Gr CY2005

WELL CONSTRUCTION RECORD 3 0 7 3 S 7
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) WILLIAM BRADLEY LEWIS CERTIFICATION#3368
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential XI Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 57eCtAH County GRAHAM )[]Ridge ❑Slope ❑Valley ❑Flat
LOWER SAWYERS CREEK-MOUNTAIN LAUREL (check appropriate box)
(Saar Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3524.113W8342.171W
3. OWNER: DAVE NICHOLS (degrees/minuta/seconds)
Address 9116 LAZY LN LatiludeAongitude source)OGPS❑Topographic map
(Street or Route No.) (check box)
7wxPA FL 33614 DEPTH DRILLING LOG
city Town State Zip Cede From To Formation Description
8( 13 }917-7005 0'TO 120' BROWN SLATE
Area codo-Phone number 120'TO 140' BLUE SLATE
4. DATE DRILLED 01/03/2005 140'TO 425' BLUE SLATE
5. TOTAL DEPTH: 425'
6. DOES WELL REPLACE EXISTING WELL? YES O NO Cl
7. STATIC WATER LEVEL Below,rop of Casing: 100 FT.
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS 1 Ff.Above Land Surface•
•Top of casing terminated at/or below land surfam requires a
variance in accordance with ISA NCAC 2C AI IR
9. YIELD(gpm): 3 METHOD OF TEST AIR BIT SIZE 5.796
10.WATER ZONES(depth): 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 road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 140 Ft. 61/8' SDR 21 PVC
From To Ft. Q
From To Ft. !
13. GROUT: Depth Material Method 1 5
From 0 To 20 FL CEMENT GRAVITY �'i •7� 0 L Crr1
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. -or"
From To Ft. in. in. � pO
15. SAND/GRAVEL PACK:
Depth Size Material 3mC-)-t=
From To FL Z,
From To Ft. —,� ==r
rap
16, REMARKS: co c i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OFT R RD HAS B PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTR G THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone Na(919)733-7015,within 30 days. "
GW-1 REV.09/2004
8 2005

a
WELL CONSTRUCTION RECORD 307252
North Carolina-Department of Environment and Natural Res laces- ivir'an of Water Quality_Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print
WELL CONTRACTOR COMPANY NAME CERTIFICATION 8.gQCe__)
SPATE WELL CONSTRUCTION PERMITS PHONE 8(S�f)4, e
am Ciro licable) A. OCIATED WQ pER16117ri
(if licable)
I. WELL USE(Check Applicable Monitoring❑ Box):Residential® O Municipal/Public Industrial❑ Agricultural O
Recovery ❑ Heat Pump Water Injection❑ Other Q If Other,List Use
2. WELL LOCATI N:
Nearest Town: County TOPagraphic/Land setting
(Sss
-a]�aYJTu%h S) n e <,_ ORidge OSlope 13V81ley Mat
eet Nnme,Numbers,Community,Su(idiwnon, (check n
Los No.,Zap e} u o box)
— Latitude/longitude de off welllacation
3. OWNE
R:. c / N
Address Hr<
..S� l 5
(�aieeatminmaataecq,ds}
[ (Street m Rome No.) �—�--- Latimde/longitude source:OGPSOTopographic map
2477r (check box)
C ty T� Sete Zip Code DEPTH D ) .IN .LOG
Are�L)-PL7�ll l From To Formation Description
cede-pMne number��
4. DATE DRILLED_/_ =2y__dS-_ tG�U2
5. TOTAL DEPTH:
6. DOES WELL REPLACE EX(STBVG WELL? YES +7
Z STATIC WATER LEVEL Below Top of Casing: (�❑3 NO — —
8. TOP OF CASING IS (Use"+^ifAbow Top ofCosiingj '1
�O
'Top ort5sia9 serminAoed Astor below laneod .Above
Land Surface* -- �
Various 01n aeeordanoe with ISA NCAC 2C.01IS. ---- Cn
9. YIELD(gpm):--3�METHOD OF TEST n,T_10.WATER ZONES(depth);
11. DISINFECTION:Type LOCATION SKETt H
12. CASING: An1po"t o-`�1 Show direction and distance in miles from at least
Dimtteter Wall Thickness two State Roads or County Roads-Include the road
From4_�p%o FL f_ °rSneilih lTt- Meters n tubers and common road names.
From To Ft.— {—_ r0!'I lotl9 9 nT ;akN 1029 N
From_To Ft.
13. GROUT: Depth
-Material Method Q ` • t'`f s
m—Tam_Ft
From I'.d Pi' /J rf Ti�rrj T N-�r O v1
To Ft cSQp Tomb ra-i7 �/lON$F �Q, 0el 12'rt�d
14. SCREEN; Depth Dia I /. _
From To ttteter Slot sire Turn !&
From PL in io Material 7 YJ t f �. �Ou �rG7
To l t��
I5. SANDIGRAVEL PACK: in.
' /d Gr/N!/ UI'f ltro'0`7_
From Depth Size Material / '
To Ft.
From To Ft. --
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS
BEgp}CI PROVIDED TO THE WELLLL OWNER
SIGNATURE OF PERSO CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Can MAR C
Z7699-1636 Phone No.[phone],within 30 days. Rale(gh,NC
GW-I REV.07/2o01

Nl --l/ - UIdNEB .- - - - (� � � MWD
ei
WELL CONSTRUCTION RECORD
Nor lb Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Sectiio'n�,.
WELL CONTRACTOR(INDIVIDUAL)NAaIE (prinl) )<1 f1.�E/S h, (,1j+1�(`+r� CERTIFICAITON M,c{y�>
WELL CONTRACTOR CONS rANY NAME r� E�r (e�"P (( CI(+_ �I tr�C� PHONE 0 fk72 h3/-•���17
STATE WELL CONS1RucT1ON rEut1"ril ASSOCIATED WQ PERMI-IN
(ifa Ir rllble) if applicable)
llrmtra®t�� i
I. WELL USE(Check Applicable Box): Residential❑'Municipal/Public❑ Indushial❑ Agricultural❑
hloniloring❑ Recovery ❑ lieal Pump Waler lujection❑ Other❑ If Odner,List Use
2. WELLLOCAT(J,ON: \ Topogmphic(Landsetting
Nearest Town:I u1A)i�1!s Irr_ _County-L L4clLL ❑Ridge QSTopc ❑VRllcy ❑Flat
l,j���,,�,.,C,�p(`. _ (check epprr)pri.te box)
(Sneer Name,Numbers,Community,Subdivision,Lot Nu.,Zip Co I,) La,utudc/longilude of welt!oeation
N 3,5021 s" f fl3 WS'3/y
3. OWNFR: LLIA fir, �S ,Icfo ( ed�pe mmee/ utn/eeconds)
Adthess3 Lalitudc/longitude source:❑GPS❑Topographicsnap
`Simet or Route No.) (check box)
_—fin fib;n�.v.1Lf-1Vc_Z- s'?T I VELM LWLIIN-"QQ
City or Tewn smte Zip c+,le From To Formation Description
(—) u 1 C ` CI
Mr*cote-rimne number l('/ _ (49 , �
4. DATE DRILLED I- II-(',<; c"/��'- 1(o5` `. .
5. TO"rAl.DEPIII:
6. DOTS WELL REPLACE EXISTING WELL? YES ❑ NO 111-
7. STATIC WATER LEVEL Below Top of Cnsing:
(Use"r-if Above lop of C.si.;o
8. TOP OF CASING IS- I FT.Above Land Surface•
•Tap of rulnp lermhrubd At/or below land nrrGre regnlres.
s.danre In.crnrdance wIlh 15A NCAC 2C.011a. —
9. YIELD(gpm): `6—METI IOU OF TEST k_�-
10. WATER ZONES (depth):
1 LOCATION SKHTCII
11. DISINFECTION:Twelial Alnoonl_1 b Show direction and distance in miles frm»at leas!
12. CASING: Wall"1Lickncas Evo Slnle Roads or Coun Roads. Include the road
Dgdh Diameter or Wcigbi/Fl. Material numbers and conunon ro names.
Fro O ro -m S' FL�_,a _ !,pi �I t
FI om To FL Cn
Floor TO Ft - —
Cil
13. GROUT: Depth Mmcr'nl Method i
From To Q,� Ft.KJ (Icl:�2a Prt�(��,nr
From To Fl. -
14. SCREEN: Depth Diamc(er Slut Size Material --
From To Ft. in. in. w
Float To Ft.—ill. in. IV 15. SAND/GRAVEL PACK: _ C5
Depth Size Material
Floor 'fir Ft.
From To F-L
16. REMARKS: RObb; dS V)
n
DO BF.RFI3Y C17R I IFYIl1ATI HIS WELL WAS CONS IRUCI-ED IN ACCORDANCE W171115A NCAC 2C,WELL - - -
CONSTRUCI IONS TANDARDS,AND TIIAr A COPY Of-11US RECORD IIAS BEEN PROVIDED TO THE WELL OWNER tx
SIGNATUREOFI'I:ItSIINCONS"1"RUCfING THE WELL DATE o
Submit the original to (he Division or Water Quality,Groundwater Secllon, 1636 Mall Service Center-Ralelgh,NC
27609-1636 Phone No.(919)7.13-3221,within-0 days. OW-I REV,07/2001

WELL CONSTRUCTION RECORD 0-kl�o 306863
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: , Topographic/Land setting
NJe'�uT�^atI Tow j�j �^ M ounty—&&j,� ❑Ridge ❑Slope ❑Valley ❑Flat
at
Lli'e k) -p (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: % (degrees/minutes/seconds)
Address L de/longitude source:❑GPS❑Topographic map
(Street Route No.) (check box)
DEPTH DRILLING LOG
City o Town S to Zip Code From T Formation Description
clay it sand
Area code-Phone number
granite
4. DATE DRILLED , 7• 05
5. TOTAL DEPTH: a4eo, ,/
6. DOES WELL REPLACE EXISTING WELL? YES,4LN0 ❑
7. STATIC WATER LEVEL Below Top of Casing: clo FT.
(Use'•+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated attor below land surface requires a
variance in accordapci with 15A NCAC 2C.0118.
9. YIELD(gpm): 4 METHOD OF TEST BLOW
10.WATER ZONES(depth): aaa )
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz 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 o To Ft. ✓ "
From�To Ft. " �
u1 1 .
From To Ft. _
13. GROUT: Depth Material Method _-
From 0 To 20 Ft. Benenite&cement pumped
From To Ft. w _` --
14. SCREEN: Depth Diameter Slot Size Material -D r-,+
From To Ft. in. in. --�
From To Ft in. in.
15. SAND/GRAVEL PACK: c.a
Depth Size Material O _
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 STAND AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE
WELL OWNER
'
P457/ / �/ — d
SIGNATURE OF IIERSON 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.002004
ff

WELL CONSTRUCTION RECORD a" 307037
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) WILLIAM BRADLEY LEWIS CERTIFICATION#3368
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE. # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) if applicable)
l. WELL USE(Check Applicable Box):Residential%l Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL,LOCATION: Topographic/Land setting
Nearest Town: County GRAHAM )❑Ridge ❑Slope ❑Valley ❑Flat
SAWYERS CREEK HIDEAWAY (check appropriate box)
(Street Name,Numbers,Community,Suhdivisiom Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: JERRY HENSLEY (degreea/minut"Acconds)
Address 234 RIVER BOTTOM RD Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
GA 30536 UF,P'fiI DRILLING LOG
Citv.r Town state Zip Code From to Formation Description
(706 )- 889-4100 O'TO 60' BROWN SLATE
Area code-Phone number 60'TO 80' BLUE SLATE
4. DATE.,DRILLED 01/05/2005 80'TO 605' BLUE SLATE
5. TOTAL DEPTH: 605'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ❑ ..�
7. STATIC WATER LEVEL Below Top of Casing: 200 FT. rn
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surfaces 1
t
'Top creasing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C oII& v
9. YIELD(gpm): 1 METHOD OF TEST AIR BIT SIZE 5.950 C n
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least
12, CASING: Wall Thickness two Slate Roads or County Roads.Include the road
Depth Diameter or WeighUPt. Material numbers and common road names.
From 0 To 80 Ft. 6l1 w SDR21 PVC '^ I e:—AwVeC
From To Ft.
From To FL NtC
13. GROUT: Depth Material Method
From 0 To 20 FL CEMENT GRAVITY
From To Ft. ce
14. SCREEN: Depth Diameter Slot Size Material ?� r� c �
From To Ft. in. in. 1,,� �Q/
From To Ft. in. in. i
15. SAND/GRAVEL PACK:
Depth Size Material �., J`�
From To Ft.
i
From-To-Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE,WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS.AND TH PY OF THIS RECORD HAS BE•N PROVIDED TO THE WELL OWNER
CONST T DATESIGNATUREOFPFRSON
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.Q9/2004
1A.ri 7 ;_�U

NC _t/ OWNLR LJ O MWD
AVELL CONSTRUCTION RECORD 3 0 g 161
North Carolina-Depaitnicul of Erwironnicut and Natural Resources-^Division of Water Quality-Groundwater Section
WELL CON"I-RACrOR(INDIVIDUAL)NAME (prinl )Cme-s 1\. I1AJ IL ci V1 CERTIFICA7 ION.�vu
WELLCONTRACTORCOMPANYNAME_Wl ter Lod) �i�1iN� PHONE, # k2a)<31-2C47
STATE WELL CONS"riau"0N PERMIT# ASSOCIATED WQ PERMIT#
(i f npplicnble) (if applicable)
1. WELL USE(Check Applicable Box): Residential U--Nionicipal/Public❑ Industrial ❑ Agricultural❑ -
Monitoring❑ Recovery ❑ Heat Pump Water injection O Other❑ If Otlrer,List Use S
2. WELL LOC J• b
TopographiclLnnd setting _
iJcsrc'sl`T�gwn: ik1,5 QI I County Gndn j til ❑Ridge ❑Slope ❑Vaticy ❑Plat
_ _ (chick appropriate boa) a -
(Stoner Name,Numbers.Coanmunily,Subdivision,Lot No.7ip Code) Latitudc/longitude orwell location
3. OWNER: �P—cn DCayiS _ (deyeedminute✓eec mM)
Addtcss 5 71 $D12e NL4- 1 _q_ Laliwddlmtgilude source:❑GP5❑Topograph rry ic p
(Sb� R, for Route No.) (check boa)
1J�b.irtLv711e iLC28771 ULlll =L41N5'WQU
City or Town state Zip code Prowl To Formation Description
Ann rode-Phone.....flier I r)' _ ;so 1 mio-
4. DATE DRILLEDS-.2S- 6S 30, Lbc ' i -
5. TOTALDFPI-ll:
6. DOES WELL RF'PLACE EXISTING WEI-1,7 YES LI NO P -�
7. STATIC WATER LEVEL Below Top of Casing: G,• _FI'.
(Use"e"it Above Top or Casing) ..,
8. TOT'OF CASING IS_�_FT. Above Land Surface"
'Top or eadnx lemilnatrd atl.r brlorr land anr6te rrqutres a T
votrnre In trrnrdance wIlb 15A NCAC 2C'Of 18' a
9. YIELD(Pprn): 6 hit rilOD OF—I FSrJ,9 ___
10. WATER ZONES(depuf): _
LOCKHON
I. DISINF C1lON:T)lic}l i Amntnd \S" Show direction and distance in m es front at Ic;�gq
12. CASING: 4Wnll'Ihicknrsa two State[toads or County Roa s. Include the road
Ur•pOt Diameter or WcighUFl. Maicrial numbers and conunon road na nes.
Flom L_Q_.ro—r2C{' 171.1:o..25_
Flout] To Ft.
10
13• GROUr: Depth hacnn Method
Ptont 7_ ._ o_2LL)'L ji;- lC Iiyid
Prom To__
14. SCREEN: Depdt Dinmcler Slot Sizc Mnterin[ 1
From To Ft. ill. in.
Fr-orn__To Fl. in. _— in. _
15. SAND/GRAVFL PACK:
Depth Sizc Malec 61
Flom ro Ft. _
PnUbOrM1SUS (�Pi
16. REMARKS:
I DO I IERFUY CERI)FY-I DA-r 77I[S W rl-L WAS CONS I RUCTFD IN ACCORDANCE W1111 15A NCAC 2C,WELL
CONSTRUCf ION STANDARDS,AND TIIAT A COPY OF IllTS RECORD I[AS BEEN PROVIDED TO TILE WELL OWNER
SIGNATURE 01:PHSON CONS'I RUCI'INU 771E WELL DATE
Subndl rile Original to file 1010%lon of Water Qunlily,Groundwater Section,1636 li Service Center-Raleigh,NC
27699-1616 Phone No.(9i9)7.13-3221,w[(hia 30 days. OW-1 REV. 07/2001 -

NC 1111111 R _.. 1)Itll
---- ---- --
ti ELL CON S'rgUCrION wiXORD 3 C g ,R
IJolth Carolina -Ucpallulcut or larvilonmcal and 1A IMA Rcsou+ces- Division or Wntet(lunlily-(Jloant wnlcr Scclioli
o'r'.LI,CIINlI1Al"IUn pN DI\'IUIIAI.)N,\ni F. 11"1no_l—� �6eec e- -- 'CFItI lrlcA our+niz L_
iy / rnul+r. a �537"Z Yy
wF.1.1.CON RACI OltCOpll'ANV NAMC_—LL/_•�(i°{-------- ---
f A IF,t\F.i.l,CONS I IU ICIIUN 1'F.INlfltl_._____-_.__----A55(ICIA7 F.11 wl)I'F,IlptPl IY —
if n r rlicnblc
1, R'L•LI.USE (Check Applicable It(, ): Rcaidrnlinl lel' Munpal/Public U Indosidal Cl AgOcullulal U
LAmiloling U Recovc+y U I Icat Pump 1Valcr InjcclioII U Ulhcr U If Olhcr,List Ilse_
2. W I°I I, 1 OCA I R) JJ*� // � Topogrnplritll.nnd rciliull
Wcalrsl'ro,vir dbUAJv 7�E ('ounty_VfaGpk "� LJltidgc Lislope LIVallry I_Il ht
1.nliludc(thuen,kg gug...
cq" o b,,,)
�e10w orwcll lurnlnu
(Gbrr1 rinme,Numbro.Cram ...fly.Snbdririo,1nl .'..i
// (drp,erdmimtln4-rnml.)
). 1.11V14IiR: GaIlP
A( JIccS y� y l ___-._— Lalitudcllongiludc suu+cc:Ll(TSUfupoglnphiu nlnp
U(1-�1--1.-/.-5----------- (check h,a)
ll,mle It,,.) J)I LUl )J�IILI,IIJIi_LU(
Oily a, Ion m�a $Inge lip('
t rloln 'rn follnarollUesclipliull
rAe
A,rn rwln I'honr Ilm,lbet /'6 r/./
4. nnlFIIitII'lEl� ��-U'f 74U.- 600 -
5 T(11'AI. IIPPI11!--404._---- ---
(. I)111iS 1\'111.1, lil'.I'I,AI'E. I(JiISI IM; \VLI.1;1 1'i;'S L1 IJU
7. S I'ATIC 1VAll I(LliVliL llclutv'1'op ur(':Ising: Q_ _-1'I• -----sue
(ll•r•'r'If Abnrr'I op of 1'n-iupl
R. 'I-Itl' OI' l'ASINI I IS _-��L - - Fr. Above I.nnd Su+laec' _ �*
•'I rl.rr c"I"p In mh,n,nl nlh.r hrinn Itud on lnre s�Ioh rr• _ — N �- --
n�rlentt In utn,dnut nJlh I5A NC'AC W- III Ip. y
9. YlFI.OQ1,119 MISll10001r'riiSl �7 / - cn
III. WA I ER ZONES (dcirill): 2490----- LQCATIU1�YtI-CCjk �-
_--_.._-_�j �+,, Shaw flit eclion and distance in miles Gom nl ast
11. UISIIJIT*C1101J:-Iypc ffT7f Nnnuul _Y�-
Wsll'Ihickncss Iron SIn1e Roads or County lionds. luclude the road
IL G15114G: IIIIIIIhCrs mld cunimon rond 111111.
11r1,111 Uimncler or 11 cI;hVrl, h1nlc+ial
FO, y�)�eu' pi'rAG�t/t6,
Boaz d°
m � To /�Y rL_�-mil _ �—
13. OROU1'; Urplll hint 6.11 Iclbl
FIVIII TV Ft.
I1.- 1-2ars.f�
14. SCREUJ: Urplh Uimueter SIO Size Malc+inl L4ke
lion(.--1" 171. in.
15. SANIVORAWLPACK:
Orptll Sirc A1rJ171.
einl
�r.
=13
00
Ull I11°I:I'Ill'('I:ICllrl'l I IA'I"'I Ill" WITI,WAS('UI IS IIII)(:I rD Ill ACCORDA110E WITH I5A IlCAC 2C;?9VJ-L v
CONS I RUCI I(JN S rAIJDARUS,AtJD'I I IAI'A CUI'1 OP'I IIIS ItECURU IIAS IIEGtJ PIIOVIUCD TU I I IL MI E 01Vi 1 -
ekt
--- -. SKRIA7UU'I (W111TSUNCOtJS17lUCI1N(i771EWELL UAGI.
Ci,bmi1 II,r o11gi11 d to ,he III l itloa 1)1 WIfIv1 I lunliIY,l:I oualltrnlet-Sectloit, 1636 NI fill Service Ce'1Vr1 hIIV rl 911, 1211111
--._.. .. ., ..,. _-_ nl.. nnn,�ntt•�1 ,:IIhIn14d'�et.

111. -- 1/111111? _ _ f)❑ ; rinu
WELL CONS'n(UC ION ► ECOM 3 0 9 8 9 2
IJotlh Clio] -Drpalln,cnl of Flivifouulcot and 14 11a1 Itcsoulces-Div Hot,of Wntel Q'Inlily-Uftnuldv'sler Scclion
.Z// BG 'uFiturICAIIUN P�—_
1%rij,(:ON I I(AC1 Olt(INltl\'1N11AL)NAME (1n IuU_ eeLr;
--- y�
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Nlooiloliog U Itccovely LI I Ical I'llow Wnlrr hijecliou U Ulhcl U If 011cr,List Usc
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-- ----si.;NAIURr Up I'1'.ItSUN C0I4SI1tUCFINU'11111 WELL DAlV
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WELL CONSTRUCTION RECORD 3 0 9 0 5 6
North Carolina Department of Environment and Natural Resources- Division of Water Quality
w'FI,LCY)NTRA('rOR(INDMn1IAI,)NAME (print) CHRIS_TOPHERL.DICKEY CFRTIFICATIONM�1
WELLCONTRACTORCYNIIPANV NAME CHEROKEE WELL DRILLING AND PUMP COMPANY. ,INC PIIONE H (828)837A00O_.__._..
S"rATF WELL C'ONSTRITMON PERMITa __ASSO"ATF,D WO PF.RMITa -
if applicable) (if applicable) -_ -
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial Cl Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injeclion❑ other ❑ If Other, List Use s
- N
Z. WELL LOCATION:
Topographic/Land setting 00
...,,,eee���
Nearest Town: ROBBINSVILLE County GRAHAM t>aleidge []Slope ❑Valley ❑Fla��" o
UPPER TUSKEGEE RD klreck appropriate box)
_ _>
(street Name.Numberv,Community,Subdivision,L.ul No 7iP("I'le) Latitudc/longitnde of well location -
3 OWNER: COY HELMS C/O RUSTY WILLIAMS ulef7ees'minmea/seconds)
— --- Lalivalc/longitude source:❑GPS❑Topograp c map
Address 3187 YELLOW CREEK RD __—.. ___. (check box)
(street or Rime No_) DRILLING LOG
ROBBINSVILLE NC 28771 DEPTH
Cilcer"Town State Zip Code Tmm IO Formation Description(828 )_479-6354 0'T_O 90' __ _ _ RED CLAY
Areac,de-Phone number 90'T0140' BROWN SANDSTONE
4. DATE DRILLED 03/10/2005 140'T_O 153' —,__ BLUE GRANITE
5" TOTAL DEPTH: 405' 15T TO 405 _ _ GRANITE
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL.Below Top of Casing: 135-_ -_ — —
(Clse"+' dAMve'I'np of('acing)
-- -
R. TOP OF CASING IS 1 _FT. Above Land Surface* -
•'1'np of ca m slnp lerinaled alA,r helmr land surface regnlrn a ----_- - _--
variance In aceardsace with 115A NCAC 2C.0118. ----- -----'_--"----- —
9. YIELD(gpm): 6 METHOD OF'TFST AIR---
It) WATER ZONES(depth): 180', 360' - -- LOCATION SKETCH
ORINE All1011nt 10o PPM" - Show direction and distance in miles from at least
11. DISINFECTION:Type_CHL___ -_ -- ---- two State Roads or County Roads. Include the mad
11 CASING: Wa11l1,ickncsS
Depth Diameter or Weight/Et. Mnlerial nunlbets and conm,on road names.
Front 0 To 153 FL 6 1/8' SDR 21 PVC_
From To Ft.
From To__Ft
13. GROUT: Depth Material Method
Front 0 'To 20 Ft.CEMENT GRAVITY__ _..
Fran,
14. SCREEN. Depth Diameter Slot Size M:dmiul -- N
Fmn, To—__ Ft. "in. __ in
Fmm in
- .ro ht. in.
---- -
ul
15. SAND/(;RAVEL PACK: 7!
Depth Size
From
16. REMARKS: ------ --- ---
1 Do IIFRFBY CERTIFY 111AT'1111S WELL WAS CONSfRUCI IT)IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS.AZ:4RS0(
OF"I ITS RRC RD HAS 13IiF. PROVIDED'fO THE WELL OWNER
SIN CONSTRIJCTTN( I I I I. DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Senice Center-
Raleigh,NC 27699-1617, Phone No. [phone],within 30 days. GW-1 REV.09/2004

3M81
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural ResourcesR*esources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (/print) c�ETY y�P CERTIFICATION# (�
WELL CONTRACTOR COMPANY NAME_ �I'"a M ANtl/I i no PHONE # (Sra0)479'-�Y�y
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PPiERMI�T#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential a Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N Topographic/Land setting
Ne��1)festTown: ` CountytzTej2g.)>n ❑Ridge ❑Slope ❑Valley ❑Flat
/-o D17&r e-,,V e 2�7]/ (check appropriate box)
(Street Numbers, y,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /' /' ✓e' (degrees/minutes/seconds)
Address _ f• ec Vtd Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
R( t�YIS(i./IN 111C 2!j77/ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
6a)- ,S 3G-60 n
Area code-Phone number .er
4. DATE DRILLED 3- 9
5. TOTAL DEPTH: 3AS-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9 y ,t
7. STATIC WATER LEVEL Below Top of Casing: .15- FT. y
(Use"+"if Above Top of Casing) 1
8. TOP OF CASING IS / FT.Above Land Surface'
`Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):a<: METHOYFTEST at
10. WATER ZONES(depth): 13
LOCATION SKETCH
11. DISINFECTION:Type Amount e'5-yS� 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. �M'atte'rial numbers and common road names.
From CJ Tom_Ft. SOf'�Ll -pro m yrT pit? vL�e13 /0.ke ka S
From To Ft. > fl t
From To Ft. GO ai� �/ ILS /UY+) / tp�hl
13. GROUT: Depth Material Method O yV1, Al
�From 0 Tq _Ft. c6,meonT .!-V O J"1 P PPIP Go VC' Gd
From_To
14. SCREEN: Depth F[Diameter Slot Size Material li/Y/1 /f'7�r ,0 n dr It'vN WCI
From To Ft. in. in. // _
From To Ft. in. in. �Q (�� G n ki -
15. SAND/GRAVEL PACK:
Depth Sin Material
From L To F - _ � t
From To Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,W&C --
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
��� 3-as-�s
SIGNATURE OF PE ON 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

01 309480
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
/(print)// .�TE� l�„,�P CERTIFICATION# O O
WELL CONTRACTOR COMPANY NAME V-mYIAM (a/e�,// Ar1111zqJ PHONE # &2 J!179-S%zf{y
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential® Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N
Nearest Town: �r�a M Topographic/Land setting
�,�T,, "� County ❑Ridge ❑Slope ❑Valley ❑Flat
/
"—"— a k R (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /pd (degrees/minutes/smonds)
Address W h:T.. oo,j�_ M Latitude/longitude source:❑GPS❑Topographic map
Rn�.
(Street or Route No.) (check box)
- or Town DEPTH DRILLING LOQ
City or Town G State Zip Code From To Formation Descripti®
Area code-Phone number 9
4. DATE DRILLED
5. TOTAL DEPTH:_3Sf0 1 a
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
7. STATIC WATER LEVEL Below Top of Casing: 1W FT. 0 '
(Use'+^if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface'
`Top of casing terminated at/or below land surface requires a
variance is accordance [th ISA NCAC 2C.0I18.
9. YIELD(gpm): —METHOD OF TEST Oar'
10. WATER ZONES(depth): Qtrsf0
LOCATION SKETCH
11. DISINFECTION:Type Amount 0,S Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/ft aterial mbers and common road names.
From Q To5_Ft._&_�_ 'q0nQl V ve- aF.L1y3 T lie off From To Ft.
From To Ft. jYl;lees �fiYY( R.0 F on /o 1r1e'
13. GROUT: Depth Material Method nn nn
Fromm To, 0 Ft. e Lo"B 1T t/ r �0.w��Ys �rE'�K 6ZO oc roZ M-/NS
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material /UY/7 �� � Q✓/ � ) `r?� OQ(� /t
From To—FL—in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: �� L T Depth Size Material p U 1
From To Ft. /
From To Ft. -
16. REMARKS:
a
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE _ no
- o
0
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

'309479
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Naturartl:Resou�rc/es-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES/�(prinoJ c.L�tT ('fyA10 CERTIFICATION#1050
WELL CONTRACTOR COMPANY NAME_Li-T0.nl_/y! 1.40/1 Jr '10V PHONE # 9.&)Y79-fr45 tf
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box):Residential N Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ if Other,List Use
2. WELL LOCATI N: Topographic/Land setting
Nearest Town: .tV+'l/ County_(- .�Iam ❑Ridge ❑Slope ❑Valley ❑Flat
�O/.✓�+^ S T h 25�771 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �'{7rvr��nr / n ��
-- — e (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographicmap
Ro (Street or Rowe No.) (check box)
Nl a i-77% DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Description
e2fr) v79- a f�6Y
Area code-Phone number
4. DATE DRILLED J-
5. TOTAL DEPTH: 330
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO O
7. STATIC WATER LEVEL Below Top of Casing: -50 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1_FT.Above Land Surface* 1
-Top of casing terminated atior below land surface requires a Ln
variance in accordance with 15A NCAC 2C.0118. CD
[-
9. YIELD(gpm):/—METHOD OF TEST ci,,r
10. WATER ZONES(depth): Z�0
LOCATION SKETCH
11. DISINFECTION:Type Amount 0,,SO 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 tubers and common road names.
Fromm Tom_FL 6- gnr n
rM Less_ T rDo y>7 r y3 d- ;Zrs /rn kl' 02-a s Cr 0
From To Ft. n ✓
From To F[. o2,+�f /)'/ /'/4-.f 7Urn /e 7-On ,
13. GROUT: Depth Material Fromm To--Q,tZ FL MPtI fo GtJc r S' Teoc,CA G-O . 0,
CN 9r1PN T 'From To Ft. Tt/Yr'! /,�17h 7- IU G✓CNr S TivoaCh Go
14. SCREEN: Depth Diameter Slot Size Material ', m //, PS T �.• s�Qy 7a
From—To—Ft.—in. in. G 7 /UYYI �e
From To Ft, in, in. T 7 GO . o2
15. SAND/GRAVEL PACK: /P n p /')l+'lNS T wNli
Depth Size Material O f) T
From To Ft.—
From—To—Ft.
a
16. REMARKS: -D
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ae- k- Y"zi P o
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE CII'
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

G_o 3 09 47 8
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural[jeso`rces- i rision of Water Quality-Groundwater Sectiio�n'c�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 7- CERTIFICATION#gy�O
WELL CONTRACTOR COMPANY NAME i t t PHONE # f5/.1Sr)1179-5:•45�f
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 LOCATION: Topographic/Land setting
Nearest Town: RdhbincV;// County YC ❑Ridge ❑Slope ❑Valley ❑Flat
,�11n -✓ C'r.o,-k D%77�_ (check appropriate box)
(bitreet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: k ZZ1 1AId O15 (degrees/minutes/seconds)
Address lru,�K G' Latitude/longitude source:❑GPS❑Topographic map
RII (Scree[a Route No.) (check box)
RLkl'1 511344 AIC Q g771 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(iz>")- !/Z2-2036
Area code-Phone number
4. DATE DRILLED a=,C,S-
5. TOTAL DEPTH: ei.tS— Q
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W
7. STATIC WATER LEVEL Below Top of Casing:—an_FT, .t
(Use"+"if Above Top of Casing) ::0
8. TOP OF CASING IS / FT.Above Land Surface"
-Top of casing terminated at(or below land surface requires a
variance in accordance with i5A NCAC 2C.6118.
9. YIELD(gpm):� METHOD OF TEST r lr
10. WATER ZONES(depth): /7_S_
LOCATION SKETCH
11. DISINFECTION:Type Amount n,3/ 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 nM,a'te'rial numbers and common road names.
Fromm To `�8 Ft. .pvc *!'oWi ,jLu�' �C�N �� lt �C'.5•
From To Ft. 1.
From To Ft. T�rl /�Y T Girl W/O&r %USkNaq NN.
13. GROUT: Depth Material nnMethod
o To QQF[. mAax 'd. �� TGo 6,7mtI S 7(
h r
From Ft. '�PS L /0 1/U✓I
14. SCRE DeEN: Depth Diameter Slot Size Material �� • U'
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. - x=
From To Ft. 2v
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
Z �-p '6w e) 3-/ -o S"
SIGNATURE OP 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

309477
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Q Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME �(print)�)N '1' �j Y P CERTIFICATION#. 0.s-1J
WELL CONTRACTOR COMPANY NAME GreAh6,n2 t�N� `fa PHONE # (Sr2kL) 79-k�A—ef
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 0 Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: ' S iZ ZI—lel County ❑Ridge ❑Slope ❑Valley ❑Flat
a a-771 — (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)Address Latitude/longitude source:❑GPS❑Topographic map
(� (Street or Route No.) (check box)
1Y/) r`ns�/lP h; ;1�]7/ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number _
4. DATE DRILLED 3^
5. TOTAL DEPTH:_ d5,u
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W
7. STATIC WATER LEVEL Below Top of Casing:SOFT.
(Use"V'if Above Top of Casing) -
8. TOP OF CASING IS_.__L_FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): .3ej METHOD OF TEST CS.
10. WATER ZONES(depth): 206
LOCATION SKETCH
11. DISINFECTION:Type ff Tye_ Amount ry,sy 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 n mbers and common road names.
From
--CLTo /O/ FL-4 _ K171!2.11 Pvc rOm =7rtT /113
From To Ft.
From To FL ls0 s 7 M "INS %UT/1 AF3 T d✓1
13. GROUT: Depth Material Method
From V
�_To_0_FL Ceyrncn'T pu t'no �PCf' TIJS��C-'�OQEE cj-O
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material r ? /E' TQn SOvTb ;orFC,
From To Ft. in. in. /,
From To Ft. in. in. G-O,
G.Srh , INS Tura lei G°a
15. SAND/GRAVEL PACK: I _
Depth Size Material IQ 7O10 Q -}, Ar Ve
From To Ft. 1
From To Ft. - -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL - 0
p
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER =tI S
SIGNATURE OF PERSON'CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Rateigh,=NC,
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 0712001

310943
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Div sion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)s�t �- tL'// I / CERTIFICATION# �Y
WELL CON"1'RAC'fOR COMPANY NAMEILrfTll jA 1, 1'll/PHONE # ��sa V79-Sr�I rS"y
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) --
1. WELL USE(Check Applicable Box): Residential 1$ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ IPOther,List Use
2, WELL LOCATI N: /� + Topographic/Land setting
Nearest Town: r County (rM.hr+ Yrr ❑Ridge ❑Slope []Valley ❑Flat
r , (check appropriate box)
( Creel Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ssnw halco (degrees/minutes/smonds)
Address N iAAlG/ ! j-&6'l( Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
)S7'7 f DEPTH DRILLING LOG
From To Formation Description
h City or Town State Zip Code
41 )-%iQ—lam/
Area code-Phone number
4. DATE DRILLED 4V=19-CLS
5. TOTAL DEPTH: /910
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT. -fa
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' .
'Top of casing terminated at/or below land surface requires a
a
variance in accordance with 15A NCAC 2C.0118. O C
9. YIELD(gpm):/—METHOD OF TEST C 4"if
10.WATER ZONES(depth): /(0d LOCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type Amount a$ two State Roads or County Roads.Include the road
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To _Ft. - — — rorHN Gc�
From To Ft. T •-�G'i,/� lQ kh•r 0rl yell
From To Ft. '
13. GROUT: Depth Material Method
From___O. To 9�0 _Ft- CeJIIGar'T c.re-e i Rd Gel 5 M"Ies' 70 hUc'Se
From To Ft. �y h ! Gt/ bb M(3 Lis(°',
14. SCREEN: Depth Diameter Slot Size Material On le &// 10ec,(y
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material --
From To FL
From To FL
_ 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 PERS(,)rrCO&STRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
GW-I REV.07/2001
27699-1636 Phone No.[phone],within 30 days. -

� 1Q942
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resource Qivvision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Il � ) _ CERTIFICATION#
WELL CONTRACTOR COMPANY NAME_)^P YY! ""eid PHONE # &,JXAr174'fr_RSZr
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential 0 Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County 6 eaJJi h ❑Ridge Mope ❑Valley ❑Flat
v,aw S/ c ire4 C R as;
771 (check appropriate box)
( reet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: I (degrees/minutes/smonds)
Address t ,'� f Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No (check box)
�IfYI /rl�iNt R�, %`77 J DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(727)
Area code-Phone number
4. DATE DRILLED y!!J;7 "0 5l '"ru
5. TOTAL DEPTH: ` el,l- a'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO R c
7. STATIC WATER LEVEL Below Top of Casing:—&> FT. r
(Use"+"if Above Top of Casing) ,
8. TOP OF CASING IS FT.Above Land Surface` r
-Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. t -
9. YIELD(gpm): QO _ METHOD OF TEST fL:r
10. WATER ZONES(depth): /`,Z•$�
LOCATION SKETCH
11. DISINFECTION:Type�[f T.�f Amount 6 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_To=& Ft. 60ral_ "A!',m Zn i 4,9 � l Y 3 -) Ke 1029 �
From To Ft. /
From To Ft. 6• o � M""le TL,rn �&�� Ct�
13. GROUT: Depth Material Method I
From L) To ) Ft. t.MQZy2B \IellD4J cre' lc /F�
�— it1-s-17'T r o� ) �
From To Ft. 71 le-'A ( 6a /d
�i c�
14. SCREEN: Depth Diameter Slot Size Material Y'i'1
From To Ft. in. in.
From To Ft. in. in. AC CL"6)11 Cn
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 BEEN PROVIDED TO THE WELL OWNER o
A (�e I �
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE ; t
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC -- -
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.0712001

41
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural
Resources-Its}ivision of Water Quality-Groundwater Sectiio"n�,�"'
WELL CONTRACTOR(INDIVIDUAL)NAME (print) - f r r�p p CERTIFICATION#�
WELL CONTRACTOR COMPANY NAME 6r i,�`'Ill Yrt (.t:/P/I p-4l" l I�l i'1�PHONE # (G'Si) t/7�/•kY7"I
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 50 Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
Nearest Town: t• County 6- ahckj'n ❑Ridge ❑Slope ❑Valley ❑Flat
Via a.�;fitLJ b @,,!jt77 / (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/smonds)
Address 0J6 A p•+t• b [ids ' t Latitude/longitude source:❑GPS❑Topographic map
(Street or Ronte No.) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Cam)-YzYSeS2
Area code-Phone number
4. DATE DRILLED - z1C
5. TOTAL DEPTH: Z)
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A 1
7. STATIC WATER LEVEL Below Top of Casing: FT. 1
(Use"V'if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface* €'
`Top of casing terminated at/or below land surface requires a U1
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_JS _METHOD OF TEST C& N
10. WATER ZONES(depth): C16
LOCATION SKETCH
11. DISINFECTION:Type Amount T i(e 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. �M�atte�riial numbers and common road names. at n y' I
Fromm To�_Ft. �c�:-t— -Pee P7 yr7T /9/3 ,oL faG / �f�e I99
From To FL t II__
From To FL �r(1 Jt5r1 /�?It�f'S %Ui'✓I 8,l�I) col
13. GROUT: Depth Material Method
j 6' 0 4- yn v
From_�_To�FL�=mA_,__^n_T_ 1ti`)E�.At71•L> b!^W2t. I Es
From To Ft. 11 � /
14. SCREEN: Depth Diameter Slot Size Material 4TU!')'l ] {l /— C7n mGGl1 — Vl—,411 6)f ki
From To Ft. in. in. `
From To Ft. in. in. T 001 6-Cl Cas CK) up
15. SAND/GRAVEL PACK: t
Depth Size Material O 0r
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4 - 26< 4b5
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.07/20ff'

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 1, 10749
WELL CONTRACTOR(INDIVIDUAL)NAME (prfnt) WILLIAM BRADLEY LEWIS CERTIFICATION 03368
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING PRONE to [phone]
STATE WELL CONSTRUCTION PERMITH ASSOCIATED WQ PERMITO
if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water njection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: ROBBINSVILLE County GRAHAM Ridge ❑Slope ❑Valley ❑Flat
JACK BRANCH (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: MARVIN 6 ANGIE LEQUIRE (degrees/minutes/seconds)
Address P.O.BOX2225 Latitudcpongitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
ROBBINSVILLE NC 28771 DEPTH DRILLING LOG
City or Town State Zip code From TO Formation Description
8( 28 )- 735-0400 0'TO 20' BROWN SLATE
Area code-Phone number 20'TO 40' BLUE SLATE
4. DATE DRILLED 04/18/2005 40'TO 605' SLATE
5. TOTAL DEPTH: 605'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 500 FT.
(Use"+"if Above Top of Casing) n
8. TOP OF CASING IS i FT.Above Land Surface* 0•Tap or casing terminated at/or below land surface requires a 3 variance In accordance with 15A NCAC 2C.011S.
9. YIELD(gpm): 1/3 METHOD OF TEST AIR
10. WATER ZONES(depth): i
LOCATION SKETCH
-
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles fro least
12. CASING: Wall Thickness two State Roads or County Roads. IncludeMe roq
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 40 Ft. 61/8- SDR 21 PVC
From To Ft.
From To FL
13. GROUT: Depth Material Method �
From 0 To 20 Ft.CEMENT GRAVITY 7�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To FL in. in. _ �—
From To Ft.—mi . in.
15. SAND/GRAVEL PACK: 3 G\
Depth Size Material Z
From To Ft. z'Ka
Fmm To FL -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THA C OF THIS RECORD EEN PR DED TO THE WELL OWNER
\ /�-QS—
SIGNA OF PERSON CONSTRUCTING LL 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

J�C
WELL CONSTRUCTION RECORD U 310748
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) WILLIAM BRADLEY LEWIS CERTIFICATION 3368
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # (dJY)837-8008
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 n)ection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 57gCOAI{ County GRAHAM /idge ❑Slope ❑Valley ❑Flat
UPPER TUSKEEGEE-SAM'S COVE (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER: MARCUS WALLACE (degrees/minutes/seconds)
Address P.O.BOX 115 Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
(, #L"KAF GA 30183 DEPTH DRILLING LOG
City or Town State Zip Code From TO Formation Description
( 0-833-4785 O'TO 20' BROWN DIRT
Area code-Phone number 20'TO 60' RED SANDSTONE
4. DATE DRILLED 04/13/2005 60'TO 80' GRANITE ^;I
5. TOTAL DEPTH: 485' �( 80'TO 485' GRANITE Y?
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A
7. STATIC WATER LEVEL Below Top of Casing: 100 FT. :%
(Use"+"if Above Top of Casing) �C 7
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance In accordance with 15A 2C.0118.
9. YIELD(gpm): 13 METHOD OF TEST AIR
10.WATER ZONES (depth): LOCATION SKETCH
11. DISINFECTION:Type CLORINE 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 dames.
From 0 To 80 Ft. 6 1/8" SDR 21 PVC
From To Ft.
m
Fro To Ft. �
13. GROUT: Depth Material Method 1.
From 0 To 20 Ft.CEMENT GRAVITY �)
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material :a a{
From To Ft. in. in. G�0
From To Ft. in. in.
15. SAND/GRAVEL PACK: /
Depth Size Material `C
From To Ft.
From To FL
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 B N PROVIDED TO THE WELL OWNER
-C15
SIGNATURE OF PERSON CONSIRU IN THE WELL DATE
i
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

lJ I' --✓__.. II II NI 1! _._—_ .. _. �\y1 f/\I�J UII
WELL CONSTRUCTION RECORD
IJolllI Ca101ina -Drpalinlcnl of Fliviruumcul and NI11,I�(I(csoinccs-Division of Wnlcr Qunlily-0"""'Valcr SccGon
IVEI.I,CON T IIACIIrIt phut V11rl1AL)NAMce- _-- 'CFnnf ICA LION n=Z-WA
rNUNr, n
IN Elf,CW41 RACI OR C(iNwANI'NAnIF,_
SIAIF,II-F.LI,CONS I IInCIlON I'F.Ilhll fM— —.—__— ASSIICIA I FI11V1)1•F,IIMI I It
if n , dicnhlc
I. ttWpl 1, USE (CIIrcV, Applicnble Ilox) Rcsidrmi:d Ll�pkill icipal/Publit: U IoJu.^,hint (J Agticullulal U
plooiloling❑ I(ccovcly lJ I Ical Pump Rana Injccliml U Ulhel (A If Ulhcr,List
2. --
Topogrnpilic i.mid selling
Wcalrslfuln:- /WiJ /� --(boWy UlUdge lISlupc CJVallcy 1J La1
(dlnk npp,ap,inle hr,.)
--- -- '- ' Lnlihulc/lon lludc of well location
($heel Nnnrc,Ihnnhnr,Cununm,ily SnbJivition,gal Nn.,lip � 6',.�
/ was°14 .f),o �✓aFs' �f6'/z./
3. ! ?J /�)(kG�e� (dcglecn/u,inuLdtrrrn,•1.)
Latitude/IungiluJc somcc:Cl(iP5171'upoglnpbic111a1)
(1,, ret(1l it,I to tin.)
z"Zr1. -- - - - - )�eeu� uluillDe Lul
Flom To founalionUcsclipliou
City o,7 u.an $lair lip loge
Arrn ndr- 1'Invm nombn ��_Cf�
d, IIAIE DIi II,I I°.II—� — (T/'i�A/. —
(. DUES \\'I°.1,1, Itl?I`I,At'I'. I°XISIIIJU \VI'L.IJ VEST 140 la- —
7. SI"ATICWAII;RLIiVI:LIIciow'1'opoIfAt... I'll_O__.- -I'I'. -- —
/ (lL.r"°'•IfALnvrlr,pall'n•.inP) —_--.'C-'i----.
I.nml Sul Flcc*
•-1 r•p rl[nlny,In l,Jnnlrrl nlhn'Lrinv irnd an we Inprhrr°
♦A,bare In [rrn du,te nhh 15A NCAC IC•1111 fl.
9. 1•11:1.0 (plan): _—G.__— p1I I II0D UP•I FS l'-�'/- —
10. WA I ER 7,OIJfS(del,fll).
If. UISILJI'h,Cf1UW:lppc i� � Am,,,,ld__`Pc ;� Sllowdilecliunauddlslnllcc
7 lllll,ilc9fl Inl . ;I
\V:dl'Ihickucn Iwo Stile I(onds or Comely Roads. Include IIIrl nd
12. CASING: nuulbcta and cotonlun road namm
I,rplh L)inulcicr or ticll;hVPt. Aln`rlal
13. OROU1: Depth Ain un lclhad
14. SCILI'L•PI: Drplll Diameter SIOSirc fvinlclinl
---
IS, S,\f,1P!0RAVFI, PACK:
UrpII, Sire hhdclinl - i
------
Ihol❑ -------
11;. ItEM All IS:
— —_— —
11?U I IFl;flll'( fl!I IPY 1IIAl' Jill!;1VP(.I,\VAS('O11SI1111C1ItU IN ACCURUAIJCIi WI111 15A NCAC 217•\I✓ELI,
CONS I MCI WIN STANDARDS,A14D*11IA1'A COPY Of 1I IN RECORD HAS DUN PROVIDED"I O 1UE WELL 0%V1IER
SIOIJA�I111 zW UP 1,17ASM C014SIRUCIINO 111E WELL DA'I11
Sul,luil (fir of 1gln•d In life Dh itlon of Wife] (Luality,Cluundlvnle, Section, Iele Almsservice C(,`�ri i;iwgii,ric 1I

WELL CONSTRUCTION RECORD 0 3 1 1316
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRAC'fOR(INDtVIDUAL)NAME (print) WILLIAM BRADLEYLEWIS CERTIFICATION N 3368
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. pIIONE # (eM 837-8008
STATE WELL CONSTRUCTION PERMrrN ASSOCIATED WQ PERMIT# - ------ - ---- - -
(if applicable) (if applicable) r
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural❑ ' f
Monitoring❑ Recovery ❑ Heat Pump Water nlection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Topographic/Land settin
Nearest Town: 5Tec-oAH County GRAHAM 4idge ❑Slope ❑Valley �1F141 I ---
UPPER TUSKEEGEE-SAM'S COVE / (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location _ 1;
3. OWNER: MARCUS WALLACE (degrees/minutes/seconds) _ J J I
Address P.O.Box 115 Latitude/longitude source:❑GPS❑Topographic map--- _
(Street or Route No.) (check box)
W#LE.SY-.14' GA 30183 DEPTH DRILLING LOG From To Formation Description
VL>CD�lOv1 home r tl 0'TO 20' BROWN DIRT
20'TO 60' RED SANDSTONE
4. 60'TO 80' GRANITE
5. CI'b161 W1 CO /.C �( 80'TO 485' GRANITE
6. ❑ NOA
7. ) FT. 3
Casing)
$. home c J I r e5, unface* f
w
9. o i��'
10.1 IPp)6,f� �j
it. `"'a`e''' ` j GAI 0 PPM LOCATION SKETCH
O�8 -7 Show direction and distance in miles from at least
12. / J ss two State Roads or County Roads. Include the road
(J— 1{7q- 3 9 og lj1} L. Material numbers and common road names.
PVC
1 Yu
13. GROUT: Depth t� Material Medtod L
From 0 To 20 Ft.CEMENT GRAVITY rJ
From To Ft. c�
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in. l704-
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 B N PROVIDED TOO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUrCrTHE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mall Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD 3
i 5 4 7
North Carolina- Department of Environment and Natural Res roes--'D//ivit ion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �C�'P��d�P CERTIFICATION#
WELL CONTRACTOR COMPANY NAME C7-1CL AY✓/ (A)& lei^ `IL Al PHONE #Ok
(X'.�SdN7Y'S'�JSy
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential K Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Ne e tTown: / County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Co(tmunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (3-N (degrees/minutes/seconds)
Address ,rY+d a Latitude/longitude source:❑GPS❑Topographic map
�Q�/ L (Street or Ro to No.) r'1 (check box)
j Y)511 r JIP `Q2 i-77/ DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Descripti
Area code-Phone number
4. DATE DRILLED
5. TOTALDEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO IS
7. STATIC WATER LEVEL Below Top of Casing:-j(06-17T.
(Use"+"if Above Top of Casing) O
8. TOP OF CASING IS / FT.Above Land Surface'
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): /a METHOD OF TEST Gam, r
10. WATER ZONES(depth): 11
LOCATION SKETCH
11. DISINFECTION:Type Amount ..p 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 ny�hers and common road names.
From G> To--? Ft.-G�-L� St?r i11 ..JOVC ,I-y�rM y77-
/I� p
From To Ft. 4/3 /Z~"`,� ` y3
From To Ft.
13. GROUT: Depth Material Method m' wrn
From__ D­To 9.6 Ft.tJy&err pumTDL?22 ff�v/� ��
s t Go. o,/
From To Ft. P m, lE /G Y✓t
14. SCREEN: Depth Diameter Slot Size Material q
From To Ft. in. in. OL jp t,-le'( Q n letr
,
From To Ft. in. in. -
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. MAR 21 2005
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC'2C;WEL'Lt Iti`%iJiJrO a-H;1[
CONSTRUCTION STANDARDS,AND THAT A COPY'OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PER ON 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

� � g548
WELL CONSTRUCTION RECORD 1
North Carolina-Department of Environment and Natural /Resources-I Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) tl�T'F ZA—/- CERTIFICATION# oyi2
WELL CONTRACTOR COMPANY NAME tt-)C� M L✓N// Ari 46/96 PHONE # 6 2y/7y7-5'S�Sy
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential W Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N Topographic/Land setting
Nearest Town: County :r %N t Yv/ ❑Ridge ❑Slope ❑Valley ❑Flat
L Dfl&r Ti 4 _N IS-77/ (check appropriate box)
(Str�ne,NumbeNumbe ,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Q Ve",, Pd5e y (degrees/minutes/smonds)
Address Latitude/longitude source:❑GPS❑Topographic map
j� I (Sweet or Route o. (check box)
L 'pAb,n5lr,'Ihl A//-- 2S-77/ DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Descript
C2)- 'Y
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: -aS 1_ .
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Z m s
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 terminated at/or below land surface requires a _
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 1 METHOD OF TEST a,'r
10.WATER ZONES(depth): 9 90
LOCATION SKETCH
11. DISINFECTION:Type Amount Q,ql' 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_To—_FL-6-�_ $p r 31 1/L Tf0%''7 7Tyl 1 /'i3 � �,�j' �p(,kL s
From To Ft. r
From To Ft. �L c,7 Mt Ies 7-Vrh lef / (
13. GROUT: Depth Material { Method _
From =Q_Toe) Ft. G h Yne�PIT 1?sL-e,212;kn a n Upper /USI((F��C� GO , 0.p',M� �P
From To Ft. / (-_ _
14. SCREEN: Depth Diameter Slot Size Material l L r n (�1' /O d v 5 Wcj l I
From To Ft. in. in. i /
From To Ft. in. in. -
15. SAND/GRAVEL PACK: C7 "
Depth Size Material
From To Ft.From To Ft. MAR 21 2005
16. REMARKS:
i, IlAli iF ' til.L'lifl'.
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
J1 2-PP !41/A P 7- - 7-05
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

308519
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resour esr Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME ((print) - . ) CERTIFICATION#,ZOr
WELL CONTRACTOR COMPANY NAME l?-YGYH L..I� / .,�[.rj? PHONE # 1$2tW7S�&S4Stf
STATE WELL CONSTRUCTION PERMIT#(if applicable) ASSOCIATED WQ PERMIT#
(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 LOCAT N
Nearest own: ; Topographic/Land setting
J' County �iQy�y ❑Ridge ❑Slope []Valley ❑Flat
_�eLUlrr rK ffF1��3 T .Z '77/ (check appropriate box)
(Street Name,Numbers,Comm ity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: —07h Tank2viS
Address bJ'01TCr-4f1f }l 9hT (degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
t (Street or Route o.) (check box)
brn Vr//F NG 12?77/ DEPTH DRILLING LOG
City or Town State Zip Code From TO
U&)-SL29- 3007 Fo oration Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: 2SS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9
7. STATIC WATER LEVEL Below Top of Casing: FT 1
g �0 FT.
(Use(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface* T t
`Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 20 METHOD OF TEST 0.?r Co t`a
10. WATER ZONES(depth): / 76' o
LOCATION SKETCH
11. DISINFECTION:Type Amount 0.3/ Show direction and distance in miles from at least ��jj
12. CASING: Wall Thickness two State Roads or County Roads. Include the roaA
Depth Diameter or Weight/Ft. Material nu hers and common road names.
From_ToNO FLfy_4_ Sn YAI VC
From To F[. ro r.y a1 man cS Ta.-y O✓1
From To Ft. �2 S G U /y/r tl�, Td r/1
13. GROUT: Depth Material Method
From_To_.LQ._Ft. C.NmdrH'T �� 1�j'I T a r) W u?It` G 1"e-r 1�( {� tog h T
From To FL 1�
14. SCREEN: Depth Diameter Slot Size Material GU !)
From To Ft. in. in. t oL dtt h,T.
From To Ft. in. in. t rST /?Of/SN c�Yl R
15. SAND/GRAVEL PACK: " ,(�/Z
Depth Size Material t &11 en l�bT
From tom'To Ft.- - • � L 1"J L,
From To FL
16. REMARKS: MAR 2 1 2
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 WILL OWNER
�.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

nr , 30 � 5 ? 0
,V
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural R ourcees/-Division of Water Quality-Groundwater Section
';
WELL CONTRACTOR(INDIVIDUAL)NAME. (print) 11 L�PP y e CERTIFICATION#�,
WELL CONTRACTOR COMPANY NAME ��-rc l-lam Wed Ar 'A'11 Cf PHONE # �g)N7In-S%4t5Z}
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential N Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N
Nearest Town: 0 t?7 '/�B Topographic/Land setting
County ❑Ridge ❑Slope ❑Valley ❑Flat
_ �/-)WBI^ Tusk ty A 77/ (check appropriate box)
(Street Name,Numbers,Commurl t Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: &r►'V S1r7iTh y (degrees/minutes/smonds)
Address '""k 1AW'Qr Tf!5.[3J°.&a6,1 Latitude/longitude source:❑GPS❑Topographiemap
fib'nS
(Street or Route No.) (check box)
L/,/!e r1$ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Descriptia
(12ld- 41Z2- Sri/O
Area code-Phone number
4. DATE DRILLED-2 -//-OrC-
W
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:1(�r _FT.
(Use"+'•if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surfaces
-Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. YIELD(gpm): 3 METHOD OF TEST. O.i r
10. WATER ZONES(depth): 3 SS
LOCATION SKETCH
It. DISINFECTION:Type Amotmt B . 63 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 rt bers and common road names.
From�To�l�Ft.� G ra. Ayc --�N
From To Ft. rom 17 ��� ly3
From To Ft. N Ga oC r 7 W leo T r n
13. GROUT: Depth - Material Method p
From To- a-Q FL. C=&MeinT y✓/ �` /`} f h7- o n >�W do -rV 5 keeRee
From To Ft. G•O /, q/yJ�'/�'s' Turn 1N><`T
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. -T
From To Ft. in. in. ' 0' rn't7F's /O 10rttV&t�Woy
15. SAND/GRAVEL PACK: y) tic }i7 (�p 7a T� d y h
Depth Size Material W E?l I
From To Ft. 0.T 6acR O lO T,
From To FL
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'
N f S
c-/4�a
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE =.^=
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,t}Q ,
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/1041 -

,/ nnrrrlr r:"` nun
w110j, CVNs'I'ItUCTION RECOM
IJotlh C:IIit n - Urpnll Ile III of linvitowucut and N1111nn1 Rcsuut)ccs- Uivisiuu of Wnlcr Qunlily- 17 ollil snlet Sccl it)n
ri! /(eei cennncnuurin
t\FIJ,CON IItACI I)it IINIIIy11,11A 1.)N,\IIi F. (pr lnly
ruullr, It1_1 --
WF1.I.CONIIL(l llllt Cllpi('ANY Nnallc___ —. . -------------------
ASSOCIA I FI)W o PERRII IN
S IAIF.tyFLL ChNSIItnCIIUN I'EIta111tl_ -_____-_-------- ilnrdicalrlc
1, l)SI' (l'hnk Applir:ddc llos) ltcsidrulial 1-1�t\lunicipal/Public LI ludushinl 1.7 AI'.licuhm:d CJ
rAvililot illy.I_I Ilcumilly L.I I Ic:d hillip W:IIrr Injrclnnl U ulhrt FI If Olbcr,Lisl I1sc____--__.---------
Neal eel I oa'nt �/' �/e // Topugnpllicli
1_IlUdge Iu1,e2, I ln'AlI ( ull} a ai S I_IVa lslcrlyl in)Lt
lllall (
(rh<rk npprrgnlme h•,•)
LnliluddlongiludcOF NMI (Death 1i
(Sort(llnnre,Nvrnbrr ,lnun
r nitn) Cul LnSion,, dIL,.,•.ip( nlr) •i/3/• W �' 0S. __
q sr�e;7e- �jo C1Cl 1/_I ,I (Tl.prtrJminul••'econnl•) _
lalihungiludc suwcc:Ll(il'SI_ll'opoq;lapbic twill
k/lo
Addlcss 5N05.._LtS_ _Nu^X-1.4-------- (r,r.< N")
1. (Su.rttnF...Ile11 ) l)Ll Uj U�III.I,l1113_Lul;
-- gr XI�I _N�_ z ��..J. . _-_.------ .ly, Fonunliou Ucscripliou <
a - YpC,.Je flout
t'it,l(nun Srnlr .--
Airn rnl
loIA
G. I)ol)s V.'F.IJ, RITLA('11 UNISIIII"\Vl'1.1,7 1'Ps LI NO U� _ y
7. S I AIIC R'At Fit I.I?VI:L 11cloll of('aeinl;: �... __Fl• -- —
nnrl,,,of1'n•in � '-
S. IT OI" CAS I I'll 7 IS-_f�L_-___ F('. Al lvc (.nod Sulluce'
O
•l vp or..Any Irnnln+IeJ nl/^r LAov End ran tort,rgnh rr•
.n,Irnrr In ,1•nre null, INA NCAC Witt IF, ----
o. Nil;111uU ul)'ll?Sl'_ -----
10. }VAI F,It ZUIJFS(dcpll):
- - Sboty dilection and distance in Il
l)"'orn ill lead
11. UIS1I11'P.0 1 IUN:13 pc / TA ---Anonnd _ �I�` hvo Stale Bonds or Connty Itonds. Include tle road
12. CASINO: \Volt Ihickncss
I)•ptl1 Uimncler of WcighVl°I. Nnlerial numbers mtd cvuunult road nnnlm
FII'1"--- '" ---
Il pill
_ 'rt�- FI------ --- -------
61n1r1 i:d Iclhud i
I1. 171iulll0 T„ I
II
lioln
1'toln_- fill.
_&li) LcZ, --
14. SCIII'F11: I)rplh Dinmcicr :ilulSizc Mall _
Flom 10--171. in. _ in. --- - - -
f1. iu. is `1
fo -------- ----- ) --- r ,
15. SAt,11110RAVITVACI:: 1
I)rpU, time hlnlcl inl -
_' JUN 2 10I ' L'
Lt, Pt• ------ p _ i
16. RHAARKS: — - - --- - ---
1 00 III'1'.1'lll'CPP,IIII"1IIAl"I IIIS NPl,l,1VAS('OIISI IIIICII'.D III ACC(IRUAIICh 1Vf111 15A IICAC 217,tVl;l.l.
IONS I ItUCI IUN s rANUAIIDS,ANU'IIIAI'A COPYUF'fI11S Itl?CUIIU IIAS BEEN PROVIDED TO111C NVI9.L UV;I IIiR
--- ----- SiGHAi(11M1) 11I!RSONCUIJS71tUl:I1NU f111?WI?LI, UA'll.
) nliq Ynlc Sccllml, IL1(plot(Scnicc(- r
Snbmil Ilu nu Il;lnd In the Ilhisluo o 1ar C ('`Vl I(I IV'1117!?II01
'•L"" I,;t. 1'lr.�ry Ph•.('!l")';)t t••I,nI16L1 'q d��t'�.

�.J- � � ! j WELL CONSTRUCTION RECORD '
North Carolina-Department of Environment and Natural Resources-D P CERTIFICATION#�_ivision of Water Quality-Groundwater Section '
F� d
WELL CONTRACTOR(INDIVIDUAL)NAME (print) � q 1
WELL CONTRACTOR COMPANY NAMES Y
R4-�j,'�y) '�,Sf j 1"f /f I hg PHONE # (V�SZS1 Z1
STATE WELL ASSOCIATED WQ PERMIT#
CONSTRUCTION PERMIT# A (if applicable)
(if applicable)
I. WELL USE(Check Applicable Box): Residential R Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W ELL LOCAT N n Topographic/Land setting
Nearest Town:
� County Ire ❑Ridge ❑Slope ❑Valley ❑Flat
fZE/)'T 7.nY t'reelt (check appropriate box)
-k Latitude/longitude of well location
(Scree Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
n` - i1Nr /�In5 (degrees/minutes/seconds)
3. OWNER:�y N yA�� r.eo/l Latitude/longitude source:❑GPS❑Topographic map
Address o rr (check box)
(Street or Route No.)ROL6 o 977/ DEPTH DRILLING LOG
r`��t � t From To Formation Description
City or Town Stato e Zip Code
(.q�L)- VS:G — 973.5_
Area code-Phone number
4. DATE DRILLED - Q
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO X
7. STATIC WATER LEVEL Below Top of Casing: IdO _F!.
(Use'•+-if Above Top of Casing) ti'"•
8. TOP OF CASING IS FT.Above Land Surface* G
*Top of casing terminated aHor below land surface requires a rn
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST 6,1 Y N
10.WATER ZONES(depth): SS —�
LOCATION SKETCH cP
11. DISINFECTION:Type Amount h�Q( Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
n tubers and common to names. r
Depth Dia eter or WeighUFt. Material r 5�'Yl t d S
From O To �d7 Ft. i �e �7dM G�mdn PC C d 3
From To Ft• pn rwy O N / j/7 t? yr up/ p<Qr
From To FL
13. GROUT: Depth Material Method i9anThe'r C.YEG'I` RA 6r0 b3 Me*,
From_O _To_JQ_Ft. Ce min 7 PGA /7 / `"
From To FL .� ,Ld. T Ga L"/ Jet '�B 7O U✓G��
14. SCREEN: Depth Diameter Slot Size Material ellw
From To FL—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 BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL r, r - DATE
Submit the original to the Division of Water Quality,Gropindwater Section 1636 Mi'ifgi F e iiLtenter-Raleigh,NC
27699-1636 Phone No.(9I9)733-3221,within 30 days.
GW-1 REV.07/2001

i
WELL CONSTRUCTION RECORDOk
"
North Carolina- Department of Environment and Natura ResourcPPP��� Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i 6V, CERTIFICATION#r
WELL CONTRACTOR COMPANY NAME rre - / 9I rlrvljf v PHONE # (f�QS)(/7S�SYS�li
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential ® Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N Topographic/Land setting
Near slt Town: County rrt*"a 'l� ❑Ridge ❑Slope ❑Valley ❑Flat
0.e T(dn R A2V77{ (check appropriate box)
(SI eet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 13,or V/ C_")!q (degrees/minuies/secomis)
Address I& Latitude/longitude source:❑GPS❑Topographic map
r
pp II (Street or Route No.) (check box)
/VC aS771 DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED G -- 2V-v 5' ,
5. TOTAL DEPTH:�9O S- S4
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO K i
7. STATIC WATER LEVEL Below Top of Casing: go FT. >' {
(Use"+"if Above Top of Casing) 1
8. TOP OF CASING IS I _FT.Above Land Surface"
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. 4JL
9. YIELD(gpm):c,y!METHOD OF TEST Q.f r
10.WATER ZONES(depth): /gD
LOCATION SKETCH
11. DISINFECTION:Type Amount r1.32 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 to name . , f T
From
To�`L Ft.y-! Sbra1 !�- �rdm 0.jmpn () Tvirn Rf�gh
From To Ft. /� p .T
From To Ft. d O, 3 r/) ,�Ie5 71) E
13. GROUT: Depth Material Method
From 0 TO-Ft. Ce MEn7 Pu mA n� %Qd G v Qr 1 yn, �(✓ 7e.1- JAJell
From To FL 14. SCREEN: Depth Diameter Slot Size Material Q n JLC T
From To Ft. in. in. t
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 I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER/
SIGNATUR9 OF PERSON CONSTROCTING,TH8 WELL 1 --,' DATE
Submit the original to the Division of Water Quality,Gro iu!W.ater Section,1636 Mail Seryide dpater-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. - GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Reesourc s-Division of Water Quality-Groundwater Section
.���
WELL CONTRACTOR(INDIVIDUAL)NAM/r(print)
,10 Fd CERTIFICATION# Q�-
WELL CONTRACTOR COMPANY NAME,S]'NA l)Ct 199 fAIErII t1� Y]6 _PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable) _
1. WELL USE(Check Applicable Box): Residential §4 Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N Topographic/Land setting
Nearest Town County �TY�yA ❑Ridge ❑Slope ❑Valley ❑Flat
N/A sn r nth R �1 7 7 1 (check appropriate box)
(Street Name,, /7/Numbers,,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: triyr4 V e:j%k . (degrees/minutes/smonds)
Address "T L.L.rrrp r e Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�n�ntncYil/e /1/GUr]7/ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:, fD
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 10 c�
7. STATIC WATER LEVEL Below Top of Casing:, 1�0 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface'
'Top of casing terminated atlor below land surface requires a Cl
variance in accordance with 15A NCAC 2C.0119.
9. YIELD(gpm):J—METHOD OF TEST 0.i r
10. WATER ZONES(depth): 19d
LOCATION SKETCH
11. DISINFECTION:Type Amount r1-:34/ 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 n tubers and common road names. /�
FromSL To-[�Ft.�nT -K-2(- YOY1't �lYl01"I t� PO Cr 6 3,7 mi'ltos
From To Ft. � /9
From To Ft. /!/,-n d'T an T4ba,CO 6ranCA
13. GROUT: Depth Material Method /` n
From s, /y�_To�_Ft. 4pt77 P" �O 1 M,'lr, / m Ie T on UOUb'Cf
From To Ft. n ,ram
14. SCREEN: Depth Diameter Slot Size Material Srr�'b��q Ord Gd1i'ILp /L/'/t�
From To Ft. in. in.
From To Ft. in. in. » 1,47 Well on �.!�I �'"
15. SAND/GRAVEL PACK: v
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 BEEN PROVIDED TO THE WELL OWNER
t
SIGNATURE OF PERSON CON$TytU Lilfi7'H&WELD- 'PATE
Submit the original to the Division of Water Quality GroundWa ter Section,b636 Moil Servipe�GCnter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. �� G\V-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- ivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME�(print)- IV CERTIFICATION#.QaSD
WELL CONTRACTOR COMPANY NAME (TY WI / ' PHONE # (fr2K)479-Sy.C/�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential P6 Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: / f1' Countyp2 ❑Ridge ❑Slope ❑Valley ❑Flat
s�n h 12 San Cla- /[ `2Fr 77J (check appropriate box)
(Street Name,Numbers,Com tnum ty Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: ( i/l j --r-P LYl (degrees/minutes/smonds)
Address ;7. 456n r-J�J2 RA . Latitude/longitude source:❑GPS❑Topographicmap
11 (Street or Routs No.) (check box)
_iQe�h s' gU r AL, 2&771 DEPTH DRILLING LOG
Cityor Town State Zip Code From To Formation Description
( - N79r5119%
Area code-Phone number
4. DATE DRILLED (— 9,1 O�
5. TOTAL DEPTH: /7,5'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ®J G 4
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing) '
8. TOP OF CASING IS_�FT.Above Land Surface*
`Top of casing terminated at/or below land surface requires a ..�t
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):16 METHOD OF TEST e1 t'y 3
10. WATER ZONES(depth): //j
LOCATION SKETCH
11. DISINFECTION:Type Amount iL 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 umbers and common road names.
From To_P__ Ft. _ r d1 L— P p YN �h? 113 d-t Fs v hr sv o Gc�
From To Ft. �
From To Ft.
.-a kF PV3
13. GROUT: Depth Material Method
From�_To�_Ft. 6omony' /''rsT Jc�>�T
From To FL 7a well on ��� ;,
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. _
From To Ft. in. in.
15. SAND/GRAVEL PACK: , 1
Depth Size Material I
From To Ft.
From To Ft. - -
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
)�P-,J� /k P t1f)-ad -45
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD ��/►J
North Carolina-Department of Environment and Natural Resources- iv' ion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
(print) CERTIFICATION#A4as)
WELL CONTRACTOR COMPANY NAME lTr'dr. A)'Vl L✓�(,Y PHONE # (Sgri) -77- 't�sy
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 61 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N t " '' Topographic/Land setting
Nearest Town: r11L�Countyn�l��}.. �i^ ❑Ridge ❑Slope ❑Valley ❑Flat
aln7 r ( n .U-771 (check appropriate box)
(Street Name,Numbers,tommunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: f )xt// A -rhI (degrees/minutes/seconds)
Address CanTFr / .rJ_1 . Latitude/longitude source:❑GPS❑Topographic map
/ 1 (Street or RO le No.) (check box)
qd"t'Pts y, /Ie fVG 22-n/ DEPTH DRILLING LOG
Cityor Town state zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED &-l7- Oct_
5. TOTAL DEPTH: 72T 791
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1 -<
7. STATIC WATER LEVEL Below Top of Casing: JIrD FT. r 2
(Use"+"if Above Top of Casing) t "�
8. TOP OF CASING IS / FT.Above Land Surface'
`Top of casing terminated at/or below land surface requires a O
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):-1 METHOD OF TEST 6-i l-
10.WATER ZONES(depth): S-
LOCATION SKETCH
11. DISINFECTION:Type 46ny Amount t1,y9 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 umbers and common road(amen. y
From C�To Ft. $12C�1 �— /O M CA I�✓)O»A PO 6- �t / o0i)'Ie'
From To Ft rn / t 117' an GonTe G� RBI
From To Ft. &
13. GROUT: Depth Material
Method
From�To�_Ft Camn7P AuT�1 h -r4 ri
From To FL sTetaaah Rd Ga o,
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. ,� 'T p j7rr 5
From To Ft. in. in. �'0�
15. SAND/GRAVEL PACK: Cove 0t/ p jfs Tvrn Al�hT
Depth Size Material t ..�- 1BT 1✓&/1 on 47-
From To Ft. G</ O/ mI /B /�
From To__FL
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 P RSON CONST(tPC7ING THE WELD-_i ---OA7E
; r•, t
Submit the original to the Division of Water Quality,Groundlwa(ei•Section T636-W2irSrnc ef,_ (f r e� -Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. i C I I REV.07/2001
f

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 113(-� Al" 0 CERTIFICATION#�O
WELL CONTRACTOR COMPANY NAME CT I(�.Y1A.'yN L��a`�CJ d,J^t r n(�PHONE It f�j2,N01
79—�N.tk/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential R Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION-
/ Topographic/Land setting
Ne rest Town: t t County�ir��ra,�iI" ❑Ridge ❑Slope ❑Valley ❑Flat
r YI R t ai.`7 7/ (check appropriate box)
(Street Name,NumbettlZommunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/smonds)
Address Mine [E � Latitude/longitude source:❑GPS❑Topographic map
� II (Street or me No.) (check box)
Oh�etyf5 U,i//p A/C `-S17/ DEPTH DRILLING LOG
city or Town state Zip Code From To Formation Descriptio ,
ogig
Area code-Phone number
4. DATE DRILLED6I4/-4-
5. TOTAL DEPTH: N 3,o G
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 01 J
7. STATIC WATER LEVEL Below Top of Casing:—4-0FT.
(Use"+"if Above Top of Casing) r n S. TOP OF CASING IS / FT.Above Land Surface*
'Tap of casing terminated at/or below land surface requires a a;a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): aL O METHOD OF TEST
10.WATER ZONES(depth): 370
LOCATION SKETCH
11. DISINFECTION:Type Amount Ej,/e&J Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dia ter or Weight/Ft. Material umbers and common road names.
From_To�Ft. � VG -From -7-47- la`I d- IL13 Take gq ^'
From To Ft. +
From To Ft. G /�a '7 i'mi,/eS Tirn IcPT ca n
13. GROUT: Depth Material n Method t t {J /
From—_6—To 2 O Ft.ceMy rrf»,�z,�„!a �lnE Ri ��
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 I I
From To Ft.
From To Ft
16. REMARKS:
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
H
cTE' yde 6—/y
SIGNATURE OF PERSO CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

a .
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and-Natural Resourcee§ f-Qivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)v/P1" MIA LJ CERTIFICATIONM
WELL CONTRACTOR COMPANY NAME PHONES
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS `--J�
(ifapplicable) (if applicable)
c �
I. WELL USE(Check Applicable Box): Residential 0 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
is
2. WELL LOCATI N: // Topographic/Land setting ! _
Nearest own: i Y/S 1 E County ❑Ridge ❑Slope ❑Valley ❑Flat i '
1 AZ Ak5 C r a c k Aro z/ (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lot No.,Zip Code .4
p ) Latitude/longitude of locan
3. OWNER: (degrees/minutes/seconds)
Address n h.A C rpp,X Latitude/longitude source:❑GPS❑Topographic map
!i / (Street p Route No.) (check box)
1S�rIAja•SV1,27Z IX/C '9 77/ DEPTH DRILLING LOG
City or TG/own State Zip Code From To Formation Description_,
(SL2Y)-g — 3(I�rSC�
Area code-Phone number
4. DATE DRILLED-6—/3--L) M.
5. TOTAL DEPTH: �gn
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO IR S
7. STATIC WATER LEVEL Below Top of Casing:—0-7—FT.
(Use"+"if Above Top of Casing) r 11 ,',
7
8. TOP OF CASING IS_�FT.Above Land Surface* z
*Top of casing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): _METHOD OF TEST (nj s'
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 Diameter or Weight/Ft. Material numbers and common road names.
From_f+_To_r_7 Ft. Sora.I =n-rJ;,9d-ly3 �Ke /�9" Gcs
From To Ft. t7
From To FL L/f� fYl t /dS Turn Rjia h r o a exk5r,
13. GROUT: Depth Material Method d f/Q C.Q �jZ9�yj,t�trS Tbrn �A-
From­—I,,J—Tom' t2 Ft.�T.emg)i T
From To FL O n <11il
14. SCREEN: Depth Diameter Slot Size Material 1Pr
From To Ft. in. in. d n G/ /gS C!^c°f�k (y 0 r 3,y rn r'{!
From Ft. in. in. 7v r n f 6'.kT U/1 wo.{n v7 �j rah
15. SAND/GRAVELEL PACK:
Depth Size Material
�jQ Q,G m/'Je TO rafNl J d/) �PT,
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J e'F�����_/n—/�n ..
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION#,kLS- t
/� 11
WELL CONTRACTOR COMPANY NAME (TMxll x We,/1 rlrll!' v 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 LOCATI N: Topographic/Land setting
t
Nearest Town: I- _ t County ❑Ridge ❑Slope ❑Valley ❑Flat
�n1.r�.-r IUSkPa7 & ,la 771 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: lJ y/71�P t en
C' (degrees/minutes/seconds)
Address ) �3,pr i u5k& N - Latitude/longitude source:❑GPS❑Topographic map
' (Street or Route Ng) (check box)
R ti 11/G 121r771 DEPTH DRILLING LOG
Cityor Town state Zip Code From To Formation Description
1,,;29--6'J Q!Y
Area code-Phone number -
4. DATE DRILLED_�TJ$ - b 5 '
5. TOTAL DEPTH: -s 3n
6. DOES WELL REPLACE EXISTING WELL? YES OLIO ® C
7. STATIC WATER LEVEL Below Top of Casing:_( ,AFT.
(Use"+ if Above Top of Casing) 1—d7
8. TOP OF CASING IS FT.Above Land Surface* t
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _ Ut
9. YIELD(gpm):_I METHOD OY TEST 6A-i t"
10.WATER ZONES(depth): (�S
LOCATION SKETCH
11. DISINFECTION:Type 7 Amount c) .,21 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 umbers and common road names.
From O To .j0 FL�-� SDN I VC, r/lry rl n-r /y3 4-1 a- N 2�jfe c2 5� iV
From To Ft. (TU a.,7 elrn /��
h Tan
13. GROUT: Depth Material Method
From_Q_To r�,, Ft.('iomF'i7! J1
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To-Ft-in. in. oti
From To Ft. in. in. 1-1_-�'�) '=L_I°r Lti_,I
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. f (iJ1jj
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
T" AP- YYdN 7-Aq-0 S
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the orieinal to the Division of Water Oualitv,Groundwater Section,1636 Mail Service Center-Raleigh,NC

2, .. �
ako
WELL CONSTRUCTION RECORD �' 4 `�
North Carolina-Department of Environment and Natural Resources
-/DivJi{is�1ion of Water Quality-Groundwater Sectiio,�n..�9�`,,�.��
WELL CONTRACTOR(INDIVIDUAL)NAME/{Q�ri�t) Me k� A41, 4 CERTIFICATION Nov
WELL CONTRACTOR COMPANY NAME lT�r .��YYI (���TTT`7777, n�PHONE k (ft 479-&SYEle
STATE WELL CONSTRUCTION PERMITq ASSOCIATED WQ PERMITtl
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT Topographic/Land setting
NPPr,,��)restTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
�Gt.[F� I7/�H7 d5Y1�� (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: !/ lMV es 6-,rorjn (degrees/minutes/seconds)
Address .92 &nr Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
4) tl5V,W10 IT771 DEPTH DRILLING LOG
City orfTown Stare Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 7
5. TOTAL DEPTH: Za6 -
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO N :a
7. STATIC WATER LEVEL Below Top of Casing:. !26_ FT. 3
(Use"+"if Above Top of Casing) � '.'
8. TOP OF CASING IS If FT.Above Land Surface*
`Top orcasing terminated aVor below land surface requires a
variance in accords c with 15A NCAC 2C.01IS. t
9. YIELD(gpm): METHOD OF TEST rw'r
10. WATER ZONES(depth):_U 35
LOCATION SKETCH ell
'
11. DISINFECTION:Type Amount 2ya Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Dia eter or Weight/Ft. bdat�enal n tubers and common road names.
From_�To /�`� Ft.. 5or21 NVG_ 71j+dC✓/ 6)mdnA Po Gd 3,C rM,'les
From To Ft. p
From To Ft. 6V"7 rNr
13. GROUT: Depth Material Method
From_[t-_Tojj�___Ft. [,,oMdl17 / .--
From To Ft. �nn� m ' ��S /urn /Q� 2 `1
14. SCREEN: Depth Diameter Slot Size Material O n P&CkC N // OG
From To Ft. in. in. t?Tt (.7"U Qe�
From To Ft. in. in. n
I5. SAND/GRAVEL PACK: m 1' t�S /C77"J1 /C�� T 41 ICU 7 +
Depth Size Material
From To Ft. on Rlg, -r
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY 7�OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE F PERION CONSTRUCTING THE WELL 7—DATE .S
Submit the original to the Division of Water Quality,Croundwliter!�Ftion;]&M a 1 Service Ce' ter-Jaleigh,INC
27699-1636 Phone No.[phone],within 30 days. i _ C W-1 REV.07/2001

NC OIPNEIi _ Hirt) _—____—
------ WELL CONSTRUCTION RE CORD
� €_ . k:
Nos ill Catolina-Department or Environment and Natural Resoutces-Division of Water Quality-Groundwater Section
r n >
WELL CONTRACTOR(INDIVIDUAL)NAME (prinl)�.� /7y Ah zCe CERTIFICATIONN /2LOJ
WELL CONTRACTOR COMPANY NAME 7// rIiNE N
STATE WELL CONS TRUCI"ION PERAII"rN ASSOCIA7"ED WQ PERMIN
(if npplicnble) (If applicable)
1. WELL USE(Check Applicnble Box): Residenlini 0-- unicipal/Public U luduahial U Agticultutal U
htuniloring❑ Recovery L1 Ilea(pump Water Injection❑ Other d] If Odier,List Use
2. WELL LOCATION / / TopogrnphictLond setting
Ncare/sl T'!o/wn: ��/'f l« Cuuuty G��`R L URidge USlope []Valley ❑Flat
/.•trT�- f/JC=UGC j• (check appropriate box)
(Street Name,Nuumbets,,Community,Subdivision,Lot No.,Zip Calc) Lalitudeflangilude of well location
3. OWNER:_7z-,'i7 r+ �j is h(4q� (dearcee/minuln/ectondi)
Address Latiludeflo,gilude source:OGPSCTTopographic map
(Street or Route No.) (clink box)
im,ITI BILL Ni Lug
City or Town State Zip Corte From To Formation Description ,
Area e, ode-Phone number y ?3 --
4. DATE DRILLED S-.211 0s 73 f`
5. TorAL DEPTU: /6,a '
6. DOES WELL REPLACE EXISTINO WELL? YES U NO 43'
7. STATIC WATER LEVEL Below Top of casing: Sy Fr.
(Ure-+^Ir Alcove lop of cminN)
8. TOP OF CASING IS �yTi Fr. Above Lmtd Sulrace•
-Top or udnl lertnlnaled aUor ,belon land murrate rtriulro■
earimce in accordsoce nUh 13A NCAC IC.01IN.
9. YIELD (gpnn): 15 METHOD OF TEST /P-/°'
10.WATER ZONES(depth): /,7$
It. DISINFECTION:Type Amount �yc r'� Show direction and distance in miles from at(cast
12. CASING: Wall Thickness two Slate Roads or County Roads. Include die road
� Depth Dimueler or WeighUFt. Matelial numbers slid cmtunon road narnes.
From To W Ft. s 1V r� �- [;F14e lra'•�
Front T'o FI. U,
From To FL_ 1/
13. GROUT: De ul Tate ill eglod ~
Front P To 2rl. 1'2 fj�,1d i'tJlu e
From 3TO,�Y Ft. 1.
14. SCREEN: Deptli Dimneler Slot Size Matelial
g
From 'To
rron, To Ft. tu- in. �� -,. zj
15. SANDJGRAVIII.PACK: CD
Drell, Size Material
moat Tn Ft. �.
1:1Oln
16. REMARKS:
IDOIIEREUYCERTIFYTIIATTIIIS WELL WAS CONSTRUCIFDp AtA;;;W��
QRl#N 1}*jTit�15&N C3C,WELL
CONSTRUCTION STANDARDS,AND/Tiiig A CO OF TI IIS REQ �lf,�WELL OWNER
SICNATUIIE OF PERSON CONS"f 1NG 7TIE WEL `'D TE
I L
Subildl the orlginal to the Mylelon of Water Quality,Croulldkater�eelFO0')1�'fGj6M USe' ice Caller-Raleigh,NC
27699-1636 Phone No.(919)733-32I1,withbi 30 days. — n.-=—`= 1 REV.0712001

NC _ OIVNEfi _ _ r� MIVO
WELL CONSTRUCTION RE,CORD `l 3 �
Nor Ur Carolina-DeparOnenl of ERvirmmlenl mid Natural Resouuirces-Division of Water Qualily-Groundwater Section
WELL CON TRACTOR(INDIVIDUAL)NAME (p bmtt)�q /(=/�/'� I�QeL� CER"11FICAT70Ng9 o3
WELL CONTRACTOR comrANY NAME /�/�l�>-r PRONE a IPzB) b'37-z fY 9
STATE WELL CONSTRUCTION PEMiITg ASSOCIA7"Ell WQ PER61110
(irnpplicnble) (ifapplicable)
1. \TELL USE(Check Applicable Ilux): Residewinl 6-1-IMuuicipal/Public❑ hndushial ❑ Agricultural L7
hlviniloring L7 Recovety L3 Ilea[Pump Water Injection❑ Other❑ If Older,List Use
2. WELL LOCATION- / Topographic/Land selling
Nwics(T'LLuwn: WW d7a 0Me- County (�rajjam ❑Ridge Mope Malley ❑Flat
22-4(juen ,f,-e AC4 (dttck Arps"Prinle box)
(Saeci Naa¢,Nunnlmra,Cmnnnmity,Subdivlelmi,Lot No.,Zip Cmle) Lalitude/longilude of well location
3. OWNER: 6'1)a"JA Jacbe' i (degreee/minntra ennndn)
Address Latiludellougilude sourcc:❑GPS❑Topograpbtc neap
(Sued w Route No.) (clink box)
pEPTIr JZ j1A19WQ-Q
City or Town State Zip Code From I'D ComrationDescription
Area a code-Phone number 0
4. DATE DRILLED
5. To I-AL DEPTi 1: 26l
G. DOES WELL REPLACE EXISTING WELL? YES ❑ NO W
7. STATIC WAT'Elt LEVEL Dclow Top of Casing: (C Ff.
(Use-+-If Above"1'np of Caning)
8. T"OI' OF CASING IS /yi IT.Above Lmid Solracc•
-Top or enlag irrreinsird atior below land eunhce requhes a
•arlxnee In accordance with 15A NCAC IC.0118'
9. YIELD(gpn ): too METHOD or TEsT' i�'''-
IU. WATER ZONES (depth): 02 LO
LocnTloN slce-r01
It. DISINFECTION:Type T! Amount '/C/r t- Show direction and distance ill miles from at least
12. CASING: Wnll Thickness two Slate Roads or County Roads. Include die road
Depth Dien¢tcr or Weiglivrt. Material numbers acid contmon road names.
Ftout To //S- 1.1. E-23- S"?rx/ /°UC
Flom To Fl.
From To FL
13. GROUT-: Depol Mar; Ixiethod
From D To _Ft. fl. ,�
From Ft.
14. SCREEN: Depol Uimucicr Slut Size Material r��1�J A
Front Tv Fl. in, in. L _
Fain To Ft. iu. in.
15. SAND/GRAVEL PACK: N
DrpUl Size Mnledal
From I'o FL
4
Fronk. o I't. ,
T
16. REMARKS:
r, r r
1 DO IIUREEY CERTIHI IIATTIiIS WELL WAS CONS'I RUC U T�A k kiAC 2C,WF,LL
CONSTRUCTIONSTANDAIWS,ANDTHATACOPYOFT111St�? RUIIASSEENPROVIDrIt!'�GITIIEWELLOWIIER
AUG 9 2005aJ—
SIUNA'IUMI OF ITRSUN COOS'IRVCrING THE WELL i DATE
Submit lite 011glnla1 to (he 1IYI51011 of Wa(er Qlrality,GranrldmTdei,Sg ldj�ijd3G M1fatl'Service Cerder-ttalclgh,NC
27699-16-16 Phune No.(919)733-32I1,n 111nh13U dnys, GW-I REV.07/2001

NC ��/ _ OIVNER 1 , , (� F)11'U
WE,LL CONSTRUCTION RLC01W
Notdi Carolina-DepalDuent of Enviruwnc it told Natural Resources--Division of Water
Quality-Otoundwalet Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) C jm Q cz, \`1 �,1� r lieu— CERTIFICATION p�1(
IYELL CONTItACI OR COa1PANY NAaIE -M ; Il p c- i( �r� I rRONE p f920 167,;2n2 4t
STATE WELL CONSTRUCTION PE"lrfp ASSOCIATED IVQ PERa1PTp
(if npplicnhlc) (if applicable)
1. WELL USE (Check Applicable [lox): Residential LYMunicipal/l'ublie U Industrial U Agricultural L7
Monitoring❑ Recovery U heat Puwp Water injection U Other U If OUrer,List Use
2. WELL LOCAT N , 7bpogrnphic/Lnnd setting
Nearest Town: I County
(rr"rn URidge USlupe U V'u UI'lal
e //t�! (check appropdnce box)
(Buret Nun,,Numbc e,Community,Subdivirla;Lot No.,Zip CWc) Laliludetlongilude of well location
_ N35°23" &3' Wg30Q-'M1'
3. OWNER: Oct Yf,n 1 n� 05 (degreer/nJnweyeaunJ.)
Address 500 S pl 3-I1 f'Ct I- K R A Laliludellongitude source:00PSL topographic nrap
(Street or Roble No.) (check box)
Roh�irn cvrllz N- Z` Z71 AEI,"III I�t1LLINGLC1�i
City or Town Stale Zip Cale Front To 'ornlalion Dcscliption
(—� Z_ ,
Arta cafe-rhone number
4. DATE DR[LLED lQ-- /1,-OA
S. TOTAL DLPTll:
G. DOGS WELL REPLACE EXISTING WELL? YES U NO ItY
7. STATIC WATER LEVEL Uclow Top of Cnsiog: <n Fr. t
(ore"+-If Above Tap of Cminp) G �re
8. TOP OI'CASING IS ( IT.Above Lard Sul face•
*Top or cning Irnnlnalyd allor below land outface orgoho a
votlonce In accordance with ISA NCAC 1C.411111. `a
9. YIELD(gpnl):Hp_METuoD or••rEsT !l2 Ln
10.WATEIL ZONES(depth):
_ LOCATM SKETCH
11. DISINFECTION:Type) Amount I i7 Show direction and distance in miles frtnn at(cast
12. CASING: Wall Ihickness two Stale Roads or County Roads.Include We road
Depth Dinutetcr or WeigilyFl. Malelial numbers slid collation load Ilanles.
Front C) -TOE Ft. io,�� s�
profit To Fl.
From To_FL
13. GROUT: Depot M tonal Method
tn rrR�_To_ L_I'1.
Front_To 201 FL �l
14. SCREEN: Depot Diameter Slot Size Material �� "V
Front To rt. in. in. U l•
From Ft.—in- in. S6
IS. SAND/GILAVEL ELPACK: �\
Depth Size Mnlelial
From To Ft.
FronLIN
t
I
1'o FL
16. REMARKS:
DO I IEREEY CERTIFY THAT TI IIS WELL WAS CONS"IRUCI Eq IMIACCORDANCE WITH15A NCAC 2C,WELL v4e�
CONSI"RUCTION STANDARDS,AND THAT A COPY OFTHIS C. IIASECENIROVIDEDTO TILE WELL OWNER � -
AUG, 9 2005 -
SIGNMORE OF PERSON CON IRUgfINO TITS WELL DATE
L----- -- ' 1 't�
Submll the original to the Dlvislon of Water Quall(y,Grow dwal ` i�ftltw ij¢;; I � Ice filer-Ilalelgh,NC
27699-IL-16 Phone No.[phone],Ivhhln 3U drips. OW I REV.0712U01

mc UIINE/i U11'U
WELL CONSTRUCTION RECOIM�p
Noldr Carolina-Dcparintcul of Ltuviturmrcul and Not at Resoul es-DIvIs1011 of Water Quality-Uioundwaler Section
WELL CON IRACtOR(INVIVIOUAL)NAaIE Qn hd) r �r�l ��ec-e— CEIrIIFICA110NN��,-1
IV ELL CON I ILACI Oft COa1rANY NAME �1•ll�i' MIME N (8)) L `fi
STATE WELL CONS I nUCIION I•EMII IN ASSOCIATHir WQ PFMIIIN
(if nl t licnl ic) (if��flcnblc)
1. WELL USE (Check Applienbie Ilox): RcsiJculial Vj-�htuulcipal/Public U Indusllial U Agricultural U
hlvltiloring U Recovety U Ilea,Puvgt Water Lljectiou U Other U If Odrer,List Use
2. WELL LOCATION' // 'fopogrnphic/Lnnd scttilrg
Ncmesllbwn: Wpbh 'YJ✓-//C- County UIUJge ❑Slope UVnlley UI°lal
�/77GSfiy (g'�/qG/. /�cl•. __ Icheckapproprlalebox)
(Surel Name, d•u Nune,l'mnnumity,SubJiv{riu�,lul No.,7-ip Cale) Lstitudc/IOugilude of well locnlion
NdS'I5V7 'wuP3°Sb'-
/ (�fJg ( �r 6 Jj (dttleealnrlmtldaecnndQ
J. OWNER: � —
Address Ia123 /�a.SSey 13myALI RA LaliludelloLlgiludesource:UGPSUTupogrnpllicntap
(Street or IloWe Ito.) (check box)
Robb'Itis�llle A/c-2 �7y1 UL'1'"l11 )LLUILIN(LIU�i
city or Town State ZlpCale flour To ForpmlionDescripliun
(--) U 70
Acra rule-rbone dumber
4. DATE DRILLED --
'2
5. 1'01'AL DEI'-111: aZ --
6, DOES WELL REPLACE EMS'1'INO WELL? YES U N0 1�' -
7. STATIC 1VATL'K LEVEL Below Top of Cnsiug: S --I' r '
(Urn•'+-If Above'1o11 or Corint)
8. 101, OF CASINO IS ` F-I-. Above Lnud StuNce• m
•lop of odor Itnnbnitd aUnr brio.land rmlate rrquh to■ `.
vultnce In accorJantt wllh ISA NCAC 2C.0118. sA
9. YIELD (Fpnt): METHOU OF TEST_ '
IU. WATER ZONES(depth): Ld 0 LOCALIOtj StCMJL
CASINO:
Show diteclion and distance in miles float at least
12. C
11. S CASING:
'ION:'1'ype �f Auwuul 7K Wnll'Ihickncss c /� two Slate Roads or Courtly Roads. Include lie road
Drpill Dintucter of WeighUFl. Material numbers slid conuuoa toad panics.
Fruit, TOJL-1:1. r23- ,0i2al A/c
Froln Tv Ft.
From Tv FL
13. GROUP: DepUl lntc', I Method
Float O Tof/aq v t
1'I0111 -3 To .2-0 FI. a7,,w to --
14. SCREL'N: DepUr Diameter Slot Size Maledid
From To fl, in. in.
14mo 'Ib__FI. Ili. iu, j
15. SAND/GRAVPL PACK:
Urpol Sire hlnledol
Eton, '1'o R.
''torn Ib Fl.
\IAItKS:
'Y CEIt'fiFY I11AT-fl IIS WELL WAS CONS IRUCI ED IN ACCORDANCE WI711 I5A NCAC 2C,WELL
ON STANDNU)S,AND TIIA1'A COPY OF THIS
ILL'CORU IIAS EEEN PROVIUEU TO TIIE WELL OWNER
SIGNMURBOF1'EItSUNCONSUM-F1NU111EWELL UAIE
the UlVilion o1 Walcr Quality,Cruundwaler Section,1636 blall Serrtce Ceder-Italeigh NC
�)73J-J121,111Ihb13U days• (1W-1 REV.07I2UU1

ao 315lt78
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NaturalResources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/E� (print)i'l0tT-I-D LkrQ1( CERTIFICATION#
WELL CONTRACTOR COMPANY `�_-PHONE # (ga.Q)UAR•2J.M
STATF.WELL CONSTRUCTION PERMIT# \q0Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential L2'�Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL
LOCATION—Topographic/Land setting
ticarest/nT�own: .�At\vft Countysaa&aina ❑Ridge ❑Slope ❑Valley Lfat
1Jt�>n Y-4tr.' �Y P It (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: -/b� 1 C (degrees/mmutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
t.t y or Tnwn State Zip Code From To Formation Description
($d3)-5 An - 983`4 0 B'J�
Area code-Phone number -1 � �0
a. DATE DRILLED b •\�o• OS -�"+ -L3 dAmk
5. TOTAL DEPTH: KOOS
REP! AC?: i,;vl�-r(nlr ixrl..!.!.'. YES ❑ NO In" _
7. STATIC WATER LEVEL Below Top of Casing—LA,�FT.
(Use"+"if Above Top of Casing)
N. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_"i METHOD OF TEST aV C
10. WATER ZONES(depth): yg5
LOCATION SKETCH
I I. DISINFECTION:Type l�'t4{ 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. Material numbers and common road names.
FYamA__Tom_Ft. 1 h,l PyC
From____To Ft. ..;e
From To Ft.
.3. GROUT: Depth Material Method `
From__0 To_20 _Ft. Acp C
From__To Ft.
14. SCREEN: Depth Diameter Slot Size btaterial fV L--'
From___ _ _To Ft. in. in.
From To Ft. in. in. O =
15. SAND%GRAVEL PACK: Ln
z
Depth Size Material
From__ To Ft.
From_____ro Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
8-Ik 0
SIGNATURE OF PERSON CON U_CTING 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. j GW-I REV. 07/2001
i

E,. sinrto
f R � ]� OWNER
RESIDENTIAL YELL CONSTRUCTION RECORD
MWD
"� .. Nonh Carolina Department of Environment and Natural Resources-Division of Water Quality
'^.....•.. NC
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 1. DISINFECTION:Type T Amount
C'/"/y �PeG•L g. WATER ZONES(depth):
Well Contractor(Individual)Name From IJQ To 131 From
To
MT R WELL DRILLING INC From To From To
Well Contractor Company Name Ran To From
To
STREET ADDRESS P . O . BOX 567 6. CASING: Thickness/
Depth Diameter Weight Material
H A Y E S V I L L E , N C 28904 From © Toj(f�_FI. 6.;1S—
City a Town State Zip Code From To Ft.
(828 )- 837-2997 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
,3 �ny�eey
SITE WELL ID#(ifapplicaW Fran-_To FL , -e^ -
e) From- Toil` Ft - & - f
V
STATE WELL PERMIT#(ir applicable) From To Ft.
DWQ or OTHER PERMIT#(it applicable) 6. SCREEN: Depth Diameter SIDI Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To FL_in. _ in.
DATE DRILLED J- 'zS—OS� From To Ft.—In. — in.
Fran To Ft._In. _ in.
TIMECOMPLETED AM9-'PM❑
9. SANDIGRAVEL PACK:
3.WELL LO�C,_jALT/IO/N: Depth Size Malarial
CITY: /7�t'E'`�f�' (le COUNTY G" �,f Y�• From To Ft.
From To Ft.
le/l`ytl Al', zw, Fran To FL
(Street Name,Numbers.Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
08161pe ❑Valley OFlat ORidge ❑Other From To Formation Description
(check appropriate box) -
LATITUDE 3 3_. 1y-07 May be in degrees, D Td C. 4y
minutes,seconds or
LONGITUDE f 3 6-6• rk( in a decimal format 61— %W
Latitude/longitude source: BOPS ❑Topographic map
(location of we#must be shown on a USGS topo map and
attached to this form l not using GPS)
4.WELL OWNER /�
OWNER'S NAME_ 6/l
STREET ADDRESS (JD ILI b1(I C 0n Fit tAC/ oa GO
PnRr�x Jt "T r )1e(OKPP A14 2 871q -„,
Ctry a Town State Zip Code
Areacode ode- Phone number --
5.WELL DETAILS: It. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOB`
c. WATER LEVEL Below Top of Casing: 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRVCTED IN ACCORDANCE WITH
OP g D FT. 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+-IT Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
If TOP OF CASING IS L Fr.Above Land Surface' �iA.t ,rTet�
*Top or casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C.0119. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): METHOD OF TEST
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. Farm GWAa
Rev.7/05

0sTAn, � hRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
-. WELL CONTRACTOR CERTIFICATION q ao S(�
I.WELL CONTRACTOR:CONTTRRACTLORR: I. DISINFECTION:Type Amount //(7
y P r ' A LO g. WATER ZONES(depth):
Well Contractor(Ind idual)Name
/�� r From /C1Ci To�;f From To
( i V . aL M 1 nJ ) AY' Try Fran To From To
Well Contractor Company Name
/ Fran To Fran To
STREEIT ADDRESS ,�; ly oO1 6. CASING: Thickness/
d�f77� Fran O DTot�k Ft f Weight' MpVC
City or Tam State Zip Code From To Ft.47 _
(�-JZ%'DNS Fran To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(d applicable) From__j[� _To—a0--Ftjfeyy n-r Puz! ,&ryO.
From To Ft.
STATE WELL PERMI7#(a applicable) Fran 7o Ft.
DWQ or OTHER PERMIT#("rf applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply RI From To Ft._in. _ in.
DATE DRILLED_?? ooCL
rh O 19—47/ Front_To Ft. in. _ in.
Fran To FC_in. _ in.
TIME COMPLETED q ,'!�_ AM O PMDd
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: RALt1-$I/l,l/!d COUNTY Fran To Ft.
' / From To Ft.
Ff .S.��P�Ar ��Z'�— Fran To Ft.
Str eme,N bars,Cammunrty,Subdmswn,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
%Slope ovalley ❑Fiat ❑Ridge ❑Other From To
(check appropriate box) Formation Description
LATITUDE 3 '15-0 I q�yn_��/ =1�in"&egrees,LONGITUDE `�S��fft(}�� C2
—i
Latitude/longitude source: s;GPS ❑Topographic map
(&cation of wef must be shown on a USGS topo map and
attached to this Joint 1 not using GPS)
4.WELL OWNER /I -
OWNER'S NAME
(.rY'''G//L\/
STRE �
ET ADDRESS /T'sii�flr Odpr
R,n1T6in I/�lL/i 2�771
City�a LO,�nT State Zip Code
(,?.I
Area code-
5.WELL DETAILS: I1. REMARKS:
a. TOTAL DEPTH:
to. DOES WELL REPLACE EXISTING WELL? YES O NO)$
C. WATER LEVEL Below Top of Casing: /no FT, i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOR14NCE Wm,
(Use'**it Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND T1ATA COPY OF TM
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS ( F'T.Above Land Surface-
'Top of Casing terminated aUor below land surface may require
a variance to accordance with 15A NCAC 2C.0118. SIG�NTATUfRE OF,r 9RT11FIED WELL CONTRACTOR DATE
e. YIELD(0pm):�_METHOD OF TEST Q.1 r' �L/ 6 t� /-f ief s
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. Famn GW-1a
Rev.7/06

O�T m -7
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division Of Water Quality
WELL CONTRACTOR CERTIFICATION# 2 E,
1.WELL CONTRACTOR: f. DISINFECTION:Type d-(T h{ Amounti�
g. WATER ZONES(depth):
W oniractor(Individual)Name m Fro a'1 r To�
r�cennq �� I -�LSL_ From To
—
To lIY1c From To From To
Well ConbaCla QthnpanY Name From To
r- Fran Ta
STREET ADDRESS 1 CXJ y\� 6. CASING:
Depth
Thickness/
f'°,m er W�e�i hn1^ Material
t Town 2S2 /
From (•`� 7o1y Ft._ `..rhlKtt( YG
Qty a Town Stale Zip Code From To Ft. _
Fran To Ft.
Area code- Phone number —'
2.WELL INFORMATION: 7, GROUT: Depth Material Method
SITE WELL ID#(if appticable) From—Q—To--,k Ft ('p✓��yrtf-
From To Ft. J
STATE WELL PERMIT#(itapph"ble) From To Ft
DWQ or OTHER PERMIT#(if applicable)
8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Rots): Residential Water Supply❑ From To Ft._in. _ in,
DATE DRILLED �/ �� f From To Ft. in. _ in.
� Fran To Ft. in. _ in.
TIME COMPLETED /L; Q AM N; PM❑
S. SAND/GRAVEL PACK:
d.WELL LOLQATION: Depth Size Material
CITY: K COUNTYG C& From To Ft.
From To Ft.
From To Ft.
(S4eei Na umbers.Community,SubtlMalon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑SIOpe OVahey ❑Flat *Ridge ❑Other From To
(check appropriate boa) Formation Description
LATITUDE 'r May lK ut degrees,
minutes,seconds Or t
LONGITUDE ` C (_ ,(� ' in adecimal format
Latitude/longitude source: g1(pGPS ❑Topographic map n
(location W"M must be shown on a USGS topo map and
attached to this yam snot using GPS)
4.WELL OWNER
OWNER'S NAME 1 To r r n -
S EET ADORES 9240,001 -
4-40\tb OSLO/
City of Town State ip Code
1>�1 T9 3� 76 _
Area code- Phone number -
5.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: 667
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO vr'
C. WATER LEVEL Rebut Top of Casing: 3/ti _FT. 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE win!
op AboveT
DP rig) RECORD NH EENLPROVIDED TO THE WCONSTRUCTON AELLL OWNER.
DARDS THAT ACOPY OF THIS
ofCasr
d. TOP p CASING IS FT.Above Land S require
��5
'Top ri casing terminal with 15A land surface may require SIGNATURE OF CERTIFIED WELL CONTRA DATE
a variance in accordance with 15A NCAC 2C.0118. ,/�
e. YIELD(gpm):�,L_METHOOOFTEST ) h _ a�l )� �I !1 1 I�I I,�(,�'^��I
PRINTED NAME OF PERSON CON TRUt7TING THE WELL
Submit the Original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27 6 99-1 617 Phone No.[phone] ext 568. Form GW-la
Rev.7/05

ww•n..,,. sl F 3n,
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
- WELL CONTRACTOR CERTIFICATION#
1.W L CONTRACTOR: f. DISINFECTION:Type Amount Q
Z
I6C S 9. WATER ZONES(depth):
Wyl(ContraActor(Individual)Name 1 From I o_o To__2k(2 From To
Vy"G-IY\('.,n.v ( �I `l `� From To To
Well Contractor Company Name I�C Fran To Fri
ST EET ADDRESS / t I -I�� To
— ���V(A(� !(.hl 5_r 6. CASING:
Lrrzyille
From Depth
tTo Ft. ' 'A4 Wbr n(�1 eight Material
City Or Torn State Zip Code From To_Ft.
( } ELM — L/6y From To Ft
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) Fro Fra ntn—To_&j_Ft. (P
To Ft.
STATE WELL PERMIT#(a appllcabie) From To Ft.
DWQ or OTHER PERMIT#(ir applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To_Ft._in. _ in.
/�� From To__Ft_in. _ in.
DATE DRILLED G'- �"n SAS From To_Ft. in. _ in.
TIME COMPLETED z?r,30 AM O PM;K
9. SANDIGRAVEL PACK:
D.WELL LOCATION: Depth Size Material
CITY: �>'Cli)IIIiCVll�o _ COUN T From From TO—Ft.
1 To Ft.
Fran To Ft.
(Street Name,Numbers,Communay,Subdroslon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC 1 LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat XRidge ❑Other From To Formation Description
(check appropriate box) nP
LATITUDE ��--cc..' n rt r r(=Iem"dengrees, ._ ,i� /��/� �� 7 LONGITUDEv 7
Latitude/longitude source: P(GPS ❑Topographic map _
(location of We9 must be shown w a USGS topo map and
attached to this form#not using GPS) -
6.WELL OWNER CD
OWNER'S NAME —+
STREET ADDRESS —6 A pv
12 i IyE
Clty or Town State Zip Code c n
Area c
�ode y19 �4 a
e I1. REMARKS:- Phone number -, --
-
S.WELL DETAILS: -
a. TOTAL DEPTH:
lo. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c. WATER LEVEL Below Top of Casing:jO©` FT 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED(USE-+ it Abate Top of Casing) IN ACCORDANCE Wr1H
15A NCAC 2C,WELL CONSTRUCTION STANDAROS,AND THAT A COPY OF 1NI5
RECORD HAS SEEN PROYIDEO TD THE WELL OWNER.
d. TOP OF CASING IS�_FT.Above Land Surface-
. *TOP of casing terminated allm below land surface may require S
a variance in acoadance wkh 15A NCAC 2C.0118. SIGNA Or CER I IFlED W EIy L CONTRACTOR DATE
e. YIELD(gpm): _METHOD OF TEST C. r _ PRINT D NAME OF PERT S}N CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Aftn: Information Mgt.,
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-1a
Rev.7105

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2 L !
4 _ S RESIDENTIAL WELL CONSTRUCTION RECORD r
'� North Carolina Department of Env"vonment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#_
1.WELL CONTRACCTIOR:1 I. DISINFECTION:Type Amount D L
W ell Contractor(I(individual)l)11 KT1 n I /t d I l g. WATER ZONES(depth):
N
From t'{—�To. �c'30 From To
hm
f_ n Il From To From To Well Contractor _ompany Name From
(1 To
STfR�EE�T�A From To
8.�DDRESS �Lp r'���7Ly CII CASING: Thickness/
u -C'� ( -7 _._ C Depth Diameter We
Iry ight Meat C
v0
From- To_,3�Ft m '/�I Serr ai _t-
C or ITavn State Zip ode From To Ft.
Lt _
o zC( From To Ft.
Area code- phone number
2.WELL INFORMATION: 7. GROUT: Depth
Material Method
SITE WELL ID#(if applcable) Frpn-0—To-aa_
FL t'e ys p n.L7��i
From To Ft.STATE WELL PERMI7#Orapplicable) From To Ft.
DWQ or OTHER PERMIT#(it applicable)
8. SCREEN: Depth Diameter Slot SizeWELL USE(Check Applicable Box): ResidentialWaterSupply,Z, From To Ft. in. _ inDATE DRILLED Z y'�- j'y It From To Ft. in. _ in9_•" From To Ft. in. _ in
TIME COMPLETED L 'Q O AM❑ PM(�
9. SAND/GRAVEL PACK:
3.WELL LO A710N: Depth Size Material
CITY: From To Ft.
y /� COUNT
1"kfJh� f1 n From To F[.
�
(Lry� �x nI From --JCL—Ft.
(S4eet Name,Numbers.CoI)imundy. ubdmewn.Lot No.,Par 7�pcel�y
TOPOGRAPHIC/LAND SETTING: _
❑Slope IQValley ❑Flat ❑Ridge ❑Other 10.DRILLING LOG
(check appropriate box) From To Formation Description
LATITUDE �7-� 6 ` L/O. t/=indegrecs.LONGRUDE Lam$-/
Latitude/longitude source: jgGPS ❑Topographic map(location of well must be shown on _a USGS topo map and O
attached to this form Knot usog GPS) ---I
6.WELL OWNER I :-:i
j0WNER!S NAME
ET ADDRESS
City or Town late Zip Code /
61-10
Area code- Phone number
5.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: L�_
b. DOES WELL REPLACE EXISTING WELL?/`YES❑ NO IX
c. WATER LEVEL Below Top dCdSing:_ y(� �' I Op HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCiEb IN ACCORDANCE WITH
°P Casing) RECORD HAS BEEN OVID PROVIDED TNHEWAND OWNER,AND
THAT A COPY Or THIS
(Use's"rf Above 7 d
d. TOP p CASING IS�—FT.Above Land Surface*
require
r�l
'Top ri casing terminated with belay land 2C.01 may require SIGN !RE OAT�1 - F CERTIFIEpY l�l WELT�OR ATE
a variance in accordance with i5A NCAC 2C.Oi 18. 'n_
e. YIELD(gpm):—L4—METHOD OF TEST. (jt' I(— 01 t
PRINTED NAME OF PERSON CONNT UCTING 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

f._ RESIDENTIAL WELL CONSTRUCTION RECORD t .m
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.W L C�ONIiRACTO(R�: 1 I. DISINFECTION:Type Amount X r1 Z
9. WATER ZONES(depth):
Well Cmtractw(Individual Name From To-2D-E�
WLYc To From To From To
From Weil Contractor Company Name -III - From To
From"al To
STREE1 qqP
T� ADDRESS 6� N' y� 6. CASING: Thickness!
�obl/^lSC�I1 I Depth Diameter Weight terial
Mc,
f� / Fran_ r_To_ KL Ft.--b-i�-
t���Clty r�ToAm StalelI Zip Code From To Ft. _
(��z} -7 7�/ �LI �i�1 From To Ft.
Area code- Pha1e number --
2.WELL INFORMATION: 7. GROUT: Depth Material ` Method
SITE WELL ID#(if applicable) From__:To, _FL CAP✓1.2'1.a� i
From To Ft.
STATE WELL PERMIT#(xapplicable) Fran To Ft.
DWQ or OTHER PERMIT#(if applicable)
8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ Frorn To Ft._in. _ in.
DATE DRILLED CI- From To Ft._in. _ in.
- /�I; Frwn To Ft. in. _ in.
TIME COMPLETED ] a;O(7 AM O PM
9. SANDIGRAVEL PACK:
3.WELL LOCATION: 11 1� Depth Size Material
CITY: JLSn�YIUIlNCtil Ile COUNT I) (1-� From To Ft.
1 /1 From To Ft.
yF i ` n`^ ( ��t�'. From To Ft.
(54 t Name. umbers,Canmundy,Subtlrvlspn,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Sk1pe ®Valley ❑FM ❑Ridge ❑Other From To Formation Description
(check appropriate box)
LATITUDE 3 S! L/ y-/Cj c3 r� May be in degrcao
minutes,seconds w
LONGITUDE� 3 J R' m a decimal format
Latitude/longitude source: Q(GPS ❑Topographic map
(bcation of we#must be shown on a USGS top,map and
attached t,this form#not using GPS)
4.WELL OWNER O
OWNER'S NAME
I
ST EET ADDRESS 1/o I (P C (ppJC
7 irl5���a� -State r-N Or Town State Zip Code
(77o_)- �/ 7tl - /gtiY
Area code- Phone number _
S.WELL DETAILS:
11. REMARKS: -
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO O(
c. WATER LEVEL Below Top of Casing! C' 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W1n1
� FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY O TM
(Use-T'"d 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 at/w below land surface may require r�r�K'� I�1
a variance in)acccordance with 15A NCAC 2C.0118. SIGNATURE OFLCERTIFIED W LL CONTRACTOR DATE
e. YIELD(gpm): `-1(7 METHOD OF TEST a&( ('
PRINTED NAME OF PERSON CONSE OF PERSON CONS RUCTyyELL
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 566. FORD GW-la
Rev.7105

ppUr.SUIEe ¢ f f-
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RESIDENTIAL WELL CONSTRUCTION RECORU 4 ct
Noah Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1.WELL CONTRACTOR: I. DISINFECTION:Type �� T AI-1 mount_
5 Il 1 n Y 111�1\V•/l g. WATER ZONES(depth):
Well f�'ontrac`t x(Individual)Name J From_O To_) From To
v 1�1 lA IF�I Otdl1}lC From To From To
W ell Contractor Company Name o From To From To
STREE In c�Ll_ 1'l�r(AP I �YY t\ 6. CASING Thickness/
Depth Diameter Wei ht 'Material
7�_ From D To��Ft' r 1. Q ��
�i City or Town State Zip ode From To_Ft. _
From To Ft.
Area code- Phone number
Depth e D:GROUT.7
2.WELL INFORMATION: P Material Method
Roma_Togo Ft.r(?r Vnp - i
SITE WELL ID#(it applicable) From To Ft.
STATE WELL PERMITN(dappiicable) From To_Ft.
DWQ or OTHER PERMIT X(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply D From—To_Ft.—in, _ in.
From To Ft. in. _ in.
DATE DRILLED �-C� _ From To FL in. _ In.
TIMECOMPLETED 6:C0 AM❑ PMXj
9. SANDIGRAVEL PACK:
3-WELL L TION: I, Depth Size Material
CITY kt"AS)li�jp COUNT 14.n.i__ From—To—Ft.
From To Ft.
.v 1"1 d I (1t,) GQ From To_FL
(Stre t Nafne.Nu berg,Oommunily,Subdlvlsion,Lot No.,PWC ,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope AValley ❑Flat ❑Rage ❑Other From To
Formation Description
(check appropriak box)
o iy MayT in degrees,
LATITUDE J minutes,secondsa
LONGITUDEt t ' �,Q in a decimal format
Latitude/longitude source: RGPS pTopographic map -
(location of we!must be shown on a USGS topo map and ,-
attached to this form R'not using GPS)
4.WELL OWNER ',-V-k \ I -
OWNER'SNAME L� q
STREET ADDRESS
CD
Lit
City or Town State Zip Code
Area code- Phone rwmber
5.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING W=-LL7 -eFS❑ NOA
e. WATER LEVEL Below Too of Casing' F? I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
_.,-„_ SA NCA^— WELL CONSTRUCTION STANDnkDS_AN,-,,.AT A c. v OF Tars
(Use-"`0 Above Top of Casing) RD I I RECCHAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS �_FT.Above Land Surface —y'7 , T
f `Top oi casing Iermineied Wor oey land suaace may require i I G X / b yr
a variance in amadance with 1SA NCAC 2C.0118, SIGNATURE OF CERTIFIIEED,WELL TRACTOR DATE
' uczLa(glom) R+ET15c7D OF TEST Ci�l PRINTED N�J AME OF 51�1�1
PERSON CONS UCTIN G 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 19141733.7111 c>Yr taR Form GW-1a

aTM. r 6 V
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ip
4
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION N_��
1.WELLL CONTRACTO,R/:�,� } I. DISINFECTION:Type 1` Amount
WN�^I Contr�Atactor(Individual)Nameme 9. WATER ZONES(depth):
1 From lye_To ) _0 From To
l ,1(L:..IV�c w n ( �J� \1 �I11 1✓)� From To From To
Well Contractor Cornpany Name From To From
/� / � To
STREET ADDRESS V 3—I H t�P 1 )Vk ko C 6. CASING: Thickness/
N/� Depth Diameter Weight aterial
1 rV1l II�6VYt( I V C7ZL From C7 To_L9 Ft.
�✓�C.ny or Town State Zip Code From To Ft. _
From To Ft.
Area code- phone number --
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) From—Q To .' FL
From To Ft.
STATE WELL PIE applicable) From To Ft.
DWQ or OTHER PERMIT 6(tt applicable) 8. SCREEN: Depth Diameter Sld Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft._in. _ in.
DATE DRILLED n From To Ft._i
a in.
"1—1 .')— ('�t-t From To
_ Ft._in. _ in.
TIME COMPLETED I n( l7O AM O PM�(
S. SANDIGRAVEL PACK:
3.WELL LO/�1T`IO\N: Depth Size Material
CITY: 1 \'C�YI`DirVl I�� COUNTY From To Ft.
From To Ft.
From To Ft.
(Sbeet Name,Numbers,Community.Subdrvlaion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope (,tValk:y [3Fiat ❑Ridge ❑Other From To Formation Description
(Check appropriate box) nP
LATITUDE 3 � oZ I_'/b_y'7 =deciml
LONGITUDE 3J - Y /
Latitude/longitude source: t<]PS ❑Topographic map _
(location of web must be shown on a USGS topo map and 0
attached to this to=I MI using GPS)
O.WELL OWNER t
OWNER'S NAME Cn 11�-1
STREET ADDRESS ( ('nGKLri
rPUK Ot
"J t.; (Vr �� 7r1
City or Town State Zip Code _
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: I rC) _
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0p1
c. WATER LEVEL Beim Top or Casing:_ /!) FT 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEp N ACCORDANCE Wml
15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THATA COPY OF TINS
(DBB`+`i(AbOve Top of Cast —LE
RECORD HAS BEEN PROw1DE0 TD THE WELL OWNER.
d. TOP OF CASING IS / FT.Above Lard Surface- •;�„�y,. ,r
'Top of casing terminated at/or below land surface may require r 61t�L1� 1' MAn
a variance in accordance with 15A NCAC 2C.0118. SIGNATU%R'E�OF CERTIFIE/D��WE(LL ONTRACTOR —t- DATE .
e. YIELD(gpm):3Q_METHOD OF TEST C_ CI )tK�-t Y� 1 K)t 05
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Infomta0on Mgt, -
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-ta
Rev.7105
L

SiA7j<a YP' V
N'y a k.
�
'' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
- WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type N T H
Amount�_
9. WATER ZONES(depth):
W ellI Goonyt-rracttor(individual)Name t
�rG.Y`GVr� we'll If/Y, l Fron�_To�_ From T°
'L/r���t t\C From To From To WHI Contractor Compa/n'y Name � 1
STREET ADDRESS 6 cJ l H)Ije 1 o Lac C&"j Fri Tc From To
6. CASING: Thic�gkhness/
4\� �InCVYI�e tY! - Depth Diarrteter Wei
Material
City
th Town State Zip ��/ From To�Ft.
/u
From To Ft.
From To__Ft.
Area code- Phone number —_
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(it applicable) From__Q_To_2DL_Ft.rQYyrG „-
From To Ft.
STATE WELL PERMIT#(a applicable) From To
Ft.
DWQ or OTHER PERMIT#(it applicable)
a. SCREEN: Depth Diameter Slat Size Material
WELL USE(Check Applicable Box): Residential Water Supply From Tom_Ft_in. — in.
DATE DRILLED —I-� '` ) J From To Ft. in.
n.
3
TIME COMPLETED �
^' .�I Fran To Ft. in. _in.
5 AM0 PM�
3.WELL L TION: S. SANDIGRAVEL PACK:
Depth
`
CITY: "�]e_ COUNTY�J�Ch��� FfOM1I To Ft Size. Material
From From To Ft.
(Sir I Name.Numbers,Canmunlly,Subd Lq No.,Parcel,Zip Code TO FL
TOPOGRAPHIC/LAND SETTING:
OSIOPe WVaOey ❑Flat ORidge ❑Other 10.DRILLING LOG -
(checkappropriatebox) From To Formation Description
LATITUDE /j]arr May be in degees,
minutes,seconds or
LONGITUDE `y L -b Ina
decimal format _
Latitude/longitude Source: ROFS ❑Topographic map
(location of"0 must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME
STADDRESSI
t
L 4���ity oyr Town ^ State Zip ode
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOIt
°. WATER LEVEL Beim Top of Casing:_ ��_FT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRN(Use'+•if Above Top a"sing) 1 SA NCAORD 2C.BEENWELL
CONSMUCTIDN
D TO THEW D RDS.AND
THAT A COPY OF THIS
d. TOP p CASING IS FT Above Land may
Surface*
equir ��1,
'Top ri casing terminal with below CA surface may require -- WiU cai 'i / 'E��cSw"� �O5
a variance in accordance with t5A NCAC 2C,0718. SIGISA'TURE OF CERTIFIED 44ELL CONTRACTOR
e. YIELD DATE
(9Prn)��_METHOD OF TEST�jyl /� 'JcJcS�i� I rl-II�ZTs '
1 . PRINTEIDl7AAme OF PERSON CONST._QTING THEJO(ELL
mit the
nal to
ivision Of Water
917 Mail Service Center-h Raleigh,NC 2 699 16117 Quality
Ph ne No (9 9)days.in 30 33-70 Attn:e Information. Mgt.,
I Ii
I i Form GW-1a
1 Rev.7106

0�.--')
RESIDENTIAL WELL CONSTRUCTIONorth Carolina Department of Environment and Natural Resources-Division of Water Quality
G
WELL CONTRACTOR CERTIFICATION# p
1.WELL CONTRACTOR:
` I. DISINFECTION:Type T!-"� Amount
g. WATER ZONES(depth):
vvell tractor(Indlvldual)Name j From
\ �To­(-hQs` From To
" Ys, (A From To From To
Well Contractor Company Name —0 From To
From To
STREET ADDRESS YAe 1p-)A 6,, 0� 6. CASING:
n p ` /� Thickness!
_1� 11*t Il IO (V c /��17� FFrontO Depth Dia/neter Weight
p( Material
-S- Ciry or own Slate Zip Code From To�—Ft al
�.Lp]p����1- From To Ft.
Area code- Phone number '-
2.WELL INFORMATION: 7. GROUT: Depth Materiad Method
SITE WELL ID#(i/applicable) From_j_To,2)0 Ft. Ce meiµ-
From To_Ft.
STATE WELL PERMIT#(H applicable) From To___Ft.
DWQ or OTHER PERMIT#(B applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To_Ft._in. _ in.
DATE DRILLED
C(— /'b_ CS From To_Fl._m. _ in.
TIME COMPLETED v7/--LQF1Q AMO PMR Fran To F[. in. _ in.
9. SAND/GRAVEL PACK:
3.WELL LOCATION: q Depth Size Material
CITY: r11.'ySYtP OUNTV \' n From To—Ft.
n From To Ft.
IShuf: From To__Ft.
(Sbeel Name.Numbers,Canmumty.Subdlnsion,LN No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING' 10.DRILLING LOG
❑Slope OValley ❑Flat gRidge ❑Other From To Formation Descri tan
(check appropriate box) P
{{'a /G/���rr May h in degrees,
✓- --
LATITUDE 3 V / minutes,seconds or
LONGITUDE �c / tys �r in a decimal format
Latitude/longitude source: p3GPS ❑Topographic map
(location o/"S must he shown on a USGS topo map and
attached to this form 1 not using GPS) ---=-
4.WELL OWNER
OWNER'S NAME —,: [k, H&J r/(k
SE\TADDRESS j �l slnl✓`.f �T O
CUU > 107� I� lac. � 7/
city a Town State Zip Code l
Area code- Phone number
5.WELL DETAILS: 11. REMARKS: '
a. TOTAL DEPTH: C/o 5
b. DOES WELL REPLACE EXISTING WELL? YES❑ N04
c. WATER LEVEL Below Top of Casing:- 256 FT I DO HEREBY CERTIFY THAT(HIS WELL WAS CONSTRUCTTE�D PI ACCORDANCE WITH
(Use"+^if Above lop of Casing)
15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND T1)ATA COPY a THIS
RECORD NAB BEEN PROvMED TO THE WELL OWNER. -.
d. TOP OF CASING IS / FT.Above Land Surface'
"Top of casing terminated allm below land surface may require
a variance in accadanm vuth 15A NCAC 2C.0118. SIGNATURE OF CERTIFIEY WELL CONTRACTOR
e. YIELD(gpm): '0(6 METHODOFTEST 0"i Ire CI /r7��-te, ��1� ,ns i
PRINTED NAME OF PERSON CONST CTINF3C1— Q THE.WELL..
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., -
1617 Mail Service Center—Raleigh,NC 27 6 9 9-1 61 7 Phone No.[phone] ext 568. Form GW-ia
Rev.7MS.:_

ti
RESIDENTIAL WELL CONSTRUCTION RECORD :
North Carolina Department of Environment and Natural Resources-Division of Water Quality r` d '
WELL CONTRACTOR CERTIFICATION# J D 6
1.WEhL CONTRACTOR: I. DISINFECTION:Type Amount
" ,1fin ill<c�vas 9. WATER ZONES(depth):
Well Contractor(IndlVldual)Name T From / o
,4-y.kY� w e l l 1Qrr I I — T From To��.. From To From To
Weil Contractor Company Name _ Fran To
//_ II'' �/J From To
STREET ADDRESS O(��/ A'f [� \`d e..(� 6. CASING: Thickness/
\ y �^1 Depth Diameter Wei ht Mal
YNiIY�YiI�P I �� rri977( From 0 ToRO Ft 3 —LYS�_
City or Tarn State Zip Code From To Ft. _
( L ��F_ — � , r"/ From To Ft.
Area code- Phone number --
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) Fri 7 To_aQ _Ft.!�Q t /.
From To Ft.
STATE WELL PERMIT#(jf applicable) From To Ft.
DWpaOTHER PERMIT#(8 applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 54 Fmxm To Ft. in. in.
DATE DRILLED g-a -C7,rj From To Ft in. in.
From To Ft. in. _ in.
TIME COMPLETED 't(13U AM❑ PM�7
9. SAND/GRAVEL PACK:
3.WELL LO Depth Size Material
ATION:
CITY: Ji I I COUNTY 'Trr Fromt TP Ft.
I From To Ft.
v Ylr16dOI^rA )�(li Fran To Ft.
(Sueet Name,Numbers,Community,Subdlnelon,La No.,Parcel,Zip Corle)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
(check appropriate box)❑Slope ISy ❑Flat ❑Ridge ❑Other From To Formation Description
(check
LATITUDE 3 .r1_ %�v (" [inutm or
bei"Ic
LONGITUDE S3,'�-/yb " a decimal torten
Latitude/longitude source: DtGPS ❑Topographic map
(location of"N must be shown on a USGS topo map and
attached to this form Anot using GPS) "
/.WELL OWNER ` I � -
OWNER'S NAME 1\ ',f"11 ULl ew,,,$ '-4
I
STREET ADDRESS y:La, rn-• �
RIL L 1;j5VjI2 lyc oZ�71 r�
ity or TOwn State Zip Code -
}
Area case- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: J nJ
Is. DOES WELL REPLACE EXISTING WELL? YES❑ NO{�
c. WATER LEVEL Beim Top of Casing:_ /b FT I DO HEREBY CERTIFY THAT THIB WELL WAS CONS
TRUCtED IN ACCORDANCE W11H
(Use'+'rf Above Ttopd Casing) RECORD HAS EEN PROVIDED ObTNHE WELL OWNRDTHATACOPYOFTHiS
d. TOP OF CASING IS 1 FT.Above Land Surface•
•Top of casing terminated at/a below land surface may require
a variance in accordance with 15A NCAC 2C.0118. 51GNATURE OF CE1171-IItU WELL CONTRACTORf._ "!DATE
e. YIELD(gpm):--/-ds---METHOD OF TEST ��L )'I t\ I r t t 1 e,5q(I�' •;
PRINTED NAME OF PERSON CON 'fRUCTINGGTT 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. .
y "-Fllrxm GW-1a IfI fji
rycev 7/05
.__

ri� 10 U IV N L rr 0 fort) -------
� � r. q
�VLLL CONSTRUCTION RI;COR
.arolina"D cp atmlcllt of L'nviiowncul and Nn�ll! l rIte�sou/c � Divisloll of water_uuality-Gtoundwaler Sccliut
6 lI
0
ARIE (Point) r �
,CUNTMCIUIt(INUIVIUUAL)N �
�l✓j.//e/' _PIIONE I p_ j?"2 S5
,LCWNTRACIORCUa1rANYNAaIE ii[ r
ASSUCIA'1'Ell\VQ rr.Mi17N
[ATE vV'ELL CONS IRUCIIoN rEM1I IN ,dcnble
if n Jicnblc
1. WELL USE(Check Applicnble flux): ItcsiJculinl�Muulcipal/l'ubllc U ludushinl U Agticullwal U
plouiluting❑ Recovery U Itent Pinup Water Injection U Olher U IfOdler,List Use
2. \V ELL LOCA7T0 / Topogrnphit/Lnnd se(illg
✓ l�i Gr�n4"� UIUJ a USlupe UVnllcy UI'lat
Ncaqcst'I*Uwl%% 0 �9! Cowdy B (cI mk tppiopdale box)
4 srex arcnck LaliluJdlungilude Orwell lucsti is to
(Sbeel Narue,Nuorbea,ConunmJly,SubJirleiar,Lot No.,Up Cale) Nis��5•,eS-s.•'k✓06'.f,.J ,d V
1�24TkC/' !ti)a G�k �� (dearcer/minuut/tecnndt) rv"
3. OWNER: Lotitude/lollgilude source:UOPSUTopoglaphic'lop
Address rL� l b lOay . (check box)
(Sit eel OF Route No.) � ll 111ULIANSi_LUQ
City or"Town Stile Zip Cale
Flom To rornlation Descliplion
Art&Bale-rbone number _O�—0)J Ty — `t2- _ G re
4, DATE DRILLED
5. TO"rAL DEPTll: 3�2
6. DOES WELL REPLACE EXISTING \VELL•1 YEs U NO)1�
7. STATIC WATER LEVEL Below Toll of Cnsillg:
L (Ure"4"If Above"fop of Caebia)
8. TOT' OI'CASING IS L rr. Above Laud Sul race"
•Tap vl ndnN IennlnaltJ Wor below land eat fait rtpuli me&
♦al l ante In&ctorit more with ISA NCAC IC.011 N.
9. YIELU(gpnl): (Z hlKI-II()DOhTES-r_-- --
10. WATER ZONES(dcplll): 6 wcATLON SKMU
t Alnuuut /yc�jG' Show direction and distance in milts Goo1 at(cast
11. DISINFL•CfION:'I'p'e 'Wall'Ihickness two State Roads or County Roads. Include We road
12. CASING: s nuubets and colllnlml toad"allies.
Depth Diameter or\Vci bUfl. MAIc`ial
r1unL�0 Sb PL G- ZS' SAPdf f u
glom -;-b' l'o i 5 rt.
morn 'fu rt.-
13. GROUT: Depol ale[ I 1cWoJ� ;t
iv,
rl0n� — ro 3 1't. c1 w1. P O �
hr0m To PI. IT ur
14. SCREEN: Depol Dialucler Slut Size Maledrd -
1'rmtt_ TO rl. iu. In.
1'1011t ro
IS. SANDAMAVI?l.PACKt Sizo Mnlcllul
Depth
rion, ro I-L ---
1:10111
16. RL•MARIs:
1 DO HEREBY CERTIPY TIIATTIIIS WELL WAS CONSTItUCrED IN ACIM BLINCE RO I1 i!D NCAC 2C,[!L LL
CONSTRUCT ION STANDARDS,AND TUA'r A COPY OI''11115 IU1COftU►IAS SEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE UI' 1111fl50N CONS fIiUC?INO771EWELL
DA7 E
Submit the of Ighlnl to the Div Ito f\Voter Qunllly,Groundwaler Section, 1636 Dlail Service COVdrI ItL'Vg07 C01
111 dnr•t.

1 rs
61
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME ( nnt)_Lr/_rjj- .'t 1 15y s CERTIFICATION# 213Y6
T WELL CONRACTOR COMPANY NAME 111%, (Ay� /rrllt Sg PHONE # 9a5`IL( "-S�e'ISLI
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential C9, Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: IL)yp'nfitri 6f. County '-r v)faVvv ❑Ridge ❑Slope ❑Valley ❑Flat
Jr (^ L,(/ (check appropriate box)
(Street N n ,NEr bers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: F7-< -n t4- Ke U 4 6 1"A) Z e (degrees1minutealseconds)
Address - TI& Latitude/longitude source:❑GPS❑Topographic map
+ ( Tree[or R to No.) (check box)
rv.rt'S,A NZ a<,- DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number -
4. DATE DRILLED
5. TOTAL DEPTH: SfOS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R t ~`
7. STATIC WATER LEVEL Below Top of Casing: FT. —3
(Use"V'if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surface* U1
`Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. --
9. YIELD(gpm): 3 VI METHOD OF TEST Cni r
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H r h{ 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. Maienal numbers and common road names.
From O TO la2_Ft. E, A .5i).f� v-L pr^orv\ C>,`i rnc,rJ (00 SSG ((i7\�
From To FL Cn H r,: W(Y -/-J ✓v ��'1.<}- in'n�
From To FL r t - r
13. GROUT: Depth Material -,Method, a r1ge r nr`+i`r�'� C r'QC' /' J "'t t I e S
From To AC Ft. o�wxpn� `Jt>10�n�
�_ —�---o turr iyJ.�-- She II S,4-ctnL.O
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material fst 1r f fr r N `a t�j h �r 3c
From To Ft. in. in. - n
From To Ft. in. in. t(�✓ftrz wc,�� O'� IStS� t,✓e��
15. SAND/GRAVEL PACK: ('t^ le 1��
Depth Size Material
From To Ft.
From Tc FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL -
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P�� ERSO NSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Jr2e ources-Div sion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Jy � i� p CERTIFICATION#
WELL CONTRACTOR COMPANY NAME yT-%^1Sl')O..I" jA l r Pi�/i 3 PHONE # j�o2k3CfF/' ifu
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ ERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential 55 Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT < Topographic/Land setting
Nearest Town: {� County n C .c ❑Ridge ❑Slope ❑Valley ❑Flat
/(Lt. 21.<A �tr y5�77� (check appropriate box)
(4btrect i. Numbers,Comit?W�kyy,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: r )r�FS f/�yC4�rin (degreestminutestseconds)
Address k/.1c/J�^ Ta' Pgq& Latitude/longitude source:❑GPS❑Topographic map
(' L (Street or Rouu; (check box)
L1lzr{J�inAiri/�ce NC a'77/ DEPTH DRILLING LOG -
ChyorTown state Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED -/-iJS� _
5. TOTAL DEPTH: a
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® r t
7. STATIC WATER LEVEL Below Top of Casing:--Y 0 FT. ro
(Use"+-if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' 'd
*Top of easing terminated atfor below land surface requires a t:
variance in accordancewith 15A NCAC 2C.0118. 6q
9. YIELD(gpm): R METHOD OF TEST
10.WATER ZONES(depth): / ?
LOCATION SKETCH
11. DISINFECTION:Type - _7 �' Amount (_.S' UZ 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 n tubers and common road/names./ G
From1j_Toy 77 Ft.� $q[� e'od n wit �I'D�'1 �I 7- / 113 vl- ;2,� /Q.ke r�p
From To Ft.
From To Ft. /�-+, r 7m '/t S
13. GROUT: Depth Material Method '�`rn Ioe ^� G �'
From_Q_To Ft. !�.omlln I"V .�-- E
From To FL e� lef t✓er �(Iskeo e, �j D �iV M,Ve s
14. SCREEN: Depth Diameter Slot Size Material `�" /�
From To Ft. in. in. /f//"'/7 r �.r(_T'o G r�,m r �E'S 7U
From To Ft.-in. in. oil
15. SAND/GRAVEL PACK:
Depth Sin Material
From To Ft.
From To Ft.
I6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RE ORD HAS BEEN PROVIDED TO THE WELL OWNER

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Secti�oon..,,',���
WF.I.L.CON1 RACTOR(INDIVIDUAL)NAME (print CERTIFICATION#-Lie�46
R'ELL CON I RA( I Ou COMPANY NAME.
PHONE # F`- 7
S'I'A'IE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) _ (if applicable)
I. WELL USE (Check Applicable Box): Residential Rk Municipal/Public ❑ industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other❑ ICOlher, List Use-
-1 WELL LOCAT19�- Topographic/Land setting
Nearest Trolwn.��*�q _tS;_,Iv,Iill— Counl�3r.' ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
�Street Name.Numhers.Cmnmywrity.S lxlivision,Lot No...�{(Z,ip Cudfe) Lalitudeflongitude of well location
�
3. OWNER: c—v-- — VY "}- r" �I"' (degreeslainotes/seconds)
Addrocs / /'7"a f o{1/y_ _t�C'.. Latiludc/longitude source:❑GPS❑Topographic map
(Street or Roure No-) + teheek box)
Z( DEPTH DRILLING LOG
Cay or Town State Zip Code From to Formation Description
Clint- G77ti N
Area Code-Phone number
4. DATE DRILLEDL -(� S
5. TOTAL DEPTH: --�3e)s 1
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO t
7. STATIC WATER LEVEL Below Top of Casing: i ..fin FT.
(Use"I"if Above Top of Casing)
R. -TOP OF CASING IS�_FT.Above Land Surfaces -
'Top of casing terminated atior below land surface requires a
variance In accordance with ISA NCAC 2C.0118. ,
9. YIFLD(gpm): StO --- METHOD OF TEST_ I r
10. WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type 17-H 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. Matenal numbers and common road names.
From__.T0152._ FL 6Y4 _._ �� - �tT� C+-N- 3 �n�' f.='•V\.o
From To R
From To Ft.
11. GROUT: Depth Material Method ,,( � �111�- Gc���l ✓`. 1 \C>C`��
From To_�_FL i�ey)C2n6-
From---To—..__ Ft_ - - ��rf6� qlf\YC C�,
14. SCREEN: Depth Diameter Slot Sizc Material Ti- QI (
From To--Ft. in. —._ in. .'IJ'y\t(„jt ` [ty+'rl� atJF rl VC. f j L� .�. ✓+i 7�Y j
From To Ft- in. in.
I5. SAND/GRAVEL PACK: ll✓` \Depth Size 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
CONSTR UCfION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON C STRUCTING THE WELL -DATE
Submit the original to the Division of Water Quality.Grwndwater Section, 1636 Mail_Scrvice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. - OW-1 REV.07/2001

S v r J
RESIDENTUL WELL CONSTRUCTION RECORD
O\�)
North Carolina Department of Environment and Natural Rcwlt[rces-Division of Water Quality ,
_ WELL CONTRACTOR CERTIFICATION# 23 0 f'+
1.W NTRACTOR: f. DISINFECTION:Type t- ,-Amount It, 17Z
g. WATER ZONES(depth) f
welf CCntract6F(Indtriduaq Name FromurTo
� From To
+ �
l�✓s�( .i`I �rllly(.Eg. From To Fran To
Well Contractor Company Name FFF pp From To From To
STREET ADDRESS �L ��yNi' Fla ICtTit•� S. CASING: Thickness/
, Depth Diameter W " M
raterial
IC ✓Kv, �,7 � (, 7� From/ � To Ft ( Ll �(
City or Town State zip Code From To Ft
. 4k
( )-Li A,• 'L(99 From To FL
Area coda Phalle number
7. GROUT: Depth Material Method
2.WELL INFORMATION: Fran_p, _To_. '1_FL CYiv+&t+- -d ,\, ;�i
SITE WELL ID a(a appfiade) From To Ft. ,
STATE WELL PERMIT"applicable) Fran To FL
DWO a OTHER PERMIT#(If applicable) S. SCREEN: Depth Demeter Slot Sae Material
WELL USE(Check Applicable Boxy Residential Water Supply From Tc Ft—in, in.
DATE DRILLED d-/�� From To Ft_in. =in.
Fran To Ft_in- _in.
TIME COMPLETED N'4l AM❑ PIn
S. SANDIGRAVEL PACK:
3.WELL LOC TIiO�N,,: Depth To
Material
CITY: 41pU/l5yi)l! COUNTY From To FL
Fran To Ft.
all cif if " <'p (2.r J. Fran To FL
(Sbeel Name-. _Suhdraion.Lot No.,Parcel.Zip Code1 -
_. __._.
TOPOGRAPHIC/LAND SETTING: _ 10.DRILLING LOG
❑Slope ❑Valley ❑Flat XRk1ge ❑Other From TO Formation Description
(deed`apprmpda4 had May be in degrers
LATITUDE LEA° minutes,seconds a
LONGITUDE� :3 O t/1 f -' l•7 in a decirrral bmmt
Latittaidlongitude source: AGPS oTopographic map �.
(location of wel must be shown on a USGS topo map and ,
attached to Mls form 7not using GPS) --T
4.WELL OWNER �� /}/� - _ •y
OWNER•SNAME [L-lG i` f III1,0h _
S EET ADDRES -i I •Ti 'n
��hrr�5✓,�
City a Toren state Zip Code
( q21 } L171 - 1/n 3r6
Area code- Phasenuoter
11. REMARKS:
S.WELL DETAILS-
a. TOTAL DEPTFt -/L/V
b. DOES WELL REPLACE EXISTING WELL? YES❑ No
rf I DO HEREBY CERTFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C. WATER LEVEL Below Toed Casetg: L/t.! FT. 'M NCNC M WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+'8 Abom Top of Casbg) RECORD HAS BEEN PROVIDED TOTHE WELL OWNER
d. TOP OF CASING IS I Fr.Above Land Surface• n � 9_ i —
'Tap Of casncein ccordeted with bal15AN lanCA 2C.01 8. require SIGNATUREOF CERTIFIED WELL CONT0CTOR DATE
a varialce in aIOcerdarrce with 15A NCAC ZC.0718. 1l
e. YIELD(gpm): 1-3_METHOD OF TEST T i r PRINTED E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:information Mgt, w-ter
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. FamG Rev.

;,.suTfa
S RESIDENTIAL WELL CONSTRUCTION RECORD J.
TI
•'.y` - North Carol'ma Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3-s!"
1.WELTO)NTRACTOR: I. DISINFECTION:Typed T/-1 Amount
I <'Lj-1 (n 1 ' \lll(y' Ci g. WATER ZONES(depthr
W ontmctor(Individual)Name From_ To .�>� From To
`n'Irc, ,C.�.`l From To From To
Well Contractor Company Name a '� From To From To
STREET
\ADDRESS 1E���n�/-/�"�YLl2 /ia:J1� ��c,C� S. CASING: s� Diameter Weight Millenal
Thicgressl
�.bbH ills �� V F� 77� Finn, © ToDepth�b FL U- AI fJV
City a Town rstate Zip Code From To Ft
Fran To Ft
Area code- Phone numbs
7. GROUT: Depth Material Method
2.WELL INFORMATION: From_0_To -O FtCGYNQ '"m ,n�
SITE WELL ID*(If appkAbe) From To Pt
STATE WELL PERMfT#(yapplicable) Fran To Ft
DWQ a OTHER PERMIT#(y appbcablel B. SCREEN: Depth Diameter SIDI Size Material
WELL USE(Check Applicable Bco):. Residential Water Supply Fran To FL—in. _ in.
Frain To Ft_m- =In.
DATE DRILLED From To—Ft—in. _ir.
TIME COMPLETED L/3(7 AM❑ PMR 9. SANDIGRAVEL PACK
3.WELL LOCATION: Depth size Malarial
CITY: /�YYJ)nrsyl�l E COUNT' Fran To FL
�r ,,//�� 1 y� From To Ft
2-5yk elind k7(Y./CIAn oel Fmn To FL
(StrnN.N e.Nunbers,Cammamy,.Su LntNo.,PNceI.Zp Cade)_ .._ _.______ . . -
TOPOGRAPHIC I LAND SETTING: _ 10.DRILLING LOG
❑Slope pvaley ❑Flat AR499 ❑Other From To Formation Description
(check apwopnate Doe)
r ,� May be inderem
LATITUDE S 161i Mimes.sewn&or
LONGn-UDE,y� ��6 �)! S in a decimal fmrnat -
Iatitude/Iongitude source: jaGPS ❑Topographic map -
fbaabbrr of we#must be shown on a USGS topo map and 1
allached to#ds(arm/nd uvg GPS)
4.WELL OWNER
OWNER'S NAME
SHEET ADDRESS 6%IL e-nc/ oJtCrC t2, C
6biosrd 1" /�'Cc '���i l
City or Town State Tp Code
Area code- Ptgne number
11. REMARKS:
5.WELL DETAILS: .
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EYJSTiNG WELL? YES❑ NO)k
1 DO HEREBY CERTIFY THATTHIS WELL WAS COKSMUCTED NACW NI ROCE WHIR
c WATER LEVEL Below Top of Casing: FT. 15A NCAC 2c.WELL CONsmuctpN STANDARDS.AND IHNT A COPY OF THIS
(Use'4'it Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d TOP OF CASING IS i FT.Above Lad Surface• �.,al,.s�,-: -r�.�L',��s / aZ��j
?alp d casing bvmnaled aUor below lad surface may require SIGNATGRE OF CERTIFIED WE COL. -NTRgCTOR DATE
a variance n accordance with ISA NCAC 2C.01 18. ^'�
e. YIELD(gprn): /h METHOD OF TEST_C't 1 � C 11.1 /' V✓1 t I I �<
PRINTED NAME OF PERSON CONST UCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information MgL, Form
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. GW-la
Rev.7105

�_ESmIDE
NTl,4 t'L WELL O RDNoah Caroliepartent ofEnvbonmenl and Natural Resources.Divaion of Water Quatily
@auw
- WELL CONTRACTOR CERT[FICATION H
FrzT;IA
TOR:
I. DISINFECTION:Type_fi rfT Amount l .�/•IL
j•-, n ( YI r Ste rndvidrra0 Name'— & WA�7-E�R{ZO�NES(depth):lie �,I r Ffcrnj +LTo4' 3 FromTo
omName Frprn To From
� ?� 1 FromTe To
SS i7',J__I f��X_ ��,tt—� Fin To_ 1 Lv 6. CASING:
:<f_ :r ✓�'� ��� r�/ 77 Depth 7hiclrrreas/
Citya Town S(,aia " '% �! Flom ` To��FL �D� � Material
Zip Code F�—T s�-rL—r5 .✓.
_ Ft.
Area cado- Phone numbs From To`FL
2.WELL INFORMATION: 7. GROUT; Depth Materiel `—
SrTE WELL ID MatMd
M(g alullcab e) From Tq�`FL CCY 1-,l j
STATE WELL PERMITYtaapptirelNe) F�—To�FL� y• inS
Frorn`^To -�FL
D WQ Or OTHER PERMIT s(d apph'cable)
WELL USE Check ) & SFr SCREEN: Depth Diameter Spl Size Material
( MPaceble Box: Residential Wafer Supply __tn.
GATE DRILLED - ?� From__` in.
Tom_FL_irl __bt.
TIME COMPLETED LOO F�—._To
PJ4O PMj)�J Ft�jn. fn
8.WELL LOCATION: 9. SANDIGRAVEL PACK:
1Z hh ��C DepthCITY: � /IF'l J COUNT' �vV�� 1 From TO FL size Material
From To
— Led.No � F�
SUbdi 7e `
CaMrtMudtY. Naton.L .Pan L lip Cade) Ft.
TOPOGRAPHIC I LAND SETTING: a e-
OSlope pValley OFIat IkRklge ❑Odrer 10.DRILLING LOG
(check appropdae yxq r �--- From To Formation Description
LATITUDE _L ', J .7`r May be in degreer, -
-7 t minme;aemrey or LONGITUDE� 3 q& " in a deeim i llurnal
Latitude/longitude source: PtGPS DTopographic map _
Pocatbn Of Wee"Am be ahuwn on a USGS lopo map and
attached to Lb is form root usbg CPS) -
4.WELL OWNER /'�
OWNER'S NAME &1d0Y1p
S/TT]RE1E�TI��ADDRESS Lr�..•2/"-LS( is- •ram /'i- y,- t/J- ,� .
L ny ur 1 D Slate %Code _-
471- Rail
Arm code- Phone number
S.WELL DETAILS: II. REMARKS:
a. TOTAL DEPTH: z )j;! _
b. DOES WELL REPLACE E)USTING WELL? YES O NO1
e. WATER LEVEL Below Top of Casing: g) .3;� ,F7, 'DO REREav cERmnrarrwa WELL Waa
(Use'i'gAbove Tap atCaaIn 1S4 NCAC 2C.WELLCONSrRDCRON STAVDMDDS Arm T1UTAC DWACOURWNCEVM
RECORD W BEER MO�e1ED To The WELL OWrrAN
d. TOP OF CASING IS�_FT.Abova Land Sugmir
"Top or cas'vlg lerminetad attar below land surface may require t LiLsPI r�/�GL�•R1rrL 'U.- -�f
a variance to acm�tdance with 15A NCAC 2C.0119. SIGNA1 URE OF CERTIFI/E�D,,W E CONfRAC70R DATE
a. YIELD(gpm)- LX METHOD OF TEST_ _,� }i n 1 '1 n �Cr n S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information MgL,
1617 Mail Service Canter-Raleigh,NC 27699-1617 Phone No.(919)733-701 S erlt S66. Form GW-1a
Rev.70

s�>Fu
RESMENTUL WELL CONSTRUCITON RECORD
+~
North Carolcna Department of Environment and Natural Resourar-DivLlwn of Water Quality
WELL CONTRACTOR CERTIFICATIONS
1.WELL CONTRACTOR:
� E DISIIF•ECTION:Type Fi± e'j amount I
Q �t- 'rN 1 /`l�I�c;A!S % WATER20tES(daphY
i
W m °or(hrdNiduaill,Nttame'� Fmmy_To c ��7 From To
�r�1,z1W� t 1 1l r1lI1i\< Fmm Tc Fran To
Wel Contractor Company Name y- /7 J From To Fran To
S EETADDRESS i�,3y/y >l Tc'1,1)'A iG+c,t:l S. CASING: Thxkmr/
---� Dapm �D'���r,ma we91a NaIe�I
3 4Tt'�fiY�IG PVC
IVt. ��77� Fran G To _Ft�L1_ I
City or Town Slab rp Cade Fran To Ft
�a~' f • 7�- `'(c5�1 From To Ft
Area Code- PhonenunWC
7. GROUP Depth llabrial llNnod
2.WELL IFORMATIOlk From�To�Q_Ft C,a vr,.G lt# n
SITE WELL ID f(If amplaNar Fmm Tc Ft T ,
STATE WELL PERMrr#Wwpkob* Fmm To FI
DWQ or OTHER PERMIT S(f appicabk) L SCREEN: Depth Dianeter Slat Sae Material
WELL USE(CMrJcAppieable Bar): Reaidadd Wafer Sapplp� Fran T Frmr To FL Ft h _in.
f it _it
DATE DRILLED —Z3C�& Fm To Ftat _in.
/
TWECOMPLETED L--Q AMU PMj* 9. SAW/GRAVELPACI(:
3.WELLL TION: f^, Depth Ste Ill
C�IT�/ Foon Ft
: i(+ �P COUNTY/rC Fmm To Ft
/G'IIC)I A' Cr p vK frA Rea Tc Ft
.(Steel Name..NadMMC0Wmalr-8Welaion.LM1ft,PaFMLZO Code)- _ __' _... _ -.i'?t'—
TOPOGRAPHIC I LAND SETTING: Is.DRILLING LOG
OSlope OVAW §(Flat DRidge DOiv From To Fomtation Description
check
LATITUDE �o7SU` Y ' Maybein aegaeA '
wsksomxamdsor
LONGITUDE c3 ° .�D� /.�. / " boadeciod' -
Latitude/lonliiude samx: HOPS DTopographic map
(bcation orwdmd6e shown ono USGS Aopo ntop and ;
afttceod b M ftrM 7not=ft GP57 C
4.WELL OWNER _ _ ,_
OWNER'SNAME�, nn r! y /Y
STREET ADDRESS Y//11A l ae IC,n Pr.r• O
CdycrTown Stale Zp Code
Area code- Phone Meter
11. REMARKS:
S.WELL DETAILS: � ''77��-,
a TOTALDEPRk `"�O(J
b. DOES WELL REPLACE D(ISTiNG WELL? YES❑ NOA(
CEKWYc, WATER LEVEL BebwTcpofCasing�FT. 1saMAC WELL TmcaNstaucnowACCOFOMICEVWM sralmwtos McO"OFIM
(Use w IAbmTop d Casing) atvrolormS BEEN WtOV083701tE WELL OWNER
d. TOP OF CASING 95 FT.Abm LaF d Salad ' i.n /22elL g /0 1
. 'fop o[caft- neled aUa belowlard aw(aee.. t. - SIGINXTURE OF CERTIFIED CONTRACTOR DATE
am in anxadaoevvih 15A NCAC 2C.OI1IL ^-
e. YIELD(gpn* METHOD OF TEsr
PRINTED NAME OF PERSON CDNSTRUCTM THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn:information Mgt, Form GW-ta
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7i 5

ssr^yo
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department orEoviroomgp and Normal Reactances-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELLCONTRACTOR: f. d81NFECTIOlt Typs_-L _Amount 1 rQ-,
9. WATER ZONES(depth):
W inaeW(hrdwiduaIl)I Nance,
(� Fnan /�Q To Fmm To
�/ I by yyl W Q t( orf I I I N! Fran Tc Fran To
We9CantrCompa�y Name s� Fran To From To
STtRREETADDRESSI �L) C� rrl . ., I2,..,C S. CASING: Thickew
f1bbl rv<v J 1Q I V L Ot*771 Femn__�T, Ft G
CotyarTown GState zip Corte From To Ft
t)�
( } L)7r1- "i8 L! Fmn To Ft
Area code- Phone turner
T. GROUT: Depth Material Me1Md
2 WELL @FORMATIOtt Fran b To 3X Ft (�fliM42V%j- o'^+a i>1,S -
SITE WELL ID#TdappicaMa) Fram To Ft
STATE WELL PERMrr#llappacaab) From To Ft
DWQ or OTHER PERMtT#(l appieabb S. SCREEN: Depth Diacekr Sid SIM Material
WELL USE(ChedtAppTmahb Raiderrar Wales Supply(?!, From To Ft bt _h�
Fmn To Ft n. _n.
DATE rum r m /c,-/ Fran Tc Ft_in _in.
TIME COMPLETED 3 3n AMO PM(tt
!L SAImfGRAVQ PACK
3.WELL TIONt 1� Depth Sine Material
CITY: in - ii ® COUNTYG 0,6nyr� From Tc FL
/� / �_ From To FL
�+b CtiG-i (�''�YI`I-�yr- l.%L�.<_K. gr...& From To Ft
(Street Name LOU
TOPOGRAPHIC t LAND SETTING:- Is.DRIWNG LOG
gN' O
Slope DYa1ey Rrt ❑Ridge 1300M From To FortnalionDmaipton
,• (dmck app�apc. .9b�o)�� ��
LATITUDE -4- t 916"-5? Mry4odombo _
mioMt,:amdsQ
LONGfTUDE�3" -37� 3E„�l" �,daimad imr,at
LadibArAon®iode so mca AIMS oTopographic map -
(bcdm daalaaatbe shom an a USGS topo nnp and _ ,
dtedred to Lis formind asN9 GPM .
,L WELLOWN ER
OWNER'S NAME
STREETADDRESS _ L6O �f..rS3 �Ic51 Y1 -
tr7v� v ak NG 9*77`y uT
a Town State ZPCode
( At?7 — C9 3'1 l
Area code- Pho a number
11. REMARKS:
S.WELL DETAI.S-
m TOTAL DFPnt r,//
C L
b. DOES WELL REPLACE DUSTING WELL? YES D NO p{
IDOHMWCB wyll ATIMWELLwASCONgOwclrDNACCORDAmCEy
es. WATER LEVEL SeIowTopdCsig: D FT. 15ANCAC7G.WULCOMmuenoa STANDARMANDIM'rAcorrornao
(Use'+'I Abau Top d Ca6g) REMWHASBMPROWDMTOTMVMLOWNSL
d. TOP OF CASING 18 / . FT.Abora Lam Soface`
'Top d oastg IMmnaled altar b dow tam surface may rerpve SIGNATURE OF CEFTTIF(�G-2-..
avariatce inaeoerdarce vaTlt 15A NCAC 2C.011& RE OF CERTIFIED CONTRACTOR DATE
e. YIELD(9Pmk-- --METHOD OF TPb'T a i (r ��:�'�"'�n 1�'L \Fg61
PRINT®NAME OF PERSON .THE W91
Submit the original to the Division of Water Quality within 30 days. Attn:Infonturdon Mgt, Form GW-1a
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7106

Olt
RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of Water Quality
`/
Q d• WELL CONTRACTOR CERTIFICATION# �5
1.WELL CONTRACTOR: f. DISINFECTION:Type hf t Amount 13 n -�
22ift"IF-I'n 11 7 g WATER ZONES(ddeepth):
Wellnb l actar(Indivbuat)Name From n ' To e7�J ' From To
(`n From Tc From To
Well Contractor Company Name r /I From To From—To—
STREET ADDRESS
`f C?�j LI N' I(X,lA C)rIc S. CASING: Thickness/
th�6bin� jle 1C. �77 � From B �7o l2r Ft G I/Li :S'h&Iull
City or Town ��Stale Zip Code From To Ft _
b `15e..1 From -TO—Ft—
Arm coda Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
`
From _To Ft CS V1101t —
SREWELLID#(aapplicable) From To Ft
STATE WELL PERMIT#(r applicable) From To Ft
DWQ or OTHER PERMIT#(I applicable) 6. SCREEN: Depth Diameter Slat S¢e Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft_in,
_ in.
From To Ft_in. _in.
DATEDRILLED l('7 .�k7-- (1 ri Fran To Ft_in. in.
TIME COMPLETED /oR c3D AM❑ PM a 9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: bl r I�Q COUNTY � From To FL
—
From From To FL
C�nrlj 1 C1i rd RCC From To FL
(Street Name.Numbers.Conmunity.SubdMsion,lnNo..Perm,Zip.Code}
TOPOGRAPHIC I LAND SETTING: _ 10.DRILLING LOG
❑SIDpe EiVaky ❑Flat Ridge ❑Other From To Formation Description
(check appropriate bar)
LATITUDE 3 I /S-�7,y It May baiseco di;ci
enlaces,urandsa
LONGITUDE D c3 r I-/s` c7 .n tr in a dedmal uncut
Iatitude/(ongitudesource: prGPS ❑Topographicmap
(location of well must be shown on a USGS topo map and
Wached to this form trial using GPS) -�
4.WELL OWNER -
{{ r
OWNER'SNAME �CIYYC Y.f,/nHP ?�
ST EET ADDRESS <S;1o,.)hj Al il.nr.t'X
9
hh IIA lac ?,kc771 `A
City or Town State Zip Code .
( * >y Lily —,' hILI
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO
DO HEREBY CERMT ATMS WELL WAS CONMUC1ED INACCORDANDE wmt
I
G WATER LEVEL Below Top of Casing FT. X HCAC 2C.WELL CONSTRUCIM STANDARDS.AND THATA COPY OF THIS
(Use-+'a Above Top of Casing) RECORD WAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS ( FT.Above Land Surface r f.�.f[�,_ �7 x � % `-
Top d casing termi ated a0or below land surface may require � .�
a variance m accordance with 15A NCAC 2C.0118. SIGNATUh OF CERTI IE�D�WELL CONTRACTOR DATE
e. YIELD(gpm): in METHODOFTF-ST GtA"li�X n4
PRINTED OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Fo m G
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. FormW-ter
G 5

0�'STATto
RESIDENTIAL WELL CONSTRUCTION RECORD
�'.� _ North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 33 �6
1.WELL CONTRACTOR: I. DISINFECTION:Type Amount 0 �
g. WATER ZONES(depth)-
W ontractor(Individual) Fmm_LQ Tc_aa5 From To
V - We 0./r1 \l n' From Tc From To
Well Contractor Company Name (( I From To From To
STREET ADDRESS �V4 /"T XC4rC I Q.Ji\ �•I.A 6. CASING: Thickness/
Depth Diameter Weight Material
b`Ui✓T�Vi�le' IiYC, ��-77) From�ToFt r/ci 21 O'Cc.
City m Town State Zip Code From To Ft
( Lj1Cr-� L j 7q_ 45-L16 L, Fran To Ft
Area code- Phone numbs 7. GROUT: Depth Material L Method
2.WELL INFORMATION: Fran To )Z Ft CN.YY�i Y�cl- •" i
SITE WELL ID#(it amftable) From To FL
STATE WELL PERMIT#(Happic") Fran Tc FL
DWQ or OTHER PERMIT#(d applicable) L SCREEN: Depth Diameter Slot Sire Material
in.
_
WELL USE(Check Applicable Boc): Residenhai Water Soppy From To Finn To Ft Ft_in.fn. _in.
DATE DRILLED ZC�' From To Ft fR in.
TIME COMPLETED /a' AM❑ PM$J —
9. SAND/GRAVEL PACK-
'LOC TIONyy: Depth S1123 Maland
CITY: ¢,bl ; Y I COUNTY From To Ft
n. 1 1 [: Fran To Ft
I �.-1 �[,� Fran To Ft.
.(Street Name.Nuabea,CmenwaA.Subdiviskm.1-004M.Parcel.Zip.Code)- .._
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope [ Weley ❑Flat ,Ridge pother From To Formation Description
(ohedc appropriate Irox) May be in degas,
LATITUDE 3 20 r/ c mirates.seconds,or
LONGITUDE 34 a:2.,5' imadeciemllamer
Latitude/longitude source: )KGPS oTopographic map 4
ibca#on of waf must be shown Do a USGS Aopo map and
aaadred to#tier form IAd usig GPS) C
r
4.WELL OWNER
OWNER'S NAME<56^,Y1',,i/)I21� `+P+e��.UrN p
STREET ADDRESS _fI t) &,%: 7 q
�t:fhe�sr;16 GA 2n�. r
City or Town State Zip Code
07r, t- r1. 7 - 6l�!
Area code- Pfone number
11. REMARKS:
S.WELL DETAILS: �t
a. TOTAL DEPTH: dal�
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO fS(
G WATER LEVEL Beiow7 of ) IDD HREBY CERIFYTrIATo4S WELL WAS CONSRXTED S AOWROANCE WITH
ap CaBing: / OJ FT. ,SIN M.WEUCDNSMLCTMSTAMARDS.1 THATACOPYOFTM
(Use'+'Ir AhWe Top df Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS_�FT.Above Land Surface' `�✓ ,�� ( �).,L��r.
'Top ri nce in accordance
With 15A farad surface may rflquae SIGNATURE OF CERTIFIED WELL CONTRACTOR ' DATE
a variance k accordance with 15A NCAC 2C.0118.
f
e. YIELD(gpm): I Y9 METHOD OF TEST Gl i�r-
1 .1 ) "u•�""� Y r t�i�•S t rn {
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., G
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 56S. Form W-ter Rev.

d.w STATto
CIA Qrl �'
- ::. S RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envimnment and Natural Resources-Division of Water Quality
_. WELL CONTRACTOR CERTIFICATION# ` t-E3 0 si/
1.WELL CONTRACTOR:
I. DISINFECTION:Type Amount DZ,
�' 9. WATER ZONES(depth):
Well Contractor(Individul)Name/ From -) To1_ Q From To
0Ir<n �, � �I/�11 I C From To From To
vv'innWell Contractor Compa/n'y Name ' ' om— From To From To
T
STREET ADDRESS �2 �Y(�� I CWV\ r`i%C j 6. CASING: Thickness/
Depth Di eter i ht M edal
(� bimfr �P 1 V � From To i !�CRL 6 Ail e-Jal
�fiCity or'Town State ip Code From To Ft. _
( a p� } � 71- Kq Fj y Fran To Ft. _
Area code- Phone number
2.WELL INFORMATION: 7. GROIN: Depth r Material Method
m Q
SITE WELL ID#(B applicable) Fran_D To Ft.(2 OV AL-From To Ft. .Q
STATE WELL PERMIT#@ applicable) 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.
DATE DRILLED lL
y� l�'- uj;r A From Tc Ft. in. _ in.
L__ , Fran To Ft.__in. _ in.
TIME COMPLETED 2-_aD AM❑ PM(�
9. SANDIGRAVEL PACK:
3.WELL LOCATION; Depth Size Material
CITY: Ize) ly�Volk COUNT From To Ft.
�7 From To Ft.
�MA'.\ l '4-PC'K ?'C j From To Ft.
(Sbaet Name,Nulamrs,Community,Subdmsm,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope OValley kFlat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
LATITUDE `�3 - 1 y y6 I t< May be in degrees,
�/ minutes,secondsa
LONGITUDEU r [. V r r in a decimal format -
Latitude/longitude source: ppGPS ❑Topographic map Y
_
(bcatbn of well must be shown on a USGS topo map and
attached to this form it not using GPS) —
4.WELL OWNER I -
OWNER'S NAME `/+ \jy< Ir Le P - PY'^L
STREETADDRES))S c-.t'L. c (q�� 12g, 15:11
l�lbr.'f.Y l�n �C <g'-7_ZL� _ -
City or Town State Zip Code
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
�
a TOTAL DEPTH: LW
b. DOES WELL REPLACE EXISTING WELL? YES O NO pq
c. WATER LEVEL Below Top of Casing: an I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THATA COPY of THIS
(Use"+'8 Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS i FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED LL CONTRACTOR ONTRACTOR DATE
e. YIELD(gpm): /0 METHOD OF TEST
PRINTED NAME OF PERSON CONSTI*JCTING 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-la
Rev.7/05

d<+STATto
{y WMM
RESIDENTIAL WELL CONSTRUCTION RECORD �+ t
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# c 11 1.WELc-Li CONTRACTOR:`�.Y f. DISINFECTION:Type r Amount
�li�,j c� t ' 11,1 r.n g. WATER ZONES(depth):
Weil
�"CC-� rracctt r(Individual)Name y/.�, 'I From rk'o To aNS From To
/J_l)nc-, uIy ` Gr1111 From To From To
Well Contractor Compan/y Name J 'j� `r— Fran To From To
STREET ADDRESS 'O I I�YC� 1 Cal u1� 6. CASING: Thickness/
1 Y7��l1GVr��E L V �__ From� ��)
OTo 20 epth Ft. Di r Wps6- . Material
VL
City or Town State Zip Code From To Ft. U
(_��- L!Try - �9 b N From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
�
Ffpm�_Tom FLCC�YYpA�-
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(a 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 From To Ft._in. _ in.
{ From To Ft.—in. _ in.
DATE DRILLE TED s 7� ( 2 Fran To FL n. _ in.
TIME COMPLETED l a�O AM p PM
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: � i�b COUNT Y 4 From To Ft.
(�(� / 1� �/S From To-Ft.
tZ t 1',L`1r () l I�sus` dln,( (t� Fran Tc Ft.
(Street Name,Numbea,Community.Subomsion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
10.DRILLING LOG
❑Slope OValley ❑Flat jeidge ❑Other From To Formation Description
(check appropriate box)
LATITUDE 3Opt,t� r May in degrees,
{r {{ minutes,seconds w
LONGITUDES U LJS (,p / in a decimal format
Latitude/longitude source: XOPS ❑Topographic map
(location of web must be shown on a USGS topo map and
attached to this form d not using GPS) "^=
4.WELL OWNER _
OWNER'S NAME ) o
S REET ADDRESS c (- , L
I�mh1Dt:c,�t'14 arc 771
City or Town State Zip ode
y7 -J�AC , 0.3SJ
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
/,
a. TOTAL DEPTH: ackK
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOA
c. WATER LEVEL Below Top of Casing: ! y _FT. i5A NEREBYC WELL
CTHATTHISWELL WAS CONSANDTHOWACCaiDANCE WIT,
15A NCAC AS W ELL C OVIDED TOT STANDARDS.AND THAT A COPY OF THIS
(Use-+•rf Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' •�; ®/� ,„ _ o,5
*Top of casing terminated allm below land surface may require SIGNATURE OF`C'E*R`TIFIED W L CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm):—i-1v) METHOD OF TEST C1 I 1 C��CkS''"If1 -�to(y s'
PRINTED NAME OF PERSON CONS�UCTING 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. Fam Gw-1a
Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
-- North Carolina Department of Environment and Natural Resources-Division of Water u v..,,,.,. Q ably
WELL CONTRACTOR CERTIFICATION#
1.WELL
CONTRACTOR: f. DISINFECTION:Type Amount / ea
Ip 'r% 1'!' Lj g. WATER
t^ZONES(depth):
Well Cmtracta(IndividulIal��)Name From 7s7 / To �i n S/ From To
From To From To
Wedtontracta Company Name ) —+yam— From To From To
STREET ADDRESS�t_I y�e Taeh znrnfli 6. CASING: Thickness/
Depth Dia%'er -weight rMatenal(Rb�j► IrYl{ From _Tp Ft. b alPLClty
_
L� a I ooWn state Zip Cotle From To Ft. _
Fran To—Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) From To A0 Ft. C-C-'W1'+ Qy. iriL
From To Ft. U
STATE WELL PERMIT#(a applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicabie) 8. SCREEN: Depth Diameter Slat Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. _ in.
DATE DRILLED 1(1—I/-n3 From To Ft_in. in.
From To Ft._in. _ in.
TIME COMPLETED S�, OO AM❑ PM
9. SAND/GRAVEL PACK:
3.WELL L,�IO�'CjATIO1N�: ff Depth Size Material
CITY: 1L�el DlCSVfL c' COUNTaa�-a� From To Ft.
4 a�^ From To Ft.
Fran Ta Ft.
(Sbeef Name,Numberc,Canmu aY,tallvicion,Lol No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley pFl j ) ❑Other From To Formation Desai tion
(check approprria0e box) P
LATITUDE 3 �p yob �36,�rl Maybeindegnes,
` mimrtes,aecoirds a
LONGITUDE X N� �Ir In a decimal fornuit -
Latitude/longitude source: ECGPS ❑Topographic map
(location of we#must be shown on a USGS topo map and
attached to this form 7not usdrg GPS) '
4.WELL OWNER (� f��J � CD
NAME EjfrnK T,Vi tCnhSgrP—✓^
ST��j EET ADDRESS JQl er pf'S (flC_ m� ,C .r•� F -
1�(rlhh�tr,✓i��s
City or Town State Zip Code
Area code• Phone number
S.WELL DETAILS: 11. REMARKS:
�� Z
a. TOTAL DEPTH:
la. DOES WELL REPLACE EXISTING WELL? YES O NOD(
c. WATER LEVEL Below Top or Casing: _FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONStRUCTED N ACCORDANCE Wm,
(Use'+•rfAbove Top of Casing) RECORD HAS BEEN SA NCAC 2C.WELL PROVIDED TO TISTANDARDS
W LL OWNERD TACOPY OF 1H15
d. TOP OF CASING IS I FT.Above Land Surface- /�J/
*Top of casing terminated at/or below land surface may require / •
a variance in accordance with ISA NCAC 2C.011 S. SIGNATURE OF CERTIFIED VVtLL CONTRACTOR DATE
e. YIELD(gpm):_y _METHOD OF TEST_ G.t^(� 4� j:1-ln 11j c;
PRINTED NAME OF PERSON CONSTR CTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt,
1617 Mail Service Center—Raleigh,NC 27 6 99-1 617 Phone No-[phone] ext 568. Form GW-la
Rev.7105

e 4STATt�."
j��yRESIDENTIAL WELL CONSTRUCTION RECORD" North Carolina Department of Environment and Natural Resources-D
iv
ision of Water Quality
_. WELL CONTRACTOR CERTIFICATION
1.WELL CONTRACTOnR:�� I. DISINFECTION:Type_ / H Amount -
g. WATER ZONES(depth):
Well Contractor(Individual)Namel From_aL TD_tkL From To
v�f C rt f From To From To
Well Contractor Company Name ( � '7- From To From To
STREETADDRESS c L` 7T1 ydp /QU,) ,/� Thickness/
(C pc o,� 6. CASING:
1Sl IDYL iJkS/;Ito j V C �C�7 7/ From _DTot2L Ft D ` Q�9hR',�I to C
Crty or Town State Zip Code From To Ft. _
g2 }_tz ]Cj- "6 4t From T^ Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID From � To�Q Ft.( Pejn P/ - ,"A In
#f^appliwbk) Fran To Ft.
STATE WELL PERMIT#(Aappkcable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Ff0f11 To Ft.-in. _ in.
p� From To Ft._in. _in.
DATE DRILLED1 7 -�6 From To FL_in. _ in.
TIME COMPLETED aLQ_ AM El PM
9. SANDIGRAVEL PACK:
3.WELL LOC TION: Depth Size Material
CITY: V COUNTY Ft-
era From To Ft.
,nP� . ^ From To Ft.
r r',°pk V1/[_1f/,(` m To Fro Ft.
(Sueet Name,Nwnberc.Community,5jwmsm,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope OVelley fflat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
U ! i/ May be in degrees,
LATITUDE 3 6 A mino ,seconds a
LONGITUDE
inadecimal format
x
Latitude/longitude source: Ja(GPS ❑Topographic map
(location of wermust be shown w a USGS topo map and 1'
attached to this form r not using GPS) CD
6.WELL OWNER
OWNER'S NAME
r
STREET ADDRESS G r n
City or Town State Zip Code
Area code- Phone number
5.WELL DETAILS: 11. REMARKS:� � !
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO
c. WATER LEVEL Below Top of Cming: _FT. 100 HEREBY CERTIFY THAT TaS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use'+'H Above Top of Casing)
15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING LS FT.Above Lend Surface* � LLps
*Top of casing terminated aVa below land surface may require S)GUATURE OF CERTIFIED LL CV4 O CONTRA
DATE
a variance in accordance with 1SA NCAC 2C.0118.
e. YIELD(gpm): METHOD OF TEST 0�1 r J ;}F t"t r1 ► Y 1I �R ryp S
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. F^^n GW-1a
Rev.7/05

�- R+ EsmENTTAL wT.0 CONST UMON RWORI) 4
Nadr Ckolm Depama dEmimoncat and Not"Rsaaow V iv"sion or Watm Qiaray
WBLLCONTRACTORCMTMCAnON9
1. ' GO .' 1. M L 'Nj A..d b P
TB^2d ( fi#aZquar _ RM TO
(V✓G�� y` Fina To From Te
Wea CordracWCoelpary Name Ti Fran To Fran To
STREET AOORESS _ Q r ° .'° C CASING, OAnI
Thk*mu r pit
�bhl✓f:dl Irr ( , � 17j� FraaQTa�_Fty_ �1 _ Yy[
CRyaTaan oM1e ZipCfiOr Frar�,_Ta R
Li/yf Qt 1 f�+-� Fran Ta Fl
Area cndeo Phan nUff"
i YY9.LNFOpNfATNAE T. GROUT: DepIR MMaY www
SR6WELL04Ps p�iel Fran '> To�Q_Rjf rv��' p;;w"f�'r,ilc
- - FmrL_To Ft T��
STATE WELL PE2h9Ta(rapparaNet Fran To FL
OMw OTHER PERiHrgffappiaekl aSpMBk OOIb Oianeaer oaskm Masse
WFLI.USE(MmAApp el7da fiW*6ork R "WAKM"p $4 Fmrn_.____To Ft`kL _hL
) From To FL-�� ��TM
DATEDRKL1571( '- -d,� FraL_To FL in iL
TIME COMPLETED , AMA PM fit e. SANOIORAVEL PAC%:
L WOJ.LOCA7wm Dam+ Sba Nbelym
CrM. ra":rKy,IIP COUNP(\JV` FrmvL Tct FL
Fmn To Fl.
Dwo-r 'S CM.I�Ii fl' l C�� FM L_To R
rav®nina.isamera
TOPOGRAPHIC I LAND SETTING. fO.pRlLuIZG LOO .
oskpe, VWMy OFM pRMge 1300`0� Fmm To Formation Drsaiptbn
boal
LAMUM 7r ll� O�, e�yr:are.q
�` 1� da�aemMaa
LONGRVDE�yLJ L,�(i7 � Iaa Qdnl6rr
IatibldrhOgrmde mum " E)TOPOPIPW MV
(uoaaaroraain"MpAmnonauses won"And .
arledrdto ris Axm/notrwig�7
�—
sTREETADDRE68 u 4QgC
Arwoode-P11ore mwba
11. REMARKS:
5.WELL OETAR.S.
w TOTALOtFM�� /
b. DOES WELLR73'LAGE EIesTM WIU? VEBO "014
/ rmxaervdarrarnusnaawaiwascaarnlclmaArxavanr
� WATER LE11�aabasrpdCrkg L(7 GT. uarJcsG.weimreran.•uena'aaroarrsw6�YAaafraf'ao
Mw ffA4aaTVdCaaiW ae/aorusearrrxawtutorleweltoaaex
d. TOP OF CASING 15 1 . Fr.Abom Lad Srraa- •�
T tva epdemlamialeddlrbdoirwdarfaeamay taglsie SIGMA OFr DATE
8-kolce tl YM I5A NCAC 2C.D113. `
a rReLafe►pk�weTNoaGFs><sT Ci�l d C ► A �f i✓ ON
PRlJTED NAIL of PERSON COMSTMCTINS THE WELL
Submit the original to the Division of water Quality within 30 days. Afro: E I V E D Far,, _{e
1oi7 Nail Seavies Center-Raleigh,NC X76WIS17 Phone Na.(919)733-TO15 5a6. pw.T
JAN 30 2006
Asheville Regional Office
Aquifer Protection

RESIDENTUL wEu.cow mucnoN RECORD
Noah Caorm Dep wUmod orEnracwom t and MmhW Raab DivW=of Woks QtM*
� 4�u
M E CONTRACTOR CMTMCAT16N 9 7Q
7.WEf.i,CONiRALTOR: r. DISIFECTWW TRW Aaaa"n /;,,F; r
QM3 a• WOLTERZONM(fd-d Cwkaelv(kwwdUd)!ev Fas inn, To—e From To
Ran TD Frank--To
Wei CN*atw C ffgxm Name ( Flan To Fmm To
STREETADORESS I D3ia C\e n T�1 . R CABMtG: ,wThec�G7dew
yl\1P N�� a�111 r+� _T zFt ` � d1
CkyaTavn Stele Lp Cab Fan To Ft
�M -''Kq , Fem�_To Ft _
Am cods Fla wlwmbw
T.GROUT: DePlh "I"" Method
z wELL INr ATwlt Fm -D—Tok_Ft U h
SITE WELL ID tpqwft*b FrmL—Tc FL
STATE WELL PERANIT#0FM§raweL Fmn To Ft
DWQ or OTHER PERMIT ONeppiaalel L S=Mk Depm DknvOw S'AS%w .9 W
WELLUSE(Chwk App6a 8C* Rea"Ws*w Su pit Feral To�h IrL
_n
DATE DRIL I FMM To Fi kl. n.
TMdE COMPLETm `nZ 007 AMO PIAPI
l� IL SANDKIRAVEL PACK:
CITY,- ,� If)i✓KiflIR COUNTY G Fmq _TCL FL s1a klmr
L� Flan. To FL
r`.� /1 C FmrL_To FL
ed/1 Aaebeea
TOPOGRAPHIC I LAND SETTMD: 10.DR&LING LOG .
osiape Ovdey j@Rt CRidge OCws Fmm To FomgllonD�Eion
tdre>< load
LATITUDE E 22 ee 147dcecob ,
�t / edaas.weoadra
LONORUDE_;O 1 .(rr faadedarl Taaa
T 4.,,.,a.ewb WC a IX= P(WS OTopogaphie n" _
(Iueaerm dradmwke a>tarn m a tls�s klpo mep as ---
anedwd b RW*NM InaT oft GPSJ
a rrNs.LolrNelt
OWNERSNAAE �' ^,nos_ CD
ADDRESSCfty -
1
�c�
aTm" �i �i CaM
d'W ),q. 7?-9771f
Ares code-Plow marker
11. REMARKS:
6.WELL DETAXS;
TOTALDPrIt UM-L—
6. DOES WELL REPLACE MWTINO WELL? YM13 NDIR
�^ ID HBWV CMnlY T W 1T IM WELL WAS CCNMEM NACCaUWM MM
a WATIER LEVEL Below Tap d Cnkg�e lls, FT. t7AWAC20.Ni91MCRIa.'WNSMOlAt!&AYDSATACCrOmE
Ww✓iAhasTapdCmW n=ollawr;MEN FMVMT0TWWXLLQWWL
d. TOP OF CASING 15 FT.Abase Lad SdfwvY G
'Tapdeokglsnilled sLWbdlw Wndwrhwmw q ' L�. .
evnimminaawrdwlarefrlt6ANCAC2C.411R SIGNATUM OF CONTRACTOR DATE
PRINIM NAME a. YIELD{paw): _YfiTHDD aFTEsr c i�-�✓� CONST=015
of PERSON THE wEu
Submit the original to the Division o!WataT Quality within 30 days. Ann:kltorm D Mgala E C E 1 V E7 ZIs
1617 Mall Seals Ceena-RahNgh,NC Z7898-1617 Phan No.(9191 T33-MI5 uR 56 1 V 7a
JAN 30 2005
ASheville Regional Office
Aquifer PrntarNinn

A* .3 2 131
RUMEIMU WEE CMS MUCnON RECORD
rwdt Caofin LeprtwortdEavirowoed wd Nam Ittwoomw PWkWa or WaraQBAW
•�"" '� WB CONTRACPORCEWMCATNOl6_ 3s7S (,
'LINULCONTRAcpore c EerweeTyp. f1 _Awww-Laa-z,
w r�rracta t�� �: I ra.J.,QQ._To�.Q,� Fmn To
(,t•, rI Fran Te From To
W M. Fmn To Frain To
srRErc�ADDRESS ,U�i H V r T �� ��1c,CI OIBMG TKGor�t
J bh ;�f;l 6 K(c" gr i Fan a / i 7 Pl Ly
CAyarTan Shk ZIpCeds Fra—To FL
[ � i L)Tel - �it"{,� Femn Tq_..•..Fl.
Area aqs Rfrors nunMrw
2-wELLeFO1iATR]It 7.GROUT: Depth 1AalerhM Mnlwd
F,W L To : O PL L�Z-�
Sfn3WElLQI�MapFaWL Frwr�_„To FL
STATE WEII PERMrT"amlusM Fmm Tq FL
DWQwOTlERPERWrdW@pniabk L SpdBE DWer Dbmdw Si she Mdodd
WELL USE(Chedr Applwila Bo¢ RaidwMki Wda MWVpk FM To- Ftl _h —kL
OATf ORB1ID I " �.' �Fi FMM_To FL fa. _iL
FmM}_To FL`jn _it
TNECOUPI.6TED 2',3(0 AM❑ PMQk
L BANDFORAHEL PACK:
WaL Depth Sbw hadam
l crri, l� I <jlq Y Fr® To FL—
,99 WI�uNT Fr=—Tq_FL
FhwL _To FL
iswew aseeeaa. raai.Pre{Zio.Code} •}ar:— _.
TOPOGRAPMC I LANO SETTM-. 1L DRIUJNG LOG
QS>gn CIVAW OFId 14IUd6n 00/rw From To FormedanDmay6ar
LATfIUDE -3- 221, r olmhs,M=06a
LONORUDE -,af qctl L "Zt/ ba dednd Erwd
Lateteleftripuift eoaFic; *WS DT%v rwtw am
(beninrrwoawatt BMW ana USGS"amw am .
.esaehsd a etr Mamlaatrwg GP9j —
OYrNERS NAAE Q1,C
ADDRESS 2 -e
IVG 771
CRY?Tan Sib ZIP Cods
AM Goa-aaaz i
11. RsulARxs:
L WELL DETALS:
i TOTALZ74 L(
e. DOMVIIELLREPLALE EIMTerD WELL? VEBD NOjq
too e. MfATrMt LEVH.BebwsopdCril>F lln sT. lL%W iVMELr.me m ANOMWA "r`"r-
(lit W 8Abm7dp dCadg) rQMDiM88891N10YLDDTOMfYGiOwrtBc
a TOPOFCASSI IS FT.MmeLad Storkwe
'Tgtdraeig larrrinird seatwiMWdaafsosmay repie SKK4 RETU OF Cry WELL�MTAFCTOR DAIS
erwiaowibacoadarreeadht6AUCAC2r.0Ii& ,
l �
a TSeLDipeep MEAiOD OP TEST _
Submit the original tothe Division Df Woter Quality wkhin 34 days. Atwinfornetio illlgt. RECEIVED F(�am,Ms'-
1617 W1 Serval Center-Retaigh,MC 276MIG17 Phone No.(619)733 Te1S M 66L JAN 3 0 Mb�
Asheville Regional Office
Aquifer Protection

` RESIDENTIAL wELL coNSTRDCnoN RECORD
North Carolina Deparenent of EaVommem and Natural Resaimes-Division
/of�Water Quality
•� � WELL CONTRACTOR CERTIFICATION If �7D� _
1.WELL CONTRACTOR: f. DISINFECTION:Typo Amount
r l � a. WATER ZONES(dW%Y
Well Contractor(IrdWidual)Name Fmm_Q°To Ss& • Fran To
Fran Tc Finn To
Wen Contractor Canpow Names, �— Fran To Fran To
STREET ADDRESS I b'�L1r2 � \� & CASINO: Depth Ttmimesst
Depth Drwrraler W
From_To_�Ft N
City a Town State zip Cade Fmm To Ft
(222k } Ll`1`1 - `FVS`\ From To - Ft
Area INFO Rome ON:
2 WELL INFORMATION: 7. GROUT: Depth Material
Method
FmmS� To I Ft
SITE WELL ID Srd amk*W) Fromm To Ft
STATE WELL PERMIT3RapWabw/ Fran To Ft
DWQ or OTHER PERMIT?(d appacaele) & SCREEN: Depth Dianeler Slut Size Mahal
WELL USE(CheckAppinble Batt Resider�Wida Supply Fmm Tt Ft 6L _n.
Ran To Ft 9L _in.
DATE DRILLED V1-91�S-12`q��S From To Ft eL in.TUNE COMPLETED c�gym. 7J AM O FM luyy�� —
A SANW(3RA11EL PACK:
3,WELL= DepthShe Nklaal
CITY: COUNTY ! Fmm To R
Fmm To R
A-A(�.VhA Fmm To FL {
.(Street Name..Nmr6ars.Conwaa�aY- ,SLotNm.ParceLZp Code)- _ _ _ --- - _ _ .4.51______.__.___.____., _. . -
TOPOGRAPHIC/LAND SETTING: 10.DRIWNG LOG
❑Slope Ovaicy Flat EIRidge DOira From To Formation DescrQUon
(tlredc Ew4
3 `2l / {{_y r/ May be sBeaus,
LATITUDE _
mmYo.aecoodsa' _
LONGITUDE,01_j: W 9 7,7 r/ a a decimal Era va -
—`rj�s t
latitudellongitude source: PS oTopographic map
(harationo(wa/rnustbe show on a(J0SGS a:po mep ad o
atladodso Mier Jbnnimrusig GP57 .,
4.WELL OWNER ` �,, -
OWNER'SNAME — 'Y Clftd X)
STREETAODRESS -UlAe
5b �rMJ\ N.C. DiAn-1I
Gilyaa ..Slide Zp Cade
cam. t-k- 1 C\- C)L
Area Code- Phone Mnatee
11. REMARKS:
5.WELL DETAILS:
a TOTAL DEPTH: a( J
b. DOES WELL REPLACE OUSTING WELL? YESo NOA
rpor� Tn Yce fFYRT7M WEtl ra wasrowsrcM mncoomoAm Eaanr
c WATER LEVEL BPJawTop of Cases: a. Fr. 15nwrx2e.VML CONSTRUCTION STANDARDS.nronutTACOPYCFTHIS
(use•+-MAhwe Top of Casing) RECORD HAS BEEN PROVIDED To WELL OWNER.
a TOP OF CASING IS . FT.Above Lad Surface KZr9 l 34r�S
'Tap of cases lara alad aver below la m d surface raw/ Qme SICNA of CERTIFl Eti_CONTRACTOR DATE
a variance in a/cc�ordance with 15A NCAC 2C.0118_
a YIELD i91xvY _METHODOFTEsTA\L `
PRINTED NAM OF PERSA//
Submit the original to the Division of Water Quality within 30 days. Attn:Inforr tation moift E C E I V E D
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 5f 8. Form GW-1
Rev.7/05
JAN 30 2006
Asheville Regional Office

RESMENTM WELLCONSTRUMONRECORD J1
Na&Caolina Depnnert ofFnvioeacd and Nasad Reo way Diveion of 1N2ta QMW
•��_ �' WELLCONTRACrORCE$TMICATION/
1. CONTRACTOR: t. VMpF6CnON:Typr A.seu* l c3D'z
`l ( w I I\ '�, o m a Z-To ZONES` r Fran To
�l �C'�tY� I�n� \Y1Par ^rme+'� G��7o Fmm Te
CMW"HxM, tt Fta1L—To Fran To
STREETADDREss ��'1 � ��l�1CZ a pin weba N�e�
�C Q`���' Ftarn�_To �a V FL
p���CityaT�aayrtl- Ste! Zipcoav Frarn Ta FL
( O 1 RLA SLA F:sn To FL _
Area cod - Rime mnrber
2 WQL,afOIBaA71Olk 7. GROUT- De�1A �'1�� (�YSI��-ir-1 ' FkAtcd
Fmn_To�R- rq"]M�r
SITE WELL ID*M ppaeW I Fmn__To FL
STATE WELL PHLRTl0app9,Ab Fran To Ft
DMw OTHER PERUff Op ppk k) tSCREM Dop9t 0aat.1 Ski Sm Matafy
UL
WELD.USE(Ct-ckApkW*60a ResidaaWWAWSlV*fA1 Fran To Ft,_in. _
Fn To Flt it �liL
D17EDRLID Fm o in in.
MIME COMPI.ETEY! c . X AM❑ PM�l, !. SAIQRiRAVFL PACK:
A WELL LOCATIM Depar Sloe MANN
CRY_'L�•-, '� � �_S�CAUNiY }iW,,l'� Fm�To Fi
P r IK_ its11.1`���5 FmIL`To FL
TOPOGRAPHIC f LAND SEITam: VL DRAUt{G LW
DStope OVAW t�Fre 13RNpe pW From To Fr To Formalbn Dessaytlpn
(didff boo If Mesked�.
/
L.ONGRUOE.E? �naQedslfonr
Lafift%k ialgimde sate= OTopDgtYpbic tmp
exaffiart orwaff ffRobe dmm on a usas two MW aw .n
afaahadfe Ak farm Ind ad'6 G%7
4.WELL OWNER � u�
OWNtli5NAME -Au,_In `(Crs'tY\R-Y1C\
STREET ADDRESS—Vl4 I Peyfl�\YY;--tS
CftyaTovm stab 40 cofe .
L v—)G-ail—I
Aremde- Pttatafawft
11. REPdARSB:
&WELL DETAILS: � T�
a TOTALD�TFt��rk7
b. DOES WELL REIACE EXISTING WELL? VESD NO
IDa1BBYCMWTMT7MWMLWASC0BT1t MMAOGQFMNCEWfa
e. WATER LEVEL SdmTopdCmkW --a--FT- AanlwTACCMMUM
((ha viAbmTopdUWRW t=Mffnga pFA noraTOTImWULGWISL
C. TOP OF CASH IS . FT.Abaa Lard&~ ZI-elLIT
. `Tep d embg lamia'!ad dW bd w bndwdvoe Mxv miiaSMAMM OF CERTN*D WEM COKTR4=OR DATE
araiormb,"., " aW t1U"CAC2C4t18.
fa, YMLD(epm$ METHOD OF TEST, ✓: ) �1, l �il�6/��
PPXrW FOW OF PERWN CONUMUTM THE WEU
Submit the original to the Division of Water Quality within 30 days. Atfn:bf eon E C E I V E�"a-la
1617 hLll SaMix Cerox-ttalaigh,NC 2789a-1617 Phone No.(9191733-Ta art So 7M
JAN 30 2006
Asheville Regional Office
Aquifer Protection

0�)
� 213 � 3
J[ smE1y77AL ws;u rnxsrnVCtTON RYCORD
North CaoCea Depwk=t afl&n*anead aed Norof Roozow PiviFicn or W*a Qmrq
WBLLC0NTRACT0RCF4TMCATI0NJ1 J� CX4
7. caeerRACraR: f. OpMFECrGON:Type Jt tt'1-� Aanaww i ^L
9. WATHt ZOtEs{dgehT �
LMl oniratta(YrdMidrtrj PMM C6OL To-Zac-L From To
Fran To Fran Te
Well C Or*SC% r Camper Net Fmn To Fran To
STREETADORESS UtJq A CAGMG: Tfilaund
DT," Oar( Wetgtd Mdett
TlS1y.,�\P NBC.. oc� 1�1I F*un_�To ' LFt1 n�1�1
COyor Tmm Stets Zrp Cade FMa To Ft
(�-41 1 C) -'LsC Fmn To Ft.___..—
Area oade• Phan numbw
1 WEELLOWORMATIDN: T. GROUT: Depth whiff" McLnd
Fmn l�_To2b Ft 0 LV4, ''� hs�
SREWHL1De(eeppace6l Frort_TQ PL
STATE WELL PERMrTa(F40;M el Fun Ti Ft
OWQa OTHER PERMITf(iappreahlel 1 A SCRM& Depth tYaWwler SblSIM MMEW
WELL USE(Cho&AppidYe ea* Resider"Waler Supply(a Fah_To R h _In.
DATEDRLIIO__ja "aa-�S '\ Fun � it.
Ft- L
Fmt To FL___jrL R
TIME COMPLETED A2 Ablo PM .
A SAIOfORAVfl,PACK:
E.VVML tTK t! Dora. SIa MRMM
CITY. Y F rpL _To FL
Fue To FL
-�l �.�a LK�YVI wsN aS F m_To Ft
MedMaMeoORa.Cm�.Gmiekn.t.aUb.Prc+R
TOPOGRAPHIC/LAND SETTING: 10.D Ul ING LOCI
(]Slope OVWft)qFtt DRLMea DOewr Fmn To Fonnefim Dmaptbn
WIN* jpapmMbe* Meyra
LATITUDE mac-- a_ 104e7r1 a .eaoedsa
LONGMUDE r".�--.Xf.�'-71I iaadxlawl60v
LMMWdlm®arde=ff= )3EMS DT0p09Mpl1k13zP
&VOMm 0(wela"bodoman a USGS Apamep and .
aeadted fo ark A7nnled ueag GpS)
(�
`WELLOWNER
OWNUM NAME
srREErADDRESS �e-- U Lc}-r'co:v- r-,S
C by aTma sum zip Cade
(ADS ), v-1 C� , a 31`1
Areamdo-P:menu rft
11. REMARK$:
a WELL DETAILS: a
a. TOTAL Z;M 2 1]—
b. DOES WELL REPLACE OWTM WELL? YMO N09k
GOO rBMY CErrFY7MT7RT&UWAS C01ESeR MMACWIMM=Wmr
a WATER LEVEL BdowTtp of Cmkg_,,,,y�(L,_FT. IMICA.2r.WRLMMMCWwa'ueorw AbOWTACtrtastM
M*eW9AhwmTapdtaeeW FrjXMrwattB1FFKWorar0n EWELQMM
d. TOP OF CASING IS_ 1 FT.Abom U d 9afwe 1� �? as GS
`Tap d vuh9 boini lyd Ww bdmhod entaCe mNrrease
rWi 151►NCAC 2C SLG1111 OF CHYt CONTRACTOR DATE
awrieerae h aemdanoa AIt�
a YIE].D(9pmj:�,_METRDDCIF TEST `
PFWrED NAME OF PERSON CONUTRIJUTING THE WELL
Submit the original to the Division of Witter Quality within 30 dayS. A :InfornVA" 'V E D Fam cw-ta
1617 Midi Service Center—Raleigh,NC 276WIS17 Plume No.(919)733 TO tart so�' Rev.7�
JAN 30 2005 j
Asheville Regional Office I
A uifer Protection

tyR(V1I,///� A/'/1
raw V
RESLDENTL4L wEm coligmucrioN Rwoxn c� qq 3' c}
Necm Cmofim DTwbwd dFirviem cnt and Hamad Resaaeea-DOOM of WOW Qta 3 2 1 J (�
WM.LCONTBAcMRCSIjTMCATtoNB 3 �a
1./WaLr.CONTRACTOR: t7
L 1. ONFr�TWM Tsp. ���' fj bjbj A...&
1 /11'S Yi _ \[�"A1lS a WATERZDIEB(dapih)-
Wid fa0acior pKbnwry
A 1 as i' To�� RW To
N,(- A-rn `Mf ll Cl i Ilif1� _ Rmi Tc Fm" Te
WeI Cadracbr CWW" Fm To Fmm Ta
STREETADORESS (,3O C. CAGM.- Thidmmw
��JCOymTaan Stato Zipcoft Fms�_Ta Ft _
fa�v} k4-1c1, 'INSA from To ta. _
Am CDda Phom mmiba 7. GRWTr: Depth 16uiaii tJdnd
SITE WELL De(a appicaWt F`aeL_TC PL
STATE WELL PERWr V M&*aef Fmn To FL
DWOor OTHER PERINT/(daipreahid EL SCR133h Depth LAMMIM SMShn Mt ris
WELL USE(Mm*AppY Rm* ResidanUNWmbw Supply FW_._To FL_h _tn_
Fm To FL h _ iL
DATE DRKMM_L;a;:Z -,-.'J.'�i FcnL_To Fi h _im
TWE comKETFA '4r Amo PU p(
i SAtOKiRAYF1 PACK:
3.W9LL LOCAT10tt Daplh SEe molm"
TY: CO� Fmm Tu FL
CI
1 g Fmn. To FL
-thy_ L.r✓C 1 i I1� FmNL_.-_To FL
TOPOGRAPHIC 1 tAND SETTM. 10.ORKLMG LOG .
OSbM OYdey " DRMpe OOM Fom To FomlaBmDouiption
(chat 4Vmpsbbc4
LONGRUOE..s-_-- 4LL' Hcj C, rna hdaW,
Lsuudrn rglM&a umm fikas oTopographic amp
fboaEbn mwrmuNea ahem m a uSGS Expo a+ap and —
MbdNdbadrbm In:1 uaig GPSj
t WELL OWMR -I—
OWNERS NAME t fin r-
STREET ADDRESS L� -
1�;.Kvi1 R s--
C*m Towr SwEa 2b coda
17
A� JAN 30 2006
S WELJ.DETARS.
= Toni t>e�TEt alb` Ashevilre Regional Office
h. DOESWELLRBRACEMMYSIOWML9 YESO Nojq -Aquifer Pr
f toomany cumvTUTTmwELLwA70010TNlCIF9w wrm
a WATEALEVB.BagaTopdCaeig �� fT. �xaeaezc.weaeoasnaaya.sauw4wnswoaurAaoPtosao
Now cAboaeTopdcaw FMCOMINtiMMMMOY1 MY01 WELLowla3c
d. TOP OF CASM IS FT.Ahm1e Land&dFaod K���' 'e/Z„ / 2�✓ f
'Tapdeciglamimiadmpar bahw Wd sNfaeemml made SEGNATdRE OFC t 1TRACTOR GATE
ev�lmaii aooadNcavdh 15A NGC 2C.e1111
a. YIFLDfppml:�._,_rETWDDaFTasr__�j,[__� .CT
PRrrr�o�oF FRs�Hm corm7crnEe THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:kdanundon mgt., Fam GW_Is
iSi7 WWI Servke Corner—Ralal^NC 27699-0517 Phone No.[phone] ma 558. Rea 7p5

Wo
RESIDENTIAL WELL CONSTRUCTION RECORD
320484
4:
y` North Carolina Department of Environment and Natural Resources.Division of Water Quality
®a s WELL CONTRACTOR CERTIFICATION ti c�� O Fl I
1.WELL CONTRACTOR: I. OISINFECTmfk Type_l7 LN Mrount pfr'y
flr�A\Vee,/,r<. s. WATERZOMES( $ i
W C(go�Qaclar\(_ �ie [� Fmm S:h./ To From To
Fran To From To
Well Cmtrator CanrparyName /] Fan To From To
STREET ADDRESS Ij,-'zi L_�:cle J —01 :�I (2\ n"- f t IL CASING: Tf�cInessl
(tiY�Sb iny,Yi)1C �\ �, cn�7T/ Fmn_jD__:DepTothl i`S' F1. 4- %1
City or Tam Stale Mp Coda From To Ft
( c6 jj,541;4 Fan To Ft
Arrmarde- Phonenumber
2 WELL.RFORMATION: 7. GROUT: Depth Mta aal Method
SITE WF1LID d(d appfeable) Fran_n_To�Kj�: './1'��i� - ^' -11S
From To Ft
STATE WELL.PERMfTS(rappicabbi From To Ft
DWQ or OTHER PERMIT f(d applcaW) /. SCREER Dq)M Diameter Slot Sire Material
WELL USE(Check Appk*b Be* Residerdel Water Supply I)q Fan To Ft ct _ in.
From To FL il. _in.
DATE DRILLED L)—/S- nr Frpn To FL i1 _i<
TIME COMPLETED 2rj' AM❑ PM tie A SANDIGRAVEL PACK
3.WELL LO(�)pTIyO`R \ Depth Sla Material
CITY: 9�tT:UrJir�hYii le COUNTY �Y�.YY\iM Fan To Ft.
+ From To R
Pl f�l�C1N\ 4S' From To Ft
Me et Nam Numbers.C Te..w.WOn InlNe..Parce%ZiPCode} _ _
TOPOGRAPHIC I LAUD SETTING: _ 10.DRILLING LOG
❑Slope oValey ORst )gRidge []Dow From To Formation Description
(alai Sad
1be in
LATITUDE '� L �
/3.1rr semnka
LONGITUDEY3" �fLi' 67 'J ma daimal fates
Iatitude/1atQnak solace RGPS oTopographic Rap
fbcaGonare/owattreal wo USGSkponwand .
alfadred to 6aa Am Ind Date GM4.WELL OWNER
j i
OWNER'S NAME 6 AYl � t�
SJPEET ADDRESS )YNyTnk\ t'
V'4 •�Ila NO- '� 7/ n
Citycr Teen Slate Zip Code
c� �a3�- idly x
Area code- Phonemanber
11. REMARKS:
S.WELL DETAILS-
a. TOTAL DEP'TIk <h(lJ
b. DOES WELL REPLACE OUMING WELL? YES❑ NO(�
1 DO,HERESY CMDFY TNT THIS WELL WAS CONSTRUCTED N ACWImANCE Wan
c. WATER LEVEL Below Tap of Casing vl Ff. 15A UGC M WELL CONSTRUCTION STANDARDS.AND TwTACOP OF TB
(tom--v If Atime Top of Cas:g) RECORD HAS BEER PROMEDTTOTHE WELL owtBL
cl. TOP OF CASING IS 1 . FT.Abare Land Surface• 'PiS<i.,.,1 ELL///1-.✓f l��/u'��C
'Tap of casig IenniNe- Won below land surface rnev require SIGMA OF FLED W CONTRACTOR DATE
ow is aCCOD1MMvdlh 15A NCAC 2C.OI10.
e. YIELD ISmm): METFIOD OF TEST Ci'� 1 T 1 l:x<'+I n Y ' l t l Lt c n t
PRINTED OF PERSON CONSTRUCTING WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information MgL, Form GW-Ia
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone] ext 568. j A N 2 4 20DT-7/m

-� \11 c 320483
RESIDENTIAL WELL.CONSTRUCTION RECORD
Nosh Carolbra Department dEnvbonmrnt and Natural Resounxs�-Divisi`on�of Watc Quality
WELL CONTRACTOR CERTMCATfON# c" 2 4 h
1.WELL CONTRACTOR: L Mff*:EC"MType E 1- Amount 6 ^7
g. WATER ZONES(depth}
Wet or(Individu✓all None 1 Fmm�Q / To� Fran To
W e 11 W I Fmn To From—To-
WON Contractor Carysry Name ii From To From To
STREE`T�ADDRESIS (;3q P J f,kj1d ),+n ac"':1 CL CASING: TNganesd Mistrial
From DTorLLK
City or Tom Stan Zip Code From To Ft
( )- L175'- 4. From To Ft.
Area Dods Plrane number 7. GROUT: Depth Material Method
2 WELL 964)Rg1AT10N: Fom__C_� _To &, Ft Lgn2 1�- '�'r'h r n ,
SITE WELL ID apt appacaw) From To Ft
STATE WELL PERM(T#XaDpk*bl Fnm To Ft
DWQor OTHER PERMIT#(ifappicahle) L SCREEN: Depth Diameter Slot Sim Material
WELL USE(Check App6eable Bata Re7idern8ai Wam Suppy
Fran To Ft err. _In.
From To Ft m. _in.
DATE DRIU M, Fran To Ft ut. _in.
TIME CONPLETm _L-'�(� 7 AM❑ PMX
A SANDMaRAYEL PACK:
3.WELL LOCATION: Depth Sim Motorld
CITY: COUNTY, Fran To Ft
From To Ft.
T2,,k5 QY5,k 1•Cn"r.d Fran To FL
TOPOGRAPHIC I LAND SETTING: _ 10.DRILLING LOG
❑Slope ovaky pFbi oRidge ❑Other From To Formation Description
(dwdr appropriate b�� �o� mdepea,
o --�
LATITUDE 3 fr 31:r mina
micas.semodso
(T LONGUOE_✓�' 3 45 ` ;,!?ti'r ma&dmm former
Latinddlonginde mum p(OPS o Topolpaphic map
(bealon ofaaelmustbe shown an a USGS lapo map and .
atlachod b ads (rm7nof using GPS)
4.WELL OWNER r -
OWNERS HAVE M4iyY1Ct/' Cm11/Z+rcl ��
STREET ADDREss Vrh Y)k.< C`/ rYt
.t.
Aphble'Azdle
City or Town Slate Zip Code 01
Ana code- Phone number -A
11. REMARKS:
S.W91 DETAILS:
n. TOTAL DEPTH:
In. DOES WELL REPLACE OBSTING WELL? YES NO 01
G WATER LEVEL BPbw Top d Casng CONSTRUCTED IN ACCORDANCE Wrr"
_Jl�FT. is5A W—W.=VJML ONSIMERV MMAUTON sWELL ww�aiaos AM IMTACOW OF IM
(Use-+-aAbae Top of Casing) aEZamtw BEEN PROMW 701W WELLOwaER
d. TOP OF CASING IS I —FT.Abase Land Surfacee 1�.V (lei +4(n�-.-.h T..ii. s
'TEpdcasingtonnh ted&W belomMW surface may rye SIGNATURECERTIFIED CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(9Pru):.�L.L_mmm OF TEST Gyf— C' 1L,h" -i r� t( �<
PRINT® OF PERSON CON TING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Fan,GW-Ia
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ezt 568. Rev.7106
JA v 2 4 2000

REUDENTUL WELL CONSTRUCTION RECORD RVv320482
L..
Noah Carolim DepaMlpn of Environment and Natural Raourcrs-Division of Water Quality
WELL CONTRACTOR CERTIITICATION[3 R�
1.wELL,QwIrRwcTOR: E OISINFECTKM Type r_1 T H amount A0 a s
�l.!:.Shn I °'11114:.nS a WATERZONES(deptlh),
Webb C�mUa+ctor(Ind-poidual)Nama Fran i G/ , To / r From To
Fern To Fran To
WellCmUactorCargaMNana / II From - To Fran To
STREET ADDRESS ti.�L/,� $.f I Cb,r\ At niC S. CASING: Thi*lew
&h ' w '• r LFran To �st �s� �1_R � —
City or Tarn State T_p Code Fran To Ft
Fern To Ft
Area code- Phone number
T. GROAT: Depth Nude" Method
WE1L.a�ORMAnON: F P+ G
mn�To �� R��'Y1non;{- O
SITE WELL ID Scat appk*b From To Ft
STATE WELL PERW*Wapp1=d)k Fran To Ft
DWQ or OTHER PERMIT#(ifappkdAe) 8. SCREEN: Depth Dianeter SM Size Material
WELL USE(Check Applicable Bmlj Resi l - Walla Stpply a Fran Tc Ft_61. _N.
Fran To Ft m _aL
DATE DRILLED 1 I-!e- c r, Fmm To R br. is
TIME COMPLETED !D ` QQ AM W PM❑ S. SANWGRAVEL PACK. --
3.WELL LOCATION: � Depth Sim Material
CITY: ���r�5v 11 o couNTY_R rJ `A Fern To Ft
y-� I Fern To R
&teed Fran To R
.(Street Hwrrehi mbem 0onmmed).SW6uiabn,lnlNm.,PIN ZOLCede)- :-i ._
TOPOGRAPHIC I LAND SETTING: - 10.DRIWNG LOG -
❑Slope pVaay IgF1d DRidge OOerer From To Fomw9on Description
(Chars WproPriere eerl
c Maybe condo,
LATfTUDE �3} ,�• cl l,. , m �s,seconds or
LONGITUDE 3e �� 1)7.b'r made®d fwm
Latialddlongro de solace: RGPS OTopogaphie map
(bcavonofwaginuslbe shown an a USGShrpa coop and .
allached m Sit ram loot mV GM
4.WELL OWNER OWNER•SNAME &��v ej-jc�(J"
r c
STREET ADDRESS 2 Ln&kO J C e rJ
&b."6,-,1IZ Ny C a<-7-1 (
CityorTown Sloe Zip Code Q�
Area code- Ptrone mamba c.J1
it. REMARKS:
5.WELL DETAILS:
a TOTAL I>Frm-2C2J
b. DoEs WELL REPLACE E) nNG WELL? YES❑ NO 0
100 MANY CEff"TIATINa WELL WAS CON.IWICEDaIACCORDANCE WRR
c, WATER LEVEL BebwTopdCasirg Fi. esANraCM%VELLmwmucmmsr NDARMANDIMTACavroFTe
(Use•+•IAbon Top d Caeio RECMH S BEEN PRO I)W70TE WELL OWtBt
d. TOP OF CASING IS i Fr.Above Land see ���_/'���,; 7/—Ib—CS
'Top ofcesi)g brmMed aiur bAoe lad striate may regkrde SIGNATURE OF CERTIF�D WELL CONTRACTOR DATE
a variance In accordmcewith 15A NCAC 2C.011&
e. YIELD(gpm):,METHOD OF TEST C2 1 q7t;tr-.
PRINTED OF PERSON CO THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GW-Ia
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7/05
JAN 2 4 2006

,�c STATF
Q RESIDENTIAL WELL CONSTRUCTION RECORD 320481
North Carolina Department of Environment and Natural Resources-Division of Water Quality
�
WELL CONTRACTOR CERTIFICATION# : �?hy�-
�
1.WELL CONTRACTOR:: i I. DISINFECTION:Type '�-��/�7r Amount in yz
n ,1 / 1 i�l i aS' < 'l5 g. WATER ZONES(depth):
Well tractor(Individual)Name I
7 From ri 1 ' T0_a E From To
lJ/1,-1�Ch,yv1 OW r l I 1 y\I From Tc From To
Well Contractor Company Name Fran To From To
STREET ADDRESS 63N /Y Y(.�e T0'+fin i`Q[•.t:+ S. CASING:
�s`c?bb,NSi rI��Y r Depth `
D' Thiclolesy
77 From To . g I
Malonal
T FLF -
City a Town State Tip Cade From o Ft _
C� � L17 J - <;-4sy From To Ft.
Area code- Phalle numba
2.WELL INFORMATION:
7. GROUT: Depth Material Matmd
SITE WELL IDA(itapplicable) From_ey_To 10 Ft-(Le ni- vrH i,n
From To FL
STATE WELL PERMIT#(1 applicable) From To FL
DWQ or OTHER PERMIT#(it applicable) 8• SCREEN: Depth Diameter Skri Size Material
WELL USE(ChwkApplic"Bcx): Residential Water Supply Fran To FL_in. in.
1 Fran To FLin _In..
DATE DRILLED / ` H _ .- G,-Ci From To Ft._in. _ in,
TIME COMPLETED /0: � AM M PM p
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Sixa Material
CITY:
LN_Jbr+�(:r1 ly 1� COUiNTY 'tiVh Fran To FL
Fran To FL
Fran To FL
(Street Name.Numbers.Canmanhy..SubdiYsbn,Lotno..Parcel.Zip Code)- -
1 9`
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Skpe OVally " ❑Ridge ❑OUw From To Formation Description
(check appropriate bar)
LATITUDE ^L!
3 ✓ Y m degees,
___7�x, mirmrri seeorrds a
LONGITUDE �� LJ r 0,3..�rr inadedmal Tamar
Latitude/longitude source: NGPS ❑Topographic map
(bastion of welmust be shown on a USGS ropo map and -
attached to Arts/nrm Iron using GPS) _
4.WELL OWNER 1
OWNER'S NAME
ADDRESS ram`ilaN..2J-„t.'•.}-2r^ 1*�s..«�
City or Town State Zip Code
( �1 75} sw - Cl ie'�'
Area code- Phone number
11. REMARKS:
5.WELL DETAILS-
a.
r _
a. TOTAL DEPTH: ass
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOA
I NC
DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wmI
c. WATER LEVEL Blow Top dCasing: _FT. , I'MAC 2C.WELL CONSTRUCTION STANDARDS.ANDTHATACO OFTHIS
(Use`+•if Above Top of Casing) RECORD HAS SEEN PROVDEDTO THE WELL OWNER
d. TOP OF CASING IS / FT.Above Land Surface• •� A�/i ;/ � LI- ( Sl U
?� Casing of terrrlalnted allot below btW surface�Y SIG iR OF CERTIFIED k"ELL CV11' ONTRACTOR DATE
a variance b accordi ncewith 15A NCAC 2C.0118.
e. YIELD(gpm):,�_METHODOFTEST C;I nG.
PRINTED NAME OF PERSON C�NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form
1617 Mail Service Center-Raleigh,NC 27699.1617 Phone No.[phone] ext 568. W-ta
f AN 2 4 ?DOB Rey. G

RESIDENTIAL WELL CONSTRUCTION RECORD 320480
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# �..
1.WELL
CONTRACTOR:(�r� I. DISINFECTION:Type Amount K O Z
'.I l�'.�}'i i1 'i 1 II I, �SC)rri 9. WATER ZONES(depth):
Wen Contractor(Individual)Native �— From /QC r To�_ From To
(A�i I �' i 1'1 Fran To FT= To
Well Contractor Compa//m•``Ntarme Fran To From To
STREET ADDRESS ,C. /6bL S. CASING: Thickness)
en , , c/� Depth D"r er Weight al
�Svr�IF /V b 77 Fran�•5 _To_ZLFt
City or Town State hp Cale From To Ft _
( 21b- L179— <,<Lf,5L1 From To Ft:
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#tif apprrcable) Fran�To Ft CP rvtP(\J� 3, ;AI
Fran To Ft J-
STATE WELL PERMIT#(aappkabk) Fmm To Ft
DWQ or OTHER PERMIT#(t applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Be)*-. ResidegoW Water Supply iR Fran To Ft_in. _in.
From To Ft_in. =in.
DATE DRILLED J._L — CJ� Fran To Ft._in. _tn.
TIME COMPLETED AM❑ PM($J
S. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: �U17hinK l'rI�Q COUNTY(3IfCl-I, VT Fran To FL
.-. Fran TC FL
ra�k9 bf,CC/) CQ('r YV'I1 re r,f'• Fn To Ft
(Street Name.Nmnbers. anmunay..Subdiwion W'A-0..PanmI,Zip.Code) _ —
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope pvaney ❑Fkd ARidge ❑Other From To Formation Description
(check appropriate box)
LATITUDE 3 If minrtes,secandyw
May in c •
�1-J�3- aods
LONGITUDE 3 r r,3 r ma decu°al finer
Latitude)iongitude source: MGPS pTopographic map
(location of W0 Dead ba shown w a USGS bpo map and
attached to On/arm snot usng GPS) _
4.WELL OWNER
OWNER'S NAME STREET ADDRESS I,' - i., �$y C� cr%
a 1 ), -A ✓`rC A(?'O
ChtyaTown State Zip Code TT
�.
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:a. TOTAL DEPTH: /--7
0 J
b. DOES WELL REPLACE EXISTING WELL? YES O NO)®
1 DO MERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:�FT. 'M"CAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use-+-t Aboom Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS / _ FT.Above Land Surface'
-Tap of casing ternai ated allor below land surface may require SIGNATURE TIFI W CONTRACTOR!1 pg7E J a variance in accoor^rdance with 15A NCAC 2C.0118.
e. YIELD(gpm): P METHOD OF TEST Ctii =(/v eT1h.� (r I I�rCr
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 566. Farm GW-la
Rev.7108
JAN 2 3 2006

,.� a11t',�•
OWNER
i4 I�GSIDLNTIAL tyELLco1VSTRDCnON RECORD
MWD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
NC
\YELL CON'rltAC'I'Olt CiAt'1'IFICA7'ION H Lf��
1.WELL CONTRACTOR: t
' t. DISINFECTION:Typs_ / t Amount '— Cl�:
g. WATER ZONES(depth):
Well Contractor(Individual)Name From O To /TO From To
MILLER WELL DRILLING . INC . From Tc From To
Well Contractor Company Name Fron To From To
STREET ADDRESS P.O. BOX 567 6. CASING: Thickness/
H A Y E S V I L L E , N . C . 28904 Fran 6 Depth
S Diameter Weight Male e L
_Ft. S
i8'S 7 P
City or Town Slate Zip Cale Fran To FI. -
( 828 } 837-2997 From To FI.
Area code• Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From IR-J 70 1/0Ft. �'eti le,,,jC a/IQ
SITE WELL ID!lpf appncaNe) From ^
? To�_Ft. /iB.<' 1n f
STATE WELL PERMITMpr applicable) Fton To Ft.
DWQ or OTHER PERMIT i(if applicable) e. SCREEN: Depth Diameter Sid Size Material
WELL USE(Check Applicable Boa): Residential Water Supply From To Ft._,In. _ In.
I From To Ft._In. in.
DATEDRILLED / -eO-�-C� Fran To FL_in. in.
TIME COMPLETED 00 AM PM MW-
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
q
CITY: y�D�7 U,iLjLv��E- COUNTY 6i--1 1117 7 From To Ft. .
From To Ft. -�(
_ From To FL
(Streetm r m eel Noma,Number,Community,Subdivision,LotNo.,Parcel,Zip Code) ,
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
(]Valley ❑Flal ORIdge OOlher From To Formation Description(check appropriate box) ;
r )(a, 9j1jOr May be in degrees,
LATITUDE 3 {
22 minutes,seconds or '
LONGITUDE N J• (Oy v In a decimal formal
Ulitude/longitude source: ❑CPS 0TOpographic map o
(location or wet must be shown on a USGS lopo map and t
attached to this form 1 nor using GPS) rU
4.WELL OWNER
OWNER'S NAME V•li. VK}�/ c� _ �'
STREET ADDRESS
F'
City a Town State Zip Code
( } i
Area code• Phone number
.I1. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: /�S
D. DOES WELL REPLACE EXISTING WELLS YES❑ NO p--�
e. WATER LEVEL"mT of Casing IOO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTTD NACCORDANCEWtm ')�"
Top g .�( 10 FT, ISANCAC TC,WELL CONSTRUCTION STANDARDS.AND THAT A COW OF THIS
(Use'+'it Above Top of Casing) RECORD S BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS I ___FT.Above Land Surface' / L(,Q /
'Top ri casing
ccordalcdwith15A land
2C.01 may require SIGNATURE OF IFIEDWELLCONTRACTOR DATE a variance In accedence with 15A NQAC 2C.0118. ,
r
a. YIELD(gpm): � Z METHODOFTEST / Z � I/ l'p /0'PfCL_
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., ram Gw-ta
1f317 Tdnil S^ vicP Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev. 7105

fr 5^Mp `Y V
,OWNER—
RESIDENTIAL WELLCONS'17tUCT1ON 1trizoim ;i MWD
4 t North Carolina Department of Environment and Natural Resources-Division orwater Quality
NC
\\'ELI,CONI"RACTOit CliltT'1 PICATION N
1.WELL CONTRACTOR: I. DISINFECTION:Type arH Amount
`t/em\ R,a,� U. WATER ZONES(depth):
Well Conlmclor(Im, v ual)Name From 2 41�) To z y1 Film To
MILLER WELL DRILLING , INC . From To From To
Well Connector Company Name From To From To
STREETADDRESS P . O. BOX 567 6. CASING: Tldcknessl
Depth ,_ D]ameleJ, Weight IrI Material/
HAYESVILLE NC 28904 From 0 To 6 Fl. G.�S �8 SYCe
City a Tmn Stale Zip Code From To Ft.
( 828 } 837-2997 From To Ft.
Area code- Phone number
7. GROUT: Depth Melerial ` D Method
2.WELL INFORMATION: From To 3 Ft.
SITE WELL ID tl(d applicable) From Tom Ft. M. tE vL
STATE W ELL PERMIT#te applicable) From To FI.
DW Q or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Site Malmial
From To Ft. In. — in.
WELL USE(Check 'Appcable ox): Residential W aler Supply O/ From To Ft._In. _ In.
DATE DRILLED 01 6S From To FI._In. _ In.
TIME COMPLETED S'li 06 AMp PMfY
9. SANDIGRAVEL PACK:
Depth Size Malerlal
7.WELL LOCAT(OM: p l From To FI.
AD GCLry7l Lei COUNTY VISA'//Gm
CITY: 0 From To FL -•
From 7o FI.
(Segel Norma.Number.Community.SubdlWalan.Ld No.,Parcel.Zip Code)
TOP
OGRAPHIC I LAND SETTING: 10.DRILLING LOG
WolDpe (JValWy ❑Flat []Ridge ❑other From To Formation Description
(check appropiate box)
f / May be in degrees, '"� H C ✓ _ l4✓.L
LATITUDE � , /D minuln,WOWS or -
t,tZ / rf in a decimal formal �z 0 "Z`'Z'
LONGITUDE�� l�J I
Latitude/longitude source: GPS ❑Topographic map
(locallon of"I must be shown on a USGS fopo map and '-
attached to this form I not using GPS) ^, ,
4.WELL OWNER rT1
OWNER'S NAME 6'JCs✓"( V5 S ^'
STRErTADDRESS �I12,DX IgI
City or Town Slate Zip Code
Area code- Phone number -
11. REMARKS:
S.WELL DETAILS: ?/'a
rnZ
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO M/
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCOnDANCE WITH
e. WATER LEVEL Below Top of Casing: FT. ISA NCAC aC.WELL CONSTRUCTION STANDARDS.AND THAT A CD"OF"as
(Use'+'0 Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
It. TOP OF CASING IS�_FT.Above Land Surface- Ay!„GZ-t— /'D -(f-0J
'Top Or casing terminated allor below land surlace may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accordance with 15A NCAC TC.0118. o
a. YIELD(gpm): �" METHOD OF TEST / 'erey �e e 0 e-
PRINTED ME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information MUL, Form GW.1a
1617 Mali Service Center-Raleigh,NC 27 6 9 9-1 61T Phone No.[phone] ext 568.' Rev.1105
v

OWNER
4} T=[ ¢ RESIDENTIALWELL CONSTRUCTION RECORD MWD
rL North Carolina Department of Environment and Natural Resources.Division of Water Quality
\VELL CONTRACTOR CERTIFICATION it NC
1.WELL C NTRACTOR: I. DISINFECTION:Type �� Amount
/y� �La g C6 U. WATER ZONES(depth):
Well Contractor(Individual)Name From �0 d To 3 0 / From To
MILLER WELL DRILLING , INC . Fran To From To
Well Contractor Company Name Fran To From To
P . O . BOX X 5 6 7 6. CASING: Thickness/
STREET ADDRESS Depth lameler Weight Material
HAYESVILLE NC 28904 Fwm—D-- F
City a Town Stale Zip Cale Fran_To Ft. _
�} 837-2997 Fran To Ft.
Area code- Phone number
7. GROUT: Depth Material �>Method
2.WELL INFORMATION: Fran­_0 To Ft. O
SITE WELL ID aOrapplicable), From .J Tp=FI. �i•/i�b,.><L E!? .r
STATE WELL PERMITa(a applicable) Fran To Ft.
DWD a OTHER PERMIT#(it applicable) 8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft.—in. _ In.
WELL USE(Check Applicable Box): Residential Water Supply®� Fran Tv Ft.—In. _in.
DATE DRILLED /0 -//- J Fran To Ft. in. _ in.
TIME COMPLETED OU 00 AMD PM[3— 9, SAND/GRAVEL PACK:
3,WELL LO/C/pT O[N: Depth
Size Material
/1 O�o�»�'�r" COUNTY 6�A'C f - Fr°r" To FI.
CITY: // From To Ft
/9pc( From To FL
(Street Hama.Numbers,Community.Subdidssm,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
CpSCpe pValley ❑Flat ❑Ridge 0081er From To Formation Description
(check appropriate box) _
so // Sr>2� May
t".sccndsos,dejeerst. D S:V C qv— /4 ut
LATITUDE _ 6- ntinuees,saonds or
LONGITUDE S) 70 ys6 7 in a decimal formal .$�U JY/.Z G/'C/j . 7i
L
Latitude/longitude source: pCl'S ❑Topographic map
(bcalion or wee musl be shown on a USGS fopo map and
attached to this home If notusing GPS) 11
4.WELL OWNER Ve� Tall
OWNER'S NAME P�
STREETADDRESS 30go Lai ktwy 80 1 113
-
aaoaW�l , 64 '5041 S-
City a Town Slate Zip Cafe
( c- 2_f } B23 _ 3 .1?2
Area cafe- Phone number
11. REMARKS:
S.WELL DETAILS: rr''
a. TOTAL DEPTH:
Its. DOES WELL REPLACE EXISTING WELL? YES NO O/
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCOnOAHCE WITH
a. WATER LEVEL Below Top of Casing: -� FT. 1SA NCAC2C.WELT CONS TAUCTRM161ANDARDS.AND THAT A COPY OF IWS
(Use'+'9 Above Top of Casing) RECORD MS EEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS / FT.Above Land Surface' 'C/Z/�`..C�L�' /0-//-GtJ—
'Top Or casing(eirninated atfor below land sudace may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a insolence In accordance with 15A NCAC 2C.0118. pp
Gam . .
a. YIELD(gpm): 3METHOD OF TEST �i / PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form Gw•ta
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.(919)733-T015 ext 569. (��9 q r�r Rev,1105

AT �srnq o,4 0) ,
r OWNER
R - -. _
T L RESIDENTIAL w1;L l,l,consrcucTluN �,yy l RecoRu � D
r North Carolina Department of Environment and Natural Resources-Divisiou of Water Quality
NVELL CONTRACTOR CESR"FIFICA110N it 0�1/0 3
1.WELL CONTRACTOR: 1. DISINFECTION:Type Amount / Lu
Zee, r Ieet e g. WATER ZONES(depth):
.Well—Cmlractor Individual)Name From /,FY To /!S From To
MILLER WELL DRILLING , INC . rim To Frown-To—
Well
Contractor Company Name From To Fran To
STREETADDRESS P . O . BOX 567 6. CASING; Thickness)
Depth Diameter Weight Material
HAYESVILLE NC 28904 rim O T° 'Z'r Ft. 4�,Xs- JIM,;(l t"z_
City or Town Stale Zip Cale From .Z Y Ta_y:�/_FL L ­&s .10F 524 r !
( B28 } 837-2997 From—To—IL—
Atea code- Phone number
T. GROUT: Depth Material Method
I.WELL INFORMATION:
From To y FL
SITE WELL ID#(Il applicable) From 3 Tom' ,FI.
STATE WELL PERMIT#(ilnpplicable) Ftom To rL
DWCI Or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
Fran To_Ft. In. _ In.
WELL USE(Check Applicable Box): Residential Water Supply�' Fran To_FL In. _ In. -
DATE DRILLED /0 G^ CS rim To_Ft. in. _ In.
TIME COMPLETED N• d61 AM E) PM L✓ 9. SANDIGRAVEL PACK:
3.WELL LOCATION: // Depth Size Material
CITY: /Id Ai,lj-/,/Ze COUNTY y/:_�..'i�a. From To_FL
Fan To Ft.
Fran To,Ft.—
(St...I Name.Numbers,Commmally,5ubalvislon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
WSiope []Valley ❑Flal ❑Ridge ❑OUIer From To Formation Description
(check appropriate box)
y j Maybe in dagrem' U — �S— C 5(/
LATITUDE 5 ( Z 1 minwes,sttonds or _
LONGITUDE 3
/r 5z ' <;s'd ina decimal r..mot �--
1.tilude/longitude source: OrPS []Topographic map
(location of waif most bP Shown on a USGS logo map and t7
1
attached to Ihis Iwrrl I not using GPS) C'1
A.WELL OWNER
OWNER'SNAME CV`lx1=i'e, �i�4 Cl4 r-CA4 Ci
STREET ADDRESS Yc j(�FY-( LCgyr. O
City of,To+m Stale Zip Code
Ateacode' Phmenumber
11. REMARKS:
S.WELL DETAILS: ) -
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOf3-
7 1DDIIEREBY CFRWY THAT nits WELL WAS CONSTPUCUD INACCORDANCF WITH
e. WATER LEVEL Below Top of Casing. J FT. 1snnCAC2C.weO CONS muclnNsIANnARns.AND n TACOPY OF Hors
(Use's'If Above Top of Casing) RECORD HAS BEEN PROVIDED 10 THE WELL OWNER
d. TOP OF CASING IS l.-- FT.Above Land Surface'
'Top of casing terminated atim bekAv land surface may require SIGNATURE OF CERI IFIED WELL CONTRACTOR DATE
a variance In accordance With 15A NCAC 2C.0118.
e. YIELD Igloo): METHOD OF TEST l (�
PRIN IED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Met., Form GWta
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] oX1568. Rev.7105

SIAN�
RESIDENTIAL WELL CONSTRUCTION RECORD
jty North Carolina Department ofEnvimnmcnt and Natural Resources Division of Water Quality
w
WELL CONTRACTOR CERTIFICATION N 3368
1.WELL CONTRACTOR: f. DISINFECTION:Type CHLORINE Amount 100 PPM
WILLIAM BRADLEY LEWIS g. WATER ZONES(depth):
Well Contractor(In vidual)Name Frain 60' To 80' From To
CHEROKEE WELL DRILLING From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 G. CASING: WS�2�Thickness/
MURPHY NC 28906 From O' ToDepth 25' R. DWrneter S Materal
City or Town State Zip Coda From TO R. PVG
8( 28 )_ 837-8008 From To Ft
Area code Phone number
2.WELL INFORMATION: 7. GROAT: Depth Material Method
From 0' To 20' R. CEMENT GRAVITY
SITE WELL ID R(ir applicable) From To Ft.
—
STATE WELL PERMIT#(d applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
WELL USE Check A From To IL in. in.
( Applicable Box): Residential Water Supply -
DATE DRILLED 12/01/05 From To FL-in. _ in.
From To Ft.-in. _ in.
TIME COMPLETED AM❑ PM
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Sze Material
CITY: FONTANA COUNTY GRAHAM From To Ft.
From To Ft.
877 FONTANA HEIGHTS RD. From To FL
(Street Name,Numhers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat Ridge ❑Other From To Formation Description
(check appropnatebox) 0' TO 20' RED SLATE/BLUEGRANITE
May be in dcgra t,
LATITUDE 3 5 46.077N 20' TO 25' BLUE GRANITE
in
del al term
LONGITUDE_8 3 50.415W in a decimal fimmar 25' TO 205' GRANITE
Iatitude/longittde source: ❑GPS ❑Topographic map -
(location of welt must be shown on a USGS topo map and
attached to the farm IT not using GPS)
4.WELL OWNER r3'
OWNER'S NAME EARL SUMMERALL
STREET ADDRESS PO BOX 44
FONTANA DAM NC 28733
City or Town State Zip Code
( 828 )_498-2481
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: 205'
b. DOES WELL REPLACE EXISTING WELL? YES NO IN
C. WATER LEVEL Below Topof Casing: 1 WHEREBY CERTFYTHAT THIS WELL WAS CONSTRUCTED IN ACCCROANCE WRN
m9� FT. 1SA NCAC X.WELL WNSmUCTION STANDARDS,AND"TA COPY OFTtiS
(Use'+•i Above Top of Casing) RECORD HAS BEEN PRODDED TO THE WELL OWNER.
d. TOP p CASING IS 1 Fla Above Land Surface' ��({l a)r 6 A ZOA, 12/02/05
'Top of casing accordance
with bel15A N and surface may require SIGNATURE OF CERTI I LL CONTRACTOR DATE
a varFartce In accordance with 15A NCAC ZC.0118. , I �
e. YIELD(gpm): 12 METHODOFTESTAIR WIWANIDLW�UIIC
PRINTED NAME OF PE SON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt,
1617 Mall Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-ta
Rev.7/05

''�f ' RESIDENTIAL wru CONSTR cb' i-ION Itrconto owNER
111 Nosh Carolina Department of Environs MWD
ucul arnJ Natural Kcsourccs-Division of Walcr Quality
' A WF,LL CON'l-ILAC-1'OH CEN11FICA'1'ION H INC ✓
1.WELL CONTRACTOR:
- 1. DISINFECTION:Type /
.` _;.1.' k Amount
WWI Cartracla(Individuaq Nama 9. WATER ZONES(depth):
MILLER WELL DRILLING INC . From iY ,J TO From
To
WeI]Conlrecla Company Name , Fran To From
EEETo
Fran To Fran STREET ADDRESS P.O. BOX 5G7 TO
S. CASING:
HAYESVILLE , N . C. 28904 Depth Thickness/
From G To ( Dia Diameter WeglJf Material
City a Town Stale Zip Code FL_i_..�- .✓ ! -/ l
828 } 837-2997 From To Ff
Area code- Phone number Fran To FI.
2.WELL INFORMATION: T. GROUT: Depth
Mate/fiat
SITE WELL ID Opr applkaMe) From c Tc 1' FI. y� el
STATE WELL PERMIT11(aappocable) Fran_--T°-Z- F1. `/t k ML•,
Ran To Ff.
DW(Q a OTHER PERMIT N(il applicable) �'—
e. SCREEN: Depth Diameter Sbf Size
WELL USE(Check Applicable Box): Residential Water Supply Fran To Material
PVY FL__In. __ M. ` P
DATE DRILLED i<•,7_ ._ %- Flan To Ff.__In.
TIME COMPLETED ( Fran 10 pt.__In
---�— AMU..--PMp __ M.
3.WELL LOCATION: 9. SAND/GRAVEL PACK: '
r Depth Size
CITY: y � i.p,,;f c, / �C COUNTY i�•r'.�a +.T From To Matelot '-
t:.,� .✓c /._/ ("( Fran Tff FL
ISneer Nama,Nkanbere,Gxnmunily.SobdlNrlon,Lol No.,pa¢el.Zip Code) Fran TO Ff. (,
TOPOGRAPHIC I LAND SETTING:
f
OSbpe OValley ❑Flal 011idge ❑Other 10.DRILLING LOG ,!
(check oppropdata box) —"-'----- From To Formation Description
LATITUDE y_ /,�. ,S'f May In in detn"'. ---- "I
mint".seconds or
LONGITUDE `�— ,J $C. ;S..L to a Decimal Pommel E
latilude/longilude source: OGPSp. C j.
flGVG' YG�
❑7-opographic map -
(bcatbn of wel must be shown on a USGS fopo(nap and ���
attached to this farm/nof using GPS) 1
4.WELL OWNER k �^� ---___
1 C —' 005
OWNER'S NAME_l. i')•'i, e, n
STREET ADDRESS
7i�7swftt8 Regional
r ect[
City at Town Stale Zip Cale
—} ---�—_
Area code• Phone number ------__
S.WELL DETAILS: 1]. RENIARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO g- f
a WATER LEVEL Below Top of Casing: rfG 100NERESY CERTIFY n/AT TIRS WELL WAS CONSTRUCTED H ACCORDANCE WmI
bme Top of Casing) Fi. i.(Use'*'N A 1SA NCAC tC,WELI CONSTRUCTION STANDARDS AND THATA COPY Or nee
RECORD NAs BEEN PROVIDED TO THE WELL OWNER. F
d. TOP OF CASING IS FT.Above Land Surface' J/�
'TOP of caskrg ferminafed­aYm below land surface may require --i=s�7w"�'t«_ /-CS
a varlanca M accordance with 15A N(�AC 2C.0118. SIGNATU E F CERTIFIED WELL CONTRACTOR tt
DATE ;.
e. YIELDlgpm): 0 _METHOD OFTEST e'i�( °•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL i.
Submit the Original to the Division of Water Quality Within 30 days. Attli: Informallon Mgt.,
1G17 Mall Service Center-Raleigh,NC 27699.IG17 Phono No.[phone] axt 568.
Faro rTW-ta

ate• �
r ' � RESIDENTIAL WEI I,consrltuc'f,16v llEcoaD OWNER
North Carolina Depanment of Environment and Natural Resources-Division of Weler Quality MWD
WELL CONTRACTOR CF_it'1'IFICA'('ION H NC
FWELLCONTIRIACTOR:ACTOR: IF-
STREETDISINFECTION:Typo Amountpnorvwuaq Name WATER 20NE5(depth):ToFromToWELL DRILLING INC . To
Company Nam From 70 ToDDRESS P.O. BOX 567 From To
ING; Thickness/ 4.
H A Y E S V I L L E , N. C . 2 8 9 0 4 Depth Diameter W,ei�h(i� Material
Cify or Town Stale Zip Coda From Toj:& -FL-'��'�Fran To FI.
( 828 y 837-2997 Fran To FI.Area code• phone numbs
2.WELL INFORMATION: T. GROUT: Depth Material
SRE WELL ID Nprappacable) From To__-1 method
-FL � r��yy� J/
STATE WELL PERMITNpl appacablel Fran- _.To-z.b FI.
Fran To Ft. i
DWQ m OTHER PERMIT A(if applicable)
a. SCREEN: Depth Diameter Slot Size Material •
WELL USE(Check Applicable Soxy Residential Water Supply p Fran To FL__In, M.
BATE DRILLED /� -b E--Od l Fran To Fr. in. _- M
--- -• Fran To FI.�_In.TIME COMPLETED .3- O(� AM❑ PML+— - - in.
3.WELL LOCATION:
9. SAND(GRAVEL PACK: '' '
/ Depth
/YCUO'ilJt%�l� Size Malarial
CITY:
COUNTY 6iQR�7r2 From To Ft. I._.
From To FL
3/1CcrJ�/.i— t.CC�� Fran ToFL—
Lot �'--- ((Sbeel Noma,Numbers. aapumly.SubtllNslon, No.,1'artel.Zip Code)
TOPOGRAPHIC I LAND SETTING:
[]Slope []Valley []Flat ❑Rid9e []Other Te•DRILLING LOG '
f
(check app(o-priale box) -- -- From To Formation Description '1
LATITUDE yl ✓ 6 p �f-7 Ainy lx in da•greev, --�
LONGITUDE �T0 '�, rZ++� insdecinai ronnat
Lai ilude/longittide source: afTS []TRpOgrapllic map
(A,cnf irm Of we►mnsf be Otown on n USGS IOP0 map and ---RECE-W Ei D
attached to this farm y not us#rg GPS)
4.WELL OWNER [ '
OWNER'S NAME_ C' �YS TC� /�,mh f c�T - 0-8 2 -6 -
STREETADDRESS
�- S eVl tt3TtaI Q J
r:.
City or Town Stale'ZIP Code 10f1
( F --- .a
Area code- Phone mm�ber
S.WELL DETAILS: IL REMARKS:
a. TOTAL DEPTH: J 5S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJa-- ,
e. WATER LEVEL Kelm Top of Casing: FT IOO IfrREBY CERTIFY THAT THI$WELI WAS CON$mUCiFe NACCOROANCE WONF'
(Use'+'HAbove Top d Carlin g) RECORD IN$BEEN PROVIDED TO THE YYELLOWN ND TNAt A COPTY OF INS;
d. TOP OF CASING IS I FT.Above Land Surface'
"Top of casing left"naled al/a belay land surface may require
a variance in accordance With 15A NQAC 2C.0116. SIGNATURE OF CERTIFIED WELL WELL CCONTRACTOR DATE I
a. YIELD(gpm): METHOD OF TEST_
PRINTED LAME OF PERSON CONSTRUCT[NO THE WELL i-
Submit the original to the Division of Water Quall(y Willifn 30 days. Attn: Information Mgt.,
1617INail Service Center-Raleigh,NC 27699-1G17 Phone No.[phone] ex1568. rmmGW fa