betl etri-, LSe-s.IiLc
14, SC RI IRI: It plh Uinwc(rr Sbd ';r;c r•tnlctinl °ec CD
in. ----
Boor----- 1 0---- 1-1. in.----.. -----
I'Iom .I. t- ---------
15. SAMI/GRAVII 1 ACK:
Situ F.Ldtnnl
Itrllh ���w
YwIll
I'm°r----lo IL-- --
16. PI PA AR I S: — — —-- -- -----------
I hO IIICI'I11' ('I'RIIP'i'I IIATI IIIS WITI,WAS COHSIIlIV11'D 111 ACCORDAIJC'WI111 15A IICAC 2C,AA'Ill.l.
C011SIRtol11ifISIAtIPARUS, AIJD'IIIAI'ACOp'i Of'IIIISIIRCORD HAS 131t_EII1'ROVIDED'10771EWFLLOP�I'ER
-
- -- - -
---Gz� ._ 11nrn.
sualnnnn ulrlRs III COIN uwCrllJcl'uuivJELI.
Submit (hr ntll;hrd I 'the Ith islon of W:ltrr I lualily,(;I umrthsnlrr Sutton, 1616 Qlnll Sealer C(1W'1 Il I"10v. 11/)1101
_•(, � IS •, t". n,I•,, ITT I"I ,111,1 rn n..� •.

00
Nvvu, CoNsinUC ION RECOM
IJnI Ih t`.uolin;l - I rrpalllncl:l of I'nvinnlun•ul nn4 I I;d111:11 HC9VIrI�ICI'9-n1VISl1111 llf 5'✓I,ICI 1)II11111y- (tln,llld\':Hill Srdinn
._ F� �� 't el II it ICA n fill n aa0q
R'FI I.CON IIt.\cIIIR(II+IMIiIIJA1.)NAIIIE Ilnlall�C:IYY5 ,5 -` `. SSE`- ---- ---- -.
1 ` _ - ___.- ----I•Iffir+C n Ly.2Y1 B3`7-a9�7
1\Et.LI'm4I It%cl UIIl Up11'AfIY N,\pIl'.YYI; E�. --6EAV. dl1l !hg -.
C1,\IE \tF LL('nry51❑Iq'1I11N I'LllPlllM.____ _ AS$III:IA'I Rll
it n , dicnbk
1, WF M I ISI'. Il'h•ck Applirnblc nn�l IG••:6lruli;J IYI�Nuniripnl/Public I I hulushinl 17 AI',liculbunl I_I
t.11•nihninJ; I..I IG•ro,cly LI Ilr:dI'nngrSVsh•1Injct Noll la Ulhrlll 1fUlhcf, List IIne-__-_._—___ _
2, R'I1I I (R';11ZII JI I
It In rgt•gJlil/I :unl t:ctliul;
1J`r` necl iJµe I_II;IuI,C I_IVall^y I Iflal
hbULl -LOL' _ . Rlvrk title
i•rwril
ICIvI _- - - I,nliluJc/Iunglhnlc of r:rll Inc.N u,n
I Irnd��l•,l',an,nuniry'..':nl,li�i.irn,I.,III•.•i ip 1'nlr)
�51 plrc,rrdminnl•,a nd•)
1, IIP;UI'P � IVv _ jJ _ _.. _
Addfr __.IUa 1'uS5 _./� h•1. : il ll ; ugilJc t-o— cal(I Jc1JlRl1l-1o,1l,,n11lIt1 aia1
I6!ic11;n
nnn
p
73 T3
l;I l It I,,
L ;!-' 80 1 1l (
OW✓\ Z millnliml cl"Iipli
✓�� ---
a nAlr• nun I 1:11_ 1D_
Y, nnl:S 5C1!1.1. ItPPLA(T.. PXIS-I IMI \':I'I I '7 .�-
7. S I A I IC 5VA 1 I:It 11;`VT Ilclu\v Top
Ta
((Lr••,• IJnI,,,,r I,.I,,,lre•;,,nl -n__------
---
J=. 1111' ill' l-ASIIUi IS _ I. 1-1. f\bf,v,• I and Sm lilcc'
•Lp el..dny In minnlyd ell•a 1•rl„n bn4 wllnrr ngnh r•+ --.--_-- --- —_-------(�-----�.
,.,Lntr ln •ron Atna nIIL IS,\ F7('Af'N'.f1I1N. \
v uF 111 U'1'InJ t© - r,uF rnvD —`A
10. NVA I ER i.11141:S (117111): LWn-1;IUj4 SYJ I 01
1' Alllnllll( _ `Q ill JlV dilcCli0II olld di91,111CC ill tltilC9 lttilil III Ica:
I I. nIS1111 1•V 11011: fypcVltiV1_����- — In•n Slnlc Road9 ur Conuty I'o. IIII udc dic 1nnJ
15'nll-I bn 4:nrs9
I2. Cr\Slpll;: numbcl9 mIJ cmillimll mad it'll
_C ^4.
I1•.I,Ih Cj Ilinmlrici III
Wright/H.H. �\hlnlct i:d
vc —
11, (illlllll : I+rPIh hl.n�lJrli:,l RlrlhuJ R�yc�
IA. �l RISL•II: I+�plll Ilimnrlrr - :;lal Si;c IJnlctinl
l5. S;\NI1/IiILAV'pI. PAL'I:: �1
11r1,111 !:ior Llydrtinl Dcl✓� -'� I � _
m
- • _ — __. ram, _
11`(1111"Ii111 (TIMI-i IHAI IIIU;WIA.1, V-W;('011;ll!IJCIFD Ill ACC(RDAIJCI'VAIII15A11CAC2C.V. II-
CUtJS I P,UI-I InIJ S I A1111A11U•C, Alit) IIIA F A C(JI''i VY I IIIS 11CCUILD IIAS DBIIN 1'11UVIDED'IU'111L V+I!I.L UV1111'.0
L 1 1ItUI I114" 111!WI!"' DA'I I!
511.81A l l 11.1 111 1'I'I(.;1 ID 1 I)Il,i
`:ubmil Ih• o111!In ,l It, Ihr Ills i,lnn Ill Wn(rl I lualdp,t:I unndll'nlcr Sccllun, 161f Moll Sri clr.rI':11141111111111

WELL CONSTRUCTION R COM 3116 61
I41.,1I1 Cato Iilm - Drpmlolc ld of LoVilour ncut moll tJ\nlulal Ilcsout7ccs-Uivir..io\n of Witter Qunlily-Utoundwntcr Sec ion
\VFI.I,CON I RACI ou(INUIVIuuAI.)NAIt1F, Iprinq_1(3vVJ_P b _l,._, .�Li242(Z 'cEmirICA-IIU11M a O14
\\FI,I,coNnlncruuconn•nm Nnn1F1�1;���c__�.•jull�r_��l;s_�------- --rnuNe n (Y2YLSs-17_29`L7
S I AI F. \V F.1,1.CItNS I IItIC'I IUN f F.IUIITH_—____—_--_--ASS(1C'IA'1 F.n\VQ I•EHAII IN
it a �lir mldc if n r 11icn6lc
I. \1'PLI, USU (Cheek Applicable Iloi): Itcaidrolinl Ill—I lllnicipal/Public U hldusidal IJ Ag6culi lal U
Nfouiloling U Itccovcty LI I leal I'mop Walri lujectioll U Ulhcr LJ If U(bct, List Usc
2. WFI I, 1 UCA 11011: 'Fopoginphil/Lnnd scllinl:
IJcm cst'fatere�y��Q,�V�y�___`__(•oulll)'__�Ir1(�—_— kjwlilge 1_ISlupe I-Milley Ul�lal
(chn#nlgiie,o vvcii)
(Sbrc lnnrt,IJvwbn.,Crnnnnm Ip,Snlnli vision,Ud Ih..,lip l'wlr) Lntlhl(1C/hlllg11 Ut1C of tCCll IUCnllvll
1. l)\C14I'11:.f(:4;L_ I lujrI_ - ___—____ (drgrerdminulydtcc,nr l.j
Address _1063_S$ _ sl._ lude/luuyiwde souice:U(;PS11ropoglaphic map
($Berl w it.nfir IJ(,.) ehrck hrn)
Awe } aL_ 3`h Q-- - -- Jul eut UIUL.I,Ir �I.Qt
('iy nr Jonn smlr Zip Cnar From To Founnlion Desclipliull
jr
nnm
Arrn crvlr rhmm (,ct
•1. DA11:, DRII.I Ifl,_�7- La_C)S
5. I(II'AL PIT III -__[o
(i. 1101:S WFI.1, It1:PLACE 1:\ISI1111; W1:1.1,7 YI!S LI 140 114— `•- _
7. S FA I IC NV 11:It Ll:V1:1, 1IVlow'r1111 1 P1( nsiuIt:-_-`�k 1 __I'L
(lI•r"r"It ALmr'I�q,or 1'n•.inpl
R. 'I(W 01' CASINI7 IS_-- -(----- 1-1'. Abovc Lnod Stnlacc• -- _
•-I rp cr c•dnp Irnnlnnlyd nllw trrinx I,nd rminre Irynit it n ---D-- —
cntlnrce In acm do.tcr xlilt ISA NCAf'1C,11119. -
0. Y11?LD rill f —
(l'.I 1 a_�_—Nil! U1''r1 51'_f _ _
IU. WA Lit Z(.)NFS (dcpIll): --___—_—_-- -- -- —
II. DISRJI'F.0 1101,1:1)pe }��j_4 s Amouul_L� Show direction nod dislance in miles Flom III Ic"I
12. C'ASMG: Wall I11;Alless 1\vo Statc Roads or Connly Itonds. Include the toad
Dcplil Uinulcicr or WcighVl:l. Alnlclial numbers n tic
d c000uun fond Omnes.
I'tonl —'fo��I"1._(e,25 �'QS3.L
I'nnn 'fo li. __--
I'nrm 'ro FL------ --- —_---
13. GROU1 Depth I\Intclinl1 Method aZ/
Flunl_ ll_.aG`
1-1. SC UTH: Dcplh Disoldcr Slot Sim NInlclinl
_ k s ?
I'tour I o_—I'I. iu. --- iu. _ /g {ems s//Y
15. SAIJIVGRAVIII. PACK: -
Ilrhth Sire hlnlclinl --. ' —
Irlonl fo I'1. —
-- Gy i
Ili. IIIir.InRI;S: — ---
I\U I IPRL•Ill'CFRTII Y_I IIA'f'I IIIS 1Vh1,1,WAS('UFIS111UCIIr.0 RJ ACCC1RUAfJCIi WITII ISA IJCAC t ,Z'�lil,l. _'l
CONS I RU(7I IU1J S I ANDARDS,AND'I IIA r A COPY OF'I HIS RECORD HAS IIFGN PROVIDED'l0 1114 WILL U1`<'K i 1
SIIIJAIIuII!tlpl'HITSIINCOIJS11lUCI1N0'1 Ill!WL'L(, DA'IL!
Submit (hc ollginil to file Dhislon of 11'Iltcr Qunlily,Gloondwnler Section, 1636 pIn11 Service Center-IGlrlgh,NC
2'6"^ 16rr r•li,nr fJo.("1")711 )221,1001111 Ito .l•,\., 11\V-I RIiV. ll//Zllrll

- row
1Jollh 31
Calnlina -Dc,.
15 ' a
( nlhnna of linviunmicnl nnJ llnlulal Itcso�wcc3-Division of Wnlcr(lunlily- GnnniJa'nlcr Section R'FIJ,CUN'I IIA('1(1R(INIII VInnAI.)NAaiE (prinl)__!fy-f 7r�
_�---�---- 'CEIt nF ICA I Iutl n Wf QU'
Kf l.l,l'pN I1t.11'I UII CI rat i'AN 1'N,\nlli /�jil�/ _—
----- - -----------I•uuNr. it Ap I
5 fA1F. 1\F.I,I,(-IIN31It nl'IIUN I'F;I1a111N_— —
iIn � rGr:d,l,• -"-"--���-------------AS3O[.'IA"I F.II \V/)PF.IIa117N
L WfLI, USp. (Chr•(k Applicnblc Il( x): Itc:idcnlinl I unicipnl/Public Cl bninsrlial Ll Alpicuhmal CI
Mulliloling ❑ Itccovcly 1_I Ilcll 1'mup R'alrr Injeclioll U Ulhcl U IfUllier, List use
2. Wp1 1, I OCA 11011: — —
Ilcalcsl 'fon.,I: 4�/c"Jv:/�� ,� 7upofraphir/l.and scltin r
Clltidgc Clslupc Malley U ht
Convnmdl)'.$nl dieislnn,I of I ln.,iAp C,vle)
I,nliluddlungi(udc or well location
1. u11141 R: skmve� /�6 _ N_;50 02"a.W83�
AdJtecs ---_— __ -_ (drgrerdminnt.de •rn,l.)
—,l'1J.__wQ�l .__--- -- --- I,nlilurldluuP,iludc3otncc:Ulil'SUfupoglapbicnnp
(3M1Ri nr It ogle Ill,.)
(cLrck Lrn)
(-il)'m 7T,Ir $Inle zip Code ujtl Ll,lll(j-1-O_Ij
(-----.)_-_...--- I:nnli 'fn fonnalion Descliplion
Arrn rr.lr. I'hn,rr unmUu ---- _
4. DA 11:. DRII,I 1:1) s/30S �— O ---- -. —'
C. I)1)I:S IATIA, RITI.AI'I! ':,XISIINt; WI:I.L7 YLS LI NU W-
7. STA I I C WA 11:R 1,1:V1:1, 11clow l(fit (IF01ciug:
— —c -
A. (II'l'ASI111; IS l L_ _ -- I 1. nLnvc Lnnd Still',cc* r �+
•llgr rl r.,L,p In mL,n lyd .1/rrr Lrinn I.nd""We
r.rLnrr In.rrnrAurcc"Ill, 15A NCAC IC,aiIN, ---- —1 "--
9. ((rplll):
IU. 1VAfElt 7,CIIJES (Jcpllq: ;ISM ' ---------- --
�.�cnziul�Ki1_c�ji—
I I. UISIIJI'IiCIIUN: 'f}pe /f?� nm„onl_ Y�4/w Sholy dilecliml and distance in ruilcs lion, at Ica;,
12. CASING: Wnli'Illirkncss "vo Slalc Roa(13(If COIIIIIY Roads. 111c11Ide the road
D-1,111 Dinuldet or/Wncighl/PI. hIRICIi:d numbers and common road names.
1`Inm -Io
I'nnn fo _EI_ 1
13. GRUU F. I)rptli NJ.wri l --- Iclhud
Flom � To Y 1'1 �4,—_��a'!�
I'lom fo d�B 11. F'c%lra_I�C �a�c7--
Iri. SCltl?EIJ: hcplli Dinnrcicr S114Si7e tlnlclinl
in.
15. SAfJUlGI(AVRL 1'/1l'1:D'I'll, Sim — � — ---'
I•Inlrrinl
jt
:I I•ul__To-- I f— ---__
16. RFMARKS:
I Itt) Ilf l!1'It} (-I:lt I11'1'.l HA I I III", WITI,WAS CMISI'ItI)C11:.D Ill ACCORDANCE Will[ I5A 11CAC-217,WI!11,
CONS I RUCI ION S I"ANDARDS,AN,I)�'I(,IAI-A C(.II'1'01:l1113 RECORD HAS BEEN PROVIDED TD'll IL WELL Ul711E11,
SIGIJAI Ult1!l 171,1!ItSUIlCV14SIItUCIIt4fj II112 Wf?LL —
DA"I P
Subnlil the Ill Igln'II to the DII illnn of 11'a(e1 I)v:di1)',(;l l,unlhvnler Sec(1un, 1GJ(i Alnll5uvice Cellfrr-IfnIrlL,ll,fit.
2'(''" 1'•IrT1e'n (^1
rfh� ");11 !_Zl, nlfhin .ill ,lnp� ,

WELL CONSTRUCTION RECORD
311 '774
idollh Carolina -Dclmllulcrl of Envilouulcnl and IJnlmnl Itcsoulccs- DivinivD of Witter Quality-(houndwnlet Seel it)11 �
1%FLL CON'I IIACI Olt(INDIVIDUAL)NAaIF, (p11111 )(_�M�P�G��. \�1�2���C)� �CF.III IIICA IIUN II¢�crt
VVFLI.CIrNIIIACIIIII I.'Oall'AN 1'N,\a14; �:�,Y_��.4.1�SJ.f.1.111-Y __ ---rm111F, 0 (S1711317:�CA9y
51-A 1 F \V ELL CONS I III CI ION 11:Ilall INASSLICIA"I FI) w1)I'F.Ilatl IN
. if n • ,licnl4r . .. . . .. ... .. . if n r dicablc .. , . ..
1. w1°1-I, t-ISL' (Check Applicable Ihu): Residential 19'h1unicipal/Public U Indusid.41 LJ AgOvullutal U
htvniloling U Itecovely 1_I Ilcal I'unlp Water hljeclivn U Other U If Other,List Use_
2. \VHI-1, 1 UCA I ION: TopogrnpIlil/Lrold .^Mini,
I Jcnicsl Counly CCs_.1---- Ultidge L( olm I'IV,IIry Ullnl
(Clerk°rpuq„iN.ban)
(Saul Plnn,<,Nnud� u,Connnnnily,$nDJirisirn,,Lnl Ito.,lip Crvlr) I,IIIIIIIl1 C/1UIIgIWdC Of wCD local nll
J. (ll1'IJI'It: j�[(`il(,L—_L 'IV Y-'�j..�� '1�.`- fUP'�L (,ItRrrr.l,ninnlr.'r.rnn,l.)
Addlcss 47 3_ILAy ,5151�:__At�__------_---- L:diludeflmlgi(udc source:CltIPSU I'opaglapbic map
(."nrrl or ILmle Da) (cheek le,.)
z sf90 1t4L'U1 I_111LL(I10 Lu1;- - -- --
1-ilyol Inor1 $tale :;1'f'��ar hnnn To ponnnlionUcsclipliml
A...r..l.- llmn.number _I — Ll(7
A, DA11: DRII,II'.I11�-_
(. DCII;S RITTLACE HXIS1114; WFI.13 VHS LI NU Lam' 3 —
7. S FA-1 IC \VA I FR LHVHL UCIow Tap of( "iug: .._SU____lrh• $a ^
(tlrr•'1•'If Ahnrr'I-q,Of 1'nrinfl) N Ynl
$. 'll\I' Ill' CASING IS ___f___ _ 1-1. Above Lmal Sul[*.'cc*•1 rp of rs.Lrp Irnnln aped off,,, her"Lad unlnrr vrinhn
r e,Lurr In.reel Carte nhh IS,\ Nl'AC IC Ill lfl. �a
a
9. 1 IHI.D (pl'111): S__—ME I IIUD UI''I HS1'_
Ill. NNIM ER 7,UPL•S (dcplll):
11. DISl ljl:IiC I IU(J:'I ype t-&\ 1 CJ5 Aimmid_ILI Show aie Ituil(I and dislauce iu miles rot at Icad
12. C ASIIJG: Wn11 thickness two Stale Roads or Comdy Roads. 111cludc the load
Ucp111 Dinulcict or WcigllVpl, binlcli:l Dumbcrs and common to,d Dlnncs.
I tnnt�_'1(1 _<C)t_I'1._� --_ S C 1 PJLL--
4 peel
11. UROUI': Drplll Well I 61CIhnd ob Jegla•'
I'Ionl—r ' 1If Pl. u __- .Q SC ,kC t--
FIonI__3'Tn_av ` pL
14. SCRI;LPI: Depth M
Dinmelcr SIO Sirc alclinl t"i hFya
I-loill
17IOIII_ _ To hLiu. ---- in. ---- -[/ E9_r
15. SANIIIURAVIII, VACK_ (_
Urptll Sifc hbdcl inl . `,..
171 o nl---111--- LI'---- . .------
17, it
1111 I IPI,,I'D1'('liltf W1.111A I'1I11)WPLI,IVAS I'UI IS fltU('I11.D IN ACCORDANCE W1111 15A IJCAC 2C,}VITl-
CUPS I RUCI IUP S I ANDARDS,Atli) I HA7'A CUI'Y UI'1111 S RECORD[[AS IIL'L•N 1'ItUVIDED'10111L WELL UW141ih i '
z
SllrIIA I M WUI I I.ItSUNCUIJSIRUCIIIJU IIll!W11 DAII!
Sulmlil the nI Ip;hrd (o the Uh islun of Walrr 1)nalilp,(:r ounlhrnlCr SeclloD, 1616 Mail Service Center-1lnlrIVII,r1C
2 b'^. 1,;'• 1'! ,•n^ f',- ("1")"J1 1121 I11111h fit ,!'Tn. O1V-1 IWV. 0//20II11

---- - '
WELL CONSTItUMLON WIFC ARU 311 '1 1' 3
1Jvllh CaOlIh1n -Uri allumd of linvirmuacol mld NnWml Rumaces-]Division of Wale" (lanlily-(Lound,enlcl Section
•celcr Ir Ica 11uN H.,75'�
YCFM CON UACI on UMUM11nAL)NAME
YVFLL CON IAACIOnCIIMI'ANYNAME,
__ASSIICIAI FI/w/)I•F.IIMIIp
S IAIF. YYF.1,I,CONSIIUt('1[ON I'F,IN117H_._..
I, R•Lil 1,USF. (Cllrck AllpIicoldc Ilos): ItcsiJrol ill l I" t L nieipnl/Public U Induslltnl 17 Aglicullmnl U ----
NI ill,iloiing LI Itecoccty LI Ilc:ll I'unq, Walri Injccliou U Ulhct 11 1rUllle" List IJsc-
2. W ITI,I OCA I ION: 'I'opo f!Inplli ll.mul Selling
IJcnlrsl'iuv:re�ya1{\ !Sy-.�.�-----Comil>•�'=�C`-ry---- UlUdge ll W)ipc ❑Volley I_Iil:,l
(chel It nly,rnp,lnle bar)
(,S'Irfrl llnnlf•rJIrIr1I`fYU. LIIIIIIdelloli,g/i�lodc of R'aell loZcili'll
loll.. 0/` (.IrplerJudnnVCrfcnn•L)
3. -F� L:Iliuulc/Imlgiludc sowcc:LlfiPSOTopn);l:y,hic atop
AdJress I�0 , _Frlm- Yek (drerkl `.)
(Sueelnrl1"'lle lu.) ) ; uILILl,lll(i_LU)i.
-Nw x1-11.y_ Br4G�1 _j�.32�$-_StSI -
C'- --��' I'nnn 'I'u Fouunlion ]Dcsclipliuu
(�il)'nl'I oan ,Ir
Arrn n.l.- I'Inmr rnnnbrr — '-- r
G. le
tl(1F.S 1\'Ii1,I, ltl?1'LACIt Il\ISIIIJU \VI'1.1,7 PISS LI NO �-
7. S 1'A I IC \Vol lilt I.I.WFI, I+clow'llgr
(the"r"If Abner lr.ir o(1'n-iapl �. �,
R. TOP 01' t'ASIN17 1S-_-_-�--_-—
-f. Abuvr• I.mal Sul licc' _--�-
•lbp rI rnlnp Ir,ndnnlyd nlh•r Lrinn Iced an Icrr,,,p h rc• 'sl
,nlmcr In ucnnluuc nilh ISA NCAC IC AI M.
9. 1'IF,1) J-.--Nil,I HOD UI' IFSI'_
IU. \\'AILitZONIS (dcplb): --_----- jLQcn IU(Ur., rcjl
T -�-
------
nd_.\/j._.—___ Show dilcclion and dislmme in miles Gom nr lusl
it. OISINI'I�.CTIUN: fypc�� hvo Slalc RoaItitds or Counly RoM1s. IIICIIIJC Ilse road
12. CASING: \l':dWeir.111/11
Ilrl,ih Uinwcicr of Wci1:hVF1, hlnlcli:J nuulLers and cauunon roaJ lames.
I'Ion_Q ro CI1 l I71._ { IW21 v!
wAl
13. 01MIJ I': I,rplll I tnlydnl Alclbod
' I�I. nm,n` �Ye,C7�di�c� rv<c IrH L�4rel R�oozC/'1
14. SCREEN: Nrplll Uimucler ,lot Sim Malclinl L .
r
15. SANIUURAVIII. VAC6:
hrplll Si)c bbdclinl
ceO
16. Rlipinril:S: - --
IDOIIPIlFI+\ flf1" IIIATI HIS TTLL WAS 11HISIRM71") IN ACCORDANCE WITH I5ANCAC2C,\VRI.I•
GUNS I R ICI II)N S 1 ANDARllS,AND I I IAr A CUPY(W'lHIS RECORD HAS BEEN PRUVIUCU TO TI IL MMLL OWNER
SKU IAIlll MtSON CUNS I RUGI'IN(1'flll!WI!I,L UA'1L'
SIII'11111 the nl tl;ln•d to Ills ph kwu of MITI: OoPy,(a uunilwater 5ccllou, IGJ6 p1n11 Scnlcc(-MVelllcrl PEW. 07/2001
,111611 -'1! 'I^Y'+.

NC OWNER MWD -
WELL CONSTRUCTION RECORD 3 11 7 +' 2
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prhrt),- Cnm I?S 9. u3/ 1SC)V-\ CERTIFICATION#2Li0q
WELL CONTRACTOR COMPANY NAME-V" I A 1 QA1 A(-,l t Y)G PIIONE # PLAO `s S T-�2y91
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential GI—Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: '',,`` �� ' Topographic/Land setting
Nearest Town: Ny{�tF.<V p Comttyy� ❑Ridge 1339ope ❑Valley ❑Flat
C,-, 1pc CwP_ I (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Lalimde/longitude of well locatioft
�^^nn N35"Z�LOv� L.J '56� L�S��"
3. OWNER: ILP. VVIe CCCi I� (degreestminutestseconds)
Address -_ C.r f'�a i J b'PRA Latitude/longitude source:❑GPS❑Topographic map
46Y (Street or Route No.) - (check box)
a v e s U 1 I I e . Z$q 0 DEPTH DRILLING LOG
City or Tan State Zip code From To Fo on Description
�) 0 - 1 0
Am code-Phone number \0, - t`ID'
4. DATE DRILLED 5 - 7, -
5. TOTAL DEPTH: a.) ; W-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 6' ,
7. STATIC WATER LEVEL Below Top of Casing: D FT, ^ V3
(Use"+"if Above Top of Casing) -
8. TOP OF CASING IS 1 FT.Above Land Surface'
-Top of easing terminated atfor below land surface requires a
variance In accordance with ISA NCAC 2C.0119. a,l
9. YIELD(gpm): 'i�_METHOD OF TEST
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type UVI PLPA63 Amount \S Show direction and distance in miles from at least
12. CASING: Wall Thickness two Stale Roads or County Roads. Include the road Iv
Depth Diameter or Weight/Ft. Material numbers and common road O:pnes. LO
Front_ Tom` (=Ft. „� �[d 1 „��� 17,
, �(a�
From To Ft.From To Ft.13. GROUT: Depth Material Method3Front_TO .-u' Ft. n t From To3 Ft. �C eS-SLkr14. SCREEN: Depth Diameter Slot Sim Material %f�« e RdFrom To Ft. in. in.FromToFt. in. in.15. SANDIGRAVELPACK:
Depth Size MaterialFrom 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 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER ,
S -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subunit 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.0712001

1111"Ij, CONSTIMCTION RECORD
1JottII CaIoIiIIn -Drpaltnlcrt of FIIVitow Ile[It cold NatulaI Itenvutcfcs-Division of Willer QunIity-Ounnldwnlet Section C
(1'F.LL CON I IIACI Oil(INI1"ll"AL)NAM F. (In I'll). �-
����� \ � �•����� ������ rnuNF n fKa Si..$37-�GS7
IN F I•L CON I it,%(- III('IrMrANI'NAnlli vvtl�.t e.�_.K.2_e"r �l-ur.i y-c��•'--- ---
IA 1 F.OF,I,I,CONSY IlpCl TUN 1'F.INIITq—___.___-----ASS(1C1 if n�IdicnldcF.1IMI7 N
I. (1'PI.I I ISti. (Ch ek Applirnlde Noa) Rc :idrnlinl I Aluuicipal/I'ublie U imitio inl U ALticultuud U —
Nvniloling U Rcrovcty LI I le:lt Irintllr %Vnlrr Injection LJ Olhel U If olhcr,List IJnc
i
fo Io •tn rhil/I nd scllin),
2. \4'PLI, LOI:A I II)IJ: 1111 � I 6 I UI"Int
IJcnlcs fvnn: A .V.�1L�---(•°unly_C`all-__.-- CJltidgc Cheek c 1IV l-,I)
S.CCP.e,k (dtnknpp,rpnm h,n)
1,116tuddlon iludcofrvclllvcnlinn
(Sbrrl rI....3.
Nmnba.,Cnnununily.Sn1 Division,Lrd IL..,lip('rvl°) ;�'iL���
\ (d<ptrrdn,innLdr•rnn�l,),
Ad,hcss 275 ��lc�cru Fly----�---" -- I_nliUldr/Ivogiludc sowceLl(i )li ol;Inphic loop
(chak M )
(Slnrt,r``nmurNo.) uILILI,INU LQ(i.
:.ip('a.-Ir Flow 'fl, FouumtiollDcscliptivn
lil)'ol In a $Isle
--_.)---------- - -- (it
Arrn nil•. 1'hrnr nnmbcr — �
A. 0AIF, I.11tiLl.1:1)
5. TO TAL 111:1 ill ----g--'P` --
--c
(. OOI:S WFL1, RITI.A(T FXISIIIJU WI'I.I,7 ti'LS CI NO 1.4— _
7. STATIC 1VA I I:IC I.I:VLI- Ilclotv'llq,of('nsinS' ..._SD _ h1'.
(V•r.•F'•I r ALoar'I nl,ar 1'n+inp 1 O
S. I t)], (1I' CASING IS.— -A----- 1-14. Above Lund S1111i cc' i=
•l rp rl rrdnp Irunhmlyd n1b1c hrine hud tin lore tnphn• -----�i--. --
anllrnrrin ,Rrnttlsnrr ,111115A NCAC I r'.01 In. ,J�lpRV
9. 1"IIiI.D (ppnl): ��-_—All:I IIUU UI''1 I:S I_�(tR — ]/ Y'
11). \\'A[Lit ZONES(dcl,tlt):
\\ Anunnd-.�� Shwv dileclion and distance in miles Golll Icasl
11. I)ISINI'F.C11014:'1)Ile) two Stale Roads or County Roa(Is. Incl c the road
Will'I hick ness
12. CASING: \VcighUfl. Alntcli:d Illllnher9 and c(nunlon rond naul
tirplll Uinnlcicr nr
iL_ _e
1'1om_S2__'fo��_ �u 25- Ric ��oro k;vl
1"tow 'fo D.
--_.---
11• 0,ROUI': Drptll Alnlclial M1lclhud fi�
—�' _o242 1 p� fl�4ad'N _ n
From fo I�1. � - �l �-. '°o
Flour_
ld. SCRLL•FI: Dgdll DIn111rICr SInISile AInlclinl �,
Fl
Flom—.__--- 1°—._--I'I, in. in. ----• �` a well
IS. SANI?IURAVFl VACF: V I
I lrplil Sire Ahdclinl L.
IG. RIiAtARI:S: ----------
I till III:1l1:11Y CIT I IPY I THAT I Ill"WITI,WAS COiI,l itOC111)IN ACCORDANCR IVITIi 15A NCAC 2C,WLI.I
CONS I I(UCI SUN SIAIIDARDS,AND'I IIAT A CC)I'Y UI:'IIIIS RECORD HAS BEEN PROVIDED TU I IILl WELL QVMIER
—T- SIGtJAlIIItCUPI'LIMINCUNSII(ULI1NU'IIILrWELL DAIR
Sub+Toil Ilic n111;Iv 11 In the DIN isinn of Water Qnalilp,(;,uuathrnlcr Section, 1636 Alnll Service Ceulcr-ItnlelSh,NC
_-- ,,, .t..... (i1V•I Ill'sV. Oil2nr11

NC ✓ 0n'NfR a (\ HIM
WELL CONSTRUCTION ItECOItll �(/���N >g
North Carolina-Dcpantment of Envirmuucal and Natural Resources-Division of Water Quality-Groundwater Scclion
WELL CONTRACTOR(INUIYIn UAL)NAbtE (prhtl) — Gmmn < (�, twI�ISR>v� CERTIFICATIONN yC
«'ELL CON TRACTOR CON rANY NAME MINT- r110NE N fvlsr) `35T--2 riY
STATE WELL CONSTRUCTION FERPH IN ASSOCIATED wQ rEM11'TN
(i r nppl icol,k) (if nppl icnble)
1. WELL USE(Cbcck Applicable Box): Itesidculial W Municipol/Public U ludustrtal IJ Agricultural ❑
Morritoring LJ Recovery ❑ licat Pinup Water Injection❑ Other O If Older,Llsl Use
2. WELL LOCATION: Topogrnphic/Land Sating
Neatest TOwtl:Rif all P-, 1)j 61 Counly '�,R1-I Mdge Mlope Cl Vollcy Mot
nluud � �`,�1 Q- , 1� (check npr'npdate be.)
(Sure)Name,Number,Commmulty,Subdivirlay Inn No.,7.ip Code) Lallluddloll ilude Of well location
l N731 715"{ Wm.�1R
3. OWNER: � mq h G12T401 (degreealtnlnuter/eecond,)
Addiess Vo 6OX 8 3 q Latlludellongitude source!0OPSU'fopographic nlap
(Street or Route N0.) (check boa)
FfCIVe5 v( lIe _Vc 2K001f- PEPTIC VDIJA "Mu
—City41own State Zip Code from To romialion Desc iplion
Arratrade- Phone number 1 h — t CY),
4. DATE DRILLED Co - IL1 OS t mom' _ ,O?130 `
5. TOTALDEPTI1: :78'' ��j - 1x5` ��:%�i,
G. DOES WELL REPLACE EXISTINO W ELL7 YES ❑ NO IJ-
7. STATIC 1VAI-ER LEVEL Uclow I'up of Cnsiug: 40 ' FT.
(We"+"Ir Above Tnp of Cmrna) ry
8. TOR' OF CASING IS I Fr,Above Lund Surface"'
-Top of rnlne trnntnated auor bdon land nitrate requhrr
enlance In accordance wlth 15A NCAC 2C.0118.
9. YIELD (gpnl):_t \ N1ETI10D 0FTESTA R
U. WATER ZONES (dcPllt):
_ LnGA1I014 SKE'fC1(
11. DISINFECTION:Typc4NIn 5 Amount 1 Show direction and distance in miles from at least
12. CASING: Wall I Itickness two Stale Roads or County Roads. Include We road
Depth Dianrdcr or WeighUrt. Material numb rs and conunon road names. ge /1-11
From b To t`55' Ff. l2-le :SX-)r /
Front!cTo J-10' FL U
Frmn To Ft.
13. GROUT: Depll A ntetml l mediod
Front n To .-9 ' Ft. 1e-4
Cos,
14. SCREEN: Depth Diamcler Slut Size
Front To
rmm I'o FL—ill. in.
15. SANDAMAVI;I,PACK:
Depth Size Mnledal
rmm To 11.
Front 'To FL A4j
16. REMARKS:
I DO I IEREBY CERTIFY THAT I111S WELL WAS CONS-IIRUCIIfD)N ACCORDANCE WITH 15A NCAC 2C,WELI.
CONSTRUCTIONS f ANDARDS,AND THAT A COPY OF'IT HS;RECORD RAS BEEN PROVIUEI970 TIRE WELL OWNER
SIONAIUIIE 01;PERSON COPE lit crIA0111E IREIX05 i DARE
I �
Subndt llte original to the Division of Water QualRy,Gro¢ndlrller Serflon, IG36 Mdl S2rrlcelcenler-Italelgh,NC
27699-1636 Phone No.[phone] within 30 tin ys. I GROW,D1"',Tr-n cfpTMN i OW-1 REV. 07/2001
3 ASHEVi!I t HF(ilJ AI i�-Hi:c J

NC __V 011TNER _ _ HIM
WELL CONSTRUCTION RECORD
Noid1 Carolina-Dcpabueut of Enviromnad and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prinQ)y�C;ovra G h, t CERTIFICA11UNs-240
WELL CUNT RACIUR coM rAN 1'NAM E 1MMoc UJo(L Cif-W ait rIIONE / fs 5A) S3 SY -?�i47
STATE WELL CONS FRUCI ION FEMII IN ASSOCIATED WQ PEMIITN
(if nppticamo MERWIN(if oppticnble)
1. WELL USE (Check Applicable Box): Itesideutial LI—Muuicipal/Public ❑ Iudushinl ❑ Agricullutal U
Monitoring❑ Recovery ❑ ►Icat Pump Water Injection❑ Other❑ If Odier,List Use
2. WELL LOCATION: Topogrnphic/Lart setting
NcnrestTown: I� J11P< fl`�P Counly (' 1rn� ❑Ridge []Slope Malley LJFIal
11,1 (�,Lj (check epprnpri.te box)
(Surer Name,Number,Community,Subdivision.Lot No.,zip Code) Latiludellougilude of well location
_ Xol�/r1 � W82-Y/' ZS•'
3. OWNER; (degrers/rnlnune�eecond+)
Address _ F)1F✓ Cov2 �� Laliludellongilude source:❑CPS❑Topoglaphic map
(Sheet orRoute N .) (check box)
2 Z If 1m)'1'1l llLt1L1L4�V0
City orT wn Stele zip Code Front To jorplalionDescription
Ares code-rhone number C' r
4. DATE MULLED (o 01_5 U rani'
S. TOTAL DEPTII:
6. DOES WELL REPLACE EXISTMO WELL? YES ❑ NO ❑ C
7. SI•ATIC WATER LEVEL Bciow T'op orcnsing: -,r) Ff.
(Ure"+"If ALnve T mp or Casing) G -
8. TOP OF CASING IS I IT.Above Land Sul race*
*Top or ening irtodneled e0or brlon land mrr.ce requho■
valence In escerdarce with ISA NCAC IC.0118.
9. YIELD(gpm): t(7 h1ET110DOFTEST LE Ln
10.WATER ZONES(depth):
LOCARQN M I-01
11. DISINFECTION:Typ Amount I s Show direction and distance in miles from tit lead
12. CASING: Wall T ilickncss two Slate Roads or County Roads. Include the road
Depot Diameter or WeighUFl. Material numbers and conunon road names. tt
Front_To—�J- �FLU K\� Ur
From To—FL—
From To FL
13. GROUr: Depth h)nictial McWod
F1oln O 1'o ail ' FL-YraALIla n[�ue
From To FL
14. SCREEN: Depol - Diameter Slot Size Material 4
Front To Ft._in.
Front ro FI. iu, in. i,
15. snNu/cl(nvl;I. PACK: SO/
Drp01 Size Mnkrinl -
rrollL FL
Front To—Fl. i AUG 9 �
16. REMARKS:
I DO HEREBY CLRTIFY TI IAT TI IIS WELL WAS CONS[RUCI ED IN AdCORDANCE-WITH ISA NCAC 2C,WELL
CONSTRUCIION STANDARDS,AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TILE WELL OWNER
SIONA1 ME OF PLItSON CONS"FRUCI-INO THE WELL DATE
Submit the mrlghud to the Division of Water Quality,Groundwater Seclloly 1636 Mall Service Center-Relelgh,NC
I7699-1636 Phone No.[phone],within 30 dnys, OW-1 REV.0712001

NIV'NEIl MIrN -------
WE L , CON LFIM 'PION IUXOIM
Nmol Carolina-Ucpaluucut of Ltnvironulcul mid Nnlual Resources-Division of Water Quality-Uroundwater Section
- - Q , )r1Snn CERIIFICA7IONN,241Q
IVELLCONTRACtort(INUIYIUUAL)NAPIE (plbd) 1 PItONE N tT�Sd F:37-2Qrj
WELL CON I RACIOR COMPANY WELL uDI( a( ,1�1 q
ASSOCIA'I91)WQ Fr.RRil"IN
STATE HELL CONsIRUCiloN FEMIIIO I f p r rllcn)rle.
if n�rliaddc
1. 1VELL USE(Check Applicnlde Flux):
{tesideulial jj_-Moulcipal/Public U Industrial U Agaicultulal U
Muuituriog LI Itecovety U I lcal pump Water Injection U Otber U If Odter,List Use
2. WELI,LOCA'IION: ` ' ' Topographit/Lnnd scum)
NCarestTo%vn: Couuly `�ltl _— UIUJga CInk per plat boxj U{"tat
(check•rp np 1
_�' La iluJdlongitude of wc1 locsnon
(Sunt Nemq Nmnbut,L' munily,Subdivisimr,Lot No.,Zip Cale) IQ Z,5 2, I id, W g3o 3 J �-o•�
J. OWNER:
LaliluJdlongilJude source❑OPSO"ropogtophic'tap
Address r U, IV (clink bo.)
}Suect or Ro le NO.) 11 t - fAULLLN-9— _U
O f l 4 nd F rornwliou Ucsaiplion
Zip Cale I'1°III ,I.°
City or foun SuitP � _ I(5'
L--) Its - -7 `
Airs code-rlmne number
4. DATE DRILLED 1 4!2 �S N<fl5 11
5. TOTAL DEPT11 1 r 71t - t7
U NO
6. DOGS WELL REPLACU r.XISI'INU WVLL7 YES ` {]
7. STA fIC 14A7"GR LEVEL Uclow fop of Cnsiugt C
(Use"t-If Above'l np or CtpinN)
B. TOP 01'CASINO IS i I°I'. Above Sullhcc• N —�t
-Top of tnrnr Irt minNnl pilot belon Imo tutt-ct requhn
rnl.nre In trcordtlrct"I"i ISA NCAC IC.011N. n '.Q
9. YIELD(9011): 10 MGrilOD OIrTEST.,.,_.---
10.WATER ZONES*011): I.00/t loN sr,CLC11
Amount t t Show ditection and distance In miles lion'at(cast
I I. DISINCGCfION:'fype —Wnli'Ihickness two Slate Roads or Courtly Roads. Include We road
12. CASING: e I unbers and colunon toad names.
l7rpo, Uiaulcicr or Wci ht/fl. Mai if
F1 onto_To '1-�--
FroIR v7�
from 1-o Fl. � a<o•"e
MNleriu Method
13, CIlOUl': Depot7�ret<.,CP
Front—To- 11ZD �
Flum f), TO--Y—I•L
14. SCRL•EN: Depot Dimueler SlotSize lll Makdal ��
Front To Ft, in. o vt 4br. '
rmin ro__Ft. In. In.
15. SANDIORAVELPACK:
Ueplll Size
Flout I'o 1'1.
Front I'o
16. REMARKS:
1 DO HEREBY CERTIFY 7IIATTIIIS WELL WAS CONS'I'I IM ED IN ACCOIIDANCC WITH ISA NCAC 2C,WL'LL
CONS-11=1 ION STANDAIIDS,AND TIIAI'A COPY OF'f1IIS RLICORD 11AS 13 IEN pR0Y1D1!
U 70 TIIL WELL
OWNER
UATu
SIGNA 1 U{lE 0I I L'IlSON CON5'I11UC'fINU 7118 WE(L
NC
Submit Ille orlghlRI to the Division of Witter Qunlily,Groundwater Seclionr 1636 Mali Service Ct"lelr"�Vgh,(ji NUUI
17699.141E Phunr Ns.(919)7JJ-J221,wllhbl 3U drays,

IVELL CONSTRUCTIQN RECOAD 0YO j a
No,a,Carolina-Deparhncul of Envitotuucul and Nnntuiat Resoulccs-UivisloR or Water Quality-Groundwater Secliuo
\VELLCONtRACIOII(INUIVII)UAL)NAME (p,lnq �JC�VVIOS \x , CE1l77rICAl1UN N�v0U
,,AAn� �� c�(',,�i,'tG -r110NF N lyI ) 937-a997
WELL CON T IIACIOR COMPANY NAMP IV ,%\\P�' ^ - -
STATE WELL CONS FAUCr1ON rEM11IN ASSOCIAI"EU WQ rFRAII IN .
(irnlllicnllc) _ (Irnpplicnlrlc)
1. WELL USE (Check Applicable Bon): Residculial hI 11,11cipal/Public U Induelrial U Agiicullulol U
Muuituling❑ Recovery U Ileat puu,p Water h,jecdmt U Olher l7 IrOlher,List Use
2. WELL LOCATION: �-� 'FOpogrnphic/Lmid scltiug
Ncaresll'uwtl: sy`\`e Couuly�$ — URIJge UJSlupe 10V-n1ley Ullal
�l..nn-,1 C'nUP I1�10( -rl (chngitureoF tn.)
LeliluJdluv ItuJe orwc11110)9% n,y
(Stint None,Nmnbtu,l'uuunnni,y,SubJivlela,,lq,Nu.,7,Ip Cole) � a 17 ry7+ B3°�T p
], 0es nWti h Yio \1, I � C R O
Address Lattudellon itud(dee rs,oeeu✓rmccin:OmtG✓rPecSnUndT,)u pugtaplric u,ap
(check ant)
(Sheet a Route No.) FLEW UL) LIH LQ-Q
, ) r z Br1 4
zt,cale Flom 1'v Con mlionUcscripliuu
City r Town Stele I D I t7to
`Aire code-Phone number h
4. I)A'1-l- DRILLED - I1-05 � 5_
5. 10FAL DEPI'11: 0605'
6. DOES WELL REPLACE EXIS'rINO WF.LL7 YES U NO Ia-
7. STATIC WATER LEVEL Below Top orCnsingt"jQ__I'C. a
(Use"It"Ir Above Ibp orr.a,lna)
B. TOP OF CASINO IS I FT.Above Lnnd Su,recc• e
e7op of urrnr Irnnindrd teor bit,-lend surhue ttpuhee•
♦silence I"mccordnue with 15A NCAC IC.el l$. -
9. YIELD(eplu): (0 ..N1EIIIOD UI.-ITS-1• A"O o
IU. WATER ZONES(dc001): I. ) ALIGN 5K1J3 j1 "
It. DISINI ECl'ION:'I'ypo
h�TF1\o. Amount 15 Show direction and distance lit miles rioul at least =LLB
Iwo Slate Roads or County Roads. Include We toad
Dimuctcr or Wcigh
12. CASINO: Wnlciglkness
UFl. Material numbers and coumton road uamcs. ILI
Fwu 1b s YI
Front I'o FI. j1 I-1
Fran, 'Fu
1]. OIIOUI: UepW M1 atetial Method
;
3 To rror,t�2—'rem90
'1 1'1• B<<� ° �c�dr,N
14. SCREEN: Drpd, Diameter Slut Site Mnlednl
From To 171, in. C,1,4 Cr
front l o__PI. In. iv. cc�
15. SAND/OILAViiI.PACK:
DeI,U, Size hinletlul
Flout Co Ft.-
From
16. REMARKS:
I DO IIEREDY CERTIPYIlWr'1I'IS WELL WAS CONS1'RUCILID IN ACCORDANCE WITH 15ANCAC 2C,WELL
CONST RUCI IONS I'ANDAMS,AND TIINC A COPY OF I111S RL'COIID I BEEN PROVIDED TO 11ILI WELL OWNER
SIONATUILE01r t'EILSUN COtJS"IlLUCriNU'r11E WELL UAIE
5ubnllt the ul iginnl to (he Ulvidun of Wnlcr Quality,Crvund,raler Sectlun,I6JG Mdl Service C(JIVIefr,1lLVg0712U01
rrrvv.t6J6 Phvnc Nu.1919)7JJ-]221,nhhhi JU dope.

NC 0IFNEI? --------
WE,LL CONSTRUCTION RLC01tll
Nol W Carolina-Dcpalbucul of Envituunlcnl and Nnlwal Resources-Divislul`l of water quality-Uroundwater Section
1VELLCUN"IIIACI Oil(INDIVIDUAL)NAME (prhd rZ
) t �Q A� < _1 `bit\ Cl CE1tI1FICA1IUNN-2'/oU
WELL CONTMCI Ott COatrANY NAME M' \I A r- u. el` ('"3I-r�� �a rIIONE N Lud Y z 7-ate)
STATE WELL CONS IrIUCIIUN rEM11IN ASSOCIA'fEll WQ PE"ll IN .
=1�Ic) (If npplitnblc)
1. WELL USE (Greek Applicable Bun): Itesidcnlinl liYh4uttictpal/Public U InduNOial U Agricultural U
Munitoring U Itecovery U Ileal l'uwp Water lujectiou U Olbet U IfOdrer,List Use
2. WELL LOCA"PION: 7bPogm dtic/Land sctlwg
Ncmcst7ba•u:�,�(AL'll•0. Cumtly UIUJge Mope UVnllcy UI'lal
(check spprgrdale be.)
(Saret Name.Number,Couunmdiy,Suhdiviolm.Lot No.,ZIP Cale) LnliwJdlmrgituJe of well location ti
NW-0a 2-1"r to SS"S'F
J. OWNER:` (draretlminuter eetnndt)
Address I ZD S{Zi Ih P LslituJdlougilude source:(-JOPSUTupogtnpbic trial)
� (Sa eel m Route N ") (chak boa)
4-CA vQ s �' I l e AlZ M D'-F MEW !!L I.LIN _Lucy
City of town Stale Zlpcode from I'll 'onlmtiouUcselipltuu
in c oil rlEAr'
Air@ rode-rhnne ninnber l01n t
4, DATE DILILLED 4- 1S
5. TorALDEPTil: ZoSl -
6. DOES WELL REPLACE EXISTINO WELL? YES U NO NIA v
7. STATIC WNMR LEVEL Below Top ofcnsiog• 50, _I-f• r
(We-t"If Mrovelnp of Caah,g)
It. TO],01'CASINO IS I 1"1'.Above I.nnJ Sill race* _
aTnp of caging renalnrdrd a0or below laml em fart requlve a
•a,lmre In accordonte with ISA NCAC IC.0118. O
9. YIELD(pptll): ID MBru000r•'rEs"r
10.WATER ZONES (depth): _ LgCALION SK�LG�l �
It. DISINFECTION:Type Auluuut t �;" Show direction and distance In miles from at least
12. CASING: Wull'I hickness two Stale Roads or County Roads. Inclu a We road
DcpUt Diameter or WcighUFl. Material nwuber;a l colllnlon toad names.
rtrnl p__To n
mill To—Fla
Ftorl, To fl.
1J. CROUP: Depth M1 e erial M<U
rrouL—Q To 3 t 1't.
From 3 To ao, FL g ✓e
14. SCREEN: Dry,dl Dimneler Slot Size Material
Rant To rt.-In. In. ,1It
riven —'I'u__1'I,
15. SANDIGILAVI:I,PACK:
UrpW Size Mnletlal
ream Tn rt. ply fs4
front rl, R.
16. REMARKS:
I DO HEREBY CERTIFY 771AT'I111S WELL WAS CONS"fRUC1'ED IN ACCORDANCE Well 15A NCAC 2C,WELL
CONS I RUM ION STANDAIWS,AND TIIAT A COPY OF 1111S RECORD IIAS BEEN PROVIDED TO ME WELL OWNER
---p SIUNATUILE Ur PERSON CONS]RUC INO TIIE WELL DATE
Subndl the or Ighlnl to the DIVblon of Writer Qunllly,GroUrldl7aler Secllol►,16J6 Mall Servlce Center-Ilalelgh,NC
27699-1636 rhunc No.[phone],,Vhhbl Ju Jays. OW.1 REV.0712UU1

HC WI'NEH 1411'1)
WELL CONSTRUCTION RECOM)
Nolot Cmolina-ocpalhuent of Envimuutmd and Nnlulal Resoulces-DIVIstolt of water Quality-Uloundwater Seclion
11�`p /2P(' C(�
ct mlrtcnnon a
WELL CON"IMCIOII(INDIVIDUAL)NAME (r,Inl) >°fi,T i c�
, (S/�� ,`Y3�'�
vvELI.CUNiMCrOIL COMPANY NAaIE /y!1/jt'l GVC(� DXi��/1/y r110NE a yy7
ASSOCIATED WQ 1`9111,111#
STAiE WELL CONS 1R11CIlON I'EllallTa (if applicable)
(i(nlllicnllc) � — ��
1. WELL USE (Check Applicable Ilup)! ResideulillI F/ Municipal/Public U lodusttial U Agticullutal
Mutliloling U Recovery U HeM Pump Willer Injection U Olher U IfOdler,List Use
2. W1LI,LUCA'f10�f� Topogrnphic/Lnndnelling
Ncmcst'1'uwu //� yej-f1/�Counly C I Ultidge 15srupe UVollcy Mat
(clnrck appnnpdnle bnQ
(Suer)Nen Nu ne, nnbru,Couununily,SuLJirlelon Up,Lot No., Ca Laliludr/louitudcOfwelllucalion
g le) t.o 1 N Ie'a.
1
7 i n1 J. UWNUI Latiluddlongilu(d,lee psrorrw✓mccin:UnnOf rPcScnEn]l+r) P091001ic nup
Address d$ C51
(cluck Mn)
(Shrrlalloule Nu.)� /V C ` �11 D� uLl'l11�--v 1 1, paLILI,INCi I,U
-` rtmu 1'v ronmliou Ucscliplimt
Oily Of"I nn'll Stale Zip Cale A
/ l (l
la
Airs radine-rLmm number /3 /D {SO C_
4. DA"I"E DIiILLI'sD / f10''yo �R
5. T0I'ALD1:PI'll: _5, S'
6. DOES WFLL REPLACII E)US'1'INO WI'sLL7 YES U 140 Lr
7. S 1'Al'IC WATER LEVEL Uclow'1'op orGtsiugc //D _1 I
(Qae"+'Ir Alrovr 7np nr Cn+Ins)
8. TOI' OF CASINO IS_�__ 11. Above Lnud Sutra es
-lop of color leunlnalyd aVor blow land nnlare tegnhu a
Val lance In accordance q will,ISA NCAC IC.91111.
9. 1'I LD(kpuq: n1ETI►OD Or'resl'
ID.WA'I ER ZONES (dcplll): S 15'
I.SZCATI.OL541S71
It. DISINrEC-11UN:Type //T// Aumuut ID jR I Show,ditection and distance In Miles wool el least
Wnll't llickness two Slate Roads or Courtly Roads. Include ale Load
12. CASING: g juillberm and conurio t toad naulcs.
Dcplh Dimueter or Wci IIVI:t. Melcdal X
Front D To lc) rt. �,.,95 LiFlom To rt.
rrvn, Tn rl.
IJ. GROUT: Depot h1metinl Method _
rrout�-7b 40 I't. eRTG Rlfo/ �vs�r ffre
ri out Tv rI• 70� mod,
14. SCREEN: Depot Ditunder Slot Size Mskdnl
Holly -rn rt.—Ill. In.
front Tv__rt.—in. lu, o
c->
15. SAND/GRAVELPACK:
Depot Site Mntedal
`-
trout C=)
cn
16. REMARKS:
I DO IIEItEUY CEIt rIFY 111ATTIIIS WELL WAS CONSUMCI"ED IN ACCOIU)ANCP WITH i5ANCAC 2C•WI!LL
CONS11/t,yCIl0N S"fANDARDS,AND THAT A COPY 01t'i111S IWCORD IIAS BEEN PROVIDED TOTIIE WELLOWNER
1YI3/��S
1
SIUNAIMWVI:PUtSUN CONS"IRUC21NU111EWELL DAIL
Su01u11 the otiglnnl to the Div lslun of IVAIvr(lustilly,Gruuudwaler Section,1636 Dlall Service Ceelllotrf RLVg07 C
17699.1636 rho tic No.[phone],tvllhbl JO days.

OIVNEN d ,g ww " gHill)
WELL CONSTRUCTION M"CORU Cam""
Nola,Carolina-Dcpartrtrcol of Ellvilmuucut and NnnIII Iat Resources-DiviSloll of Water Quality-(It ouudwater Seclio11
WELL CON"IRACfOR(INDIVIDUAL)NAME Q.1— / /7 Aece e' CERIIFICAIlONN
WELL CON IIIAC►OR WMFANY NAME %%' ,
STATE WELL CONSIRUCIlON 1•ERa1170 ASSOCIA'I Ell WQ rERMfIN
. (ifnlllirnllc) (ifnpplicnbk)
1. W ELL USE(Check Applicnble Ilox)! Residential U-�Mmmlcipol/Public U luduahinl U Agilcullulal rj
Mmliloring U Recovery U Ilcnl i'mop Walcr liijeclion U Olhcr U IfOdrer,List Usc
2. W ELL LOCATIONN 7'opogrn a✓Lnnd sclling
NcnlcslTowu:�[ Qfyl�E Cuunly Clli UI(ldge UKlope UVallcy UI`lal
(cheek rppnryrrinie box)
(Saar Nellie,Nunnbeu,Conmmllity,Subdivision,Lot No.,711,Cale) i.alllUde/IUIIg1IndC of well IUCatlallf or
b _,
3. OWNER: fasary I-S/--ro-Hen 'fAy I-k (depmee/minnrr✓recnnd )
Address C I I UJ �4 C12 5 c- La(iludellungilude source:OG oglnpllic nrap
(checckk b boxoxj
(Sneel in Ruule NoJ
z1,Coale From '1'u Forowlion Ucscriptimr
City or Town Stale1
/urC rs rile-rho"e mumber
4. UA'IE UILILL1iU
5. TOTAL DEFTN: is o
6. DOES WELL RE1'LACl1 EXISTING WELL? YES U NO la-�
7. S'I'AT'IC WAT EIt LEVEL Uclow Top of Cnsimgt Xe C _I-I'.
` (Ure"4"If Above lby or(drains)
8. TOI.OI.CASINO IS ! I"1'.Abuvc I.nod Smfacc•
•Top or tarnr In ndner ed at/or brlew lend ea rare reyuh re a
♦ariant@ In accordance with ISA NCAC IC.Oi IN.
s. YIELD(FpRn): o2- nlEfiIODOFTEST�'<"
IU. WATER ZONES(dcplb): 7-?6
LQG11.T14ILKm)1
Sllow direction and distance In miles lion,at(cast
11. DISINFECTION:Type N r Aurowd �� two Slate Roads or County Roads. include die read
12. CASING: Walllbickness
Drp(h Diameter or wci hl/Fl. Material numbers and collation road names.
�) ✓c X'r
Front D To 9z rl. �-�S� �
Flom To Ft.
From To FI.
13. GROUT; Depth IaIeIM� v et
Front D To Ft. 0 a
14, SCREEN: Depth Diameter Slut Size Malednl welt o
Front To_Ft. ill. In. CA e"y
1'rvnl To__Ft. in.
15. SAND/GRAVEL PACK: F
Drplll Size Material `q CD
Flu 1'o FL cn
or
Front 1'o Il.
16. REMARKS:
I DO I IFREDY CERTIFY TIIAT TIIIS WELL WAS CONS KIMED IN ACCORDANCE WIT'll 15A NCAC 2C,WELL
CONSTRUCI IONS"FANDARDS,AND-I f A OI'Y OF7"TITS ItL'CORD IIAS BEEN pi(OVIDEUTOTIW WELLOWNER
SIGNATUILE01:P1111 SUN CUN5'IJ(UCfINOTIIEWELL DAM
Sulnnll the al Iginnl Ill the 1)Ivhlon of 1Ynler Quallly,Croundlrnler Sec►Ien,1636 hlNil Service Ceder-ItNlelgh,NC
17699-ILJ6 rhuuc Nu.(419)7J3-J221,vthbhr JU days.
OW-1 REV.0712UO1

..° .51•'oar., A
OWNER
RESIDENTIAL WELLCONSTRUCTION RECORD MWD
Lr'll,}
North Carolina Depanmen(of Environment and Natural Resources-Division of-Water Quality
NC ✓
WELL CONTRACTOR CERTIFICATION t)
1.WELL CONTRACTOrR:: I. DISINFECTION:Type HT/f Amount �L
-Ptl; I( P U. WATER ZONES(depth):
Well Contractor Individual)Name From lv O To & 5 ` From To
MILLER WELL DRILLING , INC . From Tc From To
Well Contractor Company Name Fran To From To
STREET ADDRESS P . O. BOX 567 6. CASING: Thickness/
Depth Diameter Wei hl Material
HAYESVILLE , N . C . 28904 From To�EFt. (p,I S al ODG
City or Town State Zip Code From To Ft.
( 828 1- 837-2997 From To Fl.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
�`
SITE WELL ID Slit applicable) From�`To oZ) Ft. 'wfo2.1 e ,
From_To 3 FL J-'n/TTL/lN.
STATE WELL PERMITk(il applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply La From To Ft.—In. _ in.
From To Ft._in. _ in.
DATE DRILLED From To Ft._In. _ In.
TIME COMPLETED �, 00 AM[I PM fiK- g, SANDIGRAVEL PACK:
3.WELL LOCATION:: Depth Size Malarial
CITY: (A55/ 0w"/ COUNTY From To F
Fran To FL
l.
�l7 �ruLftr3 CoVe- (Z-d From To Ft
(Steel Name,Numbers,Community,Subdivision,Lol No.,Parcel,Zip Code)
TOPpGRAPHIC/LAND SETTING: 10.DRILLING LOG
Zlope OValley ❑Flal ❑Ridge ❑Other From To c Formation Description
(check appropriate box)
o / May be in degrees,
' S
LATITUDE 114 •DZ.372. mimics,seconds or ylS _ ( Oe_•r -
LONGITUDE)_nL pto �•3/�O0 / in a decimal formal/io Latitudengitudesource: IBL;PS ❑Topographic map
(location of wet must be shown on a USGS lopo map and ,
attached to this form 7 not using GPS) -'
4.WELL OWNER O OWNER'S NAME ti (yMue•
STREETADDRESS Citi41.N C.00*L R-J .
f�ansslb-••.+ 7-S%7- 0
City ar Town Stale Zip Code
( Sz93 } 835- �tbl`l
Area code- Phone number
11. REMARKS:
5.WELL DETAILS: /�
a. TOTAL DEPTH:
It. DOES WELL REPLACE EXISTING WELL? YES Lg' NO O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH '
e. WATER LEVEL Below Top of Casing: O T. iSA NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THATA COPY OF Tans
(Use'+-x Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' tog �� O�.—
'Top of lamina) aVth below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NgAC 2C.Ot 18, ,p
e. YIELD(gpm): .30 METHOD OF TEST l/ �i �i f-�
RIP� NTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Farm GW-la
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7MS

5-We copy M(, 3
P;i .0 9 2l. .�: ,✓ l
WELL CONTRACfOR(INDIVIDUAL)NAPIE (print) 21At PS 6- �11 t SCr n � l:Ertl rr lcA u�nx
WELL CONTRACTOR COMPANY NAME ( `SQL Iw�P A[` PIIONE a
STATE WELL CONS TRUCIION PERaII If ASSOCIATED WQ PERa11110
(irnl l licnl k) —(If MI
1. WELL USE (Check Applicable Box): Residenlial ii7-- Muulcipol/Public U Industrial 0 Agticulluiat
Moniloiing O Recovery LI Ilent Pump Water Injection❑ Other 0 IfOoteq List Use
2. W ELL LOCATION: Topogrnphic/Lsnd Setting
jJcorestTown: Cuuoly C'tA11 f316Wge OSlope Malley ❑Fla(
y- [p< f"e WA-1
6t,- s.f,.{„i -5111_�-- (cheek appropriate box)
(Silver Nana,NmnMn,Cmnmmiity,Subdivision,Lot No.,Zip Cute) Latiludellongi(ude of well lucatiml
3. OWNER: �p p v [-S (drgreea/minnta seenndQ
Address ? �.'r== %�.��?/fir;r Q Laliludc/longitude source.00PSOTopographic limp
(chak box)
(Storer or Route No.)
S A1scL11 DMILRI LVQ
Cilf or Town State Zip Cate Fto111 To FommtionUescliplion
(t ` 1�---
AreCt code.Throe number for- Lry 1p
—
4. DATE DRILLED -2- `
5. TOl-ALDEPTII: ?ag>` o
6. DOES WELL REPLACE EXISTING WELL? YES erNO O -
7. STATIC WATER LEVEL Below Top or Casing:_.j" D .17r. ,
(Use'+-If Above Iop of Casing)
s. TOP Or CASING IS__�_I i'. Above Land Sulracc•
•Top at cooing ierornHed at/or baler,land out fare acquit to a
at,lance In accordance with ISA NCAC 2C.01111.
9. YIELD(gpml): -S ... h1ETIIoD OF TESL'a"o
IU.WATER ZONES(depth): ]aQ�p�10N SKE'fC11
It. DISINFECTION:Type i1eh Amooml 16- Show direction and distance in miles From at least
12. CASING: Wall Ihickness two Stale Roads or County RoadS. Include We road
Dc11111 Diaoeler or WeighUrl. Material numbers and contmon road'Ionics. aE*
Fron�_To tQD! Ft.(
From To FL a8
From To FL `S
0
13. GROUT: Depot material McotoJ
Fronk-0 I'D —Ft. 2e�_
From_ _To n FL)�cn}ni:�o_ BPS<r,r'Q
14. SCREEN: Depot Diameter Slut Size Material r
rron, To PI. in. (o. W
u.
From To Fl. iu, in.
15. SANDIGRAVIi1.PACK: �+
Depth Size Mnterlal Q)
Fiorn lb FL 4
From To FL --------- —�
16. REMARKS: �y
I DOIIEREBY CERTIFY I BAT IIIIS WELL WAS CONSIRUC1ED IN ACCORDANCE WIT11 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIB WELL OWNER
5!- 3V- c�S
SIGNATURE OF pERSON CONSTRULTINO TIIE WELL DATE
Sub rill t (lie original(o the Division of Water Qusilly,Groundwater Section,1636 Mail Service Coder-Itslelgh,NC
17699-1636 Phone No.(919)7JJ-J121,WIIhb13U days. OW-1 RL1V.07/2001

NC NIYNER -------- /l ��l -------
WELL CONSTRUCTION 1UX01W
14011111 CarDllita-Deparnocut of L'nviruluncut nod Naluial Resources-Division ofWater Quality-Oromldwater Section
WELL CON I RACIOR(INDIVIU UAL)NAM E (ptlni) . �GVVI r� G R. 1t��1 cr,� CER IFICA-11ON 0a(/0u
WELL CONTRACIOR COMPANY NAME �Aniit6oy% tat ( Ar,k ✓lQ rIIONE 0 Irj.lfs31-0-C&3
STATE WELL CONS IRUCI ION PERAIIIe ASSOCIA'rEll VVQ PERPITIe
(ifnpplirnLlc) (Ifnpplicnblc)
1. \VELL USE (Check Applicable Eua): Residential LW Muulcipol/Public U Industrial U Agricultural U
t,luuitming U Recovery U Ilenl Puuq)Water Injcclion U Other U IfOWer,List Use
2, WELL LOCATION: Topogrnplli✓Lund selling
Nearest Town: Cuuuly '�jy( OlUdge 4Wupe Malley UFlat
1'f < l:eree , wAilt rant- �_-_-_ 11 (clink app,n,nlele box)
(Saco[Neme,Nanbas,Conununay,Subdivision,Lot No.,7.ip C'a1c) Laliludellorigilude of well location
J. OWNER; ✓t (depeeelrnlnutrr/srtnndr)
AddlcsS Lr;(1 Latilude/loogitude source:OOPSOI'upoglapbic slap
(Slice[or Iloule No.) (clink box)
►kaueS,.'II N e 2srgo.� uEl'Tii 12LULLIN94vQ
elly or Town Sule zip Core trout To roN mlion Descliplion
Arra rrde.mone number ID' - _AI Ghn(& -
4. DATE DRILLED- DI -OS ;/gl - yt)' - rZ
5. TOTAL DEPTll:,N51 o w — INS 6caylihfe -
6. DOES WELL REPLACE EXISTINU WELL? YES O NO 6ik- o
7. STATIC WATER LEVEL Dclow Top orcming: SQ--rr.
(Use-s"If Above Tnp ofcerlua)
a. TOP Or CASING IS I __ F-T.Abuvc Lnrrd Sulface•
*,top ol,nlnt tennlneled eDnr below lend surfer,rrqul,es a
adore In accordance"jib 13A NCAC 7C.011a.
9. YIELD(gpm): 1 D METHOD OF TEST' Ant
10. WATER ZONES(depth):
LOCAT 19ULS1S�:CS:)1
If. DISINFECfION:Type Amount FS S low direction slid distance in nil lesfromal lea st
12. CASING: Wnll'lh(ckness two Slate Roads or County Roads. Include Die Iasi
Depth Dinnleler or WcighurL Material numbers slid conunon toad names.
front 0 _To_S_Q_Pl• &,.1-L SDMI P V c—,-- .3
rlolll To—Fl.
Front To—FL
13. GROUT: DepUt Miller al McWod
flonV—To Z;rt. 'e
117
Flum -S' To P-01 Fl. -k
14. SCREEN: Depth Dialuelcr Slot Size Matellol
Flout To—Fl, in, In.
17
1'rnul To_FL—ill. in.
15. SAND/GRAYFI,PACK:
Drplh Size Mnlelinl �grlfefflJk � �a�'
Fluor 1'o FL 4tj A
Flour ro FL jtr V
� trek
I6. REMARKS:
1 DO IIEREDY CERTIFY 111AT1111S WELL WAS CONSI'RUC1 1 IN ACCORDANCE W11'11 15ANCA 2C,WIILI.
CONS1 RUM ION STANDARDS,AND TIIAI'A C01'Y OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
/ SIUNATURB Or I'EItSUN CONS'1'RULI INU TIIE WELL DATD
Submit (Ile orlghlni to the Dlvillon of 1Valer Quall(y,Groundwater Seclione 1636 hlsil Service Ceder-Ilalelg6,NC
17699-16J6 Phone No.[phone],lrllhbl JU dn)'s. (JW-1 REV.01120UI

NC 5' _ �4Se OIVNC It
WELL CONSTRUCTION IM"CORD 31
Noldt Carolina-Depatimenl of Envimumcul and N`alulal Resources-Divisiml of Water Quality-Groundwater Section
VVELLCUNTRAC101C(INUIVIUUAL)NAatE tpllnil1JQmEs 1L. 11i1Snrn CERIIFICAIION M x24'0 C/
1VELLCONTRACIORCOMPANYNAM: IA . (,s✓r ws-t dr:1+: PHONE M
STATE WELL CONS InUC1 ION TERM IA ASSOCIATEI)wQ PER6111M
(tf npplicnbtc) (If npplicalrle)
1. W ELL USE(Clieck Applicable Bon): Residential Ijk�1uulcipal/Public U Induanial U Agt{cultulal U
Atuniloting U ILecovery U flea(Pump Water hljeclioll U Olher U If Outer,List Use
2. WELL LOCATION: Topogmphit/Lmld selling
Neatest Towlrlr. _ rt 1 Psj, 1k0 - County tau UIUJge LISlope WAO"alley UI°lal
SIg�— (check or opintale box)
(Sarel ling Nunrbeo,l'nnnnAnniy,1SubJivblar,lql Na.,7.ip Cal<) Latitude/lutgilude of well lucaliull
J, OWNER:�lAr`A I� Y.►✓1(V ISon (degrees/nJnnlcdeecnndri
Address cm, Yy—_T Luliludeflmlgilude source:UGPSUI'opoglsphic map
(Slrerl or RAle No.) (check box)
L><BV !✓j// N[r o289d4 -- 17J.L'Lll 10111,1MLLUU
City or"I own Stile Zip Cale Flom To FoumationUescliplion
Air@ redo-Phone number
4. DATE DItILLIsD 9- �� -03 7n' - I e-IS `
5. ToTAL DEPTTI: a1205 ' 14S
6. DOES WELL REPLACE EXISTING WELL? YES U NO IU-
7. STATIC WATER LEVEL Below Top of Cnsiug: [001 rr. s
(Use"+"If Above I op er C-xlna)
8. TOI'OF CASING IS Ff. Above Lnmd Surfacc• a
-Top al enlne lennlndrd Door bete"lend rmr-re requires■ — -
♦srlmce In accordance with ISA NCAC 147.111111.
9. YI ELD(gpul): to METHOD OF TEST 14i Q
IU.WATER ZONES(dcptil):
_ L9�A]:19L IKCLGll �
11. bISINPECI'ION:Type Amount 15 Show direction and distance in miles Dorn at least
12. CASING: Wall'I bickness two Slate Roads or County Roads. Include die road
Depth Dialueler or Weight/R. Male1121 numbers slid cmlunon road names.
r .1.1
FronlQ_T'o 153 . &.2s :50 .�L PI/c[ - s.i_
Flom To FL (\ r B
From To_Ft. n r .+;1� 5 �
13. 0ROUI': Dep(h h1nlelial McWod
El
171 to-1115 LA ME
From 3 To 20• FL -
14. SCREEN: Deptr Diameter Slot Size Malednl �0
From To FI. in. iR.
rronl Tv FI, in. In.
15. SANDIGRAVI'l,PACK:
Drplh Size Mnledal
Frouh 1'o Ft.
Fronk Ib Fl. I RuitFe4
16. REMARKS:
i Do I IUItUDY CERTIFY I IIAT1711S WELL WAS CONSTAUCIED IN ACCOM)ANCE WITII 15A NCAC 2C,WELI,
CONSITtUCI ION STANDAMS,AND TIIAT A COPY Or'l IIIS IU?CORD HAS BEEN PROVIDED TO TILE WELLOWNER
7 SIGNATUItEUI'ItiIISUN CONS"fItUC1'INU77lB WELL UATB
Sulnni( the orlgimal to the Dlvisluu of Water Quality,Crou lid tvater See Ilon,1636 At all Service Cell er-II nit III It,NC
27699-I6j6 rhoue No.(919)733-32I I,n I1hbt 3U days, OW-1 REV.07120Ul

NC OIMER -------- /P1lJv ----
WELL CONSTRUCTION TUX 1lll 61 4 �' u `- 1e
NolUt Carolina-DepaiDnenl of Unviton icnl slid Naltuall Resourcc$-Div or water Quality-Uroundwaler Section
\VELLCUNIRACIoll(INDIVIUUAL)NAaIE (prbd)�M0,-, s�D CF1111FICA-11UNa.ZUDU
WELL CONTRACI.OR CUIMANT NAME\d IISOn (1 f',ij teig P110NE 0 MaitV=d fa
STATE\YELL CUNS IRUCIToN rEltnlli/ ASSUCIA'I ED`wQ PERALrI#
(if npplicnblc) (If npplicnblc)
1. WELL USE (Check Applicable Bon): Residculinl Ui Iunicipal/Irublic U Indusllial U Agricultural
Monitoring U Recovery U Ilcal PUMP Water Injection U Other U If Other,List Usc
2. WELT.LOCAT ON: ropogrilphielLnnd selling
Neatest ToWil Comity Prudge LISIopc UVnllcy UI"lal
(check orpr"pilale be.)
(Snr<i emr,A(NunJ�<u,C"rnm1m_Jly,SubJivlela4 Lul Na.,7,ip Cale) Lalitudellungilude Orwell IOC9li011
). OWNER: AynxA I C-,io� (drareerlrnlnulrchrcvndr)
llwu f-L1 Latitudeflongiludesorlrce:UGPSUIopoglaphicelap
Address
(Sneel a Route No) (clink box)
E�w� esu�ll e. N te 2Sc9D U U1.LT11 12 UMNSUO-V
oily or Town Stole _ Zip Cvile From TO rorlllalloll DCSclipliull
C—) - i n t
Aire ralr-rlivne number IN — 6W
4. DA"IT DRILLED 9-414 -MC SA' 1 ff5' t
5. TOTAL DEPTI1: /85 '
(. DOES WELL RIHILACE EXISTING WI!LL7 YES U NO 11L r�
7. STATIC WATER LEVEL Dclow Toll urCnsiug: (PO , Fr. —
lure"+"Ir Alrove l ep or Ca.ina) cr%
8. TOP OF CASING IS 1 Ff. Above Lmld Sin face• e
,[op of colt",Irnnledrrl otter below land eurl.re requtro■ U'i -
nrlonte In ocrordsate with ISA NCAC IC.0110 ,,,�II
9. YIELD(gpnl):q—ME'f110DOFTESI'kie -
IU.WATEIt ZONES(depth): LOCATION SKC1C11
�\CASING: Wnll'Ihickness Show direction anti distance In miles Rom at least
12.
11. Sntn �P.�P L Iwo Stale Roads or Comy,Ro
ads. Include We road
CASING: Wall'[
Type Atnoonl
Depth Diameter or Weight/Fl. MOIC11a1 uuRlbers and common road Ranics.
r
Flout 0 _T"o eaj2.Ft.to,,< S2LZ1 .�VC- jf.C]
Flom To 171. Goell
From ro Fl.
13. OROUF: DeptIt aletial Mn-w did
rloutQ—'ro fib, FI. .XM1s�-
rjulo To Ft.
14. SCREEN: DepUr Diameter Slot Size Matelinl
rtmm To rt.—ill. Ill. va
Front 'ru__17I. In. in.
15. SANDIGRAVEI.PACK:
Depth Size htnlednl
r-rmr(_ 'I'o
glom 1'0 l'l. �
16. REMARKS:
I DO IIEREEY CEitfIFYIHAT7111S WFLL WAS CONSTRUCfED 1N ACCORDANCE WIIII I5ANCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TIIAI'A COPY OF'1111S ILLCORD IIAS ULEN pROVII)CD TO TIW WCLL UWIICR
l 9- l�la ' LLS'
/f SIGN XI UIIE OF 1'LiItSUN CONS 711UC1"INU T"i IE WELL DAT E
Submit the orighrnl to the Ulrielon of Willer Qun111y,Groundwater Secliour 1676 Mail Service Cetuteer,Itillel C V
I7699-1616 r1to I Na.[phone],mllhht 3U days.

NC UIV'NEIt
WELL CONS'I'RUCI'ION IUTORD E
Not Ur Carolina-Depal lutenl of Unvirunnreot and Nalulal Resources-Divisloo of Water Quality-Uroundwaler Section
WELL CONYRACfOII(INDIVIDUAL)NAME (pilot)``,Q�lY1 C ri 11.E ��Otl CEtI"IIFICA710Nra—��
WELL CUNTIIACI OR COairANY NAAIE i k.� , Isnf-L la7G(( Af'N n`3 _r"ONE N 1$aa R r�-o9h,T
STATE WELL CONS MUCITON rEM11TN ASSUCIM ED WQ rERail"IN
(if nppiicnl lc) Qfmp,dlcnble)
1. WELL USE (Check Applicoble LIDO Itesidcnliul ITYMuuicipal/Public O Indushinl O Agricultural
LI
hlunitolimg O Recovery IJ Heat Puwp Water Injection O Olher U If011ler,List Use
2. IV ELL LOCATION: Topogrn ilil/Lmld selling
Neatcsl'Fown: ComllyCl — ❑IUdge 2110pe C1Vallcy uFlat
5 (check opp,apdale bn.)
(Sntel Name.Number, 'onunun •Subdiviela,,Lot No.,Zip Cale) 1,a111UddIU11g11UJC of well 1UC811U11
J, OWNER:.3,'• _.. Mn.e 6� (deareealminuledaecnndr)
Address 22ti PIUM bl•ltl Wd, Laliluddlomgilude source:00PSOT011091 sphic Illap
(Sued or Roule No.) (check bu.)
filr enj CA MEW 12LULL NS7 LQQ
^ Cllyor Tuwm Stale zip Cale rloal To rornmtioll esetiplio"
(. ) _0 C)
Alto redr.rhone number �-
4. DATE DRILLED
s. Tol'ALDEPTII: Ic��
6. DOES WELL REI'LAC11 EXISTINO WELL? YES O NO LI-
7. SI'ATIC WATEII LEVUL Dclow Top of Cnsing: GO ' 1'. c 1 .
(U.e-e"If Above Top or Cach,a) i
g. TOI' Or CASINO IS I F-f. Al,ove Lard S0,1111cc•
-Top of to Iry nlnated avor below land am lace rtyuh as a rT
rn lance In accordance with ISA NCAC IC.01111. r7
9. YIELD(gFtlth .—MUT1100 Or TEST A i IZ Ln
IU. WATER ZONES (depth): I,OCA7ION SKg 3 jj
DISINFECTION:Typo Amount 1r Show direction and distance in miles riot"al least
12. CASING: Wall'I likkness two Stale Roads or Counly Roads. Include We load
Uepul r Diameter or Wci llt1l:. Msc� L� l Rmnbers slid eonunon road Ra tics.
Flom O To r1. (o,0 {-�.zrsa— c
rtm„ To—FL
Crum To rl.
13. GROUP: Depth h1 Ietial I McWud 5`b
rlonL-L) _To _1'1. ?C 5 1K
Flom_ I To .2D' rl AE �s �l
14, SCREEN: Depol Dianelcr Slot Size MRlellal
stool Tv
rron, 'ru__rl, in.
IS. SAND/GRAVEL PACK:
Depth Size Mntedal boc�5
Front 'ran rl, p pbll;.tdj -
1'10111 Tv B. 1
16. RL•hIARRS:
I DO 11EILEUY CERTIFY T71ATT111S WELL WAS CONSTRUCIED IN ACCORDANCE WITII ISANCAC 2C,WIILI.
CONSTRUCNON S FANDARDS,AND THAT A COPY Or Ti IIS RECORD IIAS BEEN PROVIDEU TO TILE WELL OWNER
9-Js'-e)<
SIONATURE01:PI:MONCONS'lRUCFINUTIIEWELL DATD
Sul)111111lie 01lgl11111 lu the Divill011 a IValer Qunlily,Groundwater Sec(loel,1636 blall Service Colder-Raleigh,NC
17 69 9-163 6 rhone No.[phone],WMiln 30 days. OW-I REV.01/2001

NC _�___ UlYNEN ________ I(���,j an _______
S 9 CY % CF
WELL CONSTRUCTION w3C01M
Nolth Carolina-Dcpaltulcol Of LrnvirouureUt nod Natural Resources-Division of water Quality-Groundwater section
�� ��
WELL CON I RACIOil JINDIVID UAL)NAa1 E (point) :Fa CERHFICAVUN IIGzlcac
WELL CONTRACI OR COMPANY NAME LA.1Alsctn ilp (` r. u^gd riloNE a ff 4i 1137-b4.�S
STATE WELL CONS i RU1711ON 1'EMnI 10 ASSOCIAI EU WQ rERNIVIa
(ifnrplicnblc) (Ifnpplicnbic) _
1. WELL USE(Check Applicnlde Box): Itesideutinl IYMuulcipnl/Public U htdusnial U Agricultural U
hluuitoriug U Recovery ❑ Ilent Pump Water lujcclion U Other U If Other,List Use
2. WELL LOCATION: Tbpogrnphil/Lnnd Selling
Nearest row" _County UQIL_ ❑IUJge ❑Slope [ Ilcy Uhlal
�Qr 1,1QW . or (check appropdnte box)
(Sorel N.nte,Ntnnbcn, manor y,Subdirlslay Lot No.,].ip Cmle) I.alitude/lungitude of well location
3. OWNER: please[ lmlmner seconds)
Address 6rw ter' -5 /cl Lotttuddlorgiludesource:❑UPS❑TOpoglap p lricn,a
(Sited m Route No. (check box)
�u�<y(11a ?C9oy
PE1''l'lr MuJILM—LOW
c ty or Town State Zip tale 1'rpl To 30' ForiliqUou Description
Ales mie.rbone number A6
4. DATE DRILLED—q- Iq 4S'
S. TOI'AL DEPTII: RC&
6. DOES WELL REPLACE EXISTINO W ELUI YES U NO IJP '
7. STATIC 1VA7'EIt LL'VEL Bcluw l'op of Cnsiugt�,_h1•. Va
(Use-+"u-Above'I op or canlna) CD
8. 1'0I'OF CASINO IS ( 1"1'. Above Ltunl Surluce• —4
.Top al unlnr rrnnln.led.for brlow nand smiler[requhe a t
nsltmre In accordance with ISA NGC 1C.011 a. -.
9. YIELD(plim): 10 —hmETuou or rI r a'R CD
19.WATER ZONES*11111): LOCATION SK(a(S)1
11. DISINPECI'ION:Type Au,uunt lS Show direction and distance In mils from at lelst ='
12. CASING: Wnli'lhickaess two State Roads or County Roads. Include We road
Depth Diameter or wcigbul't. atedal Umnbers and conutlou road names.
frorn D To 6C ft. (o,6 • let
Front To fl. Y�
. rroDt •rD pl.
13. CItOUI': UtpW hlatninl Mediod My
iron, A' To Ah 1_Ft.A4ri11 %.* r
14. SCREEN: Depth Diameter Slot Size Material
frorn To Et. in. In-
from •ro__fl, in. in.
IS. SAND/GItAViil.PACK: vo 41
De11111 Size
rror„ To FI. ` x
Built 'rD B.
16. REMARKS:
1 DO I lmrBY CERTIFY 711AT'I IIIS WELL WAS CONS IRUCIED IN ACCORDANCE WITH I5A NCAC 2C.WELL
CONST ItUCI ION STANDARDS.AND TIIAT A COPY OF TI llS RECORD IUS BEEN pROVIDEU TO TI Ill WELL OWNER
9- / '-0s
SIUNA7 UIIE 01:1'1ittSUN CONS"IRUCTINU 1118 WELL DAM
Subull( Isle olghlnl to the Division of 1Vater Quality,Groundwater Seclltnlr 1636h1all Service Cenler-Raleigh,NC
27699.1636 rltmte No.(919)733-322l,wit66l 3U Ja}s, GW-1 REV. 071.2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carofirm Department of Environment and Natural Resources-Division of Water Quality
WELL CONTILALCTOR CERTIFICATION H_
1.WELL CONTRACTOR'. I. DISINFECTION:Type Amount_�5
_] ks' R. L.016nr) 9. WATER ZONES(depth)
WellContraetor Imonnduat)Name Frain To - From To
•
A7 r ` 6nV'1 IAW f•��• /�Q From Tc From To
Well Contractor Company Name ��— From To From To
I t � �STREET ADDRESS DD /A�i 8. CASING: Thickness/
q � 1 f/ ' Depths.,v r Diameter Wei ht Material
�[�SS !/�n I D� Front Depth.
I Ft (o�1S 1 P✓G
City or Tam State Zip Cade From To Ft.
L43k } sz '- MIR(n3 From To Ft
Area code• Phase number
GROUT:
2.WELL INFORMATION: 7. Depth Material tdefnal
From A Tn Z r. ft �Le
S17EWELLID#(itappticffik) From,Aj To 2n'Ft pj*; .
STATE WELL PERMIT#(f applicable) From To Ft.
DWQ or OTHER PERMT#01'applicable) S. SCREEN: Depth Diameter _Slot Sin Material
WELL USE(Check Appbcable aosi: Residential Water Supply 1W, From To rt_in, in.
From To Ft.—in- _in.
BATE DRILLED a`.ZQ-10 From To FL_in.. in.
TIME CG#MPLETEO .Z=OD Am 0 PM Lij—
e. SAND(GRAVEL PACK:
3.WELL LOCATION: ` Depth Size Material
CITY: r COUNTY P/oT From To Ft.
��
from To FL
5mu C ONAI From To Ft.
(Street Name.Numbers.CanmurvTy,Subdivrsiom,iM No.,Fwr j,Zip Code)
TOPOGRAPHIC I LAND SETTING 10.DRILLING LOG
Vy6(ape.DValley ❑FI* ❑Ridge []Other From; To Formation Description
(check appropriate box) 0 l o r
May be mdegrees, /as r
LATITUDEj minutes,secordsOr � A• ' 1 Qvt9
LONGITUDE_ in a decimal format (ps r� 2nqr r
Latftudeflongimde source: MGPS 0Topographic map
(location of we®mtrst be shown on a USGS tope map and -- In
attached to this form.X not using GPS)
4.WELL OWNER
OWNER'S NAME r �.�•(-�S --�
—T
STREET ADDRESS _ .r V CW &0
I
9 a dreA.rt N.C- ARID/
City or ToWn state Zip Code.. t
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: oIGS
la. DOES WELLREPLACE EXISTING WELL7 YES❑ No DY
I DO HEREBY CERT`v THAT TIM WELL WAS CONSTRUCTED N ACCORDANCE WITH
L, wATfit LEVE-+'9At ve of Casing: 5/j l FT. 15A MAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF.TfRS
(Use'*'MAtxme Top O(C38ing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS 1 _ FT.Above Land Surface' n ®® ,DS'Top of Casing terminated al/a below land surface may require K r C l41rLL
a variance in accordance With.ISA NCAC 2C.0118. ATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm).�_METHOD OF.TESTA;Z _
PRINTED NAIVE OF PERSON CONSTRUCTING Ti1EWELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699.1617 Phone No.1919)733-70I5 ext 568. ram.GW-,ta

RESIDENTIAL WELL CONSTRUCTION RECORD
4y A
North Carolina Department of Environment and)natural Resources-Division of Water Quality
'WELL CONTRACTOR CERTIFICATION#
-- —
1.WELL C0T3TRACTOR: f. DISINFECTION:Type mount
cim O S �. �A>I' �C�Vl g. WATER ZONES(depth)
Wdl COrtrrector(individual)Name From To From To—
:),.
� , n Li� �S. 11 /1A From To— From - To
Weil Contractor Cornpany Name From TO From TO
i b STREET ADDRESS 40a f 1r1 I I SI\V1 CA, 6. CASING: Thickness/
t tt Depth Diameter Wei ht Material
From D.. To 3G, Ft. $J�jJ iP✓G
City or T<mm State Zip Code From To Ft.
luyr} od"S`'- 04P63 From -To—Ft—
Area code- Phone ou_mber —
3.WELL INFORMATION: 7. GROUT; Depth Material Method
SITE WELL 10#(if applicable From b To .3 Ft. OC T qA
framJr�Tc �r_ Ft
STATE WELL PERMIT#(it applicable) From ToFt '
DINO a OTHER PERMIT i(#applicable) - S. SCREEN: Depth Diameter Slat Size Material
I WELL USE(Check Applicable Scx): Residential Water Supp(y&k-� From To rt._in.- —in.
From - To Ft_ir.. In.
DATE DRILLED - l OS From To FL—in. in.
TIMECOMPLETED_ [. oc AMC PMR-- 9. SANDIGRAVEL PACK:
3.WELL LOCATION: ` Depth Sim Material
CITY: 1411�J, U r II�E CDtINTY__Cj _ From To Ft.
T From To_FL
From TO FL
(Smear Nery m e.Numbers.Community,Svbdirsron,LW NO.,Parcel lip Cotle)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
OSlope ❑Valley OFlat ❑Ridge ❑Other From TO F rtnation Description
grees
(check appr6priate box) ♦7 i e r
LATITUDE LiNn
y be in de , I Ot .a G
seco:dsLONGITUDE decimal format
Latitudel ongitude source: MGPS oTepographie map
(location of we(must be shown on a USGS topo map and
attached to this form 7not using GPS)
4.WELL OWNER ----------------------
-
OWNER'S NAME i ON
i
STR ET SS G r s
L, ul
City or Tarn State zipCode:
(ft1A f ass9- 3yr8�
Area code- Phone number
11. REA2ARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:=5 r
b. DOES WELL REPLACE EXISTING WELL? l'ES❑ NO(y
r 1 DO HEREBY CERTIFY THAT iM3 W ELL WAS CONSTRUCTED W ACCDRDP.NCE WRH
L. WATER LEVEL Below Top of Casing'. S IFT 15A NCAC2C.WELLCONSTRUCTION STANDARDS.AND IHATA COPYOF THIS
ji.hua'•'•if Above Top of Casing) RECORD HAS SEEN PROWIOED TO INE WELL OWNER
d. TOP OF CASING IS I FT.Above Land Surface" yQr2 �. IG�A - /gip
'Top of casing accordance
with below land surface may require qlGNATUR OF CERTIFIED WELL CONTRACTDR DATE
a variance in accordance with 15A NCAC 2C.0118. _
e. YIELD(giant): _METHOD OF TEST_ liV�—y.>r;"66n
PRINTED NAME OF PERSON CONSTRUCTING THE WE'LL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Farm GW to
1617.Mail Service Center-Raleigh,NC 27699-1617 Phone No..[phone] ext 568. RMa ics

NC V U117/EH -------- PIII'll ———————
WELL CONSTRUCTION RECORD
Noldl Cmolina-Dcpaihncul of Enviivuuloul and NOMA Resources-Division of Water Quality-Ufoundwater SCCtiuu
IA�I n
IVELL CUM"T RACt OIr(INUIVIU h
VAL)NAatE (p� d L\s�)_ n.,,�p� CEIIIIrICA71UNN,2e/0
�n`I t _t- `` � ', 2 a PuoNE a ��1 c37-� )
WELL CON]RACIUR(WnIPANY NAME M 11t 1 alI NC >JNYI
S TAI E WELL CONS I'll"ll N rERAU IN ASSOCIATED IV(I PERalsln .
(ifnl)liad lc) (Irnpplicnble)
1. 1VELL USE (Check Applienble Dox)! IlcsiJculiul U Muvlcipal/Public U IRJusuinl U Agricullulal U
Mulliloring❑ Recovery U Ilcal 1'uwp Water hljecliou U Other U IfOdler,List Use
2. WELL LOCKI'I�O�""N: Fopogrn I LRnJ selling
Ncnresll'owu: +S --- —County(' I .11 ❑IUJga Uleb"') UI`lal
(think.ppntprinle n*
-- Laliludellongilude of well IUCatiOlr h
(Sorel Nnolr,Nmnbae,l'nnununily,Subdivielun,Lot No.,Zip Cale) - - _ r r, $v'/ r Zg
\rxI �� 1�I�n�
— (detpret/mlmtledeteondr)
3. OWNER:
i YGL_ LutituJdlvugiluJc svurcc:UOPSU"I'upugrnphic uc�p
Address
��3 W-6 4 L_ AEI'"hll 1LLI LL1N C�I,U�
FLou1 TO 1'oOlmtiml Desclipliun
City or lbwn Slae Zip Cola V _ IDI -
Aire, a1r-fUnne unm ber ---t o'---q�
a. DATE DRILLED i&- s-
5. ToTAL DEVI-IE_ant '
t. DOES WELL REPLACE EMSTINO W l7"L7 YI?S U No 6l'—
7. STAT►C WAFER LEVEL Dcluw'rvp I)rCnsing: 5d ' 1'f•
(Uee"f-it Above'I up of Cutb,a) -
8. TOI' OF CASING IS I -- VF.Above Lnud Smlace•
•Top n(udnr In udmlyd.Uor brlotr l.nd nn[.to reel tell to
rnl.nce In acordolte vt hh ISA NCAC IC.01III. n
9. YftiLD(gloo):_ P1---nlEruouor'resr v,
IU.WATER ZONES (deplh)t J,�CQ�ION SKI (Cyr i ��
Auww11 Show diteclion and distance !it miles role'at Icasl'�
11. DISINFECfION:'fyllo two State Roads or County Roads. Include We load
U. CASING: Wnll'Ihickness
Ucpu1 Dimuelcr of Weight/Ft. htntcrial uuulbera and conunoR road Ranlcs.
171ol11 f2�1'L �4
Flom l'o Fl. G�Oy
from Tu 1'l.
13. GROUT: Depth r h1 renal
l u_ fM�and
off-7(_I`t• e
Fron1�_ �]_I t.�LyJ� 0
14. SCREEN: DepUr Dimuelcr Slot Size hlateunl �Cj/�
Flout To Ft. Ill. ►n. le'
Flom
15. SANDIGRAVE.LPACK!
Drhlll Size Mnlnlnl
Runt I've IT
Front To I't• y
16. RUNIAMS:
1 DU I lEntlY CERTIFY TIIAT'NIIS WELL WAS CONS"I RUCIED IN ACCOMANCI?WITH 15A NCAC 2C.WELL
CONSI RUCI7014 STANDAMS,AND THAT ACUPY OF'11115 RL'CURD HAS ULIEN pRE)VIDED TO T11E WELL OWNER
� �NA'IUUI OF I'ERSUN CUNS'11tUCfINU 711E WELL DATE
Subodl rile ollgluni to lilt Dlvislou of lValer Qunihy,GrounJlraler 5tcllon,1476 hLIlServlce COWr1 I LIV.U7 2UU1
27699.1636 Phone No.[phone],11111111130 1Inys.

)IC —_-1/- OIVNN2 -------- MII'll -------
WELL CONSTRUCT LON RECOM)*
Nondi Cmoliva-Dcpaltrnenl of Ptiviruwucut and Notmal Resoutces-Division of Water Quality-Otoundwaler Section
IVELLCON"IRACIOR(INDIVIDUAL)NAME (prbd) lr'w.' < L L�3 : I�otl CEIITIFICAI ION# -2U0(-
IVELLCONTMCIOItCONrANYNAAIE ^p J,LI, 11Pr L00 �ICOLIq moNENfjj1 k1 -.24iy
STAtE WELL CONSTRUCIION rEMI11N ASSOCIATEV IVQ rERIM IN
(if npplic III,IQ (Ifnpplicnble)
1. WELL USE(Check Applienble Box): Residential w/lMunicipsl/I+ublic U lodusllial U Agticulltnal U
L1mliloring U Recovery U Ilent put,p Water IRjeclion U Other U IfOdier,List Use
2. WELL LOCAT ON: 1 �- \ � � IopoRrnphidLml�-sclliug
NcnlcstTown: d«tr+x n _County } � UlLidge ❑Slope IlWallcy UFlal
a61 ( !-14 __ 1 (check appropdare box)
(Street Name,Numbeve.Community,Subdivlelon,Lot No.,ZlIt Gale) Laliludr/lungilude of well Iocalion
n1�S'I ' do ' , w 3� ' l' ,
J. OIVNEIL: n Ff YI�r�F �'''I�C`C�Nd — (dt`nea/minnteJrecnndt)
AJdress ' 5 1 Laiiludellmtgilude surumEJU +SUTupuglaphic tuap
(Street m Route No.) (elumit bon)
l� yc zs`/ot7 Man DIUI.LINU_LQQ
City or t wn Swe ZlpCowle Flour .I'u ro Illation Desctipliou
fP I o +
Arrr, emir,phone mouber �� - ,226
4. DATE DRILLEDI-n> 1- n;j
5. T01-AL DLPT - N6'
C. DOGS WELL REPLACE EXISTINO WELL? YES U NO L-I-
7. STATIC WA7'Eli LEVEL Below Top of Cnsiug: -5E' F-F. yr
(Uee'4"If Ahnve lop or Cnehra) rel
g. TOI' OF CASINO IS t-1'.Above I-nut Surface" 1
•lop of rnlnr Imuhrattd at/mr bdow land eurlare requh re a J `7
vulawre In arcorduae with 15A NCAC 1C.01111.
9. YIELD (plim): METHOD OFT Est, 12na
to.WATER ZONES(depth): j QC�]:ION SKru 1f
11, DISINFECTION:Type Amount (Q Show diteclimr and distallce III miles Galls al(cast Y
12. CASINO: Wall1 hickness two Stale Roads or County Roads. luciude We road
Depth Diameter or Weight/Ft. Ma(elial numbers and conuuon load names.
Flout To _r1.1c 35_ s12I-131 Pvc
mom To—FI.
FIonI To F1 ass ss cw,�
13. GROUT: Depot h n etial I Medlod
1710111 Q—To "tip, 1'L 1 7i'H4c '�
From De rl. �`�
14. SCREEN: pUt Uiauelcr Slot Site Maletnl
rlmnl To rt. in. In.
15. SAND/OILAVEL PACK! T3
Drplll Site htnletinl
Flom Tn FI. _
from rn FI. r
`,
16. REMARKS:
� p;nel0
I DO HEREBY CERTIFY 111A"FTIIIS WELL WAS CONS"IRUCIFD IN ACCORDANCE W1111 15ANCAC 2C,WELL
CONSIRUCI IONS FAN DARDS,AND I I IAT A C01'Y OF I I RS IIECORD[[AS BEEN PROVIDED TO TI IE WELL OWNER
SIUNATURE OF PERSON CONS'IIIUCfINO THE WELL DATE
Sublull the III Iginal to (he DIY111on of Water Ounlily,Croundlvaler Secllon,1636 Mail SerYlce Center"Raleigh,N,
11699-1636rhomeNe.(919)7J3-J22i,nlihhl30dnyl, OW-1 REV.0712UUI

�r snri k
F ,_ ,OWNER
RESIDENTIAL N'I's1,L CONS'FRUC7ION RECORD MWD
qq] r
Nonh Carolina Depanment of Environment and Natural liesoutces-Division of Water Quality NC 1/
%%'ELL CON'I'ItAC'FOR CERTIfICA71ON N 'JOS�
1.WELL CONTRACTOR: I. DISINFECTION:Typa_ � Amount L ! �
L2Pe g. WATER ZONES(depthy
Wlell'Coripactor(Individual)Name From Ii 55 To 200 From To
MILLER WELL DRILLING , INC . rim To From To
Well Contractor Company Name Fan To Fan To
STREETADDRESS P . O . BOX 567 6. CASING: Thicknessl
Depth Diameter Weight t Tledal
HAYESVILLE_ NC 28904 _ rim c Tani FtL'/Zs- SDCZI
Cityor Imn Slate Zip Code From To_FI.
B28 837-2997 Fran To_FL
Atea code- Phone numbs
T. GROUT: Depth Material Method
2.WELL INFORMATION: Fmm—ILTo_-L rl. Nl/�
SITE WELL ID lypT applicable) Front,J_To 24
STATE WELL PERMITII(il applicable) Fran To Ft.
DWQ or OTHER PERMIT x(it applicable) B. SCREEN: Depth Diameter SM Size Malelial
Fuxn To FI._In, — In.
WELL USE(Chmk Applicable Box): Residential Water Supply O From To_FL_In. In. ,
DATE DRILLED /O -�n �C' � Rom To_Ft.—In. _ In.
TIME COMPLETED AMQL4M❑ 9. SANDIGRAVEL PACK:
].WELL LOCATION: Depth Size Material
Fran To__Fl.
CITY: )�Jlye Syj Inc, COUNTY C_LL(� From To_Ft -'
From To_Ft.
(Sheet Name,Number.Cemmualty,Sabdivimlon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
p55bpa EIVaney ❑Flal EiRldge LJOlher From To Formation Description
(check opproptiale boa) Mny bein degrrn,
LATITUDE S ��.707 minutes,secrnlJs or
LONGITUDE_5 3 SI . 321f r [in a decinul format
latilude/longitude source: OGI'S OTopogiaphic map rn
(location or nrlt must be shown on a USGS logo map and C-)
attached to this twit I not ushig GPS/ o
I.WELL OWNER `T �_
OWNER'S NAME r'C I?rl/dt� .S /1Icp P) if U'7
STREET ADDRESS �"SD GItiA'it'A� or�r.a-t wa7
City Town Slate Zip Code
AI ea code- Phone number
11. REMARKS:
S.WELL DETAILS: n /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CFITTIFY INA1 Ties WELL WAS CONgnocffD N ACCOnDAnCE WITH
e. WATER LEVEL Below Top of Casing. 7f- FT. 15A NCAC2C.WELt CONSTRUCTION STANDARDS,AND HIAT A COPY OF THIS
(Use*+*It Above Top Of Casing) RECORD BEEN PUNIOEDTOTHE WELLOWNER.
d. TOP OF CASING IS�_FT.Above Land Surface' �� / /�k',C��� ll cZ' _e9
*Top of casing terminated atior belay land surface may require SIGNA TU Or CERTIFIED WELL CONTRACTOR DAZE
a variance in accordance With 1SA NCAC 2C UI18.
e. YIELD m : METHOD OF TEST T/ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the Original to the Division of Water Quality within 30 days. Attn: Information Mgt., ForpirW.18
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] tixt 569* Rev 7105

OWNER
R 2
a lr �t RGSIUEN"/'/AIL 1v1;1,1,CONS llauclION Rl:cuuD MWD
NC
-)� Noah Cmulino Ucp:INmwd of linvirmunenl and Natural Resources•.Uivislal or Wn1cr Qualify -
WELL CONI'RACT'OR CER'rIFICA•1'10N 11 Q
1.WELL CONTRACTOR: I. DISINFECTION:TypsZg7 Amount Z
• /2 e e Cci g. WATER ZONES(depth):
Well Coldr or(Indivk)uaq Name Fran To From To
MILLER WELL DRILLING , INC . rtan TT From To
Well Calbacla Company Name Flan To From To
STREETADDRESS P . O . BOX 567 G. CASING: Thickness/
Depth Dianiler Weight Malelial
HAYESVILLE NC 20904 Fran To_FL _
City Iowti Stale Zip Cale Fran To FL _
l828 _7_E137-29.97 From To_r-I.
Alea ca)> Phvue numbs
7. GROUT: Deptll Melelial MegIW
2.WELL INFORMAT ION:
Flan To rl.
SITE WELL TO fill.IroncaNel Fan To Ft.
STATE WELL PERMITpx.PTAT.ble) Fan To Ft.
OWO or OTHER PERMIT e(il appiicaIAe) B. SCREEN: Depth Dlarnalet Sbl Size Malmial
_
WELL USE(Check Applicable Dux) Residential Water Supply Cl Fran To_FI. in. In.
r Fan To I'll.—In. _ M.
DATE DRILLED— / �r '"' Han To_Fl._111. _ in. x
TIME COMPLETED 1 DO AMU PM 1IY
B. SANDIGRAVEL PACK:
7.WELL LOCA7AIION: Depth Size Material
// y�'S COUNTY/ From To_FT.
CITY: — COUNTY To_FT
Fan To Fl
(sa F.l N.ms,Hweber.,Gmmlw,lly,Sebdlddal,Lvl No.,P..c.1,Zi,Cod.)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
p8c�ipe UValley 0171al ❑Ridge ❑Other_ Flom To Formation 0escliption
(chocA epprop late box)
hlxy IT III dfRIK1,
LATITUDE —3�F� • _ minwrs,arcmxis or
1.1..1,611.0 Gmnai l
LOTTCIruDE a30�6� f Gz.
T_=3
L�lituddlongiluJc somcc: ❑GIIS Illopoglaphic neap r�
(kxnikW of wPI must be shown on a USGS logo mop and _
aflachad to MIT form l not using GPS) P a
C
4.WELLOWNER � [ ,n
OWNER'S NAME �// J'�/>`OR� �I /U ul� _ Ln
STREET ADDRESS
Cilya lows Stale Zip Cale
Area code- Plronenumtm
11. ILEM1M1tAR{tS:
G.WELL DETAILS: F D�/)�Cd d�'f°,ye� �P.orn
a. TOTAL DEPTH: _�/D .moo S ID
b. DOES WELL REPLACE EXISTING WELLS YES NO
I DOnFirritY CFn tIFY THAI THIS WELL WAS CONSmOCItO INACCOTTOA11[E WITH
e. WATER LEVEL Below Top d Casing'. ZO FT. 15A HCAC 1C.Welt CONS mOCIRa1 SIAmIAnt16-ANO THAT A COPY OF 114S
(Use-4-G Above Top of Casing) RECORD It"BEEHHP,f%VOXD10 THE WELL OWNER. �^—
d. TOP OF CASING IS FT.Above Land Surface' � j
*Tor,of Casing lerminaled aU Wow
ow land surface may require ---Yrr------•---A---'---' "---'7-- ,
a variants sl aecoldancewith 15A NCAC 2C.0118. SIU J/TiURE OF CERTIFIED WELL CONTRACTOR DATE
a. YIELDfgpm):�_METHOD OF TEST..
PliiNl ED N�-ME OF PERSON CONSTRUCTING THE WELL
1
Submit the original to the Dlvlslon of Water Quality within 30 days. Attn: Information Mgt., ram rw-to
1617 Mail Service Center—Ralolgh,NC 27699.1 G17 Phone No.(919)7 3 3-7 01 6 Bxt 56G.' Rev 7105

A.:sing r.
h� OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD z MWD
North Carolina Department of Environment end Natural Resources-Division of Water Quality NC
WELL CONTRACTOR CERTIFICATION H
1.WELL CONTRACTOR: I. DISINFECTION:Type Amount
�P«(!! g. WATER ZONES(depth):
Wee Contractor(individual)Name From Tot �0 From To
MILLER WELL DRILLING , INC . Fan YO TD XqCL ' From To
Well Contractor Company Name From To From To
STREET ADDRESS P . O . B 0 X 567 6. CASING: Thickness/
" Depth/D / D ameler Weight MaterialHAYESVILLE NC m 28904 Fro FI. ZS U
City"Town Stale Zip Code From To__Ft.
l828 )- 837-2997 From To_Pt
Area code- Phone number
7. GROUT: Depth MaBH4 Method2.WELL INFORMATION: Fram_Q To 3 Ft. & 8 _
/
SITE WELL ID 11(7t applicable) From r To SO FL Ad?
STATE WELL PERMIT#(eeppgcabte) Ftpm To FI.
DWQ or OTHER PERMIT#(If applicable) a, SCREEN: Depth Diameter SM Size Material
From To_Ft._In. _ In.
WELL USE(Check Applicable Box): Residential Water Supply[I Fran To_Ft._In. _ In.
DATE DRILLED /jq—l0—0y— Fran To Ft.—In. _ in.
TIME COMPLETED1D/ Zo AM PMO 9. SANDIGRAVEL PACK:
].WELLLOCA�TrION: Depth Size Material
�iYt�jl// � COUNTY_ FTam To_FL
CITY: From To__Ft.
From To_Ft
(Sheen Narm,Numbera.Coomunily,Subdidsion,Lot No.,Parcel,Zip Code)
TO✓POPR_q PHIC1 LAND SETTING: 10.DRILLING LOG
S45Va" OFlal ORidge []Other From To Formation Description
(cheep appropriate box)
May be in degrees,
LATITUDE ,Q�'! 091 minulessaadsor -
LONGITUDE�} 6" Z in•decimal formal
Latitudellongitude source: OGPS DTopographic neap
(locer ion of"I must be shown on a USGS loop map and
attached to this form I not uskv GPS)
#.WELL OWNER
OWNER'SNAME NC9itpt A- (ix�oDd�+v m
STREET ADDRESS 14,11 AZI ('"J
RJ
Ln0' Syi 1 4CY 402-1
City or Town Stale Zip Code O
Cn
(Area code- Phone number
Il. REMARKS:
5.WELL DETAILS: I '�� /
a. TOTALDEPTH: /�
la.-DOES WELL REPLACE EXISTING WELL? YES NO O
1 Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCa10ANCE VATH
e. WATER LEVEL Below TopdCazing: l00 T. 15A NCAC 2C,WELL CONSDIVCTION STANDARDS,AND DNT A COPY Or THIS
(Use W 8 Above Top of Caning) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d- TOP OF CASING IS FT.Above Land Surface' ova/�_ le 1D
of casing terminated aUDr below land surlace may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accordance with 1 SA NCAC 2C.0118.
a. 0
YIELD(gpm): ,METHOD OF TEST PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Alin:Inlorma0on Mgt., FormGW-ter
1617 Mall Service Center—Raleigh,NC 276994617 Phone No.[phone] ex1568.' Rev.7105

ip
V OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD nnwD
A
North Carolina Department of Environment and Natural Resources-Division of Water Quality
,�. NC ✓
WELL CONTRACTOR CERTIFICATION
1.WELL CONTRACTOR: I. DISINFECTION:Type Amount ..C"
g. WATER ZONES(depth):
Well Contractor(individual)Name From 2-60 To7-6J From To
M T l I F R IM I n R T I I T N C, T N C . Fran : 6 To yyD From To
Well Contractor Company Name From To Fran To
STREET ADDRESS P - n - R n X 5 F 7 S. CASING: Thickness/
Depth Diameter Weight Material
HAYF VTI I NC 2R9n4 Fram�_To/ 'D Ft. (�,/ZS ,185r c/L
City or Town Stale Zip Code Fran iS2 To.l Y7 Ft. 6,12J S%CCL
(828 } 837-2997 From To FI.
Area code+ Phone number
2.WELL INFORMATION:
7. GROUT: Depth ? Material Method
From U To ✓ FL leK,r/4'/Ld �r/P
SITE WELL ID#(it applicable) From_3 To Oe) Ft. 7V c,,76
STATE WELL PERMIT#(if applicable) Fran To FL -
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Sbt Size Material
_ -
WELL USE(Check
i Applicable Box): Residential Water Supply[IFrom To FI._In. in.
To Ft. in. In.
DATE DRILLED / -,� -OSl From To Ft.—In. _ in.
TIME COMPLETED .7, -3 O AM p PM Q/ g, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: COUNTY From To Ft.
Fran To Ft.
From To Ft.
(Street Name,Numbers.Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
0910 DValley []Flat []Ridge pother From To Formation Description
(check appropriate box)
LATITUDE 3 y S 9, b Z May be in degrees, -
minutes,seconds or
LONGITUDE SrJ, y'7 in a decimal format
i7
Latitude/longitude source: ❑GPS OTopographic map n�
(bcation or wet musf be shown on a USGS topo mop and
attached to this form 17 not using GPS) o -.
ell
4.WELL OWNER f I -
OWNER'S NAME J fJSON Pl�-iII]//P
STREET ADDRESS I I S 0 ( �f!e f
Y-n5 �) Entitn Nr, 2WgO2-
City or Town State Zip Code
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: /1
a. TOTAL DEPTH: U � /
b. DOES WELL REPLACE EXISTING WELL? YES[I NO IUD
e, WATER LEVEL Below Top of Casing: / I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
Op g rP D FT. 15A NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THAT COPY OF THIS
(Use'*'0 Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS_�_FT,Above Land Surface'
'Top of casing terminated allof below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance With 1 SA NCAC 2C.0118. p
METHOD OF TEST &�i k ^ P P(/�e. YIELD(gpm): � _ p
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., ram Gw-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 668. Rev.7/05

D-
307331
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
,- iv�ision,Iof Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME n(prinQC'�%"S G&-UQG-�'n P ""^� CERTIFICATION#O�
WELL CONTRACTOR COMPANY NAME�r``� � L^�u I�akw A PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L Topogr9phic/Land setting
Nearreest.Tt1' ounty ❑Ridge Mlope ❑Valley ❑Flat
�y�`(• (check appropriate box)
(Street ame,Numbers,C unitX Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER. (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
:et o e 7 (check box)
O D t DEPTH DRILLING LQG
city o wn State Zip Code From _ To F rmati n sc ' tion
�)
Ater code-Phone number 1 g OS, 5
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 11�
7. STATIC WATER LEVEL Below Top of Casing: ��FT.
(Use"+"if Above Top of Casing) CC n f=n1
8. TOP OF CASING IS_ I FT.Above Land Surface*
*Top of cuing terminated actor below land surface requires o
variance In accordynce with 15A NCAC 2C.0119. -or"
9. YIELD(gpm): l D ME�jg�OF TEST �� o�
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from atFeast ��
12. CASING: Wall Thickness two State Roads or County Road .Include theToad C31
Depth _ i e er ��(W�ei�t/Ft. (a�tf�tial numbers and common road name . rno
From Ft. ��iG�t c-a t•(p Y"�., J n
From To F e
From To Ft.L
13. GROUT: Deplk, Ma dial Metho
From To Ft. L
From To Ft i -
14. SCREEN: Depth Diameter Slot Si Material
From To Ft. in. in.
From To Ft. in. in. (� -
15. SAND/GRAVEL PACK: u`�i D
Depth Sin Material
From To Ft. i G
From To Ft. co �-
N
O =S;
16. REMARKS: o
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -,
CONSTRUCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE rLL WNER
f!�p`LfL
SIG TURE OF PERSON CONSTRUCTING THE WELL IfATEf
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

O.,C--o
3 '07332
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resour�rcceess�r-D'vis'ioonn�o',f,Water Quality-Groundwater Section/�
WELL CONTRACTOR(INDIVIDUAL.)NAME (print) U�S G,W#-`e1��f 4�'� CERTIFICATION
N## 11 �-r�'
WELL CONTRACTOR COMPANY NAME
�iprEE�/Il1 k t�hLI 'Wail Ln�C^ PHONE # 0�0)CFI 1 �SJ
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED Will PERMIT#
(if a licable (if applicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELLLOCATj Topographic/Lann setting
Neare To aunty Midge ❑Slope alley ❑Flat
(check appropriate box)
(Street Name,Num Common' ,Subdivision,Lot No.,Zip Code) Latitude longitude of well location
3. OWNER: (degreulminutestseconds)
Address Latitude/longitude source:❑GPS❑Topographic map
S (check box)
1)LY A+�or � DEPTH DRILLING LOG
From To Formation esc 'p[ion
Ci or own state zip Code � 3�1
(—)e 3e t
Area code-Phone number\ \' 69
4. DATE DRILLED � t7�t kO'�"
5. TOTAL DEPTH: / ipyt
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l3
7. STATIC WATER LEVEL Below Top of Casing:_(p() FT. — —�
cm
(Use"+"if Above Top of Casing) CA �rin
8. TOP OF CASING IS FT.Above Land Surface* --n IViG
-Top of casing terminated at/or below land surface requires a tp
variance in accordance with 15A NCAC 2C.011#. � 1 �fl
9. YIELD(gpm): _MFlTI�OL�OF TEST �rn
10. WATER ZONES(depth): \ LOCATION SKETCH �v n?
11. DISINFECTION:Type Amount Show direction and distance in miles from at Iat st o
12. CASING: Wall Thickness two State Roads or County Roads.Include the-road Zr7
Depth Di elFrWeight/Ft. at al numbers and common road names. �o
From To {OS Ft. �T
From To Ft. ! '
From To Ft.
13. GROUT: Depth M 4al Meth
From_Q To �b� Ft.�"O�s L
From To
14. SCREEN: Depth Diameter Slot Sin Material
From To Ft._in. in.
From To Ft.—in. is -
15. SAND/GRAVEL PACK:
Depth Sin Material
From To Ft.
From
To Ft. CD y
�n
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL ,
CONSTRUCTION ST ARDS,AND THAT A 0 Y OF THIS RECORD HAS BEEN PROVIDED TO THY/WE 0 'ER
/ate//�C .� J
sTriNATURF OF PERSON CONSTRUCTING THE WELL 'DAPE
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

rx
`r 307333
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and
�tNatural R�esoouurces-Division of Water Qua'' ater Section 2C r
WELL CONTRACTOR(INDIVIDUAL)NAME
�(priintt)�w\`L/LA` "a 11 �S T�`U�:\ T--�n �S CATION p4 1 J D
WELL CONTRACTOR COMPANY NAME iT'sY t �y�`•� w`�-� v L�`�- �zv4/5-9—
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMTTe _
if licable (if applicable)_
�—
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial C al❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List U-
2. WEL A Topo ing
N wni Cot ty ❑Ridge Slo, y ❑Flat
(check
(Sveet,N me, \ ben,con 'ty,Su d 'Sion,Lot No.,Zip Code) LatitudeAOng'i' location
3. OWNER. I (degrees', !s)
Addr ss Latitude/longitude source:'" Topographic map
&(SRoute No.) `)
DEPTH 'LLING LOG
ny r ry ,�kerrO Zip Code From \To i Description
Aret coda Phone number
4. DATE DRILLED D5pti1
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES Ja NO r c
7. STATIC WATER LEVEL Below Top of Casing: . 11 rA m
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS 1 FT.Above Land Surface" t Vofl
'Top of cuing terminated atlor below land mrinee requires a �p
variance in accordsveTith ISA NCAC 2C.0118.
9. YIELD(gpm): —METHOD OF TEST
10.WATER ZONE- ,--,--,- LOCAT Q CDD
11. DISINFECTION:Type Amount Show direction and distar :es from It St
v'o
12. CASING: Wall Thickness two State Roads or Cow Include ad n
rcl� p 1Ver Wei T, riai numbers and common to. S.
From b To `D FL (O NYC
From To Ft.
From To Ft.
13. GROUT: Depth Mp�erial Metb
From To_b Ft. e
From To Ft. 1
14. SCREEN: Depth Diameter Slot Size Material a
From To Ft. in. in. 1y
From To Ft. in. in. Oo
15. SAND/GRAVEL PACK: i
Depth Size Material
Front To Ft. y=
From To Ft. co
N
16. REMARKS: b o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC ".'ELL
CONSTRUCTION STANDARD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TC :LL WNE -
2 aS
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. REV.07/2001

oo 307334
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
� 4'(ptrin�t) / S l+�I..L. LA y��l T_E.�YI .� CERTIFICATION#2- ZW
WELL CONTRACTOR COMPANY NAME k, 1�JVW 1I � I�tvt PHONE # 12�E)yJ�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)__
I. WELL USE(Check Applicable Box): Residential M /Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT is opographic/Land setting
Nearest off• - County dge ❑Slope []Valley ❑Flat
(check appropriate box)
(Stint Nai ,Numbe ,Ca unity Subdivision,Lot .,Zip Code) Latitude/longitude of well location
3. 0 (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( tractor to NoJ (check box)
DEPTH DRILLING MG LOG
Ftty y n_a,Spc Zip code From To I Fo ion Description
C Ut`t
Area code-Phone number \ ��
4. DATE
DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES TJ NO
7. STATIC WATER LEVEL Below Top of Casing:�_FT.
(Use"+"if Above Top of Casing) ,
8. TOP OF CASING IS 1 FT.Above Land Surface' t»a
'Top of cuing terminated at/or below land surface requires a Cn
variance in accordange with 15A NCAC 2C.0118. frrt
9. YIELD(gpm): Le ME O OF TEST �� m �G
W Ort
10. WATER ZONES(depth): N b
LOCATION SKETCH CID 3
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include ft road -iw
Depth r g�W,,etQt/Ft. to al numbers and common road names.{' W Z�
From � To�Ft. �/4i bllCd l•(e 1� O rno
From To Ft. ^# a
From To FL
13. GROUT: Dept M tej al 1L Metho
From_To F e
From To Ft.
14. SCREEN: Depth Diameter Slot Size! Material Yt}z
From To Ft. in. in. co _
Fronk-To Ft. in. in. 6'
15. SAND/GRAVEL PACK:
Depth Sin Material
From To Ft. _..
From To Ft. STY
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT N STANDARD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL 0 R
67 SIGNATURE OF PERSON CONSTRUCTING THE WELL D TE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 3 0 7 6 8 3
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) DAVIDF.MCKINNON CERTIFICATION N 2411
w'ELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE N [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PF,RMITN
(if applicable) (if applicable)
l. WELL USE(Check Applicable Box):Residential t! Municipal/Public(I Indushial❑ Agricu tural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Otter,List Use
2. WELL LOCATION: •h�A Topographic/Land setting
Nearest Town: �MSs I�WrJ County CLAY ❑Ridge )OSlope ❑Valley OFlat� fQ
13RASSTOWN-NEAR GREASY CREEK(PAYNE PROPERDIO (check appropriate box) rrt '"`
(Street Name,Number,Community,Subdivision,Lot No.,Zip Code) LatitudcAmigitude of well location
3. OWNER: KEVIN GREEN Co
(degrees.minuteslseconds)
Address P.O.BOX 1298 Latitude/longitude source:OGPS❑Topographic P
y� � (Sheet or Route No.) (check box) [l1
1XAI� V,!te GA 30512 DEPTT) DRILLING LOG
city or Town state Zip Code From To Formation Description
(706 )- 781-8029 0'TO 40' BROWN DIRT
Area code-Phone number 40'TO 45' BOULDER
4. DATE DRILLED 0210412005 45'TO 55' GRANITE
5. TOTAL DEPTH: 805' 55'TO 60' BROWN DIRT
6. DOES WELL REPLACE EXISTING WELL? YES O NO 9 60'TO 76' GRANITE
7. STATIC WATER LEVEL Below Top of Casing: 250 FT. 76•TO 180' GRANITEIQUARTZ MIX
(Use"+"if Above'rop of Casing) 180'TO 220' BLUE SLATE
S. TOP OF CASING IS 1 Fr.Above Land Surface• 220'TO 805' GRANITE
"Top ofcasing terminated al/or below land surface requires a
variance in accordance with 15A NCAC 2C.0119
9. YIELD(gpm): 112 METHOD OF TEST AIR
10. WATER ZONES(deptt):
LOCATION SKETCH
I I. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least
12. CASING: Well Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weighl/R. Material numbers and common road names.
From +1 To 76 Ft. 61/8" SDR 21 PVC
From To Ft.
From To FL
13. GROUT: Depth Material Method I
From 0 To 20 Ft.CEMENT GRAVITY
Froth To Ft. S2.
14. SCREEN: Depth Diameter Slot Size Material t9
From To Ft. in.
From To FL in. in.
15. SAND/GRAVEL PACK: �.
Depth Size Material
From To Ft. �. ` 19
From 'ro Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY Or T HIS EF q RRD 1 BEEN PROVIDED TO THE WELL OWNER
R %GT� E
SIGNATUREDATE
OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Crmttr- >
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD �l ^North Carolina Department of Environment and Natural Resources-Division of Water Quality 307682
WELL CONTRACTOR(INDIVIDUAL)NAME (print) DAVID F.MCKINNON CERTIFIC ATION#2411
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PF,RMIT#
(if applicable) (if applicable)
. WELL USE(Check Applicable Box):Residential)d] Mtmicipal/Public❑ Industrial❑ Agrictdtural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: b{2`tS-S OK)n1 County CLAY ❑Ridge )❑Slope ❑Valley ❑Flat
BRASSTOWN-GREASY CREEK(WELL IN SWITCHBACK) (check appropriate box) T
(Street Name,Numbers,Community,Subdivision,Lal No..Zip('ode) rTi
1 atitude/longitude of well location CO
3. OWNER: KEVIN GREEN (degrees/mitutes/neumds)
Address P.O.BOX 1298 Latitude/longitude source:❑GPS❑Topographiyiluip
(Street or Route No.) (check box) ull
GA 30512 DEP'1'II DRILLING LOG
City or Town state Zip Code From '1 it Formation Description
(7G6 )- 781-8029 V TO 30' BROWN DIRT
Area code-Phone number 30'TO 32' BOULDER
4. DATE DRILLED 02/10/2005 32'TO 49' GRANITE
5. 'TO'TAI,DEPTH: 505' 49'TO 100' GRANITE
6. DOES WELL.REPLACE EXISTING WELL? YES❑ NO 100'TO 118' GRANITE/QUARTZ MIX
7. STATIC WATER LEVEL Below Top of Casing: 90 1` 118.TO 208' GRANITE
8. T"OP OF CASING IS t (Use"+"if Above Top ofCasiag� 208'TO286'
PT. Above Land Surface GRANITE/MARBLE MIX
"Top of casing terminated at/or below land surface requires a 286'TO 305' GRANITE-8 GPM
variance in accordance with 15A NCAC 2C.01I& 305'TO 505' GRANITE- 12 GPM
9. YIELD(gpm): 12 METHOD OF TEST AIR
10. WATER ZONES(depth): 55', 165' 180'
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount Too PPM Show direction and di. once in miles from at least
12. CASING: Wall Thickness two State Roads or Cot my Roads.Include the road
Depth Diameter or Weight/Ft. Material mmmbers and common tad names.
From .1 To 49 Ft. 6 118" SDR 21 PVC
From To Ft.
From To
13. GROUT: Depth Material Method n7
From 0 'To 20 Ft.CEMENT GRAVITY `� a
From To F[. ; vA"�v
14. SCRF,EN: Depth Diameter Slot Size Material
From To Ft. in. in.
From 'ro Fl in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From "I,0 Ft. _
From 'To Ft. 0
16. REMARKS:
I DO IIERE13Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS.AND THAT A COPY( F-1.111S RECORD HAS BEEN PROVIDED TO TIIF WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THF,WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004
MAR 14 2006

WELL CONSTRUCTION RECORD 30 � 871
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prl.Q rQ aaK Z (7 V(C GLZ CERTIFICATION#1(75
WELL CONTRACTOR COMPANY NAME14--k-S Luc a-kc PHONE #-M)7YS 6
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS
(if applicable) if applicable) _--
1. WELL USE(Check Applicable Box):Residential l3 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
;r
2. WELL LOCATION: Tgrap}dcAmd setting
N stTown:� VI(�E County CLc ❑Ridge Er lope ❑Valley ❑Flat
t4 u)u 6 7sS904 (checkoppropristebox)
(Sheet Name,Numbers,Community,Subdivnioo,toot No,Tip Code) Latitude/lonpitude of well location
N 35061.902 WOF3'5"/. 76P�- -
3. OWNER:C- V UR t'14W /LI aN6J (degreweam uedaptoade)
Address O 3oK 73y5 Latiurdarlorgih:de so=oe: -nS❑TopoVWw-o map
(Street or Rome No.) (check box)
1-42�K-S Y lut. N G F 8-'lUz� DEPTH DRILLING LOG
Town sate tip code From Jo Formation Description
8Z City M-7 -6649 U
Am code-Phone camber G - f �i a l`(
4. DATE DRILLED L-27 - 55 - Q"lZamd- E[. T
5. TOTALDEPTH: a2S -r@3ti(
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 35 —/40 1- 9 It(-: (kxati dzeO Tp6c-4<
7. STATIC WATER LEVEL Below Top of Casing: S20 FT. 6?CW K (I—C- 1 7�D 2ct-K
(Use"+"if Above Top of Casing) O (A)4- t Z 1-4 1 Q
8. TOP OF CASING IS _FT.Above Land Surface' �y Cu R( µ tC C�Z 2
'Top of casing teraloated■Nor below land surface requires a
variance in accordance with 15A NCAC 2C.0I18. (31L+cyc Rcjc-tc r''�rui1 17E
9. YIELD(gpm):_y 0 METHOD OF TEST ; 1R Q+ Z
10.WATER ZONES(depth): 1 93 (`((3 S L2ekc IZoc_t-c
LOCATION SKETCH
11. DISINFECTION:Type__ALTL4 Amount O Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt Matqng numbers and common road names.
From± 2- To-Aj—Ft G VII SL 275 PVC 1 4Id FRort-� �tirlc2
From ' zi To-12-(-7 Ft. [o I l B -51221 5 y - / z G1 N TE Q T Z
From To Ft I(,Z _ 171 GL2ck jzcc t QTz
13. GROUT: Depth Material Method 17 t - 2 10 5(- c(- per,c_C'z;
From�To_aa_Ft C FrViCI�T— �i?PVITS� 2(O - 21� aectc (�
From To Ft rn
14. SCREEN: Depth Diameter Slot Size Material
From TcL. Ft in. in. t ��
From To Ft in. in. o
15. SAND/GRAVEL PACK: -o rgrn
Depth Size Material = c`
From To Ft. t y C:)
From To Ft. p igo
c'r
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION TANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
:Ll t /-31 -6- 1p. �/f rot �
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. OW-1 REV.07/2001

WELL CONSTRUCTION RECORD 3 0 919 8
North Carolina-Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)W\L�k Vkm is. T�Cvvv -Groundwater Section
WELL CONTRACTOR COMPANY NAME t�VL U..L '� ,�lJA&W CERTIFICATION 4
STATE WELL CONSTRUCTION PERMITk PHONE #
(if applicable) ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaVP
Monitoring❑ Recovery ❑ ublic❑ Industrial❑ Agricultural❑
Heat Pump Water Injection❑ Other 0 If Other,List Use
2. WELL LOCA N:
Neare own: County TOPogrophidLan setting
DRidge OSlope alley DFlat
(Street Name, mbeo,C City,Subdivision,Int No„ (check appropriate box)
Zip Code)3. OWNER: Latitude/longitude of well location
�
Address y (degrea/minutes/seeonds)
treet or it NQ.) Latitude/longitude source:OGPSOTopographic map
T DEPTH (check box)
City or wn state Zip Code DRILLING From To t ie
Ara c Phone number4. DATEE DRILLED5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES O NO 07. STATIC WATER LEVEL Below Top of Casing:�_� _
S. TOP OF CASING IS l (Use"+^if Above Top of Cuing) -- PO
FT.Above Land Surface* N
'Top of casing terminated atfor below land surface requires■
valance in accordsnr►�'lth 15A NCAC 2C.011& s ---
9. YIELD(gpm): D O ST 1 _ c� t'
10.WATER ZONES(depth): �— a
lam' ----
11. DISINFECTION:Type 1 LOCATION FT H ry
12. CASING: - Amount Show direction and distance in miles fr at least
Depth Nall Thickness two State Roads or County Roads.Incl a the rg6d
From b To (PO Ft. *fit at 'af n ben:and common road name
From To Ft.
m P
Fro To Ft
13. From_Q To-/_� Ma al
-�s.L Ftt11 Method
From De Ft. 1 Q
14. SCREEN: Depth I>ameter Slot Sim
From To . in. in. Material is
t
From Ft
To Ft, in.
IS- SAND/GRAVEL PACK- in
Depth Sim material
From To Ft. �Sg
From To Ft._
16. REMARKS: v r
a
I DO HEREBY CERTIFY THAT THIS =`
CONSTRUCTION STANDARDS, WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
S AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE�ATL OWNER i
tit
c-
SIGNATURE OF PERSON CONSTRUCTING THE WELL A - `
Submit the original to the Division of Water Quality,Groundwater Seetion,1636 Mail Service Center-RateigM'NC �T
27699-1636 Phone No.[phone],within 30 day& --
GW-I REV.07/2001

WELL CONSTRUCTION RECORD 3 0 919 4
North Carolina-Department of Environment and Natural Resources-Division of Water ali WELL CONTRACTOR(INDIVIDUAL)NAME (print) C`f Q.A.IS G '�Qlt 1."q Quality
ty-Groundwater Section
WELL CONTRACTOR COMPANY NAME - -e— CERTIFICATION p� - �! L. Lkc pt— -
STATE WELL CONSTRUCTION PERMT#
NE A
if ikableASSOCIATED WQ PERMIT#
ifa likable
I. WELL USE(Check Applicable Box):Residential MunicipaVPublic❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WEim
Ci6 my Topographic/Lan tting
Midge ❑Slope alley ❑Flat
(Sheet N Numbers,CamVL, ubdiviaioq No.,Zip Code) (check°PPtoPr;ate box)
LatitudeAongitude of well location
3. OWNE _
Address (degreedminmeilaeconds)
t Route o. �1 (11 LatitudeAongitude source:❑GPS❑Topographic map
City or own c �� ` E (check box)
tr State Zip Code D PTH
From To Forman n esc tion
Am code- _ t
4. DATE DRILLED �� DS ��3'
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (a
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING IS , Nee v^if Above To of Caning) —
FT.Above Land Surface• �_ a'Top or Cuing terminatsd h 13 below land surface require a
wrlana la aemrdsnee with ISA NCAC 2C.011&
9. YIELD(gpm): Q METHOD QF TEST L _ N
10. WATER ZONES(depth):.
11. DISINFECTION:Type rC LOCATION cIM"
12. CASING: Amount Show direction and distance in miles from at least
�p� a�teur Wall Thickness two State Roads or County Roads.Include the ad
From d To (v Ft.
'/ _ or Wei �t. ate 'al numbers d common road names.
From To FL
From To FL
13. GROUT: Depth Ma
FrorrL'To�_Ft. Method
From To Ft
14. SCREEN: Depth Diameter Slot Sim
From To Ft. in Material
From
15. SAND/GRAV Ft. in.
_ in.
LPACK: in.
EL
From Size Material
From To Ft. `-
16. REMARKS:
a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
CONSTRUCTION STAND A S,AND T A COPY OF THIS RECORD HAS BEEN PROVIDIEDAT WITH O THE C L O OWNER L71
SIGNATURE OF PERSON CONSTRUCTING THE WELL
A kGJ
Submit the original to the Division of Water Quality,Groundwater Section, Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-1 REV.07/2b01

WELL CONSTRUCTION RECORD 1I
96
North Carolina Department of Environment and Natural Resources-Division of Water Quality 1 `)C
WELL CONTRACTOR(INDIVIDUAL)NAME IF DAVID F.MCKINNON CERTIFICATION#2411
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # (M)837-8008
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential g Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: HAYESVILLE County CLAY Ridge ❑Slope ❑Valley ❑Flat '
299 TREETOP DR (check appropriate box) _
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3SoI. `5A4 0/8337,3.59IAA
3. OWNER: MARK PALMER (degrees/minutes/Seconds)
Address 299 TREETOP DR Lafitude/longitude source:NGPS❑Topographic map
(Street or Route No.) (check box)
HAYESVILLE NC 28904 DEPTH DRILLING LOG
City or Town state Zip Code From TO Formation Description
( ,jV)-757-8894 0'TO 25' BROWN DIRT
Area code-Phone number 25'TO 27' BOULDER
4. DATE DRILLED 05/05/05 27'TO 35' GRANITE/SET CASING
5. TOTAL DEPTH: 605' 35'TO 100' GRANITE
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO K 100'TO 340' SLATE
7. STATIC WATER LEVEL Below Top of Casing: 250 FT. 340'TO 605' GRANITE/SLATE MIX
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 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): 2 METHOD OF TEST AIR
10. WATER ZONES(depth): 180',360' BIT SIZE 6.069
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Shaw direction and distance in miles from at least
12. CASING: wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 35 Ft. 6 118- SDR 21 PVC
From To Ft.
Fmm To FL
13. GROUT: Depth Material Method
From 0 To 20 FL CEMENT GRAVITY
From To FL
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft, in, in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIII 115A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
rJ �/� Uw� s-c;-64S
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

31131s
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Naattmal Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME�(7prlet)J "�"2— l{!G'r0' CERTIFICATION# 31 7�
WELL CONTRACTOR COMPANY NAME .L�fEf<S LC/( T.L.a (7)!Z/LL.I1'k1 PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if licable if ap litable
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring O Recovery O Heat Pump Water Injection❑ Other 0 If Other,List Use
2. WELL LOCATION: Topographic/Land ptfing
Nearest Town: j4Z1V&!. -VJLU-- CountyS,�?/ ❑Ridge OSlope Galley OFlat
REFUEL LaivF L-0'T�4 (check arP[wrtaft bost)
(Street Name,Numbets,Community,Subdiv oa,Lot No.Tip Code) Latitude/longitude of well location
N35"6y .355` rN 093�5z W2"
3. OWNER. LG-'WiS Co",s -2tr_Ti ai.( (��xy .)
Address CJ _ 7` -- _ Latitude/longitude source:0UPS❑Topographic map
y (Strut or Route No.) (check box)
frl� =i7% �' = ('rI 3Gly DEPTH DRILLING LOG
City onm�t State Zip Code From To Formation Description
Am code-Pmoe mob t — iN
4. DATE DRILLED `1 �3 DN- Lowwa-11
5. TOTAL DEPTH: '3 Z 5 Zqx.trk 41Es7tbito P..a t<
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ( 7 - rr� 1409D
7. STATIC WATER LEVEL Below Top of Casing: /;ggK
(Use"+-ifAbove Top of Casing tD GiGe l"v' -
8. TOP OF CASING IS FT.Above Land Surface•
`Top of cado8 terminated at/or below land surface requtro a
vadanee in accordant -with 1SA NCAC 2C.0118.
9. YIELD(gpm):L—METHOD OF TEST OiR
10.WATER ZONES(depth): 1:55.
LOCATION SKETCH -
11. DISINFECTION:Type T/f Amount ! Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Diameter or,V�$ght/Ft numbers and common road Dames.
From To-� 5 Ft (0'� UC 7S y[
From S Tomy�L r
From To Ft n
13. GROUT- Depth Material 6 Method �.
From 0— To—?�O Ft
From To Ft
14. SCREEN: Depth Diameter Slot Size Material cJ1
From To Ft in. in.
From To Ft 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
CONSTRUC.rSTANDARDS.AN�PY 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

1122-6 j
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
1-/Division of Water Quality-Groundwater Section
WELL CONTRACTORUNDIVIDUAL)NAME (print) . C CERTIFICATION# 3/75
WELL CONTRACTOR COMPANY NAME /3 ytr/2s CcJ F/( l RIU(Nt7 L IVC. PHONE # am) 745-2/(G
STATE WELL CONSTRUCTION PERMIT# ecOCIATED WQ PERMIT#
if livable if livable
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELLLOCATI N: 1
Nearest Town: � 1 County CL 2 5 ❑Ri
/ �° d setting
❑Flat
ARN'.S I-09C C22/n1 nn dge lope Malley
(cheek ePProPiiax box)
(Street Name,Numbers,Community,Subdivision,lot No,Zip Code) LatitudeAongitude of well location
3. OWNER:-UCAS Jr EVE/APt*N-r 2N0 /N2RKET-1"r- z e- /V3S`d3.9y! D San
(degtees/miwser/aececacmds&))
Address _PO fSOk 1530 Latitude/longitude source:06PS13Topographic map
(Street or Rome No.) (chftk box)
1(A YCS y tt�a. N C 2 890 y DEPTH DRILLING LOG
SETown sure zip Code From To Formation Description
S( 7$} E -350N p - 59 Rep ctea
Am code-Phone comber 54 - 75 TdN C/ /
4. DATE DRILLED S 20-o S 75 - /o5 REoorv( .2.ta�, t cr p�
5. TOTAL DEPTH:_ i?S / A1.5 - /25 V68r1fee6J Abx
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 19 /25 - /SS 'Stekt: Rocs- w/QTz
7. STATIC WATER LEVEL Below Top of Casing: 2 FT, 1:5 - /&s 729 MUCK
(Use"+"if Above Top of Casing 5 — /95
8. TOP OF CASING IS FT.Above Land Surface' r44 (3[ecic Roorc
'Top of wing termtoated attor below laud surface requires a /95 — ?Is, Bf1L,,2LK
variaocela accordancewith ISANCAC2C.011L 2-(,? - 3 o-1 &RK azav t"o-K
9. YIELD(gpm):32 ME O OF TEST / 3D7- -2 2 5 p22K Gde
10.WATER ZONES(depth):. 3�/-3Z5 ZZ
LOCATION SKETCH
11. DISINFECTION:Type H774 Amount /12-7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depdt Diameter or Weight/Ft. Material numbers and common road names.
Frotr��To 5 Ft. (P 'L SPR 27,5 Pv G
From (n5 To 125 Ft fin ' SDR2f Pvc
From 2'i To l3o Ft_(_ / 8 STEEL
13. GROUT: Depth Material Method C- "I
From To Z O FL CE M--a w 1 1T Y :
From To Ft I - ig
14. SCREEN: Depth Diameter Slot Size Material N
From To Ft m. uL
From To Ft. in. in. .^
15. SAND/GRAVEL PACK.
Depth Size Material
From To Ft. -1
From To Ft. s 1 -
i I
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
,
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Rateigi NC _-
2 7699-1 63 6 Phone No.[phone],within 30 days. GW-I REV.07/2001 -

0� 3 1 '3 14 .141
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NaturalResources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (priat) �� (VZ f. V V7O t2 CERTElUCATION Qf 75
WELL CONTRACTOR COMPANY NAME 31YE=P ( D"2t t ltgG -Tµ PRONE -
STATE WELL CONSTRUCTION PERMM ASOCIATED WQ PERMTT#
if licable if ]cable
1. WELL USE(Cluck Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:: tf2 *OgraphidLand setting
YFSVJLLF County /r! dge ❑Slope ❑Valley ❑Flat
AA S LAN6 Zl14 CQ( (check app,up,iusbox)
(Sort Name,Numbers,Commwiry,Subdivision,Lot No,Zip code) IatitudeAongitude of well location
3. OWNER:I-U( a4 V oPrvl nlr P.KETtnJ6S�. /V35`o3.850' //pg?`y3.5// '
(de�a/micatntucno h)
Address _f�.(7 . t?nx IG3o Latitude/longitude source:❑GPS❑Topographic map
(Street or Rome No.) (check box)
�ct�ESVIL C- /4C ZSC1oq DEPTH DRILLING
dry"Towns seise tip code From To
( }_ 3TS -3S0S 0 _ FofmationDescription
Am code-Phone number _ tZe="D C(2�7
4. DATE DRILLED /s-I-bT 15?P_'i - 33 ybRowtu wC�p�o� 2�c t�
5. TOTAL DEPTH: !n2 5 33 _ y 3 �R21 1ZotJ�W�RADNT.
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 4TzfG�RNCP
7. STATIC WATER LEVEL Below Top of Casing: �f� FT. �-3 43 krrEG22,12oc4 E/AEO"r, rrc
(Use"+"if Above Top of Cuing) �'-�{�_ 2�
2 O£�RK �e'Zo.Y PZSck �" AsofJr Qiz,kov
� ... LIrµT CaR2.Y �A�oKi"Q2€
8. TOP OF CASING IS FT.Above Land Surface* &zj,p� mac;
'Top ofceslo8 terminated War below land surface requires a 1"s-5�7 j��2k ( J:� ` /�oc'�ZAK�
variance in accordance with 15A NCAC 2C.0118. 5-37--&ES y2ork
9. YIELD(gpm): Jv METHOD OF TEST A t
10.WATER ZONES(depth): S 37
LOCATION SKETCH
11. DISINFECTION:Type_h4 I U Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
R T �Depth Diameter or Wdght/Ft. Material numbers and common road names.
Fromm �_Ft (04 S42-21 PVC
From-A-cL_TO-! Ft !o /5t �7 PVC
From To Ft
13. GROUT: Depth Material Method
From..a_To-Z-Ft C3M61[ tefZPViTV
From To FL
t7
14. SCREEN: Depth Diameter Slot Size Material
c
From To Ft--in. in.
Fmm To Ft in. in. N
15. SAND/GRAVEL PACK:
Depth Size Material .. 0
From To Ft. Cn it
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND/aE((/�DS,AND THAT�t OPPY OF THIS RECORD HAS BEEN PROVIDED THE A OWNER
S ATURE OF PERSON CONSTRUCIING THE WELL D ATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh NC
276991636 Phone No.[phone],within 30 days. GW-1 REV.072001

WELL CONSTRUCTION RECORD 3 1 3 1 7 4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACfOR(INDW1DUAL)NAME (prim[) DAVID F.MCKINNON CERTIFICATION#2411
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # (S.l 837-8008
STATE WELL CONSTRUCTION PERMIT'# ASSOCIATED WQ PERMTT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential JX Murricipal/Public❑ Industrial❑ Agicultural❑
Monitoring❑ Recovery ❑ Heat Pump Water9njection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: f/ �✓tLt-� County CLAY ❑Ridge []Slope ❑Valley Flat
ANDERSON RD (check appropriate box)
(Street Name,Numbers,CommuniTy,Sub(fivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: JOE TIENSTRA (degrees/minutes/seconds)
Address 407 KEENAN AVE Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
Fi FL 33919 DEPTH DRILLING LOG
city r Town Mete Zip Code From To Formation Description-
(A39)-994-4364 Y TO 40' RED CLAY
Area code-Phone number 40'TO70' BROWN SANDSTONE
4. DATE DRILLED 06/15/2005 70'TO 100' GRAVEUGRANITE--a
5. TOTAL DEPTH: 405' 100'TO 405' GRANITE >n
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 50 FF. c— V
(Use"+"if Above Top of Casing) ^4
8. TOP OF CASING IS 1 Fr. Above Land Surface* iV w
'Top of casing terminated at/or below land snri'ace requires a _
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 20 METHOD OF TEST AIR gIT SIZE-6.089
10, WATER ZONES(depth): 160', 180',340',380' LOCATION SKETCH
c
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To too Ft. 61/8- SDR 21 PVC n`
From To FL
From Ti Ft. AV �p
13. GROUT: Depth Material Method \y
From 0 To 20 Ft CEMENT GRAVITYv�`
From To Ft. 7
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in in.
From To Ft. in in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS PROVIDED TO THE WELL OWNER
�r' iyJu�J` �a� 6"i6' o 5
SIGNATURE OF 1PERSO �STRUCTI�THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD -J
North Carolina Department of Erwirmin rit and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) WILLIAM BRADLEY LEWIS CERTIFICATION#3368
WELL CONTRACTORCOMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERM1T# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Mumicipal/Poblic❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County CLAY Ridge ❑Slope ❑Valley ❑Flat
FIRES CREEK COVE (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ROLAND 8 BARBARA HARDEE (degrees/minutes/seconds)
Address P.O.BOX 272 Latitude/longitude source:❑GPS❑Topographic map
(Sheet or Route No.) (check box)
M TaS I AL 36559 DEPTH DRILLING LOG
city or Town state Zip Code From To Formation Description
8( 26 )_321=0594 0'TO 20' BROWN DIRT
Area code-Phone number 20'TO55' WEATHERED ROCK
4. DATE DRILLED 07/01/2005 55'TO 63' BLUE GRANITE
5. TOTAL DEPTH: 405' 63'TO 405' GRANITE 73
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 100 FT. .9
(Use"+"if Above Top of Casing) S
8. TOP OF CASING IS 1 FT.Above Land Surface* <<
*Top of casing terminated at/or below land surface requires a "=
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 20 METHOD OF TEST AIR
10.WATER ZONES(depth): 280',380'
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the
Depth Diameter or Weight/Ft. Material numbers and common road names. .y
From 0 To 63 Ft. 61/8- SDR 21 PVC tiaQ�$
From To Ft. CF �K
From To Ft.
13. GROUT: Depth Material Method {�
From 0 To 20 Ft CEMENT GRAVITY
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in in. ' �0C)
15. SAND/GRAVEL PACK:
Depth Size Material �Y i
From TO Ft. T
From To Ft. vJ
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A OPY OF THIS RECO S BEEN P VIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINQF YBE WELL
�If-�L' ICI''' ""! ,If:� I_L-��I
Submit the original to the Division of Water Quality,Attn: '' t151 11`5e�{vlce Center
Raleigh,NC 27699-1617, Phone No.[phone],within 30 day
,- w-1 REV.09/2004
AUG 9 2005
J
QF'TON�
ASHEVII it tl-r

ti`SfATj u
RESIDENTIAL WELL CONSTRUCTION RE RD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION N �,175_�
1.WELL�CONTRACTOR: f. DISINFECTION:Type �//� Amount
�. 1/�CrOr2 g. WATER ZONES(depth):
Well Contractor(Individual)Name From /y3 To o2—GPM From To
3yGZS CIJE[L (�IWnl6 1/yC From�To o� GPM From To
Well Contractor Company Name From y3 y To 4q. From To
STREET ADDRESS ?L7 (�LLIEIZI�.,G 4wV 6. CASING: Thickness/
5taDepth Diameter Weight Material
City w T
I Fty or T E ('� ��� From�Z TO_Q_Ft. I&TIR ,I
own State Zip Code From_ To fi._Ft. (SVX /f Me4_
c70(o )- 7q 211�6 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
S y[ / From��To d Ft. CEMEr�' �iyorv�r�
SITE #(ifappicable) From—To—Ft.—
STATE WELL PERMIT#(ifapplicabte) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8, SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 0­1� From To Ft._in. _ in.
From To Ft. in. _in,
DATE DRILLED 9-28-0 5 From To Ft._in. _in.
TIME COMPLETED z1 .3e AM PMM__11 -
9, SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material cot
CITY: i/g 4t. V/ LE COUNTY C Ld—q From To Ft. -
From To Ft. --t
9 iG4 M62DowS From To Ft.
(Street Name,Numbers,Community,Sn6didslon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: p
r
10 DRILLING
G
OrSlope ❑Valley ❑Flat ❑Ridge ❑Other From TO s
(check appropriate box) O . — Q RED OCy Description
LATITUDEN L5_03- 9�793 minutes,1 May be tsecon�or q — l� I�6'DOLStLT� <.L*,V
LONGITUDE06S3' yG. 30' in a decimal format 1-7 � �nS `('J('J wl_�.r—Anieeca 'Rock.
73 C'�QB-- Wr-2,A&f2
Latitude/longitude source: Milk ❑Topographic map
(location of well must be shown on a USGS topo map and ( �96L7'7
attached to this formNnot using GPS) ►47 - ao5 �caz
0.WELL OWNER &PA0 yaerc G a v
OWNER'S NAME �., -33D AP4 A; & r•±'[arz aa—
STREET ADDRESS _,,:ksc>=AMP 47© NdRO DB2K c�a-�rP.ec�e
42n— 434r-
'S65 fler97 U2Rlc GGtas�
City thrown State Zip Code LSa6—$/2 /1'3'dQq Ln .✓ 6KssN Rmac
( )- 67L — ca5 /I(Ev2�lJEiZcf'fler/RaYur-�i'OTz
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH:_ r
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
C. WATER LEVEL Beim Top of Casing: I DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED INACCORDANCE WITH
FT. 15A NCAC]C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+a If Above Top of Casing) RECORD BEEN PROMDDED TO THE WELL OWNER.
d. TOP CASING Ir �—FT.Above Land Surfacer
*Top
of casing terminated with below land surface may require SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.O1 18.
e. YIELD(gpm):_�METHOD OF TEST_ --` '71 P wU�" - - - - -
PRINTED NAME OF PERSON.CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 668.. Farm Rev.7/OS105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION kJ I3l
1.WELL CONTRACTOR: �t f. DISINFECTION:Type /`/'7 Amount C
I—Di1 O I 1 lia t/I g. WATER ZONES(depth):
Well Contractor(Individual)Name From Tc From To
13,*25 (tX-CL/Wje_W& From To From—To—
Well Contractor Company Named'•, From To From To
STREET ADDRESS �at`i7 &A-810124 h(41 6. CASING: Thickness/
T�� Depth Diameter Weight Material
&gif2S VI(_(,g �51 From e9 To 9 Ft. !o'/� 5q�21 IJVG
City or Town State Zip Code From- 7To O Ft.�+/ J;L Z75 +`�G
From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
- 6/Z�YJY,v
SITE WELL ID#(if applicable) 0 Ft.CeweNT
2 Fran From 29 To To Ft.
STATE WELL PERMIT#(ifapplicable) Fran To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft._in. _in.
To Ft p From
. _in.
DATE DRILLED / 20- 05 / From To Ft._in. _in.
TIME COMPLETED S:oo AM[I PM i> O
9. SANDIGRAVEL PACK: C)
3.WELL LOCATION: Depth Size Materia
CITY: Y/LCE COUNTY CZ From To Ft.
From To Ft. -
-7PIUJ611H A44J AS S&Z- 0 From To FL
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) - - VA
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat edge [I Other From To
O - �9 Formation Description
(check appropriate box) � ��
� May in degees, �� �
LATITUDE/I�Q3. 273 minutes,secondsa /9 - Z/ zRd/`T2J1 L.l / ;zc L4Z
LONGITUDEW_D$3°SS. 7 in a decimal format 21 — /Z/Z /IGNTGf20�' /42tTD
Latitude/longitude source: PS ❑Too a hic ma /�- 147 Dam`= a2a.,
P E P P 1q7 LJ6HS-G,?g //22p 2icp�
(IDcation of we#must be shown on a USGS topo map and /S8- �G ,r7 G!7?✓ i'�
attached to this form X not using GPS) /yG- /97 L/6N`T 6i2Rr'.r aw Act
4.WELL OWNER .AGE RKK(MOVNy aiN /Q� -�Qp �/&2V[/6ifT 6/?P-y//23J;r'rh
OWNER'S NAME ,0-c Vac Rolm- p'NG d8o -375 L/�,rr6Rav 60 z;JW.k
STREET ADDRESS 1y4 11�3�(:;-IAIE.f i 375- 38 9 ft G?n.1 D c r
/t/as'es✓/u.E /VC 2 8 9 o y 373c?— q e-cr— L/cet7—gzR"!z Mew Re
City or Town state Zip code /TES- Hko VWY' L/GK7-6raDv s�d0 v7scyr
cZS)_
�/40 r000 116�c/Zak'eAQW W.vi
389-3 v�/
Area code- Phone—number
5.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: 06
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
C. WATER LEVEL Below Top of Casing: FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED aI ACCORDANCE WoN
LAC,]C,WELL CONSTRUCEEO STANDARDS,AND THAT A COPY OF THIS
(Use"+'I(Above Top of Casing) RE Ti /AS BEEN PRCMDEDT ELL ER.
d. TOP OF CASING IS 02 FT.Above Land Surface• > Zi � � /'97
*Top of casing terminated allor below land surface may require SIGNATURE OF CERTIFIED W ELL CONTRACTOR "1 DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): / METHOD OF TEST G?/VZ ��tO-NZ /l�Tl1t�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699.1617 Phone No.[phone] ext 568.. Form GW-ta
Rev.7/05

kJO
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WE L CONTRACTOR: ��,,,,./ I. DISINFECTION:Typ
Je /�T/-{ Amount r s
JI 14/- t 3� g. WATER ZONES(depth):
WrWell Contractor(Individual)Name From I1. From 70
,p��rU CUC4 I D2ILLI t4(o ZhLC, From tl z s From To
Well Contractor Company Name
Na�m�e From To From To
STREET ADDRESS 1ZIo &LAC-0,mc llW Y 6. CASING: Thickness/
Depth Pplameter Weight Material
BL Ifz&VlL� r'P, 3051 From�T0 Z_Ft.(or 9 Sn¢2! Pvc
City or Toan State Zip Code From Z To O Ft. t(o (y -5V 27,5
C Cb _}_ 7115 - 21(a FromQ_Tc+II(i Ft (or _p -7, PVC
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From d To ZZ Ft. C earr— r�QPY�T1
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(u applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply g/ From To Ft._in. _ in.
From To Ft._in. _in.
DATE DRILLED I1(P-65 � / From To Ft in. in.
TIME COMPLETED 4 :1 S AM O PM M_
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: IT2veSV/LL.6 COUNTY GL2rl From To Ft
From To Ft.
—
From NEI6thS SUf3D LoT� ( From To Ft.
(Street Name,Numbera,Canmunay,SubdiNsioq Lot No.,Parcel Zip Code) - -
GRAPHIC/LAND SETTING: 10.DRILLING LOG
T�
Slope ❑Valley ❑Flat ❑Ridge ❑Other From
' To Formation Description
(check appropriate box) -J �-�-- 7�Y/ .$-c'tA/Q /2mCiC
�,/ r May be in degees,
LATITUDq• 3 0 Z87 minutes,seconds or T�fL UFR711ss�^.fl :✓.�firC
LONGRUDEOf}3' Sri $//er inadecimal form at S!t ls/ O
6 _ /5b G 72av lean
Latitude/longitude source: rPS ❑Topogaphic map /$d E w y 6,�iN
(location of well must be shown on a USGS topo map and / p_
attached to this form f not uskV GPS) p 4d4 i
4.WELL OWNER 91f16RIOC.- Hfof/Arm" 3?5- 425 Da2k 422 9 5/14 7D f&C4,
OWNER'S NAME P)E ve[ar/rf vT .TAK. 1125 1��'Pt-Tadflf- C✓/ Ft 6Prtit
STREETADDRESS /96N�Y.cycrlEsr ?s- 6z5 /�/a New 1�x
Agyc-5V., NG 9901/
City or Town State Zip Code r'
( a 8 } 38 9-356 y
Area code- Phone number -
11. REMARKS: ca
S.WELL DETAILS
a. TOTAL DEPTH: 6Z S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOgII� r-,v.
100 HEREBY CERTFY THAT THIS W ELL WAS CON IN ACCORDANCE W"
c. WATER LEVEL Below Top of Casing:�_FT. 15A NCAC 2C.WELL CONSTRUCTION STANDAR AND THAT A COPY OF THIS
(Use'+'9 Above Top of Casing) REC BEEN PROAQDEOT NER
d. TOP OF CASING IS I L FT.Above Land Surface'
'Top of casing terminated atlor below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR 1 DATE
a variance in accordance With 15A NCAC 2C.0118.
e. YIELD(gpm): METHOD OF TEST_g 1 /C-77J .
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617Mail Service Center-Raleigh,NC 27699.1617 Phone No.[phone] ext 568.E Form GW4a
Rev.7105

sM SrATE,a
RESIDENTIAL WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
-. WELL CONTRACTOR CERTIFICATION N > O:S~�
1.WELL CO RACTOR: f. DISINFECTION:Type_ Amount
A� P 6r
g. WATER ZONES(depth):
W C tracts(Individual)Name I From�5�7 To Fran To
_ ?!_ , ff -p�/ � r/[it, From To Fran To
Well Contracts Canpany r- -��✓J From To From To
STREET ADDRESS (V / 6. CASING: Thickness/
e From Tot Fth Piqmeter Weigh eriaL
City ar own tale tpa From To Ft. C,
q d >_ �/7-37y Z- From To FL
Area coda- Phone number
2.WELL INFORMATION: 7. GROUT: Depth atenal
Frorn�To��Ft.
Method
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(#applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) B. SCREEN: Depth Diameter Slot Size Materiel
WELL USE(Check Applicable Boz):: Residential Water Supply❑ From To Ft._in. _ in.
DATE DRILLED 9� l7 (/J From To Ft.—in. _ in.
From To Ft. in. _in.
TIME COMPLETED AM PM„(}
9. SAND/GRAVEL PACK:
3.WELL LOCATIpN: / Depth Size Material
CITY: [/ L/�- f-s.'�lr COUNTY From To FL
From To Ft.
From To Ft.
(Buser Name.Numbers,Canmunhy,Subdivision,La No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope OVahey ❑Flat @H Idge ❑Otter From /�o Fly bon Description
(check appropriate bola h C,
May be in degrees, L�
LATITUDE _ minutes,seconds or �,
LONGITUDE in a decimat format 19C r7
Latitude longitude source: ❑GPS pTopographic map
(location of we#must be shown an a USGS topo map and
attached to this form l not using GPS)
0.WELL OWNER OWNER'S NAME p�I
STREET AODRE/S/$ / r a aL 2 pf
i'l CD
Crty Tawn State Zip Code Ofi
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
^! � j
a. TOTAL DEPTH: f f0
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO O-�
I DO HEREBY CERTIFY THAT n a WELL WAS CONSTRUCTED N ACCORDANCE WITH
c. WATER LEVEL Beim Top of Casing: Aro FT. 1M NCAC 2C,WELL CONSTRUCTION STANOARDS.AND THAT A COPY OF THIS
(Use'+'if Above Top of Casing) RECORD HAS BE a PROVEO TO ELL OW NER. n
d. TOP OF CASING IS I!0 FT.Above land Surface* �I ���
'Top of casing terminated al/or below land surface may require SIGN UR F CERT WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. UNA
e. YIELD(gpm):�_METHOD OF TEST_ CL11L�(� ( / ��✓
I R. ED NAME OF PERSON C NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-ia
Mall Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 668. Rev.7105

n
�y3 w,r v.�'a
4
_' RESIDENTIAL WELL CONSTRUCTION RECORD
''� - North Carolina Department of Environment and Natural Resources Division of Water Quality
�CWw�'
WELL CONTRACTOR CERTIFICATION ft. 7,f g�'
1.WELL CONTRACTOR: / f. DISINFECTION:Type_ Amou
CO nt
err 1 e.4 Fire g. WATER ZONES(depth):
Well C tractor(individual)Name From L,51 To From �To
C' Va /J tl f �r//iL.�. From To From To
Well Contractor Company
Name From To From To
STREET ADDRESS /a . O TC 6 6. CASING: Thickness/
♦ 1/I Depth Piametat Weight goal
From_oTo-42—Ft. S�Rai dL
City orTY State• Zip Code From To Ft. _
Fran To Ft.
Area code- a number
2.WELL INFORMATION: 7. GROUT: Depth aterial Method
.,ac Q /T
SITE WELL ID#( Jil applicable) a Fran To_g,Q,Ft.
From To Ft.
STATE WELL PERMIT#(e applicable) Fran To Ft.
DWQ or OTHER PERMIT#(i(applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Boxy Residential Water Supply 8' From To Ft.—in. _ in.
Fran To Ft._in. _ in.
DATE DRILLED g- l -d 5 Fran To Ft—in. _ in.
TIME COMPLETED--le-1-0 AM O PM&-
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size. Materiel
CITY: a 't1z i Ile
e COUNTY From To Ft.
From To Ft.
From To Ft.
(Street Name,Numben:,Community,Subdivision,La No.,Parcel,Zip Code)
TOPOGRAP IC/LAND SETTING:. 10.DRILLING LOG
❑Slope Galley ❑Flat ❑Ridge ❑Other From To
F9rrnafion Description
(fired`°ppr°p"ale box) � - (� C
LATITUDE
May be mree fordegs, �6- 4
, _ minutes,seconds or
LONGITUDE in a decimal mat
Latitude/longitude source: ❑GPS ❑Topographic map k1- aa.22 _
(location of Wa#must be shown on a USGS topo map and rTl attached to this lomt Y not using GPS)
0.WELL OWNER 1r /
OWNER'S NAME et /�Lill ye
STRF�ET ADDRESS '— �(!7 JL -
EI*es U)eT(f 2vf I" L
City Ar Tam She Zip Code
(gvi- > 2&5 - 3Ya2-
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: a2,9 7
b. DOES WELL REPLACE EXISTING WELL? YESO Noe-
1 DO HEREBY CERWY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WnN
c. WATER LEVEL Below Top of Casing: ,S" FT. 15A NCAC 2C.WELL CONSTRUCTION STAND RDS,AND THAT A COPY OF THIS
(Use'+�#gbrwe Top of Casing) 0.ECORD H4$ R DTOTHEW OWNER.
d. TOP OF CASING IS �• FT.Above land Surface' y�7�s
•Top of casing terminated allor below)and surface may require S A E OF CERT
a variance in accordance with 15A NCAC 2C.0118, IFI y LL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST_
- P INTED NAME OF PERSON TONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-1a
Rev.7105

WELL CONSTRUCTION RECORD 3
,si: s ; e s
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACrOR(INDIVIDUAL)NAME (print) JOHN ARTHUR CHASTAIN CERTIFICATION 3401
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING&PUMP CO.INC. PHONE # (ate)837-8008
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential [ Municipat/Public ❑ Industrial ❑ Agricultural El
❑ Recovery [IHeal Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/L nd setting
Nearest Town: HAYESVILLE Cowriy CLAY ❑Ridge ❑S]ope Valley ❑Flat
LUDLUM DRIVE LOT 94 (check appropriate box)
(Street Nana,Numbers,Community,Subdivision,Lot No.,Zip Cale) LatitudeAongitude of well location
3. OWNER: JOHN&JESSICA RICKETY (degrees/minutnsheconds)
Address LUDLUM DRIVE Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
HAYESVILLE NC 28904 DEPTH DRILLING LOG
City or Town State Zip code From To Formation Description
( 828)-837-9255 0'TO 20' RED CLAY
Area code-Phone number 20 TO 40' BROWN SHALE
4. DATE DRILLED 09/22/05 40'TO 60' GRANITE/SET CASING
5. TOTAL DEPTH: 205' 60'TO 205' GRANITE YZ
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 25(Use"+"if Above Top of Casing) 0
8. TOP OF CASING IS 1 FT. Above Land Suffacc'
`Top of casing terminated attor below land surface requires a
variance in acmrdancewith 15A NCAC 2C.0118.
9. YIELD(gpm): 20 METHOD OF TEST AIR o
10. WATER ZONES(depth): 160'
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 10o PPM Show direction and distance in miles from at leas(
12. CASING: Wall Tllickness two Slate Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and com nion road names.
From 0' To 6Y Ft. 6 US SDR 21 PVC
From To Ft.
From TO Ft. t
13. GROUT: Depth Material Method
From D To 29 Ft.CEMENT GRAVITY
From To Ft. J� �� N
14. SCREEN: Depth Diameter Slot Size Materal � F
From To Ft. in. in.
Lo
From To Ft. in. in. J
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
y
16. REMARKS:
I DO HEREBY CERTIFY THAT TI-US WELL WAS CONSTRUCTED IN ACCORDANCE WI'Hi 15A NCAC 2C,WELI.
CONSTRUCTION STANDARDS,A\N\D TIIATA COPY OF'f}IIS RECORD HAS BEEN IIROVIDFD TO THE WELL OWNER
SIGNATURE O P RS CONS7 RUC I ING 7'11E WLLL It D l�"L.
Submit the original to the Division of Water Quality,Attn: -Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 3Q,(lays.
GW-1 REV.09/2W4

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) JOHN ARTHUR CHASTAIN CERTIFICATION#3401
WELL CONTRACrOR COMPANY NAME CHEROKEE WELL DRILLING&PUMP CO.INC. PHONE # j828)837-8008
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Municipat/Public ❑ Industrial ❑ Agricultural ElMonitoring❑ Recovery ❑ Heal Pump Water iCclion❑ Other❑ If Other,List Use
2. WELL LOCATION:AYESVI Topographic/Land settin
4978 OLD
Nearest Town: H78OLDLLE HWY.64 EAST County CLAY ❑Ridge ❑Slope ❑Valley [Flat
FA (check appropriate box)
(Street Nainne,Numbers,Community,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER: JAN RAMSEY (degrees/minutes/seconds)
Address 4978 OLD HWY.64 EAST Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
HAYESVILLE NC 28904 DEPTH DRILLING LOG
City or Town Stare Zip Code From TO Formation Description
( 828)-389-6844 O'TO 30' SAND GRAVEL MIX
Area code-Phone number 30'TO 44' GRANITE/SET CASING
4. DATE DRILLED 09/27/05 44'TO 205' GRANITE
5. TOTAL DEPTH: 205'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 4
7. STATIC WATER LEVEL Below Top of Casing: 25
(Use"+"if Above Tap of Casing) ©
8. TOP OF CASING IS 1 FT. Above Land Surface* n
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. cr%
9. YIELD(gpm): 15 METHOD OF TEST AIR
10. WATER ZONES(depth): 80' 14V cJ1
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at leas('
12. CASING: Wall Thickness two Slate Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0' To 44' Ft. 6118 GALV
From To FL
From To Ft.
13. GROUT: Depth Material Method �Q
From 0' To 20' Ft.CEMENT GRAVITY G
From To FL ff�
14. SCREEN: Depth Diameter Slot Size Material LA
—
Front-To Ft. in. in. 6 O,
From To Ft. in. in.
15. SAND/GRAVEL PACK: v`rpL� I
Depth Size Material
From To Ft.
From To Ft.
O
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THA�TpA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�vn� )t- n I t n R L,�y � i�1 9-&ns
Cj SIGNATURE OF PERSON CONS fRU0flNG TILE WL'LG �i , D IT
LL
Submit the original to the Division of Water Quality,Attn:loNr au tion Management,1617 Miii1,N'ervice Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. 18 2005 i
GW-1 REV.0912004
_.
nr�i

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prtnt) FRc8N2. 2 V1C-7 cExTrnicAnoxa 3175
WELL CONTRACTOR COMPANY NAME DYERS (AJ eU- O J21 l)'16 PHONE S Fes)75'3-2 i6 G
STATE WELL CONSTRUCTION PERMTPM AMOCIATED WQ PERhIIT#
if licable ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopoBmlihictLand setting
Nearest Town: HP-`*&S ILLS County CL2V Midge 1991ope Malley ❑Flat
ANNk$ L$NE 2B114 CrtiV6 (check apProinure box)
(Suet Name,Numbers,Cammuniry,Subdivision.L«No.,zip Cade) Latitude/longitude of well location ,
Vc2S D&6-L0 PA' �,9" z 3S°n3. 2 WC�E3 a43, W
3. OWNER: 0 rN� 2Kc. (degreestm;nuey )
Address O ZcA, I S 3 0 Latitude/longitude source: PS❑Topographic map
(Sumer«Rome No.) (chek box)
N2tJCSViLIE fIC Z£s�fD�f DEPTH DRILLING LOG
City Town store zip code From To Formation Description
� } 89-35oy C> - c' REA ct2V
Am code-Phone number — Iq3 1�ZO�+N wEZT31fS760 wcwtc
4. DATE DRILLID �`ZZ-OS L - 7 6128✓4JE2T914ZED a k
5. TOTAL DEPTH: D22KCVz2�0 ecK
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT,
(Use-4'if Above Top of Caving)
8. TOP OF CASING IS a FT.Above Land Surface'
'Top of wing terminated at/or below Ind surface requires a
variance in accordanee"1SA NCAC 2C.0118.
9. YIELD(gpm):[lt METHOD OF TEST A iR
10.WATER ZONES(depth): 2,60
LOCATION SKETCH
It. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. I4atenal numbers and common road names.
Frozz��To-�3 Ft /o_/Y/ S02z9s �✓G ;-
From `13 To b.3 Ft r_/zf LCK _1 PVc ;may
From (oS To 6S Ft--Ie— •/If S7EEz- rt
13. GROUT Depth Material Method rN*t
From a To 20 Ft.CEwIENr C'a?v'rY -o
G
From To Ft ay
14. SCREEN: Depth Diameter Slot Sim Material o
From To Ft in. in tft
From To Ft in. in.
15. SAND/GRAVEL PACK: C E P 2 6 J
Depth size Material
From To Ft.
From To Ft.
16. REMARKS:_SOT &Xd Cg'&66 I'H YF/E CWIr 1&5 O/e T/AE A6*-Ile 1 4 lea
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- &. P .%. '- Z 2 a5
IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
2 76 99-1 63 6 Phone No.[phone],within 30 days. GW-1 REV.07/2001

O
WELL CONSTRUCTION RECORD � )
North Carolina-Department of Environment and Natural Res -Di vis ion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CY W5 (91- Y'EL,,, Z,., I CERTIFICATIO-NNIIg q
WELL CONTRACTOR COMPANY NAME ^SV�i,uc V`-^"^u--�U�U-1I-IC'� PHONE # b0/'RIS�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if livable (if applicable)
I. WELL USE(Check Applicable Box):Residential Mtn icipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: //�� � �" Topographic/Land setting
Nearest Town: t ' 1 County Q-LP(`( Ridge ❑Slope []Valley ❑Flat
ORIW -I 'FA{LPYts' (check appropriate box)
(Sheet Name,Nmbmberr (Co n nuniry,Subdivision,IA No.,Zip Code) LatitudcAongitude of well location
3. OWNER: `I`-"'� > (degmes/minutessewnde)
Address Latitude/longitude source:❑GPS❑Topographic map
tree[ce Ro No.) (check box)
DEPTH DRILLING LOG
city or tea Zip code From To Forman Sc 'ption
b 15'
A a code-Phone manber to b5 T%41
4. DATE DRILLED ?4d $o el
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J$I
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of cuing termlonted atlor below land surface requires■ Pa
variance In accordance with 15A NCAC 2C.01IS. -
9. YIELD(gpm): ME'[HO_Dt OF TEST- o
10.WATER ZONES(depth): �t6j
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the
Dap[ ,, 1 Di or Weight/Ft. Material numbers and common road names.
From To Ft. L " nleg?,1r
From To Ft
From To Ft
13. GRO : Depth Matpt(al Metho \\
FromUT a To
From Ft.
14. SCREEN: Depth Diameter Slot Sim Material
To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material /�..
From To Ft.
From To Ft Z�
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ARDS,AND THAT A COPY
//OF THIS RECORD HAS BEEN PROVIDED TO THE WNER
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

0 i ' r
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-C- - 'water Sectioon�''
WELL CONTRACTOR(INDIVIDUAL)NAME (Prni�ntr) ysli-laftyN ,>. �S C` --CATION N O' '`�a
rt T WELL CONTRACTOR COMPANY NAME� EJSVIULE I.S�-LI.-. IRA LUL4 Pli,
STATE WELL CONSTRUCTION PERMITO ASSOCIATED WQ PERMIT#
ifapplicable) (if applicable)
11110,
1. WELL USE(Check Applicable Box):Residential MunicipaVPublic❑ Industrial❑ Agr iml❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use_
2. WELL LOCAT ON: Topographic/L etting
Neare�g,t\T�owne UaAx County C�YIf Ridge ❑Slope C cy ❑Flat
(check approp .)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude : ^ II location
3. OWNER: (deyeedminum: .,.nds)
Address t r`WA&1� Latitude/longitude source:❑' 317opographic map
(Street of Route No.) r� e
DEPTH ?'!
TEEING LOG
,tpr�Q/city or town .. b tate Zip code From To i ,a 'on Description
Am code-Phone number 1 — -
4. DATE DRILLED 1 D �p
5. TOTAL DEPTH: _ -5
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO, ] _
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS , FT.Above Land Surface• t j
'Top of cuing terminated it/or below land surface requires a
valance in accerdame Ith 1SANCAC 2C.01111.
9. YIELD(gpm):_ METHODIOF TEST c:ri -
10.WATER ZONES(depth): S20
LOCATION S);2TCH
11. DISINFECTION:Type AT79 Amount Show direction and distance in Niles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Di ter or Wn t(Ft. Nateripi numbers and common road names.
From b To Ft. . % t—:5 91b. WALL
From To Ft.
From To Ft. fT�
13. GROUT: Dept! M—Ft. of M d
O
From ' To 1?XS Ft. tom.
From To Ft. i ilbl'
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC'_C,WE
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL WNER
S � d 57-
SIGNATURE OF PERSON CONSTRUCTING THE WELL A
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

as6v r
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)r1Q2/1Z /10 V/G7D)1-2 CERTIFICATION#317.5
WELLCONTRACTORCOMPANYNAME �SVPWS euetr pAa_Ll r .-7,virPHO14E # CV474'5-Z/69'
STATE WELL CONSTRUCTION PERMIT# ,tSSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential R Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
Nearest Town: 2 /[ LE County CL24 ❑ ❑
Ridge ❑Slope Valley OFlat
1412w2SSEER1vc.P RD (cbakappropnftbox)
(Street Name,Numbers,Canmunity,Subdiwnm4 Lot No,Zip Code) Latitud Ongitude of well location
-T-U Y CeeDe(Z X35°o3 Star"WQ23°sb 397'
3. OWNER: ( may
Address 1445 FREE 4lawtE (LD L )
atitude/lengibade sasce: .:PS❑Topod pl:ic map
(Street er Route No.) (check box)
CA.NYU N 6. 3 oil 5 DEPTH DRILLING LOG
City�Town Ste zip Code From TO Formation Description
(ZO} w337- 390-7
Mrs code-Phone number 1 3 q e(ZV-52NU /Rl yEa eaeve .
4. DATE DRILLED 9-2,3- 05 (o GrIESrAf260 Gx2ev Mock5. TOTAL DEPTH: 1(a5 �3fo /(S l�2Qa L/cuTCr2aY 2oc
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 2 _FT.Above Land Surface` LL'Tap of easing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.all& 3� r
9. YIELD(gpm): 7 r!i METHOD OF TEST V-f P
c�
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type T Amount 4 oz_ Show direction and distance in miles from east:'
12. CASING: Wall Thickness two State Roads or County Roads.IncludeWe road],
Depth Diameter or Weigbt/Ft Material numbers and common road names.
From_To-L$_Ft /r _ S2R27.5 PVC
From_To,3g_Ft / 4QgZL Pvc
From_3$_To—AL3--Ft_ (� -]If �e�
13. GROUT: Depth Material Method
From b ToL20 Ft Cr—W67vT _r e-9)6ay
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in.
From Tc 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 1 SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/� IJ ;� S-23-05
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Matz Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
Notch Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) y'p2egMJll.l.E �� CERTIFICATION y0211 o
WELL CONTRACTOR COMPANY NAME 'Ll`tl(Y\ • ���^m�S PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
ifapplicable) if licable
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopogWhie/Land setting
NearesJTown: lu-E County ❑Ridge Mope ❑Valley ❑Flat
db E LP -jCkk"5-_- (cheek approprive box)
(Street Name.Numbers,community,Subdivision,La No.,Zip Code) Latitude/longitude of well location
3. OWNER: \� t N•���t- (degrees/minutes/seconds)
Address X�3 LLCY ( r-; CsSwyr LatitudeAongimde source:❑GPS❑Topographic map
�, ''" (Street or Route No.) 11 (check box)
hVc'V- 'S\(\2 NC- '3M61L DEPTH DRILLING LOG
City or Town State Zip Code From To , Formation Description
- bF1(a b 45
Am code-Phone number �-
4. DATEDRILLED
5. TOTAL DEPTH: t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—Jp�.
(Use'Y"if Above Top of Casing
8. TOP OF CASING IS FT.Above Land Surface' I
N
'Top of cuing terminated at/or below land surface requires a _
variance In seeordanre with ISA NCAC 2C.0116.
9. YIELD(gpm): t3O irIETHQD OF TESTR-
10.WATER ZONES(depth): \q5
LOCATION SKETCH
11. DISINFECTION:Type —kM Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Jyia rial numbers and common road names.
From D To Lt Ft. fit.
From To FL lJ y
From To FL
13. GROUT- Depth M nil Meth
From b To _ Ft D %
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.
tit 1'1 s ate NtJY inV f.,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION STANDARDS THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THEIWELL OWNER
/a z6c—
SIGNATURE OF PERSON CONSTRUCTING THE WELL DAIM
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

r:
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division�o,f Water Quality-Groundwater Section ✓�
WELL CONTRACTOR(INDIVIDUAL)NAME
a.�((,prir�n��t)�'�`C^`I e ks G, � (k�.. CERTIFICATION s /✓M
WELL CONTRACTOR COMPANY NAME H.11TTt?5AQ Z �ISFLA_. .�ILL( n�G PHONE 8 �$�-�fIES"
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMTTB
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential0' Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topogr setting
Nearest Town: > � `` 1 County. ❑Ridge OSlope Malley ❑Flat
F\qZ5 �..�� ew Q L n oeK (check appropriate box)
(Street Name,Numbers,Communit Subdivision.Loots No.,Zip Code) Latitude/longitude of well location
3. OWNER: T L.ts.1C� ` Q7' • (depeedmiwtes/seconds)
Address Q Latitudellongitude source:❑GPS❑Topographic map
(� (Street Route o.) (checkbox)
G�rT-it'SV(l.._E _ Id �q DEPTH DRILLING LOG
City or Town stalls Zip Code From To FogaticE D cription
1:2 )- -i!:K - b 15'
Area code-Phone number 1T J3�
4. DATE DRILLED A)1 aS -
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: (nb FT.
(Use"+"if Above Top of Casing) -�
8. TOP OF CASING IS FT.Above Land Surface* r
'Top of casing terminated actor below land surface requires a Pa
variance in accordyslMee�w,,ith 1SA NCAC 2C.0118.
9. YIELD(gpm): OLJ METHO�OF TEST 4"114C Q
10.WATER ZONES(depth): 9 EO
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least''
12. CASING: Wall Thiclmess two State Roads or County Roads.Include the road
or Wei /t. Mategiial numbers and common road names.
From_D TD o�FL ter p '
From To FL
From To Ft.
13. GROUT: DeptlL� Materiel l
From D To 5GS FL QAh+tV
From To Ft. n
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WEJL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE L OWNER
��
SIGNATURE OF PERSON CONSTRUCTING THE WELL - ATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
276WI636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Sectii j
WELL CONTRACTOR(INDIVIDUAL)NAM (print) `LDS 1`t CERTIFICATION q
WELL CONTRACTOR COMPANY NAME -PHONE # (CS �I
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
1. WELL USE(Check Applicable Box):Residential M Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT ON: Topo c/Land setting
Ny>Erest To �Ounty C ( ❑Ridge 12SIope ❑Valley ❑Flat
u vn_tya xl•x]1 .a•, $tlA-s� (cbeck appropriate box)
(Street Name,Numbers,c muniry,Subdivision,Lot No.,Zip Code) LatitudeAongitude of well location
3. OWNER* (degrees/minumshewnds)
Address LatitudcAongitude source:❑GPS❑Topographic map
(Street ar Route No.) (check box)
�t.1J tl^aP.1A�s� C�t� �JOSIo'� DEPTH DRILLING LOG
Ciry or owo State Zip Code From To Forman n scription
�) h 91
Ara code-Phone number A,
4. DATE DRILLED g b TV '
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO )b
7. STATIC WATER LEVEL Below Top of Casing:--!5D_FT, r�ri
(Use•` if Above Top of Casing) U _
8. TOP OF CASING IS FT.Above Land Surface•
*Top of cuing terminated actor below land surfs"requires a N -
varlance to aeardayee with 1SA NCAC 2C.0119.
9. YIELD(gpm): 10 METHOD OF TEST M10- cn
10.WATER ZONES(depth): /
LOCATION SKETCH
11. DISINFECTION:Type t-t CR Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
DeptJ�-, gi�greter yr Weight t. jrtgt�(ial numbers and common road names.
From b To y i-Ft.
From To Ft
From To Ft
13. GROUT: Depth Meth
From D To Ft ^L rn(�^y^
From To Ft� 1 3--SO
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: .
Depth Sim Material
From To Ft.
From Tc Ft Af
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANARDS,AND THAg-A COPY OF THIS RECORD HAS BEEN PROVIDED TO WE OWNER
' ` 'q� S e / �tl�e� —�rJ�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. .' ( OW-1 REV.07/2001
.,

3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division
�-off�Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) t��i � 'al.�Tttc'4-g. CERTIFICATION A`O
WELL CONTRACTOR COMPANY NAME dncA3-gku c LS4-U-'-hy2AWtn PHONE M
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential O/Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION-. TopographiefLand setting
Nearest �
arTown: VMe%l\ County CILW i*dge ❑Slope []Valley ❑Flat
(check appropriate tax)
(Street Name,Num n,Community,Subdivision,Lot No.,tip Code) LatitudcAongitude of well location
3. OWNER: \u �.1� (degreealmiautealaeconH)
Address kLIA n8c:� _ Latitude longitude source:❑GPS❑Topographic map
at m R u a o.) (check box)
C DEPTH DRILLING LOG
1wpe/city or Sim I Zip Code From 11I Forma_ tioll DeIcription
A code•Phone numba \1 1 \�� CS
rta
4. DATE DRILLED S a 9 U LI S'
5. TOTAL DE gy
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 5
7. STATIC WATER LEVEL Below Top of Casing:— Cb FT. ci
(Use"+"if Above Top of Casing) Cn -
8. TOP OF CASING IS 1 FT.Above Land Surface' F9
'Top of caaing terminated actor below land surface requires■
variance In aecordanp with 1SA NCAC 2C.0118. i
9. YIELD(gpm): 1_ 9 THOD OF TEST
10.WATER ZONES(depth): ` •t C:3
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least-
12. CASING: Wall Thickness two State Roads or County Roads.Include the road`'
Depth q ter r��t. ,rt terial numbers and common road names.
From (� To-tom FL /u a 7. 9'��.
From To Ft
From To Ft
13. GROUT: Deptqh�- Tv -T Metho �•4/S r
From () To Ft. w�
From To Ft. �
14. SCREEN: Depth Diameter Slot Sim Material --Si)
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material 42,
From Tc Ft. p�
From To Ft. 4
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION STS,AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WqL 9WNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DMTE
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

S i RESIDENTIAL WELL CONSTRUCTION RECORD J 18 5 { 5
North Carolina Department of Environment and Natural Resources-Division of Wmtt Quality
WELL CONTRACTOR CERTIFICATION N 2261
1.WELL CONTRACTOR: L DISINFECTION:Type CHLORINE Amount 100 PPM
CHRISTOPHER L.DICKEY g. WATER ZONES(depth):
Well Contractor(Indiriduaq Name From 275' To 290' From To
CHEROKEE WELL DRILLING From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 S. CASING: Thickness/
MURPHY NC 28906 From 0' DTo 100' Ft.
Dameter Ws�� Materal
City or Town State Zip Code From 0' To 160' Ft.467�tl SCH xD PVC
8( 28 )- 837-8008 From To R.
Area code- Phone number
2.WELL INFORMATION:
T. GROUT: Depth Material Method
From 0. To 20 R. CEMENT GRAVITY
SITE WELL ID rl(it applicable) Fromm O' To700r Ft. HOLE PLUG GRAVITY
STATE WELL PERMiTS(r applicable) From To R.
DWQ or OTHER PERMIT#(if appicable) B. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply p From_Tc R._in. _ in.
From To FL—in. _ in.
DATE DRILLED 10l24/05 From To R,_kr. _ in.
TIME COMPLETED AM❑ PM❑
9. SANdGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: HAYESVILLE COUNTY CLAY From Tc Ft.
From To Ft.
COMPASS CREEK From To Ft.
(Street Name,Numbers,C urnandy,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
Slope OValky ❑Flat ORidge 00ther From To Formation Description
(check appropriate bax) 0' TO 2' TOP SOIL
minulea,seamdv a
May be in deg,aa,
LATITUDE 3 5 05.575N 2' TO 16' YELLOW SHALE
LONGITUDE 8 3 43230W la m a decbnal format 16' TO 17' GRAVEL
—— 17' TO 37' BROWN SANDY SHALE
Latitude/longitudesourm: P9GPS OTopograpfricmap 37' TO 153' GRAY GRANITENVHITE QUARTZ
(location of we#Most be shown on a USGS tope map and 15T TO 155' BROWN CLAY -
eHachedtothisfarmsnotusingGPS) 155'TO 325' GRAY GRAN ITE/WHITEQUARTZ
LL 4.WE OWNER
OWNER'S NAME ROD HARDEMAN
STREET ADDRESS 8829 LAKE DRIVE
SNELLVILLE GA 30039 0 _
City w Town State Zip Code
770 )_785-7644
Area code- Phone number
11. REMARKS: cr7
5.WELL DETAILS:
a. TOTAL DEPTH: 325'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREBYCE"F`f 1 `r THIS WELL WAS CONSnr C [)N ACCORDANCE WITH
C. WATER LEVEL Beim Top of Casing: 60 FT. 'M NCAC 2C,WELL CONSRtIICiION STANDVTDS,AND THAT AC OFTHIS
(Use'+'1 Above Top of Casing) RECORD HAS BEEN M2WOED TO THE nWELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface' / t(6k;t G�c? �/l/'` i/ 10125I05
'Top d easing laminated at/or below land surface may require t
a variance ti acrnrdalrce with 15A NCAC 2C.0118. SIGNATUREOF CERTIFIED W WELL CAN. CTOR DATE
e. YIELD(gpm): 12 METHOD OF TEST AIR C}'Tc t �'4U`J�"fY �1CkP�
PRINTED NAME OF PERSON CONST UCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GW-le
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rcsourccs. Division of Water Quality 3 18 51 l} lit
WELL CONTRACTOR CERTIFICATION# 2261
1.WELL CONTRACTOR: f. DISINFECTION:Type CHLORINE Amount 100 PPM
CHRISTOPHER L.DICKEY g. WATER ZONES(depth):
Well Contractor(Individual)Name From 301' To 305' From To
CHEROKEE WELL DRILLING From To Flom-To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 G. CASING: WThickMnessf
Depth p,� at Sgp2t Notiol
MURPHY NC 28906 From 0' To 59' Ft. 6 via" 21 PVL:
City or Town State Zip Code From To Ft.
8C 28 )_ 837-8008 From To Fl.
Area code- Phone number
T. GROUT: Depth Material Method
2.WELL INFORMATION: From 0' To 20' Ft CEMENT GRAVITY
SITE WELL ID ftf applicable) From To Ft.
STATE WELL PERMITB(yapplicable) From To R.
DWQ or OTHER PERMIT!(?applicable) 8. SCREEN: Depth Diameter Slot Size Material
From To Fl._in. in.
WELL USE(Check Applicable Box): Residential Water Supply p From To Ft. in. _ in.
DATE DRILLED 10/19/05 From To Ft. h. in.
TIME COMPLETED AM❑ PM❑
8. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY. HAYESVILLE COUNTY CLAY From To Ft.
From To Ft.
TAHLEQAH RIDGE LOT#14 From To Ft
(Street Name,Numbers,Community,SubdiAsion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) ' TO 6' RED SHALE
May 6e 1O te a' 6' TO 36' BROWN SANDY SHALE
LATITUDE 3 5 00.427N minutes,xmrds or
LONGITUDE 8 3 48.837W in a decimal format 38' TO 108' GRAY GRAN ITEMHITE QUARTZ
—— 108' TO 22V GRAY GRANITE
Latitude/longitude source: mGPS ❑Topographic map 220' TO 301' GRAY GRANITEWVHITE QUARTZ
(location of we/must he shown on a USGS lopo map and 301' TO 320' GRAY GRANITE
efteched to 8ris lbrm anof using GPSJ
4.WELL OWNER
OWNER'S NAME RAY BRODERICK
STREET ADDRESS 2814 SW 44TH TERRACE
CAPE CORAL FL 33914
City or Town Sete Zip Code
( 239 I.281-7458
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 32V
th. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I DO HEREBY CERTIFYTHATTHIS WELL WAS CONSMUCIED IN ACCORDANCE W fm
c. WATER LEVEL Below Top of Casing: 175 FT- 15A NCAC 2C,WELL CONSmucIUN STANDARDS,AND THAT A CWY OF THIS
(Use'+•iI Above Top of Casing) RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* D w 10121/05
'Top of casing terminated atfor below land surface may require SIG LATUR OF CERTTFIrD WELL CONT CTOR DATE
a variance In accordance With 15A NCAC 2C.0118.
e. YIELD(gpm): 15 METHOD OF TEST AIR LJLT1�Jl,L_.. PYL. D;cke
PRINTED NAME OF PERSON CONST�CTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information M9j�
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone]'ext 568: I f5 R j1 1a

1 '
�a�+5rA1Fu I���
RESIDENTIAL WELL CONSTRUCTION RECORD Y „ -
.,
Resources-Division of Water Quality North Carolina Department of Environment and Natural Res
. WELL CONTRACTOR CERTIFICATION# 3131
1,WELL CONTRACTOR: /� I. DISINFECTION:Type Amount
"- ;r / ' ,V1- g. WATER ZONES(depth):
vVesi Contractor(Indlvldual)Name From Tc 6$-4Vrlw To
BYFa2S W / 1J12t(1 fu ^s NC From T974�. To
Well Contracts Company Name From To
Fran To
STREET ADDRESS 1Z67 WiF izwar, guiy 6. CASING: Thickness/
Depth Diameter Weight Material
�L21(2$VlLLe 3d5(� From- To77 Ft. (or/11 274 P�L
Cltyor Town State Zip Code From 77 To i37 Ft. r6,A_ S'DY2f pvc
Qtv From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) Fran-ff_To2[L Ft. CCrt4g - G rfry
From To Ft.
STATE WELL PERMIT#(Ilapplicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. _ in.
DATE DRILLED Lb-2-7- 05 From To Ft. in. _ in.
/ From To Ft—in. _in.
TIME COMPLETED :3 tl AM❑ pM L�
9. SANDIGRAVEL PACK:
3.WELL LOCATION: ' n Depth Size Material
CITY: /('i�I"U COUNTY CLL From To Ft.
Fran TO Ft.
�E Y' Fran TO Ft.
(Sbee ame,Numbers.Community,Subdivision,Lot No.,Pamel,Zip Code)
TOP RAPHIC I LAND SETTING: 10.DRILLING LOG
lope ❑Valley ❑Flat ❑Ridge []Other From To Formation Description
(check appr6pdate box) _ ,, �,p J
g ees,
LATITUDE �O.7�r ma,be
nuts,seconds or �S
LONGITUDk O_U'S, 7H3 in a decimal/om,at </'2 - 4/ .7?Ep rJ afI
Latitude/longitude source: r- 4 - PS 0 -
Wwn o OTopog o map map F S- /37 ( ev�77on�(location d/wed most be shown on a USGS topo map and $2 - 1r.7 ,S�Fy-SLOG L� 44/
attached to this rorm7nof usstg GPS)
4.WELL OWNER /�07- i7f 1C/6 u?-Gl29.✓ -��
t� /7S- /83 /H�O.vur�e(Pa✓ „
OWNER'S NAME 1l2VE Ct7VY62rr /I'S- ,�,� .C164(7- eaJ
STREET ADDRESS 312 NI 1 Yb- �-
ra - 609at, �L 339y3
City or Town State Zip Code
CZ31��
Area code- Phone number
5.WELL DETAILS: 11. REMARKS:7 tv
a. TOTAL DEPTH: J Z5 �/
b. DOES WELL REPLACE EXISTING WELL? YES[INOeCD
c. WATER LEVEL Below Top of Casing: FT IOO HEREBY CERTIFY THATTH WELLW CONSTRUCTED NACCORDANCE WmI
1 C2C,WELL CONSTR NST D ROS,ANO THATACOPY OF THIS
(Use'+-if Above Top of Casing) C D HAa BEEN P O L OWNER.
d. TOP OF CASING IS� FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.01188.. SIGNATURE OF CERTIFIED LL CONTRACTOR DATE
e. YIELD(gpm):I_METHOD OF TEST M/1Z PE I E V IC,7V R
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568." Form GW-Ia
Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
"•F( North Carolina Department of Environment and Natural Resources Division of Water Quality
a o`
.. WELL CONTRACTOR CERTIFICATION# 2131
1.WELL CONT�-R�'ACCTT�OR:, I. DISINFECTION:Type %� Amount
Ln `✓I I I g. WATER ZONES(depth):
Well Contractor(Individual)Name
131 Fro m_To y 6?H From To
YCJ2S w E(_l- l7 iZi L-L1"ro •{-f�. From oZ 70 To �V q From To
Well Contractor Company Name From
!� To From To
STREET ADDRESS _IZ67 BLVEZIMC 4W y 6. CASING: Thickness/
Depth iameter Weight ytatenal
�3L21(L$Vll(E OC- 3O5(Z From.2Gi To G Ft. r/ S�,eAf fVC
City or Town State Zip Code From —To 0 Ft. SdR2 ,PVC.
C726-)- 7v5-21&k From To_Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT:
/� Depth Material Method
SITE WELL ID#(if applicable) Frm_.o _To_,�W_Ft. CO3vtc7,n— 6( y
From To Ft.
STATE WELL PERMIT#(ii applicable) From To_Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply H/ From To Ft.-in. _ in,
DATE DRILLED IO -28•-65 From To—Ft._in• _in.
From To Ft. in. __ in.
TIME COMPLETED SKIS AMp PM�
S. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY:NC 7 'S V ll-LE COUNTY CL� LJ From To Ft.
From To Ft.
SP21otL i312 '0 Cey6 SV?j From To Ft.
(Street Name,Numbers,Ca nmunay,Subtliuiaion,lot No.,Parcel,Zip Code) ...
TOPOGRAPHIC I LAND SETT 10.DRILLING LOG
❑Slope OValley ❑Flat 0olkidge 00ther From - To Formation Descri tion
(check apprcpdate box) 0. P
.j Mayhin degas, S l'O9a", t"lc tl WE2r8EiLEP iZQ4
LATITUDE` �,3 pi{( minuta,sxonds or 5 '2f C l.uG-flsry eya_yj ?�k
LONGITUDE�33LP.Qm(0 in a decimal format 21 35 "QED S-Izay 12bc.4c
Latitude/longitude source: 3S $'O
&? PS ❑Topographic map So 70
(location of we9 must be shown on a USGS topo map and 7 0 $$ lJ2Ro p22K Go ✓ /JiaCic
attached to this form ITrot using GPS) 7 -
4.WELL OWNER l; 6R�HrT
11 ,�.G OWNER'S NAME lJI•$ I-Dr,
L.. HqM /3p —/ �SR7c. Gf12.1
STREET ADDRESSO•30>< c3_71f J iZd�7.L�ocfc
!�/al�zss� �� 3cs46 v l�cs�-�2a�2 wL
City or Town State Zip Code — �r�k G rc9^/ ,zW,=i
(F}_3 Ste- 98' _
rn as code- Phone number
CD11. REMARKS:
S.WELL DETAILS: p I N
a. TOTAL DEPTH: O
b. DOES WELL REPLACE EXISTING WELL7 YES❑ NO b_­� Ln
C. WATER LEVEL Below Top of Casio IDOH BY CERTFY THAT THISW AB CONSTRUCTED N ACCORDANCEWH14-9 FT. 15A AC C.WELL CONS a D AND THAT A COPY OF THIS
(Use'+•8 above Top of Casing) RE RD BEEN PR TH O NER.
d. TOP OF CASING IS 62— _FT.Above Land Sudace'
'Top of casing terminated atlor below,land surface may require NATURE OF C RTIF EL CONTRACTOR DATE
a variance in accordance with 15A....
e. YIELD(gpm): 60 METHOD OF TESTO'(Q
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Foam GW-1a
Rev.7105

a RESIDENTIAL WELL CONSTRUCTION RECORD 0 'j l i
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3368
1.WELL CONTRACTOR: I. DISINFECTION:Type CHLORINE Amount 100 PPM
WILLIAM BRADLEY LEWIS g. WATER ZONES(depth):
Well Contractor(Individual)Name From 240' To 1 112gpm From To
CHEROKEE WELL DRILLING From 340' To 101rZ9p'e From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 6. CASING: Thickness/
Depth Diameter V� IM Material
MURPHY NC 28906 From 0' To 98' Ft_ B t/e F'V(:
City or Town State Zip Code From To FL
8( 28 1_ 837-8008 From To Ft.—
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: From V To 20' R. CEMENT GRAVITY
SITE WELL ID A(if applicable) From TO Ft
STATE WELL PERMITIyt applicable) From_To Ft.
DWQ or OTHER PERMIT*(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water SupplyEl
From To R. in. a.
From To Ft. in. in.
DATE DRILLED 12/02/05 From Tc Ft. in. in.
TIME COMPLETED AM 0 PM El 9, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Sae Material
CITY: HAYESVILLE COUNTY CLAY From To FL
From To Ft.
2595 CARTER COVE RD. From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG -
ISSlope ❑Valley ®Fat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0' TO 20' RED/BROWN SLATE
LATITUDE 3 5 01.064N May hs,i��'minutes,exonds or20' TO 40' BROWN TO TAN SLATE
LONGITUDE 83 53.992W ihadmimalformat 40' TO 60' TAN TO BROWN SLATE
60' TO 80' BROWN TO BLUE SLAT
LatitudcAongitude source: MGPS ❑Topographic map 80, TO 98, BLUE SUITE
(location of wet must be shown on a USGS topo map and 98' TO 405' SLATE L
attached to this form IF not'using GPS) _
4.WELL OWNER
OWNER'S NAME FRANK CALASCIONE JR. sD
STREET ADDRESS 99 TUSQUITTEE ST.
Cn
HAYESVILLE NC 28904
City or Town State ZIP Code
( 828 )_361-6590
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH:406
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO IN
W HEREBYCERTIFYTHAT THIS WELL WAS CONSm D IN ACCORDANCE Wmi
c. WATER LEVEL Below Top of Casing: 100 FT. 15A NCAG ZC,WELL CONSRUGrpN STANDARDS,AND THAT CO OF 7111S
(Use•+•If Above Top of Casing) RECORD FIAS BEEN PRMIDED 1D THE WELL ONNER.
d. TOP OF CASING 15 1 FT.Above Land Surface* �Z 6 /4
*Top or casing terminated ator below land surface may require f(' i L T R E OF _R l IFI D l T c/ TR 1� ,) 12I2 DATE
a varance in accordance with 15A NCAC 2C.0118. SIGNATURE O((F��CERTIFIED WE NTRACTOR GATE
e. YIELD(gpm): 12 METHOD OF TEST AIR V&A I&A V)Aai-Ei L-ur"
PRINTED NAME OF PERS N CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Inform ton M77e
omn
1617 Mall Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 56 IE C EJAN 3Asheville RegAntWar D.

62 0
RESIDENTIAL WELL CONSTRUCTION RECORD
j North Carolina Department of Environment and Natural Resources-Division of Water Quality
` WELL CONTRACTOR CERTIFICATION# 3131
1.WELL CONTRACTOR: f. DISINFECTION:Type ' Amount UZ.
L,on -D i I I (:t rd g. WATER ZONES(depth): /42 -/O 6Prr1 oZGO- 5-r_pm
Well Contractor(Individual)Name Fran To From To
YAR S (it1c�(,(_ (D IZ I L- .(N G ZN C From To Frain To
Well Contractor Company Name Fran To Fran To
STREET ADDRESS I 2(07 8-t/ER ior-,c 4(w Y a CASING: Thickness/
�77 ^ ^ Depth Diameter Weight Material
BP'
L w111..0 le'_ 30S(a2— From C) Tg„ :7 FL_&/Y -F 2Z6 9VG
City or Twin State Zip Code From To.7.Z _FL !o'/g S D2 Z( PJLi;.,—
( 0(,o Y. From To Ft.
—
Am code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
Fran © To 20 FL C'c Wkc,v7— Gr72vr-rY
SITE WELL ID#(N applicable) From To Ft.
STATE WELL PERMIT#((tapplicabie) Fran To Ft.
DWQ or OTHER PERMIT#(if applicable) � It.. SCREEN: Depth Diameter Slot Sae Material
WELL USE(Check Applicable Box): Residential Water Supply Od/ Frain TD Ft.—in. in.
Fran To Ft. in. on.
DATE DRILLED �2-3n O D S / Fran To Ft.—in. _ in.
TIME COMPLETED d.(7� AM❑ PM 0" g, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Sae Material
CITY: CGS 1 COUNTY C�Z;/ From To FL
'S / A9i� From To Ft.
Arj
Fran To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Pared,Zip Coda)
TOPOGRAPHIC/LAN ETTING: 10.DRILLING LOG
❑Slope []valley M06 ORidge ❑Otter From TO Formation Description
(check appropriate box) cReNr- cl-ag
May e inydegrees, �Z Slaw l CLet1
LATITUDFJV�°Oy //b3, minutes,secanondsa O&MGE-
IONGITUDEWO�° 4/9- 96/� in a decimal format .�Z - 72 .Fawn! w60-77i4t&0 /Z-ck
� 72 //U AOL scarf
Latitude/longitudesource: WIPS ❑Topogmphicmap //0 /67 4, 0 R{.gcs, Apek
(iocathn of wel must be shown on a USGS topo map and Ill dID S Lr3GJr. ,TL?3b
attached to this form Inot using GPS)
4.WELL OWNER
OWNER'S NAME E.�.rt l LE _
� rr(( r
STREETADDRES>ib/Ll* _ -
r
or Town State Zip CodeRCEIVED
C
(�- 8rf -SSSD7 G
Area code- Phone number
S.WELL DETAILS, ^
II ` JAN 30 2006 _
a TOTAL DEPTH: riL S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO q8�� ICA
I DRRDC
o v/WMUCIED 6J CORDMCE WrrN
a WATER LEVEL Belowr Tap of Casing: Fr. tsAc,WELL coNsmuC Pr of 11t15
(Use'+•If Abovee�Top of Casing) RES BEEN P)t IDEo wNER.
d. TOP OF CASING IS r>2 FT.Above Land Solace• � 3 -1)r5'
•Top of casing terminated at/or below land surface may require NATURE OF CERTIFIED W CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. ;7
a YIELD(gpm): �Jr METHOD OF TEST Q/Q /" r-
6 VIC70
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu:Information Mgt, Farm GW-la
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7/05

g
RESIDENTIAL WELL CONSTRUCTION REcoRD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3 G /
1.WELL ti
7sCONTRACTOR. ( t DISINFECTION:Type f2f- Amount
Ln DI Il("1i"[J g. WATER ZONES(depth): 3 C00
Well rCogntractor(Individual)Name From To From To
J VV 2S ( _X—U. b_1 I_L(M L From To From To
Wen Contractor Company Name ;7 From Tc From To
STREETADDRESS 1167 &0 62(M— AWV, 6. CASING: Thickness/
2)L2(2S 1I(( aterial
lE ( . 3oSIz- FranTo�Ft� .S'�/2 2/Depth Weight 1'L_
City a Town State Zip Code From Tog Ft / S'aur..$ PV C_
7( txo 1_745 Zi(o Is. From To Ft.
Area code Phone number
Z WELL INFORMATION: 7. GROUT: Depth Material n Method
SITE WELL ID#(r applicable) Fran To_,QL FL Qjr!jGf r lf',zo /
From TO Ft.
STATE WELL PERMIT#(tapplicable). From To FL
DWO a OTHER PERMIT#(d applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To FL_in. _ in.
DATE DRILLED 2'2 —O 5 Fran To FL—in- _ in.
/ Fran To Ft_fi. _ in.
TIMECOMPLETED Li-�O AM PM[�
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: (14(IRMV COUNTY G O—V Frorn Tc Ft
tt-- Fran To Ft
.2��{tS TV12lZT1 N C "K 2D From Tc Ft.
(Street Nam.,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) —
TOPOGRAPHIC I(AND SET 10.DRILLING LOG
❑Slope ❑Valley ❑Flat t ❑Other From TO Formation Description
(check appropriate box) Q — 3 i5T4 A)La C_l_A le
May be in degrees,
LATITUDE /f_�S' 61. 5-((7 nhinutes,seconds or � ei�' rL ^-;.'f^u �"Y;r�,-�
LONGITUDE LQ C! S4 a e-L.. 4 ] r in decimal format ti A e' =az?WeErJ 017-
C, y' SL ur,
Latitude/longitudesource: w6S ❑Topographicmap Y - 65 92RD 6 e•/ Zpck
(locatian of we®must be shown on a USGS topo map and _ 9_2 6r2 flc!_^ _� t�oC.4C
attached to this form loot using GPS) 97 _ i 2 YS
4.WELL OWNER // 17_k 15(o 22/f (7 6Q�iy i7 sc
OWNEWSNAME2Y()TGii l�0PPSTai)T6jR nREMARKS:
!vilreHegional
STREET ADDRESS PC)?iC Y_ Q 3_3 MuRp�y ti s9CilyaTown Stale Zip CodeC6 37-'7056Area code- Phone number 2006
5.WELL DETAILS: ,
a. TOTAL DEPTH: .3�S / ice
Ix DOES WELL REPLACE OUSTING WELL? YES❑ NO g' I m4ultur =r1rotection
/ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
G WATER LEVEL Below Top dCasing:�_FT. I SA NW.4ZC,WELL CONSTRUC STANfIARDS,AND THAT A COPY OF THIS
(Use'+•t Above Top of Casing) REc S BEEN PROiIOE THE ownER.
d. TOP OF CASING IS�_FT.Above Land Surface*
'Top of Casing terminated atlor below land surface may require S ATURE OF CERTIFIED LL CONTRACTOR
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): 35 METHOD OF TEST (2 /Dz�—/E V/C e)2
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GWAa
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

aa�te{ RESIDENTIAL IWELL CONSTIZuCTION r-ECaxn
#th.0 No; aroma De ment of and Nar=j Rt ources•Van Division
C� of ltiater QualiTt
WELL CONTRACTOR CERTIFICATION 4 pC)
Z.WELL CONTRACTOR:
� f. ikSINFECT1aN:TgPeTilO--ls�211:>-3 �y �b
S. WATER ZONES(depth):
WON Cwtm1W(Individual)Name. Frorn To Frem To
` 1 From 'fo4._ Frmn__Yo
W eiI Contractor Comame Fran To-— From To
STREET ADDRESS .;90 (A)16!Ln �r� 6. CASE: � Thickriessf
Depth DiartT15 <,y)hf
t'l Bcu�a(v l lV C � CF rmm th To LoY r Ft.Pe,D.5 GS�r j
City or Tawn State . tip Code Frorn_(pj 1 Tc B SC! Ft.L,O
From To
Atea Code• Phone nurntw
2.WELL INFORMATION: T. GROUT: Depth Material Method
SPIE WELL tD#(itappikallo) Fron1 Q_.To rwjQba
From 3` To r
.STATE WELL PERMiT#tUawmabte) FrarT Ta. . FT .
DWQorOT14ER PERMIT*(itgxokabk) ,_ S. SCREEN Depth Ownwer SkAS'i2e Material
From '. To FLt --m, __-___in-
DATE ._WELL USE(Check ApphcabW BOX): ResfArrti�Watar S;ipply f9�
From - To FL_in. _m.
DRIi h m -O5— Frail To Ft-—In. --in.
TWECOMPLETFOIL 0 _ AMP/PM❑
S. SANDI6RAVEL PACK:
3.WELL LOCATION: Depth Size Material
CI'f'Y; tAU PS Il i II A COUNTY('J (t. Frain, To F[._
L From = = To Ft.
I.gf,r Nr ,N (( �T•_ Friar Yo FI.
lS✓sae[Noma-r'tr rrbWS,Commur,Subdmawn,tolll No..Paecel.ZIP___C��c o,)
TOPOGRAPHIC JGAND SETTING' 0.DRILLING LOG
❑Slopx:mmmley 0171st ❑Ridg 00trer : From TO Formation Description
(checK eppm0ftiabox) r
May be in&atlas, C) i n
LATITUDE 3 mints,seconds or �n. �5 r
LONGITUDE_! in a daimat format
l Q-
Latiblik4ongittuie wurc : ❑CIPs pT'opographic trap
(bcatian W+se6mus7ta stA2wltnn a USG5 tepc map end
aHattradfd tlirss lam►»otvs8lg GPS)
4 WELL OWNER --.--. c
OWNER'S NAME
STREETADDRESS R'A'tf fog
9 1f -Vi(( 1— V I ;asigc)U —
GAV or Town State :Zip Code - --CS�
Area code- Phone Rurrber. .
II. REMARKS:
ti.WELL:L`SEfAt15:
a: TOTAL DEPTH:31;65 r
b. DOES WELL REPLACE E)aSTtNG WELL? YES0 No Lim
C. WATER LEVEL Beim Top of Case "I bD NERESY CERTIFY THAT THIS WELL WAS CO SrRUCTED N ACCOROAKE WhN
00 TM?6 IO i FT. t5A NCAC 2C,WEU CDFIMr1CT1bR STAMIARDS ramT TA Corr OF TM
(Use't*it Above Top of Casing). Recccw "sgift PPK1v0w T0TkE:W/EtEUW/1/"i�a -
tl. TOP*T p Of CwArg iS ( FT,Above Land Surtace' //% ? 1 1
.'Tap oaslnp tenrhBlated atlor beiat land surface tray require a variance in a SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
accordance With 15A NCAC 2C.011 B
a. YiFxntgwn> Q�METHOD OF TEST
Ad- _ r Vy : I�C;/lJ
PRJNTED NAME OF PERSON CONSTRUCTING THE WELL

Rp�
ESIDENTIAL WELL CONSTRUCTTON RECORfI
North Carolina Department of Environment and Natural Resources-Division of Water Qualac
,a
WELL CONTRACTORCERTI)~ICATION# 2yDt/
1.WELL CONTRACTOR: f. DISINFECTION:Type mount
' xLC Io< iz• r 1 Sp N g. WATER ZONES(depth),
Well Contractor(W Vidualj Name From To
1 From To
bJell
(A i �Sn� N Late)
P r• lk. VI!3 From To From To-
..ontractaCompanyNarne �—r-- Fri To
From To
STREET ADDRESS Wr
� AYl 6. CASING: Thickness!
T? yytf �1 ,w Depth r Diameter Weight Ma� Gai
U f`6�.51D L.7 i^ N C �l-�-Lf! From_. _To�_Ft. � S Dr2t V
City or Town State Zip Code From To_FL _
JS25- -_!2.37— 096S From To—Ft.
Area code- Phone number '-
2.WELL INFORMATION: 1 7. GROUT: Depth Ma riai �'` f
Method
i
SITE WELL ID#(ifapglicable) From d To�` Ft.
From_To�Q�FL
STATE WELL PERMIT#(a applicable) From To Ft. - -
flWQ or OTHER PERMIT#(rt applicable) a. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 41, From Ta_Ft.—in. _ in.
From To_Ft. n. _in.
DATE ORILLEO� [�G-(�G From To__Ft._in. _in.
TIME COMPLETED. i. 30 AM p PM e--
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: �14V�p COUNTY�ar�(___ From To Ft.
TT From To Ft.
From To Ft'
(Street Name,Numbers,Commurury,SabdrMS10r,LW No,,Pwr ,Zip Cade)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Sirpe yryyalley [:Flat ❑Ridge OOther From To Formation Descri tion
(check appropriate box) n ? r P
—— Maydegee
LATITUDE 3 s,_ minutes,saorMs a
LONGITUDE tDadwinnattamer eZLhr - 365e
Iatitude/longitudesotrrce: ❑GPS . ❑Topographicmap
(ioocari,n of weff must be Shown on a USGS fop,map and _
attached to INS form rn,r using GPS)
4.WELL OWNER MAA ((�� `'
OWNER'S NAME Ke- ` 4e, 0 4
STREET ADDRESS �jy IQ�✓errr�• •D _
City a Town State Zip Cafe r -
�FS�S�>-
Area code• Phone number
IL REMARKS:
S.a. TOTALL TAILS: r �
a. TOTAL DEPTH; 30S —�--7—
b. DOES WELL REPLACE EXISTING WELL? YESQ NOX
C. WATER LEVEL Below Top of Casin : r I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT ORDANCE WITH
CONSTRUCTED IN ACC 9 F�_FT, TEA NCAC2C,WELL CONSTRUCTION STANDARDS,ANOTHATACOWCFTHTS
(Use-i'if Above Top of Casing) RECORD HAS SEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS�_FT,Above Land Surface-
. 'Top of casing terminated at/or below land surface may require. SI ,ATURE OF CERTIFIED WELL CONTRACTOR AT C
a variance in accordance with 15A NCAC 20.0118.
it. YIELD(gnm)r' OD_METH OF TEST • t
P NTED NAME F PERSON ON
THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt.,
7 R,i7IEAait Srar✓err CFrSto!'_kgfainfil Mr 77RQ4-f R17 Vhnrea 11 1411117'tR•7n1 S on S.RR Forflt GW-la

..0 RESIDEIVTIAL W'FLL COD+STRUC-nOly RECORD
North Carolina Department of Lrvitmrment and Natura:Rtsoum -Divlsn,of w2h,r Guafit}
WELL CONTRACTOR CERTIFICATION 9 -290.�
t 7.WELL CONTRACTOR: f. DtStNFECTION:Ty 5As+ount
.__
uN S.'a n 9. WATER ZONES{deem},
W.w CDnbacta(kaaysot aj warm From To From - To _
} 11 n Ll)�l ." ./1Q Frcm : Tar_. From To
_
Well Contractor Company Name.. Fran To From
_ To
STREET ADDRESS. JD I.l'.�42r2 R� S. CASING, Thcki sr�-`
l C Depth Darnete Weight Mbteria
�rC�G�f� f1 1� CSC/ FMM b To _S F;. t"I'c sa- �G
Crfy a7uam. State ego
Flan l Sa ?o—Ft/&
From—To Fr
A sa Code- Phone numts _ t
T. GROUT: Depth Material ^!2.WELL INFORMATION: McG,ad
From
EEC SITE WELL ID#(it app7icAie) From F; e
STATE WELL PERMIT$(d awpcatge) - Fran ?o Ft «
DVVQ or OTHER PERMIT RL+f appkcable) s. SCREEN:. Depth ow"er -.Slot Six -.. kwwal 1
WELL USE(Check Appkabls Bark ResidamW W atsr&ipMy C?"- From To Pt._____m, R. I
From To__FL. in, �.
DATE DRILLED-it aa=QS-� Frcm_____To
TIME COMPL TFD g j j 0 AMC PM ID, ----
S. SANDIGRAVEL PACK:
3.WELL L11O11 CATION: : Depth Size Material
CITY:YtFrom To FL
d ��P - C4t7NTY_� 1 y�L1 FMR ?o~—FLi-- i
From To FL
{S1saN(tuna,Numlxra,CommwWy.Subeebsfm,Let Nn.,Pwcal,ZWCoCa} )
�T��O✓✓POGRAPHIC f LAND SETTING. ,itt,DRILiJNG LOG I
iigtoPe:[Waky OF* DRiage 009w From To flmftstiDn Dwzceiptian
(erred(apprdpteN ooz) ((, >. `C1r
=rd
LATITUDE 8 LONGITUDE �` 10 - (4Q51
LabtudtAOngitvdesourer COPS oTupographicTrap
;bcstAnn of"I must be shown On a Utcs tow map end
stlaoned to Ul&h mIrW rfssrg GPS) --
4.WELL OWNER
OWNER'S NAME J ,'_!Q. {U T_ n
STREET ADDRESS 1 L(
lin aflol o N C - 2�_
City or Turin State. zZ0 Code
Area code- Phcme Rumber
fi.WELLdI. REMARKS:
1 DETAILS: -
a. TOTAL DEPTH-. Lb 5i i
b. DOES WELL REPLACE EXISTING WELL? YES O NO Iy {
e. WATER LEVEL Below Top ofCaa' ,00HEREaycERnrY THAT TrasWEtLWAacaHstRtrcTED+aACCDfiDATICE.wmf i
1.�._ +mJj_..a{(�;t_-;,--._FT. t'uANGAC2C,WEt,L.OEv4_ryLt;TM SIMOAROS.AND T TA 000V OFIM
ftJOV"4'II Alpye Tqs of:Ci26Ng}. RECORD HAS SSE.N PRWOW To THE WELL OWNER,
d. TOP OF CASING IS FT.Above Land Surface-
'Tot,of Iamw ted aalcr below tat,d surface may mgv4e unm�n Q A 1`0�
a variance 0 aticordsnce with ISA NCAC 2C 01IS. _4eAnTL RE OF CERTIFIE CD WELL COrr�NTRACTOR DATE
e. YIELD f")n 10 METHOD OF TESTA19 ��CL WL G IZ IAA 1`$R_ [&
PRINTED NApLE OF PERSON CONSTRUCTING THE WELL

� a
' ' REJOiI�ENTI�L ca�T.€ c�risruracrzanTr�Cottn
North Carolina Dcpartmcnt of£mrrorrzncnr and Notate(Itesourccs•Division of Water Quality
LVEt:.i.CO?lTR.A£:T4it CETtT3F`ICA77OlV#
1.WELL CONTRACTOR: f. DISINFECTION.TyTfab'}h -a eJ5 AM aM ,:-
J Jk MQ W l Sr g, WATER ZONES(depth):
-Nall Contractor(RwMwUWJ Nanw 1 �- From TO- From To _
_ .(y'd_ _ Fan To_. Ffom To
-
STREET — _.—
W siI Contractor Company N ame. .. Fran
Ta_;___._._... From To
STREET ADDRESS 8b U.�t�,S ri rT �� 6. CASING: Th$Ckuessl
LT L'X\ ��� C ��C16 rtam Depth Diameter Weght MaterL9
_--To lib,Ft Ca-a5 �rz l.. .�LK.L__.
City or Tern State 2iO Cado From_J�4p Ta_.LC1.Q_Ft..L¢i�:._
Phone
nanu
tiraacryde- Phone nm&
2.WELLtNFORNIATION: 7. GROUT: Depth Material Method
{ SITE WELL iD#(8 aoolkabk) Frah•_�'`Tam'_Fi,
i!{ From Ta,$1�FLZrort63AE j.Ley�,(-.e,
STATE WELL PEEM*(n apphcabte) From To Et j
I DWd2 ca OTHER PERIdIT#fA appkelle) i
8. SCREEN: Depth Diemcger 50 Size MrBanat
WELL USE(Check Applk:abte Box)• Resktlentta!Weer Supr4 W, Frank To—FI-----m. .y In-
DATE _
From To fl_in. tn.�
oR111.Eo I P-aG- 05 i
TtMECOMPLETED:LItOA AM PAd{y. —�
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size tvtatedal
CITY:: gy�p�Vi IIA COUNT ('Idu Frain ___`Ta Ft._
"'�`"`Y From To - FL _
.5�1f't"P f rvtG R.1 From To FIL
iSuaW Nuea,Nrxnixie.t:ommxan4y,Subdrvislon,lot Na.,Parwl,ZIP Cade)
TOPOGRAPHIC/LAND SETTING: 40,DRILLING LOG
0 Slope PVak' QFW ElRMge QOther From To Formation Descripton
(check appro"prtte aoz)
LATITUDE 3 lmW
irartes,nsmorAre
or
clewprzsFsLRoC k
LONGITUDE s,_,,. inadaiaai foment
iatitudeRcngitude source: OGPS OTwagraphiC
(iDcafhan of we#musf fe shown w a USGS fopo reap End
attaatfedfiiDk hwrrr l'rrorirs#rgGPSj
4.WELL OWNER --'-----_ --- :,`
OWNER'S NAME .ZI
STREET ADDRESS
.3,2? \rl:rtr` C-3
CR}or Turn State Zip Code -
C.`La.B�• l A5(o -,36gL1
Area code- Phase number
S.WELL DETAILS! 11. REMARKS:
a TOTAL DEPTH;-22S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Iil/
e. WATER LEVEL Below Top of Cas' ICO HEREBY CEAT rTW,T MS WELL was CONSTRuCMD A ACCORDANCE WnN aq mp:._ 5n FT. tsr,NCA.c zC,WELL CONSTRUCTION STANDARDS,A TNATA GOFY OF TM
(Use`+'if Above Top or Cacti g). RECORD RAS BEEN.PROVIDED To THE WELL OWNER,
d. TOP OF CASING IS... 1 FT Above Land Surface'
'Top of Caft terbuted aVor below land surface may reW, r nnm o n Q t n �A inn `1-�R-O5
a variance in accordance vRBI ISA NCAC.2C.0118. SIGNATIfRE OF CER I WK-o WELL CONTRACTOR DATE
! B. WELD(gprny METHOD OF TMT A;2 � QLWXP S 1Z t.7 15r,✓�
PRINTED NAME OF PERSON CONSTRUCTINii THE WELL

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment VI and Natural Resources-Division of Water Quality-Groundwater Section o
WELL CONTRACTOR(INDIVIDUAL)NAME (print)`r1\UA�rn S l�• D�S CERTERCCAATT�IO�NC#C �&
WELL CONTRACTOR COMPANY NAME O�k4 ErV>V% , L'S� SWAU-44 PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
I. WELL USE(Check Applicable Box):Residential 2 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCA I N: �TopographictLand setting
Nearest Town* t"3l1L1� County Cx-� dge ❑Slope ❑Valley ❑Flat
W.n`--3ToC ,���v t.Xs4�Lit (check appropriate box)
(Street Name,Numbed,Community,Subdivision,Lot No.,Zip Code) LatitudeRongitude of well location
3. OWNER: a,:�r�� tt�) (degrees/minutes/seconds)
Address 153 cwz Rom. Latitude/longitude source:❑GPS❑Topographic map
(Street m Route NaJ (check box)
�tl C!sNi(l1� t.1C_ 6z.� DEPTH DRILLING LOG
City o T State Zip Code From TO Fomlatia escription
Ems- - 3QD b W
Am code-Phooa number _
4. DATE DRILLED b'
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO d
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+"if Above Top of Citing)
8. TOP OF CASING IS FT.Above Land Surface•
'Top of cuing terminated at/or below iaad surface requires a
variance in accerdanpq with 15A NCAC 2C.01IS.
9. YIELD(gpm): --t ME/GT�HOD OF TEST W Q
10.WATER ZONES(depth): 1;
LOCATION SKETCH
11. DISINFECTION:Type kkTk! Amount Show di ction and distance in miles from at least
12. CASING: Wall Thickness two Stu Roads or ty oa lude the road
Depth pigmeter or Wei' �t, at Dal numbers d co on road names.
From­-0- To !% Ft. (cf't4 min
ba
From To FL �a N�
From To Ft. F]
13. GROUT: Depth Ma C Meth p
Fronk b To$% Ft.C9x�++-ic � �oo�
From To FLU l YgsE
14. SCREEN: Depth Diameter Slot Size Material 17,
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft.
Ar-,
From To Ft. O
16. REMARKS: l5e' (=
�.T.
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 WE4 O R
SIGNATURE OF PERSON CONSTRUWRiatt DATE
Submit the original to the Division of Water Quality,Gr ndwater Section,1�,63Y36 Mail Service C later-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. FEB 0 7 2006 W-1 REV.07/2001
Asheville Regional Office

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resourcess--Division of Water Quality-Groundwater Sectioyn�J,C�
WELL CONTRACTOR(INDIVIDUAL)NAME (print)C'Y� S G. F�t�K-C�� ,. I CERTIFICATION#o_!q✓
WELL CONTRACTOR COMPANY NAME�V'LL� ���- ll--(NCB PHONE 0 tw�131' l l
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
ifapplicable) ifapplicable)
1. WELL USE(Check Applicable Box):Residential Mimicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT Topographic/Land setting
N st Tow t: JI Count Ridge ❑Slope ❑Valley ❑Flat
(check apprWriate box)
(Sheet Name,Smbers,Co nmuni subdivision,tut No.,Zip Code) LatiludeAmi gitlide of well location
3. OWNER: (devees/mirnowlseconds)
Address LatitudcAongitude source:❑GPS❑Topographic map
or s RotL) d-� (check box)
O DEPTH DRILLING LOG
t o `ity own _ $ Zip Code From Too 1 Forma'o Description
Am coda Phone number I�_
4. DATE DRILLED ; I as q1 l'
5. TOTAL DEPTH: bl /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 13
7. STATIC WATER LEVEL Below Top of Casing: u FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surface'
'Top of cuing tern lusted at/or below land surface requires a
variance In accord ee th ISA NCAC 2C.0118.
9. YIELD(gpm): . MFTHO�D OF TEST w t,
10.WATER ZONES(depth): l ul�t
LOCATION SKETCH
11. DISINFECTION:Type VkTH Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depot_, Diameter or Weight/Ft. ate al numbers and common road names. ,�'•
From D To 1 I Ft. Lo%4_1 •(�
From To Ft t\
From To Ft._ (ipod J
13. GROUT: Dep M Meth
From b To � FL O b
From Tc Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in, in.
15. SAND/GRAVEL PACK: rn
Depth Sim MaterialCA
From To Ft.
—ate:
From To Ft �
OL), tip A�L'E&
16. REMARKS: c.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL v
4
CONSTRUCTION STANNPARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL WNER
� 1 I� 0 E
SIGNATURE OF PERSON ONSTl�I�E4VW DATE
Submit the original to the Division of Water Quality,Groundwater Section 1636 Mall Servic Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. FEB 0 7 2006 GW-1 REV.07/2001
Asheville Regional Office
Aou'W Protertiot-

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
((,�p�rri�ifnft) 1. V-U-S G.A r(t<-ty.�,l(� CERTIFICATION
�-M�l+/
WELL CONTRACTOR COMPANY NAME W s�i'E��\L U5--LL- 1�LC� PHONE 0 tO'r)�"1
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if licable ifapplicable)
1. WELL USE(Check Applicable Box):Residential Or Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAIIyO�N:/ / Topogrdphic itrid setting
Near�tT wn `„`Tt1� Countyc� `f (9Ridge ❑Slope ❑Valley ❑Flat
PSG (check appropriate box)
(Street sme,Numbers,Coalmunity,Subdivision,Lot No.,Zip Code) LatitudeAongitude of well location
3. OWNER: (degmes/minutes/seeonds)
Address Latitude/longitude source:❑GPS❑Topographic map
erect ltqut£No.) DEPTH (check box)
LOG
City r own state Zip Code From To , Formagon es ription
W)- a " t� 15� �cR
Area tads-Phone cumber
4. DATE DRILLED �� D5
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 1/
7. STATIC WATER LEVEL Below Top of Casing: (eD FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of cuing terminated at/or below land surface requires a
variance to accords a with 1SA NCAC 2C.011S.
9. YIELD(gpm): 4�s METHOR OF TEST
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Diameter or Wei tTt, MOV al numbers and common road names.
FrotrL�To t'Y
From To Ft
From To Ft
13. GROUT: Depth M tgrial Meth
From a To �. Ft� lI
From De
14. SCREEN: Depth Dame Slot Siu Material
Fro To Ft in. in. \ _ j l
Fromm To Ft in. in. `t�'�-
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft. '
From Ta Ft. DO -
� pR
ter :
16. REMARKS: n
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL ''
CON UCT[ON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OIER
�..
SIGNATURE OF PERSON CONSTRUs#C��TI��N��T++HCcE W``P,,i.iCC- nn _ DATE
Submit the original to the Division of Water Quality,Gr undw�drEAXkd661�1 Service enter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
FEB 07 2006
Asheville Regional Office
An„Rnr Pr^fnMinn

j.1
,i i E l 10H sftNELL CONSTRUCTION RECORD
North Carolina-e�Department of�Environment and/Natural 1Resourrc�e_Divviissiio�n�of Water Quality-Groundwater Section
WELLQ6N UG48R(Iesu161U)NAME` (print) C>i - `-S G71 . CERTIFIC�AATTI�ONNC#�O t`J—t 7_
WELL CONTRACTOR COMPANY NAME �I,`��1 ` r--I".� W IuPHONE # In�IODI'�IIS J
STATE WELL CONSTRUCTION PERMrfW ASSOCIATED WQ PERMIT#
(if a licable (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L own N: /Topographic/Land setting
Nearest Town: ���ll County lit E3Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(street Nalne,Number,comm>m�' a\i 'sion,La No.,Zip Code) Latitude/longitude of well location
3. OWNER: n i Q� 1��� (degrees/minutes/seconds)
Address VC1 IL4 b Latitude/longitude source:❑GPS❑Topographic reap
5)%964t Roe,) (check box)
DEPTH DRILLINg LOG
y City own state Zip Code F.io�m ��Tjjor�� i Forman D cription
Arta coda Phone number I
4. DATE DRILLED Irl
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C3
7. STATIC WATER LEVEL Below Top of Casing: ` ' D FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surfaces
'Top of cuing terminated at/or below land surface requires a
varlance to accordant th 1SA NCAC 2C.0118. ^
9. YIELD(gpm):1+ME?�OI�OF TEST
10.WATER ZONES(depth): \ �14
LOCATION SKETCH
11. DISINFECTION:Type 774 Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depd4-i J�74mjer or Weight/Ft. numbers and common road names.
From D To `% Ft //l0 4
From To Ft. \
From Ft De _ V,
13. GROUT: Depth, M ten el Meth r
From To Ft
\
From To Ft. (rK��l'J-t-N�, `Ep
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in. V�
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. n
From To Ft. r ) ^ni
CD e ,
16. REMARKS: a.
mm
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C,WELL - o
CONSTRUCOON STANDARDS,AND/THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL OWKER
�— SIGNATURE OF PERSON C7Shevill�e
CC nn DATE
Submit the original to the Division of Water Quality,G 'Ei�i1�M Service enter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
0 7 2006
Regional Office
r Prnfca^ew. -

� 09196
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Div' of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
(tp[r�i�ntt))^'��_((,.V�7 C^��CC, �••l(r/
WELL CONTRACTOR COMPANY NAME��R lTa I ��, �'�( ` JI �(1 ERTIFFICATION
PH
STATE WELL CONSTRUCTION PERMIT#
(if a licable) SSOCIATED WQ PERMIT#
ifa licable
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL I N: -
Neares County Topo ic/Land setting
ORidge INSlope OValley OFlat
(Sheet Name,Numbers, o munity,Su division,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER:
ddress (degrees/minutes/seconds)
'( t or Rot N Latitude/longitude source:OGPSOTopographic map
.)Ci o own DEPTH (check box)
DRILLING G
�� zip Code From To 1
Fo [io scri lion
Aree code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: / "� +3U•/a_
6. DOES WELL REPLACE EXISTING WELL? YES O NO M--'
7. STATIC WATER LEVEL Below Top of Casing: (rD _FT.
1 (Use A
if Top Casing)
8. TOP OF CASING IS
FT.Above Land Surface* 7
'Top casing terminated h and surface requires a =
variance In aceordan IS below l with ISA NCAC SC.0118.
9. YIELD(gpm): METOID OF TEST 03->1
10. WATER ZONES(depth): II rV
to
11. DISINFECTION: T YP e� � LOCATIONS u CD
Show direction and distance in
miles from atYelst
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
FromDepAl To Ft i101 r Wn fit• aerial numbers and common road names.
. Ao ypL
From To Ft.
From De FL ppl�
13. GROUT: Depth M e}i Method
From To PLt
From To Ft. I
14. SCREEN: Depth D meter Slot is,
From Material
To Ft. in, in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sim 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 1
CONSTRUCTION STANDARDS,AND THAT A jOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WLL O R
SIGNATURE OF PERSON CONSTRUCTING THE WELL ram+
ATE a -
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