Mc CY2005

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 19/I/'\.I ' �� f CERTIFICATION/ IS�
WELL CONTRACTORCOMPANY NAME urtll(I
.. G 4 STATE WELL CONSTRUCTION PERMITS l
PHONE t(Sr�22 y-4 `4s
(ifapplicale) IAED WQ PERMITA
(ifapplicable)
I. WELL USE(Check Applicable Box):Residential 111/Munibipal/Public❑ Industrial❑ ALricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: . �Tvpographic/Land setting
Nearrst Town: rib County DO(N(L� ge OSlope OValley 0171al
/ h714 e L;fS/e D ram- (check aXwgmu bml
(Stme Name Nambcm.Conmunitr,Subdivision-Lot Na,Zip Cale) latitude/longitude of well location
3. OWNER:_ 1` 1(-)1 .n(L 1 �l/ljt (desrershnitwashaoats)
Address 57 L( 4 r4 m p K� Latitude/longitude source:EIGPS❑Topogmphie map
(Street or Rau Na) (theca boa)
�yk-r,o N t/LC DEPTH DRILLING LOG
City"Town Slate zip Code From TO Formation Description
(218 )-_7s(o- '70el f
Area code-Phnoe ember
4. DATE DRILLED /e O — 6 z ;y 46`&
S. TOTAL DEPTH: Z 0 5 ;-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO M-�
7. STATIC WATER LEVEL Below Top of Casing: 5
(Use"+-if Above Tap of Casirse
8. TOP OF CASING IS ( FT.Above Land Surface*
'Tep of eatrq wahated odor behw had sari t rebattta a
varihaee In weardsme With ISA NCAC 2C.01It rvv
9. YIELD(gpm): /b METHOD OF TEST g / /Z
10.WATER ZONES(depth): /__ /Oo_�,✓1 69 2 RO Ln
LOCATION SKETCH -.
11. DISINFECTION:Type e Amount O Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Dieuer or W et0tift Material mmtbers avid eormnon road nomm.
From DepthTO FL m
From C To=O FL-iPTV—
From 7a To__l 2- _FL y I p
13. GROUT: Depth Material Method
From To FL
From-9—To 96 Ft. 4-yRr 1 DL
14. SCREEN: Depth Diameter Slot Sim Material t TUMS
From To FL in. in. (UltfS , r-1 �iytck
From To Ft. in. in.
15. SAND/GRAVEL PACK:
_- Depth Size Material
From . To Ft. -
FTDM To Ft.
16. REMARKS: - - -
1 DO HEREBY CERTIFY THAT HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2�WELL
CONSTRUCTION STANDARD ,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER'
/ SIGNA*RE&IF PERSON CONSTRUCTING THE WELL DATE
Submit the oriRlala l to the Disision of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phnnc No.[phone],within 30 days, GW-1 REV.072001
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WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of water Quality-Groundwater Section
\VELLCONTRACfOR(INDIVIDUAL)NAME (print) yA1Zu Ii�S'��[,� crstmICAmox
.T T
WELL CONTRACTOR COMPANY NAME JJS'{i�-E �✓�-�[-Pf��t+a'! PMME of 17Z5''SK'yt/
STATE WELL CONSTRUCTION PERMITa ASSOCIATED wQ PERbirrs
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential"unicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovcry ❑ Heat Pump Water Injection O Other O If Otter,List Use
2. WELL LOCATION: c (1G[ Topographidl-aan�ting
Nearest Town: M Coumy / 0Ridtre OSlope Ellalley Mat
(check appnpriam box)
ISlreat Name.Numbers,Community,Subdivisim,Lot Na..Zip Cade) Latitude/longimde of well location
3. OWNER- ULiif! �.'N n'1L (degrea/mimashecants)
Address 18V ro ,n's G a ✓' Latitude/longilude sourcc:OGPSOTopographic map
�) � �� � IStrar ar Rome No.) (ckedc but -
ffic, �v At e- 1 i''73 Z DEPTH DRILLING LOG
Citym Town State Zip CO& From TO Formation Description
2Y )- 72G- al/-
Area code-Phane number (0— Z 4 --.�/2
4. DATE DRILLED
5. TOTAL DEPTH: l G S"
6. DOES WELL REPLACE EXISTING WELL? YES O NO 9-'
7. STATIC WATER LEVEL Below Top of Casing: FT.
(the"+"if Above Top of Casing)
8. TOP OF CASING IS / FT.Above Land Surface'
'Tap of cuff{tertalustd adar%tine pW sr4te resojee,a
variance to acmrdonce with ISA NCAC 2C At IL rlt
9. YIELD(Spin): 210 METHOD OF TEST A/I'L
10.WATER ZONES(depth): 20 PC /tun
LOCATION SKETCH
11. DISINFECTION:Type C?LOLL,Ve Amount S� ()Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depht Diameter or weigWrt. material numbers and cornmon road names.
From To FL
From_To_j!Z�FLU el y // e
From z To_*.�Ft. f t lee64`/ y.
13. GROUT: Depth Matmial Method ^
From To FL .�
From o To ,L- Ft.
14. SCREEN: Depth Diamet Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material C
From �_ To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY TH THIS WELL WAS CONSTRUCTED INACCORMNCbNTH ISA NCAC 2C,WELL
CONSTRUCTION STANDAI S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER'
Si I A OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-16-16 Phone No.[phone].within 30 days. G W-1 REV.072001

V R, k n r:'+, e 3 'a.st
.
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)�Me::v Sa S�/CI'_ CERTIFICATION
WELL CONTRACTOR COM PANY NAM E Stalicrf w! zLC..17. r"Lt,:.N� PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential d Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: opographic/Land setting
NearestTogn: MC'r;enlJ County A6 7 dge ❑Slope ❑Valley ❑Flat
IJ eA i L C (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: OMi4U helr-SS/O (degrees/minutesismonds)
Address — j N -It sr�'j C le 5 5( Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�C e WELL- S4 12 53 3 DEPTH DRILLING LOG
uy or Town stare Zip Code From To Formation Description
Area code-Phone number O p D i rt,f
4. DATE DRILLED -fin 1S <95
5. TOTAL DEPTH: 905" Fto- 105-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 11,
7. STATIC WATER LEVEL Below Top of Casing:_8!�_FT.
(Use"+^if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surface• n
-Top of casing terminated atlor below land surface requires a
variance in accordance_with 15A NCAC 2C.0118., t _
9. YIELD(gpm):�METHOD OF TEST 4+1 2 co
10.WATER ZONES(depth): V2 gl/f2eA & Q00 a
LOCATION SKETCH Ln
I I. DISINFECTION:Type C OArN L' Amount o2 Show direction and distance in miles from at least ZZyZV
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt. Material numbers and common road names.
From To Ft. dq
From U Tom Ft.�— C? R p
From /05' To /07 Ft. �t L1
13. GROUT: Depth Material Method {('113a 'K&yJO
From To Ft.
From To- lb Ft.
14. SCREEN: Depth Diametef' Slot Size Maleriall
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sim Material -
From To Ft.
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WE
CONSTRUCTION STANDARDS,ANlp THAT A COPYRECORD HAS BEEN PROVIDED TO THE WELL OWNER
SleRATL&E O V
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.[phone],within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina- Depanment of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) L3¢tJ 3'eyi'ICP- CERTIFICATION#
1\"tiLL CON'I RACfOR COMI'ANY NAME pY;U`.1r�PHONE # '72
sTATE WELL CONSTRUCTION PERMIT# aSSOC1ATED WQ PERM1IIT#
(ifa licable)101111111 (ifa licable) ....q5.
i. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑ "6
v n Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
�. Topogragyie/Land setting .10
Nearest Tow County L-(� ❑Ridge ope ❑Valley ❑Plat
Eifyr� (check appropriate box)
ir
(Street Name,NNuumbers,Community.Subdivision,Lot No.,; Cade) J Latitude/longitude of well location
3. OWNER: L/1/-AL, l7/ ���,�nrIF (degrees/minulus/saonds)
Address i f3 rrj Q t a R Co.) .t' '�/)/� 1 e S
5 Latitudcllon+iwde sourer.❑GPS❑Topographic map
t� (Street or Route No.) (check box)
1'�Gr1c'� 'hjQ�S� DEPTH DRILLING LOG
City or Town sate Zip code From To Formation Description
(�)- y*e-s�z
:Yr code. number , P-
4. DATE DRILLED IV-2!2-05'
5. TOTAL DEPTH: E'IJ.S-
6. DOES WELL REPLACE EXISTING WELL? YES t❑ ,NO
7. STATIC WATER LEVEL Below Top of Casing; ! o FT.
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS�_FT.Above Land Surface*
*Top of casing terminated atfor below land surface requires a
variance is accordance with 15A NCAC 2C.01IL
9. YIELD(gpm): dr METHOD OF TEST 4/ /Z
10- WATER ZONES(depth): ,,21 ,EpC���x,
to LOCATION SKETCH
11. DISINFECTION:TypeC7L6/2riJ Amount O " Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Fl. Material numbers and common road names.
From To Ft.
From To m Ft. y-- t c^
Fro To=L)Ft.—ma p Y//13. GROUT: Depth Ienal Method
From To Ft.
From_TDZ4_FL. — f !✓.? -
14. SCREEN: Depth Di er Slot Size Material
From To Ft. in. in. u���5s
From To Ft. in_ in.
15. SAND/GRAVEL PACK: ef!
Depth Size Material r13�
From To Ft_
From To Ft_
IG. REMARKS:
1 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
IGN R F PERSON CONSTRUCTING THEWE66-- --_- _ DATE
:.— tr,. f
Submit the original to the Division of Water Quality,Grou nd at _
W _Wtibn,-76J6.Msi13erti2e Cent cr-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
yWELL CONTRACTOR(INDIVIDUAL)NAME (print) � i. (L i.vy�lr3 j L,G CERTIFICATION# /1 G
\\'ELL CONTRACTOR COMPANY NAME .1(�7��ti¢ �J,;.L:�- f�'—. L L _PHONE If
STATE R'EI_L CONSTRUCTION PERMIT# ASSOCIATED WQ PERM1 #
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Or Municipal/Public❑ Industrial❑ Agricultural❑ c
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use
v �
2. WELL LOCATION: To of g "s
Nearest Town: 11'1/i✓._,^ County 12����=; ,Y' a p P d setting
p . --t + ❑Ridge ope ❑Valley ❑Flat / ;>
(check appTaImatc box)
(Sucel Namc,Numbers,Canmunhy,Subdivision,Lot No..Zip Caic) Latitudeilongitude of well location
3. OWNER: `✓ O.'lolaI C. Ae (degrees/minuteslsecoads)
Address , _ �4t�X '-_V /t fe�yv Latitudetlongitudesource:❑GPS❑Topographicmap
tStrea or Route No.) (check box)
rua%4e: 5 CL 7/6 DEPTH DRILLING LOG
�:ityor Town state e Zip Code From To Formation Description
Area code-Prone nanber.
4. DATE DRILLED rt/yr+�/
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7- STATIC WATER LEVEL Below Top of Casing: 4,0 FT.
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS C FT.Above Land Surface*
"Top of casing lermteated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.01 18.
9. YIELD(gpm): / METHOD OFTEST-6/f,?/t�d
10. WATER ZONES(depth): ��tyy Grp I,.Co'
y r ,t w SLR' LOCATION SKETCH
11. DISINFECTION:Type [',%.e i',L e /Amount 8 1'77_ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeightlFt. Material numbers and common road names.
From To Ft.
From I; To 57f.. FL 1,
t! t T
From To Ft. (' H yy / : brie/V
13. GROUT: Depth MTaterial Method
From To FL
From 0_To a C Ft. /v
14. SCREEN: Depth Diamet1er Slot Size Materialj ,
From To FL—in. in. y �q
From To Ft. Sc
in. in. ¢� /C
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. ,w� �- -
From To FL
16. REMARKS: `
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACC RDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THMi,, IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.1 SIG R ' FPERSONCONST__.CONSTRUCTING DATE
Submit the original to the Division of Water Quality,Groundivattr Sectianr1636Mai1SerriceiCeater-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001
i1 ,

WELL CONSTRUCTION RECORD ' 4
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
a'ELL CONTRACTOR(INDIVIDUAL)NAME (print) C-7 tL r y �b ram' 'L�' CERTIFICATION# yfS�
WELL CONTRACTOR COMPANY NAME KU fl c J-( )r i 0L.' Ni
PHONE S L 1 7ZV-%S y
SPATE WELL CONSTRUCTION PERMIT# wSSOC1ATED WQ PERMIT#
(i f applicable]
(ifappiicablc)
I. WELL USE(Check Applicable Box): Residential !X Municipal/Public❑ Industrial❑ Agricultural ❑ uG
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
s
2. WELL LOCATION:/
Nearest Tow,ft: /8,6097 ni County Topographic/ n tting �� A
❑Ridge ❑Slope alley 0171at
ISueet Name.Numben,Community,Subdivision,Lot No.,Z Code (check appropriate box)
��/1�1 tt_., - / i 1 Zip Code) Latitudellongitude of well location
3. OWNER: f�iT/<�tN ®/� r �'S ( fQ/�,�) �FIIl
Address - de so rc i:DGPconds)
LatitudeJlongitude source:❑heck❑Topographic map
(Streit or Route No.) (check box)
DEPTH DRILLING LOG
( City n Toow 1 Zip Code From To Formation Description
Area code-Phone-number
d-7
4. DATE DRILLED ,q g,n SJ
S. TOTAL DEPTH: /LS
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ff" 39 was 7, STATIC WATER LEVEL Below Top of Casing: . ljo Ff.
(Use"t"if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surface*
*Top of cosine terminated attor below land surface requires a
variance in accordance with iSA NCAC 2C.011& 4J
9. YIELD(gpm): &0 METHOD OF TEST 14/{Z
10. WATER ZONES(depth): (o DV03, &0
) � LOCATION SKETCH
11. DISINFECTION:TypcJ2 Lit t' Amount 'L Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the mad
Depth Diamc er or welght/Ft. atenal numbers and common road names.
From f7 To� Ft.
� if C
FromTo Ft. �pQ
From��To 4fO--Ft. - ! �-
13. GROUT: Depth Matenal Method -
From To Ft.
From opFL— yl 2
14. SCREEN: Depth / r
— — Diam eSize Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: 4L��
Depth Size Material \ J
From To Ft.
From To Ft- {{
16. REMARKS: Q
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r v
SIG ATU OF PERSON CONSTRUCTING THE WELL - - DATE
Submit the original to the Division of Water Quality,Grougdwaler Section,1636 hfa f'Scnice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. f W-1 REV.07/2001
0 '005
J
V; L �r� -

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Prins) �'X>;tJ ✓4}. CERTIFICATION#Z•)✓—
\\'ELL CON7'RAC`rOR COMPANY NAME T
lit t "Ig tLL De' ";WAONE # ( )
STATE\FELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (
(ifa licable) (ifa licable)
,t
I. WELL USE(Check Applicable Box): Residential ' /Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
L4
2. WELL LOCATION: l
Nearest Town: /41 14� UN Count (��C s _�Topographic/Land setting i
y E edge ❑Slope ❑Valley ❑Flat
6rt:k- Vr (check appropriate box) O� Yp
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cade) r Latitude/longitude of well location
3. OWNER: Wl'te >lhl lstzget-� j C`'� %1I/rnc (Jegree4minutes/seconda)
Address 70 d?apt /air OC/2, BP" Latitude/longitude source:❑GPS❑Topographic map
yy� (Street ar Route No.) ppd�' (check box)
! "�"'•'U � C/rZ DEPTH DRILLING LOG
City or Torn State Zip Code From To Formation Description
(-)- 't47�1 S
Area code-Phone number CJ
4. DATE DRILLED — G>
5. TOTAL DEPTH: Z Zy
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top ofCasing:. 2�_FT.
(Use'Y'if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface`
•Tap of casing terminated atlor below land surface requires a
variance is acmrdan with ISA NCAC 2C.OI IS.
9. YIELD(gpm): METHOD OF TESTJ�
10. WATER ZONES(depth): �J_S e."r`" ( f -;ZC6.6
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/Fir Material numbers and common road names.
From To Ft.
From 0 To Ft. fr G
From To A- FL -64
�L5 v 13. GROUT: Dep Mat rial el f thud t C jet
From To Ft.
From-0—To Z Ft.
14. SCREEMN: Depth Diamo Slot Sin Material fr
From To Ft. in, in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: Z
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 STANDAR S,.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA RE PERSONCONS1�RUCTINGT14E WELL DATE
Submit the original to the Division of Water Quality,G#oundivater Section,I636 Mail Ser}ice�cmer-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001
100
- j
11:

ni
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural D Res`ources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ �f12{� , Tas c6 CERTIFICATION#CV15
WELL CONT'RACt'oR COMPANYNAME_— _ :«}IC( Vt,)Q(,t; �rf'1(-�.+MZ) PHONEY
STATE WELL CO..\'.STRIJCTION PERMIT# +SSOCIATED WQ PERMIT#
10110011111111 (if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential
PP ) <R/MunicipallPublic❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use ✓r,
2. WELL LOCATION2{;O7� Count G�dLC<.L Topoe�•-,�hic/Land setting ps
Nearest Town; �1�� y� ❑Ridge LWSlope ❑Valley ❑Flat
L e.3.q !o S C ree,K b&V (check apprnnriaw box)
IStrctte Nmne.Numbers.Community,Subdivision,Lot No.,Zip Code) Laiitude/longitude of well location
3. (degreeshninutesfsecoads)
Address kal(,e Dn Latitude/longitude source:❑GPS❑Topoeraphic map
,,aa,� {Street or RouteNo.) (ch�vicb,x)
—%V\Q I't�ai N r;2 19 2L 2, DEPTH DRILLING LOG
Cityor Town sure Zip Code From To Formation Description
($28)-.72Y-M7
Area code.Plume number — S�
�. DATE DRILLED 4 OS` —T
5. TOTAL DEPTH: 7
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO B�- �O .Sara �
7. STATIC WATER LEVEL Below Top of Casing:�_FT. 9Q-l ZS' ey eAy,ZZ
(Use-+^if Above Top of Casing)
8. TOP OF CASING IS / FT.Above Land Surface'
'Top of easing terminated attar below land surface requires a
variance in acomdaW with 15A NCAC 2C.01I&
9. YIELD(gpm): &_METHOD OF TEST joi/Z
10. WATER ZONES(depth): b on,(o Zra,'
LOCATION SKETCH
11. DISINFECTION:Type P, r•rbL' Amount b'� Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
Depth Diameter or Weig)WPi. Material numbers and cormmon road names. 010
From To Ft. '7
5 From To�—FL (o —
From—(!!2_To Ft. �17
13. GROUT: Depth Material Method
From To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Fl. in. in. {�
15. SAND/GRAVEL PACK: Y
- Depth Size Material !)��S ���
From . Tc Ft. L�
VISS
FTOm To Ft
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCA 2C,WELL'S'
CONSTRUCTION T DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O ER
Sl RE OF PERS STRgCT1 G T E L DATE
Submit the original to the Division of Water ualit �---�Q IGtSapndwaterSection,1636M 9cc Center-Raleig)k NC
27699-1636 Phone No.[phone],within 30 days. h j 2005 - I GW-1 REV.07/2001
""'

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources
'-Division of Water Quality-Groundwater Section
\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) L9fff V N- ,)Vrk't cC CERTIFICATION#05 X%ELL CONI RACfOR COMPANY NAME- lO Cd it C- )ye-a— YI YR)C PHONE # jet'
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PE�R�-MIT#
(ifapplicable) 01'applicable)
I. WELL USE(Check Applicable Box): Residential LH Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
<<t
2. WELL LOCATION: "1
} " C opogtaphic/Landsetting n
NearestTown: Ol. -fil('� Count' p6i_+.i�LL tdge ❑Slope ❑Valley ❑Flat
l? P N 1 a 3 L (check aproopriate box) (.iG
iStrcct Name.Numbers,Communhy,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:C-I1�t54 �GrNLLI L
/ G
(degrees/minutes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic mapt�s °�'
(Svecl or Route No.) nf� (check box)
- ?1(•� �`�� C DEPTH DRILLING LOG
4 Cityor Totyn i state Zip Code From To Formation Description
(2)- fO'GY"' C3..1Z
Aren code-Plane nu nbe 'U i ttL+f S'0.}'7L'Ctlk
4. DATE DRILLED ❑) J O a
S. TOTALDEPTH: E05 12J lJD ':, S LLIt' 1L
6. DOES WELL REPLACE EXISTING WELL? YES O NO GK'
7. STATIC WATER LEVEL Below Top of Casing:
TC4 }')',
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surfaee requires a
variance in accordance with ISA NCAC 2C.01 I&
9. YIELD(gpm):�_METHOD OF TEST I
11 CIO. WATER ZONES(depth): 7��2f'I C?yEV9'_ tn dn(,i
LOCATION SKETCH
11. DISINFECTION:Type CL-1ZLh'G Amount � 0L 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. i dL0 For f
From O To 19 Ft. I LG tv
t YO
From 10? To �1� FL �
FromZ'�1 I Tc 129 FL
13. GROUT: Depth Material Method
From To FL
From n To FL P
14. SCREEN: Depth Diam ter Slot Sin Ma erial
/1
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft
IG. REMARKS: \
1 DO HEREBY CE TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTI ANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O
S18PATUREOF PERSON CONSTRUCTINO:T14E WELL - ,DATE
Submit the original to the Division of Water Quality,Groundti!atet Section 1636 Miil Senice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1:REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
%N'ELLCONTRACfOR(1NDIVIDUAL)NAME (prinq_)?/�7Ltt•I'' D JJ.Sfic-i- CERTIFICATION#
NVELL CONTRACTOR COMPANY NAME �': -tTl Lea t''Y�PHONEY
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
lifapplicablel (ifapplieable)
1. WELL USE(Check Applicable Box): Residential B�Municipal/Public❑ Industrial❑ Agricultural❑ F
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: pographic/Land setting G j H
NearccrstTown:OJA-r.p,J County _ 1 Idge ❑Slope ❑Valley ❑Fla(
1 �n rIJ IJL•F.CG� �L� �' (check appropriate box)
(Street Nano.Numbers,Community,Subdivision,Lot No..Ziptudc) Lalitudeilongitude ofwell location
3. OWNER: Ke V-\ lr),el 1/( (degrecs/minutes/seconds)
Address ,i 9(p Fe',,rt F'[ t.A `"- LA V\P Latitudeilongitude source:❑GPS❑Topographic map
(Street or Roate No.) (check box)
mPr• e Y— W, ?,�')�Z- DEPTH DRILLING LOG
City or Town Zip code From To Formation Description
state ` •
kv
Area code-Phone number
4. DATE DRILLED 5' #-05
5. TOTAL DEPTH: 4305'
6. DOES WELL REPLACE EXISTING WELL? YES E NO 0
7. STATIC WATER LEVEL Below Top of Casing- �s� FT.
(Use"+"if Above Top of Casing)
3. 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.
9. YIELD(gpm):- METHOD OF TEST (IT
10. WATER ZONES(depth): �f,.*x 44 Aco,
LOCATION SKETCH
11. DISINFECTION:Type,eu)Kr 4-f Amount f5i 0 7— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From--,—To
From_Tol�Ft.
13. GROUT: DepthMaterial Method j
From To Ft.
From__Tom Ft. LEJ
14. SCREEN: Depth Diameter Slot Size Material /
From To Ft. in. in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material -
From To FL
From To `Ft. �,"tt ii
IG. REMARKS: 4
i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WE
CONSTRUCTION STANDAR ,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE OWNER
SIG14ATU OF PERSON CONSTRUCTING THE.WELL- -- -DATE -
I .1
Submit the original to the Division of Water Quality,Groundwater Sec)t(oil, Q6-MWIService Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. ! .; r GW-I REV.07/2001
II r
L '

WELL CONSTRUCTION RECORD CY
North Carolina-Department of Environment and Natu I Resources-Division of Water Quality-Groundwater Sectio
(��AA a � r
\tlE1.L COSTRACTOR(Iti DIVtDUAL)NAa/E (print) P+"�-1 � L� `"�- CERTIFtCAt;T.I�ONM (�
%\'ELL CO TR,%crOR COMPANYNAME s- t-`. PHONE a (O'-W-724'4Sjfi�
STATE WELL CONSTRUCTION PERMITa ASSOCIATED WQ PE Mrrif
(if applicable) (if licable)
I. WELL USE(Check Applicable Box):Residential ff Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI G( i1(1 Topographic/Land setting
Nearest Town:- �V` County ❑Ridge fl7Slope []Valley ❑Flat
'�7(3iyti �/jyJ DAP (check appropriate box)
(Sacs Name.Numbers,Community.Subdivision,Lot No.,Zip Cafe) Latitude/longitude of well location
3. OWNER: W k, {dcg[ecslminutcslsaonds)
Address Vb )3Cx I I G9 Latitude/longitude source:OGPS❑Topographic map
IA, 19retl ar Route NoJ ,ry/ -- (check box)
Yv�� rV L �� /�� DEPTH DRI I I�OG
City or Town sort Zip Code From To Formation Description
foSS 4"(
Area code.PMxre number
4. DATE DRILLED ? o
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO &—'
7. STATIC WATER LEVEL Below Top of Casing: U 0 Fr.
(Use"+-if Above Top of Casing) '
S. TOP OF CASING IS FT.Above Land Surface' ::e
'Top steaming teruatuated attar below land surface reuaires a
variance in accorda?"with 15A NCAC 2C.all&
9. YIELD(gpm): METHOD OF TEST
10. WATER ZONES(depth): q.�Lea, e soc
LOCATION SKETCH _
11. DISINFECTION:Type C1 0 f',Nit• Amount Show direction and distance in miles fr&at le t
12. CASING: Wall Thickness two State Roads or County Roads.Inclo7e the road
Dept D)a cr or W eigbt1Pt. n'al rmmbers and comm m on road tmes.
J From O FL L m t/lit5— "'a
From TO lad FL OU'
From O() To roa FL�_
13. GROUT: Depth Material Method
From To Ft.
From To=Ft. TuKgaa
14. SCREEN: Depth Diameter Slot Size Mate'al
From To Ft. in. in. ^
From To Ft. in. in. �J
15. SAND/GRAVEL PACK:
_ Depth Size Material
From Tc FL ,� 1✓✓�
FTDM To FI.
16. REMARKS:
I DO HEREBY CERTI THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2 WELL
CONSTRUCTIONS DARDS,AND THAT A C PY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER'
SIG TUR OF-PERSON -TI NGTHEWELL DATE
Submit the original to the Division of Water Quality,Ground►fatgr Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],Within 30 days. -- - GW-1 REV.07/2001
i

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\V ELL CONT RACTOR(INDIVIDUAL)NAME (print) 1,4'_i J OS-f;CC— CERTIFICATION#
%FELL CONTRACTOR COMPANY NAME 'T6 S+i CE PHONE # pd26)'7L4'�'YB
SATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential C3'Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: c Topophic/Land setting
Nearest Town: jYjI4&1' Od County M, adL'' ❑Ridge lfiSl0pe ❑Valley ❑Flat
(3 u IZNC n �� (check appropriate box)
(Street Name,Numbers,Community,Subdivision.Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /J y,7 9e Ny� 1•0Isi (degreeslminutes/seconds)
Address F0ef 13a/ewe} rz Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.) (check box)
ANLJ Ift0fd � L Z— (VS L DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(628)- 72 - 21-17 �J
Area rode-Phone number
4. DATE DRILLED -zo —
5. TOTAL DEPTH: 705, /•Z_ [00 S4<l
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E(
7. STATIC WATER LEVEL Below Top of Casing: 'O FT. / yr
(Use"+"if Above Top of Casing) ���_ 7�t7 4 t/!w r1-3 fY/—Aw, t✓4
8. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated w1ur below land surface requires a
variance in accordance with 15A NCAC 2C.01 18.
9. YIELD(gpm): I METHOD OF TEST FI/��SI/IWJ
10. WATER ZONES(depth): /y�a,n CD QO' IC" -_
LOCATION SKETCH "`-
1 1. DISINFECTION:Type 6101ziNP Amount 8 0 2- Show direction and dislance in miles frmttaT least
12. CASING: Wall Thickness two State Roads or County Roads.lnclude tic roap
Depth Diameter or Weight/Ft. Material numbers and common road names. Ln
From To Ft.
From O To Z$ FL_QE e O k d
m Q
Fro To.,�Q_-_Ft. / c
13. GROUT: Depth Material Method 3
From To ,, Ft. oa
From 0 To go FL fibael
14. SCREEN: Depth Di�r Slot Size Material
From To Ft. in. in.
From To Ft. in. in. (�Ut. r U�
I5. SAND/GRAVEL PACK: �z{ i 5l-J
Depth Size Material L
From To Ft. O ,n,� S��^'/
From To Ft.
r
16. RENL1RKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDSS,_ANDTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1�2114 SlOLL_:�'
SIGN#rUff OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundib;+rjSeentiant, 166 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. i GW-I REV.07/2001

V 3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prior) (1�/ ey � St >t+t. CERTIFICATION# fir' ''
N"ELL CONTRACTOR COMPANYNAME -•t� :f.�.= ✓Vt4L[ 7)��.r A, PHONE PHONE # (fei3 •:2Y-<r CS�L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
• "I---licablc) (if applicable) mom
_`
L WELL USE(Check Applicable Box):Residential lt! Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Beat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: 6 Topograv�hic/Land setting
Nearest Town: /�/'��r[�et.. County ±4 , �4Sez ❑Ridge It7BTope ❑Valley ❑Flat
f.r� -4 7;den 6?.4 (check appropriate box)
(Street Name.Numbers.Community.Subdivision,Lot No..Zip Cale) Latitude/longitude of well location
3. OWNER:—
Address t� 4 ,f Latitudc/longitude source:❑GPS❑Topographic map
(Street or Raae No.) (check box)
*/Au p4J oV t� W_ DEPTH DRILLING LOG
City or Tm-n State Zip Code From To Formation Description
( 2i;)- /e=�:L
Arcs code.Phone number
4. DATE DRILLED h--t'�• "%
5. TOTAL DEPTH: �,- 44t bR✓pp:�y
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ❑," T
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Um"+^if Above Top of Casing) G
S. TOP OF CASING IS FT.Above Land Surface' r A
-Top of eosin=terminated atlor below land st rfats maim a variance in in accordance with 1SA NCAC IC.011L
9. YIELD(gpm): I —METHOD OF TEST )
10.WATER ZONES(depth): I ! »�4 F� Ln •"y
LOCATION SKETCH -
11. DISINFECTION:Type f 41?1.1r t: Amount F;Z Show direction and distance in miles from at let
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or wLighUFt. Material numbers and cominion road names.
From To FL �p�;�/pp 7
From�To /0 Ft. o
From-Z.O3--Tom Ft._1 _ l _
13. GROUT: Depth Material Method
From To Ft. C&"4 611
From__To r r Ft. & �'' ''�' {
14. SCREEN: Depth Diarnele' Slot Size M�aitil
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: LVJ�
Depth Size Material $
From - To Ft.
Frtmm To Ft.
16. REMARKS: B�
1 DO HEREBY CERTIFY THAT THIS WEL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND, HA T A COPY OF IS RECORD EN PROVIDED TO THE WELL OWNER
r �v
SIONkIbWOF PEPS07CONSTRUCTING THE WELL DATE
Submit the original lathe Division of Water Quality,Grout n r erSeetion1'1636 Mail SeiiiaeQMter-Raleigh,NC
27699-1636 Phnnc No.[phone],within 30 da)'s. I �r -� OW-1 REV.07/2001
'i
2005
L.-.__ -___._-.__,____—�
� -7�

WELL CONSTRUCTION RECORD .p e
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CONTRACTOR(INDIVIDUAL)NAME (prin -?e4 Tu.,-H e.4�-' CERTIFICATION
\'ELL CONTRACTOR COMPANY NAME ,l�r i c,� Ct'`AC4 t�/- CL /4iY PHONE # (
STATE WELL CONSTRUCTION PERMIT# —ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential M/Municipal/Public❑ Industrial❑ A_ticulttual❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If 0ther,List Use
2. WELL LOCATION: f opographic/Land setting
Nearest Town: 11'J�9f2+D.c.' County �c�ch.c'(,�- idge ❑Slope ❑Valley ❑Flal
ram.-U -zti (check appropriate box)
(SRcet Narne,Numbers.Community,Subdivision,Lot No.,Zip Code)/ Latitudellongitude of well location
3. OWN ERI=+/AJ, 'I C,rt1� -h) d /71 Qt'f�,TZ (degrecstminuk%tseconds)
Address <SLL_.eI L P . r t1l n Latitude/longitude source:❑GPS❑Topographicmap
IStrevi or Rouc No.) (check box)
,VP A-0CY0 4"e— DEPTH DRILLING,LOG
- fny or Town state Zip Cade From To Formation Description
Area code-Phone number
4. DATE DRILLED
S. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES_ ❑ NO I G Lk" rlZ�rz i
7. STATIC WATER LEVEL Below Top of Casing: ^ O FT. -
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface' r �,
'Top of casing terminated atlor below land surface requires a _
variance in accordance with ISA NCAC 2C.011&
9. YIELD(gpm): Y z METHOD OF TEST /p m
10.WATER ZONES(depth): Yz�Lr:�.Lti /as' as
LOCATION SKETCH
11. DISINFECTION:Type U eOA'A/ Amount }"e)Z Show direction and distance in miles from at lost
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diamctor or Weight/Ft. Material numbers and common road names.
From To FL
From_SZ =To Ft. �)G
From ^ t To 1x`n Ft.
13. GROUT: Depth Material Method
From To Ft. A.Wi`'�6
From To a0 Ft. Cirrr _?
14. SCREEN: Depth Diameter Slot Size Material
from To Ft. in. in. G�'� LVVro
From To Ft. in. in.
15. SAND/GRAVEL PACK: ��%
Depth Size Material
From` To FL r�1
From To Ft.
16. REMARKS: s
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDA1051,AND THAT COPY OF IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN TU F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the DIYISIOD of ester Quality,�Ir u>}�dwater,Septtol) 16361f�at1 Ctticc Center-Raleigh NC
27699-1636 Phone No.[phone],within 30 days i r '— -"" GW-1 REV.07/2001
All
i
IJ
�aaira, i sE^r �

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) qf;n(4 —TV.`J'('IGF CERTIFICATION#r21 G
WELL CONTRACTOR COMPANY NAME J05'I-rcF WZL..L f)r; LLI�_PHONE
%,rAT'E WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERa11T#
(ifa licable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑ 9
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: J:
Nearest Town: , , Count M dL—A-le ' Topographic/Lar sey j
Y Y f`� ❑Ridge ❑Slope F��Vralley Flal `
6 ye,pl/ �.{-►Z., (check appropriate box) 0 ,
(Stmvi Name,tt uribbem Community,Subdivision,Lot No..Zip Cale) Latitude/longitude of well locatitfn 3
3. OWNER: lzo.5 weme ✓G
(dtgrecshnirmtes/axantls)
Address Latitudellongitude source:❑GPS❑Topographic map
, (Strc t br P,04C No.) (deck box)
DEPTH DRILLING LOG
City or Town suue Zip Code From To Formation Description
(w)- T2 - -T7Z`� or ���� �6U 0/93 � — roe cz S' StitrJd
Area code-Phone number
4. DATE DRILLED Y-JZ- 0S
5. TOTAL DEPTH: 3 L>5" p p L�sSL•' cc({/pls
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO QT T
7. STATIC WATER LEVEL Below Top of Casing: yo PT. -
(U=-+"ifAbove TopofCasing)
8. TOP OF CASING IS FT.Above Land Surface'
*Top of mina urmiwattd utter below hind rarfuc rteatres a �
variance is accordance with 15A NCAC 2C.0110.
9. YIELD(gpm): '7:5� METHOD OF TEST 2!f- ° G
10. WATER ZONES(depth): S .1 pa 2 70
LOCATION SKETCH
11. DISINFECTION:Typee- zzOgtf Z Amount O'Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diu er or W elghtIrt. Material numbers and common road names. 4A AT,.
From To. g-Ft. 1 /, e.
From g: j$A Ft.
FromV-f Q_To-Lek-)—Ft. Lio �j22�
13. GROUT: Depth Material Method `ILA
From To FL !r
From 0 To `24+ Ft. 26 c ,te L4`4itfly
14. SCREEN: Depth Piatiniter Slot Size Matelai
From �t�O To 2 Ro F. m. _ in. 00 �,V�
From To Fin. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From O_ To_-;—;W—Ft. t(q YA0C,
Flom To Ft.
16. REMARKS: • '
1 DO HEREBY CERTIFY THAT JHIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAR S ND THAT A COPY Og-IRISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATItEO ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groygit*�tir Se'AOA,.1636 Marl Service Center-Raleigh,NC
27699-1636 Phone No.[phone],Within 30 days. III ` --- -- -- GW-I REV.07/2001
I `
i
1 �I
1

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resourcesccc-Division of Water Quality-Groundwater Section
WELLCONTRACI'ORHNDIVIDUAL)NAME (prior)� ) �'.! p/ CERTIFICATION a_EV
X%'ELL CONTRACTOR COMPANY NAME SO Si rGQL WP,,Q1 bti U.l(A PHONE a fe2p) 72Y- AA A8
STATE WELL CONSTRUCTION PERMIT!{ ASSOCIATED WQ PEINtITa
fifa livable) 6fa livable)
1. WELL USE ICheck Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural ❑ G
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
� tC`
2. WELL LOCATION: S TopogtaphiclLand setting
Nearest Town: hAantoN Countyl� Ridge ❑Slope ❑Valley ❑Flat
110 (cheel,appmpnambox) "
(Suvc Name.Number•Community,Subdivision,Lot No.,Zip Code)) Latitude/longitude of well location
3. OWNER-Era d VA(Y'V ZCnlh A)a P/L (degreealminuteasecoads)
Address _e 6Q gS l2 ASO-r-J K-dFY e�'Latitudellongitude source:❑GPS❑Topoeraphic map
(Sum or Route Na.) —f (check box)
DEPTH DRILLING LOG
City or Toan wte zip code From To Formation Description
(�zzt3)- uqe_000L
Am mde•Prune:number
4. DATEDRILLED y�28"�� 79 £/2uric
5. TOTAL DEPTH: 79 _ Sq —
6. DOES WELL REPLACE EXISTING WELL? YES O NO O'
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS FT_Above Land Surface' C76 _ qlq
"Top of casing terminated actor below hod surface requires a --p----
varbitee in aeeerdaoee with ISA NCAC 2C.91IL
9. YIELD(gpmj:20 METHODOFTEST All
10. WATER ZONES(depth): 20 �;apm&y zzO
LOCATION SKETCH
11. DISINFECTION:Type CI.0K(1UC Amount 6 OL 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 WeightiFt. Material numbers and common road names.
From To Ft. S
From To FL
Frorn To _&a Ft. �2�-
13. GROUT: Depth Material Method C/c'pss ZZ
From To FL Creek
From�Q_To�Ft. (_ 1
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 TH T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION SfANDA S,AND THA COPY S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG TU-Eff PERSON CONSTRUCTING THE WELL _ DATE
Submit the original to the Division of Water Quality,Gr iil�t for! gctioa, 1636 MaitSeAice Center-Raleigh,NC
27699-36.16 Phone No.[phone],within 30 days. I r— ''GW-1 REV.07/2001
2
i J i

00
309809
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and N/aa����tt,��"
11ral Resources-Division of Water Quality-Groundwater Section c�y�
\\'ELL CONTR.ACI'OR(INDIYIDUAL)N'Ab1E (print) Y � CERTIFICATION#Zl_]'-' v
\\'ELL CONTRACI'OR COhIPANY NAME SL�S'tfc� t. u-D r I r1 i 1tf� PHONE # f ) —zie y syQ
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED vvQ PERMIT#
_ (ifapnlicable) (ifapplicable)
L WELL USE(Check Applicable Box):Residential M Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land-setting
Nearest Town: County
❑Ridge ❑Slope Walley ❑Flat I
t:Z o id i,rt10aRf Y (check appropriate box) sJ
(Street Name,NumbcM Cro`mmunityy,�Subdivision,Lot No..Zip Cade) Latitudellongitude of wel I locatiOX
12.
3. OWNER: /4 tJ�U /'r'I/J V50A/ W �7'
(degrees/minutesrseconds)
Address 7 VO /V ea- 0 r'f tZL4 Latitude/longitude source.0GPS0Topog4ic ml
/Sow w e or Roe No.) (chock box)
AJ4LA- AJC z DEPTH DRILLING�gpG
Cily or Town sate Zip code From To Formation Descpiion'3
Area code-Plume number s L
4. DATE DRILLED-1 Z e/- 05-
5. TOTAL DEPTH: i;4S Lry_ipp n
6. DOES WELL REPLACE EXISTING WELL? YES 0<O ❑
7. STATIC WATER LEVEL Below Top of Casing: 1 O FT. /t3D S�L9f )ci
- i fo0
(Use"+^if Above Top of Casing) �
3. TOP OF CASING IS Jr FT.Above Land Surface' /,�
*Top of casing terminated atlor below land surface requires a "`r'Q_ 3
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 2 METHOD OF TEST 04 f 2
10.WATERZONES(depth): .2gomn & 2SV'
LOCATION SKETCH
11. DISINFECTION:Type Cff'd/Z,- U e- Amount ?02- Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighUFt. Matenak numbers and common road names.
From -0_To_ '0 Ft.
From Tom_Ft_ 67 9
FromJ�04D To U_L Ft. Fl A Y1.Cpf
13. GROUT: Depth Material Method �1 d
From To FL
From_ To eo Ft. t'-
14. SCREEN: Depth Diargeter 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 i5A NCAC 2C,WELL-
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER _
IGN�F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days- GW-I REV:'07/2001

WELL CONSTRUCTION RECORD \ J" 309808
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(iNDIVIDUAL)NAME (prinQ Cs.9,9y il zi;"e- CERTIFICATION
u ELL CON'1'RACIOR COMPANY NAME w0a b"" r,;, PHONE If
T
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
11000111 (ifapplicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential IG Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: 4 ,v Topographic/Land setting 9 apt
Nearest Town: //VI:1.Lrn4_J County n ❑Ridge ❑Slope ❑Valley 13VIZ
/ ATf*'t*�•S t-'"" ,"- i-.lJl t{ it .aC--- (check appropriate box)
tsucei Name,NumbCrz Commumry,subdivision,tat No.,zip Cote) Latitude/longitude of well location
3. OWNER: 42r l Z' �-rY.• G7ihe� bi�"""� (degreWminutns/seconds) O
Address V hq it 4 A It ? !ante r /Z Latitudellongitude source:❑GPS❑Topographic map
1 street or Rome NoJ (check box)
toe J pr1: L DEPTH DRILLING LOG
City or Town sae ipcoac From To Formation Description
(IP2r )-_%:S Z-_ JC, "1
Arcs code.Phone number _ sj S INN
4. DATE DRILLED
5. TOTAL DEPTH: � Wf' rY- _ lu.S'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO fY
7. STATIC WATER LEVEL Below Top ofcasing Pfl FT.
(Use"+"if Abow Top of Cuing)
8. TOP OF CASING IS / FT.Above Land Surface,
'Top of cuing lermluated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.01I&
9. YIELD(gpm): 10 METHOD TEST A
10. WATER ZONES(depth): i� M l P .4&0
LOCATION SKETCH
11. DISINFECTION:TypeOf /% 'L' Amovnt_'1 �� Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Fi. Material numbers and coizimon road names.
From 0 To Ft.=
From 0 To Ft. A J Tend
Fron�To�_Ft. G id._c __.
13. GROUT: Depth Material Method
From To FL
From__To /0 Ft.— [•'/r't ' ��,1,'•�
14. SCREEN: Depth Di weer eanf t r Slot Size Material nr���✓)'+
From To Fl, in. in.
From To Ft. is in. s4/
15. SAND/GRAVEL PACK:
Depth Size Material •. �
From To Ft.
From To FL
i
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN TURtr F PERSON CONSTRUCTING THE WELL DATE
,
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-16-16 Phone No.[phone],within 30 days. GW-1 REV.07/2001

309829
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section/
\x'ELL CONTRACTOR(INDIVIDUAL)NAME (print Cfgfa ,, /aJtWtig CERTIFICATION#t�r S0
WELL CON'IRACIOR COMPANY NAME Td.L15: 1& yLd PILZr�—PHONE
SPATE WELL CONSTRUCTION PERMIT# ASSOCIATED wQ PERDUT#
(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: ^ ppographic/Land setting
NearestTown: Indt., ag., County_9i4 �t,✓C1,.'ZeC OWidge ®Scope ❑Valley ❑Flat
aHa(L•l L+' A J (check appropriate box)
,(Street Name,Nuffitu Commun7i-ty,,su/bdi-risiioon,Lot No.,Zip Cale) Latitude/longitude of well location
3. OWNER: 6,4Xj°/1U ,�/a l'"{ (degrees/minuteslseconds)
Address - r OU Latitude/longitude source:❑GPS❑Topographic map
(Street"Route N (check box)
LylGir'.U.M1i AJ e 7 DEPTH DRILLING LOG
City or Town Starr Zip Code From To Formation Description
LA I- c1'� 4 2 2
Arcs code-Plane number
4. DATE DRILLED it- Z9-
5. TOTAL DEPTH: 2qS'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 9Y r c - G ys' (`r��h✓ 4
7. STATIC WATER LEVEL Below Top of Casing: 1.:G) Ff.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS / FT.Above Land Surface"
'Top of casing terminated attor below land surface requires a A
variance is accordance with 15A NCAC 2C.01 I&
9. YIELD(gpm): 14/—METHOD OF TEST /1//'Z
I
10. WATER ZONES(depth): / 5!!; E' -"o _
LOCATION SKETCH ea
11. DISINFECTION:Type C dYGt.Y1 Amounts z=Z. Show direction and distance in miles froiat leas
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From i! To i I / Ft� eed
From)/f To�_Ft.
13. GROUT: Depth Material Method -/
From To Ft.
Frmn g: To Ft.
14. SCREEN: Depth Diamet r Slot Size Material
From To Ft. in. in.
From To Ft. in- in.
15. SAND/GRAVEL PACK:
Depth Sin Material Lt
From To Ft.
From To Ft
t_
IL71/rtr:v a
IG. REMARKS:
1 DO HEREBY CERT,JFPHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,Wt i Lc
CONSTRUCTION S DARDS,.AND TH T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL¢WNER
r-1 NA E OF PERSON CONSTRUCTING THE WELL DATE`
=" fi� G_
Submit the original to the Division Water Quality,Groundwater Section, 1636 Mail Service Center- N
27699-1636 Phone Net.[phone],within 30 days. GW-1 'V.07/2001
I

WELL CONSTRUCTION RECORD 828
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) qk / 64;cs CERTIFICATION It
WELL CONTRACTOR COMPANY NAME PHONE # I )
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
I. WELL USE(Check Applicable Box): Residential 8' Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ if Other, List Use
2. WELL LOCATION: I Topographic/Land setting /
Nearest Town: A./l - County-as DCL%%c'�'`' ❑Ridge ❑Slope ❑Valley fit wS.
P-Lv (check appropriate box) A
(Street Name,Numbers,Community,Subdiv tontitvt No.,Zip Cade) Latitude/longitude of well location[ tF
c
3. OWNER: p (degrees(minutes/seconds) pp
Address �y Latitude/longitude source:❑GPS❑Tcpograpptc map�,q
(Street Ro eNo.) (check box) L-
AfZ1� NC �g']G,L DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Description
W--Ip S-Z' 4Q
Area code-Phone number OVAl[
M �r-
A
4. DATE DRILLED 3
5. TOTAL DEPTH: `�S -/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LH
7. STATIC WATER LEVEL Below Top of Casing:C70 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* Zr� CTL
-Top of casing terminated attor below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): C METHOD OF TEST !
10, WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Typer ,-4 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 Dianne r 'o�r W ight/FL Material numbers and common road names.
From De y�l Ft-
From "" Method
From To /,�,_f/�_Ft.
From To Ft.
13. GROUT: Depth Material Method
From To Ft. rJVtl.��
From it) Toa. —Ft. nPl �Ue - 0'iS Pr"rJ
14. SCREEN: Depth Diameter Slot Size Material Q� '�"S
From To Ft. in. in. O
From To Ft. in. in. L /'
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL �—
From To FL -
16. REMARKS:
a
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL 'D
CONSTRUCTION STANDARDS4SIGNATU
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELE OWNER�
_ y
E OF P ON CONSTRUCTING THE WELL DATE i
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center eigh,N _
GW-1
27699-1636 Phone No.[phone],within 30 days. -1,tJ07/200I
i _

309825
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\ELL CONTRACTOR(INDIVIDUAL)NAME (print) 7 ./'II"'9 It'>f-t 4= CERTIFICATION#
o'E T LI.CONRAC'1'ORCOMPANY NAME ' i r! ���= t�:' = -�/= PHONE #
STATE(VELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) / (ifapplicable)
I. WELL USE(Check Applicable Box): Residential Q Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Otter, List Use
2. WELL LOCATIONt Topographic/Land setting
Nearest Town: 421A(..1 , ?.� County '-. _:'t` ❑Ridge DSlope ❑Valley ❑Flat
',.i•.: e—- (.V i )-O In� -L4 ,ir a (check appropriate box)
(Street Name.Num
bers,Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: � C' k f-'<l.. l' F`;-C` (deemeslminutes7secgnds)
Address Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DEPTH DRILLING LOG
Ci(y or amen smote Zip Code From To Formation Description
Area code-Phone number , _ _ f_j rrj Ir
4. DATE DRILLED
5. TOTAL DEPTH: J
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO GY`
T STATIC WATER LEVEL Below Top of Casing: 'i L` FT.
(Use-• if Above Top of Casing) a
8. TOP OF CASING IS I FT.Above Land Surface* - eT
*Top of casing terminated atfor below land surface requires a t
variance is accordance with ISA NCAC IC.OI Ig. —�—
9. YIELD(gpm): � METHOD OF TEST f� 1 It
10. WATER ZONES(depth):
LOCATION SKETCH
11 DISINFECTION:Type ( Amount Show direction and distance in miles fipin at least
12. CASING: Wall Thickness two State Roads or County Roads.Inolude the road
Depth Diameter or-Weight/Ft- Material numbers and common road names.,
From (' To tt'.P Ft ,."V1, ,�l, 5 .,�
From ff'� To (.1-1 Ft 7 .1(r' 'r'(': ( / `/ (.\ /�
From (r-1l To 6-.1,-. Ft (.'��.i I w Y.. (, 1 (i,` v li r
13. GROUT: Depth Material Method
r
From To Ft.
From Pi To 7 ,-. Ft. -h�°c � r"_.� •.0 �I �--
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. 'r +✓ '°y
From To Ft. in. in. I '
15. SAND/GRAVEL PACK: d� •�- ��ro
Depth Size Material
From To Ft_ (
From To Ft_ d•fit i
16. REMARKS: ��
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANC WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS,.AND THAT A COPY OF THIS RECORD HAS BEEN P OVIDED TO THE nL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEL DATE oa
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-RaYeigh,NC fob _
27699-16-16 Phone No.[phone],within 30 days. GW-I REV.'07/200E-

WELL CONSTRUCTION RECORD 3 0 9 8 2 4
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section (-6
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ��. -1 �'1' `F/Z'�/ CERTIFICATION#—J"
w'ELL CONTRACTOR COMPANt'NAME �L� ,r �. ✓,l 4J{"fit-ir_ PHONE Y {
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(irapplicable) (ifapplicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural ❑
Monituring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ IrOther,List Use
2. WELL LOCATION: � �� a�C Topograp Land setting
Nearest Town: /I' +— rCourlty �t c ❑Ridge ope ❑Valley ❑Flat
(check appmpriate box)
(Street Name.Numbers Community.Subdivision,rot Na.Zip Cate) Latitude/longitude of wel I location
3. OWNER: (,e A ti'� L— (degreestmimncs/seconds)
Address &V �J J �r j�- Latitude/longitude source:DGPS❑Topographic map
(Svn a- utee Ro No.) (check box)
`1J� .�.�7, DEPTH DRILLING LOG
City or Town sure Zip Code From To Formation Description
( )- ?S o c3oy Q t
Area code-Plane number f� — S"U i k� S4•_�/?.•r'�.-�
4. DATE DRILLED
5. TOTAL DEPTH: S'L'i SUS fiznrh;;.
6. DOES WELL REPLACE EXISTING WELL? YES 9<0 ❑
7. STATIC WATER LEVEL Below Top of Casing: � FT.
(Use"+"if Above Top of Cuing) -
S. TOP OF CASING IS / FT.Above Land Surface"
-Top of cuing terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C.01 M
9. YIELD(gpm): METHODOFTEST�(�
10. WATER ZONES(depth): Sr M C:�>— 300 r
LOCATION SKETCH p�
11. DISINFECTION:Type 6,0A a Amount O�'— Show direction and distance in miles from at lea
12. CASING: Wall Thickness two State Roads or County Roads.lnclucac to
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From To Ft.
From,�To fpT Ft-—� '�
13. GROUT: Depth Material Nfethod`
From To FL
From To=FL -1 .ing/
14. SCREEN: Depth Diameter Slot sin Mal trial q 0
From To Ft. in. in. Gc/
From To Ft. in. in.
15. SAND/GRAVEL PACK: 0
Depth Sim Material (�c�
From To Ft.
From To Ft
r
16. REMARKS:
1 DO HEREBY CERTIFY THAT tHIS WELL WAS CONSTRUCTED IN CORDANCE WITH 15A NCAC 2C,WEi,A-
CONSTRUCTION STANDARD ,AND THAT A CO CORD HAS BEEN PROVIDED TO THE WELLDWNER a
SIGNATURk OF P995N CONSTRUCTING THE WELL DATECID
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Ralegb,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV:07/2009

309823
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 's'74'KcY T 1CFS CERTIFICATION#-e2
WELL CONTRACTOR COMPANY NAME U 1-i c E tale l_G b f, LL1 PHONE a ( )rIZ�f�(Y
STATE WELL CONSTRUCTION PERMITB ASSOCIATED WQ PERMITB
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential I310"Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI � ,,��/,+ �_�//Topographic/Land setting
Nearest Town: ,fJ,.,_iFIN �CAounty _wea, &Ridge []Slope ❑Valley ❑Flat
y,3lc OLb ti lr" i2-i (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
I 3. OWNER:._]•• 4 rU y' A N8-9 1,�-A n
v P_ I (degrees/minutes/seconds)
Address , Qb 1�QA r-X' D.— Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
z C -1 97.S2 DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Description
(�.<I- Gsa„3�
Area code-Phone number
4. DATE DRILLED R-2 3'-oS
5. TOTAL DEPTH: 405, 4•�_ ypg- �j�rq v,'
6. DOES WELL REPLACE EXISTING WELL? YES 9/No ❑
7. STATIC WATER LEVEL Below Top of Casing: -t0 FT. C2
(Use"+"if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surfaces nrt y
*Top of casing terminated atior below land surface requires■
variance In accordance with 1SA NCAC 2C.0118. '
9. YIELD(gpm):_(�_METHOD OF TEST GO
10. WATER ZONES(depth): U,2 $iB
LOCATION SKETCHLA
It. DISINFECTION:Type ILO )W O Amount,„ Show direction and distance in miles from at lea
12. CASING: Wall Thickness two State Roads or County Roads.Include the ra`a
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From0 To ,�'2 Ft. d yZ --IVQ
From—V.To 6 Yq BR �a/y
13. GROUT: Depth Material Method
From To Ft. CC.•
From_ Tom Ft. a
14. SCREEN: Depth Diameter Slot Size Millerial
From To Ft. in. in. G'ooS�Creek.
From To Ft. in. in.
15. SAND/GRAVEL PACK: Lh
Depth Size Material
From To Ft 11 ,r/ 6NLgL
From To Ft �\
I6. REMARKS: \ M�
n
I DO HEREBY CERTIFY AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -0
CONSTRUCTION STA S,AND THA A COPY tS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
aw CC)
SlqlATU`Mf0F 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;.Q?/2001

309822 G�(�
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of water Quality-Groundwater Section
/�-�5
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 77
� .4k d/ \O� r�� t�� r/}/ CERTIFICATION#Z456
WELL CONTRACT OR COMPANY NAME ..]t)S�F(Gyr(�(J-F { 4 PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential❑ Municipal/Public Ej/Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: � � p Topogra Ic/Land setting
Nearest Town: A'1Q���u.r/✓�'� Countymi;k- e- ' ❑Ridge Wtope ❑Valley ❑Flat
IQ lou-nl n 160oA &-,e (check appropriate box)
(Street Name,Numbers,Colm unity,Subdrvisi ,Lot No.,Zip Code) Latitude/longitude of well location
r 3. OWNER:�.P.n.. l � (' (degreeslminmesfsernnds)
Add(ess to DS M&S�10n--. V% f Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
1� p[C agCgl-- DEPTH DRILLING LOG
City or Tana_ Owe Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: o �pQ�i_p_ 1LAwt ulere?�^
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(Use"+"if Above Top of Casing) A
8. TOP OF CASING lS Z FT.Above Land Surface"
-Top of casing terWna[ed atlor below land surface requires a 3"
variance in accordance with ISA NCAC 2C.0119.
9. YIELD(gpm):_;Z-<_METHOD OF TEST
10. WATER ZONES(depth):�o 36,0 l
LOCATION SKETCH
11. DISINFECTION:Type Amount Z- Show direction and distance in miles frorg lea
12. CASING: Wall Thickness two State Roads or County Roads.Include the rom
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_Q_To //7 Ft-q.Yy_ IR}R 41
6
From To FL r
From To Ft.
13. GROUT: Depth Material Method
From To Ft.
From_6 Tom Ft.
14. SCREEN: Depth Dia eter Slot Size M terial
From To Ft. in. in. Y"
From To Ft. in. in. Y_ ,
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. -
From To Ft.
Deu _
16. REMARKS:
_ a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN CORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, D THAT A COPY OF T RECORD HAS BEEN PROVIDED TO THE WELL OWNER
MNATUlkEOF RSON CONSTRUCTING THE WELL DATE _ o
0
rs,
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-R2100 IVC _ —
27699-1636 Phone No.[phone],within 30 days. GW-I REVz Q7/2001 - -

Lbd--If �3
WELL CONSTRUCTION RECORD 3 0 9 8 2 1
North Carolina- Department of Environment and Natural
-Division of Water Quality-Groundwater Section
\V ELL CONTRAC-1 OR(INDIVIDUAL)NAME (print) /'4e�fr�Jus4;c-s CERTIFICATION#, l,' �
w"F'Lt.CUNT RACrOR COMPAN OBI CC.r _PHONE a &6) 714-4S'49
STRfE\\'ELI.CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if-applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential❑ Municipal/Public D,'-Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- Topogra is/Land setting
Nearest Town: t OAJ Count �,,y� LaiLf-f..
^c Y/+' . ❑Ridge lope ❑Valley ❑Flat
deaf /t L.r t'F (check appropriate box
(Street Name.Numbers,Community,Subdivision.�L.ot Nc Zip Code) Latitude/longitude of well location
3. OWNER: 41 C°fiff C4L+'h f;/eytiL (degreeslminutesrseconds)
Address - ,O C'% �,0_ �l_ Latitude/longitude source:❑GPS❑Topographic map
(Sven or Rome No.) (check box)
l)- l Na (,t i DEPTH DRILLING LOG
Cityor Town State Zip Code From To Formation Description
Z14�s 6 F-)Scams L
Area code.Phone number _ Q _ f t f Q
4. DATE DRILLED {-N S
5. TOTAL DEPTH: / 11 - 2, 2 S GrA.v. i-c rk) 4>1
6. DOES WELL REPLA E EXISTING WELL? YES❑ NO (�f « A.
7. STATIC WATER LEVEL Below Top of Casing:_90 FT.
(Use'W'if Above Top of Casing)
&. TOP OF CASING IS 2 FT.Above Land Surface*
'Top of casing terminated attar below land surface requires a _yp
variance in accordance with 15A NCAC 2C.01 18. 1
9. YIELD(gpm): 300 METHOD OF TEST I�ICo
10. WATER ZONES(depth): 4ngD&-26- -C
a 0 f Z 60 —Z90 LOCATION SKETCH
11. DISINFECTION:Type C[.o ; _ Amount A CZ. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diarpyter or Weight/Pa. Material numbers and common road names. a
From To &N Ft. & a(O AA y ,1
From To Ft. 2 iP .
From To Ft
13. GROUT: Depth Material Method
From To FL 0'r�
From lZbe Ft. 4Wi
14. SCREEN: Depth Diameter Slot Size PJanerial
From To Ft. in. in.
From To Ft. in. in. A '
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft. Ti Tl"4
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL "
CONSTRUCTION STANDARDS,.4 THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0
SI NAT 2E OFRSON CONSTRUCTING THE WELL DATE -
c>
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigtl,l+fC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.0�l200I -

evetc # Z
WELL CONSTRUCTION RECORD 3 0 9 8 2 O
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section,c
w'ELL CONTRACTOR(INDIVIDUAL)NAME (print) L7/720 - CS4 cx CERTIFICATION#Zt-�a�6
tN ELL CON'I RACTOR COM PANY NAM E ,'T1S i-I e4L�(JL0iJC( PHONE # (ixt�) 1LY��
STATE WELL CONSTRUCTION PERMIT# wSSOCIATED WQ PERMIT#
(ifapplicable) (ifapplicable)
1. WELL USE(Check Applicable Box): Residential❑ Municipal/Public V Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If 0ther,List Use
2. WELL LOCATION: Topo�phic/Land setting
Nearest Town: 92"V� >—County/1'�S&("e LC ❑Ridge Slope []Valley ❑Flat
bers,Comm
&>Q' fl(t e w`v��n a (check appropriate box)
(Street Name,Numunity,Subdivision.Lot No.,Zip Code){ Latitude/longitude of well location
rJ 3. OWNER: erf/L CZ44 C6 µL O41U✓A A (degreestaunutesfseconds)
Address (o OQy nl n c-t n c, tS�L,��Yj P _ Latitudc/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
16�6() iV C 2971' T DEPTH DRILLING LOG
CityorTm.•- state Zip code From To Formation Description
0,�A- --L113-CnEDt�� �-.
Area code.Phone number /5 d jW L leeeX
4. DATE DRILLED
5. TOTAL DEPTH: 6 00 t / !off
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO lit Ai«
7. STATIC WATER LEVEL Below Top of Casing:—FT. f
I (Use'+"if Abow Top of Casing)
3. TOP OF CASING IS 2 FT.Above Land Surface* a
`Top of cosine terminated actor below land surface requires a
variance is accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 3 METHOD OF TEST /91/Z 1
10. WATER ZONES(depth): i4e-'OM 0 So0' UJ
LOCATION SKETCH C:) ~
11. DISINFECTION:Type C cfZr N'r- Amount Ln"2 Show direction and distance in miles from at leastm
12. CASING: Wall Thickness two State Roads or County Roads.Include the roam
Depth Dia,gcler or WeighVFL Material numbers d common road names.
From O To 87 FL � AC, _ 64/J/ Z�L
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To FL /,),)a N
From_-O ToR�_FL-4 oe% l
14. SCREEN: Depth Diameter Slot Size Material y e
From To Ft. in. in. LQ .
From To Ft. in. in. 1t;� d e f�
15. SAND/GRAVEL PACK: (�Cl.nr
Depth Size Material
From To Ft. _
From To FL
r
16. REMARKS:
n
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER - -
SIGNATUA OF PBMN CONSTRUCTING THE WELL DATE -
c.r i
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh K
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 67/200I

L
e cc�-W l
WELL CONSTRUCTION RECORD 309819
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) ,I�CCI s es+i -E - CERTIFICATION# �fsa
S-1
w'ELL CONTRACTOR CO\I PANY NAME To -1 Cr Wzu' 6 r l L_�!O -PHONE # (gam) 7Lc/-45-!/rQ
STATE\\'ELL CONSTRUCTION PER4IIT# ASSOCIATED WQ PERMIT#
f if applicable) (if applicable) -
I. WELL USE(Check Applicable Box): Residential❑ Municipal/Public 9?" Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town:�'L dr;ct3 County r� ww� 2fbdge ❑Slope ❑Valley ❑Flat
GfCLr- e.LiK'4 Cin-yy /��ti,7 -r (check appropriate box)
1Slrcel Name.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
1 OWNER: .geA! CLtCt Cd tA)rCT/pu,�� (degreestminutestseconds)
Address /,fin���n t p ga �r.1 NI" Latitude/longitude source:❑GPS❑Topographic map
i5treet or Route No.) (check box)
Ai t✓ `z ?(,C DEPTH DRILLING LOG
Cityor Town s,•,1tate Zip Code on LL i7 e From To Formation Description
- �3-(o�la� ¢ e
Area code-Plume number t I"D t zG G
4. DATE DRILLED ©`J .�t04. "5. TOTAL DEPTH: £3CO Q,et,rES
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 9- �rA�ty;{
7. STATIC WATER LEVEL Below Top of Casing: GD FT. 5CA
(Use"+"if Above Top of Casing) f rJ
S. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated attor below land surface requires a tY
variance in accordance with 15A NCAC 2C.0118. r
9. YIELD(gpm): L METHOD OF TEST At2
10. WATER ZONES(depth): 11g,09 2�0 '
LOCATION SKETCH
11 DISINFECTION:TypcO L Amount g O 2. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roan
Depth Dioater or Weight/Ft- Material numbers and common road names.
From O To /32 Ft, le/v szu 4o _
From To Ft. L-
From To FL
13. GROUT: Depth Material Method
From To Ft.
From a) To r;Z Ft. Z / fTfof%o Ym 7
14. SCREEN: Depth Diameter Slt Size Material ^
From To Ft. in. in. Sal
„49
From To Ft. in. in. �PArtCc) '
15. SAND/GRAVEL PACK: £"A00 e
Depth Size Material
From To FL
From To FL - -
16. REMARKS:
n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL-:
CONSTRUCTION STANDARDS,.AN THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
2" �2s - 00
—SIIGGNATU E&PERSONCONSTRUCTINGTHEWELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raldi It,NC
27699-1636 Phone No.(90)733-3221,within 30 days. GW-1 REVS 07/2001 -

WELL CONSTRUCTION RECORD 3 0 9 g 18
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Sectio99n//(t---qq��
\YELLCONTRACTOR(INDIVIDUAL)NAME (print) O'CA,2 . -T -C�Iip C,5 t� CERTIFICATION#,7[S )
wELLCON'1'RACI'ORCO!IPANY YAME �LSS jCIS V. Q-LL Y)ri LL•N•i PHONE f (eZA Z4-4SwE
STATE WELL CONSTRUCTION PERMITa ASSOCIATED WQ PERMIT#
(i fapplicable) (ifapplicablc)
I. WELL USE(Check Applicable Box):Residential O'Municipal/Public❑ Industrial❑ Agricultural ❑ A
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Lan¢getting -o
Nearest Town: Maue-,- County a ixi.(- ❑Ridge ❑Slope p alley ❑FI�
11q (�; oeti � r a:t. (check appropriate bold
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cade) Latitude/longitude of well location -
t'3. OWNER: )�t ' old 4 (`.t.�,r�.n� (degrees/minuiusfseconds) U3 �rt st
Address --1 i �l .KA.(P/JheL1 11: Lalitude/longitude source:❑GPS❑Topogmphic map°,',
I'S rect or Route No.) (check box)
UTAGn".v_, 1W C ?,RIK DEPTH DRILLING LOG
City or Town state Zip code From To Formation Description
O- t.5Z- 4efo7R
Area code-Plume number
4. DATE DRILLED
5. TOTAL DEPTH: 165
6. DOES WELL REPLACE EXISTING WELL? YES Q­KO ❑ �yc �� el Ark
7. STATIC WATER LEVEL Below Top of Casing: /5 Ff. U
(Use"+> if Above Top of Casing) �l - r0
8. TOP OF CASING IS / FT.Above Land Surface'
`Top of cuing term(nattd atior below lead surface requires a
varianct is aecardance with ISA NCAC 2C.01I&
9. YIELD(gpm): 60 METHOD OF TEST i4 /2
10. WATER ZONES(depth): Coo!/ ,0. iLO l 00 r
LOCATION SKETCH
11. DISINFECTION:Type / Amount '60 0 L Show direction and distance in miles from at least
12- CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To -1q _Ft. /o" 5:L'110
From To q f� Ft. /a rU �tO
From,To c0 Ft. 6 / -l-=*-✓— _
13. GROUT: Depth Material Method
From To Ft,
From-_-C__Tom_
14. SCREEN: Depth Dianle of r Slot Sim Material
From To Ft. in. in. dnf�
From To Ft. in_ in. Gale
15. SAND/GRAVEL PACK: v
Depth Sim Material
From To FL
From To Ft.
b d
I6. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I ATURE OF PERSON CONSTRUCTING THE WELL DATE cc
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 KM-.07/20&' - -

WELL CONSTRUCTION RECORD
00 309817
North Carolina-Department of Environment and Natural Reesource�-st-Division of Water Quality-Groundwater Sectiion�
v\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) LI slL` I ,\�� (� c,+'i(c" � CERTIFICATION# ZL— (�
]
vv'ELL CONTRACTOR CON1PANY-NAME �l) r (�w�- \ATI��I+ c'.�.L.I—AkPitONE # I 7 '�{]s �
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERAIITif
(ifa licable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIIQN: A C 0 Topographic/Land s ng
Nearest Town: QLe �; County tl Y ` ' t-l%'�a"� ❑Ridge ❑Slope ley ❑Flat ^q
1.7 341 pCi r 157 P/9 1QA (check appropriate box) 7
(Street Name.Numbers,Community,Subdivision,Lot 11o..Zip ode) Latitude/longitude of well location 3
3. OWNER: (Ikgrecs/minutcs/seconds) a +
Address 1 4 ; Latitude/longitude source:❑GPS❑Topograla ma)i
(Snect or Route No.) (check boa) 1
C9Ct�j F�;/f :2 DEPTH DRILLING 06b 1
City or Tgwn swte Zip Code From To Formation Descroon
Area code-Phone number
4. DATE DRILLED �.
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ®P� ©[ dliA-t-
7. STATIC WATER LEVEL Below Top ofCasing: FT.
(Use"+^if Above Top of Casing) "`-
8. TOP OF CASING IS FT.Above Land Surface'
*Top of casing termiouted atior below land surface requires a
variance in accordance with 15A NCAC 2C.0I1&
9. YIELD(gpm):7T METHOD OF TEST //�
10. WATER ZONES(depth): r✓ �r.Toeo wl C"y -i 13 r
LOCATION SKETCH
11. DISINFECTION:Type 0,CQ/1i PC 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 ItlMer or W - hVFt. atenal num a common road names.
From To
FL� Z
From To�Ft. �_ / A ?
From To Ft. ,Y
13. GROUT: Depth Material Method 4� jet
From To Ft.
From 0 To—3 1 Ft. QED' •L' ' aa"'
14, SCREEN: Depth Diam er Slot Sin Material
From To Ft. in. in. 7
From To Ft. in. in. LJ
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
16. REMARKS: o
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL',
CONSTRUCTION STANDARD , D THAT A COPY OFT IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER S=
NA RE O ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-16,16 Phone No.[phone],within 30 days. GW-I REVAP12001 ;2

co
WELL CONSTRUCTION RECORD 309815
North Carolina-Department of Environment and Natural Resourcess--Division of Water Quality-Groundwater Section ma
\\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) y�A.��., 1(:S�L' CERTIFICATION# y.
s-
NNELLCONTRACI'ORCOMPANYNAME LCE ,rC4 AL L *LCLr WT PHONEY
STATE WELL CONSTRUCTION PERMITY ASSOCIATED WQ PERMIT%
fifapplicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential GYMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �f �opographic/Land setting
Nearest Town: OLb fa.- H County Oils x�eZ.L GWidge ❑Slope ❑Valley ❑Flat
/b se e.�)Lb r,�e r !9 *7 14,64C, 12a (check appropriate box)
(Street Name,Numbers,Communhy,ySuubdivisi`on,Lot No.,Zip/Code) Latitude/longilude of well location
3. OWNER: r€16- /L, ic/z (degrcWminutesrsaonds)
Address j&,SJ i G[-A r2m-d Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No-) -�T (check bon)
de o f kt y �X✓ DEPTH DRILLING LOG
Ciryor Town sum zip code From To Formation Description
Area code-Munn:number
4, DATE DRILLED 2—1 td—O f
5. TOTAL DEPTH: -3 C6
6. DOES WELL REPLACE EXISTING WELL? YES 11 NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+^if Above Top of Casing) T „�
8. TOP OF CASING IS_�FT.Above Land Surface"
"Top of cuing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.011& _
9. YIELD(gpm): J292_METHOD OF TEST i/ O
10.WATER ZONES(depth): ��ZQr;�9 ~��
/ LOCATION SKETCH _
11. DISINFECTION:Type 4' 695!� Amount D L'J� 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. W L�r'
From To Ft._
From Y7 To Ft. Pile- 6LJ/''r
From/SA T C 1 Ft--Z .$
13. GROUT: Depth ffethod f S
From To,_Ft. '
From_0To 'Z: Ft. .rcl j
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in. e,,
From To Ft. in. in.
15. SAND/GRAVEL PACK: rL/J
Depth Sim Material
From To Ft.
from To Ft
Ili. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL 3�
CONSTRUCTION STANDARDS,Alf HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER- - -
i
SIGNATURE F PO§ON CONSTRUCTING THE WELL DATE
cc
c�
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,.NC- d;
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001 - -

309814
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-QD��ii�vision of Water Quality-Groundwater section
���.�%%ELL CONTRACTOR(INDIVIDUAL)NAME (print) �dr.4 0 .3T1 CA- CERTIFICATION# rJ -
TT 1^ �y r/\%'ELL CON-1 RACTOR COMPANY NAME JV✓9'f C' w Q C-L 0ir 1 l.(.i NQl PHONEY
STATE R'ELI,CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
61'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:
Nearest Town: (hLQ I oYF Ridge 0SIope /Land setting
Cnunty ��SP6WeCL Ridge ❑Slope ❑Valley ❑Flat
)G o eA ri Sofa,r1 S IYe z L 4 w e (check appropriate box)
(Street Name.Numbers,Community,Subdivision,Lot No.,Zip Cade) Latitudeilongitude of well location
3. 0WNER:L NtUr JQju'a VVI--P�
Y (dcgrees/minutes(seconds)
Addresse&Lan c 11xtaq! G47j1-atitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.)
!a u� DEPTH (cltcck box)
(I.
t-ityorTo ��ott State ��Z C de DRILLING LOG
P From To Formation Description
Area cock Phone
4. DATE DRILLED -
5. TOTAL DEPTH: /ooe low art xlr Y
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO @�
7. STATIC WATER LEVEL Below Top of Casing: FT. -2y
(Use"+•'if Above Top of Casing) +a 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.011& r
(SrlL 9. YIELD(gpm).-Q_ METHOD OF TEST ( lr Co
Pf IO. WATER ZONES(deptli) kk ¢ $r
O
QA FR•tr�e - /r LOCATION SKETCH cn
11. DISINFECTION:TypeMottif?C Amount i. e�L Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or WeighUFt. Material numbers and common road narpes.
From To Ft, o cO tckd-
From To Ft. flU U /
From To FL /7�53 �•' e fr(P"�fcL
13. GROUT: Depth Material Method Z ¢
From To FL
From O To—ZY Ft. .tnj P1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. 1.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL .�d
IG. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL D
CONSTRUCTION STANDARDS,.AND HAT A COPY OF TH S ORD HAS BEEN PROVIDED TO THE WELL OWNER
nLAA 1
SIGNATURE OF PERS N CONSTRUCTING THE WELL DATE -- o
I19
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigbi NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV,6T12001

pr ,IbLOL be. r-rov � ` z, 5' 4, �°$ t 1w3
30
t� LL WELL CONSTRUCTION RECORD Qs
Carolina- Department of Environment and Na ral Resources-Division of Water Quality-Groundwater Sectio)nY
"'J J \\'ELL CONTRACTOR(INDIVIDUAL]NAME (print r r" CERTIFICATIONy#�-/�
\\ELL CO\TRAC-1-ORCO\il'ANY'NAME ti 1 t-�1 C�v PHONE 8
STATE\YELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
�.
�, (ifa licablc) (ifa licable)
�) 1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural ❑
J( Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
5 �
2. WELL LOCATI N:, „Q � t Topographic/Land 0Sdphe OV setting
r Nearest Town: 1 V� �nt%I��-�'Q� County �dge ❑Slope ❑Valley ❑Flat
'rj l i �� -e �ge L'i I t..A (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lo�t Na,Zip Cole) Latitude/longitude of well location
OWNER: r A1ok,L, AJ g I/°\t/{rnle (degreWminuux/seconds)
y, p Gn Address 101 6 6 k AL?- Latitudellongitude source:❑GPS❑Topographic map
(Street or omc No.) .7 (check box)
DEPTH DRILLING LOG
T—
; ,SCG{'-�1[ City ofTown tale zip code From To Formation Description
Area wdc-Pltone ntnnbe t
4. DATE DRILLED - E3 CD
5. TOTAL DEPTH: bV G q /
6. DOES WELL REPLACE EXISTING WELL? YES 9 NO 0 / -¢
7. STATICWATERLEVELBelowTopofCasing: VDU FT. .
(Use"+"if Above Top of Casing)
3. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated atlor below land surface requires a D •n<
variance in accordance with ISA NCAC 2C.9118.
9. YIELD(gpm): kz METHOD OF TEST 5401
10. WATER ZONES(depth): y2 404 00 t
LOCATION SKETCH =:=�
11. DISINFECTION:TypeC t2(N C Amount e)Z Show direction and distance in miles from at�ast s"
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/R. Material numbers and common road names.
From To FL Fl ��.�U(e�
From To Ft.----��-- H
From 0 To�_Ft.� 1 a ��-
13. GROUT: Depth Material Method
From To Ft. i
From 0 To zo Ft. Z g( 0 Klc
14. SCREEN: Depth Diameter Slot Size Material
From To FL—in. in.
From To Ft. in. in. 1 Jr�,
15. SAND/GRAVEL PACK: / i"'1
Depth Size Material. LG pyl
From To Ft. n
From To Ft. 'j`ekyU'x0'
16. REMARKS:
May"
I DO HEREBY CERTIFY THAT THIS ELL WAS CONSTRUCTED IN ACCORDAN E WITH 15A NCAC 2C,WELL -73
CONSTRUCTION STANDARDS,A HAT A COPY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER sj
SI RE O PE N CONSTRUCTING THE WELL DATE rv.
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senicc Center-RaleilIbi NC
27699-1636 Phone No.[phone],within 30 days, GW-1 REV.0712001 �`

WELL CONSTRUCTION RECORD
309 � 12
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)- U-• iC6 CERTIFICATIONC
WELL CONTRACTOR COMPANY NAME ONE # L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) — (if applicable)
I. WELL USE(Check Applicable Box): Residential hC/Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: MCI CI®/r cCounty -lb ' �LL ❑Ridge ❑Slope Galley ❑Flat
a Cq on I2 A fx' alke- R&I (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:—l(k1lieet ALL15obl (degrees/minutes/seconds)
Addressf_o, /rl4s �P.0.5rx;x 171u.L) Latitude/longitudesource:❑GPS❑Topographic map
�* pp__ ( trees or Route No.) ' (check RI
pt-ID't )rr R`7� 2 DEPTH DRILLING LOG
City or Town state Zip Code From To Formation Description
Area code-Phone number © . e J
4. DATE DRILLED 2.I
5. TOTAL DEPTH: 2 1fS
6. DOES WELL REPLACE EXISTING WELL? YES �NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT. y.
(Use"V'if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface" a
'Top of cuing terminated atlor below land surface requires a
variance in accordance witb 15A NCAC 2C.0118.
9. YIELD(gpm):1_METHOD OF TEST /I//- 0
10. WATER ZONES(depth): /®ef e—o � 200`
— ' LOCATION SKETCH rJI
11. DISINFECTION:Type C"LD2 i NK Amount 41I Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft.
From_ Tom Ft. 4,VAJ L40
From .J-, To-Z�Ft. �) �i V
13. GROUT: Depth Material Method L
From To Ft. T
From n To1Z:L—Ft. ma -�
14. SCREEN: Depth Dtae ize Material (�
From To Ft. in. in. „Q Q
From To Ft. in. in. Av
15. SAND/GRAVEL PACK: C e� y ,tt
Depth Size Material 'y
From To Ft. t
From To Ft. ^, 1�r
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH A Ck 2i`,WEifo xr
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVI O THE WELL OWNER `-
SIGNAT RE 09 PERSON CONSTRUCTING THE WELL DATE t� -
Submit the original to the Division of Water-Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC a"u
27699-1636 Phone No.[phone],within 30 days. GW-I REV'07/2001

WELL CONSTRUCTION RECORD 309811
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section xY ELL CON'1'RAC9'OR(INDIVIDUAL)NAME (print)�',Q.e4 SJJ'I`e/CF CERTIFICATION#—4/uv��^^��xx
w ELL CON1 RACfOR COMPANY.NAME SQ5;¢rC N,U AY PHONE # ( ) eq:!fSts$
STATE cN'ELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERh11T#
(ifa licable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: 4,L Count 1Acdcw Topo�gr�ejlpe Elnd setting
/1,���� y ❑Ridge Mope ❑Valley ❑Flat
Ve0 &A &,i (check appropriate box) yr.
(Street Name,Numbers,,Com
munity
,
Subdivision.Lot No.,Zip Code) Latitude/longitude of well location r.y
3. OWNER: befell P�.tIG CA
(degrees/minutes/seconds) co
Address O GX j (ia Latitude/longitude source:❑GPS❑Topograph8nap
(Street rRoute No.) (check box) iLn '
¢U� G — DEPTH DRILLING LOG
dyor Tou-n State Zip Cade From To Formation Description ;
( - eo$C/" (oO (oAi
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REP A ACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 100 FT. �r'�.✓i e
(Use"v'if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
'Top of casinC terminated attor below land surface requires a
variance in accordance with 15A NCAC TC.0I IS.
9. YIELD(gpm): (aO METHOD OF TEST A/A
10 WATER ZONES(depth): 60 Jt0ntti6wj 070 `
LOCATION SKETCH
11. DISINFECTION:Type(_?LQ�rl/t Amount 0-Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighVFl. Material numbers and common road names.
From To Ft. .— _
From Q To Ft. �TvQ- U ap�-40 ,ate414
From DeTc3 Ft. —�'-- od Tk "
13. GROUT: Depth t atcrial Method
From To FL From De th Ft.�er � [l�14. SCREEN: Depth Diam er Slot Size M goalFrom ToFt. in. in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK:Depth Size Material
FromTc FLFromTo Ft-
16. REMARKS:
r<
7
I ll0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARD ,OkND
THAT AA C,O P�YOFF�THISpRECORD HAS BEEN PROVIDED TO THE WELL OWNER — --.
00
SIGNA UR F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh N.0 _
27699-1636 Phone No.[phone],within 30 days. GW-I REV.'07/2001

WELL CONSTRUCTION RECORD " 3 0 9 8 1 0
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
l\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) B_(L.4 F� �;r�-t C/' CERTIFICATION
\\'ELL CON'IRACIOR COMPANY NAME 4 (ii . L PHONE # ( ) Zy ySy rL'
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERa ITN t
(ifapplicable) (if applicable)
a
i. WELL USE(Check Applicable Box): Residential"unicipallPublic❑ Industrial❑ Agricultural ❑ �
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use I
2. WELL L ON
NearestTown: O vtl� Topographic/Landsetting Ln ounty- ❑Ridge ❑Slope Valley ❑Flag 4
(check appropriate box)
(Street Name,Nunibm Community,Subdivision,tot No.,Zip Cate) Latitude/longitude of well location
3. OWNER: aSE3p >Z)e''
(dcgn:es/minulcs/secondS)
Address S<I/
is Latitttddlongilude source:❑GPS❑Topographic map
(Street or Route No.) (cbmk box)
` LMQ;:,� NC '� DEPTH DRILLING LOG
ny Mn) te Zi ode
- 4 .- � lVe) ifi From 7o Formation Description
Area code.Phone number
4. DATE DRILLED f _ /� C tc
5. TOTAL DEPTH: I f R'V 5.4/ /i'ac t
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO fide
7. STATIC WATER LEVEL Below Top of Casing: GPf, e/-„ e
(Use"+"if Above Top of Casing) ^�
8. TOP OF CASING IS�_FT.Above Land Surface'
'Top of casing termlaated atlor below land surface requires a
variance to accordaecy with 15A NCAC 2C.01 I&
9. YIELD(gpm): (Aft METHOD OF TEST / /Z 120— 71po A0
10.WATER ZONES(depth): CuQtp/A L4 Iyo
—� �— LOCATION SKETCH
11. DISINFECTION:Type t(.t° Amount 5'�E') L Show direction and distance in miles from at least
12. CASING: Wag Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Fr. Material numbers and common road names.
From To��,Ft. (PV �0 l%L
From To�_Ft. 3L
From sr! To—Zal --Ft
13. GROUT: Depth Ma erial Method
From To,-_Ft.
From_._To :7. 5 Ft. •tUk
14. SCREEN: Depth Dianiet rr'�Slot "Size Material lYj V '+ 0,
From To Ft. in. in. a
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sin Material
From To Ft.
From Tc, FL_
j2
IG. REMARKS: `
Y
I DO HER EBYCERTIF1y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL r -
CONSTRUCTION STIAVDARDS,A THAT A C F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER-.-
00
GNA RE OF PERSON CONSTRUCTING THE WELL DATE
ci
cr.
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service center-Raleigh,INC_
27699-106 Phone No.[phone],within 30 days. GW-I REV.07h700f

r� 306908
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
T � d5 Iw ELL CONTRACTOR(INDIVIDUAL)NAME (print) Ar4 LO
Nr ELL.CON1 RAC't'OR COMPANY:`LAME �Ura�{G� lVie LC- ()/l�l�� PHONE # ( 1.72-9 CtS—Ya
STATE\VELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT*
(ifapplicable) (ifapplicable)
I. WELL USE(Check Applicable Box): Residential M/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ if Other,List Use
2. WELL LOCATION: e p�Ldc L L Topoohic/Land setting �y
Nearest Town: rv(L7t6b� County__ ❑Ridge Slope ❑Valley ❑Fla%
l ff4yyl� 5: S t (check appropriate box) Z
(Street Name,Numbe m Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �e� U A'U t 5 (degreeslminutes(seconds) O
Address / 2 rj/5 D Latitude/longitude source:❑GPS❑Topograpt�lctmapm
(Street or Route No.) (cheek best
GO/'1 eLid5 )Ve- :2 2+031 DEPTH DRILLING LOG
City or 4 SLatc Zip Code From To Formation Description
Area code-Phone number 0 •. CI t
4. DATE DRILLED I -LLI-C)y ge— �Z.:• CG Ct4'6r
5. TOTAL DEPTH: .I V) -/
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 91
7. STATIC WATER LEVEL Below Top of Casing:�0 FT.
(Use"+"if Above Top of Casing)
8, TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.011 S.
9. YIELD(gpm): 4 METHOD OF TEST I
10. WATER ZONES(depth): i c,a.>` e 170
-Z i� �' 2.jcJ LOCATION SKETCH
11. DISINFECTION:Type f-O"'i7Zt N C- Amount 9)02, 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. S Lltt),/.'Ch
From To Ft. .�� �, ,''V,P -S'f V
From (`'�To 1- " Ft.
m O �/C� 1f`t r��`N �tUQ,p
Fro �To I-r(:(P Ft, O Ma- (y ,`GCa `/
13. GROUT: Depth Material Method t'
From To FL
From O To ZO Ft._�7 ��_ O d q�4
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. V-
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material a
From To FL 4
From To FL ./ter 0a 0u M^
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 0
SI13NAfURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Rater Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001
MAn

WELL CONSTRUCTION RECORD 3 0 6 9 0 '7
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ,I
_�_JQ! 'iCIEr� CERTIFICATION Ozi �
WELt.CON'rRACI'OR COM 1-ANY NAME �;.�„�WeLL l7/ Li tL'�`t PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential U /Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: topographic/Land setting c_
Nearest Town: D LA Irl t— County 1( -U" EKdge ❑Slope []Valley ❑Flat X
d K e ()A I� re.� (check appropriate box) tv
(Street Name,Numbers1,Community,Subdivision,Lot No-Zip Cade) Latitudeilongitude of well location 00
3. OWNER: PI14 sA tV 11WIS (degreestminutes(seconds) S
Address Latitudc/longitude source:❑GPS❑Topographicmap
trecl or Route NoJ (check box) - -
:�'?uJNV,?14C;.;I,� A.: CL sZ <477 (9 DEPTH DRILLING LOG
Cilyor Tmrn stare zip Code From To FomLation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �Zi!
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7, STATIC WATER LEVEL Below Top of Casing:&FT.
(Use'W'if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
`Top of casing terminated attar below land surface requires a
variance in accordance with 15A NCAC 2C.0I 18.
9. YIELD(gpm): f0 METHOD OF TEST /Z
10. WATER ZONES(depth): i to L 2 e p
LOCATION SKETCH
11. DISINFECTION:Typce%l VrZL6 e Amount 9 t7 7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. 6­%J4
From To FL - 70
From L To //f Ft-/0
From ! -/ To �l'3 FL v (t��
13. GROUT: Depth Material Method [ V
From To Ft,
From_r(_To 2t) Ft. :ZIFi fl!»
14. SCREEN: Depth Diameter Slot Size Material �l
From To Ft. in. in-
From
`>
From To Ft. a 'in- in. L
15. SAND/GRAVEL PACK: y,,�
ro
Depth Size Material `l"e �'cti '�a
From To Ft.
From To FL. cM
6V J.
16. REMARKS: q tl
1 DO HEREBY CERTIFY THAT THIS W L WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL ,
CONSTRUCTION STANDARDS,.A HAT A COPY OF THIS RECORD H EEN PROVIDED TO THE WELL OWNER
'SIGNA RE F PER CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV,07/2001
MAR -- 8 :'G(

MMLL CON UMON RECORD C�
ST .3 0 6 8 9 2
Notch Camlim-Dcpartm rt of Emrioaaml and Naboad Aomori-Diviaar of W*w Qrlily-Qwmdwow Sacbm
WEI.LOONTRACIFOR COMPANY NAM IR"t I;" room 0(64) 524-qsHA
STATE VVSSA.aolsTaUCXM%rogja a •••l4D VJQVRRNM
L WELL USE(Check Awficrhle Bonk RraWWM B mudci Ee IJ bmlodr l O Ag iadbal D
Muuwm [3 Rwwvwy 0 HWPM ►VWWbpcbmo Gdrro IfOd or LstUse
2 WELL LOCATI •Me _
arestTowa, Ai1.tA'�- ,. MIQV 13V&Iky DFlat
' �isuk l (dart�ppapieeaK)
tSum►ir.ir.N.a6ns.+L�aar. lsctt..rrt�ael 1+liardaQroeimdc ofvteHh
3. OWNER
Add (der)
l t.r_y �f '' saa ' l map
I a+�lL 7
art... DRUJAgGLOG
Sire Zi►grde From To FomwimDesctiptiwi
Aeseede lr L? £ �afjj,�
4. DATE DRILLEDRMLED --OUIA-et-
5. TOTAL �T --// —�
6 DOES WBI RBPLACB WBLLT YES VNO o � �, —
7. STATICWATBRLEVELBdmTapafOai, (,± rr,
8 TOP OFCASWti 1S i
Na r RAMre7lo�dCtrird
Fi.ALoaaLadS~ z
.ai.ceraeraew.a.O URMCAC2C.E1K
9. YIELD(Duo: 9_MBIVOD OFTBST ✓� ���
10.WATER ZONES(dq&)- 6,e o
• '�'-�" LOCATIONgYrtTr:t1
11. DISINFELITON:Type lG '; (r� AMW JP L Sbvrdiae�oo rod doGrra®ails 4om
12. CASprG wallhidown laoS1MaRoEdro(Caarly Rotdt 1Eelode th a lmd
¢ � or laa R, oarNlro o.iaa ad cau®nra.d oomm
Fran 1—To /Z%
FsTe 1 S 'LL
13. GROUT: Deph hfalpitl hldbod
RomT,_To F(.
14. SCREEN: D" Obladier slotshe
Fmm—To Ft._..,_Ir. q
I5. SAND d VEL:PACK io i` L� Q
Fmm—To Sim mom
Fnm_To FL U
16. REMARKS: C�5
r ,
I DD HEREBY CMMFYM AT1HN WEI.L WAS(X)MMUCTUD R ACDORqANCE WTTH 15ANCACXt VRL
CONSMUCnGNSfANDARM THATACOPYOFTMFMMMASSMpROVgMlo,MWMLOWNER
UObWMUCT=TBE WELL DATE
SuMlM1theari6waltotheDivlriraafWa4rt�,,C+ �rSacliat.W6MaiSarvieeCaadar_RWtRi,NC n
27A1163f*Yoe(h (111h733 3ffi1. 30alrys GW-1 REY.07/c
0
r_

WELL CONSTRUCTION RECORD 0 306893
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\Y ELL CONTRACTOR(INDIVIDUAL)NAME (print) l s� �l:,�t(t'Ct CERTIFICATION HZL�/So
%t'ELL CONTRACTOR COMPANY NAME .TIi %C. L` /t Ir.cyit 'r_PHONE a
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(ifappiicablcl (ifapplicablc)
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: dG�l T y idg'ep hie/Land setting
Count• tvC�L tdge ❑Slope ❑Valley ❑Flat
�.�VA I-U (check appmpriat,box)
(Sncet Name.Numbers,Community,Subdivision,Lot No.,Zip Core) Latitudeilongilude of well location
3. OWNER: 1,0A,44e Kaeg t" f"L (deg ees minutdsecond)
Address _ �t-�- 46 a9 Latitudc/longitude source:OGPS❑Topographic map
(Jtriet ar Route No.) t� ��2� � (check box)
��C D�r� N C- +'�L 26?1- DEPTH
Cn orToan ystam DRILLING LOG
y Zi Code P From To Formation Description
At"code-Pliane number
4. DATE DRILLED
5. TOTAL DEPTH: 67
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below To ofCasin : C
P g _FT.
if Above Top of Casing) fsJ—
8. TOP OF CASING IS it FT.Above Land Surface'
*Top of casing terminated atlor below land surface requires a 0
variance in accordance with 15A NCAC 2C.01 ILcn '
9. YIELD(gpm):�—METHOD OF TEST� jC
10. WATER ZONES(depth): �'z'1�se ;r•- y Sv s"
11. DISINFECTION:Typ LOCATION SKETCH
Type LOCATION
Show direction and distance in miles from at least S' `"
12. CASING: Wall Thickness two State Roads or County Roads.Include thFad _
Depth Diameter or Weight/Fi. mAcrial numbers and common-road names.
From_To /07 FL 4` ® 'cm
From J0Z To /L7 Ft. Soo
From /r tt7 To Ft._,&LY[_ / 9 /fit]L A�r�C ✓ c3
13. GROUT: Depth Material Method
From To Ft. 17
� /N+j
From fT Tom Ft. ) �
14. SCREEN: Depth Di eter Siot Size 7Ma7feria /�
From To Ft. in. in, f1
From To FL—in. in.
IS. SAND/GRAVEL PACK: ^, yv d
Depth Size Material J' 2
From To Ft.
From To Ft. �� +
16. REMARKS:
I DO HEREBY CERTIFY THAT THI WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,. DTHAT . CORD HAS BEEN PROVIDED TO THE WELL OWNER
'V 5z
IGNATU OF PERSON CONSTRUCTING THE WELL DATE -"
Submit the original to the Division of Water Quality,Groundwater Section,1636 Nlail Ser\ice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.071Mo1 r

WELL CONSTRUCTION RECORD m 8 2 7
North Carolina- Department of Environment and NaWlal Resourcres-Division of Water Quality-Groundwater Section
vl'ELL CONTRACTOR(INDIVIDUAL)NAME (print) °�`x�y Sc1s ��C� M CERTIFICATION#�- 5 �
W ELL CON'lRAC'I'OR COMPANY NAME JL`iY/('i (.Z��LG.. tJ t'�<.�✓K•L:PHONE # f 1 7zy�Y.Sy�
sTATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) —/ (if applicable)
I. WELL USE(Check Applicable Box):Residential pd Municipal/Public❑ Industrial❑ Agricultura) ❑
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: ^� tg' Topo hic/Landsetting
Nearest Town: ! h++ County�;'1'1- '� ❑Ridge Slope ❑Valley ❑Flat
�`{9 p P.Gn, I' j (check appropriate box)
1Strea Name.Numbe,rsrt.Community,Subdivision,Lot No..Zip Code) Latitude/longitude of well location
1OWNER: ( L-- qe Y ' CJ' (degrees/minutes(secmds)
Address W6 0 &A e-'I� CZ.A _ _ Latitude/longitude source:❑GPS❑Topographic map
��� '
(Street or Route No.) (check box)
�--'A /1'Ltr_w cJi1 ('. u'.5 L- DEPTH DRILLING LOG
City or Town sate zip coat From To Formation Description
1_) 4�iL - b�4&
AmcWc-Phone number i _• rJO �j%C £ f�c!•"
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO EL--
7. STATIC WATER LEVEL Below Top of Casing: zl FT.
(Use"+^if Above Top of Casing) 4�
8. TOP OF CASING IS FT.Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance is accordance with 15A NCAC 2C.011&
9. YIELD(gpm): METHOD OF TEST ✓/� Sfar t '7
10. WATER ZONES(depth): r-1; . Orr
LOCATION SKETCH pp yy`
11. DISINFECTION:Type 1' Ic Lq.. - Amount g3 0 Z __ Show direction and distance in miles from at)east Y
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Maten 1 numbers and common road names.
Front To Ft.� t �°
From z- To %QL Ft. A z�!� Lj�t
From /CZ To %C Ft. ifs 9 ems!/l/� U
13. GROUT: Depth ale Method
From To Ft.
From (L7 To_Z, Ft. � ��
14. SCREEN: Depth Diam ter SlotSi2e O
From To Ft. in. in. 2 �j��
From To Ft. in. in. %" 0 1 C
LS. SAND/GRAVEL PACK: .�wz
Depth Sim Material
From Tc Ft.
From To Ft.
16. REMARKS:
�r r�✓Q
1 DO HEREBY CERTIFY THAT THIS WE WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL:
CONSTRUCTION STANDARDS,.4NJ�T I T A COPY OplrHIS RD HAS BEEN PROVIDED TO THE WELL OWNER
i
SfGNATUREOF RIffONSTRUCTINGTHE WELL DATE -
cc -
Submit the original to the Division of Water on Ir y,Groundwater Section, 1636 Mail Service Center-Ra ' 'NC
27699-1636 Phone No.[phone],within 30 days. GW-1 RtkJ7/200
I

FROM MORETZ WELL & PUMP FAX NO. : 7044621322 Aug. 29 2005 07:44PM P9
0�1 3
WELL CONSTRUCTION RECORD
North Carolina-DTaftent of Ew,*onmemt and Neusel Res mn=-DiviaiOR Of Water Quality-GrouRdWAW Section
W)UZC0NTRACrOR0DrMVAL)NAas6 rarnam ASHLER T. MORETZ CRRTtFICATION$ 21U
wru,C0NTRACr0RC0W"ymAM6 MORETZ WELL DRILLING rRoNs # 7�62-1322
STAT4 WRla.CONSMUCrION FERIVIM TBD WQ PERMLTe
--_—... (tlsoplleabk)_ (ifmogcebk)
1. WEM USE(Check Applicable 8"),Residential I/MueicipallPublic Q Indwoial Q Agtiwleval O
Monitodus 13 Recovery O Heal Pump water iwecrtam O other t7 If 01ber.Lint Use
z WELL LOCATION:
Nearest Town et Ot Cotmty G 4 [ve c[r Nope ovaucy mu
Sow cc (alusk appapiale b64
(saeeca.Nnrab�. c /sebavmaa l�ramHacoa.> e o weu /oc�eS 3.01°Ff 61/
3. OWNBit : , �t�OR�°[� ,dew—sue (dgpeuaaaRry )
Address _- - Qa Letimrkltmokdesource:06PSOToPo
(Seen err Ns.)
grapNc map
D (erect bowl r axes r rr_.
��erTma Sty 7.ip Cede F T S, Form 1 eecxiption
4. DATE DRILLED
S. TOTALDEPTII —
6. DOES WBLL REPLACE E)CISTINO WELL? YES Q NO CY
7. STATIC WATER LEVEL Below Top of Casing __Jfe__yr,
S. TOP OF CASING IS Z -FT.Abm Lard Surfaces —,— -
'Tap of caW(rw7Wutad MW tulow lad smLn requiem a
vWnm In mmrdmee wRa 16A NCAC 2C AIIL W
9. YIELD(span):Zo METHOD F TEST t�
10.WATER TONES(depth): S� o
-------------
IACATiON SI�t?'frci
11. DISINEELTION:Typo Amvud Z Show direction and dis moe in mules from at leas!
12. CASINO: Wag TWdnem two Stabs Roads or County Roeds.include the road
L „ TDr —T D' er %?A- numbers and comma/errroadcamas.
Fem4P��Q�T � 1U� S'tC.
13. CiRo�-"-7" _ matmw Method
d
F from To Ft
14. SCMEN-. Dgaa Diameter matsim Matafal
Pro To _
IS. SAAND/Q�RAV.ELPA�CR:
F nrd t Te\ Sim� w
7 Ft
16. REbEARKS:
100 HEREBY CERTIFY'IIiATTHIS WELL WAS CONSTRUCTED 1N ACCORDANCS WITH I SANCAC 2C,WELL
CONSTRUCTION STANDARDS,ANR THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TUB WEM OWI'aM
$-2 -6s-
MUNArUM OF PERSON CONSTRU THE WELL DATE
Submit the erigiaal to the Division of Water QraW,Groandwafer smmem,1at6 Mao Rewire Cwaer-Ra1Nya NC
2709-10M phM No.(p1q)73S4321,WWR 30 dayL OW-1 REV.(17/2001

'CRETZ WELL & PUMP FAX NO. : 7044621322 Aug. 29 2005 07:43PM P8
3 6
,n
WELL CQMB.UCTION RECORD
Noah Carolina-Department of Environment and Natural Raourca-Division of Want Quality-Groundwater Section
wzu coNTRAcroRgNpWWt1A4 Kom WAt CtaTmcATW#_Z EL
W6LLCONTRACTORCOMPANYNAM MORE Z WELL DRILLING eHON6 6 i704)462-1322
6TATE WELL coNaTs =w FzRbmo Al 11 .S80CUM WQ trelebrrr6
Cifawlic") (irgpHceble)
1. WELL USE(Chock Applicable Box):RaidwW G✓MudicipaVPublic 0 laduserial© Agricultural 0
Monimting 17 Recovery 0 Heat Pump Water injection 0 Odw 0 If Other,List Usk
21 WELL LOCATION ��' M [� ®s Tapog[aplucJL�a setting
NaratTown ti i �j H�G� �� OVaAey ❑U
er11lL Oobimckiammpsieeeburs) '7 O•� /,�/
(&�OWNER:
Namben.Cordmedy,sr".mm,teeN0. Cods 1 �'T5(yi�f '
3. OWNER• e �. a � C )
Address Latituddlongi4lde somne: SC7T oP o 1s
• {meet No.) '(chest surd P
Ajguz6 s28�Sj WX42RIM
CltyorTooe son Zip Cads F T S� Fornutionpexripd�
d;r
Atha coda Fboee aewber
4. DATEDRHssD 0 c
S. TOTAL DEPTH J
6 DOES WELL REPLACE EXI MG WELL? YES[INO [Ir
9. STATIC WATER LEVEL Below T of O
(Uw'4'UAbow 7sp otCu(nd B. TOP OF CASINO IS FT.Above Land Sadaces r ;s5=
'TOP ur cedes rrELROW ader betew teed.c6a roquim a G7
vai.- -Y tfA NCAC3C Ali&.
9. YEU.D(gpm); ;I METHOD.OF BST
0.WATER ZONIS(deo): 3>`74V o ,:w
11. DISINFEMON:Typ6 Amount 9 0Z SWw direction and disswce in miles from at last
12. CASINO: Wan 7ldclmea two State Roads or County Roads.Include the road
TI7rh Ft Diagg ort�.. M�ayet numbers and conunnn road names.
Frog Te Ft �'"'► !- V[e
40
I3. PROUT: . Dqmhe..c2.��_C�dti.�"
From_To I#.
14. SCREEN: 1 Dismotcr Slot Size moor l
Frc o 4�n1, �Cn.
F To„ Fr to-�1�
IS. SAND/GRAVELPACIC: =' I
Depth Sirs Materw
Ft.
Fret To
16, R.BMAM:
i
IDOHEI"YCERTIFYMTMSWELL WAS CONMUCTEDIN
ACCORDANCE WriiiISANCgC2C WELL
CONMucTioN STANDARDS THAT A COPY OF TMS RECORD HAS BEEN PROVIOM To THH WK4,OWNER
NkUNArM OF PERSON CONSRUFTINO WUWELL DATE
Submit the orighW to the Dlvhlon of Water Q=11ty,Groundwater Sectlon,1636 Nail Servir Center-lWeigb,NC
3709-1636 Phone NIL(919)793-33Z1,within 30 days, OW-1 REV.O 2001

MORETZ WELL & PUMP FAX NO. : 7044621322 Aug. 29 2005 07:43PM P7
3
VWLL .0 ,STRUC nON RECORD
North Carolina•Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WZLL CONTRACroa 0"WInIIAL)NAME ASHLEY MO TZ CERTIFICATION 0 2585
WR1 CONTRACTOR COMPANYIttSR MORETZ WELL DRILLING raONg s f0*j2-JJ 22
SrATS Wit"CM071111MON 1FZR;1;" TikD WQ PSRaim
(ifaopIIaa�k) _ , fifaoolieable)
1. WELL USE(Check Applicable Box):Residential Ef/Mtnuclpal/Fublic❑ Iwlustriai O Agricultural O
Monitorin;Cl Recovery 0 Heat Pump Water hgeof m 0 Other 0 If Other,List Use
2. WELL LOCATION: r` Taeltogfaphic/Land setting
Npagg3 To S L �omtty I� e OSlope Macy Met
nn �s (chu ry ivwhul4
(skeet Nan%N-Aux.Casmaaw,svbdi9Ak%xamo,zip cob) / sLo/RV wo�.S7s�
3. OWNSR //CConrl fYAL+S:�L�V� 1er t ,
Address '2 7"k e,a w _ -Alib Latitaddlangiade upogmphie rasp
Ga _ewe !/ (SaentrRR�e,te) i � yS DUTH
GYry'a7bwa lBAba!{. Zip cede gat To FotAfa pq Dtipt�a
(� r
a. DDAATE nxRiLLED�
S. TOTAL
6. DOES WELL RMACEMMTINGW1 S NO
7. STATIC WATER LEVEL Below Top of
Man-+'If Abora't'sp of cadug)
L TOP OF CASINO IS- -_Fr.Above Land Sur&oco ¢
'Top of cubs t ndesssd sum balaw Wd munm rminim a _
varirn IN OA NCACaC Alm
9. YI&D(gpm);, METHOD OF TEST a,/ 1
10.WATER ZONES(depot):_ .2 d 0' o
11. DISINFECTION:TYPO— Amoamt Show direction and distance in smiles gram eNbast
12. CASINO: / ., Well Mddmm two State Reads or County R.made.Include the road'
�, TI)� -0— D� 3MM ,6M�7dd4ee�Li . numbers and common road names.
From_To Ft` _ 7 — See, /a-
Prom _To FL-
13. GROUT Dept Material Method
FrumU r.�n re /� .reo�
Fro4t_TO Ft.
14. SCREEN: Diameter Sint Stu 11410016121
F
F T
is. SAND/GRAVELPACK�
Depdt Size Materiel
To
16. R>afwxlrs: .....-
I DO HERESY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANTE WrrH I SA NCAC 2C,WELL
CONSMUCfION STANDARDS,AND THA3 A COPY OF THIS RECORD Ha BEEN pROV IDBD TO THE WML OVINM
T� Dpi�: Y
titkRVATtIREOYPMtSM OONSTRUCI7NO THE WELL
... DATE
Submit the original to the Ddvbfoa of Water Quaft,Groundwater Section,16M Mdl Ser Ar comer-Rsltk&*NC
2709-1636 Filets N0.[phone],within 30 days. OW-1 REV.0712001

11 i. f 0 ° 3,f
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
L'I n
WELL CONTRACTOR(INDIVIDUAL)NAME (print) C'J. C" At + ���fp��ff CERTIFICATION 42 UJ 1
WELL CONTRACTOR COMPANY NAME .� + {IC LoCII UAt,. /L. PHONE # (YZY)' '
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# -
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential V Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: Topographic/Land setting
Nearest Town: /0) f0AT County�eJ// ❑Ridge ❑Slope ❑Valley Pflat
�/ X e2, ,tom jG� i S�1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 9JC A-)Al�� UC-.rS (degreesiminutesiseconds)
Address 3/ Wd Latitude/longitude source:❑GPS❑Topographicmap
(Street or Route No.) (check box)
d /,/ Z y 7 6 2, DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED I- .44 -0.5-
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES WNO ❑
7. STATIC WATER LEVEL Below Ton of Casing: 1_FT. j
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS_.�FT. Above Land Surface* — 1
'Top of casing terminated at/or below land surface requires a — '9:-
variance In accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):_7 METHOD OF TEST_ba' &�,
10.WATER ZONES(depth):_ r-T.
LOCATION SKETCH
11. DISINFECTION:Type C'_in kq,Z_ Amount V� 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. aten corm
on numbers and coton road names.
.
From /e Y To g Ft. �a , r �/ /C'
From—To Ft.
From To Ft.
13. GROUT: Depth Material Method
Froml�bAO To_a-b Ft. C,=�t _ e a J e. S iQ //b 3 b1-E Ahl 'F
From To Ft. __ � /� � ,�� ��fc� aN 7-♦
14. SCREEN: Depth Diameter Slot Size Material _
From To Ft. in. in. � c?+�7E $ �i1' SAJ
From To Ft.—in. in. t�c L1 - .L�Cj0cd 4-t S� C% of
I5. SAND/GRAVEL PACK: Ls
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
Q, ep, 2 .Cet t, 3, 2eY b,y
SI .TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

0J,
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section /J
WELL CONTRACTOR(INDIVIDUAL)NAME
( �print) - Z (( C It CERTIFICATION
WELL CONTRACTOR COMPANY NAME /U i �- �- j ) T 1I t &IJONE # ! 6 — (�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential-E�Ivlunicipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Landsetting
Nearest Town: C3/d T cdk 2- County 7z&s Dil td,/i- ❑Ridge ❑Slope Palley DFlat
;X Z 6 6 1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �1L� ,,{Jr 2,}f_LLe A (degrees/minutes/seconds)
Address - ti �,_/tf' p�_�.. .e r �4'�. Latitude/longitude source:❑GPS❑Topographic map
/ (Street or Route No 6� (check box)
ZA ?�i z DEPTH DRILLING LOG;'i
City or Tow scare zip Code From To Formation DescriptTotl
9A) ��p- 2
Area code-Phone number '+ _ ` U �_-
4. DATE DRILLED CJ C
5. TOTALDEPTH: t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E3' X.
7. STATIC WATER LEVEL Below Top of Casing:�_FT. p Y'
(Use"v"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*'Cop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): /s�5 METHOD OF TEST 'AZ ti
10.WATER ZONES(depth): ' 7.-<' F-2
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept Diameter or Weight/Ft. Yalpal numbers and common road names.
From To Ft.t
From To Ft. Li
From To Ft. / j,� C
13. GROUT: Depthn }� Material Method H It �� a l
From��✓ To ))
Ft_����il7i � `r q Lir
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. �G J t ,J
15. SAND/GRAVEL PACK: G
Depth Size Material U-) ('�-f'6 ZR �-C
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WE WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN ORE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section y��r
WELL CONTRACTOR(INDIVIDUAL)NAME (print) V, C_ y _�� r /I CERTIFICATION
WELL CONTRACTOR COMPANY NAME ZU,s Li t.-, / ttL 41 4Ji i /.,V;PHONE # ( )
STATE WELL CONSTRUCTION PERMIT/ _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Er 1�Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO Topographic(Land setting
Nearest Town: 11 A) County A. � @ � �/ ❑Ridge ®Slope ❑Valley ❑Flat
--� 2 I1 3 '7 /t5 '7�1 ;z,L a! (check appropriate box)
(Street Name,Numbers,Comtnuoity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: GC- / e21CC (degealmioutes/uwnds)
Address tit Z, >z ,(3 1 t� Latitude/longitude source:❑GPS❑Topographic map
(Street a Route No.
(chock box)
o�1a, �4 .tj L1 e C y7� 2 DEPTH DRILLING LOG
22 C' or Town state Zip Code From To Formation Description
Am code-Phone amber
4. DATE DRILLED -.7 1_ 0-V
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YESg NO B- r
7. STATIC WATER LEVEL Below Top of Casing: 4E 8 FT.
(Use••+^if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surfaces "'
'Top of casing terminated■tlor below land surface requires a
variance In accordance with ISA NCAC 2C.0118.
9. YIELD(Spin): Z IS METHOpp OF TEST 8 t
10.WATER ZONES(depth): �'O f7`
LOCATION SKETCH
11. DISINFECTION:TypeLiA t 4 Amount g /Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth . Diameter or Weight/Ft. renal numbers and common road names.
From % To l.2 Ft.6,5, / 3 7
From To Ft }��
From To Ft i ) t � /C h^
13. F o0m�TTo—Ft c tife� 4 th material Method 7 .3 �je eJ
From To Ft. 0 � /1 S d tJ � a LtC
14. SCREEN: Depth Diameter Slot Size Material Ott f r
From To FL in. is Jt G `= �z
From To Ft in. in. i�
15. SAND/GRAVEL PACK: 0 s d rS C i
Depth Size Material
From Tc Ft. 7 a / h
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2G WELL
CONSTRUCTION STANDARDS,AND T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
L% /1S .
SI ATURE OF PERS 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

Neva cvow•06"rownt a ErmImmuM.1 end NeWd ReaeYlla•DWtaan Ot Wow w.ter.OIVINWwNu sKVan 3 l l y
ISM MoeSwACe Center-RgAgWN.C.27e99-1676.1` r (S/q 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION 9:
STATE WELL CONSTRUCTION PERMITS:
I
40
Delp R661d6Mlel2j- Munkipal[3 MckI6tda1Q Aflrkultur�ifBasticYNC�
1. WELL q Nast Pow Walsr kiselan ❑ 09ror o ll Other.Llat Use:
Reclarery '
2. WELL LOCATION:(Shaw SkOM of the 1O"Oon below)
fieereNTerac CorneP�
a�AudalonraLalloi naulrnla... DE P H
From To
OWNER /.M4 �rl1- y^ G �•- .%,-,i) - Fora'eSriWwIPYs+
Addroee
r n'x
4. OATE DRM — CDt. TOTAL DEPTH
S. CtT7NSCOL.0 L �0NO ,_a
7. DOES WELL REPLACE SX"MNQ WELL? Y
S. STATIC WATER LEVEL Snbw Tap d Caekrs:
woo,.a� 1,. CeAFT
sl o �
s. TOP OF CASW4 t9 FT.Above t MW SuMW
'1eFNe•alnsIernomadeYerbdwoIlM saAeeereauYe. whom"in occur
- z
a
u
1 .YfrAL0(gpnQ: rMETHM OF TEST!1
11.WATER Z (deP"- g^2A —
M 6 add6an61 Were Y rrM.J w Wd q krm
12.CHLORINATION/:� Type
13.CASINO: 'V, / K N
was YrAdwax Mew"
K (gam kgpn efd diefetice eem tt Aes:ae StW
pl.m w w w.wjn n'p haw$.Or cow Mw rokw4s Pal
From ;Z�= TO q l -
From-.----Te
Fran r_._ 79 FL
1(.GROUT:
Depth M6Yad
From [ ToCFI M6.
Frown TO FL
15. SCREEN:
pipth Olameter Sal Ski Mewdid
yam Ft In. .In ------ �fU
From '
From .__To__FL In. _In
Fran _,,,,,,_To_......FL In. — In. Zw4MRAVEL PACK'
From —
From To FL -- ---
17. RF_MMKB:
TRUCTED IN ACCDRDANCE WITH ISA gCAC�•y/ELL
I DO NERBSY CERTa°Y THAT Tts9 WELL WAS CONS
pWADEO TOTNE yI L 0%%Fp'-
C0NSTRUC1MSTANDARDS.ANDTHATACOpVOFTNtS1WCOROWASOEEN
INS WELL yea �—�-
FOR OFFICE USE ONLY Oa DF FERSMO ,m,, ww�tt av uyl
Oee911r: gub�►«Idnrlq elWNNthMSf P*V.IM
tt.a+Re.

a wSA>Fo
S RESIDENTIAL WELL CONSTRUCTION RECORU
'�. *•y �g North Carolina Department of Environment and Natural Resources-Division of Water Quality
.a wr,w^•
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
I. DISINFECTION:Type - Amount
Q Z
R� GIB 0 ( ,ALD LA)L j,L g. WATER ZONES(depth)
Well Contractor(Individual)Name From Z t D To 2 I ( From To
Il . VrY 1-Ll a w- U. 11"ll r I �C' From To From To
Well Contractor Company Name Er-� Fran To From To
STREET ADDRESS �5 6 ta.) 7.� I �7�,/ 6. CASING: Thickness/
��N13�t LL �g� QV r A Depth giameter WP�q enaL
D tU ` From. 1 To %a Ft. 'o � , i FS ste,
Q ryCity a T,oTwn ,I State Zip Code From To Ft.
"la, 4 '5`T 35g 1 Fran To Ft.Area code- Phone number --
2.WELL INFORMATION: 7. GROUT: Depth I�M_ater�ia�l' Method
SITE WELL ID From 4 To FL �'yYVF>`l-tom l)J
#(il applicable) From To_Ft.
STATE WELL PERMIT#(il applicable) From To_Ft.
DWQ or OTHER PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicjlble Boxy Residential Water SupplA/ From To Ft.—in. _ in.
From To Ft—in _ in.
DATE DRILLED Z r7 5 From To_Ft.—In. _ in.
TIMECOMPLETED 10 O AMj/FM❑
9. SAND/GRAVEL PACK:
3.WELL LOCATION- \ Depth Size Material
CITY: 6 �A iL�. T) COUNTY '' ^�`-��t''���"'�-- From To__Ft.
n r� p� Fran To_Ft.
_ 5 64 A iJ tJ a� {....1(N �� 3 O From To Ft.
(54eet Name,Numlxra,Commumry.Subtlms�o ,Lot No.,Parcel, iTL p Gotle)
TOPOGRAPHIC/LANP SETTING: 10.DRILLING LOG
❑Slope ❑Valley Q411at ❑Ridge ❑Other From / To ¢ D F rmationDescri do
(check appropriate box) ��,r n _ p�
LATITUDE 3 — May re in luees, ? ���/(]
minuta,seconds or
LONGITUDE m a decimal format 1O
Latitude/longitude source: OGPS ❑Topographic map t O ITS
(location of Wait must be shown on a USGS topo map and
attached to this form#not using GPS)
4.WELL OWNER ' `! t7
OWNER'S NAME t3 \tz ©C- a A y�
ST�j EET ADDRESS _ 'C- D _ - ZA
City,grTown State Zip Code
44a - 1953
Area code- Phone number
S.WELL DETAILS: 11. REMARKS:
r2 1 /
a. TOTAL DEPTH: yI
b. DOES WELL REPLACE EXISTING WELL? YES O NVIO
C. WATER LEVEL Beim Top ofCasln 100 HEREBY CERWY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
g: FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND VAT COPY F THIS
(Use'*'NAbove'Top of Cwing) RECORD HAS BEEN PRWDEO TO WE O NER
d. TOP p CASING IS 1 FT.Above Land Surfacer �0 � 0
'Top of casing terminated aVa below land surface may require -
a variance in aaadancevvith 15A NCAC 2C.Otnnt 6. Q Q SIGNATU1nR`E OF CERTIFIED WELL CONTRACTOR TE
e. YIELD(gpm): METHOD OF TEST lyl,� I,I ^' v, 1^L'� g "A
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 566. Fonn GW-ta
Rev.7105

p ;(
RESIDENTIAL WELL CONSTRUCTION RECORD 3 18
North Carolina Department of Environment and Natural Resources-Division of Water Quality
\YELL CONTRACTOR CERTIFICATION#
-1.WELL CONTRACTOR: I. DISINFECTION:Type Amount Z
�q L, 6V!xnl LA lZlx:1E l.,L g. WATER ZONES(depth) ,
Well Contractor(individual)Name --rp t•. From 1 6 o To 16 I From To
- From To From—To—
Well Contracla Company Name--`` ^�..�c From To From To
STREET ADDRESS -�� ' NiS II ` W-61 J �w3 6. CASING: 4 Thickness/ep� A�a
AS� fl1_. PC- ag8 06 Fran DT0 FL (9 r t
City or Tavn State Zip Code From_To—Ft.
&SL - c7 5 9 k From To Ft.
Area code- Phone number
2.WELL INFORMATION:
7. GROUT: Depth Material MMethod
Fran_To o�j�FI
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(e applicable) Fran_To Ft.
DWQ or OTHER PERMIT#(I applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Appl' able Box) Residential Water Supply From_To Ft.—in. _ in.
DATE DRILLED a a D From To Ft. in. — in.
From—To Ft.—in. in.
TIME COMPLETED AM[-I PM[V
9. SAND/GRAVEL PACK:
3.WELL LOC TION: Depth Size Material
I 'L Fran T Ft.
From To F
CITY: �T�N COUNTY a� t.
I O 0 VA ll-L- (4 A (�!I From To Ft.
(Street Name,Numbers,Community.Subdivision,Lot No.,Parcel,Zip CoEe)
TOPOGRAPHIC/LAN$SETTING: 10.DRILLING LOG
❑Slope pValley L—y/.,�(at ❑Ridge ❑Other Fro r To Fol atio Descriplan\
(check appropriate box)
May h in degr«s, i
LATITUDE 3 minutes swords or _ O "7� L.4E-
LONGITUDE inadecimalformat _� \�� " - O r'Y1
Latitude/longitude source: ❑GPS ❑Topographic map
(location of weA must be shown on a USGS topo map and
attached to this form 7 not using GPS)
4.WELL OWNER �y�x/ � ``
OWNER'S NAME � A��
STREET ADD
c��� �� 1�a �ba
City or Town State Zip Code �
( fa-% } 4Aa- it853 R
Area code- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p leg/`p
I DO HEREBY CERTIFY THAT Tes WELL WAS CONSTRUCTED INACCORDANCE WITH
C. WATER LEVEL Beim Top of Casing: FT. 15A HCAC 2C,WELL CONSTRUCTION STANDARDS,AND TIATA COPYRAE
(Use-+-B Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.d. TOP OF CASING IS A FT.Above Land Surface' c,'Top d casing terminated atfor below land surface may requireSIGNATURE OF CERTIFIED W ELL CONTRACTOR a variance in accordance With 1SA NCAC 2C.01 18. pq n
e. YIELD(gpm): METHOD OF TEST- 1'I ICE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Fo m GW-1a
1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.[phone] ext 568. Rev,?/o5

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
a p
✓WELL CONTRACTOR CERTIFICATION# .�^L I
1.WELL CONTRACTOR: f. DISINFECTION:Type #TN Amount
j�
t /Jp_ R a-55 If g. WATER ZONES(depth):
Well Contractor(Individual)Name From-QP--To.2D-' From To
AU-5s,10-l 1 bi Ph 11 i no _Z IV G From To From To
Contractor Company Name From To From To
STREET ADDRESS ��7/�'ber{v t�i_hat-chi Tel 6. CASING: Thickness/
Depth Diameter Weight Material
Tin/n rs vr`l l e AJG 28ti :4/ Fromm To /3L) Ft _pure
City or Town State Zip Code From—To—Ft.—
cam)- 44a -S399 From Tc Ft
Area code- Phone number
7. GROUT: Depth Material Method
2.WELL INFORMATION:
From To-ow—Ft.
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(d applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
From To Ft._in. _ in.
WELL USE(Check Applicable Box): Residential Water Supply L9" From To FC_in. _in.
DATE DRILLED ld-lc�- OS From To Ft in. _in.
TIME COMPLETED fo? AM❑ PM 21
S. SAND/GRAVEL PACK:
3.WELL LOCATION: (� Depth Size Material
CITY: 2n aAd;dP J COUNTYnj:b&kLJ' L From To Ft.
Fran To Ft.
From To Ft.
(Stree( .me.Nu bens,Community,Subdtmsion,La No.,parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
Clalope []Valley ❑Flat []Ridge ❑Other From To A Formation Description
(check appropriate
box) ; n
LATITUDE 3 Maybe in , y Q r a�Sy nfYlL/
minutes,seconds
or
LONGITUDE W ICl)rytl nn A in a decimal format
�o� b'�O
Latitude/longitude source: &It PS ❑Topographic map �:J
(location of we#must be shown on a USGS topo map and CD r!
attached to this form I not using GPS) L j '
4.WELL OWNER I N
OWNER'S NAME /�
STREET ADDRESS V
-r►0- 128 s5- �' -4
ity a Town State Zip Code
(may 44a- _s3ac)
Area code- Phone number
11. REMARKS:
5.WELL DETAILS: hh
a. TOTAL DEPTH: dCQS `
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 18/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH
a WATER LEVEL Below Top of Casing:__JalO FT. ISA NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THATACOPY OF THIS
(Use"+•if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS�FT.Above Land Surface' < �C:�aQp..
'Top of casing terminal aVa below land surface may require SIGNATURX OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance With 15A NCAC 2C.0118. _
e. YIELD(gpm): METHOD OF TEST /✓-Gl2
PRIN�NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GWAa
1617 Mail Service Center-Raleigh,NC 276994617 Phone No.[phone] ext 568. % Rev.7105

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (pttat) Chad IlartnesS CERTIFICATION! 2901
WELL CONTRACTOR COMPANY NAME Air Drilling Company PHONE it(704)872-7614
STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMrf#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 21 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: Old Fort County McDowell ❑Ridge ❑Slope ❑Valley ❑Flat
Deer Crossing (check aPPmFtite box)
(Saar Name,Numbers,Commtoity,Subdivi xm,to No.,Zip Code) LatiludeAongitude of well location
3. OWNER: Mayland Home Center (degteeduumacs/monds)
Address 800 Summit Avenue Latitude/longitude source:❑GPS❑Topographic mar
(Strew or Route No.) (check box)
Spruce Pine NC 28777 DEPTH DRILLING LOG
Cityor Town Stme Zip Code From To Formation Description
C-)- 0' 92' Dirt
Area code-Pbone comber 92' 260' Rock
4. DATE DRILLED 09-30-05
5. TOTAL DEPTH: 260 FT. — — — -- -
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 12
7. STATIC WATER LEVEL Below Top of Casing. 4o FT. -- -- o
(Use"+"if Above Top of Casing) ---1 _
8. TOP OF CASING IS 1 1/2 FT.Above Land Surface'
'Top of easing terminated at/or below land sarBce requires a N
variation in aceordrawith ISA NCAC 2C All&
9. YIELD(gpm): 12 METHOD OF TEST Air O
10.WATER ZONES(depth): 246 FT.
LOCATION SKETCH
11. DISINFECTION:Type HTH Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common names.
From 0 To sz Ft. PVC
From To Ft
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Grout Poured
From To Ft
14, SCREEN: Depth Diameter Slot Sir Material
From To FL—in. _ in, `
From To FL in. in.
15. SAND/GRAVEL PACK: %A
Depth Size Material
From To Ft.
From To Ft
16. REMARKS:
c.
I DO HEREBY CERTIFY THA WE WAS N U . ED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANM S A ORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON I.ONSTAUL IL NU i 14.E WELL
Submit the original to the Division of Water Quality,.Alto: Information NlsnagemenL ;ail 1.Ad Service Curter-
Ra)eigil.NC 27699-1617, Phone-No.(919)733-701&within 30 days. 1

dSrArEo
RESIDENTIAL WELL CONSTRUCTION RECORD `
North Carolina Department of Environment and Natural Resources-Division of Water Quality
lam. WELL CONTRACTOR CERTIFICATION# 213 8
1.WELL CONTRACTOR: L DISINFECTION:Type chlorine Amount I V� iaAS
James W. Camp g. WATER ZONES(depth): �f
Weil Contractor.(Ind'Ividual)Name Fran To,96 _ - From To
Camp Is Well & Pump CO- Inn- Fran To From To
Weil Contractor Company Name From To From To
STREETADDRESS P O BOX 429 6. CASING: Thickness/
Depth Diameter We�' ht Material
Ellenboro NC 28040 Fran 0 T6'L Ft, 6a SDtt21 PVC
City or Tam State Zip Code Fran To Ft _
( 828} 453-7322 Fran To Ft
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Mehod
From 0 To 20 FL Sackrete Hand
SITE WELL ID#(If applicable) Fran To FL
STATE WELL PERMIT#(d applicable) From To FL
DWQ or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter - Slot Sim .Material
WELL USE(Check Applicable Box): Residential Water SupptyT�
Fran To Ft_in. _in.
Fran To Ft._In. _in.
DATE DRILLED 10' )t S-Q S Fran Tc Ft_in. _in.
TIME COMPLETED I d. lO AM ta PM❑ S. SANDIGRAVEL PACK:
3.WELL LOCATION: al
�A Depth Size Materi
R CITY: V"Am COUNTY tAC I�s LW Fran To Ft.
Fran To Ft.
From To Ft.
(Street Name,Numbers,Community.Subdivision,Lot No.,Parcel;Zip Code) _
TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG
❑Slope oVatey ❑Flat ❑Ridge ❑Other From To. (,)�FonntRn Despt�ripry�pjn-
(check appropriate box) I' May be in degrees, . 0 ' l l X!!.1.�.. lit .l! 1`-IYJr`
LATITUDE ��a� & •j`t() minutes,semmdeor
LONGRUDED2L, 1t�aJ inadecimal format
r
Latitude/longitude sotaoe: QCrPS oTopographic map
(location of was must be shown on a USGS topo map and
attached to thk form snot USkrg GPS)
4.WELL OWNER
OWNER'S NAME III
\r [sue
STREET ADDRESS o Box 4.3? N
HICK,v G a8loo` D
City or Town I State Zip Code r_7
Area axle- Phone number
11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: 2Lg S
b. DOES WELL REPLACE EXISTING WELL? YES O N04
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:�_FT, taA NCAC 20.WELL CONSTRUCTION STANDARDS,AND THAT COPY OF THIS
(Use•+'R Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS 1 FT.Above Land Surface pp � �
•Top of casing terminated allor below land surface may require SI TURE OF CERTIFIED WELL TURE OF cERTIWFIED W ELL CONTRACTOR DATE /J
a variance in accordance with 15A NCAC 2C.0118.
METHOD OF TEST m
,.s Jaes W. Camp
e. YIELD(gpm): PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., , . o Form GW-1a
1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.(919).733-7015 ext 568. Rev.7105

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STATEWaLLC MMWC" MFARMfIM.
— --
Rom
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RMIII�NA�A6�.iFp NMaRR�YipRh _- ..
10 riT�lrry; M7DOFTEBT 4 ( o^--
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1*+IMMRRwLOCAMmaKEmH
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FNro�to FL_._ h
From _.._T* FL h h
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Fran TO_... N �
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IT. PAKW&
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320496
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resourc �Divis)"m of Water Quality-Groundwater Section �'�I
WELL CONTRACTOR(NDP✓IDUALy NAM
(�print �/ t •L OL I�C'.S .l CRRTiFICATION N�(L/
WELL CONTRACTOR COMPANY NAMR%) (ah4-Tw (1 j( 0 r:I (t A O PHONE is ffl;94 -oy8o
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMM
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Cf' MunicipaUPublic❑ Industrial❑ Agr cultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopoglRphicfl and setting
Nearest Town: /r6 v County ❑Ridge ❑Slope Malley65;
305 Ph dr-) creek ZV -z (check appropriate box)
(Sfttd Name,Numbers,Coomruatty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:iW7 (//ems &"ieS (dep"draimdes/secmds)
Address 305,` Latitudellongitude source:❑GPS❑Topographic map
--SrR.N or Rwte No.) (check box)
DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Asa coda-Phone noraber
4. DATE DRILLED /O=/3 -OS'
5. TOTAL DEPTH: / S S"
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E -
7. STATIC WATER LEVEL Below Top of Casing: Z AFT.
�r(Use"+"if Above Top of Cuf W
S. TOP OF CASING IS Fr.Above Land Surface"
`Top of cuing terminated nt/or below land surface requires a
variance in accordance with(SA NCAC 2C.0115. s�T
9. YIELD(gpm): _?METHOD OF TESTS i P
10. WATER ZONES(depth): m '
LOCATION SKETCH o m
11. DISINFECTION:Type__ee,&PC Amount /D o t Show direction and distance in miles from atTBast
12. CASING: Wall Thickness Material two State Roads or County Roads.Include the road
Depth Dianlejer Zo m pR ,I t numbers and common road names.
Fro To Ft
From To FL
From To Ft
13. GROUT: Depth Material h thod
From_0—Tow Ft�i /r l'UEe
From To Ft.
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK-
From
Ft.
Depth Size Material
Front
o a sill
From To Ft.
16. REMARKS:
I DO HEREBY CPRTIFY THAT THIS WELL WAS CONSTRU IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU STANDARDS,AND THAT A P F RECORD BEEN PROVIDED TO THE WELL OWNER
-U
91-GNATURk OF PERSON CONS CTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3,20495
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and a 1/Rfesourc 1Div is'(�n of Water tty-Groundwater Section
WELL CONTRACTOR(INMYIDUAL)NAME (print) �lf /l QL(C'S 7 CERTIFICATION,�.��� #2a�
WELL CONTRACTOR COMPANY NAM T'EC L�I2( 0 r:I I t r q_PHONE # &Rio FQ
STATE WELL CONSTRUCTION PERMrr# ASSOCIATED WQ p6mr#
ifapplicable) ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural q
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other q If Other,List Use
2. WELL LOCATION: / Topo d setting
Nearest Tow�/pi � G`C?dt/ _County,Gl�CIC� gRidge lope Malley OFlat
/ 6 GltacJ ��R 207S2 (check gmtopnau6oz)
(Street Name,Number,Conionad%subdivision,Lot No,tip Code) LatitudeAcingitude of well location
3. OWNER: G/W B .14d (deipeeahnmuwjseconds)
Address f L u) Od LatiudeAongitude source:EIGPSC3Topographic trap
(Street or Rome No.) (check box)
/Lf AP/aW fV(- 2R7S—Z DEFTH DRILLING LOG
City w Town state Zip code From To Formation Description
Ara code-Plante aumber
4. DATE DRILLED
S. TOTAL DEPTH:.._ 2 25--
6. DOES WELL REPLACE EXISTING WELL? YES q NO E7'
7. STATIC WATER LEVEL Below Top of Casing: rz FT.
�,(Use`+"if Above Top of Casing p
8. TOP OF CASING IS _FT.Above Land Surface"
'Top of wing ter id ated at/or below land surface requires a
variance is accordance with 15A NCAC 2C.0118. / _
9. YIELD(pm):�_METHOD OF TEST1 i i�r eel
10. WATER ZONES(depth):
LOCATION,NCH
11. DISINFECTION:Type C Amount /O o 2 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth-&� DiameterSCR /or L material Five-
Front — _ numbers common road names.
From-0To Ft ��/ 2
To Ft.
From To Ft. 7re �"
13. GROUT: Depth Material M od
From_S�Tc20 Ft. uH e B r-
From To Ft 14. SCREEN: Depth Diameter Slot Size MaterialFrom To Ftin. isFromTo Ftin. in.15, SANDIGRAVEL PACK:Depth Size MaterialFrom�To Ft.FromTo Ft.
16. REMARKS: #
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS ION STANDARDS, THAT A PY OF Tf�[S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PEfSON 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)7333221,within 30 days. GW-t REV.0712001

RESIDENTIAL WELL CONSTRUCTION RECORD `1 2
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•�"`w�' WELL CONTRACTOR CERTIFICATION# 2138
t.WELL CONTRACTOR: f. DISINFECTION:Type chlorine Amount Cas 5
James W. Camp g. WATER ZONES(depth):
Well Contraaa.(Indiividual)Name From Tc From Tc
Cam pi S Well & Pump Co Tnc-- From To Fran To
Well Contractor Company Name From To Fran To
STREET ADDRESS P O BOX 429 - S. CASING; We III Thickness/
Depth -, D`liaa��eter We ht Material
Ellenboro NC 28040 Fran 0 Tq�—Ft. 6 SDW21 PVC
City xTown Stale Zip Code From To Ft.
( 828} 453-7322 Fran Tc Ft
Area code- Phone number 7. GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft. Sackrete Hand
SITE WELL ID#(if applicable) From To Ft-
STATE WELL PERMIT#(B applicable) From_To Ft.
DWQ or OTHER PERMIT#(If applicable) a. SCREEN: Depth Diameter Slot Size Material
Fran Tc Ft._in. _In.
WELL USE(Check Applicable//Box): a idenliat Water Supply[�� From Tc Ft—in. _in.
DATE DRILLED '.fl 'ti0 3 Fran To Ft_In. _In.
TIMECOMPLETED iT� AMO PMb S. SANDIGRAVEL PACK:
3.WELL LOC T N: Depth Size Material
a) % C COUNTY G FYan - To Ft.
CITY: From To R.
5 D N 0 From TD Ft.
(Street Name,Num0ers.CammuNry,SUDGIVNgiQD, No.,Parcei,Zlp Code) - - -
TOPOGRAPHIC I LANDS NG: 10.DRILLING LOG
[]SlopepVahay Cl Flat [VIdge ❑Other From To (,Forrna17DegCriplbn
(Check appropdalebox) .01 K.z V t 5 n A
1. /V r Maybe in deBoea,
LATITUDE _ 4�L? ��f minutes,xcaufsa ;,Z h0_ D A 8 YOC..
LONG
RUDE S •' inadaimal format
Iatitude/longitude source: PS ❑Topographic map
(locatton of wel must be shown on a USGS topo map and —
attached to this firm 7 not using GPS)
4.WELL OWNER T ^ -(+j , - t
OWNER'S NAME o tK ( JIA '11 W
STREET DTESS h
ek� o
City or Town State Zip Code
Area code Phone number 11. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YESO NO
100 HEREBY CERTIFY 7HAT1H13 WELL WAS CONSTRUCTED N ACCORDANCE WITH
e. WATER LEVEL Below Top of Casing: job FT. 15A WAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COW OF THIS
(Use•✓If Above Top of Casing) REC HAS BEEN PROVIDED TO THE WELL OWNER. ))
d. TOP OF CASING IS 1 FT.Above Lard Surface*
•Top of casing terminated aUa below land surface may require SIG TORE OF CERTIFIED WELL CONTrAGTOR DATE
a variance In accordance with 15A NCAC 2C.0118. ,
METHODOFTEST GZI / "amES W. Camp
e. YIELD(gpm): 5- PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:information Mgt., Form GW-la
11617 Mail Service Center—Raleigh,NC 2T699-1617 Phone No.[phone] ext 566. Rev.7105

From:Scott Gantt To:Stephenie Wilson Date: 1/5/2006 Time:7:48:56 PM Page 4 of
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment,and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) SCOTT GANTT CERTIFICATION#2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS.INC. PHONE#[phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box) Residential ® Municipal ❑ Industrial❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2.WELL LOCATION: Topographic/Land setting
Nearest town: MARION county McDOWELL ❑ Ridge ❑ Slope ❑ Valley [] Flat
633 MARLER RD Latitude/Longitude of well location
(Street Name,Numbers,Community,Subdivision,Lot No,Zip Code) 35.37350/82.03 731
3.OWNER HORTON HOME OF RUTHERFORDTON (degrees/minutes/seconds)
ADDRESS 342 HWY 74 BYPASS LatitudeQongitude source:❑GPS❑Topographic map
xuedor Routs No.) DEPTH DRILLING LOG
RUTHERFORDTON NC 28139 From To Formation Description
City or Town State Zip Code 0 30 Clay
828-287-3366 30 240 Consolidated Rock
Area Code-Phone Number
4.DATE DRILLED 12/8/05
5.TOTAL DEPTH 240
6.DOES WELL REPLACE EXISTING WELL? YES NO
7.STATIC WATER LEVEL Below Top of Casing: 60 FL
(Uce"*"IfAbove Top of Casb,,d
S. TOP OF CASING IS 2 FT.Above Land Surface-
-Top of camrg krmumatsd allor blow land swracs mquvu in
accordance with ESA NCAC 2C 011a
9. YIELD(Prom: 5 METHOD OF TEST ARDM
10.WATER ZONES(depth): 220
u.DISINFECTION:TYPE HYPOCHLORITE Amount 9 0. LOCATION SKETCH
12.CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or Weight/FL Material two State Roads or County Roads.Include the road
From o To 36 FL 6 1/4" SDR 21 PVC numbers and common road names.
13.GROUT:
Depth Material Method
From 0 To 20 FL GRAVEL MIX GRAVITY L
I4.SCREEN
Depth Diameter Slot Size Material I
From NA To FL in in. W "
15.SAND/GRAVEL PACK: O
lTa
Depth Size Material
From NA 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.
1/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
GW-I REV.07/20 11
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.

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
163E Mae Service Center-Ralelgh.N.C. 27699-1636-Phone[phone] j -
WELL CONSTRUCTION RECORD WELLCONTRACTOR: ;ZA&,,Ii 12A;.4 ` iNY-
WELL CONTRACTOR CERTIFICATION # : 36
STATE WELL CONSTRUCTION PERMIT# :
:dE LI USE (Check Applicable Box)'. Residential Municipal ❑ Industrial❑ Agricultural ❑ Momto rinc t_J
Pecovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use:
',NEi-i. LOCATION (Show skett hi,the location below)
Nearest town. �'L' O F`I County �� �d h_i.L
116 ((E}STo;IC DA
=oai Nana nand Numbers Community. or Subdivision and Lot No ; DRILLING LOG DEPTH
R h &-Mye /j IVAtlA /j From To Formation Desrnotior
:,press //p kCy57I#.Y.6 b�
p4�1 won(b ree or ou a o7
A/, 2��i 2
- Tnwr State zip Code
')RII I Fr) %9'_0 5
_ .._. -)FPTH
77-9
-i',NGS COLLECTED YES NO©
I?OFS WELL REPLACE EXISTING WELL? YES NO[y]
STA'IC WATER LEVEL Below Top of Casing: FT .
(Use"+"if above Top of Casing)
TnP CF CASING IS �� FT. Above Land Surface`
. ,t. _asing terminated at/or below land surface requires a variance in accor-
laorc with '5A NCAC 2C.0116
IC vFILi) /GPM): a'ri METHODOFTEST /✓�/��•`'`
`NATFR ZONES (depth):
�A: -1RI NATION Type T/y Amount If additional space is needed use back of form
Wall Thirkness
F)enth Diameter or Weight/Ft. Material I
- -- ^ 10 3s- F}. G 1 4 v i(C LOCATION SKETCH
,gym To ct. (Showdirection and distance from at least two Sate
"gym fo Roads, or other map reference points)
t
�. ;Prltii
Depth Material Method ...
-.T To Ft -
FIT
To Ft
'S SCRFEN.
CD
Depth Diameter SIot.Size Material
" ore To FI in m. Cn `
- To Ft in in.
- To Ft in in.
'P JAND/GRAVEL PACK:
Depth Size Material
To Ft
To Ft
MARKS
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 OWNFR
cOR OFFICE USE ONLY
_44r
Quad Nn. azenz
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 :REV 1219b

NortM1 Carolina Department of Environment and Natural Resources-Division o/Water Quality-Groundwater Section ..
1636 Mail Service Center-Raleigh,N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 1704,4 .1d 12A;4,41'rVj'
WELL CONTRACTOR CERTIFICATION # : 7,5—G1)
STATE WELL CONSTRUCTION PERMIT# :
WEL i. USE (Check Applicable Box): Residential Municipal ❑ Industrial El Agricultural ❑ Momtonnc l_,'
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
nCATION ((/rShow sketch of the location below) /�
^aen•r.c Inwn •-/ d 1, /"'.,1 County /9 AI0 L4 C-4a'.
�$ C3c/ITcYCo4,AT nti
�nad Nam'ee and Numbers �Community,or Subdivision and Lot No DRILLING LOG DEPTH
'7 LNNF R / u/li(G Y From To Formation Descnnli,
praH ,p�,
IS nee or ou e No
`w or town State Zip Code
a DATED �_
'nTAI. DEPTH
S
- ,TTINGS COLLECTED YES ❑ NO©
Dr ES WELL REPLACE EXISTING WELL? YES F1 NOQ
STP WATER LEVEL Below Top of Casing FT-
(Use'+"if above Top of Casing)
"JF OF CASING IS 42 FT. Above Land Surface'
-'?r c' :asing terminated at/or below land surface requires a variance in accor-
iancc nth '5A NCAC 2C.0118
veil :"GPM). /X•h METHOD OF TEST 94i/ - a
70NFS (depth)
.'PI NATION Type 76" Amount If additional space is needed use back cf form
,4SING Wall Thickness
nepth I� Diameter or Weight/Ft. Material
to 70 Ft �z eZ7� rtAp., LOCATION SKETCH
-„ T� Pt (Showdirechon and distance from at least two S;a!e
- „ 10 rf Roads or other map reference points)
;pnl I r
Depth Material Method
r,nm To Ft. -
J
F,,,,T. To Ft F-*1 -
n
Depth Diameter Slot.Size Material CD
�T — To Ft in. in. O
— To Ft in. in. CI7
7o Ft in in
,F ;AND/GRAVEL PACK.
Depth Size Material
To Ft
�n• To Ft
?I-MARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
'-nNgTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNFo.
FOR OFFICE USE ONLY z�a/-41 12"- , /a -,?!—u �',—Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 17rpg

vcrr ':amlina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1536 Mall SAry Ice Center -Ralelg h.N.C. 27699-1636-Phone[phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR: /fn
E-411)Vd 0/1r
WELL CONTRACTOR CERTIFICATION # : ;LS-4 I
STATE WELL CONSTRUCTION PERMIT#
'Jr . . I_ISE (Check Applicable Box). Residential® Municipal ❑ Industrial❑ Agricultural ❑ Moniton-Tc '^'
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use.
r,rc -)CATION fSh rw]sketch of the location below) /J
.l�•rnwn �r'S , O County /V
Z-2/ />7 as r oN 'i
-ni ^lame and Numbers. Community, or Subdivision and Lot No) DRILLING LOG DEPTH
')WNEP Gia�ra- rS ,Pv7z.vT
From To Formation Desrr,ohn,
ncdress 13 /I'law,'ery ST
I/WAio,J (Sreeo�o�ue o.
"thy or Town _ State_ Zip Code
d �)ATF DRILLED I- O S
-.-Al DEPTH _
rTINGS COLLECTED YES O NO®
FS WELL REPLACE EXISTING WELL? YES O NONA
'./VATERLEVEL Below Top of Casing, /ii FT.
(Use""if above Top of Casing)
ASING IS {l/i FT. Above Land Surface'
:asmg termmaled attor below land surface requires a variance in accor
,iancc Nith '5A NCAC 2C 6118
11-ILJ ((;PM) 0 METHOD OF TEST Q/y/L. /_'%A
.. ,vA rr-o 70NFS (depth)-
NA T ION Type 7'40;0� Amount. J pp. -- if additional space is needed use back of form
..9 ING Wall Thickness
tenth Diameter or WeighVFt Material
-nm To 60 Ft G .25 1, /f75T7'ts LOCATIONSK TCH
r,,,,,, To q (Showdirection and distance from at least two S'a!e
to ct Roads, or other map reference points)
Depth Material Method ="
To Ft CD
To D tT1
C�
SCPEEN N
Depth Diameter Slot Size Material O
!c Ft in in. O
C:)
— Ta Ft in in.
_ To Ft in. in.
'- 9F,Nr-'/ ,RAVEL PACK.
Depth Size Material
Ii PI
To Ft
?FMARKS
! 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
GOP OFFICE USE ONLY --ir? to_� P _ O !--
Ouad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV 2/9f

I
North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section _
1936 Mau Service Center-Ralalgh.N.C.27699-1636-Phone[phone] /
V' i CONSTRUCTION RECORD WELL CONTRACTOR: ✓�o4 4521 DA
WELL CONTRACTOR CERTIFICATION # : K G
STATE WELL CONSTRUCTION PERMIT#
'ir 'SE (Check Applicable Box). Residential Municipal ❑ Industrial ❑ Agricultural ❑ MonitnnnL _
`�er:o�ery Heat Pump Water Injection D Other❑ If Other. List Use:
'NFL! LOCATION tShow sketch of the location below)
Nearest town.' ' ti County C OU.v•-F-L
',load Name and Numbers Community, or Subdivision and Lot No DRILLING LOG DEPTH
n WNER h�a /✓/9Uy .S From To Formation Dascrinonr
4 idress /LL 7 6,Jv t-Y 1?d
�(S reet of T o le No
-� v Tov✓r State Zip Code
�TF nRll_LED — 3
- -NGS COLLECTED YES ❑ NO®
h,-,FS WELL. REPLACE EXISTING WELL? YES 0 NO®
STn 'WATER LEVEL Below Top of Casing. FT.
(Use"+°if above Top of Casino) _
it CASING IS /�� FT. Above Land Surface'
.asi-�J Iermmated atTor below land surface requires a variance In accor
vn 'tin NCAC 2j0118
y �. ,GPM): d -J-- METHOD OF TEST 134 1 ti 1 i—
INATFR ZONES (depth)
�a "'P.INATION: Type. hTfj Amount 1' If additional space is needed use bark cfform
'.AS I N G Wall Thickness
tlenth �/"` Diameter or WT�I9 htfFl Material
to �Ft. 6aZh LOCATION SKFTCH
To Ft (Show direction and distance from at least two S'a:c
To Gt. Roads, or other map reference points)
14 ,Fn1 '.r
Depth Material Method raj
.. ... To Ft
O
To Ft rn
'S SCRFFIN c7
rV
Depth Diameter Slot Size Material CD
To F! in in p
C11
Tr R in in.
Tc Ft in in
15 SaN[))GRAVEL PACK:
Depth Size Material
To Ft
To Ft
FMARKS
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNFF.
-OR OFFICE USE ONLY
'a iad Nn_ SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
jSerial No. Submit original to Division of Water Quality. Groundwater Section w.thin 3C days
GW.'.. RE'! '2 9f,

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
''e36 Mau Servlce Center-Raleigh.N.C. 27699-1636-Phone[phone] _.
VVE L L CONSTRUCTION RECORD WELL CONTRACTOR: /3o�/9iv �� r%�f v e
WELL CONTRACTOR CERTIFICATION # : '7y _
STATE WELL CONSTRUCTION PERMIT#
rdF_I JSE (Check Applicable Box). Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitonnc ❑
'e""ery ❑ Beat Pump Water Injection ❑ Other❑ If Other, List Use.
vim. i LOCATION: ( how sketch of the location below) yy77
%'eruct tnwn j` bJ County M NA LUL714
5 Gn';-Asy GAget 17d
Name and Numbers Community, or Subdivision and Lot No.; DRILLING LOG DEPTH
" lfy NF R. �'Z✓/'9 /�1=1-L S'�i�LToti From To Formation Deu:nnno•
,"mess /JS' &A49 C",, C ei4Z6.k led
Iqq ree or/ ou a o.
'ity or Town State Zip Code
4 DATF DRILLED 41-1)
- 'A� -)EPTH 1;;2
TINGS COLLECTED YES Q NOE
00ir r WELL REPLACE EXISTING WELL? YES NO[k
STo"7 WATER LEVEL Below Top of Casing 4 FT.
(Use"�" if above Top of Casing)
- '1F CASING IS /5 ' FT. Above Land Surface'
terminated aVor helow land surface requires a variance in accor-
'�^•r -ca NCAC 2C 0119
,r. ,PM 7+ METHOD OF TEST
ZONES (depth)
^R1NATION. Type Amount If additional space is needed use back of form
<.rt!; Wall Thickness
Denth Diameter or Wcight/Ft Material
to CV Ftl+zz 2�, •/, ;'3c, LOCATION SKETCH
^^ To Et (Showdirection and distance from a' least two S'a•,^
rmm To Pt Roads, or other map reference points)
4 :Rnl IT
Depth Material Method
To Ft
To FI
.` �SREEN O
rn
Depth Diameter Slot.Size Material
n>
�m to Ft in � in. O _
�- __ Tc Ft in in. O
To, Ft in in Uri
�ANh/GRAVEL PACK: -
Depth Size Material
To Ft
To Ft
MZPKS
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 OWNFP
FOR OFFICE USE ONLY ,/6,wt C4tiiS.V.--r /,Z,, _c 5—
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV

0-ft
North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section � rp
1916 Man Service Center-Ralelgh,N.C. 2 7 6 99-1 63 6-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 404s"Nd /2Ark4,;VJ51
WELL CONTRACTOR CERTIFICATION # : 34' y' 'w
STATE WELL CONSTRUCTION PERMIT# :
/A[ i USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ElMonitcwic I :
raecovery Heat Pump Water Injection OtherM If Other, List Use.
-)I:oTION: (Show sketch of the location below)
F! Inwn h '1evi/ County Ills yC W k-4
757 17Z(15 I'Mr's 0:1A,J- .4 F?d
�Rnad Name and Nu/tubers,Community,or Subdivision and Lot No DRILLING LOG DEPTH
3 OWNER `. 41 � /';044 i`�/%z L d From To Formation Descnntror
Ilia 71reei Or KOU16 NO
i����fTir Si(1"ti'S �(1JL r,awt6 l7d
•L
,it,or Town State Zip Code
,ATF DRILLED
^TAi DEPTH 56
' T'.NGS COLLECTED YES ❑ NOQ
'F. N/H.L REPLACE EXISTING WELL? YES Q NO®
,N.ATER LEVEL. Below Top of Casing. le FT.
(Use"+"if above Top of Casing)
;�- �_�F CASING IS /G �i FT. Above Land Surface'
3f .ASing terminated atfor below land surface requires a variance in accor-
+ -5A NCAC 2C.0116
(GPM1 3D_V4 METHOD OF TEST ' a&7r
"<o�F1a. 70NES (depth)
�I )RI NATION: Type Amount If additional space is needed use back of form
ASING Wall Thickness
Depth Diameter or Weight/Ft. Material
To 33j Ft. LOCATION SK TCH
To Pt (Show direction and distance from at least two Sale
To Pf Roads, or other map reference points)
Depth Material Method =
T To Ft
r7
-. To FI rTl
Depth Diameter Slot,Size Material o to FI in in p
- To R in in.
(ll
To F' in in
;',N::'(:RAVEL PACK:
Depth Size Material
ro Ft
To Ft
REMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
i.ONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL.OWNFP.
- R OFFICE USE ONLY A.yr _ ;j v
Juad No. SIGNATURE OF PERS N CONSTRUCTING THE WELL DATE
IIII Serial No. Submit original to Division of Water Quality. Groundwater Section within 30 days
GW-1 REV 12'9g

WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PI TTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential Z MunicipaVPublic 0 Industrial Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:MARION County MCDWL Topographic/Land setting
WILLIAM MARVIN DR ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3.OWNER:BRUCE BUCHANAN LatitudMongitude of well location
Address WILLIAM MARVIN DR
(Street or Route No.) (degrcestmmutes/seconds)
MARION NC 29752 Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
�)—7564654 DEPTH
Area Code Phone number From To
4.DATE DRH LED lVlOI05
5.TOTAL DEPTH: 185 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From TO
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
'Top of casing terminated attor below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118.9.YIELD(gpm): 60 METHOD OF TEST ARD Two Stale Roads or County Roads. Include the road 10. WATER ZONES(depth): number and common namesHWY.#221 N.FROM MARION APPROX.1 MH.E.
11.DISINFECTION:Type CHLORYTE Amount 3.5 PAST BAXTER.RIGHT ON WILLIAM MARVIN DR
12.CASING: Wall Thickness 1/10 MH E ON LEFT.
Depth Diameter or Weight/Ft. Material
From 0 To 150 Ft. 6-1/4" SDIL21 PVC
From_To_Ft
From To Ft p
13. GROUT: Depth Material Method Tr
From 0 To 20 Ft.()UH(RETE POURED
From_To_Ft. Q' ~`
14.SCREEN: Depth Diameter Slot Size Material y
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
41
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

s
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NANII (print) W'I CERTIFICATION#3M
WELL CONTRACTOR COMPANY NAME/2KQ / Q1V �/�F>' Cl/{/� yp LLC PHONE WM0'><5�8519�
STATE WELL CONSTRUCTION PERMIT# ci
ASSOCIATED WQ PERMITIt
(if applicablz) -/ (if applicable)
I. WELL USE(Check Applicable Box):Residential Q Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ .Other ❑ If Other,List Use
2. WELL LOCATION: Topoggraghic/Land setting
Nearest Towt County Mr-- �wpa ❑Ridge Mope ❑Valley ❑Flat
9 L 8 T �e~ �� (check appropriate box)
(Steer Name,Numbers,Community,Subdivision,Lot No.,Zip Coda) Latimcl longimde of well location
3. OWNER: �FO E ..f-'1' I I SQYI (degrees/minures/seconds)
Address a fie. _ La[imde/longitude source:❑GPS❑Topographic map
�' (Ste [or Route No.) check box
fig /�( C 87� a DEPTH ( DRILLING LOG
Ciry or"Coven Stare zip Code From To Formation Description
&&i- lQ✓aR - 66 (Q n — InI Dt t
Area code-Phone number Io l - 1I%
4. DATE DRILLED - 10 -0 5J
5. TOTAL DEPTH: 305 -Ile - �—
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 5K
7. STATIC WATER LEVEL Below Top of Casing: _1�0 _FT. r,"t
(Use"+"if Above Top of Casing) n
S. TOP OF CASING IS�_FT.Above Land Surface*
"Cup of casing terminated atlor below lend surface requires a
n
variance in accordance with 15A NCAC 2C.0118.
9. YIELD (,rpm):1—METHOD OF TEST tvl ,r,
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Chlaq iae` Amount 14 +-orbs Show direction and distance in miles from at least__
t2. CASING: Wall Thickness two State Roads or County Roads.Include the roast
Depth Diameter or Weight/Ft. Material numbers and common road names. .i
From -0 To lnlo Ft.In.13S 3� Pyr,
From To Ft.
From To Ft. O—LXp(e �Ue 'c1`- - r�
13. GROUT: Depth Material Method
From To-,
jQ—Ft.
Frorn To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. j r
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 ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
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 -
d `l jr1 '

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAN4F.(priur) N_7&14 INES CERTIFICATION ia.1j
r r(b,
WELL CONTRACTOR COMPANY NANIEL�RW(/-SO/U � I/�F�� Cl/✓� f2 LL Cs PHONE(��Y��Q Y/cq
SPATE WELL CONSTRUCTION PERMIT# �J ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 21/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town t4 County ❑Ridge dKlope ❑Valley ❑Flat
F� V WPA- Ne Tfopa
�—r+ (check appropriate box)
(Sweet Name,Numbcn,'Community,Subdivision,Lot No.,Zip Code) LatitudeAongitude of well location
N35`37.931a
3. OWNER: c J (degrees/minutea/seconds)
AddressL .- lr Latitude/longitude source:❑GPS❑Topographic map
(Scr [qr Duce No.) (check box)
46d�rsoNtleetl1Z NC- a9791 DEPTH DRILLINGLOG
City or Town smte Zip From To Formation Description
x8)- 8 — 8 0 — 105 U jAt
.A=code-Phone number 10.5 — 110 SHe.11
4. DATE DRILLED I- r1 — 0.5 110 — 345 56•II - scan '+e>
5. TOTALDEPTH: 345 —r-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use'Y'if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface'
•'fop of casing terminated atlor below land surface requires a
variance in aewrdaneewith I5A NCAC 2C.0118.
9. YIELD(gpm):�( Q_METHOD OF TEST �o��g
10. WATER ZONES (depth): 3I5 r l
LOCATION SKETCH
11. DISINFECTION:Type_ Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From n To—ILD_Ft.L.II D5 yG
From - - To Ft. - 0r act SS r pl
From To Ft.
13. GROUT: Depth Material Method zo� I m ..
From_0 To ,J D Ft /rC E E �j iu.nlLYq t
From To FL f �" CI'I 7
14. SCREEN: Depth Diameter Slot Size Material _.- __ .Cs .,
From To Ft. in. in.From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
n
From—To—- Ft.
From To Ft.
16, REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Di1vision of Water Quality-Groundwater Section��jj
w'ELL CONTRACTOR(INDIVIDUAL)NAMZ�F.(print) 2RJ'e�N ( CERTIFICATION sd�^�/t(/��J
WELL CONTRACTOR COMPANY NAME/ERA i_ ON%, PHONE 092Ac'5,P-84?4L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
L WELL USE(Check Applicable Box):Residential e Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WE LL LOCATION: Topographic/Land setting
Nearest Town,/1 ov Counry/ryecep'.,.e/9 ❑Ridge CaS'fpe ❑Valley ❑Flat
44-& 5 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No,,Zip Code) LatimdeAongitude Of well location
c n #7 37,9,j'L/,gYL*oT'nr'
3. OWNER: �ptPX'h( J � OL!).�L' �. ()J9 (degrees/minutes/seconds)
Address —TJ' 4 13 h�tl 11� Flamm 1 l / Latitude/longitude source:�S❑Topographic map
(Sneer or Route NoJ - (check box)
cLetSotuUl �� ICIC a2791 DEPTH DRILLING LOG
Clry or Town State Zip Code From To Formation Description
$�) 1a87- asB� o - 6-4v 1 A;/
.Atha code-Phone number Sl'- (J
4. DATE DRILLED 1- G 3- 721'
5. TOTAL DEPTH: 22!'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ld
7. STATIC WATER LEVEL Below Top of Casing: rrI
�FT. -
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface" ul y.
*Top or casing terminated at/or below land surface requires a C'
variance in accordance with ISA NCAC 2C.01 I#.
9. YIELD(gpm):�Q_METH OF TEST-�g
10.WATER ZONES(depth): / l
LOCATION SKETCH
11. DISINFECTION:Type/'%i•n Amount R 'Vr Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept ��iametnr orSl/d Ma
terial aterial numbers and common road names.
From - O To .� FL 1 �tfL
From To FL rbSS 8 N
From To FL Ger C 1
13. GROUT: Depth Material Method i
From-�_To FL /rG E - 'T>Nazi m C—
To y
From J
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. rs
<n
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUC N 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

3 s <S
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-D/ivisiJgR of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Wen C /PNUQ'� MC CERTmcATION#27 O 7
WELL CONTRACTOR COMPANY NAMslSfil_ + GTwo1,TCc file.!( 0C:I (tAO PRONE # __
SPATE WELL CONSTRUCTION PERMIT# ---ASSOCIATED WQ PERMIT#
if licable ifapplicable) n —_tiJ
-, C--
I. WELL USE(Check Applicable Box):Residential D ❑Mimicipal/Public Industrial❑ Agricultural
Monitoring❑ Recovery ❑ Heat PuuV Water Injection❑ Other❑ If Other,List Use - I C"
2. WELL LOCATION:
Nearest To /I/ _County�te e � Topo cH'�d s ,
7_ 7 6 Ridge Malley ! t C
� y (cLeckappropriatbox) =
(Stred Name,Numbers,Community,Suhdn iuoo,tot No,Zip Code) LatitudeAcingitude of Well to
3. OWNER:R/G/S /S/Lfp4-S li-- --�
Address —2 7 ,W-4A2!f s.-gle Me Latitudellongitude source:OGPS12T s
(sweet or Rome No.) (check box) _.
10 4?ei/Oµ� �NL -7 DEPTH DRILLING LOG
City or Town side zip Code From To Formation Description
(__ )
Area code-Phone number
4. DATE DRILLED - -o5
5. TOTAL DEPTH: „�,
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing. . 4-0—FT.
__(Use"+"if Above Top of Cuing) :>
8. TOP OF CASING IS /. S FT.Above Land Surface" O
'Top of cuing terminated stior below land surface requires a
varisace in amrdswce7fth 1SA NCAC 2C.0118.
9. YIELD(gpm): & METHOD OF TEST Ti'"r�
10. WATER ZONES(depth):
LOCATI SKETCH
11. DISINFECTION:Type__CfG Amount /O a t Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth i r a t numbers d common road names.
Fro To Ft (J C
From__To Ft
From To Ft.
3. GROUT: - Depth Material Mpthod
Fro ToO Z Ft _ C/'ti E /"Xe
EA
'as -
From To Ft
14. SCREEN: Depth Diameter Slot Sim Material � •j f e O
From '— To Ft in. in. L
in.
15. SP..ND/0RAVE1 PACK. _
1?e(,zk sir- Material ()
Fro
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC ORDANCE WITH 15A NCAC 2C,WELL
^�r�T?!.' T 1rTN STATt1)AR S-A*D ".? S COPY OF CO S BE PROVIDED TO THE WELL OWNER
C. S-rZ7-os-
rs;;CONSTRUCITNG 'HE WELL DATE
'suhii:4t the 604edial to the t^..va.,Xk a os'Watxr +"ysallty,Groundwater Section,1636 Mai{Service Center-Raleigh,NO
2'1 04-105 ftoneNv ,witbin30dty& GW-1 REV.07/2001

3" 2 4 J 0 Y
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-//Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)`` Y l�mp.5 k ���(� CEWIMCAT10N.Z 4 4 I
WELL CONTRACTOR COMPANY NAME e 1\ D� \\ nT_PHONE ,f (&A)( Sol—347`t
STATE WELL CONSTRUCTION PERMIT/ wecOCUTED WQ PERNM
(ifapplicable) ifapplicable)
1. WELL USE(Check Applicable Box):Residentialn MunicipaLTublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO (� TopographidLand setting
NearestTyown: 1` \\ r� Clotmth��mCz)owCI ❑Ridge ❑Slope ❑Valley ❑Flat
1 [fie t]-nr bt XV (check appropriate tax)
(Street Name,N/uosber,Cemmuni%Subdivision,lot No,Zip Code) Latitude cnigitude of well location
3. OWNER: ` \�nn'L\C i;t1 e< *901am;mum,teonds)
Address C LC i -w N. Latitudellongitude source:❑GPS❑Topographic map
(Sheet ar No.) (cheek box)
DEPTH DRILLING LOG
or Town-73rrc­9 1/'I'Code From To Formation Description
Am code-Phone 4. �1DRILLED Il l bs
RECEIVED —5. TOTAL DEPTH: 150-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO B�
7. STATIC WATER LEVEL Below Top of Casing: (0S FT. ° 1
(Use-*-if Above Top ofCasmg)
8. TOP OF CASING IS_ 1 S FT.Above Land Surfaces
'Top of casing terminated zVor below land surface requires -_Asheville Reqional Ue
variance in accordance with 15A NCAC 2C.0I1tt Aq"ifPrPrrjtPction
9. YIELD(Pin): J'f —METHOD OF TEST \e<
10.WATER ZONES(depth): 106- 110
- ),35 LOCATION SKETCH
11. DISINFECTION:Types 2 ,'c eC C Amount 14 0 Z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diat�r or Weight/Ft Material numbers and common road names.
From�e� To' L 15 2�-4 RVC
Fromm\ To Ft 4tq 7o Cosh"
From To Ft 1
13. GROUT: Dep o Q6 Ft Ce-mCal Method
FromTT
From To Ft Q
14. SCREEN: Depth Diameter Slot Sim Materiali�
From To Ft in. in.
From To Ft in. in. 1mt I
15. SAND/GRAVEL PACK: (he� c �S La'1 gv
Depth Size Material CIJ LA e
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 onginal to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD* 3� 4299
North Carolina-Department of Environment and Natural Resources k ivisiio,'p-of Water r Quality-Groundwater Section, I
WELL CONTRACTOR(INDIVIDUAL)NAME (p or �Li,�� CERTIFICATION# %
WELL CONTRACTOR COMPANY NAME (poor)
1A W e\� �c:\\: n g PRONE # 04 GS`i•341`}
STATE WELL CONSTRUCTION PERMIT# AecOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):ResidentialEMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOTCO&
Topographic/Land setting
Nearest To County e n.Nr �� ❑Ridge ❑Slope Malley ❑Flat
l-z (dmkappeopsietebox)
(Street Name,Numbers,Continually,Subdivision,let No,Tip Code) Latitudellongitude of well location
3. OwMR ;C.ki IA) ,,,r1s (dev-shnimroealeaoads)
Address « C&r; Latitu migtude source:❑deAiGPS❑Topographic map
M (Street or Rome Noe (ebeck box)
1U.0 DEPTH DRILLING LOG
City or Towo sate tip Cade From To Formation Description
Am code-Phone munber
4. DATE DRILLED_ .A I a o OS
5. TOTAL DEPTH:_ a0lb �?Ub
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -ET' ,
7. STATIC WATER LEVEL Below Top of Casing: FT. APR rT
(Use'+'if Above Top of Casing)
8. TOP OF CASING IS —FT.Above Land Surface* Asheville fiice
'Top of casing terminated atlor below land surface requires■
varisate in accordance with ISA NCAC 2C.0118. mi Ef r rOtCCt on
9. YIELD(gpi ):_ G METHOD OF TEST &Ag C
10.WATER ZONES(depth): I15' - lf6
LOCATION SKETCH
11. DISINFECTION:TypeScp Amount 11r oZ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth, Dlametyr t Iv)�te jai numbers and common road .
Fro To Ft C Y YC ^ {�
From To FL l
From To Ft
13. GROUT: Depth )vfa Cterial Method
From TT To )(,_FL (am n-I-
From To Ft -+
14. SCREEN: Depth Diameter Slot Size Material rc�
From To FL in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK Y L6
Depth � n
size Material
From To Ft. —h
From To Ft.
a
nce--
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
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

U-J
a . _ 4
(
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh, N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:��,�pT
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE(Check Applicable Box): Residential 2/Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below) I`
Nearest To Mn1c'iOt� County.
�C�dv')�
(Road Name and Nu ers,�mmu nity,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 0.0 I�U r�AJ From To Formation Description
Address q 70 u r , t na e l�Ic
(Street or Houle N0.JJ
ALa Ica 3
City or Town st to Zip Code
4. DATE DRILLED_==
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOED-
7. DOES WELL REPLACE EXISTING WELL? YES Q N0D-
6. STATIC WATER LEVEL Below Top of Casing: -) 0_FT. "-
(Use'+'it Above Top of Casing)
9. TOP OF CASING IS LS FT.Above Land Surface- r -d
'Top of casing terminated actor below land surface requires a variance In actor-
dance with 15A NCAC 2C.0 1 8
10. YIELD (gpm): Lt METHOD OF JEST
11. WATER ZONES(depth): 412b--
12. CHLORINATION: Type-=ll=Amount _ If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or weight(R. (Show direction and distance from at least two State
— p�
From To—g"= Ft.� -.a�.-Sa— V l.. Roads,or other map reference points)
FromTo FL_From To Ft.
14. GROUT:
Depth Materia Method
From ��> '_ To �Ft. _
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. — in
From To Ft. in. — in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ds
Quad No: IG TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit orig all Division of water Quality.Groundwater Section within 30 days
Serial No. GW4 REV. 12199

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM (prinq 7S R it A' h. 'J
CERTIFICATION
�0
JQ
WELL CONTRACTOR COMPANY NAME r QI✓ :1142LLC PHONE @S�,okJA—SI7/cam
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential CZ" Municipal/Public ❑ Industrial ❑ Agricultural ❑ -
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELLLOCATIp�:
Nearest own, ���/�a r Coun yMe a6✓e l Topographic/Land setting
�S�r�iYs ft/J dRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Sweet Name,Numbers,Cwmnun Subdivision,Lot No.,Zip Code) Latit .dVgirude of well location
XT? 7U AD)zo/V i64
3. OWNER: "1 .°L17a (degrees/minutes/seconds)
Address Ito D I cin - co, Ladtude/longim source:❑de soce: GPS❑Topographic map
(5 et or flout°No.) /
(check box)
DEPTH DRILLING LOG
City or row State Zip Code From To Formation Description
( )- '17 62— 3F
7 0- izo
Aiea code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:_wr /—
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C1
7. STATIC WATER LEVEL Below Top of Casing: /lc� FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface"
'Top of casing terminated allor below land surface requires a
variance in aecordance with I SA NCAC 2C.011a.
9. YIELD(gpm):_00 METIJOD OF TEST
10. WATER ZONES (depth): 10v
s
LOCATION SKETCH
11. DISINFECTION:Type 01 CAA-1-- Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From Q To /ZSr Ft. QZY JPleZ/ vc-
- From To Ft.
From To Ft.
13, GROUT: Depth Q Ft. Material Method
From _To /YG e E f E_
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. cl
r*t
From To Ft. in. in. n
15. SAND/GRAVEL PACK:
Depth Size Material ,w
From To - Ft. o ,
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
Z //our'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, !1634Mad Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. I ." GW-I REV.07/2001

Sq e.. ,�
WELL ...
CONSTRUCTION RECO
Nor&Carolina-Dep uniast o>!gavitvatment i
tma iaal ism« afw,m -
WELL Corrawcroa(MVrvmUwt)NAME ft jw O V- DA Y-�otmd+rat�Seeaon -
WELL CUPI'raACi'Oa coMrwrY rAbm J•e` 1� �r�4==r� ��
rRONs s S_
srwTs WILL corwsrrtuctrox rEanuts— �n ,Ten WQ rESMiryt
la_iLlbie) rtf applicable)
L WELL USE(Chuck Applicable Box):Residential I�MtmicipaVPublic❑ Industrial❑ Agricultural❑Mtnritrttiog❑ Recovery ❑ Heat�p Water byecdm 0 Other❑ If Other,List Use
2. WELL LOCATION:
Neatest Town: r O ✓ County a,d,,- 6 T hic/Land setting
' y ' 1 / s s ORidge ❑Slope, ❑valley [Mat
($Peet Nema N,mbm,Comm;m s Subdividoq U No.TjP Cade) (cbe*aWWriate box)
r �
Latitudedongitude of well location
3. OWNER:
Address c (=.'>•—ci�..s�-1:��)
Latitudellonginule`source:❑GPS❑Topographic amp
/ firtdW T sure e C 7f - -- P� (check n
Cay rQ ,
or Tap code From To
Formation Description
Am cads Phone comber
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
i. STATIC WATER LEVEL Below Top of Casing: FT. --
(U""+"if Above Top of Cuing) ---- -- --
S. TOP OF CASING IS�_FT,Above Land Surface-
'Top of udna terminued udw below land sarhu ragahw a
vuianee to ac"rdanee rra.
15A NCAC 3C.a _
9. YIELD(gpm): � METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKECCH
11. DISINFECTION:Type C_ Amount Show ditection and distance in miles from at)east
12. CASING: Wall Thidmess two State Roads or County Roads.Include the road
Depth Diameter From� or Weight/Ft- Material numbers and common road names.
O To 9 ;' Ft�Z
From__To Ft �— /'/ I ✓ S /�/D✓ lV '
From To Ft
13. GROUT: Depth Material Method y/°r
From 'V/J To Ft
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in '
in. �p
From To FL in. is � 4i_
15. SAND/GRAVEL PACK
Depth Sim Material -
From To Ft
From To Ft �>/
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN..CCC RDANCE WrM I SA NCAC 2C,WELL
CONSTRUCTION 'ANDARDS,AND THAT A COPY OF THIS RECORD EL S BEEN PROVIDED TO THE WELL,OWNER
n
SI ATURE OF PERSON CONSTRL fftb f D
ATE
Submit the original to the Division of Water Quality,Gr undwater SStcrioonn, 1636 Mail Service Center-Raleigh,NC
ale -3Zi11,.•vitamin 30 days. - --
MAR 08 2006 71-;
Asheville Regional Ou^s
Ap; «- Protein )r

WELL CONSTRUC ION trrr►IIIR �
North Carolina-D%mtmW of Envuonmeu and Natual Resources Dlvuion of Wamr Q° Y Y
WELL CONTRACroR(INDIVIDUAL)NAME (pW
CDl1DlCMDONs .
WELL CONTRACTOR COMPANY NAME :c� F•SC,,./ Lam: ri" e'3��yy,�...�yy��
STATE WELL CONSIEUCISON rERMM _ PaONE s
fifawliable) ASSOCIATED WQ PUMM
liable
I. WELL USE(Check Applicable Box):Residential MtmicipaUPublic❑ Industiial❑
Monitoring❑ Recovery ❑ Heat Pump Water IMcction❑ Other D If Other,List Use D
2. WELL LOCATION:
N Town: D le/ �1 j�_` fl f T
9 G l � Oa— Midge DSIope1D nd setting
YOFlat
(Sweet Name.Nmbem Cemtaumty,Sub "Swn,lot No,Tip Cade) (dock apPmPdM box)
1 Latitude/longitnde of well location
OWNER: 0- t c r-
Address 14-1/-
Rom Latitudei'longitude source DGPS opographic trap
0�Crl �r� lu� Q!� � 7� L�.PTH (rbxtD)
�
a r «Ta)va(j s y ? T'P�e From To Formation Description `
Area code-Phone amber
4. DATE DRILLED_/a - `t 'D'�)�
5. TOTAL DEPTH: / S G ' /
6. DOES WELL REPLACE EXISTING WELL? YES D NO 6
7. STATIC WATER LEVEL Below Top of Casing:—2—/ FT.
(UM"+'ifAbm Top of casing)
8. TOP OF CASING IS�_Fr.Above Land Surface-
Top of mdoa termLuM&VW bekw land aurtaaa requim a
"rimm V araordauce with ISA NCAC 2C.otla.
9. YIELD(gpm):_//J METHOD OF TEST i
10. WATER ZONES(depth): �1
/ 'fd t LOCATION KFfC'Fr
11. DISINFECTION:Type ,S ' f— e....unt I Show direction and distance in miles from at last
12. CASING: Wall Thiclmas two State Roads or
From_TD Depth
�2 Ft Dimmer or Weight/Ft �bmy� County�: elude t�teMtoad
Fro»y�,_To FL
l') ck
From To Ft F
13. GROUT: lkpth bfatcial Method 'b v}
From Too Ft a
From To FL + ..
14. SCREEN: Material 3f m' t\� Oi�� � 1�
Depth Diamaer Slot Size � ,�
From To Ft in. in.
From To Ft in, y i"r
15. SAND/GRAVEL PACK M.
Y
>� Size Material Cq T v
From To FL y y�
From Tc Ft _
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AMRDANCE WITH I SA JCAC 2C WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD Hr,S BEEN PROVIDED i O THE WELL OWNER
SIGNATURE OF PERSON C STRU DATE
Submit the original to the Division of Water Quality,Gr undwatert�qq��,ggo �y.t��p���
ew +27-i_.r .�,:., zn a.. ._ t'AR 1& " *fl Sero(x enter-Raleigh,NC
a..- _ . vt...... ....)...
OW-;
Asheville Regional Office
!4nuifer Protectin-

WELL CON5TRUM0
North Carolina-Departmbot of Envitonteent end Na
lon of Wager f�ttj, a
WEu.CONIVACTOe(UMVIDUAL)NAM
WELL CONTRACIOB COMPANY NAM
STATs WILL CONMUC rroN 2EFaIrra raaets t ~
fifaooliable) •eapppTyO µQ Pl(RBUM
I. MW�L USE(CbeckApplicable Box):Residential Mmticipal/Pub&0 I al p ndustri A��13e o Recovery ❑ Heat Pump Water Injection o other o If other,List Use
2. WELL LOCATI
Nearest Towm i Cou P t/y f TopogmfildLand setting
Vt t s t EIRidge CISlope CIValley Mat
1Saeet Noma Ntaobas,C®muotry'.Subdindeo.lac Na ZP Cade) ( * bag)
//�� Lativale/longitude of well location
'.. OWNER !-1dLttr,: ). . VLFG' (deQem/mimu alwoo6)
Address Latitude/longitude soutce:DGPSQT
�) J rX NOS (ebedc boa)o��phie map
Cm r -sstat �Code From To DRII"L�
�r /� - t� ,g' Formation Description
Am coda Phone camber
4. DATE DRILLED /d- ' I f
5. TOTAL DEPTH: J ht L
5. DOES WELL REPLACE EXISTING WELL? YES 13 NO Gr-
STA T IC WATER LEVEL Below Top of Casing: _FT,
(U--+-ifAbove Top ofC t W S. TOP OF CASING IS�_FT,Above Land Surface* '-
'Tap of=lea tmmloagd XVW below Land s•dhes mq t,,,■
•acitmm lo aemrdaaca Wilk 13A NCACSC.011&
9. YIELD(gpm): 1-1_METHOD OF TEST �-
10. WATER ZONES(depth):-- 4l/' '
LOCATION SKETCH
11. DISINFECTION:Type L Anmmut . Show direction and distance in miles from at least
12. CASING: wall Thftimess two State Roads or County Roads.Include the road
Depth Duut;ater of Welght/Ft Material numbers and common toad
From d To-2— Ft, -7tse
From_To Ft vim'
From To Ft l rn
13, GROUT: Depth Material y Metbod 1 1 fy
FromZ' L_To Ft !1 itit.)ry/
From f To Ft
14. SCREEN: Depth From To FL D ameter slot Sin Matexiai V
in u -zzi
!�
From To FL m. uL
15. SAND/GRAVE CK Sim v "9► Ole)
Fronk—To FL material
From To Ft
16. REMARKS:
1 DO HEREBY CITIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WfIH 15 k NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H,S BEEN PROVmEil TO THE WELL OWNER
SIGN A OF PERSON ONSTR
DATE
Submit the original to the Division of Water Quality, roundwater Seo tioa 1636 Nail Ser Center-
^eoa_t 5u rti.ne w. .a�o)+�i"�1. a..s + Raleigh,NC
MAR 08 2006 :, - :-;;;---
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RE ORD 3
North Carolina.Deparearallan ofgIIvfioomemt and attEal Resomca-Di "on of wowWELL CONTRACTOR(D7m9IDDAL)NAME (pLe .0 �" /.- ../ Quality.Gromadwaner
foundwow
.40Cti0R QL
` Ct0[1UCA7IONA
WELL CONTRACTOY COWANY NAME
STATE WQ.L CONr=C'IIoNrJiiaIITyl raoNs
(d aottiiabk) WOCIATRD wQ PERbaft
/Mlm (it applicable)
I. WELL USE(Cheer very 1❑bk Box):Residential
MO°i Cd : icipaUPublic D❑ ial❑ Agdc� �p 6 Recovery $eat Pump Water Injection 0 Other❑ If Other,List Use
2. WELL LOCAT7O
Nearest Town e Z7l Cotmry ` �crl . TWoVVhidLand setting
<<_ Midge ds
( ,L o_ •� C b=) OFlat
(Sneer Namq Ntanbeo,C®moony.Sybdjyjdqi Lot Now Tp Cade) LdtltUdc/]ppg'mdC Of well location
3. OWNER VY �AiIFI�
Address d Latimde/lougitude so y O PSQI)
(ebmk Sox)apographic map
«Roars
City«Town State DEEM I2RILLiNG LOC
( �--- / - Q �z�°code From To r'armation DescriptionArea cods Phooe oimb,
4. DATE DRILLED /- 3 -
5. TOTAL DEPTH: —' �_ r I
6. DOES WELL REPLACE EXISTING WELL? YES 0 140 0�
7. STATIC WATER LEVEL Below Top of Casing: -1!�2 _FT,
(Use'+^ifAb"e Top of Caxu� -- --
8. TOP OF CASING[S_L_FT.Above Land Surface* =�
-Top of eadoa to m dated UUW below land aortae mgoIM a -
rarlaoee la aemrdanes wnb ISA NCAC 2C.Otl&
9. YIELD(Mm): )I METHOD OF TEST
10. WATER ZONES(depth):
11. DISINFECTION:Type, unt N KET( Fi
- Show direction and distance is mile from at least
12. CASING: Wall Thidmas two State Roads or CounDepth ty ty Roads.Include the road
Of Wdght/Ft f Mat numbers and roman road names.
From
To .Q Ft p
rom_To Ft K;
From To Ft F\��UhJ
13. GROUT: Depth Medmd Ert'y
From To 9G� Ft - y From To=Ft
14. SCREEN: Depth Diameter Slot Size �C
From To Ft UL in
'
From To Ft in. in. rtidaxctai Il
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft
From To Ft �—
16. REMARKS: U Ar tctt i
I DO HEREB''CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WTTH 15A NCAC 2C,WELL
CONSTRUC.ION STANDARDS, THAT A COPY OF THIS RECORD HrS BEEN PROVIDED TO THE WELL OWNER
• 'z—
SIGNATURE O PERS a (j
WEL4 DATE
Submit the o iginal to the Division of Water uali
ty> JaR4dTP�fer�Stption, 1636 all Service Center-Raleigh,NC
7�Foo_t535 axe ye 'alai-ti z,_r :a,: : a WAAII(( VV oo LUU UU OO
w.....n_ days. .... _
Asheville Regional Office
Aouf?r protection

SIDENTIAL WELL CONSTRUCTION RECORD
ON
Carolina Department of Environment and Natural Rcsourms-Division of Water Quality
• M,y
CY YIrµ.Y�•}
WELL CONTRACTOR CERTIFICATION#
I.WELL CONTRACTOR: f. DISINFECTION:Type Amount
Ashley T. Moretz g. WATER ZONES(depth):
Wea Contract«(InoWWual)Name From j- Tv, 120 From To
M o r . ny P 1 f)r i i is 0 g F om TO ZW- From To
Well Contract«Company Namee From To From To
STREET ADDRESS 6 15 9 HWY. 1 0 West 6. CASING: Thickness/
HickoryNt 28602 Framl`PNTot p( a 10f f�
Giry th ToWn State Zip Code From'7'`To FL
L]Q 4 4 - From To FL
Area cafe- Phone number
Z.WELL INFORMATION: 7. GROUT: pth Material Methov
SITE WELL 10"1 appkable), From To F1. +
pn To Ft.
STATE WELL PERMIT#(a appiicape) F From To—FL
DWQ Of OTHER PERMIT iY(if gapticaDle) B. SCREEN: Depth Diameter Slot Size Material
WELL USE(Cheek Applicable SM- Real Ilal Water Supply From Fl_in,
From To Ft. lI -in.
DATE DRILLED '•' �' / Fr To in. in.
TIME COMPL.ETED_-_7 3(7— AM PMt?
S. SAND/GRAVEL PACK:
s.WELL LO/CATI Aift Depth Size Material
CITY: V `t COUNTY G L1I Fr FL
c' / From
F �P��✓eC /°~T e�JLi, 2 ,4g/.+ From__To
(Steel t7'ame,Number,CPRun *U on,Let No.,p Wl,ZIP Code) '� •lam' '
:qA0GRAPHICI LAND SETTING: 10.DRILLING LOG
(Cheek
bof;)
Sklpe ey ❑Flat " ❑Other From To Formation Description
(otroek appragdac� —< tl[ '-�-- �
`t9.•7.•� J•aOC M8y m LATITUDE J .-3...'� minutes seLpWs«
LONGITUDE �,O G in a deamal format
1 ,
Latituddlongitudc source: VLipS OTopographic map --
(locarian of svw elf must ba Showy;on a USGS topo map and _
attached to this form jr not uahg!GPS) -------------
4.WELL OWNER 6
OWNER'S NAME
STREET ADDRESS
'City«T Scat® Zip Code
Area code. Phone number
WELL DETAILS: 11. I
�a. TOTAL DEFrm: ys _„ s RKS:� ��-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c WATER LEVEL Below Top of Cesin : IOO HEREaY CERTIFY THAT YN,3wELL WAa CONSTAVCTED N ACCWDArreE WITH
nP 9 FTC I NCAC M.WELL CONSTRUCTION STANOARDS,ArA THAT ACOPY OF THIS
(Use'«'it Alcove Tcp of Cas'mg) RECORD HAS BEEN PROVIOM TO THE WELL OWNER.
d. TOP p CASING Ir L}7.above Land S regwf SIG
� �
Surface-
'Top of nosing terminated with 15Abelow land surface may require SIG T RE ERTIFIED WELL CONTRACTOR DATE
a variance in ace«dance with 15A NcgC 2C.0118. ]] •�'' /�
e. YIELD(gpm):I_METHOD OF TESTA('[Aft PC /r lh v fe'f 7-
PRINTED NAM F PERSON CONSTRUCTING THE WELL
SUbmit the original to the Division of Water Quality Within 30 days. Attn:Info...teliemMgl
1617 Mail Servioe Center-Raleigh,NC 27699_1617 Phone No.[phone] ext 5 m GW.ta
RECEIVED R 7'ils
IFEB 13 2005
£d Wd9£:90 900E T£ 'uef EE£TE9770L : •ON XCd dWfld 8 � M Z13dOW W06A
Asheville Regional Office

RECEIVED
MAR ' 2DQ6 LL CONSTRUCTION RECORD
° n and Normal 0�
Resavees-Division of Water Quality-Groundwater Section
""ME ^ d>° cPatt2Ptcwrlox r 2 7
t L CONTRACTOR COMPANY xAMt wee C g�e/ 1dL¢/ Paola g t 6 Y9-oySc p
STATE WELL Ct7NS[AOCflON PERMTTg ASOCIATED WQ PERMISN
Ctfapplitte) litapOliable}
L WELL USE(Check Applicable sox):Residential 5"'Mun;elpallPnblic o Industrial❑ Agricultural❑
Monitoring 13 Recovery la Heat Pump Wow Injection O Other O If Other,List Use
2. WELL LOCATION: /
Nearest Town:07101%o r✓ Cry/ere(I�w TOPOS,% icaL setting
N 7��G/ �R'dg° �� C1Fiat
;,
(suaa N"OL Com10unity°Sobdivm^tat No..Zip Cak) Latitudelloagit ide of well location
3. OWNER:4ehj bWl!.s
Address Ykf. Witte IC4 at 13h e u juc Latitude/longitude s0urw.0GPS0Topographic map
(saeat a Rase Nor) (&mk bar)
F1201rr v t� >v c 2 S�L/ DEPM MILLING I NG t G
City err Tam Saw Tip Cak From TO Formation Description
Asa node.Phme mamba
4. DATE DRULED //-/7-d 5r
5, TOTAL DEPTH: A&C YYS-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ewr
7. STATIC WATER LEVEL Below Top of Casing. RO FT,
/� r, �ra"r-uAboreTopofC=ieg)
8. TOP OF CASING IS./- FT.Above Land Surface.
'Top of eadng terodwmed mar below Lad aaraaee requbw a
vwtaaee IN aee"Ance with 15A NCAC 2C.9118. _
9. YIELD(gym):t_METHOD OF r
10.WATER ZONES(depth):
I�ATjON�CH
11. DISINFECTION:Type Amount /D oz Show direction and distance ut milas from at least
12. CASING: Wall Thielmeas two State Roads or County Roads Include the road
TDsPth40 Ft 1Aa nfoer Wergbt/Ft. I aaeria(mrmbas and on road names. � e/l
F�To_sL=Ft, b �y f
Front__To Ft.
13. GROUT: Depth nMate_cia!/ Mqthod
FroZ,� Tom_Ft./ OiIG/'C lG �+,.• (C;�►
From To Ft
14. SCREEN: Depth Dia rider Sin Sine Material
From To Ft._ID, m 71
Frrom_To Ft. in. rr,
15. SAND/GRAVELPACK:
Depth Size Material
From,�f--To Ft. v� ul
Fromm To Ft \
16. REMARKS: J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCrW IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST 1 I S,AND THAT A OD+ F THIS 1 ORD HAS PROVIDED TO THE WELL OWNER
SItrT1ATURE OF PERSON OONSTRUCVRG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mad Service Center-Raleigh,NC
276"-1636 Phone No,[phone],within 30 days. OW-1 REV.07n001

RECEIVED
MAR 2 7 ? Cfi w r>
Asheville Regional Office WELL CO STRUCTION RECORD
if r Prote ion
Environment and Natural Resources-Division of Water Quality-Groundwater Section �+/�
WELL CONTRACTOR(INDIYIDUAL)A ANE la T CB�TIFICA7ION z 7 O
WELL CONTRACTOR COMPANY N W+E a UJ I¢ /' � PSONE s 67B 6 Y -oV8O
STATE WELL CONSTRUCIION PERM N ♦Rely t►TRII WQ PERmrn
(ifapplic") Of=wiabk)
1. WELL USE(Check Applicable Hex):Residential C�MtmicipallPablic❑ Industrial 0 Agricultural❑
Monitoring❑ Recovery 0 Heat Pump Water Injacnon 0 Other 0 If Other,List Use
2, WELL LOCATION: Topog,aphic/Laad settingNeazutTowo: �Caemty a Ofc7P CMW$e 1331xpe [Walley Mat
1-1-3 re eslw�; � o�.l>d.• z€ n (dW*VpqP-ift60x)
(Name,N=3bea,Commmay Lee No.,ZIP Cede) Ladiude/longitude of well location
3. OWNER:_ i e�f
Addressfait /!J Latitude catetude 9otace:0GPSI3Topographic map
r ( a Rove No.) (dwk bin)
_DIG /Coy't /VG DEPTH PAR To-,mil`T-QU
Carer`rma Sore zip Code From To Formation Description
Am code•Phone number
4. DATEDRU.LED
5. TOTAL DEPTH: /e 6 3
6. DOES WELL REPLACE EXISTING WELL? YES O NO 0-- -n
7. STATIC WATER LEVEL Below Top of Casing: 2 VS^ ,
(Un w if Above Top ofCemg)
S. TOP OF CASING IS l3 FT.Above Land Surface.
°3761F of cries t"wdoatad mer below had sarhes require a
variesa V emerdnoce wah 15A NCAC W AHL c7
9. YIELD(pm)-. 1• S METHOD OF TEST T�i
10. WATER ZONES(depth):
Id>�ATION$l4ETCx
11. DISINFECTION:Type C-C Amount /d o z Show direction and distance in miles from at least
11 CASING: Wan Thickness two State Roads or County Roads.Include the road
Fmm—.Pr Depth Diameter or W Magidnames.
numbers and common mad To .4 O Ftl_&_ /nU
Front_To Ft
From_To Ft,
13. GROUT: Depth Mamrial Mpthod
Frout_ ' To 2Q_Ft.e2nA,- e wetw `
Fronk_To Ft �9
14. SCREEN: Depdt Ditand r Slat Sin Material
From_To FtL,_in. ut,
From To Ft )n. in
15. SAND(GRAVEL PACK
""'a" Size Material ,Ael1
From. Ft
From To Ft R
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
CON ON STANDARDS, T A Y OF THUS HAS BEEN PROVIDED TO THE WELL OWNER
A7URE OF FERS&VVONSTRUCTING THE WELL DATE
Subttdt the orighusl to the Dhision of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone Na(919)733-3221,within 30 days. GW-I REV.07/2001

RECEIVE
MAR 2 7 2HE
Asheville Regional Offi GLL CONSTRUCTION RECOIL vV
North F Bwkdgmf Ramilmment and Natural Resources-Division of Water Quality.Groundwater Section'
WELL CONTRACTOR mNmlvmuwL)NwnrEgtat n�' >° CIRTmlcwTlox r 2 7�u�/
WELL.CONTRACTOR COMPANY x w ?e w rs:f��" .��e! � �� PHONE R R3�,b —f-O j 80
STATE WELL CONSTRUCTION PERmn,i OcutED WQ PUMM
(ifapplicable)
1- WELL USE(Check Applicable Box):Residential MtmicipaUpnblic❑ InduitrW O Agricultural❑
Monitoring O Recovery O Heat Pump Water Injection❑ Odra i 3 If Other,List Use
2. WELL LOCATION:
Nearest Town vi' n occ�e T T/Land sating
C;� c ot5 L2760 edge Mope OValley Onat
(SUM Name,Num (check appmpride boa)
�°"m' l No, I.A ittx6longihide of well location
3. OWNER: "cue ( )
Address r
( aRoiftlim) Latitude/Iwrgindewtnce:Obwkbulopngtaphicmap
✓fir` ryG 2776O ( bra)
City err Tma sag Zip Cak DEPTH D n.rIN nr
From To Formation Description
Are ado-Phone number
4. DATE DRILLEDo>-
5. TOTAL DEPTH:_ --os
6. DOES WELL REPLACE EDISTING WELL? YES O NO 03
7. STATIC WATER LEVEL Below Top of Casing: /6<2 FT.
� (Use•Y'ifAbm Tap of C�
S. TOP OF CASING IS /8_FT.Above Land Surface-
'Top of eadsg ewvdnaad JWW balaw land sancm rgdrn■ uJ
vwlaaee Is aecerdasee with 15A NCAC 2C Al1R
9. YIELD(pm): 7 _METHOD OF TEST
10.WATER ZONES(depth):
LOCATTON SKETCH
11. DISINFECTION:Type Amoum /(� O Z Show direction and distance in miles fmm at least
12. CASING: Dq% Wall Tb two State Reads or County Roads.Include the road
m�_ «SDR /* Material6l e numbers and commoa rid names.
From—a—, To o Ft 2 r
Fromm_To Ft
From_To Ft C S7
13. GROUT: Depth Material M
Fro TO_W Ft� G✓L� WB�I,XX
From To Ft
14. SCREEN: Depth Drier Slot Size Material
From_To Ft,—in in
From To Ft in. in.
15. SAND/GRAVELPACK.
Depth Sim Material
From )L_To Ft
From—To Pt.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS W CONSTR CfED IN ACCORDANCE WrrH 15A NCAC 2C,WELL l
CONSTR ON STANDARD,. T COPY O RECORD HAS BEEN PROVIDED TO THE WELL OWNER 1
2- Z3 - c)S_"
SIGNATURE OF CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Marl Service Center-Raleigh,NC
276WI636 Pbaae Na(919)733-3221,within 30 days. GW-1 REV.07/2001

'dnn ,,irolina Department of Environment and Natural Resources-Division of Water Quality-Grounclwater Se '
a36 Mali Scrvlre Center- Ralelgh.N.C. 27699.1636•Phone[phone]
INF I CONSTRUCTION RECORD WELL CONTRACTOR: /`n°'A�3'`y^� fury<z. <'w
WELL CONTRACTOR CERTIFICATION 0 : .Z 5-
rp�' STATE WELL CONSTRUCTION PERMIT 4
Irrl,(ahle 9n),. Residential 00 MuniaGal ❑ Industrial ❑ AgnCLII'urai ❑ vAnn rrr-,-
;Pa' n. mr water Injection ❑ Other❑ If Other, I.rst Use --,-
- T`I^•� Shrnn sketc^cf the location below)
A/,< ,l County
(J4
-,o- Name and umbers Community. or Subdivision and Lot No DRILLING LOG DEPTH
:rnINF r F-/— 43, f hi f rrom To rnmwtmn t -
/�� i, reer or R cue No I
- - Inver SIMI, Zio Codc --'-'-
_PTH .13F
r-'-F. " VET ❑ NOF�Zj --
r:Lr,_ACE EXISTING WELL? YES NO�
FVrFI- PelowToo of Casing b FT
IUse ` ' I'above Top of Casino)
FT Above Land Surface'
"avr `elav =a, s ir`are recuires a vanance it arrnr -'---
���t_ nAht �71r f -Esl 1311 , 41,7-a
I' %I NATION- Tvpe Pa Amount If additional space is needed :Ise rack ^'form
- Wall Thirkness
Dnnlh Jia teter or lVc,OIIFI Material
G7. 7 c ,,,�5;�G LOCATION SKETCH
rr
cirectlon and d=star :P `-^^ -+'
,n rt
Roads or other mac 'efer.rrp Dci­fs'
Depth Material Method .�
-n
To Ft _
rl —
Depth Diameter Slot.Size Material pp°° _—pp—vq.--.-.—D
in In
iz
r In n
In r
Depth- Size Material
To Ft Ashevilie Regional ( "fife
To Ft LArI?.) f4a
�ML K$
HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC ZC.WELL
- r1NS-RUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE!_!-
7 /
rOR OFFICE USE ONLY /"Jl--Z`-,/t. j /.J -1 -3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
�, Submit original fo Division o!Water Quality Groundwater Seotmn wdhm 3!I days
,.;v aF` ..

• a—lina Department of Environmont and Natural Resources-Division of Water Quality Groundwatif,Srcbon
0.19 Mali Sarvioo f-enter. Rale lgh,N.C. 27699-1636-Phone[phone]
!NP ' "ONSTRUCTION RECORD WELL CONTRACTOR: PRzci
WELL CONTRACTOR CERTIFICATION u
STATE WELL CONSTRUCTION PERMIT 11 �^
✓F l . JSE (Check Applicable Boy)'. Residential Municipal ❑ Industrial ❑ Agricul-ura' ❑ Mon irn,i
aPr,very ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
CATION Show sketch of the location below)
r to.,o /?h !G/v Countv .0 ,Z4
Ci 7 �5 j{,'o/%iz Al2//'12 19c4` 30
Nnmr and Nuri Community. or Suhdwisinn and of No DRILLING LOG D^F,f H _
y",F Toni TO =n+maPnr i,Cvri+n,
IJ�P e' nr HCIIEf CVO
':wr State LiD Code ----`
-r nRll IFD /2-19 -:5
FFTH / F3 --
nt _F-,TE., .rrq NO571 _
r'I 4(`r FvICTIN; 1ntC:.L^ VE$
r'Jse ihnvn Top of Casiri
' 'ASING IS zz FT. Above Land Surface'
:6rminaled aPor below land sir-ace requires a variance in actor. -
,an:r .... rA NCAC 7C 0118
fMFTHOUOFTEST
='"eA t ItIN Type Amount / 1'additional space,s needen usa gacr
Wall Thickness ,.
rlerth Diameter or Weight/Ft Material
Ir 72_ F r: LOCATION SKETCH
_ rt
Showdirectlon and distance from a•. least'wc
Tn
r: rt Roads_ or other map -efer-nce rci^•�,
Depth Material Method
Tn Ft
?, F,
Depth Diameter Slot.Size Matenal
lr, F, In In
_ TD FI in in RECEIVEll
_... _ Tn Ff in in
,PAVEL PACK' .. .:
Depth Size Material
'^ F' Asheville Regional Cffice
To Ft Aquifer Protection
c M a R K S
nn HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
w=-o .•TION STANDARt1C AND THAT A COPY OF THIS RECORD HAS BEEN DROVtOFr' re -,-IF AIFI;_ tit♦,\f`-c
-71? OFFICE USE ONLY
SIGNATURE OF PERSON CONSTRUCTING THE WELI DATE
No Submit original to DrviSion of Water Quality. Groundwater Sect•on wChm ,' i `.Avs
GW 1 REV

�9
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Na -al Resourc Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (nrint) ti._.Ch'M, CERTIFICATION# �4 4
1 I
WELL CONTRACTOR COMPANY NAME �9%qf�: W A +��.nq
STATE WELL CONSTRUCTION PERMTT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential L'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest To County M C W Q�' ❑Ridge ❑Slope ❑Valley ❑Flat
�.— "F fP_ �3 (check appropriate box)
(sued Name,Numbers,Com\mwity,Subdi!vi�sion,W Nos Zip Cade) Latitude/longitude of well location
3. OWNER: �{,O 1 a DU.,\CeC-5 (dagteetimmuredseconds)
Address &9 Lo r V;c , [�C Latitude/longitude source:❑GPS❑Topogmphic map
fk
(Sweet a Rome No.) (check bout)
6'i c r\ flI L IS 2 DEPTH DRILLING LOG
City or Town store�/gG z p Code From To Formation Description
�- �j3X- `�
Ara code Phone he
4. DATE D ® L SQS
5. TOTAL DEPTH, 115
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er—
7. STATIC WATER LEVEL Below Top of Casing:
(Use`+"if Above Top of Cuiu2)
8. TOP OF CASING IS FT.Above Land Surface'
`Top of mina tertninsuil atfor below land Tadao requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):1_METHOD OF TEST . eC
10.WATER ZONES(depth): i 5 /55
LOCATION SKETCH
11. DISINFECTION:Type + f Amount it, 0 z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Wei t/Ft Material numbers and common road names.
Fro��e� To 733 FL -as 0 7 nil C
From ` To Ft (RECEIVED
/�} 13
From To FL13. GROUT: Depth Materi MethodFro Tor—o2__To 40 FtFromTc Ft14. SCREEN: Depth Diameter Slot size Material J/�k,,� 4From To Ftin, in. f 11FromToFtin. in.15. SAND/GRAVELPACK:
Depth Size MaterialFromTo Ft.FromTo Ft s
16. REMARKS:
Regional Office
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCA uifel Protection
CONSTRU ON STANDARDS,ANRTHA A_COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submt the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3— 3243 € 0
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of`Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlet) ��v a F_ k�7 rA-,r, CERTIFICATION
ME 4 # a4()\
WELL CONTRACTOR COMPANY NAM A e l\ Zk-A_zA PHONE # &6)451-3414
STATE WELL CONSTRUCTION PERMIT# AsgOCIATED WQ PERMrr#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential B-Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: (a'ei'.,ywe or� TOPOSMIlic/Land setting
Nearest Town: Vv+ola\ County LN\tw t\� ❑Ridge ❑Slope ❑Valley ❑Flat
l t 4—I'l aQ\ (check gWgmiam boot)
(Street Name,N—bks,Commnundy,S•abdimon,Lot No.,Tap Code)) \ Latitude/longitude of well location
3. OWNER, ��,\e. N' `pt,c CC cAt�Atc l (degeea�hmimaealseeonds)
Address 17b a63 Latitude/longitude sotuce:❑GPS❑Topographic map
(Street or No.) (check box)
-LNG e^ 1=Route DEPTH DRILLING LOG
Q��`Ciry w Tows See tip Code From TO Formation Description
r Gm — V1 14
Am code-Phone ram"4. DATE DRILLED t
S. TOTAL DEPTH: WL;
RECEIVED
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0�
7. STATIC WATER LEVEL Below Top of Casing: `.S FT. u.•
(Use"+"if Ab Top of Casing)
8. TOP OF CASING IS� Above Top
FT.Above Land Surface*
'Top of ins terminated atfor below land surface regohx aa)A�7jil�e Fie4iona ffiCe
wvariance in seeordenee with l5A NCAC 2C.011& aifes• prnrar.4inr)
9. YIELD(gpm): 3_METHOD OF TEST \Iec
10.WATER ZONES(depth): (lo - 16
LOCATION SKETCH
11. DISINFECTION:Type Amount \ k , Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/FL Material numbers and common to s.
From TTo%_Ft
From To Ft.
From To Ft
13. GROUT:
From Tom( =Ft Mate Method
From To Ft
14. SCREEN: Depth Diameter Slot Size Material 1
From To Ft in. in. +
From To Ft in. in. i�m is
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL 3
Z
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION ST ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
9 0—sh-5
SIGNATURE O 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.[phone],within 30 days. GW-1 REV.07/2001

2430 �
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-^Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) LY IMPS 'c &VAd ' CERIMCff��ATION R�L 6 1
WELL CONTRACTOR COMPANY NAME �4CO:t� StIOM 1NAyr? ra'4 PRONE # )L S _ 43
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 9'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- Topographic/Land setting
Nearest Town, kox�v, , County Mcl�cwc�� ❑Ridge ❑Slope ❑Valley ❑Flat
Ah` ( Rmrwietebox)
(Sheet Name,NVumbers,Community,Subdivision,la No.,Tip Code) LatitudeAtingitude of well location
3. OWNER: Kevin - R @.1i
rdegreWmwroes/asoada)
Address ee \av Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No.) (ehakbox)
Mir A).0 �BlSZ DEPTH DRILLING LOG
CkyorT State Zip cc& From To Formation Description
lab y 38— ��f35
Am code-Phone munber r^i e A G 1\9 C P1
4. DATE DRILLED 9 L1/b S
5. TOTAL DEPTH: I O 5
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0 A
7. STATIC WATER LEVEL Below Top of Casing:__L] FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS Q—FT.Above Land Surface' shame
'Top of casing terminated stfor below land surface requires a
variance in■ecordasee with ISA NCAC 2C.0118.
9. YIELD(gpm): )Ok METHOD OF7EST (
10.WATER ZONES(depth): 4
LOCATION SKETCH
11. DISINFECTION:Type c Gl k,1 Amount 1 l) Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight(Ft Material numbers and common road names.
Fro \m�To
Fro To Ft S -5kev 3
From - To Ft
13. GROUT: Depth materiatl Method e
From Tao To L) Ft v�a o.
From---.-!—Tc Ft a
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in. Z
From To Ft. in. in. c l
15. SAND/GRAVELPACK
Depth Sim Material
From To Ft.
From To Ft. X�
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 ,WEELL OWNER
r /o s
SIGNATURE 0 ERSON CONSTRUCTING THE WELL DATE
Submit the origin to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

U r24305
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Print), Y,v�.tp f E^ (-rc-A�r\ CERTIFICATION# ea�o(1 '
WELL CONTRACTOR COMPANY NAME (�/l C i r\ W e l\ LJi'�`\,nQ PHONE #
J
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
Nears�t Town: `county�W C 1/ ❑Ridge ❑Slope ❑Valley ❑Flat
sic C)IA wobct Fk e.5 Y Got 1-5 (check appropriate bm)
(Street Name,Numbers,Community,Subdivision,[rot No,Zip code) Latitude/longitude of well location
3. OWNER: 1� ,Ara t��-. �.'S.i.\�ecS (deg«slmimmsedseeonds)
Address (0 La r ;e . r Latitude/longitude scarce:❑GPS❑Topographic sap
(Streets Route No.) (check box)
l�are� DEPTH DRILLING LOG
City or T7,3T s 9 G zip Code From To Formation Description
Am coda Phone combo
4. DATE DRILLED " 36
5. TOTAL DEPTH: 3 /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �7
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. —Asheville Regional e
'. !c
9. YIELD(gpm): 10 METHODpFTEST—� �° ' ' ti fi
10.WATER ZONES(depth): 1W Z LO
0 — 6S LOCATION SKETCH
11. DISINFECTION:Type. . �. C` Amotmt /o o Z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth q� or WeighNFt Material numbers and common road names.
From
ro To�Ft e J 7 7 to V
Front-7-1 To ld 0 FtjT e 5� 6 FS
From 107 To 110 Ft
13. GROUT: Depth Material Method
From To-20 Ft e12
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in. V
15. SAND/GRAVEL PACK.-
Depth Size Material Q
From To Ft. �J
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STTDARDS,AND THAT A CQPY OF TMS RECORD HAS BEEN PROVIDED TO THE WELL 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
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

N or!h Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mau Service Center - Ralelgh,N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /1 of 1-;rVcr
WELL CONTRACTOR CERTIFICATION # : d'!C
STATE WELL CONSTRUCTION PERMIT# :
✓JELL USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitoriic l�
Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use:
1NELi LOCATION. Show sgetch of the location below)
Nnarnst town �"1o4' County.
1"'yu1lY 0-&C4rk Rd L,Vej, > 7-eW
U�ad Name nd N Community,or Subdivision and Lot No DRILLING LOG DEPTH
3 OWNER � ofumberse�k.���f�tv^ From To Formation Descnnnnr
Andress �� 6 [ �/YFY M�• �'ld/+I:
(Streef or F<OUTO o.
_ AM),i 6-y /yam- a,?'
'.tv ,r Town State Zip Code
c !;ATF DRILLED
T^TAI DEPTH
CUTTINGS COLLECTED YES ❑ NO®
DOES WELL REPLACE EXISTING WELL? YES NO©
STAT'C WATER LEVEL Below Top of Casing FT .
(Use"�" if above Top of Casing)
`♦ TOr' OF CASING IS /� FT. Above Land Surface'
"op ' :asinq term,nated at/or below land surface requires a variance in accor-
dance w,th 15A NCAC 2C��0,1�1,.8
1r' yFll_D (GPM): �1 . METHOD OF TEST /3,411 L rh
" '.NATFR ZONES (depth). t
'•+I ;-PINATION_ Type 74jr/11 Amount t If additional space is needed use back ofform
- AC I N G Wall Thickness -
Depth Diameter or Weight/Ft Material
r. To 0 Ft. /+ tS AV5i'L' LOCATION SKETCH t-1
To nt (Show direction and distance from a'least cwc Sore
Roads, or other map reference pointer
To Ft
G z
•< ,P(-)l ;T
Depth Material Method
ron" To Ft O
Prnrn To Ft Ln
'r CREEN
Depth Diameter Slot.Size Material
• nr- To Ft in. in.
om _ To Ft in in.
r'om _ To Ft in _ in. \
If-- SAND/GRAVELPACK. -L\
Depth Size Material
To Ft
To Ft
REMARKS
l DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
7uad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99
,r,_TICPI

av
WELL CONSTRUCTION RECORD 309577
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (priatt Jl cxRTiFicATIoN A 2452
WELL CONTRACTOR COMPANY NAME FacyTtY WU DRULM 01 PRONE s 18281 324-0035
STATE WELL CONSTRUCTION PERMITM ASSO IATED WQ PRRMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 1XK Municipal/Public O Indust ial Q Agricultural❑
Monitoring O Recovery O Heat Pump Water Injection 0 Odiar 0 If Other,List Use
2. WBLI,LOCATION: Topographic/Land setting
Nearest Town nma CouattilaFIT ORidge OSlope Molloy MIat
192A FMFCP T AKF HF7arM rP (check appminiate box)
(stroetName,Nuotben.Cameo nky,S"Nam.Lot No,yip Code) Latitualc%rigitude of well location
3. OWNER:_. (',ARV Filter ( /ot�turuanda)
Address M aA 416 LatimdeAongitude source:OGPSOTopographic map
(Strad or Rase No.) (cheek box)
to nr KMT t DC 98711 DEPTH DRILLING LOG
City or Taw Shoe Zip Code From To Formation Description
(R7R 1- 775-7717
Arm oWe-Pbme another
4. DATE DRILLED O T
5. TOTAL DBP'ITi: 605 605
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EX
7. STATIC WATER LEVEL Below Top of Casing. Ftl FT, ---�—
(Un-4-if Above Top of Cuing)
8. TOP OF CASING IS 2 FT.Above Land Surface'
"Top of wing tarodosted Wor below dud oar4a regoim s
rariancc be aaordaau with ISA NCAC IC Al la.
9. YIELD(go): I_METHOD OF TESTU AMR ML
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:TYpe H1M1 TARO Amount 119 Show direction and distance in miles from at least
12. CASING: D D Wall Thickness two State Roads or County Roads.Include the road
From 0 To /y Ft b P4worwd k AASTIC materiai numbers and common road names.
From To FL 6�WCCL
From To FL
13. GROUT:
r
Method
From_ Tom_FL (32(Tth M_ Fn RFt) Y5
From To Ft
14. SCREEN: Depth Diameter Slot Size Materiel /
From To Ft,---in.
From To Ft_m in.
15. SAND/GRAVEL PACK:-
Depth Sias Materiel v�-S��✓rVauf�' /ZOXif
From To Ft. 5
Fromm To Ft,_
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrM ISANCAC 2C,WELL
CONSTRUCTION STANDARDS,AMID THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
02-1M5
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001

j A Fav
WELL CONSTRUCTION RECORD
North Carolina-Department ofEnvironmeot and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR MDIYIDUAL)NAME (prfotl NEU.I,PARIXJE CERTIFICATIONN 2f]�
WELL CONTRACTOR COMPANY NAME Hmuy W11DR TI I U (D PHONE s f 82$ 324-0035
STATE WELL CONSTRUCTION PRIabsM w OC[ATED WQ PSBMITR
1100111 (ifaWlicable) 011 ffapplicable)
1. WELL USE(Check Applicable Boa):Residential O( Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topoglaphic/Land setting
Nearest Town M4RIQV County ILL ❑Ridge ❑Slope Malley ❑Flat
384 HMI PtQn TD. (chedcapPVpdserbox)
(Sneer N-96NumbeM Community,Sabdvida%IANo�Zip Code) Latitude/longitude of well location
3. 0 JESZ$ R�%tIQJFZ/PAiM H9RBOR EIPES (�txoaas)
Address 38-4-1-H(SITY A'LgCAgLILoI�. Latitude/longitude source•.❑GHEITopographic map
h 1(1V aL23/5L ) (chwkbu)
Sim Zip
DRILLING LOG
CilyarTmm sm Zip Code From To Formation Description
Area codo-Pbooe saber
4. DATE DRILLED 12'21-05
5. TOTAL DEPTH:
6. DOES WELL REPLACE Ma T NO WELL? YES❑ NO Ey a
7. STATIC WATER LEVEL Below Top of Casing __,Fr.T
(Un +-ifAbove Top ofCasia�
8. TOP OF CASING IS 2 FT.Above Land Surface*
-top of cadag tetnW[ed*Vw bebw land sarfam rcgWq x '.
vulva to aomraaneg wab 15ANCAC 2C A11L
9. YIELD(gpm): It METHOD OF TEST BY AIR�T
10.WATER ZONES(depth):
LOCATION SKLrfCH
11. DISINFECTION:Type HIH Amount Show direction and distance is 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-63_FL ffie (ATY• cMI,_
Front _To FL rJ o
From To FL
13. GROUT: Depth Material Method ri6lA
From 0 To-.? FL ITT FaM CAPDLtr�R
From To Ft 6� �
14. SCREEN: Depth Diameter Slot Sim Material E
From To FL hL in. �✓ G fiil�
From-To FL in. hL
15. SAND/GRAVEL PACK
Depth Sim Material
From To R. R1917o41
From To Ft. s
16. REMARKS:
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C,WELL
CONSTRUCnON STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
,
SIGNA�PERSON COAPSPRHeFE^ic nn DATE
Submit the origmil to the Division of Water Quality,Braun WdIbl,,01MaB Servic Center-lWdgk NC
276994636 Phone No.(9D)733 322I,within 30 days. I GW-1 REV.07/2001
iJ FEB 13 2006
Asheville Regional Office
__.._Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) VA144 m-al-Ic-a CERTIFICATION#gt�W
%%'ELL CONTRACI'OR COMPANYNAME TUsf-- ,c tA/ L ©cz ILL;N1 PHONE # (H�)/114- 5
STATE WELL CONSTRUCTION PERMIT# —ASSOCIATED WQ PERMIT#
(ifa licable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential 14"IMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Xopographic/Land setting
Nearest Town: County OUJG(�. Midge ❑Slope ❑Valley ❑Flat
[ p f / I064 AJ44A 'i 0 J Pe I N t A R (check appropriate box)
(Strnrot Name.Numbers,
Community.Subdi/vision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER:_ 8 W41Ld
Address Met � " de sot rcc: tes/saondsl
/' Latiludc/longitude sourcc:❑GPS❑Topographic map
(street or Route No.) n — (check box)md!r0� AJ /C 7J DEPTH DRILLING LOG
City or Town state Zip code From To Formation Description
A-9 )-_&sq- qrs
Area code-Phone number r 'ILO 14/!L
4. DATE DRILLED 18"/'I-O S
5. TOTAL DEPTH: 3N0
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:—42-- _FT. �T— •/y
yoj
S. TOP OF CASING IS (Use-+"if Above Top of Cuing) 7_
FT_Above Land Surface{
•Tap of casiaa rertalaated War beNw land lactate"Reim a / u
variantt is accordantt 15A NCAC 2C.911& -S $ O A+/
9. YIELD(gpm):�z METHOD OF TEST
10. WATER ZONES(depth): 3 Yt 4 ,8 M
LOCATION SKETCH
Show direction and distance in miles from at Feast
It. DISINFECTION:Typc LO R/ f� Amount
12. CASING: Wall Thickness two State Roads or County Roads.l ttck_d le thc'tond
Depth Diameter or W eighUFt. Material numbers and common road names, n
From TO FL y� --t
'V From To= '0 Ft. qO C K/"yr f f�
From To�_Ft. � /$8 F'�r� _
13. GROUT: Depth Material Method n CCfI
D
From Tc Ft.
From�_To-.t-Ft AaAllt1`
14. SCREEN: Depth Diameter Slot Sin Material 41ax/s
From To Ft. (J/
in. in. 14A ys
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, NO THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAfJREAF 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 Na.(919)733-32 1,within 30 days. - GW-1 REV.0712001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
wELt. DIVIDUAL)NAME (print) to 17 1 �a SH (wELL CO]TR1C 'OR(f\ , -- CERTIFICATIO,N#I L S
COXTRACfOR CO.NIPANY NAME Oft (( N -
y
PHONE 72 Y-4SAPW
STATE WELL CONSTRUCTION PERMIT: ASSOCIATED WQ PERMITR
(if an (icaable) (if aaplicable)
L WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ A_grieultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: M[IPi"� -Coanty `�,(��bOCw✓c°(',� TopoaraphiciLandsettin.g
- __ h 4 k--e C_(.Lli J� I �1 DRidge tope ❑Valley ❑Flat
-f"u/e L-ol (check appropriate host
IAc�ty Name,Numbers,Community-Subdivisooh,Cot No.,Zip Cod.H
�f / L 1 Latitudetlongitudc of well location
3. OWNER: . Lek.4 [ .lf�,6 i4� =t1G .
Address � (�� (degrees/minuteslseconds)
e Latitude/longitude source:❑GPS❑Topoeraphicmap
1Sttcct ar Route No,)l z (chock box)
DEPTH DRILLING LOG
City or Town State Zip Code Front To&gq)- y5D,—2 5 l y Formation Description
Area code-Phone number
4. DATE DRILLED_ /2-2`3-d/
5. T U I AL DEPTH: & t— _ D%✓'
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO GY
7. STATIC WATER LEVEL Below Top of Costing: /00 Ff
.
, v (Use"+-if Ab,we Top of Casing)
8. TOP OF CASING IS I_7�_FT-Above Land Surface* '��' �i b' E )20C-V—
'Tap of casing terminated War below land surface requires a r _
variance is accordance with ISA NCAC ZC.011& _S tj .- Los—
9. YIELD(.gpm): J7 METHOD OF TEST 4 �]
10. WATER ZONES(depth): %2 CAOM j S-O
LOCATION SKETCH
11 DISINFECTION:TypeU012 i fUe; Amount b`Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Wewbtf - Material numberq aqd common road names.
From To Ft. �ptiD
From_ _L_To_�I_Ft. C���.I.L�'
Fromm To lP3 Ft ti
. ('nt/ � yt
13• GROUT: Depth Material Method 6+
From To Ft.-�--�-- 'ri
From Tom Ft._�e�t Jd¢ 1 -
O t"t r ra
14. SCREEN: Depth Diameer Slot Sim Material �QE
From To Ft. in. in. "1
From To Ft. in. in. n
15. SAND/GRAVEL PACK- ua
Depth Sire Material
From To Ft. 1
From To Ft_ 114Y1
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. i THAT A COPY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a- -
`SIGNATURE OF PER ON C NSTRU DATE
FC'F.i�o
Submit the original to the Division of Water Quality,Gr oundwater Section, 1636 Mail Senicc 1enter-Raleigh,NC
27699-1636 Phone No.[phone],tvithin 30 days. MAR 08 2006 GW-I REV.07/2001
Asheville Regional Office

WELL CONSTRUCTION RECORD `-
North Carolina-Department of Envitonment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CO�7RACTOR(INDIVIDUAL)NA?4E (prftt) T�1`H cri C1rRTtFICAT(Ol4 aZS"0
WELL CO-N-TRACTOR COD1PANY,AME TL7MdrW4,CjL n l.Ci1L�C.9 PHON£a��`TZtI��IS�/g
STATE WELL CONSTRUCTION PERMIT. ASSOCIATED WQ PERatr rg
(iFapplieabkJ (fapplicable)
1. WELL USE(Check Applicable Box).Residential I" MunicipaUPtiblic LI Industrial❑ Agricultural❑
Monitoring E3 Recovery El Heat Pump Water injection 0 Other O ifOther,List Use
2. WELLLOCAT10%
Nearest Town: /`1 t3tll O N Coup y 1,3r71✓ Topographic(Land setting
M ou 4 FD ORidge J Slope QValle y OFlal
(Shoe[Name NmabmC (tongit propof howl
mnmona>-SnLdirism Lot Na.rw Code) Latitude/longitude
. ngiiude of well location
3. OWNER. r Auk.ftl F{4 ideg�ees/minnteslsecondt)
Address -_3 a ao V C rA1 LatinKictlongitude Source:OGPSOT
p, eSearetQRa No,) _ ` opoeraphic map
�'PI 1-a ►U !`'. Z 9 2 S Z (tack imc)
DEPTH DRILLING LOG
Cayes Tim Seaee ZiPCude From To Formation Description
Imo)- Y42-
Amacodo-iammnumber O - !os -6 4. DATE DRILLED DEf- 1?1 2ZV5,
S. TOTAL DEPT'H: 05
6, DOES WELL REPLACE EXISTING WELL? YES Q NO i( 5
7. STATIC WATER LEVEL Below Tap ofCa sing�p
(tJse'4 ifAimeTopofCasio�
8. TOP OF CASING IS / _F7 Above Land Surtacef �Jr 1;is
'Tap esf cas)me teraaiaateA atfor below land serraee regn)rrs a
variance in actordaorr with ISA NCAC ZC Ali$
9. YIELD(gpm):9—METHOD OF TEST -Thl1,1"&
10. WATER ZONES(depth): J2 eft &f;e 6 S V
11, DISINFECTION T eeL� LOCATION SKETCH
yP �r Ne Amount 6 2 Show direction and distance in miles from at least
12. CASING: wan ihiclu two State Reads or County Roads.Include the road
DPW Diamctes err t Wmghd Material numbers and eotrumon road names.
From To FL
From 0 To_-2LFL _4yo
I.
From_To 7 3' FL--/C Mat wea Method
.(V)�c�_ .�_ ��/A!!� yZ
13. GROUT_ Depth l 21` NS
From To Ft.
From d) To
_Z0
I4- SCREEN: Depth Diamiter Slot Sim Material „J
From To Ft iu- in
From To Ft in_
15. SAND/GRAVEL PACK:
Depth Sim Materiel +
From Fr -To-FL Q -
om To Ft
16, REMARKS:
1 b0 HEREBY CERTIFY THAT S WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARD e D THAT OPY OF tS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S1GNA PERSONCONSTRUQgjFWFIf17
ATE
Submit the original to the Division o€\VaterQuality,Grmmd� ( .
27699-[636 Phone No.(9l9J 733-3L'i,Within 36 daFs, Cc ter-Raleigh,NC
w-1 REV.07n001
MAR 0 8 2006
I
ASheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- D�iivis`io�nnof Water Quality-Groundwater Section
V,ELL CONTRACTOR(INDIVIDUAL)NAME (print)
{ �j' ���,_- )G' a T(�,eZ CERTIFICATION#ZAO`,{,
�
%%ELI,CONI RACrOR COMPANY NAME_ .7v54 CE We,L(. p -r LL :nag PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED 4iZ PERMIT#
(if appl icable)
(if applicable)
I. WELL USE(Check Applicable Box):Residential C3l,-Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: &LO For tAS�yCjf(_ _` Topographic/Land setting
�Sr f� �_County yq,� lrttidge ❑Slope ❑Valley ❑Flat
f'I) $1-pr (bAt-EW�. . L (check appropriate box)
(Street Name,Numbers,Community,Sulidivision, of No.,Zip Code) Latitude/longitude of well location
3. OWNER: ka �r n f-t-Ll�ti�n�
tr �" (degrees/minutes/seconds)
Address 2 M l o T 5.,`.
�� G C-'�:`.--, � g Lalitudeiiongitude source:❑GPS❑Topographic map
(Sirce(or Route No.)
1 „ `� l'1r,,, (cheek box)
.L.L� j"' h R" -� - � ,� r DEPTH DRILLING LOG
r It or row Suite Formation Description
`,. r) 4 /_ 174 -7 Zip Code From To P
Area code-Phone n/umber / `0 2
4. DATEDRILLED 9^fY•-�S� r
5. TOTAL DEPTH: C/o Y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er �0
7. STATIC WATER LEVEL Below Top Casing:..100� FT
_—_ .
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surfacer
`Tap of casing terminated atror below land surface requires a
variance in accordance with ISA NCAC 2C.0118. j
9. YIELD(gpm): IIZ ETHOD OF TEST $'F✓/M1it_t
10. WATER ZONES(depth): _2 �Qs R.r.. 'duo
LOCATION SKETCH
C ")12i A)
11. DISINFECTION: TYPe Amount vZ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads it County Roads.Include the road
From To Ft.
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To �/17, Ft*
fv j,-�C/_/ u%
/%From 2 To f-.t _FL t PC -Tm
13. GROUT: Depth Material Method
From To FL
E J
From O To Zo FL UM f Ti
14. SCREEN: Depth Dianm ter Slot Size Material - p
From To Ft. in. in. '� r,
From To Ft. in. in, 4
15. SAND/GRAVEL PACK: •% 'fl 'r
3
Depth Size Material
From To Ft. ry.
From To FL
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELA
ONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUERSo ONS UCTING R TH W `�I VED p E
E
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Cent r-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. MAR 0 8 2006 G -1 REV.07/2001
Asheville Regional Office
Aouifer Protection

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) &/TIt'N N dt:S T�77 C L CERTIFICATION#1 J�
WELL CONTRACTOR COMPANY NAME '105• f C r ( C - r;/ L[11 t /�:Pj PHONE # (F"A 74Y-q/ 4S
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PPE "MIT#
617applicable) (if applicable)
It7/
1. WELL USE(Check Applicable Box): Residential �Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: 0LD C.,•t CountyPp.C.nd
5 �t ALL Topographic/Land setting
p. ❑Ridge WSIope ❑Valley ❑Flat
NL- (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No. e) I Latitude/longitude of well location
Ie-
3. O Q LCt I.$1 � , (!. (degrees/minures/seconds)Address Latitude/longitude source:❑GPS❑Topographic map
( (Street or Route No.)
V\ .
P_1 �' . �� r o . i -ykq
(check box)
-o DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED I Z-L9$ t r C AW
5. TOTAL DEPTH: 2 Sao — -AAN rt 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO iY
7. STATIC WATER LEVEL Below Top of Casing:LIT FT.
(Use"+"if Above Top of Casing) �
8. TOP OF CASING IS I FT.Above Land Surface'
*Top of casing terminated attor below land surface requires a '
variance in accordance with 15A NCAC 2C.011b.
9. YIELD(gpm):'—METHOD OF TEST , f 2
10.WATER ZONES(depth):�rif 2, G O C7
LOCATION SKETCH
11. DISINFECTION:Typeif Cot(Ne Amount E o 2. Show direction and distance in miles from at least -
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To�_Ft. C Vy ttd PV 'e-
From --SI To Ii FL V2 96 _ fvz
From_Tom_FL 1912 (L/ o• ,
13. GROUT: Depth Material Method fi-- iL
From To Ft. �� i�t51t;,�zyz �c:y �Uorl��
From D To=Ft.
14. SCREEN: Depth Diam ter Slot Size Material
From To Ft. in, in. 6 d 4t'"111 PiI tz
From To Ft. in. in. uax
15. SAND/GRAVEL PACK: 11��lCj
Depth Size Material ry tftKC J+Y�
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 T DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
qIGNAITRE OF PERSON.CObIQ JRr J"gJQ Tjfi WE
--pp--ppR //++ ��// rcDn DATE
Submit the original to the Division of Water Quoit ,GrolhtUlvAMF �tibiMP6 Mail Se ice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001
MAR 08 2006
Asheville Regional Office
A uifPr Protection vr�

WELL CONSTRUCTION RECORD a
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\YELL CO\TR:ICTOR(INDIVIDUAL)NAME (prior) - S• - CERTIFICATIONY `
%YELL COS7R)CfORCOMPANY NAME
PHONEY
STATE WELL CONSTRUCTION PERMIT# A&SOCIATEn WQ PERMIT#
(ifaPPlicablel (ifapplirablc)
1. WELL USE(Check Applicable Box);Residential F. /MunicipallPublic❑ Industrial❑ Agricultural❑
Monitoring❑: Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION.
Nearest TowIL� re- ¢ Count}•/4 " Topogtaphic/Lat}d setting
— - ❑Ridge ❑Slope 13Valley ❑Flat
(SMVI Nam m
Names Numbers.Comunay.Subdivision,Lol No.,Zip Cate) (conk appropriate boat
Latitudeilongitudc of well location
3. OWNER:-
Address - [deglees/minutcdseconds)
Latitudellongitude source-❑GPS❑Topographic map
(4rccrar Route No.)
(dlttk box)
DEPTH DRILLING LOG
Cily or T9um stilel FtL °Ly?7 Z�pCode From To Formation Description
AM code-Phone number �—
4. DATE DRILLED)/-Z �
5. TOTAL DEPTH, ft
6. DOES WELL REPLACE EXISTING WELL? YES NO ❑-
7. STATIC WATER LEVEL Below Top of Casing: Fr.
if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface
`Top atcadnZ termtoated al/or below(and i=lace requires a
variance is acmrdaa<e with ISA NCAC ZC A[I&
9. YIELD(gpm): 1^ METHOD OF TEST r
10. WATER ZONES(depth):
LOCATION SKETC14 I
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 Diar)ctcr or WeighvIlL Material numbers and common road names.
From To S! FL-T-J� n;:
From;j_To '�i Ft tic'
From 'Z; To Ft �t.. tin
13. GROUT: Depth Material - MethodFrom To Ft From TO = Ft
14. SCREEN: Depth Diamche- Slot Size MaterialFrom To FLin. in. CD
From To Ft. in. -p4jtI5. SAND/GRAVEL PACK: m.DepthSize Material {.�From To FL FromFLIG. REMARKS: "` YK" -
ll0 HEREBY CERTIi:Y THAT THIS D £i11 WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARD ND
� �>�;COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-----------------------------
-'' `SIGNATURE OF PERSON CONSTRUCTING THE WEI i DATE
Submit the original to the Di)•ision of Water Quality,Grourtw&09",
GW-I REV.0
27699-1636 Phone No.[phone].within 30 days. fail Se ce Center-R .0,NC
' 72001
MAR 0 8 2006
Asheville Regional Office
AgUiter Protection

q 2 2 7
WELL CONSTRUCTION RECORD
North Carolina- Department of Envitunment and Natural Resources- Division of Water Quality-Groundwater Section
\\ELL CoN'IRACTOR(1,*DIVIDI3.,kL)NANIE CERTIFICATION
/27
N%ELL CON1 RAC-1 OR CO.NIPANY NAME—I)U; C 6 (i PHONE
STATE WELL CONSTRUCTION PERMIT-- ASSOCIATED VVQ PERNIIT--
_11-,1 ficable'
iff applicable)
ficable)
I. WELL USE(Check Applicable Box): Residential 21/MuniCipal/Public[3 Industrial 0 Agricultuml 0
Monitoring 0 Recovery 0 Heat PUMP Water Iftieclion 0 Other 0 if Other,List Use
2- WELL LOCATION:
Nearest Town: MlriLw Courn." opographic!Land setting
416 Z [14 4yt - 7-A t /?;4�A_X9-a', L Ridge 0slope ovalley cHat
(SIT�14 Name,Nwnb�.C�rnunay.Snbdi,,ii��LOIN,Zip Code) (check zpprpa.1C box)
Latitudellongilude of well location
3, OWNER:
Address rdl Z C-4D C40,de Cggl;E& rC4 Latitudctionvitude source:0GI'SLITopographic map
lstreet or Roux N.-)
(rbeck box)
DEPTH DRILLING LOG
City o,To,,-n star Zip�Codc From TO Formation Description
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO G r
7- STATIC WATER LEVEL Below Top of casing- /Ce
3. TOP OF CASING IS FT.Above Land Surface* — ---------
*TUP of casing leminani tt.r below land land surface requires a
variance in accordance with 15A NCAC 2C.011&
9- YIELD(gpm). i Z METHOD OF TEST Sb4 6{. 41Z
-
10 WATER ZONES(depth).
LOCATION SKETCH
11. DISINFECTION:Type 0— Ammmty� Show direction and distance in miles From at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di3ruClCr orWeightlF, Material numbers and common road twUncs.
From To Ft.
From e) To Ft m tj Tc:��
From F1
* �ff
13. GROUT: Depth
From To
From 0
To__L-�_FL. 4,ip I
14. SCREEN: Depth
From Diamaffer Sint Size , material O tt
—To Ft. in. in.
From TO Ft- in_
__ _PACK:
15, SAND/GRAVEL
Depth Size mau=21
From—TQ Ft
Prom To Ft--
16. RENIARKS:
0 LV(04�f
J DO HEREBY CERTIFY THAT T?� CONSTRUCTED INIACCORDANCE WITH I SA NCAC 2C.WELL
A COPY WELL
CONSTRUCTION STANDARDS. THA�Tt� _DF_THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
St6IKATURE PF PEt ON CONSTRUCTING THE WELL'DATE
Submit the original to the Division of Water Quality,Groundwa Dervice C ter-Raleigh,NC
27699-1636 phone No.[phone],uithin 30 dav& Im"WED
W-1 REV.07/2001
MAR 0 8 2006
Asheville Regional Office.ct
Aquifer Protectionl

II �yoa
l WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
I , /
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Wltij ���C CERTIFICATION# 0/�-
0
WELL CONTRACTOR COMPANY NAME 'TU4;e-X yy._A/-(- 0r; U'04 CYHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential EK Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIO : A Top ogr hic/Land setting
Nearest Town:-I County ❑Ridge vpe ❑Valley ❑Flat
tSt f 0 /rte X((b-o r (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
f 3. OWNER: AyiJ- FV LL Pg (degrees/minutes/seconds)
Address 40(0 OC J) LI Le iz Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�'r-i W �' C �297SZ DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED N' Q.OS 7 —a I
4 d
5. TOTAL DEPTH: 405 / +
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9,
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(Use-+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): q METHOD OF TEST ,4/t2
10. WATER ZONES(depth): �fw d.. F ?co'
LOCATION SKETCH
11. DISINFECTION:Type C Olr1 NQ Amount 02, Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Dipnleter or Weight/Ft. Material numbers and common road names.
From O To /.30 Ft. (0 Y �o 4
From i 30 To 1$o Ft. (,yR _go Pipe +(IV\3\
From /50 To /Y Z Ft.6 yy 19s ✓
13. GROUT: Depth Material Method -
From To Ft. A e
From O To 00 Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. t
From To Ft. in. n.
15. SAND/GRAVEL PACK: w -
Depth Size Material
From To Ft. rn
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY TH T THIS WELL WAS CONSTRUCT£MNACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN DS,AND THAT OPY OF�THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN UR F PERSON CONSTRUCTING THE WELL DATE ,
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC _
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division or Water Quality-Groundwater Section'a-T
t\'ELLCONTRACfORQNDIVIDUAL)NAME (print).14ariJ V5'I-(C CERTIFICATION#s2LL.!]_D
N'ELL CONTRACTOR COMPANY NAME T((Sl-i%C � �'et,t� �;'r L(s((�E/ PHONE a �fI`JJY-U.S�J�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED\YQ PERa11T#
1111 (ifapplicable) (ifapplicable)
I. WELL USE(Check Applicable Box):Residential f�"/Manicipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: =
Nearest Town: 1'i0i� County ��pp SDOtnKU_ Topographic/Land tdLandsetting _.
/��_ �^ / 1J--- ❑Ridge 1r351ope ❑Valley ❑Flat
1—.2 ��t,Lft' (check appropriate box) L
(Street Nano.Numbers,Community.Subdivision,tot No..Zip Cade) Lalitude/longitude of well location
C1 n_ 4 _
3. OWNER:_S(5�fJ C( 6L-'h�l (_E , JZ/ C// �'Jr (tkgrets/minunx/seconds)
Address S 50 a tM,a' Yt .4'i JG Latitude/longitude source:❑GPS❑Topographic DISH
(Street or Route No.) t (check box) r n ".
?-Art rr•� f I ze, Q r 70 DEPTH DRILLING LOG
r � l
City or iown state zip code From To Formation Description
( 01 )- - Yf g© _
Area cork-Plume numbe5-1
4. DATE DRILLED .J-19- 0 5�
5. TOTAL DEPTH: 44'y
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W'
7. STATIC WATER LEVEL Below Top of Casing: FT. J 00.. Jf '3— 5.1e
(Use"+"if Above Top of Cuing)
3. TOP OF CASING IS FT.Above Land Surface* 2i7C1t
'Top of easing terminated utter betaw had surface requires a
variance in accordance with 1SA NCAC 2C.0118.
9. YIELD(gpm): Yo METHOD OF TEST AI Iff C> ' qr�/� 4XAIL
Ufe/(4
10.WATER ZONES(depth): �Q gjejtvr j 32c�
LOCATION SKETCH
IL DISINFECTION:Type-64609;We- Amount Show direction and distance in miles from at)east
12. CASING: Wall Thickness two State Roads or County Roads.Include the mad
Depth Diameter or We)ghtlFt. Material numbers and common road names. r�
From To Ft
From b To !0 Ft.
From /O To 916 Ft. to r/ r8i1 !jALU
13. GROUT: Depth Material Method
From To From t.-----���---
FCREEN: Depth FtDc
14. SCREEN: Depth Diame4Se''r Slot Sia Matrnal sl � F'
From To Ft, in. in.
From—To—Ft.—in. in.
15. SAND/GRAVEL PACK: p
Size Material
Depth
T�
From.To Ft.
From To Ft.
C
16. REMARKS: P,
1 DO HEREBY CERTIFY THAT THI WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A N'IiAC 2C,W
CONSTRUCTION STANDARDS, M THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO St�Fy OWNER'
SIGNATU E OF P)&SON CONSTRUCTING THE WELL -- DATE
Submit the original to the Division of Water Quality,Groundwater Seetiolr-163611tai/SertYcl eq'er-Raleigh,NC
276994636 Phone No.[phone],within 30 days. Ci1'J-1 REV.07/2001
I � �
5

WELL CONSTRUCTION RECORD a cl, 0 9
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)4///-y Jf1S`FiCri CERTIFICATION#Z15�
WELL CONTRACTOR COMPANY NAME SUS fr c�'L,r�(,E-o.—(U••lt1 PHONE # (e'172Y-rrs"
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: hi r'o1J County v ❑Ridge OSlope []Valley ❑Flat
Ne.6t ��— (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) CC J Latitude/longitude of well location
3. OWNER:�/(/�Ti- eL/GIQm 1'nerci L /ceAL L-.S`fA�e (degrees/minutes/smortds)
Address FZoo YC'r�qe.Qt U aLI/D• Latitude/longitude source:❑GPS❑Topographicmap
- (Street or Route No.) (check box)
VJSJl LJL;-e Ne -7&PQ DEPTH DRILLING LOG
City or Tawn' State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED OS 4
5. TOTAL DEPTH: Z 15
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 114/ _
7. STATIC WATER LEVEL Below Top of Casing: _FT.
(Use"+"if Above Top of Casing) W
8. TOP OF CASING IS FT.Above Land Surface•
'Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
u
9. YIELD(gpm): 3� METHOD OF TEST
10. WATER ZONES(depth): 3-r� phi lk 2!o u
LOCATION SKETCH
11. DISINFECTION:Type e tbf-i /Ve— Amount 0-L Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and co road names.
From To Ft. Q tl
From To 75 Ft. 4P V, -9b p(�C From--1--To_L Ft. �0� F98 (, aV I n
13. GROUT: Depth Material Method ,51-G-rc.�
From To Ft.
From 0 Tom Ft. 1 /)Itt�ea. t
14. SCREEN: Depth Dia etetti r Slot Size Material Ev� 15
From To Ft. _ in. in.
From To Ft. in. in. yy
15. SAND/GRAVEL PACK: ,e �fQ/1
Depth Size Material 4'�(.W
From To FL h Pj,p,wt
From To Ft. (Uw
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS' ND THAT A COPY QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IGNAT r
4 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 c,.�
tVELLCOVTRACfOR(1\DIVIDUAL)NAME (print) GeAFy U. d ;stici: CERTIFICATION i�LY t7
s\'ELL CONTRACTOR COMPANY NAME S e Fi�Z VPf:1A- Ord t,' PHONE a ( )LLS'-AS' e
STATE"'ELL CONSTRUCTION PERMITa ASSOCIATED IVQ PERMIT#
loan (ifapplicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential❑ Municipal/Public[3 Industrial ❑ Agricultural[]
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIONII: - L+ Topob�jphic/Land setting vG '>
Nearest Town: Paa& L County)0:66W cl-L ❑Ridge ETSlope ❑Valley ❑F]?l 1�
1,2i2c AHQ �GDZ (check appropriate box) I �.
(Strew Namc.Numbers,Community.Subdivision,Lot No-Zip Cafe) Latitude/longitude of Weil location � t.
I,NI
3. OWNER: Qad N I�AI
I � l/ /'fe on- iLS' �jr� (degreWminuoWsecands)
Address 205 - . D,,. Latitude/longitude source-❑GPS❑Topographicmap
J�Jf/r- (Strew or Rome No.) (chock box)
DVS *Ait- 1:)iV uz! DEPTH DRILLING LOG
�� c yorT —sum Zip Coda From To Formation Description
Arco code-Phone number
4. DATE DRILLED ri -6- 5
5. TOTAL DEPTH: 40 /
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO G
7. STATIC WATER LEVEL Below Top of Casing:—4tO FT.
if Above Top of Casing)
S. TOP OF CASING IS Ff.Above Land Surface'
*Top of casino terminated atfor below land surface requires a
variance in accordance with ISA NCAC 2C.011&
9. YIELD(gpm): A METHOD OF TEST-AL!I! -
10. WATER ZONES(depth): 3 1,a at k4 74/6
LOCATION SKETCH
11. DISINFECTION:Typci,CgiuI Z Amount Y)b"L Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Includef the road
Depth Diameter m W elglrtlFt. Material numbers and common read names.
From To Ft.
From_ To�Z Ft.�
From `��To�Ft. _ !���ie� i
13. GROUT: Depth atenal Method— �Jl.
From To Ft.
From_0 To 2v Ft.�r
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. Aft
From To Ft. in. in. \f-
15. SAND/GRAVEL PACK: Idle
Depth Size Material
From , To Ft.
Frrxn To Ft.
16. REMARKS: F (. �yy'
QLV �Zl 4 /
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1 CORD CE WtTH 15A N ,C 2C,WELL
CONSTRUCTION STANDARDS,A D THAT A COPY OF THIS RECORD B EN PROVIDED TO THE W. L, ER
-r
SI NATO E OF RSON CONSTRUCTING TH9 W
Submit the original to the Division of Water Quality,GroundwateY:7q Flon 1636 Mail Service Ccnldt-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days- l.. ,� -- -- GW-1 REV.07/2001
l j:

I Y
WELL CONSTRUCTION RECORD , ct
{ 4 rj
North Carolina- Department of Environment and /Natural Resources-Division of Water Quality-Groundwater Section
It \\'ELL COSTRAC1 OR 1INDIVIDUALI NAME (print)( -IaP a.� �'�'
i / CERTIfICATIONp1?15 i
T �
tt-LLI.COSRACfR O COMPANI':VAh1E IG�'ft (; 1f�r.LL t L . -t� PHONE N (C..1h S'IA7 L WELL CONSTRUCTIoN PERN11TR
' (i(a licable) ASSOCIATED WQ PERM IT#
(ifa licable)
I. WELL USE(Check Applicable Box): Residential ' Municipal/Public ❑ Industrial 11Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
?. WELL LOCATION:
Nearest Town: '1 i c%1; Topographic/Land setting
,-
�County�l� ��%�,`rn-�l
c—_—__ LaiJJA ❑Ridge E3Slope ❑Valley ❑Flat
nus.tummunny.subdivision. o.,Zip Cuae) tcheck appmpnale box)
Ate,""� Latituderlongitudc of well location
3. OWNER:_ T r�r•�s-;,a 4V l�
Address /7/ / �% C,C I��a (dcgreeVmimnu/SxomL.)
t$trccx or Rowe No.) Latitude/longitude source:❑GPS❑Topographic map
(check box)
Cny or Tm,n are tp Code DEPTH DRILLING LOG
fflArea
cod _(peem 42 E� From To_ Formation Description
arerea code-Phone number
er
4. DATE DRILLED //aIF--CC �✓ 1 Sha' t^ f
5. TOTAL DEPTH: 'r,`-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top ofCasmg:/-I FT r,
(Use"• 'if Above Top of casing)
3. TOP OF CASING IS�_F Above Land Surface' ---------
"Top of casing terminated War below land surface requires a <--
variance in accordance with ISA NCAC 2C.011S. --
9. YIELD(gpm): � METHOD OF TEST
10. WATER ZONES de(depth): t.-
11. DISINFECTION:TypcL' 1 CI' _ LOCATION SKETCH c�
11 CASING: — �-- Amount ', Show direction and distance in miles fro at least
Wail Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighVFt. Material numbers and common road names,
From C To FL I
From /S/ To /ill Ft PIC
From
13. GROUT:
Depth Material Method
From To Ft.
From_Q_To A 1) FC 7
'
14. SCREEN: Depth Diameter—Slot Size Material r r? c
From To Ft. s , +
in.
From To i Ft. in-
15, S ELPACK:ANLVGRAV in.
I!,�, --
DepthSize
From To Ft Material )+'C rs
From To Ft. )� Y
16. REMARKS: r' '
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC ZG WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�) /
SIGNANURE OF f MON CONSTRUCTING ,HE WELL
DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phunc No.[phone],within 30 days-
GW-1 REV. 07l2001

J411
WELL CONSTRUCTION RECORD
. � 0 4 3
North Carolina- Department of Environment and Natural Resources-Division of water Quality-GroundwaterSectior.
WELL CONI RACTOR(INDWIDUAL)NAME (print) CERTIFICATION
Tosji( r- WeLL 6 ('4( i&q PHONE
STATE NX ELL CO-NSTRUCTHT%PERMIT# ASSOCIATED%VQ PERNI IT#
GFapnhcablei of an�ticable)
I. WELL USE(Check Applicable Box): Residential fia" Niunicipal/Public 0 Industrial A,_,riculturalo
MonaoringO Recovery O Heal Pump Water jai
CCIT011 EJ Other 0 If Other,List Usc
2. WELL LOCATION:
Nearest To Topogmphic/Land setting
wn:. Of, F6 County 6(-,LA,)e LL opidge 15910pe OValley 0171at
Agn+ Count
(check appropriate box)
(Sheet Nm�,Numben.C unity.Subdi --ion, XQ-ZipCode) Latitudeilmignadc of well location
OWNER:gvd� el,2.014"
Address � -2 ff — (degrees1minutestsmands)
I,- a 4C Latiludeflongitude sourccOGPSOTopoLraphic map
iStrcet or Rome No.) (thock box)
DEPTH
rty or Tmnn DRILLING LOG
sm Zip Code
From
46.Q- ;k To Formation Description
Area code-phone number
4. DATE DRILLED LZ-L�05'
J. TOTAL DEPTH: /(2 yV
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L 42ZA W
7. STATIC WATER LEVEL Below Top of Casing:�0 F7r
fuse"+ if Ahoti Top of Casing)
3- TOP OF CASING IS I FT.Above Land Surface* ---------------3;�
'T OP Of Casing terminated atfor below land surf2m requires a
variance in accOrdanCt With ISA NCAC 2C.01 I&
9 YfELD(gpm): METHODOFTEST- AIA
10. WATER ZONES(depth):. /2 o" tw Yo CD
LOCATION SKETCH
If. DISINFECTION:Type Shaw direction and distance in miles from at least
12. CASING: wall Tbieu�� two State Roads or County Roads-Include the road'
Depth Diameter orlVeigbtfft Material numbers and common road names.
From TO Ft.
From -67 To 72 Ft
From 7Z To 7y Ft
13. GROUT: Depth Material
From To Ft- Method
F rom—d?—To-Z 0 Fi�
14, SCREEN: Depth Dia.C11, Slot Size Maferial .-10
From To Ft. in.
From --To Ft._in-
15. SANJ5/GRAVEL PACK:
Depth Size Material
From—Tu-_Ft
From—To—Ft--
16, RE'kIARKS:
J DO HEREBY CERTIFY T-ItHi T TH IS WELL WAS COxvISIRUCTED IN ACCORDANCE WITH 15A NCAC 2,C- WELL
CONSTRUCTION STAYD&AND THAICOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWN E R
SIONATU V 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 Na.(919)733-322f,within 30 daVS. GW-1 REV.07/2001
j

WELL CONSTRUCTION REC RD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
t\'ELL CONTRACTOR(INDIVIDUAL)NAME (print). 6;TZ� J ml:iL/,S CERTIFICATION#1/S6
w E Lt.CON'IRACfOR COMPANY NAME - n
PHONE # (R•i.1 ?zti--vS
S'1'A"rE w'Et.t.CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(i f applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential 0"'Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:_Mar-,I C County 7y7�(� ✓��Q Topo ?,,phic/Land setting
�U� W,r )) _ ❑Ridge lope Malley ❑Flat
G�!_ �'t y Pta 5 (check appropriate box)
(Street Name,Nunibtrs.Community,Subdivision,Lot Nol Zip Code)
Latitude/longi(ude of well location
3. OWNER: P -r /d S S L L C
Address — (degreestminutestseconds)
J Lati(ude/longilude source:❑GPS❑Topographic map
yy� (StreMor utcNoJ (check box)
C_�� � �'a� DEPTH DRILLING LOG
C uy or Town late Zip Code
From To Formation Description
Area code-Phone number
4. DATE DRILLED //- �LrG �
5. TOTAL DEPTH: .Jr? i Zr 23
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO f o-
7. STATIC WATER LEVEL Below Top of Casing:—e-O _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 I5A NCAC 2C.01IS.
9. YIELD(gpm): 20 METHOD OF TEST/4l R
10. WATER ZONES(depth):_ __-
LOCATION SKETCH
11. DISINFECTION:Type(1.LL>/t//ve Amount 6'L, Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To FL
From o To 714, Ft
From To /EW 9 Ft. !/ t }?j Wit u =
13. GROUT: Depth Material Method
From To Ft. L
From-_jO-_To2,:)_FL tpo / N
14 FromEEN 11
Depth Diameter Slot Size -'--MaterialI �W
To Ft. in. in, f /
From To Ft. in. in. ��J co
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. 21� 1
From To Ft. ,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND R ,AND THAT A COPYOFFTTTHHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN It S
AFUR F 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.(919)733-322I,within 30 days. GW-1 REV.07/2001

DIY WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section t
\w'ELL CONTRwCTOR(INDIVIDUAL)NAME (prim)T it �L1„/j_ — �pt CERTIFICATION 99 IJ v
�wELt.CONTRACTOR CONIPANY NAME- '.ToS -1 LE WFt—,� yy�Y ri Lt/•IPHONE # ( )—S�Q`S/�t
STATE WELL CONSTRUCTION PERh11T9(ifapplicable) —ASSOCIATED ASSOCI YYQ PERNIT(t
licable)
I. WELL USE(Check Applicable Box):Residential(Y Municipal/Public 0 Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other[] frOther,List Use
2. WELL LOCATION:
Nearest Tow ! County e( Topooaraphie/Land setting
� � Ridge OSlope ❑Valley OFlal
(chat,appropriate bo:t
(Atae Nano,Numben.C/ootOunity,Suhdivi5ion,Lol tim,Zip Code) Latituderlongitude of well location
3_ OWNER:CL4(/d,//? Vie j��of� ( minu4s secoods)
AddrLss �a9-iI.tl pr/tdLl ►'' Latitudellongitude source:OGPSOTopogmphic map
(Streit or Route NO.) eck )
�)��r7ib� e- Z�S Z DEPTH (eh DRILLING LOG
( ,c yor town a Zip Code From To Formation Description
`l O
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: !VVtS
6. DOES WELL REPLACE EXISTING WELL? YES D NO EK'
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+"1f Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface`
"TOP Of casiue terminated atfor below land mrflee requirm a
varianm is accordaItrce with 15A NCAC 3C.011& f
9. YfELD(gpm): C- --METHOD OF TEST
10. WATER ZONES(depth): 44�' / r, 2 firt
'-Tr"7
LOCATION SKETCH
IL DISINFECTION:Type 4:Ikri e- Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads,Include the road
Depth Diautcter or weight/Ft. Material numbers and common road names,
From To F(
From--O---To-91 -Ft. Zr�wCLL Cl(�I��CLi
From=To�Ft_
13. GROUT: Depth Material Method yt{U
From To Ft.
From V Tom Ft._� U
14. SCREEN: Depth Dianr cr Slot Siw " Material hi 1 K e�• �(,From To Ft. in. in. 1• ,�.( 1
From To Ft. in- in. �if/ 'i$f g 6
15. SAND/GRAVEL PACK: Cho r �
Depth Size Material
From To Ft. 1 D CD
From TD FL (3 u�
16, REMARKS:
1 DO HEREBY CERTIFY THA S WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDAR S,A D THAT A COPY O CO V IDED TO THE WELL OWNER
! IGNATURE P SO STRUCTINGTHE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Senice Center=Raleigh,NC
27699-1636 Phone No.(919)733-32-7I,within 30 dais. GW-1 REV.07/7-001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CONTR.ACTOR(I.NDIVIDUAL)NAME (print} ,f CERTIFICATION a{SO
\\ELL CON'I'R.\CfOR COMPANY NAME, .)(Y 5'f) < ! V�I eC..L /} r. 'f L, k. PHONE # ( ) 72Y-SLS"f!J
S'l'A'1'E\{'ELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplieable) (ifa licable)
L WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Otlter O If Other, List Use
2. W ELL LOCATION:
Nearest Town: Q,D tJ /County_ _ s�,., ,,. Topo�� hic/Land setting
( ORidge M51ope OValley ❑Flal
Jg y 6Gp i ��% /a E (check appropriate box)
(Street Namc.Numbers,Commu`�ty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: c+
Address It 4!I/ U L d [ (degreesmintnu)smond.)
Latitude/longitude source:OGPSOTopographic map
/,(J�trcct ar Route Ko.) tchcck bon)
C p 7S 2- DEPTH DRILLING LOG
City or Town State Zip From Code TO
O 6S7- T�'ey Formation Description
Area coda Phone number '—T— --
4. DATE DRILLED // ' I� �c>y V 1 L 7 ir2.� f 517A✓
5. TOTAL DEPTH: St VS _cy ma
6. DOES WELL REPLACE EXISTING WELL? YES V NO ❑
7, STATIC WATER LEVEL Below Top of Casing: [ c) _FT,
T_
(Use-+'if Above Top of Casing)
S. TOP OF CASING IS�_FT,Above Land Surface* «t
*Top of Cuing terminated at/or below land surface requires a W
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 2_METHOD OF TEST I �71�iCJ
10. WATER ZONES(depth): c
�� °.y]� SOD
I LOCATION SKETCH
It. DISINFECTION: Type X/ Amount �7zi 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 ght/Ft. to numbers and common road names.
From tD To /D/ fL4e,
From 4? To IULN
J
From/?/ To Ft. (� ,At L /
13. GROUT: Depth Material f
4thod ,4r
From
To Ft. 1
From—To42<Z_Ft.
14. SCREEN: Depth Dian ter Slot Size Material y/� �dc`r 1`ft ry
From To Ft. in. in
From Ft. in- in. u ty �[i ® r,
15. SAND/GRAVEL ELPACk: Ut.et �'k
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
SIGN UREOFPERSONCONSTRUCTINGTHEWELL 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 daps. GW-1 REV.07/2001

0
WELL CONSTRUCTION RECORD 320939
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CO\tRAC-1'01i((ROWIDUAL)NAME ( 4/Z I-Print) � � (y. f C\ � CERTIFICATION 8 2/5- '
\�E Lt.CO\'"CR.\CI'OR COIDIPANY NAME n)5� C'= e'(� ,(�,�r [,[_,/LJ� PHONE B
S'r A'rE tt'ELL CONSTRUCTION PERMITa ASSOCIATED WQ PERMIT$
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential a' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Beal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
A" �' x Topographic/Land setting
Nearest Town:_Lrt�:.)rc e 1" Co/ulni}•t('l - J���iL� p<idge ❑Slope ❑Valley ❑Flat
l /- _ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Lalitude/longitude of well location
3. OWNER: ` AfL -
-• —� ��—r-L4 (dcgreesminut�s/5xonds)
Address 6q Z9, t n.. ti S 1 Q R IZ a e G Latituddlongitude source:❑GPS❑Topog
I- raphic map
CC (Street or Rot to No.) (check boxf
&I &a I/t 9 2 toi-I z- _ DEPTH DRILLING LOG
City or Toren State Zip Code
7�� p From To Formation Description
(L/ )- BSI- (9G (7
Area code-Phone number
4. DATE DRILLEU /L-Zt.,- z'S' _
5. TOTAL DEPTH:_ Z
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO C1_- ,.)- _
7. STATIC WATER LEVEL Below Top of Casing: �?d FT,
(Use"+'if Above Top of Casing) -.
3. TOP OF CASING IS FT.Above Land Surface* _
'Top ufcasinE terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. W
9. Y[ELD(gpm): 36 METHODOFTEST 11/,Q
10. WATER ZONES(depth):, e �t Z14 1, 2C6 —�
i a'
LOCATION SKETCH
11. DISINFECTION:Type c°iI/�Fs Amount 0L Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Fi. Material numbers and co on road names.
From To Ft-
From <' To l 1(i FL:z (.f
From -ILL _ Ft- L 41 — .,� V
13. GROUT: Depth Material Method 1
From To Ft.
From)To Z—) Ft.
14. SCREEN: Depth DiamotiV Slot Size Material
From To Ft. in. in. ✓�� '� ��L�
From To Ft. in. in.
15. SAND/GRAVEL PACK: / J„
Depth Size Material
From To Ft.
Flom To FL � I
L C/ £
16. REMARKS: J/
I DO HEREBY CERTIFY THAT THIS,WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARDS,ANOTHAT A CO,I'Y(THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�
SIGNATURE OF, ERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

�
WELL CONSTRUCTION RECORD : ?
ti C
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) (fpoley Q. 4t-5T/L CERTIFICATION#A-94)
WELL CONTRACTOR COMPANY NAME tC W'e,LL MY.L U " PHONE # iar;+p 7�Y�IJ�yf
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PE MIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 2 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: e ,,A' Topographic/Land setting
Nearest Town: Of DF t f County C ❑Ridge Mope ❑Valley ❑Flat
SO d rewA V / •4M (check appropriate box)
(Street Name,Numbers,Community,Subdivision Lot No.,.,Zip Code) Latitude/longitude of well location
3. OWNER:&1 6 k.441"i EV C zkl'e-4.,t,c 4 (degrees/minutes/seconds)
Address PO Aqo�k fxlOv - Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
�{ Qfsl'rvs� I PJC 2 R?7 o DEPTH DRILLING LOG
ity or Town State Zip Code From To Formation Description
Area code-Phone number - -1 f3
4. DATE DRILLED1 Q .? V 5
5. TOTAL DEPTH: 6, 2 5 riscrz
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO K
7. STATIC WATER LEVEL Below Top of Casing: .5 O 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 L
variance in accordance with 15A NCAC 2C.011S.
9. YIELD(gpm): VZ, METHOD OF TE T 40Aw
10. WATER ZONES(depth): IZlte SA AP (9()r;' _1
LOCATION SKETCH
It. DISINFECTION:Type!_'tol;m — Amount (7 L. Show direction and distance in miles from at 9t
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. d',s _:;•
From To /t y Ft. yd �V �' *:Z-,d7C
Z
From To Vff 1
FromTo��/n 1 (047 Lull'
13. GROUT: Depth Material Method 'aQ.
LL
From To Ft.
From O To Ft. I1.0ee OL JP
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. M wk7 jam,+
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. d
16. REMARKS:
c
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AN THAT A COPY OF�THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IG ATUR OF 0
RSON 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 (�
N\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) 'Afz'!� A]- ,r� C��{L-� _ CERTIFICAT/IION# r2y�f/,J�
\\F Lt.CON"fR:\CI'OR COaIPANY NAME -r!g. ,e' t ✓V r- L.L. ll) PHONE #
5'1 ATE\\'ELL CONSTRUCTION PERMIT# ASSOCIATED wQ PERMITO
fifapplicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential IYMunicipaUPublic 111 Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topo�� Hhic(Land setting
Nearest Town: U',ti:l.ltOA: County -iccc ❑Ridge L�TSlope ❑Valley ❑Flat
�5/ itir t�Ca1Q'a-C °� (check appropriate brut
(Sucet Name,Numbers,Community.Subdivision,Lot No.,Zip Code) Latitudellongilude of well location
1OWNER:_,pA tot LL !t- ( 1Q ' (degreeslminut(Wseconds)
Address dS-/ �h.LlE C i-I - - C o^ Latitudellongitude souice:❑GPS❑Topographic map
1 Stecet or Route No.) (cheek box)
1�'Y`=�+.tl i,LS _7.tr'.'�S- - DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
( �r )- 732---0zU4
Area code-Phone number V- (1` / ✓n�.
4. DATE DRILLED
5. TOTAL DEPTH: ✓P G S" Gil a: y
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M," �S t
7. STATIC WATER LEVEL Below Top of Casing: &! FI-.
(Use"+'if Above Top of Casing) CO
S. TOP OF CASING IS�_FT.Above Land Surface'
"Top or casinE terminated atlor below land surface requires a
variance in accordance with 15A NCAC ZC.0118. '
9. YIELD(gpm): j%2- METHOD OF TEST�[�
10. WATER ZONES(depth): 14 - v
LOCATION SKETCH
11 DISINFECTION:Typc('PLO(?-jA ;� Amount � e)7. Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or ounty Roads.Include the road
Depth Diameter or WeigbI/PL Material numbers anrtcomm n road names.
From To Ft. ,`L} 40. '
from ToTFLtf C' 2tU
From To d L7 R. ce '
13. GROUT: Depth Material MM t� A
From To FL .,�✓i4'w'
From 41) De Lt" Ft.� ._/ /w le
jp
De �
14. SCREEN: Depth Dian er Slot Size
Ma enal t-F
From To Ft, in. in-
From—
From To Ft. in. in. V' V.-
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
ftom To Ft.
16. REMARKS:
2 �_u Lc
7 ll0 HEREBY CERTIFY T HIS WELL WAS CONSTRUCTED IN ACCORD H ISA NCAC 2C,WELL
CONSTRUCTION STANDA D ,AND THAT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
iGNATURE F P RSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.0712001

q Cl
WELL CONSTRUCTION RECORD � V
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
\\'ELL CONTRACTOR ONDIVI DUAL)NAME (print)
[ �}y.,4 Ja4-f C' CERTIFICATION#�� Shy�^
\\'ELL CONTR.\CI'OR COMPANY NAME tl�S�f CG A+J{�,L ()�i f,.��tJ PHONE # ( )�—T J�0
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
11110 (if applicable) (ifapplicable) ,
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial O Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ if Other,List Use
2. WELL LOCATION: IC �L Topographie/Land setting
Nearest Town: WMjQAA- A County — LXSls3 ff{IZidge ❑Slope ❑Valley ❑Flat
Mug) e d+ (check appropriate box)
(Saect No,=.Numbers.Community.Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: k,G;d a (dcgreeslmirmtest=oads)
Address 1 :5Ocl S,;}a.1,ei1S (vroo �rt�,ip Latitude/longitude sourcc:❑GPS❑Topoeraphicmap
tt1� Istreet Route N . (check box)
IVn(TY< t-11tnt �iC 21%(2r�-- ,DEPTH DRILLING LOG
``''^^�City�or—Torwn satep� zip code From To Formation Description
1&S)-;a 1 — fn ti rl
Area code•Phone number
4. DATE DRILLED
5. TOTAL DEPTH: IA60 20^ RS SMs '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:to O_FT. A fps-
��
I-+•'if Abnw Top of Casing)
3. TOP OF CASING IS FT.Above Land Surface'
•Tap of cmina tertalaated attar below land asrtam reamer a O t�.irQ/PL-t
variance is accordance with 15A NCAC 2C.011&
9. YIELD(brym): METHOD OF TEST 12
6,4 10. WATER ZONES(de pth . 69 Ilk E 40o "!;o lop
QW' e'P14 LOCATION SKETCH
fL I I. DISINFECTION:Type 2 Amount Show direction and distance Jn miles from at least
I2. CASING: Wall Thickness two State Roads or County oads.Include the road
Depth Diameter or Weight/N. Material numbers and common road mm.
From To FL _
Fromm To�Ft. —
From To Ft. s
13. GROUT: Depth Material elt9 shod O
From To FL �2/S
From
CREEN: Tepth FL
14. SCREEN: Depth Diameter Slot Size Material \ _
From To Ft. in. in. �(
From To Ft. in. in.
I5. SAND/GRAVEL PACK: Lt�f LJ
Depth Size Material 'lei
From To FL
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SISIIGN4UPERSON 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-1 REV.07/2001

WELL CONSTRUCTION RECORD35
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
tPELLCO�TRACt•OR(INDIVIDUAL)NAME (print) GA'VLA4 U 136 C-'Z CERTIFICATION M�, �U
tt'ELL CONTRACTOR COMPANYNAME �C ,SN e-t 11.1f tLl� PHONE r
STATE WELL CONSTRUCTION PERMIT# sSSOC1ATED WQ PERMIT#
(ifapplicable) J (ifapplicable) Within
I. WELL USE(Check Applicable Box):Residential 19 Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N! (�p ��b ) i Topogn phie/Land setting
Nearest TO" �1 County � 6 eCL ❑Ridge !$Slope ❑Valley ❑Flat
✓ 2 /' l (check appropriate box)
(Stun Name.N mbcrs.Commu City,Subdivissio r Lot No..Zip Code) Latitude/longitude of well location
3. OWNER: ► y(K 0 �.ot)k �n (dcgtecchninutestaecoads)
Address �5(,2112 /t/LtJI/ .22G .0 e-e.��Latitudc/longiludesource:❑GPS❑Topographicmap
r %4 R�c No.) (cheek box)
S DEPTH DRILLING LOO
Description
City Tn»•p_, smte Zip Code From To Formation
`� ,
Area code.Phone number f O(,
4. DATE DRILLED 3' 00 S
5. TOTAL DEPTH: 4oS —/ <� O�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 19
7. STATIC WATER LEVEL Below Top ofCasing: FT.
(Use"+"if Above Top of Casing) r•�
S. TOP OF CASING IS ( FT.Above Land Surface'
*Top of easing terminated Uler below land surface requires a
variance in accordy�n with ISA NCAC IC.91I& ^ S
9. YIELD(gpm):d 2 METHOD OF TEST t� ��
10.WATER ZONES(depth): 17 erp rvt
LOCATION SKETCH
IL DISINFECTION:Type Amount (7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or welghll t. M etial numbers and common road names.
From (D TO­-6—(— Ft. &N go_
From TOFt.
From (' To=Ft.77&�,4 ) n ( 1J L
13. GROUT: Depth Material Method ( L
From CrJ To 90 Ft.�+L�t. Fe-�=—f�—
From o
14. SCREEN: Depth Diameter Slot Size Material �t/-t
From To Ft. in. in. _ M'+Z ``-t
From To Ft. in, in. ! f a U CASE/13. SAND/GRAVEL PACK: ^ q (p
Depth Sim Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY C TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU70 STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER'
/I - IGNR OF PERSON CONSTRUCTING THE WELL DATE ,
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC '
27699-106 Phone No.[phone],within 30 days. G W-I REV.07/2001 --
v]/

WELL CONSTRUCTION RECORD # `'
North Carolina- Department of Environment and Natural Resopurces-Div ton of Water Quality-Groundwater section
N\ELL CONTRACTOR(INDIVIDUAL)NAME (print) - U ry CERTIFICATIONNZI-P�j
ELI.CON'I RAC'I'OR COA1 PAI\\`NAME Ay UJW W'aj;t, PHONE
STA1 E WELL CONSTRUCTION PERDIIT# I
ASSOCIATED WQ PERMIT#
(if anplicable)
(if applicable)
1. WELL USE(Check Applicable Box):Residential E/ Municipal/Public D Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Beat Pump Water Injection❑ Other❑ 1 f Other,List Use
2. WELL LOCATION: �1
Nearest Town: ?9" !N County ft4q X.e-Y Topographic/Land setting
Lsf El79 S&& 6W. DRidge ❑Slope ❑Valley gFlat
a-J-u--r-- (check appropriate bnal n
!Street Namc.Numbers,Comrounay.Suhdivsion,lot No.,Zip Code) Latitude/longitude of well loca-fitin
1OWNER: �icllacL /N r3,ad,�
Address LYE l A ®ef-K C de sourcc:uaGPSOT s
--f ry 4 R, Z �� ' /0 3 Sot- Latitude/longitude sourcc:DGPS❑Topd�iphic map
f S(rcct or Romc No.) x� C tp 3S/t�� (check box)
/30�NoS �@1rZes .��pF/t/�iitJt' DEPTH DRILLING LOG';
cny orTman state Zip Code From To Formation Description
Aren code.Phone numbert�-
4. DATE DRILLED-/(a-OS-
5. TOTAL DEPTH: AOS i
6. DOES WELL REPLACE EXISTING WELL? YES D NO to Sb
7. STATIC WATER LEVEL Below Top of Casing: 506 FT. gcJi /7U '
(Use IL �l if Above Top of Cuing)
3. TOP OF CASING IS FT.Above Land Surface* 222 C9Gn re�e
*Top of easing terminated at/Or below land surface requires a
variance in accordance with ISA NCAC 3C.011&.
9. YIELD(gpm): J? METHOD OF TEST 4 �-
10. WATER ZONES(depth): 3�+pirt E 770
LOCATION SKETCH
11. DISINFECTION:Type E Amount OZ Show direction and distance in miles from at least'.M
11 CASING: Wall Thickness two State Roads or County Roads.Include th
Depth Diatnctcr or WeephVFt. Material numbers and common road names. /yap
From-To IZ/ Ft. S/o per f[/f`��- poor if
From Me Tor 2 r Ft. fd
From /St To !a 3 Ft. af
13. GROUT: Depth Material Method
From To Ft.
From Ft. v2 _ A eI L
14. SCREEN: Depth Dia to Slot Size Material
From To Ft. in, in. vv rrtfll�L (((���rriL�
From To Ft. is in. /�
15. SAND/GRAVEL PACK: /
Depth Size Material
From To Ft. . t
From To Ft. 21 N
16, REMARKS: 1 1� f -
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDA ,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA RE OF KSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water utility,Groundwater Section, 1636 Mail Senice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.0712001

M c(,?, r 49 2_ C-ee.? - q0-?- 7S9-53(�/ n� 9 1 ') � °_, Q
Yv7- 30� f 11�9 WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ai�-04 \r—
S+� (� 6 CERTIFICATION# Wr_0
IN ELL CON-rRACTOR CONI PANY NAME 'TUJTC' WE LA- D r;LL; JU ,� PHONE # ' FV
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 21'�Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery ❑ Beat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION: 5 Duljtt z � D hic/Land setting
Nearest Town: oC OpFort' County_ idg a ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Sucei Name.Numbers.Community,Subdivision,Lot No.,Zip Cade) Latitude/longitude of well location
yf y I '
3. OWNER: RR5 7 J ua_ e /r} p(,( )rye AN I (degrecUminutcs/seconds)
Address A W 7 O K.0 a No.) T v Latitudellongitude source::OGPS❑TopoLmphic map
IStrect or Rome No.) (check box)
P/�kR r-16 ;-?']IZ DEPTH DRILLING LOG
City orT^• tag^ Zip Code From To Formation Description
r1'0r7�I$$t}�'�J832 �_
Arca code-Phone number / 2
4. DATE DRILLED I3 f fJ b
5. TOTAL DEPTH: 1 Z o0
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Or
7. STATIC WATER LEVEL Below Top of Casing: 62-O r FT.
(Use"+"if Above Top of coring) 2'�— /i 700 —T'e AAA,
8. TOP OF CASING IS / FT.Above Land Surface's
'Top of casing terminated atior below land sarface requires■
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I METHOD OF TEST NNd
10. WATER ZONES(depth): /�y)'/�t r_&' H70`
LOCATION SKETCH
t 1. DISINFECTION:Type P Amount 'Z- Show direction and distance in miles from at least
12. CASING: Wail Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft. .�
From�To Ft=� t/ �_ §� W AA frio ,
From To Ft. - I✓ `l• f✓10/�.�
0. GROUT: Depth Material Method t`
From TO FL c71
From O To J--
14. SCREEN: Depth Diameter Slot Size Material a .�
From To Ft. in, in. Co -"
From To Ft. in. in. C3
15. SAND/GRAVEL PACK:
Depth Sim Material -t
From To Ft.
From To Ft. ll�
16. REMARKS: 7us,}
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STAN DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
MA
SI(SNATLT OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina- Department or Environment and Natural Resources-Division of Water Quality-Groundwater Section
t\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) Gd2g,�
�-�+�t s:aS4 1(6 CERT[PICpAT��fppONpa���y'
NvF LL CON7'R.%C't'Oti COMPANY NAME a` +(C E We-rift 0,- zv4( PHONE #
S'l ATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box): Residential V Municipal/Public ❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Hcat Pump Water Injection❑ Other❑ 1fOther,List Use
2. WELL LOCATION: �
Nearest Town: b1- b �H Coun gr
ty g Topoaphic/Land setting
1717 Mik i Nzv li�CAa) /l�ar� ( ORidge Cope OValley ❑Flai
(check appropriate boa)
(Street Name,Numbers,Connummity.Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
3. OWNER: 0K t
PSS/ ' ' r (degrersimmutestseconds)
Address d Latitudc/longitude source:OGPSOTopographic map
�/ //�j (Street or Rome No.) (check boxi
2fI`t•( egfi erz FLQ 3D'70 DEPTH DRILLING LOG
SuyorTown State ZipCode From To Formation Description
(—) y47 , /� 1 P
Area code-Phone number
4. DATE DRILLED Q 3 O S- i/Z rgo'a:le
5. TOTAL DEPTH: S r/Jf� cc°/O — fie Q rzt� s
6. DOES WELL REPLACE EXISTING WELL? YES O NO M" 4D5-
7. STATIC WATER LEVEL Below Top of Casing: DO F-f, -�'a'•'�J/ '�
(Use"+'if Above Top of Casing)
3. TOP OF CASING IS FT.Above Land Surface*
*Top of cosine terminated mfur below land surface �
variance in accordance with 15A NCAC 2C.01 1g- requires a y-- — _
9. YIELD(gpm): f METHOD OF TEST S�pi(1 —t
10. WATER ZONES(depth): /end CD •?e)o
LOCATION SKETCH colt
11. DISINFECTION:Type C/0J<1 NC Amount O Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the mad
Depth Di cr rFt- Material numbers and common road names.
From 0Trt (oZFt.From 102 To /d2 Ft / # d*�e �
From 132. To Isar Ft­y,tJd /�2 trP �rAdlcr/IQ(
13. GROUT: Depth arena( Method /t ��//
From To Ft. (/ F �►F`( i/zis<JZ YWQ '�( /votef 4
From_e3 To 22 Ft. fi /
14. SCREEN: Depth Diameter Slot Size Material
From To Ft, in. in.
From To Ft. in. in. -
15. SAND/GRAVEL PACK:
Size Material
Depth a
From To Ft.
From To FL
16. REMARKS: J,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AN THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREIbFP SON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigh,NC
27699-1636 Phnnc Net(919)733-3221,within 30 days. GW-I REV.072001

6) s v} v,.
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Na ral Resources-D' ision of Water Quality-Groundwater Section
/a
WELL CONTRACTOR(INDIVIDUAL)NAME (prtat) �Dj- 6:,mr� ,S cl!;� �� CERTIFICATION
WELL CONTRACrOR COMPANY NAME .7fls�/CF 4JQLr/L U C�jy'iu,/Cil-PHONE # L )
STATE WELL CONSTRUCTION PERMIT# AssOc1ATED wo PERMIT#
0000000 (if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Ci3'Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: r? _/! TopogrgphidLand setting
��c�hown: 044Fy�tf County `���C(.� ❑Ridge OSlope ❑Valley ❑Flat
z6xI,-, Lied /1/:�c;ie (check op)ropriatcbus)
(Area Nmna.Nururnbers,Commnunit—y.subdivision,Lot 14o.,Zip Code) Latitude/longitude of well location
3. OWNER:_/L� LQ ,/l (degrecs/mirmte9seconds)
Address Y �4Q �S, �n jt � Latitudetlongitude sourer.❑GPS❑Topographic map
(Sucat or�ee o.) (check box)
DEPTH DRILLING LOG
Ci own State Zip code From To Formation Description
Arco code-
bane number
4. DATE DRILLED )i'S "3` ©. r
5. TOTAL DEPTH: ®ate
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:"_FT.
(Use-4^if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface'
•Top of easist terminated st/or below had surface mQuira a
variance in accordance with 15A NCAC SC.#1I&
9. YIELD(gpm): METHOD OF TEST �P//1 =
10. WATER ZONES(depth.
A � agof LOCATION SKETCH CO
11. DISINFECTION:Type Amouht Show direction and distance in miles Emm at mast
12. CASING: Wall Thickness two State Roads or County Roads.InAde the road
Depth Din orWq1ZbtM1. M number and common road names.
FromiV To
-=, Fy .
Frorn-ZJ�2-Top�F
FomZVV Tuj FL 1i1 6& f
13. GROUT: Depth r1crial ethod
From To Ft. e
From —To „2Q Ft. ,Z�
14. SCREEN: Depth Diameter Slot Size Material � L
From To Ft. in. in.
From Ft. in. in.
15. SAND/GRAVEL
PACK:
Depth Size Material
From . _ To FL ^' t
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY TH T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STAN DS,AND THAT A COPY qf-IHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.17
SIQWAVEOFPERSONCONSTRUCTINGTHEWELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Flail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. G W-1 REV.07/2001

0 1 W r,^ (
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural T Resources--Division of Water Quality-Groundwater Sectioon��
P'ELL CO] RACTOR(INDIVIDU.AL)NAME (print) r4 JU rG �r�"� ,_ CERTIFICATION#,4 / O
w'ELI.CON I RACTOR CO\iPANY N.AhIE Tv /LF WEC-C Al44 PHONE #
S'I'A*I E R'ELL CONSTRUCTION PER,tliT# ASSOCIATED tYQ PER\71T#
(if applicable 1 (if applicable)
1. WELL USE(Check Applicable Box):Residential 19�Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ lieat Pump Water Injection❑ Other❑ If Other,List Use
2. W ELL LOCATION:
Topo }chic/Land setting
Nearest Town: Ol n Fvr f County D"JOIC ❑Ridge [Kope ❑Valley ❑Flat
;05 lye-c(� C �t� (check appropriate box l
(Sheet Name,Numbers,CCorturo nny,Subdivison,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /I�IQe*ko e N UGg / 03
Address ! I (degrecs:minue,,/Seconds)
g h le all 9L Latitude/longitude source:❑GPS❑Topographic map
o1_n F k4 (StrccNr`utc No.) 2 !check b=)
`� DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Descri tion
(6Tg)- 6ce 9- !7C a �— P
Area code-Phoric number
1. DATE DRILLED 2 8 O ' td 1U t
5. TOTAL DEPTH: I sw�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Rf
7. STATIC WATER LEVEL Below To of 5
P g:�_FT.
(Use"+••if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface' ^
"Top or casiuE terminated atfor below land surface requires a —4
variance in accordance with 15A NCAC zC.0118. _
9. YIELD(gpm): 11 METHOD OF TEST A /2
10. WATER ZONES(depth): I q7e ar � Zs-v
r1t—
LOCATION SKETCH
11. DISINFECTION:Type V Amount 6 2 Show direction and distance in miles from at leaf
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diprt�� or Wn t5 VFt. Material numbers and common road names.
From 8 To�Ft. CO (b �� C AUK n/FromTom_FL� / $ —ynrr' 1 e
From To FL 6 L d"
13. GROUT: Depth Material Method
From To Ft. ,
From Tom Ft. `/97 J. WELL
I4. SCREEN: Depth Diamc er Slot Size MaterialFrom Tu Ft. in. in.From To Ft. in. in.I5. SAND/GRAVEL PACK:
Depth Size Material
FromTo Ft. TZ
FromTD Ft.16. REMARKS:
1 DO HEREBY CERTIFY THATTH WELL WAS CONSTRUCTED IN ACCORDANCE WICONSTRUCTION STANDARDS,A D THAT A COPY OF THIS RECORD HAS BEEN PRO
ASIATURE F PERION CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. G W-I REV. 07/2001

WELL CONSTRUCTION RECORD
UD to
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-
""LLCONTRACTOR('NDIVIDUAL)NAME (print)_ �/�7 kz U$¢�CF Groundwater Section
WELL CONTRACI'OR COM. PANY NAME T9 C, t C Ltlo�O CERTIFICATION#2/SU
--�_ A .: •��1 Sr.\TE WELL CONSTRUCTION PERMIT# PHONE !LG.W 7z -
dig
(ifa licoble) SSOCIATED wQ PERMIT#
(if licable)
WELL USE(Check Applicable Box):Residential M*Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use o
2. WELL LOCATION: n Jf 4
to
Nearest town: ✓ul� ( Topogra ic/Land setting CO
�``�' County
O 1 `n K j ❑Ridge W3Jope ❑Vail(Street Name,Numbers,Common' ey ❑Flat
T 11 %•Subdtvtson,Lot No., N Code) (ctttxk apprapriatc box) O
3. OWNER: 2-/ MIL A Latitude/longitude of well location
Address O IdcgreeslminuRs/secomk)
IStrecl a RomC No.) Latitudellongitude source:❑GPS❑Topographic map
O L,for f ll 292(.1 (chock box)
Zip Code EPT dd Cty ro a DRILLING1�nn
P 9 3 (� From To Formation Description
Arc,axis-Plmne number �w-�
4. DATE DRILLED 7-2 7_40!,57 �---
S. TOTAL DEPTH: 40§- _
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO (9�
7. STATIC WATERLEVEL Below Top ofCasing: m0 FT
8. TOP OF CASING IS IIuse"+"ifAbowTopofcasing) iuv Y�—
'Top of eastaa termWatad War below h d s Abofatt
ve Land Surface* ----�_
s'arianee in accordance with ISA NCAC 2C.011L *'#,owes a _--
9. YIELD(gpm):--2 METHOD O EST A'K Sik,j
10. WATER ZONES(depth):_/a,�,w & yp
hl. DISINFECTION:TyPe? Amount LOCATION
I_, CASING: Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads,Include the road
From To �O Dia er or)mlyjgltuFL M cr4al numbers and cormnon road rmrncs.
From '' Q To Ft--l� Alt L
i72�Ft
From, Ili- To Ft.�_(/�l 1
13. GROUT: Depm cv T—
From Material Method
To
From CJ To Z I_Ft.�
14. SCREEN: Depth Slot Size
From � Ft D' ter Material
From in. in.
IS. SAND'/GRAVELTo Ft' in
PACK: t"' -----_
From Depth Size Material
FTom�To Ft.
To Ft.
I6. REMARKS:
I DO HEREBY CERTIFY THAT THIS ELL WAS CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC71pNSTANDARD A THATACOP -
HAS BEEN PROVIDED TO THE WELL OWNER
A E OF RSON CONSTRUCTING THE WELL
Submit the original to the Division 0 Water Quality,Groundwater Section, 1636 Mail Senice C o ere
27699-106 Phone No.(919)733 3?21,n;thin 30 days. Raleigh NC
GW-1 REV.07/2001
i

V`i ;a
WELL CONSTRUCTION RECORD <) v
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section },
WELL CONTRACTOR(INDIVIDUAL)NAME (vrintl (TZ�--•-V T—ej C � i1�� CERTIFICATION. 21 -6
TELL CON'TR.%.CTOR COMPANY NAME U e_6— PHONE a
STATE WELL CONSTRUCTION PERMITtl asOC1ATED WQ PERMITa
(ifapplieabk) (if applicable)
L WELL USE(Check Applicable Box):Residential Ei- Gunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Outer,List Use
2. WELL LOCATION:
Nearest Town: Coumy s� TarogIa�hic/Land setting
❑Ridbro QRlope Malley []Flat
(Check ap,(nrq,riate box)
(Area Nano,Numbers,Community,Subdivisim Lot No.Zi Ctek) Latitude/longitude of well location
1 n
3. OWNER/PA /`IZ4,0: i �P 2w t�ep muvatsamxkl
Address _ So a VA Latitude/longitude source:MPS❑Topographie map
niDt` t�raa.) $7�
DEPTH
(taetk but
City ur o/wn Sum DRILLING LOG
Zip Code l ) !42 C236 From To Fomtauon Description
Arco code-Plane number 4. DATE DRILLED
5. TOTAL DEPTH: Z 9S
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO @w�-
7. STATIC WATER LEVEL Below Top of Casing: IO17 FT, _ }
(Use-4-if About Top of Casio
S. TOP OF CASING IS _FT.Above Land Surface' 00
'Tap of eaiaa wrimiotd uVor behw had a,va m vaquita
varhate k aRCWda°te With ISA NCAC 2C.9113. c5
9. YIELD(gpm): /Z METHOD OF TEST
10. WATER ZONES(depth):. y,o rr sx- Zoa'- LZo
11. DISINFECTION:T e LOCATION SKETCH
YP Amount Show direction and distance in miles from at leas(
12. CASING: Waal Thickness two State Roads Or County Roads.Include the road
�Pa Dhmtcter or weigUM Mateda) rnn*=3 and canton Toad names.
From To FL G 00)F X
Fran C9 To_Ft.-� I T
From_jL To `-+
13. GROUT: Depth axial MethodT^� (� V
From To FL
From_Q_Tom Ft. BY
14. SCREEN: Depth Diameter slot size attxial
From To FL in. in.
From__,To Ft, in, in. i -
15. SANDIGRAVELPACK:
" Depth Size Ft. Material
From . To tY ye
FTmn To Ft. f-
16. REMARKS:
I DO HEREBY CER7ffY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTED ANDARDS,AND THAT A COPY OFTHIS RE BD HAS BEEN PROVIDED TO THE WELL OWNER'
l SH&TUREOFPERSONCONSTRUCTINGTHEWELL DATE
Submit the original to the Division of Water Qu ality,'G fOm Aft Sectlen,1636 MW Service Center-Raleigh,NC
27699-1636 Phane No.[phone],within 30 days. GW-1 REV.07/2()O1
I

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
U'ELLCOSI'RACTOR(INDIVIDUAL)NAAIE (print) 07Q.1f-4 Z—LSI" C=t
—T--- --r CER7IFICATfON p 21
N%' LI.CUSI'RACI'ORCOtIPAN'Y'NAWIE .)t/JC'�4 L/L +, e—ek Dr (_ %�PHONE Y (� �y-1 Y
STATE WELL CONSTRUCTION PEMMITa ASSOCIATED WQ PERMIT#
!if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential VMunicipatIPublic❑ Industrial ❑ Agricultural❑
' Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WE[ LLOC. TI
Nearest Town: d rl County (. Topo�oraghiclLand setting
f 3 Pei e>ti ❑Ridge Dope ❑Valley ❑Flat
p1 B+v A1'ct
(check appmpriac boxi
(Street Name,Nurnbcrs,Community,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location
3- OWNER: Sb<c.-2A yh 0 C7&h r4
(dcgrees:minutersxomis)
Address s Z tr 2 CIS p E Latitude/longitude source:❑GPS❑Topoemphic map
e _ (Sire tc No.) (check box)
DEPTH DRILLING LOG
try or Town State Zip Code From To
Formation Description
Area coda Phone ED —
4. DATE DRILLED-1- 2 _v s 17' / (��•�
5. TOTAL DEPTH: .O Z1 _ _
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑� n
7. STATIC WATER LEVEL Below Top of Casing: &0 -
(Use"+"i(Above Top of Casing)
3. TOP OF CASING IS FT.Above Land Surface*
•Top of cazine terminated atior below land surface requires a n
vurianm is uccordaum with 15A NCAC IC.oI1F.
9. YIELD(gpm):_L.2 METHOD OF TEST 4 1 AZ Cn
10. WATER ZONES(depth):_ 1Se'®af /r4 27 d
LOCATION SKETCH Ln
1 1. DISINFECTION:TypeALo Q,'dJC Amount D2 Show direction and distance in miles from at least
11 CASING: Wall Thickness two State Roads or County Roads.Include the load
From Depth Diarttctcr or Wcighttpi. Material numbers and common road names. 3 rd
To Ft.
From Tc 7y Ft. yo QfrUCt'W
From To ,7,�Ft._-(Q__�c� / )j)j l
13. GROUT: Depth Material Method
From /
From_d9 Tom Ft. R 1Z Aft"
14. SCREEN: Depth Diam ter Slui Size Material p Pe'rh" lU
From To Ft. in, in.
From To Ft. in. in.
15. SAN61GRAVELPACK: CoM�h"ti
Depth Size Material 1
From To Ft. tr
From To Ft.
16. REMARKS: In A 494()µ)
] DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUf�N STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
rnu �L
t SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No,[phone],within 30 days. GW-I REV.0712001

V
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section
w-ELLCONT"RACfOR(INDIVIDUAL)NAaIE (print)_ &4)7 ..( � �'S.FIGN CERTIFICATION
w'ELt.CON'I R.%CI'OR COMPAN'YNAME C� PHONE 8 ( )
STATE WELL CONSTRUCTION PERMIT4 ASSOCIATED WQ PERMIT#
— (ifapplicable) (ifapplicable)
B
I. WELL USE(Check Applicable Box):Residential '/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Use
2. WELL LOCATION: ��,t n n
Nearest Town: i DvCounty-YVt ' L TopograplftclLand setting
_ ❑Ridge LMlope ❑Valley ❑Flat
(check appropriate boxi
t5ocVt Namc.NatnhCrS,Commurnty.Subdivision,Lot No.,Zip Code) Latitudeilongilude of well location
3. OWNER: Qit)'Vi'r I y �o)'
Address t!tte �
' -C,l 1 L tdegrees'minutes7saonds)
'L- Latitude/longitude sourcc:❑GPS❑Topographic map
(Suect or Route No.)
DN W Q- Q, 1S 2. (check box)
DEPTH DRILLING LOG
City or TownState Zip Code From TO
Formation Description
Arcs code-Phone number �
4. DATE DRILLED 64 �2(c'ol­
5. TOTALDEPTH: 4S In �E� SAti
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO J
7. STATIC WATER LEVEL Below To of �a 2 5:
P g:��_FT.
if Above Top of Casing) r-'t
8. TOP OF CASING IS FT.Above Land Surface*
^Top of canine terminated at/or below land surface requires a
variance in accordance with 15A NCAC ZC.0118. CO
9. YIELD(gpm): dW METHOD OF TEST 2
10. WATER ZONES(depth): (7 —1 c7 J=
cn
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at leans"t
12, CASING: Wall Thickness two State Roads or County Roads,Include the mad
Depth Diameter or Weightl t- Material numbers and common road names.
From To Ft.
From To_��Ft. &'
From_•_Tq zJ— -A �
13. GROUT: Depth Material Method A�Al1L `
From To FL_ tT- �'�•
Front (9 To 40 FL Z L=, oct r
14. SCREEN: Depth Diameter Slot Size Material .:{si I h1 Ira
From To Ft. in. in. �pAr+ /
From To Ft. in. in. J
15. SAND/GRAVEL PACK: AP
Depth Size Material
From To FLpg1G.Wlr^'-
From To Ft. Jd
16. REMARKS
I DO HEREBY CERTIFY THAT IS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDA AND THAT A COPY OF THI CORD HAS BEEN PROVIDED TO THE WELL OWNER -
ATU E ON C STRUCTING THE WELL DATE
Submit the original to the Division of Water ality,Groundwater Section, 1636 h]sii Senice Ccntcr-Raleigh,NC
27699-1636 Phone Nm(919)733-3221,within 30 days. GW-1 REV.0712001
4�V'giv7z `y6 '-

3 pt (1 1
A i J
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section r tr'ELL CONTRACTOR(INDIVIDUAL)NAME (print) $+ry r�t dS41 (� CERT(FICflflATJON#215-0� y�
ELt.CONTRACTOR COMPANY,NAME _ TU ' 6cr LI-10C_Q1,rit," PH ONE # {�C� y�Y'�J 4`L'
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED wQ PERMIT#
!if applicable)
(ifa—Dpl/icablc)
1. WELL USE(Check Applicable Box):Residential EY Municipal/Public 10' Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. W ELL LOCATION: ��
Nearest Town: QL /"�' County CJ_'Gf'4' Topographic/Lan
Petting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
(Strcut Name.Numbers,-lmmunity,Subdivision.Lot No..Zip Code) Latitude/longitude ofwel l location
3. OWNER: US I' 1t I V It5f
Address (01 E fl j G)w t {' (tk'gte�slminut�/sxondr)
Laiitude/longitude source:❑GPS❑Topographic map
(Street or Roy)c No.) (check box)
DEPTH DRILLING LOG
Aly
Tow Sure ZipCodeFrom Toll �� Formation Description
Area code'
Phone number. -�r--- -„�----
4. DATE DRILLED to S
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑j NO 0'
7. STATIC WATER LEVEL Below Top of Casing: ,FT,
(Use•'+^iTAbow Top o(Cazing) '�'�
3. TOP OF CASING IS 2YZ FT.Above Land Surface* "'
'Top of curiae term re
terminated atfor below land surface quires a _3 -
variance in accardIHIM with ISA NCAC zC 4118.
9. YIELD(KPrn) _ METHODOFTEST�f�
10. WATER ZONES(depth):-/5'J &0,oi a
LOCATION SKETCH
11. DISINFECTION:Typ _lvf2/ a Amount � Show direction and distance in milw4ftin al-icast
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weighil t- Material numbers and common road names. A
Fromm
From Tom—Ft.
TO m !7 Ft — j ✓ �,. V
Fro To Ft.-
13. GROUT:
From Depth Material Method
Ft.
From 6 Tom _Ft
14. SCREEN: A 4,eA9�j -
4
to Dian£(r Slot Size Material
From To Ft. in. in. /
From To Ft, in_ in. a L }.�6 h+ f
CC
15, SAND/GRAVEL PA CK: 1
Depth Size Material
From To Ft.
From To Ft
•
16. REMARKS:
I DO HER CERTIFY AT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STAN RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S NA E O PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Senice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. 1
GW-I REV.07/20D1

&L r, i
WELL CONSTRUCTION RECORD
North Carolina- Depatiment of Environment and Natural Resources-Division of Water Quality-Groundwater Section
m\'ELL CONTRACTOR(INDIVIDUAL)NAME (print) 17 �.L/ "yj�.�(C� CERTIFICATION# 2i J
my ELL CONI RACTOR COMPANY NAME .)�{�+�-hG�ft-:�('�.� Q 'y-,(_( , yyp PHONE it
STATE WELL CONSTRUCTION PERMIT# ASSOCIA' EE %VQ PVQ PPERRN T#—
(ifa licable) (ifs licable)
L WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: OC D 4or + County t.(..C.. /'topographic/Land setting
1 , EIRiidge ❑Slope []Valley ❑Flat
��� r��slC O` �OiT checks—s] ..♦as C. ( appropriate box)
IStrcer Name, umbers,Com unity,Subdivision,lot No.,Zip Cale) Latitude/longitude of well location
3. OWNER: - O ' r (degrees/minutes/saonrls)
Address 1 �i�') �L1 Pn nn e r •nJ 'LY) Latitude/longitude source:❑GPS❑Topogmphicmap
(� (Street or Route No.) I (check box)
`- mac, •r ^i tsi - a rK 1a 1 • 100 DEPTH DRILLING LOG
City or Town stare Zip Code From To Formation Description
"�- goy- I 'gy- iOf
Area code-Phone number 4. DATE DRILLED_
5. TOTAL DEPTH: •? fi S� '7 D— r�— ('��R�/
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO U I-
7, STATIC WATER LEVEL Below Top of Casing: Je)_FT'
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface'
'Top of cusine terminuted attor below land surface requires a
variance in accordance with I5A NCAC 2C.011#.
9. YIELD(gpm):tea_METHOD OF TEST A/r2
10. WATER ZONES(depth): JOV arw � 2. S 0
rr
LOCATION SKETCH
11. DISINFECTION:Type Amount 02 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 Weiglol t. Material numbers and common road names.
Front rU To_,��FL t z!O kek
C�
From To_��FL _ eo 4
From To 7f^ Ft. fo /fj�j � A-
13. GROUT: Material Method Depth CO
p
From To FL Co
From_Q_To 2 FL_�j{¢/ [�^
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Siu Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C.WELL
CONSTRUCTION STANDS,.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
9 /6 6
SR5NATUVOF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Senice Center-Raleigh,NC
27699-1636 Phone No.(9I9)733-3221,within 30 days. GW-1 REV. 0712001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
N- t WELL CON-TRACTOR NAME (primp ("At%A ��)���� .�C (t CERTIFICATION# 31.�
WELL CONTRACTOR COMPANY NAME !Fi I jzl?�� D AJ'V i� PHONE i
STATE WELL CO.\'.9TkCCTION PERMITg —ASSOCIATED WQ PEItaIITa
(if applicable) — / (if applicable)
C/
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agdcultuml❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATj{QN: t Topo to/Land setting
NearestTown:J�]A7 pt Coumy- - Dew
-�-�'--' ORidge 12SIope OValley OFlal
(check apprapriate Im)
(Siren Name.Numbers,Community.Subdivision,Lot No"Zip Code) Latitude/longitude of well location
3. OWNE5:su " ( � )
Address I Mid�y Latitudetiongitude sotuce:00PSOTopographic map
�J L�4 t 11'ra or R No.) Q nl' e tt (check C �L'' �TJ� -(�I D- DRIRILLINOL00
�yorT wn sm�5 Zip Cade From To Formation Description
Area coda.Naata numbed
4. DATE DRILLED `1"1` 0 S
5. TOTAL DEPTH: 6 to 4' �
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO [3/
7. STATIC WATER LEVEL Below Top of Casing: FT. 8 -
(Use"+"if Above Top of Caine n
3. TOP OF CASING IS E FT.Above Land Surface*
'Tot of ca tam termlaucd at/or betas had awtua n%uirn• cA
varlaoee in aenrdasm with I5A NCAC 2C All&
9. YIELD(Spin): _METHOD OF TEST 1 N Ln
10.WATER ZONES(depth):_ l i p p (Q 500
LOCATION SKETCH '
IL. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wa1l7Licknew two State Roads or County Roads.Include the road
peprb Diameter 0r W d03%J?L Mate" numbers and common road rmrrtea.
From To FL
From
To�Ft. MtvY
13. GROUT: Depth Material Method
From To FL ac S
From_To Ft. t�P<-
14. SCREEN: Depth Diameter Slot Sim Material W`✓,
From To FL in. in.
From.—To_Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
FTmn Tc Ft
16. REMARKS:
1 DO HEREBY CERTII'Y THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTR CTION STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON.CONSTRUCnNGTHE WELL - DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
27699-16.16 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD W 31056 ,
North Carolina Department of Environment andannd Natural Resources-Division of Water Quality
- �}
WELL CONTRACTOR(INDIVIDUAL)NAME (print)_ )L we 5 k) ' Cu-WTf Q CERTIFICC7ATION#.
WELL CONTRACTOR COMPANY NAME LGf_WI�� JD /N�HONE # CL2 �5 �i — 7zr,,j�
STATE WELL CONSTRUCTION PERMff# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential ❑ Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topopoic/Land setting
Nearest Town:
Coun1ty ❑Ridge MSlope ❑Valley ❑Flat
C
,\.4�.l]IlI� `'DIA W _ J (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
1
3. OWNER: Cn
pp et Q PLS , (degrees/minutes/sewnds)
Address B ' E' V _ Latitude/longitude source:❑GPS❑Topographic map
eet ute No. (check box)
0 yt C DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Ar(m code-Phone number
4. DATE DRILLED s S.
DEPT
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO [A
7. STATIC WATER LEVEL Below Top of Casing: too T.
(Use"V'if Above Top of Casing)
8. TOP OF CASING IS_�FT.Above Land Surface'
`Top of casing terminated st/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): MF $0�OF TEST (]A`A
10.WATER ZONES depth): _
LOCATION SKETCH
11. DISINFECTION:Type CM Amount _ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept DeptL Diaaaaaaµµµ��tuttttteter or igh tl Material nun ers and common road names.
From To Ft. � �2� ��
From To Ft. �,tJ ( __
From To Ft.
13. GROUT: Deptiy- atedal Method
From To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: v `; LJ. 25,
Depth Size Material
From To Ft. IV
Ui
From To Ft.
O
VI
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
p�rn.n 4- 1�-DS
SIgiNATU OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Ma}it$fwiie,CetiterPi r.,
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-I REV.09/2004
MAY 2 2005

os1 l 310560
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality p
WELL CONTRACTOR(INDIVIDUAL)NAME (/p -pQ a me S 0 . cama
--�r+'� CERTIFICATIONMZ2/4d
WELL CONTRACTOR COMPANY NAME CRi✓n OS L' P � 4YgI0 . 1ViGPIlONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential lk�Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest owrs�Af�- ,rn _Coon Midge ❑Slope Otebox) Flat
�-1.Q.O IO ,,,� 1�- �.(� (check appropriate box)
(Street Name,Numbers,Community Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER: — U;;re.E'r( pQ-Ir�G Yt5l (degrees/minutes/sewrds)
Address e YY6tC.a Latitude/longitude source:OGPSOTopogmphic map
PY htreet or Rollie No.) (check box)
o✓A t,YL i C a?) 3 9 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? YESL p NO ISI
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
-VIA uzzt
(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 accords re with 15A NCAC 2C.0118.
9. YIELD(gpm): J METJi.QD OF TEST_ U 6-
10.WATER ZONES(depth): I kA S
LOCATION SKETCH
11. DISINFECTION:Type _ Amount Show direction and distance in.miles J
12. CASING: Wall Thickness two State Roads or County Roads.Inc
Depth Di eter o igh I. Material numbers and common road names.
From To Ft.
From To Ft. t . 1
13. GROUT: Depth a[edalA �m (Method W `
From_To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. a
From To Ft. in. in.
15. SAND/GRAVEL PACK: +r
Depth Size Material l f11
From To Ft. O
From To_ Ft. c.rl
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCO ANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center.- -—.-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
;I
G�:�:iiJlirvrlt" ;r.OiIDN
nour�al t t RFIaJ;�ri trriv�

VW 308504
WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: MARION County MCDOWL Topographic/Land setting
LESTER HOLLIFIELD RD. ❑Ridge ❑ Slope ❑ Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER: MARTY SMFI'H Latitude/longitude of well location
Address LESTER HOLLIFIELD RD.
(Street or Route No.) (degreestminutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
8(�8)—925-7367 DEPTH
Area Code Phone number From To
4.DATE DRILLED 02/18/05
5.TOTAL DEPTH: 285 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated attor below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.011& Two State Roads or County Roads. Include the road
9. YIELD(gpm): 100 METHOD OF TEST ARD number and common names
10. WATER ZONES(depth): HWY.#226 N.FROM MARION.IN WOODLAWN.
TURN LEFT ON LESTER HOLLIFIELD RD.
11. DISINFECTION: Type CHLORYTE Amount 6.5 (BESIDE PEPSI PLANT) 1/10 MILE ON LEFT.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 160 Ft. 6-1/4" SDR.21 PVC
From_To_Ft_
From To Ft. _
13. GROU_Depth_ _Material Method '.
Fmm 0 To 20 Ft.OUHCRETE POURED N
From To Ft. _.
14.SCREEN: Depth Diameter Slot Size Material W"
n
From_To_Ft._ in. in. t
From To_Ft._ in, in. `' �
15. SAND/GRAVEL PACK: O
Depth Size Material cn
From_To_Ft
From To Ft.
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Jr
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

t s'
WELL CONSTRUCTION RECORD
Nor.S;Carolina-Department of Environment and Nag Resources-Division of
oof.//i��d,atter Oulntpity-Gzuwm water Nceuu-.: �`//
WELL CONTRACTOR(INDWMUAL)NAME (prink).f //L//-_-_Sexu(_�C 2�!n_ CERTIFICATION# 79
w ELL CONTRACTOR COMPANY 7VAn:>,acgwA-T*c (Jej( nr: l ikAn PHONE M
STATE wE:LL CONSTRUCTION PERMITS_ .,_.-_--ASSOCIATEDWQPERNaTt:
ifa licable if Ift'ahle
1. WELI.USE(Check Applicable Box):Residential V Mtnicipal/Public G.7 Industrial O Agricultfiral C] ) o
Monitoring Ct Recovery ❑ Heat Pump Water Injection CI Other Ci If Other,List
2. WELL LOCATION: / Topog�ic/I.and stetting
-T -
N stown: e County/Y7GQhWQl� ORidge SSl_ope OValley Oflat i t
(Street Name,Numbers,C«nwunity,Subdiviam Lot No,74 Code) Latitudellongitude of well location
OWNER: X
3,id.ess �--[7j Larsude(longitude source:0GPSCTopcigra{rhir .;eP
(Sveet a Ro nc No.) (chest twit
)ye& NG Z276 oEI-IH uPJLL:.NG LOG
Cay or To State zip Cote From To Formation Description
,4rm code-Phone aambet
4. DATE DRILLED S•1 Z $ -- —
5. TOTAL DEPTH:_-Z 7r 1 __ `?
6. DOES WELL REPLACE EXISTING WELL? YES L7 NO L� � --
using: -._FT.
p ,• Fi -.hbovc Top of Casing) ;}
.., _�, q _ 1 711uve Land Surfaces
PS cH3b t "9Rt:%t4Lfi A�nI}r:k�rer m 7..TYSR{ct reafnfraa a _"— � —
varfanee In accordance wftb ISA NCAC 2C.01l$. Jr
9. YIELD(gpm): METHOD OF TEST,,,��,.rr,�_
10. WATER ZONES(depth): — _— -
_ j,O,�ATTON SKETCH
11. DISINFECTION:Type—�',C1 -_^ Amotmt �D OT Show direction and distance in miles from at least
11 CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth _ rerr or Wet t/Ft. Material numbers and common road names. kN-,
Frotn��To__5�Ft_�-
From , To-_Ft---
Ft om To Ft.,__ �
13. GROUT: Depth Muter al M od
From_Tom Ft1G!44 _Sd2 ,Ji1/_r
From_ To Ft
14, SCREEN: Depth Diameter Slot Size .Material
Frorn To.—Ft._-in. in. r
From To-_Ft—.Tin. —� in. I /N
15, SANDIGRAVELPACK:
Depth Size Material
Front To Ft. _
From-—To Ft._ _ s
16. REMARKS:40g -rx,5fi_j 6—xz— ---- (�l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELI,
CONSTRU MON ST,kNDARDS D THAT A COPY OF S CORD BEEN OVIDED TO VHE.WELL OWNER
----- — --- L � �_C_ _5 E ' —
IGNATURE OF PERSON CONSTR CTING 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 Euvironment and Natural Resources-Division of Water Quality-Groundwater Sectio€,
WELL CONTRACTOR(W3)IVfDUAL)NAME (print) -49og? e /C kido.S .�r,�� CERTmCATION t1{y.5.ar
WELL CONTRACTOR COMPANY NAMS."GtTtafA-Ti (t I. Jell QP:1 I,119 PHONE
STATE WELL CONSTROCTION PERMrrtt ASSOCIATED WQ PERNIM
(if applicable) ":' (if applicable)ORIGIN
- —
1. WELL USE(Check Applicable Box):Residential ff Municipai/Public❑ Industrial❑ Agricultural 0.1
Monitoring O Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Tirpo dLand setpiag
Nearest Town,�1 /t/C961J Co GfYoG✓B �a�1
11q 05we Tone��2r( y�—� �iage (chock a�O�ebox) j
(Snag Name.Number,c,6a a uw.Sabdimoo,Lot No, opgi tat
_... _:-: --
/ zip code) Lat<tudr/I tulle of well 1
3. OWNER: m CsOd��
Edotpeahumiroer/aemed+) O '.� ),:'
Address Za/a( ( To/7t 3 LatitudeJ)ongitude aotuce:OGPSOThic dg�p
(Sereef u xbme No.) (dw*box) ri
DEPTH DRUING LOG
City or Town state zip Code From TO Formation Description
Arch code-Phaoe muaber _
4. DATE DRILLED -4 - �Y-O S
5. TOTAL DEPTH, 727-S /
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO a� Vo
7. STATIC WATER LEVEL Below Top of Casing: !K0 FT.
jUw"+"ifAbove Top of CubW
8. TOP OF CASING IS 1-5 FT.Above Land Surface*
'Top of cadea terminated stfw below tend anrfaee requires a
vaNaom In accordance with 15A NCAC 2C.0116.
9. YIELD(gpm):_$_METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type a Amount /D oL Show direction and distance in miles from at lean
12. CASING: der Wall Thiciwms two State Roads or County Roads.Include the road
FronL�To-o, � or[s n•s retght/Ft rum and common mad names. `I
—4 Ft F
From To Ft _
From To Ft err
13- GROUT: Depth Material M
From Tom_Ft. 'Ca(,K/le _Wed
�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material OO ✓
From To Ft in. in.
From To Ft in. in. 3
15. SAND/GRAVEL PACK.
eu, ah1
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT WELL WAS CONSTRUCTED ACCORDANCE WrfH ISA NCAC 2C,WELL
CONSTRUCTION STANDARD THAT A COP F S RD HAS PROVIDED TO THE WELL OWNER
r
SIGNATURE OF PERSON CONSTRUCfNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

V)
WELL CONSTRUCTION RECORD
North Carolina-Dopartment of Environment and Natural Resources- ' 'Di` n of Water Quality-Groundwater Secuof,
WELL CONTRACTOR(INDMI)UAL)NAME (Print)&Jen C ,� sf�p'{ l�n o _ CERTTFICATION x Z Z S'Y
WELL CONTRACTOR COMPANY NAMs.e�(sJS�.,Tt�A-T�e{` t��� PHONE M ( j� 'OIIYO
STATE WELL CONSTRUCTION PER61M A—OCIATED WQ PERMTT%
(ifaonlicable) (if applicable)
1. WELL USE(Check Applicable Boa):Residential LT MunicipaUPublic O Industrial❑ Agriculaual El r'
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION:
Nearest Town: P"401'aaJ County / TDp°8�dseyi
_ !?4 Dr •+ ✓✓ Furls /Zd 7 876 4 midge I°P° OVallry OFlat
(Street Name Numbers,tommuoity.Subdivoo4 tat No.,
z+P Cam) LatittdcAongitude of well location'
3. OWNER;& ( 1 A/—
/ C Cp S77 (angles m nuoestaemnds)
Address ev . dAe s Latitudellongitude sowce:C3GPSOToppgt8phic ma
(Sereet or Na.) (dreci box) p
I�l�9NiastJ DLO 2$7 j 5 pgg (�2S
City orTanvn seen zip Co& From To Formation Zkscription
Am Bodo-Phone number
4. DATE DRILLED O 5—
S. TOTAL DEPTH: _
6. DOES WELL REPLACE EXISTING WELL? YES O NO @�
7. STATIC WATER LEVEL Below Top of Casing:__gggQ_ET.
r (Use"+"if Above Top of Cuing)
&. TOP OF CASING IS -j $_ FT.Above Land Surface-
eaop of eaalaa eermiuMed war below lend surface requires x
vwlaaee in aeeordanee with 1SA NCAC 3C.a1IL
9. YIELD(gpm): :5 METHOD OF TEST mt
10. WATER ZONES(depth):
L(�(.ATION CK,�H
11. DISINFECTION:Type Atttotmt /O_e� Show direction and distance in miles from at least
12. CASING: Wall Thielmess two State Roads or County Roads.Include the road
From_ TDepth
off_Ft� a��jR ?I c U C numbery�nd commonnames.
•
From_ _,�To Ft
From To Ft. O
13. GROUT: Depth Material M Iep -
From To FL C� CPC S Je /sti `�C
From To Ft
14. SCREEN: Depth Diameter Slot Sine Material
From To FL in. in cs
From To Ft. in. in. �
15. SAND/GRAVEL PACK c
Depth Size Mate ial x
From To Ft. p
From Tc Ft.
o
to
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCjED IN ACCORDANCE WITH 1 SA NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A F RECO BEEN PROVIDED TO THE WELL OWNER
S-,3—Q
SIGNATURE OF PERSON CON U NG 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

� o
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2138
1.WELL CONTRACTOR: f. DISINFECTION:Type chlorin e Amount Ca
James W. Camn g. WATER ZONES(depth):
Well Canractor.(IndlvidUal)Name From To From To
Camp' s Well & Pumper- Tnc_ Fran To From To
Well Contractor Company Name Fran To From To
STREETADDRESS P O BOX 429 6. CASING: Thickness/
Depth�/T DWw��ller WdDht Material
Ellenboro NC 28040 Fran 0 To�Ft�_ SDR21 PVC
City )rTavn State Zip Code Fran Tc Ft. _
( 828> 453-7322 Fran To Ft
Area code• Phone number 7. GROUT: Depth Material Method
2.WELL INFORMATION: From_j To 20 Ft Sackrete Hand
SITE WELL ID#Of applicable) From To FL_
STATE WELL PERMIT#(Napplkeble) Fran . To FL
DWQ or OTHER PERMIT#(If applicable) S. SCREEN: Depth Diameter - Slot Sim .Material
From To Ft._in. _In._
WELL USE(Check Applicable Box): Residential Water Supply❑ From Tc Ft_in. —In.
DATE DRILLED L L-.21-OS From To Ft_In. _In.
TIME COMPLETED L DC AMO PM[ar' 9. SANDIGRAVEL PACK:
7.WELL LOCATION: Depth Site Material
�fl, From _ To Ft.
CITY: AY 1 ho 1- COUNTY c UD U,l e l Fran - Te Ft.
ink it I E - From To Ft.
(Street Nama.N bars.Canmunity,SubtliNsbn,La No.,ParcaL.Lp Code) . .
TOPOGRAPHIC I LANDS ING: 10.DRILLING LOG _
❑Slope oveley OFlal WIdge ❑Other F om To <a/1� n Description( May to is
s.
LATITUDE � minutes.
."�a
in a decimal rormat
LONGITUDE �e � •�� ti'r1' AD-5 S arid. ro z.K
LatitudeAongitude source: OGPS OTopographic tnap -
(location
shown
GS fopo map andoechedo fhllost lrust be o GPS
4.WELL OWNER
OWNER'S NAME Q-
ST ADDRESS a^
a
City orTown Slate Zip Code
Area code- Phone number 11. REMARKS:
5.WELL DETAILS: h ^�
a. TOTAL DEPTH: owl/
b. DOES WELL REPLACE WASTING WELL? YESO NO _
,{{ I DD HEREBY CERTIFY THATTNIS WELL WAS CONSIRUCIED IN ACCORDANCE WITHe. WATER LEVEL Below Top of Casing: _ `TL FT. 1SANCAC 2C.WELL CONSTRUCTION STANDARDS,ANDTHATACOPYCF THIS
(Use'+'I Above Top of Casing) RE D HAS BEEN PROVIDEDTOTHE WELL OWNER
d. TOP OF CASING IS 1 FT.Above Land Surface Ll.
'Top at casing teeminated at/or below land surface m@y require SIG TUBE OF CERTIFIED W ELL CONT CTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
METHOD OF TEST I r ames W Camp
e. YIELD(gpm):� PRINTED NAME OF PERSON CONSTRUC
Submit the original to the Division of Water Quality within 30.days. Attu: formaA( EIVEDFaro w-1a
1617 Mall Service Center-Raleigh,NC 27699.1617 Phone No.[phone] t 66g. FEB �7 2006 Rev. 5
Asheville Regional Office
A...riser PrntrA.MiD�

n � ..
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
Q om. WELL CONTRACTOR CERTMCATION q 21 38
1.WELL CONTRACTOR' I. DISINFECTION:Type chlorine Amount
James W. Camp g. WATER ZONES(depth):
Well Ciontracta.(Indlddual)Name From TO�_ From To
Camp' S Well & Pump Co- Tnc_ From Tc From To
Well Contractor Company Name From To From To
STREET ADDRESS P 0 BOX: 429 6. CASING: Thickness/
Depth � Diaieter Wei hl Material
Ellenboro NC 28040 Fran 0 ToI p�Ft. 6a SM1 PVC
City or Town State Zip Code Fran Tc Ft _
( 828). 453-7322 Fran Tc Ft. _
Area code- Phone number
7. GROUT: Depth Material Method
2,WELL INFORMATION: From 0 To 20 FL Sackrete Hand
SITE WELL ID#(If applicable) Fran Tc R
STATE WELL PERMIT:r(R applicable) From To FL
DWQ or OTHER PERMIT#(if applicable) B. SCREEN: Depth Diameter Slot Size .Material
WELL USE Check Applicable Box): Residential Water Supply Er Fran To FL In. _In..
( _ Fran To Ft. in. —In.
DATE DRILLED ) L- L 1 C1 Ca From To FL In- _in.
TIME COMPLETED h 0 AM O PM Gr 9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Slur Material
Fran To Ft.
CITY`: �)A A r\l sMt COUNTY G ,Q� Fran To FL
From To FL
(Street Name.Nu_mben.Community b2Lv1&m Lot No.,Parcel:Zip Cade) . . ..
TOPOGRAPHIC/LAND SETTING: 10.DRIWNG LOG
2Sklpa OValley OFlet ORidge ❑Other From .To. F{o-rmation escriptbn
(check apprW&1a 1104 . 0 ' I Y I Y San
MAY be I,ae>Qeea„
LATITUDE -5— x miwtel,tewMsor
e— e-� 1 C O in a decimal brunt
LONGITUDE .:]d-J..a1+LLt� [ %zNSAI IrIai e A YfSTT._...
Latitude/longitude source: VCPS OTopographic map
(location o/wet must be shown on a USGS tope map and r-
attached to this form►not using GPS)
4.WELL OWNER N
OWNERS NAME ""R"'^-2j-
�.
STREET ADDRESS to
ft C- IZ 13
City or Town State Zip Cale
Area code- Phone number -
11. REMARKS:
S.WELL DETAILS: tt11 cC'
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NOIlk
1 DO HEREBY CERMTHATTHIe WELL WAS COMMUCIED NACCORDANCE WrrH
c. WATER LEVEL Below Top of Casing: SC) _FT, 15A NCAC 20.WELL CONSTRUCTION STANDARDS,ANDTHATACOPY OF THIS
(use•+•.yAbove Top of Casing) RE HAS BEEN PROVIDEDTOTHE WELL OWNER t
d. TO O�tt
.P OF CASING IS 1 . FT.Above Land Sudaee• �i � V L
. -Top of easing terminated aVor below land surface May require SIG NTURE OF CERTIFIED WELL COUTRACTOR DATE
a variance in accordance With 15A NCAC 2C.0118. I
e. YIELD(gpm):, "�METHOD OF TEST Q 1 A AT Imes W. am
PRIMED NAME OF jERSON LL
Submit the original to the Division of Water Quality within;30,days. Attn:In ation M1Merp. ] 2�06 Fr c Is
1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.(919).733-7015 ext 68. Rev.no
ASheviile Regional Office
A uifer Protection

ti Ii1lI C 316g ? ,
WELL CONSTRUCTION RECORD
j North Carolina Department of Environment and Natural Resources-Division of Water Quality-
_WELL CONTRACTOR QLMIVIDUAL)NAME (print) Jame,- W_ Camp, CERTIFICATION 21 38
_VvEI4ciRAcpoRtomPANvNAME Camp' s Well & Pump_ , Tnr� PHONE a 92A esi_: 22
STATE WELL CONSMUMON PERMITB ASSOCIATED WQ PERMITB
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ❑ MunicipaUPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Q � Topogr�Rphic/Land setting
Ne estTortmh ( /�.A.a.'h^ County CV�OJJ ORidge IVSlope OValley OFlat
(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:OGPSOTopographic map
-7 Street r Rote o.) (check box)
IV C _-;?E )3 DEPTH DRILLING LOG
City or Town - State Zip Code From To Formation Description
(Am 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:�FT.
(Use"+"if Above Top o Casing) -b
8. TOP OF CASING IS 1 FT.Above Land Surface* r 3
-Top of casing terminated attor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. r-f
9. YIELD(gpm): OD OF TEST i t Ln
10.WATER ZONES(d �(�
LOCATION SKETCH
11. DISINFECTION:Type Ch.t r iri na Amount cShow 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 comm road
From_p_To�Ft. 6 1 /4 Sdr 91 - PVC 1
From To Ft.
From To F[.
13. GROUT: Depth Material Method
From__D_To 20 _Ft. Neat Pm ant HanA �a
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From Tc Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. IJw
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
`t • 1 �. bS
SLgNATURE 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 31681 ,1
. : ,North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ,3am P g W_ C`a m CERTIFICATION#
j rWRLLCONTRACTORCOMI'ANYNAME Camp' s Well & PUMp CO- r Tnr PHONE # Q7A 451_7322
STATE-WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMrr#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential%V'Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT,,,InnnOAAAN: ` (� � n eopographic/Land setting
N est own: Counq O L wj' dge ❑Slope OValley OFlat
ILk M UIPAY (check appropriate box)
(Street Name,Numbers unity,Subdivision,Lot No.,Zip Code) - Latitudellongitude of well location
3. OWNER: ` o (degrees/minutWseconds)
Address nllf m. - Latitude/longitude source:OGPSOTopographic map
treet or Ro rte NoJ (check box)
g 5 DEPTH DRILLING LOG
City or own State ' Zip Code From To Formation Description
Area de-Phone numbeQ — r
4. DATE DRILLED
5. TOTAL DEPTH: LA— _
6. DOES WELL REPLACE EXISTING WELL? YES O NO ❑ 73S q0_ I -
7. STATIC WATER LEVEL Below Top of Casing:_U T. -
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface* cn -
•Top of casing terminated atlor below land surface requires a `^ `
variance in accordanctwith 15A NCAC 2C.011& N "�
9. YIELD(gpm): METHOD OF TEST _r r I
10.WATER ZONES(depth):
LOCATION SKETCH Utz
Show direction and distance in miles from at least
11. DISINFECTION:Type(�h3-rtrina Amount -1
12. CASING: Wall Thickness two State Roads or County Roads.Include the d
Depth Diameter or Weight/Ft. Material numbers and common road names.
From�_To Ft. 6 1 /¢ Sfir 21 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From_(_To�_Ft. Neat CPmant Rana
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From I To Ft. in. in.
From To Ft. m. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To F[. is
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIO TANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNE
/ 6. t�-
SIGIIATURF 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

.. -.._._.. -.
oilp
WELL CONSTRUCTION RECORD 31 `3
North Carolina Department of Environment and Natural Resources-Division of Water Quality
'WELL4'ONMACfOR(INDIVD)UAL)NAME (print) Tam a W- ramp, .71 - CERTIFICATION# 213
wELLCONTRACCORcoMPANYNAME Camp' S Well & Pump Co- , Tnn_ PHONE # R7A dSz_7�22
STATE WELL CONS1RUCrION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential.(],*IMunicipal/Public❑ Industrial❑ Agricultural❑ _
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT1_0 � � oo - Topographic/Land setting
Near tTo Ian: � % County�l,J) ORidge ❑Slope bailey OFlat
=e ( , AQ t � (check appropriate box)
(Street Name,Numbers,Community,Subdivis'on,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds) -
Address - ley, YA C e Latitude/longitude source:0GPSOTopographic map
,i or hNo.) �/ C. (check box)
N 2 r Y `�„„ ` DEPTH DRILLING LOG
City or Town State 'ter Zip Code From To _ Formation Description
Area code-Phone number pp (�
4. DATE DRILLED - l0
5. TOTAL DEPTH: gg _
6. DOES WELL REPLACE EXISTING WELL? YE NO CT —�
7. STATIC WATER LEVEL Below Top of Casing: FT.
(1se"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface's rT"t
*Top of casing terminated after below land surface requires a
variance in accord nee with 15A NCAC 2C.0118. L-� -
9. YIELD(gpm): 1 �� ME W OF TEST Iir
10.WATER ZONES( [`� r n
LOCATION SKETCH
11. DISINFECTION:Type Ch 1.n i n e Amount Show direction and distance in miles from at least'la
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common roAname,
From_To��Ft. 6 1 /4 S ci r 71 vvr
From TO Ft.
From To Ft.
13. GROUT: Depth Material Method `
From�_To�O_Ft. Neat Cement Hand From To Ft.14. SCREEN: Depth Diameter Slot Size MaterialFrom 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 AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
T 16 D �
SO4ATURE OF PE ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Tam a Gr C'am r Jr CERTIFICATION#-24-18
WELL CONTRACTOR COMPANY NAME Camp' s We11 & Pumper Tnr_ PHONE # AJA 453-7322
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITN ' t --
ifapplicable) if applicable)
-
111100000000
1. WELL USE(Check Applicable Box):Residential W Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATIO TopoggrSIPhic/Land setting
NearestlITown:. 0.YJ011 County( ORidge 081ope OValley OFlai -
t7) P h ) 61 ��p ? �-o f �c r (check appropriate box)
(Str�ame,Numbers,Community, iibdrvremn,Lot No.,Zip C(ide) Latitude/longitude of well location
3. OWNER: r I Zz't1. e c (degrees/minutes/seconds)
Address 21- a✓ - Latitude/longitude source:OGPSOTopographic map --—
}} 1 (Street or outs N.°.) - - (check box) _ -
/�ICYpd i+ �C Y( A/C DEPTH DRILLINGLOG
City or Thm State Zip Code From To Formation Description
Area code-Phone number _ S 1� �Sa
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO E'F
7. STATIC WATER LEVEL Below Top of Casing:_�r _FT. '
I(Um"+"if Above Top of Casing)
S. TOP OF CASING IS 1 FT.Above Land Surface*
-Top of casing terminated attor below land surface requires a N
variance in accurdan a with 15A NCAC 1C.01IS.
9. YIELD(gpm): _METYOD OF TEST­q. C3 y.
10.WATER ZONES(depth): 4'D
LOCATION SKETCH
11. DISINFECTION:Type Ch 7:crr i n a Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness h+'o State Roads or County Roads.Include the roa ^�a K, r
Depth Diameter or Weight/Ft. Material numbers and common road names. !°f
From_ToJ-L5 Ft. 6 1 /4 Rd r 21 P17C 6 5-
From—Tc Ft.
From To Ft. U'
13. GROUT: Depth Material Method
From___0_To--20-_Ft. Neat Cemarit Rand
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material \From To Ft. in. in.
From To Ft. in. in. 2�
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 COPY OF THIS REC07 HAS BEEN PROVIDED TO THE WELL/OWNER
SIGNATU OF PERSON NSTRUCTING 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 308309
North Carolina Department of Environment and Natural Resources-Division of Water Quality i
WELL CONTRACTOR(INDIVIDUAL)NAME (print) A h9 C 5 i CA hi
'7' CERTIFICATION 4 �t
WELL CONTRACTOR COMPANY NAME Cl�,p't A S We I� � � O i TNI L, PHONE It (8),% q 53-2 -2 a
STATE WELL CONSTRUCTION PERMITH T— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential V�-Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
NewestTwn: County !� C- WJJ [kidge ❑Slope ❑Valley ❑Flat
� l-UC f- G Q (check appropriate box)
(Street Name,Numbers, m Comunity//,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: pp') I' I,YDI.ia (degrees/minutes/seconds)
Address 4560 DAIC Fa Latitude/longitude source:❑GP$❑Topographic map
(S or (check(check box)
n�
[°I o Y AKTC K DEPTH DRILLING LOG
City or Vorn state Zip Code From To Formation Description
L—)
Area code-Phone numbir
4. DATE DRILLED
5. TOTAL DEPTH: Z LC
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Et A
7. STATIC WATER LEVEL Below Top of Casing: U(Jl T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* ry
"Top of easing terminated st/or below land surface requires a
variance in according with 15A NCAC 2C.0115. ee
9. YIELD(gpm): IJ METHOD OF TEST ��n
10.WATER ZONES(depth): 11)()
LOCATION SKETCH A
11. DISINFECTION:Type Amount--'-�"�t— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the roa
tt,, Depth Diameter or h t. Material numbers and common road names..
From lJ To ID�i Ft. Ly, rgA / \ICIC
From To Ft.
From To FL
13. GROUT: Depth tenal Method \�
From_To�Ft.
From TO Ft. Ae�l�t CCYylp rt"� �klk VIA
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. n
From To Fts in. in. (j-
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. y'I)�,✓�'I'�/
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S- s
�rNAMIRE 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.
G`A1 2 192005

WELL CONSTRUCTION RECORD 308310
North Carolina Department of Environment and NatuIra1l Resources-Division of Water Quality
WELL CONTRACTOR(INDWIDUAL)NAME (print) J4L h9 e5 �J- C0.1blO -r-r--''Y CERTIFICATION# �)139
WELL CONTRACTOR COMPANY NAME Cd M 4 5 r.I 1 4 L)itM IQ .lJl C. PHONE # ��) rI S7i-73��
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential t?-Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: A A Topo�g�raphic/Land setting
Nearest Town: "f C unty C ❑Ridge HSlope OValley OFlat
`L.O a I S l- (check appropriate box)
(Street Name,Numbers,Community c b +a..- r-t No.,Zip Code) Latitude/longitude of well location
3. OWNER: t F't,e �O 1,J C. 1 C=J(G r,L.,CI (degrees/minutes/seconds)
Address 11R//� Da le- a^ tkvt Qi�. Latitude/longitude source:DGPSOTopographic map
-Street or Ro�u%No. __ - (check box)
a✓radt�pn !V C- -a S DEPTH DRILLING LOG
City or Tai0n state zip Code From To o mation Description
C—) U
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH: - 0 )3
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9
7. STATIC WATER LEVEL Below Top of Casing: 4 (t T.
{ (Use"+"if Above Top of Casing) �7
8. TOP OF CASING IS 1 FT.Above Land Surface*
t
"Top of casing terminated attor below land surface requires a co _
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):I() ME O b OF TEST U(A ti O
10.WATER ZONES(depth):
ar
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 ei h t. Material numbers and common road names. QA aAA^T
From To_\4_Ft. V
From TO Ft.- — pJG
From To Ft.
13. GROUT: Depth Material Method 1
From 0 To go Ft. qeat Or mr NA rtA
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material R
From-TO-Ft.-in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To F[.
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
:1- 11& US
GNAT MqfOhtkFRSON 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
LIAR 21 2005

WELL CONSTRUCTION RECORD 3 1 2 0 3 3
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME/(�p�rhA) a 1
J me 5 , �A-VV1 CERTIFICATION
'#,�I3 �
WELL CONTRACTOR COMPANY NAME t—N W1.A5 kic 11 tL 0 PHONE # (1r1.C1'f").J'7'3o2a
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
10011 (if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential U-'-Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT ON: I� Topographic/Land setting
Ne est (Town: M County �C`I (tu)Q��` Wdge ❑Slope ❑Valley ❑Flat
\xA a f. 10 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: , (degees/minutes/seconds)
Address f. E - Latitude/longitude source:❑GPS❑Topographicmap
�L (Stqe�t or o N0. (check box)
t.L 7 t eY�o Y c a 8 3 DEPTH DRILLING LOG
���''p�ity or Town State Zip Code From TO f\ Formatio Description
(a- ( s) -�3886 V Q
Area code-Phone number
4. DATE DRILLED �U �
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [ ,
7. STATIC WATER LEVEL Below Top of Casing:__Wb FT. .6
(Use"+"if Above Top of Casing)8. TOP OF CASING IS ` FT.Above Land Surface* < r
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. O
9. YIELD(gpm):,O _METHOD OF TEST
10.WATER ZONES(depth):_ \,Ob
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.Inch e e road
Depth Diameter or Weight/Ft. ater al numbers and common road nam
From O I U FL t. S� 'J, "
From To Ft.
From To Ft.
13. GROUT: Dep Materi ethod p
From_To ',Lb Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material ,
From TO Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.-
From—To—Ft. t�
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 `---- ---
IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV:09/2004

310562
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality qq
WELL CONTRACTOR(INDIVIDUAL)NAME/J�print) h,P S CERTIFICATIION# rh 3
WELL CONTRACTOR COMPANY NAME L G(kyt E C PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W Q PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ❑ Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �^^ (� o Topographic/Land setting
Near t Town:: County!�/t c g3117 JA ORidge &(Slope OValley OFlat
t'\A \IIM f1 W :16 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) LatitudeAongitude of well location
-'3. OWNER: J` t 01. Q (�h5yI1 � (degtees/minutesheconds)
Address g�`� 9 e—Y a c. 2 q Latitude/longitude source:OGPSOTopographic map
R a I f Y(7PeYllr 1 V o) ! V 2.9 1J 1 (check box)
DEPTH DRILLING LOG
City or Town State - Zip Code Frogs Tn anon escription
U- I\ L
Area code-Phone numbeF,
4. DATE DRILLED $
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE411 NO S
7. STATIC WATER LEVEL Below Top of Casing:_0 T.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
-Top of casing terminated attor below land surface requires a
variance in accordan,cre,with ISA NCAC 2C.0118.
9. YIELD(gpm):__J_l� OD OF TEST
10.WATER ZONES(depth): o�l�Jr
LOCATION SKETCH
11. DISINFECTION:Type_ Amount k Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dept D. iapieter o igh t. M-ylgtiy( numbers and common road names.
From To c
0 Ft
From To Ft. 2 V
From To Ft.
13. GROUT: Dept Material Method
From To Ft.
From To Ft.
14. SCREEN: Dept Diameter Slot Size Material ( �.
From To Ft. in. in. tV
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Dept 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
CONSTRU ON STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- Is _ 65
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Seftiee Center____-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
MNW-1 2E`�P52004

W-19 lS_l 1G !
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality_
WELL CONTRACTOR(INDIVIDUAL)NAME (print)—I`amec W_ ramps ,Tx CERTIFICATION#_2_J_M
WELLCONTRACTORCOMPANYNAME Camp' s Well & Pump CO- r Tnc _ PHONE # 62 45_ _ 22
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 1111"iviunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Neare�st T��o�w�n^: .. a 'N�n County_ .0 �Rldge ❑Slope OValley OFlat
l� C 1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudc/longitude of well location
t� ^1
3. OWNER:GA (I I 'i Y\C (degrcesrminutes/secvnds)
Address 19 1 MAre rY, 14 a Latitude/longitude source:[IGPSOTopographicmap
t (Str_ee jor Route No- / (check box)
N e h o I V C— ;29 74 I DEPTH DRILLING LOG
City or Town State Zip Code From
m 1To� FrQr�matloyp Description
Area code-Phone numbe ` -
4. DATE DRILLED
5. TOTAL DEPTH: IO (05 µ
6. DOES WELL REPLACE EXISTING WELL? YE ❑ NO 04
7. STATIC WATER LEVEL Below Top of Casing: FT. _
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface's c
-Top of casing terminated at/or below land surface requires a W
variance in accord acewith 15A NCAC 2C.011& -O
9. YIELD(gpm): _METg D OF TEST a i r N
10.WATER ZONES(depth): 3 tY V
LOCATION SKETCH C7
11. DISINFECTION:Type Ch 1 nr i n a Amount Show direction and distance in miles from Aast 's
12. CASING: Wall Thickness two State Roads or County Roads.Include the road -fit
Depth Diameter or Weight/Ft. Material
numbers and common road names. -�
From_To Ft. 6 1 /4 S A r 21 - nvr
From To Ft. LAD
To Ft. f
13. GROUT: Depth Material Method
From__D_To_2,p_Ft. Neat CamPnf- Hand From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in.
From To Ft. in. in. t
15. SAND/GRAVEL PACK:
Depth Size Material Gc,•l.
From To Ft.
From To Ft. - S
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 O 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 Naturyl,p-•�••--- n:• qf'(Water Quality-Groundwater Section
WELL CONTRACTOR(INDMDUAL)NAME (print) `� t (.L%la tJ A S y) CERTIFICATION a a- r '
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PHONE448 ) 54-3581
STATE WELL CONSTRUCTION PERMIT# 1537 A--OCIATEDWQPERMIT0
Ofapplicable)
(if
/' applicable)
1. WELL USE(Check Applicable Box):Residential Ik Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI,,O,IIN J
Nearest Town: NY ,AiL(ot,) County /I� LDc�G11- TOP° lope 0V setting �
(3 Cld tz mz/ �. t4 of c- fJ t3 Q ❑Ridge ❑Slope ❑Valley LBFIat
(rLak appropriate e
(Street(Streetm Noire,Numbcn,C unity,Subdivision, No.,Tip Code) LalltudrllonglNde Of wellll location
r--
3. OWNER: 1 t [A tZ6 10 6 1^L (deF-shniauuyhecoeds)
Address - gin;
LatitudrAongitude source:❑GPS❑Topographic map
(Stroct or Row (chszk bo:)
nAiL ��-L- 1 S� F
7 DEPT DRILLING LOG
�a IryrTowp4asw45' 3 Zip Coda Frgmr _ To i Fomlatio Descrition
4- 11 o�1�;E- �I� QJ
Area cods Phone number 4. DATE DRILLED a a l ,fk aA 9J crL
� C - __
5. TOTAL DEPTH: 1 n 1 b ` 1 Gb M
6. DOES WELL REPLACE EXISTING WELL? YES Q NO E7 - LAc F-A N)-T�'
7. STATIC WATER LEVEL Below Top of Casing: L'D ' FT.
it-+-if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surfaces
O Feu
-Top of cuing lusainated attar below land surface req ulra a
variance Ia accordance wish ISA NCAC 2C.0111. �W 0 .1 r
9. YIELD(gpm):�_METHOD OF TEST Q G -- A I e-
r�
10.WATER ZONES (depth): 5li 1 O ` P l� 1
LOCATIONSKFTCH -'m
11. DISINFECTION:Type o Amount - Show direction and distance in miles firo4 least n-ti
12. CASING: Wall Thickness two State Roads or County Roads.include t e roa=o
Depth Di'(yiler or Wfri I. le" numbers and common road names. Z
From To _FL {"f 13
From To Ft.
From To Ft.
13. GROUT- Depth Material Method C'.I.�cs✓/2.
From To-a-0 Ft. ( . Mg� Y a JRzp 1 A11A5
From FL / 1�, 9' \
14. SCREEN: Depth
pth Diameter Slot Siu Materiel j 111
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: lC J
1 DO HEREBY CERTIFY THAT T111S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL 00
c-
CONSTRUCTION STANDARDS,AND THAJsllL COPY OF THIS R ORD HAS BEEN PROVIDED T fi WE�Cd{d R CD _
FIM
SIGNATURE OF PERSON CONSTRUC'DNGTHE WELL /DA,E / V r'
Submit the original to the Division or Water Quality,Groundwater Section,1636 Mall Service Center-Ralelgh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

� V ` 27
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ~
WELL CONTRACTOR(INDIVIDUAL)NAME (print) c., r1 n Mp' ,Jr CERTIFICATION# 7 1 "1 R
WELL CONTRACTOR COMPANY NAME (Immptg Wal 1 R PLlmp (n v T C PHONE #M7R) 451_7'322
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) r� (if applicable)
oa
1. WELL USE(Check Applicable Box): Residential MunicipaliPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATIQI�: �dv, Topographic/Land setting
NearesrTown: �ram _ _County Midge ❑Slope I;Walley ❑Flat
A I t.-i- a u (check appropriate box)
(Street ame,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
r
3. OWNER: I, (degmea/mirwtes/seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Sus Rou(,e�oJ U (check box
DEPTH DRILLING LOG
City or Town Zip Code From (�0 0rma�ion escripti
�)- � S� — Dlo 0 1 1 .7t al e
Area coda Phone numb
4. DATE DRILLED
5. TOTAL DEPTH• L
6. DOES WELL REPLACE EXISTING WELL? YES V0( O ❑
7. STATIC WATER LEVEL Below Top of Casing:.�_FT, rZv
(Use"+'if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surfaces C:)
`Top of casing terminated at/or below land surface requires a
variance in accarchiRce,with 15A NCAC 2C.0118.
9. YIELD(gpm): 0 TH PD OF TEST nir
10.WATER ZONES(depth):�U
LOCATION SKETCH
11. DISINFECTION:Type_rh 1 nr i n P Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep Diameter or Weight/Ft. Material numbers and common road names.
From p Totu�
Ft.6 314 SgJa1 gam_
From To Ft.
From To Ft. �
13. GROUT: Depth Material Method
Frorr(-0--_To—,ag—Ft, Ne-.t- 9Pm, nt —�R id y
a —
From To Ft.
14. SCREEN: Depth Diameter Slot Siu Material
From Tc Ft. in. in.
From To Ft. in, in.
15. SAND/GRAVEL PACK: �� _..
Depth Sim Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY 0 THIS RECORD HAS VEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PE CONSTRUCTING THE WELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC ,*
cr:
27699-1636 Phone No.[phone],within 30 days. OW-1 REV.07/2001.

T 3pSJAS
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resource�ns7-Division of Water Quality-Groundwater Sesnou
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Rofyt1',y /J/r^i'� CERTIFICATION#22Z
WELLCONTRACTORCOMPANYNAser�x wA-T'W L)e.I( IJr-- I"nQ —_PHONE a ( p1(et19-o480
STATE WELL CONSTRUCTION PERNIM ASSOCIATED WQ PERMTTM
(if applicable) (if applicable)
e
1. WELL USE(Check Applicable Box):Residential Or Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topo c1Land setting
Nearest Town: /s/ t/ County pRidge MSlope OValley 0FIat
(stet Name.Numbers,Community,Subdivision,lot No,zip Code) Latitude/lougitude of well location
3. OWNER: A//d &YOLK/ (ds�reealmirmmNsewnds) - ..
Address-0 D%�7'N LatitudcAongitude source:0GPS13Topographic map
(Strut or Rope No.) _p (cheek box)
{N/yid%[r"'2 /UC- Ztc7.S 0 DEPTH DRR.LINQLOG
City or Town seam tip Code From To Formation Description-
(—
Am code-Phone comber _
4. DATE DRILLED —,%9' 05
5, TOTAL DEPTH: Z 413— '
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ff '
7. STATIC WATER LEVEL Below Top of Casing �/ FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS S FT.Above Land Surface' a
'Tap of cmin8 terminated atfor below land surface requires a
variance in amrdauce with 1SA NCAC 2C.0118. �-.
9. YIELD(gpm):/Q_ METHOD OF TEST %/h —'
10.WATER ZONES(depth):
j OCATION SKETCH can —
11. DISINFECTION:Type Amount /0 0 z Show direction and distance in miles from at 1
12. CASING: Wall Thickness two State Roads or County Roads.Include the
�( Depth ?fir or weighUFt. Matenal n and common road names.
m
Fro /_To 20 Ft_(a /4 SDR 2/ NU C `
From._To Ft N
From To Ft. ZZ�•(3 N
13. GROUT: Z od
From �To —O Ft O e !'►ti o�c
From To Ft. to
14. SCREEN: Depth Diameter Slot Size Material C
From To Ft in. in. �m S
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 2G WELL
CONS [ON STANDARDS,AND A CO Y F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 MaR Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.OW2001

� p8147
WELL CONSTRUCTION RECORD
North Carolina-Department of Enviromnent and jbtatural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) I1 O III A CERTIFICATION#-&Z7
WELL CONTRACTOR COMPANY NAMSZS�r�-T�ec t�J�a j A r.l �t/1 PHONE # (��t�c�'OIIFtb
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
NNNEENN if licable if icable
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑//Other O If Other,List Use
2. WELL Town:// � Topa rJLaad setting z>
Nearest Town:, b0 Count G W$ st
-,— ❑Ridge lope Malley ❑Flat
J�3 0 / s (ehaxappropriatewac)
(Shed Navin,Ni mbera,CarniumfiN Saba; ' on,tot No.,Zip Code) L.atitud0ongitude of well location
3. OWNER:&r my rAJ Iy--m e 5 (aegrewminuoea/raands) _ -
Addresses/SS 3� i1 Latitude/longitude source:❑GPS❑Topographic4*
/ (Snit or Route No.) 9 (dreck box)
/V L°!7Q jtJ C 7_�C 7 S9 DEPTH DRILLING LOG
City or Town St From To Formation Description_
Am eoeo-Phone number
4. DATE DRILLED — 7
5. TOTAL DEPTH: / / —
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑�
7. STATIC WATER LEVEL Below Top of Casing: 2 S_FT.
/ (Usc"+"if Above Top of Casing)
S. TOP OF CAST,iC IS l �.. __FT.Above Land Surface*
"K�P oY curet txm'sastA vl; Neio,v land mrfm requires a
kCAC 2C.911a. .�i / 'C
`? ,8P, i .,,l ..._ _1.t '.30DOFTEST 22/—oea 'g
10. WATER ZONES(depth):
LocaTTON SKETCH e
s t ,plc a r f C L Show direction and distance inmiles frorlt lean
Wall Thickness two State Roads or County Roads.Include the
! r or weigbt/Ft. Material numbers aft d common mad names.
From To Ft.
13. GROUT: Depth Material ethod
Fro To To�Q_Ft��Pg� e my x S
From / To Ft \p
14. SCREEN' Depth Diameter Slot Sim Material
From:y—To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK ��O
Depth Size Material AEY
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 STANDARDS,AND THAT PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�e � 1-l7 -05'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

Vv
308146
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
�
WELL CONTRACTOR(INDIVIDUAL)NAME CC?? (print) 90A-Nr- to' �' ••/T///��/ t CERT1F1CAT1ON R2e,n r 7'
WELL CONTRACTOR COMPANY NAMH.�j�fA�l�l'� (1�� I.�(t: 1�/1 PRONE tt 29hr tW- 0
STATE WELL CONSTRUCTION PERMIT!! AMOCIATED WQ PERMIT*
ifapplicable) if licable
1. WELL USE(Check Applicable Box):ResidentialMtmicipal/Public❑ Industrial❑ Agricultural❑ _
Monitoring❑ Recovery ❑ Heat Pump Water injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Togo d setting, u }
Nearest Town:G7 o/r County, / ❑Ride o Malley
DEl r--'
GresTov h�r�e s g e� '
e� �7 (peel;appmpriNe box) �;
(Shutt Hama Numbers.Co n ndaity,subdivision,let No.,Zip Code) Latitude(longitude of well locat�(ji,4 i j '
p
3. OWNER.81L (L/e
(degteeshnimrtedseconds) t?z � ..—.
Address# SI�9�/�it/ OK _ Latitude/longitude source•.❑GPS❑Topa phie.urap
Srrxt or Route No.) (ryeca bmr)
_Cid Zd DEPTH
City or Tower State zip code From To Formation Description
Am code-Phone number
4. BATE DRILLED Z —©S�
5. TOTAL DEPTH: Q,S F
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing:_4 r FT.
(Use"t"if Above Top of Casing)
8. TOP OF CASING IS /• s FT.Above Land Surface*
'Top of casiag tern"ated War below land surface requlm a
variance 1n accordanclMith 1SA NCAC 2C.013a. /
9. YIELD(gpm): METHOD OF TEST //!t&Y a <
10. WATER ZONES(depth):
LOCATION SKETCH
IL DISINFECTION:Type--LdCaYAmount lD o 2 Show direction and distance in miles fron t 1
12. CASING: Wall Thickness two State Roads or County Roads.Inclu&nhe t
,�( th/n Wei t/FL al numbers and common road names.
From U/ To 4/V FLI ,g�' U C
From Tc Ft ` O
From Tc Ft
13. GRO Material od
Fron To -�Ft1O� �i ( R•
IIx i
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material l
From To Ft in. in.
Fro To Ft. in. in. !
15. SANDELPACK Rr CpvL
Depth Sim Material
From To Ft.
From�To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONS77LUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUgP9N STANDARD;AND THAT OPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/_/2 _ 0S�
SIGNATURE O 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.[phone],within 30 days. GW-I REV.07/2001

�0 309801
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) NEIL CRAFT CERTIFICATION# 3114
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: MARION County MCDL Topographic/Land setting
2450 ZION HILL RD. ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3.OWNER:JOHN MINISH Latitude/longitude of well location
Address 2450 ZION HILL RD. _
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑ GPS El opographic map
City or Town State Zip Code (check box)
8( 28)-738-0410 DEPTH
Area Code Phone number From To
4.DATE DRILLED 03/07/05 _
5.TOTAL DEPTH: 305 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 80 FT. _
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD(gpm): 6 METHOD OF TEST ARD number and common names
10. WATER ZONES(depth): HWY.#221 N.FROM RUTHERFORDTON. LEFT
11.DISINFECTION:Type CHLORYTE Amount 7.5 ON MUD CUT RD.LEFT ON SUGARHH 3.RD.RT.
ON OLD FORT RD. RT.ON ZION KILL RD.LEFT
12. CASING: Wall Thickness ON DRIVE(&MAILBOX#2436.HOUSE AT DEAD
Depth Diameter or Weight/Ft Material END
From 0 To 110 Ft 6-1/4" SDR21 PVC
From_To Ft_
From_To_Ft._
13. GROUT: Depth Material Method
From 0 To 20 Ft.OUHCRETE POURED
From_To Ft.
14.SCREEN: Depth Diameter Slot Size Material
From_To_Ft._ in in.
From_To_Ft._ in in. t�
15. SAND/GRAVEL PACK:
Depth Size Material N
From—_To—_Ft._
From To Ft
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O 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.[phone],within 30 days. GW-1 REV.07/2001

00 309795
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(prim) NEIL CRAFT CERTIFICATION# 3114
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential N Municipai/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use_
2. WELL LOCATION:
Nearest Town:MARION County MCDL Topographic/Land setting
DINK CONNER RD. ❑Ridge ❑ Slope ❑ Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:JUSTIN CALHOUN LatitudeAongitude of well location
Address DINK CONNER RD.
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
U)-925-7367 DEPTH
Area Code Phone number From To _
4.DATE DRILLED 03/2V05 _
5.TOTAL DEPTH: 365 DRILLING LOG
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO N From To
7. STATIC WATER LEVEL Below Top of Casing: 100 F E -
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.011 g. Two State Roads or County Roads. Include the road
9.YIELD (gpm): 4 METHOD OF TEST ARD number and common names
10. WATER ZONES(depth): FROM RUTH/GO UP HWY.#221 N.LEFT ON
MUD CUT RD.RIGHT ON DINK CONNER RD.GO 1
11.DISINFECTION:Type CHLORYTE Amount 9 MILE DRIVE ON RIGHT.(547 ON MAIL BO)L)
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft, Material
From 0 To 180 Ft 6-1/4" SDR21 PVC Ci
From_To_Ft._ g
From_To_Ft_ 3
T: v uI
13. GROU Depth Material Method
From 0 To 20 Ft.OUIKRETE POURED rot
From_To_Ft c o
14.SCREEN: Depth Diameter Slot Size Material o '
From_To_Ft.—_ in _— in.
Ul
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 TH4TA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No. [phone],within 30 days. GW-1 REV.07/2001

TO
309788
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultmal ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ® If Other,List Use IRRIGATION
2. WELL LOCATION:
Nearest Town: MARION County MCDL Topographic/Land setting
2055 POLLY SPROUT RD. ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:JAMIE OXLEY Latitude/longitude of well location
Address 2055 POLLY SPROUT RD. _
(Street or Route No.) (degrees/minutes/seconds) -- _
MARION NC 28752 Latitude/longitude source: ❑ GPS ❑Topographic map _
City or Town State Zip Code (check box)
8( ZS)-738-8300 DEPTH
Area Code Phone number From To
ca,
4. DATE DRILLED 03/24/05 _
5. TOTAL DEPTH: 445 DRILLING LOG
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use-+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKEPCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9. YIELD(gpm): 60 METHOD OF TEST ARD number and common names
10.WATER ZONES (depth): FROM RUTH GO UP HWY.#221 N.RIGHT ON
POLLY SPROUT RD.3/4 MILE ON RIGHT.
11.DISINFECTION:Type CHLORYTE Amount 12
12. CASING: Wall Tbickness
Depth Diameter or Weight/Ft. Material
From 0 To 70 Ft 6-114" SDIL21 PVC r
From_To Ft_
From_To Ft n air
13. GROUT: Depth Mate_rial Method
From 0 To 20 Ft.OUIKRETE POURED
From. To Ft m
14.SCREEN: Depth— Diameter Slot Size Material O iit
From To_Ft._ in. in. Ln
From_To_Ft._ in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From_To_Ft_
From To Ft
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7
.3 S/c s'
SIGNA RE OF PERS N CONSTRUCTING TTIE WELL k DATE
Sribmit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
117699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3 © 8804
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural f Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlat) IJA STA CERTIFICATION#
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PHONEY-t8 J54-3581
SPATE WELL CONSTRUCTION PERMIT#_ 1537 ASSOC1ATEDWOPERMIT#
(ifapplicable) /' (ifapplica�le)
1. WELL USE(Check Applicable Box):Residential'B" Municipal/Publie❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ IC Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nela\lrestTown: l RIotJ County c&t^)eI..L. dge ❑Slope ❑VJley ❑Flat
, a*. ,)X S M/( e-) (chock appropriate box)
(Sweet Nurse,Numbcc�n,Community,Subdivision,tot No.,tip Code) Latitude/longitude of well location
3. OWNER: 'J l L--l- � `ltA t^% K I,�S (dep—hniwtestsecoodQ
Address _ oI /VGA y Q f-1 rJ�t iACiv LatitudcAongitude source:❑GPS❑Topographic map
(Sweet or Route o.) (check box)
Cldg�LOtil r�C agat,� DEPTH DRILLING LOG
ciryor Town State Zip Code From r To / Fo'r2ution Descnpti
Am coda Phone number
4. DATE DRILLED 0 a o5 �b D ' i<E
5. TOTAL DEPTH: �&1 0 ' / 5 b _ C" 0.t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fi0
7. STATIC WATER LEVEL Below Top of Casing: t d O FT.
(Use-s-irAbovc Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surfaces
•Top or castes lermlasted attor below lead surface requires,■
vutsau In acaordeac will,ISA NCAC 2C.0112.
9. YIELD(gpm): 'r METHOD OFTEST
� '�) �
10.WATER ZONES(depth): `Jb of — G Q m
LOCATION SKETCH
It. DISINFECTION:Type SIT O c Amount Show direction and distance in miles from t leas P
12. CASING: Wall Thickness two State Roads or County Roads.Includ�he roan
Dep.(
Ih Di r or et UFt. ate 'J numbe and common ad names. �
From 1 To D Ft. S ��� A -001
From To FL GlaN( �a
From To FL h o
13. GROUT: Dep� Material Method 2't M >a rn n
nn
From To a Ft. C�NLESN"f Co i%�,(31� 3
From To Ft. �`-=-
14. SCREEN: Depth Diuneter Slot Sim Material
From To Ft. in. in. IZ�AD C10
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT TFIIS WELL WAS CONSTRUCTED IN ACC ANCE WITH 15A NCAC 2C,WEL.L
CONSTRUCTION STANDARDS,AND THAT A COPY THIS RECORD F BEEN PROVIDED TOT7 WELL OWNER
o� 33 ,gs
SIGNATURE OF PERSON CONSTRucnr4G 71HE WELL A -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality 308816
WELL CONTRACTOR(INDIVIDUAL)NAME (print) ,_ ames W Camn. ,Tr_ CERTIFICATION# 21 3R
WELL CONTRACTOR COMPANY NAME Camp Wt.11 R Pnmp (•,p.,_r Tnr _ PHONE # A4 3-7372
STATE WELL CONSTRUCTION PERMIT# - ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential i 'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: t� p II Topographic/Land setting
NeearestTown: aa— County. MCP 6_VJ j ffll ORidge ❑Slope OValley OFlat
C'13 y t t o s l (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:OGPSOTopographic map
, / (Street or R to No.) (check box)
�y10.� � DEPTH DRILLING LOG
City or Town State Zip Code From
o To FOrmatl D ript�
�O S
Area code-Phone numbe� ' y
4. DATE DRILLED rip_, (�
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE$Q NO qy
7. STATIC WATER LEVEL Below Top of Casing: t,p Q FT.
(Use"+"if Above Top of Casing) A 9
8. TOP OF CASING IS 1 FT.Above Land Surface'
-Top of rising terminated atior below land surface requires a t/✓�'
variance in accords ce with 15A NCAC 2C.0118. _
9. YIELD(gpm):\_METHODOFTEST Air
10.WATER ZONES(depth): JO0
LOCATION SKETCH
11. DISINFECTION:Type rhlOrine Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep Diameter or Weight/Ft. Material numbers and common roadnames.
From 0 To�Ft. 6 1 /A SDR21 PVC
From To Ft.
From To Ft. - \
13. GROUT: Depth Materiel Method
From 0 To�_Ft. Neat Cement Hand
From To Ft. (p
14. SCREEN: Depth Diameter Slot Size Material {
From To Ft. in. in.
From To Ft. in. in. �..
15. SAND/GRAVEL PACK:
Depth Size MaterialCA
From To Ft.-
From—To—Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC ORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD S BEEN PROVIDED TO THE WELL OWNER
t ` '- � ,.
GNATURE OF RSON CONSTRUCTING THE WELL DATE tv
0o
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.09/2p04

Nonh Carolina - Department of Environment and Natural Resources- Division of Water Oualiry- Groundwater Section 7(1 f( 1
1636 Mad Service Center " Raleigh, N.C. 27699"1636-Phone [phone] / + � 13 P (�
9 C7
WELL CONSTRUCTION RECORD WELLCONTRACTOR: "1-AA0V"0 / o /�CIrV�
WELL CONTRACTOR CERTIFICATION fi. x,s�
STATE WELL CONSTRUCTION PERMITn:
1. WELL USE (Check Applicable Box) Residential Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATION (Show/sk sketch of the location below) 4,
Nearer;Town: County.
ZO Qrb f, mt,/-� ?d _
(Road Name and N/u�m�oers.Comn iy or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER `/ACC/ /; f✓✓/�7TGN
From To Formation Descupbat
Address G �� 194rK fid
/ trees or oule o. --
N/fdhiCiV /V 7!'> SiZ_ --
Crly or Town State Zip Code
a. DATE DRILLED x S' _
5. TOTAL DEPTH ,`Zdal
6. CUTTINGS COLLECTED YES NO©
7. DOES WELL REPLACE EXISTING WELL? YES NOF
E. STATIC WATER LEVEL Below Top of Casing: �FT. —
(use'.'it Above Top of Casing)
9, TOP OF CASING IS_i FT. Above Land Surface' —
'Tcp of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C 0119
10. YIELD (gpm): L� METHOD OF TEST
11, WATER ZONES (depth): /
12, CHLORINATION. Type 117/> .��Amount _ -
If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH -,
Depth „ Di,�rl,el�r or Welght/Ft M tedal (Show direction and distance from at least Iwo State - - "" ¢v--
Frorn. To FL �L+ / .�bh `.�' 7x�' /,/7S?��.
Roads, or other map reference points)
Frorn To Fl.
From To Fl. 6
1- GROUT 3
Depth Material Method
From To FI. IV
From To FL C+J
15. SCREEN: 0
1pt
Depth Diameter Slot Size Material Clt
From _To Ft in. ._, in. a)
A
From _ To FL in. _ in.
From _ To Ft. In. _ in.
16, SAND/GRAVEL PACK: -- 00
Depth Size Material
From _ To FL -_ _ cn
From To
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDEDTO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouac No SIGNATURE OF PERSON CONSTRUCTI THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
Se al No
GW"t HEV. I2J95

Nonh Carolina - Department of Environment and Natural Resources - Division of Water Ouality- Groundwater Section
1636 flail Service Center Raleigh, N.C. 27699-1636-Phone [phone] 1 308888
O
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 170�/��L I l7� a r ^' Iq
WELL CONTRACTOR CERTIFICATION #:
rr��}}1� STATE WELL CONSTRUCTION PERMIT#: o'
1. WELL USE (Check Applicable eox): Residential DO Municipal ❑ Industrial❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION. (Show sketch of the location below)
Nearest Town. /v//-;?A w County 12 C
4ti6/_ __;� � 9r, i.,Tsr
(Road Name and Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER �4/Vl*j/ `j�luxhS From To Formation Oescnpfiui
Address `l NVA
A;Vi pd.
y�
ueet or o> Co. r�G7 s—�
City or Town State Zip Code
4. DATE DRILLED —/,O - VS
5, TOTAL DEPTH /'.IS
6. CUTTINGS COLLECTED YES F-1 NO©
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO® _-
E. STATIC WATER LEVEL Below Top of Casing: A660Y FT.
(Use'.'it Above Top of Casing)
9, TOP OF CASING IS /J` FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In accor-
dance with 15A NCAC 2C.0118 9
10. YIELD (gpm): a r METHOD OF TEST �77
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount A 6 It additional space is needed use back of form
13. CASING.
Wan Thickness LOCATION SKETCH
Depth /'` Dia`netcr or Weight/Ft, Material (Show direction and distance from at least two Stale
From To _St_Y_ FL __ , ,qA2�, G ��gS 77 Roads,or other map reference points) T
Rom To Fl. _ r
From To Ft. _
14. GROUT:
S
Depth Material Method
From To Ft.
N
From To Ft, W
15 SCREENCD
Depth Diameter Slot Size Material + Cil
From —To Ft in. in.
From — To - F1. in. in.
From — To —Ft.— in. in. C`% --
16. SAND/GRAVEL PACK. _
Depth Size Material
From _ To Ft.
From To Ft. -
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A GOPYpOF THIS RECORD AS BE)N PCIOVIDED TO THE WELL OVV E
FOR OFFICE USE ONLY ' /4LL —_
Quad Noe. ;!SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sobmil b at to Division of Water Quality,Groundwater Section Within 30 days
Serial No. !� GW+I REV. 12/99

North Carolina Department of Environment and Natural Resources - Division of Water (Duality-Groundwater Section �y
1636 Mall Service Center Raleigh, N.C. 27699.1636 Phone [phone] / 308887
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION P: O L
STATE WELL CONSTRUCTION PERMITN.
1. WELL USE (Check Applicable eoq Residential® Municipal ❑ Industrial❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Show sketch of the location below) J
Nearest Town. ��/a w/ O/V County:
/6-,23 Z/'Cnn h/,%4 led _
(Road Name and Numbers,Community.or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 'JFGv r'� Tv�O}'L �'Y From To Formation Descriplia,
Address 15_.2 3
heel or oulo O. ---
i�v
City or Town Stale Zip Code -
.. DATE DRILLED -3
S. TOTAL DEPTH /—2 —
6. CUTTINGS COLLECTED YES ED NO© _
7 DOES WELL REPLACE EXISTING WELL? YES ❑ NO&] _
E. STATIC WATER LEVEL Below Top of Casing: ,5-0' FF.
(Use','if Above Top of Casing)
9. TOP OF CASING IS /3v FF. Above Land Surface' --
'Top of casing terminated avor below land surface requires a variance In accor.
dance with 15A NCAC 2C Q118
10. YIELD (gpm): O T METHOD OF TEST 9,14 14 ' it—
I I WATER ZONES (depth). b
12. CHLORINATION: Type fit Amount _
II additional space is needed use back of loan
13. CASING:
Wall Thickness LOCATION SKETCH
Depth r� / Diameter or Weigli Material (Show direction and distance from at least two Slate
From To /` Ft. G SO-7�.L- i TiG Roads,or other map reference points) '
From To Fl _ a
From To Ft.
14, GROUT.
Depth Material Method
From To Ft.
From To Ft. hJ
15_ SCREEN. - -i
Depth Diameter Slot Size Material 13=
From To Ft in. in. —
n>
From —To Ft. in. _ in.
From — To FL in. _ in. -
16. SAND/GRAVEL PACK:
Depth Size Material -
From _ To Ft.
From To Ft.
17. REMARKS'. ... .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1 _
FOR OFFICE USE ONLY '`
Ouac No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Oualiry.Groundwater Section within 30 days
$20a1 No
GWJ HE V. 12199

PJonn Carolina - Depanment of Environment and Natural Resources - Division of Water Quality-Groundwater Section 308886
1636 Id aJ Sernce Center Raleigh, N.C.27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: 4)4m, OA ti 4 ` -X
WELL CONTRACTOR CERTIFICATION b: XSGS�
STATE WELL CONSTRUCTION PERMITN:
1. WE ILL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
WELL LOCATION. (Show sketch of the location below)
Nearest Town: 64d f-B..% County. /,q v_4 L
I'll nrd1i:7- - 1bVS-9n N.2c //d _
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER il 3 0,,)/✓✓ !�, From To Formation Descnpeu.i
Address Z.CMG 7rayi / d —
(direct or No.
Mr�h/CN hi
City or Town -y State Zip Code
DATE DRILLED ---
5. TOTAL DEPTH
6. CUTT ING S COLLECTED YES[A NOCS —
7. DOES WELL REPLACE EXISTIN WELL? YES NOX -
E. STATIC WATER LEVEL Below Top of Casing: 17 FT.
(Use'«'it Above Top of Casing) _
S. TOP OF CASING IS IPI FT, Above Land Si
-Top of casing terminated aVor below land surface requires a variance In actor
Lance with 15A NCAC 2C .0118
10. YIELD (gpm). 4 METHOD OF TEST
11. WATER ZONES (depth):
12, CHLORINATION: Type /fi Amount It additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth �q Diameter or WeighVFt. Material (Show direction and distance from at least Iwo Slate
From To � Ft. —a/ SD.c ��` .�� �� Roads, or other map reference points)
From To Ft.—
From To Ft. --- *J
1a. GROUT' b
Depth Material Method ry
From To Ft. W
From To Ft.
15. SCREEN.
Depth Diameter Slot Size Material
From —To— Ft in. in.
From To Ft. in. in.
From To Fl, in. in.
16. SAND/GRAVEL PACK: j
Depth Size Material r
tV
From _ To Ft. pp
From To Ft. `
17. REMARKS'.
VI
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 PR�OVIVII.D..EDDJ TO THE WELL OWNER.
FOR OFFICE USE ONLY'
Quad NO SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit anginal to Division of water Quality,Gmundwaler Section within 30 days
Senal No. GW 1 REV. 12/99

Nord#Carolina Department of Environment and Natural Resources- Division of Water Quality - Groundwater Section 308885
163E Mail Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: &4,q V0 eAl't♦-4 "k'5
WELL CONTRACTOR CERTIFICATION #: JrV �j
STATE WELL CONSTRUCTION PERMIT#: / )".k
1 W ELL USE (Check Applicable Box): Residential® Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use: _
2 WELL LOCATION (Show sketch of the location below)�y
Nearest Town: / '1/-A"W'i /1XC; County.
(Road Name 7a�ntl Numbers, Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER -Z3, )0J,,Vg:A4 G,.cJ,n From To Formation Descnpuu1
Addfess
j5ueel or ouzo o. -
City or Town Stale Zip Code ..
<. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOE5?
7. DOES WELL REPLACE EXISTING WELL? YES O NOES = c
E. STATIC WATER LEVEL Below Top of Casing: 3a FT.
(Use'+'it Above Top of Casing)
9. TOP OF CASING IS 14FI" _ FT. Above Land Surface'
'Top of casing terminated allor below land surface requires a variance In actor-
dance with 1SA NCAC 2C.0118 -
10. YIELD (gpm): 10 t METHOD OF TEST /319
11, WATER ZONES (depth):
12. CHLORINATION: Type NT/f Amount J. " It additional space is needed use back of form
13. CASING:
Walt Thickness LOCATION SKETCH
Depth Diameter or Weight/FI. Material (Show direction and distance from at least two State
. r 1 G LAr Y i� Roads,or other map reference points)From To 33 Ft
From To Ft. —
From To FL
4. GROUT
Depth Material Method
From To Ft.
From To Ft, a a)
15. SCREEN.
Depth Diameter Slot Size Material N -
C.�
From —To— Ft — in. in.
O
From _ To Ft. in. in. — CAI
From _ To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From _ To Ft.
From To Ft.
17, REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY . il7 • -,o"'�'-�'� r'Z-/g-� -
Ouaa No SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Dwislon of Water Guality.Groundwater Section within 30 days
Senal No GW-I REV. IM9

Nonh Carolina -Department of Environment and Natural Resources -Division of Water Quality- Groundwater Section S kZ")$S 4
1636 Mal Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION 0: ✓ �`� G
STATE WELL CONSTRUCTION PERMIT#: F`-/ v
1 WELL USE (Check Applicable Box). Residential Municipal ❑ Industrial El Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION (Show sketch of the location below) Y1
Nearest Town. /V/)A!c,U` IV,4 - County. �l t '✓O�rl=4�
� r/ Acre 36 _
(Road Name and Numbers,Community,or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER IV19rK SKfd4 `,VS 1 From To Formation Descnpoua
Address .2.9 e S Old u/V /"07 t%—- _
j5treet o�fT.
/"/Ao..'rl;v N.C. —
City or Town Stale Zip Code --
DATE DRILLED G —6 S J
5. TOTAL DEPTH EYE S! NO6 CUTTINGS COLLECTED cy
=3
7. DOES WELL REPLACE EXISTING WELL? YES NOEX] -
E. STATIC WATER LEVEL Below Top of Casing: FT. - oo �--
(Use'«'if Above Top of Casing)
S. TOP OF CASING IS /d FT. Above Land Surface' -
'Top of casing terminated aVor below land surface requires a variance In actor- -
dance with 15A NCAC 2C.0118
10. YIELD (gpm): Zil METHOD OF TEST 13 --
11. WATER ZONES (depth).12. CHLORINATION: Type ��j/f Amount l If additional space is needed use back of form
13. CASING:
Wall Thickness LOCATION SKETCH
Depth ,,' Diameter or Weight/Ft Material (Show direction and distance from at least two Slate
From To FL I SY74 I'lL6 RAS7X�— Roads,or other map reference points)
From To FL —
From To Fl
14. GROUT:
Depth Material Method
From To FL Z
From To R.
15. SCREEN'. tV
Depth Diameter Slot Size Material W 3
From —To— Ft — in. in. O
En
From _ To Ft._ in. in.
From _ To Ft. in. in.
16. SANEVGRAVEL PACK.
Depth Size Material
From _ To Ft.
From To Ft.
17. REMARKS'.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD
��HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -
Cuao No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouality,Groundwater Section within 30 days
Serial No. GW I HEV. 12/99

309 ? 00
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) +2• C .r!/ [ }i / CERTIFICATION# L WELL CONTRACTOR COMPANY NAME ((r- +fP J( Cc7.lt ZI PHONE # ( ) `?3Y-^3 2
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ❑ Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town•,&e2 A" � lJ Coun y-,4- il,t,[(
❑Z/ � � Ridge 6Sclope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: (degrees/minutes/seconds)
Address 74(,'tl atfw ae Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
44 4 <I c 2 Y' > 3' z DEPTH DRILLING LOG
City or Town State / Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED `— s_ -
5. TOTAL DEPTH:
/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO lr� _
7. STATIC WATER LEVEL Below Top of Casing: /o .S FT. 3 ~
(Use'+"if Above Top of Casing) N
8. TOP OF CASING IS / FT.Above Land Surface*
'Top of casing terminated attor below land surface requires a
variance In accordance with 15A NCAC 2C.0118. O
9. YIELD(gpm): V METHOD OF TEST 94,,L ,4
10. WATER ZONES(depth): /a d rtj
LOCATION SKETCH
11. DISINFECTION:TypezA/c.P£-le Amount 4VI lz� Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighVFt. Material numbers and common road names.
From To �� Ft. A!
From To Ft._ r.*1 fIr s••u. 6- '� at.(� i lclr�Q /4�
From F De L - xx ^�
13. GROUT: Depth Material Method �" 16
From 0 To.N t Ft.
From To Ft. `(d LC�'e-C CA-'P-�
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. (/
15. SAND/GRAVEL PACK: V),u
Depth Size Material a / �-
From To Ft. c?�s�G/ E/c,
From To___FL /4
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL=
CONSTRUCI STANDARDS,AND THAT AAAC��OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL,bWNER _
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Rals_igGr,NC ! .
27699-1636 Phone No.[phone],within 30 days. GW-I REV.#J/2001EA
in
I

WELL CONSTRUCTION RECORD tz 09199
North Carolina-Department of Environment and Na al Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) L �?
q CERTIFICATION#Z� L
WELL CONTRACTOR COMPANY NAME L(,!,
PHONE #&Za.-'.-
STATE WELL CONSTRUCTION PERMIT#
(if applicable) ASSOCIATED WQ pERMIT#
(If applicable)
1. WELL USE(Check Applicable Box): Resident i al-Err Municipal/Public❑ Industrial ❑ Agricultural ElMonitoring ElRecovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELI.LOCATION:
Nearest Town:_. 2u , Count �ryJ,. Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,� ot No.,Zip Code (check appropriate box)
✓� Latitude/longitude of well location
3. OWNER:
Address '• (degrees/minutes/seconds)
,�yJz C_ (Street or Route to No.)
Latitude/longitude source:❑GPS❑Topographic map
LG1 �12e rt+r L' y� DEPTH heck box)
City or Town State Zip Cod DRILLING LOG
42 e From To Formation Description
Area code- hone number •-L
4. DATE DRILLED x -
5. TOTAL DEPTH:
6. DOES WELL REPLACE XISTING WELL? YES ❑ NO 'i7r� —----
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use•'+"if Above Top of Casing) -----�
S. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance it,accordw with/5A NCAC 2C.0118.
9. YIELD(gpm): �3 METHOD OF TESTAe --
10. WATER ZONES(depth):_ Z3
11. DISINFECTION: Type LOCATION SKETCH
3P .� Amoun ! Show direction and distance in miles from at least
12. CASING: Wall Thicknes !'� �" two State Roads or County Roads.Include the road
FrommDepth FL D ameter or Weight/Ft. Material numbers and common road names.From To —_�_ ,
To—FL_ /-
From To Ft. _ J '`•n•w /�-G/
13. GROUT: Depth From To Material
Method
� Ft. (CLV�
From I o Fl.14. SCREEN: Depth Diameter Slot Size Material 7,!
From To Ft. in. in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK: c.cJ /tA � vJ
Depth Size Material
From__To__Ft. D ` ' g
From To FL t..a
(") fT. A
16. REMARKS:_ .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL _
CONSTRUCTION STA ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
y _
�_ -b "O
SIG URE O PERSO CONSTRUCTING THE WELL DATE - 1 )
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center- •- t7f r 27699-1636 Phone No.[phone],within 30 days. Raleighy-"TXC
GW-I REV.07/�a01

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh, N.C. 27699-1636-Phone[phone] 309082
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Dewey Wright Well Pump Co., Inc.
WELL CONTRACTOR CERTIFICATION#: 2797
040B39 STATE WELL CONSTRUCTION PERMIT#: Jerry Wilson
1. WELL USE (Check Applicable Box): Residential EK Municipal EJ Industrial 0 Agricultural El Monitoring 0
Recovery E Heat Pump Water Injection 0 Other E If Other, List Use:
2. WELL LOCATION:(Show sketch of the location below)
Nearest Town: NIOPTH COVE County: I'ACDCteret i
OLD LINVILLE RD- OFF 221 OFF 181
(Road Name and Numbers, ommunlN,or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER FAITH MISSIONARY BAPT. CH From To Formation Description
Address 3714 OLD LI NVILLE RD. . 0 260 AY SHAI F
tvtARION I�neetor cute b.) NC 28752 2560 285 WHITE QUARTZ
C,tvnrTd.n State zip o s 295 286 WHITE BROWN QUART:
4. DATE DRILLED 1/31/2005 288 305 WHITE BRONMIUARi.
5. TOTAL DEPTH 305 Xis
6. CUTTINGS COLLECTED YES 0 NO 0
7. DOES WELL REPLACE EXISTING WELL? YES E NO E]
8. STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Use","if Above Top of Casing)
9. TOP OF CASING IS 1 FT. Above Land Surface*
•Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 60 METHOD OF TEST Air �-
11. WATER ZONES (depth)B0.00 ppm285-286 0.00ppm
0.00 qpm 0.00gpm
12. CHLORINATION: Type HTH Amount 53 If additional space is needed use back of form
13. CASING: Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVFt. Material (Show direction and distance from at least two State 41,
prom 0 To 268 Ft. 6 1/4 A88 GAL V Roads,or other map reference points) pOfil
From To Ft. \t
From To Ft. `
14. GROUT: �y
Depth Material Method `
From 0 To 20 Ft. Cement Oraeity Flan r
From To Ft. Q
15. SCREEN: tS3 y Iv�
Depth Diameter Slot Size Material
From - To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. A:4<
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEE ROVIDED TO THE WELL OW R.R..
FOR OFFICE USE ONLY t �tz �✓+', _rJ Iv
NATURE OF PERSON CONSTRUCTING THE WELL DATE
Quad No: Submit original to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV.12/99
Serial No.

From:Scott Ganh To:Stepheme Wilson Date:3/20/2005 Time:5:44:50 PM Page 4 of 6
WELL CONSTRUCTION RECORD 309118
North Carolina-Department of Environment,and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) SCOTT GANTT CERTIFICATION#2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS,INC.PHONE#[phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2.WELL LOCATION: Topographic/Land setting
Nearest town: MARION County McDOWELL ❑Ridge ❑ Slope ❑ Valley ® Flat
LOT 70 GRANTS MOUNTAIN ESTATES Latitude//Longitude of well location
(Street Name,Numbers,Community,Subdivision,Lot No,Zip Code) 35.39.120/81.59,300
3.OWNER RON HARRIS (degrecs/m nines/seconds)
ADDRESS 5904 32nd St E Latitudedongitude source:®GPS❑Topographic map
(saes or Route No) DEPTH DRILLING LOG
ELLENTON FL 34222 From To Formation Description
Cityor Toavn State Zip Code 0 45 Clay
941-729-5365 45 640 Consolidated Rock
Area Code-Phone Number
4.DATE DRILLED 2/8105
5.TOTAL DEPTH 640
6.DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7,STATIC WATER LEVEL Below Top of Casing: 300 FT.
(Usc"+^rAbove Top of Casing)
8. TOP OF CASING IS 2 FT.Above Land Surface'
'Top of cash tmninated a✓or below lamd surface requires a vanmce in
accordmccwidsl5ANCAC 2C.0118
9. YIELD(gam): 3 METHOD OF TEST ARDM
10.WATER ZONES(depth): 540
u.DISINFECTION:TYPE HYPOCHLORITE Amount 17 0: LOCATION SKETCH
12,CASING: Wall Thickness Show direction and distance in miles from at least
Depth Diameter or Weight/Ft. Material two State Roads or County Roads.Include the road
From 0 To 56 Ft 6 1/4" SDR 21 PVC numbers and common road names.
13.GROUT:
Depth Material Method ate.
From 0 To 20 Ft GRAVEL MIX GRAVITY rta
14.SCREEN Cv3
Depth Diameter Slot Size Material y
From NA To Ft in. in
N
15.SAND/GRAVEL PACK: F
Depth Size Material (=)
From NA To Ft, Ln
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2/10/05
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
GW-1 REV.07/2001
Submit the original to the Dtvislon of Water Quality,Groundwater Section, 1636 Mail Service center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
Iv

s .
WELL CONSTRUCTION RECORD
Nor&Carulim-DeptofEnvito�tandNaesalResour-ea Dirisioa aberQtuEty-GrattodwaterSeehan
wall.CONTRACTOR M9111VIDUAL)ruse tp.t S •%` :.t_ _ CZWMCATM 0 ?--�S
welt wNTn�►crortcoamuvrr►ea r/ P "L �% raolas �sl vr5 93s
STATs watt ColiffMCTION PERNXT< TID wQ Pk nirl
Q
1. WELL USE(Cheek Applicable Box):Residential Mmticipawxiblic O Industrial O Agricultural O
Mmwrmg 0 Recovery 0 Heat Puoip Water btjection 0 Other O If Other.Lint Use
2. WELL LOCATION: TopogrWhk&and setting
Nearest Town: CountY�(�C/ ORidge OSlope Malley [Mat
(CLeek apptup iste boa)
(Smxt Name,Nu`mbent.`Commtmiry,Subdividan,Lot No..zip Code) LatitudeAtmgitude of well location
3. OWNER:1 n, , 11 7 trl 0 t4 (deematm maahmods)
Address ��.Z_ LatitudeAmigitude satace:OGPSOTopographic sap
(Sueetaraoum .) (Check bus)
Mar ' CA 'C 6 � ' DEPTH DRILLING LOG
City sir roan Stem Zip Code From To Formation Description
(_)-
Am&cods Pboos comber
4. DATE DRILLED_
5. TOTAL DEPTH: Q
6. DOES WELL REPLACE EXISTING WET YES O NO
7. STATIC WATER LEVEL Below Top of Casing:, 6P FT.
(use-.-if Above Top of Castes) t
g. TOP OF CASING IS / Fr.Above Land Surface* cfdi
'Top of oAoa drmseftilWor blew lead seise,require a
vetuoe 1,aemrdsace with 1SA NCAC 2C Alla.9. YIELD(gpm): /3 M
, ETHOD OF TEST-iA L
10. WATER ZONES(depth): ��
LOCATION SKETCH
11. DISINFECTION:Type j' -: - A*noum� . Show direction and distance in miles from at least
12. CASING: Wan Thiclmess two State Roads or Cetmty Roads Include the road pry� Ql
Distirer or Welgbfft Material numbers and cormnon road S plkv/l�
From To�Ft _ ram
From_TO Ft
From To Ft
13. GROUT: Depth Mateial Method -
From_To Ft ''ate
'rroin ra Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft_-.bt in.
From To Ft m- in % lyl]
15. SAND/GRAVEL PACK:
Depth Sire Material
From_ To Ft.-
From—To—Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WE L WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2G+WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD H, S BEEN PROVIDED TO THE WALL AWNE < `
". SIGNATURE OF PERSON CONSTRUCDNG THE WELL DATE r
i
Submit the original to the Division of`Pater Quality,Groundwater Stction, 1636 Mail Service Cente �1leigh, i _
20 days.

� 10513
WELL CONSTRUCTION RECORD tee.
North Carolina-Depot of Fmha®ent and Nptural Rssomees-Division of Water Quality-
WILL CONTRACTOR M(DTV DUA.)NAME (prtiel t.e-t SON CZRTErWATM
WELL CONTRACTORCONrANYNAMX lt-h �N /l/� , / ~ raONi --
.. SLATE WELL CONSIRDCYION PnMM TED WQ PERMnf
(tfaaaliable) Ctfappliabk)
1. WELL USE(Cheap Applicable Bolts Reddeadsl B/Mu eicipaUPublic❑ IDduatrisi❑ Agricubural a
Mot»tormg❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other.List Use
2. WELL LOCATIO c opogcaphie/fand setting
N Town 0 A) Co= 9 OttJy�/ Mudge ❑Slope []Valley Mar
N Y✓)OS F) 1)F t vy '6) 7�� (check apvmwnaft box)
(Saar Name.Nuanb�-en.Cmn unity.Subdivision,tat No-2iP Code) Latitude/Iongitude of well location
3. OWNER: AJh t A-ZL (degtev/mmmalsemnds)
Address of WtycGr t.iva- LatimdeAongitWesoume:❑GPS❑Topographicmap
chack box)
/'[/�h/� /� %—)• S�7S� DEPTH ( I?RULMLOG
City ar town Sum tip Code From To Formation Description
Cs2M- r;L 2- X 14 �L l?
Arta cads.Fi sos comber
4. DATE DRILLED - ` D 5
5. TOTAL DEPTH: O / ;a
6. DOES WELL REPLACE EXISTING WELL? YES❑ j q e
7. STATIC WATER LEVEL Below Top of Casing: S9 FIy
(Use-+-if Above Top of Caring)
S. TOP OF CASING IS FT.Above Land Surface• �7
'Top*(casing terminaud War below land sarfscs requlm a c n �
variance inacmrdsace with ISA NCAC 2C.ar1R ,
9. YIELD(gpm):1�_METHOD OF TEST
10. WATER ZONES(depth): 90 ' 6 `Y
LOCATION SKETCH cn
11. DISINFECTION•Type ' Amount�_ Show direction and distance in miles from at least''
12. CASING: wail Thielmw two Stain Rjl=yd
Roads.Inclu the road
Depth Diameter or Weighot. Material numbers a .
Fromj To /3 0 Ft
From_To Ft OrraSq
From_ To Ft
13. GROUT: Depth Material Method t�
From To�2�Ft
From To Ft
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft.—in. in N.
From—To—Ft.—in. ice. {�15. SAND/GRAVEL PACK
Depth Sim Material
From To Ft.—
From—To—Ft
r _
16. REMARKS:
1 T`O HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH I SA NCAC 2C.WELL
C JNSTRUCiION STANDARDS,AND THAT A COPY OF THIS RECORD H,S BEEN PROVIDED TO THE WELL OWNER -
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Soomit the original to the Division of Water Quality,Groundwater Stction, 1636 Mad Service Center-Ral '
' Q 'ty, etgh,:I4C
�•<aa_f 41,5 96eRe Vo. !oloN 9ithin 30 days. V ry ­F..W,•_••.•. _

WELL CONSTRUCTION RECORD 310 5 6 3
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(WINVIDUAL)NAME (print)_ ,l IGl Mee, CC1 04 CERTIFI�C/�ATTIO.N1#,213�
WELL CONTRACTOR COMPANY NAME L A��I WI II PHONE # (929) 7 3-IZ7�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential�Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Ntwe�stTown: _County. �1C�t!\alp,Y/1 khtdge ❑Slope OValley OFlat
-t•- 1 `A (ti tv'� (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: t+n Gplql'Vt (degrees/minutes/seconds)
Addr, s ,J Latitude/longitude source:OGPSOTopographic map
` ( r ou e o.) (check box)
E p DEPTH DRILLING LOG
City or Town Srate Zip Code From To Forman n Descrip 'on
n15-��g� o ys
Area code-Phone num
4. DATE DRILLED
5. TOTAL DEPTH: S
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: 4 U FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS ` FT.Above Land Surface*
*Top of easing terminated at/or below land surface requires a
variance in accordance ith 15A NCAC 2C.011&
9. YIELD(gpm): METHOD OF TEST UA.Jl
10.WATER ZONES(depth): t %o
LOCATION SKETCH
11. DISINFECTION:Type Amount 1T Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. M` atPpPl tt numbers and common road names. �[
From O To $ Ft._Lj�_
From To Ft.
From P To Ft.
13. GROUT' Dep Material Method
From To Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. ( � ^
15. SAND/GRAVEL PACK:
Depth Size Material �}. v (-�l}��' UI
From To Ft. p
From To Ft. Ln
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
-} g S,
SIGNATURE OfrPERSON 1CONSTRUCTING THE WELL ,',-DATE ii
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. V AY 2
GW-1 REV.09/2004

(:0 311010
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Divisi n of Water Quality-Groundwater Section
WELL CONTRACTOR M41) VIDUAL)NAME (prta�t)r� en c R dck.s .7R CERTMCATiON
1 ,
WELL CONTRACTOR COMPANY NAM 1 ,eL�i q..T�` L7c�t Ar: Vag PHONE a (FQQ,� 'O48Q
STATE WELL CONSTRUCTION PERMTTk ASSOCIATED WQ PERMff#
if applicable)--- ifapplicable)
I. WELL USE(Check Applicable Box):Residential Muuicipal/Public❑ Industrial O Agricultural O
Monitoring❑ Recovery ❑ Heat Pomp Water injection 0 Other 0 If Other,List Use
2. WELL LOCATION _�°graph
e ic/Laztd setting =-_
Nearest Town: 6 Cot my / (3RidgOSlope ❑Valley [Flat.I
(ehsck appmpriate box) .
(Street Name,Noinbem Conaotmity,Subdivisim,Lot No., ) LatttudeAongiwde of well location:
u
3. 01 RM96k M4,11-el (deg mnuoeal8 m) G
Address M:f /'qJ&C°Lo Latitude/longitude souwe:OGPSOTopof phkc map
/ (S t or Route No. (cbeck
t Y' A) L 2 SS-7 PEPTH DRIL LNG LOG
City or Town State tip Code From To Formation Description
Ain coda Phone onmber
4. DATE DRILLED Z'2
5. TOTAL DEPTH: O 5 I
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0' S
7. STATIC WATER LEVEL Below Top of Casing:dl D ' FT.
(Use"+"if Above Top of Casing rD
8. TOP OF CASING IS �.s FT.Above Land Surface'
`Top of cadog termioated atfor below brad surface requtm a ;T3
Yu i="in Amr4mcl wftb 15A NCAC 2C.0118. !q
9. YIELD(gpm): METHOD OF TEST_,2f3�10. WATER ZONES(depth): oM
LOCATION SKE CH
11. DISINFECTION:Type Amount leg O Z Show direction and distance in miles from at It*st
12. CASING: Wall Thicimess two StaLd
lude the'�oad
�( Depth or$� /gh iFt. Material numbe
From K--' 1.Ft yam— -�-�From To Ft ]/�,,�eFronx To Ft =13. GROUT: / Dep� Material y9eM�From To Ft From To Fk14. SCREEN: Depth Diameter Slot Size MaterialFrom To Ft. in. in pFrom To Ft. in. in.15, SAND/ RAVEL PACK:Depth sue material k
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR COED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCI=ST. ARDS,AND THAT PY OF S;CO BEEN PROVIDED TO THE WELL OWNER
Si W-
S16NAT6RE OF PERSON CO TRUC ING 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

311C2 '
WELL CONSTRUCTION RECORD
North Carolina-Department of Enviromnent and Natural Resources--Divisl n of Watery Quality-Groundwater Sections��/
WELL CONTRACTOR(INWMUAL)NAME (print), ,I/e.1 C 16 C^Jla5 4)r CERTuncATioN#_. 29'
WELL CONTRACTOR COMPANY N'M �` 1 -W yf'i"T'�` 1�( ,.!(t' (t 11_-T--PHONE # fflu
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PEMUT0
(ifappiitable) (ifapy)icable} _____
1. WELL USE(Check Applicable Box):Residential fW MunicipaUPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other❑ If Other,List Use
2. WELL LOCATION: Topo tJLand setting
}Nee stt TO :�� �County.�ea
We � ORidge Slope QValley L300
rf' C v d e (check aPp*oPnM box)
(sneer Name,Numbers,tonunway,Subdivision,Lot No,Zip Cock) 2$'I Z Latitudellongimde of well location. -
3. OWNER:I!'%S e m0/`AA/CJ (3 emino /scow i ;
Address 2 3 t /y e �- Latitudellongitude soume:C]GPSOTopographicimap
pp (Street«Rame No.1 (cbeck�}
2yy30 DEPTH DRILLING LOG
city of Town state Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED L '2 _ O 5
5. TOTAL DEPTH:_
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ""
7. STATIC WATER LEVEL Below Top of Casing:
(Use-+"if Above Top of Caning) `''�'
8. TOP OF CASING IS /' : FT.Above Land Surface•
'Top of eaaing terminated ader below land mrAee requim a _ =ij
variana in aeeordaa 15A NCAC 2C.0IIL --f
9. YIELD(gpm): d METHOD OF TEST. f 1� o
10. WATER ZONES(depth):
11. DISINFECTION:Type Amount O 7 Show direction and distance in miles from at lead
12, CASING: Wan Thickness two State Roads or County Reads.Include the road
�( WeightiFtMaterial
f!t L numbers and common road names.
From--
To�Ft-M � I'
From ! To Ft p
From To Ft "W
13, GROUT:
From_ To2�Ft6�� L �
From To Ft Q
14. SCREEN: Depth Diameter Slot Size Material
From Tc Fr. in. in.
From To Ft in. in.
15. SANDIGRAVELPACK
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
d �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CO S CTION STAND �ANDT A CQ�Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER C\
SIGNA .OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-i REV.07/2001

311024
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nab/n/gl Resources-nDiivisionn of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prtnt)A// C/7 t 4,�1 ',/t h^D el Q 3 3-8 CERTIFICATION
WELL CONTRACTOR COMPANY NAMsSfy�e�"(A31sTT WrA OL- I Kdo PHONE M £S3.V)(2HQ-ONFO
STATE WELL CONSTRUCTION PERNM ASSOCIATED WQ PERiIIIT#
if licable ifapplicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ AgncultumlpLl
Monitoring❑ Recovery O Heat Pump Water Injection O Other O If Other,List Use
2. WELL
LOCATION:
LOCA TIO N: Topo cJand setti,ng
tylL4 e � Odge lope Malley "b
ratN st Town:� Coun G i ( .ppnp )°I Creszold Cue
(sheet Nnma Numbers,Coeunuoity,Subdivision,La No.,tip Code) Latitude/longitude of well lOcgtlon
3. OWNER: �fA.StQ (degccWmm°oes(seconds)�
Address 7 sGtO tl/Rn E G Latitudellongitude source:OGPSOTopographic map
( a I No, g (chock box)
D4V 1E�/ A/9 j 3 3 Z CJ DEPTH DRILLING LOG
City or own state zip Code From To Formation Description
Area talc Phone n=ber
4. DATEDRILLED y-25"5.5
5. TOTAL DEPTH: Qtr
6. DOES WELL REPLACE EXISTING WELL? YES O NO ff'
7. STATIC WATER LEVEL Below Top of Casing:-_Z!2-yr.
,pp // (Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
- 'Top of caning terminated Wor below Band surface requires a
vortance in aecurdsace with 15A NCAC 2C.011& CJ
9. YIELD(gpm): 30 METHOD OF TEST .^,e-v,'
10. WATER ZONES(depth):
LOCATION SKETCH �
11. DISINFECTION:Type Amotmt /D o Show direction and distance in miles from at lea
12. CASING: I1JJ��a�ppyyc�e�r� Wall ThorWcickness two State Roads or County Roads.Include the
tt�__9f T Ft_(? � SICK Z/L Mate UG numbers and common road names.?io
Fro ToFrom To Ft d°�From To Ftod
13, GROiJ2: /� y�From_ TDoZ,-Ft t-� WeT' iyi XFmm To Ft14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft in. uL
From To Ftin. in.
15. SAND/GRAVEL PACK:
Depth Sire MaterialFrom_�To Ft. /
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS NSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONS P ION STANDARDS, T A PY]ZRECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PEF^N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Semite Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

; 11421
WELL CONSTRUCTION RECORD
North Carolina-Department of Envitnnn ent and Natural Resources--Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME Odint)H//eA; C /C4Delw5 TR CERTIFICATION ttG,-2-41
WELL CONTRACTOR COMPANY NAML SuxA—F 1A!LT� h1ri l Ott: I (*.n�. _PHONE a 29t4 HBo
STATE WELL CONSTRUCTION PERMTTa ASSOCIATED WQ PERMIT#
applicable) - - (if applicable) aft®fA
1. WELL USE(Check Applicable Box):Residential[3"/MunicipatTublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water dejection❑ Other❑ If Other,List Use
i -
2. WELL LOCATION: / TopogWhir,JLand settin
Nearest Tppwn:f�Y ¢ i o�itJ County acay-'_t ❑Ridge ❑Slope ❑Valley at
AG; �ore� sf IA 6 Div z�f 7S'2 (mat.ppoari.teca�)
(Street Name.Numbers,Commtmity,Subdivision,Lot No,Zip code) LautudcAougitude of well locadpD
3. OWNER:C/ ♦• W/ CD X�e On Ill�ei �yIPNfCS (degiudm®rtes/semeds) + �.—
Address / rs1f S' Div A GAryp Latitudellongitude source:❑GPS❑Topographic map
(Street or Route No.) (chwk box)
IW 47 /o ty ry c- '2R 7--sr-7 DEPTH DRILLING LOG
City or Town swe Zip Code From TO Formation Description
Am code-Ply number
4. DATE DRR.LED y
5. TOTAL DEPTH: ZOS'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0' s
7. STATIC WATER LEVEL Below Top of Casing:-I-Z--FT.
�QQ p (Use"+"if Above Top of Casing)
8. TOP OF CASING IS L"FT.Above Land Surface-
`Top of cadog terminated War below land surface regaim a
variance to aecordaace wltb 15A NCAC 2C.91i&
9. YIELD(gpm): (i 0 t METHOD OF TEST / ee
10. WATER ZONES(depth): cat
L ON SKETCH m
11 DISINFECTION:Type C Amount Show direction and distance in miles from at least .
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth a Weight/Ft hiaunal numbers and common mad names.
Fron>eV To_70 FL� $pR.2/ !uG Del 0 e
From Tc Ft
From To Ft
13. GROUT: Depth From_�To-zO Ft,�� Method
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From__To Ft in, in (p \\
From To Ft in. in.
15. SAND/GRAVEL PACK 90
Depth Size Material
From To Ft.
From To Ft. JJU
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS TR CTTON STANDARDS AND=THATY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-e� `1-//- oi—
1
SIGNATURE OF P4KSON 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

3110 ,t.
10
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division ofWater Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Prtnt) )9I�8`I G (C JtDC sc CERTIFICATION#�L.� u
o
WELL CONTRACTOR COMPANY NAmsSw TfA�ig-Tw Wei1 Ar. i Leta. PHONE # ( &G_q,p-Oyi7O
STATE WELL CONSTRUCTION PERM F# ASSOCIATED WQ PERMIT#
ifapplicable) if licable
I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural O ' _
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other O If Other,List Use
2. WELL LOCATION: / �rpogrgpbju/Land setting I
N st ova /t/0 KJ Coun YI tAoG�e ( Idge ❑Slope QValley [71Iai
Ptsa/eYl�9 .vw 0 .�� (check Wropriatebox) —'
(seat Nuns,Numbest Canmuutty,Subdivision,I.//a No,tip Code) Lafidade/longitude of well location
3. OWNER:(-`e "r4 aal4sq)h ' Oh I,7 3-/9MCS (aeg�mwtesreocoods)
rf Address &k eY sk P/O xw esW/C44A itude/longitude source:OGPSOTopographic snap _
(Sweet a Route No.) (ehak best) I
��_ Ad fy C., 2�7S 2 DEPTH DRILLING LOG -
City or Town State zip Cade From To Formation Description
Area coda Phone ILLED �number/ _
4. DATE DR / O S
5. TOTAL DEPTH, SO S' ' I 3
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Tap of Casing:—ZhQ-__FT. _
(Use^+^if Above Top of Casing) ;
8. TOP OF CASING IS AI FT.Above Land Surface'
-Tisp of easing terminated aVar below land suite"requires a
variance In secordwa 1SA NCAC 2C.011g.
9. YIELD(gpm): Y .�THOD OF TEST rw e
10.WATER ZONES(depth):
11, DISINFECTION:Type Amount /O o Z Sho m mules from at leaaA
12, CASING: aver Wall Thickness two on Roads.Include the road
Depth�_Ft t/ � t UG numbers d co n road names
From` To
From To Ft. •�'e
From To Ft
13. GROUT: Depth Material od }-
From_74-1 To -2 O FL Con CPC le Loop
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in
From To Ft in. in.
15. SAND/GRAVEL PACK: hlLo a
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
CONSTP,LTY,TION STANDARDS,AND PIAT A Y OF THIS CORD HAS BEEN PROVIDED TOTES WELL OWNER
- � -os-
SIGNATURE OF PERS9fq 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

311018
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NaturalResources-Division of Water Quality-Groundwater Section �
WELL CONTRACTOR(INDWIDUAL)NAM�Es (prlat)/"Y��en r- A Del t-S c-rx CERTmcATxiN G Z 7 //
WELL CONTRACTOR COMPANY NAMR>LlJ tO Fi,-T�e(_L)cj( 0p:Ili r1.9 _PHONE a &ftG9%:ag70
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# -- -
if licabie if licable - -
lip
1. WELL USE(Check Applicable Box):Residential MimicipaUPublic 0 Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other,List Use _
2. WELI.LOCATION: / graphin/Land gating
/
Nearest To jAr/0/tCounty07C-eOWC/� 13Slope QVaUey. Mal
2 3/ px"" ^y"'e w Kd 2 8 757 (ah«k.,�Prim bok)•.
(Stmt Name,Na bcM Community,Subdivision,Lot No,Tip Code) Latitude/longitude of we iQg9nOn u
/
3. OWNER: n�Gc3JC7r E�W0.PCv/l (aegreedm;maes/a��-
Address 2S/�?LY1[WW — Catitude(longitude sowccOGPS opographic ma-._,."J'
(Street or Route No.) (check box)
1 /'i UW nLG 28 7 5 2 F DRILLING Loc
City or Town Stan zip Code From To Formation Description
}
Area code-Phone nainber
4. DATE DRII r n 7 ` ` O S-
5. TOTAL DEPTH: -ZZ
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q Ek
7. STATIC WATER LEVEL Below Top of Casing(Use"+"if Above Top of Caring)8. TOPOFCASINGIS /•,� FT.Above Land Surface°
'Top of easing termlaxted attar below land surface requires a
veriaace Is aeosrdance with i5A NCAC 2C.4i1& T W 9
9. YIELD(gpm): I_METHOD OF TEST /i lwCW
10. WATER ZONES(depth): Ln ^n
LOCATION! EICH
11. DISINFECTION:Type C Amount A0 O'z Show direction and distance in miles from at le
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di or Welght/FL Material numbers and common road names, ,
From---To 70S'Ft_� so�P2/ t/G �' �/ r d/
From To Ft _
From To Ft t�
13. GROUT: Depth M
Fomr
mGM&aal j WC jC
From
To Ft )
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/ RAVEL PACK: N
Depth Size Material
From-.... Ft.
From Ta Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORD WITH 15A NCAC 2C,WELL
CONSTRUCTi}STANDARDS,AND A COP F THIS RE RD HAS BEEN PROVIDED TO THE/WELL OWNER
SIGNATURE OF PERSON OONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nam/tV Resources-Division of/j7Jatet tty-Groundwater Secti-o�n��+,
WELL CONTRACTOR(INDIVIDUAL)NAME (prlat) /jl//Ten / r /�,I- G LDS R CERTmCATION#f, [ U y
WELL CONTRACTOR COMPANY NAM •1 rLJ. A-�i'� hJ�1 QP- 11'11T__PHONE # MRVG H O
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ PERMIT#
(if applicable) (if applicable) -
I. WELL USE(Check Applicable Box):Residential O' Municipat/Public❑ Industrial ❑ Agricultural 0 .-
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other,List Use
2. WELL LOCATION: W B Togo c1L and setting
Nearest Town: Coumy � ORMdge lope QValley ElFlat
��_._���/OI�_7 (chockappmprimbox)
(Street Name,N�um� �Coaunway,Subdivisiao,Lot No.,Yp Code) Lantudeolongitude of well location
3. OWNER:A_'LXCId_L n 6 (dw"MUMUM/seroads) =.
Address g3 cryh, Latitude/longitude source:OGPSOTopographic malt
(Street or ute No.) (obs&box) ' _..
!?1 Ah.osaJ It) G. Z 75 2 DEPTH DRIUI1NG LOG
City or Toav Shoe zip Code From TO Formation Description
Area cads Phoce number
4. DATE DRILLED_ -
5. TOTAL DEPTH: J _ S
i
6. DOES WELL REPLACE EXISTING WELL? YES O NO 93�
7. STATIC WATER LEVEL Below Top of Casing:�.
(Use"+"if Above Top of Cumli) r
S. TOP OF CASING IS A JO FT.Above Land Surface*
'Tap of caslna termtaated Wor below land surface requires a
w
var(aace to aetordauce wnb ISA NCAC 2C.9111. -'
9. YIELD(gpm): Z#-70" METHOD OF TEST /n leclr+
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount /0 D 2. Show direction and distance in miles from at lea
12. CASING: Wall Thirlmess two State Roads or County Roads.Include the road
,rv/ Depth AM orD Z/ght/Fe A ateriat numbers and common road names.
From To FL
From To FL Q N
13. Fragiod
m�To?�_FLe04/UT- Depth Ma"td fad L fit)Q,a
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material WQ/(
From To Ft. in. i . •
Fro.,+-. W.-�—To Ft. in. in. '
15. SAND/ RAVEL PACK--
Depth Sin Material
From To Ft. C�
Prom4E:To Ft. L
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS U ION STANDARDS, THAT PY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PEqbN CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raieigb,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

0 311016
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural.Resources-Division Water Quality-Groundwater Section Sq�t/
WELL CONTRACTOR(MVIVIDUAL)NAME (prinr)AZ/(�!') G Ql^yNL $ �� CERTIP1CATdpN#Z707
WELL CONTRACTOR COMPANY NAMs�A-T4ec' t e �1 J P:i (t A.q PHONE v t'�'ONFO
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential W-/Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: T e/Land settin l
N st Town: tJ Cqunty Meet we Mdge ❑Valley al -
SOtAA � DX1gr 137ife.�t�;o."e.5T (meckapptWraftbm)
(Suet Name,Nambeets,Canmuoity,Subdivision,la No.,Zip Code) Latitude,7ongitude of well location
3. OWNER: elA �6W/dr/`� u� 11111 ow (delp"sh m,ms/ses�)
Address lli2. DMZ Latitude/longitude source:❑GPS&iopo0sp1ictrap
(Sacct m Rceate No.) (check box) -
1 19/'%opil fv e— 2 DEPTH DRIt.LING LOG
City m Town stm Zip Cone From To Formation Description
Aren cod>Phooc oumSrr
4. DATE DRIILED 3-Z0/- 0!j �
5. TOTAL DEPTH: �O f
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Tap of Casing._ D ' -FT. t
cS ((1sc'+^if Abwc Top of Casing) .f
S. TOP OF CASING IS FT.Above Land Surface* _y
'Top of casing term(aated War below land surface requires a
valance bt accordau i5A NCAC 2C.6IIL
9. YIELD(gpm): METHOD OF TEST l irh a r n
10. WATER ZONES(depth): �1
LOCATION SK_FTCH
I I. DISINFECTION:Type—r C& Amount /O O'L Show direction and distance in miles from at least
12. CASING: Wall Thicimess two State Roads or County Roads.Include the road
Depth DiankowY S 2/ t numbers and common road names.
Fro To Ft SpR V G
From___To Ft
From To Ft
13, GROUT: Depth Mqtbod
F=a To 2 D Ft. Or1M e^' A LO G1(
From To Ft t'd
14. SCREEN: Depth Dialneter slot size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVELPACK:
Depth Size Material r �.
From To Ft.
From To Ft.
� t
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL.WAS CONSTRUCTED IN ACCORDANCE*=M 15A NCAC 2 ,
CONS ICTION STANDARDS THA COPY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

311063
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natual Resources-Division of Water Quality-Groundwater Section
t
WELL CONTRACTOR(INDIVIDUAL)NAME (print) !9 d//I/C CERTIFICATION g0-V7
WELL CONTRACTOR COMPANY NAMSA�Wog-T- ,w Wej( Ar' I (tn� PHONE z (9ft4L49-o4F®
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIIti
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 0 Municipal/Public❑ Industrial 13 Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: /)0 / .N Topograp iclLand lley IMq. -,
Nearest T�/own:ylY©//7�l�"o/A Coe County, l 47e pRidgc ape Malley C3lelat
4t �,'/7 �pti'�Ap G 5 Z 7Ko (check app Wriatc box)
(Sumer Name,Numbers,Cosnmimity,Su�Lot No.,Zip Code) LatitudeAcing7tude of well location E-�-
O
3. OWNER: A/& >e�/ p�WSoft� (degseesimimawwcoods)
Address rn iAa Latitude4ongitudesoume:f3GPS0Topogtaph3!rp
7u
///�� " )(Sweet« No. �) (r1 box)
�nd1J(jti;Iva cme- c 2F1760 DEPTH DRILLING LOG
City or Town Stan Zip Code From TO Formation Description
Am code-Phone nomber
4. DATE DRILLED- Z'/7-B�V
5. TOTAL DEPTH, Z (e S'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO LA
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS 1, !7 FT.Above Land Surface*
`Top of casing terminated mfor below land surface requires a
vartance In ussardanc with ISA NCAC 2C.0116. r—
IF
9. YIELD(gpm): `Y O METHOD OF TEST 1✓A _ $'
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type if,Csd Amount /0 OZ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth - er asoRgy�t numbers and common mad names.
From_� ¢To Ft. 2 UG
From To FL
From To Ft. / v
13. GROUT-
T o yth
I� �O
Fmm� 70 Ft�YKI; e Wer-vi X p
From To FL
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in. !!!
From To Ft. in. in.
15. SAND/GRAVEL PACK:
DaptL size Mattxsa[ \_ 5 DR ,5out
From To Ft. Y) �01
From To Ft. h
_ q
16. REMARKS: 5 �o SP . O rf.Zi 1A w0011 W.Ole? r1
I DO HER CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL,
CONSTRUCT N STANDARDS;AND THAT P THIS RECORD HAS BEEN PROVIDED TO THE WELLOWNER
SIGNATURE OF OERSON CONSTRUCTING THE WELL DATE, -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-R sleigh,NO
27699-1636 Phone No.[phone],within 30 days. GW-T RM 07/2001

311841
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section�r�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) (fI P t155F- CERTIFICATION# �
WELL CONTRACTOR COMPANY NAME—RAA S<C 1 i It7 je (I :DY- I— I .L IV C PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential R'Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topog�ra�phie/Land setting
NearestTo%yn: L�.rt7✓ County�� ❑Ridge 2cpe OValley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:- p^t "°^ (degrees/minutes/seconds)
Address f '-�—,yam "�� Latitude/longitude source:DGPSOTopographic map
(Street or Route No.) (check box)
9-yl 9 7S t DEPTH DRILLING LOG
Citvor Town stare Zip Code From To Fo anon Description
( ate- 7 93b —� it
Area code-Phone number -
4. DATE DRILLED-4 - 49- QS
.5. TOTAL DEPTH: -?D.S
6. DOES WELL REPLACE EXISTING WELL? YES O NO 110---
_
7. STATIC WATER LEVEL Below Top of Casing:_ &6 FT.
' (Use"+"if Above Top of Casing)
8. TOP OF CASING IS J / _ FT.Above Land Surface* < ^s
*Top of casiug terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. * — '97—
9. YIELD(gpm):_4 METHOD OF TEST LE a. — --
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type 1-F 1- N Amount _ Show direction and distance in miles from at le'
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. M�a'te�riaall, numbers and common road names.
From__"_To----Ft. _
From To Ft.
13. GROUT: Depth Material � Method
From To_,�Q_FL_ry�aC/— <
From__To—Ft.
14. SCREEN: Depth Diameter Slot Size Material
From_ To _Ft. in. in. -
From To Ft. in. in.
15. SAND!GRAVEL PACK: `- I
Depth Size Material 0 '�
From To FL
From To_ Ft._ I4
ir-
16. REMARKS: ---r•-r----
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WEI;11
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL Q-byNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section, �,
WELL CONTRACTOR(INDIVIDUAL)NAME (print) LL 5 5 e- I j CERTIFICATION# a4 g3 /
WELL CONTRACTOR COMPANY NAME LL55 E L I )l I Y t 1' Y11 1- NV C. PHONE # I JS-
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential CX Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other❑ If Other,List Use
2- WELL LOCATION: \ (� Topographic/Land setting
Nearest Town: /'AWAY✓ Cou�nty 2n LY:n...�� �idge ❑Slope OValley ❑Flat
'afFll
a�.�(.u.✓ 0 __ (check appropriate box)
(Street Name,N bers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: dMo/LetA) ® ) (degrees/minums/seconds)
Address / •-� s'a — Latitude/longitude source:OGPSOTopographic map
(St et or Route No.) (check box)
DEPTH DRILLING LOG
Ciry or Town State zip Code front To Formation Description
(Rfig) i� sv z 09 8 o Spa t
Area code-Phone number �v2 r .�V-t -
4. DATE DRILLED - / Os
5. TOTAL DEPTH: e�kh� _
6. DOES WELL REPLACE EXISTING WELL? YES O NO B-�
7. STATIC WATER LEVEL Below Top of Casing:�'_FT.
(Use
'' / J
8. TOP OF CASING IS FT.Above Land Surface* S
*Top of casing terminated atlor below land surface requires a �
variance in accordance with 15A NCAC 2C.0118. — -
9. YIELD(gpm):_�_METHOD OF TEST -
N
10.WATER ZONES(depth): 44�' — —"
LOCATION SKETCH O
11. DISINFECTION:Type- ! T f Amount Show direction and distance in miles from at Iasi
12. CASING: Wall Thickness two State Roads or County Roads.Include theme ad
Depth Diameter or Weight/Ft. Materials numbers and common road names.
From_ ._To �r�Ft. _-P I/L,
From_—._To Ft.
From To Ft. _
13. GROUT: Depth Material Method
-�.'_---
From�J To�Q Ft. 7 From__To Ft. rn
14. SCREEN: Depth Diameter Slot Size Material 77 _
From To _Ft. in. in. -
From--To--Ft.—in. in.
15. SAND./GRAVEL PACK:
Depth Size Material
From To Ft. <
From To FL_
1
16. REMARKS:
i
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
' I
1# 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

3118931
Norte Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1e36 Mali Service Center-Ralelgh.N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /70f /4A/,/ 0A I,
WELL CONTRACTOR CERTIFICATION # :
,� /STTATE WELL CONSTRUCTION PERMIT# :
'v5 I. USE (Check Applicable Box): Residential E—, Municipal ❑ Industrial❑ Agricultural ❑ Moniternc
?ecovery Heat Pump Water Injection Other If Other, List Use:
4S I LOCATION ( how skrrtch of the location below) M
Nearest town. �� �`r d'd County
6/��s` Syy>rth �Ui�l.
=�nd Neme a�ndVfNum ers Community. or Subdivision and Lot No DRILLING LOG DEPTH
1WNER f "/ �r/1 � � � A. � From To Formation Descr.IT
;:dress y'� -QfiShn e No
—�-7S" me or out .
m cr Town State Zip Code
;ArF f)RII I-FO
A -)F,.PTH
- '`:NGS COLLECTED YES Q NO® -
- DOES WELL REPLACE EXISTING WELL? YES ] NO®
o S TAT'C WATER LEVEL Below Top of Casing: 4 FT . C) _
(Use'+" if above Top of Casing)
9 TOP OF CASING IS FT. Above Land Surface'
"op a' rasing terminated at/or below land surface requires a variance in accor-
dance with '.5A NCAC 2C 0118
1C vEILU (GPM): 240* METHOD OF TEST /6/4
VATFR ZONES (depth):
"A
(.Ht. RINATION: Type Hf� Amount /, If additional space is needed use back o'form
Wall Thickness
Denth Diameter or Weight/Ft. Material -
o ifa t ay.� spy yfU IOCATION SKETCH
To �^ Ft (Showdirection and distance from at least two «ate
Roads. or other map reference poirts)
To Ft
'd -,Pr_`' IT I
Depth Material Method - • -
To Ft
To Ft
I
'E SCREEN.
i
Depth Diameter Slot.Size Material _
� nm To Ft in In.
..��. _ To Ft in in. j -
� nr^ To Ft in in.
IF SAND/GRAVEL PACK: --
Depth Size Material
to Ft
om To Ft
FMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY �jei �„�c. 5--/•5-e 5
'),,art No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV '.;roc.

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Sectionf-
1636 Mau Service Center-Ralelgh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �d 0/% hiN 1
WELL CONTRACTOR CERTIFICATION 8 : ;3d q 4
STATE WELL CONSTRUCTION PERMIT 1
✓BELL USE (Check Applicable Box). Residential Municipal ❑ Industrial❑ Agricultural ❑ Moniton,c t
Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other. List Use:
?CATION. (Show sketch of the location below)
vcar^st town /rl4 A1',PA/ A/C, County /`fi j peaa ,544
-nnd Name and
Numbers.Community,or Subdivision and Lot No DRILLING LOG DEPTH
n\1JNER 7,4Al • 44 Li AYrAr From To Formation7tr Desc;rn'n
NL6aet or Routs
NyezBaG/
.,to or Town State Zip Code
a i)ATF DRILLED '.2 -i3
5 rOTAI. DEPTH 7'F7
F; Cu'TINGS COLLECTED YES ❑ NO®'
DOES WELL REPLACE EXISTING WELL? YES NO�
WATER LEVEL Below Top of Casing FT. G
y (Use's`if above Top of Casing) `+
d TOP OF CASING IS 15 FT. Above Land Surface (,A
'or cf casing terminated at/or below land surface requires a variance in accor-
dance with '5A NCAC 2C 0118
VI-'.I :) (GPM) /yt METHOD OF TEST
' �;n-Fn ZONES tdepth)
-.,-ai f:RINATION- Type Amount If additional space is needed use back of form
A51NG. Wall Thickness
neDth Diameter or Weight/Ft Material
- to s?, Ft L $b .2 y.� 405T,4 I OCATION SK T •H
To rt (Show direction and distance from at least two State
Roads or other mac reference points)
la :R(-)IIT -
Depth Material Method -- -
rom To Ft
- .m To Ft
i
,C c;r,P F FN _
Depth Diameter Slot.Size Material -
,��. To Ft in in.
- nm To Ft in in. -
.�m _ To _Ft in in - -
Th SAND/GRAVEL PACK: --
Depth Size Material To Ft
n To Ft
�FMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
nNSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T/HEE,WELL OWNED
FOR OFFICE USE ONLY
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV `1%

311889
I Carolina Department of Environment and Natural Resources-Division of Water Ouality- Groundwater Section
1636 trial Service Center - Raleigh, N.C. 27699-1636-Phone [phone] fJ
WELL CONSTRUCTION RECORD WELLCONTRACTOR: / ctr "� E �� ' ',t''^' S
WELL CONTRACTOR CERTIFICATION 0: ao iiirL
�{STATE WELL CONSTRUCTION PERMITN: _/ >V x
1 WELL USE (Check Applicable Box): Residential CJ Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION. (Show sketch of the location below) M
Nearest Town. ��^'�a, '�`+� County. `
.�ziz /{•ddFti hq+�� 4Gv 4„a 17 _
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER 727f Wz" From To Formation Descni
Address 4 .9`UN Atli /=f M7 Ad
Ati
!reel or Dula DT
—'City or Town State Zip Code
4. DATE DRILLED % -
5. TOTAL DEPTH - 0
6. CUTTINGSCOLLECTED YES NO�' 131
7. DOES WELL REPLACE EXISTING WELL? YES 7 Ni _ --
-t
E. STATIC WATER LEVEL Below Top of Casing: _7j—_Ff. „
(Use'+'it Above Top of Casing) F
9. TOP OF CASING IS {S FT. Above Land Surface' �J
-Top of casing terminated allor below land surface requires a variance In actor-
dance with 15A NCAC 2C 0118 no,
10, YIELD (gpm): 3 }- METHOD OF TEST -
11. WATER ZONES (depth).
12. CHLORINATION: Type A`T/d Amount Z It additional space is needed use back of form
13 CASING.
LOCATION SKETCH
Wall Thickness
Depth Uiamemr or WeignVFt. Material (Show direction and distance from at least two State
From To Tom) Fl, G SOn]7.Z �6sY.� Roads,or other map reference points)
From To Ft.From To Ft. --- - - _ -
14. GROUT:
Depth Material Method
From To Fi.
From _ To Ft. j
1 S. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. _ in.
From To Ft. in. in.
From To Ft.— In. In.
16. SAND/GRAVEL PACK.
Depth Size Material
From _ To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
FOR OFFICE USE ONLY
Quad No SI NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW I REV. 12)99
Serial No

North Carolina Department of Environment and Natural Resources- Division of Water Quality- Groundwater Section
1636 Mal Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: r ub' � � tea" KC. -V Y
WELL CONTRACTOR CERTIFICATION #: lS4
STATE WELL CONSTRUCTION PERMIT#:
1 WELL USE (Check Applicable Box): Residential ml- Municipal ❑ Industrial❑ Agricultural❑ Moniloring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION. (Show sketch of the location below) /�
Nearest Town: M/a A/O, / County. -£ jo
3391, /`:��/. yI=uw /t d _
(Road Name and Numbers.Community or Subdivision and Lot No.) DRILLING LOG DEPTH
3, OWNER 1006fALd x • RX/o�Fv J,d From To Formation Descripl,u.,
Address 3 ge I-/ J`I/✓ —
Sir
et or Houle No.)
City or Town ;gSttale Zip Code -
DATE DRILLED ,w%?-3 'v`t
5. TOTAL DEPTH 166 ;c
6. CUTTINGS COLLECTED YESD NOE!]�_ ^-
7. DOES WELL REPLACE EXISTING WELL? YE� NO�
E. STATIC WATER LEVEL Below Top of Casing: FT. sA
(Use'+'if Above Top of Casing)
9. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated eUor below land suAaca requires a variance In scoot-
dance with 15A NCAC 2C A,,lya
10. YIELD (gpm): L7 METHOD OF TEST
11, WATER ZONES (depth):
12 CHLORINATION: Type Am If additional space is needed use back of lorm
13. CASING:
Wan Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
Front G' --V ! To Ft.—6 ,S On a7•C 4P<t_s;'l Roads,or other map reference points)
Frorn To Fl.
From To Ft.
1— GROUT — ,I
Depth Material Method _ ,���'`7
From To Fl. -
From To Ft.
15. SCREEN. ,I
Depth Diameter Slot Size Material
From —To— Ft — in. in.
I
From _ To Ft. in. in. —
From — To Ft. in. in.
16. SAND/GRAVEL PACK: -
Depth Size Material - - --
From _ To Ft. -
From To Ft.
17. REMARKS'.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD Hi BEEN PROVIDED TO THE WELL OWNER
/1
FOR OFFICE USE ONLY i/�5/r�L/
Quad NO SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Oualily.Groundwater Section within 30 days
Senal No. GW-I REV. 12/99

311888
North Carolina - Department of Environment and Natural Resources Division of Water Quality-Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: / l12A4wd ^� « "Ai 5
WELL CONTRACTOR C RTI FICATION N: SG9
STATE WELL CONSTRUCTION PERMITp: jJn
1. WELL USE (Check Applicable Box): Residential ER� Municipal ❑ Industrial ❑ Agricultural❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ It Other, List Use:
2. WELL LOCATION. (Show,sketch of the location below) n n
Nearest Town: A/4nr O^/ N.C, County: A'C ✓UW ES L
d'�i�W.a[Kf1. Rd-�/iddlilyt.o4's fST�ioi# 8 _•
(Road Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER AA� po,t,$Z141 Sys J.�' From To Formation Descnpno,
Address l34 c,,4 V/A rr pw- f{{ —
tSireet o� o.
Nf0%-S 9,y 7'drsl /-V Ci
City or Town Stale Zip Code
DATE DRILLED -✓ ` 'D •"�
5. TOTAL DEPTH ✓'$'Z ,$
6. CUTTINGS COLLECTED YES F_� NOJ� —
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOEJ_ 3 7—
6. STATIC WATER LEVEL Below Top of Casing: AI f,AFT.
(Use'+'it Above Top of Casing) tV t'e
S. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface requires a variance In actor. 0
dance with 15A NCAC 2C.0118 _
10. YIELD (gpm). ,1 METHOD OF TEST
1 t. WATER ZONES (depth).
12. CHLORINATION: Type ff TH Amount / d If additional space is needed use back of form
13. CASING'
Wall Thickness LOCATION SKETCH
Depth Diameter or WeighVF1 �Material
(Show direction and distance from at least two State
Front To 4 r FL G b dh z7, !C Roads, or other map reference points)
From To Ft.From To Ft. —
14. GROUT:
Depth Material Method
From To FL
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material From —To— Ft in. — in.—
From To Ft. in. in. — -
From — To Ft.— in. in.
16. SAND/GRAVEL PACK:
__----.
Depth Size Material
From _ To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS �E ECCjOORRED HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY -r -_ �ZJ "� / - 1
2 _ O�
Quad No: SIGNATURE
amURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality.Groundwater Section within 30 days
6enal No. GW I REV. 12/99

311 '7
Norm Carolina Deparlmern of Environment and Natural Resources Division of Water Oualny- Groundwater Section
1636 Mail Service Center Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: � ' `'� ' A`�
WELL CONTRACTOR CERTIFICATION s: 3C1G
STATE WELL CONSTRUCTION PERMITC I V o
1 WELL USE (Check Applicable Box): Residential 2ST Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Heal Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCATIONN. ( no sketch of the location below) �1�
Nearest Town. "/ hiw: : County. memo w'tzG L
(Roan Name and Numbers.Community,or Subdivision and Lot No.) DRILLING LOG DEPTH _
3. OWNER 9^c� Off F/oS From To Formation Descnpt,uI
Address T Ta/ out Y /2cl _
eel or N if
City or Town 7 Stale Zip Cade 'r-?
4. DATE DRILLED J "+ �%'0
5. TOTAL DEPTH ZI
6. CUT71NGS COLLECTED YES
7. DOES WELL REPLACE EXISTING WELL? YES F� NO�}��. -
E. STATIC WATER LEVEL Below Top of Casing: yy FT.T— c»
- (Use'.'it Above Top of Casing) y
9. TOP OF CASING IS FT. Above Land Surface' O t"
'Top of casing terminated a1/or below land surface requires a variance In actor-
dance with 15A NCAC 2c,,�}}1a n// ���
10. YIELD (gpm): dT METHOD OF TEST 4
11. WATER 20NES (depth).
N r1A ---
12. CHLORINATION: Type Amount — II additional space is needed use back of lorm
13. CASING:
LOCATION SKETCH
Wall Thickness -
Depth Diameter or We ht/Ft. Material (Show direction and distance from at least two Stale
From— To �b FL Z [ d'46 C Roads, or other map reference points)
From To FI. —
From To Ft. --
14. GROUT: t_-
Depth Material Method
l
From — To —Ft. -
From To Ft. -
15. SCREEN: _ �I
Depth Diameter Slot Size Material
From To Ft _ in. in.
From To Ft. in. in. --
I c F ! d
From To Ft._ In. in.
16. SAND/GRAVEL PACK _
Depth Size Material � ' t r--
From __ To Ft.From To Ft.
17. REMARKS'.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quao No: SIGNA URE OF PERSON CONSTRUCT NAG—THE WELL DATE
Submit original to Division of Water Quality,Groundwater Section within 30 days
GW I REV. 17J95
Senal No

lam` - 310710
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resourc D/i/vision of Water Quality-Groundwater Section ���3
WELL CONTRACTOR(INDIVIDUAL)NAM (PAWL) f t/ ` r� // CERTIFICATION
WELL CONTRACTOR COMPANY NAME /r` ' PHONE # Iq �
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ P
ifapplicable) ifapplicable)
111110101
1. WELL USE(Check Applicable Box):Residenti Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use/ `
2. WELL LOCA l n r Topoe/Land setting
Ridge lope
❑ Malley OFlat
E12 (check appMnatebox)
(Steel Name,Numb Community ubdivision,Lot N .,Zip Code) Latitudellongitude of well location
3. OWNER: (depemlinimtes/seeonds)
Address Latitudellongitude source:❑GPS❑Topographic map
No.) (eheea box)
DEPTH DRILLING LOG _
City a Town State tip Code From To Formation Descriptiof3
Area code-Phone taunber
4. DATE DRILLED, d
5. TOTAL DEPTH: pp
6. DOES WELL REPLAC STING WELL? YES❑ O '>
7. STATIC WATER LEVEL Below Top of Casing: FT. '
(Use'**"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Cuing)
'Top of casing terminated Wor below land surface requires a
variance(�;rdaneA7d(h 15A NCAC 2C.011S ( g--
9.
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 WeightTL Material numbers and common mad names.
From To Ft 7O
From_To FL �L
From To Ft
13. GROUT: Depth
From To Ft�=++ '�__Lk
From To Ft t�
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK--
Depth Size MaterialFrom—To—Ft.
From To Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS CTION ST S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THP WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DfATE
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
Q�
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section v6 d3
WELL CONTRACTOR(INDIVIDUAL)NAME riot E I // CERTIFICQA�TQIO/N p ?
WELL CONTRACTOR COMPANY NAME I I✓�N L i II� /�°PHONE # "' `�D �J
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if liable if ap 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 N: �,/� ������,,��� Topo d setting
Nearest j County/,- t`�C ILv J1 ❑Ridge ope ❑Valley ❑Flat
g"7,-a k (check app Wnate boot)
(Shad Name,NI umr,be Community,Subdivinoonn,Lot No.,yP Code) Latitude/longitude of well location
3. OWNER: Ki(Y) Imo[ oQDC4 (depees/mimnesttsecmds)
Address 111')A I Latimddlongitude sunace:❑GPS❑Topographic map
check box)
TII I&O (stteee j Route No.) ��� DE ( DRIFTING LOG
City or Town Stan tip Code From To Formation Description
Area ado-Phwe m®bes
4. DATE DRILLED 3 O ty
5. TOTAL DEPTH: 92
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
n
7. STATIC WATER LEVEL Below Top ofCasing:
(Use-+-if Above Top of Casing) CO
8. TOP OF CASING IS FT.Above Land Surfaces z
'Top of casing terminated attar below land surface requires■ e3
variance in acenr4ance with ISA NCAC 2C.01xS Ul
rr
9. YIELD(gpm): W METHOD OF TESTl3a 1. XaL '
10.WATER ZONES(depth): c-50
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 Welght/Ft. Material numbers and common road names.
From To Ft
From Tc Ft
From Tc FL j�
13. GROUT: Depth
From To
14. SCREEN: Depth Diameter Slot Size Material
From Tc Ft in. in. ----
From To Ft in. f'v
15. SAND/GRAVEL PACK 1
Depth size Material ". ... 1
From To Ft.
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT SWELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS ON STANPARD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUAE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27 6 9 9-1 63 6 Phone No.[phone],within 30 days. GW-1 REV.07/2001

0 0010709
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and patural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDrADUAL)NAME (print) R+4R a GkA6 CERTDrICATION
WELL CONTRACTOR COMPANY NAME J �IAC I i X�c h lI N -PHONE #
STATE WELL CONSTRUCTION PI ASSOCIATED WQ PERMIT#
if linable ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT N:
Nearest To OOmy ERidgeSlope all ❑Flat
Io9G �C g36y (check appropriate box)
(Street Name,Number,C4nrunity,Subdi
visi
on,Lot No.,Tip Code) Latitude/longitude of well location
3. OWNER: 10 co t/'(/ W �DEL� (degrcdminnuWso=nds)
Address Tn ��3 �' Latitude/longitude source:❑GPS❑Topographic map
dwk box)
y(s Route No.) n DES ( DRILLING LOG
City or Town State tip cone vS From To Formation Description
Am code-Phone ruznber
4. DATE DRILLED -3 19 t
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ery ro
7. STATIC WATER LEVEL Below Top of Casing:
(Use if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* w
'Top of wing termimted sHor below land surhcc requires■ o
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): I g Q_METHOD OF TEST�C
10.WATER ZONES(depth): /q 0
_ 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 weightiFt. Material numbers and common road names.
From To Ft Ltd
From—To FtFY5
/
From To Ft ��
13. GROUT: Depth
From To Ft l�j,�1�` '` r
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. Tc Ft. L
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS UCTION ARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED T THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

� ii " Li Z'
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) ROBIN MCNEELY PTT WELL CERTIFICATIONPHONE# (8251453-0662
WELL CONTRACTOR COMPANY NAME TMAN BORING,LLC
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agrr77 ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: To 1nc/Land setting
Nearest Town:MARION County MCDWL Topographic/Land
❑Ridge El slope ❑Valley El Flat
HOFFMAN TRAIL
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code)
LatitudeAongitude of well location
3.OWNER:RICHARD HUDSON
Address HOFFMAN TRAIL (degreestinuales/seconds)
(Street or Route No.)
MARION NC 28752 Latitude/longitude source: Elkbo El Topographic map
City or Town State Zip Code (check box)
DEPTH
U-- From To
Area Code Phone number
4. DATE DRILLED 04/28/05 DRILLING LOG
5.TOTAL DEPTH: 34 From To
6.DOES WELL REPLACE EXISTING WELL? YES® NO❑
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use`.+,,if Above Top of Casing)
S.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD(gpm): 14 METHOD OF TEST STEEL TAPE number and common names
10.WATER ZONES(depth): HWY.#226 N.FROM POLKVII LL LEFT ON
HWY.#64 L LEFT ON MT.OLIVE CHURCH RD.
It.DISINFECTION:Type CHLORYTE Amount 6.4 LEFT ON HOFFMAN TRAH-LEFT(a,)FORK
12. CASING: Wall Thickness HOUSE ON LEFT na DEAD END.
Depth Diameter or Weight/Ft Material
From 0 To 34 Ft 24" CEMENT
From_To_Ft. to
From_To_Ft_ y
13. GROUT: Depth Material Method -c
From 0 To 20 Ft.CEMENT POURED w
From_To epth_Ft
14.SCREEN: D Diameter Slot Size Material can
From_To_Ft._ in, _ in, a
From_To_Ft._ in. _ in
15. SAND/GRAVEL PACK:
Depth Size Material
From 14 To 34 Ft 78M GRAVEL
From_To_Ft
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
HAS BEEN PROVIDED TO THE WELL OWNED
CONSTRUCTION STANDARDS, AND THAT A COPY OF RECORD
cl-, >> 0 e
SIGNATURE OF PERS,'O) ONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:NEBO County MCDL Topographic/Land setting
COLLINS LANE ❑Ridge ❑ Slope ❑ Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3.OWNER:GLENN YUTZi( Latitude/longitude of well location
Address COLLINS LANE
(Street or Route No.) (degrees/minutes/seconds)
NEBO NC 28761 Latitude/longitude source: ❑GPS ❑Topographic map
City or Town State Zip Code (check box)
8( 28)—652-7056 DEPTH
Area Code Phone number From To
4.DATE DRILLED 04/07/05
5.TOTAL DEPTH: 345 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use"V'if Above Top of Casing)
8.TOP OF CASING IS 1-112 FT. Above Land Surface" LOCATION SKETCH
'Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD(gpm): 60 METHOD OF TEST ARD number and common names
10.WATER ZONES(depth): HWY.#226 N.FROM POLKVILLE.LEFT ON
LANDIS LANE.GO APPROX.2.5 MILES.LEFT ON
11.DISINFECTION:Type CHLORYTE Amount 9 JOE BRANCH RD.RIGHT ON COLLINS LANE.1/4
12. CASING: Wall Thickness MILE ON RIGHT.
Depth Diameter or Weight/Ft Material
From 0 To 40 Ft 64/4" SDR21 PVC
From_To_Ft_
From_To_Ft._
13. GROUT: Depth Material Method ]
From 0 To 20 Ft QUIKRETE POURED 3
From_To t_F
14.SCREEN: Depth Diameter Slot Size Material ?
From_To_Ft._ in. in.
From_To_Ft._ in. in. o
15. SAND/GRAVEL PACK: c n
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
CON534UMON STANDARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
'4) -- /��"�17
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

3114 i' ry
WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) NEIL CRAFT CERTIFICATION# 3114
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial Ll Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: MARION County MCDL Topographic/Land setting
14036 HWY.#221 N. []Ridge [-] Slope ❑Valley [—]Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:JOE OUINN Latitude/longitude of well location
Address 14036 HWY.#221 N.
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
8828)—756-4406 DEPTH
Area Code Phone number From To
4.DATE DRILLED 04/26/05
5.TOTAL DEPTH: 265 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES® NO❑ From To
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD(gpm): 30 METHOD OF TEST ARD number and common names
10.WATER ZONES(depth): FROM MARION GO UP HWY.#221 N.APPROX. 1
1/2 TO 2 MIMES PAST BAXTER.HOUSE IS ON THE
11.DISINFECTION:Type CHLORYTE Amount 6 RIGHT WITH WHITE VINL� FENCE AROUND TT.
12. CASING: Wall Thickness #140 =
Depth Diameter or Weight/FL Material ( 3G1 t .
From 0 To 105 FL 6-1/4" SDR21 PVC y
From_To_FL
From To_Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.OUHOtETE POURED
From_To_FL
14.SCREEN: Depth Diameter Slot Size Material I :i
From_To_Ft_ in. in. Lnt'
From_To_Ft._ in. in.
15. SAND/GRAVEL PACK:
Depth Size Material { I
From_To_Ft._
From To Ft.
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE/WELL OWNER
*� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center—Raleigh,NC
27699-1636 Phone No. [phone],within 30 days. GW-1 REV.07/2001

0. 311994
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
7(1/p
WELL CONTRACTOR(INDIVIDUAL)NAME (print) d C. - r LZc H CERTIFICATION#�
c
WELL CONTRACTOR COMPANY NAME t ��_ CJ= L I 1)IL ]1,, () PHONE # 0� 2 3! 37
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential 6' Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Tow R 3r,,\ As .County .;tlit, f/ 4idge ❑Slope ❑Valley ❑Flat
is (check appropriate box)
(Street Name,Numbers,Community,Subdivision,
Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:_XOM�� �--�-�—��� 04 J 14 —� (degrees/minutes/seconds)
Address a'3 y '� Cat —611' L*, Latitude/longitude source:❑GPSOTopographic map
(Street or Route No.) (check box)
0J �f'.0 2�`� ,C'2 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
C&-' 73D' d3& g
Area rode-Phone number
4. BATE DRILLED — aZS lJ S
5. 1 OTAL DEPTH:—__ _
G. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fir
7. STATIC WATER LEVEL Below Top of Casing: &ay5' FT.
(Use"+"if Above Top of Casing) r5
S. TOP OF CASING IS FT. Above Land Surface* -- ---N
*Top of casing trrminated at/or be:ow hand surface requires a — --
varianee in nccordan``e with 15A NCAC 2C.0118.
9. YIELD(gm): METHOD OF TESTAJa r r J_1--_ITS
10.WATER ZONES(depth):-�� F`T ---- M
LOCATION SKETCH a
11. DISINFECTION:TypeC'.ea1 1;_ Amount! Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. 1
From/ i —Ft.--6L1s 1{ J et
From___To_--Ft.---_ 7IT_ ��>;t,G ..Cl r
From_____To__Ft._
13. GROUT' Dep�jt� Material Method S 11 S 1���� e e
Fromil,TmC Y__Ft._Cfl z, .x���. _ (�Ics't- Gnu 1,\4' �1t, hl�. i5 A&
From To__ __FL y
14. SCREEN: Depth Diameter Slot Size Material
From__To—Ft. in. in. �t �,a
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. -ZkX
From To Ft.
1 b. REMARKS:
I DO HEREBY CERTIFY TI1AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELLi
CONS7RIICTION tINIDARDS,AND THAT A FOPY 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.0712001

rn
North Carolina.Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mail Service Center-Raleigh,N.C.27699-1636-Phone[phone] 2 9 3 2
WELL CONSTRUCTION RECORD WELL CONTRACTOR: S� l��f rh)w Z.;
WELL CONTRACTOR CERTIFICATION#: ;2 lJ:S—
STATE WELL CONSTRUCTION PERMIT#: I7 d e rer—
1. WELL USE(Check applicable Box): Residential[9—Municipal ❑ Industrial❑ Agricultural❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION:(Show sketctl of the location below) .N a
Nearest Town: ;�Qn r d N County. //7C- kw
JU
erz h�a. cA/OS
(Road Name and Numbbe Community or Subdivision Lot No.) DRILLING LOG DEPTH
3. OWNER <C'7f'1 y-/, do .5 PaOA r From To /Formation Descriptforb
Cn
Address e(f�sL,( G�za riS z ���-� ,La� �z --
toweetor Route o.
/3J,Q4?i A it/ /UC
City or Tom Stale zip coos
4. DATE DRILLED 5�''-F
S. TOTAL DEPTH I"')
6. CUTTINGS COLLECTED YES❑ NO[cJ
7. DOES WELL REPLACE EXISTING WELL? YES NOe o 0
8. STATIC WATER LEVEL Below Top of Casing: �_FT. $'
(Use'+'8 Above Top of Casing)
9. TOP OF CASING IS FT.Above Land Surface* ca cam_
'Top of easing terminated atior below land surface requires a variance In aeeor.
dance with 15A NCAC 2C.0118
10. YIELD(gpm): JoL METHOD FTEST —
11. WATER ZONES(depth):
N <"x
rn�
H2W Amount�. If additional space Is needed use back of foN
12. CHLORINATION: Type P —_
13. CASING: z
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/FL Material (Show direction and distance from at least two State
From ToQg Ft. 6-- - _ Roads,or other map r erence points)
From To FL—
From To Ft. zn T6e_
14. GROUT: �d
Depth /ablate ' Method
From To s Ft. e.2 r� i/l,Y e— a
From To Ft.
15. SCREEN: i
Depth Diameter Slot Size Material
From —To—Ft— in. —in.—
From To_Ft. In. In.
From _To_FL in. in. L — '
16. SAND/GRAVEL PACK: T c
Depth Size Material
From To - Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL F =-
CONSTRUCTION STANDARDS,AND THAT A COPY 0 THIS RECORD HA BEEN PROVIDED TO THE WELL OVEN Bj.l Gm ,
�.r
FOR OFFICE USE ONLY
Quad No: SIGNATURE IbP PERSON CONSTRUCTING THE WELL DATE .
Submit original to Division of Water Quality,Groundwater Section within 30 days
Serial No. GWt REV.12199

0-�o
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ' 10148
1636 Mail Service Center-Raleigh,N.C.27699.1636-Phone[phone] Q
WELL CONSTRUCTION RECORD WELL CONTRACTOR: �� �� °•'aJ Qom" '
WELL CONTRACTOR CERTIFICATIONS:
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE(check Applicable Box): Residential El Municipal❑ Industrial❑ Agricultural❑ Monitoring❑
Recovery❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: v d " ////' County: �I/lk 161460C-
tI
�r
(Road Name and rs.Comnxmi or S�ugivision and Lot No.) DRILLING LOG DEPTH
3. OWNER Q Sh Oct TC T From To Formation Description
Address In �g `g
(street or Moule —o
X,QGIr`a ' P
City or Town State Zip Code
4. DATE DRILLED S /2-42 n
5. TOTAL DEPTH AQ 0
6. CUTTINGS COLLECTED YES❑ NO©— � -
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ-
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'.'s Above Top of Cuing) Co
9. TOP OF CASING IS FT.Above Land Surface* o
'Top of"sing terminated at/or below land surface requires a variance In accor. :E1:
10. YIELD(gpm): oZd METHOD OF TEST
11. WATER ZONES(depth):
12. CHLORINATION: Typed Amount If additional space Is needed use back of form
13. CASING:
LOCATION SKETCH
Wall Thickness
1 / Depth _ D or WeighrlFL enal (Show direction and distance from at least two State
From�To Ft. 6 Roads,or other map reference points)
From To Ft.—
From To Ft. er �a
14. GROUT: C��
Depth ate al Method
From To 00 Ft. �� n?i srBr !7'
4
From To Ft. ( S
15. SCREEN: S
Depth Diameter Slot Size Material
From _To_.Ft in. in.
From —To—Ft. in. In.
From _To_Ft. in. — in. y
16. SAND/GRAVEL PACK: p
Depth Size Material 77
From To Ft.
From To Ft.
17. REMARKS:
i
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL a ,
CONSTRUCTION STANDARDS,AND THAT A COPY OF TH RECORD HAS BEEN PROVIDED TO THE WELL OWNER. -0
FOR OFFICE USE ONLY
Quad No: SIGNATURE OR9ERSON CONSTRUCTING THE WELL MATE.�-; c7t _
Submit original to Division or water Quality,Groundwater Section within 30 days , - _
dW�T.REV. @!9
Sedal No. _
- cap
1

�e
308488
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
-7
WELL CONTRACTOR(INDWIDUAL)NAME (pilot). yD/?T�2 CERTIFICATION#z /
..
WELL CONTRACTOR COMPANY NAMn3we4—.71t}'1`� It seii OP:I Uag PRONE # &941 '0.00
STATE WELL CONSTRUCTION PERMrr# ASSOCIATED WQ PERMTf#
ifa livable ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: �000graphic/Land setting a
Nearest Town: r�A/t/ /V County ! u9 dge ❑Slope ❑Valley ❑Flat
#'/9 i45� —!3—./rla7-�� /�"�nas 75i79,(�— (�kappropriamboa) N
(Sued Name,Numbm�ity,Subdivision,Lot No.,2Ip Code) Latitude4ongitude of well location-
3. OWNER:_�L([K ,5'M/ 7'`7 (degtees<minuestsesonds)
Address ofr/^r ,—Pd� Latitudellongitude source:❑GPS❑Topo"hic trap
(Snort or Route Ito.) (chatbox)
fflAA-16iU N zb 7" DEPTH DRILLING LOG
City w Town state tip Code From To Formation Description
(^}-
Area code.Phone Wombat _
4. DATE DRILLED 7. `�S�O$ _
5. TOTAL DEPTH:�//6i
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Eiz�
7. STATIC WATER LEVEL Below Top of Casing:—FT.
(Use'+-if Above Top of Casing)
8. TOP OF CASING IS /.5 FT.Above Land Surface"
`Top of casing termtaated aUor below land surface requim a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(pm):_ZQ_^METHOD OF TEST T/�w e/ 00
10.WATER ZONES(depth): LOCATION SKETCH N
11. DISINFECTION:Type Amount 6 02 Show direction and distance in miles from at le(A 33
12. CASING: Wall Thickness two State Roads or County Roads•Include the ad
or WeighUFt. Material numbers and common road names.
Ftor To FL of SDRz/ pvc gfti �//' e1�(/
From To FL S IY9co5
From To Ft
13. GROUT: Depth Materiq ethodJul�To70FLCMCIOO)jif WP / 6•From To Ft VV
14, SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft, in. in.
\ cc
15. SAND/GRAVEL PACK:
Depth size Material I t .
From�To Ft. Ru
From To Ft. ���
t „
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL
CONSTRUCT ION STANDARDS,AND-�Eie�}'A COPOF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF RSON 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

l�
� 08495
WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print) ROBIN MCNEELY CERTIFICATION# 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If other,List Use
2. WELL LOCATION:
Nearest Town:MARION County MCDWL Topographicd and setting
VEIN MTN.RD. ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:KENNETH PRESNELL Latitude/longitude of well location
Address VEIN MTN.RD.
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑GPS ❑Topographic map
City or Town State Zip Code (check box)
8�)—584-9590 DEPTH
Area Code Phone number From To
4.DATE DRILLED 02/09/05
5.TOTAL DEPTH: 47 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 27 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1 1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated at/or below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD (gpm): 20 METHOD OF TEST STEEL TAPE number and common names
10.WATER ZONES(depth): HWU.#226 N.FROM GOLDEN VALLEY.LEFT
ON VIEN MTN.RD.APPROR.3 MILES ON LEFT.
11.DISINFECTION:Type CHLORYTE Amount 9.2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 47 Ft 24" CEMENT
From_To_Ft._ i
From To Ft
T:13.GROU_Dep_th Mate_rial Method
From 0_To 20 Ft.CEMENT POURED
7
From_To L_F
14.SCREEN: Depth Diameter Slot Size Material co
From_To_Ft._ in. in. C
From_To_Ft._ im in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 27 To 47 Ft. 78M GRAVEL
From_To_Ft
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1 C �
SIGNATURE OF PE CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center—Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

r F ^
L 308507
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:MARION County MCDL Topographic/Land setting
MARVIN WH,LIAMS DR ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER: MARTY SMITH Latitude/longitude of well location
Address MARVIN WH LIAMS DR
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
8( 28)-925-7367 DEPTH
Area Code Phone number From To
4.DATE DRILLED 02/07/05 _
5.TOTAL DEPTH: 185 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 5 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing tenninated attor below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two State Roads or County Roads. Include the road
9.YIELD (gpm): 60 METHOD OF TEST ARD number and common names
10. WATER ZONES(depth): HWY.#221 N.FROM MARION.STAY STRAIGHT
ON HWY.#221 N.APPOROX. 1 1/2 MILES PAST
11.DISINFECTION:Type CHLORYTE Amount 3.5 BAXTER
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 40 Ft 6-1/4" SDR21 PVC
From_To_Ft._ `S
From
T: To t_F _ _
13. GROU_Depth Material Method a
From 0 To 20 Ft.OU1KRETE POURED ,
From_To Ft o�
14.SCREEN: Depth_ Diameter Slot Size Material 0 f"
From_To_Ft._— in. in. cJt
From_To_Ft. is 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
CONSTRJJCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAAM OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i I0.1'VleS A/l.). l/+et.YVt'�Oi— CERTIFICATION ki 119
WELL CONTRACTOR COMPANY NAME�O5 eI .�. PN1M C, i LYtC• PHONE N &n Y53-�3��
STATE WELL CONSTRUCTION PERMITN ASSOCIA E�PERMrrN
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential P1 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: ,f� Topographic/Land setting
Near st Town:_�1 (I,p'jv�. County, &C aalz pRidge ❑Slope 'Valley OFlat
(check appropriate box)
(Street Name,Numbers,Community Subdivision Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: � (de source:Ds/seconds)
Address ( l-}i d n �I C'te.) ern Latitude/longitude source:OGPSOTopograpfiic map
(Street or oute No.) l (check box)
Mq Oy ( S2— DEPTH DRILLING LOG
City or Town State Zip code From F nation Des ripti
O
Area code-Phone number
4. DATE DRILLED -
5. TOTAL DEPTH::
6. DOES WELL REPLACE EXISTING WELL? YES,0�NO iel
7. STATIC WATER LEVEL Below Top of Casing: V FT. C�
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* JL
"Top of casing terminated at/or below land surfatt requires a
variance in accordan a with 15A NCAC 2C.0118. —
9. YIELD(gpm):— THOD OF TEST �A
10.WATER ZONES(depth): .ld V
LOCATION SKETCH O
11. DISINFECTION:Type Amount CAAX Show direction and distance in miles from Deast
12. CASING: Wall Thickness two State Roads or ounty Roads.Include the roa
Depth Diameter or Wei ht/Ft. Mater)al numbers and comm road names. p
From c�To_V FL__�L Ss4 VC. (/W4J�
From To Ft. 11SS I
From To FL
13. GROUT: Depth Materia eth
From_D_ _a .�
From To Ft. V1ectt Cetnen-
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.in. GU
From To Ft, in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
-4
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
SIGNATUR3 OF PERSON iEONSTRUCTING 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 REAR 221 2005
i" Stl

WELL CONSTRUCTION RECORD
308307
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James W. Camp CERTIFICATION#2138
WELL CONTRACTOR COMPANY NAME Camp' s W 1 1 & Pump Cc)Trir._PHONE # (8�322
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
11111111 (if applicable) L (if applicable)
1. WELL USE(Check Applicable Box):Residential ur�Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopoRraphic/Land setting
Nearest Town: - County ORidge Elope OValley ❑Flat
U&A Ll 0 e (check appropriate box)
(Street Name,Numbers,,Community,Subdivision,Lot No,Zip Code) Latitudellongitude of well location
3. OWNER: AA (degrees/minutes/seconds)
Address p 1�� A L Latitude/longitude source:OGPSOTopographic map
treet or Route No.) (check box)
nL y�l/ ( -) S DEPTH DRILLING LOG
tt, 3 iry. ate 3 zip code Flom '0 Format'c D(e�c/,�ipti�
Area code-Phone num er l V 1 D 11�f�
4. DATE DRILLED -
5. TOTAL DEPTH: U
6. DOES WELL REPLACE EXISTING WELL? YES P NO It
7. STATIC WATER LEVEL Below Top of Casing: UU T. yam„
(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 c�
variance in accordanc with 15A NCAC 2C.0118.
9. YIELD(gpm): —METHOD OF TEST Air In
10.WATER ZONES(depth): q 5 N
LOCATION SKETCH
11. DISINFECTION:Type Ch 1 or i n e Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. (r
From_4._Tm 3-"Ft. 6 1 /4 J5DR2U PVC tVA4'
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. Neat Cement Hand
From To Ft. J w
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
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.69/2604
MAR 21 20

rapV _ h '1
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR(INDIVIDUAL)NAME (print) James I4_ Camp .Tr_ CERTIFICATION% 211
WELL CONTRACTOR COMPANY NAME Came s Wpl 1 R pump CO s Tnr PHONE N 6 A4 7,-73 -2
STATE WELL CONSTRUCTION PERMITH - ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential ErlMunicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: ^ (� Topographic/Land setting
Nearest Town:�1�r CountyAL.n,f1r1;, ❑Ridge LWtope ❑Valley ❑Flat
137,�_ ..Dca_cto, Dr. - (check appropriate box)
(Street Name
11,Numbers,C\om�munity,Subdivision,Lot No.,Zip Code) Latitude9ongitude of well location
3. OWNER: kAA.". o l i liA (degrees/minutes/seconds)
Address 13 a D e o ca rn Dr. Latitude/longitude source:❑GPSOTopographic map
ryry (Street or oute No.) (check box)
NI A Y i r YL ( C DEPTH DRILLING LOG
City or Town State Zip Code From To Ic nation Description
C-)- 0 5
Area code-Phone number
4. DATE DRILLED •a - 0 S7 - "}
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES®-NO ❑
7. STATIC WATER LEVEL Below Top of Casing: ±0 FT.
(Use"+"if Above Top of Casing) Z C3
8. TOP OF CASING IS 1 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): S —METHOD'OF TEST Air
10.WATER ZONES(depth): 4%0
LOCATION SKETCH
11. DISINFECTION:Type Chlorine Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 ToAZFt. F 1 /4 SDR21 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method - n
From 0 To_2L_O_Ft. Neat Cement Hand
From To Ft. ('
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in.
From To Ft. in. in. r"^�-•^ �t.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS: D t�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN A CORD NCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- D
SIGNA RE OF PERSA CONSTRUCTING THE WELL DATE
Submit the original the Division of Water Quality,Attn: „y�y T' 2a?It J.�T,anR,jenienl,161, M fforvice Center
-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 da�si
9W-1 REV.09/2004
JUN 2 7 2005
I

00
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources/-Division of Water Quality-Groundwater Sectiiaii
WELL CONTRACTOR(INDIVIDUAL)NAMEa (prier C /��It xg CERTIFICATION#�F�41
WELL CONTRACTOR COMPANY NAMx�fi� (�tg-Tec r JtJ( 'J . ItAPRONE # (1Qi�n�'(398Q
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 21 Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other,List Use
2. WELL LOCATION: ,/ Topographic/Land setting
Nearest Town: 4 County well ORidge OSlope OValley BFfat
1052' OY ,'{�(f ce Z 76 Z (ehWc appropn mbox)
(Sve%Narne,*NuzdScM Coounun)ty,subaivisia Lot No,tip Code) Latitudellongitude of well location
3. OWNER: (degadmbams/sormds)
Address Latitude cligitude source:OGPSOTopographic map
IS
or ionic No.) (Cheek box)
wee
C14y A4— 2176 z DFPTH DRILLING LOG
City or Town stem tip Code From To Formation Description
Arn cods Phone number
4. DATE DRILLED _-0
5. TOTAL DEPTH: r}
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top ofCasing:--Zj2—FT. r—
_ (Uca"+^if Above Top of Casing) Z !?
8. TOP OF CASING IS /•$ FT.Above Land Surface•
'Top of casing terudanted at/or below land surface regeira a
variance In accordance with 15A NCAC 2C.011L
9. YIELD(gpm):_Z-I;— METHOD OF TEST /�hv Y
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type C Almunt /O o Z Show direction and distance in miles from at least
12. CASING: Wail Tbickness two State Roads or County Roads.Include the road
Depth Di or Weight/FL Material numbers and common road dames.
From To > Ft. P Z/ p l r Av
From_To Ft.
From To FL
13. GROUT: Depth ,,,Material/�� Mept
From_ To_Z(Z FL1�ttCrrr AxrL -
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From —^'To Ft in. in
From To Ft. in. in. p
15. SAND/GRAVEL PACK.-
Depth Size Material A ;--
From To Ft.
From To Ft. —
i i
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST ARDS,AND THAT A Y OF S RECORD BEEN PROVIDED TO THE WELL OWNER
/ ( �� 5�/.3 -OS
SIGNATURE OF PERSON CONS79kUCTING 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. 07/20OI

V" k �) � ; I
;
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Divilion Water Quality-Groundwater Section
'9�/
WELL CONTRACTOR(INDIVIDUAL)NAME (Print) n
/' K Ao t'S �/P CERTIFICATION#- 7
WELL CONTRACTOR COMPANY NAME S lA)•P+E l A)J�q 6 g!f PRONE a =A)
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential L9-I'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: t Topogm
phictLand setting
Nearest Town: County 0NGd[9W el� ❑Ridge IBS ope [ alley ❑Flat
#—/ jexxo1G orye S 7$7ls S/ (check eppmpiude boat)
(Street N&ne6 N=b6s,Community,Subdivision,Int No.,Zip Code) Latitude/longitude of well location
3. OWNER: %/ e5 (devem/a muslacemds)
Address Latitudellongitude souroe:❑GPS❑Topographic map
� �±/'/U/L W C ) '� d '6n y DEPTH (DRILLING LOG
City or Town state tip Code From TO Formation Description
L�
Am code-Phone mmmber
4. DATEDRIILID b- 7_� -O5� 9
5. TOTAL DEPTH: 7 O S m
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO G
7. STATIC WATER LEVEL Below Top of Casing: ` '7 FT.
(Use`+"if Above Top of Cuing) 0
8. TOP OF CASING IS FT.Above Land Surface'
`Top of eadoa terminated at/or below land surface requires a
variance )rdauc};wnh 15A NCAC 2C.0118.OF --:
9. YIELD m :_0 _METHOD OF TEST �
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type—CC Amount A0 D -e Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth piaq�ter or Wei t/Ft� numbers common road names.
o
Fro To O Ft r L
From To Ft W
From To Ft -
13. GROUT: Depth Material M,t
From To��Ftlajre7e we f M.
From To Ft
14. SCREEN: Depth Diameter Slot Size Matetial
From To Ft im. in.
From To Ft in. in.
15. SAND/GRAVEL PACK--
Depth Size Material V
From To Ft.
From To
Ft. —CS = ,_
16. REMARKS: r, j
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC ORDANCE WITH 15A NCAC 2C, - '1
CONSTRUCTION STANDAR AND THAT A COPY O RECO B OVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINPIE 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
. 4 � 9 .
North Carolina- Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section ��11
w'ELL CO.NTRACr OR(INDIVIDUAL)NAMEr�lftp_rat)— O ^� {, r/�) CERTIFICATION It �50
\YELL CONTRACTOR COMPANY NAME +.Y Cel L11 J 1 I�� PHONE # ( 3 /--I
S I A'l E w'ELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifa licable) (if applicable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION: I Topogra hi d setting
Nea cis Towfr�} r11lLtgU County c ❑Ridge Io Valley ❑Flat
'•42 ^r C;RI (check appropriate box)
(Street Name,Numb a,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: �Q,r 'Y�.'t
^�'_"^'� t�rr (degrees/minwes/seconds)
Address 1`3 '6�a • OXZ{ Latitude/longitude source:❑GPS❑Topographic map
!fin (Street or Route No r-t f-� (check box)
/ r IdJ�L'�1�-� YU a� 1 ��- /,'7s� DEPTH DRILLING LOG
ClryorT Zip Code Fry Fo ion Description
Area code-Phone number -
4. DATE DRILLED "'�Y''�5� 2
5. TOTAL DEPTH.
6. DOES WELL REPLACE EXISTING WELL? YES O NO I;r
7. STATIC WATER LEVEL Below Top of Casing: FT. -�
(Use"+"if Above Top of Casing) 7
8. TOP OF CASING IS f FT. Above Land Surface*
^v
'Top of casing terminated at/or below land surface requires a G J
variance in accordance with 1 A NCAC 2C.0I18. ='!
9. YIELD (gpm):accordance
OF TEST
10. WATER ZONES(depth): C26>. 12(`�' . 2
LOCATION SKETCH _
11. DISINFECTION:Type Amount Show direction and distance in Ogle from at least ` — - -
12. CASING: Wall Thickness two State Roads or County Roads. In lode_ the road ,_ I
Depth Diameter or W tght/Ft. nal numbers and common road names. -- —
From 0 To 150, Ft.
From To Ft. '
From To Ft.
13. GROUT: Depth Material Method -q ___
From To Ft.-_-�c �' J('-o"'_zl{' , •-,
From To Ft. 7
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.-
From—To—Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL W S CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THA COPY OF T O HAS BEEN PROVIDED TO THE WELL OWNER
!�Z As- <: 5 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
27699-1636 Phone No.[phone],within 30 days. GW-I REV. 07/2001

00 314864
WELL CONSTRUCTION RECORD
North Carolina-Department of Envimumcnt and Natlual Resources-Division of Water Quality-Groundwater Sectio�n�p�'
WELL CONTRACTOR MMTVIDUAL) (prlat .�Ls [�_ jti and' a s4 CERTIFICATION 0bpLjV
WELL CONTRACTOR COMPANY NAME (,(1Z&_.t.. Q�- PHONE a tdz8t�7 Ql,
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMM
ifapplicable) if livable
1. WELL USE(Check Applicable Box):Residential MmticipaUPublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION. Topograpldc/Land setting
❑Ridge ❑ ❑Slope Valley C3f�lat
(Seat Name.Numbers,Cbminuatty.Subdivldon,rut No.,Zip Code) Latitude!! nude of box)
//////��������-��- ��� ouugittide of well location
3. OWNER SeHT�Arfuw�lri'r i1.0 �/��jfylS (�m;otoodse�)
Address u//_�.nlJ � rtsT LatitudeAongitudesotree:❑GPS❑Topogtaphicmap
MO
(Sewer (check box)
/ti onJ TUG 7G DEPTH DRILLING LOG
Cdy or Tuwe sue Zip co& From TO Formation Description
Area code-Phone comber
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO UP -
7. STATIC WATER LEVEL Below Top of Casing:--/,cL_FT.
/ �- (Use"+"ifAbove Tap ofCwhW
S. TOP OF CASING IS FT.Above Land Surface-
'Top of adaa ter=bded atla below land sorlm regabw a
vatince In aao u}s with 15A NCAC W AllL
9. YIELD(gpm):rd ")'b METHOD OF TEsT—a;e—vraZ
10.WATER ZONES(depth): L4
LOCATION SKETCH o t
11. DISINFECTION:Type AmowU lg2 0 2 Show direction and distance in miles from(R leastas
12. CASING: Wall Thickness two State Roads or County Roads.Include the mad-4
�D70 «W� tt err and common road names.
Fro Toa S Ft S DR 2/ /lC3 g
From To Ft �C
From To Ft
wt v
13. GROUT: Depth 6Matenal
F �G�
rottt�_To 2.�Ft G G
From To Ft. A
14. SCREEN: Depth Diamobw Slot Size Material
From-0—To---Ft in. in. U (�
From—To—Ft.—in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From o Ft.
Fmm To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCrION STANDARDS T A F S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OP PERSON CONSTR G TE
Submit the original to the Division of Water Quality,Groundw n,1636 Mail Service CC LRaleigh NC
27699-1636 Phone No.[phone],within 30 days. Cr"rl iiREV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)DELBERT PITTMAN- CERTIFICATION#2159
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE#[phone]
STATE WELL CONSTRUCTION PERMIT#— ASSOCIATED WQ PERMIT#—
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential MunicipaVPublic 0 Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use—
2. WELL LOCATION:
Nearest Town:NEBO County MCDWL Topographic/Land setting
THE CASCADES-LOT#4 ❑Ridge ❑ Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:JIM CHAMNESS Latitudeilongitude of well location
Address THE CASCADES _
(Street or Route No.) (degrees/minutes/seconds)
NEBO NC 28761 Latitude/longitude source: ❑GPS ❑Topographic map
City or Town State Zip Code (check box)
(W3J-4174244 DEPTH DRILLING LOG
Area Code Phone number From To From To
4.DATE DRILLED 07/12/05
5.TOTAL DEPTH: 305
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. LOCATION SKETCH
9. YIELD(gpm): 5 METHOD OF TEST ARD Show direction and distance in miles from at least
10.WATER ZONES(depth):— Two State Roads or County Roads. Include the road
number and common names
I I.DISINFECTION:Type CHLORYTE Amount 7.5 HWY.#226 N.FROM POLKVILLE,RIGHT ON
12. CASING: Wall Thiclmess GADDY RD.GO TO STOP SIGN.RIGHT ON
Depth Diameter or Weight/Ft. Material HARMONY GROVE RD.APPROX.2/10 MILE.
From 0 To 60 Ft 6-14" SDX21 PVC LEFT INTO"CASCADES" SUBDV.GO
From_To_Ft_ THROUGH GATE. V4 MH.E ON RIGHT.LOT#4.
From To Ft
T: T
13.GROU_Depth Material Method
From 0 To 20 Ft OUMETE POURED
From_To Ft_ a
14.SCREEN: Depth Diameter Slot Size Material
From_To_Ft._ in. in. + °a
From_To_Ft._ in in. D
15. SAND/GRAVEL PACK:
Depth Size Material
From_To_Ft
From To Ft- a 3
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON UCTION STANDARD
THAT A COPY OF HI CORD 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

14885
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Sectiion�
WElX CONTRACTOR(INDWH)lJAL)NAME (priat),AL L q_f, J�o d m-S a�2 CggTtt c knor, Lff f7
wELL CONTRACfoR coMPANY NAME,GeC(Aj P P)OtW,O/ei' w Pi// 4 PWs i? PHONE ► (Sze
STATE WELL CONSTRUCTION PERMTIp ASSOCIATED WQ PERMM
(ifawlicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential VMunicipal/Public E3 Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Meat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: r J�� _ / � T �l�id setting
Nearest Town:1� /�/D/J County ❑Ride EIo Malley
t
$3 HAPme r-/ Ceve. 2rI g (cheek riatebox)
(saes Narec,NN-ambem Cormrevai&Mi iv ioo,Lot No.,7kp Cone) Latitude/longitude of well location -
3. OWNER: ✓ ifa ? l el-
Address Latitude/longitude source:❑GPS❑TopogPVhic ta$p
t (straw Rove No.) (Check box)
277/0/ D TxP DRILLING LOG:
City a Town Sow Zip Code From To Formation Description
L---)-
Am Code-Phone mmbw
4. DATE DR11LED -3 -D S-
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: LZ FT.
��pp// Nk w if Above Top of CasioW
8. TOP OF CASING IS_A FT.Above Land surface—
'Top of Satins ter®Lated atfor below Lad surface requhw a
vats L aeeordaaa with 13A NCAC 2C.011$
9. YIELD(gpm):_IS- METHOD OF TEST 7 _
10.WATER ZONES(depth):
NATION SKETCH
11. DISINFECTION:Type Amount /d a't Show direction and distance in miles from at least
12. CASING: Wall Thiclmess two State Roads or County Roads.Include the road
Dept, or Wa t numbers and common read names.
From__To Ft
From To Ft
13. GROUT: Depth / Material Method
From__To—ze Ftf we toe(�
From e Ft D e
14. SCREEN: Depth Diameter Slot Size Material '
Fro To Ft in. in. i
From=To Ft in. is
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
FZo 'ro Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TAA F THIS B PROVIDED TO THE WELL OWNER
-0 57
SIGNATURE OF PERSON CO STR q'JI $TELL_.__-_.--- DATE
Submit the original to the Division of Water Quality,Groundvi tl �
igp163b�Sertice C m Rakigh,NC
27699-1636 Phone No.[phone],within 30 days. LJ Lb L LUU7 REV.072001
Ac�r�—_

xiC
_ WELL CONSTRUCTION RECORD
North Carolina-DepsttmBnt of Eavho®eot and N Resoarcet-
Division of Water Quality. gxtiop
WELL CONTRACrUll(U(DIYIDUAI) (P' CM30111CATWN 0-3 S
W6LL CONTRACTOR COWANY NAmz eJ---I ou
STATs WRLL CONSTRUCTION PERanTs AnOQwTZD WQ Pt.BDIIT'R
tf limbk rf livable - --
L WELL USE(Cheek Applicable Box):Residential Municipal/Public C Industrial❑ Agricultural P
Monitoring❑ Recovery ❑ Heat Pomp water Injection 0 Other C If Other,List Use
2. WELL LOCATI
Nearest Tows /l��1^G Cq�y / e<J�' TOp°�h1d'�d setting
Midge CGSIope Malley 13Flat
7._ (Cheek Vwopms bax)
(Street Name,Nomben,Cam-Maly,Subdivt-o,I&NO-zip Code) Latitude/longitude of well location --
3. OWNER: t+--L/ /" (daaeedmimmaheemdti �—
Address \ r��cy //�, �� LatitudrAongitude3Omce:GGPSCTOpographtcmap
y� MUea Oe�_ (Check box)
?5 DEPM DRjLQU LOG
L aJty ar Seem , r Zip Code From To Formation Description
Area Cate Phone manba.—
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES C] NO El
7. STATIC WATER LEVEL Below Top of Casing:-3UL Fr.
(Uw'+`if Above Top of Cuing)
S. TOP OF CASING IS FT.Above Land Surface*
'Top of Cadaa terWaated War blow land serface tequim a
varlanae in arxordaace with 15A NGC 2C.0118.
9. YIELD(gpm): METHOD OF TEST - i f �$
10. WATER ZONES(depth):
LOCATION SKETCH ='
11. DISINFECTION:Types/--,- Amount _ Show direction and distance m miles from at least
a CASING: Wall Thickness two State Roads or County Roads.Include the road
Depdt Diameter or WeaghtTt numbers and common toad names.
Frog * —
. -, To2[_Ft—Z _
From To Ft
From To Ft II \
13. GROUT: Depth Madmal 1„f ,. a ✓'�l .S f--'I�— _� e �,
From 2%e To L Ft \L`.
From To Ft ? P
14. SCREEN: Depth Diameter Slot Sitx Material y �u
From To Ft in. uL \\
From To Ft m. in
15. SANDIGRAVEL PACK: 9 t r
Depth size Material
From To Ft �f h
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY TH\T THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH ISA NCAC 2C.WELL
CONSTRUCTION,STANDAF.DS,AND THAT A COPY OF THIS RECORD H,S BEEN PROVIDED TO THE WELL OWNER
25
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
160o_1635 Phone No. (0191 30 days. •:�w-; v %. ?�;;-VVi

ry M xr TMl L
C 4. T4 'iky�C yF F a;..S�hK4 f 1
gun t -
WELL C JN TRU ._ins
North Carolina-Department ofEavbonunmt and aEet
WELL CONTRACTOR M01VIDUAL)NAME ft~
q d C AT10[1% .r°•-.
WELL CONTRACTOR COMPANY NAME ,� -1'/S DN iUJ.e/ h; E r ?ROME /
STATE WELL CONSTRUCTION PERMITS __—ASSOCIATED WQ PE111IITa
tf liable y
1. WELL USE(Check Applicable Box):Residential MnuicipaUPublic O Industrial 0 Agrienlnral 0
Monitoring O Recovery 0 Heat Pump Water hUcchan 0 Other 0 If Otter,List Use
2. WELL LOCATTOg g
Nearest Towm / ! oN County C DO uJp// Midge: OSlope Malley ❑Flat
'� h 3 Iv o f �i (a wk I I I i.m bm)
(Stteel N a'4.t TC. tM s.Ad!oa to No..rip Code) Latituddlongimde of well location
3. OWNER J V S[f/ G w _ (dspea/mimmelaeeao6)
Address /3 63_t�Q A-s I . A"V _ _ Latitude/longitude source❑GPSOTopogmphic map
(stint or"aae No. -_ _ (tom b=) ---
✓zH I-/7!! JL C FD P 1Ti DRILLING LOG
C'ay o<Taws state Zip Code From To Formation Description
Ate cods Phone olmbc /
4. DATE DRILLED 6 D
5. TOTAL DEPTH: '
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER:.EVEL Below Top ofCasing: / FT.
(Use"+'if Abo Top of Casmg)
8. TOP OF CASING IS FT.Above Land Surface* r
'Top or casing teradeated Wor below Led surface requbwco
a a.
variance L acoerdaare with 1SA NCAC 2C.011L
9. YIELD(gpm): t _ METHOD OF TESTS
10.WATER ZONES(depth): /lJ o {'7t — Ul 'A
LOCATION SKETCH
11. DISINFECTION-Type Amount Show dirocuou and distance in miles from at least
12. CASING: Wall Thiclmess two State Roads or County Roads.Include the toad
Depth Diameter ofWeight/Ft numbers and common road names.
Fronk TOO To_,�Ft_� ao uJ iG Sf
From_To Ft
From To FL
13. GROUT: Depth A:a:eaMI Method
From��To ' �Ft
From To Ft
14. SCREEN: Depth Diameter Slot Size Mattaial
From To Ft in in. 7
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Sim Material J
From To Ft
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2C,W 21
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD Rt S BEEN PROVIDED TO THE WEli.OWNER
n Z/ -z�6- o�(_
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Faleigh,NC
!'t(,en_t Fil,•1tiaRe V.,. ,otot^1]_-.--1.`Ytt in 10 days. - ••• _ _ .•

w w..
WELL CONSTRUCTION RECORD
North Carolina-Departmiu ofEwirmused and Natural Reaome�es Divisia of Weber Quality f9totmdaratas SaeCon
WELL CONTEACIOR MO)r DUAL)NAME WW (9-P(1Q tl',��I P� '{{O h < �gbCA•npN
wELLCONTRACrORCOMPANYNAMi Lir'FSorl b �,�� -t-�f` l -�� PHONEa'( 117�59' `7, SSa
STATE WELL CONSTRUCTION PERAUTY ♦SSOCIATiD WQ PMUTS
Ctfaopticabk) CtfaoaBcable) i
1. WELL USE(Check Applicable Box):Residential 12 Monicipd(Public❑ Induatriai 0 Agriculbual Cl
Monitoring❑ Recovery ❑ Heat Pump Water Injection 13 Other❑ If Other,Lint Use
2 WELL LOCATION: C ` Topoj;Whidl d setting
Nearest Town: r i 0 )) County. f�wC I (q dge ❑Sle ❑ ❑pe Valley Flat
N o Cep y T b n� I+ c(V (check appropriate boa)
(Sceet Name,Numbm, wiry.Subdivmcia,Lot No,Zip Code) Latitude/longitude of well location
7. OWNER: Or lnq LCQ (Y), (depedmi ubWso rob)
Address ) 7 C Po 7 n j T'o r�,l I atiti de/longitude source:❑GPS❑Topographic map
(Shen..or No.)
(melt bra)
a r i D ti C _> k 7 5 �— DEM DEILUNG LOG
Cry or T 4 S Zip Codo From To Formation Description
7 42dor'M 1 P .
Ara code-Phow wmbv
ILLED 4. DATE DR Sc, �'
5. TOTAL DEPTH - '
6. DOES WELL REPLACE EXISTING WELL? YES NO ❑
7. STATIC WATER LEVEL Below Top of Casing-
(UM-+'ifAboro Top of CasbW
S. TOP OF CASING IS �FT.Above Land Static.• CO
'Top of oMa tenoiaated War hWw Wd aarfus mgaho■ r
nvtuce be=ordamm wfth 15A NCAC 2C.0121. • '
9. YIELD(gpm): L24- METHOD OF TEST )r- - r-
10. WATER ZONES(depth): U �'
10.E LOCATION SKETCH
11. DISINFECTION:Type Shur C Amoum l ' Show direction and distance in miles from at least
12. CASING: Wall Thicimess two State Roads or County Roads.Include the road
DepthFt31 Diameter or Weight/Ft Material numbers and common road names.
To From --Q
From—To Ft /) 0 In i M
From To Ft V L - r
13. GROUT: Depth Maumal Meihnd
From 10y To L Ft !�
From To Ft
14. SCREEN: Depth Diameter Slot Size Material � �
From To Ft m uL T
From To Ft.--in. in.
15. SAND/GRAVEL PACK:
Depth Size Material J v
From To FL—
From—To—Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR fN A-CCnM-ARCE'N1TH 15ANCAC 2G WELL
CONSTRUCTIO STANDARDS,AND THA'.A COPY OF THIS RECORD Hr,S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTINGT �� _ THE.WELL :. DA
Submit the original to the Division of Wuver Quality,Groundwater Suction, 1636 MailAervim Center-Raleigh,NC
1140 -1535 Phone NO. (oto)rt1_...'vahi : '0 days. � I

W 314688
WELL CONSTRUCTION RECORD
North Carolina-Department of Envirormtent and N pal Resources-Division ofWater Quality-Groundwater Section
d��
WELL CONTRACTOR(INDIVIDUAL)NAM (print) C ACL? CERTIFICATION ap jZ
WELL CONTRACTOR COMPANY NAME ONE # A# X 6 $9 p
STATE WELL CONSTRUCTION PERafIT#-_ ASSOCIATED wQ P
dealit
(if applicable) (ifanolicablei
I. WELL USE(Check Applicable Box):Residential a Municipa Tublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery (3 Heat Pump Water Injection O Other O If Other,List Use
2. WELL LOCATION: Lr Topographic/Land setting
Neere t own:_�� �L_County
�9�I�- -1►-A—�-�. � ,s. Ridge pSlope Malley ❑Flat
(Strut Name,Numbers,Community,Subdivision,fat No.,Tip Code) (cluck a FWriaa box)
t' Latituddlongibide Of well location
3. OWNE JyG?i / ( )
Addre, Seamor ,V o.) Latitude/longitude source:OGPS❑T hic ma
•(Stmeto Rohe No.) (checkbm) gmP P
X C t��7cSZ DEPTH D LOG
City or Town Sure From To
(_ _ ^-------. ��e Formation Description
Meer cede.Phone D /
4. DATE DRILLEED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO 19
7. STATIC WATER LEVEL Below Top of Casing: 1
(Use"+"if Above Top of Cuing)
S. TOP OF CASING IS S- —FT.Above Land Surface
'Top of oadna terminated War below land surface mquhra■ � Toy nrianee in accordance with 1SA NCAC 2C.0118.
9. YIELD(91m):1Q_METHOD OF TEST J.- i.p
10. WATER ZONES(depth):
LOCATION. il jE
11. DISINFECTION:Type Amount Show direction and diets° a in miles from at least
12. CASING: Wall Thickness two State Roads or Coun Roads.Include the roadO
From_(2 Tom. -t Ft SI/��t' numbers and common to names. rj a�Se
FrOn To Fi� b
From To Ft
13. GROUT: Depth
From To-';)Z�Ft-j� 5
From To Ft
14. SCREEN: Depth Diameter Slot Sim Material
From O Ft in. in.
From
To Ft in. is
15. SAND GRAVEL PACX-
th
Sim Material
Fro nh -- Ft. - --- .
From e To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCTION STANDARDS, T A COPY OF THIS RE ORD EEN PROVIDED TO THE Cr i OWNER
SI A OF PERS N CONSTRUCTING THE WELL UATE
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.omoo1

rJorth Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mall Service Center.Ralelgh,N,C. 27699.1636•Phone[phone] �'<n/ n 'jL''/l `- '` •' ,
WELL CONSTRUCTION RECORD WELL CONTRACTOR: "D�✓`� � 1 r ' I I t rN
WELL CONTRACTOR CERTIFICATION (nG
STATE WELL CONSTRUCTION PERMIT If
;NEI I USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitormc
�nrnvery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use'.
^ram' -)CATION (Show sketch of the location below) C
rnsi town. County , ` — n LAB f ` '
SIy4 5 (!� ar �-� � f � 2
Road Name and Numb .Commun or Subdivision and Lot No DRILLING LOG DEPTH
I OWNER I -e r From To Formation Descnntirn'
4ddress
�n rl`,Free to`rr ue o.)
')Oy or Town t �State, �CZip Code
PATE DRILLED S
- rCTAI DEPTH f
- 'TINGS COLLECTED YES ❑ NO[Er'
Pr,FS WELL REPLACE EXISTING WELL? YES ❑ T .
W-1' ATER LEVEL Below Top of Casing. �F
x r (Use'+"if above Top of Casing)
,F C,F CASING IS FT. Above Land Surface'
�oo a' -asmg terminated at/or below land surface requires a v na ce m af�or-
rlance with '5A NCAC 2C 0118 41 L=h
'FIi "1 r(-'PM): XL4-METHOD OF TEST
' • ,Vo'�a 70NES (depth).
-�I_''RI NATION: Type i4TH Amount If additional space is needed use back or form
.. BASING. Wall Thickness
Depth , ( ^ r Di m ter or Weight/Et M tgrial
vrr„ To �Ft. 5D1•� IRSfIC- LOCATION SKFTCH
r•. To t (Show direction and distance from at least two State
to 4t Roads. or other map reference points) _
+a ;RnIIT �
Depth Material Method
Croom To Ft.
.,n To Ft nt
Depth Diameter Slot.Size Material C�
Ln
nr� To Ft in in
To R in in. (�
-gym To Ft in in ��` t, L
>AN! VGPAVEL PACK: ���A•.�5, /
Depth Size Material
To Ft
r,om To Ft yj'-
17 REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD 14AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No. SIGNATURE 0#PERS(Jq ONSTRUCTING_THE WELL DATE
Serial No. Submit original to Division of Water Qaality, Groundwater Section within'30 days
GW-1 REV 1219q

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mall Service Center-Raleigh,N.C.27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: _L?644A c(
WELL CONTRACTOR CERTIFICATION # :
��/STATE WELL CONSTRUCTION PERMIT# :
HELL USE (Check Applicable Box): Residential 2 Municipal ❑ Industrial❑ Agricultural ❑ Monitnrirg❑
!recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use:
NFLI LOCATION. (Show sketch of the location below)
veam,u town- County
/Js� OALI v,�t 1?a
Road Name an Numbers, Co/m/munity or Subdivision and Lot No DRILLING LOG DEPTH
3 OWNER 2/ �/�1] /�3 �% �� From To Formation Descriotior
address 92yv9 sue../«. /qd.
or Town / State Zip Code
e CATF DRILLED
'(`.TAI DEPTH
. ."TIN(',S COLLECTED YES ❑ NO©
", )F`; WELL REPLACE EXISTING WELL? YES ❑ NO CZ
WATER LEVEL Below Top of Casing: Zn FT ,
(Use'+' if above TOP of Casing)
`' F OF CASING IS �1y FT. Above Land Surface'
"op c!rasing terminated at/or below land surface requires a variance in accor-
dance with !SA NCAC 2C 0116
1C YFILU (GPM): lVY METHOD OF TEST IJ-k)JL.Aii—
WATFP ZONES (depth).
I .mot OPI NATION: Type Amount 't If additional space is needed use back of form
AS N G. Wall Thickness
Depth Diameter or Weight/Ft. Material
To 6W I=1 5,"77 G LOCATION SKETCH
To Ft. (Show direction and distance from at least two State
to ht Roads, or other map reference points)
f
'4 ;RC)I7T r`l
Depth Material Method J
C
�•-gym To Ft. C
To FI r `-'"
Depth Diameter Slot.Size Material
"I'm _10 Ft in. In. �� �J'� U7 !
—To Ft in. in. �
w\.
16 SAND/GRAVEL PACK:
Depth Size Material
to Ft
am To Ft Y
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 HAS BEEN PROVIDED TO THE WELL OWNFp.
FOR OFFICE USE ONLY —�/�� � � - �2 . 65—
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12194

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
if
,936 Mau service Center- Ralelgh.N.C. 27699-1636-Phone[phone]
WELL. CONSTRUCTION RECORD WELLCONTRACTOR: OA /Xt,:(-4
WELL CONTRACTOR CERTIFICATION # : c?66L 6
STATE WELL CONSTRUCTION PERMIT#
NELI. 'JSE (Check Applicable Box). Residential Municipal ❑ Industrial s❑ Agricultural ❑ Monitcrinc❑
' ecovery Heal Pump Water Injection ❑ Other-0 If Other. List Use.
AIELL LOCATION: (Show sketch of the location below)
Nearest town ���"w rr/ County V 0w C 4 L
04W61d201 GiAFly bge'4 IV Esr 467miilF 1-7
%end Name and Numbers Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
71NNER C�hrey I�pO/S From To Formation Descr,cror,
Andress ,141G ZOM6�Y R�✓
�btree or ou a o.
/✓IE3i i'mf A!C . a8?S
';rty or Town State Zip Code
DL- RILED
`-
� f DFPTH
-'INGS COLLECTED YES ❑ NO©
Dr-)PS WELL REPLACE EXISTING WELL? YES 0 NO®
S'�"C WATER LEVEL Below Top of Casing. __l;rl:�_FT.
(Use"+-if above Top of Casing)
CASING IS ,1$_'L FT Above Land Surface'
asl^.g+erminated at/or below land surface requires a variance in actor-
'.once .v,Ir t5A NCAC 2C 0118
1p H -) f(-,PM)'. ', METHOD OF TEST 2f)f
rVATFR ZONES (depth):
r;HLORINATION: Type //Tf/ Amount *t If additional space is needed use back of form
,. C.ASING Wall Thickness
Depth QQu� __ Diameter or WeighVFt Material
To �4 1. 4 � I OCATION SKETCH
To Ft (Show direction and distance from at least two S%Vp
To Roads, or other map reference points)
��• t
'a ,PnuT
Depth Material Method
To Ft
r.,...,., To Ft
Depth Diameter Slot.Size Material C
� /
" To FI in in �r CVO t
To A in in.
nT _ To Ft in in
11- SAND/GRAVEL PACK:
Depth Size Material r.
„r To Ft
n To Ft
REMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNFR.
FOR OFFICE USE ONLY
Quad No. Z2 r+
GNATURE OF PERSON COH$TI C7.a THE WELL_. QATE
Serial No. Submit original to Division of Water Quality, Gmt ndwater Section within 30 days j
Iq G ;191iV 12g8
I I
I

fi
(J 4
Nortn Carolina Department of Environment and Natural Resources-Division Of Water Quality-Groundwater Section
1636 Mall Service Center-Raleigh.N.C. 27699.1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: U����
WELL CONTRACTOR CERTIFICATION # : ,3f7�C
STATE WELL CONSTRUCTION PERMIT III :
AJE.I I. USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection O Other If Other, List Usei
1\1F1 l OCATION 'Show� ` r 6AI County /VC sltetch of the location below) y1
ven st town. � u6eU I?4<
OFi�bxd,7�1 Gtcn/ .4fAvy.V 6S�"/6T.tx �3
Road Name and N mbers Community, or Subdivision and Lot No DRILLING LOG DEPTH
3 OWNER blAa9 1)wl s From To Formation Descnotior
Address .(fL oQ �P/2d
/V//4ir ;ery �S raeA14IQ NO gl f) x
h, or Town State Zip Code
f)aTF DRILLED
rCTAL DEPTH .'?G6
1=. ^.I;TTINGS COLLECTED YES Q NO©
()OES WELL REPLACE EXISTING WELL? YES [] Q NO
c Tr,-,C WATER LEVEL Below Top of Casing v FT
// // (Use'+"if above Top of Casing)
,-!F CASING IS FT. Above Land Surface'
ar " .asmg terminated at/or below land surface requires a variance in accor-
dance ,if, 15A NCAC 2 0118 O
wFII.D ((-,PM)_ METHOD OF TEST
voTER ZONES (depth).
;'RINATION Type /"7i`r` /ram Amount If additional space is needed use back o'form
d S I Wall Thickness
Depth Diameter or Weight/FL Material "
^T To 30 1=t L PA P2 4e,7� - LOCATION SK T .H
To Ft (Show direction and distance from at leat�wo 'Atti
4,o To a Roads, or other map reference point r,
m 1
td ;POlIT
Depth Material Method
r.^rn To Ft. (J7
To Ft
SCRFFN )
Depth Diameter Slot.Size Material
To Ft in in.
^m _ To Ft in in `
!F SAN[)/GRAVEL PACK: J
Depth Size Material
To Ft V
.or., To Ft
?FMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ON LYy , r <Yrll nz.. !, .- L -- 6
` Quad No, SIGNATURE OF PERSON CONSTRUCTING THE WELL - - - DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 1219r.

worth Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section -1636 Mau Service Center-Ralelgh,N.C. 27699-1636-Phone[phone]
WE LL CONSTRUCTION RECORD WELL CONTRACTOR: 7'f°/,,n/d 12A �',L t,f A'j
WELL CONTRACTOR CERTIFICATION # :
STATE WELL CONSTRUCTION PERMIT # :
,NFI I USE(Check Applicable Box): Residential—Municipal ❑ Industrial❑ Agricultural ❑ Monitonnc 11
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
1r,ATION 'Show sketch of the location below,
s,'town. Aik?w o.", .L County. M I
Pier h alive %e Afbpf , Ne bb
-rind Name and Numbers Community or Subdivision and Lot No) DRILLING LOG DEPTH
4 7 h
VVNER f ary .SQ rry From To Format,on Descnrl,,,
rr « 113a 3 r er
Ze/ePIsire,l or Rome
� r �N"CIS ]`d
?rr or Towr State Zip Code
G DATE DRILLED 6--le -e
rCAL. DEPTH /7 b
`TINGS COLLECTED YES Q NOK
- 1EC WELL REPLACE EXISTING WELL? YES NOQ -_
JVATER LEVEL Below Top of Casing WT .
(Use""if above Top of Casing)
-�- -!f CASING IS }w FT. Above Land Surface-
'-�G ,I :army terminated at/or below land surface requires a variance in accor-
danre with 1 5A NCAC 2C 0118 -2
�' IGPM): /10� METHOD OF TEST / 911 ��^
- ,v�r�R 7.0NES (depth).
ral_TiPI NATION Type NTT Amount /-` If additional space is needed use back of form
-,p�ING Wall Thickness •�^^
Denth Diameter or We Material
Material
0 3 y Ft L a7. LL ;r'e LOCATION SKETCH
rn (Showdirection and distance from at least;wn
Ft
e Roads, or other map reference points) 13
z R(-1! T C
s
Depth Material Method r n
r.r,m To Ft
To F1
.. �rD=FN cn
Depth Diameter Slot.Size Material '��� t71
.� To Ft in in.
To Ft in _ in. t,
To Ft in _ in 0\-
-/+Nf'/GRAVEL PACK:
Depth Size Material
To Ft
To Ft
'-/EMARKS:
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
".ryNSTRUCTION STANDARDS- AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNrc
FOR OFFICE USE ONLY _,C,,, (�Liue'� S—/G ' O 6-
-Quad No, SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV +)'9°

0 314327
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality"-
WELL CONTRACTOR(INDIVIDUAL)NAME (print) lames W ramp jr_ CERTIFICATION#_2_1- 8
WELL CONTRACTOR COMPANY NAME Camp' s Well & Pump CO r Tnr_ PRONE # 67fa dri't_7122
STATE WELL CONSTRUCTION PERMHrit ASSOCIATED WQ PERNIIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential p/Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: \ ,�• -� ➢ Topographic/Land setting r'
Ne estTo • County ULL \ bR'idge ❑Slope OValley OFlat
�`� ( (check appropriate box) C
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well locatioff ".
t N 'a
3. OWNER: �1 lr O 4M C 1't�l�t w—n�,-,— (degnxs/minutes/sewnds) '—
Address Aug: erl1+ �l"i La[itude/longitude source:OGPSOTopog eEghic npp
(Street n r;Route No ��� S ^ - (check box)
CC
J. DEPTH DRILLING
LOG==i
City or Town State Zip Code From To F s'Ination escriptio)t'
(� �o
Area coda Phone number
4. DATE DRILLED ki
5. TOTAL DEPTH: �A L7 () U
6. DOES WELL REPLACE EXISTING WELL? YESJJ NO Ill
7. STATIC WATER LEVEL Below Top of Casing: J U FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1 FT.Above Land Surface'
-Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): _METH,QD OF TEST pi r
10.WATER ZONES(depth): �. r�J� LOCATION SKETCH
11. DISINFECTION:Type f'h1 Sri na Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Dep Diameter or Weight/Ft. Material numbers and common road names. ,
From�_To�Ft. 6 1 /4 Stjr 1 - PVC
From To Ft. ;e
From To Ft.
13. GROUT: Depth Material Method d'
From_Q_To 2n Ft. Neat C PmPnt- Hanc3 !� L
From To Ft. rJ-
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: �
Depth Size Material e !) Lt W LL')
P4
From To Ft. (yY
From To Ft.
l
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
� -j -05
OGNATURE OF P&SON CONSTRUCTING THE WELL DATE _
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 d'a�ys:
GW-1 REV.09/2004

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N al Resource�Js-/Di` `oa of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (WW e, C /Llt6d/�i YR CERTIFICATION�Afi
WELL CONTRACTOR CObRANY NAME Ct? l t/Q t/ go�` Y gue"'a PRONE 0 � (r L- L'O /0D
STATE WELL CONSTRUCTION PERMIT/ ASS -M8 Qpnwu _
if icable if mphable
1. WELL USE(Check Applicable Box):Residential Municipal/Public 13 Industrial❑ Agricultural❑
Monitoring O Recovery ❑ Hest Pump Water Injection O Other O If Other,List Use
2. WELL LOCATION: /
r / Topographic/Laad setting
rT G ORtdge ®Slope MalleyOFlat
(StreetNanw,Numbds,Commmtty,Svb&WN08,LotN0.,ZiPCode) Latitude/longitude of Well location
3. OWNER: Q��1 cs/" - (degtadmimoeNaeomds)
Address Z 7 L3 �_ Lautudellongitude source.MPSOTopographic map
�1?A,rtocfi ryGl�) 287� Z DEPTH ( DRILLING LOG
City orTown Suss Zak From To Formation Description
Ain code-Phone n®bx
4. DATE DRILLED �D S. TOTAL DEPTH: O S'
6. DOES WELL REPLACE EXISTING WELL? YES O NO IS
7. STATIC WATER LEVEL Below Top of Casing:
/(Uw"t'ifAbm Top ofCui* W -_-
$. TOP OF CASING IS f•4 FT.Above Land Surface*
*Top of easing ter0taated atlK belm lmd surface requires a a
saetaam btamerdance Ul
jfkbISA NCAC 2C.011L t -
9. YIELD(gpm): METHOD OF TEST
10.WATER ZONES(depth): 4
LOCATTON SKETCH
11. DISINFECTION:Type rr Amount 10 O L Show direction and distance in idles from at keg
12. CASING: Wall Thi bum two State Roads or County Roads.Include the road
Depth pp,,.� t.or Weights Material no common road names.
F To_pyL Ft SOR Zi /BUG V
From-,_To Ft 1�
From To Ft �l'.
13. GROUT: Depth blaterisl Mptbod
From_Tom_FLjc, T We .-"
From To Ft
14, SCREEN: Depth Diameter Slot Sim Material
t
From�To Ft nL ia.
From To Ft.----in. in.
15. SANDIGRAVELPACK
Depth Sim Material
F To Ft
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCITiD IN ACCORDANCE WITH I SA NCAC 2C,WELL
CON STR STANDARDS,AND=2kCOPYTHIS HAS BEEN PROVIDED TO THE WELL OWNER
-30 -os
SIGNATCRE OF PERSON,PONSTRUCTING THE WELL DATE

OCT 1 0 2005 ;WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality-
! WELL CONTRACfOTi{T q"WUAL)NAME (print) ,Tamps W_ t^a m P-r J r CERTIFICATION H 21
WELL CONTACTOR COMPANY NAME Camp' s well & Pump Co- a Tnr PHONE # R2A d51 772Z
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential �Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery O Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: - Topographic/Land setting
NearestT �t�( ,,�jv. County pfdge ❑Slope OValley Flat
-p-��'tl•" - (check appropriate box)
(Street Nano,Numbers,Community.Seubdii�vision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /yam f) (y�+��,rr�- (degreea/minutes/seconds) -
Address � Hwy/ 0 Latitude/longitude source:OGPSOTopographicmap
(Strce[or oute No.) (check box
e o N( � DEPTH DRILLING LOG
City or Town State , Zip Code From ` To t n escn t n
Area a code-Phone number n `
4. DATE DRILLED,
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE %NO F __t
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS 1 FT.Above Land Surfacer ^' _
"Top of casing terminated at/or below land surface requires a W
variance In accordance with 15A NCAC 2C.0118. t9 +�
9. YIELD(gpm): ME�4IjO�OF TEST ir ut
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Ch 1r1ri na Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From--D_To I Ft. 6 1 /q Srlr 21 PVC
From TO Ft.
From To Ft. -
13. GROUT: Depth Material Method `f
From__D_To__2.OL_Ft. Neat Cemant- Hantj ✓r"�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material / t5 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
S RE OF PERS N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center-
Raleigh,NC 27699-1617, Phone No.[phone],within 30 days.
GW-1 REV.09/2004

007 1 0 2005 L' j LL CONSTRUCTION RECORD
North �Department of Environment and Natural Resources-Division of Water Quality
RWWUCWTi pW "1NUVQ}UAL)NAME (pda) Neill Pardue CERTIFICATIona 2609
w +4
_-MpArjypAME Air Drilling Company pMNE # (704)872a614
SPATE WELL CONSTRUCTION pERMPI'a ASSOCIATED WQ pERMITa
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box).Residential® Muoicipal/Pidi is❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water injection O Other 0 If Other,List Use
2- WELL LOCATION:
Nearest Town: Marion County McDowell dge 0S ope IJVand setting
Rock House Road DRtdge �SIoPe QVaIIeY OFlat
(Sfta Name,Numbeas,Conmmny,Sub&vbl 4[.a No,Zip Cade) (ch-k aPPmPnW box)
Latitudellongitude of well location
3. OWNER:- Resource Companies LLC (damemiewwaeeamr)
Address 2000 River Edna Parkway-Suite 8so Lab IC1011ongitude source:13GPSOTopographic may
(Street or Rows No.) (check box)
Atlanta, GA 30328 DF THP DIt_it r IN LM
City or Iowa Sim Zip Code From To Formation Description
(-- - 0' 92' Dirt
Are code,Phaoe number 92' 400' Rock
4. DATE DRILLED 08-27-05
5. TOTAL DEPTH: aoo Fr.
6. DOES WELL REPLACE EXISTING WELL? YES O NO W "
7. STATIC WATER LEVEL Below Top of Casing. 80 FT. rn
MW"+'if Above Top ofCaiog) _
8. TOP OF CASING IS 1 1/2 FT.Above Land Surface* rn
`Tap of ealq to auss eder below bed arbre require a --_
va==1ffi eead"eewnhl5ANCAC2C.a11L ;-
9. YIELD(gpm).- 5 METHOD OF TEST Air rn
10.WATER ZONES(depth): 120 -1 388'- 3
LOCATION SKETCH
11. DISINFECTION:Type HTH Amomo Show direction and distance in miles from at least
12. CASING: Wall 1lrlokneas two State Roads or County Roada.Include the road
From 0 De th FL Diameter or Weighu t Material numbers and common road names.
PVCF
From To Ft ko Ur72L�
From To Ft
13. GROUT: Depth Materiel Method
From 0 To 20 FL grout Poured
From To Ft 14. SCREEN; Depth Diameter Slot SizeMabaialFrom To Ft. in. in.
From To Ft in. is
15. SAN67GRAVEL PACK:
Depth Size Material
From To Ft T From To FL T
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED AI ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A �j�J OF THIS R�RD HAS BEEN PROVIDED TO THE WELL OWNER p
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center-
Raieigh,NC 27699-1617, Phone No.[phone],within 30 days.

- - 316858
OCT 1 0 2;'„5 WELL CONSTRUCTION RECORD
-- North Carolina Deperm=t of Environment and Natural Resources-Division of Water Quality
ASHEVNd1u,�tfOM►RACroR Neill Pardue
(QhIDIVIDUAL)NAMB(prlat) CERTIFICATIONa 2609
WELL CONTRACrMcompANY NAME Air Drilling Company p� K (704072-7614
STATE WELL CONSTRUCTION PERMITa ASSOCIATED WQ PERM1711
(if mutable) (if aoolirxbk)
1. WELL USE(Check Applicable Box):Residential® MuoicipaMbuc O Industrial❑ Agricultural O
Monitoring❑ Recovery 0 Heat PUMP Water Injection 0 Other C] If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: Marion County McDowell ❑Ridge OSkhpe []Valley OF7at
Rock House Road (check aWroprim box)
(Street Name,Nw*ws,community,unity,Sabdivisiaa,tut No.,TP Code) Latitude/longitude of well location
3. OWNER:- Land Resource Companies LLC O
Address 2000 River Edge Parkway-Suae 850 Latitudellongi(ude source:0GPS0Topographic maI
(Scrod or Ram No.) (check box)
Atlanta, GA 30328 DEP' DRILLING LOG
City or Tom store Zip Cods From To Formation Description
0' 43' Dirt
Am code-PhOOe Water 43' 365' Rack -
4. DATE DRILLED w27-m
5. TOTAL DEPTH: 365 Fr.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO to —
7. STATIC WATER LEVEL Below Top of Casing 20 FT. e
(the"+"if Above Tap ofCesiog) r' --
8. TOP OF CASING IS 1 1/2 FT.Above Land Surface* Q'
'Tap of min tauiused allor below land sorfare requires a
variaaee to ateerdsauwith ISA NCAC 2C At IL cn
9. YIELD(gpm): 19 METHOD OF TEST Air
10.WATER ZONES(depth): 93'-5 170'-10
197'-3 LOCATION SKETCH
11. DISINFECTION;Type HTH Amount Show direction and distance in miles from at least
12. CASING: Wall Thicluless two State Roads or County Roads.Include the road
Depth Diainew or weight(Ft. Material numbers and common road names. {
From 0 To 43 Ft PVC �j oGfl
Fmm To Ft {(1ni1 �C V5 t7
From To FL
13. GROUT: Depth Material Method
From 0 To 20 Ft Grout Poured
From To Ft
14. SCREEN; Depth Diamder Sbt Size Mstaial
From To FL in. in.
From To Ft.
15. SAND/GRAVEL PACK: p H
Depth Size Material
From To Ft.
From To Ft St1-pv
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAAPA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ V
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.

316859
OCT 1 0 2005 �i ��' WELL CONSTRUCTION RECORD
NorthCaroli ta Department of Environment and Natural Resources-Division of Water Quality
AL)NAM� (P.I.r) Jerry Watkins
CERTIFICATION# 2452
Air Drilling Company 764 672-7814
PBONE# ( 1
STATE WELL CONScable) ON PERMITF ASSOCIATED WQ PERMM
(if applicable) (if applicable)
1. WELL USE(Chock Applicable Box):Rpaidential'R MtmiciPst P lic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION:
Nearest Town: Marion Coonry McDowell Topographic/Land setting
Rock House Road ❑Ridge ❑Slope ❑Valley ❑Fiat
(Baca Name,NineM Comnmiq,Subc ivisioq L t No.,Zip code) (d—k apprap W box)
Latitude/longitude of well location
3. OWNER: Land Resource Companies LLC
Address 2000 River Edge Parkway-Suite 850 Latiftumongiq� 0 pS0T
(Street or Race No.) (Check box)oPo!>alc mat
Atlanta, GA 30328 DEPTH LRILLING LOG
CkyerTowO Stole Zip code From TO
�} Formation Description
Area oode•Phone avm6u 0' 122' Dirt
4. DATE DRILLED 08-26-05 122' 350' Rock
5. TOTAL DEPTH: 350 Fr.
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO hr
7. STATIC WATER LEVEL Below Top of Casing, e0 FT,
8. TOP OF CASING IS ttrl (Une'4"dAbaft TojTWCag)rio
FT.Above Land Smfacea
*TOP of cad"teealaated Wor bebw had strfaee rsgat.• "a •�
varhate to seeurdaeeewhk 1SA NCAC 2C.01IR _-
9. YIELD(gpm): 3 METHOD OF TEST Air
10.WATER ZONES(depth): 333 FT. o
]I. DISINFECTION.T HTH LOCATION SKETCH
Type Amount Show direction and distance in miles from at leesk_;
12. CASING: Wall Thickness two State Roads or County Roads.Include the road`
Depth Diameter or Weight/Ft Material numbers and VU
From 0 To t2z t. PVCFrom To Ft 13. GROUT: MFrom 0 To�20 FtMut«tBPoured
From To Ft.14. S�EN: TDeprh Diameter Scot SideMataidFt in. m.From To Ftin in.I5. SAND/GRAVEL PACKFromDA Size Material
FtFrom To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH IS _
CONSTRUCTION STANDARDS,MID THAT A OF THIS A NCAC 2C,WELL
BEEN PROVIDED TO THE WELL OWNER
SIGNATU OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center
-
Ratelgh,NC 27699-1617, Phone No.[phone],within 30 days.

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N Resources-Di ' ' n of Water Quality-Groundwater Section
WELLCONTRACTOR(OD1VIDUAL)NA➢i� (pre 1 -37 CERTIFICAnONa /macc
WELL COIiTRACTOR COMTANY N Y' iU,4 f/' (A1 L I� 9 P za 2 PHONE R Z !(JO
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ Py.RMITa
{if at�lic�Ie) (if applicable)
I. WELL USE(Check Applicable Box):Residential 03 'MunicipaUPublic 17 Industrial❑ Agricultural D
Monitoring D Recovery ❑ Heat Pomp Water Injection'D��Other D If Other,Littse U
2. WELL LOCH- I �tY�cu1�L hi, OV setting
Nearest To
3 z�;L_ Q/ of /7. 2$ -Y w DFlat
(Sueft Maim Nmbc.Cmmmay.Sub&viam,W No.Zip Coae) Latift"ongitndeof well location
3. OWNER
Address L/ (��, Latitude/longitude source:MPSOTopographic map
/ a Raste Na) (CbKk box)
DZM DRILLING LOG
City Tower Sure Zgi Cade From To Formation Description
Asa coda-P6o0a num6q,�
4. DATE DRUJUM6-21?-DS'
5, TOTAL DEPTH: lt'G 5 v o
6. DOES WELL REPLACE EXISTING WELL? YES D NO E _
7. STATIC WATER LEVEL Below Top of Casing: lrs0 FT.
(Use"t"ifAbow Top of Casing) O
S. TOP OF CASING IS A S FT.Above Land Surface"
'Top of culag tamiaated aver bekw had swfacs regdros a
•adiecer smrsls with 1SA NCAC 2C.011&
9. YIELD(gpm):�'7, METHOD OF TESTZLM�
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount 2 Show direction and distance in miles from at least
12. CASING: Wall Thidmese two State Roads or County Roads.Include the road
From�Depth or WeighdFt. y�iaoezial numbers and common road names. > ,
To &, Ft 42 2 l UL
From_To Ft.
From To Ft
13. GROUT- Depth terial
From_ Ma
TO 2Q_Ft cre /�P��
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
Fro To Ft_n. in.
From To Ft in. in.
15. SAND/GRAVELPACK
Depth Sim Material —
From Ft
From To Ft
16. REMARKS:
I DO HEREB CERTIFY THA?7I113 WELL WAS NSTRIJCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTR M ON STANDARDS, T A OF THIS RD HAS BEEN PROVIDED TO THE WELL tR
SIGNATURE OF PERSOICONsTpucnNO THE WELL DATE

W1�.LL l;V1VJ11CU1:11VIV Kr:I:VKL Fl �� ti
North Carolina-Department of Environment and Natural Resources-_I)ivisioq,of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlst) he" C. A 3di 7 CERTfFICATION#-27 y/
WELL CONTRACTOR COMPANY NAME C e �r & 17 1 U PRONE or ( 16V?
STATE WELL CONSTRUCTION PERMIT# wecOC1AD�VQ PE
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Qr'MUnicipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: graph
Nearest Town:1M1�/4Ciil�FLi County � ow / TDPDBS1op eJLand setting
f/1L/t 1�r).' S Z29 ❑Ridge ope ❑Valley ❑Flat
(Street Nama,Numbers,Comm C b �rn / (checkmide iaa box)
unity,Subdivieiaq Tot No.,Tip Cade)
Latitudellangitude of well location
3. OWNER: W01012 �LVKI �� �f/j�/�/�j 7/ (degreWm aides seconds)
AddressZ i) P Latitude/longitude source:❑GPS❑Topographicmap
(Street w Route No.) (check box)
yGy /V L d 74 DEPTH DRILLING LOG
City or Iowa spa Zip Code From To Formation Description
(---)
Area code.Phone n mbq-, _
4. DATE DRILLED_?
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO f3�
7. STATIC WATER LEVEL Below Top of Casing: 2 -
(Um"+"if Above Top of Casing)
8. TOP OF CASING IS—�FT.Above Land Surface*
'Top of casing terminated War below land surface requires a
variance V aecerdauee with 15ANCAC 2C.011A O
9. YIELD(gpm): "2 SE METHOD OF TEST/.r2 ear' +
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type C' Amount /O o.z Show direction and distance in miles firom at least
12. CASING: Wall Thickness h
late Roads or County Roads.Include the road
�h cor„We�i t Material rs and common road names.
From Tom Ft 5 Dff U L 'Alf
From To Ft
From Tc Ft QV(j
13. GROUT: Depth
From To 2 Q FtC Material I�t M a 0J P
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in, in,
From To Ft in. in.
15. SAND/GRAVELPACIC:
Depth Size Material
From_ o Ft. �.
From To Ft. �//
16. REMARKS:
I DO HMU( TIFY THAT THIS WELL WAS CONSTR COED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTANDARDS,AND A PY OF S RECORD BEEN PROVID TO THE WELL OWNER
SIGNATURE OF PERSON CON UCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources- %r;Sion o Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL) (print) N1 G / .7 CERIIFICATTON#,lz/?
a I
WELL CONTRACTOR COMPANY NAME 4te U Z er Ci:N_ (SL'�)PHONE 0 4Lfi'fJr��'
STATE WELL CONSTRUCTION PERNM A -OCIATED WQ P
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0-"Municipal/Public Cl Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION-
Nearest Topo wand g
Nearest Town.. - / County
❑Ridge lope ❑Valley ❑Flat
(cheeks wWnate boot)
(Sheet Name.Number,Continually.Subdivision,Lot No.,tip Code) Latitude/longitude Of Well location
3. OWNER M111 ^. f S (degedmimreeNsecaods)
Address Latitudellongitude source:❑GPS❑Topographic map
or Rome No.) (cheek box)
DEPTH DRILLING LOG
City or Town sine Zip Code
From To Formation Description
Area code•Phone o®ber
4. DATE DRILLED -� 'G 5~
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑, -No a
7. STATIC WATER LEVEL Below Top of Casing:!Q_FT.
r J (Use''+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Laud Surface'
'Top of easing terminated War below land sarreee requirm a
variaea to aeeordaae with 15A NCAC 2C.Oil& p
9. YIELD(gpm): �METHOD OF TESTZ =
10.WATER ZONES(depth): i
LOCATION ETCH
11. DISINFECTION:Type L7= Amount JO c Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
From
TDo�`�FLJ=
ej t i C n ,t and common mad names.
From To FL a V
From To Ft. {j
13. GROUT Depth Material
M thod 1
From To_��Ft C e C k'
From To FL
14. SCREEN: Depth Diameter Slot Size Material {`\
Fromm To Fit in, in,
v� O
Ft,—in. in.
15. SAND/GRAVEL PACK ` ,•J
Dep Ft
th Size Material Q
Fro To
From To Ft.
16. REMARKS:
I DO Yffffi&Ezf::
NSTRU 1N ACCORDANCECON U OF THIS CORD HAS HEEN PS 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

I W
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nplural Resources- v ono Water�QuaeliYty-Grouodwatzr Section
WELL CONTRACTOR MD1YIDUAL)NAME (print} "d �, T CERTIFICATION iv
ME j
WELL CONTRACTOR COMPANY NA r `3 of L,)O l/ PHONE t
STATE WELL CONSTRUCTION PERMM AS_cOCIA7'ED WQ P
(if applicable) Cif applicable)
L WELL USE(Check Applicable Box):Residential WMmucipaMblic❑ Industrial❑ Agnmlgmal❑
Monitoring❑ Recovery O Beat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: / City . 1 q��d setting
Nearest Town:_��/f �U% , Qgidge IaS}� QVsile, Onat
(Strout Nsme.Numbcm Commtmity.Subdivision,Lot No.,Zip Code) (chat appropriate boa)
Latitu&Aongit ide of well location
t
3. OWNER ilJ, ' <-e k- 14r,
f"I e r (degeea/mim,tea/gappd,j
Address y� ' k! 7�, ri m✓ LatitudMongitude sou ce:OGPSOTopogtaphic map
a Rase No.)
L r- ---F c� • -`�_ DEMDRILLING Lt1t`
cny«Town Swe Zip Code From To Formation Description
L--)-
Am code-Phaoe mtmbw �.
4_ DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ O Q
7. STATIC WATER LEVEL Below Top of Casing: >� FT.
i/(Usti if Above Top ofCasmg) --T
8. TOP OF CASING IS _FT.Above Land Surface' t
-TOP Of Codas terminated Rua below land Barbee requires a
vIUD b aaerdaay O ISA NCAC 2C.OF r _
9. YIELD(gpm): it METHOD OF TEST fh p «-
10.WATER ZONES(depth):
IX)CATION SKETCH
IL. DISINFECTION:Type t.�./>, Amotrm�, J Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth _ t numbers and common road names.
Fro Tom Ft r� pat
nu
From_To Ft e
From Tc Fk �.
13. GROUT,
FromPm Material �-
To�Q FC P (" Gik' -
From To Ft_ 1
14. SCREEN: DqA Diameter Slot Size Material `�--
From—
To Ft in. is
From To Ft in. in. J
15. SANDIGRAVEL PACK
\;
Degah Size Material ('
From To Ft. _-
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS NSTRU IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON U! ` T ION STANDARDS, A PY OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
` % _w
L z 7
SIGNATURE OF P CONSTRUCTING THE WELL DATE J
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

61 � p
WELL CONSTRUCTION RECORD up
North Carolina-Department of Environment and t !Resourrces- 'v/y4ion o Water�Qtuality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (pr(at C t/
CERTIFICATION#2 7 /
WELL CONTRACTOR COMPANY NAME E9 U 1.°/" (,tip PHONE # (52xtl ,G
STATE WELL CONSTRUCTION PERMIT# ,LCcOCIATED WQ P
(ifawlicable) (ifimpteable)
I. WELL USE(Check Applicable Box):Residential®' Muoicipal/Public D Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ heat Plrmp Water Injection 0 Other(3 If Other,List Use
2. WELL LOCATION:
Nearest Town: i' _ County /I C T��d setting
�d8e N ope OValley OF1at
(cbakapproprimtax)
(street xame xuatbenI Canmrm ty.StMi v,;W,Lot No,zip Code) I atitude/Iongitude of well location
3. OWNER: 1/i t c' r 0. (desn'"' uwea/�dc)
Address ?77 ✓ Latitude4ongitude source:OGPSOTopogtaphic map
or Ram No.) �r
(dtrYboa)
Cnory Town Ste Co1'w DEPTH RR ti.f IN i ti
From To Formation Description
Ara code-Phone amber -,
4. DATE DRILLED
5. TOTAL DEPTH: / 957
6. DOES WELL REPLACE EXISTING WELL? YES p,,�O�13 ci
7. STATIC WATER LEVEL Below Top of Casing: r.
./(Use^+ if Above Tap of Cams)
8. TOP OF CASING IS _FT.Above Land Surface*
'TaP of cam terminated War below land surface regaieu a
variance IN ace*emu with 1SA NCAC 2C.0113.
9. YIELD(Spin): METHOD OF TEST /3t
10.WATER ZONES(depth):
UQCATION SKETCH
11. DISINFECTION:Type C.-/. Amount. IO a > Show direction and distance in miles from at least 13
12. CASING: Depth Wall Thickness two State Roads or County Roads.Include the road
Diameter munj�rsand common road sames:
Fro F[�8 _�
From To Ft
From„To FL
13. GROUT: }
From_Tp�Q Ft
From To Ft �)
14. SCREEN: Depth Diameter Slat Size Material
From To Ft in, in,
From To FL in. in. I-3
15. SAND/GRAVEL PACK: 1�
Depth T Sum Material
Fro To FL .,
From TO Ft.
16. REMARKS:
I DO Y CERTIFY THAT tkACFP
WELL WMU 7N ACCORDANCE WITH ISA NCAC 2C,WELL
CON ON STANDARDS T OF THIS RD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNOCANSTRUCMG THE V DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Ratelgh,NC
276WI636 Phone Na(919)733-3221,within 30 days. GW-1 REV.07/2001

W L'LL I:VIVJIICU(:11ViV KLI;VI(f) J _E ( V u`
North Carolina-Department of Environment and Natural Resources- ivisio of Water Quality-Groundwater Section
(INDIVIDUAL)WELL CONTRACTOR NAME (print) /egveC 4'C & A? — CERTmcAT10N#Z 7 y
WELL CONTRACTOR COMPANY N a o P C/ (� PHONE # ( )li 41 C?Y t7
STATE WELL CONSTRUCTION PERMIT# wscOCIATED WQ PE #
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential ge'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: I /
Nearest Town: q/ ° 0//L/ County /GOOCtJf Topographic/Land setting
7Z/ ❑Ridge Mope ❑ box) at
(Street Name,Number,Community,Subdivision,Lot No,tip Code) L.atitudell itudeappropriate�)ongitude of well location
3. OWNER: / 1//teLoO y/p (degedmiwrcs/sxondr)
Address Steet err Route No.)
U y �( Latitude/longitude solace:❑GPS❑Topographic map
(Sh
/U L Z 7,1 E (chock box)
City or Town suet y p Code / PTH DRt ING LOG
From To Formatioo n Description
Area code-Phone number n
4. DATE DRILLED
5. TOTAL DEPTH: 2 C) S-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO E3 '�
7. STATIC WATER LEVEL Below Top of Casing:---J�?-- FT, '?
(Use`+^if Above Top of Cuus)
8. TOP OF CASING IS—�FT.Above Land Surface' t=
'Top of using terminated atlor below land surface requires a —�
variance in acurdance��wyn 15A NCAC 2C.0118.
9. YIELD(gpm):�METHOD OF TEST,rn C'd l
10. WATER ZONES(depth): o
LOCATIONS F 1 CH
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
> ��b Ft a Wd rt Material numbers and common road names.
From To5ply
From To Ft
From To Ft
13. GROUT: Depth /�Material M �V
From To
From To 2�Ft. t°
Ft
14. SCREEN: Depth Diameter Slot Size Material
From_,To Ft, in. in.
From To Ft. in. in.
15. SANDIGRAVELPACK:
Depth Size Material
Fro To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRM STANDARDS,=ANDAOF S RECORD BEEN PROVIDED TO THE WELL OWNER
�)
SIGNATUREOFT, ON CONSTRYMNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days, GW-1 REV.07/2001

f
31 w tC 7210
WELL CONSTRUCTION RECORD"
North Carolina-Department of Envirot nem and N 1 Resources- . ion o Water t
V/�S Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (Print), � l 1 C.- !� CERTIFICATION#�7 fiq�
WELL CONTRACTOR COMPANY NAME- 5iA:' , M fl, C;;(' PHONE # )�y�i��/80
STATE WELL CONSTRUCTION PERMIT# aSOCIATED WQ #
(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: / T
gra
Nearest Town: P d setting
Midge Mope 13VaUcy Mal
13 L/ �' P De�� ry '!l7 116 (a�xk aPP�apria4(woc>
(Shot Name.Numbers,Community,subdivision,Lot No,Zip Code) Latitude/longitude of well location
3. OWNER:_ r-h
Address t tl3l/ f/'ee
Latitude/longitude source:❑ pogtaphic map
(street or Route No.) (c6ah bwkbm box)
�ti C '3 76 DEPTH DRII LING LOG
city or Town sore Zip Code From To Formation Description
Arm code-Ph"mtm -
4. DATEDRILLED�-Z '�SP
5. TOTAL DEPTH: 7_Z5-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO B� n
7. STATIC WATER LEVEL Below Top of Casing: i! FT.
.((un"' 'ifAbove Top of Casing) -
8. TOP OF CASING IS _FT.Above Land Surface' t D
'Top of easing terminated new below land surface requires a
variance In accordance with ISA NCAC 2C.011L
9. YIELD(gpm): METHOD OF TEST L
10.WATER ZONES(depth): z
LOCATION SKETCH
11. DISINFECTION:Type C:4 Amount /O Q z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
�y� D p �(ei UFt numbers and common roadLxx
From_' _To_-v Ft r� _ =From To Ft
From To Ft13. GROUT: Depth MaterialMFroTOI�Ft .Cf C r F CC" j7TFrom Tc Ft14. SCREEN: Depth Diameter Slot Sin MaterialFrom To Ftin. uL
From To Ftin. irL
15. SAND/GRAVEL PACK: U/
Depth Size Material
From_!;?( To Ft
From Tc Ft - - ---
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL -
CONSTR ON STANDARDS,AND A COPY F THIS RE HAS BEEN PROVIDED TO THE WELL OWNER
Ge � _z _ o
SIGNATURE F PERSON CO TRUCPING THE WELL DATE
i
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 1
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

N orin Carolina Department of Environment and Natural Resources-Division of Water Quality-Group water Section
'636 mau Service Center-Raleigh,N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Aa4ful / n^ r c�rX�S
WELL CONTRACTOR CERTIFICATION p : 3,7 uG
STATE WELL CONSTRUCTION PERMIT fir :
: F l USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitorinc
Recovery ❑ Heat Pump Water Injectio ElOther❑ If Other, List Use:
I.00ATIOM (Show sketch of the location below) //11
N aresf town. ` County A o-,':VC4
/flair Sr-43119 Sl
o?ad Name and//yy��umbers Community,or Su4divlsion and Lot No.) DRILLING LOG DEPTH
3 OWNER j l_f9� / �l9��/ From To Forrnation Descrrotm,,
Address /(jr1(r ISreT oue�A;0l ST
o
/1/.G. a8)s z
rtv nr Town State Zip Code
n i,ATF DRILLED s 65"
rCTAI DEPTH //'S
TTINGS COLLECTED YES Q NO®
DnES WELL REPLACE EXISTING WELL? YES ❑ NO®
WATER LEVEL Below Top of Casing: y (, FT .
(Use-r"if above Top of Casing)
-i- .JF CASING IS F7. Above Land Surface'
_r -asmg terminated at/or below land surface requires a variance in accor-
'.ence .nth '.5A NCAC 2C0118
vE�11) r(',PM): -9 METHOD OF TEST
vaTGR ZONES (depth).
'PINAnoN Typo NTH Amount If additional spate is needed use back of form
N C, Wall Thickness
Depth Diameter or Weight/Ft. Material
' rpm To '�o Ft �!r Z.6 Apgr'� LOCATION SKETCH
r-rim To Ft. (Showdirection and distance from at least two Stale
�mrr To Ft Roads, or other map reference points) 5
to DpUT p n'l
{'
Depth Material Method n—I
rim To Ft —'
C13 n
rnrrt• To Ft -
c c( pFFN.
O
Ut
Depth Diameter Slot.Size Material
To Ft in. in --..
�^ To Ft in. in
r•nr. _ To Ft in in.
le SAWI/G RAVEL PACK:
Depth Size Material
To Ft
..,,., To Ft
REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY 9!,,2 (� „Z �-a5�- 6 S'
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV 12/99

WELL CONSTRUCTION RECORD
North Carolina-Department of Envirourneut and
/N�a�tonl Resources-PivWon of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM/E�(pristj�/ /!P/11/ C /t�io S S/��'�11 CxWrMCpTtoN
WELL CONTRACTOR COMPANY NAME`1_�A�Pp Y U,RS�P� �� % /-Zrrn PHONE a ( A fo 5'%-o ySG
SPATE WELL CON3PRUCrI NY PERMITR ACcnr^r TED WQ PERMITI'
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0Mrmicipa"ublic O Industrial❑ Agtieultural O
Monitoring O Recovery O Heat Pump Water buection❑ Other O If Other List Use
2. WELL LOCATION: hic/Land suing
Nearest Town O/d_ (5/ County/Y�COOw e l/ Llwtop OSlope OYaIley OFInt
// LYI.%/ (/Ireo f l 2'67G 2 (riectapprapruebm) `
(&red Nana Nimrbrm,CommrocN sedmatv;®on,Lot No.,Zip Cade) Latitudellongitude of well location
1 OWNER:A/,!' la !'/9 (daBeedmmuta/recapda)
Address Latitude4ongitude source:OGPSOTopographic nap
( a Rome No.)
/ J V C 2 F 7 (dam boa)
Coy car Taw stag Zqr Cade From To rl.i wa r lVi
(_} Formation Description
Arta code-Phone amber
4. DATE DRILLED
5. TOTAL DEPTH:_� _
6. DOES WELL REPLACE EXISTING WELL? YES O NO 0-�
T STATIC WATER LEVEL Below Top of Casing:__Jko _FT.
8. TOP OF CASING IS S TOP of CNEW
Fr.Above Land Surface*
'lop of eadat termLated a far below tud sari&,,regKbw,e -
rart&e,,In acaeManee with 15A NCAC 2C.0118. O
9. YIELD(gpm): /0 �METHOD OF TEST_Zin e-c�
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINF$CTION:Type < Atmmnt //��- Show direction and distance m miles from S%bast
12. CASING: Wall Tbickow two State Roads or County Roads.Include tWroad 1
. — or Material numbers and "�load names.
Fro o To f) FL SI) Z VL
From To Ft
From—To fit ,¢
13. GROUT:
cPlt�
Depth Material Method
9m_�To 20 Ft C-
From To FL
14, SCREEN: Depth Diametcr Slot Size Material �M 1
From—(?' To Ft m. in.
From To Ft 11L r
15. SAND/GRAVEL PACK
Depth Size Material
m Fro _�To Ft
From To Ft
16. REMARKS:
I CX)HEREBY ERTIFY THAT THIS WELL W CON CTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRU N STANDARDS,AND COPY THIS HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON COOS1RUCIING THE WELL ` ATE - U
Submit the original to the Dtvistoa of Water Quality,Groundwater Section,1636 Mail Service Ceuta-Raleigh,NC
276WI636 Phone No.[phone],within 30 days. GW-1 REV.07/2ool

North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
1636 Mall Service Center-Ralelgh.N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: A6'l12ud
WELL CONTRACTOR CERTIFICATION # : O
STATE WELL CONSTRUCTION PERMIT #
` rdFi i USE (Check Applicable Box) Residential Municipal ❑ Industrial❑ Agricultural ❑ Momtorine❑
Pecnvery ❑ Meat Pump Water Injection Other❑ If Other, List Use:
1,� I OCAT10N1 (Show sketch of the location below)
vea rest town: /ri$L.,`ehG County
�7 IZ 'yy.72e Sa. T6
:%r,nd Name and Numbers Community. or Subdivision and Lot No.) DRILLING LOG DEPTH
'-)WNFR TGUA 4 ,0 From To Formation Descriotio,
r„o�s 7791 //Y .2!24' s.:—h
/7'Jlaa,a.v ;scree neyc; 2F9s-2
City or Town Stet& Zip Code
DATF DRILLED I
'11)e- O b
T,"`nl DFPTH
`TINGS COLLECTED YES ❑ NOO
r-,r)FS WELL REPLACE EXISTING WELL? YES ®NO
' TIcT ;,; WATER LEVEL Below Top of Casing. gO FT .
(Use"�"if above Top of Casing)
n TUP OF CASING IS 13 ,, FT. Above Land Surface'
or o• -asmg terminated at/or below land surface requires a variance in accor-
ianrn with '5A NCAC 2 118
(GPM): 0 1" METHOD OF TEST /kI y Ll
ti'o'F R ZONES (depth) //
'�l `PI NATION: Type 7 Amount — If additional space is needed use hack o`form
F N(l Wall Thickness
Depth Diameter or W ight1l t. Material LOCATION SKETCH
U� ,r> 80 c�i, s Hr 7snL
To Ft (Showdirection and distance from at least two S'ate
To Ft Roads, or other map reference points)
14 GROUT
Depth Material Method
.� To Ft ...
To Ff O
—4
i
Depth Diameter Slot.Size Material — ,
CJ
r-gym — To Ft In. in-
To Ft in. in. 0 T
01
r- — To Ft in in
'r- ::Ant['!GRAVEL PACK:
Depth Size Material
.., To Ft
To Ft
PPVIAPKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL.
7ONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNFQ
FOR OFFICE USE ONLY
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL-- DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30;days
GW-1 REV 121nf;

Noon :arefina Deoanment of Environment and Natural Resources-Division of Water Quality-GRSun dwa�te)Section 6) ?, r•
1639 Mall Sorvice Center-Ralelgh.N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR: 94A^/d 4 ��✓4
WELL CONTRACTOR CERTIFICATION p : .YK'G
STATE WELL CONSTRUCTION PERMIT p
.;JELL USE (Check Applicable Box): Residential r,4;6
ld Municipal ❑ Industrial❑ Agricultural ❑ Moniterinc❑
Recovery Heat Pump Water Injection Other If Other, List Use:
IA/EI_I. LOCATION. / how sketch of the location below) ��77
Nnarest tovm 2' v'iiP County. C (/y�rr►
LAB., oL a Ce6Ai Qk /f d_
'Road Name and Numbers Community,or Subdivision and Lot No.) DRILLING LOG DEPTH
3 i-)WNER 441hy CAA/OCL. From To Formation Descrvi,
Andress 54vQ BX j 4CL494A Cr-J5Elf, /� d
( reef(bireef or ou a o.
it,or Towr State Zip Code
f--aTF DRILLED _ 'd
-f-'-AI DEPTH 41-2
'TINGS COLLECTED YES Q NO®
'Y)FS WELL REPLACE EXISTING WELL? YES �; NOE]
�_. wA'ER LEVEL Below Too of Casing: _FT ,
/S1re (Use"�" If above Top of Casing)
CASING IS FT. Above Land Surface'
-.as,q terminated at/or below land surface requires a variance in accor-
dance with 'SA NCAC 2 0118 �7 ,
'C. YFIL_1 (GPM): bf' METHOD OF TEST 60 tA 'C"
1NATFR ZONES (depth)
'.HI ^,RiNATION: Type Amount If additional space is needed use back of form
ASING Wall Thickness
Depth �y Diameter or Weight/Ft. Material
•r.rr to t7/s Ft� '7 LOCATION SKETCH
, m To Et. (Showdirection and distance from at least two State
To t Roads, or other map reference points)
Depth Material Method -°`i
m To Ft
r„„r, To Ft CD
� �rPGcnj. —i
Depth Diameter Slot.Size Material W
to Ft in in. O
n — To Ft in in.
rr^ _ To Ft in in. _y
16. SAND/GRAVEL PACK:
Depth Size Material
To Ft
om To Ft
?FMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
SONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
OR OFFICE USE ONLY f l` 9-'29 -l7�
Quad No SIGNATURE OF PERSON CONSTRUCTING THE WELL - .... DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30!days
- - GW-1 REV 12/9r•
OCT 2 4 2005

V � A I^ r•.
^J,� (:arn Iina Department of Environment and Natural Resources-Division of Water Qua lity-Grou 6A 1ndwater Section `T
�i Mau Sarvlca Center -Ralelgh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i1 ;,4oN �k ✓'�
WELL CONTRACTOR CERTIFICATION ff : I
STATE WELL CONSTRUCTION PERMIT p :
NE1.: USE(Check Applicable Box): Residential Municipal El Industrial❑ Agricultural ❑ MOn110ri�C L_.
Recovery Heat Pump Water Injectio ❑ Other If Other, List Use
'NFI_I LOCATION (Show sketch of the location below) /� _
' 'nAl,'town r� l �^ A rm' County. /Y�G FJ L7WI-L.L
.Ica
=',ad Name and Numbers Com/mnunity, or Subdivision and Lot No ) DRILLING LOG DEPTH
CT\NNER G5y,AA 0'/d j`s �� From To Formation Descnn ,,
Andress 4X �^��,,�� 57­/-L.ryA oil
0 OA/ jbireet or a o.
Town State ZIP Code
nATF DRILLED 9.14 cs
'ai DFPTH :SI
'INGS COLLECTED YES Q NOW
t IF`• WEI LREPLACE EXISTING WELL? YES�NOi
NATFR LEVEL Below Top of Casing FT
if above Top of Casing) -
4 �ASING IS 45 F7 Above Land Surface'
.asing terminated at/or below land surface requires a variance in actor
'ante H th '5A NCAC �j 0118
vEll_D IGPM)� �v`�- METHOD OF TEST 13'gl'k
W4TFR ZONES (depth)
PINATION'. Type 1IL11 Amount If additional space is needed use hack of form
.- ,ASING. Wall Thickness -
nepth Diameter or V@ght/Ft alma(
11Ci r�/ to 1, Ft�_ �/iG jafi'�t LOCATION ';KFT .H
To It (Showdirection and distance from at least'wc S'atr
r Pt Roads, or other map reference points)
e
Depth Material Method
'i
To Ft
To Ft
O S
�i
Depth Diameter Shot Size Material
- to N In in. W _�
_ To —Ft in in. O �'
cn
— To Ft in. in
tg SANWGRAVEL PACK'
Depth Size Material
To Ft
� To Ft
-FMAPKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
^.ONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TD THE WELL OWNER
I 7OP OFFICE USE ONLY ,, � C)- � �.j'L -d 5-
wart No. SIGNATURE OF PERSON CON�CTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW1 REV +210r,
24 2005 jLt:
I

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
�f�
WELL CONTRACT"OR(INDIVIDUAL)NAM (print) II _- // �J CERTIFICATION
WELL CON"I'RAC I Oil COMPANY NAME N�A(/L(.A16 Ill 1 ��� ��1�11 (_ UT PHONE #
S"LATE WELL,CONSTRUCTION PERMIT# �� ��'' ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION: jr'' Topographic/Land setting /
Nearest Town:() Count
TO+)� County fV�� ❑Ridge ❑Slope ❑Valley VFlat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) �35L3/IppQltO C Of Wepll�lOsa�lgn�� `
3. OWNER:` AM lJ p (degreesh/minutess/seconds) LG/IIISV. G/t6/49C
Address (!y Lati ude/longitude source:❑GP$DTopographic map
(Street or Route No.) I (check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED �� b
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 at/or below land surface requires a
variance in accords,,c�with I5A NCAC 2C.0118. / '
9. YIELD (gpm):�—METHOD OFT ST Z (
10. WATER ZONES(depth): (O� I g
LOCATION SKETCH
It. DISINFECTION: Type Amount Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads. Include the road
Dept Diameter or Weight/Ft. Material numbers and common road names.
From T Ft.
From To FL :J
From To Ft.
I3, GROUT: Depth arena�. Method to
From To Ft, 'ee rn '
-v
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. Cp
From To Ft. in. in. Ln
.A
15. SAND/GRAVEL PACK:
Depth Size Material `^
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH WELL WNER
�a o�_'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE if
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 Old °
North Carolina-Department of Environment and Natural Rcsources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(MVMUAL)NAME Jeanne B.Beggs C[ntjMCATtONa2715
WELL CONTEACIOR COMPANY NANB MASMM Wet Company,Inc. PHONIC If (704)5395515
_ STATE WELL CON6IRBG77pN pERMTnr ASSOCIATED WQPERMr1W
d.' le Of ficable
L WEL.L USE((heck Applicable Bois Residential Muoicig aUpnblic❑ Industrial❑ Agrika lmEW❑
Monitotmg❑ Recovery ❑ Heat Pump Water Injection 0 Other❑ If Other,List Use
2. WELLLOCATION:
- Nearest Town: li e b Topographi�d setting
Countyn'lcDowel t UgdBe USiope avalley OFlat
VYI nro o �D (dwkWpup,imebax)
(Suva Near-NUMMIJus,Cemarand1r,Seba I&No-Zip Coft)T Latitudellongitude of well location
Address (saeaarRaae Na) LshbrdeJlwrgitude souroa13GPSL7Topographicmap
�P TUC (cbwkbm)
Cur,«rows Sate ? F DEP'1 o DRILLING LOG
otmap Description
Am csdo-P6sie mm�6er - i✓ T
4. DATE DRILLED '-2
5. TOTAL DEPTH: Y '
6: DOES WELL EXISTING WELL? YESj3
7. STATIC WATER LEVEL Below Top of Casing ,)FT,
I (Un-4-FA6we Tap of Casino --4
& TOP OF CASING IS 1 FT.Above Land Surfae
�PaIuWw6atlar6eiwM0ewr8aregobna .
Wwik eia LSANCACZCAj&
10. YIELD METHOD OF TEST . v�w
WATER (fir).
LOCATION SKETCH
11. DISINFECTION:Type Amount cL Shove direction and distance in miles from at least
12. CASING Wall Thidmese two State Roads or County Ros&
From _�q Z Ft hf ntmrbers and common mad Cannes,
Include the road
From To Ft �—
FrOm To Ft
13. GROUT: Delle M Method
From_To�Ft
From To Ft W!�ev) ,my,
14. SCRF3EN: Depth Diameter SlotSia Material apt
From TO FL in. in.
From To Ft in is %
- 15. SAND/GRAVELPACK:
Depth Sin Material (/
From To Ft _ --
- From Tb Ft
1 , iaw,a
16. REMARKS:_
1 DO HEREBY cERTIFY THAT IM WELL WAS CONSTRUCTED IN ACCORDANCE WTIH i5A NCAC 2C,WELL
CONSTRUCTIOTWANDARDS,AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SICM OF PERSON CONSTRUCTING THE WELL DATE
Sa6ait ortkWtOtbeNvUvnofWaterQRaGty,GroeadwaterSeeligE,1676i1 M$avkrCeoter-Rddgd,NC
27699-1636 pfeft Na(919)7333UM within 30 days, — - GW-1 REV.07=01

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACrOR(INDIVIDUAL)NAME (print) Chad Hartness CERTIFICATION# 2901
WELL CONTRACTOR COMPANY NAME Air Drilling Company PHONE 0 f704)872-7614
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:
Nearest Town: Nebo County McDowell Topogrdphlc/Landsetting
482 Marshall Road ❑Ridge []Slope ❑Valley ❑Flat
(Sbect Name,N utubeo.Cmowm Su (check appmpriate box)
ty, bdrvtagq iat No.,zip Cock) Latitude/longitude of well location
3. OWNER: Mayland Home Center ( meawaa�aaaa)
Address 800 Summit Avenue Latitude/longitude source:❑GPS❑Topographic mar
(Street or Route No.) (check box)
Spruce Pine NC 28777 DEPTH DRILLING LOG
Cityor Town State zip code From TO Forniatiou Description_
C--} 100 0' 87' Dirt -
AIe D Phone kLS 87_ 305' Rock
4. DATETE DRILLED os-zi-os -
5. TOTAL DEPTH: sos F CD
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO
7. STATIC WATER LEVEL Below Top of Casing. 45 FT. —
Nae"+^if Abovc Top of Cwmg)
8. TOP OF CASING iS 1 1/2 FT.Above Land Surface* — C
*Top of*allot W=huted at/or below land swfaee regaim e
verlm"in aecordua with ISA NCAC 2C.011& _
9. YIELD(gpm): 10 METHOD OF TEST Air
10.WATER ZONES(depth): 292 FT
LOCATION SKETCH
11. DISiNFECT)ON:Type HTH Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft Material numbers and common road names.
From 0 To e7 Ft PVC
From To Ft
From To Ft Z 13. GROUT: Depth Material Method
From 0 To 20 Ft. Grout Poured
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in. ,
From To FL—in. in. _
15. SAND/GRAVEL PACK: an
Depth Size Material �,n
From To Ft. \,' Pivy 70
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THIS LL ON RUSTED IN ACCORDANCE WITHISA NCAC 2C,WELL
CONSTRUCTION STA�THFVrTM RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1 7
SIGNANRE OF PERSON CCN8T2L_CS:u tG TI .'XE?L.... .. _ DA t
Submit the original to the Division of Water Quality.Attn:Information Management. 1617 Mail Service Center-
Raleigh.NC 27699-1617, Phone No.[phone].within 30 days.

MILL CONSTRUCTION X-WORD
Nottq Carolina-DepaNanat of Blrvlromnent and Natural Resources-Division of Water Quality-Groundwater Section
warr.cONTRACrnn(urorvmoAL)NAML m.tu, ASHLEY T MORETZ czRTtyicAnaNr L5U
wat.r.CONTRACrOR COMPANY NAME MORETZ WELL DRILLING ?RON, is J20 )A62-1322
STATE waldr CONSTRUCTION PERMrro__Z T$
A680C1At1 WQ PERattTe
if le A b
I. WELL USE(Chock Applicable Sox):Residential emunieipal/Public 0 Induatrial 0 Agricult u tl Q
Monitoring Cl Recovery C3 Heat Ptmtp Water Injectitm 0 Other 0 If Other,List Use
2. WELL LOCATION:
Nesirm TAW C w !/ 1 T 0 CLSphic/L and setting
C
/ll4e ClSbpa Malley i7F1at
(54vet Naaw,Numbma,Cmmafmiq,.lh"vtdm4[at No,zip Cade) (ahedc ypropof I
a ofr�ltlocatiog$r w
3. OWNSR:�J An3s�Ai S/�56.D
Address °` � �� Latitudcllong)tude son rce: SOTopogtaphic amp
`= ' � g�--��— `` M .CMG=
cityarraft �p Conch From TO Fo n Deacripti
Mam=6Phmwambw r'
4. DATE DRH LSD 4 =ps-
S. TOTAL DEPTH: /S7 S- .�/
6. DOES WELL RSPLACB BIIISTING WELL? YES C3 NO l7
7. STATIC WATER LEM Below Top of Casing l/O Fr,
S. TOP OF CASING IS (Um 0+•itAbow Tap of Casing)a
_Z FT.Above Land Surface
-Top oraulas nrdeatd ww hdww And aerw royals a
varhum In amorda yrkk 19A NCAC 2C Ali&
9. YIELD(gpm): ;20 METHOD OFF EST i e-
10.WATER ZONES(dv&):, 21 °
01
IBGATLQN SKETCH
11. DISINFECTION:Type Amount O Z Show direction and distance in miles from at least
I2. CASINO: /�
R Wail Thickness two State Roads or Couto Roads.Include the road
Pro T ^-�.-.L F Material numbers and common road 1tiatCa. /
out.'" To.�....Fat�
ProL_a To Ft
13. FGrUT• To Ft Material Nettled
d�nD,Ku�>,-l�1
Fm To ei�±
o
14. SCREEN: Diarmter . Slot Size Material C7
F To F �'
F T h,, w
IS. GRAVELPACK
size Material o
FrotR ._ To Ft ut
Fro To
16, REMARKS:
1 DO HEREBY CERTIFY THATTH)S WELL WAS CONSTRUCTED IN ACCORDANCE WITH l SA NCAC 2C,WELL
CONSTRUCTION STANDARDS,W THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SNMTURE OF PERSON CONsTkucnNO THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,I&U bull Service Center-Raleigh,NC
Y/699-1636 Phone Na.(919)7XI-3221,within 30 days. GW-1 REV.07/2001
bd WUST:90 S00Z 02 'daS EEETZ9bb0L : 'ON XUJ dWfld 2 -mm Z13aOW WO219

IY
WELL CONSTRUCTION UCQM
)yore,C allea-Dapartmmt of 8nvirmmnaet and Nanval Resosroa-Dividott Of Water Quality-Cirotmdwatcr Section
Wl1L CGA'TaACTOsplg9MUA4 KAM toauae—. —LEY T MQRETZ CmTRICATEori a-LUE
wMLC0MTRAcr0Rc0MPANYAAMS MORETZ WELL DRILLING rlt0avre a t74LrJ+62-1322
STAT9 ww,c*mV ==c"P8aM1TY TtiA wp rsaMraaa
1. WELL LT6E(CAatk Appticubls RAtWeWial Mu77icWubHc Q ind iai O AYriautuaml A
Monitoring a aenwey 13 Heat Pump Water hum ban o Odw o if Omer,List v
t Vl=LOCATPO E T d
Np xe flat 1 Y` s qty G�Owe� � ai1�Fiat
IS j
(9nartt'trarl,lP CamrlWy,Behdlvidm,laNa.TJpCEtda) (eaartc y{rcrp�siroa)
3.
ON
Addrm Iassrttt Na) L adm�IoeSb9We apographictnup
agm tan =
ChyerT"a Sam zip CO& FSone � T , POrI itD�ppm
4. DATE DRRILLEDEZ�/3`��` f0'
S. TOTAL
6. DOE$WELL AHFLACII EXMTINO WELL? YES VNO E3
7. STATIC WATER LEM Below Top of CsoWg-. L0.FT.
S. TOP OF CASINO IS�_FT.Above Land Sur$ce•
"M of�a WoMided�Wrbataw Ind anNy ragom a
.- awwfta.asMAXCACJCAlt
9. YIELD(Span): 3 d mmov OF TEST
10,WATER ZONES(dapft /O,=S- 2�
11. DISMFECTION:TYP Amouaa 0 Z- Show direction sad distance is tulles Som at low
11 CASINO: wail Twd4mi two Stab Rands or County Roads.Include Ow road
% q ww ' M material rumbas aed ocmmon rand nears.
Front-_ To ,,.,,,_,PL . s�
hom-1 TDO ,, _ —^_Fes
13, P�roa�,- apqTo,.pS,CLFt Cretins �3t�
14. SCREEN: D da DLmaur Slot Sim Mx*W :-
F To FL-- ..io.
Fmm Ta Fr In, C o
15. RAVELPAC9L• -
slm Matari.l
w
1d. REMARICSt
I DO ROMY CERTIFY THAT THIS WUJ,WAS CONSTRUC=IN ACCORDANCE WITH i SA NCAC WEU-
ODNMI=ON STANDARDS,AND THAT A CIF Tly RECORD PROVIDED TO THE WELL OWNER
3(/L[ 2—/ -0
slouTURA OF P CONSTRU WRM- DATE
Submit the cr Wasi to the Dlvlsloa d Water Qua11ly,Groandwtter Swoon,I&u Mail Same*c.ne.._Rtr►dA Mc
3709 M Pbaaa Mo.(919)M4=,WMa 30 days. OW-1 REV.0T/b001
28 WUST:90 S00Z 02 .daS ZZ£TZ9770L : 'ON XHd dwnd 8 -113M Z13NOW W08A

Vs
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment And Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential Z Municipal/Public ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:MARION County MCDWL Topographic/Land setting
LONNIE MAC DR-LOT#37 ❑Ridge ❑ Slope ❑ Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:JOHN HUNSINGER Latitudellongitude of well location
Address LONNIE MAC DR-LOT#37
(Street or Route No.) (degrees(mmutes/seconds)
MARION NC Latitude/longitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
8( 28)-286-3611 DEPTH
Area Code Phone number From To
4.DATE DRILLED 09/02/05 _
5.TOTAL DEPTH: 605 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES❑ NO® From To
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing teminated at/or below land surface requires a - Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118. Two Stale Roads Or County Roads. Include the road
9.YIELD(gpm): 1 METHOD OF TEST ARD number and common names
10. WATER ZONES(depth): FROM POLKVILLE GO HWY.#226 N.LEFT ON
11.DISINFECTION:Type CHLORYTE Amount 16.5 WALKER RD.GO 1-314 MILE.RIGHT INTO HIDDEN
12. CASING: Wall Thickness HIDDEN LAKE.GO 1/2 MMII E.RIGHT ON 1
Depth Diameter or Weight/Ft Material GRAVEL DRIVE.LONNIE MAC DR HOUSE ON
From 0 To 80 Ft 6-1/4" SDR21 PVC LEFT.LOT#37.
From_To_Ft
From To Ft _
13. GROUT: Depth Material Method
From 0 To 20 Ft OUIKRETE POURED
From_To Ft. o -
14.SCREEN: Depth Diameter Slot Size Material c--� -
From_To_Ft._ in in. r
From_To_Ft._ in. in. Q`
15. SAND/GRAVEL PACK: o
Depth Size Material crt
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 TION STANDARDS,AND THAT A COPY OF S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
n
SIGNA7URE OF PERSON CONSTRUCTINGTTIE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina—Department of Environment And Natural Resources—Division of Water Quality—Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME(print)RODNEY ROBBINS CERTIFICATION# 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING,LLC PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT#_ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential ® MumcipaVPublic ❑ Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town:MARION County MCDWL Topographic/Land setting
102 CANNON FARM RD. ❑Ridge ❑ Slope ❑ Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
3. OWNER:DANNY BARTLETT Latitude/longitude of well location
Address 102 CANNON FARM RD.
(Street or Route No.) (degrees/minutes/seconds)
MARION NC 28752 Latitudellongitude source: ❑ GPS ❑Topographic map
City or Town State Zip Code (check box)
8t 28)—738-4569 DEPTH
Area Code Phone number From To
4.DATE DRILLED 09/23/05
5.TOTAL DEPTH: 305 DRILLING LOG
6.DOES WELL REPLACE EXISTING WELL? YES® NO❑ From To
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use"+"if Above Top of Casing)
8.TOP OF CASING IS 1-U2 FT. Above Land Surface* LOCATION SKETCH
*Top of casing terminated atior below land surface requires a Show direction and distance in miles from at least
variance in accordance with 15A NCAC 2C.0118.9. YIELD(gpm): 40 METHOD OF TEST ARD Two State Roads or County Roads. Include the road 10. WATER ZONES (depth): number and common namesFROM 64/74A GO OUT COVE RD.STRAIGHT ON
11.DISINFECTION:Type CHLORYTE Amount 7.5 SUGAR HILL RD. LEFT ON ZION HILL C$ RD.
12. CASING: Wall Thickness RIGHT ON NIX CREEK RD.CROSS BRIDGE AND
Depth Diameter or Weight/FL Material GO 1/2 MILE.LEFT ON CANNON FARM RD. 1
From 0 To 130 Ft 6-1/4" SDR21 PVC HOUSE ON RIGHT.
From To_Ft_ 3
From_To_Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft.OUIKRETE POURED 4
From_To Ft I
14.SCREEN: Depth Diameter Slot Size Material
From_To_Ft._ in in. 3
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 TIO TANDARDS,AND THAT A COPY OF RECORD HA BEEN PROVIDED TO THE WELL OWNER
r
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center—Raleigh,NC
27699-1636 Phone No. [phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
�/� F J 7
WELL CONTRACTOR(INDIVIDUAL)NAME (print) �- �K + Lj�C'. )4 CERTIFICATION#e C v
WELL CONTRACTOR COMPANY NAME /L( [ 1 C k GLt�.I I J7 u e .✓� PHONE # t )
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box): Residential B__�Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI D,rt ,^6�G!/ Topographic/Land setting
�
Nearest Town-- �J /r Is Counw,,Y •LJ ❑Ridge 2Slope ❑Valley ❑Flat
ld. ? &rt A /eY� aa;l (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cade) Latitude/longitude of well location
3. OWNER: C�� 1f,c�L+ l�Js i N AJ1 (degrees/minutes/seconds)
Address ,L (e 05;i;/e. Y /Z' d, Latitude/longitude source:❑GPS❑Topographic map
,� / (Street or
Route No.) (check box)
/�IJc2`t i 15 C, , a r 7 2 DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
Area code-Phone numb�+�,
4. DATE DRILLED2-
5. TOTAL DEPTH:' / d c.�r_
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO e— o
7. STATIC WATER LEVEL Below Top of Casing: ,J S T.
(Use"+"if Above Top of Casing) I p_
S. TOP OF CASING IS FT. Above Land Surface* m
-Top of casing terminated at/or below land surface requires a
variance In accordance with 15A NCAC 2C.0I18. ,
9. YIELD(gpm):Z oZ METHOD OF TEST,4_?i Zc ?
10.WATER ZONES(depth):
�t LOCATION SKETCH
11. DISINFECTION:Type e/V h 0 X AmounL4 0 _�,2 r Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth D' meter or Weight/Ft. Yaterial numbers and common road names.
Fromt�To_&Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Werial Method -f 4&1e.Al d .if �1G�
From'-7`' To 2)) Ft. (,
From To Ft. of c 1 ! C� cal �f
14. SCREEN: Depth Diameter Slot Size Material l `, 1 1 �,
From To Ft, in. in. �Cl.M le- lRJ k < ?rp L 4
From To Ft. in. in.
15. SAND/GRAVEL PACK: /A /2 �1 �C.
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,Alp THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S� - e.. 2?C .A" 5'_ /s a s
GNATURE OF PERSO_N_CONSTRl:J£TtNP1T1E WELL DATE
Submit the original to the Division of Water Qualify,Groundwater Section,1636 Mail'Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.,`. - GW-1 REV. 07/2001
18
i

North Carolina Department of Environment and Natural Resources-Division of Water Qua lity-Gro ndwater Section cl C F, C..
1636 Mau Service Center-Ralelgh,N.C. 27699-1636-Phone[phone] ` 0 0
WELL CONSTRUCTION RECORD WELLCONTRACTOR: o
WELL CONTRACTOR CERTIFICATION 9 : 30 S<L
STATE WELL CONSTRUCTION PERMIT 9 :
SAE Li. USE (Check Applicable Box): Residentialo Municipal ❑ Industrial❑ Agricultural ❑ Monitoring LJ
`recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
vc l O(-_ATIO Show ketch of the location below) ��JJ
Nearest town.`�0 County ZYC, a it,4 4,L
ICS'7a 4AAr414,*ooa QA
0,ad Name and Numbers.Co�mAmunity. or Subdivision and Lot No DRILLING LOG DEPTH
^ (.\^fNFr .E' Cit k A -)PC L From To Formation Descrintioc
Tess JGO 49666 rwe.od J'l Street or Route NO
';Iry or Town / State Zip Code
a DATE DRILLED �` _U
rr-AI. DEPTH 116
TINGS COLLECTED YES Q NO®
DOES WELL REPLACE EXISTING WELL? YESf NOQ
S 'iC 'W
ATER LEVEL Below Top of Casing. FT .
(Use'+"if above Top of Casing)
10P OF CASING IS FT. Above Land Surface.
:ring terminated atfor below land surface requires a variance in accor-
ya,rr Nth 'Sp NCAC 2C 0118
:GPM 1_ � � METHOD OF TEST 611i A CI-1
.,rArFQ 70NES (depth):
-HI.ORI NATION Type Amount_L<< If additional space is needed use back of form
q q N G Wall Thickness
heath Diameter or Weight/Ft Material
G ��•j LOCATION SKETCH
r,T To ct (Showdirection and distance from at least 'wc Sa r
ro Ft Roads, or other map reference Points)
14 ,ROLIT _=
Depth Material Method _.
To Ft
To R
Depth Diameter Slot.Size Material p
7o Ft in. in.
_ Tr _Ft in in
'f -nN':rGRAVEL PACK
Depth Size Material
To Ft
To Ft
" ��MARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL.
.ONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/
FOR OFFICE USE ONLY 4,r ��ZZ �Q - „ - " �J L pj✓
Quad No. SIGNATURE OF PERSON COWSTRINIJING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV +2'PP

00
North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
.Fyfi Mau Service Center- Ralelgh,N.0.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELLCONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT #
IJF I.I USE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Mon,tc,mc;
'SFr- �ery 0 Heat Pump Water Injection E] Other O If Other, List Use.
`ATfINi r';how sketch of the location below?
:_r, toll. 04d A++r- County /1 0
&54? U).rteh IZd
Pnad Name an Numbers Community, or Subdivision and Lot No DRILLING LOG DEPTH
3 OWNER S� ��"h'� ��� From TO Formation Descrnmo�
r�ririress � {O yL4L r il
Se, )/3 Q
a 7`
oNd ,�Fr nice.
=ity or Town -State Zip Code
$� as
.. :1P F)EP ED
"'AI DEPTHH
' r!NGS COLLECTED YES Q NO®
WFI L REPLACE EXISTING WELL? YESD NO(Z
,NATER LEVEL Below Top of Casing FT.
(Use "I'if above Top of Casing)
,r- CASING IS ��• FT. Above Land Surface'
facing terminated atlor below land surface requires a variance in actor-
lancr, v,tl` '5A NCAC 2C 0118
�F i(-, r o7 FS't METHOD OF TEST
.. ,.z' ir1NFS ldeothl
'.`RI NATION Type hl / Amount -/ b If additional space is needed use back of form
,AS I N G. Wall Thickness
Depth Diameter or WeightlFt Material
To I'd FI = .27."t , C, LOCATIONSKFTCH
To nt (Show direction and distance from at least two S?a'F
To Tt Roads, or other map reference points)
'c ,� i i7
Depth Material Method
M To Ft
-.. Tn Ft
N
Depth Diameter Slot SizeMaterial C07 4--
in in -'
r
-- _� TO ft in in
Tr, Ft in in
^.",RAVEL PACK_
Depth Size Material
To Ft
To Ft
17 RFMARKS.
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
-)INSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL. Owl
FOR OFFICE USE ONLY �j ,,,� '9-`J
quad No. SIGNATUR OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV t7190

aA
( w p
North Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section R
1639 Mau Service Center-Ralelgh,N.C. 27699-1636-Phone[phone] y i
WELL CONSTRUCTION RECORD WELL CONTRACTOR: CL AxC CA 4,
WELL CONTRACTOR CERTIFICATION III :
7
STATE WELL CONSTRUCTION PERMIT# :
✓dF I : OSE (Check Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitonnc_ l
recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other. List Use:
4,l , .-)CATION_ (Show sketch of the location below)
'Jenrost town Moi..GF/ County
J 3! S/5 yV;r�'w D.+ /y/AA•'s^/ !?!c.�78'>�j.
� ,ad Name and Numbers.Co�mJmunity, 9r Subdivision and Lot No.) DRILLING LOG DEPTH
<1A�rNER Lyn/ /3v:. p�N From To Formation Descopfio,
=,tie5s��fy" Arr+hFK JZidgK d4� Ta:•YNc�,.7$�GR
/� b ree or ou 7 ,
-:iv or Town �y State Zip Code
r"ATF DRILLED ' -��
"^'Al DFPTH y1.2
.; TINGS COLLECTED YES Q N0�]
C)'?ES WELL REPLACE EXISTING WELL? YES Q NOQ
.-TAT'C WATER LEVEL BelowTop ofCasing. A42 FT.
(Use"+" if above Top of Casing)
- 101' OF CASING IS IVIll, FT. Above Land Surface'
'op o' :as,ng terminated at/or below land surface requires a variance in accor-
iance wdh '5A NCAC 2C.0118
vpi'.1l l("PM): J F METHOD OF TEST .Q14/r'13A
7(TNF,S (depth).
n �-,PINATION'. Type /-17;Ar Amount if additional space is needed use back of form
A S I N 6 Wall Thickness
Denih Diameter or We hVFt atenal
1n GO FI �� p„r<. LOCATION SKFT .H
To rt (Showdirection and distance from at least twc Snra
rt Roads, or other map reference points)
Depth Material Method
F-nm To Ft. Cn
n1
... .. 7o Ft 'O "
,c 4CRFFN N
Depth Diameter Slot.Size Material )
L.-"IT To Ft in in. cn
To Ft in in.
;AW 1f RAVEL PACK'
Depth Size Material
To Ft
To F1
�FMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
",nNSTRIJCTION STANDARDS. AND THAT A COPY OF THIS REC/O�RD HAS BEEN PROVIDED TO THE WELL OWNFR
cOR OFFICE USE ONLY 1//c -I& l/�
Quad No. SIGNATURE OF PERSO_N-CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1,REV 1219P

W
Nnnh Carolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater section sa 4 F;
'F36 UPI' Sery ire Center-Raleigh.N.C. 27699-1636-Phone[phone] J 1 U l
WEt l_ CONSTRUCTION RECORD WELLCONTRACTOR: _/'9OX~4/ ®Rf k1"V'9
WELL CONTRACTOR CERTIFICATION # : L
STATE WELL CONSTRUCTION PERMIT#
MA
'JJFLL. USE (Check Applicable Box): Residentiall,6il Municipal ❑ Industrial❑ Agricultural ❑ Monitcrinc t�
Recovery ❑ Heal Pump Water Injection ❑ Other❑ If Other, List Use:
rNF I_I. i OCATION: ( how skjtch of the location below) �y
Nearest town. p�16
N County
G/ fl&if y/r)-mW Bi-
ooad Name and Numbers Community or Subdivision and Lot No DRILLING LOG DEPTH
�!^JNER G6a Age CO rpFk From To Formation Descn.nt,o,
> (b rT—ee Of due 6s,�r�y,'�.�� oh
O.
':nv or Town State Zip Code
r)nTF DRILLED
(�FPTHPTH 7
'1'NGS COLLECTED YES ❑ NO®
''CfES WELL REPLACE EXISTING WELL? YES M NOQ
STAT.0 WATER LEVEL Below Top of Casing y5"S FT .
(Use'+^if above Top of Casing)
y TOP OF CASING IS or{ FT Above Land Surface'
`c o' :asing terminated at/or below land surface requires a variance in accor-
iance -Th 'SA NCAC 2C 0118 ,
L' Ir'PM) METHOD OF TEST
.vaTFP ZONE epTh)
(;H(-ORINATION: Type A719 Amount ,..,✓_ If additional space is needed use back of form
ASIN, Wall Thickness
Depth Diameter or Weight/Ft. Material
to 010 F11` SAs�:A b/25'1`/L LOCATION SKETCH
To rt (Showdirection and distance from a? least 'wc
to Ft Roads. or other map refererce points)
1T Pl.
Depth Material Method _
To Ft .�
m Ft N
S
u �(;R FFN O
Depth Diameter Slot.Size Material Qq
"nm _ To Ft in. in.
To Ft in in.
To Ft in in.
r!-. �,ANU/GRAVEL PACK:
Depth Size Material
To Ft
nm To Ft
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 HAS BEEN PROVIDED TO THE WELL OWNFP
i FOR OFFICE USE ONLY
!� DOad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality. Groundwater Section within 30 days
GW.I REV 1 nor

V" w (?
Noun r,,,rr,hna Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
'93F Man Servire Center .Ralelgh,N.C.27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: J10��Oa/ � d^�hLrv�
WELL CONTRACTOR CERTIFICATION # . -2 9
STATE WELL CONSTRUCTION PERMIT# :
NE USE (Check Applicable Box): Residential Municipal Industrial❑ Agricultural ElMonrtn cmc I
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
n�F LOCATION yr Sy�how sl�etch of the location below) L
tica� st town "`�hrOw County. � �0 w i
_>3 A. 6A./ .72 1 s
Gnad Name and�Nu/mbers. Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
nWNER /O!„Al -4AAi yoel From To Fo,manon Dev:not-n�
press 177.2 bL 22IS
(bireef or ou a o.
.` lover State Zip Code
RII.I.ED -20-6T' --
-',Ai DEPTH
-'IN( S COLLECTED YES a NOQ
WFLI_ REPLACE EXISTING WELL? YES NOD
' NATER LEVEL Below Top of Casing FT
(Use if above Top of Casing)
CASING IS :201Fr FT_ Above Land Surface`
oc " 'as,q term,naled at/or below land surface requires a variance in accor-
dancc w,th SA NCAC 2 011E
vFil.;,i ((;PM): 6 -0- METHOD OF TEST A1k srl+
VA ZONES (depth).
_. ,'INIATION_ Type Amount If addlhonal space is needed use back of form
Will Thickness
Depth Diameter or Weight/Ft. Material
LOCATION SKETCH
to Ft
�t. (Show direction and distance from at leas' ;w
To e -aye
ro ct Roads, or other map reference points)
Depth Material Method,
To °7i0 Ft G
To Ft
-_nrrN .2
Depth Diameter Slot Size Material
r
to H In in nJ -
,F To Ft In in. q
To F[ In in.
tr SAND/GRAVEL PACK:
Depth Size Material
Tc Ft
To Ft
�FMARKS
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
'.ONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNFR
=OF OFFICE USE ONLY
'JOed Nn S ATUR F PERSON CONSTRUCTING THE WELL DATE
Serial No. Submit original to Division of Water Quality, Groundwater Section witgirh70 1�w
1 .GW

•d•�r .,-n,l,na Department of Environment and Natural Resources-Division of Wator Quality- ,undwster Se^rnn ( 5
;,19 Mau Aarvire Canter-Ralelgh.N.C. 27699-1636-Phone[phone]
`NELE_ CONSTRUCTION RECORD WELL CONTRACTOR: 6441f 644 f,'��.a �`h/
WELL CONTRACTOR CERTIFICATION # : 6F44 _
STATE WELL CONSTRUCTION PERMIT#
ESL Check Applicable Roy): Residential Munlclpal ❑ Industrial ElAgneultural ❑ Mnn �r
Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use:
All' :1 OCATION (Show sketch of the location below)
Nr�,resr town. M�K s o%�/ County. /V77'
�nad Name and N !7
Numbers,�C//ommunity, or Subdivision and Lot No DRILLING LOG DEPTH
^ NER Chid 0ci,%IC' From To FormationDevr,orn-
n-ess 421 4/tti !?�
f;�� onr4r ou e o
,..,-. Gtatr_ Zip Code -"
'TRILLED - `Ji -.6
n i)EPTH Ii "
!'JGS COLLECTED YES ❑ NO® '
' nF ,VELL REPLACE EXISTING WELL? YES F -
`,AIATFR LEVEL Below Top of Casino FT rri
-o =
(Use',' ifabove Top of Casing) 1
ASING IS !i F7 Above Land Surface'
a.i re-•n,nated at/o Gelow land surface requires a variance in accor C-5,-"�'�`"'
mr- '5A NCAC 7C�0.11-18 c^ _
vFll IGPM1'. ��_ METHOD OF TEST
I.ATER ZONES (depth)- -
\,A1 ION Type 11"7/1 Pit Amount A If additional space is needed use back of rprm
Wall Thickness .-
flaoth Dla eter or We'ight/Ft. Material
fo CFO Ft S %I 6 AST/'� LOCATION SKETCH
* To n1 (Show direction and distance from at least two
10 4t Roads. or other map reference points)
Depth Material Method
n To Ft
To Ft
r rru �N
Depth Diameter Slot Size Material
-__ In F' in m.
To P in in
•ten• _ To Ft in in
+6 SAND/GRAVEL PACK:
Depth Size Material
To Ft
To Ft
�cfv S
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
InOR OFFICE USE ONLY � �i, ,
Quad No. SIGNATURE OF PERSON CONSTRUCTING THE WELL OATE
Serial No Submit original to Division of Water Quality,Groundwater Section within 30 days
GW-1 REV 1^1g<_-

0S,
J � IY � � J
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resour es-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM,[F��(^pr/^in�t) ,�t'77 J/' n CERTIFICATION
3
WELL CONTRACTOR COMPANY NAME i Iwn �/ TC.�II I4 EN ' �� y PHONEk
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (ifa 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 .` '`y`�P/ Topogra 1c/Land setting
earest Town
�I ,s ��j/.V , ounty +� er-1t ❑Ridge ope ❑Valley ❑Flat
•—�� 19 T �C' T r •a��5 �� k-'1 1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,
'�Lot�N,,o.,/,Zip
Code) - / Latitudello gitud of weI loc tlpp�d
3. OWNER:&�t 1U �{t/I`�64C '�U `vC3J~� 7. (D � �Y41
2 (degrees/minutes/seconds) c I/, 0'5t /
Address HCJ y T Latitude/longitude source:❑GPS❑Topographic map
Kr/ n( «eet or Route No.) (check box)
. I1 fN' JUL a$* I� DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
Area code-Phone number O -
4. DATE DRILLED
5. TOTAL DEPTH: t _
6. DOES WELL REPLACE EXISTING WELL? YE NO 931
7. STATIC WATER LEVEL Below Top of Casing: U FT. In
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface`
I
"Top creasing terminated aUor below land surface requires a
variance in accords c h ISA NCAC 2C.0118. _
9. YIELD(gpm): MEcTLFFpq D QF TESIGC76, o
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From —G— TO '7 it Ft.
From To Ft.
From To Ft.
l3. GROUT: Depth Ma p ethod
From Depth
FL�t C(_. bi.
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,"ELL
CONSTRUC N STANDARDS, ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ozc O�
SIGNATURE O 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

l ji a3 i v
WELL CONSTRUCTION RECORD
North Carolina-Department of Envimnment and Naha 1 v•....._-- r,:..:.:,..,nf Water I Groundwater Section
n 1\— AA Quarry- y
WELL CONTRACTOR(INDIVIDUAL)NAME (pdal) 6 1 LL I i 0' rA S I I CIRTIPICATION 0­2N.�—{)
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. ll�1 g 54-3581
STATE WILL CONSTRUCTION PERM R 537 PIIONIY�
a_(ifapplitable) �OCITRED WQ PEIRMITa
applicable)
L WELL USE(Check Applicable Doz): Residential 4; Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ litat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: {��� ( 9 N CountyC J Topographic/Land setting
CAdidge ❑Slope ❑Valley ❑Flat
(Street Neme,Number,Cemmuniry,Su Tuition,[rat No.,Zip Code) (•�k apptopriuc boa)
(� Latitudc/longitude of well location
3. OWNER:. _J-_ ��(�tJ m 1 L-\,li
Address G/7� � ,%,io -06-1 -- (deDocs/minue./rec°Od�)
• -I 1 Latitudcflongitude source:❑GPS❑Topographic map
(Street oc Route No.� ` ^ L (chock boa)
I� ' N�S1fil 1 tx DEPTIi DR)LLM . OG
ry"Town Stu, _ ZipCode a rDR L q
UL'2)-- d-4- .� A Fro - i I O To i FG J b 2(,S�De'2�t'IN
Am code-Phone number
4. DATE DRILLED ) L 0 ei 11 e t - 4-5c T E
5. TOTAL DEPTH: 9, 10 LR !'QL ' "-1 -
6. DOES WELL REPLACE EXISTING WELL? YES ® NO ❑ �� c f 7 (�� � ` " t t
7. STATIC WATER LEVEL Below To ofCasin b" � (o 1 t - ,PI-1
(Ure • if Above Top
8. TOP OF CASING IS -
FT. Above Land Surface Surface
•Tep create"brmlaeted aver below lad ruriare requlru• _
varies"le acurdenc Itb ISANCACIC.0119. 17 2 -
9. YIELD(gpm): _METHOD OF TEST J`'I c: - /) t dZ
10.WATER ZONES(depth):_ 5j C — ' _. t w1 P 1
WCADON SKETCH =e
11. DISINFECTION:Type
(D' c ^
Amount 1L I Show direction and distance in miles from Weast'-.,.
12. CASING: Wall Thickness two State Roads or County Roads. Include the road:
Depth D' er or W ig$h L Ifrid numb n end common mad names. --+
From :1_ TO-L�FL= Sl)��(�
From Tc Ft.
From To Ff.
13. GROUT-qq Depth hfaterial Method \....`
From ..L To i�D Ft. Ltr tlll.lb
From To FL 1
14. SCREEN: Depth Diameter Slot Sire Material
From To Ft. in. in.
From To Ft. in. in. S�I '("11(` I
15. SAND/GRAVEL PACK: `If I- d2-' t`I (Lt-
Depth Size Material
From To FL ' al
From To FR. j�� `
16. REMARKS: f (/1! G
I DO HEREBY CERTIFY THAT Tills WELL WAS CONSTRUCTED INAC ORDANCEWTDf ISANCAC2C
CONSTRUCTION STANDARDS,AND T1fAT A CqTY OF THIS RECORD BEEN PROVIDED TO THAr�'
ER
+ ^ r�
v
SIGNATURE OF PERSON CONSTRUCHN THE DA
Submit the original to the Dlvlsiou of Water Quality,Groundwater Section, 1636 Malt Service Center-RAle)ah,NC
27699-1636 Phone No.;[phone],within 30 days. GW-1 REV-07/2001

3 15 d v 3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nnatural o.a..•• n:..:.;^n of Water I Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prier) Ll i�..L 1 t3 �A SS t1 CERTIFICATIONS �� 1
WELL CONTRACTOR COMPANY NAME RF.UBEN CALDWELL DRILLING, INC. PItONEY I537 ff11g�"8 54-3581
STATE WELL CONSTRUCTION PCRMITa_(if applicable) A�OCIATED WQ PERMITa
` (ifapplicable)
I. WELL USE(Check Applicable Box): Residential 0 Municipal/Public❑ Industrial❑ A
Monitoring❑ Recovery ❑ flea[Pump Water Injection❑ Other❑ If Other,List Use cultural❑
2. WELL LOCATIO :
Nearest Tow}: �I0� a
County C �Cwi�Ll �Topnfphlc/Landsetting
I'..I r5 I^�I Y I Q r L G'C -1.-7 Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Cosnmuniry,Subdivision,LA No.,Zip Code) (che lr appropriate boa)
Calitude/longitude of well location
3. OWNER: t3&D✓ i�1 ) Ll t JL_. (dtv m w¢a seemds)
Address -litl„f N.l'�^� r5 j�; �d�" titudcAongitudesource:❑GPS❑Topographic map
(i�n�rsJl (Street1t o RouteNo.) (check boa)
D-ERTClrym Town S Ip Code �n N DRILLING O
TO
Y F1 !^ 4 Co ti�fSJ �j16 Area code-RIL number 6 fig--- , i
4. DATE DRILLED—6 11_ __iQ� - i� �� ILA
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: tOLIO FT,
(Use'.'if Above Top of Cuina) G"`
9. TOP OF CASING IS FT.Above Land Surface* 2
*Top ofculo(larmlaated aver below lead surface requires a
Varian"in accordance with 15A NCAC 2C.0112. 6 Q p
9. YIELD(gpm): G METHOD OF E k
ST it 6-r`17`-'
CJ3
10.WATER ZONES(depth): _
LOCATI_ ON 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
DcPth Diu�eler W or ci ht/Ft. Material nyrr)ben and common mad names.
From To )a FI. b rl S �� ( 4(-
From To Ft.
From To Ft.
13. GROUT: Depth hiatcriJ Method
From To___�e Ft. n� .�.
From To Ft. �,,
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in.
From To Ft. in, in. 9 JC'A
15. SAND/GRAVEL PACK: 7
Depth Size Malcrial
From To Ft.
From To FL fl V
16. REMARKS:
I DO REREDY CERTIFY rilAT THIS WELL WAS CONSTRUCTED IN A CORDANCE WITII 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,.AND THAT A C Y OF TIDS RECO IAS BEEN PROVIDED TO THE PLn.OWNER
ca
SIGNATURE OF PERSON CONS N THE WELL DAV
Submit the original to(he Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RE non _
NortltCarolina-
DepartttatlntofEavho®eat and N uralRewmces Dma' nOfwaterQ=Hty-(leo�mdw�gaeyh
ME
L-
WELL CONTRACTOR MURVIDDAw NA - .• GT20N p �.3a✓
if
WELL CONTRACTOR COMPANY NAME r r �.. PROM a L'7 i M/:���-°-�"�
STATE WELL CONSTRUCTION PEEMIl'I •L�'C"ATED WQ P ".I
t�
rVapplicable) (if applicable)
1. WELL USE(ChecltApplicable Box):Residential Mmicipal/Public O Indmhid❑ AgritmlutmI❑
Monitoring O Recovery ❑ Heat Pump Water Injection O Other O If Other,List Use
2. WELL LOCATI
Nearest Co � T�ph��d setting
Midge fey Flat( appropriate bu)
(Shea Name,Numbas,Commanay,&Jxhv awM Lot No.,Yip code) Latitude/Iongitude of well location
3. OWNER - "•°'i✓ (dePuanenmas/reemds)
Address u/1 G {2 Latimde/longitrade sotace:17GPSOTopographic map
(Sveet ar No.) (ehwk bu)
DEPTH D n i ING LOG;
( Cay or T m State Zip Code From To Formation Description
AM cods Phone
4. DATE DRILLED 09
5. TOTAL DEPTH: / 0 G") 71
6. DOES WELL REPLACE EXISTING WELL? YES 13 NtYO/
7. STATIC WATER LEVEL Below Top of Casing: _FT.
(Use^+-if Above Top of Cuing 60 ,
3. TOP OF CASING IS FT.Above Land Surface
'Top of adoa tarmisated atlor be4w rand sudsy requires a -
•arimce V aeeerdmat with 13A NCAC 2C.011t
9• YIELD(gpm): ZZ7 METJIOD OF TEST �
10. WATER ZONES(depth): Y_3
LOCATION SKETCH rr9 1
11. DISINFECTION:Type —,-LC— Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads,Include the road
Dapd, Diam;rer, orWeight/FG numbers and common toad names.
From To
Fromm_To Ft !
From To Ft
13. GROUT: Depth Material Method tf O
From TOP To y Ft 3; ,
From To Ft 1Q
14. SCREEN: Depth Diameter Slot Sim Material _�j
SRv r V
From To Ft—in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CON.'TRUCTED IN ACCC RDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ANDARDS,AND THAT A COPY OF THIS RECORD Hs BEEN PROVIDED To THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELT. - DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC -
^400_t434 vy...V , ;o1at ' <_+..within 10 days.

2;
.2
WELL CON TRII
North Carolina-DeQa¢m>bnt ofEwAroatoent and N total Resor�n Dt "irm tt QtalGlr= x 9et lion
wELL CONT"Cron(umtvmowt l n,►Mts N ' S d CMIEFICATiCet433��T
w6LL t-ONTs Cron C0MI`ARY NAM1s rsora 11 6it>- ' .3s,5"
SrATX WELL COMILUCTIDN PERhars ,�eecnrr.•�p WQ pay
�s=able) � (itawueabk)
1. WELL USE(Chwk Applicable Box):Residential 0 MunicipaVPublic O Indaahial 0 Agricultural C
Monitoring❑ Recovery 0 Heat Pump Water lnjection❑ Other 0 If Other,List Uae
2. WELL N LOwn: Y T )*Amd sethu
� �'—'nC rl �� Midge Mlope DValley E3FIat
✓J/9r /0l/
(Shret Nam Numbers, ( box)C.ommmity,Subdtvidrq Lot No,T�Cade) Latidtddlongimde of well location
3. OWNER r 9- C L( (de�eclm®�samd�)
Address J ;n/ r !U) r / /i Lantude/longitucie sotase:0GPS0Topogmphic map
}r T�( ) ' S" J Jr ,!� (mock box)
IL$EIII DRILLING LOG
d Ch or Town stop Zip Code From To Formation Description
Ci
Ara code•Puree comber .--
4. DATE DRILLED U S
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL Below Top of Casing: FT.
(UM`+"ifAbow Top of C
3. TOP OF CASING IS / FT.Above Land Surface• Pa
'Top of cadet termLued adw below land surt s regnim a �D �
vadmee in aemrdu with UA NCAC 2C.011L
9. YIELD(gpm): //I METHOD OF TEST �4i 4 k L
10. WATER ZONES(depth):
`� ` LOCATION SKETCH
11. DISINFECTION:Type .L& :Ie- Amount Show direction and distance is miles from at least
12. CASING: Death Wall Thielmess two State Roads or County Roads.Include the road
From _IOGt To�Fti DIGMew or WeighUFt Material numbers and common mad names.
From_�—To Ft
From To Ft
13. GROUT: Depdt Material Method \`
Fro,w ��,, To�,�Ft
From—To Ft X
14. SCREEN: Depth Diameter Slot size Material r
From To Ft, in. in.
From To Ft in. in. l y O KAs/C
15. SAND/GRAVEL PACK 4
Depth Size Material
From To FL
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 111 ACCC RDANCE WITH 15A NCAC 2C•WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD BLS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREOF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Srcrion, 1636 Mail Service Center-Raleigh,NC
!'AGQ_/6e6 p41ne Vn ala\"14_l��l NA' 'r A ..._.
._ . _ .. _- v....rn_0 days. aucUtll _.

_ � ♦ �IA 4L� YteYtl 4 u6" Yfi
S -„
North Carolina-Department ofFavirvammt and Natural Resousc Div'on of Water QtaBey.Qeo®dwaler g«y� -7'°'
WeLL CONTRACTOR(INDWIDUAL)NAME,(/mac) '� �•- O ✓�-J clQ[mcA'lTl)n s yS �". `. _
WELL CONTRACTOR COMPANY NAME
STAT=WELL CONSTRUCTION PEB6II'i>r. •�OCIAIZD WQ PERMM -
(ifaaplicable) (ifapoliable)
L WELL USE(Check Applicable Box):Residential 0f Municipal/Public:❑ Industrial 0 Agricu heal❑
Monitoring(3 Recovery 0 Heat Pump Water lmection❑ Other O If Other,List Use
2 WELL LOCATION- � g
N Town: r t Cop Ty V ✓r ! opo9MhiQT.=d setting
( h �� Midge ❑$Tope Malley ❑Flat
(Stteet VsmS N en,b Camm (cbwk an-ptiaft bet)
'm"t's �"1OOq N°- )3. OW,'Q1:R: LatitudcAongimde of well location
)� !ate i l/� (deVeesm®aauaecmdt)
Address Latitude/longitude source:OGPSO opogtaphic mapDEFITI
)
(�C�4� S� L . �� (Check
GP D n1IN 2
(_ . From To Formation Description
AM code-Phase m®ber
4. DATE DRILLED FJ -3U "D��
5. TOTAL DEPTH: ,/3 l --
5. DOES WELL REPLACE EXISTING WELL7 YES❑.NO lTY
7. STATIC WATER LEVEL Below Top of Casing: -1
(Um.+"ifAbove Top ofC=W :
8. TOP OF CASING IS / FT.Above Land Surface-
'Top of mdoa termlaeted odor below lead sorfare regetrn a N -,i
vartaace In armrdsoce with 33A NCAC 2C.e11L
9. YIELD(gpm):_119 METHOD QF TEST _
10. WATER ZONES(depth):
LOCATION CSKETCfi
11. DISINFECTION:Type- - Amotmt Show direction and distance in miles from at lease
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or weight/FL numbers and common road names.
From To�_Ft_� (l
From_To Ft
From To Ft I C q
13. GROUT: Depth Material MethodFrom'TT To� FtFrom To Ft14. SCREEN: Depth Diameter SiotsizeMarais!From To Ftis �From To Ftin. u15. SAND/GRA Depth CK s� MaterialFromTo FtFromTo Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSnUCTED IN ACCC RDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD Hr.S BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL E a O S+
- DATE .
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
"1600_1 Fay ahoae NO, !olot 1j3-322. •vithin?n 44ys
v+V UVi

.kMG•ry ,..l a �i"��E
WELL CONSTRUCTION R
North Carolina-Department Of Environment and Nantral Resources-Division of Wstee _
/' 1 ~CL1ClDl;iL'ISQfi
WELL CONTRACTOR M(Dri1DUAL NAMEWWILr...`. S;
WELL CONTRACTOR COMPANY NAME t I a .. " '"'"`�' '� .,.:>�
STATE WQ,L CONSTRUCTION pERAffn «OC[ATID WQ iiR11IIlY '
Of malleable) ftfmylieable)
L WELL USE(Check Applicable Box):Residential O Mtmicipal/Public O Dial O AgriculturalD
MomWrmg O Recovery, O Heat Ptmzp Water Injection O Other O If Other,List Use
2. WELL LOCATION
_ ng
Nearest Town: `, 71 �� f Count, L} ,i TopogiPphir/r d�
t v . . ` h i Midge OSlope [3Val1ey [Mat
(Sues Name,Nombeq Community,Subdiv otr,Lot No,Tip Code) (th«k�
Latimde/loagitade of wen location
3. OWNER: _ c + r (deDe�m®rraavo6)
Address Latitude/longitude souau:OGPSOTopographic map
_ - (Street err Route No.), (lhtlek box)
Idy err DEPTH QMLLING LOG
C Town. State(�} % case From To Formation Description
Area oads Phone aionbuz _ s
4. DATE DRILLED
I
5. TOTAL DEPTH: ' !-
6. DOES WELL REPLACE EXISTING WELL? YES O NO Q n
7. STATIC WATER LEVEL Below Top of Casing - FT, — ^
/ (Um-+-if Above Top of Cum&)
3. TOP OF CASING IS_L_FT.Above Land Surface*
"Top oreWMg terulaated War below Led sWfaea requim a O +w
vartMm la auanrdana with 15A NCAC ZC.011&
9. YIELD(gpm): X METHOD OF TEST 11. 1 ✓'
10. WATER ZONES(depth): L '
LOCATION SKETCH
11. DISINFECTION:Type Amount /' Show direction and distance in miles from at least
12. CASING: Wall Tbiclmets two State Roads or County Road&Include the road
Depth Diameter or WeighbFt� numbers and common road names.
From s G I �To i" Ft '
,i
From—To FL_ l
From To FL
13. GROUT: Depth Material Method
From ` r To�
From To Ft
14. SCREEN: '-
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. is
15. SANDIGRAVEL PACK:
� FL size MaterialFrom `
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCC RDANCE WITH 15A NCAC 2G WELL
CONSTRUCTION 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, 163t-Mail'Setvice Center-Raleigh,NC
•�eoa_�535 Phone Yo. 'a19N+u�_:�... `rthin 39day,.