Ja 1 CY2005

-614� s-
«rELL CONSTRUCTION RECORD �r �
North Carolina- Department of Environment and Natral Re�sourcle�s-Division of Wate uality-Groundwater Section /
WELLCONTRACTOR(INDIVIDUAL)NAME (printt)n)] r— ) �trED
< CERTIFICATION# 3—
WELLCONTRACTORCOMPAN\'NAN1E 'n A�J71'6 1 � dt HONE # (40JLSTATE w ELL CONSTRUCT ION PERMIT# ASSOCN'QP N!IT#
(ifapplicable) (if applicable) -
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural❑ u
Monitoring❑ Recovery ❑ Heat Pump Nat Infection❑ Other❑ If Other,List Use
2. WELL LOCATIOt D Topographic/Land settin.
Nearest.Town: 0�-�k&9''--'R°�ounty ❑Ridge ❑ 4iipe ❑Valley ❑Flat
f �e"ck appropriate box)
(Street Name,Numbers:Community.Subdivision,Lot No.,Zip Code) Latitude/longitude Of well location
3. OWNER: (degrees%runu¢srsecunds)
Addre - l Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No. G '/ (check box) -
Z/ Y�3 DEPTH DRILLING LOG
Ci:;orTo,,n Sate Z,pCode From To Formation Description
Area ah!e-Phone number
4. DATE DRILLED 6 7 ' a /to-
5. TOTAL DEPTH: o�� � / ? D
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA / .�Z
y. STATIC WATER LEVEL Below Top of Casing: 4/ 0_FT. p ( Z
(Use'+'•it Above Top of Casing) 1Vz--a as T _
S. TOP OF CASING IS j FT.Above Land Surface' ti
'Tap of casing terminated atior below land surface requires a 01
variance in accordance n'ith 1 iA NCAC IC.0118' J�
9. YIELD(gpm):�_METHOD OF TESTA 5
10. WATER ZONES(depth): L)
LOCATION SKETCH
11. DISINFECT ION:Type 1--r-- Amount IQ- Sho\c direction and'distance in miles from at least
12. CASING: Wall Thickne>s two State Roads or County Roads.Include the road
Depth pigirixter or Weight.'Ft. Material numbers and common road names.
From To, - ,Ft. -Sp/L_Z _00c
From To Ft.
From To Ft.
13. GROUT: Depth Material Method _
Front�6 Tom_Ft. '•-�+ .,r� "�- _ � /� /�
From—:—To-7-9� Ft.
14. SCREEN: Depth Diameter Slo:Size Afateria! „r'" ( I(/
From To Ft. in. in. r Otis
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 STA�iARDS,AND THAT A COPI'OF T. N. �'�OF.D HAS BEE*'PROVID�EDD TTOO"THE\\'FLL OWNER
SIG�RE t.iF PER50'.Cr-0\S 1 RUCTI\G THE WELL ��•�T E
Fubmit it:e o,i,ti[InI t : the. nivisinn of Nx titer Qualin, Groundwater Section;'I �:� -en r- a e:g h.,NC
RECEIVED ` �v n
FEB 07 2006
Asheville Regional Office
urfer Protection

«TELL CONSTRUCTION RECORD(tOA
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTR.ACTOR(INDIYIDLAL)NA\IE (print) p �
CERTIFICATION% O L� /
\YELLCONTRACTOR CO?IPANI \4>IE�' .. >. ��� L�-PHONE X (kl"- SdGa-SSSQ
STATE\YELLCONSTRLC.IONPERMIT' ASSOCIATED\YQ ERMIT:
'-(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box): Residentiai4 Municipal/Public ❑ Industrial❑ Agricultural❑
Idonitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATI `: Topographic/Land setting
Nearest Town: County ❑Ridge ❑Slope Valley ❑flat
'y' (check appropriate box)
(Sven Namt;Numbers,Community•,Subdivision,Lot No.,Zip Code) .
s Latitude/lonsitudeof well location
3. OWNER: VAn/ (degreezminuteslseconds)
Address Got.
/IJ Latitude/longitude source:❑GPS❑Topographic map
(Streetcx ute No.) (check box)
U-K -7-7 ff DEPTH DRILLING LOG
Cm Town State Zip Code From To Formation Description
(LA, (, 31 - 30 "Ll
Area tale-Phone number
4. DATE DRILLED L&
A) 1 J / /o
5. TOTAL DEPTH: - 7
6. DOES WELL REPLACE EXISTING WELL? Y NO, 7 (
k �eJ
7. STATIC WATER LEVEL Below'Top of Casing: ES T.
(Use"I"if Above Top of Casing) r-V ,e
S. TOP OF CASING IS r FT.Above Land Surface*
r
*Top of casing terminated atlor below land surface requires a _-
snriance in accordanSSt with IiA NCAC 2C.011 S. =
9. Y'IELD(gpm): ' l� f—NIETHOD OF TEST--t a� ^a
10. WATER ZONES(depth): ` y t/ D
r LOCATION SKETCH CD
It. DUIN`'ECTION:Type T—LI Amount .:hot%direction and'distanee in miles front at41st
l2. CASING: Y\"all Thickness Y two State Roads or County Roads.Include theroad
Depth Diameter or Weiehc'Ft. �h t�cn-�I/ numbers and common road names.
From 0 To 2 Ft. Lo 4—,ikf-41 eG(.�-e-s.�_
From To 'FL ) _
From Ft.De
13. GROUT: Depth Material Method
From (j To� FLUegf1—
Front Tot J FL,
14. SCREEN: Depthpmeter Slo: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. -
1
16. REMARKS:
I DO.HEREBY•CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,IVELL
CONSTRL Cf ION STANDARDS,AND THAT A COPY OF THIS R�ECO�/,14AS BEEN PROVIDEATO THE WELL OWNER
SIG.::�CUKE�rPERSONrW\SIKLC-fING THE t�ELL DATE
Submit the original to the Division of N ater Qunlity,Groundwater Section, 1636 Mail Service Center-Ralei;h,NC
- "1. 0 2r1o1
RECEIVED
FEB 0 7 2006
Asheville Regional Office ,
Aguilar Protection`

w �,�ry� (01 7 �S.
WELL CONSTRUCTION RECORL(�X" 7 Lo a�l4 'g �-2L(o
q
North Carolina- Department of Environment and Natural Resources-Di!XIsion of Water Quality-Groundwater Section
\TELL COCTRACTOR(1\DIVIDL'AL)NASIE (print) 0"-4 / + CERTIFICATION R 3 �.
WELL CON'rRAcTOR CO>IPANI'NANIE Low PHONE k4 Zdl-5- - -s 6
STATE\1 ELL CONSTRUCTION PER>IM ASSOCIATED\1'Q PER> IT-
(ifapplicable) - _ - (if applicable)
I. WELL USE(Check Applicable Box):Residential X Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other n If Other,List Use
2. WELL LOCATI N: Topographicf and setting
�N#ear stTown: C unty f+� ❑Ridge $Slope ❑Valley ❑Flat
jcheck appropriate box) _
(Street Krone,Num6ers,Commu Subdivision,Lp�No..Zip ode) �'7 titude/longitude of well location
3. OWNER: '�'�� (dcgrees'minutestseconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or R qui^e No.) (check box) "
ut NoL 7k 7 DEPTH DRILLING LOG
Ca,or Ton s or tate ip Code From To - Formation Description
t L e i — 0(0 PLJ
Area code-Phone number
4. DATE DRILLED 1 2 1 0 1 70 -- 2 0
5. TOTAL DEPTH: b 512 G)U — 9-3
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO );a !z3 g.So
7. STATIC WATER LEVEL Beloty Top of Casing: In 6 FT.
(Use"+"if Above Top of Casing)-
S. TOP OF CASING IS I FT.Above Land Surface'
•Tnp of casing terminated atior below land surface requires a
variance in uccordi nce with liA\CAC 2C.0118.
9. YIELD(epm): ,(n METHOD OF TESTA I v-
10. WATER ZONES(depth): D cn
LOCATION SKETCH p
11. DISINFECTION:T,vpe � L Arnount -n,Q 6- i�.l- Sho�r direction and distan-e in miles from at trait
12. CASING: Wall Thickness G two State Roads or Count} Roads. Include the road
Depth Diameter
ter or P'eight'Ft. Material numbers and common road names.
Front 0 To 7 r Ft. SDQ-.2l —1�L)
From To Ft. �
From t.e f D
13. GROUT: Depth Material � kthod
From U To�_Ft.
From_ F
14. SCREEN: Depth t.Diameter Slot Size Material `f� It
From To Ft. in. in.
Fro m To Ft. in. in.
15. SAND GRAVEL PACK:
Depth Size Material
From To Ft.
From To - Ft.
16. REMARKS:
i
I DO HEREBY CERTIFY THAT THIS 1�ELL WAS CONSTRUCTED IN ACCORDANCE WITH IiA NCAC 2C,N%ELL
CONSTRi;CTION STAN DARDS,AND THAT A COPY OF THIS RECORD" HAS BE P 1'ID`ED TO THE R ELL OWNER
SIG`+AT'GRE O'JERSON COS.RUCTING THE WELL DATE
So1)1114 the on^inal to the F);kin of 1N ater Qualit). Grou n d Nc a ter Seetion, 161611ail Service Center-Raleigh,NC
r RECEIVED-
FEB 0 7 2006
Asheville Regional Office
Aquifer Protection

9539 , gfVI
WELL CONSTRUCTION RECORD
. _ t
North Carolina-Department of Environment and N tral Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAINT (paint) CERTIFICATION# r
WELL CONTRACTOR COMPANY NAME W�t'F3—" '� PHONE
STATE WELL CONSTRUCTION PERJIIT# ASSOCIATED WQ PE 9 IIT#
(if applicable) if applicable)
1. WELL USE(Check Applicable Box):ResidentiaW Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT I Topographic/Land setting
NearestT t County !X '7 ❑Ridge lope ❑Valley ❑fit
7 -7 Icheck appropriate box)
(Street Name,Numbers,CcV6munity,Su ivision,Lot No.,Zip Code) Latitude/longitude Of Well Iocatio(,n
3. OWNER: (degrees/minutes/seconds)
Address O Latitude/longitude source:❑GPS❑Topographic map'`
(Street or Route No.) (check box)
1 C " 7 7 DEPTH DRILLING LOG
ciryor own state Z`ode ,From To Formation Description
��- 39Gi
Area code-Phone number a --�fq
4. DATE DRILLED '� S' p S 7
5. TOTAL DEPTH: 7 e- - 7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �c 7 7 — 2-Z U
7. STATIC WATER LEVEL Below Top of Casing: I n FT. 2 d - 23 2
i (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.
b 33x�ft//
9. YIELD(gpm): I L_METHOD OF TEST 1t%
10.WATER ZONES(depth): 7 )—
LOCATION SKETCH
11. DISINFECTION:Type 1-F-f-7- Amount iiy p�r� .,how direction and distance in miles from at Teas[
12. CASING: Wall Thickness / - t3eb State Roads or County Roads.Include the road
Depth Diameter cr Wei¢ht/Ft. Material numbers and common road names.
From­--C�--To �J Ft. U R U G
From To Ft.
From To Ft.
13. GROUT: Depth btaterial M thod L,
From O - To�FL
From�_To Ft �
14. SCREEN: Depth Diameter Slot Size btaterial
From To Ft. in. in.From,­To Ft. in. in. /n
15. SAND/GRAVEL PACK:
Depth Size Material 1 L
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN.ACCORDANCE WITH 15A NCAC 2C,WELL ' -
CON� UCTIO1: A '!)7HAT A COPYO� TFIQ ?7.^ORPrI'_$BCLT+FP.O'���D TO Tr~E T7;LL O'+VNE R -- --
J
at6i4AlURE OF�RSON CONSTM[1('Tll'fpTFTCpr=siTpp*',�/—EFD
Submit the original to the Division of Water Quality,Grounds ater ScF[S8}t,�3PRtaTI52Y�Ce Center Raleigh,1:C
27699.1636 Phone No.[phone],within 30 days. FEB 07 2006 GW-1 REV.07/2001
Asheville Regional Office
uifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and tural Resour s- ivision of Water Quality-Groundwater Section [L// ,
WELL CONTRACTORQNDIVIDUAL)NAME (print CERTIFIC�AATTIIOON'#��J—T /
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PER\1ITp ASSOCIATED WQ PERM g
(if applicable) -_ (if applicable) —
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest To Coun ❑Ridge C lope ❑Valley ❑Flat
check appropriate box)
(Street Name,Numb is,Community.Subdivision,L t o., ip ode) - Latitude/Ion,
of well IQCatIOn -
3. OWNER: Aa9==t=J (degrees/minutes/seconds)
Addre s Z�/ t Latitude/longitude source:❑GPSOTopographic map
(Street or oute No.) (check box)
a QQ DEPTH DRILLING LOG
CiryorTown State zip Code From To Formation Description
&V)- C,2-4c — I (0 9 4
Area code.Phone number _
4. DATE DRILLED e O J
5. TOTAL DEPTH: y zl S>1) Z
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N'O'*)L`I
7. STATIC WATER LEVEL Below Top of Casing:_ �LV FT. L
(Use-+"if Abort 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 15 A NCAC 2C.0118.
9. YIELD(gpm): 5— METHOD QF_TEST / t� ✓—
10.WATER ZONES(depth): S
LOCATION SKETCH -
11. DISINFECTION:Types Amount how'direction and distance in miles from at least
12. CASING: Wall ThicknzssYo State Roads or County Roads.Include the road
Depth Diameter or\Veieht(Ft. aterial numbers and common road names.
From Q To�Ft.�
From To Ft.—
From­
To F[.
13. GROUT: Dept Material Me hod t�
From_D To Ft. ✓
From_To,2.0
14. SCREEN: Depth Diameter Slot Size ' taterial ..-�-�yn- I.Q f?f ` L
From To Ft. in. in.
From To _ Ft. in. in. r .)
15. SAND'GRAVEL PACK: 1 Lrl
Depth Size Material O
From To Ft. tT
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH liA NCAC 2C,WELL
CONSTRUCTION STAND.-V AND A COPY OF THI$ C HAS BEER PROVIDED TO THE WELL OWNER -
y - c) 0 1
- -c3
- Sc6i�A'CGt.L IMF �liKSuN wn":,tny�.. pCE//+�►p ,�`y�'ECDn - .
Submit the original to the Division of Water Quality,Groundwat r Sectili 4631yM4'i�5lrhellCenter R eigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 R V.07/2001
FEB 0 7 2006
Asheville Regional Office

tzJ 55 91 d'w
C 7 & zv -� � -5��,3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- ivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print �R' I-' CERTIFICATION
WELL CONTRACTOR COhIPANYNAME �) PHONE # IYL£'i Sb 'SSS v
STATE WELL CONSTRUCTION PER6IIT# ASSOCIATED\ Q P RNIIT#
(if applicable) _ (if applicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2: WELL LOCATI 1 . Topographic/LandDV setting
Near�Town: -County ❑Ridge ❑Slope ❑Valley 'fat
7V77 (check appropriate box)
(Street NaNumbers,Community, ub ' 'sion,Lot No.,Zip Code) LatiNde/lOnglmde Of well 10Cat10n
3. OWNER: 4246.A 'O�—'-`� (degrees/minutes'seconds)
Address 9 M I,(_tlzty-tR Latitude/longitude source:❑GPS❑Topographic map
(Street or Route NoJ (check box)
2 ����( �Q _5�� DEPTH DRILLING LOG
ty or Towl State zip Code From To Formation Description
Area co e-Phone number �.7
4. DATE DRILLED R Z7 0 � �7
5. TOTAL DEPTH: (p 157 �C-
6, DOES WELL REPLACE EXISTING WELL? YES ❑ NO CX (� g 1W
7. STATIC WATER LEVEL Below Top of Casing: )_U_FT. kp _ S-Z
(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 wit 15A NCAC 2C.0118. ) —
9. YIELD(gpm):_� METHOD OF TEST -- —
10.WATER ZONES(depth):
1Sj LOCATION SKETCH
11. DISINFECTION:Typ( T�f ~`�--Amount !iJ y�il Show direction and distance in miles from at least
12. CASING: - Wall Thickness _6 two State Roads or County Roads.Include the road
Depth D meter o``r��WTe�igh't/�Ft.� Mat 'at numbers and common road names.
From_-To��Ft. sew _
From To FL
From De Ft. /
13. GROUT: Depth Material Method i llliii
From To Ft.
From TO Ft. (.t.) a
14. SCREEN: Depth Diameter Slot Size aterial
From To Ft. in. in. h cit
From To Ft. in. in.
15. SAND/GRAVEL PACK: C-D
Depth Size Material - I Oti
From To Ft.
From To Ft. -
16. REMARKS:
- I DO NFRFBY CERTIFY TFI.AT THIS\YELL WAS CONSTRUCTFD IN ACCORDANCE WITH I5A NCAC 2C-\\TLL - -
C;ONSiRUCI tuiY S7 A1vD� l-LS,Ai J-II-IAT A COPY OF; IS'SCORD HAS 6tEN F;.O'v IG1.D IC
FFtL V'HLL b C NcR.
S!Jlv A :U! r OF PER:SN C. .STRUC TFNO THE\VFT.L DATL.
Submit the original to the Division of Water Quality,Groundwat-r Secti1tLV16s) J2VJ!J3enter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. C�V LG GW-1 REV.07/2001
FEB 0 7 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD
j 0 9
North Carolina Department of Environme t andd NNattual esources-Division of Water Quality ` � a
WELL CONTRACTOR(INDIVIDUAL)NAME (print) -.- - f 1 r CA
I- -A CERTDICATION.ROb
'-:.'WELL CONTRACTOR COMPANY NAME ' •. CAA Ban a 0rga s 5�1. - SX-S, a
., LONSMUCTION -
C PERSBTR ASSOCIATED WQ P R�D'Cll STATE WELL
.z(S ': ..-.. (if applicable)
applicable) ;;
L WELL USE(Check Applicable Box):Residential� Municipal/Pubtic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery 0 Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest Town:' County Midge ❑Slope ❑Valley _Peat
Z /� (checkapPmpriamb-)
(91ircet N m Numbers,Comons ,Sutdills ion,Lot No.,Zip Code) LatitudeAtingitudc of well location
3. OWNER - ' - (degtoeslminuawwoods)
Address Latitude/longitude source:❑GPS❑Tcpographic reap
(
checkboz)own ut o.� a-�7 1 7 DEPTH ( DRILLING LOG
'Ci(ry orToxv Smxa, Zip Code. From To Fonnanort Description
(� 7y 3 - 5UrV
.. Area code-Phone amber
4. DATE DRILLED fo- - 945 ii?J
5. TOTAL DEPTH: 3 TT} T- 2qJ - 2`t-3
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ar 3 y o
7. STATIC WATER LEVEL Below Top of Casing:AFT. Z o —
(Use"+"ifAbove Ioporcasing) -
8. TOP OF CASING IS I FT.Above Land Surface•
-Top of casing terminated at/or below land surface requires a N -
vartaaceln accordance with l5ANCAC2C.011& — r
9. YIELD(Spin): 10 METHOD OF TEST At k---,
10.WATER ZONES(depth): 70 O
LOCATION SKETCH
11. DISINFECTION:TypeIt:_ _ Amount 'Show direction and distance in miles from at least
12. CA STNG' Wal!Th'rtin•ss vo State Roads or County Roads.Include the road
Depth Diam Ter er Wcll r AFL maie ial •�' � rs ani;;:o-nir�n roar mm�.c.
` From U To a� Ft. ,$Qg_� 0 C.> �y�1
From To Ft. - / V
. From To Ft.
13. GROUT: Depth Material Method
From O To Ft
From__3_To `Z0 FL
14. SCREEN: Depth Diameter Slot Size Material ^
From To FL in. in.
From To Ft. in in.
15. SAND/GRAVEL PACK:
Depth Size Material
From—To—FL—
From—TO FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
✓��- ';�LNAI Uxt 0£) RSON CON ,r)WCTING THE WELL" DATE
Su Un:ii t1a croina!to the Division of Water.Quality,Attn: Information Maaageniert,i619 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/2004
RECEIVED
FEB 07 2006
Asheville Regional Office
Aauder Protection

z z. 1ro7o
� 5'2 �o� w
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NA01E (print) (.0 w CERTIFICATION 0_119-It
WELL CONTRACTOR COMPANY NAhIE 'l UH--- PHONE # (9;t.4S-R&6 —SSS d
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED PE MIT#
(if applicable) (ifapplicable)
I. WELL USE(Check Applicable Box):Residential Or Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOC Topo aphic/Land setting
Neare, n `dam C ty —DR ope ❑Valley ❑Flat
� eZ--�7' L (check appropriate box)
(Street Name, tubers,Community,Subdivisi ,Lot ,zip Code) / Latitude/longitude of well location
3. OWNER: l [ (degrees/rmmn sheconds)
Address AR D ,I tL L) l Latitude/longitude source:❑GPS❑Topographic map
/� (Street or Route No.) (check box)
p t� Y'\ C DEPTH DRILLING LOG
( C orro� states 5 jp Codc From To Formation Description
Area code-Phone number
4. DATE DRILLED O � �J S- — V7o =T
5. TOTAL DEPTH: �t Lp t( 7 j
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (4 7 3 'SOU
7. STATIC WATER LEVEL Below Top of Casing: 14"D FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* N
-Top ofcasing terminated at/or below land surface requires a, — L,
variance in accordance with ISA NCAC 2C.0118. //v�
9. YIELD(gpm):_ 30. METHOD OF TEST 1 e� _— t7)
10.WATER ZONES(depth): q-7 U
LOCATION SKETCH
1 I. DISINFECTION:Type i-+ T 14 Amount 1 '...ow direction and distance in miles from at least
12. CASING: Wall Thickness VJ two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Mate;ial numbers and common road names.
From 0 To_Leb Ft. (,� 91 12 V C---
From To Ft.
From To Ft.
13. GROUT: Depth Material Method S 4—
From U Tom_Ft.
From__,-Tq__*Z-d Ft.
14. SCREEN: Depth Diameter Slot Size Mai teal
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material - 1
From - To Ft.
From To Ft.
16. REMARKS:
- - i DO HFRFRY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,•WELL-
CONS FRUCTION S LANYARDS„, vDYFHAT A COPY OF THIS RCCOP.D HAS bEDN FRO VIDED TO Ti-IL V.,.LL O:vNEP, --
Ji r,,,,_
—'�` cICV�TUPc OG nEP.S�1J'.�ZTt�S-TRre-LlR�©"HF
- . R VE(]
Submit the original to the Division)of Water Quality,Grounds ater Sec Cron,RECEi33T�aR S'¢fCTt:e Center Raleigh,I;C
27699-1636 Phone No.[phone],within 30 days. FEB 0 7 2006 GW-I REV. 07/2001
Asheville Regional Office
Aquifer Protection

7s� 7 goZ7
j WELL CONSTRUCTION RE RD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section, �/J
WELL CONTRACTOR(INDIVIDUAL)NAbIE (print) `� CERTIFICATION#—LS
WELL CONTRACTOR COMPANY NAME LC+ HONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PER I1T#
(if applicable) (if ap alicable) -
1. WELL USE(Check Applicable Box):Residential W Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N: Topographic/Land setting
ea a own - oun edge ❑Slope -❑Valley1at
�J�� (check appropriate box)
V.(Street Nam' becrsQCcmmunity,Subdi sto Lot o.,Zip Code) - Latitude/longitude of well location
3. OWNE ' A t (degrees/minutes/seconds)
Address O Latitude/longitude source:❑GPS❑Topographic map
(Street or Route ) (check box)
3o oa`4 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
( - 9 a - fs 2 ? ---�--
Area code.Phone number
4. DATE DRILLED R/��l �� y I 'Z`f0 b—- L*
5. TOTAL DEPTH: 3 �� 244- qA—
6. DOES WELL REPLACE EXISTING WELL? YES NO;O � 3T
7. STATIC WATER LEVEL Below Top of CasingQ y ate.-F3.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface'
-Top of easing terminated allor below land surface requires a -
varianceinaceordancewith SANCAC1C.0113.
9. YIELD(gpm): I .S METHOD OF TEST ---fit
10.WATER ZONES(depth): 2V U _
LOCATION SKETCH o
11. DISINFECTION:Type 1'f' T/ Amount f I _ -ow direction and distance in miles from a`Pleast
12. CASING: Wall Thickness C' t'o State Roads or County Roads.Include the road
Depth Diameter or Weieht/Ft. M erial
numbers and common road names.
From To 2.6 Ft. C, 11 6fl 2 (
From To Ft. ea ) /V/'�(/—n",�1 a(
From To Ft. � �
13. GROUT: Depth Material It d
From 0 To Ft.
From—To FL
14. SCREEN: Depth Diameter Slot Size IAVL rl-ff�
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 AVELL- -
- CON57 RU4TION S CANDAR,,P,,dD THAT A COPY Or THIS RECORL nAS BEEN PROVIDED TO THEY,? -L.OWINEP
S�GNATURT'OF PERSON CONSTRUCT NG THE WELL_R -DATE
Submit the original to the Division of Water Quality,Grounds ter SeRECEMet) :,ewer-Raleigh,IBC
27699-1636 Phone No.[phone],within 30 days. GW-1 EV.07/2001
FEB 0 7 2006
Asheville Reglonel Office
AGUffer PrCAFL-4inn

tit J s � 05J
7 s7a 5� 7oaS
WELL CONSTRUCTION RECO
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater section
�
WELL CONTRACPORQNDIVIDUAL)NAME (print) U �I 1�= CERTIFI CATION# 2J J
WELL CONTRACTORCOMPANYNAME C W` HO\E # rF 4' �Ssr v
STATE WELL CONSTRUCTION PERI ASSOCIATED WQ PER}IIT#(if applicable) - _ (1f 3licable)
1. WELL USE(Check Applicable Box):Residential J�KMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nea stTown: Coun ❑Ridge ❑Slope ❑Valley lost
( Cj (check appropriate box)
(Street Name,Numbers,Community,Subdivision,LotiNo.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Addrz�s Latitude/longitude source:❑GPS❑Topographic map
(St et o er out 'o.A 6— (check box)
3Z DEPTH DRILLING LOG
Ci or To n State Zip Code From To Formation Description
Area code. number I J e) Q7�
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOXI
7. STATIC WATER LEVEL Below Top of Casing: &=:b_FT.
(Use'Y'it Above Top of Casing) '�5 1
8. TOP OF CASING IS I FT.Above Land Surface*
•Top orcasing terminated atlor below land surface requires a
vartance in accordant with 15A NCAC 2C.ol l8.
9. YIELD(gpm):--- /�ETHOD OF TEST I J
10. WATER ZONES(depth): a."
3 S y LOCATION SKETCH
11. DISINFECTION:T)pe_.hL3-- Amount ff. Show direction and distance in miles from at least
12. CASING: Wall Thickness. heo State Roads or County Roads.Include the road
Depth Diatjteter or Weight(Ft. M ena! numbers and common road names.
From 0 To �o S Ft. (terfd
From To Ft. Co
From Ft.De
13. GROUT: Depth Material n
_�_ Method
3 T
From��To Ft. �a.Q,S
Frotrt To�Ft.� CCJ
14. SCREEN: Depth Diameter r—
From To Ft. in. - in. v
Fron-L To Ft- in. in. N
Ul
15. SANDIGRAVELPACK:
Depth Size Material
From To Ft. C0
From To Ft.
16. REMARKS:
- ID.0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED I\ACCORDANCE WITH 15A NCAC 2C,WELL"- -
CONS T RUCTION STANDAtPDS,AND.TH.4T A COPY CP 11-fIS:RECORD E ,S-BEEN PROVIDED TO THL WILL 0«—NE
- rl .r,FPERSM CO ,.,'f*LUCT TPF P,-EI T, PATE
Submit the original to the Division of Rater Quality,Ground ater SRiEQE1MEDeCenLCr kaielgh,\C
27699-1636 Phone No.[phone],within 30 days. GW- REV.0712001
FEB 0 7 2006
Asheville Regional Office
Aquifer Protection

3 SSKaTw
rj s- -7 K -0
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N tral Resguur�cees�-Divi bon of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) s C CERTIFICATION'# CJ 4�L
WELL CONTRACTOR COMPANY NAME - ONE # �✓SSC!
STATE WELL CONSTRUCTION PERhIM ASSOCIATED w'Q PE MIT#
(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential OV Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N:
Nearer own: Con Topo aphic/Land setting
3 t ❑Ridge lope ❑Valley ❑Flat
7 ­7< (check appropriate box)
(Street Name,Numberi Community,S bdiviston,tot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Qf" - (degreeslminutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(( � ///J�{{"��e�,[,oa�r Route No.) �t (check box)
(. lbX z`-� 7�) DEPTH DRILLING LOG
City orrown s to Zip Code From To Formation Description
Area code-Phone number -
.36
4. DATE DRILLED -s G (� — 2 Z e7
5. TOTAL DEPTH: 07/ 2_2,0 — Z2 3
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N0�lk
7. STATIC WATER LEVEL Below Top of Casing: L7tr l FT.
(Use'•+"if Above Top of Casing)
g. 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.011 S.
9. YIELD(gpm): 3 METHOD OF TEST At �
10.WATER ZONES(depth): v22 0
LOCATION SKETCH
11. DISINFECTION:Type /-F T f*- Amount Show direction and distance in miles from at least
12. CASING: Walt Thickness P -+vo State Roads or County Roads.Include the road
Depth Diafrteter orWeight/Ft. -�Ia'te'n^al numbers and common road names.
From C) To Ft.
From To Ft.—
From—- To Ft.
13. GROUT: Depth Material Method
From U To 3 Ft. 2X= T
From_To Zr ) Ft. b tU
14. SCREEN: Depth Diameter Slot Size b1arerial U 1 -
From To Ft. in. in. v
From To Ft. in. in. cn
15. SAN'D/GRAVEL PACK: o
Depth - Size Material
From To Ft.
From To Ft. t ;.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTH 15A NCAC 2C WELL-
CUNS P UC iO17 S IANP kDS ANI)T TAT A COPY OFT US RECORD I1AS bCF\PRL-IDED TO TFiE WLLL O%'YTER
SIG AVJRE OF PERSON QO�S'Pft'UCTING THE WELL DATE
-------------
Submit the original to the Olvision 01 1Vaier Quality, GrouaGlTHtc, So�u��;y,�h�ajy��Cen:er
2 7699-1 63 6 Phone No.[phone],within 30 days. V YY GG GW-1 EV. 07/2001
FEB o 7 2006
Asheville Regional Office

) 1 -3 �2ay f (oce
R'ELL CONSTRUCTION RECORA (1 , -7 r 4� 7 - S S' -/ 7a(,l
North Carolina-Department of Environment and Natural Resources�D' is- n of Water Quality-Groundwater Section
� / 3(�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 411% CERTIFICATIO\#---c= .l 6
%VELLCONTRACTORCOMPANY NA>IE n ( PHONE # (tY2�'S�p SSSd
STATEN ELLCONSTRUCTION PERMIT# ASSOCIATED IN PERMIT#
- `-(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box): Residentlal,gV Municipal/Public ❑ Industrial ❑ Agricultural ❑
{i
hlonitorin� ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearer wn: C y ❑Ridge ❑Slope ❑Valley lOat
C 2 SC 7� (check appropriate box)
(Suet Name,Numbers,Comma '; Subdivision,Lot No. ip Code) Latitucl&lon4itude of well location -
3. OWNER- u�l/f (degrees ininutes4econds)
Address Latitude/longitude source:❑GPS❑Topographic map
tree[or Route No.) ` ,r ^ ,7(� _ (check box)
_� �� �-p1Je�_ ) �, o` d DEPTH DRILLING LOG
/y J Cny or Tmcn Stale jr Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED D 7 _ (p Zy
5. TOTAL DEPTH: 41S—C) Co"Z y —G Z�
6. DOES W'ELL REPLACE EXISTING WELL? YES ❑ N,�O-SfL
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use-,-if Above Top of Casing) .s
S. TOP OF CASING IS�FT.Above Land Surface' ,s
'Tap urcasing terminated at'or below land surface requires a .is -
variance in accordance with 13A:N'CAC 3C.0113' �x - l"
9. YIELD(gpm): , METHOD OF TEST It I
10. WATER ZONES (depth): (a Zed
LOCATION SKETCH
IL DISINFECTION:Type Amount V.5, . hos direction and,distanre in miles front at least
12. CASING: Wall Thickness :,,,o State Roads or County Roads. Include the road
Depth Diameter orWei_ht.'FL Material numbers and common road names
From To q `- FL f
From To Ft.
From To Ft.
13. GROUT. Depth A atcrial Method
From To 3 Ft.
From To 2-3 Ft. #e,,r
14. SCREEN: Depth D Slot Size Nateria!
From To Ft. in. in.
From To Ft. in. in. 0 \
15. SAND.GRAVELPACK:
Depth Size Material - o
From To Ft. -
From To Ft.
1
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I3A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAS A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL.OWNER
` S:G sIfLi:E OF PER�OA`•"CO\ST },CTiNO THE V,ELL DATE
Submit the original to the Division of\\'titer Qualih', Ground•-titer Section, 1636 dlail Ser> resat -RaleivFtbb
h NC
FEB 0 7 2006
Asheville Regional Office
u'rfer Protection

WELL CONSTRUCTION RECORD f. ,
North Carolina Department of Environment and Natural Resources-Division of Water Quality
.WELL CONTRACTOR(INDIVIDUAL)NAME(print) Q f r ✓ CERTIFICATION#�
WELL CONTRACTOR COMPANY NAME PHONE # (kU —S&Cn
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
- (if applicable) - (if applicable)
I. WELL USE(Check Applicable Box):Residential DC MunicipaVPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIOl : Topographic/Land setting
Nearest Town:. ou �' ❑Ridge 9$lope ❑Valley []Flat
(checkappmpnatebox)
(street Numbers,Conan ,Subdivision, t No.,Zip Code) / Latitudellongitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( et or Route No.) check box
S_T_ DEPTH ( DRILLING LOG
City or Town
`y�' b state ! 7) Code From To Fo tion Description
Area Phoneumber �� X
4. DATE DRILLED 7' / C� O S 4
5. TOTAL DEPTH: 3" 2 U tf Z
6. DOES WELL REPLACE EXISTING WELL? YES❑ NOA _a
7. STATIC WATER LEVEL Below Top of Casing:_�FT.
(Ilse"+"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): � METHOD OF TEST A 1
10.WATER ZONES(depth): ZY J
LOCATTON SKETCH
11. DISINFECTION:TypeMmete
�Amount ^ Show direction and distance in miles from at least
12. CASING: ss itwo State Roads or County Roads.Include the road
Depth t. Ma at
numbers and common road names.
From U To 1�1 Ft. /
From To Ft.
From To F[.
13. GROUT- Depth Material Method
From U To=Ft.
�
From To F[. (�
14. SCREEN: Depth Diameter Slot Size aterial /'lt_y)
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material �
From To Ft.
From To Ft. t7
co
16. REMARKS: s
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
_
�'�!�,,�-i�^�_ .� Y_r1 r G h r r /0 ' 1 � ' L
JfGNAI LJ RSONT�ti3'I'RUCT HE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Mana a ter-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. 1 RECEIVED
GW-1 R V.09/2004
FEB o 7 2006
Asheville Regional Office
Uffer Protection

e �-moo
-
3� RESIDENTIAL WELL CONSTRUCTION RECORD _
5 North Carolina Department of Environment and Natural Resources-Division of Water Quality op
WELL CONTRACTOR CERTIFICATION k 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type H-'T H Amount 16oz
Russell S. Taylor g• WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
.redden Brothers Well Drilling, Inc. From To From—To—
Well Contractor Company Name From To From—To—
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING: Thickness)
�DTo 44 ,/ Diametar Weigyt„ Material
Eti n_a kl i6n, NC 28734 From ep Ft. ./tom
City or Town State Zip Code From To_Ft.
( 828 7- 369-9591 From To—Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
./ _ M t/OQ(j From_Q_To 20 Ft.CgIH'it & IHYnite AgMd
SITE WELL ID#(It applicable) 75�2 n(7 T!}�
From To_Ft.
STATE WELL PERMITI Ir applicable) From To—FIL
DNQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
N ELL USE(Check Applicable Box): Residential Water Supply❑ From To_Ft._1n. _ In.
r.i /n r ' -66 From To_Ft.—In. _ in.
TIME DRILLED n(qq From To_Ft. in. _ In.
TIME COMPLETED cX . �� AM PM
8. SAND/GRAVEL PACK:
0.WELL LOC%IL I: Depth Size Material
CITY From To_Ft.COUNT From To Ft.
From To Ft.
Mttllttt, umbers,Community, ubdlNaion,Lot No.,Parcel,Zip Code) -
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat []Ridge ❑other From To Formation Description
(check apptdpdale box) 0 s _ Clay & sand
I May t o in degrees, r s
L•TITUDE �� �� (;ranit-a
pp,,�� N� minutes,seconds or ----
LONGITUDEiJ g &L_ in a decimal fonnat
Lati'ude/longitude source: OOPS ❑Topographic map
,location of wegmust be shown on a USGS topo map and
attached to this form I not using GPS)
4.WELL OWNER
OWNER'S NAME
ST " TADDRES D CD -
City or Town State Zip Code
A�aa code• Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
to. DOES WELL REPLACE EXISTING WELL? YES❑ NO O
//�� ��tt
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WAT ER LEVEL Below Top of Casing: _-660 FT. 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use"+'If Above Top of Casing) RECOR BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT.Above Land Surface•
•Top of casing terminated at/or below land surface may requireI `r
a variance In accordance with 15A NCAC 2C.Ot 78. SIGNATURE OF CERTIFIEDt6CA0?N+ACTOR DATE
e. YIELD(gpm): METHOD OF TEST BlOW Russell S. Tav
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information 1617 Mall Service Center-Raleigh,NO 27699-1617 Phone No.[phone] ext 568. IIRECEIV�etL�OS
FEB 0 7 2006
le Regional Office

.,""sTA7Fd
I 1VQN�RESIDENTIAL WELL CONSTRUCTION RECORD,_
11 111 �1
on Carolina Department of Environment and Natural Reso.uccs•Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 2045
1.WELL CONTRACTOR: 1, DISINFECTION:Type H T H Amount 166Z
James B. Bx'own g• WATER ZONES(depth).
Well Contractor(Individual)Name From To From To
He den Brothers Well Drilling, IriC. From To From—To—
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
h DTpth D We. Malarial
From o l
NIC 2A734 Ft.F - ntyklioin
Slate Zip Code From To_Ft. _
Saa 369-9591 From To Ft._ _
Asa code- Phone number - -
7. GROUT: Depth Malarial Method
2.`t,LLL INFORMATION: - FromQ_To�_Ft..CE[Ta t & 17HYtltt.2 �n2ti
$11E WELL ID*(if applicable) From To_Ft_.
STA,TE WELL PERMIT#(II appiiceble) From To_Fl.
DW9 or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
From To Ft. In, in.
WELL USE(Check Applicable Box: ❑Residential Water Supply —
� From To_Ft._in. _ in.
DI 1 E DRILLED J From To_Ft. In. in.
710 . :OMPLETED AM PM 9. SANDIGRAVELPACK:
3.W!ELL LOC TION Depth Size Material
From To Ft_.
CITV; COUNTY LII From To_Ft.
�p From To Ft.
/Street Name,Numbers,fornmunity,SubdlNslon,am No.,Parcel,ZIP oat)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope pvalley ❑Flat ❑Ridge 00ther From To��//L� Formation Description
(check apPrdprlate box) May
format
, 0 Clay_an & sand
Mayte iamendso , r CiL'dTllte
LATITUDE ,� _ minutes,aecoMs or
LONGITUDE_ in a decimal
Lafftude/longitude source: ❑GPS oTopographic map
(:'ooatlon or we#must be shown on a USGS fopo map and
silached to thle loan not using Gy 11P5) _
4.w•;i,L OWNER rJ
ViNER'S NAME
STREET ADDRESS
6�
ity or Town Sla a Zip Code -
Area code- Phone number
11. REMARKS:
S.W'%.L DETAILS: t
a. ",OTAL DEPTH:�,3
Is, ODES WELL REPLACE EXISTING WELL? YES 0 NO❑
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
e. WATER LEVEL Below Top of Casing:--1.50D.-FT. 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Uas'+'N Above Top d Casing) RE "Al BEEN PROVIDED THE WELL OWNER.
d. FOP OF CASING 18 2 FT.Above Land Surface* � D5
'Top of casing terminated stlor below land surface may require IGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accord ce with 1 SA NCAC 2C.0118.
e. YIELD(gpm): METHOD OF TEST 131OW James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: In rmatio RECEIVED
+E I VE D Form G •1a
1617 Mall Service Center-Raleigh,NC 27699.1617 Phone No.(919)733.70t5 ex 568. Rev.7/0
FEB 0 7 2006
Asheville Regional Office
Aou'rfer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD,;\
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION fl 2045
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 16 z
James B, Brown 9. WATER ZONES(depth: I
r
Well Contractor(individual)Name From To From To
Hedden Brothers Well Drillinc7, Inc. From �b rTo ` /s� ' From To
Well Contractor Company Name - From To From To
STREET ADDRESS 73 H011y Hills Vista Rd S. CASING: Thicknessl
Depth D' m'ter Wei h M terlal
_FYanklinFNC' 28734 From To1y�Ft.= y[,� �[�
Clry or Town State Zip Code From To Ft.
( 828 )- 369-9591 From To_Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material - Method
From_.Q_To 20 Ft. OaTEnt &hfflalt2 7
SITC WELL ID#(If applicable) From To Ft.
STATE W ELL PERMIT#(Ir applicable) From To_Ft.
DWQ of OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameter Slot Size Material
W -_USE(Check Applicable Box): Residential Water Supply p From To_Ft_in. _ In.
From—DA le
'.E DRILLED t I 'I l-Q From To To—Ft_In. _ In.
T,Vh COMPLETED AM p PM❑
9. SANDIGRAVEL PACK:
3.WELL I- ATION: Depth Size Material
NTY ­�� From To_Ft.
From To Ft.
c From To - Ft.
(Strut arcs,Numbers,Community,SubdrYsion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC!LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Rldga pOtner F% Formation Description
(shack apprdpdate box) r
May be in devices. & Band
r r
LATITUDE _L_ minules,Seconds or --Granite
LCt'�l:TUDE__ in a decimal formal
U T .ac/longitude source: ❑GPS ❑Topographic map
(location or web must be shown on a USGS topo map and
attached to this loan A,not using GPS) 4�-
4,WL61L.OWNER
OWNER'S NAME
ST4' TAD RESS
city or Town Sts{p Zip Cods
C_U L/f 1-
A s ,,do. Phone number
11. REMARKS:
5.W,-L()ETAILS: r
A COTAL DEPTH:-
-b. LUES WELL REPLACE EXISTING WELL? YES p NO p
�((J�l.� I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE Win
e. WATER LEVEL Below Toed Casing: FT, 15AN C20.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+'S Above Top of Casing) R HAS SEEN PROVIDED TO THE WELL OWNER.
d, TOP OF CASING le 2 FT.Above Land Surface- ///7/J S
.'Top of casing terminated Wor below land surface may require NATURE O CERTIFIED WELL CONTRACTOR DATE
a variance In accordance With ISA NCAC 2C.011 S.
e. *=LD(gpm):_3 METHODOFTEST Blau James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Sul.,tit the original to the Division of Water Quality within 30 days. Att : Inforr@t�l 'V E D F m Gwaa
161 all Service Center—Raleigh,NC 27699.1617 Phone No.(919)733-70 5 ext S�d8B1e Fi .7/05
FEB 0 7 2006
Asheville Regional Office
Aquifer Protection

STA7r
d �
RESIDENTIAL WELL CONSTRUCTION RECORD_:
North Carolina Department of Environment and Natural Resources.Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 2O45
1.WELL CONTRACTOR: - 1. DISINFECTION:Type H T H Amount 1 68z
JCS B. Brown g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
HeWen Brothers Well Drilling, Inc. From To From—To—
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6, CASING: Thickness!
Depth Millimeter W i h ter' I
;4nkTinF,N(: �8734 Fro m�To Ft. _
•City w Town State Zip Code From To Ft.
( M 1- 369-9591 From To_Ft. _
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
, From_Q_To20 Ft._WfElt & fflarli T111pH3
SITE WELL ID#(If applicable) 1,AD� ' G77 ` /Pt(� From To Ft.
STAYS WELL PERMITO(if applicable) From To Ft.
DWG or OTHER PERMIT N(if applicable) S. SCREEN: Depth Diameter Slot Size Material
W i,..l.USE(Check Applicable Box): Residential Water Supply From To—
From
_ In.
From To Ft.
n._in. _ In.
D:t_DRILLED From To_Ft.—In. _ in.
TIME COMPLETED AM❑ PM t/ S. SAND/GRAVEL PACK:
0.WEL L LOC I Depth Size Material
CIT. COUNTY From To_F.
From To_Ft.
From To_Ft,
(S reef t Nama,Numbara,Oommuniry,subdlWalon,Lot No.,parcel,ZIp Cods) -
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑flat ❑Ridge ❑Other From To Formation Description
(check apprdprials box)
May t e in seconds
Y & Sand
LATITUDE �� t r (:rani
p� minute,eaonds or
LC'r'GITUDE�[ in a decimal format
L.t� .,-/longitude source: gUPS OTopographic map
acallon of welf most be shown on a USGS topo map and
attached to this loan 7 not using GPS)
e.WELL OWNER
OWNERS NAME l
STREET ADDRESS
73
City or Town 43 ale Zip Code -
( 9,41 )-
An, code- Phone number
11. REMARKS:
5.W"..L DETAILS:
a. I OTAL DEPTH:_(S,�_
b. frf1E5 WELL REPLACE EXISTING WELL? YE$p N0
'--7(y�U�— IDO HEREBY C WELL
CONSTRUCTION
THIS WELL WAS CONSTRUCTED AND THAT
IN ACCORDCOPY OF THIS 1
e. WATER LEVEL Below Top of Casing: FT. taANc C.WELL CONSTRUCTION STANDARDS.aNOTNATACOPY OF TIIS
(Vse'+^HAbwe Top of Casing) REO N $BEEN PROVIOEO NE WELL OWNER.
d. TQP OF CASING IS 2 FT.Above Land Surface-
*Top
/� U�
^Top of casing terminated st/or below land surface may require NATURE OF C IFIED WELL CONTRACTOR DATE
a variance In acc dance with 15A NCAC 2C.0118.
e. YIELD Igpm): METHOD OF TEST B1aW James . Brown
PRINTED NAME OF ERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Informatlon MR E C E I V E 4orm GW-1
161' JvIl Service Center—Raleigh,NC 27699.1617 Phone No.[phone] ext 56 Rev.7/06
MAR 0 8 2006
Asheville Regional Office
„AquifAr Pro1P^ '

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print p Q L[�d[V G// CERTIFICATION 9 '313
WELL CONTRACTOR COMPANY NAME- cmre�Ml. 6r}}J�trryy Wt II J &hip, D-C. PRONE #JL4 G7Sp 'J/74
STATE WELL CONSTRUCTION PERMIT# /5 __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. WEI.I.LOCATIOI_J: Topographic/Land setting
NcarestTlown: J y� County ',Ridge ❑Slope ❑Valley ❑Flat
T e7 Ha A� /act e s (check appropriate box)
(Street Name,Nundicts,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_ I uc- IR1 At 7'otD'54 4 IJ�j eAPA (degrees/minutes/seconds)
Address —_ 4 ).3 --r)nl Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
t S t I Ne )8 7 BG DEPTH DRILLING LOG
city or Town State Zip Code From To Formation Description
( } 6 83 '
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
REPLACE 1rv,IS!!N(' WELL? YES L1 NO �( -
7. STATIC WATER LEVEL Below Top of Casing: 2,06 FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Top ofcasing terminated aUor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): /A6 METHOD OF TEST
10. WATER ZONES(depth): fl DS ' - /Do _
LOCATION SKETCH
IL DISINFECTION:Type kT f_ Amount /S/ ,Ll1JA , 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--K3-Ft. G �I pile
From _To Ft. _
From To Ft. l.`{
13. GROUT: Depth Material Method
From To_,p�Ft. - a -- 4
From �a,To Ft.
14. SCREEN: Depth Diameter Slot Size Material --
From----To Ft. in. in. RECEIVED
From To Ft. in. in. CO ,
15. SAND/GRAVEL PACK: Q'
Depth Size Material MAR 0 8 2666
From To Ft.
Front_--_-__To Ft. Asheville Regional Office
16. REMARKS: A uifer Protection
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

00 't �� � �"
.. ey a �, c
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N rural Resources-Division of Water Quality-Groundwater Section
W ELL CONTRACTOR(INDIVIDUAL)NAME'(print),�j�Eli� O✓&L —n ,�f CERTIFICATION# _J,y
WELL CONTRACTOR COMPANY NAME�� ezwi�(�N� � S,�I)GLL Y-III MI� PHONE # (PZ5) 6 V6 - f/J C)
S FATE WELL CONSTRUCTION PERMIT#-14 0 Z- .__ASSOCIATED WQ PERMIT#
(if applicable) — (if applicable)
Id'/
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: 11 A Topo�hic/Land setting -
Neare tTown: L CounJ C OA) ORidge ®Slope OValley ClFlat
/ S Am .�no, AL S LIu-V (check appropriate box)
(Street lJNaaame.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location -
3. OWNER: (degrees/minmes/seeonds)
Address /55 SUL,�Ni/�. SQL/ �J7 Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
k 4g6M LL ac- 2-87� (, DEPTH DRILLING LOG
city or Town State Zip Code From To For ation Description
Area code-Phone number f
4. DATE DRILLED /Z -7.7 -05
5. TOTAL DEPTH: ,�✓nn.5 ' _
'J!)FS 11�C1.1_ REPLACE yv,(Srin(ri WELL?° YES❑ NO r l
7. STATIC WATER LEVEL Below Top of Casing:q O FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surfaces
-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 Zil s
10.WATER ZONES(depth): ZOO
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 atenal numbers and common road names.
From-0—To 9& Ft.b g _p✓c,
From To Ft.
From To Ft.
13. GROUT: Depth Material Methoj� _
From_Q_To Z'y Ft..�
From To Ft. _�
14. SCREEN: Depth Diameter Slot Size Material RECEIVED CDFrom__To FF—m. in.
From To Ft, in. in.
c�
i5. SAND/GRAVEL PACK: M pp q C
Depth Size Material nR 2 7 2ON5 -
From To Ft.
From __To Ft. Asheville Regional Office
16. REMARKS: Aquifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAL UURE 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

NYELL CONSTRUC ION RECO 7 3_ 6e;7- Sr -3 3
North Carolina Department of Environment and Natural R/esouurces-Division of Water Quality e�
WELL CONTRACTOR(L J
NDIVmUAL)NAME (print) / L4-:7y, J�t�+-I�4- CERTIFICATION# ,2 ��) 7
WELL CONTRACTOR C06IPA.NY NAME AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential K Municipal(Public❑ Industrial❑ A.iculmral ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION':, Topographiciland setting
Nearest Town: '" - .L County / /V Midge Lope ❑Valley ❑Flar
.JF 4� (A-C, - lE� s -- z ea /r _ (check appropriate box)
(Seeet Name.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: I l 0:& -Y l �i_i�Lv--C� --tom_ i ] 1 (degrees minutes/seconds)
Address �) '�• ,� -tih�--. f Latitude/longitude source:❑GPS❑Topographic map
— Sdeci q; ute No) 1 i - (check box).
11, C 9eY 7r 5 DEPTH DRILLING LOG
—CIryL'r�iown� qte c, ip d From To Formation Description
Area code. bet
4 DATEDRILLED '�9
:2� 0
5. TOTAL DEPTH:
6. DOES WELL REPLACE
EXISTING WELL? YES ❑ NO FT. � !(s t 9
7. STATIC WATER LEVEL Below Top of Casing: , 2_ ' i
(Use-,-if Above Top ofCasin_) L..� _ LZ].� _.`
8. TOP OF CASING IS_ FT.Above Land Surface'
'Top arcasin;terminated at'or below land surface requires
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): � (•) METHOD/-O/F TE j
10. WATER ONES (depth): �> '`�t - -
LOCATIONSKETCH
It. DISINFECTION:Type Amount O Show direction and distance in miles from at least
12. CASING: �ti all Thickness two State Roads or County Roads. include the road
Depth Di�a�peter or Weight/R. Material, numbers and common road names.
From C) TZ� Ft.�%-�
From To Ft. ��
From To Ft.
13. GROUT: Depth Material Method
From— �To 3 Ft. 114-Z
From 3 To r,2 Ft. :, I .� a.s,,,., V1J
14. SCREEN: Depth Diametzr Slot Sizz . Material '
From To Ft. in. in.
From To Ft. in. in. -
15. SAND;GRAVEL PACK &-li=C',/t- - �
Depth Size Material
From To Ft. �"E' 4
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WE L WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU 1 N ST N - ,AND AT A COPY OF THIS RECORD HAS BEEN PROVIDEDTO T E WE L OWDi R
3 , 60
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quali ,Attnrt rjsfajioq b�{�te.�ment,161 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.(919)733-70I5,Nit in 30 t�i CC 88 VV LL
sr� r-n GW-1 REV.09/2004
Asheville Regional Office
Act Uifer r rotection

`YELL CONSTRUCTION RECORD �.�C 73 /V
North Carolina Department of Environment and Natural esources-Division of G=4 7-. l ,
WELL CONTRACTOR(LNDIVIDUAL)NAME (prlat)J (&' G 'z.L) CERTIFICATION A_:36
WELL CONTRACTOR COJIPANY NA3IE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. pHONE A [phone]
STATE WELL CONSTRUCTION PERN1174 ASSOCIATED WQ PERM fN
(if applicable) (if applicable)
L WELL USE(Check Applicable Box):ResidentiaA MunicipaVPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection[I Other❑ IF Other,List Use 324284
2. WELLLOCATION:,. J TopographicQandsetting
NearestTewn: County ' ❑RidgeXSlope ❑Valley ❑Flat
14.1/. _ (cheek appropriate box)
(Street game.Numbers,Community.Sub,fivision,Lot No.,-Zip Code) - -1 Latitude/longitude of well location
L
3. OWNER: r 1'-' C`'-Gr�,L (degrees/minures/seconds)
Address 57 ' Latitude/longitude source:OGPSOTopographic map
(Sweet or Route�'�p) (check box) .,
/ C _Q 3 7, 1 DEPTH DRILLING LOG
City orTown State Zip Code From To Formation Description
(?-)- 770 ... SSA 5 —SC- 32--
Area code. ber
4. DATEE DRILLED DRILLED
r) L
5. TOTAL DEPTH: b°
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N0 3P
7. STATIC WATER LEVEL Below Top of Casing: 4 ; T.
(USc-+-if Ahove Top of Casin_) -
8. TOP OF CASING IS_�FT.Above Land Surface.
'Top orcasiag terminated at/or below land surface requires a
varisnceia accords cewith l5ANCAC2C.0118.
9. Y"IELD(gpm): METHOD OF TEST / V-
10. WATER'GNES(depth): 170
LOCATION SKETCH
11. DISINFECTION:Type Amount .Y L S Pow direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di eter or Weighb'Ft. Mate numbers and common road names.
From 7'oLt/ Ft. 5PIZ 2
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To
Ft
From ? To �"[; Ft.,c��.c'-
Slot Size
14. SCREEN: Depth iamztaD 2r h(aterial ✓.y��1L�
From To Ft. in. in. /
From—To—Ft.—in. in. � 6K�1L Lzi� 7
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
From—To—Ft.
16. RENIARKS:
1 DO HEREBY CER IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT( ANDARDS,AND THAT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
U�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Atta: Information Management,1617 mail Service Center-
Raleigh,NC 27699.1617, Phone No.[phone],within 30 days. ----
R E C E I E D Gt -I REV.09/2004
i
Asheville.Regional Office
A uifet Protection

YELL CONSTRUCTION RECORD 7& 3 6 71 3 ,
North Carolina Department of Env'mirr/o
icunent and Natural•Re'sources-Division of Water Quality
WELL CONTRACTOR(CIDIVIDUAL)NA3tE (priot)IJL• /yam" e' CERTIFICATION#-3�t��
WELL CONTRACTOR CObtPA.\Y NASIE AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERAIIT# ASSOCIATED W'Q PERM1nT# \(\\/\�-XJ-'j✓
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residentiao Municipal/Public❑ Industrial❑ Agricultural❑ 6) q p
495
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use f" �+ O
2. WELL LOCATION'.. .
. ,/_ Top Mlopfc/Land setting
\{t{ores[Town; 6L Zt„i �Counry �/-� ❑Ridge �S'lope ❑Valley ❑Flat
T ( JCL[✓i� «� ?—,�G �� (cbeckappropriate box)
(Seca Name.Numbers.Community,Subdivision,``Lot No.tip Code) LatiNde.90ngi[ude Of WCII location
3. OWNER:[ _�f L��, :4, GC, (degrees/mioutes/seeonds)
Address �j 3 (: t .:. /--.y...Ci Latitude/loneimde source:❑GPS❑Topographic map
(Street or Route No.) (check box).
� Z�,U ) ) C, >Z S 7 Y � DEPTH DRILLING LOG
C-- State zi Code From To Formation Description
V53- 5(--- Z,
Area talc-Phone number ' I
4. DATE DRILLED 0 - 7 G' f Uc-
5. TOTAL DEPTH: YLTo — / U
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A 11
157 cf�—
7. STATIC WATER LEVEL Below Top of Casing:_ /0- FT. p/� , y
(Usc'•+"if Above Top of Casing) C '
8. TOP OF CASING IS FT.Above Land Surface-
—
-Top ornsin;terminated ae'or below land surface requires a
variance in accordance with 15A\CAC 2C.0118.
9. YIELD(gpm): , IvfETHOD OF TEST i v�
10. Ll ATER .'.ONLY (depth): `� l
- LOCATION SKETCH
11. DISINFECTION:Type t I Amount 3 (✓ 4ti Show direction and distance in miles from at least
12. CASING: - Wall Thickness Y two State Roads or Count'Roads.Include the road
Depth Diameter or WeightTt. Material numbers and common road names.
From C 'Tcij �Ft. Y /JR ZI n✓ �, -
From To Ft.
From To Ft. �
13. GROUT: Depth Material Method
From l. To Ft.
From _To 7G, Ft. i,sK���._,(.� jf,U
14. SCREEN: Depth Diameter Slot Size 17 Materi I JC•-G�Z-c-
From - To Ft.—in. - in.
From To Ft. in. in. r
15. SAND GRAVEL PACK: t%
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
CONSTRUCTIONS NDARDS,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,Attn: Irtfeittratioo-Irha7ia'g men , ai enice Center-
Raleigh,NC 27699-1617, Phone No.[phone],Within 30 days. RECEIVED
i GW-1 REV.09;2004
r r1
r „
Asheville Regional Office
Aquila Protection

`YELL CONSTRUCTION RECORD
North Carolina Department of Env" amen and Natural Resources-Division of Water Quality .
WELL CONCRACTOR(LNDIVIDUAL)NAME (print);-./ /!�`"L�{ - CERTIFICATION# 30 v(
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PMNUT# ASSOCIATED W'Q PERIDT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Jk( Municipal/Public❑ Industrial❑ Agricultural❑ 1 c) 9
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use .G O 6
;2. WELL LOCA ON; Topo.araphic/Land setting,Near• tTown �Cr--Ci County` ❑Ridge OSlope ❑Valley ,QFlat
y I'kl s L 7 2 ) (check appropriate box)
(Street Name.,Numbers.Communiry ubdivision,Lot No.,Zip Code) Latitudeflongirudz of well location
3. OWNER: 4i 7 i7.e' (degrc&nninutes/seconds)
Addffdess ) � L Latitude/lon-gitude source:0GPS❑Topographic map
�^ (Street or Rowe No.) (check box).
F4 J / DEPTH DRILLING LOG
6tv or Town 5
Mpt I �' / Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED l ��" O �J )( p 216 C-
5. TOTAL DEPTH: ;C l
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -
7. S7ATIC WATER LEVEL Below Top of Casing: (L4) FT.
(Use-+-if Above Top fCasin¢)
8. TOP OF CASING IS 3 FT.Above Land Surface-
'Tap of using terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C.0118.'
9. 5'IELD(epm): Zij METF(QD OF TEST IU/
10.W',STFR�ONFS (dcpth)� C) -
-- —--- ---_— LOCATION SKETCH
11. DISINFECTION:Type Amount 1 Show direction and distance in miles from at least
12. CASING: Wall.Thickness "two State Roads or County Roads.Include the road
Depth Dia eter. or WeightTt. NI ena numbers and common road names.
From !] :To•) a )46
may ,,.�
From To Ft.
From - To Ft.
13, GROUT-( Depth M4terial Method �y l
From C� To_ Ft. [ c'//�u:�—I �
From To YJ.._r1l IZI-L��+
14. SCREEN: Depth Diameter Slor Size teriat
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
From--To—Ft.
16. REN(ARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Iv ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDEDTO THE)YELL WNER
c2
StGNATLME OF PERSON CaMTRUCT[NG THE WELL OATE
Submit the original to the Division of Water Quality,Attn:Informatiaa.h a ail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],Within 30 days RECEIVED GW_1 REV.0912004
! Asheville Regional Office
( Agl,lif2s' i'roteciiDn

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and lnNattuural Resources-Division of Water Quality '7
WELLCONTRACTORUNDIVID ME UAL)NA (prlat) D f r �i CERTIFICATION Z &',
-WELL CONTRACTOR COMPANY NAME& PHONE #
_ STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable) ry
1. WELL USE(Check Applicable Box):Residential X Municipal/Public❑ Industrial❑ Agricultural❑ 2 4 O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI01 : Topographic/Land setting
Nearest Town: ou ❑Ridge [3$lope ❑Valley ❑Flat
z (check appropriate box)
(Street ,Numbers,Communl ,Subdivision, t No.,Zip Code) 1 LatitudeAtingitude of well location
3. OWNER: (degrecs/minutes/xconds)
Address _ LatimdeAongitude source:❑GPS❑Topographic map
LL,.6 (Fteet or Route No.) /) (check box)
X� ) 3 q S DEPTH DRILLING LOG
City or Town State Code From To Fo anon Description
Area code-Phone number V �'
4. DATE DRILLED 7-
5. TOTAL DEPTH: S 0-2 2 o tf Z
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA u Z -3 c2J
7. STATIC WATER LEVEL Below Top of Casing: _FT.
(Use"+^if Above Top of Casmg)
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(gpm): METHOD OF TEST_ A I J _
10.WATER ZONES(depth): J
LOCATION SKETCH
- 11. DISINFECTION:Type Amount _ _ ^P how 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/FL Mat ria numbers and common road names.
From 0 To_'�U Ft. (,V,t— 11 J
From Ft.T
From To Ft.
13. GROUT: Depth Material Method
From To�Ft.e)
From To Ft.
14. SCREE Depth Diameter Slot Size atenal -trZ�>
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: t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER _
':§e ArU—v)�RSON `UCT HE WELL DATE
Submit the original to the Division of Water Quality,Att*:InforRa�eivl®e[eraenA,1617 Mail Service Ceater-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. 6. L::�t 11!! GC LLJJ
OW-I RFV. 09/2,004
.,
Asheville Regional Office
Aquifer Protection

t YOM . .3LL CONSTRUCTIO\r 7s r" fIl '" fig/
North Carolina Department of Env o t and N�1atC 1 esources-Division of Water Quality
r
WELL CCIDSYmL'AL)NA}tE CERTIFICATIONM
ONfRACCOR( �I
. "' •..,.)YE AAA GRE EWGOSLV , O (828)Sa8-5o50
YYA E BROS. .
LLCONTRAC70RCOSIPA h
'
y.c'�c..,•-x<.: ;sx.. .- ASSOCIATED W - _ -
STATE WELL COSSTRL'CTIOY PER-vtII% Q PER.�QTq:'..;' (if aPPlicablt) -- - -
(if��jliciblc)
1. WELL USE(Check Applicable Boz):Residential MunicipaVPublic❑ Industrial❑ Agricultural❑ /e.J
Monitoring❑ Recovery ❑ "Heat Pump Water Injection❑ Other If Other,List Use fJ
2.'WFLL LOCATIO Topographic/Land setting
Near Town: Lim C*µnry ❑Ridge _OSlope ❑Valle tat
l tt" �q/ ,_ (check appropriate box)
(Svctt Name,Numbers,Communtry Subdivisi Lot�.,Zip Code) _ Latitude/longttude Of well location "
3. OWNER. G i r (degrees/rmoutestwonds)
Address - = Latitudenongitude sourcc:OGPSOTopogmphic map s
(Sa'ea or Route No) (chmkbox) -
(jtf,Z DEPTH DRILLING LOG
iryorT wn rate2,/�-� Zip code From To Formation Description
828 f
Area code•Phone number
4. DATE DRILLED !L a 3_-RVO
5. TOTAL DEPTH: -
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO tg� O
7. STATIC WATER LEVEL Below Top of Casing: V:�LQ_FT. ,e 0 — s C y
(Use"+"if Above Top of Casing) 6—/Z _ U
8, TOP OF CASING IS FT.Above Land Surface'
-Top ofcasine terminated allorbelow land surface requires a -
variance In accordance with 15A NCAC 2C.0118. n
9. YIELD(gpm): ;4') METHOD OF TEST !T I {J
10.WATER ZONES(depth): �V/a/ 0 LOCATION SKETCH
5
!.-P(S(NFECTION•Type _ j_ Amount
I - Show direction and distance in miles from at least
L Wall Thickness 'fwo State Road;at Coun.tq Roads Include the Toad
CASNTFE
Depth Diameter d or Weight/Ft. hlateriai numbers and common road names
From 0 Tc �Ft.14_
From To FL C=
From Ta FL
13. GROUT: Depth Mgterial (ethod
From C� To 3 Ft.
From_To_�_Ft. W r `"'"' •
14. SCREEN: Depth Diameter 1Slot Size Matznal
From To Ft. in. - in.
From — Tc Ft in. , in. : ;g
15. SAND/GRAVEL PACK: -'
Depth Size . Material
From r
From To " "
Ft. -_ _
From To Ft . , - Y
I6. REMARKS: j
a +:
IDO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC2C WELL
CONSTRUCr1ON STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CO IJSu, Ir
Submit the original to the Division of Wpter Quality,Attn:Information ivlanagement,7617 Mail Service Center
Raleigh;NC 27699-1617, Phone No:.(919)-733-7015,within 30 days._ - ��•; ! RF.V 09'200.1
RECEIVED
. i
Asheviile Regional office
Aatail'at_�Prctection

CONSTRUCTION RECORD 17,57 3 0 ./
North Carolina Department of Env'ronment and Natural Resources Division of Water Quality
t WELL CONTRACTOR(LYD[✓mUAwLLNIE (print)' CERTIflCATION.N �o
AAP.GR NE BROS.WELL DRLG.OFSriV C. PHONF B [phone] r -
�}YECL CONT2ACTOR COMPANY NASIE
'= STATE WELL CONSTRUCTION PER.yt1Tf. - ASSOCIATED WO PE DT8 `
"-'(if applicable) -- - (if applicable)_'
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring 0 Recovery J3 Heat Pump Water Injection❑ : Other❑ If Other,List Use
2. WELLLOCAT[ Iopographic/Landsetting
Nearest Town. unty [Midge ;❑Slope []Valley ❑Flat
d' 77� :(shack appropriate box) .:.
(5¢cet Name,Numbcrs, mmunrry Subdivis n,Lo o.,Zip c) , Latitude/longirude of well location
3. OWNER: (dcg ecs m nuus seconds) .,"
Address Latitudellongitude sourceOGPS❑Topographic map
. . a roNo. - _ (check box)
(S¢e .`
�� •"-M? 7 DEPTH DRILLING LOG
City,�o Town sote zip Code From -To _. Formation Description
code-Phone num DAber -
4. DATEDR[I.LED �l / t U� z
5. TOTAL DEPTH: L ly Z ±�
6. DOES WELL REPLA E EXISTING WELL? YES ❑ NO 5K
7. STATIC WATER LEVEL Below Top of Casing:� O k I,
(Use"+"if Above Top of Casing)
g. TOP OF CASING IS FT.Above Land Surface-
-Top ofessing terminated actor below land surface requires a
variance in accordance wit ISANCAC 2C.0118. n
9. YIELD(gpm):_�METHOD OF TEST A I r,
10.WATER ZONES(depth): 20 D
LOCATION SKETCH
11.-DISr\TECTION:Type_ Amount.�� ���� Show direction and distance in miles from at least
I2. C FrS.ti G: ti „ i:i l - )'livo S t,,c Ponds or Corey P.oads Include the road
Depth D' me er or Wei VFt. MateriaF'/ numbers and common road names.
From y To 'W Fr. 502 zr 4y✓G [ /�From To Ft.
From To FL
13. GROUT:
_ Depth � lethod
T hl9ted
From ' o �O
3 FL _ V t—
From__'�_ _To 2.0 Ft.
._14. SCREEN: .. Depth Diameter Slot Size ,Material .From To FL in. _ in.
From - To Ft. in. in.
15. S.AND/GRAVEL PACK:
- Depth - Siz_e`. .Material
From To Ft. X
From To "Ft. 7 .
16. REMARKS: b
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED,INACCORDANCE Wri-H 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S TjY
fl
S _ v .T R� li t .S'JAC .r!_ C-1 T ,H, DAi.
Submit the original to the Division of}Yter Quality,Atto:Information Maaagement,1617 Mail Service Center-
: Raleigh,NC 27699-1617, Phone No.[phone],withru 30 days.
G\'/-1 REV.09;2oo=
PECEIVED
Asheville Regional Office
) At:*,uife( Protection

s ° . HELL CO\rSTRUCTIO y'RECORD
North Carolina Department of Environment and Natu 1 Resources-Divtston of Water Quabry
WELL CONTRAC[OR(CID[VtDLtAL)NA}� (print) CERTIFICATION R_,'j 7 ����''✓ #.
. 's ? ' 828 586-5o50 r t
.. -WELL CONTRAC[ORCOivfPA.\Y NAS(E OGRE EBROS.WELL DRLG. VA,INC. "PHONEA ( ) .;
-STATE WELL CONSTRUCI'ION PER?fIT% ' ASSOCIATED WQ PER}tITM '
(ifappliEable)`- - - ( PP
t WELL USE(Check Applicable Box).Rest enha Municipal Public❑ 'Industr al❑ Agricultural❑
Monitoring Recovery O Heat PumpWa r njection❑ Other If Other,List Use Rd
2.`WELL LOCAT ). '� - _Topogemphic/Land settin¢ j
Ne e To ❑Ridge Slope =OValley lat
7Zeck appropnate box)
¢at Name Numbers Commumry Subdi son, ahlL ongitude of well location -
c - i a . �r
3. OWNER:' = ` (degmcinsinums/secoods)
Address ` Latitude/Iongitude source:OGPSOTopographic snap
(S¢ ct or Route No.) _ (check box) .r
- DEPTH ' DRILLING LOG
Ciry or own State -Zip Code - -From :To For nation Description
8(_ Z�
Area code.Phone cumber --
4. DATE DRILLED f�3
5. TOTAL DEPTH: tO
6. DOES WELL REPLACE EXISTING WELL? YES O O
7. STATIC WATER LEVEL Below Top of Casir g T.
(Use"+-if Above Top or Casing)
8. TOP OF CASING IS FT.Above Land Surface•
-Top of using terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(¢pm): METIjOD OF TEST 1 {�
10.WATER BONES depth):
LOCATION SKETCH
IL DISINTECTION:Type Amount Show direction and distance in miles from at least
12. CASING: /Jl�•%o Stata Road;or County Roads include the road
Depth -D)ameter or Wcig L - Materials numbers and conmon road namzs
From I To�5�Ft. L S 012- Oy G
From To Ft.
From To Ft.
13. GROUT: Depth Mated
- From d To .3 Ft.
From To 2O - FL 7 v T ✓Y
14. SCREEN: Depth Diameter Slot Size Ma[enal
From To Ft. in. in.
From To - Ft. in. in.
15. SAINOGRAVEL PACK: - - - --u
Depth Size' -Material
-:.From To Ft.
. ::
From To Ft.
zs
16. REMARKS:
t 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
-_ - ` IC ;A U L 0 _y THE REL1 D I E
Submit the original to the Division or W,later Quality Attn:I form2doh Management 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No:[phone],within 30 da . RECEIVE
d -1 REV. 09/2004
Asheville Regional office
Aa lifer Pro?ectiort

WELL CONSTRUCTION RECORD 7
North Carolina Department of Environment and Natural Pesources-Division of Water Quality ([/ `
e > WELL COCfIR:ICCOR(fYDIVmUAL)NA.NE (print)��Z'-i'—^ "2�� CERTIFICATIOYM � 7 -I
WELL CONTR1&bR C051PA.YY NAbIE AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # (828)586-So50
STATE WELL CONSTRUCf10Y PASSOCIATEDR
lT%. ASSOCIATED WQ PENOT%
c if applicable) - (if applicable)
1. WELL USE(CheckAppluable Box):Residential NlunicipaVPublid❑ Industrial❑ Agricultural❑
Monitoring❑ _Recovery.❑ Heat Pump Water Injection❑ Other❑ If Other,List Us!
2. WELL LOCATION ©© Topographic/Land setting
Nearest Town ` L County ❑Ridge :-1 lope ❑Valley ❑Flat
-'(cheek appropriate box)
'._(Sacct Name,N..bbters.Commumry,Subdivision,Lot No.,Zip Cade) = tatitiTcleflonintude of well location
3.'OWNER (degrecs/minutes/seconds)
Address t hn YYtit: St72-0 atitudcAongitude source:❑GPS❑Topographic map
�R Route No.) ..'j It (checkbox) -
DEPTH DRILL ING LOG
City or Town _ SdtM Zip Code From To Formation Description
Area code.Phone number -
4. DATE DRILLED -/37>
5. TOTAL DEPTH: is-2/ 7 T -,;1 7-7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO or- a 7 7 — 3 r!Z
7. STATIC WATER LEVEL Below Top of Casing: (4u FT.
(Use'•+"if Above Top or Casing)
8. TOP OF CASING IS FT.Above Land Surface`
-Top orcastog terminated actor below land surface requires a -
variance in accordance with 13A NCAC 2C.0118.
1
9. YIELD(gpm): --METHOD OF TEST
10.WATER ZONES(depth):
LOCATION SKETCH
11,-DIS(N F.CTInN'Type r Amount Show direction and distance in miles from at least
12: CAS(CG: ` _ \Fall Thickness
Stat Roadl- c Comay Ro'+at rn Cluriz t"c a .,t
Depth Diameter- -or WeighVFL Matena1�11 numbers and common road names.
From C) Toja& Ft. h yE SAIL Ll P�C�
From To Ft.
From To Ft.
13. GROUT: Depth Material fethod 0
From d To 3 Ft.
From 4 TopesFL
14. SCREEN: Depth Diameter - Slot Size .Material G1�ef\9—+ <
From To Ft. <--in. in.From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material _ -
From To -'FL
From - To Ft.
16. REMARKS: •; 1, ah
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W17Ii ISA NCAC 2C,WELL
...CONSTRUCTION STANIJARDSAjqD THAT A COPY OFT IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Submit the oriainalto the Division orVVpter Quality,Attn: Informitiong�M: an�aQa,emeyn�,® at Center-
Raleigh,Nf•27699 1617, Phone No.[phone],within 30 dayi.1 -8'2 sms E1 \r E
{ "2' ' REV.OT?0Q'
i
Asheville Regionai Office
i Aruifer Protection

WELL CONSTRUCTION RECORD 76 2 2- - 33 - S 6 s'7.
North Carolina Department of Enviro�I ///Qnt and
eNa cso es.-Division of Water Quality ;
WELLCONTRACTOR(IYDTVIDUAL)NAME (print) {./�r�/i,r - /1
�� CERTIFICATIONi LI V-/,
WELL CONTRACTOR CON�,4YY NA11tE�' PHONE M 2
STATE WELL CONSTRUCTION PERMTTA ' - ASSOCIATED WQ P -Irro
'«• (if applicable).ep'- zer ..-$ -1if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ -Recovery ❑-Heat Pump Watef Injection❑ Other❑ If Other,List Use
2: WELLLOCAT Nc i nr
Topographic/Land setting
N arestTown. " Countyp` '� Ridge ❑Slope ❑Valley ❑Flat
" (check appropriate box)
(Street Name,Numbers, Subdivision,Lot No.,Zip Code)7 z Latitude/longitude of well location ,
3. OWNER. x�da�-o (degrecsrmioutes/secoods)
Address 7-0 - Latitude/longitude source:❑GPS❑Topographic map
(Surd or Route (checkbox)
Z $7-7 DEPTH DRILLING LOG
ityor Towa State Zip Code .From To Formation Description
QGI - gn9 ()
Area code-Phow number
4. DATEDRILLEDIO 04 It q _ 5o2s-
5. TOTAL DEPTH: C a 5 S2 Y
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Q( S z6 (a �Z
7. STATIC WATER LEVEL Below Top of Casing:- i� FT. - Ica
(Usc"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' -
-Top ofcasing terminated actor below land surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_ METHOD OF TEST l it t 1
10.WATER ZONES(depth): 5 a
LOCATION SKETCH
1 I. DISINFECTION:Type (.{-j(,(- Ar¢ount 7S 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/FL Material numbers and common road names.
From D To /2�_Ft.__�_� 5otzZ- 61) ✓C,
From To Ft
From To Ft.
13. GROUT: Depth Material - Method —�
From__LL To 3 Ft
From To 2.D Ft.
14. SCREEN: Depth Diameter Slot Sze terial r rJ
From To FL in. in. ____ 7yc
From To Ft. in, in. p I
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 A OPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/o /s- 0 1
SIGNATURE OF PERSON CONSTRUCTING TVE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 NI26 Service Center- -
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.-----------
RECEIVED GW-I REV.09/2004
Asheville RedOrl,Til O lice

3 '" WELL CONSTRUCTION REC RD < � �
North Carolina Department of Environment and Natural Res` ces Division of W r ate Quality
-
i uWELLCONTRACTOR(LYD[VIDUAL)NA.�� (prtot) / { /LJLC� CERTIFICATION0 '� c s
';'F-.�"�"`�, "'st•'k"'.-^y .yam•�j,s"'¢'"l'`(- # "
SWELL CONTRACTOR COaIPA.\'YN.L�[EGREENE BROS.WELL DRLG.OF SYLVA. 50 INC PHOYEM (828)58SSa �''gj ,a's' "' -
'Y STATE WELLCONSTRUCTION PERV[ITa r�`' ASSOCIATED W
Q PERVQT% - 'sac✓`-� �`
,
1. WELUU$E(Check Applicable Boz) Restdetitial f bturitcipaVPublic❑ Industrial❑ Aricultural❑`
h[omtonng❑ Recovery ❑ Heat Pump Water In3echon[� Other❑ If Other List Ls
2. WELL LOCAT[O\r s s v k v
Toponraphtc/Land setting
1\earestT _wn County ❑Ridge_ Slope ❑Valley ❑Flat
:(check appropriate box)
(Soeet Name,Nu Commumry, i n,Lot No.; tp ode) `' Lahtude/longtude ofwmelwl locanonr r
3. OWNER." + (de eon es/mnu esheds) na
Add ,
WI
M Latitude/lon�it rde source.❑GPS❑Topographic map r
(Seett r Route No) = (cAcck box) ax y
f _ � DEPTH DRILLING LOG
or ioWn State - s. zi Code " From Tod Formation Description
82s 2R ��
Area code-Phone number —�
4. DATE DRILLED frj
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO f 7�
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 orcasing terminated at/orbeioW land surface requires a - _ .
variance in accords W th ISA NCAC 2C.0118.
9. YIELD(¢pm): J� METHOD OF I" 1 {J
10.WATER ZONES(depth): 9 7 c'
LOCATION SKETCH v
11. DISI\TE.CTION:Type_ R TR Amount 9,7 Show direction and distance in miles-fror at least
1 L I.» NG l,'aIl Thic'�esscss /'Fro"o St.. Road- or County Ro d, heL2h!he ro=ri
Depth - Dia eter or%Veight/Ft ptaterial'� numbers and common road names. s
From (] To a Ft.
From To FL
From To FL �jLsu�
13.-GROUT: Depth Mdterial tethod
From d To 3 Ft.
From=To D Ft.
14. SCREEN: Depth Diameter Slot Siie Material -`
From `- To Ft. in. in.
From To Ft. in. in.: - s=
15. SAND/GRAVEL PACK:
Depth- Size Material '
".,From To
. . . . �, ,
From To 4R.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS LL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCTION STANDARDS, B OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S
--- — --
- �rJ .!URE OF PF,i SOS C.ON kC f�C�� r I_ C:Aih
Submit the original to the Division of Wpter Quality,Attn:I orrmaApon ayetp gtlb})Njail SCri Center-
1106 h,NC 27699-1617, Phone No,[phone],within 30 day . r j I„r �, LJ t
MT-1 pFV n�-1on_
r
Asheville Regionai Office
A4 ljle� Protection

.YELL CONSTRUCTION REC RU
North Carolina Department of Env[roam t and Natu I Res es D[vtsion of Water Quahry r
,l
t SWELL CONr12ACCOR(LYDIVmUAL)N.1-�tE (pr[ot) �, �[.0 X` � c -2 CERTIFICATIONM �j
� Ly ELL CONTItACCOR CO�tPA.\Y hA.�tE AAAGREENE BROS.WELL DRLGLG OF SYCVA,INC PHOYE
h
STATE WELL CONSTRUCTION PEP-*,[IT% -" ASSOCIATED WQ pERNQT% s
--(ifapphcable)'w
I. WELL USE(Check Applicable Box) Residential Mumcipal/Public❑ Ind utnal❑ Aincultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other❑ If Other List Ls 42
2. WELL L CATION Topo¢�raphiv1and setting
NearestT'wm County ❑Ridge,,ia,Slope '❑Valley ❑Fla[
•` �-,.
(Socct Name,Nu Communtry twt n,Cot No+ tp ode)„ LiitituddI6ng[tudeofwell location ;
� rY
3. OWNER.`� '. _ `, ,ra _ ' ay(degrces/nnnu�slseeonds)
Addr ss '�- LatitudeAongitudz sourceiOGPS❑Topographic map_.. _ :,.
(S¢cet r Route No)> ' r(check boa)
DEPTH or Town State Ziggeode From To =`Formatior Deserip[ion
828 12c? ")Area code Phone number �'
4. DATE DRILLED-/�-' ��� _
5. TOTAL DEPTH: 7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 5K jyd ;�q 7,;-
7. STATIC WATER LEVEL Below Top of Casing:_(AFT.
(Use"+^if Above Top of Cuing) -
8. TOP OF CASING IS FT.Above Land Surface- t
'Top orcaaiao terminated at/orbelow land surface requires a
variance in accordan wth 15A NCAC2C.0119• 'y
9. t'IELD(¢pm): J� METHOD OF JASTz_„r( 1 k-. CD
10.WATER ZONES(depth): 17 «
LOCATION SKETCH
11. DISINFECTION.Type` _ Amount -Show direction and distance in miles from at least
12. LC C,,S . ,: Wall ThmA,C s o St I cr Ccunry P ate. IncInde the roid
- - Depth - Diameter.. or Weighh'Ft, t laterial numbers and common road names.
From t] To 9 Ft.�9% SDR?- CPV
From To Ft.
From To FL
13. GROUT: Depth Material tathod
From Q To 3 Ft.
From To�_Ft.- 1J21j W 7�N�', l/
14. SCREEN: Depth Diameter Slot Size Matzaai h
V\ y
From - To Ft. ' in. in.From To Ft. in. in.
15. SANOGRAVEL PACK:
Depth Size- Material
From To Ft. .
From To Ft. `I
16. REMARKS: 1
d DO HEREBY CERTIFY THAT THIS LL WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC 2C,WELL 3
`CONSTRUCTION STANDARDS OF THIS RECORD FiAS 13EEN PROVIDED TO THE WELL OWNER /
STANDARDS,; -> i ., S ate'
(2- 3 (
`rC .IUFf 0)FPFL50N1,
Submit the original to the Division of'Wpter Quality,Attn:Inf 16aiAaatt S^ms-e Center-
Raleigh,NC 2769-9-1617, Phone No.[phone],within 30 days. E2 R L 1 YP f.Z D -
G: 8J r (CPr t PFV. 0917(1Qd
Ashev�ilie Regional Office
Aquifer F(i otection

WELL CONSTRUCTION RECORD ��` �
7��1
North Carolina Department of Environment and Natural Resources-Division of Water Quality /WELL CONTRACIOR(LYDIVIDUAL)NA.-*rE (priotJ� � J CERTIFICAT70YM �D �(
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA INC PHONE B [phone]
STATE WELL CONSTRUCTION PERbIITX. ASSOCIATED WQ PER70Tp -
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential❑ MunicipaVPublic❑ Industrial❑ Agricultural❑
hfonitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land Setting
Nearest T n: Coun
J1Ridge ❑Slope ❑Valley ❑Flab
/' -..(check appropriate box)
(StreetN ,Nu hers, ommnniry, u ivision, ,t a., ode) Latitudeflongitudeofwelllocatiom-
3. OWNER: (de3reeshninuta/seconds)
dress Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No (check box)
M L � DEPTH DRILLING LOG
8 City or Town state Zip Code From To Formation Description
( 28 -
Areacode-Phone n beyy
um ��.. /
4. DATE DRILLED- � r J r
5. TOTAL DEPTH: S -a2
6. DOES WELL ERL:PLACE EXISTING WELL? YES ❑ NO ! ,�a y
7. STATIC WATER LEVEL Below Top"i Casing:� �/) FT. ���—
(Use"+"ifAbove Top fCTasing�)
8. TOP OF CASING IS�_FT.Above Land Surface-
*Top of casino terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm: METHOD OF TEST {�I
10. WATER ZONES(depth): �ij (�7
_ LOCATION SKETCH
1 I. DISfNPECTION:TyPe_. Amount_ �(, - Show direction and distance in miles from at least
12. CASING: Wall Thickness n
!� °o SLne oads or County koads. Include the road
Depth Diameter or WeighUFt, M�at ri'af11
umbers and common road names.
From Q To /30
Ft.
�From To Ft. /�++ n /'
From To—De FL / _ ;, i / // }
13. GROUT: Depth Material kthod vl �®`
From (� To 3 FL C�
From ToX_Ft.
���---"----fffF-----------,�, � L
14. SCREEN: Depth Diameter Slot Size Material
.Prom � To Ft. in. in. 0 -( - --
F To FL in. in.
15. SANAN D/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16, REMARKS: 1
I DO HEREBY CERTIFY THAT TH S WELL AS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND T OF THIS ORD HAS BEEN PROVIDED.TO THE WELL OWNER /
..( .I I-E C PERSt \ CO\STk;-- r,G 1-1 iE r4ELLL
Submit the original to the Division or Water Quality,Attn:Info mationk"rfijV6Lf oil Service enter-
Raleioh,NC 27699-1617, Phone No.[phone],within 30 days.
Asheviiie Reeionai oft
Aglai*e r'rntert on

32395 Ls
v WELL CONSTRUCTION RECORD 7 3 Z_ 7 S t�
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACCOR(LNDNIDUAL)NAME (print)"- k'Y Q-s ,✓ CERTIFICATIOYp
WELL CON- ACT OR COMPANY NAbIE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE.# [phone]So
STATE WELL CONSTRUCTION PERMIT% ASSOCIATED WQ PERNnT%
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Nfonitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIOO: / , Topo raphic/Land Setting
a s T^ T _ (�t- �� C ntY ❑R die lope []Valley ❑FIaP
te-WIl� -- „ 2 �ti check crude ifwi I)
".....�... . �. �r �+• - C.atrtude/longitude of well location
3. OWNER S/ !A IS �p��� d (degrees/minutes/seconds)
Address �-7 2,0-0 [ - Latitudeflongitude sour ce:[]GPSOTopographic map
I7 S¢eet or Route Na; (check box) -
W1�,. DEPTH <DRILLNGLOG
CT iry or Town 5 Lp Cade From To � Formation Description
aza 331 — �t` yK�)
Area code-Phone number
'- 4. DATE DRILLED I I 140
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO rda7 , /0 2_
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use-+"if Above Top fCasing) 17� /7d/- -
8. TOP OF CASING ISO_FT.Above Land Surface' / 7 t' — 1,0-0
'Top of Casio-terminated actor below land surface requires a -
-variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): I )-, METHOp OF TEST /7 l
10.WATER ZONES(depth): ) a LOCATION SKETCH
11. DISINFECTION:Type _'[�'/-'. Amount Show direction and distance in miles from at least
12. C'AS[NG: WallThickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. . N to ' numbers and common ad rapes.
s.
mm Fro To�_Ft.
From To - Ft.
From To. . Ft. � 4CJ ��^::Lc ^s
13. GROUT: Depth Material Method
From To 3 Ft. ✓2"""}f• /L(R
From__3To Zd Ft. r-
14. SCREEN: Depth Diamete- Ma
From To Ft. - in. in.
From To Ft _ in. in. -
15. SAND/GRAVEL PACK:
Depth size Material
From To - Fr -
From - TO Ft. -
16. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARD D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—
SII;'v.ATULE OF ;FRSON CO\S�-' ;VG Tt'r y,rL t D4TF
Submit the original to the Division of Wafer Quality,Aft `.Infor A 1617 Mail ervice Center-
RaleiA,NC 27699-1617, Phone No.[phone],within 3C days.
G' ( FP`•i.r9Ni4
Asheville Regional Office

N _. - �f
RECEIVED
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quflify
MAR 20 2C'1
h'hnnvn+°` WELL ELL CONTRACTOR CERTIFICATION 8__ 6Z Asheville Regional Office
1.WELL CONTRACTOR: I. DISINFECTION:Type n
CLan '-L g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
Fran Tc Frwn To
Well Contractor Company Name Fran To From To
CRANE BROTHERS WELL DRIL MM, Y1 6. CASING: Thickness/
STREET ADDRESS -'48
Dep",;�- ler Weight Material
/
FRANKLIN, NC 28734 From Tt FI.�r /
City or Town Slate Zip Code Fran—To—Ft.
From To FI.
u
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
Fran_L-To, E
SITE WELL iD#(il applicable) Fran Tc Ft.
STATE WELL PERMIT#(ilapplicable) From Tc Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ Fran To FL in. _ in.
From To Ff. in. _in.
DATE DRILLED Fran To FLin. _in.
TIME COMPLETED AMD PMp
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: COUNT el Fran To F
p Fran To Ft.
.
fJl�1'� e1� Crk. Fran Tc Ft.
(Sheet Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10,DRILLING LOG
❑Slope OValley ❑Flat ❑Ridge ❑Other From To Formation Description
(check spproprlate box)
— — May 6e in degrees, S
LATITUDE 3 mia decimal for al
or
LONGITUDE in a decimal format
Latitude/longitude source: OGPS ❑Topographic map
flotation of wed must be shown on a USGS lope map and r
attached to this form/not using GPS) I q Es L:
4.WELL OWNER
OWNER'S NAME T ,lA l�' IV
STREET ADDRESS I✓PO U-,)C. y y u J
iAJ C o21 AghPyiiie en10;Ir31 I
City or Town Slate Zip Code
Area case• Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO.g-
mt
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W
C. WATER LEVEL Below Top of Casing: V O FT. 15A NCAC ZC,WELL CONSTRUCTION STANDARDS,AND THATACOPY OF MIS
(Use's'II Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' ��-[�
'Top of casing terminated atlw below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): Q 5 METHOD OF TEST � � � L `✓ n�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt., FormGW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568- Rev.

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ilia aKabie�
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1 --r, ( Y(3/08 Z ; z7 ON(

WELL CONSTRUCTION RECORD Z '
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedderl Brothers Well Drilling,Inc PHONE N [phone]
STATE WELL CONSTRUCTION PERMIT# 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 LOCATIO l: Topographic/Land setting
Nea stTown. Count ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,N/uundat rs,Community Subdivision, t No.,Zip Code) Latitude/longitude of well location
3. OWNER: ( � Juoot .2/1i1�0� (degrees/minutes/seconds)
Address P2 Bak 3127 Latitude/longitude source:❑GPS❑Topographicmap
(Street r Route No.) (check box)
N _ IN-1/7 DEPTH DRILLING LOG
City or Town St<te Zip Code From To 1 Formation Description
g( pg )_ �(�number
l g Clay it Sand
Area code-Phone number 1625, Granite
4. TOT
5. TOTALL DEPTH: ,/�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ip
7. STATIC WATER LEVEL Below Top of Casing:.�F
(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):4C METT OD OF TEST BLOW LI
10.WATER ZONES(depth): rr = !� o LOCATION SKETCH
11. DISINFECTION:Type H T H od Amount 160, 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 Wet htt/FL Material numbers and common road names.
From_�To�_Ft. to
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite g Cement pumped
From To FL
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: ;y
Depth Size Material w
From To Ft. b
From To Ft. r
4
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRWfflON STANDARDS,AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0.Zy"05'
a SIGNA RE OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 9 A c r ='
North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
n '/ n WELL CONTRACTOR(INDIVIDUAL)NAME (print) I C,'( - /C/�.Q/p'� CERTIFICATIO
WELL CONTRACTOR COMPANY NAME�1 �=tL S ���q !r// PHONE N ?
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PEILIIIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential 4YMunicipnl/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATION- Topographic/Land setting
Nearest Town: (/ — grCunty ❑Ridge ❑Slope ❑Valley ❑Flat
FF�S (check appropriate box)
(Street Name,N mbers.Community,Subdivision, Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: iC J (degrees/minutes/seconds)
Address
kk&1v _5q Latitude/longitude source:❑GPS❑Topographic map
(Sheet or'R"o�ute No.) (check box)
k 1)h) FdG-✓ /I/L rac?A DEPTH DRILLING LOG
Cilyor Town tale Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED
�- DS
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 64PO 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): ),A-1f�- METHOD OF TEST_ y- _
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 Dian ter or WeighUFt. Material numbers and common road names.
From 0 To 3 5 Ft. 10 Zz
From To Ft. _
From To Ft.
13. GROUT: Depth Material I�2 Method
From To W Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From—To—Ft in. in. _ '-
From To Ft. in. in. I '
15. SAND/GRAVEL PACK:
Depth Size Material O
cn
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 RECOGD HAS BEEN PROVIDED TO THE WELL OWNER
0
SIGNATURE OF PERSON l'ONSTRUCTING THC WL-LL} DATE
Submit the original to the Division of Water Qual4 i �'undwaler Section, 1636 At�il Service Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days. ;(I` OCT 2 $ Zllu'J GW-I REV. 07/2001

a��SrAMo I
,}T i !3 /p
�J' RESIDENTIAL WELL CONSTRUCTIONRECORD C.
�,+,� � - North Carolina Department of Environment and Natural Resources-Division of Water Quality
Wu
WELL CONTRACTOR CERTIFICATION k 2187
1.WELL CONTRACTOR: FF
N:Type WT H Amount- 160z
RllSSell S Tay1Dr S(it th):Well Contractor(Individual)Name o FromTo
Hedden Brothers Well Drilling, Inc. o From To
Well Contract or Company Name o FromTo
Thicknessl
STREETADDRESS 73 H011y Hi11S V1Sta RDpth p Diameter Weight hi
EYaTilcI' nit ?8734 From To / Ft. (&-
City or Town Slate Zip Code From To Ft G•" s
369-9591 From To Ft.
Area e- Phone number 7, GROUT: Depth Material Method
2.WELL INFORMATION: C,1 From�_To`20 Ft. canEr t & bH-ITli�
SITE WELL ID#(If applicable) Cl� 1643'Sd-744 I _ From To_Ft.
STATE WELL PERMIT#(if applicable) From_To_Ft.
DvVQ or OTHER PERMIT#(g applicable) S. SCREEN: Depth Diameter Slot Size Material
From_To__Ft._in. _ in.
N .rE USE(Check Applicabl Residential Water SuPPIY O From To FL_in. _ In.
r:AfE DRILLED ,,,/ From To_Ft._in. — in.
TIME COMPLETED AM uo Pt"I 9. SAND/GRAVEL PACK:
Depth Size Material
7.WELL LOC. ON: ��/���s, ,, ,,�ry,a From To Ft.
CITY: COUNTY L�" Jd, 1lSt From To Ft.
Ug From To Ft.
(S,nN lama,Numbers.Community, ubdMaion,Lot Nc.,ParcN,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From T50
o Formation Description
(check appropriate box) 0 ' Clay & sand
May be in degrees, 1, M OD r Cram e
L,TITUDE _ minuta,seconds or -- -
in a decimal format
LONGITUDE_ _
Lati'rlde/longitude source: ❑GPS ❑Topographic map _
,location of wed must be drown on a USGS ropo map and
attached to this form r not using GPS)
4.WELL OWNER ' ' A y�,� C,/��
OWNER'S NAME L1_D lOrnl) 1 Illy tL/L�a ±
STH"ET ADDRESS 3I r ^ .
�s6
City or Town State Zip Cade rJr —
�$?$)- 7513 -07c?�l
Area code- Phonenumber 11. REMARKS: --
5.WELL DETAILS:a. TOTAL DEPTH: =D
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
c. WATER LEVEL Beim Top of Casing:JM _FT. 16A NCAC 2C,WELL CONSTRUCTION STANDARDS,ANDTHATACOPY OF THIS
(Use-+-If Above Top of Casing) RECOR S BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT.Above Lend Surface- _�/lC 16411 .0 I 1J/ 0'�
*Top of casing terminated aVor below land surface may require SIGNATURE OF CERTIFIED W E CONTRACTOR A
a variance in accordance with 15A NCAC 2C.0118.
METHOD OF TEST BLOW Russell S Tavl DE
e. YIELD(gpm):� PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
16117 Mall Service Center—Raleigh,NC 27699.161T Phone No,[phone] ext 565. - Rev.7105

WELL CONSTRUCTION RECORD
t j
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Tavlor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# 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 LOCATI (� Ash Topographic/Land setting
Near Town: [� County \}p, y,
T".r.."` ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(JReet Name,Numbers,Community,Subdivision,Lot No.,,Zip
Code) Latitude/longitude of well location
3. OWNER: h.2 (degrees/mmutes/seconds)
Address /A U 7k Latitude/longitude source:❑GPS❑Topographic map
�J (Street or Route No.) (check box)
2 T 7-7 DEPTH DRILLING LOG
City or Town State '' Zip code From To Formation Description
826 Clay&Sand
Area c number /� Granite
4. DATE
DRILLEDDRILLED 9.4•05
5. TOTAL DEPTH: 375 '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Z7 FT.
/1 (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 m accordance h 15A NCAC 2C.0118.
9. YIELD(gpm):_ METHOD OF TEST BLOW
10. WATER ZONES(depth): �3(0 11
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth rrrrrr////// Diameter or Weight/Ft. Material numbers
numbers and common road names.
From To Ft. ''
From R To Ft. "
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped f'3r
From To Ft. r`
14. SCREEN: Depth Diameter Slot Size Material p "
From To Ft, in. in. "
From To Ft. in. in. r
15. SAND/GRAVEL PACK:
Depth Size Material CC�:)
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 TION STANDARDS,AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0 'oS
SI ATU OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management;1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 4 w
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) JameS B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI i : A Topographic/Land setting
Ne stTown: V County �J ❑Ridge ❑Slope ❑Valley ❑Flat
14eA ._� - (check appropriate box)
(Street Name,Numbers,(ICommunity,Subdivision,Lot No,Zip Code)
J Latitude/longitude of well location
3. OWNER: !I,« A � C1
F . j!.•1.1 Q !C-12i4j (degrees/minutes/seconds)
Address 4' d (A b W - iatitudeAongitude source:❑GPS❑Topographic map
f / S�eet or Route t�o. (check box)
I.li`Z,l�(/_Lf�� r�' lil7 DEPTH DR[LLINGLOG
City or Tow ' Zip Code From To Formation Description
828 - ( 1�— 0 Clay&Sand
Area code-Phone number qq , (,< <' Granite
4. DATE DRILLED �J05
5. TOTAL DEPTH: (}'
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:A_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): 1�(jL METHOD OF TEST BLOW
10. WATER ZONES(depth): 7� �'�5 (•)y�`
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depthi F
Diameter or Weight/Ft. M tenal numbers and common road names.
From 0 To L t_ '
From it To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Senonite&Cement pumped
From To Ft. O '"
14. SCREEN: Depth Diameter Slot Size Material
From TO Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: O
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 STANDA 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,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GWA REV.09/2004

a
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT10 / Topographic/Land setting
Ne�jye��tTTonw_n: County'✓ ❑Ridge []Slope ❑Valley ❑Flat
�-�_ A6 *l - (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) __ ll Latitude/longitude of well location
3. OWNER: I 0)v (degrees/minutes/seconds)
Address e'n4 2/ Latitude/longitudesource:❑GPS❑Topographicmap
/' 1 ,� et Ro a o.) �� (check bRI
(i(.,(Q,� DEPTH DRILLING LOG
City or Towynf States Zip Code From T Formation Description
B(?B )- 5X7,o 5b U 0 Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED_ 9•�a '6,5
too
5. TOTAL DEPTH: k-500'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: J7400 T.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): 6 METHOD OF TEST BLOW
10.WATER ZONES(depth):_(:jeW3 i 3yz 0 y'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth� r/ Di eter or Weight/Ft. Mae -al numbers and common road names.
From 0 To�pz F[. a ,� &
From R To Ft.
From To Ft.
13. GROUT: Depth Material Method o
From 0 To 20 FL Benonite&Cement pumped 1
From To Ft. J-
14. SCREEN: Depth Diameter Slot Size Material C:)
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 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
2,
? —a
5-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD W 1. �S �
y`�V 'J f
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT Topographic/Land setting
Ne stTow County ❑Ridge ❑Slope ❑Valley ❑Flat
��fltt(I L'J (check appropriate box)
(Street Numbers,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location
3. OWNER: n ;1S r (degrees/minutes/seconds)
Address (/��yqt Latitude/longitude source:❑GPS❑Topographicmap
(Steen Roue No.) (check box)
Ya DEPTH DRILLING LOG
City or wn I State Zip Code From To Formation Description
B(Via)- mbar Clay it Sand
Area code-Phone number p
4. DATE DRILLED. Granite
5. TOTAL DEPTH: i
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface•
*Top orcasing terminated attor below land surface requires a
variance in accordancf with ISA NCAC 2C.0118.
9. YIELD(gpm):- /_M)1"(',H�p OF TEST BLOW
10. WATER ZONES(depth): r
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth rr55 Diyter or Weight/Ft. Material numbers and common road names.
From o To �J F[. _
From It To Ft. a i
From To Ft.
13. GROUT: Depth Material Method CJ -
From 0 To 20 Ft.Benonite&Cement pumped I
From To Ft. 'a
14. SCREEN: Depth Diameter Slot Size Material C!1
From To Ft. in. in. 1.+1
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS: n /��
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTS IND ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU O ERSON CONSTRUCTING THE WELL D T
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # ( )369-9591
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
Near st Tow i ��. o my 4 �•
❑Ridge ❑Slope []Valley ❑Flat
t ` all '1 � (check appropriate box)
(Street Name,Numbers,Community,SubQt lion,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 'Al (degrees/minutestseconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(S �treet or ten .) Z. (check box)
1 / DEPTH DRILLING LOG
City Ioo""" wn Zip Code From TO Formation Description
�)-_Z /5 / 0 Clay&sand
Area code-Phone number / �.-' - Granite
4. DATE DRILLED
5. TOTAL DEPTH, (,�Ci
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: ,U-i F
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated attor below land surface requires a
variance in accordamse with 15A NCAC 2C.011&
9. YIELD(gpm): 1i- METHOD OF TEST BLOW
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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
From o To_ Ft.
From tt To Ft.
From To Ft. O
13. GROUT: Depth Material Method "=
From 0 To 20 Ft.Benonite&Cement pumped t
J-
From To FL
14. SCREEN: Depth Diameter Slot Size Material t7
C31
From To Ft. in. in.
From To Ft. in. in. ..;z
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 ITERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
111100 (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 Ne L st TowATI pN: wj�,,,, , Topographic/Land setting
County (J/, --- ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(S eet Name umbern,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degmes/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( �1 (check box)
G7 7 DEPTH DRILLING LOG
city or T�oIw.rn /15p tre Zip Code From . Formation Description
828 - ��d/' otOJ. l --- Clay&Sand
Area code-Phone number r r Granite
4. DATE DRILLED /0.10.O5
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /50 JT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS c—FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accords Sa with 15A NCAC 2C.0118.
9. YIELD(gpm):—(.e METHOD OF�2T BLOW
10.WATER ZONES(depth): lnJ p
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di e��er oc Weight/Ft. Ma- -P numbers and common road names.
From. To 9p�FL___ nt _ ,DQ
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped o -
From To Ft. "C
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. C=) 1
Ln
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 S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATLTRE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

H:p$rAiF o
. RESIDENTIAL WELL,CONSTRUCTION RECORD W
n I T�� ,s ,�
North Carolina Department of Environment and Natural Resources-Division of Water Quality C
WELL CONTRACTOR CERTIFICATION# 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 166Z
James B. Brown g. WATER ZONES(depth):
Well Contractor(Individual)Name Fro,d OW oO 61;�. From To
Hed nBrothers Well Drilling Inc. From 3iIG 70 From To
---
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thicknessl
//�� De in Dianne Weight M epal
FY'ankl i n a NC 28734 From To Ft. (e• -2;
Ciry or Town State Zip Code From To Ft. /e•,
( 828 t- 369-9591 From_To_Ft.
Area code• Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
aDPlicaEle)SITE WELL ID illi�ia►Y$ 7sa7.87•I�95 From_Q_To 20 Ft. CH[H7t. & IJHYS11tg�]II�
From To_Ft.
STATE WELL PERMIT#(II applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To_Ft.—in. _ In.
DATE DRILLED I O'I 17'OS From To__Ft.—in. _ in.
From To_Ft._in. _ in.
TIME COMPLETED 3:00 AM❑ PMX 9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: GL. CO TY�® 7 From To_Ft.
From To Ft.
/ff,lm -� p sF From Tc Ft.
(Suety Name,Nillembers,Community,SubdlNal n,Lot No.,Parcel,Zip C
TOPOGRAPHIC/LAND SETTING: hw'n•CraCt *5 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Q Formation Description
(check apprdDrlate box) rClayrAn & sandMay be in degrees,LATITUDE _ minutes,seconds or r r (:r ni t
LONGITUDE in a decimal format -
Latitude/longitude source: ❑UPS oTopographic map
(location of we3 must be shown on a USGS topo map and
attached to this torn rnof using GPS)
4,WELL OWNER 'A`nA
OWNER'S NAME "j1h 1 -
STREET AODR;SS ,
. LET
City
iry o or r Town State Zip Cotle °�
(=—)• �n-70?7�0
Area code• Phone number
11. REMARKS:
5.WELL DETAILS: a
a. TOTAL DEPTH: Aft
y.
b. DOES WELL REPLACE EXISTING WELL? YES O Nptp
/(0 \\ 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W m1
e. WATER LEVEL Beim It Above of of Casing)
`i FT. RE NCAC AS WELL CONSTRUCTION TO
ELLOe,AND THAT COPY OF THIS
(use•+•n Above lop of casing) RECO AS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT.Above Land Surface' _
•Top or casing terminated atior below land surface may require NATUR O CERTIFIED WELL CONTRACTOR a variance in accordance with 15A NCAC 2C.0118. DATE
e. YIELD(gpm):44;� METHOD OF TEST Blrxa James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW1a
1617 Mall Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

WELL CONSTRUCTION RECORD * 3 18 t'
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ID Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIOn _ " L Topographic/Land setting
Ne estTown: County_ ❑Ridge ❑Slope ❑Valley ❑Flat
��� (check appropriate box)
(Stree Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degmes/minutes/seconds)
Address Is Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City Town state zip code From To Formation Description
8 -
Areaa code-Phone number Clay& Sand
--�� Granite
4. DATE DRILLED • I '0
5. TOTAL DEPTH: Oca ' t�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 14
7. STATIC WATER LEVEL Below Top of Casing: ._J00 FT.
(Use"+"if Above Top o C ing)
8. TOP OF CASING IS__ FT.Above Land Surface`
"Top ofcasing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): /,Q _METHOD OF TEST BLOW
10. WATER ZONES(depth):��3�:�,�
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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_4Ft. [p•• , �8(j �r/°-�,f/'1 -
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method _
From 0 To 20 Ft.Benonile&Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. I
15.
SAND/GRAVEL PACK:
Depth Size Material O
From To FL ut
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL.
CONSTRUCTION ST RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

e:s SiAMa�4 RESIDENTIAL WELL CONSTRUCTION RECORD f� /
North Carolina Department of Environment and Natural Resources-Division of Water Quality 31 t, P „i
°•a WELL CONTRACTOR CERTIFICATION 9 2045 t [ fa
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 1 66Z
James B. Brown g• WATER ZONES(depth):
Well Contractor(Individual)Name From— - ToLa�A From To
HeWen Brothers Well Drilling, In From 054•Toy'3 WA From To
Well Contractor Company Name From� }o 3�-7/ From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness)
Depth Di me�er Weight rial
rankline NG 2R734 From To Ft.� _
City or Town State Zip Code From To�Ft. rr
( 828 )- 369-9591 From To_Ft.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
From—Q_To 20 Ft. (anent: & UHYT1itH 101fL 1
SITE WELL ID#(iNppaeable) I LAO- .J(J� e(7 From To Ft_.
STATE WELL PERMIT9(11 applicable) From To—Fl.
DWQ or OTHER PERMIT#(6 applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply O From To_Ft._in. _ In.
From To_Ft.—In. _ In.
DATEDRILLED 10'I44 '05 From To—Ft._in. in.
TIME COMPLETED u • OO AM(KPM❑ 9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
it� From To Ft.
CITY: COUNTY From To Ft.
a&WaL�dC1/'�,,, From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge OOther From To a Formation Description
(check apprdpriate box) O r Clay & Sant
minute,secconmwsds or
LATITUDE Maybein , 1 1 Granif-a
_.3_ _
LONGITUDE in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(IOcahon of we0 must be shown on a USGS topo map and
attached to this form l not using GPS)
4.WELL OWNER
OWNER'S NAME
STR ET ADDRESS0 -
- a
a
ity or TOWn Stata Zip Cade
( 82R )- 58(� P �
Area code- Phone number ,e
11. REMARKS: Lrl
S.WELL DETAILS: Q�y1
a. TOTAL DEPTH: J OV
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)(
I DO HEREBY CERTIFY THAT TITS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
e. WATER LEVEL Beim Top of Casing: FT. 1$A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+-6 Above Top of Casing) 0.E OHAIs BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 19 2 FT,Above Lend Surface' ; Q
'Top of casing terminated allor below,land surface may require SIGNATUR OF CERTIFIED WELL CONTRACTOR
a variance in accordancewith 15A NCAC 2C.0118.
DATE
e. YIELD(gpm): _METHODOFTEST BLOW James B. BrOWR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt., Form
1617 Mall Service Center—Raleigh,INC GW-19
C 27699.1617 Phone No.[phone] ext 568. 05

RESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of Environment and Natural Resources.Division of Water Quality 3 1
C C? "+ 7
WELL CONTRACTOR CERTIFICATION k 2045
1.WELL CONTRACTOR: I. DISINFECTION:Typo H T H Amount 1 6OZ
James B. Brown g. WATER
�ZONES(depth):
�1 s
Well Contractor(Individual)Name From 360 ' To ;310A From To
ng
Hedden Brothers Well Drilli Inc. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING Thickness/
Depth Da eter Wei hl M teri
IYank1 i nF NCA7 t4 FromQToJ�Ft. 't
City or Town State Zip Code From To Ft.
( 828 )- 369-9591 From To__Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROAT: Depth Material Method
SITE WELL ID#(if applicable) e11 �0- '1L-Ro�9 From�To-20 Ft. C3iHlt & 1713Ynite L1IIp�]
Q From To Ft.
STATE WELL PERMIT#(If applicable) From To Ft.
DWQ or OTHER PERMIT#(N applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply p From To Ft._in. _ In.
From To Ft._in. _ in.
DATE DRILLED •�'�� From To_Ft. n. _ in.
TIME COMPLETED AM dr PM
9. SAND/GRAVEL PACK:
3.WELL LOCATION: 111�'`/� [�f�j � Depth Size Material
CITY: COUNTY--` V From To Ft.
` from To Ft.
From To Ft.
(Street Name.Numbers,Common y,Subdivision,Lot No.,Parcel,Zip Co
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat ❑Ridge OOther /Frroom�To¢��/��y Formation Description
(cheek apDrdprlale box) -4L _ (,'laV & sand
LATITUDE May t e in degrees, r
�. — minutes,seconds or (;rani to
LONGITUDE in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location or well must be shown on a USGS topo map and rr
attached to this form/not usHrg GPS)
4.WELL OWNER U I
OWNER'S NAME -
STRFE,T ADDRESS
`y'(w n
/X[�1C..,�i�ty or y' / Slate 9 Zip Code e
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: 3%O
Id. DOES WELL REPLACE EXISTING WELL? YESX NO❑ -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C. WATER LEVEL BROW Top of Casing: FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+'It Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASINGIS 2 FT.Above Land Surface' �-
*Top
of casingterminated atlor below land surface may require O IG A URE CERTIFIED WELL CONTRACTOR DATE
a variance in accordance vdth 1 SA NCAC 2C.0118.
e. YIELD(gpm):_.a0i—METHOD OF TEST B1CFa James B. BLOWI7
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-1a
Rev.7106

WELL CONSTRUCTION RECORD 3 t S s,
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION p 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE N [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITN
(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
Neare/y�'t Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
` b (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Ro to o.) (check box)
�— t SC Aq+y4 DEPTH DRILLING LOG
C try
$r Town State G� Zip Code From To , Formation Description
(reas)- b�3 number
7 b7� Clay it Sand
Area code-Phone number ' r Granite
4. DATE DRILLED 10'5•b S
5. TOTAL DEPTH: 1gCO3
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /,= T.
^^ (Use"+"if Above Top of Casing)
8. TOP OF CASING IS d 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): .015 ME OD OF TEST BLOW
10.WATER ZONES(depth): 140
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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/FI. terral numbers and common road names.
From 0 To Ft. to"
From It To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite a Cement pumped
From To Ft. - T
14. SCREEN: Depth Diameter Slot Size Material Q
From To Ft. in. in. c
From To Ft. in. in. I
15. SAND/GRAVEL PACK: r :n
Depth Size Material CD
From To Ft. c11 '
From To Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST CTION STANDARDS,AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
p•Z ,0!5�
SIGNAr OF PE ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

CONSTRUCTION RECORD
WELL " `
North Cafolins-Department of Emhooment and�N�aluurd Ressew=-Division of Water Quality'-Groundwater Section
WELL'CONTRACrOR(DIDrv'WUAL)NAUIt be�o,;1 Z Lin i s ,LI)�^^�-•:• ���cm6ri fete
weu.coNTaAcrortwaaMilyrt rsgrtca121� L'--3 V-b 0
srATe well,C0148TRUCr10N TEMbOrr AssoeG►Tm w sRasrri -
(if applicable) •(ifapolicabta) .
I. WELL USE(Check Applicable Box):Residential7YMwdcipaVPublic 0 industdal 0 Agricultural Q
Monitoring 0 Reeovcry 0' Heat Pump Water W0gtI04 0 Other C7 If Other,List Use '
2.-WELL LOCATION: 1Bgtapj)jtJj and setting .
Nearest Town: 04 S h i e LS " county—japeS gif dge OSlope ❑Malley .OFlat
No/afty. 2a - Tht O;iL-C' (abe&"MPtkWWs)
(sum Name,Numbers,cetamasitf,s"vi"Lei No..rAP coat) L'abtudellongitede of well location '
3. OWNER: iqa i (de�xahaipataheoonds)
Addreu /DO AA 0' to?/Z5Ladtude/Iongihidesootce:DOPSOTopogmphicmap
/ (Sneer or Plot"N4 (cbedcboa)
336 6 a- DEPTH DRILLING LOG
City•orT sous zip Cos. .From TO Formation Description
Arc+mat•rbme otanb"r .-C-
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO. 1
7. STATIC WATER LEVEL Below Top of Casing: // )FT.
(Use^I^if AbuvaTop of Caiog)
9. TOP OF CASING IS FT.Above Land Smfm*
-Toporeulaatarmiaat+dallorbelpwlfadaarfaarpalrisa .. -
varla Lasem"asse vA&ISR?fCAC3CA11L
9. YIELD(gpm): .30 MMODOFTBST
10.WATER ZONES(depth): S
''� LOCATION SKETCH
t i. DISINFECTION:Type -Amount � Show direction and.dia(ance in miles.from at least
12. CASING: Wag Thidows two Stale Roads or County Roads.Include the road
� D�'�' or We(Iglt K numbers and common road names.
From_p— LSS i�_l�_
From-To-FL-
From Tp FL_ _
13. GROUT: Depth Materiil Method.
Fro._ To_c2D_
From To TL l' z
.4. SCREEN: Depth Diameter Slot Size : • Material o
C
From_ To Ft,-__ tn in. t
From To Ft__ja in. -
S. SAND/GRAVEL PACK: _
Depth size Material cn
From To FL
From To Ft. - --_
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC176D IN ACCORDANCE Wfl)i ISA NCAC_2C,WELL'
DNSTRUCTION STANDARDS,AND THAT
"./ l l COPY PY �THj{'Q,LL'n RECORD HAS P40VIDED TO THB.WELL OWNER
/ Zi — ,Z y C1 'S
SIGNATURB-DF PERSON CONSTRUCIINO THE WEI1 DATE -
Submit the origiaal-to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleleh,'NC
.1-7699-1636?how No.(9l9)733-3221,within 30 days GW-I REV.0712001

WELL CONSTRUCTION RECURD' )
North Ca&IIna-Department of Envlronrtmnt and Natural Re:otacas-Division of Water Quality-_ Qmundwater Section�y/-
WELLCONTnAcrost(Dmi)MMUAL)•�tA�ya6 [prteQc r(VIt S� ���,y�1'�J(I.,n'I."`- '�- CL�IIP[CATIOri LY'
WELL cowritACTOR COMPArkY 14Aaat•IX tQ 4Q,j�(}ery4 11PAI Q`(�j,.}(y� Tit' ,•PHOT.a.:IF"3 zzH 0 .
STATE WELL CDNSTItUCrtoN PuMiTo .. A880C(ATBDW UJUIY
(ifappl'tcabie) •(if4ppliwb(e) .
1. WELL USE(Check Applicable Box):Residerdial7Y Mun(cipaUPublic❑ Industrial 0 Agricultural Q
Monitoring❑ Recovery O' Heat Pump Water Wection❑ Other CI if Otker,List Use
2--,WELL LOCATION: , ogr>�bWA_md setting .
Nearest Town: keg S -- Co tm S G/ dge OSlopa OValley lDFlat
(Street Name.Nmabeo.Caauauoity,Subdiviiioa,IA No.Zip Code) J Fr (1 a ft �idt;6f a bad
may, - ol'.Sr7i ] - I;atitudPJlongitudaofwcll location
3. OWNER: Q.S l;0F_R:: � (daaraes)miuura✓aecbnda) .
Address 9 2 60A ►2:da.-R— Latitude/longittide source:OGPS❑Topographic map
//�� (SamtaRom9NoJ (ebaeaboa)
l A S {) r YKS N Ak 7" 7 DEPTH ' DRILLING LOG
ry a Jt s�_ SW4 9 ap Code From To _Formation Description
14.
Am mde•Phone Dumber „ :� _ Lr, t 'I z
4. DATE DRILLED /L 2. J w S
5. TOTAL DEPTH: �6 '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT:
N0^N if Above Top of Catio4
8. TOP OF CASING IS�_FT.Above Land Surface*
'Tap of carlsa tarmin"allor blow IEttdear4aa ragalra a
vsria to aaeardaaoo laR7(CLC 3C AIIL
9. YIELD(gpm): ,5 METHOD OFTBST�jL-9A,
10.WATER ZONES(depth):
Id2CK'fTON SKETCH
11. DISINFECTION:Type Amount Show direction and.dlatanee In milos from at least
12. CASING: Wall Thickness two State Roads or Cotmty Roads;Include the road
/� Depth / or waiit"FL numbers and common road names. -
From_-,{lam To PL 5 -
From Tc FL
Front To—Ft.
0
13. GROUT_ Depth Matedw Method. e
1
FrorrL_TZnD_F
From. To FL '
.4. SCREEN: Depth Diameter . Slot Size Material o
From To FL_itL- in. rn w
From To FL in in.
S. SANDlGRAVELPACK:
Depth size Material
From To FL
From To Ft
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTBD IN ACCORDANCE WR3I iSA NCAC 2C,WELL
ONSTRUC(i0N STANDARDS,AND THAT A COPY OF X!X RD BEEN P11r0VIDED TO THB.WBLL OWNER
S)GNATURB'OFPERSONCONSTRUCTINGTHBWEuL DATE -
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Ralelgh,NC
,'1*7 699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECeRD'
North Cni olina-Department of Envimnttte a and Natimal Resouroa-Division of Watw Quality--Groundwater SectionT
WELL CONTRACTOR(INDI W\ AM UAL)Ns (prt n<�l_ff lwt5 '� dt..' - �. CtffFTIFICA140tt a 1•-r�4P
weLL coNTRACToR coMPA1VY N - 'rllorm s 4(f'_�5�11 3 A b O
STATE WELL CONSTROCTiom rzn*s. _ .. Aa: , . -..
(if applicable) OAtfgpp W LRIHI'1'a - -
-- - •(Ifgoplteable)
1. WELL USE(Check Applicabit Box):Retidattialt"I;unicipaUPublic❑ Induslrfal 0 Aglicultura4Q
Monitoring❑ Recovery ❑` Heat Pump Water IWogtion❑ Other Ef IfOd'tvr,List Use '
2.-WELL LOCATIO : jQP6g1ap�RelLend setting
Nearest Town: 2 CoLo L c his. ❑Slops Malloy .❑Flat
I70 w err P i a..y Id7l s a 97 83 (eludt loos)
(St m Na--Nmabm,Community,SUIXI p{at,l.a Na. Code
may za ) L'atitodcllotigituda of well location _
3. OWNER: �J��r�'CiAddress b 3 Dn� (Mateeilmiauuaheconda)
4 scsueal r RodWe .. fLd Latitudellongittide source:❑GPS❑Topographic map
L i -le it Ee-4 e a- Ale �E 9 (ebadc loos)
P.ti�TLi ' DRILLING LOG
AmCiTy T° � state
T'v coax From 6Q Formation Description
Nn cods Phone number
4. DATE DRILLED /0 -1 R SAS iv, t
5. TOTAL DEMM; ebb '
6. DOES WELL REPLACE EXISTINO WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:lQ-,FT:
(uo-r If Above Top afCubW
8. TOP OF CASING IS�_FT.Above Land Surfacaa
-rap ar�taa rred..tw war be(a„le.asa,s...ragab:,.
varlaea h1 tamrda rrltb'ISxNuc tC Al1L
9. YIELD(917M):J0 METHOD OF TEST �Jd/Jr�Ld
10.WATER ZONES(depth):
Ll� -A"l70N KET H
I l. DISINFECTION:
.Type Amotmt Show direction and.distanee in miles from at least
12. CASING: Wan Th(cimen two Stale Roads or County Roads;include the road
Depth / Dt or weightTL numbers and-eommon road names.
From—�To-19&pt S,a�'
From To Ft
From Tq FL�
13. GROUT_ Depth Materiil Method
From To r A. SCREEN: Depth Diameter . Slot sin : � Material .
From To Ft`_(n. in.
From To FL__hL in. '
S. SANDIGRAVELPACK: _
Dept+ Size Material
From Tt FL__
From To Ft
6. REMARKS:
DO HEREBY CERTIFY THATTMS WELL WAS CONSTRUC)ED IN ACCORDANCE Wf13i 15(1 NCAC2C WELL
nNSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD HbLS BEEN P40VIDED TO THQ.WBLL OWNER
SIGNATURB OF PE=N CONSTRUCIINO THB WBLL . DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Ctnter-Ralelgh,NC
.77699-1636 Phone No.[phone],within 30 days, GW-I REV,07/2001

WELL CONSTRUCTION RECORD'
North Ca 6iina-Department of Emirommiilt and Natural Resources-Division of Water
L Quality'-Groundwa ter Section
WELL CONTRACTOR(INDIV•ID1UAL)"R be%*sbL H yi Is ltl,�J I%1.w.I, : : •, CAT10N a I'
WELL CONTRACTOR COaarAh NAL+C•I-l°Ahr.c VA110 j4A I!� a 1 Y I+;•1e,,iL,.—.3—.t r rfi �_.�'.L 4-�.3 a2(2. D
STATE WELL CONSTRUCT/or(pERnitra ABSOC(aTED WQ¢RRRR
--- -- --(if applicable) • *aWlicable) -
1. WELL USE(Check Applicable Boxy Residezitial7Y UtwucipsUPublic❑ Industrial❑ Agricultural ,
Monitoring❑ Recovery ❑' Heat Pump Water injection❑ Other C( If Other,List Use
Z."WELL LOCATION: . Town1c/Land setting
Nearest Town: IPL u e � county JACICStiaU
dge MopeMalley .❑Fist
�g 7 T3 ohs*vpropd.lsbox)
(sum Name.Nwabom Community,SubddiAstou,Lot No.zp Cone) L`atitudeJlongitads of will location '
3. OWNER: JP(2c Il I �j5'ir1✓
(dastaedmtaulaheobaat) �.
Address 4=.t 99 -1 t`tt)R D E7 2 Latitudenongitd&aouree:❑GPSOTopogmphic map._
(Sit moraom W) I .(ebeck box) _.. .. '
*fi t7f DEPTH DRILLING LOG
{+�gCiry or T /� Stagg- 603 �^ '_zip Cale _.From To,,((' Formation Description
4. DATE DRILLED Zn — t l^(_a
5. TOTAL D
.. �' inzi�Y i _ ; 7-
6- DOES WELL REPLACE maniNG WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: .4 c o" P7:
(Uw"N if Abow Top ofCufogl
8. TOP OF CASING IS�_FT.Above Land Surface*
'Top orrulag tumiaatd aWrbelarrlpdaarlaea ngairba _
mur ie&*card W16-15Kwakc 3C.011i
9. YIELD(gpm): Y�'MBTAODOFTEST,
10.WATER ZONES(depth): 7 D
LOCATION SKETCH
11. DISMFECTION:•Type Amount Show direction and.distanee In miles from at(east
12. CASING: Will Thickness two State Roads or County Roads.Include the road
Depth _ � or We1�lUPL numbers aud'colmaon road names.
From To�r Si
From_To Ft,__
From Tq FL_
13. GROUT_ Depth Material Method.
From_To�F�..�� T
From To Ft -
.4. SCREEN: Depth Diameter . S)ot Size Material
From To Ft`_in. in.
From To FL_yn• in.
S. SAND/GRAVEL PACK
Depth Size Material -
From To Ft
from To FL
6. REMARKS_
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCt$D IN ACCORDANCB Wflil ISA NCAC XQ WELL
ONSTRUCTION STANDARDS,AND THAT AA COPY OF/� S RECORD HAS BEEN P$OVIDED TO THE WELL OWNER
AA
SIGNATUREOFPERSONCONSTRUCTINOTHEWEM DATE -
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
17699-1636 Phone No.[phone],within 30 days OW-1 REV.07t2001

V
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water ry/duality-Groundwater Section p
WELL CONTRACTOR(INDIVIDUAL)NAM' print)1 a_4 �0L.0 An F�ib CERTIFICATION# .� /6
WILL CONTRACTOR COMPANY NAMELLILL 66., L -3M,6
STA7"E WELL CONSTRUCTION PERMIT# �SlD.2• ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Q�i unicipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Topographic/Land setting
NearesttTown,,-\Mar-4�14V 1g�_�ounty` Soap ❑Ridge ❑Slope OValley tiFlat
P I D T' F�2)S[lYYx (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: .�I !` (degreesiminutes/secands)
Address ___ I t a� &I l�rt oen YY1��1 e �r Latitude/longitude source:OGPSOTopographic map
/ (Street or Route No.) (check box)
�L DEPTH DRILLING LOG
City or Town State zip Code From To Format. Description
O © /SD
Area code-Phone number / •/6-5
4. DATE DRILLED �/- I a -d •Y
5. TOTAL DEPTH: .CLD�
fi
I r Lc WIA,1 REPLACE l:v�crinir_ WLLI L' YLS rt NO ram
7. STATIC WATER LEVEL Below Top of Casing: /d 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 15A NCAC 2C.0118.
9. YIELD(gpm):_L METHOD OF TEST
10.WATER ZONES(depth): J-0 �/r5yy)
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 /S0 Ft. 6 )/
From To Ft. _
From To Ft.
13. GROUT: Depth Material Method `
From_(5 To_QQ_Ft. (A P, s-: • I
From To Ft. ^�
7
14. SCREEN: Depth Diameter Slot Size Material (
From To Ft. in. in. Cil
From To Ft. in. in. O
15, SAND/GRAVEL PACK: un
Depth Size Material
From---- To Ft -+
From ____To Ft.
16. REMARKS:
I DO FTEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND THAT A COP 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

E
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-/Division
�of�Water Quality-Groundwater Section
WFLI.CONTRACTOR(INDIVIDUAL)NAM{EE (print)Zjl Ate, /�Li,[�s �, [_Jey d.� CERTIFICAAT.,I(O�N#`/6�
WLLI,CONTRACTOR COMPANY NAMIiG.d e e.,_/ OS . lJil1 JC.t 9f pj1 iy�Rr C/-C • PHONE # (.V (I Y/9 ' '3/7&
STATE WILL CONSTRUCTION PERMIT# �/'.G ASSOCIATED WQ PERMIT# ,_
(if applicable) (if applicable) ----
L WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agpculr=1❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2_ WLLL LOCATION: Topographic/Land setting
Nearest'I'own: L4t " _County_ ❑Ridge 291ope OValley OFlat
—C) j+- a. �Sit m — r r�a ��. (check appropriate box)
(5trat Nam,,Numbers,Community,/Subdivision,Lot No.,Zi Code) Latitude/longitude of well location
3. OWNER: Cl 4 yam__ t
(degrees/minutes/seconds)
Address t00 /523� Latitude/longitude source:DGPSOTopographic map
Y/�iStreet.or�'ute No.) (check box)
J I JJL DEPTH DRILLING LOG
city or Town State zip Code From To Formation Description
) n 99 '
Ares code-Phone number
a. DATE DRILLED /D - ^/ - D s
5. TOTAL DEPTH: '
e. l/\CC lli l:t I UI:UI n('I: If VIl9Yb4l U%I:I 1 '1 Vla rl hi(1
7. STATIC WATER LEVEL Below Top of Casing:
A. TOP OF CASING IS (Use"�"if Above Top of Casing) -" ----
FT.Above Land Surface*
*1 op of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gin):_/,T'_METHOD OF TEST__:2�
10. WATER ZONES(depth): JD5f
LOCATION SKETCH
11, DISINFI:iC'PION:Type _ Amount 6t� f�/L� 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.
1:rom Q To._99 Ft. i1
From._,__To—Ft. _
t rom To Ft. O
l i. GROUT Depth atenal Method n
i ram _O_To 2� Ft. _ t
1 rom To Ft—
11, SCREEN: Depth Diameter Slot Size Material 0
Fn»n_. _ To _Ft. _in. in.
To Ft. in. in.
i�. SAND/GRAVEL PACK: -
Depth Size Material
Prom......_—To—Ft.--
From— --To--Ft.
16. REMARKS:
I DO HEREBY CERTIFY"THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
(.GNti IRUCTION STANDARDS,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. GW-I REV.07/2001

WELL CONSTRUCTION RECORD'
North Ceetotina-Department of Envhomnim and Natural Resources-Division of Wsta Quality-Or-onadwater Section "
WELL CONTRACI.0R(INDMouA4NAM6 (erM1c�/1%IS �t�,��t�. �.�'y�p((�,A'ft0►(i ot��( .
WELL CONTRACTOR COMPA NAM . 'PHONL a t( SZ#4 -3 At, �
STATE WELL CONSTRUCTION PUA60 - "- Ae!
(ifapplkabla) OCL►TEDW RRMrr#
(iTesplicaWe)
1. WELL USE(Check Applicable Boxy Raidential7rMunicipeUPubiic •Indttatrial D Agdoulturai Q
Monitoring D Recovery D Heat Pump Wtta Injection D Other C! if Otlia,List Use
2.-WELL LOCATI I: _ ' 'Lmd soft
Ncares�To�!� l be County 12 7 C 1C 6,�J j� C1Valiey .Met
In n L t -t f� a S (da!k"Nowbus)
(surer Name.Niest}}w--s.Caauofobf,S"vWM Lot Na.Zip Code) Laatude/ioagitude of wall location '
3. OWNER- �J
Address 5 k,-S q /V P ( t F., + Latitcddlongihido soocce:DGPSDTopogmphic map
or Rom - (clmdchmQ .
b Q a4,n, -�A2 k f l: \3 .� C 6 3 DEPTH ' DRILLING LOG
F h- 9 91 �Sous L b q 'Tq,cbds From To S 1�lion Description
Ana mdm Phone eum6ar -n'� — -�S�'• (ti
4. DATE DRILLED / I _1 5--LA
`7h �;: c^ 2 , ,
5. TOTAL DEPT —D S i i1: _ -
IL
6. DOES WELL REPLACE EXISTING WELI.7 YBS D NO.:
7. STATIC WATER LEVEL Below Top ofCasmg:
(Uw"1"i<Above Top o(Caia�
8. TOP OF CASINO IS_�FT.Above Land Surfice•
'Top of m lea tarWnated ador[S�q Wgurfm nqub"a - -
vartaara In aeeerdsou w th' 2C Atli
9. YIELD(gpm): __L0 MTgHOD OF TEST
10.WATER ZONES(depth): (n-
LOCATION SK)jTCH
11. DISINFECTION:Type Amotmt Show direction and.distam is ndics from at least
12. CASING: Wall Thidolm two Sttte Roads or County Roads:Include the road
tI�QDeplh� or watgkuPt nambers and-oommon road names.
Fro —To � " Sam :
From—To FL
From TO FL�
13- GROUT-- Depth Mater(•al. Method- z
From To_C&
From To R —
.4. SCREEN: Depth Diameter : Slot Size : Materiel W
From To F) _in in, o
From To FL._ __In. hL
S. SANDIGRAVELPACK Ln
Depth Size Materiel
From To R.
From To FL
6- REMARKS:
DO HEREBY CERTIFY TNATTHIS WELL WAS CONSTRUCrW IN AGcoRDANCa W n ISANCAC 2q WELL-
'ONSTRUCnONSTANDARD8,ANDTHATACOPYOF RECORD H&S BBEN PROVIDED TOTHE-WELL OWNER
SIGNATURE'OP PERSON CONSRUCIINO THE WELL DATE -
submit the or(gim d to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-RateilkNC
17699-1636 Phone Na(919)733 3221,within 30 days OW-1 REV.07/2001

WELL CONSTRUMON RECORD'
North Catolina-Depannunt of Enviroumdnt and Natural Resources-Division of Quality'-0mundwater Section
WELL CONTRACTOR(ntDMDUAmmatz .w - .nPlts 1�2.!_13.�-'�• ' ' " cuEisrta.T,ori�_��
WELL CONTRACTOR COMPAk, .•_ -PiWNLi��a—Q-3 Alp 0
-
STATE WELL CONSTRULTION VZOA1I0 aacnreaTgp y y :- '
((Applicable) (ifapplicable)
I. WELL USE(Check Applicable-Box).,-R=Montialzd- micipaMblic E3 IndusgW 3 AgricultuwlEl
Monitoring O Recovery O Hen Putrtp Water Injection El Other 17 ll`6 er,List Use '
2.-WELL LOCATION:. Z
d Selling
Nearest y / c@� Mops []l Q iat7 4 2 -. Res Ieheetpadrbgo
(Sum Name,Numb am Commm ity,S60vivico,Lot No.,24 Ca&) - 4tituu4c longitude 6fwall location -
3. OWNER: JdromaS._ �dcl ( I
Address S 83 San C/en'L vY i p!- LatiWddlongihido source:OGPSQfopogmphic map
tsheataRmaettoJ (gtelcbaa) -
U 122h�o .pOKIt� F—/." 3 �DD3 DEPTH DRILLING LOG
uP Cc& From To F6rnartion Description
AM cmd�Phome umber
4. DATE DRILLED / !-•/b"-0"�5' � -- � �". 9.•7• 90S ��� .
S. TOTAL DEPTH 9
6- DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top oroWng:,,7 0 FT:
(Wa'Y^ifAboreTopof�
S. TOP OF CASING 13_� FT.Above Land Su&"*
'Top oreaHag tarm4atea athr below ltadaorhu ngtdrba
vaetum to amrdaaw wub,15A'rf=:C.611s "
9. YIELD(Pm): a `/a. bWHOD UFTB4P 119�j a4
10.WATER ZONES(depth).-
IL
- LOCATION SK(�CH
DISINFECTION.Type Atnouat Show diiectioa aud.disGnca hi miles from u least
12. CASING:
Depth
Wa11 Ttddotea two State Roads or County Roads Include the road
orwalglaTt. _-umbers and-ooum u.road names.
From To FL S,j2�
From fl • Toy=3 Ft
From To Ft.__•_ i
13. GROUT_ Depth Mataul Method-
Frorrt_Q_Too_� z
From To FL ' - . . Cm)
.4. SCREEN: Depth Dimmer . Slot Size
From To Ft-_(n. in.
From To FL iR in. C3
S. SAND/GRAVELPACIC _ 3
Depth Sin Material - -
From To Ft
From To FL
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL,WAS CONSTRUCTED IN ACCORDANCE Wfl7(M NCAC 2C,WELL-
ONSTRUCTION STANDARDS,ANDTHATA COPY OF,THIS RECORD HM BBBNPROVIDEOTOTHE.WELLOWNEP
SIGMATURF-OFPEMNMNSMucnNO THE WELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Cuter-Ralelgh,'NC
017699-1636 Phone No.(919)733-3I21,within 30 days OW-1 REV.07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD �,Lt
al North Carolina Department of Environment and Natural Resources-Division of Water Quality _€
WELL CONTRACTOR CERTIFICATION k 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 166Z
James B. Broom g• WATER ZONES(depth):
Well Contractor(Individual)Name . FromI To /z;L From To
Heclden .Brothers Well Drilling, InC. From11LETo /,Af From To "
W ell Contractor Company Name Fromm Tod, From To
STREETADDRESS 73 .Holly Hills Vista Rd 6. CASING: Thickness)
Depth DI mlyter Wei ht� Material
FYAnkI i n F NC 28734 From 0 To�Ft.�_ �,Sd
City or Town State Zip Code From_To Ft.
t 828 )- 369-9591 From—To Fl
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From— To_2,0 Ft. talatt & bffn-lt:2
SITE WELL ID#(If applicable) From To_Ft.
_ j2al
STATE WELL PERMIT#(It applicable) From To_Ft.
D W Q or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 0 From To_Ft._in. _ In.
From To_Ft.—In. _ in.
DATE DRILLED From_To_Ft._In. _ in.
TIME COMPLETED �rr �d AMC PM CY 9, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Malarial
From To FI.
CI COUNTY �' From To_Ft.
From To Ft.
(Street Name,Numbers,community,SubdiMslon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(cheek apprdpd 3ale box) ` Clay & sand
May be in degrees, Q t a 1 Crani to LATITUDE _ minutes,seconds or -
LONGITUDE in a decimal to=,
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form#not using GPS)
4.WELL OWNER Le
OWNER'S NAME - - _
_S'fRE D ESST AD
C-
CitywTown State Zip Cade r•Y
Llzb. -71J3- 3r/I1
Area code- Phone number -
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 3EJD 1
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO g
of Cuing: f/ I OO HERESY CERTIFY TNAT THIS WELL WAS CONSTRUCTED INACCORDANCE Win
c. WATER LEVEL Below Top g: / F 1EA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Uee'4'NAbove Top of Casing) REC R AS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING le 2 FT.Above Lend Surface'
'Top of casing terminated al/or below land surface may require ATURE OF CERTIFIED WELL CONTRACTOR
a variance in accordance with 1 SA NCAC 2C,0118.
a. YIELD(gpm): ay. METHOD OFTEST bjgy James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,16117 Mall Service Center-Raleigh,NO 27699.1817 Phone No.[phone] ext 568. Form Gw•ta Rev.

RESIDENTIAL WELL CONSTRUCTION RECORD
5 b, r :, _�
North Carolina Department of Environment and Natural Resources.Division of Water Quality
WELL CONTRACTOR CERTIFICATION A 2045
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 166Z
James B. Brown _ g, WATEZ ZONES(depth):
Well Contractor(Individual)Name From To From To
Heciden .Brothers Well Drilling, Inc. From To / From To
Welt Contractor Company Name From To From To
STREETADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
De lh �/� Dia eter Wei i M erial
FlranklinF NC 28734 From�ToQZFC w t
City or Town State Zip Code From To Ft. _
( 828 )- 369-9591 From To Ft._
Area code- Phone number
2.WELL INFORMATION: - T. GROUT: Depth Material Method
From__Q_To20 Ft. Carl & b3YSlit I
SITE WELL ID a(If applicable) From To_Ft.
STATE WELL PERMITO(If applicable) _ From - To FL
DWQ or OTHER PERMIT B(if applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply p From To_Ft.—In. _ In.
from To_Ft._In. _ In.
DATE DRILLED NMI �5 From To Ft In. _ In.
TIME COMPLETED I IS AM4:� PM p
9. SANDIGRAVEL PACK:
3.WELL LOC TION: Depth Size Material
CITY• ^^ COUNTY From _ To_Ft.
DY A" MdA-(_, From TO F
From ____:To FL
(St"at Noma,Numbers.Community.SubdMalen,Let No.,Parul,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope DVailey ❑Fiat ❑Ridge ❑other From� C1ay & sand
To Formation Description
(check appr6priats box) �4-
May lK in degrees, r r
LATITUDE J- _ minutes,seconds or Granite
LONGITUDE_ in a decimal format
Latitude/longitude source: ❑GPS D Topographic map
(location of wes must be shown on a USGS topo map and
attached to this form snot using GPS)
4.WELL OWNER
OWNER'S NAME
S'f TRH ADDRESS n���
Iy or Townr(S state
lip Code N
11-
Area code- Phone number
11. REMARKS: C n
S.WELL DETAILS: ,
a. TOTAL DEPTH:
to. DOES WELL REPLACE EXISTING WELL? YES❑ N036
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITHc. WATER LEVEL Below Top of Casing:,_y5FT• - 1SA NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'6 Above Top of Casing) RECORD S 6EEN PROVIDED TO THE WELL OWNER..
J. TOP OF CASINO IS 2 FT.Above Land Surface- r
'Top of casing terminated atfor belay land surface may require AT RE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 1 SA NCAC 2C.011 S.
e, YIELD(gpm): /b METHOD OF TEST BLOW James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No,[phone] ext 566. Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources.Division of Water Quality"
WELL CONTRACTOR CERTIFICATION d 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 1 WZ
James B. Browr1 g. WATER ZONES(depth):
Well Contractor(Individual)Name i:Ir i_To From To
Hedden Brothers Well Drilling, Inc. From ro From To
Well Contractor Company Name From To - From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
Depth _ Diameter Weight_ material
FYankl inF,N(' 28734 From_[L To 0-5FL �� 5174
City or Town State Zip Code From—To_Ft. _
369-9591 From Tc—Ft.
c 829 )• —
Area code- Phone number
2.WELL INFORMATION: - 7. GROUT: Depth Material Method
From_D_TD 20 Ft. CaTert & bffniite gEEEd
SITE WELL ID#0f applicable) From To Ft_.
STATE WELL PERMIT#(it applicable) From_To Ft.
DWQ or OTHER PERMIT#(If applicable) 6. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply p From—To—Ft._in. _ In.
From_To_R._In. _ In.
DArEDRILLED a'05 From—To—FL_in. In.
TIME COMPLETED ; 40 AM PMK-
9. SAND/GRAVEL PACK:
3.WELL LOQA I , Depth Size Material
CITY: COUNTY from To Ft.
From To_Ft,
1' From To Ft.
(Strut Nama.Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check epprdpdab box) May
0 ' Clay & sand
May be in degrees, t t
LATITUDE _ minutes,seconds or C;ranite
LONGITUDE in a decimal format
Latitude/longitude source: ❑GPS DTopographic map
(location of wait must be shown on a USGS Opp map and
attached to this form Mnot using GPS) _
a.WELL OWNER J1•_ CD
NAME—trt�YAI'
75
S'rR Ey) T AQj.S a-7/ r'Y
_ sit/,zoe /1IC- rr
City Or Town State Zip Code
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: �Y 1
a. TOTAL DEPTH:J t/�IJ V/ I,
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO m
//�` 100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
e. WATER LEVEL Below Top of Casing: _ FT. - 15A NCAC se,WELL CONSTRucmoN STANDARDS,AND THAT A COPY OF THIS
(Use'+'9 Above Top of Casing) ;;NATU
HAS BEEN PROVIDED TO THE WELL OWNER,
d. TOP OF CASINO 18 2 FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require R 0 RTIFIED WELL CONTRALTO
a varlanca in ecco dance with 15A NCAC 2C.0118.
A DATE
6. YIELD(gpm): METHOD OF TEST Bllxa .Tames B. Brown
11 PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., FormGWla
1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.(919)733-701.5 ext 568. Rev.7105

. RD
ESIDENTIAL WELL CONSTRUCTION RECORD \ ��; rx A
'yr North Carolina Department of Environment and Natural Resources.Division of Water Quality J S
WELL CONTRACTOR CERTIFICATION 9 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 166Z
James B. Brown 9. WATER ZONES(depth): 1
Well Contractor(Individual)Name From L �Te f-4 a From To
HedrTen Brcrthess Well Drilling Inc. Frwn To From To
Well Contractor Company Name From To From To
STREETADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
Depth Di meter Weight. Metenel
FYankl i nF NG 28734 From_ To�FL_�
Clly or Town Slate Zip Code Rom To Ft.
( 828 1- 369-9591 From To_Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
.I FromQ_To 20 Ft. ceTa t & 17t3Y.T11tg QIf�
SITE WELL ID#(If applicable) 1L I0•49 ATM Prom To—Ft.
STATE WELL PERMIT#(If applicable) From To—FL
DWQ or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply mr From To_Ft.—in, _ In,
G From To. Ft.—In. _ In.
DATE DRILLED �d• •O J From To_FL_in. _ in.
TIME COMPLETED l I.: i 5 AM Qf PM[]
9. SANDIGRAVEL PACK:
3.WELL LOCATION: 1/�\n. L, From Depth Size Material
CI Y: COUNTY b �(]�) To_Ft.
- From TO_Ft.
]� e QJ From 70_Ft.
(Street Name,Numbers,Commu ,SubdlNalen,Lot No.,Rare*;,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge OOther From To Formation Description
(cheek apprdprlate box) J�.J L
May be in o r
/�D����1 Clay & Sane
LATITUDE � _ minutes,secondscoeds or rT'a^i 1•a
LONGITUDE__ in a decimal former
Latitude/longitude source: ❑GPS ❑Topographic map
(location of web must be shown on a USGS topo map and -t
attached to this form b not using GPS)
d.WELL OWNER
OWNER'S NAME i c7
STREET ADDRESS �7D IC-
_ l l ry400
City or Town State Zip Code
c 828 1. P49- 09%
Area code• Phone number
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: 600r
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOj
- c. WATER LEVEL Below To _. 100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH.
P of Casing:- 30a FT. 13A NCAC tC,WELL CONSTRUCTION STANDARDS,AND THAT COPY OF THIS
(Use'+•If Above Top of Casing) RECO AS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING le 2 FT,Above Land Surface' �!
'Top of casing terminated aVor below land Surface may require ATURE O RTIFIED WELL CONTRACTOR/ DATE
a variance in accordance with 16A NCAC 2C.0118.
e. YIELD(gpm):wMETHOD OF TEBT Blow James Be BTOWT1
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt:,
1617 Mail Service Center—Raleigh,NC 27699.1$17 Phone No.[phone] ext 568, Form GWta
Rev.7105

U�Jo
s RESIDENTIAL WELL CONSTRUCTION RECORD u ,
North Carolina Department of Environment and Natural Resources.Division of Water Quality y
WELL CONTRACTOR CERTIFICATION k 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type H`T H Amount 1 60Z
Russell S. Taylor g• WATER ZONES(depth
Well Contractor(Individual)Name From sTo�• From To
Hedden Brothers Well Drilling, Inc. From Tom,r From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING: Thickness/
Depth Di meter Weight� M_glenal
Franklin, NC 28734 From To�jFt. ee ,iaa u0
City or Tawn Stale Zip Code From To Ft. _
( 828 )- 369-9591 From—To_Ft.
Area code- Phone number
2.WELL INFORMATION: - 7. GROUT: Depth Material Method
SITE WELL ID a(if applicable) �• g. From_Q_To�20 Ft. oBTEnt & �TT1itE i]EpEd
�J.S 7.7 9 From_To Ft.
STATE WELL PERMITII applicable) From_To_Ft.
DWO or OTHER PERMIT N(If applicable) 6. SCREEN: Depth Diameter Slot Size Material
From To Ft.—In. _ In.
M ELL USE(Check Applicable Box): Residential Water Supply 1K From To_Ft._in. _ in.
r.: rE DRILLED 1/' 7.06 / From To_Ft.—In. — In.
TIME COMPLETED o�. 30 AMC PM(g
9. SAND/GRAVEL PACK:
3.WELL LO TION: Depth Size Material
CITY: COUNTY From To Ft.
Y- _ JS.J
From To Ft. -
From To Ft.
(Street fileme,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat ❑Ridge ❑Other From To Formation Description
(check apprdprlala box) 0 - r Clay & SaI1C1
May o in degrees, ID 1 r .r n i
L�71TUDE te
� _ minutt es,seconds or
LONGITUDE_ in a decimal former
Lati'ude/longitude source: ❑OPS ❑Topographic map
pocatbn of weNmust be shown on a USGS topo map and
attached to this form/not using GPS)
4.WELL OWNER
OWNER'S NAME nT
��A
STREK ADDRESS Cl)_1tL A�YJr�
:A JA �„o Nl_ Mai y
City or Town State Zip code
L-129 Ifg
Araa coda• Phone number
11. REMARKS:
S.WELL DETAILS: s
a. TOTAL DEPTH: �.SO
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO k
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Balm Top of Casing: f!�?; ,050_FT. 15ANCAC2C,WELL CONSTRUCTION STAN04ROS,AND THAT A COPY OFTHIS
(Use'+•N Above Top 0lCasing) RECOR AS BEEN PROVIDED TO THE WELL OWNER,
d. TOP OF CASINO IS 2 FT.Above Land Surface- CJ
'Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED\ LL CONTRACTOR D E
a variance In accordance with 15A NCAC 2C.011 S.
e..YIELD(gpm): . 3 METHOD OF TEST Blow Russell S. Tay or
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GWta
16117 Mall Service Center-Raleigh,NO 27699.161T Phone No,[phone] ext 568. Rev.7/05

! _ RESIDENTIAL WELL CONSTRUCTION RECORD
1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type 1411 H Amount 160Z
g, WAT ZONES(depth): r
Well Contractor(Individual)Name From To4'1 I From To
Hedden Brothers Well Drilling, Inc. From To From" To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD S.-CASING: Thickness/
Dept Di elPr Weight t rlal
Franklin. NC 28734 From +To Ft. �
City or Town State Zip Code From To Ft.�_ A1F�
Area co_)
369-9591 From To_Ft. _
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION:
From_,Q_ToL2Q_F1. GHIHIt: & I7E[L111tP
SITE WELL ID#(If applicable) Fran Tc Ft.
STATE WELL PERMIT#(If applicable) From To_Ft.
DWQ or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
to cLL USE(Check Applicable Box): Residential Water Supply❑ From_ To_Ft._in. _ in.
from To—Ft._In. — In.
I r.A rE DRILLED // -�OS) From To_Ft._in. _ in.
TIME COMPLETED O{/Y 4b AM❑ PM
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CIT - 4 COUNTY, u.� From To_Ft.
� //�I '� / From To_Ft.
Q//lr-J' l k4,W From To Ft.
L�(St eet Name,Numbers,Conununity,SubdlWaion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑^,lope C)Valley OFlat ❑Ridge OOther From To Formation Description
(check apprdprlaU box) May
O t C1ar t sand
May be in degrees, s 1
Lr'T!TUDE � _ minutes,seconds or -. Granite
LONGITUDE in a decimal format
Lat.i'ude/longitude source: ❑GPS ❑Topographicmap
(location of we#must be shown on a USGS loop map and
attached to this k rnot us/ng GPS)
e.WELL OWNER
OWNER'S NAME
STR" TADDRESS _
C 7 C0
City or Town State Zip Code
ATF 1. 74 3 " 7561 ,
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: e
a. TOTAL DEPTH: .5 5
b. DOES WELL REPLACE EXISTING WELL? YES❑
,p�^� 100 HEREBY CERTIFYTHATTHS WELLWAS CONSTRUCTED NACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:- 360- - FT. 1SA NCAC 20,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use•+"If Above Top Of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASINO IS 2 FT.Above Lend Surface-
'Top of casing terminated Eliot below land surface may require IG ATURE CE TIFIED LL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
a. YIELD(gpm):1_METHOD OFTEST BlOca --
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
16117 Mail Service Center—Raleigh,NC 27699.1617 Phone No.[phone] ext 568. Rev.7105

aT`r - �
L �t I - _ RESIDENTIAL WELL CONSTRUCTION RECORD 5 .. 4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
U
WELL CONTRACTOR CERTIFICATION N 2187
1.WELL CONTRACTOR: 1. DISINFECTION:Type H/'T H Amount 16oz
Russell S. Taylor 0• WATER ZONES(dee tth/h�T): i
Well Contractor(Individual)Name From—ILTom_ From 390,To ,390�
Hedden Brothers Well Drilling, Inc. From LZ.E To 130 From To
Well Contractor Company Name From ' To Z 3g, -From - To
STREET ADDRESS 73 Holly Hills Vista RD S. CASING: Thickness/
Depth Ft. DiaT7+elyr Weight M)prial
Franklin, NC 28734 FromT04N or YG
CI at Town State Zip Code From=To, �
( $2g )- 369-9591 From To Ft._
Area code- Phone number
T. GROUT: Depth Material Method
2.WELL INFORMATION: From_g___To720 Ft. CEITUt & uffXrdtE j1TPd
SITE WELL ID N(if applicable) From To_Ft.
STATE WELL PERMITM(if applicable) Ftom To Ft.
DWQ or OTHER PERMIT*(If applicable) 8. SCREEN: Depth Diameter Slot Size Material
_
M':LL USE(Check Applicable Box): Residential Water Supply[IFrom To_Ft. _From To_Ft._In. in.
In. _ In.
(r ,rE DRILLED0 From—To_Ft in. in.
TIME COMPLETED Od AM7�PM❑
9. SANDIGRAVEL PACK:
3.WELL LOC I, N: Depth Size Material
From To_Ft_.
CITY: COUNTY From To_Ft.
From To_Ft.
(Strait Name,Numbers,Community,SubtlMsion,Lot&.,Parcel,Vp Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat ORidge ❑Other From TO Formation Description
(check appr6prla4 box) May
0 r Clay & sand
May be in degrtta, s
I_TITUDE � _ minutes,saondeor Granite
LONGITUDE_ in a decimal formal
Lati'ude/longitude source: OOPS ❑Topographic map
,location of well must be drown on a USGS topo map and
attached to this form a not using GPS) T
4..WELL OWNER OWNER'S NAME N
STHA'ET ADDRESS W
He- .48723 ,
City or Town L13-
State Zip Code
�g 7 G 9�8
Area code- Phone number
11. REMARKS:
5.WELL DETAILS: f
a. TOTAL DEPTH;
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0A -
�j� 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:... -..'661 . FT. 15A NCAC 20,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
✓(Use' If Above Top of Casing) RECO s BEEN PROVIDED TO-TTHHl E WELL OWNER.
d -. TOP OF CASING IS 2 FT.Above Land Surface* I1-g"05
*Top of casing terminated allor below land surface may require SIGNATURE OF CERTIFIED W E ONTRAC OR DATE
a variance In accordance with 15A NCAC 2C.0118.
e..YIELD(gpm): METHOD OF TEST B10W Russell S. Taylor
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1a
1617 Mall Service Center—Raleigh,NC 27699-1617 Phone No,(919)T33-7015 ext 568. Rev.T05

RESIDENTIAL,WELL CONSTRLICTION RECORD
' North Carolina Department of Environment and Natural Resources-Division of Water Quality
•"v aw�'
WELL CONTRACTOR CERTIFICATION A 2187
1.WELL CONTRACTOR: f, DISINFECTION:Type HFT H Amount 160Z
Russell S. Taylor g. WATER ZONES(depth): r
Well Conractor(Individual)Name From To 01 From__To
Hedden Brothers Well Drilling, Inc. Tbs
From ,1 I From To
Well Contraclur Company Name From 124�iTo��/ � From To
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING: Thicknessl
�Depm , Diameter Wei 1 Ma erlal
Franklin. NC 28734 From To Ft. lOr
City or Town Stale Zip Code From To_Ft.
( 828 )- 369-9591 From To_FL
Area code. Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From_Q_To"20 Ft.C3IH1t & L8'rflite L1T[t7 d
SITE WELL ID#(if applicable) From To_Ft.
STATE WELL PERMIT#(If applicable) From To Ft._
Dil or OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameter Slot Size Material
From To Ft.—In. _ In.
10 --LL USE(Check Applicable
Box): Residential Water Supply 91 From To_Ft._in. _ In,
C'.ArEDRILLED From To_FI._ln. _ in.
TIME COMPLETED 1 •• 3O AM❑ PM
9. SAND/GRAVEL PACK:
3.WELL LOC ION: Depth Size Material
CITY: COUNTVV From To_Ft.
..L From To_Ft.
r-5 — #Z• From To_Ft.
Street Name,Numbaa,Community,SubdMaion,Lot No.,Parcel,Zip Code) -
TOPOGRAPHIC f LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat CRldge ❑Other From To Formation Description
(check apprdprlab box) M0 12ay
r rrAn Clav & Send
May be in degrees, r r
L.'l ITUDE � _ minutes,seconds or Granite
LONGITUDE in a decimal format
LaWtide/longitude source: 'DGPS ❑Topographicmap
(location of we#must be shown on a USGS topo map and —
attached to this form Inot using CPS)
a.WELL OWNER "•
OWNER'S NAME
ST "E A I ESS 7b 2-119 `n
City or Town Starts Zip Code
c4� � 011(0-943-10
A,aa code- Phonenumber
11. REMARKS:
S.WELL DETAILS: E
a. TOTAL DEPTH:
Id. DOES WELL REPLACE EXISTING WELL? YES❑ NOX_
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Cuing: � gno FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY Of THIS
(Use's'N Above Top of Casing) - REC0 AS BEEN PROVIDED TO THE WELL OWNER.
cl. TOP OF CASING IS 2 FT.Above Land Surface'
*Top of teeing terminated aVor below land surface may require SIGNATURE OF CERTIFIED W L CONT CTOR s r DATE
E
a variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): aQMETMODOFTEST B10W Russell S. Tay
11 PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-ta
1617 Mall Service Center—Raleigh,NC 27699.1617 Phone No.[phone] ext 568. Rev.7/05

WELL CONSTRUCTION RECORll LU
North Carolina - Deportment of F.nvi«nument and `ptura/l Resources- Division of Water Quality-Groundwater Section
\\'t:LL I'U\'I R:\('['Olt 11NUI\'111U:\L)\:\i�I F: lyrinr) /y CEwrIFIC TION PW
I1.1,('ONIl(WI(fit(ONIPAN\ :\\u•:_fy/l/ CF_C ��F '- yam' ---- ---rtorva: a
NI i fE\vl.1.l.CONSIRCCTION reuYlrra ASSOCIATED\vQ platmali
lilapplicahlel (ifa ,licahlel
I WELL USE (Check Applicable Box): Residennal lr�Municipal/Public❑ Industrial ❑ Agricultural❑
:1loniloring ❑ Recovery ❑ Heat Pump Wafer Injection ❑ Other❑ 1I'Olher, I_isl.Use
WIiLL. IOCATION:
/ Topographic/Land setting
C'omu•.J4C ) 1/
// ---y---�/ —= -------- L9rtl�e ❑sh,pe ❑valley ❑rlal
(check,appwl,nate box)
/Simrl Nann'.Nu...b. .('mnm n- \isim,,Lan No_Zip C,dv) Lett 11 ude/longl[tide or Well location
3 llV N 1:14.. AA✓ _ -- Idcgrccs;minulcs/seconds[
.-wdlrss �,Z ' Y- L to itldClongitudc source:❑GPS❑Topographic map
IS lrrel or 12oun'Np.) ('dmck N,z)
_k/ / e L S 6/Z7 DEPTD DRILLING LOG
I'll, or'r,nrn State zip Cndc from To Fo- lotion Dcscripl ion
l. D,\'Ili URII_LIiU"� �—
Dlil'lli.4�_ , Ole,
6. DOES WELL REPLACE EXISTING WLLL'' YES ❑ NO M1__
7. S'I'A1'IC WA'rEIt LEV1 1. 13elow'rop ol•Casig,,: goP'I'.
I Dse••+"if At Top of Casing) -
S. l'OI'OF C'ASIN(i IS____ 2__ FT. Above l.and Surface*
*'fnp fir casing terminated aimr helms land surface rer,,tirny a
variance in ucamlun[e th 15A NCAC 2C'.0118.
'). Y'1IiLD(elms):_ NILmIODOFTI.iST A•l
IU. \WA"I-IiR /.ONIiS(depth):— _
LOCATION SKE"I'M
11. DISINFECTION.Type 712L Am.um ShuW direction and distance in miles from al least
12. CASING: Wall hickness two State Roads or County Roads. Include the road
Dep[h Dia e or V. ' 1dhl. Iatcri:d numbers and common road names.
{
-
Il. GROUT: Ugnh
Be .Ma ri:J Alcthod
V.fP
I-I. SCRI`I'.N: Depth Diameter Slot Size Material C" in
-
lionl-------
15, SANWORAVI71.I'ACK: -_
Depth Size ;alalerial ,
Prom 'ro Ft.
from.._ _—fo—'--- IL------ -----
I6. Itli\I:1RKti:
IIN) Ill'.RIiHY' C'li1<'III'Y 'l-IIA"r"FIiISWEI-LW'ASCONSI'RUCTEDINACCORDANCEWITH15ANCAC2C,WELL -
CONS-1 RUCI ION STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED 10 1-I1E WELL OWNER
S GN Ai L'RE OF 1'Ei2SON CONSTRUCTING THE WFLL DATE
r
Submit the ori-11inal to the Division of'Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC _-
27699-1636 Phone No,[phone],Within 30 day,. G W-I REV.07/2001

WELL CONSTRUCTION RECORD
Not Ill Cal'Jlma - Deparmicln of Flivil-011111CIl(and i'J:(Ural/)Resources- Division of Water Quality-Ground wafer Section
w l(i.t.('ON I R A!A Olt DI VIDUA I.)NAM F: ,riot) //Z� r\ ��{0�1/�P� CF.Ii'rIF'IG\'I'IONq�,O/
COVI'n ACfOn('OMPANYNANIF: l6.e 44,le G�'+� _ 1'IIONF: N �
S I,YET:)M-L C ONSTRUCHON I'Fnm rrN :xssoCl,k,fED\vQ nftmrrN
Iir applicable) (inapplicable)
I WELL USE(Check .Applicable Box): Residemial M Nlunicipa VPublic ❑ Industrial ❑ A_,ricullural ❑
..\loniloring ❑ Recovery ❑ Heat Pump Walcr Injection ❑ Other❑ IrOthcr, List Use
_. WELL LOCATION'
�✓aQGc� To setting
Ncalcsl , Vols .._�� { Count•: f�'(tidec ❑Slope�� ❑Vallry ❑I:IaI
(check appnq,mile hoc(
l5liere.Nan Nnlpbcis,(lnumu//oil V.5ubdivisiun,Lau No..lip C,xlc1 [-ill it Lid c/longi(title or well location
\Jdlcs' �✓• LaliIII(IM(m"iunle source:❑GPS❑Topographic map
/ / I Xn'rcl ur 12umc Nn.l
`J�/ Lr fcheek.hnsl
NC. nc '77�`' DI-:P-rn DRILLING LOG
iy ix l,nvn.' Ianr Zip Cade From T41 F Iro Description
.\nv nda I'Ln�c mm�6cr. �/ J�
1. D:\lai . DI P-I11:�O"�Y"
>. l"U'f,1I. UI•:1'l'li:_�.$� --
6. DOGS WELL REPLACE EXISTING W'LI,L'? YES ❑ NO
1. S"I':\TIC WATER LI:VGI_ Hcluw Top ul'Casing: 1,5— P'I'
t Use••+"if Ahuvc l'(,p of Casing)
S. 'I OP OP CASING IS C;?- FF. Above Land Surface` -
*'cup of casin,Icnninalyd a1/ur 6eluw(and surface rewtires a
lrari:ulce in urcurdanc)•cv�ith 15A NCAC 2C.01 IN.
11. YIELD(ghn ):5 tie[:TrIOD OP n S-r 41;—
10. WATII.R ZONES(depth):_ —
LO C•ATI O N S K E 1-0 I
IL DISINFECTION. Type Ant.ant Show direction and distance in miles From at (cast
I'. CASING: Wall --hickuess two Slme Roads or County Roadi. Include the road
7 Depth�� DD)u11cI or l!�I, �eria� numbers and common road names. -
14om Ft. rd�y r/ ✓w ail
I I GROU I: Dcpol, NI •vial Nlelh, `
7 Z
I I. SCRIA:Nt Depth DMincter Slot Size --- Material =
Plnnl _ ..._. To H. --ill.
on
I?. SANDIORAVC•L PACK: O r
Ucptl1 Size ,vinlerial un
Pron1I'n FI.
------ -- -- l
.
Ih. Ifl{�NIr1RKS: -
I DO III:RI:I3Y C'HOIFl"hHATTHIS WELL WAS C(•NSTRUCTED IN ACCORDANCE WITI I I iA NCAC 2C,WELL
('ONE I RUC I ION Sl':\NDARDS.AND THAT A COP`,OF THIS RECORD I-IAS BEEN PROVIDED 10 THE WELL OWNER "-
. (iNATUREOFPEiiSONCONSTRUCTINGTHE WELL
DATE
Submit file original to the Division or Water Quality,Groundwater Section, 1636 Mann Service Center-Raleigh,NC
27699-1630 Phone No.1919)733.3221,within 31)dari. . I GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resource - ivis'on of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM�F,/�tpriot)_ J�f. CERTIFICATTON/#ppL�
WELL CONTRACTOR COMPANY NAME r / R �I 11 WPERMII
PHONE # Vj 7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ
617a licable) (ifapplicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N: l' Topogr4pfSc/Land setting
Nearest Town: h,Q ,�County y ❑Ridge 2Lope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Nu tiers,Community,Subdivision,Lot No.,Zip Code) -Latjtind It i e w 11. �t
3. OWNER:
Address (delimmIminutestwonds)a
Latitude/longitude source:❑GPS❑To o 1 p graphic map
(Street R are � ` (check box)
DEPTH DRILLING LOG
it or Town State Zip Code From To Formation Description
Area code-PhoneED
no
4. DATEDRILL
5. TOTAL DEPTH: t
6. DOES WELL REP ACE ISTING WELL? O
7. STATIC WATER LEVEL Below Top of Casing:YFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_I FT.Above Land Surface'
-Top of casing terminated War below land surface requires a
variance in actor Ith ISA NCAC 2C.0118.
9. YIELD(gpm): _MET�(�J3�Qf TES' — I
10.WATER ZONES(depth): ,a(; I
LL( CATION 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�6L Ft.
From To Ft.
From To =7
Ft.
13. GROUT; Depth e T
From To FqjM
CD
From To-4—Ft —
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. - O ."
From To Ft. in, in. u7
15. SAND/GRAVEL PACK:
Depth Sin 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
CONST CTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE 71.0 R
SICNAT RE OF PERSON CONSTRUCTING THE WELL D TE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.(9I9)733-3221,Within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resource - Division of Water Quality-Groundwater Sectinoon��� �
WELL CONTRACTOR(INDIVIDUAL)NA (print) 2� Y / CERTIFICATION#alav3
WELL CO:\"fRAC FOR COMPANY NAMEWch tN- I' `I �� PHONE # �r/a"1
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERX #
(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 ON: �� A, Topogra c/Land setting
Nearest Town: Count _ ❑Ridge El Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,\Community,Subdivision,Lot No.,Zip Code) Latlln�e/IOnglt of well localioq h�
3. OWNER: 1 17WU C)OQ��ING N A ��o Wnti IQ,1 TO J
(degrees/mimites/seconds)
Address ��-� �j a5 - Latitude/longitude source:❑GPS❑Topographic map
^,!l-� t—St tt or Route No.) 1 (el� )
v`vK�cl rt�G�U vie a q I51 DEPTH DRILLING LOG
- 'City or i6oju state Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED - Q�
5. TOTAL DEPTH: � �
6. DOES WELL REPLACE EXISTING WELL? YES Cl NO
7. STATIC WATER LEVEL Below Top of Casing: U FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS I FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a
variance in acwrda ce h ISA NCAC 2C.0118.
9. YIELD(gpm): METH'
OF TES'I�1�-�
10. WATER ZONES(depth):
.— 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
Dept Diameter or Weight/Ft. Material numbers and common road names.
From E)7 To Ft.
From To Ft. 3
_.1
From To Ft. L
13. GROUT: Depth, Mat al Me od CD
From To
From ToI tT ":7
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. OCrI
From To Ft, in. in. --
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
From—To—Ft.
16. REMARKS:
1 DO HEREBY CERTIFY TH THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR TION STANDARD ,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF-PERSON THE WELL ATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001
J,' �ir

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natur esource6.Q Division of Water Quality-Groundwater Secttiio�n��Q
WELL CONTRACTOR(INDIVIDUAL)NAME n(print) a �� f3 ( �n CERTIFICATION#d�GjQl,n
WELL CONTRACTOR COMPANY NAME 1 1 i 1 N 9t PHONE # U /OZO2 a
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
L WELL USE (Check Applicable Box): Residential 2 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery D Heat Pump Water Injection❑ Other❑ if Other, List Use
2. W ELL LOCATI :�'f�t Q. " r Topogr hic/Land setting
1egres own: CountylJCll-i�JUW ❑Ridge Slope ❑Valley ❑Flat
LL,,��.. �rVZ) (check appropriate box)
(Street Name,Numbers,Commodity,Subdivision,Lot No.,Zip Code) de I It w III a
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:DGPSDTopographic map
IStreet (check box)DEPTH DRILLING LOG
City or Town Stare Zip Code From To Formation Description
Area code-Phone num d
ber ^I O�
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES D NO
7. STATIC WATER LEVEL Below Top of Casing: —'8— FT.
(Use-+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance g accordance with ISA NCAC 2 �
' . r _
9. YIELD(gpm):IIZ3C-Ai METHODDOF OF TES.1�'"`.. b
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
Dep Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From To FL-
Fro It To Ft. 7-,
13. GROUT: Depth Ma Met Z
O
From To F .0
From To Ft I o'+
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. O
From To Ft. in. in.
Cll
15. SAND/GRAVEL PACK:
Depth Size Material `
From To Ft.-
From-To Ft.
16. REMARKS:
I DO HEREBY CERTIFY TJJAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONST CTION STAND DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
� as
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Su nutinal 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

North Carolina- Department of Environment and Natural/Resources- Division of Water Quality Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �L( Cl/�jG/t�F
/^1�- CERTIFICATION# t�,
WELL CONTRACTOR COMPANY NAME l_.t'r4m d&s ��^ ) �b
�...Jc/3[G PHONE #
STATE WELL CONSTRUCTION PER-NIITN ASSOCIATED WQ PER-VH1#
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box): Residential-ET Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Towm:y4 U Topographic/Land setting
�. Tl County �e ❑Ridge ❑Slope ❑Valley ❑Flat
f ice (check appropriate box)
(Street Name,Numbcrs!Community,Subdivision,Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER: o � risk!
(degrees/minutes/seconds]
Address _ 30/ o✓ BvtS dw/ �i.
Latitude longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
©f1)67r�'6 yt 3 c1 DEPTH DRILLING LOG
City or Town State Zip Code From TO
Formation Description
Area code-Phone number _
4. DATE DRILLED_5y�S— C Ay
5. TOTAL DEPTH:_-� sfY )
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS / FT.Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. -
9. YIELD(gpm): .-7? U METHOD OF TEST
10. WATER ZONES (depth):
_ LOCATION SKETCH
11. DISINFECTION: Type Amount Show direction and distance in miles�om alkast
12. CASING: Wall Thickness two State Roads or County Roads. h ide the road
Depth Diam7er or Weight/Ft. Material numbers and common road names.
From To /D`J FL_ I
From To Ft.
From To Ft.
13. GROUT: Depth Mat rial Method
FroMQ—To b_Ft.
From To FL -
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in U
From To Ft. in. in. t
15. SAND/GRAVEL PACK: co
Depth Size Material l
o From To Ft.
From To FL _)
16. REMARKS:
it
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
/L t // �
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE 6
Submit the original to the Division of 1i'ater Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days.
GW-1 REV. 07/2001

. . ._�.�.. .....�.viiw�• ir_vi� 1cL.l,lJtClJ ���,�' ' S rj
I - -
North Carolina- Department of Environment and Natural Res00rc(3- Division of Water Quality- Groundwater Section.
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 11
CERTIFICATION
WELL CONTRACTOR CONIPANY NAME wwl 2,7jc" 7/!A
PHONE q
STATE WELL CONSTRUCTION PERMITq(if applicable) .4SSOCIATED WQ PE10111k
(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:
Nearest Town:�t� /Q�u Coun -'ty ,�q y��iJ Topographic/Land setting
�`—'z --- ❑Ridge ❑S)ope ❑Valley ❑Flat
o T klws--e 5- — (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER: - I n15 ,I
10.3D/ Py?rE tom/QJ�f Lali (degrees/minutes/seconds)
Address
/il tude/longitude source:❑GPS❑Topographic map
(Street or Rome No.) (check box)
�/
'•7•v'✓/OIIJ 'EZ DEPTH DRILLING LOG
Cary or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED - � �'j e
5. TOTAL DEPTH: `�
6. DOES WELL REPLACE EXISTING WELL? Y S ❑ 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 atfor below land surface requires a 9 -
variance in accordance with 15A NCAC 2C.0118. C
9. YIELD(gpm): 020-A`?—METHOD OF TEST_4jy _
10. WATER ZONES(depth):
_ LOCATION SKETCH Lit
It. DISINFECTION: TypeAmount Show direction and distance in miles from atleast
12. CASING: Wall Thickness two State Roads or County Roads. Include theroad
Depth Diam ter or Weight/Ft. Material numbers and common road names.
From To o)? FLU
From To Ft.
From—To Ft. l +._..... ._-
13. GROUT: Depth `"Matterial Method
FromTo_ 'AFt 'kdL- liz
z
Froln To Ft. { .♦; a
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. I
1
From To Ft. in. in. c
15. SAND/GRAVEL PACK: `
N
Depth Size Material o
From To R. _ "`I
From To Ft.
E ,
16. REMARKS: _ _•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Alai]Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North C'.amlina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
W r.Li,CO.NA RACfOR(INDIVIDUAL)NAME (print) L,rg{�._._sI� �7 CERTIFICATION#
WP:LL CON'fRACIOR COMPANY NAME�F1IE__1J�5 (/Va %( V /{�!11ACw %J" PHONE # • `�&'3� ��
S"I ATE WELL CONSTRUCTION PERMIT#_____�O lL 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
ca N /r}�,•st Tgwn: 0A. County vidge ❑Slope OValley ❑Flat
AP'o IA ti0 ( ak /J2 (check appropriate box)
Street dame,, Numbers,Community,Subdivision,Lot No.,Zip ode-)/ Latitude/longitude Of Well location
3. OWNER: `..L_.>__+.+, `11 an w ,w4 tr /lJ-C-L[�-L�P/).0 (degrees/minutes/seconds)
Address _�Jt{ _h�,_::•_b__� Latitude/longitude source:OGPSOTopographic map
I Street or Route No.) (check box)
ill!' ?$& DEPTH DRILLING LOG
cay or own State ' Zip Code From
�� To I Formation Description
Areacode-Phone number (O 17
4. DATE DRILLED
S. TOTAL DEPTH: / 15_
rp,L., ul.it ul.-nt nCE WH L" YuSU NO
7. STATIC WATER LEVEL Below Top of Casing: 767 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 15 NCAC 2 18
9. YIELD (gpm):�MEYIOD bF G�T �, A r S
l0. WATER ZONES(depth): ;5�DD t
LOCATION SKETCH
I I. DISINFECTION: Type Z Amount a/8 f�145 . Show direction and distance in miles from at leash
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. r—
Fr<an O ._To Ft. le " P
From_ To Ft.
From- -_To FL Coo
I3. GROUT: Depth Material Method O —
1 U�
From To �2,6 Ft.,
To Ft.
i 4. SCREEN: Depth Diameter Slot Size Material
From_-_ __To Ft. in. in.
From— To Ft.—in. in.
1S. SANDXiRAVEL PACK:
Depth Size Material
From To Ft.
From. To Ft.
REMARKS:
i DO f hRF.BY CERTIFY THAT THIS WELL WAS CONSTRUCIED IN ACCORDANCE WITH ISA NCAC 2C,WELL
< UNSTRl1C,''[ION STAND RDS,AND THAT A COP F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRU CC'HNC�T iv�F,1.1.D DATE
Submit the original to the Division of Water Quality,GroundwaatterGGSe``ctioon,1636 Mail Service 7enter-Raleigh,NC
27099-1636 Phone No.[phone],within 30 days. '1 A►I 3 Q 2006 GW-1 REV.07/2001
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
Notch Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /
WELL CON'I RAC"IOR(INDIVIDUAL)NAME (print)_ E"r I U. C CERTIFICATION
W E Li,CONTRACTOR COMPANY NAME G,CPe-vl� s_�. € '4PsluApr PHONE # 1929 L_tq({- ;i1 -70'
Si'A TN;WELh CONSTRUCTION PERMIT# 2. 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
=. WELL LOCATION- _ Topographic/Land setting
Ncare.st Town:- S V CL County Z-,. (511's Ridge ❑Slope OValley ❑Flat
_ l / _ (check appropriate box)
(Slreet Naoiv,Numbers)Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER__!,Id 1. Y rT_ (degrees/minutes/seconds)
Addresti Ct Latitude/longitude source:OGPSOTopographic map
reet or Route No) (check box)
i+-r o NC o� DEPTH DRILLING LOG
ary or Town State zip Code From To Formatb Description
�S
Attu uWe-Phone number ,elS 2
4. DA"fE DRILLED
S. TOTAL DEPTH:------af-)_S
r _ I'1:1 ( PEP! A( E I:YICI-I nf_ W!l I '+ VCl rl NJ) IN
WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Casing)
R. "TOP OF CASING IS FT.Above Land Surface*
,.i up of casing terminated actor below land surface requires a
,ariance in accordance with 15A NCAC 2C.0118.
v. YIELD(gpm):-�.,5—METHOD OF TE T �r5
M WATER ZONES(depth): � 5 , - I 1 - r.-
(n - t vY. LOCATION SKETCH
I I. DlYNFF,CT ION:Type-LET-Li— Amount MJ4M.1, Show direction and distance in miles from at least
2. C'ASIN'O: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Fn;tn_ D—To Ft.
from To Ft. _
From _ To Ft. _
.3. GROUT: Depth Material i Method -=
From— _To_ C Ft.-_ f'l,.:-�-a=.1
From To Ft.
13. SCREEN. Depth Diameter Slot Size Material CD
From__ To Ft. in. in.
o�
From To Ft. in. - in.
15, SAND/GRAVEL PACK:
Depth Sire Material
Prom To Ft.
From To Ft.
16. REMARKS:
i DO I f EREBY CERTIFY"THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
t ONSTRU( HON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
C
SIGNATURE OF PERSON CONSTRUCIINQZ111iTE
pp C hh p ``''CC n/
.Submit the original to the Division of Water Quality,Groundwatels3e%6ff"36wiA;5Crvice Cen r-Raleigh,NC
27699-1036 Phone No.[phone],within 30 days. G -I REV.07/2001
JAN 3 0 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD Y `
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
K'EE,l.('t)NTRACTOR(INDIVIDUAL)NAM (prin0 _n J_J tt II CERTIFICATIONq .SY
WELL C (.ON IRATOR COMPANY NAME, TCp,Pev/e/_.. Lam/-1Zl y Lt D' r l+c(_ PHONE # (SIB �-y� -3/70
S-I A I E WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) momm __
I_ WEI,I,USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. ' kl-L LOCATIO Topographic/Land setting
Nea/restsTown:—Jz G/n County Ridge ❑Slope ❑Valley ❑Flat
Lo a 2 �. e 126 >`� i-• (check appropriate box)
street Namc,Numbers,Community,Subdivision,Lot No,,Zip Code) Latitude/longitude of well location
i. OWNER t.gq (degrees/minmes/seconds)
Address /y� �+)- e�r.,re nrr4 �,. Latitude/longitude source:❑GPS❑Topographic map
(Street or Route Nn.l (check box)
DEPTH DRILLING LOG
cny nrmw state zip code From To Formation Description
(__-)- f) / ) 3
nrua u,du-Phone number /)� t �a t/,5' t
4. DAFEDRILLtiD
�. TOTAL DEPTH: 1 �S t
^„t,`. Nr Pj..(, Y.l'.Pi nr"I. i.vicrinui �ni).,I •r Ycc fl NO V,
7. S'rATIC''. WATER LEVEL Below Top ofCasing: ql.16 FT. _
(Ilse-+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface-
"lup of casing terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C.0118.
9. YIELD(gpm): /—> METHOD OF TEST a k f S
I0, WATER ZONES(depth):", /-? 6 1 - tJ
LOCATION SKETCH
1 DISINFECTION:Type H-17 H Amount 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 //,S Ft, /n 't IP y C'-
From To Ft.
From _ To Ft.
i 3. (iROI'T: Depth Material Method y
From D To 2.D Ft. C&rv�
From _ To Ft.
14, St REEN: Depth Diameter Slot Size Material
From To Ft, in. in. _
From To F[. in. in.
G�
SAND,GRAVEL PACK: o
Depth Size Material
From To Ft
Fran; To Ft
'6. REMARKS-
DO)IFRFi13Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
( ONSTR.UC'TION S'rANDA DS,AND THAT A COPY OF IIIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON COI, 3TRUCTINGTE
RECEIVED
Submit the original to the Division of Water Quality,Gro ndwater Section,1636 Mail Service Ce ter-Raleigh,NC
27099-1636 Phone No.[phone],within 30 days. JAN 30 2006 -I REV. 07/200I
Asheville Regional Office
u'rfer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment II
and�a,(tura`l-ResourceAA���s-DDi//v��ision of Water Quality-Groundwater Section , 7
WELL CONTRACTOR(INDIVIDUAL)NAME (print) fv I I1 C�}tw� I C7/l''u"17- CERTIFICATION# L
WELL CONTRACTOR COMPANY NAME 1��'ltiC'.l U�l /CLIh'i"eA 2 ./)f- PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION• — Topographic/Land setting
Nearest Town: County G 1 ❑Ridge lope ❑Valley ❑Flat
` 11 i de t a t (,76 u e ( appropriate box)
(stree.Name,Numbers,Community,Sub di sine,La tU.,Zip Code) titude/longitude o
lf well location; -(
rLiS°d�1 f tf..�l u C?X3ol7 .3
3. OWNER: Leanusus (degecalmrmttes/secoeds)
Address t), AX 44 1X3 Latimdeflongitude source GPS❑Topographic map
(Street or Rome No.) ( box)
1 ,�� �C� DEPTH DRILLING LOG
City m town smre tip Code From TO Formation Description
Area coda Phone ember
4. DATE
5. TOTAL DEPTH: '<E)/
6. DOES WELL REPLACE EXISTING WELL? YES❑ N00k
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'4"if Above Top if g)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated■ or below lead surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST
10.WATER ZONES(depth): 370
LOCATION SKETCH
11. DISINFECTION:Type ()TN rw I TL a Amount ru Show direction and distance in miles from at least
12. CASING:' Wall Thickness two State Roads or County Roads.Include the road
Fromm TD o!7.7 Ft m wp numbers and common road names.
Fron To Ft ,
From - To Ft
13. GROUT: Depth Material aw
Fro
To Ft.
From TO Ft cC-)
14. SCREEN: Depth Diameter Slot Size Material l
11
From To Ft in. in.
c
From To Ft in. in. o
15. SAND/GRAVEL PACK:
Depth Size Material
3
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT S WAS CONS TR IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIONS AND O�Y S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATWE OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

320503
WELL CONSTRUCTION RECORD
North Carolina- Dcliarunent of Environment nvirunment and `J•tural tZesources - Division of Water Quality-GroLndwater Section
„,A.L(US"I, cTcn(INDIVII %Y Z&kl o CF.j rO-'ICA„ON# r;f3lgr
a
s f.crr:w r.l.l.cusrel:crws rr:Ra)rra_ ASSOCIATED WQ PERNnra
I i l'applicable) (if applicable)
I WELL USL(Check Applicable Box): Residenr,al Nr Municipal/Public ❑ Industrial ❑ Agricultural ❑
Nloniloring❑ Recovery ❑ Heat Puntp Walcr Injection ❑ Other❑ If Other, t_ist.Use
'_. WLI.1.. .0 *A lI / /i // Topographi�'Landsetting
Nearest 'I'owII:.S lug_ Count"L�9C Sr'n/ "idgc ❑Slope ❑Valley ❑Plat
P LJ`---- - ------- wheck appropriate box)
/\ncd Nanm.Nun .;('Donn....iry,sul"Im iuo,Lae No..Zip Cale) Latlttldtl/lOrgltll&or Wcll location
. . (ANNLR. ,�, S ,I �r (tlegreesninules/stcuuds)
Address -- — -fi7l(aliulda/longitude source:❑GPS❑Topographic map
Ititmd or li�c Nn.l lvvr I'd.cck box)
-17/ 3 �1 ��C r DEFT(( DRILLING LOG
f'in Drbarn S(ur Zip c'e IQ Front �To Ft -n olio Descriplion
axle.I'LDne uumhs / q2
DILII_LLU
DLI''I'I1:_
h. DUGS WL•'LL RI:PLAC'L EXISTING WLLL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: d 3 FT. ---
I IJ,u"•'*if Above I op of Casing)
M. '1'OI'OI'C'ASIN(i IS FT. Ahovc I and Surface*
`Top of casing Immix:aril al/or belim land surface rey uirex a
Variallec in ucc..rtiao Will, TiA NC\C 2C.OI IN.
e. Y'IELD(epnl):_c)O METHOD OFT( ST/71" _
10. WATF'R/.ONES(depthy -_
LOCATION SKIiTC'f-I
I I. INSINI I:CTION:'hype Anse unt Show ditcefion and distance in miles from at least
12. CASINO: Wall -hickticss two Stale Roads or County Roads. Include the marl
Ueplh Uj;rlrkfcr o;V,,C1g 1, 1. k; cna/ roomers;rod common
/road names.
Tt
Prom 'I'o
Prom ----.fo
i GUUI pt Deh ---R Material N clhotl _
Front TO L-20 1:1-4 e_� `^ .
I-I. SC•RI[FN: Dapar Diameter Slot Size Material
Iion..
iron--------' in.
I SAND/GRAVL1. PACK: p Ga
Depll Size Material U1
From '1 a FL
6. RI'.NIARKS:
I Uf) I IIiRIiB1'CL'!tI1FY""I'11r1"f'iFI1S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC2C,WELL
C ONSTRUC-(ION ti l'ANDARDS.AND THAT A COPY 01'THIS RECORD HAS BEEN PROVIDED TO THL WELL OWNER
,qfGNATUREOF PERSON CONSTRUCTING THE WELL DATE
r
Submit file original to the Division of 1Vater Quality, Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1656 Pillow No.[phone],within 31)loci• GW-I REV. 07/2001

RESIDJj �J '
ENTIAL WELL CONSTRUCTION RECORD ,w _,ry
North Carolina Department of Environment and Natural Resources.Division of Water Quality 320615
w.v.w'•
WELL CONTRACTOR CERTIFICATION N 2187
1.WELL CONTRACTOR: f, DISINFECTION:Type Hd'T H Amount fLQ
Russell S. Taylor 9. WATER ZDPES(depth):
Well Contractor(Individual)Name s
From��To y(nz From To
Hedden Brothers Well Drilling, Inc. From - To From To
Well.Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING: Thickness/
Depth..., r - Diameter Weight_ M rlal
Franklin, NC 2873d From � To_(f—Ft. Ibd
City or Town State Zip Code From_To Ft. _
( 8281• 36 —95 1 From To_FL_
Area code• Phone number --
2.WELL INFORMATION: �fL�1.7 G 7. GROUT: Depth Material - Method
SITE WELL ID#(If applicable) 1 Jd 1'�� �QV From_Q_To 20 Ft. Cerrer t & 1;13Yillte t1IIp83
From To Ft.
STATE WELL PERMITB(e applicable) From To Ft.
DWQ or OTHER PERMIT e(If applicable) 6, SCREEN: Depth Diameter Slot Size Material
H'ELL USE(Check Applicable Box): Residential Water Supply Cl From_To_Ft._In. _ In.
,^�GG From To_,_Ft._In, _ In.
TIME
rE DRILLED l I 4 '
( W _
TME COMPLETED LI i AM O PM 3�-- From To FL _in. _ in,
9. $AND/GRAVEL PACK:
3.WELL LO ATION: Depth Size Material
Cl Y: Alla.lon,
UNITY From To Ft.
From To Ft.
From To Ft.
(Street Name,Nu bare.Commu y,S Lot No.,Parcel,Zip Code) - - - -
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope CIValley ❑Flat ❑Ridge ❑Other From T Q Formation Description
(check apprcpriala box) O ! r Clay & sand
L.T ITUDE [�,,a, degrees,
-� — econds or (:ranif-xs
LONGITUDE l fannat -
Lati'ude/longitude source: ❑OPS ❑Topographic map
iloeation Of WON must be Shown on a USGS tope map and
allached to this form IF not us Mg GPS) _
a.WELL OWNER GO A
OWNER'S NAM
CD
STREET ADDRE lVZ SS
1..le a�a)t iJt=
((�] ke!
City por Tow'n '' s 7State Zip Code
A,aac Gam•-�! Z I —
Araa code• Phone number
S.WELL DETAILS: 11. REMARKS:Q
a. TOTAL DEPTH: U
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOIK _
c. WATER LEVEL Below Top of Casing: - FT. i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use•+'11 Above Top Of Casing) REC7OrAS EENLPROVIDED TO THE WELL OWNERDTMATACOPY OF THIS
d. TOP p CASING IS 2 Fla Above Lend B require
'Top of cueing terminated with below lend surface may require S GNATURE OF CE TIFIED WEL ONTRACTOR
a variance in accordance with 15A NCAC 2C,0116.
e,.YIELD(gpm):�_METHOD OFTEST Blow _ Russell S. Taylor
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the DIVielon of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Serviee Center—Raleigh,NO 27699.1617 Phone No,(919)733.701.5 ext 568. Form GW1a
Rev.7105

UU.. '
RESIDENTIAL WELL CONSTRUCTION RECORDNorthCarolina Department of Environment and Natural Resources•Division of Water Quality 320614
WELL CONTRACTOR CERTIFICATION k 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type HO_T H Amount 1
Russell S. Taylor q. WATER ZONES(depth): a
Well Contractor(Individual)Name From /Q L To J 6 3 r From To
Hedderi Brothers Well Drilling, Inc From 150 it To From To-
Well
Contractor Company Name From G 8 rTo From To -
STREET ADDRESS 73 Holly Hills Vista RD 9. CASING: Thickness/
Depth Diameter Weight Material
FrTgin, NC 87 4 From To Ft. PVC
City or Town State Zip Code From To�Ft.(A
369-9591 From To Ft.
Area code- Phone number --
2.WELL INFORMATION: 7. GROUT: Depth Material 1.X3���`_ Method
SITE WELL ID 0(aappllcable) 7547-$7- li9 5 0 lt.From__Q—To"2 Ft. Offre & IYIllt2 TzxloEd
From To Ft.
STATE WELL PERMITe(Ir applicable) Fran__To Ft.
DWO or OTHER PERMIT N(if applicable) S. SCREEN: Depth Diameter Slot Size Material
N ELL USE(Check Applicable Box): Residential Water Supply Q' From To Ft._In. _ in.
; rsArEDRILLED H- 1 •0S From_To—Ft.—_In. _ in.
From_To_FL_in. _ in.
TIME COMPLETED I � � 00 AM�pin O -
9. SAND/GRAVEL PACK:
3.WELL LOCATION: (� � Depth Size Material
CITY: OLINTY From To Ft.
` From To_Ft.
-ram 1 r n, - � From To Ft.
(Street Name,NumDera,Com niH. ubdlNa on,Ld No.,'Parcel,Zip code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑slope ❑Valley DFlat ORldgs ❑Other From To� Formation Description
(check epprdprlBN box) r C1aV & Sand
Li 11TUDE L3yindegrees,3 ,seconds or 91 � r (,Yan ito
LONGITUDE mal formal
Lathide/longitude source: DOPS ❑Topographic map
I location of wed must be shown on a LISGS topo map and
attached to this form N not using GPS)
4.WELL OWNER n
OWNER'S NAME t:.+
STREET ADDRESS
G �
City or Town State Zip Code
=Aeacode�- _22L -'12710
r • Phone number
6.WELL DETAILS: �O,
11, REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NCA
C. WATER LEVEL Below To Of Casing: /DO� . IOC HEREBY CERTIFY THAT.T11e WELL WAS CONSTRUCTED INACCORDANCE WITH
P 9 FT. 1M NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF 7413
(Use-�-If Above Top Of Caaing) - RECORD S BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASINO IS 2 FT,Above Land Surface-
*Top r7s
•Top of eaainq terminated aVa below land surface may require g'_. - RE OF CERTIFIED WEL ONTRA TOR A E
a variance in accordsncewith 15A NCAC 2C,0118.
a..YIELD(gpm):�_,METHOD OF TEST Blow Russell S. Taylor
PRINTED NAME OP 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 GW4a
Rev.7/05

"CJ �" . �• RESIDENTIAL WELL CONSTRUCTION RECORD Q .,' North Carolina Department of Environment and Natural Resources.Division of Water Quality 320613
.,
WELL CONTRACTOR CERTIFICATION 9 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type HI;T H Amount 16oz
Russell S. Taylor g. WATEg ZONES(depth)
Well Contractor(Individual)Name From_ To1p6 From To
Redden Brothers Well Drilling, Inc. From To From To
Well.Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD 6, CASING: Thicknesst
Depth Diameter Weight Material
Franklina NC 2 34 From To Ft.
_
Clry or Town State Zip Code - From To_Ft. _
( 828 1- 36 — 5 1 From_To_Ft.
Area cods Phone number --
2.WELL INFORMATION: - 7. GROUT: Depth Material
���„ Method
SITE WELL ID#(If applicable) Ftcm_ —To�Ft..CEITEnt. & A 1.,,�Arnjtg IIIIOEI
From To FL
STATE WELL PERMIT#(If applicable) From_To__Fl.
DWQor OTHER PERMIT*(Ifapplicable) S. SCREEN: Depth Diameter Slot Size Material
YP dLL USE(Check Applicable Box): Residential Water Supply❑ From To Fl._in. _ In.
r-t rE DRILLED 1' I DO� __From_To_,_Ft.__In. _ In.
i From To Ft._In. _ In.
TIME COMPLETED � _ AMO PMO
8. SAND/GRAVEL PACK:
3.WELL LOC TION: Depth Size Material
CITY: COUNTY ( From To FtSS .
From To Ft.
4XIULD Cc From To Ft.
(SI t Name,Numtoni,Community.but MR81011.Lot NO.,Famill,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat ❑Ridge 00ther From To Formation Description
(check apprdprlsto box) 0 f Clay & Sand
L T ITUDE LiMn
be in de2s -
-�— — tes,seconds er r _ Crani 1-e
LONGITUDE ecimal format p
Lati'ude/longitude source: ❑GPS C)Topographic map
(location of wal must be shown on a USGS loco map and
attached to this form Fnct using GPS) .
4.WELL OWNER
O
Si
OWNER'S NAME
ST "ET ADDRESS
� � City a T n State Zip Code
L32.LL�1- I
Area code- Phone number
11. REMARKS:
S.a. LL TOTAL
r �YESc
a. TOTAL DEPTH:_b. DOES WELL REPLACE EXISTINGWELL? NO
c. WATER LEVEL Below Top of Casing: _FT. I DO HEREBY CERTIFY THAT THIS WELLWAS CONSTRUCTED INACCORDANCE WDH
O 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use"t•H Above Top of Casing) RECOR AS BEEN PROVIDED TO THE WELL -HER.
d. TOP OF CASINO 18 2 FT.Above Land Surface-
'Top of Casing terminated War below land surface may require 19615
a variance In accordance with 1SA NCAC 2C.0118, SIG ATURE OF CERTIFI W CONTRACTOR D E
e..YIELD(gpm): ' 5 METHOD OF TEST BLOW W RllSSell S. TaYlDr
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt.,
1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No,[phone] ext 568. Form GW1a
Rev.7/05

yT/�
RESIDENTIAL WELL CONSTRUCTION RECORD
q North Carolina Department of Environment and Natural Resources-Division of Water Quality 2 0 61 2
U'4o-a.».w�'.
WELL CONTRACTOR CERTIFICATION A 2187
1.WELL CONTRACTOR: f. DISINFECTION:Typa H"T H Amount 16oZ
.Russell S. Taylor g. WATER ZONES(depth):
Well Contractor(individual)Name From To—+y�jr From �Tc,
Hedden Brothers Well Drilling, II1C. From To OG' From To
Well Contractor Company Name- From To1 ZLL_ From To
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING: Thicknessl
F� Depth Diameter Wei 1 Material
FYall$liIIa NC 28734 From_(1 To Ft=
City or Town Stale Zip Code From To Ft. _
( 8281- 369-9591 From_To Ft.
Area code- Phone number '
2.WELL INFORMATION: 7. GROUT: Depth Material Method
75�7 93 .5a38 From_Q_To720 Ft. CSIHYt &hffr sits Il7[pB3
SITE WELL ID M(II applicable) To Ft.
STATE WELL PERMITNI(it applicable) From_To_Ft.
DWQ or OTHER PERMIT#(if applicable) It. SCREEN: Depth Diameter Slot Size Material
0 ELL USE(Check Applicable Box): esidential Water Supply O From To Ft._in. _ in.
GAME DRILLED ICJ
�+ From To__Ft.__in, _ In,
From_To FL__In. — in.
TIME COMPLETED I�. OD AMp PM%
9. SANDIGRAVEL PACK:
a.WELL LOCATION- Depth Size Material
CI Q COUNTY From To_Ft.
From To_Ft.
From To Ft.
(Street Nam*,htumbem.Community,SubdiNsicn,Lot No.,Pareal,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑8lOPe CIValley ❑Flat ❑Ridge ❑Other From TO
Formation Description
(check appr6pda4 box) O s (...'lay & sand
Em.
x in deyeea, r
I ITUDE ,-,')_ _ a,aaonda or C;rani 11
LONGITUDE_ cimal format
Lati'ude/longitude source: ❑GPS ❑Topographic map
ilocation of WON must be shown on a USGS topo map and -
attached to this form Knot using GPS) T
♦.WELL OWNER
OWNER'S NAME FIL --- -
ST,FiEET ggDRESS
a. FI. 57 _
ppC--it��y or Town����JJ �� ��CS�taQpte�� � Zip Code
L_.pL.�]-�+G1SL�C1.�_
Area code• Phone number
I1. REMARKS:
8.WELL DETAILS; I s
a. TOTAL DEPTH: �b
b. DOES WELL REPLACE EXISTING WELL?G,YEE�S❑ NO k
c. WATER LEVEL Balm Top of Casing: - k -' FT.- ON STANARDS,100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH.
(Use'+'NAbove Top of Casing) neco�itns EEN PROVIDED T WELL O THE WELL OWNER.D THgTA COPY OF THIS
d. TOP OF CASINO IS 2 FT.Above Land Surface- Dl
'Top of casing terminated at/or below land surface may require P/2
a variance In accordance with ISA NCAC 2C,0118, SIGNATURE OF CERTIFIED W L CONTRACTOR ID ATE
9..YIELD(gpm): HU METHODOFTEST B10W Russell S. TaVl r
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt.,
1617 Mali Service Center—Raleigh,NC 27699.1617 Phone No.[phone] ext 568. Form GW-1a
Rev.7106

_ _ ' .tic:;•... -. .. .-
wELL CoxMUCTU t B&C,= 3. 20640
N«sbC -DepatmauotBuvhomneuaudNalxaliie o�-Dlvldono QuaUry- u
WELL cowraACTOR(omll(wifAW _ f� l> AI.1 .'' i .. . . '17oN11_ .l!
we"COt T"CrottoorvAt�ntM -I+t+(S J611nwA
SrATe Wet.L CONSTROC[tott mnihi - - A9aoCYAT1CDW TM _,' .
(irapptiabla) . •tifapt,Unble) --
1. WELL USE((makAW§cmbWBock-RWidant>?a17YMuakipaUPubEc •laduWWQ Apkabaralp
- + tvlooitoriag O Rxoray �'.Hest Pump Wturx Igjetxioa O Odter CT lft�er,Lld Use � - .
Z"WELL LOCAT N: , ,�-] q cJj jpd sing
N tTowu :11 '- Catmty /} C lCSdT� 13Vdey .MWt
� 4- C z� s L z a zs (do* boo
cSeen Name,t�aobe�R,Ooomomiq, tsttie�,ztp t7eae) ...... - - ailb"on SULff oitYt:B htwtbm .
;- OWNER, ,Tams
Address 59.3 ' fan C(enl!A/Ti A.Q. LaftxWksgibidesom=D orupombicmap
Raw Patil%, pi,- 3 aoa3 DRILLING LOG
t7q' ees stmr ' t7pCode. , ..Fran To. - FaraatlouD=alpdou
Q� �9i_ abo9 ' �r
a" DATEDR�u.LBD�i /.-ice cS . .. -
5. TOTAL Q
(L DOES WELLREPLACEBXISTIIlf.IWBLLY YHS1] Nl):
7" STATIC WATBRLBVBLBdMTopotCaflW Q2D—Q ) l:
(Wa^Y'VAbmeTq ofCmlv4
>L TOP OF CASH IS�_FT.Above Load Smf&m*
prep deedq trrsleetM etlert�katae6eetegabies .. .. -
.aAuar.«orer«.dtr 2C.alu
9. YMM(gptp)- 1[BMD40FTBsr �
10.WATER TONES(depdtk k'
,. LOCATION
11. DISINFECTION: Ammo Show diceetim and.dWtu>cs hi mile from u lau!
'
12. CASINO: Wdl76ieban twolitato.RoadsorOamtpRoods.Indude0amad
Depth � �°► a Wei�btlR _ 3mad eta and`eaataon load tames.
Frmy_To Ft
FmuL Tp Ft, ey
13- GROUT. mamm l6ahod co
From�_�o_�Ft.�2q��,
From To 7R. - - -• �.
.4. SCREEN: Depth Dbm*r . Slotshs : mderw m
FroaL—To Ft---Ju• in.
From._ To Ft`_hL ht. o
S. SAND/GRAVELPACK _ C
Deptb Sae Atatuial
From To Ft
From —To Ft
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WBLL WAS COjiSTRIXM IN ACCORDAI•)C8 WIH ISANCAQM WBM
'ONMLCM)NSTANDA[MANDTHATACOIrVOF RBCORD BEBN"AVMEO,MTWWSLLOWNER
/I1&J,
SIOHATURB PPBRSONCONFIRUCrINOTHBWSW DATE -
submit the original to the Divhton of WaterQu&U%Groundwater Soetlottt 16M NO Serrtee Coates-Ratdgb,'NC
J769SW 676 Phone No.[phone],within 30 days OW-1 REV.071=1

' _ - .WELL• CONSTRIICTIUN ,
.. - 320638
H".C�O=-Deparr�cr13nv8omieotae DlvW o a Qoatiy�Groundwatersection
,,v.,.CowrRncroA(vmt,au%,M ' (n•�n _ wts l Jln ;.4 ' +�at7tr
wa.t.00nrwc,•oacowulvn...r1j.l;: Ikkh�lift0i'lid'i a& 0
r .
srwre weu.CoHnvUCrM rsaaftnSMIMMEMEM
-
[traoWiabta) Qtaodteable) ?
I. WELL USE(Check AppBtabhi Box?.- 0 .Iodu*W O Agttaaauat p
Monitoring o R77 [I'. Eieat Ppaap WSW El Olber It ifodiar,Liu Uar_
2.-WELL LOCATI 41�1Lepd setting
N own<—LJ_LI T��Skpe 0llapry DIat
-1 LR P, (eMdcwrap4taheo0 .
isua+i+®ci+m�.{u-.-�,00�.w,�:.u--,/r-y�io..i.«rio..�rcoaol .. .. Latitaldlarigiatdacfw.plllocuion '
Address ri JP A IV (2.f i=v" [adb plgjbj�app=pQPSOT
(StertaaawNoJ �, (a.a�haal�xmpw map
DEPTH DRILLMG LOG
Tara 3ma OoAa. From TO .Fofmatiat Deacrlption
Ma ends PI aanMt .;.i.,� '-•S� l
4_ DATE DRILLED ) -�1 • . r_ '"��
S. TOTAL D i v c `>h n c e�
,� -
6. DOES WELL REPLACE BXL4T W WBLL7 .YES 0 NU.:
VBL Below Top OrC
7- STATIC WATER LEa� n b'
((MM xUAhenTerarC&*4
8. TOP OF CASING IS__ �____ FT.AbaeLaud Smfisee*
Tap oraalaa orNea lavw
9_ yMb(Pq* /D 7=4()FTEST
10.WATER.ZONES(depd*-�_
11. DISINFEMON: Amotmt Show d[leetloo aadH hwn u kas!
IZ CASINO Amount
bmStippRoadsor County Roads.Ittdudo the toad
Fmm L To �n DlapoetR .or aQmbera and ooiwton road mmee
Froai__'I'n Ft,_..
Fmm-Tg Ft _
13. GROIII_ Depth - b(athod
Fww _ToL.
rrl
.4. SCREEN: Depth Dhooff - Slat sin Matww
FinaL _To FL ____ij�
Frak_To FC ie ip p
S- SANDIGRAVEL PACK _ Ul
Depth Sin Material
From To Ft_ ='
Fmot-__To FL
6- REMARKS:
DOHEREBYCERTIF MTTHISW=WA$OMMRWMINACCaWACBN �VMIsAN=2gW=-
UNSTRUCTKkJSTANDAgDS,ANDTHATA00PYOF RBOORD BMP$OVIDBDT0mMW=0WM
SlONATE7Ri�FPBRSONOD167RUCt1NG[IiBWpi1 DATE ..
Submit the original to the DlvBion or Water Quality,Groundwater sectlop,1636 bW Saviee Canter-Ralefgh,'NC
.27699-1636 Pbone Ne.(919)733-3l21,wltb(n 30 days GW-t REV.07/2001 ..

320637
WELL CONSTRUCTION RECORD'
North Cafolina-Departmatt of BnvimoDreRt aad[xtu l Ratotoca-Dlvlaion of Quality-Quality'-Oroundwata Section
WELL CONTRACTOR(INDI1tIDUAt4?(At,(ItbdNO%IV rl in l�I,%).w CATIONS Y
WELL CONTRACTOR cwarArnr plAastr .( i c f}aI f(�N I!1 J 1Y d 'teoro(rSt`141'_Sa 4-3 b O
STATt WBLL CONBTROCT1ON P9RMhT aUOC.( TSD W iRMtTa •'; -•
(if avaliable) {if applicable)
I. WELL USE(Check Appllcabls Boxy Reaidep4IV-j "ip&Mblic 0 Industrial Cl AgticulhRal O
Monitoring❑ Recovery ❑'Heat Pump Watei lnjeedon O Other 17 If Otlia,Lilt Use '
2.-WELL LOCATION _ �lt/Land setting '
Nearest Tow, S� fV� Ctwnty.�/a-CICSin � ' Q d pe OKtUoy .Flat
S ✓ /) N W A AI ni rA a 1s 77 1 (etrdrapplepdga a
(Sum Name,Namben6 Community.3"Oploo,Lot Na,zycme) Ljidtugooiigitude ofw.pll location .
3. OWNER:L�) 2l?�y l-l�1, a; ( ; )
Address �.S/ S W R-y d e/1 Ladtude/loriglttide source:00PSQT hic map
P
(sheatar aaRlsN0.) �+ I(ebedrboa)
P, r'f- S f LuP i C,. 1 3 %S•3 ,DEPTH ' DRILLING LOG
City a Tura s Tip Cade From To ' Formation Deaeription
(7*7 1 2 e %
Am cock.Phone stmber .,.I ,
4. DATE DRILLED i/` l -U -
, ,
5. TOTAL DEPTH: TS ' �-
6. DOES WELL REPLACEEXMWO WELL? YES El NQ:
7. STATIC WATER LEVEL BalowTopotCasing: ' 0 • AT;
(Un-e(fAbaw Top orCaA W
s. TOP OF CASINO 13_ FT.Above Lard Surtaces
'Tap oreastaa terd"ted a%6atart((haaaarfaea ngairb a
varlua In—wilaaee With-, CAC3CAt1R '
9. YlELD(gpto)- .3 %_T METHOD OF TEST
10.WATER ZONES(dapth): 7 '
' LOCATIONS
11. DISINFECTION:.Type Amoalt Show direction tmd.distaace la mhos from at last
12. CASING: Wan•(him two State Roads or Cou*Roads;Include the road
D Dhpctw or Weijhr/Ft nurnbars rmd`commott road names.
From Q . To 97 Ft S
From_To PL
From Tq FLU••_
13. GROUT-- Depth Makriil. Method
From To c�& Ft �r
From To 7L71
o
.4. SCREEN: Depth Diameter . Slot Sim Material
From To Ft.___in, in. —
From To Ft,__ia in m
5. SAND/GRAVEL PACK: _ o
Depth Sim Material
From Tc Ft
From To Ft
6- REMARKS:
DO HEREBY CERTIFY THATTHIS WEIL WA$CONSTRUCTED IN ACCORDANCE Wnn ISp NCAC.2t~WELL
DNSTRUCf1ON STANDARDS,AND T�HAAT AA COPY OP S RECORD H S BBBN P40VIDEIT TO TIMWELL OWNER
SIGNATUREflPPMMNCONSTRUCTINOTHB WBIL DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-RalelgI4 NC
.27699-1636 Phoae No.[phone],within 30 days, GWA REV.OW2001

a n
RESIDENTIAL WELL CONSTRUCTION RECORD 320486
North Camfma Department of Environment and Natural Resourcs-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# Q 0 J d
1.WELL CONTRACTOR: I. DISINFECTION:Type.P r1l Amount[Q,35-o
_^r'd�`I`' y�N, - 9. WATER ZONES(depth):W Well Contractor(Ind ' uan Name From To From To
_() rn b m We A/-t,14 r/1 G1 FrmT To From To
W ell Contractor Company Name f7e `/J T CY From To From To
STREET ADDRESS 63 T A `d'1A114 6' CASING' Thickness/
Depth I R nc, Dineter Weight Material AleAS-77/ Frmn�To��Ft � _ Ivor T
City or Torn State Zip Cade From To Ft
9 0,.,_ From To Ft _
Area code, Phone number -
7. GROUT: Depth Material Method
2.WELL INFORMATION: Fran O To QQ FtXPrr)EYIT' pym,�n,'hD�o
SITE WELL ID#(if applicable) Fran To Ft
STATE WELL PERMIT01 applicable) From To Ft
DWQ a OTHER PERMIT#(if appkaMe) a. SCREEN: Depth Diameter Sbt SIM Material
WELL USE(Check Applicable Box): Residential Water Suppty lM Fran To FL—in. _ in.
DATE DRILLED �� '7 `d� Fran To Ft_in. =in.
From To Ft in. _in.
TIME COMPLETED AM IK PM❑
9. SANDfGRAVEl PACK:
3.WELL LOCATION: Depth Size Material
From To FL
CITY. COUNTY lTct^-s OYI From TO FL
lY rq,Yddsl'7A From To Ft
—
(Street w(Street Nae..Nnbers.Cunmm+ay sioq.SUMir Lot Him,Parcel.ZlpLo�c9de)- .- - —-------- - _.i q'--—---
TOPOGRAPHIC f LAND SETTING- 10.DRI W NG LOG
❑Slope OValley LIFlat %Ridge ❑Other From To Formation Description
(check appropdate long
May be in deVees.
LATITUDES oSrl2 minute.seconds or
LONGITUDE__3f 1 in a decimal Comet
Latitudetiongitude source: ®OPS oTopographic map
(location of wet must be shown on a USGS login map and
attached to this form Tnot using GPS) O
a.*ELL OWNER c �+ r—/ n
OWNER'S NAME �/�yaIYIAS
STREETADDRESS U')Y3 h I &w FS%n` -'05
'7rj1, Nc_ e2fl7st9 s
City or Town State Zip Code -
Area code- PtNxTe number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:'30
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO U
100 HEREBY CERTEY THAT Ties WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top Of Casing: �O FT. 15A MAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use.4.if Abm Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS I FT.Above Lard Surfae �P >� //,J LO /l y
'Top of casing terminated allor below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR N DATE
a vaiarce n wcordwm vvM 15A NCAC 2C.0116. 1.
e. YIELD Minn): I METHOD OF TEST Qf�r 11
PRINTED NAME CVF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ezt 568. u j iG 2 4 2u03tw-7105

gg ( RESIDENTIAL WELL CONSTRUCTION RECORD
5 _..._
' North Carolina Department of Environment and Natural Resources-Division of Water Quality -
WELL CONTRACTOR CERTIFICATION fl 2045
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 166Z
James B. Brown g• WATER ZONES depth:I
Well Contractor(:n4irdua!)Name From To From To
Hedden Brothers Well Drilling, Inc. From 3`To-.5' From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
Depth Di meter Wall I ater I
pYanlclinF,NG 2A734 From—L—To Ft. "
City or Town State Zlp Cade From To Ft. _
( 828 )- 369-9591 From To Ft.
Area code• Phone number
WELL INFORMATION: 7, GROUT: Depth Material Method
2.W Iapplicable) �5�[n -9�'�8h From 0 To 20 Ft. CHn3 j_.L1t &hffrnit d
SITE EL WELL ID
From_To To—Ft.—
STATE STATE WELL PERMITM(u applicable) From—To—Ft.
DWQ or OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check A plicable Box): Residential Water Supply 0From_To Ft._tn. _ In.
From_To Ft._in. _ In.
DATE DRILLED From__To Ft.—In. _in.
TIME COMPLETED AMC PMM/
8. SANDIGRAVEL PACK:
3.WELL LO ,ATION: Depth Size Material
From To Ft.
CITY: COUNTY From To Ft.
From To Ft_.
(Street Nam ,Numbers,CoMmUnItIf.Subdivision,Lot No.,Pucei,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10. DRILLING LOG
❑Slope ❑Valley OFlat ORldge ❑Other From To Formation Description
(check appr6prlats box) C� Clay f- Sand
May be in dearea, r r RTanite
LATITUDE � _ minutes,seconds or
LONGITUDE in a decimal format
Latitudeilongitude source: ❑GPS OTopographic map
(location of wee must be shown on a USGS topo map and ,
attached to this form Y not using GPS) CA
4.WELL OWNER _
OWNER'S NAME s'T
STR T A RESS
_ c—
City or Town Z t e Zip Code
Area code• Phone number
11. REMARKS:
6.WELL DETAILS: r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO�l
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Balm Top of Casing: _FT. iSANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'If Above Top of Casing) R HAS BEEN PROVIDED TO THE WELL OWNER.
G. TOP OF CASING IS 2 FT.Above Land Surface* �•- ;�
.'Top of Casing terminated at/or below land surface may require IGNATURE 0 CERTIFIED WELL CONTRACTOR DATE
a variance in accordance With I SA NCAC 2C.0118.
e. YIELD(gpm)!� 6 METHOD OF TEST B1C+W James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
11617 Mall Service Center—Raleigh,NO 27699.1617 Phone No.(919)733-70115 ext 56B. Rev.7105

� RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 0 2045
1,WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 168z
James B. Brown g. WATER ZONES(depth):
1 / 1
Well Contractor(Individual)Name From�,'o� From— To 991Q
Hedden Brothers Well Drilling, Inc. From To From—To—
Well Contractor company Name From To From—To—
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
Depth �j I Dia eter Weight Ma r'aI
FYankl inA N(' 28734 From To .7 Ft. '// � "�
City or Town Slate Zip Code From To FL /
( 828 1- 369-9591 From--To Ft. _
Area coda Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION:
�' / FromQ_To��FL C8L8'lt & Uarnite �nm
SITE WELL ID#(Il eppllcable)� n�_�(Llp"/ From To_FL '
STATE WELL PERMIT#(a applicable) From To Ft.
DWQorOTHERPERMIT#(Ifapplicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply E( From To Ft. _ in.
� FromTo_FL_In In,
DATEDRILLED 0.� From To_Ft._in. — in.
TIMECOMPLETED I AM PM OK S. SANDIGRAVEL PACK:
3,WELL LOCATION: Depth Size Material
From_____To Ft.
CITY: _ COUNTY From To Ft_.
From To_Ft.
(Street Name,Number6lCommunity,Subtl ri Ion,Lot No.,Parcel,Zlp Coca)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑ pflri ❑Ridge OOther From Formation Description
(chock check apPrtipdate box) r Clay & sand' I May be in degrees, t t rranite
LATITUDE minutes,secondsor
312
LONGITUDE(�,af��pp��-/_.(:V 61,U in a decimal format
Latitude/longitude source: a6PS ❑Topographic map
(location of wall must be shown on a USGS rood map and _
attached to this form IF not using GPS) {'
a.WELL OWNER
OWNER'S NAME /.1
STR T ADDRESSZA11A, --UAW U
Yfry or T /+n S ate Zip Code
L �3g�,3LAz3
Area code- Phone number
11. REMARKS:
e.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NOK
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH
c. WATER LEVEL Sem7op of Casing: FT. 15A NCAC IC.WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS
(Use's'9Above Top of CBeing) RECOR AS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT.Above Land Surface'
.'Top of casing terminated Wor belay land surface may require SLMATI IRE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): f METHOD OF TEST Blfh/ James B.
PRINTED NAME OF PERSONON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW1a
11617 Mail Service Center—Raleigh,NC 27699.4617 Phone No.(919)733-TO15 ext 568. Rev.7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
"North Carolina Department of Environment and Natural Resources.Division of Water Qualit
m "„',AP'
WELL CONTRACTOR CERTIFICATION# 2045
1.WELL CONTRACTOR: f, DISINFECTION:Type H T H Amount 1 66Z
James B. Brown g. WATER ZONES(de th): a
Well Contractor(Individual)Name Fmm H 73 To From To
Hedden Brothers Well Drilling, Inca From To From To
Well Contractor Company Name -- From To From ,- -To
STREET ADDRESS 73 Holly Hills Vista Rd C CASING: Thicknessl
Depth Di meter Weight le ial
FYanklin N('_ 2A734 From�To Ft. �
City or Town State Zip Code From�S,To Ft. ," .i�-T2.
( 828 )• 369-9591 From To Ft. _
Area code• Phone number
7. GROUT; Depth - Material Method
2.WELL INFORMATION:
From_Q_To, 20 Ft. CHfEilt & I7HY217.tE turp7g�1
SITE WELL ID#fit applicably Fran_To Ft.
STATE WELL PERMIT#(If applicably From—To Ft.
DW O or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
From_To_Ft._In. _ in.
WELL USE(Check Applicable^BBox): Residential Water Supply 0 From To Ft,_In. _ In.
DA:rE DRILLED 1 I . 3D•r/1J From To—Ft. In. _ In.
TIME COMPLETED AV-00 AM115"PM0 9, SANDIGRAVEL PACK:
3.WELL LOC TO Depth Depth Size Material
CITY:
COUNTY From To Ft.
IVY Jd� 1 From To_Ft .
!1 /A, /,YTQ LtI . From To Fl.
(Street Name, berg.OOmmun ty,Subdivision,Lot No.,Parisi,Zip Code)
TOPOGRAPHIC l LAND SETTING: 10.DRILLING LOG
p Slope y ❑Flat DRidge OOther From Formation Description(check .
(check apprcpdals box) ' (r'].ay & sand
May be in degrees, r r ranite
LATITUDE , _ minutes,seconds or
LONGITUDE in a decimal format
Latitude/longitude source: DGPS OTopographic map
(location of wed must be shown on a USGS tope map and
attached to this form Inot using GPS)
1,WELL OWNER ,�JJ
OWNER'S NAME Ahj U
ST T ADDRESS r—
i1j, AA
City or Town Slate Zip Code
'745-M 17
Area code• Phone number `11
11. REMARKS: T
S.WELL DETAILS: a __
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOK
1 DO MERESY CE0.IFY THAT TIIS WILL WAS CONSTRUCTED IN ACCORDANCE WITH
c.WATER LEVEL Seim Top of Casing:,�_FT. -' 15A NCAC 3C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF NIS
(Use'+'H Above Top of Casing) REC HAS BEEN PROVIDED TO NE W ELL OWNER.
all. TOP OF CASING 18 2 FT.Above Land Surface• - ..;fj.tv5
*Top of casing terminated aVa below land surface may require GNATURE OF CERTIFIED WELL CONTRACTOR DATE
. " a variance In accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): METHOD OFTEST BlQW James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GWta
1617 Mail Service Center—Raleigh,NC 27699.1517 Phone No,[phone] ext 668. Rev.7105

RESIDENTIAL WELL CONSTRUCTION RECORD ' ? 19 7
North Carolina Department of Environment and Natural Resources-Division of Water Q V�. uality
WELL CONTRACTOR CERTIFICATION # 2045
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 1662
James B. Brown g. WATE ONES(depth: F
Well Contractor(Individual)Name From— From To
Ii3en Brothers Well Drilling Inc. From (73 To From To
I
Well Contractor Company Name FromrTo �KR From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness)
Depth ^ Dipmgjer Wgipl)I, Material
Frank)j,n,F N(' 28734 From TO 14 FL,�n>_" , IM
City or T0W0 Slate Zip Code From—To Ft. _
c 628 ). 369-9591 From_Tp Ft.
Area code- Phone number
7. GROUT: Depth Malarial Method
2.WELL INFORMATION:
�
7J`LOi5��03-a►5� From_To 20 Ft. Ca[97t & ba:all te �ed
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMITk(if applicable) From__To Ft.
DWG or OTHER PERMIT N(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
From_To_Ft._in. _ In.
WELL USE(Cheek Applicable Box); Residential Water Supply UKFrom_To Fl._ia _ In.
DATE DRILLED /d '9 '1�1 5 From_To Ft._In. _ in.
TIME COMPLETED I//.a(O� AM E�'PM Cl 9, SANDIGRAVEL PACK:
3.WELL LOC TIO Depth Size Material
From To Ft.
CIT COUNTY From To Ft.
From To Ft.
( real No ,Numbm,Co u SubdlNslon,Lot No..Pareel,Zip Cads)
TOPOG PHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge C)Other From To Formation Description
(check appr6pNete box) -'� , Clay & sand
May be in seconds
o I Granite
LATITUDE �p� �. -i minutes,seconds or Granite
LONGITUDE LLl in a decimal format
Latitude/longitude source: 216PS ❑Topographic map
(location of"I must be shown on a USGS topo map and
attached to this lone Ynot using GPS)
4.WELL OWNER
OWNER'S NAME
STR TA DRESS VA7 ".<
A/City or Town State Zip Code
Area code• hone number
11. REMARKS:
b.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOY
���� �Q� � � 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 1—FT, ISA NCA EC,WELL CONSTRUCTgN STANDARDS,AND THAT A COPY OF THIS -
(Use'F'a Above Top ofCasing) RE BEEN PROVIDED TO EWELL OWNER.
d. TOP OF CASINO IS 2 FT,Above Land Surface- /�5
.'Top of casing terminated attor below land surface may require NATURE OF C RTIFIED WELL CONTRACTOR DATE
a variance in accordance with ISA NCAC 2C.0118.
9. YIELD(glom):_ _METHOD OF TEST Blow James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GWla
1617 Mail Service Center—Raleigh,INC 27699.1617 Phone No.[phone] i 566, Rev.7105

: RESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of Environment and Natural Resources-Division of Water Quality `
WELL CONTRACTOR CERTIFICATION 9 2045
1.WELL CONTRACTOR: f, DISINFECTION:Type H T H Amount 166E
James B. Brown g. WATER Z NES(depth):
r
Well ConrRctor(Individual)Name From•a,�iTo r yg� From To
Hedden Brothers Well Drilling, Inc. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASINO: Thickness/
Depth 6a Dia Bier Weight trial
FYankl inF NIC 28734 Zrin To Ft. ��p�
City or Twm Slate Zip Code From To FL� r rnu
( 828 • 369-9591 From To_FL
Area Code• Phone number
7. GROUT: Depth. Material Method
2.WELL INFORMATION:
114-I w 4 Fro To�Q_F CBfEitt. & h13YSllte d
SITE WELL ID 11(It applicable) LJ If/ Fromrn To Ft.t,
STATE WELL PERMITM(If applicable) From To_Ft.
DWQ or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
From To_Ft. It. _ In.
WELL USE(Check Applicable Box): Residential Water Supply
From To_Ft._In. _ In.
DATE DRILLED �/ From To Ft._In. _ in.
TIME COMPLETED ' AM/0 PM 9, SANDIG RAVEL PACK:
3.WELL LOC TION• Depth Size Material
CITY: COUNTY From To_Ft.
From To_Ft.
From To_Ft.
(Street Name, umbers,community,Sub IYlslen,Lot No.,Parts],Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley OFlat ❑Ridge ❑Other From To Formation Description
(check appr6prlats box) _Q Clay 81 Sand
0_.. iQQ May be In deyea,
LATITUDE � r_J ,(_ minutes,seconds or -971 -3W1C,ranite
LONGITUDE pa l� In a decimal format
Latitude/longitude source: 04 PS ❑Topographic map .
(location or weif must be shown on a USGS topo map and
attached to this form I not using GPS)
4.WELL OWNER
OWNER'S NAME r—
STR T AD RESS
City or T State Zip Code _
Area code• Phone number --
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:_
to. DOES WELL REPLACE EXISTING WELL? YES Cl NOX
�/•� 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:- FT. 15AN C]C.WELL CONSTRUCTION STANDARDS,AND TNATA COPY OF THIS
(Use'*'Ir Above Top of Casing) RE HAS BEEN PROVIDED TO THE WELL OWNER.
cl. TOP OF CASINO IS 2 FT,Above Lend Surface' at
�,,,�yJ�
'Top of calling terminated at/or belay land surface may require GNATURE O CERTIFIED W ELL CONTRACTOR DATE
a variance in accordance with ISA NCAC 2C.0118.
e, YIELDigpin): �a METHODOFTEST BLOW James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., FormGw•1a
116117 Mail Service Center—Raleigh,NC 27699'1617 Phone No.[phone] sit 568. Rev.7106

321034
.WELL CONSTRUCTION RECORD,
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (priaO<� s-97 1-7HOWELL CONTRACTOR COMPANY NAM P �P
Alp 0
STATE WELL CONSTRUCTION PHRmh o �RSOCGTP.D W It IT# "
(if applicable) (if spplicable)
1. WELL USE(Check Applicable Box):Residential onicipal/Public❑ Industrial❑ Agricultural C]
Monitoring❑ Recovery ❑` Heat Pump Water lnjecf)on❑ Other EF If Other,List Use
2.-WELL LOCATION: . gfapbidLand setting -
NearestTown: S v I VA county. � 1 s d pSlope Malley ❑Fiat
I, 'IS A ,,V A' l /d /its rh ni. `' (cbeek appropriate boa)
(Street Name,Number.Community,Subdivision,Lot No.,Zip Code) - Utitude/loligitude of well location
3. OWNER: Z-19- 1212-4 � 17 1 > Q--� , (depxslmivadsecbnda)
Address cf S i -S tJ R-L/J e Latitudeliongiuide source:❑GPS❑Topographic map
(Street or Roue No.) m (cbmk boa) -
o rt- 3 }• Luc •r e— ,/'/ 3 q-,7S•3 DEPTH ' DRILLING LOG
City ur Town, !rte Zip code .From TO - •Formation Description
Meet code-Phone aumber , • _ , r `�[ l n�O
4. DATE DRILLED ` / -�'� 2LA 417C�
5. TOTAL DEPTH: JOSS'
� cLh : o _
6. DOES WELL REPLACE EXISTING WBLLi YES❑ NO<
7. STATIC WATER LEVEL Below Top of Casing- ZUU FT;
(Uaa"+^if Above Top of CodWS)
8. TOP OF CASING IS FT.Above Land Surface*
'Top or culoa termluated atior belaw iaod.aurfue requb is a
vorlaaw to accordance with ISAIIUC3C Alta.
9. YiELD(gpm): ,-,2 %� METHOD OF TEST
10.WATER ZONES(depth): /. '7 dV
LOCATION SKETCH
11. DISINFECTION:.Type #TA Amount Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di la or Wei&lrtlFL Matey" 'numbers and common road names.
From�To 97 FL_LZsa Q.X.
From To FL
From Tp FLU,_
13. GROUT- Depth Materiel Method
From_To_.-?D—FL -/'""— _ . W
From To Ft.
.4. SCREEN: Depth Diameter Slot Sim a , Material cri
c
From To FL__in. in.
From To Ft, in. in.S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From Tc FL
6, REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCM IN ACCORDANCE WITH 15A NCAC 2C,WBLL
DNSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD H S BEEN P40VIDED TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
s-ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh;NC
,2,7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 �'�

WELL CONSTRUCTION RECORD" 2 1 0 31
North Carolina-Department of Environment and Natural Resources-Division of Water Quslity--Groundwater Section
WELL CONTRACTOR(INOIV,IDUAL)NAML (prtut) atlllllI`��' CLKTIFICATION/ J-1-71e
WELL CONTRACTOR COMPANY NAM •- lileilly-ill-,R4YRONLi�-y'3 �"6 .
STATE WELL CONSTRUCTION PERMIT§ ksSOCfA.TED W 9RA111Y
(if applicable) " -((rapplicable)
1. WELL USE(Check Applicable Box):Residential unicipal/Public❑ Industrial❑ Agricultural 13
Monitoring❑ Recovery ❑` Heat Pump Water Injection❑ Other f7 If Otlier,List Use
2.-.WELL LOCATION: Topoggtap (Mind setting
Ncarest Town: - 11shipty Countyffla—./C� Midge Mope Malley ,❑Flat
& R,6 As P r2 • RuDKs- F3 a. Lpy- tf 3q (lack appropriate box) ^
4
(Sued Name,Numbers,Community,subdivision,Lot No.,Zip Code) Utitudetiongitude of well location
3. OWNER 0 b e Y-TR YI d P R5 Ua S R (desrcet)minuterlaecbn&)
Address 3 // 5'RMUGI DL. Latitude/longittidesource:❑GPS❑Topographicmap
(Strut ar Route Na) I (check box)
/Y)e l b 3 A 9 3 Ll DEPTH ' DRILLING LOG
City'or Town ��29 . Zip Codc .From To - Formation Description
Aru code.Phone nmber t '` _ - ./ t- • t +L
4. DATE DRILLED /.2-/3 —D .5
5. TOTAL DEPTH: 7Din'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing; .FT:
(Uu"h^if Above Top of Daiwa)
S. TOP OF CASING IS�_FT.Above Land Surface"
"Top of coins terminated actor belpw iFadsurfaoe requires a
variance In aeeordanu with"ISA74CAC 1C.0113.
9. YIELD(gpm):s�_METHOD OF TEST
10. WATER ZONES(depth): SD
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 D�'%p�ter .or weloUPL Ma 'numbers and common road names.
From To- 1 F= &: jC p
From To FL
From To_Ft._ _
13. GROUT-- Depth matedil Method From­a_To_�'D-FL,�Dw+n n .0 r— -
From To TL
.4. SCREEN: Depth Diameter Slot Size Material t -
From To Ft. in. in, r13
From To Ft. in. in. C:)
5- SAND/GRAVEL PACK: _
Depth Size Material -
From To Ft. -
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTIONSTANDARDS,AND THAT A COPY OF THIS RECORD H&S BEEN PROVIDED TOTHE.WELLOWNER
13 0 5 f
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original-to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
1Q699-1636 Phone No.(9I9)733-3221,within 30 days. GW-I REV.0712001

lye y : RESIDENTIAL WELL CONSTRUCTION RECORD . IRt:.
• North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type 1VT H Amount 160z
Russell S. Taylor g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
Hedden' Brothers Well Drilling, Inc. From To From To
Well.Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD S. CASING: Thickness/
Depth 4 Diameter Weight M trial
Erankl ins NC 28734 From To Ft.�'r am_
City or Town State Zip Code From To Ft. (�••
( 828 f- 369-9591 From To Ft. _
Area Code. Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
�' From_Q_Too Ft. OHIHlt & berlcrike AII�
SITE WELL ID#If appilcablaj (�LQ,J [Q l0 U From To Ft.
STATE W ELL PERMIT#(If applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) 8. SCREEN: Depth Diameter Slot Size Material
From To Ft._In. _ In.
0£LL USE(Check plicable Box): Resid l)al Water Supply 0 From To Ft.—In. _ in.
i r'A DRILLED From To_FL_In. _ In.
TIME COMPLETED AM❑ PM
6. SANDIGRAVEL PACK:
3.WELL LOC I N: Depth Size Material
CI COUNTY / From To_Ft.
From To_Ft.
From To_Ft.
treat Name,Numbers,Community,SubtlMston,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
p8lope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check apprdpeab box) 0 r Clay & Sand
L�T ITUDE �S� 7.g09 May t e in secondelds
o rf r GraIlit2
s°Z M�Y/� minutes,Feconds or
LOt4GITUDEry� rLJI/ in,decimal format
Laf tide/longitude source: Q.GPS ❑Topographic map _
Ilocation or well must be shown on a USGS lopo map and _
attached to this form IFnot using GPS) '
n t _
4.WELL OWNER c.J
OWNER'S NAME Cn -
ST. " T,ADDRESS
City Or Town Slate Zip Code
( z,& _1.3 989g
Area code- Phone number
11.I RFFJvIAR]CS �
5.WELLTO DETAILS:
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES I$' NO CI
_ _ TOO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm1
c. WATER LEVEL Below Top of Casing: FT, /SA NCAC 2C,WELL CONSTRUCT'AN STANDARDS,AND THAT A COPY OF THIS
(Use'+'IfAbove Top of CaaingJ RECORD BEEN PROVIDED TO THE WELL OW R.
d. TOP OF CASING 2 FT.Above Land Surfwa- ,,+
'Top of casing terminated aVor below land surface may require SIGNATURE OF CERTIFIED WE CONTRACTOR AT
a variance In accord nce with 15A NCAC 2C.0118.
e. YIELD.(gpm): METHODOFTEST BLOW Russell S. Tavlo
L_ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:information Mgt., Form GW-1a
1617 Mail Service Center—Raleigh,INC 27699.1617 Phone No,[phone] ext 568. Rev.7/06

04w
' 209RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources•Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2187
1.WELL CONTRACTOR: I. DISINFECTION:Type Hof-T H Amount 1 6oz
Russell S. Taylor g• WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
Hedden Brothers Well Drilling, Inc. From To From To—
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD S. CASING: Thickness/
Depth Diameter Weight Material
Eonklin, NC 28734 FroIn I W Ft. VC
City or Town Stale Zip Code from To_•4 Ft.
( 828 1- 369-9591 From To Ft. _
Area code, Phone number
2.WELL INFORMATION:
' � 7. GROUT: Depth Material Method
f - / 7 -CYI A,n From_Q_To.720 Ft. CEIiE'llt & hIffni tE I
SITE WELL ID S(if applicable) / (D / e3lpt�`j From To_Ft_
STATE WELL PERMITe(If applicable) From To Ft.
DWQ or OTHER PERMIT a(If applicable) S. SCREEN: Depth Diameter Slot Size Material
N:cLL USE(Chet From To Ft._in. _ In.pplicable Box): Residential Water Supply From To_Ft. n. _ in.
C.y.fE DRILLED 4 10 t9W`-5 From To_FL_In. _ in.
TIME COMPLETED 3.00 AM❑ PM
9. SANDIGRAVEL PACK:
3.WELL LO TIN: Depth Size Material
CIT OUNTY,� From To_Ft.
From To_Ft.
From To_Ft.
(S feet Name,Numbers,Community,SUbd.Msion.Lot No.,Parcel,Zip Code) '
TOPOGRAPHIC f LAND SETTING 10.DRILLING LOG
OSlope OValley ❑Flat ❑Ridge ❑Other From T Formation Description
(check appropriate box) 0 6 r Clay & sand
May be in degrees, t r Granite
LF T ITUDE J- _ minutes,seconds or
LONGITUDE in a decimal format
Laf?ude/longitude source: ❑GPS OTopographicmap
,location of war must be shown on a USGS topo map and
attached to this form#'not using GPS)
a.WELL OWNER
OWNERS NAME
Uf-
STRE- ADDRESS
City or Town State Zip Code -
� RRq
Area code- Phone number -
11. RE ARKS:: �{
S.WELL DETAILS: , ,l1Qod_4I
a. TOTAL DEPTH:JMt.Jr�
Id. DOES WELL REPLACE EXISTING WELL? YE O NOX _ p
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
c. WAT E R LEVEL Below Top of Casing: FT. 1SA NCAC 20.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'If Above Top of Caging) RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
d. 70P OF CASING 19 2 FT,Above Land Surface' / rJ '' ]LJ& 6r
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED LL CONTRACTOR DA
a variance in actor a with ISA NCAC 2C.0118. -
a ll YIELD BlOW Russel S. TdY Or
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Dlylsion of Water Quality within 30 days. Attn:Information Mgt., Form GW1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext$68. Rev.7106

e°""RA1F o
RESIDENTIAL WELL CONSTRUCTION RECORI
North Carolina Department of Environment and Natural Resources.Division of Water 4Q
WELL CONTRACTOR CERTIFICATION}4 2187
1.WELL CONTRACTOR: I. DISINFECTION:Type H .:,
Russell S. Taylor 9. WATER ZONES(depth):
Well Contractor(Individual)Name From To
Hedden Brothers Well Drilling, Inc. From To
Well.Contractor Company Name From To
STREET ADDRESS 73 Holly Hills Vista RD 6. CASING:
7� Depth DI
Franklin+ NC 28734 From (I To�Ft._(
Clly or Town State Zip Code From TD_5­4_Ft._
TD_5­"4_Ft._
828 )• 369-9591 From To—Ft._
Area code. Phone number
2.WELL INFORMATION:
7. GROUT: Depth
yy
SITE WELL ID p(I/appilubly r/ 5 "67 From_Q_To.20 Ft.CHFrom To Ft._
STATE WELL PERMIT#(Il applicable) From To—FI._
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Dianne
MILL USE Chec From To Ft._
( pplicable Box): Residential Water Supply� From To Ft._
(C�AfE DRILLED.
From To Ft.
TIME COMPLETED 3.OU AMO PMK 8. SANDIGRAVEL PACK:
3.WELL LO TI N: Depth ;
From To_Ft._
CIT - OUNTY From To_FL_
From _ To FL_
(Street Namo,,Numbers,Community,SubdMalon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.SQILLING LOG
❑Scope ❑Valley ❑Flat ❑Ridge ❑Other Fr Dirt T F
(chock apprdprlala box) 0 r C
May be in degree; r ,
I_ PTUDE y1 _ minutes,seconds or
LONGITUDE in a decimal format
Lati'tide/longitude source: ❑GPS ❑Topographic map
llocatlon of well must be shown on a USGS topo map and
attached to this form a not using GPS) --
4.WELL OWNER --
OW NERS NAME 11111 _
STRE ADDRESS _
City or Town State Zip
A,ea code• Phone number 5�99
11. RE RK�S�: ,�{.
5.WELL DETAILS: r i
a. TOTAL DEPTH: /01I/)
b. DOES WELL REPLACE EXISTING WELL? YE ❑ NOX
100 HEREBY CERTIFY THAT THIS WELL WAS
c. WATER LEVELBelow Top ofCaainp: FT: ISANCAC2o,WELL CONSTRUCnONSTANOA
(Use'*'If Above Top of Casing) RECOR HAS BEEN PROVIDED TO THE WELL
d. T OP OF CASINO 18 2 FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED LL C
a variance In accord nce with 15A NCAC 2C.0118.
e, YIELD(gpm): METHOD OF TEST BLOW Russell S. Tay or
PRINTED NAME OF PERSON CONS
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mail Service Center—Raleigh,NO 27699.1617 Phone No.[phone] ext 568.

WELL CONSTRUCTION RECORD `
Novi,Carolina-Department of BnAronmcnt and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACiOR(INDWIDUAL)NAME "[) -rIRI �j(3�.+�r�,�• 'v CLRTMCAT10NY 11�?
WELL CONTRACrORCOMPANYNAM PHONE g�4-3 90
STATE WELL CONSTRUCTION PERMIT/ ASSOC(ATEDW ERMIT'a
(if applicable) - -(if applicable)
1. WELL USE(Check Applicable Box):Residential' unicipal)Public❑ Industrial O Agricultural Q
Monitoring❑ Rccovery O` Heat Pump Water Injection O Other C1 If Other,List Use
2.-W ELL LOCATI Toppgrapbicamd setting
Nearest Town: J. County�� Ci� �xnJ dgo OSlopo Walley ❑Flat
PA P L4(„ P(J �"t\ 12 02 7 7 `� (chock appropriate box)
(Stntct Name,Numbers,c((,, ..unity,subdivision,Lot No.,Tap code) Utitudellongitude of WOII location
3. OWNER: Z�IUL� C `1 Gn��� (deWoeslmiauledseconds)
Address J 97 a7 ,71 1y 9 Y Latitude/longitude sourco:OOPSOTopographic map
(Strew or Rowe Na) (cheek box)
LL` I. " r ,'J/' t3-3C! 7Gl DEPTH ' DRILLING OG
�City"' mutt State tip Code . From To ' ,Formation Description
Area code-Phone number ' _-
4. DATE DRILLED _;93 'L P C 412
f 2_
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO .
7. STATIC WATER LEVEL Below Top of Casing 2_ FT:
(Use"+"if Above Top of Casing)
9. TOP OF CASING IS_�FT.Above Land Surface'
'Tap of mlog termluated ador belgw)Fndeurfaeo requires a -
variaace in accordanu with ISANCAC 3C.0111,
9. YIELD(gpm):_ "5 0 METHOD OF TEST_
10. WATER ZONES(depth): /<,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 D'�eeppoteerr or Wcotfft Material numbers and common road[tames.
From_To�FLU_sa—
From To FL
From Tq Ft. r_
13. GROUT: Depth Materiel Method -
From TOM—FL -� t
From To FL W
4. SCREEN: Depth Diameter Slot Size Material - p
From To Ft. in. in.
From To Ft. in. in. _
5. SAND/GRAVEL PACK _
Depth Size Material
From To Ft•
From To Ft. - -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT AA'COPY OFT S RECORD W BEEN PROVIDED/TO THE-WWHU OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Ralelgh,NC -
17699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

WELL CONSTRUCTION
C a 210 o
RECORD -
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-(Imundwater Section
WELL CONTRACTOR(INDMIDUAL)MME (p ay PM%IS ' lints e�. s. CY[�TWICAT10Na �7�
WELL CONTRACTOR COMPANYNAM PBONR
STATE WELL CONSTRUCTION PYRMITa A-iOCIATED W In
(if applicable) - -(wapplicab10) -
1. WELL USE(Check Applicable Box):Resident al-0-1 unicipal/Public❑ industrial O Agricultural O
Monitoring❑ Recovery ❑` Heat Pump Water Injection❑ Other O If Ot)ier,List Use
2."WELL LOCATION: _ T bidLand setting
Nears Town:O i 11 S herc Couaty -9 C_(c 5 iu ' dge OSlope ❑Valley ❑Flat
I'S ) 2( P_ S 0 12 eV . n2kVJ (eho*appmptlatebox)
(Street Name.Numbers.Community.Subdivision,W No..rip Cone) Utitude/lorigitade of well location -
3. OWNER: /a C le-
Address _ A 2.n1 : f H o o ! I Latitude/longitude source:❑GPSOTopographic map
or Roue No.) (check box)
t)n't li 04374 r IN 0 .DEPTH DRILLING LOG
City'"Town suu tip Code .From To ' .Formation Description
q/ - S
Area code•Phone number r I
4. DATE DRILLED1o7�a aQ v;S f
5. TOTAL DEPTH: z 3 r1/>
6. DOES WELL REPLACE EXISTING WELL? YES❑ I
7. STATIC WATER LEVEL Below Top of Ceding: lc 0 ".
(Usa'e if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
-Top of cuing terminated over below ivadsurfaee ngalres a
vartaoee In aeeordaata with"15A7iCAC 2C.OLa.
9. YIELD(gpm): f ` METHOD OF TEST_
10.WATER ZONES(depth): 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
Depths Di t_er or WciZht1FL Material_''numbers and common road names.
From iL FL
From Tc FL
From Tq FL_
13. GROUT- Depth Material Method
From To_,�D_FL n T �A . - C _
From To FL
A. SCREEN: Depth Diameter Slot Sim Material u
From To Ft`_in. in.
From To Ft. in. in. o
5. SAND/GRAVEL PACK: _
a�
Depth Size Material -
From To FL
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
DNSTRUCTION STANDARDS,ANDTHATACOPYOF SRECORD BBENP40VIDEDTO 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
.2'f 699-1636 Phone No.[phone],within 30 days. _ OWA REV.0 001

WELL CONSTRUCTION RECORD
yt,�
North Carolina-Department of Bn m vironeht and Natural Resources-Dlvisioa of W ales Quality-Orotindwater Section /?
W ELL CONTMCTOR M(INDIV•IDUAL)-NAe (punt) c7),e ri n i s /Lj I n1 A rI� CLI`TIPICATION Y I'`
WELL CONTRACTOR COMPANY NAM ritoria S�_. q-'3
STATE WELL CONSTRUCTION PXRMIT'/ ASSOCIATeD W BRMITY
(if applicable)
1. WELL USE(Check Applicable'Box):Residential' unicipal/Public❑ Industrial O Agricultural p
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other CT If Otiier,List Use
2.-WELL LOCATION- Topat�iiio. l and setting
Ncaresi Town: d -(' t Copunry 7� /Sh'�s`'ddggc 11Slope Malley ❑Flat
/,/.-I !U / t / /)Ae- (cheek appropriate boa)
(St NtecrTame,Numben,Community,Subdivision,tat No.,Zip Code) Latitu(le/longit ide of WOII location
3. OWNER \5'9 C IC' LC) ��ll'/��f (depaslminutmlaecbnds)
Address .:3(,-.3 � ('_4 1 C/-r q,Fr Latitude/longittide source:OGPS❑Topographic map
(strayer Route NO.) (cheek boa) .
��U /✓ rA r, . ��/ -3 3 0/ S /) DEPTH DRILLING LOG
City'or Tovm� Zip Codo .From To - .Formation Description
�Ma code-Phone number
4. DATE DRILLED I_ n,S
_ - .
S. TOTAL DEPTH: b
6. DOES WELL REPLACE EXISTING WELL? YES O NO_._
7. STATIC WATER LEVEL Below Top of Cuing: (2 FT:
(Uu"+"if Above top of Cuing)
8. TOP OF CASING IS�_FT.Above Land Surface'
?op of coin&terminated actor belgw lead.surface requires a
variaaa In accordanu wItk ISATICAC 3C.011L
9. YIELD(gpm): 1 IL METHOD OF TEST
10 WATER ZONES(depth): L .S : .� Pri
LOCATION SKETCH
H. 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 Diappie�terr or WeightlFL Metediii ''numbers and common road names.
From Toz/-5_171L Zc -,Ft_e
From To Ft.
From Tp FL_ _
13. GROUT: Depth
'/��7�� Materiel M��etho,d�l C_
Fromm TO�iL FL n r � _ h
From To FL
i
4. SCREEN: Depth Diameter . SloiSize Material
From To FL in. _ in. CD
-_
From To Ft. in. _ in, - m
5. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrm ISA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THATCO S RECORD PROVIDED TO THB.WELL OWNER�PY
/"-) - a z --,D - .
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
1,7699-1636 Phone No.[phone],within 30 days. GW-I REV.07)2001

RESIDENTIAL WELL CONSTRUCTION RECORD /
6 i v
North Carolina Department of Environment and Natural Resources-Division of Water Quality _
WELL CONTRACTOR CERTIFICATION 9 2045
1.WELL CONTRACTOR: f, DISINFECTION:Type H T H Amount 1 WZ
James B. Brown g• WATER ZONES(depth)
Well Contractor(Individual)Name From :i l3y�l From To
F1eL1deT1 Bxgthers Well Drilling. InC. From 1(8,To17 D� From To
Well Contractor Company Name From To_„— From To_,�_
STREETADDRESS 73 Holly HMS Vista Rd 6. CASING: - Thickness/
Depth Diameter Weight terial
F4-ankl y��j{' 28734 From�To Ft. e
City or Town State Zip Code - From .5 3 �To Ft.-_•,
( 828 )• 369-9591 From To Ft. _
Area coda• Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION:
SITE WELL ID#(if applicable) h 54 8-4 I -H l (y From m_To 20 Ft. matt & bHYllll LDe�
From To_Ft.
STATE WELL PERMIT#(If applicable) From TD_Ft.
DWO or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply O From To_Ft. in. _ In.
-77 From To_FL_In. _ in.
DATE DRILLED From To—Ft._in. — In.
TIME COMPLETED 2/•CiD AM❑ PM; 9, SAND/GRAVEL PACK:
],WELL LOCATION: Depth Size Material
CITY: COUNTY From To Ft_.
Fran To_Ft.
yr , from To Ft.
(Street Name.Numbers.Cfjnumity,Subdusion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑other From TO Formation Description
(check apprdprlab boa) Claw & sand
May bein degrees, r r
LATITUDE _I- _ minutes,seconds or Granite
LONGITUDE In a decimal format
Latitude/longitude source: ❑OPS ❑Topographic map
(location or well must be shown on a USGS tope,map and
attached to this form I not using GPS)
♦.WELL OWNER
OWNER'S NAME (.l•,C�Jt n
STREETADDRESS
m&Lua r t zg 20
City or Town t Slate Zip Code n
( %;2_8)• (031 - L-17 34
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: )
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX
��^^ 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WOH
c.-WATER LEVEL Below Top of Casing:_s�70 FT. ISA NCAS,2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+•B Above Top of Casing) RE 0 ASSEENPROVID EDTO EWELLOWNER, r
d. TOP OF CASINO IS 2 FT.Above Land Surface' /-p(a-aeY
'Top of casing terminated attor below land surface may require ATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accordance with 1SA NCAC 2C.011 S.
e. YIELD(gpm): if7 - METHOD OF TEST B W James B. .Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wlthln 30 days, Attn: Information Mgt., FormGWta
16117 Mall Service Center—Raleigh,NO 27699.1617 Phone No.[phone] ext 568. Rev.7106

NVELL CONSTRUCTION RECQPJ)r w -� 3 5 � 09 0,
North Carolina Department of Environment and Natural R ources-Division of Water Quality
TOR(LY UAL)DIM NAME (print) �// "
WELL CONTRACTOR.. ., ,. . .;.., .- ,` 'CERTIF/CATIONi
WELL CONTRACTOR COrBANYNASfE PHONE# (C7 ".
STATE WELL CONSTRUCTION PEP-NaTN - ASSOCIATED; QP -'DTJ
- „(ifapplicable) ": - ' (ifaypGeable) -
1. WELL USE(Check Applicable Box):Residential Munkipa)/Public❑ Industrial❑ Agricultural❑
❑Monitoring Recovery ❑ Heat Pump Water iection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Landsetting
Nearest Town: County, ❑Ridge []Slope ❑Valley Wlat
(Bocci Name.Numb , m $ 77� (cbxk appropriate box)
Co m,n', tpy,,Subdivision;Let No.,Zip Code) - Latitndellongitude of well location
3. OWNERZ- 6-&/ l..a /LCJ, j � (depees/minumsheconds) -
Address _�9 Gc9 - _ Latitude/longitude source:OGPS❑Topographic map
(Street or Route No.) �+ check box - _
_ n 6i OZ 7 7 / DEPTH ( I DRILLING LOG
Cio or Town state - Zip code From - To Formation Description
.. Area code-Phone number
4. DATE DRILLED / Q 7� 2
5. TOTAL DEPTH: Klyl
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: zoo F1.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
• •Top ofcuing terminated atfor below Land surface requires a
variance In accordance with 13A NCAC 2C.0119. //��
9. YIELD(gpm):V — METHOD OF TEST A-I
10.WATER ZONES(depth): C�
LOCATION SKETCH
11. DISINFECTION:Type // TL L- Amoun S w direction and distance in miles from at least
12 CASNG: IM,7hi t;�ss �� two State Roads or County Roads.Include the road
llep:h uiamctcr or Ylcighl/FL Ntatcrial at,n:bc ' .:d coaur uc mu:.d na�ra.
From To -YFt.t`o From TO Ft. _
From To Ft. -
13. GROUT: Depth Material Method
From 6 TO—_Ft
. —
Fro To. Zt I Ft.� t�gye� C-U r�
14. SCREEN: .Depth Diameter Slot Size Matte erial/
From - To FL in, in. 7`
From TO Ft. in. _ in, Cl
15. SAND/GRAVEL PACK:
- 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 STANDARDS,AND THATACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O R
SIGNATURE O PERSON CONS r RU TING THE WELL IYATE
�„hmit the on-�:ral to t3mc 13ima=w° o;:Vag=* m"!it)•,Aitn. ,¢rui fnatien Mullaeem en t,1617 Mali Service Leal,, -
Raleigh,NC 2 7699-1 61 7, Phone No.[phone],within 30 days.
_ ...._..... .. GW-1 REV. 09/2004
RECEIVED
FEB 07 2006
Asheville Regional Office
- A u'rfer Protection

f w
- a 7
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Uivision of Water Quality-Groundwater Section
VWELL CONTRACTOR(INDIVIDUAL)NAN1E (print) 1 ts'� CERTIFICAATTI�OpN—#—
WELL CONTRACTOR COMPANY NAME ONE # Q
STATE WELL CONSTRUCTION PERJ9IT# ASSOCIATED WO PEILNI #
(if applicable) (ifaPPlicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO' . 3bpoeraphic/Land setting
Nearest Town: unty ❑Ridge dope ❑Valley ❑Flat
(check appropriate box)
(Streit Name,Numbers,Communitty,'' bdivision,Lot No.,zip code) _ Latitude/longitude of well location
3. OWNER: r - 66 cs_ (degrees/minutes/seconds)
Address�C) JCS. A Latimde/longitude source:❑GPS❑Topographic map
�trlee[or R^oute No.) (check box)
Y _ �- 3 3 7C% DEPTH DRILLING LOG
City or Town State - Zip�,C°Qe n(� From To Formation Description
( 6 701 — LfS� o—v Iil![u�X
Area code-Phone number LF
4. DATE DRILLED 7-a 'K '� S
5. TOTAL DEPTH: �515 y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO.�
7. STATIC WATER LEVEL Below Top of Casing:SqU FT. S
(Use"+"if Above Top of Casing) ([
S. TOP OF CASING IS FT.Above Land Surface" T
.Top of casing terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C.01I8.
9. YIELD(gpm): ,�-S"— METHOD OF TEST A t V-�
10.WATER ZONES (depth): a-$
114 LOCATION SKETCH
11. DISINFECTION:Type {�'][ a Amount 51tow 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. atenal numbers and common road names.
From C? To sQ1Ft. 11� SD221
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To---S.. Ft.== L�
From_To Ft. • LC)
14. SCREEN: Depth Diameter Slot Size b aterml �.Y1.�-r.••_�1-r'l.9 '
From To Ft. in. in. cnLn
-
From To Ft. in. in.
15. SAND/GRAVEL PACK:
cs
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,R'ELL
COS iS IRUC-HON STAND?.RL'S,AND THAT A COPY OF THIS RECORD HAS BEEN PRG'c9DEu T O THE�i'$LL 0\VNEP,
SiGNP.TUP,F OF_°ER`0A'COVS?'Rt�C?fNi - t#F-�s. {-- DATF,
R�C�IV
Submit the original to the Division of Water Quality, Groundwater Section,163F7ail Set,ice enter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.. FEB 0 7 2006 GW-1 REV. 07/2001
Asheville Regional Office
A uifer Protection

VVW7� S (� /o - 8/97
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section (
WELL CONTRACTOR(INDIVIDUAL)NAME (print)/PV C CERTIFICA�TTIO,,, �24r •7-
WELL CONTRACTOR COMPANY NAME AZYf1—IM Dz..� _ I/U�� PHONE # (d : -��e �•S S a
STATE WELL CONSTRUCTION PERMIT, ASSOCIATED WQ PMNIIT,
(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 LOCATI }Q: Topographic/Land setting
Nearest Town: Co n ❑Ridge-J381ope ❑Valley ❑Flat
C I g2u-,W&J" P 4Axi-r— y t C (check appropriate box)
(StreetName,Numbers,Community,Subdivision,Loth .,,fZip Code) ,Lk- 7;?.a Latitude/longitude of well location
3. OWNER:__,/!.; -1P��r- "` -J,_ � (deg ees/minutes/seconds)
Address j a"]L4 /�3-A:.-e-L, tezy-, � UCo -k Latituder7ongitude source:❑GPS❑Topographic map
�1 (Str et or Route No.) (check box)
(I , �'d C a2'C 7� Z, DEPTH DRILLING LOG
� City orTown State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED S " `� 'C) too _ Z,�
5. TOTAL DEPTH: �2 t7 `_ zh0 _-')-k Z
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CF ;)-r 2 — Z
7. STATIC WATER LEVEL Below Top of Casing:&0 FT. -A g-p - q
(Use"+"if Above Top of Casing) 3 iX Z—V e 0
g. TOP OF CASING IS f FT.Above Land Surface'
.Top ofcasing terminated at/or below land surface requires a
Variance in accordance with 15A NCAC 2C.0118.
9. YIELD(epm):_2-__METHOD OF TEST I� t
10.WATER ZONES (depth): �1 �
�-3 LOCATION SKETCH
11. DISINFECTION:Type s-i' t Amount X, t`Show direction and distance in miles from at least
12. CASING: - Wall Thicknzss �'rts'o State Roads or County Roads. Include the road
Depth 'al or WeighVFt. Material numbers and common road names.
From Q To & FL-= S� (��'' - ^-� n
From To Ft. t-)-
From To FL
13. GROUT: Depth Material Method
From_QTo 3 Ft.
From_To-2.e)--Ft.
14. SCREEN: Depth Diameter Slot Size Material N
From To Ft. in. in. CfI
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft.
From To Ft.
16. REMARKS:
i DO HERFBY CERTIFY THAT THIS WELLWAS CONSTRUCTEDYN'ACCORDANCE WITH 15A NCAC 2C,1VELL - -
CONS"iRUCTiON STnNDARDS,AND l HnT A COPY Or TrilS RECvRD HAS BEEiV PROI'ID::D TO TfiE`.Vi:LL'Jq i,cR - -
orr. , t' rnFl:`.'7�TC-JrS�...��CTf`.:,L;Tur•A'Fi i_, _ �!TF__..- _ ._ ..
i
Submit the original to the Division of Water Quality,CgoundslREU!i 3RQ Serrice 'enter-Rate igh,NC
27699-1636 Phone No.[phone],within 30 days. I GW-1 REV.07/2001
FEB 01 2006
Asheville Regional Office
Aquifer Protection

A� s9u <F4zc
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Pivision of Water Quality-Groundwater Section ' /
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION It3 0 `�'
WELL CONTRACTOR COMPANY NAME ( PHONE # fCk(.,"SSSU
STATE WELL CONSTRUCTION PERMIT# ASSOCIA ED WQ ERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential l2e Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL rest To Y f OJ N: - Topographic/Land e. lo letting
T�C f��.- Ne�restTo 1��1��r ounty ❑Ridge lope ❑Valley ❑Flat
5 1 77 (check appropriate box)
ZINC (Street Name
eNumbers,
,Comnnun ,
itt �Sulbddiviisiol,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER'l.JL-t/t(.V/,(/t t/�JLW'� (degrees/minutes/seconds)
Address D C)ti (a "I Latitude/longitude source:❑GPS❑Topographic map
! (Street or Route ^o.) - (check box)
� I / r C. 2.�Jv2-S DEPTH DRILLING LOG
C�yorTown State' Zip Code From To Formation Description
(�
Area code-Phone number A f
4. DATE DRILLED 7 -ZcJ - O r I q 1
5. TOTAL DEPTH: q nyy
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I ( L
7. STATIC WATER LEVEL Below Top of Casing: T.
(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 accordan a with 15A NCAC 2C.0118. — y
9. YIELD(gpm): METHOD OF TEST I V'
10.WATER ZONES(depth): ) �D _ Cn
LOCATION SKETCH
CD
11. DISINFECTION:Type _ Amount HYn, - I how direction and distance in miles fromrat least,
12. CASING: Wall Thickness Y 'f vo State Roads or County Roads.Include the road
Depth�T Diameter or Weight/Ft. Material numbers and common road names.
From C To aC.V Ft. (or/u St 6PV C"
From To Ft.
From To FL p,
]3. GROUT: Depth MaterialMethod
From To3 Ft. ,tJ
From_To=Ft.
14. SCREEN: Depth Diameter Slot Size Materia
From To Ft. in. in.
From To F[. 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'TW RD-H BEEN PROVIDED TO THE WELL OWNER
o IGIVATURE OF T' RSO ONSTRUCTrNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwatgr S C, n 6 i��Slervice Cedter-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. " r �� Y G Y G -1 REV. 07/2001
p FEB 0 7 2006
1 AeFsaiille �....1..�_I nte__

AW f
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- ivision of Water Quality-Groundwater Sect' y�/
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION# 7
WELL CONTRACTOR COMPANY NAME W ONE it �-S SS q
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PER: IT#
(if applicable) (if applicable) -
1. WELL USE(Check Applicable Box): Residential tff Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recove'ry ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topo aphic/Land setting
Nearest Town: Co my 1 ❑Ridge Mlope ❑Valley ❑Flat
S7 -77 (check appropriate box)
(Street Nam umbers,Community,Su ivision, of No.,Zip Code) Latitude/longitude of well location
3. OWNE (degrees/minutes/seconds) -
Addres Latitude/longitude source:❑GPS❑Topographic map
(Street or Route (check box)
a b' ? Z �J DEPTH DRILLING LOG
�Cityo oHn _ a to C Zip Code From To Formation Description
Area code-Phone number i —
4. DATE DRILLED 4d 1 20— 2 3 U
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE ❑ NO 2 -33 — � 3y
7. STATIC WATER LEVEL Below Top of Casing: -rD 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 Ith ISA NCAC 2C.0118. —
9. YIELD(gpm):_ � METHOD OF TEST A I —
10. WATER ZONES (depth): _2;�IQ _
LOCATION SKETCH
11. DISINFECTION:Type E-f' T J 1 Amount ``Show direction and distance in miles from at least
12. CASING: � Wall Thic}:ness
/ 'Iwo State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Mate [at numbers and common road names.
FromQ To )(,3 Ft.le
From To Ft.
From To Ft. n
13. GROUT: Depth Material _n Method (/,�J
From _�_ — „�i'c3 _ l,/ fit.
1�To Ft /h v I ,
From To Zd Ft. �,n �+>,__-♦'_- _�y���� (, - O
14. SCREEN: Depth Diameter Slot Size � Material t- � 2.�--Q--� o 6'
From To Ft. in. in.
From To Ft. in. in. coil
15. SAND/GRAVEL PACK:
Depth Size Material I
From To Ft.
From To FL
16. REMARKS:
-"I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTP IN ACCORDANCE WITH 15A NCAC 2C WELL -
�: Sl. DlD rtl w;"IE:�.f ^ (_'�`r`t r'i :r: HAS13L)_N I'RQ-.:EDE.L?C l"IiL „ _iL OR; L,. R
IO
,NATURE 6_NR '.P,SON CONSTRUCTING THE WELL DATE;
Submit the original to the Division of Water Qual' y,GroFJrV(;pJcpoq W36 Alail S rvice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days GW-I REV. 07/2001
FEB 0'r 2006
Asheville Regional Office
Annifnr Drn}cnHnn

WELL CONSTRUCTIONRECORDAP' S
7 s-.53
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDMIDUAL)NAME (print) � � C - CERTIFICATION#..�
WELL CONTRACTOR CObfPANY NAb1E
STATE WELL CONSTRUCTION PER WQp�QI# ASSOCfATED 1f1TA -
(tfaoo`licable) -.:
`(if applicable)
1. WELL USE(Check Applicable Boz):ResidentiaI OO Mutni ipal/Public❑ Industrial❑ Agricultural❑
Monitoring'❑ 'Recavcry ❑ Heat Pump Water injection❑ Other❑ If Other,List Use G r
2. WELL LOCATIOI Topographic/Land petting
Neargst Toi' oun []Ridge ❑Slope -❑Valley fat
37' (checkapprpriambox)
(Smrq I qatiarNunibm�tonordunity,Su ion.Lot o, 'p Code) - .. LatitudeAongitude of well location
3. OW/NE (degreea/minutes/acec, ) .
Address Latitude/longitude source:❑GPS❑Topographic map
SCCete Route NoJ - (checkbox) _
DEPTH DRII LING LOG t
City or Toy Srate - zip Code From To Fo 'on Il&tionArea code-Phone nwnberc, _�
4. DATE DRILLED / .L7 d J
5. TOTAL DEPTH: 7�v Zyl -
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO.&
7. STATIC WATER LEVEL Below Top of Casing: tL 0 FT. 7
(Use'+^if Above Top of Casing) 2 7 0 2-
8. TOP OF CASING IS J FT.Above Land Surface' 7 ::) 3`7
• -Top orcasing terrain a led■t/or below land surface requir"a
variance In accordance with 15A NCAC 2C.0111.
9. YIELD(gpm): .30 METHOD OF TEST N i ej
10.WATER ZONES(depth): op-6
0 LOCATION SKETCH
11. DISINFECTION:Type HTf} Amount 9 direction and distance in miles from at least
12. CASING: WaD Thicvness i two State Roads or County Roads.Include the road
Ucpai,'/ ilia:°lcr o:VJzlgt✓Pt M� .d i• .bcr.: and Cc:-u - Oar;
From�_To 2CN Ft (p t{ ) #4
From To Ft.
From De Ft.
13. GROUT: Depth _ Material - - Method - -
From 0 To 3 Ft.
From_ To �Ft. ,�,� , u,rr-
14. SCREEN: Depth Ft-
.I) itaterial /
From Tc -'Ft in. in. //_N
From To Ft.in. . in. TlW n
15. SAND/GRAVEL PACK:
Depth Size Material - `-71
From—TO—Ft.—
From To Ft. r-
16. REMARKS: ,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDn,A�P Tsi e T A COPY O�RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/0 -)7- d !K-'
• NATURE OF PERSON CONSTRUCTING THE WELL DA'I E
t'C L fun:; Cc.'L ? oT f::Yt 1Cz�tir-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
_7 W-1 REV.09/2004
RECEIVED
FEB 07 2006
Asheville Regional Office
A uffer Pfotedon

WELL CONSTRUCTION RECORD7<0
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACrOR(INDIVMUAL)NA.a (prlat)
' CERTIFICATIONS
WELL Cot T1tACIOR C0,5PA.NY NAMI
STATE WELL-CONSTRUCTION PERMITS - ASSOCCATED WO PE NDTS
'(ifapplicable) - (ifaoolicable)
I. WELL USE(Check Applicable Box):Residential t;l MunicipaL'Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIC F.
Near st Town: Co ry Topographic/Land setting
CoZ 7Wdoe Ji0ope 'OValley OFlat
tS et amc,Numbers,Community,Subdivisi gtot No pCadc : (cbeckappmpriatebox) :.
a ' •, "
Latinide/longimdeofwelllocation -
3. OWNER
Address (degrees/minutesheconds)
Latitude/longitude soutrce:OGPSOTopographic map
,Q (Sneeto note NO.) (check box)
City— .or State G �Ar 7 9 DEPTH DRILLING LOG '
T wn St F
-_ N�¢� zip Code From To Formation Description
Area code-Pbone n
4. DATE DRILLED o
5. TOTAL DEPTH: -� O
6. DOES WELL REPLA E E ISTIA'G WELL? YES O NO I& �Lo" -/0 �
7. STATIC WATER LEVEL Below Top of Casing: to 'D FL
(Use"+"if Above Top of Casing) - -
8. TOP OF CASING IS / FT.Above Land Surface'
*Top of caning terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C.OII&
9. YIELD(gpm):_ .3U METHOD OF TEST A t --
10.WATER ZONES(depth): /(a t7 C) �—
LOCATION SKETCH
]I. DISINFECTfON:Type -J)-(�__Amount r .:ihOw directior.end distance in miles from at least
I2" CA.MC;• /L -�.•n Stite)?oads or Connty Roads. Include the road
r or Wc�gnV iv),,t ;pL n aU.11,e o a,"comm ro
m
Fro _To /v Ft
(y
From To Ft
From To FL
13. GROUT: ToPW Material Method
From 6 To 3 FL-/ > Lt/ ��
From_iTo 7r) Ft V a(
14. SCREEN: .Depth Diameter Slot Size blateri J
From To FL in. in.
From To FL ln. — in.
15. SAND/GRAVEL PACK:
Depth Size Material r
From - To Ft. -
From Tc Ft. - -
N)
16. REMARKS:
1 �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WfTH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS REC BE nPROVIDED TO THE WELL OWNER
�<L_PGNATURC Ut ttRSON CONSTRUCTING THE WELL
DATE
the Division of i'v"ater Quality,Attn:Iuformation hla;;ager':,t:y 1617 blai!Senice Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days
RECEIVED Gt. -IREV oKC3!
FEB 0 7 2006
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD 7G 71
North Carolina Department of Environment and Natural Resources-Division of Water Quality d
WELL CONTRACTOR MCIVEnUAL)NAl1fE (print) y CERTEFICATIONR- 3 L[/
WELL CONTRACTOR COSIPANY NAb� rev 2tQ PHONE 0 �� SIT- /SlS co
STATE WELL CONSTRUCTION PEP--vfTTk ASSOCIATED Q R ♦flT# -
(ifapplicable) -
- - 'crapplicable) -
1. WELL USE(Check Applicable Box):Residontiay� Mtmicipal/Public❑ Industrial❑ Agricultural❑ e '
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ -Other❑ If Other,List Use
2. WELL LOCATI I: Topographic/Land setting
Nea est Town: County. �G J2Ridge -[]Slope ,Malley Mat -
- (chockappropriatebox)
(St t Name,Numbers,Community,Subdivision,I.ot No,Zip e) J Latitude/longitude of well location -
3. OWNER: K r (dcgtees/minutnhewads) .
Address ` Latitud o girude source:❑GPS❑Topographic map -
(Saees or koute No.) �� 7N (cbeck box)
o!o DEPTH DRILLING LOG
City or �c cue o Zip code From To Formation Description
.. Area code-Phoneaumber y�
4. DATE DRILLED'21IC16 4�
5. TOTAL DEPTH: /oD0
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: F7.
(Use"+"if Above Top of Caring).
8. TOP OF CASING IS-__L_FT.Above Land Surface'
'Top of casing terminated atior below land surface requires a -
variance In secorda a th ISA NCAC 3C All&
9. YIELD(gpm): . THOD OF TEST__4_6�j _ U 1
10.WATER ZONES(depth):- 11'7 S'
LOCATION SKETCH— 'J
11. DISINFECTION:Type Amount sir direction and distance in miles from at least
I? CAFTNO: u,il1 I-hicr'-ess two State Roads or Cmmty Roads. Include the road
Depth Diameter or CieignUl-L Nlatcual a,.Lam-s. - -
From
-__0 Tc "3 �( Ft.
From To Ft: - -From To Ft.
13. GROUT- Depth - Material Ma'`
From_ To—a—F , 1�• if
- From To Ft.L aaadad
14. SCREEN:: .Depth Diameter Slot Size V Materi -
From To FL—in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth - Size Material - - I)-.
From TO Ft. 6lX
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C;WELL
CONSTRUCTION fSTAN?A"AND THAT A fC,QPY OF THIS H BEN PRO.. TO THE WELL OWNER
/D/j/
7SIGNATURtF PERSON CONSTRUCTING THE WFLL DATF.
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. -
RECEIVED r.1v-' rw-o.;-zooi
FEB 0 7 2006
Asheville Regional Office ;
urfer Protection

WELL CONSTRUCTION RECORD" T s4 ~
73. 39 7 39�Z
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL C0NTRACC0R(]3NDIV1DUAL)NAME (plot e cERTmcA-noli
-WELL CON.rRACCOR COMPANY NAME - PHOYE 818j.-fSb — SSS a
STATE WELL CONSTRUCTION PER-,rrr# ASSOCIA WQ ERNIrr$
*:1(ifdpplieable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaMblic❑ Industrial❑ Agricultural❑,
Monitoring❑ Recovery ❑ Heat Pump Water lajecdon❑ Other❑ If Other,List Use
2. WELL LOCATT Topographic/Land setting
crest Town: County CY ❑Ridge'1531ope ❑Valley ❑Flat
Yl 7 !jj (check appropriate box)
(Strcet Name,Numbers,Cc== Subdivision,Lot No. Zip Code)
�: Latitildellougitude Of well location
3. OWNER: /'//>f� .�.a. {' l,L 0'r/`7� - (degreed—urcV—oads)
Add res Latitudellongitude source:❑GPS❑Topographic map
-- (Sneer Route o.) o9 (check box)
0 -a' 7 7 DEPTH DRILLING LOG 'r
Ciryt rTowa State - .Zip Code From 'To Formation Description
. Area code-Phoac Dumber
4. DATE DRILLED r- 3 I ' 0 J
5. TOTAL DEPTH: :0)
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO7
7. STATIC WATER LEVEL Below Top of Casing:_ O
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface•
--Top of cuing lerminated_atlor below land surface requtres a
variance in accordance with 15A NCAC 3C.0118. h
9. YIELD(gpm): l D METHOD OF TEST tt 1"A.
10.WATER ZONES(depth): ( b' ,7 y ra
LOCATION SKETCH
11. DISINFECTION:Type -0q' T/—� Amount i $how direction and distance in miles from at least -
12. C.A.S.WG' IV,'I) 1; -t - vo State Roads or Cnuety Roads,include the road
Leptir rarnetez or\Ye ro>d oamo5.
From O To //D Ft. 5ue— � .06/C
From To Ft.
From To > - FL � /J 13. GROUT: DepthMat Icthod x4
From O To FL a /
From_To�4FL 7Ttr /Y _ _/ (- .
14. SCREEN: Depth Diameter Slot Size Mat aI T7` Y a�
From To FL in. in.
From To Ft. in. in.
15. SAND/GRAVELPACK:
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 STANDA g $,AND THAT A COPY OF THrS S BEEN PROVIDED TO THE WELL OWNER
71/J/ 5�
NATURE 9r.PEIUS-0N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 da3:a
RECEIVED GW-111Ev.09/2004
FEB 0 7 2006
Asheville Regional Office
Aquifer Protection

NVELL CONSTRUCTION RECORD loSS
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(LNDIVIDUAL)NA� (print) CER CATIONp G YJ
-. WELL CONTRACTOR C061IPANY NAME QpQ- PHONE ) S '-S.Scr CT
STATE WELL CONSTRUCTION PERNITTp ASSOCIATED WQ PERtiDTp -
_ �(ifapplicable)` -"(ifapplicable) - -
1. WELL USE(Check Applicable Box):Residential MunicipaVPubEc❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ ,Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCA77p Topographic/Land setting
Ne est Town,- Z-C_4� Co - Ridge []Slope ❑Valley []Flat/t G (check appmpriatebox)
( t Name,Numbers,Co unity,Subdivision,Lot No.,Zip Cod Latitude4onetude of well location
3. OWNER ^ �-7 (degrees m nucesheeoudq)
Address g2 ( /� [C�� Latitude/longitude source.❑GPS❑Topographicmap
(Strect or RO ,No.) I L (check box) .
✓—b-- 30i/V DEPTH DRILLING LOG ' .
",CCC ry or I own sax rp code From To Formation I)escription
��t
9�L - .r to -- 7y
Area code-Phone number 2
*42
4. DATE DRILLED /U J
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ct
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•t/or below land surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):.—METHOD OF TEST 4/l-,
10.WATER ZONES(depth): y-/U
LOCATION SKETCH
11. DISINFECTION:Type / Amount 121 )how direction and distance in miles from at least
12. CASING! Wo'i Thickness two State Roads or County Roads.Include the road
tiYei r 5 "is and co"Imull ,. .t �
� ��`�FL a�7s1 .�v�
From To -
From To'-"- Ft.
From To Ft:
_ 13. GROUT: . Depth . Material bIT
From To�_FL
cthod
From To_�Z Ft.b Material
14. SCREEN: Depth Diameter Slot Size Maferial
From To Ft. in M. v
From To Ft. in. in.
15. SAND/GRAVELPACK: 2
Depth Size Material - w
From To FL
From Tc ' Ft.
16. REMARKS:
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA`r15 AND THAT A COPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.GN.ATUF, PERSON!CONSTR CTINIG TfrC WELL DATE
<,tit) IIo�P ) �`t,,.�It ,❑ %L �r2 C 'l1iC < il. ,u.(, J.i.)Mlle -a:pt, V /. tAli Je -�L".
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004
RECEIVED
FEB 0 7 2006
Asheville Regional Office

WELL CONSTRUCTION RECORD ,3o
North Carolina Department of Enviro ent and Natural Res urces-Division of Water Quality 3
WELL CONTRACTOR(h` �IDIMUAL)NAM (print) CERTIFIC�jA�TIION# /
WELL CON7RACFOR comPANYNAb i PHONE # ir".Az
STATE WELLCONSTRUcnON PERND'C# - ASSOCIATED WQ PERbD'I#
if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaMblic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water jection❑ Other❑ If Other,List Use
2. WELL LOC '9 Topographic/Land setting
Ne estTown: ✓ ,- o my Midge 3MIope ❑Valley ❑Flat
(check appropriate box)
(S N umbers,ComQQmuniitty,S]ubbddiivision,La No.,tip Code) Latitttdell0ngitude of well location -
3. OWNE /IAJi�h.. / o llC _ (degmes/minuteshemnds)
Address 7,9 q IE (2 92-'--& Latitude/longitude source:❑GPS❑Topographic trap
(Street or Route No.) _ (check box) _
DEPTH DRILLING LOG
C' oriown S Zip Code From To Formation Description
( 4� l - 5 �3
Arcs code-Phone number -
4. DATE DRILLED / O
S. TOTAL DEPTH: / Z p _ / z 7✓
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO I k 'ZZ - i Lz
7. STATIC WATER LEVEL Below Top of Casing: ,(V I r
(Use"+"if Above Top or Casing) /1<-
8. TOP OF CASING IS�_FT.Above Land Surface' _
-Top orcasing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C.0I18, n
9. YIELD(gpm): ./0 METHOD OF TEST t7 /L-) —
10.WATER ZONES(depth): /y/o
LOCATION SKETCH fJ
11. DISINFECTION:Type Amount 7, Z Show direction and distance in miles front- @least."
•12. CASING' - Wall Thicl:necs _0�S two State Roads or County Roads. Include,tte road
Udptir 51 Liaff Ili or W cighvl e n Maoal ==o-nue s r c.;o,;vmin road a2, .ts. u�
From O To Ft. (�`/lf SP L 44 PLk--
- From To _- Ft.
From To Ft. p� Jj.��[.., � �y9 13. GROUT: Depth Material Method I / ' 1^r J\
Fromm To $ Ft.=-��
Fromm Tom Ft-Ile
14. SCREEN: Depth Diameter Slot Size" MSt nal�
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From—To—- Ft -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARM AND THA. �OP OF S 8ECORD HAS BEEN PROVIDED TO THE WELL OWNER
b-A
^-NATURE OP IVERSON CONSTRUCTING THE WELL - Df TE—�
f
Submit the ariginal to the,Dhision of Water Quality,Attn:InformaCon Alanagcment, 1617 Mail Senice Centcr-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
= GW-I REV.09/2004
Regional

NVELL CONSTRUCTION RECORD 7l0
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CON, CTOR PWIVIDUAL)NA-NE (prin - CERTIFICATIONN
WELL CONTRACTOR ComPANY NA.� _ YE ! (A21 —Vs,
STATE WELL CONsmuc IOY PERSDTti - - - ASSOCIATED WQ PERS 41
"(ttapplieable) ` _ - (itapplicable) -
1. WELL USE(Check Applicable Box):Residential Munfcipal/Pablic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOC
Nearest To County%�CLCL't��� Topogralope and setting.
Midge tope;,❑Valley CdF1at
l � - chak appropriate box)
(Street ame, en,Cotmnunity,Subdivision,Lot No,Zip Code) . . LatitudellOngitudt of well locatfa
3. OWNER: - - �(d<gteetrminuresheconds)
Address - Latitude/longitude source:❑GPS❑Topographic reap
(S t�'rRoute No - (cbeckbox)
S 3 t TY )EPTH DRILLING LOG
„ .City or TT N s cc D Lip code From To 'Formation Description
(� oloC
. Area code-Phone number -
4. DATE DRILLED
5. TOTAL DEPTH: 3fV Lk 2 _ 'S-0
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO �-V frZ
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 af wing terminated attor below land surface requires,■ 103 --31 )
variance In accordan with ISANCAC2C.0118. /] /.ri
9. YIELD(gpm):_ METHOD OF TEST > 71 J i r 5S - 3 SZ�
10.WATER ZONES(depth)jld� / 3 —
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASNG: Wx±!TFtc}�e�c `s two State Roads or County Roads. Include the road
<<ll Depth D:am^In or n c..ippnui L ", '�% �.�W.d cui ❑c,.ro d c..i::ic:.
From V To, �Ft. �l/"�G
From To Ft.
From To FL o�
13. GROUT: Depth Material
From
From�To FL— 0a�—14. SCREEN. .Depth Diameter Slot Size 61 Ma,tcr6i
From - To FL in. in. /
From To Ft. in.
15. SAND/GRAVEL PACK: n
Depth Size Material
From To - FL—
From—TO Ft. -
16. REMARKS:
I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THISAECORD HAS BE RO ED TO THE WELL OWNER
SIG' ATU}tr�PF--RSONrCONSTRUCTING THE WELL DATE
to the J.ti t,.r,•; ,, .,.1Quai..),ALtL:1111urn.atioa IManagcment,♦ur'il,eiiSet z CCZttF_
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. - -
GW-I REV.09/2004
FEB 0 / 2006
Asheville Regional Office

J 5 a2 q 7
WELL CONSTRUCTION RECORD A 76 2 z - 33 S ( S-7
North Carolina Deparhnent of Enviro nt and NatU eso s-Di
µ' vision of Water Quality -
/(I/d',jO�ELL CONTRACTOR (prin0 CERTIFICATION#-3— y�
WELL CONTRACFORC06BANYNA.� PHONE # 2 cSss D
STATE WELL CONSTRUCTION PER.NHT# ASSOCIATED WQ P BHT#
';��f (ifapplicable)
(if applicable)
1. WELL USE(Check Applicable Box):Residential l Mur icipal/Public❑ Industrial❑ Agricultural❑
Momto'ring❑ Recovery ❑ Heat Pump Watez Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N: Topographic/Land setting
SN arestTown County �n ) )EIRidge. ❑Slope ❑Valley ❑Flat
(. 7 Z. .7 (check appropriate box)
(Street Name,Numbets,OfirmamaitV Subdivision,Lot No.,zip Code) Latitude/longitude Of welllocation
3.
(degrees/minutes/secoads)
Address 20 Latitude/longitude source:❑GPS❑Topographic map
(Strect or Route No.0 (check box)
a 87-7 C/ DEPTH DRILLING LOG i
try or Town State Zip Code From To Formatioti Description
d� 5 - An9a
. Area code-Phone number
4. DATE DRILLEDIO d(4 Ir4 — 5a
5. TOTAL DEPTH: !o s a 5 5-2 Y
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO X 5 Z6` (a >Z
7. STATIC WATER LEVEL Below Top of Casing: LI_L FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface-
-Top of casing terminated atlorhelow land surface requires a
variance in accordance with ISA NCAC 2C.011L nn
9. YIELD(gpm):_ METHOD OF TEST l�
10.WATER ZONES(depth): a
LOCATION SKETCH
11. DISINFECTION:Type )+j y{- Amount •7S 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/FL Material numbers and common road names.
From O To L9 _FL (,'lq 5otct1 CD UG
From To Ft.
From To , Ft. fl-
13. GROUT: Depth Material Method _
From_ To 3 FL // n
Fromm Z_D FL a R
De
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 FL
From To Ft. .�
16. REMARKS:
I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND 6PY OF W RECORD HAS BEEN PROVIDED TO THE WELL OWNER
to ' (s 1
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Atin:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
RECEIVED Gw_1 v.o9nooa
FEB 0 7 2006
ASheville Regional Office
Aquifer Protection

pd„a.SAA Fa _
11
RESIDENTIAL WELL CON S;rRUCTION RECORD
'A
''stir North Carolina Department of Environment and Natural Resources-Division of Water Quality
.. WELL CONTRAC-FOR CERTI FICA'1-ION N_ /r
1.WELL CONTRACTOR:
{ I. DISINFECTION:Type Amount
i C. CAA,Ie— U. WATER ZONES(depth):
Well Contractor(Individual)Name From_ To From To
From_ To From To
Well CorLtFacB t'yl�� TT (.t DPILUXG, UZI. From_. To From To
STREET ADORES 48 CRANE CIRCLE 6. CASING: Thickness/
RANKLIN, PIG 28734 Depth Di meet Weight Material
From i�) To:��Ft. [�
City or T-1avn State Zip Code From To_Ft. _
From. To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROU": Depth Material Method
� _y� ♦•
SITE WELL ID ll(i!applicable) From e To�_Ft._ I From—Tv.—Ft. g01
STAI'EWELL PERMIT#(irapplicable)_ _ From",__To_F'1.
DWQ or OTHER PERMIT#(if applicable) 8. SCREfEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft—in. _ in.
From To Ft. in. _in.
DATE DRILLED II���'"UJ _ Rom.,_To_Ft._in. —
9. SANCIGRAVEL PACK:
1.WELL L�4.✓ hCV' COUNTY )-1C IJepth Size Material
CITY- (�c4'✓) From To _FL
jj�� � From To Ft.
Tr%t'e �f A,l From., To__Ft.
( beet Ulm,Numbers,Canrnunity,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLNG LOG
CISlope CIValley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box)
— — i
b
May be n coeds o -fit--
LATITUDE 3 M
_ e n degrees,
LONGITUDE in a dermal fnrmat T '
Latitude/longitude source: ❑GPS ❑Topographic map (1) 7— �.7 e—"j
(location of well must be shown on a USGS topo map and
attached to this form Inot using GPS)
4.WELL OWNER
OWNER'S NAME P.
L�KIj')�pA1
STREET ADDRESS _ ( .C-. J\OJL -
CA --y-ok�.e-e /V'C �2 a719'
City or Town State Zip Code --- ----------
Area code code- Phone number
5.WELL DETAILS: 11. REi14ARKS:
_
r
a. TOTAL DEPTH: a- -
b. DOES WELL REPLACE EXISTING WELL? YES O NO
c. WATER LEVEL Below To P Of CaSln : (� DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH
9 FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use-+-if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface,
*Top Of casing terminated with 15Abelo land surface may require SIGNAT RE OF CERTIFIED W EELL CONTRACTOR DATE L�
a variance in accordance with 15A NCAC 2C.0118. J /�
e. YIELD(gpm): L METHOD OF TEST 11 i r L+ 1. �/al1P
PRINT D NAME OF PERSON
{ EL{
Submit the original to the Division of Water Quality Within 30 days. Attn: Info tion Mg .1E C E I V
1617 Mail Service Center—Raleigh,INC 27699-1617 Phone No.[phone] ext 56 1. Form GW-1
FEB 0 i 2006Rev'7/05
Asheville Regional Office

C
� jj RESIDENTIAL WELL CONSTRUCTION RECORD
. g North Carolina Department of Environment and Natural Resources-Division of Water Quality
.. WELL CONTRACTOR CERTIFICATION
1.WEL
8bP C' "/ONTRACTOR: I. DISINFECTION:Type Amount
oPN Ale. g. WATER ZONES(depth):
Well dontractor(Individual)Name From_ To From To
MANE BROTHERS`�X.L Dc r s _ r Fran_ To__ From To
Well Contractor CoRili ERrilINIE CIRCLE Fran To From To
FRANKLIN, NC 237,4
STREET ADDRESS 6. CASING; Thickness/
DTolh D Ft Dia--GX' Weight Material
From Q
q�I<�Cit�y or Town /,G State Zip Code From,_To Ft.
(U 1 t( )-Z-j _ Y/, From_ TC FL
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From_JQI__To , tl Ft. C.�mri rf
SITE WELL ID#(if applicable)_ I From._,_To Ft. fY`.J -(_'c'.
STATE WELL PERMIT#(if applicable) From_To Ft.
DWQ or OTHER PERMIT#(if applicable) I. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply$ From__To Ft_in. _ in.
_ From To Ft.—In. —in.
DATE DRILLED /- %-� From To Ft_in. _ in.
TIME COMPLETED AM❑ PMQ
9. SANDiGRAVEL PACK:
3.WELL LOCATION: I /' Depth Size Material
CITY: _CLlf )PA COUNTY p,CkiS�w% From To Ft.
.� r �` From To Ft.
14 kety� G Ze From_ To Ft.
(Street Name,Numbers.Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILL.!NG LOG
❑Slope ❑Valley ❑Flal ORidge ❑Other From To Formation Description
(check appropriate box)
LATITUDE
May be in degrees,
3
_ minwes,secondsor -
LONGITUDE in a decimal format �y ._�,?�_ 9✓✓cl7y 12L
Latitude/longitude source: ❑GPS ❑Topographic map _
(tocatlon of we#must be shown on a USGS topo map and -
attached to this form#not using GPS) _
4.WELL OWNER /�� _
OWNER'SNAME k 1't ni(L / A-e t� -
STREETADDRESS E D LBby 1196
City or Town State Zin Code --
L—)-
Area code- Phone number '
11. RE:LIARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: f1 v
b. DOES WELL REPLACE EXIST114G WELL? YES❑ Ito Cl
c. WATER LEVEL Below Top W Casing: �`'V FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 3C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+•if Above lop of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS_ I FT.Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance With 1SA NCAC 2C.0118. SIGNS RE/OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 0 METHOD OF TEST_yT, ✓ '
PRINT NAME OF PM�_
Submit the original to the Division of Water Quality within 30 days. Attn: Infor E D
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext�5Form G -la
2006 Rev.710
f
al Office
. ..

�n�v
..° t`'RS RESIDENTIAL WELL CONSTRUCTION RECORD .
North Carolina Department.of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 0L)�...3
1.WEL ONTRACTOR: I. DISINFECTION:Type Amount
x �Fy-il g. WA rER ZONES(depth):
Well ontractor(individual)Name From_, To From To
aayr s n From To From To
—
Well `or poptnnartyHpll CIRi,LF From- To From To
STREET ADDRE�gANK�4;~1, 6. CASING: Thickness/
Q Depl Diarpet¢p Weight Material
From T �
o �� Ft.
City or Town State^7 Zip Code From To Ft.
(�}_ / /-y/ c, From--TO—Ft—
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
� p /
From To,,16) Ft.
SITE WELL ID#(if applicable) From To Ft. E'A),4V. —''
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) B. SCREEN: Depth Diameter Slot Size Material
_
WELL USE(Check Applicable Box): Residential Water Supply O From To Ft.—in.
To FL—in. in.
_in. _ in.
DATE DRILLED 42-A'U J From-_To Ft.—in. _in.
TIME COMPLETED AM O PM f3 9, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
/'
CITY V
//: I A COUNTY L1c �/1J From To Ft.From To Ft.
From_ To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC f LAND SETTING: 10.DRILI;NG LOG
[]Slope OValley ❑Flat ORidge ❑other From To Formation Description
(check appropriate box)
May he in degrees,
LATITUDE 3 _ minutes,seconds or 1-- -� rr i✓ —
LONGITUDE_ _ in a decimal limemt fey cf-
Latitude/longitude source: ❑GPS ❑Topographicmap !i
(location of well must be shown on a USGS topo map and
attached to this form If not using GPS)
4.WELL OWNER
OWNER'S NAMESTREET ADDRESS r d e-
U�itI; eI, Q $7� _
City or Town State Zip Code
Area code)- Phone number
11. REMARKS:
S.WELL DETAILS: _t—
a. TOTAL DEPTH: S J
In. DOES WELL REPLACE EXISTING WELL? YES NO[3
c. WATER LEVEL Below To of Caging I DO HEREBY CERTIFY THAT INS WELL WAS CONSTRUCTED RI ACCORDANCE WITH
p g: FT. 15A NCAC 27.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+•if Above Top of Casing) RECORD WS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS J _FT.Above Land Surface*
*Top of casing terminated atlor below land surface may require SIG FTUI2E OF CERTIFIED WELL CONTRACTOR DATE
t'
a variance in accordance With 15A NCAC 2C.0118. r
e. YIELD(gpm): 3 v METHOD . -
PRINTED AME OF PERSON CONSTWCTING THE WELL
Submit the original to the Divisic n of Water Quality within 30 days. Attn: Information Mgt.,1617 Mail Service Center-Raleigh, 4C 27699-'I6t b RhtnwJllp.[phone] ext 568. JAN 9 200� Formw-1a
Form G 5
Asheville Regional Office
uifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural R_sources-Division of Water Quality
_. WELL CONTRACTOR CERTIFICATION �3UP/
1.WELL CONTRACTOR: f. 011,NFECTION:Type Amount
Lgnoye Ct-Ane, _ g. Wh TER ZONES(depth):
Well Contractor(Individual)Name From_ To From To
From To From To
Well Cont 35 .". From To From To
248 CRANE CIRCLE -'
STREET ADDRESSFRANKLIN, NC 23734 6. CASING: Thickness/
�) Depth Di ele Weight Material
Frcnr !/ To1Q�FL Z J�
City or Town State Zip Code From To Ft.
From To Ft.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method From D To-a 0 Ft.
SITE WELL ID#(If applicable) From To FI.
STATE WELL PERMIT#(if applicable) From___To FL
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q' From Tc FL—in. _in.
DATE DRILLED �1 From To Ft—m. _in.
oC V J From_Tc Ft—in. _in.
TIME COMPLETED AM PM43' 8, SANDIGRAVEL PACK:
3.WELL LOCATION: [Depth Size Material
+ I pp t r From.. To Ft
—
From wllr r 1 r 'e/V� COUNTY �� �L h' From. To Fl.
J Y-Ad le r ICJ A I From" To Ft.
(Street Name,Numb rs,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
[]Slope DValley ❑Flat ❑Ridge 00ther From To Formation Description
(check appropiiale box)
May be in degrees,
LATITUDE 3 _ minutes,seconds or
LONGITUDE_ _ in a decimal format " u T
Latitude/longitude source: ❑GPS DTopographie map
/location of we#most be shown on a USGS loon map and
attached to this form#not using GPS)
4.WELL OWNER
OWNER'S NAME 4 1,,,,,rZ
STRE€T ADDRESS P, t\-
City or Town State Zip Code
G'1
( )
Area code- Phone number
11. REMARKS:
5.WELL DETAILS-
a.a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
1 DO HEREB f CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W"
c. WATER LEVEL Below Top of Casing: FT. IM NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THATACOPY or THIS
(Use'+'if Above Top of Casing) RECORD H 3 BEEN PROVIDED TOsTHHE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface- �A�(�2/ /_�Jfo
*Top of Casing terminated attor below land surface may require SIG TUBE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): METHUD OF TESTE!RlhllEU hill Uri Or_ ���/r° «�
pp ��++pp 11,�,/F nn iRUCTING THE WELL
Submit the original to the Division of Water Quality wi in 30 BAF`1 AR-AnTokRon Mgt., Form Gw4a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phon No.[phone] ext 568. Rev.7/0S
FEB 07 2006 J N 19 2006
Asheville Regional Office
AQu'Ifer Protection

oft
NNELL CONSTRUCTION RECORD
TlorthCa[olina Dz' -mentofEn.: ... entard�turalResourccs- ivisionoflVaterQualiry-GroundwaterSection`'
WELL CON7RACTOR(INDIYIDUAL)NAME (print) CERTIFICATION
p OCj s4.
WELL CONTRACTOR COSIPANYNA>IE PHONE 9 JV_Tr-S -SSS'�
STATE WELL CONSTRUCTIONPERYIIT: - ASSOCIATED RQ PE �IIT.
! - (ifipplicable) (if applicable) -
I. WELL USE(Check Applicable Box):Residential Pr Municipal/Public❑ Industrial❑ Agricultural ❑
hfonit0ring❑ Recovery ❑ Heat Pump Water Injection❑ Other[I If Other,List Use
2. WELL LOCATI Topographic/Land satin?
Nearest Town: County
Midge (@Slope []Valley ❑Flat
(SuetName,Num c:s,Community,Subdi`.isior.,Lot No.,2i Cole (eh•;<approyna:cboa) '
P ) Latitude/longitude of well location
3. O�S'NER: (d r smirus'secands)
Address Latitude,7ongitude source:❑GPS❑Topo;aphi:map
(S:rcct ar Ract:NuJ G (check lox)
Y1 e- �x-7-r DEPTH DRiLLTNG LOG
(�oy orT -5 a:: zip cede From To Formation Description
c1 Jo c1 c-�"Y �
Area cock-Phone runsber
4. DATE DRILLED 7� - 7
5. TOTAL DEPTH: 3< � I
6. DOES WELL REPLACE EXISTING WELL? YES NO k
7. STATIC DATER LEVEL Below Top of Casino: C) FT.
(Vse if Abov:Top of Casing) 27 _
S. TOP OF CASING IS�_FT.Above Land Surfa:e-
•Top of eastnZ terminated 2vor below land surface requires a
variance In accordance with ISA NCAC 1C.0119.
9. YIELD(epm):_�S=_METHOD OF TEST_
10. WATER ZONES(depth): J 7 0
'zz LOCATION SKETCH -
11. DISINFECTION:Type f f T7j— Amcun: ? 0 c 2irzceoa and distance in mile;from at least
12. CASING: Y4aa 7F.ickre>; t o Stara Roads Or County Roads. Include the road
Dep:h Di_., a P,eizh:Tt. Ma: numbers and common road names. .
From To �� �2! �_�F[._
From To Fr.
From To—Ft. n l
13. GROUT; Deepth DTaterial I thoC
From To Fr. 597 ��may ,
From 3 To F[. _
14. SCREEN: Depth Dixmexr Srot Siz; Ma:e;ial /�L r,. >` �i � N
From - To -Ft., - in. in. c17
..From - Tc Ft. in. in. _
b
1.5. SA.ND'GRAVEL PACK: oi
'.Depth dize Ma:r.iat
From - To Ft. q
From To Ft.
16. REMARKS:
a •
I DO Ii:.R=EY CER T Ir) H ATTHIS 1':ELLW'AS CONSTRUCTED TN ACCORDANCE V,1TH 15A NCAC 2C,WELL --
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS CORD HAS BEE\, P? !DED TO THE V.TLL Ot',1zR
�p p -! f os
-
SIGNATUREOFPERS N CONS TRUCt•?�6TR�E1't
�,i^.1I fig 1'!: al :C etc )1`"�_I � �,'. 2[2 � '_ '❑�I�RP' J:rIT�
:. 0 u'ra ' Sacfw aJ � enRr-R Ieigh,NC
27699-1636 Phone No.[phone] Yvithin.30 days. - GR=1 R V.07/2001
FEB 0 7 2006
Asheville Regional office.
uifer Protection

(%aD J J rQ) 3 o1w-
WELL CONSTRUCTION RECO%4P . 179/ 9 9 6o 0d'5'-7
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NA�� (print Cr-�,s.Q (�- 2� � CERTIFICATION#30 V1
WELL CONTRACTOR COMPANY NAME q_ � Q 0NE #
STATE W ELL.CONSTRUCTION PER'MT# U ASSOCIATED WQ P RrDT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Munfcipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water ejection❑ Other❑ If Other,List Use "
2. WELL LOCATIO Topogr�aphic/Iand setting '
Ne stTown: Co ,/t Midgedope - ❑Valley. ❑Flat
r �.` (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip ay.71y Latitude/longitude of well location
3. OWNER:
(degrecs/minuteshecoads)
Addressu7 Latitude/longitude source:❑GPS❑Topographic trap
IS Route N. y, r / (check box)
�tTG�t �.iJvi viO ® 1"1-c �Fi�'� 7� DEPTH DRILLING LOG
City or Town m ` Zip Code From TO FOrma60nD p n
. - Arta code-Phone number
4. DATEDRH,LED 5—OLI-0 T— 7 ��
5. TOTAL DEPTH: 7
6. DOES WELL REPLACE EXISTING WELL? YES❑ 7 NO 7 — �
7. STATIC WATER LEVEL Below Top of Casing:_ r�d- FT. --si
(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): . /-5-- METHOD OF TEST
10.WATER ZONES(depth): r //
J LOCATION SKETCH
IL DISINFECTION:Type Amount ( , -ehgw 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/FL Material numbers and common road names.
From_1LTo /Da--Ft f�t1_ S02zt 69L/ Q
From To FL
From To , Ft. A,
13. GROUT: Depth Material ethod
From_ To 3 FL
Fromm To�Ft. (�
14. SCREEN: .Depth Di r Slot Size aterial may,
From TO Ft._in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: N
Depth Size Material U7
From—TO—FL— o
From To Ft. av
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 ORD HAS BE PROVIDED TO THE WELL OWNER
/O /S O
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/2004
RECEIVED
FEB 07 2006
Asheville Regional Office I
Agu'lfer Protection

NVELL CONSTRUCTION� * c 1
_ RECORD
North Catolma Department of Environment ar d N al Resources-Divisi of Water Quality-
W Groundvrdter Section
'ELLCO\TR.ACTORQNDIVIDUAL)NA>!E (print) - qq '�
CERTIFICCATTI01,k cJ q f
WE LL CO\7RACT0R COMPANY NA)IE PHONE
STATE WELL CONSTRUCTION PER�IITk ASSOCIATEti wQ pER�n7:
(ifapplicable) " (ifapolicable) -
I. WELL USE(Check Applicable Box):Residential[ J MunicipaLPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery [I Heat Pump Water njection❑ Other❑ If Other,List Use
2. WELL LOCATI \:
Neares %n: -Topographic/Land setting
C °°ry Midge []Slope Ovall-y ❑Flat
(Street None,Numbe?,Conmuni �' de (chrkaudeOf boat
. ry, aSs.nision, ott:o.,2'p Ca.) Latitude/longitude Of Well location
3. OWNE
� (� (de¢:rt'miaums'seeord;)
Address )l! -'Latituda,longimde seurce:❑GPS❑Topog,aphi:m_2
(Scent or Rou;:No.) (ch• k box)
C, -7S DEPTH DRILLING LOG
upy or�own smx zip Celt From -To
(_) Formation Description
Area code-Pbon:number
FI:
a
4. DATE DRILLED K- _ y
5. TOTAL DEPTH:� �S2) (�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ D N ,I J ,> q C
7. STATIC PATER LEVEL Below Top of Casing:�OQ FT.FT. --$�f—
(L'se`:"VAba,.-Top ofCasir.r) 21
S. TOP OF CASING IS I FT.Above Land Surface' 7
-Top of easing terminated aL'or below land surface requires a
variance in accordance s,leh ISA NCAC 2C.0118. - -_
9. YIELD(epm): -3 y METHOD OF TEST_ _
10. WATER ZONES (depth): -
LOCATION SKETCH
11. DISINFECTION:Type_-I��-Amoun:___(e _ 7d,ow 2irectior.a7.d distance in miles from alas:
12. CASING: VI a:I 7hic", -ss n.o Sta:e Road;er Coun y Road;. Include tf�'rozd.•w
Depth ' . er Vfeiah:Tt. b e numbers and eonumon road names.
From_ToC�Ft._
From To Ft.
Frem To Ft.
13. GROUT: Depth Malarial Me:hod (�� /. . _ Q
From 0 Tom_Ft. "�""•��J
From_To_ Ft.
14. SCREEN: Depth Diameter Slot Size Ma.erial
From To Ft. in. in.
From To Ft. in. in.
li. SAND,'GR4VELPACK:
Depth Size Mate.ial
From To Ft.
From Tto Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE PITH 15A NCP.0 2C, V ELL
CONS TP.UCTIO\'ST.A]'D4R^5,..'.\T TH2.TA ff,-YAD Tr SF.=CGv, rr l =E\ t'r J,V!D-, TUTf-, 'Wi:.L OV,;,ER
SIGNATUREOFPEP.SONCO\STRUC -- D.-SF. 4
RECEIVED i ihL ori,inalto the i.iivision 01 R a ter Qualih,Cround�ra rSect ' 3636Mail Sanice Center-F leieh,NC- -
2 7699-1 63 6 Phone No.[phone],Within 30 days. GG:-1 R V. ON2001
- FEB 0 2006
Asheville Regional Office
taifer Protection

76�o a J Nr
WELL CONSTRUCTION RECORD ,t
North Carolina-Department of Environment and Na a]Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NA`IE (print) CERTIFICATION# -s G
WELL CONTRACTOR COMPANYNAAIEJ '6 —PHONE # (�11P�t,r2 sS S�
STATE WELL CONSTRUCTION PERhIIT# ASSOCIATED WQ PE&N IT#
(ifapplicable) (ifapplicable)
1. WELL USE(Check Applicable Box):ResidentigM Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting "
Near e T wn: Cou q�dge ❑Slope ❑Valley ❑F(6 ..
kl C zY 7 l.: (check appropriate box)
(Street Name,Numbers,Communi Subdivi on,L(A f4o.,Z#Code) Latitude/longitude of well location[=
3. OWNER: (degrees/minutes/seconds)
Add ss 4&atitude/longirude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
L 7 Z DEPTH DRILLING LOG
or Town St to Zip Code - From To Formation Description
Area code-Phone number n D
4. DATE DRILLED 0 J —
5. TOTAL DEPTH: ,L,. ��� _ Z?
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO,& 2 Z o
7. STATIC WATER LEVEL Below Top of Casing:��FT. d T O
(Use"+"if Above Top or Casing) O r
R. TOP OF CASING IS FT.Above Land Surface*
*Top or casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0 t I8.
9. YIELD(gpm):— 3 METHOD OF TEST a
10.WATER ZONES(depth): zo
_ Dr LOCATION SKETCH
11. DISINFECTION:Type ��T Amount - Show direction and distance in miles from at least
12. CASING: Wall Thickness V two State Roads or Co my Roads.Include the road
m
Depth Diameter orWeight/Ft. rial numbers and como oad names.
From (D To �L Ft.. C, �,k SO12 I) C
From To Ft.
From To Ft. f
13. GROUT: Depth Material Method 0('d
From = To a, Ft. 7
From To Ft- Mc.1 (D-
V
14. SCREEN: Depth ameter Slot Size aterial `F C/.''L4r.— (/L�
From To Ft. in. in.
From To Ft. in. in. v l
15. SAND/GRAVEL PACK:
Depth Size Material 1
From To Ft.
From To Ft. -
1 F. REMARKS:
I DO HFP.L^Y C::RTtFY THAT TF;iS k' L^'SAS CONS—RUCTED FN ACCORD' F tiCE 7,IT}T ',A' ^.AC 2C,1111-Er I.
CONSTRUCTION STANDARDS,AND THAT A COPY OF TFIIJ RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
Tppt_CCsvrrr,}. \—�CE-n—�.'-i-
Submit the original to the Division of Water Quality,Groundw ter See iAl gAlii$lP pCenter- sleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001
FEB 0 7 2006
Asheville Regional Office
Anuifer Protection

- 5 - i ��- LcJ
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and�j Na/�yNNatural Rego ces- iivision of Water Quality-Groundwater Section�s
NY ELL CONTRACTOR(INDIVIDUAL)NAME (print) " e CERTIFICATION#§V41
R'ELL CONTRACTOR COMPANY NAME W HONE #
STATE%%ELL CONSTRUCTION PERMIT# —ASSOCIATED NV PER.IIT#
(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 Nearest T LOCATI �: Topographic/Land setting
own: unty ❑Ridge Lj�lope ❑Valley ❑Flat
C D-k -7 79 (check appropriate box)
(Street Name, umbers,Community,Subdivisio , of No., Code) Latitude/longitude of well location
,3. OWNER: 1t.rw - (degrees/minutes/seconds)
Address a i Latitude/longitude source:DGPS❑Topographic map
(Street or Route No.) (check box)
4fpa �, �� C a & 7�_ DEPTH DRILLING LOG
CitvorTu,n State zip Code From To Formation Description
S9-(n '7
Area code-Phone number 0
C,
4. DATE DRILLED ?Ili b , �l l 'Lc3
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -Z!'r-
7. STATIC WATER LEVEL Below Top of Casing:--l-A::�-FT. Z/ lz;'- - 2!7
(Use"+"if Above Top of Casing) -47 Zv z
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 IiA N'C.AC 2C.0118. � `
9. YIELD(epm):�v METHOD OF TEST— _ n
10. WATER ZONES (depth):
a-1 r LOCATION SKETCH
11. DISINFECTION: Type �LT/4- Amount :Show direction and distance in miles front at least
12. CASING: Wall Thickne two State Roads or County Roads. Include Qroad '
Depth Di eter or N'eichb'R. ntj'U l numbers and common road names.
From To_�.Ft. low SOR J tj'
From To F
From Ft.L
De
13. GROUT: Depth Material tethod
From O To�Ft. 64 zy
From f -_To 2-1_Ft. w
14. SCREEN: Depth Diameter Slot Size Material 'tZ+-rr�r2GJ Gym.
From Tia FL in. in.
From To FLin. in.
15. SANDIGRAVEL PACK:
Depth Size Material t
Front To - FL
From To FL
16. REMARKS:
1 DO.HERE3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C,WELL
CONS i ION COpt'OF THIS I'LCO, 'H')u BFi N FROVID' TO T'IE 'ELL OIV`:EC
/ O
SIC\�TUf2L OF PLl2` �(t\S fRIrCT ;TH Rr LL DATE
Submit the orivinal to the Division of Water Quality, Groundiz;.t>,.,. el -t2aicieh,;\C
27699-1636 Phone No.[phone],is ithin 30 days. RECEIVED G '-t REV.0T3001
FEB 07 2006
- Asheville Regional Office-

No `YELL CONSTRUCTION RECORD North Carolina-Department of Environment and tv'atural Resourceitls- ivision of Water Quality
WELL CONTRACTOR(INDIVIDUAL)N•A�IE (print)
WELL CO:\TRACTOR CO.VIPgA'y NgVIE Q ry-Groundwater Section p�
./ CERTIFICATIO\'#STATE WELL CONSTRUCTION'PERMIT# U
(ifa licable ASS T PRONE k ,t
OCIATED 5VQ PERMIT"
1. WELL USE(Check A Q6a licable)
Monitoring erY Applicable Box): Residzntial� 1lunici al Public❑
❑ Recovzry ❑ Heat Pit Water njectifu icP Other❑ If Other,IndusList trial
,
Air culNral❑
2. 1VELL LOCATI :
Nea . Town: — _
Co�nry Topographic/Land settinO.
(S�reea Name,Numbers,Coifi unity, 9 ❑Ridgz Slope ❑Valley Flat
Subdivision,Lot No., I a �~' / `— (check a
�P CO�e) PPropriate boa)
3. OWNER: Latitude/longitudeofwelllocation
Address P L a
(degrces.m '(S:rcec or Route 'o.0 e!Ion
7J 7 LatiN inutes'seconds)
dgiNde souree:0GPSOT000gra Chic map
ry Por 7o Su DEPTH (check boa)
( - 7u .a, -- c� Zipccc- DR11UNG OG
Am cede Phone number From To Formation Description
4. DATE DRILLED U S
S. TOTAL DEPTH: _ j m
6. DOES WELL REPLACE EXISTING 1S'ELL? }'ES ❑ — Z6
i. STATIC WATER LEVEL Below Top of Casine: AO !Y—
iJ7/ CL �, 747>
S. TOP OF (Use•.+'•iFAbo:r To; . := c
CASTNG IS o.CaFi,ce --�
ar oteastng �FT.Above Land Su:face• �__
P terminated at/or below land sort requires a
variance in accordun. with lSA\'CAC ZC.Ot IS.
9. }'IELD , �---- "+
(_epm):— METHOD OF TEST —�--
10. WATER ZONES(depth): —_ 3—
I I. DISINFECTION:Type
-- ^-
SP n ��� LOCATI=TCH to
12. CAS[KG: —o — �— Amount__y ShoS direction and dista.,ce in nilzs fret !lea
Depth Thickae;; t•a'o State Roads cr Cour,h'Roads. Ineluh, ro
From Z% To Diameter or R"eightTt. bfDater;ai numbers and common road ramzs.
From To Ft. S'D- 2 J�
From To
13. GROUT:
Depth Material � {,
From__To Z� s Method LL�y/�L[�i1✓
From_ To 2--�-Ft. �•�5x-o-�._ j
14. SCREEN: Ft. 1
Depth Diameter ,-. Kk
From TD Slot Size Material
From FL ir..
L Ft in. l
Li. SAND/GRAVEL PACK: m. to �14lei
Depth Size .. __.._From To Ft. - Rfat.rial
From To ' {
Ft.
16. REMARKS:
I I
i DO HEREBY CERTIF}-THAT THfS SCELL k'CONSTRUCTION STAND.A' S,AND THAT A C'q5 CONSTRUCTED IN ACCORD
AVCE lt7TH I5A NCAC 2C VE'CL ,l
OPY OF THIS RECORD HAS BEE\PROVIDED TO TF'E SELL q},,1-Ep _
\� CL.r,
SIGNATURE OF PERSON CONSTRU 1 L'�
Submit the original to the Division of 1Vater G THE `,ILL DATE __ !
2 7699-1 63 6 Phone No. 919 22 Qualm', Cround5va ter Section, 1636 A1ail Service Center-
( )733-3__I,Within 30 days. Raleigh,NC
GW-1 REV. Oi/2001

IT S ly tv
' WELL CONSTRUCTIONRECORD %�3 �-5� ,.(� (�
North Carolina-Department of Ea/vyy��nmenynd N rural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)¢�A�j (p Q ty-Groundwater Section
WELL CO\TRACTOR COMPANYNA�IE �'=�`�— CERTIFICATION- _3O(//
STATE WELL CONSTRUCTION PEAN1iT# ' PHONE R ff1- 5�5(ifa licable) ASSOCIATED 1Y'Q PERMIT: 7
(ifa licable)
--------
I. WELL USE(Check Applicable Box):ResidentialV Municipal Public O Industrial ❑ Agricultural ❑
Monitoring❑ Rzcove'y ❑ . Heat Pump Water Injection O ' Other❑ If Other,List Use
2. WELL LOCATIOt r:
Nearest Town: Topoo aphic/Land Settins.xl ounry y,
yl� ❑Ridge y*lOPe ❑Valley ❑Flat
(S;rett Name,Number,Communiry,Subdtnsion,Lot No.,Zip Co ) / �-- (check appropriate box)
;s.B'77y Latitude/longitude-of well location
3. OWNER: �� f
Address /ice'Li�w
'� - (d<grcs'mirurs/second;)
S or Route Latiude/IongiNdes0urce:OGPSOToponaphicmap
(check )
Cill or Town DEPTH
( •-- - �4> Zip code From DRILLINGpti
To Formation Description
Area code-phone number
4. DATE DRILLED
5. TOTAL DEPTH: ch7]J 5- �
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�} L 7
7. STATIC WATER LEVEL Below•TopOfCasinn: r /
ter" - k
S. TO?OF CASING IS j (Us- T trA`'o`'Top orC�asi,j) --- i
'Top of using termin3rcd ah'or below find s Above ace Land es Surface* —urf _ —
variancetna<carda eu'i•h1>ANCACX.011S. -- ^v 'M
9. YIELD(ep t): _METHOD OF TEST__ --
10. WATER ZONES(depth): '.077
co
H. DISMIFECTION:Type_F 1 T�L+ LOCATI�KETCH
1_. CASING: Amount Si 0t dir;etion and distance ir.miles from at�st F a!I Thi:kner tw'o State Road;Or Courn•Roads. Include the road
From D•p,h ��` eter or«-ei¢ht'F;, Material
m.:n;Szr and commor,road name;.
From.�—To FLU/ D Li �,
To - Ft. 5
From To Ft.
13. GROUT: Dorpth Material SA (f!�/IVn� v
From1 M1, fethoC_
From
Ft.
14. SCREEN: _
_5 To-2�L Ft. -
Depth
P Diameter Slot Size Material .�-�2cia•y-�2�yy.
From To -Ft. ✓ n
From in. in.To 7
15. 5.4ND'G FL 1°' M.
RAVDz hACK:
From p ,Size Material
To Ft.
From
To FL
16. REMARKS:
!
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN p
CUNSTRL'CTI N STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE �tiLLlO'•i1ER
ACCO.,DANCE 1bITH 1 iA NCAC 24� RF'LL
SIGNATURE OF PERSON CONSTRUCTING 7HE 0.•ELL
DATE
Submit the original to the Division of Rater Quality,Groundwater Section,1636 j-RaIlieh, _ -_ —„
27699-1636 Phone No.[phone],within 30 days. Mail Service Center nC
GW-1 REV. 07/2001 _. _' j

Korth Carol WELL CONSTRUCTION RECORD ! 6-
ina- Department of Environment and ' ural Resource;-Uiciso
\s ELL CO.cTR.A6'OR UND.I\7DCAL)\'.aNIE n Of}Cater Quality �U 7 t(
' [/� (PrinQ C,LrvQ_- Q Y Ground\,'aterSection
\DELL CONTRACTOR'CO>I P.\\}'\.a�IE/`�'
CERTIFfCATIOS d-�� f
STATE 1%ELL COSSTR I'CTIO\'PERMIT, Y"
(ifappticabie) HONE k O� i _sue
ASSOCIATED tt Q PER11M
I. }\'ELL USE rp (iraoolicable)
(Cheek A� livable Box):Residential MunicipaNPublic❑ Industrial ❑ A_s
A(onitorimt❑ RecJcer} pea Pump} a,
ere�lnjlction ❑ O:h:r O It Other, Litt Use rculnlral ❑ 0 f S
i. V."ELL LOCATION': 1 S-
Ne'ardst To,cn:-
co' n Topog
rzphic�Zznd s.«!,g
a.V -r, - Ietblope ❑t'alley c r
U:r_:i.\'a::::.\�a3ea.Cor.::nu Svb•i.,i ' - ❑.la.
Code) 6.c:appmpra[:box)
=. OWNER: � tihi:7e:'longirud:O e well location
Addr:ss 0
=^•e:or Rou::Na) Lati nidc:'IJr'._itude�psO::ra:OGPSOTopo,raphic nap .
s:a:e O DEPTH DRILLINGLOG
oL co e From
TO Formation Des.rl ion
DATE DRILLED p
S. TOTAL DcPTH:
I S - Lj C7
"
F' DOES }'•'ELL P.EPLACE EXISTING l.'ELL.
i. STAT(C WATER LEVEL Belo. Top ofC ' YES
asir.,,:S.
TO?O F CAS!\'Q IS
�y
FT.Abo:e Lan{ SurGi:e- efi Gra:ina;:d�::ur heiou laid surrvice rry uire,
,>:ian;r it ae;urJv x<a ith 13:\
CAC 2C.01 13.9. 5'f_r LD(_c.^;:- c-' '.!ETF'ODOFTES � �—10. C•'ATER ZONE Id=pth): 01 T I 3
_ X
11. D!S!NFECTION:12,
CASING: �— � �i ,',J,, dir:ctiun n
} T,i� ='1 r
Dew - _ c \ _ [ t'O S:!:a Road> or Ce.nc.Ro,i 1 lud` ,a t^a
D a ` f
Fro- -� To_ . Ft 4il 2 f BUG .. a:and cJ':L^�^rn, i >. L
Tc A
Fr�M�_T�
IS SCREEN:
Fwr. D:ure;ar .J;Sze
r.: Ft.
Fro
To FL ut
.. SAND GCS% _`L P:1Ci
Dec:;
Fro- To S:z:
To Ft -
6 RE?!:}RAS
I DO HEREB}'CEPT!5} Th:4T TF'�S 1'.' :: -
CO\'ST,?._�T!0� ELL l AS CONSTRUCTED IN p, n N r
D RDS AND Tc a,T. COP}"OF TF.';S p_ CO..DA\'CE\:ITr: l?A\'C?,C C, C.T_LL
=CO.RD 1--AS BEEN PRDt-IDED TU THE b."ELL 0:.1=R:.;
S t?_
!GSATUREOFPERS0.\ CO`.STCTI\r uc 5., T, - C.ELL D-SE
Submit tilt original to the Di+iiion of%%rtr Quuliti Cround.,;
099-1 bio 7 t2r .S2C['Jn, 1536 Mail S:ni;r Ra!ei,
L ,•ithin,i0da,s. h,.NC .
Gv.-1 REl'. 07

- WELL CONSTRUCTION REC
North Carolina Department of Environment / &w ,5/r
' ^°mom e°t�d ra) CO"Resotuces-Division of Water Quality
WELT.cocrrRAcroR(LNmcvtnuAl)rArtE Af7�c�U.G, rR,j
WELL con dDt � '//TRACTOR COMPA:Ny NAWE AAA GREENS B �v CERTIFICATION# �W
STATE WELL CONSTRUCTION PERVIIT# ROS.WELL DRLG.OF SYLVA,INC. PHONE # (828)58� 8= **I!!!
WENNIII, applicable) ASSOCIATED WQ PERVHT#
1. WELL USE(Check Applicable Box):Residential ❑ (ifa licable)
Monitoring❑ Recovery ❑ Municipal/Public❑ g
Heat Pump Water Injection❑ Industrial❑ Agricultural❑
Other❑ If Other, List Use
2 WELL LOCAT O *:
Ne st Town:
ounry Topo ra hIC/Land setting
(Street Name tubers,CommC n ❑Ridge pe ❑Valle
ry,Subdivision,Lq NO., i Code t ,Y check
a m Y ❑Fla[
p ) Latitude/longitude poft well location
3. OWNER;0
Add r ss
(degrees/minutes/xconds)
(Street or Route No.) n9 _ Latiude/longitude source:L]GPSOTo 0!�Qa -7 P graphic map
Ciry .Town Sere DEPTH (check box)
62c _ Zip cede DRILLING �G
Area code-P From To
one Dumber Formation Description
I. DATE DRILLED ( —/ -0 LIL
5. TOTAL DEPTH: _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Bzlow Top of Casing: Y — ,
—L '
8. TOP OF CASING IS �5t ` 'fAbDve Top or Casing)
*Top orcasing terminated avor below 'Above Land Surface'
rariantt in accordance with 15A NCAC 2C 0118 surface requires a
9. YIELD(gpm):
0. WATER-ONES(depth): MET]HgD_QF TEST
o 11 DISINFECTION:Type 1 CD
12- CASING: A t tin LOCTCH
Wall Thickness - two State Roadsirection aordCounnce in miles from at least
From (� DepthG�� Pia meter
From To---`pt 1% S W t(FL Nj�{er}'al numbers and common rod names,include the toad
To FL � V"vG
From To
13. GROUT: Ft.
From to Depth Material
�_
To�_Ft Method
From To_h /
14. SCREEN:— Ft.
Depth
From Diameter Slot Size _
To Ft. tatenal
From TO m. in. VC
15. SAND/GRAVELFt' in• �C
PACK: � 1❑.
Depth Size ( L
From To Ft Material
From To
16. REMA
RKS:
1 HEREBY CERTffY.THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE CONSTRUCTIONS NDARDS,AND THAT A C Py OF THIS RECORD HAS BEEN PROVIDED N THE
RDANCE WITH ISA NCAC 2C,WELL -
WELLOWNER .,
SIGNATURE OF NSTRUCTING T `y �_
Submit the pri HE WELL DATE I
Sub - gin
0 the Division of Water Quality,Attn: Information Nlana
h,NC27699-1617, Phone No.[phone], 'within 30 days. Bement, 1617 Mail Service Center
i
GR 1 REV 0012004 `r I

1VI;LL CONSTRUCTION RECORD � � � `� �► '
IJollh l'alolina - Wpm I111Clll of Iinvinnuncul 111111 1411iu,.,1 Rcsoulcca-Uivirion of water Qunlily-Chunndwater Sccliun
tvFl.l,C11NIIIACI UIt(IIJUII'I UIIAIJN,\nl F, fl"IOII_,('Q'lL��ee (s ___ �CF iir ICA11MIn �yo•�
I%ELL CON I I(ACI Oil C'On1I•AN v N.\nIR
SIAI-F,t1FlA,('ONS1 "Flo"1 N—_..—_-_-- ASSOCIA"I F.I1 tVQ PERIMIN
it a • '14 al1c) if n I dicnbic .
I. \VPLI,USE (Chrck npplic:l6lc 11(m): Itcsidvillinl P-Nfunicipal/Millie U bufustlial 1] Aiticuilulal U
proniim ing U Itccomy LI I Ical !'uugl 1Valcr hijcclilm U Ulber U If Ulhcr,list tlsc
2. R'1'I.I, I UCATIU�r•I�: ILpngrnphil/Lmxl xlliu(;
IJcarest'folvn: �+c r'' � C•ollo ly •�kC�f°r_ Ultidgc L lSlnpe, Clvallcy Ul lat
(1G.11et ofe.!'l'�r '•g• _-. -. _ (fhefk npprryninle b•r<)
($Ulrl IJmnq Nvnll•rl•,Cnnnl,unily,Salvlivisivn,I al ILr.,lip('rvle) l,nlllUll C/1UIIg1111dC Of 1VCI1 1tIC 811 n11
vfr`-? 'ssc''ti'a�. `zo'tQ/„
�{p(f/�T/G�E (�bpl erdminvlrf4ccrvl•h
AdJlcss -/.G•bcll__ rl>_QO OO_X 34]�_ I,:di(udlllougi(,idcsumcc:LV;VS(_Jfupugl:rphic map
(^h<r1 nr Rnnie Ill,) (check N")
_ I)J LI
1��L' IIIU_LU(;
Ckerokee._ VC_2$T19____.____—
IJ1 .
-- pnn❑ "fu pouualiuu Uc,clipliou
(-il1'nr I my, $lole Zip l�vJe
AIfO f�YI!� Ih•rn!Ilnlnh!r 6S Cr
4. DA11; DIM i P.I) S _ yf�' dZZ Gluly, f_v
5. I I I I Al. PIT Il l:_
6. I (IFS \VI?I,I, It1T1,MT FXIS 1lHil Vr'PI IJ )TS L_I IlU 1-1' _
7. S I'AIIC 1VAlFit LIMA. Ilcloty"fnp of(':r.iug:
/ (U•r"r"Ir ALnvr lr,p nrl'n<iupl �-�
R. HW 01'CASlrll; IS _l L____ 1 1. Abuve Lnnd vIIIlhcC* C
•'Lp of[.dnp In nJnnlyd nlPrt Lrinv InnA rur In rr ngnh rr• — — —��-.,� �•
vnrinrtr In rccnl d�nft nllh IS,\Nl'AC 11'.III Ifl. (,F1
Q. 1'IFLD(gl'nl) _ _ _Nil;I HUD UI''1I:SI'_ --
$ze
10. WAIERZ(NJES ((Icplh):
II. DISII ITC11U1J:'f}pc_/>'T/t Amlunll / IwotvdilcctiunmorCistanccinnlilcsGumnleloa
12. C\S1NG: 1Vn1I lh;ck1cs7 Iwo Sale Roads or Coan1 Roads. Include the load
11.;Idh Uimuclrr or\I'cil;hVl 1. M1hdcli:11 numbers and cnunnult road rinlncs.
I-Iml fo /Of 14._G-fir _,/5�' sfQe!
Lu,111 _--
Ll. GRUU 1': 14p1h jlnJ�ia� M1lclhud
I [mll 0 to_� I'1.
H. SCRI;L't1: I1cplh I)Inlllelef Sh'iSin M1lalainl
I-Imil
Il v,tl------ Io- ----11.--iu' -
15. SAWD/URAVI'I. VACF:
11rp16 Sifr hlnlclinl
I DU III'Cf IIti" lf1"'l IIA I 'I111.1 NITL NVA S('01IS I RMAFD Ill ACCORDMICE 1VI711 15A IICAC 2Cr NVITI,
CUNS I IlUC11014 S I ANDARUS,AND'I I[AI*A CUI'1'of:,l I11S IILCURD IIAS URL•N 1,I10VIDCD'IU'I'1ILI 1VL'LL 0N1'I ICR
s of"
SIl;11A Ultl?I)]:I'I[RSUN CUIJS11tUC111IU'11IH WELL DA'I R
S it lnniI fit 1,111;11 ir11 to the Dlr itiun of Wnll•r Qualily,(:nnuulwnter Section, 1(,J6 AInll Service Ceufcr-Itnlrlgii, rlf'
:'h"" i„'" t•L,o. l'r (^I")')1 )•I 1,„Ifllin n! �h,t� GW-I RIiV. W/111101

uc ✓ uurr) )r unu
WELL CONSTRUCTION IMCORD 3
Well I C:aolitm -Drpatlolent of Flu itouu lei am ill ftnlotal Itcsoulccs- Division of Wnlm duality-Ounuldtvnlet Sccliq)li
f �rr/ �e�LG `(_F.I(IIFII.'AIIUtIM�7r/3
wFl.I,CON IIAC llllt(lNlll\'11111AL)N,\mIF, IprIn11.____—�--- --
ruuNe n 1b'�)-29fJ
11 F I.I.CON I IIACIIIII('UMI-ANY NAnik: �(/'e�".-------------- ---'---
I I F RF.I,I,(-(/Ns I It IIC_ I[ON r FIRM I10__—___.____.__-------Ass(ICIA'1 Fill wl)r•F.Ilmll l n
irn , Ilicnhlr
1. 1l'frl.l, I ISIi. (Chrck Applicnhlc Iox): Itcsidrulial IlA t luniripal/Public CI InJushinl I 1 Agticuhulal U
r•tvnilotiolt ❑ Recovrly 11 Ilad Pump 1Valri lujectioll U Olhcl LI If Other,List Usc— --
2. \CI'II, LOLnl7Ot ; // Tupo(!Inpltiell.nild !cltiul,
I Ica lcsl'Io".it! (��to�D�Cz__--_('ouuty �4L(7J0/1 111tidge t- Ilupe, LIVallry Llllnt
Lnlilud/'dlun dude of well location
isorrl tin nlr,IJvnA� , Conunmiiry 5 rl li rision I I Ila„7)p l'wlc) N3s��T_Ss 3" N/Q j;.1's/y.��,,yri
eno / �f f _..__—_ IdrRrerdu,innbCerr.nrl•)
1. I,mittoldloogiludesoulcc:Llrtl'SOfupo)paphicnlap
Addicss Ciir j', ul G�ff___�013rryL !_ ..-- (chrck N")
(shrrl nr p,,lie Ili.)
—r--Z 7'N Ii�L'Uj IllRIl.1.I1JU_I,QI er _ -- --- --
— I'nnn I'o fmulalion Ucttnplivu
lo„„ still, 7.ip Cade
A�rn r�dr FLmm moiler �r -- -
d. DA lti DR l
5
6. Dtil:S 1\'1?LI, 111:11LAILT I?SISIIN(i WI'I.I:) Y7P.S L-1 NO _--
7. S FA I IC 1VA I Fit.L6Vl?L 11clow'fn11 of l'a^.iugi(.z0- __ _-f 1. — Cd
(. ((I+,"✓'lr n6nar-I'll,ull•n'Inpl
S. "ft l' OI' ('AlNJI; IS L. 11'. Above I.nnd Sutlhce* . . $
•l rp cl rnlnR In uJnnl ill nlhrt In L,n I,nd•,n ter,ngvl,rl• -<
,ellnice In �ccm t4nce nhh 15A NCAC IC.II11R.
pllillI0D0I• •IIiSf A(� --
II). \\'A1 ER 7.OIJES (drplh): Ln -- ---
- - 7 _�_ Shaw dileclion and distance in miles fionl III 1"t
11. DISIIJfI(C fION:lype�J(r7` Anunnd__Yu two Stale Roads or County Koatts. INclutle Ill, and
12. CASING: Wnll'lhi,kmrss
tJrl,lll Dinulctcr or Wcit;1101. /'tYGlI cumbers and common road names.
floor o —'1 5�0 _ rL 6- - m � _
Yo
fort❑ fo ._Lt—. -- ---- - ----- _ �
Il. ORUU 1'; 14p11, Intrml lethod
floor O fo�— Iu
n
r•fe
H. SCREEN: 11rPlll Dinmcter SI01 Si7c hlntrlinl
15. rANII/URAVFLI'AUK: � I
Drpll, Sirr M1Lticlinl - _
16. Itlihlnitl:S: -----
I n0IIfRI'Ill'CPRrll'1'1IIA'f'1I11S will WAS('0I1SIRIA-11i1) Ill ACCORDANCE WITII 15A IiCAC 2C,V il.l.
CONS I IIUCI ION S I ANDARDS,AND l IIAi'A COPY Of'l III S RECORD IIAS IILEIJ PROVIDED TO 7IILI SVELL OV,111R
,S' O`- e)5
;rIAI OtIItI. !( -
-- — SlGOPI'IIIiSON CONS IItUC'I1NO'f Ill!WELL UA7L.
SulnniI Ihr 11111111111 Im Ilie Div ido11 of Wn(pr 0oalit),(:I olulthrnter sirdlun, 1636 mull Service Crnl(r-rinlrll;hl PC
-.. .... I ,_ ,r, .,...,. (AV-1 1lI:V. U7 M)l

WELL CONSTRUCTION RECORD 11 8
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION it 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential EI Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest own: County ❑Ridge ❑Slope ❑Valley ❑Flat
M�Q �jp (check appropriate box)
(Streets ame,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1 (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(S for Route No) (check box)
DEPTH DRILLING LOG
City or Town State ode From i Formation Description
g( )--5�" Clay it Sand
Areaa code-Phone number
Granite
4. DATE DRILLED
5. TOTAL DEPTH: dAD al
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below To of
P Casin B• F m
(Use"+"if Above Top of Casing) �
8. TOP OF CASING IS�-FT.Above Land Surface* i
-Top of casing terminated actor below land surface requires a -
variance in accordance with 15A NCAC 2C.0118. C
9. YIELD(gpm):J MEpTHyOD OF TES�Tj BLOW ,=
10.WATER ZONES(depth): L-/ �` ) / a `n �;
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least = _
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth ,/ Deter or W i ht/Ft. MSS r numbers and common road names.
From To Ft.
From it To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped - —'
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 STANDA ,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,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 311829
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION N 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE if [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 17 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: /I _ // __`` Topographic/Land setting
Nearest Town: County ,/I,/(iUO3'L� ❑Ridge ❑Slope ❑Valley ❑Flat
Ronk, ~— (check appropriate box)
(Street Name,Numbers,Community,{Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �/ Di.✓ /// [(�,(�� (degrees/minutes/seconds)
Address F�0—&Y o Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or Town Sate, Zip Code From , T I Formation Description
B( 28 )_ •o _ Clay&Sand
Area code-Phone number ,a n Q r Granite
4. DATE DRILLED r�
5. TOTAL DEPTH: Ago r "u
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �Q
� ` ci
7. STATIC WATER LEVEL Below Top of Casing: T.
(Use"+"if Above Top of acing) 3
8. TOP OF CASING IS _FT.Above Land Surface• „y
*Top of casing terminated attor below land surface requires a fV .9
variance in accorden c dh 15A NCAC 2C.0118.
9. YIELD(gpm):_ __METHOD O TEST BLOW --
10. WATER ZONES(depth):A161 1 3 IO I O �
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 enal numbers and common road names.
From O To rrii Ft.
mFro o=Ft. In,• - ;
From To Ft.
13. GROUT: Depth Material Method -
From 0 To 20 Ft.Benonite&Cement pumped
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 FL -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-U
/ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

310789
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) -:f:- 4 J e % CERTIFICATION# A43:c
WF,LL CONTRACTOR COMPANY NAME a' 5Gs\4P a S 'Q� i�D PHONE # (SLE) (oC+S-Zo rZ
STATE WELL CONSTRUCTION PERMIT# U _ ASSOCIATED WQ PERMIT#
(ifa licable) (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: Topo�grj hic/Land setting
Nearest Town: County �QC.k.'SOvs ❑Ridge 11dSlope ❑Valley ❑Flat
5 eiz*yr W QOO,L�. (check appropriate box)
(Street Name,Numbers,Community.Subdivision,Lot No.,Zip Code) Latitude/longitude of weil location
3. OWNER: (--N`'>\'or1 '� Okf2 )
y (degrees/minutes/seconds
Address 1`1g Sh S Wo.V Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�aS¢ V,atQec4 nc- a$'2to DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
($Z8)- (o'6\- 5 %C\ \ \lo Uvsn �
Area code-Phone number
4. "DATE DRILLED
�� 0 3GS Crra.�c�
5. TOTAL DEPTH: (o S —/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO RY
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 l5A NCAC 2C.0118. t3
9. YIELD(gpm)_ y METHOD OF TEST f-'-
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type .�.y� Amount 20 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 V To %ko Ft. to It 18 S12�
From To Ft.
From To FL t
13. GROUT: Depth Material Method -.
From 0 TO Zu Ft. O'-Qvn Q✓lt ouC r
From To FL
l
14. SCREEN: Depth Diameter Slot Size Material I`_
From To F[. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: - J
Depth Size Material
From To Ft.
From To Ff.
1 I _
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 RECO AS BEEN PROVIDED TO THE WELL OWNER
�10-e }h �(� Ay y -\1-oS
SIGNATURE OF�PERSO NSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 1, 10647
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) if applicableMENEENE
1. WELL USE(Check Applicable Box):Residential 111 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
NearestT wn: CountySUfJ ❑Ridge ❑Slope ❑Valley ❑Flat
Nearest
cr (check appropriate box)
(Street Name,IINu'm��bers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: lA Jwtyg5t D£ 011 FF5 Lja (degreesiminutes/seconds)
Address L16 10 ILxwYr 17L` -AWGLAPA FY24V Latitude/longitude source:❑GPS❑Topographic map
(Streator Route Vim. 54 (check box)
N I�JFFA2£T'/A t G• DEPTH DRILLING LOG
City or town State Zip Code From To Formation Description
g( 28 )_ 52(.4510 0 q"�/��i� clay&sand
Area code-Phone number ' C� granite
4. DATE DRILLED y' 13 'o5
5. TOTAL DEPTH: ism 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO K A
7. STATIC WATER LEVEL Below Top of Casing: (IjL-QFT.
(Use"+"if Above Top of Casing) a.
8. TOP OF CASING IS 2 FT.Above Land Surface'
-Top of casing terminated attor below land surface requires a N.
variance in accordant with ISA NCAC 2C.0118.
9. YIELD(gpm): I cP METHOD OF TEST BLOW '3
10.WATER ZONES(depth): r?CO:l' 'a144 5� (��
f� LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept )meter or Weight/Ft. lMaterial numbers and common road names.
From To Ft� ;�. __L•
Froro m To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite a cement pumped
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
CONST CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PERSON CONSTRUCTING THE WELL MATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

1
WELL CONSTRUCTION RECORD 310646
North Carolina Department of Environment and Natural Resources-Division of Water Quality -
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential El Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO I: Topographic/Land setting
Nei r stTown: S4 I-c County__,. Q( d ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Namel Numbers,Cortonum Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: b (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route o. (check box)
Ts se&MV 4.. AL -3 0 DEPTH DRILLING LOG
City or Town State �p Code From To Formation Description
- 421 m clay it sand
Arearea code- number lei 66, granite
4. DATE DRILLED__
5. TOTAL DEPTH: ������,,,ffffff �y
6. DOES WELL REPLACE EXISTING WELL? YES ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'Y'if Above Top of sing) 6
8. TOP OF CASING IS 2 FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance In accorden with 15A NCAC 2C.0118. T
9. YIELD(gpm):--METHOD OF TEST BLOW
10.WATER ZONES( epth): r3i
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least 1av
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weigph atenal
From 0 To Ft numbers and common road names.
_ . e t r
From _To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite 8 cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
if NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD t 10 6 4 J
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential © Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO 1 Topographic/Land setting
Nearer Town: FI I n^ County $(]a ❑Ridge ❑Slope ❑Valley ❑Flat
�4"F T L.L- Vp (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: I 111AITESIDE C,.l.1 FFS_ LLB_.— (degrees/minutes/seconds)
Address KA,alL eLAn7b LV. Latitude/longitude source:❑GPS❑Topographic map
(� (Street or Route No. (check box)
11 [ ^tiLaQf -�Q 1� 3C�bl� DEPTH DRILLING LOG
City o Townown� to Zip Code From To Formation Description
6 - '/3(, I�55 0 �1� clay itsand
Areaa code-Phone numbee r granite
4. DATE DRILLED • C}•( ' '
5. TOTAL DEPTH: t t� ry
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_5CO FT. m
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*"Top of casing terminated atlor below land surface requires a — r.3,
variance In accordant w th 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW O
10.WATER ZONES(depth): NOW, A73', 3� 1 U�
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth1111 Diameter or Weight/Ft. Material numbers and common road names.
From To I#"
love-
From t To Ft.t. l i" -DEE �
From To Ft. --
13. GROUT: Depth Material Method From 0 To 20 Ft. Benonite&cement pumped
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 STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7 L4 I A.5105
NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD DP u (t 6 4 4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential E) Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT] 1 Topographic/Land setting
rest Town: N/77/ CourtE J ❑Ridge ❑Slope ❑Valley ❑Flat
13.f114AQN fmxYGQ (check appropriate box)
(Street Name,Numbers,Community,Subdnnivi_sion,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: .WA .5 1.A5 Abt (degrees/minutes/seconds)
Address 11 1 ZU A-D Ltr fAF +-�f Latitude/longitude source:❑GPS❑Topographic map
t or Route o,) (check box)
2vt
$e, 293 DEPTH DRILLING LOG
, Code From To t Formation Description
ubar T( 0 0�, gray h sand
Area code-Phone number �� t grande
4. DATE DRILLED
5. TOTAL DEPTH: ( ��y///
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO at (�t
7. STATIC WATER LEVEL Below Top of Casing:1� T. p'
(Use"+"if Above Top of Casing) to
8. TOP OF CASING IS 2 FT.Above Land Surface' 9 K
*Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 50 MET OD OF TEST BLOW
10.WATER ZONES(depth): 1`1 art �}3
LOCATION SKETCH Llrl
11, DISINFECTION: Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To�L Ft. dt>�
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite 8.cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. j
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.-
Frorn7 To Ft. ...
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST3RIU4CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S
S ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD (� " 1 10 6 4 j
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable)
1. WELL USE(Check Applicable Box):Residential O Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
N arest To n: I S County! A) []Ridge []Slope ❑Valley ❑Flat
g
M /.1(1A[- 5lQ A%J (check appropriate box)
(8freck Name,Numbers,Community,Subdivision,Lot No.,Zip Code Latitude/longitude of well location
3. OWNER: r a. ( E CW& (degrees/irnutes/seconds)
Address O _ Latitude/longitude source:❑GPS❑Topographic map
G . (Street or Route No.) (check box)
JFt �C 44314/ DEPTH DRILLING LOG
Cary o�r Town Mate Zip Code From To 1 Formation Description
number 7$ 3� granite
it sand t
Area code-Phone number— ranite
4. DATE DRILLED y � w
5. TOTAL DEPTH: 1 9
04
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: I M T. til to
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated at/or below land surface requires a —d7—
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): e9O METHOD OF TEST BLOW
10.WATER ZONES(depth): 115 rl a1Z�= LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 of Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept hh�'�t Diameter or Weight/Ft. Material numbers and common road names.
From_qZTo Ft.t. o
From To Ft. ! I
13. GROUT: Depth Material Method
From 0 To 20 Ft. eenonite 3 cement pumped
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 STANDARDS,AND TRHAAATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
OWNER
SIGI TURF OF PERSON CONSTRUCTING THE WELL D IE J!0 s
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV,09/2004

WELL CONSTRUCTION REC�OyRD
77
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRAC(OR(INDIV•IDUAL)NAMx (print) Sri Pit,� Je��I�1,.�r1. a. Clcl` FICAro-
WELL CONTRACTORCOMPANY NAM�' PNONE
STATE WELL CONSTRUCTION PSRmrro - SSOC(ATP.D W 9RMM
(irappucable) Illinois
rfappltpble) -
1. WELL USE(Check Applicable Box):Residential'tYMunicipal/Public❑ Industrial O Agricultural 0
Monitoring 0 Recovery 0' Heat Pump Water Injection❑ Other 11 If Other,List Use
2. WELL LOCATION: . Topogfap d setting
Nearest Town: S t� County _, C C S o > ORidge o�81 pe ovallcy .Whit
0 V Sr 7 7 % - (chock appropriate box) . a
(Street Name,Numbers,Community,Subt1hWem Lot No„Up code) Latitude/IOngitude of Well location
3. OWNER: C 1C { , e S (desteer)miaute✓aeconde)
Address L,, 11,4 4 ­4-3. Latitude/longittide source-00PSOTopographic map
(Street or Route No.) �^ - (cited box)
��S l'� A/ � d � � � DEPTH DRILLING LOG
or Towa Statc Zip Code From To - Formation Description
Area code•Phone number -, _ _ '
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO.=
7, STATIC WATER LEVEL Below Top ofCasing AFT: _
(U".+^if Above TopofCaimg)
S. TOP OF CASING IS�_FT.Above Land Surface* "� w
-Top of cuing terminated atior belatf Itndaurfaeerequirex a
varlance In accordance aitht4ANCAC 2C.0110. - W
9. YIELD(gpm): 3 O METHOD OF TEST A IMJ o t'
10.WATER ZONES(depth): �2 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.SD F( j or WeighUPt. Ma_teygl_ 'numbers and common road names.
From To
From To Ft.
From To Ft.
13. GROUT- Depth Materiel Method - -
From
From—�—To-Ft. '
4. SCREEN: Depth Diameter Slot Sim - Material
From To FL in. in.
From To Ft in. in.
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTCD IN ACCORDANCE WITH 15A NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS EEN P$OVIDED TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTTNGTHEWELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Servlee Center-Raleigh,NC
a*7699-1636 Phone No.[phone],within 30 days. _ GW-1 REV.07/2001

3 '11995
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV.IDUAL)'NAMB on �P►1 I .+�� - te
(prima < V115 ' � n C�TwicATioN1 �• r
WELL CONTRACTOR COMPANY NAM `pbONg 0 -'3 �b 0
STATE WELL CONSTRUCTION PBRMITi - ASSOCfATED W ERMM
(if applicable) ' :fifeppBeable) -
I. WELL USE(Check Applicable Box):Residential' unicipatIPublic❑ Industrial C3 Agricultural
Monitoring Cl Recovery ❑- Heat Pump Water Injection❑ Other C7 If Other,List Use
2.-WELL LOCATION: . Topoggrip&land setting Nearest Town: S L/ / V 0- County C1e olkidge 1251ope []Valley .Oflat
j,� 1 / e Z e-eC_ C 12• c�&77 q (monk aWniniata box) a
(SIM[Name;N mben,Communiit,Subdivision,Lot No„TaP CMde) UtitudcAoripude of well location
/
3. OWNER:. '`0y\' / 1 IQ�i P S ' . - (depeer)miuum/aeconda)
Address ._1QQ (ktT 2' ItyJ (1h 25 Latitude/longittidesource:00PSCITopographic map
(Street ar Route No.) - (clwebbox) .
J 2Aj 9 5 DEPTH ' DRILLING LOG
e ywTown state Zip Code From To Formation Description
4. DATE DRILLED S—/ 3 -aS Q-
_ V
5. TOTAL DEPTH: 5_
6. DOES WELL REPLACE EXISTING WELL? YES EI NO
7. STATIC WATER LEVEL Below Top of Casing:
(Umc-1-if Above Top of Caaiag) .
S. TOP OF CASING IS �_FT.Above Land Surface•
N
-Top or casing laminated atbr betasr Iwdaarhce ngnkes a
variance in accordance wtth75ANCAC 2C.0118. •�
9. YIELD(gpm): ` METHOD OF TEST_� L
10.WATER ZONES(depth). .�.5
• ` LOCATION SKETCH
IL DISINFECTION:,Type Amount Show direction and distance In miles from at leas)
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth� pteter or Wa�hht/Ft -Matey'pl number and common road names,
Fromty'?_" ) YLZ4�
From To Ft.
From Tq FL__
13. GROUT: Depth Material Method
From To 4M
_F I_"—_
From To Ft.
A. SCREEN: Depth Diameter . Slot Size Material
From To FL in. in.
From To FL in. in.
5. SAND/GRAVEL PACK:
Depth Size Material
From Tc FL
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT13D IN ACCORDANCE WITH 15A NCAC 2C,WELL c-
'ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P$OVIDED TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE -
-Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
.0'7699-1636 Phone No.[phone],within 30 days, GW-I REV.07/2001

WELL CONSTRUCTION RECORD 31 ? I
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Redden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIO + Topographic/Land setting
Nearest To County ORidge ❑Slope OValley OFlat
(check appropriate box)
(Street Name,N bero,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address 0 Po Latitude/longitude source:OGPSOTopographic map
(Sire t or Route No. (check box)
3 DEPTH DRILLING LOG
City or To S tte Zip Code From ' Formation Description
(-70%)- ,577-Al03 t clay&sand
Area code-Phone numberD�(cl 1 ( s granite
4. DATE DRILLED
5. TOTAL DEPTH: �
6. DOES WELL REPLACE EXISTING WELL? YES O NO '
7. STATIC WATER LEVEL Below Top of Casing:_ FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface' C 3
-Tap of casing terminated st/or below land surface requires a .y
variance in accordan,4with 15A NCAC 2C.0118.
9. YIELD(gpm): LP METHOD OF TEST BLOW N
10. WATER ZONES(depth): y
LOCATION SKETCH cn
11. DISINFECTION:Type H T H Amount 16oz 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 t/Ft. Material numbers and common road names.
From 0 To—,2 Ft._�n„ S� -
From To Ft. -- -
From To Ft.
13. GROUT: Depth Material Method
1 7-
From­0 To 20 Ft, benonite 8 cement pumped I --
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material i- ,-
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
i
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNVURE 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

�J1 ? ? t I
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential® Municipal/Public O Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION• Topographic/Land setting
Nil s Town: 0 ounty ❑Ridge ❑Slope OValley []Flat
2Y
(check appropriate box)
(Street Name,Nmbers,Community,Subd' ision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address Latitude/longitude source:OGPS OTopographic map
��(Street o ute No.) (check box)
� �R��y DEPTH DRILLING LOG
'��tt��-,a,,, or own Sta zip Code Fri Formation Description
ma ode/ Ten- m� clay&sand
Area code-Phorte number � granite
4. DATEDRILLED SZy-a5
5. TOTALDEPTH:�
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing:OF .
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface'
-Top of casing terminated attor below land surface requires a
variance in accordance with ISA NCAC 2C.01IS. C_
9. YIELD(gpm): HOD F TEST BLOW
a
10. WATER ZONES(depth):
— LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include thecRad
Depth Diameter or Weight/Ft. trial numbers and common road names.
From To �� Ft.
From 3 ,3 To. 3f Ft._1�' ,/J�
From To Ft. -
13. GROUT: Depth Material Method _ I
From 0 To 20 Ft. benonite&cement pumped
From To Ft. I -
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 ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division o ater 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 12 2 (p
North Carolina Department of Environ
me
nt
and Natural Resources-Division of Water Quality ..�-r�--77
WELL CONTRACTOR(INDWIDUAL)NAME (Print) 1 "�` `\ ")'�- \ CERTIFICATION a of J !�
WELL CONTRACTORCOMPANYNAME�keCl V-�p of )--\Ac--�0 'PER # -b qD
STATE Wn.L CONSTRUCTION PER " ASSOCIATED WQ ble) N
M
(if applicable) (if applicable) 00100000010
1. WELL USE(Check Applicable Box):ResideentiaA Municipal/Public❑ Industrial O Agricultural❑
Monitoring❑ Recovery O Heat Pump Water" Iojebtion❑ Other O If Other,List Use
2. WELL LOCATION: To
setting
Nearest Town; `l`i�J o� County— r.ALkC ,-D-1 OBiZ5 TSTope OValley OFW
(cb It appropriate box)
(strew Name:Numbers,C nt V,sut—vTvoa Lot Nd.Zip Code) Latitudeflongitude of well location o
3. OWNER: ( aecmaa)
Address h nX 19�3 I.atitttddloogit�e SOTopographic map
(Street or Route No.) )
S SC, Q DEPTH DRILLING LOG
From rnC
Ares To� Fomtation.Description
erode-Ph'o�seRlmwber �(3.01 q i�s { .u. vr ✓ lC 'aim
4. DATE DRILLED `J-c27 'b3` /yam- SDa n I tC
5. TOTAL DEPTH: SO o"Z
YES O NO�
6. DOES WELL REPLACE MUSTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS Ff•Above Land Surface*
*Tep of eaaug W E"2ted attar eetaw bed swe'ee""Oft a
a i 15A NCAC 2C AII L
9. D(fgpm _ MITHODOFT EST % pw
'
10.WATER ZONES(depth): 'Huo LOCATION SKETCH
I1. DISINFECTION:Type i:, Amount Show direction and distance m miles fig at least
12. CASING: Watt Thiclmess two State Roads or County Roads.Include the road
Depth `Diarncctteer or WeighVFt. Material aranbc and common road names.From
From To Ft.
From To Ft
13. GROUT: De! _ Mat Method
From 0 To a Ft. ti
t_ �
From To Ft. z
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. _ in. (V
From To Ft. in. _ in- `y.
IS. SAND/GRAVEL PACK: U1 t'
U1
Depth size Material F2
From To Ft.
From To Ft. ` c
16. REMARKS: j��SV11�lhTIiY+.[(�iP�_( , a - r ��PC� I/ P �� t/vhfAP� LC✓)CP�t r 'IP s
ef V! $1 Oft . _.
I DO BEREBY CERTIFY T THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH ESA WELL
CONSTRUCTION STANDARDS,AND T A COPY OFTHIS RD HAS BEEN PROVIDED TOO THE W EIrL OWNER'
SIGNA'f (tE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Pheae No.(919)733-7o15,within 30 days. GW-I REV-09(24D04 -

WELL CONSTRUCTION RECORD 10 P, 1 8
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell$ TaVlor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# -
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential O Municipal/Public ❑ Industrial❑ Agricultural❑ - -
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other Q If Other,List Use
N _
2. WELL LOCAT N: Topographic/Land setting [ Ln
Nea�re tTIown: 1 County Jf�a ❑Ridge ❑Slope ❑Valley ❑Flat
1. E -rQ<E (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location ,
3. OWNER: 01 >Q t1� c�TONltr (degrees/minutes/seconds)
Address O Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�, e,vvI3(o DEPTH DRILLING LOG
City or Town rate Zip code From To � Formation Description
828 - ?one• O clay it sand
Area code-Phone number ' • granite
4. DATE DRILLED k4 •8 05
5. TOTAL DEPTH:'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 2,00 _FT.
(Use'Y'if Above Tap of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated et/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): G _METHOD OF TEST BLOW
10.WATER ZONES(depth): aZ sO t LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
two State Roads or County Roads.Include the road
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material numbers and common road names. -+
From c To 4 1 Ft. GO f k —13
a
From-4�—LI -To Ft. fin,• --319GL s7 _
From To Ft.
13, GROUT: Depth Material Method yy
From 0 To 20 Ft. Benonite a cement pumped r
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. _ in.
15. SAND/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
CONST4UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
^` IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 308530
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO d Topographic/Land setting
Neare own: County Ji DRidge ❑Slope (]Valley OFlat
/ — (check appropriate box)
(Street Name,Numbers,Comm ity,Subdivis n,Lot No., ip Code) D Latitude/longitude of well location
3. OWNER: eG (degrees/minutes/seconds)
Address f-b Latitude/longitude source:❑GPSOTopographic map
(Street or Route No. (check box)
dfdf CC 7 DEPTH DRILLING LOG
City or Town State q _ zip Code From To t Formation Description
6( 26 )- e50 7- 3(-(NZ l(i7U71f Tf 0 7 clay&sand
Area code-Phone number granite
4. DATE DRILLED AA'05
5. TOTAL DEPTH: 15
A
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: A00 FT.
(Use"+"if Above Top of Casing) {
8. TOP OF CASING IS 2 FT.Above Land Surface' a.
*Top of casing terminated at/or below land surface requires e
variance in accordance with 15A NCAC 2C.0118. 3
9. YIELD(gpm): —�O METHOD OF TEST BLOW
10.WATER ZONES(depth): (A) lt `4wp— -2J�t
LOCATION SKETCH �t
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Vale ial numbers and common road names.
From 0 To I eA Ft. to (''
From�To Ft. (e•• � J
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped
From To Ft._
14. SCREEN: Depth Diameter Slot Size Material i t.is -
From To Ft. in. in. '� �l 17 fir,
From To FL in. in.
15, SAND/GRAVEL PACK:
Depth Size Material
From To FL MAR 21 2005
From To Ft.
16. REMARKS: •.� '.''
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PER N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

y�
WELL CONSTRUCTION RECORD 3 0 8 5 2 9
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest T wn: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,L t No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
mee"t or Route No.) �q (check box)
IV O ag / DEPTH DRILLING LOG
Citior ToA Stay Zip Code From To Formation Description
8( 29 )-'4a G • 141% 0 13g_�._ clay&sand
Area code-Phone number ��jg Z�O� granite
4. DATE DRILLED •d
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:;5o FT. :9
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS 2 FT.Above Land Surface* _
"Top of casing terminated at/or below land surface requires a y
variance in accordaneg with 15A NCAC 2C.0118.
9. YIELD(gpm): METH.QD 9F TEST BLOW r�
10.WATER ZONES(depth): p
LOCATION SKETCH D
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from acnast
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. ten I numbers and common road names. F3
From 0 To /Ft. t' ,S
From=Toj eel'
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped
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 From To Ft. MAR 21 2005
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL'1
CONSTRUCTION STANDARDS, HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

\t� rJ
WELL CONSTRUCTION RECORD u U 3
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Dle :¢K '!l sb, 'Syq�eT; CERTIFICATION# I�Ml.
\YELL CONTRACTOR COMPANY NA ME tN!OG S6.J\.e-La A geh Uo-\\A.h ..,la p PHONE # JLZ 4,S-20gZ
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if a 'cable) - (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ -Heat Pump Water Injection❑ Other❑ If Other,List Use - -
2. WELL LOCATI N: Topographic/Land 1c/Land setting
NearestTovm: � Vrs County Sr.c(.�fbh ❑Ridge IRSlope ❑Valley ❑Flat
aa4 1,'V- \dQ ->• 6sm .n —Pcx \ (check appropriate box) - r =-
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Ma�f S
P (degrees/minutes/seconds)
Address _225 M .n+w, ^ Ill Latitude/longitude source:❑GPS❑Topographic map
-- -(Street or Route No.) (check box)
Jam*\ 'lam a4?7 l9 DEPTH
DRILLING LOG
�cnyorTown State Zip Code From To Formation Description
a&&a *k y9 pYe� Pa,ede
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �.
6. DOES WELL REPLACE EXISTING WELL? YE NO.
7. STATIC WATER LEVEL Below Top of Casing: L� 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 accordanya with 15A NCAC 2C.0118. -
9. YIELD(gpm): 1 METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type c;\\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. Y"
From \ To " _Ft. 6 v �-I;2\
From To Ft.
From To FL y
13. GROUT: Depth Material Method C1'
ern
From O To 20 Ft. -:t m
From To Ft. bra.
14. SCREEN: Depth Diameter Slot Size Material t -urn
From To Ft. in. in. p�
From To ft in, in. uv v
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. �{ Y /q W N:<
From To Ft. a 4.� m�
n
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL _
CONSTRUCTION STANDARDS,AND THAT OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
l a/s
SIGNATURE OF 'ARSON CONSTRU-MNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.(919)733-322I,within 30 days. GW-I REV.07/2001

`�vv4 308219
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor _ CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATM"161�
Topographic/Land setting
Neare�[Town: County ORidge ❑Slope Walley OFlat
l (check appropriate box)
(Strcet Name,Numbers,Community,Subdivision,Lot No.,Zip ode) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPSOTopographic map
(Stye or ute No. J (check box)
5 DEPTH DRILLING LOG
City or Town state zip Code From r Formation Description
g( 28 )- Jam' it- 0 clay&sand
Area code-Phone numbers �,. r granite
4. DATE DRILLED
5. TOTAL DEPTH: �
6. DOES WELL REPLACE EXISTING WELL? YES 0 t30
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated st/or below land surface requires a
variance in accordant W h 15A NCAC 2C.0118.
9. YIELD(gpm):_ METHOD OF TE BLOW��.y
10.WATER ZONES(depth): p( IQ
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth �c
Diameter or Weight/Ft. Ivl,�erial numbers and common road names.
From 0 TomFt. �p•r
From_ To__Xn Ft.
From To Ft._
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped = W_
From To Ft. 3r '�
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. t -
From To Ft. in. in. CJ
15. SAND/GRAVEL PACK: -
Depth Size Material
From To Ft. rJ
From TO Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A.NCAC 20,WELL
CONSTR TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a•ly•o5
SIGN 0
URE OFrMSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

� (i821 $
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO �0� Topographic/Land setting
Nea st Town: County /�1_1 DRidge ❑Slope ❑Valley DFlat
V.� yr 1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location
3. OWNER: - (degrees/minutes/seconds)
Addr 3&i ,Q e Latitude/longitude source:DGPSOTopographic map
$ et o Route IVn,� � 3 (check
e A F DEPTH DRILLING LOG
y�ciry or TB`�n s e� A��.L,zip�Clodle� From To f Formation Description
0 _ _`W_.. clay it sand
Area code-Phone number �-/-rQ��_��It—'_ granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES D NO
7. STATIC WATER LEVEL Below Top of Casing: .100 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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): JO METHOD OF TE T BLOW
10.WATER ZONES(depth): �0 5 LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth,./p gtnigeter or Weight/Ft. Ma numbers and common road names.
From 0 To /p Ft.
From 'JR7To FL 0•, •M8
From To Ft. =C W
13. GROUT: Depth Material Method - ;;a
From 0 To 20 Ft. Benonite&cement pumped 1
From To Ft C,7
14. SCREEN: Depth Diameter Slot Size Material CD
From To Ft. in. in. U
From To Ft. in. in.
15. SAND/GRAVEL PACK:
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
CONSTR TION STANDARDS,AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J C7_ y A • 14 os
SIGNATr OF PER-90N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I V!-T I-USE(Check Applicable Box):Residential Q Municipal/Public ❑ Industrial❑ Agricultural ❑
\,i nitorir.g❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION dgeTopographic/LandDOV setting
Nearest_Town: County ❑Ridge ❑Slope Walley Flat
*� (check appropriate box)
(Street Name,No eis,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: r (degrees/minutes/seconds)
Address Latitude/longitude source:OGPSOTopographic map
�{{��//�//,�� //11J (Street or Route No.) �J �/ (check box)
'L.t,11114L�2r NO- —ag /Q/ DEPTH DRILLING LOG
City or Town State Zip Code From jr9 1 Formation Description
8( 2B )- Lle njum -,`)*�j�� clay itsand
Area code-Phone number granite
4. DATE DRILLS g
5. TOTAL DEPTH::
6. DOES WELL REPLACE EXISTING WELL? YES O j�0 Jp p
7. STATIC WATER LEVEL Below Top of Casing: FT. „
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT,Above Land Surface*
-Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118, C.L
9. YIELD(gpm): .� M�E�TqHOD OE TEST BLOW
10.WATER ZONES(depth):
- - LOCATION SKETCH
11. DISINFECTION:Type H T H Amount ` 15 oz Shot;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. JI2 r lW
From To Ft.
From To Ft. - ptii,
13. GROUT: Depth Material Method r .,
From 0 To 20 Ft. Benonite g cement pumped
D
From To Ft. - -
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in.
From To Ft. in. in. _
15, SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG RE 0 ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES ((prrnt)G/f'i7/7 5P/9,Ael — CERTIFICATION#
WELL CONTRACTOR COMPANY NAME/ / .vI'/','/� Lyf��)L—�'[��rn n PHONE # fV14
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 LOCAT/IO+N: 1j Topographic/Land setting
NearestTownY.L2e .'e"�y County a r"i - ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: j,1 f`h Y e,&1y; h—r
(degrees/minutes/seconds)
Address �'B/'�� . G, Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
411�E= DEPTH DRILLING LOG
y�City or Town State Zip Code From To Formation Description
(�=--�1-
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: <j l
6. DOES WELL REPLACE EXISTING WELL? YES a- O ❑
7. STATIC WATER LEVEL Below Top of Casing: Q T.
(Use"+"if Above Top of Casing) 0
8. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): O METHOD OF TEST0,ir.-
10.WATER ZONES(depth): d
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 _ToZ—Ft. .:7-6, 1 11� 6r' /� /f/
From To Ft. 6 Ta e-vin /7 j�{� Pi
From To Ft. Ld y
13. GROUT: Depth� ,.� Material Method
From 0 To I-C✓ _FrJJ 2e.1-1 791/1 i1
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:
r
"i u.'bi
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C,WELI;
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-Raleigfi,:NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV!
Q `001

WELL CONSTRUCTION RECORD 312,
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential® Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L own: J / 4W&Qa?U Nea Town: otyTopographic/Land setting
❑Ridge ❑Slope l]Valley l7Flat
(Street Name,Numb ,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER:
Address p (degrees/minutes/seconds)
Latitude/longitude source:DGPSOTopographic map
/ ( t or Route No - (check box)
l�City
DEPTH DRILLING LOG
clry or wn s e Zip code Fro T Formation Description
( = - r P
Area code-Phone number clay&sand
�n( r
4. DATE DRILLED 'V T _granite
5. TOTAL DEPTH: air T 6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: F
(Use"+'if Above Top of Casing) .wn
8. TOP OF CASING IS 2 FT.Above Land Surface* r=
-Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_f Q MEN OFF ST BLOW
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads. Include the road
/� Depth amFter or Weight/Ft. aterial numbers and common road names.
From 5�_ To_ a Ft. t r
From-as�Sf--i�To 0, Ft.�_ ,iR S '
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft, benonite&cement pumped
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 ISA NCAC 2C,WELL
CONS CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
TRUCTG HE WELL DASI URE ERSON CONS o OS
Submit the original to the Division of Water Quality,Groundwater Section,163611f;1ite�vyce l7enter Ralergti`NC 27699-1636 Phone No.[phone],within 30 days. '
Il 'f r
i

DO J
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Russell S.Taylor
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc CERTIFICATION#2187
STATE WELL CONSTRUCTION PERMIT# PHONE # [phone]
(if applicable) ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box):Residential® Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 0 If Other,List Use
2. WELL LOCATIO
N est Town: ty / Topographic/Land setting
� C []Ridge ❑Slope ❑Valley OFlat
rfl'�--`Code) (check
St et Name,Numbe ommumty,Subdtvrn No,Zip Code) appropriate box)
3. OWNER:
Latitude/longitude of well location
f
Address (degrees/minutcsiseconds)
(Street or Route No.)
Latitude/longitude source:DGPSOTopographic map
(check box)
DEPTH DRILLINGLOa
ty°J I M'"�=6 m r1 Zip code From
(g _[�- / Formation Description
Area code-Phone number clay&sand
4. DATE DRILLED granite
TH:
5. TOTAL DEP �_ cl
6. DOES WELL REPLACE EXISTING WELL? YX >
7. STATIC WATER LEVEL Below Top of Casing: T,
8. TOP OF CASING IS 2 (Use +'•if Above To
c
FT.Above Land Surface" -- Z :{
*Top of casing terming d atlor below land surface requires a
variance in accords with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW
10.WATER ZONES epth):
11. DISINFECTION:T e H T H LOCATION SKETCH
YP Amount 16oz Show direction and distance in miles from at least -
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
To R
From O Depth Di eter or WeighUFt.
Fro trial numbers and common road names.
Ft.
m To Ft..
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft, benonite&cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From Tc Ft. in. in.
From To Ft. in.
15. SANG RAVEL PACK: — in..
D/
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
CONST UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG TURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Divtsion of Water Quality,Groundwater Sectipfi; cementer- I
27699-1636 Phone No.[phone],within 30 days. ) � Qil NC

22 �7
WELL CONSTRUCTION RECORD
North Carolina-Depacmueot of Environment and Natural Rem n of Water Quality-Groundwater Section
WELL CONTRACTOR(Pm.VIDDALI NAME 1�Z K. (,� CW718ICATION 4 E 3
WRu CONTRACTORCOMANYNANZ , r� ll PHONE R 93-90?0?3
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ
Mitsui d tieable 7 If le
1. WELL USE(Check Applicable Box):Residential MunicipallPublic D Industrial O Agricultural 0
Monitoring O Recovery O Heat Pump waters Ir j-ectim 0 ,rOther 0 If Other,list Uae
2. WELL Near TLOCAT d�
U1�GK�SiII WOgrap Dg
Vol 5 , �o®ty ( � []Flat
(suwtNoM Naomi.Cam.Satd�.I d ea,L—Na.Zip Ceeb) ladmdd onginide ofwe➢bin
3. OWNER:�(L" J1Qq(� I, (dereabdus ahemadr)
Address e Latituddlongit de sotmov.MPSOTopographic map
BZRQDn.�°°"7F MIL 33 51� DEPTH ``ten ILI M(.10
CayarTum sure Tip Code From To Fomtation ob'on
L�
Am code-Pheae umber � �C
4. DATE DRILLED_ z n
5. TOTAL DEPTH• / ,
6. DOES WELL REPLACE EXISTING WE� a
7. STATIC WATER LEVEL BelowTop of
(Usa NM ifAbm Top of Casio
8. TOP OF CASING IS FT.Above Land Surface-
'Top of adaa qmbeated aNw below Ind sarfew requhu a
vmtime to ample Wide LSANCAC 2C AUL
9. YIELD(gpm): METHODQF TES'! -'
10.WATER ZONES(depth): ( 3CX�
LOCATION SKETCH
11. DISINFECTION:Type Am000t Show direction and distance in miles from at least
12. CASING: Wall Thidmess two State Roads or County Roads.Include the road
Depth Diameter or WejgbzTL Material tarmbars and common road names.
Frorom—ToFt— —
Fromm To FtMA� �
13. GROUT: Depth Material mod
From To Ft(:� MC-
�
From To P t
14. SCREEN: Depth Diameter Slot Size Material
From. To Ft_in in.
From To Ft_m. in.
15. SAND/GRAVEL PACK
Depth Size Material
Front—To—FL—
Fronk—To—Ft
16. RAMAM:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL-
CONSTRUCTION
ST AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED OWNER
7Z-y- ,&S -
SIGNATURE OF PERSON CONSTRUC1WG THE WELL IDATE
SobZttheriginal to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phase No.[phone],within 30 days GW-1 REV.O7l2001

0� n 2 5
WELL CONSTRUCTION RECORD
Noah Carolina-Department of Fnviromnat and Natural -Division of Water Quality-Gmmdwa�Section
LL WECON[RACfOR(ROMMOAL) (ate i � 1 s CEQ17BtcATtONa Cs0
WELLCONTEACToa ANrNAhm A- R IR F'I! ti! mon s Ca$ilo$,3-7223
STATE WELL CONSTRUCTION PR M M 'tiro WQ
(If Obligible)
1. WELL USE(Check Applicable Bm*Residaai d MaicipsUPoblic D Dial D ApienllomI D
Mooitariag D Recovety D Hat Pare Water h jedicn D Othta D IP011sm Lint uae
2. WELL LOCATI N / � dge il�' /yam
Neatest Town r 11 c�ty6 `JO1 Dp; D\(aIlx) OFlat
A i L TR . I X (asac.pprapa.asaa)
N=0611 mI Caentimlg S"dda%�IMNu.Zjp0xU) - LatlUlddl00 adE of Well bCifiOn
3. OWNER 6�AGV X7 �rf'o; E6, (aapeakdase heooeds)
Address ! ( 77 EI L_t7A � 9 Latim&Aougiwde somce:DGPSOTopograpldc map
sLILV'A- �)CEamsNa) n b��� DEM (eit* T ab
C7tyorTown SFre 2iPCbde From To Formation Dacripdbn
Ataaoads Phoaea®bw �
4. DATE DRIIS ED Z-O`J tv
5. TOTAL
6. DOES WELL REPLACE EXISTING WELL? YEAP NO o
7. STATIC WATER LEVEL Below Top of Casow =g
=-+-ifAbmeTapcf0udW
S. TOP OF CASING IS 1 (t FT.Above Land Surface'
`Top oteWna tneWaed sow aalsw land sofim rpSafkas a
MUM Y GU � I 10.WATERZONES(deA): o
11. DISINFECTION:Ty"—T Amount Show won and dWaoe in miles 5can at least
12. CASING: Wan Thirtom two Stab Roads or County Roads.Ioclode rho road
DV Diamea r or wa&n Mound ambers and common road names.
From- To tL Ft
From=To Ft _
From_,_To Ft _�-
13. GROUT:
trt__To�Fro FI�Cz�`
FrouL_To Ft
14. SCREEN: Dept Diameaa Slat Sian wmedd
From To Ft---jn. in.
From To Ft_Jn. in.
15. SANDVGRAVEL PACTC
Depth Sim Material
From—To Ft
From Tc Ft
16. REMARKS:
I DO HEREBY CERTIFY THA THIS WELL WAS CONSIRUCITD IN ACCORDANCE WITH 15ANCAC 2C,WELL
7�;=
ACOPY OFTHIS RECORD HAS BEEN PROVIDED TOTHE WBCLOWNER
- 0�s
SKINATUREOaF PERSON OCINSTRUCTING TEE WBI7. DATE
Submit the original to the Division of Water Qualty,Groundwater Swdoa,1636 Man SellaCarer-Raldth,NC
2709-1636 Muse No.(919)73"221,within 30 days. GW-I REV.072001

WELL CONSTRUCTION RECORD :
North Carolina-Department of Env)ronrn6nt and Natural Resources-Division of Watw Quality-Groundwater Section
WELL CONTRACTOR(INDIY,[DUAL)TIAMB (prig[) s. ��/-
li p7 t S / J 12.±�e� - CL1a;TtFInnC�AT[,O//H►�Y'
WELL CONTRACTOR COMPANY NAM - PNONIfEA-h}--���-3 a-6
STATE WELL CONSTRUCTION P8RMITtr ASSOC(ATPA W(4RRMM
(if applicable) E17110plicable)
1. WELL USE(Check Applicable Box):Residentfal• unicipai/Public❑ Industrial C3 Agricultural CI
Monitoring❑ Recovery ❑' Heat Pump Water injection❑ Other Cf If Other,List Use
2.'WELL LOCATION: . }oBogtaphielLand setting
rest Town: ( County Ll is>ti� dge ❑Slope Malloy ❑Flat
n 2 Cue J O G.r> J h-e,e i"'t• " t)1,3 (chock appropriate bolt)
(Street Name.Number,Community,Subd(visian,to No„4 Code) Latitude/Ioagituds of well location
3. OWNER, Pa U SO tf. r (dagrcer/miautcebecmrds)
Address ` -0• H x '7/ V Latitude/longittide source:❑GPS❑Topographic map
(Street or
Route NoJ - - (check bolt)
ct 1((ht16t e e /1/G k fa 3 D.EM - DRILLING LOG
City«Town- sort zi code From To Formation Description
u 3 p D P 7 Q —
Area code Phone aumbar '` - , * - �" _ •4 A-
4. DATE DRILLED ^ ='� - / S ' (� lU� LL-V�ct, . t A-
5. TOTAL DEPTH: rY6,5 '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 0- ' FT:
(Use"f"tfAbove Top ol'Cuiag) - t_
8. TOP OF CASING IS FT.Above Land Surface* 2 n
Top of cuing termlosted atlor below lonasurlue requires a
variance in accordance u4thT4A71CAC IC.0118. co -'
9. YIELD(gpro):�_METHOD OF TEST
10.WATER ZONES(depth): 3/ S Ln
LOCATION SKETCH 71
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 DII�=t-er .or weim ` numbers and common road names.
From--L. To "1 Ft. o Sb,ff,9 ,.
From To Ft.
From Tp_FL_�
13. GROUT: Depth Materiia Method
From To­c'2V—Ft.
From To Ft
.4. SCREEN: Depth Diameter Slot Size : Material
From To Ft. in. in. —
From To Ft. in. in.
5. SAND/GRAVEL PACK _
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE Wrm I5A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT
C0� S RECORD H&S BEEN PROVIDED TO THE WELL OWNER
C1 ab-0s
SIGNATURE-OFPERSONCONSTRUCTING THE WELL _ DATE
-r'ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC -
,0'7699-1636 Phone No.[phone],within 30 days. GW-t REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # (E28)369-9591
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 LOCATI I �, ,,—• Topographic/Land setting
Near%twT.own� County�C�K�fIOr-� ❑Ridge ❑Slope ❑Valley ❑Flat
dJW (check appropriate box)
(Street Name,liumbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: I &A44) (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
,� _ Street or Royte o.) Q (check box)
/�('� O DEPTH DRILLING LOG
`airy of��` 'q Zip Code From To Formation Description
8(3�- "f'') /� Clay&Sand
Area code-Phone number h , Q� Granite
1
4. DATE DRILLED - /A -6
5. TOTAL DEPTH: 3(p0 r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_,2_1_M_FT.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS aZ 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): 120 METHOD OF TEST QLOW
10. WATER ZONES(depth): a4fsrf Z&of.- LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth DI
eter or Wei ht/Ft. Material numbers and common road names.
From To—aB �� tf _
From if To Ft.
From To Ft.
13. GROUT: Depth Material Method C W
From 0 To 20 Ft.Benonite&Cement pumped Z
From To Ft. N
W
14. SCREEN: Depth Diameter Slot Size Material s
From To Ft. in. in. 0
From To Ft. in. in.
ut J
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 STAN RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -- - - -
SIGNAT RE F PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 UV:D9/2004

WELL CONSTRUCTION RECORD 0 ! -I
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION o 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE [phone]
STATE WELL CONSTRUCTION PERMIT14 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 LOCATI N: Topographic/Land setting
Nearest Town, County ❑Ridge []Slope ❑Valley ❑Flat
(check appropriate box)
(Street N4ne,Nu bers,Community,Suadivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: t, (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
�Streero oute o.) 0 (check box)
DEPTH DRILLING LOG
828Ciry orT wn �Stgte Zip Code From To _ , Formation Description
7 � J�(J Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED
5. TOTAL DEPTH: y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J�(
7. STATIC WATER LEVEL Below Top of Casing: ;100 T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at r below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 10 METHOD OF TEST BLOW
10. WATER ZONES(depth),3. g-, s3s: is r LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least -
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
Depth Ft Diameter or, Weight/Ft. aterial numbers and common road names.
From To
From R To Ft. treC
From To Ft. Z „t
13. GROUT: Depth Material Method fV
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. p
14. SCREEN: Depth Diameter Slot Size Material Ul ..�
From To Ft. in. in.
m Fro 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 ST RDS,AND THAA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
iRS?-t�SON CONS
SIGNA ERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center
-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004
i

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
NeArestTowg: Q County ❑Ridge ❑Slope ❑Valley ❑Flat
PluM & (check appropriate box)
(Street Name,Numbers,Community,Eprodivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: amA (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or oute No.) (check box)
DEPTH DRILLING LOG
City Town i State Zip Code From To J Formation Description
8( 20 )- , /e.rf W Q 35 Clay&Sand
Area code-Phone number �G �3s 3�01 Granite
4. DATE DRILLED G•1 5• W
5. TOTAL DEPTH: .3,QO t t,,�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO u
7. STATIC WATER LEVEL Below Top of Casing: and /P1"
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS oZ 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): 3 0 METHOD OF TEST BLOW
10. WATER ZONES(depth),:_ 9 51 j 30TF--
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 160z 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. NUt Cal numbers and common road names.
From 0 To :7o✓Ft. I.� j�1M
L� -
From h To _Ft. �
From To Ft. 4
13. GROUT: Depth Material Method L '^
From 0 To 20 Ft.Benonite&Cement pumped C �'
2 +�
From To Ft. IV
14. SCREEN: Depth Diameter Slot Size Material W
From To Ft. in. in, v
From To Ft. in. in. UI
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 S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER ---- --- ------
SIGNATURE CrF P SON CONSTRUCTING THE WELL DATE
i _
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center 4�
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -..
GWA REV.109/2004 -

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Russell S.Taylor
CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ID Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATI N: n(� __ ''� - _�- � Topographic/Land setting
Ne est T wn: County! ORidge ❑Slope OValley OFlat
1 n Q (check appropriate box)
(Street Name,Nut6%rs,Community,Subdiwsipn,Lot No., ip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address Latitude/longitude source:OGPSOTopographic map
,��s1 a or Route No40 (check b DEPTH DRILLING LOG
City or T wn d S e Zip Code From To Formation Description
( )' - day&sand
Area code-Phone number Q Rranite
4. DATE DRILLED • 7.05
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:Joi)—_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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): 10 MEnTHOp OF TEST BLOW
10.WATER ZONES(depth): .a 73'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road'
Depth�,n Diameter or Wei t/Ft. Material numbers and common road names. �?
�l� �— �—Ld� v�
From To Ft.
From To Ft.
From To Ft. y
13. GROUT: Depth Material Method W
From 0 To 20 Ft. benonite&cement pumped O =1
From To Ft. C3 +
14. SCREEN: Depth Diameter Slot Size Material uz
.91
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 ISA NCAC 2C,WELL
CON TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G21 �
SIG TURE 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
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION H 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE H [phone]
STATE WELL CONSTRUCTION PERMITH ASSOCIATED WQ PERMITH
(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 LOCATIO : Topographic/Land setting
Ne stTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name um rs, ommuni (check appropriate box)
e ry, ibdivision,Lot No.,zip code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
�S eet or Route No.) r/ (check box)
�/�� DEPTH DRILLING LOG
dry or T w S to zip code From To _, Formation Description
8�-)-��� —�a-r�Zrry/�/ft�Q--- Clay&Sand
AreacEDRILLEDber t Granite
4. DATE DRILLEode-Phone D—
5. TOTAL DEPTH: I
6. DOES WELL REPLACE EXISTING WELL? YES NO,I'�
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):_ 5 _METHOD OF TEST BLOW
10.WATER ZONES(depth): 445--
LOCATIONSKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth ddd(� Diameter or Weight/Ft, atenal numbers and common road names. 93
From To Ft. 'r
91
Fromft
To__L Ft. �' f/B -._
From To Ft.
13. GROUT: Depth Material Method _ _ w
From 0 To 20 Ft.Benonite&Cement pumped -`
From To Ft. - C) +'
14. SCREEN: Depth Diameter Slot Size Material Ln
From To Ft. in. in.
From To Ft. in. in. --
15. SAND/GRAVEL PACK: �I
Depth Size Material
From To Ft.
From TO Ft. fit.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
lli•11•105
eGNATM OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD11, := c .a
North Carolina Department of Environment and Natural Resources-Division of Water Quality a
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
MENNEN
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
Ne�estTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
,(, Owl! (check appropriate box)
(Site t Name,Nu ers,Co unity,SubdFivision,Lot o.,Zip Code)ode) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address r Latitude/longitude source:❑GPS❑Topographic map
(See or Route (check Mz)(M7z 1 DEPTH DRILLING LOG
City or o State Zip Code Fro To r Formation Description
B( 8 ' --� � Clay&Sand
Area code-P one number 05 ' • Granite
4. DATE DRILLED
5. TOTAL DEPTH: ��'?
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 1,65 T.
(Use"+"if Above Top of Casing) •L
8. TOP OF CASING IS a- FT.Above Land Surface* G
"Top of casing terminated attor below land surface requires a
variance in accordant with 15A NCAC 2C.0118.
9. YIELD(gpm): 4po METHOD OF TEST BLOW `
10.WATER ZONES(depth): J&4 r ��J -- r 3
I . LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least '
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di eter or Weight/Ft. Material numbers and common road names.
From To=Ft. Jole
t.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
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. - -"- J
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS AUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
2?•0 5
NAT F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources.-Division of Water Quality-Groundwater Section�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) iJ'- -kY /,VIA eo CERTIFICATION#gnpz)
WELL CONTRACTOR COMPANY NAME r)'-r4 /tr2-W &)01I atal j/� PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 50 MunicipaUPublic ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County y 3ektwn ❑Ridge ❑Slope ❑Valley ❑Flat
�J(i��',ISn.yy �e (check appropriate box)
(Street Name,NNuumbcm,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER:zRd�.or7 Res4nO7'77 (degrees/minutes/smonds)
Address � //' e T a-, J"m Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
('�c�rn p kp We ; / DEPTH DRILLING LOG
orTo City wn State Zip Code From To Formation Description
Area code-Phone number ±g
4. DATE DRILLED
5. TOTAL DEPTH: 40n
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 10 r r
7. STATIC WATER LEVEL Below Top of Casing:-an FT.
(Use"+"if Above Top of Casing) — ?
8. TOP OF CASING IS�_FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST C,.?r
10.WATER ZONES(depth): 4100
LOCATION SKETCH
11. DISINFECTION:Type HJ•rs/ Amount 6.7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth 'Diameter or Weight/Ft. Material n tubers and common road names.
Fromm To�Ft. 1' Snr9J �t'� - rO rvi o0mo t't PO Ga Ji w�"' °S 7'-,
From To Ft.TT
From To FL JLo 7" 0 f) 71J� CT /,4'
13. GROUT: Depth Material Method TUl•n At'hT a-r ,E)r+,T 7141 C-h cab kee GC
From O To--&O Ft. ift-M,�t2T Pam&'j2a � p
From To Ft. 3,k rvt ,`1t .
5 4,r17 'T0n cd5'�10 Tpml
14. SCREEN: Depth Diameter Slot Size Material Go, ). 7 »t1�Je •r'N Rl ITdn �at'nT
From To Ft. in. in. p 1 p 1�
From To Ft. in. in. Twi'1 RA CT© la f/nl IO',,5 Tf/rn A1�r/17
15. SAND/GRAVEL PACK: 1 n A10 T f edsc.-m ��r 6 q fJV S
Depth Size Material �fv lT� u' ` Mt
From To Ft. _ -arr3 Ri b ( Or) C berry e-rePk
From To FL
Go a(o mf'les Te Lt/eJI on Je-�T,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSONCON$TR L"TIN44THEWELL _ DATE
Submit the original to the Division of Water Quality,Groupdwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
'- kgg 0
North Carolina Department of Environment and Natural Resources-Division Zer Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Weil Drilling, Inc PHONE # f )369-9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) if applicable)
1. WELL USE{Check Applicable Boxy,:Residential © Municipal/Public❑ Industrial ❑ Agricultural 0-
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT[0 Topographic/Land setting
Ne rest Town,. County ❑Ridge ❑Slope Malley ❑Flat
��l/m�hiwu2, (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
No.) (check box)
DEPTH DRILLING LOG
fflly �
Zip Code F^rom 'T^oq Formation Description
�•r Clay it sand
Area code-Phone number �����L, ��L Granite
4. DATE DRILLEDEPTH:5. TOTAL DEPTH::w�- yyy...��,�..
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:ate- T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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):_4_METHOD OF TEST BLOW
10.WATER ZONES(depth): -
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di meter or Wetph�t. �Material numbers and common road names.
From 0 To Ft
/t115 sz�pQ_
From 0 To Ft.
From To Ft.
13. GROUT: Depth Material Method g
From 0 To 20 Ft.Benonite&cement pumped
From To Ft. C "�
14. SCREEN: Depth Diameter Slot Size Material r
From To Ft._in, in. C17
From To Ft* in. in.
15. SAND/GRAVEL PACK: C=1
Depth Size Material 75
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY_PL4IiT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST A S,AND THAT A C Y OF THIS RECORD HAS BEEN PROVIDED TO THE.WELL OWNER _
17�U
SIG ATU RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information ManagenwMr-16#7 ervlceTjWtepF7­ ',.
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. �� �;�, I, vl LS .
r --- 6W-TRE1 ,400$'
Tor
f

WELL CONSTRUCTION RECORD *
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION M 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE M ( )369-9591
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
'L WELL USE(Check Applicable Box):Residential 10 Municipal/Public❑ Industrial.❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Ne stTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Z�veet Name,Numbers,Community,Subdi ision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
AddressC980 Latitude/longitude source:❑GPS❑Topographic map
Stre o R No.l (check box)
7 DEPTH DRILLING LOG
��j�q,�ty or T�o '�j State Zip Code From o Formation Description
(7 f�-�7J -11/ 7g Clay it sand
Area code-Phone number/FFF-���� Qa r Granite
4. DATE DRILLED 1.OJr•
5. TOTAL DEPTH: t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �S
7. STATIC WATER LEVEL Below Top of Casing:nk T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated atior below land surface requires a
variance in accordance with I5A NCAC 2C.0118.
9. YIELD(gpm):60_METHOD OF TEST BLOW
10.WATER ZONES(depth): nM 'f 7
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep Di eter or Wei ht/Ft. Material numbers and common road names.
From 0 ToFt. r'
From R To Ft.
From To Ft.
13. GROUT: Depth Material Method A
From 0 To 20 Ft.Benonite a Cement pumped a
From To Ft. L p
14. SCREEN: Depth - Diameter Slot Size Material
From To FL in. in.
From To FL in. in. Cil
15. SAND/GRAVEL PACK:
Depth Size Material Ul
From To Ft.
From To Ft.
16, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND ;AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER _
SIGNATURE 0 ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management, t 3. r_
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. ! ��, L� U �1 Ln
J�JI. 2 0 2005

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling,Inc PHONE # ( )369-9591
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 ION/ dge 13 lope Land setting
Near st Town:�.lA''9u,I County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Nuum , ,Community,Sub/d�ivi_sion,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Id/1/H//� (degrees/minutes/mconds)
Address /ysn i 0W4 Latitude/longitude source:❑GPS❑Topographic map
(street or oute No.) (check box)
p �� (n 95 DEPTH DRILLING LOG
City or Town State Zip code From To Formation Description
(9U 633•number _0 7W Clay it sand
Area code-Phone number // �� Granite
4. DATE DRILLED [O*
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Topo asmg)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated attar below land surface requires a
variance in accordance ith 15A NCAC 2C.0118.
9. YIELD(gpm):�METHOD OF TEST BLOW
10.WATER ZONES(d pth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness - two State Roads or County Roads.Include the road
Depth /J Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 7 Ft. ' C
From ToFt.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&cement pumped C
1
From To Ft. r r,
14. SCREEN: Depth Diameter Slot Size Material 1
From To Ft. in. in.
From To Ft. in. in. p -
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 STANDAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
nTE/ -� S
SIGN�Tl1 0 ERSON CONSTRUCTING THE WELLO ERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality,Attn: Information Manageme t4` 7 t rvtee fn p h —)
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. i:, (' r., �; 'L I r.i
I I '
JUL 20 27J5 � � Ij
„ I

WELL CONSTRUCTION RECORD z �)
l „ P
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Redden Brothers Well Drilling,Inc PHONE 9 )369-9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential © Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Neares Town: County ❑Ridge []Slope ❑Valley ❑Flat
fe.. (check appropriate box)
(Street Name,16m ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address o Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
ity or q crate Zip Code From T / Formation Description
moo{ 540 Clay&sand
Area code-P one number ' Granite
4. DATE DRILLED 1p
5. TOTAL DEPTH: 'cr
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O�
7. STATIC WATER LEVEL Below Top of Casing:_'Z0 T.
(Use'Y'if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm):�_ME''TCTtt��IHJOD OF TEST BLOW
10.WATER ZONES(depth):1 596'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di eter or Weight/Ft. Matrn,al numbers and common road names.
From
a To Ft.
From�ft To Ft. �••
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Senorita&Cement pumped
From To Ft. c
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. N
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 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,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
55
—J
I

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
CERTIFICATION 4 2045
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown 369-9591
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc _PHONE 8 ( )
STATE WELL CONSTRUCTION PERMITk ASSOCIATED WQ PERMM- (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)J� � Topographic/Land setting
NearestTown:�[[ County� ❑Ridge ❑Slope ❑Valley ❑Flat
/. 1 • .w J_ rrr (check appropriate box)
(Street Name,Numbers,community,subdrv,s,on,Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER:W/.. ✓1{I/iLA_ _ (degreWminutes/seconda
Address n/MP Latitude/longitude source:❑GPS❑Topographic map
(check box)
(Street or RouteNo.) ag, DEPTH DRILLING LOG
,C or To Sta Zip Co
�V From To Formation Description
C' or To t de r 0 Q, Clay&sand
Granite
Area code-Phone number
4. DATE DRILLED=
5. TOTAL DEPTH: uuu1,�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /a�
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
•Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. BLOW
9. YIELD(gpm): 6 D±METHOD OF TEST
10.WATER ZONES(depth): )��� LOCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type H T H Amount 16oz two State Roads or County Roads.Include the road
12. CASING: Wall Thickness numbers and common road names.
Depth Diameter or Weight/Ft. Mpterial
From 0 To Ft. rr �"�—
From�h To�O Ft. s • ,/�� �uWe—
From To Ft. n
13, GROUT: Depth Material Method
From 0 To 20 FL nenonite&cement pumped (,-. G2
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material 1
141
From To Ft. in. in. j
From To Ft. in. in. O
15. SAND/GRAVEL PACK: ut
73
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 D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI A OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. �� _1�RE�J O�1;0�4`

WELL CONSTRUCTION RECORD * � g %; `} C; 1)
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown
CERTIFICATION S 20 55
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE S ( )369.9591
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(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 ION: /� _ Topographic/Land setting
Ne estTown. County' LLv ❑Ridge ❑Slope ❑Valley ❑Flat
snbn ', O U (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,2rp Code) Latitude/longitude of well location
3. OWNER: (degreultninuteslseconds)
AddrE Latitude/longitude source:❑GPS❑Topographic map
(check box)
(Street or Rout AN�o) / DEPTH DRILLING LOG
Zip code fI From , o , Formation Description
\/ /�/�QCiry or Town _ Sta P 0 Clay&sand
Area code•Phone number Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO F
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above ToT.
p o Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. BLOW
9. YIELD(gpm): &1) MEiTH�QD OF TEST
10.WATER ZONES(depth): LOCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type H T H Amount 16oz two State Roads or County Roads.Include the road
12. CASING: Wall Thickness numbers and common road names.
Depth D'am ter or Weight/Ft. Material
From 0 To Ft. --�/�1 1/(-J�K!
From_Zj;Q7To FI.
From To Ft. W
13. GROUT: Depth Material Method -.„
C
From 0 To 20 Ft.Benonite&cement pumped r' r)
From 1 To Ft. -
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. _ in. O
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 STA S,AND THAT A COPY OF THIS RECORD RAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU PERSON CONSTRUCTING THE WELL DA E
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. y �9F2004
L `I
2005
JUL 2 0 I�._ 1

WELL CONSTRUCTION RECORD a t y
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION 112187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE N [phone]
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMITN
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Pui)lic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Near eFtTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
�� (check appropriate box)
(Street Name,Numbers,
^Community,
__Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: I Y JL.�.1�/ryJ ��• MPI (degrees/minuteslseconds)
Address 105 Latitude/longitude source:❑GPS❑Topographic map
(Street or Route Nod (check box)
agD41 DEPTH DRILLING LOG
City or Town S'a[-� Zip Crde
From T Formation Description
� ) 5/ $ _ S�Sf�` Clay&Sand
Area code-Phone number a7 Granite
4. DATE DRILLED �o•J_ :�-
5. TOTAL DEPTH:_ �(
6. DOES WELL REPLACE EXISTING WELL? YES ❑ O k
7. STATIC WATER LEVELBelowTopo£Casing: FT.
I1 (Use"+"if Above Top o Casing)
8. TOP OF CASING IS 0 - FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C.0118.
9. YIELD(gpm):6 MET OD OF TEST BLOW
10.WATER ZONES(depth): I' / LOCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type H T H Amount ss two State Roads or County Roads.Include the road
12. CASING: Wall Thickness
Depth Di eter or Wet ht/Ft. atenal numbers and common road names.
From Q To 0 Ft.
From ft To Ft. t3
From To Ft. w,
13. GROUT: Depth Material Method
From 0 To 20 Ft.senonhe&Cement pumped
From To Ft. t
14. SCREEN: Depth Diameter Slot Size Material F
From To Ft. in. in.
From To Ft. in. in. Ln -4_a
15. SAND/GRAVEL PACK: =-�f
Depth Size Material =v
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
,� sla i05
SIG TURF OF PERSON CONSTRUCTING THE WELL DAITEI
Q s .._. S_ 1 Mail Service
NC 27699.1617, Phone No.[phone],within
Submit the original to the Division of Water Quality,Attn: lnformatioaMana Management,1617 M ,
310 day . GW-1 REV.09/2004
LuUJ_.�,v,J
i
crrT10N

WELL CONSTRUCTION RECORD
3 a • n
North Carolina Department of Environment and Natural Resources-Division of ater Quality �1 .f- 4 U J
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell 5 Taylor CERTIFICATION N 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest pwn: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Cam tty/Subdivision,Lot No.,Zip Code) Latitude/longitude Of well location
3. OWNER: �*(Sveet
Y1.�/iVt/ (degrees/minutes/seconds)
Address Latitude/longitude source:DGPS❑Topographic map
Reute No.) nn (check box)
®1 N� A07e DEPTH DRILLING LOG
City or Town Zip Code From To Formation Description
0( 28 ) ,7•�•��fy•�/� _ .�7 Clay it Sand
Area code-Phone number A t�t Granite
4. DATE DRILLED •/3 •a3
5. TOTAL DEPTH: t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: T
(Use"+"if Above Top Casing)
8. TOP OF CASING IS o2 FT.Above Land Surface*
"Tap of casing terminated at/orbelow land surface requires a
variance in accordance ith 15A NCAC 2C.0118. BLOW
9. YIELD(gpm):W METHOD OF TEST
10. WATER ZONES(depth): LOCATION SKETCH
Show direction and distance in miles from at least
1 DISINFECTION:Type H T H Amount 16oz two State Roads or County Roads.Include the road
12, CASING: Wall Thickness
Depth Diameter or Wei hUFt. Material numbers and common road names.
n
From To01471
_Ft.�_
From It To Ft.
From To Ft. -
13. GROUT: Depth Material Method
From 0 To o?a Ft.Benonite&Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material G
G-3 rt
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: O 4
Depth Size Material v�
From To Ft. x
From Ta Ft. '.t
sta
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 WELLOWNER
7 2 (1S
SICUATURE OF PEKSON CONSTRUCTING THE WELL DAT
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW-I REV.09/2004
Ili '
I_ASHE'll t k'f t,l;J;ig;

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION 2187
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential EI Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
Near Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
eAe iAtt (check appropriate box)
(St et name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �1, A! ✓��+ (degrees/minutes/seconds)
Ad ress Z14fL Latitude/longitude source:❑GPS❑Topographic map
(Street or Route N .) (check box)
ZZI_ DEPTH DRILLING LOG
City,or Town S tf Zip Code From rT0 I Formation Description
T Clay&Sand
Area code-Phone number Z Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N�O
7. STATIC WATER LEVEL Below Top of Casing:�q�1/ T.
(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): IvjETHOD OF TE T�ByL�OW-�—
10. WATER ZONES(depth): _74 � y T LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth 22 Diameter or Weight/Ft. Material numbers and common road names.
From_ It To Ft. c.o... VC
From_
It To Ft. _
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
a
From To Ft. <
14. SCREEN: Depth Diameter Slot Size Material p, 7
From To Ft. in. in. C
From To Ft. in. in.
15. SAND/GRAVEL PACK: -
Depth Size .Material
L
From To Ft. crt s�
From—To—Ft.— ~"
e.0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT N STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN RE OF PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004
t_
ASNf,u o —

WELL CONSTRUCTION RECORD 6"
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION m 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ID Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO 1: Topographic/Land setting
rest Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
nn f)/r& (cheek appropriate box)
(Sneer Name,Numbers,Community,
,,S.,,u�bdiv-isiion,_Lott No.,Zip Code) Latitude/longitude of well location
3. OWNER: ftzo �J/�1(�! ILLJ�.(JY (degrees/minutes/seconds)
Address VA-1 lm NJu Latitude/longitude source:COPS❑Topographic map
(Street or Route No.) (check box)
�,e/,n $717 DEPTH DRILLING LOG
City or Town tare Zip Code From To Formation Description
828 - ZZ(0-33U(0 ! , 51 Clay& Sand
Area code-Phone number linm Granite
4. DATE DRILLED T Z1 'os
5. TOTAL DEPTH: 1 OI:0D f
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use`Y'if Above Top of asing)
8. TOP OF CASING IS_ FT.Above Land Surface•
"Top of casing terminated at/or below land surface requires a
variance in accordance w h i5A NCAC 2C.0118.
9. YIELD(gpm): THOD OF TEST BLOW
10.WATER ZONES(d pth): LOCATION SKETCH
11, DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di eter or Wet t/Ft. Material numbers and common road names.
From To Ft. t t —Ale- ftw
From it To Ft.
y
From To Ft. -
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped C •ny,
From To Ft. C
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. _
From To Ft. in. in.
15. SAND/GRAVEL PACK: ^e+
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
CONST CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
zos
SI TURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-) REV.09/2004
Li AUG 2 3 2005 IiL

WELL CONSTRUCTION RECORD 3 _t a q /ap
JJ
North Carolina Department of Environment and Natural Resources-Division of Vi ater Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S Taylor CERTIFICATION m 2167
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE g [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
111110111111
1. WEi.I USE(Check Applicable Box):Residential © Municipal/Public❑ li,dustrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Usz
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County ❑Ridge ❑Slope ❑Valley []Flatmi Q )100 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude Of well location
3. OWNER: (degrees/minutes/seconds)
Address r� oah — LatitudeAongitudesource:❑GPS❑Topographic map
(Street or Roue NoJ (check box)
DEPTH DRILLING LOG
City or Town n sta^ Zip Code From T Formation Description
828 Clay&Sand.
Area code-Phone number Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO X
7. STATIC WATER LEVEL Below Top of Casing: /Ob FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS e�,—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):1.2� _METHOD OF TEST BLOW
10.WATER ZONES(depth): 98��5 / fff--, LOCATION SKETCH
11. DISINFECTION:Type H Ti H Amount 16oz 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. 1� "
From It To Ft. -
From To Ft. -_
13. GROUT: Depth Material Method -3
From 0 To 20 Ft.Benonite&Cement pumped A -
From To Ft. C
G7
14. SCREEN: Depth Diameter Slot Size Material t
From To Ft. in. in. -_
From To Ft. in. in.
15. SAND/GRAVEL PACK: U7 _.�
Depth Size Material
From To Ft. °=J
From- To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION V AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG TURF OF PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days
-GW-1 REV.09/2004
ILI
iL I AUG 2 ! � -'

WELL CONSTRUCTION RECORD �P 314536
North Carolina- Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME, (print)
CER"r1E1C,\770N# 3D 7/
\VELI,CON'IlL\CTOIt COaIPANYNAME �I�fIF SR Tp pFRS WeIEI I_ Bill IING INC. PHONE q f )
STATE WELL CONSTRUCTION PERNIF`I'd 248 GRAN U\VQ PEIiIF11TN
(ifapplicable)
' I applicable)
I. WELL USE(Check Applicable Box): ResidentiaL�iMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATIO
N Topographic/Land setting
earriil/Dt l�e� �e county Iar il/J ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: o (degrees'm in oes/seconds)
Address N L Latitude/longitude source:❑GPS❑Topographic map
y�1 (Street or Rou a No.) (check box)
'�f�l C ✓a 3 0� )y DEPTH DRILLING LOG
City or Town State Zip Code From TO
Formation Description
Area code-Phone number�``
4. DATE DRILLED_ k-6\
5. TOTAL DEPTH: 7 SOS r7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 7
7. STATIC WATER LEVEL Below Top of Casing: C}T) PT,
(Use'4"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
"Top of casing lerroloated atlor below land surface requires a
variance in accordance wilt 15A NCAC 2C,01I8. rV
9. YIELD(gpm): _�p METHOD OF TEST
10. WATER ZONES (depth): _ p
LOCATION SKETCH '
11. DISINFECTION: Type Amount _ Show direction and distance in miles from at-1@ast
12. CASING: Will Thickness two Stale Roads or County Roads. Include the road
Depth Di meter or Weight/Ft. Material numbers and common road names.
From 0 TO L-,,P Ft. Al _
From To Ft.
From To FL _ n
13. GROUT: Depth Material
F Method i Y G-rt
From To_Q 0 Ft. Ir ,�r _FOt'H n� l c _
1 ,
Prom To Ft. _ _� r— c
14. SCREEN: Depth Diameter Slot Size Material ; Iv
From To FL in. _ Iv
From To Ft. in. in.
15. SAND/GRAVEL PACK: -- o
Ueplh Size MaterialG��i�
From To Ft. - - ._ H, _ __
From To Ft. t
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TILL WL•LL DATE
Submit the original to the Division of 15'2(er Quality, Groundwater Section, 1636 Dlail Service Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD R 3 i 4 5 3 j
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
\YELL CONTRACTOR(INDIVIDUAL)NAME (print)! J ae < I�' zzg CERTIFICAI[ON K-61;71
WELL CONTRACTOR COMPANY NAME PHONE N f )
STATE WELL CONSTRUCTION PEILM II'q "r t< °?ROTHFR$WELL D !Jt NG �C.
��''f c� DO PERNIIT"N
(if applicable) "RAhIKt ins n:^ �R Ppplicable)
1. WELL USE(Check Applicable Box): Residents Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCAT ON: Topographic/Land setting
Nea est Town: i _County RCJ�-
/x� 'rO�Y/ --�'" ❑Ridge ❑Slope ❑Valley ❑Flat
`U Ai �'� '� -
(check appropriate box)
(Street Narne,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
Nu
3. OWNER: +a) .—Z-1 (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or Town Stale Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED aS eE J -
5. TOTAL DEPTFI: .5-OCT- ;Z 'S�5-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: oZOD IT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS � FT.Above Land Surface*
-Top of casing lerrulnated at/or below land surface requires a
variance In accordance whir 15A NCAC 2C.01 18.
9. YIELD(gpm): u METHOD OF TEST
10. WATER ZONES (depth): _ Ln
_ LOCATION SKETCH
11. DISINFECTION: Type Amount Show direction and distance in miles from Aeasl
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diar�uter cr WeighUFl. Material numbers and common road names.
From-To-Ft. e� � yet Jr�
Prom To FL
From To Ft.
13. GROUT: Depth Materiat Method n Lrll
From L To �C' Ft. L / /,gyp �J eMs F19i 7Net e� C- C ;;
From To Ft. =z r--
��
14. SCREEN: Depth Diameter Slot Size Material zc N
From To Ft. in. in.
From To Ft. in, in. c"ZnN
15. SAND/GRAVEL PACK: o
Depth Size Material 7 :� css r-
T P_
From To Ft.
From To Ft. ,
16. REMARKS:
I DO HER CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CO TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRJCTING THE WELL DATE
Submit the original to the Division of N'ater Quality, Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phrase No.[phone],within 30 days. GW-I REV. 07/2001

�
WELL CONSTRUCTION ROR)D o toc
North Carolina Department of Environment and Natural Reso ces Division of Water Quality
WELL CONTRACTOR(LYD[VmUAL)NA:�[E (Print) 7t1 /Lu.�i tiles l7 `m p/t / CERTIFICATION# t'1
WELL CONTRACTOR CObIPANY.NAbtE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # [phone]
_ - STATE WELL CONSTRUCTION PER 11T# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box);Residential Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT Topograp /Land setting
Nearest Town: County ,i-s+ ❑Ridge ❑Valley ❑Flat
(check appropriate box)
(Strcet Name,Numbers.Communiry,Subdivision,Loot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1 F�f l�L� (degrees m notes/xeonds)
Address 7 I I Latitude/longitude source:❑GPS❑Topographic map
(Sweet or R toNo.) /1 (check box)
-II Y DEPTH DRILLING LOG'
--City or Town State Zip Code From To Formation Description
g( 28 )_
Area cod.-Phone number (/ '
4. TOTEDRILL J(J y- C3 Y
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)
S. TOP OF CASING IS�,2 FT.Above Land Surface*
'Top orcasing terminated actor below land surface requires a
variance in accordance with liA NCAC 2C.0118.
9. YIELD(gpm): M OD OF TEST
10.WATER-ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type` Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Da meter or Weight/Ft. Mate numbers and common road names.
From_ �� To 3.7 Ft. V
From To Ft.
From To Ft.
13. GROUT: Depth Material rt— Method ma
From To 3 Ft. �� w�r Vlt!-✓�
Fro _TomF —J�m•• '�- U—`-S ` I.,¢,y,r- --� L
m L ,,,t
14. SCREEN:• Depth - Diameter Slot Size Material C ti
From _To Ft. in. in. T­
From To rt._in. in. Co
is. SANEGRAVEL PACK:/IC/..
Depth Size Material _
From To Ft. Q -12
From—To Ft.—
16. REMAU a'LC J
I DO HEREBY CERTIFY THAT THIS WEL WAS CONSTRUCTED IN ACCORDAN WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND A COPY OF TH RD HAS B PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING t G THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail service Center-
Raleigh,NC 27699-1617, Phone No.[phone],.within 30 days.
i GW-1 REV.09/2004
� � 2M i

v 14
WELL CONSTRUCTION RECORD '7
North Carolina Department of Environment and N/atjtn��raI Resources-Division of Water/Qtlaliry —�3'"/�
WELLCONTRACTOR(L`rDIYMUAL)NA3tE (print)�il�/t� /d• /I�J�LGC/L�CJ CERTIFICATION# Y
.. . . WELL CONTIt:ACTOR COMPANY NAME.AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHOYE # [phone] -
STATE WELL.CONSTRUCTION PERS(IT# ASSOCIATED WQ PERVDTM 1n
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ A_riculrural❑ /
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCwATION: Topographic/Land setting
Nearest Ton: Coun
❑Ridge�Slope ❑Valley ❑Flat
,m h^• Z, • ' , (check approptiatz box)
(Strect Name,Numbers,Community,Subdivision of No.,Zip Code) 4 Latitude/longitude of well location
3. OW N E0 (degrecs/minutcs/seconds)
Address S. `� )Z42cl . KLLI 44Latitude/longitude source:OGPSOTopographicmap
(S tor .t 'o.) (check box) 1.
L V v DEPTH DRILLING LOG'
Firy rTn n Srsatz�-I pCode From To Formation Description
5t85'6 - 79 .
Axa code-Pbonc number a. DATE DE,ILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO _ d
7. STATIC WATER LEVEL Below Top of Casing:1 a T. p ,a3y
(Use`+'if Above Top of Casing) ��a �-� lHi
8. TOP OF CASING IS� FT.Above Land Suface• � l3D'7_'Top oreasing terminated atlor below land surface requires a vaciaacein accord ce with 15ANCAC2C.011s.9. YIELD(gpm):=METHOD OF TEST10. WATER ZONES(depth): Q51 `_ _rLOCATION
1 I. DISINFECTIOY:Type I mount a JI ow direction and distance in miles from at least
12. CASING: Wall Thickness /"3 ^010f
two State Roads or County Roads.Include the road
Depth D'a a er or Weigho'Ft. Material numbers and common road names. "
From C7 To �.� �LyCi /J
From To Ft. �Zll
FromToFt. f13. GROUT: Depth Material Method
From_Q_To _Ft.— Q.'C L3
From__To Ft. ,C_.
14. SCREEN: Depth Diameter Slot Size N serial .7�
From To Ft. in. in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. L'
From To Ft.
tV
16. REMARKS:
Ln
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOBIANCE WITH 15A NCAC 2C,WELL71
CONSTR CTIONA 'D THAT A C Y THIS RECO A N PROVIDED TO THE WELL OWNER t
0
SIGNATURE OF PERSON CONSTRUCTING THE WELL - DATE
Submit the original to the Division of Water Quality Attn: Information Mauagetnent,'160 Nina Service Center-
- Raleigh,ANC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09' 004

A ( � �
WELL CONSTRUCTION RECORD as-/7s7
-- North Carolina Department of Env m ent and
Natura/�7/7Teesso�u�rces-Division of Water Quality
WELL CONTRACIOR(L`lDIVIDUAL)NAME (Print)&tt C_—Q � CERTIFICATION R 3:f
WELL CONTRACTOR COMPANYNA_NIE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # [phone]
ESTATE WELL CONSTRUCTION PEPMM ASSOCIATED WQ PMNaTa
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential NlunicipaVPublic❑ industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Nea tTf%n: Co try tQT} ❑RidgeASlope ❑Valley ❑Flat
(check appropriate box)
(Svicet Name,Numbers tCommuniry,Subdivision Lotc'o.r ip Code) ,'��? a[itttde.0ongi[Udt Of Well location
3. OWNER:C_z (degrees/minutes/seconds)
ess 0 Latitude/loneirude source:OGPSOTopographic map
Q� �ceet or'A to
Ny. (check box)
,i t G! 1LC i 10 o2g�a_57— DEPTH DRILLING LOG'
Ciry or Town Sp+te Zip Code From To Formati3On Description
Area code•Phone numb:r
4. DATE DRILLED � � - �S-
5. TOTAL DEPTH —
6. DOES WELL REPLACE EXISTING WELLS YES ❑ NOA
7. STATIC WATER LEVEL Below Top of Casing: FT. 9�
(Uw"*"if Above Top o asmz) r;
8. TOP OF CASING IS FT.Above Land Surface. C2
'Top of casino terminated actor below land surface requires C
variance in accordance with I5A NCAC 2C.0118. F"
9. YIELD(gpm): NtF�THOD OF TESTi(..ti
10. WATER ONES(depth): I `S- 4aq Ca
LOCATIONSKETCH 0 :
1 I. DISINFECTION:Type_�'��Amount �Nfateri
how direction and distance in milts from attlA;[
12. CASING: Wall Thicknesstwo State Roads or Counry Roads.Include the road
Depth Diateter or WeighrT umbers and common road names.
From To_CAFt._r^
From To FL
From To Ft. �(• p
13. GROUT: Depth Material Method -�iLr L,4L. /C...�rC /
From D To__--I_Ft. 11E /
From To _Ft. @.L, - Co �l z`�"-�' -
14. SCREEN: Depth Diameter Slot Size Marerial
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
CONSTRUCT N ST ARDS,ANDIJEUT A COPY OF THIS- HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division Of W'ater,Q ualirv,Attn: Information Management,1617.h12il Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. _-
GW"-I REV.09/2004
I%' i

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Naru 1 Resources-Division of Water Quality -. -..
WELL CONTRACTOR(LYDIVMUAL)NA..NIE (print) JIJ / ' s �-Ck!Li/WZ// CERTIRCATIONM�
WELL CON-MACCOR C0d1pA.Ny NAS[E AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. :PHONE k [phone]
STATE WELL CONSTRUCTION PER.NnTX ASSOCIATED WQ PERSRT#
(if apolicable) - (if aoplicab(e)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W'F1 L LOCATION: n� � Topoor hic/Land settin
Nearest wn: �^--� County 4L�P/� 'dgz ❑Slope ❑Valley Flat
(check appropriate box)
(Scret Name,Numbers,Cofhmutu , rvAi of o., ip e) Latittrde/tongirude of well location
3. OWNER: --d L (degrees/mioutesseconds)
Address ` Y Latitude/longitude source:❑GPS❑Topographic map
(S er or gayte t
No (check box)
} 1 a 7 7 9 DEPTH DRILLING LOG"
Ci a Town Sure Zip Cade From To Formation Diseription
(828
A:ca;ode-Phone number-
4. DATE DRILLED — j
5. TOTAL DEPTH: } c� 7
6. DOES WELL REPLACE EXISTING WELL? YES r0"f� �aS71
7. STATIC WATER LEVEL Below Top of Casine: (G FT.
sz"+"if Above Top of Casing) C._.
8. TOP OF CASING 1S FT.Above Land Surface, r
-Top or casing terminated ao'or belos land surface requires a
variance in accordant-wit 15A NCAC 2C.0118. 1
9. '1.— (epm): -._ /LMETHOD OF TEST CID
10.WATER ZONES(depth): CD
LOCATION SKETCH y'
11. DISINFECTION:Type Amount Show direction and distance in milts from at least;-
12. CASING: Wall Thickness two Slate Roads or County Roads.Include the roa
Depth �+/ Diameter or Weigho'Ft. Material numbers and common road names.
From_To 6&.Ft. % :517 R 7/ #01
From To Ft.
From - To Ft.
13. GROUT: Depth Material Method
From--0 To Ft. .-._
From_ToFt. ��
14. SCREEN: Depth Diameter Slot Size N aterial
From To Ft. in. in.
From To Ft. in. in. r -
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
MC � ue'rtA fr — l `/'p�
SIGNATURE OF PERSON CO'.JSTRUCTIN,. G THE WELL DATE
Submit the original to the Division of Water Quality,Atto: Inforfnadcsq NIansgejnent;1617 ht�r7 Spence Center-
Raleigh,NC 27699-1617, Phone No.[phone],.within 30 days.
¢�04 REV.09/2004
AUG 23 2005

((`�� � ? f � � q JS 2�SiVKJ
WELL CONSTRUCTION`REC`�ORII 7SG _ i�a�
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(LNDrMUAL)NAME (print) ? /// • - CERTIFICATION#_`�,�
WELL CONTRACTOR COMPANY NAhIE PHONE # S5�
STATE WELL CONSTRUCTION PERINIIT# ASSOCIATED WQ PERNDT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Mu6cipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N Topo�aphic/Land setting
Near overt: Co ty - ❑Ridge r sipcpe ❑Valley ❑Flat
(Street Name omm �'(rcLheck appropriate box)
ry,Su ri ion,[.ot No.,Zip Code) r G Latitude/longitude of well location
3. OWNER.
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(52ctt_ ar R'oure No.)�,/t a0 V3 (check box)
✓ CT/_ DEPTH DRILLING LOG
or own Sta t,4 Zip Code From To Formation Description
Area code-Phone nur..be. •7 - .r-^ - —
4. DATE DRILLED �n - � J 'O S A
5. TOTAL DEPTH: S-7) Lj
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
tk-
7. STATIC WATER LEVEL Below Top-i Casing: ?r. FT.
(Ux"+"if Above Top o�mg`)
8. TOP OF CASING 11 FT.Above Land Surface*
-Tap of cuing terminated attar below Land surface require a
variance In accordance with 15A NCAC 2C.0113.
9. YIELD(gpm): METHOD OF TEST 10.WATER ZONES(dept )): [
r LOCATION SKETCH
11. DISINFECTION:Type Amount how 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/FL Material numbers and co on road names.
From
_0_To_5 -R. 'J
From To Ft.
From To Ft.
13. GROUT: Depth M,aterrial� Method
From b To
From_ To�, Ft. �
14. SCREEN: Depth Diameter Slot Size Matenia r-- =
From To Ft. in. _ in. � � rC-
From To Ft._in. in. tv
15. SANT)/GRAVEL PACK: co «'
a1
Depth Size Material C3
From To Ft. ctl f
From Tc Ft. J
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wflH I SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r,%.)- rn fr Cwrr• '7' -aO' Of
SIGNATURE OF PERSON CONSTRUCTINJ THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Infortnagan{b_fao� e tent;.161�blatl Se vice Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
r �i
1 REV.09/20N
i

WELL CONSTRUCTION RE� � S Sw
Q�ry - i9 - 'Ss83
North Carolina Department of Environment and Natural Resources-Division of Water ua t 42
WELL CONTRACTOR W(DIVIDUAL)NAINI6 (plat) cr �✓ ��VV` cERTIFIcATION# 2/
WELL CONTRACTOR COMPANY NAME l��vl �✓tD t PHONE Y 8A �5-
STATE WELL CONSTRUCTION PERNIITY ASSOCIATED WQ PER.NUTY
111101 (if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑ -
Monitoring ElRecovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Landwtt g
Neare§tTo ounty ❑Ridge ❑Slope ❑ValleyFlat
C�1 �G (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,&.cod.01�— a— - Latitude/longitude of well location
3. OWNER.---
Address Latitude/longitude source:❑GPS❑Topographic map
(S ar Ro i o.) ,C (check box)
O Y !1 1 C� DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Are ca ode-Phone
4. DATE DRILLED �2(_ b
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑
7. STATIC WATER LEVEL Below Top of Casing:aaFT. �
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' L
•Top orcaaing terminated at/or below land surface requires a r-
varianceinseeorda ce with ISA NCAC 2C.011& IN ,1
9. YIELD(gpm): I METHOD OF TEST_ to j
10.WATER ZONES(depth): 44 O
LOCATION SKETCH cn
11. DISINFECTION:Type �-�- Amount Show direction and distance in miles from at least '--t
12. CASING: Wall Thickness two State Roads or County Roads.Include the road '6
Depth
q Diameter or Wet t/Ft Material numbers and common road names.From_
- To l�n t. t/. e�j'1 j
FromFrom To FL��
From To Ft.
13. GROUT: Depth Material Mgt}od
From To� Ft. U
From To 7,0 Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in,
From To Ft. in. in.
15. SANOGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrm 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRU ING THE WELL DATE
Submit the original to the Division or Water Quality,Attn:InforntAdoq-Nhmapo ce.CSnter-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. - I , +
- - --- ,=Q*-I REV.09/2004
U

0)�' � F � (� � � s3f)a3fO
WELL CONSTRUCTION RECbF D a 6
�S k S�__S-l — 6
North Carolina Department of Environment and Natural Resources-Division of Water Quality �/J
WELL CONTRACTOR(MtMUAL)NAME (print) V SNZ e CERTIFICA-T1ION#cz l-O
WELL CONTRACTOR COMPANY NA.NIE PHONE # (R.Ry
STATE WELL CONSTRUCTION PERNUT# - ASSOCIATED WO PER.NUT#
(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 LOCATIC Topo aphic/Land setting
ear Town: County4
❑Ridge ope ❑Valley ❑Flat
�2573 (check appropriate box)
(Sneer Name,Numbers, corn u 'vision,Lot No., dCode) Latitude/longitude of well location
3. OWNER �1+ I /N sr ^ ^t-D__� (de sours :EIGucoods)
Address t (� I �/ � LG [ Latitude longitude source:❑GPS❑Topographic map
�^n SSncaor�y�� a (cbcckbox)
Oii7///(.Yxc )—"I l_--a%7 3 DEPTH DRILLING LOG `
ry or Toj cart p Code From To FormationDescription
t•�yS1yr51- — ! — �ol
- Area code•Phone number L/
4. DATE DRILLED
5. TOTAL DEPTH: J D [�L�1�
6. DOES WELL REPLACE EXISTING WELL? YES N�
7. STATIC WATER LEVEL Below Top"i Casing: O FT.
(Use"+"if Above Top of umg)
8. TOP OF CASING IS FT.Above Land Surface'
-Top of cuing terminated atlor below land surface requires -
variance In accordan a with 13ANCAC 2C.011& _
9. YIELD(gpm):�METHOD OF TEST f Y'
10.WATER ZONES(depth): t4 (J — �i o LOCATION SKETCH
11. DISINFECTION:Type f�ALL oust Show direction and distance in miles from at least
�—Wall Thickness two State Roads or County Roads.Include the road
12. CASING: numbers and moron road name n
Depth Diameter
ight/FL, Ma_ tjri n e.l'C Ci
From O To Ft 1
From To FL
From To Ft. C_ t"
13. GROUT: Depth Material Method
t r
From Q_ToFt. -r�✓��, �� Y _a Q N =;
From 3 To Ft. L? {ir��^"��"�����-v-'`s[ 1 CO :a
14. SCREEN: Depth Diameter Slot Size M erial V From To Ft. in. in. CJtLn
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�I - cnSCr ')- aa- os
SIGNATURE OF PERSON C STRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Inforntafipn)4lsaap meotr4617-MstilSecrice_Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
s , — g pi REV.09/2004

00
WELL CONSTRUCTION RECORDS 1_ 4 f 0 6 Js- t `� -7 7to
5 0 6 r 1� ' (D I O ,
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (prinQ u - CERTIFICATION#C.�� �'r.
WELL CONTRACTOR COMPANY NAME12
PRONE # 5 n
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential.& Mumcipal/Public❑ Industrial❑. Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCA N: Topographic/Land setting
N arestTown: County, ack
" ❑Ridge ❑Slope ❑Valley 1plat
(check appropriate box)
(Street Nan umbers,Community, ubdivnn isiio ,LotnNo.,1 it Code) Latitude/longitude of well location
3. OWNER: k v` t `1,K� eje, (degrees/minutes/seconds)
Addres C) Z Latitudellongitude source:❑GPS❑Topographic map
� ( (S a or to No.) (check box)
l9 1 l t VYN b U-3 e, �7a DEPTH DRILLING LOG
rxQ
Giryor 9 r Sr f n zip Code From To FotmationDeicription
Area code-Phone number
4. DATE DRILLED 711
3 ,C5
5. TOTAL DEPTH: ,_ —Je
6. DOES WELL REPLACE EXISTING WELL? YES`fJNO
7. STATIC WATER LEVEL Below Top of Casing: 0 T.
(Use"+-if Above Top of Casing)
8. TOP OF CASING IS r FT.Above Land Surface'
-Top orcasing terminated aNar below land surface requires a _
variance in accordance�!tq 15A NCAC 2C.0118.
9. YIELD(gpm):�METHO OF TEST' k'
10.WATER ZONES(depth): .,— �a 1�__
v 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/FL Iy to al numbers and common road names.
From D To Ft.� � 2( 1{� _
From To Ft.�T
From To Ft.
13. GROUT: Depth Material Method
From0 To_ i Ft.
From To a Ft.
14. SCREE Depth Diameter Slot Size Material-
From
To Ft. in. in. •'L zb
From To Ft. in. in. C
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. CA
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
1r C ► it n,,. 7--aO- 0 5
SIGNATURE OF PERSON CONSTR CTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30.days.
1 _ fry8FV.09/2004
4,
V r'-i'

NC ?_/ UIVNEN MIVU
WELL CONSTRUCTION RECORD
Not Or Carolina-Dcpai Wtenl of L'nvirorunent and Natural Resources-Division of Water Quality-Oroundwater Scclion
WELL CON"IRACIOR(INDIVIDUAL)NAME (print) /�''l �L"°eG CERI WICATION It o?y43
WELL CONTRACT OR COMPANY NAaIE // r11014E A f Q)�1I'�Sr17
STATE WELL CONSTRUCTION PERAIII0 ASSOCIATED WQ rt"11101
(ifnpplicnble) (ifnpplicnblc) _ "
1. WELL USE (Check Applicable Bon): Itesidenlini W Municipal/Public CI Industrial ❑ Agiiculluial I]
Moniloting❑ Recovery 17 Ilcat Puulp Wa1cr hljecliml LI Other CI If 011ier,List Use
2. WLLL LOCATION: `/ Topogrnphic/Land soling
Newest Town: r-4E'/fife County l'icbo'r IJR)dge []Slope Malley LIFlal
_f"(�itY'lC�JCi Rd - (check appropriate boa)
(Sued Naim,Number,Conmrutity,Subdivielor,Lot No.,Zip Code) LaliluddlOrigilutse of well location /t
J. OWNER: />OVIe 6017 (dereee)mlmrtesIffmon(r)
Address GA P�PAZ (fe;7P• Latihdde/longilude sotlrce:OGPSOTopographic neap
(Street or Route No.) (check boa)
DCPTI IZLt Ll luELVti
City or Down State Zip Cowle Front TO Fornialiolr Description
Act&code-Phone number d L Q
4, DATL% DRILLED 2— %- -le-
5. TOTAL DEPTI I: ;2,6 Z-
6. DOES WELL REPLACE EXISTING WELL? YES L1 NO 1J�
7. STATIC WATER LEVEL Below Top ofCnsiog: 5- 0 vr.
t (We,,+-If Above lap of 04ing)
8. TOT'Or CASING IS 1L I-I'.Above Lnud Stuface•
•Tep of trrrtne Irnnlnaltd Wor brlow land nnfare requhtr a
•ailance In accordance with ISA NCAC TC.OIIa.
9. YIELD(gpm): S_hiE'CIIOU Or TEST /�
10. WATER ZONES (depUl):
LOCATION SKETC.)
11. DISINFECTION:Type_/?TN Amount l4 t Z Show direction and distance In miles from at least
12. CASINO: Will I hickness two Stale Roads or Comity Roads. Include We road
llcplh_ Diameter or Weight/Ft. Material numbers and collation road names.
From To S 7 r(. 6-�J_ -VW Z1 iac'
From � 7 7 0 1:1. 6- 21 /sD e`
From To rl
13. GROUT: DepW talesf tat cWod
Flour C_To V _FI. (un�
Flour_ _To �O 1:1. 4,1 z �y�L—
14. SCREEN: Deptli Dimuelcr Slot Size Materinl JJ�
Froth To
riour To_fl. in.
13. SAND/GIt-AVI?I,PACK: �
Depth Size Mnlelinl
Flom
From lb Ft. a
16. REMARKS:
I DO HEREBY CERTIFY I"IIATTI IIS WELL WAS CONS IRUQ14'Q)N ACLT)IU4ANCE WITiI IAA NCAC 2C,WELL
CONS7RUCC ION STANDAIWS,AND TIIATACOr OrTlll$II ��RDIIASBHBNPROV16EPT©TIIE WELL OWNER
%µ �GL q 2i.O
A'
SIGNATUIILO�CONSTRUCfINOTDEWELL DATE
Submit the origliml to the Division of Writer Quality,Gr(iundtiXy Ellgtl;_�Gati h1aIl,Service Cer -1 RLIV.07/2001
gh,NC
27699-IGJG Pliuue Nu.(919)7JJ-J221,Ivilhbt JU dnys. — -- OW-1 REV

NC — --- 0IMEI? -------- C# HIM -------
WELL CONSTRUCTION ltLC01W
NoiUl Cniolina-Depathucnl of L'nvitmuneul told Not 1a1 Resources-Division of Water Quality-Otoundwaler Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prhd) Aea e CERTIFICATION P
WELL CONTRACTOR comrANY NAa1E !��" PHONE s 1A(9)8f7"R fY9
STATE YVELL CONSTRUCTION rERa11TN ASSOCIATED 1VQ PEMIITN .
(if applicable) (if applicable)
1. WELL USE(Check Applicable Dux): Residential LJ�hlwdci)ml/Public CI ludualrial Cl Agticulttual L7
Monilm ing❑ Recovery ❑ I Ical Pump Walcr Injection❑ Other❑ If OUler,List Use
2. WELL LOCATION* _a�bm ❑ TopographidLand selling
Ncarest'l'uwn: Ce'ebz Counly JRidge []Slope alley ❑flat
(�() LLI,454 "1y /i't (chnk.PProprinle box)
(Suret Name,NumFerr,Cunmmnity,Subdivision,Lot No.,ZIP Cale) Latiwdellongilude of well iocalitnu
3. OWNER: Cu-//I erooll VO/7G a (dearerelminnta/secondQ
Address Latiluddlongilude source:❑OPSOTopographic null
(Street Or Route No.) (clink box)
VEPTI MULLIN0 L2Q
City or Town Stale Zip Cale Frorr To Formation Dc5cliption ,
Ales cafe-rhnne number b J�
4, DATE DRILLED 6 —6/-0) 20 — Sad
5. TOTAL OFPT'11: 5 60
6. DOGS WELL REPLACE EXIS'ITNU WELL? YES IJ NO
7. STATIC WA-I ER LEVEL Below Tell of casing: I I'.
L (use-+-Ir Above l'np or Ceslnx)
S. TOP OF CASING IS / L Fr. Above Land Sullecee
.-top or oslnr Irnnln.ted OV.r below land sun r.ce requhn a
♦srlmre in snordsoce with ISA NCAC IC.atla.
9. YIELD(gpm): _METHOD Of TEST ,/&
10.WATER ZONES (depth): y LOCATION SKt'T01
c CASING: Show direction and distance in miles from el(cast
12. C
1 I. SNG: ION:'t'ype f��� AtuOOOI Wall � two Slate Roads or County Roads. Include We road
DCpUt Dimncter or WcighuFl. 5 qtele l numbers and couunon road names.
Finis _To_$Ll rt. 6,Q ,L8 1
Rout To—Fl.
ft°In T° FL
13. GROUT: DepUt late iot ,Hind
Crone D To 3 ft. 6✓'/ 'r
rtDm Ta 30 1:1. 1/Z
14. SCREEN: Depth Dim lder Slut Size Material
From To Ft. iu, in. ��j� 1�3
Emnu 'ro FI. iD, iu. ,�� L
15. SAND/GRAVF-L PACK:
Drpllt Size Motel lot
From fu I'1.
Front 'fo FI.
Ili. REMARKS:
I DO I I ERE EY CERTIFY THAT TI IIS WELL WAS CONSTAUO EO INACCORDANCE Will],IJA NqAC 2C,WELL
CONSTRUCTION STANDARD S NDT A'fACOPYOF17il�RECORD�IAS�L N7']COVIDI'DTbTiIEWELLOWNER
etie maser A(1G 9 2005 �. - D� OS
SIGNATURE 01:PERSON CONS]RWC11N0 T 11E WELL I DATE
lJ ' `Fl ` &rvic jCenter-Raleigh,NC
Submit the artninal to the Division of Water Quality, t ,L
27699-1636 Phone No.[phone],Wlthh130 days OW-1 REV.07/2001

314297
.WELL CONSTRUCTION RECORD
. ' .
North Catolina-Department of Envirorunent and Natural Resources-Division of Water Quality--(Irowtdwater Section
WELL CONTRACTOR(INDIV•IOUAL)NAMB tprht)eh� TIFICATIONa �l'l
WELL CONTRACTOR COMPANY NAMPHONBi S"Z 1•!-'3 a;-6 'D
STATE WELL CONSTRUCTION PERMIT# AstgocuTED W 6RMrrs
(irapplicabte) • -(ifapplteable)
1. WELL USE(Check Applicable Box):Res)dential' unicipal/Public 0 Industrial❑ Agricultural El
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other EF If Ot)ier,List Use
2."WELL LOCATION:
Nearest Town: S V CountyJA Ch S urJ Topograp�idLtind salting
C)Fidgii Mope #Valley ❑Fiat
f2 /} Z£/ lintl/hid 02 7 9 (cheek appropriate box) i
(Sweet Name.Numbers,Com anih ,Sabdiviii lot No.tip Cede) - Lat(tude/longitude of WOII location '
3- OWNER:J / t'1CAr?r �n-�I�I 412-Cv (dearxJmiauuJaeconda)
Address `N O ,F,3 D x .F 9 D Latitude/longitdde source:❑GPS❑Topographic map
(Suet or RouteNo.)L r�, (check box)UC u .�E_c T (711 , 017� . 3 01(L 1f DEPTH DRILLING LOG
C orrowo State Zip Code. From To
'Formation Description
-
DSO- -? ��7--7-s1�
Area code-Phone number
4. DATE DRILLED 7-
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO. 9
7. STATIC WATER LEVEL Below Top of Cuing. /D D FT:
(Use"t"If Above Top of Cuing) �7
8. TOP OF CASING IS�_FT.Above Land Surface* � t
'Top of cuing terva uated actor bda 1Md.sar4te requires a - N
variance In aceordaaee wok ISA NCAC 2C.O11A
9. YIELD(gprn): -3 METHOD OF TEST
10.WATER ZONES(depth): Ln
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 To FL Di ter$or Wei�llt/FL Matetia numbers and common road names.
From a 4
From To FL
From Tp FLU_
13. GROAT_ Depth .Material n�Met�hod, -
From To-.-�D—FL -
From To 'Ft. -
-4. SCREEN: Depth Diameter . Slot Size Material - -
From To Ft tn. in.
From To FL in. in,
5. SAND/GRAVEL PACK:
Depth Size Material - -
From Tc Ft.
from To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C.WELL -
IONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN PIf 0Y1DED TO THE WELL OWNER
SIGNATURE-Of PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
;71699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

314296
.WELL CONSTRUCTION RECORD"
North Carolina-Department of Environment and Natural Resources-Division of W eter Quality--Oroundwater Section
WELL CONTRACTOR(INDIVIDUAQNAM►. (p dc).9hyLS J JIi3a:d. � ' - `• -CP.TMCATION' �7IP
WELL CONTRACTOR COMPANY NAM •'
STATE WELL CONSTRUCTION PERMITI A_SSOMATED W SRKM '
(if applicable) •(ifWplicable) -
1. WELL USE(Check Applicable Box):Residents al'Id- MunicipaVPublic❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ . Other C1 If Oilier,List Use
2.-WELL LOCATION: TWgtaptidl dsetting
Nearest Town: Coimty�J . C C. va'� ORIdge ❑Slope Walley ❑Flat
C• /--'n 2le led .�k'7? g (dis* ppropriawbox) . , "
(Street Name,Numbers,Community,Subdivision,tat No..Tip code) Lptitudellotigitude of well location
: / f 3. OWNER / Q5f2.Ie- �f�-,X W 04, . (deytee�miautalaaonda)
Address D. Id 6 X z o l J. LatitudeAongitdde source:❑GPS❑Topographic map
S
(Stromor RanuNo.) p (cluck box)ir ii lL Al (7� 4 0 '7 9 2 DEPTH DRILLING LOG
c' br Town State 'Zip Code From TO, Formation Description
(� 5D 8-9 2 a U n 3
Area code-Phone awnber
4. DATE DRILLED `I --1 3 -V E
5. TOTAL DEPTH: OS`
r
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO- 3
7. STATIC WATER LEVEL Below Top of Cuing:J O O FT: ry
(Use"+'if Above Top of Casing) r-
8. TOP OF CASING IS_�FT.Above Land Surface' N 3
`Top of cuing terminated actor bdgw lost rurfap requires a
varinu In accordance with ISA NUC 2C.011a. T
9. YIELD(gpm): �jL METHOD OF TESTj(. aa_#:_ Ln
10.WATER ZONES(depth):_ _19n fl
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
Depdk� D' ter .or WeiighUFL Mate' _ 'numbers and common road names.
From_Q . To Ft. t�
from To FL
From Tq FL_T - - -
13. GROUT: Depth MateriA Method -
From_ a—To-.-O—FL_Z0
From To
4. SCREEN: Depth Disrneter Slot Sin Material - - -
From—To—FL—in. in.
From To Ft._in. in.
S. SAND/GRAVEL PACK:
Depth Size Material -
From To Ft. - - -From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL-
ONSTRUCTION STANDARDS,AND THAT nA COPY OF S RECORD BEEN PROVIDED TO THE WELL OWNER
- - ) 14 1 7-1 3 - 6-5
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh;NC
r7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

31440 -S c� �
WELL CONSTRUCTION RECORD 7� �U 2-5aa,
North Carolina Department of Envir rat and Natu I Res sites-Division of Water Quality V //[[
WELL CONTRACTOR (p ) 7az X//�f�� /Q/g(/, �7'
(.INDIVn)UAL)NA.ME riot ^t=(_iF:+z��r �! o CERTIFICATIONq C7
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE N [phone]
STATE WELL CONSTRUCTION PERNnTW ASSOCIATED WQ PERM1nTk /
(if applicable) (if applicable) _
1. WELL USE(Check Applicable Box):Residential'Municipal/Public❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water n)ection❑ Other❑ If Other,List Use
2. WELL LO 'AT V �
. _ > Topographic/Land settins G n
Nearest`>T,o Va: County h Ridge VSlope OValley ❑Flat t" t.
(theck appropriate box) tJ
(Street Name,Numbers,Community.Subdivision,Lot No., rp e) 4l ,La[itude/longiNde of well location
3. OWNER: `'JV� (degredminutes/seconds) S
Address Rom_ Latitude/longitude sourec:OGPSOTopographic map
(Street or oure No.) / (check box)
DEPTH DRILLING LOG
City Tuw- State zip Code From To Formation Description
828 - CE
Area code-Phone number
4. DATE DRILLED ! - ) `0� // F 7
S. TOTAL DEPTH: J
6. DOES WELL REPLACE EXISTING WELL? YES O NO I!r
7. STATIC WATER LEVEL Below Top of Casing: W FT. -OL
(Use"+"if Above Top orCasing) a
8. TOP OF CASING IS I FT.Above Land Surface'
'Top orcasing terminated actor below land surface requires a
variance in accordanc
e-4
itb 15A NCAC 2C.8118.
9. YIELD(gpm): METHOQQ OF TEST t/-'1
10.WATER ZONES(depth): S
p LOCATION SKETCH
It. DISINFECTION:Type unt oQ. Show direction and distance in miles from at least
12. CASING: Wall Thickness o State Roads or County Roads.Include the road
Depth Diarricter or Weight(Ft. Material numbers and common road names.
From_d To /D Ft.-`o 5On 21 P
From To Ft. - —
From To Ft.
13. GROUT: Depth Material Method
From _To�Ft.
From_j To Ft. _
14. SCREEN: Depth Diametcr Slot Sizz 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 M ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS'THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
'>� S /2, '_�
SI&IATM OF PERSON CONSTRUCTIING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

v�
WELL CONSTRUCTION RECORD 71.O��-5 * -- Iac
North Carolina Department of Environment and Naturall Resources-Division of Water Quality ' r
WELL CONTRACTOR(INDIVIDUAL)NA.NIE (print) ry fZ . Ja�2 L¢l _ CERTIFICATION#_a�o ,n. .
WELL CONTRACTOR COMpA.NY NA}IE AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # [phone] _ o p�
STATE WELL CONSTRUCTION PER:NIIT# ASSOCIATED WQ PERNITT# (`ij`'�
(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 r
Nearest Town: L am`' County I\\V J ❑Ridge Slope ❑Valley ❑Flat ,
7 _ _ (check appropriate box) -e,
(Suez[Name,Numbers,Commumry,Subdivision,Lot No.,Z p Code) v-V a Latitude/longitude of well location p` - eg
3. OWNER: (degrees/minutes/seconds)
Address ' Lautude/longitude source:❑GPS❑Topographic map
tree or c to No.) (check box)
DEPTH DRILLING LOG
Cityor Town Stara zip Codc From To Fo a �Description
i o23 Area code.Phone cumber
4. DATE DRILLED '�5 - 10 _V _lad;
5. TOTAL DEPTH: -3 SZ
6. DOES WELL REPLACE EXISTING WELL? YES Cl NO
7. STATIC WATER LEVEL Below Top of Casing: "_FT. —3
(Use-+"if Above Top of Casing) O�
8. TOP OF CASNG IS ( FT.Above Land Surface*
-Top ofcasing terminated atlorbelow land surface requiresa
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): '40 ME HOD OF TEST A l l�
10.WATER ZONES(depth): '� O
L LOCATION SKETCH
11. DISINFECTION:Type�� Amount Show direction and distance in miles from at least
12. CASNG: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/FL _[vletey numbers and common road names.
From To _ t. Sb2 2t.. �..11
From To Ft.
From F De L
J2-/'CAL t' J
13. GROUT: Depth Material Method
From To Ft. -
From To_2ed _Ft. .� LA)
14. SCREEN: Depth Diameter Slot Size Mat at
From To Ft. in. in.
From To Ft. in. in.
15. SANEIGRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA RDS,AND T AT A 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,Attn: Information Management,1617 Mail.Service Center.
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
',GW-1 REV.09/2004

NC _ ✓ _ OIVNEIt ------- MirB -------
WELL CONSTRUCTION RLC01tll
314432
Nolat Carolina-Dcpartrncat of Envirumnenl mid Nn ural/R/esouurces-Division of Water Quality-Oroundwaler Scc"ugrr�/n
WELL CON TRACTOR(INDIVIDUAL)NAIVE (print) e�lY /1•e'eL� CERIIFICA-tIONN
WELL CONTMCIOR COa1rAN)'NAPIE
/ x� r1IONE N (gfir012rriJ
ONSfttUC11ON rE
WELLC " MtIT"N ASSOCIAT'ED VVQ PEMII.10
STATE
(iONScnl lc) (if applicnblc) `"-
1. WELL USE(Check Applicable Dox): Rcsidculial 1]4-*'�MuntcipaVPublic❑ Industrial d AgliculWtal Ll
t Iouiloring CI Recovery O Beat Pinup Water htjection CI Other 11 If OUrer,List Use
2. WELL LOCATION- /( 'lbpographie/Land selling
NcareslT/',uwann:, CJJt/OCCG County Jack
en OWdge []Slope ❑Vnllcy Ul-lat
�IVp✓/(G d.�n�/1. Latiludellonitude of well location
appropriate bra)
(Sueel Neme,Number,Community,Subdivision.Lot/ l No.,Zip CoJc) g
3. OWNE11 or of 604-- _ (delreealminote✓recnnd.)
Address G✓D on cc ion LaliwJdlougilude source:UiGpso opographic crap
(cliftit box)
(Sneer or Route No.) RUM 1 LL-lNO LW
City or Town SUIe Zip Cale
From To Formation Description
C—) n , ra r
Area cede-rhone number
4. DATE DRILLED
S. TOTAL DEPTI E.
6. DOES WELL REPLACE L'XIs'1'INO NYLLL7 YES O NO W _
7. STATIC WATER LEVEL Below Top of Cnsiug: 3—Orr. _ p
y (Use"i"Ir Above Tnp of Csaina) n
B. TOP Or CASINO IS /Z IT.Above Lard Surface" l `
-Top of raring lerrnlnded wer below land surface requires a
Variance In acwrdatice with ISA NCAC IC.011 a. O I"
9. YIELD(grin): 6- —hIEf110D Or TEST ZL!
10.WATER ZONES(depth): PZ-5 A
LOCATION 5KE'rC11
//T Amount �(� Show direction and distance in miles frmn at least
It. DISINFECTION:Type
Wall 7lti —Pq two State Roads or County Roads. Include We road
12. CASING: g numbers and common goad names.
kness
DcpW Uiarnc�cr or�9ci hurl. Molerial
Front To77 Ft.
rrolrt 7 y To /00 Ft. LeW
/f!b Sfee
Prom To FL
13. GROUT: DepW 9t9rial/ Wod �N Vet�r
Front) To'Ft. oPT7`✓lc. r"» ec.
Rom q _To 30 Ft.
14. SCREEN: DepUr Diameter Slot Size Malerial
Frain To Ft--ill— "I' h f) (,-eel<
From ru FL—ill. in. wl't y
15. sAND/GRAVI?LPACK:
Depilt Size Mntelial
rrom To rt.
trout_ fo FL
16. REMARKS:
1 DO HEREBY CERTIFY TIIATTI IIS WELL WAS CONSTRUC 12D IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TIIATACOPY OFTI[IS RECORD IIAS BEEN pROVIDEDTOTIIE WELL OWNER
SIUNAIUREOFPLRSONCONSIRUCIINO Jim WELL DATL'
Subndl the original to the DIVIslon of Iva ter Qunl(ty,Croulldsra(er Section,1636 Mall Service Center•Raleigh,NC
1169 9-163 6 rItitne No.(9I9)733.3221,111 Ithhl 30 dnps, OW-1 REV.0712001

314 ,126
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section //—r
/ 4
WELL CONTRALTOR(INDIV,IDUAL)NAML (prlaQsiwr 1) "'�dl ' a: Cil`TIP[nCA170/N9 /
WELL CONTRACTOR COMPANY NAM PI[ONn a EFii1 —.��y"3 a�'6
STATE WELL CONSTRUCTION P&Rmrro ASSOCIATED w BRMITa
Orapplicable) •(ifapplicable)
1. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial❑ Agricultural Q
Monitoring❑ Recovery ❑` Heat Pump Water Injection❑ Other CI If Ot*List Use
2."WELL LOCATION: iWO9178A.M it setting
Nearest Town: CountyJR•CIC5o>ti+ (midge ❑Slops ❑Valley ❑Flat
Her c r ul 1— t D (check appmprfakbox) -
(Su me et Na ,Numbers,Community,S" Lot No.. Cade) - LatiludeA.on tude of wol)location
' � � 1eA ag� -1 / 7
3. OWNER: gv I� � t � . (degreea)miautceheconds)
Address 5hr/ZT4RAV8 d e n e R, Cot1.,,1t7; e.)0 B Latitude/Ionginide source:❑GPS❑Topographic map
(Saco ar Roma NoJ (check box)
(1 hal"I0It _ ;tl C_ oZ DEPTH DRILLING LOG
City«Tows Suu Zip code From To Formation Description
Area cod�Phone aninbor
4. DATE DRILLED rJ oZ �O S
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO:_ a
7. STATIC WATER LEVEL Below Top of Cuing. las FT. c
(Use tr if Above Top of Cuing) , I r,}
S. TOP OF CASING IS—�—FT.Above Land Surface' f V
`Top of casing termtuted atior bela-risa Surfaace requires a O
variance In accordance Mtb 15A NCAC 3C.911L 4Ln
9. YIELD(gpm): � L4_METHOD OF TEST &I x
10.WATER ZONES(depth): �.ZL ' /
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 road
Depth D�'ap er or Weom Material 'numbers and common road names.
FromTo_J�/-_FL_ jb._S Y '(+
From To FL
From Tq FLU_
13. GROUT: Depth Material Method
From_To FL�Q¢7d_F .
From To FL i- -
4. SCREEN: Depth Diameter . Slot size Material
From To Ft. in. in.
From To FL in. in.
5. SANDIGRAVELPACK:
Depth Size Material
From To Ft
From To Ft. I
.--
6. REMARKS:
DO HER CERTIFY THAT THIS WELL WAS CONSTRUC=IN ACCORDANCE WITH 15A NCAC 2C,WELL
'ONSfRUCTION STANDARDS,AND THAT A COPY OF TMS RECORD BEEN P40VIDED TO THE WELL OWNER
0
SIGNATURE-OF PERSON CONSTRUCrINO THE WELL DATE
submit the original to the Division of water Quality,Groundwater Section,1636 Mail Service Center-Raleigh;NC
p7699-1636 Phone No.[phone],within 30 days. GWA REV.07R001

WELL CONSTRUCTION RECORD 15 18 5
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE S [phone]
STATE WELL CONSTRUCTION PERMITS 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 LOCATI II ����,,� """""" ��`��` �,,,, ''''''"""""" '''''' Topographic/Land setting
Nears Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Strett Rame,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address / Mir Latitude/longitude source:❑GPS❑Topographic map
geet'or Ro�'�` oJ (check box)
WV ag789 DEPTH DRILLING LOG
City or Town St6te Zip Code From To Formation Description
8( 28 )- rJ'$�• 02V 0 J/b Clay it Sand
Area code-Phone number � Granite
4. DATE DRILLED
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)
8. TOP OF CASING IS 2 FT.Above Land Surface•
"Top of casing terminated at/or below land surface requires a
variance in accords ce with 15A NCAC 2C.0118.
9. YIELD(gpm): _MET 3D 9 TEST BLOW
10.WATER ZONES(depth): /I
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth ,I Di eter or Weight/Ft. Material numbers and common road names.
From 0 TO '�Ft. q&&Q
From tt To Ft. _
From To Ft.
13. GROUT: Depth Material Method **+
From 0 To 20 Ft.Benonite a Cement pumped p 3
C
From To Ft. G)
r=.i
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. ;a
From To Ft. in. in. o
ul
15. SAND/GRAVEL PACK:
Depth Size Material �3
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 ST ARDS,AND T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG-NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

to
WELL CONSTRUCTION RECORD a q v_ m 1
North Carolina Department of Environment and Natural Resources-Division of Water Quality 0 d
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE # ( )369-9591
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 LOwn: ' ®®®��- dgeTop 0 lope Land setting
Neares town: County ❑Ridge ❑Slope ❑Valley ❑Flat
' (check appropriate box)
Aa/
(Street Nam ,Nu era,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street Route No.) (check box)
offy DEPTH DRILLING LOG
C11 Tow: g o State Zip Code From Formation Description
ry�0-,- 0 Clay&sand
Area code-Phone number r 00 - Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO +'L
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated attor below land surface requires a
variance In accordant with 15A NCAC 2C.0118.
9. YIELD(gpm):_J ___ME OD OF TEST BLOW
10.WATER ZONES(depth): Q //71 LOCATION SKETCH
11. DISINFECTION:Type HT H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di ate r or Weight/Ft. Material numbers and common road names.
From 0 To�Ft. � /8g �
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method _',$
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft.
33.
14. SCREEN: Depth Diameter Slot Size Material CC=
From To Ft. in. in.
From To—Ft—
in. in.
15. SAND/GRAVEL PACK:
Depth Size Material N
From To Ft. 711
From To Ft.
ta4
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION 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,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 3 15
� © tit
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#22045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE 0 ( )369-9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential © Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION Topographic/Land setting
Nearest Tow County ❑Ridge ❑Slope ❑Valley ❑Flat
�, (check appropriate box)
(Street ame,Nu is,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude Of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Su t or R ute (check box)
DEPTH DRILLING LOG
City o ow Sta Zip Coe From Tyyy��� Formation Description
pya(- 5��e Clay it sand
Area code-Phone number Granite
4. DATE DRILLED /5
5. TOTAL DEPTH: 1g0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO K
7. STATIC WATER LEVEL Below Top of Casing:_o _FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated avor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 80-t _METHOD OF TEST BLOW
10.WATER ZONES(depth): L(d 111T — LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Q Diameter or Weight/Ft. M te te numbers and common road names.
From 0 To D Ft. ` ---
From�To Ft. A��d�—
From To Ft. '
13. GROUT: Depth Material Method r-s
From 0 To 20 Ft.Benonite&cement pumped 3 . Mr
From To—Ft. C
c= —,
14. SCREEN: Depth Diameter Slot Size Material _ ITI
From To Ft. in. in. rn 73
From To Ft. in. in. 0 re
15. SAND/GRAVEL PACK: to
Depth Size Material
From To Ft. ii
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND RDS,AND THAT A CO Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699.1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD -1 8 2
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION 4 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE a ( )369-9591
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMITN
(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: ! � p�j y��� Topographic/Land setting
l �tToyvnt4Yk;`J Mo CountT� ❑Ridge ❑Slope OVaoey ❑Flat
O,(�/ �'"� (check appropriate box)
(Street Name,Numbers,
Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: / //L�� /�Ci5Kl7V. (degmes/minums/seconds)
Address aa Latitude/longitude source:OGPSOTopographic map
(Street or Route No. (check box)
DEPTH DRILLING LOG
try or T wn toe zip Code From To r Formation Description
� - 0 '70 Clay&sand
Area code- hone number T Granite
4. DATE DRILLED/ 70' 3t�
5. TOTAL DEPTH: �b
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /O0 T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface•
"Top of casing terminated atlor below land surface requires a
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):If METHOD O T S„T BLOW
10.WATER ZONES(depth): a 10 L�
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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. lo
From�ToFt._(� f7-1
From To Ft. j
13. GROUT: Depth Material Method
-
From 0 To 20 Ft,Benonite&Cement pumped C
From To Ft. c-3 r-+
14. SCREEN: Depth Diameter Slot Size Material —Cn
Lr.?
From To Ft. in. in.
From To Ft. in. in. p fe
15. SAND/GRAVEL PACK: fs
Depth Size Material
sr
From To Ft. f+$
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD 0_ O
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # ( )369.9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential (J Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIQ;y. Topographic/Land setting
Near�si/rTown:—Z ��,. —County4 ❑Ridge ❑Slope ❑Valley OFlat
�( YLCL1 m _ L1dA (check appropriate box)
(Stret Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
dak
3. OWNER: XA (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street orF to No.) (check box)
DEPTH DRILLING LOG
-City'OrTowd state Zip Code From Formation Description
cam- 5 $ T Clay it sand
Area code-Phone numberer r560, Granite
4. DATE DRILLED5�Q_—
5. TOTAL DEPTH: O4t
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: V040 T.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.01I8.
9. YIELD(gpm): /a METHOD OF TEST BLOW
10.WATER ZONES(depth):� y3p{ � LOCATION SKETCH
IL DISINFECTION:Type H T H Amount 16oz 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 Weig t/Ft. Material numbers and common road names.
From 0 To�6Ft. .Jr' �� . l'S�
From R To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.aenonite&Cement _pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material CZ
From To Ft. in. in. c "�
1..
From To Ft. in. in. rn
15. SAND/GRAVEL PACK:
Depth Size Material C
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 ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IGN T RE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
-- GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 3 15 1 S' 0
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION M 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE M ( )369.9591
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMITM
(if applicable) (if applicable)
1. 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
Nearest Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
#�3n ^� A (check appropriate box)
(Street Name,Numb rs,Community, ivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 6 - (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route o.) (check box)
�� .34&,9.Z DEPTH DRILLING LOG
Cityor Town Sni�}I Zip Code From To Formation
Formation Description
(,� - 5 ' bl Y'/ Clan it sand
fod
Area code-Phone number Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO K
7. STATIC WATER LEVEL Below Top of Casing:. FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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 —METHOD OF TEST BLOW
10.WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 Wet t/Ft. Ma era numbers and common road names.
From 0 To /,:2g?,Ft.--&•• BLS L
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. cri
From To Ft. in. in. 5
15. SAND/GRAVEL PACK: ro 4
Depth Size Material
From To Ft. 'J
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
77
SIriNATCRE OF PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD Ek 1 if
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION N 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE # ( )369-9591
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 LOCATI N: i Topographic/Land setting
_eara_s�Town County, ❑Ridge ❑Slope ❑Valley ❑Flat
��d•L�1—CO.r„'h�e1Lz,— el(J I yrT�ft�f/� (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zrp Code) Latitude/longitude of well location
3. OWNER: (degrees/minutcs acconds)
Address Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No. (check box)
as�83 DEPTH DRILLING LOG
i Zip Code From To Formation Description
��d�L,pyC�ity or T wn a P 0 Clay&sand
Area code-Phone number Granite
4. DATE DRILLED rJ ,iy e
5. TOTAL DEPTH: Lt•"t�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: '+b FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
*Top of casing terminated atlor below land surface requires a
variance in accordaaye with 15A NCAC 2C.0118. BLOW
9. YIELD(gpm): _METHOD OF TEST
10.WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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.
From ft To Ft.
From To Ft. -`
13. GROUT: Depth Material Method
Benonite&Cement pumped
From 0 To 20 Ft. P P r�
From To Ft.
C
14. SCREEN: Depth Diameter Slot Size Material G-t ^^r
From To Ft._in. in. '
From To Ft. in. in.
15. SAND/GRAVEL PACK: O
Depth Size Material cn -
From _ To Ft. -:
From - To Ft.
16. REMARKS: Ix ) i2 � 117.o
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S GNAT F PE SON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 315 178
WELL CONTRACTOR(INDIVIDUAL)NAME (print) JameS B. Brown CERTIFICATION a 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 19 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : � � Topographic/Land setting
Nearest Town: County l)L1(,IQX� ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,
Lot No.,Zip Code) Latitude/longitude of well location
I,(/3. OWNER: K (degmes/minutes/seconds)
Address / fEdeVUa6Ath Ed Latitude/Iongitude source:❑GPS❑Topographic map
(Street or Route No.) ^�� (check box)
AAa"Aq(�I pf� a DEPTH DRILLING LOG
City or Tom Fate Zip Code From o Formation Description
(e28 - iy9� Clay it Sand
Area code-Phone num r p Granite
4. DATE DRILLED!A 'aZ•on
5. TOTAL DEPTH: '.Tco'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO,.F�
7. STATIC WATER LEVEL Below Top of Casing: /(DO_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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):�g�METHOD OF T'�/ST BLOW
10. WATER ZONES(depth): .3 755 t `t�1E-
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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�FL " ,LP
From It To Ft.
From To Ft. c3
13. GROUT: Depth Material Method
From 0 To 20 Ft.aenonite a Cement pumped a m
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. p�
From To Ft. in. in.
15. SAND/GRAVELPACK: CD
cn �M
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 S NDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATION-� ' , Topographic/Land setting
Near tTown:� ,�M/V4. County ❑Ridge ❑Slope ❑Valley ❑Flat
�4 IA h r 1P (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
'] DEPTH DRILLING LOG
City or wn Sta Zip Code From To Formation Description
828 _ — 0 114, Clay&Sand
Area code-Phone number 114 40A Granite
4. DATE DRILLED 4 D
5. TOTAL DEPTH:PTH: '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:y5C) T.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated atlor below land surfs"requires a
varlance in accordance with 15A NCAC 2C.0116.
9. YIELD(gpm): JOt METHOD OF TEST BLOW
10.WATER ZONES(depth): 14R'1T � LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From o To�Ft.&_ ./5i7 goo
From It To Ft.
From To Ft.
13. GROUT: Depth Material Method c�
From 0 To 20 Ft.Benonite&Cement pumped a
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material _
From To Ft. in. in.
Q%
From To Ft. in. in. -`
15. SAND/GRAVEL PACK: rC `�
Depth Size Material From To Ft. `:'3
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIONATM OF PER ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699.1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD n 1
15' 170
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
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
Nears Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot N ., ip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
iry or own State Zip Code From T Formation Description
828 O Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED � I A S'
5. TOTAL DEPTH: 5b0'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 450 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
"Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. BLOW
ZOO
9. YIELD � D F�ST�_ —
10.WATER ZONES(depth):: y 77 LOCATION SKETCH
Show direction and distance in miles from at least
16o
12. CASING: Wal
11. DISINFECTION:Type H T H Amount ess two State Roads or County Roads.Include the road
l Thickness
Depth D' eter or Wei Ft. M erial numbers and common road names.
From c To Ft.
From�To Ft. /ter ,
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped a tr
From To FL
14. SCREEN: Depth Diameter Slot Size Material
it
From To Ft. in. _ in. ON
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 S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S
SIGNATU OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30days. - - - - GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Res ' ' ' fi;(ti,,. :t -
WELL CONTRACTOR(INDIVIDUAL)'NAME (p ources-D
rlut) c.-�(f%t I vision ofWatcrQuality-Oroundwa(erSection
WELL CONTRACTOR COMPANY NAMS,��hhr � llnwl ri
�+ --------» cutrfatcATloH r d l7 CP
STATE WELL CONSTRUCTION PERMIT# PHONE
(ifa lieable) SSOCIATED vv ERMIT# .
(ifa licable
I. WELL USE(Check Applicable"Box): Resident'iel'rd'Munici aVPublic❑ Industrial ElA
Moniloring❑ Recovery ❑ Heat Pump Water Injection O P Other 1 If Ondu List Use Agricultural[]
2. WELL LOCATION; T
C-1C
Nearest Town: S To
County�J S." ImrraPhi B
cland setting
-
LUrrae
C rJ r ge []Slope []Valley OFlat
(Si <t Nune N mben,Commumry,Subdmsion.Lot No.,Zip Code) .�77 (check appropriate box) x
3. OWNER: LatitudeAtingitude of Well location
�J ; ey,,.a„ 1 •A t2 n v tl
Address f X�] Ude p (deYroes7minutW.aonds)
I t �n�(sucet o RS C) Z qr ry LatitudeAongitude souree:DGPSOTopographic map
(�A
-- — rn e y (check box)
�}��CryrT n Snte Zip DEPTH DRILLING LOG
(.p..2,7- .B, 3n (% From -
Phone number - - 7 e Formation Description
Area code- (� �_ C-1
4. DATE DRILLED O L_ 5..--`--z_ - .D 7 e `Jp S• _jj(UQ.
5. TOTAL DEPTH: 90=_ —_ M4-%� r•a.
6. DOES WELL REPLACE EXISTING WELL? YES O NO 7. STATIC WATER LEVEL Below Top of Casing: a y :FT,
(We"t"if Above Top of Cuing)
FT.
8. TOP OF CASING IS�_ c
Above Land Surface* �'Top of cuing terminated at7or belgw lendaurtaee requires■ tV variance In accordance witk'ISA NCAC IC.01IS. ���� C+•)
9. YIELD(gpm):�_-METHOD OF TEST
10. WATER ZONES(depth); --- N
I I. DISINFECTION:Type L OCATIONr
12. CASING: AR10Unt Show direction and distance In miles from at least
WaI1 Thickness Depth two State Roads or County Roads.Include the road
From Din I or W�OtlFt. Mate ' I 'numbers and common road names.
�_To 0 Z Ft. Sr R,S ' D
From To Ft,
From To Ft
13. GROUT: Depth Material ntea nt al
From Method
From—�To To Ft
-pad"A
4. SCREEN: Depth Diameter From . Slot Size Material
To Ft. -in. in.
From To FL—in.
5. SAND/GRAVEL PACK: in.
Depth Size Material
From T° Ft
From To Ft. -. -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I WELL .
WE
2C,
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO Sp NCAC AC 2C WEELL OWNER
SIGNAL URE OF PERSON CONSTRUCTING THE WELL s,
DATE
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center
,17699-1636 Phone No.[phone],within 30 days, -Raleigh;NC
GW-I REV.0712001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of W '
WELL CONTRACTOR(INDIVIDUAQ NAME rtat afar QU811ty-QrOUndWa(Cr$ECf10n /�
U )��11 PI t Ir�/I n��� C"T[PICATION# of�7 i P
WELL CONTRACTOR COMPANY NAM '
STATE WELL CONSTRUCTION PERMIT# PNONE # l f/.- -3
(ifa lieable) 3SOCIATEDW ERMIT# .
{ifa licable -
I. WELL USE(Check Applicable Box):Residential'. znieipal/Public❑ Industrial O Agricultural p
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other C7 If 6t6r,List Use
2. -WELL LOCATION: _
Nearest Town: ��/ VGL Count !� 1 ,op°�PbidLand setting
dge OSlope ❑Valley OFlat
(Strew Name,Numbers,Community,Subdivision,Lot No.,Zip ode! (check appropriate box) '
LatitudeAongitude of Well location
3. OWNER:*(SL"el
�P/Address <: / , (degreeshminutea/seconds)
g,�oJ Latitude/Iongitude source:OGPSOTo 0
f S�&C - y ?� 6P(chack box) graphic map
C Y r own State
ZipCodc DEPTH From
DRILLIN . LOC
Phone
n b er q 7!4 To Formation Description
Arcs cock- numb c � '
4. DATE DRILLED -
5. TOTAL DEPTH: QJ SS, ' �-
6. DOES WELL REPLACE EXISTING WELL? YES O NO ;
7. STATIC WATER LEVEL Below To P of Casing:.f(u FT:
(Uwe"+"if Above Top of Cuing
8. TOP OF CASING IS Fr,Above Land Surface* �-Top of cuing terminated at/or below land Turfs"requires a rs
vartanae in accordance with ISA NCAC 2C.0118.
(gPm :
)
9. YIELD c 2
_ L METHOD OF TEST �_ —
10. WATER ZONES (depth): • S C:)Cil
ca'
--
I I. DISINFECTION:Type LOCATION CATIONSKETCH
12. CASING: �— OLLnt Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
From Depth Dia `ter or WeighUFl. Mate '' I 'numbers and common road names.
�_To�,z Ft. _5a R-2 1 D y
From To Ft.
From To Ft.
13. GROUT: Depth Material -
From Method
From—�To Ft.
To Ft._�_
4. SCREEN: Depth Diameter Slot Size
From To Materiel
Ft.__in. in.
From To Ft.—in.
5. SAND/GRAVEL PACK: in.
Depth Size Material
From To Ft.
From To Ft. �—
6, REMARKS:
i
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH NCAC 2C,WELL
S RECORD H BEEN PROVIDED TO THE WELL OWNER
�+
otuNAIUKtlOF PERSON CONSTRUCTING THE WELL 6 DATE
..s-Lbmit.the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center- t
.17699-1636 Phone No.[phone],within 30 days. -Raleigh,NC
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department ofBnvirortment and Natural Resources-Division of anti Water WELL CONTRACTOR(INDIVIDUAL)NAME (prtnt) , � :.:.Q tY'Groundwater Section
WELL CONTRACTORCOMPANYNAM � --1TIFICATIONY or-?/7(o
STATE WELL CONSTRUCTION PERMITY PHONi Y e2 I-1— o2G Q
(ifa lieable) SSOCIATED W ERMITY .
-(ifa licable
amom
I. WELL USE(Check Applicable'Box): Residential',., cl a l/PublMonitoring O Recovery ❑' Heat Pump Water Injection�um 0 p OtherlU If OthersList qe Agricultura60
2. "WELL LOCATION: _
Nearest Town:4h; 9; A, County JAC4C5faV To OgraPhie/Land setting
2YIJ W RC v ep-5 p, rer Jr F� r� ledge OSIOpe OValley []Flat
(Su m m
t Name,Numbers,Community,Subdivision,Lot No.,Zip Code) . . (check appropriate box)
3. OWNER: tLatitude/longitude of well location
Address 3$J 7-U L /.J. igp , ,d D , (degrxs7minutealseconds)
(s 1 Route No.) e� �7a� Latitude/Iongitud0source:OGPSOTo 0
C. PEPTH P graphic map
(check box)
1 C ty �&°6_ $ L- Zip Code DRILLING LOG
( - 701$ _ Fr°=-' Formation Description
Area code-Phone number -m t
4. DATE DRILLED
5. TOTAL DEPTH:_(pp`
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: / 75�FT:
8. TOP OF CASING IS (Uu•t'ifAbove Top orCuiog)
--�--FT.Above Land Surface* ---_ _ a
'Top creasing terminated atlor betpw leodsuriea requires a
variance In accordance with ISA NCAC IC 10119. - -- IV
9. YIELD (gprn): 3 METHOD OF TEST ---- — c s
10. WATER ZONES(depth): , - ----_ o
11. DISINFECTION:Type LOCATION SKETCH �
2. CASING: tL_ OLLnt- Show direction and distance in miles from at least 's
Depth
Wall Thickness two State Roads or County Roads. Include the road
From Dter or Weight/Ft. Matedal 'numbers and common road names.
FromTo ,7 Ft..—n..e
To Ft.
From TO—Ft._
13. GROUT: Depth Material
From Method _
From To Ft.-- - �
4. SCREEN: Depth Diameter
From To F Slot Size Material
FL—in,From To Ft. in. in.
5. SAND/GRAVEL PACK: in. ,
Depth Size Material
From To Ft.
From To Ft.
,
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
awnA 1 URE OF PERSGN CONSTRUCTING THE WELL DATE
` S
s-ubmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center-Raleigh,NC
.17699-1636 Phone No. [phone],within 30 days, -
GW-I REV. 07n00I __

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 13 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO ///��� ��, Topographic/Land setting
Ne/a)(est/T/pr�w-n: County_jdth"XL ❑Ridge ❑Slope ❑Valley ❑Flat
s+a 1 rAZI, �/M� / (check appropriate box)
(Str et Name,Numbers,Commumry,Subdivision,Lot No.,Ap Code) Latitude/longitude of wel I location
3. OWNER:
(degrees/minu[es/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
get
(check box)
DEPTH DRILLING LOG
iry or From To Formation Description
B(.28)- number Clay it Sand
Area code-Phone number, • ai Granite
4. DATE DRILLED
5. TOTAL DEPTH: 6 r
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO\
7. STATIC WATER LEVEL Below Top of Casing: 6n T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm):yO.O METHOD QF TpE�ST BLOW
10.WATER ZONES(depth): a$� )$.F T ES
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 _A�r/
From— Ft. Cv'
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
"O
From To Ft. N
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.From To Ft. in. in. -_._ _ Ln
15. SAND/GRAVELPACK:
Depth Size MaterialFrom To Ft. . .. _ ..
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST RDS,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,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GWA REV.09/2004

3M59
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. BroWn CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
111111111 (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. WELL LOCATIO l: n ' Topographic/Land setting
NeargEtTown:0 &VAdAt. County ❑Ridge ❑Slope ❑Valley ❑Flat
FO (check appropriate box)
(Street Namo Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:Affr
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street r Route �^l (check box)
(� d 87r 3 DEPTH DRILLING LOG
B( 26 )ry o93. 9423 7 Zip code From Formation Description
Y
Area code-Phone number Granite Sand
4. DATE DRILLED p
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)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0I18.
9. YIELD(gpm):_�_1 METH,9D OF TEST BLOW
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 t/Ft. Material numbers and common road names.
From o To Ft. `p„p
lo
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite a Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in.
From To Ft. in. in. _
15. SAND/GRAVEL PACK: o -�
Depth Size Material ...
From To Ft. - o clt -
From To Ft. "".
16. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST 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,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

F7 1f + P C' Cl
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
111111111 (if applicable) (if applicable)
1. 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
Near stTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
ML ((((((////// --- ��---- (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: .B" (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street r Ro [e No. (check box)
0. NG �a7/7 DEPTH DRILLING LOG
(g28 )-
Cityy or Wit State
39 Zip Code From To Formation Description
-S�/°'� / 0 (ID Clay&Sand
Area code-Phone number
4. DATE DRILLED (.p' 1101 Granite
•/S•OS
5. TOTAL DEPTH: I KID/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J�
7. STATIC WATER LEVEL Below Top of Casing:__- 0 _FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordaggf�e with 15A NCAC 2C.0118.
9. YIELD(gpm): b01' METHnD OF TEST BLOW
10. WATER ZONES(depth): 1 (a 1'71'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 MMt5nial numbers and common road names
From 0 To Ft.__-(,11_ c
From-j5-9ft TokeP Ft. I
From To F[.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. L - -
14. SCREEN: Depth Diameter Slot Size Material t-,) .
From To Ft. in. in.From To Ft. in. in. - N
15. SAND/GRAVELPACK: - c::)
Depth Size Material C3 --
From To Ft. LillFrom To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA RE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.TaylOr CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ID Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Neares own: Q, County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street me,Ni tiers,Community,Subdivision Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minu[es/seconds)
Addres M MIAV ffM, Latitude/longitude source:❑GPS❑Topographic map
�7n(Streeter outeNo (check box)
,(,(yX Q� L DEPTH DRILLING LOG
City or Town Scatg, ' Zip Code From To Formation Description
B 8 - 50 7• 85 17JJ 9 Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED nn
5. TOTAL DEPTH: �
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOX .3
7. STATIC WATER LEVEL Below Top of Casing: -60 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS -cl FT.Above Land Surface*
-Top of casing terminated at/or below land surface requires a -0
variance in accordance with 15A NCAC 2C.0118. to
9. YIELD(gpm):,3 METHOD OF TEST BLOW N
10.WATER ZONES(depth): ��ln7t r-t
LOCATION SKETCH -st
11. DISINFECTION:Type H T H Amount 16oz
Show direction and distance in miles from at least 3
two State Roads or County '-'12. CASING: Wall Thickness tY Roads.Include the road
Depth Diameter or Weight/Ft. aterial numbers and common road names.
From To "
From�ToQ Ftt____(� -
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material v �.
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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTUAJfTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J q /� l
S ATURE PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

r t o r n a
WELL CONSTRUCTION RECO"•
North Ca 61ina-Dep U=g of Envhonmcht and Natural Resources-Division of Wrier Quality-Otoondwater Section
WELL CONTRACCOR(1NDrV,1DUAtaNAafE faalae c�l_HVII S ,,,..1.'`• - - _ .
WELL CONTRACTOR COMPAYN .. .. A..:'PHONXa �.�:�..•3 a'Zb
STATE WELL CONSTRUCTION PERMITS- -A330C1ATBDw LRltll'I'S
(ifappliesbis) •(ifappliable) - -
1. WELL USE(Chedk Applicable Box):R01111 e17d' frtutdcipabPublic❑ Industial❑ ASrieultural p
Monitoring❑ Recovery ❑` Heat Pump Water Neotion❑ Other 1T If Other,Llat Uae
2.-WELL LOCATIO?Ly Tp 094bidLend setting
Nreucst Town:? (r Yl Costly\/4 C!C S()/j/ DK ddgge ❑'Slope ❑Valley ❑Flat
Fc,t .h� 1�-n res cQ.'_l Ca fP2 A, 7 ect 3 (p - (ch .pgapiatsbuc)
es+(su Name.N=ber.,Conweitr u ,subalviaim,tat Nq� Cole) Laatudc(lorigitude of wcll location
3. OWNER /7 I qL� �� S1� (deataalmiauwdecortda)
Addreu 3 f Q 5 M O ia't 1 ) rL, S 7 LatitWellongittide source:❑OPS❑Topographic map
(Sheet or Baoo Mj -
T rt pL )l. 3 � (7 a 9 DEM (DRILLING LOG
ary or ovre Sun 73p Cade From To ' Formation Description
(8t 3} r35.3 - O 7 n t 7
4. DATE DRILLBD /b— D S r am
5. TOTAL DEPTH .4b.S
6. DOES WELL REPLACE MaSTINL3 WELL? YES❑ Nb_
7. STATIC WATER LEVEL Below Top ofCaling:
(Uses^t^if Abm Top of Cuba)
& TOP OF CASING IS—�—FT.Above Land Surface'
-Top of aflat Urals"War e
rartaaee V"mrdaaoo w4b*I5K E;1d 3CAlarli a
9. YIELD(gpm): 1S MEMODOFTEST
10.WATER ZONES(depth):
I OCATION SKETCH
11. DISINFECTION:Type Amount Show direction and.dIatance in miles from at[cut
12. CASING: Wag Thickim two State Roads or County Roads,Include the road
/t 1 ,< or We jhUFL numbers ettd`common road names.
From__To -3.7 Pt
From_To PL
From To FLU-_
13. OROUT: Depth Mato i6( M�(edwdFrom TO-CM-FL-C424,4 �.
From - To o
.4. SCREEN: Depth Diameter Slot Size Material
From To Ft,
_in in _ y
From To FtL_jn, in w
S. SAND/GRAVEL PACK - o
Depth Size Material cn
From To FL
From To FL _
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WTM 15/1 NCAC 2C WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF T14S RECORD BEEN PROVIDED TO THE-WELL OWNER
SIGNATUREOFPM NCONSTRUCTINGTH8WELL DATE n -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
.17 6 99-1 63 6 Phone No.(919)733-3nl,within 30 days, OVJ-( REV.0712001 -

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WE NTRACTOR(INDIVIDUAL)NAME (print)_ JA(Y) S 5 W!J CERTIFICATION H ZoN S
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE S [phone]
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS111100 #t
(if applicable) (if applicable) r
I. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOwn: Topographic/Land setting
Neares Town: County
!� ��/ ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street ame, "5010'40777,
,.Community, bdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degreestr inmes/sewnds)
Address Latitude/longitude source:❑GPS❑Topographic map
%�
;�W (�Str et or Route No.) (check box)
1b iC.• DEPTH DRILLING LOG
City or wn state zip Code From To Formation Description
e -��'
Areaa code-Phone number umber 40 Clay&Sand
6 _�0_
4. DATE DRILLED 9 p '6J� Granite
5. TOTAL DEPTH: {.,.
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO JC'
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):15 METHOD OF TEST BLOW
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep Diameter or Weight/Ft. Materi numbers and common road names.
From�To_ o� Ft. ./$$ -
From it To Ft. _
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped -
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. CD
From To FL in. in.
15. SAND/GRAVEL PACK: ..
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS: 6� AStA4 FxmyQ-rD -f &cnell i FD mALe_ r &ze miLNG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRJd15TION STANDARDS-AND THAT A COPY OF THIS RECORD S BEEN PROVIDED TO THE WELL OWNER
.& L15
SIG URE RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004
G 2 4 r
I

WELL CONSTRUCTION RECORD G�North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Ru55ell S.Tavlor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
INEEN (if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential © Municipal/Pubiic❑ Industrial ❑ Agricultural ❑ '
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use -
2. WELL LOCATI Topographic/Land setting
Ne estTown: County_ zLj ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers Numbersy Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address - Latitude/longitude source:❑GPS❑Topographic map
(Street or Ro a^NAo.)w,^ r (check box)
DEPTH DRILLING LOG
City or own ray /Lip Code From To r Formation Description
� - t) s�
Area code-Phone number Clay&Sand
(�-7
4. DATE DRILLED �' J t-)() Granite
5. TOTAL DEPTH: 1000,
6. DOES WELL REPLACE EXISTING WELL? YES Q NO
7. STATIC WATER LEVEL Below Top of Casing:-5 0 FT.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS �I- FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.01181
9. YIELD(gpm): 4' ME HOD OF ST�B--L�OW
3 S
-�r---
10. WATER ZONES(depth): (Da5 ,i t
1 U J LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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. �leerial numbers and common road names.
From TZ�Ft. rr r
From ft To Ft.
From To Ft.
rJ
13. GROUT: Depth Material Method � -.
From 0 To 20 Ft.Benonite&Cement pumped �t
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
W a
From To FL in. in. CD
From To Ft._in. in. un
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From Tc Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THATrA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA RE OF PERSON CONSTRUCTING THE WELL DATE/
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days..
GW-1 REV.09/2004
G 7 Z 4

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 3 j. -k
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
MENNEN
I. WELL USE(Check Applicable Box):Residential O Munieipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery O Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Near Town: County•'�{�/ ❑Ridge ❑Slope Malley OFlat
(check appropriate box)
(Street ame, umbers,Communityy,(Subdivision,Lot No.,Zip Code) t Latitude/longitude of well location
3. OWNER: ( �I/�ff P( �II �®fit 1 ///i/1�/iss)
Address r-- (degrees/minutes/seconds)
s D GL 5 Latitude/longitude source:0 GPSOTopographic map
(StreFtt or Route rNo't) (check box)
^"� / 3O.J tl DEPTH DRILLING LOG
ary or sown ySta/� zip Code Fro— Formation Description
(828 )-��©V 5/t+z'q Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED •G
5. TOTAL DEPTH: <t 7j '
6. DOES WELL REPLACE EXISTING WELL? YES 13
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top o Casing)
8. TOP OF CASING IS_01' FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 3C.0118.
9. YIELD(gpm): a) METHOD OF TEST BLOW
10. WATER ZONES(depth): 6T 90'1 4,�
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep p Di meter or Weight/Ft. teriat numbers and common road names.
From To p Ft._
From 3d h ToFt. (" ,• ,If i
From To Ft. - -
13. GROUT: Depth Material. Method
From 0 To 20 Ft.Benonite a Cement pumped
From To Ft. o
n
14. SCREEN: Depth Diameter Slot Size Material ­4
From To Ft._in. in. W
From To F[. in. in.
15. SAND/GRAVEL PACK: p '
Depth Size Material Ln
From To Ft. z
From To F[. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND RDS,AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IO
SIGNA RE OF PERSON CONSTRUCTING THE WELL D E oS
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.__.. ..__.._. -..
GW-1 REV.09/2004
0C i 2 4 2G�,;

WELL CONSTRUCTION RECORD
North Carotins-Department of Environment and Natural Resources-Division ofVator (yam all Groundwater Section
WELL CONTRACTOR(INDIY,IDUAL)?IAML -
1
i oll7
WELL CONTRACTOR COMPANY cx;PTIPICAnooN
NAM
STATE WELL CONSTRUCTION P$RMrrs �G�CfATZ�D $RM{Yy - �
-- (ifapplicable) ' -Cfapplieabie) -
L WELL USE(Check Applicable Box):Residential F--gunicipal/Public❑ Industrial Cl Agricultural
Monitoring❑ Rceovery ❑` Heat Pump Water Injection❑ Other[J If Other,List Use
2."WELL LOCATION.-
Nearest .
Town: n L- LJ Vi e -'L S T i;sapbic/Land settingn .
1County IC S ahi " dge ❑Slope Malley OFlat
G, alryti� t�-YJ R� �S7� 3
(Street Name,Numbed,
IICmdmay, N _ (dmk WP�aa box) . a
vsaqIot a,zip Code) Lati tudebgrude of well location
3. OWNER: �d m � S h to r' C 0 (tkataealmiouwheeonda)
Address { (S at }Ranalt :!t r' xy� Latitude/longiWde source:❑GPS❑To hic ma(Surat r I Na) c� t PogmP P
LL t I O Lt�11 t'•f !I, G n[ �i'7,!- 3 DEPTH (e DRIbeck )L City or rows Stag Zip Code I
From To
!/ 3 3� / Formation Dexription
Am code Phom number n "/' �.. 1.
4. DATE DRILLED �- / —c`_ -
S. TOTAL DEPTH: _ a
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /k�
(Uaa'4'if Above Top of CWV
S. TOP OF CASING IS pT,Above Land Surface*
,rop or cuing termtaated atior betgw Itwd.att rm regairea a
nee .—�_-
"rim"In seeorda wirk tsANCAC 2C.e11L "
9. YIELD(gpm):_fit=METHOD OF TEST
10.WATER ZONES(depth): 3 ID
11. DISINFECTION:.T Sh LOCATION MUM11
YPe Amount ow direction and.distance in miles from at least
12. CASING: WallTdicknen two State Roads or Coanty Roads;Include the road
From Depth � Di°�'�r or Wplght/Ft. Ma numbers and common road names.
Q_To
From Tc FL__
From Tp FL_�
13. GROUT_ Depth Matmiii Method
From_Q_To y
From To— Ft` t 3
.4. SCREEN: Cn
Depth Diameter . Slot Size : , Material
From To Fl. in. in. o
From To Fr is Cn
S. SAND/GRAVEL PACK
Depth Size Material a
From To Ft,
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrM I SA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TlqS RECORDHM BEEN PROVIDED TO THE.WELL OWI R
SIGNATURE OF PEM N CONSTRUCTING THE WELL I LS j o0
DATE 1
Submit the original to the Division of Water Quellty,Groundwater Section I636 Mail Service Center-Raleigh;
i
,2Q699-1636 Phone No.[phone],within 30 days. t --
OW-1 REY.07 2OOl
i

'NC OITNEH N II'I1� -------
WE, LL CONSTRUCTION RECORD
Nolth Carolina-Depvinlcut of Lltviruuoleul and Nnitual Resoutces-Division of Water fluality-(3loundwaler Sccti 'll
WELL CUM"IMCFOII(INUIVIUUAL)NAaIE (Ira hd CERIIFICA-11ON N116/e)%"��r`�C��
r1IONE a f9�s'16'Ji-zf'S 7
WELL CONTMCIOR COMPANY NAME
STATE«'ELL CONS tnUCIION rEnAmo ASSOCIAI'Ell WQ rERaturl
(ifnlllicnllc) _ (Ifnpplicnblc)
1. \VELL USE(Check ApplicnLle Box): Rcsi(jcolial&I MuulcipaUl'ublic U Induabial U Agricultural U
Illollituling U Recovery U Ileat I'uwp Water hljecdoll U 011rer U Irolher,List Use
2. W I:Lt.LOCATION: 'ropogrnphil/La ld setting
Svlda CuuW 7,a fee DRIdge USlope ❑Valley UI'lal
Ncmcsl 7bwu: y
F2fg1/iF14'.t 2c�. (dteck apptopel boa)
r
Latiluddl nt{)ilude of well location
uutb
(SUtel Nan¢,Neu,C'mnmwttty,SuLJivlelay Let-No.,ZIP Cale) ��C�•!Q'F27 '•
/I f�!}�c)/ old yJt�7c�� CC.'/N ' (drgteeelminutef/accnnde)
1. OWNEII: lferit
Address Lalitud Uc/longilude soulm iPSOTOpoglnpllic"lap(check box)
(Succt a Route No.) J)LI'11I 12 ULLjt1(UQ(L
City or town SWe Zip Cale
Front 1'0 rounn(ion Description
C_—_J-
Alta code-rhone nievtbe�
4. DATE DIULLED
5. TOTAL 1)1:VIl1: 4 73 —
6. DOES WELL REPLACE EXISTINO WELL? YES U NU 13
7. S FATIC WAI EIL LEVEL Delow'rop of Cnsing: 30 —1'r•
/ (uae••t-If Above Tnp of Cating)
B. TOT' OI'CASING IS 1"I'. Above Loud Stnlacc•
•Tap or t.dng let m1nttled allot below land out fete Itqult to
♦ulance In xecorJurte w114 15A NCAC 1C.0118.
9. YIELD(ppnl): S y N1HTNOD0F,FE•SI�—
10.WATER ZONES (depth): 6;Jo I.p Al IS7I KCLC11
1 I. DISINFIiCIION:Type C T Amvuu( C Show direction and distance in m Gm
iles o at'cast
Wnll l bickness two Stale Roads or County Roads. Include We road
12. CASING: numbers and conuoo I toad nnnics.
Depth D{autcter or WeighVFI. Material
Flout O 1.0-L0c/L_FL 6•Z Sa/af r f
Flom To 14.
morn To Ft. m
m
13. GROUT: DepUl 1s lal / McWuJ n
rronL�,_To
Ft. �iYIG./C ; Cn
/.K Gsl� L
Flom � To ,fl Ft. de�f�' _--- o
14. SCREEN: Depdi Diaructer Slot Size Matelinl
Fluid 'ro
trout
15. SANDIGILAVFLPACK: t
Drpllt Size hlnterlol '', SEP 26
_ 1 j
rton, ro Ft.
Flout To
16. REMARKS:
1 DO I01HY CERTIFY 711AT'Ii11S WELL WAS CONSTRUCfED IN ACCORDANCE W1111 ISA NCAC 2C,WELL
CONSI llUCI IUN STANDARDS,AND TI lA"1'A COPY OF TI IIS RECORD IIAS BEEN PROVIDEU TO 111E WELL OWNER
SIUNNIUILE01.,PERSON CONS'IAUCIINUTIILIWELL RAIL
SUh till l 111e original to(he DIFleloR of%Vnter Qunii(y,Gromldwater Sec done1636 Mall Scrvice CtI 9 1 RLVgh 2001
.. .... . ... .... t�.t.l" ill t..,. -

WELL CONSTRUCTION RECORD 4 G D
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential I Municipal/Public Cil"' Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
NeargA Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
(.{- *2 (check appropriate box)
(Street Name,Numbers,�Comn m`i1ry,Su divisii'ofn,,Loot No.,Zip Code) Latitude/longitude of well location
3. OWNER:��) „-L . -rtVJ []L.ICJ'1 (degmes/minums/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
14IV qJ fJ1f-. Ak— 973& DEPTH DRILLING LOG
or7own Sta zip Code Fromv o Formation Description
ate - honenu clay it Sand
Area code-Phone number
Granite
4. DATE DRILLED_ •/• I
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES , NO ❑
7. STATIC WATER LEVEL Below Top of Casing: qOb FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS o2' FT.Above Land Surface"
"Top of casing terminated at/or below land surface requires a
variance in accordanc with 15A NCAC 2C.0118.
9. YIELD(gpm):�METHODe TEST BLOW
10.WATER ZONES(depth): �7 9't 5
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 Wet' It t. Material numbers and common road names.
From To &D Ft. ']~
From tt To Ft. - -
From To Ft.
13. GROUT: Depth Material Method -73
From 0 To T Ft.Benonne a Cement pumped !,I
C3
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material r;a
m _
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: cIl
Depth Size Material O id
From To Ft. cn
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCT STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G!5
SIG NA TuT
PERSUN CONSTRUCTING THE WELL DATE/
Submit the original to the Division of Water Quality,Attn: Information Management,1617jMail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004
2 6 2005

WELL CONSTRUCTION REC��ORD
Nonh Carolina-Department of Environment and Natural Resources Division of W ater Quality-Groundwater Section
WELL CONTRACTOR(INDIV,IDUAL)'NAMS (prlat)S7)P h V115 1 ,AvA CC[i77IPIICCATIO/NY oll-Re
WELL CONTRACTOR COMPANY NAMPHONL
STATE WELL CONSTRUCTION PZRMITa Ae-eOC(ATED W ERMITY
(if applicable)
.(if applicable)
I. WELL USE(Check Applicable Box):Resident'ial'r;� unicipaVPublic❑ Industrial ❑ Agricultural
Monitoring❑ Recovcry ❑ Heat Pump Water Injection❑ Other U If Other,List Use
2. WELL LOCATION
Nearest Town: S ti ►' [? Count J,� C ICS cam T phie/Land setting
dge ❑Slope Malley ❑Flat
/(Boca Name,Numbers,Community,Subdirision (check appropriate box),tot No.,Zip Code) Latitude longitude of Well location
3. OWNER: ��.'lyV r e1 A S (dcgrecrlmiautes/aeands) .
Address . L oI if S if TZt t2 — L p graphic map
T atitudrJlongitude source:❑GPS❑To 0
(Sucet or Roum No.)
)Zt O S Q� qq �' (check box)
ny or Two Sum Zi
L' de 1 S DEPTH DRILLING LOG
�� � _ � �� C' P Cade From To ' Formation Description
Area code-Phone number r� ,
4. DATE DRILLED d � � Ur /�
5. TOTAL DEPTH: S y5/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: L.I2 FT.
(Use"+"tf Above Top of Cuing)
8. TOP OF CASING IS _ FT.Above Land Surfacee
-Top of cuing terminated atior below land.surreu requires a r1J
"Hance to accordance with.ISA NCAC SC,et is. rn
9. YIELD(gpm): T;V- METHOD OF TEST
10. WATER ZONES(depth): 7 5-`
LOCATION KETCH
] I. DISINFECTION:Type Amount Show direction and distance In rniles from at least Ln
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di a ter or WeOL/Ft. Metej' 1 'numbers and common road names.
From_0 To 1 Ft.
From To FL
From To Ft.
13. GROUT: Depth - Material Method
From To_��
From To 'Ft. -
4. SCREEN: Depth Diameter . Slot Size , Material
From To Ft._in. in.
From To FL—in. in.
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
ONSTR UCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
s-ubmit the original to the Dlvislon of Water Quality, Groundwater Section, 1636 Mall Servlee Center.Raleigh,NC
J1699-1636 Phone No.[phone],within 30 days. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
Nonh Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIv,IDUAL)"NAME (prlaq c�f 11 Y)1 S f �J n C Ut TWICATIO/N Y -11 -
WELL CONTRACTOR COMPANY NAM 'PHONEYiD —.�.Z
STATE WELL CONSTRUCTION PERMITa ASSOCIATED W ERMITY
orapplicable) "(ifapplicable)
1. WELL USE(Check Applicable Box):Residential• unicipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other ET If Other,List Use
2. -WELL LOCATION: P gn bi mg
Nearest Town: L( 'h • i �tl County- 4 i S ea.> 'd lope ❑Valloy ❑Flat
j3/4jeV,tfi­,S 0Ora -e el- tp-.v k 92 ' h
�7j% (check approprialebox)
(Such Name,Numben,Communi ,Subdivision,lot No.,Zip Code) LatitudcAonginfde of well location
3. OWNER: J �I ti L�n n r�: )1 (degreedmiautealaeconds)
Address I S e 6A f-r�e P-a Latitude/longittide source:❑OPS❑Topographicmap
(Street or Route NoJ �j (check box)
6A" 14 + �� �g / DEPTH DRILLING LOG
C"ty or Town State Zip Code From To Formation Description
(22
Arcs code-Phone number e t' �,_
4. DATE DRILLED 9-.� i-D _ —T
5. TOTAL DEPTH: L?S
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:-f- Z FT:
(Uae"+"if Above Top of Cuing)
8. TOP OF CASING IS�_FT.Above Land Surface'
'Top of cuing termlaated Wor belgw laad.eurface reyulna a
vaAaece In accordaoee with ISA NCAC 1C
9. YIELD(gpm): METHOD OF TEST_
10.WATER ZONES(depth): 1.3 0' 0 ' 0
LOCATION SKETCH
IL DISINFECTION:Type Amount Show direction and distance in[Hiles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth
th Die ter or WcOt/Ft. Material 1 'numbers and common road names.
From To Ft.=S.a
From To FL =4)
ttr
From To—Ft._ rs
13. GROUT: Depth - Material Method� � �
From_ To*_Ft, /10b -0 '>
From To 'Ft.
4. SCREEN: Depth Diameter " Slot Size Material CJT
From To Ft.—in, in.
From To F—in. in, r�q
S. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. - -"
From To—Ft.
6. REMARKS:
cn
r�
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL _U
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER r
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Servlee Center-Raleigh,NC
e11699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

In,
LL CONSTRUCTION REMIT
No,it,Cmolina-Depailmcut of Lrnvirouulcul and Nntufj al Resountces-Division Or W81er(uualily-Oloundwater Scclion
/LPt1/ leecL CERnrICAIDUNgx
IV ELL CONi MC10R(IN VIVID UAL)NAa1E (vf lu0c,� / //ll r1IONE g
dy
//!ll C%
\YELL CONi{LACfOR COa1rANY NAME ASSOCIA'1"ED\VV eERNII 10
STATE WELL CONS rRUCI ION rEMt1Ta a,Jicnble
irn Jicablc
1. WELL USE(Check Applicnble ItOa): IlcsiJcOlinl L1"'Municipal/rub0e U Induallial Cl Agricullural U
ptouitotiug U Recovery U Ilcal lruuyt Water Injccliou U Ulher U ICOdier,List Use
/ LL I'opogmphicJLnlid Setting
2. WGLLLOCAT10tJ:// Y 5gc!(Joti ❑IUJge C1SIope UVttlicy UFlat
L YI e/C1ZE� (.UUtll ,--�-- (check oppfetwlnfe box)
Ncnresl Tbwn: �
_Un_'o/� — Lalitudrlloltgitudeof well location
(Sued Nearo,Nmubcn,C'enunw,ity,SubJirlela4 Lai No.7.Ip Cole) ++�pS f S '
NJS`Zi'd, y __--
' degfeee/ndnutc✓recnnd+)
-'r !jl n kut il„� ��v 7,6�1 l�nsf. t
), OWNER: Te LalihtdcJhntgituJc sourcc:OGPSUl'Opvgtnphic leap
Address (cheek box)
(Sued m Route Nu.) P .-1L''I11 DWI-I'll l (L(L
Sblc Zip Cale
prom T'o rouniclion Descriplimt
City of Town
Afro cede-fbnne mm�berQ���-AS' vZy _ map, _
4. DATE DIALLED
5. TOT-ALDG'TIL• �p1
G. DOES WELL REPLACE GXIS'1'IN(7 WELL? YES UDNO vr.
7. Sl'A-I'ICWATER LEVEL lBelo-1-011O'^'^vekl•oil e final
8. TOIr Or CASINO' IS
/2' I"I'.Above I_nud Slit race*
--[or of twins trnnlnxled oUnr below land all,tote requhn
Vac)once In accord mute with ISA NCAC 2C-0111-
9. YIELD (gpm): METHOD OFTEST
19.WA-r1 R ZONES(Jcpth): !50 ' J•QC(�LI4N�lCLZG11
/j Ff Auwun( r _ Show direction and distance In miles Gon1 al(cast
It. DISINFGCI'10N:Type — two Slate Roads or County Roads.Include the road
Wnll'Ibickness
12. CASING: Dianeler or WcighUfL Maletial number and cmlunon{onJ names.
Depth UL
0 To F.I. 6. Cs sDRzr St¢t
rtc1R
FlonL_Wc _TO /01 'FL. � N
morn To—rt. rn
aler al 1eWud� —O :A
13. 0ROUI': Depth /if v, t Ln
Ftvm To .ZC' Ft. ,rr o
14. SCREEN: Drpd, Diatnelcti11. slot Sizeitl. Matninl � --_— i _ _ -
Flom TO rt.
rrntrl rn
pt.—Ill. In.
15. SANDIORAV1"1,PACK! Sixa Mntedal
Depth S E P 2 6 M5
rronr 'ro r•L --
r1011 lb iL
16. REMARKS:
IDOIIEREUYCERTIFYINAT7111SWELLWASCONS'1'TBISGDIN DItASllEEN RO II ISA NCAC WELL
CONSTRUCI IONS TANDARDS,A14D THAT A C rY Of THIS IIGCORD IIAS OGL'N PROVIDED TO 12S C 0 OWNER
� '•e�`�/ DAIG
SIGNA I URL'OI 1 Lf RSON CONS IAUL1''NU 771E W GLL
C
Subnllt the orlglunt to the DlYlilon of JVater Quality,Groundwater Section,1636 Moll Sen'" OW.I RL1V.07 2001
,.I ro. rnIQIIII1171 vlllfb,111Jnl'+.

0IVNEI? .hfll'D, ____
W1,FLL CONSTRUCTION 11MORD
No11h Caloliva-Depailtilenl of EmvilouDlcul and Noluial Resources-Division of Water Quality-Uloundwaler Section�03
WELL CON IRACI Olt(INDIVIDUAL)NAME (point) PezII lZeece. CEII"IIFICA-IIUNa
IVELL CONTIIACIUR COMPANY NAaIE
/11,Mel- r11ONE a (YI;'I
STATE WELL CONS rRUCIION rEMll10 ASSOCIA7"Elf VVQ PERMr10
(if nl I limb Ic) (If nppltcnhle) -
1. WELL USE (Check Applicable 1104 Resideuiial I3-�Mmofcfp8l/Public EJ Induahinl ❑ Agricultural Ll
Muuiluring ❑ Ilecovcly O heat rulop Water hijectiml❑ Other O if Other,List Use
2. WELL LOCATION-/ 'Ibpogniphic/Laud Setting
Ncntcsl7bwu: Cheljhee Cuuuly ❑IUdge ❑Slope UVoliey 171181
(check opplolnlate boa)
(Sutcl Nsnrt,Nmnhep,Couununity,Subdivision,"I No.,7111 Cole) IAtitlid C/IUiI IWJC Of WCIf Iucaltoll /e
3. OWNER: y,t�e n f 911w7 CMG L L <<%Sf ldeg ee✓nilmnee recmlA.)
Addicts Latitudd10,191ludc eourcc: 30PSL1Topoglnphic utep(check box)
(Suecl o Rowe No.) ULI''l71 121ULL.INULLUQ
rr C. to Town State Zip Code
rroul To Formation Mscliplion
Ain rude-Phone nionbtr
5. TOfALDEPTN: '
6. DOGS WELL REPLACE EXISTINU WI'sLl l YES ❑ NO L-
7. ST'A7"IC 1VATEIt LEVEL Dclow'1'op of Cnsfug:6_171%
r (Use"4"If Ahove'lnp or C.mtog)
a. T'OI' Or CASING IS / z, Vl'.Above Land Sur lace'
-Top of odng let udnsled aver-below am face tequil tt a
V.,lance In accordance with ISA NCAC 1C.01111.
9. YIELD(Fpml):_ 7 hIETIIOD Or TEST AT t Y
IU.WATER ZONES(dep01): '1S
1.QGATl4L—SIMU-01
/f Amount �V Show direction and distance in miles Gold at least
1 I. C S IN GCT'ION:'fypo two Stale Roads or Counly Ituads. luclude We road
12. CASING: Wall l ight/Fss
Ucplh Dimnetcr or�4cigbUP1. Molaial mmilhcro and couunonroad names. -
Flolu_Q__To i.Z6 FI. 4-,ZS— sACrl p�,`
i
rrom To PL "
rrom To F[.
13. GROUT: Deptll at r al McWo v
/ :
from L� To,_3 Ft. '� ��`�'rd °` (s
Flom_ To iZ6 Ft. o V
14. SCREEN: Depth Diameter Slut Size Matalnl Ln „t
rlonr To Ft. in. In. r`
15. SAND/GIIAVEI.PACK:
Dcplh Size Mnlednl
rrn,tl fo rt. SEP 2 6 2005
rrNru TD rt. ,
16. REMARKS:
DO HEREBY CERTIFY TIIATTHIS WELL WAS CONSI'IIUCfED IN ACCOIU)ANCE WITH 15ANCAC 2C,WELL
CONS I MC11ON STANDAIWS,AND THAT'A COI'Y Or TI IIS RECORD IIAS BEEN PROVIDED TO T'I Ili WELL OWNER
�i
SIONA'IUIIE Ur I'LIIISUN CONS]RUCIINU TI It' WELL DATE
SubmllI file 01Igiaal to the Division of Water Quallty,Groundwater Sections 1636 Nall Service Center-Itafelgh,NC
I7699-1636 Phone No.[phone],m U116131) days. UW-I IILIV.07/2UUI

(� 315625
WELL CONSTRUCTION RECORD 0
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME u n at) &U11,��1, 44 -7��21 S\ -r- CERTIFICATION#�s{�
WELL CONTRACTOR COMPANY NAME TtvXk�et tl.+l* k l �nT 1 `J PHt)rIE # ' "�-B7'70
STATE WELL CONSTRUCTION PERNIM ASSOCIATED WQ PERMIT#
Main (if applicable) {{ ' (if applicable)
I. WELL USE(Check Applicable Box):Residential MunicipaUPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Inj tion❑ Other❑ If Other,List Use
2. WELL LOCATIO r__.aCcrl Topogtaphic/1,and settin
C]R
Nearest Town: e�(�JCr� Couaty�
idge ❑Slope ❑Valley
(Check appropriate box) ku
(Strew Name,NumbeM Community.SSubdivisioa.Lot No.,Zip Code) �titude/longitude of wgll location /t
3. OWNER: �4A YI jjry 7�13.2' W093°;a'[b.g
Address tk r :\l� F. (de@xN�scwds) -
Latitnde/longitude source- S❑Topographtc map
(Street or Route No-) (c box)
\y� �C ��119 DEPTH DRILLING LOG
Ctiry w Tmn St"D Zip Code From To Formation Description
Am wde-Phone amber qF
4. DATE bRILLED `I-6,3( -05 C, ^c+2t�
5. TOTAL DEPTH: ��SCJ r c
6. DOES WELL REPLACE EXISTING WELL? YES❑ I ❑
7. STATIC WATER LEVEL Below Top of Casing:I FT.
(Use`+"if Above TOP of Casing)
S. TOP OF CASING IS FT.Above Land Surface"
`Taparcaadg rasYatea Celow mad.arrace requbma
variance in uwrdence with 15A NCAC 2C 911& }}
9. YIELD(gpm):�—METHOD OF TEST �r 1 `L)
10.WATER ZONES(depth):llorj J
i OCATION SKETCH
11. DISINFECTION:Type a Amount Show direction and distance in miles from at least
12. CASING: Wall Thtekaem two State Roads or County Roads.Include the road
Depth Di or Weigtit/Ft. Ma 'al numbers and common road names.
From�'�To Ft I,,l
From�_To, FL- (091j,
From To FL
13. GROUT- Z r Mat 'agr I - Method
From.�__�T To FL 1e-. cn
From To Ft.
14. SCREEN: Depth Dimroter Slot Sim Material 'D
t
From To Ft. in. in. N
From To Ft. in. in. O
15. SAND/GRAVEL PACK cn
Depth Sim Material -
From To Ft.
From To Ft.
16. REMARKS:
�vrSir;Y1 .
I DO HEREBY CERTIFY THAT Tt$S WELL CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRU N STANDARDS THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
9,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1417 Mail Service Center-
RaI igh,NC 27699 4617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
Ce,rth( :,Fo ilia - Department of Los ironment and Natural Resources-Division of Water Quality-Groundwater Section
w F.0 (0.,fit k(']OR(INDI\'IDU% )NAME (print) _.\'\Q C(._ y�u t'r. C I -_- '11
- ^ CER"IItTCpATI()ti#_ 6 s5 rjy
\ 1.11..(0`,1R:\(-I OR Co)tPANN'N;�\If; l."lt"CLr>-L_ -f'�a__u�Q_l1. < VJ (p.JL_U yY 2>
h _-_PIIO,NE #
SI.\I6 %IA.1.('ONS IRUC'TION PERM IT#- \yQ pl ASSOCIATED WO PF.RD11f#
(if applicable)
LSE:(('heck Applicable Box): Residential 13' Municipal'Public ❑ Industrial ❑ Agricultural ❑
\L,ri,tw ng ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other. List Use---
AT ION
'\e.,rc t Town: (� Topographic/Land setting
r .. '1___ County Oil ❑Ridge ❑Slope ❑Valley BElat
esea" I I check appropriate twx)
wnhc,.(-oninnorm.Subdicmm�-E,N,,../ip('orie)
�v Latitude longitude of well location
-`ej� �3�dr1 (degrees.minutes seconds)
"kilo" n.ri 2d Latitude-longitude source:❑GPS❑Topographic map
Staet or Rome\u. (check box)
k !,(Yet' �4 t a SIC r�flrl r2ly DEPTH DRILLING LOG
From To
- Formation Description
_.-c- —
i phone number 51 3ti5 DkILLED eZ
-I U I AL, DEPTH'•: 3L15 -—
`. nliiui-nl t r I. I xi. I i n r, U L! i - } i., r l� n.(I __1,
Is A 10 \V" I ER LEVEI Below Top of Casing: _FT. —
ICse "if Abos e Topnt(amp) --- -- —
iOP OF CASING IS_A FT. Above Land Surface' "-------- __
'Top of casing terminated aVor below land surface requires a
.arnmee in accordance with ISA SC.AC 2C of 18 -
1lF.LD Igpm): _�__ METHOD OF TEST _—
u v1 FIR ZONES(depth):
_ 1 0('ATION SKETCH
DIS19'Ff_(-TION:Type --_�`}-'y'H _ Amount_ _ Show direction and distance in miles from at(cast
\bull lhickne" two State Roads or Cuunty Roads. Include the road
De'p-h Diameter or WeightI I. %latcrial numbers and common road names.
F1,mr _. _ To. Ft. '
Frr to _ To Ft ..---
(ikUl l` Depth Slatcrial - -- IV
Method
Tn_a�_
Frnu
To
_
u1 1. �r I+I I Depth Diameter SIoI Sim Material -
I non_ _ to Ft—_in. in.
Pnm, - To FL_ _in. in.
F _-
S.\s-D (;k:\V L PACK:
Depth Siic Material
Pr- Ili _-To Ft.
To_._ Ft
l a. KI.AI9kFti
Is,(( IIrKFB}-( IiR11F1'THATTHIS \k-ELI_ gASCONSIRCC7-EDINACCORD.ANCE N'ITIIISANCAC2C',AL"ELL -�
t1UN S I ANDARDS,.AND THAT A COP% OF MIS RECORD HAS BEEN PROVIDED TO THE'A ELL OR'NER
C�—Ke_r1 -------
SI(iN'�1 I'CHE OF PERSON _ NSTR I;CTIN(i THE N'ELL DA'FF.
Submit the original to the Division of Water Quali[v,Groundwater Section, 1636.Dail Service Center-Raleigh,NC
27699-16.16 Phone No.[phone]. Within 30 da}"s.
GW-I REV.f17'2001

WELL CONSTRUCTION RECORD
� ,nh( :.nlma- Department of Lm'iron merit and
/r1Nat UTaI Resources- Division of Water Quality-Groundwater Section
N) I i t ON'I RV I OR(INDI\'IDLAL)NAME (printll1 e}'A(:cI_...S) Lp 1
- - - CF,R'TIF'ICAI ION'p_,2e1Qd
Nr.I.(.(ON IR\r'roRCoxtvAN)'NAME
Clf,1�-1L_yy�__dvp���u4 vtloNea (l;aa)11.c11 -b�-lo
titCII.NFI.I.CONSTRUCTION PERSIITN '1�1a _.._. _
ASSOCIATED N'Q PERNIt1W
(it applicable) --- - -__ __
fif apphcablel
I-SI-: (('heck Applicable Box). Residential 63'Municipal,Public ❑ Industrial ❑ Agricultural ❑
',i,mnormg ❑ Recovem, ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
bA I-1-I. L.U( ATfC N:
1UnrCit Toxcn:- Topographic/Land setting
Countyy , n^
C`3kidge ❑Slope ❑Valley ❑Flat
" ' Aana' 'emnku¢C'ommunitc.SnbJici.u.n.(nt N,o Zip Code) Icheck appropnate box)
Latitude longitude of well location
(t AA S FR' t L� _rbC rl
:,durctis al fir- --- idgrees in seconds)
_ Latitude longitude source OGPSOTopographic map
�/�,, IStreet 6. nrtc Kn.l
�- (checkNoo
�
�cl''A DP.PTH DRILLING LO('
(vsu SU, Zip<1>i,
_ From pTo Formation Description
U 1TI-(DRILLED
r Trfi-AI_ DLPTH ? $5
t r,. �.xisiin r. uf.ti ,
ST DTI( W- I -R LEVEL Belo% Top ofCasing: \U_PT. -- — —
II_sc"+"if:AhoNe Tnpnf('A91nL) —'
'(ll'OF CASING IS \ FT. Above Land Surface* ---- _
-Top of casing terminated at/or below land surface requires a
.ariance in accordance with 155 N('AC 2C_.Ot IA ----- ---
'�- 1 IL:I-D(gpiny -SO METHOD OF TFST ,)-h✓y ---- --
'.4 R:A1I R /.ONES(depth): ..
fiISINFL("LiUN:Ty e- -4 ---_--�-- LOCATION SKETCH
P T —_ Amount—__ Show direction and distance in miles from at least
%4all Thickness two State Roads or County Roads. Include the road
Depth Diameter nr"eight Ft. Material numbers and common road names.
--- —
Prm: _.._-. To LTV L Pt. -...
To FL_
(IRO( "1 : Depth Material
FnanFt. (' Gt!AnD w t C.�
To FL--
S( KI.P.�. Dc Depth er _. .._—._ Ut
P Diameter Slut Size Material
FI'm -- f o__I'L_ ----in. in. o
i-ru(n_ _ To Ft
1' 1) (i RA I'LL PACK _---- __-- ----- .
Depth Size Material
Pnmt To -----Ft.
- -
rown To Ft. —_ --.
�.. RI \1:NRKS
"nIIitk( M ( I-.RIIF1'THAF THIS VAIT1. WAS CONSlRC(:TLD IN vORD.ANCE WITH is NCAC2( WNELL
r f)�.Sl R( (TION, STANDARDS-:AND THAT:N COPY OF THIS RECORD II:NS BEFN PROVIDED TO 1 HE RA ELL ONNER
SON':VI t-RE OF PFRSON )NS I Rt)C'TING THE WELL -
DAIS:
Sabmit the original to the Dixision of Water Qualiti Groundwater Section,1636.Mail Sers'iee Center-Raleigh,NC
27699-i636 Phone son.[phone].within 30 days.
GW-I REV.072001

C> 315 726
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(UMPADUAL)NAME (print) ,/ "r 4,r llao laxo— CERTIFICATIONNIGQ4
WELL CONTRACTOR COMPANY NAME C� PRONE# PS?') V8-ft45-
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMrr#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential❑ Mtaucipal/Public❑ Industrial❑ Agricultural,13
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other R3 If Other,List Use 'Crr-
2. WELL LOCATION1/-� / Topographic/Land setting
Nearest Town li,G' r&r County ❑Ridge ❑Slope ❑Valley MFlat
&ii1__ r (cbxlcwpropnovbox)
(Street Name,N bcm, we ,Subdivision Lot No.,Zip Cade) Latitude/longitude of well location
3. OWNER: /'rA.'--1�-�- (degmdmimti"laeconas)
Address SF sR.s rl- . cl3ar l7� Latitude/longitudesmuce:❑GPS❑Topographic map
($tlCetar Rau t) (obxk box)
�ue r.a, ilJ G Z.Y 71 83 DEPTH DRILLING LOG
citym] State Zip code From To FoM on Description --
Area code-Phone mmnber
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO be N
7. STATIC WATER LEVEL Below Top of Casing:__Z2_FT. i0
(Use"+"if Above Top of Casing) �>
8. TOP OF CASING IS_�`FT.Above Land Surfae
-Top of acing terminated aeon below land surface requires a
vaNance in accordance with 15A NCAC 2C.0118. 7
9. YIELD(gpm): N(A- METHOD OF TEST 1 -4 4.-..1
10.WATER ZONES(depth): 17-I f
LOCATION SKETCH
11. DISINFECTION:Type /7e7ef Amount 6/cre..e Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt. Material numbers and co11ffiwn road names.
From o To /7 Ft /%Y Y�4 h< A--
From To Ft
From Ta Ft
13. GROUT: Depth Material Method
From O To 9- Ft /A4/'y-J g _ Z--t
From To Ft - t "�✓
14. SCREEN: Depth Diameter Slot Size Material
From__Z7 To_!�J_Ft /!Sv in. /Garr is
From TO Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From I v- To '^i 917;.-
From To ''nn Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT! STANDARDS,AND THAT A COPY OF RECOIA HAS BEEN PROVIDED TO THE WELL OWNER
U
ATURE OF PERSON CON)FRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,16M Mail Service Curter-Raleigh,NC
0699.16M Phone No.[phone],within 30 days. GW-1 REV.07/2001
i

3F
WELL CONSTRUCTION RECORD r°North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCATJSI�/y- /
Ne est To n:_ (��ifC�/YJ Count _� Ih� Topographic Land setting
pyV L y ❑Ridge ❑Slope ❑Valley ❑Flat
7mi f ;} (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: IL (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�(� DEPTH DRILLING LOG
Ait1yority or State T n �y Zip Code From T1o'1't Formation Description
8(�-_-74'A- (02i7E Q (pT Clay&Sand
Area code-Phone number ^C [ • C 4 Granite
4. DATE DRILLED �p• 29
5. TOTAL DEPTH: 00 t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:MDFT.
(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):to METHOD OF TEST BLOW
10.WATER ZONES(depth):_3_ t_ -7(4't $1
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt Material numbers and common road names.
From Q To_:10&Ft. f�•r __( -�
From ft To Ft.
From To Ft.
13. GROUT: Depth Material Method C
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. C J "t
14. SCREEN: Depth Diameter Slot Size Material CD
From To Ft. in. in. O s»
From To Ft. in. in. cn
15. SAND/GRAVEL PACK:
Depth Size Material r
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCIWN STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
:L
SIGNA RE OF—PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
-- GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_Russell S.Taylor CERTIFICATION k 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT4 ASSOCIATED WQ PERMITH
if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public Q Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
At�,T1Aow^n: County ❑Ridge ❑Slope []Valley ❑Flat
Lk#.� (check appropriate box)
(Street Name,Numbers,Ckunicarity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographicmap
SStreet or Route No.) (check box)
OAO1 oAn N 3� DEPTH DRILLING LOG
City or T�o1wn Statv zip Code From To r Formation Description
(Area
c )- '7ne 3 amber
Clay it Sand
Area code-Phone number � Granite
4. DATE DRILLED Q.t.��") ,a�5
5. TOTAL DEPTH: i AM,
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:�FT.
(Use"+"if Above Top o asmg)
8. TOP OF CASING IS oZ FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance rth 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW
10. WATER ZONES(d pth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roast
Depth Di eter or Wet ght/Ft. Material numbers and common road names.
From To__-I Ft._= za5 MtLp
From 0 To Ft.
From To Ft. c)
)
13. GROUT: Depth Material Method U3O a
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. C3
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 T UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d
SIGN RE OF PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days..
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 10 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
U"WA )y��y,LbA, y E (check appropriate box)
(Street Nam ,Numbers,Communi' ty,Subdivision,Lot No-Zip Cm@ Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address O ]3nk- 31 K Latitude/longitude source:❑GPS❑Topographic map
eetor oute No.) (check box)
Str
u Ncr '-'M 7 DEPTH DRILLING LOG
City or Ton State Zip Code From 0 t Formation Description
B(�- 7-Y3 -07.� Clay&Sand
Area code-Phone number �qt Granite
4. DATE DRILLED 7- '?`
5. TOTAL DEPTH: l ODt)1 �(
6. DOES WELL REPLACE EXISTING WELL? YES NO K
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 War below land surface requires a
variance in accordagQe with 15A NCAC 2C.0118.
9. YIELD(gpm): 1__ METRO ,OF TEST BLOW
10.WATER ZONES(depth): ��
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth������jjjjjj((((((��7��7 Diameter or Weight/Ft. Material numbers and common road names.
From ToFt. rr
From To Ft. :w
From To Ft. C
13. GROUT: Depth Material Method �?
From 0 To 20 Ft.Benonite&Cement pumped
3
From To Ft. Ow-
14. SCREEN: Depth Diameter Slot Size Material t0
From To Ft. in. in.
CJl
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
CONSTRUCTIAN STANDARDS,3 THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
bf
SIGNATIJE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

W P4
WELL CONSTRUCTION RECORD e.�3 I r 6
e3 es L 4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ Ru55ell 5.Taylor CERTIFICATION 4 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 171 Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI (� Topographic/Land setting
Near own: Q County �►Q,��1eQQll> DRidge ❑Slope []Valley ❑Flat
�` (check appropriate box)
(Street Name,Numb Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address 3 Latitude/longitude source:DGPS[]Topographic map
(Street rate a (check box)
�'. ,9Si�5 DEPTH DRILLING LOG
City or Town tatee Zip Code From Formation Description
828 -�/ 3► ! C-N'�'"' t" Clay&Sand
Area code-Phone number CC
4. DATE DRILLED Granite
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES [] NO
7. STATIC WATER LEVEL Below Top of Casing: /OQ FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS L._FT.Above Land Surface'
`Top of casing terminated af/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):74d_METHOD OF TEST BLOW
10. WATER ZONES(depth): 7$' $ 353 '
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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 r Ft.
From3�To Ft.
From To Ft. 'w
13. GROUT: Depth Material Method C '
c>
From 0 To 20 F[.6enonite&Cement pumped rA _
From To Ft. o
14. SCREEN: Depth Diameter Slot Size Material O
From To Ft. in. in. ut
From To Ft. in. in.
15. SAND/GRAVEL PACK: a:
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
CONSTRUCTIO TANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
5 OS
SIGNATURE CfERSON CONSTRUCTING THE WELL DAIIE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD w
North Carolina- Department of Environment and Nat al Resources- Diviision(of Water Quality-Groundwater Section
'��//
xVEI.I.CON'I'RACI'OR(INDIVIDUAL)NADIE ((Prrfinnt) f� Y`1 r.t�\ ��--- CERTIFICATION#3t�_Jkjf(f
ll'ELL CON1 RACTOlt COMPANY NAME -t11�---PHONE # ( �Kl C�7S �fy O l
SI'A'rE w'E.LL CONSTRUCTION PERMIT# __ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IN Municipal/Public ❑ Indus(rial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use _
2_ WELL LOCATION Topographic/Land setting
Ce []Slope Nearest Town:_ IsC ount y ❑Ridg ❑Valley ❑Flat
P, (check appropriate box)
(Strcci Name Numbers. mn bers.Cmmtity.Su
{{b
��division.Lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER'. t")CQC[ K5 (degrees/mmutesiseconds)
Address Lalnude/longdude source:❑G PS❑Topographic map
(check bos)
(Street or Rou te No-) i
'J KfC ��1� ,_ DEPTH DRILLING LOG
ity or9 iwn State Zip Code From To Formation Description ,t
CQr 41 7i
Area code-Phone numM1er -
4. DATE DRILLED 7i -I5� - C) S _ rn
5. TOTAL DEPTH: O r -y -
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W - 1
T STATIC WATER LEVEL Below Top of Casing: �Q_FT. -
(Use"+"if Above Top of Casing) O ,
8. TOP OF CASING IS FT.Above Land Surface'
-Jup of casing terminated actor below land surface requires a e.
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): q-.-__METHOD OF TEST OuC
10. WATER ZONES(depth):_ Qg{'t�
LOCATION SKETCH
11. DISINFECTION:Type j4 Ely Amount-.5 rn7 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/Fl. /Material numbers and common road names.From ( To—�_�—FL —L —J—r1�— T fG Jvt r-1+ 6,5 o� Hwy y G` 7Y
From To Ft. I.v
From To Ft. � YLVc1 ' �' v'.1+3� �i15t1 �-iJM K
if t-tyk+
13 GROUT: Depth Material Method 'aeci 6tfti - �e4 ems,
From_To__.3.0 FL a,g vrt(ley 'F"U f/V E"'��-G5o 0'1
From---To—,__Ft.____.- _
14. SCREEN: Depth Diameter Slot Size Material e^-Vr'\ le d- 0t +e' j- ocos1- L' reeg
From To__ Ft. in. _ in. O.� .vx(�¢5 f-C:CrI 2f �' e�n}e p�1ft'}-21�
From To Ft it) in. -.
15. SAND/GRAVEL PACK: Or, 0, (in1V-'E5 1'ufe-\ �i-'Jlk-
Depth Size Material nn
From To Ft. Ssc do d3 Qc),,cl dc (X QA c) r\
From To__FL_ - —" �1b-
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 CONSTRUCI ING THE U FLL DATE
Submit the original to the Division of Water Quality o.Groundwater Section, 1636 Mail Service Center-Raleigh,NC _.
27699-1636 Phone No.[phone],within 30 daps. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natu 1 Resources-Division of Water Quality- Groundwater Section
WELL CON'I RACTOR(INDIVIDUAL)NAME (print �r^^ ` -) r ' \ _— CERTIFICATtONBZU1 6
tV ELL CONTILtCfOft CON PANY NAME_ S_S.zU v,-,— - WL +rl�l'ry Cam._PHONE p (%M 1-175 97 y
S'I A I E WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMITM
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 29 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use---
? WELL LOCATION: Topographic/Land setting
Nearest"Fown:_ �_ tstc County atC.,�'S,$p—r� ❑Ridge ❑Slope ❑Valley ❑Flat
_ �1.� � �nl 1 (check appropriate box)
(Smet Name.Numhem Cennmunity.Subdivision,Lot No..Zip Cale) Latitude/longitude of well location
3. OWNER: l A'Q hs (degreeslminutesiseconds)
Addiets -Hes- �1-_�t��(t�C -- Latitude%longitude source:E3GPSOTopogrtphic map
(Street or Route No.) (check box)
y(✓c4 (�C _ .7 _ DEPTH DRILLING LOG
City or-row-n Stated zip Code From To Formation Description
Area crate-Phone number -
4. DATE DRILLED `>2o�^!�h
5. TOTAL DEPTH: ,��i/'1.S' rT1
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO PQ _
T STATIC WATER LEVEL Below Top of Casing: QUO FT. _ t
(Use"I"if Above Top of Casing)
R. TOP OF CASING IS—L—FT.Above Land Surface' o
r,
'Top of casing terminated atior below land surface requires a -�
variance In accordance with 15A NCAC 2C.0118. ---"
9. YIELD(gpm):_ate METHOD OF TEST_ CAll, — 4
10. WATER ZONES(depth): / 05
LOCATION SKETCH
It, DISINFECTION:Type TH Amount R`? Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth r' Diameter or Weight/Ft. Material numbers and common road names. f
From-_j`� To�941 FL�`t-- W� _ -�6.--- 5`E' OyY `}--It„�� lc'( �ZI O.J n,IleS
From To Ft. n
From To Ft. �c�5� Qil�G)pf0 exiol-- rJfn f`14o {Yd
13. GROUT: Depth Material Method Ort;c 4-1A'ZQI o IIO�
From O To_0,Q_Ft. Ce_nfs- l- .._ ). oApL t ).
From _To FL :-O � )e" O'f40 aPplea-far, ` r. ScSQ
14. SCREEN: Depth Diameter Slot Size Material n
From To Ft. in. ___ in.
From To Ft. in. in.
Is. SAND/GRAVEL PACK:
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 STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON NSTRUCTING THEWELL 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

010
WELL CONSTRUCTION RECORD 315562
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION is 2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# 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
Nearest Town. Co *Z, ,d,)!��
❑Ridge []Slope ❑Valley ❑Flat
00,Qk 1� �"L Q/iiAA/Q (check appropriate box)
(96eet Name,Numbers,CommuN ,Subdivision, of Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( treet Route No. (check box)
DEPTH DRILLING LOG
CI or Town State i Zip Code From To Formation Description
828 )- ry�9.4WO Clay&Sand
Area code-Phone number
4. DATE DRILLED 8•dS!•05 Granite
5. TOTAL DEPTH: ,SQO'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 300 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS .Z FT.Above Land Surface*
*Top of casing terminated actor below land surface requires a
variance in accordance with I5A NCAC 2C.0118.
9. YIELD(gpm): 10 METHOD OF TEST BLOW
10. WATER ZONES(depth):�73•I {�' 3 4 y'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 160z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth D' eter or Weight/Ft. aterial numbers and common road names.
From To Ft.
Fromft
ft
To Ft. [a•• J f$�- �
From To Ft. cn '_-
13. GROUT: Depth Material Method rri
From 0 To 20 Ft.Benonite&Cement pumped I --
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material O
From To Ft. in. in. to '
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Front—TO—Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU ION STANDARDS.,,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL��OWCrNER
I/l/ W
SIGNA OF PERSON CONSTRUCTING THE WELL D TE
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. -- - -
GWA REV.09/2004

WELL CONSTRUCTION RECORD 1
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling Inc PHONE # (82B)369-9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El MunicipaUPublic❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nea t Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
- it�a�e (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address PQ 3 Latitude/longitude source:❑GPS❑Topographic map
(Street or Route)= /j 1 J _ (check box)
2/Z 1 C1: _d& DEPTH DRILLING LOG
City or Town Srate Zip Code Fr Formation Description
)- �-&y'6- 7 0 I Clay&Sand
Area code-Phone number ' Granite
4. DATE DRILLED
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_t0o_ FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS y 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): .Z METHOD OF TEST BLOW
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz 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.
FromOft To Ft. (y,• /$� :`Af��.
From To Ft.
13. GROUT: Depth Material Method �
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material I -1
N 1
From To Ft. in. in. -
From To Ft. in. in. ccn
15. SAND/GRAVEL PACK:
Depth Size Material �¢2
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 ION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN RE OF PERSON CONSTRUCTING THIi WELL D TE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
- GW-1 REV.09/2004

.w�TA7Fo RESIDENTIAL WELL CONSTRUCTION RECORD �(\�\
°�
_ North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION k A047
1.WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 1 66Z
B QI.I['A 1� ..1►10 1d.Q1� g• WATER ZONES(depth: r
Well Contractor(Individual)Name FromTo From To
HI°..Cden Brothers Well Drilling, lI1C. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 lolly Hills Vista Rd 6. CASING: Thickness/
Depth Diameter Weight Mat rial
Franklin, NC 28734 From_aTo_AdFt. to , ItSr�
City or Town State Zip Code From_To Ft
( 828 )- 369-9591 From To_Ft. _
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION:
( ) 7554-87- `}55(o Rom_ToIZ_� Ft. oanatt & UalaZitE canoed
SITE WELL ID#if appllcaMa From To Ft.
STATE WELL PERMIT#(if applicable) From To_Ft.
DWO or OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameter Slot Size Material
From_To_Ft._in. _ In.
WELL USE(Check Applicable Box): Residential Water Supply❑
From_To_Ft.—In. _ In.
DA'rEDRILLED 10-7-1 '05 From To Ft. in. — in.
TIME COMPLETED log 00 AM[] PM OK
S. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
1 '1 From To_Ft.
CITY:
1 CASFI1fpS COUNTY A Fran To_Ft.
(11 Y. bers.Co.� E I I From To_Ft.
(Str}e� ama,Nummmunity,SubtllMdon,Lot No.,Pared,Zlp Cotle)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
OSlope OValley ❑Flat ❑Ridge ❑other From Tort Formation Description
(check oppr6priate box) ^ Clay � Sand
May be in degrees, r r Granite
LATITUDE J_ _ minutes,seconds or
LONGITUDE in a decimal format -
Latitude/longitude source: ❑GPS [)Topographic map -
(bca#on of"I must be shown on a USGS topo map and ° -
attached to this form if not using GPS) c
4.WELL OWNER -�
OWNER'SNAME ' !�I-Ha n' � r a
SIRE T ADDRESS MS C MYCA ST - 1
r� _ay ►os
City or own state Zip Cotle
( g28 )- 5hb-Z39(o
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: O 1
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm1
c. WATER LEVEL Below Top of Casing:.. ao FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'H Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
i
d. TOP OF CASING IS 2 FT.Above Land Surface' I 42110
'Top of casing terminated attor below land surface may require GNATURE OF ER7IFIE ELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C,0118.
e. YIELD(gpm): METHOD OF TEST Blaa 11(.'E Llry-&#H
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-la
11617 Mali Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7105

RESIDENTIAL WELL CONSTRUCTION RECORD tY C' Lj
15t�i -1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2045
1.WELL CONTRACTOR: g. W/gT�E�R ZONES( epth
rn2S B Brown TOP_4gM Bottom Tope Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
HFdden Brothers Well Drilling. Inc Top Bonom Top Bottom
Well Contractor Company Name Thlcknessl
7, HoIIV HIIIS Vista RD 7. CASING: Depth Diameter- Weight Material
Street Address Top Bottom_Ft.
_J=ranklin: NC '�28734 Top BonomFt.
City or Town Slate I Zip Code - Top Bottom_FL '
(228 ) 369-9591
Area code Phone number - 8. GROUT: Depth Material Method
2.WELL INFORMATION: �1/� GG 11e1 OO Top 0 Bottom 20 FL Cement 8 pumped
WELL CONSTRUCTfNN PERMIT# jifoU -6,a -. 2 0W _ Top Bottom_Ft.benonite
OTHER ASSOCIATED PERMIT#(il applicable) Top Bottom Ft.
STTEE WELL ID#(if applicable) ) 0 9. SCREEN: Depth Diameter Slot Size Materiel
3.WELL USE(Check Applicable Box)) Residential Water,Supply❑ Top _ Bottom_Ft_in. _ in.
DATE DRILLED 10 Top _ Bottom Ft—in. _. in.
TIME COMPLETED 5 ,10D AM❑- Ply,V Top Bottom_Ft_in. _ In,
A.WliL OCA ION: 10,SANDIGRAVEL PACK:
- Depth Size Material
CIyY.. —COUNTY Top Bottom_FL
�)) - Top Bottom Ft.
-IJtreet Name,Numbers,.Communi y,Subdivision,Lot No,Parcel,Zip Code) Top Bottom_Ft
TOPOGRAPHIC l LAND SETTING: (check.appropriate box)
[-)Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
/�� —. Top Bottom Formation Description
LATITUDE _,3_5__°ELLd' 'DMS OR 3x XxxxxxxxX DO 0' / Clay R Sand
LONGITUDE 83 '.DMS OR 7x.XXXXXXXXX DD / Granite
Latitude/longitude.source 'iii []Topographic map
(location of well must be shown on a USGS topo map ar{danached to /
this form if not using GPS) /
/
S.WELL4NER, I /
caner Name r /
't et Ad res
/ Etta
QC�ity�r Tow/n- Slate l Zip Code J
Area code Phone number -
n�� d
2? lan'
6,WELL DETAILS: p(t„yv DJr
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES OIL NOK I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
r-. WATER LEVEL Below Top of Casing: a5 FT, ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"t"if Above Top of Casing) STAN RDS,AND THAT A COPY OF THIS RECORD HAS BEEN
P ED TO THE WELL OWNE
d. TOP OF CASING IS 2 FT.Above Land Surface'
-Top of casing terminated atfor below land surface may require �r
a variance in accordance with 15A NCAC 2C Ot t8. GNATURE OF C R IE t-CO RACTOR *ATE
e. YIELD(gpm):�_-METHOD OF TEST b IOW _ James B Brown - --- ---- ---�-"�"-""""i
I. DISINFECTION:Type T H Amount l6oz _ PRINTED NAME OF PERSON CONSTRUCTING THEIELLL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form]W-1a
1617 Mail Service Center, Raleigh,NC 27699-1611:Phone : [phone] .�,� 9. Rev.2 9
25 2L
y

tic ✓ uitUcR trlii;
NVcr,i, CONS'rltUC'r1oN ita COI(l) U 3 p 6919
Notth Carolina-Depailment of Euviionnrc it told Nnlu)al Resoulces-Divisiolr of water Qunlity-Groundwater Secliort
IVELL CON I RACI Olt(INDIVIDUAL)NAME (prbn)_ �'l/t (��L L—. CFRIIFICAnUN n✓��C.>'
r.a,y- r110NP.
IVFLL CON I RACI Olt COairANV NAP4:-__�%�.</l" —_--
51ATEIN ELL CUNsIRiiCI ION rF.MII10 --_---- ASSUCIA"r Ell WO I'ERMI'I N --
if:+ +licnldc ifardicnble
I, R'I 1,1, 11SF.(Check Applicable lk+s): Residential EI�Municipal/Public❑ Industrial CI Agticullurnl U
�loniiming U Recovery ❑ Heat Pmnp %Viler lojection U Olhcr U If Olhcr,List Usc --._.-
2. Wul 1. I OCA 110N: // ! Tupogrnphic/I Auld setting
NcnreslTu+cn._(-�R.��lZ�-r -----County, aC/[tC�2 y
URidge ❑Slope UVnllc LII'lat
� (chttk appropdnre hoe)
tsuerr Nnme,Number,Community,5a1. In+sioo,I t No lip Calc) l,aliluddlaugiWJe ofDell I�catinn
3. OWNER: 'Z`-T"�4pC:'r/ie"! (Jegteedminntce/recond+)
AJdress Latitude/longilude sourec: maropogiapbic map
(Sueet or Route No.) (check Mn)
nA ,M ,4� If, G z u ,WL Id ► Q-Q
{ City or Town Stale Zip Cale From To Formation Description
Aira care-rhone number
4. DATE DRILLED
S. TOTAL DEPTII:
6. DOES WELL REPLACE EXISTING WELL? YES U NO
7. STATIC WATER LEVEL Below Top of Casing:
/ (Uae"+"Ir Above Top of Caring)
8. TOP OF CASING IS L Ff.Above Land Surface" z"
•Top orcning lermina/ed al/or below land aurrace repuirea a
variance In accordance with 15A NCAC 2C.0118. _ 00
9. YIELD(gpm): %S MET}IOD OF TEST j f,
0
10.WATER ZONES(dcpdi):
]LOCATION SKETC3[
11. DISINFECTION:Type T Amount �Y�.` Show direction and distance in miles from at st
IL CASING: Wall 11ickness two State Roads or County Roads.Include the ad
Depot Diameter or WciRhuFL Material numbers and common road names.
Front_ To r
From To Fl.
From To FL
13. GROUP: Depth Material Method
From_C—To_`�_Ft /t.
From e2To J Ft. 4',-ft f� iiT rya c
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in.
From To Ft. in.
IS. SAND/GRAVEL PACK:
Depth Size Material
From To FL
Froul To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT Tl[IS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15ANCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
SIGNATUItP Oh PERSON CONSTRUCTING THE WELL DATE
Sublidt the original to the Division of Water Quall(y,Groundwater Section,1636 Mall Service Center-RNlelkh,NC
37t 99-I(att Chunc Nn.(v 19)7)1-3221,n Rhin ,l0 da}'e. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD V" ' U t O 4
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print),lames B.Brown CERTIFICATION 9 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 13 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring O Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCAT N: Topographic/Land setting
Ne estTo/wli 1 aoeo County�,�AJ ORidge ❑Slope OValley Flat
till y/>'r (check appropriate box)
(Street Name Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: QQW-e eX/ AAV1_ (degrees/minutes/seconds)
ddress ftma So 'S Latitude/longitude source:13GPSOTopographic map
(Street or Route No.) (check box)
LLf�B020 . NC a87as EPT DRILLING LOG
City nQX4 �1���'sit�atij,., zip code Fr m r Formation Description
-.idle'f 0? clay&sand
Area code.Phone number granite
4. DATE DRILLED •O5
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:�1 Q2 T.
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of easing terminated st/or below land surface requires a
variance In aceordan e w,P ISA#CAC]',Q1C.0116.
9, YIELD( T 10.WATER ONES(d /a(U 0 QIQ BLOW
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16OZ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depths , Di tinter (/or Ft. M erial numbers and common road names.
From To-�]y7L/��Ft.
From To Ft.
From To Ft. "1
13. GROUT: Depth Material Method -
From­-2_To 20 FL benonite&cement pumped
From To Ft.
o
14. SCREEN: Depth Diameter Slot Size Material -
9
From To Ft. in. in.
From To Ft. in. in. =--:
15. SAND/GRAVEL PACK:
Depth Size - Material ry .
D
From To Ft. -
From To Ft.
16. REMARKS:
a:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-U
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC T
27699-1636 Phone No.[phone],within 30 days. \ • GW-1 REV.07/2001

WELL CONSTRUCTION RECORD U 306855
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Ddlling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential® Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: , �../I /� Topographic/Land setting
Neare own'. /%(ryJ7illCllt CountyC�IL��J #Ridge ❑Slope OValley OFlat
.Kole �! _ (check appropriate box)
(Street Name,Num ,Community,subdivision,Lot No.,zip code) Latitude/longitude of well location
3. OWNER: Wd (degrees/minutes/seconds)
Address Latitude/longitude source:OGPSOTopographic map
street or Route No.) y p (check box)
Ajr( " �! DEPTH DRILLING LOG
City or t Zip Code Fr To a Formation Description
(jam- ydZ�_ clay 8 sand
Area code-Phone number ' granite
4. DATE DRILLED. 5
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO {�
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance In accordesce with 18A NCAC 2C.0118.
9. YIELD ZOO ;—MET�IQD OF F�STC BLOW
10.WATER ZONES(depth): /� r �—
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diarrister or Weight/Ft. Material numbers and common road names.
From To ?Ea Ft.F Fro 42 n
m To]?Ea L r-1
From To Ft.
13. GROUT: Depth Material Method e
From—2—To 20 FL benonite 8 cement pumped
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material 7D
From To Ft4 in. in. _
From To Ft. - in. in.
15. SAND/GRAVEL PACK: V
Depth Size - Material �b
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 STA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
O
SIGNATU PERSON CONSTRUCTING 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-I REV,07/2001 ry

WELL CONSTRUCTION RECORD 3 G 6 8 5 6
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) if applicable)
1. WELL USE(Check Applicable Box):Residential(a Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO dgc, O aphic/i.and setting
Nearestt7,•own: C(_ County Ridge ❑Slope Valley OFlat
c! n/ h (check appropriate box)
(Street Name,Num ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:OGPS17Topographic map
(Street or Rouie No.) (check box)
IC DEPTH DRILLING LOG
CityAl
Town A 7'�zip Code Fr s Formation Description
clay&sand
Area code.Phone number granite
4. DATE DRILLED
5. TOTAL DEPTH: � ,,11,��
6. DOES WELL REPLACE EXISTING WELL? YES O NO K
7. STATIC WATER LEVEL Below Top of Casing: /oD FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
•Top of casing terminated actor below land surface requires a
variance In accordan a with ISA NCAC 2C.0118.
9. YIELD MET OD OF T S BLOW
10,WATER ZONES(depth): � �
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di m cter or Weight/Ft. Meal numbers and common road names.
From To FtNY
. `
From To Ft.
From To Ft. ,v -
13. GROUT: Depth Material Method
From 0 TO 20 Ft. benonite&cement pumped
From To Ft. W.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. ry
From To Ft. - in. in. xn '
15. SAND/GRAVEL PACK:
Depth Size - Material
From To Ft.
From To Ft.
16, REMARKS:
I DO HEREBY CERTIFY AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION S D S,AND THAT A Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATtfffOF 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
MAR

WELL CONSTRUCTION RECORD C 306858
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if aPPlicable) (if aPPlicable)
1. WELL USE(Check Applicable Box):Residential O Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI A County Topographic/Land setting
Ne ❑Ridge ❑Slope OValley OFlat
(check appropriate box)
(Street Name, embers, mmun, ,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address 0 Latitude/longitude source:OGPSOTopographic map
(Strew o R ute o. (check box)
I ��'7 11 DEPTH DRILLING LOG
try or o vt to r Zip Code From T t Formation Description
(8Pc _ - � clay it sand
Area code-Phone number � t ' granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+• if Above Top of asing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated niter below land surface requires a
variance in accordant with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW
10.WATER ZONES depth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di meter or Weight/Ft. M enal numbers and common road names.
From 0 To Ft. to
From' ' ToFt. A _.,Vi W
From To Ft. r) - --
13. GROUT: Depth Material Method J1
From 0 To 20 Ft. Benonite&cement pumped -
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. ry _
From To Ft. `D
16. REMARKS:
I DO HEREBY CERTIFY T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION S DA S,AND THAT A C PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/-C,?> -D
SIGNAT RE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-Y REV.09/2004

WELL CONSTRUCTION RECORD &V 306860
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION*2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE * [phone]
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO I: Topographic Land setting
Near tTowt I County Ridge ❑Slope C]Valley Flat
(check appropriate box)
(Street N me,Num rs ommuniry,Sub 'vision,Lot No.,Zip Code) Latitude/longitude of well location
t
3. OWNER: (degrees/minutes/seconds)
Addre Latitude/longitude source:0GPS Topographic map
(Str or Route No.) (check box)
DEPTH,1 DRILLING LOG
(miry or T n State Zip Code ., From T�op/ Formation Description
8a c �. ���- clay it sand
Area code-Phone number III � r granite
4. DATE DRILLED
5. TOTAL DEPTH: r
6. DOES WELL REPLACE EXISTING WELL? YES No
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of asmg)
8. TOP OF CASING IS 2 FT.Above Land Surface•
-Top of casing terminated attor below land surface requires a
variance in accordareQtvith 15A NCAC 2C.0118.
9. YIELD(gpm): MET D OF TEST BLOW
10.WATER ZONES( epth): 0
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Watertal numbers and common road names.
From 0 To Ft.
From=Tc Ft.�`'
From To Ft. -
13. GROUT: Depth Material Method1
From 0 To 20 Ft. Btnonite&cement pumped _
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. co £=
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material W
From To Ft.
From Tc Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—t�
SIG1,TATURVOTPERSON CONSTRUCTING THE WELL DATE
Submit the origins to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,INC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV..
09/2004

WELL CONSTRUCTION RECORD GP 306861
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential O Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other C If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Neare t Town: n`, 1nnn County CRidge ❑Slope OValley OFlat
8 n (check appropriate box)
(Street ame,N on,Community,Subdivision"ZipCode)Lot No., Latitude/longitude Of well location
3. OWNER: (degrees/ndnums/seconds)
Address v Latitude/longitude source:OGPSOTopographic map
( treet or oute No.) (check box)
3/p 04 DEPTH DRILLING LOG
�ry or To ,f rate � //Gzip Code From To Formation Description
828 - `um'7 - �-F5 —�% nj?� clay&sand
Area code-Phone number /� t �
4. DATE DRILLED / ' 7 , O .� Granite
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: T.
(Use"+"if Above Top f Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordant ith 15A NCAC 2C.0119.
9. YIELD (gpm): METHOD OF TEST BLOW
10.WATER ZONES( epth):
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall ThicF,eu two State Roads or County Roads.Include the road
Depth , Di eter or Wei ht/Ft. Material numbers and common road names.
From o _To:�.. L Ft. 00 -
From To Ft. �n _
From To Ft. r" _-
I3. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite a cement pumped Fv
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material -70 r
From To Ft. in. in. `.
From To Ft. in. in.
15. SAND/GRAVELPACK: w
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 S,AND THAT A C Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- 19 -a
SIGNATUKE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No,[phone],within 30 days.
GW-1 REV.09/2004
,fir� Lv7

30 � 81 '7
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
{4 LL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Ne�arrestTown: County a ❑Ridge ❑Slope OValley ❑Flat
r►r 6 fxrA, t"s-r fj'( (check appropriate box)
-(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: FQ.A0 K- t TaV A r-esmi-M (degrees/minutes/seconds)
Address "(o ra 2¢ES FS7 Latitude/longitude source:OGPSOTopographic map
_lu iyil.(Street Route 'IT (check box)
_T n( DEPTH DRILLING LOG
City or 1p 3 ,$tale Zip Code From of Formation Description
(628 )- (p • y`l�3 0 clay&sand
Area code-Phone number granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLAC E TING WELL? YES O NO (�
7. STATIC WATER LEVEL Below Top of Casing: 02 FT.
(Use'Y'if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface'
-Top of casing terminated attor below land surface requires a
variance In according with 15A NCAC 2C.0118.
9. YIELD(gpm): �M HA9D OF TEST BLOW
10.WATER ZONES(depth): leD r
LOCATION SKETCH
L;DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di a eter or We' ht/Ft. Material numbers and common road names. >-
From 0 To> D F[. & 0 ��
cm
From-.-- Ft. (e - -n
From To Ft. r n rn
13. GROUT: Depth Material Method `y to -Urn
From 0 To 20 Ft. Benonite&cement pumped
From To Ft. _ —+c:;
14. SCREEN: Depth Diameter Slot Size Material - a nX
From To Ft. in. in. ..-
tr1
From To Ft. in. in.
a�
15. SAND/GRAVEL PACK: vv - cn:E
Depth Size Material n
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTR TION STANDARDS,AND THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division o Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD � 3 0 7 9 5 2
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential © Municipal/Public D Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI "" �� Topographic/Land setting z+
Nearest Town: Court ❑Ridge ❑Slope DValley DFlat. .n '
(check appropriate box)
(Street Name um ,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location -
•
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:DGPSDTopographic map
�,
(Stre or RouteN .) (check box) .-.
C DEPTH DRILLING LOG
city or Town Stave Zip Code From o 1 Formation Description
B( 26 )yPp. g3 0� clay it sand
Area code-Phone number � s r granite
4. DATE DRILLED Oi '
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES D NO
7. STATIC WATER LEVEL Below Top of Casing: ;i�-_ T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance In accordan with 15A NCAC 2C.0118. BLOW
9. YIELD(gpm): _MET OF TEST
10.WATER ZONES(depth): �l�.� LOCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type H T H Amount 16 oz two State Roads or County Roads.Include the road
12. CASING: Wall Thickness
Depth Di mete or�W�et�,ht/Ft. aten numbers and common road names.
From 0 To� Ft.�p_ t /iJQ
From To Ft.
From To Ft.
13. GROUT: Depth Material Method C crn
From 0 To 20 Ft. Benonite&cement pumped 'l
From To Ft._ rnt9
14. SCREEN: Depth Diameter Slot Size Material =C3
-oa
From To Ft. in. _ in. �
m o0
From To Ft.—in. _ in. p crv'ii
15. SAND/GRAVEL PACK:
Depth Size Material trl o`'
zn
From To Ft. ,�— cnp
From To Ft. O
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND 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,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW-1 REV.09/2004

WELL CONSTRUCTION RECORD V 307951
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE it [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION I^,, �,,,,,� Topographic/Land setting X-
Neares wn: County ❑Ridge ❑Slope ❑Valley ❑Flat
n[I / (check appropriate box)
(Street ame, mb Community,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
ram:
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic mfrytl'
� la
treeout�eiq'' 1p pp (check box) ���
J�—C�')o�oo DEPTH DRILLING LOG
City or Tow" StetaT Zip Code From To t Formation Description
8( 20 )-.�(p 3 clay it sand
Area code.Phone number granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO f�
7. STATIC WATER LEVEL Below Top of Casing: /5C FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of cuing terminated at/or below land surface requires a
variance in accordant ith 15A NCAC 2C.0118.
9. YIELD(gpm): X METJ-IRDOOF�EST BL W
10.WATER ZONES(depth): ��((//
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Ft. Diameter or Weight/Ft. Material numbers and common road names.
From 0 To tt Oa
From�'�' ToFt. Ul cr'5
From To Ft. mn
13. GROUT: Depth Material Method W �<
TT[
From 0 To 20 Ft. BenonOe 6 cement pumped �t7
From To Ft. i
[T o�
14. SCREEN: Depth Diameter Slot Size Material -p rn
From To Ft. in. in. � A-r=
From TO Ft. in. in. W Zo
15. SAND/GRAVEL PACK: o
Depth Size Material O 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 STAND S,AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—0
SIGNATU ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV. 09/2004

WELL CONSTRUCTION RECORD
307950
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT4 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
no
2. WELL LOCATI /�- , _ Topographic/Land setting
Nearest Town: County ❑Ridge ❑Slope ❑Valley ❑Flat - _-•"
f- V (check appropriate box)
(Street Name,Numbers,Community,Subdivision, Zip Code) Latitude/longitude of well location
3. OWNER: QeYa l — (degrees m notes seconds) r
Address "(Sct.,
Latitude/longitude source:❑GPS❑Topographic map
yA (check box) -
.LJ DEPTH DRILLING LOG
Corp,To Stain Zip Code From Tot Formation Description
g( 28 ) SQ&-2&Z o I clay it sand
Area code-Phone number TF TM, granite
4, DATE DRILLED ' 0-5
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top o Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated st/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):�_METHOD Q T,�j T BLOW
10.WATER ZONES(depth): �G5 j7
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To Ft. to"
Arc-
From__5iyFTo Ft. /T• Sa
From To FL r�jy C=m
13, GROUT: Depth Material Method -� mrTi
From 0 To 20 Ft. Benonite&cement pumped W m—
7J m
'From To Ft. -am
14. SCREEN: Depth Diameter Slot Size Material C�
From To Ft. in. in.
From To Ft. in. in. 3 ��
15. SAND/GRAVELPACK: GJ o0
Depth Size Material Z
From To Ft. o mo
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�Od
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV. 09/2004

-� 307949
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential- Municipal/Public VF� Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
D
2. WELL LOCATI Topographic/Land setting �r
Nearest T wn: County ❑Ridge ❑Slope ❑Valley ❑Flat ti f
(check appropriate box) 4'
cz
(Street ame,No is,Community,SubdiA ,Lot No.,Zip Cod Latitude/longitude of well location r.a
3 OWNER: (degreesluunutes/seconds) cJa
Address Latitude/longitude source:OGPSOTopographic:rfiap i7,
Street or Roure o. (check box) - -
hwm Q� DEPTH DRILLING LOG
City or Town State ',,,.}, Zip CodeFrom Formation Description- -
6(ie )-� I •'f300 r.��u ,�# o oZ clay 8 sand
Area code.Phone number granite
4. DATE DRILLED 06
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: 600 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated at/or below land surface requires a
variance in accordant w th 15A NCAC 2C.0118.
9. YIELD(gpm):��MET jI/D OF,TEST BLOW
10.WATER ZONES(depth): / %f,/
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least 7�
12. CASING: Wall Thickness two State Roads or County Roads.Include 8 road �m
Depth D' meter o:Wei ht/Ft. terial numbers and common road names. CA —n,�
From - _,0 To Ft. rn :<,
From To Ft. Ad
From To Ft. "
13. GROUT: Depth Material Method a rrn
From 0 To_.Sy -Xt. Benonhe&cement pumped "fl nx
From To Ft._ 3 ��
0
4. SCREEN: Depth Diameter Slot Size Material W ZQ
From To Ft. in. in. rnQ
From To Ft. in. in. C�
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
From—To—Ft.
6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND ,AND THAT=THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
/— —d
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

f1
N C OWNER �-'ivJ P16J D
----- 308166 -
WJJAA, CONS'l.RUCTION RECORD
North Carolina-Department of Environment Stud Nat(Tal Resour es-Division of Water Quality-Groundwater Section
WELL CONTRACT Oft NAaIC (prinp_{r//'�/�It� �C��[e- CER"rIPICA7 ION
�/�
WELL CON TRACTOR C051PANV NAME /z'//�er PHONE I fwv )F/J-zf3;
STATE WELL CONS"fit UCf10N PEMI IT# __fSSOCIA'1"P,D WQ PP,RNITI4
(ifnpplicahlr) (if npplicnble) -
i. WELL USE(Check Applicable Box): Residcnlial 14-1etunicipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Ileal Pump Water injection❑ Other❑ If Other,List Use _rn
2. WELL I.00AIION: �a
[ Topographic/Land setting
Neirr"tToan: �_ i�. 0 ee Couuly fc/'-7C�� ❑Ridge ❑Slope ❑Valley Mat
(chmk+ppngwiate Mx)
ISnerl Neroe, Jumbrre,CoimmRnhy,SubJi,ision,Lnt Nr, lip 0.1e) Latitudellongitude of well location
3. 0WNFR: 7<I
_ _.____ (degree✓mimnre/eceond+) '
Adthcss `�' ( =tt Latitudellongilude source:❑(iPS❑Topographic slap---
(Street or Rome No.) (check tx,x)
City or Imrn SIMe zip CM, From 'Ib Formation Description
A,r Me-rhnne nnoibc, 0
4. DAFEDRILLED -. "45J
5. TCITAI.
6. DOE S WELL REPLACE EXISTING WELL? YES LI NO LY
7. STATIC WATER LEVEL Below Top of Casing: /D 171•,
_4 (Use";--if Ab(ve'6,p of Casing)
8. TOP OF CASING IS /_ F1'. Above land Stufacc'
•7"op of ruing trrminatrd War Irrinw I+nd snrrare rapdrer
rvl+are In arrnrdamr wllh 15A NCAC 2C.011 s.
9. YIFLD(pin):%Y METHOD OFTFSI- /9� —
10. WATER"ZONES(dep(h):
_ _ L.4C�T14IL5.G1iMl
11. DISINFECTION:T)Ilre 1`7`r�Anwn_ul %�cct4 Show direction and distance in miles from at Icast
12. CASING: Wait'ILickness Iwo Slate Roads or County Roads. Include the road
Depth Dialuctcr or Weight/H. Matrrial numbers and common road names.
Fron%_'ib
Froln ? y Toss" pL Wr Ii�e- /
Front To Ft.
13. GROU"r: Depth '%9atc inl Method a
From To 2,11 Ft.=v�i'i'.
14. SCREEN: Depth Diameter SIu1 Size hlalerial O
Fiom TO_FL in. in. Qf
Front_ To__ ill. in. in.
15. SAND!GRAVFL PACK:
Drplh Sizc Martial
From To Ft.
From To PI
16. REMARKS:
1 DO NPRFBY CLRI'IFlS"I HATTIIIS WFLi,WAS CONS II(IICUPI)IN ACCORDANCE WI711 15A NCAC 2C,WELL ,
CONSTRUCI ION STANDARDS,AND THAT A CQPY OF MIS RECORD HAS BEEN PROVIDED TO Till!WELL OWNER
SIONATURF OF Pfiit.SCN C'ONSTRUCIING I IIE WELL DATE
Submit file orighial to the Dilision of Rater Quality,Groundwater Section, 1636 Mall Service Center-Raleigh,NC
27699_I616 Phoor No.(919)7331221,within 30 dnys• OW-1 REV.07/2001
a

NC _ OLINErl _ 308166 NWD _
WELL CONSTRUCTION RECORD
Not lb Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (priinnt)) Al-, V lee e- CERTIFICA"I'ION t/cc VQZ
WELL CONTRACTOR COMPANY NAME PIIONE N tr2f)
STATE WELL CONSTRUCTION FERM I N ASSOCIATED W Q PERMITS
(if npplicnble) (if applicable)
I. WELL USE(Check Applicable Box):Residential(3�NluuicipaUpublic❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Real Pump Water Injection❑ Other❑ If Odrer,List Use y
2. WELL LOCATION: T•opogmphie/Lmtd setting -
Nearest Town ;- County - a L ❑Kidge ❑Slope [Walley ❑Flat to
(chat appropriate bax) -
(Stmer Nome,Number,Crumnuity,Subdivision,IA No,7ip U.le) La(iluddlongitude of well location
// / / L ivyre�L3' YS.I''a/nyyoos .�-
3. OWNER: C;V'.11 G77L // 114 _ _ (deirreex/minmet/tecmmdf)
Address Get,fe LnliWddlon dude source:OOPS❑Toro is phic mn
—CfB—JT—�---- -- 8 { 8 ! R
($heel rn aome Nu.) (chat box) ,
ML'Cll 12BILLINU LQ4
City or11mt,t Suite zipcaie From To FomrationDescription
Ares v b,Phone naniber 6
4. DATE DRILLED
5. TOTALDF,PTEI:__
6. DOES WELL REPLACE EXISTING WEI.L7 YES ❑ NO Er
7. STATIC WATER LEVEL Bclow Top of Casing:—.Z-vo,FT.
1-7-
(Uee"t­-if Abuve Top of Casing)
8. TOP OF CASING IS y Fr.Above Land Surface"
'Top of rninr lerndnatird eVor below land enettre requires a
verlenrt Ia errnrdenre with 15A NCAC 2C.0119.
9. YIELD(grim):—2j—_METHOD OF TFS I is i
10. WATER ZONES(depth):
L DISINFECTION:Type lfT"i Amount �,G Show direction and distance in miles from at Icast
12. CASING Wall'Ihicknens two Slate Roads or County Roads. Include the road
I)Cplll Ditunctcr or\Vci thUP1. htntclial ntnobers and common road names.
From D Ib�ZF1
Ftook To FI. _ S
Flom
17. GROUF: De til 1m tipl -- 'method
From l� To�FI. ? C4
From To Pl. CD
14. SCREEN: Drplh Diameter Slot Sire btalerial N
Frorn Tn 14. in. in.
Fmnt Tn_ _FI. in,
15. SANDIGRAVEI.PACK:
Depth Sizc 1,111mial
Front To Ft.
16. REMARKS:
DO HEREBY CER71FY TIIATTIIIS WELL WAS CONS I RUCfED 1N ACCORDANCE WTRI 15A NCAC 2C,WELL
CONSTRUCTION S'rANDARDS,AND THAT A iCOPY OF/-11119 RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU W OF P RSON CONSTRUCTING T1III WELL DATE
Subudl the original to file Division of Water Quality,Groundwater Section,1636 Midi Service Center-Raleigh,NC
27699-wi;Phone No.[phone],within 30 days. OW-1 REV, 0712001

N C — -- OWNER -------- ^ t�� M W D ----
308166
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CON'TRACTOR(INDIVIDUAL)NAME (p,Im) —AiLl-/ /L ee" a CER'TIFICA7TONN of ydl
IN ELL CON]RACI OR COMFANYNAMF. /h/,'l/cr PHONE N &,,ie)SYP 59)
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# _ ..
(i f nppl icnblc) (i f applicable)
I. WELL USE(Check Applicable Box): Residendiul ET'Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ heat Pump Water Injection❑ Other❑ If Older,List Use - '
2. WELL LOCATION: Topographic/Land Setting
Nenrest Town: / t/a Courtly 12c /-10/1 1111idge ❑Slope ❑Valley ❑Flat 4k.
UC✓'/l«1 ('�C�e,e /ec(. (check appmprirh boi) - c-
(Street Name,Numbed,Community,Subdivision,Lot No,lip Cole) Lalitudellon Ilude of Well location
3. OWNER: •T CD�V 6Gf/!1le i1 pkgreedminulesiseconda)
Address Laliluddlongilude source:❑GPS❑Topographic map _
(Sheet or Route No.) (check Not) "
1241111 DRILLINGLOu
City or Town Slate Zip Gvle From To Formation Description
Area tale-Phone nnmtwr
4. DATE DRILLED /- !Z-GS� /t'— z
5. TOTAL DEPT►L• 2 U
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El-
7. STATIC WATER LEVEL Below Top of Casing: U F-F.
(Uce***"if Above Top or Caning)
8. TOP OF CASING IS /y FT.Above Land Surfacc•
-Top or casing brmtnated atJer heron Rand asor.ce requirta a
vntance In acrmdance nab RSA NCAC 2C.0II9.
9. YIELD(gpnt):_/O btE"r110D OF TES /72,/
10. WATER"ZONES(dep(h): Z VO '
L4��Zt4I�SKL•1:�1.i
11. DISINFECr10N: rype�hrTly Amount iy( c( Show direction and distance in miles from at least
12. CASING: Wall'Iliickor's two Stale Roads or County Roads. Include the nrad
Depth Dian elcr or WcighUFl. Material numbers and common road names.
Front To S-Y FL 6..2S''
FnmL,}_Y_To JS_ Ft. d. 03_ lYY Suez% _
From To FL "-
13. GROUT: Depth tmcrinl tctliod
Fronts TO FI. /1%iif ."�/_ � s'
Flom- To aZ C) PL_Lregl`c2'Fe'__ CD
14. SCREEN: Depth Diameter .Slal Size Molerial LIT
From To Ft, in, in.
Frotn__To Ft. in. in.
15. SAND/GRAVEI.PACK:
Depth Size hlntelial
Front TO FL _
From To Ft.
16. REMARKS:
DO NP.RF1IY CERTIFY TIIATTIIIS WELL.WAS CONS I RUCI ED IN ACCOIWANCE WI'Ill 15A NCAC 2C,WELL r
CONSTRUCTION STANDARDS,AND TIRAT A COPY OF'I HIS RECORD HAS BEEN PROVIDED TOITHE WELL OWNER .
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit tire nrlginni to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
17699-1636 Phntie Nu.(919)733J221,within 30 days. OW-1 REV. 07/2001 -

WELL CONSTRUCTION RE, r CORD 30,8164
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)
/ry/�iQ[G� CERTIFICATION NZ
Yo3
WELL CONTRACTOR COMPANY NAME //, I/ei PHONE N (Aap) 77
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential G3-Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring u Rmc,:c:; n Heat Pump Water Injection❑ Other D If Other.List Use s
n
2. WELL LOCATION:/ ` [ Topol raphic/Lnnd setting
Nearest�Town: CF'�,//��'`ee- County 5elc�cJoll ❑Ridge LtSiopc DVaiicy rlMat
/
�/ C L'd /l J (check appropriab•box) -
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: le P ir)/ (degrees/minutestseconds)
Address Latitudellongitude source:DGPSOTopograpltic reap
(Street or Route No.) (check bon)
QEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Area code-Phone number - — /'Zf C!4 y '
4. DATE DRILLEDJ'/3
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES D NO 9'
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use'W'if Above Top of Casing)
8. TOP OF CASING IS /z- 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 1,41
10.WATER ZONES(depth): L L LOCATION SKETCH
11. DISINFECTION:Type NT Amount i'YG Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighUFt. Material numbers and common road names.
FronL�_To / ' Ft. • ZS le'z 1 °'G
From_ZLL-Tom_Ft. f;,J3 /56 (fee l
From To Ft.
13. GROUT: Depth attenal Method _
FL
From�Q_To c9
From�_To�L—Ft. /.�cnfca fe ✓ eA t
14, SCREEN: Depth Diameter Slot Size Material
From To Pt. in. in. cn
o
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 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT IUN STI"M R nS;AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE •PERSON CONSTRUCfINU IFii3 DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
GW-1 REV.0712001
27699-1636 Phone No.[phone],within 30 days.

NC OWNER MWD
WELL CONSTRUCTION RECORD 308160
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prInnyty) � CERTIFICATION#Z 03
WELL CONTRACTOR COMPANY NAME PRONE # {g;7y)PJ7-2 y9J
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
-_ (if applicable) (if applicable) -
I. WELL USE(Check Applicable Box): Residential R'�Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use -
2. WELL LOCATION 2 / Topographic/
L and setting
NcareslTowtl: GViwff r County kC I0r1 ❑Ridge ❑Slope ❑Valley ❑Flat '
2-10'aw cevc 'ej
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latittuddetlongitude of well location
3. OWNER: 141-uG%J1I SzFG�fO/t (degreeNminutea seconds)
Address Latitude/longitude source:OGPS❑Topographic map
(Street or Route No.) (check two)
DEPTH DRILL1VQL_Q-Q
City or iown stnie Zip Code From To Formation Description
Arm code-Phone number D jrJ G ky
4. DATE DRILLED
5. TOTAL DEPTH: i'Y Z ' S'U 35fz Givir.'f e
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IJ
7. STATIC WATER LEVEL Below Top of Casing: /­?D Fr.
(Uoe"t-if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surrace•
-Top ofnsing terminated at/or below land surface requires a
varlsnrt In accordance with 15A NCAC 2C.0119.
9. YIELD(gpm):_V METHOD OF TEST
10. WATER ZONES(depth): i2-r6 '
LOCATION SKETCH
11. DISINFECTION:Type if r7` Anuum( /q Show direction and distance in miles from at least
12. CASING: Wall 1Lickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From O To Ae FL 6.4 f022/ love
From To FL
From To Ft.
13. GROUT: Depth �n1 at vial �rvI ethod
' ` W4 �"',,o From O TO_�Ff. di 4oJ
a�
From 4/ To V Ft. ei»��• fL py�ori t
14. SCREEN: Depth Diameter Shot Size Material —'
From To FL—in. in.
From To Ft. in. in. tti
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
Frmn To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT TlI1S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF 1111S 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
17699-16.16 Phone No.[phone],within 30 days. GW-I REV.07/2001

NC _1/ OWNER _ _ 00 M Q
WELL CONSTRUCTION RECORD
Norlh Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prinq_ �rry eeeece CERTIFICATION NeZ3
40q
WELL CONTRACTOR COMPANY NAME Pl1ONE N (9ZP)e'j��z yS
STAI E WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERNIITN
(i f applicable) (if appl icnble)
I. WELL USE(Check Applicable Box): Residential e' Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ heal Purnp Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:/ Topographic/Land setting
m Nearest Town, CJ7vz'o�eG Cudy GC off ❑Ridge ❑Slope ❑Valley ❑plat
_0/j 5-060 'ej, (check appropriate box)
(Stmel Name,Number,Community,Subdivision.Lot No.,Zip Cale) Latitudellongitude of we I location �r
3. OWNER: Carl 4• /'/�'S' c11 (deyeea/mimnea/eecond�)
Address Tn'k( CG'z) `• Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
pl:P fl l VJULL 1HU L_Q—Q
Cityorlown State Zip Cade From To Formation Description
Ara code-Phnne number C Gy
4. DATEDRILLEO
5. TOTAL DEPTH: �oZ
r
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0 h
7. STATIC WATER LEVEL Below Top of Casing: 80 FI'.
z (Uae"F"if Above I'op of Carina) �O '
8. TOP OF CASING IS / Z' FT.Above land Surface*
'Top of coming lerminated atfor below land surface require,a
variance In acterdance with 15A NCAC 1C.011 a. N
9. YIELD(gpnt): 10 METHOD OF TEST r
10. WATER ZONES(depth): l5S' u7
LOCATION SKETCH
11. DISINI'ECTION:'fype / T Amount �(Cu/' Show direction and distance in miles from at(cast
12. CASING: Wall 17hickness two State Roads or County Roads. Include the road
Depdt Dimncicr or Wci);hUFt. ntelial numbers and common road names.
Fionl,I_To��Ft. G•zS' 06( �dG
Fronl__Z2_To32 Ft. 6.%tS" ./fr8' .5fee l
From To Ft.
13. GROUT: Depth tnletial �elbod
From 0 To F. rIMA4l Ila
Fivin Tu_ ZL 0 Ft.
14. SCREEN: Depth Dimncicr Slot Size Material - -�
From To Ft. in. in. co -. -
From To Ft. in. in. _ o -
15. SAND/GRAVEL PACK: _ -_ C=)
Depth Size Materini
From 'fo Ft. .:�;
Front To FI. -
16. REh1ARKS:
I DO HEREBY CERHFY TI IAT TI IIS WELL WAS CONSIRUC(ED IN ACCORDANCE Willi 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COP OF I HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Z ` 4f-0S
SIG ATURH 01;PERSON CONS]RUC TING THE WELL DATE
Submit the original to Hie Division of Witter Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
17699-lots Phone No.[phone],within 30 days. OW-1 REV.07/2001

WELL CONSTRUCTIONRECORD S
North Carolina Department of Environment aid Natural Rfsources-Division,of Water Quality
WELL CONTRACTOR(INDMIDUAL)NAME (prfnQU1�J p. A1(AA' -4, o CERTEFICATION#
WELL CONTRACTOR COMPANY NAME QV it 0.� iG1'L-� PHONE # ( )
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIA
IN (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 LOCATIO Topographic/Land setting
Near [Town: County dT7 ❑Ridge Az lope ❑Valley ❑Flat
ak appropriate box)
(Street Name,Numbers,Community,49u. 'vi Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address }7j''[p l.L� V. zw.^� Latitude/longitudesource:❑GPS❑Topographicmap
.s (Street or Route No.) �-/Q (check box
/L� �Yf DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
nu r
Area code-Phonene numbe`r �� t
4..DATE DRILLED
5. TOTAL DEPTH: -s` A
i �'6. DOES WELL REPLACE EXISTING WELL? YES❑ NO� �_
7. STATIC WATER LEVEL Below Top of Casing:��FT. -
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS _FT.Above Land Surfaces
'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 /Y—
10.WATER ZONES( `ep thy): a$-6 FA
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 Made ' 11 numbers and common road names.
From :E� Ft.— {� (
From To Ft. //��,,
From To Ft. &� , zr p " /v� ,
13. GROUT: Depth Material Method ^Wt�L'ecp �Kd CL/L
From To � Ft.
m._-
FroTom' Ft.
14. SCREEN: Depth Diameter Slot Size aterial ,�y� /�
From—To—Ft.—in. in. —htI
From To Ft. in. in. B�3n
15. SAND/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
CONSTRUCTIONS ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE _
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- V -
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.D972004

WELL CONSTRUCTION RECORD S' `
North Carolina Department of Environment and Natural Resources-Division of Water LZuanty�/ S �-
WELL CONTRACTOR(iNDYADUAL)NAME (print) CERTIFICATION#_a0,/
W ELL CONTRACTOR COMPANY NAME ��( I t )J&I PHONE # �
STATE WELL CONSTRUCTION PERMIT# _ ASSOCIATED WQ PERMIT#
if applicable) - (if applicable)
I. WELL USE(Check Applicable Box):Residential V Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other❑ If Other,List Use
2. WELL LOCA N: Topographic/Land setting C?08 n
N//y��{{CCestTown: An County, / Midge []Slope ❑Valley ❑Flat V
IL A E _ C 01 Idi (check appropriate boz) v
(Street Name,Numbers,Comm u Vision,Lot No 7.,�p Code) La6tude/longitude of well location
3. OWNE ' & (degrees/minutes/seconds)
Address _Y Latitude/longitude source:❑GPS❑Topographic map
(Sullet or Route No.) /' q (check box)
l_ OC 7 DEPTH DRILLING LOG
ny or o State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 0 _
6. TOTAL DEPTH:_
6. DOES WELL REPL CE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: // __ T.
j (Use"+"if Above Top-o Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface' y
-Top of casing terminated War below land surface requires a
variance In accords a with 15A NCAC 2C.0118. N r4
9. YIELD(gpm): METkiOD OF TEST�� —
10.WATER ZONES(depth): yo-O
LOCATION SKETCH CA
11. DISINFECTION:Type W Amoun p2 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
- Depth Dia eter or Weight/Ft. Mate al numbers and common road names.
From To�_Ft. $ �U
From To Ft.
From To Ft
13. GROUT' D th Material Method
From
To- 3 Ft.
From 3 To GOB Ft.
14. SCREEN: Depth Diameter Slot Size Materials}r��+Z--�
From To Ft. in. in.
From To Ft. in. in. n /
_ 15. SAND/GRAVEL PACK:
Depth Size Material /� p
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 A
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- j
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.. -
GW-I REV.09f2004 p
x
ry

WELL CONSTRUCTION RECORD S 5 5O?� mu
North Carolina Department of Environment and Natur4 Resources-Division of Water Quality] IG 0 J U �S7 _.
WELL CONTRACTOR(INDIVIDU AL)NAME (print) CERTIFICATION# -
WELL CONTRACTOR COMPANY NAME PHONEE #
STATE WELL CONSTRUCTION PERMTi# ASSOCIATED WQ PERMIT#
if applicable) - (if applicable)
1. WELL USE(Check Applicable Box):Residential 10 Municipal/Public❑ Industrial❑ Agricultural❑ ®v
Monitoring❑ Recovery ❑ Hea[Ptmmp Water Injection❑ Other O If Other,List Use o.
2. WELL LOCATION: Topographic/Land setting
Nearest Town: , County 7-- ❑Ridge []Slope OValley Flat
/ 1 (check appmpriatc box)
(Street Name,Numbers,Conuffu-nitylSd5division,Lot No.,Zip ode) Latitude/longitude of well location
3. OWNER: F P - �f 1ll'�.�� - (degrees/minutes/seconds)
Address z) / /Yl K-c.r� _ Latitude/longitude source:OGPSOTopographic map
(Street o Rou No.) (check box)
j DEPTH DRILLING LOG
or own State Zip Code From To Formation Description
Area code-Phone number !,
4. DATE DRILLED 7 �c
5. TOTAL DEPTH:
AFA
6. DOES WELL REPLACE EXISTING WELL? YES❑ 0 60
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 accordaace with ISA NCAC 2C.011&
9. YIELD(gpm):!—METHOD OF TESTA I, 3
10.WATER ZONES(depth): S— C
LOCATION SKETCH N
11. DISINFECTION:Type Amount Show direction and distance in miles from afleast
12. CASING: Wall Thickness two State Roads or County Roads.Include tb=oad '
D numbers and common road names. Ul
Depth Diameter or Weight/Ft. atenal n
From y S'K2121 �
From Too Ft.t.
From To Ft
13. GROUT: Depth Material Method
From Tom Ft. r - / ,1
From_ To �Ft.—�to �C W
14. SCREEN: Depth Diameter Slot Size atenal
From To Ft. in. in. 'T7
From To Ft.—in. in.15. SAND/GRAVEL PACK:
Depth Size Material
From TO Ft. lv 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 THEWELL OWNER
SIGNATURE OF PE CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- - -
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-I REV,09/2004.
y

WELL CONSTRUCTION RECORD -, .13 01 ,1-/
na. l..,Mina up3 'w:Rt Lt'li�❑ .:; .wtl] i�atut I:C>OuQ•-p.�.�1�. .vi i;at2i .� _. .}`' "-- .:d ,:;-r5 _.. i j/ .
\VELLCO\TRACTOR(ISDIVIDCAL)SANII'E�(�prin,Q.,�'fL7/-�� 7� (»K.I/Cs[/ r CERTIFICATION.-
WELL CO\TRACTORCO.�IPA\YMME�/r{-���� /�J� __PHONE C •'J S
STATE 1%E LL COSSTRCCTION PE R.161M 7V1—� - ASSOCIATED wQ PERMIT:
(ifaoplicabte) - (ifa=licable) "
I. WELL USE(Check Applicable Box): Residential Pt Nlunicipa�Public ❑ Indust;ia! ❑ Agricultural❑
Dlonitc,rina ❑ Recovery ❑ Heat Pump Watt;Injection ❑ O:her❑ If Other,List Us: 08
2. VI -L LOCATIO ' TopographiciLand setting ®�
Kea c;t To a' ' County faid_e OS!opz ❑Palley ❑Flit
�" (chec,a;prJpria:e bus)
((J/�/.:::nc'in'. pcode) LatiiL'dtlong:Nd2 o"well location
3. OWNER-- 14J•40tt-. Q-"-- (dez:aiaiouasixords):
Address 5SCt I1 t'p _ _ Latin:dc'longitudesour,-:OGPSOTtpo_rpI1iemap
DEPTH DRILLING LOG +
f Jr7bs j�. 621i ` 11Q:3 From To - Formation Description
Arc i cod:-PF.a:z ra:ai,r (� _
4. DATE DRILLED G, J`-
?. TOTAL DEPTH:
6. DOES % ELL REPLACE EXISTING WELL? YES ❑ r0
7. STATIC \CATEP.LEVEL Gels. Tv orCa;ing _FT.
(Cie i.`A''o..To;orCasi:._1
S. TOP O. CASING fS I FT.Abe•..- Land Surfnze' S
-1 y of canny;t-arnilneted ar.br bclu,lane surricc rcypirei a
aaria.^.:e i-a:cordio:.ui:h liA\'CAC 1C.0113. a {
9. L,!,ET.HODOF ESTA ) e �� }
10. C:A.TER ZONES(dopth): S ^'
-�,^ LOCATION SKETCH
11. D!S!\FECTIO\:T}pz tk--E7-4 S: o. diraction a^d'ti>::n:r i s r..ilc>frorl a >'
12. CASING: %:_I Thick-- r.vo S:ax Roads er Ca.:x F.ca_'s. lnz:ude t:boa
D c c•�``zic :Ft. �'rJ-" r,�.::.._es and common ra_' r.=cs.
Fro::: T� Ft. SprZ �L��
Fro-: To Ft.
Fr:::i To Ft.
Fr, ,��Tc�Ft -�
14. SCREE,\: D._;,: D. r.e:er o.Size �la:er;a:
From. To Ft—in. in.
From, Tc Ft. in. in.
13. SAND GRAVEL PACK: -
De,th S.ze �L...._.
Fran: To Ft.
Fron., To Ft. -
16. RE\!-\RKS
I DO H=F.ESY CERTIF't THAT THIS V.ELL V:A.S CONSTRUCTED I\ACCO.'.DA\CE 1PITH IiA NC.AC'C V.FLL
CONST:",CT10\ -kND?4DS.AND T :ATACOPY OF THIS FPCORDF.AS BEEN PROVIDMTOTHEV,.ELL0X\ER
SIG\nTL:rE r cR-- . 'CONSTRCCTI\G THE V.ELL DATE - -
Submit the original to the DiNis;on or%%ver Quality. Ground«nte; Section. 1535 ?IailS.ni:e Cer.ar Ra:zi�h,SC
2%599-1535 Phan¢No.('919) i_3-_3'1.a'•ithin 30 day S. G�`•'! RE�c�O',20'):i _a

308703 2QC,,S�- J,(
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources. ivision of Water Quality-Groundwater Section� /�- ,
WELL CONTRACTOR(INDIVIDUAL)NAME (print) C" CERTIFICATION K'v ro
WELL CONTRACTORCOMPANYNADIE `^ � � �.// PHONE .j 7J1
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT# .
(if applicable)
1. WELL USE(Check Applicable Box):Residentlalg Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land Setting
NearV Towl: Cou ❑Ridge ❑Slope>;QValley ❑Flat
(check appropnote box) -
(Street Name,Numbers,Community,Subdivision,to go.,##p Code) J Latitude/longitude of Well location
3. OWNER: (degreesiminutes/seconds)
Address .+; kJPnAcs2ce,%r,. Latitude/longitude source:❑GPS❑Topographic man
Scree or Route o. (check box)
� ( O-S—7 - DEPTH DRILLrNG LOG
( ,. City To`�ti State 4
71ip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED � — J=�S— �
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N�
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface* A
-Top orcasing terminated ab'or belon`land surface requires a
variance in accordance x th I5A NCAC 2C.0118. r Pd
9. YIELD(gpm):�I`f1�THOD OF TEST 041f
10.WATER ZONES (depth): S—
_ LOCATION SKETCHrTa
11. DISINFECTION:Type 1-1 7-[4 Amount Show direction and distance in miles from a ast
12. CASING: Wall Thickness two State Roads or County Roads.Include t road -
Depth__„ Diameter or Weiehb'Ft._�M teria�l numbers and common road amen.
From To Ft._CC:4 � 11 /t)[l( , -.c �Gc� de-0 -�J
From - To Ft. f7 /
From To Ft. 2S J
13. GROUT: Depth Material Method
From—To Ft. q
From �To Ft.-b� C
14. SCREEN: Depth Diameter Slot Size a 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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THI5=RECORD HAS BEEN PROVIDED TO THE IVVTLCflW KER"----
SIGNATURE OF PERSON CONST CTNG 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. 07/200I -

WELL CONSTRUCTION RECORD
t.oFW uwoltna uepaztwcnt at t.nvtrutunent and Natural Resources lltvtstou of Watci lluatny y ,,
WELL COIN RAC[OR(INDIVIDUAL)NAME,.(print)' - (,t�" " C
,, ERTIFlCA7[ON/ �n
WELL CONTRACrOR COMPANY NAME PHONE d
STATE WELL CONSTRUCTION PERWT# ASSOCIATED WQ PE&N1TN
(if applicable):'_ - (if applicable) - 9
1. WELL USE(Check Applicable Box):ResidentialA Municipal/Public❑ Industrial Ef Agricultural❑ e! O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use (�o n
eg
2. WELL LOCAT N: Top hic/Land setting J
Ne rest T wn: CountyACd.)
9Ridgepe ❑Valley []Flat
A'4i--J Al(Sheet Name,Numbers,Community. a ivisito,Lot , , f� (check appropriate box)
\� . _ Latitude/IongiNde of well location
3. OWNER: f' ��.�/z - (degrccs/minutes/seconds)
Address r 1e.7 LatitudeAongitude source:❑GPS❑Topographic map
�/l• p n (StreetirRouteNo.) (check box)
c-% 7e<3-j DEPTH DRILLING LOG "
City or Town State J Zip Code From To Formation Description
Am code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �
6. DOES WELL REPLACE—EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above lop o C mg)
8. TOP OF CASING IS FT.Above Land Surface' A
'Top of casing terminated al/or below land surface requires a
variance In accordance with 15A NCAC 2C.0118. ns rY
9. YIELD(gpm): METHOD OF TEST 1 1/
10.WATER ZONES(depth): ds— _ y
LOCATION SKETCH
11. DISINFECTION:Type Amount - Show direction and distance in miles from at least R
12. CASING: _Wall Thickness two State Roads or County Roads.Include the road
Depth to peter •-or Weight/Ft Material numbers and common road names.
From_O_To -'�2 Ft. 5:DfzL34 -
From To FL
From To Ft.
13. GROUT: Depth Material Method -
From To Ft.
From�_ToZd Z Fi. I
14. SCREEN: Depth Diameter Slot Size Mat 'alq%^
From To Ft. in. in.
From To FL in. in.
15. SANE/—GRAVEL—PACK: !/ -
Depth - Size Material (� -
From- TO Ft n
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S w, r`t 3 - s
SIGNATURE OF PERSON CONS CTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD S 3� S7o
- North Carolina Departmdnt of Environment and Natural Resources-Division of Water Quality
- a�
-WELL CONTRACTOR(INDIVIDUAL)NAME (print)� C .t CERTIFICATION to
WELL CONTRACTOR COMPANY NAME -1 Jo�� PHONE # 47aGD S��S a —6
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residentialtl Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 30869 ,
2. WELL LOCATI N- Topographic/Land setting -
Ne estTown: + C my -' � ❑Ridge ;$Slope ❑Valley ❑Flat
(check appropriate box)
(S&ect Name,Numbers,Community,Subdivision,Lot No,zip code) LatitudcAongitude of well location
3. OWNER: (degwestminutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Stre oi?Route ) (check box)
ry — _11A4 DEPTH DRILLING LOG
C; or Town State Z Code From To Formation Description
( `7-�
Afea code-Phone number
4. DATE DRILLED 5Z J `�S
5. TOTAL DEPTH: W o D
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 1r 3
7. STATIC WATER LEVEL Below Top of Casing: aD F 1. 1-Ap
(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 accordsace with 15A NCAC 2C.0118.
9. YIELD(gpm):—Y-2,METHOD OF TEST i
10.WATER ZONES(depth): ;3 4 0 ' -r to
LOCATION SKETCH T. '4
11. DISINFECTION:Type (t'T/�fl Akoldnd-�� Show direction and distance in miles from mast
12. CASING: Wall Thickness two State Roads or County Roads.Include the•road
Depth Diameter or Weight/FL Material numbers and common road names. C3
From To 0#_Ft..-./ / SD2 LI �1 Ln
From To Ft. _ � /„� �
From To Ft.
13. GROUT- Depth Material Method
From_To 3 Ft.
�From a To Z Ft.
14. SCREEN: Depth Diameter Slot Size
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
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON COPNI517RUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-I617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

. WELL CONSTRUCTION RECORD
north Carolina Department of Environment and Natural G(o
Resources- 01\1sion of Water Quality'- un 4Lt ,Sec,Lbn,
W ELL CO\TRACI'0R(1\DI\'IDCAL)NA>IE (print) C CERTIFICATION.��j
WELL CON'rRACrOR CO> �I IPANYNAE QTee�e--- raa I �.f�PHOVE
srATE\CELL CONSTRUCTION PER�IIT� ASSOCIATED%VQ PER.Ifs T
(ifapolicaSle) - (ifaoolicable)
1, WELL USE(Check Applicable Box):Residential Municipa Public❑ Industrial ❑ Agricultural❑ J\(onitorin ❑ P.eco\'zry ❑ Feat Pump\Va;ar Injection❑ O:he,❑ IFOther,List Us:
2. V:ELLLOCAT N: Topogrphiclandseating 99
Ne 'To 'n: �LIJ County ❑Ridgelope ❑Palley ❑Fla:
77/ (:heck appropr{ntebo<)
i iiior., orNz.Zip Code)` Latitndc'lonci«Ide of well location,
s /
:. On'NFR: C/
Addr ys 7 La;i;ud_'longi«tde soer;c:❑GPS❑Topographic map
D°PTH DRILLING LOG '
C crlo.^ !it- Zip Cc,'--- From To Formation Description
ry 3-o a
4. DATE DRILLED__ 0 7�0S
=. TOTAL DEPTH:.
6. DOES V:ELL REPLACE ESISTIXG WELL? YES ❑ NO {
7. STATIC WATER LEVEL BelosTo.,orCasim;: 1-n FT.
if A*es -,Top mwcasir.zt :_1
S. TOP OF CAS!NG IS�_FT. Abose Land Surra:e'
1,,;0c t,rminj zed v'ur b el.,lee d s erf"rcq eirrs u.
s vr:un:c is Deco rd s.-:r ci:h I>:\\O\C:C.0113. 3 �
9. 1'!RD t_o.^..;: alerHoo of resr
It). IVATER ZONES Idcp:h): -554,5 1 r13
LOCTInN S.l'ETCH
I !. D!SINFECTION:Ty, T ❑n Sho.v direction anA'dION in r..iL-•i fnm a d9a>t
12, CASING: 1cvo S:a:e Roa'dsor Coa^R di '- a\`: i Ta:ckn.>s RJ±�,. Inclu�. [:�'o:d 'A�
D: , �D:r,u,::ar e-V �°,•i"FE. J' -:.� m;-.--rs and eoc<man na-'.
Fro :�_To�F't.T SG2 it �m17r,
Fro-• To—Ft.
Fro;:!—To Ft.
From—S T: F[Fromw I ZL
14. SCP.EEN: Dr;; Dian:eter Sb;S;�e \L:e
From To_ Fc._in.
Frog To 9 F[. in.
I.. SANDGR.A\'EL P:\Cl;: l/ h
Daoth Size "Oaten"! .
Fro.:: To Ft.
-Fro,:: To FI.
16. P.ccVARKS:
I DO HEF'.E8V CEr.T!FF THAT THIS V.ELL V:A3 CONSTRUCTED IN ACCO:D=.NCE V:ITH I?A NCAC'-C,tiT_LL
CONSTR_CTION STANDARDS.AND THAT A COPY OF THS P_CORD HAS EEEN PROVIDED TO THE V.-ELL OV.-NER
C
5'GNAT L:R EOFPER50NCO SCT2P_ tINGTH-- V:ELL DATE
Submit the original to the.Dicision of N ater Qunlity, Ground;%nter Section. 1536>I:fI S:r\i:e Cer,:::-R±:ei�, NC -• ..
27699-1536 Phonic No.(919)733-312I,1,ithin 30 days. GV. REV. 07:2CF0:

WELL CONSTRUCTION RECAW bi q 30-75� vV Y rr
North Carolina Department of Environment and
Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)2-D /f �' e / .CERTIFICATION# 1
WELL CONTRACTOR COMPANY NAME /n /ds J�J__ _ PHONE # f +- '2 J�'
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 LOCATI N Topographic/Land setting
Nearest Town: ,tXiL Court ❑Ridge ;$Slope ❑Valley []Flat
(check appropriate box)
(Street Nance,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: aAll, - .. (degnxs/mioutes/sewnds)
Address h e v,E _ Latitudellongitude source:❑GPS❑Topographic map.
(Suc o Route I .) �y (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number 5.--
4. DATE DRILLED —
5. TOTAL DEPTH: &O C9
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 217 — zi
7. STATIC WATER LEVEL Below Top of Casing: QD FT. s-np
(Use"+"if Above Top of Casing) N AA
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 15A NCAC 2C.011&
9. YIELD(gpm): METHOD OF TEST
10.WATER ZONES(depth): !) t a
LOCATION SKETCH
11. DISINFECTION:Type [+ ' oti& Show direction and distance in miles from pUeast
12. CASING: Wall Thickness two State Roads or County Roads.Include the roada
Depth Diameter or Weight/Ft. Material numbers and common road names. 1=3 F: -
CA
From�_To c Ft. [^/� —PE L/ a2ce
From To Ft.
From To Ft.
13. GROUT' Depth Material Method _
From_Tom Ft-
From�_To 7 Ft�
. GC1 ��.(
14. SCREEN: Depth Diameter Slot Size &Ma rial -�Ys p✓
From To Ft. in. in. _.#.
From To Ft.—in. in. Yw/
15. SAND/GRAVEL PACK:
Depth Size Material ry ,. y .z
Front—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,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. - - -
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 0
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential O Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: �( _ , Topographic/Land setting
Nearesfiown: County llt�(+�,5(T`�t_> ORidge ❑Slope OValley ❑Flat
/71 Nn /)A 11��'Li__ (check appropriate box)
(Street Name,Numbers,Community,sutff ivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/rninutes/seconds)
Address I Latitude/longitude source:OGPSOTopographic map
treat or Raute No.) (check box)
r o DEPTH DRILLING LOG
City or T,wn .y tate Zip Code From 0 Formation Description
6( 26 )- a73 ,.7��� clay it sand
Area cod;_Phone number y& ' AW, Granite
4. DATE DRILLED 3. 1.05
5. TOTAL DEPTH: 3OO
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: J(_)Q— T.
(Use"+"if Above Top of casing)
8. TOP OF CASING IS 2 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): —METHODF TEST BLOW
10.WATER ZONES(depth): :U 71 r cZ g � LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dth Diameter or Weight(Ft. Material numbers and common road names.
From 0 Teo' Ft.
From�57
ToFt. , �fr� �IS¢41� r
From To Ft._ 0
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped �iS7
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Fc in. in. g aA
From To Ft. in. in. o
15. SAND/GRAVEL PACK: srcn mO
Depth Size Material
From To Ft. N
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTR CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7 OS
ATURE OF PERSON CONSTRUCTING THE WELL DAT
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service_Center
-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

3 P 8 9 4 3)
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
/-Division of Water Quality-Groundwater Section
\kE IA,('ON'[RAVI'OR(IN DI VIDUAL)NAM I. (print) CIV-1-1&SS WV yI�n � p_ CERTIFICATION
//11 pp�� _
WELL(ON'"rRA('7OR COMPANY NAMFor-e-ehe 13ips,-LZ)o_/ l ti ,eat r)� rc,P110NE # L. 6_fil. _'3/7�
S'rA'fE WF;I,L CONSTRUCTION PERMIT#_ /3/K ___ASSOCIATED WQ PERM 114
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water In)ection ❑ Other❑ If Other,List Use
2. WELL 110('A'C10 j Topographic/Land setting../"Near-st T. o n: Coun/ty��11 ❑Ridge ❑Slope ❑Valley Whir
P a Ylfr1 �/Y (check appropriate box)
(Street Namc,Moot,s,Comm unity,.SU1.1.visio lot No.,Zip('tale) Latitude/longitude of well location
3. OWNER:[.,I Q. �1 .A s w.-ry_'--�-�„�� (degrees/minutes/seconds)
Address - .._- 321 / '72&/l Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No,) (check box)
/ nP_T "( ABC .;2'9'J�p DEPTH DRILLING LOG
-T—T
c'ny r,r "nwn State zip('ode From To ) Formalti.00 Descnption
(. . d
Area code-1'hnne number
4. DATE DRILLED_ ?__/$-OS L
5. 1 OTA1. DEPTH:
_ IHN'�; %%1.! Ulll,t Al'I. LX!el ih(i AA/I!I I ;I Y!.'� 11 NO I14
7. STATIC.WATLR LEVEL Below Top of Ceasing:__"_,__FT.
(t,se"i"if Above Top of Casing)
R. -1OP OF I ASING IS�_FT.Above Land Surface•
lop of casing terminated actor below land surface requires a -------- --- -- __ -�� -
variance in accordance with 15A NCAC 2C.0118. II _
9. YIELD(gpm): /0 METHOD OF TEST ryes -
10. WATER ZONES(depth):.__--
LOCATION SKETCHI]. DISINFI?("(ION:Type_ Amount JtL4Z 1�_ Show direction and distance in miles from at least
12. CASING: Wall"I'hickness two State Roads or County Roads.Include the road 't'
Depth�// Diameter or Weight/Ft. Material numbers and common road names.
From_ l o j- _-Ft.
Pram To FL_
From _-.._ To Ft._--
13. GROUT: Depth Material Method b
fromTo Ft.
From To FL
14. S('K EEN: Depth Diameter Slot Size Material O
From__ _. To _._Ft.—in. -- in. cil
—_--
From-. To Ft. in. ----- in. _
15. SAND/GRAVEI,PACK: -
Depth Size Material
Front. . _ _- To Ft. _
From _ __To Ft.
16. REMARKS:
I DO HEREBY('ER"I'IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION S'1'ANDAR S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON C'ONSTRUC'TIN6 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-1 REV.07/2001

WELL CONSTRUCTION RECORD 3 0 9 0 5 0
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # (828)369'-959)
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# _
if applicable) (if applicable) -
1. WELL USE(Check Applicable Box):Residential EI Municipal/Public ❑ Industrial❑ Agricultural❑ __ "t. L
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List UseCIO
- s
N
2. WELL LOCATI N: _ Topographic/Land setting = c
restTowp: County ORidge ❑Slope OValley DFIaY'—` N =
i �"- (check appropriate box) - -
(Strreet lq e,Numbers,Com nity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 11l{1Jl.AC,. et&A feu (d nu egrees/nites/seconds)
Address ���9� LatitudeAongitude source:DGPSOTopographic map.
_.
Jyk (Street or Route No.) (check box)
I 3 1j'y DEPTH DRILLING LOG
City or Town State �..pp Zip Code From To s Formation Description
a( );-3, -9�n9. 1",Q o l Q 2 clay&sand
Area code-Phone number ' granite
4. DATE DRILLED 3.9 .05
5. TOTAL DEPTH: 100b,
6. DOES WELL REPLACE EXISTING WELL? YES NO X
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of acing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated attar below land surface requires a
variance In accordant with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW
10.WATER ZONES( pth):
- LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road =
Depth Diameter or Wei ht/Ft. Material numbers and common road names.
From o To� 1 Ft. l0 r J8b Ste 0
From To Ft.
From To Ft._ a K
13. GROUT: Depth Material Method za
From 0 To 20 Ft. Benonite&cement pumped N
From To Ft. W
Diameter Slot Size Material 0
14. SCREEN: Depth
From To Ft. in. in. cn
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
CONST UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
%0AW � V14 , 318oS
SlGrTURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD J $ S G✓
`7 & 70? -
North Carolina Department of Environment andd�Natural Resources-Division of Water Quality /
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Pet',x.�Y E"J , �1.G(,.�— CERTIFICATION#.. Td t7l
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# _ 309068
(if applicable) J (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 LOCATIO : C �Topographic/Land setting
Barest wn: "�" only, ,//,. 1YJRidge ❑Slope ❑Valley ❑Flat.
treet Name,Nuo unity,Subdivision, t No., i Code S""�> (check appropriate box)
1 p ) .,�`- LI titude/longitude of well location
3. OWNER: /�"+ _ 2�}— (degreesiminutes/seconds)
Address '-] ) -� �x1 ,61 Latitude/longitude Source:❑GPS❑Topographic map
' I ($tree[or Route No.) (check box)
I t_F1� 5��6rZ� A) C V 7 DEPTH DRILLING LOG
City or Town suite Zip Code From To Formation Description
Area code-Phone number - �
4. DATE DRILLED 1 - S- � �
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 12
7. STATIC WATER LEVEL Below Top of Casing: ] y L) FT. ,
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' 3
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. -err
9. YIELD(gpm): 1 1!/.2 METHOD OF TEST I
10.WATER ZONES(depth): Ci 0
LOCATION SKETCH , _
11. DISINFECTION:Type F-{ -)-'j-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 Diameter or Weight/Ft. Material numbers and common road names.
From To Ft..
From To Ft.From To F O --.�
L 64
ak
13. GROUT: Depth Material
From To )) _Ft. �T_
From --7 To �/ 0 Ft.
14. SCREEN: Depth Diameter Slot Size aterial ✓i--�- „t(
From To Ft. in. in. J "�
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
Front—To—Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL --
CONSTRUCTION STANDARDS,AND T A CO THIS THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
` 3 z d�
SIGNATURE OF PERSON CONS 1 RDCTING THE WELL DATE n
L•
Submit the original to the Division of Water Quality,Attn:Information Management, 1617 Mail Service Center- I
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days-
GWA REV.09/2004

WELL CONSTRUCTION RECORD S Vt(J
(7aV - � ` -& 779
North Carolina Department of Environment and Natural Resources-Division of Water Quality_ WELL CONTRACTOR(INDIVIDUAL)NAME (print) :P/7,/.uk 16 f6AUCs� CERTIFICATION#
- WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG OF SYLVA INC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOC_IATED WQ PERMIT#
(if applicable) -
(ifappllcable)
1. WELL USE(Check Applicable Box):Residential ' Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water In ❑ Other❑ If Other,List Use 3 0 9 0
2. WELL LOCATION: 3o°►a I
Nearest Town: d ✓ Topogra hic/Land Setting, ✓ fo
�� Faunry��C��sC1� p e
❑�-7 �G ��I^ ` L m R dge Mlope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Commumry,Subdivision,Lot o.,Zip Code) Latitude/longitude of well location
3. OWNER:
Address n (degrees/minutes/seconds)
it It Latitude/longitude source:❑GPS❑Topographic map
1 , Street or Rou a No (check box)
1 I Y it L ''� 'S 7 DEPTH DRILLING LOG
City or Town State Code From TO
8a c r - Formation Description
Area code-Phone number _
4. DATE DRILLED 111 C° —U_" -s� 7 _
5. TOTAL DEPTH: -e� SSTL
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 'fJ
Ck
7. STATIC WATER LEVEL Below Top of Casing: ­2(D FT.
(Use-+••if Above Top of Casing) _
8. TOP OF CASING IS_1_FT,Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordan a with 15A NCAC 2C.0118.
9. YIELD(gpm): , L� METHOD OF TEST ) )/
10. WATER ZONES(depth):_ a
LOCATION SKETC—H
11. DISINFECTION: Type _.._—Amount Show direction and distance in miles from atlast
Wall Thickness `_L_"/
]2. CASING: '-) two State Roads or County Roads.Include tvroad
From e: Depth Diameter or Weight/Ft. Mate ' numbers and common road names.
Tom(Ft._.�: /�/ .5- -� - C-�
From To Ft. TT 1 u1
From To FL '13. GROUT: Depth Material Method L 4 L-�• '
From Tom_Ft.
__C
From De To_1L� Ft.
14. SCREE Depth Diameter Slot Siz Ma rial
From To Ft.
_in. in. - t
�C�
From To Ft._in. in. r / !5
15. SAND/GRAVEL PACK:
- Depth Size Material
�y �! (.°1"t C �L
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 ST��,AND THE('A COPY RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�'��/( 2z-vs
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
71
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center- 1
�IJ
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
1
GW-1 REV.0912004 "'

y _
WELL CONSTRUCTION RECORD 7�/'s �
North )3 3 7!N
Carolina / W 1 Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR � (P n
(LYDIVIDUAL NAMnnEn��71 rintC�C - Y ' CERTIFIC��//ATION# [[IPP
WELL CONTRACTOR COhIPANY NA11IE nn�l- 111-e^�� ,� r f PHONE # Id
STATE WELL CONSTRUCTION PEP.
(if applicable) ASSOCLITED WQ PERbIIT#
(if applicable)
1. WELL USE(Check Applicable Box):Residential$L, Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: r'
N arest Town: County 1�_S _�� Topographic/Land setting
( ORidge Slope OValley ❑Flat
(Sc t Name Numbers,Commumry,subdivision,Lot No Lip C (check appropriate box)
n�Z3.7 I Li Latitude/longitude of well location
3. OWNER.
Address �=j h- S (degrees/minutceseconds)
Latitude/longitude source:OGPSOTopographic map
G (Street or Rou/tte No. c�
�V ,d ,;� / t�'� O 7 7 (check box)
Cayortown State DEPTH DRILLING LOG '
_ zip Cade From To
(X 2 k)- — '� �1 Formation Description
�'
Area code-Phone Dumber .1
4. DATE DRILLED -/p_ p S— /
5. TOTAL DEPTH: �p i _
4-
6. DOES WELL REPLACE EXISTING WELL? YES O NO _ �' —�
7. STATIC WATER LEVEL Below Top of Casing:.50 O
(Use"+-ifAbovc TopofCasiog) /A-rt
8. TOP OF CASING IS�_FT.Above Land Surface' at S
'Top of casing terminated at/or below land surface requires a ' w
variance In accordance with 15A NCAC 2C.0118. 6
9. YIELD(gpm): it METHOD OF TEST J� r
10. WATER ZONES(depth):.�'`i ------
c
LOCATIONSKETCH
11. DISINFECTION:Type_{ jal cunt y Show direction and distance in miles from at least
12. CASING: Wall Thickness 7two State Roads or County Roads.Include the road
Depth D)im aeter or Weight/FL Material numbers and common road names.
From ,To�q Ft. L-- YY f2_L_jrq
From To
From To Ft.13. GROUT: Depth —Material Method (( / / "L L.'r�•c�
From C`J To Ft. 6.a - .o'er
From To�Ft. (-;cT}vim✓-Xsj�-/�,�_�-y�� t:J �., ,�tc �
14. SCREEN: Depth Diameter Slot Size ` . Material
From To Ft. in. in.
From To Fc_in _ in
15. SAND/GRAVEL PACK: �
Depth Size MaterialN
From To Ft r a
From To Ft'— s3
i
16. REMARKS: A
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT10Ij,$TANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE x-
Submit the original to the Division or Water Quali
ty,ty,Attn: Information Management,1617 Mail Service Center.
Raleigh,NC 27699-1617, Phone No.[phone];within 30 days.
GW-I REV,09/2004

WELL CONSTRUCTION RECORD
rin
WELL CONTRACTOR(4YDIVIDUAL)NAME (prinntt) ^-� , 1 `—Cv���-7i,(r�-t CERTIFICATION# 2L& 0 _.
WELL COiNT'RAC[OR COTANY NASIE A All GfPeY)`_ 2-�.{-,J ( (o PHONE #
STATE WELL CONSTRUCTION PER..NOW(if applicable ASSOCTATED WQ PER.�ITI# -
-. ) -
(if aoolicable)
1. WELL USE(Check Applicable Box):Residential MunicipaVPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use - 3 O 9 O 4
2. WELL LOCATI N: I 8
Nearest To : County Topographic/Land setting
ORidge JOSlope OValley ❑Flat
(Street Name,Numbers,C �� check appropriate box)
'ry,Subdivisi q Cot N ,yZ;p Code) EJ� atimde/longitude of well location
3. OWNER: �/LPAk� _Pj /� �'
Address Q _ C U (degrees/nunutes/seconds)
n Latitude/longitude source:OGPSOTopographic map
/ vQ 1) '0 (Street� or Route No.o.,)^ �. r, (check box)
( Cry f or Towo sntc , I zip <2-1 71
7 DEPTH DRIL_- LING LLO
�11 From - To Formation Descriotion
Area code-Phone number
4. DATE DRILLED - 7
5. TOTAL DEPTH: 7j °y w�ilz _ _ _ 5
6. DOES WELL REPLACE EXISTNG WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:510 _FT.
r (Use"+^if Above Top of Casing) a
8. TOP OF CASING IS / FT.Above Land Surface-
-Top creasing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): �J, () METHOD OF ST I )�
]0.WATER ZONES(depth): N--,
t
LOCATION SKETCH
11. DISINFECTION:Type_ Amount Show direction and distance in mil fro t7
es
12. CASING: nXAleast'
Wall Thickness o State Roads or County Roads.Include the roa;
Depth D'atryeter or WeighVFt Ma vial numbers and common road names.
From_ToLLL Ft. I $w1a
From To Ft.
From To Ft.
13. GROUT: Repo Material h{e1
From n To � Ft. hA-j�1.
From To F �A LU -� t
14. SCREEN: Depth Diameter Slot Size Material n'P
From To Ft. in. in.
From To Fr.—in. in.
15. SAND/GRAVEL PACK: _
Depth -�
From Size Material
To Ft.
From To Ft. U
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 CO UCTNG THE WELL
DATE _
-1617, Phone No.[phone],within.30 days.Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mall Service Center-
. Raleigh,NC 27699 . -
Y
GWA REV.09/2004
t. n
c�
c»
v:

WELL CONSTRUCTION RECORD �Y-5"3 V-y QLt) =x'
75L{y,
North Carolina Department of Environment and Natural Resources-Division of W ater duality
WELL CONTRACTOR(INDIVIDUAL)NANEE —(print)) U .m�:
/� Q
�Lt-r' CERTIFICATION# L
WELL CONTRACTOR COMPANY NA.�µAll CfePYI '�. 3'4- 0 t el, PHONE # L,?AV
STATE WELL CONSTRUCTION PERdQT# ASSOCIATED WQ pER�QT#
(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 109062
2. WELWLOCATI N: "Neare County Za a 3✓ Topo aphic/Land setting
1, ❑RidgeASlope ❑Valley ❑Flat
(Street , s,C " ' v (check appropriate box)
'ty,Subdivisi n,Lot ,Zip Code) atitude/longitude of well location
3. OWNER p �Z� / f IG'LoICEJ9
Address G L( U U (degrees/minutes/secands)
Latitudellongitude source:❑GPS❑Topographic map
(Street or Route N.o�.J,�n n
/ I C t^C v 7! (check box)
City or Town State , I Zip Code o / 7 DEPTH DRILLING LOU,
1)- - -�S�� From To Formation Description
Area code-Phone number J,� -
4. DATE DRILLED- LI Q 5� 1V Fes! ,3 —
5. TOTAL DEPTH: 02 1�
6. DOES WELL REPLACE EXISTING WELL? YES[I No )a) -� --0
7. STATIC WATER LEVEL Below Top of Casing: ,?D FT.
(Use"+"if Above Top of Casing) —��C
8. TOP OF CASNG IS I : n
FT.Above Land Surface
' 'Top of casing terminated aHar below land surface requires a -------ru__74
variance In accordance with 15A NCAC 2C.01I8. -
9. YIELD(grim): 7 METHOD OF TEST 1 !�
10.WATER ZONES( epth)—: CDSa I L r '-4 J<',t�l
A ---Efl-
7 LOCATION SKETCH
11. DISTNFECTION:Type mount Show direction and distance in miles from at leas
12. CASING: Wall Thickness o State Roads or County Roads.Include the road
Depth DJin)cter or t Material numbers and common road names.
FromFrom�To _FL L �, i/
To Ft. -
From To Ft. �L^,Ze,•��C..SC
13. GROUT; Depth Material - Method
From : To > Ft.-, irk/ �jJ.l.y�.c-.l
From��Depth �,
14. SCREEN: Depth Diameter Slot S¢e atenal
From To Ft. in in.
rom
F To F[._in. in. ( / �`
N 15. SAD/GRAVEL PACK: ,
Depth Size Material
From To Ft
From To Ft., l�4�uq_ ./ �`
16. REMARKS: j
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
J .D . Mi 3 c G5
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- 2�
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV,09/2004

WELL CONSTRUCTION RECORD r�� /ZT 5 3 g R
WELL CONTRAC70R(INDIYCDUAL)NA[1fE (prin((�t�) ��s U .1'Yti�:.`LL� CERTIFIC!A/T^IO''N#
WELL CONTRACLOR COMPANY NAMP A A TI l�!'c�P7c e � � - P r�[�( ���
STATE WELL CONSTRUCTION PERNU7q
(if applicable) OCIATED WQ PERMHT# -
(if applicable)
L WELL USE(Check Applicable Box):Residential t MunicipaMblic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat PUMP Water Injection❑ Other❑ If Other,List Use �?
2. WELL LOCATE N: -�---�, ® 9 V -
Nearest To County Topographic/Land setting
❑Ridge ❑Slope ❑Valleyflat
(StrCet Namc,Numbers,CA ty Subdivisi (check appropriate box)
n,Lot N ,yZip1/C1ode) atitudeAongitude of well location
3. OWNER: ��2.Q,p.,�'�"'`-" �.��
rc
Address - Y U Ch f3 T/_ �f �'C (degrecshmauttsheconds)
Adress p�(S¢eetorRoncNo.) , Latitude/longitude source.❑GPSOTopographicmap
/ C �0 71 7 DEPTH (check box)
Cary or Town Sratc Z,p code DRILLING LOG*'
S From - To Forniatior.Description
Area code-Phone numbcr
4- DATE DRILLED gJ S Q S
5. TOTAL DEPTH: Z 5 ) Lk)"{ ( 7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: IO-V FT
8. TOP OF CASING IS ' (Use-�_if Above Top of Casing) im
FT.Above Land Surface'
'Top orcasin8 terminated atlor below land surface requites a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST ) )�
10.WATER ZONE depth),: - O
rr
It. DISINFECTION:T f-} 7 /../_ LOCATION SKETCH
Type Amount Show direction and distance in miles from at(east
12. CASING: - Wail Thickness o State Roads or County Roads.Include the road
Depth D)'att}eter or WeightIFL Material numbers and common road names.
From To FL —"')`'-
From De Ft. (-�'"`-C�c7i-�•` SZ 13. GROUT: Depth —Material _
From n To .3 Ft s-�- — Method
From_To J FL
14. SCREEN: De th
P Diameter Slot Size aterial
From To Ft. in. in
From To __ .
15. SAND/GRAVEL PACK: Ft. in. — in. -
Depth Size Material
From 7o Ft.
From To FL l� �G fib
16. REMARKS: J V
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
1rl
C.
SIGNATURE OP PERSON CON __,,,.THE WELL
DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 MIall Service Center. D
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. - - -a �
GW-1 REV.0912604 c�
cam.

309566
-. 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: l7CC� (G('/ 9��'✓ra71�
WELL CONTRACTOR CERTIFICATION q: 2y6% ,S�
STATE WELL CONSTRUCTION PERMITa: g—�
1. WELL USE(Check Applicable Box): Residential I_1 Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery Election Heal Pump Water In-
1 ❑ Other ❑ If Other, List Use:
2. WELL LOCATI N: how sketch of the location below)
Nearest Town: County:
C(Roatl Name Nulroers. mnun4 yf7,o�r. SuivisandLotNo)
A3. OWNER 1L 1 DRILLING LOG
DEPT
H
Address
From To oyDe scpGonQ V1!e or lo n
l �
� SKJ
City w To Stm p 4 S N
It
4. DATE DRILL D
5. TOTAL DEPTH C
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YE
B. STATIC WATER LEVEL Below Top of Casing: FT,
9. TOP OF CASING IS_ 0 lu"•. d Above Top of Casing)
FT.Above Land Surface•
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C_.�11e
10. YIELD (gpm): ��^ METHOD OF TEST r
11. WATER ZONES (depth):
12. CHLORINATION: Type Amounl
13. CASING: - It additional space is needed use back of form
Depth Well Thickness LOCATION SKETCH
-}-a P Dia Ior m We' t. t dal (Show direction and distance from at least two State
6 y
From To Ft. ,/tSb
From To Ft. Roads,or other map reference points)
From To FI.
14. GROUT: /
Depth �Mater' Method
From To _C2�_b Ft. �Yo tr
From To Ft. y
15. SCREEN:
Depth Diameter Slot Size Material
From —To—Ft— in. _ in. '
From —To_FL_ 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 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 Vs7 G' a9-��
Quad No: SIGNATURE OF RSON CONSTRUCTING THE WELL "' DATE - - - ---
Submit original to Division of water Quality,Groundwater Section within 30 days _
Serial No. GWI REV. i7J"

309599
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater section
WELL CONTRACTOR(IND1v,1DUAL)'NAMR (priuOs��
`fuf'J1L�1.,- ClclY IPICATtON s l7(p -
WELL CONTRACTORCOMPA"NAM •' _ 'pjtpNL.STILV_.524-3 ;zb 6
STATE WELL CONSTRUCTION PitRMIT/ !RgOCtATED W ERMITP
(if applies bit) •(ifappl(pble)
1. WELL USE(Check Applicable Box):Residentlial unicipWublic❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other Ci If Oilier,List Use
2."WELL LOCATION —
Couty
Nearest Town: n �Q.t1G C rn_� ❑Ridge ❑Slope ❑Valley .TopographidLand setting([iHBt
4'41 Al.. Ls n.•e'tle— R ol, o'i 21'71 (chockapproprlatataz) . ' a
(Street Name,Numbers,Community,Subdivision,t.a No.,zip Code) Lptitudc/migitude of well location
3. OWNER: - - (it cgraer)mitm Ws.words)
Address Latitude/longitude source:❑GPS❑Topogmphic map
(check�a�
(Strew or Route No.) )N >,(, ni c, .2 o a
DEPTH ' DRILLING LOG
Gryw7owo Sim zip Code �— '
��O0e.a��p�•� S2 p(3 9 From To Formation Description
Area code-Phone number ., _ �--i .
4. DATEDRILLED 3 3a —0 S - _ '�s1r— _ 12k.� }
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 7' FT;
(Uu-+-if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface* J
-Top of cuing terminated moor below ltadsurrace requtka a
variance to accordance wu615ANCAC 2C.011L - -�
9. YIELD(pro): 1-5 METHOD F TEST
10.WATER ZONES(depth): 3 g i / 5 5'
LOCATION SKETCH LA
IL DISINFECTION:Type Amount Show direction and distance W miles from at least O
12. CASING: Watt Thickness two State Roads or County Roads.Include the road
Depth Diapicter .or weighUFL `Ltnt.rinl --numbers and common road names.
From_ )_TO FL_.
From To F
Fro,; _Tq 3_FL
13. GROUT: Depth . Materil Method
Fmm_L_TOLMLFL
From To
.4. SCREEN: Depth Diameter . Slot Size : Material - - L-
From To Ft. in. in.
From To Ft. in. in. '
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. _
from To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P90VIDED TO THE WELL OWNER
�k �� 3 30 o S
SIGNATUREOF PERSON CONSTRUCTINGTH13WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
a7699-1636 Phone No.[phone],Within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD i, - 309418
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL Lown: rI: dge O lope Land setting
Neare^tTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name, tiers,Cornn iity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degreesiminutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
t or cute No.) (check box)
„z r A r Sri- Ayy/ DEPTH DRILLING LOG
City or Town tar Zip Code From To Formation Description
6( 28 )_ �1( D(- �N COI T clay&sand
Area code.Phone number CJ �C — granite
4. DATE DRILLED 3y5
5. TOTAL DEPTH: 700, y�
6. DOES WELL REPLACE EXISTING WELL? YES NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT. p
(Use"+"if Above Top of asing) :J
8. TOP OF CASING IS 2 FT. Above Land Surface* o
*Top of casing terminated attar below land surface requires a rt
variance in accordancetwith 15A NCAC 2C.0118.
9. YIELD(gpm): METHOD OF TEST BLOW
10.WATER ZONES( epth): w
LOCATION SKETCH Ln
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth_� Diameter or Wei ht(Ft. aterial numbers and common road names.
From 0 To Ft. (O • IS�
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite a cement pumped
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 STA ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV. 09N004 '.
GT'

WELL CONSTRUCTION RECORD aP 309417
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # (e26)369-9591
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 LOCATI Topographic/Land setting
Nt
Co my ORidge ❑Slope OValley ❑Flat
(check appropriate box)
(Sbers, omm ninitySub ision,Lot No,Zip Code) Latitude/longitude of well location
3. O C• (degrees/minutes/seconds)
A Latitude/longitude source:COPSOTopographic map
n (Sh)eet or J Route No.) (check box)�11?�iV1MYL, NC 973& DEPTH DRILLING LOG
City or Town sea Zip Code From , Formation Description
(28 1 - 0 clay&sand
honenu
Area code- mber
' granite
4. DATE DRILLED 3 G O5
5. TOTAL DEPTH: t7 f yy
6. DOES WELL REPLACE EXISTING WELL? YES O NO p
7. STATIC WATER LEVEL Below Top of Casing: 2_40 FT. �.
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS 2 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): cRI) —METHOD OF TEST BLOW
10.WATER ZONES(depth): n 10-i :3-��—
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di meter or Weight/Ft. Mallanal numbers and common road names.
From 0 ToA_Ft. fa
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped
From To Ft.
14. SCREEN-7 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
CONSTRUCTION STAN S,AND THAT A Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
siONATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-F REV.00i�004
- ,J

WELL CONSTRUCTION RECORD l,_ 309416
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # (62e)369-9591
STATE WELL CONSTRUCTION PERMIT# 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 LOCATI - Topographic/Land setting
CW
Nearest Town: �f�CO County ❑Ridge ❑Slope ❑Valley ❑Flat
Noh T M * 1° s (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNE4r �n
(degrees/minutes/seconds)
Addres Latitude/longitude source:❑GPS❑Topographic map
zst4e
ortip
(check box)
DEPTH DRILLING LOG
c Fr�pom �5Iy RRr Formation Description
(8� II(g2'7� clay it sand
o t Granite
Area code-Phone number_� , N
4. DATE DRILLED r�� -/�
5. TOTAL DEPTH: -7
6. DOES WELL REPLACE EXIS-iINGWELL? YES)�-NO ❑
--- T _.T -
7. STATIC WATER LEVEL Below Top of Casing: � FT. °x*
(Use"+"if Above Top of Casing) T
8. TOP OF CASING IS 2 FT.Above Land Surface* t 7
"Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C.011S.
9. YIELD(gpm): .3D METHOD QF TEST BLOW f,--
10.WATER ZONES(depth): t� I LOCATION SKETCH
11, DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Walt Thickness two State Roads or County Roads. Include the road
Depth Diamter or Weight/Ft. atenal numbers and common road names.
From 0 To 57 Ft. (,p
From�To—IRYFt. /e„
SUM-
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Bennie&cement pumped
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 ISA NCAC 2C,WELL
CONSTRUCTION STAN DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7=
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE �-
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. _
GW-1 REV. 02004
1�
"w3"1

WELL CONSTRUCTION RECORD 0-0 309415
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) dames B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest T��Wt n: Count ❑Ridge ❑Slope ❑Valley ❑Flat
�l 1 'nA N-E-�. W (check appropriate box)
(Street Name4-4-
N tubers,Community,Subdivision,L g No�tp Code) Latitude/longitude of well location
3. OWNER: (degrees/minuteslseconds)
Address IDV Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
C6� a e NC_ 21911 DEPTH DRILLING LOG
city cr Town s to Zip Code From ..Tff0 f Formation Description
6( 28 ) 7N 3 clay it sand
Area code Phone number .C1 Z ' � � granite
4. DATE DRILLED a i 2.�
5. TOTAL DEPTH:
-6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+"if Above Top Cuing)
8. TOP OF CASING IS 2 FT.Above Land Surface' t i
'Top of casing terminated at/or below land surface requires a
variance in accordant with 15A NCAC 2C.0118. -v
9. YIELD(gpm): METHOD OF TEST BLOW
10.WATER ZONES( epth): LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 or Show direction and distance in miles from at least ;
12. CASING: Wall Thickness two State Roads or County Roads.Include thoad !''•
Depth ,./ Diameter or Weight/Ft. M nal numbers and common road names.
From 0 To / Ft. to
From'�To Ft. to„
From To Ft.
13, GROUT: Depth Material Method
From 0 To 20 FL Benonite&cement pumped
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 S,AND THAT A COP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Serviee Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. "
GW-1-REV.09k004
Cn
- cn

WELL CONSTRUCTION RECORD 00 1 0 4c 4 14
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: d ) Topographic/Land setting
NearetTown: O County �
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lo o.,Zip Code) Latitude/longitude of well location
3. OWNER: n AI f (degmes/minutes/seconds)
Address -1-6 Latitude/longitude source:❑GPS❑Topographic map
Q (Sneer or Route No.) �1pp ryy�// (check box)
0/tlut NC, A l"'A0 DEPTH DRILLING LOG
6(�ry or^w�3_�tg ems,^ Zip Code From T� , Formation Description
o(enI 1515`-� clay it sand
Area code.Phone number granite
4. DATE DRILLED 3- 4 05
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT. �p
(Use"+"if Above Top of Casing) t
8. TOP OF CASING IS 2 FT.Above Land Surface* _
`Tap of casing terminated attar below land surface requires a
variance in accordan ith 15A NCAC 2C.0118. r
9. YIELD(gpm):��MF,T�H�U OF,�T9EST BLOW rn
10.WATER ZONES(depth): tipa
LOCATION SKETCH 11
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft, Material numbers and common road names.
From 0 To Ft. (o" 0188 5h 1 _
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite 8 cement pumped
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 ISA NCAC 2C,WELL
CONSTRUCTION STAND MS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—D�
2—
SIONATUR9 OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2d64
T -

WELL CONSTRUCTION RECORD � 310 511
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
l. WELL USE(Check Applicable Box):Residential M Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Neares(Toj n: Con ORidge ❑Slope OValley ❑Flat
l (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:C Q ( 60-u�Cl,/IU (degroes/mmutes/seconds)
Address hm qk N Latitude/longitude source:OGPSOTopographic map
I r RouNo. (check
110 (� DEPTH DRILLING LOG
City or Tpy{n _Srat Zip Code From T t Formation Description
g( 2B )_ one u e '� Qb 0 � clay it sand
Area code-Phone number 0 t granite
4. DATE DRILLED
5. TOTAL DEPTH: t
6. DOES WELL REPLACE EXISTING WELL? YES O NO
T STATIC WATER LEVEL Below Top of Casing: )00 T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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): _METH RD OF T, ST BLOW
10.WATER ZONES(depth): � J2 0. 0'
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth- Diameter or Weight/Ft. Material numbers and common road names.
From 0 To (n F[._�� a-11-tRaR1 ?tAacF�WZ1L
From To Ft.
From To Ft. 3
13. GROUT: Depth Material Method !�
From 0 To 20 Ft. Benonite&cement pumped N C1J
Froln To Ft.
14. SCREEN: Depth Diameter Slot Size Material O
From To Ft. in. in. CJ7
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�ION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER _
SIGNA RE OF PER SO CONSTRUCTING THE WELL DATE I T II
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service&-nth
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 310 510
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable)
1. WELL USE(Check Applicable Box):Residential El --Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N: Topographic/Land setting
Nearest Town: . e I&OK e County 6A) ❑Ridge ❑Slope ❑Valley ❑Flat
_
.` l LW Qe_ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,^L(ott No.,Zip Code) Latitude/longitude of well location
3. OWNER: AAr L `W JE$ • 11\ LIL" (degrees/nnnums/seconds)
Address 4 I Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
C11 . I to"eEll Nc— nug- DEPTH DRILLING LOG
City or T w State Zip Code From To Formation Description
g( 2g )- aq� - 16,57 0 �Q Sf clay&sand
Area code-Phone number �1 granite
105, (],� r
4. DATE DRILLED •p3 9 05_._.__ - —
5. TOTAL DEPTH:`
6. DOES WELL REPLACE EXISTING WELL? YES_p NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordan a with 15A NCAC 2C.0118.
9. YIELD(gin): _METHOD OF TF�'�•T BLOW
10.WATER ZONES(depth): ��•f (rJ •�f__ _ = -
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Wet ht/Ft. Material numbers and common road names. I"
From 0 To M Ft. I o"
From To Ft. a, W
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material N
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 (<
CONSTRJJr,TION
,STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER < _-
SIGNAT OF PER CONSTRUCTING THE WELL DATE T
Submit the original to the Division o ater Quality,Attn: Information Management,1617 Mail Service Center- "'
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

♦y L`LL t.Vl\JlAVl..11V1\ 1\L(.Vl\L �\� �r n
North Carolina Department of Environment and Natural Resources-Division of Water Quality 3 1 V �j `�
" " 6
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
NearestTown:� k County ❑Ridge ❑Slope ❑Valley ❑Flat
[7Adgl�Dl S W, (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 1)Q+4 V11 M f�EP—LA-1 (degrees/minutes/seconds)
Address K Q 0 ' Latitude/longitude source:❑GPS❑Topographic map
J� (Street Route No.) (check box)
r
VQA_f�GD�LIA145_ . 1— L, DEPTH DRILLING LOG
City or Towk Ste 'Zip Code From �To ' Formation Description
6� m—U i�S� o clay&sand
Area code--Phone number s _ granite
4. DATE DRILLED ,t 1
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YEyS O NO
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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): .5 METHOD F TEST BLOW
10.WATER ZONES(depth): 5M' (oy 3' -
LOCATION SKETCH
11. DISINFECTION: Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To1 Ft. " �
From T To Ft.
From To Ft.
13. GROUT: Depth Material Method .a9
From 0 To 20 Ft. Benonite a cement _ pumped .Z7 ty
From To Ft. Ul
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. C� it
From To Ft. in. in. Ul
15. SAND/GRAVELPACK: R
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 ST S,AND THAT A Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�Q
1,7 SIGNAT OF ERSON CONSTRUCTING THE WELL DATE
Submit the origi al to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. -
GW-1 REV.09/200da

WV,1.Ll;U1Nb1KUU11U1N K1HC 0" eaterQuality
3105 ., 5
North Carolina Department of Environment and Natural Resources-Division o
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if a Iicable (if applicable)
WELL USE(Check Applicable Boxy Residential O Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION: Topographic/Land setting
Ne r St Town: (, IT CI County ON ❑Ridge ❑Slope ❑Valley ❑Flat
Ln!ir 1 01 &A� (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: am 5 C AAA (degrees/minutes/seconds)
Address ` 0 N16 jtlS ntAg_r Latitude/longitude source:❑GPS❑Topographic map
(Street or Royce No.) r1 (check box)
RITL(�tJ0 1 1- q07/551 DEPTH DRILLING LOG
City or Town ^SSttaatre, Zip Code From To(((��1 s Formation Description
8(28 )- �ffi um RCi'u� clayitsand
Area code-Phone number granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES V�NO ❑
7. STATIC WATER LEVEL Below Top of Casing:_c2J_C0 FT.
(Use'Y'if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance In accordan with ISA NCAC 2C.0118.
9. YIELD(gpm): METHOD I TEST BLOW
10. WATER ZONES(depth): 3a0 3 S7[T--
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or;i h Ft. Material numbers and common road names. _
From o To la I Ft.From To To Ft. z
From To FL rtY
13. GROUT: Depth Material Method C
From 0 To 20 Ft. Benonite&cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material N rn
From To Ft. in. in. fJ7
From To Ft. in. in. C3
15, SAND/GRAVEL PACK: cll
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 STA RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG ATURE OFTnSON CONSTRUCTING THE WELL DA E
Submit the orig nal to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV!.09/2i�4
r.�

WELL CONSTRUCTION RECORD 3 1116 3
North Carolina-Department of Environment and 7fNatural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
/�{(print)_�J�� 6 �j✓'/IlIG CERTIFICATIONN4_7L)2/
WELL CONTRACTOR COMPANY NAME (VA-r/f_. /,lM S• PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) -
1. WELL USE(Check Applicable Box): Residential' Municipal/Public❑ Industrial ❑ Agricultural ❑ r
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use
2. WELL LOCATION:
y_ � so.�► Topographic/Lan4 setting
Nearest To t/Mn p Count ❑Ridge ❑Slope ❑V61ley� ❑Flat.
� •rt. 1✓ 1-- . (check appropriate 6.)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of tyell tgcatior
3. OWNER: A--f' d / v
Address Q ilV ab Z - (degrees/minutes/se rda#i
Latitude/longitude source:❑GP ❑Topogra}�hlc trap
/ ll �" ��'(Sttree(or Route No.) (check -
--�lJ f/t�5 A"L- r�) S' -7 y1 DEPTH DRILLING LOG
City 6r Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILL H: / O d5__ � Q —
5. TOTAL DEPTH: /DO_� �
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:/9'0 FT.
(Use'•+"if Above Top of Casing) -..
8. TOP OF CASING IS�_FT.Above Land Surface'
r t
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. E
9. YIELD(gpm): / METHOD OF TEST A,'r w '1
10. WATER ZONES (depth): o 4
LOCATION SKETCHcA -
11. DISINFECTION: Type Amount Show direction and distance in miles from ai ast
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth"2 Diam�et r or Weight/Ft. Material numbers and common road names.
From d To_y Ft. //[L _
From To Ft.
From To Ft. _
13. GROUT: Depth Material �yt/t IMe hod _
From To 2��FL_6�
From To Ft.
a 14. SCREEN: Depth Diameter Slot Size Material K j
From To Ft. in. in. _ 1
From To Ft. in. in. -
15. SAND/GRAVEL PACK: --_
{=
Depth Size Material a -
From To Ft.
From To Ft.
I6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON RUCTION 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 , LLJ
­7-:Z 7,9- - Ok -/ G's-
North Carolina Department of Environment and Natural sources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_c-7—� Ir � i1/IJt2�l CERTIFICATION# G/
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SY—LVA,NC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) - qqqq,,,,rrrr....,, (if applicable)
77WELL USE(Check Applicable Box):Residential ) Municipal/Public❑ Industrial❑ Agricultural❑ 3 1 1 5 R 0
Monitoring❑ Recovery ❑ Heat Pump Wate Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO F G' 'r-,\ ___ /in Topo raphic/Land setting
Nearest Town: Its' County��)__. ❑Ridge VS1ope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:- n A-C t' a-A -,Sri (degrees/minutes/seconds)
Address 4 _ Latitude/longitude source:❑GPS❑Topographic map
-J (Street or Roue No.) (check box)
Cc k. C 70 DEPTH DRILLING LOG
City or Town Sta zip Code From To Formation Description
CUB)- 3 `- 3,767s
Area code-Phone Dumber / ("t 4�;1;�
4. DATE DRILLED /1 ( '--/(,, 0l[
5. TOTAL DEPTH: ` E
6. DOES WELL REPLACECE EXISTING WELL? YES ❑ NO GS"
7. STATIC WATER LEVEL Below Top of Casing:. FT.
(Use"+"if Above Top of asing,
8. TOP OF CASING IS FT.Above Land Surface`
`Tap orcasing terminated attar below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): �(() METHOD SF TEST ✓ ✓
10.WATER ZONES(depth): 4 •X
LOCATION SKETCH
11. DISINFECTION:Type Amount 13- 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 & ToL Ft._ S'Da
From To Ft.
From To FL L `"
13. GROUT: Depth Material [/[Method 5
From__Tol Ft.
From ToZyi Ft.- � " (/
14. SCREEN: Depth Diameter Slot Size '-Material �ju..� LPi
From To Ft.—in. in. ✓ �� /t /
From To FL 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 CON.ST CTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD
767J - 0 (v 8o2�r
North Carolina Department of Environment and Natural
Resources
-Division of Water Quality
WELL CONTRACTOR(INDIVWUAL)NAME (print) ``>I. w �t/^�`�"/ CERTIFICATIONN
WELL CONTRACTOR COMPANY NAME AAA GREE4 BROS.WELL DRLG.OF SYLVA,INC. PHONE [phone]
STATE WELL CONSTRUCTION PE&NHT# ASSOCIATED WQ PERbnTM
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential CX Municipal/Public❑ Industrial❑ Agricultural❑ rr
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: C my L'��' dne ❑Slope ❑Valley ❑Flat
�_ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code j/�CLafitude/longitude of well location
r1 Z
3. OWNER: (degree✓minutes/seconds)
Address O Latitude/longitude source:❑GPS❑Topographic map
(Strector Ro No.) 3� p)� (check box) .,
C:Ql� G�� a DEPT DRILLING LOG
C — aZ or To Stag -�ZitLClyde n �J7 _ From To Formation Description
aza - S Ltl LCt e¢ (7lQ/f Le �
Area code-Phone number
4. DATE DRILLED v2O — -�
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO J8j
7. STATIC WATER LEVEL Below Top of Casing: f 437) FT.
(Use"+-if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface.
'Top of casing terminated at/or below iand surface requires a
variance in accordance ith 15A NCAC 2C.01I8.
9. YIELD(gpm): ( METHOD OF TEST I +�
10."'ATER ZONES(depth): IRO
3 LOCATION SKETCH
11, DISFNFECTION:Type' Amount3Q75 f5Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept ,,/ iameter or Weight/Ft. M2,t iri Cumbers and common road names.
From
�To� LS Ft. SDR-Z/ (�
From To Ft.
From To Ft.
13. GROUT: Depth Maten_ 'al Method ..
From 0 To Ft.__a
From To�Ft:
14. SCREEN: Depth Diameter Slot Size fat rial
From To Ft. in. in. _ m
From To Ft. /Z�(in. in. L..Q.
15. SAND/GRAVEL PACK:
Depth Size Material ,p
From To Ft. /x —n
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,CA�ND THAT Al�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�1J - IN) T C t..f M 5' — 1 0 ^ CS ,
SIGNATURE OF PERSON CGOSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617Mail Service Center-
Raleigh,NC 276994617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

WELL CONSTRUCTION RECORD --L. Y--< �7J_� r ,J(�
TIenarunent of Environment and Natural Resources-Division of Water f-J6 `� 7/.
k' �1
LC/�Yf` CERTIFICAATION# `G,L, / �---
'G J / "� - 4 PHONE# C'� :5��4• '.5'�J
ASSOCIATED WQ pER�T#
(if applicable)
MunicipaL'Public❑ Industrial El-- Agricultural❑
action❑ Other 0 If Other,List Use c3 15
7
J
rt� Top a hic/Land setting
) 7 4RidgePe OValley OFlat
ode) J (check appropriate box)
Latitude/IongiNdeof well location
_ Latitude/longitude ource OGPSOTop 1 0
,e ? (check box) raphic map
y DEPTH DRILLING "
�, .,W.. ...N...,.� From To
Arca code-Phone number Formation Description
4. DATE DRILLED / — /)l —0 $
5. TOTAL DEPTH: �,�— .�
6. DOES WELL REPLdCE EXISTING WELL? YES❑ No
/
7. STATIC WATER LEVEL Below Top of Casing: —
8. TOP OF CASING IS Nu"+'if Above Top of C mg)
'Top of casing terminated aVor below land euAace requ ve Land
Surface* �__
variance In accordance wit 15A NCAC 2C sou,M.
9. YIELD(gpm): METHOD OF TEST_ -
10.WATER ZONES(depth): -7` 1 S f
11. DISINFECTION: Type J /-'�j� AT ION SKETCH
12. CASING: �— AmoUnt 5 - 4_show direction and distance in miles from at least
DepthWall Thickness two State Roads or County Roads.Include the road
is eter -- or Wei ht/FL From To S� Ft P �i : J�� Mate numbers and common road names.
From To Ft. !�[y� �
From Ti) Ft
13. GROUT: Depth "
From_�j' Ft Material ,, Method To rite From _
14. SCREE To
_ Ft. _
Depth Diameter Slot Size �a� u'r
From To Mat ial ¢r--illL�tl W'c"'
From To Ft.— .
in. • J' _
15. SAND/GRAVEL PACK: Ft--in in.
Depth Size
From To Material
From Ft. - 1
16. RE
TO t.
-- /MARKS: F
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED N THE
IT'D r_ WELL OWNER
+tom c� C.",,
SIGNATURE OF PERSON CONST
CTINGTHEWELL DATE
Submit the original to the Division of Water Quality,Attn:Information Managemenq 1617M '1-S�tvi¢e'Cetiter
Raleigh,NC 27699.1617, Phone No.[phone],within 30 days.
.,.. 1ri ,
-GW7 REV.09/2004

WELL CONSTRUCTION RECORD 3 115 7 2
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)Russell S.Taylor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME Haddon Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:/ Topographic/Land setting
Near Town: �—County ❑Ridgedge 09lope ❑Valley ❑Flat
M iNA (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �(4 (degrces/minutesheconds)
Address y1'�4• Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or T St tj Zip Code Fr m I t Formation Description
clay&sand
Area code.Phone number A ' ° granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO k
7. STATIC WATER LEVEL Below Top of Casing:_JQ0 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface"
-Top of casing terminated War below land surface requires a
variance In accordane w th l5A NCAC 2C.0118.
9. YIELD(gpm): M��TTjjHOD OF TEST BLOW
10. WATER ZONES(depth): 7�y >� ram°
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount t6oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di eter or Wei t/Ft. Material numbers and common road names. ,..,
u �.�, -n E
From To�Ft.� �df� <'?
From To Ft.
From To Ft.
13. GROUT: Depth Material Method < ;-y
From 0 To 20 Ft. benonits 6 cement pumped N
From To Ft. t'
14. SCREEN: Depth Diameter Slot Size Material CD
From To Ft. in. _ in. Ln ;1
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
CONSTRUPTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
5- io -65
SIGN�PURE 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
`' \kc' 31
North Carolina Department of Environment and Natural Resources-Division of water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S Taylof
CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME
Hedden Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#(if applicable)
(if applicable) -
1 1riELL'JSE(Check Applicable Box):Residential O Municipe:,'P++blic L1 Industrial O Agricultural ❑".tonitoring❑ Recovery ❑ Heat Pump'Nater Injection❑ Other❑ If Other,List Use.-
2. WELL LOCATI N: n — , _ Topographic/Land setting
Ne es wn: County_ J ORidge ❑Slope l7VallCyox) ❑Flat
�� I� — (j check appropriate box)
Latitude/longitude of well location
trees Name,Numbers,Community,Subdivision,Lot No.,Zip CodeCommunity,
(degrees/minutes/seconds)
3. OWNER: Latitude/longitude source:❑GPSOTopographic map
Address (check box)
(Street or ute No.y rf DEPTH DRILLING LOG
sIS Code 5 / Formation Description
Z+ Code From T )
C of Towp'H31t���.1^ 0 clanite
(HST)- 'i granite
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES F1�
7. STATIC WATER LEVEL Below Top of Casing:
T.
(Use"+'if Above Top o Casmg)
8. TOP OF CASING IS 2 FT.Above Land Surfaces
*Top of casing terminated Wor below land surface requires a
variance in accordance with 15A NCAC 2C.01Is.9. YIELD(gpm): METHO OF TEST BLOW
10.WATER ZONES(depth): a�x LOCATION H
Show direction and distance in miles from at least
11. DISINFECTION:Type H T H Amount 16 0Z two State Roads or County Roads.Include the road
12. CASING: Wall Thickness numbers and common road names.
Depth Diameter or Weight/Ft. aterial
u
From o To Ft. ra
n
From�To Ft.
From To Ft. y
13. GROUT: Depth Material Method
From 0 To 20 Ft. Bcnonita&cement pumped rV A
From To
Ft. t
14. SCREEN: Depth Diameter Slot Size Material N
From To Ft.—in. in.
From To Ft. in. _ in.
15. SAND/GRAVEL PACK:Depth S1zC 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
rJ•10.OS
SI ATURE OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW!-1 REV.09/2004
I

WELL CONSTRUCTION RECORD
3115r) o
North Carolina Department of Environment and Natural Resources-Division of Water Quality2t 87
CERTIFICATION#
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor PHONE # I8281 2191
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc
ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# A if applic2illi
if a licable
1. WELL USE(Check Applicable Box):Residential 1-1 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Top[]Ridge
[3 lope Land setting
N restTiow}: _County ❑Ridge ❑Slope ❑Valley ❑Flat
�n (check appropriate box)
Lot No.,Zip Code)
Latitude/longitude of well location
(S eetame,Numbers,Commumry,Subdivision,
(degrees/minutes/seconds)
3. OWNER: Latitude/longitude source:❑GPS❑Topographic map
Addres is;
(check box)
DEPTH DRILLING LOG
Formation Description
Zip Code From(�iry � p clay 8 sand
7� r � aranite
Areacode-Phone
number
4. DATE DRILLED
5. TOTAL DEPTH:
—�
6. DOES WELL REPLAC EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use-w'if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface* —_
"Top of casing terminated at/or below land surface requires a
variance in accordance whits 15A NCAC 2C.0118. BLOW --
9. YIELD(gpm):�—MET OD O TEST
10.WATER ZONES(depth): ia� LOCATIO
Show direction and distance in miles from at least ;y
11. DISINFECTION:Type H T H Amount 16 oz 1—State Roads or County Roads.Include the road
12. CASING: Wall Thickness numbers and common road names.
Depth Di meter or weight/Ft. MaterialMaterialu..,
From o To Ft.�_ ,
From__To Ft.
From To Ft. '— '
13. GROUT: Depth Material Method -mot ,,.y
From__2_To 20 Ft, eenonits 8 cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To—Ft. in. _ in.
From To Ft._in. _ in. ,
15. SAND/GRAVEL PACK: Material
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S•10 'U
SI ATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Servi r ce Center _
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW-1 REV.i09/2004
_ I

WELL CONSTRUCTION RECORD ��� 1
North Carolina Department of Environment and Natural Resources-Division of Water Quality 3 11 e! ! 1
CERTIFICATION#2tB7
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Ta for pHONE # f 8281369-9591
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc ASSOCIATED WQPERMIT#
STATE WELL CONSTRUCTION PERMIT# if a licable
if a licable
1. WELL USE(Check Applicable Box):Residential© Municipal/Public 0 Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
Topographic Land setting
2. WELLLOCATIO : County ORidge ❑Slope DValley DFlat
Nep st Town: (check appropriate box)
w Latitude/longitude of well location
(Street Name,Numbers,Commumry,Subdrvts,on,Lot No,Ztp Code)
(degrees/minutes/seconds)
3. OWNER: Latitude/longitude source:OGPSOTopographic map
Address (check box)
,n (Street rRouWNo.) g''rr�'�' DEPTH DRILLING LOG
J // _,nANAlt� Formation Description
zt Code From To i clay&sand
City or Town Sta P
820 - t aranittee---
Area code-Phone num er
4. DATE DRILLED `> '
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO J�
7. STATIC WATER LEVEL Below Top of Casing: IQC_D
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface* -_
*Top of casing terminated st/or below land surface requires a _�—
variance In accords with 15A NCAC 2C.011a. BLOW
9. YIELD(gpm): METHOD OF TEST
10.WATER ZONES epth):
H T H Amount 16 oz Show direction and distance in miles from at least A,
11. DISINFECTION:Type two State Roads or County Roads.Include the road
Wall Thickness ?
12. CASING: numbers and common road names. �
Depth D' mSter or Weight/Ft. tenal
From o Pvn
To Ft.
From ToFt. p N
From To Ft.
Material Method '*
13. GROUT: Depth pumped From 0 To 20 Ft. Benonite&cement pum 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: Material
Depth Size
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 TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG ATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Divis on of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.

WELL CONSTRUCTION RECORD 0�
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION N 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # [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 ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:, Topographic/Land setting
rest Town: (lJ County []Ridge []Slope !]Valley OFlat
7� (check appropriate box)
(Sugar Name, tu Community,Commu tnity,Subdivision,L o.,Zip Code) Latitude/longitude Of well location
3. OWNER: (degmes/minutes/seconds)
Address 17, QQJ fa. Latitude/longitude source:OGPSOTopographic map
(Sir t or Route No:) (check box)
DEPTH DRILLING LOG
Ci or Town State Zip Code From Formation Description
- 0 o( clay&sand
Area code-Phone number 0 granite
4. DATE DRILLED 3 -30 -05
5. TOTAL DEPTH: 4(00'
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: = FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 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): .30 METH D OF TEST BLOW
10.WATER ZONES(depth): 11�r TZ¢5t
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth„ Diameter or Weight/Ft. Maa 1 numbers and common road names.
From 0 To Ft. .�i 6-t
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite a cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. W
From To Ft. in. in.
r
15. SAND/GRAVEL PACK: C�J1
Depth Size Material s.
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIONS ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
J- 0- 05
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center-___
Raleigh,NC 27699.1617, Phone No.[phone],within 30 days.
L GW-1 REV�09/2004
I

31162
WELL CONSTRUCTION RECORD'
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACI'OR(INDIvIDUAL)TIAME Pits ! ' .w cl CPJl2iPICAT20N1 L(o
WELL CONTRACTOR COMPANY NAM PHo 'o nL.5a4-'3 A6 6
STATE WELL CONsTRUCTION-P$RMITa aOCtATP.D W ER MITI
(if applicable) •(if applicable?
Ease
1. WELL USE(Check Applicable Box):ResidentiaC unicipal/Public❑ lndustrfal 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other f7 If Other,List Use
2.-WELL LOCATION: .
Nearest Town: /I . �,mh (� L � DTopogtspbidLtiitd�g '
Ridge OSlope ffdVailey 0Flat
i P -�7-7 01 (ehockapproprish:box) . ' a
(Street Name,N Commrmiry,Subdivision,Lot No.,22p code) Latitude/lotlgitude of well location -
3. OWNER--
Address 155 3 B I at to i� )r t� .S t• Latimde/longitude source:UGPSUTopographic map
(Street ar Raw No.)S (ehak box))u h ni , , Af ,` f� DEPTH ' DRILLING LOG
(9 r>!yw t state zpcode From -To ' Formation Description
Am cod&Phone another
4. DATE DRILLED J�—/
5. TOTAL DEPTH: -5-n^ 9-
6. DOES WELL REPLACE EXISTING WELL? YES 0-NO=
7. STATIC WATER LEVEL Below Top of Casing: to Q FT =
(Use'Yr if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
-Top or cuing termluated arlor belgn Iwtsurface requires■
Yuri**"to aaardana waatYANCAC 2C.01IL
J, METHOD
10. WATER ONES(d1 eptthh): l4e0 OF TEST
/m/, U1 �.
LOCATION KET H
11. DISINFECTION:Type Amount Show direction and.distartce In miles from at least -
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di"ter or Weight/FL `Materigt,'-numbers and common road narnes.
From a - T(i gaFL to , • '/�lg -S -:te
From To FL _�?�'
f— r
From To—Ft._ i
13. GROUT: Depth Material Method
From_To 4;D_
From To FL
.4. SCREEN: Depth Diameter . Slot Sim Material • - '
From To Ft,
_in. is
From To Ft. in. in.
5. SAND/GRAVEL PACK: _
Depth Sim Material
From Tc Ft. -
From To FL _
— a
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTIH 15A NCAC 2C,WELL
'ONSTRUCf10N STANDARDS,AND THAT A COPY OF THIS RECORD H&S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THE
WELL DATE
-rubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mali Servlee Center-Raleigh;NC
.0'7699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

WELL CoNSTRU e North Carolina_D L'TjONj C• 31 .1 U ? i
ePertnunt of Environment and Natural
'
WELL CONTIZA(1.OR(INDIYIDU ,kt
AL)-NAAIE (Prin imal f°Ump-DiviaioA of W
WELL CONTRACTOR COMPANY NAM .. QUAIL '
ty''Groundwater Section
FATE WE +• - .-
LLCONgrRUCTIONPL/RMrry - -
(ifa livable CA•I'IONO 17(e
I• WELL USE aaDC►ATeuw Mims _ PNO� a
Monitorin ( 'c APPllcableB livable
8 0 Recovery01).Rsidentiaf
p. Hest Pum '� Mno.,' al/Pubtic p
2•-WELL LOCATION: P Watei Injection❑ ether If p
tlurLiat�e ASricultutatp
N�e�arest Town. _ '
(alas eI N te.Num e Come
TOppp�l1C/LRnd
3. OWNER: 6"r caamuniry,Subdivis, Let No„Tp code go OSIOPe OVa11cy .
) (dachapl�Mlakypa Fiat
Address t� b CL1 S?T La titutle/Iottgil4de of
n .011location
2c12 t, (aura or Roate No.) — �— Latitud (de minutes
2-6-
�f11raTowa Sao �2C2 �I e/lon8ihidesource:pGP ) P .
2-6�- 0 �S jn . ?,tP coat� -(Urock boa)OP0911 hit map
AR coda Plmae number _ FrpmD�_��-g�,��j .
4. DATE DRILLED =-� --`�?C— .
5. TOTAL D r(/ �� F°-?otationDescription
6. DOES H:_ _
7. STATIC W L REPLACE g STING ! 2
8. TOP ATERLEVELBelowTopOfC v.yRS NO: 7
OF CASING IS (th"`" ifAbM T0PP 1T.
9. YfELD"riaawk aaE ur withT4Ab�wttada wiaee re sUtface• —� —eeordan NCAC SC.0 IL
(BPAt): 30 �
10. WATER ZONES(d ZONES SHOD_OFTEST n,
1 I. DISINFECTION:Type r
12. CASING: Amount `� -
Show LO aTTnN«ETr ua
From /� Depth Di Wall ThiclotGyt direction and d
From To-" �- or Wet�ht/PL `M n bmtwo IIoCo� Roads,
om to from at Include
ode the road
From -AFL-� ��i names. toad
13. ro Depth Ft--_•-
/�
From•-0-Toy-&-FL `
.4. SCREEFroN- To Ft� "'ly7ahod
Depth
To
--I
To Dlame� Sl
5. S ot Size.
F-�iMaterial
AND/GRAVEL PAC n -� In.
From_ �_Ft`�_in.
K In �_
From Depth From Sisize
--To---�.Ft. Material
Ft.
6. REMARKS: _ —�
CE RTFYTHAT7}i13WELLWASCONONSTRUCTIONSfANDARDS,AND
J—_-,
STP
THAT A COPY 0'U D IN ACCORDANCg
CORD BEENP40 DED oCAC2C,WELL .
SIGNA L THE.WELL OWNER
pp ON
WELL submit the • `5--// — C5� -
7 1636 Phone Ne•tg 9)7D322I of Water Quality,Ground - D -
a 699- ATE
( ,within 30 days, water Section
t 16361ya0 Service Center.Raleigh,NC
OW-1 REV.07/2001