Hy CY2005

- -- ,. 3168ej
—' iYELL CONSTRUCTION RECORD
�ii r� sc n�ni
North Carolina De` partmc—nT=0 fllviionment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Print) 1 " �<' J. 7lo rhiY, l0� e� S CERTIFICATION
1 a .oc -'- n �. \
wF.I,I,CONTRACTOR COMPANY NAME PHONE „
'e—�—
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box)_Residential O 'ylunicipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ if Other,List Use _
2. WELL LOCATION: Topo�gr�hie/Land Setting
Nearest Town:
l(J�cyaPSUi��P" County �- C✓ DRidge L21ope ElVaPey Dflat
(check appropriate box)
Veocc�e Sea4a t\t;, e Latitude/longitude of w(;'I location
(Street Name,Numbers,Community.Subdivision,Lot No-Zip Code)
,� (degrees/minutes/seconds)
3. OWNER: Latitude/longitude source:0GPSi_3Topogmphic map
Address 90 I R Jee ov1-tdtorad (check lxn;)
(Street or Route No.) DEPTH DRILLING LOG
cah{o. as�l(n
Zip Code From rrTo Formziion Description
State
cr'fown p
Area code-Phone number _ —
.^�
4. 'DATE DRILLEDS. TOTAL DEPTH: --"
6. DOES WELL REPLACE EXISTING WELL? YES 0JFT-
(Use �
O
7. STATIC WATER LEVEL Below Top of Casing:-:
-+"if Above Top of Casing) v
S. TOP OF CASING IS �
FT.Abovc Land Surface' Tc
*Top of casing terminated aUor trelon'land Surface requires a 4p
variance in accordance pith I SA NCAC 2C.0118.
9. YIELD(gpm): 15 METHOD OF TEST Rl-c4 �f
en
10. WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type Amount
Show direction and distance in mu es from at least _ A
two State Roads or County Roads. Include the road
12. CASING: 1 Wall Thickness
Dept t}., ` Diameter or WcighUFt. Material numbers and common road namr:.
From�0, To Ft. P
From To Ft.
From To FL
13. GROUT: Depth Material Method
From To �Ft. fl"•e°fys �Jn From To Ft. =
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To" Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size MaterialQI'f `
From To Ft.
From To Ft.
J
16- REMARKS:
I DO HEREBY CERTIFY THAT THIS WELLWAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.'VELL
CONSTRUCTION STANDARDS.AND THAT A COPY OF TH) ECORD HAS BEEN PROVIDED TO THE VTLL OWNER
� - y-s
SIGNATURE OF PERSZ7N CON UCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section, Mail Service Center'REh,RV.g NC
NOl
...a,jai il7l within 30 days.

UIVNEH -------
NVLLL CONSTRUCTION RECORD 3 17 a s
Nm W Carolina•Ucpallnrenl of L'uvirouulent and Nnl�al Resources-Divislou of Watc�Quallty-otou w ter S ptiol
CEIII
WELL CON"IMC1Olt(INDIVIDUAL)NAME (pdnq /e-/ � .--
11e- r11oNE p (Ylgl b'_ 3r ys9
WELL CON TRACI Olt coMrANY NAME
ASSOCIAT'En WU PE"11101
STATE t1'ELL CONS tRUCI JON PEM11"1N If n,dicnblc
if n�dicnblc
1. W ELL USG(Check Applicnbla Ilox): ResideulinI 11YMunleipalA'ublic U Indusllial CI Aglicullulal U
Moniloling U Recovery U heat I'umgt W oter Ilyccliun U Olher U Irodler,List Use
2. \VELI.LOCATION: / 'ropogrnphiclLmld selling
Ncmresl'1'own: "&Y/KJv``Ile _Cuunly `�`tl_ `V4�� UltlJga USlupe []Valley ❑Plat
(ebeck apptopdole box)
z1,Code Lai i dellougiludeofwelllocation
(Sued Nau,e,Numbeir,conunmJly,SubJivlJa,,Lol Nu.. I ) ss�.z a! /�,��'[� a Qt 0.2.1r�
zUllt /���`�--F (derttes/minutef/retnnd,J
3. OWNER:_ f LaliluJdluugiludc solucc:UCPSUTupoglnphic nwp
Address Iy0 rt.k (chmk box)
(Sheet or lloule No.) 1) ;-1 121ULIARUMQQ
City or"town State zip Code
I7I0111 To rorumtionDesclipliml
(_) 0 — 7, k
Me■code.rbone number 7L,6 cu
4, DATE DRILLED 5
5. To rAL MITI I! 600
G. DOES WELL REPLACE LXISTINO N P.LL7 YES ❑ NO 8
7. STATIC WAl LK LEVEL Lclo N"op orcr sing: 1,3— Imp) FT.
g. TOI'OF CASINO IS L .Above Land Smrace•
•Top of urinr ItnnlnwltJ at/or below luul rmlxce requltn■
♦ulxnre In nccor Jrnre wills ISA NCAC IC.911p. `
s. YIPLD(@Fnl):2_METHOD OF TEIST___
to.WAT"ER ZONES (depth): S�� LUCATMIKI- 1i
/ T Amount �irc Show direction end distance in miles Gan at(cast
11. DISINFECTION:T)pe�— Wnll 7lhickness two State Roads or Couuty Roads. Include Ule road
12. CASINO: numbers and couunon toad names.
Dept, Dimncicr or\Vci 61/Fl. Material
Flom o To 7 r1. '
DR.�I
t 4 l Toll. G.;tS s e
Flow r*t
Prom To FL o
h file[ at
13. OIlOU1': Depotof a
Flom 0 To 2 rL
Flum_ To u1
14. SCREEN: DepUl Diameter Slut Size Matednl
Tn Ft- iu. In.
From iu.
Front T0___P1, lu.
15. SANDIGRAVI'l-PACK:Depth Site htnlelial
Fiumt Tm rL
1:10111 ra FL
16. REMARKS:
LL
IDOIIEREDYCERTIrYTIIAT-1111SWELLWASCONS'I'R11C1"I?DINACCOIIDANCERO II ED10TC2C,ELO
C0NS11WCII014 S"I'ANDARDS,AND THAT A COPY Or TI IIS ItLCORD HAS BLZEN PROVIDED TO�LEl�LL�VNLR
SIONATUItL 01;1'EI(5ON CONS"I11U( 17NO771L WELL
DATE
Raleigh.NC
SUimldl the orlglnnt lathe Dlvislon or Water Qunilly,Crowldtraler 5ecllmt,1636 Mdl Service CcO1Wr1 RLIV. 07 2001
.,. ., Bonn nl »11 r,llhin 111 dn1'+.

00 3 16 13 9
WELL CONSTRUCTION RECORD
Not Ili arolinu - Ucp;u'uucnt of t nvironment and `d'tur l Isouuks )(vision of Water Quality-Groundwater Section
VAI(L1 lUA'Ili.A('IOIt r-,I)IA"I Dt AL)N%.N IlI ,trwt)_ /c�" I/I CE It rill C.A'l ION'#���7�/
\c ba l C(IC'Il t.\('1OIZ(O\I I':\\\ \ \\IF:f[/� ���.- ✓��� - ._- V _--. -. _ INIONE #
I.CI I:\\l-.I.L(O\S'IRt C'IIOS PEWN111# \StiOCI,\'I ED\\'Q i,Eit\Ifr#
(it applieuhlc) _,� (if alllicablc)
I. AA'ELL USE tChcck Applicable Box): Rcsidenual L�1 MLHIMI)aUNublic ❑ Industrial ❑ A_ericuhurul ❑
\"lonilnrhlu ❑ Recovcly ❑ IICat Pump Water Injection ❑ Olhcr❑ II Othcr, List Lsc
W ELL. I.OG\TION.
/�'1�14�/y�$1/,/ � / � fI'opn�ral�hic;Land setting
NcIresl fIIVII: - Counlc7O �f
- - - -- -------- Itid--c ❑Slope ❑Valley ❑flat
`�✓✓ oK-'.✓ -- (check aprrupnmc boa)
11'I A Iola,Ni /C(uumn lv,.Subdivisi m,I ul No.Zip C'.alcl L atltndCrlUll'll(IdC 0I AVCII 1ne(Itloll
M% NL:R _ _ '(J Id br 9:Sniunl�ncwndsl
Addl�l,, L:II11(IdC lonkitlj&source:OGf S❑Topographic map
ISlrµla Itnme ,. A (check bm)
DI'.PT 11
DRILLING LOG
( Ily Of nrn Slane ZIP I...le 1-1 In To I' n o f Description
A«e code-I'b.nm uuulh�
t. DA'I L DKILLIiD -
�. "loT'AI. DPI"IlL_�»v:� — �,���✓ /�1��J'✓O_ =I-�
(I. DOGS WELL REPLACE EXISTING WELL' YHS ❑ NO R7
7. S"I'A I IC \VATER LI VGI. Helow 'fop ol'Casing:
I I)sc'4"i1 Ahosn Top of Casing)
S. 1"OI'OP C:ASIN(.i IS_ _fT. Above I:old Suffice*
"1'oP ell ca%in);let'millme(l at/or below laud surrace rr.p'sires a - _—
rarianee it,accunlancc will, 15,\:NC:\C 2C.ol 18.
v. YIt.LU (epnl): 10 Ml;fIIODOI' IL'SF / " ,/
l U. ll 'ATHR ZON bS(dcpth):
1.0CKIION tiKIfIY'FI _
II- DISINfIfC"(ION."type_ Anleunt_ Showdirecti0n:md(IISI:IrCC in miles from at least
1 1 CASING: Wall"thickness two State Roads or County Roack. Include the rein)
Depth I:Inlelcr or V.c"u;,IL,PI ,pnal numbers and common road names.
fronl --- I_ ht.�1� _��_ Le/ f
loon- ------- fo
- --- rr,
Iolm---_—__
ill GROU I- Deplll, blow ial/,. Method - I `
boll) O TO 1-0
I-loin._-____._. ho_—____ II. CD
1-I, S(- It P.IiN: Ucpih Ui: m uncr Slot`.ire h'h1(Crial C71 --
f non to
a
I runl'-_—__. l
15. SANDA;RAVEL, I'AC K:
Depth Size plaleritll
vum to PL
11,. RI'.'JI:ARKS:
1 1)O IERI:H1 C'ERllfl""I-IIAT MIS WELL WAS C(`NST'RUCTED IN ACCORDANCE WITH IiA NCAC 2C,WELL
CONS"I RUC I IONS TANDARDS, AND THAT A COPY Oh THIS RECORD HAS BEEN PROVIDED TO 1-I1E WELL OWNER
IGN,ATURL- Of I'Ei:SON CONS'f RUCI'ING THE WELL DATE
Submit the or to the Division of Water Quv.lity,Graoridwater Section, 1636!flail Service Center-Raleigh,NC
2 7 699-1 63 6 Phone Nu.[phone],within 30 dacs. GW-I REV.07/2001

lam " Gv3
WELL CONSTRUCTION RECORD
Not II1 C atolina - D pai Ii uat of l neinnunuu arld 'd•anal cso tree} DI is ion of Water Quality-Grallndwate'r Sections
\\I!LI.C ( ' l ' -- / ^ _
CFfllU\li\ lOIt(INUI\IDl \IIV\\I (pnnQ �� IG\'l[ON#0XW
mtumlr / ` at,9/\\b:LI ( U\'I t. < ' 1 ,( y
II(
\\li1.I-UO'Ns'I'RCCtION PFRNI IT
1iI;giplicahle) (it applicable)
I. \\'ELL USE(Check Applicable Dos): Residem:al L\S MunicipaliPubhC ❑ Industrial ❑ A'_ricullural ❑
Moniloring ❑ RCC0Very ❑ 1-1ca1 Pump Wa>;r Injection ❑ Olher 0 If Other, List Use
WELL. LOCAT ION t:w� �TopogralihiciLand setting
Nrare l I vn. 1/v / ('nunl'r �� L7flwe-c ❑Slope ❑Valley ❑flat
.Op �� - — -- ----
...� =F-�--- Ichcck appropriate ha,l
(Alicei Naute.N:I... .Conunu nily.$uhdi visi.:n,I_ot No_lip Cudcl L:111(IId C/I Ullgi(UdC oIkYCII IoCalioll
---r �- �
{ (1W NI:.IL: Iticgrcc5hninumsisccundsl
,AJdlcss __ Latitude/longitude sourer❑GPSOTopographic map
�
t9lrect u. .nutc No.) �yC� J Ichcck hos)
I /el / DI-:I'TII DRILLING LOG
—i.. nr l slate zip horn "'o P�f�•matins Description
:\rca o,�drl'h�inc uwnh- 5�ots" y ;j
I I�n"rL uRn.11•:u GG��CC1��••LL__ �r D Ne
a. DOES WELL REI'LAC'E EXISTING WLLL:' 1'I'. ' NO C1'
7, SI':\"IIC: W'ATGRLEVULleIow,roporcasir : �� PT
(1)se11+-'it Above I Or ol'Casing)
N" "I OP Of CASINO IS - � _ F"1,. Above I.and Surface' —
`'I'up al'casiin;m oo,tated al/ur helow land sur(nee rez;nires a _— —
vamm"inaccurIancc rhI-%N('AC2C.OIIY.
'1. YIELD IgpnO:� _ML PiIOD OP TLST ��� � --
IU. Ak'A'fL-.R ZONES (depth):— --
LOCA"IION SKETCH
I I. I)I SIN fHCTION.Type Anx lot __ ShuW direction and distance in miles from al h4oa
I_ CiASIN(i Wall -hickness tvvu Slate Roade or County Roads. InclLtdc th(' m
�� Depth Dy:myp� or k%cighttI t. Ma/mil nunlben and common road names.
Fit.... ITS PL (([�'Y iu�7
lool—
ROUl Dcplll NIaIII lal Method e.0
Prune �___ ro�'d _ fL
I.1um "fu PI
I) RI LN: Depth Diametcr Slol i,ne Material -an
I.1nm _.._-. to ._. _ I-L..____.—_.in. n
II1. -
,
I7nn1------_ Io----.__ in.
Ii SA N DIIG RA\'Ft, PACK: ---- — --
Ucplh Size Ivtetlerial
hon1 Tn Pt.
Il will "I a----- I I. —
Ih_ It l[AI:ARKS:
1 A) Ill-RIMY C'FRIIt:) 'IIIAT THIS WELL W'ASO.•NSIRUCTED IN ACCORDANCE WITH 15A NCAC2C,WELL
CONS HUUC"IION S f ANDARDS.AND THAT A COP`C OI;THIS RECORD HAS 13L'EN PROVIDED TO THE WELL OWNER
SIGNAIURE OF PE SON CONSTRUCIING THE WELL DATE
Submit the origi n:d tothe Division of 1F'ater Qu:'•lity, Groundn'a ter Section, 1636 Mail Scrcice Center-Raleigh,NC
27699-1636 Phone No. [phone], within 30 daps. GW-I REV. 0712001

D - 31610
NVELL CONS"('RUCTION RECORD
Noah C atolina -hcparuucnl of h:nvinuunall:uld N•uurall RCSIXINCS- Division of Water Quality-Gra(Ind Water Section G
\YP:ILCO♦'llt.\('IIIIt(INDI\'IDI AL)N:\DIIo(priu ) 4�L f�. O_ -_-__— - CFR'I-IPICCIION fl,
\crl Lcos'rR.\(`rnr,cow'.\v `Y_------_------.—rno:�l•: # 1
L\\I:LL C'O\ti flit,C"I ION I'IiRM I'r#_ _kSSOCL%I ED\\'(j l'Ewm r#
I it applicnhle) (i Rlpplicahle)
I. N'GI_I, USG (Check Applicable Box): Residcncal ❑ Municipal/Public ❑ Industrial ❑ Agricultural 21*�
\{onilor il"" ❑ Rccovcl v ❑ liaat Punlp Wa;cr Injection ❑ Other❑ I I Other, List Use
_. W'ELL LOCA-1 K To ogra chic/Land setting
N c:u'csl "Illtvn:-�/ Q C o!unt >� f ❑RiJ�a ❑Slnhc ❑Vallry ®1'lal
���� __ lelnck appropriate hull
I S1,n9 Na..w• Numhu S,t'YIII IIIIIn 11 V,SubdivieLm,Lol N,,_Zip Cock) Lalllude/longitude or well location
9
). IIWNI,i IL:_'C' �l_ .A/ �� ,�✓ LJcyrccs;5ninuWskceundrl
Vddrass J� ! C'-- _ Latitude/IongiWdc source'.❑GPS❑Topographic map
n IS!raci ur Itoutc No.) 0.-h"k bwu)
`� ._____ I�• �: _ 7� / Dha'l'II DRILLING LOG
p�C'in-ora urru til;lm hp code Fro1D To Par n ion Descriplion
:\m,!code- I'hnn•na!uh�r —9N
t. DA11 DRILLIJ) �`-c]� CJ "�:�
a "; -
S � /-
6. DOGS W'LLI_ RLPLACL EXISTING WELL? YVS ❑ NOzze
7. I':V1'IC W/\'I FI: l Il-VI?1- 13clow"fop of"cash /C`j F'r.
(Use"r'II Aburc Tnp nl Ca"11g I
'I.OP OF CASING IS FT. Above I,:md Surface'
"llgr nl'caving 4•rminah•d a/ar hclnw laid vurfaci,rn;i!h,s a —
cari:umc in aeninl ante a Ih 15A N'CAC 2C.III I.S.
MI;TIIOD OP TFsr )Q/�
U. W'ATGR 7.ONGS(de)th):
_ LOCATION SKNTChI _
I I- DISINFECTION."type_ Am and Show direction and distance in miles from al least
I_'. C':\SLNO Wall-'hickness two Slate Roads or Couniv Roads. Include the matt
Ueplh Dial n Ic nr A`.,.'ah tJFl. F Iel!al mmllbeis and common road names.
1-ram 'ro— Fl. r
Prom_._._._ I o_----- FL_--_
F -14
rom 'ro I'L__-- —. -- i
Ill GROU I . Ueplh Maleri:d Nlediod I .3
liotl lu IL _ _ C:)
fe-
LI. ll Ill LN: Depth Di:uncle] tilut.`,ize Nlalerial C -a
l�. SAND ORAVEL PACK:
Depth Size Malcrial -- --
I Ionl I PI.
limn-------Io----- 11"----- -- ---.._
- 16 kkMARKS:
10O IILREB1' CERTIPI'THATTHIS WELL AVAS C( NSIRUCTED IN ACCORDANCE WITH 15A NCAC2C,WELL
C(INSI RUC I IONS T:\NDARDS.AND THAT A COP''OF THIS RECORD I-IAS BEEN PROVIDED 1'0 II1E WELL OWNER
SIGNAIURE OF IIEi:SON CONSI RUCIING TIiL WELL DATE
Submit the original to the Division of Water Qu: Mv, Groundwater Section, 1636 Mail Scr%ice Center-Raleigh,NC
27 699-1 6 3 6 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

Ng 316 13) 6
WELL CONS'rRUCTION RECORD
North( ,mina- Dcp:lrllncin of Cncironni nt and ':liIlul,;(d, CSOL Ices Diivis, oil of Water Quality-Groundwater Section �/y\YIIII ( ON'I-It.\( I Y Ili(IN D I\'I DL \I.)N A!N I (p,j.,) /_ / ✓//i'A��- CFIirl fICLATTION q3CN
( (IN'lltA( If,I:C'O\IP:\\A N.\1I h:Pr/�-4.5/w� PDONP. p I'�'ro,6
r err:ACI'Ll,CONSrRI CI ION Pl.,wNII ra--- —Assoc/cl,crr:D Wt1 PI:Rsn ra
(it applicable) (i l applicable)
A1'LI.1_ U'SL' (Check Applicable RoN): Residenr,al IH'�MunicipaUPublic ❑ Industrial ❑ Aericultural ❑
;Muniloring ❑ Recovery ❑ heat Pump Vva'!cr Injection ❑ Olhcr ❑ If Othcr, List Use
_- WI-'I-L. LOCATION -/ Topugra l lhic/Land setting
I��y;ll�,ci " u„•1':/ f}'J Q C'(,unl•, - WtxOV �,
[// _ _ ❑Rid¢c LKllope ❑Valley ❑Peal
-- Idtea apprpram n„s)
(1I : N-m,.NI,nfl t. ('onw:amly.Sat divki 'I Lot No.lip Cud,) Latllude/longilale Of Well location
_ (IW NI,:R w 4/- W e C. Idcyrccc, ninuWshenutds)
Lalituddloneilude sourcc:OGPSOTupo raphic map
ISlrat I Itu::t,No.l
CA DRILLING LOG
(-
dyur-town si. Zipc::de fl�nn .�•,o_ P n ltio Dascriplion
s. fU'f,11. DIi P-II -- �'� //� JAd _
L r4n//" e
(t. DOPS WELL REPLACE LXISTING WLLL'' )'IdS D NO Hl�
7. S I'A'I'IC WATER I.I'VFL Below'fop ofCasivg: —
I Ilse••_"if Ahoac Top ul Casing)
N. "I"OP OF CASING IS_�___FT. Above Land Surface'
"1'np al ca,mg,l®'mm:lwd al/or below Will surface requires a —
rarimwc in accord:uree,ritl, IA NCAC 2C.01I8.
). vIELD I^.pnU:_ ',IL.,-FIIODOI:TI;S,, alr
10. AVA'I-I'.R ZONLS(depth):
LOC'A'I'ION SKEI'Cl f
I. DISINI I!CTION:Type_ — An)r met Show direction and distance in miles from at least
CASING: Wall-thickness two Slate Roads or County Roads. InCLIdC Ills road
^^�� Depth i ncler or P.o IIPt. 14 tonal IIUlIIbeIS and common mad names.
From �CX fo fL �r3a - �d
I�rum Io
I'rol "fa IL _ N
ri
I GR(lU hry: Depth nMulcri:d Nlothod
19ui l
cD
11, SCRI I'.N: Dcpd) "-- Dimnetcr SlutSi-cc Mulcriul C)
I'r will -
U. SANDIGRAVEL. PACK: -
Depth Size vLdeied!
Flom
Isom__._--- I"°--- "---
10 RIALARKS:
II) IIIRI'H1'CLMIF1'1HAT"THIS WELL WAS C( NSIRUCfED IN ACCORDANCEW111I 15.A NCAC2C,WELL
CUNS"I RUC I IONS I AND:ARDS.AND THAT A COP"OP THIS RECORD I1AS HLLN PROVIDED TO'-I-IE WELL OWNER
m
. IGNATURL OF Pl-i SON CONSTRUCTING THE WE'LL DATE
Submit the original to the Division oT Valet Qu:1Hy,Groundn'nter SCCtintl, 1636 Mail Screice Center-Raleigh,NC
'-7699-16361'hunc,N(u.(7l9)733-3221, )vithin 311 does. GW-I REV. 07/2001

Q�yp 31613' 5
WELL CQNSTRUCTION RECORD
No n II('.uol ina - IlepuI In lc nlol luvi roil men Wild 'N/'{rtluraI/p`esoulce+ /'Dill is ion of Water Quality-Groundwater Section
A%Ih:I.I ( ("IllA('IOR IINm 1111 AI )N':\Dll�,nnl) I CrYAJI A'AJ/'/'12 ---- — CEil rlrlc%r ION a����
N\I:I.I CON I ItA(I OR I OAH,AN N\\I I': �'i�C._( e(/r �[ ----_ - --------POONF. a
xr.cIE t\EIA,(OAS rac(-r ION'rhlt\Irrn._ _aswa,rreu wr1 PERMIT#
!il'applicahlel � lif:giplic;lblcl
I. AA'lil_I_ USL (Check Applicable Lox): Rcsidem!sl ld"/Nlunicipnl/I'ublic ❑ Industrial ❑ Agricultural ❑
V[o] ilo"'o. ❑ Rccovery ❑ Hcat Pump Wat.r Injection ❑ Olhcr❑ IhOthcr, List Usc
_. W I I. I OC':AIION
/ _-✓` Topor Olt ❑t yihlc;Land selling
IN I �lI fo 'n �uf�J(� ( ainl•,. I Slope ❑V,Illcy ❑I:kll
`MY- --'��%�e --_ _ — Wr k"y prnpoato huz)
I Inca Nunn.N..... Coinnnmiiy.Subdivision, Lul No,,;TI Codcl I.(IlltndC/I0IIl otndC of WCII IUCatlon
IJ h cgrcc� ninulcs/sccunJ.a
Latitude/longitude source:❑GPS❑Topographic map
is r 9 r liu I N .1 Icheak Nos)
DI.:PI-II DRILLING LOG
u� l/ -n Ile zrpcn& Prom To P n Itiol Description
:A¢a code- I'Ienm uwnb.r J /
?& 4-
S- DOTAI. DI!I REP O� � �
tr. DOLTS A1'GLI_ RI_'I'LACL L'VSTING bVGLL° YES ❑ NO
7. S"f:\1lC l4'AI'EK I_HVt?I- 13clow Top of Casir,: 3-_I:'I'
A6us e I op nt Casing)
X. 101' OI'"CASING IS _ � _ FT. Above land Surface* —
"Tup nt caging let rminated at/ur Neltm [:still surface rr,'.sires a -----_ —
A aname m secant:me with I5:\NC.AC 2C.III I H.
Q. YILLDIr�lnit ML;'CIIODOI'"CEST�'��
LOC'AIION SKPTC I I
I I. DISINI'LCI ION:Type— Amcanl Show dircclion and distance in miles from❑l (cast
I_ C:ASINU: Wall hickness two Stale Roads or County Roo 111s. Include the road
Ueplh icter or V.e h '11 erial numbers mil common l road names.
(roll, To1o3FL % _ "�_ ,^(
1`r oil l
�—_------"Il r------- I '"--
II- GROL1"I(ra)` Ucpth r Material Methodrri
L loin _--..--_ I t r---_.—_ I'L-
1-1. SCI<IIEN: Drplh Ui;unctcr Slu[i:i!c Maa•riul 'f
Soil To I`I. iu. in. Qn .4
I'nml lu _ _ II in. in. "^
11 SAND/GRAVLI. PA(K: I
Depth Site 'vIaiertal
I mill l n Fl.
I loin._- -----fo_--__--_ II.
It, RI MARKS
I Ut) HHHO CEI<III:A 'I"HAT "THIS WELL (VASC( NSIRUCTED IN ACCORDANCE WITH IjA NCAC2C,WELL
(ONSI RUC-IION S[ ANDARDS.AND THAT A COP`:'OI'THIS RECORD HAS BEEN PROVIDED I"O THE WELL OWNER
SIGH NAI L'RE OF P ;:SON CONSTRUCTING THE WELL DATE
Submit the original tit the Division of 11'afer Qua.[ity, Groundn'atei Section, 1636 Mail Service Culler-Raleigh,NC
'_7699-161G''hone No. (919)733-i�21,within 311 dais• GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
Nardi Carolina - Department of Environment and`J•tureI Resources-Division of Water Quality-Ground Water Section
�p
P-I•:I.L uo%I-it:\CTOR(IN DIVI DU:\L1 \aIP print) F4 MiTIF'IC:\TION 8�rb!
hY ELL CON I lt,%Crou COsn':vNr —ruoNE a
S l rr:"ELL COS%rncrnON reatatrru ASSOCIATED%VQ peew•ra
1 it applicahlcl (if applicablO
I \1'LLL USE (Check Applicable Box): Rcsidervml B-IMuniciptd/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ II'Olbcr, List Use
'_. WELL. LOCATION: r ,/ / Topographic'Land setting
Nearest T twrt: rQC -.SC/ e C•olull:, ❑Ridge lope ❑valley 01Ia1
(ch,ck appruprialc bust
1 S1rce1 Nan,,Nnmba",C,..mmmily.Subdivis_wn,Lx,1 No..%ip CMv) Latitude/longitude of Well location
?. l!WNEK; J, C'v��"' Iticgrccs minulcshttundsl
:\ddless 1 O t.vN ®/'• Latitude/longitude source:❑GPS❑Topographic map
ISn'sc1 ur Ituutc Nn.l relteck.bnsl
(n/WawsV,Af /1/,C `7f3� OFPTII DRILLING LOG
In/n-r I [ scI 1c zip C„.le From 'Fitit' m do l )cscription
:\rcu e,de-Photo•unmhcr� - � 4' .O
>. I OTA1. 1)I;PI'l1:_�J
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 12"
7. S'I'r\'I'1CWATERI..EVI1. 13clowTopol'Casing:35 1'T.
111sc"+'il'Abnrc l'op of C:uingl -
s. TOP OF CASIN6 IS — FT. Above Land Surlacc`
-rop acasing R•rminated aUnr below land surrace rcr,::ires a
variance in ammi:mee will, 15A NCAC 2C.01 Ia. ,/
YIELD(gpnl): Z6 ME"rIlODOFTESI-A/�
10. WATF'R ZONES(depth):_ --
LOCATION SKI;rCH
1 I. DISINFECTION.Type Antcunt Show direction and disl:mce in miles from al least
12. CASING: Wall Iiickiiess two State Roads or County Roads. Include the road
DcplII DDiaJ9eh•r or V.e1' vl•t anal numbers and common road names.
.y
Flom _To --
I
I.. (ROUT. Dealt""—� -- taterial Method
I = '�i (�
From. Q_ 'foci_ FI. E'M -
1 7
I-L SCREEN: Dc1,111 Diameter Slot Size bEttcriml
I�ILIll To I t.
I5. SAND/GRAVEL PACK: - 4;
Dcpth Size :vlatcrial II
Front____._
Ir,. REMARKS: �--
I DO IIEREBY C'ER'l IFY THATTFIIS WELL WAS C(•NSTRUCTED IN ACCORDANCE IVITI 115A NCAC 2C,WELL
C'ON.S"(RUC"PION STANDARDS.AND THAT A COPY OF THIS RL'CORD IIAS BEEN PROVIDED 1�011iE WELL OWNER
__/111 q,C� 0�
GNATURE OF I'Ei6ON CONSTRUCTING THE':WL'LL DATE
Submit the I)ri+gin:d to the Division of Water Qu:llily, Groundwater Section, 163611fail Service Center-Raleigh,NC
27699-16361'hnne Nn•[phone],Widtin 31)day;. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North(':u'oI ma DcpalImcnl of line irunnlent and Natural Revnurces- Division of Water Quality- Groundwater Section
R:\( I(m(IN I]I\'I D( \I.)N:\i\...
.Erin.) r�� CERrIFIC\110N# ,.,"/ f
# �O'�'7��=-/:J
s IA 11:\\1 1.1,C oN1 rRCCI'IoS!'F;IZ.\I I'r# :\S.SOCh\'rFD\\'Q I,EICAI IT#
I il'applicllble) (if-applicable)
I AA'LLL USE (Check Applicable Box): Residential LET Mffll cipafl'ublic ❑ Industrial ❑ Agricultural❑
\ionil0ring ❑ RccOVery ❑ HCat Pump AV:dCr Injection ❑ OthCI-❑ If Olhcr, List USe
\VI:LL. 1-OC'ATI)N. ''// � y' / opographic,,'Land setting
N caJ(•�}sIl'gown: IV-7D,y- C'ounl'r �LS°jy Zidgc ❑Slope ❑Valley ❑flat
.4,I-✓U �_ — _- ,-_— ___._. lehcck upprup:ialc host
11i n'cl Nunn•.N.... s.('ownutn il),$u6dirisiml,Lul No_Zip C'udel I:ItIltlda/lungimda OF WCII IIC'atlml
-� IJcgrccs;uunmashccundal
Address ���_ LIn11llde/IOrl6tLItlC source:❑GPS❑Topographic map
I 9r.n or Ruing No.l lehcck hiss)
C -ry— N`t — DEPTII DRILLING LOG
t'in I,yI Slue Zip Cu,ic Prom TO hly1, alio I Dcscriplion
OS
6. DOES WELL REPLACE EXIS'I'INC WELL' YTS NO
?. S"FAIIC WATER LEVEL 13clow'Topul"Casio,: ", Z ----
IosC" if Ahuv,Top or CUsinGl
S. I OP 01'CASING IS�— I'T. Above L:uld Surrice'
"rap nl'cesing ter m113A.1 a/or below hIld surface rer•.:ires a _—
variance ill accordance with 15:\:NC:\C_'C.Ill 18.
`). �_Y'IGLD (epm): Q_M1IETHOD Of TEST�•(�
0, WATER ZON I''.S(dc)th):— _.
LOC•A'IION SKI'fC•II
11, DISINFECTION. Type Am Lill[ Show chicction and distance in miles from at (cast
13. C':\SING: Wall"i hickness two Slate Roads or County Roads. Include the road
Ucplh7 c�nc er or V.eighth N4=l_ tel lal numbers onyd�common road names.
from , Tt>_JW PL ---- — /
fall' /JO-- —"rl' -- fL---- — - --
rr,lm Tu Pt.
(iROU I Depth, /wbl:lteri:d Method '
I'rum__. 'fu___.—_ Pt.
-t
I _ SULI ! N: Depth Ui:unetcl SIu1Svc Malu lal n '-
I will
Il oot - To
1i SAND GRAVEL PACK: �---- _---
Depth Size IvLa Ocrial C.71
Flom III PL__
Ifolll...__"---
16. IZkMARKS
t
1 DO HI RI:13Y CHR 111'Y'I HAT THIS WELL WAS C('NSI RUCTED IN ACCORD ANCE--WITI1 I5,,VNCAC 2C,WELL
CONSI RUC I IONS I ANDARDS.AND THAT A COPY OP THIS RECORD HAS 13LEY PILOC[If>ED t10 THE WELL OWNER
q - 1-oy
IGN ATU'RE Of PEi<SON CONSTRUCTING TI-IE WELL. DATE
Submit the on-,io:d to the Division of\Vatcr Qw life, Groundwater Section, 1636 Mail Service Cenler-Raleigh,NC
27699-1636 I'hnnc Nn.[phone],within 311 days. : GW-I REV.07/2001

F2 ti T. r. �. 1
WELL CONSTRUCTION RECORD
;Not IIt Caw[ma - I)cp: iInlcnt of h:nvirmunenl and ` aural////�Res/QAlice/}' - ivisiun of Water Quality- Groundwater SectioJn�
\\I:II ION III.A( UB16UI\IUI V.)NAME vino " x P.74Tp/�/�____ CER'fIFIC\7 ION
J#�';Yg?-�•yG
\\'1:11 (IlNIItACrf 1R(.Tpll'k\1 \' 7�' W—Z /y _ -_ ________I'IIONI•: # �+l7 uU Jp
S I k11,oA JA L CONS I'RUC IION I'F,R\11'1'#_ __:\SSOC'I:\'I ED WQ PERM,r#
t if"al,plic:lhle) (if applicable)
I VA'LI_I. USE (Cheek Applicable 13os): Residential 0/�Iunicipal/Pubhc ❑ Industrial ❑ Agrl Cllllltral ❑
:\ioniluring ❑ Rccovcry ❑ 1-[cat Pump \Valor Injection ❑ Other 0 If Other, List Use
W ELL. LOC'A1 )24. Topogra icl.andsetting
NI/rcpsII n fuwl�.._ ___-___—Caunl•: L'U ❑ILidee c ❑Vallry ❑II:u
!."Z=)*r � � (e...k upprop..atc bur)
7 Nh.c! Naun•.Nnmha..C'u......!v.Suhdirivi::n,t.ot No.-/ip Cock) LallludClUnUitude 0rAVCI InCahn❑
_ A%NER:- --p/�-rA,y��"}�C'j�� (Jcgr<cs;minulcs/seconds)
:AJJless 7/-�--.. �/ le_ Laliulde,longitudcsuurcc:OGPSOTopographicmap
/I (S!!,-el,., Ituua N0.) (cbcck b0c)
[� —_--44L_,�._Z2 DFiPTII DRILLING LOG
I'uy„ 'r,!„:I •-!:ac /IpC'udc Prom To F n� y n itiof Dcscripliu
\rc:!codr I'h,:nc mnnh 6 -- — •ef�
7'
e. DONS WELL RITLACIi GXIS"PING WLLL? YES NO B�
?. S"I':\"hIC \V'ATI R LIiVIiL Below Top ul'Qtsie F(O Fr — —
I lJxc"r'if Ahocv I ,p 01 Casing)
S. 1 01' OF CASING IS �' _ H. Above !.and Surface'
"fop of c:triug Icnnina led al/ur lid uw laud vu0vice requires it — —
rariann•iu acnrrA an •n'i if I5A NC1C'-C.oI IN.
YIELD(gpnl): - ivILTIIOD Oh TFS F 4//
I0. WATER ZONES(dcpth):_
LOC•A'FION SKFITII
11. DISINI=1'_CTION.Type__- Anu,unt Show direction and diSlance in miles Imin All [cast
1 C'ASINO Wall ;hickooss two Stale Roads oI County Roads. Include the road
Dy,ihL/ 'u�ictel or V.mvhtfld. N ucrlal•, numbets and common road nanus.
LI„m�a 0
Flom— 'I n_ -- PI --
_ x
I;. ( KOUI. Depth /rNl'net 'if Method
Ilan �_ In b_ FI._1,s�"4 e."�/.__
I7UIn 'fu Pt. n
I I. SCF<IfEN: Depth Di:unelcr Slot:,;Zc Millet ill[ I -.
I S.ANDI(iRAVFL PACK:
Depth Size Malerial ..
I will
Ill. REMARKS:
I UO IIIr:RI'.IY•C'ER1lPY IHATTHIS WELL WAS CC•NSTRUCTED IN ACCORDANCE WITII I5A NCAC2C,WELL
C ONS I RUC I ION S I ANDARDS,AND TIIAT A COP'i OF THIS RECORD I IAS HFEN PROVIDED 101liE WELL OWNER
Ci
SI(INmuRE OF I'Fi< ( N CONS,rRUC"l ING TIC WELL DATE
Suhmil the III i'„inal to the Division of Water Qu:'aily, Groundwater Section, I636!Mail Service Center-Ralcigh,NC
27699-1636 Phone Nil.[phone],n'ithin .10 dal,s. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North C.uohna - Dcpnrtit tenIt' I nvironment and " •turaI R souk ti /I� ivi.ssf"on of Water Quality-Groundwater Section/Q
\\1-:I 1. 0'11 It k('IOUONDI\'IDl \L)N.v% (Prim) /_r ^�_l �Z CFRTIIICAl ION ll,; A/
\V ILL ON (O\I P:\\1 N.UI15_ fL_t{—__y_v #
r:\l ")A A.CONS'I It CC"II ON PI",[IN]IT#._— ASSOC1:\"1'F:D\V'Q PER\I rrp --
(it applicable) (if applicable)
AA'LI_I- USE (Check Applicable Box): Residential �Municip:d/Public ❑ Industrial ❑ A_-mcultural❑
.Aioniloring ❑ Recover-V ❑ Heat Punlp W;d;;r Injection ❑ Other❑ 1I'Olhcr, List Use
WELL 1_O( A'1' l l; y� / /,' Topographic/Land setting
Nc' 'C51huq'Ir -/Dl.- Count•:F. i1l
��r,. ---------- - 00v giz"Idge ❑Slope ❑Valley ❑Elal
!S� _ I<hcck npprupnate hue)
Ot...I Name.Nwnhou-('ommu,wI,Su hJ i v i I III,Lot No..Zip Csalt) Lanl mlC/lOngi WtIC Of WCII InCiltioll
1)W Ni f R df,4e �� IJcgrccshninmcsiscconJs)
\ddre>s _�,0 - Ur ___ I-atitude/lonei4tde source:0G I'S❑Togo graphic map
ISned uur�Rem,N���i`o".FFF)��� (check bu..)
DI'.PTII DRILLING LOG
ee��Cip „J�"T„t.0 p tar Zip c:de Fran To Fyr mli it Description
A"'!CIO, I'hun,nm..
I. DATE: DRILLGL)—y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. S"I'A'ITC WATER LIiVF.l. l3eluwTopufCasiog:
t the -Abort Top of Casintl
S. TOP OF CASING IS _-____ F"f. .'Abuvo Land Surl'acc'
''rnp al casing tvrtnina(ed al/ur b,lnw land surfan•minire'a
variant,in avnml:mce sri(h 15A NC\C 2C.n119. !!11
o YIELD (epm): _�NIETI-IOD OP TFS-C
10, NVATUR ZONF.SIdcplh):_-
LOCATION SKIiTCH
11. DISINFI'CTION.'fype _ Am(-:mt_ Show direction and(IISIJnCI'in miles frnnl al Icast
12, C'ASING: AVail hicknesa two Scuc Roads or County Roads. Include the road
Depth taitc" or V.eighth-t. tv rill nun)bers;md common roar) names.
I:Iom Q Tta_77—
Ft. �rC
- I'ru01 'hn_---- FL__,----
Enun
13_ GLOU I Depth Material Method ! r -
loml Fit H.
O
1-1, SCREEN: Ucplh Di.aneler Slut l,ize Matcrinl �
I
IS. SANUi(iRAVEI, PACK: COI7
Depth Size b1alet al
I runt To PI.
Nunn
_._------ ------ It' --
I(,- RFM ARKS:
1 A) I IPR11:131'CH I IPY THAT THIS WELL WAS C(,NSTR UCTED IN ACCORb ANC'E \VII I 1 iA NCAC 2C,WELL
CONS I I'C IION S'I':ANDrAR DS.AND THAT A COP','OF TFI IS RLCORD I IAS BEEN PROVIDED l O THE WELL OWNER
C
gi-(y-o5
SI(;N:AIUREOF PE1<SON CONSIRUCI'ING TILE WELL. DATE
Submil the original to the Division or Wader Qunlitv, Groundwater Section, 1636 Mail SerNice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 31) days• GW-1 REV. 07/2001

NVELL CONSTRUCTION RECORD
North (';uolma - Ucparuucnl ill P.nvinnuncll and '11 _./
'J aural R our es- Zvi ion of Water Quality-Groundwater Section
wPa.l.('f)\IItA('l Olt QNIII I'liltAL)N.k�I ' prinQ� / __ }(���
1cb:LLC(r]"I It1("rfllt(O]II'.\\1'\.\�1P: lr 1. IWO 1_�C'_._v, _-F.-- NIONEa Qi'•`
N1:LL CO♦S'I It CC I10S PEICNI II#—_ _:%SSo C I,\I'E l)11'Q 11E 101 rrp
ul;glplicuhlc) (il';giplicablcl
I. \\'L'LI. USE (Check Applicable Box): Residell iel B/ Municipal/Public El Industrial ElAgricuhuml ❑
Monilorirtg ❑ Rccovery ❑ Hcat Pump Watar Injection ❑ 01her❑ II'Other, List Use
WELL. LOC'ATI /
�D ����,.,/ Topographic/Land setting
N rest 'f nvn. '-/ _ ('omu'r q '✓4 ❑RIIIYC ❑Slutu
j(yyj 1 :dlq• ❑Plat
� Icheck apl.mprialc hurl
I Sna't Name,Nmuhcu.C'uinnninity.SuNJi risiun,Lut N0..7p C.11) LallWdc/longltudle or lvei location
j, (1W NER: _ _ Id/'✓� -- IJcgrcclhninulcsisccundxl
Lat11ndC/1011g61ude source:❑GPS❑Topocraphic map
(Street ur Iy' nae Nil (chevk Nus)
DRILLING LOG
rile ur n,rn s it zipC„1e Prole I'o F n Ili() Description
rude-RIL numh,:DA r
,
-t. :\Il[ URILLIiI? '
G. Dr>IiS 14'IILL REPLACE LXISTIN(J WLLL7 YES ❑ NO LCI'
7. S I'ATIC: WATLR LF-VFI- Llclow'rop orcasieg: /S F'r.
(I)se"+,frAN,,,Top ol'Casing)
S. "I OP 01:CASING IS_ _PT. Above I-and Surface* -
"t'np nl'easing IrrminalM al/ur(Semis land surface re:;•.•ir"a
cariancc in arcenl:umc n'ith 15A NCAC 2C.0111.
0 YIELDI,;pm): /O METIIODOFTLSF
10. WA-FER ZONES(depth):
LOCATION SKUTCI-1
I I. DISINFLCTION:Type_ Amrant Show direction and distance in miles from at least
12, CASING: Wall - lickncs.c two SLuc Roads ur County Roads. Include the read
Depl1 Drip i• or P.cig lit I'I rea nunn l.- numbers and coo road names.
From o� To o2c� PL_� --, $jL ���
Ilunl----- I�o------ Pt.-----
I:. (iROU 11 Depth Material Method -
Fn1m__
I mill ro_—__ I t - O -
1-1, SCRI IiN: Depth Dl.uneter slot Size Materiel n
Pram to
will
1? SANDe'(IRAVI:L PACK:
Ueplh Size Maio al CDC.rl
Prom to Pt.
I`will to I1
Ih. RkMARKS:
I [MIN RI 131 C'EI<III 1' THAT"rl-IIS WELL WAS C('NS11tUCTED IN.ACCORDANCE.WITII 15A NCAC2C,WELL
f ONS I RUC I ION S I \NDARDS.AND THAT A COPY OF THIS RECORD I IAS BEEN PROVIDED 10 THE WELL OWNER
_-� -- G-g-o -
SIGNATURE OF PE;2SON CONSTRUCTING TFIE WELL DATE
Suhnlit the original to the Division of NA':der Qu;.lit y,Grounthvater Section, 1636 Mail Service Center-Raleigh,NC
76'P)-16361'hunc No.(919)733-:12'1,within 30 da.j. CW-I REV.Phone No.t919)733-;1??1,within 311 das.c. CW-I REV. 07/2001

z3 A a
WELL CONSTRUCTION RECORD
North Um olina - Department of Environment and `I tural esources-,Division of Water Quality-Groundwater Section
\\'ELI.('OC'I RAC I Oft(INDIV,DU:%I.)N'AME prim) r� CER'r11'ICATION N-1210
\\'1:1.1.CONl]t.\("roll coo I.kN\'NAME.���._�.�� �UM �.__...____.____ 1'IIONF: p
51'.\"I F:V,F.I.I.CONS'i'RCCI'ION PERMIT11 ASSOCL\'1'ED wQ PERM 'r#
Iit:q,plicahl¢I (il appliathle)
I. %% ELL. USE (Check Applicable Hos): Residencal 12' Municipal/Public ❑ Industrial ❑ A_,rictdtural ❑
\loniloi in.-, ❑ Recovery ❑ Heat Pump Wa:cr Injection ❑ Other❑ If Other, List Use
WE[ L LOCATIC N: �// / Topographic/Land setting
cal sl 'I'u \•n:. '�rC_N C'ount`. ,�! -CI f7 ❑Ridtle ❑scope ❑Valley QI'f.i.
Q yp Id+eck appropriate thus)
\heel Nam0. umhu s,Comm�mily.Subbdiviaivn,lxn No..lip Caulcl L:IIIttIdC/IUlll;l tilde 0I'WCII Je Catlnn
. O\VNI:IC:��� U A /�^�IJ✓/{ (dcyrccilninulcJsc(:unds)
Address _�,3�,1 L p�e —,�c d . Lalimden011eitnde source:ocpS❑Topooraphic map
�j I`trrel ur Roan'N,.I rcheek Ma)
DFPTII DRILLING LOG
coy l,rll,un Slaac - Zip code Prom ;'o F 'n Ilion Description
(--) —'--- - �1
A onlc-I'h,nm wunh:
UI<ILI.IiU �',�
/ n e
6. DOES WELL REPLACE EXISTING WELL' YES ❑ NO EI-
7. Sl':\'IICWATERI..EVEt_ HclowTopol'Casing:�' FT, --
I Ilse•'+"it Ahoea Top of Casing)
S. TC)P OF CASING IS � FT. Above Land Surface*
'Top of casing imeinah•d:II/or helm,land surface rew,irev a
v:lri:ulce ill arc or(Ianc•+ ith I5A NC\C 2C.01 IN.
1. 1'IIiLD IgpnU:— NIF,rl lOD of TIs r A-% _
II). WAT F'R ZONES(depth): _
_ LOCATION SM: ni
11. DISINFECTION:Type Am(ant Show direction and distance in miles from al least
I'. CASINO:: Wall'-hickness two Stale Roads or County Roads. Include the road
Depth 12mainctur or V.c bt/ht. I: en d numbers and common road nauncs.
Prone_ ( 1=t. !
Prom__ 'I'n Pt. (l(•I!
I GROII Depth t;ucrial Method
Fnrnl. V To _ PLO•�Gv� O
19,pot-..._..—_.1.(l—_.—_ I•L_____ .. ____.— -n-( .
[-I. S('l,]A:N: Dcplh Diameter Slol Size Material I -
O\ a
Plasm.. .. _.._. I'u_.-_..-...._ 1`L in- in.
ra_ Fl. in. -- iu. _— O -
li. SAND/GRAVE1. IIACK: -
Ucplh Size Mlal eri:d
i
11+. REMARKS: -
1 10)11 FR IM Y CERTI FI'l-I IAT TI I IS WELL WAS C(`NSTRU'CTED IN ACCORDANCE-WIT[115A NCAC 2C,W ELL
('ONE IILUCI'ION SI ANDAR DS.AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
4fGNATUREOF I'Ei:SON CONSTRUCTINGTHE WELL DATE
R
Submit the oril"in:d to the Division of Wader Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 I'hone No.[phone],Within 30 day i. - GW-1 REV. 07/2001

� • . _
WELL CONS'rRUCTION RECORD
Noi Ih('arolina - Dep:rlmun nl l'.nvironment and ` aural capurccs --Division of W.Iter Quality-Grotmdwater Section
�( p- 2
_
\\IIL( ON"Ili\l'Inu1tV U1\IU(..\1.1 N,\NI priut) l" � CERFIFIC:\TIO/N q2
NN111 (ON"I'It\('I /lt("()Nil \Nl :N'.UII ♦�- fLr . _ _ _—I'IIONH. W Q&46- -Wg
51.CI'I!%%1._1.1,Cowrliuct ION pram ITN.__ ___,\SSOCIA I ED WQ PEII\IIT#
liI appliclhlul �� (i(:Ipplicable)
I. A1'LLI- USE (Cheek Applicable 13o.N): Resi(Iencal L1f IblunicipallPublic ❑ InduSIMil ❑ A,rictlltural ❑
:Monilorl lg ❑ Recovery G I-leaf Pump Wahar Injection ❑ Olher ❑ If Olhcr, List Use
WELL. LOC:-ATIQN.
/ Topographic/Land setting
/Iv( ucs 'I-,an lAN O,�✓_— _Connl•.' r4 l_V_C_O_CJ L�d_c ❑Slope ❑Valley ❑I:lal
`� �-'--^-�---e1.F.��� � IJIe(A appr I ,,at hurl
ISI I Nam, N nul a<.C'um uunilV Juhtlivi'iml,Lul.No.Zip CLLI,1 LaIMI(ICAUnglln(IC orwen I0C•lti0o
- (1\VNI:.I(. ��U� / -- IJcgrccs;winwcsisecunds)
1-fnlltlllel 011gltUdO sourcc:GGPSGT opocraphic map
ltiacel ur Route No.)
u4afus�c� DEPTH DRILLING LOG
City ur l:nrn , lane Zip Iudc Prone To Fig rl afiul )escriplion
A, code- Phouv nwnh:
i DRII_LGU O _ _� rD . -+,,,os ✓�
6 DOLS W'HLL REPLACE L'.NISI'ING WLLL7 V"PS�G,,NO L�
?. STi\'IlC \VA"I'IcR L.EVFiL 13clow"fop ol'Casing: �_I:"1' ---
(Use^..•it Above Top M Casing)
S. TOP OF C:\SING IS---(22_ FT. Above Land Surface'
'.Toil ofcasing Icnnin:aed zUor helosv I:md surface regtdrex a — —
Iarianrein:acurdw, lit I-A NC\C2Ca1111.
0. Y'IELD (gpnl):—= rIFFII0DOFTIIST i/
LOC'A'I'ION SKE:FCII
II. DISINI'I iC'TION_Type__ Amc!Im Show direction and dislance in miles from at (cast
CASING: Wall llicklcss two SIMC Roads or Counly Roads. Include the road
�/. Dcpfll Di N ncr or V.c chill 1. -lterial- numbCI S and common road names.
from!�lb V^— Pt.�� -i� ! Z'
d roll-----TI'------
I (TROUT Dcplh Matuial Method
I loll( -& I" _. �+ n /r'O="'Biv JL ___ _
1 foul Tu I't._s—____ _---. CD
t
I . 1C. PAILN: Dcplh Drululcr Slot hrzc Mami:l
i. SAND'(iRAVFL PACK: O 4-
Ul
Ucplll Size :'vlW trial -_
Flom I o Ft. -
limn To
Ib. RI'MARKS:
I DO I IERI'MY CEI<Il P\"-I HA F TI IIS WELL WAS CC'NSTRUCTL'D IN ACC•OR DANCE WITI I 1 i.A NCAC 2C, WELL
I ONS IRUCIION S'I-ANDARDS.AND THAT A COPY OF"FHIS RECORD I[AS BEEN PROVIDED TO T[IL WELL OWNER
SIG�I'El(SON CONS-FILUC"PING'IIIE W'ELL, DATE
Submit the original to the Divisiuu of Water Qu:lily, Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 1'hnnc Nu.(919)733-:3221,within 30 days• GW-I It1:V. 07/2001

31 � 4 �'7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) AMSoW"��t S CERTIFICATION# fit_-130
WELL CONTRACTOR COMPANY NAME ^t �$'� G W�pc 5d 4, ^ A'3 �--PHONE * fi?A) Ce6,5 eLZ„
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# _
(ifapplicable) (ifapplicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use _
2. WELL LOCATION: Topogra hic/Land setting
t /
Nearest Town:.W 4yT eI of/ram County 06e,4 ❑Ridge EKlope ❑VaLey ❑Flat
eE;Y)ei L.,-t t4,CQ J ­IEMfa (check appropriate box)
(Street Name,Numbers,Community.Subdivision,Lot No..Zip Code) Latitude/longitude of well location
3. OWNER: auslw vi%&4C (degrees/minutes/secocds)
Address (o5a Mal s. e-bYf RA Latitude/longitude source:❑GPSE]Topographic map
(Street or Route No-) (check bo:Q
LZ 0, r e F.�1C� j�gq DEPTH DR ILLING LOG
city or town State Zip Code From To Formztion Description
(Bab)- 6Q�'1 8e3a 1 34 our!�wf n
Area code-Phone number /s• s
4. 'DATE DRILLED 7- 3 4 afeS _�- IS
5. TOTAL DEPTH: 96S -
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO U
7. STATIC WATER LEVEL Below Top of Casing:SFT.
(Use"�"if Above Top of Casing) CS7 .t
S_ TOP OF CASING IS FT. Above Land Surface• ry =)
*Top of casing terminated attor below land surface requires a ---�'
variance in accordance with 15A NCAC 2C.0118. q - O
9. YIELD(gpm):_-j _METHOD OF TEST /C f� or
10. WATER ZONES(depth): m
LOCATION SKETCH 4-
11. DISINFECTION:Type Amount t6 Show direction and distance in miles from at least
T 12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. NaIcT,1 numbers and common road name:.
From To3_Ft `
y 51A 4I 'I l 'e'
From To Ft.
From To Ft. i yv
13. GROUT: Depth Material Method
From y To QO FL, C'J;g-mf!nJ :—v-C_.Te'—d
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. s�Pa i<an haw"
From To Ft. in. in-
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. • ✓e!(
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 COP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERS CONSTRUCTING TWELL DATE J .
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

416
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) '1- 4-4b. -� +w"s�� S CERTIFICATION# A n
WELL CONTRACTOR COMPANY NAME Sc ' K ^ '^'Q—�x k��-`�, PHONE k IRA") k�� ?-Z
J
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 LOCATION: Topogrghic/Land setting
Nearest Town: IC LG " County fa70tj ❑Ridge Mlope ❑Val-vy ❑Flat
751 fn t2,z Rnci'a (check appropriate box)
(Street Name.Numbers,Community.Subdivision,Lot No-Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/records)
Address 33i a-ntt6.ti@-P (lr o.d Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.) (check bore)
�.1rlt' ►)c :7 a\ DEPTH DRILLING LOG
CC'd'y or"Town Stare Zip Code From To Formeaion Description
Area code-Phone number -
4. DATE DRILLED _ — 6-
5. TOTAL DEPTH: /
6. DOES WELL REPL CE EXISTING WELL? YES ❑ NO 9
7. STATIC WATER LEVEL Below Top of Casing:.CO FT. -
(Use"-"if Above Top of Casing) �s
8. TOP OF CASING IS FT,Above Land Surface•
*Top of casing terminated at/or below land surface requires a ^�
variance in accordan a with ISA NCAC 2C.0I18.
9. YIELD(gpm):. _METHOD OF TEST-4
10. WATER ZONES(depth): r' <a
LOCATIONSKETC.H Ut
11. DISINFECTION:Type o>,\v6 Amount le Show direction and distance in mi�es from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road"
Depth Diameter or Wcight/Ft. to t numbers and common road names.
From \3- To A - Ft.�. ._ SOA o l
From To Ft.
From To Ft.
13. GROUT: Depth Material Method H ,'0 9 e 0-C' rret
From O To ZO Ft. Ce.tr&1\4
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material * a
From To-Ft-in. in.
From To Ft. in. in.
16
15. SAND/GRAVEL PACK: M�sJ,�
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,'VELL
CONSTRUCTION STANDARDS, D THAT A COPY OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
7
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC -.----
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

30 313 24
WELL CONSTRUCTION RECORD
North Camlina-Department ofEnvirmmant and elect Resources-Division of Water Quality-Groundwater Sectio/n-n
wELLcomvACrmmwrvwuAu (R1• S ca>Zwwwnom
WULCONTBACI'OE COat?ANYNAaa �!! _ �� lHONE i a� -
ffATE WELL CCONTRIDMON lERIQIa TW WQ Psna"
flf=DUC"l Of le
1. WELL USE(Check A"ficable Boo-Reaideotial Mmi4aliPublic 13 ha3*d 17 Apiculhnal 0
Momtomgo Recovery 0 HWPnmpWataW=donl3 OtherO UO&wlatUse
2. WBLLLOCATION:
Newest MAQQ10 V. mfwv Me" ovalley Mt
QW"NM%NemDegC mioip; lAWv rVC0M Ladtm%rgoogim&Of won braltion
3. OWNER it 7?I l ' 4;.�! (�)
Address wex I DE. IF70-7— Letimddlongilude eaace OCBsmapograimc map
Chyar7wre Stye ZIP OM& From To PormationDesaipdon
Aw cede-Paoaea®ber 0�
4. D �.�
ATE DItBS ED
5. TOTAL DEFM- w;a
cl
6. DOES WELL REPLACEEXISTING WBLLR YES OC NO y
7. STATIC WATER LEVEL Below Top of Casing __ fF ern
(Un-4-tfAbow TopdCmbW -r
& TOP OF CASING IS l FT.Above Land Surfwe* tv
7R dndq lwwfeerM etlrr adew bmd r.I fegwma _..
ManaeY r jWMISANCAC3C.01M O
9. Yffi,D W)' 2 T GAI. c A
Io.WATERZONES(deptb): LOCATION S1
11. DISINFECTION: � Aonmot Show motion and 4stance in miles from at beast'
It CASING: wallThidmeas_ - two State Roads orComtyRoeder.hwhWethemad
Diameter or WoigbM Maoemil numbas and common toad mores.
From,'"To Ft. �pT 1 rr1 rlPc11 .
FrcnL—To Ft-
From--To Ft l�
13. GROUT: Dq* Ma ' TML�-4
From�To .LFt�O/1l 11(�rc _FmnL _ToFt14. SCREEN: DV& 1 Slat Sim Mamie!Frona_To Ft io. in.
FYom_Tu - Ft_ia in.
15. SANDJGRAVEL PAC[G
From—To Ft.
Fmm_Tc Ft
16. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WI FI 1SANCAC 2C.WMLL
STAND ANDTHATACOPYOFTHIS RECORD HAS BEEN PROVIDED TOTHE OWNER
SIGHATUREOF PERSON CONSTRUCIING THE WEIL TE
Submit the original to the Division of Water Quality,Gremdwater Section,16M Mati Service Center-Rdelgb,NC
2709-1636 Pbsee Na.(919)M3321,within 30 days. GW-I REV.=200i

WELL CONSTRUCTION RECORD
North Carolina-Department of Envtronment and ataral of Water Quality-Groundwater Section
WELL CONTRACTOR(ufnrvmuAt)t+,+a+•E (Plai) or N 2 S I c3MCrIF1CAT10N#,A4m63
WELL COMMACrOR COMANY NAME /iPPA1 Lg i i�PHONE # c��3 a3
STATE WELL C(ENSTRUMON PEFJIM MM WQ P
if liable rf liable
1. WELL USE(Che&Applicable Boa): MmicipaVPubEc Industrial O Agricultural El
Mouituring O Recovery 0 Heat Prmrp Water hrjecbon O Other[] If Odm List Lase
2. WELL LOCATION: TOpo e andsetting
Nearest Town: A 1� p'l iE Coin � ��J ORidge Mope Malley Mat
M11)Dll Ton (chackTt I box)
(StreetNaMNUM&Mc Sobdridan, Nazipoa Iu Of wen bneon
j .;3. owNER � eM Address fyliQLACM��C c Latitude/longitude soerx:OGPSOTopographic map
I rIP€�GiE, vA�«Y KIC O gR7 57 DEPTH (�DRILLINGLOG
rows stak zo code From To Formation Description _-
Area code.Raise
a®tbr
4. DATE DRIILED G- O ,
5. TOTAL DEPTH: ff ,
6. DOES WELL REPLACE EXISTING WELL? YES O NO ro
7. STATIC WATER LEVEL Below Top of Casing:
c
(Ura'Y'ifAbae Top afCaeeo
8. TOP OF CASING IS FT.Above Land Surfueo F
`Top efdq ter tea agar bdew and swim re I I ■
9. YIELD(�): METHOD O TEST A W 1 Gn — 17
1
10.WATERZANES depth):
LOCATION SKETCH
11. DISINFECTION:Type Amo®t Show direction anddiafaoa inmles Sum at least
12. CASING: Wag Thidmen two state Roads or County Roads.Include the road
FromDept Diameter erweight/Ft Material numbers and common road names.
To�FtFront —To—Ft—
Mop F��m
Front —To—Ft—
13. GROUT:
From p` To Ft�r K C T�
From To ��' Ft��• '�
14. SCREEN: Dept Diameter S7otSiae Menial
From To Ft_in. in.
From—TO Ft._ia, in
15. SANDIGRAVEL PACK:
Depth Size Material
From Tc Ft
From To Ft
16. REMARKS:
t..
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE V=15ANCAC 2C WEI.I,
CONS UCTTON STA)MARM AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED To THF4WELLOWNER
1 '—
SIGNATURE OF PERSON CONSTRUCII NG THE WELL 'DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mal Service Center-Raleigh,NC
27699-1636 Phase No.[phone],within 30 days. OW-1 REV.07/2001

North Carolina- Department of Environment and Natural Resources-Division of Water Ouakty-Groundwater Section
1636 Mail Service Center- Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Phie U)dj Q— M.
WELL CONTRACTOR CERTIFICATION N:
STATE WELL CONSTRUCTION PERMITN:
1. WELL USE(Check Applicable eon): Residential Lam) Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection
❑ Other II Other, Lisl Use:
2. WELL LOCATION: (Show SkqtcNf I e location below) / -
Nearest Town: r VA e County:
o (qn
(Roa ante Nu ers.Co unily,or S division Q,Lot No.) DRILLING LOG DEPTH
3. OWNER �r i i I From To
Address •7 00 -N Fo also Description
Qr�ug stract or 0uw�.l ,J �61s — 7cL� O� 1/6ry
a
City Or Town state 3f�6_// Zip Code b ''rAp 'vim 've
4, DATE DRILLED��d 1-o187I C'
5. TOTAL DEPTH ry (
6. CUTTINGS COLLECTED YES Q NOQ _
7. DOES WELL REPLACE EXISTING WELL? YES NO
B. STATIC WATER LEVEL Below Top of Casing: Fi,
9. TOP OF CASING IS (Use'-'it Above Top of Cuing)
FT.Above Land Surface'
*Top of casing terminated at/or below land surface requires a variance In actor.
dance with 15A NCAC 2C. 11e -
10. YIELD (gpm): tll METHOD OF TEST-/2 r F
11. WATER ZONES(depth):
12. CHLORINATION: Type Amount It additional space is needetl use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Dia for or We' hVFt. M erial -
T tea/ - r (Show direction and distance from at leas!two Slate
From Tom Fl.� _v-C`3.�5_ =�7�P/ Roads,or other map reference points)
From To FI.
From To - Ft. # ,3O
14. GROUT:
Depth Mater al Methodis
From G To, Ft: '^" �.'�' .:
From To Ft. l �,'�-, - c_. 03
15. SCREEN:
Depth Diameter Slot Size Material
Ln
r • 1
From -—To— Ft — in. _ in. In
From To FI, in. in. CA
From To_Ft. in. in.
i ass
16. SAND/GRAVEL PACK: 4
Depth Size Material `_ L
From To Ft.
From To FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS,AND THAT A C?COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY i ?% `��,c *� a —GLy—
Ouad No: SIGNATURE OF KRSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Senal No. GW.1 REV. 12r99

WELL CONS,rRUCTION RECORD
North Carolina - Depatimcm of Fi %iron lie it and N-Itural/ResoureCS- Division of Water Quality- Groundwater Section
Nl(1.1 ('USfIt:\( fUIt UN DIN'1111 \L)N:�NII (I+ring t�'/"1�y✓/�� --- Cr:RFIFICXIION#2r
Iv1:1.Lcrlxrl<.u'mr.coNmnv NAME �^i :. fit /�a ✓ _... —. ------rnoNr: s dz (r�`37-1SSy,�
I \11-1 MI.L(ONS rnccrws rr:RNu ra __ASSOCIA I ED WQ PERNlrrn
(il'apPlicahlcl (if applicablcl
I. AA'LLL USE (Chock Applicable Box): Residemial Municipal/Public ❑ Industrial ❑ Aflricullural ❑
\ioniloring ❑ Recovery ❑ LICal Pump Wwa r Injection ❑ Oilier ❑ If Other, List Use
'_. WELL LOCATION: � �Topographic;Landsetting
NcalcSl ToWm W-1 /I/ ✓. G' Connly �C�_
��/y 2id�c ❑Slope ❑Vallry ❑Plat
[— [-sr � - -'— _ (ch,,k appropriate hos)
(\iicpt N,,me.Numb,,,,(bnununlly.Subdivision,(_ut No_/.ip C(ide) Lalitude/luto,it dC orweii location
- � Qlcgrccs/i n7nwcsGrxunlLv'I
AddresS i � LatituddloncituJc s0urec:E1G1lSElTopoeraphic mall,
I (Si ¢i or Room No 7 / (check hox)
-{NQ /V ✓����✓• �• /�!v DI-:P'rll DRILLING LOG
I o++n Suc Zip c',Ide I'roul To nr laho I Description
AIL'codr-1'Lonc uuod'cr O
I. DA 11s
(I. DOGS WILL RLPLACL EXISTING WELL? YLS Q NO BY
7. S FA IIC \VATER LEVEL Hclow`fop ol'Casinq: 3'/ —
^� (1)sC"1"ii AhoVc lop of Casing)
X. '1 01' (IF CASING IS OC _ FT. Above I.and Surface'
1'up ol'",%ina Ill mmoted at/or hetnw Luul surface requires a —
rariince in acrordxnce with 15A NCAC]C.nl III.
0. YIELD (epm): _� - NILTIIODOFTPS.r /7''
IU. AA A I-FR ZONES(depth):— --
LOCATION SKFI'CFI
1 I. DISINFECTION:Type Amcamt Show direction and distance in miles From al least
12. CASING: Wall hickuess two State Roads ur County Roads. Include the road
Devh Dia neler or%, i hhl'I. nen, nu'mrbms and
'common
/road names.
I:rom_�- `ft+1 FL _ iJ?SJ' '�'�— L " 7'Y I
IYom iij
`I FI. /'f" �
Innn To Ili. L �
C
13. (iRUlil: Ugnh Matrrial Method
I will �= 'I" FL o-,e-- t
IIrnn__ _.fo -_ Pt �
I . SCRI.LN: Dcgnh Diameter Slot Sire Nlatcriul co
LF1
I�. SANU,'CiRAVP.I.PACK:
Depth Size M:derial
P tun(_
If, RilVi;ARKS.
I DO I II:-PERY CER IIFY THAT THIS WELL WAS C('NSIRUC'TED IN ACCORDANCE WITH I iA NCAC 2C,WELL
C3JNSTRUCIIUN RD .AND THAT A COPY OI'THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Sv4`LL,� ��;� DATE
Submit the original lu the Division of VValor Quelit_. 1F(.','Pntlhdwatcr Section, 163G!1IaiL +ckice Colder-Raleigh,NC
37699-I036 Phone No.[phone],Icithin 30 dais. � ' , -iili GW-I REV. 07/2001

NVELL CONSTRUCTION RECORD
Nurlh(':uolin:t- Dcpm'lnlent of Fto ironnient and Natural espurces - Division of Water Quality-Groundwater Section
\1T:1.1 ( ON'lltA('IY)I(IlN ulna( \1,)N:\pIF ^�e --- — Cr:nnrlCATION
w'I'I.I ION"I RA(.rot CU)Ipkm "%vil j__ _ (� /� 1•IIONE p
\lFM 1-1-(ONSI'Rf:Cl ION I ERNIrfN_ _:\SSOCIA'rt:U\YQI'ER\Iff#
IIf applICA)IC) (it applicable)
VC'ELL USG (Check Applicable Box): Residenl:al I1C Pvlunicipal/Public❑ Industrial ❑ Aericuhural ❑
:Mouilofing ❑ Rccovcry ❑ Beat Pump Walcr Injection ❑ 011ie] ❑ II Usher, List Use
1 WGLL. LOCATI N: Topographic/Land setting
Nca resl awn: " Count" _�� ❑Ridge erlope ❑Valley ❑111t
<h
t, ue
� 10 t� (cheek appnipriale hull
lShcet -Neu—n:6ca,Cuinmunit Y.Su6Jir isim:,Lut No_Zip CuJcl LalitLI IC/IUtlh'llrlllC 0r\VCII Ineali0o
)W NLR:J/^f�Vl�/ Ifs- eIJcgrccs;minutc�iscconJs)
Address QEG /AIAH�IS?L _ Lnriludc/longiludc Source:OG I'S OTopgraph is map
/� ISlnn or IWm,Nit ` (check b.,,)(F�^' _✓—_ -'�W 71-- DIiPTII DRILLING LOG
('ilpo l,�rn SI:Je Gp(1,du Flom 1�r1 uliol I cscriplion
A"...on lc- PIu.nc..
DRILI.EU 'o? -©� -- - .
L2r�
h. DOES WELL REPLACE EXISTING WELL" YUS Q NO Ul' —
7. S"I'ATIC WATER LEVEL Bclowl'op ol'Casin : _ 3a PI'
(Ilse"+"d Above Top M ca,ng)
ti. TOP O1 CASINO IS _ C;� 1T. Above (.and SIIrF:ICC°
1'np of c:mug rtrwin alrJ 0tl(sr below land surface redid:es a
vari:u:ce in accor,f:t,, iol-,k NCAC?C.III IN. '
'). YIELD(ppto _Q _ iv1L'TI-IODOPTI/STAll'
10%\ATP.1270NfSldcplhl:
1_OCA'ION SKI':rC'll
1 I. DISINFECTION.Type ShuW direction and distance in miles Gom at least
I I CASING: Wall :Ilickit"s t\vo State Roads or County (Loads. Include the road
Depth })r ruler or V.�,. �hvrl. Lycoal numbers and common road names.
Flom- 'I o -- Fl.
I nnu----T°---- -
I 6ROUI: Depth p Material Method C-
14unt .(p___ Ib_�r PI.L r—e�� G '
--- r A
('nun_ "fu_ Ft,
1I. SCRIIhN: Depth Di:anerer Slut;izc Material C.A
Plow O
milt _ ru_ Il in. ot. C.l1 `
IS. SAND/GRAVEL PACK: _
Depth SiZQ x1aleI'ial
I rom I'o EL
Ikon 'ro I'I.
16_ REMARKS:
IUO LRIM) Ch- TIDY"IIIATTIIIS WELL WASCUNSIItUCTED IN ACCORDANCE WITH I5ANC\C2C,WELL
CUN)S JI RUC 7 IONS"TANU;ARUS.AND TI1AT A COP`(OF TB.1 Sit-EC=EHtD-H- k3lckAhf'-I,L9WL9.I1,)TILIE WELL OWNER
SIGNATURE OF I'Ei.SON C10NSTRUCIING"rI-IE WELL l` DATE
Submit Ilse original to the Division or Water Que lity,Groundnater Section, t4-4 Mail Suxic',e Centet'-Raleigh,NC
2 7 699-1 63 6 Phone No.[phone],\within 30 da\s. i Ci1V-I REV. 07/2001
i

NVELL CONSTRUCTION RECORD
North(atolina Dgmi limn) of Limi-onnient and("' llurrall Resources-///Division of Waler Quality-Groundwater
Section)l p
gTal ( (ISra.((-n)It( Vlll k'1nl tl.):'V:k�.,t{f✓, (\rrinppt)JI(fr'1 > /J✓✓ e Ceara rICXI ION# 2 ,—
nk I I (Lls'I Itk('10It CU kI I'.kU N k\I L.Y?)Gy_ �// -/ T✓M VI10NE p fX ^�7✓
— - -�----------�__.- ----- to
I:c11,kN'1 1.1,('(1 N SI'ILC CI ION VE,w%I vrk.-- nSS0CIA I ED NVQ PE 1011TM
1 it;q>plicablcl (if applicthlcl
I. WELL USE tCheck Applicable Hox): Residen:ed N"�Nlunicip:d/Public ❑ Industrial ❑ Agricultural ❑
\iunilorinp.❑ Recovery ❑ Haal Pump Wwa r Injection ❑ Olher ❑ IfOthcr, List Use
_. W'I'l I I OCATI )N: /_/ Topographic/Land selling
❑Rid�c ❑Slope ❑Valley ❑PhII
JI IV J Ichcck aplm.pom,hu,l
11 i N unc.M1:nl l: ('umm�oily,Sobdi vi 11111 Lot No../-ip('odc) L:IIIt LldeilUngttllde of WCII 10C1tio n
O�. WHI ��R: x / O Idugrcc�,ininuR.dxcumLs)
� q ��%/ +�grr\ Laliwda'lanciunlc sou ❑r(c GPS❑Topocr:qphic map
/ (11rr<i a r.l (dmck box)
�q"'.Y�^�__ /U (,•� ��6 Dh:PI'll DRILLING LOG
( ns nrlinco �O rra-�7 zip C,l10 1710111 To P n ati(n )escripli0n
:An'n ca<I.-Phunc nwnh:
1 D,crls uRu.11:H
6. DOES WELL REPLACE EXIS'ZING WELL' YES ❑ NON?'
'. SI'AIIC WATER L EVEL below Top ol'Casiv(y:�FT.
,Use"_"it Ahovc Top of Casing)
'R. TOP OP CASING IS _ ';?, — FT. Above Land Surfnce'
•'1'up ol'e:niog m n:lnaled::Uor Lclo(, land�urfaec rr.;ulcer a —
Iariancc in acmrdnny��ri 1L I5.k NGkC 2C.111 I R.
,. Y'11H-U I�11—):_Y0 MGTI-IOD OP TFSF Plr
IU. WA'hl:iR ZONES(dClith):
LOC'A'1l )N SKI-PCH
I I DISINFECTION:Type Ana:'unt Show direction and distance in miles from at (cast
I'_ CASIN(J: Wall "llickness two State Roads 0r County Roads, Include the road
Dcplh i I ncler or V.eight/Fl. bf jtcriat, numbers and common road nannes.
I�nml To Pt.__
I;. (iKUUI:// Ucptlt p Matcl�� Method
:7
Flom. _"fnt—
I-I. SCRI`1:N: Dgvh— Di:nneer Slut t.i/c Matrr
Iinl 1101
G.71 `.�
!t7
I7um _ 'fa li. in. C.il
I5. SANUHiRAVFI. PACK:
Depth Si/c 'vl:ocriul
foul to PI.
10, likM ARKS:
I DO I ILIZEl3N C'EkTll'Y IIIAT'i111S AVL•LL W'AS CONSTRUCTED IN ACCORD ANC'E WIl'I 115.A NCAC 2C,WILL
CONS I-RUC I[ON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDEDI O I'HEE�WELL DOWNER
Illy
r qq—�S )NAI URL OF I Hi.SON f I PIG DATE
FILL I1bI LL
1 12LC
Submit the of ighud to the Di%ision of 1V Iter Qu.,lity C p,Ltnl ivntLr Section 163611:n1 Refk ice'C'elder Raleigh,NC
2 7 6 9 9-1 636 Phone No. (919)733-322I,kvithm 111(Inks. I GW-I REV. 07/200I
i

Y� 3 � 3g5g
.. North Carolina- Department of Environment and Natural Resources• Division of Water Duality•Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #: 1V ,> , _ � 'e
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE(Check Applicable Boa): Residential2 Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑Recovery 0 Heat Pump Water InjectionD Other It Other, List Use:
2. WELL LOCATION: (S ow sketca of the location below) J /
Nearest Town: �` County:tYld/7ia
(Road Name n Numb is.Community bdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER
Address ! _= From To jeprgation ascription
WA Uj rector oull 0 /+d
y or Town state $_ S -3ry//Zip Code 4/�
4. DATE DRILLED OS- r74� �S
5. TOTAL DEPTH 7?
6. CUTTINGS COLLECTED YES Q NOM
7. DOES WELL REPLACE EXISTING WELL? YES O NOZ_
8. STATIC WATER LEVEL Below Top of Casing: —0 FT. t
(Use'a'd Above Top of Casing)
9. TOP OF CASING IS c;;> FT.Above Land Surface'
•Top or cuing terminated 0Vor below land surface requires a variance In actor
dance with i6A NCAC 2C.01 e• s
10. YIELD(gpm): METHOD OF TEST 1!2'1— 1
11. WATER ZONES (depth):
�—T
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
.A` Depth g/Oarrkjo or W (Show direction and distance from at least two State
From�To �" Fl. :/ Roads•or other map reference points)
From To FI. r
From To Ft. CCU
14. GROUT:
I � ,
Depth Material/ Method
From To �Fl. .rtgN,r I _
From To Ft. �.._
15. SCREEN:
Depth Diameter Slot Size Material
From - To Ft in. — in
From —To FL_ in. — in.
From —To Ft, in. — in.
16. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT AvCCOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Cued No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouality,Groundwater Section within 30 days
Sadal'No. GWn REV. 12/99

LUS 31 -3 C Q- 0
WELL CONSTRUCTION RECORD
North Carolina-Department ofEnvLro�eat and s arapl D' isioa of Water Quality-Groundwater Sectioon�(�`�
WELL CONTRACTOR(JNDrAVUAL)NAME dat C CERTIFr TION i 0I(Vv`T
WELL CONTRACTOR COMPANY NAME 1 ' ]^t ( PHONE a9aa
STATE WYLL CON"RUCTION PERa1dT1I1 ASSOCIATED WQ PERM1T#Lj
(if liable (If liable
I. WELL USE(Chock Applicable Box):Residential MaticipaVPublic O Industrial❑ Agricultural O
Monitoring I] Recovery 0 Had Pump Water Ittjectim,O Other 0 If Other,List Use
2. Nearest WELL=.7 �Ik D / TW0grV mrdsettingTovm 0Rx1Se M91ope Malley [Mat
(per bu)
(Sb4KName.Nu/mb MCMmdy S7ub�diMMM LatN0.ZP C ) 'tiS�� Cof".'`l' '°°►�/ga
3. OWWNER: / N1pc�l l?'i�l IQL ( (G
("Iq N 1`DJ�I /V� ) l LatmajeJlaogdtde mace 0(G*P bM opographio map
DEPTH DELLL=LOG
CdywTr sine rVCD a From To FormationDesctipdon
C—�
Ara Cods Plow amber
4. DATAL DMY ED � 3 0�
5. TOTAL DEP1H:
6. DOES WELL REPLACB EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL.Below Top of Casing CD Q FT.
(U38%r ifAboes Top ofCmdoO
S. TOP OF CASING IS FT.Above Land Surface*
'Top ofeadeq erCdu4d aVw bdvw land arfaa requires a
9. YIELD d tsANCAc1c OF
10.WATER ZONES(depth): !}S ()
LOCATION SKETCH
Show direction and distance in miles from at last 11. DISINFECTION:Ty;1EMtt AMDZMt-0
12. CASING: Wall TLiclmeas . two State Roads or County Roads.Include the road
Dep Diameter a Weight/Ft. Material numbers and common road names.
Frout_a-To Ft
From_To Ft
From To Ft
13. GROUT: DV&_Z =?
From To e- Ft -*
Fromm_To [7—Ft'� C
14. SCREEN: Depth Diameter Slot Size Material c n
From_To Ftn+. in, rn
From To Ft_fa. in o
15. SANDIGRAVEL PACK: ern
Depth Size Material
From To Ft
From To Ft,
16. REMARKS•
I DO HEREBY CERTIFY THAT WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR ON STAND S, THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THEWEIIOWNER
Ile
S11111" RBOFPERSONCONS7RUCIINGTHEWELL A
Submitlthe urtVnsi to the Division of Water Quality,Groundwater Section,16M Mall Service Center-RdOgh,NC
27699-1636 Phase No.(919)733-=I,within 30 days. GW-1 REV.072001

315 '
'k
NVELL CONS,rRUCT[ON RECORD
Not Cawlimt - Dcp:u9mcnl of[-it%wnment and N tu/rtl Resources- Division 01'Water Quality-Groundwater Section
M.V,I.LI CON I R\C f(pd()\I I';�1 V,( ntl`�J,j�in (�3�� E? ------ CratonCXTIONN a'� � p
III ION
[ION Po-:RSlrra _ASSOCI.krI ED%VQ PE101ITa
ul appI icah lc) (ifuppl icable)
I. AA'GLI_ USE t0leck Applicable Box): Residell.:al C' hlmlicipal/public ❑ Industrial ❑ A_ericullural ❑
:Moniloring ❑ R"o%cry ❑ Beat Pump Walcr Injection ❑ Odor ❑ If Othcr, List Use
at I L LOC':vI ION� Topographic/Land setting
N� u�a,����w��n�CJ/9i✓ /�_ _ C onnlc _/z_I_£ 9'1'L1dgc 011upc ❑V dlry ❑Plat
A�I: i N,mw.N inl r:l Comn:r uirV,SubJivi,i n.L :No_Z p C udil - Lallltldc/101121 l&Of WCII loCatio I
N If R' _ --Idegrecswinureshecundxl
\ddress Latialde/IOn�iftide Sourcc:OGPSOTopo raphic map
ISircci rr Kuum Noa (chcck box)
0Ry/v�SJ.I e _�✓c �S7g� Df:Pr11 DRILLING Loa
rl nc nr rrr a \,de
m Lip c Flom To F thn anon l cseriplion
'7 iA - -�'�_ �►
/Q!5
>. TO"rA1. 0I[1'lli:_ j
h. DOES lt�ELL R :PLACL' EXISTING WELL" YES Q NO Q
7. S TA IC WATER L@VEL Below Top ol'Casirg:
tllsu":"it Abuw Top ol'Casingl
X. I(W 01:CASING IS_ C2 _ FT. Above Land Surface' —
"I'ap al casing 1,11.1 n:ded atlar below land surface —
vari:wce in acnrnl antic will, 15A NCAC 2C.011N.
rl- 1'I ELD Iepm):_J-- M,,11 IOD OP TEST R'r�
IU. Ab'.AI'ER ZONES (depth):-- -- _
_ l_OC'A'IION SKFTCI-I
II- UISINPI'.CIION.'I'ype� Amrlm Show direction and distance in miles from at least
I_ C'ASINC;: Wall hickness two Slate Roads or COalllV Roads. Include the road
-L Ucpol Ylqycr or A'.--iebr•'Pl N,1;1YeriZ11 ._ numbers MI(I common road n;unes.
Front j,'� lo�� I'1. __ l✓ sy!/ '�!
Flom._ Iu_ I L_ /OG
I Iom
II. (;ROUT: Dcplh�7,, // M;ucrial Method -t
I-runt I o fL Cr% '.
I-I- SCI,I-IiN: Depth Diallwici Slol Size Material
I-tote To--__._.._ O c
I?mot_____-__- fo.___—_- -A
IS. SAND,'(il�AVb:L, PA C'K: .,
Ucplh Size :'vlaiel tal
Flom To F1.
f l om..---- -Io-- --- I'I ----
Ih- RI'.:AIARKS:
I UO HEREBY CERII PI"rHA"r THIS WELL WAS CONSTRUCTED IN ACCORDAANCE WITII 15A NCAC2C, WELL
t_(INSIRUC I ION S TANDARDS.AND THAT A COPY OF rHm3 RECORD HAS BEEN PROVIDED I O THE WELL OWNER
T,;z5-cS
. IGNATURE OF I'ERSON CONSTRUCTfNG,TI IE WI:LL DATE
Su bnl it the ori;;i u:d to the Division of NVater Qan.life, Gron ntlttater Section,1636 Mail Scrcice Center-Raleigh,NC
27699-1636 1'hnne No.(1)19)73.3-3221,within 311 t1a%s. M-1 REV. 07/2001

(: t e:• g u
WELL CONS,rRUCTION RECORD
Nonh Cat�llina - I1cp;Irinlem of I{nvi nnunenl alic xUral Resources/- Division of Water Quali(y-Groundwater Section
)%IIt:w I't u(IN 0 Ill IDI, %1.)N;\NII ) �—L�?VJJ»/i(Prior _ � CF.RfIfIC.\'f(ON#9 dI
\\ra,l.c(nru.\r`rnr,co\rr\m c\w: "_Ce_ ------___nnoNl: # kL21./a�7-SSSt�
r:CIL\C I'LL t ONS'IRLC'IJON PERNII'1'#_ .. ---'k OCl,\'r F11)\\'Q 1•RIi NIIT#
lit applicable) (ifnpplicable)
I. 1V'ELL USF(Chock Applicable Box): Rcsiden;ial 0 Nlunicip:liPubliC ❑ Inrluslrial ❑ Agricullutal ❑
.Monilorim ❑ Recovery ❑ Beat Pump %!cr Injection ❑ 011ie, ❑ II-Othcr, I Use
_. WELL LOCATION
Topo, raphidLnnd settim:
C Count h1�p c ❑Slope ❑Valley ❑Flat
p�, ' [/jam - lAverl
"�-" ''✓ �_(�-----._ laheck appropriate 6u\,
),tin eat Name.N,...lm�s,l/ Sandirisiun,LW No..Zip C,alvl LIIIttICIC/1011gi[ULIC orlvell location
�. (1\VNLIt' 'V 1 -- Idcgrceshninutcusccundsl
:\ddlrxs _ - nN� Laliludulongitudc source:❑GPS❑Topoeraphic map
(clmck
1l uorl or)(auto No.) hoe)Q _____.y-C. ? Dh:rill DRILLING LOG
Cii, ni 11n, t °Tale Zip(,,,I, Flom 'I'll
D:ArLDRu.LED 7`/ - OS X
h. DOES WELL RLI'LAC'LEXISTING W'L'LL° YIiS ❑G NO
',. S I'A IIC WATER LI:VHI- Below"fop ol'Casin :�L__Pl'
IU>c"T'IrAl")"Top of Casing) —
X. l-OP OF CASING IS�__ FT. Above Land Surface'
`Top of ca,inl;tel lminocd;w(Jr Geluw IauA snrF.mc rer,air es a —
cariance in accordance n'irh I5:\NC:\C'_COl 13.
'l. Y'IBLD(_epn0: —Nu rilODOrTLS"C
10. A1'ATHR ZONES!depth): __-
LOC'A"IION SKPTCH
1 I. DISIN I:LC_IION:Type AlJm:.nn Show direction and distance in miles from at least
12. C'tASIN('i: Wall Meknes, two Slue Roads or County Roads. Include the roar)
Uc D�a�cter or lA eighdl:l. N1, eriul numbers and common road names.
Momt pth to C� I.1.
lion "I o ---- h1
Ft t om -� o I�1. -- ---- --------- -st
I', (a ROIL l: Depth 4luhod
limn "l0_ 0 H V-
I
ioin
i I . SCI:I[IiN: Depth Ui:une0.'r Slut j,jp ---Material
Ilom _..-... to
Frulu 'fo I�t. in. iu. O
1>. SAND/(;RAVE!" PACK: — — — C71
Depth Size :Material e;'g
Front...__.—__ to Ia_
16_ Rh:11ARKS:
I DU II[RIiB1'C'L-!<I II:I'"Il I:\"f'fFIIS\4'ELL\1'AS C('NSl'RUC'TED IN ACCORDANCE WI-I'I 115A NCAC 2C,WELL
CONS I RUCTION S IAM)ARDS.AND TI-IAT A COP`."01:"FHIS RECORD I-IAS BEEN PROVIDED l'O IIIE WELL OWNER
/
I iNA-fURL OF PE!<SON CONSTRUCTING TI-IE WELL DATE
Sub ill iI the ori"iIlaI hl the Division of N ater QucliIy, Groun(IWatel'See lion, 1616 N):IfI Se",ice Comer-Raleigh,NC
27699-1616 Phone No.[phone],within 30 da\s• GW-I REV. 07/2001

NVELL CONSTRUCTION RECORD
Nol!II Carolina - Dep❑nnlent or I: "ironnlenl and IxuralLResowces- Div ision of Water Quality-Uroundwaler Section
\clil1 I ON IR.\('m It(1N1)1\Int ll N;\BII pnnr)1 e(�A — �7/�
/� --_— — CFR HFICA'IIONN (X�`
(1\'ll:.\( I"R('O\I I'\\\ N.\Nl l:��, _ �l . Dry Q- 6a/' y7.�s/V
1'l l(IN IC k tsvnr(GiA'
\\'1.1.1.('t/NS I ill:("PION I'F RMIT#._
l
\SS 0 C I A I E1)W'Q PE 101 rrn
il'applicablcl � (il' ppliIbl-1
\\'I:LL USG (Check .Applicable Box): I:csiden,ia11G�I�lunieipal/Public ❑ Industrial ❑ Agricultural ❑
::\lunilorine ❑ Recuvery ❑ Heal Pump W:ucr Injection ❑ Other❑ If Othcr, List Use
W GLI.. LO('AIION:
N nest I'own:rjl/4 �✓ - ✓ / TOpOgrel)hic,/Land Belting
-- 1..�1.� --_('onnl•;_ . l {y6Oe� I_c ❑Sloe ❑Valle', ❑Plat
� tl w� - IcLcck appropriate host
A sh,l Nunie-Nnmha s.Connnunity.Subdi...... I_ol Ne-Zip Code)
Lulitudvlungitude of well location
Idcgrccs;minulcsi>ccuntlsl
AddlcsB r� Lanluder'IonAlludc Suurce:0GPSOTopo raphic map
ircat41,Ne.I,�r , r _ Iilioxk box)
J lr' DI-:I'TII DRILLING LOG
l lt) ::r a Slue ip C'uJo
�" fnn❑ To 1'�,IJ allot yDoscnpliun
,l. D:\'II[ UILILLL'U1 05—_ •—�t�� Or r0
If DOES WELL RLPT;A('G L;.\ISTING WE'LL? YES Q NO 2(
7. STA"I IC WATER LEVEL 13clotv Top ul'Casir z3o p'I'.
(IJse"-"if At ve Top of Cast,,,,) —
s. fOI' OF C:\SIN(] IS_ CI—) — FT. Above I.Inld Surface'
'114)0'cas11114'lerudn sled it heluvv land surface rer,uires a ----
cari:mcc io ace."'ho ce with 15A:NCAC'_C.o1 Is.
IHLD (eprlt):11'— NIF Ff-IOD OF rl9S f_/_g"r
I I!. k\ ATI'.R ZONI'S(depth):
LOCATION SKFl"C'1-1
I. DISINI IiCIION:"I'YPe Anr-um Show direction and distance in miles from at least
12- CASING: Willi llickuesS two State Roads or Countv Roacls. Include the loud
Deplh ia�uacr or Rcighti R. N a •fiat numbers and common road names.
Il-nnl� lu�� FL
I --rmtlm n_ _ 133 l
Iliu ---- Iu . _ IL -- -- -------- -
I UR(W I: Ucpth Male:till Method
Ih
ta. SC!<FEN: Depth Diameter— Slut.•,izeIo-
SAND (iRAVt I PA( K: _— _ 0
Ucpol Ln
Size :Material s
I la _.. FL
17nm
---- —
Ili. RLVMARKS:
I Ul l l lt.RI IiP CE!YI II Y"I}L\T r111S WELL WAS Cp NSI RUC'TE•D IN ACCORDANCE WITII ISA NCrAC 2C,-WELL
CONS IRUC IIONS'I AAND:A�R�DS-AND THAT A COPY OF THIS RECORD I IAS BEEN PROVIDED'1'O II{H WELL OWNER
IGNATURE
OF I'Ei:SON CONSTRUCTING I HE WELL DATE
Suhnlit the orip,inal to the Division of Water Qu::lily, Groundwater Section, 1636 Mail Serrice Centel•-li:deigh,NC
27699-1636 I'hnne No.[phone],within 30 da}'s' GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
Not Ill Car,dina In jell of l mironmellt and ` Final cso Ices - Division of Watcl Quality-GrOnndmier Section
VAP:Il.if)N"rnI("Iolz(IN )IAIII UAL)N.%Ni (pnul)� y A v " { '1 //�
_r / -- -- CElt rll'ICA'1ION# 7b
VAka 1 (71VlliAC 17)lt(Om l'\N1 N'ti Ili .^Ie � f.S*1 jo IONE
-cy
I.A.1.(:ONS'Fitt C"I ION I'rnmrra 1 iRq>plicahlcl __
SSOCIA'IF D\vQ rt(a\u ra
- (if;lpplic'ablcl
I Vl'Lt.[- USE (Chick Applicable 13o.N): Residemial 2�­Nlunicipal/I'ublic ❑ Industrial ❑ AC,ricuhutal ❑
::Munilurill1❑ I(aa"cry G Beat Pump Waco Injection ❑ Oilier l] I1'0(hcr. List Use
WELL L LOCA 1 ]ON:
NC uCsl 'rnwn -B>"�?J�'�_ _ C'...... ire _��/.Topo-rahhic/Land setting
-��,���1�+1?'J � �--___-- L71ttd_c ❑Sin,c ❑V,dlc•
r SII cl Nanrc_Nh In l I"C'ouln unify Subdi vi"i q t„I'Vo Zip CudU 1 h ck:Tprupri tc buvl
/ LaIiItId C/1n1141ILIdC of well locnlion
:Atilt css �i7 0010 ------- I(leg rccsini lit II eundsJ
t= L;nlluClc/lon"itudc suurce:CGPSCITopog rlphic map
(Slrcrl or Ro l[Nu,)
_ N.C Nick burl
CO D1=I'TII DRILLING LOG
Cihul'lo,rn Slat' Zip CuJc
) 3 � �ya Pr�wjn to P nation-Description
A",unit-I'h,ma nuw1'r" —✓— "'�� _
S. TO"rAL IM,II
-I: ✓ -- __ >!'XJ 1�A -vim
6. DOES V 11t,REPLACE EXISTING WL I,L'1 YES ❑ NO Hr—
7. S"I';\'I IC F4'ATFR L.I:VEL Below Top ofClslu,:
` IIJle"r it Ahoec Top of Grsingt —
T01 OI'CASING IS_ FT. Above I ;Ind Surface*
'"1'up ur ruing Irrurin:ued at/ar below land surface
sari:mac in nrronlanc•ssiif I-ANC\C212.0118.
`,. YIGLD (epnl):_. '-Y' METHOD OF TIiS 7 •�
lU. APATER ZONES(depth):
LOCATION SKI I`C I I
I. UISINI EC"PION:"type r Am, mt_ Show direction and distance in miles from❑1 (cast
12 C/ASINCi: Wall hickness tWo Stu1c ROads or County (Loads. Include the roa(I
Ucplb i:yntcicr or\1 eieh UFt. It'julelial numbet.s and common road names.
Drum "I n --- _--_— PI. �}- ���
----
'rnlll _ 1 _ 1'1.
Material !klcthod
Drum � 1n "L�'^'(G',^i� _7
14u1 i lo--.___._ I 4
I I. SCRI FN: Ucplh Uilmctcr Slur:;i/c N1uct'i;d �
will
rrOul Cn
li. SAND PACK: --- -- C:)
Depth Size ivl:Feria! Ln -wZ
I tom ToI'tL_—_—
!,- RIfM:ARKS.
I Ut t Ill RI-B\" (E!:I IFl"I I IA r TI-IIS WELL WAS C(-NS-1RUC'TLD IN ACCORDANCE WIT(115A NC\C 2C.WELL
CON�tS�I ItU�C II�ON SIANDAR DS.AND TI-IAT A COPY OF rH IS RECORD IIAS BULN PROVIDE/D-TO'l IIE WELL OWNER
IGNAIURE OF IIEi:SON CON S T R UCfING rHE WLLL DATE
Submil the of igilml to the Division of Water Quclit-v,Gruundu'att'r Section, 1636(Flail Scr\ice Cenice-Raleigh,NC
27699-106 Phone IN'o. [phone], within 30 d(lvs.
CiW-I REV. 07/2001

tr A - � 3
1 O �- e� (. tR
WELL CONS"fRUCTION RECORD
Noll l C aioling - Dcp:u III tcnl ill,EIn ironnlenl;md,`J/--I'tu`raall/(,jesouurces- Division of W;Iter Quality-Ground Waler Section
\�F:II (ONIItA[17 pt(INUI\'1Du it l.)N.\JII ,rinl)�G�T1 �j (f1 -
�,e------- clat'nFlc•\novaa����
VA L:I I f ON't It.W f OR CONI 1,kN N N.UII'i
s I A 11: \\1 1.1.CONs'I'eC CI ION PF 1011Ta :\Sti(�:-��---------
Iil';q,plicahlel (i l'�q>pliethl•)
USE (Check Applicable 13ox): Resi(Icjj al lid' Munieipul/Public ❑ Industrial ❑ ASricuhural El\ionilonne ❑ RCC01'Cry G lieal Pump Wa:ur Injection C101hcr❑ If Other, List Use
\YELL. LOCATION:
To olrmihic/Land setting
Ni Idyl 'hii\au.. .__ ��Count•, h7 P o I
1-!/,`�-�/ ❑Slope ❑Valley ❑I;hu
J Sit I N:vue.N mI ,,,C'o......y.3uhdn'I� n I ul NO Zip C udo 0.h ik appn p hull
Latitudc./lungltud or of wall location
Z_ _.. - Idcgrecs%Ininnlcs/seconds)
:\ddress d.x__ Laumddloncihlde source:DIG PS OTopogrlph is map
lt�U TC . (iil"k ho.)
DL:I'l'I I DRILLING LOG
l n, r'l.nn. Sl;Ile Zip(,'de T(1
(525 _ Prom Fr}t;n ti m )ascription
S. 10 LAL DEPTic__
e. DOES N'ELI-REPLACE LXISI'ING WELL? YES ❑ NO � �50
7. SI'AI'ICW'ATEIZLIiVE1. 13clow'"fopol'Casin,,: p"l'
t lJse"+"d Ahovc IS,p of Curing)
S. "r41' OF CASING IS_ F 1. Above Land Surrncc* —
'"I op of e:mllg M-olkilled aUnr brinw land surface requires it
16,ml tc in ucurrd:t, o' I I_:\.NC\C 2C.nl 18.
`). Y I ) Icpm):_�N1E'riIODOFTEST �'
IU. WATER 7.ONLS(depot): —
LOC'AIION SKI!TC'H
IL DISINI I.CTION.Type _ __ A ... ..t ShoW dIICCtIOn un(I dlFt(mCC in miles from al lead
12. CASING: Wall"i hickness two State Roads or County RnadS. Include the roa(I
Depth Mittel- or V, JITt rinl numbers ;md common rnad nanws.
Panu__Q�To Pf.�fJ L� .�i7S - ,h.�c " U
I:Iojll7
-- ----
I GItUUI: Ucplb l61;ueri:d Method
Prom d _ fn_-•2p PI.L-�`=-^+C-t/ 'a
II. SCR I':FN: Ucpth Diamelel Slut Site Mntil'llll _ C ,q
I will _ 'fu G)
ill. O�
15. SANDAilI,X\/lil. PACK: - --- _
Uc,111 O
I Size \t;llCl'I:tl Ul
From l'a FI -'
I will - -- ---
IL. RI-MARKS:
I LI) I ILPF13), CER-HILY"I LIAT THIS WELL WAS C(."NSI'RUCTED IN ACCORDANCE WITH I I5A NCAC 2C,WELL
CONS I HUC"I IONS"I:ANDARDS.AND THAT A COP`(OF THIS RECORD HAS BEEN PROVIDED 10 THE WELL OWNER
IGNAIURE OF I'EI:SON CONSTRUCTING 111E WELL DATE
Submit the nrigi oat to the Division or\\titer Qua lily,GrountAvater Section, 1636 Mail Serrice Center-Raleigh,NC
-7699-16361'Ilonc INn.[phone],within 3I)davi. G W-I REV. 07/2001

5 A 2
J � . � �� 4
EVE
LL CONSTRUCTION RECORD
Notlh( an)lin❑ - Dcparinlet]I of Cnvi roontenl and P4.aIt Ira l RCSOUlces- Div isioil of Water Quality-Groundwater Section
V,PI I ( OAI It I oil(INInAInt AI,IN':A-Nll
G\cEll (()CI H.\( lyry;CU\II' / / ----- Cr,2 rIr16crION* 6/
LL(.0, ltcC"r1oN rr:uNn'rx-- j - ------ rnoNl•: #
4.0-- vir
hpbe:d,lel assoc'Inreu\rQ l'es)u'rn
I 11'GI_L USE (Cheek Applicable 13o.N): kesidencat Cl MiloiciPal/Public p 6tduslriul ❑
:M olliloring ❑ krcovery ❑ Beat Pump 1'vd,cr In j cctiun ❑ Olher❑ If Ulher, List Use Agricultural❑
IVI:LL. L.00A1"ION:
N� n sl fow°
tTZsL 'vvi . W A1 ._tnUm,�Su-b-d-i—visl-n ( o_ c TOp�
�IilLt
ollill, sett ing
Jcl `C/d ❑tilnpC
n Nciv ❑Plat4 aey
I /tpC'd ) l b Ck'9praprialt box)
UW'NLR Loliludc/lungitodC ol'mcll lucelioo
- : —
Addles.v -.. �1)Y� �C- ..-- (ticyrccsnninulcsiscconJs)
No.t 1_anlndd1o"6tlI1lC S011rcc:0GPS0Topogrtpbic map
> �•r-lo"n DEI'Tll DRILLING LOG
/7 Sr,ii• Zip Cmic
Pro t0- m To 9"�ll�ihcl 0 � P .nr lion )CscriPliun
-l. DAIT'' URILLhU_ —�--
(�. UUIiS WI:LI_ RGl'LAC'L' EXISTING RL1.L': -
T S1'A IIC \VATLR L,I!VEL 13CI01V Top orCasir,: NO H-� ------- r"�'•'� p
(U Ahovr Top or Casio,) — ----__X. 'f(tl'UPC;\SING IS. I f. Above I.:ntt! Surricc*
.ro'ol'easiag - —a ----__1 IcrutinateJ al/or below Imul sur6ue reG uircv a ariun,e ill acoonlancc with I5A:NCAC 2C.01 IN. --"
o YIELD(gpo))-11�METHOD 01:TL+S"F 41 --
tU. W'ATER 70NVS Idcplb):_
I I. UISINI'LC"PION:Type LOCALOCA"I I(�p�rutf
1= CASING: Amount— Show Direction and distance in miles from al least
Nall hickness tWo Stale Roads or County Roa(Is. Include the road
UepO' atytgter or�eiel %Pt. rial numbers and co lonon roa' names.
Front 7
I oil]
---- 1u-��`�ft.
DC11111M:ucri:d - E;F
I htn❑ r �lcthod -
_. ___ ��7�
Pm
Itro E`-"�---
-
11. SC121 LN: Lkpllt --
Slot
li,nn �I-o hl�nrri;d
_..._..
17m n I n. QN
I?- SANU:Y,R 1\'L L, I'M R: nt. _
o
UDell(f) W
Size llutcrial
14ont. I'o_ PI.
- Ih. RIi:11:\RKS: —�----
I DU IILRIil31'CERIIF)''IIIAF MIS WELL WAS 0,
N�TRUCC ONSIRUCTION S'IANUARDS.AND T14AI-A COP`:OI TFi STRGCED ORD I,AS BEEN PI ORDANCEIV IIDEU O T 1E WELL OWNER
. Ic iNAl UR60P1'EhSUN CONSTRUC"PING TjjL- 7
UATE
Submit the original to tltr Dirision of Water Quality, Cri)undn':I(er Section, (i,N'lail Scrvitt'Cooler_lialcigh,NC
27(,99-I(,16 I'hone,No. (919)733-32?1, Ivilhln 30 d jN s. I63
GW-I REV. 07/2001

NVELL CONSTRUCTION RECORD
NonhC:uolina Dymrtnl mill nlLnvironmurl;Ind V uualRsour(cs Divislonol•Watcr Oil,dity-Groundwater Section /
\\I I LI II\'I It IoI IIN I)I\'I DL %I,I N:\NII
\\11.1,COX I RM.,I' It C0,11,ty NUIF: /, � ' - _�✓ vyfQ
\\'F:1.1.(USSI'R4C"PION 1'I?IiBII'f#_ —_ASSUCIA'J , )\\'O I'HIt31ff#
(it;q>plicahle) tif;q)plicnbltl
I. \\'LI-I. USL Whcck Applicable Box): Residemial NJ tvinnicip;l/Public ❑ Industrial ❑ Agricullnral ❑
\ionilutillg ❑ Recuvery ❑ Beal Pump Water Injection ❑ Olhcr ❑ IfOlhcr, List Use
_. WELL. LOC'AI ION:
Nc,Ir�,l 'I'I,wn:�1/ ` ��Topographic/Landsettinl•
/A• L+TI(nlec ❑Slope ❑Valley ❑Plat
�V t (,beck appmprietc huxl
LtiI rI N`amc.n nnhas,C'own:unity.Suhdlei_i u Lon Na_7il c,del
Latitude/lungnude of well location
!. (0,VN1-:Ii:N/J�t1r_f —�-- j,�r�' S
��lILL77Qe IJcgrccs;uiinmcsisccondsl
\ddlers Q� _ alinlddlongihldcs�ur�e:OGPSOTopogr.Iphicmnp
_ � p (S reel ur I(ome No.)
�q 4wj (check box)
DRILLING LOG
1,: "'I talc /ill('udc
Drum 'f0
Fg. .ali n Ucscripli.on
aice c�nlc-I'h�nie nwuhn' ) � ND
fU"fAL Dlil'lli:__3 ��-7 O
/ v^r o. UIJLS WELL RLI'LAC'L EXISTING WELL? 1'I::S El NO � —'
,7, SI':A'IlC 1VP.TIR I,I;VGL 13cluwl'op OfCasim,: 3;'
I Use•4•'d Ahurr I ,p o1 C IIA"') -
S. TC)I' OPCASIN(i IS_ _ FT. Above I and Surtnec`
"full of""11"tcrmin atcd aJur heluw I:md wr(are req•.'irer a —
yadaocc in acc."flanec win. I5A NCAC ZC.()1 in,
'7. YIELD(epnl): /O_ MEFITOD OFTHS-f A(1
Ill. AVAIIiR :CONES Idcplb):_-
LOCATION SKI- fC'lI
I. DISINFIiCITON:"fYPe- Am:vuL_ Show dircction;md diSIIIIICC in miles from al lead
12, C'ASIN(i: Wall 'hickucss two State ROads nr County Roads. Include the ioa(1
Uep(h I�1)r )eler or V`ci Ohl;Pt. ,P/�icrial numbers:md common road names.
Flom — rl'
I GROUI: Depth Material Aielhod - 7a
u___._._._ FL, —
SCI1 N: Ilhpll, n
Ui uIc in tilut Sizcln 'vlatcri:d
Irma `
N '
Pr:ull
-- —
I.�. S.ANU`(ili;A\'hl. l';\CK.
Depl't Size vkIlel al
Drool PI. _
I11❑u--------I°-- ---- It---- ---
16. If I?AI:ARKS:
CP011F1 THAT MIS WELL WAS C( NSIRUC'TED IN ACCORDANCE WITI 115A NCAC 2C,WELL
CONS"IRLIC IIONS fANDARDS.AND THAT A COP`:OP THIS RECORD I]AS BLLN PROVIDED TO THE WELL OWNER
7-
GNATUI L Oh PEitSON CONSI.RUC1 ING I-HE WELL - DATE
Submit the original to the Division of Water Qu:,lity, Gramidwatcr Section, 1636 Mail Strricc Center-Raleigh,NC
27699-I636 I'hom .No.[phone],within 30 daas. - �".� - GW-1 REV. 07/2001

308484
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �I
WELL CONTRACTOR(INDIVIDUAL)NAME (pclnt)_��=R'"C' ram— CERTIFICATl0N#ZZ_ //
WELL CONTRACTOR COMPANY NAM mArigAZw a ex • y I U Ag_PHONE # S9 (c 'ONSO
STATE WELL CONSTRUCTION PERMTT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential E Municipal/Public❑ Industrial❑ Agricultural CI
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: graphicILand setting
Neatest Tow : & W ��-7-C,oAunty U90.0�,� dge ❑Slope []Valley ❑Flat
_17FllLL �—y���7n (checkappvpdaxbox)
(Sneer Name,Numbers,Community,Subdimon.Lot No.,zip Code) Latitudellongitude of well location
3. OWNER:�re SIiNAl�dIQS ( WmimlSs°a&)
Address �� A�e7t�! /17 Latitude4ongitude source:❑GPS❑Topographic map
/3 e#9/ (S/URnute No.) z8 7 S� DEPTH (cbockbox)
DRILLING LOG
City or Town Stax zip Code O From To Formation Description
Am ccd�
4. T LED A ig
5. TOTAL DEPTH: 6 S
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_!�F_FT.
(Use"+"if Above Top of Casing) ALn
8. TOP OF CASING IS LS FT.Above Land Surface•
*Top of casing termtaated stfor below land snrlace requira a
variance in accordance with i5A NCAC 2C.0118.9. YIELD(gpm): 3 METHOD OF TEST M{10.WATER ZONES(depth):
11. DISI IFECTION:Type Amount /D a t Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth pM� m�L� numbers and common road names.
From_4 To . Ft /a T_ S Z V
From To FL
From To Ft
13. GROUT: Depth Material Method �� --r-
From_ To W Ft�G ! C I1'eJ�nI/fl
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To—Ft. in. in
From To FL in. in. C
15. SAND/GRAVEL PACK:
�( Depth Size Material
From- 6!-_-To Ft. {�Ke q/)? f?O
From / _ To Ft.
16. REMARKS:
1 DO HEREBY ERTIFYTHATTHIS WELL WAS CO UCIM ACCORDANCE WITH I5ANCAC 2C,WELL
CONSTR ' STANDARDS,AND A COP F THIS RD HAS BEEN PROVIDED TO THE WELL OWNI?R __..
i N
SIGNATURE OF PERSON C)6NSTRUCTING THE WELL DATE :� a
o - -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ralelgji,3+C -
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001..

North Carolina- Department of Environment and Natural Resources -Division of Water Duality-Groundwater Section
7636 Mail Service Center- Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ll(k- a-yAR ,'1_
WELL CONTRACTOR CERTIFICATION N:d�69 /C/V- 4 � >
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential2/Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ It Other• List Use:
2. WELL LOCATI (Show sketch of the location below)
NO rest Town: County; i"C93C�C'
(Road Name and Numbers.Comaxinity.or Su�ivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _tr77Zn
Address Fsr�om To `naho oescnption
r auto o. • N' o �
Cdy or T Stale by Caoe 9r0 q Nd S N�
4. DATE DRIL ED v.7 9 -co, O - �✓�
5. TOTAL DEPTH -R VS_
6. CUTTINGS COLLECTED YESQ NO[D
7. DOES WELL REPLACE EXISTING WELL? YES (D NO
B. STATIC WATER LEVEL Below Top of Casing: 31t FT.
(Usa'd N Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C.011e
10. YIELD (gpm): /-A METHOD OF TEST /492�f�
11. WATER ZONES (depth):
12. CHLORINATION: Typewz& Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
-) Depth 79 D' for or Weight/Ft. a nal (Show direction and distance from at least two Stale
From.:-CIS_.To Ft. C Roads,or other map reference points)
From To Ft.—r q
From 7o Ft. o
1!/
14. GROUT:
Depth'" Material Method y
From 0_ To _{�=Ft. +Pw •�
A
From To Ft. to
15. SCREEN: C
Depth Diameter Slol Size Malarial
From - To Ln
_Ft _ in. in.
From To_Ft._ in. — in C-11
l
From To_Ft._ in. _ in.
16, SAND/GRAVEL PACK:
i II ''
Depth Size Material L� u JUN 2 1 _00 From To Ft.
From To Ft.
17. REMARKS: GROAN F` TFn .^.FCTjpN
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY v'�J ✓, ° —�
Cued No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouality,Groundwater Section within 30 days
GW1 REV. 17179
Senal NO.

- North Carolina- Depanmenl of Environment and Nalwal Resources.Division of Water Quality•Groundwater Section
1636 Mail Service Center - Raleigh, N.C.27699.1636-Phone[phone] .yn
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /
WELL CONTRACTOR CERTIFICATION #: Cod/ /�i1�Q ti 4 e
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Boa): Residential 2STMunicipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heal Pump Water Injection ❑ Other ❑ 11 Other, List Use:
2. WELL LOCATION: (Sho�ww sketch of the location below) l,�J,/� /
Ne resl Towne, V r ._County/? r Y li
i
(Road Nam d Number .Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER From To Fjo alto Description
Address �Aj7U
we or_ oulu 0.
o
Cft br sown ale Zip Code
4. DAT RILLED
S. TOTAL DEPTH O
6. CUTTINGS COLLECTED YES Q NO[::]
7. DOES WELL REPLACE EXISTING WELL? YES NO�
8. STATIC WATER LEVEL Below Top of Casing: 13 FT.
(Use'+'9 Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surlace'
-Top of casing terminated aVor below land surface requires a variance In accor.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -I-jQ-_ METHOD OF TEST Ally
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 1t additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth�tt/� D�''�et�r or We'�UFt. ena11ena11/{ (Show direction and distance from at leas(two State
From To WLYFI. M ..Z/r Roads,or other map reference points)
From To Ft.—
From To Ft. JT C�
14. GROUT: -
Depth Malarial Method
7�
From To Ft. C� t P N
From To Fl.
1S. SCREEN:
Deplh Diameter Slot Size Material u7
From —To—Ft — in. — in C=)
Ln
From —To Ft.— in. — in r--r—""-- 71
From _To Ft.— in. — in.
16. SAND/GRAVEL PACK: V
Depth Size Material
From To FL LI JUN 1
From To Ft.
17. REMARKS:
I DO HEREBY C8RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCO
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ' E
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Quad No:
Submit original to Division of Water Quality,Groundwater Section within 30 days GW I REV. 12199
Serial No.

34d i_ North Carolina- Department of Environment and Natural Resources - Division of Water Quality-Groundwater Secuon - 'y
1636 Mail Service Center- Raleigh,N.C.27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMITJI:
I. WELL USE(Check Applicable Boa): Residential Municipal ❑ Industrial❑ Agricultural❑ Moniloring ❑
Recovery❑ Heat Pump Water Injeclion ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Sho skelch of the location below)
Nearest Town: N • rt' County: 'YI/rL'e'-e
I-o-4 0
(Road Name and Numbers) f ly,or Subdivision nd Lot No.) DRILLING LOG DEPTH
3. OWNER �Ia From To C� uon scnption
Address 42,3�9 7
/ram J 1/—(Sneer or .�0��(G , -,. /r<J
wA,
L City or7To'wnL Sule > o._ �7�� !.D
4. DATE DRILLED -S�J�'C✓ �•S" �� -a�c.;�ipCoda use r. N--S/
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQ tJ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO2
8. STATIC WATER LEVEL Below Top of Casing: a( Fr. Z
(Use Y e Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface' _
'Top or casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): A5 METHOD OF TEST /L}'
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth D,'urgelar or Wfi�q�,VFL Malarial (Show direction and distance from at least two Stale
From To-fC� Ft. / Roads,or other map reference points)
From To Ff.
From _—To Ft.
14. GROUT:
Depth Material Method
From To �Ft.
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Malarial
From -—To—Ft — in. in.
From To in.� . — in. h I r
From To_Ft. —_ in. In.
16. SAND/GRAVEL PACK:
Depth Size Material =� JUi',
From To Ft.
From To Ft. ;t;r
17. REMARKS:
1 DO HEREBY UhTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -J_a
Quad Na: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Quality,Groundwater Section within 30 days
GWt REV. 12199
Serial No.

31 !
i
. North Carolma• Department of Environment and Natural Resources -Division of Water Quality,-Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: &�i Gt,>> g .a ?
WELL CONTRACTOR CERTIFICATION #:-,� �e, ` �_
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Boa): Residential El Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery [D Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: (Show sketch I the location below) /�
Nearest Town: II/ fY 1Co�County:17_'q"1wL''rc_/
4
(Road Name anti urrlb rs. ily,or #division and Lot No.) DRILLING LOG DEPTH
3. OWNER r L�LJ From To Forpatioi oescrotion
Address ' C11 £• �*,
Ifeef or oulo 0. Q Q / O r 6 W.0
City or Town _ Slate ( Zip Code �C' "rrJ.3- l
4. DATE DRILLED -C /'Avid(
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES O NOD
7. DOES WELL REPLACE EXISTING WELL? YES NO2r' r,
8. STATIC WATER LEVEL Below Top of Casing: _ 3 G FT, c
(Use':it Above Top of Casing)
2
9. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C
10. YIELD (gpm): METHOD OF TEST rJ`91�__
ctt
11. WATER ZONES(depth): '
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wag Thickness LOCATION SKETCH
-'-a Depth Diaasar cr' S15 yfl. leria� (Show direction and distance from at leas)Iwo State
From To 5 Ft. ' / Roads,or other map reference points)
From To Ft.
From To Ft. , 11557
14. GROUT:
Depth) Material Method
From To l u FL y--FL'•"lam=v�
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To— Ft — in. in.
From To Ft.— in. in. f� i
From To—Ft.— in. in. r--- n
16. SAND/GRAVEL PACK: [�DL
Depth Size Material ; f uN 2 r'
From To FI.
i
From To FI.
17. REMARKS:
r I -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW1 REV. 12199
Serial No.

_ North Carolina- Department of Environment and Natural Resources -Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh, N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: k h-lu>, /
WELL CONTRACTOR CERTIFICATION N: �ii `1 TU P
STATE WELL CONSTRUCTION PERMITII:
1. WELL USE(Check Applicable Boa): Residential Municipal ❑ Industrial❑ - Agricultural❑ Monitoring❑
Recovery El Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATION: Show 4lt�ttc of the location below) -
Nearest Town: / Cou
r� / rV-/&
(Road Name axaNumbers.Community, ubdivision amp lot No.) DRILLING LOG DEPTH
3. OWNER ,t
From To 7.71 ion escnpeon
Address �S 1Za
yz a fJ1
[feet 0
C y or Town I Ie Zip bode
4. DATE O�—DEPTH
TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOR�
8. STATIC WATER LEVEL Below Top of Casing: _39 _FT. (j
(Use':it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface' - C
'Top of casing terminated at/or below land surface requires a variance In actor- r.
dance with 15A NCAC 2C.0118
10. YIELD (gpm): —,Zd METHOD OF TEST_Z9-t Ln
11. WATER ZONES(depth): O
.ram
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
� Depth DiaroeI or WqjghVFI. dal J (Show direction and distance from at least two State
�
From TO Ft. £S / Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth'a Material Method
From To ! Ft. U'"�
From To Fl.
15. SCREEN:
Depth Diameter Slot Size Malarial
From —TO— Ft — in. — in
From To_Ft.— in. _ in.
From To_FL_ in. — in.
16. SAND/GRAVEL PACK:
i
Depth Size Material (( J 1J
From TO— Ft.—
From To Ft. _ 7
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY —I' f� / y E
Quad No:
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days GW t REV. 12/99
Serial No.

. Nonn Carolina• Depanmern of Environment and Natural Resources-Division of Water Ouabry•Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone [phone] p
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION W:
STATE WELL CONSTRUCTION PERMITfI:
1. WELL USE(Check Applicable Box): Residential E STMunicipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATIO : (p w`ket of the location below)
Near e [Town, County: Wt o/
(Road Name aT Numbers.Co unify,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER + I S
From To o tion escriplion
Address O D
reel r out o.l • 3 -
o
CA own Slat Zip
a. DATE DRILLED l 0 r N l
5. TOTAL DEPTH 1
6. CUTTINGS COLLECTED YESQ NO[D
7. DOES WELL REPLACE EXISTING WELL? YES (__j NO L
8. STATIC WATER LEVEL Below Tap of Casing: _,5j FT. �—
(Use'.'it Above Top of Casing)
9. TOP OF CASING IS C� FT. Above Land Surface'
*Top of using terminated atfor below land surface requires a variance In eccor• O -
dance with 15A NCAC 2C.0 8
10. YIELD(gpni METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Typeount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
From�,r Depth/ l Di t r or we' t. rial (Show direction and distance from at least two Stale
To Ft. � Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth7 Material Method
From To �(U Ft: -"'^'e'��
From To —Ft. _
15. SCREEN:
Depth Diameter Slot Size Material
From -—To—Ft — in. — in
From To_Ft.— in. — in.
From —To—Ft.— in. — in
i
16. SAND/GRAVEL PACK: —��
Depth Size Material ��GN j
From To Ft.
From To Ft. I
17. REMARKS:
'ii t Nr Gi Jdb,+ u`ni;L
I DO HEREBY Cl!FTIFY 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.
FDA OFFICE USE ONLY .--f�'"� •� y"'ZEE y-r3 i-OS
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Suttmit original to Division of water Quality.Groundwater Section within 30 days
GWI REV. 12/99
SenarNo.

319
- North Carolina• Department of Environment and Natural Resources• Division of Water(Duality-Groundwater Section
1636 Mail Service Center -Raleigh, N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: r'c, to,
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE(check Applicable Box): ResidentialDST Municipal ❑ Industrial❑ - Agricultural❑ Monitoring ❑
Recovery D Heat Pump Water Injeclion ❑ Other It Other, List Use:
2. WELL LOCATION: (S ow sketch the location below)
(�Neare lTown: (its NGSVr County: GV O/ _
�u or Comma I Y.or S bdivision and Lot No.
3. OWNER I DRILLING LOG DEPTH
Address
/ From To
lion escnplion
" oNA,.7" �7�✓cl� _ 42 r
LNG � _ IreCl or ou a 0 Q
J . r
it,or Town Stale Zip Code
4. DATE DRILLED
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ED NOE) i
7. DOES WELL REPLACE EXISTING WELL? YES Q NO�
8. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use':g Above Top of Casing)
9. TOP OF CASING IS C;� FT.Above Land Surface'
'Top of using terminated atfor below land surface requires■variance In eccor• `1„
dance with 15A NCAC 2C.01
10. YIELD(gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type _Amount If additional space is needed use back of form
13. CASING:
Wall TNckness LOCATION SKETCH
cY Depth /// DD �jflflfluI or Ft. -dal (Show direction and distance from at least two State
From / To _//6 FI.-1— r� Roads,or other map reference points)
From To Ft.—
From To FI. 7
14. GROUT:
s� Depth Material Method
From t/ To Ft. ,Me V
from To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From - To_FI _ in. — in.—
From To_Ft.�_ in. _ in. r =
From To—Ft. in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material l
From To Ft.
From To Ft. —
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Ouality,Groundwater Section within 30 days
GWI REV. 17/99
Senal'No.

cj,e �) 8
.. North Carolina• Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] n
WELL CONSTRUCTION RECORD WELL CONTRACTOR: , r � W 11)
WELL CONTRACTOR CERTIFICATION #:0? q ` e
/STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential `LJ Municipal ❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATI (S w sketch of the location below) /
Nefr aest Tpwn: /V ry A/ Court /.yOOD/
h/ ue
(Road Narge,and N mbers, munity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER to /✓e- / —
Address
F m To Fo s7 wuon escnpu Ve ©
i treat or t d 7r,o
Ci or sown Stara g�„Ziode
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YE NO
8. STATIC WATER LEVEL Below Top of Casing: 6T5 FT.
(Use'.'if Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surlace'
'Top of casing terminated at/or below land surface requires a variance In actor-
dance with 16A NCAC 2C.0118
10. YIELD (gpm): /0 METHOD OF TEST All' �
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
II additional space is needed use back of loan
13. CASING: -
Wall Thickness LOCATION SKETCH
,t Depth Di ft r w weighvFI. "ria - (Show direction and distance from at least two State
From TO� Ft. Roads,or other map reference points)
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From To _0k Fl. yp"�e 74-
From To FI.
15. SCREEN:
Depth Diameter Slot Size Material
From - To FI _ in. — in.—
From To_Ft. in. _ in. - - — ---
From To—Ft. in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To 51.
From To Ft.
17. REMARKS: --=— -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT Av�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �T of
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submil original to Division of water Quality,Groundwater Section Within 30 days
GW.t REV. 12199
Serial No.

pt r
� 14 "� 91
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) L� &- SecLa)y Qf$ CERTIFICATION qa 4
WELL CON7RACiOR COMPANY NAME e'gjf_�eta"� 1% � Sc,n }f JI } ®�HOP"E .Y (<? ie fes-ZG2�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable) - -
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ industrial ❑ Agricultural P -1: -
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use_
I `
2. WELL LOCATION: Top o hic/Land settipg
Nearest Town: Wn' heSut County A moo ❑Ridge slope ❑Valley 11F19t
ri rI2� (check appropriate box)
(Street Name,Numbers.Community,Subdivision,Lot No..Zip Code) Latitude/longitude of well l0gat1cm
( �7
3. OWNER: -Sn)�r\ Jew -c E�J�C (degrees/minutes/seconds) I
Address 581, C'a\tee I3ecntK l °i Latitude/longitude source:❑GI'S❑Tojographicmap -
(Street or Route No.) (check box) - -
nt `I 7, 15 b(o°1 DEPTH DRILLING LOG
Ciry State zip Code From To Formation Description
(o43b
Area code-Phone number
4. DATE DRILLED y'�3Y-S-- ( zts
5. TOTAL DEPTH:��]
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO _
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing) a
S. TOP OF CASING IS Above Land Surface* _
`Top of casing terminated aUor below landnd s surface requires a N
variance in accordance th 15A NCAC 2C.0I18. y�
9. YIELD(gpm): METHOD OF TEST t 4 -- "
10. WATER ZONES(depth): —� ---
LOCATION SKETCH
11. DISINFECTION:Type Oi S Amount a Show direction and distance in miles from at least
12. CASING: T— Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weieht/Ft. Matenal numbers and common road names.
From 'J—To�L_FL G r Y
From To Ft.
From To Ft.
13. GROUT: Depth Material MethodrK
tte ( QFrom��To�Ft. C.e+oxen _A[1t.OPeC1 From -To Ft.14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.15. SAND/GRAVEL PACK:Depth Size Material
FromTo 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 CONST(U TING 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. GWA REV.07/2001

310790
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Rejsource/s'-Division of Water Quality-Groundwater Section r
WELL CONTRACTOR(INDIVIDUAL)NAME (print) t/et0-:e> `h - Jf-ct-i`�f Qis CERTIFICATION# 'R7�4
WELL CONTRACTOR COMPANY NAME f �c Wyei < l 2e 11� '�' &,,JS HONE # fiW4 io 4S -
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED wQ PERMIT#
(ifapplicable) (ifapplicable)
I. WELL USE (Check Applicable Box): Residential td Municipal/Public ❑ Industrial ❑ Agricultural ❑I --
Monitoring ❑ Recovery ❑ Heat Pump Water injection ❑ Other❑ If Other,List Use
2- WELL LOCATION: Topogra is/Land settings
Nearest Town:-, WGYneS u {if - County Aavtoe-01 ❑Ridge Wlope ❑Valley ❑Flat
a�aT (check appropriate box) �
(Street Name,Numbers Commufiil} b sion.Lot No.,Zip Code) Latitude/longitude of well locaupn
3. OWNER: DG&Q ZSC-Cr:S (degreesiminutes/seco ids—)
Address 3Zis - ove 'Ko�d Latitude/longitude source:❑GPS❑Topog�aphicmap
($tree[ Route No.) (check box)
c�� �C �A� al DEPTH DRILLING LOG
ppCu, Town statue Zip Code From Tog Formation Description
Q)'>01- CAOSa4 �
Area code-Phone numbeSS _
4- DATE DRILLED 7—Ja- C/` (o �y c= k, k j
5- TOTAL DEPTH: 1
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
T STATIC WATE3 LEVEL Below Top of Casing: /m d FT. --� -e
(Use"+"if Above Top ofCasing) pG
3. 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-0119. —
9. YIELD (gpm):_ a 0 METHOD OF TEST R t
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type n:/!S Amount Show direction and distance in males from at least
12. CASING: T Wail Thickness two State Roads or County Roads.Include the road
Dept Diameter or WeiehdFt. Material numbers and common road names.
From_To Ft.&X_ # L
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 4,_To90 Ft_ C.e isv e nk pO izre
From To Fr (]
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in- k�
From To Ft. in. in- ,
15. SAND/GRAVEL PACK: f
Depth Size Material 17 �
From To Ft. f
From Tci Ft.
16. REMARKS:
1 DO HEREBY CERTI;=Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,'NELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
il-'a-S
SIGNATURE PE ON CONSTRUCTING THE WELL DA-,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-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 1JeV00k }lec�Ab, -SoJ i+ LDS CERTIFICATION# Sys to
WELL CONTRACTOR COMPANY NAME C u�\ " S t\,41 w.A PHONE # (RL?) 906;5-2e L'L__
STATE WELL CONSTRUCTION PERMIT# CJ 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: Top ogr hic/Land setting
Nearest Town: t. ,n2SN:xte - --County Maw ❑Ridge ISSlope ❑Valley ❑Flat
—,o-\, CAce y rIS`�V (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Tom TkatY ofx (degrees/minutes/seconds)
Address PO 1�0k Wa Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
o n c Fit '1 DEPTH DRILLING LOG
Cory or Town Zip Code From To Formation Description
(%Z%)- Z2fe• 3oSnt 1 51 C)..or• (Sc.r�r..
Area code-Phone number
4. DATE DRILLED 3 mot•09
5. TOTALDEPTH: abS /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO "E
7. STATIC WATER LEVEL Below Top of Casing: too FT. �E
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* r
-Top of casing terminated atfor below land surface requires a N
variance in accordance with 15A NCAC 2C.01 ig. t t�
9. YIELD(gpm): Li, METHOD OF TEST R , W
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount 12 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 Weipht/Ft. Material numbers and common road names.
Fromm Ft. (a fii ,• '*ee t
From To Ft.
From To Ft.
13. GROUT: Depth Material Method IP
From To Ft. f
From To Ft.
t+
14. SCREEN: Depth Diameter Slot Size Material Je
From To Ft. in. - in. A C•ossa oa¢a L
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 WASCONSTRUCTED 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 SON 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

311403
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-�[t Division of Water Quality-Groundwater Section --��---����99��
WELL CONTRACTOR(INDMDUAL)NAME (print) i r E' 14!10 ✓x CERTIFICATION#—(p/
WELL CONTRACTOR COMPANY NAME I'rr�Se n) U Y3/cll 7Nril/inn PHONE 690 6 —ZZ1q
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check.Applicable Box):Residential 16 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION- Topographic/Land Topographic/Land setting
NearesaEETown: /'./t1(7;Q County# ❑Ridge ❑Slope RIVAey ❑Flat
I Sf Z�rr Awn Tn,_1��,,,,,�.� (check appropriate box)
(Street N e,Numbers,Community,Subdivision,Lot No.,Zip Code) Lan d ongimde of well locat' It
3. OWNER: `Z degrees/minutes/ tends)
Address L Latitude/longitude source:ZC'iP5❑Topographic map
(Sneer or R�No.) (check box)
�C:C[11-4 /A44 euxll DEPTH DRILLINGLOG
Cry or Town State Zip Code From To Formation Description
(8�- ��y-�2.7� o Area code-Phone number '-
4. DATE DRILLED a — OS� G �
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M-
7. STATIC WATER LEVEL Below Top of Casing: SED FT.
(Use'+'if Above Top of Casing) C,J
8. TOP OF CASING IS_�FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a r'
variance in accordance with IiA NCAC 2C.Ol la.
a
9. YIELD(gpm): METHOD OF TEST s
10.WATER ZONES(depth):Z,20
LOCATION SKETCH
11. DISINFECTION:Type H 7 A/ Amount 6Z. Show direction and distance in miles from at least
l2. CASING: Wall Thickness two State Roads or County Roads.Include the road -
Depth Dipmeter or Weight/Ft. Material numbers and common road names.
From 0 To�Ft.
From To Ft.—
From—To Ft. i
13. GROUT: Depth Material Method
From To ae) Ft. CnnCro P6 t�'r-J '
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material =
From To—Ft— in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material _
From—To—- Ft. G/y � �
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 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

3110
- North Carolina- Depanment of Environment and Natural Resources-Division of Water Duality-Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: L f(/r'r-
WELL CONTRACTOR CERTIFICATION #:CW6 9 v
/STATE WELL CONSTRUCTION PERMITII:
1. WELL USE(Check Applicable Boa): ResidenGalg Municipal Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other,List Use:
2. WELL LOCATION: (Shpw sl c f lh location below) _.
Nearest Town: A rq- E county:'/
(Road Name and umbers.Conapunily,or ubdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �7 ° ,,� 5 From To F anon escepbon
Address b ,P / , ('?U L
beet of houlo o.
/ : % U•4 1
Caq or Town State - G Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YESQ NOM
7. DOES WELL REPLACE EXISTING WELL? YESNO�
B. STATIC WATER LEVEL Below Top of Casing: O Fr. �a
(Use':it Above Top of Casing) �5
9. TOP OF CASING IS__(2�_ FT. Above Land Surface' .r
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 20.0 a
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type ZLZ2Z Amount If additional space is needed use back of form
13. CASING:
WallTnickness LOCATION SKETCH
Depth arfJ��te or w i 1. cMalna,1/ (Show direction and distance from at least two State
From To �� Ft. =, L Roads,or other map reference points)
From To Ft.—
From To Ft. ��JrOT
14, GROUT:
Dept
//yy..yy /Y Mater � Method
From To Ft. �
From Tb Fl.
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft — in. — in.—
From To Ft.— in. — in.
From To Ft.— in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Ouad No: SIGNATURE OF RSON CONSTRUCTING THE WELL
Submit original to Division of Water Ouality,Groundwater Section within 30 days GWI REV.17179
Serial No.

311d '� 9
North Carolina- Department of Environment and Natural Resources-Division of Water Ouabry-Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION: '-)V&y Ilerg �a v�4r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential2E Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (Show sketch pf the location below) .�/
Nearest Town: r L�F County:.4,l'`yr rt✓
�vve
(Road Name d Nurnpers,C,o;rvnunity.or SLiodivisiion and Lot No.) DRILLING LOG DEPTH
3. OWNER wy V_/ V_'Vy ' R M From To Fo at escdptlon
Address
svltivector ouzo o. ,� ^�O t_1� 9'^°GT
� ter- Glrl' �7 �.�� r ---
Gil or town y Slate, .� 'Cl.,?b `J 7j?4ip cod.
4. DATE DRILLED /V- :9.7-c,.5 '-
5. TOTAL DEPTH .3,� ;
6. CUTTINGS COLLECTED YES Q NOD
7. DOES WELL REPLACE EXISTING WELL? YES Q N0R�
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use':it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
Top of casing terminated at/or below land surface requires a variance In actor- '.
dance with 15A NCAC 2C.o116
10. YIELD(gpm): ��i_METHOD OF TEST q"r ` y
11. WATER ZONES (depth): "-
12. CHLORINATION: Type Amount It additional space is needed use back of form c )
13. CASING: O
Wall Thickness
LOCATION SKETCH _a
!y
4- -1 Depth q la to or weighl/Fl. renal (Show direction and distance from al least two State
From `"' To � Ft. Roads,or other map reference points)
From To Ft. Ct
From --To Ft. l
14. GROUT:
Depth)�� Material Method
From 0 To .xv FL
From To F.I.
15. SCREEN:
Depth Diameter Slot Size Material
From _To_Fl _ in. — in.—
From To_Ft.— in. — in.
From —To—Ft.— in. _. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Ft.
17. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL
Submit original to Division of Water OualilY,Groundwater Section within 30 days GW t REV. 12J99
SenalNo.

3110 ,78
North Carolina- Depanmenl of Environment and Natural Resources- Division of Water Quality-Groundwater Section
1636 Mail Seryrce Center- Raleigh, N.C.27699-1636-Phone[phone] ,Q
WELL CONSTRUCTION RECORD WELLCONTRACTOR: r orC� % UfI -
WELL CONTRACTOR CERTIFICATION N: i
STATE WELL CONSTRUCTION PERMITa:
1. WELL USE(Check Applicable Box): Residential DD Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery Heal Pump Water Injection ❑ Other ❑ II Other,List Use:
2. WELL LOCATION: (S w sketch of the location below)
Near st Town:��Av1! ^� County: 410b
(Road Name/�;o}1,Num/tiers, mmuni ,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER �!' // N- i./,7 From To aeo escnpeon
Address 1/.�"/,L�/ , Llg 11� _
/A-,-I SuectorRou��o.T—C ��y
�, lit��' / 6 j �d o- -v e
C or Town Slate��» Zip Code
a. DATE DRILLED �- ` -o6— ya76 � G '
5. TOTAL DEPTH 3nS
6. CUTTINGS COLLECTED YESQ NOED
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: _,L,5— Fr.
(Use':it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface' t -
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C.011e �. rJ
10. YIELD(gpm): p2t�— METHOD OF TEST Aw l'— o =
11. WATER ZONES(depth):
12. CHLORINATION: TypeAmount If additional space is needed use back of(arm
13. CASING:
Wall Thickness LOCATION SKETCH
'7 Depth [/{ DD'' jt0r� or WeighVFt. t al (Show direction and distance from at least two State
From�¢ To _l.� FI./LZ!_� 2 Roads,or other map reference points)
From To Ft.
From To Ft. _
14. GROUT:. !Y
Dept ty Malarial_ / Method
From To Ft. ^
From To --Ft. -
15. SCREEN:
Depth Diameter Slot Size Material
From - To FI _ in. —in
From To Ft.— in. — in.
From To Ft.— in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Fl.
From To Ft.
17. REMARKS:
I DO HEREBY CLRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL
Submit original to Division of Water oualtly.Groundwater Section within 30 days GW t REV.12/99
Serial No. � i

3114 "17
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Sorvrcu Center• Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �'ice
WELL CONTRACTOR CERTIFICATION J ��5lv/•_�
r- STATE WELL CONSTRUCTION PERMIT#: ref
1. WELL USE(Check Applicable B E
Boa): Residential I.� Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection [D Other E] H Other, List Use:
2. WELL LOCATION: (S ow skqcf 1 the location below) /
Nearest Town: i v r Pam. _County: jLL�noCi
9
K J rL
(Flird flamepnd Numbe S.Community r Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER -`4 From �7To on anon escrip6on
Address ,..1N � � Ob
eto onto O. f�
Car r Town es Sate.g2r6- P COdB
4. DATE DRILLED
5. TOTAL DEPTH 'S-
6. CUTTINGS COLLECTED YES Q NOD
7. DOES WELL REPLACE EXISTING WELL? YES N00_
B. STATIC WATER LEVEL Below Top of Casing: '35 FT,
(Use*.'if Above l®op^`ol"Ca—sing)
9. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated It/of below land surface requires a variance In actor-
dance with 16A NCAC 2C.0118 2
10. YIELD (gpm): _. . METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
De t Di)'j'f for or w Ft. �M'a/len�al� (Show direction and distance from at least two State
From To �n Fl. (a'/Y y� Roads,or other map reference points)
From To FI. J y
From To Ft.
14..GROUT:
Depth'�,� Material Method
From Q To -_10 Ft: '���'
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From —To— Ft — in. — in -
From —To—Ft.— in. — in.
From To_Ft. in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4_Q_0,1D
FOR OFFICE USE ONLY a
Quad No:
SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Quality.Groundwater Section within 30 days GW t REV. 12/99
Serial No.

C
IO
"l
_ Nonh Carolina• Depanment of Environment and Natural Resources•Division of Water Quality 3110
-Groundwater Section -
1636 Mail Service Center• Raleigh, N.C.27699-1636-Phone.[phone] D
WELL CONSTRUCTION RECORD WELL CONTRACTOR: ] p- W V'"7e
WELL CONTRACTOR CERTIFICATION #• e
STATE WELL CONSTRUCTION PERMIT#:
1//
1. WELL USE(check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery El Heat Pump Water Injection ❑ Other II Other,List Use:
2. WELL LOCATION:.(Mow sketch of the location below)
Nearest Town: _County: `�O
(Road Name and Nu is,Cormo ly.or Subdivision an Lot No.) DRILLING LOG DEPTH
3. OWNER 012wo Uef From To o #lion escription
Address wp6,
tie or Au)Oro.)
Wy or Town // S1nte Zi Code yND M�
4, DATE DRILLED Z07(O"O� - - 7' p ..r.sr r.q.i/i• >U
S. TOTAL DEPTH _
6. CUTTINGS COLLECTED YESQ NOM
7. DOES WELL REPLACE EXISTING WELL? YE�NO��
8, STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.'if Above Top of Casing)
9. TOP OF CASING IS t2 FT.Above Land Surface' 3 w
-Top of casing terminated after below land surface requires a variance In actor-
dance with 15A NCAC 2C. 1 E -G
10. YIELD(gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional sgace is needed use back of term
13. CASING: -
y WanThickness LOCATION SKETCH
Depth /p,,,airget/nr or w,�t,XFL nal / (Show direction and distance from at least two State
From / TO �Ft..lLl'L r SS 2255 �/ Roads,or other map reference points)
From To Ft.— 3
From To Ft.
14. GROUT:
Dept Mat h'1�, arial Method
From To 32V Ft: e^�
From To Ft. -
15. SCREEN: -'-
Depth Diameter Slot Size Malerial
From -—To—Ft — in. — in.—
From To Ft.— in. — in.
From —To—Ft.— in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To— Ft.—
From To Ft.
17. REMARKS:
I DO HEREBY CL RTIFY 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.1
FOR OFFICE USE ONLY DATE
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL
Submil original to Division or Water Quality,Groundwater Section within 30 days Gwn REV. 12199
Serial No.

W309572
- North Carolina- Depanmeni of Environment and Natural Resources-Division of Water Duality-Groundwater Section
1636 Mail Sorvtcu Center•Raleigh, N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: lr(e tilpf/iIt fl% •-?.
WELL CONTRACTOR CERTIFICATION q:a� , .�
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check applicable Box): Residential2/ Municipal ❑ Industrial❑ - Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection
1 ❑ Other ❑ It Other, List Use:
2. WELL LOCATION: (S ow sketch of the location below)
Neatest wn: �!-V ,' ✓
County: r AY61f.•p
(Road Name d Numoer , on ,tly,or Subdivision and Lot No.)3. OWNER / DRILLING LOG DEPTH
Address From To o of n Description
1. All
V treet or auto a, 0
• v
Gity or town Stale cb
4. DATE DRILLED OS p"SSa.Sz�pc°°e r - ,p e
S. TOTAL DEPTH :/�-4�v/ (=.
6. CUTTINGS COLLECTED YES❑] NOO
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ�
B. STATIC WATER LEVEL Below Top of Casing: �FT.
(Use';a Above Top or Czsing)
9. TOP OF CASING IS
ve Land Surface*
'Top of carting terminated at/or below land surfaced requires a variance In actor-
dance with 16A NCAC 2Cy,o'tla
10. YIELD (gpm): :- i METHOD OF TEST e%_
11. WATER ZONES(depth):
12. CHLORINATION: Type _Amount
13. CASING: - It additional space is needed use back of form
Depth Wall Thickness LOCATION SKETCH
P t,// 'arytgto or WeipnuFl. eclat _ (Show direction and distance from at least two Stale
From To ll Ft. j ,s
From Roads,or other map reference points)
To Ft.
From To Fl.—
14. GROUT:
Dept Material Method C�J
From TO' Ft. .rs(7-✓7
From To Fl.
�O -t.
15. SCREEN: t
Depth Diameter Slot Sizo Material Ln
From - To_Fl _ in. _ in. O
From To_Ft. in. — in. run
From To_Ft._ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To— Ft.—
From To Ft.
17. REMARKS:
I DO HEREBY C8RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY , 7% 71 e
f e
Ouad No: SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submil original to Division of Water Duality,Groundwater Section within 30 days -
SenalNo. GW-1 REV. VIVO

3095 "12
- North Carolina- Depanmeni of Environment and Natural Resources-Division of Water Quality•Groundwater Section
1636 Mail Service Center•Raleigh,N.C.27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: frCN L E�j f✓ ':ra -?.
WELL CONTRACTOR CERTIFICATION If:.�
STATE WELL CONSTRUCTION PERMITM:
1. WELL USE(Check Applicable Bo:): ResidentialE Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection
❑ Other ❑ It Other,List Use:
2. WELL LOCATION: (S ow sketch of the location below) /
Nearest Town: !.v im Couny:L�YI✓ rr'."1
if g Fr lCr�
(Road Name d Number , o ny,or Subdivision and Lot No.) DRILLING LOG OWNER DEPTH
1 / '.
Address
From To-
fio tali n Description
- S�: � ?
tree[or ouzo '--
/l0
City or Town SiaIeQY7"l3`/�.'S:54 LP Code
4. DATE DRILLED� �-G,S �47 'D
S. TOTAL DEPTH 3l
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NOQ'�
8. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use*-'it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
-Top of casing terminated aUor below land surface requires a variance In actor•
dance with 15A NCAC 2C 1e
10. YIELD (gpm): METHOD OF TEST �q r_
11. WATER ZONES (depth):
12. CHLORINATION: Type _Amount If additional space is needed use back of form
13. CASING:
- Wall Thickness LOCATION SKETCH
Depth , >r 'arpgto or WeighvFL eiiat _ (Show direction and distance from at least two State
From To � Ft. Y Roads,or other map reference points)
From To Ft.—
From — . To Ft.
14. GROUT:
Depth, Material Method
From 0 ToFt. ^IL°^�� a
From To F.I.
15. SCREEN: 1
Depth Diameter Slot Size Material r11
From To_F1 _ in. _ in.
C)
From To_FL— in. — in.
From To_Ft, in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Fl. ---
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C,WELL -
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�aa-tis.
FOR OFFICE USE ONLY �����e
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
SanafNo. GW.t REV. 499

309571
- Nonh Carolina- Depanment of Environment and Natural Resources-Division of Water Quality•Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone[phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: 'l`rrC �V w2
WELL CONTRACTOR CERTIFICATION #:"6 ii� U '
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE(Check Applicable Box): Residential Rr Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑Recovery❑ Heat Pump Water Injection
❑ Other ❑ It Other, List Use:
2. WELL LOCATI : (Show k c I(h w)
location below)
Nearest Town: r p County:17'9'1"�iEfL3'1CY
e/ e;
(Road Nam nd umo s,C mumy.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER ,
Address IvelV From To Fo afo Description
tv to �a7 "raC 'C,
C>fA rJr,N, Win,,., 7� a
City or o St e p
-�2 ? •y31 ZI ceaa
4. DATE DRILLED -�fJ'L�
5. TOTAL DEPTH -1
6. CUTTINGS CO-L CTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO&!J_
8. STATIC WATER LEVEL Below Top of Casing: — Fr.
9. TOP OF CASING IS O _ FT.Above Land
Surlasinp)
FT.Above Land SuAace'
'Top of casing terminated atfor below land surface requires a variance In actor-
dance with 15A NCAC 2C.011a
10. YIELD (gpm): _O— METHOD OF TEST Ali r
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount It additional spac
13. CASING: e is needed use back of form
Wall Thickness LOCATION SKETCH
'F�";� Depth�c? ayn t r or y VF6 rial/ (Show direction and distance from at least two Stale
From _Lam_ To .3S Ft. I
Roads,or other map reference points)
From To Ft.—
From To Ft.
14. GROUT:
Dept Material Method
/��
From _L.G_ To -xy Ft.
from To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
t
From —To_ Fl — in. — in cl1
From To Ft. in. _ in. O
From —To_Fl._ in. — in. rs
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CLRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE -
Sub",original to Division of Water Quality,Groundwater Section within 30 days _
Sadal No. Gw-i REV.,1T/99 -

cdo
309570
North Carolina• Depanmenl of Environment and Nalural Resources-Division of Water Duality-Groundwater Section
1636 Mail Service Center• Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION It:� 6 ��rX q Uf;taP
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check applicable Box): Residential21/ Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: S ow sk Ich I he location below) /Nearest Town:,/(.y>i / U County:klays—rcl
(Road Nam/e� d Numbers.Com~miry`, r Subdivision and Lot No.) DRILLING LOG
3. OWNER / r' DEPTH
Address l• 70 v From To For�ion escnption
Fi` o2o /
1,A14VA&fe6l//� ueetor out o. 75Z / — O n✓J
1/p, sl
wn St rti odi
y or To" Lp Code
4. DATE DRILLED - -OS 'yam 1 (�
5. TOTAL DEPTH oe&-19- _
6. CUTTINGS COLLECTED YES Q NO[:)
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOE
8. STATIC WATER LEVEL Below Top of Casing: ` g FT.
(Use'-'a Above Top of Casing)
9. TOP OF CASING IS 3- FT.Above Land Surface-
'Top of casing terminated sum below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 ^
tO. YIELD (gpm): �)ZMETHODOF TEST
-1�'rr�
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 13. CASING: 11 additional space is needed use back of form
Wall Thickness LOCATION SKETCH = _
fa Depth/ P� or or uFt. enat (Show direction and distance from at least two Slate- -
From To �LiL FL JC1.L� a/E!5 Roads,or other map reference points) --
From To Ff.
From To Ff.— SI�57
14. GROUT:
O Dept 11, Material Method 9
From To Ft: n -,
From Tb --Ff.
15. SCREEN: yo
Depth Diameter Slot Size Material ,
From To_ R — in. — in rs1
From To—Ff._ in. — in. o
From To FL_ in. — in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY f `2t r� a 0 /
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Quality,Groundwater Section within 30 days
Senal No. GW-I REV.12199

W 309569
- North Carolina- Departmenl of Environment and Natural Resources-Division of Water Quality•Groundwater Section
1636 Mail Service Center,Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �✓����/�r�lrlf
WELL CONTRACTOR CERTIFICATION gr09
/STATE WELL CONSTRUCTION PERMITN:
1. WELL USE(Check applicable Boa): Residential L7 Municipal ❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection
❑ Other ❑ It Other, List Use:
2. WELL LOCATI N- (S ow sketch of the location below)
Near s1 Town:�.. ._ County: U/
(Road Name an \umoel.,, ymmw�,,;, _. - bovision and Lot No.) DRILLING LOG
3. OWNER a DEPTH
Address l From To o atio escnpbon
•% "" ;'/D tj Ire I o ou a ✓7' �T—
/ /l�
City or Town Syln zip code -0tC gNfJ
4. DATE DR
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: ':z,0 FZ.
9. TOP OF CASING IS_,� Fr. '-'it Above Top of Cace,
FT.Above.Land Surface,
*Top of casing terminated at/of below land surface requires a variance In accor-
dance with ISA NCAC 2C.011E _
10. YIELD(gpm): � METHOD OF TEST o"I r-
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness -LOCATION SKETCH
Depth D ler or W i I. Mal riai
Fromy1� ��7�i� / 7 f (Show direction and distance from at least two State
To L FI. Roads,or other map reference points)
From To Ft.
From To Fl. l�
14. GROUT:
Depth Material Method
From 0 To 20 Ft. ^'s
From To Ft. B
15. SCREEN: ' n
Depth Diameter Slot Size Material
From --To—Ft — in. _ in. 1
From To_Ft._ in. _ in. o w
From —To—Ft._ in. — in. cn
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17, REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2 � , 0 ,
FOR OFFICE USE ONLY f�L� .._,c 3-9
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE `-
Submit original to Division of water Quality,Groundwater Section within 30 days ..
Serial No. Gw•i REV. 12/99

309567
. North Carolina- Depanmenl of Environment and Natural Resources - Division of Water Quality-Groundwater Section
1636 Mail Service Center •Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C ': ✓.-�
WELL CONTRACTOR CERTIFICATION a:— ` Ai� f.e
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check Applicable Sox): Residential 2ST Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑Recovery El Heat Pump Water Injection ❑ Other f Other, List Use:
2. WELL LOCATION: (Sho ske ch of the location below) 4
�Near Sd own: � �
{/ /1 County:
(Road Name a Numbe s.Community,or Sub i ision and Lot No.) DRILLING LOG DEPTH
3. OWNER
Address
From To F at escriptfon
g j �� a�b rf
cc or of u.
arm, ltUs
Slate 7 ,+Zi Code _ iw _ ;V ''�'f'
t or town .-��' N`-
4, DATE DRILLED " GL`'
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOD
7. DOES WELL REPLACE EXISTING WELL? YES n NO2-
8. STATIC WATER LEVEL Below Top of Casing: _ 5 FT.
(Use'-*it Above Top of Casing)
9. TOP OF CASING IS_ c2_ FT. Above Land Surface'
'Top of casing terminated avor below land surface requires a variance In accor-
dance with 1SA NCAC 2C.0118 y1� /
10. YIELD(gpm): �[Q— METHOD OF TEST�Y'iJ
11. WATER ZONES (depth):
12. CHLORINATION; Type Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
,�� Depth Diarpe a or W ' Ft. MMa(?rtial (Show direction and distance from at)east two Slate
From To FL� Ems! Roads,or other map reference points)
From To Ft.
From --To Ft. ;7 i�
14. GROUT:
Dep� / Material _ Method
From © To 1 Ft. Li e i Y
From To FL
15. SCREEN: -�0 13
Depth Diameter Slot Size Material
t I
From - To_Fi _ in. —in LT1
From To_Ft.— in. _ in.
From To_FI._ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. -
FOR OFFICE USE ONLY V�s��y L'
Quad No: SIGNATURE OF RSON CONSTRUCTING THE W ELL .DALE
Submil original to Division of water Quality.Groundwater Section within 30 days 1.1. I - .
SedalNo. GW1 REV. 121"

W 309568
. North Carolina• Depanment of Environment and Natural Resources- Division of Water Quality•Groundwater Section
1636 Mail Service Center- Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J.ryt N LL)�ir�� Grp
WELL CONTRACTOR CERTIFICATION #: ,±-zzy'
STATE WELL CONSTRUCTION PERMIT#: E
1. WELL USE(Check Applicable Boa): Residential L=1 ' 'Municipal ❑ Industrial❑ Agricultural❑ Monitoring❑Recovery❑ Heat Pump Water Injection
❑ Other ❑ II Other, List Use:
2. WELL LOCATI f(S,$w sketch of the location below) !!��
Nearest Town: / vP. County:1'�'�,fo.��
(Fload Name nd urnoem CRopprip.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER
Address From To 'ofinalf escnption
TSuec/-ifut O'�e/ Pik+--j/
or Houle
o J�D/
City or Town Stale¢+�c
J_aJ' 7- /M/ Zip Code
4, DATE DRILLED a�- c � Q
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOQ �r
7. DOES WELL REPLACE EXISTING WELL? YE � NOD
8. STATIC WATER LEVEL Below Top of Casing: FT.
(use'-'it Above Top of Casing)
9. TOP OF CASING IS FP.Above Land Surface'
'Top of casing terminated War below land surface requires a variance In actor-
dance with 15A NCAC 2C. a
10. YIELD(gpm): METHOD OF TEST
11. WATER ZONES (depth):
1 . CHLORINATION: Type
13. CASING: Amount If additional space is needed use back of form
-
Wall Thickness LOCATION SKETCH
a-a Depth _ Dian lO or Weight/Ft. ,fin lenal.- (Show direction and distance from at least two State
From To Ft. ' ;nA Roads,or other map reference points)
From To FL
From To FL
14. GROUT:
Depth Material Method w
From To Ft. I ✓ �"
From To Ft.
15, SCREEN:
Depth Diameter Slot Size Material U1
From -—To—Ft _ in. _ in.
From To—Ft. in. in.
From To_Ft._ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CL`RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL .--"
CONSTRUCTION STANDARDS,AND THAT A'C�iOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE,-,
Submit original to Division of Water Qualily Groundwater Section within 30 days _.
Sedal'No. GW1 REV.;12199

309565
- North Carolina- Department of Environment and Natural Resources - Division of Water Quality•Groundwater Section
1636 Mail Service Center- Raleigh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR;
WELL CONTRACTOR CERTIFICATION #.�6y i
STATE WELL CONSTRUCTION PERMIT#:
I. WELL USE(check Applicable Box): Residential 2/Municipal ❑ Industrial❑ - Agricultural❑ Moniloring ❑
Recovery❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (S ow sketch 90he location below)
Nearest Tcn: L i/i County: YG�✓
(Road Name anU u lbers.Co uney,or ivision and Lot No.) DRILLING LOG
3. OWNER c� DEPTH
Address 90 From To ation Description
1leel or oulo
O P I/
City crown Ia1e �8-4j5-_2�sa�ipCode 0 t .✓�
a. DATE DRILLED _3-V� P
S. TOTAL DEPTH -i-_2 6'_
6. CUTTINGS COLLECTED YES Q NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
8. STATIC WATER LEVEL Below Top of Casing: 07,R FT.
9. TOP OF CASING IS (Use*-'it Above Top of Casing)
FT.Above Land Surface'
'Top of casing terminated atior below land surface requires a variance In accor.
dance with i6A NCAC 2C.0118
10. YIELD (gpm): _ /0 METHOD OF TEST_Ar I-
11. WATER ZONES(depth):
12. CHLORINATION: Type Amount If additional s2ace is needed use back of form
13. CASING:
Waif TNckness LOCATION SKETCH
Depth 9��ta�f t�r or We' t. leriat (Show direction and distance from at least two State
From + To � Ft.. 1` _ /5555
Roads,or other map reference points)
From 7o Ft.
From To Ft. -
14. GROUT:
Depth Material Method v
From 1_ To R_Fl. ^�ei7 -n
`7
From — To Ft. 1 1
15. SCREEN:
cn
Depth Diameter Slot Size Material C=)
From To FI_ in. _ in. N
From To Ft. in. — in.
From To_FI._ in. — in.
16. SAND/GRAVEL PACK: -_
Depth Size Material
From To Ft.
From To FL
17. REMARKS: —
100 HEREBY CLRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER., _FOR OFFICE USE ONLY J �
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE _
Submit original to Division of water Quality,Groundwater Section within 30 days
Senal'No. GW1 REV. 12199

Afd -
WELL CONSTRUCTION RECORD 3 0 9 0 6 7
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CO.NTRACTOR(INDIVIDU at) .F�j IJ�A� �/ .V'L�7 _ CERTIFICATION# 3C) 7 1
WELL CONTRACTOR COMPANY NAME AAA GREENE BR a.WELL ORLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
IIIIIIIIINIIIII (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: I I Topographic/Land setting
Near st Town:_ Vf� Court - G ❑Ridge ASlope ❑Valley ❑Flat
i " C O s--Cry'i (check appropriate box)
et Name,Numbers,C6=u ,Subdivi io ,Lot No. i Code) ;Q LatimdcAongitude of well location
3. OWNER: (degrees/nunutes/seconds)
Address '�+ p b 6 Y 1 /,p y,�'��Latitude/longitude source:❑GPS❑Topographic map
tteet or Route No _ r � (check box
4�, -7b DEPTH DRILLING LOG
try or Town to Zip Code From To Formation Description
-
Area code-Phone number -
4. DATE DRILLED 3 --//3
5. TOTAL DEPTH: �
6. DOES WELL REPLACEEXISTING XISTING WELL? YES ❑ NO �r
7. STATIC WATER LEVEL Below Top of Casing:AFT. <
(Use"+''if Above Top of Casing) a to
8. TOP OF CASING IS�_FT.Above Land Surface`
•Top of casing terminated at/or below land surface requires a pg L
variance in accordance with 15A NCAC 2C.0118. L�
9. YIELD(gpm):�—METHOD OF TEST /
10.WATER ZONES(depth): CA
LOCATION SKETCH
11. DISINFECTION:Type —f"' Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diame1er or Weight(FL Wterial numbers and common road names.
From To�_FL h f %r _
From To Ft
From To Ft.
13. GROUT: Depth Material Method
From To FL_I'1J/J712„
From 3 To Ft. i Cal � i/b!/♦ 11lJ��
14. SCREEN: Depth Diameter Slot Size Maten' f/
From To Ft. in. in. ' p
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 - -
CONSTRUCT STANDARDS,AND T G COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER y
3-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE t
VI
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. r
GW-I REV.d 9/2004

ov
s
Nonh Carolina• Depanment or Environment and Natural Resources-Division of Water Quality-Groundwater Section " 0 � g � p
1636 Mail Service Center• Raleigh,N.C.27699-1636-Phone [phone] O
WELL CONSTRUCTION RECORD WELLCONTRACTOR: l-✓ N We '1- vM
WELL CONTRACTOR CERTIFICATION#:>1W AW -r
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Boa): Residenlial DSTMunicipal❑ Industrial❑ - Agricultural❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other M It Other, List Use:
2. WELL L0CAT1r0N: (S ow sketch of the location below) /
Nearest Town Counry:'9 �LfU6"`C✓ _
(Road Name and Numbers. ommunity,Of Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _
-7 C From To 1_7al Description
7 .3,�� G(
Address iNy�-I'Rr ,Cj 26)
_ 1�%
FYc 1 cur% q x
City or Tovovm 4. DATE DRILLED -�.��.����•---.----•--St--#tear
L /_5�'
"t7.� "" ,�3.} /,crrv✓ �/
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES[] NO[]
7. DOES WELL REPLACE EXISTING WELL? YES F-1 N0ED—
8. STATIC WATER LEVEL Below Top of Casing: .� r- FT.
(Use':it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
*Top of casing terminated at/of below land surface requires a variance in accor.
dance with 15A NCAC 2C.011e
10. YIELD(gpm): /-�— METHOD OF TEST ,41.1-
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount II additional sRace is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �0iarrrppeter or Wei 1. AL/
(Show direction and distance from at least two State
From `�` TO � Fl.� ' L/ Roads•or other map reference points)
From To Ft.—
From __To Fl. (� -v
14. GROUT: ^c
Depth Materia Method 'n !`�
From To 'A) Fl.�'l •E''✓ rn rn'-
-or'^
From " To Ft.
15. SCREEN:
• �o
Depth Diameter Slot Size Material =
From _To FI in. — in.- =p
From —To_FLU— in. _ in. O Con j--->
From _To_Ft._ in. in. ca
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
GW.1 REV. I2/99
Serial NO.

_ North Carolina• Department or Environment and Natural Resources- Division of Water Quality-Groundwater Section 1636 Mall Service Center. Raleigh,N.C. �C 27699.1636-Phone[phone] 0 " p
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 9 ✓ + CP �ti/ C7
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Boa):Residenlialo �'Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other M If Other, List Use:
2. WELL LOCATI ow sketch of the location below)
Nearest Town:� �� County: a I14/4 ra
(Road Name and NuTriber Gomm yly,or Subdlvis antl Lot No.) DRILLING LOG DEPTH
3. OWNER C'f Address From To F. ion Descnplion
�r .�
IreCl pyto "n '� ' V-1
G y or Town State Zip Code �/ J zd��ti
4. DATE DRILL ED (�.$�vcSZS-�i�T�'��70� �r.�'i .7r.•S .0
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[:]7. DOES WELL REPLACE EXISTING WELL? YES NO _
8. STATIC WATER LEVEL Below Top of Casing: -,ZQ_FT.
(Use':a Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
-Top or casing terminated aver below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 _
10. YIELD(gpm): Z_ METHOD OF TEST Q r r
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth or We'�ameter, edal 7 (Show direction and distance from at least two Stale
From L To R FL / Roads,or other map reference points)
From To Ft. F
From To Fl. C' %°
14. GROUT: �Lt/ a�L) 7 L4 -
Depth�,�'�/', atenal Method f�*1 F�
From To �Ft: ^+ � V� 11 �o
From To __Ft. oC
15. SCREEN: -o nx
Depth Diameter Slot Size Material o�
From To Ft in. —in
From —To Fl. in. _ in.
From _To FI._ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
17. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
SenatNo, GWn REV. 12199

North Carolina- Depanmenl of Environment and Nalural Resources• Division of Water Quality-Groundwater Section o �" 6 1636 Mail Serwco Center- Raleigh,N.C.27699-1636-Phone[phone]
3
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 7'e- lz > Y
WELL CONTRACTOR CERTIFICATION W: - -
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(check applicable Boa): Residential� Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATII (Sh��ff""sketch of the location below) /
Nearest Town: '9"IV rr�M County:
a rk -
(Road Name An/I Numb rs.Community,or/S version and Lot No.) DRILLING LOG DEPTH
3. OWNER / 4Z.4CIC�f /j >JNy�iy� From To Fo atio "Dezcnption
Address z �yD Gl✓, b D 7 s
Lvecl or oXyytRyy q. D,qf S
City or Town -� a�� 3T-'V49zip Code ! t D
4. DATE DRILLED �"`��O � N
5. TOTAL DEPTH S
5. CUTTINGS COLLECTED YES 0 NOD
7. DOES WELL REPLACE EXISTING WELL? YES/❑','� NO�
8. STATIC WATER LEVEL Below Top of Casing. --62c FT.
(Use':if Move Top of Casing)
9. TOP OF CASING IS x FT.Above Land Surface' -
'Top of casing terminated at/or below land surface requires a variance to actor-
dance with 16A NCAC 2C.0118
10. YIELD (gpm): /'— METHOD OF TEST eg, --
11. WATER ZONES (depth):
12. CHLORINATION: Type _Amount If additional space is needed use back of form
13. CASING: -
WallThickness LOCATION SKETCH
Depth �p Diia'r etor or a UFt. M erial (Show direction and distance from at least two State
±From To 7 x7 Ft.-�C.'W �S!�5 Roads,or other map reference points)
From To Fl. 4�1'1 Q fl�
From To Ft. C--r"
14. GROUT: -q -nm
Depth.� Material Method rnW =C
From U To _ 0 Ft. `� 1 =o
From To -Ft.
15. SCREEN: c'sa
Depth Diameter Slot Size Material o0
From - To_FI in. — in
Q fnp
From To Ft.— in. — in. CD
From To—Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY vv "
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Duality,Groundwater Section Within 30 days
GW1 REV. 12/99
Serial No.

V
.. North Carolina• Department of Environment and Natural Resources - Division of Water Quality•Groundwater Section 0 / 8
1636 Mail Service Center- Raleigh.N.C.27699-1636-Phone[phone] p
WELL CONSTRUCTION RECORD WELLCONTRACTOR: �� f Ll/1fP
WELL CONTRACTOR CERTIFICATION #:� S�°y E'yJ� A r' .(•'
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check applicable Box): Residential E /Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other. List Use:
2. WELL LOCATIOtk(Show sketch o the location below)
Nearest Town:WN/ "4 County:
(Road Name a Numbers.Cc nity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER C From To F9 ati n Description
Address SC �r�5- ,C !"i �f.%
IreCl or o I NO 1 �9
�C of Townr,l/� sl, ��. -.,• .2-7777'per°� — /S�
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO[D
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: �FT.
(Use':it Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): -5-- METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth-., Dia elor or Wei h Ft. Mat nal (Show direction and distance from at least two State
From
To FL '�/V
Roads•or other map reference points)
From To FL 1f C o�
From To 3
FL -f-!
14. GROUT: In m�
Dep14 Material L Method
From T:71 171. +�-y .
to C�a
From To Ff. _ -p �i
15. SCREEN: -+0
Depth Diameter Slot Size Material =o
From - To FI _ in. —in _ mfl
From To Fl. in. _ in.
From To Ft._ in. _ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FI.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GWt REV. 12199
Serial No.

ao
North Carolina• Depanment of Environment and Natural Resources•Division of Water 0uality-Groundwater Section 3 O ! 8 r5 9
1636 Mad Scrnce Center• Raleigh, N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: t' l 14)N���/vi"�
WELL CONTRACTOR CERTIFICATION q:a�y��/ r<75d �i< v
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check applicable Boa):Residential Municipal❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery D Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI N: ho�,v sketch of the location below)
Nearest Tow !JC County: w ovI
(Road Name annbers.Co��ily,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER _ /­ iumfin /-/Awcj s From To F anon escnption
Address 2p Unl_<e� 1� © �D q
Q/J uecl or oule V`'/"7-2/ G g�
C Ot Vi .✓
Gry or Town Statyi,.� 'i/6�_� `Z�Coda - niO �-
4. DATE DRILLED -' ?7'OS 7 7 0 v.
5. TOTAL DEPTH _/
6. CUTTINGS COLLECTED YES Q NOE]
7. DOES WELL REPLACE EXISTING WELL? YES NO�—
B. STATIC WATER LEVEL Below Top of Casing: FT.
(Use':if Above Top of Casing)
9. TOP OF CASING IS cl� Fr.Above Land Surface'
'Top of casing terminated atfor below land surface requires a variance In accor-
dance with 15A NCAC 2C. la
10, YIELD (gpm): METHOD OF TEST Aye
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diarr� r or WeighVFl. renal_ (Show direction and distance from at least two Slate
From�To 3k Ft. � Roads,or other map reference points)
From To Ft.
From — To Ft. ��j,j O
14. GROUT: _n ern
Depth �Malarial Method W .lC
From To Ft. M /-�� 9 �o
From To F1.
vD oD
15. SCREEN: - 'o
c�i z
Depth Diameter Slot Size Material o�
From - To Ft in. —in.
Zo
From To_Ft.— in. — in. W mA
From To—Ft. in. — in.
16, SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No: SIGNATURE OF RSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Duality,Groundwater Section within 30 days
fWa REV. 12199
Serial No.

WELL CONSTRUCTION RECORD
\orth ( unlhna-Department of Cm ironment and Natural Resources- Division of Water Quality-Groundwater Section
�
ski.I.I (O\'1'R%(ION IIN DI\dDU\I.)NA%IE (Torino- 0'.r1't n ijs_�`D._. _ CERTIFICATION
Ni.l-i O%Ik.\(TORC NII[i NAME Q1y, (�Q'Q '�`ff�� -._
NI.17i.Hi.l.l,CO,NSTRLIC'TIONPERNII-I# ,�yyL \SSOCIATED%kQ PERM I#
(it applicable) (if applicable) -- - - _-- - -
VVI.LL I;SF: (('heck Applicable Box): Residential II Municipal'Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other. List Use
\SI IA I.O( nTION:
Topographic/Land setting
County
❑Ridge ❑Slope ❑Valley f9}`lat
i)1 M (check appropriate Ixtxl
CommunlI,Soh 1ir Lot SU.,Zip[(she) Latitude longitude of well location
elN N1 R degrees minutesseconds)
L yr� Latitude longitude source:❑GPS❑Topographic map
IStrect or Route No
(check box)
DEPTH DRILLING LOG
I swra Lipc"de F om To Formation Description
- - � �a
II A t i Dkil i.LD. "AAl-Lb --
rul —
..
STATI( WA I LR LEVEL Below Top of Casing: l I n _FT. - ---- -
l;.c"--it%bmc Top ot(a,ingl --- -"— - - ----
i. T UP 01:CASIN'G IS_ IT FT. Abo,e Land Surface-
(it)of casing terminated atlor ti land surface requires a
variance in accordance pith 15:1 VAC 2C.O118. _
'I Ylf.l-D(gpm)- U-5 METHOD OFTEST_.�_h✓3
U_ MR 70NES(depth):
-. LO('ATION SKETCH
I&)1Vi-I( I ION: Type_ Amount _ Show direction and distance in miles from at least
( :ASING: AA all I Incline,, two State Roads or County Roads. Include the road
Dcpth Diameter or Weight I t. Mutcrial numbers and common road names.
To
In no
Front - -_ .. To FL - -
from To Fi
4R0I-1-' Depth Material Method D
i nmt To Q0 Ft,
Pnvm To _ --
a. S( RI.I'.N- Dcpth Diameter Slot SILc Material C.77
In _ __._in. in. o
I nm To Ft. in. In. Ul
GR,A%TI. PACK: -- -
Depth Size Material -
Fnnr. _ To Ft.
irn;r. To--
i2i AL1RKS
I+n lit KFLiI( f.RI IFY TIIATTHIS 1A 1-7.1 R"AS CONSIRUCI U IN ACCORDANCE WITII ISA M XC 2(' WELI,
'I ION STANDARDS,AND TI I:A F A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE R'ELL(M NER
w r. Cv_Sa K_k_ lv_IA os
SKIN:ATDRF OF PFRSON (0NS"1 , TING THE WELL DAIS
Submit the original to the Division of Water Quality,Groundwater Section, 1636'11ail Service Center-Raleigh,SIC
27699-1636 Phone No.[phone],within 30 daps. GW-I REV,072001

WELL CONSTRUCTION RECORD
�; nn ( an lira - Department of Lm-ironment and Natural Resources- Division of Water Quality-Groundwater Section
)sI.It,tONI R 4( IOR(IN DIN I DUu.)N:Uff: (print 1 L_ . 1�
-- -- CER'l1 FIC.4T10\# ✓J5
Rill (0NIR.\('IORCOMP.1v NAME C-Af,LLV1e_ - - -
of sl F. ss F:LL(U.\,ti1 RUCIlU\PER\III'# kt-`._��_____
- _ ASSOCIATED'A Q PERMI"!#
u t applicable) (if applicable)
\4'i_i.I. L'SF. (Check .Applicable Box): Residential M'�Municipal Public ❑ Industrial ❑ Agricultural ❑
'.LmtiorinL, ❑ Recovery ❑ Hear Pump Water Injection ❑ Other ❑ If Other, List Use
Ill ATIONt -
,"Vcsl I„t,.n, Topographic/Land setting
C
V�� - _ ounty
CgRidge ❑Slope ❑Valley ❑Flat
Cnmmomh.suh,h cis;on.I.,An..Zip C„Jel - Icheck appropriate Mnl
Lahtuderlongitude of well location
N'I-.R bda --
\y�a degrees minutes seconds)
Latitude:longitude source-OGPS❑Topographic map
1 Simci nr Route 10. (check bm)
v5sa I I ° ms— ;L l0 DEPTH DRILLING LOG
state Zip(-,tile
) From 11To Formation Description
� I h.ma ember
�(rlirtttj
L4
[AT!( %k A I ER LEVEL Below Top of Casing: FT. —
(l_ae"-* itAhme Top utCasing) —
TUI'OF C:ISING IS 1 FT.Above Land Surface* — ---
'i tq)tit casing terminated ab'or belox land surface requires a
variance in accordance xith I5:\]('.4C 2C.III lA. - — -- '------- -
-% Y16LD("pm): _ Imo— METHOD OF TEST --
\TI[R ZONES(depth I, _.-god.
LOCATION SKETCH
I)1\Ilhl:.( -IIUS: Tvpe_, _- :\mount _ _ Show direction and distance in miles from at least
%N all Thickness Mo State Roads or County Roads. Include the road
Depth Diameter or Weight I t Material numbers and common road names.
To_j� Ft �,t Pv
Ruin To -- ---
Pn To
("R01 I Depth y1atenal t
Method
Frnm. � To�i7 Pt.
F1' m —�1.�-. �L "—
To 1't. - ---- c -.
Dmth Diameter Slot Size Material tA)
Pram_ fn Ft. in.
F rule_ To_- Ft _in.
- ---. ._ in. CD
Depth Si>c Matenul
I-run; _To PI.
-rear. To_--- I'r---- --
6. RI.A1,ARKS
li(i I iP ki li) f f.R I IF1'"THAT THIS \4FLI_ U:A5 C'ONS'IRGC-I-ED IN A('(ORDANCE N'ITII 1 s A N(AC 2C,"'ELL
( uAti ItI ( t ION STANDARDS._AND TH%F A COPY OF I HIS RFCORD HAS BEEN PROVIDE[)TO THE WELL ON:NFR
SI(rtsAILREDF 9UN ( ONSIRCCTIN(i TliEWEI_I. DAIF.
Submit the original to the Division of Rater Qualih, Groundwater Section, 1636 31ail Service Center-Raleigh,NC
2 769 4-1 636 Phone NO.[phone].within 30 da}'s. ' - -
GW-I REV. 07'2001

WELL CONSTRUCTION RECORD
arulina - Department of Lm-irunment and Natural Resources- Division of'A ater Quality-Groundwater Section rr����
ss(1 1 (UNIRA(I OR ONUTAIUt%I.)N,%%I F. Iprino/)� t- TVY"a-u ('ER"FIFICAIION#_355J�
n F.L, (ON T RAC IOR CONIPANI N:1'1IEO1' `�{ F'j] 1 ( 1L_ Y- Phi PHONE # q
s I A'I F.N EI,I,('ONS"rRUCT10N PF.R IIIT# --_- ASSOCIATED N'Q PF:R'111'f#
(it anplicable) -
(if applicable)
\4 PLI. CSF-K heck Applicable Box): Residential EK"Municipal'Public ❑ Industrial ❑ .Agricultural ❑
Vhmitorme ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List lise _
1.0( :1TION:
\ :aresl Tussn: �/ Topographic,Land setting
Cuunty�`L`�l)(yy�[� EIRid9c ❑Slope ❑Valley ❑Flat
.� .e ae Nu:nbea,('ommu(utc.Suhd(v(vnn,l.n N .,Z:p Code) ` (check appropriate box)
Latitude:'longitude of well location
(dcgrees.minutes.wconds)
--.__6Stren or koun Kn ( Latitude longitude source:❑G PS❑Topographic map
- -
�� �9-� e (check box)
state — DEPTH DRILLING LO('
/ip ode
( _ From To Formation Description
� I. •Lnuc numSer __ ,�� �� ___
D.s F! DRILLED-1--A O�._-- - --
S? kA A TFR LEVEL Below Top of'(asing: k FT ---
II_.e"--if:Aboss Top of CavnW - -
--
T(:POFCASINGIS FT. .46
L ---
-. ove and Surface' --------- ----
I op of casing terminated aUor Woe land surface requires a
i ariance in accordance with 15A N('AC 2C.1111a. --
'i. (gpm): METHOD OF TES'1 --
''l. \ .\TFR 7ON'ES (depth):
P
DKIAFLCTION: Ty. e -- -� LOCATION SKETCH
P _N - Amount Show direction and distance in miles from at least
wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight r Ft. Material numbers and common road names.
Fr,:m-.11. To a-] Ft. -
tnnn
(-r i:m --
------- -- 1
-_ -. To Ft. - -- t
<�kUl l ---- --
Depth A1a[cnal Mcthod A -
FrI ur. '� To-Q�a_._ Pt.
F rum To Ft
LrI
L �rI<I.f`.!s- ,I, Diamelci Slol Size Material -
Fnnn _ Ib_.
- - - m.
---- C)7
-. . . Tu___ Ft. in. in. ...
Depth Size 1aterial
Fnam To Ft.
F r:dn -To -.-. ..
__ Ft
t. Pi Ai,ARKS
I IO I il.kFBI ( !`RI IPl'THAT THIS \1'El.I 11 AS( ONSI Rl I LD IN ACCORDANCE RN ITH I SA NCAC 2C,N'ELL
( t r'SI RL( I IUN ST ANDARDS, W D I'I IAI ,A COP1 OF THIS RECORD HAS BEEN PROA'IDED TO THE D ELL ONT'ER
SI(1,A;I TCRE OF PERSON (" "IR1iC'TING THE 1AEI_I. DAIAI L OS
F
Submit the original to the Uicision of Water Qualty%,Groundlcaler Section, 163( :11a11.Serrice Center-Raleigh,NC
27699-I636 Phone No.[phone],within 30 days.
GW-I REV. 072001

WELL CONSTRUCTION RECORD
aroiina - Department of Lnvironment and Natural Ren!^o�ur�ces-Division of Water Quality-Groundwater Section
1\1I i (ON U'I R. "I OR(IN DI\I DL \II NAME (print) 1 .LlI�CL� CERTIFICATIO\
F1t_L1 ( O\'IRM IOR COhIPAS) NAME. C (`CIA,V'�� L11 �h F -V�11r,, _PIIOsE # � )
s LCI F\\I LL I:O.NSIRUC'IION PER\11 I#,-1 Q�_-,_-- ASSOCIATED N'Q PERM(I#
(it applicable) ------ -----
(ifapplicable) ---
1,SF: (('heck Applicable Box): Residential LB'-Municipal'Public ❑ Industrial ❑ Agricultural ❑
\ionunrmL ❑ Rccovcn' ❑ licat Pump Water Injection ❑ Other❑ If Other, List Use
Nrurc,t Tovvn: /t,� ,� ,, Topographic/Land setting
\ aLL�J County�{ ., ❑Ridge ❑Slope ❑Valley &Mat
(check appropriate box)
,,,,,r�' cmnurs,commaoa}.SuhJiwswc.t�t 7ip(„ncl Latitude,longitude of well location
',adre ss �`` a\ \ A t k __- — _ _ --- - IJegrees.mmutesaeconds)
�—�-� V'1__.-^L�_.—____, Latitude longitude source❑GPS❑Topographic map
f Stra9 ur Nuulc Ku. (check box)
Ca Np r��l llD DEPTH DRILLING LOG
T. ..,,,i state Lip(E Je From To
( y1 Formation Description
\,. cc F.u',e number
vll DRII.LED�- -C� .__ ._- -1 —
TUi :AI DLPT H:. pS
R"AIFR LLVEI. Below Top of'('using: _t!c __FT.11 sc"✓ it Ahocc Tnp nt CCaamg) —..—.—.-_--
`Ot' ()I- (.ASIN(i IS—A—FT. .Above Land Surface* -----
-Ilip()('casing terminated twit,belms land surface requires a
,ari:mce in accordance with I cA SCAC 2C.0118. _ -----�----
'i_ Itf1.LD (gpm): _�'D _ METHOD OF TFST_C 1ti ----
u AV�'%Tf.R ZONES(depth):
—. LOCATION SKETCH
UfSINf IJ TiON: Tvcpc. _ Amount Show direction and distance in miles from at(cast
\SG IN . -
\A-all Thickness rice State Roads or County Roads. Include the road
Depth Diameter ur W'elght Fr. Material numbers and common road names.
From-- p 1 o qA _Ft. ._ — -----
From---- .. To Ft. .
-- --- ...
,. GROI.-I` Depth 11utcrial — — -'
Method
Faun_. b To�,�--- Pt.-� -- ry
C l
Fr,.m_ _. To.
S(YtLI=N- Depth Diameter slntSize ,Material O
CJl
To - }-I, _in. is
_- To ___ FL —in, m. '
S:'\ND(iit:1V LL PA('K: - -_. -
Depth Sin Material
17on: . __To It,
-nar, To
- Ft----
itlA1.4RKS
I) ( I it-Rhffl ( ERI IF1'THAT THIS\TELL. AAAS CON'S1RU(TED IN -%M)RDANCF Vb'I"Ill I.iA NCAC 2C,WELI_
t U1�1 Rl t (ION S IANDARDS,AND"I'il,1T:1 COP('OF THIS RECORD HAS BEEN PROVIDED To THE WELL OWNER
9-6-its
SI('N%I (A T kF( E ( ONS-1RCCTI NG THE WELL DATH
Submit the original to the Division of Water Quality,Ground"-ater Section,1636.Avail Service Center-Raleigh,NC
27699-1636 Phonc No-(919)733-322I,within 30 days.
GW-1 REV.072001

1 � ♦ 1
WELL CONSTRUCTION RECORD
'1,ulh ( arolina- Department of Lncironment and NaturalResources -Division of Water Quality -Groundwater Section
sNk,Li ( O\'I'Na("IOR(ISDBIDLU.)N:\91E (prinp_ )h(�,�] � w�kj�.. .... CERTIFICATION
\\el.) (ONII(V (ORCOVP:AN\ N,AAtT:. _`1Y (jyt 1! PnoNe
ti l k i F. n F:1.1.(ON'STRUCTIO\PERMIT# VA Q k—__-_ __p550C1ATBU W(1 PF,R1t rf#
(if applicable) -------
(if applicable)
_ A41.1,1. CSF(Check Applicable Box): Residential ET'�'kfunieipal'Publie ❑ Industrial ❑ Agricultural ❑
V-111uring ❑ Recovery ❑ Hcat Pump Water Injection ❑ Other ❑ If Other. List Usc _
\V-hl i l O(:ATION:
"cafe': Iosvn. Topographic/Land Setting
Cnunt\ ❑Ridge ❑Slope ❑Valley flat
-- � IN -,, (check appropdem box)
umbers.cummunin Subdicmm�.1„t o..zip(ode) Latitude longitude of well location
t,A\ NI R
(degrees,minutes seconds)
Latitude longitude source:❑GPS❑Topograph is map
(Street or Roues So.
�(111 pA 1� Ki� �y�$ f (check hm)
DEPTH DRILLING LOG
state Zip('oJc From To
1 Formation Description
TUT,\I. UIiPTH:�OS _ -- ------ ---._._-..—
ST AT I( \VA"I F R LL VEI. Bcloa'Top of Casing: N0_,__FT. - ----------_--
((_sc"+ if AMmc T,,Pof( asmg) --- —. _ _
T OP OF C.ASING IS_ FT. Above Land Surface*
A op of casing terminated aUur below land surface requires a
,ariance in accordance with 15:\N(':\C 2C.n118.
't 1-If![ D(gum): '01O _ METHOD OF TEST �4�✓� -�- -
(i-AV'ATLR ZONES(depth):
-- LOCATION SKETC'11
.- IiISISF L.(-TIUN: Type_ . _ :Amount _ Show direction and distance in miles from at (cast
( :'SIN('_ wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weigh(Ft. ,Material numbers and common road names.
f nnn_ Q To_�_ jb Ft.
i 7un To Ft
To
- ---- ^� .
Ft.
(iR(iCl : Deplh Material --_ .
Method
f rots_.Q _ To�.O _ Pt.-�l�Y ILy`9_ to(D
I-r,nn_ To
"L ti( RET Depth Diameter Slot Size F Material o -
CA
;�nr, lo__ Ft. in. in.
I rnnl io _ Ft. —in, in.
S IND GR:\l'1,1. PACK.
Depth Sizc Material
Frtar - _ro_—_- - It. _
Rf M ARhI
OU I FkE131 CERTIFI'llIAT THIS NT.LL AS CONSTRUCTED IN %((ORDANCE 'AITII I5A NC.AC'2C'.WELL
I IUN SIANDARDS.:AND TH A I:A( OP(-OF THIS RECORD IF%S BEEN PROA IDED To)TIIE "'ELL OR'NFR
SI(,N V 11 RF OI P NSIRLA TING THE WEI L DATE
Suhlrot the original to the Division of Rater Qualit\, Groundic'aler Section, 1636 Mail Service Center-Raleigh,NC
27699-I bd6 Phone\o.[phone].within 30 da3a.
GW-1 REV 07.2001

WELL CONSTRUCTION RECORD
\,.rth ( srolioa- Department of Lrn'ironment and Natural Resources- Division of Water Quality-Groundwater Section
Rel.l.(ON IRA("I OR(IN DI%7 DUAL)NAME (print)_ _Day O_L` CERMICAT105#_�514
Csf.l.i.(O\IR:k("IOR(O%IPA,N\ Nk)4:.`�'(Qeile _. r1.i L�J-)�.u._T. PAJ_X P____PRONE # (�1d11L�19-31�0
I I.KFAA (ONS IRLCI705 PERMIT#__�� __ _ ASSOCIATED NQ PERD1IT#
fit applicable) hfapplicable) - - -- --
\i i,l-f USE (('heck Applicable Box): Residential 9'_Municipal'Public ❑ Industrial ❑ Atnicultural ❑
V.,mtonng ❑ Recoe-ery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
P. I I. I.(A A FION:
Topographic/Land setting
'�rarcct Tuvvn: __ __ County Upp'{
6A 1 J- - Midge ❑Slope ❑Valley C4f(at
(check tulle of
ell
..cm '.emc. Qimlx¢(nmmumh.Sandicumn.Lm �Ao.,7.tp(nde) Latitude longitude Of sk'CII location
f-.L (degrees minutes,seconds)
Latitude longitude source:❑GPS❑Topographic map
(lemo or R uute Nit I check tins)
CU Nf- ��1.11_ DEPTH DRILLING LOG
titan Zip(2.de from To Formation Description
_ -- PC O"A
-
tD R[I'.0 •ember .�1 l,n
ST,AT1( bCA IER LLVEI. Belov, Top of('acing:yam _FT, -
tl_se if dhow Topot('aeinpl --
TM,Of CASING IS_� FT. .Above Land Surface` -----------
'Ibp of casing terminated ateor betook land surface requires a
s aria.ce in accordance with I5,%NC.%(- 2C.011a.
SIELDIgpm)-_ 30 METHOD OF TEST c)LV-vrS
\\:\TI,RZONES(depth) ap5
LO( ATION SKETCH
DISINFL( T ION: Type-� __ _ Amount Show direction and distance in miles from at least
( \SING. Amall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight Ft. Nalerial numbers and common road names.
fn�nl_.Q To . )\_ Ft. k.D "
Pruin. -- TO -Ft..._.
From _-_. To Ft. -- - --- -'
.. (iROI"I_ Depth .\1atcrial Method a
F rnm Q_To��_ Pt�Q_,( _-t_ _ n
To _ FL ,
-i. S(RLL_N: Depth Diameter Slot Siie Material U '
Fnir _ 1o__-- Ft. _i n. in. O -.4
Penn_ To _ Ft. ia in. Ln
(lRAVLI_ PA('K. - - — —
Depth Siic Material
F roan. __To _ Ft.
_To F1.- '— —
(. R1.Ai1RK1,
I;U I IFRFB'1 (I-RI IFY III.AI THIS WELL NAS CON SI Rl1Cll'DIN ACCORDANCE R'ITII 15A NCAC 2(',WELI.
( t 1'sS I Itl t T I SIANU%R US. AND TII:1 F s,(COP) OF THIS RECORD 1i AS BEEN PROVIDED 10113E WELL OWNER
S16N:NII RE01:PERSO, 'SI RhC TI NG'THE AtEI_L DATE
Submit the original to the Division (if\N aler Quality, Groundwater Section, 1636.\fail Sens ice Center-Ralei,,h,NC
27699-1636 Phone No.[phone].within 30 days.
_ GW-I REV 0T2001

WELL CONSTRUCTION RECORD
tiinh ( an,Ima -Department of Environment and Natural Resources- Division of water Quality--Groundwater Section
N r:I.L(O\I k:k("IOR(IN DIN T DL.U.)%ANIE (prim) iJ�,L.Y-0—" - CER'I IFIC.ATION p_�q
N i.LL( O\Ik:\(7UR CONIPA\l \':1Nt F, �Yr�erit-._ V�'} 1 \n 11 4 _ „�s!1,tGy S' �110
s l Nil.NNT.I.L(CONSTROCTIOR PERMIT'#_��'�� _ ASSOCIATED NVQ PERMIT#
(it applicable)
(i(applicable)
AO i-111,Sk I( heck Applicable Box): Residential 10� Municipal/Public ❑ Industrial ❑ Agricultural ❑
\L,nrurmP ❑ Recovery ❑ Hcat Pump water Injection ❑ Other ❑ If Other, List Use
1 Of A"r ION:
���_ Topographic/Land setting
:�carc.t pToss C
- ounty n: HRidge ❑Slope ❑Valley ❑Flat
QcC- (check appropriate h)x)
Aumber,,('arum u n i I, Subdivision.I ni Nn.,Zlp(talel Latitude longitude of%veil location
Wevees minutes:seconds)
A5 7S_ _ - Latitude longitude source:❑GPS❑Topographic map
i Street nr Rome \L I (check host
M
- - -� �—L-T- DEPTH DRILLING LOG
i ,I; of i',i,n state tip Cock From To Formation Description
. . It;urc number -. -._ _"'---�__. - l't✓�_
D \tI DRILLED
TUrVLDEPTH:. 5 _- - -- - -- _--
�i i I I i iU'
ti F A f I( wA"rFIR LEVEL Below Top of Casing, _FT.
It.ac if:Ahose Topof('as'ing)
'; TOP OF ( NSING IS FT. Above Land Surface* -------
'Top nl casing terminated allm-below land surface requires a
s ari:mce in accordance with 15A N('AC'2C.III la.
1lLL.D(gpm): _ I METHOD OF TEST_ala,, —
U. Al \TI:It ZONES (depth): ��___1���.�n-L
— .
- p on LOCATION SKL-TC'H
L DiSI'SFI',("I IOti: Tvpc_ -+ oust Show direction and distance in miles from at least
I ")I \Null-I"hickocns tnvo State Roads or County Roads. Include the road
Depth Diameter or %'eight Pt. Material numbers and common road names.
Frim_ Q Toa�-Ft, _�0„ ---"- JOVO
iruin - _ To Pt. r
likUl I' Depth V1aterial NIcihnd -- C
From, Q To_��_ I t (�
ro Ft. _ _ Ln
S( RI I`.S. Depth Diameter Sint Size Material
Il�nn -I-o r�
- _ Fi._. ui. ut. Ul
limn_ _To___-_ hi.___m. in.
s S.A%D (iRAA'Ii1 PACK: -
Depth Siic Material
h Inn _ To Ft.
Ft.
r,. RI.V ARK"
I ti() I IERFBI"CERTIFY I HAr THIS%k H I.WAS(ON'STRLCTED IN :V OkDANCE NN"ITII LSA NCAC 2C.%'ELL
( i 7SSlRt f NUN STANDARDS.:AN1) 1I1'%1 COPY OF THIS RECORD HAS BEEN PROVIDED 10 TIIE'ELL WA NE:R
SI(LK:ATUkE OF PE R SON Gws-114ATIN'(?TH F NN'EI" DAfE
Submit the original to the Division of Neater QualitN',Groundwater Section, 1636 Mail Service Center-Raleigh,NC
-7699-1636 Phone No.[phone]. within 30 days. GW'-I REV.07'2001

WELL CONSTRUCTION RECORD
tionh ( ,ro l ina- Department of Environment and NamraI Resources- Division of Water Quality-Groundwater Section
N E A,(0`,1RAC 10R(INn14'IDLAL)N:UtF: Iprinp_.1L(J Z_�-.L],(Z�'�(�-. CERTIfIC4T10\'#.fy �.
Nt l.l./0\7 R:\( 10RCOMPANI NA,ML ci(kV -. 5?jypS_U'�.,k - 1`110NE # of
S f, f t.1\F,I.L CONSTRO(`fION PERAIIT#- `��a. _-- _ASSOCIATED N'Q PERNILI Al
(if applicable) lif applicable)
U-J-1 1, I,SF I( heck Applicable Box): Residential ETA Municipal'Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ I{cat Pump Water Injection ❑ Other❑ If Other, List Use
LOCATION:
Nearest To%%n1 ` ` TopographidLand setting
`� C'ounty t'I`1 1 n , icod ❑Ridge ❑Slope ❑Valley LaNat
- --� Cr?Cr (check appropriate bore)
`aoc:':cure. Aunmers,(nntmunn, SithJni,inm Lot .,Zip_(ode) -
Latitude,longitnde of well location
-- Idegmcs minutes:seconds)
Latitude longitude source:❑GPS❑Topographic map
LYrcct or R utc Au.i (check box)
1 I DEPTH DRILLING LOG
Zipn.dl From To
Formation Description
r
D \ n DRn LeD 1��4-95 __ �u t -J —
t i(rr;,I. DEPTH: r, JS --
, :;, ,,, I i urns. ,,,. i.ci i in,; st i.l i , .,.. l ii n,�i it✓
STtri( WA TER LEVEL Below Top of Casing: AkC) FT. —
(L,e"='i}'Abuse --_—.—
()P Of (.ASING IS_'l FT. Above Land Surface*
"lot N casing terminated at/or bolo, land surface requires a _—
,ariance in accordance with 15:\5CAC 2C.h11A. --
v. } ILI_1) ("Pin): - ) METHOD OF TEST�l�r3 -- —
b. 1c,ATER ZONES (depth):
_ LOCATION SKETCH
. LAINF I`( I ION: Type- It _ - Amount _ Show direction and distance in miles from at least
\all Thieknes, two State Roads or County Roads. Include the road
Depth Diameter or weight Ft. Ma:crial numbers and common road names.
From- Q To L0 Ft. �Q t� -.— VL
tnnn To Ft.
To Ft._ — -- '-
(:R01 I Depth - - 3
P Material
Method C
From n Cro Ft.
Y RI F5. Depth Diametc, Slot Size Material
Fn,n' -__ ro Ft. in. _ in. O
to
To - - Ft._ in. in. --- -
(iR.AA'I,I. PACK: - -- - — -- ,
Depth Siic Material
F r un -To Ft.
: ki.AIAkKS
I ;,U III REB't (TR'I IF)'THATTHIS H ELL N AS CONSTRUCTED IN ACCORDANCE\b'1TI1 I SA N(AC 2C,WELL
( (I's I RI ( rION STAND.ARD.S, AM)l IL. rI COPY OF THFS RECORD IIAS BEEN PROAIDED TO THE WELL ON'NF.R
SIGAArLRF OF PERSON CO "- UCTING THE N'ELI_ D;AT�-��
Submit the original to the Division of Water Quality,Groundwater Section, 1636,Hail Service Center-Raleigh,NC
27694-1636 Phone No.[phone].within 30 daps
GW-I REV. 072001
i

WELL CONSTRUCTION RECORD
y, rt6( in,I na - Department of Linty ironment and Natural Resources- Division of Water Quality-Groundwater Section
NtI I (ONIR%( [OR(INDI%ID141.)NA%IE (pri,n) _ ya-jJ
- cE.RnElcArufN# 3354
tst.Li (o\1Rs( IORCOMPAN\ NAME C149.A+"(2. _ ��. ti tip _PHONE # llO
s 1 vl I w f.LL(ONS(RUCTION PERM II# _ ASSOCIATED WQ PER SD'f#
(if applicable) Of applicable)
VA ELL LSE (('heck Applicable Box): Residential 2'�Municipal'Public❑ Industrial ❑ .Agricultural ❑
%h,nitorine ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other. List Use
I LOf :1TION:
'\curet Town: ❑
C'ounty�V 1(h'Y7)< Topographic/Land setting ��
L-0_VP �4i 7 ---_---- Ridge ❑Slope
❑ bValley at
4 wnc. ^u:n6crs,( tmun h.SuhJlcmm�.Int\o..71p('ode( (check appropriate box)
Y Latitude,longitude of well location
I tl2greeS minutes,jeCVn(IS)
Latitude longitude source:❑GPS❑Topographic map
ril
(Suec9 or R e 1n (check box)
NC �"��-I�— DEPTH rn 1 m. �r. I oo DRILLING LOG
0 State hp C oJc
From To Formation Description
� a PLauc num5er _ _—I��` - Cl 2llY �
(, (L DRII-I.ED -
S F. TIC WATER LEVEL Belon Top of C asing: _FT. --
Il.cc" if Ahosc Topot('usfngl
? /P OF CASING IS 1 FT. .Above Land Surface' ----------- __
Top ofcasing terminated an'or below land surface requires a -
saronce in accordance..ith 15:%]('AC 2C.(1118.
METHOD OF TEST
�I'Li _
U. 'A %TI:R /ONES(depth): AU`j_. --
_ _ --- LOCATION SKETCH. UISIN'f LC ION_Tvpe_ �" T� Amount Show direction and distance in miles from at least
( .ASIN(,- Vkali Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight Ft. Material numbers and common road names.
Fri nn Q in�.Ft. - 1o „ _ Sort
From
To--- Ft.
Depth ,Material Method
F rm To Ft --- - -----.. (_
- _ n
Depth Diameter Slot Si<e Material N
Fnnn . fo_ Ft. in. in. ell
From To--- Ft_- in. -- - CD- m.
�. S:�ND GK:y\'I�:L PACK: ------- cn
Depth Siic Material
To Ft.
- -
--rO--_ Ft_--
t,. ki:�L1kF:S
I)(l IiFkl BV"( CRNF)'TIFATTHISV4Fl I.R NSC'O.NSTRtA FEDINA( ORDANCF. WITH 151 N(AC2C,%4'ELL
TfoN SIANDARD.S.AND TILAT A COPY OF THIS RECORD I IAS 13EEN PRO%"IDED To THE WELL OWNER
SION All-.RE OFPE N ( 0NSTR t (:FISG/TIE wElL
DAIF
Submit the original to the Division of Rater Quality G rouddw ater.Section, 1636,%tail Service Center-Raleigh,SC'
_27699-I636 Phone Nn.[phone], within 30 dacs.
Sc� Z 0 �.:u0 GW'-I REV. 07^_001
I '

OV10
WELL CONSTRUCTION RECORD
N, nh ( :,n-Tina-Department of Lm ironment and-Natural Resources- Division of A'ater Quality-Groundwater Section
INGI,1 t 0NIkA("10 It(I N DI\'ll)L'':\L)NA NI E (p ri n 1)_.kq'sef_ U_'r(-`� CERTIFICATION# J_ Y31A
w F.1.1.l 0N'1 it ("10 R(: MI P:a N)'NANI E ('N(`e.er)C 7_�)__QU .f,_P cyf"Y n PHONE # .i
ti 7.c11 N FIT,CO,NSTRECTION PERMIT# 4 c 2- __ ASSOCIATED WQ PERMIT# _
(if applicable) (if applicable)
V11.11 USE it heck Applicable Box): Residential EK Municipal/Public❑ Industrial ❑ Agricultural ❑
\Lnitoring ❑ Recovery ❑ Heat Pump Water Injection El Other ❑ If Other, List Use
O< :A"FION. ---
Topographic/Land setting
Cuonly_n)y,aa L,,�f�f�
S— ❑Ridge iXope ❑Valley ❑Flat
I check appropnate box)
,.,nv,Nunii,ers_(o,nm to_Suhdh,,i,.,L.,t '. z,p(,xlei Latitude longitude of well location
�"`- -�—"--- ---- Idegrces minutes seconds)
d;irc x
Latitude longitude source:❑GPS❑TOpograph is map
Istmct or Rout,No. Icheck I+nx)
DEPTH DRILLING 1.06
t .r. ,,,,,n stain 71p rode From To
Formation Description
c Phonv nember ,a LA\6
D \TI IIRIL.L.ED tq.�,-.�'j �j. —
TUi,11. Dl-PTII:—u{��j - - -- --
\T 1( WA I FIR LEVEL Belo% Fop of Casing: FAO _ FT. ----- -
IC se if.Above Toput(asin gl
TOP Of CASING IS_�_ FT. Above Land Surface• ----
.'I np nl"sing terminated at/or below land surface requires a --.—..._—.
,arianee in accordance with 15:\.N('AC 2C.OI la.
}-
IfiLD (gPmo: "c11Z METHOD OF TEST_ c�41✓,5 ---- ---
bV'1Tf I2 ZONES (depth):
___ LOCATION SKETCH
DItiINF L( TIUN:Tv e_ --��--
' _P Amount Show direction and distance in miles from at least
\\all Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighrFt. Material numbers and common road names.
Fn,Ir.-�. To1A Ft._ — PVe_-
Eton; To Ft. _ _ -
( ROI;I : Depth Muterial Vielhod C
i nnn 0 To O._._ Et.
P r, To To
.. ti( RI I N ocp:h Dianxtcr Slot Si/c Material
I T,in I o_ CD
-_F"I"-_.-_ut. m. Ln
Depth Siie Afateri;d
ITran To Ft.
IInn; --To- _ FL
Ih. Pi N11RKs
1)0 i IFkLB) ( ER I IF} I IIA F THIS \4FI I Al AS CONS[RUCIED IN ACCORDANCE N'ITII l5A NCAC 2C,WFLL
(UN,ti I RI C'TION STANDARDS.AND THAT A COPY OF PHIS RECORD HAS BEEN PROFIDFf)TOI-IIE N ELL ON TER
S I(i NATCRL Of PERSON C STRI.f TINE THE WELL UA'IV
Submit the oril;i naI to the Division of Witter Quality,Gro u It de'ater Section, 1636 Mail Sers ice Center-Raleigh,NC
'7699-1636 Phone No.[phone] within 30 days.
__ GW-I REV.072001

t. - U
WELL CONSTRUCTION RECORD
( :-dint,- Department of Dn%irunment andNatural Resources - Dicision of Water Quality-Groundwater Section
sAr. ON 1 Rso IOloW%IIA'IDU ki.)N.AAlV (print)/VN](_ r '_NkvC'_.0 CERFIEICgATION p 3554
N EIA (OSIk.\( 1ORCOMI"o"I NAME `vicene -.L&.� l._a_�M �.- PHONE # OL�1�3-�1-IG
tit CI f.s\1.1,1,(.()NS IRUC7lON PER.%II'F# ,_-. :\SSOC'IATED R'Q PERNII'F#
of applicable) (if applicable) ---- --- -
\KEEL LSE it heck Applicable Boa): Residential V Municipal Public ❑ Industrial ❑ Ao icultural ❑
Monitoring❑ Recocerc ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Uwe__
I. i (A F/ION
:
TopographiclLand setting
County �i dgc ❑Slope ❑Valley ❑Flat
I check app,.pn.te IN,,,)
, .rc' �Imic. 's unl hers.(nmmumt}-Su6dr.Lion.Lot Nn../Ip(txle)
Latitude longitude of well location
AN AFR _�JJ.��(tYYt-r_ — —
-- - —.- (degrees minutt a seconds)
\"ul"s ��� t--�'-�� ' Lan rude,longitude source:❑GPS❑Topographic map
street m Rwne No l check hm)
DEPTH DRILLING LOG
)' From To Formation Description
'. tic r}„ins nember _
p1.111,r Ll rrl,I In /� A1 II n(� �
S I.\TIC W.4 t LR LEVEL. Belo\+'Top of Casing: __-UO -_FT. -- - --
T(Il'OF< :A)ING IS_ FT_ Above Land Surface'
'f op of casing terminated atlor below land surface requires a
sariance in accordance with 1S:\ NG\C 2C_'.UI1N.
�. 111.I_D ((-Pill): _ -_ METHOD OF TEST_�V _ -- --- --
U. U":',.TER ZONES (depth):._ �5
LOCATION SKET('H
FE( T ION:Type Amount_ Show direction and distance in miles from at least
\Vall"Ihickneas two State Roads or County Roads. Include the road
Depth Diameter or Wcight Ft. ,Material numbers, and common road names.
To Ft.
To Ft.-- -- - -
(iKOI'll Depth Material Method a
1 Totn. .� To_,�L fNn n lw i
-- —` __
'ro In _ To Ft. (7)N
r. �( R1.1 5 Depth Diameter �-- U Slot S¢c N1atcrial l
P ri,lr To_ _FL .—_in. _. _ in. O
f Yout _. To_ _ Ft_ _in.
Depth Siic Mateiial
I-rani To Ft.
RI VL RK\
I ;n 1 I,f Rh B1 ( I.RI IFY THAI-THIS VA-ELL 1VAS CONS'fRCC'iED IN ACCORDANCE WlT1I ISA NCAC 2C. WELL t t'�ti 1 Rl t"RUN S FANDARDS. AND TIFM ACOPY"OF THIS RFCORD ILAs BEEN PROVIDED TO THE WELL CM NER
SIGN-AI'CkE OP PERSO SfRI{TIN'GIHE WELT. DAIS
Submit the original to the Dicision of Rater Quality,Groundwater Section, 1636 Mail Stroke Center-Raleigh,NC
7699-1636 Phone No,t919)733-3221, within 30 days.
G\i'-I REV.g7'2UU1
,_ u

WELL CONSTRUCTION RECORD
'.unh ( aot ina- Department of Lncironment and Natural Resources- Dicision of Water Quality-Groundwater Section
11 FLI (ON I k.-ACTOR(INDll"IDl AL)NAIIF, (print)_ ya-1.3-
11 EL1 (U\'I R:1(-IOR Cfl1I P:aTI \:\ylE.CV,QfeV�e. Vu5 1 1 \�, ' ' _.-- __ ,yt^
d.�_ _PIIONF. # [Dace
\SSOCIATFD WQ PER911't#
l f appliccable)able) (if applicable)
U LLI. USL(('heck Applicable Box): Residential 2� Municipal!Public ❑ Industrial ❑ Agricultural ❑
\innuormg❑ Recocep ❑ Heat Pump Water Injection ❑ Other❑ If Other, List U.ce
' VVi.i.I I (A :1 f )N:
r.ht Tol+n: Topographic,"Land setting
❑Ridge ❑Slope ❑Valley Elfiat
..— �'--
jx)
._. ,:u:.v '�wnhcn.Cnn�munitc. ' . - , heck lSpdl,1yIOn.L.n Sn./ip(udel Latrtudccongrude of vwell location
---- IJeGmcs.minwee:'sttundsl
A
lu(:resti _e.i--- - -
S �.
Latitude longitude source:❑GPS❑Topographic map
Strev:t or R ut
(checkDLPTH
tipc�,dc DRILLING LOG
From To Formation Description
- _�_ a� cs i. Fhouc num6cr —
' II I)RILI_LD--�,a_q-� —r�Y ��`1
.-Oi Al DEPTH: Cds -- _ -- _ --
V),A I ER LLVFI_ Bcloll Top of ('acing: `7 Q_FT.
(I le^ it Ahocc Top ot(znng) - .- -.----_
i OP OF CASING IS ( F'I. Above Land Surface' -- ---- _
"Top of casing terminated i t/or I land surface requires a
,sriance in accordance with ISA SCAC 211
IN.
`I. 't IGLD Igpm): _-,3—'-) _- METHOD OF TEST ,IVA r3 ---
..I. V,.ATFR ZONES(depth): CwS)
. : IiIbINFI-( TION: Tv e _ T LOCATION SKETCH
. P - - —Y}_ _. Amount_ - Show direction and distance in miles from at least
DepV1-all Thickness twoState Roads or County Roads. Include the road
To
Dlanletcr or A`'eight It. Material numbers and common road names.
.S�� FL �9.� ------ QV_�
i I' m To Ft. _.
(:RUC I- Depth Material 0_ Method
Q_ To_o rt- �
Fn:m _ To I tr-
-l. S('RL.FN Depth Diameter Slot ,Size ,Material N
I o
PL_.. m. __ in. U7
Fn,rn _ To .. Ft- in. in. - O -'
- --. .__._S:\Nfl (iR;l\'I�.I. PACK: - ----- �- u7 -
Depth Sna %laterial
Fnait To Ft. -
From _To-- Pt.
In. RI.AIARKS
I-.RLf31 (I.RT IFY MAT THIS \`"FT I R;AS CONSTRUCTED IN ACCORDANCE R ITT I 151 N('AC 2C,WELL
0:',ti fRl11( I ON STANDARDS..AND IIIAT A COPY OF MIS RECORD IIAS BEEN PROVIDED TO THE WCLL ON'NF.R
SI[,N ell:RE OF PERSON ( qN CTINO THE WELL
DnTE
Submit the original to the Dicision of 35'ater Quality,Groundwater.Section, 1636 Mail lien ice Center-Raleigh,NC
27699-1636 Phone No.[phone].within 30 dacs, - -
GW-I REV.072001

WELL CONSTRUCTION RECORD
� nl ( arolma - Department of Lm"ironment andNaiural Resources - Division of Water Quality-Groundwater Sectio�n'\NHA,(ON"I'RA( [OR(I NDI\)DLAL)NAM(E( (print). j'UL 7 - � �. _ C'ERTIF'IC4TIOS#prt-1`p_
ssf.I.I.(ON-INA( IOR CONIPAN\'NAME, �``11 pp'� PHONE # 4 --
ti I%I I R ELL CONSIRGC'IION PF.RMI'I'# _.�1V a_ -_ASSOCIATED K'Q PER'?11T#—'
(i I applicable) (if applicable)
N"i.IT I;SF: (Check Applicable Box J: Residential �Municipalr'Public ❑ Industrial ❑ .Agricultural ❑
Monioring ❑ Reco%'ery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
VC .Ll. I..(A ATION:
'Topographic/Land setting
',ctre,��//.��T,,,,o��wn.U,'CU inPtvUILA-- County I )Occl ❑Ridge ❑Slope ❑Valley M3 at
Ma LA e LL '-'�(I"`"l ' �� (uheck appropriate box)
Ne �.n;ennnne�.(" mnnn S�n ii�i.inn. tan n­_7,p(„de) Leditude longitude of well location
(degrees nrimutes seconds)
,lddre„ S 4� Latitude longitude source:❑GPS❑Topographic map
(Street r Haute No , (check box)
T\1L 1)1 -1 QU DEPTH DRILLING LOG
r T T" sere 7T(od, From To Formation Description
— --�-� _—
!. I)Arf DRILLED7 :l
;OIaLULPTH:_LAC 1`�----- ---- --
...
ti-f.\ll( WA"Il R LEVEL Below Top of Casing: --\L(:f _FT. — -- --- —
ilnc"-"if Ahoce Topot Casingl
<.. T()J'OF(.ASINO IS_., TT. Above Land Surface' ---
'I op of casing terminated atlor bettor, land surface require,a ---_ _-_
ariance in accordance with 152%NCAC 2C.0118. -
'1. l ll{LD(gpm): l i;T METHOD OF TEST.
ATER ZONES(depth): -3'4`a_.
LO('ATION SKETCH
fl:I LION: Type _ mount __ Show direction and distance in miles from at least
- ( :AKIN(' \A all Thickness two State Roads or County Roads. Include the road
Depth Diameter or 1Celght Ft Material numbers and common road names,
f turn_. Q. lb - 0*C) _ Ft.
Fnnn -- �
To Ft.
I r,dn To Ft. _
. ,. (,R(A I' Depth -- Meterial Method
Frr'm- Q To-,SLa Ftj _
From _ To Ft. _
Y RI.I-.N_ Depth Diameter - _-Slot Size Matenul C 7
Fnan Ib _Ft. ._ -in.
To Ft. in. in.
Cn
Depth SVC Material LIT
Ft.
i non; To
Ri.A1,1KK>
i I d I I,i REM ( CRT IF1'THAT THIS WFI.I. A1'AS CONST Rt'(I LD IN ACCORDANCE KITH I5A NCAC 2C,A EL1.
I ION STANDARDS.AND f 1l XT:N COPA'OF'7 HIS RECORD HAS BFFN PROAIDEDTO THE 'A ELL OWNER
T SI(iNa"fCKE OE PERSON('ON C TF_
( FHN I '.
ti o�
DATE
Suhmit the original to the Division of Rater Quality GroundMfater Section, 1636'11ail Service Center-Raleigh,.NC 37699-1636 Phone No.[phone].within 30 days.
SEP
0 r i�,l GW-I REV.072001

WELL CONSTRUCTION RECORD
tiorih( arolina - Department of Ens ironmcnt and Nat ral Resources- Division of Water Quality-Groundwater Section
R rA.i, O [R d('I OR(IN DIN I DI n V.)NANIe (nriro'_-l..n�S„11 �� � _ -_. CERI IF]CATION#I-glj�n
ssi-LI ( ONIRA("IORCOsi PANI NNIF...Gf.r�L� -y
SIA1 Y.N LLL CUNSTR UC3TON PERIs11TA _ - `�o\252--_ - .ASSOCIATED WQ PF,RNI 1'I#
— —
(if applicable) ----- --
� (if applicable)
I;SI (('heck.Appl icabl c I3o.N): Residential nr -Municipal,'Public ❑ Industrial ❑ Agricultural ❑
\i,.nuonnu ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
l\ ..l.l 1 Of \TION:
Topographic/Land setting
Ncnrc,t Tuur: V7fNVl __ County�CLial �YX]'� ❑Ridge BYope ❑Valley ❑Flat
1 t� �`6' I check appropriate box)
`.n,-�•� 1tILz.�.ulntx o.Communn,l "r,I"t No..Zip csiei Latitude.longitude of well location
I.R-TO, y�-VV�L'- __ --- - ---(degrees minutes seconds)
"`tor`» �����-1L-`L12-4 �i V1 Latitude longitude source:❑GPS❑Topographic map
(Street or R rme No0 (check box)
Y�1C. ��'gs DEPTH DRILLING LOG
"y " "'II 'state /Ip(odz Front 7�QTo Formation Description
.-��—
rr F I D R I I.1.i_:D 5- C b _ -�0
..•, �� ;.�.: U!.nI ,,1,,. x.I, I ��, ;-;,, �.� .,.I LI a:!) LIB
1Ti( WATER LEVEL Below Top of(asme: c20 FT. -
_�_ '
( -sc �f.Ahme Top of Ca�smg)
T((P OF CASING IS FT. .AboNe Land Surface-
-((ip of casing,terminated atlor below land surface requires a
stria nce in accordance with 15A N(',\C 2( .III IN.
IL.LD Igpm): _�Q�_ METHOD OF IEST_�.I'l('S -_
a W yTF.R ZONES(dcpth):
---_ LOCATION SKETCH
I)ISI,NFIJ TION: Typc _�_ _ .Amount Show direction and distance in miles from at least
Wall Thicknes two State Roads or County Roads. Include the road
)epthq� Diameter or W'eiuhrFt. Material numbers and common road names.
Fnnn- Q I 3D Ft.
From ToFt.
- ---
mtn To Pt. _
iP011 Depth - %latcrial Method a
Prom Q I o_ Q_Ft.�`� _
Y RI-If _ To-._- L.._. P
S( -_-_ -
REh_K. Depth Diameter Slot Site Material c.rt
F rnn:_ _ To_-_ Ft.. _. - in. _ in. O
Prom _ Ta Fr. in.
In,
I ? Sa^D (iRA\'I.I. PACK: -_
Depth SI/C Material
f-rom. . . _ To Ft.
;t-.. P; MNRKS
a 1 I!kL M ( I RIIFY THAT THIS VCELL V`s!AS CONSTRUCTED IN ACCORDANCE VM11 1.:A NCAC 2C',WELL
( u<SIkl ( TUNSTANDARDS,:ANDTIL%' A('OPl'OFIIPSRIR(ORD IIASI3EFNPRM!DFp TQ`lHE WELL DA4'NER
__ __ 3•�q -ems
SI(iNa'I'URE UI' PERS6 )INSIR U(TI NG TH E WEI.L DATE
pp 2 ^1��jj.Submit the original to the Division of Water Qualih. GtoOndsrate��hction,9 ��S 16fail Srn ti4enler-Raleigh,1C
21699-I6.6 Phone No.[phone], within 30 daps. GW-I REV.07?001

V A n
� I t
WELL CONSTRUCTION RECORD
"" ru: ( an,lina - Department of Lm lronment and
Natural Resources- DIy101on of Water Quality-Groundwater Section
\\I.I.I.((/S1'RA( IOR(INDIN IDLAL)NAUIF. Iprin4_k1<1i 2Ln `/J.G..1O 1`]. _ _-._ CERIIFICAIION k-pc]Lq_
"I.I.t.(0Nt RA( IORCONIPASti sLNIECXfQer. _rJy[;S._Ll­k-1- Y—�l-L..� �J PHONE # L9 L1_'�
SLS I L N ELL CON'STRUCHON PE:RNIITk \�O.P..- -.- —ASSOCIATED NQ PER%Il rq
(i f applicable) (if applicable)
\1'P.LI-USE, Wheck Applicable Box): Residential 0�-Municipal Public ❑ Industrial ❑ Agricultural ❑
\Ljnmoring ❑ Reccoery ❑ Heat Pump Water Injection ❑ Other❑ If Other. List Use
\Ai-.Ll. I.0C;A710N Topographic/Land setting
Ll
\u:�rcS/t \
1 lu un: �V-LUC Coumv� ❑Ridge ❑ ❑Slope Valley l�at
_ �fYNE U
I check appropriate box;
Latitude%longitude of well location
(degrees m mutes seconds)
Latitude longitude source:❑GPS❑Topographic map
Street or Route No (check box)
DEPTH DRILLING LOG
state i'p rsle From To Formation Description
mc rumher
,, a u I i J u L.In ,,, I- i.c I. I i n.. At i.i I -i ♦-i c l I �„ A.i'
T.ATI(- WA I ER LLVLL Bclovv Top of Casing: ��__FT. -------
I sae 'It Abosc Top of(ltuogl(Al OF ( ASING IS FT. Above Land Surface" --- --
'I rip of casing terminated at/or below land surface requires a
sarlance in accordance with ISL N C:\C 2C.0I la.
•,. i"fF:LD Igpml: L-10 METHOD OF TEST —
o \\,\TFR ZONES (depth):
--._ LOCATION SKETCH
DISINIAJ I ION:Type-- 13ft-- Amount Show direction and distance in miles from at(east
('%Sln('- Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or%Leight Ft. Material numbers and common road names
-
E r an--.tQ To`�-_Ft. U"
Film ---- To--- I t. ------ —
Lri To_.__ Ft
<iROI:I Depth ---Material
. - . _ -- --_ _W_thod
rom To�J
l( To __Ft, _ aCC
tiRfF Vt. i
p Dtmctcr Slot Size u-It
To - - - Ft. _. _in. in. o
i To--- Ft. ._—in. in. UI .
Depth SiicMaterial
To It-
rrnc To Pt.
. kl AIAftKti
I i tI I I i RFbI-( FRTIFY TIME THIS \k'EI.L RAS CONS TRU('TED IN ACCORDANCE WfFll 15A NCAC 2(',N'EIT
RI,Y TION SEANDARDS,.-AND TI IAE A('OPS OF 1111S RECORD I IAS BEEN PROA'IDFI)TO TI IE WELL ON NE.R
1 _ __
SIGN:A'I-URE OE PERSON`(() IRLC'TIN(i IHE WE-LI_ DALE
Submit the original to the Dirision of N1'ater Quality, Groum1v%aler Section, 1636 Alail Service Censer-Raleigh,RC
27699-I636 Phone No.[phone],within 30 dad s.
' SLa 2 0 %.JV5 GW-I REV.07.'2001

WELL CONSTRUCTION RECORD
;,roline -Department of Em'ironment and Natural Resources -Dic-ision of Water Quality-Groundwater Section
1\k.LL(ON I'RA("ION(IN DI\'IDt \I.)NAME. (print) � U,\'awl, CER'FIFIC.4'fION#„
cNi I.1 rON IRA(-'IORC'OMPAN\ NAME. Iii
\ PIIONE # (&
NT\7f %NFII (:ON'STRGCTIONPER\I1T#. 1Oklb�_- _ ASSOCIATED VNQ PERM["1# _
(if applicable) �/ (if applicable)
\\F:1.1 I Sk (('heck Applicable Box): Residential C7 Municipal Publ is ❑ Industrial ❑ Agricultural ❑
\Inmmwnng ❑ Recovery ❑ Hcat Pump Water Injection ❑ Other❑ If Other, List Use
I. i (A A NON:
Topoggra�hic/Land setting
_('aunty ❑Ridge L`}Slope ❑Valley ❑Flat
Itheck apprnpnate box)
n,mmena�.s,�ndin.iot�-t,n N /,p( de) Latitude.'longitude of well location
----- (degrees mmuresaeconds)
Latitude longitude source:OGPS❑Topographic map
(� IStruct a tare 1u (check hoz)
�_C� �gl to DEPTH DRILLING LOC,
;t,,.n state %,p(-ode From To
r Formation Description
-t \TI. URII.LFD_�i' �\ _G�_ ---- - is �a�_-_ _.
-01 V1, DEPTH: UAC _____ - -
ST.ITIC W'A 1 FIR LEVEL Hclow Top of Casing:i—F'T. - -
It_, ' i f.Ahoce Tnpof Casing)
TOP OF ( ASING IS_�__FT. Abo,'e Land Surface* --
"fnp of casing terminated at/or 6elos. land surface requires a
.ariance in accordance s,ith 15,% N('A( 2C.n11A. - -- -
`i. A IIiLU (0171): ___�_ METHOD OF TEST a. --
tl. WATER ZONES(depth):
--- _ LOCATION SKBTC'H
I- DISINFE('TiON:Tcpc �- :)mount Show direction and distance in miles from at (cast
Wall Thieknes, nco State Roads or County Roads. Include the road
Ucpth Diameter or WeighrFt. Material numbers and common road names.
i- im. '� To S-1 Ft. __.lS, _-
i runr.. _.__- To_-- Ft._
To _ Ft.
Depth Material —� %Iethod
inun p _ To�l7F ,'�,Q /1 To__
-- - _- 1"
1. S( i2f l.S Depth Diameter Slot Size Material '
.::m- Io Ft. in.—.__ in. _ N
h n,m To Ft- Cn
---in, _. n.
Depth O »
P Svc Material C.fl
-To-- Ft.
fr':In. To -I't -- —_.
n. ki %IAkhS
DH) I i i kLI51'( F.R FIF)'THAT THIS U F7.L W,%S CON,S IRU(TED IN ACCORDANCE Willi 15A NCAC 2C.WELL --( i;;�, I R U( TION S LANN�DA\RD�S,,�-AND"FIIAT A COP}'OF I IIIS RECORD HAS UIEEN'PROVIDEUTO TFIE W ELL OWNER
O S
SI<iN4TCR EOI PERSON ( 'i R U(TING FHE WELL DATE
n0r
Submit the original to the Di\ision of\Pater Qualih 'tlN,Groun 'ater Se �i
ction 1636 1fa l Smite Center-Raleigh.NC
37699-1636 Phone No.[phone], H-ithin 30 days. -
GW-I REV.07'2001

v 016 F i9id
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ C YP re Lll N "1 tx -t. CERTIFICATION#.B S8-Z
WELL CONTRACTOR COMPANY NAME-&r]mm /pro,- WPI/ j Pa,,,,� 7"n( PHONE # IV# L ✓9" 31V
STATE WELL CONSTRUCTION PERMIT# /yd.l ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential l—x4unicipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- ``Topographic/Land setting
Nearest own: County BiCidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: l.. P h r • AA
(degrees/minutes/seconds)
Address _ 1/�' e ./ i r - Latitude/longitude source:❑GPS❑Topographic map
(S et or Route No.) (check box)Ia N C a �7.2- DEPTH DRILLING LOG
City or To t 9tate zip Code From To Formation Description
a 7s ' _
.Area code-Phone number
4. DATE DRILLED y
5. TOTAL DEPTH: 1 d s'
rJ^LS REPLACE 1.vrrrinq; ian:).i o Y-:c Lt nj0 r�
7. STATIC WATER LEVEL Below Top of Casing: -o O FT.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface•
"Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0I18.
9. YIELD(gpm):_— METHOD OF TEST ?_/., 3
10. WATER ZONES(depth): 4�,S f
LOCATION SKETCH
I I. DISINFECTION:Type Amount 3G 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--C- To 7,5' Ft. '1 P y a
From To Ft.
From To Ft.
13. GROUT: Depth Material Method rn
D To .20 Ft. 0 if
Fiom e..r. a.. N ..
From _,_To Ft. fV -
14. SCREEN: Depth Diameter Slot Size Material - --"-
-- to #y
From To Ft. in. in-
From To Ft. in. in. -- ;::1
15. SAND/GRAVEL PACK: tM
Depth Size Material MAY 15 2007
From—._To Ft.
From_____To Ft.
16. REMARKS: -
I DO IiEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAR S,AND THAT A COPY O IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
8 -3/- DS
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-I636 Phone No.[phone],within 30 days. C v r i 10 2l��0�5 GW-I REV.07/2001
r

WELL CONSTRUCTION RECORD =
North Carolina-Department of Environment and Natural Resources- ivision o Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/-f print)r �� _� �p_ CERTIFICATION#'/OHO
WE'LL CONTRACTOR COMPANY NAME_V.L'1G/IC /..5{. • tiG • PHONE # (6.lA GYO —3�7,1
STATE WELL CONSTRUCTION PERMIT# �yD.L _ASSOCIATED WQ PERMIT#
(if applicable) t� if applicable)
1. WELL USE(Check Applicable Box):Residential p Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water njection❑ Other❑ If Other,List Use
2. WELL LOCATIO _ Topographic/Land setting
Nearee�stTTJown: i• County_ ❑Ridge ❑Slope ❑Valley Flat
S1LL;✓� Ko . (check appropriate box)
(Street Name,Numbers Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �& &/)YAPS (degrees/minutes/seconds)
Address _ /S"�f/ ye, ye- , Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
Lli 4'e c )'G 3 3517 X DEPTH DRILLING LOG
City or'rowm—�State Zip Code From To Formation Description
A.code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
lu,i:S IN ELL REPLACP. WELL? YES U NO � _ -
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 casing terminated at/or below land surface requires a
variance in accordance��ith ISA NCAC 2C.0118.
9. YIELD(gpm): —METHOD OF TEST t-.S .
10. WATER ZONES(depth): .3.9.Y • - R q P1"+
LOCATION SKETCH
IL. DISINFECTION:Type ) 7-P Amount ji,61k 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__IQ_To
�Ft. It a Ile-
From To Ft.
From To Ft. `
13. GROUT: Depth Material ethod
From__To�.�Ft. C Ctxe a_'J!' rTt
T1
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material +d _
From _To -Ft. in. in. RECEIVED
From To Ft. in. in. -
15. SAND/GRAVEL PACK: --
Depth Size Material MAR 0 8 2006
From To Ft.
From -To Ft. Asheville Regional Office
16. REMARKS: Aquifer Protection
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDJR�S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

32 9 e
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and/Natural Resources-Division/of Water Quality-Groundwater Section
���p
WELL CONTRACTOR(INDIVIDUAL)NAME
� (print) Lh/2�(-1.5n.__j(n/P _ CERTIFICATION#_er�L
WELL CONTRACTOR COMPANY NAMEG!'Se,tLL /�✓�S. We II Pk.a.02r LNG PHONE # ( R G
STA'IT WELL.CONSTRUCTION PERMIT# /*d 1 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ Agricultural D
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WE .L LOCAT,,IO`N` : ),', // Topographic/Land setting
Nearest Town-Wa&#neSut l le, County�l/ W,2eJ DRidge ❑Slope OValley %Flat
Y/yi n ae 1 e -P r.r�ae (check appropriate box)
(Street Name,Numbers,Community,Su �sion,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �N[ I ry-1dt rsk (degrees/minutes/seconds)
Address 41n A alxL, - -gt*ue r -M . Latitude/longitude source:UGPSUTopographic map
n (Street or Route No.) (check box)
C/�•Q wttdrr r SC .2 DEPTH DRILLING LOG
cay ur rown State Zip Code From To Form/a�ti�on Description
( ) D .S9 10Ja-u
Arca code-Phone number Sly S�4y- � 41
4. DATE DRILLED /,7- ,29 -05
5. TOTAL DEPTH: T-�5 1 �
f . P,EPLACL' FXN'riN(y WN 1 ' YFS Ll NO e,
7. STATIC WATER LEVEL Below Top of Casing: O G FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I METHOD OF TEST a EIrs
5 a - .
10. WATER ZONES(depth): 4 y
.S 4)5 I - LOCATION SKETCH
1 l. DISINFECTION:Type HT H Amount 9 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 To S1 Ft. Z O PVC
From To Ft.
From To Ft.
11 GROUT: Depth Material Method
From D To 0 Ft._C
00!� --
From__To Ft. --I
14. SCREEN: Depth Diameter Slot Size Material _
From___To Ft. in. in. RECEIVEDCD
From To Ft. in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material From To Fr MAR 08 2006
From To Ft.
Asheville Regional Office
lb. REMARKS: 1 Aquifer
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS NO THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
--- '
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
/-Division of Water Quality-Groundwater Sectio�n'��ry
WELL CONTRACTOR(INDIVIDUAL)NAM (print)Lf�n��c /rp/,� lj� y� CERTIFICATION#J41
WELL CONTRACTOR COMPANY NAM2eee NC '//2i»S. W�/� r Pun,A, 2- - PRONE #
STATE WELL CONSTRUCTION PERMIT# 11"o2 ASSOCIATED WQ PERMIT#
(i£applicable) (if applicable)
l. WELL USE(Check Applicable Box):Residential, Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W l'iI.LOCATIO Topographic/Land setting
Nearest 'Ei1. County_ �/ly w CRidge ❑Slope Valley Flat
G p e .r✓ • I h (check appropriate box)
(Street Name,Numbers,Communn o���iitty, bdivision,,AtLott No.,Zip Code) Latitude/longitude of well location
n,, ,! /'Jr
3. OWNER: _
��^7 (degees/minutes/secgnds)
Address /o z14, Pri. iy Latitude/longitude source:❑GPSOTopographicmap
/r (Street or Route No.) (check box)
L/JQiinLSV"/jr r Ae -;�.q Pr&_ DEPTH DRILLING LOG
c'ayfor Town state Zip code From To Formation Description
O p ;8
Area code-Phone number 419 , 1y51
4. DATE DRILLED -.29 -16S
5. TOTAL DEPTH: /
c- L`L),',S A?�FLI" ut:of nCL: l:v1S r1n1f; p;l:!.!:' YES L1 N1,4
7. STATIC WATER LEVEL Below Top of Casing:-__AFT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface*
*Top of easing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_--$--T METHOD OF TEST CS .
10. WATER ZONES(depth): /.7S ' - 8 t�0.w
/r LOCATION SKETCH
11. DISINFECTION:Type ,ITN_ Amount ,5 -Eh)4%, 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.
From0 To--#9--Ft. 40 1/ PVC
From__To Ft.
From_ To Ft.
13. GROUT: Depth atonal Method rTl
7
From
DTo�D Ft. .zA� yLo a _
From _To Ft. --.I
14. SCREEN: Depth Diameter Slot Size Material CD
From To Ft. in. in. RECEIVED Q'
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material MAR O H 2O06
From To Ft.
From___ T° Ft. Asheville Regional Office
16. REMARKS: Aauifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONS"FRUCTION ,�7 STAND�A3DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
__41 i oods (;;R i- -.fi- .4
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

.1 cR g
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources11-� Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/E''�(print) k'7 r we-(nl7__- _ CERTIFICATION# //}}II��
WELL CONTRACTOR COMPANY NAME 6rirer�r 31-W WQI(F'-D4 P W-1— `TACK PHONE # �4�s
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential OlMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION Topographic/Land setting
Ne est Town:/ tnGSUi��t Coomy,4� b6W ❑Ridge BS(ope DValley OFlat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: LaX((r 1L 1 Y\-k D`d - q✓^L 0 60-- (degrees/minutes/seconds)
Address LOA<- Latitude/longitude source:DGPSOTopographic map
(Strcet or Route No.) (check box)
Wan tfv;f fr " � b'� 0 DEPTH DRILLING LOG
City m Towm state Zip Code From To Formation Description
Are.code-Phone number
4. DATE DRILLED /�'��'oS� FF
5. TOTAL DEPTH: YLf S�
WELL REPLA`'1: 1:YIU9l NIA WFI 1 9 YES Ll NO
T STATIC WATER LEVEL Below Top of Casing: '1- AFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C.0118. /
9. YIELD(gpm): J METHOD OF TEST a
10.WATER ZONES(depth): 3 d.f
LOCATION SKETCH
IL. DISINFECTION:Type Amount FC/Ta /6 rS Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth D)�ameter or Weight/Ft. Material numbers and common road names.
From
_�To�J.(o FL L�/' pre—
From To Ft.
From To Ft. _
13. GROUT: Depth Material Method
From
_Q_Tom Ft.�� —
From To Ft. "n
rn
14. SCREEN: Depth Diameter Slot Size Material CA
From To Ft. in. in. RECEIVED — -.
From To Ft. in. in, j
15. SAND/GRAVEL PACK: f MAR O C� ?OOG r73
Depth Size Material
31
From To Ft. -
From__ To Ft. Asheville Regional Office
_Aquifer Protection
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC ION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Envirournent and
�Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMLE�(�p�rY���'Y//Cn �Yh DQ�'S V CERTIFICATION - 7O Q�/
WELL CONTRACTOR COMPANY NAIL/W tee 1' W/¢ /' f���i PRONE / cn 6 YN'-oo
STATE WELL CONSTRUCTION PERMIT/ .a--OCIATSD WQ PEBMI D
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential U Municipal/Public;❑ Industrial❑ Agricultural❑
Monitoring 13 Recovery 0 Heat Pump Water Injection 13 Other 0 If Other,List Use
2. WELL LOCATION: / T hirll and setting
NearestIRA
/ U 19 W00 page j� QValley OFlat
2
�q C Ae rAgw,14e, (Qh d Vpotaiuebm)
(Suva Name.Numbers,Counwhy,Subdi mn,Lot No..Zip Code) Latit iticA ngitude of well location
3. OWNER &) 1li*jVP AAA
Address /y2 !?.9 a G.0 Latitude/longitude source:OGPSOTopogtaphicmap
/ (Sueeta Romew) ( boa)
C/Q/IJCON ItJG $7�� DEPTH DRILLiNGLOG
City err TOwn Sim Zip Coh From To Formation Description
L_)-
Asa codm Phooe number
4. DATEDRI LED I
5. TOTAL DEPTH: 2*
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO (3'
7. STATIC WATER LEVEL Below Top of Casing:
�i (UN-+-ifAbae Top of Comas)
8. TOP OF CASING IS_$_FT.Above Land Surface* EQ
*TOP of coin teeddted Adw hdon had sancn requbw a
ruriasee IN aemrdinin with ISA NCAC 2C MIS. /
9. YIELD(pm): 2 D METHOD OF TEST /i;'-"e
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type (_C H Amount_/(j 2 Show direction ad distance in mites from at least
12, CASING: Wall Thickness two State Roads or Cc"Roads Include the road
Depth Diameter or Wei& Material numbers and common road names.
From �_To SD Ft /_ �/ SpR2/ t. puc C/�i1J(,�rJ
Frmu_,_Ta Ft ,,JJ
Front--TA.-Ft
13. GROUT: Depth Material Mvdted •
From(_To�Q_Ft.4::,� 4
From To FL_
14. SCREEN: Depth Diameter Skit Size Marais!
From_ To Ft m. in.
From__To Ft in.
15, SANDIGRAVEL PACK:
Depth Size Material
From -To Ft
From To Ft
16. REMARKS: GQ e/ w S,/�H /9Q/[ a m M
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL N z n
CONSTRUCT i0 ANDARDS,AND THA Y O RECORD HAS BEEN PROVIDED TO THE WELL O <CD
i\-) M
2 7-O5
SIONAYURE OF PERSON STRUCTING THE WELL DATE m
Submit the original to the Division of Water Quality,Groundwater Section,16M Matz Service Center-Raleigh,N
27699-1636 Phase No.[phone],within 30 days. GW-I REV.072 I

PAN"
I ION cn S ra•Dep graor- l of l^N.C.27 wrd N.wNJ Rmotw.m•OMWoR of WOW Queft•Gmurrdwatw saw '
1ff3!M.NStevkaOerdw•Ralelph N,C.a7sM•1s:1LNwyOif)T33-M/
WELL CONSTRUCTION RECORD wELLcoNTRACTORt Gf )e, lk C FQ
STATUVMLL S Rp(�pN APERMITI• // 3
1. WELL US1LLchgek Ap0t"bIg Sw*RmWerltl.l�' MunblpAI D I
Room" orduWld D Agricultural D Mongorinp Room"LJ I�..l Pump wNa Iry.otbn a Do ifOf ter,U411 Use:
2. WELL LOCATION:(Show sketch of the locavon below)
"*oral To": t�A ucS0lr � Cow.-14F3ya C
- I au9
(Rood 1hriN}p MAT" ,Commwrdty,or BubaNrkn srW Lot No.
3. OWNER l:" � - . � G, l aztir¢ 1 DRILLING LOG _ DEPTH
Address
S
�.__1
aM«tbRR ��sE state �oeor ' -
<. DATE DRILLED /�IiV ar k.- C,X 4 A/i T f
S. TOTAL DEPTH .S. i ft
�° C6. CUTTINGS COLLECTED YES[ NO®7. DOES WELL REPLACE EXISTING WELL? YES(] NOQ
S. STATIC WATER LEVEL Below T of Caop ektp. R FT.9. TOPOFCASING13 yAboveTOOof corky)
L FT.Above Land Sm.m.'Top of oaobmy lerv*Wed oV.r below isnd ewram to**"a rwlaneo Y ssgft
doom w1h teA NCAC 2C..tt.
/0. YIELD(I)pm): METHOD OF TEST R r5
11. WATER ZONES(depth):. ----Asheville Aewonauxtv-p—
OW
12. CHLORINATION: Type If.ddllkNW
13. CASINO; .paeA Is matted use Dark o1 loan
Depth W.eTNdtrare _LOCATION SKETCH
From To dD Ff. « aMissile!WOUhVMissile! (Show dlraoe mleaston WW taeter from at least wm 91sts
�.. 4fr V L
-- — Roads,or other map relerwroe pokNs)
From To Ft­
From To FL
14. GROUT:
Depth �__Maledal Method /n
From d To �_Ff. _ ;.r, �C /�(, %4 KL
From To Ff.
1S. SCREEN: d�
Depth Diameter Slat SIz6 Material
From __To_Ft_ In. _ In.
From To __Ff.__ in. _in. r
From `To!FL r In. _in. o
10. SANWGRAVEL PACK, n�
apth Size Malarial
From To Ft
From To FL '
17. REMARKS:
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF HIS RECORD HAS 81
EN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY 17Jj� J- 1,
O"odMR $*NATtA1E OF PSReON COMImucTme TNa WEII nATE
so"No. v*W to DM*""No"puatky.OwwW&Yw Sector,WIMdn 30 days
OW-1 REV. 1NN

WELL CONSTRUCTION RECORD
ecpanntent„t I nN ronment and Natural Roourcc, - Di,ision of Water Quality-Groundwater Section
..: ( U,IkA( IOR IINUTA'IDI AL)N.%)IE prau)�_k_ S !) /'t L_L:c. �.���• �- ceRll FICATIOSa .7f(
5, . usl kAf IOKCOMPANT N9VE ,' U7ta.y, (.:� e_1 L«1L_ 'z1 s"I'L_PlloAEa :'
ASSOCIATED N'Q PF,R.VI771 -
t applicable) I if applicable)
.: ',11 LSI. ((heck Applicable Box)'. ResidentidA Municipal Public ❑ Industrial ❑ Agricultural ❑
„I„ring ❑ Recovery ❑ I-lcat Pump Water Injection ❑ other ❑ If Other. List Use
1 TupographiaLand setting
+n ft L') �� _ County �t[ 5�.,,` ❑Ridge ❑Slope ❑Valley xFIaI
dieck appo)p,iate N,x)
Latitude:longitude of well location
Ida c,tnlnutcs. cconds)�
J cL - I atitudc hmgitudc Sr LA cc,DG PS❑Topographic map
V i a at ii ,n i fchstk bowl
I Lp_�1LL J C I i (.�_ _ DLI'TH DRIL1.IN6 LOG
From To Formation Description
R LEVE L Rckm Top Id C a,mg FT. -
,L I, d brie T,ip I(a.Iuw ---- — - -- — —
i!)P (it 'I"I NG 1.) FT Above Land Surface*
up ul oasis;terminated auor halos land surface requires a ------- - - --- — - _-_
..n sore w acunrdanI,e With 15,1 NC AL 2( .01I8.
t gpm i 1151 _ ,NILTHOI.)of I I ST
7.O'sICS (depth)'. �. ') —__`�� _
LOCATION SKET(If
ISI f I It)N:-I-N-pe_ F 4 -T Anwunt _}�_l-�. - Sho" direction and distance in miles from at[cast
Nall I incknce, t NNo State Roads or County Roads. Include the road
Depth Diameter ,r W'cight I-t. AWtcrial numbers and common road names.
To D
To rt
u<<)C Depth Alatenal Alcrftod _
to Ft
Depth Diameter Sint Sitc Material
To_ _ _- FL m_ in
in. in
_. ---- _—
:)cpth Siic 1latcn:d
-. . to Ft.
'r ,.i 6F.IS} rh.i: IFY'TIIAT TIIfSWF_IJ. WASf.ON,SIRI (FFDIKAC(ORDAN(LWlIIl I iA NCAC2('. WELL
%ADAR,y1`fu)}{ 4ND llf%f A(OM tq II`III ( DI
ISRL ()RIASf3FINPROVIDLI)TO TIIEW'FL W LONER
SI4N VI I:KF OF N,RSC)N ( ONSI RiX I IN(i IIIE WELL DATE
-n m.nl the original to the Uirision of H ater Qualitt,CroundaRE.CrE1,VfiE11il Senic Center-Raleigh,NC
.. 60-1 hih Phone No.[phone].within 30 dacs. GW-I REV_07 2001
JAN 30 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD
Department of FnN uon vent and Natural Rc,ources -Division of Water Quality-Groundwater Section
ONIkA< IOR iINIII\'1u( %I,)NANO (print) f 1, JUryv I
0.
/1� CBRIIFICAT10Np
( 011RA( [OR(ONIPAN) NAME is1etlie ai plic oN PERM ITn I_( . - : (`- •.-P IIoP -a--
,' L(1
applicable) \SSo(IAIEDNQPERNIITp
(iappliceble) _I I:SF. I( heck Applicable Box): Rcsidcmial)� .N4unicipal:'Puhlic ❑ Industrial ❑ Agricultural ❑
Recovery ❑ Ilea Pump Water Injection ❑ Other ❑ ItOther, List Use
NON.
Topo r aphiciLand setting
(ionic
❑Ridge IPSlope ❑Valley ❑Flat
(check appropriate lws)
Latitude longitude of well location
^,li< I Y♦L_ �� (ir _
.J a mintne, :ecunJsJ
au4r Vn_Itudo source:❑GPS❑To obra hic map m
Ichc,k h
r (� _(.L- -- DEPTHDRIIIIN(j To(;
Ptah /ip( .d` I-roul To -
Furma/7uo� Dcxnphon
I I( vA-f FAR LEVEL Top of Casings:
—
%1 .a.. It Aho,e T,,p MCa.mgl
P OF t ASiN(i IS - FT. Aborc Land Surtacc* -- - - --
n,ul casing terminated aVor helms land surface requires a -
.anance m'W"dance With ISA NC.1C 2C.UI IF.
,%ILTHOD Of TEST — - --
�_ —. — I_O('ATION SKLT('H
Amount-L-1'7 4 Show direction and distance in miles from at least
sA all I hiclone" two State Roads or County Roads. Include the road
')cpth DmnlClcl or Wewfit I I. Material numbers and common road names.
T,I�I,- I t _ C " P\I C
To Ft
To Ft
f Depth VImcnal ptethnd
.,�.__C> To •�C._ Pt. ;Y.�t<,.><� - � III: -
I
-el RLLA Depth Dianictcr Slul S(ie Alaterial� :7
r, ni To I t.
if, To Pt.
ocptli Svc %latcrial
To — fto.
-.__---_
n Hf ul 'l.k If TIIAT THIS N EIT 1A 1S( ONS IR1:( 1LD IN W ORDAK( E W I I I I I)A NCA( 2( StFLI.
tit YARDS, AND Il lA 1 :N ( Opt OF II IIS fit,( OR[)HAS 13LEN PROA'IDLD 10IIIL WELL Mt NFR
S)(,.NA ,RL Of PI-:RSON ( ()NSTRUC I N I1VED DATE
",b°u( the original to the Ditisiun of Rater Qualih RE 1 69, Ground Section, 1636 Mail.Senic Center-Raleigh,NC
;vhav ;p36 Phone No,(919)73 3-3 221, )s-ithin 30 dats.
JAN 30 2006 Gw-1 RFv_orzool
Asheville Regional Office
Aquifer Protedon

Q
WELL CONSTRUCTION RECORD
QO
I W Il,ld - Dcpartn)ent of Em o-omnrnt and Nalmal Resourecs-Dieision of Water Quality-Groundwater Section
1 (,1Nl RA( CON IINDINID( t1.)N AA 1 rind �, / ,/
7Q�F P ( �I ( � r r Zt_-r;_ —!,_t _ ('FRTIFICAT]ON
..... ONik%( IONCO)IP.1A1 Nn]II" It i / �c !L.1'1s 1.�,- —�C/n1TI6e. _PHONE: a LYZL tl �"_.3,`;'^
I It! sl.l,l (0N`,I RUCTION PLR III# (s
, - .
- 1`z`__� soreDwQ PFRNu ra
,f applicable) .Nsa,c(if applicable)
f. f:7i 1('heck Applicable Box): Residcntial)�( .Municipals Public ❑ Industrial ❑ Agricultural ❑
r-n:ric� ❑ Reco%cry ❑ Heat Pump Water InicAiun ❑ Other ❑ It Other. List Usc
I ION' �
�( Topographic/Land selling
Cuunty "� ❑Ridge OSlopc ❑Valley ❑Flat
(check appropriate Ns)
ip( de) Latitude longitude of well location
4
1 11C .euWde longitude source:❑CPS❑Topographic map
s" et III I+ Irha.k h,:x)
t -- --- -. -- - DEPTH DRILLING LO(i
I� From To Formation Description
fLt )
( si rA, I R 1 1-.%1 L Below Top of(asine:
I .c.. J Abase Top
%I (iIS FT ghcore Land Surface' -- ----
I.:ul cas:n•� urinated aVor belies and surface requires a
.:ranee ni:u'a,rdann'With ISA 1(:'-C 91I8.
• Iu :Y1GT HOD of:TLST_ —
{. tF�^ ` --— — — I.O( Vf10N SKPT('I I ---- --
-I 14ti: TNpe_�L7 N _ Amount 7 6 -I I w, I Shodirection and distance in miles from at least
U all Thickne,a thvo State Roads or Cowry Roads. Include the road
')eplh Diamatcr or N1elght I-t. ,Material numbers and common road names.
Ft.
To ----
'..-Kl,li Depth Materialfo Ft, .N1N11od
'It 61:N Ucpth Dlanicler Slot Size A...-
iatcrlal
n.
Ucpth Svc Ni:dcnal
•'. irtI 51 f-H IIFY TILV 7 it ISNF:LLNl AS(ONS"IRCCI El)IN ACCORDAN('L N4lll 115A N(AC 2C WELL.
D.ARDS_,AN1)71IA I ,N(OPI Ol. I IIIS RECORD IIA5 13EEN PROFIDED 10 TIIE tkul-Ov, 1—R
SII:N:VIi RF OF 111 RSOIN I ONST �titr yr=b
Y UATE
`,oi:out the original to the Division of kN ater Quality, Grounde titer Section, 1636.Nlail Ser%ii v('enter-Raleigh.NC
it1h Phone No.[phone].ttithin 30 days.
JAN 30 2006 GW-I REV. 072001
Asheville Regional Office
A u'rfer Protection

WELL CONSTRUCTION RECORD
Noah Carolina- Department of Environment and N ral Resources ivision of Water Quality-Groundwater Section
WF;Lt,CON'l'RAC'fOR(INDIVIDUAL)NAME ( int) A I j
CERTIFICATION#,
w IIA,(,ON'TRAC T OR COMPANY NAME��_jj___ __ r � PHONE # (,P-�,P �+ Y d '3/7 a
S I A FE WELL CONSTRUCTION PERMIT# `/'•Q ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water ejection ❑ Other❑ If Other,List Use
1tiBLL LOCATIO 1: paf Top phic/Land setting
Ncar•st To" '' le- County-L�" ❑Ridge ope OValley OFlat
p x�4 d 'L 2Cl cheek appropriate box)
(Street Name,Numbe/r/S���C�ommunity.Subdivision,Lot No.,Zip Code) 9 Latitude/longitude of well location
3. f}WNER:____-LI-G6�CllJ (degrees/minutes seconds)
Address _. ..._"1/ M4z_('o in n Latitude/longitude source:DGPSOTopographicmap
(St(Street or Route No.1 (check box)
rom-a,J.%/+ .t/(' .?8' 7 F' �- DEPTH DRILLING LOG
cry,r Tnwn s� zip Code From To Formation Description
—)-- ) 3 S
Area code-Phone number 11; t
4. DAFEDRILLED g- .2.2 0s-
5- TOTAL DEPTH: yt � '
1.. " `; `Y;:.;_!. RL.PLA('r I.Y ici loin WELL'. YFS U NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. 'TOP OF CASING IS FT.Above Land Surface*
'fop of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118. /
9. YIELD(gpm): 6 METHOD OF TEST__ h rc __
I(i. WATER ZONES(depth):_ ye)5­ — 30 4",
LOCATION SKETCH
i. DISINFF.CI ION:Type kkT Amount '1 R f61 _ Show direction and distance in miles from at least
2. CA SING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From__-To Z5 Ft. �o '
Hom_ To Ft.___
Fr,in__-- To Ft.
3. GROUT: Depth �Naaterial -1- Method
From__6 __'fo--,;?e-?Ft._t_e.vwp�.C.
From To _Ft._ Co
14. SCREEN: Depth Diameter Slot Size Material C
From_ ,- To To Ft, in. in.
From-_, --To Ft. in. in.
1S. SAND/GRAVEL PACK:
Depth Size Material
From.
From_ _To Ft.
16. REMARKS:
( (JO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
( ONSTR UUC FI'ON S'fANNDQRQS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/6P
SIGNATURE OF PERS7Section,1636
DATE
Submit the original to the Division of Water R
Quali y,Ground636 Mail Se vice Center-Raleigh,NC
27699-16,36 Phone No.[phone],within 30 days. GW-I REV.07/2001
AshevOfficeon

j
WELL CONSTRUCTION RECORD*
v �i,na )cpartment it I.m iri mnent and Natural Resources- Disisiun of Water Quality-Groundwater Section
( ON I k:A( l OR(11,DIA11)1 AI )N.AAIE (Print, _' _ .
CER rIE1CA770N
stir tc,IIR\( 7UR U)\IYA1,1 \\\Ir;
sl \Ii \\ht.l.(ASJIkucr10SPI:R\71Ta /-y��. ._ \SSOCIAI'EDN'QPE.R\il'I# _-_ __
.t applicable) (ifapplicable)
Y,I LI_ LSI-. I( heck Applicable Boxy Residential$1 Municipal.Public ❑ Industrial ❑ Agricultural ❑
❑ Recovery ❑ Heat Pump Water Injection ❑ other❑ If Other, List Ui c
FION�) Topographic/Land setting
s ten _-C�__l(` (--. .` 's- _ <'owuvr� i •..-�
❑Ridge �ope ❑Valley ❑Flat
—1 J ('" Ei - ( 1���_ Nock appropnate box)
nxn (- „mnn I ,inn 1 v lip( dci Latitude,longitude of Nell location
„ AI I< . yam-.-! 1 �CL_ Idectvvn minute, vmnd,) _
JIV, C kf7, I P_ r(s�, _ I_11 itud longitude source:❑GPS❑Topographic map
Svvct nr R ]c „ , (check boil
DLPTH DRILLIN(; LOC
Smt< i,ip I:Id, From To Formation Description
amber
1 DRiI_LI D y
.I it AAfLR LTA ILL Bclrw Flip of( asing: _ FT_ — —
i -e --
I.i'OF C :ASIN(; 1S_._j F7. Abovc Land Surtace' -----.--------
lip of casing terminated atlor below land surface requires a -— ---
rl live in accordance with 154 N('.%( 3C.0118.
U tgpml ---/Z)_-- :WA HOD OF TLST _-
--
I.R/_OK6S(depth)- —
II)('ATION SKET('If
1)I')i'si I loss. I'ypc_ T/-1_ Amount _] L_.4 LJJJ—, ShoN direction and distance in miles from at least
Nall Thickness two State Roads or County Roads. Include the road
)cpth Diamcicr or Height it %laterial numbers and common road names.
i-t
Ft.
n l o Ft_
Ocpth ytalcnal 1lcthnd
'• rv,t r, fo Ft
ihptlt Lmittcter Slit"lie % ate ial
f I to
To FL_ in_ in.
�:',♦ii 4HA'�H. PA( K:
Depth Svc llutcnal
Ft.
Iti..LVch.S
I.k i 11- "IIIAT I III,Wl'I.I.N'AS t ONJ I It('("IED IN A('(ORDANC'E Null 15A NCAC PC,WELL
. . . I JO, S A NDARDS, AND I'I1.-1 I -N(OPY OF TI III RL(()RD I OS BEEN PROVIDED TO 171E WELL OWNER
SI<>!s,A I1;kF.OP PFkSON (01 " (^,,�;;;lEo;F A"rE
Iobo it the original to the Di\ision of\N'ater Qualih,Gro ndNatPr'.YPlf7R11'1�7R.Y13iTService Ce ter-Raleigh, \C
--'1';9-;h1h I'ltone Vo.[phone].within 30 days. (W-1 REV. 072001
JAN 30 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
Panment of Em inmment and Natural Resources- Limsion of Water Quality-Groundwater Section
.•r t Ue I It.A(lOR([NU1MDIL AI,1 A.1Ai 'nil 1 / /r/pn �i ,c� �1�J-CI'.{ _ CERTIP'ICA110.\#
fix l I I OR COMPAA1 N XN114'jL!.:-,/,_/_ f yam PIIoAY. kLLLI-( r/.
,. -, r,is LLI,t U\\IItUCP105 PFHMI7# �
'� ASSOCIAI'EU WQ PHHA1118
r,t applicable) (if applicable)
1_ CiF(('heck Applicable Box): Residential Municipal'Public ❑ Industrial ❑ Agricultural ❑
.i„nnorinp Li Rccocery ❑ Heat Pump Warcr Injection ❑ Other❑ If Other, List Use
1 (A
-- y "FION:
--� ToporapiLand
t setting
uc) Ridge ❑Slope ❑Valley Flat
check vppwpuutc box)
. n r 1' 1111,1!1t Yand,i,w 1, _/ip( oda -
Lautudc,longitude of well location
I_alitudr lnneimdc source:❑(jPS❑Topographic map
bocci or N „t, trhnN hoe)
DLPTH DRILLING LOG
"010 r •� Prom To Formation Description
n vi ..i. its r_ uI ei � Ii si
ER 1.1:VLL Below Top of Casing:
I .e It Above Tap dl'e.uiel — —
P Of- ( :A)ING IS - _ FT. _Abose I and Surface' — - - ---- - --
f o1,of essatq icrminated at/nr helve and surface requires a -------- ---- —_ _
i ce r.accordance with I S t\CAC 2C.h1 Ia.
I thltm): �;�_ METHOD OF T1iSl'
A i 1rR /UNI.S (depth):
LOC ATION SKETCH - - —�
I:itiiNi F.t 1 iUS. Type_ i 1'7- /4 -4mount ,�l - {b Irk chow direction and distance in miles from at least
%s all l hicknc`v two State Roads or County Roads. Include the road
depth Dwmeter or Weieht I t xui t riul numbers and common road names.
e '
__. t. __ _ _ _ .�. .Lc_f
FI
u Ft
Depth -Material - Method
fo Ft
,: RL Cs, Depth Diarnact Slot S¢e 1latenol
'--
To -- It.
�. . h ('R1 I.L PACK. —_-.
depth Cve Material
. . _ to Ft.
•_.t_ _ I o-. Il.
IU fsl 'l.R I IFY Fit\T I IIU N ELI.N-:U( (Mls I RC('I FD IN ACCORDANCE Wl l I{ UA NC'.AC 2C, WELL
,' ti ( ft(iAti� DARDS..ANU III A1 (-OMOI1HIS RE( ORDHAI, BEEN PROM IDED 10THE MULL MNLR
S14N.Vl:RE OF Pf-HSUN ( f �M,i}kFiERR$'}EEyfjcc{}pEEt V._ . � D:1 tE
`.eom it Itie original to the Disision of N'a ter Quality,Grin nil NsIR Se2Rioi�Si ,11fiib9latl Service 4 enter-Raleigh,\C
t(rty-Iy ih Phone Ao.[phone],a-ithin 30 days, GW-I REV, 072001
JAN 30 2606
1
Asheville Regional Office
Aauifer Protection

�oWELL CONSTRUCTION RECORD
,. w,,,: a - iicpanmcnt of I'.ml moment and Natural Rc,ources -Division of Water Quality`-Ground"ater Section
P ,.t U\Ik1( I0R INIMIDIAL)%%\IE (Pon,)_ f C /�t..l Lll.'/( «_ CF.RTIFICA1101S#
..i t (IN IR:S( IOR CUIIPA]1 AASIF. v'-1` tµ —PHO.N. #
`1 Cl:tn .to-. �Lt ll_ � �J -
I,, SS FAA,i II I(L'd:T1OS PF:R)II I _ � �� (s.1-_ A.S.SO('[At F:U NQ PERNII.1# _-
nt applicable) (if applicable)
. I IJ_ LSL I(-heck Applicable Box): Residential Municipal.Public ❑ Industrial ❑ Agricultural ❑
.. r,:nnrlul,❑ Rccmcry ❑ Heat Pump Water Injection ❑ Other❑ If Other, list Lcc
A IO\: -
7 t Topographic,Land setting
(. �f < ountq �: �tLLl
-ILL,
I ❑Ridge Slope ❑Valley ❑Flat
L-ti rt .. _ �llJ✓__ — (check apprnp,w,hm)
1
t-I ^ 7,p r ��do latitude longitude of'wcll location
.IJ< rsL l.4y � iol ' : 1.1. IJi .nmesermJ.)___
auludc lungiiudc ,ource MOPS[]Topographic map
- I Svod of k:cic,. ,.', i rLr<k hoc)
Di PTH DRILLING LOG
�`0r'= n I. fntm Fo Formation Dewription
IiJ
A I i( a4'ATI R ITAf- _ Below Top of Ca,Ing. _ -2 6� , FT
it Abort lop I l.i.inel
iW OI' ( ASiNG IS_� - - FT. Abose Land Surface* --- --- - --
:p nl casing terminated aIlnr heloa land surface requires a --- - ---
,.:nance a,accord.ncc eith 15A V%( 2(.011 M.
-
:Itll) luptn) - lu ) MLTHODOI TEST
LI< LUNLS (depth):
LOC ATION SKE L( it
(ype_—,<-/ TH__ Amount t_�, i.d; a� Shoe% direction and distance in miles from at (cast
15iSt, Nall Thickoc„ two State Roads or County Roads. Include the road
Ikpth D;ameler or Nehht I I_ Material numbers and common road names.
Tn- �1 Z/_- Pt. L- n -- __i �
o Ft
..,t. fo F't. _
-rt tf I Dcplh Vla%ral Vlclltnd
_ I o
ro
c( RI i:N Depth D'alleter Slot Siic -�- Varenal
it Fo _ FL .-.-_,_I». -. __. in
r lo. _ FI .—_In. It _.
!)epth Svc Matcn.d
..,n to 11.
...• To Pt.
-- -
..IK1.131 'l k i If 1 If IAT Ti i 11, VVhI_1,b1:A S( ON S I k l;(-I P.I) I N M OR DAN(F W FI I I I�A N( V 2(:.N ELI,
( Ili IN y I AN])rDS, ANI)TIIAf -A(UI')�Of 1l IIS Rti(TIKU ILAS BEEN PROyIDCU�10 IHEWELLOR'NI�I?
1 J
j /1 _
✓ .
is LC,U1. - '!
SIt:N:Ah:Rf.Of I'I.It S(iN (YJ. . .CCCE .VE,D DATE
w is;!ui the uritginal In the Uicision of N ater Quality,GroundlR E.�ecTToi,1h3S'Cfail sett is Center-Raleigh.\C
o9v_:n,i61'hunc'\o.(919)7333??I,within 30 days. (AV-I REV,07;2001
JAN 30 1006
Asheville Regional Office
Aquifer Protection

(�# ) .I
WELL CONSTRUCTION RECORD
,lu"re :cpar1n)en1 of I.m uonment and Nat u{al Resources- DiN ision of Rater Quality-Groundwater Section
fONlkN( IORl6n1A'in %LjN-N's f: (print) l {�Z,_ d� _PLC{" <���- _ CERTIFICAI ION# 5t/
,. . tUNIkA( l(1R COAII',AN1 NAplt; Lb311�\1}c(, PHONE # 11) c, r...__ / •::
i. N t.LL( ONSI RUC IION PLRNII Iii _1SSOClATELIWQPERV1114
I,'applicable) (it applicable)
l I. i:SI heck Applicablu 13us): Residential* Municipal Public ❑ Industrial ❑ Agricultural ❑
m.iorlt Rccoccr ❑ Heat Pump ss "ater Injection ❑ Other ❑ If Other. List Use.
( \1 ION Topographic/Land setting
/
�c L ,', 1,< ��
D � Cunniv �--- ❑Ridge ❑Slope ❑Valley I�Plat
t GY[ / _ _._ . leheck ippropnac rwx)
hd,-.�,�, �I` �.�_i�p r,���) Latitude,longitude of well location
Lattude longitude source.❑fil S❑Topographic rnap
R W '� (� 1 ich,ckho,)
i
KStL ^�r` DI'PTH DRILLING LOG
Fran To Formation Description
tnih o�h�r . ,
:VI i R Ll VI-I_ licloN� fop of Casing. -
II le it phn,e l q l nme. —
,!' 1)t ASING IS _ FT. 'lboce Land Surface"
•.1,ni ca,,ng lerminaed et/ur bcluw land surface requires a -- —
anance m accordance with 15.1 NC to 2C.III IA.
n-.lnrn _-�'✓_--_ METHOD OF TLST
.R /UNFS (depth)- —
_ _ LOCATION SKET('If
)N: "Fype_ H j,l, Shoti direction and distance in miles from at Icast
V%all I ickne,. two State Roads or('ounty Roads. Include the road
i)Vpth )iamcicr or N4eight FI- Nfatcrial numbers and common road names.
Ft
-i o Ft _
'.h(al T )' th /M1atenal t Method
f o _ Ft _
Depth Di,'nwtcr SImS¢e %Ucrlal
.r To___ _ FL_ _ _m. in.
(ikA\ FI.PACK -
I)cpth 1vc \fiuen:d
To I
lb-__._.. - G1.
uF.I:'. V.R III Y 1IIAI THIS WVFlLAtASCONSIRl.( If.D IN ACCORDANCE V+ll II IAA N('AC 2(',WFI 1.
I1r�1 51 4ND.-ARDS, IIAI A(0M OF 11115 RL( ORD HAS 13FEN pROI"IMI)TU THE skELL M',NFR
till,N.AII;RFOI PE RSON ( ONST 77. Rr ECEVE : E
'.ubtult the orininal to the Division of R"ater(lualih, Groun seater Set•tion, 1F16'%lail tieoice Cente -Raleigh, NC
fish Phone No.[phone], rsithin 30 days. GW 1 REV. 07r2001
JAN 3 0 2006
Asheville Regional Office
Aquifer Protection

(�o
WELL CONSTRUCTION RECORD
I cpannient oI I ncnooment and Natural Rc ources - Dnision of Water Quality-Groundwater Section
.! U\ikV IOR(1\DI\'I III % ICs\IF. Ip.00 I er -t Ji L kjC1 CERf[FICA"]IONN537�f
7 I � ���
„ri.. I (,Ilk%( IOR(OHPAN) N%NIF. C+-I.Cc! ,-c' �l�/ U(�1Z `J 6e 1.11ONE H L il4
FAIL CONS IRhC'[ION PF.RN11'fa /7_�'1 ASSOCIAI-t:U\1Q YERNf ITp --
I it applicable) (if applicable)
GSI (C'heck Applicable Box):Residential Municipals public ❑ Industrial ❑ Agricultural ❑
oaln nt_ ❑ Recovery ❑ 1Ica( Pump Water Injection ❑ Other❑ If Other. List Use _
. I (A 11 ION
-
P I ]] Topog aphic/Land setting
� ,� ❑Ridge Slope ❑A alley ❑Flat
/CLLG- Lt _ check appmpiate bav)
(JOnmun ;...•� I [gyp( .du Latitude longitude of well location
`- t t 7 _ < ' I�_ - i tJerr cs mmume..ecuud.)
_ J '� •_I �(�� � I _t . I_antudc longitude source:❑GPS❑Topographic map
I Y.111 uI N.,mc i I check boxl
._y Lc rt1( _''( I`• DLI'TI I DRILLING LOG
Ntaw /p t From To Formation Description
ATFR LFA LL Below 1AIp of asing: �C` I-T — ---
II..e_ dAbo;e I op iCtangi
(,i• (�F t A,)iN(i IS f — FT, Abu%c Land Surface --- -----
'qI of casutq terminated at/nr helnn land surface requires a --- -- -- --
:;L­ia rc,If, with 15 k N(A( 2f .(IIIN.
,L_ bi[THOD OF TEST__ --
„111 R /O''i (depth) _ L`i '
LC OATION SKCTC.H
iType_J� T N1110unt I_ y.�;�� Show direction and distance in miles from at least
Null lh icknc,. two State Roads or County Roads. Include the road
Depth Demeter or A4'ci ehi Fi. 4latcrial numbers and common road names.
s Ft.
F - — --._
rd01 i )cpth %lateral Method
Ft ?Ii has.[ - F e r
_ I't.
�' RLI-'� Ucpdi DIflI11Ber SIo13izc 1111cn11
in �s
in. in.
:),pill Nvr Maten:d
I f'I.
To II_.
i k F:f41 ! i-.k i Ty THAT T 11Is AA f:I.L N AS( ON I kCI l fD IN ACC OR DAM E 1N 1111 15A NCAC'2( %k ELL.
t l'Yy N 4ND.ARDS. AND 11l:aT %(OPS of 1111s RI_( OX[)IIAS I31C1:N PRoA'IDLL TO 171E%ELL ON,k f.R
r
Q2-
,I(INSA11:RFOI 1'I-RNON ( ONSIRt-, 111Ti'TTtf. .. DAIE
Nnbant Inc original to the Di%isiun of y1'ater Qualih", Groundw aEeECIFE 116VE�IDil Service :enter-Raleigh, SC
'(,19 t(3h Phone No.[phone].ssithin 30 dae5. GW-I REV. 072001
JAN 3 0 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and
/^•Natural Resources-Division of Water Quality-Groundwater Section
'�
WELL CON TRACTOR(INDIVIDUAL)NAM print)( /Q�h rX.�+ CERTIFICATION#__p
W4a.L CON"1'RACCOR COMPANY NAME���,Pd y/_.`//E]-�4 L�d E r/ / �Pr�ty_PHONE # �4n/I g ' -3� 7'
STATEWELL CONSTRUCTION PERMIT#___ _/3-' _ASSOCIATEDWQPERMIT#
00100011 (if applicable) (if applicable)
I- WELL USE(Check Applicable Box):Residential K'Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
WE!WE!,[,LOCATION: I -
,[,Ncarc�t T con:_. oe Sy t Topographic/Land setting
,(f�) �@. County k.)r.ncrC DRidge []Slope []Valley Flat
- E �X V'le r E71 1 () (check appropriate box)
;`:h'eet Name,Numbers,Community,Subdivision,Lott,,No-Zip Code) Latitude/longitude of well location
�. UVv'N)iR:__ e. r n `�')+� 'L D 0 A (degrees/minures/seconds)
Andress 35 Elot I ),q� Latitude/longitude source:DGPSDTopographicmap
'Street or Route No.) (check box)
111 —�rie—sv 11�< N C `l,r�% p DEPTH DRILLING LOG
T city or owh $tale zip Code From To / Formatio Description
b 6 4/
Arc,code-Phone number �/� r
4. DATE DRILLED I ; T
5, TOTAL DEPTH: '3C c '
a tF.c u:;'.Lt. uFrpi,nC F. ci rnu; to l.,l I o YcS 11 NO
7. STATIC WATER LEVEL Below Top of Casing: a C) FT.
(Use"+' if Above Top of Casing)
&. "FOP OF CASING IS ' FT.Above Land Surface'
F I op of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. YIELD(gpm): ab METHOD OF TEST
I0, WATER ZONES(depth): -S -
LOCATION SKETCH
DIS1NFE('l'fON:Type L+T H Amount 1.-{ Imo Show direction and distance in miles from at least
(.'ASINCi: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
rr, ___0__To '4 4 Ft.
From _.._ To Ft,
From To Ft. �-
13_ (TROUT; Depth Material Method
From 0 To2b _Ft.
From To Ft. _
14. :SCREEN Depth Diameter Slot Size Material t]
J�
From To Ft. in. in.
From _To _Ft. in. in.
I9. SAND/GRAVEI.PACK:
Depth Size Material
From To Ft.
Frum __ To Ft.
i6, RP;NIARKS:
I DO I IIiR EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
t CONSTRUCTION STANDAA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUC 'CCW//E��LL�� ``''CC DATE
Submit the original to the Division of Water Quality,GroundWIlter SecR&Cyi®1M5DCenter- sleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I V.07/2001
JAN 30 2006
Asheville Regional Office
Anulfg r PrnfiaMinn

WELL CONSTRUCTION RECORD J
North Carol ma-Department of Environment and Na//tural Resources-Division o��f'I/W ater Quality-Groundwater Section
WELL C'ON'IRAC'FOR(INDIVIDUAL)NAMQE�1I(print)_eLn 1.�L O (n ]E lA n o �.n CERTIFICATION#
WELL CON'I RAC"FOR COMPANY NAME Sit y '_.{/J1�3�", a d d F �j_ t C PHONE # ($ffG((S!� - 3/'/D
S'I AFL WELL CONSTRUCTION PERMIT#___Z7� - ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I WELL USE(Check Applicable Box): Residential�, MunicipaVPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
. W ELI,LOCATION: f Topographic/Land seit'
NearestTo-wn.:"Ll�p-i.,I Iage I�e_ County ��er • ','('�,,{ ❑Ridge ❑Slope ❑Valley Flat
_�♦—�.2�` Vr'I la cre_, o-F isle �-I ('a.
1 - 'FJ ^ • (check appropriate box)
S!rcer Name,Numbers,Community,Stbdi,ision,
..Lot No.,Lip Cale) Latitude/longitude of well location
3. OWNER: 1�1.11JLK.�Jhp (degrees/minutes/seconds)
Address �/�'7 (°N �. IY)-�-r, Q,�; Latitude/longitude source:❑GPS❑Topographic map
(Stree or Route No.) (check box)
P D t p __ N C' '-7 �- DEPTH DRILLING LOG
cry or Town ate Zip(cde From To / Form^an n Description
hrea code-Phone number
4, DATE DRILLED
5 TOTAL DEPTH: tIASI
' ,'( 'C W!,! l p ll I A!'I. l:Y1C Ilq( O_ \vll Jl VCl U No
7, S 1 ATIC WATER LEVEL Below Top of Casing: '�C, _FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface-
'I op of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):�_METHOD OF TEST rs
(i. WATER ZONES(depth): 50-
- 5 r LOCATION SKETCH
I. DISINFECTION:Typc_HTr_ AmA nt 1.-)'l 4-k 14,, _ Show direction and distance in miles from at least
2. (`ASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Fran_b To�c a Ft. („ ti P V C,
i-rom_ __ . _To FL
Frum______To Ft.
3. GROUT: Depth Material Method L
Fo,m--jC�—_To�.�
From _ To FL
14. SCREEN: Depth Diameter Slot Size Material CO
From_"_ - To Ft. in. in.
O
From_..___To _Ft. in. in. 0-1 �
I;- SAND/GRAVEL PACK:
Depth Size Material
From _-_ To Ft.
Ft-From To—
6- REMARKS:
I DO I LREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDAR7S,AND THAT A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
__ _ -� a �ei /.;z --3i_ o.s,
SIGNATURE OF PERSON CONSTRUCTING TILE WELL DATE
Submit the original to the Division of Water Quality,Gro dwatf�Eit JD��0rvice Ce er-Raleigh,NC
2 7699-1 636 Phone No.[phone],within 30 days. G -1 REV.07/2001
JAN 30 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resour [vision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAIyE (print) 2�__ l,��J CERTIFICATION# 3L3514
N'F:1.1.CONTRACTOR COMPANY HAM.__V_ey)H v' we PHONE # 01 L.q %- 31 17 D
STATE WELL CONSTRUCTION PERMIT# i t}D .D- _ASSOCIATED WQ PERMIT#
(if applicable) (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 LOCATION: Topographic/Land aphic/Land setting
Nearest Tlywit C-Y.fL County�� ❑Ridge `Slope ❑Valley ❑Flat
✓2 r(_'r /' [R� (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 0�1e
(degrees/minutes/seconds)
Address i✓ . Latitude/longitude source:❑GPS❑Topographic map
CQ
(St eeSSor Route No.) / (check box)C l )I C_ Zip C ) DEPTH DRILLING LOG
city or Towm star ode From To / Forma 'o Description
Area code-Phone number
4. DATE DRILLED I I
5. TOTAL DEPTH:_
Dr)I:S yrP: : REPLACE :iv�S rin,r; t,A;1:11,t V1:S -
7. STATIC WATER LEVEL Below Top of Casing:__��FT,
(Us'e`+"if Above Top ofCasing)
S. TOP OF CASING IS L T. 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): .70 METHOD OF TEST
10. WATER ZONES(depth): 51P5 ' - as ��ra
LOCATION SKETCH
1 I. DISINFECTION:Type �T}- - Amount I 0'l 4���. 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. Materi I numbers and common road names.
From�_To 90 Ft. 11 10Vc
From To Ft.
From To Ft.
]3. GROUT: Depth Material Method
From, To
�V—Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in, - --
From To Ft, in. in.
15. SAND/GRAVEL PACK: Co
Depth Size Material o
From To Ft. ua :-
From __—To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA D AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/I -3/ dS
SIGNATURE OF PERSON CONSTRUCTING THE WELL TE
Submit the original to the Division of Water Quality,Grotiodwateif",61"Qrt,ice Cent er-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. G -1 REV.07/2001
JAN 30 2006
Asheville Regional Office
Anu'rfer Protection

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Secti�on'��p
W r,LL CONTRACTOR(INDIVIDUAL.)NAME
(print)-U, Je, f�a.� � CERTIFICATION#-yja
W F:LL CONTRACTOR COMPANY NAME (�YPPss��/...i r'o„zy( o 4 V t^='s^ .�S.� PHONE # (9-4Z L/�Y7n
S l A"FE WELL CONSTRUCTION PERMIT#_ K P ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 16 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
. WELL LOCATION: Topographic/Land setting)
Nearest Town:_ �,.,�.r�V- County 1>ai ❑Ridge ❑Slope OValley Flat
41 n i+ SOfr C rrirE divisiTr ) _ (check appropriate box)
1 Snvet Names Numbers,Commnl Sob on,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ _ (degrees/minutes/seconds)
.Address _._ o _ Latitude/longitude source:DGPSOTopographic map
1Street.or Route No. (check box)
Y r<y t f Cam' n s-7 ri DEPTH DRILLING LOG
t'o)or V n St ato ) zip Code From To t Formation Description
I D/ /,
Aura utde Phone number �O C� 1
4. DATE DRILLED_
5. TOTAL,DEPTH:
rmu: ruri i o vt.c I t N�" bd
7. S7 ATIC WATER LEVEL Below Top of Casing 3DO FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
,ariance in accordance with ISA NCAC 2C.0118.
9. YILED(gpm):_ I METHOD OF TEST
10, WATER ZONES(depth): Li D S ' — C av,-
LOCATION SKETCH
1 1. DiSINFF('FION:Type Amount 1 51 4 1 as , Show direction and distance in miles from at least
2. C'ASINCi: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. 1
From— Kam—_To 1v q Ft. (o I t a v r
From_ _ _ To Ft.___
From To Ft.
3. OROCT: Depth Material (} Method
/
From Q _ 'forma Ft. ( -9- 3 • • ..f, r
From - To Ft. -
1.4. SCREEN: Depth Diameter Slot Size Material `
From To _Ft. in. in. c-p
From_... To ..Ft. in. _ in.
.5_ SAND/GRAVEL PACK: u:
Depth Size Material
From To Ft.
From To Ft
!6. RLMARKS:
I DO l 1 G;REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
' ON ST R UC RON STA D RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WE`L'LC^ ATE
Submit the original to the Division of Water Quality,Gro ndwatRECEA 6�a�IService C ter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. W-I REV.07/2001
JAN 30 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Ni rural Resources-Division /of Water Quality-Groundwater Section
l//
t4 FAA,CONTRACTOR(INDIVIDUAL)NAME'(print)l—No/ CERTIFICATION# �
"Fa.6 CONTRACT OR COMPANY NAMF,Y�'! J_-.�/5/�ta�- LWa, ----PHONE #
S'I A'rE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE.(Check Applicable Box):Residential IV( Municipal/Public❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
1 WLLL LOCATION: Topographic/Land setting
Nearest Town:_ County ZJbe� ❑Ridge ❑Slope OValley setting
6J p */,Z > (check appropriate box)
1 Street Name.N be ,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3. resR Add .:
(degrees/minutes seconds)
Address _ -__ 2 Latitude/longitude source:OGPSOTopographic map
(Streetq Route No.)�A� r 7 / ` (check bon)
—_ o C t U DEPTH DRILLING LOG
cuy o,Town State ' zip Code From To I Formation Description
Area code-Phone number ) �� ,�
4. DATE DRILLED 1 a, - 1 2 — S
5. TOTAL DEPTH: Y r
REP:.^.:'L. YI:N U nn
7" STATIC.WATER LEVEL Below Top of Casing: /d,p FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
"Top of casing terminated atlor below land surface requires a
variance in accordance w'h 15A NCAC 2C.0I18.
1). YI LLD(gpm): cD)Y.� METHODOFTEST
I0, WATER ZONES(depth):, — c7—e'OL .
LOCATION SKETCH
1 DISINFF.<'fK)N: Type /-� Amount 1 -(F1,1� Show direction and distance in miles from at least
f 2. CASING: Walt Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Frran_l- _To MP, Ft.L. u c'
From__ - " _To Ft.
From---,--To Ft.--- '-
I3. (4ROIJT: Depth Material Method
From To--,2L Ft.-
From _To Ft.
14, S(.'REEN Depth Diameter Slot Size Material -
From_.. _To Ft. in. in. co
From To Ft. in. in. O -
u�
Iti. SANDiGRAVELPACK:
Depth Size Material
From____ To
From_- _To Ft.
I6. REMARKS:
i DO F[EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
t ONSTRU(TI,ON (STANDARDS,AID FIAT A COPY O�ECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON((ONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwat r Secti 1�6��rnt�'� �ef��7 fkenter-R eigh,NC
27699-1636 Phone No.(919)733-322I,within 30 days. �V V G • G L/(nt V.07/2001
JAN 3 0 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD �•1`�'
North Carolina- Department of Environment and Nat rat Resources-Division of Water Quality-Groundwater Section
W 'f FCL CONkAC'I OR(INDIVIDUAL)NAME (print) 20 1.(�,,, CERTIFICAT.I,ON#
ss'f:LL CONTRAC IOR COMPANY NAME � Lc� Q. _ PHONE #
S'I A FE WELL CONSTRUCTION PERMIT# �y�.2. ASSOCIATED WQPERMI'f#
(if applicable) (if applicable)
1 WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
3. 'd!(iI.L LOCATION: _ TopolVmphic/Land setting -
Nearest T wn: a e County, zJoo� /
f�fl�� �� t ❑Ridge `1Slope OValley OFlat
Gr X.k appropriate box)
1 Street Name,Numbers,Community,Subdivision,Lot No_Zip Code) Latitude/longitude of well location
3. OW NiR:-�dtl �O ne /C! (t �,
(degrees/minutes seconds)
Address _ _31`, r-I 5'ne n I Pei Latitude/longitude source:OGPSOTopographic map
yStreet or1Routte�too.) (check box)
I J@X�tc t 7J C $ 7 _ DEPTH DRILLING LOG
r its or state —f zip Code From To Formation Description
--) 9
Are;,code Phone number 9�/ t Z y—it
4. DATE DRILLED 1 7.- 14 -L)S Y'
5. TOTAL DEPTH: 1.J5
Yt-� U NU
7. STATIC'. WATER LEVEL Below Top of Casing: S FT.
(Use"+"if Above Top of Casing)
8. i-OP OF CASING IS)_FT.Above Land Surface*
-lop of casing terminated atlor below land surface requires a -
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I pr_4-METHOD OF TEST �YS -
i0. WATER ZONES(depth):- 125 , /'Q }-X
LOCATION SKETCH
I DISINFECT TON:Type Amount el 5 4-61�� _ Show direction and distance in miles from at least
C'ASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_Q To Ft.
From____ To Ft.—-
From__.-__To FL
13. GROUT: Depth Material yy tylethod
Fn,m-j__ Fo-a�Ft. f 4 wnx a . is •-{-'4-^y^l- C7
Flom—-.—To Ft._ ___ 1
CD
14, SCREEN: Depth Diameter Slot Size Material
Prom___,. -To Ft. in. in.
From__ _To _Ft. in. in.
ii SANDfGRAVELPACK:
Depth Size Material
From _ To Ft.
From - To Ft.
f6. REMARKS:
DO I ILREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
('O!vSTRUCTION S'L ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S16NATURE OF PERSON CONST T}IE WELL DA rE
RECEIVED
Submit the original to the Division of Water Quality,Groom water Section,1636 Mail Service Cent -Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. JAN 3 0 2006 G 1 REV.07/2001
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /
WELL CONTRACTOR(INDIVIDUAL)NA (print)__- /-� I � CERTIFIC�yATION#
WELL CONTRACTOR COMPANY NAME?tS_(=y]y_ IJYc-S YVr I ) "f t' . i`�11F-t' PHONE # P ��I R ' 3)7 D
STATE WELL CONSTRUCTION PERMIT# y U ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION://} / Topographic/Land Setting
Nearest c j�t County [ ;aZLtll�6GL ❑Ridge ❑Slope OValley Flat
��` o V r (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1 1 1/ t yr )(- /: (degreesiminutes/sewnds)
Address ti 1 1 1 Latitude/longitude source:❑GPSOTopographic map
(Street or go NO.)No.) (check box)
Cb I I/X z 0— a S 7 L ) DEPTH DRILLING LOG
vy or Town Snub zip Code From To Formation Description
Z '
Area code-Phone number G /�.
ce
4. DATE DRILLED
5. TOTAL DEPTH:
1V:fLL REPLACE uvw'r(N(i 1",�li!] ° YES U NO � -
7. STATIC WATER LEVEL Below Top of Casing:_ 10 FT.
(Use"+"if Above Top of Casing)
& 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 Q METHOD OF TEST rs
10. WATER ZONES(depth): 1 9 S
�1—�— LOCATION SKETCH
11. DISINFECTION:Type I--FTI-1 Amount 1 4� 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. PyL
From To Ft.
From To Ft.
c_
13. GROUT: Depth Material Method
From_D_To—DD—FL C Q-a
From To Ft. �-
14. SCREEN: Depth Diameter Slot Size Material C7
From__To Ft. in. in. Ln
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 CC,,lt/I pp nn TE
Submit the original to the Division of Water Quality,Grou dwatelREQ 76�AS(Lice Cen r-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. G -1 REV.07/2001
JAN 30 2006
Asheville Regional Office
A UHer Protedon

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
�-Division of Water Quality-Groundwater Section
WELL.CONTRACTOR(INDIVIDUAL)NAME1 (print)�(� t 1_ Y., f� J'— � CERTIFICATION
WELL CONTRACTOR COMPANY NAME( Cjjp UroT . \A/ 11 -1 YuPHONE # (�-`!�
STATE WELL CONSTRUCTION PERMIT#_ /5/0.2 _ASSOCIATED WQPERMIT#
(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 LOCATIO : -
Nearest e , �e. County Topographic/Land settiD _
❑Ridge ❑Slope ❑Valley Flat
(check appropriate box)
(Street Name.Nu/mb rs,Community,Su division, o No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ IIt�I a,ta_, '� '/ A-I. (degrees/minutes/seconds)
Address NRGI ('frr 'fr .�- Pry Latitude/longitude source:❑GPSOTopographicmap
�e (SStreet or Route No (check box)
n C 7 DEPTH DRILLING LOG
(.sty or Town I Staid Zip Code From To FOmla�i0 Description
Area,ode-Phone number
4. DATE DRILLED l/.-/.a
5. TOTAL DEPTH: .2 Q
<, 11—)FS jai(.! I. REPLACE Ylig Lt NO
7. STATIC WATER LEVEL Below Top of Casing: Lil� FT.
(Use"+"if Above Top of Casing)
S. 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.
y. YIELD(gpm): 2!_METHOD OF TESTS
10. WATER ZONES(depth): (n c� '
n
LOCATION SKETCH
11. DISINFECTION:Type_} amount��5141.145 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��Ft. A 11 P ye—i
From__To Ft.
From To Ft.
13. GROUT: Depth Material
Method
From D To �� Ft. �p
From__To Ft.
14. SCREEN: Depth Co
P Diameter Slot Sin Material _
From__To Ft. in. in. C-3
From To
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From Depth
Ft.
From_____ To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND R $AND THAT A COPY 9IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINGcc//��C ����pp TE
Submit the original to the Division of Water Quality,Grou dwateiRilllr�b161INAO
27699-1636 Phone No.[phone],within 30 days. ' rvice Cen er-Raleigh,NC
G -I REV.07/2001
JAN 30 2006
Asheville Regional Office
Acluffer Protedion

WELL CONSTRUCTION RECORD 3216S4
North Carolina-Department of Environment and atpral Resources-Division of\ ater Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print), /�f Ar js CERTIFICATION#
/�u.(\ . _w ,.^ n p/�r��j !
W ELL CONTRACTOR COMPANY NAME_/ Q�.2 �4 nA - /,!� d 1� r PL4 ¢,PHONE # 6.. g 5� 7b
STA"I'E WELL CONSTRUCTION PERMIT# /�/6 , ._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
Neares own: Co ty 1 ❑Ridge ❑Slope OValley I�'lst
(check appropriate box)
(Street Name, m¢,ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: A/L/l\l �� / .�f (degrees/minutes/seconds)
Address _ ,j��_�[�/n Latitude/longitude source:OGPSOTopographic map
(Streept qq��Royy,t o.) (check box)
/ - Ll/L(i Q +r nI C 7 S) DEPTH DRILLING LOG
ity 'rn state Zip Code From To Formation Description
Arcs code-Phone number
4. DATE DRILLED I ) �{ -p`J - —
5. TOTAL DEPTH: a[ r
L-. Dncc W1r;.1. REPLACE 1._v IS'rfnir; )xrLl!7 YY,S U M-)
7. STATIC WATER LEVEL Below Top of Casing: 11) FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS / FT.Above Land Surface"
*Top of casing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.011P.9. YIELD(gpm):__.�_METHOD OF TEST o� A rs .
10. WATER ZONES(depth): a /5 ' - 1 a c p rn
LOCATION SKETCH
11. DISINFECTION:Type H'T Amount 4.7-!-), -L. 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_D—To N O Ft. 1, 1 t P UL
From__To Ft.
From To Ft.
13. GROUT: Depth �IMaterial Method t--
From CJ To 11) Ft. C o w
From To Ft. -- --
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in. CD
From To Ft. in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From____To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC'TIION S=;;z
PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
VO /-? 3/ USER CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,FASheville
V DDIlail Sery a Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
0 2006
gional Officerotection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural nnResources-//Division of water Quality-Groundwater Section
WELL.CONTRACTOR(INDIVIDUAL)NAME}�J{Print) .� rt � �p/I� � _ CERTIFICATION#44//_9
WELL CONTRACTOR COMPANY NAME_/_ — [ �,p () �_ I PHONE # (AQ, Aj -3/ '7
STATE WELL CONSTRUCTION PERMIT# 31"�-,?,- _ _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. WELI.LOCATION:
Nearest Town: !� ne5v t 1 County cpA Topographic/Land setting
E.f. _ 9 ORidge ❑Slope OValley [Flat
T-+P C e'-K A Is (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: t kICI �� p rY qLC% (degrees/minutes/seconds)
Address 4 U1 1U 1 , - L a (f — Latitude/longitude source:OGPSOTopographic map
_,N� (Street or Rogto No.) (check box)
1 t 'agl'e Vn l lr Mc a r;' DEPTH
- - �( DRILLING LOG
(.ny o T State zip Code From To � Formation Description
Area code-Phone number 10 , � t
4. DATE DRILLED I 1 - 2-O.Pj ZS A 2
5. TOTAL DEPTH: 2 DD '
r, DC)FS %`,T!-l. REPLACE I x;lS'n�i(; �a�1:1.1_� vuS �I NO -
7. STATIC WATER LEVEL Below Top of Casing:__ 'aC2-FT.
(Use"+"if Above Top of Casing)
8. 'TOP OF CASING IS ) FT.Above Land Surface'
'Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 0,6_METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
1 l. DISINFECTION:Type--HT�4 Amount 4L�+L 14 , 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
_]2__To-_4&_S_Ft. (o I` _ \
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From_.}__To Ft.
From To Ft. r
14. SCREEN: Depth Diameter Slot Size Material "—
From To Ft, in. in, c�
From To Ft. in. in.
15. SAND/GRAVEL PACK: CD
Depth Sire Material Cn
From To Ft.
From To Ft. -
16. RFMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSIRUCTION STANDARDS,AND THAT AAC�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONS fete�/�C, E E
Submit the original to the Division of Water Quality,Groom water 1t-onylb36'Mail SerDvice Cente -Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW 1 REV.07/2001
JAN 30 2006
Asheville Regional Office
uifer Protection

�#
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and a_tural R/gso D[�'/.igion of/W/pter/QQQJua ity-Groundwater section
,//n
WELL CONTRACTOR(INDIVIDUAL)NAME ( riot) ) / �J)(_h_ ICU�G�a. CERTIFICATION gyLK
WELL CONTRACTOR COMPANY NAME_ -P�u LYt-o% . � q m�.y�t, PHONE # (VA �X — �� 7 Z-1
STATE WELL,CONSTRUCTION PERMIT# ��� _._ASSOCIATED WQ PERMIT#
(if applicable) �/ (if applicable)
I. WELL USE(Check Applicable Box):Residential ( Municipal/Public 0 Industrial ❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION, _ Topo phic/Land setting "
Nearest Town: s t e County_T�"A ORidge Shcope LIValley E]FIat
L _r 14 Y'n Y S r�V hec appropriate box)
(Street Name. 'umbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_- L )om Oe �1 (degrees/minutes/seconds)
Address 1 h I- 'Y'es Pin C- Latitude/longitude source:OGPSOTopographic map
(Scree(or Route No.) I _ (check box)
I4 ,_, ✓�F y_) e 1`1 C_ 2`k rl CS(p DEPTH DRILLING LOG
city c(r Town State Zip Code From To Formation Description
fl ��
Area code-Phone number �� c 1 �,
4. DATE DRILLED 1 i - .?61 -Oa
5. TOTAL DEPTH:_ 1 Lz r
h. '),)ES \",'I'I L REPLACE I:v lyripu; A",rl_!! ? YES U NO
7. STATIC WATER LEVEL Below Top of Casing: I I_ FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS--FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):—R—METHOD OF TEST__�_ �
10.WATER ZONES(depth): i7!y rr
l 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 To _Ft. Co r Q V C. _
From To Ft. -
From__To Ft. r
13. GROUT: Depth Material Method
Fromm_To Ft. i.�.
From To Ft. ra
14. SCREEN: Depth Diameter Slot Size Material CD _
From___To Ft. in. in. rn
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 STAN ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—id-2 _ I_? - 3/—6-s'
SIGNATURE OF PERSON CONS RUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Groun w RECEIVED
ater Section,1636 Mail Service Cent( -Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. JAN 30 2006 G I REV.07/2001
AS hevllie Regional Offlce
uffer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section.,
WELLCONTRACTOR(INDIVIDUAL)NAME+ (print) D _- DiA J4 � t CERTIFICATIOON#- rl T--"
WELL CONTRACTOR COMPANY NAME" ree ve./Bros " \�tle1) -4 At4 —n .�yr_-PHONE # (�3 Io�s ' =� 70
STA"FE WELL CONSTRUCTION PERMIT# �ct L� „Z —ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
l. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WFd.I.LOCATIO Topo aphic/Land setting
NearestyT�oown. .c County ❑Ridge lope ❑Valley ❑Flat
r t /e- f h/ ) )PC' c,4 (check appropriate Lax)
(Street Name,Numbers,Communit ,Subdivisan,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: aC//14✓I (degrees/minutes/smonds)
Address �(��j v . ,�'r Latitude/longitude source:❑GPS❑Topographicmap
11 (Street or Route No.) (check box)
,te c V t 1 1� I IQ Cr —2$% � 1p DEPTH DRILLING LOG
city or'rown State Zip Code From To I Form Yon Description
( � O a
Area code-Phone number 5 1 r c7//
4.:57i
4. DATE DRILLED
5. TOTAL DEPTH: W '
i., —DES \\n:I : RE:nLACF EX!S r1N: \\/I:I ).r YI:S r,t
7. STATIC WATER LEVEL Below Top of Casing:--dl) FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�"FT.Above Land Surface'
*Top of casing terminated atior below land surface requires a
variance in accordayce with ISA NCAC 2C.0118.
9. YIELD(gpm): (D F METHOD OF TEST
10. WATER ZONES(depth): 4 4 cT
LOCATION SKETCH
I I. DISINFECTION:Type /-fY 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__To 4 Ft. 'I
From__To Ft.
From To Ft.
13. GROUT: Depth aterial Method
From b To aV Ft.
From To Ft.
14. SCRIiEN: Depth Diameter Slot Size Material
From _To Ft. in, in"
From To Ft. in. in. co
15. SAND/GRAVEL PACK: t�
Depth Size Material v�
From_-_ To Ft.-
From—-----To Ft.
10. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"I RUCTION STANDA D ,AND THAT A COPY OF MRD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,GroFR
7RO910MIMO
r-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. -1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and ��a/tural Resources-/Division of Water Quality-Groundwater Section
�WELL CONTRACTOR(INDIVIDUAL)NAME/printe -._ r _./t-d/jl-,t!L__ � CERTIFICATION
WELL CONTRACTOR COMPANY NAME.')_('/,_„///,Ic.j,L.key_ ''// -0 �B®/' 'I LaiNpjr (p.t PHONE # [1V G�S
STATE WELL CONSTRUCTION PERMIT# �YD ___ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIO -
Topographic/Land setting
Nearest Town: `County ❑Ridge ❑Slope OValley WFlat ...
(check appropriate box)
(Sweet Name,Numbers,Community,Subdml n,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: KILI q (degrees/minutes/seconds)
Address $/] 0 Latitude/longitude source:OGPSOTopographic map
tSt et or Route No.), (cheek box)
- --(n � DEPTH DRILLING LOG
ny or Tn state Zip Code From To y Formation Description
( )e C� d -
Area code-Phone number � `� �
4. DATE DRILLED /C)--�?O -Z) �
5. TOTAL DEPTH: St( !
\OtaI-L REPLACE !..v igrinir; Aqn±i 1_> YuS rl NO
T STATIC WATER LEVEL Below Top of Casing:_§-,Q
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD (gpm): .306 METHOD OF TEST_
10.WATER ZONES(depth):
LOCATION SKETCH
1 I. DISINFECTION:Type 6-I`ZI-1 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_ D To--W—Ft. , if QjJC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From Z_To-,96 Ft. ,y�p
From To Ft.
c_
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in-
From­To Ft. in. in. ca
15, SAND/GRAVEL PACK:
Depth Sin LD
Material N -
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
�:I
SIGNATURE OF ER EE �� DATE
Submit the original to the Division of Water Qual y,Grount�aTerk i[onE�f636 Mail S vice Center-Raleigh,NC
27h99-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
JAN 3 0 2006
Asheville Regional Office
kcigifer Protection

V 320502
WELL CONSTRUCTION RECORD
Not'IIt('molina - Deparuuem of P.nviron ment and Natural Resources- Division of Water Quality-Clroundwaler Scow
\Vr:[.L CON I IZACI OR(INDIVn)t\I )NAatt rt1nl) "V A Z < �r A � CEimPCn•IION#-?
\vILI.COX]RACIORCONIPAN\ NV\H•:�' ✓_"?,C'.----_---ruoNR s KM, (.�7..3YVsf
r.VrL:\ct.t.l.coszrncc ru)N rt Rxnrn ASSOCIA1 ED lvO P -mmi-rt
ti(applic;tblcl (il:tpplicablel _ -- _
I \\'GAL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural❑
\inniluring❑ Recovery ❑ Heat Pump Water Injection ❑ Oilier❑ If Other, List.Use - -
'_. WEI L. I.00ATIOt v( A/k
��Topographic/Land Setting
,'rr�sl 'I'mvI : r'C Count\- 'C? L`11CIdge ❑Stolle ❑Valle)' ❑11m
//�kl7J it I chc<k:ppwp,wlc box
I tilircl Name.N..... ,Conu„unity.Suhdiaiaiun•Lx,t No..Zip 00e) Lat llude/lungl[tlde or Well location
O\YNfW lam\ "� (dcyrociminulcshccunJsl
Addicss — a .�", Laliluddloncitudc source:❑GPS❑Topographic mall
.Ile
ti -•9 ur4 le W.I 1'check.Nix)
Ae . 4H ICI-.rn1 DRILLING LOG
,fn n,„ erne Zip C,Mi: I roal To 19, r tiun I escription
\m:n0c-I'umv uumlmr ) q N
1. D,\"flf UICILLGU /,' CC_
6. DOES WELL REPLACE EXISTING WLLL? YES ❑ NO B",
7. S'l':\"I'ICWATEIZI.,HV81. I3elowTopul'Casirg:3_1.T.(Ilse'•+"il'Ahow Top of Casing) -
N. 'I Oil Ol- C'ASIN6 IS Fr. Above Land SurGtcc•
•'1'up of casing laminated al/nr helow land vrrface rewtim a
r:arwiwe in oeeorda with I:,\NC\C 2C.01 Ia.
9. YILLD(gpnU: Ni LiTI IOD 01:TGSIF 14� —
10. WATIiR ZONES(depth):_-
LOCATION SKETC 1I
I I. DISINH:CTION.Type Amount Show direction and distance in miles from at least
12. CASING: Wall hickncys two Slate Roads or COLHIIV Roads. Include the road
.� Depth ctln to or\',ciehliht. ���cr}Ay numbers and common road names.
Proof�3 "ra_; —tL � __.._ 'I y
Prom
o
I I (iRUIJ"r: Ucpdt " �bt:neri;d bic[hoJ
-a
1-I. SC'RIJ:N: Depth Diameter Slut Size Material •-
p
I?. SAND/GRAVEL PACK:
Depth Size [vl:nerial
hook To _—. --
Ih. Rl:%IARKS:.___
I DO IIERIMY CE10IfY THATTHIS WELL WAS C'C•NSTRDCTED IN ACCORDANCE WITI 115A NCAC 2C,WELL
CONS IRUC HON STANDARDS.AND THAT A COPY Of TIIIS RECORD I[AS BEEN PROVIDED I'D THE WELL OWNER
11-3o-O-� -
—�g ATURL OP I'ER30N CONSTRUCTING THE WELL DATE r
tiubmit the ill i,,'imal to the Division or Water Qua lily,Groundwater Section, 1636 Mail Seri ice('enter-Raleigh,NC
27699-1636 Pl a is No.[phone],within 30 daes. G W-I REV.07/Zl)01

WELL CONSTRUCTION RECORD 320504
Not Uniolima - Department of Euvir(on)ent and `I:tural Resell • s Division of Water Quality-Groundwater Sectiioo�nJ ('
%N'ha.l.('ON'Ot.k("'MR(INDIVIDUAL)%NAlK (printt-/ � p e_ CERTIFICATION NIMZ
U'rLL(YtS'r ItA("1'O R(,()NJ 1,t".Y N.N NI I..J/'f(e_wed— 1- -- 1•11ONEa .�
5 r.\TL:)(-61.1.('ONS'r1iCC"IlOX PF.IiAII'fq_ ASSOCIATED wQ PERNlrra
1 il'applirahle) _ (ilapplicahle)
I. \\'L' -L USE (Check Applicable Box): Residemmi C7/Municipal/public❑ Industrial ❑ A_ricultural❑
:Mollilof ❑ Recovery ❑ Heal Pump W:Ccr Injection ❑ Olher❑ 1Willer, List.Use
'_. WI;I.L. LOC'AII0N: '
• // � �Topographtc,'Lanlsctting
Ne:lresl 'town: v_`IC'onnit �WJC'C-y
CC, . .__ _ �� _ .. —...=..-._._ �I(itlge Slope ❑Valley ❑Flal
4/hrtx� /CA 10z v e Ag.• tcheck approp ate hoN)
!\�LLq Name.Numbers,Coinnnmiiy.Suhdivieiun,Loa NO..Zip C,KILI Ialltude/IOngitude orwell location
I. OWNt(I(: —Ny�r'/:✓ S ldcgrashuinutcs/sccunJsl
:\Jdi �. Ci �/ Lutimde/loneiwdc source:❑GPS❑Topogrtphic map
ISir .i r Rotnc Na.l ��ss �YC�e //-� (dieck hos)
jf ( . C ✓%y D1:PTI I DRILLING LOG
( ur t " Slate zipCudc hoot To Rile ttin Description
( 6I- 2?AZ- 7r,/os _ (Y
Arc.nKIL I'hmm numher - - Ae
.1. DA'Il DKII_LELt 'r.� —©� •a"
OS aR& -_ Mivvv,
6. DUBS WELL REPLACE EXISTING WELL? YES ❑ NO Yr
7. Sl'e\I'IC WATERL6VIi1. 13elowTopol'Casimg: 34k, FT.
(Use"a"if Ahove Top of Casing)
S. "rill' UP Ct\SING IS _ F r. Above Land Surface'
"1"np ur cming terminated at/or below land surface rctj:orce a
Variance in accordance with ESA NCAC 2C All 18.
'). YIELD(ellmy NIE-TIIOD OF TEST l�'K
10. WATFR ZONES(depthy
LOCATION SKI;rC'H
11. DISINFEC'IION.'rype Amount Show direction an([distance in miles from at least
12. CASING: Wall'-hickness two Sate Roads or County Roads. Include the road
Depth Di: ncler or V:eight/Ft. vjutee call numbers and common road names.
Front ' Tt, 1.3 FL ---
hoot 'ro VI. j
From ------
I d. GI(UUT: Depth --- r Material MethnJ
Frum___��-_"fu_�
from To PI.
1-1. SCREEN: Depth Diameter Slot Sire Niamial _ a
Boni 'to H. ill- in. QN "9
Prom.---------fu_ H. in. in.
1;. SAND/6RAV171..PACK: -- -- ul -
Depth Size Maicrial
IronL 10.._.._.._._— I'I _—___ --_ -
I'rom l'o I:1. --
I DO I IIiRIiHI'C HO lFY"TIIr\r'ril IS WELL WAS C(ANSI'RL'CfED IN ACCORDANCE W ITI 115A NCAC 2C,WELL
CONS I'RUCHON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDEDTO THE WELL OWNER
GNATURL'OF 1'Ei(SON CONSTRUCTINGTHE WELL DATE
Submit (he original to the Division or Water Quality,Ground)eater Section, 1636(Nail Service Center-Raleigh,NC =-
27699-1636 Phone No.[phone],within 30 davi. - GW-I REV.07/2001 -

WELL COVS'f`RUCTION RECORD �f 32M7
Noah(';it,)lit - Department of I'm ironment and`J•t Lira
/I C1UttrCel- DIVI'SIOn or Water Quality-Groundwater Section
���
\C IU.L I'OS'llim I'Olt(INOI\IDC:AL)NAME. (print) /Y" Z Q _ CERTIFICATION
\vl;t.L CUN ru.u'rou covtr:ANv N.ANIh: ire_tf/e'l Q'- w� -_-_—_----_ —rnoNl•: a
s I %11:\eh.1.1.CONSTucC I]ON PERMIT# - ASSOCIATED\VQ PERMIT#
I I'applictblel (il'applivahle)
I. WEI_I_ USG(Check Applicable Box): Residem•al 6•Ivlunicipal4'ublic❑ Industrial ❑ Agricullural ❑
;Monitoring ❑ Recuvery ❑ Haat f ump Water Injection ❑ Other❑ If Other, List Use
WELL LOCATION: / Topographic/Land setting
Nc.l s( Town: t/4 jwe V/� Cbmn•:1 11her l�lgc ❑Slope ❑Valley ❑flat
.4V(N ��� ___ -_ Ich¢ek appropriate hul l
�SII-CIel NNamv.NII...1,,,(.........11/1/il,SuI,di,Y,i,,n,LR,No..Zip C,NII'1 LeI11 tId C/IUligllndl'o \Veil location
. . IW'NI R:fbN I/C/s.LSr�= -- Idegrce Minutes/s¢unds)
/�lL- L oiiludorlongittide suurce:❑GPS❑Topographic map
IShl-LI"'It Ic No.I ('check.IRIS)
DPPTII DRILLING LOG
Coy—,r I- Iu slow /_Ip Qale Prom To F 'nyntiun )escription
(--I ---- (� Cj _ �'4
ante-I'Lonc uwnh:r � � ...
UTAILLlil7�_��
5. ruTAL Ul:rrll,-_1115-
(I. DOES WELL REPLACE EXISTING WELL YES�❑�NO ti
7. S'I':\TICWA'rEiiLEVEL_ 13clow'ropol'Casing:-c2p—1''f. —
I Use"*"if Ahovc Top of Casingl
X. 'IOP OI'CASIN6 IS (5Z; Fr. Above Loki Surface*
*Top nr casing Ienninaled atlor helow Iund surrace rewdrex a
variance in acnad:mce with 15A NCAC 2C.01 IN, •� /
0. YIFLDtgI'nt):—Z—NIETI-IODOFTGS-r /g
10. WAl'L:R ZONES(depth):
LOCATION SKurci I
It. UISINPEC•TION.Type Amcunt Show directionand distance in miles from at least
I I. CASING: Wall hickness two Stale Roads oT Counly Roads. Include the road
Uepth Di:ppe�tcr or V.cight/VI. Material numbers and common road nanies.
61[
hoill
I (iROU r: Depth Material h-iethod -
Prom Gp To — PL me:-✓i _ ro
I`nnn Tu FI. 'fl
I-1. SCRIi1:N: Depth Di:uncter Slot Sizc Material _
llmll.. . ... ._. Tofl. in. __._...._ in. __ ...—. Q1,
-
I5. SAND/(;I AVI?L.PACK:
Depth Size Material
fromrtl._____._—I'I _—_-- --_
16. RIikI:\I(Kti:
I DO I IfRl:l3Y CER1ll:) I I IATTHIS WELL WAS C'('NSTRUCTED IN ACCORDANCE WITI 115A NCAC 2C,WELL
I."ONS I RUCTION STANDARDS.AND THAT A COPY OF'rH IS RECORD 1-IAS BEEN PROVIDED TO TIIL WELL OWNER -
(;NATURE OF PEi60N CONSTRUCTING THE WELL DATE
Submit the original In the Division of IIVater Qu:dity, Groundwater Section, 1636 Mail Service('enter-Raleigh,NC
27699-1636 Phonc No•(9I9)733-3221,within 31)da.s. - CW-I REV.07/2001

WELL CONSTRUCTION RECORD � 2Q506
Nunh(':I I o I i I la - Dep:vunent al l mlronnunt:aid(`/']f u�r�a��l esn uceti- Division of Water Quality-Groundwater Section
,V I:I.IA ON'IRA('1 OR(INDIVIDI-U )NAME.4print) MC!,.1T/ '�J {/yJ �-rQ-- CE-RTIPIC,•fIO,N'NV`V 9`•9
,v I:I.I.CON IR,%CA Olt(O\I rAN, NAM E. --�"y,T�T---�t���i_ L� /�� _1. IONK # r�
S I k I F%%ELL CON5IRCCIION' PERMfT# ASSOCLPLED\VQ PERAIrrtl
III applical,10 (ifapplieable)
I. Wid-1_ USE(Check Applicable Box): Residencal Cl bhu,icipal/Public ❑ Industrial ❑ AllriCUltural ❑
Nloniloring❑ Recovery ❑ Heat'Puutp Water Injection ❑ Other❑ (('Diller, List.Use
Wlil.l. LOC•ATR Topographic/Land selling
NWp'esICotow, / � 0?�I1c ❑Slope ❑V:dlcy ❑Plat
J,Q ,1 Khrck xpprupoalc box)
01 None,Nombo ,C'omnnatily.S.Ildwilw.l,L.ot Nc+..,%ip Cock) I atllrlde/1Ungitudc of Well location
(AN NLR: Lem .'Y7'C/ (degrees:numic.,/scrounJs)
:\ddtrs --Lao , ,��,`. '_may;-�y,_._ Laulnden,n, itaLle.nnree:❑Grs❑Topt,.rapbit:map
(Stwo or Lnu•N..) Nlreck.box)
/ _= _��_ 1)HPTII DRILLING LOG
--- ('i y„r sco I Slale zip Code Prom To P n• li 11 Description
,4ca exly-rtnnlc nunlh`r
5. RIVAL DEPTH: C)
6, DOES WELL REPLACE EXISTING WLLL? YES ❑ NO ❑
?. Sl'ATIC WATER L.b:M. l3clow Top ol'Casirg: /L 1,1'.
(Ilse"+"if Ahovc Tnp of Casing)
x. 'I'OI'01:CASIN6 IS�o _ FT. Above(.and Surface•
-Ary of easing m....hntled alh,r heluw fund surface regv:ires a
variance in ac<oMooce with 15A NCAC X.011H.
11. YIELD( rl,o:— _mimlODOPTLST —
w. WATt'R ZONES(depth):
LOCATION SKffrn i
IL DISINPIiC'I-ION:"type An,clmt Show direction an(]distance in miles from at least
12. CASING: Wall'o hickness two State Roads or County Roads. Include the road
ProneDe nh // r to or\i.ciciyhl;ht. coal numbers and common road names.
•fo�G PL _ C
Drum--_-Ill (iRO13T: Depth r7 /�Mtacrial Method
From._ To li= hI/y-x�[>•r/ — r=
Prom To PL _____.. __-- n
1:1. SCRI[I:N: Depth Diameter slot.`;i-re Material .-
Plum . .... . . I t. in' in. cn
Flom _ 'I'o __
li. SAND%(iRAVEI. PACK: -- CD 7_
CJI
Depth Size :,'Ialerial ..
I'loin.___.___.._..._To FI. —_ •`
I'rain..--------1°-----.Pt'----- ------- _�
Ih. RI',NIARKS:
I Ut)I1ER1:13Y CL-'RTI PI•THA'Fri I I S WELL WAS CC:•NSTR UCTED IN ACCORDANCE WIT(115A NCAC 2C,WELL
CONSI RUCTION STAND.AR DS.AND THAT A COPY OI'THIS RL'COILD IIAS 13L•'I-'N PROVIDED I'O THE\YELL OWNER
.ff
GNAI'URL'OE PERSON CONSTRUCTING,rHE WELL - DATE
r
Submit the original to the Division of Water Qualily,Groundwater Section, 163E Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 31)da}-a. (IW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 320505
Noah C oohna-Department of 1 I»ir(nmlent and^9tural esources Division of Water Quality-Groundwater Section
\\ ..I lI. ON'Iit.I(.I'ott(IN❑I\'I DC\I)NAMEprint) ^e)��/�� CER'fll'[C,\'I'IONq���
EI.L(o\I it k C I'(It C'o M 114\N\ NA\IF: `�
S r.crF:,\LI.I.cussrecc'rION PF:ABllrq ASSOCIATED\vt2 PERMITa
(il applicahlel (il applicable)
I WIAJL USE(Check Applicable Box): Residencal Municipal/1'ublie❑ Industrial ❑ Agricuhural❑
::\lonituriug❑ Recovery ❑ Heat Pump1'v ate
Igjcctiun❑ Other❑ 1Miller, List Use
'_. WFIA. LOCATION, � j �� -I MopeTopographic,Tandsetting
Nc:utsl 'I'u,vu: :4 �I/ j_t_f Cololl•. _�?✓.�'r!?f..__ NrRI(ge Mope ❑vallcy ❑Plal
�/q-�ni.v� C ��X � -_ IeheeA appropriate huzl '
4,0 N;uue,/N/n`/�j',hu 5,(/o}u/v7tolV.Subdleiaiun,(all No..tip Clxlc) I-allltide/1011g,tltde 0I'\VCII lueilti011
UWNI_'It: I�-1�LG✓ � — — (dcgrccshninwcs/srxunrlsl
:\ddlcss' o Latitudes(h,ngiwdo,.,nree:❑GrS❑Tnrn�raphien,;l1)
ISIr.•el or Rome NO fcheek M1RI
Dr-.r�rH DRu.1.INCL.oG
y � ZipC„dc I'1(� U 'r ,a,t ,n Description
f-I
"l-'-
h. DOES WELL REPLACE EXISTING WELL? YES ❑ NO '6�- —
7. S I'/\TIC W'A,rEli LEV l3l. Below Top u1'Casing: 30 1--r.
11Jsc":"if Ahoee Top ol'C:uing)
S. '101'OP CASING IS Pr. Above Land Surface
"fop urcasing n•nain:ded ul/or below land zurbrce rcquires a —
varimwe in accordance with 15A NCAC 2C.0118.
o. vIHLD Nil;TIIODOFTISr —
I0. W AI1iR 7.ONES(depth): _
LOCATION SKI;rC'1-I
I I. DISINFECTION.Type Amcunl Show direction and dislance in miles from at least
12. CASING: Wall !hickuess two Stale Roads or County Roads. Include the road
Dej Qiavicler or V c e ITt. Materia numbers and common road names.
from "Ill Ft.62
front - —'I'll
--- hl'
from— -- __—.—
I I (JROUT: Depth Material j Method
cn
Fluor .F __...__I'L—__—__—. r11
C)
fl. SCICI(I:N: Depth Diameter Slut`,izc Material _ t ._
Floor -. .__._ Tu I"t _-___.iu, in.
I SAND%GRAVEL PACK:
Depth Size Material
from
If,. REMARKS:__--__
I DO I IERIMY C•ERTIr1'THATTHIS WELL WAS C(,%i'RUC'rED IN ACCORDANCE WITI 115A NCAC 2C,WELL -
t."ONti l RUC]r ION STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO I HE WELL OWNER
GNATURE OE 1 ,,ONN CONSTRUCTING THE WELL DATE e
Submit the on-"final to the Division of Water Quality,Cro it it d n•a ter Section, I63h Nl(til Service Center-Raleigh,NC
27699-1G}G 1'lunlc No.1919)7}3-322I,,vithin 311 d'a)'s, - OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
•-i.: :(di, i - ;)epannlent o1 fimvnninert and NaattuuraI Resources- Division of Water Quality-Groundwater Section
,.i ,.( ON IkA( TOR IISDI\l Dl \I1N.\\4: (print) IJ t i� V t,_ lt CFR rIFICA110\4 33by
,.( ON IHT( IORCUVIPAAA N%VIF. rl',�� I`;., c.� .. �Lll '1_.Fo"'i �:,, PHONE p C]` G
� Nfr. ,\LLL( (lU1RL(_"fl0\ PF;H\11Ttt � 1L ,1 _.:\SSOCIATk;U NQ PF,R\11Tp
.r applicable) (if applicable)
.. .I 1 t.Nh.I<'heck Applicable Box I: Residential 1A Municipal!Public ❑ Industrial ❑ Agricultural ❑
.I,a::I:,nn L, ❑ Recocen ❑ deaf Pump AA'ater Injection ❑ Other ❑ If Other, List (,sc
, (A ;:I ION' Topographic,ILand setting
..,,n: _�u _ County�'�r; sy�i� ❑Ridge ASlopc Malley ❑Flat
11 (check appropriate box)
�.,,.,b he,,( „mmnr s-(d,n,u gin. ,,, N o..[:p Latitude longitude of well location
_ Ide , m nute,nw-i,d,)
_. L. cI C• � cL_-a. �_�_ .I I �L•� lr�� I:inludc l ongitude source:❑GPS❑Topographic map
tcheek box)
PI.C, _ -1 ' )..� F ^_ _ DEPTH DRILLIN(i I.OG
state Fnan To Formation Description
.i:',I. DEPTH: `Y 5 :, ------------- -- ----- - - ---- —
PT.
,I..e-., -d Abo,e Top ICa,ine:
FT- Abore Land Surface*
np ul vain;terminated avor helun land mrfuce reyuire>a -- — ----- --— -
..,r,ance,naccordancewith 15% N('\(.2(:.011a. _
i._ i) (gp,n7- _.—� fv1 CFHODOF TI,SI .__ __,ry
'., .vILR %OSI'ISl depth C _. _.......`�
_ LOCATION SKETCH
I I()N:Type_I I_T I- _. Amount Show direction and distance in miles from at least
wall Thickness two State Roads or County Roads. Include the road
Ucpth Diameter or WeI_c-ht I t. %ldtenal numbers and common road names.
n. [ lo_� (\_Ft. L, u — _. Vc __
o Ft.
To FI.
Depth Material Method -
_it_ } .
To Ft —
, L: cN Ucpth Ummcler SInI Sttc Alaternd
To - FG__ M. -- ---- in. t�
(,RA f`L PA('K_
Depth we Material
To Ft.
To-
Pi WI rIPTIF) FIIAT TIiIS A F_LI_WAS( ONSIRUCIP.D IN ACCORDANC E W l 111 IAA V M,2(', Ak ELI.
Ii')', i1NDARDS AND fll1%1A( 0) OF IIIIS PIJ ORD HA', MAIN P RM IN DTO I HE q ELL OWNER
SI(aN'.VI;RF:UPI'I:KSUN (�ON>IRIl51lA'{n1�4i�Fy1�� DATE
�ubunt the orig6t al to the Dicisiun n(N-ater Qualih,GCuunde ater Section, 1 l6.Nail�4erviee .crier-Raleigh,N'C
t,•w- p:h Phony Nu.[phone].within 311 days. IAN O g006 GAA:-I REV.(17 2(101
Asheville Regional Office
_AQUIf, PNf�nMI

irrp 828 V-7211 10
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•"•,•,•r' Vb'RY.L.4'ONT'�TtAC')('ORCRR1fIR►CA.TNQN'R ai � a
7_
f vrswFECnnN type_--.._.._._-. Ameamt .._ ._..
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- ---- _- . .-. h, tMAi'fAtMIBSP(ah): — - -
. _- �Nul fmtpadar(MnIuePMj Alnme -
Fmm...
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WoACRRMaior(:ramrp F•mm__.
GTREET RF'ESfi ��� I From..,„--,..Ta,^.---. fYnm,_..__—_ro---
nn
7.GMMG: TNANnestt
C �S aPln g7emeMr rigght M�tRrar
T
Fmfft—._._,T'n.-__ Ft— _...�..
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mdc. Phone.number --
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faem
weu.cp7uTRtx rIgMPF,RMrra —
.._._.. . - ---- Fmm _.7n --Fs,
OTHER?.waFTr.ur,,(-unoARActRS,PS.00IATErt)PERMITi(—dn_M-wa _ FrarqR�M_:--._.(N.Tpnt,A^ FQt1.-R.m_--A.-t_a_.r..P,lli nIt,.StWAMMIAbloo": NAtden11P1 WWT Supply
M.. R_-t_e-_-
r.iR_lRn Tu— _ F,I ILRQP ' -0C t`L1,17C
nner AMA AMO _.
antaon _--•-.--
--
I �,,,,, WiWANPOORAM PACK:
ROM To
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�`„H'`^x��"�nn+F. munitr.sWWrtaim,r+d Nn,PnrtM,'S C c�
tt?PO
(iRAP!CIC I LANE)SETTING:
A SMWa A(�� q Fint 0 RMda A oft _.`=____.
�y��R'z Wwo A"q 11,IrRILr rNf'i.<X
t.nTwwr, fv p n Adry TaandgpaaS From To
`-`'('�_ � .�pat,�l V Mrs $pr FPtmafian Qaecdpfi4n
I.OMGPUPF, c �P• l� ma amrmat COMA( �3G`- --_..
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H. TgTAt,
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,,. "MR rontreRltrctarPT nur 7xs ww,.w.scaisT7nrCrKn W/CC.UnnR„rl(MAn,
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d. 1+01P OF CD18kJ(A IR l FT.Abow 14nA$91ACR""Tn nnarwle AAA,,Ryrp te�lnalndmrnr hMM lRna t"Wa4 MAY raqutrk BICNAT.IHF,Q .FPlT1F� iF'p 1NEL`.�pNT�A p �`-'_�- ,�e R pa aigrgryyRm whh ISA NCAG RC,0119. CT ftft PATF.
... YR�r R 41•"`I,_...t�__..MET"QP PF TE$T,_/S r`/
PR1NTFp MAMf M'PF,RSONF STRUG71NC 7F1�yyELL
Sun �nil ye Ah ry --T_._..._._.__ _._----------•--_..—nf the arf e Divt*,On o(Wetor Quality 30 00", .AtW remreal IOr Mot„
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„a STA Eo
9 8 C. ,, ;�
�- -J E0
RESIDENTIAL WELL CONSTRUCTION RECORD tj
4 North Carolina Dganment of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# -
1.�Wr�ESLLL CONTRACTOR:/g f. DISINFECTION:Type_(/o.,,.. Amount �ffd,
1� ,IL/1� 1-1fl-NE-S g. WATER ZONES(depth):
)YR11 Contractor(individual)Name From_�ef- _To From To
A_ lf, From 7/5- To From To
1,.e89.ontractm Company
Name / /] From To From To
STREET ADDRESS /�/ �� L lA� � ('f/A1 6. CASING: Thickness/
i Depth Diameter Weight Material
IR /'7P From To7L,1 Ft.
City a Town State Zip Code From To Ft. _
(223 )- 358- Sy9 6From To FL
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
/^_ 'J)Ip iJriiv¢
SITE WELL ID#(if applicable) /►T Rom_0 To Ft. CWA!fFrom To FL J"-"�--J-
STATE WELL PERMIT#rf applicable) From To- Ft.
DWQ or OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To FL - in. _ in.
From To Ft.—in. _ in.
- DATE DRILLED //"ZL-Of Fran To Fl._in. _ in.
TIME COMPLETED AM L7 PM
9. SAND/GRAVEL PACK:
3.WELL LOCATION: / Depth Size Material
CITY: (Ncr„csu//! COUNTY > v.,, Fran To Ft.
From To Ft.
SX�lnnc L. ity, From To Ft.
(Street Name,Nu tiers,Commun Subdidsion,Lot No.,Parcel,Zip Cotle)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
lope pValley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
LATITUDE 3 � r =, dlcg, D ' GS�/ yJY - 7'/LONGITUDE Z -r 7E5 Aj
Latitude/longitude source: E PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 7 not using GPS)
4.WELL OWNER
OWNER'S NAME � l/y �q�
STREET ADDRESS Q ¢ ve, N -O
Wa o/v /'IC, /U .87FG ( .
� �pCit.i�typpor own State,J Zip Code
JI _
Area code- Phone number Crib
5.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: .T4r /
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO EI
C. WATER LEVEL Below To I DO HEREBY CERTIFY THAT THIS WELL WAS CON INSTRUCTED ACCORDANCE WIrH
P of Cain 9 D FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+'d Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS T FT.Above Land Surface'
'Top of casing terminated atlor below land surface may require a variance in acc SIGNATURE/OFJ ERTIFIED WELL CONTRACTOR DATE
accordance With 15A NCAC 2C.0118.
a A
e. YIELD(gpm):_�METHOD OF TEST 11 - r q a '
1 HINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, -
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-la
Rev.7/05

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and to Resources-DIVL;sip of Water Quality-Groundwater Section ✓��� (�
WELL CONTRACTOR(INDMDUAL)NAM[E�(print) CERTIFICATION#Q U�2
WELL CONTRACTOR COMPANY NAIVE lwiil IC llfill MYCLAM p. LC PHONEb=.'159-H�9�
STATE WELL CONSTRUCTION PERMIT# �Jf ASSOCIATED WQ PPIERMIT#
(ifarplicable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential 0/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
?. WELL LOCATION: Topogm ' /Land setting
Nearest Town: County ❑Ridge lope ❑Valley ❑Flat
✓nn/ t �II/ ��� Z�.9 MC (check appropriate box)
ISvea Name,Numbers,Community,Subdivision,Lot No.,Zip C/ode) Latitudellongitude of well location
3. OWNER: S // wi,//1 (//,, 41 G�� T71./lf) A C/, 709,
C/� ea6.I �4'tirEu$ 1 (degrees/minu[es/ Dods)
Address dad- Lan/tude/longitude source: PS❑Topographicmap
/` / (Street or Rou¢No.) (check box)
DEPTH - DRILLING LOG
p���City or Town ' State Zip Code From To Formation Description
W- &kby'- q n may/ C��
area code-Phone number 2 v 3 n y,?�dwtP
4. DATE DRILLED (d /!a/AS /V3 — q?
5. TOTAL DEPTH:,t/S— —/ Y9 — A LIS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L'
T STATIC WATER LEVEL Below Top of Casing:2�FT.
(Use"+­if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated sour below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):91)_METHOD OF TBSTA6,I;dj—pm Jfq
10.WATER ZONES(depth): /3Q '
LOCATION SKETCH
11. DISINFECTION:Type ththPiroUt Amount 6n z 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 Wei ht/Ft. Material numbers and common road names.
From__:V �I_To EFt. S
From To Ft. /
Front To Ft. (/(�
13. GROUT: Deptha— Mw er Method
y Ile-,
From_
_ . q rn
N
From To Ft. ,
i 4. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in, : ip-
C=)
From To Ft. in. in. --
15. SAND/GRAVEL PACK: SEP
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 STANDARD) A COPY �THIS ORD HAS VIDED TO THE WELL OWNER
SIGNAT OF PE ON CONSTRUCTING THE WELL /D�Iy
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
2 16 9 9-1 63 6 Phone No.[phone],within 30 days. GW-1 REV.07/2001

DMSrArFo
Q RiSIDENTIAL WELL CONSTRUCTION REC RD
North Carolina De artment of Environment and Natural Resources-Division of Water Quality
WELL CONTP. CTOR CERTIFICATION#- i>?Li 3 l7
1.WELL CONTRACTOR: I. DISINFECTION:Type 2p:A\ Amoert
7e5m,cK NA , 460-V3 CS g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
C.�'1dP �6d�- {, d "CIA
o From To From_ To
Well ontracta Company Name From To From To
STREET ADDRESS O 6. CASING: Thickness/
Depth Diameter Weight Material
1 O E1 C oQ Sri Fram k \ To ?d Ft _ — R\ plat*:C
City a To Stabd Zip Code From To Ft.
t_ B& (D&A- aOyZ From To, Ft
Area code- Phone number
7-WELL INFORMATION: 7. GROUT: Depth Material Method
FTM_D To Ft.
SITE WELL ID#('rr applirabie) From To FL VQ t
STATE WELL PERMIT#(ifappticable) From To Ft
DWQ a OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Sot Size Material
WELL USE(Check Applicable Box): Residerd IlWaterSupply[j From To FL_in. _in.
From To Ft—in. _in.
DATE DRILLED 3 d -S_ From To Ft.—in. _in.
TIMECOMPLETED A 10 PMOJ}
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material _
From To Ft.
CITY: 4YnPl o,�� - COON w Frorn To FL—
From—To FL
(Strst Nam ,Numbers,Canmonay,SubdiNslon, f No.,Psrcel,Zip Code)
TOPOGR1ArBg,Ht,{IC f LAND SETTING: 10.DRILLING LOG
❑Slope 9 alley ❑Flat ❑Ridge pother From To Formation Description
(check appropriate box)
May be in degrees,
LATITUDE minutes,seconds or 41 3 7 n.ttt but A o n
LONGITUDE— in a decimal fonmat
— /32 - s (
Latitude/longitude source: ❑GPS oTol bgraphic map �cc�:to
(bcahnn of We#must be shown w a USG map and
attached to this form rnot usbg GPS)
4.WELL OWNER _I
OWNER'SNAME iwn �J
STREET ADDRESS
�—
Cityo Town State Zip ode
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL YES O NO[�
c. WATER LEVEL Below Top ofCasing: 5AA2LCNS WAS RDs. TACr. 15ANCCC WECONUTIDNSTANDDARDAN; HATOPa
(Use'+'if Above Top Of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.A ive Land Sudace•
'Top of casing terminated at/or below land urface may require SIGNATURE OF CE CONTR CCTOR DATE
a variance in accordance with 15A NCA C.0118.
e. YIELD(gpm): 'r METHOD OF ST z e-cC:cK bn,Z1gt 6
PRINTED NAME OF PERSON CONSTRUCI`NG THE WELL
Submit the original to the Division of Vater Quality within 30 days. Attn: Information Mgt, Form GW-1a
1617 Mail Service Center-Raleigh,NC 99-1617 Phone No.[phone] ext 568. Rev.7105

ono W�yC �bM
S RI SIDENTIALWELL CONSTRUCTION RECORD
c
North Carolina De anment of Environment and Natuml Resources-Division of Water Qualh}
WELLCONTR CTOR CERTIFICATION#- nZ 4 3 6
1.WELL CONTRACTOR: f. DISINFECTION:Type � \�_ \'J Amount a s
:4L1t NA . 60-VI is g. WATER ZONES(depth):
Well Contractor(Individual)Name Fran Tc Fran To
6 {, a p (J,Q,�\ "Sapp From To From TO
G an Well tractor parry Name 11 From To From To
STREETADDRESS t4B96 tA%A ;!Oq 6. CASING: Thickness/
ElC o�$"i Fran Depth Diameter Weight Material
t•t0't
City a T4LJstw Zip Code From To Ft. Tom'
C 8}_tea f.S- a 0 2 7- From To Ft.—
code, Phone number
2 WELL INFORMATION:
7. GROUT: Depth Material Method
From Toy20 Ft. if -- Pf�t` o uC ASITE.WELL ID#(it applicable) From To Ft
STATE WELL PERMIT#(aapplicable) From Tc Ft
DWQ or OTHER PERMIT#(R applicable) 8. SCREEN: Depth Diameter Sit Size Material
WELL USE(Check Apphcoble Box): Resident Water Supply❑ From To Ft—in- _ in.
_ From To Ft_in. _ in.
DATE DRILLED /. — S From To Ft—in. _in.
TIME COMPLETED v d ❑ PM B�
9. SANDIGRAVEL PACK:
3.WELL LOCATION: - Depth Size Material
From To FL
CITY: COU r LV a d From To - Ft.
tftf Fran To Ft.
{Street Name,Numbew,Canmurtrry.Subdivision, t No.,Parcel,Zip Code)
TO GRAPHIC/LAND SETTING: 10.DRILLING LOG
IOPe ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degecs,
LATITUDE 3 _ minutes,Seconds or {'1 ? ) n.l tt burdon
LONGITUDE in a decimal fommn
-- � (lC 1E
Latitude/longitudesource: ❑GPS oTol .graphic map
(bceRan of we#must be shown on a USG map and
attached to this form that usarg GPS)
4.WELL OWNER n
OWNER'S NAME rYrS
h�
STREET ADDRESS
QC�it'y7(�Town State
Area code- Phone number -
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: 4-
6 Sb. DOES WELL REPLACE EXISTIN
I DO HEREBY CERTIFY THAT TM WELL WAS CONSTRUCTED INACCORDANCE WITH
G WATER LEVEL Below TopdCasing: ! Ff. 15A NCAC 3C.WELL CONSTRUCTION STANDARDS.AN:THAT A COPY OF THIS
(Use•+-If Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1. TOP OF CASING IS \ . FT.A ive Land Surface J/ j �..> _ 07
op d casing terminated aVa below Iand tr ace may require SIGNATURE OF CERTIFIED WeCL CONTRACTOR DATE
a variance in accordance with 15A NCAC ZC.0118-
a. YIELD(gpm): METHOD OF1 6 awry t L t,
—"�'— PRINTED NAME OF PERSON CONSTRUCTNG THE WELL
Submit the original to the Division tf ;ter Quality within 30 days. Attn:Information Mgt, Form GW-ta
1617 Mail Service Center—Raleigh,NC 99-1617 Phone No.[phone] ext 568. Rev.7I05

SRiSIDENTIAL WELL CONSTRUCTION RECORD
North Carolina De artment of Environment and Natural Resources-Division of Water Quality
WELL CONTIL CTOR CERTIFICATION#- nZ 4 16
1.WELL CONTRACTOR: f. DISINFECTION:Type :\\ Amount .3 -t
:CK Nji . &a-ul CS g, WATER ZONES(depth):
Well Contractor(individual)Name From To From To
G C, a o iJ2\\R ^S UMp From To From To
Well ontracr0omlopany Name 1 From To From To
STREETADDRESS tLt Slab %A%Z gOq6. CASING: Thickness/
Depth Diameter Weight Material
liOt A /Uc Ds From�_ToV-Ft _ _fit O1nSf,�
City or T6Ct:nC cistaff — Zip Code .. From To Ft. —T`Y
'-!MR (per S' a a t Z From To Ft.
Area code- Phone number
2 WELL INFORMATION:
7. GROUT: Depth Material Method From �— i Toa U Ft. eiJ out2-1_
SITE WELL ID#(8 applicable) From To FLLresn
STATE WELL PERMIT#(ilapplicable) From To Ft
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter 53t Sae Material
WELL USE(Check Applicable Box): Residery 0 Water Supply❑ From To Ft -in. _in,
From To Ft—in. _in.
DATE DRILLED �� � S From To Ft.—in. in.
TIME COMPLETED I "40 p PMdi
9. SANDIGRAVEL PACK:
3.WELL LOCATION: - Depth Size Material _
From To Ft. _
CITY: W4ni/T PI U.��-0- COU 66 From To FL
C Q From To Ft
(Street me,Numbers.Co un Subdivision,I t No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SLIT G: 10.DRILLING LOG
❑Slope []Valley ❑Flat idge ❑Other From To Formation Description
(check appropriate box)
May be in degrees,
LATITUDE 3 _ minutes,seconds or a't iy�f' n.t tt "tOAr-t d o n
LONGITUDE in a decimal format
•7 (3
Latitvde/Iongitude source: ❑GPS ❑T _gaphic map 112 GCG-f%;to
(location of wel must be shown on a USG map and n
attached to this form►not using GPS) —
4.WELL OWNER
r,
OWNER'S NAME l71 p
STREET ADDRESS S Ca<OC.
71
City or Town State Zip Code
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
& TOTAL DEPTH: 7 5� /
It. DOES WELL REPLACE EXISTING WELLrLand
O S
I DO HEREBY CERTIFY THATTHIS WELL WAS CCNSTRICiED NACCORDANCE WITH
C. WATER LEVEL Beim Top of Casing: FT. TSA NCAC 2C.WELL CONSTRUCTION STANDARDS,AN'.THATA COPY OF THM
(Use'+-if Above Top Of Casing) RECORD HAS BEEN PROVIDED TO THE WELL WNER.
d. TOT OF CASING IS FT. rface•
op of casing terminated at/or below landequire SIGNATURE OF CERTIFIED WELL TR-.CTOR DATE
a variance in accordance with 15A NCA
e. YIELD(gpm): /S' METHOD OF T Q:V, Qt't 1 awc \'>\• b nJ� E t 6
—"� PRINTED NAME OF PERSON CONSTRUCTNG THE WELL
Submit the original to the Division of Vater Quality within 30 days. Attn:Information Mgt., Fo m GW-1a
1617 Mail Service Center-Raleigh,NC 99-1617 Phone No.[phone] ext 568. Rem,7105

e"`AAtFo
A 5i 1
SRJ SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina De sitment of Environment and Natural Resources-Division of Water Quality
WELL CONTP, CTOR CERTIFICATION#-_ e243 b
1.WELL CONTRACTOR: - I. DISINFECTION:Type!P� Amount
:CK Vi . bark CS g. WATER ZONES(depth):
Well Contractor(Individual)Name From Tc From Tc
6 From To From To
Well onbactor Company Name From To From To
STREET ADDRESS 14 ala 10 l{Z jZOCJ 6. CASING: Thickness/
Depth Diameter Weight Material
1 Ot 6 C of$7y3 From�Tv �Ft. _
CityaT0SW Zip Code From To Ft.
From To FL
Area code- Phone number
2 WELL INFORMATION: 7. GROAT: Depth Material Method
From_0 _Toa6 Ft Le&t- o!y,� ,A
SITE.WELL ID#(if applic" From To Ft. —
STATE WELL PERMIT#(n applicable) From To. FL
DWQ or OTHER PERMIT*(if applicable) B. SCREEN: Depth Diameter Slot size Material
WELL USE(Check Applicable Bar):_ Resideril d Water Supply❑ From To Ft—in. _in.
From To Ft—in. _in-
DATE
DATE DRILLED �I'cZ/ 5 From Tc Ft—in. _ in.
TIME COMPLETED 3.c)U A 10 PMp/
9_ SANDIGRAVEL PACK:
3.WELL LOCATION: - Depth Size Material
CITY: COU c✓c Fop To Ft -
\G. V' �vp RA . From Tv Ft.
(Street Name,Numbers,Canmuniy,Subdivis on,I t No..Pineal,Zip COEe)
TOPOGRAPHIC l LAND SETTING: 10.DRILLING LOG
❑Slope pvalley ❑Flat mRrtTge pother From To Formatk,ri Description
(check appropriate box)
May be in degrees,
LATITUDE _ minutes,seconds or ^+I tf but A o^
LONGITUDE in a decimal format
&C6n:t2
Latitude/longinadesotuce: ❑GPS ❑T graphicmap
(bcetion of welf must be shown w a USG map and
attached to this form Inot usrg GPS) r"7
4.WELL OWNER '---'*'t--�
OWNER'S NAME 1
�x N
STREET ADDRESS ��—
DW V 1' . .�C_ oZ -
Cily State Zip Code
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: SY.S /
b. DOES WELL REPLACE EXISTING WELL YES❑ NO B
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSDYICTED N ACCORDANCE WITH
c WATER LEVEL Balm lop of Casing: /G C7 FT. 1SA NCAC 2C.WELL CONSTROCTIOil STANDARDS.M-i THAT A COPY OF THIS
(Use'+-If Abom Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL ER.
d. TOP OF CASING IS FT. " Land Surface' - ---- -
op d casing terminated ally below land urface may require SIGNATURE OF CERTIFIED WEL NTR=,CTOR f
a variance in accordance with 15A NCA C.0118.
e. YIELD(gpm): METHOD OF ST� Q ecc:c1A \�.. 6 o,1J-yet a
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of ater Quality within 30 days. Attn: Information Mgt, Fans GW-1a
1617 Mail Service Center—Raleigh,NC 99-1617 Phone No.[phone] ext 568. Rev.7105

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and�,ya ral Resources-Divisi of Water Quality-Groundwater Section �t (''�
WELL CONTRACTOR(INDIVIDUAL)NAME (prinq CERTIFICATION# UGi0
WELL CONTRACTOR COMPANY NAME 1t' l(,CDA1� Will (JIV r1 PHONEA.2aa59-ENA4�
STATE WELL CONSTRUCTION PERMIT# J ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ETI�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: ��{{ TopogrSWC/Land setting
Nearest Town: Celli 'dy //County Qf f ❑Ridge p ope ❑Valley ❑Flat
/r-L`' (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/lol] itude Of w 11 location ra s e
Gt/. r a ' ?Z i
Aft
3. OWNER: V I 1 ,1 J t B If e'rY r <Y (degrees/minute/ eeond(s)
Address � [�,o hLtH N(�t Latitude/longitude source:ITGPS❑Topographicmap
S1u or RoNN J ko (check box)
er tf DEPTH DRILLING LOG
City or Town $m[e Zip Code From Formation Description
Areacode-Phone number fNz.
5. DATE DRILLED4
5. TOTAL DEPTH: ( —
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO <S/
7. STATIC WATER LEVEL Below Top of Casing: 43 FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface"
*Top of casing terminated atior below land surface requires a
variance in accordance with 15.4,NCAC 2C.0118. rp 1 !�
9. YIELD(gpm):— S METHOD OF TEST h1a.I,' �ICi q
10.WATER ZONES (depth): 3 f,y)f J J
LOCATION SKETCH
11, DISINFECTION:TypeA C 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 Weigh_t/Ft. Material numbers and common road names.
From__�To��Fr. 6,AA 2./Gr I.0 0 _L2/2_/ n JJ
- From To Fr_
� Oil Y.�4ive
From—To—Ft.—
13. GROUT: Depth Materiall Method
From_D To �Ft. l ,p g
From To Ft. CJ _
14. SCREEN: Depth Diameter Slot Size Material c-a
From To Ft. in. in. I _
From To Ft. in. in. C n
15. SAND/GRAVEL PACK: O
Depth Size Material Ln _
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 13A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TH T;A COPY OF THIS RECO HAS BEEN PROVIDED TO THE WELL OWNER
i
GNA U OF PERSON CONSTRUCTING THE WELL _. ATE "
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,INC
27699-1636 Phone No. [phone],within 30 days. GW-1 REV.07/2001 -

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAMzE�(print) A,gi k/1/ . (A)I CERTIFICATION#22 1Q
WELL CONTRACTOR COMPANY NAhIE/��IZQ / O/V S t ,I :&✓d I LL PHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(i f applicable) (if applicable)
_ �r
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
Ci Nearest Town: wt�^ County ❑Ridge OSlope ❑Valley ❑Flat
14%:%r� Ald (check appropriate box)
(Setec Name,Numbers,Community,Subdivision,Lot No.,Zip Code) �ro enongitude of well location
3. OWNER— O (degrees/min�u/tesfs/�yeconds)
Address c rho e see V Ladtude/longirude source:IZOPS❑Topographicmap
nn,-,
(Smeet or R [e No.) 1 (check box)
AE&W t1�� � � t)-9W(p DEPTH DRILLING LOG
City or Town Suite Zip Code From To Formation Description
SIR)- as e�- �aa9� D - L/
Area code-Phone number Z/— 2 6
4. DATE DRILLED I- L/ - ar
Z6 7r� ) iK
5. TOTAL DEPTH: Zfl.i _.
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO o
7. STATIC WATER LEVEL Below Top of Casing: e,D FT. n '
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface" -
-Top of casing terminated atlor below land surface requires a
variance in accordancewith ISA NCAC?C.t1118. O
9. YIELD(gpm): JO METgOD OF TEST 19
10. WATER ZONES (depth): 90
l �l
t LOCATION SKETCH
11. DISINFEC_TION:TypeC'loi/et Amount 6LS Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth QQiameter or Weight/Ft. Material numbers and common road names.
From d . To_Zk—Ft. 6./A- 17f V 'Ap✓G
From - To Ft.
From To Ft.
13. GROUT: Depth Material -�Method
�_ '(\-
From�_To-,2-0—Ft. E E \ ` ' `
From To FL -
14. SCREEN: Depth Diameter Slot Size - Material
From To Ft. in. in.
From To Ft. in. in.
15, SAND/GRAVEL PACK.,„
Depthr Size Material _
From To Ft.
From To FL
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
/-Ll - or
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
Noah Carolina-Department of Environment and ral Resources-Divisi of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION p
WELL CONTRACTOR COMPANY NAME t P _PHONE,&Ua5S2- 41-
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Topogr Ic/Land setting
Nearest Town: �'gFL}� County .t 7r ❑Ridge Slope ❑Valley ❑Flat
L f O� I (check appropriate box)
(Sweet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/liVude of wgll location
,/� -T '� r s` t� yyy ,C'sS�P��
3. OWNER: !�e V� T cfn a It-�Flel(f�Qfl�f\ '
� (degrees/minute Dods)
Addre• '20� Q 141 Pf Latitude/longitude source:06PSOTopographic trap
(Sneer or Route No.) (check box)
n4^^I if 6-�(�! yj DEPTH DRILLING LOG
-D & 4 ,}f�t� Zip Code From To Formation Description
(�,
AdU _L 4kW 1�1
Area code Phone number
4. DATE DRILLED^ 7
5. TOTAL DEPTH: - —/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LS `
7. STATIC WATER LEVEL Below Top of Casing: ;7a FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS,D FT. Above Land Surface'
"Top of casing terminated attor beluw land surface requires a
variance in accordance with ISA NCAC 2C.g118.
9. YIELD(gpm):_<>?4 _METHOD OF TEST
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type r K, Amour[ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
From Depth Diameter or WeighdFt. Material numbers and common road names.
_�_'fo�'�FL G r RS 2/ ,/� /\C' • � ,;,Z. �
From To Ft.From To Ft. rl & .I&A2 !'tl
13. GROUT: Depth n Material/ Method
. Front- 0 To�QFt.lOH iLe 2trf4 / +Qy�Ohj )fC.
From To Ft. 1.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in, in, 1p -
I5. SAND/GRAVEL PACK: rrI
Depth Size Material 1 -
From To Ft.
From To Ft. 0 _
to ~,
16. REMARKS:
,
LL�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TH A COP OF TH C HAS BEEN PROVIDED TO THE WELL OWNER
STGNATI J OF PERSON CONSTRUCTING:THEE WELL ATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
Not tIt(':Dot ilia - I)uparmlctit or Environment and ^I• uraI esou ces - Division of Water Quad ity-Groundwater Section NV HI.CON lld:(( t(tl((INDIVIDC:11,)N:\All•: nO / �i U �_ CERTIFICATION V,7,44Lry3%%1:1.1.COXIIt%C]'0R(COM i':\NY;NA\I h: iL�✓L�c( _yG ...-------_ —1•uoNo-: a 7d
S I.t l E wL1.l.('UNS'rRL'C''I'ION PEIINli,ra ASSOCIATED%VQ PER\Irra
(i l'appl icablr! (if,appl icable)
I WELL USE (Check Applicable Box): Residential Mr'Municipal/Public❑ Industrial ❑ A,riculttlral ❑
:Moniloi ing❑ Recovery ❑ Heat PUMP \Va(cr Injection ❑ Other❑ II'Othcr, I_isl.Use
WLLL. LOC:\ll0 Topographic/Land setting
Nearestutvn: _ �N Q/✓ c( ul;- 1J (�GfrL�/ ���� g
---- ldRidgc ❑Slope ❑Valley 01Ia1
(cheek appropriate hurl
JSnecl N;uuu.Numhcl i,Col ,unity.Suhdivisi,m,toi Na..Zip Qx(r I-aii(mic/iongianic orweii location
. . (ddlesR: % _ (dcgrms,'winulcs/ewundsl
\ddles.. 2 Laliluda/lon_ilude source:❑CPS❑l•upographic map
/q' [Sir.•cl or Rome W.) '7 IOwd hoxl
-- /L/, -- O�':'; �1 _ DI:PTII DRILLING 1,00
Ca,or lm,n ' St Ile Lip Cude Front To I' � , )e5er1P11011
Aw.t rule-(Than•uuolhs
rOT'AI. DF19 H: r.
(I. DOES WELL REPLACE LXISTING WL•'LL7 YES ❑ NO
7. S'I'I\l'(C WATER I.6VF:I- Bdow Top ol'Casing: lai) l'r. --
Msc"+"it Ahuve Top of Casin,n
S. 1(W OF C'ASIN(i IS (>� Fr. Ahovc Land Surlilce*
*"1'np ar casing terminatnl:It/ur Lehr land snrraee regoirei a
rariatwe in accordance with 15A NC\C 2C.I11 IN.
'/. YIELD(gpnp:_3—Nua'rIIOD OF TEST dLLe'
IU. W'ATP'R ZONES(depth):— -_
LOCATION SKI;.ro I
1 1. DISINITCTION.Type Anucunt Show direction and distance in miles From at least
12. CASING: Wall -hickness two State Roads or Counly Roads. Include the road
--Uepth/�/ isJ�ytl:r or V,ciehdl'I. crial numbers and common road names.
Front � 'ru '_T C� FL / r ' J i
From __'1'0 _ �
Front_--- ro__ Ft. _ __
I J. (AMIYI : Depth, Material Method
(hoot ._ 'ru___—_
1-1. SCLI.I:N: Depth Diamc(cr Slot;ize MaMial
Iimn (=
li_ SAND/GRAVELPAC:K: -
Depih Size Material
From___.
Prow 'ru PI.
lb. Rl:. IARK5:
1 Ut)I IERGBI'C'kiR I IFl"I-IIAT"iIIIS WELL WAS CY•NSTRUCTED IN ACCORDANCE WIT(115A NCAC 2C,WELL
CON(IRUC'IION STANDARDS.AND THAT A COPY OI'THIS RLCORD HAS BL'L'N PROVIDEDI'Ol'I1E WELL OWNER
16
eeNW� OS—
GN 1TL'RE OF PEi`SON C I?LL DATE
r
Submit the original to the Division or 1V:Uer Qu lily,Gann dn•ater Se5•��ion, I636 Alai Serrire Center-Raleigh,NC
?7h99-106 Phone No.(919)733-37_21,within 311 tht s. 1AN 3 O '1006 CW-I REV.07/2001
Asheville Regional Of&e
A uifer Protection

WELL CONSTRUCTION RECORD
North C'm olina -Dcpanniew of Environment and `/ i u`�a/l esources- Djvisioil of Waler Quality-Groundwater Secti'o�n/�
\\'H I.L CON'I'itm I'OIt IINDI%-I IA kI.)NANI I•: ,riot) -N"/ C --/— / � CEirrmc,vi'm#-'W/ p
11"ha.l.('flx'l J(A("fr11i CUNI1':\N1'N:\�Ih: ( �r_T—L'i"l`+, �--r L�/7T_---------1'11ONE N &64� �
S I.Cr r:%A ELL C'UNS"IRCC-r10', rh:RNirrm ASSOCIXI ED\VQ I'EfOirrk
(it applicable) (if applicable)
I. \1'LLI. USE(Check Applicable Box): Residenr.al ld' Municipal/Public ❑ Industrial ❑ A�ricuhural ❑
:Moniloring❑ Recoveiv ❑ Heal Pump \Valor Injection ❑ Other❑ If Other, List Use
_. WEI.1.. I.00ATI'OI,N: J/ opngraphic/Landsetting
Ncaa'e.al 'fuwu: �(•��/✓e"n/ _C'uunl•.� �'�r<( /
ILiJge ❑Slope ❑Vniky ❑Plat
lelleck appropriate hos)
l Snccl N;mn•.Nnmhas.Conananity.Sulalirisiun,L.ot No..Zip Axle) LaIiIII(IC/lOngitltde orwcll location
j. OW'NI.Rfuiv
Idcgrccaminvles/xcunJsl
addles �,r✓ /ah • Lalitudcrlongitu(Ic source:❑GPS❑Topoer.Iphic n,ap
c - 0.6_ a tYhec
( DI'.I'TII DRILLING LOG
2 l n Ir 1L++n " sc+le zip Ct,de Prom u P •not Description
ems -.— - w
A roe c.dc"Phone uumher
1. DA'1.1 DIAII_LEU l• _ ,n. <r ,h'�
h. DOES WELL REPLACE EXISTING WELL' YES ❑ NO 0'
7. STATIC WATER LEVEL Bclow,rop ol'Casing:SL�1-1'. --T_
1 se••+-I'Ahoac Top of Casing)
S. l'(W OF CASING IS C>� FT. Above Land Surface`
*Top of casiuF tenninaleJ al/ur helaa land surface regnirei a
variance in avcorAanc %'it ISA NC\C 2C.n11N.
!1. YIELD(gpn,): 4;;Z— Mli"ri IOD OF TL'ST
10. WA'rl'.R ZONES(depth): —
LOCATION SKI�,rcii
11. DISINFEC'IION:'rypc Amc ant Show direction and distance in miles from at least
12. C'ASINCi: Willi':hickness two State Roads or County Roads. Include the road
•7L I.)eplh �I:g/ntel/er or N.eight/h1. 1 en:d numbers and cununun road names.
Frant_�'fu 50 1.1.JK-x-ci— --- ;�r� -.
-
I+. (iR(-)U 1: _Depth Maiorial Method r— _
From.—�_
Pena'_--..-- I-o—.—_ I'I----__. —_---
t-I. SCRI`IiN: Ucpth Ui:unetcr Sit)[;i>.e Material
D
'ro_.._ -- PL...___.in. it). t7dll
e�
--
15. SANIMMAVELPACK:
Depth Size Mawrial
Front
11'. REMARKS:--
I DO I IliRb:B1'C'ER"I"IF1"fllr\'r'rIIIS WELL WAS CGNSTRUCTED IN ACCORDANCE WITI I IiA NCAC 2C,WELL
MN>I'RUCHON STANDARDS.AND THAT A COPY OFT HIS RECORD HAS BEEN PROVIDEDTO THE WELLppWNER
S GNATL'RE OF PERSON.0 I S L R G ME WL'LL ATE
i RECEIVED
Su hnfit the origi imIto the Division of NVa ter Quality, Grit a nd wit ter Section, 1636 Mail Scryi•e('enter-Raleigh,NC
2 7 099-1 63 6 Phone No.[phone],within 31)days. JAN 30 2006 G W-I REV. 07/2001
Asheville Regional Office
Aauifer Protection

WELL CONSTRUCTION RECORD
Nunh( u olio, - Ucparintcm of l uvinnunun nd ` atur R(,v�ure:es- Division of Water Quality-Groundwater Section (�
\\'El.l (ON'I HACIOlt(INDIVIDUAL)NAME print) �f 4/((yy'.'.�/0 CERTIFICATION"I:I.I CON IRA('[*(Ill COMPANN N.NF;` �✓� LL��y±_(-/(✓i X
51'.\'I'F.\CELL C(1.\til'RCC'I'IOA I ERMITq ASSOC[AI ED WO PEft3 rrit
l ilapplicahle) (inapplicable)
I WELL USE(Check Applicable Box): Residemial IS Municipal/Public❑ Industrial ❑ Agricuhural ❑
:Moniloring❑ Recovery ❑ Heal Punip Water Injection❑ Other❑ II'Other, List Use
W tile).. LOCA'rI)N
Nt Com)t• Topograp hic'Land settingv YU� ❑Rid c ❑Slops Malley �<ur Icheekapprnpdnte n„slo✓
t' Iw N;lay.Num�boos.('onVimnay.Sulldiekwn,Lot No..lip C-11) Lat11lIde/lUngitlde or Well location
. . U\VNI:R:` e� /
-!! 1 dcgrtcs/win W csh�cunJsl
Address :4NNr ✓CVC' LalittldaAom_iludesource:❑GPS❑l'opographic map
Hose!or Hoare Na.l
(g"k✓ _ �r �. r 97Y 1)HPTII nl�tkb,a)
DRILLING LOG
t'ih t�.r ��j„� til:�lc zip(•tnlc From To Pr r iu Description
(K2) 1 ' Dv� — p ,
All'A malr Phone number/
I. D:\'ICI: UId11.L1i1')
N�
(,. DOB WELL REPLACE EXISTING WL•'LL7 1'E' NO N7J
7. S'I'A'FIC WATER LE -1. Below Top orCasirg: , U Pl'. —
(Use'Y'ifAhuvc Top ofCaging) _ —
s. 'IY)P OP CASING IS lr;� — i."r. Above Land Surface'
''Pall of casing Ierminuled al/or below land surface rer,::irc,a
1-:rian- in accrd:utc ith I5:%NCAC IC.m Ia.
1 — _hmri[ODOPT LST4. Y1iLD
10. WATI'R ZONES(depth):
LOCATION SKETCH
11. I)ISINrI:CI-ION.'rypc Amc unt Show direction and distance in miles front at least
12. CASING: Wall Thickness two Slale Roads or County Roads. Include the road
I Rplh - ne,cr or V.eight/Ft. err L , numbers and common road mutes.
From __ "ro___ Pl.
Pnml__- o __ Ft. __ `.
I7. GROU I Depth M:uerial Method e_ -.
I'L�C�_•'jC✓—�t/� I -
17nn
14. SCLIf I:N: Depth Diameter Slut Size -_— Macri:d
p
from _..._.err,._._.__.._ 1:1._____.in. in.
frolli__ 'fu __
Iti. SANIMMAV171. PACK:
Depth Size Material
Iiuttl... _—Tu—..--- I I---- _—'----
Ih. RFMARKS:
I Df)1IERIMY C'ER T IF1')'HAT THIS WELL WAS C(-NSTRUCTED IN ACCORDANCE WITI I 1 iA NCAC 2C,WELL
CONS l RUCII ION STANDARDS.AND THAT A COPY OI'THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATU'REOF'I'ERJ t , G-fHE WEL ATE
RECEIVED
Submit the original to the Division of Water Qualily, Ground Water Section, 1636 klail Service('enter-Raleigh,NC
27699-1636 Phone No.[phone],\vilhin 311 da.s. JAN 30 2006 GW-I REV.07/2001
Asheville Regional Office
Aquifer Protection

"�pn„a STAir a0
yyyr A •� 1� ��) E{ F 6. J
RESIDENTIAL %vr•LL CONS RUCTION aecoaD
North Carolina Department of Environment and Natural Rc nurces-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#_ 14-o
I.WELL CONTRACTOR: I. DISI VFECTION:Type
R (1� L Amount �.
'`e"�'by'„ -'�`'`�w�'I I g. WA'ER ZONES(depth)
Well Contractor(individual)Name From I o To Z i
From To.
euOU &AALue,lI Ori1V ;nQ
From To From To
Well C m
ontractor Company Name From
..\\ o To From To
STREET ADDRESS S51 I 2 W �ie—i r-QS t1 e/r Hui 6. CASING: Thickness/
�Shevtlie rJC ag�X� V Dep th
G T ly or own State Zi Cho From To .
FI. Dg'/x rI I rl
P From To Ft. _
( Vk% )- ZM - 35$ I From To Ft.
Area code. Phone number
2.WELL INFORMATION: 7. GRDUT: Depth Material Method
SITE WELL ID#(if applicable) Frorn_4—To �0 Ft. CEA16t0-r lb d(�,�'
from To FL
STATE WELL PERMIT#(il applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable 130
1): RResidentW Water Supply p From To Ft.__in. _ in.
DATE DRILLED From To F _in. in.
((/ 77'� — From To FLt.__in. _ in.
1
TIME COMPLETED 1 '- o O AM pJ/ PM p
9. SAND/GRAVEL PACK:
�.WELL LOCATION: Depth Size
CITY: �.A N`ro e. v O OO From To Ft. Material
COUNTY A
..'�77 From To Ft.
O }j N S a iJ ��'�YV� (Ls.-, A 0 From To Ft.
(Street Name,Numbers.Community.SubdiNelon,Lot No..Parcel.g Code)
TOg9GRAPHIC/LAND SETTING:
Slope C)Vail 10.DRILLING LOG
ey ❑Flat ❑Ridge ❑other From /To For)nation Description
(check appropriate boa) � -) � J p
May 0 �Q-�:_:Q.Oil rJLATITUDE 3 1 LONGITUDE w/1C.E- — 1�r.Y-s
Latitude/Ion Rude source: GPS g-e S, _ (�CLY. A L.T
6 O ❑Topographic map
(location Of"I must be shown on a USGS fopo map and
attached to this form 7 not using GPS)
4.WELL OWNER
OWNER'S NAME C,'T'C
STREET ADDRESS D Q ._�t
City or 1 own State Zip Code '.
*7
Area code- Phone number
L'
S.WELL DETAILS: II. REMARKS:
5 '
a. TOTAL DEPTH: q- o /
b. DOES WELL REPLACE EXISTING WELL? YES C) NO EV
e. WATER LEVEL Below Top of Casing. g D FT IDOHEREBYCERTTY THAT MIS WELL WASCONSmUCTEDNACCORDANCE WITH 15A NUC}C.WELL CONSTRUCTION STANDARDS.AND TNAT A COPY OF MIS
(Use'✓BAbove Top O(CaSing) RECORD NAS BEEN PROVIDED TO TtjpWELL OWNER
d. TOP OF CASING IS -,Ili FT.Above Land Surface'-Top of casing iBrom aced BVor beloW land sudace may require S*—
a variance in accavttlance with 15A NCAC 2C.C718. /t 00 bwNATURE O CERTIFIED WELL CONTRACTOR qTE
e. YIELD(gpm): METHODOFTEST RIG- A11 , /�� ..
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-la
Rev.7105

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Reso ces--Di ilr Ion of Water Quality:-:Groundwater Section R WELL CONTRACTOR(INDIVIDUAL)NAM (print) \ Vp{ CERTIFICATION UQ q2
WELL CONTRACTOR COMPANY NAME E l I PHONE # 1 201 J
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ pERMI
(ifa licabie) (if applicable)
L WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAff �U Nyyk J Topo GLand setting
Nearest Town. County �� 1'>f�l.� ❑Ridge lope OValley OFlat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,
Lot No.,Zip Code) � t gi f Wel�Id118lippN a ///_
3. OWNER: ' Lt/ �SOt '{ �D�(]1�tV
Ad res (dcgrecsiminutWseconds) (Q V" (�G9
_ Latitude/longitude source:OGPS❑Topographic map
IWT
-lft.. IIpG t o Rou�ty`o Q' Q (check box)
t J t t C "t U v� DEPTH DRILLING LOG
Cry or Town State Zip Code I From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPT
6. DOES WELL RE A EXISTING WELL? YF�g jJ0
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 cuing terminated at/or below land surface requires a
variance in accord b 15A NCAC 2C.011$
9. YIELD(gpm):, ME }�D OF TESIG6• _
10.WATER ZONES(depth): . �[�
C, 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 To Ft.
From To FL
From To Ft. o
13. GROUT: Depth Mate ' I eth
From To FL � r� rn
From To FASS ��hN'nC.I -
I4. SCREEN: Depth Diameter Slot Size Material CD :'-
C.rl
From To Ft. in. in.
From To FL in.. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY T T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST UCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOT WE O §R—.
V(
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Res ur//ees//-Division of Water Quality-Groundwater Sectiioonn/n�^,
WF.LLCONTRACTOR(INDIVIDUAL)NAME (print) �U [S CERTIFICATION#�1QQW1�
WELL CON'TRACrOR COMPANY NAME /i PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery El Heat Pump Water Injection El Other El If Other,List Use
2. WELL LOCAT O , A ''//��1t To o ra rc/Land setting
Nearest Town: fd Rl/E Count _C� ❑Ridge g one ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,St division,tut No.,Zip Code) a tude/longitude of w 11 location
3. OWNER: � �•�la- ��
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
WA (5 o Ro e 9� (check box)
DEPTH DRILLING LOG
Cn or town state Zip Code From To Formation Description
Area code-Phone number �r b D�
4. DATE DRILLED 111) 7JM
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? Y ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+'•if Above Top of Casing)
8. TOP OF CASING IS ✓/ FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accord eaaith 15A NCAC 2C.0118.
9. YIELD (gpm): _METHO,p OF TESTI7L•�A1�-1
10. WATER ZONES(depth): RO )
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
Dept i Diameter or Weight/Ft. Material numbers and common road names.
From To FL
From To Ft.
From To Ft. 'a
13. GROUT: Depth Mae " I Met d
From To Ft.
From To Ft. 1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. tT
From To Ft. in. in.
O
CD
15. SAND/GRAVEL PACK: CA
Depth Size Material -`
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC ION STANDARD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
276994636 Phone No.[phone],within 30 days. / '� ,. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD `) `
North Carolina-Department of Environment and Natural Resource - Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM (print) 60
I CERTIFICATION#��
\VELI.CONTRACTOR COM PANY NAME r ,,pp����&/f,-3
� / PHONE # IdJID)�E.7
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 LOCA I N: //
Nearest Town: 1 4 Topo_graa is/Land setting
CountVTD`I� ❑Ridge BSlope ❑Valley ❑Flat
P �� ' (check appropriate box)(Street Name,Nt tubers,Community,Subdivision,Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER' D N Q,
(degreeshninutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
�Vhr& (S[ree or$ou[e No, (check box)
►LYIG DEPTH DRILLING LOG
C tyty o� State Zip Code From To
Formation Description
Area code-Phone number O
4. DATE DRILLED 10 (.•Jx
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES Q
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):57.METHOD OF TES<'l f
10. WATER ZONES(depth): M!nlJ
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
� Dept Diameter or Weight/Ft. Material numbers and common road names.
From e To Ft.
From To Ft. . . 1/
From To Ft.
13. GROUT: Depth Maten Meth. o� �Q/" �`J�l
From To Ft
From To�Ft� -M1
14. SCREEN. Depth Diameter Slot Size Material
O _
From To Ft. in. in. G
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material CD a
From To Ft.
From To Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,A2 THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
l o -.z G _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-1 REV. 07/2001

3 6 4
WELL CONSTRUCTION RECORD/
North Carolina- Department of Environment an Natur Reso rc s- Divi ion of Water Quality-Groundwater Sectio
WELL CON]RAC OR(INDIVIDUAL)NA E ( rintt)) 1 p- v t^,'i' I CERTIFICATION
WELL CONTRAC-1'OR COMPANY NAM NZ N \ 1� II PHONE #
S'fA1 E WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential MunicipaFPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCH / Topogra is/Land setting
Nearest Town: / Q `I�', County ❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,
Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: N(Rs,- `- C& a5 (degreeshninutes/seconds)
Address D 1 Q. Latitude/longitude source:❑GPS❑Topographic map
Y (StmeRto -Q. too.) �O�J� rzp (check box)
y(\ (.1/1 � lY'z �LP"��� DEPTH DRILLING LOG
Cry or Town State Zip Code From To Formation Description
Area code-Phone number 3
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: $4-0 FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accor9atocrwith 15A NCAC 2C.OI IR. � t�
9. WATER
U(�wIETHOI�OFTES '�Cl•
10. WATER ZONES(depth): .1i0, y'O
LOCATION SKETCH
11. DISINFECTION: Type 033t 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.
Fromm Too) FL
From FL
From To FL
De
13. GROUT: Depth Material```r
From To Fl .T�—
From To Ft
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. vO
From To Ft. in. in. o
15. SAND/GRAVEL PACK: Ln "
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU N STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
SIGNATURE OF PERSQ04 GgNS44k�6+1H8
{R�E ��+ DATE
Submit the original to the Division of Water Quali ,Grou'RRIP 91MA636 Mail Set vice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001
JAN 30 2006
Asheville Regional Office

d„c srAlr
RESIDENTUL WELL CONSTRUCnON RECORD
: - North Carolina Department of Environment and Natural Resources-Division of Water Quality _
WELL CONTRACTOR CERTIFICATION# Q0,5_6
1.WELL
CONTRACTOR: I. DISINFECTION:Typo Amount/0
Y�N g. m_pad_ o 63n
W1#JI Contractor(Ir1di i Name/ ye ! From To-y�L�l From To
yr Y1CLr! (_Jai �A,h l[i nn From Tc From To
Well Contractor Company Name Oz
n t1 From To Fran To
STREET ADDRESS 6 -/ J�i� o 7y wi, /SA 6. CASING: Tweight hickness/ MaterialRD�y`ji,n5i�,+//E /1IG Qfi77/ Fran_Q_Depth
To�3 Ft 6QG3C YYG
City or Town State Zip Code Fran To Ft.
( wuq-)_4179g,?,V5Lf From To Ft
Area coda- Phone mrmber
2.WELL INFORMATION:
7. GROUT: Depth Material Method
SRE WELL ID#(N appltcable) FTnm�To�_Ft CF'M.on'T
Fran To Ft
STATE WELL PERMIT#(l amicable) Fmm To Ft
DWQ a OTHER PERMIT#(d applicable) 8. SCREEN: Depth Diarnater Slat Size Material
WELL I1SE(Check Applicable Box): Residential Water Supply pj From To R Ft_in. _ in.
an To Ft_in. _ in.
DATE DRILLED ��) n/9'-/1� From To Ft—in, _in.
TIMECOMPLETED ri[ .'Q� AMO PMIQ
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Steel Material
CITY: A7%ri COUNTY / &/,fo/�. m Fm Tc FL
R� �I ` Fran To FL
R!!l���
'r� From To Ft—
(Su."glim.Nuinbers.Cam^uNtY�SuEtlle%fon.t.utNa.Parch.$-Cotlel_ —
TOPOGRAPHIC I LAND SETTING: 10.DRIW NG LOG
❑Slope pValey ❑Flat pLRidge ❑ether From To Formation Description
(check appropiate ba0
LATITUDE 3
.97_10.� / namtm seconds
a
LONGITUDE--6-af n;S�/St/:D ma decimal farm's
LatitudeAongitlde source: ®GPS oTopogaphic map
(bca#on of weloxistbe slaws on a USGS bpo Ytmp and CT
a0achad to bus faro lnot usM GPS)
4.WELL OWNER �
OWNER'S NAME
STREET ADDRESS C.71
I'll
n n v f ho /✓G
C' a Town Stage Zip Code _
CU& ) 73G-ash'V7
Area code- Phone number
11. REMARKS:
5.WELL DETAILS: �7
a. TOTAL DEPTH: 6 c]y -
h. DOES WELL REPLACE EXISTING WELL? YES❑ NO Jill
c. WATER LEVEL Below Top Of I DO HEREBY CERM THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
OP aSPlg: FT. 15A WC 2C.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THS
(Use'+•if Above Tap or Casing) RECORD WAS BEEN PROVIDED TO THE WELL OWNER
d. TOP p CASING IS FT.Above Land Surfacer �f't� Ae ''Top ri cain c or'danc with blow,lend 2C.01s may requtre SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
a. YIELD(gpm):�_METHOD OF TEST e&I r
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the origiyal to the Division of Water Quality within 30 days. Attn:Information Mgt., Fo m GW-ta
1617 Mail Serf Center—Raleigh,NC 276994617 Phone No.[phone] e)tt 568. Rev.

0 200�' 316843
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
CERTIFICATION#,� _�
WELL CONTRACTOR(INDIVIDUAL)NAME (Print) 1 ' l Al y`1t"
e
PHONE #
WELLCONTRACTOR COMPANY NAME
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
Cun{on - County '� f400 flR//idge ❑Slope ❑VaI'ity ❑Flat
Nearest Town: (check appropriate box 1
enucF Q 1 v Code) to
(Street Name.Numbers,Community.Subdivision,Lot No..
ZIP Latitude/longitude of well location
`d (degreeslminutes/xecom s)
3. OWNER: o Latitude/longitude source:❑GPS❑Topogmphicmap
Address (check bn:.)
(Strecto Route NO) 01 II(3 DEPTH 2R1111NGLOG
Ct tbtk-�-°^r Fr Jm Forrnz Description
Gty or Town Slate Zip Codc U ... �ty d,on
(891%)- va\ 3t2�
Area code Phone number
4. "DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO FT. '
7, STATIC WATER LEVEL Below Top of Casing: n
(Use"+'if Above Top of Casing) .------�--»y
S. TOP OF CASING IS FT.Above Land Surface`
-Top of casing terminated atfor below land surface requires a --_ "-------------�—
variance in accordance with ISA NCAC 2C-0118- ... -..
9. YIELD(gpm):�_— METHOD OF TEST ;0
10. WATER ZONES(depth): ON SKETCH Ul r
Show direction and distance in mi'.es from at least
_:� Amount -�y
11. DISINFECTION:Type_. Wall Thickness two State Roads or County Roads. Include the road
12. CASING: numbers and common road names.
Depth Diameter or Weight/Ft. Material
From To Ft. 4 4 ShR
From T° FL
From To Ft. WA ((
13. GROUT: Depth Material Methodf
To RO Ft. -(tee
From �./�.
From To FL------ 1 •
14. SCREEN: Depth Diameter Slot Size Material co �1'y (/'•yr
Ft. in.
From T° in. A4.
From To Ft. in. in. Cr so
15. SAND/GRAVEL PACK: Material
f
Depth Size
From To Ft.
From To FL ---- �Wy
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, YELL
CONSTRUCTION STANDARDS,AN THAT A COPY �C�BEEN PROVIDED TO THE w�" O�—
3
rrrtdr`THF WELL DATE

OCT 0 -Ml5
� 6842
i
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundvater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Prior) �`'\t" 'S VM>r< S CERTIFI<;ATION#�.-d
o a c ow PHONE Jr Rl7 Cnt�`5 Z.Z
WELL CONTRACTOR COMPANY NAME J
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) _ (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 LOCATION:
a 11 a R9 t� TopoVphic/Land stt ng
❑Ridge e ❑Val cy ❑Flat
NearestTown: County �tW--§ L (check appropriate box)
Latitude/longitude of weil location
(Street Nmne,Numbers,Community.Subdrvtsmn,Lot Ne..Zip Code)
3. OWNER: �JQ-'yr 2P\� $oflP4 (degrees/minutes/secoe(s)
Address iel•. Cove Ron A Latitude/longitude source:❑GPS❑Topographic map
(check bo::)
(Street or Route No.) DEPTHDRILLING LOG
or QA8 l l to
z Code From To FormrtionDescription
City or Town State P 1 SIR war ®w'dPe1
Area code-Phone number
4. "DATE DRILLED 1- 1-5 Y2
5. TOTAL DEPTH: 3 /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO G }
7. STATIC WATER LEVEL Below Top of Casing:__4-0_FT. _ r
(Use"•'if Above Top of Casing)
S. TOP OF CASING IS FT,Above Land Surface*
-Top of casing terminated atior below land surface requires a -
variance in acmrdaw with ISA NCAC 2C.0118.
9. YIELD(gpm): s METHOD OF TEST-
1 D. WATER ZONES(depth): —r-
LOCATION SKETCH
Show direction and distance in mi'.es from at least _;"
11. DISINFECTION:Type Amount n two State Roads or County Roads. Include the road -'
12- CASING: Wall Thickness -
Depth Diameter or Weight/Ft. Material numbers and common road name:.
From__To g;- Ft.s. _
From To Ft. ' - r`` Mill
From To Ft.
13. GROUT: Depth Material Method ,o
From—Tor FL e �tuta�
From To Ft. !j
14. SCREEN: Depth Diameter Slot Size - Material p
From To Ft. in. in. Qal COJe
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,'NELL
CONSTRUCTION STANDARDS,ANDS A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W[LL OWNER

311048
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of `Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) .c_t a� i-ks & r,(/nP Eh CERTIFICATION#-4-YL
WELL CONTRACTOR COMPANY NAME,( —eht:.._/I�/YAALSqq, /yp� .� PtLr..-n . PHONE # fffA G'18 - 3l'7b
STATE WELL CONSTRUCTION PERMIT# TUd _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
l. WELL,USE(Check Applicable Box): Residential 9'�Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: M�tair 1 e _County ❑Ridge ❑Slope OValley [3FIat
[�l ("° �'L �����II���" (check appropriate box)
(Street Name,Numbers,
Cornet it ,Subdivision!Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ GLEN �lv (degrees/minutes/seconds)
Address 74 I r t- in; na44, Qrti Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
—I �LAAneSy 1 )s f l C �?$ '7 DEPTH DRILLING LOG
(;ty or/town state zip Code From To / Formon Dese 'ption
Artie cWe Phone number
1. DATE DRILLED 1,5 - a a _pC� -
5. TOTAL DEPTH:
S. P ns trrr.i L ula,l.nCi- i-v i�rrnir �,,pL::' Y:.S L3 NO LV" - -
7. STATIC WATER LEVEL Below Top of Casing: aD FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface' i-
{'cop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): .5 METHOD OF TEST
IO. WATER ZONES(depth): .?zi/.S' - $cj�,.-�
LOCATION SKETCH ' r
I (. DISINFECTION:Type._ Amount 3L fb 1 k5 . Show direction and distance m tulles frpm at IeasI.- I
_ _ —
12. CASING: Wall Thickness two State Roads or County Roads.Include the roafi--
Depth Diameter or Weight/Ft. Materia numbers and common road names.
From_-(Z_To j 1)1 FL_14 "
From___.-_.To FL
From __._To Ft si
13. GROUT: Depth Material Method
From..'
From To Ft.__
v
19. SCRGL•N: Depth Diameter Slot Size Material
From To Ft. in. in. CJ
From
— To Ft. in. in.
15. SAND/GRAVEL PACK: r0
GIl
Depth Size Material
Prom _ _To Ft.
—
Front_
16. RF.MARKS:
[DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTR`UJCTIION STAN_DJ-ADDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7-- —C' �/JtRe�f l y
SIGNATURE OF PERSON CONSTRUCTING TI IE 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

311047
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_( l.n y/taq 1ZJP- �����
WELL CONTRACTOR COMPANY NAME Lys- T� � t CERTIFICATION#— �r a
r1P..._Is7t'rx l.y � 4 1Yt t w,,, T� S�� IoPHONE # ( CIS —.3I`-JD
STATE WELL CONSTRUCTION PERMIT# _ ERMI #"'
(if applicable) — R —ASSOCIATED WQ PRMIT#
(if applicable)
I. WELL USE(Check Applicable Box):Residential B"'Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WI:I.I,I OCATIO / /
Nearest own: u County y�t�J J Topographic/Land setting
r. ? I r- TT""`-�— DRidge ❑Slope ❑Valley L4el
at
1 St t Name,' tubers,C.ommumty,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER: 'T 1 Latitude/longitude of well location
Address Q /7 `�'`,.�,r/ ,3 S r7 (degrees/minutes/seconds)
(street or Route No.) Latitude/longitude source:DGPSUTopographic map
_:RC, k v t 1 It I 1//9 a 3I V 6 DEPTH (check box)
C itv or [own State Zip('ode DRILLING LOG
From To Formation Description
Area code-Phone number 7(, L ' 4
4. DATE DRILLED (Z • R -p l� 7G G ' 6R s r j-
5. T OTAL DEPTH:____,�'g� /
r !)r_)!S %t 1u-1"I u1:1'I ni l: is v14-rin';G \x%1:1 I v
Vnc li n�� INS
7. STATIC WATER LEVEL Below Top of Casing ).26 FT.
S. TOP OF CASING IS ((Je if Above Top of Casing)
.I"op of casing terminated atlo d $urface*
land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): _ IA. 5'_METHOD OF TEST r5
10. WATER ZONES(depth): 6
5r1 S � c)P r„
1 1. DISINFECTION:Type l �S , LOCATION SKETCH
Amount 1o�t.),)i-5 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-I"l I Ft. & PP
From---- To Ft.
Prom___ Ft
To
.
13. GROUT: Depth Material
Prom Method ..»
t.
From _To FL_
t4. SCREEN: Depth De
P Diameter Slot Size Material W ,
From- --To _Ft. in.
in.
From To— - Ft. O
Ft—in. }..
15. SAND/GRAVEL PACK: in.
c
-a
Depth Size Material
From_..-__To Ft. -
From Ft.
16. REMARKS:
f
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC
CONST 2C,WELL
RUCTION ST RDS,AND THAT A COPY OF THIS REC D HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI I WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-//Divisionof�Waterr Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM rint)_C /Y� 1P_S Abin LC/YI CERTIFICATION#4
WELL CONTRACTOR COMPANY NAME &QJ L "/,Xt OS �.J� °I L PHONE #
STATE WELL CONSTRUCTION PERMIT# __— / (y —ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential M/Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO . Topographic/Land setting
NearestT,p.yn: County � I ❑Ridge ❑Slope OValley �t
(check appropriate box)
(Street Name.Num Community,Su_ ivisio Lot No.,Zip Code) Latitude/longitude of well location
II 11 r /n/ �)
3. OWNER:. rf J/1) Jt , `�e .C_�t l � (degmes/minutes/seconds)
Address Jy30 /.,'>'il: ?90 F ' -• Latitude/longitude source:DGPSOTopographic map
�Street or Route No.) (check box)
�-� xnc ,?br 7 DEPTH DRILLING LOG
city or Town State Zip Code From To Formatio Description
(—I- _ /S/
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:_$D 5 r
1)1,)cc to let RI.), nr'r rvlS ring; \nil: i o Y1:S ii �NO
7. STATIC WATER LEVEL Below Top of Casing: 116
1 ,AFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):/—METHOD OF TEST rs
10.WATER ZONES(depth): _TD m
LOCATION SKETCH
It. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Z� Depth ''/,, Diameter or Weight/Ft. Material numbers and common road names.
From_.61 To /mod Ft./P
From____To Ft.—
A
From To Ft.
13. GROUT: Depth aterial Method
Prom_Q__To_ Ft._ ��g-p- - --< r-}
From To Ft. 7
14. SCREEN: Depth Diameter Slot Size Material W
From, _. To Ft. in. in. t7
--From To � Ft. in. in. ul
15" SAND/GRAVELPAC:K: `l
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 -
CONS"IRUCTION STAND, S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI IE 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

311045
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and a/ural Resources-Division of 1�t1�''IIater Quality-Groundwater Section
''//
W ELL CONTRACTOR(INDIVIDUAL)NAME/t((print) , 1LiL CERTIFICATION#o'A4 8
WELL CONTRACTOR COMPANY NAME S,T['e[�,p� - /LS' V Ve'/� �.t1�D+ Tll PHONE # 8 L 4-8 -3)7 D
STATE WELL CONSTRUCTION PERMIT#__ 4' _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential a--Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELT.LOCATION-. / Topographic/Land setting
Near own'1" County ( ( ❑Ridge ❑Slope Walley Cd lat
(check appropriate box)
(Street Vine,Numbers,Comm un'ty,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3. OWNER:_ (degrees/minutes/seconds)
Address Latitude/longitude source:OGPSOTopographic map
(Sur etor Ro No.) y // (check box)
4 t--,_y ) (:' 2 17/[-- DEPTH DRILLING LOG
city or Town state zip code From Ti Formation Description
Area code-Phone number - 95 / J�6,57 I
4. DATE DRILLED
5. TOTAL DEPTH: 5-65 '
�. :Y 11.�; tt,ti I Pla,l nC•I: is vicri xiCi �a,r l:( I q Y1._c t� P!O 1�
T S-I ATIC WATER LEVEL Below Top of Casing:aa)r, AFT.
(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
rariance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):_ A METHOD OF TEST a A rs -
10.WATER ZONES(depth): 02
�/G 5-- /3%6/ y p y,., LOCATION SKETCH
1 t. DISINFECTION:Type N 7W Amount 1712 f/,/d i 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.
Front_../To__q,L Ft. /o
From ___To Ft. 0
From ____To Ft. _ S
13. GROUT: Depth — aterial Method
m ;-5
Fro ___To ,g 3L Ft.
From To Ft._
14. SCREEN: Depth Diameter Slot Size Material O
From_.__To__Ft. in, in.
From__ To Ft._._in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From- __- _To Ft.
16. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL- -
CONS I Rt1CTION STAND DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC -
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

311044
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and N tural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_L�l q J 1 Z P✓+11�-��-D CERTIFICATION N 3 82
Br -1. 4 PIIONE p �_-31'7
WELL CONTRACTOR COMPANY NAME Yf-En(=FJ �{
STATE WELL CONSTRUCTION PERMIT#_ d ASSOCIATED.__ WQ PERMIT#
(if applicable) (if applicable) _
l. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:nn Topographic/Land setting
Nearest Town: ( .� .Y'trrL. County �Y�y[.�o�� 5&dge ❑Slope OValley ❑Flat
l.a-cJ I,e e (check appropriate box)
(Street Name,Num� (ommunity,Subdivision,Lot N��o.{t'Zip Code) Latitude/longitude of well location
John w
3. OWNER: . r�I/)i / ./) n �._. _ inutes/sewnds)
Address / ,/ �t�it{-O-r Latitude/longituddee source:
our source:OGPSOTopographic map
(St et or Route No (check box)
50 Ilp��e y �i„) DEPTH DRILLING LOG
cuy or town State Zip Code From To 1 Formati n escription
D �� _
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: 1,05 J
r'. tYJI.S �i,r.�_:. ul:;':.^:G rvicri niC; �aila.I o Y!i.i 1 i NO l"
7. STATIC WATER LEVEL Below Top of Casing: / Sb FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS I FT.Above Land Surface*
*"fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.01 18.
9. YIELD(gpm): / , 5 METHOD OF TEST
10. WATER ZONES(depth): 'd& 5I - .5 c w,
LOCATION SKETCH
I l- DISINFECTION:Type F-/7f-/ 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-O To—gLFt_ r` P V17_
Front To FU _
From_.__To FL
13. GROUT: Depth Material Method
From_Q__To_,Q,0_Ft._ n..,..a., f- -'�i,� c,.t �n
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From --To Ft. in. in.
From_ To - Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From— To Ft -
From_ _- __To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND RDS,ANU"THAT A COPY OF CORD HAS BEEN PROVIDED TO THE W84L 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-P'REV.0712001

311041
WELL CONSTRUCTION RECORD
North Carotin-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print).__. CERTIFICATION a335'1
D
WELL CONTRACTOR COMPANY NAME�Cp,L'j1� S Wt-I1 -4 uhip-Ti+c. - PHONE # (,?AV4
STATE WELL CONSTRUCTION PERMIT# T _ ASSOCIATED WQ PERMIT# —
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Er�Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : Jopographic/Land setting
Ncarest Town:4f4y ne5 y/ //E County 711 idge ❑Slope OValley OFlat
ft 5y.f� �j� (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: aJa e.�.-r� `' yv5'� � (degrees/minutes/seconds)
Address 5� /I l Latitude/longitude source:OGPSOTopographic map
I(Street or u.No.l (check box)
,') $�J DEPTH DRILLING LOG
city o, I State Zip code From To Form lion Description
Area code-Phonc number `= 9/$ 7
4. DATE DRILLED .�-2S'a •`� i
5. TOTAL DEPTH:
-� nrUa Prl'1f VI it n!'11"Y tl'� �AIl: \1%1:1 Y!'S I1 NO t
7. STATIC.'WATER LEVEL Below Top of Casing:__&.Q_FT. T
(Use`•+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*'top of casing terminated attor below land surface requires a -.
variance in accordance with I5A NCAC 2C.0I18.
9. YIELD(gpm):. c,? METHOD OF TEST -
10.WATER ZONES(depth) In
6 / .. � ,•.-s LOCATION SKETCH s� �
I t. DIS[NFI;C'fION:Type ___ Amount_ads {(,J is Show direction and distance in miles from at leas'itj -
12. CASING: Wall Thickness two State Roads or County Roads.Include the roan
numbers and common road names.
Fro
Q To�Depth g� Ft._Ui m/ter or WeighUFt Material y�
m_ _ 0—
From To Ft. _ Ca
Froln____To Ft. _
13. GROUT: Depth Matenal Method
From._To__,,2p_Ft._ _ '! Ln
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From—. . To - Ft_in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From____ To Ft. _
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C'ONS'hR[)C'TI�STANDAI{� AND cA COPY OFF T�RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

311042
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division
'of/Water Quality-Groundwater Section' �
WELL CONTRACTOR(INDIVIDUAL)NAME (print).(,tWV LLY�P S �Q�i r n n L!/JLh CERTIFICATION#I/�s /
WELL CONTRACTOR COMPANY NAME rrP ne _.9_ r_LS I� /� GQ Y YLtmP_o.�._PHONE # (ga�n 7P'-3)'7D
STATE WELL CONSTRUCTION PERMIT#_ _._ //� --ASSOCIATED WQ PERMIT#
(if applicable) _/ (if applicable) _
1. WELL USE(Check Applicable Box):Residential H Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W IiLi.LOCATIOX. I Topographic/land setting
Nearest own: County 44-t4W7di ORidge CHSlcpe OValley Flat
_ C'! U e, (check appropriate box)
LStreet Name,Numbers,Community,Subdivision,Lott No.,Zip Code) Latitude/longitude of well location
um
3. OWNER: f ' 1 i Cd-r, I Y IV I C'� (degreesimmutesiseconds)
Address _ FsD q �(7 tAii" P-A Latitude/longitude source:OGPSOTopographic map
(street or,Route No.) �— (check box)
LLGI r1 P 5 V I l l e ILI C 529 7 g CD DEPTH DRILLING LOG
city orr wn state Zip code From To Formation Description
Area code-Phone number
4. BATE DRILLED 3 - 25 -GS
5. TOTAL DEPTH: .24-5 '
�. :)111-.1 11 1.1 1. g1:0l All.. %ifFl o Yi.-� I I NO i
7. STATIC WATER LEVEL Below Top of Casing: 6- FT.
(Use"<"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
-fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):�^' ;2_METHOD OF TEST a hf5
10.WATER ZONES(depth):— . .25 ' - '7 S prv.
LOCATION SKETCH
i l. DISINFIXTION:Type )-4_Y_tom— Amount µ 3 +L I+.s Show direction and distance in miles from at leasi-
12. CASING: Wall Thickness two State Roads or County Roads.Include the to
.-
Depth Diameter or Weight/Ft. Material numbers and common road names. '?
From_-L To-5�FL_I!, Pyc- S
From To Ft. z'.c
From__To Ft. W -;
13. GROUT: Depth Material Method
From _To 02b Ft. L.... ..- i- O
From To Ft.__ ,
14. SCREEN: Depth Diameter Slot Size Material -
From-_._To_ Ft. in. in. -From To - Ft. in. in.
15, SAND/GRAVEL PACK: _
Depth Size Material
Frum To Ft.
From- To Ft. I .
16. REMARKS:
c�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL-; -
CONS TRUCTION ST ARDS,AND THAT A�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 6WNER
_ 1'
sAJdAJ-
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

311043
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME print), j(�' e 6i n ZdeP Zh CERTIFICATION#a4/8
WELL CONTRACTOR COMPANY NAME py) /;}ro z�a B W- P PHONE # Jgg"Yg
STATE WELL CONSTRUCTION PERMIT#. _ �YD� _ASSOCIATED WQ PERMIT#
(ifapplicable) (ifapplicable) _
I. WELL.USE(Check Applicable Box): Residential 2"-Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : Topographic/Land setting
Nearest jT,own: County�,l'II . ❑Ridge ❑Slope OValley OWlat
l � Aa re ��o�- (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Cie n/-e- F3at1p (degrees/minutes/seconds)
Address I29 P/a 4., A- � r uep, Latitude/longitude source:OGPSOTopographic map
6 (Str t or Route No.) (check box)
t n!( 2 DEPTH DRILLING LOG
cry or sown State Zip Code From To Formation Description
S�2 )
Area code-Phone number
4. DATE DRILLED J
S. TOTAL DEPTH: '/O 5
�)t�)a W11! l VI. I I 1r\ I
7. STATIC WATER LEVEL Below Top of Casing: q6 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
"fop of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_ /7 METHOD OF TEST 2 Airs
10. WATER ZONES(depth): _3 SS 1 - ) 7 a P.,,,
LOCATION SKETCH
1 1. DISINFEC rION:Type N Amount 74 fL/-fs Show direction and distance in miles from at least
l'_. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. .
Front_._Tog�2—Ft.tA P Vc 1.3
Front— To Ft.-
From—To Ft.
1,3. GROUT: Depth Material Method
From 6 __To D Ft- 06 •,- ± ��p_._ W 31
From To Ft. - 1
14. SCREEN: Depth Diameter Slot Size Material C:)
From____ To Ft. in. in. Ln
...
From To Ft. in. in. 'g
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From _.--_To__Ft-
16. REMARKS:-
--I DO([EREOY CERTIFY THAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONS-I R,,U''CTJJION STANDAR S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
AA ZCl 07�A t ftt/� SL.3D d
SIGNATURE OF PERSON CONSTRUCTING TI IE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,.NC
27699-I636 Phone No.[phone],within 30 days. GW-I REV.07/2001

- C�" 311050
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �GIPY (//�/y���jL CERTIFICATIONS# 3U:35
WELL CONTRACTOR COMPANY NAME G�C.BnL—I3+-eS (/LIT I I P . PITONE # SL I
STATE WELL CONSTRUCTION PERMIT#—_ �'j/U ASSOCIATED WQ PERMIT#
(if applicable) if applicable)
1. WELL USE(Check Applicable Box):Residential M-Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: /ropographic/Land setting
Neartess Town:_" Cjq r �: I�County tdge ❑Slope OValley ElFlat
ll nzD)& -�r- gmC )4a.. F2�� (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lit No.,Zip Code) Latitude/longitude of well location
3. OWNER:, Fr is, f !'E P-AJ (degrees/minutes/seconds)
Address loL1b .S ar Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
Q a 1 e I�n I II' j , NC '2 Sr 7 DEPTH DRILLING LOG
city —state zip Code From To Formation Description
g I
Area ade-Phone number
4. DATE DRILLED_ ` �S
5. TOTAL DEPTH.
^r tcc Wli r uFPL.^.0 t: rv.i5n nv; As 1A( [ ,t Y[ c �i NO ILK-' - -
7. STATIC WATER LEVEL Below Top of Casing:_,,Y0 FT.
(Use"+"if Above Top of Casing) -
8. TOP OF CASING IS FT.Above Land Surface* _
*'fop of casing terminated atior below land surface requires a - --
variance in accordance with 15A NCAC 2C.01 18,
9. YIELD(gpm): METHOD OF TESTr� -
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECT[ON:Type�__[� Amount /99 Yr'/-Ls. Show direction and distance in miles from at least -
i 2. CASING: Wall Thickness two State Roads or County Roads.Ineli do the road .
Depth Diameter or Weight/Ft. Material numbers and common road names. --
From__ _- To FL _
From—-—To Ft
13. GROUT_ Depth Material Method 3
From L> To c9D Ft.___
From-_ - To Ft._
Q
14. SCREEN: Depth Diameter Slot Size Material ;.4
From...-To--FL—in. in. W 1
71
m_Fro _,. To Ft. in. in. C:)
15. SAND/GRAVEL PACK: Ln
Depth Size Material
From To-_Ft.
From To Ft.
16. RF.MARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD 30 �8 9 4
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ,/
N'ELL(.ONI'RACTOR(INDIVIDUAL)NAME
��(print) Q_ �L.LV�_ ___" CF,RTIFICATIOpON# 3/-5- .`t
WE1.1.CoN'1'RACT'OR COMPANY NAME (Srr-crv) L7 Y.c Li ae IlD .(. � ,..,,,n`�,r_PHONE, # �p_rpT o-.'_3170
4T.A"I ENN ELL CONSTRUCTION PERMIT#,""_. �i(-D 'Z_ASSOCIATED WO PE��RMIT#
(if appl icable) (if applicable) -
l. WELL USE.(Check Applicable Box):Residential)6 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Usc
2. WFI1,LOC'A'FION: Topographic/Land setting
Nearest own: L/,Al , 1'.SY�County 4 / �Y.'(y ARidge ❑Slope ❑Valley ❑Flat
_�rp P L" S 6 — Ln.4- (check appropriate box)
(Street Name,NnmbeN,Community/,'Subdivision,I,)t No.,Zip(ode) Latitude/longitude of well location
3. OWNER: - + m As5,( -t-) (degrees/minuteslseconds)
Address I L�gC) I S'c�:�{, e E Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
at DEPTH DRILLING LOG
city or Town Stare e From To Formation Description
)-. - —0 ao
Area arch Phone number r
4. DATE DRILLED I
S. TOTAI.DEPTIf: C7 _�-- r�a/
r" nnnc U;ni i uuUl nrc LF'le9 lnir: \A;).� I o VLc I I nn Y
7. STA'F[('WATER LEVEL Below Top of Casing: 4/6FT.
(Use"+"if Above Top of Casing)
----------
8. TOP OF CASING IS�_FT.Above Land Surface`
*rop of easing,terminated atlor below land surface requires a - ---'--- --
variance in accordance with 15A NCAC 2C.8118.
9. YIELD(gpm):t—METHOD OF TEST a k rS
10.WATER ZONES(depth):.""___ loJ ( _
LOCATION SKETCH
11. DISINFEC`HON:Type HT Amount Flo_+ JJ Show direction and distance in miles from at least
12. CASING: W'all'1'hickness two State Roads or County Roads.Include the row
Depth Diameter or Weight/Ft. Material numbers and common road names. O Crn
LA
From. "p b-_To Ft. " — �1�(t. -rt mm
From—__ _ To -----Ft..___-- — �
m
From -_ - To Ft. A�
13. GROUT: Depth Material Method
From _ Ta_ Ft._Cn.....n_._.f -1-,T.r.
From To Ft.----- I'���
14. SCREEN: Depth Diameter Slot Size Material
From To Ft._ in. _- -_— in. - - -
O rn From _ To__.._.Ft. in. in. — P
15. SAND/(iRAV1iLPACK:
Depth Sire Material -
From To
From _.- To Pt.
16. RF.MARKS:
1 DO HEREBY CFRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL.
CONSTRUCHON S I DARDS,AND TI IAT A COPY OF IS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
--71/c-) zz- 3/ 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

C"i
WELL CONSTRUCTION RECORD 3 0 �8 9 0
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL('ONT'RACI'OR(INDIVIDUAL)NAME (print) C.� �.e,aa, _Po_6,-,�Q"b CERTIFICATION#3�L�
WEI'l,('.ON''1'RA(TOR COMPANY NAME-(Ir r-e,"c Bra tK)—]d.m�1 nG PHONE # c 4S) 3.I ')D
S'rATh;WF,I.I.CONS'1'Ruc,riON PERMIT#_..__ _�_''�' � . ___ASSOCIATF,D WQ PERMIT# --
(if applicable) (if applicable)
1, WELL USE(Check Applicable Box):Residential19 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Hcat Pump Water Injection ❑ Other❑ If Other,list Use _
2. WTi1.L LOCATION:
Topographic/Land setting
Nearest Town:_ " 6uI__)_l,County a. LJ ❑Ridge ❑Slope OValley AFlat
milli, + r Cru TrPL (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:❑GPSOTopographic map
(Street or Route No.) (check box) -
5`(1[ina or JR r7S I DEPTH DRILLING LOG
—city r�r�� n�v Staff zip c'nde From Tppo,, Formation Description
Area ade-Phone number S(C/ 1 5-)J t C c z. .�.-FL
4. DATE DRILLED J � -D J
5. TOTAL DEPTH: S Q.5'__
RHI nC!, l:vlit In:(i tAt).( I ,r YI.,� U nu) t i
7. STAT'IC WATER LEVEL Below Top of Casing: I D FT.
(L)ve"i"if Above Top of Casing)
R. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a _ —
variance in accordance with 15A NC'AC 2C.01la.
9. YIELD(gpm): f4i --METHOD OF TL'ST_�
10. WATER ZONES(depth): 31� -_.51 P
LOCATION SKETCH
11. DISINFECTION:Type_ H T HI Amount-q(P ,Flo A+5„ Show direction and distance in miles from at least
12. CASING Wall I hickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From _D_ Tom _Ft. (k It _ ���_ ® g:p
From ur (—17s To Ft,_._._ —n
From To Ft. "Irn
mt^
13. 6ROUT: Depth Material Method
vr�
From. rJ.Z—_To - FL_-- }_ Q cD o�
From _ To _Ft.
14. SCREEN: Depth Diameter Slot Size Material '0 �
n`
From T 3
_. _._. o Ft. in. in.
a
From _ To Ft. in. in.
15. SAND/GRAVEL PACK: - CD N
Depth Size Material
From _ _To Ft. _
From. _- _To —Ft.—_-- --
I6. REMARKS:
I DO l ILRF.BY uE12'I'IFY TFIAT THIS WELL.WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS-[RIX TION STANDARDS,AND THAT HAT A COPY OF I MS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONS T 1C'TING TI IE 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 RLV.07/2001

WELL CONSTRUCTION RECORD 30 �891
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WF:I,1,('ON"I'RA('IOR(INDIVIDt1AI,)NAMF, (print) QX_ u���C_-(-�--� 1 CERTIFICATIONN ,/33
/' LJAJ� * t' l�i�-PHONF, A (Vt 4_Z_5�._3)
w'F:L1,('.ON'1'RA('"1OR COMPANY;NAME l3fEi✓Y11e,�.. . -7 t�`� �m�r
S I A E WELL CONSTRUCTION PERMITq_ I_�.D�_ASSOCIATED WQ PERMIT'p _
(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 Usc _
a
2. WEI,L LOCATION' r _
' f l Topographic/Land settin},
I�B
Nearest Town: __County b0� .Ridge ❑Slope OVallcy ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip C(sic) Latitude/longitude of well location -
3. OWNHR:_- m— k T("T'L'+L, (degrees/minutes/seconds)
Address _ �'�C� �� ��i t�i Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) t.(.,wa,{ 43o (check box)
aryy or Tr(wn rb FL -m DEPTH DRILLING LOG
C s shale Zip coafe From To Formation Description
Area code-Phone number
4. DATE DRILLED
S. TOTA1,DEPTH: L2 �-S"—
(- nnLc %Y!! ! 1 ( Y!., r 1 nO
7. STA'I W WATER LEVEL Below Top of Casing: J FT.
(Use'4"if Above Top of Casing) ---- --
R. TOP OF CASING IS FT.Above Land Surface*
`lop of easing terminated at/or below land surface requires a - -'--
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):1 METHOD OF TEST r5
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. 7
s
From,_ O_To .70_Ft._� " _ �1L CA _c:rq
Front To Ft..-.---- -- -r7 ^rtn
rrl
From To Ft. _-- _-- W -C
13. 6ROUT: Depth Material Method I -Vrq
From 6 _To_,�Ft. if e b&k,�L p�
From To Ft._
14. SCREEN: Depth Diameter Slot Size Material =C
From_. To _Ft. in. in. cro
From To _Ft. in. in. 0 TS
I5. SANWGRAVFI.PACK: Cn M
Depth Size Material n
From To Ft. _
From To Ft.-
I). RFMARKS:
1 DO HEREBY CI?Itl lFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WFLI.
CONS-IRUCrION Sl A DARDS,AND TI IAT A COPY OF PHIS RECORD HAS BEEN PROVIDED TO T11E WELL OWNER
- 5/ -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-1 REV.07/2001

WELL CONSTRUCTION RECORD '�J, � =
North Catolma Depattment of(prinEnvironment and Natural Resources D�ivision of Water Quality
TRA;WELL CONCTOR(fi#D UAL)NAME t)' %`y ,HT - CERT li&TION to U"2
.WELL CONTRACTOR COMPANY NAME H�hP PHONE # • .S -S .'�� :.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable)
1. WELL USE(Check Applicable Box):ResidentiiMt Municipal/Public❑ Industrial❑ Agricultural O t?
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATI N: To po phic/Land setting /®�
New stTown: s,� L ounty ORidge Slope OValley...OFlat
6r � 'iJ f -"i '� C I Obkwq� (check appropriate box)
(Street Name,Numbers, ommuniry ubdinsion, of No.,tip Code) Lai' de/longitude of well location -
//(( -IY7 s7
3. OWNER: MU-Q t6f—PGf2(�- (degmes/minums/seconds)
Address
!l Latitude/longitude source:OGPSOTopographic map
(Street or u No.) / (check box)
7 I d(o DEPTH DRILLING LOGS
City or own Sta Zip Code From To Formation Description
( -
Area code-Phone number
4. DATE DRILLED r, -Q S—O 1 _
5. TOTAL DEPTH: /f)Q U _
6. DOES WELL REPLACE EXISTING WELL? YES O No v _
7. STATIC WATER LEVEL Below Top of Casing: .?/-;> FT.
(Use"+"if Above Top o�mg)`
8. TOP OF CASING IS FT.Above Land Surface*
`Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): METHOD OF TEST
10.WATERZONES(d th):
LOCATION SKETCH _
11. DISINFECTION:Type Amount ! Show direction and distance in miles from at le
12. CASING: Wall Thickne s o State Roads or County Roads.Indu9the r
Depth D' pt r or Weight/Ft. Mat rial numbers and common road names.
From_C) To�(�Ft. S�I) Z/- ��
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
_ . From O To�_Ft.
From_To Z Ft. LV - O 14. SCREEN: Depth Diameter Slot Size aterial
From To Ft. in. in. f_ ] 0
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
CONSTR STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
- A CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center r�•
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/2004
,a

WELL CONSTRUCTION RECORD 308945
North Carolina-Department of Environment and NaturalResources-)Division
�of Water Quality-Groundwater Section
C'OV'PRA("1'OR(INDIVIDUAL)NAME' (print).( �nn ,-/s S p/j In.—�1L CERTIFICATION#
WELL('.ONTRA(:'I'OR COMPANY NAM E I riy- PHONE # (�,��L-y Ff�-.i� ?6
J
S1L1"fN;WELL CONSTRUCTION PERMIT#_ 09 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I_ WELL USE(Check Applicable Box): Residential 94 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use__
2. WELL LOC A[ION' `1 Topographic/Land setting
Nearest Towrc_�Q�_ee. th �F„ C.u>�u�nty{. - 6o�, DRidge ❑Slope OValley
4,_�[N�t fTCrT Flat
(check appropriate box)
(soect.Na�nl�4lsimbcrs,Cn��11—nry,Sandivi,iou.Lot N., .,;p toxic) Latitude/longitude of well location
3. OWNER: y L
(degrees/minutevseconds)
Address _. (_S�'�-1/+ / Latitude/longitude source:OGPSOTopographic map
(Street n1r'Roure No) r (check box)
M CIA it V a Q �h r N C -)on t—/ DEPTH DRILLING LOG
( 'T or Ttkwal State Zip Code From To Formation Description
)-_ __
.Area adc-('hone number
4. DATE DRILLED .� •LH - DJ
S. TOTAL DEPTH: 1L,,�-'__
AVL! 1 U1:1)I A!'41:YICI INIi AAi GI l ? VLC �I NII
7. STATIC WATER LEVEL.Below Top of Casing: .Y' FT. _
(lise"I"if Above Top of Casing)
R. TOP OF C'.ASING IS FT.Above Land Surface'
*Tup of casing terminated at/Or below land surface requires a ------" _ �
variance in accordance with 15A NC AC 2C.011a.
9. YIELD(gpm)i_ i I'L _MF,THOD OF TEST._ 2_�-� -
10. WATER ZONES(depth):
LOCATION SKETCH _
I I. DISINFECTION:Type /-/T N Amount—rJ_-4�LJ}S Show direction and distance in miles from of(cast t�n
12. CASING: Wall'fhickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From _D_To—,2_g_Ft. 6 tl
Prom— _ To Ft. V-C
-- --
From -__TO—Ft._
I3. GROUT: Depth Material Method
Tl-- ,6
From To
14. SCRF.IN: Depth Diameter Slot Size Material p
From .._To ._.Ft.—_Mn in.
iCfSS
From- To _Ft.—M. _-_ in. a
IS. SAND/GRAVFL PACK:
Depth p size Material
From. --. _.._-_To Ft.
From. _—To Ft "-
!J7
16. kFMAkKS:
I UO I ILR EBY C'ERI IFY THAT TI IIS WELL WAS CONSTRUCTED IN AC'C'ORDANCE WITII 15A NC'AC 2C,WELI.
CONS-fRIJ( NON S"I'ANDARDS,AND THAT A COPY OF 1111S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
2 a t>S
SIGNA'fURF,'OF PERSON CONS 'RUCTING TI IE 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 308944
North Carolina-Department of Environment and NaturalResources-Division of Water Quality-Groundwater Section
WELL('ONTRAUFOR(INUI VIDUAL)NAME (print) lta �p.4 CERTIFICATION#g�-'/
[8
%NELL('ONTRA("IORCOMPANY NAME&Ir-e'ne-/ - CDC- )e/) `I( &�" PHONE #
51'A'IE WELL('ANST'RUCTION PERMIT#,... J7(J_a ASSOCIATED WO PERMIT'# _
(if applicable) (if applicable)
I- WEId, USE(Check Applicable Box):Residential1A Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELI. LOC'A'FION: Topographic/Land setting
Neaarr�•y/.,Town:_ C,Rio-J_� County ❑Ridge ❑Slope ❑Valley '(slat
-.....-.L]_f VP y _ rC-S 1 � - Icheck appropriate box)
(Street Nuns,Number,,/Community Subdivision,Lot No.,Zip('Wc/t) // Latitude/longitude of well location
ee.rr-lrscl Llo.. I Cy
L I /e �� . ae✓eZa P4✓isht�C
3. OWNER: Ca"r D/J 41 p�l s& �JJ (degrees/minutes/seconds)
Address ,_-j_ C4 0rc11 '$,�- , ___ Latitude/longitude source:❑GPS❑Topographic map
11 (Street or Route No.) (check box)
rtr� Y-�-a, t N r 9-7 ( DEPTH DRILLING LOG
('ay or Tawn State Zip Cole From To , Formation Description
Area aide.Phnne number _20 3 'els-! AA
4" DATE DRILLED
5. TOTAL DEPTH: S-!
Vl1; 1'k111 UI:UI A('L LVllllpll: \A/I:11 '1 VLIII pall lb
T STA NC WATER LEVEL Below Top of Casing:440 FT.
(Use"+"if Above Top ofC'winto
R. TOP OF CASING IS— FT.Above Land Surface's
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIH_D(gpm): a0 Mf:TH�iUD OF TEST ;v rs
au
10. WATER ZONES(depth)' .._.
JJ 5- - y(o LOCATION SKETCH
11. DISINFI'.("PION:Type_—L-LY--11_ Amount_/Q.�_-/1 Show direction and distance in miles frolti at least
12, CASINQ Wall I hickness two State Roads or County Roads.Include the road.
Depth Diameter or Weight/Ft. Material numbers and common road names.
From _ 6—To gg Ft. P VOL c
From _ To Ft.---_--- _
From __To Ft.-
13. GROUT: Depth Material Mclhod N
From_Q__.. To I O Ft. • .. W
PromTo Ft.
(� F 14. S<'REEN: Depth Diameter slot Size Material
From _..._To _FL_ in. "--__-- in.
From_ __",__7o ht. in. in. _
I5. SAND/(TRAVEL PACK:
Depth Size Material
From To Ft.
From .._--Fo----FL—.__--- --
10. RFNIARKS:
1 DO I IEREBY(TR'I IFY'fIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
N fl IAT A COPY OF 'lfllS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
O S Rl1CTION STANDARDS, r-
SIGNA'I URE OF PERSON C'.ONSTR UCTI a TI IE 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 3 0 8 9 4 2
North Carolina-Department of Environment and Natural Resources-`Division of Water Quality-Groundwater Section
'/
WELL('ON IRA(TOR(INDIVIDUAL)NAME (print) QQL1L� j_'(i_I�L_Cn—�e-Ejf7 CERTIFICATION#
w'ELLCON'rRA('"1'ORCOIHPANYNAME_G�"CCYIe_ �31.n.5.�k�L T� (a�.6 41�.. -3/ yD
- G PHONE # "
S'1'AIEWELCONSTRUCTIONPERMIT#_". / T -2ASSOCIATED WQ PERMIT#
(ifapplicable) ,/ (ifapplicable)
I. WELL USE .,g
(Check Applicable Box):Residential I Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use__
2. WELL LOC'ATIO ��/ Topoigaphic/Land setting
Nearest ]L_�_'L�C' �Ol..c ❑Ridge ❑Slope ❑Valley $Flat
1- �a � ) (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No Zip(ode) Latitude/longitude of well location
3. OWNER:—13e
$ /r7i:_»-ej (degrees/minutes/seconds)
Address _ -__$7 /,), �/ ,_j._D=-,-�? Latitude/longitude source:❑GPS❑Topographic map
(Street u,Route No.) (check box)
.2eLvi 11, AIL DEPTH DRILLING LOG
( ,ty o rovvn Suite zip Code From To / Formation Description
.Area ade-Phone number .� ` 609
4. DATE DRILLED__/✓�'G 5
5. TOTAL DEPTH: —
I)!)It�: PI-PI A/'1. LYIL'I IAili AA11111r VLC U
7. STATIC WATER LEVEL Below Top of Casing:_'A FT.
(UJ "i"if Above TopofCasing) - —
R. TOP OF CASING IS ,FT.Above band Surface*
'Trip of easing terminated allor below land surface requires a --- --
variance in accordance dh ISA NC'AC 2C.m 18.
4. YILLD(gpm):=-METHOD OF TEST o�
10. WATER ZONES(depth):,—_.7Q$' 7
LOCATION SKETCH
I L DISINFECT ION:Type_— _ Amount S5 - Show direction and distance in miles from at least -
12. CASING: Wall"Thickness two State Roads or County Roads. Include the road
From Depth Diameter or Weight/Ft. Material numbers and common mad names.
From To Ft.
From" -_ _ To Ft._
13. GROUT* Depth _Material Method
From. �._-- To C) Ft. l�..�_.4m�-__ _ fV 't,1
W
14. SCREEN: Depth Diameter Slot Size Material CD
Prom To _Ft._in. .. in. Ull
_--
From To Ft. in. _._-- in. -
1.5. SAND/GRAVEL PACK:
Depth Sizc Material
r
From. _. To
From To----Ft.
-- ---- _ -. .
10. REMARKS:
I DO I IEREBY('ERTIFY THAT TlhS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WF,Ll,
CONSTRIJ(TION S'CANDARDS,AND'I'l1AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
SIGNA'IURE OF PERSON CONS"ERUCTING 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 308941
North Carolina- Department of Environment and nnNatural Resources-Division of Water Quality-Groundwater Section
WELL('ON'7RA(TOR(INDIVIDUAL)NAMES (print)_C-Aar ALS 1�.6 if it_-��lj�_ CERTIFICATION#�1�'
WELL CON'TRA(I OR COMPANY NAME. 6Z?r—nC, ' d'o-1 Wee a pp LT4,c_.PHONE #
S'INII,WELL CONSTRUCTION PERMIT# �z Doi _ASSOCIATED WQ�PERM IT# _
(if applicable) (if applicable)
1, WELL USE(Check Applicable Box):Residential N1 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W'i?LL LOCATION, Topographic/Land settin
NcaJrs�st Town; �t _I County � e4 ❑Ridge ❑Slope OValley Flat
(check appropriate box)
(Street Namc,Numbcr ,Community,Subdivision,Lot No.,Zip code) Latitude/longitude of well location
3. OWNER:__ (degrees/minutes/seconds)
Address j - F Latitude/longitude source:OGPSOTopographic map
(StreeturRZNo.) (check box)
/V C DEPTH DRILLING LOG
(Ity .„r roten state zip axle From To / Formation Description
Area wele-1'h LLFJ)ber '`,, �Z)
a. DATEDRILLEn � - �' -bS �.2
5. TOTAL DEPTH: 2e -
'1 - —
---c t)!)Cl lA :1 1 U1:111 A/'I. I,YIC`"I Ini(: AA/1:1 1 o VL�� I 1 N�()
7. S'f A'rIC WATER LEVEL.Below Top of Casing:_V_FT.
(Use"t"if Above Top of Casing)
R. TOP OF CASING 1S FT.Above Land Surface*
*Top of casing terminated atlor below land surface requires a --
variance in accordance with 15A NC'AC 2C.9118.
9. YIELD(6pm):—/6_METHOD OF TEST_1��1�.
IO. WATER ZONES(depth):_f�p( g,�.?,,,(,
- ") LOCATION SKETCH
I1. DISINFECTION:7 c t
Yp tf YN Amount_?i.S_}�I _Show direction and distance in miles from at leas[ -
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, 6- , "_To Ft. _�
Prom To Ft._ _
aFrom _To
13. (jROU'r..... Depth - 01
p Material Meth°d
From n .} - T ) :,
From To Ft.--- -3i
14. SCREEN:Depth Diameter Slot Size Material C�it
From __...To FL- in _- in.
Front To _Ft. in in. _
I?. SAND/(TRAVEL PACK: _
Depth Size Material
From _ __To Ft.—-
Front
16. REMARKS: -
I DO I ILR E:EY CTR"IIFY'H IAT TIIIS WELL WAS C'ONSTRUC'I'ED IN ACCORDANCE WITI 115A NCAC 2C,WELL.
('ONS'I"R(J( f lON STANDARD.',AND'fHAT A COPY OF'I'HIS RECORD 11 FEN PROVIDED TO THE WELL OWNER
SIONAI'URE OF PERSON C'ONSTRUC'TINCi 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 308940
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �JJ
WELL C'ONTRA('TOR(INDIVIDUAL)NAME (print) _ Lt�s..C�--- CER"rIFlCAT10N#.33-5_/'
WELLCON'I'RAC"fORCOMPANVNAMF.L- eretaE --pS- Z,, PHONE # dal 41 Ile,
,/ J
S'CTI'N;W F.I,I.CONY"rRUCr10N PERMIT# . . f Y2�' _ASSOCIATED WQ PERMI"I#
(if applicable) (if applicable)
l. WELL. USE(Check Applicable Box):Residential 1¢ Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELLLOC'A'f10 Topographic/Land setting
�[[
Nearest To CountyJ}�wn: �unnty ❑Ridge ❑Slope ❑Vall �E'lat
•L (check appropriate box)
(Street Name,Numbers,Community,Subdivision,[Ail No.,Zip(\de) Latitude/Iongitude of well location
3. OWNI?R:__ Gg� (degrees/minules/smonds)
.Address wr � Latitude/longitude source:❑GPS❑Topographic map
tor House o.) (check box)
A C �_�_ DEPTH DRILLING LOG
ay\,r n,wa State zip C'Ide From To Forma ion Descri tion
�_
Area ade-Phone number •
4. DATE DRILLED
5. TOTAL DEPTH:
(. O111..� \4'L1 Ul:nl Al`I. LYIll 1Al(. \A1111 I O b'Ll' I Fl\ 1�
7. STATIC WATER LEVEL Below Top of Casing: � FT.
(I.iux'v'if Above Top of('asing)
R. "LOP OF CASING IS / FT.Above Land Surface'
*Top of easing terminated alone below land surface requires a --- -- -- _
variance in acem-dan a with 15A NCAC 2C'.0118.
9. YIELD(gpm): —. ,METHOD OF TEST /
10. WATER ZONE S(depth):.__,
� ( LOCATION SKETCH
1 1. DISINFEC"fION:Type Amount )q-1.��- Show direction and distance in miles from at least
12. CASING: W'all'ihickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From, Q _T'o �Ft. G •� _ __eGZo -
From _ To Ft-From- _. _. _. To Ft.-
13. GROUn Depth Material �y Method - a W
From_.1L— To-a—b
From To Ft. _ - - N -
14. SCREEN: Depth Diameter Slot Size Material - W.
Prom_. _---To _It,—in. in. C=)
Front _. _ To . Ft. in
-- trt
15. SANDA;RAVEL PACK: -
Depth Size Material
Frolo To Ft.
Front. - _To_Ft.____-- _— - - -
16. RR.MARKS: --
I DO IIEREBY(TRI IFY THAT TI HS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
('UNS'fRIJ(`fION Sl'ANDARI S,ANIJ J HAT A COPY OFJHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
-- --- a - -2 q_Z)S
SIGNA'I'IJRE'OF PERSON CONS'f IN(i 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 3 p g 9 3 9
North Carolina-Department of Environment and/Natural Resources-Division of Water Quality-Groundwater Section
WELL CON'IRACfOR(INDIVIDUAL)NAME (print) ( y.�l�_//11_ J CERTIFICATION#--2��FI
WELL CONTRACTOR COMPANY NAME I pPp M I., OS lJ<_l l J Yt�.+ o .r,.[-._PHONE # (922 L 1/S --3 1 71
'T
STATE WELL CONSTRUCTION PERMIT#—__— D„2 _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 LOCATION: I Topographic/Land setting1_
Nearest Town:���..�,��Q n41r �n Ip,�County Hn. ,r,�.�.�1 ❑Ridge ❑ f dFSlope ❑Valley lat
- L04 L4� n )..44.5 TTTTT (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ Clrv^_lY �i-s�-�� (degrees/minutes/seconds)
Address .'30 q 1 f- vi r T� C Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
LU ra FL 43 r76 / DEPTH DRILLING LOG
<ay orrown State a--�T Zip code From To Formation Description
—)— /) �-
Area code-Phone number
4. DATE DRILLED_ a - r/-D 5
5. TOTAL DEPTH:_ 5
nr,nc W!n ! i ono( At i. rvtcrinu; fair.( vr:c U NO
T STATIC WATER LEVEL Below Top of Casing:_%n FT.
(Use"+"if Above Top of Casing) f
8. TOP OF CASING IS—1! FT.Above Land Surface*
`Top of casing terminated at/or below land surface requires a ._
variance in accordance with 15A NCAC 2C.0118. -
'). YIELD(gpm):_�_METHOD OF TEST 7 hrc _
10. WATER ZONES(depth):_ r5 z - P -
LOCATION SKETCH
It. DISINFECTION:Type Amount_/on LL I,tom 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_..D To_�Ft. L 11 PVC
rum--- To Ft.
torn To Ft. m
13. GROUT: Depth Material Method
T
Fr(,m_( __To—W Ft.
From To Ft. -
14. S(REEN: Depth Diameter Slot Size Material N
From_ - To Ft. in. in, G3
From To - Ft.__ in. in. C3 .
15. SAND/GRAVEL PACK: cn
Depth Size Material
From---- To Ft.
From_____To Ft.
W REMARKS:-
-I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"FRUCTION STANDARDS,AND THAT A COPY OF THIS gE�')RD HAS BEEN PROVIDED TO THE WELL OWNER
zz)j /sho., . Cam\ � -2
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 3 0 8 9 3 8
F:urtli(and it - Department of F,nviroument and Natural Resources-Division of water Quality-Groundwater
___.. Section
NE11 CONIRA("IOR(INDIVIDUAL)NAMEpHnt/,15 \JaU CEWFIPICATION#-13,-V
RA( IORCOMPANYNAMF ( re-e e Wo-11 1 >rl =31
7'
Y k
(it applicable) ASSOCIATED WQPERMI #
(if applicable) - - -- --.
1. W1:LI, I-Sh(Check Applicable flux): Residential ly Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ heat Pmnp Water Injection❑ Other❑ If Other,List Use
:'. Wl',I.f. LO(_A'FION: Topo graphic/Land setting
Nearest Town:. 11/ �/c County )) ❑Ridge .PSlupe ❑Valley ❑Flat
�� - �rN�CS if ESTG (check appropriate box)
ktl cd S:uuc. Nwn;bera,Conninonly,SoWivisiou.Un No.,Zip(late) Latitude/longitude of well location
3. OWNER: p Li
(de nceshninutes/secunds)
Aduur ss D ;77;rra_LG,yi n r �t _.. Latitude/longitude source:❑GPS❑Topographic map
(Str,ct or t(uutc Idu
_� S POYn�»z>�l C - " n �� neS>)t e DEPTH (check bur)
ly�,i'I,w,u stare Zip(bde • DRILLING LOG
f i_- ZVe -2 879 G From To Formation Description
A; ;n;
T. DAIL DRILLED a -
P! All NO
7. A'CK WATER 11E VLL Below Ton of Casing:_ "----
g !D I"r.
77 (L' c•.+..if Above'I opof('asing) --
1 UP OF CASING IS (, _. ._FT. Above Land Surface* - _------------------ ------ -
-top of casing terminated atlor below land surface requires a -----_ __-
oanance in accordance with 15A N('AC 2( ,61I8, /
r). Y fL:I.I)(gpntl:.__ 1--_ML"t HOD OF TES-1 - hYS
IU. W'ATIKZONfcS(depth): __ .._��S��_--. /,'alp,, ---
LOCATION SKETCH
f f DISINt F(.TION: Type �f T/'� Amount. _f -� - Show direction and distance in miles front at least
f_1. ( ASIN(i: Wall Thickness two State Roads or County Roads. Include the road
Depth _O Diameter or Weight/Ft. Material numbers and common road names.
Frnm ro_6-qFt. to rt
Fenn _ 'fo
Ft. 3
13. (�KOL''I : Depth
P /7 Material Method N
To_�_ ;` l D _�L�l. . _ G'1.
Fn m Tu - C
J_ 'S( k1 I N: Depth Diameter Slot Size Mutcntll C1
Ftow To Ft., in in.
Front to Ft _ in I
1`•. S%ADKrRAVI.I PACK: -- -
Depth size Material -
To -- _Ft. _
loom _— - -.•
t DO I IIREBY CFR'IIFY'I HAT THIS WELL WAS('ONS'IRI/C'TF.D IN A('COKDANC'E WH 11 15A NCAC 2C,WELL
( ONS'l RUC'"I ION STAN}D�ARDS,AND THAT A COPY OI:THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- ._
SIGNATl1RE OF PERSON('ONS"f RUC'IINCi'fllk:Wfil.l UAl'E
`submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone].within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 3 0 8 9 3 7
North Carolina-Department of Environment and N tural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/F (print)_- P /r . !/ill/0 /y�� CERTIFICATION#-3.454/
WELL,CONTRACTOR COMPANY NAME LTY &—hL_T G��._ id�L_o 7T ._PHONE R��G cIS '3/9�
STATE WELL CONSTRUCTION PERMIT# _ __ASSOCIATED WQ PERMIT# _
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaUPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Nearest Town: ,/i Ile, County ❑Ridge ❑Slope ❑Valley %Flat
(check appropriate box)
tstreet NamtJ Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /1
lte (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
Street Route 'o.) (check box)
-- if 7r-- � ? 972/ DEPTH DRILLING LOG
r.ny or�own State zip Code From To Formation Description
Area Code-Ph number 4. DATE DRILLED a2 - .?
5. TOTAL DEPTH: 7 5
WLLL" Y!I 1 1 N(-' 111
7. STATIC WATER LEVEL Below Top of Casing:4_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS--FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_?/�) METHOD OF TEST rs
10.WATER ZONES(depth): C2_� - ,..2A � 1L—
�� LOCATION SKETCH
11. DISINFECTION:Type f-/Tj/ Amount <fo 14/,ram 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.
Front- Ft. 4 _� PyLr
From____.To FL
From --To Ft. _
13. GROUT: Depth Material Method n' G
From r (�
Q _-To-'W Ft. e o I N G7
From De Ft
14. SCREEN: Depth Diameter Slot Size Material
From_ _To
Ft. in. in. CJ7
From_,_To FL___in. in. -
I5. 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
CONSI RUCTION STAN ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- a - tea- �s
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 J V
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_(N'Y2�� ��, r+ 1TP
/? CERTIFICATION#31 R2
WF,Id.CONTRACTOR COMPANY NAME �/PN,nr. /J✓OS //� // g! P���-_�� PHONE It
STATE WELL CONSTRUCTION PERMIT# / Y D 2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residentiallo- Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest`Town:_ � nN s yr Coun Topographic/Land setting
V , rxJ ty—g Ridge ❑Slope []ValleyOFlat
/ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER: �� vi5
Address _ 9 Q (degrees/minutesiseconds)
u-- y---/� r Latitude/longitude source:OGPSOTopographic map
/, ' (S[rCet or Route Nr/) (check box)
�(/4�n"t' ' / I r �� DEPTH DRILLING LOG
(.rt down State Zip Code From J
Cr � Formation Description
Are.code-Phone number �/ r
4. DATE DRILLED / - 3 / - 6 S V --.--5
5. TOTAL DEPTH: R 2 �-r
. :Y�i.�• WL I ula,l nC t: I.viS rl n�C, ��;pl I o YI:� �i nO
7. STATIC WATER LEVEL Below Top of Casing: /�?!) FT-
(Use"+"if Above Top of Casing)
M. TOP OF CASING IS�_FT.Above Land Surface*
'rop ofensing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0115.
9. YIELD(gpm):_fir METHOD OF TEST
10. WATER ZONES(depth): $QD
LOCATION SKETCH
it. DISINFECTION:T e
YP — /—/ 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 (�To—Ft. /c " PYr
From To FL
From Tc Ft.
13. GROUT: Depth aterlal Method
From-0 To FL
t7
_ m_
From To —._ _ _ b Ft__ �14. SCREEN. Depth Diameter Slot Size Material " fV
From
_...._To Ft. in. in. t4
From _To - Ft_ in.
15, SAND/GRAVEL PACK: -- in. _ O
CJl
Depth Size Material -
FromTo Ft.
From-.----.__To Ft. /( _
16. RE..MARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTION STAND RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
� 8_ ds
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 a 9 5
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section�/Ad(,
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_hQ Y_/f_$ p1j�_ CERTIFICATION# a 7
WELL CONTRACTOR COMPANY NAME"[:_&P-! PHONE # (KO 4-!;6f 3 '7�
STATE WELL CONSTRUCTION PERMIT# �Y D.Z _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELI.USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water In3ection O Other❑ If Other,List Use
2. WELL LOCATION: Topo phicILand setting
Nearest
To/w,tt: V t I County t.?bD� ❑Ridge Slope OValley OFlat
Z Z'/ A rr7`/,, (check appropriate box)
(Street Name,numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location t
3. OWNER'_ AIL) vN /,, d (degrees/minmes/secands)
Address Trm v l."( I C'�.y� Latitude/longitude source:OGPSOTopographic map
1/ 1 (Streeter Route No.) (check box)
DEPTH DRILLING LOG
State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED / '7 - d a
5. TOTAL DEPTH:_ t�5'
WLI I RLP A`•)._ l.vi�"rini(; �ail:1 t , YrS L7 n!O R
7. STATIC WATER LEVEL Below Top of Casing: A 6 FT.
I (Use"+"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):_(�j_METHOD OF TEST 2
10. WATER ZONES(depth):
.J LOCATION SKETCH
1 t. DISINFECTION:Type__;�J_r' Amount ( fit//c . 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 erial numbers and common road names.
m__Fro 6 To__,��Ft. It G
From___To-Ft. t>'
Prom__To Ft. �
13. GROUT: Depth tvlaterial Method x"
From 0 To, Q�Ft. N
From ��_To Ft.
14. EN':From Depth Diameter Slot Size Material CD
From_.___To Ft._ in. in. - Cfl
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
CONS"I RUCTION/S._T,�/ANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOF Or-PERSON CONSTRUCTING TI IE 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 3 0 8 9 2 8
North Carolina-Department of Environment and Nat ral Resources-Division of Water Quality-Groundwater Section
--
WELL CONf RACTOR(INDIVIDUAL)NAME (print)_- Ll
//n�1, II CERTIFICATION
WELL CONTRACTOR COMPANY NAME-`&- fj 1_C_PHONE #
STATE WELL CONSTRUCTION PERMIT#.__ _ (-r
(if applicable) —1 --ASSOCIATED WQ PERMIT#
(if applicable) —
I. WELI. USE(Check Applicable Box):Residential)6 Municipal/Public❑ Industrial❑ Agricultural O
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: Count Topo aphic/Land setting
.� � ❑Ridge Slope OValley OFlat
L L�l (check appropriate box)
`ummm,C. mmumty,Subdmsion,Lot No.,Zip C e)
Latitude/longitude of well location
3. OWNER: �e
Address (degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(Street or Route No-) �/ f��J
_. JAY1 H.0 / 1 P N c ,�S /6 ([r (check box)
DEPTH DRILLING LOG
u �y n state 7.ip Cafe
(_ From To Formation pescription
Area tale-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:_ a� i -
,),u.�; ta,r:iII:v1�riniC; �y1rl1 ? YLSLl NO fb
7. STATIC WATER LEVEL Below Top of Casing:_gip/FT.
8. TOP OF CASING IS (USe ` if Above Top of Casing)
�_FT.Above Land Surface*
op of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_b0 METHOD OF TEST
t —_�
10.WATER ZONES(depth): _a�5 _
LOCATION SKETCH
11. DISINFECTION:Type 1-- *-r Amount /l .. . t
12. CASING: J-=��- Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads.Include the road.,
Depth Diameter or Weight/Ft. Material numbers and common road names. Ri FCom_p To�Ft._ _ P Vs� Q
Front— To Ft.
From ---To Ft. b -tvC
13. GROUT: Depth Material t]
From Method N
—�--T -��Ft.� w
- From Too Ft.
14. SCREEN
: Depth Diameter - C
From.. Slot Size Material Ut
--TO—_Ft. in. in.
From_ _To Ft._—in.
15. SAND/GRAVEL PACK: m.
Depth Size Material -From--- --To- Ft.
Ft. *.
Front_
16. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAR S, ND THAT A COPY OF THIS RE
Lei
SSRg,(fAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NaturalResources-Division of Water Quality-Groundwater Section
tn p
WELL CONTRACTOR(INDIVIDUAL)NAME ,(,print)_T'��(Q��LYI Ll )Q��^j CERTIFICATION#Or��y
Wb;I.1.CONTRACTOR COMPANY NAME I'lCPpn_C:Ly )5_�)p LI v. P�.trnp PRONE # (�1911ya4'31'1O
STATE:WELL CONSTRUCTION PERMIT#N�Od ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential H'�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County ❑Ridge ❑Slope OValley L9�at
�[C1— Q-.�S (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER_'uf (deg ces/minutes/seconds)
Address PQ Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
_'MLl.AQ ke _Vj le L t4c r�l�lri� DEPTH DRILLING LOG
<-ny o vn staid zip code From To Formation Description
513 LA
Area code-Phone number S3 a 5
4. DATE DRILLED U- i,-05
5. TOTALDEPTH: Ads
ul.,ol_ACE i:vi};r)n�r; �x;)rl 17 YpS ❑ ��/) LI✓ —
7. STATIC WATER LEVEL Below Top of Casing: 4 n _FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): aiD —METHOD OF TEST o hys
10. WATER ZONES(depth): IQh QQ�p(h
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,,.___To Ft. -
°i
From To Ft.
13. GROUT: Depth Material Method
From__To_�'Z_Ft. C t M 6 ill _ 7MP _ C ,
From To Ft. c') --+
14. SCREEN: Depth Diameter Slot Size Material
From---- To Ft. in. in. W
From ._To Ft. in. in. O
15. SAND/GRAVEL PACK: LA _
Depth Size Material `3
From To Ft.
From_____To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH 15A NCAC 2C,WELL
CONS'fR UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
\ko —O
SIGNATURE OF SON CONSTRUCTING TF(E WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
— i

MU, 3154,
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
V,ELL CONTRACTOR(INDIVIDUAL)NAME (print)Ox11p1._wQ.yjh CERTIFICATION#-J` 1
WELL CONTRACTOR COMPANY NAME�7fP�,V1'( ��4 tJJ�Q-)..t -F��f\2(O PHONE # jl�, A _t)11 0
STATE WELL CONSTRUCTION PERMIT# �kOr). ASSOCIATED WQ PERMIT#
(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. WELL LOCATION: ` "'� Topographic/Land setting
Nearest Town: County i�u(1_ ORidge ElSlope OValley �L
J - L�Hlat
0—'4'� (�K 1� C 1 ne 4 (check appropriate box)
(Sweet Na e,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
.3. OWNER- bvu '11a r _ (degrees/minutes/smonds)
Address "a. 8 (tJ.>rY\PlAli lLCY12 Latitude/longitude source:❑GPSOTopographicmap
(Street or Route No.)) (check box)
�V�� qP5 V11 1 s NkL DEPTH DRILLING LOG
it,n lbwn state zip Code From To Formation Description
)---- D SS C lc.
Area code-Phone number 3lD S r aewl
4. DATE DRILLED- L9'F-OS
5. TOTAL DEPTH: .3US
i. !)r)!_c ia;F.!_!, R;PLA(•I: !:v!c,'!!�jr; \all[!.! ' Y!.', rl r ) INS -
7. STATIC WATER LEVEL Below Top of Casing:_k 01) 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): \U METHOD OF TEST otL tiQurS
10. WATER ZONES(depth): 6LAb' \\pgnrvr
LOCATION SKETCH
11. DISINFECTION:Type tA'CF} 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__Q_To_5rb Ft. �k
From___To Ft.
From To Ft. A
13. GROUT: Depth Material Method?
??t
From_Q__To ap Ft. tLYYt.I.•--)r
From To Ft.
14. SCREEN: Depth Diameter Slot Sin Material - -- -, CC:)
FromTo Ft. in. in. - 51
From To Ft. in. in. -
i5. SAND/GRAVELPACK: - -
Depth Size Material
From___To Ft.—
From--To Ft.
10. REMARKS: - - -
I DO HF.RFBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"I RUT TON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
• _, r��^ 'ash— I lIl O`�
SIGNATURE OF PERSON CO RUCTING 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

'I As
!1 `
F. . W
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) sl. of LUNrciy�i _ CERTIFICATION# 35
WELL CON TRACTOR COMPANY NAME—QaDeft-e- _ y 'RtM` PHONE # Q O- \—LO
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if ap lliieable) (if applicable)
I. WELL USE,(Check Applicable Box): Residential D"'Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topograpbic/Land setting
Nearest
Town: �_ County I4idge ❑Slope ❑Valley ❑Flat
6 �4.a-sue c I 1111 11 (check appropriate box)
(Sncct Name,0mbers,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3, OWNER: AQ�rYMm V^'_� h (y Lotn
l� (degrees/minutes/seconds)
Address _ '� (ItQk y '� Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
Ll L- Q19-7 43I6 DEPTH DRILLING LOG
('vy rown crate zip code From To Formation Description
— _ Q `LO C1ee
R red code-Phone number `Itp �It> �1rA->1-ik
4. DATE DRILLED y-\a-O rj
S. TOTALDEPTH: N!JOS
ru)Irc ie;r�.t u1:nl nr'r U� _
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 atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): Jf`.METHOD OF TEST A-V-
10.WATER ZONES (depth): U
LOCATION SKETCH
1 I. DISINFECTION:Type �6 Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road,-'I
Depth Diameter or Weight/Ft. Material numbers and common road names. `.
From
__p___TonD Ft. U t• ��,_ ,,.
From To Ft. a
From _-To Ft. C
G1
13. GROUT: Depth Material Method N
From_.>._Tom Ft.
From - __To _Ft. _ CD
14. SCREEN: Depth Diameter Slot Size Material Ln ^fir
as
From__ To Ft. in. in. -
From — To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From____-. To Ft.
From—_---—To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. - _ 1 GW-1 REV. 07/2001

, �
3e 335 �� 19
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Y L' V lL`S"'lill CERTIFICATION# 63cb4
WELL CONTRACTOR COMPANY NAME�fePIIPw3�j/� 1.7P11`r pctMn PHONE # (J8Ukk"— 1ZO
STA"FE WELL CONSTRUCTION PERMIT# 1qG rli ASSOCIATED WQ PERMIT#
(if applicable) 111111111 (if applicable)
I. WELL USE(Check Applicable Box): Residential 93�Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other D If Other,List Use
2. WELL LOCATION- Topoggrat ic/Land setting
Nearest Town: County ORidge C�Slope DValley DFlat
�Qu[ lji l' Cow CA I (check appropriate box)
(Street Name,Num ,Community,Subdivision.Lot No.,Zip Code) Latitude/longitude of Well location
3. OWNER: . _ -Ip(O (degrees/minutes/seconds)
Address .(� .(�(,�y y da. Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
libaretvUla nIf an' I DEPTH DRILLING LOG
city or-- n State Zip Code From To Formation Description
Area axle-Phone number LAS !;Q 5 �1 r71+nc�'C
4. DATE DRILLED �J•3\•'Q 5 l � -
5. TOTALDEPTIE �JCFY_ _
c iTr;:`4 Nr°LL PI:PI_n,r(._ I:Yis;r(�ir Via;f'1 17 YF�' :I NO — -
7. STATIC WATER LEVEL Below Top of Casing:jL_�FT.
(Use"+"if Above Top of Casing)
&. TOP OF CASING IS FT. Above Land Surface*
"fop of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.01I&
9. YIELD(gpm): �METHOD OF TEST .1-V\eS
10. WATER ZONES(depth):_��5
LOCATION SKETCH
1 i. DISINFECTION:Type_4A� 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-0—To 'A"D Ft. Utt pYC
From---To—Ft.—
From To Ft.
13. GROUT: Depth Material Method C1
F'rom_Q_To aD Ft. CJJW
FromTo Ft C
14. SCREFN: Depth Diameter Slot Size Material A
From _ To Ft. in. in.
From To Ft. in. in. 4f
15. SAND/GRAVEL PACK: v fr
Depth Size Material
cJt y
From_ _To Ft.
From ___To _Ft.
10. REMARKS:
I DO HEREBY CERTIFY THAT-THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
C'ONSfRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
SIGNATURE OF PERSON CONSTRUCTING THE WELL :DATE
Submit the original to the Division of Water Quality,Groundwater See'tion,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

Ww I f. e9 1
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 'IJ 11 \�fl LJ CERTIFICATION83;S�
WELL CONTRACTOR COMPANY NAME�1'�[,t,LC�\Q y[1p ItJ�S �prt fxA ]_PHONE # (�L)19�14-31�0
STATE WELL CONSTRUCTION PERMIT#�Q of __ASSOCIATED WQ PERMIT#
(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. WELL LOCATION: Topographic/Land setting
Nearest Town: nd(-,l �/ \\ U County RI£idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community, -
Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:__LW WJ.^ (I ll_t_rSyf (degrees/minutes/seconds)
Address a I'2d Latitude/longitude source:❑GPS❑Topographic map
(1 � �� (Street or Route No.) (check box)
_�LYl.A�fr sL 29y0-1 DEPTH DRILLING LOG
cdy or l own State zip Code From To Formation Description
,Area code-Phone number —
4. DATE DRILLED tAI 4- 05
5. TOTAL DEPTH: 105
(_ !" r.c (xil_I I RL.pl.V, !: l:vls,liNi i jai)..) I o YEli ❑ NO I-s✓ _ -
7. STATIC WATER LEVEL Below Top of Casing:—AL—FT.
(Use"+"if Above Top of Casing)
3. 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 a _METHOD OF TEST his
I0. WATER ZONES(depth): Lo 95
LOCATION SKETCH
11. DISINFECTION:Type \J,-TE""\ 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___To gl_b Ft. U"
From__.__To Ft.
From To Ft.
13. GROUT: Depth Material Method
From Q__To_ c10 Ft. CDlv`,Arii _ {p
From To Ft. c '
14. SCREEN: Depth Diameter Slot Size Material
N �t
From____, To Ft. in. in. W -
From------To Ft. in. in.
15. .SANDi6RAVEL PACK: o
Depth Size Material
CJ7
From_ _To Ft.
From ...,._To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS PR(1C"PION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CON 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. - -"
� GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carol ina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
ELL CONTRACTOR(INDIVIDUAL)NAME (prin)'?�c Durcw CERTIFICATION# 3354
C
WELL CONTRACTOR COMPANY NAME ree— !t, UJe l *\'U..Mp PHONE # (117)19N4'311�
STATE skELI,CONSTRUCTION PERMIT# NQa ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) ,.
I. WPELL USE(Check Applicable Box): Residential 01�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELI. LOCATION: Topogra�hie/Land setting
Nearest Town: �.t'n1-Wee CountyN u,t ,oOCj ❑Ridge W101pe OValley l7Flat
_ C �ClC l7 Rot (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ f!4` ,- P..w me (degrees/minutes/seconds)
Address _�J'Q k-r1�4..!) t. �ALL6Lk`- Latitude/longitude source:OGPSOTopographic map
n1 (S�rR to Ro.) (check box)
l 1 hcl P nLL a$-I al DEPTH DRILLING LOG
coy or wn State Zip Code From To Formation Description
0 u-t C1a.
Area ax Arele-Phone number W1 NOS
4. DATE DRILLED LIl W 05 J ��
5. TOTAL DEPTH: 4l�i
c ijr)I.c %t,:r.l_r PEP! 'W!C YES u n;rj LtY -
7. ST.ATIC WATER LEVEL Below Top ofCasing: t-)O _FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
°Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_'METHOD OF TEST o�hr3
M.WATER ZONES(depth): 345
LOCATION SKETCH
11. DISINFECTION:Type 441,H Amount Show direction and distance in miles from at least
12. (ASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_9 To p]_FL U ., PV G
From__"_To Ft.
From To Ft.
i
1.3. GROUT: Depth Material Method
From
—()—To Ft. CJP c-nT +0C?
a
From _To Ft. Ci"
14. SCREEN: Depth Diameter Slot Size Material 1%) =',i
From To Ft. in. in. W
_ I
From__ To Ft. in. in. p `
15. SAND/GRAVEL PACK: Cil ..
Depth Size Material
From_.._ To Ft.
From---_ To Ft.
16. REMARKS:
1 DO HF.ItEBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—Lu
SIGNATURE ERSON CONSTRtICTtNP,1Ti$-"V✓ LL is li ,`,DATE
' e)
Submit the original to the Division of Water Quality,Groundwater Sectlisn,1636 Mail ServieR Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. ' 6W-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELLCONTRACTOR(INDIVIDUAL)NAME(� (print)� N t vn 11 CERTIFICATION# 5�6�
WELL CONTRACTOR COMPANY NAME ll,,'f`` Y)�. •.''.J7J1LC� L,3,PL1 -1 piny p PHONE # (SX)Ugt -31-I(�
STATE WELL CONSTRUCTION PERMIT# `1�a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
i. WELL USE(Check Applicable Box): Residential B"'Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: �/t Topographic/Land setting
p
Nearest Town: �&YCtnyl County ❑Ridge ❑Slope ❑Valley Hflat
____ft(h J M0ado--o_� (check appropriate box)
1 Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Ri \I (degrees/minutes/seconds)
Address -.J� .TrAIGn " LLS lgp Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.) (check box)
�a yrx-+CSt/lllt �C �9'7gID DEPTH DRILLING LOG
cry Mown state Zip Code From To Formation Description
b q0
.Area code-Phone number %) a
4. DATE DRILLED •a\-
5. TOTAL DEPTH: ds
PIyP! nC•!._ Evlc'rini!; \".t l':Ll.'' Y1iS ❑ N') — -
7. STATIC.WATER LEVEL Below Top of Casing:I FT.
(Use'•+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
'Tap of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):_ 0 METHOD OF TEST
10.WATER ZONES(depth): j 05
LOCATION SKETCH
1 1. DISINFECTION:Type 6 T 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. hMaterial numbers and common road names.
From To 40 Ft. 'U 't
From,_"__To Ft.
From _To Ft. G
13. GROUT: Depth Material Method Sa r
C
From 0 a_ToD Ft. 0P.+'MO w� to C3 Cy
From_._To Ft. _ INJ s
14. SCREEN: Depth Diameter Slot Sim Material
From _ To Ft. in. in. O sa•,
From____To Ft, in. in. Ln .,.,y
15. SAND/GRAVEL PACK: ;31
Depth Size Material Al
From To Ft.
Front—___._To Ft.
16. REMARKS:
f DO HER E13Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"IRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
C �� m- 05
SIGNATUR PERSON CONST(Uj3C�THE WALL
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Genter.-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. - p _ 1 -� GW-'I REV.07/2001
'i t 6r;111N�1' 7F� ; t igiV j

COP
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and
Natural Resources-Division of Water Quality-Groundwater Section
WELLCONTRAC'TOR(INDIVIDUAL)NAM/E (�print) 1�' ] r r-� CERTIFIC,�A�T�I�O�N"#�� p6
WELL CONTRACTOR COMPANY NAME.�I,�.Yrj��,l+P V1P � VOS k1YPLI&UfVtp PHONE # dg, +J .4 -�)Vio
STATE WELL CONSTRUCTION PERMIT#yW ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Er-Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. W'ELL.LOCATION: ��" ��� Topographic/Land setting
Nearest To�wtn: [{1 t u County ❑Ridge ®Slope ❑Valley []Flat'-b(1� (check appropriate box)
I Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ILA_.\).�.L_Sk (degrees/minutesiseconds)
Address p7.( D (-j\aU-)00 LAL AV" Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
)fP5V l.�,f ��- a�ZBFj DEPTH DRILLING LOG
cty o own since Zip Code From To Formation Description
0
Area code-Phone number ' p a�e�
4. DATEDRILLED 5-;LE)-Ob
5. TOTAL DEPTH: ALL")
f . Y!'S D NI) i
7. STATIC WATER LEVEL Below Top of Casing: dZ FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): UO METHOD OF TEST r-J-l-VS
10.WATER ZONES(depth): o2yrh
LOCATION SKETCH
i I. DISINFECTION:Type Amount Show direction and distance in miles from at least
12- CASING: Wall Thickness two State Roads or County Roads. Include the mid
Depth Diameter or Weight/Ft. Material numbers and common road names.
From __To UG Ft. 1,0 04 C
From_ To Ft. _
From To Ft._ 7
N
13. GROUT' Depth Material Method [�
From_,C) —To —Ft. G '+a,n`F t—'p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. - -
From___To Ft. in. in.
15, SAND/GRAVEL PACK:
Depth Size Material —
From____To Ft.
From_ _To Ft.
16. REMARKS: - -
I DO HEREBY CERTIFY THAT'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"I"RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
i
— Z-_C1ru�1P ,TCi _ Q'lu nh
SIGNATU 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

BA 3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section mm
WELLCONTRACCOR(INDIVIDUAL)NAME (print) 1, \)u�l 1 __ CERTIFICrATION#�
WELL CONTRACTOR COMPANY NAME�,Y',�'nCIC_�1Ab—U]Plt s-paftsp. —PHONE # (Sal) (IltiLS_"r3_��
STATE WELL CONSTRUCTION PERMIT# a _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. WELI.LOCATION:�"" ''A+�� Topographic/Land setting
Nearest Town:yN I "A County�l IYY.I t ❑Ridge ❑Slope ❑Valley 6wlat
I l 1 4�1(a,_�CK{ l� (check appropriate box)
(Street Name,Numbers,Community,Subdivision Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �)t .Q UmflrwocIi (degrees/minutes/smonds)
Ad \\ ^DC Latitude/longitude source:❑GPS❑Topographic map
0.0
� (Street note No.) (check box)
l'Da r-M NC. a�-'j\gyp DEPTH DRILLING LOG
0y or Town state Zip Code From To Formation Description
Area code-Phone number kAQ 5
4. DATE DRILLED .'!J'�a-OS s
5. TOTAL DEPTH: q0r-,
oa YES ❑ NO le _
7_ STATIC'WATER LEVEL Below Top of Casing: aC FT.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS \ FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance w(th 15A NCAC 2C.0118.
9. YIELD(gpm): 1 Q. METHOD OF TEST
10. WATER ZONES(depth): 6 5
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
''ff��
Depth Diameter or Weight/Ft. Material numbers and common road names. -
From_0___To tJ� Ft. k_0" f
From To Ft.
From To Ft. A
13. GROUT: Depth Material Method
From O_To a0 Ft.1`D VJAA r --E®p W ` ,
From _. To Ft.
14. SCREEN: Depth Diameter Slot Size Material O
From____ To Ft. in. in.
C It
From_ _To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From____ To Ft.
From To Ft.
16. REMARKS:
i DO TIER EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THI ^R'E(ORD HAS BEEN PROVIPEDITOO E WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL @ DATE
i
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

op
QI 5 s s
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
I
WELL CONTRACTOR(INDIVIDUAL)NAME (print
(print) _ lLY t! 1 _ CERTIFICATION#
WEf.l.CONTRACTOR COMPANY NAME yl_-eer � W2J�.1..V 1�1.lft'p _PRONE # (99)UM 1`�'�
Sl ATE W'EI.L CONSTRUCTION PERMIT# \yc a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
i.. WELL USE.(Check Applicable Box): Residential LM�'Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
1 WEI.I.LOCATION: " � �� Topographic/Land setting
Nearest Town:�LY 5 CfPA1L Counry�(y�gL ❑Ridge ❑Slope ❑Valley 19'Ilat
(check appropriate box)
(Stmel Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ��00 d (degreeSlminutes/seconds)
Address _ nP Mt i� Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
t-- L 120 DEPTH DRILLING LOG
City r,t Town State Zip Code From TO Formation Description
.Area code-Phone number
4. DATEDRILLED U-1-05 W
5. TOTALDEPTH:_cpaY
'H)E' `A'P: ! RI,PI ACI� I:vlcrinl(; Y!_c U No il, ' ._
7. STATIC'WATER LEVEL Below Top of Casing:_L�) FT.
(Use"+'if Above Top of Casing)
S. TOP OF CASING IS \ FT.Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance m accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): L 9 METHOD OF TEST h✓b
10. WATER ZONES(depth): _ Jt)
LOCATION SKETCH
1 i. DISINFECTION:Type \aVr1ri Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
ff�� Depth Diameter or Weight/Ft. Material numbers and common road names.
From_.h1 To teFt. 10"_
From To Ft.
From To Ft.
13. GROUT Depth Material Method
From Q To 3 Ft. `1 - AJ3
From _ To Ft.
14. SCREEN: Depth Diameter Slot Sim Material
From__ To Ft. in. in. v `<
From To Ft. in. in.
15. SAND/GRAVEL PACK: N ell
Depth Size Material
From To Ft. CC:)
From—____.—To Ft. -:
16. REMARKS:
I DO I IEREBY CERTIFY THAT 1"HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C'ONSI RUC"1-10N STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUKT OF PERSON CO Tl CTINGTHSWELL "-"-- DATE
Submit the original to the Division of Water Quality,Groundwater Section,1�36MIfil Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. - iW-1 REV.07/2001
i
7 �

WELL CONSTRUCTION RECORD
worth Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
W ELF.(:ONTRACTOR(INDIVIDUAL)NAME
' (po.r �.�- ., .._ UVO-0- ) - D CERTIFICATION#3351
n] rit1ItiELL CON"TRACTOR COMPANY NAME PHONE # 1�`U4 '�.
STAT h W ELL CONSTRUCTION PERMIT"#��O a _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WALL USE(Check Applicable Box): Residential Kr Municipal/Public ❑ Industrial ❑ Agricultural❑
:Monitoring❑ Recovery ❑ Heat Pump Water injection ❑ Other❑ If Other,List Use
W CI.I, 1,0CATION: Topographic/Land setting
Nearest'Iown:�(lU \�Q ��t. County EKidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Srrec''varne.I':umbers,Community,Subdivision,
`Lot No.,Zip Code) Latitude/longitude of well location
C)VA 11,1'.k7 p,a'A \ ,OV cb ` 1 I _ (depees/minules/secands)
Andress -� �Y1rYt7P✓YU 1(L✓Y' _ Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.) — (check box)
DEPTH DRILLING LOG
t n.„ r wn State zip C Ode From To Formation Description
'jA LJ RILL umber -
4. DATE DRILLED X
TOJ At,DEPTH: IQIQ�
t.c LJI NO fi.✓ ._
7. STATIC WATER LEVEL Below Top of Casing: l e & FT.
(Use`•+"if Above Top of Casing)
h. 'f OP 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. YILLD(6'Pm)' U _METHOD OF TEST
WATER ZONES(depth): A-7 -_ A IOL1riS�P rT' LOCATION SKETCH
I)1' IFNF EC'7 ION:Type N}}{ Jt Amount Show direction and distance in miles from at least
ASINC Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Front_ Q- To q, FL,_ 't Y
From _...-.__ To Ft.
From.. __.._To Ft.
i i. GROUT' Depth Material Method
1-ronn, Tod _._Ft. e-a4
From ...---To _Ft a,
14. S( kEENN. Depth Diameter Slot Size Material C
7 r
1"rom 'ho FL in. in. pJ
From_ . To Ft. in. in. CJ
1 5. SAND/GRAVEL PACK: -- 0
Depth Size Material CJl '
Pro n- _ro __ Ft.-
From _ To Ft.
L. REMARKS.
i DO iiEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
<-ONS IRI G,(-(ION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIONA"PURE OF PER. 'OjJS1RUCTIN(i THE WELL, L I DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mad Se"ice I enter-Raleigh,NC
27699-1fi36 Phone No.[phone],within 30 days. i !' GW-1 REV.07/2001
J.

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ",
WELL CONTRACTOR(INDIVIDUAL)NAME (print !C/�/lP.- �jt /Ip�I t CERTIFICATION# 333y
WELT.CONTRACTOR COMPANY NAME C4reL•nt �jr_C, Weil 4Sy�rn( T-1 PHONE # -3 ye
STATE WELL CONSTRUCTION PERMIT# 41//' :7— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water njection ❑ Other❑ If Other,List Use
2. WELLLOCAN
Neare�To�w�n:�7���� Topo phic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (/ Ol-i 41e A
Address ��j� (degrees/minutes/seconds)
` 2 Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
/VC -4 k'9/ G DEPTH DRILLING LOG
City or Town state Zip Code From To Formation escription
O
.Area code-Phone num D �?ber p /d S
4. DATE DRILLED S - / -
5. TOTAL DEPTH:_
._ r�r)i...�;ixn.i u1,oLnrc 1_vlc'rl nit, WLI-L4 YLS ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: — FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS— I._ FT. Above Land Surface'
•Top of casing term /or b
inated at/or land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): " METHOD OF TEST__
10. WATER ZONES(depth):
LOCATION SKETCH
1 I. DISINFECTION:Type }--f TN 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 Q _To z . Ft. It p V 0,
From To Ft.
From To Ft. t.
13. GROUT: Depth /Material Method _
From--I)—To Ft. ( o ��•e- f
From To e Ft.
14. SCREEN. Depth Diameter Slot Size
From To Ft in. is
From To Ft. in. in. -, i Q [�'r �. ice. !=
15. SAND/GRAVEL PACK:
Depth Size Material
From
From—___To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR(JC'TI/ON STANDARD{$,AND THAT A COPY 0 IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
$-3/- d 5'
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-] REV.07/2001

Dip
9 2 ri
WELL CONSTRUCTION RECORD `t '€
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) /7 CERTIFICATION# -33S�
W ELL CONTRACTOR COMPANY NAME G-t P w+ �t»c IA� 1 /� .,Pf T PHONE # ( )
STATE WELL CONSTRUCTION PERMIT#_ D 2. ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box):Residential 04'�Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- /
Nearest Town: County �Y �o Topographic/Land setting
Tf
- -- Midge []Slope OValley GWIat
1 Street Name, - hers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER:
Address (degrees/minutes/aewnds)
----�1 `�� �� 7` C Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From TO
Forman n Description
.Area cude-Phone number 10 5_
4. DATE DRILLED 7- -O,y— S / S
5. TOTAL DEPTH: r
pr)L.g WILL RI:P!.^.:•!' rvlc r!y(i t�iEL.L' YI`9 ❑ NO LA'
7. STATIC WATER LEVEL Below Top of Casing:_-16 _FT.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS_i!_FT,Above Land Surface'
xTop of caring terminated attor below land surface requires a
variance in accordanch 15A NCAC 2C.0118.
9. YI e n
ELD(gpm):_ _METHOD OF TEST _4 s
10. WATER ZONES(depth):_ / Q S
LOCATION SKETCH
11. DISINFECTION:Type
1 . CASING: ���H Amount �, Show direction and distance in miles from at least
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. & " PVC c,
From To Ft.
From To Ft. rn
13. GROUT Depth Material Method �
From O To a6 Ft. (�o.� . Y- � � 1
From To FL I�) 1
14. SCREEN: Depth
Diameter Slot Size Material
from To Ft. in. in. OCT�'
1 0 2005
From To Ft. in. in. ,7
15. SAND/GRAVEL PACK:
Depth Size Material ---------------
From__To To Ft.
From_- Ft �. ___ �' �_ —� -----�
16. REMARKS:
I DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COP F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�
SIGNATURE OF PEItSK7N 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

n1 r �ti,
� 3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resource Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME Pun
(printt7n n /
uIla �C CERTIFICATION# 33s5�
WELT.CONTRACTOR COMPANY NAMEr E_g fl
s ',// r c �� /) g a TCc PHONE # Ild�o�/8 3i7e
STATE WELL CONSTRUCTION PERMIT#_ �i�
(if applicable) ASSOCIATED WQ PERMIT#
- / (if applicable)
I. WELL USE(Check Applicable Box): Residential LN' Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Near estJ�Town C on ty /'�� Topographic/Land setting
[yb/ -�j Y ORidge ❑Slope OValley gi6at
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latit Latitude/longitude of well location
3. OWNER:-_ ] , WAI o.�rv, •�.d,
Address j � 1n��' (degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(2,10 (S reet or Route No.)
1 e /LAC a 8 `J2 (check box)
y o-- r T`n �b�te DEPTH DRILLING LOG
Zip Code From To
d T z Formati It Description
.Area code-Phone number
4. DATE DRILLED 7-.16
5. TOTAL DEPTH: 9 a S 1
!„ 1i!)LC \Ai t,:� I ULpLA`9? I:YI C'1"I N(: WEI O Y—IS El �!O
7. STATIC WATER LEVEL Below Top of Casing:-_ —FT.
8. TOP OF CASING IS—�--Use"+^If Above Top of Casing)
FT.Above Land Surface'
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):-=30 METHOD OF TEST rS
10, WATER ZONES(depth):
DISINFECTION:T
1 I. e — LOCATION SKETCH
YP —_-L T H Amount 4 Show direction n and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Welght/Ft. Material numbers and common road names.
From-_-4—_To Ft. _ 1!
From To P U e
Ft.
From To Ft. ?
13. GROUT: Depth Material
F Method rn
rom
_�To_d&-Ft -8 - rr'
From—.---To Ft. iII
14. SCREEN Depth Diameter Slot Size LJ
From
Material
To Ft.To Ft in. in. -
From 0 Ft.—in. r--
in. _ �� rrt
15. SAND/GRAVEL PACK: �!
e " L�
Depth Size Material
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
y le-)
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
3� o S
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
Gw-I REV. 07/2001

c tD 1 C}
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM (print)
CERTIFICATION# 33s5�
WP:LL.CONTRACTOR COMPANY NAME e_fUtle. � � v�'
""�� -PHONE # (O.{Q� z/fj-3/ 7-6STATE WELL CONSTRUCTION PERMIT# /yQ
(if applicable) —'---��---ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box):Residential 2"Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other O If Other,List Use
2. WELL LOCATION:
Nearest own nn 1 �/Je,, County TopoVSlope Land setting
y ( �, -7— ❑Ridge (Slope ❑Valley ❑Flat
1 Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
99 Latitude/longitude of well location
3. OWNER: LC/1 /'ILLa. ,-• L t LC
Address —I_ I Rn�j �7e� V (degrees/minwea/seconds)
Latitude/longitude source:OGPSI]Topographic map
)9 (Street or Route No.) p
//fit rl ��0 /V� 1b �XS' (check box)
Ury or own Stain DEPTH DRILLING LOG
Zip code From To
(—) �SD 2 Formation Description
Area code-Phone number
4. DATE DRILLED_ 7- -(},j SD ' .2Q5 z
5. TOTAL DEPTH:
rDQL' W!-!L! PPPLAC•lr f_�tcT1N!i WCLL:' Y!iS G NO ram/
7. STATIC WATER LEVEL Below Top of Casing: ?/) FT.
8. TOP OF CASING IS / (Use"+^if Above Top of Casing)
FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):._I A METHOD OF TEST_ .� .
10. WATER ZONES(depth): i{!$ / 3
z _
11. DISINFECTION:Type_ T/ LOCATION SKETCH
12. CASING: Amount 3/., .L�,) Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt. Material numbers and common road names.
From 40 To-5Q-Ft. /o t 1 p V From To Ft. _
From To Ft.
13. GROAT: Depth Material
From Method
From To Ft. �-
14. SCREEN: De th �!i�
P Diameter Slot Size Material
From To Ft
From To Ft. in. n.
I!I ) 1
15. SAND/GRAVEL PACK: n �Q y
L L OCTO f1 2r 9"
Y�
From Depth Size Material !
---To Ft.
To
From __ Ft.
0
Ste_ ;
16. REMARKS:
I DO IIEREBY CERTIFY THAT TI;IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF Turq RECORD HAS BEEN PROVIDED TO THE WELL OWNER
w ,, .6 n s (z
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 316-
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)
WELL CONTRACTOR COMPANY NAM //�1 CERTIFICATION# ..335'�
EC�J��he. PHONE #STATE WELL CONSTRUCTION PERMIT#_ �aIQ/ �W�J(if applicable)applicable) ASSOCIATED WQ PERMIT#
(ifapplicable)
1. WELL USE(Check Applicable Box):Residential W/Municipal/Public❑ Industrial ❑ p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use gricultural❑
2. WELL LOCATION:
Nearest Town: Court ty . _/ Topographic/Land setting
R. 0+ idge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,7.ip Code) (check appropriate box)
n Latitude/longitude of well location
3. OWNER:_ ( lr S �a
(degrees/minutes/seconds)
(Street.or Route No.) Latitude/longitude source:❑GPS❑Topographic map
6'�aw,nP S I/r/& ;y e �' g \ (check box)
ty or-Town State ��� DEPTH DRILLING LOG
( Zip Code From To
---)--Phone 14 3/ 1 Format on Description
Area code n umber
4. DATE DRILLED r/-.?F1-A S- 3�' 4/ s '
5. TOTAL DEPTH: <:
5. rJ!)Lg WLLL RI:P!-^.Cli L:vlgr!nu; iaiC:� ., Y!SS ❑ 5'O
7. STATIC WATER LEVEL Below Top of Casing: -M FT.
8. TOP OF CASING IS , (Use'•+"if Above Top of Casing) -------_
FT.Above Land Surface' ----_
-Top of casing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.9. YIELD(gpm):_ 60 METHOD OF TEST_ /t
10. WATER ZONES(depth):
/ is
11. DISINFECTION-Type 'T p LOCATI ON TCH
12. CASING: �— Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From___Q--.To j/ Ft. 4 't
From To Ft. i
From To Ft
13. GROUT: Depth Material 7
From Method
Cn
Tom_Ft. ° m
From ___ To Ft 'a
14. SCREEN. Depth - "— i
P Diameter Slot Size Material
From To F ('xJ
L ✓ I - `:
in. in. _---- —,�
From To Ft. in. i
15. SAND/GRAVELPACK: m. _.
�.
From_ —Depth Size Material
FL —
From.-----To Ft. �_- _
b ,;I i
A -. (
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC'SION STAND S,AND THAT A COPY TfiIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL D J / u�
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

k C f ) ru
WELL CONSTRUCTION RECORD Oil ej _
North Carolina-Department of Environment and Natural Resources ivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMF.�(print)
ryl--�l�� 'o ,f t/Q CERTIFICATION#�5V
WF.I,L.CONTRACTOR COMPANY NAME Va1A De p�u �j,a e�
y A p�,�y
STATE WELL CONSTRUCTION PERMIT# Q PHONE # (ga/p ! �— -3/7�
(if applicable) '2 ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box):Residential GY Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest To Count Topographic/Land setting
;. [Widge ❑Slope DValley pFlat
Numbers,Community,Subdrvts on,Lot No.,7.ip Code) (check appropriate box)
3. OWNER:
Latitude/longitude of well location
Address _ _ (degrees/minutes/smonds)
(Street or Rout NAA.) Latitude/longitude source:OGPSOTopographic map
DEPTH (check box)
City or Town state Zip�e DRILLING LOG
From To Q� Forrctatio escription
.Area code-Phone number
4. DATE DRILLED f' -.0 -OS' SS___! /,4 S-1
5. TOTAL DEPTH: Gn z
5. DOLS `.t'EL!.RIiPLAC?? !_Y,tcrini(; t�iELL7 yt:S ❑ D!0 LNG
7. STATIC WATER LEVEL Below Top pf Casing:_i_FT.
A. TOP OF CASING IS (Use"+"if Above Top of Casing)
FT.Above Land Surface*"Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.01 18.
9. YIELD( N lop METHODOF BEST
ZONES
rs —
10. WATER ZONES(depth): 1 6'
11. DISINFECTION:Type
LOCATISK
ETCH
-�/TH
12. CASING: Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads.Include the road
From Depth Diameter or Weight/Ft. Material numbers and common road names.
Tq._O_L Ft.
From To Ft.
_
Py
From To FL
13. GRO[IT Depth Material —
From /� Ft. } Method rrI
�i To��Ft.�!L =_ �L �"__
From To _ -
14. SCREEN, Depth Diameters N
Slot Size Material
From To Ft. in - o e
Prom . in.
--TO Ft. in. in.
15. SAND/GRAVEL PACK: u 3
Depth Size Material
Frum_.___To Ft. I
From To p(_
---
16. RLMARKS:
f DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A COPY
(OOFFFTTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL r
V 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
,-DDivision f Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) r.�C/^ CERTIFIC'ATION#�J`
WELL CONTRACTOR COMPANY NAME �I��Ji,«_/ n� /��I D ? ep1fONE # (f�8(GS/b
STATE WELL CONSTRUCTION PERMIT# �D2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery El Heat Pump Water rejection❑ Other 0 If Other,List Use
2. WELL LOCATION:
Neare t Town: e$v�Countyquo c� ge IR a c2a V setting
(� ' ❑Ridge lope ❑Valley OFlat
!:54 r n•- (check appropriate box)
(Street Name,Numbers,Community,Subdi`vision, t No.,Zip Code) Latitude/longitude of well location
/
3. OWNER: Y P_Y t p rw_4 • (degreesiminutesismonds)
Address .S3/ .. _ —��, Y�/, Latitude/longitude source:OGPSOTopographic map
(S eet or Route No.) , I a N¢/ (check box)
(�L„_ eZ . ;/C .[ O ! DEPTH DRILLING LOG
City m To tate Zip Code From Tg Formatioll Description
Area code-Phone number
4. DATE DRILLED -
5. TOTAL DEPTH:
';. DUL-S W,._1 REPI ALI.: uviq'rini(i WLLL? YLS ❑ NO tr
7. STATIC WATER LEVEL Below Top of Casing: /O T.
(Use"+"if Above Top of Casing)
6. TOP OF CASING IS FT.Above Land Surface"
'Top of casing terminated attor below land surface requires a
variance in accordance ith 15A NCAC 2C.0118, q
9. YIELD(gpm): I a�2 METHOD OF TEST d K
10. WATER ZONES(depth): / -
11651, - LOCATION SKETCH
11. DISINFECTION:Type 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 _To 69 Ft.
From To Ft. ---
From To Ft. N —_
13. GROUT: Depth Material Method -rnfl
From_Q_To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material TC)l
Prom To Ft. in, in. jIua, � � _
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From. FL
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND'AARR/pS,AND THAT A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GWA REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources--Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
EEt(print) [ypp r0 S/IP r CERTIFICATION# J.2 yZ
WELLCONTRACTOR COMPANY NAMEfj/'2 e_S/1J'as_Wp/1 rt ...��•�, PHONE #
STATE WELL CONSTRUCTION PERMIT# /
_ �7�.�L
(if applicable) ASSOCIATED WQ PERMIT#
11111111 (if applicable)
I. WELL USE(Check Applicable Box):Residentia)( Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other O If Other,List Use
2. WELL LOCATION-
Nearest To County Topographic/LandOV setting
Ridge ❑Slope OValley !]Flat
t 1ze (check appropriate box)
I Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) PProP
1 Latitude/longitude of well location
3. OWNER: � /�P a Q
Address _ / t/Q yy/,,. _ JJ�=f - (degrees/minutes/seconds)
/v'l Latitude/longitude souroe:OGPS�Topographic map
(Street I/lute No.) (check box)
l' /" �� P DG DEPTH DRILLING LOG
City or Town State Zip Code From To
- ��S/ Formation escription
Area code-Phone number qv
Z ,
4. DATE DRILLED A- /S-D,S
5. TOTAL DEPTH:_ 1 S- ' _-
S. `,""_I L RI'PLA( 'srELLP Y!:c rl NO
7. STATIC WATER LEVEL Below Top of Casing:_�0 FT.
R. TOP OF CASING IS (Use•'+^if Above Top of Casing)
FT.Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): W METHOD OF TEST_
10. WATER ZONES(depth); Q(.a ,
IL. DISINFECTION:Type /-/'T/.� LOCATION SKETCH
YP Amount f 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
From__Q,TZ� Ft. 11 P V1,
numbers and common road names.
"
From To Ft - �'•y
From To Ft.
13. GROUT: Depth ,Material ethod r---
Fri
From To_,W-Ft. ! _ -�'v
From -.To Ft - 't
- - '3
14. SCREEN: Depth Diameter Slot Size Material
I rom To Ft. in. n 1 '�=.
Ft.
From T in.
o
in. 'I
15, SAND/GRAVEL PACK:
a
From Depth Size Material 2') _
TO Ft.
From To
—.._._ Ft.
10. REMARKS:
f DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A C OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�- 8--3/- oS-
SIGNATURE OF P ON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES (print) CERTIFICATION#-fy/,?
WELL CONTRACTOR COMPANY NAME C.7��y;p /,fro^ /i�. O C ,j. r �I�PHONE # (FI Ri L fIK —+'/ 7�
STATE WELL CONSTRUCTION PERMIT#_ Z�{D 2 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 LOCATION:/�
Nearest Town:_ C:wu — County � Topographic Land setting
�� ❑Ridge ❑Slope Ote box) Flat
�h�n r o h (check appropriate box)
(Street Name,Numbers,Community,Subdivision.Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ // 1 A ti.r /�/r yr� �J (degrees/minutes/seconds)
Address ?S/ ,, Latitude/longitude source:OGPSOTopographic map
Street or Route No.) (check box)
N C DEPTH DRILLING LOG
city or Town state zip Code From To Formation Description
Area code-Phone number 2 y�
4. DATE DRILLED 8-aG - oS
5. TOTAL DEPTH:
C)LS `•4"c' 1. RIiPi-^.:'ir I.YIc'n n,(, A 1.1 I ' yl.c C. D!(�
7. STATIC WATER LEVEL Below Top of Casing: iz) FT.
(Use"+"if Above Top of Casing)
R. TOP OF CASING IS_�FT.Above Land Surface*
'Top of casing terminated attar below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): .2 METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
I I. DISINFECTION:Type H T/-/ Amount /9 r/ ><6/f5 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 nfu:SFSe<ts-lmif omtllon road names.
From .Q To�_Ft. (o t t - _
V C
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To Ft. 4!nrp
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. -- -- re
From To Ft, in. in. — N
15, SAND/GRAVEL PACK: CD
Depth Size Material --
From __ To Ft.
From__ ._To Ft.
16. REMARKS:
f DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND IAR�S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J 2 (Q g 3 / os
SIGNATURE OF PERSM 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

31 320
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ..-t'((���j)9 E.S --,])LLq C, CERTIFICATION#_3.,3.`a_�
W'ELL CONTRACTOR COMPANY NAME G r[P t1e._l,/c'OS I .�D 4 `�- It j ,PI10NE # '.jfQ'ie g-3 70
STATE WELL CONSTRUCTION PERMIT# �'7` ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential O�Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �7 Topographic/Land setting
Nearest Town: r: C. e County- �, 0'( ❑Ridge ❑Slope OValley 2FIat
ry' -1-n PAn (check appropriate box)
(Sheet Name,Numbers,Community, 'f Subdivision.
�io//n.Lot No,Zip Code) Latitude/longitude of well location
3. OWNER:�ek. C" 'L!n (degrees/minutes/seconds)
Address a2�o D p_e_r� :7Sn 1, Latitude/longitude source:OGPSOTopogmphic map
n (Street or Route No.) (check RI
/ •�.c�.-l/.-- /�l C �p 7� �o DEPTH DRILLING LOG
try or Town star zip Code From To Fo tion Description
_—J io 1,.11Ln
Area code-Phone number
T. DATE DRILLED
5. TOTAL DEPTH:
6. !).!!.i� P!!t!.t. REPI nr'!. W!..1.!° Y!._S I i NO 1,41
7, STATIC WATER LEVEL Below Top of Casing:_,2ID T.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS [__.FT.Above Land Surface*
"fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011S. )
9. YIELD(gpm): —1 a METHOD OF TEST
10. WATER ZONES(depth): _ 4 D5 I ) a In m
LOCATION SKETCH
11. DISINFECTION:Type kJ7—/:4 Amount '7 y +k Ids , Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads._Ittcludell a oad--
Ft. Los B� flames.
From_._Q_To Depth Diameter or Wet ht/Ft. Material numbers and common road a c
t r B '1
From _To Ft. -
iT
i
From To Ft. _
13. GROUT: Depth Material Method
From_To_2gO
From To Ft—
14. SCREEN: Depth Diameter Slot Size Material -
� i
From To Ft. in. in. ;`.... I .._
From To - Ft—in. in.
15. SAND/GRAVEL PACK:
Depth Size MaterialFrom To Ft.
From To Ft. 1.. .. . . . . -_
16. RF.MARKS:
I DO I IEREBY 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
—_bJ hoedi . — .5-3/-GS
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural'1Resources-Division''o•f',Water
\\Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) YCb �O�rn W_ CERTIFICATION#'/�
1 � Pul8
WELL CONTRACTOR COMPANY NAME��r,e._._>3�' -S 1 _= 711ONE # (SSA{ G�Y'P- -I/7d
STATE WELL CONSTRUCTION PERMIT# U _.. ASSOCIATED WQ PERMIT#
(if applicable) — (if applicable)
1. WELL USE(Check Applicable Box):Residential LN'/Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land arest o setting��
Newn: /�ra 4ne_c a 1 /IIt. 1 County ❑Ridge ❑Slope OValley fL'F'"lat
_ mod-I/n 1
- // /.p J. - (check appropriate box)
(Sir'_et Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ I LJ)d ) Bra 5 [ Ll (degrces'/minutes/sewnds)
Address r . Latitude/longitude source:DGPSI7Topographic map
(Street or Route No. (check box)
i n s v_ 1 e � )1 P g 7 g 6 DEPTH DRILLING LOG
cay or Te sate Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 5 -I`7 -05T
5. TOTAL DEPTH: / n5 I
IV ICC U'I:I 1 RE 1 AC! 1:4'ICI"I AII: W!l! 1 O VI:C 1 1 TjO
7, STATIC WATER LEVEL Below Top of Casing: I FT.
(Use"+"if Above Top of Casing)
li. 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.011S.
9. YIELD(gpm):_ �METHOD OF TEST
10.WATER ZONES(depth): �S 1"yv�
LOCATION SKETCH
i l. DISINFECTION:Type---L4T._i-__ Amount I fS 461 4s . Show direction and distance in miles from at least
12. CASINO: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_. To_a_3_Ft. ip I) _ PV 'CJ
From___,.To FL .._,.JI
From_ To It
13. GROUT_Depth Material Method
Frmn_Q_To a 0 Ft._ 0 Is -1 c.
From To Ft. -- C
<
14. SCRL';EN: Depth Diameter Slot Size Material
From....__To Ft. in. in. py
From To - Ft.--in. in. ,
15. SAND/GRAVEL PACK: �=' j �' fe
c
Depth Size Material
From To Ft.
From- ---To Ft.
16. REMARKS: -
I DO I IEREBY CERTIFY TI{AT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STAN S,AND THAT A COPY OF THIS RF.CO AS BEEN PROVIDED TO THE WELL OWNER
&)1� °5 -3/- 6S
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

313318
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural Resources-/jDivision
'o�f Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �06. .. LCJ.P�� CERTIFICATION# �
WELL CONTRACTOR COMPANY NAME&r t+'te,._.�5 ls�P-I/ V_IP"Ispr�PRONE # �.•?� G ��' 3�78
STATE WELL CONSTRUCTION PERMIT#. —_�'i<4 vZ 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: 1 Topographic/Land setting
T
Nearest Town t't; County�g� ❑Ridge ❑Slope OValley Oi5lat
I eL i A 0 ' I.s -LA (check appropriate box)
(Street Name,Numbers,Community,9lubdivision.Lot No.,Zip Code) Latitude/longitude of well location
U'4' I . rYN0e s1
3. OWNER: Mcxvv 5 .ya 1 = (degrees/minutes/seconds)
Address PC R C. I o 8 Latitude/longitude source:OGPSOTopographic map
(Street or Route No.l (check box)
_____ ns r.De_.0 1 E1... .34aa,'} DEPTH DRILLING LOG
city or TLwn State Zip Code From To Formation Description
- -- D `r<a
Area code-Phone number _ //_2 >
4. DATE DRILLED S ' ) io - 0 S
5. TOTAL DEPTH: 17 9 5 1
nr)Ls; Yl..c 11 NO LJ"
7. Si ATIC WATER LEVEL Below Top of Casing: /ItO FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
.F fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD('gpm):_�METHOD OF TES
10.WATER ZONES(depth): 05 1 T - 1
5/ - 3 LOCATION SKETCH
11. DISINFECTION:Type_J•_-j_T�� Amount Show direction and distance in miles from at least
t2. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth' .� Diameter or Weight/Ft. Material numbers and common road names.
From__.b To Ft. Lp It Q y r, -
_ !From_---_,To—Ft.-
From—To Ft. i
13. GROUT: Depth Material Method L
From
From_ To FL � M
14. SC RLEN: Depth Diameter Slot Sin Material -
From To Ft. in. in. O
in. CJl
Ft.
From To - -_ i
n•
15. SAND/GRAVEL PACK: ^
Depth Size Material s
From---.__..—To—_Ft. L_. - .-
,..
From___.._To _Ft.
16, REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS IR.UCTI ION STANDARDS,AND THAT A COPY OF THIS RECORD HAS �OVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TII LL 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

U" 31 ) '7
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section '/
WELL CONTRACTOR(INDIVIDUAL)NAME
EE1(print) ' 1 LL CERTIFICATION# -93S 1
WiWELLCONTRACTOR COMPANY NAME �✓ ax,.—/ _ S. LL/,t.��L V U.e ,t -.PHONE # �� �Y9 -3/7v
STAT �'r`�E WELL CONSTRUCTION PERMIT# .2. ASSOCIATED WQ PERMIT#
(if applicable) _ (if applicable)
1. WELL USE(Check Applicable Box):Residential 121/Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELI,LOCATION- 1 Topographic/Land setting
Nearest Town: &11-io County 44 ,)oncC. ❑Ridge []Slope OValley QF at
esThp-r-V:)1A I (check appropriate box)
i Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ a V t C�_ a/�'y �� � (degreesiminutes/seconds)
Address _-'{5 I'Ind In Ls . vf� Latitude/longitude source:OGPSOTopographic map
� p (Street or Route No.) (check box)
D a �l/rz �g�71_6- DEPTH DRILLING LOG
City or Towne state Zip Code From To Formatio Description
o 941
Area code-Phone number C�D 5
4. DATE DRILLED 5-/ - O�
5. TOTAL DEPTH: •apt t
(, 1Y)E", WELL PEPLn•C'Ir t:vi��n nlr; �q;p) i v YtLS ❑ S!O L,—kl —
7. STATIC WATER LEVEL Below Top of Casing: lb FT.
(Use"+"if Above Top of Casing)
8. "POP OF CASING IS � FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):�__METHOD OF TEST rS .
10.WATER ZONES(depth): 1 S5 / - O �sga„ti7
LOCATION SKETCH
1 1. DISINFECTION:Type H7-)-/ Amount 31, iJ)k 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 9a Ft. & II , .. \1
—i sj
From_To FL
From To Ft.
13. GROUT: Depth Material Method
G
From
_Q To-,?,.Z Ft. C_
From
C K
;4. SCREEN: Depth Diameter Slot Size Material PO
03
From To Ft. in. in. j
From To Ft. in. is !i _� C );
15. SAND/GRAVEL PACK: s�
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
CONSTRUE'"PION STANDARJp-�j�S�AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- Z�lJt 2A�a t .S' -r/- 0 S—
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

1 . 1_ bj
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-'Division of Water Quality-Groundwater Section
WF,LLCONTRACTOR(INDIVIDUAL)NAME (print)— [ 0)" /llp /� �, CERTIFICATION#-.Z�
WELL CONTRACTOR COMPANY NAMEL 7NPP.ne /x5l: os- WaU 4- Pu,i 1;+ PHONE # (9-4 1A i? -3i 70
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) i-:::
r
1. WL-LL USE(Check Applicable Box): Residential 9/Municipal/Public❑ Industrial❑ Agricultural
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use u
i
2. WFI.I LOCATION: / Topographic/Land setting:
Nca,�rest T�ow� n: - e. Coun ❑Ridge ❑Slope ❑Valley CWlat
M CA�C.0 .yr - r n /e e�� (check appropriate box)
(Street Name,Numbe ,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location,
3. OWNER: (degrees/minutes/seconds)
Address fi r) g °7 3 j In r_ Latitude/longitude source:❑GPS0Top6raphicmap-
n ISveet or Route No.) (check box)
_)-70Cv l�n-�L FL -�3 34DEPTH DRILLING LOG '
chy orrown state zip code From To Formation besenphon
Area code-Phone number JpliG r, 30S
4. DATE DRILLED - /D -DSx'�'
5. TOTAL DEPTH: 365 '
!.. 9',!'$ %tv c! ( Rl:ol nCt. t:viS rtnv lit. i v uS L11 NO ._
7. STATICWATER LEVEL Below Top of Casing:--4-[ZFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS j FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
"Hance in accordance with 15A NCAC 2C.0118.
9. YIELD('gpm): R D METHOD OF TEST
I.O. WATER ZONES(depth): $j' Q P r.,
LOCATION SKETCH
11. DISINFECTION:Type f/'T/-/ 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-0 To 30 le Ft. U 11 -P ltc-
From___To Ft.
From To Ft.
13. GROUT: Depth Material Method f4
C)
From D To­�[v Ft. a
From_ _To Ft. C
14. SCREEN: Depth Diameter Slot Size Material ,z
From _ To Ft. in. in.
Prom �To Ft._in. in.
Co
15. SAND/GRAVEL PACK: d
Depth Size Material ull
From_-__To Ft.
From___._To—Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
('ONST'RUC'TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

f't
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
/�!,
WELLCONTRACTOR(INDIVIDUAL)NAME (print)_ .1) CERTIFICATION#�
WELL CONTRACTOR COMPANY NAME �rCC�1 Y-eo (,LZ�� ),y LLrYfm PHONE # (1. 2 31 70
STATE WELL CONSTRUCTION PERMIT# 31- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE(Check Applicable Box): Residential EI/Municipal/Public❑ Industrial❑ Agricultural❑ - 3
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use T F,
i
2. WFLI_LOCATION: _ Topographic/Land setting V Jj
Nearest Town: & County l ❑Ridge ❑Slope ❑Valley w1at I '�
A (check appropriate box)
(Street Name,Numbers,Co y,Subdivision,t.ot No.,Zip Code) Latitude/longitude of well location U I
Te ,�GI t
3. OWNER:�n Ct d /P Y-fi/^rt L)AP'✓Yl (degrees/minutes/seconds)
Address P -3 AciG s4T6 Latitude/longitude source:0GPS0Topo0aphiq map
(Street or Route No.) (check box) — }
es VI/ ti/( Q r7 '9 DEPTH DRILLING LOG
City or Tbwn State zip code From To Formation Description -- - - -
O-
Area code Phone number ! :2 -1.6a t
4. DATE DRILLED S,9
5. TOTAL DEPTH: 7D S
/ ! r1LC WELL REPLACh I:YII"I IAiL A/I:I 1 9 VI`C U NO I/
7. STATICWATER LEVEL Below Top ofCasing: 66 FT.
(Use"+^if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface-
'Top of casing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 3 METHOD OF TEST
10. WATER ZONES(depth):_ 4 O q, , - a ry,
7D5!- / , LOCATION SKETCH
11. DISINFECTION:Type 14 Tu Amount /G9'b�,�c 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 &n 9 Ft. 6 'r
From___ To Ft.
From To Ft.
13. GROUT: Depth Material Method
From-__To 211 Ft.
From, To Ft. • C
2
14. SCREEN: Depth Diameter Slot Size Material ru
From To Ft. in. in. CIO !3
From ___To Ft. in. in. O
15. SAND/GRAVEL PACK: rA
Depth Size Material �y
From To Ft. t3
From_ ___To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONS'IRUC TION STANDARDS,AND THAT A COPY OF THIS RECORD^HAS
) BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3 '
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
''-,,Division of Water Quality-Groundwater Section
WELL.CONTRACTOR(INDIVIDUAL)NAME (print) ��h W� �L CERTIFICATION#�
WELL CONTRACTOR COMPANY NAME�4Ldecj)p-�J/.Y�>YI�S .L d L 4 w LPyONE # d '/��•3/-7 6
STATE WELL CONSTRUCTION PERMIT# Imo/ ),a ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential P-Municipal/Public ❑ Industrial❑ Agricultural❑ _-_---�--"'-" -I
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting I
Nearest Town, /,-County ❑Ridge ❑Slope ❑Valley 2 1 t _ 1 _
Ink Sd .3 1 �H ems,�✓t P•,) B (check appropriate box) I I �I
(Street Name,Numbers,Co�Subbddivision,Lot No.,Zip Code) Latitude/longitude of well location 1
/Tit_. -Pe-all
3. OWNER: (degrees/minutes/seconds)
Address _ 7 a�kt `• Z� Latitude/longitude source:❑GPS❑Topographic mkp
(Street or Route No.) (check box)
C24en e S V r // Al C 1 V '7 B DEPTH DRILLING LOG
city o towu State r zip code From To Formation Description.
Area code-Phone number --
4. DATE DRILLED_____. -QS
5. TOTAL DEPTH: r7 l�>S
(- t�,)l i' IA(Ia I 41:DI A1'111:VICr1All: \1/1.:11 9 Vla fl N-II w-� --
7. STATIC'WATER LEVEL Below Top of Casing: ,5 do FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS___L 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): -2 METHOD OF TEST_ C7t _
10.WATER ZONES(depth): d "/ -
7n5 r - LOCATION SKETCH
11, DISINFECTION:Type 6dT/-1 Amount /G , 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.
Fmm_© __To Ft. L1 f 1`
From To Ft.
From To Ft. C_
13. GROUT: Depth Material Method 2
From---To-j4P_Ft ;
.
From _ To Ft co
€
14. SCREEN: Depth Diameter Slot Size Material O ,
Prom _ To Ft. in. in. C41
From—To Ft. in. in.
15, SAND/GRAVEL PACK:
Depth Sizc Material
From To Ft.
From.- To Ft.
16. REMARKS:
I DO FIERF,BY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST RUCTION
�7STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North.Carolina-Department of Environment and Natural R//esources�-Division of Water Quality-Groundwater Section f'
WELLCONTRACTOR(INDIVIDUAL)NAME (print) _1 / yl / LC"/��t-ev CERTIFICATiI,Or�N#.7-1/O
W1:1.1,CONTRACTOR COMPANY NAME (Yr�s Zi / , /Isy °/ (-lAN .PHONE # (S..?d /o CIS ' 3� 7d
STATEWELL CONSTRUCTION PERMIT#_ 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
NearestTown:(J-1�County 1_ ❑Ridge ❑Slope OValley fikFa
l b )L e5 'f t/ t J D. .. ,e (chock appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
tJ
3. OWNER: _ L4.&r pe y—,41 (degrees/minmes/sewnds)
Address _-/A /7__R7 j"�r 1 'GL� Latitude/longitude source:OGPSOTopographicmap
/ � (Sweet or Route No. (check box)
C�/aUnt--=4 / r o18 -796 DEPTH DRILLING LOG
City orh nvm Some Zip Code From To Formation escription
Area code-Phone number �Q �� 5
4. DATE DRILLED g 'd�
5. TOTAL DEPTH: 7G S ' ,
(,. U )cc jai L:r r REP n('l. lnj; u,'Fl 1 r Yl:c Ll nj()
7. STATIC WATER LEVEL Below Top of Casing: FT. -
(Use"+"if Above Top of Casing) Cm
8. TOP OF CASING IS �FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST
10. WATER ZONES(depth): 2 �
IJ LOCATION SKETCH02
a _
1 1. DISINFECTION:Type -'-T1 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. Mate 'ai numbers and common road names. -1 --
Prom Q_Tos7 F[._/, It pVep-
From---To Ft.
From To Ft.
13. GROUT: Depth Material y Method
From_© To Ft._ C oA�X
From_ To Ft. "—T-
14. SCREEN: Depth Diameter Slot Size Material (—
From--To Ft. in. in.
From _To Ft. in. in. N
15. SAND/GRAVEL PACK: co S
ri
Depth Size Material O
From ____To Ft. Cli
From .__To Ft. z�9
sr�
16. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL,WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS'IRRLI-CTIION�JSTANDAR S,AND THAT A COPY OF THIS REC RD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTR JCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundv ater 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 '' /I
WF,1,I,CONTRACTOR(INDIVIDUAL)NAME ((print) CERTIFICATION#335f�
W ELL CONTRACTOR COMPANY NAME &re e��, CO +G PHONE # f )
STATE WELL CONSTRUCTION PERMIT# ,)aZ —ASSOCIATED WQ PERMIT#
(ifapplicable) (ifapplicable) --- - -r,:
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 LOCATION: opographic/Land setting
Nearest
}T�owg1 County o �ge ❑Slope ❑Valley ❑plit
G/IOC I •• a t/ ' . v n _ (check appropriate box) -'
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well locatiotl
3. GWNER:s��l l ,ODA JAD4k_/ (degrees/minutes/seconds)
Address _ /Sc) P A' F1 4D 7)r . 1, Latitude/longitude source:❑GPS❑Topogt1'aphicLrnap,
(Street,o` 'rt Route No.) (check box) -
._magotr ll"1 !w-i A!C al$ '751 DEPTH DRILLING LOG
Ct ry or f4w�nl state Zip Code From To Formation Description"
0 36 _
Arcacode-Phone number �P ry�s
4. DATE DRILLED .S-1e - C6 /
5. TOTAL DEPTH: 725 ,
( rp)l:c WL! t u):of nr l: ,:vic'rl n,(, i EL! o Yi.c U NQ fY
7. STATIC WATER LEVEL Below Top of Casing: //) F'T.
(Use"+"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.011 S.
9. YIELD(gpm): 1,R—METHOD OF TEST a h/S
10. WATER ZONES(depth): .��S r - l q 2AI
_ LOCATION SKETCH
11. DISINFECTION:Typed Tf/ Amount 1_1 })z 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 C) -_To .310 Ft. 1,
From ___To Ft.
From _To Ft.
13. GROUT: Depth ,(Iitonal 1 Method
From _e To .2� Ft. ( o."•, * r p
From To Ft. C
14. SCREEN: Depth Diameter Slot Size Material =
N
From _ _ To Ft.—in. in. co
To Ft. in. in. _ o
15. SAND/GRAVEL PACK:
Depth Size Material
From__To Ft.
m Fro __To Ft.
16. REMARKS:
I DO I IF.R EBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�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
27699-1.636 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#3'35"/
WELL CONTRACTOR COMPANY NAME I7Y�' S�f -3) 7 6
STATE WELL CONSTRUCTION PERMIT# �,j/l�1- ASSOCIATED WQ PERMIT# -� ----f -- -,
(if applicable) (if applicable)
i. WELL USE(Check Applicable Box):Residential E3-"Municipal/Public ❑ Industrial ❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
1 �
,
2. WELI.LOCATION: 1 Topographic/Land setting
Ne ow ,it �Q�kiCounty�/lcJOnel p11'idge ❑Slope OValley OF+ai --
Y117t 6 n L m e f (check appropriate box) i
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
AA �
3. OWNER: (degrees/minutes/seconds)
I Y0
Address _—
t
Latitude/longitude source:OGPSOTopographic map
l to Route No.) ' (check box) I t
t n JL j4 /l( $ ] DEPTH DRILLING'LOG_--__
city')Nhown State Zip Code From To Formation Description
.Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
Pppl nr ). wlcnnr i�;n.).1 , y);S rl NO C.✓
7. STATIC WATER LEVEL Below Top of Casing: o?D FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
*'fop of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.9. YIELD(gpm): 50 METHOD OF TEST oV A r s
10. WATER ZONES(depth): SAS / - 'T/1
_ il' LOCATION SKETCH
i I. DISINFECTION:Type Amount I a7 /1,J.)-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. M tepl numbers and common road names.
From_6 To ­15 Ft. Eve
From To Ft.
From De Ft.
{)
13. GROUT: Depth Material thod
From_ To_—,2L Ft. Q�.Q� r'—
C
From_ To Ft.
14. SCREEN: Depth Diameter Slot Size Material N -`
From co
Ft. in. in.
From __To Ft. in. in. C '•'�'
15. SAND/GRAVEL PACK: CJl
Depth Size Material
From____T0 Ft.
From____To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSJ RUCTION)STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(e
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

31 0
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of WWater Quality-Groundwater Section
WF.LI.CONTRACTOR(INDIVIDUAL)NAME (print) /Jnn v- ,3, CERTIFICATION#3354
WELL CONTRACTOR COMPANY NAME�Y Pam_u__/aYGS HONE # (9V Io yL�
STATE WELL CONSTRUCTION PERMIT# �`>L L�,2, ASSOCIATED WQ PERMFIV
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential l3/Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: __� Topographic/Land setting
Nearest Town: County flff<ge ❑Slope ❑Valley ❑Flat
�a r,i C 1�_ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lat No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ 1 (degrees/minutes/seconds)
Address I_SD nz�(. F'ro r (-� / _ti Latitude/longitude source:❑GPS❑Topographicmap
y� S eet ppr ��teute No) (check box)
t,P P� NC' DEPTH DRILLING LOG
c, mown State ' ' Zip Code From To DescriptionFormation
32
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH- 7 a,5
--t,n r.i Via,L:I i uljol nr•n rvi� ri nr, w('i i , Yl:e Lt NO t+✓
7. STATICWATER LEVEL Below To ofCasin
P g:�10 FT. � ' __ I ..i
(Use`•+"if Above Top of Casing)
R. TOP OF CASING IS 'FT.Above Land Surface' '
*Top of casing terminated aUor below land surface requires a
variance in accordance with 15A NCAC 2C.0115. _
9. YIELD(gpm):ID METHOD OF TEST
10.WATER ZONES(depth): y T S 1 - J p p a_ no r? I
r LOCATION SKETCH
11. DISINFECTION:Type H-7rJ= Amount 13) 411 is lI jI -
Show direction and distance in miles fr�ltt� east
]2. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
_.
From-6 __T032L�LL Ft. err P l/ C. ...._
From-—To Ft.
From To Ft. '
13. GROUT: Depth Vaterial Method
From To Ft.
_ To
From ._ Ft /
14. SCREEN: Depth Diameter Slot Size Material
From______To Ft. in. in.
From___To FL in. in. O
15. SAND/GRAVEL PACK: CA
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
CONS'l RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
o ') Y', , -31 - 65
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

��# 3
1 ? . r 9
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
' 'o
WELT,CONTRACTOR(INDIVIDUAL)NAME (print)-���7�bt n /,d e- h t CERTIFICATION#�Q
WELL CONTRACTOR COMPANY NAME Tr r , 17�D5.- we//�i�Lsee.PHONE # Lel 6 4"k 31 7 a
STATE WELL CONSTRUCTION PERMIT# /Y'U.Z. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential 9--Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: g Topographic/Land setting
Near tTown: - County i4Fi.�i.Jn / ❑Ridge ❑Slope ❑Valley 0131at
(check appropriate box)
(Sl,eqLVN.me,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: :z4=. Nr�n ,L/P,- (degrees/mintues/seconds)
Address z/3 f' Dr Latitude/longitude source:❑GPSOTopographic map
(Street or Rou No.) (check box)
d s i A/[ .7 S,7 S / DEPTH DRILLING LOG
('11 State y Zip Code From To Formation Description
Area uxte-Phone number
4. DATE DRILLED S-OS' - --S. TOTAL DEPTH:
ELL REP LAC!, Wt..)? Ync Ll NO
7. STATIC WATER LEVEL Below Top of Casing: 114 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. '-
9. YIF_LD(gpm): METHOD OF TEST
10. WATER ZONES(depth): .56 '
/ 7�6 S ? ' i LOCATION SKETCH - o
I I. DISINFECTION:Type H-T-" Amount Show direction and distance in miles from At least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road- iJ
Depth Diameter or Weight/Ft. Material numbers and common road names.
From _Tom_Ft. 611 Py/`
From To—Ft--
From—To FL
13. GROUT: Depth Material J1 Method 0
From__To OD Ft. r ewu.R-u�f
From_ To FL C
c
14. SCREEN: Depth Diameter Slot Size Material
From___ To Ft. in. in. ry
03
From _-To Ft. in. in. -„
15. SAND/GRAVEL PACK o :"
CJ1
Depth Size Material
From To Ft.—
From-— _To -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
dud.-dud.-U, 6D s .a -.f/-e s
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

7
WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section's
WELL CONTRACTOR(INDIVIDUAL)NAME (print)- A CERTIFICATION
WELL CONTRACTOR COMPANY NAME C/PP.YIE, /.'rJ _ o�/ (L/72�JI PHONE It
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 111' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L.00ATI Topographic/Land setting
NT,;t Town: County ❑Ridge 2S`lope ❑Valley ❑Flat
�i C k 5 -ry, � - �/ �'t t/ /,t � (check appropriate box)
Cirreet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
It�J 3. OWNER: ` C4 c-;��iErr. /
(degrees/minutes/seconds)
Address f�9 *y1 l LL2 V e 01 P?d Latitude/longitude source:❑GPS❑Topographic map
/ (Street or Poute No.) y (check box)
.�L 5 V, I Le lu , JO 7 9 6 DEPTH DRILLING LOG
City or lown state Zip Cade From To Formation Description
Area code-Phone number kG
4. DATE DRILLED jn
5. TOTAL DEPTH: (o O5 1
YESIA1 /!1 '-
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(Ilse"+"if Above Top of Casing)
R. TOP OF CASING IS ( FT.Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.01IS. I
9. YIELD(gpm): 3 METHOD OF TEST
10. WATER ZONES(depth): q g5 t R o
_._iA0S t 1 TP rr, 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_oTo_ 1LFt. lo it Pye
From To Ft.
From To FL_ f
13. GROUT: Depth Material Method
From_ To ,'D _Ft._ 0 pwvA" } C ct
From _ To Ft. Z
14. SCREEN: Depth Diameter Slot Size Material N
From 'fo Ft. in. in. co
From To Ft. in. in. O
15. SAND/GRAVEL PACK: _ Ln
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
C:ONSfRUCTION STANDA/RIDI�,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

Ot jJ .t �
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural/Resources-Division.of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMF Jprint)�L�6/n ® CERTIFICATION# 8
WELL CONTRACTOR COMPANY NAME {L'/ I�1 9� hlt PHONE # (I�& G�� ' 3/70
STATE WELL CONSTRUCTION PERMIT# I�{U aZ ASSOCIATED WQ PE
RMIT#
(if applicable) (if applicable)
I. WELL USE,(Check Applicable Box):Residential Lz)/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L own
Nearest Town: Topographic/Land setting
_County ❑Ridge g316pe ElValley OFlat
(check' appropriate tax)
(Street Name,Numbers,Community,SJbdtvis on,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER' L (degrees/minmes/seconds)
Address _ Cn7p �, Latitude/longitude source:0GPS0Topographic map
�} (St t or Roue 'o.) (check box)
DEPTH DRILLING LOG
City or Town Staff Zip Code From To Formatiot Description
5
Area code-Phone number 3[J�
4. DATE DRILLED �/-�1 -65
5. TOTAL DEPTH:
(; rA)I;S r I- I PI: t /• vi}Jr1 nor. �tl l.::.) o YljS [l N() I'.1�
7. STATIC WATER LEVEL Below Top of Casing:42FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. /
9. YIELD(gpm): 6 METHOD OF TEST h rS
:
M. WATER ZONES(de(depth): �2(�.S - agpr"
P /
LOCATION SKETCH
11. DISINFECTION:Type- - Amount _�L-!A 1715 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. 6 'f P�(p.
From__._To Ft.
From To FL
3. GROUT: Depth Material Method C
From,—To c20 Ft. C_L b:ce� f
From _To Ft c
14. SCREEN: Depth Diameter Slot Size Material
From___ To Ft. in.To Ft, in. _. Cil
CD
From in. in.
15. SAND/GRAVEL PACK: - yM
Depth Size Material
From__._To Ft.—
From - _To Ft. t
.'6. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
(ONS'fRU('TI N STANDARD. ,AND THAT A COPY OF THIS
(RECORD HAS BEEN PROVIDED TO THE WELL OWNER
\' "�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

31F) 1
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
W ELL CONTRACTOR(INDIVIDUAL)NAME (print) �f)6 E r s V jO CERTIFICATION#3355Y
WELL CONTRACTOR COMPANY NAME GYPPN�,I �..,US we�` `4 4ttt �S ) rIC . PHONE # (.�1R/o r/S" 3)'��
STATE WELL CONSTRUCTION PERMIT# � .L ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
I. WFLL USE(Check Applicable Box):Residential &­'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WEI I LOCATION: / Topographic/Land setting
Nearest T County Jlg14(/!tJ`2'!� ❑Ridge dope OValley ❑Flat
77" ��-- (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ ' (degrees/minutes/seconds)
Address p O 13,02c 6 9 -T Latitude/longitude source:OGPSOTopographic map
// //� (Street or Route ' .) (check box)
_ �2Kr ll,n rz I. N ,2997 4 DEPTH DRILLING LOG
city or T own State Zip Code From To Forman n Description
.Area ode-Phone number 7Q'9't o'1L55'f _
4. DATE DRILLED q -I G S
5. TOTAL DEPTH: -?,D
F !Y)E'E tUl:l UOpr nr'I: r`Yll'11ni!_ A;P� o !,S fl nj(1 1-4-1, — -
7. STATIC WATER LEVEL Below Top of Casing:,�( Q_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_FT.Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 14 METHOD OF TEST
10. WATER ZONES(depth): / R ri m
LOCATION SKETCH
IL. DISINFECTION:Type T/--/ Amount _�54 +L/k , Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road -
Depth / 1 Diameter or Weight/Ft. Material numbers and common road names.
From _ T O o(J/� 9, Ft. 6 '1 OVn
From_-_ To Ft.
From _To Ft.
13. GROUT: Depth atonal Method r-- "M
From _ C©,—To Ft. y
From _To FL tv eW
14. SCREEN: Depth Diameter Slot Size Material CO
From To Ft. in. in. O
From_ _To Ft. in. in. Ul
:s
15. SAND/GRAVEL PACK: -
Depth Size Material AJ
From_ " To Ft.
From--__. _To Ft.
16. REMARKS:
1130 IO EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL '
C'ONSIRUCTION TANDARDS D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL WNER
J��A/f� Q�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
i
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center RaiCigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV:Q712001 ✓
r-

00
31
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM (print)__ CERTIFICATION#'/qV1 WP:I,L CONTRACTOR COMPANY NAME —��j�rJ �,f1eL C/ (y., TPHONE # ��y_rL3� 70
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) — / (ifapplicable)
1. WELL USE,(Check Applicable Box):Residential Its Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WL^LL LUCATI Topographic/Land setting
Nearest T� �County Hai, get. ❑Ridge ❑Slope ❑Valley C3FIat
- e— .n- 'r ri=1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lin No.,Zip Code) Latitude/longitude of well location
3. OWNER: u ilI Ch (degrees/minutesoseconds)
Address I171 rj r(` ,. . --d)r . Latitude/longitude source:❑GPS❑Topographicmap
yet (Street or Rome No.) 1 ' (clink box)
1 1 INDYe:S'�t''t YN r� R ) 4- DEPTH DRILLING LOG
( ly or Town State Zip Code From To Formation Description
el� !) 3
Are.code-Phone number �/1-3 S
4. DATE DRILLED 3- 30 - Gyr
5. TOTAL DEPTH: Q 2 cs I
i r�r i:c WELL Pl:p A x .L? YES U NO ._
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):_ IS METHOD OF TEST
10. WATER ZONES(depth): a > - I. ej Qv,�
LOCATION SKETCH
11. DISINFECTION:Type "-T )-) Amount ale I 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 a To & 3 Ft. to )I
From, —To Ft.
From--To Ft. -i
13. GROUT: Depth Material Method v
F7oln--D__To—,I(Z c From___To Ft. Z
14. SCREEN: Depth Diameter Slot Size Material N e
From-__To—Ft. in. in. eb 5
From _To Ft. in. in.
O
15. SAND/GRAVEL PACK: Ln
Depth Size Material =�
From- —To_Ft.
From____,_To Ft.
16. REMARKS: r
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WE�L -J
CONS"1 RucTiON STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL{OWNER
3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE --
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center Ra)eighy NC -
27699-1636 Phone No.[phone],within 30 days. GW-I RLV 07/2001
1

01 � �
0 2
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment �
and ral Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM Print) T4 I'n /L ) 1r� CERTIFICATION#��1�{
WELL CONTRACTOR COMPANY NAME A Dwo S 4ka y,. L(Ya/' pj It-Y PHONE # (VA /n 70
STATE WELL CONSTRUCTION PERMIT# .Z, ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Id/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- Topographic/Land setting����Neare Towp: County ❑Ridge ❑Slope ❑Valley L at
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ S (degrees/minutes/seconds)
Address _ J �A/o o o o� Latitude/longitude source:❑GPS❑Topographic map
�t}7�tort or Route No.) (check box)
C L Z Al C ? f17 2 J DEPTH DRILLING LOG
city o State Zip Cody From To Formation Description
Area code-Phone number
4. DATE DRILLED J ' 2 8 d 5
5. TOTAL DEPTH: zc3s
`M_L!. REPLAC•l., 1.v!�,�r!�it: ?ul.a.l v YE'' 0 N!) C. — -
7. STATIC WATER LEVEL Below Top of Casing:__&_FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS �_FT.Above Land Surface•
`Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9- YIELD(gpm):_ #0 METHOD OF TEST___ _
10.WATER ZONES(depth): 2 2-5 ' — 4
LOCATION SKETCH
1 1. DISINFECTION:Type H 7—td 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 WeighVFt. Material numbers and common road names.
From__To"-'4"Ft. PVC
From To—Ft. t=x
From To Ft. t3
13. GROUT: Depth Material Method
From_.Q To_�20 /i
_Ft. t 0 e .. C
From__ _To Ft.
14. SCREEN: Depth Diameter Slot Size Material N From _To Ft. in. in. Co
From To Ft. in. in. O
15, SAND/GRAVEL PACK: Cn
Depth Size Material i
From. To Ft.—
From— _--_To Ft � IA
16. REMARKS: ;v - --- -: ..� _ . .i
f DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C VAELL 1 `
CONSIR[`CTION STANDARD AND THAT A COPY OF TTHI^S,rR,ECORD HAS BEEN PROVIDED TO THE WELV/60WNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center I�idergk,NC ` I i
27699-1636 Phone No.[phone],within 30 days. GW 1 R�V:a7/2001
'

�10
WELL CONSTRUCTION RECORD 3
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_l p"Ln CERTIFICATION#
WELL CONTRACTOR COMPANY NAME 'x�payo W,� q C.0 4'C' -PHONE # {Fa'ff &J_q - 317a
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential E '�Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L Topographic/Land setting
Nearest Town:
h S County ZT ❑Ridge ❑Slope ❑Valley bf1at
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/m inures/seconds)
Address + Latitude/longitude source:❑GPS❑Topographic map
OSt et or Rou( No.) u (chink box)
DEPTH DRILLING LOG
City or low State Lip Code F7 To Formation Description
(—}- -
Area tale-Phone number
4. DATE DRILLED / /- a 3 - b 5t-
5. TOTAL DEPTH:_—, 3p'T,
i,, ri.;cc �u L:i i uI:PI.AC?f lrvlcr)nir. y./j.a _ Y):c ❑ -
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 actor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 9 METHOD OF TEST �2 A r e
10. WATER ZONES(depth):
LOCATION SKETCH
1 I. DISINFECTION:Type Amount 6& j-��-{s Show direction and distance in miles from at least
1�. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From__Q__-To 6q Ft. 61,
From_ To Ft. ���- ='
From To Ft. C)t
1.3. GROUT: Depth Material W
Method C {
From p To_..�Q_Ft. C/t0 1vr >{"o
From _To Ft. Nelt
14. SCREEN: Depth p Diameter Slot Siu Material C3
From____ To Ft. in. in. O
From__To -Ft. in. in. G.J1
]5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From—__ To Ft. ---------
I4. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NC
AC 2C,WEL T -
�`� 11 �
CONS"CRU'CP/hO fN STANDARDS, ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED i0 THE WELL
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-
27699-1636 Phone No.[phone],within 30 days. GW-I
r�

\� 3 el 3 t` V
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and�Natu'1ral Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) / VQ I D A CERTIFICATION#33S�
WELL CONTRACTOR COMPANY NAME l�Ytgy\C. rJl-o5 ���) � Pt, P d. PHONE # (& QI k`/8 • 3) 7D
STATE WELL CONSTRUCTION PERMIT# I D„tL ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
l. WELL USE,(Check Applicable Box):Residential Q-/Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WE L LOCATION.
^ ! Topographic/Land setting
Nearest To - (�Ucl County M<idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �J gn[21 Q Dt 0 (degrees/mintnes/seconds)
Address P n G mL 1 +`I 5 Latitude/longitude source:❑GPS❑Topographic map
`I Street or Rgute No.) (check box)
�e /�L DEPTH DRILLING LOG
p fl wn Sate zip code From To n Fo on Descr'ption
.Area code-Phone number /\ 5 µs
4. DATE DRILLED a - a Al-b S (Dq
5. TOTAL DEPTH: S'4.
DY"Lc, ",-ILL PF.PI ACI. i:vl rl nir; {r 7.1 ) o Yus L, m) 12/ —
7. STATIC WATER LEVEL Below Top of Casing: VO FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
*Top of casing terminated atfor below land surface requires a
variance in accordance w.th 15A NCAC 2C.0118. q
4. YIELD(gpm): _METHOD OF TEST o! rs
10. WATER ZONES(depth): Sa S
LOCATION SKETCH
11. DISINFECTION:Type F--I T 1-1 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__. Tq_f 0 cl Ft. I t n) R$
From___.To Ft.
From To Ft.
13. GROUT: Depth Material Method C
From_Tom' Ft. �.tnr�c_ Z
From____To Ft. ry
14. SCREEN: Depth Diameter Slot Size Material co
From—,-To Ft. in. in. O
C.ri From__ To Ft. in. in. .�
15. SAND/(TRAVEL PACK:
Depth Size Material - - -- .-I
From----.—To Ft. -
From To Ft r -"
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WILL,). ,. ,. I•
CONS fRUCT10N STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WEL4ff f-)WIf1ER
.3.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE '
I 1
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center �tetgh)TiC = --
27699-1636 Phone No.[phone],within 30 days. -
Y GW-1 R�V.07/20 l -----__

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/E� (print) (7(�f� (tGt St p CERTIFICATION# 32Sa
WELL CONTRACTOR COMPANY NAME Tr %n�_ 1 .rn" Wk i i 4 .-I c-.PHONE # (DW/8 - 31 '7D
STATE WELL CONSTRUCTION PERMIT#_ ��{� 02 ASSOCIATED WQ PERMIT#
(if applicable) if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nepces<Town: ^-_- ia+, County ( ORidge ❑Slope OValley Wlat
t l^ f y P (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:7:11 v t A I L1 � )I'a yy,S (degrees/minutWuconds)
Address 3 3b �A hba-1-} ea Latitude/longitude soume:OGPSOTopographic map
(Street or Route No.) (check box)
_Q� N C DEPTH DRILLING LOG
<-its<:it'or I "l state Lip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED -IL
5. TOTAL DEPTH: 3Ga ffi - at,ski y w L
i, 1i)!_1 \, t ul: dart']!.? YrS n nu)
7. STATIC WATER LEVEL Below Top of Casing: .7 6FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. 1
9. YIELD(gpm):/LL METHOD OF TEST o� hr s
10.WATER ZONES(depth): .345
LOCATION SKETCH
11. DISINFECTION:Type F-/T/-) 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__-_To Ft.
From__._To Ft. - ;n
From To Ft. KJ
13. GROUT: Depth Material a
ethod L W
FromQ_To =-2D Ft. i,% C_
From To Ft. ,•'3
14. SCREEN: Depth Diameter Slot Sizc Material N try
From To co
Ft. in. in.
From To Ft. in. in. t:
15. SAND/GRAVEL PACK: C tl
Depth Si7k 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 ,.
CONS I RI C rION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
of
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ra1��g1iT):C-.
27699-1636 Phone No.[phone],within 30 days. GW-1 REW.07/2001 --

wivo 310390
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and-Na4ral Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM' (print). L ' / CERTIFICATION#, SY
N'ELL CONTRACTOR COMPANY NAME Ifs__ ✓O_ S V. r_"/�/LQ�4.�i*G__PHONE # e ?lI-3J 7�'
STATE WELL CONSTRUCTION PERMIT# ____ _� U.2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 2-Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2, WELL I.00ATION�. Topographic/Land setting
����
Nearest Town:_ L County tJ�°C� ❑Ridge []Slope OValley CI lat
/aJ(a f y� =ia (check appropriate box)
1 Street Name,Numbers, ommunity,Subdivision,,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ /1Q � (deg reestrommestseconds)
Address ' Latitude/longitude source:OGPSOTopographic map
(Str t or Route N�o.) (check box)
r,,. /�/C DEPTH DRILLING LOG
City or Town State Zip Code From Ti,, Formation Description
Area code-Phone number
4. DATE DRILLED % ' -3 -
5. TOTAL DEPTH:_ _$j I
,. :1Vj.g �aiL .t Pl:nl nt l: �:vi�Ti�ir \u l't.:.� Y!'SU NO if
7, STATIC WATER LEVEL Below Top of Casing: /D FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C.0118. n '
9. YIELD(gpm): g16 METHOD OF TEST
10.WATER ZONES(depth): 46-
LOCATION SKETCH
1 t. DISINFECTION:Type Iq %H Amount Show direction and distance in miles from at leasttttM�
12. CASING: Wall Thickness two State Roads or County Roads.Include the ros
Depth Diameter or Weight/Ft. Material numbers and common road names.
From....._ To Ft. l. ,r . R '(�_
From To Ft.
From To Ft. -- Co
13. GROUT: Depth Material Method CC3
From_To ;0 Ft._
From To Ft._ 'rry
14. SCRGLN: Depth Diameter Slot Size Material J
From _ _To Ft. in. in.
From. --To Ft.__in. in.
15. SANUGRAVEL PACK: _
Depth Size Material zY
From To Ft.
From
16. REMARKS: ----
5
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"CRIJ('.TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.' ��iLt
SIGNATURE OF PERSON CONSTRUCTING TI IF 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

310391
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and/N�•tatural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES (print)._( /zY/ 6 - & �� CERTIFICATION#n7y/y
WELL CONTRACTOR COMPANY NAME 'n'P NFL.,_/f�1 rB5 �i ?Ii of k± n_.a_�PHONE # f
STATE WELL CONSTRUCTION PERMIT#_ Y Q _ASSOCIATED WWQ PPERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential L9-lMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 1I � County ORidge ❑Slope 13Valley CKat
C It_y„t a +h-5 k, i e t (check appropriate box)
(street Name,Numb rs,Community,Subdivision,Lot `o.,Zip Code) Latitude/longitude of well location
3. OWNER: P (degrees/minutes/seconds)
Address V Q 0 r:3 rn / 1 G Latitude/longirude source:OGPSOTopographic map
(Street or Route No.) (check box)
7 / DEPTH DRILLING LOG
it r ,wn State Zip Code From To Form ti ;Description
Area code-Phone number 'l - r /�_ _
4. DATE DRILLED
5. TOTAL.DEPTH: L4!' B
`. nr)l:v WL1.1- \e;Ia.l •, YI:S 11 nj0
7. STATIC WATER LEVEL Below Top of Casing: 9/5 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. .y
9. YIELD(gpm): —L —METHOD OF TEST
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount 2,W 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.
F'rom__.6) TO_5�& Ft. rt _P ri
_�
From----To FL
From__-_To Ft. {'
13. GROUT: Depth Material Method V
From L7_To ;2/9_Ft.
From To Ft._ .�
14. SCREEN: Depth Diameter Slot Size Material — 7
From To Ft. in. in. Co a
From To - Ft. in. in. r=
15. SANDIGRAVELPACK: cn
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 _
CONS(RUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE-
vi
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center'-Raleigh,
27699-1636 Phone No.[phone],within 30 days. GW-h REV.07(#01

310392
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL COST RACTOR(INDIVIDUAL)NAMES (print)---_ CERTIFIC`A�jT-IxO�N#
WELL CONTRACTOR COMPANY NAME &6PP * -�� �.V�P II d �u r>� PHONE #
STATE WELL CONSTRUCTION PERMIT# L�0 a _ASSOCIATED WQ PERMIT#(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Gi-�Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIO : Topo_grghic/Land setting
Nearest Town: IlesJ. l E County tJvo�- ❑Ridge LNSlope OValley OFlat
L-D>I ., rPP .S�_t� (check appropriate box)
(Sveet Name,Nu w,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3 OWNER[ AAA, (degreeslmmutes/seconds)
Address %!o Latitude/longitude source:OGPSOTopographic map
(Street or R/oute No. �� ,/ (check box)
`/4-M mil- 3 l¢ DEPTH DRILLING LOG
City or town I State Zip Code From Taoa / Formati It escription
Area code-Phone number - %f/J t ,J y -_ /t-n-• -
4. DATE DRILLED O S
5. TOTAL DEPTH:_3LA 6 '
I)OI[S WEIR- RFPI.nC'I: 1:vi�nnir p/�:1 i o Yi:S t t NO
7. S1 ATIC WATER LEVEL Below Top of Casing: -/�FT.
(Use`•+"if Above Top of Casing)
R. TOP OF CASING IS FT.Above Land Surface'
*'top otcasing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.011g.
9. YIELD(gpm): . 1 r METHOD OF TEST
t0.WATER ZONES(depth): ri 4
LOCATION SKETCH
I L 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_r9 To Sd Ft.��t . �J
From_ To Ft. _
a
From----To Ft. � "<
13. GROUT: Depth Material ++ Method
From Q To aD Ft. (D
From To Ft.__,
14. SCREEN: Depth Diameter Slot Size Material Cn
O
From. --To—Ft.—in. in.
From__- To Ft. in. in.
15. S.ANDiGRAVEL PACK:
Depth Size Material
From To Ft.
Front_- -._To _Ft. _
10. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS I RUCTION STANDARDSAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER - -
Lzd
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,07/200$'S ,

310393
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resource Division of 7Water Quality-Groundwater Section ,/
WELL CONTRACTOR(INDIVIDUAL)NAME}(priint)._�j CERTIFICATION#3.�51`
L7ZPL i-3.-'.Y .,^) D 'iy .PHONE # n� y�=3i 7L,
WELL CONTRACTOR COMPANY NAME b _
STATE WELL CONSTRUCTION PERMIT# --�yO2 .__—ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential B'�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO 1: Topographic/Land setting
Nearest Town: �e County AI isJAC - ❑Ridge QSlope OValley ❑Flat
N� ' 4 ,. C e Qom., (check appropriate box)
(Street N,ne,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
^� 41nun CD7797".
3. OWNER: /2YCt, (degrees/minutes/aeoonds)
Address / 36 o.^/f FrPa /-6 . Latitude/longitude source:DGPSOTopographicmap
I (Street or Route No.) '
(check box)
n as , G 9G DEPTH DRILLING LOG
Cit or'Few
n State Zip Code From TO � FO tion Desc ption
t ) /� /�
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: .3�L.5
Yl.s t� NO L✓
T STA'rIC WATER LEVEL Below Top of Casing:_,1/2_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
_,."fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 40 METHOD OF TEST t%r-S .
10.WATER ZONES(depth): I S7 r"7
1 / LOCATION SKETCH
1 L DISINFECTION:Type /�'7��/ Amount Show direction and distance in miles from at least
i 2. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth� `` ��� Diameter or Weight/Ft. Mineral numbers and common road names.
From__.d TLJ� Ft. ,I ,8 D
From___ To Ft.
From To Ft.
13. GROUT- Depth Material Method -
Irrom--,Q_ ToU>Ft.. �From To To Ft._ _s
14. SCREEN: Depth Diameter Slot Size Material ;
From To—FL—in. in.
From_,_ To__FL__in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To—Ft.-
Front To_Ft. _
t6. REMARKS:
!DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF j.IfIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001

310396
WELL CONSTRUCTION RECORD
North Carolina-Department of Enviromnem and Natural Resources-Division of Water Quality-Groundwater Section ''//
WELL CONTRACTOR(INDIVIDUAL)NAM (print)_. CERTIFICATION#,-'Y�
WELL CONTRACTOR COMPANY NAME n(,. Srr 1 D tx.n.'� Znr- . PHONE #
STATE WELL CONSTRUCTION PERMIT#—-_ _ASSOCIATED WQ PERMIT# ----
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Er/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W EI I.LOCATIO'N, :/I Topographic/Land setting
Nearest Town:_( i County ORidge @Slope OValley ❑Flat
�7[P v (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location
3. OWNER: 7/ !' d, Ad 4 (degreestminutes/seconds)
Address 19 Vyer, ( )f7l'rv, Je--Z . — Latitude/longitude source:❑GPSOTopographic map
(Street or Route No.) (check box)
y 2 Ale ?if 796 DEPTH DRILLING LOG
w town State zip cede From To Formation.Description
Arva code-Phone number
4. DATE DRILLED
5. TOTAL.DEPTH:�.Z1
c Dr)I-c wni I REPI n*! l:vie-ring; pO.:L1 o Yi..S 11 NO 5
7, STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
N. 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): ag9 _METHOD OF TEST_�+' 5—_
10. WATER ZONES(depth):_�,�h5 '
LOCATION SKETCH
11. DISINFECTION:Type_ T N Amount �D �s . Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
ig
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_.Z) To 3 3 Ft. G " Ot-1 y,
From__To Ft. -�
From___To Ft.
13. GROUT: Depth /1Material ,t Method co
From To-'b Ft._ O '
From To Ft._ Ln
Id. SCREEN: Depth Diameter Slot Size Material
From_ --To—Ft.—in. in.
From To Ft. in. in.
15. SANDKiRAVEL PACK:
Depth Size Material
From___ To Ft.
From - To Ft.
16. REMARKS:
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,.WELL
(ONSSIRUCTION STAND j�S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSa6rCONSTRUCTING THE WELL DATE -
r�
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

310395
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of water Quality-Groundwater Sectioonp�-,/
WELL CONTRACTOR(INDIVIDUAL)NAME//�'(print)� Y u._((Li l 11 j CERTIFIC"AAT�IION�#"��`t
-LLl_4 L7 t"-L'-�,�,-/�/ ) 4 /emu Mp/�-PI10NE #
WELL CONTRACTOR COMPANY NAME YI���_ Y�.1-L—
STATE WELL CONSTRUCTION PERMIT#___�_'Y"L�sd__—ASSOCIATED WQ PERMIT# _
(if applicable) (if applicable)
i. WELL USE(Check Applicable Box):Residential 2" Municipat/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �/ Topographic/Land setting
NearGs�Town:_l i County- L./D / &I idge ❑Slope ❑Valley ❑Flat
��P hY / ✓/ (/i 1 I'YI P�' e.Ju nct"'r"Y (check appropriate box)
(Street Name...'umbers,Community,Subdd�ivvision,Lot No.,Zip Code) l Latitude/longitude of well location
3. OWNER:- EMI � / 1 / (-,1YG (degrees/mmutes/sewnds)
Address q© U)o/ ia'i,, )eA Latitude/longitude source:❑GPS❑Topographic map
/ � (Street or Route No.) (check box)
DEPTH DRILLING LOG
City r'fown Stater Zip Code From To / Fornlatl n Description
O
Area code-Phone number
4. DATE DRILLED /- 1'7- ,6.S
5. TOTAL DEPTH: -?D 4-
�.
T STATIC:WATER LEVEL Below Top of Casing:AFT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS / _FT.Above Land Surface'
*'fop of casing terminated at/or below land surface requires a
variance in accordance nh 15A NCAC 2C.0118.
9. YIELD(gpm):_ p METHOD OF TEST ,� r s
10.WATER ZONES(depth):_ 4?e T / - !/y ")
// 74) 1 - ,.,., LOCATION SKETCH
1 t. DISINFEC'TION:Type H 7'/-/ Amount Show direction and distance in miles from at least
i 2. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. 1,
FromO TZt�Ft. 6" e
From____To Ft. _
from To Ft.
l3. GROUT Depth Material Method .Z7
From_0 Tom_Ft.._�n t
From To FL_
Co
14. SCREEN. Depth Diameter Slot Size Material CCD
From _-__To Ft. in. in.
From__To - Ft. in. in.
I.S. 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 _
CONS I RUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
n
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
cn -_
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 0/2001 S`n

310394
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and 14atural Resources-Division of Water Quality-Groundwater Section II//
WELL CONTRACTOR(INDIVIDUAL)NAME
ED(print)_fir l� LJ In.Y'_ I, I "Al r / -r— CERTIFICATION#.�.3.SY'
WELL CONTRACTOR COMPANY NAME (�✓a�t1(r._ rLi_YYa<J��V n`Q--� -L`�- =-PRONE # c0.2 L� - 317 6
STATE WELL CONSTRUCTION PERMIT#.——_D �� __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 O If Other,List Use
2. WFI.L LOCAT Topographic/Land setting
Nea ICIrest Town: 1' < ii County L 1trige ❑Slope OValley OFlat
vr�t ky ___�`w a• .,, „„ - jam,f $`) (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) / Latitude/longitude of well location
ql3. OWNER: E ryl i I a P I( 1 rr 'e,U (degrees/minutesismonds)
Address 2/42 /[�. �_ Latitude/longitude source:OGPSOTopographic map
I (Street or Route No.) / (check box)
I ' Aff, ,? �'J Pep DEPTH DRILLING LOG
ON r Town State Zip Code From TO � Formation Description
D 51. 4
Area code-Phonc number - 5/ G r /2 Y.S '
4. DATE DRILLED 2- / 7 - d S
5. TOTAL DEPTH: /?'/5 '
-c f me w! !-I- uE i n ): pviS"rims;Aeit. i o i.'i U Ni t r
T STATIC WATER LEVEL Below Top of Casing: �,Q_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface`
'rop of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):�METHOD OF TEST At-S
10.WATER ZONES(depth):_ �o -39p rti.
LOCATION SKETCH
It. DISINFECTION:Type_-Ll'TN Amount 225 )-b/l . 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_.D To J- G Ft. L ^ PP VC
From To Ft.
From __To Ft.
13. GROUT: Depth Material Method xa'
From D To FL_ •'� _
From To Ft. co
—
14. SCRLLN: Depth Diameter Slot Size Material
From._, To Ft. in. in. CCD
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 a
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -0
SIGNATURE OF PERSON CONSTRUCTING TI IF WELL DATE cn
ry -
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 REVe07J2001 �'"

'
D' 31039 '7
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and nNaetural Resources-Division of Vater Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME/3(print) (��/DJ �N-�-. p CERTIFICATION#��a�S��B
WELL CONTRACTOR COMPANY NAME�Lj'ILC'dL�/__Lr&P . 4E- PHONE #8,�'�,�Za �3/mod
S"I'ATE WELL CONSTRUCTION PERMIT#_� T�� _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential C17'Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
? WELL LOCATIO j �� Topographic/Land setting
Nearest Town: County QG ❑Ridge ❑Slope Walley 8}Flat
/CJ (check appropriate box)
(Street Name,Numqq rs,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: L/[ /// t- (degrees/minutes/seconds)
Address 9/ 7 !7 x,";A6 .PL Latitude/longitude source:OGPSOTopographic map
Street or Route No.) (check box)
� /(a DEPTH DRILLING LOG
City or Town State Zip Code From TO ✓ Forma'o Description
Area code-Phone number _ - /� �j
4" DATE DRILLED
5. TOTAL DEPTH: 105 [
!:`J I'S N:F!-L 3FI'l..^.fir- 1:vi�l'Iwir; s,tr.i •tY!.S Ll NO IUD
7. STATIC WATER LEVEL Below Top of Casing:--5Z_FT.
(Use"+"if Above Top of Casing)
8" TOP OF CASING IS FT.Above Land Surface'
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):. &4_METHOD OF TEST 416
10.WATER ZONES(depth): Y6�-�[P i)-
LOCATION SKETCH
1 l. DISINFECTION:Type__Z Amount /9 ��//s Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads. Include the mat
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_"Q—To_ L-Ft. [y _P/�,_ a
Front To Ft. �V
From To Ft.
13. GROUT: Dept atenal Method — L
From__To > Ft._ co 3
From To Ft__ Off'
14. SCREEN: Depth Diameter Slot Size Material �7g
From"__ To Ft—in. in. '
From To - Ft. in. in. t
15. SANDIGRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
10. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONS CRUCTION STANDARDS,,NN THAT A COPY OF THIS D HAS BEEN PROVIDED TO THE WELL OWNER- n,
SIGNATURE OF PERSON CON Ti UCTING TIIE WELL DATE tv
tst
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

310402
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-/IDivision
''of
ff Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print).. nv/5 �Df+/I'1 L!/2�_ CERTIFICAT ION# �y/8
nn Qru /J d- .�� PRONE # f8-?�_L z/fr - 3/ 7 6
WELLCONTRACTOR COMPANY NAME ( 7YPP rle____.— - ul�- �R�J>>--=
STATE WELT.CONSTRUCTION PERMIT# _ /Jel 6 _—ASSOCIATED WQ PERMIT#
(if applicable) — (if applicable)
I. WELL USE;(Check Applicable Box):Residential [Er/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
L WELL LOCATION: Topographic/Land setting
Nearest Town: S � 7_a County 03u „[��M�it'� ORidge ❑Slope OValley C3'Flat
1'Y)ac I--I-s (check appropriate box)
(Street Name,, tubers,Community, ubdiXrsron, or No.,Zip Code) Latitude/longitude of well location
r
3. 0WNF,R: G r.- /Y1�11--�t E�i l� (degrees/minutes/seconds)
Address P 0 /3 r—e— 5/1.S Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
M ap A l U l a.a !✓l 7 P 7 S-7 DEPTH DRILLING LOG
city or own Swte zip Codc From To Formation Description
( ) 10 &U' G ' OPA,.
Are.code-Phone number - 9 J,4, 765'
4. DATE DRILLED V-Z:'5"
5. TOTAL.DEPTH: 9�4 5 '
NO lye
7. SI ATIC WATER LEVEL Below Top of Casing: 86 FT.
(Use••+"if Above Top of Casing)
k. TOP OF CASING IS FT.Above Land Surface`
fop of casing terminated a7or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I.METHOD OF TEST �` s
10.WATER ZONES(depth):_y3P / 4��
.39-T Pram LOCATION SKETCH
i L DISINFECTION:Type & TH Amo t 124 tAlls Show direction and distance in miles from at least
11 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 g/,G Ft. /. " -P✓c
From___ To Ft.
From __To Ft. _
13, GROUT: Depth Material Method 1's%
From To Ft. _ a WZ
14. SCREEN: Depth Diameter Slot Size Material -0
From_. - To Ft. in. in. t
From ., To Ft._ in. in.
15. SAND/GRAVEL PACK:
Depth Size Material C1
From--_- ToFt.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 A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J G�)
SIGNAI ORE OF PERSON CONSTRUCTING TI fE WELL DATE '
c.n
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.09/2001

310401
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
+ (print)__exe_rr� S_L3 m Dbr[� CERTIFICATION
�#�-
WELL CONTRACTOR COMPANY NAME U1'17/e[.��?o wC / / Lam"=. 'PHONE # t p�6Y'6_- 7!�'
STATE WELL CONSTRUCTION PERMIT#._._ _l! _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential [9 _�Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO / //Topographic/Landsetting
Nearest Town: County 2f idge ❑Slope OValley []Flat
1r e�12-a 1= //S Z Z)� m, (check appropriate box)
(Street Name,Numbers,Community,Subdivision,L No.,Zip Code) Latitude/longitude of well location
3. OWNER: LJ[rz2.=2 NS /J' (degrees/minutes/seconds)
Address F 3 cf Latitude/longitude source:OGPSOTopographic map
(Street r Route No.) (check box)
A/C �2 87 / G DEPTH DRILLING LOG
C ity or own State Zip Code From To FomlatiBn Description
O
Area code-Phone number
4. DATE DRILLED 3-/ 7 - d 5
5. TOTAL DEPTH: Z 05-I
!"JI:S %.!(! 1 U1:U1 A;'I: I:YIC-il N(; Uil. 't.? Y!.S ICI NO
7. STATIC WATER LEVEL Below Top of Casing:�_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*rop of casing terminated War below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
4. YIELD(gpm):.26 METHOD OF TEST��j r5
10.WATER ZONES(depth): __?&? aC?q J,r
LOCATION SKETCH
I. DISINFECTION:Type__--k[J kll _ Amount SS" IA16. 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.
Fron).._p To_,2,Q_Ft._
Front----- To Ft.
From— To Ft.__ C
13. GROUT_ Depth Material Method a'
"O
From 0 --To .10 Ft.__ � 4%t�a
From_ To Ft c
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. 0 �'
From_,.__To Ft—in. in. CA
15, SAND/GRAVEL PACK:
Depth Size Material
From______To Ft. _
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARD ,AND THAT A COPY OF T(HI CCOOJRD HAS BEEN PROVIDED TO THE WELL OWNER S -
YL10, 3/ IS Sz
SIGNATURE OF PERSON CO—R"RUCTING TI IF WELL DATE r. ,
;7
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 4?
iJ

310400
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Reso!urcces/-Division of water Quality-Groundwater Section
'��O
WELL CONTRACTOR(INDIVIDUAL)NAME
7�(print)_ yle5 15DD/ s �� CERTIFICATION
�'#-2'&9
WELL CONTRACTOR COMPANY NAME
"�Lt- C.1f0„5 We-/I 4PHONE It
STATE WELL CONSTRUCTION PERMIT#—_ 4,� __ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential 01-Municipal/Public ❑ industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO �J7� / dgeTopographic/LandOOV setting
Near est Town:_ i �- County_��� / ❑Ridge ❑Slope ❑Valley Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: PS f/V71u v,04, - � . e"x, JP (degrees/minutes/swunls)
Address // 2 /?9/?9' ,Srm ,-- Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) - -^-T 1 (check box)
DEPTH DRILLING LOG
cav (town Stare Zip code From Ti Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: _j66 )
t-. :Yi(i`;tour... P.11Pl.nC l: I:vl�-ri Nir; �ar)'a.t.' Y1:Q I i( Ni(- 1
7. STATIC WATER LEVEL Below Top of Casing:J'FT.
(Use"+"if Above Top of Casing)
N. 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): s,_METHOD OF TEST,��s .
10. WATER ZONES(depth): ,0E'5 .2D 1p�
LOCATION SKETCH
I l. DISINFECTION:Type H.r Amount 55�� _ 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.
I;rom_.(�To /J3 / Ft. /, " _-PVC_ 3
From____ To Ft. tAt
From___To Ft. U�
13, GROUT Depth Material Method AO
From_b,_To ,20 _.Ft. D•^, o .. �" ap t^,t
From To Ft. Is
14. SCREEN: Depth Diameter Slot Size Material
From ToFt. in. in. O (-
From_, To Ft. _in. in.
i5. SAND;GRAVEL PACK:
Depth Size Material `
From To—Ft.—
From-
To Ft.
10. REMARKS:
I DO IIEREBY CERTIFY THAT TI[IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS tRU(TION STANDAR S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
N -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NCTi
27699-1636 Phone No.[phone],within 30 days. GW-I RIV.07/1
0
I _
�V

3110 `� �
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMEq(print)_0.a/td piJlh ({f.� b� CERTIFICATION#�/'
WELL CONTRACTOR COMPANY NAME b_f&op_ _Chas /iLil IV P, � _PHONE # (94 4,1f9 -3)00
STATE WELL CONSTRUCTION PERMIT# __ D ASSOCIATED WQ PERMIT# _.
(if applicable) (if applicable) -
I. WELI.USE(Check Applicable Box):Residential ®"Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI01 , / Topographic/Land setting
Neare Town:_ 1/ County_ !T ❑Ridge ❑Slope DValley 12flat
ZT,1 JI ia. (check appropriate box)
(Street NaiA.,] u/rnlbcrs�Communi ,Subdivision.Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: [Gry Qh/� /��/t� (degrees/minutes/seconds)
Address / 33 3 1 _ Latitude/longitude source:OGPSOTopographic map
(Street or R ute ry,) (check box)
C eD. UD /Y�. ��~/ J DEPTH DRILLING LOG
caTy nr o Some Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 4 -1 - GS
5. TOTAL DEPTH: J�
Ifl.i v YI:S 1 1 n;CI
7. STATIC WATER LEVEL Below Top of Casing:__4D FT. 3
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS_�FT.Above Land Surface`
"lop of casing terminated attor below land surface requires a
variance in accordance with 1SA NCAC 2C.0118. r..
9. YIELD(gpm):__I4 CUR
METHOD OF TEST a rs .
10.WATER ZONES(depth): / / -
$' - yt LOCATION SKETCH
11. DISINFECTION:Type /-TIj Amount _Jg,1A/,A 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__Q To Ft. �o t[ _ PVC -
From To Ft. -
From ___To Ft.
13. GROUT: Depth Material Method
From—f�...._
Flom To Ft. -
14. SCREEN: Depth Diameter Slot Size Material
From_..___To Ft. in. in.
From— To Ft -_in. in.
15. SAND/GRAVEL PACK: =
Depth Size Material
From To Ft.
From- To Ft.
16. REMARKS: "-
I DO IIL-REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS"CRUCT[ON STANDA D ,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

311097
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and
�Natural Resources-Division
,oof Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMEH,(pnnt) IV-11A- i�� �pA6i�l�p/ / CERTIFICATION#.I 412
WELL CONTRACTOR COMPANY NAME !�.P.pa.c.'' /J10� . UJ..E.C+� r_u i�L�GPHONE # U
STATE WELL CONSTRUCTION PERMIT#__ �Y� _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL.USE(Check Applicable Box):Residential M�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL.LOCATION: Topographic/Land setting����
Nearest Town:_ cue. < _County L ❑Ridge ❑Slope OValley Lllat
/1 LL 166 02 -r-r / (check appropriate box)
(SL'eet Name,Numbers,Community.Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ 6eorAc 42 r C)S (degees/minutes/seconds)
Address 51,/d X W 1.117'4 Latitude/longitude source:❑GPSOTopographic map
/) (S et or Route No.) (check box)
EL 330 '74 DEPTH DRILLING LOG
Cey or'rown Sm Zip Code From T9G r Fo Lion Description
b f o
Area code-Phone number - g + 121,50
4. DATE DRILLED S<-/.2 -0 5
5. TOTAL DEPTH: 1,76.5 1
REPL AC:: Yi.,S I i Nu "K {ry
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface* `
*"fop of casing terminated at/or below land surface requires a ei
variance in accordance with 15A NCAC 2C.0118. CJ
9. YIELD(gpm): t/a METHOD OF TEST
10.WATER ZONES(depth): 65 1 - i a
LOCATION SKETCH �.,�
IL DISINFECTION:Type_ -1_-EP Amount Show direction and distance in miles from at leastl`;�
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 41 q Ft. 1, )t d d 1 ,
From__To FL
From __To Ft
13. GROU'T: Depth (Material Method
From_Q_ Tom Ft._�y1,�q.
From To FL__
14- SCREEN: Depth Diameter Slot Size Material _
From_. _ To Ft. in. in. -
From-_ To - Ft. in. in. ,
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.From To Ft.
16. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONS'LRUCTION STANDAR S,AND THAT A COPY OFTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT"URE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-)Divisio/n of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES (print)_.L�t"/" k A. /'JPl i CERTIFICATION
�#.74(ZI
WELL CONTRACTOR COMPANY NAME frr e__ rv6_JA&L( '/��_PHONE # y&g"I'M 7"'
STATE WELL CONSTRUCTION PERMIT#__ _ ,( D.2 _-ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
I. WELL.USE(Check Applicable Box):Residential e Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Topographic/Land setting ��
Nearest Town: County t✓aa� ❑Ridge ❑Slope OValley QFlat
SQ ukd Ip i� k4e; - u, (check appropriate box)
I Street Name,.Numbers,Commud' ,Subdi ision,Lot NO.,Zip Code) Latitude/longitude of well location
3. OWNER: um
_ l� S j}1 (degrees/minutes/seconds)
Address I Al. iAJ. / �[ zbnnntl Latitude/longitude source:OGPSOTopographic map
(St et r Route No.) F (check box)
DEPTH DRILLING LOG
city t,r rown Aate Zip Code From To Formation Description
Area code-Phone number _ 3 f/ r to Jr
4. DATE- DRILLED
5, TOTAL DEPTH: In A5" 1
I)r ,.�• ��n:i E 1UTI nl"I: r.vicr�n'fi \a;I:I I •, YI:c I i n'�n ILI'
7, STATIC WATER LEVEL Below Top of Casing: Y'S_ FT.
/ (Use"+"if Above Top of Casing) y.
8. TOP OF CASING IS / —FT.Above Land Surfaces
'rop of casing terminated atior below land surface requires a _ +.
variance in accordance w'th 15A NCAC 2C.0118.
c'
9. YIELD(gpm):. METHOD OF TEST v_5
10.WATER ZONES(depth): 365" 5 �-0"�" eJ'1 -M
Q ,,,.t LOCATION SKETCH10
11. DISINFECTION:Type__J-trH Amount 1l/3 -N,)fs 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_._40 To 3 q Ft._! v ye
From To Ft.
From__To Ft. -
13. GROUT: Depth Natenal Method _
I'roln_ To Ft.
Ft.___ __
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From...__To__Ft. in. in.
From_.. To - Ft. _in. in.
15. SAND/GRAVEL PACK: -- _
Depth Size Material _
From To Ft.
From_ _.__.—To Ft.__
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDA�RgS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT"URE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

r
jo
WELL CONSTRUCTION RECORD
• ' an:l:r.a- .:cpartmcnt oI tin%Ironment and Natural 12c,nurces- Dig isiun of Water Ouality-Groundwater Section
)
((ON ik%( 1(OR DNDIA[DI AL)A%%IL (Punt) f'�(' f{.-k�-L _ 1 �r `� I _I_ __. (�FRtIFICATl0:5q
t u.Ikk( I(OR(OAIPAA1 SAxIFkluLa t� J Ct �tc_��l ,. Puuse p
i ,s 11 I.( ONSTRC'(TIO� PERMITa - _ /y(' .(.SSOCIATF.D WQ PF.R.x7 rfp
it applicable) lifapp licable)
..I.i. I:�i (('heck Applicable Box): Residential Municipal:Public ❑ Industrial ❑ .Agricultural ❑
`.,cnurn:g G Recoccrx ❑ Hcal Pump Water Injection ❑ Other❑ If Other, List Use
(•( :A I(L
r_..._),1...,(In C. �n �._<-tea i—� �—(_._ __ (ounn. �`• roP(cgh a
Land
setting
❑Kidge Slope O ley ❑Flat
pPro x)
:m.»n �dd;,:.�:,:�.I r,t ]o.i:p<.:d,) Latitudes longitude of Well location
I t /
• i, 1i.1( r-1 � �(�_ _ / ci;_:.�.�-Ae";�— :di ces.m:nutes:.uunds)
I aniude.I ongiwde source'.❑GPS❑Topographic map
( :Svicet:,r P.w�c A• , [check boil
k l r t L k .''. N -� _) y�_ DI!PTH DRILLIN(j LOG� -
'wt, /ip t •d. From To / Fannatlon Description
- I "I R LEVEL Belot, Top of(asing. -71 FT.
.'e tAbu,(Top.)Cep ne:
'.w Or( :%SING IS L_ _ FT. Above land Surface` ---- -- --
up uI casin; erminated al beloe land surface requires a -- — ----
-.�
".; LI.0 IF __.METHOD OF "f --
'(i LR /',;Ni.S (depth):
._..-- --- — -- LO( ATION SKET(AI
�ItiWvI I ( 1 1(),ti Tope_ /j T/-I. Amount Wit_ 4111 Show direction and distance in miles from at [cast
">IA( AA all Thickncx, two State Roads or County Roads. Include the road
oupth Diameter or Weight Et. Material numbers and common road names.
fo_ t _F(
Ft
.ir. To it
cU. i kpth �ntNlatcnal %leth"d r _
•n. To Ft.
.< RI I Ucpth Diameter Slot Si/c %la(cnal
:;.,m 'o Pt, in in.
--.m ib_ _—.. Pt. in in.
',),pill Site Material
r. To _It
To Ft
It I li'; : I.fC I If TI LAT I IIIS N'El1, WAS( ONS I Rt I E:D IN AC('ORDANCE Null GA N( M 2(,WELL
I V, <TAN )AR A.AND i IIA 1 ,1 CUP) 01 I1HSSr HE( ORD IIAS BEAN PR(A IDLD TU TFT WELL OWNER
,1((SAILRE.Of- PI.RSON ( UNSfItCClIZAM11f9r
IVE fE
�ui,nitt the o-r�ginal (o the Div Won of Ni'ater Qualih',Groundwateratn ice Ce ter-Raleig ,NC
(,:b Phone So.[phone],within 30 daex. 0 201(AA'-1 REV. 7 2001
gional Office
rotection

f
WELL CONSTRUCTION RECORD
•I t� + .,n I•uLl- Department oI Ilmironnear and Nat Ina Resource.)-DIv1Mon of Water Quality-Groanduatcr Section
(IN;,;AC IOR(1.AIl15IDI AI_I,AA��{1�F. IprfnQ L�¢ I Ii_�rL L!'L 1.L- � � (E'RI IFlC%110A#-1Y/I
IORCOpI
CY.2OA.SIRt,( II0A PhR]Illa ZJV -p ASSOC IA I F D N'Q 11ERM 1"1'a
___— III applicable) fit applicable) -
I I(heck Applicable Box): Residential D' Municipal Public ❑ Industrial ❑ Agricultural ❑
nr_ ❑ Recovery ❑ heat Pump Water Injection ❑ Other❑ If Other, List Use
1 1 1-i rl AIION - /
I opographiciLaod setting
Coumv ❑Ridge ❑Slope ❑Valley gnat
chink appropriare NIx
�.,,. unlhyr',.tol„I,;,Illil. :andl i. on. L,n �o i 1 i IId.; I_unmde,longitude of well locution
:!`tl:•' j-� �' [--L _ !!.._ . _ Latitudr lungnudc .ourrc:❑GPS❑Topocraphio map
cikm I< ul Iv„ idho bra)
If DRILLINO I.OG
L,I,(d, Front To Formation Description
�I I
•`s \TER LLVLL. Bclo%N Top of Camn>, i_i'(_'_FT. - --------...._. -..
II.. If
t..','\IN(, IS � FT. Above 1-and Surface* --- ---- --- -
op of easm;t terminated error below land surfaee requires a
_I ieo , m aocu Nanee with ISA SC INC 2C.bl I8.
I !) t�pul �._ p,1LTIlOU OF L1 S7
---�t_i— -- - --- --- ---- - _..—
. LOCATION SKPTCH
gliNl rt l ION: IN -�-��--- - -
Pc H T F j _ Amount- f "Li�,j.{� Show direction and distance in miles from at Icust
"all I hiakncss mo State Roads or County Roads. Include the road
Dcp1h Dmrnctcr or weight FI, Material numbers and common read names.
SU C..
. .ran__
Depth -_. _-- ---SI ----- _
'ucn Method
'J
Depth Dlumelet S1o1 Sve Material -�
P m;ti I o tit- in. ir.
in. -_ in.
IRA VLI-PA( K_
Depth Si;.e %letcn:d
T I _ I t._
To
I<1.15 i ( I-U IP', HIM IM I]W') N FI_I wk AS CUNSI RI C I ED IN AC( ORDAN(F.WIII 115A NCAC_'C,W ELL
t '10 C IAND, RDS. AND H IAT:1 C OPE OF THIS RECORD I IAS BLEN PROVIDED M TI IL W LLL U14NLR
SR T,AII RF UI PIBSUN Ct)NS { - N' �VED -- - - UA re - - -- -
o„ rt itC :Iri;;inal W the Unrsiun of�Na4r Quahtr Grounihti Ater Section Ibih Mail Ser ice('enter-Raleigh, NC.
.. tin i•hnue No.191g1733-i?2I,vvilhm 30 tier}'b. CiW-1 RLV. 0'-?U01
JAN 3 0 2006
Asheville Regional office
Aquifer Protection

WELL CONSTRUCTION RECORD
,cIli, II 111-110 -Depaitnleut oft and Ndwral Rex)urccti Drvluort oI W'atet Oualny-Groundwater Section
Ll I0'e$RA( I OR IISDIA I D111.),VA31 E fPrinp_ �c. : c ` e
J -j, _. _� (ER]IF'ICA'110A p
J
c U,SI RAc ]OR UIMI .AvA NAME' D ruo"t: s L _)
1'.Ei.L(USS I RL CI10.11NER.MHO .( 'Lt_2_ .. __,__:1SS(1('IA I EU\tiQ PERM I#
of applicable) (if applicable)
:'.I.I.I I.SI ((heck Applicable Box) Residential El' Municipals Public ❑ Industrial ❑ ,agricultural ❑
i'-:Imol,l:g ❑ Recovery ❑ ]]cut Pump %kater Injection ❑ Other ❑ It-Other, List Cse
i IIA AI ION, Jopographic,LandSating
I�^ n le -elf/e Counn'17-Lyfi ,� [6idge ❑Slope ❑Valle}' hi
_.:Li-I/-L��re"',�_ ch�'A appropnete bul l
"LlbliIIIIIIIII, Lol So /i l ,d0 Lantudc longitude of R'ell location
k. e
Lnttude lonmtude suurcc=0GPSI3Toj,ogjapII1L neap
1-r i r.lro.i
-JJ XI II_.r _J,L.y._ 1 v `_ -`_�.�.�- -- DIl1'111 DRILLING LO(,
From Tti Formation Description
-- 1� -
11.: unlnbrr -- — ( ��'-�
Al'4TCR I.IIVLL Below Top of Casing i_- __PT. -- ------ --- —
IL.e --d:Abocel ,t ,e-
p soul --_—
ASINGIS _ L9- Abo%e Land Sur face' —_ _----.__ _.
7 op of caang lerminated aUor below land "rface rryuire�a
nriaoce in accordance with I5A]CAC ZC.0118.
-. _pn)l _It-_---- MI=THODOFTL:ST____.�_ I)eS__.
_ LOCAI ION SKFT If
)1>li,l i CI ION: Type_ Amounn _4_L.ALI j Show direction and distance in miles from at least
VA'all Ihlcknecs tun State Roads or County Roads. Include the road
Dcplh Uiameler or Raght.Fl. Material numbers and common road names.
0 V.(I
Doplh ,Ahaen,ll V1ethod_— -
L• _
F -
-IIJ I '• Dept t D„llmer Slol Svc Vlhmnal ..�
1 `ii -Iu I
,r To
_ _ I t.. nn. in.
A'1,1, PACK:
Dcplh Cvc ".tutcn:d
Io I-t.
To
. .� -1 NI ii ( IRIIFI' Ili,\1IIIISVi'I.LIR'AS('ONSIRI:CI LD IN ACCORDAN('F N I1I11 SA N(:AC 1C. WLLL
NdNSI:ANDAft.DS \NDIII:AI A(01"1 (A THIS RECORD HAS BCGA PRO%IDI-D [0 IIIEVCLLL0A4NLR
sfONAILRL ()l III Jt St)N C-ONSI VI M.
wLnut the ur;},,inal to the Dnision of III,aler tlualit Gromrdllater Section, 1636.Mail Sej ice Cenler-Raleigh, SC
ib I'hone No.[phone],within 30 days.
1
JAN 30 2006 G"`-' RL°. 07200'
1
Asheville Regional Office
Aquifer Protection

.I
3 i '•
WELL CONSTRUCTION RECORD
elolum Deparvnent of 1 11%nonmcnt and Natural Ruource,- Dnision of Water Quality-Groundwater Section
stIII (ON I It k(. ]OR I I NIM I DI AI.I.NANIF (printl . I` C C• E t -U�f�I[ C ER I I FICA'1 ION 3SA
J
cstLrf OSTk 4(7UR COAIPANI AA?IF(;r UxC., �- t �i<�� � � so,s.,i Pf10NE # (��'i C
,I.AII'_NF A,(.ONSI RL CTIOF PERNII'I# _- ;%SSOCIATt:UWQPER.N11T#
(d applicable) (if applicable)
\A LLL USE (('heck Applicable Box):Residential [A--Municipal,Public ❑ Industrial ❑ Agricultural ❑
ytonnoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use _
tsl1 1 LO(':A I ION' Topographic/Land setting
u r C Vec0ey county-_�t, it rl ❑Ridge L�llope ❑Valley ❑Plat
-gA -. ch,, Aappropriate box)
commnnm.�nhdn,ion,Ln'so..np( ,J,l Latitudes longitude of well location
IJ i,rees minutes seconds)
\ Id1os �l tl rl ri,cl0 •-�-�� A_'<,l Latitu ❑de longitude Source:❑GPSTopographic map
j n1r Iul is 1 1cLecAbos)
2 DEPTH DRILLING LOG
/p t „de From To Formation Description
- - t -
UIlRI1.1 1 D (1- I `I
!I \1 III.PTH: `i=��i� ------ -- - ----- —
.... to 1.! V t I �,i t I
I A I I( bi'A f I R LEVEL Below fop of Casing: 3!_ F"F.
(Gc'--It Abow Top of(acing) -.
1()I' OF CASING IS _ FT. Above Land Surface* -- ---
i up of casing terminated albor below land surface require,a ---- - - -- -- --- -- ----
ariance in accordance with 15A N('A( 2C.1)118.
,1 � 11_I_1)(14pm) .—MFFHODOFI-LST ,,z1,i-S_- ----- --
.nLR z()NL.S(depth):
44 LOCATION SKETCH
: I UlblMf ("IIUN.Type_ N-T I-I__ :Amount Ibl1,._ Show direction and distance in miles from at least
l%all Thickness too State Roads or County Roads. Include the road
I)cp 11 Diameter ur Al eight It, Material numbers and common road names.
i 'I'll L- I Ft. C< "
! Iou: to Ft.
,.:ow. -. ._ fo -- lit--- -
(Jt(f I Depth Material -� Method _
I I0111 D fo L) I t
i i nn To f I _
4LJ-N Depth Dla:ncicr Slot Svc Material 17
I Ion]_ _ Ib_ _ Ft. In. In.
S-AND (rRAV LL PAC K: - - - - --
Ucplh Slrc 1Lncnaj
n"In To I:t
I nan.. - To _ Ft_
. iU.AIr41LKS.
u,kt HiM ( LkIlf` " lIIAI MIS \tiP.LL.WASCONSlKLC IEDINA000RDANCF.A41711 IiANCAC 2C,N'LLL
1'�S11U (lIUN SIANDARDS. :AND IlfAI V( OP`(OOI IBISRPCORDIleASBFFNPROVIDFD'IOTtiEbIFI L OAtiNER
SI(,N.AIURLOf TI RSUN CUNSI ' pRC�.,r/r'�c p^^ DAII.
,uitn d lire or igival to the Division of kN ater Quality,Ground"ater S!(17lCEI V:RGDice Cent r-Raleigh,NC
='ouy 106 Phone No.[phone]."ithin 30 days. G -I RLV. 07^001
JAN 30 2006
Asheville Regional Office
Aquifer Protection

�o
WELL CONSTRUCTION RECORD
North Carolina-Department of Enviromnent and Natural Resources-14ivision of Water Quality-Groundwater Section /
'A ELL CONTRACTOR(INDIVIDUAL)NAME (print)_ _ CERTIFICATION#-IrY5 �"
WELL(ONTRACTOR COMPANY NAMF>�A e n ..e P+ HONE # (,Y.LS_L J/ --. 7G
S LATE WELL CONSTRUCTION PERMIT#____ J O __ASSOCIATED WQPERMIT'# _ _
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0( Municipal/Public❑ Industrial ❑ Agricultural ❑ _
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use'
2. 'A "-L LOCATION )) Topographic/Land settingr-�,.�.'��Nea st Town County + >t{, ❑Ridge ❑Slope ❑Valley wdt
(check appropriate box)
(Strcct Name, be Community,Subdivision,Lot No.,Y Code) Latitude/longitude of well location
3. (OWNER: (degrees/minutes/secon(s)
Address _ Z Latitude/longitude source:❑GPS❑Topographic map
/1 (S or Route No.) (check box)
C 4, All-, —2 g-71(o DEPTH DRILLING LOG
city or Town srau zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 4,5
5. TOTAL DEPTH: /FIS
Y!.c Ll N,I
T STATIC WATER LEVEL Below Top of Casing:_.2,0 _FT.
(Use"+"if Above Top of Casing) -
8. TOP OF CASING IS FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gm): & METHOD OF TEST r5
10, WA1 ER ZONES(depth): /6,4 r
_ LOCATION SKETCH
i 1. DISINFLCTION:Type__14XA Amount Show direction and distance in miles from at least
1-. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Fnrm_Q-___To'CIS Ft. L11 P✓(r.
From., --To Ft. p -
From—To Ft.
I3. GROUI Depth Material Method I
From _ U1 -'
From To Ft. o
1 SCREEN: Depth Diameter Slot Size Material Lill
From..._..- ---T° Pt. in. in.
From. To Ft.—in. in.
15 SAND/GRAVEL PACK:
Depth Size Material
Frmn___. To Ft.- ---
From_ -To—_Ft.
16. RI:;MARKS:
!Du 11ERE13'i CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
(.ONS IRIX FIO9N STANDDls RJ[)S,AND'I HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD" `'
North Carolina-Department of Environment and Natural Resources-Divisionof/Water Quality-Groundwater Section ,/
Wr:LL CONTRACTOR(INDIVIDUAL)NAME
EEs(print) GY',�I, /J// upd-! /t CERTIFICATION#.33-301
w ELL CONTRACTOR COMPANY NAME sr•P[rTl'.—�C_(�_, IL1LG I� ^! (`a o-,..� �// .PHONE # (8&k e-3)7,6
S I ATE WELL CONSTRUCTION PERMIT#_---Z�10-1,__ ASSOCIATED WQ PERMIT#
(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 LOCATIONA _/ Topographic/Land setting
Nearest"Town: (.;Q..et�p-o _County zc.Y%z'�� ❑Ridge ❑Slope ❑Valley XI lat
t
V PJ d J rr/Sli T rI V P (check appropriate box)
(Sueet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
S. OWNER: M&a �� _ i�a
(degrees/minutes/seconds)
Address _ �?g0 i &")en r'le ' � Latitude/longitude source:❑GPS❑Topographic map
(-screeor Route No.) (check box)
.4 9 '7l! DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Descri lion
_ _ L) /S��o t P
Area code-Phone number
?. DATE DRILLED___?- �L9 -b5"
5. TOTAL DEPTH: _3,5" 1
1 IM: Uil-1 1 ,) Y!(s I�t N]o 1�
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing) —
R. TOP OF CASING IS FT.Above Land Surface'
fop of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0115. _
v. YIELD(gpm):_3 METHOD OF TEST Q�rt -
10. WATER ZONES(depth): .2ft51
LOCATION SKETCH
11. DISINFECTION:Type---LIT N Amount 54P+A)-)-, _ Show direction and distance in miles from at least
11 CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From D,_. To /44 Ft. La It P1/0,
From_ To Ft.__
From To Ft. _-
13. GROUT: Depth Material Method 0
From O_To
-2-0e ..�, „ } r�
—FL C C ,
From To Ft.
ld. SCREEN'. Depth Diameter Slot Size Material U'1
From. .----To _Ft. in. in. _ o
From,_ To__Ft. ._in. in.
i�, SAND/C;RAVELPACK:
Depth Size Material
froin
From__. _To___Ft.
i6. REMARKS:
f uU HEREBY CERTIFY'HIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
:.'U 43TRUCTION ST RDS.AND THAT A COPY/OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.____.4)%) ./t-Q2�t.1�„ l lJ /1-1S'-DSO
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27fi99-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Na al Resources--Division of Water Quality-Groundwater Section ./
WELL CONTRACTOR(INDIVIDUAL)NAM print)— CERTIFICATION#336 cf
W ELL CONTRACTOR CONIPANY NAMES-Iw Q��, - PHONE # (Ug 4 Sib -
%l'.A]I,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'
_. W L'LL LOCATIO 1 � � Topographic/Land setting
Nearest ,c. _ County ER1dge ❑Slope El Valley OFlat
79 C r e leCy (check appropriate box)
(Svicet Name,Numbers,Community,Subdivision,tat No.,zip Code) Latitude/longitude of well location
1 /
3. OWNER: [ // (degrees/minutes/smonds)
Address _ .73 e_- ave e-m Latitude/longitude source:❑GPSOTopographic map
/y (Streelor Route No.) (check box)
A/C .�8'7 /(o DEPTH• DRILLING LOG
ny or Town state zip Code From a m
To ) Fotatio Description
�
Area axle-Phone number G '1 r �,OS -
d. DATE DRILLED g-p S
TOTAL DEPTH: .,20
\4/1:1 1 UI:DI A`'1: I:YlI'illJl: \Alta I O V, Q I I 1,I11
7. STATIC.WATER LEVEL Below Top of Casing•_26 FT.
(Use"+"if Ahove Top of Casing) ---
x. TOP OF CASING IS_L—FT.Above Land Surface*
=Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_3Q_METHOD OF TEST �yS
10.WATER ZONES(depth):�5 )
LOCATION SKETCH
1 I DISINFECTION:Type Amount Show direction and distance in miles from at least
• CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or W'eiebt/Ft. Material numbers and common road names.
1 rom_�_To (D o._Ft. (o I t Ry e
From__-_— Io Ft.__
Front To Ft. O
13 GR.OU7: Depth Material Method� rn
-'"—T
I rom O_To�F't. �r7 y,.n ,. i� (
Isom To Ft. In
hl. SCRLEN: Depth Diameter Slot Size Material 0
From ----To___Ft. m. in.
From___To__FL—in. in. 3
:?. SAND.'GRAVEL PACK:
Depth Size Material
-rom__ ..,..__To__Ft. __
From_.. _.—To___Ft.
1,6_ REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS IRUCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI IE 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 Sectiotn'/,p
W ELI.CONTRACTOR(INDIVIDUAL)NAM (prinQ�/' Ic �B�� n//1® �. a CERTIFICATION#�/ a
WELL CONTRACTOR COMPANY NAME YGF�e_ 6!ry [JS . We /J oI YU�r . ' PHONE # L
S IAT E WELL CONSTRUCTION PERMIT#__._-_ O z ____ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential 9 _Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: UDC ❑Topographic/Land setting
Near/estlown: nt__Couy-AL/ ❑Ridge ❑Slope Valley Flat
LJ H C e to (check appropriate box)
Street Name,Numbers,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3. OWNER: 41' (degrees/minutes/seconds)
.ddress _T4.2 9 -H.r A Latitude/longitude source:❑GPS❑Topographic map
IS for Route No.) (check box)
187 1 DEPTH DRILLING LOG
cn,or Tr tare zip Code From To Formation Description
--J - — D �ty
Ara code-Phone number �{ r
4. DATE DRILLED 9-,2,7 D _
. TO"PAL DEPTH: j: S '
_. :S Al;L!.!. RI ^.CH I.:v(Q rINr; o, I 1 .9 VI:c U NO 6'
7. STATIC WATER LEVEL Below Top of Casing:__40_FT.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS� _FT.Above Land Surface"
-Top of casing terminated at/cr below land surface requires a
variance in accordance with 15A NCAC 2C.01I& _
9. YIELD(gpm):_30 METHOD OF TEST
1 O.WATER ZONES(depth): IDS r - 3p _.�
LOCATION SKETCH
11, DISINFECTION:Type__WS�_ Amount 20 Show direction and distance in miles from at least
I=. 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. it __f��/�
From_ _To—Ft.
r1
From To FL
13. GROUT: Depth /� Material 1 Method p
From._n To___,2IZ Ft..1..Q.-w 1 —
c )
From___ To Ft. _ 1
14_ SCRLEN: Depth Diameter Slot Size Material Ln
From. . .__--To_._Ft. in. in. _. O -1
Frmn. _To Ft. in. in.
1-., SAND/GRAVEL PACK:
Depth Size Material
From_ _. To___—Ft. ,_. _
From_.. To Ft.
Ib. REMARKS:
1 DO ItEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
I ONSI RUCTION STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
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-1 REV.0712001

F
�5
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section p
WELL CONTRACTOR(INDIVIDUAL)NAM . print) CERTIFICATION#_� 6
W 1•.I.1-CONTRACTOR COMPANY NAME QQAyt_ Ls / D +sl ♦ / I,t... PHONE # (YJJ 4. �S' 3I7o
SIATE WELL CONSTRUCTION PERMIT# �'f�o z __ASSOCIATED WQ PERMIT#
61'applicable) - (ifapplicable)
i. WELL.USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Waterfeetion❑ Other❑ If Other,List Use
WELL LOCATIO / Topographic/Land settin
\camstTown: /J _County�LC. ❑Ridge ❑Slope ❑Valley {Flat
F"r�.LI c r ♦L. (check appropriate box)
,Street Name,Numbers,Community,
Subdivision,Lor/rNo.,Zip Code) Latitude/longitude of well location
3. OWNER:�� ( �v t 9, `F-�
(degrees/minutes/seconds)
Address _ _'2 D PZ7�h 4 •1-y) . Latitude/longitude source:❑GPS❑Topographic map
or R out5no.) �� / (check box)
C DEPTH DRILLING LOG
iy or Town glare zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED__- _
.,. TOTAL DEPTH: ^Y65 -
d.- 'I led GYl•Str�. �
Y11.� \v:ai Marl "(I- I:v(c n!`:�i WLl 1 " yi.g L� n 1
7. STATIC WATER LEVEL Below Top of Casing: OD FT.
(Use"+"if Above Top of Casing)
h. FOP OF CASING IS � FT.Above Land Surface'
'lop of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_�, METHOD OF TEST_��j_�-�_ _
M, W ATER ZONES(depth): 4,290 1 - g
LOCATION SKETCH
11. DISINFECTION:Type ___ Amount_La_7 ,I-bJ4, Show direction and distance in miles from at least
12. CASING- Wall Thickness two State Roads or County Roads.Incl4__de the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
1 rom To Ft.
From _..-- To Ft.Lrom —To Ft _
,3. OROU'l Depth aterial Method CD
From _O_To D� Ft Al 4- m
From __To Ft. i
14. SCREEN: Depth Diameter Slot Size Material Cn '-'
From, _ To Ft. in. in. CD
Prom... To Ft. in. in. ul
15. SAND/GRAVEL PACK: -
Depth Size Material v
Prom____.___To_ FL __ _
From_.. __—To_-._.Ft.
16, REMARKS:
1 00 HEREBY CERTIFY TILAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
i'ONS IR UUCTION�(STANDA D AND THAT A COPY OF THIS RECORD RECORD ILAS BEEN PROVIDED TO THE WELL OWNER
S j
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
JnW(Mjif the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GWA REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources r-r�DDivision,of Wat r Quality-Groundwater Section
VVELL(ONTRACTOR(INDIVIDUAL)NA print)�E���S ���J CERTIFICATION# E
WELI.CONT RACTOR COMPANY NAM. e n. /il/I1 ¢ R ILJ6K - PHONE # (kIK04
_e__--
SfAfE WELL CONSTRUCTION PERMIT#__"_-_ ls/d2 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 LOCATION: Topographic/Land setting,
Nearest"I own: _ County ❑Ridge ❑Slope ❑Valley lat
�OhL/ __o w Loll — . Q zu J � (check appropriate box)
i Sract Nao, ,numbers,Colmmunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:� (degrees/minutes/seconds)
:i<idress SD //r.0 Latitude/longitude source:❑GPS❑Topographic map
Street or R o�ie^ o.) J (check box)
/!C DEPTH DRILLING LOG
t."ny or Town Staw zip Code From To Format o Description
t _ ) _ p
r v code-Phone number 7,01
T. DATF. DRILLED -rZD ,dS
S. TOTAL DEPTH: S45
WF1 !- REP!_ ( ! Ev_!ti i IN'l �ql i:! !-o Y!:c L NO l
7. STATIC WATER LEVEL Below Top of Casing:4D FT.
(Use'+"if Above Top of Casing) - ---
Y. 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(gm): In/) METHOD OF TEST—a krs__
10.WATER ZONES(depth): S , -
LOCATION SKETCH
1 l. DISINFEC'I ION:Type /-f-'Ti(-_ Amotmt _ Show direction and distance in miles from at least
1-. CASINGS 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. 6 It __P VL -
From-____To—Ft. Q
1-vom To Ft. tT1
11 (;ROUT: Depth Material Method n =
1
From _-Q To�'�
From_.. To Ft.
11. SCREEN: Depth Diameter Sloe Size Material 0
CI1
i=rom__.____To___Ft. in. in.
Prom To Ft. in. in. -.
IS SAND/GRAVELPACK:
Depth Size Material
Prom_
Front_ _. _To --Ft.
lit_ RIIMARKS:
I DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C ON tiTRUICTIONN,STAND4RQS,AND THAT A COPY OF TIJTS,gE 'ORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. _ _.. GW-I REV.07/2001

i
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and lijapprall Resources-Division of Water.Ouality-Groundwater Section A
WELL CONTRACTOR(INDIVIDUAL)NAM"& (print) _ _ CERTIFICATION CS S 8 A
WILL CONT RACTOR COMPANY NAMEi>V_�.,QQ,/t,t-____ �ilr/� PHONE # (o y-317v
SIA7 E WELL CONSTRUCTION PERMIT# �Z p�OCIATED WQ PERMIT#_
fif applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential. Municipal/Public❑ Industrial ❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
'_. WELL LOCATION- Topographic/Land setting
Ne res 'Town: A A �� ' —County . Z 916dge ❑Slope OValley 0Flat
+�Jl I`J7i�u (check appropriate box)
i Strcei Name,N rs,C munity..Subdivision t Nno.,Zip Code) Latitude/longitude of well location
3. OWNER: Y D " LL • j (degrees/minutes/seconds)
Address Latitude/longitude source:OGPSOTopographic map
(Street rR u No.) ^ (check box)
9 7.51 DEPTH DRILLING LOG
(it r wn State zip Code From To Formatio Description
10 7s '
Area code-Phone number ! 3 2.5 /
4. DATE DRILLED __ -LJ s
5 TOTAL DEPTH:
_____
EL v Y):c Ll NO XI
7. STATIC WATER LEVEL Below Top of Casing: 1.6 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_ / FT.Above Land Surface'
'I op of casing terminated st/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. `11LLD Qpm):_ /-S' METHOD OF TEST__,"rs
ii). WATER ZONES(depth): 30d6
LOCATION SKETCH
1 I. DISINFECTION:Type _ Amount Show direction and distance in miles from at least
121. LASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Prom --To, 7-3 Ft.
From_._To Ft.__
From To Ft.
1
13. G120UT: .Depth Material M
T— tl7
m Fro .._�To_�6 Ft. eA y,�o ,.
From _To CDFt. _ L
14. SCREEN Depth Diameter Slot Size Material "r
Prom. ..._---To--Ft. in. in.
Protn To Ft--in.
I,S. SAND/GRAVEL PACK:
Depth Size Material
From__ To__Ft. _
From__
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUUC.TI)ON STANDAR S, ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

0A)
WELL CONSTRUCTION RECORD r� >- e"
North Carolina-Department of Enviromnent and al Resourcess-�ivisiton®of Water Quality-Groundwater Section ry
WELL CONTRACTOR(INDIVIDUAL)NAM print)—Al'&Aj a ` '� . b.r� CERTIFIC'AATION#
W EI.1.CONTRACTOR COMPANY NAME „Q� �,_/ lt�CLL I 9i P.+..p�_,_.PHONE # iFjt1 7
S IA TE WELL CONSTRUCTION PERMIT# �3` r�-__—ASSOCIATED WQ PERMIT#
(if applicable) fif applicable)
I_ WELL USE(Check Applicable Box):Residential �.+ Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Use
WE I-L LOCATI / / Topographic/Land setting
ivea "f st own: countyLNet( pRidgedge OSlope W ,alley �jFlat
_�15 �'� L'Q-/-2/Dnr- LI (check appropriate box)
greet Name,N m ion umbers,Community,Subdivist,,Lot No.,zip Code) Latitude/longitude of well location
3. OWNER: _ �-0 1°?. (degrees minutes/seconds)
Address _ R9 a,Q r Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
C. .2�r7�(e DEPTH DRILLING LOG
('ity or wu State Zip Code From To Formation Description
ip & g I
ai L.
Arw de-Phone number 6 9 1 9 6S 1 l e
4. DATE DRILLED Q_(o - U-c
5. "rOTALDEPTH: 9D51
W11.1. PI'PLI AC L!:X!S!!r.iC; tAn:L!-,r Y!,c Hirt
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+'if Above Top of Casing) — ---'--
8. TOP OF CASING IS FT.Above Land Surface'
ibp of casing terminated at/or below land surface requires a
variance in accordanc�e�rth 15A NCAC 2C.0118.
9. 4 IELD(gpm): '/ 2. METHOD OF TEST ..5
10. WATER ZONES(depth):
LOCATION SKETCH
11, DISINFECTION:Type Int N _ Amount Show direction and distance in miles from at least
12. C'ASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
IromQ TO49-9—Ft. L, I I pvr'
From____To Ft--
prom-To Ft (11
FioreO: Depth Material Method
Ftom O To ;R _Ft. Cd m., ;f _ ut
Flom �To Ft._
0
i4. SCR Depth Diameter Slot Size Material UT
From._...--7o Pt. in. in.
From. __ To Ft. in. in.
1 _ SAND/GRAVEL PACK:
Depth Size Material
prom__. --To---Ft. _
From_" __To___Ft.
!6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
('GNSIRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1630 Phone No.[phone],within 30 days. GWA REV.07/2001

ow
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 'I
WELL CONTRACTOR(INDIVIDUAL)NAME� (print) —1J t� CERTIFICATION#3-3 `r
WELL CONTRACTOR COMPANY NAMJ�7 ,,, , LA, PRONE # f8,0?4 Co it S O
STATE WELL CONSTRUCTION PERMIT# 1 '"� ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 2--�Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring O Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. W LLL LOCATIO Topographic/Land setting
Nearest Town: CountyJL all D( LIidge ❑Slope OValley ❑Flat
:Pt a � eA (check appropriate box)
Street Name,Numbers,Community.Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: J(!_t-r y (degrees/minutes/seconds)
Address $ S . ._� ,,. �r Latitude/longitude source:OGPS OTopographic map
(Street or Route 0) (check box)
�tev t'I)e N e ,2 g R 01 DEPTH DRILLING LOG
City or Town state Zip Code From To Forman n Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
DQLS t 'LLB RITLAI r WLLi?r uc n NO tl,�
7. STATIC WATER LEVEL Below Top of Casing: L D FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): 3 o METHOD OF TEST_ rs
10. WATER ZONES(depth): (Q5'- Q tP m
1 �,�,.�., LOCATION SKETCH
11. DISINFECTION:Type H-r Amount ?a 4 1,1_,Is . 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 D To_a,?_4__Ft._ _LD t t _ Q 1/
From To Ft.
From To Ft.
13. GROUT: Depth Materi-I Method n
From d_To_VD FL t
From To FL
(n
14. SCREEN: Depth Diameter Slot Size Material C:)
From To Ft. in. in.
From To Ft. in. in. ...,
15. SAND/GRAVEL PACK:
Depth Size Material
From—_- _To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STJANfARDS,AND THAT A COPY OFF THHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GWA 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) 7�9 e r �"\Ic �(�Z CERTIFICATION#�5`t
WELL.CONTRACTOR COMPANY NAME(�r CP vs� Br�c.1. c 1 0 -.f Tl�v,. -4—PHONE # (9L4 t, �
STAIE WELL CONSTRUCTION PERMIT# 1 µ h ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 2'�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Munitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topo�gra�phie/Land setting
Nearest Town: Sl1 t 1 le Coun L-�06CI ❑Ridge L-FSlope ❑Valley []Flat- D roc L (check appropriate box)
(Street Name,Numbers,Community,Sub M is' ,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: fYle A 11 (degrees/minutes/seconds)
Address ( A lam- r- p It 1 Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
Z nw c_ Ill)F 1�C �7�C(r DEPTH DRILLING LOG
City or Town I state Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 9 - a o -CS
5. TOTAL DEPTH: 185
1-Y oS' 'YLLt.RE PLI M,L IIYICI'!N(i wl-1.1 .r YLS L1 NO Fig
7. STATIC WATER LEVEL Below Top of Casing:--LLO FT.
(Use"+^if Above Top of Casing)
K 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.0I18. q 1
9. YIELD(gpm): -7r,� METHOD OF TEST oC ,h r4
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type._-4ZN Amount 3 3 +1.1 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.
FromTo �Ic Ft. It P�)r
From To Ft.
From To Ft.
13, GROUT: Depth Material Method --
From-0 Tom Ft. Ce, 1#u
r*I
From__To—Ft. n
14. SCREEN: Depth Diameter Slot Size Material t
(f1
From To Ft. in. in. _
From To Ft. in. in. pj
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,JNP THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a S
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/N/++atural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME+ (print) Lsere I'l I I J I� �( CERTIFICATION#�/_aj
WELL CONTRACTOR COMPANY NAME&r_en RrrC�a , 1 l —( Ty+�-'R,�.PHONE # (9-,SSG Y B 3J 7�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 9- Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: JJ Yropographic/Land setting
Nearest To/y. : �J_-- t, Coup ei idge ❑Slope OValley OFlat
^x' A ^J I (check appropriate box)
(Street Name,Numbers,Community,
lSubdivissii�o/n,,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: p V (^r✓, I y- r 1-(t (degrees/minutesiseconds)
Address _. -21,A e ce r 7r/ Latitude/longitude souree:OGPSOTopographic map
(ytrmt or Route No.) (check box)
f _a,�c�7bx /t/(' -900716 DEPTH DRILLING LOG
Cry or Town gene zip Code From To Formation Description
d 5l r
Area code-Phone number —S7 I IzN5g
4, DATE DRILLED �/- /G -OS
5. TOTAL DEPTH:
5. DULS WLI—L REPLnCL Wt.'I o YES O NO L.✓ _
7. STATIC.WATER LEVEL Below Top of Casing:_�U FT.
(Use"+"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):,2Q_METHOD OF TEST
10. WATER ZONES(depth): I Id n
LOCATION SKETCH
IL DISINFECTION:Type k� Amount 3 G 411+s . Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_0 To—"LF[. G tt Poe,
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From_,a_To--J,0_Ft.
From __To Ft. r
14. SCREEN: Depth Diameter Slot Size Material CA
From To Ft. in. in. p
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From---To—Ft.—
From F[.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

t
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME' (print)Cl.a�r)e S \� t+ 1z�b p�t CERTIFICATION#
WELL CONTRACTOR COMPANY NAME G�.�e_yiy grc�_ � �/ d Q .,..f t-J(-;� PHONE # MA 448 - 317D
STATE WELL CONSTRUCTION PERMIT# f q D ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential M'�Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographicland setting
Nearest Town: Ileftill � County ,/;y ❑Ridge ❑Slope ❑Valley C�'Flat
1 r S��'^^ — 1 P y�^�y�1r (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: c e4 '/py�004 (degrees/minutes/seconds)
Address ,�LrK. .55(n Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) J (check box)
Vr /�� h/� �,� 78co DEPTH DRILLING LOG
City or Tow stare T Z p code From To Formatio Description
i 7 i
.Area code-Phone number 7
4. DATE DRILLED 9-/s"-A S
5. TOTAL DEPTH: Aln 5 1
DY)LS is/:'Ll-REPLACE (:v!};'rin'�ri \"./ELL° yES "1 NO l!✓
7. STATIC WATER LEVEL Below Top of Casing: 1o,0 FT.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
-Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): A METHOD OF TEST
10. WATER ZONES(depth): _3</S - /DO 1?p,
LOCATION SKETCH
IL. DISINFECTION: Type N� Amount (rt ,4 4. 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 L3 _To (4- 2 Ft. / )I
From To Ft.
From To Ft. -
13. GROUT: Depth Material Method
From-_ To '10 Ft.
From To Ft. 1— n
I
14. SCREEN: Depth Diameter Slot Size Material Ut _
From To Ft. in. in.
From To Ft. in. in. 0
(€l
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
C'.ONSTRUCTION ST N ARDS,AND THAT A )F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
� it .2
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

n, A
WELL CONSTRUCTION RECORD - - -
North Carolina-Department of Environment and�nNtatural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES print) CERTIFICATION# 73
WELL CONTRACTOR COMPANY NAME�4�lgQpl,/C3/y 0
STATE WELL CONSTRUCTION PERMIT# �7" 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
Nearest,T wn: !� ointy �f�(./unod ❑Ridge ❑Slope ❑Valley bat
4 Cl da — (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: mY_5 T H EIJ&6 � � (de greesmatnuotsl econds)
Address _ 30 Fr ,, Ue�.�.. L�9 a Latitude/longitude source:❑GPS❑Topographic map
(Street or Route 1 (check box)
—}P�s- )e F L- 3 J0%b DEPTH DRILLING LOG
City or Town State Zip Code— From To Form to Description
Area code-Phone number jn� 1 36
4. DATE DRILLED R - 1 Lj
5. TOTAL DEPTH: =506 1
VIrC rrl NIO (�J/
7. STATIC'WATER LEVEL Below Top of Casing: roj3 FT.
(Use"+"if Above Top of Casing)
R. TOP OF CASING IS_�FT.Above Land Surface'
*Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.01I8.
9. YIELD(gpm):_ 10 METHOD OF TEST
10. WATER ZONES(depth): Q La S ' - -0q$' I O 4 am
-�— LOCATION SKETCH
11. DISINFECTION:Type Amount SL, 41,1�-z -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 WeightlFt. Material numbers and common road names.
From _To I Da Ft. In PVC,
From To Ft.
From -To Ft.
13. GROUT: Depth Material Method
From_ �To_ Q _Ft. 6 � rn -
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material 1
CJl -(
From To Ft. in. in.
From To Ft. in. in. O
15. SANU/GRAVELPACK:
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 STAN DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-tia- R // .1.2-DSS
SIGNATURE OF PERSON-CONSTRUCTING TI iE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,INC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)1le"i'.ft zl r—e '6, C�a CERTIFICATrIsON#�.�
WELL.CONTRACTOR COMPANY NAME��rx.s� r t')_�1 q kVns , 11 i PHONE # (Vpl G S
STAT"E WELL CONSTRUCTION PERMIT# e 2 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 13/Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION: —�/` Topographic/Land setting
Nearest Town: County 0't LYKidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1r) , 6_ A. i I" � ' (degrees/mmutes/seconds)
Address _ 1 5 ,,..,�,, D Latitude/longitude source:OGPS❑Topographicmap
` (Street or Route No.) (check box)
- L ) DEPTH DRILLING LOG
City or Town State .ip Code From h To 9 f Fortn ti n Description
( )
Area cedee L7-Phone number t �• bs t
4. DATE DRILLED 4 - 14 - ©S
5. TOTAL DEPTH: a O S t
DQLS`,?"aLL REPLACE I,v,Icrrinir; AuELL? YES ❑ NO
7. STATIC.WATER LEVEL Below Top of Casing:__�_FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I D METHOD OF TEST
10.WATER ZONES(depth):_ 'R 5 t - 1 6 r n ws
LOCATION SKETCH
IL. DISINFECTION:Type Wr H Amount 3 L �61 a-s . Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To-5-7_Ft. 6
From To Ft.
From To Ft.
13. GROUT: Depth Material L Method
From_CJ._To__�Q_Ft. ea�,...a". l fn `
From___To Ft. n
14. SCREEN: Depth Diameter Slot Size Material 1
iJ1
From To Ft. in. in.
From To Ft. in. in. D
15. SAND/GRAVEL PACK: ul
Depth Size Material -
From ___To Ft.
From ____To Ft.
10. REMARKS:
I DO I TEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C'.ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IJ
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 v
North Carolina-Department of Environment and Natural Resources--Division of Water Quality-Groundwater Sectioon4 Y WELL CONTRACTOR(INDIVIDUAL)NAM (print) (4ppprir � o 1'Z_11 vs.//-��rP CERTIFICATION#,/l'�_x
WI:L[.CONTRACTOR COMPANY NAM L o c..[ > m . C.�.xA� q Y��,,�,.a� .pHONE # f �/e Y d '�/ 7�
STATE WELL CONSTRUCTION PERMIT# SVDL ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Er-Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: ` 1 �dTopographic/Land setting
Nearest/Town: 11P fefkCounty_ a,c.,.�.,M pge ❑Slope ❑Valley ❑Flat
l r-Q-64-re> (check appropriate box)
(Street Name,Numbers,Community,,Su�bdiv—isiion,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1 1 1 c— IL (degrees/minutes/seconds)
Address $ cI�r i Latitude/longitude source:❑GPS❑Topographic map
/� (St eet o((Route No.) (check box)
l D • -I�c�U ��� DEPTH DRILLING LOG
Cay or Town I State I Zip Code From To ) Form ti Description
( ) n 29
Area code-Phone number a� 1 �g�,
24
4. DATE DRILLED �1 - 1 3 OS
5. TOTAL DEPTH: a R C t
WI LL ul:nt nL•r 1.v,tc ri nrt tar i:Li t YcS El
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 casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):__$C_) METHOD OF TEST s
10.WATER ZONES(depth): a(0_!E t — '96 ,c^'�
LOCATION SKETCH
I I. DISINFECTION:Type 1-1T I-1 Amount S'/ -L,�� 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. (n t L PV1�' L,.t
From To Ft. C-I
From To FL I
r11
13. GROUT: Depth Material Method
From Q Tom_Ft. `�o _� _ C
From CrI
To Ft.
14. SCREEN: Depth Diameter Slot Size Material _.
From To Ft. in. in.
From To Ft. in. in.
15, SAND/GRAVEL PACK:
Depth Size Material
From—,—To Ft.
From___To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
('ONSTRU 'TION STA D S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

O�
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) p®?-t CERTIFICATION# 3ss -
WELLCONTRACTORCOMPANYNAME, PHONE # 044.g9— SI_'"
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential M_ Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO ' 1 TopograppIc2and setting
Nearest Town: ��_County -{ _ ❑Ridge 9116pe ❑Valley ❑Flat
n �} Y e � (check appropriate box)
(Street Name,Numbers,Community,/Suubdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. Oddness l� l<�C._a. LO (degrees/minutes/seconds)
Address 3Cq (' 1 C sd e Latimde/longitude source:❑GPS❑Topographic map
(meet or Royt�o.) (check box)
t �N opg DEPTH DRILLING LOG
Cay or ToState zip Code From To I Formation Description
In �o4,54
Area code-Phone number t $ r —
4. DATE DRILLED 9 - /a-j$�
5. TOTAL DEPTH:
DULS`.".'ELL RIiP1.AC1! !.v1c'rinr(; lA�t'LL:' YL'S n No L�
7. STATIC WATER LEVEL Below Top of Casing:_ ?n FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated atJor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):, 46 METHOD OF TEST _
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type 1-�_T 1� Amount z.�\�-}s Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To &J_Ft. (n 11 P V
From To FL
From To Ft. -
13. GROUT: Depth Material Method -
From_Q_To
_�Ft. Co .-,�� �
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material e i
From To
Ft. in. in. On
From To Ft. in. in. _
15. SAND/GRAVEL PACK: CD
tJl
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 STIA DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
// 2 2 O S
SIGNATURE OF PERSON'UONSTRUCTING 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) CJP(r�a-ld V s 1 e 1,, 231 1 CERTIFICATIOON#,/ 2
WELL CONTRACTOR COMPANY NAME-tu P d,
STATE WELL CONSTRUCTION PERMIT# 5�y� ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential GP Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO
Nearest Town: _County Topographic/Land setting
�� �:.3 3 d . f Fa tdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zipde
ry D Code) Latitude/longitude of well location
3. OWNER: 1 p.J[ D,��IL_ (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographicmap
0 .1, X
(St rr et or Route No) 7 (� (check box)
6 DEPTH DRILLING LOG
City or Town State Zip Code From To FomationjDescription
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
JQ' SV,"- I REP1 x! r.- - , .. L NJ 4Z -
7. STATIC WATER LEVEL Below Top of Casing: 1.o0 FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS -FT.Above Land Surface*
`Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): a METHOD OF TEST
10. WATER ZONES(depth): S/[.n S -
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 To Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material M`
. et'hod
FromS�To_aQ_Ft C_-0- a �r j
T o
From__-_ To Ft. rTt -
14. SCREEN: Depth Diameter Slot Size Material C)
From To Ft. in. in. ct7 `a
From To Ft. in. in.
15. SAND/GRAVEL PACK: C:)
ctt
Depth Size Material -
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 STJA-'NPARDS,AND THAT A COPY OF IIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

c A r•
WELL CONSTRUCTION RECORDO �� -i " , .1
North Carolina-Department of Environment and Natural Resources-Division f water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM)E../(print) CERTIFICApTION/#'/�p
WELL CONTRACTOR COMPANY NAME. n . '/& )O I Yn PHONE # (Y,?J
STATE WELL CONSTRUCTION PERMIT# �'S'//�C ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential B /Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: II County ❑Ridge I�pe ❑Valley ❑Flat
s ((��
U t ) A �. e T O' I (check appropriate box)
Street Name,Nuntbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: E + +Jy L-X- �•-�-�— (degrees/minutes/seconds)
Address 4 8'l4 Lr4b}r M}.,., -t Latitude/longitude source:❑GPS❑Topographic map
($tree[or Route No.) (check box)
C a t,2 o M e DEPTH DRILLING LOG
City or Towd State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: o t
7. STATIC WATER LEVEL Below Top of Casing: I D b FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
'Top of casing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. `
9. YIELD(gpm): I U METHOD OF TEST a hrs
10. WATER ZONES(depth):— - 85 ' - IC) opvT
LOCATION SKETCH
I I. DISINFECTION:Type � Amount 61, }b }r , 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._�i_To ID Ft._ (o 11 4)\1G
From To Ft.
From -To Ft.
13. GROUT: Depth Material �L Method
From_-D_To_,a0__Ft. (_g.��._ -
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material m
From To Ft. in. in. I
From To Ft. in. in. cJl
15. SAND/GRAVEL PACK: O
Depth Size Material [J7
From__To Ft. _
From___To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C'.ONSTRUCTION STA ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

V 9 9
WELL CONSTRUCTION RECORD -
North Carolina-Department of Environment and Natural Reso-urrcces/-Division of Water Quality-Groundwater Section
�� p
WELL CONTRACTOR(INDIVIDUAL)NAM print) �/(A6 .. CERTIFICATION#, t
VN ELL CONTRACTOR COMPANY NAMEJ�J Obwv/ " cl PHONE # (b'a GryS'3�7�
s PATE WELL CONSTRUCTION PERMIT# d� __ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
I. WELL USE (Check Applicable Box):Residential 2'Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
W ELL LOCATIO Topographic/Land setting
Nearest Town: ?, County ORidge OSlope OValley L9Flat
.3 7 - (checkap
propriate box)
Srteei\amc,Numbers,Cotonou i ,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3" OWNER: _ (degees/minutes/seconds)
Address _ P C /- `_(" 1 6 Latitude/longitude source:OGPSOTopographic map
Street or Route No.) (check box)
c ,9 9 7.2 0 DEPTH DRILLING LOG
sty or Town I state zip Code From To FOon Descri tion
_ _)-_ A /;qA
Area code-Phone number i _ �• ) / —
9. DATE DRILLED__:
`. TOTAL DEPTH:
W! 11 REPL (T Lx!'rI n!Ci to Li,.r Yrc 11 NO
7. STATIC WATER LEVEL Below Top of Casing:___L O FT.
(Use"+'-if Above Top of Casing) -
8. TOP OF CASING IS FT.Above Land Surface*
"'Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. YIELD(gm): y3l METHOD OF TEST e?�.•
10. WATER ZONES(depth): 3105I - 0
LOCATION SKETCH
11. DISINFECTION:Type_S _ Amount 2.1_4,� /Js 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 tenal I numbers and common road names.
Prom__Q.-._To.—,Z,8_.Ft. /o /t
From__- To Ft. _
From__To Ft.
13. OROUI: Depth Material Method
From. ..tb To_-Z[L Ft._ca_,..a . } _� -
From To
1 4. SCREEN: Depth Diameter Slot Size Material r'n
From.. . To__ c_�._Ft. in. in. !
From..__,__To Ft.---in. in. .. U7
i�. SAN'D/GRAVEL PACK:
Depth Size Material CD -
C 7
From..-. .---To__Ft. _
From__.
to REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS I`,RUCTI1ION STANDJAA DS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.�. 1 A p D" -- ) //-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
Nutt:Caroima-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section '/
V,IAA,C ONTRACI'OR(INDIVIDUAL)NAME (print)__ _ pC" t^ �!n 1 CERTIFICATION k3.351/
/l p
`A'EI-L CONTRACTOR COMPANY NAME l�Ve=t;rre L�.r cam_LA,�A t A �4��t�µ� PHONE 6 V f5- .7174
S I A TE WELL CONSTRUCTION PERMIT#-------L40 a __ASSOCIATED WQ PERM IT# __
Cif 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'
?. WELL LOCATION: 1 , Topographic/Land setting
Nearest`I"own: e Ery.t��E�County F- ,l r c•0 ❑Ridge ❑Slope ❑Valley �at
1 ©r y' 0A ��` (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: :1 Jr.y, W � r� c (degrees/minutes/seconds)
Address _" I :Lan`1 S _I')i I r) C'r e w h EA Latitude/longitude source:❑GPS❑Topographic map
_(Strect or Route No.) (check box)
_��n r IC a..tr i I a t=✓r" 3 a.a.1 4{ DEPTH DRILLING LOG
Ca,or Town State zip Code From To t Fo a ion Descrip ion
(- )- 38
P.na code-Phone number
4, DATEDRILLED _a_4-o5
5" TOTAL DEPTH: 19s ,
,., .•«, ., u,na i ocn( nCI: is vic'ri N(: trnn-ILL? vuc -I No
STATIC WATER LEVEL Below Top of Casing 10 FT. —"
(Use"+'if Above Top of Casing) —"--
:s. "?'OP OF CASING IS FT.Above Land Surface'
"I OF of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0115.
9- YIELD(gm): 1Q--METHOD OF TEST �rs
i0, WATER ZONES(depth): 5 1 - 1 ,0 nc __
� LOCATION SKETCH
11. DISINFECTION:Type )--�iT t-�_ Amount 33 tG, �s . Show direction and distance in miles from at least
'=. C„SING- Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weigbt/Ft. Material numbers and common road names.
From._"_To 3 8 Ft. & '1 _ ,��-t. 1,
From To Ft­—
From­—To Ft_ _
Li. GROUT: Depth Material Method
From �_To-,2(Z Ft 2,._. s .. �" _ t-
From To Ft._____ _ r-t --
C7)
11- SCREEN: Depth Diameter Slot Size Material
Farm To
From Ft. in. in.
To
-_— Ft. in, in. o
I SAND/GRAVEL PACK: ut
Depth Size Material
To Ft
From_.. To Ft.
6. 1Z[!vIARRS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONS IRRUCJTION STANI?AR�DS,,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

l6
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
'/ (,
WELL CONTRACTOR(INDIVIDUAL)NAME (printer/�n, c /J 1/1 1 ) ) _ CERTIFICATION#�.���jP�a
'A ELL CONTRACTOR COMPANY NAME Trp irk t�JroS. i.� p,� -1 Ri.Tr43�.& PHONE #
SIATF.WELL CONSTRUCTION PERMIT#_ -__ v oC ---ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
L WELL USE (Check Applicable Box):Residential P-/Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
_. WELL I OCATIO Topographic/Land setting� �
Nearest 1 oWn: v t ) ?e- Colinty���4�.��,Tlt.��y�.�'�'�'� ❑Ridge ❑Slope Walley LN'Flat
�_ E C (check appropriate box)
Litres Nal Numbers,Community,Subdivision,Lot No.,Lip Code) Latitude/longitude of well location
}, 0%NLR:_ -S 4 (degrees/minmesheconds)
Address -2 F-� t�ti.v.� �•]-„ „iV T 1 _ Latitude/longitude source:OGPSOTopographic map
(Stteet or Route Nu.) T (check box)
—1 tte > IlEt 11C —2 rSCp DEPTH DRILLING LOG
city or TJWn State zip Code From To Formation Description
Area Code-Phone number
4. DATE DRILLED S ' I S-D S 9J
5. TOT AL DEPTH: 3-a 4
a l/1Ll WELL UI:UI n/'1: I:YICI'I pil: VA 11 '1 VCl i I
7. STATIC.WATER LEVEL Below Top of Casing: /i n FT.
(Use"+'if Above Top of Casing)
ri. TOP OF CASING IS FT. Above Land Surface'
•`Top of casing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm)_ 1 S METHOD OF TEST__�_�Zrc -
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type 1-T Tom_ Amount L b-L�, } Show direction and distance in miles from at least
I,.. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth --b " S �Q� road names. 1
Pnnn�j To
Ft. Diameter or Weight/Ft. Material numbers and common -
Prmn.__---To Ft.
Flom To Ft.
13. 6ROUT: Depth Material Method -
From_ CL To_,,-1Ci_Ft. 'o ,-_
From__--_To Ft.
14, SCREEN: Depth Diameter Slot Size Material u
From __..._To---Ft. in. in. _ u1 ..'
1-rorn _To Ft._in. in. ._ to
li_ SAND/GRAVEL PACK: CA
Depth Size Material
From__
From__
16. REMARKS:
I DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C iNStII LA TION STANDA D ,AND THAT A COPY OF THIS RF. ORD HAS BEEN PROVIDED TO THE WELL OWNER
//- Zpl_d s�
SIGNATURE OF PERSON CO CTING THE WELL DATE
Sahmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
7699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resoiu­ -nivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
� (print)��`' .�IvT�--�-D-�-1L-j CERTIFICATI/�ON.. 3.!"8.2
WELL CONTRACTOR COMPANY NAME..Crf Ehe.y/- -, yt/p /� cy �e {�,I�PRONE # (Vft
STATE WELL CONSTRUCTION PERMIT# - �`t boG ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Er/Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: ` Topographic/Land setting
Near Town: - County /—l�a..tat�_)ODcL [�dge ❑Slope OValley []Flat
1 4 T I r ^ � -�-- (check appropriate box)
I Street Name,Numbers,Comm nity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ m4r m �f YI e (degrees/minutes/seconds)
Addressc-IL I µ 2 8 Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
n i 4 A.,t " I Il n T�C' �$'j�( n DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number R� " 3,05
-�
4. DATE DRILLED l (o— OS
5. TOTAL DEPTH:
r ncc ii:r_, 1s: PLAC'I: i.vlrrinu; WELL? YES D1 NO
7. STATIC WATER LEVEL Below Top of Casing: /o O FT.
(Use"+"if Above Top of Casing)
8, TOP OF CASING IS FT.Above Land Surface's
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(glint):NQ METHOD OF TEST
10. WATER ZONES(depth): 1 Lp y " — an
a—
LOCATION SKETCH
I l. DISINFECTION:Type Amount b(a 41•.I�s .Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. -
From_Q___To ga Ft.� -
From To Ft.
From To Ft. _
13. GROUT: Depth Material Method
From_Q_Tom -b FL_� r� -
From - To Ft.
14. SCREEN: Depth Diameter Slot Size Material 1 -
From Cf1 y
To Ft. in. in.
From To Ft. in. in. C3
15. SAND/GRAVEL PACK: cI'1
Depth Size Material
From_,_---To_Ft.
From____To Ft.
16. REMARKS:
I DO IIEREBY CERTIFY TiIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL _
CONSTRUCTION STAN DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- l7�/ 0 ?2 AS'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

f.. .e
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)---Ce VA tel Sr iP imo CERTIFICATION#
t
,4M-L CONTRACTOR COMPANY NAME Pd'.tlC:..- ..1-fig Well w Pil.-t.,p y J-HONE # (S � �A S�k _ 3 / 7�'
I S ATE.WELL CONSTRUCTION PERMIT#-____ /�— ASSOC�IATEDWQ P/ERMIT# _
_ _(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential ®-1-Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Nearest"own: t County [�dge ❑Slope OValley ❑Flat
RLl (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:❑GPSOTopographic map
n (Sire t or Route No.) (check box)
/A/1- . 1 r7/� DEPTH DRILLING LOG
t'rty or I own State I Zip Code From To Formation Description
'vea e Phone number
4. DATEF DRILLEDJ_/ o S
c. TOTAL DEPTH:_ &M! ' /
C11 REP! A,"! !:V!S 1 I-I nlr: WC 1 O VI:C 11 NO lmr
7. STATIC WATER LEVEL Below Top of Casing:_blFT.
(Use"+'if Above Top of Casing) - -
:�. TOP OF CASING IS_ .�FT.Above Land Surface`
,lop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 7. 7 METH9D OF TEST___� rt
10. WATER ZONES(depth)_ 2,51 _ 9.-Sr q Re"
LOCATION SKETCH
11. DISINFECTION:Type_- —T4-_ Amount VA 3L2/�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 WeighvFt. Material numbers and common road names.
From From_Q _r a ' .
___To Ft.__ _
1-rom To Ft._
i3. GROUT: Depth �t"Material Method
Frwn,._0 To_JQ—Ft.y�, � _
From__ _To Ft._ _-
14. SCRLEN: Depth Diameter Slot Size Material
From. .. _To___,_Ft. in. in.
from To Ft. in. in.
SAND/GRAVEL PACK: co
Depth Size Material Ul
-roin._....--To__—Ft.
From_ To____Ft.
.t. P17MiARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI4 15A NCAC 2C,WELL
CONSTRUCTION ST DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
W ELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION#.�2 82
WELL CONTRACTOR COMPANY NAME ., PHONE # (Zgtj,
STATE WELL CONSTRUCTION PERMIT# /Y'D-2 ASSOCIATED WQ PERMIT#
111110 (if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 9—'—Municipal/Public ❑ Industrial ❑ Agriculumil ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use-
WELL LO(ATIO Topographic/Land setting
Ncaresl"o _County_ ❑Ridge ❑Slope ❑Valley LW at
—� (check appropriate box)
i Street ftamc,Numbers,Comm\ iTy,Subdivision,Lot No.,Lip Code) Latitude/longitude of well location
3. OWNER: Q,L D—��— � (degrees/minutestseconds)
Address g1p �q a� /,pea)- Latitude/longitude source:OGPS❑Topographic map
(Street or Route No.)� ��� (check box)Its AAA— DEPTH DRILLING LOG
city or own state a -° Lip Code From To t Formation Description
t-_Area code-Phone
une number 7 '3 A
4. DATE DRILLED 8-�D -DSO
5. TOTAL DEPTH: J
iu\I_c \ll1..i.1_ Pl,:nl n('1 ):Yll'IIA \A11:I 1_) VI?t LI NO IX
7. STATIC WATER LEVEL Below Top of Casing:_.�_FT.
(Use"+"if Above Top of Casing)
N. TOP OF CASING IS _�_FT.Above Land Surface*
'Dlp of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. 1
9. YIELD(gpm):_�D0 METHOD OF TEST_e2 `jr,�_,
I0, W ATER ZONES(depth): Z4 5 - .24 .Q�... _
� — LOCATION SKETCH
11. DISINFECTION:Type J� Amount ?�.L/�< - Show direction and distance in miles from at least
I_. :.ASING: Wall Thickness two State Roads or Comfy Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Ffom______To
From To Ft. _
i 1 GROUI: Depth Material Method
From_f>__To_,QD—Ft. C n-�
From To Ft.
1 SCREEN: Depth Diameter Slot Size Material
From_ To__Ft. in. in.
From. To Ft. in. in. r t
15. SAND/GRAVEL PACK:
Depth Size Material C17
From To__Ft. _-
From_._. _To_—Ft. cr1
16. RI2MARKS:
1 DO I(EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C ONS I'Rti('�IO)S TANDA AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON C'.ONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,INC
2 7 694-➢636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section`w ell,CONTRACTOR(INDIVIDUAL)NAME (print) �DAIr!/// 1/ CERTIFICATION#.3.35` -''//
Wl:l.l.CONTRACTOR COMPANY NAME e fAe._It "�1S�yyP I J Y.�J ,*` PHONE # (87$ CV SL�317 0
S IAIEWF.LL CONSTRUCTION PERMIT#-__.__ / D..0 __ASSOCIATED WQ PERMIT# __.
(if applicable) (if applicable)
L WELL USE(Check Applicable Box):Residential tn"/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use'
2. WLLL LOCATION: Topographic/Land setting
Ned St Town: ounty t'y�ol ❑Ridge lope Walley OFlat
e (check appropriate box)
Srrcct Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
_. OWNER:_ .- �. `r��-e-_. (degrees/minuteyseconds)
AddressSU n )1 Latitude/longimde source:OGPSOTopogaphic map
^ (Sve or Raute Noj e, (check box)
( + At C fig'7 ) (e DEPTH DRILLING L,OG
(II;or Town State T Zip Code From To 1 Formation Description
Ar.:a code-phone number Q 1 S(�O s 1
4- DATE D--DRILLE __g__CL5—
�- "DOTAL DEPTH:
UI:OI"­( 1- I-VIC'11.'Ixitz \A1./I:I I9 VI;eiI NCO
7. STATIC WATER LEVEL Below Top of Casing:__#�_FT.
(Use"+"if Above Top of Casing)
e,. TOP OF CASING IS I FT.Above Land Surface*
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9" YIELD{Tin):_--:5S METHOD OF TEST_- r 5
10. WATER ZONES(depth): q P rn
LOCATION SKETCH
11. DISINFECTION: Type _}_-� Amount $S 4-),1 4s . 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
__D___To__11-_Ft. t. I1
From____
Irom__To Ft.
GROUI Depth Material Method
From_.©_To-D Ft, �'ea.,,` -�Far--,-. rJ -
._I — n
t rcml_ To Ft._",_
i4. SCREEN: Depth Diameter Slot Size Material I
Clt i=rom ----T°—._Ft. in. in. -
Fiow ._._----To__FL in. in. CD
SAND/GRAVEL PACK:
Depth Size Material -
Frum._i rom- -.To-_.Ft.
Iu_ R MARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
('ONS IRU '. ON STAN S,AND THAT A COPY OF T141S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-- ✓� G—�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nz(ural R, %sources-Di, vision of Water Q altry-Groundwater Section
'/'o
WEI.f.CONTRACTOR(INDIVIDUAL)NAN print) /Y/1/J b/�. CERTIFICATION
WELL CONTRACTOR COMPANY NAMk QR./.Q-_AiY I/ "J __Y . PHONE # &AIAy8-.3� 76
`s)'A rE WELL CONSTRUCTION PERMIT# .____ASSOCIATED WQ PERMIT#mnmm=
f if applicable) (if applicable)
.. WELL.USE (Check Applicable Box):Residential ❑ Municipal/Public Industrial ❑ Agricultural❑
Nlomtoring❑ Recovery, ❑ Heat Pump Water Injection 0 Other If Other,List Use
?. VJLLL LOCATI�57TJ
Topo,�phic/Iand setting
Nearesi�T{own: Cot ty Midge RSlope OValley OFlat
/7tL li . (check appropriate box)
}rrcef Name,Nu bers,Community,Subdivision,Lot No.,Lip Code) Latitude/longitude of well location
.3. OWNER:- (degrees/minutes/seconds)
eiddress .0 n.�a _ Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
PO )got /O/� I J . rely,)h f!7$ DEPTH DRILLING LOG
Cny or Tuwn State + zip ode From To I Formation Description
Area cede-Phone number / 7
4. DATE DRILLED -a 2 -1C)S -
T OVAL DEPTH: .?6 S J
. 1e "! S \a/1-11 REP A! hLv!CI !N(� \Ai l`I I •, Vlll I
7, STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use"+'if Above Top of Casing)
S. TOP OF CASING IS I FT.Above Land Surface'
"]op of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
v. YIELD(h'lim): METHOD OF TEST
10. W Al ER ZONES(depth):
LOCATION SKETCH
. :. D SINFI C'1'ION:Ty Amount_q Show direction and distance in miles from at least
I'. 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__Tq_-72_Ft._S f I Ss 4I 1
PromQ.--To 19 Ft. 1, eyC,
From To Ft.
13. OR UI Depth Material Method C73
From_D To_�Q Ft. 92j --- •_ �_
From To Ft.___ 1
14. SCREEN: Depth Diameter Slot Size Material Cn
From _To__Ft. in. in. _ o
From____To Ft. in. in. _ L1 '
I�. SAND/GRAVEL PACK:
Depth Size Material
From
F-rom__.. To Ft.
10. REMARKS:
I Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
(.'ONS I RUCTION STAN A DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

V J.
J. v
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural
Resources-Division of Water Quality-Groundwater Sectio,n`��ry
WELL CONTRACTOR(INDIVIDUAL)NA���IE'Ir�(prin ((JJ16 y,���// y,�,—�C.eJ�JL(i-fie... CERTIFICATTIIOON# 11 6
''A ELI,CONTRACTOR COMPANY NAMi!ti�,Q,�-;if.rQ`" Vq�� Y Ellr)l0 .\Yllf PHONE # �.Cd iKS-.3/70
SI ATE WELL CONSTRUCTION PERMIT#_. 2- _ASSOCIATED WQ—PERMIT# _
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential r Municipal/Public A Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Inlet,tion ❑ Other❑ If Other,List Use
2. WELL LOCATIO
4, 11414 Topographic Land setting
Nelare�st Town: countypRidge ❑Slope OValley Flat
—GV!1 661 e2 /S - ! I I (check appropriate box)
i Street Namcy umbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: t"'6 i J (_i� S (degrees/minutesNeconds)
Address C.� ' ('�eL-�y-� )t I�rn.���.n..,� Latitude/longitude source:OGPSOTopographic map
(Street or Rout Nu.) (check box)
PDSa1c IJa tSvrl�e , A/C 3$796 DEPTH DRILLING LOG
C'uy or Town State Zip Code From To Formation Description
,nm ctxlz-Phone number ��
. DATF DRILLED ID --a - DS Ir Z
5- -f0'fAL DEPTH: a b C 1 _ �/
REPLn(T Pviq'rinl( ta;1-IF". vl:c i�i NO ki
7 STATIC WATER LEVEL Below Top of Casing:
(Use"+^if Above Top of Casing)
X. TOP OF CASING IS FT.Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. Y1LLD(gpm): ) 0 V METHOD OF TEST_ r 5
10.WATER ZONES(depth): ,;�b K 1 - 16 >
LOCATION SKETCH -
11. DISINFI C'ITON: Type__#T{{_._ Amount-4U-_}� j�} - Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di ._-er or Weight/Ft. Material numbers and common road names. o -`
From D—Q---T°J I Ft._9 ,1_ 1 -�-ep f`1
From C_To-_ I j 1__Ft. to 11- - _.PVC,
From To Ft.__ Ln
13. CROUT: Depth Material Method O
From,. . To._a[�Ft. C o a C-n -
From To Ft.__
14. SCItIiLN: Depth Diameter Slot Size Material -"
From - To—-_Ft. in. in.
From To__Ft. in. in.
i SAND/GRAVEL PACK:
Depth Size Material
From
From
16 RFMARKS:
I DG ILLREBY CERTIFY"HIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
(.ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-2636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD VV
North Carolina-Department of Environment and NaturalResources-Division of W ter Quality-Groundwater Section
WELL.CONTRACTOR(INDIVIDUAL.)NAM print) l r� e i � _ ( CERTIFICATION#
WELL CONTRACTOR COMPANY NAME _. .PHONE If LQ
STATE K'ELL CONSTRUCTION PERMIT# WQ PERMIT#
(if applicable) (if applicable)
I. WELL,USE(Check Applicable Box):Residential Er"Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
'. `kE1.L LOCATIOI ' J Topographic/Land setting
Nearest T-own:_ Q7�__Coupe ❑Ridge ❑Slope ❑Valley 011at
—�-�' ' • `bi-, p--n j (check appropriate box)
i Jnuet Name,Numbers,Community,Subdivision,Loot No.,zip Code) Latitude/longitude of well location
.i. OWNER: S�eU a- �ara h wsr
(degreesiminmes/secunds)
\ddress 414 `1 i. )1J-1.5 Latitude/longitude source:❑GPS❑Topographic map
t ( reel or Route No.) r7 (check box)
Ad r �g 1 CD DEPTH DRILLING LOG
City a Town Stale zip Code From To Fo t n Descri tion
,•.rea code-Phone number ,3 �bS
} TOTAL DEPTH:��U b , `d' atos} y —
aLL
.J<11:�, 11�1:!.:. RPPL A('!: ):viN'r inpi WlLt i ? Yi:c L I NiO Him
7. STATIC'.WATER LEVEL Below Top of Casing: 166 FT.
(Use"+"if Above Tap of Casing) '— ------ -
8. TOP OF CASING IS_�_FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_J—Ijb_METHOD OF TEST-- __jj-r :
10. WATER ZONES(depth): 3 W ! -
CII S 149 a nr LOCATION SKETCH
i i. DISINFECTION: Type HT)-�.__ Amount_7+J��)�_ Show direction and distance in miles from at least
CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material nwnbers and common road names.
To=14—Ft. L It
Flom_-.—_To Ft.__, _
Prom__To Ft. _
;3. GROUT: Depth Material Method
From _Q__To_,,20 Ft.
— O
From -
n
,4. SCREEN: Depth Diameter Slot Size Material ( -
From_. . To Ft. in. in. _ CJ1
Fiore......__To__Ft. in. in. 0 a�A
SANDiGRAVEL PACK:
Depth Svc Material
L rom.
From_. --_To
15. REMARKS:
1 DO I IE•REBY CERTffY TI iAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C�ONS,IRUCTION ND STA R AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and/Natural Resources-Division of W ter Quality-Groundwater Section /n
WELL CONTRACTOR(INDIVIDUAL)NAM�/�lt/p�rintt)��L, ,d _ �9D/� _ CERTIFICATION#_,/QL6
3r-".`�-�'a"`_ ""_ (S/ PHONE #fa�a'��L� ..7�� '1 v Wt:LI,CONTRACTOR COMPANY NAME '
STATE WELL CONSTRUCTION PERMIT#_,._._ 1 T/16 'z __ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
l. WELL USE(Check Applicable Box): Residential B--.Municipal/Public ❑ Industrial❑ Agicultural ❑
Monitoring❑ Recovery ❑ Iteat Pump Water Injection❑ Other❑ If Other,List Use
'_. WILL LOCATION:: Topographic/Land setting
Nearest Town: l A � _County 1, "A ElRidge ❑Slope OValley BFSat
r n e �� `j_Ct ' D (check appropriate box)
t Saner Name,NunibC, o`� mmunity,Subdivision.Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: U t m F1 �s (degrees/minutesismonds)
Address —_Pp �- ' ) 05 3 A Latitude/longitude source:OGPSOTopographic map
0 (Sri for Route No.) (check box)
,ft N C DEPTH DRILLING LOG
(sty or Tow- n State zip Code From To Formation Description
x f
Area code-Phone number l -SD OS r
Aew
4. DATE DRILLED__-t0_._-_20— O
5. i OTAL DEPTH: -
n„nS ttrci i ucm mT i._vrci !N, ttnn ., vuc r I NOiy
.-
7. STATIC W ATER LEVEL Below Top of Casing:_# D_FT.
(Use"+"if Above Top of Casing)
X. TOP OF CASING IS FT.Above Land Surface`
"I op of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. YIELD(gpm): QO METHOD OF TL'ST_
10, WA I FR ZONES(depth): IDS-1 - a.o g P
�T LOCATION SKETCH
11. DISINFECTION:Type _- _ Amount_:a 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 40_. To 4R1 Ft._�o I1 _ Py _
From___ To Ft.__--- t�
rvl
From To Ft.
13, GROUT: Depth Material Method 1
From.._O__To- "L fl _Ft.--C-Q,_., -l'
CJI
From- To Fc _ O
14. SCRLPN Depth Diameter Slot Size Material -
Fiom.._ To Ft. in. in.
From, _To Ft, in. in. _
15- SAND/GRAVEL PACK:
Depth Size Material
From
From.-- _ To__.Ft.
i6. RFMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C ONSIRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD ILLS BEEN PROVIDED TO THE WELL OWNER
SI-GNA RE OF PERSON C STRUCTING 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 o Water Quality-Groundwater Section
�� ('
WELL CONTRACTOR(INDIVIDUAL)NAM' (print)( L I CERTIFICATION
WELL CONTRACTOR COMPANY NAME �.._ ! PHONE # (Vjrj a-3� 70
S I ATE WELL CONSTRUCTION PERMIT#______ �-5 Lam,(, ASSOCIATED WQ PERMIT# "
(if applicable) (if applicable)
I. WELL I)SE(Check Applicable Box):Residential 9-Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WILL LOCATION: _ Topographic/Land setting //
Nearest T own: I &__County tJooc� ❑Ridge ❑Slope Malley I tat
Kn (. kl —rn (check appropriate box)
i Srze�ame,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: CJ�t. 1 I lt !' ���� S (degrees/minutes/seconds)
Address 51<j r �„)'.a 7-r/ Latitude/longitude source:OGPSEITopographic map
(Street or Foute Nt.)I (check box)
hull 114 16�L 2,1726 DEPTH DRILLING LOG
city or awo State zip Code From To Forma .o Description
( .) _ D / .2d
Arca code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: %(p
W!11i PL.UL CI:I:YIt I Ihl(: \l/I.11O VCltI niu IY/
7. STATIC WATER LEVEL Below Top of Casing: -1b
(Use'• 'if Above Top of Casing) --
8. TOP OF CASING IS " __FT.Above Land Surface'
`Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. _
9. YIELD(gpm):--LD[7 METHOD OF TL'ST��1-S
1 O.W AI'ER ZONES(depth): l q 5 ,
LOCATION SKETCH
11. DISINFECTION_Type Tq_ Amount _ Show direction and distance in miles from at leas(
12. CASING: ' Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. Q
From D....._To /ao Ft. I1 5t Cn
— n E
From _ To Ft. t -
LYout_ To Ft. rs
13. GROUT: Depth Material Method CD
From _ ---}. ^,
..D _ To -R
_ ) Ft.
prom_._ To Ft.
14. SCRLEN: Depth Diameter Slot Size Material
From.. To___Ft. in. in.
From_ To Ft.--in- in.
IS SAND/GRAVEL PACK:
Depth Size Material
I rom____ To_ Ft.
From_. To Ft. —
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
C ONS'IRUC TTION STANDAR S, ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
UCv` A i4 1 //- IS-OS
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

�o
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /
WELL CONTRACTOR(INDIVIDUAL)NAM/f���(print)—,__" CERTIFICATION# 3.35_S•
WELL CONTRACTOR COMPANY NAME v✓e-PJ'�y� ���_�$� �s� "AL PHONE # ('JAt
STATE:WELL CONSTRUCTION PERMIT#____,/_'j .__ASSOCIATED WQ PERMITT# _
(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'
?. WELL LOCATIO Topographic/Land setting
Neare t^Town: ____Court E!6idge ❑Slope ❑Valley ❑Flat
1�r-1�Srei �' RA • (check appropriate box)
i Strcct Name,Arnhem,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3, OWNER: �YI G /� S.Y may--- (degrees/minutes/smonds)
Address 3 / ;St 2 ,, I�ta.ac Ft-C Latitude/longitude source:❑GPS❑Topographic map
(S.tr/t-et or Route N� (check box)
�+ J ;T )I C. a g 7/ n DEPTH DRILLING LOG
t'dy o,Town state / Zip Code From To FOnn tl n Desccipti n
Are,,,.de-Phone number 30— —_�D
4- DATF DRILLED_�1L) -ds
5. TOTAL DEPTH: ,f D 57i_
RLPI ACE EX!Sr!N!i WELL? Y!.:S L l NO L�✓
STATIC WATER LEVEL Below Top of Casing:—,2Q_FT.
(Use"+"if Above Top of Casing) ---'
R_ TOP OF CASING IS_�_FT.Above Land Surface"
"1'op of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011 S.
9" YIELD(b'Pm):2Q—METHOD OF TEST__
IO. WATER ZONES(depth): I - aIts
---�-� LOCATION SKETC
I I. DISINFECT-ION:Type N�r�.-d _ Amount q.,2 " 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. Materi.IE numbers and common road names.
From Q To �t', Ft. L r r
Frwn___ To Ft. ` a
From To -Ft._ - CD
13. GROUT': Depth Material fTt
Method n
From. _Q__To_ZkQ_Ft.
From_ To_—Ft. — U7
14- SCREEN: Depth Diameter Slot Size Material o
From" To_.__FL in. in. `
i-rom___To_._Ft. in. in. --
1 SAND!GRAVEL PACK:
Depth Size Material -
Front—
From__ __To__—Ft"
16. REMARKS:
i DO III-REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
ON SIRU �NDARD A -D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TFIE WELL OWNER
SIGNATURE OF PERSON CONSSING 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
.:;n Ili „ina - Department of Environment and Natural Resources- Division of Water Quality -Groundwater Section
..r...:.t ON kA(:TOR(INDIViDLAL)NAME (print) �r �' � �
/� !� ._ cERrIPICAr1oN# 335'�
'•....�.:0>"i kA(�fOR COMPANY'NAME
.j,ZCC'.C.rtC -_ _r0�_.[�y�� y -Y'/ ---
S- klt. sl ELLCONSfRUCT10N PERMIT#____ /y/O,Q, b T�PHONE XUM(� '/$-3/7/
I it applicable) --- —ASSOCIATED WQ PERMIT#
-- (if ambesble)
CSb(Check Applicable Box): Residential W- MunicipallPublic ❑ Industrial ❑ Agricultural ❑
.,s;101`115c ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
. :.0( 4-nol�;t
�,. `I y�,� Topographic/Land setting
e C'ounry- �
`ct iY r� p /v �`� ❑Ridge []Slope ❑Valley [21%t
r� �.ris- .umbers,Community, (check appropriate box)
Subd,lislo�n,LutyNoo, Zip C.-oder Latitude/longitude of well location
-
,.:urc.• -- (depees/minutes%secorMs)
--� �or Latitude/longitude sourne:OGPS❑Topographic map
I Suxi or Raum No.r
'2 8 7� DEPTH (check box)
1." s am zip et de DRILLINGt OC
_ From To / Fo ion Desc 'ption
cumber
�i. DEPTH:_—/
I.
it WATER LEVEL Below Top of Casing- FT.
Gse if Above Top of C'ssing)
CASING IS _FT. Above Land Surface*t up of casing termloated aVor belOw land surface requires a
'ar:ance in A-ma dance with 15A NCAC 2C.01IS.
"Li'D 1 gpm): -- ) METHOD OF TEST__,_._
70NES(depth): / -Y
r.�i7.riCI ION: Type /�T� Am LOCATION SKETCH
_ Amount 33 +{,/+ Show direction and distance in miles from at least
1 Depth Wall Thickness two State Roads or County Roads. Include the road
Diameter or Weight Ft. Material numbers and common road names.
,,, ---- rO _FL -
„iri To
- _ Ft.
To Depth� _ FL Mete __.._Method C:: _..
- To Ft .__ rV .
Depth P Diameter Slot Size Materiel �
f O _.. in. --.
' TO Ft. ---- ' `. r•- r r p�(�-1l �
_—_in. --- in.
i :,kA\El- PACK:
Depth
-. Ft._ -- - SEP 16
r�--_ Ft.
i;.rccts i f hkTIFY THAT THIS WELL WAS C'ONSTRUC"IhD IN ACCORDANCE WITH ISA NCAC 2C,WELL
;().',STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
L/ I
-- --- __SIGN:ITURE OF PERSON C'ONSTR GCTING THE WELL � ' /� _ Gj
DATE
.lunmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
:-6Y9-I6,46 Phone Np.[phone],within 30 days.
GW-I REV.07,2001

ao
WELL CONSTRUCTION RECORD ' - Et `"
I ( -Department of Ens,'ironment and Natural Resources- DMsion of Water Quality-Groundwater Section
"I I i (ON I R 1("IOR(INDI\-IDI %L)N:UIF. (prior)_.' Li J_0 _ 11 11
//'' y �N CER'I"IFIC4TION#_,�35 Y
R(.Lt (ON'I R.\( MR CONIPANI'NAME L.lre-- )�_ `J CS__._ e l.-i, ,' \✓fit _ ___ PHONE #
Ni a ll. sl F.LI.1 ONS IROC HON PERMI T# _ \.y_Q_�____-._ __;4SSOC IATED 44'(j PERDU"I#
(it applicable) (if applicable) -- -- -- _------- -
UIJ-I-LSl-:(( heck Applicable Box): Residential lia�MunicipaVPublic ❑ Industrial ❑ Agricultural ❑
\innunring ❑ Recovers ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
VAl-.I-1. 1.(A ATION: ---
4„rc,; 11ncn. OrtL Y f N _ County I fnpographiciLand setting
❑Ridge @Slope ❑Valley ❑Flat
, ':nnu N(lbicers.(nmmumn.5nbdiruion.lnt r`o_7,tp Cudel (check appropriate 1N,)
Latitude longitude of well location
alt.rcu --- Ide4rees minutes seconds)
- t-Z -.__ _ Latitude.longitude source:❑GPS❑Topographic map
I street or Rowe Nn.I
v e l t o NI -- of DEPTH (check bar)
' D ..... state /,I,( xle DRILLING 1.06
i_ From To Formation Description
1)V I 1 DRB
r)I:\I
. a'.� : utrn ,r i. i.vl. lin r, tt �.; i �'i el,i Ott p✓
' tiT fl( \4A IER LEVEL. Below Top of Casing: —
Q—_FT.
Ilnc"_'ii Ahrn'e Top of('aany)
T(:P of CASING IS FT. Above Land Surface'
'7rgt ofcasing terminated a✓or beloe land surface requires a
,zriance in accordance with 15A NCAC 2C.0118. --
). Y(h:LD (gpm): A�_ METHOD OF Tf_ST�11t'j - ---
'ILA4.ATER /ON'ES(depth):
DISINF6("IION: Tv pc -�� LOCATION SKETCH
Pam_-�__ Amount _ Show direction and distance in miles from at least
Nall Thickness two State Roads or County Roads. Include the road
Depth Diameter ur Weight Ft /mau rial numbers and common road names.
I-nnn. �. To 'Ill, o _ Ft.
To_ Ft. -�-
I-tr,n'--- --- To_—Ft,---
Depth �latcrial MethodImin �__ FOA0 _FT_`{�,y }
To -- .
C
,. Sl kFIIN Depth Dtamctcr Slot flue _--,11aterial rV
Fri
UIoFC___ in. in.
Fnnr. To Ft. —in __ __— CD m. Cfl -
(iRAblll- PACK: -_
Depth SIZC Material
r,nn _To__- I-I.
To- _ Pt.
t r(I EkFlil ( F.RIIFY THATTHIS \:ELL1A1 S CONSIR UCL ED I N A( OR DANCE W'I I I I I-S1 NCAC 2C W'ELL
11)Atilitl ( I ION SIANDARDS. AND THAT ACUPVOF MIS RF(.'ORD HAS BEEN PROA IDEU TO TfIE WELL OWNER
SIC,N:A-ITR@ OF ( SIR IE TING FHL N FLL -
DAIF
auhmit the original to the Division of N'ater Quality,�,
�round.vater Section, 1636 Mail Service Center-Raleigh,NC
2709-I06 Phone No.(919)733:i221,within 30 days. 1 -
SEP 2 0 2005 GW-I REV. ozzoos

WELL CONSTRUCTION RECORD '!
Department of Lm ironment and Natural Resource,- Division of Water Quality-Groundwater Section
'sit ' rUV"tRl( 7pRO"MN-IDt %L)AAME (print),
s cF:R rIF Ic.4noN u_
sr.I.! rONIR.%( I OR(O%l P.s�., .NA�NE a�IIJ 1fCe le t�Jrin PHOSE tt jlDti14-� 1 i0�Y.VLss F.L(it p1Scahl )RUCTION PERISIIT# -� G�. -- __ ASSOCIAfEDW'QPE.RJII'f4
(if applicable) -
01'apillicable) -
\% f.1 1. I;SE,K heck Applicable Box): Residential B�Municipal'Public ❑ Industrial ❑ Agricultural ❑
llonw)ring ❑ Rceoven- ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Usc
f (A AT ION
:
'warc;r 'T„srn: Topographic/Land setting
- ✓�—� ._ County
- ._- lyn6 N 7r ❑Ridge ❑Slope ❑Vanev &PILL
-u �wnb rs.(ommmntc.subdn'ivon.Lit 50../ip( nlcl (check appropriate box)
LattudC longitude of well location
k (decrees minutes seconds)
-C_ 'T' Latitude longitude source:❑GPS❑Topographic map
Sint or Route No i ._..
L�(ty E t �� 1��D (check hox)
.t..e o„n state DEPTH DRILLING LOG
zip G,dc From
�. ° Formation Description
"i f) II IIRILi.fD `1'�lf-Q_'� l� esl _
— —
ti R LLVFL Bclow Top of Casing: _�_._FT.
t Gee"='if Ahosc Top of(';ssingl --
r)P OF CASING IS_ FT. Abose Land Surface' ----- -- --_—___---
--"'fnp of cosine terminated at/or beloss land surface reyuires a --
s ariance in accordance with 15A NC:\C 2C.(11 IN. --
''. 1";1 LD (gpm)_—U— ;METHOD OF TEST_�_h
4. 1\:A7LR /ONES(depth)- _ 01�, —
_ f)IS1AFL("TION: Tvpc LOCATION- -�I�_- Show direction and distance in miles from at least
Wall"Fhicknc,, two State Roads or County Roads. Include the road
To Di Wallameter or Weight F t. Alarcrizl numbers and common road names.
nn _ o L
Ft.
( l UI:Il Depth Material ---- -s
Fri m Method
Depth Diameter ---- on
Slot Size viatcnal
Ih in .. TcL Ft. -
Fn n - _.
- To___. Ft- -
- ----in. Q1
- m.
Depth SVeMaterial
Inml To _ Pt.
I Inm To,_ - Et
1<I V:Aithh -
bS ( I:RIIFt THAT THIS NFI.I. ABAS CONSIRU(CTED IN,I000RD.ANCE N'ITH 1 1NCAC 2C,WEI_I.
is ( t101.STAND.ARDS. AND I HA I N C"OPY OF THIS RECORD I IAS BEEN PROA'IDED TO THE R'ELL ONTFR
C1tYPv S ----- Y '� 5 o
SIGs";A1[,REOF " )N CONSIBUCTINti TI1G "ELL
_UAi"E
'Submit the original to the DiPi5iOn of Rater Qualit Groundealer Section,1636;Mail Sersice Center-Raleigh,NC
27699-I636 Phone No.[phone].within 30 dasa.
GW-I REV.072001

WELL CONSTRUCTION RECORD Re
'%,.n!I ( andiva- Department of Enaironment andd Natural sources- Division of W"ater Quality-Groundwater Section
R F.I A r ON-f RA(,IOR(IN,DIA IDIi%L)NAN4- fPrinn. ?C,V - �v &-u
t\EII rUN-IR:\("IORCONIP NJ \\]IF, 01 rc.�rC � 4, -- (.f.RTI FI #,
-- Pam_ -- IONF. # (p.9))
t n+at�y_
6'I Ai F. Nf.1.L COSSTRUCTIO\PEKDII'r# \y Ca � �--
PI
(if applicable) - - - ASS(1CIATEDN'QPF:RMI'r#
(If applicable)
\O III.I. I;SL(Check Applicable Box): Residential LR�Municipal'Public ❑ Industrial ❑ Agricultural ❑
\Lntlwring ❑ Recover}• ❑ Heat Pump Water Injection ❑ Other ❑ IfOther, List Use
lV I I in ATION:
`\,.eR,l Totsn. �IVTCWI ount Topographic/Land setting
Cy U e❑Rid E ❑Slope ❑Valley C3FI'at
I:ne. '�u nhcrs,CI mums ......
P m. Litt Ao..Zip Cade) IcLecA appropriate boxt
Latitude longitude of well location
- Ilecrees.minutes seconds)
1 d(1fC 1, _ ---
-�—� o 611 r'r -- ---- Latitude longitude source OGPS OTopograph is map
(t 1 IStrcd or Runic�n t _-
q C aX1 1 (chock boil
DEPTH DRILLING LOG
I) I 1 I DRII ., via: Zip t ode Prom To
( r Formation Description
11 .,. Fb�m�run her --- y9 _
I LD—�-1'1----
1 1I
S 1T1( N'A I ER LEVEL Below Top of Casing: --c�1 FT, --
II-,c•' if Above Topot(Cdsmel
TUP OF CASING IS_ 1 FT. Above Land Surface*
-'(rip of casing terminated at/or beluss land surface requires a -
.ariance in accordance with I5A NC:\C 2C.nl IR. — _--- -- -- -- -_
}"II,LU IgPInF _kL METHOD OF TEST --
b W FIR ZONES(depth) O ` 3
\ - 1,0(Al[ON SKETCH I)ISIKPh( TION:Tvpe_ } mount_ Show direction and distance in miles from at least
Wall Thickness Mo State Roads or County Roads. Include the road
Depths e,J Diameter or Weight Ft. taterIoI numbers and common road names.
!-rl,m- 0 lb—L _ Ft.
i To Ft, —_—
P-;In; To -
Fr.
Depth Fr Material Method
om L7 '-
FrIIm _- Io- "J-- Material
. .
I Ft
.. Yt It' ilti —_—. _.—._ -._ -.—_ C
Ucpch Dlalo'ICr .Slot Siie h l . .
i-ann latcnal
-- To _ _ Ft.- -in. --_ rV
Tit Ft. in. In
___. - In. ---
5:1,AD (IR VVf L PACK: - -- --. O
Depth Svc. UT • -
V1atcrial —
I-rim. _To Pt.
nn
R1.A1ARK1,
ul I IFkE Hl-( I:R I IFY TIIAT THIS VA Fl.l_ N AS CONSI RL(-ILD IN AC(ORDANCF WITII I sA NCAC'2(',AVELL
RUN S7 4NDARDS. AtiD it L'1T.A DOPY C)F [III,, Ru ORD H,AS BEEN PROAIDFD 10 THE WELL ON-KER
SI(IN:1l—[ RE OI-PERSON (ONSIR " ING THE:W-ELL
DATE
Submit the original to the Division of N\aler Quality.Groundwater Section, 1636.Nlail Semice Center-Raleigh,NC
_7699-1636 Phone No.[phone], within 30 days.
OW-1 REV.07;2001

WELL CONSTRUCTION RECORD
. ren ( en,i:na - Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
.Ni; C ON'I RAC FOR(INDIVIDUAL)NAME (Print)__-HDq
r � � 3� - -
�C l)a I( CERTIFICATION q 3357
O VIICAC FOR COMPANY NAME�.G n� ---
ht r.�....Lt�^Dp a! /� �1 �Lt PHONE # 7�B �1 "
x t r tt,L CONSTRUCTION PERMIT#_
(if applicable) --�---- —ASSOCIATED WQ PERMIT#
-- (if applicable) —
�-i.i.L (,SF. (Check Applicable Box): Residential 13�i Iunicipal,Public ❑ Industrial ❑ Agricultural ❑
•d,nnr,ring. ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
a -.,.:. !.O(. .ANON:
<arcst'If/own- County 'YjCL TOpographic/Land setting
ttil.JnPt t p --- '— ❑Ridge ❑Slope ❑Valley RKat
`s^ w�cers,t.ommum (check appropriate box)
rr.SubdMsion,Lot No.,zip code( Latitude/longitude of well location
j,r�••. , e!eY Idegrcevminurev"ee Ids)
(Street or Route No) - — Latitude longitude source:❑GPS❑Topographic trap
(check box)
i• w State LIp(o.1e DEPTH DRILLING LOG
Fro/m� To Forma ion Description
..iac Ph.mc number
u., i. URII_LED_ 7-/9 -b J?A ' .3lx
- _ .i.of ter(. t.Yi�� in.�; �A„i.) i �)-� �( n.t� (�✓
I It W ATER LEVEL Below Top of Casing. , 6 FT.
t Lne"*' if Above Top of Casing) ------- -
CASING IS 1 FT. Above Land Surface- --- _7 op of casing terounated avor bebw land surface requires a
unance in accordance with 15A NCAC 2C.011g.
: 11-1-0 (,,pm): 45_ METHOD OF TEST_ - ---- - --
F Ek ZONES(depth):__ $5 — ---
%I`•I^;1-Ll."1ION Type_ / LOCATION SKETCH
Amount 54 -_4-//4:s . Show direction and distance in miles from at least
\1 r• Depth Wall Thickness two State Roads or County Roads.Include the road
h "( Diameter or"eight i Ft. Material numbers and common road names.
Ib�- Ft. _ ofPtl� :S
— -nnr To_ Ft. ---'-_--- A
Depth -- —___—. .. _. �
lJ To_.Q l;t, Matµri aerial 1 Method N n•m — L
Ft
ki-.i. Depth Diameter _ O
Slot Size Material CJl '
To Ft. --- _
erkAVIA,PACK —e to in.
Depth Sve Material
... Fo-- Ft.
To_____ Ft ------- _._.
Fir\I :.Kn�
t.Ek TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,W'ELL
K(.t !IU:h N-LAUDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA IURE OF PERSON CONSTRUCTING THE WELL
5unmit the original to the Division Of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
'b99-IG36 Phone No.[phone].within 30 days.
GW-1 REV.07,2001

W"
WELL CONSTRUCTION RECORD
tin. t arwtna - Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
ON'I RAC TOR(INDIVIDLAL)NAME (print)-_-
/' p - CERTIFICATION a 335'/
`.c.. .:GN'f i(AC'1'UR COMPANY NAME bTr t3.hc 9)O�._-.(�j+1J�
PHONE N
?.afE lYELL f applicable) ON PERMI'rp_____ /��� -
i If applicable) -------ASSOCIATED WQ PERMIT#
(if applicable)
SE (Check Applicable Box): Residential 2' MunicipaL'Public ❑ Industrial ❑ Agricultural ❑
r,u„r;ng ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
nO
County _) Topographicd and setting
_p "� [3ftidge ❑Slope ❑Valley ❑Flat
`= umben.Community,Subdivision,Lot No-Zip( (check appropriate box)
Latitude,longitude of well location
.'�'���'" Q —O- Idegrees/mintttesiseconds)
is re•t or Route No,j -�--Z—. Latitude,'longitude source:❑GPS❑Topographic map
ILA�G �C I. (check box)
SWe -- 9 DEPTH DRILLING LOG
Lip code From To
S� / Forman n Description
. -JKI LE-D 6 -2 3 -
- DEPTH: _qp�r -
. ! �!'P;..�.:'l. !-X!. in t.. fit,
i 1, WATER LEVEL Below Top of Casing: ``L n
---�D FT.
if Above Top of Casing)CASING IS -----___
-I op of canto to land
s Above Land Surface• -----_—.__
g chit,, ed a 15 NC (sad surface requires a —�—
•anance in accordance witY 15A NCAC 2C.Ol 16. ---_-------'
I1_t_D (gpm): --447 METHOD OF TEST --_--
',i �T f.R ZONES(depth):
nir.rtC 1 ION: Type rFTs/ Am LOCATION SKETCH
ount S�f /J � Show direction and distance in miles from at least
Depth
Wall Thickness two State Roads or County Roads. Include the road
Diameter or Weight i Ft. N1,denal numbers and common road names.
"ro Sz FL 6•l
-. . To _Ft.
To
.G Depth Method n
iO-s?'Q._ l-t_�, . _ C
Depth
P Diame U1
ter Slot Sias :Ytaterial � -
To_ Ft.
_ _._--in in. Ln
To
Ln
El, PACK _ —
Depth Sac
- To Material
--._ Ft.
To-_.—_- F[.
ER TIFY 1NAI 1"HIS W ELL WAS C'ON STRUCTED IN ACCORDANCE WITH 15A NC-AC 2C,WELL
i f0n STANDA SAND TI iAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN'A IURE OF PERSON 'ONST UCTING THE WELL g iy -c S
�uondt the original to the Division of Water DATE
c 6"-L6.16 Phone No.[phone],within 30�days.th Groundwater Section,1.636 Mail Service Center-
_. Raleigh,NC
GW-I REV.07;'2001

WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources-Division of Water Quality -Groundwater Section
.. . ( UNiR,%( I OR(1NDIVIDUAL)NAM/E� (prioq__�)-C�_q� _�.}(L 1 __ CERTIFICATION# .34yI
. . r : ONikA("FORCOMPANY NAMEi Treelle /.3rolao-: IMP ( �1 A�,-,.�� r t PHONE #j44t_y�5 3! 7 c.
.. \i t. At-'I.CONSTRUCTION FERMI]# ,_-__. ._ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) ------ --
.� l. is Si: iCheck Applicable Box): Residential e-/Municipal./Public ❑ Industrial ❑ Agricultural❑
♦I.rrnwnng ❑ Recovery ❑ [feat Pump Water Injection ❑ Other❑ if Other,List Use
t'. I_. . Ui ATION:
_County wbod Topographic/Land setting
t)l� P ❑Ridge Cil<ope Malley ❑Flat
., , ".umbers,Commumrv,Subdivision,Lui No..lip(rurel (check appropriate box)
Latitude/longitude of well location
-PC) _ J�rr 4's'-`n-C— (degreevmuutevseconds)
-Street Latitude/longitude source:❑GPS❑Topographic map
n ( ur Routc�'u.i - --
Tl Q. �' 1 (check box)
DEPTH
wi Suit DRILLING LOG
Zip(ode o From T -
Formation Description
1'11u11c number
;i DEPTH.
. Vi.pl ♦ 'L 1.\ i Ilnr. (blll " t-I.Cil 1r1
it W ATER LEVEL Below Top of Casing: 2r_FT.
((ae"""if Above Top or Cssing)
ASING IS_�FT. Above Land Surface'
7 up ul cusmg terminated stYor below land surface requires a
ariancc in accordance with ISA NCAC 2C.011R.
I F.I1) gpm): ;' Q__METHOD OF TEST__ rS —
',; k ZONES(depth)
l;r♦i'sh�Cl ION: Tyre 2.-/Tfi/ LOCATI��i
?.mount-.J3_ Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight Fr Matenal numbers and common road names.
---Ft._
Depth Material ---- --_ C
fo
Method n
_-�'O Ft._ ry is
_ Fr._ ---- _. .- Cil
fo __
Depth Diamctur Slot Size Material 0
10__ FL _in. - cn
. ,. Tb _ Ft. is ----
..; 1,k4\i7. PACK - tn. _ -
Depth Svc Material
To _ Ft.
—_---
I�RHFY THAT"THIS WELL WAS CON STRUCTED IN ACCORDANCE WITH 15A NCAC'2C,WELL
`TANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE HELL OWNER
IGNA LURE OF PERSON C-O S
fRUCTING THE WELL------- —'—
DATE
Sufmin the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
-69v-I I,s6 Phone No.[phone],within 30 days.
GW-1 REV. 07;2001

WELL CONSTRUCTION RECORD
..:-:n t an,lung - Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
n..._. ( O\'I RAC:FOR(INDIVIDUAL)NAME (priat)-f-4 r/GS KDA,.. __ CERTIFICATION# ? /�
....... ; ON I kACTOROOMPANI NAMEf—iec-ne 6rq;;._.!zlOA v_Q, .PHONE # J?g'GS/& 2-
' / a
r.Yt t:Ns EI,L CO.NSfRUCfION PERMI"f#____ /y Q� --,- ASSOCIATED WQ PERMIT#
;if applicable) (if applicable)
(Check Applicable Box): Residential @"—Municipal/Public ❑ Industrial ❑ Agricultural ❑
+1 >01[nnng G Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
I.0( .- T10N: /
c,: (own �. (/n /' C'ounry R 6 uo��( Topographic/Land setting
�F r Fti t `� ❑Ridge ❑Slope ❑Valley 17i
-' an�. '.umbers.Comm ity,Subdiriswn.Wr No.,Lip Codci (check appropriate box)
� JJ Latitude/longitude of well location
It ---- --
,;\. 1.. _._�_� !� (&Weesminuiesisecorids)
-__-__ Latitude/longitude source:❑GPS❑Topographic map
(:tract or Route Ko.1 (check box)
�1I'e- c..Qdo r Ale •�g7Sl DEPTH
p I s� `T7 DRILLING LOG
Lip c\air From To Formation Description
r
: ' I UI.DI +/"1. 1. 41♦ I In 1 \A 1.1 I
DEPTH-
'I, WATER LEVEL Below Top of Casing: Sy FT.
IL,s -+'if Above TopofCasing)
41" CASING IS_1 FT. Above Land Surface*
"S op of caamg terminated Nor below laud surface requires a ----
'seance in acrordautt� th ISA NCAC 2C.0118.
(6'Pm)' J 1 METHOD OF TEST ���
ZO.NES(depth): _ __
LOCATION 5KETCH
!ION: Tvpe /-1 T /-/ Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight,Ft. .Materials numbers and common road names.
I Ft.
TO—Ft, rl
To— FT
Depth Material - - C
Method L7
U r o_-'Q._ Ft v` ' _. N
'- Depth Diameter Slot Size hlatenal O
r.x;. Io Ft. in. in. (n
To _ Ft. in. in.
.
EL PACK
Depth Ize Material
To—_ Ft.
. . ... To------Ft. ------------
ER TIFY THA'1 "THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
1O, S IA, D✓AR,DS,AND THAT.A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SItiN:1TURE OF PERSON CONSTRUCTING THE WELL
DATE
�unmit toe original to the Division Of Water Quality, Groundwater Section,1636 Mail Service Center-Raleigh,NC
"Ytvs-i G36 Phone No.[phone],within 30 days.
GW-] REV. 072001

WELL CONSTRUCTION RECORD
wa - Department of Environment and ral Resources- Division of Water Quality-Groundwater Section
..c:.;.i ON I ILx("IOR(INDIVIDUAL)NAME+ (print)-__t+�I—�i'r[,,���_2 _�( CERTIFICATION a 33 6 S�
. a..l.a UN fkA('TUR COMPANI NAMEr4_tir�' ____rg -� a/ .y p _r r • PHONE p
E t/ELL CONSTRUCTION PERM11a 12_-_--__ASSOCIATED WQ PERMIIT#
;if applicable) (if applicable)
i:Sli (Check Applicable Box): Residential l3'Municipal,Tublie ❑ Industrial ❑ Agricultural ❑
�1„o�tunng ❑ Recovery ❑ Heat PUMP Water Injection ❑ Other❑ If Other,List Use _
(A A"FION:
n"v% Topographic/Land setting
v Counry 4 ❑Ridge BSlope ❑Valley ❑Flat
I (check appropriate hox)
+ern 'wmoers,Commump.SuWlriaon.Lut No_lip C'odrl Latitude/longitude of well location
kdegrec,m
Latimde/longitude source❑GPS❑T
Streetopographic map
or Ro N. l (check box)
C 7 / DEPTH DRILLING LOG
Sun, Lip Codr From TO
/ Formation Description
—
r ;)R1LLE-D .2:2 _- 64/
It WATER LEVEL Belor Top of Casing:
'CYO -FT.
ILse"*`if Above Top ofCsSinp)
V Ut" CASING IS FT. Above Land Surface'
!op u1 casing terolimted avor tie1ow land surface requires a
vnance in accordant with ISA NCAC 2C.01IS.
1)igpm): 31�METHOD OF TEST a h rs -
o 4? i�R /ONES(depth):
r LCT ION: Type— LOCATION SKETCH
Amount !SS + I{.5 . Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight,Ft. Material numbers and common road names.
To� Ft. . !a +' PVC
C
To Ft. ---
To— Ft
` Depth
p Material Method
Depth Uiamcter Slot Size Material N
to--- F1.-.__. in. _— in. UI - :
„u
10. Ft
(,rc til. PACK -- —... -- �
Depth S¢e Material -
To
- K; VIiK1�
i:k IIFY THAI I"HIS W ELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC''-C,WELL
t,L t it))ti I4NUA -4NU THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O}PERSON C'ON'STRUc-r THE WELL --
__ DATE
>uotnit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
_-69'1-i 636 Phone No.[phone],within 30 days. -
GW-] REV, 072001

WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
.•i'.,-i.< O�I RA("FOR(INDIVIDUAL)NAME (print) ( ,-
CERTIFICATION
•+r.,.i ( UVTkaC'fOR COMPANY NAME �E(� �F,2�_-/�• DI d 4rhn T PH �o
ONE # .� 3/
sLa TE t{ELLCONsiRUClION PERMIT#__1y�6:1
(if applicable) _---_ASSOCIATED WQPERMIT#
_
�_
1`au (if applicable)
f1.i- I;SE (Check Applicable Box): Residential M nicipalipublic ❑ Industrial ❑ Agricultural ❑
.1„nn„r:ng❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
(A -%TION:
u-n C'oun Topographic/Land setting
-�J{la� 1 �l cat-- �l p
ry s 'k ❑Ridge 121ope ❑Valley ❑Flat
• canners,(om nlxh uy,��hdwuwn,luWo..Lip CWei (chock approprule box)
Latitudei longitude of well location
k � ���[ -a
.:a rc t• Lp �p__f. J — (de�eevminutevsecondt) —
(street or Route N',., � '�-�'--- Latitude/longitude sour'ce:OGPS❑Topographic map
FL (check box)
sate�— 3 0 g DEPTH DRILLING LOG
Lip t«ie From To
__ _.. r Formati n Description
-„-
- . ,
a i.�l. DEPTH: 5 r _- t --
WATER LEVEL Below Top of Casing: a 00 FT.
Lse"-'-if Above Top of Casing) --�---_
'm (,t CASING IS __FT. AbovSurface --
'1 op ul casing terminated&Vor a Land ' ---___
+Honer in accordiii with ISA6NCAC SC.O1Ia.e regaves a
,11.1.0 fgpm): _1 L METHOD OF TEST_ /•r S --
'.� FP ZONES(depth): —. &o.S , _ r
,I�iSte< 110N. hype LOCATION SKETCH
---E� Amount i) SKETCH Show direction and distance inmiles from at least
�I�( Depth Wall Thickness two State Roads or County Roads. Include the road
Diameter or W'eight>Ft. Material num
bers and common road names.
d To_ s- Ft. ..(p it AVC
—Ft,— ---- ------
! o.rr To ---
Depth .Material - -- CZ
CJ To `n--y.ateria-I'r—,L� Method r--
_L�n .7
b.i Depth Diameter
Slot Ft. Size Material
- TO--- Ft. ..._—.in - in. ----- ut
-. •i; ',k,;l'EL PACK' --_m" In,
Depth Svc Material -
_ To__ . FT
., _To_—. Ft--- -- --
i i-.h f;p, t.ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH/} 15A NCAC
+� 41_t :kv% STAN, DARDS,:'1ND THAT.A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER C',WELL
SIGNATURE OF PESON CONSTRUCTING THE WELL —
--DATE--._..--
>ubmit ehe original to the Division of VI'ater Quality, Groundwater Section, 1Q36 Mail.Service Center-69Y-16:+6 Phone,Np.[phone],within 30 days. Raleigh,NC
GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
( .o dma - Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
f IrA,i (IN"I RA('[OR(INDIVIDUAL)NAME (print) q
CERTIFICATION a,�I i
UN'I IAA( IOR COMPA\)'NAME_�Ivl \,L l ,p)tQl� PHONE 8 is l I1C)
�l
e IN P.Lf,CONS'rRUCT1ON PERM]"fd 1\!A_ -- . ._ASSOCIATED WQ PERMI'fp
f if applicable) - - (if applicable)
.:--.i.L CSf. (Check Applicable Box): Residential 131'�Municipal;'Public ❑ Industrial ❑ Agricultural ❑
.iomwnn,+ ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
fit -a FION:
r t I l/v:n:_�ruv n N� Count41,p
Topo� jope Land setting
yW� ""` ❑Ridge ❑Slope ❑Valley B'�at
G�.�-) ]✓l- (check appropriate bon)
,umbe Commune S Wivision.Lot No.. Cr I
Latitude.-longitude of well location
_- -_— -O---is- (degrees minutevseconds)-.1 . l Latitude/longitude source:
pographic map(Strcxt or RoueSo _ (check;t DEPTH DRILLING LOG
/Ip("`le From To Formation Description
----
'e
. ; f l( WATER LEVEL Below Top of Casing: 10 FT.
if Above Top of Casing)
5 tit' (�: CASING IS ___FT. Above Land Surfaces
-I up of casing terminated at/or below land surface requires a
anance in accordance with 15A NCAC 2C.0118.
iII.LD IgPm) - ) METHOD OF TEST ---- --_-----
A =, f f�P ZONES(de th " ���-- ------
LC"I ION. T%pe— LOCATION SKETCH
Amount - _ _ Show direction and distance in miles from at least
W'af Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight.FE, Material numbers and common road names.
C To `�Q---- Ft. `o_`- -- —P_Y.O _ ...
To--Ft. —.
To P't_ ------ GCj
Depth Materiel _. . _ IV
Method Cil
:( ki I `. Depth Diameter —� — Ul
Slot Size Material
lb _ Ft. in. -
inui. To Ft -. in.
--- .
-- m.
Vfi1.PACK: --_
Depth Svc Material
fo
—_ Ft.
--- -
To -----
t R HFY THAT THIS\4ELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
...... P ( IUN S I ANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
14I6h,1T1.IRL OF P SON C'ON *1 RUCTIN(I THE WELL --- --
DATE
�ubnlii the original to the Division of Hater Quality',Groundwater Section, 1636 Mail Service Center-Raleigh,NC
699-i 636 Phone No.[phone].within 30 days.
_ Gw-1 REV. ozlzool

WELL CONSTRUCTION RECORD
a„-ima - Department of Environment and Natural
Resources- Division of Water Quality-Groundwater Section
'.+i.LL( ON'I RAC FOR(INDIVIDUAL)NAME (print) —y
CERTIFICATION
l.Lt.i.( )\'fRA<"1(1R COMPANYNAME_,,_f1,1.Q__C,y.1. '.]y'�(�S�j.,.�Q �1" t. y_ztlf\' -.PHONE adJ q3-3110
b I )-f L w ELL COSS'1'RUCf1ON PERM)I#-_1 l it applicable) yQ�._. ASSOCIATEDIATED WQ PERMIT#
- — -_
(if applicable)
(;SF. I Check Applicable Box): Residential S-�Nlunicipal,'Public ❑ Industrial ❑ Agricultural❑
`•i„nn„n rig ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
aT ION:
w V Topographic/Land setting
--AL.L-?__k-W—_County ❑Ridge OSlope ❑Valley ❑Flat
)check appropriate box)
.e .um xrsf Commumn Subd:oa,on.Lot No,/,p Coder -
Lahtude.10ngitude of well location
(degrees.mmut<s saonds)
Iz'ci-_- Latitude,longitude source:❑GPS❑Topographic map
1 Strtttur How r , :
)check box)
DEPTH DRILLING LOG
Lipl W. From To
Formation Description
._ .,uc Prna,c number
I; I i)RILLED LIl-�3
RATER LEVEL Below Top of Casing: - CLi _ - FT.
,lac'� it Above Top of(aning)
01 CASING IS FT. Above Land Surface-
top of casing terminated avor beluu land surface requires a -
.anance in accordance with 15A NCAC 2C.0118. _
/ S 11,I.D(gpml: .�L - METHOD OF TEST_
✓, .;f f_k /ONES(depth):-tea --- - ------
I II�Ia:Fi.CT10s, Type LOCATION KETCH
P AA Amount _ _ Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight:Ft, Material numbers and common road names.
-10-51�)-_ Fl, -�v'
------
Fo F.t -- - - - ---
Depth-Material Method
t To_ Ft. -
Ki 1.' . Depth Diameter Slot Size Material '
__- _ Ft._.. --_III.
ull,
To Ft.
in _- in,EI. PAC nK. --- ___.-- .
Depth N
P Svc Material Q1
CD
To_ —.__-...
leb 1 b f( }k FIFY THA I TTIIS W F.LI- N'AS CONSTRCC f FD IN ACCORDANCE WI"CH 15A NC'AC 2C.WELL
( I(1O" �IANDARDS-AND i-HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI(�NATUR F.O} SON(ONS"IRUCTIN(i THE WELL
DATE
bubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
i'69ii-i 616 Phone No.[phone].within 30 days.

WELL CONSTRUCTION RECORD
. :nn an:nna Department of Environment and Natural Resources - Division of',4'ater Quality-Groundwater Section
, p\I It%( (OR(INDIVIDL YI.I NAME (print) t;� �^
'-11.1 � _ CERTIFICATION#1�`y_I_3_
.`L^ PHONE #
'�c(.t.<OS'i kA("IUR COMPANY NAME _ V��b ��q�-1 � �.,t � - l U� � yy ,/Y t
ti t YI t w F.Li,CONSTRUCTION UCTIO:N PERM]to _ _- ASSOCIATED WQ PERMIT#
if applicable) - - (if applicable)
.i i. USE,,(Check Applicable Box): Residential ER9 Municipal'Public ❑ Industrial ❑ Agricultural ❑
.iunn„nng ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
( (A A"IICN:
Counrylq � ll y.,,� ToPogr�phic/Land setting
❑Ridge L9Slope ❑Valley ❑Flat
II, .uo'se s,Communrtv.Su Mlrt sewn. Lot K2.Lip C,dc) (check appropriate box)
Latitude,longitude of well location
;u .f k _
(degrees;mmute"econds)
Latitude,longitude source:❑GPS❑Topographic map
(Street or Route No i
(chmk box)
p_11U DEPTH DRILLING LOU
zIpt ride From To
Formation Description
- �: (hone(umber
k4c-)
i DEPTH. I ---- ----
: IUI q!-L LAllllt„ AA1.11 'r L1411 � ..
7I! \VATER LEVEL Below Top of Casing: b J---FT.
(Lx"' if Above Topof Casmg( _
(W(A CASING IS __A__FT.Above Land Surface _
'lop of casing terminated avor beta land surface require,,
,>riance in accordance with 15A NC.AC 2C.Ol J8.
Y If.1.1)(gpm): 1 __ METHOD OF TEST aVl -"--- ---
':( -.14T6R /O%ES(depth):
T ` -- �� LOCAT ION SKETCH
)"Pe V­rr�i Amount--- Show direction and distance in miles from at least
Udall Thickness two State Roads or County Roads. Include the road
Depth Diameter or W e(ghtFt. Material numbers and common road names.
In SLA Ft EyC
To Ft. ._._.
%O Depth Material -
Method ID
Ft
To Ft. ----_.-_
Depth Diameter Slot Size Material L
n,rr. ib Ft. In C3
_Ft.---_in. — In. U'1
V-E.L PACK: — --
Dcp[hTo S¢e Material
' ' Ir_f ( t:- r ERrIFY THAT THIS W ELL W'AS CONSTRUCTED 1N ACC'OKUANCE W'lfH ISA NC'AC 2C,W'ELL
IAN'DARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI(iNAI URE OF PERSON NSTRUCTING THE WELL---- ---
. DATE
Subn(ii the original to the Division of Hater Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
:.`699-1 ,6 Phune No.[phone], within 30 days.
GW-7 REV.07/2001

v )
WELL CONSTRUCTION RECORD
ttn( ,R.111m - Department of Environment s and Natural Resources- Division of Water Quality-Groundwater Section
1 1 n
' r.11,( ON I RA( [OR(INDIVIDLAL)NANIE (print)-_1 Obu\ . ..Q '�_ __ ____ CERTIFICATION k;Lki
ON IRA(."1'OR COMPANS NAh1E_C Y�Y..a_V\t_ 3 s -` ) ( .f. y`'LI _ -
PHONE #
,` -- ilv -31,10
51.0lt. s(CIA,C plicRUCf10N PERMI'Ik
lit applicable) --„___ _ ._ASSOCIATED WQ PERMIT#
able) (if applicable)
I;51-. (Check Applicable Box): Residential ❑ Municipal.'Public ❑ Industrial ❑ Agricultural ❑
.L,r,rtr.r rig ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
:�.FION:
v County Topographic/Land setting
' r -- ❑Ridge ❑Slope ❑Valley EW]at
Zip rxlcl.umoen,('ommun:n,Subdib on. Lot No C (check appropriate box)
Latitude;longitude of well location
(degrecsimrnutmseconds)
�3Z n_UL-, -- Latitude/longitude source:❑GPS❑Topographic map
i Streit or Route r.u.r
QAcC (check box)
V - v SWtr �---� DEPTH DRILLING LOG
Gp( ndr From To Formation Description
r. 'lRfl-LED e -Z�p-p�--. _
T4f-s1_ DEP7fI
. _ . Lnl 1/'r. LFrl,r In i A1'1-I.IV V'1_A �I nrr 1�/ _
-.,TI( WAFER LEVEL Below Top of Casing;
Csc v+ � FT.
-if Above Top of Casing) _
!))' Oh CASING IS A-_FT. Above Land Surface' —
'I op ul casing terminated at/or below land surface requires a
anance in accurdanu with 15A NCAC 2C.611a.
r. :II,LU (gpmF`A52._ METHOD OF TEST_. ----
'r 1`.R /ONES(depth): A_U�2 Zp ----
1,Q
M I LOCATION SKETCH
,r'1''Ft f iON: rYPe—� '�_ Amount___ Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
liepth Diameter or Weight:Ft. Material numbers and common road names.
O fo �D �_ Ft 1L---
To.__Ft,
F n'Ir To Ft.-- -- --.. ------
;;r(d Depth Material .__
rr,.,r Method
'- To Ft'
-- - c
Depth Diamtcter Slot Size _.
_ Material fV
Io Ft --in in. N -
. 5rr. . To_ __—_.
In. O c.0
. F.1. PACK: Gil
Depth Svc Material
fo
_. Ft.
IFt 11iY r 6KTIFY THA h THIS W F,LL WAS CONSTRU'CFED IN A(C'ORDANCE WPFH UA NC'AC 2C,WELL
I(),h .S I--Ar
NDARDS,AND TH.AT,A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W'ELLOWNER
SIGNATtiRE OF PERSON C' RUCTING THE WELL- - --
DATE
`,ubmil the original to the Division of Water Quality,Groundwater Section, 1636:'%fail Service Center-Raleigh,NC
['699-iGs6 Phone,No.[phone].within 30 days.
GW-1 REV. 07i2001

WELL CONSTRUCTION RECORD
( archon -Department of Lncironment and Natural Resources- Dicision of Water Quality-Groundwater Section
NNE] I.(ON Ik%('IOR(IM)IA I DU Al.)NAME (Torino (}�� _-�)ksYa—U CERTIFICATION
1p_-��5�
Nt.I.L.('ONIk.\(C-1'ORCONIPANN NA.UE. -1.Y11 r�.e. �jv>t1�_1�J,bl.� �-\��I VYs 11 PHONE Is �LY9�-1c)
SI NH,N%i:LL(.ONS'IRL'ICTION PEkMI I'# .,1Q� .. NSSOC I ATE NQ PE'RBi`r'14N`_
(if applicable) (if applicable)
f.l.l. U% (('heck Applicable Box): Residential Lr Municipal'Public ❑ Industrial ❑ Agricultural ❑
\Ior ing❑ Recovery ❑ Hcat Pump Water Injection ❑ Other❑ If Other, List Use
VA1 I I I.U( AT[ON: Topographic/Land setting
Sc:ucsst�Tr�uN'n-. A(la If V 1- OV\CU County�AOu ,t O ❑Ridge ❑Slope ❑Valley LRKI t
(check appropriate Taxi
°,:-cc"�:mm.�K(u(:ynhe�rs.C�ummu�mr}.pSnhdn'i.:nn.lot—S[u..7:p(,)deI Latitude:longitude of WCll location
UU Nf.k _ �,�—J+�t-t l[���( t ✓\L dryrees minutes'seconds)
Latitude longitude source:❑G PSOTopographic map
!t1 � � 1 Street ar R.mc 1:,.: (check box)
Ls_- &Ln VA— L 1 1 C a �� lG DEPTH DRILLING LOG
^-( stain /-m('fie From To Formation Description
-a. d i R11 L
r) \ t nRu 1.ED l e- \s_c5-----
:OI:\!_ DEPTH: --- -- ----
i...: 111 : . A1l.11 " A'1.II I nil L�
S"f.1 Fl(- U A I ER LEVEL Below Top of Casing: [�n ___FT,
tlse"=-It hose Tapnf(asing) -TOP OF CASING IS 1 FT.Above Land Surfaces — ---- -
-I op of casing,terminated auor belts,land surface requires a
sariance in accordance with ISA NCAC 2C.0118.
v. I MILD (gpm): 6n_ METHOD OF TEST ;L V%r3
,IL AA'ATLR 70NES(depth): �_atL
-- LOCATION SKETCH
I)ISIN FU I ION:Tvpe_ ,�}_T _ Amount Show direction and distance in miles from at(cast
( "")IN( AAall Thickness thvo State Roads or County Roads. Include the road
Depth Diameter or .Weight Fr. Material numbers and common road names.
Fnnn_. To�U _Ft. ---�`_ _ - _ Py_C_-_
Froni — _ To Ft.
Iran, _-_ To Ft.----- -
(,RUI N Depth Material Method
To- Pt. C -
Y( Depth Diameter Slot Size Alatcrial tV
Fo __ F(__._in. _-- in. U9
F rrnr To Ft, in. in ,
SVNDCik:AAF:I PACK: ---- U
Depth Size Material -
I-n an_ . To Ft.
J Ft
In. kl.AI:ARKS.
f rO IIIRFB) C ERTIFY THAT THIS VA ELL. WAS( ONS'IRIX ILD IN ACCORDANCE Wllll UA NC'AC 2C,WELL.
I I I aS RC( [[ON S I:ANDARDS.AND THA I A COPY OF THIS RECORD HAS BEEN PROA'IDED TO THE V4"ELL OPrNER
Af kk
SIGN:ATORE OF PERSON C'OfN4S7-RI1C'TINCi THE WEI.I- DA 11:
Submit the original to the Dicision of\Rater Quality,Groundwater Section, 1636.Mail Service Center-Raleigh,NC
s7699-I636 Phone No.[phone].within 30 days. GW-I REV.07'2001