Ma CY2005

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309598
WELL- CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of W ater Quality-Groundwater Section
WELL CONTRACT'OR(INDIVIDUAL)'NAMB (prinnsh�i)%1$ � � ,w.1 ' CP.I�TtFICAT10Ni o1�7le
WELL CONTRACTOR COMPANY NAM PHONR i �_-�S.i L/-3 ot-(ri O
STATE WELL CONSTRUCTION PRRM17y- A�OC[ATEDW ERMITa -
(if applicable) •(ifapplicableMass
I. WELL USE(Check Applicable Box):Residential q- Municips"ublic O ustrial q ricultuual p
Moniloring❑ Recovery ❑- Heat Pump Water Injection❑ Other f Other,List Use
2.-WELL LOCATIO
Nearest Town: L County. Topograppicamdsetting
�!s 307g_C— ek � fjrJ;'t f ORidge (❑Sack pe Ote box) .�Fi><t'
ppre of box)
(Street Name,Number:,Canmuniry,Subdiv;imn,l.ot Na,Tap Code) LatiRldeJlongitude of woll location
3. OWNER:*N&
AddressLatitudellongittide souroe:OGPSOT'opographic map
p
,IQQ,fI l - /lP/ �d �'� (check box) .
� DEPTH - DRILLING LOG
.g City'";� aT D� . lap Code From To ' Formation Description
wrca code-Phone number
4. DATE DRILLED —1 nE4 . f�� s+
5. TOTAL DEPTH: �DO 11 K-O` SOU
6. DOES WELL REPLACE EXISTING WELL? YES❑_NO:
7. STATIC WATER LEVEL Below Top of Casing: 4 '-FT;
Man-t-if Above Top of(Bering)
8. TOP OF CASING IS_�FT.Above Land Surfaces v-Top of cuing terminated attar belan Iwd.aurfaee requires a
variance to accordance w10115ANCAC 1CAIIL
9. YIELD(gpm): METHOD OF TEST -
t
10.WATER ZONES(depth): Q& o-I_3ts r
' LOCATION KET H �
11. DISINFECTION:Type Amours( Show direction and distance In[Hiles from at least �
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dinu rter .or Weiijhgt. -Matetigl_ -numbers and common road names.
From_ _To Ft._
From To FL
From_0Tq ItfO FL-
13. GROUT: Dept -Materil Method
From_ To_�FL no-
From To
.4. SCREEN: Depth Diameter - Slot Siu 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 IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD BEEN P40VIDED TO THB WELL OWNER
k 1 ip�., 3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-submit the ariginai to the Division of Water Qusilty,Groundwater Section, 1636 Mail Service Center-Ralelgh;NC
-P7699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION REC,(O�RD ` 0 5 9 �
North Carolina-Department Of Environment and Natural Resources-Division of Water tY`Quall Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)-NAME (prlat)s��
-----"- �a�him A A CEJ!TWICATION Y d I7(P
WELL CONTRACTOR COM PANY NAM PHONE Y ;a 14 3 96
STATE WELL CONSTRUCTION PERMM'Y - •SSn-(ifazpp71icablcg
RM[TY
(irapplicable) -
1. WELL USE(Check Applicable Box):Residenfiafid­ (vlunicipal/Public❑ Industrial Q Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other EF If Other,List Use
2.-WELL LOCATION:
Nearest Town: i County ographidLendsetting
C GLt lc] P t7 e e 0 dw Be ❑Slope OYalley ❑Flat
l l)n I u T Cn r> D,a (check appropriate box) . , %
(Street Name,Number,C munity,Subdivision,Lot No.,Zip Code) d f rr 3 Littitude/longitude of well location
3. OWNER: vt I, �Ip�d (desroulmiautWseconds)
Address 9 n/„„ T u r d
Latitude/longitude source:❑GPS❑Topographic map
(Bute[or Route No.) .
F1212.kk/ —Q `f 7- V (check box)
P1rPTH DRILLING LOG
a. 5-wn ssSf- State Zip From To Formation Description
(�S- a/r 9 n (A
Arc&code-Phone number -,
4. DATE DRILLED 3al —Us ��r q k' 2 t2 t
5. TOTAL DEPTH: D — Sc?-n, C trm P
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO_ 1 r 4 12 L t) e- r te an 'fi
7. STATIC WATER LEVEL Below Top of Casing:
(Use"i"if Above Top of Cuing <
8. TOP OF CASING IS FT.Above Land Surface*
'TOP of cutaa terminated allor belaw laud.surface requires a90
variance In accordance with ISA NCAC 3C.011L -
9. YIELD(gpm):4 METHOD OF TEST y
10. WATER ZONES(depth): S3Sr rsvy,
LOCATION SKETCH O T'
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
/ t a FL Di ter S or wejott t. Material -numbers and common road names.
From "
From To Ft.
From To FL
13. GROUT: Depth Materiel Method - -
From_(—To r'?D Ft.—a; -�m�� ) _
From To Ft. 1 -
.4. SCREEN: Depth Diameter . Slot Size Material - - -- -
From To Ft.
From To Ft. in. in.
5. SAND/GRAVEL PACK: `-
Depth Size Material
From To FL -
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 THIS RECORD 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 Mall Service Center-Raleigh;NC
e'J'7699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV•fDUAL)MAME (prinO c�p Hgll s 1 .� '
----� 1J.if.':_..."' ' " C6�TIF(CA'rION f of l7
WELL CONTRACTOR COMPANY NAM - `pj(ONB oil St�_.5�4--3 �.b
STATE WELL CONSTRUCTION Pli:RMIT/ - ASSOCIATEDW ERMITS
(ifapplicable) • .(It pplicable)
I. WELL USE(Check Applicable Box):Reaident'ial' unicipal/Public O Industrial Q Agricultural O
Monitoring O Recovcty ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2."WELL LOCATION -// �� �To hiclLand setting
Nearest Town: LjN —Coup( 1111t0ge OSlupe (]Valley Mat
(Sate,Name,Numb* unify,Su(diviiice,l.a T)o.,tip Code)2�r/3 7 [,stitudcA(chgitude of v appropriatemll location
3. OWNER: leIOVaS CtQ 011J )T-el - •(deareedmiautahaonds) .
Address 3 fa / 1 C P /?.!JoA1 Latitude/longitude source:OGPSOTopographic map
�� (Street ar aw��t/�No) Q (cheek boa)
DEPTH ' DRILLING LOG
Arc�C"vor ° Q— S zipC� From To 'I FgrnationDescription
e•Phone numbee,
4. DATE DRILLED J —off =LLS oI t/ ' �e ri e*Ya�•,t t
5. TOTAL DEPTH: ,
6. DOES WELL REPLAN EXISTING WELL? YES O-NO: yT
7. STATIC WATER LEVEL Below Top of Casing. as '-FT; o
itr A
(Uu'V^ifAbove Top acailnO t
8. TOP OF CASING IS_�FT.Above Land Surface" (,r(
-Top of eulag terminated atlor belay 4adiurfaee require*■ - y
variance in aecerdeace whYT?ANCAC 2C.e1i0. CD1•'•
9. YIELD(gpm): METHOD OF TEST.~�1 Ln
10.WATER ZONES(depth):—. :f 7 '
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 Di 5 or WeiBhFF( M 'numbers and common road names.
From To 2�Ft._�` ,�$,.� ., ✓✓
From To Ft.
From Tq FL_ -- -
13. GROUT: Depth . Material Method)
From__To_A�&_FL
From To Ft.
A. SCREEN: Depth Diameter , SlotSim Material
From To Ft,__in, in. -
From To Ft. in. in.
5. SAND/GRAVEL PACK:
cT
Depth Sim Material
From Tc Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P40VIDED TO THE WELL OWNER
��a� 3 ae o s
SIGNATURE OF PERSON CONSTRUCTING THE WELL - DATE
-submit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh;NC -
a*7699-1636 Phone No.[phone],within 30 days. OW-1 REV.07l2001

WELL CONSTRUCTION RECORD
309421
North Carolina Department of Envitonment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (prinq 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 LOCATION Topographic/Land setting
Near tTown: County ffi . ❑Ridge ❑Slope ❑Valley ❑Flat
O^ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
(degrees/minutes/seconds)
3. OWNER: Latitude/longitude source:❑GPS❑Topographic map
Address (check box)
treet or oute N I n log DEPTH DRILLING LOG
Cit
y or Town Statte f 0!k Zip Code tiell O_ From T Formation Description
Civ�
28 �y� i 1 �N. 0 clay itsand
(_8�-_. ' granite
Area code-Phone number
4. DATE DRILLED cS
5. TOTAL DEPTH:
b. DOESWELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: �eFT.
(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 accordance with 15A NCAC 2C.0118. BLOW
9. YIELD(gpm): ME HOD OF TEST
10.WATER ZONES(depth): IQ 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 0 To _Ft. (ri r 4J��u'APFrom�To _Ft. (a a
From To Ft. v
Material Method
13. GROUT: Depth
From 0 To 20 Ft. Benonite i cement pumped .�
From To Ft. o
14. SCREEN: Depth Diameter Slot Size Material
From To Ft.—in. is
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 RDS,AND THAT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
444 SIGNA OF P 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.09/2044.
Z

WELL CONSTRUCTION RECORD Wg> 309 4210
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 LOCATIO : Topographic/Land setting
Neares Town: U County rylAulka ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers, mmumty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑T-opographic map
(StregtorR to No.) (check box)
L AN p�.K a973i� DEPTH DRILLING LOG
City or Town �f StatQ Zip Code From To s Formation Description
aze - 6ZN'L><03b o 30 clay&sand
Area code Phone number 30, Zt{Or granite
4. DATEDRILLED
5. TOTAL DEPTH:
--
6. DOES WELL REPLACE EXISTING WELL? YESX NO ❑
7. STATIC WATER LEVEL Below Top of Casing: /50--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. BLOW
9. YIELD(gpm): METHOD OFT STD_
10.WATER ZONES(depth): �;5� � � 30 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 h
12. CASING: Wall Thickness
Depth Diameter or WeighVFt. �MaJte_rial numbers and common road names.
From 0 To Ft. 10 _
From�To t �
From To Ft. _
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite&cement pumpedCil
p
From To Ft. m l
14. SCREEN: Depth Dizeter Slot Size Mat
From To Ft. in. _ in.
From To Ft. in. _ in.
D/15, SAND/GRAVEL—RAVEL 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 nq,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUFMTOF 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. z.•
GWl REV.OM04

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 309435
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 : Topographic/Land setting
Near tTown: 0A County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Nu ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: _ (degrees/m nums/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
��(,Stre�at/or ou o.) (checkbox)
.� � � �� 91 :?3 7'0---!5 DEPTH DRILLING LOG
City or Town Smte Zip Code From To Formation Description
6( 28 )- cs -0A-1 te11 iw j 0 1 clay&sand
Area code.Phone number granite
4. DATE DRILLED "S- 11-05
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 14 50 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.0118.
9. YIELD(gpm): La METHOD OFdd EST BLOW
10.WATER ZONES(depth): 5�` W 5 IG
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. ten numbers.and common road names.
From 0 To )0-5 Ft.� y 0
From To Ft.
From To Ft. 07
13. GROUT: Depth Material Method "Foo "`•
From 0 To 20 Ft. Benonite&cement pumped 70 t
From To Ft. 1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. C�
From To Ft. in. in. LA
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
3 7 - 05
SIGN AYT IRE OF P7rRSON 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

310507
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Wakr Quality-Qroundwater Section
WELL CONTRACrOR(INDIV.-IDUAL)?IAME (print)_[ bmis �JJ • 0 —' - CzKnncATIom# J Ile
WELL CONTRACTOR COMPANY NAM� ' 'PHONY. ,
STATE WELL CONSTRUCTIONPIrRMIT/ AaSOCUTED W ERMITa
Orapplieabie) - - '(ifirpplicable) '
1. WELL USE(Check Applicable Box):.Residentiel' unicipaUPublic❑ Industrial 0 Agricultural Q
Monitoring❑ Recovery 0' Heat Pump Water Injection❑ Other 5 If Other,List Use
2.-WELL LOCATION: DgraphidLtind settiDg
Nearest Town: t 11• 1) County, AC ).A/ 'dga GSlope GValley .GFlat
g!j 1 5 I�a..1\0 A . 4 1) 'R A. a PUP 3 (ebaek apWoPdak boa) �
(Street Name.Numbers,Commonily,Subdivision,Lot No,zip Code) I.4titude/Iougitude of Well location
3. OWNER: T t'Yl +� N �v �t��: Yl (depeeslmiauter/a xonds)
Address -:)A 1 5 L A 'P' [S LQ n G _ LatitudellongiNda souree.GGPSDTopographic map
(Street a Route No.) - (cheekbox)
�JpvT S7-feu t=1. 3 a L5- (0 DEPTH DRILLING LOG
City or
town stun zip Cork From To ' Formation Description
91.1w-��Sa7- sae 2 r7 to l --
Area codo-Phone number 6) 1
4. DATE DRILLED Af—/ 3 —6 S
5. TOTAL DEPTH: &5 IN
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing .2•5-Q�FT.
(Use"+"if Above Top of Casino 7 .
S. TOP OF CASING IS_�FT.Above Land Surface•
Top of cuing termlusted allot belaw IMdsurfsa requires a
variattee In aecordsnee withIRANCAC 2C.01I8.
9. YIELD(gptn): /D METHOD OF TEST
10.WATER ZONES(depth): (r V 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
Depth Dia" or Weight/FL M I_ -numbers and common road names.
From To_L2(_FL S-D RA
From Tc Ft. i
From To FL—._ _
13. GROUT: Depth Materiil Method v
From_To
�FL _ : .�
From To Ft.
.4. SCREEN: Depth Diameter Slot size Material
From To Ft. in. in.
From To Ft in. in. Ln
5. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft. --
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 154%NCAC 2C,WELL �` T
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN PROVIDED TO TH&WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
submit the original-to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleig 14& C
GW-1 REV 1
a:'1699-1636 Phone No.[phone],within 30 days. �2$0 ;�

310506
WELL CONSTRUCTION RECORD
1. ,(w y
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV,IDUAL)'NAME (print)c�1 r)PII s lj w. TIF(CATIONf 1'�
WELL CONTRACTOR COMPANY NAM _ PRONE 47V_S2y-'3 ZZ& Q
STATE WELL CONSTRUCTION PSRMITa - AasOCYATEDW ERMTI•a
(irappucabie) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential 0-- unicipal/Public❑ Industrial❑ Agricultural Q
Monitoring❑ Recovery ❑- Heat Pump Water Injection❑ Other Cr if Other,List Use
2--WELL LOCATIO TgpograjibidLand Setting Nearest Town: 4 L, �'Dsty ifMdge ❑Slope alley ❑Flat
(eheekappropriakbox)
(Street Name.Numbers,Community,Subdivision,tat No'.rip Code) LatitudeAmigitude of well location
3. OWNER: hr"14 ,) -h U le f? (depoerlmiluteyueondq
Address <� LirT�d2 i!}3t l M : ye- 12 c4 Latitudei longitude source,❑OPS❑Topographic map
(Street or Route of� (cluck boa)12 CLti1 IC b)t� //O� ��3 DEPTH DRILLING LOG
ity orTown�C s Zip Code From •�TO Formation Description
coda-Phone number - -.
4. DATE DRILLED , " t
5. TOTAL DEPTH: S;,)
6. DOES WELL REPLACE EXISTING WELL? YES❑-NO-
7. STATIC WATER LEVEL Below Top of Casing- _el FT:
(Use-e if Above Top of Cuing)
S. TOP OF CASING IS�_FT.Above Land Surface*
-Top of cuing termluated attar below tax&surfaa requires a .
varlancc to accordance w1tbTBANCAC3C.o1IR .
9. YIELD(gpm): _-3_METHOD OF TEST_ !/
10.WATER ZONES(depth): qi 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 Di or Weiom. Ma numbers and common road names.
From�To�FL ki4 $jj -
From To FL
From To Ft
13. GROUT: Depth Material Method -
From_Q_To_c�&_FL n- ,!]• _
From To FL
.4. SCREEN: Depth Diameter Slot Size Material - - -
From To FL (n. in.
From To Ft. in. in. a
5. SAND/GRAVEL PACK: N
Depth Size Material
From To Ft. I
From To Ft. - Ln t
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCB WITH 15A NCAC 2C,WELL
'ONSTRUC HON STANDARDS,AND TH�AT/A}COPY OF/� S RECORD BEEN P40VIDED`TO THE.WELL OWNER
I I I 1 ��
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Servlee Center-Raleigh,TiC I
0'7699-1636 Phone No.[phone],within 30 days. - GW-I REV.07n001 --

WELL- CONSTRUCTION RECORD' 310505
North Carolina-Department of Envirorunent and Natural Resources-Division of W stet Quality-Groundwater Section /-
WELL CONTRACTOR(INDIV•lDUA.Q-NAME (prlan-Sly ril IS J S _�L1irind. CERTIFICATION# 1 le
WELL CONTRACTOR COMPANY NAMO ' PHONEi .�.5'�I.4-'3 ;.Co
STATE WELL CONSTRUCTION PItRM17Y ASSOCIATED W ERMITO -
(ifappl(able) - {(fapplicable)
1. WELL USE(Check Applicable Box)rResidential' unicipaUPublic❑ Industrial O Agricultural O
Monitoring O Recovery O' Heat Pump Water Injection O Other 17 If Other,List Use
2."W WELL LOCATION: _ o p-idII d selling
Nearest Town: County r�/ c +Y( � ge OSlope �Veltey .OFlat
Z Lk 1 S - HA Af 1Y f4 ()Y'-t'� .�h / n �� (cback appmpdate box) . %
(Street Name,Numbers,Crom' muni y,Subd(viaion,Lot Iles,Zip Code) L9titudenORgitude of well location
3. OWNER4 Q-1 t✓ (1)P, 1 b LL C- h- E 2 (degtaaalmitmretheconda) .
Address =_En5 s• C')0 FCL v.D 2- n t-- Latitude tingittide source:OGPSOTopographic map
(Strect or Route NQ _ - -(check box)
(Ir�lt+Iel( _r� f.. 33@� DEPTH DRILLING LOG
Town suu Zip Code From - To ' Formation Description
,
Area code-Phone amber )` 3
4- DATE DRILLED —/ Z 3 7 p' /f•`c! R L L'P C l2 a I, : 7 ¢�
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7_ STATIC WATER LEVEL Below Top of Casing:
(Un-t-if Above Top ofCuins)
S. TOP OF CASING IS�_FT.Above Land Surfaces
'Top of cuing termtuated atlor belay landsurface requires a -
varlanu In accordance with-MANCAC 3C.0110.
9. YIELD(gprp):_��14SBTHOD OF TEST
10.WATER ZONES(depth): /lr 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
Depth Dia ter or Wei�hVFt -Ma numbers and common road names.
From--L— ��` FJ=S-DRA , Qfell
From To FL
From To_Ft._
13. GROUT: Depth . Material Method -
From To�Ft.... 0
From To Ft.
.4. SCREEN: Depth Diameter Slot Size Material a
From To FL in. in.
� r9
From To Ft. in. in. Iv
5. SAND/GRAVEL PACK:
Depth Size Material O Y
From To Ft, Ln
From To Ft. A
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL '
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P$OYIDED TO THH.WELL OWNER,
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
-`ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ralelgi*' i
a'7699-1636 Phone No.[phone],within 30 days. GW-1 REV,qin061 --"=-"--'
- r

310504
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACI'OR(INDIvIDUAL)'NAME (pdaO c &.rl P'I1S ' Jl"2.±..rl. ce�•1•�tc,�T(oNr J171p
WELL CONTRACTOR COMPANY NAM PHONE a 4-'3 ab a
STATE WELL CONSTRUCTION PJRM17Y w.acOCGTED W ERMITa -
{if applicable) • -(if applicable)
1. WELL USE(Check Applicable Box):Residential' ut icipal/Public❑ Industrial 17 Agricultural Q
Monitoring O Recovery O' Heat Pump Water injection❑ Other C7 If Other,List Use
2. WELL LOCATION: Topogtapbt d setting
Nearest Town: / Li CountymiQ ElRidge pe- Walley .OFlat
G q Cc Lis L' P_ (chock appmpdatebox) . . %
(Street Name,Numbers.Community,Subdivision,W No.,rrp Code) 'r" Latitude longitude of well location
3. OWNER:_I—Q-20(u m02 92S (degtees)miautetha:onds)
Address / 4.3 —tte n W : t 1 fl 0 LatitudeJlongitude souroe:00PSOTopographic map
(Sues a gouts No.) (cheek box) .
Fn on i, is tJ N t"� F`13 DEPTH DRILLING LOG
chy'«Town suu - zip Code From TO ' Fo(mation Description
Ama codb Phone numbs .�^ !� S ' - '— £
4. DATE DRILLED //—t1�
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O-NO
7. STATIC WATER LEVEL Below Top of Casing: A-O FT:
(Use"e if Above Top of Casing)
8. TOP OF CASING IS-_ I —FT.Above Land Surface'
-Top of cuing terminated attar bdgvr Isad.surOta requires■
variance In accordance wltbl9A7fCAC 3C.0111.
9. YIELD(gprp): METHOD OF TEST-A
10.WATER ZONES(depth):
IOCATION 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
Dep Diapeter S or Adopt ' ntimberg and common mad names.
From To © Ft C;.
From To Ft •
From To Ft
13. GROUT. Depth Material Method
From To_C�D Ft. 0 �]/D,f�
From To Ft. f 3 ' g
.4. SCREEN: Depth Diameter Slot sin Material
From To Ft._in. in. tv
From To Ft. in. in.
S. SAND/GRAVEL PACK: o
Depth Size Material Qn
From To Ft. - -
From To Ft. - -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrm ISA NCAC 2C,WELL r�
'ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD BEEN P40VIDED TO THE WELL OWNER 1
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
1'
submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 1a0']699-1636 Phone No.[phone],within 30 days. _ OW-1 REV.07/2001- -"

WELL CONSTRUCTION REC,(o�RRD 310 5 0 3
North Carolina-Department of Environment and Natural Resources.Division of Water Quality--Groundwater Section
WELL CONTRAC-ron(INDIV•ID (pelot)UAL)WAME e tS Pt[ ,� CP.IETIFICATlON Y o1�7 _
WELL CONTRACTOR COMPANY NAM � _
__ - PRONRi�j_�-3 ;.(, O
STATE WELL CONSTRUCTION IOMPZItMUs - • eOC(ATRD W BRMM -
(ifapDlitable)
•(ifapplicable)
1. WELL USE(Check Applicable Box):Resident'iel• unicipal/Public 0 Industrial❑ Agricultural❑
Monitoring 0 Recovery 0. Heat Pump Water Injection❑ Other C( If Ot)ier,List Use
2.-WELL LOCATION:
Nearest Town:_E,f A&l LL; n/ County Q .yu T P is im setting
�n!L !_ F� e%S C i2 ev b a 1 �� Gwi ge ❑Slop* OValley .OFlat
(Street Name.Numbers,Co mnuni&.Subdivision,lot No..Ziip Code) (chock appropriate box) a .
Witude/longitude of well location
3. OWNER:_- J II 'r1
Address (doateea/miputeYaeconda)
(sues Rol N Latitude/longitude 3MUC :OOPSOTopographic map
1=�za�,�/� ) �= � DEPTHH ( box)
r_city or Town Slue Z• �e DRILLING LOG
(X q L< < , From TO Fomution Description
Arta code Pbone number _
4. DATE DRILLED
S. TOTAL DEPTH: i' ' (n n t, 2 ` 4 ti `
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO.
7. STATIC WATER LEVEL Below Top of Casing: 7ZI —n;
(Uaa"1•'if Above Top of Casia�
8. TOP OF CASING IS_� FT,Above Land Swface*
*,top of easlsa tarealasted atfor belay Isud.aurfaee requires a
variance In accordance withItANCAC 2C.*11a.
9. YIELD _[ i(fE�HOD OF TEST
ZOO
10.WATER ZONES(depth): I
11. DISINFECTION:T c LOCATI_ ON SKETCHH
yp Amount Show direction and distance in miles from at least
12. CASING: Depth
Wall Thickness two State Roads or County Roads.Include the road
D,,iizap1zt��er or Wei t/PL 'Ma I numbers and common road names.
From
_0—TZLD—
From t-__ a.
From To—Ft,
13. GROUT: Depth Materiel Method
From_Q_To D Fc Ft... �'' "
m�� )
From TO 1".4. SCREEN: Depth Diameter Slot Sim Material
From To F[,_ hL in. v
From To v
Ft. in. in. �
5. SAND/GRAVEL PACK: N j
Depth Size Material -
From To Ft o '
From To FL ut
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I
ONSTRUCTION STANDAR Sp NCAC 2C,WELL
DS,AND THAT A COPY OF S RECORD BEEN PROVIDED TO THH.WELL OWNEtt_ = I r
IV
�,�" f. 7 S C i4
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
,rubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-R '-a%699-1636 P sleigh N ,
hone No.[phone],within 30 days. GW-1 REV.07/2d01 -

♦r sraJSJ a.vi..a a �,� "'
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)
?. WELL USE(Check Applicable Box):Residential ElMunicipal/Public ❑ Industrial ❑ Agricultural C
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. i
LL LOCATI Topographic/Land setting
iestTown: County V ORidge ❑Slope OValley 0Flat
fM (check appropriate box)
1 Latitude/longitude of well location
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
3. OWNER: (degreesiminutes/seconds)
Addr as Latitude/longitude source:OGPSOTopographic map
treet or Ro No.) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To t Formation Description
(�8 ) �7- O p �p.� clay&sand
Area code-Phone number
lei
granite
4. DATE DRILLED
5, TOTAL DEPTH: r
6. DOES WELL REPLACE EXISTING WELL? YES O NO ❑
7. STATIC WATER LEVEL Below Top of Casing: A00 FT.
(Use"+"if Above Top ar 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.0115.
9. YIELD(gpm): a D METHOD OF TEST BLOW
10.WATER ZONES(depth): —LOCATION SKETCH
Show direction and distance in miles from at leasthf
11. DISINFECTION:Type H T H Amount 16 oz two State Roads or County Roads.Include the roag
12. CASING: Wall Thickness
Depth DIametar or Weighblct. M teria numbers and common road names. -
From 0 To . Ft. �� Ci
From To Ft. Nei
From To Ft. C!1
13. GROUT: Depth Material Method O
From 0 To 20 Ft. eenonits a cement pumped Ul
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 AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTIONS D S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA 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 " -
N
N ' _

♦r 1 11V1l 1\l:� Ai I l \✓l/ ' y 3
North Carolina Department of Environment and Natural Resources-Division of Water Quality "21
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
Neare Q County AGDtJ []Ridge ❑Slope ❑Valley ❑Flat
ll.TM (check appropriate box)
(Street Name,Nu m mbcn,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location
J3. OWNER: A%o S'rxtnf, ) (degrees/minutes/seconds)
Address -PA-'RCY I f„c47 Latitude/longitude source:❑GPS❑Topographic map
((�- (Street or Route No.) (check box)
Fa-AtoYrLJ%% NC �Rl3y DEPTH DRILLING LOG
City or Town State zip Code From s Formation Description
0 clay&sand
Area code-Phone number granite
4. DATE DRILLED 3' O�J
5. TOTAL DEPTH: 1 AO r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(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): I eti METHOD q,F1T T BLOW
10.WATER ZONES(depth): 9!5' 4 ITy 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 tameter or Wei ht/Ft. ater numbers and common road names.
From 0 To_Q0 Ft. �,� ,185
From To Ft. 19
From To Ft. 0
Method
13, GROUT: Depth Material
From 0 To 20 Ft. Benonite&cement pumped �O
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material IV
From To Ft. in. in. Cn
From To Ft. in. in. CAA
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 STAND S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
9-J`GJ4ATURECF 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 I
y7

l
YY L' LL 1.V1\J 111V 1.11V1\ 1\L` l.V1W o 37
I"
North Carolina Department of Environment and Natural Resources-Division of Water Quality el
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
Nearest Town:ALLM County CO 0 ❑Ridge ❑Slope OValley ❑Flat
ny99 f1 mou— (check appropriate box)
(Street Name,
^Nlummbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: i \ 1006 U.�.. (degrees/minutes/seconds)
\ ,S
Address ' '� Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or Town Suit Zip Code From To f Formation Description
(ems_ l IQb 3��$ 0 51 clay it sand
Area code-Ph'o1n-e number ccam+ 0. clay
granite
4. DATE DRILLED " 1' 16-05
5. TOTAL DEPTH: 1 \no,
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:_ 1050 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-with 15A NCAC 2C.0118.
9. YIELD(gpm): L S METHOD OF TEST BLOW
10. WATER ZONES( ptth)�: 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. t ial numbers and common road names.
From 0 To61 Ft. " C
From 3' rTo lob Ft. Le" i
From To Ft.
13. GROUT: Depth Material Method `":t
From 0 To 20 Ft. Benonite&cement pumped iV
From To Ft. 'J
14. SCREEN: Depth Diameter Slot Size Material C
From To Ft. in. in.
From To Ft. in. in.
15. S A N I1/`G`P_,A V E L 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 S,AND THAT A C PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER-
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-I-REV.09/2004
iv
cam''
0
- cn

C^ �� 311 � Ei �3
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Na,�al Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) I T��(7�M/,� -L CERTIFICATION# �J/
WELL CONI RACPOR COMPANY NAME A trCC 1 6N 05 PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residentialer'Municipal/Public ❑ Industrial ❑ Agricultural❑ 1�
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATP2,L Topographic/Land si�tting`.,
Nearest Town:� ' County Q-" ❑Ridge ❑Slope ❑Vallery bFlat —
(check appropriate box) I.
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well a L)
3. OWNER: 2('S
( g) / de rees/minutes/secondAddress . 0 / � Latitude/longitude source:❑GPS❑Pap4raphic map[or Ro to No,.) � /! (check box)!� /kJ�. o� 0io DEPTH DR 'L:ING LOC,.--------�
City or Town state Zip Code From To Formation Description
O
Area code-Phone number 4
4. DATE DRILLED �34-o5�
5. TOTAL DEPTH: ZM
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:_3 _FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT. Above Land Surface* ..
*Top of casing terminated at/or below land surface requires a
variance in accordance�s j[h 15A NCAC 2C.011B. -
9. YIELD (gpm): 5 METHOD OF TEST AY
10. WATER ZONES(depth): r
LOCATION SKETCH LA .�
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 DiamV r or Weight/Ft. Material numbers and common road names. . _
From To I*-LD Ft. 0 / --
From To Ft. ' ,g:'..---- "
i
From To Ft. �' rn
13. GROUT: Depth Material Methody
From l7 To �FL_� -<
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
'j 1 25
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material �:� _ lrt7
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
'S 5
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 3111
North Carolina-Department of Environment and Natural Resources-Division of Water Quality- Groundwater Section
����j
WELL CONTRACTOR(INDIVIDUAL)NAME
++((�print) �4L/� OA 0,� CERTIFICATION��AZ_/ /
WELL CONTRACTOR COMPANY NAME l."/>cN A- PHONE # b �b
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
_. (if applicable) (ifapplicable) --
1. WELL USE(Check Applicable Box): Residential-a�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
I
2. WELL LOCATION;- Topographic/Land setting
Nearee/stt�Town. County J ❑Ridge ❑Slope ❑Valley ❑Ebt
(check appropriate,box) 3i
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of welt location r
3. OWNER: t t/ol� �SWS (degrees/minutes/seconds)
Address fq, Z -sic l'%rc% Latitude/longitude source:❑GPS❑Topographicmap
,�1 (Street or Route No.) (check box)
QJ[c y N C- J � d.3 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: tg 85-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: �d FT. _
(Use"+"if Above Top of Casing) d
8. TOP OF CASING IS_�FT. Above Land Surface*
-Top of casing terminated at/or below land surface requires a fo3
variance in accordance with 15A NCAC 2C.m 18. -"'
9. YIELD(gpm): �J —METHOD OF TEST,k le-
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
er or Weight/Ft. Material numbers and common road names.
From__To Ft._ _ UG
From To Ft.
From To Ft.
r_
13. GROUT: Depth n _Material Method -
From To 0- 7 Ft. t C
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
CON
7UCTION 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 3 1 1 1 6 5
North Carolina-Department of Environment and Aur/a'l Resources- Division of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAh1E/(Jpr_i�t) I irL/c d�mp&f CERTIFICgATION
WELL CONTRACTOR CONIPANY NAINIE)� S, PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERNIII'#
(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
i
2. WELL LOCATIO Topographic/Land setting
Nearest Town: /7�—Countyae' 12 ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box) _ -
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:ILgArU �GCI#VC��f (degrees/minutes/secodds) —
Address �— Latitude/longitude source:❑GPS❑Topographic reap
(Street or Route No.) (check box) --
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number —
4. DATE DRILLED a-a3--05� 5:f
5. TOTAL DEPTH: 5__
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: AFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS—L—FT.Above Land Surface* S
"Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): f METHOD OF TEST ✓ _ `}
10. WATER ZONES (depth): _ m
LOCATION SKETC)
11. DISINFECTION: Type Amount Show direction and distance in miles from A east
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diam ter or WeighbTt. Material numbers and common road names.
From To �� Ft.
From To Ft.
From To Ft. -_
13. GROUT: Depth Material Method
From O Tow Ft.� --- L_7 ( - ,
From To Ft. f l
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft, in. in. m - --
15. SAND/GRAVEL PACK:
Depth Size Material o
From To Ft. 7; f l
From To Ft. h-: ---_
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
; 1,;v ( 4r'_- 3 '�=cam
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Afail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORDO1 311164
North Carolina-Department of Environment and Na ralResources-pDivision of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMES (print) pzt/ f CERTIFICATION Ill( /�/J/
WELL CONTRACTOR COMPANY NAME PHONE p
STATE WELL CONSTRUCTION PERMIT!! ASSOCIATED WQ PERNIITN
(if applicable) (if applicable) i
1. WELL USE(Check Applicable Box): Residential.O_Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use
I
2. WELL LOCATIO Topographic/Land setting
Ne estT/ wr �/. County,rnA1r_AW ❑Ridge ❑Slope ❑Valley ❑Flat
9V�l' A_ (check appropriate box) "
($9treet Name,Numbers.Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: .t,t1( �-GY (degrees/minutes/seconds)
Address ? 6 AZ4 16 3 Latitude/longitude source:❑GPS❑Topographic map
(Street Rout,Ncl (check box)
Vd At _ 2 Q b L DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATEDRILLED
5. TOTAL DEPTH: -6_-5__
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: a/�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 accords a with 15A NCAC 2C.0118.
9. YIELD(gpm): u METHOD OF TEST, V
10. WATER ZONES(depth): a
LOCATION SKETCH_ 5.
I I. DISINFECTION: Type Amount Show direction and distance in milUTrom atl least
12. CASING: Wall Thickness two State Roads or County Roads. Include" e road
Depth Dm'i-n,9tp�r or WeightlFl. Material numbers and common road names.
From To FL � wC- _
From To Ft. '
From To Ft.
13. GROUT: Depth Material Method
From To_ Ft.-6�11aP�— �t)kr �- �`
From To Ft.
14. SCREEN! Depth Diameter Slot Size Material = rD
From To Ft. in. in.
From To Ft. in. in. -
15. SAND/GRAVEL PACK:
Depth Size Material {I 1
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
CONS 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-1 REV. 07/2001

WELL CONSTRUCTION RECORD (J A " 3 1 1 1 6 2
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR INDIVIDUAL NAME /7
(INDIVIDUAL) prinQ (J'Agy'L CERTIFICATIONR3 ,7a
WELL CONTRACTOR COMPANY NAME OV1")S �•- PHONE B JP` — V4
STATE WELL CONSTRUCTION PERMITN .ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): ResidentiaFH-�Municipal/Public❑ Industrial ❑ Agricultural ❑ r
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use -.
2. WELL LOCATION: Topographic/Lan`i setiin
Nearest Town: T+ k 1,*J County ❑Ridge ❑Slope ❑Valley ❑Flat
(check approprialq box)
(Street Name,Numbers.Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of III location,,
3. OWNER: J'tjpq A, M'< k Jo+ (degrees minutes/seconds}
Address �"aJ Latitude/longitude source:❑G1'r UTripograpl4Elryap
� •' (Street or Route No.) (check box)
I I H iV k . ty t_ lz:1Y1 3 y DEPTH GRILLING LOG'
City or Town State Zip Code From To Formation Description
Area code-Phone number
-4. DATE DRILLED_--IS— bS ��—
$�-
5. TOTAL DEPTH: ASS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO f7
7. STATIC WATER LEVEL Below Top of Casing: c2 D FT. y
(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 -Ir _
variance in accordance with 15A NCAC 7C.0118.
9. YIELD(gpm):3-�bq_METHOD OF TEST i _ c
10. WATER ZONES (depth): _
_ LOCATION SKET
1 I. DISINFECTION: Type Amount Show direction and distance in mi es from At least
12. CASING: Wail Thickness two State Roads or County Roads. Include`the road
Depth Di am r or Weight/Ft. Material numbers and common road names.
From D To ��—O—Ft. L
From To FL
From To FL _
13. GROUT: Depth material Method
From � To�Ft.—jr
I✓� ..�� i ` '�'
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From 'L To Ft. in. in. j
From To Ft. in. in. I
0
15. SAND/GRAVEL PACK: 7,
Depth Size Material ';_ f`"I
From To Ft. --
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 04 ACCORDANCE WITH 15A NCAC 2C, WELL
CONS y(CTiIOSTANDARDS,iND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL ��
�,/L_�� 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. G W-I REV. 07/2001

WELL CONSTRUCTION RECORD �) �
North Carolina-Department of Environment and Mural Resources-Division of Water Quality- Gro q nkaterq Se tion
.
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ell_ / zg- CERTIFIC7AT`ION#-JQV;-_//
WELL CONTRACTOR COMPANY NAME CL'ggz�&D-1- L• PIIONE #
STATE WELL CONSTRUCTION PERMITH ASSOCIATED WQ PERMIT#
(if applicable) (its licable)
1. WELL USE(Check Applicable Box): Residential♦Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATI Topographic/Land setting
Nearest Tow : V ..r� County MA&)Al ❑Ridge ❑Slope ❑Valley ❑Flat
i_ A"J (check appropriate box)
(Street Name,Numbers.Com unity,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
3. OWNER: L9-�[ /I i-y (degrees/minutes/seconds)
Address ��Y L(�E;3/¢_['�j,g�.��r1 Latitude/longitude source:❑GPS❑Topographic map
(Street or Rome No.) T� (check box)
✓ ✓ k1,'a/ Nc- cam? $73y DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Area code-Phone number D
4. DATE DRILLED_ — /-
5. TOTAL DEPTH: T.S
6. DOES WELL REPLACE EXISTING WELL? YES NO ❑ r
7. STATIC WATER LEVEL Below Top of Casing: LIZ 6 FT. c 2
(Use,,+,,if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* -5
-Top of casing lerntinated al/or below land surface requires a
variance In accordance with 15A NCAC 2C.at18. :3
9. YIELD(gpm): 42— METHOD 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 II//nn Di a etp or WeighUFt. Material numbers and common road names.
m .
From r7 To Ft. (hJG From To Ft. 7
From To Ft.
13. GROUT: Depth Material/ Method ,
From_Q_To 6 Ft. s�T
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material _ cD
From To Ft. in. in. .,
From To Ft. in. in. o
c
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 NClA02C,WELLI
CON UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO{Thy WELL OWNIE(L -i
L ` /� q
SIGNATURE OF PERSON CONSTRUCTING THE WELL
4
Submit the original to the Division of Water Quality,Groundwater Section,1636 k1a11 Service Qeattit-RaW,N
27699-1636 Phone No.[phone],within 30 days. ,G�1 REV. 07/2 1, 'I

WELL CONSTRUCTION RECORD C0 3111 6 1
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prints), •7C-�pd ( -/A'/l e- CERTIFICATION!!y
WELL CONTRACTOR COMPANY NAME C`HYUe �U Y(D 5� PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATI Topographic/Land setting
Nearest Town, 1'A County-X6��r— ❑Ridge ❑Slope ❑Valley ❑Flat
—nth 3(moral JA4L IJ[L (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ROnJ tkf)C (degrees/minutes/seconds)
Address a3 2 4D4;e n)U;34e ow Latitude/longitude source:❑GPS❑Topographic map
(Street or Route yo.) (check box)
_ III N L co8735� DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(—)
Area code-Phone number p.t
4. DATEDRILLED ?-3-D5
5. TOTAL DEPTH: X�3 -b
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:�U y 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.01I8.
9. YIELD(gpm):_Z METHOD OF TEST 41'r _
10. WATER ZONES (depth): _ - -
LOCATION SKETCH -a
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 Di mt r or Weight/Ft. Material numbers and common road names.
From To V _Ft. _ c-
From To Ft. _
From To Ft. _
13. GROUT: Depth Material Method
Fromm To -L6 Ft.�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. - - LO
From To Ft. in. in. _
15. SAND/GRAVEL PACK: v
Depth Size Material
From To Ft. -- - -
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELI I .
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO 7HE WELL©WNE
SIGNATURE OF PERSON CONSTRUCTING THE WELL i DAI E - -
7 I
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Rale y lC NC�
27699-1636 Phone No.[phone],within 30 days. w I REV. 07/20 1 i

WELL CONSTRUCTION_RECORD 3 1 1 N O 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)
1. WELL USE(Check Applicable Box):Residential O Municipal/lrublic❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery Q Heat Pump Water Injection O Other❑ If Other,List Use
2. WELL LOCATI Topographic/Land setting
Nearest Town: 1 County ORidge ❑Slope OValley OFlat
A - ol—, (check appropriate box)
( et Name,Numbers,Com unity,Subdivision,Lot No.,Zip Codej Latitude/longitude of well location
3. OWNER: AVIn (degrees/minums/seconds)
Address -74 4 Latitude/longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
-�` GA 30050 DEPTH DRILLING LOG
City or Town tate Zip Code From �O t Formation Description
(IL-)- !A 21-ZDZA - ' Clay&Sand
Area code-Phone number ' Granite
4. DATE DRILLED • IQ'DS
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: Ib0 T.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface*
*Top of casing terminated aflor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):Z'n —METHOD F TEST BLOW
10.WATER ZONES(depth): 4 Z1'F 91(p' LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads.Include the road,
12. CASING: g numbers and common road names. ,
Depth' [� � Diameter or Wei ht/Ft. aerial .,.
From To Ft. 'f 3C
FromTo Ft. � I �J_
From To Ft. < i!
13. GROUT: Depth Material Method
From 0 To 20 Ft.Senonite&Cement pumped L3
From To Ft. c_n '
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
CONSTRUCTION ST ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-o S
SIGNAJInTE 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._0912004

WELL CONSTRUCTION RECORD CO)
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 Dnlling,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 Topographic/Land setting
Nearest Town: /Counity ❑Ridge ❑Slope ❑Valley ❑Flat
d - (•OJN,(j ho HN12 --Qa-41 (check appropriate box)
( eet Narle,Nu ben,Co ruty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( treet or u e No.) (check box)
DEPTH DRILLING LOG
City
or''T/Iown State Zip Code From T f Formation Description
ewe Y( )- z)- U 0 10 clay it sand
Area code-Phon<numbr• p 00 ' granite
' D 4. DATE DRILLED_ 'OS
5. TOTAL DEPTH: r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Topp9o'�Casi�ng)
8. TOP OF CASING IS 2 FT.Above Land Surface*
-Top of casing terminated at/or below land surface requires a .
variance in accordsg a�'ith 15A NCAC 2C.0118.
9. YIELD(gpm):IU ME OD OF TEST BLOW '--
10.WATER ZONES(depth): ` n" Z('e =-
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 ryryry 1iameter or Weight/Ft. -Material numbers and common road names.
From 0 To Ft. 'r y�� ;
Nc
From=To Ft , �quTgo— v
From To Ft. x
13. GROUT: Depth Material Method W ^
From 0 To 20 Ft. eenonite&cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material t.11
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:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND ,AND THAT A COP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA U 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.
GWW-t REV-,00/7001
I "N

WELL. CONSTRUCTION RECORD
North Catolina-Department of Environment and Natural Resources-Division of Water Quality-Grotmdwater Section
WELL CONTRACTOR(INDIV•1DUALIVAME (print) 1 n-^^ ' CLK7SPiCAT[Or(0 of��
PROIIL a
WELL CONTRACTOR COMPANY NAMIZIew I q la
STATE WELL CONSTRUCTION PERMIT/ - Aa60C'(ATED W ERMM
(ifapplicable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residentisf unicipal/Public O Industrial CI Agricultural Q
Monitoring❑ Recovery ❑' Hest Pump Water Injection❑ Other CT if Other,List Use
2. WELLLOCATI90. Topogla d setting
Nearest Town: L L County []Ridge ope []Valley OFlat
1,7 3 �/ (eAeelt appropriate box)
(Street Name,Numbers,Community,Sufdivisioa,LA No.,Zip Code) Latitudii/longitude of well location
2
3. OWNER: y Y N/Q-h 6 �� (depeealmimnahaonda)
Address Latitudellongitude aource:OGPSOTopographic map
r (Sued or Race NoJ (cbeckbox)
11EPTH DRILLING LOG
Citybr Ttnvn tug zip Code From o - Formation Description
( � S� �t,c �D /
Area Code.Phone mtunber `
4. DATE DRILLED -- "6 S y3' /n e , C U I + -e-
5. TOTAL DEPTH: C=' nn ' e ` ,
6. DOES WELL REPLACE EXISTING WELL? YES 17-NO:
7. STATIC WATER LEVEL Below Top of Casing S FT:
W=-1-if Above Top of C%*V t
8. TOP OF CASING IS FT.Above Land Surface* n'
-Top of using terminated Wor btigw landsurtage requires a
u to
varian in seeordaunwi6SAN TCACIC.011L -
9. YIELD(gpm):�_METHOD OF TEST
10.WATER ZONES(depth): ` e-a
//,S - 1.nCATION SKETCH to
11. DISINFECTION.Type Amount Show direction and distance in miles from at least
12. CASING: Wag Thickness two State Roads or County Roads.Include the road
Depth Dispiew orWe(OUR M numbers and common road names.
From_OL TO A ' FLT(2_•SZR34 .
From Tc FL
From To FL
13. GROUT: Depth .Materiel Method - r —1
From To Ft. -
From Tc FL I -
-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 FL
From To Ft.
6. REMARKS: -
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrM ISANCAC 2C,WELL
1)NSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P90VIDED 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
a`/699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/ 001 .

311837
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 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❑ If Other,List Use
2. WELL LOCATIO `�,��fTopographic/Land setting
Near stTown: County_I&M ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,No ,(Community,Subdivision,Lot N .,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
Sir etor oute .) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From
��_I! r Formation Description
8a c - LumObe, ' ---� f 3L- 0 Clay it Sand
Area code-Phone number e �C � Granite
4. DATE DRILLED 5-1 3'(.3�-�
5. TOTAL DEPTH: --'�GoI
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 1 O
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS r J _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 nOt METHOD OF TEST BLOW
10.WATER ZONES(depth): �- _G�7�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
Depb Diameter or Weight/Ft. terial numbers and common road names. -
From To a
0: Ft. (o n �^.
From ft To t Ft. [o"
From To Ft. �g
13. GROUT: Depth Material Method S ra
From 0 To 20 Ft.Benonite a Cement pumped >.
From To Ft. <N ;.+
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
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 -- 1
CONSTRUCTION STANDARD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER .--
i
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
� I

311836
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Bmwn CERTIFICATION H 2O45
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE H [phone]
STATE WELL CONSTRUCTION PERMIT4 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
Ncares,T wn: County ❑Ridge ❑Slope ❑Valley ❑Flat
( (check appropriate box)
(Street ame, umbers,CommunityN,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /.( t;{9L (degrees/minutes/seconds)
Address t,o ¢ IS__ Latitude/longitude source:❑GPS❑Topographic map
it, or or A"to No.) 3�4 (check box)
DEPTH DRILLING LOG
City or Town Stare��IIpp Zip Code From To Formation Description
(838')- tn7 r�- 177'DiO Clay&Sand ....
Area code-Phone number r1 n/1 t Granite
4. DATE DRILLED 'cat Q,06
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑,,,,....[[[[NO � -
7. STATIC WATER LEVEL Below Top of Casing:_FT. I
(Use"+"if Above Top of asmg)
8. TOP OF CASING IS_ /_FT.Above Land Surface*
-Top of casing terminated aUor below land surface requires a
variance in accordant dh 15A NCAC 2C.011&
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'
two State Roads or County Roads.Include the roaA
12. CASING: Wall Thickness
Depth Di eter or Weight/Ft. M enal numbers and common road names.
From To Ft. n
n
P
From,JKft1ToFt. [n"
From To Ft. tv
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped O
From To Ft. Ul
14. SCREEN: Depth Diameter Slot Size Material .x
From To FL in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN 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

WELL CONSTRUCTION RECORD 3 1 1 8 3 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 # [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
County _ ❑Ridge ❑Slope ❑Valley ❑FlatNeare t Town:S _,
AkA t�d„,4,r4 (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
to Route Np. (check box) -
N DEPTH DRILLING LOG
City or To state Zip Code From T Formation Description
8( 20 )_ � y-,560 3 Clay&Sand
F _ J
Area code-Phone number Granite - -7
4. DATE DRILLED 5 LQ -
5. TOTAL DEPTH: SOO
6. DOES WELL REPLACE EXISTING WELL? YE ❑,CIO'< ! `
7. STATIC WATER LEVEL Below Top of Casing: _- (OU T. I _ -
(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): 1�po+ METHOD OF TEST BLOW
10.WATER ZONES(depth): �Y�UJ�y/ �-
LOCATION SKETCH t. -,�
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at leas[ --..._. ,
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. aten numbers and common road names.
From--a—To Ft.
From To_��FL U'
From To Ft. y
13. GROUT: Depth Material Method 0
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. S
14. SCREEN: Depth Diameter Slot Size Material pt
From To Ft. in. in. N
From To Ft. in. in. t
15. SAND/GRAVEL PACK: 3✓
Depth Size Material Ul
x
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
SIGNATU F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Ralcigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

311834
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)
I. WELL USE(Check Applicable Box):Residential O Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIOp�i.� .1 Topographic/Land setting
Nearest Town: CI7/Vr. A) County_ ❑Ridge ❑Slope ❑Valley ❑Flat
AQ_U c - C'U24 (check appropriate box)
(St et 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
® d'04i eet o4 oute No.) �q�- ` (check box)
� lt•VEC Z�l. DEPTH DRILLING LOG
City or Town Zip Code From TRR t Formation Description
aze - ,5Qq -.5U0 1 ��p `fb Clay&Sand
Area code-Phone number —F-0 i 10 Granite
4. DATE DRILLED -IO`OJ -y
5. TOTAL DEPTH: �r ,-;
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J
7. STATIC WATER LEVEL Below Top of Casing:__ _ T. -�
(Use"+"if Above Top of Casing) y
r�
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): /o O fi ME HOD OF TEST BLOW g
10.WATER ZONES(depth): r , d 4U'
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 ry Diameter or Weight/Ft. Material numbers and common road names.
From__Z To 1 Ft. 1,, _�y _
From / 1 It To � ) FL�� 1� � -
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 FL in. in.
From To Ft. in. in.
D/ _
15. SANGRAVEL 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 S,AND THAT A CO Y OF TIES RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUIZE 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 3 11 8 3 3
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 : Topographic/Land setting
Ne r [ own: . CountyAvfiy, ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers, mmunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address / Latitude/longitude source:❑GPS❑Topographic map
Str ebor Rou No (check box)
e DEPTH DRILLING LOG
��City or Town Bray Zip Code Fr m `Tpgl Formation Description
826 Sln7- /L� Clay&Sand
Area code-Phone numMrt '�{ I .' O Granite
4. DATE DRILLED74
5. TOTAL DEPTH: t
6. DOES WELL REPLAC 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* N I
-Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I. ti ME D OF TEST BLOW
E S(d en
10.WATER ZONE ��b i 5 767 N 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 , Dip�eter or W i hUFt. Material numbers and common road names.
From To Ft. (0'
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.
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 CO OF THIS RECORD 14AS BEEN PROVIDED TO THE WELL OWNER
_ �0
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 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD 18 `{
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (prini) 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
Ne �t,Ty.o�wn: n County ❑Ridge ❑Slope ❑Valley ❑Flat
/XAX y4_F4— (check appropriate box)
Mitreet Name,Numbers,Com uni , ubdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: t .C/14 _ (degrees/minutes/seconds)
Address _ 309 0 UJ0,,Q;FLatitude/longitude source:❑GPS❑Topographic map
)AQ� O�t(Stree[gCRloute No �36I� (check box)
1L/'-' DEPTH DRILLING LOG
City or Tos n Q Atate Zip Code Fro o I Formation Description
628 - SZi "_I�1—I A Clay&Sand
Area code-Phone number O� ' Granite
4. DATE DRILLED
5. TOTAL DEPTH: 3yo _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -
7. STATIC WATER LEVEL Below Top of Casing:aa6 F .
(Use"+"if Above Top of Casing) 1`e9
8. TOP OF CASING IS_ _FT.Above Land Surface*
-Top of casing terminated-it/or below land surface requires a
variance in accordance uh 15A NCAC 2C.0118. 3 —�
9. YIELD(gpm): W METHOD OF TEST BLOW =' -
10.WATER ZONES(depth): 3)$t 33JI P D nT
LOCATION SKETCH r-
11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least y
12. CASING: Wall Thickness two Stale Roads or County Roads.Include groad
Dep Diameter or Weight/Ft. Material numbers and common road names. Yd
From To Ft. ruc
From ft To FL to
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
I--
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY T T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ISA S,AND THAT A C Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
_/ - o�
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 3 11g3 ;
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 LOCATION: Topographic/Land setting
Near TowpiA Cot ty Topographic/Land
❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,N be Community, bdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minums/seconds)
Address 0 Latitude/longitude source:❑GPS❑Topographic map
rn D (Street or Rom No.) I (check box)
DEPTH DRILLING LOG
City or sown State zip code From To t Formation Description
828 - c5ao- �I r�.'� r�" Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED �.J-
5. TOTAL DEPTH: e-�?00
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO fY
7. STATIC WATER LEVEL Below Top of Casing:1FT.
(Use"+^if Above Top of Casing) _
8. TOP OF CASING IS a_, Above Land Surface*
'Top of casing terminated at/or below land surface requires a fV
variance in accordance With 15A NCAC 2C.0118. 7.
9. YIELD(gpm): 15 ME F1 P TEST BLOW
10.WATER ZONES(depth):_ 'J� �]F,(/i
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 160Z Show direction and distance in miles from at]east
12. CASING: Wall Thickness two State Roads or County Roads.Include the road '
Depth Diameter or Wei It L Material numbers and common road names.
r
From To Ft. lD , I�
t,
From ft To Ft.
From To Ft. -
13. GROUT: Depth Material Method I -
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 STANDARD D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/a-D s
-- SIGNATURE F PERSON CONSTRUCTING THE WELL DATE
Submit the original t 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
North Carolina-Department of Envirownent and Natural Resources-Division of Water Quality"-Groundwater Section
WELL CONTRACTOR(INDIVi)UAL)'NAM9 (prlan cbef1P11$ JLIj��, �" CtrJ(2iFICA170ti N o1/7(P
WELL CONTRACTORCOMPANY NAM •' PHONLa 2 �6
STATE WELL CONSTRUCTION PBRMIT/- ASSoctATP.Dw mairro ---(if applicable) ' •(Kapplicable) -
1. WELL USE(Check Applicable Box):1Residential' unicipaItPublic❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0- Heat Pump Water Injection❑ Other ES If Other,List Use
2. WELL LOCATION: . oglapluc/Lnnd setting
Nearest Town: f,2 Q at 11 I;-)J County Midge Mop Malloy .Mist
d /✓ ; dd e > Ct a1 v 3 (Chcek appropriate box) ^ a
(Street Name.Numbers,Community,Subdivision,La No.,zip CO&) Latitude/lotigitude of well location
3. OWNER, Le, e e l t) n S (degrae>JmiauteYseOonds)
Address 6'e e f d u.ti- R d a -e 0- t r c I -e- Latitudellongitude source-OGPSOTopographic map
S 1`• ,(Straat or Route NQ (Cheat box)
C n,(- r/ • '3"�o tgU DEPTH DRILLING LOG
City'Gerawn State Zip Cade From - To Formation Description
P( �9- sv3st !J �3 '
Am code-Phone number
4. DATE DRILLED H --a 5-A S
5. TOTAL DEPTH: 3
Inn J6S, Vf12mjCulat �
�S - 11 � r 37.5' � I u c
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO..
7. STATIC WATER LEVEL Below Top of Casing- Za-5 '-FT; p
(Uta`r if Above T0p of CuhW �e
8. TOP OF CASING IS�_Fr.Above Land Surface* t
-Top of cuing termtuted zor betty Iwdsar(ace regarea■
variance In seeordance althta•ANCAC 2C.0111.
9. YIELD(gpm): 3 Q METHOD OF TEST o
10.WATER ZONES(depth): / '}
• LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance In[[tiles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di" or WeightlFL -matey'p1 'numbers and common road names.
From _To // FL k�� 51821 Nr"
From To FL -
From To Ft.
13. GROUT: Depth MFrom
aterial Mellmd - -
From—LTo FL no4 T
.4. SCREEN: Depth Diameter " Slot Sim : Material -
From To FL in. in.
From To Ft. in. in. -
S. SAND/GRAVEL PACK-
Depth Size Material -
From To FL
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TtqSRECORD 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 Servlee Center-Raleigh;NC -
d07699-1636 Phone No.[phone],within 30 days. OW-1 REV.07l2001

WELL CONSTRUCTION RECORD'
North Catolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV,mUAL)'NAass: aos��ll pllS /inI a.A, : �TtCATIONt: KI'1
WELL CONTRACTOR COMPANY NAM PHONE Y1yLV_' Sq'4 3 ;z
STATE WELL CONirrituCrlom PBRM17y - __-ASSOCIATED)Y EItIHl7•i
(if applicable) •(if spDlicable)
1. WELL USE(Check Applicable Box):Residential' w&ipal/Public O Industrial❑ Agricultural(J
Monitoring Cl Recovery O- Heat Pump Water Injection O Other U If Other,List Use
2."WELL LOCATION: / To hiclLand setting
NearestT�ppurn: �Q/} ( IeLI �l/ County-L� � �
��S N E I -A d s/v n� nc� 1°g° OSIO Malley l7Flat
k T.3 (theca appropriate box) i
(Strew Name•Number,Community,Subdivviision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: C {7 Q P- t A IJ I r 42 R i'1
Address Q (dearees)mitt tmstaaotuis)
a �%f ! �,4i� R 1� i 12 ! e Latitude/longitude source:OGPSE]Topographic map
(Street or Route� No.) (check boat)'C I ' 73 DEPTH DRILLING LOG
City or Town state Zip Cade From To - Formation Description
Area code.Phone nurnbu
4. DATE DRILLED -41 -,,�L RI Z teem ;
5. TOTAL DEPTH: 4D. ' t
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO-
7. STATIC WATER LEVEL Below Top of Casing-. /.SO FT;
(Uu"f'if Above Top ofCuing)
S. TOP OF CASING IS�_FT.Above Land Surface* l
•Top of cuing terminated War belaw lead.surfus requires a -
variance to aceordaut MtiT?ANCAC 3C.0118.
9. YIELD(gprn):•�_METHOD OF TEST o
10. WATER ZONES(depth): Saco'
LOCATION SKETCH
11. D(SINFECTIONJype Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diapieterk or we�tm. 'Ma��- numbers and common road,tarns.
From To��Ft M�� n
From To Ft.
From Tp Ft.
13 GROUT- Depth . Materiel Medwd .
From
From—To ' FD now
A. 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 CONSTRUCTBD IN ACCORDANCE w1TH 15A NCAC 2C WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD HM BEEN PROVIDED TO THE.WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-s'ubmiI the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
ed'7699-1636 Phone No.[phone],within 30 days. OW-1 REV,O7/001

WELL CONSTRUCTION RECORD 310753
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (prlmt) DAVID F. MCKINNON CERTIFICATION Al 2411
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP CO.,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# --- -
(if applicable) (if applicable) ' --
. i
1. WELL USE(Check Applicable Box):Residential)8( Municipal/Public ❑ Industrial❑ Agricultural C]
Monitoring❑ Recovery ❑ Heat Pump Water nlection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
I
Nearest Town:ANDREWS County MACON Midge ❑Slope ❑Valley 13Flat
LITTLE CHOGA RD,THEN 1ST RD TO RIGHT (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location -
3. OWNER: MARY LOU HAYES C/O RICKY BARNARD (degrees/minuteslseconds) - -----
Address P.O.BOX 1241 Latitude/longitude source:❑GPS❑Topbgrapbic map
(Street or Route No.) (check box)
ANDREWS NC 28901 DEPTH DRILLING LOG
City or Town State Zip code From To Formation Description
8( 28)-321-4133 0'TO 10' FILL DIRT
Area code-Phone another 10'TO 30' BROWN DIRT/BOULDER
4. DATE DRILLED 04/28/2005 30'TO 80' RED DIRT
5. TOTAL DEPTH: 405' 80'TO 90' BOULDER
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 90'TO 120' BROWN DIRT
7. STATIC WATER LEVEL Below Top of Casing: 75 FT. 120'TO 140' GRANITE/SET CA MG
(Use"+"if Above Top of Casing) 140'TO 405' GRANITE
8. TOP OF CASING IS 1 FT.Above Land Surfacea
•Top of casing terminated at/or below land surface requires a _ ti
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 2 METHOD OF TEST AIR
10. WATER ZONES(depth): 360' BIT
SIZE 8.075 cy
LOCATION SKETCH o
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles rounat le
12. CASING: Wall Thickness two State Roads or County Roads.Include the rid
Depth Diameter or weight/Ft. Material numbers and common road names.
From 0 To 140 Ft. 61/8' SDR 21 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method Q L
From 0 To 20 FL CEMENT GRAVITY Lj rrL
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in
From To Ft. in. in
15. SAND/GRAVEL PACK: 4�
Depth Size Material '
From To FL 5� IL
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 PERSO&CONSTRUCT114G THE WELL DATE
Submit the original to the Division of Water Quality,Attu:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No. [phone],within 30 days.
GW-1 REV.09/2004

. 310729
WELL- CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(IND1v,IDUAL)VAMR (print) riVlt j14=A' • CLIkTg cATIom# -
WELLCONTRACTORCOMPANYNAM PHONLf 4'3 �6
STATE WELL CONSTRUCTION PLRMIT/ - ASSOCtATP.D W RRMrra(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residentfal- unicipaUPublic❑ Industrial 0 Agricultural 11
Monitoring 0 Recovery 0" Heat Pump Water Injection❑ Other 11 If Other,List Use
2.-WELL LOCATION: . Twogep end setting
Nearest Town: / L DS County M a n� Midge ope Malley .OFlat
7 tf I (eMek appropriate box)
(Street Name.Namben common ty,^suuaivi.bioo,Lot No.,Zip Code) LatitudeA.ongitude of well location
3. OWNER:KeV : h ` 0-0I2" r _ (degeeJmitwtet/aeeonda)
Address b• B O A i 3 6 Latitude/longittide source:00PSOTopographic map
1 (Sum or Roam No.) (cbeck boa)
14 i t) h 1 D c Al C, a 7 4 / DEPTH ' DRILLING LOG
ci orlown Sum zip code From To Formation Description
5a6 - 09
Area�code.Phone number y'! `O S - - - rJ6• . Ct. : t L
4. DATE DRILLED
5. TOTAL DEPTH: O
6. DOES WELL REPLACE EXISTING WELL? YES D NO._
7. STATIC WATER LEVEL Below Top of Casing:_(ate Fl. M
(U="+"if Above Top of Cuing)
S. TOP OF CASING IS�_FT.Above Land Surface''Top of a
� 1
accordance rrtthlaAl'i CAC 2C.01IL urfact ngakeaa
variance to a - -
9. YfELD(gpm):�^M�THOD OF TEST co
10.WATER ZONES(depth): S +-
LOCATION SKETCH Ul
11. DISINFECTtON:,Type Amount a Show direction and distance in Wits from at least aM
12. CASING: Wall Thiclutess two State Roads or County Roads.Include the road
Depth Dia�prAcr or weighM. `M�ateedal__-numbers and common road names.
From D To�,L FL hL , ;aQ , •tom "w—_ -
From To FL
From To Ft. _
13- GROUT: Depth Materiel Method) -
From--0—To_x2n—FL,�jq
From To FL
-4. SCREEN: Depth Diameter . Slot Size : Material - -
From To FL in. in.
From To Ft. in. in.
5. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCIED IN ACCORDANCE WITH 15A NCAC 2C,WELL
7)NSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD 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 -
a`J699-1636 Phone No.[phone],within 30 days. GW-I REV.07P2001 .

WELL CONSTRUCTION RECORD'
310727
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groimdwater Section
WELL CONTRACTOR(INDIV,IDUAL)NAME (prtut) fly)1 1� ^^ "- CE1�7'iRICATIONY 211
WELL CONTRACTOR COMPANY NAM PNONRa 4�3 a6 a
STATE WELL CONSTRUCTIONPERMrr8 ASSOCIATED W ER'Mrr/ _ --
(ifapplieable) .- - -(if applicable)
1. WELL USE(Check Applicable Box):Residential' unicipaVPublic❑ Industrial❑ Agricultural El
Monitoring❑ Recovaty ❑' Heat Pump Water Injection❑ Other 11 If Otlier,List Use
2."WELL LOCATION: Topograpldd*d setting
Nearest Town: 1 G Ff L. County a t +ra ❑Ridge ❑Slope Malley
�yr— 12f•F L. Q A — h'C m'Fo rac 14�_' (checkapinopriatabox)
3
(street Name,Numbers,Conmtunity,subdivision,La No.,Zip code) Q d-'7'f t Lstitudellongituda of well location
3- OWNER: 0-D m A 10- 04 I1 y S (depeeslminutnlaxoadt)
Address '7 Ro Or-m 1 .60 V 2e I l 5 P- Latitudellongiuide source:❑GPS❑Topographic map
(Street a Route No.) - (check box) -
r t J 1� �/(, a DEPTH DRILLING LOG
Cfty'or Town4-9_ S7� Zip Code From To , Formation Description
n
Area code-Phone number �i '` _ ' i� �-i +-i.: �r
4. DATE DRILLED '7—1 � ­0
5. TOTAL DEPTH: a
6. DOES WELL REPLACE EXISTING WELL? YES 0-NO
7. STATIC WATER LEVEL Below Top of Casing Z FT:
(Use"Y if Above top of Casing)
S. TOP OF CASING IS_�FT.Above Land Surface'
-Top or cuing terminated actor baiter lawl.00rt=requires a - 1...
variance to accordance wltbTYANCAC 3C.01IL wx
N r
9. YIELD(gp a): .5 n METHOD OF TEST,., —�L
10.WATER ZONES(depth): 5 7' , 1416'
LOCATION SKETCH
I I. DISINFECTION:Type Amotmt T,4 Pj Show direction and distance in miles from at least
12. CASING: Wall Thicimms two State Roads or County Roads.Include the road
Depth D' or Welot(Ft. `Matey numbers and common road names.
From ._ D To=�FL S a R X
From To FL
From Tq Ft
13. GROUT: Depth . Me al Method '
From__To_D Ft.- -P= . 1. . - . '
From To—'Ft.-
A. SCREEN: Depth Diameter . Slot Size Material
From To Ft. in. in.
From To F[ in. in.
5. SAND/GRAVELPACY,
Depth Size Material -
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISANCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN P40VIDED 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
a`J699-1636 Phone No.[phone],within 30 days. GW-I REV.O7/ 001

WELL CONSTRUCTION RECORD %' 311297
North Carolina-Department of Environment and Natural Resources-Divisi n of Water Quality-Groundwater Section _
WELL CONTRACTOR(INDIVIDUAL)NANJE (print) blggl / CERTIFICATION# d S 'S(WELL CONTRACTOR COMPANY NAME Sin D/N..IA,S V ? /i�l� PHONE #add) 7fi'a 7rf ;L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) --
r
1. WELL USE(Check Applicable Box):Residential Er_�M_unicipaUPublic❑ IndusVial ❑ Agricultural❑ l __-
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
i
2. WELL LOCATION-
County G AlTopographic/Land setting
Nearest Town: I ❑Ridge lope Malley ❑Flat __ I
(check appropriate box) C
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address 5- vcv(o Lg 1. r f, Latitude/longitudesource:❑GPS❑Topographicmap -
�/ ( treet or Route No.) (check box)
I �f- ?O 3ad� DEPTH DRILLING LOG
City or Town State Zip code From To Fo lion Description
Area code-Phone amber
—
4. DATE DRILLED -
5. TOTAL DEPTH: fe�^ d 7
6. DOES WELL REPL-- EXISTING WELL? YES ❑ NO 6^
7. STATIC WATER LEVEL Below Top of Casing: YDjq T.
r (Use"+"if Above Top of Casing) g---
8. TOP OF CASING IS /, D FT.Above Land Surface'
*Top of easing terminated at/or bdm land surface requires a — `?
variance in aeeorda°��` ,th 15A NCAC 2C.0118. W
9. YIELD (gpm)i METHOD OF TEST
^_ 0-
10. WATER ZONES(depth): C�a p ut
LOCATION SKETCH -�F
11. DISINFECTION:Type.i=J./- Amount Show direction and distance in miles from at least
12. CASING: Wall Thickne two State Roads or County Roads.Include tJte roa�
Depth I)iarpeter or Weigbt/F t. NUterial numbers and common road nam s. w\rr'_t4
From (' To Y Ft.
From To Ft. r
From To Ft.
13. GROUT: Dep al ethod
From b To Ft. a�r
From Ft.De
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
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
CONSTRUCTION STANDARDS,AND T COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O SON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 0 3 1 1 2 9 6
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print), fj[' (,py CERTIFICATION#3 e>S5__
WELL CONTRACTOR COMPANY NAME S ✓r.f PRONE # (766) 7 _37V,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED QQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0 Municipal/Public❑ Industrial ❑ Agricultural❑ r -
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 1
2. WELL LOw / Topogr9bic/Land setting
Nearest To n: /i144 County //'J4Sett ❑Ridge Mope Malley ❑Flat
(check appropriate box)
(Street Notes,Numbers,Community,Subdivision,Lot No.,Zip code) Latitude/longitude of well location _
3. OWNER: / r/rGj�knK (degreeslminuts/seconds)
Address d, r to-q Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box) JLI
�7 rJ DEPTH DRILLING LONG
City or-TownState Zip Code From To Formation Descrip tion
Area codo-Phone nurober O _ 3— S atl
4. DATE DRILLED ��1-/5. TOTAL DEPTH: G< y 7
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO @�
7. STATIC WATER LEVEL Below Top of Casing: (0_� T.
3a
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS / FT.Above Land Surface*
*Top of using terminated atfor below land surface requires a tJ
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): METHOD OF TEST r
10. WATER ZONES((rpth): /a
LOCATION SKETCH
11. DISINFECTION:Type /-/Tt-/ 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 G)Qe /UFt. Material numbgSs arl common rQa{(flames. I f
From To D Ft. '/-S FK4,Jp
From To Ft. ^
From To Ft.
13. GROUT: Depth Material Method
From - Top Ft. �e fi/ancF cprf
From To Ft. Q
14. SCREEN: Depth Diameter o Slt Sie Material
From To Ft. in. in. lti''w 611
From—TO—Ft.—In. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From—To—Ft.—
From To Ft.
16. REMARKS: y) f ��VI�JI
I DO HEREBY CERTIFY THAT THIS WELL WA ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST S, T PY OFjHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA ERSON 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.(919)7333-3221,within 30 days. GW-I REV.07/2001

- 311 � 4'7
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /-
WELL CONTRACTOR(INDIV,IDUAL)-NAM6 (pint) .—OnP11S aCK
T[PICATIONY oZ�7�
WELL CONTRACTOR COMPANY NAM PRONE 96
STATE WELL CONSTRUCTION PHRMnl ASSOCIATED W ERMIT!
(ifapplicable) - - -(If applicable)
1. WELL USE(Check Applicable Box):-Residential• unicipal/Public❑ Industrial❑ Agricultural
Monitoring❑ Recovery ❑- Heat Pump Water Injection❑ Other C( If Other,List Use
2. WELL LOCATION: . TWK
bic/L ind setting
Nearest Town: r/R AA111L'i Al County Q Lem✓ dpg 1pope ❑Valley ❑flat
6 t!- Po t! 5 13 2. 12-,1 ?r7 3 (ebaek appmpriam box) . '
(Street Name,Numbers,Community,Subdivision,Lot No,Tap Code LOtitudanongitude Of Well location
3- OWNER: 21 Q, ✓ VY )t (degtxdmilutaahaonds)
Address =Q, RD K �b 5 LatitudeAongitudesource:❑GPS❑Topographic map
(11 ar Rauu No.) � 1(chock boa)
�f2Qn IC 1,✓U 7 3 DEPTH DRILLING LOG
City«Town Swe Zip Code. From - To Forrroation Description
Area code-Phone number � '` _ - �{,S � In 7 '
4. DATE DRILLED S--S vim ' - (07' 2- dram% .t
5. TOTAL DEPTH: a s
6. DOES WELL REPLACE EXISTING WELL? YES El NO- tj
7. STATIC WATER LEVEL Below Top of Casing-. 7(i -FT: ro
(Use'Y"if Above top of Cuing) y T4
8. TOP OF CASING IS_�FT.Above Land Surface•
-Top of casing termtusted attor below lauaaurha requires■
varianu In accordance wttkTSANCAC 3C.0113. _
9. YIELD(gpm): J C- METHOD OF TEST
10.WATER ZONES(depth): !-S Ln
LOCATION SKETCH
11. DISINFECTION:Typo Amount Show,direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dia or Weigltt/Pt. Ma -numbers and common road tames,
From To�FLh SZ02 Q:K 4r
From To FL
From To_Ft.
13- GROUT: Depth . Materiel Method
From To-gM-FL
From To Ft.
.4. SCREEN: Depth Diameter . Slot Size Material
From Tc FL jrL in. �= _i
From To Ft in. in. 1
S. 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 1SA MAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT ACOPY 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
a'7699-1636 Phone No.[phone],within 30 days. - GW-I REV.07/2001 .

WELL CONSTRUCTION RECORD
North Catolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section)
WELL CONTRACTOR(INDIV.611A. )NAME (print)S�t 11111 S � �In„AAl czl(TFICATIONs /-71e
WELL CONTRACTOR COMPANY NAM '611a411AP60?1C Y�y-'3 ;Z6
STATE WELL CONSTRUCTION-POMIT/ ASSOC(ATED W ERMIT/
((rapplieable) • -CfaPpliable)
1. WELL USE(Check Applicable Box):,Residentl8(- unicipaVPublic 13 Industrial❑ Agricultural 0
Monitoring❑ Recovery 0- Hest Pump Water Injection 13 Other E7 If Oilier,List Use
2. WELL LOCATION: .
NearestTown:�Q AALL:,f/ Cousty-, QGrxJ pD SIopclLMlloting .
&41/)•, Tinj w c !'�(�r t /� re •e e S to,, &4 ._ dge chock po OVaox) .C "R
--r-1 /' !C- (cbeelc appropdak boz) i
at
(St«ct Name,Number,Cor a ounn ry,subt0vision,tat No.,zip Code) 73 f./ Utitude/longitudo of well location
i
3- OWNER, 0 ra 'FAD �/1in ( (desmadmiautra/aaon&) .
Address I A Q I r E .Ati I R q At i i g 2 rt Latitudellongittide source:E3GPSE3Topographic map
�^ (Street ar Roum Na) � u —r (check boot)
!' a 0V I n.� ' /C, o�A � 3 DEPTH DRILLING LOG
City or sown sratc '_ztp Code From To ' Formation Description
�- 3 4� 9 - 8 5R en n '1.1/
Area code-Phone number - , `
4. DATE DRILLED -S =-d I a5 ' .i V-45 t 2 tL wi
5. TOTAL DEPTH: u' $I t, e- r, v am
6. DOES WELL REPLACE EXISTING WELL? YES 0
7. STATIC WATER LEVEL Below Top of Casing .F/5 FP: O
(Ilse"1^itAbovc Top ofCasma) =
8. TOP OF CASING IS FT.Above Land Surface*
c-Top of easing«rmlaated aUor below IMdaurfaa rerequires• (t[1i
variance In accordance wltaTSANCAC 1C.01 IL
9. YIELD(gpm): METHOD OF TEST
10.WATER ZONES(depth): o f'
- LOCATION SKETCH
Show direction and.distance in miles from at least 11. DISINFECTION:Type Amount
12. CASING: Wall Thickness two State Roads or County Roads.Include the road }'
Depth Dispieler or We!ghtIFL -Material 'numbers and common road names.
Fro
C FL
From Tp Ft.
13. GROUT: Depth . Materiel Method - -
From T'— -
From�To'—Ft
.4. SCREEN: Depth Diameter Slot Size - Material
From To Ft. in. in.
From To Ft. in. in.
5. SAND/GRAVELPACK:
Depth Size Material -
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I SA NCAC 2C,WELL-
'ONSTRUCTION STANDARDS,AND THAT A COPY OF TlqS RECORD H&S BEEN PROVIDED TO THE WELL OWNER
&4t Ljo 5-3­0 S
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
a'7699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

• - 31134A
WELL CONSTRUCTION RECORD"
North Carolina-Department of Environment and Natural Resources-Division of Water Quality"-Groundwater Section
WELL CONTRACfOR(INDIVIDUAL)TIA_MB (prtat) he Vll1L5 /L II(LA rl, CEATMCATIONi ELI (P
WELL CONTRACTOR COMPANY NAM 12JC,12 V-3 A6 �
STATE WELL CONSTRUCTION PERMM A3SOC1ATED W gRMM "
(ifapplieable) - (itepplicable)
1. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial❑ Agricultural p
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other C1 If Oilier,List Use
2. WELL LOCATION: . T �iclsnd setting
Nearest Tow/n:� WL i /l� County1 d�Rl g O Fpe Malley .❑Flat
�C�7.3 ( (check opprapdato boz) .
(Smear Name,Numbers,Community,Subdivision,Let Ho„Zip Code) I;atituddlongitude of w.gll location
3. OWNER. (R'F n n CO 1)n 61 1 (de miauteahecandt)
Address 596 11,n ; t*iJ �3 C it ne, I R L at d. itude/longittide source:❑GPS❑Topographic map
�
((S4W a Roue No.) (check boa)12 Qr l I,aJ �t�C gI7 DEPTH " DRILLING LOG
Cityar Town Son; Zip Code From To Formation Description
Arta code-Phone number .(, C
4. DATE DRILLED 7� ' . .3 n —R I U-e, (L f-aa-m ; to--
5. TOTAL DEPTH: ` /) '
6. DOES WELL REPLACE EXISTING WELL? YES❑-NO-
7. STATIC WATER LEVEL Below Top of Casing S�FT: p
((He"e if Above Top of Casiog)
8. TOP OF CASING IS FT.Above Land Surface v 91
-Top of casing terminated at(or belae(IFudsurfaee requires■ _ -4 0
varlum to accordance vritkTSANCAC 2C.0111.
9. YIELD(gpro): 3 METHOD OF TEST r s
10.WATER ZONES(depth): ) q o
LOCATION SKETCH cn
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•" or Weog pt. -Material 'numbers and common road names.
From . TL�,;'2­Ft... . 821 ,.--01 er
From Tc FL
From To_FL - -
13. GROUT: Depth . tvta[eriid Method
From To
From To Ft, i
.4. SCREEN: Depth Diameter Slot Size = Material
From To Ft. in. tn.
From To Ft. in. in. "
5. SANDIGRAVEL PACK-
Depth Size Material
From To Ft. - -
From To Ft.
6" REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTND IN ACCORDANCE WITH 15A NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OFM=,
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
n;'/699-1636 Phone No.[phone],within 30 days. GW-I REV.07/ 001

WELL CONSTRUCTION RECORD 3 1 1 9 9 6
North Carolina-Department of Environment and Natural Resources-Division of Vhter Quality-Groundwater Section
WELL CONTRACTOR(INDiV•1DUAL)NAME (pAonc —P A V1 I czvrimcAnoms o117le
WELL CONTRACTOR COMPANY NAM •PHONs sS�LV—ArZt/ 3 96 0
STATE WELL CONSTRUCTION PiRMIT/ ASSOCIATED W ERhtITa
(ire licable) • -(ifaPPlitutble)
I. WELL USE(Check Applicable Box):Residential'Ld-�MunicipaVPublic❑ Industrial 13 Agricultural E3
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other Cf If Othi List Use
2."WELL LOCATION: . T hidLand seating
Ne rest Town: A`.' County„ ge OSlope Malley�! .ORlat 4 r S -Fe s S e J-)I �� I2 �+_ k�& 3 (e6edc Wmpdato box) . ' 1
(Street Name,Numbers.Community,Subdivision,t.a No,75p Code) Latitudellongitude of well location
3. OWNER: S Cu (? C ?Y/ f1-� (degtxs)miputex/a xonds)
Address D V <5 '7 7 LatltudPJlongittida souroe:OGPSOTopographic trap
(Streeter Route No.) - - - -(epoch box)
y11 L 4 C a . �Ct. DEPTH DRILLING LOG
City or Town J State Zip Code From To ' .Formation Description
Cia
�a.... r-�.
Area code Phone number
4. DATE DRILLED �-/7-0 U L C_ _
5. TOTAL DEPTH: .SD.s
6. DOES WELL REPLACE EXISTING WELL? YES O-NO:
7. STATIC WATER LEVEL Below Top of Casing: .-2n CO FI 13
(Wa"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* r?
'Top of Cuing terminated allw betty iwdsur4[e require,a
aa =?)
po
variance in aecordee vrltbZBANCAC 3C.0118. rri
9. YIELD(gpm): /D METHOD OF TEST
10.WATER ZONES(depth): d'S ' CA
LOCATION SKETCH
11. DISINFECTION:Type Amount 279A Show direction and.distance In miles from at least
12. CASING: Wall thickness two State Roads or County Roads.Include the road
Depth DiepzW or Weiijht/FL numbers and common road names.
From�_To�7 Ft. h- S�,. • Ma0�k
From To Ft
From To FL_
13. GROUT: Depth Material Meihod
From.To�_Ft. nay
From Tc 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 FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P40Y1DED TO THE WELL OWNER
SIGNATURE-OFPERSON CONSTRUCTING THE WELL DATE -
-submit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh;NC -
a'7699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

�J
WELL CONSTRUCTION RECORD 3 ? ? ' V
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (pri1nt) —r��. CERTIFI�CpA�TIION#!T�/ 0
WELL CONTRACTOR COMPANY NAME I f rl I (d,� )fP2�JY1e.(\ ,.�J!"0.v PHONE K V��1 �/%,' Ip
STATE WM CONSTRUCTION PERMTTN ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) NAmmmmmi_
1. WELL USE(Check Applicable Box):Residential,( .Municipal/Public❑ Industrial❑ Agriadtmal❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : Topographic/Land setting
Nee(r/est Town: 104 County- Maeon ❑Ridge 051ope ❑Valley Tat
Cal l��s'C (check appropriate box)
(Suva Name,Numbers,Comrmnity,Subdivision.Lot No.,Zip Code) Latitude longitude of well location r)
n1 5°5'.3S.cl" 0083°aq 143•a
3. OWNER: l 1G. L b f,6 (� � )
Address L4X) Vtuefsyde, nck Latitude/longitude sauce PS❑Topographtc map
r� (Sheet or Route No.) ,J IIcheck box)
1'd7'vt,)_It 1) to)( 2973 DEPTH DRILLING LOG
m Town t—Sty Zip
Code From To Formation Description
ho�U L1993 $ - 300 or �
Area coda}'sae number i t t
4. DATE DRILLED
5. TOTAL DEPTH:— -�
6. DOES WELL REPLACE MaSTING WELL? YESA NO,*
7. STATIC WATER LEVEL Below Top of Casing:_ _FT.
(Use"+"if Above Top of Casing)
g. TOP OF CASING IS I FT.Above Land Surface*
•Tap of caning twWtei attar Mbw In"sprrace requires a -
variance in accardae�`�wiM l5A NCAC 2C AIIA II
9. YIELD(gpm):—] METHOD OF TEST d Qo TCtr
10.WATER ZONES(depth): 90(o LOCATION SKETCH
11. DISINFECTION:Type Gt of i 0C Amount Ct...O Show direction and distance in miles from at least
12. CASING: Wall Thickness u two State Roads or County Roads.Include the road
Diameter or Weight/Ft. Material numbers and common road names.
From��TToth�Ft.OJ2,' 5DR,2j PVC_
From To Ft.
From To FL
13. GROUT: Depth Material Method l i7
From 0 ToA as Ft(/,evil-pn t jP. (��'�' V14(��C�`� n
From ToL Ft K
14. SCREEN: Depth Diameter slot Size Material = 7
From To Ft, in. in. i
From To Ft. in. M. N 79
15. SANDIGRAVEL PACK: C) id
Depth Size Material
From To Ft.
From To Ft. p �//
16. REMARKS: �A :ln a i �j n� ,C � IP I cle 11 ((der �ILeCUI�L C3/r��P/S
I DO HEREBY CERTTFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL .,I
CONSTRUCTION STANDARDS,AND TTjHAATTJA COPY OFF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER `- l ;I
S��'� - �� �1 .
GNA OF PERSON CONSTRUCTING THE WELL DATE -:: -
Submit the original to the Division of Water Quality,Attu:Information Management,1617 Mail Service Ce Rr�
Riddg4,NC 276994617, Phone No.[phone],within 30 days. _
GW-1 R�V.-/2004-" -
rl

WELL CONSTRUCTION RECORD
0
North Carolina Department of Environment and Natural Resources-Division of Water Quality '��
WELL CONTRACTOR(INDIVIDUAL)NAME (prier) J L�1;.� CERTIFICATION%- _7
WELL CONTRACTOR COMPANY NAME 1 tiVr 0Aec L b JeJ 1,(ecA i eJ, TrtL PuoNE x 192U 1 D74'O
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) _
1. 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 Topographic/Land setting
Nearest Town: Ct1✓t� 'tV-\ County { aC-1C")1-) jkticip ❑Slope ❑Valley OFhd
(check appropriate box)
(Street Name,Numbers,Community.Subdivision.Lot No..Zip Cate) LatitudeAougitude of well location
1! 35cia'o�•A" vUoS30'ag 37.R i1
3. OWNER: �Q-Y)Aerj =� L (degrecs/�ta/sxmds)
Address $ Cct,�P 5 e C i v C — Latitude/longitude souuce:C IGPS❑Topographtc map
(Street or Route No.) (check box)
2 9 7-M DEPTH DRILLING LOG
City or Town state Zip Caic From To Formatimg Description
SL 52q- /08,7 n - /no cat I
Area code-Phone number /00 _ 322 _ plm U.rVI (C CC"(n1 '
4. DATE DRILLED 0 5
S. 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�_FT.Above Land Surface'
*Top orwYg tandeared War WNW Jana wrMe regWrs a
variance in acwMrce with 15A NCAC 2CJ9118. /� 1
9. YIELD(gpm):--METHOD OF TEST fC 0 ter;.✓�('
10.WATER ZONES(depth): �5�i 2— 3 i d LOCATION SKETCH
11. DISINFECTION:Type Cif Amount 1 ,2 C tn, 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.TC Materiel numbers and common road names.
From To l d�n Ft. . 10? �� )C�
From To Ft.
From To FL
13. GROUT: Depth Material Method
From_ Tom_Ft� rl}orb tC'- 4-5t-j
From To Ft.
14. SCREEN: Depth Diameter Skk Size Material C
From To Ft. in. in.
From To Ft. in. in. t kg
15. SAND/GRAVEL PACK-
Depth Size Material O
From To Ft. Ln
From To Ft. I
16. REMARKS: M i6410.E� '5 u'Vl,e l c c\tr y)\eA we U.I jer /r CC r7 Seo dy✓, !Ip✓S
5 'ev a1.51 o a
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 HAS BEEN PROVIDED TO THE WELL QWNER r
1
PERSON CONSTRUCTING THE WELL, DATE �- -j
Submit the original to the D}visioa of Water Quality,Attn:Information Management,1617 Mall Service C atcj
z ,f
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. s
GW-I I ZW09/20Q-tCD
i ,�;+ can C

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) )C �gl� t"�ly. 111 ) CERTIFIC�.jA11'ION# x ,�
WELL CONTRACTOR COMPANY NAME_/L l/�1Ft' LA 1`e-f }{(�" �t'1L PHONE # (/ioy �-O
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) 'q,. (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: A y I County M Q i n ❑Ridge ❑Slope alley ❑Flat
. )pr � p6, (check appmIRK—
pnate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latilud0llongitude off well location
3. OWNER: de minutes/seconds)
Address L-00 V00,6, Latitude/longitude source:P(GPS❑Topographic map
(Street or Route No.) (check box)
�fCl,)q L Ln1 Ail! 29731-1 DEPTH DRILLING LOG
City or Town Stale Zip Code From To Formation Description
(�- 31-1R- 3 �/-1 0 - 610 1 _
Area code-Phone number 9 o- q a.A cr._ )w[(z grt SD-t r &{-C n t T e.
4. DATE DRILLED_,/-0.5
5. TOTAL DEPTH:=via ,
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO P(
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(L1se"i"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface'
"Top of casing terminated stlor below land surface requires a
variance in accordance with ISA NCAC X MAS.
9. YIELD(gpm):- METHOD OF TEST - A t i-
10. WATER ZONES(depth): 300 l
LOCATION SKETCH
It. DISINFECTION: Type Amount
�' Show direction and distance in miles from at least
C t II_
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighVPt. Material numbers and common road names.
From To yaD Ft. 6_1, . D
From To FL
From To Ft.
13. GROUT: Depth (7 M11aterialL' Method �ry
FromToAjNto�,Ft.1`rE':1T0rltTL'
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material C
11<1
From To Ft. in. in. Z tg
From To Ft. in. in. l "?
15. SAND/GRAVEL PACK: tV
Depth Size Material O
From To FL c.71
From To Ft. '
16. REMARKS: miq-vie-1
�51' £f Ui StOn
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 _
SIG RE OF P SON CONSTRUCTING THE WELL DATE ,
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-t
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.(?034 ...
JI
j

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION#
_
-' (I'1P�. --✓1_..
WELL CONTRACTOR COMPANY NAME IOC(hP � Id)C5= PHONE # 6i2- n, '(�7�C7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) _ (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaVNblic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 0 If Other,List Use
2. WELL LOCATION: f A Topographic/Land setting
Nearest Town: '"--�1�--1 i n County 7�\0.0 U- �a_ Wdge (check
ppm[]Valley priate OFlat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) v tLatitude/longitude`t of weh location
05-? F,I 5R )inlos3 ,Z7' si-? 1t
3. OWNER: Y Iof CAr (��
Address r' "� '^/) I-lr 11 Latitude/longul source' PSElTopographic map
' (check box)
(Street or Route No.) DEPTH DRILLING LOG
�lCt^' y - o a"87 From To Formation Description
City or Town State Zrp Code r�
W^ui- FnL1
Area code-Phone number ��- =3 QQ
4. DATE DRILLED�f)
—
5. TOTAL DEPTH: 3cc) .per
6. DOES WELL REPLACE FmSTING WELL? YES❑ NOrgi
7. STATIC WATER LEVEL Below Top of Casing:-,5___FT*
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated attar below land surface requires a
variance in accordance with,ISA NCAC 2C.0118. 1
9. YIELD(gpm):_:3 'k METRO_D OF TESTf 1�7G(
10.WATER ZONES(depth): D t OCATION SKETCH
Show direction and distance in miles from at least
11. DISINFECTION:Type (� f✓ Amount two State Roads or County Roads.Include the road
12. CASING: Wall Thickness numbers and common road names.
Depth/(� Diameter or Weight/Ft. Material
From To _ Ft. _
From To Ft.
From Tc Ft.
13. GROUT: Depth Ma enal Method
From_Q )(J_To 1 �Oa1 _
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material '
From To Ft._ia in. W4
From To Ft. in. in. Z
15. SAND/GRAVEL PACK: t
Depth Size Material N z 3
From To
Ft. p =
From Tro Ft. C"
16. REMARKS: I �1CauJ2 �Y PC, w�l IAaTAPs( �iLe1 Sf0\ i' 1L°u
iVL S
5'�y/�}��✓V�S i t�✓1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
p OF PERSON CONSTRUCTING THE WELL DATE t= -
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Man Service C *y -f
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. GW-1 IkV.69/2004-

WELL CONSTRUCTION RECORD 3 1 2 }, A s
North Carolina Department of Environment and Natural Resources-Division of Water Quality ^�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �^.u u u,t A I t ( II CERTIFICpATIION A IX f 7R
WELL CONTRACTOR COMPANY NAME a4r kf l !h.)0. T TiIP!'i'fi✓I1C-'l1� ,fr'If PHONE !! (42�1 ��i C1 'b7y0
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PER6IIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Resideutiai� Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topo phic/Land setting
NreazestTown: County�Lai1_ ❑Ridge A !ope ❑Valley ❑Flat
G-ebn6-fC Le (check appropriate box)
(Strect Name,Numbers,couununrty,Subdivision,Lot No.,Zip Code) Latitude"Ongltude Of well location 1 t
U 35" 08' S�.N'' W0130 it' 617-7
3. OWNER: \1 "s1� (degrmslminuteslseconds)
Address _1p� r^ tr Latitude/longitude source:�GPS❑Topographic map
(Street or Route No.) (check box)
ABC` -)$']3� DEPTH DRILLING LOG
City or Town State r7 r V n Zip Code From To Formation Description
Area code-Phone number �D /a — oZ(off i lR ✓M
4. DATE DRILLED — "L S
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)
S. TOP OF CASING IS + FT.Above Land Surface"
-Top of casing terminated War below laud surface requires a
variance in accordance with 15A NCAC 2C.0118. �t
9. YIELD(gpm):_ (a METHOD OF TEST
10.WATER ZONES(depth): �i a Q / ----- U i OCAITON SKETCH
11. DISINFECTION:Type G1lot i r12 - Arnouat ['it,� 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 I_ Material numbers and common road names.
From
To. FL_(.,.Las
From To Ft. f
From To Ft.
13. Depth
M1t
M�mpFrom0 ToZ�F � 7)it�From To Ft. I , rra
14. SCREEN: Depth Diameter Slot Size Material fV
From To Ft. in. in. rul
From To Ft. in. in.
t!!
15. SAND/GRAVEL PACK:
Depth Size Material z'
From To Ft.
From ^T/(o Ft.
16. REMARKS: MILr,O�� MLCI .tde. \\Pc�, uJel� IICe�ISP� ��ri hers
"DL4ffUis:oyl
I DO HEREBY CERTIFY T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
n
p OF PERSON CONSTRUCTING THE WELL DATE T 'LtiL
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Cent m z �c
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days, GW-1 RE .Yi9 004 r,
:n
r't -
l.._

WELL CONSTRUCTION RECORD W 310 217
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)
;. WELL USE(Check Applicable Box):Residential C' Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nears ITown, County cfflk—� ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
OWNER: L (degrees/minutes/seconds)
3. O
AddrE Latitude/longitude source:❑GPS❑Topographic map
(check box)
1 i (S ee/ypr Route No 3�5�A DEPTH DRILLING LOG
City or Townn Sate Zip Cade
J From To Formation Description
(828 'ObloU 0 clay&sand
Area code-Phone number
p ' aranite
4. DATE DRILLED 3" '�S
5. TOTAL DEPTH: A QQ l
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O
7. STATIC WATER LEVEL Below Top of Casing:�_
(Use'Y'if Above Top of Casing)
8. TOP OF CASING IS 2 FT,Above Land Surface*
•Top of casing terminated al/or below land surface requires a
variance in accords a with 15A NCAC 2C.01IS. BLOW
9. YIELD(gpm): MET OD 0 TFS _
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 r
Depth Diameter or Weight/Ft. aterial numbers and common road names. 8
From 0 To Ft. (o• pit 3:2.
From=To 'J I Ft. Ly_
From To Ft.
13, GROUT: Depth Material Method 03
From 0 To 20 Ft. Benonite g cement pumped O
From To Ft. LF1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft._m. _ 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
1( - 13 .DS
GNATURE OF PERSON CONSTRUCTING THE WELL DATE
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. GW-1 REV.09/2 -
- Z5

3. 08510
WELL CONSTRUCTION REC
��O
�4RD
North Carolina-Department of Environment and Natural Resources-Drvtsion of W •
1, star Quality.-Groundwater Section
WELL CONTRACTOR(INDIV,IDUAL)NAME (prloQ.c 1)-d/1 N IL I „n -1. .41C"TIFICAT,ION Y 21/7�0
WELL CONTRACTOR COMPANY NAMPNONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W BRMITY 1
orapplicable)
(if applicable)
1. WELL USE(Check Applicable Box):Resident'ial'f1—IvlunicipaVPublic❑ Industrial ❑ Agricultural IJ
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other[I If Other,List Use
2. -WELL LOCATION: ,�^
Nearest Town: J� t C,'-H LAA/ Count TopographidLand setting
4LE• TIJ QTLE DpA/� �1Rhi�❑Slope ❑Valley ❑Flat
(check appropriate box) y
(Street Name,Numbenl_,Community,Subdivision,Lot No.,Zip code) Latitude/longitude of well location
3. OWNER:-BD,27 ab
S (degmes)minutes/ettonds)
Address -CQ Tl_ Ve Latitude/longitude source:❑OPS❑Topographic map
G1��7 - (Strttt or utc NoJ
4-4 ke r:!!t Q� (check box) .
c DEPTH DRILLING LOG
ny or"0 J,te Zip Code From To Formation Description
Area code.Phone numbtrr,� 41AI�
4. DATE DRILLED
5. TOTAL DEPTH: 32 S . alpjp t C-.
6. DOES WELL REPLACE EXISTING WELL? YES2 NO
7. STATIC WATER LEVEL Below Top of Casing: 6FT:
(Use"t"if Above Top of Cuing)
8. TOP OF CASING IS—J FT,Above Land Surface* ---------------
•Top of cuing terminated&Vor below laud.surfaee requires
variance In accordance w tb 1SA NCAC 2C'0118 - -- - s
9. YIELD(gpm):_ 1.5 METHOD OF TEST-�L�n (/
10. WATER ZONES(depth): /7n e O
LOCATION K T H
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
FromDepth Diap�eter or Wcott t. Mate ' I 'numbers and common road names.
_To IQ_Ft.___�_ ��.
From To Ft.
From To Ft.
13. From_—GROUT: Depth Material MT etrn� d�
From_ To_a�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 THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL N
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD 1­14tS BEEN PROVIDED TO THE WELL OWNER
0
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's
.71699-1636 Phone No.[phone],within 30 days. GW-I REV. 0712001

308511
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Dmston of W 1 ator Quality-Groundwater Section /�
WELL CONTRACTOR(INDIVIDUAL)NAME (print)s'h-elj h a s ` 1 ..v ri ^ C"TIPICATIO/N s 117 Y
WELL CONTRACTOR COMPANY NAM PHONEY
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W ERMITY 1
(ifapplicnble) .(if applicable) -
I. WELL USE(Check Applicable Box): ResidenCial'O'A•tunicipal/Public❑ Industrial O Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other 5 If Other,List Use
2. WELL LOCATION:
Nearest Town: n/tA/lGL; Count YM � ,, ��� � Topographic/ V setting
+" Midge jr�OValley ❑Flat
6 4W l: II 8 0 12 S e u /Y1- rQ (L Lauer (check appropriate box) i
(Street Name,Numbers,Community,Subdivision,lot No.,Zip Code) 2 g73 LatitudeAongitude of well location
3. OWNER: 1CQ.. Sf RLLi y--'- (d<yraarminute✓saondr)
Address C girls» R • Latitude/Iongitude source:❑GPS❑Topographic map
(Street or Route NoJ / (check box)
admow '�� a ��� 7 DEPTH DRILLING LOG
Qry or sown State Zip Code From To Formation Description
(2W. sfA56_�- '74,i/9 e [ a
3
Arcs code-Phone number
4. DATE DRILLED 3-/—[)-5' _jn3 - t ri va - T-4-
5. TOTAL DEPTH: 'SCcd'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO- �t
7. STATIC WATER LEVEL Below Top of Casing: SP FT. Ps1
(Use"+"if Above Top of Cuing) ,
8. TOP OF CASING IS I _FT.Above Land Surface' 2-Top of cuing terminated at/or below land.surfaee requires a
variance In accordance with ISA NCAC 2C'0118' �7
9. YIELD (gpm): S METHOD OF TEST 1
10. WATER ZONES(depth): eIS'
LOCATION SKETCH
H. DISINFECTION:Type Amount Show direction and distance in miles from at least Ln
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Di'jncter or We• III/Ft. Matep' l 'numbers and common road names.
From To�,�Ft. $ate )9 X
From To Ft.
From To FL_
13. GROUT: Depth - Material - Method_
From Tom_Ft, n�.
From To pt.
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. z
n
6. REMARKS:
N
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL o ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H S BEEN PROVIDED TO THE WELL OWNER moo„
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
$7699-1636 Phone No.[phone],Within 30 days. GW-I REV.07/2001

U-
308512
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of or Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlaq h- t1 r I s !�in, A, •�t C"T[FICATION Y 2Z/'7� .
WELL CONTRACTOR COMPANY NAM PRONE Y yn L/-3 2(0 6
STATE WELL CONSTRUCTION PERMIT#_ wSSOCIATED W ERMIT# 1'
life licablc)
(if ePPlicable)
I. WELL USE(Check Applicable Box):Residential' unicipaVPublic❑ Industrial 13 Agricultural p
Monitoring❑ Recovery O Heat Pump Water Injection O Other Ef If Other,List Use
2.-WELL LOCATION: Topographic/Land nFF
Nearest Town: Court A/1 �GOn ❑Ridge (]Slope alley L]Flat
.S - l d -oLq -P73T (check appropriate box)
m x
(Street Name,Numbers,Commun ,Subdivision,tot No., ip Code) / Latitude longitude of well location
3. OWNER�0..R2an / a7LenAa U,
(degroea)minutWaeconds)
Address l l ?f DYA ra - D,1 Latitudellongitude source:OOPSOTopographic map
(Street or Raut<NoJ �t r - - (check box)
FYZI}NICLiA� itlL r5c6 73 DEPTH DRILLING LOG
City br Town S Zip Code From To Formation Description
(&a)- � c�_ peg 97 a i
Area code-Phone number
4. DATE DRILLED ?-- 3—US �( 7 to
5. TOTAL DEPTH: .ADD
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:_/�-FT;
(Use"+"if Move Top of Cuing) n1
8. TOP OF CASING IS_�FT.Above Land Surface"
-Top of cuing terminated it/or below landsurface reeuira a _
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):_(_�METHOD OF TEST
10. WATER ZONES(depth): /�f� _/�L t
LOCATION SKETCH Co
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
Deptht- Diapieter or We'lliht/Ft. Matey 1 numbers and common road names.
From To Ft. 5 O..Y
From To Ft.
From To Ft.
13. GROUT: Depth Material R MTh
From To�Ft. n0
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 tv
From To Ft.
From To Ft.
0
- o
6. REMARKS: eS
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 --
" a 3 - 3-u s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original-to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
-17699-1 636 Phone No.[phone],within 30 days. OW-I REV. 07/2001

308217
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 I Municipal/PublicX Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO 1: Topographic/Land setting
NnestT wn: T County ❑Ridge []Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community, u ivieion, of o,Zip Code) Latitude/longitude of well location
3. OWNER: (degmes/minutes/seeonds)
Address .0 0 Latitude/longitude source:❑GPS❑Topographic map
treat or ute o.), / (check box)
A/ DEPTH DRILLING LOG
ity or T n state Zip Code From To Formation Description
0( P8 )_ _ ( I— clay it sand
Area code-Phone number /Q� ' granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 100 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): M THOD 44F��T""EST
ES(d BLOW
10.WATER ZONE 40',y�a,1
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._ „ Diyp!�ter or Wei ht/Ft. Material numbers and common road names. I
From 0 To-L//1�`='( Ft. x•• �N�aW/IL a
From To Ft. p
S
From To Ft. 3>•
13. GROUT: Depth Material Method
From 0 To 20 Ft. Benonite 8 cement pumped
f.�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material F'
From To Ft. in. in. _ Ln A -
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
CONST CTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7-l4,05
SIG TURF 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 Nature]Resources-DlvlalOp of W ater Quality-Groundwater Section �-7 "
WELL CONTRACTOR(INDIY.IDUAL)NAMie (print)s��rl V31 /r1'1�.___r. Cxi�TIPICATION a_��('
WELL CONTRACTOR COMPANY NAM _ R i�PHON L/-3 a e,
STATE WELL CONSTRUCTION PJPM1Ta_ - w4gOCCATED W ERMITa
(irapplieable)
` � (ifapplicable)
1. WELL USE(Check Applieable Box):Residential7�htunicipaVPublic 0 industrial Cl Agricultural❑
Monitoring 0 Reeovery 0' Heat Pump Water Injection❑ Other C1 If Oth'er,List Use
2.-WELL LOCATION:
Nearest Town: ;�nr /Yil'!� Li//Counry yv Topograpp.' and setting .
Co 4 L /4rr Z lr a i.4Ci A' ( OlUdge Y°'°Pe OValley .[]Flat
(Street Name.Numbers, -' ---�:4`-Q (eh" appropriate box) ' a
bon,Ctunmuaty,subdivision,tot No.,zip Code)` a-$.7 3�_ LktltUde/IOngltDdeaf well location
3. OWNER:
Address s Iy.3 I %v P IQ -e-ki - D Q aro inutcilrewnds)
LatitudeAongittido
sourcrce;OGPSOTopogrephic map
(Street u Rouu Na) box)
nq- Q ern,, EPTH (check bDRl .IN , OG
Cnyw Tewo Sum. zi Code From To Formation Description
�F7 - 7�S - (p'7S� P �
Area code-Phone ember ^`--�- 7�
4. DATE DRILLED C� -9 -6-5 - - - 1 ci Ij-4
5. TOTAL DEPTH: �_7—
6. DOES WELL REPLACE EXISTING WELL? YES CI NO
7. STATIC WATER LEVEL Below Top of Casing:
_ / ;
(Uaat'" if Move Top of Casing)
8. TOP OF CASING IS C
_�FT,Above Land Surface•
-Top of colas terzntutad stlor bdpty lartd.aurfaae require a o.
variance in aecordana withlSANCAC 1C v1.011L 5
9. YIELD(gprp):- n MBTHOD OF TEST kazwj��
10. WATER ZONES(depth):�?_ / _ )� -u` f Cn c`-
^f4
I i. DISINFECTION:T LOCATION SKETCH
. YPe Amount Show direction and.distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
DeP� y DiapreW S or We�hVFt. `Makp'gl_ numbers and common road names.
From De FL a
From To FL
From Tp FL_
13. GROUP: Depth Material Method
From_ To_ 7D_F '
From Tc
_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 1N ACCORDANCE WITH I SA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H S BEEN PROVIDED TO THE WELL OWNER
SIGNAT IRE'OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center,Raleigh,NC
.:7*7699-1636 Phone No.[phone],within 30 days.
Gw-I REvrasnoai,

WELL' CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACI'OR(INDIVIDUAL)NAME (prletLc��11 P11 1i2,A -
CYJ(TWICATION Y'i y
WELL CONTRACTOR COMPANY NAM PHONE i n q 3 a(�
STATE WELL CONSTRUCTION-PYRMIT! AaSOC1ATED W ERMITs
(if applicable) •(if applicable)
I. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrihl 0 Agricultural El
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other 17 if Ot)ier,List Use
2.-WELL LOCATION: q^ TopographielLand setting
Nearest Town: L i County /t"' QLpx� QM4d�OSlope Walletting t
C Q AIf (n h �0�1 el - P-L) i n h:o��i 5 (4� (chock appropriate bar) ,
(Sued Name,Numbers,Corrhtuni(y,Subdiyi:ion,Lot No.,Zip Code) �a)r7 3 V Latitudellongitude of well location
3. OWNER:(— U rCF 1 ,' le l 1 Address (aeDoa)minue✓aecondr)
1 4Ip rn I d )d -I-Is- � Latitude/longittide source:OOPSEITopographic map
(Sweat w Raw No.)
Oy,PSTV; 2cJ TI • 3 a 5-3 (`hock boa)
City wTown state Z; Code DEPTH DRILLING LOG
( SD) c0[7 _ $(� 9 . _ p From To _Formation Description
Area code.Phone numb" - � _
4. DATE DRILLED - ' ' '—S' ""` i...JyT�--
5. TOTAL DEPTH:_ Lu Is t l I-e C r - t e_
6. DOES WELL REPLACE EXISTING WELL? YES❑.NO.
7. STATIC WATER LEVEL Below Top of Casing:_/("i- -FT;
Me`e if Move Top of Cuing)
8. TOP OF CASING IS_I FT.Above Land Surface*
-Top of cuing terminated at/or belgw Iwdaurfaa nqulru■ "vp
varlance in accordanu with TSANCAC 2C.0131.
9. YIELD(gpm): METHOD OF TEST r_
10. WATER ZONES(depth): I�C, [ Q]
LOCATION SKETCH
if. DISINFECTION:Type Amount - Show direction and.distance in miles from at leash -17
12. CASING: Wall Thickness two State Roads or County Roads.Include the to
Depth Diapicter or We�htfFt. Material numbers and common road names. l
From_ To
From To Ft_
a
From Tq FL
13. GROUT- Depth .Material Method
From_To­C�D_Ft '
From To
.4. SCREEN: Depth Diameter Slot Size ' Material
From To Ft.__in. in.
From To Ft. in. in.
5. SANDIGRAVELPACK:
Depth size Material -
From To Ft,
From To FL -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT11D IN ACCORDANCE WITH 15A NCAC 2C,WELL
ON5 RUCTION STANDARDS,AND THAT A COPY OF TH 'RECORD 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 Mall Service Center-(Raleigh,NC
e;'7699-1636 Phone No.[phone],within 30 days.

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV•1DUAL)NAM6 (prl¢tLc��
CPJ`TIYICATION a •f'
WELL CONTRACTOR COMPANY NAM PHONR 1112 4--$ a•6
STATE WELL CONSTRUCTION-P$RM17Y ASSOC[AT6 W 6RM1Ta
(ifapPlieable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential' unicipaVPublic❑ Industrial ❑ Agricultural Q
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other 11 If Other,List Use
2.-WELL LOCATION:pded� "� To ppic/Ltilld setting
Nearest Town: EK^v�1L '/)l County Y;Wdge ❑Slope ❑Valley ❑Flat
-5'le A.S �� m rn, I J-e a rJ 3 (check appropriate box) '
(StrectiLmoc.Numbers, mun(ty,Subdivision,Lot No.,Zip Code) L&titude/Ioligltude of Well IDCatiOn
3. OWNER:mM4,ntim,e tee L-T-D (degroulmiautalsoconds)
Address / Via eeip Q,k Latitudeflongitudesourcc:OGPS❑Topographicmap
(Street m Ro Na) , / (check box) .
�QlLnILf� /U r���3 7 DEPTH DRILLING LOG
ny or Tow¢ Sate Zip Code From To Formation Description
2 j' 3��, rl/7 9 !.�t
e noxnber
4. DATE DRIAm wdc� LLED G— — UJ� - irn -4��Z a+rt+L
5. TOTAL DEPTH: D s' c
6. DOES WELL REPLACE EXISTING WELL? YES❑ N0: �
7. STATIC WATER LEVEL Below Top of Casing: /o o FT; -14
�
(Use"+"if Above Top of Cuing) _
8. TOP OF CASING IS_� FT.Above Land Surfaces
'Top of cuing terminated atlor be1aM Iwd.aurtsa requires a
variance to accordance wlthTSANCAC IC.OIIL 1.
- - C) -'fi
9. YIELD(gpm):-4 METHOD OF TEST_ t/ a
10.WATER ZONES(depth): l a U"
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
_L_To�FL D $i or Wei' FL `Matey'gl numbers and common road names.
From
From To FL
Front,--To_FL
13. GROUT: Depth . Material Method
From To�FL '
From To FL
.4. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. -
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WEI:L -
ONSTRUCTlON STANDARDS,AND THAT A COPY OF TH S RECORD BEEN Pl OVIDED TO THE WELLQWNER,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh.,iNC
a'1699-1636 Phone No.[phone],within 30 days. GW-1 UV.Of/$,tlpl -
qc..F :.

WELL CONSTRUCTION RECORD
:.j.yy.� , -
North Carolina-Department of Environment and Natural Resources-Division of W atcr Quality--Oroundwater Section
WELL CONTRACTOR(INDlyIDUAL)WAMB (prlonc �nPltS ' ,�I(LA t�. - CYl`TWICCA,TIOON#__9117'1e
'WELL CONTRACTOR COMPANY NAM PHONL a i�'a2sF "3 a•6 Q
STATE WELL CONSTRUCTION PERMIT/ - ASSOC(ATEDW 9R,MUM
(if applicable) ' {if applicable)
t. WELL USE(Check Applicable Box):Residential unicipdTublic❑ industrial CI Agricultural 0
Monitoring 0 Recovery 0' Heat Pump Water Injection 0 Other 17 If Oder,List Use
2. WELL LOCATIO : TopogfapWdL.and tting
Nearest Town: kG i County Midge Valley .Mat
cp� - Sci d gq 3 (�[ (ch@aaPPWP!i*at")
(Strect Na me.Nu m m Comment*,Subdiyirio�n,Im 4,�) Latitude/lotigitude of well location
3. OWNER: I�Ob /"e Y 1 I/ &4d-i 2— (depeea7miauurheands)
Adddrre'ss _E (F C 2a )2.a- Latitudellongitude source:00PSOTopographic map
�� H - -(CbeClt box
.3 '�`" , ' DRILLING LOG
City or own Stale Zip Cade From - Tq ' Fo tion Description
Area code-Phone another
4. DATE DRILLED G�23=0S
5. TOTAL DEPTH,, 0,5`
�9
6. DOES WELL REPLACE EXISTING WELL? YES 0-NO.
rt
7. STATIC WATER LEVEL Below Top ofCuing. .frL: -FT: � -
(Uae W"if Above Top of Gains)
S. TOP OF CASING IS_ FT.Above Land Surface"
-Top of cuing terminated atfor belay laataurface requires a - Cn
variance In amrdsaee wlthTSANCAC 2C,0118. / '- 0
9. YIELD(gpm): 3 0 METHOD OF TEST/2(flI ut
10.WATER ZONES(depth): ,;2/.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
Depth Di" or Wool/Ft. -Ma 'numbetg and common road names.
From To FL 51 RA Q.X e-
From To Ft
From Tp FL_T - -
13. GROUT: Depth Material Method
From_To_C2D_FL T ,r
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 IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OFM=EN
PROVIDED TO THE WELL OWNER
�Yl i%Gf`
SIGNATURE-OF PERSON CONSTRUCTMG THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
e0'1699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of at
Quality-Groundwater Section
WELL CONTRACTOR(INDIY,IDUAL)'NAMB (primt bz 11 P11s 110,A T[FICATIONY �'
! - - --1 ` ' mot,... CAT16 ��r
WELL CONTRACTOR COMPANY NAM _ PUONRip,�•SO � 4-3 �-(7
STATE WELL CONSTRUCTION PZRMhV - A4e.001ATEDW RRMITY
(irappucabie)
{ihpplicable)
I. WELL USE(Check Applicable Box):Resident'iaCra- tvtunicipal/Public❑ Industrial q Agricultural p
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other ET If Ot)ier,List Use
2.-WELL LOCATION: . T phiclLtind setting
C
NearestTown:f,2 JlLl County � c' dgi e Slope []Valley ❑Flat
ltifGS C� { cm2f YLc4 ? F 34� (check appropriate box) '
(Bute[Name,Numben,Ccnnrrkoiry,Suldivuioa,tax No.,Zip Code) LatltudcAongitud0 Of WoII Iocaticm
�Ry
J. OWNER:_ l - i(�_l2 Q ri C.z— IC eS •(degmea7minutWaeconda)
Address I b 9t D IR uftNo) Latitude/longitude source:❑GPS❑Topographicmap
(Staeet a Route Na) � - (check box) '
�t cal P cc�na_ l�I 3 4a DEPTH ' MILLING LOG
C't eM'n Suta Zip Code From To Formation Description
t� �bg- ��
Arta code.Phone amber �... .. , � / . _
4. DATE DRILLED `GS
5. TOTAL DEPTH: D, �-
6. DOES WELL REPLACE EXISTING WELL? YES❑.NO:va 5 v se
7. STATIC WATER LEVEL Below T ofCasin : 1
Top B .�FT:
(Una"t"if Above Top of Casing) �
8. TOP OF CASING IS�_FT,Above Land Surface'
'Top of cuing terminated atlor bdgw lwdaortur require a Z '
variance to accordance withISANCAC 2C.01IL
9. YIELD(gpm): 4L METHOD OF TEST m
10.WATER ZONES(depth): or
LOCATION SKETCH fn
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
FromDepth Dia ter or Wei ht/Ft. -M I ''numbers and common road names.
_To I j�Ft.____ - Q, ' „ �.
From To FL
From To—FL
13. GROUT: Depth Material Method
From -
From To
.4. SCREEN: th -
D°P Diameter 31ot Siu � Material
From To Ft. in. in.
From To Ft. in. in,
S. SAND/GRAVELPACK:
Depth Size Material _
From To Ft.
From To Ft.
L
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF/T�H S•R,EnCORD BEEN PROVIDE/DTO THE.WELL OWNER
l U LX QiGc C� % d
SIGNATURE OF PERSON CONSTRUCTING THE WELL, DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center.Ralelgh;NC
a;'7699-1636 Phone No.[phone],withla 30 days. _ GW-I REV.07/20o1

VL . 132 2
WELL CONSTRUCTION RECORD' :
North Catolina-Department of Environment and Natural Resources-Division of W atcr Quality-Groundwater Section
WELL CONTRACTOR(INDIvIDUAL)-NAMB (print) -e n iol t S W •A .I L '� CIL1tT•IFICATION o l7(,
WELL CONTRACTOR COMPANY NAMWJ)U91I q A01101AA PHONE i r,2U 3 'L6 O
STATE WELL CONSTRUCTION P$RMrr# •aaOCGTE I W . MIT9 '.t
(ifapplicable) (ifaPPlicab;o.
1. WELL USE(Check Applicable Box):Residential unicipaUPublic❑ Ind.,.;;ial C) Agricultural11
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other C7 If Otfiu, List Use
2."WELL LOCATION: r ,)gfephiAand setting
Nearest Town: 0'1f7� Counnty( ❑Ri;. Mope ❑Valley
47 ( S • Q t�p// S�eJ (chock appropriate box) .
(Street Name.Nummbberr,Community,Subdivisi ,Lot No.,Zip Code) Let. ";ongitudeofwc)Ilocahon
1OWNER: /% ki - 1+2 C�,x g oe�minuta aewnds)
Address I D 5 6 (' vn.,, a- .Q ►Z a Latitude/long, U.Je source:❑GPS❑Topographic map
(Street or Route No.) (check box)
Sfa�lz h 2;A° lsze O a DEPTi: DRILLING LOG
City or Towo to " zip code From - Formation Description
Area code-L'LZv- _nunber
So % — .��5
4. DATE DRILLED - / -0 S a h 46 V.Q' �-
5. TOTAL DEPTH: yS ' -3 Z� 112 e- e-
`at
6. DOES WELL REPLACE EXISTING WELL? YES 11-NO
7. STATIC WATER LEVEL Below Top of Casing: .L S 'FT; —
(Un"+'if Above Top ofCuing) --- z ra
8. TOP OF CASING IS_�FT.Above Land Surface•
'Top of cuing terminated atlor belgw loadaur4ca nquh u■ d.
varl"co in aeeord"o,wltb TSANCAC IC AI IL Co
=,r
9. YIELD(gpm): 3. ' METHOD OF TEST _ o f
10.WATER ZONES(depth): SS'r Ln e
It. DISINFECTION:Typo )�KET
YP Amount Show direct d distance in miles from at least
12. CASING: Wall Thies two State R r County Roads.Include the road
Depth Diap ter orweot/Ft. -Mateiial numbers any ..non road names.
From-0—To /7 L;
From To Ft.
From T9 FL
13. GROUT: Depth .Material Method -
From__o_To r;D FFL
L n°
From To
.4. SCREEN: Depth Diameter - Slot Size • Material - - —
From To Ft.in. in. -
from To Ft. in. in.
5. SANDIGRAVEL PACK.,
Depth size Material - -
From To Ft. -. : ..
From To Ft.
6. REMARKS: _
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE': :5A NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF 'RECORD H S BEEN N 'D TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THE WELI DATE
-Submit the original to the Division of Water Quality, Groundwoter Sectlonr 1636 scrvlce Center-Raleigh;NC
a`J699-1636 Phone No.[phone],with(n30days. _ GVr'-I REV.O7/ 00I

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION k 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE it [phone]
STATE WELL CONSTRUCTION PERMIT4 ASSOCIATED WQ PERMIT9
11111111 (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
Nr rest Town• ,� County_ ❑Ridge ❑Slope ❑Valley ❑Flat
�1>t's In (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: zh ',,,n (degmes/minutes/seconds)
AddressAT Latitude/longitude source:❑GPS❑Topographic map
,,
(Sbeptror o�uj�No— - i-�)r`--� (check box)
JAAAI& I N 29 DEPTH DRILLING LOG
City or Town StAte Zip code Fro���rrrttt �/Ip�Tggg Formation Description
Bac -may.number Clay it Sand
Area code-Phone number
4. DATE DRILLED_ �•9.05 Granite
5. TOTAL DEPTH: 16,06 ,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I�
7. STATIC WATER LEVEL Below Top of Casing:_":Zo fT`•.
(Use"+"ifAbove Top of Casing)
8. TOP OF CASING IS eZ 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): WC) ''METHOD OF TEST BLOW
10. WATER ZONES(depth): A&V s 46 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 Diameter or Weight/Ft. Material numbers and common road names.
From To tg(0 Ft. to" �j$ ,8t10
From It To Ft.
From To Ft. +✓
13. GROUT: Depth Material Method L
From 0 To 20 Ft.Benonite&cement pumped Z rw
From To Ft. N rs
14. SCREEN: Depth Diameter Slot Size Material w
From To Ft. in. in. p
From To Ft. in. in. cn
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT TIES 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 OWNERel
5GNAT URE OF PERSON CONSTRUCTING THE WELL DATE
i
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.
GW-I REV.09/2004--,

WELL CONSTRUCTION RECORD z
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 171 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO nn�//JJ Topographic/Land setting
Nearest��To�w��n��: County(Yl(:�,C.t`.'11., ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ,t Aj V l!y(( s/F:/, (degrms/minutes/seconds)
Address 3La a/ Latitude/longitude source:❑GPS❑Topographic map
d4A (Street or Route N (check box)
J(/ ,L), / a87-� DEPTH DRILLING LOG
City or Town Some Zip Code F����rm To Formation Description
828 - . �9rj7d Clay it Sand
Area code-Phone number � � � Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE OWN
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): b METHOD OF TEST BLOW
10.WATER ZONES(depth): 3I[p 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 D'am�ter or Wei t/Ft. at�dal numbers and common road names.
From To1�Ft.�
From�To /D5 Ft. (D„ j
From To Ft. fA
-
13. GROUT: Depth Material Method
From 0 To 20 Ft.Bennie&Cement pumped
From To Ft. C TZ
14. SCREEN: Depth Diameter Slat Size Material Z n
From To Ft. in. in. tV M
From To Ft. in. in.
15. SAND/GRAVEL PACK: e Cll
Depth Size Material "F3
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 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 Cai(er--
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.,09/2004
r- t _

WELL CONSTRUCTION RECORD II`JV7"J
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 LOCATIRL,. Topographic/Land setting
Ne stTown: UAtZ County ❑Ridge ❑Slope []Valley ❑Flat
(check appropriate box)
(Street Name Numbqk 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)
N DEPTH DRILLING LOG
City or Town ./State Zip Code From Formation Description
(NW)- !V.I- Qp Clay&Sand
Area code-Phone number C5 r Granite
4. DATE DRILLED
5. TOTAL DEPTH: � r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Vr
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_ �L FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): . 50 METHOD OF TEST BLOW
10.WATER ZONES(depth): 5 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
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To FL an
From�To�Ft.to I/� 0
From To Ft.
13. GROUT: Depth Material Method �— Z
From 0 To 20 Ft.Benonite&Cement pumped Z a
From To Ft. IV
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. Ln q—
From To Ft.—in. in. C.11 +�
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 NDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -
SION 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

r
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 # (82B)369-9591
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
000000 (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 LOCATION, Topographic/Land setting
Ne I wn: / County_ ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name, tubers Co muniloSubdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
/� ($tr etpr R rte No) (check box)
i31'f R/'' 0 Ale - DEPTH DRILLING LOG
City or Town —State, Zip Code From To / Formation Description
8 - Clay&Sand
Areaa code- number ''// r Granite
4. DATE DRILLED 7
5. TOTAL DEPTH: ,Sao,
6. DOES WELL REPLACE EXISTING WELL? YES 02 NO ❑
7. STATIC WATER LEVEL Below Top of Casing: jCQ T.
(Use"+"if Above Tap of Casing)
8. TOP OF CASING IS_Ai 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;7�EST 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 D' eter or WeighUFt. Material numbers and common road names. r
From To Ft. t PING
From_3Tft:ToFt.��
From To Ft. C
13. GROUT: Depth Material Method Z
From 0 To 20 Ft.Benonite&Cement pumped N
From To Ft. to
14. SCREEN: Depth Diameter Slot Size Material C:) ¢=
From To Ft. in. in. Cn
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
m Fro To Ft.
16. REMARKS:
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
SI N TURE OF PERSON CONSTRUCTING THE WELL DATE I
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Clmer
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV_'09/2004

WELL CONSTRUCTION RECORD 3 0 6 9 9 7
North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (prinq WILLIAM BRADLEY IEWIS CERTIFICATION d 3368 I W
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE N (2291837-8008
STATE WELL CONSTRUCTION PERMITM ASSOCIATED W Q PFRMIT$i
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 11 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: .4Que-J(!. County MACON )[]Ridge ❑Slope ❑Valley ❑Flat
WAYAH RD-IST ROAD ON LEFT PAST BOAT RAMP (check appropriate box)
(Street Namq Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: KENNETH"JACK'HUNNICUTT (degreen/mmuten/seconds)
Address 766 GA HWY 111 Latitude/longitude source:❑GPS❑Topographic map
(Street m Route No.) (check box)
Ivl JLILTf�I E 1 GA 31768 DEPTH DRILLING LOG
City m Town Sate Zip Code From To Formation Description
2(_19_)-985-7841 0'TO 60' BROWN DIRT
Area code-Phone number 60'TO 80' BOULDER
4. DATE DRILLED 01113/2005 BU TO 100' BROWN SLATE
5. TOTAL DEPTH: 705' 100'TO 120' BROWN SLATE/GRANITE
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO {x 120'TO 127' GRANITE
7. STATIC WATER LEVEL Below Top of Casing: 180 FT. 127'TO 705' GRANITE
(Use"+"if Above Top of Caning)
8. TOP OF CASING IS 1 FT.Above Land Surfaces
'Top of casing terminated aVor below land surface requires a
variance in accordance with ISA NCAC 2C.011R
9. YIELD(gpm): 1 METHOD OF TEST AIR
10.WATER ZONES(depth): NEW BIT
LOCATION SKETCH CD _.
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from al4e8sl = _
12. CASING: Well Thickness two State Roads or County Roads.Include thqoad
Depth Diameter or Weight/Ft. Material numbers and common to mes. �
From 0 To 127 Ft. 61/8" SOR 21 PVC t
From To FL
From To Ft.
13. GROUT: Depth Material Method -
From 0 To 20 FL CEMENT GRAVITY r=�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material ,f
From To Ft. in in in in. �� rl �D ,
From To Ft. . .
15, SAND/GRAVEL PACK:
Depth Sin Material
From To Ft.
From To Ft. IJ1�
16. REMARKS: A
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS,AND THAT
OF TUBS REC D HAS BE PROVIDED TOTHE WELL OWNER
SIGNATURE OF PERSON CONSTR MG THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone Na(919)733-7015,within 30 days. -
GW-I REV.0912004
MAR - 8 2005

307371
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /-W ELL CONTRACTOR(INDIYIDUALyNAME (prlet)��Mplls /r��l� +,r� CP.�TIPICATIoNY /7(e
WELL CONTRACTOR COMPANY NAM ' PHONLY7O .-.��eZ LI-'3 �6 0
STATE WELL CONSTRUCTION PERMIT#. •aSOCtATeD W ERvir" -
(if applicable) (if applicable) -
1. WELL USE(Check Applicable Box): Residential' unicipaVPublic Cl Industrial❑ Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 if Other,List Use
2."WELL LOCATION: ogrnphiclLand setting
Nearest Town: F P 9N�CL i/✓ County��(�(� [Vi2 slope Malley OFlat
&( (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lot No.,Zip code) Lstitudetiotigitude of well location
3. OWNER: �faV.¢._ Penn eA-
(degreesJminuteilseeonds) '
Address Q. Rt>Xf 0/ Latitude/longittida source:❑GPS❑Topographic map
(Street ar Route No.) - (check box) .
`297 DEPTH DRILLING LOG
Gt or Towp State Zip Code From To Formation Description
C (C
Ara code-Phone number - �� _ �r
4. DATE DRILLED 30 ' S a5. l t-..� -
5. TOTAL DEPTH: r�D.Sr
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO-
7. STATIC WATER LEVEL Below Top of Casing:-/,2�FT:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
'Top of cuing terminated atlor betgw landsarface requires a
variance In accordance with-(SA NCAC 2C.01 is. - -
9. YIELD(gpm): -a—METHOD 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 Di ter or Weiyitt/Ft. Matey' 1 'numbers and common road names.
From
_�To-,LFt._�" $ O,.Y�
From To FL
From Tq Ft._
13. GROUT: Depth Materiel Method
From_2 To�Ft. n0� - I va
From To Ft. -P Co otD
.4. SCREEN: Depth Diameter . Slot Siu Material - ::0 v mm
From To Ft. in. in. t c)
From To Ft. in. in.
5. SAND/GRAVEL PACK: K
�+ N Depth Size Material
Materiel - _ .� �- cep �
From To FL - �+
G�
From To Ft. i-,z
r
6. REMARKS: -
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 154 NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD BEEN PROVIDED TO THE WELL OWNER
� i - a 7�os
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 76 99-1 63 6 Phone No.[phone],within 30 days. OW-I REV.07/200I

WELL CONSTRUCTION RECORD
(w
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
� �—r�"
WELL CONTRACTOR(INDtV,IDUAL)NAME (prlot) c M17 h-IS ' ,r l%].A � CEATWICATiON#
WELL CONTRACTOR COMPANY NAM PHONEY ` �-'3 �•F�
STATE WELL CONSTRUCTION PERMIT/. ASSOCIATED W ERM1.0 _
(if applicable) - _ ' -(ifapplicable)
1. WELL USE(Check Applicable Box):Residentiat nd vunicipal/Public❑ Industrial O Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other C7 If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: ®� County QL ❑Ridge ❑Slope Malley et
414 /1 S —P l e 4 S2nT a ile aj H— ) (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,rip Cade) y63 - Lstitudcriongitude of well location
3. OWNER: // t % lei 0•b t e- (degrinulminutaheconds)
Address 1.24 P 1 eQ SQ nTr Co ✓e- Rd- LatitudeAongitdde source:OOPS❑Topographic map
(Sweat Rome No.) a i / - (check box)
DEPTH ' DRILLING LOG
City or Town State - Zip coda From T r _FO Tnation Description
rm
(Sdod- sa _ R sG F
Area code.Phone number 4. DATE DRILLED 1 �-3 1-o-S � _ �
5. TOTAL DEPTH:_ I���
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: .2- -FT:
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surfaces
'Top of cuing terminated atlor belgw laadsurface requires■ -
variance In accordance with 15A NCAC 2C,0I13.
9. YIELD(gpm): / ) METHOD OF TEST_ (/
10.WATER ZONES(depth): 1,4 .PD'
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/ n D1 ter .or WeiAhM. Material numbers and common road names. .
From� 6 To x Ft.= 57LrG1
From To FL tJ�,s► mf
From To FL - t-t1 ;<
13. GROUT: Depth Material Method �O
From To `,= Ft, n a 00 �o
From To Ft. art
.4. SCREEN: Depth Diameter Slot Sim Material - 1' 3 y
�;a
From To FL_m. in. Co W is
From To FL_in. in. NU
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
ONSTRUCTION STANDARDS,AND THAT COPY OF THIS RECORD HA.S BEEN PROVIDED TO THE WELL OWNER
//I yuOf�- 1-31--os
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
J-7699-1636 Phone No.[phone],within 30 days. GW-1 REV,07/2001

WELL CONSTRUCTION RECORD 3 O 7 3
North Carolina-Department of Environment and Natural Resources-Division of Water.Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)"NAME (prlaQcb'Pti ils f JJ)Q'Ar" - CXITIFICATIONY dMe
WELL CONTRACTOR COMPANY NAM PHONE it 14-'3 -L Q
STATE WELL CONSTRUCTION PERMIT#. ASSOCIATED W 9RMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential' unicipal/Public❑ Industrial ❑ Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 If Other,List Use
2."WELL LOCATION: q Topographic/Land setting
Nearest Town: � County nn /`T�� Midge ❑Slope ❑Valley 4 at
At ea iO aT CO V t. 'P.1 -QTU fr'7& 3 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cwc) Latitudeflongitude of well location
3. OWNER: In I (delp"Vminuwheconds) .
Address is tL Pl e2rm., Co y Latitude/longitude source:❑GPS❑Topographic map
(Straet or Route No.) �t (check box)
olin 7,RF. a 176 � DEPTH DRILLING LOG
City'' Town Sine Zip Code From To Formation Description
Area code.Phone number r
4. DATE DRILLED —/ —O �( . ap•
5. TOTAL DEPTH: -
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: �FT:
(Use"t"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surface•
-Top of casing terminated at/or below land surface requires a
variance in accordance wltb ISA NCAC 2C.011#.
9. YIELD (gpm): /Q METHOD OF TEST
10. WATER ZONES(depth):_.��5' o94"1
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 Diapteter or Weight/Ft. Material 'numbers and commonroad names.
From--L—To�Ft. �
From To FL p crn
From To FL ?sc'
13. GROUT: Depth Mat anal
-0<
From To Ft. now. T rn� _ -" MWC7
From To Ft. Co po
4. SCREEN: Depth Diameter , Slot Size Material - ' sm
From To Ft. in. in. _ �, _ ��
From To Ft. in. in. o - p�
5. SAND/GRAVEL PACK: _, LJ c:) c
Depth Size Material
From To Ft.
n
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 THnSREC®RDHEEN PROVIDED TO THE WELL OWNER
cp
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
,Tubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Ralelgh;NC
_q?699-1636 Phone No.[phone],within 30 days. OW-I REV. 07/2001

307374
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /WELL CONTRACTOR(INDIVIDUAL)"NAME (print) c��PI 15 � f, A r�` . "� CElt(TIFICATION 7 M 1 `f
NYE LL CONTRACTOR COMPANY NAM PHONEY ;2q-3 ZZ6
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W ERMITY
(ifapplicable) ' .(ifapplicable)
1. WELL USE(Check Applicable Box): Residential' unicipal/Public❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other Ei If Other,List Use
2.-WELL LOCATION: To lc/Land setting
Nearest Town: �� NlGLj� County Lp� g�e ❑Valley ❑Flat
• 1 (check appropriate box)
(Street Name,Numbers,Communi ,Su'odivision,Lot No.,Zip Code) Latitud0ongitude of Well location
3. OWNER: E1 2 QfY(.fDeII (degroulminutes/i.monds)
Address �D. B�5 Latitude/longitude source:❑OPS❑Topographic map
(Strect a Route No.) p (check box)
Fkam!1� w c c� t) 7 y-q DEPTH DRILLING LOG
City'or Town Stale Zip Code From To Formation Description
(� 3 6 umber (n l
Area code.Phone numbest n�Zt'�i e
4. DATE DRILLED `o) `V—Sr, df�S• L
5. TOTAL DEPTH: SS'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO"
7. STATIC WATER LEVEL Below Top of Casing:•a2Q�FT.
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surface•
-Top of cuing terminated it/or below Iaudsurface requires■ -
variance in accordance with ISA NCAC 2C.0118.
9. YIELD (gpm):_ 540 METHOD OF TEST
10. WATER ZONES(depth): S '
LOCATION SKETCH
I I. DISINFECTION:Type Amount LAA 5 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diaprieter or Weight/Ft. Material numbers and common road names.
From—To �-S Ft. Sg D.,. •- �
From To FL O u"o
From To Ft. tJs n
13. GROUT: Depth Material Method rTi•t �„�
From To r!PD Ft. T � v OD -css''t
From To Ft. op
4. SCREEN: Depth Diameter Slot Size Material
From To Ft. in, in. - °O
From To Ft, in. in. to oC2
5. SAND/GRAVEL PACK: _
Depth Size Material _ _. in
From To FL
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCB WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H MEN 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
8 769 9-1 63 6 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3C6928.
WELL CONSTRUCTION RECORD RECEIVEDjDENRjD1','Q
,(+ Quality-North.Carolina-Department of Environment and Natural Resources-Division of Water ualf Groundwater Section
AQUIFER PRnTFC 11, !'SEDTIu
WELL CONTRACTOR(INDIV•IDUAL)NiAME (print)s�l'rkyl t S L I�i3 - ),A�'� 3 j. / ;
CLIkTTPICATION# g �7�
WELL CONTRACTOR COMPANY NAM PNONE # 14 -3 Aeo 4
STATE WELL CONSTRUCTION PERMIT#. AgSOCIATED W aRMIT# -
(if applicable)
(if aPPlfcable)
L WELL USE(Check Applicable Box)!Residential'cd—tv)unicipaVPublic O Industrial 0 Agricultural p
Monitoring❑ Recovery O Heat Pump Water Injection O Other CT If Other,List Use
2. WELL LOCATIO
Nearest Town: iQ L . County Q 40 - ,,, Tge Mope MalleyLand setting
q a�4 f-A � n + L --4 ! ter"°8e '7Slope tebox) (]Flat
��12 d (check appropriate box) i
(Street Name,Numben1,Community,Subdivision,Lot No..zip code) .7 F 73 y Latitude/longitude of well location
3. OWNER:_ Sl VL (/-� �A�.yt�t� (degtaalmiauter/uwnds) .
Address F?0.(Street or Route No.) Latitudellongihide source:OGPSOTopographic map
(chock box)
a{7 Io..dS iYC/ 7 fr 7 fp/ DEPTH DRILLING LOG
12fl`y Ti - sfjt4P3 - zip Code From To Formation Description
Area code-Phone number - n .3 fe
4. DATE DRILLED I•-aS -0.5 —P-L_ t
S. TOTAL DEPTH: /�/t/J • �Oln\ _ &et.`
6. DOES WELL REPLACE EXISTING WELL? YES O N0.-
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_ FT.Above Land Surface'
-Top of cuing terminated atlor belgw landsurface requlru■
variance In accordance wlth75A NCAc 2C.sits
.
9. YIELD(gpm): -'1_MKTHOD OF TEST
10.WATER ZONES(depth): Y: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 Di ter .or Weot/Ft. Material numbers and common road names.
From
_L-To�Ft. a "
From To FL
From To-Ft._
13. GROUT: Depth Material Method
From_D—To­cnD-_FL
From To FL n
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 Tc FL -
From To FL -
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
�)l �0 � + / o1S
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
pubmit the original to the Division Of Water Quality, Groundwater Section, 1636 Mail Service Center-Raleigh,NC -
_717699-1636 Phonc No.[phone],within 30 days. _ OW-1 REV.07/2001

3f' 6S29
WELL CONSTRUCTION RECORD
4l
North Caolina-Department of Environment and Natural Resources-Dlviaion of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV1)UAL)NAME (print) c �1'�rls l Jn.vv ' CZTIFICATIONY 7�
WELL CONTRACTOR COMPANY NAM PHONE
STATE WELL CONSTRUCTION PERMITY AATED WERMITN
(if applicable) QaOCI
licable) ATiplicable)
1. WELL USE(Check Applicabic'Box):Residential7YMunicipal/Public❑ Industrial❑ Agricultural 0
Monitoring❑ Recovery ❑` Heat Pump Water Injection❑ Other ET If Other,List Use
2.-.WELL LOCATI L• , T pbic/Land setting
Nearest Town: County ge ❑Slope ❑Valley ❑Flat
�J f:l/ul:Y)LI• .f2� Ln�'�'a � Nff.n-}ONe )A 4./C C. (check appropriate box) .
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip code) - Latitudellongitude of well location
.0 3. OWNER: IlrlC�Lr .ty-ddL4 C/i if e
(degraes)minutes/sxonds) .
Address Rie Rea Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No.) - (check boa)
411-a M n-.7- r I. 3 A7 D I DEPTH DRILLING LOG
Ciry br Town Sme Zip cod. From T�( � Formation Description
Area code.Phone number -
4. DATE DRILLED 1 — ab—D .r7
5. TOTAL DEPTH:_�Q(y'
BD' g5a 13LO2 (tr2Q not 2.
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N0.-
7. STATIC WATER LEVEL Below Top of Casing: r/_n -FT:
(Use"t"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface-
-Top or cuing terminated at/or belgw landsurface requires■
variance in accordance wltklSA NCAC 2C.o1 is.
9. YIELD(gpm):�—METHOD OF TEST
10.WATER ZONES(depth): L5 (M '
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 Dia ter or Weot/Ft. Mate* I_ numbers and common road names.
From_�Tcf� Ft._rSaf D,.Y
From To Ft.
From To Ft._ _
13. GROUT: Depth _Material Method
r�
From To r
_F[. n T fi`.
From To Ft. t���
.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 IN ACCORDANCE WITH 15A NCAC 2C,WELL s
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH(S RECORD H/�S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
7699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001 -'

. � 3068r�' Ilk
WELL. CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources Division of Water Quality--Groundwater Section
WELL CONTRACTOR(INDIV•IDUAL)NAME (pr1nQ bZ11 _1 ! lln. A'* s CV�TIFICATIO/NY/.117(e
WELL CONTRACTOR COMPANY NAM PHONE q-'3 9b
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED W ERMITY '
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial CI Agricultural 0
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other 5 If Other,List Use
2.`WELL LOCATION: Topograpi setting
Nearest Town: i County /�Q aLl ❑Ridge pe ❑Valley ❑Flat
SD TI��� (check appropriak box) . , i
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) UtitudeAoligitude of Well location
3. OWNER:1.il�I ii a,,- . 146-a 2) s - (desteea)minututtecands) .
Address "PO- Ro x �&. Latitude longitude source:❑GPS❑Topographic map
(check box)
/YJQ GAJ G A. J ?0�1 D R - /� DEPTH DRILLING LOG
-ititycrTown State Zip Code From To Formation Description
Area code.Phone number - ---C Y/Jss, /7� ^i
4. DATE DRILLED —/ C f —!) S.t• c3. RL It e- C' tY Q/al'. t e-
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO-
7. STATIC WATER LEVEL Below Top of Casing:
(Uu"t"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
-Top of cuing terminated actor belliv(laaditurface requires■
variance In accordance with ISA NCAC 2C,0113.
9. YIELD(gpm): !do -t-f- METHOD OF TEST
10. WATER ZONES(depth): ASS
LOCATION SKETCH
11. DISINFECTION:Type Amount 2 T,4 A Show direction and distance in miles from at leas(
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter -or We!Zht/Ft. Mate I- numbers and common road names.
From To__%5�FL $ P
From To Ft.
From To Ft.
13. GROUT: Depth Material Method _
From_To_�sLD Ft. n
From To Ft,
.4. SCREEN: Depth Diameter . Slot Size • Material
From To FL in. in. Z
From To Ft. in. in. - N
S. SAND/GRAVEL PACK: v7
Depth Size Material -
C From To Ft. C11
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 S RECORD H 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
o 699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 r.-

3067 '73
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality.-Groundwater Section /
WELL CONTRACTOR(INDIVIDUAL)NAME (prla[)S��Y)Plls f -110A ,r� CV. TIFICA=N#-,97/7 Y•
WELL CONTRACTOR COMPANY NAM PHONE s�L/ 3 ZZ
STATE WELL CONSTRUCTION PERMITM ASSOCIATED W ERMITM 1'
(if stool icable) (if applicable)
I. WELL USE(Check Applicable Box): Resident[al7d_Municipal/Public❑ Industrial Q Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 If Other,Lot Use
2.-.WELL LOCATION: Z&OTOSlope
ographic/Land setting
/Nearest Town: '-Ei LPL 11-/6'Dq County /�1 c,trn� ❑Valley ❑Flat
LP L l) a�& 12 a —Q &7 (4- 1 (check appropriate box)
m m i
(Street Name,Numbers,Community,Subdivision,toot No.,Zip
Code) LatitudeAongitude of well location
3. OWNER: (degrees)minutes/seconds) .
Address ) LatitudeAongitude source:❑GPS❑Topographic map
(Street or Roue NoJ (check box)r 417 �o,, All G ��y'� DEPTH DRILLING LOG
city rTown Sum Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED -//-h_S .Se F?/UL (1•/e Qni rd-.
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Z�O FT.
(Use"e if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surface-
-'top of casing terminated at/or below landsurfaee requlrts■
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): Y1 METHOD OF TEST- �4W (/
10. WATER ZONES (depth): 3(06'
LOCATION SKETCH
11. DISINFECTION:Type Amount Q L4 A Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roaFn '
Depth Dia ter .or Wc0t/Ft. M�ate� I ' 'numbers and common road names, r fYry
From_ To So Ft. $�
From To Ft. v
From To Ft.
13. GROUT: Depth Material Method
Fro To ;D Ft.
From To Ft. - o
4. SCREEN: Depth Diameter Slot Size Material o
From To Ft._in, in.
From To FL—in. in.
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. .
From To Ft.
S
b
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT
yA�COPY OF THIS
�R�ECORD H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINGTHEWELL DATE'
ubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh,NC
077699-1636 Phone No.[phone],within 30 days. _ OW-1 REV. 07/2001

307742
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �""WELL CONTRACTOR(INDIVIDUAL)NAMB (print) J� -r)MIS IL 10'Ar�, -�� cjc�TIPICATIONY J-Re
WELL CONTRACTOR COMPANY NAM PHON]L # 4--3 ;L
STATE WELL CONSTRUCTION PERMIT# aSSOCIATED W ERMIT#
(ifapplicable) (if applicable)
I. WELL USE(Check Applicable Box): Residenl'ial' unicipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other E1 If Other,List Use
2. WELL YJ LOCATION: Topographic/Land setting_
Nearest Town: 6 County ❑Ridge ❑Slope ❑Vslley e�Ff t
q C/1 S uL e a PJ.— r A , h' (check appropriate box) ' x ,
(Street Name,Numbers,Community,Subd- ' ion,Lot No.,Zip Code) Latitude/lotigitude of well location - -
3. OWNER:_-Bo SfePL -8LL2vi T-f— (de greestminuteshaonds) -
Address Lf 3 /41 Dact h a V2 m D 12• Latitudeflongitude source:❑GPS❑Topographic map'
(Suter arRyute NoJ - (check box)
FI2 Q.1l41Z N�i r�92 3 DEPTH DRILLING LOG
City or Town state zip code Frotp To Formation Description
Area code-Phone number --
4. DATE DRILLED / S
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 'Q� FT:
(use"t"if Above Top of Cuing)
8. TOP OF CASING 1S_�FT.Above Land Surface'
-Top of cuing terminated War below landsurfaea requires a
variance In accordance with ISA#CAC 3C'oil
l ta.
9. YIELD (gpm):_�METHOD OF TEST
10. WATER ZONES(depth): e,2L5, e
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: �7 Wall Thickness two State Roads or County Roads,include the road
Dep
—� .2✓ Ft.
From Co p Dt_ $or Wei g}VFt. Ma`ep�t numbers and common road names.
Y Q c�
From To Ft. 'sl mrn
From To—Ft. rn =<
13. GROUT: Depth Material Method - IV
From Tom`- —Ft. no- �m9� �
From To Ft. y""'" — '-0 nx
4. SCREEN: Depth Diameter . Slot Sin Material
From To Ft. in. in. iV =o
From To Ft. in. in. rJt tnp
5. SAND/GRAVEL PACK: �' M
Depth Size Material
From To Ft.—
From—To—Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sbbmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
.17699-1636 Phone No.[phone],within 30 days. _ OW-I REV. 07/2001

WELL CONSTRUCTION RECORD
307741
North Carolina-Department of Environmdnt and Natural Resources-Division of Water Quality-Groundwater Section "
WELL CONTRACTOR(INDIV.IDUAL)NAME (print) c��ff PI t 5 /j,l l n7 *A" :. n CEIVTIPiCAT10N# of l (e
WELL CONTRACTOR COMPANY NAMPHONLY�y-'3 �6
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W ERM1T# '
(if applicable) -(if applicable) -
I. WELL USE(Check Applicable Box):Resident'ia17YMunicipaVPublic❑ Industrial 0 Agricultural 0
Monitoring❑ Recovery 0 Heat Pump Water Injection❑ Other C7 If 6t6r,List Use
2. YELL LOCATION:
Top oic/L setting
NearestTown: p lei 14 CountY ❑Ridge 0SIope ovallcy Il Ea__�
60 LLU) SMy i h E) , 11 2A — 20 »1 dwCn V t /z a (cheek appropriate box)
(Street Name,Numbers,Commuaily,'Subdtivision,Lot No.,tip Code) i Bgrl yL LatitudcAongitude of well location
3. OWNER: cl )1 Q avI W h r21-e/(_. (degraes)m;twew,euam) -
Address Z 0017 OOI A•12 C o v-e 2& Latitude/longitt(de source:❑OPS❑Topographic map
r
^ —(Sk\eet or Route No.) - (check box)F?Y/YY11_ILA l i1/� Q 9 13 DEPTH ' DRILLING LOG
City be Towo sun - zip Code From T Formation Description
d2m( saw - .3 �� � .
Area code.Phone number '` t
4. DATE DRILLED 4—IL -0 5
5. TOTAL DEPTH: 1 R:0'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:
(Use"t"if Above Top of Cuing)
8. TOP OF CASING IS�_FT.Above Land Surface*
'Top of cuing terminated attor below iandaurface requires a _
variance In accordance with 75ANCAC 2C.0lsa.
9. YIELD(gpm): -3 - METHOD OF TEST
10. WATER ZONES(depth): '
• LOCATION SKETCH
It. DISINFECTION:Type VTP. Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dispicter .or Weight/Ft. M_atepa) -numbers and common road names, Q�
From To Ft. ;,�'! • 'ti t. c,n c>�
From To Ft. m r"
From To FL_ - - t9 -urn
13. GROUT: Depth Material -Method l N �
From_To_c-2D_FL ) _ - ps7
From To FL �r"
4. SCREEN: Depth Diameter . Slot Size Material
From To F[. in. in. N �o
From To Ft. in. in. Ln (Isp
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H&S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
5ubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mill Service Center-Raleigh,NC
a'7699-1636 Phone No.[phone],within 30 days. GW-1 REV,07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division ofUdter Quality-Groundwater Section WELL CONTRACTOR(INDIV,IDUAL)NAME (print) c�V1 I S ��1��c� CERTIFICATION# of/7 yO
WELL CONTRACTOR COMPANY NAM t.e PHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W ERMIT#
(if applicable) - .(ifapplicable) -
1. WELL USE(Check Applicable Box):Resident]ial'LYMunicipal/Public❑ Industrial ❑ Agricultural❑ _ -
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other cl If Other,List Use
2. WELL LOCATION:
Topograp4iclLand setting
Nearest Town: F �L1 County ge Mops ❑Valley ❑Flat
'2( / S d - _ e)Lr.-.G , (check appropriate box) 4�
(Street Name,Numbers.Com, pity,Subdivisio I.ot No..Zip code) o2$r/35� Latitude,Aongitude of'xoll location
3. OWNER: 3QGI6 �gQn.. (degree>rminuta✓eewndr) ram' ' -
Address 2,J b/d 41 &MI kAlbP 2c2 Latitude/longitude source;❑GPS❑Topographic map
(Street or Route No.) (check box)
,c12 Rr el,-IJ &C. Q DEPTH DRILLING LOG
City or sown State Zip Code From Formation Description
4<� S Slo_ �
Area code-Phone number e / r •f e
4. DATEDRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: EZ FT:
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surface'
-Top of cuing terminated atior below landsurfaee requires■
variance In accordance with ISA NCAC 2C.0119.
9. YIELD(gpm): -Z METHOD OFTEST_�10. WATER ZONES(depth): -41S40 ' (/
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 Diapteter or Weight/Ft. Met'' I 'numbers and common road names.
From TLZQ5 Ft. S Dt
..
From To Ft.
From To Ft. - rrn
13. GROUT: Depth Material Method W
From To Ft.
From To Ft. 1 _ O
4. SCREEN: Depth Diameter . Slot Sim Material
From To Ft. 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 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
cubmit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center-Raleigh,NC
o7699-1636 Phone No.[phone],within 30 days. OW-I REV.07/2001

WELL CONSTRUCTION RECORD 3 1
North Carolina-Department of Environment and Natural Resources-MY.ision of Water Quality-Oroundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) se ll his J.�ijQ�A'A J clegiFICATION It 1-7
WELL CONTRACTOR COMPANY NAM PHONE fi7k' . n4--3 ';Z6 a
STATE WELL CONSTRUCTION PERMITA- wSSOCIATED W ERMITN
(ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box): ResidenCial'u—Municipal/Public❑ Industrial 13 Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other E f If Other,List Use
2. W ELL LOCATION: T,",�r ogrAphic/Land setting
Nearest own: �I-/ county ZMA L3,dge OSlope OVaey ❑Flat
Q �' Wet n a,m. e G�ita..l2 d a 9?'3 V (check appropriate box)
(Street NznenNumbers,Community,Subdivision.,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:4/ m -eI?i 0ir, `S (degrees)minuteslsewnds)
Address 335 ypd L Laa p Latitude/longittidesource:OGPSOTopographicmap
(Boca or Route No.) (check box)
IIPQ.r kl� �� "2rf2`3 y DEPTH DRILLING LOG
City'or Town Zip From T— o Formation Description
_J)Stale 4a Code F 0
Area code-Phone number s
4. DATE DRILLED
5. TOTAL DEPTH:_
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO —� B 1 U r el
7. STATIC WATER LEVEL Below Top of Casing: /D 0 FT:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface"
-Top of casing terminated auor below land surface requires a
variance In accordance J4Ib ISA NCAC 2C.011a.
9. YIELD ZOO ME TEST
10. WATER ZONES(depth):--9r /j'�- - j/—
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 Dieuuter S or Ft. Mao tey�l numbers and common road names,
From—�To n / Ft. [rL C'r
From To Ft.
From To Ft.
13. GROUT: Depth - Materizl Method W
From To�Ft, n0� T M A
From To Ft. - -
4. SCREEN: Depth Diameter . SlotSize • Material
From To FL—in. in. O
From To Ft. in. in. UI
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 I5A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H 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
.776 9 9-1 63 6 Phone No.[phone],within 30 days. OW-1 REV, 07/2001

30 '7 '770
WELL CONSTRUCTION RECORD
iti.'4
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMB (prlat) �r) i15 f�1)Q,A A' ` .t., CERTIFICATION Y`oZ�7 y'
WELL CONTRACTOR COMPANY NAM PHONIC
STATE WELL CONSTRUCTION PERMITA ASSOCIATED W ERMITN
(ifapplicable) - .(if applicable)
I. WELL USE(Check Applicable Box): Resident'iai' unicipal/Public❑ Industrial❑ Agricultural Q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 if Other,List Use
2. WELL LOCATION:
_FeA.vkL i� Count Ma- To he OV setting
N/earest Tow1ln: y_/,ry_/� ge ❑Slope OValley ❑Flat �
CO 4�.t� r&n:Q-Yl -. N, P j .A� H P-, -1 k?3 (check appropriate box) 4
(Street Name,Numbers,Community,Subdivision,l.ot No.,Zip Code) Latitude/longitude of well location
3. OWNER:-R2 i QiYy R a d yc uJ"e/I (degroealminute0aewnds)
Address /( -Y- O(.L 4 Latitude/longitude source:❑GPS❑Topographic map
(Streator Route NoJ - (check box)
��p,tLi �/[J �Xr7;3 DEPTH DRILLING LOG
City ur7nwn sate Zip code From To Formation Description
(Sf"- 3 ro 9- PS D 3 9 '
Area code-Phone number - � l�-' 7 a _ •!-rS n -e-
4. DATE DRILLED o2- (-;A �� /�n 7 e o l+-e-
5. TOTAL DEPTH: 5.5o'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:-/SD FT.
(Use"+"if Above Top of Cuing
8. TOP OF CASING IS FT.Above Land Surface*
-Top of casing terminated attor below laud surface requires a
variance In accordancewlth ISANCAC2C.0118. / ,"- [7
9. YIE (LD(gpm):�_METHOD OF TEST J ',�10.WATER ZONES (depth): Z5- 6LOCATION 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 Dia ter or We'ight/Ft. Mate I 'numbers and common road names.
From To_(o Ft. to
From To Ft.
From To FL r1n
13. GROUT: Depth Material Method, co ,r
From To `�_Ft. no,,M QM�
From To Ft.
4. SCREEN: Depth Diameter Slot Size Material o ri
C
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 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H S 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
a,7699-1636 Phone No.[phone],within 30 days. GW-i REV.07/2001

WELL CONSTRUCTION RECORD 30
North Carolina Department of Environment and Natural Resources-Division of Water Quality ` 8 8 g
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187 e!
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 O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
'a
2. WELL LOCATIOY: Topographic/Land setting
NearestEv Ton: County ORidge ❑Slope OValley ❑Flat
I '
x 1L 1 (check appropriate box) -
(Street Name,Numbers,Co uty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location r*
3. OWNER: (degrees/tninutes/seconds) --
Address J Latitude/longitude source:OGPSOTopographic map
(S eetor RouteiNo,) ry (check box)
�b� DEPTH DRILLING LOG
City or Tow star Zip Code From To Formation Description
8(_2) �t�j ,{�/� ——L � clay&sand
Area code Phone number t granite
4. DATE DRILLED
5. TOTAL DEPTH: l0 O
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:yQ(L_F
(Use'Y'if Above Top Casi
ng)
ing)
8. TOP OF CASING IS 2 FT.Above Land Surface'
-Top of casing terminated allor below land surface requires a
variance in accordance y1th 15A NCAC 2C.0118.
9. YIELD(gpm): _METHOD OF TEST BLOW —
10.WATER ZONES(depth): Q%QG� 7 a� �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 CountyRoads.Include the road
12. CASING: Wall Thicklm—ll
Dep ,I Di meteror Wei ht/Ft. Material eria numbers and common road names.
From 0 To '1 D Ft. atfL O rN
From To Ft. al
From To Ft.__ AG
13. GROUT: Depth Material Method CIO -vQ
From 0 To 20 Ft. Senorita&cement pumped x1 - am
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material 3 aA
From To Ft. in. _ in.
From To Ft. in. in. =�E
15. SAND/GRAVEL PACK:
Depth Size Material c7
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTmma
THAT OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�J
TU 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.
GW-1 REV.09/2004

11
WELL CONSTRUCTION RECORD O �y
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor _ _ CERTIFICATION#2187 O
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 Topographic/Land setting s
NearestTowf �CountyAI&J �2 ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Num ers,Community,Subdivision,L No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds) -
Address q Latitude/longitude source:❑GPS❑Topographic map
treet or ouo•7 No.) (check box)
i
l �iA Al t 4 �iG �� DEP DRILLING LOG
�)ry or T�ow� sra n Zip Cow From I Formation Description
0 ft clay it sand
Area code.Phone number � (��
DEPTH:
r granite
4. DATE
5. TOTAL DEPTH:: 01
6. DOES WELL REPLACE EXISTING WE YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 400_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 accordan a ith 15A NCAC 2C.0118.
9. YIELD(gpm):�f METHOD OF TEST BLOW
10. WATER ZONES(depth): /5Rrbh
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 'a�
From 0 To Ft.
or W ' UFt. terial numbers and common road names.
Ft.
From To Ft.
From To Ft._ �A
13. GROUT: Depth Material Method tVq _ n
From 0 To 20 Ft. Benonite&cement pumped "rI
From To Ft. t2o
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. O . P
From rn
To Ft. Cl
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
SIGNATU r
F PER N 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.
GW-) REV.09/2004

WELL CONSTRUCTION RECORD 0J-P 3 0 '7 9 5 4
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 PERMITN 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❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Neare Tgwp: County ❑Ridge ❑Slope OValley ❑Flat, -
�_ i (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 'A`fl' (degrees/minutes/seconds)
Address U D Latitude/longitude source:OGPSOTopographic map
Street o Route N . (check box) -
Z 7 DEPTH DRILLING LOG
City or w State Zip Code From T Formation Description
8( 26 )-��—Z7yZ 0 granite
(Area 828 de-Phone number yQ L7 —0 q, � granite
4. DATE DRILLED
5. TOTAL DEPTH: 2y0
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:��
(Use'Y'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 accords ce with 15A NCAC 2C.0118.
9. YIELD(gpm): ' METHOD OF T BLOW
10.WATER ZONES(depth): /ZDt42Z
—� 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 3 Ft. �r
From_T To Ft.�� p�
From To Ft. COJI C=rn
13. GROUT: Depth Material Method �G
From 0 To 20 Ft. Benonite&cement pumped r•'1
From To Ft. n
14. SCREEN: Depth Diameter Slot Size Material CD
From To Ft. in. in. —o �x
From To Ft. in. in. S
15. SAND/GRAVEL PACK: CJ zoC3
Depth Size Material r ua p
From To Ft. O
From To Ft.
16, REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST DARDS,AND THAT OPY 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

308099
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)"NAME (Print) cl)P/IN Is fLIIIIA �" CEItTIFICATIONY ol/7� .
WELL CONTRACTOR COMPANY NAM PHONR # 'k-'- S2 t/ 3 941 �
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W ERMTTM '
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential' unicipaVPublic❑ Industrial 0 Agricultural p
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 If Other,List Use
2."W WELL LOCATION.. yTpe graphic/Land setting
Neearrestt'Townn' IeL i County��GdYL� k idgo OSlope ❑Valley ❑Flat
T2,1,"9173V (check appropriate boa)
(Street Name,Numbers,Community,Subdivision.Lot No.,Zip Code) 7 Utitude/longitude of well location
3. OWNER: 00LT/np1 �0- M. (degir"sWoutulseconds)
Address il- 4 fi'd Latitude/iongitude source:❑OPSOTopographic map
(Street or Route No.) (check box)
nT Sl.M"a e 3 / DEPTH DRILLING LOG
City br To 5 Zip Code From To Formation Description
Area code-Phone numb �
4. DATE DRILLED I_
5. TOTAL DEPTH: .3 2,5-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—A2---�FT.
(Use"+"if Above Top of Cuing) K
8. TOP OF CASING 1S FT.Above Land Surface" a
-Top or cuing terminated avor below laadsurface requires■ I �
variance In accordance with ISA#CAC 2C,Oils.
9. YIELD (gpm):I L METHOD OF TEST
10. WATER ZONES(depth): —3SD' CD r
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 Diap�t"er or Wetght/Ft. Mate pill "numbers and common road names.
From To_91_Ft. $a R.� D r�
From To Ft.
From To Ft.
13. GROUT: Depth - Material Method
From To—,nn—Ft, n T rn•�
From To Ft.
4. SCREEN: Depth Diameter Slot Size , Material - • - -_..,,
From To Ft, in. in. -«_.
From To Ft. in. in.
5. SAND/GRAVEL PACK: _5
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 H S 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 Mall Service Center-Raleigh,NC
,AO7699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

� pg � 90
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
nn /"WELL CONTRACTOR(INDIY•IDUAL) NAME (print)s�-ehVJlS J � ,.A r� CYItTIFICATtONY o�/-7y'
WELL CONTRACTOR COMPANY NAM PHONIGY �--3 �6 a
STATE WELL CONSTRUCTION PERMIT,#. •SSOCIATED W ERMIT# 1'
(ifapplicable) - -
— �(if applicable)
I. WELL USE(Check Applicable Box): Residential' unicipaUPublic❑ Industrial O Agricultural O
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other 17 If Other,List Use
2. WELL LOCATION
Nearer[ Tom, graphicland setting
T^o/wn: /CL i County UHtTdge'❑Slope OValley ❑Flat '
s�_� /✓ U DS / 2 L1•/ 'L (check appropriate box) ' a
(Sweet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude longitude of well location -
3. OWNER: Q.e I00 (degreealminutea/aaoads)
Address LatitudcAongitude source:OGPSOTopographic map
(Street"Route No. ((,, - (check box)
t°12Yh n nT / T 7/I DEPTH DRILLING LOG
Gl or Town ate Zip Code From To Formation Description
Area code.Phone number
4. DATE DRILLED-9—
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: -Z FT;
(Uae"t"if Above Top of Cuing)
S. TOP OF CASING 1S�_FT.Above Land Surfaces
-Top of casing terminated Wor below landaurface requires■ a r•+
variance In accordance with ISA NCAC 3C,011a.
9. YIELD(gpm):�AQ METHOD OF TEST
10. WATER ZONES (depth): __ '4/0S .5
LOCATION SKETCH Us
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 Die ter or We. t/Ft. Matepill numbers and common road names.
From To Ft.
From To Ft.
From To—Ft.
13. GROUT: Depth Material MT ethod_ .
From To_�Ft. G,1•J,d-^rL)
From To Ft.
4. SCREEN: Depth Diameter Slot S,W , Material
From To Ft, in. in.
From To Ft, in. in.
S. 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
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H&S 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 Mall Service Center-Raleigh,NC
c1'7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

v
WELL CONSTRUCTION RECORD 3 S g 9
North Carolina-Department of Environment and Natural Resources-Division of W star Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlot). pill I I n, A ''
---........L ' CERTIFICATION Y of l7 e .
NYE LL CONTRACTOR COMPANY NAM PRONE M IV--3 9 �
STATE WELL CONSTRUCTION PERMIT#. wSSOCIATED W ERMIT#
(ifapplicable) -
(ifaPplicable)
1. WELL USE(Check Applicable Box):Resident'ial'0- Ivlunicipallpublic❑ Industrial 11 Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 5 If Other,List Use
2. WELL LOCATION:
Nearest Town: y Topogra hic/Land setting
�4lS e9L�� Count &QLtJ7L� a Slope ❑Valley ❑Flat 'o
�Z (check appropriate box) 4 -�
(Such Name,Numbers,Co tuniry,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (A' Y 2 t72C10hA (deg ecs)minutealseconds)
Address a-9 or
�- - .0 Q .� Latitude/longitude source:❑GPS❑Topographic map
(Sweetc a n Route No.) t�l (check box)
21� ehL-elf 17 3 3RIteT DEPTH DRILLING LOG
City or Town State Zip Code From To Fo ton Description
Area code.Phone number
4. DATEDRILLED A—! US r 2_
5. TOTAL DEPTH: e
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_!f—FT.
(Use"+"if Above Top of Cuing "
8. TOP OF CASING IS _ n FT.Above Land Surface`-Top of cutna terminated atfor below land surface requlru a 0
varlanee In accordance with 15A NCAC IC.0118 z1
3C ,0
9. YIELD (gpm): 3 METHOD OFTEST_d�1� f/ n
10. WATER ZONES(depth): ' t )?
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at leash
12. CASING; Wall Thickness two State Roads or County Roads. Include the road
Depth Di a to or Weight/Ft. Matep' I numbers and common road names.
From To 16 Ft. ;L?R,2 T D Y W
From To Ft.
From To Ft.
13. GROUT: Depth Material Melhod -
From To
From To Ft. 'KT�i
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 IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TT�HIS�RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Q C 2 l+II QX C9 /
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original-to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
o27699-1636 Phone No.[phone],within 30 days, OW-1 REV.07/2001

3081
41
WELL CONSTRUCTION RECORD
North Carolina-Department of Envi onment and N tural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (wtot)_ y ` 13411 CERTMCATION o?S 7 7
WELL CONTRACTOR COMPANY NAMEWT Q i na PHONE x _ZTrl6c t-OCI Sa
STATE WELL CONSTRUCTION PERMTTB ASSOCIATED WQ PERMT1Yi '
(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 LOCATION: 5 ogrdphic/Laild setting
Nearest Town: F/ ✓/l/l� �i`i� County M 19 cG u Mdge ❑Slope Malloy ❑Fiat
201 Ana t/ eo,� e rI d Z�i 7 S� (cheele vi rope box)
(Stec[Name,Nualtees,Cammusd%Subdivint o,lot No.,Zip Code) Latitudetlongitude of well location
3. OWNER: e / (degewintramtsc000ds)
Address W0/ g441 of 0 d LatimdcAongitude source:❑GPS❑Topograpbic map
F ✓I K/fit] (street o ute Nee Neck box)
/'2 G 7 f' 7 .� Y DEPTH DRILLING LOG
Cityorrown State Zip Code From To Formation Description
C--)-
Atea code-Phooe number _
4. DATE DRILLED
5. TOTAL DEPTH:_
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO .3
7. STATIC WATER LEVEL Below Top of Casing:--Z,fFT. t
(Use"+"ifAhme Top of Casing)
8. TOP OF CASING IS �•3 Fr.Above Land Surface- 0
13
-Top of casing terminated attar below land surface requires a
varfism to accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): 3 f� METHOD OF TEST /i!0 WC
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type C 15 Amount /d ,j •Z Show direction and distance in miles from at least
12. CASING: Wall Thickaw two State Roads or County Roads.Include the road
th
Fro _ To m ( /fW Ft-�'t or weighm material numbers and common mad names.
Frotn__To Ft
From To FL
13. GROUT: Depth Material Method
Fro mTom_Ft. G B/c wCl- miX
From To Ft
14. SCREEN: Depth Diameter slot size Material r
From To Ft-
-in. in
From To Ft in. in. 3 OU 15, SAND/GRAVEL PACK:
Depth size Material L_ ram,
Fro Tri Ft.
Fro�To FL_ r4N
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTIONrolj.:J�
ARDS,AND THAT A COPY OF S REC HAS BEEN PROVIDED TO THE WELL OWNER
GNAT O tP-§ON CO TRUCITNG 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 � 308192
North Carolina-Department of Environment and Natural Resourrce,ss, - Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
7'y(print)� p
jQeG �-f-g4'LL CERTIFICATION#��I
WELL CONTRACTOR COMPANY NAME I J AUt/K dU1 Ak-e— 6Z11 % -0"— PIIONE # W)S-7�1-�/y7L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(il'applicable) (if applicable)
1. WELL USE(Check Applicable Box): ResidentialD Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: Fj i A) County AL. -
[]Ridge ❑Slope ❑Valley ❑Flat
zrrifr
(check appropriate box)
(Street Name,Numbers,C muni(y,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:/11 ry &1S4&.A (degrees/minutes/seconds)
Address `� / i L/t (w. Latitude/longitude source:❑GPS❑Topographic map
(Street nRou to No.) (check box)
1 ca47I0-3 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number G
4. DATE DRILLED
5. TOTAL DEPTH: 1106 _S ry f
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ Q can
7. STATIC WATER LEVEL Below Top of Casing: /7S FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface* 11121
*Top of casing terminated altar below land surface requires a '(�jnl
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): _METHOD OF TEST zy
10. WATER ZONES(depth): _
_ LOCATION SKETCH z4
11. DISINFECTION: Type Amount _ Show direction and distance in miles I*1 at leu'V'f
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diame er or Weight/Ft. Material numbers and common road names.
From 'b To /N Ft. 1.f
From To Ft. _
From To Ft.
13. GROUT: Depth Material Method "^
From C' Tom2t, _Ft. Ceftl u� yT( tt r�l✓ mm
From To Ft._ T N
14. SCREEN: Depth Diameter Slot Size Materiel
From ;` To Ft. in. in. _
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material _ �t
From To Ft.
From To Ft.
16. REMARKS:
)DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED Od ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�lJ.MA4t�� e/L4o­, "P as as
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD �✓ 308191
North Carolina-Department of Environment and Nato a) Ressofu_rces-Division of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) // C5J��✓ t ' CERTIFICATION
WELL CONTRACTOR COMPANY NAME ('YNst✓IfA15, (Lilt �',��, �✓IL PHONE gf•�`''1`SY7�/Ito
STATE WELL CONSTRUCTION PERAIITN ASSOCIATED WQ PERaIJT8
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential.Er Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATION- Topographic/Land setting
Nea est Town: • /i/H County AA-66A) ❑Ridge ❑Slope ❑Valley ❑Flat
t- 1A— �' ,i r,� (check appropriate box)
((SStreet Name,Numbers,Community,,Subdivviist� No.,Zip Cale) Lalitudeilongitude of well location
3. OWNER:t t{% Are/ 0! R Sp r - (degrees/minutes/seconds)
Address �V 1-ti"116ui r k Latitude/longitude source:❑GPS❑Topographic map
(Street or Routy No.) (check boa)
FRlrvjk4%; ; L 3?y _ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number a
4. DATE DRILLED �S Z - v" S�-
5. TOTAL DEPTH: S
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ O �c
7. STATIC WATER LEVEL Below Top of Casing: -'25-6 FT. "^rn
-e1 r
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_I FT.Above Land Surface* IL A=r
Top of casing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C.0118.
9, YIELD(gpm): Zt-� —METHOD OF TEST A.✓
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION: Type Amount _ Show direction and distance in miles frpgi at let
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diae4e or WeighUFI. MDateral numbers and common road names.,
rom m
F To�Ft. & Joyc-
From To Ft.
From To Ft.
13, GROUT Depth Material Method 'r�
From Tom Ft. 1 Y _ m
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. r n
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL—
From—To—Ft.
16. REMARKS:
I DO HER 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-1 REV. 07/2001

WELL CONSTRUCTION RECORD 308190
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 7
WELL CONTRACTOR(INDIVIDUAL)NAME
(print) t-/�r1✓y�G, CERTIFICATION
�M'`'�/dam//
WELL CONTRACTOR COMPANY NAME OAA)L &Ib5, vC-LS�I rX�U C. PHONE q
STATE WELL CONSTRUCTION PEIUvIITN ASSOCIATED WQ PER511T'4
(if appl icable) (if applicable)
1. WELL USE(Check Applicable Box): Residential42Y Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATI I - Topographic/Land setting
Ne re t Town: / /crx1 County / AC.-JAL ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Ambers,Com/m-uvnity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: e\b1g64 P'�F" I_ha{✓ (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
;61 ill L a�(7 3 y DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number D J
4. DATE DRILLED I ��aS ty7-
5. TOTAL DEPTH: 5-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ t ,L
7. STATIC WATER LEVEL Below Top of Casing: AFT. 4m
_ (Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT. Above Land Surface* �
"'Top of casing terminated eVor below land surface requires e
mr
-tA
variance In accordance with ISA NCAC 2C.0118. �o
9. YIELD(gpm): .?D l METHOD OF TEST ,4;r _ L4 X�
10. WATER ZONES (depth): _ ��
LOCATION SKETCH w ci
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
Depthh(� Diamert r or Weight/Ft. Material numbers and common road names.
From To Ft. Lf Q✓r_— _.
From To Ft. / _From To Ft.
"n
13, GROUT: Depth Material Method - M C `
From To-2o Ft. t ji'N
From To FL �' s)
.. -
14. SCREEN: Depth Diameter Slot Size Material �-
From ;r To Ft. in. in. o g G
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 Ild ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
% � � &1 _ �z-aa-vs
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. 0712001

WELL CONSTRUCTION RECORD �
308188
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NA�M�ffE``(printh,,,L/ "17//ir[ C/-,9✓G CERTIFICATION#A� /
WELL CONTRACTOR COMPANY NAPIEQ- ti eAnA US -��/,` �� y�t/�G — _PHONE 0
STATE WELL CONSTRUCTION PERLMIT# ASSOCIATED WQ PERMITM
(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 Topographic/Land setting
Nearest TowOCATIn: %d Countyz .4 6,0 ❑Ridge ❑Slope ❑Valley ❑Flat
7Zd de (check appropriate box)
(Street Namf,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:&4 f r 1-AA (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Rome No.) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number U—
4. DATE DRILLED
5. TOTAL DEPTH:_ oS
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I*]
7. STATIC WATER LEVEL Below Top of Casing: -2 U 0 F . o�
(Use"+"if Above Top of Casing) _ a
8. TOP OF CASING IS FT, Above Land Surface* fin s, t
•Top of casing terminated nt/or below land surface requires a --1R't ;r- 4
variance In accordance with ISA NCAC 2C.0119. -am
9. YIELD(gpm)304- METHOD OF TEST /��r j ate_
10. WATER ZONES(depth):
LOCATION SKETCH-te -RA
11. DISINFECTION:Type Amount Show direction and distance in mile%Wm at
12. CASING: Wall Thickness two State Roads or County Roads. Include th zd
Depth Diar)r ter or Weight/FI. Material numbers and common road name§ W e� _
From To-,42-5— Ft. le ZX
From To FL
From To Ft. {{
13. GROUT; Depth Material Method <-> 'n �
From
__Q�_To
n�A Ft. C`0�1'L&ai:From--To -Ft._ _.___ �; 1►r1 ' �;
14. SCREEN: Depth Diameter Slot Size Material - ` Call
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
CONSSTT UCTION 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 SerNice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD Li-A 308187
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) C-IJ'�A}y✓Ls CERTIFICATION N--Z141
WELL CONTRACTOR COMPANY NAME e/' vDs Gl/�1�`//if/G�C. PHONE NYGc�I.Jy
STATE WELL CONSTRUCTION PERMIT11 ASSOCIATED WQ PERMITN
(if applicable) (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 LOCATIONTopographic/Land setting
Nearest Town: T L/MLO�Z:�/ County _ ❑Ridge ❑Slope ❑Valley ❑Flat
All Jt -,[ (check appropriate box)
(Street Name,l uum--bets.Communit Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: .cAI& R{A5 (degrees/minutes/secmtds)
Address �7(a_ !/�7�""� �✓ Latitude/longitude source:❑GPS❑Topographic map
L(Street or Route No.) (check box)
�iFYA/,[/e,i , n/G aLg73,y DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone numbe p (�
4, DATE DRILLED I-a - o S" O a�
5. TOTAL DEPTH: ❑ ❑ O rn 6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: D D Ff. r 7
(Use"+"if Above Top of Casing) r1't
8. TOP OF CASING IS. FT.Above Land Surface'
*Top of casing terminated atlor below land surface requires a LNA �fl
variance In accordance with ISA NCAC 2C.0118. per*^--
9. YIELD(gpm):/U -/5' METHOD OF TEST ice✓ _ "0
10. WATER ZONES(depth): _ c�
LOCATION SKETCH •• ul .
11. DISINFECTION: Type Amount Show direction and distance in miles ,pm at lot
12. CASING: Wall Thickness two Slate Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and..common road namesr
From_5 To AD Ft. / %1 Or/r r
Prom To FL �— 3
From TO Ft.
11, GROUT: Depth Material Method
From
To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -- r_' ycTb c-
From To Ft. in. in. _
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material 4
From To FL
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ill ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T14E WELL OWNER
SIGNA I URL 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

01
WELL CONSTRUCTION RECORD 3 0 9 9 0 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 # (E29)369-9591
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❑ If Other,List Use
2. WELL LOCATION: �) Topographic Land setting
Nea;estTown: 4,��*„ —County ►(IQCgµ-, ❑Ridge ❑Slope ❑Valley ❑Fla[
Crl e,f art0, (check appropriate box)
(Street Name,Numbers,01mmunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER (degrees/minutes/seconds)
Address .{D Q3 Latitude/longitude source:❑GPS❑Topographic map
(Sir et or Route No.) (check box)60
F) DEPTH DRILLING LOG
City or sown crate Zip code From To Formation Description
law)- clay it sand
Areaco code-Phone number r ' granite
4. DATE DRILLED 3' l'O5
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: (pM 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 'V
variance in accordsm%xwith 15A NCAC 2C.O11S.
9. YIELD(gpm): et+ METHOD OF TEST BLOW
10.WATER ZONES(depth): 11RI,tU50.46 —, ro {
LOCATION SKETCH pp
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at Fast
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighVFt. tenal numbers and common road names.
From 0 To 3 Ft.
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.
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
la 64JA'a�e
L8 n�
NATrater
OF PE CONSTRUCTING THE WELL ATE
r
Submit the original to the Division of Quality,Attn:Information Management,1617 Mail Service Center- T
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/200T'
m

309878
11'li;l�l, t 't11V i 1RUCTION I(I;l_(1_RD
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1 it a dir:;l•I - - it r I i�'a1�L
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309970
WELL CONSTRUCTION RECORD
North Carolina-Department of Environmtint and Natural Resources-Division of Water Quality-Groundwater Section,—�
WELL CONTRACTOR(INDIVIDUAL)NAML (prtut) -Iiints IIn.+� `� CTATIPICCAMooNIt -7 to
WELL CONTRACTOR COMPANY NAM •' PHONL a�¢�t�7.s�_�3 �-6
STATE WELL CONSTRUCTION-PiRMl7Y - ASSOC(ATP.D W14tititirro .
(if applicable) (ifapplicabit) '
1. WELL USE(Check Applicable Box)rResident'ial' w icipavpublic❑ Industrial O Agricultural O
Monitoring O Recovery 0' Heat Pump Water Injection 0 Other C( if Other,List Use
2.-WELL LOCATION- TopogxrI d setting
NearestTown: 1 t'/ LICLi /11 County-NA 'NV ' Midge omSTpe Malley OFlat
�/✓ � Citt.P�A/l2-�. - ' 2 (2 c' (check appropriak box) ' a
(Street Nano,Number, muniry,sanbdiviston,Lot No.,rip Y LAtitudellongitude of Well location
3. OWNER: LP t`L�i, (�`-� P_-c-e__ - •(degrces)miautWieoonds) .
Address /7L ,I 5111 T-eaa I Latitudellongitudesource:00PSOTopographicmap
(Street or Rouen Na.) V (ebaek box)
lY2�+ sfrti , Shnr�S . L')• 337c � DEPTH ' DRILLING LOG
City or a State zip Code From To ' Formation Description
mcod .39/ - s9 1�
Arco coda•Phone number �, �` - �+ �-
4. DATE DRILLED Lf — S-G�
5. TOTAL DEPTH: /n e^l- '
6. DOES WELL REPLACE EXISTING WELL? YES D NO
7. STATIC WATER LEVEL Below Top of Casing: Z ` -FT:
(Ua"t'if Abeve Top of Casing)
8. TOP OF CASING IS�_FT.Above Lend Surfaces
,Top of casing terminated actor beigtf iwasurface mquiris a
variance is aeeordaaee withTSANCAC 2C.011a.
9. YIELD(gpm): MBTHODST /m OF TE I mod-,
10.WATER ZONES(depth): '
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter .or WciighVFL `Mategill 'numbers Ind common road names.
From . To `, _, - i_ ro
From To FL qp
From�Tp AFL L"" e n x eE
13. GROUT: Depth Materiil —Method l N `�
From_To�_Ft. now ..
From To FL C 3
.4. SCREEN: Depth Diameter Slot Sim - Material cr�
From To Ft. in, in.
From To Ft. in. in.
5. SAND/GRAVELPACK: _
Depth Sim Material - - -
From To FL
From To Ft. -
6. REMARKS: 7
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTBD IN ACCORDANCB WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF RECORD HAS BEEN PROVIDED To THEMELL OWNER IXI
SIGNATURE OF PERSON CONSTRUC)iNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC --
a7699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

.309969
.WELL• CONSTRUCTION RECORD'
North Carolina-Department of Environment and Natural Resources-Division of 't Quality-Groundwater Section
W ELL CONTRACTOR(INDIV.IDUAL)-NAMg (prlat) t r i PI t 5 I i .A TIPICATION a /7 4e
WELL CONTRACTOR COMPANY NAM •• ,PNONR aqnf,�L/"3 a•6 0
STATE WELL CONSTRUCTION PLRMITa ASSOCIATED W ERMrTa
(if applicable) {ifapplieable)
1. WELL USE(Chock Applicable Box):Residential' unicipal/Public❑ Industrial❑ Agricultural O
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other CI If Ot)ier,List Use
2.-WELL LOCATIO : TWO pg<a h' .and setting
Ne^aryrest,To j //�L i County > ❑Ridge o Malley .❑Flat
o /V /�/ i 12 noyt (zZ _ W .IIUk1 (Jund2d (eheekappropdatebaa) . - a
(Street Name.Numbers,Community,Subdivision,Lot No.Zip code) I&-7 3 yC Liltitude/longitudo of wcll location
3. OWNER: (dayeedmiautUISWon&) .
Address 13-5 w X L 4V N LatitudeAongitude source:❑GPS❑Topographic map
Ale No) a K�3 LI DEPTH
E TH (DRILLING LOG
City ryw Town Zip Code From To - Formation Description
( -_�•hL,. 3Sratei7 n 3.3 ' �/
Area code•Phone number "` - ^ - Q ,
4. DATE DRILLED � —/ —�S _
5. TOTAL DEPTH: SS '
6. DOES WELL REPLACE EXISTING WELL? YES❑-NO
7. STATIC WATER LEVEL Below Top of Casing: AFT.
(Use"e if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface*
-Top of ruing termlusted Wor betaty laodsurfaee requires■ -
variance In aecordang witht?ANCAC 3C.0110.
9. YIELD(gprtt): Y0 7-METHOD OF TBST //ll/ aw=G
10.WATER ZONES(depth): SD ' ft
LOCATION SKETCH
11. DISINFECTION:Type W= Amount Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
—I)cpth_ Did 5 or Wei
3 Ft `Qypl -numbers and common road times.From o_y�j J.
From To Ft,
From To Ft._
13. GROUT: Depth Materiel Method
From To_a -Ft.. notes,ZM c 9'T
«;
From To Ft. 2� - - - 11
.4. SCREEN: Depth Diameter Slot Size a Material - N
From To Ft. in. in.
From To Ftti_in. in. C:) 4
5. SAND/GRAVEL PACK: LnA
Depth Size Material -
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WTM 156 NCAC 2C,WELL ?
17NSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD R&S BEEN P40VIDED TO THE WELL OWNER
SIGNATURE-OFPERSONCONSTRUCTINGTHBWELL - DATE -->
3 ubmiI the original-to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC -
a'j699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001

( a01
310004
WELL CONSTRUCTION RECORD
North Carolina-Department of Environmeht and Natural Resources-Division of W eterQuality-Groundwater Section
WELL CONTRACTOR(INDlYIDUAyMAMB (pAu* K g-i],1'11� 11 ^A a CLA7WICATIONi of��te
WELL CONTRACTOR COMPANY NAM YUONii4-'3
STATE WELL CONSTRUCT1oN PLfRMTrp ASSOCiATED W 1W rro -
<ifapplieabie) - �(lfappl)cable)
L WELL USE(Check Applicable Box):Residential unicipal/Public❑ Industrial O Agricultural Q
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other ET If 66ter,List Use
2.-WELL LOCATION: ograpltidLnlld setting
Nearest Town: �%/y LICL n� dun �` � dge ❑Slope Malloy .❑Flat
Q N .SL2�nc)PR-S trwti rL� - 0±n Ci vDVF- Q-.'._ (hack appropriate box)
(Street Name.Nuummbem Commuoify,SubdiWwa,lat No.,7.rp Coii!4 a g 7 3 of Latitudo/lotigituda of well location
3. OWNER: 12n-u ct� I � .Pir...� (daareJmiautahecondr) .
Address -- (o�4 n- -� Latitude/longiWile source:❑GPS❑Topographic map
(Suitror Route No.) c (cheek box)
a aj,l - S .1/C, n`1.6 93 Vz DEPTH. ' DRILLINGLOG.
City i, Town Stye . Zip Coda From To Formation Description
(gam 3 6 -_
Area erode-Phone number
4. DATE DRILLED - '
5. TOTAL DEPTH: r Q
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: 1 FT:
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS ! FT.Above Land Surfaces
-Top of easing terminated agar below Iwtrurface requires a
varlance In aecordanee th t9ANCAC 2C.0118.
9. YIELD(gpru): 7 METHOD OF TEST
10.WATER ZONES(depth): / qL
LOCATION SKETCH
11. DISINFECTION;Type Amount Show direction and distance In miles from at least
12. CASING: Wall Thiciuless two State Roads or County Roads.Include the road
Depth Diar of We0UFL `MakkDD -numbers and common road names. 3
From_O To�Ft, S K
From To Ft.
From To—FL tV L
13. GROUT: Depth Materiel Method l O
From To-z2D_Ft.
From To 'FL _ -
-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.
ar
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrm 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN PROVIDED TO M WELL OWNER
a))1 'lam ' =
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE -
-submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
v0'1699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001---:

308749
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources Division of Water Quality'-Groundwater Section
WELL CONTRACTOR(INDIvIDUAL)NAME (print) I� .A a cet�TtpI�CATTe/ONs!J174o
WELL CONTRACTOR COMPANY NAM PHONlt 1i�"3 �6
STATE WELL CONSTRUCTION PERMITS ASSOCIATED W4 ERMrr#
(ifapplicable) (ifapplicnble)
1. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial Cl Agricultural 0
Monitoring❑ Recovery ❑' Hcat Pump Water Injection❑ Other Ef If Other,List Use
2.-WELL LOCATION: Icdmd setting
Nearest Town: Q/tp County I$1(rdgo C1SIope Malley ❑Flat
4 V l .S S I 0-10 C(2. E A. (check appropriate box) . a
(Street Name,NN/uy�mbem Cotnmunii Subdivision,LM No..Zip code) - Latitude/iongitude of wall location
3. OWNER: l " Ih AD. IC D LL - - (degreeJmitwta/aeeond;)
Address SC' $ I W V D I r.-rt-h'e e P flp w Latitude/longittide source:❑GPS❑Topographic map
SWei or Route No.) - — -(check box) .
Neu) Pori 9:ekL, t=1. 3 ci 53 DEPTH " DRILLING LOG
Ciry or Town S Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 3 — / —OS p R l v -e ✓4n, I t
5. TOTAL DEPTH: /,L/0 S'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO_
7. STATIC WATER LEVEL Below Top of Casing: O r Ff:
(Use"t"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surface* t�
-Top of cuing terminated aulor below ipad;urface require;a
variance in accordance with ISA HCAC 2C.0114 a
9. YIELD(gpm): (jo, _METHOD OF TEST_
10. WATER ZONES(depth): / N
LOCATION SKETCH —
11. DISINFECfION:.Type Amount Show direction and distance in miles from at least C:
12. CASING: Wall Thickness two State Roads or County Roads.Include the road rn
Depth Di ter .or WeovFt. Mate 1_ 'numbers and common road names.
Fro m�To�4Ft.=S�2
From To Ft.
From To_Ft.
13. GROUT.: Depth Mated I Method
From To�_Ft.
From To Ft.
.4. SCREEN: Depth Diameter . Slot Sin Material '
From To Ft. in. in.
From To Ft. in. in.
S. 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"
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H&S BEEN PgOVIDED 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
,y7699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

308748
WELL CONSTRUCTION RECORD
North Catt'olina-Department of Environment and Natural Resources Division of Water Quality-Oroundwater Section /-
WELLCONTRACfOR(INDIV,IDUAL)'NAME (print)='tf t1Nl5 II(1 a CEIk7sFICCATIIOOMY�oZ,,��7`c I
WELL CONTRACTOR COMPANY NAM PH ONE 9
STATE WELL CONSTRUCTION PERMITp ASSOCIATED W ERMITI .
(if applicable) {(fapplicable)
I. WELL USE(Check Applicable Box):Residential' .unicipal/Public❑ industrial❑ Agricultural Q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 11 If Other,List Use
2.-WELL LOCATION: Topograp ' d setting
Nearest Town:/ A*k L i N/ County..Al A� ' / Midge ope Malley OFlat
"I /V 0,+ -t CL�ll dt.k D T)P� Oct 173 '7' (check appropriate box) . f
(Street Name,Numbers,Community,Subdivision,Lot No.,zip Code) LatitudaAotigitude of well location
3. OWNER: . C hn d (r-eI?,I 6LLk - (degrouhninutedsIwonds)
Address ID501 /) 12"110— Ifs 't• LatitudeAongitudesource:❑GPS❑Topographicmap
(Street or Route No.) -(cheek box)ffi .
!/ .moo lG(" 3 R(0 L� DEPTH DRILLING LOG
cay'r Town Sum Zip Code From To ' Formation Description
Area code-Phone number 3 - —�� • �73• -
4. DATE DRILLED O—' jj • 3 6_9*1 R i U e- G Y „ +� r-e-
5. TOTAL DEPTH: �-S•
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO,-
7. STATIC WATER LEVEL Below Top of Casing:—4-a-JT. R
(Uu"+"if Above Top of Cuing)
8. TOP OF CASING IS_�FT.Above Land Surface•
-Top or cuing terminated atlor belpw laadmrface requires a - a
variance In accordance wlth7SA NCAC 3C.0111.
9. YIELD(gpm): . 21) METHOD OF TEST N_
10.WATER ZONES(depth): /900
LOCATION SKETCH O
11. DISINFECTION:Type Amount Show direction and distance in miles from at least u7
12. CASING: Wall Thickness two State Roads or County Roads.Include the road €,3
Depth Dia%ppaeter or We0tiFL Mate 1_ numbers and common road names.
m � --
Fro To_ Ft.�
From To Ft.
From To Ft._
13. GROUT: Depth Material Method l -
From_lD--To—,nD--Ft. n ..�ddL..
From To Ft.
4. SCREEN: Depth Diameter Slot Size r 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 I5A NCAC 2C,WELL
ONSfRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Sections 1636 Mail Service Center.Raleigh,NC
.0"1699-1636 Phone No.[phone],within 30 days. GW-t REV.07/2001

308747
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of or Quality-Groundwater Section "
WELL CONTRACTOR(INDIV,IDUAL)NAMB (printLcbV_t)"I S CP,R.T'[pICAT10N 7/1 o1� y
WELL CONTRACTORCOMPANYNAM PHONLd i_S2t4 3 ZZ
STATE WELL CONSTRUCTION PERMITIF ASSOCIATED W ERMITN
(ifapplicable) -(ifappllcable)
I. WELL USE(Check Applicable Box):Residential' unicipaUPublic❑ Industrial Cl Agricultural lJ
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other[I If OtFier,List Use
2."WELL LOCATION: 746imphie/Land setting
l2 Nearest Town: ram i,, i_ A County , A-f Mdge Mope Malley ❑Flat
4415 5 S 1!-•a kI EI N R eL-14 n v c e C h D� (check appropriate box) . I
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) tz r a l L$titudeHongitude of wall location
3. OWNER: v .0 S? I/
1YYl�U/YI Il.�
Address �b) lo�)ag �` , (degraealminuus/ieconda)
C Latitudellongitude source:❑GPS❑Topographic map
(Sure,or Raute No.) (( L� -(check box)
5�11(� 3 `L C �l S DEPTH DRILLING LOG
Citybr Town State � zip code From To Formation Description
17.a- (� 4,0 . 3 i4_5 D �•
Area code-Phone amber
4. DATE DRILLED 3 —U Z,� -- os k S Tio t t2 }
5. TOTAL DEPTH: .SAS '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /D 0 FT:
(Use"i`if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
•Top or castna terminated at/or betpw teadsurface requires a
variance In accordance with 15A NCAC SC,01IL 13
9. YIELD(gpm): 1 METHOD OF TEST = m
10.WATER ZONES(depth): 1 U' A- I SD 1 a 0
LOCATION SKETCH rV
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 r
Depth Di ter or Webht/Ft. Mate ' 1 -numbers and common road names. Ln
From_f_To_L� Ft- $-a, f -
From To Ft.
From To Ft.
l3. GROUT: Depth Materiia Method -
From_(ZTo_ao�D Ft, n n `
From To FL r
-4. SCREEN: Depth Diameter . Slot Size Material - - -
From To Ft._in. in.
From To Ft. in. in.
S. SAND/GRAVEL PACK:
Depth Size Material
From To FL -
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 H BEEN P90V D D TO THE WELL OWNER
SIGN ATUREOFFPP(E/RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mali Service Center-Raleigh,NC
,p 7699-1636 Phone No.[phone],within 30 days. - GW-I REV.07nooI

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality - 808 77
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Taylor CERTIFICATION#2187 8
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❑ Agriculturai❑
?Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N: Topographic/Land setting
Ne estTown• County�(�Q'_ DRidge ❑Slope Walley DFlat
& y UAlkl (check appropriate box)
(Street Name,Numbers,Commum ,Subdivision,Lot o.,Zip Code) Latitude/longitude of well location
3. OWNER: aistti (degrees/minutes/seconds)
Address O Latitude/longitude source:DGPSOTopographic map
(Street or Route o.) (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From T , Formation Description
(ago)- t - r 0 3 clay&sand
AreaPhone number _ _ ' d granite
4. DATETE D DRILLED
5. TOTAL DEPTH: DO '
6. DOES WELL REPLACE EXISTING WELL? YES D NO
7. STATIC WATER LEVEL Below Top of Casing: ROO 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 accordanf�a Ith 15A NCAC 2C.0118.
I
9. YIELD(gpm): n METHOD OF TEST BLOW
10.WATER ZONES(depth): (/5' 428(� 30 —
LOCATION SKETCH
11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. -
From o To Ft. G tr
From To(L
34 f Y t
From To Ft._ O �
13. GROUT: Depth Material Method rr%,
From 0 To 20 Ft. Benonite&cement pumped ya -01
From To Ft. AQ
14. SCREEN: Depth Diameter Slot Size Material 4
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: w ya
Depth Size Material nc7,
From To Ft. t7
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND T AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-R O C� `1 06
SI ATURPM 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 30 ,9051
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 Herren 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 O Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI dge O lope OV setting
Nearest Town: County ❑Ridge ❑Slope OValley OFlat
1 V444k 1 � (check appropriate box)
(Street Name,Numbers,,Cmm ,omu ubdivision,Lot No.,Zip Code) Latitude/longitude of well location
`
3. OWNER: le (degrees/mmutes/seconds)
Address )010 Latitude longitude source:OGPSOTopographic map
(Street or Route No.) (check box)
e $734 DEPTH DRILLING LOG
City or Town State Zip Code From 9� f Formation Description
B( 2B )- 5Zy-L(Uj 1 0 clay&sand
Area code-Phone number granite
4. DATEDRILLED 3- 16 •a5
5. TOTAL DEPTH:
--��-
6. DOES WELL REPLACE EXISTING WELL? YES O NO d(
7. STATIC WATER LEVEL Below Top of Casing: SCO 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 w th 15A NCAC 2C.0118.
9. YIELD(gpm):_U METHOp F TEST BLOW
10.WATER ZONES(depth): a 3 f 3t Ip
�-1 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. Mateeri'at numbers and common road names.
From 0 To 93 Ft. (o•r fY/ -
From�- • To Ft. (e,• t/ _, a {
From To Ft.
13. GROUT: Depth Material Method N)
From 0 To 20 Ft. Benonite&cement pumped W
From To Ft. CD
14. SCREEN: Depth Diameter Slot Size Material Ln
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 _ J
CONST TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER: t
4
SIG TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center sp -
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.0,11fQ04 _.

WELL CONSTRUCTION RECORD30911 3
r(w:
North Carolina-Department of Environment and Natural Resources-Division of Water Quality Groundwater Section
r Q tY`
WELL CONTRACTOR(INDtyIDUAL)NAME (print) <��►j p11 / � "` ' .^` I" "
CY�TWICATIONY oZ17(P
WELL CONTRACTOR COMPANY NAM
STATE WELL CONSTRUCTION PI(RMt7'Y. - AggOCCATED W RUselessness RMITY , "
(ifapplitable) -
((fapplicable)
1. WELL USE(Check Applicable Box):Wrient'ial O-14unicipal/Public❑ Industrial 0 All ricultural0
Monitoring 0 Recovery 0 Heat Pump Water Injection O Other Ef If Ot)ier,List Use
2.-WELL LOCATIQN:
Nearest Town: Q / County, v . � Topogtsir"olLand setting
(o _ L t sr✓ c I q L/ Midge OSlope Malley(Street Name,Number:,Commumry,subdivision,Lot No,Zip Code) (eheek appropriate box)
LptitudcAOngitude of wall location
3. OWNER: f (dJ @$ / (dellrees)minutealaeeands)
Address 3 7 S'7 /3//r S as rr- H-S 2 r+ Latitudeflongitude source:OGPSOTopogmphic map
(Sues or Route No.) (check box)
P L'A, a g73� DEPTH " DRILLING LOG
ary or Town ute zip code From To
36 ?- �3ss n FormationDescription
Area code.Phone number ,
4. DATE DRILLED ��-D - _ - S rf�'
5. TOTAL DEPTH: L
6. DOES WELL REPLACE EXISTING WELL? YES D NO T-Q"
7. STATIC WATER LEVEL Below Top of Casing. FI;
(Uae'Y"i(Above Top of Cuir,0
8. TOP OF CASING IS _FT.Above Lend Surface*
'Top of eulna termtuated atlor belaw laad.mrfaw requires a
variance in accord ay wltkTSANCAC2C.011a.
9. YIELD(gpm):_0 METHOD OF TEST
10.WATER ZONES(depth):
11. DISINFECTION:T e LOCATION KETCH
yp Amount Show direction and.distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weom -M pl numbers and common road names.
From To�M FL_ hZ_
From To FL
From To FL y.
13. GROUT: Depth Material Method
2 N
From— To_a�F` now
From To ►—"— o _
A. SCREEN: Depth Diameter Slot size Material - Ln
From To Ft. in. in. - P
From-—TO—Ft. in. in. -
5. SAND/GRAVEL PACK:
Depth Size Material
-
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT IS WELL WAS CONSTRUCII D IN ACCORDANCE WITIJ 15A NCAC 2C,WELL ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN PI;OVIDED TO THE WELL OWNER
" �rs�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
n0'7699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001 -- --

WELL CONSTRUCTION RECORD 3 O 9 1 1 2
North Carolina-Department of Environment and Natural Resources-Division of Water Q uality•Groundwater Section
WELL CONTRAC-rOR(INDIV,1DUAt)'NAM¢ riot(P )��n n 1 5 !�n 11 n - czjqmcATi No /7(e
WELL CONTRACTOR COMPANY NAMPNONL
STATE WELL CONSTRUCTION PERMITY— -(if applicable) AaSOCIAT¢DW ¢AMITY
_-
(if applicable)
1. WELL USE(Check Applicable Box): Residential 7a—tvtunicipal/Public❑ Industrial E3 Agricultural 0
Monitoring O Recovery ❑' Heat Pump Water Injection❑ Other Cf If Oilier,List Use
2. WELL LOCATION:
Nearest Town: QAykL ; /y County_ A CdYv Topogt Sp ' and setting
u/ n/ R�B 81 T o, (� 2 -D D A .rEr R d Midge ope ❑Valley ❑Fiat
(Street Nam mm
e,Numbers,Coumry,Subdivision,tot No.,Zip Code) (chock appropriate box)
a673tf Latitude/longitude of well location
3. OWNER: lj i
Address -__jO�{ I // �— ' - (desreer7miautesheeonds)
— 4'f9Di ee �Sr P_r Latitude/longittide source:OGPSOTopographic map
(Street or Re No. V
i �4� (check box)i . ,-�,f 07 (� DEPTH DRILLING LOG
OLrr��,�C,ity or T�wp State Zip Code
2 -_s•„2( 9 _ a 7� q _ _ From To .Formation Description
i Area code-Phone number -, P-1 all
4. DATE DRILLED_ 3—// �
5. TOTAL DEPTH: _4DS' Ei /f (:�tAP—
6. DOES WELL REPLACE EXISTING WELL? YES❑ N0.
7. STATIC WATER LEVEL Below Top of Casing: /D b -FT:
/`
8. TOP OF CASING IS /
1 aa"+"tfAbovc Top orCasin� .
—rTr'T---FT.Above Land Surfaces,
'Top creasing terminated auor bekw landsurfaee requires■ -
variance In accordance wlth7SA NCAC 2C.OIIR
9. YIELD(gpm):___[YS METHOD OF TEST
10. WATER ZONES(depth):, ,2D_�, �9 51 1
11. DISINFECTION:Type LOCATI_ ON SKETCH_ iii333
YP Amount Show direction and distance in miles from at least y
12. CASING: Wall Thickness two State Roads or County Roads.Include the road : !�
Depth Dia ter or Weot/Ft. Mate 1 numbers and common road names. N
From To,—FL_�$.j2�' =1
al
From To Ft. 0
From To Ft. Qn
13. GROUT: Depth Material Method
From To "I'M FFt t.
From To 7"""`�—
.4. SCREEN: Depth Diameter . Slot Size • Material
From To FL in. in.
From To Ft. in. in.
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCMD IN ACCORDANCE WITH 15A NCAC 1C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD BEEN PROVIDED TO THE WELL OWNER--
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Qu all ty,Groundwater Section, 1636 Matt Service Center-Raleigh,NC
.77699-1636 Phone No.[phone],within 30 days.
OW-1 REV.07/2001

WELL CONSTRUCTION RECORD v-
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 Topographic/Land setting
Neare Town: 4 CountyffW32kme ❑Ridge ❑Slope ❑Valley []Flat
1 (check appropriate box)
(Street Nam Numbeerrs,Conua unity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (j 1/]/io (degrees/minutes/seconds)
Address 07e�CAILatitude/longitude source:❑GPS❑Topographic map
(Street or Rou No.) J (check box)
'/ DEPTH DRILLING LOG
City or To i §tat6 Zip Code From Formation Description
3 _��,,�_� Clay&Sand
Area code-Phone number Granite
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 121
7. STATIC WATER LEVEL Below Top of Casing: 60 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.0118.
9. YIELD(gpm): _METHOD OF TES BLOW
10. WATER ZONES(depth): 1rt ]�� tl
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 roadq
Depth Diameter or Weight/Ft. Wterial numbers and common road names.
From_To_�/L Ft. Jr•• .�A8
From 0 To Ft. C
2 +
From To Ft. tV
13. GROUT: Depth Material Method W 715
From 0 To 20 Ft.6encnite&Cement pumped ^'
a
From To Ft. OLn
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 T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIONS D RDS,AND T COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER _
SIGirATURE 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 -
j

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section "
WELL CONTRACTOR(INDIVIDUAL)NAME (prla0 c�PII PII I It7�ter(. A CEI�TtpiCAmii# l
PHONE Y
WELL CONTRACTOR COMPANY NAM 17V'_.S2 L, 3 ;Z6 O
STATE WELL CONSTRUCTION PERMIT# - ASSOCIATED W ERMIT#
(if applicable) - (if applicable) - -
I. WELL USE(Check Applicable:Box):Residential' unicipaVPublic❑ Industrial❑ Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other EF If Other,List Use
2.-WELL LOCATION: Topog2apic/Land setting
Nearest Town: 0 County �� Midge )]S)o.�o'[ Valley ❑Flat
/ S �>✓ S S•e iZ'} .rt- e_ 1 rr-7 :`3 (check approprista box) - '
(Street Name,Numbers.Community,Sub/di No.,Zip Lot N zip Code) LAtitudellongitude of well location
3. OWNER: �}/Pig -ems /J ULIL Ct h t��
Moth
) .
Address .3 LatitudeAongitudesource:❑GPS❑Topographicmap
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City"
Town Suu Zip Code From To Formation Description
Area code.Phone number
4. DATE DRILLED 6 - —CAS
5. TOTAL DEPTH: Sb '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—.�PT:
(Use"t"if Above Top of Caving)
8. TOP OF CASING IS FT.Above Land Surface* C
'Top of cuing terminated atior belgvr leattaurfaa requires a
varlance In accordance with ISA NCAC 2C.0118. r— ttt
9. YIELD(gpm): _METHOD OF TEST I
10.WATER ZONES(depth): a2/,;2 ' r-n
LOCATION SKETCH O
it. DISINFECTION:Type Amount Show direction and distance in miles from at least is
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di a ter or We AIR Mate ' 1 numbers and common road names.
5.a�
From To FL
From To FL_
13. GROUT: Depth Material Method
From_b—To—c�&—Ft. n.-
From To Ft.
.4. SCREEN: Depth Diameter _ Slot Size Material
From To FL—in. in.
From To Ft. in. in. 1
S. SAND/GRAVEL PACK: ! r -
Depth Size Material -
From To Ft. ' CD
From To Ft. `3
c�
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 H BEEN PROVIDED TO THE.WELL OWNER
err►a c-S C/-a G
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
rubmit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
."699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

CONSTRUCTION v CTION RECORD
North Carolina-Department of Environrricht and Natural Resources-Division of W akr Quality-Groundwater Section
!�L . �.....__- " VeWELL CONTRACTOR(INDIVIDUAL)NAMR (p, * be YfvtS CP77 FICA0Nt ofJ
WELL CONTRACTOR COMPANY NAM PBONL i(Ai -
_S14-3
STATE WELL CONSTRUCTION P9104rrY w».;OCIATED W BRatITa
(ifapplieabie) - (ifapplkcabie)
1. WELL USE(Check Applicable Box):Residential- unicipal/Public❑ Industrial O Agricultural p
Monitoring O Recovery 0' Heat Pump Water Injection❑ Other Cf If Oilier,List Use
2."WELL LOCATION: . Top Land setting
Nearest Town: 1tD County 4 n ORidge lope OValley OFlat
a 0'7 �, � (eb�aapp�Pd.abwt> .
(Suer Name,Number,Commuairy,Subdivision,lot No,Tap Code) Latitude/kOngitude of Well location
3. OWNER:1_i n S �� -e i2 (depeeJmiautes/aoconds)
Address 5 3 C 3�n kJ CC z ej e I I (2s 1 Latitude/Iongitude source:00PSOTopographic map
(Street or Ra No.) (chock box)
i 4 v T fe I; 33,560 DEPTH DRILLING LOG
_ orTowa Sum zip coat
L� 57- - From To - .Formation Description
7lvS o
Area code-Phone number -
4. DATE DRILLED 1 4f—Z15 `) f y hn ) /
4a
5. TOTAL DEPTH:�/�` � - f�
6. DOES WELL REPLACE EXISTING WELL? YES O.NO: `
7. STATIC WATER LEVEL Below Top of Casing: r
(Use' r if Above Top of CasirWGn
t _?
8. TOP OF CASING IS�_FT.Above Land Surface*
•Top of wing lambasted atior below lwd.sarfaee requhms a
varlaaee In accordance witbt9ANCAC 3C.0118.
9. YIELD(gpm):—_METHOD OF TEST~
10.WATER ZONES(depth):
LOCATION
11. DISINFECTION:Type Amount Q TA Show direction and distance is miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
From�Depth Di or Weiylt"FL Material ''numbers and common road names.
To oZ L rr� , J:�j� : _S�Pe =;1,
From To FL J
From T9 FL_
13. GROUT: Depth Mate"
From �-- �To 'zD—FL From To Ft.
.4. SCREEN: Depth
Dep Diameter Slot Siu : Material
From To FL in. in. �--�1 0 --
From To Ft. in. in
5. SAND/GRAVEL PACK-
Depth Siu Material
From To Ft. zL _
From To Ft.
6. REMARKS: --
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCI'BD IN ACCORDANCE WM 15A NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN P40VIDED TO THE.WELL OWNER
� (7' C. ) �7_>
SIGNATURE )F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
o7`7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD 0 " i
-i- 4 o 14)
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. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery 0 Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL L ow, N: Topographic/Land setting
Nearest�TJ,orwn, County 7�j ❑Ridge ❑Slope ❑Valley ❑Flat
IL.h (check appropriate box)
(StreeAPhone ?
um Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OW
(degrees minutes/seconds)
Add Latitude/longitude source:DGPSEITopographic map
r cute No. (check box)
y /SIC aR744 DEPTH DRILLING LOte' Zip Code From T Formation Description
(828 Clay&Sand
Area code-Phone number `G 1 Q Granite
4. DATE DRILLED 0_f
5. TOTAL DEPTH: JZ00 r
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 aVor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 8D METHOD OF TEST BLOW
10.WATER ZONES(depth):4Y 3', �9s �, -- —
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 mprter or WeiQ,ht/Ft. Material numbers and common road names.
From 0 To Ft. .
From ft To Ft.
From To FL Cl
13. GROUT: Depth Material Method IZ71
From 0 To 20 Ft.Benanite&Cement _pumped C „
From To Ft. .,
14. SCREEN: Depth Diameter Slot Size Material I
From To Ft. in. in. C
From To Ft. in. in. O 115.
15. SAND/GRAVEL PACK: UT _-
Depth Size Material -
From To Ft. .1
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON ST CTION STANDA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG ATURE OF PERSON CONSTR WNG.THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Inf f 'W.Management,1617 Mail S rY�ae Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. 9 I
�.l AUG 23 2005 � a REV.09/2004

17.
314947
WELL CONSTRUCTION REC,,(ORD
North Carolina- Department of Environment and Natural Resources-Division ofW
W ELL CONTRACTOR(INDIVIDUAL 'NAME rtnt 11 ater Quality-Oroluldwater Section
(D )�,°(7 VI I S Irf»I i n - t �. CEi1tTIPICATION s /'�p WELL CONTRACTOR COM PANY NAM '
STATE WELL CONSTRUCTION PERMM PHONE Y '`/--3 ;26 Q
SSOC
(if applieable) -ASSOCIATED W SRMITa -
(if applicable)
I. WELL USE(Check Applicable Box)- Resident-iial' unicipal/public❑ Industrial q Agricultural q
Moniloring❑ Recovcry ❑ Heat Pump Water Injection❑ Other CT If Otlier, List Use
2. WELL LOCATION:
Nearest Town: �/���/�[ County 4d of raphielLand setting
l q L% /c L TA Ii p 1 ,0 f,yj image 0Slope OValley ❑Flat
(SUMName,Numbers,Community,Subdmsion,hot No.,Zip Code) (check appropriate box) t
�a Latitudi:Aongitude of well location
3. OWNER: C o ' VL
Address f k ,T'e+ � �T , (deareex'minutcYsegnds)
(Street or Reate No.) Latitude/longitude source:00PSOTopographic map
111; " .Ile, a ?,I (check box) .
Gry or Town From state LIP Code F DEPTH
cm- DRILLING LOG
as a is_ 3 7� To Formation Description
Arco code-Phone numbu
4. DATE DRILLED . —US
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 11 NO
7. STATIC WATER LEVEL Below Top of Casing: 167 (ng)
8. TOP OF CASING IS OF"t^ifAbove Top Surface
�Y�—�FT,Above Land Surface' -'Top of c cuinsn accordance
rdance with
h IS below land.surl$ requires a
nrlmce In aewrdaaea wltblSA NCAC gC.OIIi.
9. YIELD Wm):�_METHOD OF TEST �-
10. WATER ZONES (depth): 1
DISINFECTION: LOCATIONSKETCH 1. 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 Di to or Weotif t. Mate ' I 'numbers and common road names.
From
To 20 Ft._M Sit R_
From To Ft, a g
From To FL C K
13. GROUT: DeP� Material °f
From Method
�_To _FL
From To Ft, TP" (
4. SCREEN: Depth N
P Diameter . Slot Size • Material
From To Ft. .
in. in
1131
From To Ft.__in, in
5. SAND/GRAVEL PACK:
From Depth Size Material To Ft. [..-.-._--...__-.y
From To Ft. _
6. REMARKS: =_ c
4)
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU
15
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH WELL
S RECORD H BEN P90V WITH
TO THE WELL OWNER
„I
`'I No
SIGNATURE C PERSON CONSTRUCTING THE WELL _
DATE
,stibmit the original to the Division of Witter Quality,
ays. Groundwater Sections 1636 Mall Service Center•Raleigh,NC i
J'f 699-1636 Phone Na.[phone],within 30 days,
GW-I REV.0712001

4946
WELL CONSTRUCTION RECORD
-------------
ll '
North Carolina-Department of Environment and Natural Resources-Division. W '
NYE LL CONTRACTOR(INDIVIDUAL)NAME (Rrint)sh?11NI Ater Quality Groundwater Section
. 11n �r
WELL CONTRACTOR COMPANY NAM CrJVMCATiON 11-1/7(�
STATE WELL CONSTRUCTION PERhtITYPHONEY �4--g �(, Q
(if applicable) ASSOCIATED W ERMITY
difapplicable)
WELL USE(Check Applicable Box): Resident*.el7d�tYlunicipaVPublic❑ Industrial q Agricultural El
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other Ef if Other,List Use
2. WELL LOCATION:
Nearest Town: �/t'A'&k L;,Il - �graphie/Land setting
County C 'dge IDSlope OValley ❑Flat
iP�/U�:1C 4 -/�r f. lad- ,2 8vJ3 cL � v
(Sues Name,Numbers,Community,Subdmsion,Lot No.,Zip Code) - . - (check appropriate box)
1/ / Latitude/longitude of well location
3. OWNER: V_ O,41e L F2 CSOry
Address '7 Q16 ! 'eF/e�f-.�G Pa nd C 1' ! 4f/ g' (degreedmittuteduconds)
(street or Rouu No.) _ Latitu_de/lon nude sourcCOOPS❑Topographic map
FCVT myeas 6'/ 33 � b s] (check box)
Cny or Town Sate Zip Code DEPTH DRILLING LOO
(Qi)- -3'7- J'S6 6 From TO - r Formation Description
Area code-Phone number n
4. DATE DRILLED 7- JS _.
5. TOTAL DEPTH: A/ T� J31u t (�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—7D--FT:
8. TOP OF CASING is Use +^tf Above Top ofCuing)
FT.Above Land Surface*
*Top of culaa termlueted allor below landsurface,requires■
variance In accordance with ISA NCAC IC.ol la.
9. YIELD(gpm):�L METHOD OF TEST �-
10. WATER ZONES(depth): 3 90 1
11. DISINFECTION:T e LOCATION YP Amount Show direction and distance In miles from at least t5
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Die ter or Weft/Fl Mate ' I ''numbers and common road names, a
From_Q To q / Ft. '2=
From To FL
From To Ft._
U. GROUT: Depth Material Method p ':
From_ To��Ft. u7
From To Ft.
4. SCREEN: Depth Diameter Slot size - ;
From To Ft. Material
__in, in.
From To Ft.—in, in.
D/ AV
5. SANGRELPACK: _
Depth Size Material - --'--------
From To Ft.
From To Ft,
6. REMARKS: > a
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU z
CTED IN ACCORDANCE WITH 15A NCAC 2C,WELL I�
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H S BEEN PROVIDED TO THE WELL OWNER C"
7as � s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE z
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC �C
e17699-1636 Phone No.[phone],within 30 days.
OW-1 REV. 0712001 -

WELL CONSTRUCTION RECORD f? 3 '1 4 5 3 9
North Carolina-Department of Environment and Natural Resources-Division of Water Qua1.
WELL CONTRACTOR(1NDn7DUAL)NAME ( y-Groundwater Section
print)
WELL CONTRACTOR COMPANY NAME CF UHUIHERS WELL DRILLi , 737 — CERTIFICATION#
STATE WELL CONSTRUCTION PERMIT# FRANKLIN, NC 2^ PHONE #� �G
(if a licable) �tS OCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box): Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATIO
Near st TowmL'/ �_Counry_ �J Topographic/Land setting
IJA .R r- ��W ❑Ridge ❑Slope
r-�_--�Y ❑Valley ❑Flat
. (check appropriate box)
(Street N e,Numbers,Community,Subdivision,Lot No.,Zip Code)
1 Latitude/longitude of well location
3. OWNEAddress L � :3 v9 /
Address ,l/ -; (degrees/minutes/seconds)
(Street or Route No.) Latitude/longitude source:❑GPS❑Topographic map
—D'715 bDYu AJ C- a T 7 ZS (check box)
Zi
City or Town State DEPTH DRILLING LOG
p Code From TO
Formation Description
Area code-Phone number
4. DATE DRILLED
(p7— -7 'o
5. TOTAL DEPTH: S-d
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ --- —
7. STATIC WATER LEVEL Below Top of Casing:�_FT.
8. TOP OF CASING IS_�___se"+^if Above Top of Casing)
FT.Above Land Surface* ---- -- c_ T
*Top of casing terminated at/or below land surface requires a �-
variance in accordance with 15A NCAC 2C.0118
9. YIELD(gpm):Qs . r
3 o METHOD OF TEST_ �'y --- N
10. WATER ZONES(depth);
11. DISINFECTION: T e LOCATION SKETCH
YP Amount Show direction and distance in miles from at lest
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
From Depth Diameter or Weight/Ft. Material numbers and common road names.
To_�L FL__y � _
From To Ft.
From To Ft.
13. GROUT: Depth Material Method n
From U To_2,_Ft. C j
From To Ft. -
14. SCREEN: r
Depth Diameter Slot Size Material � G �I
From To Ft. in. in. tv
From To Ft. in. in.
15. SANGRAVEL PA
D/ CK:
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 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�aQS� 3 1 4 5 3 8
North Carolina-Department of Environment and Natu al Resources- Division of Water Quality- Groundwater Section
\VELL CONTRACTOR(INDIVIDUAL)NAME (print)—X�[� LATr�,P
CEI2TIEIC,ITION N
WELL CON"TRACTOR COMPANY NAME
ttss, PHONE N f So2tL`Y'97�
STATE WELL CONSTRUCTION PE12;111TN 2A8 CRANF MIRjMFIA-1ED\VQ PERAIITH
(if applicable) FFFk'1l IN 1C_573�.i fapplicable)
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:
Nearest Town: County /h.Ae-Jrt.) Topographic/Land setting
La LyU � � 1M ob.J1( — ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER: 71--�s C. /dI-A 1
Address (degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
k 3y DEPTH DRILLING LOG
City or Town Slate Zip Code From TO
Formation Description
Area code- Phone number — �-
4. DATE DRILLEDS
5. TOTAL DEPTH: _ / ✓_}_�
6. DOES WELL REPLACE EXISTING WELL? YES ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'Y'if Above Top of asing) C—
"
S. TOP OF CASING IS�_ FT. Above Land Surface* `
•Tnp of casing terminated attar below land surface requires a ...1
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 1 5' METHOD 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 Diameter or Weight/Fl. Material numbers and common road names.
From b To -3/_Ft. 4P'(y
From To FL
From To FL
13. GROUT: Depth Material Method
f ,
From O Tom Ft. -4j(1Zt1 �."� C—
From To Ft. 1 7�L __ c
r
14. SCREEN: Depth Diameter Slot Size Material
From To Pt. in. in.
From To Ft. in, in ' ro
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. r' --7
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED I1J�C�ORTSANL6yGITIfil3atitlEAC 2C, WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING T11E WL"LL
DATE
Submit the original to lire 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 r �
North Carolina-Department of Environment and Natural �� 1453ral Resources-Division of Water Quality- Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ l!. ��L -7
WELL CONTRACTOR COMPANY NAME CERTIFICATION# lam/ 7/
STATE WELL CONSTRUCTION PER:bHT# 248 CR PHONE #
(if a licable) RANKI.4N, I�C�Q ATED WQ pERJyIIT#
2873Fifa licable)
1. WELL USE(Check Applicable Box): Residential❑ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION-
NearestTown- County_ �yt/ Topographic/Land setting
4)4'ab , of pv ❑Ridge ❑Slope
� ❑Valley ❑Flat
totr«< Community,e,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER:��`
Address �y�� �y�.r (degrees/minutes/seconds)
Stre or Route No.)—�— �� .) Latitude/longitude source:❑GPS❑Topographic map
(check box)
—3ya DEPTH DRILLING LOG
City or Town State Zip Code From
To Formation Description
Area code-Phone number
4. DATE DRILLED - QL
5. TOTAL DEPTH:_
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:_Z610 FT. --
(Use"+"if Above Top of Casing) �a
8. TOP OF CASING IS_ I FT.Above Land Surface* e
-Top of easing terminated ab'or below land surface requires a r
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):. _METHOD OF TEST "I
10. WATER ZONES (depth):
rr
11. DISINFECTION: Type LOCATION SKETCH ;.
Yp Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diame(e or Weight/Ft. Material numbers and common road names.
From__To—JZ—Ft._
From To Ft.
From To Ft.
13. GROUT: Depth Material Method c— l
From
(�.— To��Ft. `P, ) 11 , 'L;
Ft
From To ` ,�_.
14. SCREEN: Depth Diameter
Slot Size Material
From To Ft.—in. in. z ti N -FF -1
From To Ft. in, in _ N
15. SAND/GRAVEL PACK:
From Depth Size Material o
To FL
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACC ORDA,NCF,,WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HA�$EEN-PROVIDED TO-THE.WEL�OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD W 3 11 4 5 3 4
North Carolina- Department of Environment and N ural Resources- Division of Water Quality-Groundwater Section
WELL CON]RAC FOR(INDIVIDUAL)NAME (print) r���q/l 1I`\ 3
CERTIFIGATION#3v
WELL CONTRACTOR COMPANY NAME E BROTH RS YdELL ^'"'s:.LE"I:;;, iitir,
STATE WELL CONSTRUCTION PERM Tr# FRANKLII�S"Sb'"Li Jh£�wQ PEIir\RT#
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box): ResidentialLY Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: �A� jk/� L County 2��LJ Topographic/Land setting
J�;o re ❑Ridge ❑Slope ❑Valley ❑Flat
Q (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
Laliludeilongitude of well location
3. OWNER: �Py,
Address (degrees/minutcs/seconds)
Latitude/longitude source:❑GPS❑Topographic map
((Street or Rome No.) t (check box)
F /mod Rf 'y A) C .- �7 a./ DEPTH DRILLING LOG
City or Town State Zip Code From TO
Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top g of Casing: a IT.
�Z _
(Use"+' if Above top of Casing) C—
Nq
8. TOP OF CASING IS I FT. Above Land Surface* -
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118. J j
9. YIELD(gpm):_ate METHOD OF TEST
10. WATER ZONES(depth):
Ln
_ LOCATION SKETCH
11. DISINFECTION: Type Amount Show direction and distance in miles from t least
12. CASING: Wall Thickness two Stale Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To !&�- rt._-694
From To Ft. T`
From To Ft.
13. GROUT: Depth Material To Method T
Frames- �0 Ft j2ZMG✓� QL,Vat),
From To Ft. T
14. SCREEN: Depth Diameter Slot Size Material I
From '' To Ft. in.
1
From To Ft. in. in.
15. SAND/GRAVEL PACK: ' -
Depth Size Material - '�� �' -a
From To Ft. i � b
Fro"'-To-Ft. � L
?I
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED-IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSyjUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—a a —
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE �
Submit the original to the Division of Wafer Quality, Groundssater Section, 1636 Alai]Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days,
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD *0
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Grou�d1 4 Se 3
ction
WELL CONTRACTOR(INDIVIDUAL)NANIE (print)-. C��Kh CERTIFIC 1IIOON#3t�)3
WELL CONTRACTOR COMPANY NAME PHONE IF jLSofpt�,So -�Gfo
STATE WELL CONSTRUCTION PERD117'#
248 f RAM-0111CLEFED WQ PER➢IIT#
(if applicable) FRANKLIN, NC 28784pplicable)
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
Nearest Town: "�� County mAt2AJ Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat M 6ssc Al to go Q
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:-& L Address I (degrees/minutes/seconds)
�I�/Q4.�1 �y �� Latitude/longitude source:❑GI,S❑Topographic map
(Street or Rome No.) (check box)
City orTown .t41C Zip Code �'y _— FroDEPTHTo DRILLING LOG
Formation Description
Area code-Phone number
4. DATE DRILLED- S-12- 06
5. TOTAL DEPTH: S- ` -g!
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below To of Casing:g: 1 75- FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_.�_ FT. Above Land Surface*
-Tap ofcasing terminated at/or below land surface requires a "
variance In accordance with 15A NCAC 2C.0I18. ....1
9. YIELD(gpm): _ :�,z> _METHOD OF TEST 1� _ =
10. WATER ZONES (depth): i
Ln
LOCATION SKETCH
1 I. DISINFECTION: Type Amount Show direction and distance in miles frost least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Di'a^mer IF or Weight/Ft. Material numbers and common road names.
From__To )(0 Ft.
From To Ft.
From To FL
13. GROUT: Depth Material J
Method %I C �
From To Ft. P2/1ll�z� �))�r/l // c -d
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material � a
v
From To Ft. in. in, " c
From To - o
Ft.—in. in.
15. SAND/GRAVEL PACK: = I o
Depth Size Material _
G i
From To Ft.
t
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
C SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Gro ndat aler Section, 1636 Alail Service Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days.
cW-1 Rev. 07n001

WELL CONSTRUCTION RECORD OU 3 14 j 3 Q
North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CON]RACTOR(INDIVIDUAL)NAME (print). Y ,p
/'Y!{a�C CERTIEIC.\TIONbM)-�
WELL CONTRACTOR COMPANY NAaIE
tRlif STATE WELL CONSTRUCTION PERhl1Iq BR248 CPANE CI RCK%SOCCtIT ED WQ PEAiITpPHONE k
(if applicable) FR''NiK"i'd '""=S7S4 (ifapplicable)
1. WELL USE(Check Applicable Box): Resideutial.O'�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Beat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town — ]v Topographic/Land setting
C� — Count �nryc�til ❑Ridge ❑Slope ❑Valley ❑Flat
r --�/��4YI� r c,1
(Street Name,Numbers,Community,Subdivision LotN Zip Code) (check appropriate box)
Latitude/longitude of wet l location
3. OWNER:�p4reet
V ^ Bt�� °Addl'e5S ` /��(Y (degrees/minWes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
or Route No.) (check box)
�`�"�`�,� 1U?7� F Z�� / DEPTH DRILLING LOG
City or Town State Zip Code From TO
Formation Description
(—)
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:_
6. DOES WELL REPLACE EXISTING WELL? YES O NO ❑
7. STATIC WATER LEVEL Below Top of Casing:­/c v FT,
(Use"+"if Above Top of Casing) 's
8. TOP OF CASING IS_1 FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a t—
variance in accordance with 15A NCAC 2C.0118. r--
9. YIELD(gpm): 64N Vo METHOD OF TEST I/ rd
10. WATER ZONES(depth): d --
LOCATION SKETE1 `"
11. DISINFECTION: Type Amount Show direction and distance in miles frond at least
12. CASING: Wall Thickness two Stale Roads or County Roads. Includi the road
Depth Diamc} r or Weight/Ft. Material numbers and common road names.
From (_To_�� Ft. �p a fC
From To Ft.
From Pt.
De
13. GROUT: Depth Material Method
From-�-To.:) 6 Ft.
From To -C4 9 �jy
Ft. 'C
14. SCREEN: Depth C:
p Diameter Slot Size Material t—
From To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK: tv
Depth Size Material - o r=
From To Ft. T �"
From To Ft.
—/
' 16. REMARKS:
I DO HEREBY 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 CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-i REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)S_/ .���ie � { CERTIFICATIONS 67/
WELL CONTRACTOR COMPANY NAME Gs hl4f.,
--�' 'HIRE BROTiiFRS1"7 + PHONE # XI /e
STATE WELL CONSTRUCTION PERMIT# 248 CRAlvt. . ��QLE
,:A TEU WQ PERnIIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residentia�E unicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATIDN Topographic/Land setting
Nearest Town: �" County_, ❑Ridge ❑Slope ❑Valley ❑Flat
.ni14ML/U lJd/ (check appropriate box)
m(Street Name,Nu ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER;JJj-j (degrees/minutes/seconds)
Address -a tea J & �'/�� Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
.tzL o2 q 7 V DEPTH DRILLING LOG
city or Town State Zip Code' From To Formation Description
Area code-Phone number
4. DATE DRILLED 3-0 - OS :2
5. TOTAL DEPTH: :36:s-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 4!�Q FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�_FT.Above Land Surface" `^
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. -
9. YIELD(gpm): '21D+ —METHOD OF TEST ,4a cn
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 Diamet r or Weight/Ft. Material numbers and common road names.
From G To 5— Ft.
From To Ft.
From To Ft. L �
13. GROUT: Depth Material Method
xT� a b➢
From U Toted Ft L'PifltirlrL
From To Ft. / - ✓ -' � c
14. SCREEN: Depth Diameter Slot Size Material ' r
From To Ft. in. in.
From To Ft. in. in. �_-- - c-
15. SAND/GRAVEL PACK: ' o
o
Depth Size Material
From To Ft.
From To Ft. r _
16. REMARKS: ---
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INAC�C0R1)A'NCE-WITH 15AANCA-C 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
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
II
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_464ai L Cz fla ftO CERTIFICATION U7�
WELL CONTRACTOR COMPANY NAME
—PRftN�BRBitIERS I+IEEk IAPrI 6iP 6, k9iC PHONE # T/
STATE WELL CONSTRUCTION PERMIT#_ 248 CRANE CJNtkIATED WQ PERMIT#
(if applicable) FRANKLIN NC 23734if applicable)
1. WELL USE(Check Applicable Box): Residential,8- Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATIO li
Near t Town: County "x) Topographic/Land setting
I LYA)�100 - 41Q ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Num ers,Community, (check appropriate box)
ISubdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER:--A)ek Ll —_
Address a� p(p /�/ de sours mutes/seconds)
✓ A Latitude/longitude source:❑GPSOTopographicmap
rI Street or (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED,
5. TOTAL DEPTH: .
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 1--1)FT. — '
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface" C—
•Top of casing terminated at/or below land surface requires a variance in in accordance with 15A NCAC 2C.0118. tV
9. YIELD(gpm): -'I-05 METHOD OF TEST
10. WATER ZONES(depth):
cry-"
11. DISINFECTION: Type LOCATION SKETCH
�t
Amount Show direction and distance in miles from al last
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diamet r or Weight/Ft. Material numbers and common road names.
From To,��Ft.� �
From To FL
From To Ft. _
13. GROUT: Depth Material Method
From O To-,2_6 Ft....
z
From To Ft. LIA o ` J
14. SCREEN: Depth Diameter Slot Size Material `. 0 4 i
From To Ft. in. in.
From To Ft. in. in. N `
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS: q;a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAG2C,WELL
CONS UCTION STANDARDS, AND THAT A COPY OF THIS RECORD-HAS BEEN PROVIDED TO THE WELL OWNER
'q-'2CJ vs�
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

314585
WELL CONSTRUCTION RECORD.-
North Carolina-Department of Environment and Natural Resources-Division of W stun Quality-Groundwater Section
WELL CONTRACTOR(1NDIvIDUAt.)NAME
I .. .. CCRT'fFICATION Y �7
WELL CONTRACTOR COMPANY NAM PHONjffj7V_ 2V 3 fit; �
STATE WELL CONSTRUCTION PERMITS ASSOCIATED W ZRMI'ra __
(ifapplicabie) ' -(ifapplicable)
1. WELL USE(Check Applicable Box):Residential' umicipal/Public❑ Industrial L7 Agricultural 0
Monitoring❑ Rccovery ❑` Heat Pump Water Injection❑ Other 5 IFOtiier,List Use '
2.-WELL LOCATI To
Nearest Town: Count .r pp-"e infl setting i
ge ❑Slope Walley ❑Flat �
r��E elf, 2e4 ljpineu'. FeeLV-t3Lb� (check appropriate,box)
(Scree[None,Number,Ltanmuniy,S"vision,Lot No.,zip code) a k'7 3 y Latitu lelbngitude of well location I
3. OWNER:111ty) n',3 4)ee I (degreealmiml[va7aeconda) s
Address `1 3 O S != I �- La n e_ LatitudrJlongitude aouroe:❑GPS❑Topogrsphic(nap � --
� (Str�or RmdcNa) (check boa) I -
1 I V.I cl^n`e S'f P a'4 I I 3 O 3 3 DEPTH ' DRILLING LOG . .
�-
ny�S�Town From Stab - Zip code m TO'- Formation Description n
Area calla Phone number — •� �-a
4. DATE DRILLED r7-- :)0 -0 S
5. TOTAL DEPTH: - 5?h)nl 1 2�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NQ=
7. STATIC WATER LEVEL Below Top of Casing ,3�F r.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land surface-
'top of casing termtaated actor belpw lsadaarface requires a r
varlance to secordaoe 1C with 1SA NCAC .01IL - N
9. YIELD(gpm): _METHOD OFTEST- L —t
10.WATER ZONES(depth): �6-1A• o
LOCATION SKETCH Ln
It. DISINFECTION:,Type Amount Show direction and distance In mites from at least 3
12. CASING: Wall Thickness; two State Roads or County Roads.Include the road
Depth Di ter or Weightyt. Material numbers and common road names.
From Tti i U Ft. S.a� -
From To FL
From Tq Ft,
13. GROUT_ Depth Material Method
From To_M_Ft.
From Tfi Ft
.4. SCREEN: Depth Diameter Slot Size - Material
From To FL,_in. in.
From To Ft. in. in. '
5- SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT AA COPY OFn S RECORD BEEN PROVIDED TO THE.WELL OWNER
� a -a
SIGNATURE-OF PERSON CONSTRUCTINO THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
p7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

3 4")84
WELL CONSTRUCTION RECORD
North Cer'oiina-Department of Bnvironmedt and Natural Resource-Division of WatW Quality-Groundwater Section
WELL CONTRACTOR(INDIY•IDUAL)41AME (priaO cI7C t1 YII S 1 .A '
a:
WELL CONTRACTOR COMPANY NAMPI[ONE ia'�4-3 �6 a
- `' - -
STATE WELL CONSTRUCTION PERMI7Y -. ASSOCIATED W ERMrri
(if applicable) if liable ,._ .__._—.-
ir
I. WELL USE(Check Applicable Box):Residential' w icipaVPublic❑ .Industrial❑ Agricultural ElMonitoring ElRecovery ❑` Heat Pump Water Injection❑ . Other Er If Other,List Use
2.-WELL LOCATIO
Nearest Town: >J County. 2/ r� 7�pgfaPbidL»nd setting
ge ❑Slope []Valley ❑Flat �
(check appropriate box) . %
(Street Name,Numbers,Community,Su dan, t No.,Tap Code) / Latitude/longitude of well location i
3. OWNER: — P t C '
, (degrealmiautudeconm)
Address L nn—'T Latitude/longitude source:❑OPS❑Topographic gtiap
(Strut at RoutoNo.) o� ,
rp��1l L i}J /j/CJ (ab� )�rI3 DEPTH DRILLING LOG
city or Town SUIe Zip Coda From To' Formation Description
t�- .� M 9 -n 9r 7 6 ' 0 65r
Arcs ado-Phone amber '`-! -_�i•,, g -, ('
4- DATE DRILLED 7—/.F—/!_fi '_ �`�"�-`:�•�. � tv � Yam - t-�•
5. TOTAL DEPTH: Sa.S '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO'. ;,-
7. STATIC WATER LEVEL Below Top of Casing /Tn _FT:
(Un"r if Above Top of Cuing) t_ ;rf
8. TOP OF CASING IS_�FT.Above Land surface, C=
'Top of cuing termloated atlor boltithadaarfaee requires a - N
variance in accordance with ISA NCAC 2C.01Is. J --
9. YIELD(gpm):—(e METHOD OF TEST
10.WATER ZONES(depth): of
LOCATION SKETCH
11. DISINFECTION:Type Amount c2TAA Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di ter m Weight/Ft. Ma numbers and common road names.
From�To�FL F�4 S.a, � -
From To FL
From Tq FL_^ .-
13. GROUT-, Depth Material Method -
From To�FL n OOMA .
From To Ft -
-4. SCREEN: Depth Diameter Slot Size Material - -
From To FL. 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 CONST RUCTBD IN ACCORDANCE WTM 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TIqS RECORD BEEN P40VIDED TO THE-WELL OWNER
( � p �7-/k' — � 5
SIGNATURE-OF PERSON CONSTRUCIING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Servlce Center-Ralelgh,NC
;7699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD'
North CniDlina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section -"
WELLCONTRACTORUNDIV•IDUAL)'NAME (prfaOc yI YIIS �,j�i�. -• - rIP1CATIONs el I7/�oy
WELL CONTRACTOR COMPANY NAM O � /-N � b Q
STATE WELL CONSTRUCTION PERMITa OC(ATEDW &RM17y
(ifapplicable) . - -((fe licable
1. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial❑ Agricultural p
Monitoring❑ Recove ❑' Heat P Recovery «inp Water Injection❑ _ Other C7 if Other,List Use
2.-WELL LOCATION: lc/Ltind settin
Nearest Town: Flu- le Ltd_county_, f r� �0Pe Malley ❑Flat
a�.15 S 1,2 Ca.✓l e c (dock qp box) . >
am(Strect Ne•Number,Community,Subdivision,Lot No„tip code) ' - Latitude/lotigitude of well location I
k'
3. OWNER: t t ,SCkw�, .S (degrau)miautdaeeands) � _'
Address Latitude/IongiNde souree:❑GPS❑Topographic madr
(SumtarRauallo.) r^ (Check box) t
f_izn4, Ir I n,) A A � DEPTH DRILLING LOG _
City or Town 5ute ' zip Coda From TO - Formation Description
35
Area code.Phone amber __
4. DATE DRILLED O
S. TOTAL DEPTH: b.S"� 7 r S { % t e�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_.2_�Fr. _
(Wa"Y if Above Top of Casing) �„,�
8. TOP OF CASING 1S—�FT.Above Land Surface'
'Top of cuing terminated atlor hew land surface requires a _ C t
vadaaceMaceordaeeewhilSANCAC3C.011L
9. YIELD(gpr r i): METHOD OF TEST iv '`i
10.WATER ZONES(depth): / b
' LOCATION SKE'{'GH tto Z
It. DISINFECTION:Type Amunto Show direction and distance in miles from at least
12. CASING: Wag Thickness two State Roads or County Roads.Include the road '
Depth Di
From_ flZ� 't or Wei�FtUPt. Maternal '"numbers and common road names,
. To `� �� -
From To FL
From Tp Ft
13. GROUT: Depth Material Method
From f7rtv�To�FL T"V--
from To 'FL
A. SCREEN: Depth Diameter . Slot Size : Material -
From To FL in. in.
From To Ft--in. in.
S. 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 THAT A COPY OF S RECORD BEEN P40VIDED TO THE.WELL OWNER
-'j s
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh;NC -
p7699-1636 Phone No.[phone],within 30 days. GWA REV.07/2001

`VELL CONSTRUCTION REC:URU 3 14 6 12 V�
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NA.E.A�(print) ..Q LQ'lA -c--�J CERTTFICATIO'i
WELL CONTRACTORCOMPANYNA-NIE Auto W14� —PRONE # f 1
STATE WELL CONSTRUCTIONPERMIT# U ASSOCIATED WQ PER.�ITT#
(if applicable) - (if applicable)
1. WELL USE(Check Applicable Box):ResidentiaW Municipal/Public ❑ Industrial Cl Agricultural Cl
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Use :
e`1
2. WELL LOCATIO • Topographic/Land setting
Nearest wn: County Ridge ❑Slope ❑Valley ❑IIM
(check appropriate box) r- ra
(Street N ,Nuagm,Community,Subdivision,Lot N Zip ode) ' -/(p l.atitudcAongitude of well location-a
♦ Y -`� CO
3. OWNER: W Y 1 Ci (deirms/minutes/secoads) O
Address Latitudellongitude source:❑GPS❑Topogr*ltic magi _
(Scee o ute No.) (check b
3y �} DEPTH DRILLING LOG
CtyorT 2Ss3 gState b Zip Code From To Formation Description.
- Snh
Area code-Phone number 7- 5 - -
4. DATE DRILLED ( -
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES,� NO,* -
7. STATIC WATER LEVEL Below Top of Casing: U FT.
(Use"e'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 accordsrpc th 15A NCAC 2C.0IIL
9. YIELD(gpm): ! f 9-� THOD OF TEST h r
10.WATER ZONES(depth):M" W "-'Q a 6 LOCATION SKETCH
11. DISINFECTION:Type—I Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth tameter oror W j Alsteri numbers and common road names.
From O To V t.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method (�
From To Ft. lam'�LOJ ✓7�"ate" c'"�
From_Te _ ize
Ft.
14. SCREEN: Depth Diameter Slot S aterial
From To Ft. in. _ in.
From To Ft. in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From Tc FL
16. REMARKS:
I DO HEREBY CERgTpff T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT N/ 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:InformxNott-Nlanageplotl161-7 Nail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. ! ' I _
j QW-I REV.09/2004
I` I '
u ..� AUG 2 3 2005 '
I

WELL CONSTRUCTION RECORD 3 a 4 6 h`�
North Carolina Department of Environment and NaturalResources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)�//���t, t Pa/t e::::- , CERTIFICATION#�_O C�
WELL CONTRACTOR COMPANY NAME AR D VXLe¢�r.x` st (AJL-LX PHONE #( )
STATE WELL CONSTRUCTION PERMIT# U ASSOCIATED WQ PERMIT#
1111111 (if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ff Munkipal/Public❑ Industrial❑ Agricultural❑ -
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIOiA
Topographic/Land setting to
Nearest To County ❑Ridge []Slope ❑Valley ❑Fat
Street Name, um ,Communi Subdivisi t o.,Zi Code s—� Latitude/longitude(checkappmprifwellate ) C µy
( ry. P ) ofwelllocatioE—
3. OWNER: LcmC _ L (degteeshtunuteshecoads) -d
Address Latitude/longitude source:❑GPS❑Topogra6c map
C( uc o oute No.) check box) ccnn
y., i 3 y r5 a. DEPTH ( DRILLING LOG `
ryorTgon 2State s 7 pCodc From To Formati.onDescnpnont"
255 �l " fo
Area code.Phone nurher -.•
4. DATE DRILLED ^a R b _
5. TOTAL DEPTH: 0 , 1
6. DOES WELL REPLACE EXISTING WELL? YES - NO,*
7. STATIC WATER LEVEL Below Top of Casing: FT.
f (Use if Above Top Casing)
8. TOP OF CASING IS / FT..
Above Land Surfaces
-Top of cuing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): /0 7 METHOD OF TEST 6 r
10.WATER ZONES(depth): p / - qq — I
/OD '� LOCATION SKETCH
11. DISINFECTION:Type{-� Amount t Show direction and distance in miles from at least
12. CASING: Wail Thickness two State Roads or County Roads. Include the road
Depth tameter or Weight(FL ,A rated numbers and corzupon road names
From O To �Ft. t/ Z� l}'(f
From To Ft.
From To Ft.
13. GROUT: Depth Material Method J
From To—'S _Ft.
From_To�_Ft. w
14. SCREEN: Depth Diameter Slot Size aterial
From To Ft. in. in. �yp�
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.—
From—To—FL
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCT ANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-7�/9/0S—
SIGNATURE OF PE ING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1¢17.NhRSersice-Centerc,
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days. r li Vu.6 ( -'
' ` )LjU9/2004
P.°Grti n a �

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality �-
WELL CONTRACTOR(LYDIVIDUAL)NAINIM ((pdt) �L']�l�--r—P� CERTMCATION#
WTLL CONTRACTOR CO-NtPA.\Y NA}CE L[-_PRONE #'
STATE WELL CONSTRUCTION PERHIT# - U ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):ResideudalZS`l Municipal/Public❑ Industrial❑ Agricultural❑ =
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION Topographic/Land setting
Nearest Town, - ounty Ridge ❑Slope ❑Valley ❑Ft�
Ltd-: (cbcck appropriate box) N
(S¢eex Name,Numbers, ommuairy,Su6di ioq La No.,Zip Cade) LatittidellOngimde of well location -i
A �, O
3. OWNER: W Y 1 Ci �1 (degees/minuushecooda) Ln
Address Latitude/longitude source:❑GPS❑Topographic map
0(Saxe[o oum No.) (check box)
=t� � 3 y rJ�-) DEPTH DRILLING LOG
r„CryorTgs! 2Smtc SZ 2p Code� From To Fonnadon-Description _.
Ama�coddee-Phone aur..berl
4. DATE DRILLED 7—/ — b 5" rn
5. TOTAL DEPTH: �j b h Cn (Z- A 3?
6. DOES WELL REPLACE EXISTING WELL? YES NO 7. STATIC WATER LEVEL Below Top of Casing: FT.
/ (Use"+"if Above Top of Casing)
S. TOP OF CASNG IS / FT.Above Land Surface'
'Top ofessing terminated ab'or below land surface requires a
variance la accordance with ISA NCAC IC.0lta. ry
9. YIELD(gpm): r=METHOD OF TEST h r
10.WATER ZONES(depth): ) O r—
LOCATIONSKETCH
11. DISINFECTION:Type ffa
Show direction and distance in miles from"ast
12. CASING: two State Roads or County Roads.Include dQ road-'
Depth Diameter numbers and common road names. Ot s=
From O To M t. (� /..t :.
From To Ft.---
From To FL
13. GROVE: Depth ,Material Method
From To_ Ft. t
From_Tot_FL
14. SCREEN: Depth Diameter Slot Size aterial
From To FL—in. in.
From To Ft. in. M.
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 15ANCAC 2C,WELL
CONSTRU N ST A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE pWELLL OWNER
�/ / /GSA
SIGNATUREZF11ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
- Raleigb,NC 2 76 99-1 61 7, Phone No.[phone],within 30 days.
G,W 11 fEY 09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of EnvirontggDt and Natural'Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i JaY� e lA�F �Di:-$C CERTIFICATION#�,9
WELL CONTRACTOR COMPANY NAME' ff��'C.I IA�L��P(' Ifc c' end ZIC ruoNE #(? .&C�-U740
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MmdcipaliPublic❑ Industrial❑ Agriculttual❑
Monitoring❑ Recovery ❑ Heat Pump Water jection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land settinWr
NeMestTown: fCv(\ )al County 1G�CC) ❑Ridge OSlope ❑valley lat
B2 SI D I house k r pi (check appropriate box)
(Street Name.Numbers.Community.Subdivision,Lot No.,Zip Cade) Latitudellongitude of well location
I1f35!Ley ';�7,i't 1+)r•&3°i9' Lt ,C)
3. OWNER:_�S�t?fc�L' /�. (�i't G$
Address /33, (i) 1,ni r:P 'e1it--T - Latitude/longitudesotucejl21GPSOTopographicmap
(Street or Route No.) (`check box)
�✓f�rl h� J1�P ���3� DEPTH DRILLING LOG
Crry or Tows stare zip Code From To , Formation Descriptigp
36 4- 13 b — �d San; F Lanse Ec,ks
Area code-Phone number O 9
4. DATE DRILLED -v�?J-L�5 G$T- g
S. TOTAL DEPTH: a '
6. DOES WELL REPLACE EXISTING WELL? YESANO ❑
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 caamEsurnihosted ataar below land sarr"rdlatn a _
"A"ce m Accordance with(SA NCAC 2C.011t
9. YIELD(gpm): OD OF TEST C
10.WATER ZONES(r d < /9 a ' act Y Gp,n
LOCATION SI'.F��
11. DISINFECTION:Type Y Amotmt , Show direction and distance in miles from at least
12. CASING: Wall Thicktress two State Roads or County Roads.Include the road
1 Deptb Diameter m Weight/Ft. Material numbers and common road names.
From ( To 'I! Ft.4:12- $D al uC
From— To.J _Ft. 6.
From To Ft.
13. GROUT: Depth Matqq�ta1 1 Metbpd > .�Juh tr-- a-
From_Z_To -3 Ft. Ux( ter«," Pel
From=- To2c' Ft. �
tan. SCREEN:: Depth Diameter slot sin Material �v/ 0 $:
From To Ft. in. in.
From To Ft. in. in.
15. SANDIGRAVEL PACK-
Depth Size Material
From To Ft.
From To Ft.
16_ REMARKS: N ICAO 1e 1 S /l'1`Clu re r��111 1 tiel k* rl P r �c r sec i If r
St�-joerUl's, on
I DO.HEREBY CERTIFY(TIKTHIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSTRUCTION ST AND THAT A COPY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
6/ �` 3 /a
SIGNATURE OF PERSON coNgTRucriNG THE WELL, DATE
• _
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC27499-161T, Phone No.[phone],within 30 dajr5:
GW-I REV.09/2004
i' yt,

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality ''J7
WELL CONTRACTOR(INDIVIDUAL)NAME (print) J Er�m'e C_y� CERTIFICATION#J6.��
WELL CONTRACTOR COMPANY NAME Tht'e l a 1c+.�w Tea r.( TnC . PHONE# LDfi 3�9-07 4E)
STATE WEr.L CONSTRUCTION PERMM 'ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):ResidentialA Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: I Topographic/Land setting
�4 Own: '✓a yr �I„n county a eo t l
❑Ridge ❑Slope+alley ❑Flat
eI .Jli�h Gll, (check appropriate box)
tStreO a�'�Na-,mum. 1?0.,Zip Code) titudel o gilo, of well location r)
3. OWNER:-s �yC .xe � 35ol��tO�. li1 )no83°a3 '�l� Ll
Address cc !)r� Latitudenongitudee sourw.0GPS❑Topognq tc map
(Sued Or Route No.) (check box)
EkPA ;t\ QC DEPTH DRNLLINGLOG
City Or Ttrwa sty Zip Code From TO , Forrmatioa on
( - Sa4-5.733a,'� d ec
4. DATEDRILLED Ia2IDS
S. TOTAL DEPTH: I q ova
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 4 w'd 76
7. STATIC WATER LEVEL Below Top of Casing: Z/0 FT.
(Use"+"if Above TOP of Casing)
8. TOP OF CASING IS—�—FT.Above Land Surface*
-TOP of caatit Rreppted atfor helvar hmd mrlare requires a
vaiaecc IN rrRY 15A NCAC 2C AHL n n
9. YIELD(gpm): Zf METHOD Of TEST
10.WATERZONES(depth): (/00'l`Pin I �14a'7 6
LOCI ON S FK TCH
11. DISINFECTION:Type 1 Amount t<of Shots'direction and distance;m miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter m Weight/Ft. teri numbers and common road nam
Frorn_`kl To 86 Ft.6 11 a5 15�) ✓ �{�
From To Ft. Y
From To FL
13. GROUT: Depth Material Method L
From To7-1
=�F j
From_3_Tom Ft. T_ �� r_ -1
14. SCREEN: Depth Diameter Slat Size Material , / — j
From To Ft, in. in. CD To Ft. in. in. q,`�.• LF1
15. SANDIGRAVELPACK: Y
Depth Size materialrl
From To Ft
From �Tpo Ft.
16. REMARKS: l yl id r P l( S. 00 I ar A jla:, wall l t 4.odcr I n/,sed d1-J 11Prr s
Ste' y/�erurSron.
I DO HEREBY CER 4
T TIRS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ,AND THAT A COPY OF THIS ORD HAS BEEN PROVIDED TO THE.WWELOWNER
6 O /
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
4
Submit the original to the Djvisio0 of Water Quality,Attu:Information Management,1617 Mail Service Center-
Raleigh,NC 276994617, Phone No.[phone],.within 30 days... ._.____..
GW-I REV.09/2004

WELL CONSTRUCTION RECORD .t
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR tINDIVIDUAL)NAME (print) :: PpC 1'C1M . J, C'V(,(,t J-C CERTIFICCATTION#--b-3�
WELL CONTRACTOR COMPANY NAME /(i J)Ieel fA k `1el"1i-pjinC,/11 —,Y✓1C_ FaONE#&&30.O740
STATE WELL CONSTRUCTION rERMiT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential UrlMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring a .Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELLLOCATJ ✓an To g
Nearest�Town: 1..� Comty a C Uv\ ❑)Udgr g515 eon Malley ❑Flat
(`)4 K•-i•✓� S!-re.P'f (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot Ne.,Z.ip Code) Latitude/longitude of well location
Nis'° v7 'oa.9r� iJ )83"a.3'
3. OWNER:(jeC� 5;(�yJ�\ 0�
(elaDcec/n�aes/seoonds)
Address C)C44SS4 jk Latitude/longitude sommCIGPS❑Topographicmap
(Sheet or Route No.) (check box)
1.7C Df 24 DEPTH DRILLING LOG
Cityo[To st Suk zip Code From To , Fo 'on on
C�J a �`l3 t D�So Zi a oe
Area code-Pane number Rd' lIS r
4. DATE DRILLED 6I a p
S. TOTAL DEPTH:
6. DOES WET.I REPLACE EXISTING WELL? YES❑ NO pg - 3R3
7. STATIC WATER LEVEL Below Top of Casing: '/O
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS—1—FT.Above Land Surface'
-fop Dreams ternsibenten attar below IaaS sauce ngawea a
variaace is aorxdasce with 15A NCAC 2C.011t
9. YIELD(ginnY /,5 METHOD OF TEST „r - :
10.WATER ZONES(depth): (35 6 e 15 G,0;0
LOCATION SKETCH
11. DISINFECTION-Type H ) Amount Show direction and distance is miles from at least
12. CASING: Wail Thickness two State Roads or County Roads.Include the road3
Depth Diameter vv5S,,Wc4ht/Ft. a�a1 numbers and common road names.
From To 1aS- FtL./25 S -97( JC
From To Ft r
From To Ft, 14
t¢ )
13. From_�ToaC�th date . tf Med� ��c� U7 r
From To Ft,i vhxl- ew,em..? ra.r g
14. SCREEN:. Depth Diameter Slot Sim Material
From TO Ft. in. in.
From To Ft. in,
15. SANDLGRAVELPACK-
Depth Size Material
From To Ft.
From /T�o 1� � Ft. qq nn 11 0o
16. REMARKS: (Vlle.{�CA S. mryl d A.,,Le. �MA' we-0 (M1Ll f IICt'r'tSPd (Ae,Oel3
SLL U�5ivfl -
I DO HEREBY CERTIFY THIS WELL,WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ARD AND THAT A COPY S RECORD HAS BEEN PROVIDED TO 1T�WEI LWNER
d ai
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attu:Information Management,1617 Mail Service Center-
R21 igh,NC 27699-1617; Phone No.[phone],witMh 30 days.
GW-I REV.09/2W4

NC _ �/ OIFNER MIT
WELL CONSTRUCTION RE CORD ,
t $_
North Carolina-DepatDncul of Envirtnuncut and Not lot lot'R/esout es-Division of Water Quality-Gtoundwaler Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prin ?e e- CERTIFICATION II ff9'?02
WELL CONTRACI.OR COMPANY NAME_ -liel- PHONE 0 (1'411122
STATE WELL CONSTRUCTION rERAl1TM ASSOCIATED WQ PERAII'TII
(irapplicnblc) ((f opplicnbte)
1. WELL USE (Check Applicable Box): Resides lial(Municipal/Public U Iudustiial U Agricultural U
Monitoring U Recovery I] lleal Pump Water Injection U Other U If Older,List Use
2. WELL LOCATION: 7bpogmphic/Land selling
Neorest Town: A'/ C v County ❑Ridge ❑Slope ❑Valley UFlat
G'L Ayr, /[ C61 (check eppn.printe box)
(Shret Name,Numbers.Community,Subdivlelmi,Lot No.,lip Cale) Laliludellongilude of well location
/ I"d A/3S'/3 `SS"' a.18g037 rFZ"
3. OWNER: h U ,fs(/�h� (depreeitAnlnunec/xecondr)
Address 109 6 AA T_cl 6 Lattludellougilude somee:tJGPSUTopOgtaphic neap
(sheet m Route No.) (check box)
o 'vL 28 K UEI I(I L21UN1N WOO
City rTown Sule Zip Cale Flom TO FormationDeseription
AirC &Mode-rhnne number, Oy.. _0 —G J C .y
4. DA'I E DRILLED G
5. TO"rALDEPT►1: -600 '
6. DOES WELL REPLACE EMISTINO W ELL7 YES U NO 4a'
7. STATIC WATER LEVEL Below Toll ownsing:-Zit—Orr.
(Use"+"if Above-1 iqt or Crimp)
S. TOP OF CASING IS l 1"1'. Above Laud Stnfacc•
o top orndnr Irrndnoird at/or below land ouncre requiter■
ntltmre In aceordonte with ISA NCAC IC.01 la.
9. YIELD (glint): l NIET►IOD OF TEST' /f't
10. WATER ZONES (depth): 360 '
LOCA.I.LON SfSMH
11. DISINFECTION:Type /f T Amount eye. Show direction and distance in miles from al Icast
12. CASING: Wall Thickness two Stale Roads or County Roads. Include We road
Dcpdt Diameter of WcighVl't. Malelial numbers and cotmnon road names.
Front D To T Ft. l- Sri z/ /`�'G
From To Ft.
From To FL
13. G1t0UT: Depth talejtnl Mcutod
From D To L_FL 'c%jifn�
d c'
From 3 To 2� Fl, lge,.Iew'fZ
14. SCREEN: Depdr Diameter Slot Sim Material A�
Front 'To Ft. in. in. ( 0)
rrom To Ft. lu.
15. SAND/GRAVEL PACK:
DrpUo Size Mntetial
rront To Ft.
Front To
16. REMARKS:
I DO HEREBY CERTIFY T1IATTIIIS WELL WAS CONS'l RUCIED)N ACCQRDANCE WIT71T5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,ANDTIIAT 4upyOF'17115 WELLOWNER
SICNAilJRH OF PERSON CON 1'kOM I IE L j DATE
i
Subndl Ilse oIlginnl to the Dlrlslon of Water Quality,Groot dwata ftlionj163(rL M.'Strvice Coder-Italelgh,NC
27699-1636 Phunc No.[phone],vvitlthr 10 days. ASHEVil I t a-r JOW-1 REV. 07/2001

NC D11'NEN
WELL CONSTRUCTION KLCORll � r
Noidi Carolina-DepaHOncut of L'nvitolmlcul sold Not Hal Resources-Division of Water Quality-Otoundwaler Section
WELL CONTRACTOR(INDIVIDUAL)NAAI E (print) / l7V ///e«e— CERi1FICAT1UNgZ�C1
WELL CONTRACTOR COMPANY NAME �?I!/e/ PIIONE Is
STATE WELL CONSTRUCTION PERA11"TN ASSOCIAI"ED WQ PEM/1710
(i r npoicnwo (if nppl icnble)
■
1. WELL USE(Check Applicable Box): Rcsidcnlinl 13'Muuicipal/Public U Indusbial U Aglicullurol U
hioniloriug ❑ Recovery U heat Pinup Water Injeclirnl U Other 13 If Odter,List Use
2. W LLL LOCAI'lo ) Topographic/Land setting
Nearest I.own. J2�/res Couuly %""`oaf ❑Ridge ❑Slope ❑Volley Urlal
e,0&V4V W . _ (check sppwprlele box)
(Sts el Ne(nq Numbcn,Community,Subdivision,Los No.,Zip Cale) Lalitude/lougilude of well location„
3. OWNER: Tµ>`F �% - (degrets/lnimno/secondQ
Address vp Laliludellongilude soufcc:UGPSUI'opogrnphic map
(Sorts a Rouic No.) (check box)
Nl z�-►8! M lIfil MU-J-jALR".Q-Q
City o Town Stale Zip Cale Prom To Formation Desmiplion
AsC t ced e e-rhone number 0 — 70
4. DATE DRILLED 4 ZT'�f ?o_ S Lf' 1, c-
5. TOTAL DEPTII! S �p
6. DOES WELL RLPLACL EXISTING WELL? YES U NO ❑
7- SI'AI"IC WAl ER LEVEL Bciow Top of Casing: -&0 Fr.
(Use-+^If Above's op or cmtog)
8. TOT' OF CASING IS hI'.Above Lind Sul Face*
•Tap et same lennindnl Wor below land sus4ce requlrer a
rnlxnre In■ccordsnct with ISA NCAC IC.011S.
9. YIELD(gpin): IS" METHOD or rm /�%�"
10.WATER ZONES(depth): L-^0
LOCATION SKEI"C�
11. DISINrECr10N:Type /fell Aluouul l,qc- -4 Show direction and distance in miles fsoln at(cast
12. CASING: WnII Ibickaess two Slate Roads or County Roads. Include Use road
Depal Dimaeler or WeiggIll/FI. Malelial numbers and collunon Toad names.
From 0 To `�/ Ft.
Mont To F(. 3
Prom To Ft. C ='
13. GROUT: Depth alelial etllod
FHot„ Ft. t�• /
14. SCREEN: Depth Dimncler Slut Size Malerial l
Front To Fl. in. in. _ ��� '
Fran To Ft._in. in,
15. SANDIGI AVEL PACK!
Deil'
,h Size Mnnelial r
Flom fo FI. i I� ILi AU,j G
16. REMARKS:
ON IIEREBY CERTIFY WAS I C(ADCN ) SA NCAC WELL
CSTRUCION STANDARDS,AND 7IIAT A COPY OFTIISRLCOR PROVIDED TO TIL WELL
OWNER
2Y,00
SIGNAIURL OF 1'EItSON CONSTRUGHNa THE WELL DATL
Submit the otightnl to the Dlvislon ur Water Qunli(y,Groundtvaler Secllon,1636 Mall Service Center-italelglt,NC
27699-1636 rhune Nu.[phone],vvi(ltlm 30 dnys, GW-1 REV. 07/2001

NC _ OIVNEIt _ nl MIN) -------
WELL C0NSTRUCTION RECORD
Nos Of Carolina-Department of Envirollulcul and Natural Resources-Division of Water Quality-Groundwater Section
WELL CUNT RACTOR(INDIVIDUAL)NAME (pilot) /L eZ��e% CERTIFICATION g. Zye2
WELL CONTRACT OR COMPANY NAME //7//Pr ruoNE a VM 5f'7-zfS7
STATE WELL CONSTRUCTION FERAII IN ASSOCIATED WQ MRAIr10
(irnpplicnble) (irspplicable)
1. WELL USE(Check Applicable Dux): Rcsidcnlial L3'Municipal/Public U Industrial U Agricultural U
hlolliloring U Recovery ❑ Heat Pump Water hejcclion U Diller[] If Older,List Use
2. WELL LOCATION: TopogrnphidLnrrd selling
Nearest Town: jre«j County Ullidge []Slope []Valley ❑Flat
t-04 dz p (check Opp,oprl"le box)
(Suer,N u¢,Number,Canmunity,Subdivielan,Lot No.,Zip Cale) Latitude/follggitude of well location
/ N3.5`V0'3'e-!'r 4VoR3 g 0
3. OWNER: �r f f `!'li. (dcgreee/minuteVemonde)
Address Z ND a idrG v/ g I A-i V2 Latitude/lougi(ude source:UGPS[]Topoglaphic nap
(Start or Houle No.) (diml,box)
Z RMPTI IMILLINSLL(ZCe
city o own State Zip Cale Flonl To Formation Description
Aire rbnne nwnber 6 — l0
LRI k-}� '
4. DAT- DLLED ' yp. {cam �,ug•Y ' _ ,
5. TOTAL DEPTI1: 4(65-
6. DOES WELL REPLACE EXISTING WELL? YES U NO e"
7. STATIC WATER LEVEL Dclow Top orcusiug: 60 _r r. i'
(Uxe-+"Ir Above'I np or Caning) _
8. TOP OF CASING IS F1'.Alcove Lmld Surrace• 75
*-top of cntng lerornafed allor below land emr.ce requhre a
♦silence in■ecordsirce with 15A NCAC 2C.01 Ill.
9. YIELD(gpm):/_METHOD�OFTEST /y,
10.WATER ZONES (depth): 250 LOCATION SK E 1
11. DISINFECTION:Type 7` Anlouul VV" Show direction and distance in miles from at(cast
12. CASING: Wall Thickness two Slate Roads or County Roads. Include die road
Depth Diameter or Weigl,UFI. Material numbers and conuncn toad names.
From O To 2a�r
From To—Fl.
Fran, TD rt.
13. GROUT: Depth l {list, ty)eUwd,
From To y rL `/ a /L 1
From To ,10 Ft. �e�//a. to :> r'.
14. SCREEN: Depdi Diameter Slot Size Material
From To rt.-ill. in, _ _ _ $5
ri-mTu Fl. in.
15. SAND/GRAVI?L PACK: — -- —
Ugeth SILO Mnteriol -
From ro Ft. � AUG 9 200� '
rloul TD FI.
16. REMARKS:
I DO HEREBY I II 2C,WLLL
CONSTRUCION STANDADS,ANDTIA AC01 Y OFlS WELL WAS TIISItE-CORDIIASEEN PROVIDED TO TIIE WELL OWNER NER
e- - "R— /7- 0/-
SIGNATUIlL01'1'ERSONCONSTRULTINOTIIL WELL DATL
Submit (he original to the Division of Witter Qualify,Gruwtdsvaler Section,1636 hall Service Center-Raleigh,NC
27699.iot; Phone No.(919)73J-322l,wl(h1n 30 dnys. OW-I RLIV.07/20U1

WELL CONSTRUCTION RECORD"
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV•IDUAL)NAME (prtaq j��r♦n l s .+��� ��� CP.it,TIFICA110N Y o1I7 Y'
WELL CONTRACTOR COMPANY NAM PHONE 421 q--3 �6
STATE WELL CONSTRUCTION PERMITY ASSOC(ATED Y1 ERMITY
(if applicable) - {if applicable)
1. WELL USE(Check Applicable Box):Residential' unicipal/Public❑ Industrial ❑ Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other f1 If Other,List Use
2.`WELL LOCATION:
Nearest Town: �RA NkL1 II/ Count qq�t( ly,> Topographic �d setting
YJ ❑Ridge CdS16pe ❑Valley ❑Rlat
C I k S C h�p 1 CO w-e-- 73 (( (cheek appropriate box) 1
(Street Name,Numbers,Cantu nity,Subdivision,Lot Ile..Zip Code) ° Latitudellongitude of well location
3. OWNER: '[ U7J C1-Cu)O.LT (degreesTminutw/aeconds)
Address `f -n, b X e5-fi Latitudetionginide source:❑OPS❑Topographic map
(Saeet w Route NoJ - (chock box)
F12 (i 01 rZ DEPTH DRILLING LOG
City or Towa Sure Zip Code From To For[nat_ion Description
6M6- '3 — '3 O S 5 C
Area code.Phone ember
4. DATE DRILLED —3 6 —C)S --±SSS(Z ( l
S. TOTAL DEPTH: J-so '
6. DOES WELL REPLACE EXISTING WELL? "YES ❑ NO_
7. STATIC WATER LEVEL Below Top of Casing:
(Use"t"if Above Top of Casing) G
8. TOP OF CASING 1S_�Fr.Above Land Surface*
-Top of casing terminated actor belaw lead surface requires■ - -
variance in accordance with ISA NCAC 3C.0118.
9. YIELD(gpm): _MBTHOD OF TEST
10.WATER ZONES(depth): c.1 0 ' can
LOCATION SKETCH
11. DISINFECTION:Type 414 Amount Z T,4A Show direction and distance in miles from at least
12. CASING: Wail Thickness two State Roads or County Roads.Include the road
Depth Diapp��t�er .or We;ghypt. Mate. 1 "numbers and common road names.
From­ —Ft.=Sa)2:,'d9. O..>P -
From To Ft.
From To FL
13. GROUT: Depth material nmMeAth�od,
From--O—To—='�D—Ft. 00 From
To Ft.
4. SCREEN: Depth Diameter . Slot Size Material
From To Ft, in. in.
From To Ft. in. in. 7
S. 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
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H&S BEEN PROVIDED TO THE WELL OWNER
(I a LL�,("` 'I
SIGNATURE-OF PERSON CONSTRUCTING THE WELL DATE
�i
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center lih;N4tUG 9 2005
X17699-1636 Phone No.[phone],within 30 days. GW-1 V.
j07/2001
i
AJ-'�.._ L ll-FI'.i l i

WELL CONSTRUCTION REC,(ORD '
North Carolina-Department of Environment and N1,atural Resources-Division of Water Quality'-Groundwater Section
WELL CONTRACI'OR(INDIV,IDUAL)T1AME (prinO-she rl VI �M-p ll(1„n r� - '[7g[CATION/ 0�•�7(a
WELL CONTRACTOR COMPANY NAM ?HON$ L/•-3
STATE WELL CONSTRUCTION PERMITY ASSOCIATED W ERMITa
(ifapplicable) -
(if applicable)
I. WELL USE(Check Applicable Box):Resident'ial'fd' ptunicipaVPublic❑ Industrial❑ Agricultural El
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other CT If 6t6r,List Use
2. WELL LOCATION: r '
Nearest Town: JCL' County ` OS coia/L and sating
�/ 13 r . k�3 dge ❑Slope Malloy ❑Flat
-
(Sued Name,Numbers,Community,Subdivision,tot No.,zip code) Li (check appropriate boa)
ttitudeAongitude of well location
3. OWNER: L12C h"h 1�G.Z-P4-r Y- jL (degreeJmiautes/aeconds)
Address t 7 b� 7;h p Latitude/longitude source:❑GPS❑Topographic map
(Sucet or Route No.) - (check box)
DEPTH DRILLING LOG
Gry or Town Sol Zip Codc F[Om O
(R2c�- .� LE Ci _ 0 �9 , / Formation Description
Area code.Phone number 7 ,
4- DATE DRILLED �I �D S - yam
5. TOTAL DEPTH:_ r7 b i-? I if r:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO "^
7. STATIC WATER LEVEL Below To / O
P of Casing:g .___.Z_F1:
(Use"+`if Above Top of Casing)
S. TOP OF CASING IS _ Fr,Above Land Surfaces (-- :•'
'Top of casing terminated at/or below loadsurfau requires a
variance in accordance with-ISA NCAC 2C.011a.
9. YIELD(gpm): 1 (_�2`METHOD OF TEST
10. WATER ZONES(depth): .SOO '
CD
LOCATION SKETCH �
1 I. DISINFECT-[ON:Type Amount - Show direction and.distance In miles from at least
12. CASING: Wail Thickness two State Roads or County Roads.Include the road
Depth Di ter or Wcot/Ft. Material -numbers and common road names.
From_ Tq ,�FL_�$ D)
From To Ft.
From T9 FL_ _
13. GROUT: Depth Material Method
From_ To _Ft.
From To FL T"--
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 IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUC ION STANDARDS,AND THAT A COPY OF S RECORD BEEN PROVIDED TO THE WELL O r_'
wN� '�D u V L�, r'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE ;J
AUG 9 2005
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center Raleigh,hC
eq'7699-1636 Phone No.[phone],within 30 days. OW-1 REV.07�001 -- —"�

. 314298
WELL- CONSTRUCTION RECORD'
North Catolina-Department of Envirmunent and Natural Resources-Division of Wa;Quality-ei immdwater Section
WELL CONTRACTOR(INDIV•IDUAyNAME (print)< f_TlRt rj f,}aitr�„A rS. <. CliA=CATI0Nf oL7(�
WELL CONTRACTOR COMPANY NAM '-- j s
4 1 14H q4 ,PNO 44N{f . r 4"3 �•b
STATE WELL CONSTRUCTION PERmrra AAeOMATED W ERMI7Y
((rapplieable) ' 111'applicable)
1. WELL USE(Check Applicable Box):Residential' umcipaUPublic❑ Industrial❑ Agricultural p
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ . Other CT If Other,List Use
2."WELL LOCATION: . o IdLand se
Nearest Town: (On Court lie&' , ��Pp
ty lnRidge ❑Slope OValley ❑Flat
44t _S Z-iSu.t�L�A. 12.; r�4e 1�-a ,d`�"7(03 (eMCk.pprapdaee eox) �
(Strcet Name,Numbers,Community,,subdivi:ma, No„Tip Cade) - Latituddlongituds of wall location
3. OWNER JQN)t,0S C-I i a S2YV (deateerlmiwteaheen„de)
Address I a Dn F l u e Fo'K p l a e 2 Latituddlongitude source:❑GPS❑Topogmphic map
(Stan or RouteNo.) .(ehoeb boa)
� CL CU 10. DEPTH '' DRILLING LOG
city brT state� Zip code. .From TO , Formation Description
c 5 � � ' _
Arcs coda Plane ameba 'F -_� 7 - S .
4. DATE DRILLED — J S
5. TOTAL DEPTH: / V 7 %L36 4t�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing Z FT:
(Use'+'if Abort Top of Caine
8. TOP OF CASING IS_�FT.Above Land Surface' c
•Top of wioa terminated atior be&N ltndaurfaee nqulro a - r z
variance In aceordsam wM ISA NCAC 3C.011R tV
9. YIELD(gpm): a%z METHOD OF TEST
10.WATER ZONES(depth): /70` /�/�o' -3�� (l o
LOCATION SKETCH Ln y
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�'ap�eter or WciiSht/FL Mate -numbers and common road names.
From=To FL /�N $ tRal 19
From To FL
From Tp FL_ _
13. GROUT_ Depth Mater4�iel n Method
m Fro To_ `�q�,4�� : — /TLt�
From To FL I _
A. SCREEN: Depth Diameter Slot Siu - Materiel
From To FL in. in.
From_ To Ft._in. in '
5. SAND/GRAVEL PACK:
Depth Size Material
From To FL
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 USREC=ORD
EEN P40VIDED TO THE WELL OWNER
SIGNATURE-OF PERSON CONSTRUCnNG THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
p7699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

314295
WELL CONSTRUCTION RECORD
(i:.
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDWIDUAL)'NAME (print) I,] ��� -•" -
l'tw- 0 tLJ:L __� CLIZ,T[F[CATIONY I7Ip
WELL CONTRACTOR COMPANY NAMPHONL #jjV—S;2 Li Ab
STATE WELL CONSTRUCTION PERMPPa ASSOCYATRD W BRMITY -- ,•
(if applicable) {(fappNcable) -
I. WELL USE(Check Applicable Box):Residential CP-1 tunicipal/Public❑ Industrial ❑ Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 11 If Other,List Use
2.`WELL LOCATION: T
Nearest Town:, F4 /C L/ County �(,2 4 ( Alj6graphiclLand setting
Zf V/ it a 2 7 h. to _ Ledge ❑Slope Malay ❑Flat
ri cJ0ivel¢ (checks appropriate box)
(Suter Nana,Nu/tubers,Community.Subdivision,l.a No.,Zip e) �gyj '3 (L Lowdenongitude of well location
3. OWNER: L i--I-- ll.11 //(.fir{ / (depeer)miaumr/uconda) .
Address 3.5/ Latitudallongitude source:❑GPS❑Topographic map
(Street or Rau No.) ( � - (check box)
�'(Pc2,n1e1.h 3 A/G' C2 L 7 DEPTH DRILLING LOG
C,ty Town sum z p code From To
9 '19 i _ ��' Formation Description
Area code.Panne number - -, S ,
4. DATE DRILLED 7—k—0 5 S 4 s, Lai U L' �L A n ,t-E 5. TOTAL DEPTH: ,50 '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO_ y
7. STATIC WATER LEVEL Below Top of Casing: 2_FT;D.— .?
(Uu"+'ifAbove Top of Casing) C
8. TOP OF CASING IS FT.Above Land Surface• r--
•Top of cuing terminated at/or below landsurbee requires a ry
variance In accordance Itb t5A NCAC 3C.011t
9. YIELD(gpm): � MHTHOD OF TEST
10. WATER ZONES(depth): C
' LOCATION SK)
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 Di ter or Wcot/Pt. Material ' numbers and common road names.
From
_P-- Ft._ l " saw DY
From To FL
From Tq Ft.
13. GROUT: Depth Material Method
From_To—c2D—Ft. n/n2
From To Ft. -
.4. SCREEN: Depth Diameter Slot size Maerial - -
From To _ Ft. in. in. i
From To Ft. in. in,
5. SAND/GRAVEL PACK: _
Depth Size Material -
From To FL
From To Ft. -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT!?D IN ACCORDANCE WITH ISp NCAC 2C,WELL
ONS7RUCTION STANDARDS,AND THAT A COPY OF TH S RECORD 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 Mall Service Center-Raleigh,NC
ay699-1636 Phone No.[phone],within 30 days. _ GW-I REV.07/2001

L,)>uj 3 � 314403
WELL CONSTRUCTION RECORD
North Carolina Department of E - ent and N�hiral R�snttrces-Divis- n of Water Quality
:. --7/ l (sir
WELL CONTRACTOR(LNDIVTDUAL)NAME (Print) /a -(� / t 1 , CERTIFICATION .J
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
"I
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural ❑
13
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �,J. Topographic/La d Setting � %,
Nearest Town: �rf)-/UIC t /U� _County n'1 `' a ❑Ridge ❑Slopealley ❑Flat '£'
(checks rus"box
p p ) O
(Street Name,INumbers,Commumry,S ston,Lot No.,Zip Code) Latitude/longitude of well location. DA -
3. OWNER: l/u'( l / C— I-De tJ 'IC (,� ` (degrees/minuces/seconds),
Address a .N Latitude/longitude source:❑GPS❑Topographic map
¢ee[or Aoute ) (check box)
At-) A � I U 3� DEPTH DRILLING LOG
,Tf, City or Town State �p,.[ode From To Formation Description
Area code-Phone number -
4. DATE DRILLED 9 J- e>5 S - `:ZL U t'
5. TOTAL DEPTH: 5 SU W ell am", � /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ 0 _ / 7�
7. STATIC WATER LEVEL Below Top of Casing: -FT. 170 -/-7
(Use-+"if Above Top of Casing) - / 7-;2 — VUS
8. TOP OF CASING IS_�_FT.Above Land Surface'
`Top of casing terminated at/or below land surface requires a
variance in accordance with t5A NCAC 2C.0118.9. YIELD(gpm): METH D OF TEST 4 1 ✓ S/S -G /
/i //„ <� r
10.WATERATER ONES(depth): a. S Ci �. 5 / --J 1 — i LOCATION SKETCH
11. DISINFECTION:Type Amount S�Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.imlude the road
Depth Diameter or Weight/Ft. Maten numbers and common road names. u
Fro To
J� Ft. (,2 V� 5; Z/ 7QLG
From To FL 1
From To Ft. �(
13. GROUT: Depth Material Method �•r""`" \ I�
From To FL '7�- 7L/y,
From To Ft.
Ft. -
14. SCREET Diameter Slot Size renal
From To Ft. in. in.
Front—
To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ��•(j t��_
From TO Ft.
16. REMARKS:
I DO HEREBY CERTffY H HIS WELL WAS C NSTRUC ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA ,AND T ^ OFT CORD HAS BEEN PROVIDED TTO HE WE L OWNER
J
SIGNAT RE FP R SON CONSTRUCTING THE WELL --- -- ._. DATE
Submit the original to the Division of Water Quality,Attn:Information Management,140 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],Within 30 days.
GW-I REV.09/2004

31440
2
WELL CONSTRUCTION RECORD
North Carolina Department of Env' - ent nd (N aural ources-Division of Water Quality O
WELL CONTRACTOR(LNDIVIDUAL)NAME (print)'\.ILf"-LM /J �� I CERTIFICATION#_d
WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERM1DT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):ResidentialNl MunicipaVPubtic❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: J Topographic/La d setting G ✓�
Nearest Town: F/ /)I de I I � County MA 6--0� Midge ❑Slope alley ❑Flat ` ,1
{�- I LL' C— - (check ap priate box) i
(Street Name,Numbers,Community,Sulod,won,Lot No.,Zip Code) �—, L,Latitude/longitude of well locations
l N G De LJ (degrees/minuies/seconds)
3. OWNER: Lt F
Address Ce"P Latitude/longitude source:❑GPS❑Topographic map
treet or Route ) (check box)
J p i fa— J C)3 DEPTH DRILLING LOG
CIN or Tnwn Srate i^ ode From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: W f'(I S, - �
6. DOES WELL REPLACE EXISTING WELL? YES ❑ N9 ❑ 7 1
7. STATIC WATER LEVEL Below Top of Casing: FT. _.
(Use"+"if Above Top of asmg)
8. TOP OF CASING IS FT.Above Land Surface'
'Top orcasing terminated at/or below land surface requires a
s ariance in accordance witil 15A NCAC 2C.0118.
9. YIELD(gpm): / THOD OF .ST /✓
10.WATER ZONES(de h
LOCATION SKETCH
11. DISINFECTION:Type j--T /_L mo L Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth 6,4L
D/ia1meet{er or Weight/Ft. Mated numbers and common road names. .,
From_To�Ft. -e
From To Ft. '
From To Ft. �(
13. GROUT: Depth Material Metho`d�/,'-,�
From To Ft. '7�---- �' } G°„ "l--'
From To / !' S F .
14. SCREEN: Depth Diameter Slot Size tenal �r
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL D :
-�ifJ v V
Depth Size Material
From - To - Ft. I L'
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND S AND THAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
V,A
IGNATURE OF PERSOt CONSTRUCTING.THE.WELL.. ..__._____.._..DATE
Submit the original to the Division or Water Quality,Attn:Information Management, 1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

NVELL CONSTRUCTION RECORD �!' 31 4
1
North Carolina Department of Envjpcgment�rtd NAturalurces-Division of Water Quality -
WELLCOIVTRACTOR(LNL[VIDCAL)NAM(E ring (G) (�) lG CERTIF[CATIOiYq
WELL,COMMACTOR COMPANY NA-ME AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE p [phone] "
STATE WELL CONSTRL'C ION PERMITS ASSOCIATED WQ PERMIT# -
(if applicable) (if applicable) ;t{
1. WELL USE(Check Applicable Box):Residential MunicipaVPublic❑ Industrial❑ Agricultural ❑ y
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use r✓
2. WELL LOCATION: To oera hic/Lalid setting N a
Nearest Town: FI f�n)I r n , County n'14 -�'�� ❑Ridge Os lope �EValley ❑Flat IJP
(— l O w e y- Ln!1() M- O—A 7V(k-' ,� 11V C _ (check ap priate box) s
(Street Name.Numbers,Community.5ubdftision,Lot No.,Zip Code) ,Latitude/Iongitude of Well location
�t!�
3. OWNER: w N G De LJ '��--�-�t �° (dcgrees/miautes/seconds)
Address Ce.-v 1. Y Latitude/lon�irude source:❑GPS❑Topographic map
� � meet or Route ) - (check box)
DEPTH DRILLING LOG
City or Town Snare ip ode From To Formation Description
Area code Phone number _ _ 41
4. DATE DRILLED b S /r % .
5. TOTAL DEPTH: 's C, LV
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �k
7. STATIC WATER LEVEL Below Top of Casino: 4-IrD FT.
(Use"+-if Above Top of Casing)
8. TOP OF CASING ISI FT.Above Land Surface' s
'Top orcasing terminated aCor below land surface requires a
variance in accordance with I5A NCAC 2C.0118.
9. YIELD(apm): v_ METHOD OF TEST /
10. WATER ZONES(depth): '1`j 3 C� L
LOCATION SKETCH
11. DISINFECTION:Type -T L4-- Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness tw"o State Roads or County Roads. Include the road
Depth Diameter or WeighbM. Materi numbers and common road names.
From To Ft. �iLt�2_- �Cr'e.l.
From To Ft.
13. GROUT: Depth Material Method
From To_ :J_Ft. > " }�f `f'c�- —
From, _ToL�FC� '�`-� � Lc.J -11,L—'
14. SCREE\: Depth Diameter
From To Ft" in. in.
From To Ft.—in. in. `s��
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 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 Attlar f, formation hlanageinent,T61,71i1a8 Service Center-
Raleigh,NC 27699-1617, Phone\o.[phone],µithin 3O davk- .. -
GW-I REV.09/2004

WELL CONSTRUCTION RECORD 01D 314416
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR MDIVDUAL)NAME (primt) WILLIAM BRADLEY LEWIS CERTIPICATION#3368 + __-
WELLCONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC. PHONE # (828)837-$008 "
STATE WELL CONSTRUCPION PERMIT# ASSOCIATED WQ PERMIT# j
(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
T t ,
2. WELL LOCATION: Topographic/Land setting '
Nearest Town:A000NE County MACON ❑Ridge J�Slope ❑Valley ❑FUC,
OLD ROCKY BRANCH RD ch k appropriate box)
' C—
(Street Name,Numbers,CommuoiTy Latitude/lontulle o well location,Subdivision,Lot No.,Zip Code) gl
36 N fl,
3. OWNER: JOE STEPP i(degrees/mint es/seconds)
Address 74 OLD ROCKY BRANCH RD Latitude/longitude source.XGPS❑Topographic map
(Street or Route No.) (check box)
AQUONE NC 28781 DEPTH DRILLING LOG
City or Town State Zip code From To Formation Description
8( 28 )-321-4378 0'TO 20' BLACK DIRT/CLAY
Area code-Phone number 20'TO40' GRAVEULOOSE ROCK
4. DATE DRILLED 07/20/2005 40'TO 60' GRANITE
5. TOTAL DEPTH: 145 60'TO 145' GRANITE _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 5 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Lard Surface* E
-Top of"sing terminated at/or below land surface requires a t
variance in accordance with 15A NCAC 2C.Olt&
9. YIELD(gpm): 20 METHOD OF TEST AIR
10.WATER ZONES(depth): 100', 120'
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Shop'direction and distance in miles from at leas
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 60 Ft. 61/4" .188 GALV.STL
From To Ft. w
From To Ft. —
13. GROUT: Depth Material Method
From 0 To 20 Ft CEMENT GRAVITY D <�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. S
15. SAND/GRAVEL PACK: v
Depth Size Material a�
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 T OPY OF THIS RECO HAS BEIN P VIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUC G TA 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 ✓ U HIM EN --------- Ff it,U -------
WELL CONS•1•RUC'1•lON IMCOM v- / 31. 4430
NorUt Carolina-DcparUucut o(Lnvirvuulcul and N/n�jwall/Resources-Div isiuR of Water Quality-oroundwater Section
WELL CUNTRACIUR(INDIVIDUAL)NAME (ptinni) / 'r1 CEIl1IrICAT1UNp
WELL CUNTRACIUR CUPIrANY NAl
/�J !ems r11UNE a r'f'L`n�i,�r f�F 7
if
ASSUCIA1 tit wQ rRM11'10
STATE YELL CONS r ) N rEM1►ra ire r ilicnblc
n�dictinldcbic
1. WELL USE(Check Applicnble Ilux): l(esitlentinl Lt-�Muuicipal/publle U htdusirtal O Aglicullural U
Muniloriug❑ I(ecovery I7 Ileal I'uwp Water Lyccl{on O ()liter O If()User,List Use
2. WELL LOCA'IION* T'opoginphic/Lmid setting
NcarestTuwu /7iX`/z 1 Cuwdy /!�'CG"� UlUdge ❑Slope ElValley ❑llal
CZA L/4 ? � ----- /Lockitude onto cll
Lalhuddluugimde of well location ,
(Still,Stiee,Nau�CpOmiu„tty SubdivJelun.Lot No.,Zip Curie) /'fir fso(0 �,3S 'r1 y
1 L F/u, y (deateeeAnlnnteJenondi)
3. OWNER: /�( ( NQ Lalitudellungilude source:OOPSOTopogtaphic Irup
Address r (clink bait)
(StieeimR uleNo.) u ;.(1 ''1)I j�U)..LINCLLP-0
1 - "i _
� Fonmlion Ucscrilrriwl--_-. _
Zip Cale 1°runt To -'-
Cttyor -own Su,e 1
614
Airs late-rirnne nirnteer ,-�!_JS 7L5 u f f • /Af1. Z- -
4. DATE DIM'LED C
5. TorA . DEPTIL•
6. DOLS WELL REPLACL LXISTINO WELL? YES U NO El'
7. STATIC 1VATEK LEV LL Uclow Top of Cnsmg
(Uwe"�"if Alrnve lnp of Coeinp) `
B. l'OI'OF CASING IS
I-71%Above Linid Surface•
-Top or call"[In d mined.Unv bclo"land eucl.ce requlrn
♦etlence In eecutdetee"Jill 15A NCAC IC.0I la.
9. YIELD(91111 : hl"TNODop,I'csf_= —
10.WATER ZONES(depth): 13
LCLC�.1141�LSCL4)1
Auiuuut �Y Show ditection and distance in miles Gmn bticast
i 1. DISINfEC1lON:Typo /Z two Slate Roads or County Roads. Include We road
12. CASING: Wnll'Ihick less
Uimndsr or WeighUpl. Material numbers and eouunon road mm�cs.
�7 1'l. �%ZS S/��Ll
frnl,l D TO d�- ���y
From �"j TDB rL 's
Front To FL f�cWud� a
13. GROUT: Depot taleJJial C
houl�_To 3 pl, /C t •3
Floni_ To FI.
14. SCREEN: Depal Dimileter Slut Size Mptednl a -
Front To pJ. in. Ill. LA
Front
'fu FL—ill. lit.
13. SAND)GRAVI;L PACK: Mnitdol
DepUt Size
Flom ro I-L --
front Ib 16
16. REMARKS:
I DO IIEREDY CERNpY 111AT'IIIIS WELL WAS CONS-IttliCfLD IN ACCORDANCE WITII 15ANCAC 2C,WIiLL
CONSTItUCIlON STANDARDS,AND TIIA'f A C01'Y Or TIIIS IIIICORD IIAS LLLN pROVIDED TO TI IL WELL OWNER
7—vd"—OJ'"
SIONAIUIlL01°I'LI(5UNCONS'll(UC INU11111WLLL RAIL
Submit the orlghlal lu tilt n e Uivislu of 1Vnler Qualllyl Groundlraler Sections 1GJ6 hLll Smlcs CdW-I Raleigh,
0712UU1
I7699-1636 phone No.[phone],11 I(hht 3U dnys.

WELL CONSTRUCTION RECORD
North Catalina-Department of Envirmuneht and Natural Resources-Division~ofta or Quality'-Groundwater Section
WELL CONTRAMOR(INDIV•IVUAW?iAME (print c�P_HNiS l Ilta,.�rL -• TM�C,,A,,T°I�ONa I7(o
WELL CONTRACTOR COMPANY NAM +PHOttE a —S;2 L/-3 A 0
STATE WELL CONSTRUCTION PERMITM ASSOCIATED W ERMITM
(irapplicsble) -(ifapplicable) -
I. WELL USE(Check Applicable Box):Residential' unicipaVPublic 0 Industrial 0 Agricultural E3
Monitoring❑ Recovery O' Heat Pump Water injection 0 Other 17 if OtFier,List Use
2."WELL LOCATION:
NearestTown:_FRfYiL'/z/ /� Count CG dge 0 apai setting
Y� ORidge pe OYailey OFlat
�4- L Af; e Ir tc. , 13 R L/5 6-.0 r20 c e- 4 A (abackappropriateboz) .
(Street Name.Numbers,Co nmuaity,ISubdi too,tat No..Zip Code) 6Lj,7 3 V Latitudenoagitude of well location
1OWNER: J �,,S It (degvaltnimttes/gaonds)
Address (c 0 1 5 30Y-k S 1-re e r 8 o L,i-k-) Latitude/longitude source:OGPSOTopographic map
(Sava or Rot a No.) .3 - -(check box) -
ST Pet ens bu 2a f=1 . 37 7✓ DEPTH DRILLING LOG
Chy or Towa s Zip Code From To-' .Formation Description
�- 8m�-taf 9 _ � �
Arm codo-Phone numbs [ ..O
4. DATE DRILLED - a `7 -US
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7- STATIC WATER LEVEL Below Top of Casing: L-I FT.
(Use"-r If Above Top of Casing)
8. TOP OF CASING IS Fr.Above Land Surface*
-Top of caslag termh,stW at1w bataw loodsodsiot requires a variance In accordance with-1SA NCAC 3C.0110.
9. YIELD(gpm): 30 M OD OF TEST
10.WATER ZONES(depth): O S
LOCATION SKETCH
11. DISINFECTION:Type W= Amount QLAR3 Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di ter or We UFt. Matey'gl 'numbers and common road tomes.
From TO /O/ Ft $a O1 ��.
From To Ft
From To_FL c
13. GROUT-- Depth Materiel Method - t ..i
From_Q_To
_ate FL N
From,--_To Ft. - O
4. SCREEN: Depth Diameter . Slot Size Material rr
From To Ft in. in.
From To Ft in. in.
5. SAND/GRAVEL PACK:
Depth Size Material - -
From To FL
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C,WBLL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THffS R�E-CORD p�S BEEN PROVIDED TO THE.WE I OWNER
_6 s
SIGNATURE OF PERSON CONSTRUCnNG THE WELL DATE
submit the original to the Divislon of Water Quality,Groundwater Section, 1636 Mall Service Center-Ralelgh;NC -
r1699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

•. _ '.. r ... : • -•• � 314428
WELL CONSTRUCTION RECORD
North Catolina-Department of Environment and Natural Resources-Division of ater Quality ()rowtdwater Section /-
WELL CONTRACTOR(INDIV•IDUAL)NAM ("aL -11 inIS / Ii� ..�.: � - � CLIt=CAT10INi - /�Y' - - -------
WELL CONTRACTOR COMPANY NAM PHONE i 72jd . .4-'3 0�•b D
STATE WELL coNaTRUCTION PFRmrro A9SOCfATED W lt1tMlTd
(Uappltcably) •(ifappiitabla)
I. WELL USE(Check Applitmble"Box):'Residentiai' unicipaVPublic O Industrial 17 Agricultural 0
Monitoring❑ Recovery 0' Heat Pump Water Injection❑ Other 17 If Oilier,List Use
2.-WELL LOCATION:., grapiclLand setting
Nearest Town: F,P 4 jilr L:.i/ County . dC93ti ge Mops Malley OFlat
( 4 E ' — 141,,i oL P Se Q.V (chock aRnpri m boa) - - % - -
(Strect Name,Nuum` Contmaity,Strbdiviiioo,Let No.Tip Code) ,oZ. 03 3 y Ladtude/longitude of well location
3. OWNER- u- �OCaL-P- L7 �r7I rlj (de�seaimiouwdewnda)
Address 9/4 • 12% d-cw Latitude4ongittide sourceOOPSOTopographic map
(Street or RaaeNo.) (cMek box)
DEPTH ' DRILLING LOG
City cr Towa sum ' zip Coda .From To'- Formation Description
( Sam-oaa e3 53 '
Arex code-Phone amber - ""` •-- ,S 2 < .Sosj 1e
4. DATE DRILLED �I—a —D S
5. TOTAL DEPTH: oS'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing. L O FI: P
(Uw'4^if Above Top of Cong) C
S. TOP OF CASING IS_�FT.Above Land Surface* c s
Top of cuingtarmloated aUorbtlinflfndsartaa requires a
varina la aeaordaaa_ISA NCAC 3C All0. tV
9. YIELD(gpm): METHOD OFTP=' A LN& C
10.WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION;Type Amount Show direction and distance in miles from at least 'J
12. CASING: Wall Thickness two State Roads or County Roads.include the road
/� Depth Diameter or WeightiPt. Mate' 1. '-numbers and common mad names.
From/ _To S•3 FL�S - -
From To Ft.
From- Tp FL _
13. GROUT: Depth Materiil Method -
From_To_�FL
From To 'FL
.4. SCREEN: Depth Diameter Slot Sim : , Material -
From To FL in. in.
From To FL_in. in.
S. SANDIGRAVELPACK: _
Depth Size Material
From To Ft.
From To Ft. L__
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPYOFT fIiSRECORDBEEN PROVIDED TOTHE.WELLOWNER
,+fJ
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Matt Service Center-Raleigh;NC -
p7699-I636 Phone No.[phone],within 30 days. GW-1 REV.07/ 001 .

WELL CONSTRUCTION RECU"' : 3 1 4 ;< 2 7
North Csolina-Department of Environment and Natural Resources-Division of Witty Quality'-Groundwater Section
a: ?
WELLCONTRACTOR(INDIV•IDUAI)NA4Z (prim) „NIS � 1►�=—d, 11'lptCATIONi ot-�7l
4.-. r /
WELL CONTRACTOR COMPANY NAM ' PHON$ /aI'-ifl —S�4"3 10
STATE WELL CONSTRUCTION PERMIT, ASSOC(ATEO W 1110M
(ifappliable) •(if4ppliable) -
I. WELL USE(Check Applicable Box):Residential' unicipal/public❑ Industrial 0 Agricultural O
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other U If Other,List Use
2."W ELL LOCATION: T p'ic/Land setting
Nearest Town: ,IC L i / County n�., dge CISlope OValloy OFlat
7 ? Al Q, i 12o t-t- LA _ B /r 1L , r h a,"hl)n..� /--C,11S (obackappropdaw box)
(Street Nam Num�ben,Community.subdivision.Ld No..Zip CA �T g q yt I.11titude110ngitude Of Wtrll location
3. OWNER: M A-i 1/- PA U X- wonds)
Address 1(;L D f e r- PA L L l a,._o Ladtudenongivide source:OOPSOTopographic reap
(Surer or RmueNo) (cbsck box)
333 9 7 D DEPTH ' DRILLING LOG
City or Town z p code, From To Formation Description
6SLb '7 9S —snnS3 6 5 n"
Area code.Pharr number - `` --- 'G r �7 (L' -- .
4. DATE DRILLED ,� � s 7 4 ' S FiS s 1 r-
5. TOTAL DEPTH: S S.5 r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO_ Ci
7. STATIC WATER LEVEL Below Top of Casing: In O FT.
(Use Oe if Above Top of Casing)
g. TOP OF CASING IS�_FT.Above Land Surface' cei
'Top of castes terminated atior b4WIs%&surfan requires a
wrtanu to aewrdano wtb"1SA NCAC 2C.OI IL rV
9. YIELD(gpm): IS METHOD OFTBST
10.WATER ZONES(depth): JPD' Se2,5 ' Ln a.
LOCATION SKETCH
it. DISINFECTION:Type Amount Z -Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di or WcOt/Ft. Matey. 1. 'numbers and common road[tames.
From_�To�Ft $�2R�, D1
From To FL
From Tq FL_
13, GROUT: Depth tvfakriel Method
From To_c2D_FL2Qy(dZ.
From To FL i.-
.4. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in.
From To FL in. in.
5. SAND/GRAVEL PACK: _
Depth size Material -
From To Ft.
From To F L t.
i
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD BEEN PROVIDED TO THE.WELL OWNER
7a -G s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
Y7699-1636 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 J
WELL CONTRACTOR(INDIVIDUAL)NAME (Pent)--LA ILLIAM BRADLEY LEWIS CERTIFICATION#3368
WELL CONTRACTORCOMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY INC PHONE # g 6)837-8008
STATE WELL CONSTRUCrION 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: a P7-0.) County MACON Ridge Mope ❑Valley ❑Flat
EAST SILVERMINE TO MASON RD (check appropriate box)
(Street Name,Numbers,Community,Subdivisioq Lot No.,Zip Code) Latitude/longitude of well location
3518.588N/8335.888W
3. OWNER: BRUCE TAYLOR (degrees/minutes/seconds)
Address 2103 WASHINGTON AVE. Latitude/longitude source:❑GPS❑Topographic map
(Street or Rome No.) (check box)
PA scA Gf 4 I MS 39567 DEPTH DRILLING LOG
CuyWrTown State Zip Code From TO Formation Description
(-2.r)-769-0314 0'T 2 0' BLACK DIRT/SANDSTONE
Area code-Phone number 20'TO 40' BLUE SLATE
4. DATE DRILLED 07/25/2005 40'TO 345'
5. TOTAL DEPTH: 345' SLATE
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ja
7. STATIC WATER LEVEL Below Top of Casing: too F F
(Use-+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface* C 1
*Top of easing termhwW s i r below land surface require a
variance in accordance with 15A NCAC 2C.011& iM
9. YIELD(gpm): 9 METHOD OF TEST AIR o r
10. WATER ZONES(depth): 300' o
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount too PPM Show direction and distance in miles from at least,.!y
12. CASING: Wall Thickness two State Roads or County Roads. Include the roach
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 40 Ft. 61/8' SDR 21 PVC
From To Ft. tlgr f
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft CEMENT GRAVITY
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material Q
From To Ft. in. in. u
From To Ft. in
15. SAND/GRAVEL PACK:
r
Depth Size Material ,
From To Ft.
From To Ft. �/
16. REMARKS: 2 /
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS B PROVIDED TO THE WELL OWNER
/�G 'r►u 4 b0t,c i n,, 7 �7 c75
SIGNATURE OF PERSON CONSTRU 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. -
GW-1 REV.09/2004

-NC Y-__ OIDVEIl
Of II'D
WELL CONSTRUCTION IMCORD 6' 151 S 8
NorOt Carolina-Depatmncut of Environment and Na�yial Resources-Division or Water Quality-Otoundwater Section
WELL CON"rRAC10R(INDIVIDUAL)NAME (pilm) i e/!Y Ize(--e CER"IIrICAT1UNNot ��'�
WELL CONTRACT OR COMPANY NAME 71P'll2s- PIIONE N fb'.18)g"9-.1557
STATE WELL CONS TRUCIION rEMI1TN ASSOCIATED WQ PE"tI"rN
(if npplicnble) (if applicable)
1. WELL USE(Check Applicable Box): Residential I�K Municipal/Public O Industrial 11 Agticulluial U
Monitoring I] Recovery O l Ical Pump Water Injection O Olher O If Older,List Use
2. WELL LOCATION: Topogrnphic/Land selling
NcarestTown: 1 44pe^If County A",a.ce 2 OWdge ❑Stops ❑Volley UFlat
(check sppioprlene box)
(Sneel Name,Number,Cornrnuuiny,Subdivision,Lot No.,Zip Code) Latitudellongitude of well/.1 location
p ` N$S'/6'yy" , tW�3e39 29-4
J. OWNER: Nnt�X. Kea: �kP/G (degreee/minuteyeecnn�Jv)
Address 2 3 4 1 Su RQ ll1_SSk[( Lali udellongilude source:OOPSOTopographic map
(Sliest or Route No.) (check box)
f}anInntL Al'c-29T03 P1:C:[11 121MULI& —L0W
cit or Town Stale Zip Cixle Front To FormationDescliptioll
Ain code-rhone number D— 15'j
4. DATE DRILLED G -/J - ys--- �y� L Win,fe
s. TorAL DEPTu: 3gr2 "
6. DOES WELL REPLACE EXISTING WELL? YES CJ NO Er
7. STATIC WATER LEVEL Below Top ofcnsing: 6 O FT.
(Use"+"If Above Top of Cming)
8. TOP Or CASING IS l IT.Above Lmnd Sufface•
a'Ibp of cning Orintnded eUor below lend surface requltre■
♦rtlann in accordente with I!A NCAC IC.01 rs.
9. YIELD(lapin):_--METHOD OFTE-ST
10.WATER ZONES(depth): ,s'Ad
LOCATION SKE'rCll
11. DISINPBCTION:'fype /r r/ Amount VY�✓ Show direction and distance III miles from at (cast
12. CASING: Wnll Thickness two Stale Roads or County Roads. Include We toad
Depilt Dinnncer or WelghVFt. Material numbers and couunon road names.
Front To b f rt -C
tv
Front Tv I:L C
IJ. GROUP: Depth tale))ial �1eWod r
wont To .� rt. c.•T/•nc�
Front 3 To ' 1:1. ffuWfan./f -
14. SCRLEN: DepW Diarnelcr Slot Size Material ccn
wont To—FL—in. Ill.
rronit •rn F1. in. in.
15. SANDIGRAVFL PACK:
Drpnlr Size Mnlelial
Front To FL
Front To 1:1.
16. REMARKS:
I DO I IEREBY CERTIFY TIIAT TI IIS WELL WAS CONSTRUCILID IN ACCORDANCE Will 15A NCAC 2C,WELL
CONSTRUMION STANDARDS,AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TI IE WELL OWNER
SIGNATURE Or PERSON CONS'IRUCI'INO THE WELL DATE
i
Submit (he Driglnal to (he Division of Wa(er Quality,Groundwater Sec(lon,1676 M1i11 Service Cenler-Itatelgin,NC
I7699-1636 rinone No.[phone],wl(Inhn JU tiny%. GW-I I1LlV:07/20U1

WELL CONSTRUCTION RECORD
.. North Carolina Department.of Environment and Natural Resources-Division of Water Quality.--;.,. .
WELL CONTRACTOR(INDIVIDUAL)NAME (print) .lames B. Brown CERTIFICATION B 2045
WELL CONTRACTOR COMPANY NAME Hedden 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 El Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic/Land setting
Near.cst,T�own: County ❑Ridge ❑Slope ❑Valley ❑Flat
J(_(fz(J _A// Q,, (check appropriate box)
(Street Name,Nu ers,Community,Subdivision,Lot No,Zip Code) Latitudellongitude of well location
3. OWNER: Akw Aliw 4r,_.) (degrees/minutes/seconds)
Ad ress I Latitude/longitude source:❑GPS❑Topographic map
(Street or .��911 Route No.) (check box)
FA.. DEPTH DRILLING LOG
i oriown state zip code From Formation Description
(3�I)- to'124251P 0 Clay&sand
Area code-Phone number ' Granite
4. DATE DRILLED 1'5,0 6
5. TOTAL DEPTH: Bcol
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 6,2-0 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): In METHODQF TEST BLOW
10. WATER ZONES(depth): 4R/T JIM 7'��
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. Nkterial numbers and common road names.
From o To rre
From-To Ft. /
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped C
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. ov
From To Ft. in. in. O
15. SAND/GRAVEL PACK: cn
Depth Size Material
From-To Ft. "s
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 PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA 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 I 111 J
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 ID Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : Topographic/Land setting
NearestTopyn: County. ❑Ridge ❑Slope ❑Valley ❑Flat
r;Z4(0 (check appropriate box)
(Street Name,Numbers,Community, ubdivision,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)
/I,J 11 A, FL 3r�7L� DEPTH DRILLING LOG
��,ry�ttyorTown ' State Zip Code From To f Formation Description
t31/- a 4• d3 0 Clay&sand
Area code- number S8t r]0(�r Granite
4. DATE DRILLED
5. TOTAL DEPTH: 7] 0 '
6. DOES WELL REPLACE EXISTING WELL? YES ] NO
7. STATIC WATER LEVEL Below Top o£Casing: 00
(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.
9. YIELD(gpm):--., 0 METHOD %T~BLOW
10.WATER ZONES (depth): Ali/�
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 Diameter or Weight/Ft. Material numbers and common road names.
From o To Ft. •� _ ✓G
From�To Ft. &
From To Ft. =,d
13. GROUT: Depth Material Method -1
From 0 To 20 Ft.Benonite&Cement pumped j
From To Ft. y.
14. SCREEN: Depth Diameter Slot Size Material C
� A
From To Ft. in. in. _ 'i14
m Fro To Ft. in. in. Cr%
15. SAND/GRAVEL PACK:
Depth Size Material cc n a..
From To Ft. -e
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
h ) 7-aLy-o5
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 Wo
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 # I )369-9591
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 : Topographic/Land setting
Nearown: County ❑Ridge ❑Slope ❑Valley ❑Flat
d. Any�I (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 R o.) (check box)
B0 DEPTH DRILLING LOG
Ciry or own ra Te Zip Code From TO Formation Description
(�- Phone
0 ,'aY Clay it sand
Area code-Phone number ��/ ������ ''' a��aT--�n-n7�� Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES OK
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 attar below land surface requires a
variance in accordanchwith ISA NCAC 2C.0118.
9. YIELD(gpm): 3 METHOD O TES BLOW
10. WATER ZONES(depth): �D3 yQ� 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������QQQQQQ D1 Teter or Weight/Ft. Material numbers and common road names.
From To Ft. Cn•� V
From MY TO Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft. a '
14. SCREEN: Depth Diameter Slot Size Material
G7
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: o
Depth Size Material to Ry
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 C Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S 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

WELL CONSTRUCTION RECORD w, �
. . North Carolina Department of Environment and Natural Resources-Division of Water Quality (..c1
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 ICJ Municipal/Public❑ industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: I Topographic/Land setting
Ne/a�restTown' L) County ❑Ridge ❑Slope ❑Valley ❑Flat
l J("k, A 11Jii:y (check appropriate box)
(Street Name,Nu ers,Com munity,Subdivision,Lot No.;Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Ad ress / Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
itlo Town`, Stgte Zip Code From T , Formation Description
- e y5d� 0 Clay it sand
3 Area code-Phone number � Granite
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 060
7. STATIC WATER LEVEL Below Top of Casing:5_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.
9. YIELD(gpm):J�METH Oj�FT ST BLOW
10.WATER ZONES(depth): e�7 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 A( Di eter or Weight/FL M t/e'nal numbers and common road names.
From o To / Ft.
From�To__7T _
From To Ft.
13. GROUT: Depth Material Method 3�
From 0 To 20 Ft.Benonite&Cement pumped C
L-] w
From To Ft. '
—
14. SCREEN: Depth Diameter Slot Size Material rn .,
From To Ft. in. in. o
From To Ft. in. in. cn -«
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,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 -Q " 1. 51 a' .�
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION H 2O45
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE # [phone]
STATE WELL CONSTRUCTION PERMITH 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 Topographic/Land setting
Ne rg est Town: County ❑Ridge ❑Slope ❑Valley ❑Flat
�� d (check appropriate box)
(Stre Name,,(Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: L11/yYl h�i� - - (degmes/minutes/seconds)
7
Address �pf! — Latitudeflongitude source:❑GPS❑Topographic map
/ �Su l
(Street �No.) t (check box)
eyq DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
� - �a!- .3�-5�33R 0 IIS Clay&Sand
Areacode-Phone number 115' �� Granite
4. DATE DRILLED 9 05
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: .460 T.
(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 accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):10 METHOD OF TEST BLOW
10.WATER ZONES(depth): IRO' 3 Z.D
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. ibipterial numbers and common road names.
From 0 To Ft. a 'f ryd _
From ify--tt To Ft. 6„ ags IrC
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.aenonde&cement pumped dip
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material •�
From To Ft. in. in.
From To Ft. in. in. 7-
15. SAND/GRAVEL PACK:
Depth Size Material � 1^
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 Y OF TH[S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-� �0'C
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004

11
3A, x
.WELL CONSTRUCTION RECORb
North Carolina-Department of Environment and Natural Rwourcw D' h,(("
WELL CONTRACTOR(INDIVIDUAL)"NAME (print) rvislon of Wtitor Quality-Ground water Section
� rihlS /jf1
WELL CONTRACTOR COMPANY I I 4AMala Ila 14 10P41
CrRTIFICATION I of/7,1!10
STATE WELL CONSTRUCTION PERMIT# PHONE if L/-,3 �6Q
(if a lieable) SSOCIATED W gRMIT#
.(ifs licable - -
1. WELL USE(Check Applicable Box): Residential'J�ct�untctpaVPublic ❑ Industrial ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other I J if Other, Agricultural ElList Use
2. -WELL LOCATION:
Nearest Town: CL_4/ County PogmPhie/Landsetting
_�41 n/_ ' y,, 1 -Q�U /T � dge ❑Slope ❑Valley ❑Flat
(Stree(Name,Nurn 0.Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:
LatitudeJbngitude of well location
S h ��_
Address o210 Yoo(� won fL (degrea7minutWstoonds)
(sacct or ko Q LV L L Latitude/longitude sourcCOGPS❑Topographic map
I I {/ a a { 3 V DEPTH
�(j (check box)
Cityor Town State Ziy Code DRILLING LOG
( -�( _ (p p From To Formation Description
Mca code-Phonee ut a'
nwnbe �(] ,3
4. DATE DRILLED ••
5. TOTAL DEPTH: rI .S— 9 '17 - } -
6. DOES WELL REPLACE EXISTING WELL? YES 13 NO
7. STATIC WATER LEVEL Below Top of Casing:
—2-0—FT: 4
(Use"t"if Above Top of Cuing -------
g. TOP OF CASING IS�_Ff.Above Land Surface• —_ as
-Top of cuing terminated at/or It leadsur(ace requires a C
varlance In accordance with ISA NCAC 1 IC.01 IS
9. YIELD(gpm): 1 METHOD OF TEST
10. WATER ZONES(depth): 1 (y -- --
11. DISINFECTION:Type -- LOCATION SKETCH CAa
12. CASING: _ Amount Show direction and distance In miles from al leas)
Wall Thickness two State Roads or County Roads.Include the road `*
From Depth D1a tier or Weot/Fl Mate ' 1 ''numbers and common road names.
_�To X' I Ft._�$, &'J j'
From To Ft.
From To Ft
13. GROUT: Depth Material
FromTo Method .
_r Ft. ne
From To Ft.
4. SCREEN: Depth Diameter Slot Size From TO—Ft.__in. e Material
From To Ft. in.
in.
5. SAND/GRAVEL PACK: to
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
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER
��A F lG o 5
SIGNATURE OF PERSON CONSTRUCTING THE WELL
' DATE
-sLbmit the original to the Division or Water Quality,Groundwater Sections I636 Mall Service Center-Raleigh,NC
.17699-1636 Phone No.[phone],within 30 days.
OW-1 REV. 0712001

WELL CONSTRUCTION 3154 �x Q
CTION REC,(ORD
North,Carolina-Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME c Q ty-Groundwater Section
(prlao-she d NIC /In ljr7 ., 1 _ -
wELLCONTRACTORCOMPANYNAM ' �---� C"TWICATIONY of/7(e
STATE WELL CONSTRUCTIONP6RMr Lf PHONLM�y_g
fire linable) SSOC[ATED W ZRMITM
LL(if4pplicablO -
I. WELL USE(Check Applicable Box):Resident'ial'l�cipaVPublic O Industrial [J Agricultural p
Monitoring ❑ Recovery ❑ Heet Pump Water Injection❑ Other CT If Other, List use---.2. WELL LOCATION:
Nearest Town: /L L j �pbic/Land setting
CountyCVy [a[t'i e kr7 eg 0 �� ; � dge ❑Slope Malley ❑Flat
(at a Name Numbers,Commumry,Subdivision,Lot No.,Zip Codc) (check appropriate box)
n ''_ Lwituddiongitude of well location
3. OWNER:C[1 A D e /)r") OA L
Address _� I C ) /y5 0 n,i n�' (deareea7minutWaeconds)
` (SLMI"Reu "li.) Latitude/longitude source:❑OPS❑Topographic map
�1 t2/a&L 1 1J NO (check box) .
ctv T Sul zpceee DEPTH DRILLINGLOG
_ From To
Mel code-Phone number Formation Description�fir
4. DATE DRILLED —/b .-6 5 - -�Je-__,
s. TOTAL DEPTH: C.�S --�= 3 • I B-e- f, n A
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top ofCasing:-- �FT
8. TOPOFCA +(Oae 'if AbnveTop otCun� - C=SING IS
—�Y-�FT.Above Land Surface* —•-�__ G-3
-Top of cuing terminated Wor belgw land,urraa require,■ N -.1
vartaau In Accordance with 15A NCAC 2C.011ii ----
9. YIELD (gpm): l METHOD OF TEST �--
10. WATER ZONES(depth): c�P1
11. DISINFECTION: Type
AmoWtATION_SKETiH 3
12. CASING: Show direction and distance In miles from at least
Wall Thickness two State Roads Or County Roads.Include the road
From Depth Dt `tie or Weot/Ft, Mate ' 1 'numbers and common road names.
--�TaD Ft.--�Z S D R '
From FL
From To Ft.
13. GROUT: Depth Material
From Method
From To�Ft. -L /Tux J
To FL—_ 7- -
4. SCREEN: Depth Diameter
From To Ft. in,. Slot Size Material
From To in.
5. SAND/GRAVEL PACK: Ft �n' in.
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
i .-
I
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ONSTRUCTION STANDARDS, I SA NCAC 2C,WELL
AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER
6JUNATURE OF PERSO /y 6 S
N CONSTRUCTING THE WELL DATE
.stibmit the original to the Division or Water Qusilty, Groundwater Sections 1636 M
a7699-1636 Phone No.[phone],within 30 days. Raleigh,NC t
Mail Service Center-
OW-1 REV. 07/2o01

WELL CONSTRUCTION RECORD
North Carolina-Department Of Environment and Natural Resources Division of W
WELL CONTRACTOR(INDIv,IDUA4)'NAME hot akr Quahty-Groundwater Section
�° )�� n' l 1 '^ _ (P WELL CONTRACTOR COMPANY NAM Ila A 11i I
CERTIFICATION c-a 17
STATE WELL CONSTRUCTION PERMITYPNONRY „yj�4-3
(if applicable) ASSOCIATEDW gRM/TY .
(if a licable
I. WELL USE(Check Applicable Box): Residential'l�cipaVPublic❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovcry ❑ Heat Pump Water Injection ❑ Other[I If Other, List Use
2. WELL LOCATION:
Nearest Town: Fie A' / L i A/ County G � - ,,, �Pbied itnd setting
_` L�h�Rle Y Alr nr, n E A 9 S ry , midge ❑Slope ❑Valiey ❑Flat
(Sued Nsme,Numbers,Community,Subdmsion,Lot No.,Zip Code) - . - (check appropriate boz) a
Latitude/longitude of w.el l location
3. OWNER:
Address / r a.e/ r (degrees)minutWaaonds)
(Sveet«Route Latitude/Iongituda source:❑OPS❑Topographic map
e�.nk/ � �i/C. �.C'73[/ DEPTH (check box)
Cnyor Town State �1 Zip Code f DRILLING LOG
From Formation Description -...
Arco code-Phone number �± /
4. DATE DRILLED d LJ —O 5 s r
5. TOTAL DEPTH:� i
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO t
7. STATIC WATER LEVEL Below Top of Casing: D a m
�_FT./ (Use"+"if Above Top of Cuing)
c
-------- �
S. TOP OF CASING IS FT,Above Land Surface, — --
'Top of eesing terminated atlorTbelaw Iaadrvrtau requires■
variance In accordaote wltb I5A NCAC 3c.01la.
9. YIELD (gpm):�_MET OD OF TEST — o
10. WATER ZONES(depth): -------
I. DISINFECTION:T LOCATION SKETCH
ype Amount Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads,include the road
Dep Die ter or WcOt/Ft. M�at,e��' 1- numbers and common road names,
From TO�FL f_$-a, ,
From To Ft.
From To Ft.
13. GROUT: DeR� Material Method
From To Ft. now
From To Ft.
4. SCREEN: Depth Diameter Slot SizeFrom Material _
To Ft. in.
From To Ft.__in, in.
5. SAND/GRAVEL PACK: _
Depth Size --- ---- —
From Materiel -- r
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 H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATOE
S
- I.
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-I REV. 07/2001 _ _

u5 4
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Wdtor Quality i.
WELL CONTRACTOR(INDIVIDUAL)NAME (prim., .pnht erQ ty`Groundwater Section
— —_ f _ y WELL CONTRACTOR COMPANY NAME, . —�'�--�� T�ICATIONY
STATE WELL CONSTRUCTION PERMIT# - PHONR Y �L/--3 �,6
Ora liable) SSOCCATED W ERMIT#
'(ifs licable
i. WELL USE(Check Applicable Box):Resident1iel',. _kunictpaI/Public❑ Industrial Q Agricultural C)
Monitoring O Rccovery ❑ Heat Pump Water injection un❑ Other C7 If Other, List Use
2. "WELL LOCATION:
Nearest Town: �x4z County /� 1�grvlliclLand setting
Q ( v� 11 0 Kedge OSIOp i OValley 0FIat
(St t Name N mben,community,Subdivision,Lot No.,Zip Code) 17 3 7 (check appropriate box) i
(" Latitude/longitude of well location
3. OWNER: '` ID e Sred� n✓rI
Address �E�'�. I��.dA (de#rxalminutes/seconds) .
(S rear o Rouu No.) Latitude/longitude source;OGPSOTopographic map
o�C�J �e (check box)
e ry r To sum ip ode DEPTH
z DRILLING LOG
(-��Qi• 3a-s - C 9-Rr/ _ From To Formation Description
Area code-Phone number
a. DATE DRILLED -S-U
5. TOTAL DEPTH: C-5 r �� dI Sc
6. DOES WELL REPLACE EXISTING WELL? YES O NO _7. STATIC WATER LEVEL Below TopofCasin : --------�_ c s.
(Use"f"if Above Toof�FT: �__
8. TOP OF CASING IS__ / N
FT.Above Land Surface' r o*Top of cuing terminated aVor bNaw laodrurfaes requlreaa valiance In accordance with 75A NCAC 2C.01 is. - ��— p :r
9. YIELD(gpm):--_L 5_METHOD OF TEST
10. WATER ZONES (depth);
11. DISINFECTION:Type_ LOCATION K T H
12. CASING: Amount Show direction and distance in mhos from at lease
Depth
Wall Thickness two State Roads or County Roads. Include the road
Di tV or Weot/Ft. Mate '
From To S -3 Ft.= I 'numbers and common road names.
g D)P�,�
From To Ft
From To Ft
13. GROUT: Depth Material
From Method
From—�To4_Ft."' PCw xTo Ft
)
4. SCREEN: Depth From Diameter Slot Size Materiel
-
To Ft
From -_--in' in. -
To Ft._._in.
5. SAND/GRAVEL PACK: in.
From
Depth Size To Ft Material
From To Ft. ---------:--_..
- ,
6. REMARKS: i
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC
TED IN ACCORDANCE WITH ONSTRUCTION STANDARDS,AND THAT A COPY OF TH 15A NCAC 2C,WELL '
S RECORD H BEEN PROVIDED TO THE WELL OWNER
[�
bJUNA URE OF PERSON CONSTRUCTING THE WELL E
DATEsubmit the original to the DIvlslon of Water Quality, Groundwater Section, 1636 Mall Service Center-
.77699-1636 Phone No.[phone],with In 30 days. Raleigh,NC L -i
GW-1 REV, 07f2001 -
-__

WELL CONSTRUCTION
RECORD
North Carolina-Department otEnvironmeht and Natural Resources- �',(`''
WELL CONTRACTOR(1NDIYIDUAL)NAME (print)
1, Division of Water Quality-C}roundwater Section
(P ) c!)foilIS 1 WELL CONTRACTOR COMPANY NAM i.11n ~""�—� . C"TIFICATIONY or-17ico
STATE WELL CONSTRUCTION PERMIT$ °wu0 PHONE
(ifs D W ERMIT$
licable) SSOCIATE .
(ifs licable) -
I. WELL USE(Check Applicable Box): Residential' unicl a Monitoring ❑ Recove ❑ P .p Other
❑ Industrial ❑ Agricultural ❑
ry Heat Pump Water Injection❑ Other CJ If Otlur,List Use
2. WELL LOCATION:
Nearest Town: f 1f A A'/�r - 41 CountyA a r,y� Topographl setting
I ❑' f��, Nis ❑RidgeW>kOP0 [ Valley ❑flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code ,3. '7 3 V (check appropriate box)) a
—� Latituiloongitude of w.Gll location
3. OWNER: / Im �O c�2a1 .
Address (C A"�l(I- Sri r- 7" (deareedminutes/seconds)
(sued«Rouu No.) LatitudeAongitude source:❑GPS❑Topographic map
�c Af n. n cf
(e Dr (check box)Cit -
Y Sian ZtpCodc DEPTH
(3 DRILLING LOG
&lc) 3(ctl _ S6S�L From To ForrnationDescription
Arca code-Phone number
4. DATE DRILLED -� - /IL,S"[7 rt fro 5. TOTAL DEPTH: � _�
> c '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: lie,)r FT: _
8. TOP OF CASING IS (Use +^ifAbovcToporCun� — n.
FT.Above Land Surface* e
'Top or cuing terminated at/or belkw land surface requires a G-3 1
variance In accordance with ISA NCAC 2C.01 is. �-- N
9. YIELD (gpm):____e_METHOD OF TEST
0. WATER ZONES(depth); i CD
Cn
11. DISINFECTION:Type LOCATION SK Trt
12. CASING: �O nt Show direction and distance In miles from at least
Wall Thickness two State Roads or County Roads.Include the road
From Depth Pt Dia ter or Wc.6ht/Ft. Mate I numbers and common road names.
_Q To -- s1_5 Y�
From To Ft
From To Ft_
I}. GAOUT: Depth _ Materiel
From -;ID Method
From—�To Ft. Method
J`•To—Ft.--
4. SCREEN: Depth Diameter
From To Ft. Slot SizeMaterial -
From To __m in. .
5. SAND/GRAVEL PACK: Ft_—in in.
From Depth To Ft. Size Materiel -
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ,W
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO I Sp NC WELL
AC AC 2C 2C WL OWNER
^'URE Uh PERSON CONSTRUCTING THE WELL G S
DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC
,77699-1636 Phone No.[phone],within 30 days.
OW-1 REV. 07/2001

WO
WELL CONSTRUCTION RECORD 3 1 6 5 6 4
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: Topographic/Land setting
Near stTown: County ❑Ridge ❑Slope ❑Valley ❑Flat
O" l`5 (check appropriate box)
m(Sweet Na , umbers,Community,Sub ivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: D�/� �,(4 (degrms/minutes/seconds)
Address 7� / n Latitude/longitude source:❑GPS❑Topographic map
(Sacet,,orr Route No.) (check box)
t7 ,Y �� _ DEPTH DRILLING LOG
City o�o-�nn�// CState Zip code From To Formation Description
Are�de-Phonenuber J�O� 30' 7d Clay&Sand
EING
Granite
4. DATE DRILLED5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISWELL? YES NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+'&Above Top o Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface•
-Top ofcasing terminated at/or below land surface requires a
variance in accordant ith 15A NCAC 2C.011&
9. YIELD(gpm): W 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 QQ Di e er or Wei ht/Ft. M dal numbers and common road names.
From o To
F. g rTI
FromTo Ft �y •r r/fj$ rTI
From To Ft. tV .
13. GROUT: Depth Material Method -- - - O .
From 0 To 20 Ft.Benonite&Cement pumped'
From To Ft. C
N
14. SCREEN: Depth Diameter Slot Size Material ---
From TO Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material -
From TO Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIO=ST �,AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
��d2
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
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION is 2045
WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc. PHONE [phone]
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMITH
(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: Topographic/Land setting
N.earis't Town:
.,,,� �1,, Co�runty ❑Ridge ❑Slope ❑Valley ❑Flat
,C17.e� ub n,^ - (check appropriate box)
(Street NamFFVV,,,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location
3. OWNER: _�/ ,�, /Lz//1 J�J�,Aif (degrees/minutes/seconds)
Address �3 !� Lr Latitude,9ongitude source:❑GPS❑Topographic map
A (Slret or Rrule No.) 4 DEPTH (check box)
(!A6/ �l• DRILLING LOG
Ctry or Town Jtate Zip Code From To Formation Description
Cla
qXon �/ _ImLd� Y
Area )e Phone number
-, p9 .0154 0 Sand
4. DATE DRILLED • Gan&
5. TOTAL DEPTH:— I"x00'
6. DOES WELL REPLACE EXISTING WELL? YES l"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 accordant with 15A NCAC 2C.0118.
9. YIELD(gpm):�METHOD OF TEST BLOW
10.WATER ZONES( epth):
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 Dipmeter or Weight/Ft. Material numbers and common road names.
Froma_To a Ft
From h To Ft.
From To Ft.
C*3
13. GROUT: Depth Material Method -
• :'S. ......
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material O
From To Ft. in. in. a'! ' Lill
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 STAND S,AND THAT A COPY 0 TIES 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 W 316562
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 to [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 LOCATION; Topographic/Land setting
Ne estTown: County MQ(�CSIL, ❑Ridge ❑Slope ❑Valley ❑Flat
� a 2� (check appropriate box)
(Street Nat4,'Numrs,Community,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minu[es/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
71 Nr zip Code -9 DEPTH DRILLING LOG
City orTo" State From To Formation Description
B( 28 ) 5 •5��{ 0 34• Clay&Sand
Area code-Phone number C 4. DATE DRILLED �jy' ) p(y Granite
(p 'OS
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELLS YES, O ❑
7. STATIC WATER LEVEL Below Top of Casing:ItFT.
(Use"+"if Above Top ofC mg)
8. TOP OF CASING IS 2 FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith 15A NCAC 2C.011&
9. YIELD(gpm): W METHOD OF TEST BLOW
10. WATER ZONES( 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 Diameter or Weight/Ft. Material numbers and common road names.
From 0 To 3�t. cc
From 3 3R To [�• . LR$ _ �_
From To FL t
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonile&Cement pumped I �
From To Ft. -- --- jr
14. SCREEN: Depth Diameter Slot Size Material I jt
From To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL n ,
,. � � ', F � - -
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 COP F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU 0 ERSON CONSTRUCTING THE WELL DATE J�
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

v 316561
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 O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI �tpO " Topographic/Land setting
Neare Town: County, '_ ❑Ridge ❑Slope OValley OFlat
�f t VOi (check appropriate box)
(Street Name,Numbers,Commun' ,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: rq?Av
(degrees/minmes/seconds)
Address a75D t 2AA tit A 1 Latitude/longitude source:❑GPSOTopographic map
/J ( treet or Route No.) (check box)
Ut . Clj� 3b350 DEPTH DRILLING LOG
City or Town lgate zip Code From To Formation Description
(ea c )- � C�L-7� Clay&Sand
Area code-Phone number
4. DATE DRILLED Granite
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:__J000_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
`Top of casing terminated attar below land surface requires a
variance in accordan with 15A NCAC 2C.011&
9. YIELD(gpm): __—Ivj 31JPW7G5 BLOW
10. WATER ZONES(depth): -],S7f
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 Cccl11 Diameter or Weight/Ft. Material numbers and common road names. -
From 0 To Ft. G"
From�To Ft. L._
From To Ft. — i -..—, _--.,.__ _ __. to L'
13. GROUT: Depth Material Method -R From 0 To 20 Ft.Benonite&Cemem _ pumped - - .b
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. - -�i'r' Ln
From To Ft. in. in.
15. SAND/GRAVEL PACK: t"
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY T 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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the origina 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 0 3 1 G' i 1 8
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ Russell S.TaVor 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
N estTown: /,1 ountyrn� ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
St eet Name,NumbeCo uni• Ty,Su vision,Ld No.,Zip C� ode) Latitude/longitude of well location
3. OWNER: (degrws/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
�J Street or Route No. (check box)
DEPTH DRILLING LOG
city or wrt Ste Zip Code From T Formation Description
��- V_ y3 Clay&Sand
Are Phone number Granite
4. DATETE D DRILLED
5. TOTAL DEPTH: '
6. DOES WELL REPLACE 9XISTING WELL? YES ❑ N f�
7. STATIC WATER LEVEL Below Top of Casing: 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): _MET$Q8 9F TEST BLOW
10. WATER ZONES(depth): ��CC
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 O To
FromToFt.
From To Ft.
13. GROUT: Depth Material Method �I )
From 0 To 20 Ft.Benonite&Cement pumped
From To F[.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
L N H
From To Ft. in. in. _
15. SAND/GRAVEL -7
Depth Size Material =_ __.i,_ -- 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
CONSTRU ON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
_c.�le� �u�,,� 9'lG•t�
SIGVTURE 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 C 3 16 1�1 6
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)
0111111111
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 N: Lo Topographic/Land setting
Ne estTown: County�A�` Topographic/Land
❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street me,Numbers,C nunity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrms/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No-) (check box)
f 11i A. F41 '•S345Q DEPTH DRILLING LOG
Ci g o own State / ZZ Code From To Formation Description
W
g( 2e )- f 7�i Clay&Sand
Area code-Phone number 4. DATE DRILLED —r7t/'�-GYn.�1t•L Granite
'��
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:y!Z FT.
(Use"a°'if Above Top of Casing)
8. TOP OF CASING IS o2 FT.Above Land Surface*
"Top of casing terminated atfor below land surface requires a
variance in accordance tb 15A NCAC 2C.0118.
9. YIELD ZOO —ept METHOD OFT L?.
10. WATER ZONES(depth): // �' a
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 rrrr���� Diameter or Weight/Ft. Material numbers and common road names.
From To FL
FromTo Ft. ----
From To Ft. �I -- i�------_- -
13. GROUT: Depth Material Method L
From 0 To 20 Ft.Benonite&Cement pumped ,
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. I M
From To Ft. in. in. .=.,
15. SAND/GRAVEL PACK:
c
Depth Size Material r
From To Ft.
From To Ft. (A
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
� 9� IG•o5
S A RE O TUF 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-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina-Department of EnvitDtunent and Natural Resources.
WELL CONTRACTOR INDIVIDUAL)WAME �f HPlr DWlaion of atW Quality
( (prlan c Q z Groundwater section
WELL CONTRACTOR COMPANY NAM)tS /InM —» RRTIFrCATTONI oZ/74 .
STATE WELL CONSTRUCT(ON PERMITS - - =PHONE, i C/.r3 aZb Q
(ira livable) - - OCtATEDyy gpbq�y ::. -
{ifa leable - .
I. WELL USE(Check APpI(cable Box):Residential' unite al/Public❑
Monitoring❑ Recove ❑ •p Wustriial 13 Agricultural[]
ry Heat Pump Water Injection❑ Other Cl If Otfier,List Use
2.-WELL LOCATION:
Nearest Town: M Topographie/Lend setting ,
4� / S ' c; ❑Ridge Oslo
(Seen Nano,Number,Cantu ---4 C,&) (oaf �� . .
�'.Subdrru,a,,tat No.,TaP Code) -
Latitude/longitudO of Well location
3. OWNER: /i ti r1 � �
Address 3 tL /:� �, (depr«a>miautaheebay) .
(sera«Ramie,) LatitudeAongittide source:❑OPS❑To 0
® -- 1lf t l G �, (cheek boa P graPhie map
C!YMTZya S - _ - )
(k3v _D tL- '7 ziP coax From DRI IN Loo
Formation Description
Ana code-Pbom aaaber -
4 /i'/
. DATE DRILLED
5. TOTAL DEPTH.
6. DOES
7. WELL REPLACE EXISTING WELL? YES❑ NO. /
STATIC WATER LEVEL Below Top of Cuing: --
Nu'Y+itAb&nTopofp�une
•-�__
8. TOP OF CASINO IS FT AboYe Land Surfaces
'TOP or"'Ing tarmiaaied War ba(aw yadaurraa require,a
rartaau la OaOMaaee with ISANCAC 3C.01IL9. IELD / O MB OD O TT
10. WATER ZONES(depth): F _
7,5
- --
It. DISINFECTION.Type
Amount LOCA77Aty SKL�('r•H
12. CASING: Show direction arld dlsanee!a miles from at least
Deptb orW 'rB Thickness two State Road'or County Roads;Include the road
From_L_To�F, 4+,�5 MnaI� I .' numbers and common road names
From To Ft.
From Tp FL '-
13. GROUT.• Dept
From_-_Q_To /lnM,at�e-riel`• M`e-th'od� .-- - -- - .
From To�F�4�" ' ..RQu�/_
.4. SCREEN: c"
From �t D1ameter u Material
-
Fromk.To FL SlotSi
in. (n r.)
5. SAND/GRAVEL PACK in. -o
N
Depth S( 'a
From Material
Fro To Ft. u O
m
ro pt`� --- Ln
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU ONSTRUCf10N STANDARDS,AND THATA COPY OF CTED ACCORDANCE\V1TTI I5A NCAC 2C,WELL .
RECORD Ii�S BEEN P40VIDED TO TIM WELL OWR
�'
SIGNATURE wrPBRSONCONSTRU /3 DS
CI7NOTHEWFLI DATE
submit the original to the Division Of Water Quality,Groundwater Section, Mall Service Center-Raleigh,17 69 9-1 63 6 Phone No.[phone],within 30 days.
NC
OW-1 RBV.07/2001

WELL CONSTRUCTION_ RECORD
North Carolina-Department of Environment and Natural Resources. iS�(�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) c��f1 N I Dlyia(OntOf WatW Quality.Groundwater Section
WELL CONTRACTOR COMPANY NAM /,�„n + -LZ --�'—'-» CP3(TIPI�C`A.,T�I/ON t/�. /7(P
STATE WELL CONSTRUCTION PERMITYPNONE
11111010111101111 (ifa licable) OCIATED W ERMIT/
-Of a licable - ,---------
I - -. WELL USE(Check Applicable'Box):Residential', �unicipaWublic❑ Industrial q
Monitoring❑ Recovery O Heat pump Water injection p Other c If0 Industrial
her,List Use
Agricultural p
2--WELL LOCATION:
Nearest Town: CountysettingTopoglpc ,and .L-L qIn e r ( Midge .
.
OSIOpe Malley a�Kf t
(St et Name Numbers.Community,Subdivision,Lot No.,Zip Code) (check aDPropdak box) ' >.
3. OWNER: i (M0_p_ �0 LatitudeAongitudeof Well location
Address a h
t_ , (depeea7minutWaeeonda)
(Street or Route No.) (� p� Latitude/longitude source:OGPSOTopographicmap
g l P ,Z taJ f 1 3 T `)D b (Check heal
City or Tows State
L ZIP cod` FromDEPTH ToPon
DRI IN r p
Area code.Phone number _ Formation Description
4. DATE DRILLED___
3. TOTAL DEPTH:gip �P C � - U � „ ; -7 .�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 7. STATIC WATER LEVEL Below Top of Casin :
8. TOP OF CASING IS (tlae"t"if Above Top ofCas n� ---�__
- -_nd yrcq�a Surface*temmatodat/oorbbetawlturr(� .
variance In accordance with ISA NCAC 2C.01Is
9. YIELD(gpm):--�_METHOD OF TEST
10. WATER ZONES(depth): - ----
--------
IL DISINFECTION:Type LO ATION KET
12. CASING: Amount Show direction and distance In trines from at least
Depth Wall Thickness two State Roads or County Roads,Include the road
From 01 To 1 Ft. D' 4er or Weight/Ft. Material -numbers and common road names,
From To pL c-a.ei,. ••SP.1 -
From To Ft._�
13- GROUT: Depth . Material
,' tj
_�To��F� Method
I c
From
From
.4. SCREEN: Depth Diamete (1 r !
From To Slot Size • Material - + I Il.,
Ft.—n. in. tv
From To Ft. in. - tt
5. SAND/GRAVEL PACK: tn' j- ,y
` '
Depth Size - - C crir1 tw
From TO Ft Material - ,, ;
From To Ft.
6. REMARKS:
O HEREBY CERTIFY THAT
ONSTRUCTION STANDARDS,
HIS WELL
OD TH WAS AT A CO OF CONSTRUCTED S IN ACCORDANCE WI
TH I D NCAC 2C,WELL.
BEEN PROVIDED TO THE WELL OWplp((
DNA URE OF PERSON CONSTRUCTING THE WELL 9
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service CennterE
.77699-1636 Phone No.[phone],within 30 days, Raleigh,NC
GW-1 REV.07/2001

W
ELL CONSTRUCTION RECp�' 31 L' C U
North Carolina-Department of Environment and Natural Resources- ?�Q
WELL CONTRACTOR(INDIYIDUAL)NAME DtY1910n of W
(Prlat) H / � ater Quality Oroundwator Section
WELL CONTRACTOR COMPANY NAM —$ 1 `
-'-� C�TIPICATTON Y of/7(P
STATE WELL CONSTRUCTION PERM17yr
(ifa liaable) SSOCIATEO W PHONY Y -+e+Zo1`�_3 �6 O
ERMITY
I. WELL USE(Check q (if>, liable -
Monilorin ❑ Applicable Box): Residenlial'��iP aEpublic❑
6 Recovery ❑ Heat Pump Water Injection ❑ Industrial O Agricultural❑
Other CT If Other,List Use
2. WELL LOCATION:
Nearest Town:
R T�2 l n � ---_County /j �Pegrephickand setting
(Arco Namc,Numbers,Co muniry,Subdivision,Lot No.,Zip Code) C� Lid$e ❑_SiOPe ❑Valley ❑Flat
$F, (check appropriate box) �
3. OWNER: 4 2 2 LatltudeAorigitudeofwelllocation
Address _ l,� '
(Street or Route o.) Latitudellongitude s a p 110I 0
Cry rT �" 73 (� (check box) P K+aPhic map
S tL (1 7 - , Zip code{ QULIdLQ LAreOC
DA code-Phone number - From
rn 0
4. DATE DRJLLED �— .F°�tion Description
5. TOTAL DE -
6. DOES WELL REPLACE EXISTING WELL? YES [] NO
7. STATIC WATER LEVEL Below Top of Casin
_
g: /� ��
8. TOP OF CASING IS��u,e^+^itAbove Top ofCasin�
'Top er culo¢«rmin,ted��//��,uo//r E����el----w...I FT.Above Land Surface+
---------
VA of la,ccordm wI h ISA NCAC IC oils, nqulres a --
9. YIELD Win):S METHOD OF TEST '-
10. WATER ZONES(depth):
I t. DISINFECTION:Type OCATI�N CKE,ht;�
12. CASING: _ Amount Show direction and distance In miles from at least
Depth Wall Thickness two State Roads or County From To To c Dla tiV or Weot/FL
FL Mate ' l 'numbers and common road names.
s.include the road
From ��Ft. S n,Pf
✓--=�"=
From To Ft
13. GROUT: Dept \ _
From_ To Ft. Material
no Method
_
From TO L7m.
4- SCREEN: De th 'Ft.
From p Diameter Slot size To FL - Material
From To —__in.
5. SAND/GRAVEL PACK: Ft.�_in. in. i
Depth Size
From To Ft. Material
From To Fl.�_ '-
_.
6. REMARKS:
a
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RE IN ACCORDANCE HORI3ANCE WI
BEEN PROVIDED DED TO THE CWELL OWNER
SIGNATURE OF PERSON CONSTRUCfINGTHEWELL
submit the original to the Division of Water Quality, Groundwater Section DATE
17699-1636 Phone No.[phone],within 30 days, 1636
r Mall Service Center.RalelQh,NC
GW-I REV, 07/2001

wEL
;. : CONSTRUCTION RECORb
North Carolina-Department orEnvirontneht and Natural Resources-WELL CONTRACTOR(INDIVIDUAL)NAML (print) C4 / Dmston of Water uali -
Q ty Grotndwater Section
WELL CONTRACTOR COMPANY NAM J II n
STATE WELL CONSTRUCTION pERa417•/
(ifa licable) OC(ATEDW SRMITN J" yr3 �eo 0
I• WELL USE Check , (ifa licable
( Applicable Box):ResidenCial' , ��unicipal/Public❑ Industrial q p
MonitorinK❑ Recovery ❑ Heat Pump Water In ec�t oR❑
Other Cf If Outer,List Use Agricultural
2- -WELL LOCATION:
Nearest Town: '�/j lL; �� n , ��� .r
Coun graPhidLand setting .
` ° 3 de ❑S)o(Strcct Name,Numbers,Communi pe ❑Valley ❑Flat
h.Subdivision,[at No.,Zip ) (check nppmpdate box) >•
3. OWNER: - ) pe, CaS Liltitudellongitudeofwele1ocation
Address j3S r r L Q
(dearaea7minuta/�aondr)
(street«Ryme�lo.) LatitudeAongittidesouroe:❑OPS❑To 0 11/1!f yf/�1 i1/ ( , a/7 / P graphic map
City br Town Sute e�4 / 3 _ (check box) -
Ew_ r 9 44 T p code From DRILLING DRILLING LOG
Area code.Phonenum�ev, o To .Formation Description
a. DATE DRILLED `7-i ' -LIS j---
5. TOTAL DEPTH: O�—'-' S �+-
6. DOES WELL REPLACE—y WELL? /r`�-�L e 7. STATIC WATER LEVEL Below Top of Casing: ❑ N
8. TOP OF CASING IS �Uu-�''tAbove Top of Casing) --------
'TOP or cuing taminated at/or be lit, FT.Above Land Surface'
variance In accordance with ISA CA Itaadaurfaee requlrb a -------
-�
9. YIELD(gpm); MN C iD'O F
l0. WATER ZONES(d-pth): METHOD OF TEST —'
H. DISINFECTION:Type =:
Amountkness PATIO_ N�SKu
12. CASING: Show direction and distance in miles from at least
Depth Din ter orr WcOIM two State Roads or County Roads;Include the road N
From_ Tc J S FL k S M�r� l_ ' numbers end common road llamas, rn
From To Ft._
-A.
From ry
To FL o
13. GROUT: Depth
From Material Meuth�od) _
From To _Pa
- Ln
4. SCREEN: De th
From To Diameter . Slot size . , Material
From To Ft. in. in. li
5_ SAND/GRAVEL PACK:
Ft�—tn" in,
— 12OOJ i
Depth Size
From To Ft Material
From --
To Ft. —
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUD
IN
ONSTR UCTION STANDARDS,AND THAT A COPY OF TH SS RECORD ACCORDANCE WITH I SA NCAC 2C,WELL .
( ^ n HaSBEEN PROVIDED TO THE_WELL OWNER
nr:yr .MOSON CONSTRUCTING THE WELL
Submit the original to the Division of WaterDATE
Quality,Groundwater Section, 1636 Mail Servi
,77699-16J6 Phone No.[phone],within 30 days, ce Center-
Raleigh;NC
GW-I REV.0Tn00J

519T1 , nl� Ii r� A
RESIDENTIAL WELL CONSTRUCTION RECORD
i III- North Carolina Department of Environment and Natural Resources-Division of Water Quality
' WELL CONTRACTOR CERTIFICATION N _)ILAO 1
1.WELL CONTRACTOR: I. DISINFECTION:TyPeLglp&ff Amount lam
g. WATER ZONES(depth):
We51 Contractor(ndivldual)Name From To From To
—
Cell F21�' E 1 1 �ra a
1„Jr�111 Y� F f(1(a n. From To From To
Well Contractor Company Nam{e� Its From To From To
STREET ADDRESS PC) 6. CASING: Thickness/
(� .�p('��� Depth Q, Diameter E er Weight 1 Material
��\1��� �`\ ('S'(-M10 From_To Ft.
City or T1orn State Zip Code From To Ft.
�)-8NI.ELM From To Ft.
Area code- Phone number 2.WELL INFORMATION: —
7. GROUT: Depth Material Method From To-aU—Ft.C EtnFAIT & VM
SITE WELL ID d(if applicable) From To FL
STATE WELL PERMIT!(if applicable) From To Ft.
DWQ or OTHER PERMIT S(ff applicable) 8. SCREEN: Depth Diameter Slot Size Material
_
WELL USE(Check
.Applicable
�Box): Residential From To Ft.—in. in.
ial Water Supply p� From To Ft.—in. in.
DATE DRILLED 1,_tt,C Ul C)S From To Ft. in. in.
TIME COMPLETED AM 0 PM 9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Sao Material
CITY: COUNTY J&U1.1 From To Ft.
From To Ft.
From ToFt.
(Street Name,Numbers,Community,Subdivision,Lot No.,parcel,Zip Code)
TOPOGRAPHIC I LAND SE7NG: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat box) a OOther From To Forma_ LIA'\ 'D�E\s�crri�p-tT
(check appropriate box) _01 \laa 1{1LJJ_J.,2nTY,"]!"X,]_L.iJ.LlL
� p ��q-'� May be in candyd;gRX , C�
LATITUDE 3 � o-s-L-r.aL1.�—f� minutm,seconds or \�—��
LONGITUDE 8 35-gz ll� in a decimal format 1 L 1 f'�R���\-r �SE.T rF\SIAY
r{RA�l1SF- ,
Latitude/longitude spruce: �GPS ❑Topographic map -
(location o/we/must be shown on a USGS tope map and
attached to this form Anot using GPS)
O— =
4.WELL OWNER C7
OWNER'S NAME�E2 Atmn�1
STREETADDRESS �_ytp2) L
� t �t��in3 r
City a Town fate Zip Code
�o -�3-tr�D,50 Q
Area code- Phone number "-#
11. REMARKS:
5.WELL DETAILS: 'L
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO OY
DO HEREBY CERTFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: _FT. I'M NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS
(Use'+'IT Above Top of Casing) RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
d. TOP OF CASINO IS_�Fr.Above Land Surface'
'Top of casing terminated at/or below land surface may require ATURE OF`CERTIFIED WELL CONTRACTOR 4ATE
a variance in accordance With 15A NCAC 2C.0118.
e. YIELD(gpm): METHODOFTEST ktR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Informallon Mgt, Form GW-ta
1617 Mall Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 568. Rev.7N5

WELL CONSTRUCTION RECORD o I d U
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) JOHN ARTHUR CHASTAIN CERTIFICATION#3401
WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING&PUMP CO.INC. PHONE # IlZ,')8)837-8008
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) ,
1. WELL USE(Check Applicable Box):Residential MunicipaVPublic ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water 1 lection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town:&, _County MACON Ridge ❑Slope ❑Valley ❑Flat
EAST SILVERMINE ND. (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location
3518.362N 8336.247W
3. OWNER: ALLEN RICHARDS (degrees/minutes/seconds)
Address 13074 VIA FLAVIA Latitude/longitude source:XGPS❑Topographic map
(Street or Route No.) (check box)
pL I13,1A FL 33946 DEPTH DRILLING LOG
Cityor Town State Zip Code From To Formation Description
_)-697-8794 0'TO 12' RED DIRT
Area code-Phone number 12'TO 28'
4. DATE DRILLED 09/29/05 BROWN DIRT
28'TO 40' BROWN DIRT
5. TOTAL DEPTH: 405' 40'TO 60' GRANITE/SET CASING
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I 60'TO 405' GRANITE
7. STATIC WATER LEVEL Below Top of Casing: 300
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
-Top of casing terminated atlor below land surface requires a
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 2 1/2 METHOD OF TEST AIR
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least
12. CASING: Wall Thick,, two Slate Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0' To 60' Ft. 6 118 SDR 21 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0' To 29 FL CEMENT GRAVITY
From To FL
14. SCREEN: Depth Diameter Slot Size Material �`v C-3
From To Ft. in. in. _
From To Ft. in. in.
15. SAND/GRAVEL PACK: 4p +
Depth Size Material V
From To Ft. O
Fro To Ft.
m 9
a
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT
LAyLC(�Ot�PY OF THIS RECORD HAS BEEN PROVIDED TO IT IF WELL OWNER
SIGNATURE�hh
us
OF PEER CONSTRUCTING THE WELL �Q 1TEE -
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3401
1.WELL CONTRACTOR: I. DISINFECTION:Type CHLORINE Amount 10O PPM
JOHN ARTHUR CHASTAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
CHEROKEE WELL DRILLING&PUMP CO.INC. From To From To
Well Contractor Company Name From To From Tc
STREET ADDRESS PO BOX 1007 9. CASING: Thickness/ Mai
Depth ter Sgj2EW
MURPHY NC 28906 From 0' To 80' Ft 6P��
City or Town State Zip Code From To Ft.
g( 28 )- 837-8008 From To Ft
Area code Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: From 01 To 20' Ft CEMENT GRAVITY
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT!(a applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft._in. _ in.
DATE DRILLED L 5105 From To R.—in. _ In.
TIME COMPLETED AM El PM 0 9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
NANTAHALA COUNTY MAC From To Ft.
CITY: ON From To Ft.
2071 CAMP BRANCH RD. From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope 17Velley []Flat ®Ridge ❑Other From To Formation Description
(check appropriate box) 0' TO 20' BROWN DIRT
MIay be in det;ircut. 20' TO 40' RED DIRT
LATITUDE 3 5 15.541N minutee,seconds or BROWN DIRT
83 38.567W in a decimal rmtnat 40' TO 60'
LONGITUDE_ 60' TO 80' GRAN ITEISET CASING -
Latitude/longitudesource: ©GPS ❑Topographicmap 80' TO 806 GRANITE
(bcation of wet must be shown on a USGS lope map and
attached to the firm Anal using GPS) 0
4.WELL OWNER
OWNER'S NAME DAN HAWLEY
STREET ADDRESS 6926 S.TAMIAMI TR. n
SARASOTA FL 34231 Li7
City or Town State Zip Code
l 941 )_809-3662
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 805'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 13
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Waif
c. WATER LEVEL Below Top of Casing: 500 FT. IM 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 CASING IS 1 FT.Above Land Surface' ��.�
'Top of casing terninated atfor below,land surface may require S ATURE OF CERTIFIED WELL CONTRACTOR
a variance in accordance with 15A NCAC 2C.0118. `'``-` Q
e. YIELD(gpm): 1 METHOD OF TEST AIR awl.
` . �
PRINTED NAME OF ERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GW-ta
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] eat 598. Rev.7/05

TARO
OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD MWD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
NC ✓
WELL CONTRACTOR CERTIFICATION 4
1.WELL CONTRACTOR: 1. DISINFECTION:Type _� Amount �� (.✓
/Clry /Z.eec e• WATER ZONES(depth):
Well Contractor(individual)Name From 3 5— To 3Y 6 From To
MILLER WELL DRILLING . INC . From To Fran To
Well Contractor Company Name Fran To From To
STREETADDRESS P . O . BOX 567 6. CASING: Thickness/
Depth Diameter Weiphl Material
rQ /
HAYESVILLE , N . C . 28904 From Ci To 1{ Ft 6
City or Town State Zip Cale From To Ft.
8828 ) 837-2997 From To FI.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth aler'al Method
From C To y FL -'< �+s/(-/
SITE WELL ID#In applicable) Fran_'(_To ;70 Ft. to ✓*- e:
STATE WELL PERMIT#(ir applicable) From To FI.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter SM Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q_-11 From To Ft.—In. _ in.
�.^/Z -CSC Fran To Ft.—In. _ in.
DATE DRILLED f From To FI._In. _ in.
TIME COMPLETED �s 0O AM D PM E3✓ 9. SANDIGRAVEL PACK:
3.WELL LOCATION �/ Depth Size Material
CITY: /�!a///(.`L I R COUNTY 1,aco/I From To Ft.
/ Fran To Ft.
(�tit//r R, -'S �Ie��V C-t( Wt��CI) From To Ft.
(soee1 N ma,Numbers.Cammuniry/ ubtllvisbn,L 1 No.,Parcel,Zip Code) -
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG -
IRI.5 a ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
LATITUDE J /3:d 7 f May be in degrees,
minutes,seconds or - G
LONGITUDE g 3 3C• 10 in a decimal formal 7C` YO c/ (9lyd%
Latitude/longitude source: BUMPS ❑Topographic map
(locafion of we#must be shown on a USGS topo map and
attached to this form 1 not using GPS) -
O
4.WELL OWNER --.L
OWNER'S NAME el) 4mrbel lym
STREET ADDRESS Dv
l o nfo w .NC Z S' 731
City OF T State Zip Code
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: T
b. DOES WELL REPLACE EXISTING WELL? YES❑ NI;,n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORD ANCE WITH
e. WATER LEVEL Below Top of Casing: / 0 FT. 15A NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+*8 Above Top or Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1.I-
d. TOP OF CASING IS 91 FT.Above Land Surface'
-Top of casing terminated atfor below land ggurface may require a variance in accordance SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
/ with 15A NCACl2C.0118.
(gP ) _.L_ P/�yRE C ce,
e. YIELD m : METHOD OF // '� 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 568. Rev.7105

f SIAI(o
L��,vvv��Vlllll OWNER
R 3
RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department or Environment and Natural Resources-Division of Water Quality MwONC ✓
WELL CONTRACTOR CERTIFICATION #
1. )L
WELL CONTRACTOR: 1. DISINFECTION:Type - Amount
/G�i-/'}) ea e, g. WATER ZONES(depth):
Well Conlr ctor(Individual)Name From -40 To f"4/ From To
MILLER WELL DRILLING . INC . From To From To
Well Contractor Company Name From To Rom To
STREET ADDRESS P . O . BOX 567 G. CASING: Thickness/
Depth Diameter Weight Materi�I
HAYESVILLE , NC 28904 From To !�G Ft.� _ •/85 ;tee/
City or Town State Zip Code From To Ft.
( 8281• 837-2997 From—To—FL-
Area code- Phone number
7. GROUT: Depth /MateLrial Meth
2.WELL INFORMATION: From )'a1/[ / -r�---3
To�_FI. ^�-r c F�z y
SITE WELL ID#(if applicable) From ! Toeeq Ft w�
STATE WELL PERMIT#0l 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 ly From—To—Ft.—In. _ In.
From To Ft.—In. _ in.
DATE DRILLED `7��t 05 From To Ft.—In. _ in.
TIME COMPLETED AM[ PM B- 9. SANDIGRAVEL PACK:
3.WELL LOCATION:///-/ Depth Size Material
CITY: F�a/)2 7 COUNTY �YIq GOVL From To Ft.
_ A/ -,.>) fa�T4l4 /rt.9/l1alcrt From To Fl.
From To FL
-
(Street Name.Numbers,Community,Subdivlslon,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10. DRILLING LOG
❑Slope 94aIley []Flat []Ridge ❑Other From To F "matron Description
(check appropriate box) //� -7
�-J May he in degrees,
J
LATITUDE /C•S�Z minutes,seconds or
LONGITUDE . 39. �o in a decimal format -
Latitude/longitude source: ❑GPS []Topographic map
(location of welt must be shown on a USGS topo map and -
attached to this form 1 not using GPS) _
4.WELL OWNER )C- _
OWNER'S NAME �_
STREET ADDRESS z-Yn n ewe v eA I ny'i If _
�oOLO I'( AIC 9 9781 a ul
City a own Stale Zip Code
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES[] NOp�
p g FT. ISA NCAC 2C,WELL
1 DO HEREBY CERTIFY TNAT THIS WIDE WAS CONSTRUCTED N ACCORDANCE WrIH
o. WATER LEVEL Below To O(C851n f S CONSTRUCTION STANDARDS.AND THAT ACOPY OF THIS '
(Use'+-If Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS L FT.Above Land Surface'
'Top of casing terminated allor below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance In accordance with 15A N¢AC 2C.0118. p
e. YIELD(gpm): D METHOD OF TEST % lel,,Y A e e e
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Inlormatlon Mgt., Form GW-ta
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.(919(733-7016 exl 668. Rev.7/05

3. 17
WELL CONSTRUCTION RECO"'
Novi,Csaiolina-Department of Ewdronnu tt and Natural Resources-Division of W star Quality-Gro(mdwator Section
WELL COW ACMIt(tND1VW1JAL)WMX (prindt dill // ,w d,.;
.. /�J1.�..� � cln�ts[cATt0Ne_Z/7tP
WELL CONTRACTOR COMFAh rlto t 14-3 a 0
( .
STATE WELL CONB qN PEW1117y. �Aa0MATEDW Lltltfl'I'/
(if applicable)
) •((fppliable)
I. WELL USE(Check Applicable Box):Rarlderttialtl` nicipal/Public❑ IndusKal El Agricultural p
Monitoring O Recovery ❑` Heat Pump Water Wection 0 Other Cf If Otiux,List Use.
2.-WELL LOCATION: gcapic/Lend Setting .
Nearest Town: a,�'[��-, /1� -- County M�C[ht-� dge OSlope Malay OFlat
4/4 i N. tL h h:v �r 2 e /z�+ — 0 87� i (ehalt.pprewhla boz>
(Baal Name.Naabga.Commuaity,SabsVision,La No.zip Code) LbtitudP/lOngltnda of wGli location
3. OWNER: Am e012, Cf'
Address S SS Al P K L Lao r Latitudellongittidee soourve'OGPS❑Topographic map
iSuee a Raea NoJ (etwdc tan)
/�1�2rI ✓'L� Aj� 3 DEMM ' DRILLING LOG
ry a Twa State zip Cade , ..From To - _Formation Description
Am coda Phan amber �i �j .� �.r Qm r L
4. DATE DRILLED_,( Lf -(J S �7`
5. TOTALDEPT)i: hS —
6. DOES WELL REPLACE EXISTING WELL? YES E3 Nb t!
T STATIC WATER LEVEL Below Top of Casing _2a� k f:
(Ua'4*irAboxTop of Cadp4
g. TOP OF CASINO IS_—Fr.Above Land Surfacee
Tap of asiag taralaand atlor blow itutdatwlaa rpolrb a .
varWeeV aeesNara waY'15A MC.ZC iC Ai1L _ -
9. YIELD(gpm):ALL METHOD OF TEST
10.WATER ZONES(depth):_ a.50`, 3 S D
)ACA"I'ION SKETCH
IL. DISINFECTION:,Type 7Amotmt Show tiyac4oa and.disttnee In miles from at(east
12. CASING: Wall Thidmess two State Roads or County Roads;Include the road
/t D' or Weight/PL numbers and`oommon road names.
o
From_(i_To:5L u �q��
From_To FL
=emu7• nt
From Tp FL t 1
13_ GROUT-, Depth Mate iw Method. o
From�_To_G'� �00a: n/ill,(� Ln
From To FL _ "
A. SCREEN: Depth Diameter . Slot Size � Material - _3
T
Ft___ in: in.
From To FL__hL in
S. SAND/GRAVEL PACK
Depth Size Material
From Tc Ft•
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WA$CONSTRUCTED IN ACCORDANCE WTM ONMUCTIONSTANDARDS,AND THAT A COPY OF B) S
SRECORD BEENMOVIEITO THE SA ZWELL OWNER
SIGNATURB�OF PERSON CONS'IRUCIINOTHEWELL DATE -
Submit the original to the Division of Water Quality,Groundwater Sectfop,1636 Mail Service Center-Ralelgh,'NC
1'j699-1636 Phone No.[phone],within 30 days. OW-I REV.07/2001

q.
WELL CONSTRUCTION RECORD'
Nosh C l(na-Department of Ertvhotmttint and Natural Resources.Division of WatW Quality--Qroundwater Section
WELL CONTRACTOR(1TlDnnmjAL)NAMZ (aetan c fI911S f,} Jl�:,;.1,'• �. c s►/cnnoN>r /71
WELL CONTRACTOR C014PA4y NAM •' PHONis V_.'D.L/ 394,
.. .. ..� .
SPATE WELL CONSTRUCTION Plilpnl7y A 0CtA=W RRatTI'a
(iTappTtablacibic)) {ifapplhgble)
I. WELL USE(Check AppEcsbtti Box):Aeaidential7YMunicipaUPubtic❑ Industtfal O AgrIcultrnalp
Monitoring❑ Recovery ❑• Heat Pump Water l4ection❑ Other 11 if Other,List Use
2.-WELL LOCATION: 1 clLlind 3ettin
N Town: / Cormty Cc9t�. 8� g
c l' �4 -a-o vim- � In ry d®Ri ge pSlopa ❑Vailay .❑Flat
(dwdtepproprLlsboz) '
(sues Nemc. Coauwoity,suldiviaiaq tot Wo.,Z'W case) I;atitudetiorigitudo of w.oii location -
3. OWNER.-
Address e'�3-S 13 i n t s r I. _ Ladtuddlongitride aouroe:❑GPSOTopographic map
(Sneer ar Rome lio.) (ebeebboa) .
e 3 3 rt ^ 3 � - DRILLING LOG
Ciry or Torva sure - Zip Code From To .Formation Deaeription
Ato mde•Phooc somber ..,
4. DATE DRILLED
5. TOTAL DEPM.,� y ele W
6. DOES WELL REPLACE E)QSTINO WELL? YES❑ NO.:Ql/' -
7. STATIC WATER LEVEL Below Top ofcasing; Q&_
(0ea^N if Above Top of CWW
S. TOP OF CASING IS�_FT.Above Land Surface+
'Top orns4a tern"ted ador belpr 1pdtor(w regdrp e
"Kr V swords wRb'lS6TICx6 2C.01IL -
9. YIELD(gpm): -2/) METHOD OF
10.WATER ZONES(depth);
LOCATION SKBTCH
IL. DISINFECTION:Type Amount y Show duecdoa and-distance(ri adles from at leas)
12. CASING WaIl Thicimess two State Roads or County Roads;Include the road
Depth Dlapruer S or weighUFL 'numbers and common road names.
From To Ft`h
From To FL
From Tq Ft. '
13. GROAT_ "Depth Materiil. Matlrod.
From To• rya FL-4e4p A24-1 o
From To FL -n--i
.4. SCREEN: - 1
�Pw Diameter Slot Siff � Materiel � - .. W :;q
From To Ft`in. in.
From To Ft.Jn• in CD
S. SAND/GRAVEL PACK _
Depth Size Material
From To Ft.—
From—To—FL
6. REMARKS:
DO HEREBY CERTIFY THATTMS WELL WAS CONSTRUCM IN ACCORDANCE WTM I5A NCAC 2C,WELL
t3NSTRUCTION STANDARDS,AND T�HyA,T�A COPY OFTIiI S RECORD Hfffi BEEN P40VIDED TO THE.WSLL OWNER
SIGNATURE-OF PERSGN CONSTRUCTING THE WEM DATE -
Submit tha origlaal to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
.2,7699-1636 Phone No.[phone],within 30 days. OW-I RBV.07/2001

WELL CONSTRUCTION RECORD
r:. . North Carolina Department of Environment and Natural Resources-Division of Water Quality -
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ Russell S.TaVIOr 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 LOCATI N: Topographic/Land setting
Neares Town: k 1,4(.) County# YJL- Midge ❑Slope ❑Valley ❑Flat
1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:
(degrees/minutes/seconds)
Address .� .�j yam_ LatitudeAongitude source:❑GPS❑Topographic map
(Ftre t ;r oute o.) (check box)
1 DEPTH DRILLING LOG
City or sown Sta a Zip Code From " ,T' Formation Description
826 - - � "Q3�f � Clay&Sand
Area code-Phone number �) TY Granite
4. DATE DRILLED `Y_ .- `-
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_p� _FT.Above Land Surface*
"Top of casing terminated attor below land surface requires a
variance in accordane with 15A NCAC 2C.0118.
9. YIELD(gpm): MET� ;
H/OD OF TEST BLOW
7
10.WATER ZONES(depth): � .431
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
�1
Depth Di eter or Wei t/Ft. Material numbers and common road names. -
From G To Ft. a "� ' 469ca
From R To Ft. 1
From To Ft.
13. GROUT: Depth Material Method .-.
From 0 To 20 Ft.Benonite&Cement pumped q
From To Ft. W
14. SCREEN: Depth Diameter Slot Size Material r�
From To Ft. in. in. C3
From To Ft. in. in. =.
15. SAND/GRAVEL PACK: _€7
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
p5
SIGNA OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of ater 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 llM A r,
North Carolina Department of Environment and Natural Resources-Division of Water Quality -
WELL CONTRACTOR(INDIVIDUAL)NAME (print) LLc,95£L�.S.� (,O tY. CERTIFICATION p_21,1
WELL CONTRACTOR COMPANY NAME H_edden Brothers Well Drilling Inc PHONE a [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential O Municipal/Public D Industrial ❑ Agricultural
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
ryI_(� Topographic Land setting
Neese tTown: County ///� ❑Ridge ❑Slope ❑Valley ❑Flat
Le �J �S�a�� (check appropriate box)
(Street Nam ,N> rs,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: - (degrees/minutes/seconds)
Address ti32 (\)W Latitude/longitude source:❑GPSOTopographic map
istr-K.eet or Route No.) (check b
1't 30307 DEPTH DRILLING LOG
City or Town State Q Zip Code From t Formation Description
�'( )- 53( 4 W— 63� Clay&Sand
Area code-Phone number s
4. DATE DRILLED -D$ Granite
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NOX
7. STATIC WATER LEVEL Below Top of Casing: �p FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS tat FT.Above Land Surface"
•Top of casing terminated et/or below land surface requires a
variance in accordance nb 15A NCAC 2C.0118.
9. YIELD (gpm): w METHODDF TEST BLOW
ES 10. WATER ZON (depth): �3ji
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 T Diameter or Weight/Ft. Material numbers and common road names.
From To 8a Ft. 'r
From�To=Ft. -'
From To Ft.
13. GROUT: Depth Material Method CD
From 0 To 20 Ft.Benonite&Cement _pumped --I
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. C "
From To Ft. in. in. Uri
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 THA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d d L�-�
SIGN 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
i _

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 LOCATI N: Topographic/Land setting
Near ,tTown. County ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. OWNER:
(degmes/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
( eet or Route o.)
(check box)
DEPTH DRILLING LOG
City or sown Ste Zip Code From 0 Formation Description
Area code-Phone number
4. DATE DRILLED Granite
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—ODD FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS J FT.Above Land Surface*
•Top of casing terminated atlor below land surface requires a
variance in accordance nh 15A NCAC 2C.0118.
9. YIELD(gpm): _M$$THOD(?F TEST BLOW
10. WATER ZONES(depth): [p,�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 Di eter or Weight/Ft. tenal numbers and common road names.
From To Ft._ " y�G
From ft To Ft. t,)
From To Ft. `
13. GROUT: Depth Material Method =*
From 0 To 20 Ft.Senorita&Cement pumped —t
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
W
From To Ft* in. in. O
From To Ft._in. in.
15. SAND/GRAVEL PACK: 1
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
Z44
SIGNA I U 1
OF PERSON CONSTRUCTING THE WELL 19ATE
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 Cafolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDtV,1DUAL)NAM$ (priaf)s�ll)YIIS f '�n�j'• �•-`^ �ptCAviiNa Lille
WELL CONTRACTOR COMPANY NAM •[IlOttt4 a1X1 _..�] 2EI-�3 a26
STATE WELL CONSTRUCTION PBRMrr/ A�OCIATED W $KNIT/
arappEable) (fappiicable)
1. WELL USE(Check Applicable Box):PaWential'cd�ivtutticipaWublic❑ IndusKa)❑ Agricultural E3
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other C1 IfOtiier,List Use
2.'WELL LOCA- Topograppic/Ltind setting
Nearest Town:: / �J�/% , " County Cow Midge ❑Slope OVaU g
ey . t
1 Q1Ic S -h nn 1 C� rY m '7.3 U— (dNdcappopdatabu) . 46
(Strcct Name,Numbers,Conuueiity,Strbd'ivhion,La No..Tip Code) '- LetitudcAorigitude of well location -
3. OWNER.-L
p uv/aaonda) .
Address q7> /to,.(C S C' h Lstitude/longittidede sourcc:ource:❑GPS❑Topographic map
i- (Suow or Rase Na.) (Check boa) .
1 12 4"M L 10,) DEPTH ' DRILLING LOG
From To .Formation/
4. DATE DRILLED Description
Am coda Phonec - "� '' - (p a, d. i5rce- S TUkA--
ED —/ g--lJ S -
S. TOTAL DEPTH: S-6 S
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO_ '
7. STATIC WATER LEVEL Below Top of Cuing: % O F .
(Usa"N tf Above Top of Ca*4
9, TOP OF CASING IS I FT.Above Land Surface*
'Top of cuing terminaud add belgrl yadsurface requires■
variance to accordance witblSAf{CAC 3C.0IIL
9. YIELD(Spin): ::11 _MBTHOD OF TBST�,
10.WATER ZONES(depth): !d Sr
LOCATION SKETCH
11. DISINFECTION:Type Amotmt Show direction and distuice In Wits from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dispreter a Wes UK numbers and common road names.
�From_ To boa, Ft k�4 S IdX.Nd+
s
From To FL_
From Tp FL_ �
13. GROUP: Depth Materiel Method v
From_To rv
_ Rain. .
From To FL
-4. SCREEN: Depth Diameter . SWSize r Material
From To FL in, in.
From To Ft in. in.
S. SAND/GRAVEL PACK: _
Depth Size Material
From To Ft.
From To Ft. -
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAI;CONSTRUCTM IN ACCORDANCE WITH I SA NCAC 2C,WBLL
ONSTRUCTION STANDARDS,AND THAT A COPY OF IM RECORD BEEN P$OVIDED TO THE.WELL OWNER -
nt 1 Ll S
SIGNATURE OF PERSON CONSTRUCTING THE WELL - DATE _
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleleh,NC
17699-1 636 Phone No.[phone],within 30 days. _ GW-1 REV.07/2001 -

3 C
WELL CONSTRUCTION RECORD
North Cnolina-Department of Environment and Natural Resources-Division of Water n -Groundwater Section
WELL CONTRACTOR(INDtKIDUAL)NAMB (prwn c H PI I S � 11tZ�°• ^ Cxj�TWICAT(ON
WELL CONTRACTOR COMPANY NAM eeo N�a ST`�St—S'a 4-3 a O
STATE WELL CONSTRUCTION P8RM171's Aaanr(ATEDW SRM110 '
_-- ---- (if applicable) 017applicable) -
1. WELL USE(Chock Applicable Box):Residential' unicipatiPublic❑ Industrial❑ Agricultural p
Monitoring❑ Recovery ❑• Hcat Pump Water injection❑ Other C( If Oilier,List Use
2.-W WELL LOCATION: To b1t/Lend setting
Nearest Town: (�/�7? County, �.•� /IYt &jmaga ❑Slope ❑Valley Mat
If If I S t l.f n I l A 1 e J a A_ A 911 k � (cheer k sox)
(Suter Nano,Numbers,Cemmmiry,Subdiviaioo,Lai No,Zip Code) Lat[Wdo/longitude of Wel[location
3. OWNER: C>L 12 P Iti �117 i�� I f n r (deFaeJmiautu/ae�ndr) .
Address '7 (4- ri I i J p I I a -1; ' C,)/�16a A LatitudeAongitude source:❑GPS❑Topographic map
or(Street Kowa No.) 0 _ (cbP*b=) -
1 , DEPTH ' DRILLING LOG
City or Town State tip Code From sc
To Formation Deription
(� oo tn_ i S S SA -�'—t —
Arcs Wdt•PIIDaa numbar� v"�
4. DATE DRILLED- D - 6 � - - �
5. TOTAL DEPTH: :� S' I' I b P—
/
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Caging. ±.S ' -FT;
(Usa"t^if Above Top olCuinf)
8. TOP OF CASING IS�_FT.Above Land Surface*
' op of cuing tuatiaatad Mfor bdgw lrwtrarface regalris a .
vartasa M aeeordaaa wlu lSAHCAC 2C Al1L
9. YIELD(gpm): ? METHOD OF TESTA !!
10.WATER ZONES(depth): 310'
LOCATION SKETCH
11. DISINFECTION,Type Amount Show direction and distance In miles from at least
12. CASING: Wall Twdm n two State Roads or County Roeds.Include the road
Depth Di or Weighm numbers and common road names.
From_To �fS' Ft`=5.D&VI '
From To FL
From Tp FL .
13. GROUT4 Depth Material Method.
From__To- �/ rn
From ToF1FL
.4. SCREEN: Depth Diameter . Slot Size a Material
From To FL 4L is D
From To FL_in. in.
5. SAND/GRAVEL PACK _ L
Depth Size Material - R3
From To Ft
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 156 NCAC 2C,WELL
'ONSTRUCTION STANDARDS,AND THAT A COPY OF Tip RECORD HAS BEEN PPOVIDED TO THE-WELL OWNER
SIGNATURE OF PERSON CONSTRUCI7N0 THE WELL DATE
S u bmit the o riginal-to the Division or water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
,+.7699-1636 Phone No.[phone],within 30 days. GW-t REV.07/2001

WELL CONSTRUCTION RECORD
North ofW Carolina-Department of Environment and Natural Resources-Division ater Quality-Groundwater Section
..
WELL CONTRACTOR(INDIVIDUAL)NAME (prlat)s��N{'IIS i`IY' „n.� ClUi TIFICAT,,,I,/OONf 2iLle
WELL CONTRACTOR COMPANY NAM PHONia iS1 _..�d.LI•�3 Z6
STATE WELL CONSTRUCTION PERMITp wOCCATED W ERMIT/
(if applicable) (ifspplicable)
I. WELL USE(Check Applicable Box):Residential'0Ivlunicipal/Public❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery O' Heat Pump Water Injection❑ Other 0 If Other,List Use
2.-WELL LOCATION:
Nearest Town: r dC/ County M 4 C D�pbidWd setting
�l 4 ) A/ - 9 t C 12 e e/L l� — �� 73 dge CSlope []Valley Mat
(check appropriate bex) i
(Street Namc,Numbers,Community,Subdivision,tat No.,zip Code) Latitudellongitude of Well location
3. OWNER: (degroWminute✓eaconds)
Address Latitudellongitudesource:00PSOTopogmphicmap
(Street or Route No.) - (check box)
7T! .
112Qm( /,a � SrJ 3 � DEPTH DRILLING LOG
Gty or Iowa Sum Zip Cade FroQt To - Formation Description
am—
Areacode•Phone
number "
4. DATE
7
DRILLED �— L- - G,�_
5. TOTAL DEPTH:_ _7 ' �7spill r t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO-
7. STATIC WATER LEVEL Below Top of Casing: - Fr
(Usa"t"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
-Top of cuing terminated actor below laadsurfaee requires■
variance In accordance with-ISA NCAC IC.011L 'x
9. YIELD(gpm): � 0 METHOD OFTESTI/w (/
10.WATERZONES(depth): -�-30
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 Dia ter or Weight/FL Mau' I 'numbers and common road names.
From7 To q Ft.
From To Ft. ,
From To FL (YY
13. GROUT: Depth Material Method - rq
From_O_To—,.'D--Ft.
From To FL_
.4. SCREEN: Depth Diameter . Slot Size Material - O
From To Ft. in. in. - rJt '
From To Ft. in. in.S. SAND/GRAVEL PACK: _ 's
Depth Size Material - -
From To Ft.
From To Ft.
i
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT AA COPY OF TH{S RECORD BEEN PROVIDED TO THB.WBLL OWNER
aRE
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original-to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC _
.7699-1636 Phone No.[phone],within 30 days. _ OW-1 REV.07/2001.- .�

WELL CONSTRUCTION RECORD
North Carolina-Department of Eavimumeot and N*at_ural Division of Writer Quality'-Oroimdwa�Sectionn /-
WELL CONTRACTOR("",.mUAuWME tprtan c/KID P11S ! '�/1.A� r C CATIONf�!LY
WELLCONTRACTOROOMPANY'NAM • YHO/t�f `• --Sa.4-3 oZ•b
STATE WELL CONSTRUCTION PERMIT/ As Ts�)W4 ItRMtrf. ""•>' .
(Irawic") (IttPal3ubk) '
1. WELL USE(ChcckApplicableBox):Res Miu -idoa6I*- paVPubl(c O Indttagial I7 Agricuitmal p
Monitoring❑ Rcco7 0- Heat Pump Watir Injopdon a Other Cf If Otk List Use
2..WELL LOCATI "
Topogrsp end Stiffing�-
County� y Midget OSlo0c Malloy .fit
Nearest Town:
d-_ ArnfA �n1�C✓ a',S'7� 1L j4wa tappraprBtebao) a
tsueet Namtws.c//�am�miy.s Lallo.zi► ) _ . . J LidhdellongiWdaofw"olllocation
3. OWNER`2D {l e r� co �
Address CCCCCC{{{{{{ cl 5 H P A 1 L L� ra A LatihdMongidide source:130PSOTopographic map
t'f2 Qn(C l. J A/�J r 8 3 �� DEPTH (DRILLING LOG
Cxy arrows sure - zip Code ;From To " Fogna_'on Desed ion
Am cods-
bw
4- DATE DRILLED �� -C�' "— C ji;- = vt J
5. TOTAL DEPTH: CD,5.Si - 1 e @ T f 2
6. DOES WELL REPLACE EXISTING WELL? YES 13 NO
7. STATIC WATER LEVELBelowTopofCasing
�
(um`r^KAMo"Tap ofCwW
8. TOP OF CASING IS_ FT.Above Land Surface*
'iop or eaalaS arasUwd arlor Melaw isaaaarft=rpjka a - -
vartaaee In aaerdaaes wRM7SAitCAC 2C.011L -
9. YIELD(gprp): --�0 MSfHOD OF TEST.
10.WATER ZONES(depths 16e' . i a r{d
LOCA1fONSKETCH
11. DISINFEM014..Type Amount Slow dimcdom anddistance in mile;from at least
12. CASING: WaE Thiotttw two State Roads or County Ronda.Include the road
Depth _ D or WeightlFL Marnial "numbers and common road names.
From To Ft
From Tp FL o =I
13. GROUT- Depth Material MAeUwd. —+
FromToLC�&—
From To f� +�9�--
.4. SCREEN: Depth Diameter . Slot Sin Material C3 t=
From To Ft._In. in.
From To Ftd_in. in
S. SANDIORAVELPACK
Depth Size Material _
From To Ft.
Front—To—FL
---- -
6. REMARKS:
• i
DO HEREBY.CERTIFYTHATTHISWELLWA$CONSfRU=INAcCORDANC WIMISANCACIICWML• t
VNSTRUCf10N STANDARDS,AND THAT A COPY OF THIS RECORD HAS OEM PIR MEDTOTEM.WELL OWNER
SIGNATURE"OP PERSON CONSTRUCTINO THE WEE[ DASH -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
.17699-1636 Phone No.(919)733-3I21,within 30 days. OW-1 REV.07/2001
—'

HELL CONSTRUCTION REC0t�11D"
North Cdo ina-Department of Environment and Natutal Resommes-DWon of Wy"attir Quality--6vi=
WELL CONTRACTOR(IND11!6UAQWAM5 brla S dy11S .+i `�citiig
WELL CONTRACTOR COMPANY-NAM WMQMONS I
STATE WELL CONSTRUCTION PERmrro Aunrnq•ID SRM[lY -
(irappliable) *applicable)
1. WELL USE(Chock Applicable Box):Residential*Mwlicip&Mbllc❑ luduW210 Agticulb
Monitoring❑ Recovery O' Heat Pump Wets[bjec.don❑ Other cr if Otlia,List use
2.-WELL LOCATION!
Nearest Town: / j T�Biptkand i
County.,M� ORidge OSiope Mal
lslrea NambeMCosaaolty,3" hiaa.taHe.rpeme) Latimddloagitodeofx�
3. OWNER: Chi 19 Q: '
Address 9cg L t4(?a LatitudeAongidido sourca:OGPSi
�J .��7 3 (a.rxb
�fZClnitl, DgpTy
-( ag!«3 ef'/ TOO �f 7 From To ' Font
Mrs cedes West somber � � _S
4- DATE DRILLED_
5. TOTAL DEPTH:
6. DOES WELL REPLACE MaSTING WELL? YES 13 NO=: —
7. STATIC WATER LEVEL Below Top ofCafing: 0 . ---
(UW-r if Metre Tap orCnW
S. TOP OF CASING IS FT.Above Land Surfacoo —
'Top Orem,"'sands""aver beta r l"taarew ragatria a -
varlaaa In aaordoee with iSAJJUd3C 4111L
9. YIELD(UM): Q MBTHOD OF TEST.
ID.WATER ZONES(depths /G2.S , 5'r - —_
LDCA-TION 3KETC
11. DISINFECTION:,Type Amours( � Show direction and distance in mi
12. CASING: Wall'ibidmen two Stott:Roads or County Roads
Depth or WeightlFL M■tedd '-numbers and common road Hama
From_Q_To��Ft { -.tee
From To Ft
From_ Tp Ft�
13. GROUT. Depth Mataml Method)'
From-0—To_=5DFt� ygs, T MA
From To Ft
.4. SCREEN: Depth Diameter . Siot size : • Madrid • .
From To FL__in; in.
From To in.
5. SAND/GRAVEL PACK: _
Depth Size Material
From To Ft
From To f.
i
6. REMARKS:
DO HEREBY.CERTIFYTMATTHIS WELL WAS CONSTRUCIBD INACt7DRDANCl1 W1'ff(ISANCAC2'C,i ;
'ONSTRUCTION STANDARDS,AND THAT A CDPY OF S REDGRD BBEN p40VWE)TOTIIB."
SIGNATURE OF PERSON CONS7RUCnNG THE WEIy DAME
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-
1'f 699-1636 Phone Na(919)733-322I,within 30 days. Ogi-I

WELL CONSTRUCTION RECORD
n
North Carolina Department of Environment and Natural Resources-Division of Water Quality �t
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S.Tavlor CERTIFICATION#2187
WELL CONTRACTOR COMPANY NAME He_dden 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
Ne estTown: tv1WIJ County Topographic/Land
❑Slope ❑Valley ❑Flat
1 acr. �C u (check appropriate box)
(Sneet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: MI uu ,/ (degreesiminutcs/seconds)
Address �— f� Latitude/longitude source:❑GPS❑Topographic map
(SVeet or Route No.) (check box)
NC a�'13tJ DEPTH
1 DRILLING LOG
City or Town State Zip Code From To , Formation Description
028 °9 it/// Clay&Sand p
Area code- berg ---1�.
4. DATE DRILLED �/ Granite
5. TOTAL DEPTH: A '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: a= 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.011&
9. YIELD(gpm):n METHOD OF TEST BLOW
10. WATER ZONES(depth): 17-1 'r 139'r '�,7—d
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 Weight/Ft. Material numbers and common road names.
From tj, To__T.)- Ft.
.-
From To Ft._ (e•' 1r
From To Ft.
13. GROUT: Depth Material Method r
From 0 To 20 Ft.Benonne&Cement pumped 7
From To Ft. `
14. SCREEN: Depth Diameter Slot Size Material FrI
From To Ft. in. in.
%f
From To Ft. in. in. cn
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. cn
_t)
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTI STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SITUVol'P RS NSTRUCTING THE WELL D E D5
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
SEP 2 6 2005

A.
. , ( A u
WELL CONSTRUCTION REC,(ORD 3 1 G t ':
North Carolina-Department of Environment and Natural Resources-Division of W .akr Quality-Groundwater Section
WELL CONTRACTOR(INDIvIDUAL)NAME (print) S�4 11 FI 15 .ozal "
CERTIFICATION
WELL CONTRACTOR COMPANY NAM L0d� Sd L/ -3 a-6 0
PHONL Y '
STATE WELL CONSTRUCTION PERMIT/_ ASSOCIATED W ERMI7'Y
(ifapplicable) "
(if applicable)
1. WELL USE(Check Applicable Box):Resident'ial'o tvtunicipaVPublic❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other Cf If Other,List Use
2."WELL LOCATIO J:
Nearest Town: 2 / _County 'l2__� - T graph,iclL.and setting
�V /L� $T lJ p p/l i� J QlKdge ❑Slope Malley ❑Flat
(check appropriate box)
(Street Name,Nu ben,Community,Subdivision,Lot No.,Zip Code) aB93y LatitudeAongitade of w.e11 location
3. OWNER: � ht'
Address $ dirinm OpQ (dearees)miauteaheconds)
( treat or Route No.) Latitude/longitude source:❑OPS❑Topographic map
r-'CG,,,kJ 10 k C 3 (cheek box)
Cny or Tewn Su c DEPTH QBI +IN LOG
Zip Code� From To Formation/ascription
Arn code-Phone number , 7 4. DATE DRILLED -O S J` 6' aL 14'5 �
5. TOTAL DEPTH:_ /�_ ?q So S ' �(G e- 2R �i t4
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing; s, 0 D Fr;
(Use"t"If Above Top of Cuing
8. TOP OF CASING IS�_FT.Above Land Surface's
-Top or c"Ina termloated atlor belEw Isodsurfau requires a
vsrlaace in accordance with 15A NCAC 2C.01Ia.
9. YIELD (gpm): .S METHOD OFTESTI�
10. WATER ZONES(depth): S`00 '
LOCATION SKHTC14
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wag Thickness two State Roads or County Roads. Include the road 7
Depth Die} ,,ter or We�)IUFt. Mate p' I -numbers and common road names. `811
From�_To -7 L Ft._LL� N C
From To FL f-rl
From Tp FL D
JYk
13. GROUT: Depth Material Method U1
From-0—To r9D F�-Cp ..� -
From To N
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
- _- r,-,
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL 1
ONSTRUCTION STANDARDS,AND THAT A COPY OF n
nTH S RECORD H BEEN PROVIDED TO THE WELL OWNER
ate, n o s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
s-ubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh,N(
.Yf 699-1636 Phone No.[phone],within 30 days, _ OW-I REV. 0712001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources Division of Water Quality-Groundwater Section
WELL CONTRAC-rOR(INDIVIDUAL)NAME (prlar) <1)�nnl �rM��Q,v�r� Cz3TIPICAT,,IO/NY
WELL CONTRACTOR COMPANY NAM PHONZ Y 5f1 =.��14 (, 0
STATE WELL CONSTRUCTION PERM'71 ASSOCIATED W ERMITM '
(ifaDDlicable)
(ifapplicable)
I. WELL USE(Check Applicable"Box): Residenttal't� umc'ipal/Public❑ Industrial ❑ Agricultural C7
Monitoring O Recovcry ❑" Heat Pump Water Injection❑ Other CT If Other,List Use
2. "WELL LOCATION:
Nearest Town: !�4-�",2/l L ` �/ CountyAPIRMde) (check appropriaappropriate,box)
Topo hirlL,and setting
I N L HI) q j/-� ZkRid'90 ❑Slope ❑Valley ❑Flat
(Sheet Nimc,Numben,Community,Subdirision No, " L�tituQdlOngitude Of Well location
3. OWNER: A i CI't_ S
Address ` •O r , (degroes)minutu/ieconds)
(Since'ar Route No.)
Latitude longitude source:OGPSOTopographic map
(check box)
I2Qyt I "7J a/ E�� 7 DEPTH DRILLING LOG
ny or Toc wn Stale Zip cock From TO
b 30' .Formation Description
Arca code-Phone number 0 1,q
4. DATE DRILLED 9- 7-0 (v - ^' IU - Clnii �
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO"
7. STATIC WATER LEVEL Below Top of Casing: S U FT;
(Uu"+"if Above Top of Cuing)
8. TOP OF CASING IS�_FT,Above Land Surface*
'Top of cuing terminated at/or beige,leadiurface requires a
varlaace in accordance with ISA NCAC JC.0118
9. YIELD � METHODOFTEST
ZOOS 3 •
10. WATER ZONES(depth): � G`�- �/G '
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 Diay ,tier or We t/Fl, Mate '�1 'numbers and coon road names,
From To30 Ft.=$ O>�' . common
From To Ft.
From To Ft.
13. GROUT: Depth - Material Method
From0 To 9V_Ft.—a
From To Ft.
4. SCREEN: Depth Diameter Slot Size I • Material a
From To FL—in. in.
From To Fl._in. in. X,'?
S. SAND/GRAVEL PACK: _
Depth Size Material C: a
From To Ft. r`
From To Ft. --
6q
6. REMARKS:
�' cn
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
k c�L /�' 7
L �
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE o
u,
-s-ubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC _
J7699-1636 Phone No.(9I9)733-3221,within 30 days. OW-1 REV. 0712001

WELL CONSTRUCTION REC,(O�RD
North Carolina-Department of Environment and Natural Resources-Division of Water
WELL CONTRACrOR(INDIVIDUAL)NAMB (print)c��Y1 YII / � � Quality-Q�OWIdWatCi Section
r4 CrATIFICATION Y of 17(e
WELL CONTRACTOR COMPANY NAM c,,/ L/—
�6 3 0
PHONL Y dJ-ifl _�'S�
STATE WELL CONSTRUCTION PIRMITY
licable) _ ASSOCuTED W mdIT#
(if app
difaPplicable)
I. WELL USE(Check Applicable Box): Residential' unicipaVPublic❑ Industrial O Agricultural []Monitoring[] Recovery [] Heat Pump Water Injection❑ Other C7 If Otlur,List Use
2. WELL LOCATION:
Nearest Town: County , C[w Topographic/LFIJ sett' B
tOu i , FDA, e P re.t,/2. 5i rP J F7 Ll edge []Slope(check appropriate boa)lavvey 0Flat
(Svee,Name,Numbers.Community,Subdirision,Lot An,,Zip Code)
Latituac/Iongitude of well location
3. OWNER:—Sf�oh�n� UrtmL�
Address 7`hr»tit s (degreeilmioutabeoonds)
Latitude/longittide souree:OGPSOTopographic map
(Street or Route No.)
r—rQ4'I tC/gin) /r �/T-3 DEPTH
(check boa)
❑y or Town State Zip Code DRILLING LO
From To Formation Description
_ 3h9- 9r1 n/9 /
Area code-Phone number , , 5 , a r „Se 7
a. DATE DRILLED - 7-0-5
5. TOTAL DEPTH: 3bs,
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:AFT;
(Use"+"if Move Top of Cuing)
8. TOP OF CASING IS�_FT,Above Land Surface*
'Top of cuing terminated at/or belgw laudsurfaee requires a
variance to accordance wltIs iSA NCAC 3C.0110.
9. YIELD METHOD OF TEST
ZOO O ~�
10. WATER ZONES(depth);__� g�o/
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 Dig ter or We0VPL Material 'numbers and common road names.
FromTo2 Ft._ r `
From To Ft
From Tq Ft._
13. GROUT: Depth Materiel Method C7
From_L—To r9D Ft.
From To Fl. rA- � � '-:
4. SCREEN: Depth Diameter Slot Sin Material
^
From To FL_in. in. Ctg 3
From To FL—in.
5. SAND/GRAVEL PACK: in. _ � y
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL rn
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER v
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE ti Cn
submit the original to the Division of Water Quality, Groundwater Section s I636 Mall Service Center-Raleigh;NC ( o
J1699-1636 Phone No.[phone],within 30 days, OW-1 REV, 07/200h
i,
I ._ .-.

.WELL CONSTRUCTION RECORD
North.Carolina- Department of Environment and Natural Resources-Division of W '*ter Quality-Groundwater Section
cv ELLCONTRACTOR INDIVIDUAL)"NAML riots �MNI 11'
( (P ) n l l n ! cLRrrPtcAnoN M d l7(p
WELL CONTRACTOR COMPANY
STATE WELL CONSTRUCTION PLRMITY_ ASSOCIATLD W L16MiTt1 PHONR 1 a
(ifapplieable)
_ �� (ifaoPlicab)e)
I. WELL USE(Check Applicable Box):Resident'ial'C�tvtunicipaVPublic❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Hcat Pump Water Injection❑ Other Ef If Otter,List Use
2. WELL LOCATION:
Ncares(Town: 'CLr �� _County � 4 erV �Phie/Land setting
1 !/1 y 1D1� 7' 11 e / 6 r,.I ln, �2 P)3OlUdge Mope ❑Valley ❑Flat
(S,Fcc,name,Numbers,Cammuldty,Subdivision,Lot No.,Zip Code) (check appropriate boa) x
Latitudellongitude of well location
3. OWNER: L/ r ✓✓/ J /I()O ? lC
Address YV& C /)7 gtn, - -f-r (dellroa7minutWaeconda)
(Soar or Rouu No.)
Latitude/longittide source:13OPS❑Topographic map
�72!!n li/aJ (check box)
Cnyor urn State DEPTH DRILLING LOG
Zip Codc
_ ,• rig_ 3Lnn6, From To .Fotmatio�nDescription
Area code.code.Phone number , —� �� /S
_ ----d=:Lh
4. DATE DRILLED �- a -0 $ Of), 5'a . }z
5. TOTAL DEPTH:_ L� /5
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
T STATIC WATER LEVEL Below Top of Casing: /�S6 FT;
(Use"+"if Above Top of Cuing)
g. TOP OF CASING IS�_FT,Above Land Surface*
•Top of cuing terminated at/or belgw Isodsurface requires■
variance In seardance,wltklsA NCAC 2c.011a.
10. WATER ZONES(dME�0 5 FTEST
it, DISINFECTION:T e LOCATION SKETCH
YP Amount Show direction and distance In miles from at leas(
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di ter or Wcot/Ft. Mate I 'numbers and common road names.
From To &-d Ft.= '
From To Ft.
From To Ft.
13. GROUT: Depth Material
To Ft. al Mod
_ � .�.•'
e�th�( � rn
From �_ T„_
From C71
4. SCREEN: Depth Diameter Slot Sim Materiel --
From To Ft.__in, in. a- crt
From To Ft._in, in.
5. SAND/GRAVEL PACK: _
Depth Size Material
From To Ft, -
From To Ft. :.
r f` i
'71,
6. REMARKS: i`J
CO
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15 q NCAC 2C,WELL - Ian
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE
WELL OWNER t�
SIGNATURE OF PERSON CONSTRUCTING THE WELL a DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC I
07 699-1 63 6 Phone No.[phone],within 30 days. GW-I REV.07/2001 `' I

57
WELL CONSTRUCTION RECORD a
North Carolina Department of Environment and Natural Resources-Division of Water Quality `
WELL CONTRACTOR(INDIVIDUAL)NAME tzori-t K(o,-�(CA LCCL;)i CERTIFICATION# (�J
WEI.L CONTRACTOR COMPANY NAME A \eP� -I- PHONE #
STATE WELL CONSTRUCTION PERMT# ASSOCIATED WQ PERMIT#
__(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
El Recovery ❑ Heat Pump Water Injection ection❑ Other❑ If Other,List Use
2. WELL LOCATION' Topo phic/iand setting
Nearest Town: ('LL✓L ❑Ridge , Stope !]Valley ❑Flat
(ch appropnatcbox)
(Street Nara,Numbers,Community,Subdivision.Lot No.,Zip Code) Latitudf./longi of N)yfll location
3. OWNER: Kfio A kp 15 (depec hmmaealsermds)
Address Latitude/longitude soume:UOPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
City or Toam state Zip Code From To Formation Description
L l- LPL-_ (- Y
Area coda Phonenumber 7Ctn it1�
4. DATE DRILLED 9-,�G, [7,�j
kad
5. TOTAL DEPTFL 4 K$ r
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:.&0 —FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS Z —FT.Above Land Surface•
'Top efcaWg lanolzated alor below hod sarrbc reguRoa
varhaee in ocearelosee with 15A NC.AC2C All&
9. YIELD(gpm):�1—METHOD OF TEST Y D i,
10.WATER ZONES(depth): S$0
(o_R D LOCATIONS ETCH
11. DISINFECTION:Type(')�`n� Amount a Show direction and distance in miles from at least
12, CASING: Walt Thickness two State Roads or County Roads.Include the road
Depth Diameter or�Wciglt t at/criel numbers and common road names.
From�_To1Ql_Ft. /n SiVa,� L '1.-_ _
From TO Ft.
From To` Ft
13. GROUT: Depth Material , Method fNTt
From_® _To�410 Ft '3Prtn"''EP P
From --Tom.Ft. C e,/nert} t
14. SCREEN: Depth Diameter slot sin Matuiat N
From To Ft. in. in. o
From To Ft in. in.
ut
15. SAND/GRAVEL PACK
Depth Size Material - a
From To Ft.-
From—TO Ft. CC nn J
16. REMARKS: J . Y✓I � j I� i �f�� (ACE' f LLI�(L f� /l�l'.r'ISCU
rt I ea� �WWA CONSTRUCTED
I DO HEREBY CERTIFY THAT SWELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRU N STAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
_�S� GNAT
CJ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Mana9gment;1611 Mali'Service Center-
Rakigh,NC 27699-1617, Phone No.[phone],within 30 d234.:
GW-I REV.09/2004

�, ,(� l(J 315626
WELL CONSTRUCTION RECORD D �
North Carolina Department of Environment and Natural Resources-Division of Water Quality
q r
WELL CONTRACTOR(INDIVIDUAL)NAME (prio0 'L CERTIF[CATION
ME
WELL CONTRACTOR COMPANY NA I(x rVIPC'� l 1 I+CRA-11 CIA JA C_ PHONE N (E2 -ilr+Qi C2/ 0
STATE WELL CONSTRUCTION PERaIIITN ASSOCIATED WQ PERMlT4
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal&ublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump W Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: /` ToP� Fhic/Land seUiu
Nearest To-a: /-74u k�� Cournty��.�_ OR.idge ,QSlope ❑galley ❑Fla[
(chec appropriate box)
(Shea Name,Numbers,Convora ty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER VO�/7 �1C7()G^� N 35 fi5eev / msc�mda]3�/L15 1
Address Latitude/longitude sauc GPS❑Topographic map
(Street or Route No.) (check bur)
DEPTH DRILLING LOG
CitymTown Staic zip code From To Formation ascription
�-
Arse code-Phone numbs L
4. DATE DRILLED C
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:-e—
(Use"+^if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface'
"Tap ofcoNg termlintea War bebw rat aarf at requires a
variance fa wib 15A NCAC 2C AIIL J
9. YIELD(gpm): 1S METHOD OF TEST r ;�fYCY
10.WATER ZONES(depth—): rj QD
4 LOCATION SKETCH
11. DISINFECTION:Type L'V1 (^ry:aI Q, Amount _—h`� Show direction and distance in miles from at last
12. CASING: Wall Thickness� A two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
Fmrn-+- _To 3.3 Ft.� . 1;,M / PL�
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From_Tom�Ft. e 7 r bL y rn
From_Tom Ft CP s�c t [t rno
14. SCREEN: Depth Diameter Slot Sim Ma t
From To Ft. in. in.
N
From To Ft. in. in. p =
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft.—
From—To—
/�-� Ft. q q�� �(!�
16. iLl� Lpj 5, 14'(z(' �(L- �Jr��P� u oz, L' Ph � iIP�ISPC 1
�1 �ti£J i SS�DfT�lSrvll
I DO Y CERTIFY'1TiA�'THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSTRUCTI STAND ,"THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE/WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEIL.L DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Rahigh,INC 276994617, Phone No.[phone],within 30 days.
GW-I REV.0912004

WELL CONSTRUCTION RECORD a9\0 3 1 5 6 3 4
North Carolina Department of Environment and Natural Resources-Division of Water Quality /
WELL CONTRACTOR(INDIVIDUAL)NAME (pd-t) (1 AA.St (1.t)l-s CERTMCATIONM�y�
WELL CONTRACTOR COMPANY NAME ' PPI !\. A lleo,1 /ibne� TOC' PHONEAI(��-07�/O
STATE WELL CONSTRUCTION PERM[Tft ASSOCIATED WQ PERMM
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipat/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI Ne ^ Topographic/L.lmd setting
NearestT 11Y1 Conty_�,Q� h1KRi,t Mope OVallcy ❑Flat
{{YrrCCC____ (check appropriate box)
(Sheer Name, 'ty.Subdivision,Lot No..Zip Code) Latitude/longitude of well location /
3. OWNER: C. kC r� S� se IS N jS'o3 (.39.9 u OG )as iS.9, /
Address Latitudenongitude PSOTopographic map
(Sheet or Route No.) (c rk box)
DEPTH DRILLING LOG
ar'7�` O S 1 1 z�Code From �To Fexmationl)escaildion
Area code-Phone ntm
4. DATE DRILLED �j
5. TOTAL DEPTH: 3 X D
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO j'
7. STATIC WATER LEVEL Below Top of Casing:1,2D FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface'
`Top areafq LvaYated SL%r below Iowa mrhee regahra a _
vathme In ocwdaae with 15A NCAC 2C All&
9. YIELD(gpm):�METHOD OF TEST
10.WATER ZONE (depth): I�
ZIO LOCATION SKETCH
11. DISINFECTION:Type 2 jE Amount Show direction and distance m miles from at least
12. CASING: Watt11 Tht� two State Roads or County Roads.Include the road
Depth Diameter ar Weight/Ft. Material numbers and common road names.
IDeR
From To Ft
From To Ft.
13. GROUT: Depth Material Method
FromrY3_To C90 Ft. 1 t m
From-C To_3_Ft, 0 cmexA�-
14. SCREEN: Depth Diameter Slot Sim Mat&Wt
From To Ft. in. in. tV From To Ft. M. O "-�
15. SAND/GRAVEL PACK rn `^
Depth Size Material
From To Ft.
From To Ft. 1 1
16. REMARKS: filic n-1S. Mi�.((.t/t__ Jr R iL5Pa l Ii ej- ) cens4 t r,"Oev$
5l1've4 J S,L)4 o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSTR N S NDA�gS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
SIGNATURE(�/oIG~ OF PERSON CONSTRUCIING THE WELL DATE
DATE
Submit the original to the Diivisioa of Water Quality,Attn:Information Managgment,1617 Matz Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

eD U iU c7
WELL CONSTRUCTION RECORD DO
North Carolina-Department of Environment and Natural Resources-Division of W . •afar Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMZ (prlatLc��111'IIS frI - if- , ' � t celf;TmCA170NY o1l7w
WELL CONTRACTOR COMPANY NAMPNONRY '�-�'3
STATE\YELL CONSTRUCTION PERMI7`Y_ ASSOCIATeD W BRMITtY 1'
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential a— unicipal/Public 0 Industrial C3 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 5 If Other, List Use
2. -WELL LOCATION:
Nearest Town County ,�( � °P°B P�ic/Land setting -
s dge Slope ❑Valley ❑Flat
--"--�'-sf (check Appropriate i
(Street Name,Numbers,Community,Subdivision,IAl No.,Zip Code) Latituddlongitude of well
location
3. OWNER: AV-. �— Rd 143, -Fe n—
(dcareet)minu eslsecondsj
Address 1 I I til I S F e, W AV LatitudeAtingitude source:00PSOTopographic map
i,•a ,' A (Street or Route N ) �sq - -
MASE� � 32 3TJ 3 (check boat
�./ �City orTown� Sum Zi Cie m DRILLING LOG
tl VV) S7G _ S776 P From To a .Fo sait nDescription
Arcs code-Ptwne numb*
4. DATE DRILLED_ 1f- ,2 yl—U 5 -
5. TOTAL DEPTH: f r S ' e t' l Q Z 6 " t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
T STATIC WATER LEVEL Below Top of Casing: , "l FT.
(Use"+"if Above Top of Cuing)
S. TOP OF CASING IS�_FT.Above Land Surface*
-Top orcasina terminated atior below,land.surfs"requires a _
variance In accordance with ISA NCAC F 3C.0119. r
9. YIELD (gpm): A METHOD OFTEST
10. WATER ZONES(depth): Ci 0 c s
LOCATION SKETCH ry
11. DISINFECTION:Type �S` n
YP Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads,Include the road o�
Depth Di ter or We1PVPt. Mate ' 1 'numbers and common road names.
From �_To_ Ft.=aE,1�
From To Ft.
From To Ft._
13. GROUT: Depth Material Method
From_To�(Z FL now. nU ) .
From To Ft. T "m"
,(
4. SCREEN: Depth Diameter Slot Size Materiel
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 CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
� az �s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC
J7699-1636 Phone No.[phone],within 30 days, OW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of W 77
afar Quality-Groundwater Section /"
WELL CONTRACTOR(INDIv,IDUAL)NAME (pruao) �Jn' 6 A'A ^ CXIiTWICATIONY JI-Re .
WELL CONTRACTOR COMPANY NAM PHONEY L/ -3 a.6 LO
STATE WELL CONSTRUCTION PERMITY -'
(if applicable)
ASSOCIATED W ERMITY '
- (ihpplicable)
I. WELL USE(Check Applicable Box): Residential' unicipaVPublic❑ Industrial 13 Agricultural❑
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other C If Other,List Use
2. WELL LOCATION:
Neyrest Town: (L;,Y County Two ographiclLand setting
P J L4RTdge ❑Slope ❑Valley ❑Flat
�et
(Suter Noma Numbers,Community,Subdirision,Lot No.,zip code) L (check appropriate box)
Latitude/longitude of w.cll location
3. OWNER:_` ��/G TD/1Y S (degroe�minutcalseconda)
Address '�• h1��p_t� Latitude/longitude source:❑GPS❑Topographic map
(Stroct or Route No.) )
���j'.f✓�C, .d li �X F S'V (chock box
City or Town Sum zi code DEPTH DRILLING LOG
P From To ' Formation Description
Area code-Phone number , - r
4. DATE DRILLED r_G :/ 9 0 5 - ` _ aQ o
5. TOTAL DEPTH:_ cd00' 41 f e-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7, STATIC WATER LEVEL Below Top of Casing: a o -FT; -
(Use"+"if Move Top of Cuing
8. TOP OF CASING IS�_FT.Above Land Surface' :
c
'Top or casino terminated aVor bdaw lagdaur(tu requires■
w C'7
variance In acrdance w tb ISA NCAC ZC.011a. tV
9. YIELD (gpm):_/ L M THOD OF TEST
10. WATER ZONES(depth): 7�oi 9�i/��e ' CD K_
LOCATION SKETCH Ln
IL 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 Di ter or WeighVFt. Matey' 1 . numbers and common road names.
From _Toll: FI.f Sa!
From To FL
From To—Ft.
13. GROFrom Depth Material Method_
From To�Ft. now.
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 WITH 15A NCAC 2C,WELL
ONSTRUC ION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE.WELL OWNER
Lo
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
s-ubmit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC
.7769 9-1 63 6 Phone No.[phone],within 30 days, OW-I REV.07/2001

WELL CONSTRUCTION RECORD
Nonh Carolina-Department of Environment and Natural Resources-Division of Water ua4 Q ty-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)s
1 11J1I— CEI(TIFIcCAT,I,O/N 0 oT 17 y
WELL CONTRACTOR COMPANY NAMPHONs;
STATE WELL CONSTRUCTION PERMIT# '
ASSOCIATED W ERMIT# '
(if applicable)
- 4if applicable)
I. WELL USE(Check Applicable Box): Residentiial'0--kunicipaUPublic❑ Industrial ❑ Agricultural O
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other C( If Ot)ier,List Use
2.-WELL LOCATION: TopoglaphidLand setting
Nearest T9wn: Li Al County2 Mom- �e OSlope ❑Valley ❑Flat
/Y m 1 �U b • (check appropriate box) i
(Sued Name,Nnmbert,Community,SSuu�bdiYisim,tot No.,Zip Code) 8 7 3 LJ LtititudcAongitude of well location
3. OWNER:.. /Y-1 ! 1 s (_' �:--ill N-1 S (de greeslminutedaeconds)
Address 5-3 / K r-& (0 A is- ••' LatitudcAongitude source:OGPSOTopographic map
(Street or Route No.)
�pi AAi i,-O Ale, ^ r 7 (chock box)
CiryorTon Sate Zip Code DEPTH DRILLING LOG
M .3�9 3 ,��O P From To .Formstion Description
r
Arc.code-Phone number p
4. DATE DRILLED -1 6 —D S
5. TOTAL DEPTH: �-
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: JEO_FT. v "t
(Use"+"if Above Top of Cuing) C
8. TOP OF CASING IS�_FT.Above Land Surface* ry
-Top of cuing terminated atlor belgw Isadturface requires a r1J
variance In accordance with ISA NCAC 3C.0119
9. YIELD(gpm): as METHOD OF TEST ZJOYJ
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 Dia to or We'I•ght/FI. Mate ' I 'numbers and common road names.
From, To /6 Ft._
From To Ft.
From To Ft._ _
13. GROUT: Depth Material Method
. From To _Ft, n0 `
From To Ft. -
4. SCREEN: Depth Diameter , Slot Size 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 CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD H BEEN PROVIDED TO THE WELL OWNER
�m � �Z:= 19 05
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Servlce Center.Raleigh,NC
.77 69 9-1 63 6 Phone No.[phone],within 30 days. OW-1 REV.07/2001

WELL CONSTRUCTION RECORD DO
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 PRONE # [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: �L-(�.� Topographic/Land setting
Neare tTown: up County— []Ridge ❑Slope ❑Valley ❑Flat
r
(check appropriate box)
(Street Name umbers,Community,Subdivision,LoQ1o.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address 7 (kf , 4/ Latitude/longitude source:❑GPS❑Topographic map
�9�L�(Street or Route No.) / 9 (check box)
N e b 7p DEPTH DRILLING LOG
city or,Town� state ,I zip ode From T I Formation Description
B�_)- S2� • SLaO Clay 8,Sand
Area code-Phone number 1 r Granite
4. DATE DRILLED
5. TOTAL DEPTH: 000 1 ,,,///
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 eC.. FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance tth 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 D6neter or Weight/Ft. Material numbers and common road names.
From To Ft. G 0 `
From To FL
From To Ft. '
13. GROUT: Depth Material Method n
From 0 To 20 Ft.Benonite&Cement pumped
From To Ft.
O in
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. O
From To Ft. in. in. Cii -
15. SAND/GRAVELPACK:
Depth Size Material ,fis
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
Q.4 g 5105
SIGNATUI OF PERSON CONSTRUCTING THE WELL DAIr.
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 W ater Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)������,•(i A CZITIPICATIONY 2Zl7(e
WELL CONTRACTOR COMPANY NAM ���ttttttPHONL YV—,�i d 4-3 a-6
STATE WELL CONSTRUCTION PERMITY_ ASSOCIATED W ERMITY
(irapplieable)
{ifaPplicable)
1. WELL USE(Check Applicable Box): Residenti81'41—fvtunicipal/Public❑ Industrial Cl Agricultural 0
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other IJ If Other,List Use
2.-WELL LOCATIO q
Nearest Town. 2 l' /(�., /I/County /1� .; bpographielLand setting
�� F dge ❑Slope ❑Va11cy ❑Flat
(check appropriate box)
(Stre9 Name,Numben,Community,Subdivision,l.ol No.,Zip Code) l
LatitudcJlongitude of w.el!location
3. OWNER:
Address C 11 7- r. t- (degre"7minutWesconds)
Latitude/longitude source:❑GPS❑Topographic map
(Settee or Reute No.j
V e VL o ��l i1 F j c (check box)
Cil or Town s Zip Code DEPTH DRILLING LOG
���1��-��SL �� _ t�'je/9 �. P From To ForiFtlon Description
Mca code-Phone number LL l
4. DATE DRILLED „r,
5. TOTAL DEPTH: -SS' f 7 es S` —BlLr� C y m d Z
6, DOES WELL REPLACE EXISTING WELL? YES NO .
7. STATIC WATER LEVEL Below Top of Casing: Cn n FT.
(Um"t"if Above Top of Cuing)
8. TOP OF CASING IS I —FT.Above Land Surfaces
-Top of cuing terminated at/or belgw land surfs"requires a
varlaace In accurdsn"wltblSA NCAC IC.011a.
9. YIELD (gpm): �f O METHOD OF
10. WATER ZONES (depth): 1�.3n ' ,I '
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 Dia} ter or Weot/Ft. Matey' 1 -numbers and common road names.
From->Z ToL_Ft. S32_R 2 41 O Y
From To Ft.
From To—Ft. C/3
rn
13. GROUT: Depth Material Method
From To D Ft.
From To Ft. I -
4. From To
Depth Diameter , Slot Size - Material CCD
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 15A NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD 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 Mall Service Center-Raleigh,NC -
.17699-1636 Phone No.[phone],within 30 days. _ GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
Nonh Carolina-Department of Environment and Natural Resources-Division of Water
WELLCONTRACTOR(INDIV.IDUAL)NAME (print � rJ^ - , ..Quality-Groundwater Section
CEJiI7FiCAT,.IO I/N Y of/7
WELL CONTRACTOR COMPANY NAM PHONE YJ71() _. 24-3 a.6 0
STATE WELL CONSTRUCTION PERMITY_ wSSOCIATED W ERMIIYI__ (if applicable)
(inapplicable)
I. WELL USE(Check Applicable Box):Residential' Uri, pal/Public❑ Industrial ❑ Agricultural E)
Monitoring Cl Recovery ❑ Heat Pump Water Injection❑ Other Ci If Other,List Use
2. WELL LOCATION:
Nearesl Town: Count y To phic/Land setting
u l Qtk s � It e1' i (In m m r ge ❑Slope ❑Valley ❑Flat
p..
(Boca Name,Numbers,Comm iy,Subdivision,lot No.,Zip Code) (check appropriate box) &
11 II Latitude/longitude of well!ocation
3. OWNER: 1O-V-e- /�FQPYQI�
Address .� V- / C 22¢f/ Q (dearecdminuta/aeconds)
Latitude/longitude souree:EIGPS❑Topographic map
(Street w Raule No.) (check box)
I�r an kl.� NCB � � '7� zl
City or Town Soto ZipCode DEPTH MILLINGLOG
( � / cf 71 � From To ' Formation Description
Arc&code.Phone number ('+ n
4. DATE DRILLED r1 �� `I-dS 4� f ' SQ ­124 �tJ
5. TOTAL DEPTH:Tf SS 4146"5 ' 6/n e- 6-:raq r r e
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: &I gT;
(Uae"+"if Above Top of Cuing)
8. TOP OF CASING IS�_Fr,Above Land Surface*
-Top of eulna terminated st/or below laadeurraoe reyuirea a
vedanae In aewrdance with ISA NCAC 3C.011a.
9. YIELD(gpm): f 5 METHOD 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 n/ Dia ter or We;ghVFt. Mate dal I 'numbers and common road names.
From To L i Ft.�_$ ..R,�. �' _}
From To Ft. Pa
From To Ft. (n
13. GROUT: Depth Material ITT
Method —t7
From
To FL1. 1 r';
From To Ft.
4. SCREEN: Depth Diameter Slot Size Material O
From To Ft. in, in rs
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 IBA NCAC 2C,WELL
ONSTR UCTION STANDARDS,AND THAT A COPY OF/T�HIS-RECORD H BEEN PROVIDED TO THE WELL OWNER
�/� /•+2-��cQhr �
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC
,Y1699-1636 Phone No.[phone],within 30 days. OW-I REV. 07/2001

WELL CONSTRUCTION REC,,(ORD
North Carolina-Department of Environment and Natural Resources Division oC Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV,IDUAL)NAM¢ (prlus) She11t'II s /J, 11/J.,n A _" C¢�'r(plCATeIO�NY
WELL CONTRACTOR COMPANY NAMPHON¢ M741 _.��4-3 �-(�
STATE WELL CONSTRUCTION PERMIT#_ wSSOC1AT¢D W ¢EMIT#
(ifapplietble)
(if,
PPlicable)
I. WELL USE(Check Applicable Box): Residentiel'L —VUnicipaVPublic❑ Industrial ❑ Agricultural El
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other C7 If Otlicr,List Use
2. WELL LOCATION:
Nearest Town: Eg,tile L CountyA co". TD p,.ic/Landsetting
ge (❑Slope []Valley ❑Flat
/C check appropriate box) k,
(Strea Name,--Nu m
//tubers,Community,Subdivision,Lot No,Zip Code) Witud0ongitude of well location
3. OWNER:
Address ) 4 4 ( ("� t o I' 't w I I A (degrailminUU413c onds)
(Sheet or Route No.)— Latitude/longitude source:❑GPS❑Topographic map
� -
a.3 Z` � (check box) .
RHahaSr t f= I DEPTH DRI . IN . LOG
�Gty or Towa sort Zip coat From TO
)e c3� r Formation/ ascription
Mca code-Phone number �, -
4. DATE DRILLED
5. TOTAL DEPTH: I _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: T26 .FT;
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS�_FT•Above Land Surfaces
'Top of wing termlosted atfor below loud surfs"requires a
valance in accord aoee wltblSA NCAC IC.0111.
9. YIELD (gpm): ( _METHOD OF TEST
10. WATER ZONES(depth): I a0 '
LOCATION SKETCH
1 1. 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 Weot(Ft. Mateli l numbers and common road names, ,
From _3O FL_r " $� Dy �y
From To FL N
From To Ft. m
13. GROUT: Depth tv(atenit Method i
From To—,SD—Ft, e0 +l
From To - Ft. 0
4. SCREEN: Depth Diameter Slot SizeMaterial
From To Ft._in, in.
From To Ft._in• in •
5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
ONSiRUCTION STANDARDS,AND THAT A COP,(YI OF THIS RECORD H/p�$BEEN PROVIDED TO THE WELL OWNER
fm &'k c40 r2rl t S 4t
SIGNATURE OF PERSON CONSTRUCTING THE WELL . DATE
,rubmit the original to the Division or Water Quality, Groundwater Section, 1636 Mell Service Center-Ralelgh,NC
.77699-1636 Phone No.[phone],within 30 days, OW-1 REV, 07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlaQ)h-e)1Pll r}� JJ0,Ar1 "" CX7TWICATIONP JI7�-
WELL CONTRACTOR COMPANYNAM ' PHONit Y 0 L/--3 9FJ Q
STATE WELL CONSTRUCTION PERMITY. wSSOCIATED W ¢RMITM
(if applicable)
-- (if applicable) -
I. WELL USE(Check Applicable'Box):Residers al' unicipaVPublic❑ Industrial CI Agricultural Q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 11 If Otfier,List Use
2."W WELL LOCATION:
Nearest Town: County
- opo�phic/Land setting
Yya eReniITS BFi6A- )e S ?3e/ dge ❑Slope ❑Valley ❑Flat
(S«ca Name,Numbers,Community,Su (check appropriate box)iaion,Lot No.,zip code) LittitudeAongitude of well location
3. OWNER: (desr"Vatinutaheconds)
Address fA b azi N �r _ Latitude/longitude source:❑GPS❑Topographic map
(Street or Route 11 � 7 (check box)
FRyON , d N DEPTH DRILLING LOG
any or Town ute zip code From To
tea+ s"p eJ'_ LAW �g Formation Description
A n Area code.Phone nwn ., �&f• c e� 1 t/
4. DATE DRILLED I-- Z3—US � - - [. "' r /�' �S!liui� tan-4.
5. TOTAL DEPTH: 3 DO ' U 4a a 13 la V l l 1 t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO_uui131 ItsT-e-
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS�_FT.Above Land Surface'
'Top of cuing terminated at/or belpw lend surface regatria a
variance in aeaordaoe with ISA NCAC IC.011a.
9. YIELD(gpm):3_METHOD OF TEST
10. WATER ZONES(depth): . )SD . a�4.0'
LOCATION SKETCH
IL 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 Dia ter or WeOt/Pt. Mated al numbers and common road names,
From To I I I Ft. "
From To Ft.
From To Ft._
13. GROUT: Depth - Material Method
From To r*D Ft.. a0
From To Ft. - - c/)
4. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft--in. in. v ''
S. SAND/GRAVEL PACK:
Depth Size Material L '
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 THIS RECORD H BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINGTHEWELL DATE
-571ubmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center-Raleigh,NC
J7699-1636 Phone No.[phone],within 30 days, GW-1 REV. 07/2001

WELL CONSTRUCTION REC,(ORD
North Carolina-Department o[Environment and Natural Resources-Division of W
WELL CONTRACTOR(INDIVID (Plint) ch�rt v3 I aUAL)'NAML fer Quality Section
n I l0 1 r;
WELL CONTRACTOR COMPANY NAM Cri TIFICA=N a
STATE WELL CONSTRUCTION PERMTI'Y PHONE Y L/..-3 1;2(� Q
(irt licable) -------------ASSOCIATED W ERMITY .
{ifs licable
I. WELL USE(Check Applicable Box):Residential'rd-IvlunicipaVPublic❑
Monitoring q Recovery q Heat Pump Water Injection❑ . ustrial q Agricultural p
Other C( !fIndustrial
Other,List Use
2. WELL LOCATIO I:
Nearest Town: `��L Cl I Count 4 C[ T�Pphicland setting .
Zk5 e dnlm• 'SCl a, �� 73U go ❑Slope ElValley Oflat
(Suet,Name,Numben,Community,subdivision,Lot No.,Zip Cade) / (theca appropriate box) x
Latitude/longitude of well location
3. OWNER: Jr� eh2 V--r- -J A-C_te S cati
Address cQL S/ slit (dcaroer)minuteslaewnds)
rr u NI I (sueuorRotoNo.) q ( Latitude/Ion gitudesource:CIGPSDTopographicmap
— d Irv,) . /n �2 0 7 � � (check box) .
Lily orLT wu J Zilue zip code DEPTH _ - DRILLINGLOG
�)- From Folition Description
Arcs code.Phone number - �/ C�� It 4
4. DATE DRILLED 6 6 5
5. TOTAL DEPTH: -CI_ 4 . C
6. DOES WELL REPLACE EXISTING WELL? YES [I No.vr��� } 2
7. STATIC WATER LEVEL'Below/` Top of Casing: P7 FT: ---------
8. TOP OF CASING IS ae"+^it Above Toporeuing)
---fee-------FT.Above Land Surface*
'Top of eulaa termloaled aVor below landsurface requleu■
"duct In aecordaaeo with 15A NCAC IC.0111 —�--
9. YIELD (gpm):�_METHOD OF TEST
10. WATER ZONES(depth): O
--
1 I. DISINFECTION:Type Amount LOCATION SKETCH
12. CASING: Show direction and distance in miles from at leas,
Depth
Wall Thickness two State Roads or County Roads.Include the road
Di ter or Wcot/Ft. Mate • I -numbers and common road names.
From 17 To / L) Ft. _$ DIP :
From To Pt.
From Tq Ft,
13. GROUT' Depth — t,4eterisl M -
From�.To AD Ft,
From -'
To Ft.
4. SCREEN: Depth Diameter Slot Size C/3
From To F(_ Material
_in. v
From To Ft.—in. in.
5. SAND/GRAVEL PACK: _ -.t
Depth Size Material c= --
From To Ft, _ CA ,
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 H BEEN PROVIDED TO THE.WELL OWNER
L U
SIGNATURE OF PERSON bNSTRUCTING THE WELL
' DATE
submit the original to the Division or Water Quality, Groundwater Section, 1636 Mall Service Center-Raleigh,NC
.17699-1636 Phone No.(919f 733-3221,within 30 days.
OW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and tural Resources- Division of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �/'_s{9�� '_I' CERTIFICATION V/! qq
WELL CONTRACTOR COhIPANNA:NE OaCP)
_ �LJN�I�.%✓-C. LNG. PIIONE H -V7 I /4
STATE WELL CONS"rRL'CTION PERN ITk ASSOCIATED WQ PERa11Tq
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residenlial6 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2- WELL LOCATIO • Topographic/Land setting
Ne est Town:� � County ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: &Aes+ RWIIJ IG (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
rVA_,/,�7f AlC- 0V) -3y DEPTH DRILLING LOG
Cityor Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED Le
1—Q� p Le
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:_,2(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.Ul18.
9. YIELD(gpm): l0- 1 a- METHOD OF TEST,4�L____ _
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 D'amcter or WeighbTt. Materiai numbers and common road names.
From To AltP FL /�e_ �],[(, _ w
From To Ft. /
6
From To Ft. _
13. GROUT: Depth Material Method p`
From 0 Tomb Ft. C146e"V
From To Ft-
14. SCREEN: . Depth Diameter. _ Slot Size Material - o
From To Ft. in. in. cn
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
CO TRUCTION STANDARDS,AND THAT A COPY OF THIS RECOLD HAS BEEN PROVIDED TO THE
WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATEa�r�s
Submit the original to the Division of Water Quality,Groundwatprgection, 1636 Mail Sendce Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days: '" L j$ � ' � GW-I REV. 07/2001
i
i

WELL CONSTRUCTION RECORD �V
North Carolina-Department of Environment and N. rat Resources- Division of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i e_ CERTIFICATION p
WELL CONTRACTOR COMPANY NAME E -mlt PHONE a
STATE WELL CONSTRUCTION PERINITM ASSOCIATED WQ PERRIII'p
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residentiala" Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use
2. WELL LOCATIONTopographic/Land setting
Near t To�fw'n: County & I✓ ❑Ridge ❑Slope ❑Valley ❑Flat
h%O V'A )e' (check appropriate box)
(Street Name(,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
3. OWNER: (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
//(Strreet or R,w,o/Im`,e No.) L (check box)
Pi k / 4L_ DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Area code-Phone number _
4. DATE DRILLED
5. TOTAL DEPTH: yai.S
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 1;"'� _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 in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):; D METHOD OF TEST:Ir
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 D'a ter or Weight/Ft. Material numbers and common road names.
From To—"—Ft.
From To Ft. _
From To Ft.
13. GROUT• Depth Material Method s ,
From To FtTix"Aowri,Alei_
From To Ft. CD
14. SCREEN: Depth Diameter Slot Size Material I
x—
From To FL—in. in.
From To Ft. in, in. C3
15. SAND/GRAVEL PACK: C.rl
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,N'ELL
COMqTRUCTION 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
JET 2 8 .JS
I� i r i I I

WELL CONSTRUCTION RECORD �
North Carolina-Department of Environment and NaturalResources -Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME
,r(,,pr-i'n_t(`.1pJ�D�L'/I`JQ `�1i41'1!I(-n, � CERTIFICATIONI�'/ /
WELL CONTRACTORCONIPANYNAME 0f;V4' AAS• LAIL��(.%JC JiN� — PIIONE
STATE WELL CONSTRUCTION PERMI"r# ASSOCIATED WQ PEI0II7"p
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential H' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 7^I�AIj�/.a�_County /1'lf}L'dlt�
/1 �� LL _ �� ❑Ridge ❑Slope ❑Valley ❑Flat
C A-irl-T c "- (check appropriate box)
(Street Name mbers�m,Nutunty,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
3. OWNER: r Vd �d�iL'_ (degrees/minutes/seconds)
Address es Vr?,(12 /v`e Latitude/longitude source:❑GPS❑Topographic map
(StreeRe Na.) (check box)
L Akt i�f4'1. �'/• 3 (y DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone numbe
4. DATE DRILLED 7- i
5. TOTAL DEPTH: �l�y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: JO FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface*
"Top of casing terminated allor below land surface requires a
variance In accordance with 15A NCAC 7C.0118.
9. YIELD(gpm): /UD f- METHOD OF TEST,;V .
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.Includethe road
Depth ,/2) Diameter or Weight/Ft. Material numbers and common road names. 6From if") To1QL Ft. /o1Y
From Tri Ft. o
t
From To Pt. _ 1
13. GROUT: Depth Material Method -c"' :�+
From To
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, )IZLL
CON TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRICTING 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 r;-,? 2 $ Li u`J GW-I REV. 07/2001
G�

WELL CONSTRUCTION RECORD I� r
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) C t— CERTIFICATION k✓U��
WELL CONTRACTOR COMPANY NAME � & PHONE
STATE WELL CONSTRUCTION PERMIT# .ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential t7- Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATI Topographic/Land setting
Nearest
Town: -- Al_County m�/— ❑Ridge ❑Slope ❑Valley ❑Flat
l (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNERk,—,T C
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
� (Street or Route oJ (check box)
1J,(G� /V e)`d y DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone numbe --'T-
4. DATE DRILLED ''?D -0
5. TOTAL DEPTH: 0 as T
6. DOES WELL REPLACE EXISTING WELL? YES ❑ 0 ❑
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):_+' METHOD OF TEST A.r
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 Di mft r or Weight/Ft. Material numbers and common road names.
From t� To /1'f Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method 0
From To Ft. !� le r"q� �
From To Ft. i
J'
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in. o
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
CONS RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/,--> lb-c1 C
SIGNATURE OF PERSON COT sF�KV-&MG THE WELL DATE
` f```
I
Submit the original to the Division of Water Quality,GMuridwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. {i.I $ ;;, GW-1 REV. 07/2001
U
r a�7.

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) d hA,1,Iy 1 ( A�14/Z'G CERTIFICAATIIOON#
M E
WELL CONTRACTOR CO NI NAME l 4nank &SY LUC(/ QV,AWDO _PHONE # (O d111•S.ZI�YL�JIp
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED•WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential E!r Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION. Topographic/Land setting
Nearest Town: )/ County &4�Q ) ❑Ridge ❑Slope ❑Valley ❑Flat
S+ p 1J,4d (check appropriate box)
(Street Namam Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: J 1 Ly env (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
\""(Street or Route No., (check box)
a fly �/ . 3 DEPTH DRILLING LOG
ciry or sown State zip code From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: Ins
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 1�!O 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 in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 16 y METHOD OF TESTA;r _
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 Diame fr or Weight,'Ft. Material numbers and common road names.
From Tom Ft.to�y �1LSL
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 Tofu _Ft.& u
From To Ft. t`?
14. SCREEN: Depth Diameter Slot Size Material o rx
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material £,_
From To Ft. -
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,GrImh6vater Section, t636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001
28

WELL CONSTRUCTION RECORD �P � P, 11
J . � . 1 �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 0 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT[ _ ,+ Topographic/Land setting
N rest To n: 1 County , rx- ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Sheet N te,No ,Community,Su ivision,Lot No.,Zip Code) Latitude/longitude of well location
3. E TW (degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
} C(Stree[grBoute No.) (check box)
(�� DEPTH DRILLING LOG
City—or 1'own�,I State Zip Code From TJ� Formation Description
B(�B )' 4enui7 , U 0 �`I ' Clay it Sand
Area Code-Phone number -F�f--- ?f—
4. DATE DRILLED (' 6 Granite
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 attor below land surface requires a
variance in accordanceFfith 15A NCAC 2C.011&
9. YIELD(gpm): 4e 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 Di eter or Wei t. terial numbers and common road names.
From o To�Ft. F
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 DiameterCD Slot Size Material C --
From To Ft. in. in. I ,�
From To Ft. in. in. r F
15. SAND/GRAVEL PACK: O1
Depth Size Material Ur
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 DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
—'O
SI 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
3
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 (8281369-9591
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
NI. est//Town: County �Mt at , ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,C(immunity,Subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER: zk n t �/ (degrees/minutes/seconds)
Address _ Latitude/longitude source:❑GPS❑Topographic map
(Street o Route No.) 9{c ��� (check box)
� C71� DEPTH DRILLING LOG
City or ion rate _J Zip code From To Formation Description
0( - 0 //,.vrj' Clay&Sand
Area code-
-Phone number /� ` -,)�i' Granite
4. DATE DRILLED ;�� �-(.�
5. TOTAL DEPTH: 4j(1,[)
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO, 1..
7. STATIC WATER LEVEL Below Top of Casing: /CP T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface*
"Top or casing terminated aVor below land surface requires a
variance in accordance with 15A NCAC 2C.01I&
9. YIELD(gpm):�.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 0 To Ft. A)` VC
From. (kf ftTo Ft. /C•'
From To Ft. ej
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite a Cement pumped
From To Ft. C
14. SCREEN: Depth Diameter Slot Size Material F
From To Ft. in. 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
CONSTRUCTIONS RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE PERSON CONSTRUCTING THE WELL D TE'
Submit the final 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

d'r STArfp
l i` ? . RESIDENTIAL WELL CONSTRUCTION RECORD ?�
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
'`w a.u.su''
WELL CONTRACTOR CERTIFICATION# 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type H-FT H Amount 160z
Russell S. Taylor g• WATER ZONES(depth):
Well Contractor(Individual)Name From )57,To (A 1 t From To
Hedden Brothers Well Drilling, Inc. From To Z35 From To
Well Contractor Company Name From 23g,3g,To Z�-( 1 � From To
STREET ADDRESS 73 Holly Hills Vista RD S. CASING: Thickness)
De th} Di meter Weight Ma11ebal
Franklin, NC 28734 From To /S Ft. 'e
City or Town Stale Zip Code From To�' Ft. . r88
( 828 1- 369-9591 From To FL
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From_Q Tom 2 10 Ft. carent & 1;1H8 rnit'LE L1M[ Ed
SITE WELL ID#(If applicable) From To Ft.
STATE WELL PERMIT#(il applicable) From To Ft_
D WQ or OTHER PERMIT#(If applicable) 6. SCREEN: Depth Diameter Slot Size Material
M ELL USE(Check Applicable Box): Residential Water Supply❑ From To_Ft._in. _ in.
,r C From To Ft._In. _ in.
r•AfE DRILLED. 9W From To_Ft._in. _ in.
TIME COMPLETED AM 2/�PM❑
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
From To Ft.
CITY: 1w. COUNTY From To Ft.
From To Ft.
(Street Name,NLIIIibers.Community,Sub)Sslon,Lot No.,Parcel.Zip Code) '
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope OValley ❑Flat ❑Ridge ❑Other From To / Formation Description
(check apprdpriale box) 0 6 r Clay & sand
May be in degrees,
I_ 11TUDE _ minutes,secondsot r t C�ranita
LONGITUDE in a decimal format
Lati'ude/longitude source: ❑GPS ❑Topographic map
ifocation of we#must be shown on a USGS topo map and -
attached to this form#not using GPS)
4.WELL OWNER 0
OWNER'S NAME -
ST-EET ADDRESS .
Cit oriTown State Zip code
Area code• Phone number
11. REMARKS:
S.WELL DETAILS: I
a. TOTAL DEPTH:—_a,50
It. DOES WELL REPLACE EXISTING WELL? YES❑ NOYL
c. WATER LEVEL Below To Of Casing:�y,��FT, 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
P1M NCAC 2C,WELL CONSTRUCTION STANDARDS,ANDTHATACOPYOFTHIS
(Use'+'If Above:Top of Casing) RECO AS BEEN PROyV1D/E1DTOTNE WELL OWNER.
d. TOP OF CASING 18 2 FT,Above Land Surface' u .
'Top of casing terminated at/or below land surface may require -12 0- 4t6'
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED W L CONTRACTOR DATE
e..'YIELD(gpm): !OO METHOD OF TEST B10W Russell S. TaVlOr
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., For,GW-1a
1617 Mail Service Center—Raleigh,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

WELL CONSTRUCTION RECORD (0 1 C -, -n,
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 Herren Brothers Well Drilling,Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
11111111 (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
Nearest Town: _ ^ Countyffl�� ❑Ridge ❑Slope ❑Valley ❑Flat
12410 (check appropriate box)
(Street ame, timbers,Community,Subtivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address $g7 Lk­iWW1 Latitude/longitude source:❑GPS❑Topographic map
--,A �(Street or Route No.) (check box)
_ /uLZL AGGt O� ?y/a8 DEPTH DRILLING LOG
City or To n June Zip Code From o Formation Description
(8�-_23u/be �1�� o`jA0 Clay itSand
Area code-Phone number Granite
4. DATE DRILLED J#
5. TOTAL DEPTH: -JAW ,,,,,,ttlffI,,,,,,���r��
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 11,50 T.
�^1 (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): METH7�0 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������111111 QQ Diameter or Weight/Ft. M,q�ial numbers and common road names.
From To F YY
From ft To F[.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.Benonite&Cement pumped C "'
From To Ft. I
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. o _
From To Ft. in. in. N
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 TION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CZ44 cn 10zq •01"
SIGNA,YJRE 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

R.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Cembhha Department of Environment and Natural Resources Division of Water Quality
I
WELL CONTRACTOR CERTIFICATION# 3401
1.WELL CONTRACTOR: It. DISINFECTION:Type CHLORINE Amount 100 PPM
JOHN ARTHUR CHASTAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From To 180' From To
CHEROKEE WELL DRILLING&PUMP CO.INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 S. CASING: Thickness/
Depth DiA2reter Weight
0 tdatetial
MURPHY NC 28906 From To O. b? 168 CiALV
City or Town State Zip Code From To R.
8( 28 1 837-8008 From To R.
Area code- Phone number
7. GROUT: Depth Material Meftwd
2.WELL INFORMATION: From 0. To 20' R. CEMENT GRAVITY
SITE WELL ID#(it applicable) From To Ft.
STATE WELL PERMIT#(d applicable) From TOR.
DWQ or OTHER PERMIT#(1 applicable) e. 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 10/10/05 From To Ft. in. In.
TIME COMPLETED AM❑ PM❑
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: NANTAHALA COUNTY MACON From 7o Ft.
From To Ft.
986 LONG BRANCH RD. From To FL
(Street Name,Numbers,Community,Subdivision.Lot No.,Parcel,Zip Cade)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
IdSlope []Valley ❑Flat .[]Ridge ❑Other From To Formation Description
(check appropriate 0' TO 60' BROWN DIRT
13.8
May be m hgces, 50' TO 0' FRACTURED QUARTZ
LATITUDE 3 5 13.891N minul®,aecondv or
8 3 36A51 W in a decimal format 60' TO 70' GRANITE/SET CASING ,
LONGITUDE__ 70' TO 205' GRANITEr
LatitudeAungitudesource: eqGPS ❑TopograpMenarp
(focafimn of wel must he shown on a USGS fopo map and C2
attached to this form bnof using GPS) C-
4.WELL OWNER
OWNER'S NAME STEPHEN MCKENNA CO
STREET ADDRESS 3533 ROXBORO RD.NE APT.2
ATLANTA GA 30326
City or Town State Zip Code
( 404 T- 575-2571
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH:205'
b. DOES WELL REPLACE EXISTING WELL? YES O NO
I DO HEREBY CERIIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 20 FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'II Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
*Top of casing tenrvnated at/or below land surface may require S ATURE OF CERTIFIED WELL CONTRACTOR -I-U-ILDlAITE�
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): 20 METHOD OF TEST AIR trN
PRIN ED NAMV--E O�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 566. Rev.7M5

WW
31 "
WELL CONSTRUCTION RECORD `
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WRr r.CONTRACTOR(INDIVIDUAL)NAME (prietL �.6f7/)'(.h fA 6L)�l CERTWI"C�7A�T1poN a
WELL CONTRACTOR COMrwNY NAME tAllleel WPC r j/Palmen4 ..)_i'IC PHONE M I3✓d .' i�-c 7z/U
STATE WELL CONSTKUCnON PERMITA ASSOCIATED WQ PERMIT#
11011 (if applicable) (if applicable
1. WELL USE(Check Applicable Box):Residential l Municipal/Pub6c❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water niection❑ Other U If Other,List Use
2. WELL LOCATi �/� i To hic/tand setting
Ne tTowa: t—y h'o ta- II Countyffl (�,1f1_ llltj e �lope CIValley t]Flet
/7O54"."n}1�P �LtFi C ( ' (check elproWiatebox)
(Sheet Name;Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 754a'/ t 0 33 c'(7y' t 9,7" Woz3 Flo I qaa' I 'l
(de�oes/�nPtdaecwds)
Address 2Q �- t-- 1c ,4.. Latitude/longitude sovrceMPSOTopographic map
(S �ltouteNo-) (check box)
aV (D3 DEPTH DRILLING LOG
dY or Town State zip code From To Formation Description
8� 3Li9-�/tiS O l-S Sri jj��
Area code.Phone number
4. DATE DRILLED
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:—3-0 _FT.
(Use"+ if Above Top of Casing)
S. TOP OF CASING IS I FT.Above Land Surface*
'TOP Ofuahg[vg11015 below land serfaee requim a _
varit•ce to accordance with 15A NCAC 2C 911s.
9. YIELD(gpm):30 METHOD OF TEST
10.WATER ZONES(depth): gQ
WCATION SKETCH
11. DISINFECTION:Type '(rlt L"` i A oe— Amount L..� r .� Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Wcight/FL Material numbers and common road names.
From_To .COL Ft. /,a,� 5 P R 1 Lite ,_
From To Ft
From To" Ft.
o '13. GROUT: Depth Material Method -
c�
From' .3 To-9J,-Fc ti --t -.
From Tom_Ft. () z) Pr't)t n N
14. SCREEN: Depth Diameter Slot Size-{ &W
From To Ft, in. in. CD _
From To Ft. in. M.
15. SAND/GRAVELPACIC
Depth Size Material
From-To-Ft.-
From-To-Ft.
16.NMARKS
1 DO HEREBYCERTD-Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15ANCAC 2C,WELL
CONSTRUC N S THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
k
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Mamagement,1617 Mai Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
OW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR ONOWIDUAL)NAME (print), Ct/� r/y �,/Q(ill 5 1 CERTtF1CATtoNp��5s
wELL CONTRACTOR COMPANY NAME )Cidipel 1 hku TrPCIt-rheftr lam(, —PHONE a �J ��D�l(C7
STATE WELL CONSTRUCTION PERWTR ASSOCIATED WQ PERMIT/{
01111110- (ifepplieable) (if applicable)
111111111110
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: Ytti C /� County r r`CCC C%t� Topographic/Land setting
ORidge lope OValley OFlat
check appropriate box)
(Street NROM.fNinon=•Co ry,Subdivision,Lot No.,Zip Cade) ^� '1 Latitude/longitude of well location
3. OWNER:_l�&rren tlolk Vv31 .01 3q,5 '( 1q)p43 '2 1149 ,�2 1
Address l --IM f tQk (dew 'ids)
---3A Lattude/longitude source: GPSOTopogaphic trap
(Street or Raule No.) (check box
00';' N n G - 5a S DEPTH DRILLING T IN
Cdy or Towv State Zip Code From To Formation Description
73
Area code-Phone number •j
4. DATE DRILLED 42-Q 9- 44
S- � 1+�1iii✓il F)crc G C.^ii
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: .ten FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS ( FT.Above Land Surface*
"Tap arcasteg terapWted athr Below load mrfue regabes a _
variaaes IN aecordmee with ISA NCAC 2C.111L n _
9. YIELD(gpm): METHOD OF TEST! i ! KO c
10.WATER ZONES( th): 2;'C4— Mo ej
LOCATIONSKETCH
11. DISINFECTION:Type(I_RN ,�Y Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roads
Deprb Diameter or Weight/Ft. Material numbers and common road names.
From From •i-1 To-Ta �3 F jo•%, S 4, PLC
From To Ft. CD
13. GROUT: Depth Ma erial , Method -4
From . To { Ft. vL
,
From Tom_Ft. ne Ct 1
14. SCREEN: Depth Diameter Slot Size- 'LN �
From To Ft, in. _ in.
Frorn To Ft. in.
15. SAND/GRAVEL PACK
Depth Sits Material
From To Ft.
From gToo �Ftt. p! / f J 16. REMARKS:_CLL�G�1 1 �. l�LahLU drd1P(, We l twzL1- Cet1Sl[( rll t � �L✓�
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSTRUCTI61d S� T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�'
SIGNATURE OF PERSON CONSTRUCTING THE WELL PATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 276994617, 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) \ CERTIFICATION a,2k,4V
WELL.CONTRACTOR COMPANV NAME ie��er ;.P a'k TinC_ PHONE,l (U1?r�'Wg9'-n 7410
STATE WEI,L CONSTRUCTION PERMITM ASSOCIATED WQ PERMM
1101 (if applicable) (if applicable)
INNEW
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water )eCtion❑ Other❑ If Other,List Use
2. WELL LOCATION: Togog phiclt,end settin
Nemeat Town: ty� _ pgi t� p�rauep E3Flat
;r 14 [o r`t) I C �!X 4 �� 1(chhee k appropriate box)
(Street Name, .Comtmnity,Subdivisioq Lot No.,Zip Code) Lea�titudbl'onp>iltude oF�gll location ' i )
3. OWNER:_ P_ r p 1tJ 35 0io 34.8 In)OR3` a t o3.?
Address �U -T&I - i-fl /!kin •P Latitude/longitude XUPSrn)
(Street or Rod' No.) `c ����e�p
ry�, 1 (check box)
r`,1- [ -7 J DEPTH DRILLING LOG
Cny or Town stare zip code From To Formation Description
uva� Z�aW- 3
Area code phone namt)417
4. DATE DRILLED 9 o2Lf'D�_
d n 3 CIIITC.
S. TOTAL DEPTH: �3 cx`) I
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO j'
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use`+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
"Tap Of-11 g twmd"tcd aUor arbor rand aarraee requires a
variance in ateordaaa with 15A NCAC 2C A118.
9. YIELD(gpm):: Lj _METHOD OF TEST ( ,,
10.WATER ZONES(depth): j 80 r
LOCATION SKETCH
11. DISINFECTION:Type('�, c„ riP m,-
Amount p (J Show dim,-pion and distance in miles from at least
12. CASING: Wail Thickness two State Roads or County Roads.Include the road
Depth Diem or WeightTt. Materiel numbers and common road names.
_I From- _To�__Ft.zz .J`D 1231
From To FL
From To Ft. i
13. GROUT: Depth Material Method ;
From_,_To ! _Ft. R i f- - ll
From Toyer Ft. nPC* pP,viP T �
14. SCREEN: Depth Diameter Slot Size -a From To Ft. in. in, r\)
7
From To Ft._in. in. -
15. SAND/GRAVEL PACK: o
Depth Size Material rs
From To Ft.
From - a
T10 Ft.
16. i I(1 li'Clod 5 iV lei II /P �rt ��P� In) ( I [ p� l ICCi7 4fi�
r�cis supc4u1Slca✓'1
I DO HEREBY CERTIFY THAT S WELL WAS CONSTRUCTED IN ACCORDANCE.WITH 15A NCAC 2C,WELL
CONSIRU N ST ARD , THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TBE WELL, DATE
Submit the original to the Division of Water Quality,Attn:Information Management 1617 Mail Service Center-
Raleigh,NC 276994617, Phone No.[phone],within 30 days.
GW-i REV.09/2004

V
5x RESIDENTIAL WELL CONSTRUCTION RECORD ' 'd
y
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3368
1.WELL CONTRACTOR: f. DISINFECTION:Type CHLORINE Amount 100 PPM
WILLIAM BRADLEY LEWIS g. WATER ZONES(depth):
Well Contractor(Indimcktaq Name From To 120' From To
CHEROKEE WELL DRILLING From To 140' Ftem To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 1007 6. CASING: Thickness)
MURPHY NC 28906 From 0' DTot 100' R. bpi,�eter �Sa� Material
City or Town Stale Zip Code From To R.
8( 28 ) 837_BM8 From To R.
Area code- Plane number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
From 0. To 20' R. CEMENT GRAVITY
SITE WELL ID f(ir applicable) From To R.
STATE WELL PERMIT4(r applicable) From To R.
DWQ or OTHER PERMIT a(6 applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To R.-in. In-
From- TO Ft.—In. _ in.
DATE DRILLED 10/13105 From To Ft.-In. _ in.
TIME COMPLETED AM❑ PM❑ g. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth size Material
CITY: ANDREWS COUNTY MACON From To Ft.
From To Ft.
JUNALUSKA TO SWAN DRIVE From To R.
(Street Name,Numbers,Community,Sulxrivision,Let No.,Parcel,Zip Co(le)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley []Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0' TO 40' SANDREDIBROWN DIRT
LATITUDE 3 5 01.739N May�mdc�' 20' TO 40' SAND GRAVEL
minutes,xconds m
LONGITUDE B 4 70.556W m a decimal format 40' TO 60' BOULDER
60' TO 100' BLUE GRANITE
Latitude/longitude source: mGPS ❑Topographic malt 100'TO 185, GRANITE
(location of wel must be shown one USGS lopo map and
aasched to tlus lam/not usiig GP8)
4.WELL OWNER
OWNER'S NAME SCOTT SMITH
STREET ADDRESS 4465 PAPERMILL RD.
MARIETTA GA 30067
City a Town State Zip Code
( 770 )-7784MO
Area code- Phone number
It. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: 185'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOIZ
1 WHEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTHt
c. WATER LEVEL Below Top of Casing: 50 FT. 'M NCAC 2C,WELL CONSTRUCTION STANDARDS,MOTWATAC�IXTHIS
(Use'+'N Above Top of Casing) RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
d. TOP p CASING IS r 1 FT.Above land Surface' �� IQ Aa y� ��,L���.�,J�L�.dC)
'Top dnce in accordance Edith beloISA NCnd surface 8. require S NCI ATURE OF RTIF D CTOR DATE
a variance in accordance with 15A NCAC 2C.01 18. -
e. YIELD(gpm): 50 METHOD OF TEST AIR �i LLi m l a F1" �a I)Is
it PRINTED41AME,OF PERSQN NSTRU INGG THE WELL
f ,
Submit the original to the Division of Water Quality within 30 days, Attn:Information Mgt, F«m cw-1a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext Slit!. } j - Rev.7A5

0-0
RESIDENTIAL WELL CONSTRUCTION RECORD
NNorthCarohrha Ikparfinenl of Environment and Natural Resources Division or Wales q
Quality
b
WELL CONTRACTOR CERTIFICATION H 3368
1.WELL CONTRACTOR: f. DISINFECTION:Type CHLORINE Amppnt 100 PPM
WILLIAM BRADLEY LEWIS g. WATER ZONES(depth):
Well Contractor(Individual)Name Fran To 160' From To
CHEROKEE WELL DRILLING From To From To
wen Contractor Company Name From To Fran To
STREET ADDRESS PO BOX 1007 6. CASING: TWhickneW M rs
Depth . Uameta g€" pVt; i
MURPHY NC 28906 From 0' 7o Ft.B 1l8
City or Town State Z4 Code Fran To Ft.
8( 28 )_ 837-8008 From To Ft—
Arm code- Phone number 7. GROUT: Depth Material Method
2.WELL INFORMATION: Frmn 0' To 20' R CEMENT GRAVITY
SITE WELL ID#(#applicable) From To R.
STATE WELL PERMIT!(#applicable) From To Ft.
DWQ or OTHER PERMIT=(#appicable) 9. SCREEN: Depth Diameter Slot Size Material
From To R.—in. _ in.
WELL USE(Check Applicable Boxy Residential Water Supply® Fran To R._n. _ In.
DATE DRILLED 10/19/05 From To R._n. _ in-
TIME COMPLETED AMO PM11 9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth size Materiel
MACON From To Ft.
CITY; ANDREWS COUNTY From 7o Ft
JUNALUSKAIBIG CHOGA From To FL
(Street Name,Numbers,Community,Subdmslon,La No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
!&Slope ❑Valley ❑Flat ORidge ❑Other From To Formation Description
(check appropriate box) 0' TO 20' RED DIRT
Airy 6e in degrm, 20' TO 40' BROWN DIRT
LATITUDE 3 5 10.425N rtw,aa"nd+a 40' TO 60' BROWN DIRT—BOULDER
LONGITUDE 83 41.138W nadwimalfamat 60' TO 80' BROWN DRUB—LIJEUViJUTE
Latitudc/longitnde source: f9GPS DTopographic map 80' TO 88' HARD BLUE GRANITE/SEr CASING
(location ofwe#=at be shown on a USGS tope map and 88' TO 805' GRANITE
.ttached to this fmm I not usingGPS)
4.WELL OWNER
OWNER'S NAME GLEN HAY INC.
STREET ADDRESS PO BOX 187
ANDREWS NC 28901
City a Town State Zip Code
( 828 )_321-2389
Area code- Phone number 11, REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:8()s
b. DOES WELL REPLACE EXISTING WELL? YES NO®
I DOREREBY CERTIFY TWIT MS WELL WAS CONSTRUMED IN ACCORDANCE Wml
c. WATER LEVEL Below Top of Casng: 150 FT. Im MAC]C,WELL CONSmlICiION STANDARDS,ANDTHIITACDPYOF n16
(Use'+'i Abmre Top of Casng) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above rand Surface* & W20105
'Top ofcasing terminated atla below land Sudace may require SIGNATU RE OF RTI D W LL CONTRACTOR DATE
a variance In accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): -8 METHOD OF TEST AIR ""11110r►�
PRINTED NAME OF PARSON CqNSTRUCTINQ 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 276994617 Phone No.[phone] ext 568. , _ Rev.7105
J
�OiYI F, It ii r_ -

Rnn UJI
-
x RESIDENTIAL WELL CONSTRUCTION RECORD 5 9
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 3368
1.WELL CONTRACTOR: L DISINFECTION:Type CHLORINE Amount 100 PPM
WILLIAM BRADLEY LEWIS g. WATER ZONES(depth):
Well Contractor(Individua6 Name From To From To
CHEROKEE WELL DRILLING From To From To
Well Contractor Company Name From To From To
STREETADDRESS POBOX1007 6. CASING: Thickness/ GW
Depth Diameter 5��27 PVl:ial
MURPHY NC 28906 From 0To 20' Ft. 6 tle
City or Tovm State Zip Code From To Ft.
8( 28 1. 837-8008 FromTo Ft.
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: From-(-) To 20' D CEMENT GRAVITY
SITE WELL ID#(if applicable) From_To R.
STATE WELL PERMITK(ff spplipble) From_To R.
DWQ or OTHER PERMIT!(?applicable) 8. SCREEN: Depth Diameter Slat Size Material
From_To R.—in. _ in.
WELL USE(Check Applicable Box): Residential Water Supply© From_To FL—in. _ in.
DATE DRILLED 10/20105 From_To FL—in. _ in.
TIMECOMPL.ETED AMO PrAII 9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth size Material
m
MACON Fro To Ft.
CITY: ANDREWS COUNTY From To Ft.
LITTLE CHOGA From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
0Slope OVailey ❑Flat ajRidge ❑Other From To Formation Description
(check appropdale box 0' TO 20' BLACK DIRTIGRAVEL
hby be in degrees, 20' TO 505' BOULDERIGRAVEUGRANITE
LATITUDE 3 5 11.695N minuLim,seconds or
8 3 41.316W in a dmnnal format
LONGITUDE_
Latitude/longitude source: MGPS oTopographic map
(bcatbn of wet mull be shown on a USGS tope map and
attached to Cris form Knot using GPS)
4.WELL OWNER
OWNER'S NAME MIKE HENRIE
STREETADDRESS 702OLMSTEADST.
WARNER ROBINS GA 31098
City or Town State Zip Code
( 478 )_955-1649
Area code- Phone number It. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: 505'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
I W HEREBY CERHfYTHAT THIS WELL WAS CONSMuCIED IN ACCORDANCE WITHc. WATER LEVEL Below Top of Casing: 10D Fr. ISA NCAC X,WELL CONS,RocTxoN BrANOARDS,ANDTHATA COPY OF THIS
(Use'+'I Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS 1 FT.Above Land Surface* , 11 '1e. 7]�Q!'�'F- t7 f,) 10121105
'Top of casing temilated atfor below land surface may require SIGNATURE OF CERTIFIED VWLL CONTRACTOR DATE
a variance in accordance YAM 15A NCAC 2C.0118.
e. YIELD(gpm): 4 METHOD OF TEST AIR ' - Y `(
P INTED NAME Of IRSO CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn:Information Mgt, FonnGW-ta
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.[phone] ext 568. I 1 j Rev.7105

WELL CONSTRUCTION RECORD :
Norrh.Catoi-ura-Deparknent of Enriroprrtent and Natural Resources-Division of WatW Quality-C)toimdwater Section
WELL CONTRACTOR(MVWrmuAL)WMIstw+:n_c�PlvlrS l�Ila, ,1,'`• '-' C.Zpi=cATJOJNi /71P
WELL CONTRACToa CoatPA�Y NO • hhrC f�A .l 1J1 al�-L✓_IJ�s T-•� 'ruorir(s14-3 ;z6 A
sraTa WELL CONSTRUCr10N PYRa(lT/ .xeOCIATiD w
(if applicable) •(ifapplteable)
IRMNI
L WELL USE(Check Applicable Boxy Residen alu-Iriuweipal/Public 0 Industrial O Agricultural p
Monitoring 0 Recovery ❑" Heat Pump Water Necdon 0 Other Ej IfOt}ier,List Use
2.-WELL LOCA70 T IuclLand setting
Nearest Town: /LPL, 4 - Cowty yt? P
Ch;Nau2P:rt mrh a �9�
gtdtt>d a IStopa Malley .0Fiat
(Sum NaMeNumben.Cmeeaty,Sub Vuio0.Tat No. PCo&) (ehedte tsbox)
Led►uddbrigirodado of wall location
3. OWNER-. R ( a � (demiauteslseobndr)
Address Su 7 d 1 A M R � Latitudellongitude source:00PSMopographic map
(Streaor Raft No) .. -(Clink box) . .
5- RATSpnra I 4 a 3 l2� DRILLING LOG
ry a V 50 - S Y•5F 3 •Zip Cods. .. _ ., From To - Formation Description
Am code-Pboac comber
4. DATE DRILLED —/ 4•-(}$ e '*g
5. TOTAL D ,
6. DOES WELL REPLACE EXISTINO WELL? YES 0 NO::
7. STATIC WATER LEVEL Below Top of Casing:
(use`N"irAbove Top of Cam
8. TOP OF CASING IS�_FT-Above Land Surfamo
'roP sf prmla.ted edw 6e(a�r((Ipdsar4u rpakes a
wrWee in to sa,e eeNaap whl"15AT1GtC 1C AlIL -
9. YIELD(SP10): 5_METHOD49FTEST_
10.WATER ZONES(depth):_ c.1
LOCA"ITON SKETCH
11. DISINFECTION:Type ;kwwa Show direction and.distanca in miles from at last
12. CASING: Wag Thickness two State Roads or County Roads.Include the road
Depth or wei+ght/FL numbers ad common road names,
From
From�To
From Tq FL.
13. GROUT, Depth � �^1M-,,a--t-erw Msdwd.
From ToD
From To TL
.4. SC T SCREEN: Depth Diameter Slot Siff � MMaterial .
Fl`_in in
From To Fr in, jn, ,
S. SAND/GRAVEL PACK: _
Dept Size Material -
From Ta FL--
From To FL
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE Wftif ISA NCAC.2C,WELL.
ONSTRUCTION STANDARDS,AND THAT A COPY OF S RECORD BEEN Pi{OVWED TO THH.WBLL OWNER
opYi�;IL � /p� i b
SIGNATURE'OPPERSONCONS uenNOTHEWELi DATE .
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ralelgh,'NC
.27699-1636 Phone No.[phone],within 30 days OW-I REV.07/2001

31 r C `
WELL CONSTRUCTION RECO�,,RD'
North Cuolina-Department of Environment stud Natured Resources-Division of Water
)NAM_ x taalWl skaniS .r. .-sty 0roimdwator section
WELL CONTRACTOR(INDWWUAL �y
, - C�7V[CGA.TIOri
WELL CONTRACTOR CDMPAA NAM _ PHott\ at,�V_.ria.N-.3 A 6 0
STATE WELL CONSTRUCTION P1LRal177! .. ASSOC(ATYD W
(irappliable) - •(Itmppliable)
1. WELL USE(Check Applicablo Box):Resideotiel 1Q' MWd1C1paVPublic❑ lndusGial q Agricultural Q
Monitoring O Recovery lT Heat F)tmp Water dejection O Other Ef If OI}ier,List Use o
2.-WELL LOGTION:. Tdbogltlpj�j�nd salting V
Nearest/�: A.KD e t 5 Lt�J dga OSlopo QYalley . Fiat
Y'5 ��vaty , . (ebackappmptiatsbax)
(Street N.aw,Numbtma,Community,Subdivision,W No.zp code) C>_ Labtude/loligituda of wclllocation
3. OwNER: e E �� (de,ttanitamutat/uandt) - ! '
Address a I D.D!" d o d o sJ L N Latitude/longittide sonree:(70PSOTopographic ttjap Crma No.) -' -(Cbo*boa) =--------- __.-
FjakkL:Al .N c' c1 ?13: - j� - DRILLING LOG
ry or O a sme zip Cads From To Ftitmation Description
1c9 - �a(o9
Arm rods Pbana w-1—
4. DATE DRILLED
5. TOTAL D r '
6. DOES WELL REPLACE MOSTINO WELL? YES O NO.c`
7. STATIC WATER LEVEL Below Top of Casing:ZQ FT:
(the"t"if AbM Top of CasbW
g. TOP OF CASINO IS—f—FT,Above Land S.&cee
'rbP or mttat twashWad attor bakw Ipd.aar(aea rashes is
varlaan la aaesrdaaaa witb'IS/CftCxC 2C Alla. -
9. YIELD(gpm): -5- METHOD OF TEST
10.WATER ZONES(duestlt):
'- LOCATION SKETCH
I I. DISINFECTION:
ING: andWraa CASING:
12. C Type Amount Show direction .dis in miles from at least
ASING: Wall Thh;trtea tyro Stste Roads or County Roads;Include the road
DeP�qq or Weight/FL numbers and common road names.
From T0_:yl '
From To FL
From Tc FL
13. GROUT_ Depth Materiil Method
From
_q_ToLATv_Ft' '
From To FL
.4. SCREEN: depth Diameter , Slotsire . Material
From To Ft�(n- in.
From To FL__im in, '
S. SAND/GRAVEL PACK-
Depth size Material From To FL
From To Ft
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCM INACCORDANCE WfI3I 15ANCAC.2C,WELL.
DNSTRUCf10N STANDARDS,AND THAT A COPY OFTIM RECORD HM BEEN PROVIDED TO MIE.WELL OWNER
/D ' 7 o S
SIGNATURB-OFPERSONCONSTRUCIINO THE WELL DATE -
,submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
,17699-1636 Pboac No.[phone],within 30 days, GW-1 REV,072001

WELL• CONSTRUCTIONREb0im,
North Odo tax-Department of Envimturoka and Natural Resources-Division of Water Quality'-Oroundwator Section
WELL CONTRACrOR(INDMIDUAL)NAL_Sa taai�n< Pf%t5 ,— r ,n �'
ceiTiiltCAT,ION a /7
WELL CONTRACTOR COMPANAM _ ettoNa s
STATE WELL CONSTRUCr10N PE7116'/ .. AS30C(ATED W
(if applicable) {U'a)Wllable)
I. WELL USE(Check Applicable Box?Residential Ld�MunicipaUPub(ic❑ Industrial I] Agricultural p
Monitoring O Recovery 0 Heat Pump Water lrjogdon 0 Other CT If Oilier,Last Use
2.-WELL LOCATION: Topod selling • v
Nearest Town: CAA- 1-AL CouR
a N• tR polar Ra ty— ORitige OValley .OFIat
(ebecicappteptLtabox)
(Stma Name,Nmabom Comma*,solsjlyi at,Let No.,TN Cade) - Littitude/longituds cf wFll location
3. OWNER-M Ar 2th,+ 13 IQ.i-f'tA7y tdayKehaiauta/ucondr)
Address o 4 S. W,4 C P R jZI,?w V a Latitudellongiuide source:OOPSOTopographic map
n/� (sweet or Rana 11L) (ebeeic boa)
0 0 f 6L vh h I a., S_Q . 01. 9 D D DEM • DRILLING LOG
Ciry ar Toav state r+P Coda From To ' Formation Description
(F[li3a �I'7 9_ 3 (a 97 / ,
Ara code-Phone ember
4. DATE DRiI.LBD— I n5� — 4/
5. TOTALDEP'I8: 3J D�'
6. DOES WELL REPLACE M(ISTINL3 WELL? YES❑ NO_
7. STATIC WATER LEVEL Below Top of Casing: `7c} . FT
(rise`t^(f Abo"Top orcub,4
8. TOP OF CASING 1S FT.Above Lund Swrfaeea
'Tap of casnaa tarmtaated u allor help�((Ipdaor4p rpalres a
-
•srtu to&*earaae with'IS=1"2C.0112.
9. YIELD(gptp): /b D OF TEST. -
I D.WATER ZONES(depth): J D'
" LOCATION SK -,'H
H. DISINFECTION:•Type Amotmt Show direction andAlstenee In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter,r or welffi Bt. numbers w4coltnmon road names.
From To�Pt '
FromTo FL
Froth T9 FL�
13. GROUT_ Depth Material Method
From_ To*T�
m
Fro To
.4. SCREEN: Depth Diameter Slot Sire Material .
From To Ft`_jn in
From To FL in jn,
5. SAND/GRAVEL PACK: _
Depth Size Material -
From To FL
From To FL
6. REMARKS:
DO HERESY CERTIFY THATTMS WELL WAS CONSTRUCM IN ACCORDANCE WAHI
fli(t3pNCAC.2C WELL
ONSTRl1CT10N STANDARDS,AND TH�AT�nA(X)Pl OFT S RECORD BEBN P$OVJDBD TO TtIE.WELL OWNER
13 0 5
SIGNATURBOF PERSON CONSTAUCTING THE WELL DATE -
submit the origlaal to the Division of Water Quality,Groundwater Sectiop,1636 Mail Service Center-Raleigh,NC
17 699-1 63 6 Phone No.[phone],within 30 days, OW-1 REV,072001

WELL• CONSTRUCTION RECORD" :
North Ca 6iina-Deparunettt of Envwnment and Natural Resources.Division of W der Quality'-Groundwater Section
� �-r
WE
LL CONTRACTOR(rIDl1(IDUAL) s rprt.n cf�� r{Pt r C. 11T]�n,+.Alt,. ,„_". CI!('!iP[CATtoN ate'!
WELL CONTRACTOR COMPAaY NAM III•ItC I���ser����dl`r.11T,r�• �",tt , ltiONR#121C f .4--3 a6 �
STATE WELL CONSTRUC110N PRRa�lN ARSOCIATRD W SRIrTIY
(ifappl(eabla) •(Uapp)fable) - -. -
1. WELL USE(Check Applicable Box):Resider al7YMuni-cipaUPublic❑ Induatrid q Agriculhral Q
Monitoring[] Recovery 0` Heat Pump Water Wogtion 0 Othcr C] If Otliu,List Use
2. WELLLOCATIO p bjclaadspiting
Ncarest Town: �/ L r . County dge OSlope Malloy ,Mat
C i A e L.3 C) FI APLeI- Ra dj (elasltapgaPrfa0abw0 . '
(Suers NawK Ncarbom Communk,Satdivpioo.Let No.rW Cade) Li(titudeAotigitude orwFll location
1owNER Q It o Id . R 411 i, sc_ (daNn�mipuwliaohmis)
Address C t)R A ! Q a LatitgdeAongittde soturce:OGPSOTopogrsphic map
Rq� (Sweat or RooalloJ <./1- .. (cbedcbos)
L oot e 1 r, 'i(/� 42,f P 3 V _ 'DEPTH ' DRILLING LOG
City orTr9. SWa zip Cosa From , 0 '
2 3 formation Description
wm cods Pbon aambu .. � LgA . S(cw Lr
4. DATE DRILLED I6 '/ 4 5 !
5. TOTAL DEPTH: 3 75 ' �-
6. DOES WELL REPLACE EXISTING WELL? YES 0 Nd
7. STATIC WATER LEVEL Below Top of Casing:
(UN-+-if Abon Top of Cam
S. TOP OF CASING IS FT.Above Lad Surface#
'Top ota,iaa tarmlaatb atbr beta Ipdavr4w rpairea a - -
mri n is aseord WUh'15XffCAC 2C AIIL
9. YIELD(gpip): METHOD OF TEST
10.WATER ZONES(depth): /fib '
T
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction uud.dlatance in mile from at least
12. CASING: Wag Thidotw two State Roads or County Roads.Include the road
Depth _ Diapatter or Wellght/PL numbers and common road tames.
From To_(9_0_rL___F2_$�
From To Ft
From_Ty Ft.
13. GROUT_ Depth gM�a�t�eriaal Method.
Front_D,To_C'&_'
From To Ft
.4. SCREEN: Depth Diameter Slot sin : Material
From_ To FL_(n, in.
From_ To FL___jn. in, '
S. SAND/GRAVELPACK:
Depth size Material .
From To Ft,
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL.WAS CONSTRUCTED IN ACCORDANCE Wrl7i ISA NCAC IC,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TlqS RECORD BBBN P$0VIDEt9 TO THE.WELL OWNER
SIGNATURE-OFPERSONCONSTRUCTINGTHR WELL DATE
submit the original to the Division of Water Quality,Groundwater Section,1636 Ma(I Service Center-Rslel(:h,NC
.19 6 9 9-1 63 6 Phone No.(919)733-32I1,within 30 days. GW-I REV.07/2001

.WELL CONSTRU ON RECORD
� ,,R ,• - . . . : - .
North Cafolina-Department of Bmlmoment and Natural Resources-Division of Water Quality-GmundwaW Section
WELL co TRACTOR(uW1WVuAL)NAM8
WELL CONTRACTOR COMPAkY YItoNBa -'3 ab o
STATE WELL CONSTROCTION FEWA39. ASSOMnO ER,Mnv -•
(ifapplieabk) ' •(ifaodicabk) .
1. WELL USE(Check AppUrxblti Boxy ReaidatGeliYtMiwdcipal/Public O IndustrW 13 Agricultural Q
Monitoring[] Recovery O' Hat Pump Watei Wection O Oduu Cf if Otker,L*t Use
2.-WELL LOCATION: 1
Ne rest Town: �R 9/L�Li i1� County ORidge ❑Skips []valley t
4, C i euJ (0si*apri valle a
(sumN.oK Nur.tan canmual7.g„td"oa LaNa ziPcoae) '8'7 3 y Lotitude/longih1daofwC11location "
3. OWNER.
�Qlz� �aF.s '• (depealmiautnGeaawdr)
Address LatituddlongitWo sourca:OOPSC�'I'opoglaphic map
ea
(Srna#aRmaeNo) (etmbwt)
1,—g aw/10 �� 0��7 3 V.. D.EPTIi ' DRILLING LOG
Ch
airy or Too Sure T•tP Cass From Formation Description
( sa�- 44'7
4. DATE DRILLED /I-/L -/i S , Fenn_ *— `%4 ` n r
5. TOTALDEPTH; -
6. DOES WELL REPLACE E)MINO WELL? YES 0 Nl_3:
7. STATIC WATER LEVEL Below Top of Casing •-O - P P;
(Un-+-ifAbmeTop orC&seW
8. TOP OF CASING IS_�FT.Above Land Smiltece
`Top of wing ternbutM avoraan W&#WrW requires■ .
nAesee laar:ordNW Wkb"15X?tCAC3C.611i .
9. YIELD(gpm):•_ 0 .METHOD OF T83T
10.WATER ZONES(deptitr
' LOCA"1•ION SKBTCH
11. DISINFECTION.Typa Amoum SbowdiectionandAlstanceinmiles from atlast
12. CASING: Wag Tbleloma two State Roads or Cotmty Roads;Include the mad
or weightlFt numbers and common mad names.
From Q • To Pt $�
From To FL
From Tq Ft
13. GROUT.,
From_1L Depth
From To Ft l'-- p
.4. SCREEN: Depth Dieineter . Slot Size . Mat«iat - t
From To Ft__in, in w
From To Fin -
S. SAND/GRAVELPACK: CD
Depth Size Material Ln
;-
From To Ft._
From To FL
6_ REMARKS:
DO HEREBY CERTIFY THATTHIS WEIL WAS CONSTRUCTED IN ACOORDANCE WrM ISANCAC 2t:,WELL'
-ONSTR(K?ION STANDARDS,ANDTHATAWPYOF SRECORD HAS BERfPIIOVIDFATOTHE-WELLOWNER
SIGNATURE-OF PERSON CONSTRUCf(NO THE WELL DATE -
submit the original to the Division of Water QuaUty,Groundwater Seedoo,1636 Mall Service Cater-Ralelgh,NC
.7699-1636 Phone No.[phone],within 30 days. _ OW-I REV.07/2001

WELL CONSTRUCTION RECORD,
Nosh Char'ol(aa-Department of Badromm"and Natural Resources-Division of Watw Quality--Groundwater Seolim
WELL CONTRACTOR(1ND9XWUAWNAME (wmo.• lines
! I -� •' � h.CL�17FtCA7IONf otII�P
WELL CCHMACTORCOMPA�V esoNs.�-3 ab o
STATE WELL CONSTRUCTION Ptttwihl ASSOC(ATED W xnatrri :s
grapotiesbic) -((fappllcable)
1. WELL USE(Check Applicable-Box):Reaidixi aVQ dapal/Publie 0 Industrial l] Agrioulum l Q
Monitoring O Recovwy 0 Heat Pump Water lnjec*u❑ Od w f1 If Other,List Use '
Z."WELL LOCATION: . - TQpoV*W Leting nd set
Nearest T 7iown: ,4111LI L i/y Cpuph ..
t7lzage (� k� �F%at
C'a S P eA_ Eva y
(Sum NalkNeahaa,caamuRsT.S"V61en,LetNo,ripCude) LaatrxleAorigitudaofwqlilocation '
3. OWNER: �Q-- 5' A h)t t )
Address 1 (k /V P_ I3 o>U H i't 1 ea • Latituddlongitude soutce:QOPSQTopogniphic map
DEPTH
(check box)
Cary«Tow sure - DRILLING LOG
MpCode From To FormadonDescription
Ara Cede•Plume number `
4. DATE DRILLED I/ — a 5 '-'- - n
5. TOTAL DEPTH �
6. DOES WELL REPLACE EXISTING WELL? YES E3 N0>
7. STATIC WATERLEVELBelowTopofCWmg n ' PT;
(uaa-r(rAbara Tep arc.
8. TOP OF CASINO IS�_FT.Above Lard Sorficea
-Top ofeutaaterwlaatd aderbeigr(Ipdaarraaregairiea -
van""to eaerdaaawab'I&VffCAC2C.a11L `
9. Y[EI,b(gpm): MBTHODOFTEST
10.WATER ZONES(delsft SZTh' '
LOCATION SKBTCH
11. D(SINFECTION.Type Atrwunt Show direction and.diatance in miles t)om at least
12. CASING: Wau Thid=a two State Roads or County Roads.Include the road
Depth�� w Wc(ghtlPt number and coDtmoa toad names.
From To FL
From Tp FL__ _
13. GROUT_ Depth Matgiil. Method-
From Tt Tt
.4. SCREEN: Depth Diameter . Slot Sias Material
From To Ft`-(r. 11L
From Tc F(,__)IL in
5. SAND/GRAVELPACIC _
Depth Size Material -
From To FL_
From To FL
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS OONSTRUCtRD IN ACCORDANCE WITH 15ANCAC 2C,WBLL
'ONSTRUC`nON STANDA9DS,ANDTHATACDPY OFTW RECORD HAS BEEN PP*OVIDE6TOTH3.WBLLOWNER
SIGNATURE-OP PERSON CONSndrnNO THE WELL - DATE -
Submir the original to the Division or Water Quality,Groundwater Section,1636 Mail Santa Center-Ratelsh,NC
27699-1636 Phone No.[phone],within 30 days. OW-1 RBV.072001

6
.WELL• CONSTRUCTION RECORD'
North Cafolina-Depa[atwnt of Enriroomdnt and NatuN Resources-Division of Weirs Quality'-Groundwater Section
WELL CONTRACTOR(tND1X1VUAQWMs �0 ►1Ptt5 11ll,..d,•� - ". Citl7SP[CATIolis a171e
WELL CONTRACTOR COMPAkV NAM.•• rnor(s s�s`J•Stti' ��4--3 Ab o
STATE WELL CONSTRUCTION PHRF" -" A9a0c[ATEDW LR_MM
(ifspptiable) {ifappilable)
t. WELL USE(Check O •Wu*W 0 Agrieultunl p
Monitoring O Recovery O' Heat Pump Water Injection[3Other El if Other,List Use '
2.-WELL LOCATION:. T bicUndBettiDg
Nearest Town: FPAN/LL: " County (mv Mope OVallay .OFlat
0 Al r_ofla_ Chu rze A. RA a7.a k' !g (e,** papttatrbm) ,
ra(Se Namr,NambeM Conummiry,subdvutaa,Lot No.T+p Code) '. I;ntih[tld!ongih*of W,FII location '
3. OWNER: Q v 0 n e
Address 10.10 H U urn 13 DY 7- S 7 • Latituddlongihido somow.00PSOTopographic map
�✓ �3l eruct Odd o'rt. a) 3 �� � � � • (e6edcDRILLING LOG
d by iwT o P �S• zipCc& From TO S
ra Formation Description
A coda Pbou emnbv .. .. ' ct
4. DATE DRILLED ro
5. TOTAL DEPTH: / 7 '
6. DOES WELL REPLACE EXISTING WELL? YES O NO'_ .
7. STATIC WATER LBVEL Below Top ofCasing: :.SLR' P1
mo ;
(Un-VifAbTop*(Cadn4 _
S. TOP OF CASINO IS_�FT.Above Land Surface*
r1'aps[eutag trrWaand atler beiatr lNtdwrhesrpakesa
rarhaa In aaordesm With ISXNUld2C AIIs.
9. YIELD(gpm):_ 0 METHOD OPTBST
10-WATER ZONES(depth): /!b'
' — LOCA_(ZON SKETCH
11. DISINFECTION:•Typo Amou t Show direction and.diateace In miles fiom at least
12. CASING: Wau Thichxaa two State Roads or County Roads.Include the road
Depth 4 or Well W numbers and common road macs.
From_QTo �s � _
From To FL -?
From Tp `
13. GROUT_ Depth tr(stldw Method- O
From_D—ToV FL_4Qq�q
N l
from To FL La
.4" SCREEN: Depth Dianbter Slot Size - Material
From To FL__in. hL
From To FtL__ja in. `R
5" SAND/GRAVELPACK _
Depth Size Material
From To Ft.__
Front-To-Ft. -
6" REMARKS:
DO HEREBY CERTIFY THATTHIS WEIL WAS CONSTRUCTED IN ACfARDAN(S WJ7H IS}1NCAC 2C,WELL
'ONSTRLhMONSTANDARDS,ANDTf•HnAT)yA.{'COPYOF"//J/� R1D�wORD BEBNP$OVB)EDTO' HE-WELLOWNER
SIGNAT()RE•OPPERSONCONSTRUCTINOTHBWELL DATE -
S-ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Ratdgh.'NC
.27699-1636 Phone No.(919)733-32I1,within 30 days. OW-1 REV.0712001

WELL CONSTRUCTION RECORD
North Catolina-Deparpnent of Environment and Natural Resoutcea-Division of Water Quality-Groundwater section
WELL CONTRACTOR(IN0lv-1oUAL)NAMB (prlan c fl�115 ' 'If'1 ,r�� - r• CKPTIPICATI0N0 9 (e
WELL CONTRACTOR COMPANY NAM PHONE a��"3 A& 0
-..� .
STATE WELL CONSTRUCTION PERMITa ASSOCIATEDW 6mrra
(irapplieable) - •(ifapplicable)
1. WELL USE(Check Applicable Box):Resideritial7YMunicipalMubtic❑ Industrial❑ Agricultural D
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other f1 if Other,List Use
2.-WELL LOCATION: . T lI1On.8Dd setting
Nearest Town: r—X1u1 1 ;12 County c o/ - dge ❑Slops ❑\!alley ,❑Flat
&4 kr. //J!I L (I Q raP/G /Zc'_ 3 (dw&Wroprift box) - - a
(Strect Name.Number.Community.Subdivutun,1A lie..Zip Code) Uiituddlongitude of woH location
3. OWNER:7-A/A 114.4 e_ 1 n 10--e-= (deperlmiautaYse ds)
Address h F F W < i VC/ -C_ LatitudellongiNde source:00PS❑Topographic map
DEPTH ' _ (� DRILLING LOG
(2jry«T7
n Some Zip Cade From TO Formation Description
Area code-Plane amber
4. DATE DRILLED - / 7-0� _ G C) f /Lt /LO
5. TOTAL DEPTH: S, •
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO..
7. STATIC WATER LEVEL Below Top of Cuing b L37.
(Uw"!"ifAbm Top ofCwin�
8. TOP OF CASING IS_�FT.Above Land Surface*
-rop of mina terminated actor Will Isod.surfm requir a a _.
varlaaa In secordanee with 1SA71CAC 3C AI IL
9. YIELD(gpm): / S METHOD OF TEST_,LQ)(
10.WATER ZONES(depth): S 5 '
j OCATION SKETCH
it. DISINFECTION.Type Amount Show direction and.di"nice In miles from at least
12. CASING: Wall Thickness two State Roads or County Roeds.Include the road
Depth D'ryaeter or weight/FL Metey'p1 'numbers and common road names.
From�To �/� ft k�4 S.i2� p.X.Ny.
From Tc FL
From_ Tp FLU
13. GROUT-, Depth MaterisI Method o a
From_ To_a- Zj!� �7��
Front To FL 7""•�— W
.4. SCREEN: Depth Diameter . Slot Sin Material O
From To Ft in. in. ur ,
From To Ft in. in. a
5. SAND/GRAVELPACK: _
Depth Size Material .
From To Ft.
From To Ft.
6. REMARKS:
DO HER CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC2C,WELL
-ONSTRUCTION STANDARDS,AND TjHATTAA COPY OF THIS�RECORD H&S BEEN PROVIDED TO THE.WELL OWNER
SIGNATURE-OF PERSON CONSTRUCTING THB WELL 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. GW-I REV.07/2001

~ RESIDENTIAL WELL CONSTRUCTION RECORD �l
North Carolina Department of Environment and Natural Resources.Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 2O45
1.WELL CONTRACTOR: f, DISINFECTION:Type H T H Amount 166Z
James B. Brown g• WATER ZONES(depth):
Well Contractor(individual)Name Fro m_'=ToW From To
Hedden Brothers Well Drilling, Inc. From To From To
Well Contractor Company Name From To From To
STREETADDRESs 73 Holly Hills Vista Rd 6, CASING: Thickness/
Depth Di a;er Weight a ial
mains NC 28734 From To Ft.
CIry or Town State Zip Code From Fl.
( 828 l• 369-9591 From_To_Ft—
Area code- Phone number
T. GROUT: Depth _ Material Method
2.WELL INFORMATION: _ Ftom,Q_To_ 0 Ft, CH[H1t & hg=-dte 1].EpgJ
SITE WELL ID M(if applicable) Frwr_To_Ft.
STATE WELL PERMIT#(Itappllcable) From_To Ft.
DW 0 or OTHER PERMIT N(if applicable) 6. SCREEN: Depth Diameter Slot Size Material
—/ From To_Ft._in. _ In.
WELL USE(Check Applicable Box): Residential Water Supply 12 From—To—Ft.—In. _ In.
DATEDRILLED� Jr'�C7 From_To_Ft. in. in,
TIME COMPLETED IO. DD AM 31e"'PM0 9. SANDIGRAVEL PACK:
3.WELL LO ATION: Depth Size Material
From To_Ft.
CITY: bAtCOUNTY From To Ft. �—
From To Ft.
(streat Name,Num bon,Com rK.ni ubMa en,Lel No veal,ZIP Code)
IT
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ClValley ❑Flat ❑Ridge ❑Other From To Formation Description
(check apprdpdate box) r Clay & sand
LATITUDE May In decrees, r t Trani i•e
_ minutes,seconds or
LONGITUDE in a decimal format
Latitude/longitude source: ❑OPS oTopographic map
(Iodation of we#must be drown on a USGS topo map and
attached to this form r not using GPS)
rt)
4.WELL OWNER - W
OWNER'S NAME
Es
S i R(_ET ADDR S
1—CL4
hrylJror Tovn State Zip Cade
(fig,. 349 4 /D
Area code• Phone number
11. REMARKS:
5.WELL DETAILS: Q� r
a. TOTAL DEPTH:
Id. DOES WELL REPLACE EXISTING WELL? YES 0 NO
100 HEREBY CERmFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
--d. WATER LEVEL Below Tap of Casing:. AM FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'II Above Top of Casing) RECOR S BEEN PROVIDED TO THE WELL OWNER.
P OF CASING 16 2 FT.Above Land Surface'
d. TOT p of casing terminated aVor bet land surface marequire
o varlanee in ccorrddaance with 15A NCAC 2C.Oi 16 S, ATURE OCONTRACTOR CER I IED WELL DATE
e. YIELD(il 3V METHOD OF TEST B1OW 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
11617 Mail Service Center—Raleigh,NO 27699.1617 Phone No.(919)733.701.5 ext 568. Rev.7105

RESIDENTIAL WELL CONSTRUCTION RECORD t
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 42045
1.WELL CONTRACTOR: f. DISINFECTION:Typo H T H Amount 166Z
James B. Brown g, WATER ZONES(depth):
Well Contractor(Individual)Name From, j2.4,5- To 071.7 From To
Hedden Brothers Well Drilling, Inc. From ?*7q' To 270' From To
Well Contractor Company Name - From To From To
STREETADDRESS 73 Holly Hills Vista Rd 6. CASING: - Thickness/
Depth Diggm�er Weight
As•'••�al
FYan Ycl Jz C 28734 From To Ft. `
City or Town State Zip Code from T0—AA--Ft f,
--3'
t 369-9591 From To_Ft.828 ). —
Area cods Phone number -
2.WELL INFORMATION: 7. GROUT: Depth - Material Method
FromQ_To 90 Ft. CaTEnt & hlarnite pxpel
SITE WELL ID#(if applicable) From To_Ft.
STATE WELL PERMIT#(If applicable) From To Ft.
DWCl or OTHER PERMIT#(If 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.
DA:rEDRILLEDjb•Z7•05' From To_FL_in. in.
TIME COMPLETED I, 55- AMel' PM❑ 9, SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
r,, _ From To_Ft.
CITY: q�¢ArN1K,L.l n1 COUNTY— mfF[�d From To Ft.
� N1rSL9 From To_Ft.
(Street Name,Number. munity,SabdlNFien.Let No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope oValley QFlat ❑Ridge Mother From To Formation Description
(check opprdprlate box) 0r Clay & Sand
LATITUDE May be In degrees, I t rrani t
_L _ minutes,seconds or
LONGITUDE_ _ in a decimal format
Latitude/longitude source: ❑OPS MTopographic map
(location or web must be shown on a USGS topo map and --
attached to this form snot usatg GPS)
1,WELL OWNER \\
OWNER'S NAME �fFIQ�A'�F}' d A)I N� "=• -
STREET ADDRESS 94 3S13
_ .A'rlY" N f ZS 73N
ly or Town r State Zip Code rj
c 5 2,1A =f ,G-7
Area code• Phone number
11. REMARKS:
8.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Nam—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 50 FT. 15A NCAC 20,WELL CONSTRUCTION STANDARDS.AND THAT COPY OF THIS
(Use W U Above Top of Casing) RECORD 1 BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING 16 2 FT.Above Land Surface' �S
'Top of caring terminated at/or belay land surface may require SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm):Z_METHOD OFTEST B10W James B. .Browri
It PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Gw•ta Form
1617 Mail Service Center—Ralelgh,NC 27699-1617 Phone No,[phone] 111 Form 05

RESIDENTIAL WELL CONSTRUCTION RECORD A
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION A 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 166Z
James B. Brown g• WATER ZONES(deeppttthh�y)r�I
Well Contractor(Individual)Name From To= -A— From To
Hedden ro h r Well Drilling, Inc. From To From—To
Well Contractor Company Name- From7h�To 5J From To
STREET ADDRESS 73 Holly Hills Vista Rd a. CASING: Thickness/
Dept G Di el�r Weight terial
F4-anklinA- NC 28734 From To 5 Ft.�
City or Town State Zip Code _ From Tc FL L•,
( 828 )- 369-9591 From To Ft. _
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
FromQ,_Tq 20 Ft. ogner1t & Iff=itE_EgMEd
SITE WELL ID#af applicable) From To_Ft.
STATE WELL PERMIT#(If applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply p' From_To Ft._IM. _ In.
From—To Ft._In. _ In.
GATE DRILLED A'24 '05 From To_FL_in. — in.
TIME COMPLETED Id' S5 AMUr PM❑
9. SANDIGRAVEL PACK:
3.WELL LOC ION: Depth Size Material
CVA COUNTY From To_Ft.
CITY.
From To_Ft.
From To_Ft.
(Street Name,Number&,COMIFlurfitY.Subdivalon.Lot -Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ORldge ❑Other From Torrr777 Formation Description
(check epprdpdab Dax) May
Clay t- SdI1C1
May be in degrees, r r Clam to
LATITUDE � _ minutes,seconds or
LONGITUDE - in a decimal format
Latitude/longitude source: DOPS ❑Topographic map
(location of we#must be shown on a USGS topo map and
attached to this form rnot using GPS) �.
4.WELL OWNER
OWNER'S NAME QJ• N
STREET ADDRESS Rb `A'
n
City or Town State Zip Code _
t %2S - 3q9- 6I'1ln
Area code- Phone number
11. REMARKS:
a.WELL DETAILS: r
a. TOTAL DEPTH:
III DOES WELL REPLACE EXISTING WELL? YES❑ N0)(
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:. 4/00 FT. ISA NCAC7C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'i'N Above Top of Casing) RECO ASSEEN PROVIDEDTOTHE ELLOWNER.
d. TOP OF CASINO IS 2 FT.Above Land Surface-
'Top of easing terminated atior below land surface may require A URE OF ERT I D WELL CONTRACTOR DATE
a variance In accordance with ISA NCAC 2C.011a.
e. YIELD(gpm): I METHOD OF TEST DjgW 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 Mall Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 566. Rev.7/06

NELL CONSTRUCTION RLCO�tD
North Cafolina-DeparRnent of Envimomoiu mid Natural Reaourm-Division of Warm Quality-Otoimdwater Sectionn7 /I��
WELL CONTRACtOR(D(DIWO\UAL)VAMta 4 0 Hyte$�dA 11�1av { r G�77FiCA1'70/tYI�� -
WELL CONTRACTOR COMPA;tv"N.• PRONRsib —S;214--3 9•4 0
STATE WELL CONSTRUCTION P&Ra1FM wsaOcW6DW RRmnv ..
(irapplieahm { npolable) -
1. WELL USE(Chmi ApplicebleBox):R=Wmuial7YMuniopsYPubUc O bWustrlsl O Aocultutal 0
Monitoring O Recoray O' Beat Pump Water InjeMion O Other C1 if Other,Lin Use, '
2."WELL LOCATION: , _7 9apbidLi,Dd setting
N�eatTown: IELI -� County ! - -�Rldge OSlope OValloy .OFiat
(o y to �} IZ t- �S I A P t R d 3 k73 tf (etmh.ppereos) -
(Sued Name,NomblM Comv*.SabdMirubq LotNa,Tap Code) - I;StiwoUob*of W.411 location '
3. OWNE RO trT /1 Q.7f2. -in� (day.�mippaleoad�) .
Address 3 Latmddlongltdde souree:00PSl7Topographle map
(SberaRawNa) '(ebeehbmt) -
L� IQLIL M Fn. N• 'e• DEPTH I DRILLING LOG
Ciry orTow Sam rip caa. .From To ' Fop muou Description
Arta rode.Pbooe aimber - ..
4. DATE DRILLED ll,-l D (15 - y 5
5. TOTAL DEPTH: (o DD "
6. DOES WELL REPLACE EXISTING WELL? YES)7 Nd
7. STATIC WATERLBVELBelowTopofCamig: `fD• FT;
(Ume-e if Above Top ofCuia4
8. TOP OF CASING IS_�FT.Above Laud Surface*
'Top areutaS terminated urorls 9. be�v(C41awr6e.nq.6ea.
varlues la aaeraavw vrW" xNCA 2C.61ti
10_WA ERZONES1 SDOFTEST'
(depth):
LOCATIONSKjr'CCH
11. DISINFECfION:•Type Amount Q TA A Show direction and.distance In miles from atIng
12. CASING: WaE Thidnteu two St*Roads or County Roads.Include the road
DepthDilmser or Wd�htIft �' b mm ets and-common road names.
From 17 • To 7.S ptS.a „� -
From To FL
From To FL�
13. GROUT_ Depth Marais: Method. o
From To-m— 423Z 2 N
From_ To F4
.4. SCREEN: Depth Diunoter . slot sin Material
From- To Ft,_(n. in. o
From Tc Ft.__ln. in. cn
5. SAND/GRAVELPACK
Depth Size Material
From To Ft.,_
From To Ft
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WA$OONSTRUCTBD IN ACCORDANCE Wf[H I5ANCAC 2C,WELL-
ONSTRUCTIONSTANDARDS,AND THAT ACOPYOF'14S RECORD H&S BEM P$OVIDEOTOTHE-WELLOWNER
/ I40 - 6 -5
SIGNATURB-OP PERSON CONSMUCM40 THE WELL DATE -
submit the original to the Division of WaterQuaHty,Groundwater Section,1636 Mai)Service Center-Raleigh;NC
rf 699-1636 Phone No.(919)7333221,within 30 days - 01#4 REV.07/2001

.WELL CONSTRUCTION REC01W
North Catbliaa-Department of Envitounant and Natural Resources-Division of Writer Quality--Qrcimdwator Section
WELL CONTRACTOR(ntntl(IUUAL)?IAMs (•p1$Q� 1115•15 ' r�• - + CL3�77RtGTlo!(� �c
WELL CONTRACTORCOMPAkYNAM Pti*oeai
STATE WELL CONSTRUCTION PxBalmI ,Oli ATi�D W44RR.RUN
(ifawlieabk) (ifappilabk)
1. WELL USE(Check Appllcabhi Boxp.-Radden"U--Ow iicipdAlublic❑ Wu*W q Agricultural Q
Monitoring O Recovery O' Heat Pusnp Water Injection O Other[ if Otker,List Use
Z WELL LOCATION: . T,„,,,�„"c/Lend Sating
Nearest Town t i County.,M g G " dpR;dge OS]gw Malley .OFlat
g Al wf fern. 14" AA Covert (dwctapptop"bw) .
(SOW Naawc tbaa em Ca.uau t S"iWM W No..rAp Cosa) .. d$'79 y LatituklaAougitude ofw-pil location
3. OWNER. mod. -j3/}Nk5
, (desteerJmimtWaaeondt)
Address S7 D _ l Dud c- use t w U 2 Latituddlongihide Soprae:OGPSQfopogtaphic map
L u7 7- (SaaR l 1t 3 SS Sf DEPTH
- (dwebbu)
H ' DRILLING LOG
City«Tower Stave ' ztp Code .From To - Ftignalion Description
( 1 4f 14-- 6871 c _. 4) by • , .
4. DATE DRILLED g 5 l C cc n t -e�
5_ TOTAL DEPTIL 4S6
6_ DOES WELL REPLACE EXLTMW WELL? YES NQ_
7. STATIC WATER LEVELBeiowTopofcasing;
Was^N if Abow Top of CaWW
8. TOP OF CASING IS�_FT.Above Land Sarfux0
'Top of nela f tonMotW a&%r beibW t"$Wfap ngabu a -
rartuee N aeeoMuu WR67sA7tCxC ZC Al li, _ - .
9. YIELD(pt(ty�_METHOD OF TBST
10.WATER ZONES(depth):
LOCATION SKETCH
It. DISINFECTION,.Type Amount Show direction wai,distance in miles from at least
12. CASING: Wall Thicknen two State.Roads or County Roads:Include the road
Depth harerr wallghUFt num common and`con on road names.
From fl • To�_PtS� �. .
From To FL
From To FL_••_
13. GROUT-* Depth Mateml. Mad�wd�).
From_D—To—_
From- To o . .
.4. SCREEN: Depth Diameter Slot Sim : Materiel e
From To Ft,_(rL in tv
From To Ft,_in in _
5- SANDIGRAVEL PACK _ _ o
Depth Size Material Ln
From To FL _
From To FL
6. REMARKS:
DO HEREBY CERTIFY T HATTHIS WELL WAS CONSTRUCTED IN AOOORDANCE W H ISA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF Tw RECORD HAS BEEN PROVB)EOTO THE WELLOWNER
SIGNATURE-OF PERSON CONSTRUC =THE WELL DATE -
Submit the original to the Division of Water Quail%Groundwater Section,1636 Mail Service Center-Rilels NC
.27699-1636 Phone No.[phone],within 30 days OW.-1 REV.07R001

WELL CONSTRUCTION RECORD-' ,
Nonh Cafolina-Depulosor t of Envitountent and Natund Resources--Division of Water Quality--Orountiwater Section
WELL CONTRACTOR(tNDMDUAta7(ANz faAaD xUd9115 �,� ��'• •� CL�IIR[CAT[ON/ tl/7�
WELL CONTRACTOR CONPV�Y NAM _
STATE WELL COMTRUCTIONP29hih/ ANOMATIMW RRAM - --�-
Cfappiiubta) *volume) '
1. WELL USE(Check Applicable'Box):Residen&—Q- p .'-.OaVPubBc O Indushial D Agricultural Q
Monitoring❑ Recovery O Heat Pump Water tgjccdon i] Other Cf if Otkar,L(st Use "
2.-WELL LOCATION:Nearest Town: OE72
/C L; - County,/Y) A C&, .. Tdg lope [Dealer Flat
a�� Yee bend 9 f93 ;�_ (oheet nre wicthoo I.
(SvmNamgtdmntrne,coawu�hy.sald'iv;woa,lotHo.,rapCode) LgtltudenWlgltudaotWQllltication -
3. OWNER-
Address /S 0 :n d t n Lati(t"()RgihWo sonrce:(70PSC1Topographic map
(SueaaRawl7oa - (Cbed:box)Sr. /} cs u S f.h t /. 3 a o x 60 DEM • DRILLINO LOG
�ry"rT sum rwcode From TO ' F6xwationDescription
9( D'H rJ 97-�1e 5 . .. n
Am codo-Phone nonLr � 's"`'` — �Y'S� —��
4. DATE DRILLED
5. TOTALDEPTH 30Sr
6. DOES WELL REPLACE EXISTING WEL[7 YES 0 NO._
7. STATIC WATER LEVELBelowTopofCuing: . Jf --'-FT:
(Ua^I^)f AbMTop ofCuiW
S. TOP OF CASING IS_�_FT.Above Land Surficso
'Top of Cuing tararluted War heistt(�itad.eartm ngWm a
"duce In saeordanw nth"15A'NCAC 3C A11L _ -
9. YtELD(gpw): 30 METAODOFTBST�
10.WATER ZONES(depm�-- a( '
LOCATION SKETCH
It. DISINFECTION:•Type ARtomd - Show direction and.dtatanca In wiles ffwn at least
12. CASING., Wall Thicklicss two Slate Roads or County Roads.Include the toad
Depth or weightllR numbers and common road mantis.
From fl • TOLLZ
From_T( Ft
From Tq FL__,_
13. GROUT: Depth Malariil Mathod
From—a_Tom_
.4. SCREEN: Depth Diameter . slot size Materiel
From To FtL_in in ry
From To Ft`—jn.
5. SAND/GRAVELPACK: _ o
Depth Size Material ct1 '
From To Its_
From To Ft
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISAN. CAC 20,WBILL
'ONSTRUCTION STANDARDS,ANDTHATA COPY OFT- RECORD HAS BEEN PROVIDED TOTHE.WBLLOWNER
SIGNATURE•OPPERSONCONSTRUCTINO THE We" DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mau Service Center-Raleigh,NC
.1,7699-1636 Phone No.(919)733-3N 1,within 30 days, GW-I REV 07J2001

.. �•�..� �.vr�oinC'1. 11V1V I_____k:LURD
North Carolina - Department of Environment and Natural Resourccs- Division of Water Qualitv- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)
WELL CONTRACTOR COMPANY NAME S- � �k 1 y., �),Mu CERTIFICATION 9 QA11,
�! N /_
STATE\\'ELL CONSTRUCTION PEIib1I1'4 PHONE
n SSOCIAI ED WQ PERAUTN
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): ResideiitiabH�Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATIO
Nearest Town: CountyLQ�/ Topographic/Land Setting
aw �1ly� / ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision, Lot No.,Zip Cude) (check appropriate box)
S�t�p�J-1 Latitude/longitude of well location
3. OWNER: 3
Address - (degreeshuinutes/seconds)
—� Latitude/longitude source:❑GPS❑Topographic map
Geer or oute No.) (check box)
—041G 0i'? y DEPTH DRILLING LOG
Gty or 7 own State Zip Code From To
Formation Description
Area code-Phone number _
4. DATE DRILLED J%�5-
5. TOTAL DEPTH: TV tj
6. DOES WELL REPLACE EXISTING WELL? YES ❑ No ❑
7. STATIC WATER LEVEL Below Top of Casing:_ 4�—Z_FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_L_.— FT.Above Land Surface* _
`Top ofcasing tenninaled at/or below land surface requires a --
variance in accordpace with 15A NCAC 2C.01 18. C
9. YIELD(gpm): ii�JOL METHOD OF TESTA y
10. WATER ZONES (depth):
_ LOCATI��KA
11. DISINFECTION: Type Amount Show direction and distance in miles from 2teleast
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
From_ Dept Dyamp}er or WeighUFl. Materia' numbers and common road names.
_To Ft. e
From To FL "—
From To Ft. "-
13. GROUT: Depth Material / o
From Method To Ft. �� Y ,�n7i Method
From_- To F[. _
14. SCREEN: Depth Diameter Slot Size Material`
From To Ft. in, in.From To Ft. in. in.
15. SAND/GRAVEL PACK: t �A
Depth Size Material r co r From To Ft. o -'
From To FL ,r CD -
16. REMARKS: L
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC`2C, WELL�v _
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECOF D HAS BEEN PROVIDED TO THE WELL W'NE
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwahtr Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION
North Carolina-Department of Environment and N rat Resources-Division of Water uality- at _f e ` el
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Q Groundwater Section g
WELL CONTRACTOR COM PANT'NAAIE CERTIFICATION
SPATE WELL CONSTRUCTION PERdIII'# P110NE #
(if applicable) ASSOCIATED WQ PERMIT#
(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 LOCATIgj�I-
Ne est Towil: County Topographic/Land setting
j=(e%C ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Manners.Community, (check appropriate box)
Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: ) EtfY'�
Address 1's-fi. (degrees/minutes/seconds)
1T �_7 /) '✓'c/� Latitude/longitude source:❑GPS❑Topographic map
(rStreet or RoutetNo.)
fir`-yuX/'n/ �L 271 j (check box)
City or Town State DEPTH DRILLING LOG
Zip Code( From To—)- Formation Description
Area code-Phone number
4. DATE DRILLED LI'o2,�,05 C
5. TOTAL DEPTH:__ ?FPS-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:nFT
8. TOP OF CASING IS --
(Use'+"if Above Top of Casing)
C FT.Above Land Surface" ---------__ c`a
`Top of Casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011 S.
9. YIELD(gpm): (hc> METHOD OF TEST �i�/ -- -- C7%
10. WATER ZONES (depth):
1 I. DISINFECTION: T - e LOCATION SKETCH
11 Amount Show direction and distance in miles from atieast
12. CASING: Wall Thickness two Stale Roads or County Roads. Include the road
Depth Diam r or Weight/Ft. Material numbers and common road names.
From___-To_&3_ Ft. &
From t=--To Ft.
From To Ft.
13. GROUT: Depth Material Method
From—_To_a26 Ft., URg� ,-__
From To Ft.
14, SCREEN: De th — {,''
P Diameter Slot Size Material -
From To—Ft. in. in.
From To Ft. in. in. o
15. SAND/GRAVEL PACK: — ft
Depth Size Material
From To Ft
From To FL
t c
0
16. REMARKS:
I DO HEREBY CERTIFY THAT TI4IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, (CELt
CO TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7
SIGNATURE OF PERSON CONSTRUCTING THE WELL,
W - DATE
Submit (he original to the Division of Water Quality, Ground/r'aIer Section, 1636 Mail Sen3ce Center-Raleigh,NC
27699-1636 Phone No.[phone],Within 30 days.
JAN — ,Or [nr.iiJ- CrW-I REV. 07/2001

WELL CONSTRUCTION RECORD ��� ' � �` � `�'
North Carolina-Department of Environment and Natural Resources- Division of Water Quali y-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)
WELL CONTRACTOR COMPANY NAME /q/J�/ q CERTIFICATION
CJ YDS e�f�l v%/.b✓G i/ PHONE #
STATE WELL CONSTRUCTION PERMIT#
(if applicable ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE(Check Applicable Box): Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATIO
Neares Town: Counry�Rrj)J Topographic/Iand setting
lieF .ash ❑Ridge ❑Slope ❑Valley ❑Flat
(Stet Name,Numbers,Community,Subdivision,Lot No,Zip Code) (check appropriate box)
Latitude/longitude of well location
3. O WNER: � �f�A�
Address y / (degrees/minutes/seconds)
R (Street or Rout No.) r------ Latitude/longitude source:❑GPS❑Topographicmap
A 1I� ,P �� �,� 4/ (check box)
DEPTH DRILLOG
City or Town State
Zip Code From
(—) To Formation Description
Area code-Phone number
4. DATE DRILLED —p
5. TOTAL DEPTH:_ _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ No ❑
7. STATIC WATER LEVEL Below Top of Casing: FT. --
8. TOP OF CASING IS_ (Use"+"if Above Top of Casing) ---
FT. Above Land Surface" ---___
"Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118. ---�-
9. YIELD(gpm): METHOD OF TEST �iY' —�— '
10. WATER ZONES(depth): n
11. DISINFECTION: Type Amount LOCATION SKETCH --
12. CASING: Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diamet Or Weight/Ft. Material numbers and common road names.
From_-V—To�l�Ft. /e /
From To Ft.
From To Ft
13. GROUT: Depth Material
From_4—To " Ft. �e/�/i&'l
From To Method
Ft. t _
14. SCREEN: Depth Diameter
From Slot Size Material
To Ft. in. in.
From To Ft. in.
n.
15. SANGVELPACK:
D/ RA o
C
From Depth Size Material
To Ft.
From To Ft. °°
O
16. REMARKS: CD
I_
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C'WELL CONS RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WECI.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. I:. <
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
1eNorth Carolina-Department of Environment and Natural v
Resources-Divisi on of Water Quality- Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)( ,r)/l/1 f
CERTIFICATION#3e21
WELL CONTRACTOR COMPANY NADIE e1we p-
G
STATE WELL CONSTRUCTION PEIL'NIT#
PHONE # j - 4
(if applicable ASSOCIATED WQ PERb11T#
III )
(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
Nearest Town: J County -e-i Topographic/Land setting
1 2 A� R ❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Number ,Co munity,Subdivision, Lot No.,Zip Code) (check appropriate boa)
Latitude/longitude of well location
3. OWNER: )r _jQ�eq
Address JJ5— f DYL ( v (degrees/minutes/seconds)
(Street or Route No.) Latitude/longitude source:❑GPS❑Topographic map
�� (Jr�J�y (check box)
E / DEPTH DRILLING LOG
City or Town State Zip Code From To
Formation Description
Area code-Phone numbe
4. DATE DRILLED -Q— -p,5-
5. TOTAL DEPTH: _ e_
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:�t FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* -
•Top of casing terminated avor below land surface requires a _
variance in accordance with 15A NCAC 2C.0118. J
9. YIELD(gpm):A_METHOD OF TEST j r _ T
10. WATER ZONES(depth):
Ln
_ LOCATION SKETCH
IL DISINFECTION: Type Amount Show direction and distance in miles from aI"feast
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diarn)e er or Weight/Ft. Material numbers and common road names.
From_._To,�,y_ Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To�2 6 Ft. e e/Y1e4 -
From To FL --. --
14. SCREEN:
Depth Diameter Slot Size Material i
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: - o
Depth Size Material - c
From To FL _ t
From To Ft. ` w
c
16. REMARKS:
sr
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2CyyF WELL
CON RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL OWNER-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division or Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
i GW-I REV. 07/2001
-

WELL CONSTRUCTION RECORD ����
North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Ir::
p 1 II y� ^ CERTIFICATION#�
WELL CONTRACTOR COMPANY NAME /,1">4aY/ & Li1Jl��(JY7�� w --�/ PHONE # S,rJ�,{'_y/•//{/f'�
62l/ .�Jw,�•z=—
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERIb11T#
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box): Residential8 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION
Nearest To County Gc Topographic/Land setting
f {5 p_„ ❑Ridge ❑Slope ❑Valley ❑Flat
� u� (check appropriate box)
(Street Name,Nu ers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: / p
(degrees/minutes/seconds)
Address G /i_L ah� Latitude/longitude source:❑GPS❑Topographic map
(Street or o"u/te No.) (check box)
/u e`) yY k DEPTH DRILLING LOG
City or Town State Zip Code- From TO
Formation Description
Area code-Phone u
4. DATE DRILLEE D3-a_<)- 65-
4
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing:�_FT.
8. TOP OF CASING IS (Use'•+"if Above Top of Casing)
FT.Above Land Surface*
'Top of casing terminated allor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):. /'j'- METHOD OF TEST ,4;Y -t
10. WATER ZONES (depth): rn
_ LOCATION SKETCIT
11. DISINFECTION: Type Amount Show direction and distance in milaTrom at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diam9ter or Weight/Ft. Material numbers and common road names.
From
From To Ft. /
From To Ft. _
13. GROUT: Depth Material Method
From Tom_Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
L
From To Ft. in. in. �- CD -
C
From To Ft. in. in.
15. SAND/GRAVEL PACK: r 1
00
Depth Size Material
From To Ft. o
From To Ft.
t
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C WELL n 7
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 nail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION REC,OTM
2122
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /WELL CONTRACTOR(INDIV•IDUAL)VAML (prlot) s, Z n VI 1 S ! � R�r� �: Ctrl`7'IFICAT[ON M` 17
WELL CONTRACTOR COMPANY NAM tmis ArillooA 61011 PtiONZ i jL�a.L.t�_"3 �•6
STATE WELL CONSTRUCTION PZRMhY AUOC(ATPD W I
(if applicable) -(if applicable)
I. WELL USE(Check Applicable Box):Resident'iat-0 M icipal/Public❑ Industrial 11 Agricultural 11
Monitoring O Recovery O` Heat Pump Water Injection❑ Other CT If Other,List Use
2. WELL LOCATION: , Toea�aPbjr/Land setting
Nearest Town: U County -i/A7 Pglddgge OSlope OValley (]Flat
'7"//S Cr A l , f}eL I C' h i j 12r iv eA_ .,2� 7&;, (chick appropriate box) . ' '
(Strew Nunc,Numbers,comma ,subdivision,l.ot No.,Zip Cede) - Utituddiotigitude of WgII location
3. OWNER: Q'1�-t 0, 0-i'I P Ll - (deyxilmiaubalaeconda)
Address 7 41 N ejc tt�d LatitudeAongitude source:OOPSOTopognphic map
(Strew or Route NoJ ^ (check box)
r" ft �10 oC l DEPTH DRILLING LOG
City or Tmw Swc Tp Code .From T Formation Description
Mu codo-Phone number
4. DATE DRILLED 'U L` G 2 A,Y i 1 't
S. TOTAL DEPTH: .r[ S'
6. DOES WELL REPLACE EXISTING WELL? YES O NO c
7. STATIC WATER LEVEL Below Top of Cuing:
(Use"+'if Above Top of Cams)
8. TOP OF CASING IS�_FT.Above Land Surface*
•Top of cuing terminated atlor betZr IwoLryrfaee requires a
varlua in acmrdanu wttb'ISA74CAC 3C AIIL
9. YIELD(gpm): 0 METHOD OF TEST
10. WATER ZONES(depth):
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• ter .or Weight/Ft. Ma!f numbers and common road names.
From�To�FL=$ate O.K.
From To FL
From To_FL
13. GROUT: Depth Materiel Method
From`To_='�P—FL T,r]� 1
From To Ft.
4. SCREEN: Depth Diameter . Slot Size Material CD
From To_FL in: in. RECEIVED cr,
From To Ft. in. in.
5. SAND/GRAVEL PACK, �AN 3O Z��6,
Depth Size Material
From—To—Ft.—
From To Ft. Asheville Regional Office.
6. REMARKS: Aquifer Protection
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC XC WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H&SBEEN PROVIDED TO THE WELL OWNER
FYI � P s
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh;NC
17699-1636 Phone No.[phone],within 30 days. GW-1 REV,07/2001

WELL CONSTRUCTION RECORD
.
North Carolina-Department of Environm6it and Natural Resources-Division of Water Quality-Groundwater Section
Ts J: _ (
WELL CONTRACTOR(INDIV•IDUAL)NAME (pr t) K-nNIs �J/IA rI� CZATiF[1C,ATIONt-1 1 r`-e
WELL CONTRACTOR COMPANY NAM W,
STATE WELL CONSTRUCTION PERMIT/ 4MOC(ATED W4 LIMITS .
(ifapplieablc) " {tfapplicable) -
1. WELL USE(Check Applicable Box):Residential' un)cipaUPublic❑ Industrial❑ Agricultural 0
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other CT If Other,List Use '
2.-WELL LOCATION: ograpbidLand setting "
Nearest Town: r�Aiy/CL1/Y County�A_Lxd2 " " ❑Slope ❑Valley ❑Flat
&�640 SU n -S C 2 C e/L /q tV_p % 02 8'73 tV (check appropriate box) .
(Suce(Name,Numbers,Community,subdtri.ion,Lot No.,Tip Code) I:atitude/longitude of well location
3. OWNER: Z: 0 VAn/ 14-sT %//p (degroes)mimutedaxbnds)
Address S3 D(lpT24' CD yi .i¢e/e LatitudcAongiNdesouree:❑GPSOTopographicmap
(skeet or Rowe NaJ (cbeek box) .
A 5#P_ lr/, 3 a Q sd DEPTH DRILLING LOG
City Town ,e zpCodc From TO ' Formation Description
47':. 2 jw to O /
Ara code.Phone number (: 7 � E 3. r
4. DATEDRILLED qS Jc 1� U e- G-r� , r e
S. TOTAL DEPTH: .3Q5 ' -
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO c
7. STATIC WATER LEVEL Below Top of Casing:
_ FT:
(Use'e if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface"
-Top or wlag terminated suer belaw land.surface requires a - -
variaaee to saordana wItk ISANCAC 3C.0118.
9. YIELD(gpm): S`y METHOD OF TEST_61MJ
10.WATER ZONES(depth): 75'
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' ter or We'tovft Ma numbers and common road names.
From To n FL=S g[.
From To FL
From To_FL L
13. GROUT: Depth Materiel Method
From. To;_FL
From To FL tD <
4. SCREEN: Depth Diameter , Slot Size Material Q
From To FL_in. in. pC Cr "C D Cn
.
From To Ft. in. in. _ fl L G.I Y G -
S. SAND/GRAVEL PACK: i
Depth Size Material j,aN O 2�06
From To Ft. i
From To Ft. s Asheville Regional Office -
6. REMARKS: AgWifer PirgIgglion
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WE[.L
DNSTRUCfION STANDARDS,AND THAT A COPY OF THiS RECORD H&S BEEN PROVIDED TO THE-WELL OWNER
LA
SIGNATURE OF PERSON CONSTRUCINOTHEWELL DATE
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. OW-1 REV.07/2001

°T 320611
R~� .. ESIDENTIAL WELL CONSTRUCTION RECORD
' North Carolina Department of Environment and Natural Resources.Division of Water Quality
WELL CONTRACTOR CERTIFICATION 4 2187
1.WELL CONTRACTOR: f, DISINFECTION:Type HST H Amount 1,6oz _
Russell S. Taylor g, WATER ZONES(depth):
Well Contractor(Individual)Name From 7/.R To '2'20' From To
Redden Brothers Well Drilling, TiiC." From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 Holly Hills Vista RD 6, CASING: Thicknessl
Depth ,„,F Di meot Weight. Material_
Franklina NC 28734 From—To Ft.
City or Tawn State Zip Code From To Ft. _
( 8281- 369-9591 From To Ft,
Area code.. Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID elf applicable) From_Q_To 20 Ft. 1$IB)t & hgrnjtLjAEEEd
From To Ft.
STATE WELL PERMIT01 Ihapplicable) From To Ft.
DWQor OTHER PERMIT e(ifapplicable) 8, SCREEN: Depth Diameter Slot Size Material
N cLL USE(Check Applicable Box): Residential Water Supply 0 From To_Ft. In. _ in.
r.l.rE DRILLED —1(2$•05 From To_Ft. in. _ In.
1 From To_—Fl._In, _ In,
TIME COMPLETED ) ( r.l >i l AM� PM
5. SANDIGRAVEL PACK:
3.WELL LOC TION: Depth Size Material
CITY: el COUNTY From Ta Ft
- From ,To FL
From-. To Ft.
(Street Name,Numbers,Community,SubdMalon,Lot No.,Parcel,ZIP Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope OVellay ❑Flat ❑Ridge ❑Other From To Formation Description
(check apprdprlste box) Clay & Sand
L,T ITUDE [mydecimal
in degrees,
-� — ,secondsor �' r Granil•a
LONGITUDE_ format
Lail'ude/longitude source: ❑CPS oTopographic map o
,location of well must be shown on a USGS topo map and
attached to this form rnot us arg GPS)
4.WELL OWNER —
Q�
OWNER'S Nl;!.1E -
ST "ET ADORES WAtr„
c
City or Town State Zip Cods `T
m's ?v(c9 $59 g
Alas code• Phone number -
S.WELL DETAILS: 4 L 11. REMARKS:
-LCO
a. TOTAL DEPTH: '
It. DOES WELL REPLACE EXISTING WELL? YES❑ NO)L
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C. WATER LEVEL Below Top of Caaing:. . _ApQ.. .FT. 15A NOAC 7C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'9 Above Top of Casing) - RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT,Above Land Surfc7 f A�
'Top of casing terminated eVor below land surface may require
a variance In accordance with 15A NCAC 2C.01 18. SIGNATURE OF C R IFIED WELL NTRACTOR DATE
e..YIELD(gpm): METHOD OF TEST Blav Russell S. Tavlor
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 GWGa
Rev.7/OS

320646
WELL CONSTRUCTION RECORD'
Nosh Carotins-Department of Environment and Nattrral Resources-Division of W ater Quality 0roundwater Section 1
,L11.,E J:
CCF7'1FICAT10Nr�I'
WELL CONTRACTOR(tND1V L).tDUANAME (prinU �`IY.Ijn'�a —�
rxotYE s`s7°� ' 4--3 o•b
WELL CONTRACTOR COMPANY NAM '
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED W EItmrr#
(if applicable) •(irapplicable)
t. WELL USE(Check Applicable Box):Resideatt'al' unicipaVPublic❑ industrial 0 Agricultural 0
Monitoring❑ Recovery 0, Heat Pump Water injection El .Other El If Other,L Use
2. WELL LOCATION: opogtapbiclLand setting
Nearest Town: r /L County 9 dge GSlope Walley OFaat
11) e'_fi min, 5217?i L (chock appropriate box)
(Sweet Name,Numbera,Commuuoity,SuMv,sion,Lot No.,Tap Code) I.atittldo/)orlgitude of well location
3. OWNER: I I I` >�� /Yl I . , (desroealminutaa/aecbnds)
Address 't e1 U) 4 V I- ' Latitude/longitude source:00PSOTOpographicmap
(Sweet ar Route No.) (check box)
I J() V` a / 3 3/ DEPTH. D�RST.t.tNG LOG
F,%m To .' F '`lion Description
Cltycr Town Statc Tap Cock ,
Ara code.Phone amber
4. DATEDRILLED -� 7 ' �l� en'm • cvi; r
5. TOTAL DEPTH: DS' ' 1D COOS' 8 L U e. Ca- r 0..,n r r '2--
6. DOES WELL REPLACE EXISTING WELL? YES U NO
7. STATIC WATER LEVEL Below Top of Cuing: a e a FT:
(Uu"t'if Above Top of Gimil)
8. TOP OF CASING IS_ - FT.Above Land Surface'
. 'Top of cuing torminated atior below Isad surface requires a
variance to socordaece wUk 1SANCAC 2C.01 IL
9. YIELD(gprtt):1_METHOD OF TEST
10.WATER ZONES(depth): 3 Loc ATION SKETCH
i t. DISINFECTION:Type Amount Show direction and distance in miles from at!cast
12. CASING: Wall Thickness two State Roads or County Roads.Inciudc the road
Depth D'* peter or WeijjhM MR numbers and common road names.
From_To L Ft.�2=5�[j
From To FL o
From Tq Ft. cat
13. GROUT: Depth . Material Method .—
From FL -C2
From To FL O
4. SCREEN: Depth Diameter . Slot Size Material Ln -
From To FL in. in.
From To Ft, in. in. ,
S. SAND/GRAVEL PACK -
Depth Size Material
From To Ft.
From To Ft.
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTTH 15ANCAC 2C,WBLL
ONSTRUCTION STANDARDS,AND THAT A COPY OF TES RECORD BEEN P40VIDED TO THE WELL OWNER
uac-
SIGNATURE'OF PERSON CONSTRUCTING THE,WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Ralcigh;NC
1?699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/4001 .

WELL CONSTRUCTION RECORD `3 6 4 5
Nora,Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIV,IDVAL)NAME (Print) ���('{%1 S I '+\ e. TWICATION a -A
�_ �;'.
WELL CONTRACTOR COMPANY NAMliji4lPHONE aJjj/_.'Jr�4--3 o2b 10
STATE WELL CONSTRUCTION PERMI71 ASSOCIATED W ERMrro
(if applicable) ()fapplicable)
I. WELL USE(Check Applicable Box):Residential' unieipal/Public❑ Industrial❑ Agricultural Q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other[7 If Other,List Use
2.-WELL LOCATION: pog7apCJLan bld setting
Nearest Town: DST n County Z A- C ICJ "die ❑Slope ❑Valley ❑Flat
!!24/ I TCSS'rH-te-G RA 07,f,743 (chack appropriate box) '
(Sueet Name,Nuumm^ n•/
,Communityy,,subdivision,Lei No..Zip Code) Liltitude/loftgitude of w.cll location
3. OWNER: / (� V fIGA !eI /,yS (desrees)minutaYaxbnda)
Address �/Y � G-n/.L' /?Y 11/I-L-- Latitudellongitude source:❑GPS❑Topographic map
(Strcet ar Aouta Na) - (cheek box)
//CZ�t! / 3 a. D 3 3 DEPTH DRILLING LOG
City'"Town Stec Zip Code .From To ,Formation Description
"I 9/'n- //n 'q 3 3'
Area code-Phone number - ' '` 3� ' tc)n' /{'•-Q—�
4. DATE DRILLED 6)/), 366 RLbG P-a,Iv > 1 z
5. TOTAL DEPTH.,
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing - 0 FT:
(Uea'Y'if Above Top of Casias)
S. TOP OF CASING IS_�FT.Above Land Surface'
-rap of cola{termlaated atlor belarr laadaurfaee»quires a -
variance,n accordance with ISANCAC 2C.011a.
9. YIELD(gpm): 5<0 METHOD OF TEST
10. WATER ZONES(depth): /Sb 0 `
LOCATION SKETCH
11. DISINFECTION:•Type &17A 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'*�y�r-W�er or Wcot/FL hoe numbers and common road,tames. o
From_To�F=- saw
From To Ft. n
From Tq Ft m
13. GROUT: Depth Materiel Method CD tw
From To-,=
From To TL
4. SCREEN: Depth Diameter . Slot Size Material
From To FL in. in.
From To Ft. in. in. _
S. 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,WBLL
ONSTRUCTION STANDARDS,AND THAT AA COPY S RECORD HAS BEEN PROVIDED TO TFawe L 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
.17699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 .

�WELL CONSTRUCTION RECORD � 0 6 4 4
North Csrolina-Department of Environment and Natural Resources-Division of W atw Quality-emtundwater Section
WELL CONTRACTOR(INDIV,IDUAL)TIAML (prmO � 1 ri yl 1$ IL i&:V . s. CV TWICATION s It
WELL CONTRACTOR COMPANY NAMZ�"IS i11011044A
STATE WELL CONSTRUCTION PERMhl ASSOCIATED W CRMITa
(if applicable) (Vapplicable)
1. WELL USE(Check Applicable Box):ResidentieC unicipal)Public❑ Industrial Q Agricultural[]
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other C( If Oilier,List Use
2.-WELL LOCATION: . TopograppicIland setting
Nearest Town: 0 7" County. ❑Ridge ❑Slopc OVs11ey at
8 76 3 (chock appropriate box) '
(Street None,Numben,Community,SubdivifioN Lot No.,Zip Code) Latitude/longitude of well location
3- OWNER: .&V t lV ki A I S'Ti9 (depecdmiauur/ucendr)
Address o4 (gel /r eeilz'4 LetitudeAongittido source:❑OPS❑Topographic map
(Stung a Rowe No) (cheek box)
Ice an-wI A/C/ DEPTH DRILLING LOG
City«Town State z p, From To Formation Description
Arcs code.Phone amber - , ', _' 4 ES a 9 �-
4. DATE DRILLED d -d5 C?r , axis e • re
5. TOTAL DEPTH: eaZOS'
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing 3 O _ FT:
(Uu"+'if Above Top of Cuioo
8. TOP OF CASING IS_�FT.Above Land Surface"
-Top of cuing terminated&Vor betpv INtdeurUca requires a -
vari"ce in aeeordanes wRb7SANCAC 1C.0IIL
9. YIELD(gpm):�Q_METHOD OF TEST
10.WATER ZONES(depth): 1 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 r(FR
Depth Diappe�rr or We'oun Matedel -numbers and common road names. n
From�_To�q-Ft.= Sfee
From To FL
From Tq Ft._ _
ut
13. GROUT: Depth Material Method - -
From_�To_�FL120402 jQnjA,4­)_ -
From To 'FL I '
4. SCREEN: Depth Diameter . Slot Size Material
From To FL in. in.
From To Ft. in. in.
S. 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
ONSTRUCTION STANDARDS,AND THAT A COPY OF NS RECORD H&S BEEN PROVIDED TO THE.WELL OWNER
-!%] &,Qt 9
SIGNATURE OF PERSON CONSTRUCTINO THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC
1?699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

HELL. CONSTRUCTION RECORD: 320643
North Cafotim-Departrmnt of Eaviromnent and Natted Resources-Dirialoa of W hrato Quality--Qrouadwater Se¢tioa �"
WELL CONTRACTOR(tND/N,IDUAL)NAME(mtaDc ra P11$ , 'ji : CERTIPICAT10Na /7[P
WELL CONTRACTOR COMPANY NAM •' -PR,O 11NE iIfi_. '.I�•�3 a•�1 Q
STATE WELL CONSTRUMON PXR whw A30C(ATED W ERMiTa -
(ifaopiieabic) (tftwpliwbl¢)
1. WELL USE(Check gpplicable"Boxp ReeideatiallD- ern cipaVPublic O Indushial 13 Agtiwlturai C7
Monitoring O Recovery O Hunt Pump Wa[ar lajactioa O Other L7 if Oilier,List Use .
2.-WELL LOCATION: T Ind setting
Nearest Town:_X.4-Al l- /l� County 4 f
//JA L A / 2 P L/Z Mile ope OVa ft .Mist
�- , ,� (�et`"copd0bax) .
(sues tame,Numbom Com¢aeny,Subd[tid?a,Laib..�Coda) Liidlutjdlotigitudc cf well location .
3. OWNE NA i1 4 e
Address 7& k 0 h F F v. C' i rC/ a Latitudellougiltide sontce:OOPSOTopolimphic map
(SUM rE¢me)' (ebedtbox)
Ne & 7�9 DEPTH DRILLING LOG
�^GryarTava swe •�Cme . ..From TO Farnation Description
Am code.Phom:number
4. DATE DRII I-R 14 - / 7-@ - r' /O /LD.rr: 2
S. TOTAL DEPTH . lt.s i Y
6. DOES WELL REPLACE EXISTING WELL? YES_ O NQ
7. STATIC WATERLEVELBetowTopofCasing; I6U fir;
M a`4^VAbmeTopora*d
g. TOP OF CASING 1S,_�_FT.Above Laud Surface•
'TOP ofoeta{tum atelWerbdgwb d.earrae¢epsbw0
.+ - ,
ranee Is aawrenee whi-ISANUC iC A11L
9. YIELD(gptn): / 5' MBTHOD OF TEST
10.WATER?.ONES(depth):- =P 52)'
I.00ATION SKETCH ;
11. DISINFECTION;Type Atnount Showdimctioa and tlistantx In wiles from at lei
12. CASING: Watt Tbickom two State goads or Cowry Roads.Include the r�d
�Wh or Weight/PL nwnbwa and-cononon road names.
Fromfl . ToL P rn
From To FL
From Tp FL_T �
13- GROUT: Depth MaWiii Medved.
From_Q_To1—JAIMI —P4 ePLI�a
From To Ft
.4. SCREEN: Depth Diameter . Slot Sin MaWW
From To PL __ja; uL
From To Ft,__in, irL
5. SANDIORAVEL PACK:
Depth Sin Material
From To Ft`_
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WRL WA$ODNS7'RUCrOD IN AOCORDANC$Wf H I5A NCAC 2C,WBLL-
UNSTRUCT[ONSTANDAgW,ANDT,H�AT!A�CDPYOF SREODRD BMNPt;OVIDEDTOTHB-WBLLOWNER
SIGNATURE-OFFERSONCONMucnNGTHSWELL DATE -
Submit the original to the Division of Water Que ty,Groundwater Section,1636 Mail Service Center.Ralelgb;NC
14699-1636 Phone No.[phone],within 30 day& GW-I REV.07/2001

F:
320642
NanhCafolioa-DegtMMOTHnvho =ktmlNaunl Dfiddmp(s w�lity�
��,, •• . - - •• .
�'+ _Qow wwawsectim
WELL CONTRACMItUKDtl�7DnA14` 't"'�a ida ct ►T"I R:gm
WCLL COHTRACMILCOMP. l4V IlF .ltlits ila...i ImIlky'.11 v T_..r.e PUolO_ -StZJC_ Q--3 V-b a
$TATaWZLL tattt WortrZRA*ff� .....
I1Ftmotiabkl y ' �' •-(IfaooNwble) . • �} - T
1. WELL USE(CheckgpPliab Sox�-RpideWulTrM p 1 1 Q AgtkubW-Q
Mottitodng O Recovery M Had PM*WsW hVmdm O Other U Ifd�,O List Um
Z"WELL LOCATIOM -
NE n� T� I trlBng
f �t ORMp OVaBey .O u
tweaNaxwo„wn,000�,e°>ti. r ea taiia.aPC .. -893 taottgptepdMeheo�
3. OWNER ( �a �s � Wda cCpSA Ww1im '
Addmm - /'9,6 rQ n os iP 40mve>Atiartafaeoaadc)
OlaoetarRareltsJ WbWOS P O ppogtaPbicomp
C2/Ln L -I/ , �4'73 5 DRtLLINOL00
(Tan OHO ` From To ' FotmatfmDuctiptica
Mn m6.prose oost6er .. .:.
4. DATED !/ /L -G S � r
5. TOTAL ��.
6. DOES WELLREPLAC6BJUSYpypWN-J;q.YES 13 Nil
7. STATIC WATBRLSVELBelowTopot'Qliitil; --O
8. TOP OF CASIIi()i8 NN"-lrAbowTepmFCmh )
_yL_FT.Ab.Land 3ta66e+
'Top ofndaBM�luwagor' w� iMdrire ..
.�etua to oontioeovflgt -
9. YIMLD(gpmk MBTAODOFTTIST
MWATERZONES(depe* F
' x--
1 1. DIS ION: Amount Show ditecdetl aeddispma in twist Am at last
IL CASaNOINM. WaBTMeVft hrusateRadaOr Cwmly Rosh.Include the toad cn
Frout l7 . T y a W _ mmbem ml-cmrmm mad umn%= �
From—TO F< '
13. OROro tl�TqDV* �W blethod U1
From To
4. SCREEN: Depth Diwuter • slotsh:e A4a0etial
From—To Ft___ jn; in.
From To FL _jn in. .
5_ SAND/GRAVELPAM _
Depth
materid
From TTcL____R.
�_
From To Ft`__
6• REMARKS:
DO HEREBY CERTIFY THAT'THIS VAU WA$ODNBTRUCTBD INACCORDANg WnH ISANCAC.=WELL
014SiRUCi lON STANDA¢Ds,ANDTHAT AOOPy OF
RBDORD PROYMYOTTBd.WBLLOWNER
attui►Tult6�+PBRs0Nt1SiRUCi7N0iFr8WBiy // �� U5
• DAYS - .
ubmit the original to the DlvWoa of Watar Quality,Groundwater Sedioat 1
7699-1636 636 Map SenrJce -Ra y�-
Phone No.(9I9)733.i221,withip 30 days.
(MI REV.07=1

WELL• C0NSMUCrlQN REC6.RD' ,: 3 2 0641
NoribC oiiaa-DepuUmMofEmhoama=dNadxtlReaounee -Divillon Quality,Qmimdweowr Section
tr�
WELL CONiaACCORIDiffil UAWttA�ps arty} pit iln,.. •'• ��'- �=.Ca7�TWIGTioels��
Weu coNraAcmeowsrAlYMM= ,p c f�alki
SCATS WELL CommuctiolJ P6WNt'ltl -
(VaooBabis) (uiaioBeabiai
I. WELL USE(Chat App Eoxk-i era..l .ur riu o .kdu*Wa ,pbuilhua►"
Y Monitodus t] R=77 D'-Um Pip w,ckhoo ica u Omer ct ifo9ler,pat
-2. YELL LocATION: 70p rya: .
Ne�Town i /i/ Coyauy., AA C&r t]Sbpe biaft
b 4- �A (Z1- 5/AP,.-k 1� /td a k�a � (aa*,tpnpi*wo -
tsneaN.mcNwn>,m.exa q. aogLaiio,rrcalri .. tatiaapolaaOft*ofwgilocuion '
3. OWNER: /CobtrTQ: � iry
-O• ox /n23 ''
Addieu La84ddlmgipidemiacmOQPSClTopogtaPhiemap
OibaiRarawatraa - '(eboctbmo
� arya1.T(o9- P095 F� o Fotme_doaDaauiption
5. TOTAL DEP7H
_Z� L
6 DOES WELLREPLACEMUSfM WELLY YES El RLEVEL NO_
7. STATIC WATEBebwTopofCatibi� `fO- FT.
M=-4 �AbmlepdpiiW -
8. TOP OF CASING IS Ff.Abmna Lead Sudko*
'Cap ofodn/tradaaW � _66e�� kai.aarfiatsaakiaa .. :
vaehaeala axarlawwb'1a1r1tG�CIC,alii -
9. YIELb(mm): 1 Y2- biumoDOFTE3T,
l0.WATERZONBS(depdi). J 7S'
11. DISINFECTION: Aawmd Sho*dkvc6oa=tldbbm 6i miler f m at baal
12. CASINO: WaBTiddutem two SUM.Roadaor County Rotd Include themd
Depth or Wets nombeis and ootisaon road names.
Froa�sT4_7S pf • �i N,
FronL—To Ft
rTt
Final_Tq FL_„_ _ c�
13. GROUT.- Depth Mtaerul- Me"
rn
From—To— p
A- SCREEN: Depth Member mot Stm : MaOxW • ' cn
From To Fes.—ia, ia. - .
From—TO m ig in
S. SANDIORAVELPACK:
Deter Size Material - -
Froitt__To Ft
From—TO—Ft,-
6- REMARKS:
DOHEREBYCERTIFYTHATTMWMJ.WA$COMSTRUCTeDiNACOWtDAN=WnHl5A K' ',MW.BEL-
'ONSTRUCTIONSTANDA9MANDTHATACOPYOF Rl =D NOBE@1PIIOVR>B!STOTIMWBILOWNER
SKBIATURB-OP PLUM CONSTRUCTiNOTHBWPLi DATE ..
submit the original to the Dividon of Water QuaBty,Groundwater Seedon,1636 Mao Seerhe Center-AaleiSkNC
,2?699-1636 Phone No.(911)M-3221,withla 30 days. - OW-I REV.OMMI

'WELT.COMMUCTIC REC6ItD 320639
NoahC&um-Depa wmof�andNWudRemxtoes-DividwofWaaQueiity` arootdvuaomrSearoa
W[LLCONTRACC"Mminew`u0A� 4 ¢etaUs _Milt j�'f1.w •`• •�- '• .fMs.ant!
W9MCONTRACTORCOM►ANTN_h- C ata-lL��ri�.�;,•. -i-''►•�' ,' �y"3 Zb G -
SfATEWEI.LCOMTaOCtMtsRlliFn
(ifaootiabk) ` ' ' {tfapplkabk) —
1. WELL USE(am&AppBobla i o*-Raidend %I--,d +icwr cipd/P�lie a .laid a AgdwRunl D
f ModWtbtga Reoovery a• Mat PumpWatbiI*diona Odwt171f6dw I etna
2.-WELL LOCATION: /t :-/ Ttypo 8
NesrestTown 7R,//NL!L �Y Co�mtyy ,� ' " �]( a Malloy Brat
HD d v S PQ. ;5- A uc Ea a.1a a ,ts e_ �gaa y R4edcaypaptiekbra) '
Isom Name,. ,i dieilfoq LotNa,t7pCoda) I.iaiwdb twoawolllorstiou '
3. 13 _
Address l u� Ale 3 H 1411 2d • Ladtuddlmigitude sootmmps0To wpwbk map
(6taeetarllaoeaHoJ `- --- - .. (darcaea0 '
FRAAi1LL: r/ NG o28r/31{ per• DRILLING LOG
Clry urroars sdt - T.q Cods. . ..Flom o ' -F!ipna#oa Deaai;"
( �j ,S2tF.S6S'G ' l4y
4. DA ET DRILLED //-!tt-0 5
i• - -
5. TOTAL DEPfH _� ,+
6_ DOES WELL REPLACE MCISCMOWELL? .YES0 NO_
7_ STATIC WATERIME1.11slowTopoir .j/) Fr
(Ws`rtrA6eaaTaport=b*
L TOP OF CASING13 PT.Above Land SurbW
•TapNaWtswow Watlx_�Ckadeae6�atpdriae - -
Varl""tsan daanvft 1CAtii
9. YMLb(gpM)r -SLO METHODOFTEST
10.WATER ZONES(depdtr '
1 t. D1S[NFECTION: AnaRmt - Show ditcctioa ad didwxs to miles Sea at least
12. CASING: Wdl7bldoma two Stab Roads or Cooly Us&Include the toad
Deph or wd!iph pt. numbers and-common toad[lames.
FroM Q . To� Ft
From_To Ft
Fromm--Tp Ft.----
13. GROUT: Depth i0l e - Method
From---0_To_c-*&—Ft�[►�47s1y
From To Ft. n
C-
.4. SCREEN: Dept Dhmdw . Met Sim : t&tcrw
From—To-Ft,_jn, in, m
Froat_To Ft,_bL in. ' o
5_ SANDIGRAVELPAM, cn
Dwh S5x Mataid -
From To Ft,_,__
From To Ft,__
6. REMARKS:
DO HEMY tMW THATTHIS W6LI.WAS CONSfRiCM INA=RDANm WR'H MNCACM WKL-
-ONSTRUCTlONSCAMXVJ ,ANDTHATAOOPYOF�R�E�OORD BEEN PI(OVIDBISTOTfI WELLOWNER
/rt'9.f16Lt1
SIGNM RIIOPPBRSMOON ]RUC17NOTHBWELL DATE - r�
Submit the origiad to the Dlvislon of Water Quality,Groundwater Seetiop,1636 Mali Sondes Cater-11ddeh•'NC
1'f699-1636 Phone Na(919)733-3ni,within 30 daps GW-I REV.07/2001

HELL CONSTRUCTION RECORD'
Nonh Caiolina-Department oramrimument ate NadRal Rest-----Division of Quality'-Oroundwator Section
WELL CONTRACrOR(tHMSDUAL) 3I
O �PNaOS
WELL CONTRACt• RCOMPANYNAMiCr.0 J1Q—,j 1j�P111a,rii Pawn;atYs�_Sia.4--'3
n.
STATE WELL CONSTRUCTION P2111417'/ waanr•raTRp W
(if applicable)
(Ifatadictble)
1. WELL USE(Check Applitabic-Boxr-ResidoatialU-' aieipaUPublic O Industrial O Apicultaral Q
Monitoring O Recovery E3 Heat Ppttgt Water tajection O Other[7 if Otlier,List Use
2.-YELL LOCATION: -
Topo $ '
Nearest Towtt �P 4 !iICL
Coon !j b idge W31ope alloy .Oh9at
_ COME- Sy0—e eaee eD
(Secet Name,Nambm.Coamma➢y,8ob6rufo0.i otNo.,T.q,Cods) _ - E Adtugd!oaglhlde Of W.CA location -
3. OWNER/!Yi 1
Address c k/ NF.17/n Prr /d i L < Latitudenongibide sounWOOPSOTopogtaphic map
(Saw a Roue - (slack Loot)
4i7eanill 1) A <lf-23C•L_ DEPTH • DRILLING LOG
C'narTOwx Sws Zip Code IFrom To FtirrmdonDeacription
__
4. DATE DRILLED /-/
5. TOTAL D ,
6. DOES WELL REPLACE EXISTING WELL? YES O NO_:c
7. STATIC WATER LEVEL Below Top ofCaung: Fr:
(Ua^N irAbm Toy orC&"
g. TOP OF CASING IS I FT.Above Land Smfacee
`Tap Greasing tanhu"d Wab4W ImArar(aa rrgalro a .
"rim"to aeserdaasa aMY16A71C,(C 2C.a1aR -
9• YIELD(gplu):C_METHOD OF TEST
10-WATER ZONES(doplbr .Ft T//
LOCA"170N SKRTCH
11. DISINFECTION:
INO*
C
12. CASING Type Amount Show direction and.diat um In miies from at least
Wau TWdmm two State Roads or County Roads.Include the toad
Depth or Wd t ghli Msaeygl --numbers;and-co mlon road names.
From Q • To yy�_Ft et 57`�ef.
From To Ft.
From Tq Fc�,•_
13. GROUT-, Depth Front _ INatetial h(qhod
From_ Ta
T_TL o
.4. SCREEN: Depth Diameter . Slot Stze : Material C-,)
Front__To Ft.-_in; In.
From To FL_bL hL Q'
5- SANDIGRAVELPACX. o
Depth Size Material -'- Ln
From To Ft.
From To FL- _
6. REMARKS:
DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC.2C,WELL
'ONSTRUCTION STANDARDS,ANDTHATA COPY OF SRECORD BEEN P$OVIDFbTOTHB.W�LOWNER
r.
SIGNATURE�PPERSONCDNSTRIICI)NGTMWELL DATE
c�
Submit the original to the Division Of WaterQuall(y,Groundwater Section,106 Mail Service Center-Raid& NC
17699-1636 Phone No.[phone],within 30 days, OW-1 REV.0712001

RESIDENTIAL WELLCONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9 2045
1.WELL CONTRACTOR: 1, DISINFECTION:Type H T H Amount 16OZ
James B. Brown - g. WATER ZONES(depth):
Well Contractor(Individual)Name From To s From �To
Hedden Brothers Well Drilling, Inc: From=fl li, From—To
Well Contractor Company Name _ From To- From To
STREETADDRESS 73 H011y Hills Vista Rd C CASING: Thickness)
Depth Di meter Wei M aria
FYanklin� NC 28734 From�ToFt._
Clty or Town State Zip Code from To_Ft.
f 828 1- 369-9591 From To_Ft. _
Area code. Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: From—Q_Tc2_Ft. CeiHlt & b3011tE Ii f
SITE WELL ID#0f applicably From To_Ft.
STATE WELL PERMIT#(If applicable) From To Ft.
DWQ or OTHER PERMIT#(B applicable) S. SCREEN: Depth Diameter Slot SD* Material
WELL USE(Chx ppllcable Box): esidenlial Water Supplyp From To—Ft.—In. = 1n.
from To Ft._In. _ In.
DATE DRILLED J From To FL in. In,
TIME COMPLETED �. AM❑ PM LU
- S. SAND/GRAVEL PACK:
3.WELL LOC TION: Depth Size Material
From To_Ft.
CITY-- �OUNTY From To FL
0 From To_Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Par I, Ip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley OFlal ❑Ridge OOther From To Formation Description
(check apprdpdate box) , - Clay & sand
LATITUDE _L � If May t e in degrees, t t
/�/ minutes,seconds or Granite
LONGITUDE -�� in a decimal forat
Latitude/longitude source: (RIOTS ❑Topographic map
(locatlnn of we#must be shown on a USGS fopo map and
attached to this torm s not using GPS) _
4.WELL OWNER
OWNER'S NAME 11 c,
STREETADDP,ESS
W
City or Town State Zip Code
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: ,
a. TOTAL DEPTH: Q�
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO I!(
�/-� 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH_. _
c, WATER LEVEL Below Top of Casing; . /W FT. --' ISANCAC20,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use's'If Above Top of Casing) RECO S BEEN PROVIDE D THE WELL OWNER,
d. TOP OF CASINO IS 2 FT.Above Land Surface'
'Top of casing terminated attor below land surface may require NATURE OF C RTIFIED WELL CONTRACTOR DATE
a variance In accordance with 16A NCAC 2C.0118.
It. YIELD(gpm):—AL. METHOD OF TEST BI_QW James B. BrOWi1
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,NO 27699-1617 Phone No.[phone] ext 568. Rev.7I05

RESIDENTIAL WELL CONSTRUCTION RECORD
, ^' t
't North Carolina Department of Environment and Natural Resources-Division of Water Quality e; q�
WELL CONTRACTOR CERTIFICATION H 2O45
1.WELL CONTRACTOR: f, DISINFECTION:Type H T H Amount 1662
James B. Bzcw t 9, WATER Z?NPS(depth):
Well Contractor(Individual)Name From 7 To �5 b , From To
Heciden Bzothers Well Drilling, Inc. From7-�Nrro ID From To
Well Contractor Company Name From To From To
STREET ADDRESS 73 HDllY Hills Vista Rd 6. CASING: Thickness/
,f1 Depth DI titer IN M�197ja1,
Franklyn, NC 28734 From To Ft.
City or Town Slate Zip Code From_To Ft. _
L828 .
369-9591 From__To_Ft. _
Area coda Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: - From_.Q.__To 20 Ft. Ci & g=litL_2322�
SITE WELL ID#(if applicably From_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 plicable Box): Resident I Wafer Supply p From_To__Fl._in. _ in.
F} From_To- Ft. in. _ In.
DATE DRILLED � J / From_TO Ft.—In. — In.
TIME COMPLETED p�'.CX`) AM PM Z
9. SANDIGRAVEL PACK:
3.WELL LOCATI N: Depth Size Material
CITY: 10" COUNTY U From To Ft.
From To Ft.
From To Ft.
(Strut Name,Numbers,Community.buodivisicn,Lot No.,Parcel,Zip Code) -
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
pSlope (chock
❑Flat ❑Ridge ❑Other From Formation
FormationDescription
(check apprcprlate box) r Clay 8r SdIICl
LATITUDE , 6a May bein degrees, 1 r G2 anit2
V�lpU?-.127) minutes,seconds or
LONGITUDE in a decimal format
Latitude/longitude source: 5<PS OTopographic map
(location of we#must be shown on a USGS lopo map and
attached to this form#not using GPS)
4.WELL OWNER
L
OWNER'S NAME
S'i ET AODRESS
City or Town Slate Zip Code O
La2L)- 107 -yi,,
Area code• Phone number
11. REMARKS: -
5.WELL DETAILS: O t
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO fk
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH. -
c. WATE R LEVEL Below Top of Cos ing: A-0_FT. 15ANCAC2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'It Above Top of Casing) REC AS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 2 FT.Above Land Surface' �S
'Top of casing terminated attor below land surface may require NATURE OF CERTIFIED WELL CONTRACTOR r DATE
gpm
a variance in accor re with 15A NCAC 2C.Oi 1S.
e. YIELD( ): METHOD OF TEST Bloc, 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
16117 Mail Service Center-Raleigh,NO 27699.1617 Phone No.[phone] ext 568. Rev.7/06

1.24
WELL CONSTRUCTION RECORD* :
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(WDIV•IDUAL)WAME (prlu0 c1��r)in tS 1%J.+. '� TfFICATloN# /74t
1— ` cZ1t.
WELL CONTRACTOR COMPANY NAM •PHONRfSC?-4tC_�ri �y-3 V-6 0
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED w ER14lrrs
(if applieable) - (ifapplii:able)
t. WELL USE(Check Applicable Box):Resident••ta1TY Umc(paUPublic❑ Industrial q Agricultural E]
Monitoring❑ Recovery ❑` Heat Pump Water injection❑ Other E1 If Odier,List Use
2.-.WELL LOCATION: . Topo ppe d setting
Nearest Town: G L County,/�/�,4 ("M : ❑Ridge o []Valley .❑Flat
y 23 u C/C e 12 f E p .�2.�.2 (cheek appropriate bee) . : a
(Street Name,Numbers.Community,Subdivuioa,tot No.,Zip Code) I.atihRlellongitado of Well location
3. OWNER: /y7Yl l9l.S Q /ti (deareea)miautes/tecottdt)
Address 44 k/ H F, / n P/! i4; LL C LatitudeAongihide source:❑OPS❑Topographic map
/ (Streator Route pW) . (check box)
A/(�i o2d-;7 3 DEPTH ' DRILLING LOG
City'ur Towa stag ' Zip Coda .From To - .Formation Description
Area coda DRILLED,
oumbw , • ._--L'
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7, STATIC WATER LEVEL Below Top of Casing- Fr.
(Use"eifAbove Top ofCasin4
8. TOP OF CASINO IS�_FT.Above Land Surface*
`Top of mina terminated add below atmtaurGtee requires a -
varlasainseardaaa with"ISANCAC 2C.0laf. -
9. YIELD(gprp):C_METHOD OF TEST
10.WATER ZONES(depth): - , // '
LOCATION SKETCH
It. DISINFECTION.Type Arnomu Show direction and distance In miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth D
From To Ft ' ter or Weight/_FL Mateygl_'-numbers and common road names.
TLL5L
�` StCef
From Tp FL_ _ r--
13. GROUT_* Depth Materiel Method
From_Q_To_c�P_FL_ - w
From To 'Ft
.4. SCREEN: Depth Diameter Slot Size Material C:)
From To Ft in. in.
From To Ft`_itL hL
S. 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 15A NCAC 2C,WBLL
-ONSTRUCTION STANDARDS,AND THAT A COPY OFT
S RECORD HAS BEEN PROVIDED TO THE.WELL OWNER
SIONATURE OF PERSON CONSTRUCTING THE WELL - DATE -
Submit 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-1 REV.07/2001

191onI
WELL" CONSTRUCTION REC,(0�MD'
Nosh Csr'o)ins-Departmant of Em(mnmeirc andNabual Resources-Division of Water QuaBty--Qroimdwater Section
WELL CONTRALTOR(iNDIXIDUAL)l"X taata0 ch rl Pit 5 ILJIA,. A.'i• r C611Y7FiCAT10N/ 1 17(P
WELL CONTRACTOR COMPAkY NAM •• -'PEIOIiIt/i{1 — 3 �•b
STATE WELL CONSTRUCTION P0000 •a -- ARaOC(ATM)W ERaam -•
(if applicable) *%evl(able)
1. WELL USE(Check Applicable-Box):RxsWW&I lY Mwdcipal/Pub1ic E3 Industrial❑ Agricultural Q
Monitoring O Recovery O' Heat Pump Water lnjaetioa O Other[? If Otl(tar,List Use -
2.-WELL
LOCATION—T.opo 'e/Lend setting.
Nearest Town: r CLi/1l Ctwnty (s�rt� aope p OSlKalley .OFlat
l0 F. : JLV_� 13 45W-> B tV .. (eludtappropdal¢boa) - - ,
(Sues Namc,Nambms,Canna ft subt Mon,La%4 Zip cane) - Littitoddicnigitttda avmu location -
3. OWNER: A�WOA,d-.�T63?
Address - L 3 7 ERG/ t2o sr i goy Latitudellongittide sourceAOPSOTopog�raphic map
( 404orRwteNo.) - (elwdcboa) -
S A-AsnTfF `P 1 c�.4 a ck I DEPTH DRILLING LOG
Clry o ? a'own sate Zip Code FromT4 - Fomtation Description
Am cad6 Flom camber �-
4. DATE DRILLED I - � .S (03 ' 4(C a l ' �Ur°
LLS
5. TOTAL DEPTH: �SJ S
6. DOES WELL REPLACE E=ING WELL? YES O NO:c
7- STATIC WATER LEVEL Below Top of Cuing: iS6 FT;
(Uss-r ifAboreTop orC&*kg) -
g. TOP OF CASING IS_—FT.Above Lend Surfaced
-Tep oft"aa tvaleated atlor be(aw hataartwengalres a - -
.ar{a.a.to aeardwee whi-isA7tCwZC 2C Ana. ..
9. YIELD(pm):_-5- WZMOD OF TEST_ "/mil,
10.WATER ZONES(depth): 5�—
LOCATION SKETCH
11. DISINFECTION.Type Amount Show direction and.distance In miles from at tag
12. CASING:
Depth Wag T6ldotea taro State Roads or Canty Roads.Include the road
or woom numbers and common mad names.
From-AL.mTLLa_Ft1 SZ
From To FL
From Tq Ft,�
13. GROUT-- Depth material b�deda�d�.
From.-
From To
.4- SCREEN: Depth Diameter . SlotSise Majedal w
From To Ft_(n. in.
From To 0
Ft`(n, in. rn
5- SANDIGRAVEL PACK. _
Depth Sin Material
From To FL
From To FL
6- REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC'lp.D INA000RDANCH WIf♦ISA NCAC 2C,WELL-
ONSTRUCfi0NSTANDARDS,AND THAT ACDPYOF THIS RECORD HAS BEBNP40VIDEDTOTIM.WELLOWNER
SIGNATURE-OF PERSON CONS7RUC1'INO THE WELL DATE -
submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-RalelskNC
-17699-1636 Phone No.[phone],w(tbin 30 days. OW-1 REV.07/2001

WELL CONSTRUCTION RECORD"
3. 7
North Carolina-Department of Environment and Natural Resources-Division of Watw Quality-Oroundwater Section --
WELL CONTRACTOR(INDIV.IDUAL)NAMEtpriat) -f-np115 L TIFICATIONi eZ/7Y
WELL CONTRACTOR COMPANY NAM PHONE 01461 -.S2 4-'3 ;Z 6 Q
STATE WELL CONSTRUCTION PERMITIF ASSOC.fATED W44ERMM
(if applicable) {(f applicable)
1. WELL USE(Check Applicable*Box):Resident'iat-0Yv nicipaUPublic❑ Industrial❑ Agricultural Q
Monitoring❑ Recovery ❑` Heat Pump Water Injection❑ Other CT if Other,List Use
2."W WELL LOCATION: Topo
gtaphid!azld salting
Nearest Town: G-lf LAAID/ ' County r-M Midget a ❑Valley ❑Flat
Ll ! e k"7—'�4.L_ (check appropriate box) . '
(Street Name.Numbers,Community,Subdiv/i�sioa,Lot No.,Tip code) - I:atitudellongitude of wolf location
3. OWNER: 4/2T/ �L l ReSS _ (degroe�minuteslaxand)
Address 02 SILI• E• c2 31ect• S'T r LatitudeAongitude source:❑GPS❑Topographic map
(Siren or Route No.) - (check box)
0) fbvi IY A'ND(2S tT/. 3 3 3 d S DEPTH ' DRILLING LOG
City or Town Stain ° tip Code From TO ' ,Formation Description
B 574 - / 3S ,
Aru wda-Phone ember • L. RM /t-e
4. DATE DRILLED - S
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 30 FT:
(Use"h^if Above Top of CaAm4
S. TOP OF CASING IS�_FT.Above Land Surface*
-Top of miss It rmloatad atfor below lan4i aurfaee rpalres a -
variancs In seeordaaee wltb ISANCAC 2C.01IL
9. YIELD(gpm):_ G METHOD OF TEST
10. WATER ZONES(depth): / 9D '
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 Din ter or Wej;ht/FL Me 'numbers and common road names.
From To--c2,-Ft
From To FL
From To—Ft.
13. GROUT: Depth ateriil Method -
From To�FL-6 n C
From Tc FL 1
ca
.4. SCREEN: Depth Diameter . SlotSize Material o
From To FL_In. in. �
From To Ft. in. in. -
5. SAND/GRAVELPACK:
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 -
ONSTRUCf ION STANDARDS,AND THAT A COPY OF THIS RECORD BEEN P40VIDED 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
17699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

o�rATEo
5/ " . KON�RmDENTIAL WELL CONSTRUCTION RECORD SM# (9 F
5'y North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9 2187
1.WELL CONTRACTOR: f. DISINFECTION:Type MT H Amount 160z
Russell S. Taylor g. WATER ZONES(depth): , /�
Wall Contractor(individual)Name From gals To VA From sTo�_
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: Thicknessl
Depth Die a}er We�i9h� Material
'
Franklin. NC 28734 From_�To�Ft� JAL f
City or Town State Zip Code From—To_Ft. _
( 828 )- 369-9591 From_To_Ft. _
Area coda Phone number
7. GROUT: Depth Materiel Method
2.WELL INFORMATION: From__Q _Tc_AW� _Ft. CEI Eilt & bH'Cllit2_EU d
SITE WELL ID#(If applicable) From_To_Ft.
STATE WELL PERMIT#(N applicable) From_To Ft.
DJVQ or OTHER PERMIT#(If applicable) 8. SCREEN: Depth Diameter Slot Size Material
M-LL USE(Check Applicable Box): Residential Water Supply❑ From_To Ft. in. — In.
,,
From To_Ft.—In. _ In.
I r.A rE DRILLED J ( '29 '05 From_To_FL_In. in.
TIME COMPLETED IL.00 AMC PMg
9. SANDIGRAVEL PACK:
3.WELL LOC ION; Depth Size Material
From To_Ft.
CITY: COUNTY Naai�=— From To_Ft.
I'll . �[, From To_Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope pValley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check apprdprlate bo>d May
O Clay f- SdI1CI
May be in degrees, ,
1-i TITUDE � _ minute,seconds or � ni
LONGITUDE in a decimal format
LaWtule/longitude source: ❑GPS oTopographicmap
ilocatbn of well must be shown on a USGS ODD map and
attached to this form rnot using GPS) _
4.WELL OWNER - o,,L
OWNER'S NAME Vit(.lrT tY[JR
ST "ET.AQDRESS _ YI�LII. E5 CD
wilrI D , NC_ aR7e v
Ity a T own State ZIP Coda _
(gM. )- 303-A9a q0
Araa code- Phone number
11. REMARKS:
5.WELL DETAILS: �O1W s
a. TOTAL DEPTH:Is. DOES WELL REPLACE EXISTING WELL? YES❑ N0*'
/''�
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITHe. WATER LEVEL BBIOW Top of Casing: lob0 o ' FT. 15A NCAC 20,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'If Above Top of Casing) RECORD BEEN PROVIDEDTO THE WELL WNER.
d. POP OF CASING le_ 2 FT.Above Land Surface' , iP j
'Top of casing terminated al/or below land surface may require SIGNATURE OF CERTIFIED LL CONTRACTOR CATa variance In accordance with 15A NCAC 2C.0118.
e,.YIELD(gpm):�_METHOD OF TEST Blow Russel.
S. Tayl r
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,NO 27699.1617 Phone No,[phone] ext 568. Rev.7106

rk NER
3
)f Y RESIRESIDENTIALwba.L colvs"I'Itl1 ,C C"IION OItU 3 2 u26 MWD
3 :
North Carolina Department of Environment and Natural Resources-.Division of Water Quality NC
WELL CONTRACTOR CERTIFICATION N
1.WELL C NTRACTOR: I. DISINFECTION:Type T Amount
K7"r}/ Ie EG — If. WATER ZONES(depth):
Well Conlrac or(Individual)Name From 376 To _11 From—To—
MILLER WELL DRILLING , INC . From To From To
Well Conllaclor Company Name From To From Te
STREETADDRESS P . D . BOX 567 G. CASING: Thickness/
Depth Diameter Weight Material
HAYESVILLE NC 28904 From O To6_Fl s'
City or Town Stale Zip Code From To Ft.
c829 y 837-2397 From To FL _
Area code- Phone number
T. GROUT: Depth IwetJJe//dal Method
2,WELL INFORMATION: From LT To� Ft.
SITE WELL ID#bf applicable) Fron­7 2 To. °�Ft. fc
STATE WELL PERMITOul applicable) Ron To FI.
DWQ o OTHER PERMIT lf(if applicable) 8. SCREEN: Depth Diameter SM Size Malarial
From—To—FL—in. _ In.
WELL USE(Check Applicable Box): Residential Water Supply W� From To Ft. In. _ In.
DATE DRILLED /I/— t 0 I From To FL In. _ In.
TIMECOMPLETED d7.-CD AMD PM LkY
S. SAND/GRAVEL PACK:
7.WELL LOCATION: , Depth Size Material
CITY: 411, COUNTY 60" From To FL
From To Ft
6) y^ C y-e CSC From To FL -
ISNeeI Name,N e be,,.Commmrily.SubdM;ion,lot No.Parcel,Z1p Cotle)
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
Ua-S a DValley []Flat ❑Ridge FjOmer From To Formation Description
(chew appmr dale box)
,T May be in ftrem,
LATITUDE 3 ��' G ' / mines,secnn hor 0S O (�Gj
LONGITUDE g .j 3 j, s''' in a Jeaimal finmar S'U �:f',Z G:s'N•Tr'
Latilude/longitude source•. uMS ❑Topographic map
(bcnfbn orwer must he shown on a USGS fopo map and -
attached to this total I not using GPS)
1.WELL OWNER
OWNER'S NAME
STREET ADDRESS t'f3�h WQ-S-f' PaH'I!d"ll-W. N -
City Or,Town Fare Zip Code C.A '
Area code- Phonenumbn
11. REMARKS:
S.WELLDETAILS: J r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO€Y
I DO HEREBY CER TFY THAT THIS WELL WAS CrJNSTRDCTFD N ACCORDANCE MIN
c. WATER LEVEL Below Top of Casing-. FT. ISANCAC2C.WELL CONSMUCTrTl SIARDARDS.ANO THAT A COPY OF IMS
(Use'+"R Above Top of Casing) RECORD HAS BEEN PROVIDED 10 THE WELL OWNER.
d. TOP OF CASING IS�_FT.Above Land Suface' o�1GtL. � dz-os
'Top ol casing terminated War belay land Surface may require SIGNATUR OF CERTIFIED WELL CONTRACTOR DATE
a valance in accordance With 15A NCAC 2C.0118.
a. YIELD(gpm): -3 METHODOFTESTJ,12�/ �`Lr'LIf ec,d
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-Ratelgh,NC 276994617 Phone No.[phone] exl 668. Rev 7105

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-D
i f W a ivision ofar Quality-.Groundwater Section /-
WELL CONTRACTOR(INDIV,IDUAL)NAMR (print) c�rl F11S !c}Q'/0'A 41 CLIKTIFICATIONY /�`a°
WELL CONTRACTOR COMPANY NAM PHONL 9�4'3
STATE WELL CONSTRUCTION PRRMI7Y ASSOC(ATRD W RRMM
(if applicable) -(ifapplicable)
1. WELL USE(Check Applicable Box):-Residential' unicipaUPublic O Industrial❑ Agriculture)Q
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other 5 If Odier,List Use
2.'WELLLOCATION: nn To biat- Ddsetting
Nearest Town: /l// County Pfdaga OSlope ❑Valley ❑Flat
'/{/ S C- TW e-e f-A 1-4 8 2r1 ..-4''/3 l f (cheek appropriate box)
(Strtc(Name•Numbers,Community,SuuIxIivision,l.ot No.,zip Code) . - I;ath4enotigitude of w.01 location
3. OWNER: D�(k.a-� I�fl�l`'-'' - - (degreea)minuteshaunds) .
Address C1 S g6 o M e S T F A7'-� C D U 2T LatitudeAongittide source:OGPSOTopographic map
(Boca ar Route NoJ (check box)
Cl PAO 1 zN im 33 7 SJ DEPTH DRILLING LOG
City urro stain " Zip code .From To ,Formation Description
�2) 799- 39bG n mil= n i9;�
Arm code.Phone Amber .35 -
4. DATE DRILLED / -�f�G'S SS ' ��5;0 �i 2 G ✓a +�S. TOTAL DEPTH: SSLU '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Caging Z S..Fr:
(Una a if Above Top of Caning)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated actor belgw Im4l.surface roquiru a
vartaaa in accordance with-ISANCAC 2C.01IL
9. YIELD(gpm): METHOD OF TEST IUID,xd-,
10.WATER ZONES(depth): .3,;20'
LOCATION SKETCH
1 1. 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��r .or We: hm M�a�ep�I number and common road names.
From To SS FL=-QRi � Q
From To Ft. n
From To_FLU_
13. GROUT: Depth Materiil Method o
From To
_0-FL CD
From To FL ctt
4. SCREEN: Depth Diameter . Slot Siu • Material -
From To FL in. in.
From To Ft. in. in.
S. 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
ONSTRUCTION STANDARDS,AND THAT A COPY OF T14S RECORD H&S BEEN P40VIDED TO THE.WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mal)Service Center-Ralelgh,NC
,27699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001

WELLCONSTRUCTION RECORD
North Carolina-Department of Euviroruneht and Natural Resources-Division of Watw Quality-Groimdwatw Section
.: /7//__
WELL CONTRACTOR(INDIV•IDUAL)NAME tpriat) _Yl talc 11A A, CCI7'FIFICATIONY/ `f'
WELL CONTRACTOR COMPANY NAM ' YKONE f .'a 4'3 a'6 0
STATE WELL CONSTRUCTION PERMIT{ ASSOCLATRD W ERmrr# .
(if applicable) -(ifapplicable)
1. WELL USE(Check Applicable Box):ResidenfielTYMunicipaUPublic❑ Indu3K&l 17 Agricultural O
Monitoring❑ Recovery ❑' Heat Pump Water Injection❑ Other L7 If Ot)ier,List Use
Z. WELL LOCATION: . ogtapbidLand setting
Nearest Town A,v14L: A/ County,( tdge ❑Slope ❑Valloy OFlat
L oaQ73't` (clwek appmpdats boa)
( tree, ama,Numben,Community,Subdha on,t.ot No.,Zip Cade) 1.4titudellongitude of WFII location
3. OWNER:V. 11`, /l. IR LA-le 4. 1IO M"" �L µC• - (dograea)miautedaxondt) .
Address 10 k 3 C.n R I-2 . LatitudeAongittide sotrce:OGPS❑Topographic map
(Strew or Route No.) (chock boa)
u L A 0-4, .3 0 5 S cL DEPTH ' DRILLING LOG
City'arTo%n State tip Code From To Fq tion Description
(mod 55 D • 3 5 y S < h_=�_
Area code.Phone anmbu L � — Sh UO- !'3'�U_� C
4. DATE DRILLED
5. TOTAL DEPTH: �FAD'
6. DOES WELL REPLACE EXISTING WELL YES❑ NO c
7. STATIC WATER LEVEL Below Top of Casing.-ZLa FT:
(Uu"e if Above Top of Casing)
8. TOP OF CASING IS�_Pr.Above Land surfaces
'Top of casing laminated atior betgw a -
variance in accordance wits I5X7jCAC 3C.011a.
9. YIELD(gpm): ram_METHOD OF TEST
10. WATER ZONES(depth): 70 "
LOCATION SKETCH
11. DISINFECTION:•Typo Amount Show direction and distance In stiles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diaper or Wetogt. Matey -'numbers Rod cemmon road flames.
From—L. To SO Ft.-112-$ f?: f X '
From To Ft.
From To Ft. n
13. GRO(IT_ Depth Material Method rn
From FL by
�_To�_
From To TL CD
4. SCREEN: Depth Diameter Slot Size Material - O -
From To Ft. in, in. G,'1
From To Ft, in. in. - -
5. SAND/GRAVELPACK _
Depth Size Material
From To FL
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 F THIS RECORD 1H&S 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
'7699-1636 Phone No.(919)733-)221,within 30 days. OW-1 REV.07/2001

WELL CONSTRUCTION RECORD
Nora,C—Moline.-Department of Environment and Natural Resources-Division of W ater Quality-Groundwater Section
WELL CONTRACTOR(INDIV,IDUAL)'NAM6 ("It -t1 vllS !c}Q�IOM r�� CKRT1F[CAT"I�ONf M4
WELL CONTRACTOR COMPANY NAM PHONR a17
STATE WELL CONSTRUCTION PERMIT/ A93OCIATP.D W14ERmrrf —(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential' unicipaVPublic❑ Industrial❑ Agricultural p
Monitoring O Recovery ❑' Heat Pump Water Injection❑ Other f1 if Ot)ior,List Use
2.-WELL LOCATION: ' ograpbic/Land setting
NerestTown, F)1#A/l/e�LI4 County' 'dge ❑Slope OValley ❑Flat
(26mYh, U(t--(e/I.et it-/Zc_-a.E73yI (check appropriate boa) - - 4 .
(St=(NzAne,Numbers,CoiAtnunity,subdivision,Lot No.,Tip Cade) Latitu4c/lorigitude of well location
3. OWNER: II -/(/ �-I (dearoesJminuter/aeebnde)
Address 23 PIC/21014 l! R Latitude/longittide source:❑GPS❑Topographic map
(Sake;or Route ) (drools box) .
�QAkkL, q, AIL' -3 DEPTH DRILLING LOG
� ��ny a Towo Stain zip Code ;From To ,Formation Description
Arcs code-Pt o number A A/.
4. DATE DRILLED I U - _Tn ' SS'm' -v L i t A—
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing.—j-K _FT.
(Un'a if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surface'
-Top or cuing to alaated ever belay landaurfau requires a -
varfmu In arrordaou with-ISA71CAC ZC'01IL
9. YIELD(gpm):�Q_METHOD OF TEST�0VJ1
10. WATER ZONES(depth): �9/-, S&R, I (/
' 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 aer or Wet�ltt/FL numbers and common road;tames.
From To ,r Ft._�' SR.1f
From To FL
From Tq FLU_ -
13. GROUT: Depth Materiea Method c7
From Tom FL '/""I�mIL. e�"�i
From To FL rro
.4. SCREEN: Depth Diameter Slot Size Material - CD --
From To Ft. in. in. p
From To Ft, in. in.
S. SAND/GRAVELPACY, _
Depth Size Material - -
From To Ft• -
From To FL
6. REMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
ONSTRUCTION STANDARDS,AND THAT A COPY �I COORD H&S BEEN P40VIDEDTO THE.WELLOWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ralelgh;NC -
17699-1636 Phone No.[phone],Within 30 days, GW-I REV.071 001

WELL CONSTRUCTION RECORD"
North Carolina-Department of Environment and Natural Resources-Division of Watw Quality-Groundwater Section
WELL CONTRACTOR(INDIv-1DUAL)NAM1t (prmt) fnt'1.15!r}�Jl n,+. ctT CATIONi /7/P
WELL CONTRACTOR COMPANY "11a4e14 W6111 Y-1 11 iu q�
STATE WELL CONSTRUCTION PaRMhV AssOC(ATLD W CRMITI - -
(ifappliable) {ifapplicable)
1. WELL USE(Check Applicable Box):Residential' unici*Tublic❑ Industrial ❑ Agricultural 0
Monitoring O Recovery ❑ Heat Pump Water Injection O Other C7 If Other,List Use
2.-WELL LOCATION: . Topoglap PJI and setting
Nearest Town: t.eh Yle i A/ County ORidge opo OValicy ORlat
SO C& a- 1). 9 e e /L S u b b;r r s ;rwJ e 2 F?.? y (check appropriate boa) 41
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) I;atitudenongitude of well location
3. OWNER: BDUJQ,,LC S tee-S - (depees)minutedscebnds)
Address 3 R E /HQ; K, 'S 7 - Latitude/Iongitude source:❑GPSOTopographic map
(Sues a Route Na) - (check boa) .
FileQ�n6C/ r 0` 973 DEPTH DRILLING LOG
City'orTown State Zip Code From To Formation Description
Area code- -
4. DATE DRILLE Q 1 466S . ,�,/U E- _ it A6.t I-
S. TOTAL DEPTH.-,
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO c
7. STATIC WATER LEVEL Below Top of Casing; YOD FT.
(Uso"+"if Above Top of Casing)
8. TOP OF CASING IS�_Ff.Above Land Surface•
'Top a miss terminated at/or bdg,,!lsad.sur(w requlrts a
variance in accordance with-1SANCAC 3C.011L
9. YIELD(gpro): -5-_METHOD OF TEST n/lam
10.WATER ZONES(depth): /S 6 _ (�
T
LOCATION SKETCH
11. 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 D��'yap�d�e�rr .or We:ghUFL Ma numbers and common road names.
From To�FLU_$
From To FL
From Tq FL
13. GROUT: Depth .Material M�o"hod -
From__n_To-AM—FL-4p ��`iJd1SL,
From To FL o
m
.4. SCREEN: Depth Diameter . Slot Size Material n
From To FL in. in. rat
From To Ft. in CD. in. � -
S. SAND/GRAVEL PACK: _ o
Depth Size Material C1 ---
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 THIS RECORD H&S BEEN P3 OVIDED TO THE.WBLL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
S ubmit the original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh;NC - - -
+,17699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
C . . CO�(��
North Carolina-Department of EnVirmuncnt and Natural Resources-Division Niter Quality-Groundwater Section
WELL CONTRACTOR(INDIV•IDUAL)'NAME (print)�ri.�,� Il , . - J' CY�TErCATIONIL `c
WELL CONTRACTOR COMPANY NAM PHONE s�y-'3 Z-6 Q
STATE WELL CONSTRUCTION PERMh1 ASSOCIATED W gRMr1Y _
(if applicable) -(if applicable) '
1. WELL USE(Check Applicable Box):Residentie17YMunicipaVPublic❑ industrial ❑ Agricultural Q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other Cf If Other,List Use
2."WELL LOCATION: Topogra setting
Nearest Town: rRA/f//LL%N County ❑Ridge opt ClValley ❑Flat
�. jI Q�)D/G Ce V L �.�T � B jr'y'�p (dmk appropriate box) . �
(Street Name,iluummben,Community,SubdivisioN Lot No.,Tip Code) T utitudellongitude of well location
3. OWNER: U AA1 �A4/UE - (dc)pe�minutedsecbnds)
Address -D Latitude/iongitude souroe:❑GPS❑Topogmphic map
(Boca ar Rowe No.� (cheek box)
A•tt .
(� I r S j�,s M / � �� �le DEPTH ' DRI ING LO
ny'orr sum zip code .From To Formation Description
g 1_ M/h �( Ar/
Ara code-Phone ember '� ` - fn.S ^,.) tL' , �—u
4. DATE DRILLED US ��tLe sq�• G r t e-
5. TOTAL DEPTH: .SD D '
6. DOES WELL REPLACE EXISTING WELL? YES 13 NO,
7. STATIC WATER LEVEL Below Top of Casing. / 5 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface•
Top of cuing terminated actor belgw lutd.aurfm requires a -
varlm"In accordance wltlr ISANCAC 3C.011L
9. Y I ELD(gpm): METHOD 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 Diameter or Weom Matf a numbers and common road names.
From­ To/V-FL k7' $ Q
From To FL
From Tq FL_ _
13. GROUT: Depth Material Method ® -
From_To—aD—Ft. n
tV
from To TL 'T' ��� O
4. SCREEN: Depth Diameter Slot Size Material _
From To FL in, in. CD
ut
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 IBA NCAC 2C WELL
ONSTRUCTION STANDARDS,AND THAT A COPY OF'� S RECORD HAS BEEN P40VIDED TO THE WELL OWNER
�P is -i a 45
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quallty,Groundwater Section,1636 Mal(Service Center-Raleigh,NC
17699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001 ...

Is._ RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9 2045
1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 160E
James B, Brown g. WATER ZONES(depth):
Well Contractor(Individual)Name From I li:1 t-to lill—r From To
iSe�9den Brothers Well Drillincx, Inc. From Nob To ISQ' From ro -
Weil.ContractorCompanyName From To From To
STREETADDRESS 73 Holly Hills Vista Rd S. CASING: Thickness/
Depth Di elpr We�lggt� Material-
-anklinF NG 28734 From�_To�FI.�_ t �oL
Cfty or Town State Zip Code From To Ft.
( 828 1- 369-9591 From To_Ft.
Area cods- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: From_Q_To_20 Ft. CHtt31t & hg=1ite E2M d
SITE WELL ID#(if applicable) FrDm To_Ft.
STATE WELL PERMIT#(If 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 0 From To_Ft._in. _ In.
From To_Ft.—In. — In.
DArEDRILLED 5 From—To—Ft. in. _ in,
TIME COMPLETE AM❑ PMR(�
8. SANDIGRAVEL PACK:
3.WELL LOD TION: Depth Size Material
CITY: COUNTY From To_FL
t�/� p � From To_Ft.
LY ' s� From To_Ft.
(Street Name,Numoom community,Subdivlelon,Lot No.,Portal,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ClVallay ❑Flat DRidge ❑other From To Formation Description -
(check apprdpriate box) Clay & sand
LATITUDE Maybelnonds or degrees, KK�A�(( r � ==err
� _ minutes,secconds o Trani to O
LONGITUDE_ _ In decimal format n
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wed must be shown on a USGS topo map and n
attached to thla form#not using CPS) —
a.WELL OWNER
OWNER'S NAME dA
$T; EET ADDRESS
i by-Al NL 26-73V
City Or Town State Zip Code
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: /(00
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOK
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W RH
c. WATER LEVEL Below Top Of Casing: ao T. 15A HCAC 2C,W ELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'S Above Top of Casing) RECORD HAS BEEN PROVIDED TO 7HE WE LL OWNER.
d. TOP OF CASINO 10 2 FT.Above Land Surface'
'Top of casing terminated at/Dr belay land surface may require NATURE OF CERTIFIED WELL CONTRACTOR ` DATE�
a variance In accordance with 15A NCAC 2C,0118.
a, YIELD(gpm): ,3 5 METHOD OF TEST B1OW James B, Browri
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form Gw•1a
1617 Mail Service Center—Raleigh,INC 27699-1$IT Phone No.[phone] ext 568. Rev.7106

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 1662
James B. Brown g. WATER ZONES(depth): 2 I
Well Contractor(Individual)Name From�L'To. From To
Heciden .Brothers Well Drilling, Inc. From To From To
Wall Contractor Company Name - From To Fr^i+i To
STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/
Depth Diameter Welghl Materiel
Frank!in F NC 28734 From_ To Ft.
rA ,tax S�a—�
City or Town State Zip Code From To Ft. _
( 828 )- 369-9591 From To FL
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION: - From�To 20 Ft. CIMMt & bgni be 3�JB3
SITE WELL ID#(II applicable From To Ft_.
STATE WELL PERMIT#(If applicable) From To Ft.
D WO or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Slze Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft.—In. _ In.
From Tc Ft.—In. — In,
DATE DRILLED ,aoo5 From To Ft_in. In.
TIME COMPLETED , OO AMC] PM
8. SANDIGRAVEL PACK:
3,WELL LOC TION: Depth Size Material
From To Ft.
CITY: •V COUNTY From To Ft.
From Tc Ft.
(Street Name,Numbers, muniy,Subdivision,Lot No.,Parcel,Zip Code) -
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check apprdprlate box) 0 471 Clay & stand
LATITUDE May be in degrees, r s (;rani to
_ minutes,seconds or —
LONGITUDE In a decimal format
Latitudellongitude source: ❑OPS OTopographic map 7
(location of wed must be shown on a USGS topo map and ;'T
attached to this form snot using GPS) a
4.WELL OWNER m -I
OWNER'S NAME ICA AMA
S7 E ADDRESS _n
ny or Town I State Zip Code
C16B)- 42A-- 100
Area code- Phone number
11. REMARKS:
S.WELL DETAILS: 9 aD
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO;
11
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: FT. 15A NCAC 20,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
(Use'+'O Above Top of Casing) R 0HAS BEEN PROVID D TO THE WELL OWNER.
d. TOP OF CAGING 18 2 FT.Above Lend Surface* -
'Top of casing terminated at/or below land surface may require GNATUR O CERTIFIED WELL CONTRACTOR
a variance in accordance with I SA NCAC 2C.0118.
DATE
e. YIELD(gpm): • 50 METHOD OF TEST DIQW 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
116117 Mail Service Center—Raleigh,NO 27699.1817 Phone No.(919)733.701.5 ext 568. Rev.7105

�y aµ STATj u�
4T m n'
RESIDENTIAL WELL CONSTRUCTION RECORD
4
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 7 7
U2e
1.WELL50N,TRACTO/R1: f. DISINFECTION:Type Amount
7 r ej 1.V-A-/) •e, g. WATER ZONES(depth):
Well Contractor(Individual)Name From To From To
MANEPRMRFCr }l Fran_ To From To
Well Contractor C .'nvL From To From To
i dC 23734
STREET ADDRESS 6. CASING: Thickness/
Depth , Dismal Weight Material
From-�To�L Ft._ 7/fG
City or Town qState Zip Code From To Ft.
(�)- 5r?y—V—l�l�J" From To Ft.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material Method
From lr To20 Ft.
SITE WELL WELL ID#(if applicable) From To STATE WELL PERMIT#(k applicable) From,_Tq FIFt._
DWO or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft.—in- _in.
L From—To—Ft.—in. _in.
DATE DRILLED la-�0—Q J Frwn_ To Ft.—in. _in.
TIME COMPLETED AM[3 PM[3
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: y�1 1�Ad'bl kl a/ COUNTY J I yt�I,� I,)lt' From.. To Ft.
From To Ft.
��f/ r ti'G> From To Ft.
(Street Nam Numters,Cam 7unity,Subdivision,Let No.,Parcel,Zip Code)
TOPOGRAPHIC!LAND SETTING: 10.DRILLING LOG
❑Slope []Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May e in degrees,
LATITUDE 3 _ minutes,seconds or
LONGITUDE_ _
in a decimal format.
Latitude/longitude source: ❑GPS ❑Topographic map -
(incaution of we#must be shown on a USGS topo map and ..
attached to this form#not using GPS) r,
4.WELL OWNER
OWNER'S NAME B—Lb iLw i- 1- l l-4 hl
STREET-ADDRESS 3b&C'
r ✓ rile -Y` ;73Y
City or Town State Zip Cade
Y —
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: lJ
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
r DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WrIH
c. WATER LEVEL Below Top of Casing: „Z.D� FT. 15A NCAC IC,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+'i1 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 aVw below land surface may require SIGN T/URGE O(F CERTIFIED W ELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. S, �Jr ,
e. YIELD(gpm): METHOD OF TEST PRINTED NAME O PERSON CQNSTftUCTING THE WELL
Submit the original to the Dlvi ion of W1111= �tPC& 30 day . Attn: Information Mgt., Form Gw-la
1617 Mail Service Center—Rate!!g 1,NC 27699-1617 Phone No.(919)7 3.7015 ext 568. Rev.nos
FEB 0 7 2006 JAN 19 2006
Asheville Regional Office
Arnilfar Prnfn rite..