Md CY2005

3
0SIO
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-�Division of Water Quality-Groundwater Secuon
WELL CONTRACTOR(INDWMUAL)NAME (print)
-R1�24/7 e LP h ll CERTIFICATION#�pz?17
WELL CONTRACTOR COMPANY NAME S dC9TJAIlQ-"t'E.(� L jejI ()it:I ItaCL PRONE M m�,7'OtIFO
STATE WELL CONSTRUCTION PERMIT# .ASSOCIATED WQ PERbUT#
ifapplicable) ifapplicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: /Topographic/Larld setting
Nearest Town: 11!/91t51t�1�� County.& / &'L) Mdge ❑Slope [ Valley ❑Flat
Ylt-7 lo f a t/ ,ICc( (check Vpoprtau twx)
(soar Nambem Community,subdivision,tat No.,zip Code) Latitudellongitude of well location
3. OWNER:S(de /J/t00 (degraslaum�oeslsaoods)
Address� 7 f Latitudellongitude source:❑GPS❑Topographlc map
/�tSb t or Aawe No.) (cloak bo[)
�h/$1P5/i/lij/ DRILLING LOG
City or Town state Zip Code From To Formation Description
Area code-Phone mrmba
4. DATE DRILLED_.I'Zlo -05--
5. TOTAL DEPTH: 6 O 67
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Er'
7. STATIC WATER LEVEL Below Top of Casing: /60 FT. AM 19
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1-5 FT.Above Land Surface*
*Top of cmduX terminated atlor below land surface regnh m a
varlaau to ttm &°ee�witbr ISA NCAC 2C.4IIL r. /
9. YIELD(gpm):J- iF—METHOD OF TEST /.91rd �t
10. WATER ZONES(depth):
LOCATIONS :ETCH
I i. DISINFECTION:Type Amount �e) n 2 Show direction and distance in miles from at 1ea
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Di or Weight/Ft. Material numbers and common road names.
From To 60 Ft. $PC 2/ PUS_
From To Ft 1 (j P
From To Ft.
13. GROUP: Depth Material hiethod {
From Tom_Ft C011CW—Ae f Itsi
From To Ft D
14. SCREEN: Depth Diameter Slot Sim Material a
From To Ft in. in. �` 3
From.To Ft in, in. V
15. SAND/GRAVEL PACK: I
Depth Sim Material
From To Ft.
From To Ft 6
16. REMARKS: Q
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C.WELL
CONS AUCTION STANDARDS,AND OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
;V /"26 - os'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.(919)7333221,within 30 days. GW-I REV.07l2001

308144
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTORM1117VIDUAL)NAME (print) I `ohti/"e" l?/W CERTIFICATION#,Z9__,'7
WELL CONTRACTOR COMPANY NAMS W gTu (A)"I ()(: Fitts PHONE # 0_kJo49.4U56
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 1e!/unicipal/Public❑ Industrial❑ Agricultual❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,list Use
2. WELL LOCATION: Topogggpitic/Land setting
Nearest Town: 5& Coun ❑Ridge Enlope Malley Mist
lThd(() 9Wy7 ( / / !S 3 (cheek appropnate box)
(Street Name,Numbeta,Commuatty,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: /J C(� //'l>J (depeeslmsmstestseconds) -
Address -Z 7 3/ cw s r9I cl %o wn� /Z _ Latitude/longitude source:❑GPS❑Topographicmap
/ (sheet or Rome No.) (ehwkbox)
m-il e'Sh/4`/ YY C_ x z S 3 DELI j?RILLING LOG
City or Town state tip Code From To Formation Description
Atea code-Phone samba
4. DATE DRH LED I 6 —C) S_
5. TOTAL DEPTH: / 4 ! -_
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO � iA
7. STATIC WATER LEVEL Below Top of Casing:
,_(Use'+"if Above Top of Casing)
8. TOP OF CASING IS A 3 FT.Above Land Surface• y
'Top of easing termioated attar below hod surface requires a
variance In aernrdmoe with SSA NCAC 2C.011S. a
9. YIELD(gpm): 6 METHOD OF TEST /�r
10.WATER ZONES(depth): a—
LOCATION SKETCH 01 r
11. DISINFECTION:Type C Amount /G t_ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
or Wei t/Ft numbers and common road names
Fro To '1/0m Fti= ! ---
From To Ft
From To Ft.
13. GROUT: Material Mqhod
Fro ToZQFtLO; VJ e
From To Ft `7 l
14. SCREEN: Depth Diameter Slot Sim Material
Fro To Ft.—in. in
Fro To Fc in. in.
15. SAND/ RAVEL PACK / W
Tod Ft. Stu Material
From
Fro To Ft. -
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STAND S,AND THAT A COPY OF THIS RECO HAS E PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING ITiE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 3 0 8 8 8 2
North Carolina-Department of Environment and Natural n......_-- n:... ,f Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (pint) B 14.L18 f P, S11 CFATIFICATIONY a-1_1 I
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PRONA4 8 154-358I
STATE WELL CONSTRUCTION PERMIT# 1537 ASSOCIATED WQ PERMIT#
(ify)plicabie) (ifapplicable)
1. WELL USE(Check Applicable Box): Residential 13 MunicipaVPublic 0 Industrial❑ Agriculnual ❑
Monitoring❑ Recovery ❑ Heal Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: 3
Nearest Town: CAR o County Am S 00 Topographies and setting �� e o
a 3 A CA fib'm ( ) O ❑Ridge ❑Slope ❑Valley �fihit_ N
(chew appropriate box) g
(Street None,Numbers,Community, ubdivision,lot No.,Zip Code) Latitudr/Iongitude of well location
3. OWNER: �O IY� --\YT(LE l.-1— (delpeea/miaure/aecmds)
Address GA d1$M o A D
Latituddlongitude source:❑GPS❑Topographic trap
t 1 c�. HA1.1— TJ �.. �.$�J3 (check box)
DEPTH DRILLING LOG
ttyor Town Sure ,,/ Zip Code From To Fo�nption Descnptio
- 6+cf— D 4 1 b 1 — (0 0 C J b 2A�" Ti
Alga code•Phone amber G 6 t — ( go, C� EU•ry iT6
4. DATE DRILLED 3 - Ib -0 f*T
tikn' fXrs�tce�
5. TOTAL DEPTH: -/
6. DOES WELL REPLACE EXISTING WELL? YES VINO ❑
7. STATIC WATER LEVEL Below Top of Casing: 6 '0 _FT.
,( (Use`+-if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
'Top of wing laminated attar below load surface requires a
variance Is accordance with ISA NCAC 2C.011 a. O
9. YIELD(gpm): io METHOD OF TEST iCAG 1(Z
10. WATER ZONES(depth): 1 $o r —
I,OCATfON SKETCH
11. DISINFECTION:Type —e o Amount Z Show direction and distance in miles art at but
12. CASING: f Wall Thicknesstwo Stale Roads or County Roads.Ingwc thefoad
From Tops 6 Ft. i ter or Weight/Fe. Material numbers and common road names. ro
From To Ft. GvA �{JU
From To Ft. _
13. GROUT, Depth Material Method I 5 tr
Froln_l—To a6 Ft. rTIr 116 00-Eb n
From To Ft. rJr1Qn�A2.D
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. 3
From To Ft. - in. in.
15. SAND/GRAVEL PACK: Z J
Depth Size Material
From To Ft. /
From To Ft. s�'T
�GOfi'
16. REMARKS:_CC'6(160 fuM 1 L we,riT'
I DO HEREBY CERTIFY TTIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT COPY OF THIS REC HAS BEEN PROVIDED TO THE WE OWNER
SIGNATURE O PERSON CONSTRUCI7NG THE WELL IAkTE
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. OW-1 REV.07/2001

309027
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural n-•-••---- nr•.t•r,...nf Water Quality-Groundwater Section y
WELL CONTRACTOR(INDIVIDUAL)NAME (print) 1.S 11.1 _145� c--) AS� CERTIFICATION#a`� 1
WILL CONTRACTOR COMPANY NAM! RF.UHEN CALDWELL DRILLING, INC. PHONA 8 ?54-3581
STATE WELL CONSTRUCTION PERMIT# 1537 ASsOC1ATED WO PERMIT# - _
ifa linable if■ linable
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
s
2. WELL LOCATION: A Topoglaphlsetting
Nearest To County A 01 w�i ❑Ridge ❑Slope 'Valley ❑ Dmi °
13 1 A7NNrz ;�.L�e�s 3J.� y (chock apwoprisdobox) o
(Sheet Name,Numbers,Community,Subdivision,Ent No..Zip Code) Latitude/longirude of well locatioq,
3. OWNER: I A . %_ACG Cc, --a cl1E
Address V %rsI aA—� '(µB�2 ` Cwat� O _ LalitudeActngitude :❑GPS❑Topographic map
(Street ce Route No.) (chock boa)
- A LG/A O Dv it- to C' AV'-1" I DEPTH DRILLING LOG
or Town Stain Zip Code Fro / To Fo tiers eseription
Ann coda Phone number
4. DATE DRILLED 5 - 1 © —
5. TOTAL DEPTH: `1 0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CY
7. STATIC WATER LEVEL Below Top of Casing: 1 C 0 FT.
A( (Use-r-if Above Top of Casing)
8. TOP OF CASING IS L FT.Above Land Surface•
•Top of cuing terminated Wor below land surface requires a
rarlanm In aeeorda9gra wli1,hy,ISA NCAC IC.011a. �
9. YIELD(gpm): Se t7YP'� FTHOD 9F TEST ktO-A t
10.WATER ZONES(depth): 121 4'0 '160 bf ro—
I LOCATION SKF,TCH
11. DISINFECTION:Type JV i N b o Amount A Show direction and distance in miles from at le
12. CASING: Wall Thickness two State Roads or County Roads.Include the itkii
.( Depth Di ter or e3t/Ft. ate 'ai numbers and common road names. m
From y Tor¢ Ft. 5q 1 ��� 1:1.
From To Ft. ;c5r^
From To Ft. ��G5
13. GROUT, Depth Material Meld
From 1 To �-o Ft._ t-Wt 3 k
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material Q M QbNO
From To Ft. in. in. 1 .,rtB�
From To Ft. in. in.
15. SAND/GRAVEL PACK: \
Depth Sire Material
From To Ft. A
From To _ Ft.
16. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WrfH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND I7
;gA-TnA nCOPY OF IS_RECORD
HAS BEEN PROVIDED TO THE LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL I D TE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Ralelgh,NC
27699-1636 Phone No.(919)733-322I,within 30 days. GW-I REV.07/2001

311023
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nat/tt/�a_1 Resources-Division of Water Quality-Groundwater Sectioon-� /�
WELL CONTRACrOR(I MMDUAL)NAME (print
/C/7 /� R/N�n C7 eSj iL CERTIFICATION R�7
WELL CONTRACTOR COMPANY NAMHS21e-1 w 4T4W hJr-J( I,+ i%:1 t A q PHONE a (ate -QgY0
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT@ _
ifapplicable) ifapplicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Pubiic❑ industrial❑ Agricultural O
Monitoring❑ Recovery O Heat Pump Water Injection 0 Other O If Other,List Use
2. WELL LOCATION: / Topogmohic/Land settir}g
Nearest Town: /9PS�►i0�� Co ty yY1Ak90w ORidge HSIope Malley 1C7F�at
7 SJ al Ge,1/ c�p�U a M&'5,1,g -V 7-g 3 (check sppmpriue box) ---
(Sheet Name,NumbCk Couun unity,Subdivision,Lot No,2Ip Code) Latitude/longitude of well locittion
3. OWNER WV ! Tes..i e Ne s e✓ (�g,eearmea�r ass) ! .
Address 16 ft" Pits py DR La(itudeftongihule source:OGPSOTopogmphic map
or Rot&No.) (max box)
IV (- �� 7s'3 DEPTH
City or Town Su to zip Code From To Formatiori Description
Axtt Bodo-Phone number
4. DATE DRILLED L/-/ - s
5. TOTAL DEPTH: 3 2 5 t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO l3w' 7
7. STATIC WATER LEVEL Below Top of Casing:
(Use"+-if Above Top of Cuing)
S. TOP OF CASING IS 1•J FT.Above Land Surface' _
°Top of casing termtuated Wor below land surface requires a
varies"in accordance with ISA NCAC 2C.01l& /
9. YIELD(gpm): & _METHOD OF TEST_iMI H ea
10.WATER ZONES(depth):
LOCAd ION SKETCH
11. DISINFECTION:Type e' G"fif Amount /0 cT-t Show direction and distance in miles from at leaky
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth _�,"ap�cter or
t Material numbers and common road names.
From To S Ft t iv J^ 2 rye__
From_____To Ft
From To Ft
13. GROUT: Depth Material��
From � To—,2Q_Fttteceele We f /* r OG'
From To Ft rJr O
0
14, SCREEN: Depth Diauaetcr Slot Sim Material COGc
From_ To Ft. in. in06
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
ln�To Fro Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC M IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS I ON STANDAR=THATPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
cZ 91/1.9'-05—
SIGNATURE OF PEFAbN 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

311019
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR MDWIDUAL)NAME (Prrint)T� /0'w ad/les 3-R CERTMCATION#27
EY
WELL CONTRACTOR COMPANY NAMR. sIGJ Haig-T—'e(` Ja 0it: I It 39 PHONE # MaG4ing1p0
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ PEERRMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential a-'MunicipalTublic❑ Industrial❑ Agricultural Cl
Monitoring❑ Recovery ❑ Heat Pump Water Injection f3 Other❑ If Other,List Use
2. WELL LOCATIO , , Topogt§plfclLand setting
Nearest Town: 0 P s County j?�1/����lJ Midge CCISSlope []Valley Mat
317 c toC/j'W'&d 2 8 6"3 (ebmk apprapdaft box)
(street Name,//Numbers/Cntnm1v uty,subdivision,LAI No,zip Code) Latitudeliongitude of well location
3. OWNER: l>//0t/ T �PW%� (aam�+ussown�s)
Address 1 ft JW ST Latitude/longitude so=c;OGPSOToPogmphic map
��hCa v �s�t1V �toate�A1 �g1 �// DEPTH (cbe*box)
DRILLING LOG
City or Town state zip Code 7 6 From To Formation Description
Area node-Pboae mtmber _
4. DATE DRILLED d
5. TOTAL DEPTH:_, �, !k -
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO C
7. STATIC WATER LEVEL Below Top of Casing>?gY,5.TAfT.
(Use"+'if Above TOP of Caving)
8. TOP OF CASING IS L -FT.Above Land Surface* _
'Top of wing tenataated at/w below tend surface requires a aj
variance In aetardana wltb ISA NCAC EC.411&
9. YIELD(gpm): V D METHOD OF TEST /i r e
i4.WATER ZONES(depth): LOCATION SKETCH
11. DISINFECTION:Type_ Amount /O D L Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the mad
Deptlt Diameter of gWFL atrial numbers and common road names.
From> _ To Ft PUC
From__ To Ft---
_
From To FL
13, GROUT: Depth �M"�a t
"terial Me
Fro z—�ToQ_Ftc wet t%r.- C
From To-Ft
14, SCREEN: Depth Diameter Slot Size Material
From Tc FL in. in.
From­__:___To Ft in. in. _
15. SAND/GRAVEL PACK:
Depth Size Material
From_X�To Ft. _
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS ION STANDARDSG=TA OF 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 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days GW-1 REV.07/2001

3110
15
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division qf Water Quality-Groundwater Section
���/
WELL CONTRACTOR MDIVIDUAL)NAME tmtat ,e C >°.5 CERTIFICATION
WELL CONTRACTOR COMPANY NAME ff P / PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
culoo
1. WELL USE(Check Applicable Box):Residential®' Municipal/Public❑ Industrial❑ Agri
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other[] If Other,List Use
2. WELL LOCATION: � `mot
NearestTown:;� Comty /SO ORid eg o OVA I OF1 2
/zy Zn ��pf,/( ,-3o�-p2 277s g (check )
(Sued Name,Numbers,Community,Subdivision,Lot No,Tap Code) Latit[lfle/InngltltdC O{ 1 Yd4bon(
'I
3. OWNER: l�Y LJ/�fcd (degredminuoe� = �� i r�
Address %,z f:+Mst///94 a�� /N LatitudcAongitude source:OGP o�ographicmag — i
neet a Rome No.) (fir ) ; 1
/77/9 /.Y�g �!G 28�s DEPTHDRILLING
City or Town gone tip Code From To Formation Description
Am coda Phone mmber _ ^
4. DATE DRILLED 3
5. TOTAL DEPTH: Z O 5 C3
6. DOES WELL REPLACE EXISTING WELL? YES f�f�NO ®�
7. STATIC WATER LEVEL Below Top of Casing: I
(Use"+"if Above Top of Cuing) -'$
8. TOP OF CASING IS�FT.Above Land Surface*
of"dog terminated War below Ind mrfam requires a M
varinam In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):�METHOD OF TEST—Trn��! "t
10.WATER ZONES(depth):
LOCATION SKETCH "
11. DISINFECTION:Type Amount /,0 !9 7 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.In 1 road
Dept a rpt/Ft numbersand common mad names.
Fro To Z2 Ft ��Q2/ (1G s
From__To FL (�
From Tc Ft
13. GROUT: Depth t/o"o Materialk 6 ,eMethod
/ �s
From_ To Z%i F 'i" w
From To Ft
14. SCREEN: Depth Diameter Slot Sim Material
Fro To Ft in. in.
Fro To Ft in. in. / �e
15. SAND/ VELPACK: 5
Depth Size Material r
From
�To Ft.
From To Ft
16. REMARKS:
1 DO HERE Y CERTIFY THAT THIS WELL WAS STRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONS U ON STANDARDS, T A OF THIS CORD HAS BEEN PROVIDED TO THE WELL OWNER
3 -Z-2
SIGNATURE OF PEWN 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

310785
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION# ca43(_
WELLCONTRACTOR COMPANY NAMES%% ! eC@wc eca d�ea a
f-- —tini2.-.i�Pua.mx? _PHONE # (&%) teb$' a0-L2
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
I. WELL USE(Check Applicable Box): Residential 0?/ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
I t Topoggr3�pphic/Land setting
NearestTown:_ UK ui.�l - County G.d, $0 ❑Ridge Mlope Malley ❑Flat
CCar..eaJ ' f Bd `?S�-i (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER:-W" 11s cr-M F s t 1 d S (degrees/minutes/seeonds)
Address _Pa i�.ne ¢-.c Latitude/longitude source:❑GPS❑Topographic map
(Street or Rouutete No.) (check box)
DEPTH I DRILLING LOG
t City or Town State Zip Code From To Formation Description
( tom+)- iof?9 cf5y.-
Area code-Phone number, AN
4. DATE DRILLED_S
5. TOTAL DEPTH: $ f*it SIN,I,R
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: $O FT. C
n(Use"+"if Above Top (Casing) a o 68. TOP OF CASING IS_L_FT.Above Land Surface' I
-Top of casing terminated attor below land surface requires a N
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm):�—METHOD OF TEST
10. WATER ZONES(depth): 33
LOCATION SKETCH
11. DISINFECTION:Type h 1 I�� Amount 1-S Show direction and distance in miles from at least
12. CASING: / Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or WeighVFt. Material numbers and common road names.
From R To Ft (A—' �TCc d
From To Ft.
From To Ft. 'Wfp --- `I
13. GROUT: Depth Material Method
From O To-,20—Ft. e@rn4n} ��
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
t r<ck
From To Ft. in. in. h
15. SAND/GRAVEL PACK: \�
Depth Size Material
From To Ft. s— i
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTI N STANDARDS,A THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
3— �-5
SIGNAT OF PERSON TRUCTING THE WELL DATE
Submit the original to the Divi on of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-J REV.07/2001

31141- 0
WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section ��99��
WELL CONTRACTOR(INDIVIDUAL)NAME (print) /�/i r �' 14h, in CERTIFICATION#.mil tp
WELL CONTRACTOR COMPANY NAME /Cl r�45 Wf
a) Well -hrt`Il�na PHONE i Iea__Z /q
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
-. _(if applicable) (ifapplicable)
I. WELL USE(Check Applicable Box):Residential [11,1�unicipal(Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: f Topographic/Land setting
Nearest Town:_MORS)Ik�� County M4el i5oel Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well local' It
3. OWNER: C (de grees/minuteaisecinis)
Address t iaf o Latirude/longitude source:❑GPS❑Topographic reap
(Street or Route No.) (check box)
��Q1LA 7 &75.� DEPTH DRILLING LOG
C!ryorTo 9�Stat p/ Zip Code From To Formation Description
(
9 O ?d` Cl
Area code-Phone number 2 f cI b,
4. DATE DRILLED_,/- (o— 0 67 �6 G C G AbE_
5. TOTAL DEPTH: 0.�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2�
7. STATIC WATER LEVEL Below Top of Casing:_t a FT.
(Use"+"if Above Top of Casing) r
8. TOP OF CASING IS FT.Above Land Surface* ?
*Top of casing terminated attor below land surface requires a '
variance in accordance with I5A NCAC 2C.0118. xy'.
9. YIELD (gpm): 7 _METHOD OF TEST n I'
10.WATER ZONES(depth): /�p
LOCATION SKETCH `
11. DISINFECTION:Type fy 7f/ Amount 6Z. 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 toad names.
From__Tob_Ft. L-S SOR ] ) vC.. '.
From To Ft. - _-
From To - Fr
13. GROUT: Depth Material Method -
From
__-_(Z To a!1 FL ConC ra �e PO -
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. Qn/a I/4 U1 A C."1C -
16. REMARKS:
t 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-1 REV.07/2001

3114 (� 8
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section -�-,�p�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) irlar E' /�L'��eh CERTIFICATION MAY (p/q
WELL CONTRACTOR COMPANY NAME �% .5e�_(,�jLII Zlrrl/� PHONEOS'41 Ie V3-9S�r/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaVPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: 1 Topographic/Land setting
Nearest Town: jpf� j d� County /'rla.ni60� ORtdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well l9catnip
3. OWNER: degrees/mmutes/seconds)
Address Flea&-.A .411 Latitude/longitude source:❑GPS❑Topographic map
7(Street or Route No.) (check box)
�C o?AM9 DEPTH DRILLING LOG
City or Town State Zip Code From T.q Formation escrt non
(BqB,-_b AJ- sit s/ lA s�p , iy
.Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT. ..
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top of easing terminated auor below land surface requires a �—
varianceinaccordancewith 1SA NCAC 2C.0118. CJI A
9. YIELD(gpm):,—METHOD OF TEST
10.WATER ZONES(depth): y3 D '9
LOCATION SKETCH
11. DISINFECTION:Type H T fL_ Amount 6z. 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_,a,Ft. t,� ,SCR.
From To - Ft.
From To Ft.
13. GROUT: Depth Material Method
From-6—To a11_Ft. Lone ro T)" -
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. -
From To Ft. in. in.
15. SAND/GRAVELPACK: I _
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 OWNE$
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

311407
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section --��
WELL CONTRACTOR(INDIVIDUAL)NAME (print) Ar k '4 it,h CERTIFICATION#,3,?
WELL CONTRACTOR COMPANY NAME ICCCa✓ S<o al Wf i l -h r 11/ k. PHONE eA) Oa-95 l
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
yTLown:: Mnly s /l,_(L County Ma k;I ot) 0<idge ❑Slope ❑Valley ❑Flat
W h• IL7 1 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well 1 Cation
�/ ai
yr r+ -1) I a�
3. OWNER: s LfJjyC— n degmes/minute seconds)
Address Latitude/longitude source:❑GPS❑Topographic map
(Street orR dt No.) - (check box)
GLAA L-&r /VF e?f�1SY/ DEPTH DRILLING LOG
&� ry orTown e 9' �� ;p code From To Formation Description 9
on [number �t i?
Area code-PhoneS S
4. DATE DRILLED oi/ - o
5. TOTAL DEPTH: k 9
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [4Y v
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing) `n
S. TOP OF CASING IS FT.Above Land Surface* - ^�
4
*Top pleasing terminated atlor below land surface requires a t
variance in accordance with ISA NCAC 2C.01la.
9. YIELD(.,Pm): '7 5 METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type & 2 f� Amount /.3 6Z- 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 commdn road names.
From a To fan Ft.�-� SDtt 2( _jwG
From To Ft.
From To Ft.
13. GROUT: Depth Material me"'
From_ To qt) Ft. Conero �-� p r;,y
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 F[.
From To Ft. ,/y) �/'// -
16. REMARKS: / ' / a," *Z/ , NC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/- ;;l.Z-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

� 11406
WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Mi Division of Water Quality-Groundwater Section -� p�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) r �' 41 t sn CERTIFICATION#,32&
WELL CONTRACTOR COMPANY NAME .14-1 eo e) Well hr"11,11 PHONEW,QJ Ie Y3-J SZ1
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential MunicipaUPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 11.4 trm5 County I,`9IAd�'ocl ❑Ridge ❑Slope Wiley ❑Flat
Td IL k r� H 1l (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Lati de/I 'N0dO�f�W�e IOCa tonjgie 3D
( egreesmmutes(se`conds)3. OWNER: Stv
w
Address Y71 YYnA Latitude/longitude source:0CrPS❑Topographic map
(Street or Route No.) (check box)
.f",a;6f- AC 008751T DEPTH DRILLING LOG
City orOTown 9 State Zip Code From To Formatio De crtption
.Area 6 r>2v o n car
ea code-Phone number r 9�.�}
4. DATE.DRILLED o7- U - O�- sY, u�a � h�
5. TOTAL DEPTH: ' /J_5
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M-' C�
7. STATIC WATER LEVEL Below Top of Casing: /D FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface* z
"Top of casing terminated at/or below land surface requires a
varianre in accordance with ISA NCAC 2C.011S.
9. YIELD(gpm): /n METHOD OF TEST
10.WATER ZONES (depth):
LOCATION SKETCH
11. DISINFECTION:Type f�� Amount Q 6L- 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 roadnames.
From 0 To 67 Q Ft. L T, .rnv a 1 PV(-
-
From To Ft. --
From To Ft. -
13. GROUT: Depth Material Method
From�To A!) Ft. Crrn_ro6
From To Ft.
14. SCREEN: Depth Diameter Slo[Size Material
From To—Ft—in. in.
From To Ft.—in. in.
15. SAND/GRAVEL PACK: ` ---
Depth Size Material
From—To—- Ft.
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAN ARDS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
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 3113 `
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDMDUAL)NAME (print) 'Jnr E' 4h, Vh CERTIFICATION#
WELL CONTRACTOR COMPANY NAME Sa 1 We'll -Nril(f»n PHONE emn to S�.1''9}Zr/
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 I11 ection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: MOBS PJ/ County 'Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/lot gi[ude of well loca on
_ 11I_ I1 u 0801 v/
3. OWNER: N(�PL4 C- cS b-Ify Pi J (degroes/minutes/s onds
Address .?7/d MaA4:5N:/1 116ji— Latitude/longitude source:❑GPS❑Topographicmap
($nee[ar Roure NoJ 7 (check box)
2a7 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
off_ Glv.Area. ea code-Phone number
j .� t
4. DATE DRILLED 3 - 7S - O S' rSL
5. TOTAL DEPTH: a 4 S
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO li;�- t-
7. STATIC WATER LEVEL Below Top of Casing: cPO_FT. a
(Use"+"if Above Top of Casing) :A
8. TOP OF CASING IS FT.Above Land Surface* W
"Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118. "
9. YIELD(gpm):�3D METHOD OF TEST Rr`$ cn
10.WATER ZONES(depth): 1A9
LOCATION SKETCH -a
I t. DISINFECTION:Type H T f� Amount /d 6Z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads onCounty Roads. Include the road
Depth - Diameter or Weight/Ft. Material numbers and common road names.
From-TZ —Ft. 4 a aka I Svc- --
From To Ft.
From To Ft. ', -
13. GROUT: Depth Material Methods
From_(Z To 'a t) Ft. lone ro {-e. -
From To Ft.
i -
14. SCREEN: Depth Diameter Slot Size Material -
From To Ft. in. in. -
From To Ft. in. in.
15. SAND/GRAVEL PACK: + — --
Depth Size Material
From—To—- Ft. -------
From To Ft. Ale
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
X/�Zz a4t--� 3 05
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3113g `t
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section -�-�
WELL CONTRACTOR(INDIVIDUAL)NAME (print) irlRr �' 14i t, h CERTIFICATION WAY (pgyp/
//
WELL CONTRACTOR COMPANY NAME ICI[p,,fQ A) Well 7lr'ill.S j PHONE*9-V) If3—,9
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential/y'+(� Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: NP&ITAll County IladtSOw ❑Ridge ❑Slope ❑Valley ❑Flat
5nma (; I (check appropriate box)
(Sheet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/ongitude of well loc.lion
1✓
3. OWNER: A- (degrees/minutes second)
Address tiu Nut// Latitude/longitude source:❑GPS❑Topographicmap
(SnOet or Route .l (check box)
�(�n /li - DEPTH DRILLING LOG
City or Town State Zip Code From To Fo tion Description
Sey� • �3ra D D /3
.lea code-Phone numbs& -
4. DATE DRILLED J? —2- O li r
5. TOTAL DEPTH: 360,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lee ..-j
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 allor below land surface requires a '^,e
variance in accordanc with ISA NCAC 2C.0118.
9. YIELD(gpm). METHOD OF TEST_ w `?
10.WATER ZONES(depth): 1?Dn
LOCATION SKETCH rs ^, "
11. DISINFECTION:Type H 7 fL Amount /� 0L- Show direction and distance ip-miles from at least• � -
12. CASING: Wall Thickness two State Roads or County Roads.include the road 4
Depth Diameter or Weight/Ft. Material numbers and common road names.
From. To Ft.6_ SRD d/ yc "
From To FL
From To Ft.
13. GROUT: Depth Material Method a
From To QCS_Ft. L`onC ro 6 pa ure_�
From To Ft.
l4. 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. / - �R �� � •n n_''/Je'
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
dim- - F- `7-0ff
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 * 0
I19S4
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) -Sava �' % CERTIFICATION# o
WELL CONTRACTOR COMPANY NAME S PHONE # f2M) CoC 5-2v Z.Z
(
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
l. WELL USE(Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATI N: t Topographic/Land setting
Nearest Town: rs 4 County 1 -(Oh ❑Ridge ❑Wpe ❑Valley ❑Flat
\n O-QA (—Mile qs 15LI (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of we]I location
3. OWNER: a; �tn fIr (degrees/minutes/seconds)
Address I\b OaK Lane Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
1V\GJ*N%0.k% fNC ols.-I DEPTH 'DRILLING LOG
City or Town state Zip Code From To Formation Description
(Bl'&- f3$6• 015510 1 �d_S lS s.t mar..
Area code-Phone numbe`'
4. 'DATE
5. TOTAL DEPTH: !i _/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Gd S ?
7. STATIC WATER LEVEL Below Top of Casing:—FT.
(Use"+"if Above Top of Casing) tV ^y
8. TOP OF CASING IS y FT.Above Land Surface*
-Top of cuing terminated atior below land surface requires a O
variance to accordimcf with 15A NCAC 2C.0118.
9. YIELD(gpm): —METHOD OF TEST,._
10. WATER ZONES(depth): tl
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.'i Diameter or Weight/Ft. Material numbers and common road names.
Fromm To� Ft. Ji 11tit.
From To Ft.
From To FL S1'
13. GROUT: Depth Material Meth
From O To 30 Ft. C yt.A—'C— \ Jtl( 6 k �n
From To FL II )i a
14. SCREEN: Depth Diameter Slot Size Material k
From To_ Ft. in. in. )
From To Ft. in. in. `p
15. SAND/GRAVEL PACK: �t`
Depth Size Material
From To Ft.
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WASCONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A C RY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER .�.-
t�,
SIGNATURE OF SON CONSTRUCTING THE WELL DATE
r.:
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

309028
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Na�ttu??ral n-•^••--"-nt••t•t..a )f Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prioQ F��I-3-t t rJ A S j{ CERTIFICATION# S-1 1,
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PHONAJ8 J54-3581
STATE WELL CONSTRUCTION PERMIT# 1537 ASSOCIATED WQ PERMIT#
(if applicable) (ifapplicable)
1. WELL USE(Check Applicable Box):Residential Ck/Municipal/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopographicA and setting
Nearest Town: P Aid&RA 6-'L- County bi SorJ Midge ❑Slope Malley let
rnetr1 -XVO W-eaAyet.x". (check eppmpriue box)
(Street None•Numben,Community. vision.Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER, 4lJI C o�-E (deyroWminutedswoods)
Address t 1 S 1 rvlo r-N 19-A I ` LatitudcAongitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
W k;A J e Rd l t.t,e. TJ C_ DEPTH DRILLING LOG
Ciry or Town stele zip code Fr�m� T�o_ � For�nationpescnp on
( ) �, - 6 4 9"I4 O y tali r�Leo
Am coda Phone number 4-.1 1 — R-i n
4. DATE DRILLED a- 'I - 0
5. TOTAL DEPTH: 4-112
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ed
7. STATIC WATER LEVEL Below Top of Casing: a 0Fr. n
(Use"+"if Above Top of Cuing
8. TOP OF CASING IS - FT.Above Land Surface*
-Top of culog terminated actor below land aortae*requires a �O
variation In accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): `,3 METHOD OF TEST - A Uu
10.WATER ZONES(depth): 1 0 3' G C M
LOCATION SKETCH o
11. DISINFECTION:Type �i l ao Show direction and distance in miles from�leas
Amount -
12. CASING: Wail Thickness two State Roads or County Roads.Includt�ge ro
r( Depth Dpt_er or weight/Ft. Material numbers and common road names. fV r'
Frotrt_ 2 To a Ft. /X Sp'2=� 4G
From To Ft. YTI�I t'
From To Ft.
13. GROUT- Depth Material Method vjCCSled�
From�To 0.0 Ft. (' M�nl`( o J^r-e I
From To Ft. .,3 /u`✓ �q �L.
14. SCREEN: Depth Diameter Slot Sire Material (�p
From To Ft. in. in. tr
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Sim Material
From To Ft. A 77 )((I•�3
From To Ft. 4 J fw
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THATAr5OPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL OWJ�[ER i
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

Cr 310228
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nah,nl D.-^Q•--- n:••�•t^„�f Water Quality- Groundwater Sation
WELL CONTRACTOR(INDIVIDUAL)NAM E 1prl.t) 8(ate CERTIFICATIONa /
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. P{{ONE4 8 , 54-3581
STATE WELL CONSTRUCTION PERM ITa 1537 ASSOCIATED WQ PERMTra
(i f 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: Topographic/Land setting
Nearest Town: County $Ridge ❑Slope ❑Valley ❑Flat
1 A ry ' Days :c i-L A'JLN f6 (rLeek appropriate box)
(Streel Name,Numbere,Cammu�niiry,Subdivinon.Lot No.,Zip Code) LatitudcAongitude of well location
3. OWNER: e'V&'1e- ' ( t r (deyeea/mioutes/acoodr)
Address 1. 1 9(o / B =5 e7\ — Latitudc/longitude source:❑GPS❑Topographic map
(Strut or Route No.) (chock box)
�✓I(. t n11 �AC=` UC 2- 5;�' yS3 DEPTH DRILLING LOG
Ciryor Town stem Zip Code Fro To j Fo tion Description
2 Y9
�S6 (a6 — 4 4 el;rzn� >-op N
Ard Bodo-Plto%m num— 44.r .- 1'i),U n
4. DATE DRILLED Sal rl �� n (o N l n
5. TOTAL DEPTH:Tt1�U o ' cx Ica - (3rrN
f � 1 'cZ O � -_ 3-cl O� rJ i T.E .
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [a— lg0 , CJtc�3� - a (r1
7. STATIC WATER LEVEL Below Top of Casing:�°p FT. tq p ._ 4-1 0 ' G 2Aa>iY C:,
(Ure-+-if Above Top of Cuing)
8. TOP OF CASING IS I. - FT.Above Land Surface• 3
•Top of cuhg Ierminrted Wor below had surface requires a ''^ '-A-
rarlma In accordance with IJA NCAC]C.011a. � -
9. YIELD(gpm): _METIIOD OF TEST R\L-
10.WATER ZONES(depth): 0 3.T•
,2 it., LOCATION SKETCH cn
11. DISINFECTION:Type Amount Y3 H5 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. 14terid numbers and common road names.
From? /— 70�_Ft.--4p_ / Yam. ,E/ n �1
From To Ft. JP
From To Ft. A „gym DNS
13. GROUT: Depth fatcrial Meth J�'LA NCH
Front—To�_Ft. 1 _
From To Ft. `
14. SCREEN: Depth Diameter Slot Sire Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: ) wI al3
Depth Size Material
From To FL z-
--
From To Ft.
16. REMARKS:
=rJ tc _
1 DO HEREBY CERTIFY TI{ATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WR11 I SA NCAC 2C,WELL;
CONSTRUCTION STANDARDS,AND THAT A COPY O lIS RECORD It BEEN PROVIDED TOTE iWE OW-Iy1:R '
x 44 �0 c
SIGNATURE OF PERSON CONSTRUCTING T fE WELL DA ^o
Y?.a
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mieli Service Center-RA lift, C
27699-1636 Phone No.[phone],within 30 days. GW-1 RED. 07/2001 - "-

31022
2
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nantm,n......_..__ _n;,s;,,,,
^ of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) iJ 1 L ` I
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. rnry'icATloNa ��71
STATE WELL CONSTRUCTION PERMIT# 1537 PHONEY 8 54-3581
(if applicable) OCIATED WQ FZRMrra
(if applicable)
1. WELL USE(Check Applicable Box):Residential MmicipaVPublic❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other❑ If Other,List Use
2. WELLLOCATIO14:
Nearest Town- /1 -1411 b N �.L County 1 A 0 i S.,r,3 OpOgrpPhILDd setting
N cK f-R&e& dge ❑Slope ❑Valley ❑Flat
(Sheet Nsnc.Numben,Cotnsnunit),Subdivision,Lot No.,Tip Code) (�k apptoprim box)
3. OWNER: LatitudeAongitude of well location
Address _ l 0 4 l 1 t-.LS i Y �, (dePee+tmiautn/eecoods)
(' SuectceRouteNo.) pp LatitudcAongitudesoume:OGPSOTopographicmap
1' A /L T -T (check box)
DEPTH DRILLING LOG
iry or own S Zip Cade
Cq I0 • �' 3 - � J ' Fr m o Formation�Descriptiop
Asp code.Phone number
4. DATE DRILLED n ,
5. TOTAL DEPTH:_ ,S !o T�— / b Ow n t c - ) ttj pr 1
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO — c 3 i n
7. STATIC WATER LEVEL Below Top of Casing: 610 FT. Ga
8. TOPOFCASINGIS i (Dee-r-if Above Topofcuing) —
-----__
'Top of cuing Iermleat FT.Above Land Surface*
ed attar below lend surface requlrea a �_ 00
Yarinnce In accordance with ISA NCAC 2C.0118
9. YIELD(gpm): 1 5 MET)iOD OF TEST i'-I G - A t(Zp-
10. WATER ZONES(depth):_ 7 (nc ' ( rf\
11. DISINFECTION:Type c(O`,b LOCATI_ ON KETCH
Amount 2- 1 Show direction and distance in miles from at least
12. CASING: Will•�ckness two State Roads or County Roads.include the road
Depth iTxIer or Wei t/FI. Material numbers and common road names.
From �- Toil- Ft. rS SOLI QJ'G,
From To Ft,
From To Ft. L
13. GROUT:From -: �th� b Material MegtdFt. 0 rA n rFrom To 14. SCREEN: Depth Diameter Slot Sim MaterialFrom To Ft. In' inFt. in. in.15. SAND/GRAVEL PACK•Ih MaterialD'P SiuFrom To Ft.
From To Ft.
16. REMARKS: IOW Z S - Z 0
a
I DO HEREBY CERTIFY TI)AT TI)IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COP OF THIS RECORD BEEN PROVIDED TOT •WE pWlgBR Na _
SIGNATURE OF PERSON CONSTRUCTING T CWE(y, 4 ' V ;
ATE cr
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

C� 31022J
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nahvol n......--- n:..:.L,,,of Water Quality-Groundwater Section
E WLLCONTRACTOR(INDIVIDUAL)NAME (pries) G f L—L.t AS 'A
REUBEN CALDWELL DRILLING, jN(;, CERTIrF2ICATION# ' 1l
WELL CONTRACTOR COMPANY NAME P1loNrlj (B ) 54-3581
STATE WELL CONSTRUCTION PERMIT# I537 ASSOCIATED WQ PERMIT/
(if applicable) (i f applicable)
1. WELL USE(Check Applicable Box): Residential KI'*'-Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: � Topographic/Land setting �
Nearest Town: � 1�`S IA�L County N���1�c+ ' ❑Ridge ❑Slope Malley [a'L=1at
`)S A b L\T 1 t_G 3)t5 C IL.t%A D- (y\-Al LS i(A L t_ (rbecr appeoprim box)
(Street Name,Numbcn,Commun
i
ty.Subdivision,ld No.,Zip Code) LatitudcAongitude of well location
3. OWNER: 4� ti C (Lk FL-if 4 (dezrowminuua/seconds)
Address J39,l-' 1-1-I 1Le- •NC C A n LatitudcAongitude source:❑GPS❑Topographic map
n (Suec(or Route No.) (chock box)
lrlflfS �A`­L- Q-�-7A;3 DEPTH DRILLING I OG
Ca� ryJiow-n pte zip Code Frgm/— io', Fo lig Description
3 b� 1 _QfLf�ur oe,�
Ann code-Phone number O 5 C- r- / _C {1.A"i t C
4. DATE DRILLED 'I- _ J
5. TOTAL DEPTH: I O
�r r�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 6 O FT.
1SL'- t f — _ n . Ott c
(Urn"+'if Above Top o(Cuing)
8. TOP OF CASING IS FT.Above Land Surface•
-Top o(culog tersolosted at/or below fond surface requires a
varlanu le accurdsx v,116 I5A NCAC 2C.0113. CO --%
9. YIBLD(gpm): � 31 METHOD OF TEST Q4 - IL
10.WATER ZONES(depth): . u C - -.; G,AM Ln -rt
3 (/a C'plM, LOCATION SKETCH
11. DISINFECTION:Type l�- Amount Va- M Show direction and distance in miles from at least`
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depd� I F Diller or��IV171. a
From To '.�l )Cliil numbersand common road names.
� L � �l C.
From To FI.
From To FL 1i 5 3 a U
13. GROUT: Depth Material Method
From A To �o Ft. L MVN i C J D
From To Ff. `t L-e Q1n c Fr
14. SCREEN: Depth Diameter Slot Sim Material
From To Ft. in. in.
J Cytu
From To Ft. in. in. lRc AtG
15. SAND/GRAVEL PACK: JZ4
Depth Sim Material
From To Ft. 6 �' M
From To Ft. AA
16. REMARKS: IaLE#ObtsiL R0
I DO HEREBY CERTIFY TRAT T1(IS WELL WAS CONSTRUCTED IN ACCORDANCE WMI 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF 77HS RECORL)A{AS BEEN PROVIDED TO TtDIWELLOWNER�. DD
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
(Jl
Submit the original to the Division of Water Quality,Groundwater Section,1636 MJI Service Center-Raleigh,NC.,:. r
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/20U)
cT

0q
31
WELL CONSTRUCTION RECORD
Nor&Carolina-Department of Fav➢raam o and staral Resources-Division of Water Quo&y-Groundwater Section
%ML C0MuACwR(D'iDIVIDUALI NMf,�[QEj� C M=CAII !ZZ,�
WELL CONTRACTOR COMPANY NUM.D✓J�� « PBMM a a
STATZ WH.L OOMMUCTION PXXV Ti ASSOMMWQ
If )t
1. WELL USE(Check Applicable Boer}Residential Mmic*Mxublic 0 bahmtrial 0 AgicaWaal 0
Monitoring 0 Recovery 0 Hat Pump Water bjecben Cl Other El NOther,I*Uae
(deetappeaI f bm)
(saeuriamaN.ebec� m s*aim lmwo.zlpcmb) l�nwarioneftwoofwdllocatioa
3. O 1 U P( (droam7mimRmheeoode)
Address Latim&llaogiw&souroe:Ot3P30Topograwc,map
a S75 3, � ( �,
OWarTmn Sao Z*Code From To FoamationDescrip*
A.cad
4. DATE DRILLED
5. TOTAL DEPTH
6. DOES WELL REPLACE wasrim WELL? YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing:_f_C FT.
((Trewf'AbmaTapafCmeM _
8. TOP OF CASING IS i FT.Above Land Sudicee )
'Tspefemba l I I &Mwbeiewtamd wraree rg . a
9. YIffi(�; 15AIDul&�IT�c..c�
10.WATER ZONES depth):
IA)CATION SEETM
11. DlSJNFELMON:Typq--L=fS22L Amour Sbow directioa and dimumm in miles fie at bast
12. CASING: wall 13idmera. two State Roads or County Rorb.Include the road
TDo fi orwaigWPt Material numbers ad road n
FrontFes_
emea.
Fromm To Pt +�- -)3 U�
13. Front—To,pth
Frorq_ToPt,�����
14. SCREEN: Depth Diamga Slat Size Material -'
FronL _To Ft,_m. in.
Frow--To Ft,---in. m.
15. SANDIGRAVBLPACI
Depth Sine Meterid _
From—To—Ft.-
Prom—To—Ft -
c�
16. REMARKS:
IDOHEREBYCEItTIFYTHATTHIS WELL WAS CONSTRUCTED INAOCORDANCEWfIH15ANCAC2C,WIIL --- -, ;
ODNSIRUCf10NST ANDTHATACOPY OFTM RECORD HAS BEEN PROVIDED T07114
OoW�NER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submk the or4ftal to the Dividon of Water QaaNty,Groundwater Section,16M Man Service Ceader-Rddgb,NC
2709-IA6 Pbsae Ne.p19)733.=I,within 30 days. GW-1 RSV.07=1

113221
WELL CONSTRUCTION RECORD
North Carolina-Department ofEnvhoomant and NMW Rescue a-Di ' 'on of Water Quality-Grmmdwater Section
- cvu. �xrx„Ct cat oAt) As�, f�ft� ccA ram 73
WBI.I,CONTitACTOACODIPANYNAa!$(`�",�n"(�`� ,PC 'S � ` �' � ra�ta s
SEATS WML CONSTSWnON FIRMU" mo W(P PROMM
rjfwoHcable) Ofaeolic")
1. WELL USE(Cbear Applicable Hoak Rodriwdid O MoraapalMublic D lodmbial 0 AVieoll mal 0
U=W mg 0 Recovery 0 HeatP®p Waterbgegbn 0 Mw U If0diw.Lst Use
2 WELLLOC A 1 �5``P Comity PsO �1 T ag
(SnauN901gN��d11iaMCOMWMI .skaddak iartb.zip cob) - Latimmm ashomofvmubation
3. O (d +Wmomde)
Addmea l h [atimdollooggiwde sow=CKIPSC3Topoga*c map
ClryorTmn Seem zip code From To FoondionDesmiptian
L�
Ameeode-I4ome oem�b ,�- V
4. DATE DRIIS 1�
S. TOTAL DEM,
6. DOES WELL RHPLACE EXISTING WELL? YES 0 NO
7. STATIC WATERLEVEL Bebw Top of Casing LOU FT.
Mm-+^VAbomTopofCeWed
s. TOP OF CASING IS FT.Above Land smixe•
7apetembs memlaewatAwhod wbodwrimregiee■
- wafres` rraY15ANCAC1CAtli �_,,."
9. YIELD(um):PJQ MITIJQDOFTESr '
lo.WATER ZONES(dapd+): 4 x Q
I l
11. DISINFECTION:Type Amoant Sbow dmcdon and d dmm in miles tram at least
12. CASING: wan Tb ickw s. two State Roads or County Ron&loclode the mad
Depth D amaer orwaglsdrt. Ma gnat � es bm and common mad nam
Fmcf—k -71.�L- R Nu, a5- a
From__To Ft. ,
13. GROUT: To Ft
Dom, i�t � �-� � cx�
From'Toy'�Ft� ,-
14. SCREEN: Deph Diamaar MaSbe Ma+mid �-
Front_To Ft
_b in. ,
From To Ft_ba. in. "Ln
15. SAMCYRAVELPAM -71
-
Deph Mae Material y
From—To Ft
FronLTTo Ft
Jj
16. REMARKS: -
I DO tESYCERTIFY111ATTMSWBLLWASCONSrRucrmiNAccoRDANcEwrm 1SANCAC 2G WELL
ooiqSMWnoNsr AND THAT A OOPY OF THIS RECORD HAS BEEN PROVIDED TO THE VflaLOWNEIL
SIOMTbRE OF PERSON CONSTRUCl!M THE WELL PAMB
Submit the original to the Divides of water Qaadty,Groamdwater Section,163t:Mar!swice Ceatx-Ratdgh,NC
2709-16M Pbane No.(919)7333221,within 30 dayi GW i REV.0712001

6r R n
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nahvnt D........,,-- n:,.:.:,,,,,,f Water
{� Quality-Groundwater Sation 1
WELL CONTRACTOR(INDIVIDUAL)NAME (pr1eO 1" )l-L.Im IJ AS CERTIFICATIONS
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. r� 8 -'
54-3.581
15�7 STATE WELL CONSTRUCTION PERMITS PHONEY_ wccOC1ATED WQ ptRMRS
(ifapplicable)
�/ Arapplicable) -
1. WELL USE(Check Applicable Box): Residential L�J Municipal/Public❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Wafer Injection❑ Other❑ If Other,List Use _
2. WELL LOCATION:
Nearest Tr: kkS ��l�t- County AkAAi Sort cpogphi�Ddsetting
fLoA R I w C og d 2 cA n 44 Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Number!.Community,Subdivision,Ld No.,Zip Code) (cheek appmpriue box)
LatitudeAcingitude of well location
3. OWNER: G 0�') Lld a V 1 t. 0(i (Z.S
Address 140 C N r2 _L O TTg t G.) (depece/miwlee/reruny)
Latitude/longitude source:❑GPS❑Topographic map
(Street a Route no
A5AA\f, , t 1� 1JC 01-9-�a3 (chock box)
rFiryor Town Swe o �zi Code � / DRILLINGLOU
( pn) �C,i O � p From f rATo Fo �lio}�Descriptiop
Am eodeoda phone number VI , 6 r`-"'L) (3 /J
4. DATE DRILLED �J I-I t
5. TOTAL DEPTH:_ O V o
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Iff/ - A4� �- 10
7. STATIC WATER LEVEL Below Top of Casing 0 2FT
_ .
(Ure'+'if Above Top of Cuing
8. TOP OF CASING IS FT.Above Land Surface• e-- al
'Top oreulup termlaated at/or below lud enrfart requlru a
variance in acwrdsoa}}with ISA NCAC 2C.0111.
9. YIELD(gpm): J. METAQQD OF TEST C. F-
10. WATER ZONES(depth): '3 �4 l7 F
r 0 ATION SKETCH
11. DISINFECTION:Type O Amount 1 i� 0 Show direction and distance in miles from at le
12. CASING: Wall Thickness two State Roads or County Roads. Include the eSfid
Depth qq Di ter or Wei i L Material numbers and common road names.
From 1O7 Ft. {Glhl
From To Ft.
From To FL
13. GROUT: Depth Material MethodrL"-A'A-e�-
rv✓
From 1. To a J Ft. � .Mute rdT -o
From To Ft.
14. SCREEN: Depth Diameter Slot Sim Material From To Ft. in. in.
From To Ft. in. in. �C15. SAND/GRAVEL PACK: L- h 1!
Depth Siu Material From To Ft.
From To Ft.
16. REMARKS:
-i
1 DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELT, 1 CONSTRUCTION STANDARDS,AND THAT OPY OF THIS RECqJD HAS BEEN PROVIDED TO TIJE WC•I.L WiIER'I -'
C'� r� 0
SIGNATURE OF PERSON CONSTRUCTING THE WEf1. PATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 M15a11 Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

co
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Naturst n....••--. n:..:. n f Water Quality Groundwater Section
WELL CONTRACTOR(1NDtVIDUAL)NAME (yr1a) 81 LLI <✓ tJ A 5 14
RF.UBEN CALDWELL DRILLING, INC, CERTIpFICATIONaa-t7
WELL CONTRACTOR COMPANY NAME rRONEY 8 54-3581
STATE WELL CONSTRUCTION TERMrTI 1537
(if applicable) AOfOCIATED WQ PERMTTa
(if applicable) —
1. WELL USE(Check Applicable Box):Residential 130"MunicipaVPublic❑ Industrial ❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use _
2. WELL LOCATION:
Nearest Town:—AU 11 A L t Counry MA A l S Orzt T°pogrdphicUnd setting
AA .A n ISon1 1 tG E dge ❑Slope, ❑Valley ❑Flat
(Street Name,Numbers,Canmwrty,Suldirision,lot No., ip Cade) (check appropriate box)
Latitude/longitude of well location
3. OWNER:_ 11 , V" r.)Z E J emectviec
Address A{t L A r.]Q P (dripua/mmutes/second,)
C�/ (Strut ar Rou1e No.) Lalitudc/longitude source:❑GPS❑Topographic map
AJ rt 6�1 l^l�� /J C. '�.�0 q"' (chock boa)
(�iy or Town stare Zip Code DRtLL_ Des O(:
- a5 - a g o a p From / To / Fo�j�a�ion Description
Area coda-Phone oumber �r q5 OdG22QJR.Og'd�
4. DATE DRILLED_ 6 Z '3 /O J cis r 1 0 C2 RA rJ1-r'E
5. TOTAL DEPTH:— - ')o ' C.RFyt C.E- a GPM
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 9( 1b03So S SS*' C2AAr31 r'E-
7. STATIC WATER LEVEL Below Top of Casing: a Ff. =S�2�aytcC Ig-GpM
S
(Use-.'ifAboveTopofCaainZ) — Sol - 370 S Nf-If
8. TOP OF CASING IS �' FT.Above Land Surface•
•Top of casing rermlmted at/or below,laud surface rrqulru a
variance In aacor la a with ISA NCAC 2C.011 a.
9. YIELD(gpm): �D METHOD OFTEST (-I6 —A(R
10. WATER ZONES(depth): '— n 1 14
1 CO �
LOCATI_ 0`N SKFTCH o
11. DISINFECTION:Type a Amount a Show direction and distance in miles frorwt lea
12. CASING: Wall Thickness I two State Roads or County Roads.Include the rd"
Depth Di ter or Wcight/Ft. a nal numbers and common road names.
From To A_L Ft.U_ sitRa t _
From To Ft.
From To Ft.
13. GROUT: Depth M}terial Method
m A,'If�QISpfJ
Fro 4 To 610 Ft. mmewT N,)2E b
From To Fl.
14. SCREEN: Depth Diameter Slot Size Material )
From To Ft, in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material to
From To Ft. �(N f 9
From To FL
a �
16. REMARKS: -
!DO HEREBY CERTIFY TiIAT THIS WELL WAS CONSTRUCTED IN AC ORDANCE WRN 15A NCAC 2C,WL•LL
CONSTRUCTION STANDARDS,AND THAT A COPY n ilS RECO BEEN PROVIDED TO THE WELL W)NER
Q 5` .
SIGNATURE OF PERSON CONSTRUCTING THE WE[L ATE -
Submit the original to the Division of water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NCI'
27699-1636 Phone No.[phone],within 30 days. G W-7 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Na Resources- ivisi n of Water t c: uv-Ciroundvrater`'sectw!,
WELL CONTRACTOR(INDIVIDUAL)NAME (pRct)w- 'rej/L__ _ _S._� CERTIFICATION k /
WELL CONTRACTOR COMPANY NAMFLXa)�R �T [lr.l( �` I_ �./I.� PRONE It 299Ga -Oy'�o
STATE WELL CONSTRUCTION PERMIT# _A OCIATED WQ PERMTO
iF livable) ifapplicable)
I WELL USE(Check Applicable Box):Residential i"Murucipal/Public❑ Industrial 0 Agricultural 13,
Monitoring 0 Recovery ® Heat Pump Water Injection Q Other❑ If Other,List Use W-pF
iVF,LL LOCATION: r T'opo�c/Land.settil - >)
�yatcst Town:-Mx Co _/SG dgo lope []Valley QlZ t
fT gW �JE C�/9S (Chock _
npntyeeiam bcr}
r no Zip ) Latitude longitude of well loc 4:2
nbeck Nanta,Nutnbcts,Communit ,Subdivisi Lot No.,.•. Cnde3 OWNER:/j Llre , / Gocs`.,Address �[U P[ g Latitudc!Iongitude source;(7GPSO'I'oie nipSuect° a No. (check box) r 1
Q�YLkYd�f tom/ c c 2�Z��_ i2r i? L c 1,�--J
city w Town state Zit Cede From To Formation ----
�'rca coda Phone numbs -'-----
4. DATE.DRIFLED_£-/O ..Q f� _ --- .--
5. TOTAL DEPTH:—I S_
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO @K _
7. STATIC WATER LEVEL Below Top of Casing: VO FT.
C/(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_,��.FT. Above Land Surface• ------- ------- ....�,.__`
-Top of casing u mloated atJor below hand surface requites a —
rariaace In aeeordaoce with 15A NCAC 3C,.OI1S. _
9. YIELD(gpm): fV— METHOD OF TEST_%
IU. WATER ZONES(depth)!
_ LOCATION SKETCH
11, DISINFECTION;Type,_..(,'--�� Amount j4E� Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depthd Diameter or WeighUFt numbers and common mad names.
Fro To 40 Ft 91/ Me& c
From_ To Ft
From To--_Ft. �— �_ 3 r-
3. GROUT' Depth Materal Me od i
From__,To_mo FL �o✓!G/"f�_ Wo
From To Ft
14. SCREEN: Depth Diameter Slot Size Material o
From To Ft. in. in,
[Il
From_To Ft._____, in. in. e
15. SAND/GRAVEL PACK; Ft._in.
Depth size Material S�
From ._._ To Fe.
From _To Ft._ _
16. REMARKS: ..
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL �.
CONSTRUCTION STANDA AND THAT A COP F T W CORD t BEEN PROVIDED TO THE WELL OWNER
os
SIGNATURE OF PERSON CONSVZUCTINGTHE WELL DATB
Submit the original to the Division of Water Quality,Groundwater Section, 1636 @Mail Sesviee Center-Raleigh,NC
27699-1636 Phone No.(919)73-1-3221,within 30 days. GW-1 REV 07/2001

4 A
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-�Division/of Water Quality-Groundwater Section c
WELL CONTRACTOR(INDIVIDUAL)NAME (pMt) �1�1 �C' /�/I�ta�6 e 5 J"2 CERTIFICATION#Z
wrt��-��>P�t�A''T'E(� l t��( 1)It (t/1 70
WELL CONTRACTOR COMPANY NA p PHONE k (Sf�l�'0-gY0
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERM U
(if applicable) (if applicable)
L WELL USE(Check Applicable Box):Residential&-,�mlicipal/Public❑ Industrial❑ Agrictdtmal❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: Topograp}m3e/Land setting
Nearest Town: //_ ❑Ridge ope ❑Valley 11fist;j
/ _2 7S' (check appropriate box) I i
(Street Name.Num unity,Subdivision,Lot No.,zip Code) Lautude/longitude of well locati it i
3. OWNER: Rvsq l _ (deFeMft=eslseeonds)
Address c30l 'tM XL LatitudenongitWesource:❑GPS❑Topog%'*i map
(fit or R o.) (check box) II
Nc 287.E3 DEPTH DRILL LQfJ r ,.
City or Town State Zip Code From To Formation Description--=- -- -
AM code-Phone ameber ? ei
4. DATE DRILLED 577 /-d5
5. TOTAL DEPTH: 2 Z rT
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO R-- n
7. STATIC WATER LEVEL Below Top of Casing:--Z-C _FT. W
�'3�+ ,(Use.+^ifAbo Top of Castes)
8. TOP OF CASING IS (1_FT.Above Land Surface"
-Top of cache terminated aUor below land sartece rega(rea a
rartaace to accordance with 15A NCAC 2C.0115. ,
9. YIELD(gpm): /7—_METHOD OF TEST lz#wew
10. WATER ZONES(depth): LOCATION SKETCH
11, DISINFECTION:Type Amount /y 0 -E Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth J or gtei (/Ft MMz�<rist numb and co n names.
Fro To _ Ft. yZ/ —L�UC-
Fron _ To Ft I
From To Ft c
13. GROUT: Depth Material Melhod
From_ TO_ 7 Ft 7 E C Hfi� �e
From To FL -—
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: � Q
Depth Size Material r
From_--To Ft.
From To Ft.
I& REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STAND .AND THAT A COP F S RE RD HAS B ROVIDED TO TIM WELL OWNER
=3
SIGNATURE OF PERSON coNmu=40 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

314389
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Haw l p--^••-^-- �t••t•:.... nf Water i Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) J' t�L.� N)A S+J CERTIpFICATION#
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PIIONEY�8 ) 54-3581
STATE WELL CONSTRUCTION PERMITa 1537 ASSOCIATED WQ PERMIT/ - ---
ifa liaable (if applicable)
1. WELL USE(Check Applicable Box): Residential MunicipaVPublic ❑ Industrial❑ Agricultural[]
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,Cut Use - -
2. WELL LOCATION: TopographiuLand setting
Nearest To 000E V' 1 C County YVAIAi-S
❑Ridge ❑Slope ❑Valley at
2
GA-Tu(? bD4Js S
(cbaJ<appropriatc box)
(Street None,Numbers,Co nmuniry,Subdivision,Lot No.,Zip Code) LatitudeAongitude of well location
3. Oddress V— 1 1�� (deva+/miouteahecmds),
Address -�_ . e X ��S LalitudcAongitude source:❑GPS❑Topographic map
(f �f '? (Sueel a Roule N .) p v (chock box)
N 4 e ",N &0 0 C p S 1J DEPTII DRILLING LOG
�City orTown swe zip code Fro ! Tp i Fo�JJn�ti tese�riplion
l ssl 1�L 1 S' [t p .; r IttS1J[L0�iJ
Ara coda Phone number
4. DATE DRILLED b - a 3 - D 5 D G(,LA^)'T
' 1 C8- rj
5. TOTAL DEPTH:�'3O � �b �Q_ �rho� la" RAne t T�i M
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 6/ r�j .�f la . ( )3 GWM
7. STATIC WATERLEVELBe low Top ofCasing:C_FT. tI10'-- 51C)
(Use-+-if Above Top of Cuing)
8. TOP OF CASING IS FT.Above Land Surface*
*Top
of cuing laminated attar below load surface requiro a
Varian"In acwrd a Itb ISA NCAC 2C.01 If. J r
9. YIELD(gpm):_L METHOD OF TEST ill G C `
10. WATER ZONES(depth): I A C e o ;� M =
Sao ' - i G Q ✓N, LOCATION SKETCH
11. DISINFECTION:Type t ' �.c. Amount Show direction and distance in miles from�Fjeast '
12. CASING: Wall Thickness two State Roads or County Roads. Include 99 roan
1 Depth, I D ter or 4ei¢h i t. IIgn'aJ numbers and common mad names.
From �_F
From To FL
From To Ft. � �� �'0 �Itw ¢/'t e
13. GROUT: Depth Material Method
From I To as Fl. Cif N�� Jl?-6 o
From To Ft. h
14. SCREEN: Depth Diameter SlotSiu Material
From To Ft. in. in. ,
From To Ft. in. in. a c`�L •
15. SAND/GRAVEL PACK: � rCC k"re,
Depth Size Material `%r� > !T^
From To Ft.
From To FL
16. REMARKS:
1 DO HEREBY CERTIFY TI[AT 7111S WELL WAS CONSTRUCTED IN ACCORDANCE WTITI ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A PY O 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 Mali 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-Di ' ion of Water Quality-Gmnndwater Section
WELL CONTRACTOR(INDPADUAL)N r (print -.[IBC CERTIFICATION
WELL CONTRACTOR COMPANY NAME —/JN .lJ PHONE /N6AIT.,Q V'Wb
STATE WELL CONSTRUCTION PERMM_ /,V� A SOCIATED WQ PERMrr#0010010
(ifappticable) CENyucable)
1. WELL USE(Check Applicable Box):Residential H Municipal/Public❑ industrial❑ Agricultural❑
Monitoring❑ Recovery 13 Heat PUMP Water Injection 0 Other O If Other,List Uge
2 WELLLOwn: n Topographic/Landsettin
Nearest Tows 1' JeCmmri g
/J Midge �SIOpe OVba) OFlat
—ICI (drakapp a of well
(sneer Name.Numbms.Camatdty,Subdivis;oa,I.ot Na,Tap Code} Latinrde/longitude of well location
3. OWNE
/�/.GI/ (depaa/m�aeilseomds)
Address Latitude/lon gitude source:OGPSOTopogtaphic map
(dwekboa)
C• .2 J, Z" DEPTH D IU IN M
City er Town . Side zip code From To Formation Description
Am oode•Phan amber ��jj
4. DATE DRILLED 0la�5
5. TOTAL DEPTH: S•/oS
6. DOES WELL REPLACE EXISTING WELL? YE 0 NO (8 _
7. STATIC WATER LEVEL Below Top of Casing:,�FT. -
8. TOP OF CASING IS r (Use��if Abme Top of Cans[W
FT.Above Land Surface
-Top of cuing terminated aNer Wow had anrtn a requim a -.
variance In leesrdaaee with 15A NCAC 2C.e11L
9. YIELD(gpm):- 4 METHOD OF TEST�tQ�
10.WATER ZONES(depth):
ir1rATIpN SKETCH
11. DISINFECTION:Type Ammmt Show direction and distance in miles from at least
12. CASING: D�th� Wall Thickness two State Roads or County Roads.Include the road
Froar_ _To ZS tL Ft cejf�1/� numbers and common road names. o u)4t P
Fromm To Ft Flo
From_To—Ft
13. GROUT: Depth F ��
From_To.,p2Q Ft._�j tJ�
From To Ft
14, SCREEN: Depth Diameter Slot Size Material
From----,—To Ft in. nL
Fro Too Ft in. in.
15, SAND/GRAVEL PACK:
Depth Size Material
Front--
Ft. n h _
From / To Ft. e� 7
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2G WELL
CONSTRUCTION 8 AND COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNED
SlqNkM OF PRMON CONSTRUCITNG 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 - -. -

O3 4154 'Ale 4
WELL CONSTRUCTION RECORD
Notch Carolina-Department of Environment and N tural Resources-Di 'shun of Water -Groundwater Section
0-
WELL coNTRwcroR(txnlv>nuwL)NAM E farint1 cER7 n 1cATtox
WELL CONTRACTOR COMPANY NAME CN! 1 o O-- PHONE ( )
STATE WELL CONSTRUCTION PERMM ASSOCIATED WQ PgRMCr6
(ifavDlicable) (if pplicable)
I. WELL USE(heck Applicable Box):Residential2 Municipal/Public O Industrial E3 Agricultural❑
Mouitoring❑ Recovery O Heat Pump Water hiijection❑ Other[] If Other,List Ux
2. WELL LOCATION: TopoB�hic/Land setting
Nearest T L` ��F j �otmty d ORtdge J@Slope OValley 13Flat
4(_5'l [ 7 gVwpeme box)
(strut Name.A b . h .®m,mity,Sebdh4sim,tot No,Tap Code) LatitadeAongitude of well location
3. OWNER: 47—
_ ( )
AddressLatitude/longitude sotnce:OGPSOTopogtaphic map
Zz ' E _ ��� (eheclr box)
sun DEPTH DRILLING LOG
City or Town sa
Code From To Formation Description
Aron mda Phme samba ,
4. DATE DRILLED �_
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO N
7. STATIC WATER LEVEL Below Top of Casing:�F'I'.
8. TOP OF CASING IS (UN-+-if Above Top Of cuing)
a
Z,S FT.Above Land Surface
`Top of easing terminated safer bWw lad surface requires a
variance to accardanel with 15A NCAC 2C A11L
9. YIELD(gpm y _METHOD OF TEST��
10.WATER ZONES(depth): CD
t_tx'ATTON S CH "�
11. DISINFECTION:Type Amount /& $ Show direction and distance in miles from at leash
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depd,t/�, �a�e� or Wei t_AM numbers and road names.
Fronl�Tom FL_l
FrnnL—To Ft
From__To FL
13. GROUT: Depth Mat Jed j�
Frotn_Q-To�Ft�
From To Ft
14, SCREEN: Depth Diameter Slot Size Material
From T Ft in. in.
Fro��To Ft in. is
15. SAND/GRAVELPACK:
Depth Size Material
From o Ft.
Fro To Ft.
16. REMARKS:
i DO HEREBY CERTIFY THAT THIS WELL WAS CONFUIN ACCORDANCE WITH 15ANCAC 2G WELL
CONSTRUCTION STANDARDS TACO CO HAS BEEN PROVIDED TO THE WNER
SIGNATURE OF P CON CfING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Manz Service Center-Raleigh,NC
27699-1636 Phone Na(919)733-3221,within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD ( ` 3 1 1
North Carolina-Department of Environment and N 1 Resources-I�'v ion o Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prlut) F1 C-- -S cilur 1CAATIoN a 2Z2��{}
WELL CONTRACTOR COMPANY NAME O E` 4 C!s L 1+e PHONE N L_YSLL1 V ry CKJ
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ P
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0--1 Mmucipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION- I opographic/Land setting
Nearest Town: S J 11 County / dge ❑Slope ❑Valley ❑Flat
2#'lz trotyl ✓ (v�sr�r� i2i? 75 (check gWWnete iwa)
(Sheet Name.NumbftNtammuniIN Subdivision,Id No,Tip Cede) LatitudeAcingitude of well location
3. OWNER: jilwu &CF (dep-emimcros/aeoorA)
Address / rr :�rr2'ri 3 /Z� Latitude/longitude source:❑GPS❑Topographic map
(Street or No.) (check box)dig// IZ- DEPTH DRILLING LOG
City w Town Site Zip Code From TO Formation Description
Aces code-Phone comber
4. DATE DRILLED Z$ U 5
5. TOTAL DEPTH: 3O5—
6. DOES WELL REPLACE EXISTING WELL? YES NO RY- M,
7. STATIC WATER LEVEL Below Top of Casing: O FT. O
,/(Use"+"ifAbove Top of Casing)
8. TOP OF CASING IS 1e.. FT.Above Land Surface' 3
-Top of caning terminated allor below land surface requires a _
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):LC/ METHOD OF TEST i
10.WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type-4c Amount ,O y-a Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth �tayeter `i�gg>rt/Ft �' numbers and commQa ad names.
Fro To 'd Ft(�%Z (/K L/ S
From To Ft
From To Ft N� oil
13. GROUT: ( 7
From l� TDoFt .tt L <M t71
From To Ft
14. SCREEN: Depth Diameter Slot Size Material VeI
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 S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CON CTION STAND SAND TACO OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIdATUROF PERSON CONSTRUCDNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,16-36 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WIC1.Ll V1VJIKU(:11V1V KEl Vlll)
North Carolina-Department of Environment and Natural Resources- ivistory/of Water Quality-Groundwater Section L,
WELL CONTRACTOR(IPIDIYIDUAL)NAME Wet) rpn A fX([' CERTIFIC'ATI`ON/#27 J
WELL CONTRACTOR COMPANY NAM C i!e P # PHONE #
STATE WELL CONSTRUCTION PERMIT# wscOC1ATED W,Q P #
(if applicable) (ifapphcabie)
1. WELL USE(Check Applicable Box):Residential 2*'Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: /astTow : T Od setting
Ne n ois0 7dge pe_❑V all ❑FlatLl A 19 de A-53
(check appropriate boa)
(Steet Name,Numbers,Community,Sub 'vision,lot No.,Zip Code)
Latitude/longitude of well location
3. OWNER: t sc;. ao (degreeshnimrbnUaxands)
Addres�st 9?' f c lf is N t Y✓ Latitude/longitude source:❑GPS❑Topographic map
-J //// (Stec[a�me No.) (dmk box)
�j F 7 S '3 FnTH DRILLING LOG
City or Town Stan: �Code From TO
Formation Description
Am codm Plume number .
4. DATE DRILLED
5. TOTAL DEPTH: I y3
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0"
7. STATIC WATER LEVEL Below Top of Casing:—Z.L-_FT, w
(Use-+-if Above Top of Cuing) -. 3
S. TOP OF CASING)S _FT.Above Land Surface*
'Top of casioa terminated attor below land surface require,a
mianee In acsordame with 15A NCAC 2C.0114.
9. YIELD(gpm): (00 METHOD OF TEST_
10. WATER ZONES(depth): {"
LOCATIONS ETCH 3
11. DISINFECTION:Type C Amount 7(� O z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
�iatpyter or Wei tTt Material numbers and common road names.
From_ To Ft (� ( _
From To Ft
i
From To Ft
13. GROUT: Depth Material M / , e l/
FromL �Ti Q_FLI�
From To Ft
14. SCREEN: Depth Diameter Slot Size Material �
From To Ft. in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
77=ACOPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O PERSON CONSTRUCfING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, Mail Service Ceater-Raleigh NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NaturalResources-D/�vts-on of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME ld CERTIFICATION R2ZEy
WELL CONTRACTOR COMPANY NAME S.twae%? tudje.^ Well '7 Ptti,ar�_PRONEs Balk`/�/u5rfi'o
STATE WELL CONSTRUCTION PERM U ---ASSOCIATED WQ PBRIIIIT'N
Ofappliable) Ofaoaliable)
1. WELL USE(Check Applicable Box):Residential lYMunidpal(Public O Industrial[3 Agricultural d
Monitoring O Recovery O heat Pump Water h jection❑ Other❑ If Other,List Use
I
2. WELL LOCATION: Topographic/Land setting
Nearest Town: 014/'5k.9// County, � i � Midge OSlope QVaney L9Flaf i
2/1`✓ Kint /3jvd Z`d75`3 (eheekappmprieleboz)
(Sweet Nem%N Community.Sab&visioo.Lot No.,Tp Code) Latitude/longitude of well location
3. OWNER:C/%P5ovd k,n s IdeDca/ reomula)
Address z//S-(�«Cs,v c, 71,d Latitude/longitude soince:OGPSOTopographic map
2�75 3 ( DRILLING LOG
City or Town state Zip Code From TO Formation Description
Area ecda Phone amber
4. DATE DRII,LED p/ —/(, G 5�
5. TOTAL DEPTH: / S-
6. DOES WELL REPLACE EXISTING WELL? YESQ NO fl
7. STATIC WATER LEVEL Below Top of Casing: F7.
(Uu'4"if Above Top of Cming)
S. TOP OF CASING IS 7 S FT.Above Land Surface•
`Top of cuing terminted at/or below land surface requires a c"")
varimet to accordance with ISANCAC ZC Atlt
9. YIELD(GPM):2Q METHOD OF TEST »e- c�
10.WATER ZONES(depth):
LOCATION SKETCH clt
11. DISINFECTION.Type Amount /(� c'z Show direction and distance in miles from at least,,3a
12. CASING: Wall Thidmess two State Roads or County Roads.Include the road•
� _L4L`L_ �J _ numbers and common toad names.
Fro To D FL Z G
Front—To—Ft,—
Front—To Ft
13. GROUT: Depth Material M91hod
From To 20 Ft �2 e )N f p";x
From To Ft
l4. SCREEN: Depth Diameter Slot Size Materiel
From_ To Ft in. in. x
From To Ft_-XL in.
15. SAND/GRAVEL PACK: Ye��
Depth Size Material
From_�To Ft. �� c
From—To Ft
16. REMARKS:
I DO HEREBY9ERTIFY THAT THIS WELL WAS CON IN A ORDANCE WITH 15ANCAC XC WELL
CONSTR)J N STANDARDS,AND OF RECO BEEN PROVIDED TO THE WELL OWNER
A —��
SIGNATURE OF PERSON CONS UCTING THE WELL DATE

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIMIUAL)NAME Whrt) a _ CERTt cA noN a z 7
WELL CONTRACTOR COMPANY NAME ee 1.U19/[ 9 AA,;i3OE2 PRONE a
STATE WELL CONSTRUCTION PERMTT11 --ASSOCIATED WQ PIRMM
(ifapplicabte) (ifgplicable)
_
1. WELL USE(Check Applicable Box):Residential Er"Municipal/Public❑ Indurtrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use -
'i
2. WELL LOCATION:
EMWNearest Tows S /A cotmtyll�A�SG!?>
ge ❑Slope ❑VaIlOFIat
g5 70 Z! 70 2�75`3 (dtecicappeapri.teboa) I
(Sint N..mNw*em Cmimmay subdvitiaa,taro.,Tip code) Latitudellongi(ude of well location s.
3. OWNER: fUPGPT� /4l�iGl�U (depealm®mm/re000da) _.: :_- -j.-,fi
Address - 1fL__,_ Latitudellongitude sourceAGPS❑Topogiaphic map
(sow Rome W) (dink box)
/V L 2 FPS`3 DEPTH DRILLING
City or Tb� St oe zip Cade From To Formation Description
Am code.Pbwe somber _
4. DATE DRILLED
5. TOTAL DEPTH: Z'f5-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 05 -'
7. STATIC WATER LEVEL Below Top of Casing j2 PT.
_(Use"f'ifAbove Top of Casing) '
8. TOP OF CASING IS A. 5 FT.Above Land Surface'
`Top of eeisg tersWted saw betas baud wrfaa regmrw a -
v= misaaerdu wMISANCAC2C.011a. t
9. YIELD(gpm):—,tS -•—METHOD OF TEST k el
10.WATER ZONES(depth):
LOCATIONSKR I CH
11. DISINFECTION:Type CCZ Amount IC o-z Show direction and distance in miles from at least
12. CASING: Wall Thickwo two State Roads or County Roads.Include the road
Depth Diameter
� or Weightft numbers and common road
From_ To_f�FtY
From—To Ft,—
From—- To Ft
13. GROUT: Depth Material Method - ==--
From W e/ --
From`To FL
14. SCREEN: Depth Diameter Slot Size Material
it; To FL in. in.
From To Ft._in. in. -�
15. SANDIGRAVELPACIC
Fro�Depth size Material
_To Ft N 3
From To Ft
16. REMARKS:
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
��d STANDARDS, THAT (COPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
f 0 5�
SIGNATl7RB OF P)ORSON CONSTRUCTING THE WU1 DATE

0J) x Y
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater section
WELL CONTRACTOR M(DIV DUAL) t. (prhn a/&I (: /f6aUCl`n pr CERTIFICATION a 2 7
WELL CONTRACTOR COMPANY NAME L.-) l'P// J Pt"_PHONE #,(&-ZLJ s/ p
STATE WELL CONSTRUCTION PERNM A-�S^r'r�TED WQ PERMTTa
if livable 1110111111 if livable
I. WELL USE(Check Applicable Box):Residential Municipal/Public 0 Inds al❑ Agricultural❑
Monitoring❑ Recovery 0 Heat Pub Water Injection 0 Other O If Other,List Use
2. WELL LOCATION: TWO�cti,aad setting
Nearest Town:/?9 /'S���� City 11 5G U
3o.5 Pond rti,7/ li�AdscX z - (Valley Q�at
(dusk appmpdvc box)
(Soon Name,Numbrm Community.Svbd;t^W140,Zip Code) Latitude/longitude of well location
3. OWNER:--DJ90/ ¢
Address ._305- laor+d lw.'// /?tj f
Latitude/longitutde source:l7CiPSOTopoBmPhic map
411,
(SUW err Rmne No.)
J4/� died box)
yL'G Z 6 7 5-3 DEPTH ( DRIILRJG L^G
City or sown Seen ZipCodo From To Formation Description
Am code Phone mmtber 4. DATE DRILLED °I /y'0 5_
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Q-'
7. STATIC WATER LEVEL Below Top of Casing:
(Use''`if Above Top of Casing) a
8. TOP OF CASINO IS 1. s FT.Above Land Surface*
*Top of codes term6oted at/or below taM aerfoee regWm a
varisaee to aemrdaatt sin ISA NCAC 2CA11L /
zi
9. YIELD(gpm): /o Q METHOD OF TEST /=eQ
10.WATER ZONES(depth): c ,
LOCATION SKETCH
11. DISINFECITON:Type Antoumt /D o z Show direction and distance in miles from 960
12. CASINO: wall 7hiclntess two State Roads or County Roads.Include the road"-,
From T Ft pia eter-- r ers a� hFL g�/ Material
To Ft al numbers and common road names.
�YN �
From To Ft
13. GROUT: Depth Material M tbod p
From To-.(,Z FL611Crele P ,' v
From To Ft �
14. SCREEN: Depth Dissue[er Slat Sine Material
From .0 Tc Ft_uL in '
From—To—Ft.—in- in. y
15. SANDIGRAVEL PACK:
Depdr size Material Q,
From,42L-�TO Ft.
From To FL
16. REMARKS: �JiGJ /�G• P -
I DO HEREBY CERTIFY THAT THIS WELL WAS CON CTED IN A ANCE WITH 15A NCAC 2C,WELL
CON MN STANDARDS,AND COPY THIS RECO BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONS UCTING THE WELL DATE

WELL CONSTRUCTION RECORD
North Carolina-Department or Envimnmcnt and Nah,m)o......_.- n:..:,;,,,¢,I_f�iiWater Qudiry-Gmundwatcr Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prfat) 16 \1 L_i1 dJ�.S Il CERTIFICATION a��y'�{
1 1
WELI.CONTRACTOR COMPANY NAME REUDEN CALDWELL DRILLING, INC. PIIONCY t
rr11 2g 54-3581
STATE WELL CONSTRUCTION PERMrtt 1537_ AccOCIATCD WQ PERMIT/
ife lieable ira livable
1. WELL USE(Check Applicable Box): Residenlial Municipal/Public ❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ lrOther, List Use
2. WELL LOCATION:
Nearest Town: (Y\�.4 S I�d Lit County +�� cl t S i• 1� TopDg°phica$Dd setting
4 3 ° S PQ i A)11 k L� rG/LA ael-( IL�0 Midge ❑Slope ❑Valley tat
(Street None,Numbers.
Carnwity,Subdivision,lnt No.,lip Code) (�k appmpriete box)
�J LAtilude/Iongitude Orwell location
3. OWNER: ro t(3 v ilg L�- -)
Address k<
LaiitudcAongitude source:❑GPS❑Topographic map
,,/� (Strrcr ar Raute No.) C, (check box)
_mil' 1 F1:2.S r-i Al-1_ N C. '� 1 DEPTH DRILLING I OC
tty or T1ewn stets zip Code
YJ lr� 4.Ci __ i S Fro To / Forrn Iion7Description
Ana coda-Phonenumber " C C:�C�fJ,{/.)._.41�/V
4. DATE DRILLED_ - C{ - D S a o' — 3 1 a (; , L.
0 -1f�w't
5. TOTAL DEPTtI:_ 3 5 :� / �
6. DOES WELL REPLACE EXISTING WELL? YES 9 NO ❑ 1 O
7. STATIC WATER LEVEL Below Top or Casing: (O 3 FT.
(Use-1'if Above Top of Caring) -;y
8. TOP OF CASING IS FT.Above Land Surface-
*TOP er<arleg ferrofaafed at/er b0oe Iaad eurfe ce re getru a
varlaaca Is acmrduca wlta IfA NCAC 7C.01 it. 77 F"
9. YIELD(gpm):�_METIIOD OF TEST 41,G - I\ i t' --- *--"
10.WATER ZONES(depth): 3 \ o _7 o
LOCATION SKFTCH -•
11. DISINFECTION:Type hl o c Amount Z 1 Show direction and distance in miles from at least f'l
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
'f Depth % ,)er orr r wc'ht/Fl. ►Afayce numbers and common road names.
From i To R Ft. '6 j•'V (�
From To Ft.
From To Ft.
13. GROUT- Depth a0 M.tar at Malhod ¢
From To FL L. XeI� O,1 ('M D 4-
From—
To FL .ZSM SfY�-i�eL�
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. CL�
wAI- :!ter
From To Ft. in. in. Ct� tl�
15. SAND/GRAVEL PACK:
Depth Size Material 9 �
From To Ft.
From To Ft.
VI
16. REMARKS: rTt
t
I DO HEREBY CERTIFY T7IATTIIIS WELL WAS CONSTRUC)ID IN ACCORDANC WI7}I 1 SA NCAC 2C,WELL Cn CONSTRUCTION STANDARDS,AND TI IAT A COPY OFTM RECORD HAS DE • PROVlDFDTOTIfEWFlJ4OWNERl ---
SIGNATURE OF PERSON CONSTRUCDNG THE 4Ef DATE '
Submit the original to the Division or Water Quality,Groundwater Section, 1636 Ault Service Crater-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 - -

eafi � `r ;Rx.1
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and NahtrQ+I Dom,^..--- n:..:,1,,,,,tf Water Quality.Groundwater Seetiio -1
onr -/
WCLL CONTRACTOR(INDIVIDUAL)NAME (pMw) tJ I I_t_.1 13 /`l AS 14 CtRTIPICATION a 6k 1
WELL CONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING PIIONlY, INC, rrll�g 54-3581�
STATE WELL CONSTRUCTION PERMIT/ 1537
(ifel><slicable) wccOC1ATCD WQ Pt RAtrra
/ (ifappliriblc)
1. WELL USE(Check Applicable Box): Residential Q� Municipat/Public❑ Industrial❑ Agricultural ❑
Monitoring❑ Recovery ❑ Real Pump Water Injection❑ Other❑ If Other, List Use
2. WELL LOCATION:
Neest TownT•�4 A-"-I-)t—AQTJ �b IS Topographic/Land setting County 1a ❑Ridge ❑Slope ❑Valley &la l
(Sheet Neme,Numben.Community.Subdivision,!rat No..Zip Code) (Chock`ppm9dete bon)
LatitudcAongitude of well location
3. OWNER:_ 9 At-42 hI A")CT C- 1._.-r-:- <deve<+/mioutnhaottdr)
Address (Street or Raws No.) Lalitude/longitude source:❑GP ra S❑Topogphic Dap
(check bon)
DPPTII DRILLING I O(
try or Town Stem Zip Code
`a 3 1- 19110 From f To / Forittation Description
3 % 1 t R(iet(�t�1n20
4. Area
eow ED' a3 05 3st ' - (bo "aA
5. TOTAL DEPTH: o (bO' C 1r0u 6 to Gera
l dNN1 ( �6. DOES WELL REPLACE EXISTMG WELLT YES❑ NO ltiJ 'bo/at D ,a fo
7. STATIC WATER LEVEL Below Top of Casing: b4� FT. 1 ao 6('M
(Use-e-if Above Top of cuing) `a 10� opt pr ('� �,
8. TOP OF CASING IS FT.Above Land Surfacee'
*Top afeulal larminatrd atlor below lead surface requlru a (q C7
varlmu in accordance with ISA NCAC 2C.0111. 0 '
9. YIELD(gpm):,�v _METI IOD OF TEST M1t G la 1 (Z,
�—___
10. WgTERZONES(depth): t �s0 No S'T`r� Gil =w
alo - oloGC rr- LOCATION SKETCH 11. DISINFECTION:Type-9;n - Q GO Amount 9 Show direction and dislance in miles fra at le t
12. CASING: Wall Thickness two State Roads or County Roads.Include the fdad
Depth Diameter or We ht/FI. Material numbers and common mad names.
From Tom 4 Ft.— If .t )(Ti r
From To Ft.
From To FL J
13. GROUT: Depth Material Melhod 9sfrC GItA/
Frort,.�_To a Fl. QAIv�E?1.1`r a
From To Ft.
14. SCREEN: Depth Diameter Slot Sim Material t4fvoma
From To Fl. in. in. I
From To Ft. in. in. Ca�Es
15. SAND/GRAVEL PACK:
Depth Sim Materiel (V
From To FL - --
From To FL - .-
16. REMARKS: A2v+nep6Jlt_t�, µan)
M1
I DO HEREBY CERTIFY TH Z3AT TV ITS WELL WAS CONSTRUCTED IN ACCORDANCE WTT71 I SA NCAC 2C.WELL
CONSTRUCTION STANDARDS,AND T71AT A,COPY OF THIS RECORD IIAS BEEN PROVIDED TO 7IB701WNER
��
SIGNATURE OF PERSON CONSTRUCTING THE WLLL DA
Submit the orleinal to the Division of Water Quality,Groundwater Section,1636 Matt Service Center-Rxfelgh,NC-'
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

AfF-P
3 � � 6t1
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Nittural Resources-Division of Water Quality-Groundwater Section
C # 66
WELL CONTRACTOR(INDIVIDUAL)NAME (print) q C� CERTIFICATION(/� [�a
WELL CONTRACTOR COMPANY NAME A ,A i N Gi� I �I 4{ 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 LOCAT +{� Topographic/Land setting
NIe^ares{j.Tgwq�n: "' AA � County ��h'�w Ridge ❑Slope ❑Valley ❑Flat
Y"-' 7 4-9 A e-t-/ 1 E W 65 lnt '[�_> (check appropriate box)
(Street Name,Numbers,Communi ,Subdivision,Lot No.,Zip Code) l long ❑de 0 w 0 atio 98.3
3. OWNER: 14flUIv-t WGCSI: �Ck (degrees/minutes/seconds) E(EV 9,33
Address INQ S Latitude/longitude source: map {e
♦i Re
or S.ayre.[Ja) C2�7-5// , (check box)
I�ZL j N lam'+ ^/P 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? YE NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accord nh 15A NCAC 2C.Ol 18.
9. YIELD(gpm):in ME�1:1,0D
10. WATER ZONES(depth):
LOCATION SKETCH
It. DISINFECTION: Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two Stale Roads or County Roads. Include the road
Depth �' Diameter or Weight/Ft. Material numbers and common road names.
From—� To l i J Ft.
From To Ft.
From TO Ft.
13. GROUT: Depth Material d r
From To Ft i3
From To_FL ty*177.
14. SCREEN: Depth Diameter Slot Size Material '3
1
From To Ft. in. in. cD
From To Ft. in. in.
15. SAND/GRAVEL PACK: (Jr!
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
CONSTRU N STANDA S, D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T�H/E�7 LPL O ER
as-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

AIL
qaV S RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: I. DISINFECTION:Type 'TN 0 r_ Amount )
O UL,es rJ �pl V ,(�- W i s g. WATER ZONES(depth):
Well Contractor(individual)Name From lbo To ZG ( From To
Well Contractor r Company
any Name From To From To
` ,,pp Fran To From To
STREETADDRESS S51 /v (�bJ " ICe S leK gl'r1/ 6. CASING: / Thickness/
/ N p Y DTothla O FL, Dia ter SWWghl( Ma r al
AS ��b'Y t L„� L a g U From ( 2.
City or Town State Zip Code From To FL
( � �v5 dr — 3 5s 1 From To_Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
Fran_,`To aO Ft. LEWE�rOT PO cr"P
SITE WELL ID#(if applicable) From To_Ft.
STATE WELL PERMIT#(if applicable) Fran To_Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Fran To FL—in. _ in.
Fran To_Ft.—in. _ in.
TIME COMPLETED
DATE DRILLED D1 L 0 J� ! Fran To_FL—in. _ in.
6 =.P o AM❑ PM(�
9. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY:4944 '041`L� COUNTY t^&N 50r3 Fran To Ft.
cc From To_FL
sr Jti lS G1.iS(JJ �V�IJs`jto6J Fran To_Ft.
(Street Name,Numbers,Canmunily.Subdivision,Lot No.,Parcel,ZIp Cp e)
TOPOGRAPHIC/LAND SETTJNG: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat Idge 0Other From To
(check appropriate box) I Y 1 I / FPr I In"Description
May be in degrees, 1 cl `t l3 fL f�•J ZOu 1�
LATITUDE 3 = nimulmsecondsor 1 IS I 2Lee � C> Ct-P wa ,k C
LONGITUDE in a decimal format 'L60`- OLb I ` c.2e� lS Es — 30 C>QM
2,6 t' - 3oS ' CoQA�TI��
Latitude/longitude source: ❑GPS OTopographic map -
(location of we#must be shown on a USGS topic,map and _9
attached to this form#not using GPS) t
4.WELL OWNER 11II `-
OWNER'S NAME auteY I 6 yvz5 ),, CDU.YIke-V n
STREETADDRESS 53cli, SL§--Jwioj Lki rJS
LA)LA4bfkg6 %_iL o_�C 1%-1XI
City or Town Stale Zip Code
( Ba% -11a-�ao�
Area code- Phone number -
5.WELL DETAILS: 11. REMARKS:
� 0 S
a. TOTAL DEPTH:
h. DOES WELL REPLACE EXISTING WELL? YES❑ NOZ
c. WATER LEVEL Beim Top of Cash t O � �DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wtm
9 t FT. t5A NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use-+-0 Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS i Ff.Above Land Surface' R# __� �� a 3 a�TE
�j
'Top of casing terminated with 15A CAlan 2C ace.01 may require SIGNATURE OF CERTIFIED WELL CONTRACTOR D
a variance in accordance with 15A NCAC 2C.0118. 1p�
e. YIELD(gpm): Q METHOD OF TEST_RIG - A I K " 1 I-L-I C tj AS IJ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days, Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW1a
Rev.7105

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Nah,r.1 n__....�__ n:. of Water t
rr��I��I _ ` ^ e Quality-Groundwater Sxtion I
WCLLCONTRACTOR(1NDIVIDUAL)NAME (pAae) 6 t In 1 is fJ A S C[ATiPICATION/ a7-1 1
WELLCONTitACTORCOMPANYNAMC REUDEN CALDWELL DRILLING, INC. PIwNe44 8 54-3581
SEAT[WELL CONS ) OC1ATCD WQ PERAirla ON PeItM ITa 1537
_ wcc
if a livacableble
ifapplicable)
1. WELL USE(Check Applicable Boa): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ heat Pump Water Injection ❑ Other Cl If Othcr, List Use
2. WELLLOCATI I:
Nearest Town: u 091Z— County {VXA AI S0kb To!" tic/Land setting
�A^10V�1�IA) 0-0A O ❑Ridge lope Malley ❑Flat
(Street No m
ne,Numben,Comwiry,subdivision,IN NO.Zip Code) (�k apprwriue boa)
L``� `s LalitudcAongitudeofwelllocation
3. OWNER:_ r {yl)M2S F�l.� CQY�6'"
Address - o ni( V (�aeeereauu,4y/.rned.)
Latitudellongirude source:❑GPS❑Topographic map
(Steret v Noure No.)
1'1�(.niArLASYtt�C{ i3t' �6`7DC�A (chexie box)
_ DEPTFI _�GG
cry or Town S Zip Code Fro
`t l Q, —i�C3 U ! Tot1-- F oiip[p[p[(((DDD Des lio
Ares cods Penn,number
4. DATE DRILLED
5. TOTAL DEPTH,_ '-- / `40
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cd �Y0
7. STATIC WATER LEVEL Delow Top of Casing: 60 FT. —t
1 (Use'e'if Above Top ofCuina) 78. TOP OF CASING IS 1 FT.Above Land Surface*
'Top Of cut-9 larmiuted aver below)led surface requlro a p
vartuce Ia aceardaaes wleb 15A NCAC 2C.0118.
9. YIELD(gpm): 15—MEq7�gD OF Tf:ST
10. WATER ZONES(depth): rA --
LOCATION SKFTCFi
11. DISINFECTION:Type Amount Show direction and distance in miles from at least
12. CASING: Wa117'hickneas two State Roads or County Roads. Include the road
From
'P ® p .ter t. ,yam( numbers 4T'/rSar),d co on mad names.
Ft. D vV
From To Ft.
From To FL t
13. GROUT: Dep M�elJ�og,
From�To !0 FL l.A *bf3'y� d.Jy'- 1•J q �
From To Ft. rt J
14. SCREEN: Depth Diameter Slot Size Materiel J
From To Ft. in. in.
From To Ft. in. in
15. SAND/GRAVEL PACK:
Depth Siu NIalerial ) M
From To Ft. Z �m From To Ft. 1(,i^ ,I N)
16. REMARKS:
1 DO HEREBY CERTIFY TI UTTIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITIt 1 SA NCAC 2C.WELL
CONSTRUCTION STANDARDS,AND Tl A C Fg'FIIS REC RD IIAS BEEN PROVIDL•D TO tET�Ll.' OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL I DAJrH
Submit the original to the Division of Water Quality,Groundwater Secrinn, 1636 Mell Service Center-R.Ielgh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

ryyr �• �� I/V\tM'1rj\VIt1\VII
g~ ;- RESIDENTIAL WELL CONSTRUCTION RECORD
- � North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type t: Amount
�� "-e, � 1 d-we', g. WATEER ZONES!(depth):
W I Contractor(Inds duall) ame 9 y. From 9� To 1 prom
Qu bpm �G11 �I (h C. To
G I From i 58 ' From To
Well Contractor Company Name 1
'' II 11''�� From To From To
STREET ADDRESS 3�-� d�C./ ���r Ilfl1 6. CASING:
Thickness/
d t Depth'O qi gter Vyei 1 Mayer
From -1 To__Ft. 6 6 S Y
Sarybo Tav? �¢State359I Zip Code From
U- From—To—Ft.—
rom To_—Ft.
Area code- phone number --
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID Of applicable) From-1—To Q-0 FL C46� t l Ct dL-C
From To Ft.
STATE WELL PERMIT#(B applicable) From Tc Ft
DWQ or OTHER PERMIT#(if applicable)
8. SCREEN: Depth Diameter SW Size Material
WELL USE(Check Applicable Bo ): Residential W ater Supply From To Ft. _ in.
DATE DRILLED ( a Q 5 From To_Ft__in. — in.
From To Ft._in. _ in.
TIME COMPLETEDt;a O O y AM�PM❑
9. SAND/GRAVEL PACK:
3.WELL LOCATION: �/ Depth
CITY: 6AQ.NAQl) VIIl i c Size Material
COUNTY W Sc l� Frorn To Fl.
�} �,/ From To__Ft.
ftlr3r `D jlaL olOrnmum l/ From _To(Sa 1 N me.Numbers,Communtry,SubtltNston,Lot No.,Parcel,T Code) FL
TOPOGRAPHIC/LA SETTING:
❑Slope OValley lat ❑Rid9e ❑Other 10.DRILLING LOG
(check appropriate bolt) Fro r`To6 5 Fopnation Description
LATITUDE 3 Mayhin degr«; 04($'�- J��V
minutes,srtdsor '�5 ` O� �jZ NtT�
LONGITUDE in a decimal format C U ` M
— — �b' _
Latitude longitude source: ❑GPS ❑Topographic map � / 1 _
(location of"I must be shown on a USES to 5t: I t Cg — � 6 fY1
attached to This form OF not using GP po map and ( ) _ t) ) t(�-
4.WELL OWNER r-
OWNER'SNAME 2LS
STUETADDRESS 13-7a GA NW o
70 9 fv
City or Town Slate Zip Code —t
(Area code acode�- � 16 - 9�toa
.—Phi number
S.WELL DETAILS: / 11. REMARKS:
a. TOTAL DEPTH: Q0,5
b. DOES WELL REPLACE EXISTING WELL? YESO NOV
C. WATER LEVEL Below Top of Casing: b D FT I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
(Use'+•it q(p,,e Top of Casi 15A NCAC 2C,WELL CONSTRUCTON STANDARDS.AND THAT A COPY OF THIS
n9) RECORD HAS BEEN PROVIDEDTOTHE/W�ELL O�WN,ER. �t
d. TOP'T p CASING IS FT.Above Land Surface'require
� p 1 'n (),11 I 'A
'Top of casing terminated at/or bHow land surface may require ten- �.0-0- ,�A.�. '/'
a variance in aaardance With 1SA NCAC 2C.01 118. /I q SIGNATURE OF CERTIFIED W ELL CONTRACTOR DA E
a. YIELD(gpm): 313 METHOD OF TEST T`t G� r` �tom" (p I)-L kE N AS jA
PRINTED NAME OF:PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
;! 236
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext$68. i t0 C Form GW-1a
LuJ� Rev.7105
=.ram-

V f ! !I
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CON]FACT VI DUAL)NAM (print) ��[[ RI• I'tt Qll�? �p ATION —Z(k
WELL CONTRACTOR COMPANY NAME�R'ahy11/kn/ Well D!l/l/,wq PHONEI# CAD
STATE WELL CONSTRUCTION PERMIT#
(ifalicable) ASSOCIATED WQ PERMIT#
(ifa licable)
I. WELL USE(Check Applicable Box): Residential Municipal/Public O Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2. WELL LOCAT 0
Nearest Town: ( h County �$�l�y topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
�L7/J T ,t �(itpde,/longitp fwe IgcatioJy„ C a
3. OWNER: ��/ICIU E J�1 IV 1{�(p IOYj p�' C.� tr0
Address I- �o� (degrees/minutes/seconds)
s.4.1 Latitude/longitude source:OGPSOTopographic map
($trees or Route No..�� l� � (check box)
DEPTH City or Town State DRILLING LOG
Zip Code From TO( )_ Formation Description
Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑TNO CY
7. STATIC WATER LEVEL Below Top of Casing: La_ FT.
(Use`+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface*
*Top creasing terminated allor below land surface requires a
variance in accord a with 15A NCAC 2C.0l I8.
9. YIELD(gpm):_ MgT OF TEST�f.�.Q / (/
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
FromDept Diameter or Weight/Ft. Material numbers and common road names.
To Ft.
From To Ft.
rs
From To Ft.
13. GROUT: Depth Mate 'a Method
From To Ft
-tbu� o
From Tc F[ 1 ht -�t
14. SCREEN: Depth Diameter Slot Size Materi I tT
From To Ft. in. in.
From To Ft in. in.
CD `.
15. SAND/GRAVEL PACK:
Depth Size Material "-
From To FL
From - To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT TF)S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRU ]ON STANDARD :/AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE L OWNER
llt�j E/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

l _
WELL CONSTRUCTION RECORD 1V
North Carolina - Department of Environment and Natural Reso Ire ss- 4tGv)sion of Water Quality-Groundwater Secti n
WELL CONTRACTOR(INDIVIDUAL)NA E (print)&WVe'/. al J //��
WELL CONI RACfOR COMPANY NAMEJWN RC61 CERTIFICATION AL
-- I I I IUe'f PHONE # 0.\K-w-LO<,OI 'r
S"rATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifa licable)
(ifa licable)
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 LOCATION-
Nearest
Nearest Town: I Count r i{ 0 ographic/Land setting
Idge ❑Slope ❑Valley ❑Flat
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cade) (check appropriate box)
3ti�ud 1 gityy)a gf w II anon
3. OWNER: 7�}7vly 'V `t'"{(G �E✓, e2.I�J�J
Address ` K (degrees/minutes/seconds)
Latitude/longitude source:OGPS OTopographic map
l l��� et or T�o.) (check box)
f—Vh- 3 DEPTH DRILLING LOG
Gty-, I own State Zip Code From TO
(_)_ Formation Description
Area code-Phone numb
4. DATE DRILLEDe) _ i
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:LOD FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS_�_FT.Above Land Surface'
*Top of casing terminated at/or belo land surface requires a
variance i w n accord nh 15A NCAC 2C.0118.
9. YIELD (ZON �� THOU OF S sR'(•�ON�c
10. WATER ZONES(depth): o
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
p Diameter or Weight/Ft. Material numbers and common road names.
From et To -
FL
From To FL
From To Ft.
13. GROUT: Depth M"Q (o etho1From To F s(From To Ft 0
C
14. SCREEN: Depth Diameter Slot Size Materia -
From To Ft. in. in. aT
From To Ft. in. in. O
Ji
15. SAND/GRAVEL PACK-
From Size Material
De 'a
p
From To FL -=3
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STA)4DAPPS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/< / o�
SI URE OF PERSON CONSTRUCTING THE.WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,INC
27699-1636 Phone No.[phone],within 30 days. /J _ - GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD � 6 3
North Carolina Department of Environment and Natural Resources-Division of Wate
r Quality
-- WELL CONTRACTOR CERTIFICATION q
1.WELL CONTRACTOR-
I. DISINFECTION:Typ C Amount Z/ A4 r
g. WATER ZONES(depth):
Il Contractor Individual)Name 'From ZbD To
ALt / /� From To
-
From L7 �l ` , From 7No To From To
Well onVactw CompanyrYyyName /—� Jam— Fri To
J/3l .Ew [ i� ]EiZ From-To-
STREET
ADDRESS � ,O(/, 6. CASING:
�tp�y D Depth
Diameter Weight Material
a1/3 From To1/0_FL L./Zf" fJ�Z/ L
Ctty or Tvwn Stale Zip Code From To Ft. _
CXR > to From To Ft.
Area code- Phone number
7..WELL INFORMATION- ,,// 7. GROUT: Depth Material Method
SlTE WELL IDOf applicable)_ N FromiTo' X0 Ft. CoAcr% 'nQU,,; a
From Tp Ft. ]`"`-�`�
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT Nif applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box) Residential Water Supply 21/ From To FL - in. _ in.
DATE DRILLED
From To Ft_in. _ in.
I�"/s�-O� From To Ft_in. in.,
TIME COMPLETED 2 AM❑ PM 1?1
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
/
CITY: 'j 14111 COUNTY/Oc, FITCT Tc Ft.
From To Ft.
C4f0� t �r From To Ft.
(Street Name,Numbers, ommunny.Subdlmsron,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC I LAND SETTING:
gJlope ElVall 10.DRILLING LOG
ey ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate boz) _ P
LATITUDE 3 May be in degrees, (7
Zr7' minutes,seconds or %0/' -Wa
LONGITUDE L ?d, 7S)• in a decimal format //0- UGr _&­k
Latitude/longitude source: E4PS ❑Topographic map
(location of we0 must be shown on a USGS fopo map and
allached to this form Anot using GPS) ---i----
4.WELL OWNER
OWNER'S NAME yJ TQir�rS
I
ST.. ET ADDRESS �IvID �- �' - J�i,•ng �/� —41L' -
33�� ; I
f'fa r fd s v1/e 11W a 74 9
Clry w Tovn State Zip Code r
L2.)- (RaU- a16053
Area code- Phone number -
S.WELL DETAILS: `/ 11. REMARKS:
a. TOTAL DEPTH: b/'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO/
C. WATER LEVEL Blow Top of Casing: ro I DD HEREBY CERTIFY T T THIS WELL WAS CONSTRUCTED IN ACCORDANCE W"
FT. 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS
(Use"-'if Above Top of Casing) RECORD NAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS�_FT Abe Land Surface* ­0�
"Top of casing terminated at/w below land surface may require rl/ /Y-fly-
a variance in acc�o7rdanm with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): J METHOD OF TEST r - I q
J RIMED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days" Attn:Information Mgt,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. -- Fwm GW-la
Rev.7/05

D 320494
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and a Resoure Divis' n of Water Quality-Groundwater Section 1
WELL CONTRACTOR(INDIVIDUAL)NAM�Ev (�prloq -r- ^/�� CEirrMCATION#
WELL CONTRACTOR COMPANYNAMB.X11 WA-Tw �( Dp:11;09 PHONE # jk@ N$O
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if alntlicable)
1. WELL USE(Check Applicable Box):Residential Z"I'Municipa"ublic❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: / opoVVhiamd setting
Nearest Town:/6//•'/NSN-&// County, r/ 'le aeui BRidge
-705 zld&z�f/ _?$'7E3 ( °pp Vbe)} Mat
(Street Nam4 NnmbcM Community,Subdivision,Lot No.,zip code) Latitude longitude of well location
3. OWNER: A /I'tC (depece-Matedsocands)
Address /306 /'A/'/P A"&V /0 Latitudellongitude source:❑GPS❑Topographic map
// (Streetm Route No.) (chock)wx)
/nN�Y/la
JV e- �? 7 5_3 DEPTH DRILLING LOG
City or To" State Zip Code From To Formation Description
Am code-Phone manber
4. DATE DRILLED /V 0.5
5. TOTAL DEPTH: 204`
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:
(Use-+-if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface"
•Top of casing tetmiaated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0IIL
9. YIELD(gpm): �Z METHOD OF TEST /i,;tare
10.WATER ZONES(depth):
LOCATION SKETCH
11, DISINFECTION:Type C Amount le a t Show direction and distance in miles from at least
12. CASING: Wall Thicimess two State Roads or County Roads.Include the road
Depth Di or WeighNFt Material nuupbers
cotamon road dames.
From__To� b/76 Ft� - 5'0'e z( Ell C-
From To Ft •��.
From To Ft
13. GROUT: Depth r Ti
Material M hod
Frorn_�Tp_W _Fk Cf; '
From To _ Ft. 4'
14. SCREEN: Depth Diameter Slot Sim Material p CD
From_To Ft. in. in. Cn _
From _ To _ Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From-4--�To Ft.
From To Ft,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C,WELL c- _
CONS CfION STANDARDS, T A 'OPY OF RECORD HAS BEEN PROVmEB TO THE WELL OWNER
SIGNATURE OF PEI))ON CONSTRUCTING THE WELL ' DATE -
c
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 j

320493
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and R^esourc lDivis' n of Water�QJng(ity-Groundwater Sectioon��' /
WELL CONTRACTOR(INDrVIDUAL)NAME (print // /l/Q�CS ,y�['1 CERTINICATION S G/ ()J
WELL CONTRACTOR COMPANY NAM W6 TIC [ &-J�1 J P:i I r A O PHONE 0 (�it$�p��ONItO
STATE WELL CONSTRUCTION PERMTI'0 ASSOCIATED WQ PRRMrra
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential 01"Municipal/Pubiic O Industrial❑ Agricultural O
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopognTitic/Land setting
Nearest
�[�.//County ✓YO/L) ❑Ridge CRSlope OValley ❑Flat
1,1C g�' LO yY 2 g 9S3 (chests appropriate box)
(Street Name,Nuu/mber,Community,Subdivision,Lot No,zip Code) Latitude/longitude of well location
3. OWNER: 'h '0*' S (deveadminuts0secmds)
Address 3$0 rove W LatitudcAongitude source:❑GPSOTopographic map
yA �uxt or Route No.) (chak boa)
'Le[ / l tI G 2?75`3 DEPTH DRILLING LOG
City or Town State zip Code From TO Formation Descriptioq
(---)-
Area code-Phone number _
4. DATE DRILLED,, C C) -d9
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO C3�
7. STATIC WATER LEVEL Below Top of Casing: 3e F,
�� (Use"+"if Above Top of Casing)
8. TOP OF CASING IS 1FT.Above Land Surface"
-Top of wine termtonted actor below Ind surface requires a
vatiana to aecerdance with 1SA NCAC 2C.0115.
9. YIELD(Spin):_ /�_METHOD OF TEST
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type Amount le a Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
To 60 Diameter �5" �LtIFt� numbers and common road names.
From-0—To Ft fo%y r?
Front_____,_To Ft c
s
From To Ft o�
13. GROUT: Depth Material
Frorg,_&To_�QFt�gp M a++i' -a cn
ut
From To Ft
14. SCREEN: Depth Diameter Slot Sim Material - -;
From To Ft in. in
From To Ft in. is
15. SAND/GRAVEL PACK:
Depth Size Material
From__41—To Ft.
From Ti Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTP
( JCITON STANDARDS,AND T A CpPY OF THHII RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSORCONSTRUCTING 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

WELLCV1Na1KUCTTUY RECORD
320544
North Carolina.Deparnnent Environment and Natural Resources-Division.of`Water Quality-Ground meter Sectioc
WELL CONTRACTOR(1`7D1v1 L?N,4YiE (print) 'l�. @.�CCk H �Ca't.J�t e c S t".ERTIItICAflON N oZy�Io
T—
WELL CONTRACTOR COMPA, _NAME 'j��Cs�- S-��' -'"'� I�i i� _.Pttove a y� io{os-atsr
STATE WELL CONSTRUCTION. RKITR ASSOCIATED'AWQ PMNUTa .
(if applicable) (ira licabte
1. WELL USE(Check Appli b1e Box): Residential El Municipatlpublic CI Industrial ❑ ASricultnrai 17
Monitonrig 13 Recovetj< Heat pump Water injection❑ Other El If Other,List Use
2. WELL LOCATION: Topogr phic/Land setting
NearostToan; 4'S4/l County 4iS L7Ridgc { opt OValley OFiat
(chec'c a,pmpriatc box)
(Stet Noma,Nombv,Commu�ty,Subbdi-,isinq Lot No.,ZIP Code) - Latitude(lorigtradd of well location
3. OWNER: A4.
'"t-�' e �t( - (degree&r,iwtes•'sxotMs}
Address as P\c two clvec�y e Latitndelongitude�otsce:[3GPS0Topogfaphic map
(Street or Rbbte No.) —_ (cn;cx box)
aaQcv¢c�:�Vp A C , I)S,I;L_LINGLOG
Or/or Town State zip Code F(om - o Formation De8en hon
C t,�y$ lysu\
AM coda Phone number
d. DATE DRILLED 6- 3 1' _ o S _ e� -<.k
5. TOTALDEPTH: o -
6. DOES WELL REPLACE I XISTrNG WELL? YES❑ NO tY rt
i. STATIC WATER LEVEL Blow Top of Casing: S�—kT
(Um if Abovc Top of Cesiag) M
S. TOP OF CASING IS FT. Above Land Surface*
•Top of easing terminated ao'o Setaw tend sorface requires 4 r
variancela aceord*ncewith l NCAC 2C.0118.
9. YIELD(gpm): ETHOD OF TEST__�Q _ _ -�
10.WATER ZONES(depth); LOCAT&V SKETCH
Amount /S Show direction and distance in miles from at]east
I I. DISIFIFECTION:Type___ - two State Roads or Cavity Roads.Include the road
12_ CASING: {g Wa.iThickness
Depth - t Diamalef or Weightrft. Ma erisl- n bens and commo'i read names.
From_To 3 g [. _ �_- Tp_4ff_ `C
From To t. S�� o
From To k Ee�
13. GROUT: Depth Material Method / $Mpg
From__`—To 2 CI
From To - _fit•
14. SCREEN: Depth I Diameter Slot Size Material
From To t. in. m.
From- Tot.__Jn• in. �• . ((
15, SAND/GRAVEL PACK:
Depth Size Matcrial
Frotrl,, _ Te Ft—
Front To F't. --
16. REMARKS:
I DO HEREBY CERTIFY TF.AT�tI S WELL WAS CONSTRUt T£D IN ACCORDANCE WITH t SA T CAC 3C,WELL
CONSTRUCTION STANDARD AND TFATI&COFY 0£THIS RECORD HAS BEEN PROVIDED 70 THE WELL OWNER
� .��_ y(1-3l-s
-
IGNATURE OE (taON CONSTR4CTING T.R WELL DATE
Submit the original to the DJ sion of Rater Quality,Groundwater Section, 1636 Mail Set ,e Center
t Raleigh,N l0l
27699-1636 Phone No.(919)733 222,within 30 days,
r
l
s

`t„a 5TA]Fo
RESIDENTIAL WELL CONSTRUCTION RECORD 320628
.` � North Carolina Department of Environment and Natural Resources-Division2 O of Quality
`N WELL CONTRACTOR CERTIFICATION Al
1.WELL CONTRACTOR: f. DISINFECTION:Type D
YP Amount t 2 O -
R y D>G C A LIJ w V-1-\ _ g. WATER ZONES(depth):
Well Contractor(Individual)Name From ) (a 3 To ) 6 From p To
1\b U�C,N C1\I.QW� �-L YJILL.)Al Gj NC.. From To
yL From To
Well Contractor Compa7ny Name From To
STREET ADDRESS 3S ++ From To
n f �a(.0 L0I GESSI('R. fvi-+// 6. CASING: Thickness/
Depth Diameter Weight Mae al
From_To Ft. In s, -Vol �}
� �Clly or Town State ZG p ` Zip Code From To__Ft. _
Lfam} �X� _ JO 1_ From To_Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) From j To3-a FL C414JQATf vrvs b1
From To Ft.
STATE WELL PERMITC9 applicable) From To Ft.
DWQor OTHER PERMIT#(Napplicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable B ): Residential Water Suppty❑ From To__Ft._in. __ in.
DATE DRILLED 1 \ 1 O s Front To__Ft.__in. _ in.
From To_Ft. in. _ in.
TIME COMPLETED 11 '• 3 qM�pM0
9. SAND/GRAVEL PACK:
3.WELL LOCATION: \ Depth Size Material
I \CITY: AkS '4 1"N COUNTY r'n A Di a JJ From To_Ft.
AIL p � From To Ft.
- 1-' A11 From To_Ft.
(Street Nama,Numberc,Community,Subtlmsion,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To
(check appropriate box) / Ci
/ Fo/{mation Description`
LATITUDE 3 — May Ix:i�
In -minute / — 163/ G (L"A J t-r
LONGITUDE ina de (omuit (�- /`" b C- �1Lo s I rT1
Latitude/longitude source: OGPS OTopographic map
(location of we#must be shown on a USGS topo map and
attached to this form#not using GPS) rY
4.WELL OWNER // [] rT1
OWNER'S NAME o l' V(L-(f✓
STRWT ADDRESS 1 Q 17 C A RL-0I-M )Iw` �.
City or Town State Zip Code
(S k(L lq`6 - 9 ©c)3
Area code.-Phone number
S.WELL DETAILS:
11. REAIARKS:
a. TOTAL DEPTH:__ 5 b 5'
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOV
C. WATER LEVEL Below Top of Casing: `1 FT I DO HEREBY CERTIFY TRATDIIS WELL WAS CONSTRUCTED N ACCORDANCE WrIR
1SA NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF mIS
(Use- -AAbove Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELLOWNER.
d �/
. TOP CASING IS /1 FT.Above Land Surface' ` �'" ^l',xX I c2D bS
'Topp of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC ZC.01118. qq /1 SIGNATURE OF CERTIFIED WELL CONTRACTOR D E
e. YIELD(gpm): 4- _METHOD OF TEST - A ) 1 � ) L-I-) I& V-3 A 3 0
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt.,
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form GW-1a
Rev.7/05

�=V
RESIDENTIAL WELL CONSTRUCTION RECORD J LMI5 q 9 rl (3
North Carolina Department of Environment and Natural Resources-Division of Water Quality V�-f 1
•@`"" WELL CONTRACTOR CERTIFICATION#' is %Allk*
1.WELL CONTRACTOR: _. f. DISINFECTION:Type O:iT . Amount
dd g. WATER ZONES(depth):
�@ CC'LIrC �e0�ti+ s] �'t QCS
WNI Contracts(Individual)Name T— From To From_,_,To
Oil Lit y-,� From To From__To
Well orthactorC m(Name from To From__To
G. CASING: Thickness/
STREET ADDRESS t"iQ$$ Y-!1 Q05 Depth Diameter Wegt!( 1�lpted�l
y.� From
To �Ft. [ Y %ilb/i14
�: Tc Ft.
CityaT State 'Zip Code Fmm
From To Ft.
c a8)- ".S-QOZL
Area code- Phone number 7. GROUT: Depth Material Method
2,WELL INFORMATION: From-0 To ?U Ft. C-C�— O-Lk
SITE WELL ID#(it applicable) From To Ft. —
From To Fl. _
STATE WELL PERMIT#fd applicable)
DWQ or OTHER PERMIT#0f applicable) 8. SCREEN: Depth Diameter :M Sae Material
Prom To Ft._in. _ in.
WELL USE(Check Applicable B�o+x): Residential Water SuPPIy From To Ft. in.
DATE DRILLED I Q- I9^,] From To Ft —in. -_in.
TIME COMPLETED AMO PM O 9, SAND/GRAVEL PACK:
Depth Size Material
3.WELL LOCATION: p To Ft _
CITY: 1N'��.f,<In& - COUNTY r O From To FL
}luY (03 .2%'?SS From To FL
(Stall Name.Numbers.OorRmuRrry.Subdmaon,tin No..Parcel.Z,p Code)
T OGRAPHIC/LAND SETTING: 10.DRILLING LOG
TO
❑Flat ❑Ridge ❑Other
From To Formation Description
(cheek appropriate box) }I
May be in degrees.
LATITUDE 3 minutes,seconds or
in a decimal format
LONGITUDE_ —
Latitude/(ongitude sontce: ❑GPS OTopographic map
(location of wail must be shown on a USGS tope,map and
attached to this form snot usatg GPS)
6,WELL OWNER r'7
OWNER'S NAME 0) C..SV C %0-1)
STREETADDRESS t"t� Hi
City a Town State Zip Code ----Zj
Is 9?0 osr,5
Area code- Phone number 11. REMARKS:
5.WELL DETAILS: IpS
a- TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 6Y
100 HEREBY DER TffY THAT THIS WELL WAS CON:IRUCTED NACCOROAN Wm`c..WATERLEVELBelowTopofCasing: ICI FT. 1sANCAC2C.WELL CONsMUCTIONSTANDARDSANOTHATACOPrOFTHS
RECORD BEEN PROVIDED TO THE WELL 0"IER.
(Use'+•if Above Top of Casing)
d. TOP OF CASING IS FT.Above Lena surlaW DATE
_ +Top of casing terminated aUor below land surtace may inquire SIGNATURE OF CERTIFIEDL COh TRACTOR
a Variance in accordance with 15A NCAC 20.011S.
e. YIELD Opm): IJ METHOD OF TEST PRINTED NAME OF PERSON CONSTR 7CTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW-1a
1617 Mail Service Center—Raleigh,NC 276994617 Phone No.(919)733-701 5 eXt 568. j J [; Rev.7ro5

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section�
WELL CONTRACTOR(INDIVIDUAL)NAM (print) B R fl-ly . ( (j I mes CERTIFICATION AkQ
WELL CONTRACTOR COMPANY NArVIE7&kQ A6N s IAJE// zald 4p j LLC. PHONE A2 ��85<91.L
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) —/ (ifapplicable)
I. WELL USE(Check Applicable Box):Residential Rr Municipal/Public ❑ Industrial ❑ Agricultural ❑ -
Monitoring ❑ Recovery ❑ Heat Pump Water Injection Cl Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Ne�aarrersETown: County^ ❑Ridge ❑Slope 2Galley ❑Flat
/"�O.pn�jfr r„en (check appropriate box)
(Speer Name,Numbers,Communiry,Subdivision,Lot No.,Zip Code) La i[ude/longitude of well location
3. OWNER:_ _ s bS (degrees/minutes/secands)
Address 1 L S A.f�Ur. Latitude/longitude source:3 PS❑Topographic map
(check box)
DEPTH DRILLING LOG
Ciry or Town Smte zip Code ' From To Formation Description
&$ -$- Ins 9- 5 11 �; v -,71 'Ov-. t
Area code-Phune number 37- 7 f' f<<//
4. DATEDRILLED 2- 2-Os- /4/r- �yc
5. TOTAL DEPTH: /y,
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:AFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
"Top of casing rerminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.01 IS.
9. YIELD (gpm):J0 METHOD OF VEST��[J
10.WATER ZONES (depth):_ i �0 Ala
LOCATION SKETCH
11. DISINFECTION:Type Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.htclude the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft. ./Oa 'W'frw .�.UGN�(�•
From To Ft. - 5 N
From To Ft.
13. GROUT: Depth Material ��,,�Mnet�h�,o,d,� 'y l��$ i� t `-•
From_To Q_Ft. /rC E E \ rO
From To Ft. rnt..�
14. SCREEN: Depth Diameter Slot Size Material i
From To Ft. in. in. t.n
From To Ft. in. in. O
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONST UCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSGN:COL�STRUG'FIN&.7'IIE.]YL4 DATE
Submit the original to the Division of Water Quality,Groundwater Set.tfon;' 1061VIai1 Serviee Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. ! GW-1 REV.07/2001

WELL CONSTRUCTION RECORD '
North Carolina- Department of Environment anciVa4tirid Resources-Divisigq of Water Quality-Groundwater Section
WELL CONTRACTOR COMPADUAL)NY
NAME (print) ) _ CERTIFICATION#4W 00
WELL CONTRACTOR COMPANY NAME tEk�ut: 1S 1 fI ONd I pyLLC- PHONE0=959- IL
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
01111111111111111111 (if applicablel
(if applicable)
I. WELL USE(Check Applicable Box):Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
/ graphic/Land setting
Nearest Town: ct � County% `C,r / / C29idge ❑Slope ❑Valley ❑Flat
Ale,&d4ct r tr(.{ (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) r
Latitude/longitude of wel'h�oc��ation (�
3. OWNER: JZ,f gl �t H, ��.. ryz (degreeslminu�[ �ds)
Address Latitude/longitude source:t76PS❑Topographic map
(Street or Route No.) (check box)
c-CtlAiv&,T nd 1✓r :2 k77? DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
&1- !ate- 73ar7 -as D;`�
Area code-Phone number
4. DATE DRILLED / S we
5. TOTAL DEPTH: I405 - - Mr
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er 3!6 I yds lie
7. STATIC WATER LEVEL Below Top of Casing: 02A FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT. Above Land Surface'
'Top of casing terminated at/or balmy land surface requires a
variance in accordance with 15A NCAC IC.0118.
9. YIELD(gpm):_-�_METHOD OF TEST (yv:Na-�i'a
10.WATER ZONES (depth): /�/ r d J
��� LOCATION SKETCH
11. DISINFECTION:Type '� t Amount---1-6-t8 a-= Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or.. Wei ht/Ft. Material numbers and common road names.
From_To 3 5- FZo S_ 2-16r C S' ,ZZ/ �/�
From To Ft. /��`(�QADW `7 LU�/6i /"�P,,// �l!_-
From To Ft. ! A 13. GROUT: Depth Material Method ,n/( pkt� .`�'N L
. From.._0 To .Q Ft.l
From To Ft. c i
14. SCREEN: Depth Diameter Slot Size Material t
From To
Ft. in, in.
From To Ft. in. in, 0 ."
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL )
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND AT A COPY OF THISMOAS BEEN PROVIDED TO TTH/E' WELL OWNER
SIG ATU,,M OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Ser0ce Center-Raleigh,NC
27699-1636 Phone No.[phone], within 30 days. rF GW-1 REV.07/2001

WELL CONSTRUCTION RECORD - '
Nonh Carolina- Department of Environment and ral Resources-Divisigal of Water Quality-Groundwater Section �� ('�WELL CONTRACTOR(INDIVIDUAL)NAME-^-(purmt) eQg CERTIFICATION p�� (T
WELL CONTRACTOR COMPANY NAME� D I ) , LLt'_ PHONE 0=,Q5�'STI�
STATE"'ELL CONSTRUCTION PERMIT# J ASSOCIATED WQ PERMIT#
(ifapplicablel (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:
``// y 4_J r. _ �pograppe Land setting
Nearest Town: �nr�GfTC/` Count r Idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: Uj9/v C'r, VSs'
�� / (degrees/at, u_[es/ ands)
Address �,S/d r n/ „% Latitude/longitude source:l3GPS❑Topographic map
(Sucee onr Rome No.) (check box)
✓4 ✓ C .--) q 7 n 1' DEPTH DRILLING LOG
City or Town Stare Zip Code From To Formation Description
US)_ -3_L`�S� 7 o -yy
Atea code-Phone number
#. DATE DRILLED CAA,K ✓ )r�'.
5. TOTAL DEPTH: 'T5yz
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ir
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surtace*
*Top of casing terminated atlor below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(um): 3 _METHOD OF TESTq
10.WATER ZONES (depth): //p'-- /fib — 1(� J
LOCATION SKETCH
11. DISINFECTION:Type C'h lb /11#4 Amount �� 2 Show direction and distance in miles from at least
t2. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_I To S1 Ft. 6Jr 7 2/Lfe- aAj Sf/ /
' From—To—Ft.
From To Ft. JJ
13. GROUT: Depth Material er;a1 - Method 416=7 /Vc
m From_To�,�FL-( t7fi �€
Front To Ft. Q 1 -f S��/n19S
14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. -
From To Ft. in. in. t'rt 1.
15. SAND/GRAVEL PACK: n
1 -
Depth Size Material cll
From To Ft.
From To Ft. P- �
16. REMARKS: '3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THA C ,COPY OF THIS RECOQ.B,14 N PROVIDED TO THE WELL OWNER
SIGNATUfFE gle PERSON CONSTItUCTING THE WELL 7bPOE
Submit the original to the Division of Water Quality,,Grounidwater.section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.. ' GW-I REV.07/2001
q - �

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and ral Resources-Divisi of Water Quality-Groundwater Section ��
WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION#ANII0(�
WELL CONTRACTOR COMPANY NAME ts�,(,CON 1C Ldill all/dt p4� LL/'_ PHONE¢(, A5 S?-S�{4tL
STATE WELL CONSTRUCTION PERMIT# - ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑ -
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: ographic/Land setting
Nearest Town: (^5 t County )�✓ idge ❑Slope ❑Valley ❑Flat
G s N C. (check appropriate box)
(Suaet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/lon 'rude of we l locatiop
J� / i/ W 3.3_ 2 WS,sbs
3. OWNER: C/r=,g��Q I/�- (degreesrmirmt, onds)
Address W/ O jli'/� . Id Latitude/longitude source: PS❑Topographicmap
//� � (Sueer or Rou a No.) (check box)
(.t ,e_o/,J 33:75 DEPTH DRILLINGLOG
City or Ton State Zip Code From To Formation Description
Area code-Phone number _ q j s N P
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLAC XISTING WELL? YES ❑ NO 12f�
7. STATIC WATER LEVEL Below Top of Casing: fqL1 FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface*
"Top of casing terminated aVor below land surface requires a
variance in accordan ewith 15A NCAC?C.6118. p�"� ,
9. YIELD(gpm): t 7- METHOD OF TEST�I:d
10.WATER ZONES (depth): t%78 ' JJ JJ
LOCATION SKETCH
11. DISINFECTION:Type e Amount JLe 2 Show direction and distance in miles from at least
t2. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road nes.
From_To__ ad__Ft. b r73' 2.((o�/ltS �(IC f 0,9 jx( /�,,/
From-To-Ft.- "J3 C��Ly f f�� rN(2 /Pa ,
From To Ft. 11
13. GROUT: Dzpdt Material - Method
From
_D_To-4q_Q_Ft.
From To Ft. 1-rt
14. SCREEN: Depth Diameter Slot Size Material e"I
1
From To Ft. in. in. Ln
From To Ft. in. in. _
15. SAND/GRAVEL PACK: C=)o
Depth Size Material
From To FL k
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,ANQ THAT A COPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
5/3n%rs
SIGNATURE �o�STRUCTING THE WELL D E -
Submit the original to the Division of Water Quality,Groundwater Section,�'1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. ` GW-1 REV.07/2001 ._

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment ands ral Resources-Divisip of water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) P 6 b t I 1A �t 0
CERTIFICATION#, UO{d
WELL CONTRACTOR COMPANY NAh1E ��v��
PHONE SfddOi�s Q-
STATE WELL CONSTRUCTION PERMIT#
(ifapplicable) ASSOCIATED WQ PERMIT#
(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 To wn: '�I?��County /SQ,v TOP°gr1C/Land setting
r � p ❑Ridge Slp ope ❑Valley ❑Flat
r✓'%tC .^{Icy iP
(Suee[Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
� Latitude/longiNde of yell location
3. OWNER: > wd d !eS C 1 Z '/'.$*y'
Address (degmes/minye slteconds)
SAD!/J Latitude/longitude source: GPS❑Topographic map J (Snee[or Route/p1�.j
J z"VAS (check box)
City or Tow 9m[e DEPTH DRILLING LOG
Zip code Formation Description
( _� ��/� From /�Area code-Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 51 �SA S �� , ,Xe
7. STATIC WATER LEVEL Below Top of Casing:_4,12 _FT.
(Use--+'if Above Top of Casing)
S. TOP OF CASING IS_L_FT.Above Land Surface*
*Tap of'casing terminated atior below land surface requires a
variance in accordan with BA NCAC 2C.01 IS. �rnn�/ !�9. YIELD("pm):
_METHOD OF TEST , �-
10. WATER ZONES(depth):_ 2rp
11. DISINFECTION:T e ' tie LOCATION SKETCH
YP Amount_ /�n z- Show direction and distance in miles from at least
l2. CASING Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. M- aterial /numb
Fro ers and common road names.
m—To .3(� Ft--�. .� �./�./. 5 Z
- From To Ft. -
From To / /D/q,.tf �(Sev62e'
Ft. /"/GN� t✓
13. GROUT: Depth Material t
From Method / __�To _Ft. ASS/'Pr�� /�/r C'" _
From To R
14. SCREEN: Depth P Diameter Slot Size Material r"I
From To FL__in. in. n
From To t
Ft._in. -
15. SAND/GRAVEL PACK
Depth � '
From Size Material 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 STANDARDS,AND THAT COPY1OF THIS ORD EEN PROVIDED TO THE WELL OWNER
SIG, A. PERSON C� TRUCTING THE WELL *' d S
DATE
Submit the original to the Division of Water Quality,Groundwater Se_ctipn, ;1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. -
GW-I REV.07/2001

C, � ,
WELL CONSTRUCTION RECORD
Notch Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAMZ�P,(print) ,�
WELL CONTRACTOR COMPANY NAME/�R�I//_��s of[ /�F/ awd -Alm,j LLG PHONEIF[C�ATI^`17e,1��'
STATE WELL CONSTRUCTION PERMITk Y akJA`�
(if applicable)
ASSOCIATED WQ pERMITN
(if applicable)
1. WELL USE(Check Applicable Box):Residential 13'Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
Nearest Town* /�%/ Topographic/Land setting
�' County d/�/.ro-, EIMdge []Slope ❑Valley ❑Flat
/� r^
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box)
L itude/longimde of well location
3. OWNER: C�iccc � £�d@ cc53f� 67-'t
Address r(, �n t! %q�`� (degmes/minutes/seconds)
Latitude/longitude source:EI -PS❑Topographic map
(S eet or Route No.) (check box)
k..UC/UY/�'� �C Or7 DEPTH DRILLING LOG
Ciryor Town / State Zip dl0/� 7
From To Formation Description
�)-- fo P
Area code-Phone number
4. DATE DRILLED (c - ZY-Of' 9a sf Sli��
5. TOTAL DEPTH: S'C 5' rr' r;i iw.-la
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CJ
7. STATIC WATER LEVEL Below Top of Casing: (0d FT
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS-�_FT.Above Land Surface*
-Top of casing terminated aver below land surface requires a
variance in accordance with IS.A NCAC 2C.0118.9. YIELD(gpm): I 'YE METHOD OF TEST_&W ff
10.WATER ZONES(depth): o
LOCATION SKETCH
I1. DISINFECTION:TypeClO--e Amount 2 L fzCt Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth gqiameter or Weight/Ft. Material numbers and common road names.
From To r+T Ft. G,/ / f,(JdZf /�✓G
From
To FL �% �Li`� —
From To FL o --
13. GROUT: Depth Material Method {�y�/�� `' � ' m
From�_To Q_Ft. /YC E e '4i r�fT,•„ra /'t I Z
From To Ft. �`�-`-�- t11
14. SCREEN. Depth Diameter Slot Size Material
From To Ft._in, in 0
From To Ft._in. In. --
15. SAND/GRAVEL PACK: 1
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 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
2 9
i

WELL CONSTRUCTION RECORD -
North Carolina-Department of Environment and Natural Resources-Division of Water uali
WELL CONTRACTOR(INDIVIDUAL)NAM ` Q ty-Groundwater Section
(print) 2
WELL CONTRACTOR COMPANY NAME E t CERTIFICATION f�_-
STATE WELL CONSTRUCTION PERMIT# QN L�G PHONE dj*
(if applicable) ASSOCIATED WQ PERMIT#
(ifa licable)
I. WELL USE(Check Applicable Box):Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION:
NearestTown:�r- J a� CountyL�7c�/��� Topographic/Land setting
ea«..f� [^vine, < 0Mdge ❑Slope []Valley ❑Flat
lon t N m ,Numbers,Commumry,Subdwision,Lot No.,Zip Code) (check appropriate box)
Latitt�de/lon giitude o Zell location ,
3. OWNER: p/3!" `/f'(J1 7✓t)Y2°y2 5-07
Address L t (degrees/minutes/seconds)
(street or Roule No.) Latitude/longitude source:13'GPS❑Topographic map
DEPTH (check box)
Clry or Town State ZipaBde DRILLING LOG
5 a (_ O�— From To Formation Description
Area code-Phone number ��� :f
4. DATE DRILLED�G�'
5. TOTAL DEPTH: --
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ere
7. STATIC WATER LEVEL Below Top of Casing: 8'49 FT.
8. TOP OF CASING IS (use"+"if Above Top of Casing) ------
FT.Above Land Surface"
`Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118. ---
9. YIELD(gpm):�_METHOD OF TEST ��tJ
10.WATER ZONES(depth): 0-0' _Ala'
11. DISINFECTION:Type C1, �� LOCATION N S__ KETCH
12. CASING: Amount��',t t Show direction and distance in miles from at leas[
two State
or
P Diameter orlWeigh Weight/Ft. Material numbers and common roadro d untynames Include the road
From
Depth m To &wt Ft Zr tyr?/ /�✓C
From To Ft. /'
From To Ft. �pttv�-f�Czave-I-� -
13. GROUT: Depth Material
m Fro Method p
—CL_To��Ft. /✓C EE ryq Ir,/M �CS�P61, KC- ,
From To Ft. -7- 1 t \
REEN
14. SC : De th [
P Diameter Slot Size Material cri
From To Ft. in.
Froth To in. p
Ft. in. in. cn -
I5. SAND/GRAVEL-TACK.
Depth Size Material
From To Ft
From - To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER D
71
SIGNATURE OF PERSON CONSTRUCTING THE WELL Or
TE
Submit the original to the Division of Water Quality, DA
Groundwater Section, 1636Mai1 Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days.
- GW-I REV.07/2001
2 i

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and
WELL CONTRACTOR(INDIVIDUAL)NgrylE Natural Resources-Divisi of Water Quality-Groundwater Section
(print)
WELL CONTRACTOR COMPANY NAME CERTIFICATION#4& P
6
STATE WELL CONSTRUCTION PERMIT# ivd I 14A 11 PHONE
61 applicable) ASSOCIATED WQ PERMIT#
Iiiiiiiis� (ifa plicable)
I. WELL USE(Check Applicable Sox):Residential L3�MUnicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
?. WELL LOCATION:
Nearesstt Town: 4�4/5`(ql� County gt Topogr Ic/Land setting
12=c4; of/iA/C' ❑Ridge ETSlope ❑Valley CIFlat(Strec[Num 6.Numee s,Commumry,SubJinsioq Lo[No.,Zip Code) (check appropriate box)
Latitude longitude of vell local.
3. OWNER: ac%5..'„_ �a / 5 /2, 141�SZd G..(p
Address owgrees/mtn�uies�iseconds)
Latitude/longitude source:Ld6 Topographic trap
n (Street or Roue of
/Y/�9-/C �)'s•-/� /{�C__ J G7S- D (check box)
ry r row State � DEPTH DRILLING LOG
�� ` _ 9 y 2,p Code From TO
FOrmatl0 Descrip[ion
Alta code-Phone number S _
4. DATE DRILLED-__-� ('�'� — r �<v z 5. TOTAL DEPTH r
;ci /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C'l 7. STATIC WATER LEVEL Below To of Casing: - ���� C P e 1Q__—FT.
S. TOP OF CASING IS— I (use . b Above Top of Casing) -----
FT.Above Land Surface* --
'Top of casing terminated at/or be]
uw land surface requires a
variance in accordance with RSA NCAC 2C.o118. --
9. YIELD(gpm):._�_tiIETHOD OF TEST�1;Na_/2 q 10.WATER ZONES (depth):_ /7/J ' --� -J
11. DISINFECTION:Type �( � LOCATIONCH
12 CASING: - Amount Sri Show direction and distance in mites from at least
Depth Wall Thickness two State Roads or County Roads.Include the road
From P Diameter or Weight/Ft. Material numbers and common road names.
- From Ft. r S �z� p `
From To—Ft. j13i
13. GROUT: Dee pth
From,__f-__ -LD Ft mat Method
From FL _ --
W. De. SCREEN: Depth tq
P DiU
From ome[er
To FL Slot Size Material
From nt• in. C3
To Ft. 1`t
15. SAND/GRAVEL PACK: in 10' n
Depth t
Size Material From To Ul
Ft.
From To Ft. rp
t6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIT L
H RSA NCAC 2C,WEL,1tgCORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTION STANDARDS,AND THAT A COPY OF THl$
r //
S C URE OF PERSON CONSTRUCTING S
THE WELL_ _ f D E
Submit the original to the Division of Water Quality,Groundwater Section, 1636 MallService Center-Raleigh,NC
27699-1636 Phone No.[phone] Within 30 days.
GW-I REV.07/2001
i

WELL CONSTRUCTION RECORD
Nor-[h Carolina-Department of Environment and hlalairal Resources-Divisigal of Wateruali%VELLCONTIZACT (print)OR(INDIVIDUAL)NAIYIE�/'' Q Groundwater Section
, t
WELL CONTILtCTOR COMPANY NAME 1 �I/ 6Af I( �l 1'I-1 i rC CERTIFICATION#��
STATE WE•LL CONSTRUCTION PERMIT# —''f�-'/ �'�PHONE y�a5
V
l f spf�l icob lz) ASSOCIATED WQ PERMIT#
(ifa plicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
'-. WELL LOCATIOI\:
Nearest Town:_ r / Topogra Ic/Land setting
---�/ Count / S AA
12c e L �G ///r Ridge tope ❑Valley ❑Flat
(Sweet Nan",Numbers,C(mmuniry,Subdivision,Lot No.,Zip Code) P /a/ (check appropriate box)
n Latimde�ongin(de of well I catiaa
3. OWNER: / /e�yfy�1 [�/d/I r�( !u✓S� �Qrrr
Address //� j/„ (degrees/minure Dods)
•;� (Street or Roure ) AZ Latitude/longitude source: GPS❑Topographic map
rr(l Zoa 6 (check box)
Cry or Tow Stale n DEPTH DRILLING LOG
)' 770�' 7/y7 /// I Zip Code From To Formation Description
Area E D ILL number ---�� w r
5 DATE DRILLED , a%'✓.
�. TOTAL DEPTH:
ti. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 7. STATIC WATER LEVEL Below Top of Casing:--Zr/��JFT.
S. TOP OF CASING IS_ ' (Use"+"if Above Top of Casing)
"Topofcasi casing FT.Above Land Surtace* ------
terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C.0118. ---
9. YIELD(pm): 15 METHOD OF TEST210i,It
10.WATER ZONES (depth): '------
i> r
11. DISINFECTION:Type 'l /1 q/G LOCATION
1?. CASING: Amoun[ r Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads.Include the road
Depth Din serer Or Wei ht/Ft.,���Mrarer�ia�l,� numbers and common road name
From L1
From To Ft. �NL' A/ L�S-G/'Y�
13. GROUT: Depth /� Material Merhod �cS/rQ��/From To—a.J2.Ft.l 'o/t oFlc
From To FLU_ :'f
14. SCREEN: Depth Diamerer Slot size From TO Fr la _ Material O -
m. Cn
From To F[. in. n
L PACK: -15. SAND/GRAVE in. 1
S
Depth LnSize Material
From To
F[. o
From To cJ1
F[.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CONSTRUCTION STANDARDS,AND T A ISA NCAC ZC,WELL
- COPY OF THIS REQQ{tD H BEEN PROVIDED TO THE WELL OWNER
11
T17UF PERSON C FqRULTIN TIIE_WELL
D E
Submit the original to the Division
27699of Water Quality,GroRndwaterlSection 1636 M
2 7699-1 63 6 Phone No.(919)733-3g1 1-11,n 30 days. ' - ,"e1'fica Center-Raleigh,NC
GW-I REV.07/2001
29
i i

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and
ral Resources-Divisi of Water Quality-Groundwater Section
WELL CONTRACTOR(INDMDUAL)NAME (print)
WELL CONTRACTOR COMPANY NAME 1 CERTIFICATION p
D
STATE WELL CONSTRUCTION PERMIT# PHONE 4=59-Q�}q(�
(if applicable) ASSOCIATED WQ pERMIT#
(ifs plicable)
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 Tow t: County .27. 1S A �6PDgraphic/Land setting
l0ya.rr r r �
qei a p�tdge ❑Slope ❑Valley ❑Flat
(Sire t N me,Numbers,Commumry,Subdivision,Lot No.,Zip Code) (check appropriate box)
r n/� ` /(/�� Latitude/longitude of well Carlo
r5
3. OWNER: l2 6etr! -t'IrV,C7` br1;; ti :5 S. Y' •� V7,P61 ,
Address IO lj �„ S (degmes/minurefsi onds)
�J (Street or me No.) Latitude/longitude source:QGPS❑Topographic map
LJ1-6 d�5/ r yi. e 5' (check box)
Cry or Town State DEPTH DRILLING I Zip Code From To
I// y Formation Description
Area code-Phane number / y.
4. DATE DRILLED 14, Z — /ZOr�
5. TOTAL DEPTH: T-'Ti'a`�— / J r> — 2 S
6. DOES WELL REPLACE EXISTING YES ❑ NO 2
7. STATIC WATER LEVEL Below Top of Casing: 4�2 _FT.
-----_
8. TOP OF CASING IS (use"+•if Above Top of Casing) —
'To of casing �—FT"above Land Surface* -
P terminated allar below land surface requires a
variance in accords�With ISA NCAC 2C.tt1 IS. ---
9. YIELD(gpm):— �METHO OF TEST �-
10.WATER ZONES(depth): 3 71 '"9 -- ----
11. DISINFECTION:Type -�Lt? /� _ � LOCATION
12. CASING: Amount---�u6a�_ Show direction and distance in miles from at least
Depth
Wall Thickness two State Roads or County Roads.Include the road
Frotn Diameter or Weight/Ft. Material numbers and common road name
To
From To
—�`�FL /,,? LJ/, S dtL v2L [1 Ft.
From To Ft. Liz/ l I / �� Ies' �
13. GROUT: Depth Material
From /� Method �J��'�+fl'/�r N�
From—To-al�Ft. oF��
To Ft.-
14. SCREEN: Depth Diameter - O
From To Ft.
Size Material tTi
Ft. n.
Fro C r
m m. t
To Ft. in. ,.
15. SAND/GRAVELPACK: ut. Ln ."
Depth Size Material
From To Ft (n "
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF TH S RECORD HAS EEN PROVIDED TO THE WELL OWNER
S NA UB na fwtva RUCrINGTHE WELL_ A
Crdu
Submit the original to the Division of Water Quality, T h5 1
27699-1636 Phone No.[phone],within 30 days. gdwa�gf SaLtton, Ib36(tlad
II �eryice Center-Raleigh,NC
GW-1 REV.07/2001
NOV z s �005
r
_ _ s
ra' ,l

WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section 2
WELL CONTRACTOR(INDIVIDUAL)NAM (print) 3Ri�A )�� ��h, J;&F,S CERTIFICATION iIdp��,{�
WELL CONTRACTOR COMPANY NAME E 0 .�(d �� Q/I/d gyp L•L,(' PHONE"I
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* Topograahic/Land setting
Nearest Town. <.-s- ,+�i/ County /mac�C.�•r ❑Ridge dope ❑Valley ❑Flat
V//� �.A '& (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) La ttude/loongitude of well location
3. OWNER: �1 �/3f�Sy 127f✓ Y/OYZ' b 7r
Address (degrees/minmes/seconds)
• —01 A IMI IP e Latitude/longitudesource:2iPS❑Topographicmap
��nn \\ 11(Sneer or Raule No.)
(check box)
DEPTH
City or Town State Zip Code DRILLING LOG
p g P From To Forte anon Description
Area code-Phone number 7 s�
4. DATE DRILLED #--el— ds—
'/ .�✓ /
5. TOTAL DEPTH: rS 4s— / -
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2
7. STATIC WATER LEVEL Below Top of Casing: .20 FT.
(Use" 'if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): Z METHOD OF TEST�d�
10.WATER ZONES(depth): //r ; 21/,, ' l
LOCATION SKETCH
11. DISINFECTION:Type Amount //'ids Show direction and distance in mites 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. p
From © To ?1 Ft. 6,Izr .fOi7Cs ✓C {1(Ar] b )CL m V r Ay QY
From To Ft. Ih�
From To Ft. /11 k/fhy lk#/Y r
13. GROUT: Depth Material Method
From__To ;0 Ft. /✓C E E ��u.n.ryq �(',S �;�r/ I/1t _
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To FL_in. in.
From To Ft. in. in. cJ't
15. SAND/GRAVEL PACK: y„
Depth P Size Material
From—To-- FL
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

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section�Q{
WELL CONTRACTOR(INDIVIDUAL)NAMzF�(print) 1 CERTIFICATION#n7
WELL CONTRACTOR COMPANY NAME I ERQ Z O/V 4.Vd M 3 LLC PHONEt 81 o'CS�B�{9�t
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
2/
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:f✓�� �..ie/ County �a+lsio idge ❑Slope ❑Valley ❑Flat
'`— -�'- (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latltnde/longitude of well location
�� 11 XJi—�n s/f6'vgie
3. OWNER: (degrees/minutea/secnnds)
Address Latitude/longitude source:C PePS❑Topographic map
(Sneer or Route No.) (check box)
,1) t, II DEPTH DRILLING LOG
ity or Town State Zip Code From To Formation Description
(� - lo0%�- aoa 1 F> FI 1>>d
Area code-Phone number
4. DATEDRf.I.En 7-27-_/A-' n7.- i•-da c..-�,.k
5. TOTAL DEPTH: 69r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: yo0 FT.
8. TOP OF CASING IS (Use"+"if Above Top of Casing)
FT.Above Land Surface
-Trip of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm):4—METHOD OF TEST
10.WATER ZONES(depth): /GB , 6—')V, f
LOCATION SKETCH
11. DISINFECTION:Type CrhF,;.e Amount la ,•ire 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 o _Ft. ewr fPe2-/ ✓c-
From To Ft.
From To Ft. P/C
13. GROUT: Depth Material Methodff-� /•
From_D To-Z�Ft. "'2 E E
From To FL t�
14. SCREEN: Depth Diameter Slot Size Material t
From To FL_in. in. Ln _
From To Ft. in. in. 0
I5. SAND/GRAVEL PACK: clt
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
`4 '
a ;` %ti.�rc.�— .2-) -O1.2-) -a to
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
29 LL....

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section Q
WELL CONTRACTOR(INDIVIDUAL)NAM (print) 11-Rj&t�l� / , &J "N_ES CERTIFICATLOs N�it/ydp���p
WELL CONTRACTOR COMPANY NAME E SON S LIJE�� 4�✓� i LL,G PHONE
STATE WELL CONSTRUCTION PERMIT
# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Cr" Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topo�graphic/Land setting
Nearest Town:A-1I/ h4d County/1.11.4a ❑Ridge ipip1ps ❑Valley ❑Flat
/3 (check appropriate box)
m(Street Name,Numbers,Coi unity,Subdivision,Lot No.,Zip Code) Latitude/longimde of well location
3. OWNER: °��yrc'
(degmes/minutes/seconds)
Address 1-}� pVe I2,4 Latitudellongitude source:PfGPS❑Topographic map
„, (Street or Route No.) I (check box)
k�/,(�},�.`I N r 2 9 TS(4 DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(4a)- u ft 0 - 7r /9 -f
Area code-Phone number 'IT_ j,y f�[�
4 DATE DRI ED i_ i!__-.i
i.,..LL..a.
5. TOTALDEPTH:_Vur
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO t�
7. STATIC WATER LEVEL Below Top of Casing:4DFT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING 1S�_FT.Above Land Surface-
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0118.
9. YIELD(gpm): Zo METHOD OF TEST
10.WATER ZONES(depth): /ZJ 320'
LOCATION SKETCH
11. DISINFECTION:Type(tAadh L Amount 21-' kfr 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. Z./2 r f/JeL/ put #w h a(3
From To Ft.
From To Ft. 'I t �C
13. GROUT: Depth Material Method '
From__To 2 Ft. /rG E E 4
From To Ft. T
14. SCREEN: Depth Diameter Slot Size Material O --
From To Ft, in. in. sn
From To Ft. in. in.
15. SAND/GRAVEL PACK: cJ't
Depth Size Material O
From-To-- Ft. LIT
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 c _ -
u

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section Qg WELL CONTRACTOR(INDIVIDUAL)NAME,.(print)�jdl , CERTIFIIC.�ATIOONN#5M
WELL CONTRACTOR COMPANY NAME!�KWL��nfY S L�� 1&VJ / j L�,� PHONE#"95J-8y/�
STATE WELL CONSTRUCTION PERMITk ASSOCIATED WQ PERMITN
(if applicable)
(if applicable)
1. WELL USE(Check Applicable Box):Residential C3" Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
?. WELL LOCATION: Topographic/Land setting
Neare tTown:�o-r f,�j/ County/�hr,!rdn ❑Ridge ❑'STope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitnde/longltude of well location
3. OWNER:�r¢N (4n.�rrw /'�S(dr2,fL7-a/Orr"tf
(degrees/minu[es/secands)
Address q 3(g /�Lr. � r k Latitude/longitude source:OOPS❑Topographic map
(Street or Route No.) (check box)
n ll:it JJ k7ly DEPTH DRILLING LOG
City or Town State Zip Code From To Fo anon Description
=)- 7ia- elWp9 D. 44p- r
Area code-Phone number Sii-f _ :S,Cs/l
,i n.mE 11 rG_ r-n�
5. TOTAL DEPTH: UO:J' 0/
6. DOES WELL REPLACE EXISTING WELL? YES Ell NO
7. STATIC WATER LEVEL Below Top of Casing: "W FT.
(Use"+"if Above Tap of casing)
S. TOP OF CASING IS_�FT.Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance w th 15A NCAC 2C.0118.
9. YIELD(,,pm)- Y METHOD OF TFST Vikf,nj g
10.WATER ZONES (depth):'7.0 f J,0`17 ' J
LOCATION SKETCH
11, DISINFECTION:Type e'fv�•itC Amount Z/ Lc4: Show direction and distance in miles from at least
12. CASING: Will Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From Tor r Ft. L•/rr rAYt/ A c
From To Ft. ' 546 ���ierz arA.�t
From To FL 7Jt{'lJ
13. GROUT: Depth Material Method „n ,�< AW
From_._To 20 FL Ife E E ;��,, ,,� „, /{�IYnr-�-+
rn
From To Ft. .n _-
14. SCREEN: Depth Diameter Slat Size Material G-7
t
From To Ft. in, in. (.rl
From To Ft. in. in,15. SAND/GRAVEL PACK: o C3
Depth Size Material
From To Ft. -
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater'Section, 1636 Mail Ser_v_ice Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001
I

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDMDUAL)NAM (prin[)�g.�"�J � ''JJ
CERTIFICATION p .. -#e�
WELL CONTRACTOR COMPANY NAME E O I 4 �0 9 LLG PHONE&2
STATE WELL CONSTRUCTION PERMIT#(if applicable) ASSOCIATED WQ PERMIT#
(ife plicable)
1. 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:
Nearest Town-s!// Count o Topo�gr�aphic/Land setting
♦�' ; y�� -' ❑Ridge L4SIope ❑Valley ❑Flat
met N .r,Nun checks p )
( ude rime box
(Strom Name,Numbers,Commnmty.Subdivision,Lot No.,Zip Code) L titude/longitude of well location
3. OWNER: �am_ /y�� NTT° c/r,f-e/Z�ya P.T� ?43�
S ' '—i�'�' As A rwz?/e (degrees/minutes/seconds)
Address 715 i»nLf`=C¢ ge - MLA�, Latitude/longitudesource:
�t (Stree ; (check box)
aGPS❑Topographic map
t or Route NU
lL /z, )
�J � ��'P H G o1?96(e DEPTH DRILLING LOG
Ciryor Town State Zip Code Formation Description
From To P
fir - Ln94
Area code-I'llone number �
4. DATE DRILLED
5. TOTAL DEPTH: 71t/Y /
6. DOES WELL REPLACE EXISTING WELL? YES El NO Ef
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above"fop of Casing)
S. TOP OF CASING 1S—L--FT.Above Land Surface*
*Top of casing terminated actor below land surface requires a
variance in accordance will, 15A NCAC 2C.0118.
9. YIELD (gpm): METHOD OF TEST J' - i
10.WATER ZONES (depth):
LOCATION SKETCH
11. DISINFECTION:Typef�0�__ wtL___ Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From _To-,2L_FL. Ilr rywu AC-
From To Ft. ,f
From To Ft. '^'/ r(15W epl
13. GROUT: Depth - Material Method ��
From_To_�_0 Ft. tYCP,E e "' LNcf2
From To Ft.
14, SCREEN: Depth Diameter Slot Size Material ..'i
Fro To Ft. in. in, Cn
From To Ft. in. in, rn
15. SAND/GRAVEL PACK:
Depth Size Material rs `=t
From To Ft. -
From To Ft. O .
77
16. REMARKS: +.1
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL
CONSTRUCTION STANDARDS,.4ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THElWELL -.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 ItEV.07l2001

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section Q WELL CONTI2ACTOR(INDIVIDUAL)NAM (print) gj n-„�}� CERTIFICATION RtyNp�/p/
WELL CONTRACTOR COMPANY NAME E O1A Affly aN LLG PHONES
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential R-� Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Near
/e��jTown: /�7o•f!e/j County H<d•4ma 131kidge ❑Slope ❑Valley ❑Flat
ZW (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
o,cire TY.cry'
1 OWNER: 1... 1'. O (degrees/minutes/seconds)
Address Latitude/longitude source:21 PS❑Topographic map
�N/A� (S[ et or Route NoJ (check box)
�fGb/S �/ /YC �fC7Scf DEPTH DRILLINGLOG
Cary or Town State Zip Code From To Formation Description
2 3
Area code-Phone number
4. DATE DRILLED&
5. TOTAL DEPTH: zd- fo4C
6. DOES WELL REPLACE EXISTING WELL? YE40 NO Y
7. STATIC WATER LEVEL Below Top of Casing: /t�j FT.
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS�_FT.Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0119.
9. YIELD(gpm): 2f" METHOD OF TEST d�Gli
10.WATER ZONES(depth): AW 130 ' 6
LOCATION SKETCH
11. DISINFECTION:Type (^ �.;,.. Amount -la t<f r Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 0 To -241_Ft. leJ2>' SA421 i'✓c -
From To Ft.
From To Ft.
13. GROUT: Depth Material Method From To_,aD _ Ft. /IC E e '�j (>k>Z)'tlq (!M h
From To Ft. I T
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. -
15. SAND/GRAVEL PACK:
Depth Size Material
From To - Ft. '
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
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.0712001

WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAM (print) t
CERTIFICATION t�31110
WELL CONTRACTOR COMPANY NAME E O ' 41✓ LLC PHONE#8381�O•'Sy/�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
1. WELL USE(Check Applicable Box):Residential l3 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: County rc%•o ❑Ridge 1381ope ❑Valley ❑Flat
C4 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
�1/ST"•sf �Y A Vn'Jr,5G 1
3. OWNER: r-CA t t (degreeslr inute�econds)
Address _�� . - a&762M3 i, Latitude/longitude source: PS❑Topographic map
(Street or Route No.) (check box)
/�
Ar'sA*t// /ci;2975q DEPTH DRILLINGLOG
g2�odcity or Town State Zip Code From To Formation Description
(
Area code-Phone number number
4. DATE DRILLED 'ID—ao- oY IT- L1or
5. TOTAL DEPTH: 2& r /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ff
7. STATIC WATER LEVEL Below Top of Casing: Irf' FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS�_FT.Above Land Surface'
*'fop of casing terminated at/or below land surface requires a
variance in acrordance with 15.4,NCAC 2C.0118. ppp'''
9. YIELD(gpm): � METHOD OF TEST—&W r�.�
10.WATER ZONES(depth):1U ,7JD, ' J
LOCATION SKETCH
11. DISINFECTION:Type Amount j0 Afs 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 21' Ft, 6•/LT From To FLU
From To Ft.
13. GROUT: Depth Material Method
From To-,(Z Ft. me- E e
From To Ft. T-
t
14. SCREEN: Depth Diameter Slot Size Material (Jl
From To Ft. in. in.
From To Ft. in. in. is
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,.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.Y GW-1 REV.07/2001
JAN 2 4 20M

1
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources
-Division of Water Quality-Groundwater Section 2
�
WELL CONTRACTOR(INDIVIDUAL)NAMz�F.(print) R%(1-�1/ 7l, LIJ;/yE.S CERTIFICATION i�jHtir �/p/
WELL CONTRACTOR COMPANY NAME/ EKAL/S d t/yd zA0$ LLG PHONE
STATE WELL CONSTRUCTION PERMITp ASSOCIATED WQ PERMITq
(i f appl icable) (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: Topoggrr hic/Land setting
Nearest Town: ^',s4c P j County /'7c��en ❑Ridge L4Slope Malley ❑Flat
W, 4Of ff.'( (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location
_ /oL /f3rOS9u'A-o t* 3Y.�Irr'
m
3. OWNER: - fin,/( (degrees/minutes/seconds)
Address d/fte.. .9d i Latitude/longitude source:C3CrrPS❑Topographic map
(Street or Route o.) (check box)
�� Yl' �SXD DEPTH DRILLINGLOG
Ciiv or wit tate� Zip Code From To Formation Description
(O-_ a� �a 9 g o - L ci
Area code-Phone number - �
4. DATE DRILLED /0
5. TOTAL DEPTH: .ZDT-
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2"'
7. STATIC WATER LEVEL Below Top of Casing: UO FT.
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface-
-Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(gpm): 20 METHOD OF TEST O fd(q�g
10.WATER ZONES(depth): s"f'. 1-?Aa ` l
LOCATION SKETCH
11. DISINFECTION:Type (C/ar.^L Amount fcf' 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 ell Ft. 6,A r 1AWZ/ X--c �j
From To Ft. /is IerAlva 1 •
From To Ft.
13. GROUT: Depth Material Method
From Q To 2 6) Ft. /rG E E
From To Fr
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
rt�
From To Ft. in. in. C-)
15. SAND/GRAVEL PACK: I
Depth Size Material
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
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
`//T �f.�f d� /O-/S- or
SIGNATURE OF PERSON CONSTRUCTING THE WELL - -_..-:- - DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC -
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001 -
4

N�l
0, .. I 1 1
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section Q WELL CONTRACTOR(INDIVIDUAL)NAM (printer CERTIFICATION itH��/p/WELL CONTRACTOR COMPANY NAME E t 41✓ LLC PHONE tom')�d`-8y/cam
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) (ifapplicable)
I. WELL USE(Check Applicable Box):Residential @/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Toploggraa hic/Land setting
Nearest Town: n1i AN Countyle!? ❑Ridge L�1'Slope ❑Valley ❑Flat
G-tg� Iq/Ce s 0 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) �tltLde/10ngi[Lde Of well location
3. OWNER: 0 AEG/' 7 r (degrees/nummewseconds)
Address Q In _ , ,ell'. 1e. I t!(i Latirude/longitude source:126PS❑Topographicmap
(Street or Rep to No.) T— (check box)
,r]L"A �1L/i f/t N 19 7 DEPTH DRILLING LOG
p&Cty or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED !6'-C;'
5. TOTAL DEPTH: .3 Yf- /
6. DOES WELL REPLACE EXISTING WELL^ YES ❑ NO 2
7. STATIC WATER LEVEL Below Top of Casing: XO FT.
(Use"+"if Above'fop of Casing)
8. TOP OF CASING IS,�_FT.Above Land Surface*
`"fop of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C.0118. gy
9. YIELD(gpm):_3 NIETH pOD OF TEST -p q
10.WATER ZONES(depth): .2lT' 320' I J
LOCATION SKETCH
11. DISINFECTION:Type gn/�a.,.+t Amount /Y ASa 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 14997 Fr. ./Zr 5Peel V✓G
From To Ft. C67 6rr-et/ /)erY� �r,.
From To Ft. d �f'
13. GROUT: Depth Material Method
From_D —To 2_Ft. /rC E �iu.nt'..ra
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To FL—in, in. r7 `
From To Ft, in. in. )
15. SAND/GRAVEL PACK:
Depth Size Material CD
From—To—. Ft.
From To Ft.
16. REMARKS: -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/5. - / 9
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater$ection, '1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. _ — GW-I REV.07/2001
i

WELL CONSTRUCTION RECORD
North Carolina-Depmmnat ofEnvirournaut and Natural Resources--Division of Water Quality-Groundwater Section p�/WELL CONTRACTOR 21MMMUAL)NAM,EE �.�.�.241WS f— CERTIFICATION# 7U
WELL CONTRACTOR COMPANY NAM$-�w�P a 1 �' ,PHONE s ( zD b Y9=o`l�jo
STATE WELL CONSTRUCTION.ERaIITa A�ecnrrs WQ PERba"
f limble rf k
1. WELL USE(Check Applicable Box):Reaidentia3 Mtmicipaypubtie❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pomp Water Injection❑ Other❑ if Other,List Use
2. WELL LOCATION:
y
_ T�olpap6drJLaad awn
Nearest Totem Count /7�r/��o/�i ❑R� Mope Malley 0Flat
(Street Nuaq,N bcm Subdhi�o,t.ot No. Zip C� trlc*fteeck papof en
/ Latitadegongitnde of well location
3. OWNER:_f7e/'/ Ituaj(/Ueo,' < taoaa)
Address /M L /e/✓ .gr� c C' Latitudencen itude somce:00PSOTopographic map
/f�Rwe No.)
28 T S 3 (wed )
CeywTowa sue Zip �� D Ir.Inq -W9
From To Formation Description
Area coda Phone a nat er
4. DATE DRILLED Z�-3U -as
5. TOTAL DEPTH, �05�
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO E�
7. STATIC WATER LEVEL Below Top of Casing._Y<2 _FT,
• (Use'4'ifAhove Toy or cubs)
8. TOP OF CASING IS�_FT.Above Land Surface*
*Top atcasiK rerodan"d Wer adew lad swieft requires a _.
vadamee IN ROOM""wGh 15A NCAC 2C.811L Cp
9. YIELD(pm): /r METHOD OF TEST ll e
10.WATER ZONES(depth):
L4CATiON ELM
11. DISINFBClTON:Type Amount / Show direction and distance in miles from at least
12, CASING: Wall Thickness two State Roads or County Roads.Include the
Dept or
W ' c numbers and common road names-re B
From /1J To Z�Fc_JC�LZ l� Z
Fro�T"To Ft a\
Fromm_To Ft
13. GROUT: Depth IMOWY •
From�To_�,ZFt ,� yr, S
From To Ft
14. SCREEN Depth Diameter Slot Sim Material
From— To Ftm, uL
From To Ft m. ill,
15, SANDIGRAVEL PACK:
�( DepthSim Material t
From (�J To Ft D
From To Ft v / L D
A <
16. REMARKS: m n
I DO HEREBY CERTIFY THAT THIS WELL WAS CO U IN ACCORDANCE WITH ISA NCAC 2C WILL O Co m
CONSTR STANDARDS,AND A OF THIS ItAS BEEN PROVIDED TO THE WELL OWN O " C
-� m
o
SIGNATURE OF TRUCITNG THE WELT. DATE rn
N
Submit the original to the Division of Water Quality,Groundwater Section, Mali Service Center-Ra►eigh, C 276WI636 Phone Ns.[phone] within 30 days. OW-1 REV.07)2001

%C C. 11 F'.. I "
:
WELL CONSTRUCTION RECORD ;? r �3
North Carolina-Dopartment of Environment ent and Natural Resources-Division of WOOterr.Quality-Groundwater Section
(IM
WELL CONTRACTOR IMUAL)NAME t �/�"It��; l D dt- V /Q CIdtTIMATION X z 7 0Q'Y
WELL CONTRACTOR t:OMPAITY nAa1R- wee J`' W/Q A�i-
STATE WELL CONSTRUCTION PERMM wrcOl<gATgp WQ PERatrfN
rf a if ieablc
1. WELL USE(Cbeck Applicable Box):Residential Mtmicipa"ublic❑ Industrial❑ Agrimitu al 0
Momtormg 0 Recovery 0 Heat Pump Water Injection❑ Other O If Other,List Use
2. WELL LOCATION: T c1I aced setting
Nearest Tp+�.M _ .�� Cry /�O� opt slop
235W/�l,`f4i I urix�r N;y /�iqi' 't tSr7s-9 Aga I3S lope ovauay, OFlat
(Shea Num6m,Cm�muaaY.s .1ot Na,22p Code) ( appmPrift boa)
LatitudaIongiuxk of Wan location
3. OWNER / of (depeeym®ra�esoaas}
Address 19173 Sec/ .,�+ _ Lataude/longkotleSOUrMCIGPSOTopographicmap
4/LC a) Z _ DEPTH ( DRII.LINGLOG
Ciryw`rmra 9mr Zip Code From To Formation Description
Area node-Phone number _
4. DATE DRILLED_/
S. TOTAL DEPTH: 205-
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO f3 '
7. STATIC WATER LEVEL Below Top of Casing:
/. (UW'4+ ffAbMTopaC*,W,
8. TOP OF CASING IS _FT.Above Land Surfacc•
"Toll of erVa tadaided allw hdew hW wr6a require■
vrlaaar Is atserdaue With 15A MCAC 2C.0118. /
9. YIELD(gpm): h/O METHOD OF TEST /i HrC/!
10. WATER ZONES(depth):
Id)CA710N 3K_F•I'CH
II. DISINFECTION;Type Amount //9 e z Show direction and distance is mike from at IQft
12, CASING: Wall Thickness two State Roads or County Roads.Include the road
Fro
to Depth� Ft= a50,� 2/ern t4ptenal numbers and comment road names.
Fro�_To Ft zzz ell
Fromm_Tom—Ft r
13. GROUT: Depth Material Mqtbod r D M
Fm Tom_Pt s r•
FrotrL_To Ft ID a n
14. SCREEN,,,:,,,,,,[[[ Depth Diameter Slot sin Material z
From To Ft m. in cp rfl
From To Ft in. in. / 0 " C
I5. SANDIGRAVEL PACK: o R1
From�Depth Sim Material
Tck Ft. i
From r To Ft CDRKS
16. REMA ;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSMgM IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCl70 S.AND THAT Y OF S RECORD EEN PROVIDED TO THE WELL OWNER
2
SIGNATURE OF PERSON C.ONSTR THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27699-1636 Phome No.[phone] Within 30 days, GW-1 REV.072001

r 1 q9 MM tlarvka Carter'Ry FnvWr rM and NsMY Rasaress.Division at Wass'QUO".prp�ayr gecy� '
aI^N.C.ZME.16 Ohms(E1E)7113-Mi
WELL CONSTRUCTION RECORD wmcoNTRACTDR:
8WEM CONTRACTOR CERTErICArON It:
lVATE WELL CONSTRUOTION PERIy .
1. WELL USE t:hutr ApplHabls asak RsrAdEnVdM Munbtpd ClIrtdutdd❑
Amovery C] Heat Pump Wet«14"llon ❑ Ghat p N Otter,Lid Us@: A9rloutural❑ MwrWAnp[�
2. WELL LOCATION:(Stott sketch below)
NOT Town:
(Read Name and Nurreers, ryT,er Sumvielon and tome.) DRILLING LOG 3. OWNER t jl l� r<e f�D - _ DEPTH
Address QIS C) &$ From_ Fprr aapn Dasr+bllen
yy� �oessr ur RorA � GU 4J' ta.ld�lt�:
�[)A S ILC G �7 ��SY —137 � f!' O a�tila
City aTeen EtaM MoGoes I _ Ll iC
4. DATE ORILLEO i t
S. TOTAL
CUTTINGS
6. CUTTiNGgCOlLEC7E0 YES[] NO StcS_ L.;. e CiIL'f1FATti`7. DOES WELL REPLACE EXISTING WELL? YES QNOW
S. STATIC WATER LEVEL Below Top o7 Caslnp: 1-7d_FT.(Us --
9. TOP OF CASING IS / Fr. A. s AeLa rep u fawrd7its '
tT.Above Lend Surface.
-Top or easkre Isnnlnarad seer bsbw lend 4W"e rutatws a valance In sneer.
dance Mier 15A NCAC 2C.011e
10. YIELD(ppm): 1� METHOD OF TEST I�
11. WATER ZONES(depth):
12.CHLORINATION: Type T1L Amount 119 eVI le13. CASING: Al WWOfi f IbteC(iOr,
WON T Nekneas LOCATION SKETCH
_ Q Depth 04nwpr or wdgwjn tp(atadd (Stow direction E d distanp kom sl Nut two State
From To 13(0 FL f,I a" Roads,or Other nap reference Points)
To Ft.
From To Ft.
14. GROUT:
0 Depth^� Mate" Method
From d To CCU FLFrom
To FI,
1S. SCREEN:
e
Depth Dlsnteler Sbt ski Material �.) Gk�RRd
From __ To__FI_ M __. In.
From —To—Fl._ in, in.
From To_FL In. in. 71
3 n1
1S. SANDIGRAVEL PACK: 2� _
Depth Size Material o From To Ft.
From To
Ft.
17. REMARKS: ACCORDANCE
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CONSTRUCTION STANDAADS,RAND THA A COPY OF THIS RECOD HAS LrEN PROVIDED TO THE WELLLOWNER.
FOR OFFICE USE ONLY
Oasd tea RATLIKE OF PERSON CotaaTRRCTOro THE WELL
Su"island kf DhrMm of Wow DATE
lfarld No. Ousmr.Orouxlsdar Meaen w11Mn 30 data
OW-1 REV. ILO

�:,.SiArFo
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality
.. WELL CONTRACTOR CERTIFICATION N- 3 1 TO
1.WELL CONTRACTOR: I. DISINFECTION:Type C'/- '..- Amount 2� Az s
�/C r�'N /.ff/•N E-S g. WATER ZONES(depth):
II Contractor individual)Name From /�i— To From To
r /
�a FII QN� l[Mr� �rr Fram SD To From To
—
From Company Name
/ J From To From—To—
STREET
ADDRESS t�1 �((� [ 1'6'EU 'Z 6. CASING:
Y.
Thickness!
_ tit z/ ����� Depth Diameter Weight Material
lI t From (i To rJ- Ft G/ram L-�rti fR.c
ully or Town State Zip Code From To Ft. _
�5(SCR )
From To Ft.
de- Phone
Area co number
1.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) NA From__To 200 Ft. COWrete
From To Ft.
STATE WELL PERMIT#(irapplicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply I From To Ft. r in. _ in.DATE DRILLED /Z—7' 0 From To Ft._in. _ in.
! / Frran To FL in. _ in.
TIME COMPLETED l 'T) AM❑ PM 13
S. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: /7<•il4// COUNTY From ' To Ft.
From To Ft.
a��A A� rs From To Ft.
(Street Name,Numbers,Ctanmunily,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
10.DRILLING LOG
❑Slope ❑Valley ❑Flat J)box ge ❑Other From To Formation Description
(check appropriate box) �t p
LATITUDE 3 SS Ur ZLf' May be in degrees, 0/e7
mmulm seconds or L/ - 412 S4r'/
LONGITUDE Y Z Jr, yyj ' in a decimal format d!'- roc
Latitude/longitude source: KGPS ❑Topographic map
(bcatbn of wed must be shown on a USGS topic,map and -
attached to this form d nol using GPS) --- ---
4.WELL OWNER
OWNER'S NAME ( /./✓f r /.� 2 r
i evr .-
STREET ADDRESS ai l0 J.�en��• Lc(�F� ' ��f` ' ___
CIry or Town Stale Zip Code
($1K )-
Area code- Phone number --
S.WELL DETAILS: 11. REMARKS:
a. TOTAL DEPTH: for b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD/1'
I DO HEREBY CER11iY THAT THIS WELL WAS CONSTRUCTED IN Wm1
C. WATER LEVEL Belau Top of Casing: "/O
(Use'+ if Above Top of Casing) REO D NAS BEEN PROVIDED TO THE WE OWN RD THATA COPY OF THIS
it. TOP OF CASING IS FT,Above Land Surface' �J
*Top of casing terminated at/or below land surfacemay require N �' -�"'�� IZ-7-or
a variance in accordance with 15A NCAC 2C.011 B. SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 6 METHOD OF TESTARINTE:D
A- II
. NAME OF PERSON CONSTRUCTING THE WELL
bf
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 S68. Farm GW-1a
Rev.7105

�..+siArEo
4 RESIDENTIAL WELL CONSTRUCTION RECORD _a O "
�g North Carolina Department of Environment and Natural Resources-Division of Water Quality
.. WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: I. DISINFECTION:T
�{� A Ype Cho:,,oC Amount Z/ Aef,
K �.)N/ e �S g. WATER ZONES(depth):
�IIy/C;ontractor Individual)Name / ` �r From Ada To From To
�7�-t 4/✓Q?lwn,2 L,�-Li From SS To From To
Well3tontracta CompanyyName /—�'� ) From To From To
S REET ADDRESS LEdE[K (/, 6. CASING: Thickness!
Depth Diameter Weight Material
.�3�t/Jp /'��— Fram�_TD r3 Ft. LJ' fl
Q^�pCity or Tow OOState / Zip Code From To Ft.
L49O_} �i 5 n 49/o From To FL —
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
SITE WELL ID#(if applicable) /{rA Frortt—�Toy20 Ft. COMC r . e-
From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) —/ B. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Er From To Ft. - in. _ in.
From To FL_in. _ in.
- DATE DRILLED 12.1=17r _/ From To Ft.—In. in.
TIME COMPLETED 3 '00 AM❑ PM t,?
S. SANDIGRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: /'7..s All COUNTY/'lcirro� From To Ft.
From To Ft.
Numbers
ale .Pd Fram To Ft.
(Sweet Name, ,Community,Subdimwn,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑SIOpe ❑Valley ❑Flat QKidge LjOther From To Formation Description
(check appropriate box) p
i =indegms,LATITUDE 3 = CI�i"3[7 LONGITUDE r Z. -1jr (,
Latitude/longitude source: CdGPS ❑Topographic map
(bcation of well must be shown on a USGS topo map and �—
attached to this form C not using GPS) ---r---
4.WELL OWNER
Crl LSD/U2/' 1
OWNER'S NAME `ED _i ;.^Y �. )Nn m
STREETADDRESS !/U zk -Cti�2d U " G—
��n�� %l NYC �87fU I
City w Town p State Zip Code
Area code- Phone number
5.WELL DETAILS: // 11. REMARKS:
a. TOTAL DEPTH: //71e1 /
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO[�
c. WATER LEVEL Below Top of Casing. CERTIFY THAT DO HEREBY CER THAT THIS WELL WAS CONSTRUCTED INACCORDANCE Writl
(Use`+'d Above Top of Casing ISA DHAs BEEN PROVIDEDUCTI THEON WELLOWN RD THAT A COPY OF THIS
d. TOP OF CASING IS�_FT,Above Land Surface' Aym �� �/
'Top ri casvariance
in terminated with belay land surface may require �NtAAE
IFIED WELL CONTRACTOR DATE
ca
a variance in accordance with 15A NCAC 2C.01 16.
e. YIELD(gpm): METHOD OF TESTERSON CONSTRUCTING THE WELL <�
i
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, -
1617 Mail Service Center-Raleigh,NC 276 9 9-1 61 7 Phone No.[phone] ext 568. Farm GW-1a
Rev.7/05
i_._--.__._

1
iOl'
RESIDENTIAL WELL CONSTRUCTION RECORD eloF
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3
1.�WELL CONTRAC�TVO"R: I. DISINFECTION:Type 610 A' Amount
b) g. WATER ZONES(depth):
Vol L;i tractor individual)Na//m))e From 12� To Fran To
-,' b IE/l LL/✓Q �d /I ( From 27r— To From To
Welll &w-t&=tor Canpan�yyNa9m)e From To From To
STREET ADDRESS r�/JI .�(� L (�FSTF? tU(/. 6. CASING: Thickness/
/ Depth Diameter Weight Material
/7, From 49 To4P_Ft. L./y �...c_
City or ToGwne, OState/ Zip Code Fran To Ft. _
8�R ai✓d O Y9 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 7. GROUT: Depth Material Method
Fran_pTo-20 FL C' ACrefer
SITE WELL ID#(il applicable) f/�'/1 Fran To Ft. j—`--J-
STATE WELL PERMIT#(d applicable) Fran To Ft.
DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 2/ From To FL - in. _ in.
DATE DRILLED
From To Ft._in. _ in.
��"�4 -O/� From To Ft.—In. _ in.
TIME COMPLETED AM❑ PM❑
9. SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size Material
CITY: L_/r�5 ��� COUNTY�ac/ From To Ft.
^ rog From To Ft.
C.v�ir. .fZ /.t From To Ft.
(SUeel Name,Numbers,CTommunRy,Subdivision,Lot No.,Parcel,Zip Coce)
TOPOGRAPHIC/LAND SETTING 10.DRILLING LOG
❑Slope ❑Valley ❑Flat pWdge ❑Other From To Formation Description
(check appropriate box)
LATITUDE 3 S� 7y7 � ff,,,
�inconds , �r-Gv �y
tes,seconds or
LONGITUDEL _?d, rZilr ecimal format G0- Z-- er"_xr
Latitude/longitude source: ❑GPS OTopogaphic map ------ -
flocation of cast must be shown on a USGS topic,map and
attached to this form T not using GPS) �O
4.WELL OWNER
„ J IJ I'•nC -
OWNER'S NAME r/YJ 3 1.`I ZQIIO-- t y
ST ETADDRESS 6M� G - t-
�i-c��fQ� /YG �P7fi�
City Or Town Stale Zip Code -
Area code- Phone number
11. REMARKS:
5.WELL DETAILS:
a. TOTAL DEPTH: ,721—
b. DOES WELL REPLACE EXISTING WELL?nn YES❑ NO 2-
/
c. WATER LEVEL Beim Top Of Casing: O � FT I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
g 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
(Use'+•if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS 1__FT.Above Land Surface' �A�i,' 9,/i,•^•✓ �l��C �s�
'Top of casing terminated with below land surface may require SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
a variance ui accordance with 15A NCAC 2C.01 76.
e. YIELD(gpm):�—METHOD OF TEST r q •'4 RINTED NAME OF PERSON CONSTRUCTING THE WELL
"ijbinit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, -
161/Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form
Rev.7/05/05