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/ V t WELL CONSTRUCTION RECORD North Carolina- Department of Environment and Natural Resources-Division of Water Quality- Groundwater Section 7 \vh71.(:ONT R.ACI'OR(INDIVIDUAL)NAME (print)_- I�wl" "" t Ih CERTIFICATION# �u lF'EL.L CON TRACTOR COMPANY NAME—- �L1{4Y-Y—Z_�.1.Q1_ 'r—�f-- -PHONE N3 A1E WELL CONSTRUCTION PERM ITN ASSOCIATED WQ PERMIT# (if applicable) (if applicable) mommomm __ I. WELL USE (Check Applicable Box): Residential IN Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ IrOther, List Use 2 WELL LOCATION: Topographic/Land setting Nearest Town:. pY�-�- _County �C/d 'n ❑Ridge ❑Slope ❑Valley ❑Flat //� J ��J � (check appropriate box) G T Latitude longitude of well location (Strecl Name n Numbers,Comunity.SUNIM5lUn,Lot No..Zip Code) n I 3. OWNER (/ rT AG (A (de sheonds) Address Latmdclongitude source:131GPS❑To pographic — map /2 (Street or Route No_I (check box) !7(��6�r��� ���L 9vSk713 DEPTH DRILLING LOG Cdyor Town ! State Zip Code From To Formation Description Area code.Phone number 4. DATE DRILLED-6 S. TOTAL DEPTH: i�O 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W m 7. STATIC WATER LEVEL Below Top of Casing: 60 FT. 1 -" (Use"1"if Above Top of Casing) J R. TOP OF CASING IS � FT.Above Land Surface' Top of cashig terminated at/or below land Sarfaee requires a variance in aca rdance with 15A NCAC 2C.011S. - -P 9. YIELD(gpm): 1� METHOD OF TEST Gx t r 10. WATER ZONES(depth): LOCATION SKETCH 11. DISINFECTION:Type ram{_—._ Amount y, 7 Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material numbers and common road names. From_.._To go I Ft. 6 I_ __ �al t I troYVN Isxli (Oct on Htuy 19 711 From To FL I �'.�t� From To Ft. �Cnl H' 7'�5 C c� O_ 'a mI C5 17. GROUT: Depth Material Method i� From_To_.!� F t. CLPryIL'(�k _ Jtn Ji rs< J i✓\ � r'1 f D r r'L-J From_To__ Ft 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. __ In. C..SSPC!t GJr� pPr" G('�er From To FL in. in. IS. SANDIGRAVELPACK: �jr-,1Gfry S"tvi 2 Depth Size Material From To FL From To__Ft. 16. REMARKS: _ 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNTURE SF SF REPO'�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.(919)733-3221,within 30 days. GW-1 REV. 07/2001 c iA v'. � 00 a WELL CONSTRUCTION RECORD North Carolina -Department of Environment and Nat I Resources- ivis�7io_n of Water Quality-Groundwater Section xl6 ,.; - 1116 Y_- CERTIFICATION# t JJ 6 VVFLLCONTRACTOR(INDIVIOUAI,)NAME (p/ri/nnF),, - - \\"ELI.CON'IRAC"fOlt COMPANY NAME JSd.LlCntn—w e r Y)5�---PHONE # S"TATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# f if aPPlicable) (if applicable) ONEENOMMEM-- WELL USE (Check Applicable Box): Residential 29 Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ I f Other, List Use 2, WELL LOCATION: �� Topographic/Landsetting Nearest Town: _6t_i _ ( �en C� Countyc r ❑Ridge ❑Slope ❑Valley ❑Flat arYvim! 1 r\, Q r,� (check appropriate box) l Latitude/longitude of well location (Street Name Numl11x--rs,--Community.SuMlivision,JJ_hhL�'ot No..Zip Cole) 3. OWNER: CY�1f�1�. �� •(- 0 (degrees/miuutes/seconds) Address T� _ ��� -- L-aliludc/Iongitude source:❑GPS❑Topographic map (Street or Route No) (check box) C a5C 70 A __ DEPTH DRILLING LOG Cityor Town State Zip Code From To Formation Description Arcude Phone number 4. DATE DRILLED - - 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO I to 7. STATIC WATER LEVEL Below Top of Casing: 000 FT. -n (Use"+"if Above Top of Cuing) i R. TOP OF CASING IS FT.Above Land Surfaces -- - T —fop of cashig terminated actor below land surface requires a 0 ry variance In accordanc with 15A NCAC 2C.01 IS. 9. YIELD(gpm):_ ___METHOD OF TEST �)`L r — }`L 10. WATER ZONES(depth): HOC, LOCATION SKETCH 11. DISINFECTION:Type_ �l 2t- Amount cz 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. Matenal numbers and common road names. From__-TO FL A__. —INC-- S'Y-C' '�.J 00. From To Ft. I From To FL — }� fU 900ra kof) gcx' r� 13. GROUT: Depth Material n Method From, 0._-- fo_�_FL Ce y� `�'� _40_yp'R� fL VVL 1 �e S 4'U 1 r\ Qt tjkti- d r e• From- To-- Fr -- — --- (� /� 7 ` 14. SCREEN: Depth Diameter Slot Size Material CJoCJ�_,IC }-�� I�xCxJ tic ap rrles From To Ft. in. _ in. V /� From To Ft. in. __ in. �t?t'n �tffh�- OfTi'O 'QSI YE CUc^Y IS. SAND/GRAVEL PACK: Depth Size Material From_To_Ft. From To_ FL 16. REMARKS: _ 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL. CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER STdNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality.Grom adwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1636 Plume No.(919)733-3221,within 30 days OW-1 REV. 07/2001 WELL CONSTRUCTION RECORD North Carolina - Department of Environment and Natural Resourc/e�s- Division of Water Quality-Groundwater Section WELL,CON'T'RACTOR(INDIVIDUAL)NAME tut) (�1/� 7 rl Y L'I I u CERTIFICATION M (/ i1'ELLCON"I'RACTOR COMPANY NAME ft l --PHONE p �a �� 1 9sy S"fA"I E WELL CONSTRUCTION PERM ITa ASSOCIATED WQ PERMITN {if appl icable) (if applicable) I. WELL USE (Check Applicable Box): Residential W Municipal/Public ❑ Industrial O Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use - 2. WELL LOCATION:� � Topographic/Land setting Nearest Town:__ QY�.. [.—County^ ✓ ❑Ridge OSlope ❑Valley ❑Flat F S{_._, /G,f ci rr(�7 i (check appropriate bnxl G (street Name.Numbers.Community.Subdivision,Lai No..Zip Code) Latitude/longitude of well location 3. OWNER:_ 1 _ ram. (de source E3s/seconds) Adriress G_:..St A A--` Latitudciloneitude source:�GPSOTopographic map (Stm.t or Rorie Na.) DEPTH box) C � �TE �lA1 3 _ DEPTH DRILLING LOG dy or Town Stare Zip Code From To Formation Description ti Area code-More number _ - 4. DATE DRILLED 61/— 5— C 5. TOTAL DEPTH: L3�t75 ` 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (& 7. STATIC WATER LEVEL Below Top of Casing: aa0 0 FT. (Use"+"if Above Top or Casing) Q R. TOP OF CASING IS FT.Above Land Surface' -Top,Icasing termtnated wor below land surface requires a ° variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm):_�__METHOD OF TEST C1,1 r 10, WATER ZONES(depth): 60.5 LOCATION SKETCH y Show direction and distance in miles from at least 1 I. DISINFECTION:Type i-tTH Amount k,/ 0 2 two Slate Roads or County Roads. Include the road I2- CASING: Wall Thickness Depth Diameter or Weight/Ft. Material numbers and common r9iid names. From. 0 To i UI FL (._ ,s.rI �'`_�C �rovvv C-\fyVrkj ("O, I..`� rrrl IPs hI�F+� 'e��'/ From To Fl. OY\.fo -74F- �, �.� w+t'Ir5 I"v�n 'PiiSf�f Gd F,r,f6y From To FL G rr? 6f3l, for✓1 9I5lki- onto 13 GROUT: Depth Material Method •3 •� S Fv�ti iC��- ov�d-o From_Q To-d-0 Ft.(�vheroE From---To FL - — --- C ), 7 14. SCREEN: Depth Diameter Slot Size Material tiro o, 2 kU i,Je)( From To Ft. in. _ in. _ From To Ft. in. it' _ 15- SAND/GRAVEL PACK: Depth Size Material From To Ft. From To_-_Ft. _ - 16. REMARKS: - I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO�THE WELL OWNER S16NATURE OF PERSON CONSTRUCTING THE WPLLOF PERSON CONSTRUCTING THE WPLL DATE Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Senice Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV.07/2001 lJ" riA 31 WELL CONSTRUCTION RECORD North Carolina- Department of Environment and Na al Resources-Division of Water Quality-Groundwater Section �6 ( WELL CONTRACTOR(INDIVIDUAL)NAME �(prin11t))� sb rl t I kc,�S CERTIFICATION#—i [[/ WELL CONTRACTOR COMPANY NAME `Jre fNr+1 L.)C\\ O I\ 0,, PHONE STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) _ 1. WELL USE(Check Applicable Box): Residential (rMunicipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: ! Topographic/Land setting Nearest Town: Ar t=/� County^ LA 6%.%YN ❑Ridge ❑Slope ❑Valley ❑Flat r).,D -� !X`�7( S (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location n/� n 3. OWNER: /32f I h � r (degrees/minutes/seconds) Address r)154-,,>4e-, qA Latitude/longitude source:❑GPS❑Topographic map (Street or goute No.) (check box) RCy� nG I-�I�jC aSI DEPTH DRILLING LOG Gty or Town t State Zip Code From To Formation Description (VD- !J70/ - C700 Area code-Phone number ' 4. DATE DRILLED 5. TOTAL DEPTH: eZ rn __- 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fT 7. STATIC WATER LEVEL Below Top of Casing: FT. 1 (Use"+^if Above Top of Casing) 8. TOP OF CASING IS l FT.Above Land Surface* r� -Top of casing terminated at/or below land surface requires a (.fy ' variance in accordane with 15A NCAC 2C.0115. 9. YIELD(gpm): METHO OF TEST Cl I r 10.WATER ZONES(depth): a LOCATION SKETCH 11. DISINFECTION:Type HFH Amount /O rnz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. M,alenal numbers and common road names. From r�To�Ft. 6 YI .�D�� — 'M D�\`MclnCtl' PO 15p From To Ft. (� o/ From To Ft. �e L r\d0 �7�' 3,0, 8't)m 13. GROUT: Depth Material Menem tho L ro� G,k4f�r 40 '*I 5'�)C From To &0 FL Co tfv 1= 1" Yv� t ,M 1e� qc fCSS ovr! (0aS5 ' From To Ft. f.�.,y� M �, 14. SCREEN: Depth Diameter Slot Size Material 6- q 51 'h 1` `\ �(1v�D' - �� " I't^'� From To Ft. in. in. A,6p t'+t,�f5 ni'tifn (�-F6' d�n�w a1'ct From To Ft. in. in. dt f IAW ern crux pQC-KrWe(f Pyi2n nc 15. SAND/GRAVEL PACK: gin 5 rt, S J I� MID t� c�rn Depth Size Material g ' G`aQ �J ,t 1 .}�(E �`(Y,51' /J OO b From To Ft. Ko}�,r`5cry 1 a `�+.1 tit From To Ft. �c� J CVd S C,"12 � LA *ern (1;��'uul' cn �11� 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDA{^R�DS,AND THATyA CC/O,`PYt OF THIS RECORD HAS BEEN PROVIDED TOO THE WELL OWNER V G$ R f1 1 V WELL CONSTRUCTION RECORD North Carolina- Department of Environment and N ural Resources LDivision of Water Quality-Groundwater Section / iVELLCON'7'R.AC7'OR(INDIVIDUAL)NAME (print) I CERTIFICATION# b \ WELL.CONTRACTOR COMPANY NAME (--fir In' �J C 1\ �1 PHONE # SPATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box): Residential W Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use 2- WELL LOCATION: Topographic/Land setting Nearest Town: 1 t County .v-d r, ❑Ridge ❑Slope ❑Valley ❑Flat s i jiiea,( Cq)1, (check appropriate box) (Street Name.Numbers,Numbers,Community,Subdivision,Lot No..Zip Code) Latitude/longitude of well location 3. OWNER: DYlrt L 9K� (degrees/minutes/seconds) Address A1,09J ✓HnfiP t2t` Latitude/longitude source:❑GPS❑Topographic map (Street or Route NoJ (check box) dn'c 7Y /fC 7 DEPTH DRILLING LOG ' Cily o�T St m< Zip Code From To Formation Description -7Z y i1 Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 01 7. STATIC WATER LEVEL Below Top of Casing: i_(Z_FT. (Use"+"if Above Top of Casing) ` 8. TOP OF CASING IS 1 FT.Above Land Surface* r r, *Top of casing terminated at/or below land surface requires a variance In accordance with 15A NCAC 2C.0118. -: 9. YIELD(gpm):—,E—METHOD OF TEST 0k t f- 10. WATER ZONES(depth): 7'�kc) - LOCATION SKETCH 11. DISINFECTION:Type_ 7 Amount -0 Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter er We' ht/Ft. Material numbers and common r`oaad,i\names.. From ToCZ Ft. 6 �4 -fir =! tr- � ,(�M\, �v� I ` rli t� _' From To FtFrom To Ft.From1P "CCJJffff From To Ft. ,forte ( <--'6-v S-c- 1�`5 13. GROUT: Depth Material ,��'}Metethhood�� ll FrommTD- +-�-FL /'P.��fw�r.. . .Y- ----f _.a- C/-VvC1V� �• r�„'Kr7 d-Jr From To Ft. _ 14. SCREEN: Depth Diameter Slot Size Material C , From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER 26-06 SIGNATURE OF PERSON C STRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Grwndwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV. 07/2001 WELL CONSTRUCTION RECORD North Carolina - Department of Environment and Na cal Resources- D'vi� lion of Water Quality- Groundwater Section_�6 / .{-�A- I�y`9' CERTIFICATION# t��w� w'ELL CON'IRACI'OR(INDI VIDUAi,)NAME (Prit 1 1 //p}l�FF,,�' PHONE 9WTJ_ �l/ tr ELL CUN"r12AC'fOR COM PANV NAME Vl�,�ar+�--�+-=-i'---ad+ S'I ATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT# I if applicable) (if applicable) I. WELL USE (Check Applicable Box): Residential R Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use — 2 WELL LOCATt N: Topographic/Land setting Nearest Town: .�C1�_C%)- County SJr 1 h ❑Ridge ❑Slope ❑Valley ❑Flat S (check appropriate boxl t Street Namer.Numtars,Comm<Cunu/y(Subdms de) Latitude/longitude of well locationon,Lot No..Zip Cn 3. OWNER (degreeslminmes/seconds) Lantuddlongitude source:❑G PS❑Topographic map (Street or Rome No.) p (check lwx) DEPTH DRILLING LOG Cnyor Town State Zip Code From To Formation Description tic)- 4 W tv�- 7li� Area curie.Phone number 4, DATE DRILLED pig _- 5. TOTAL DEPTH: LL SD rn _-p 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO {� m 7. STATIC WATER LEVEL Below Top of Casing: I Sa FT. t (Use"+"if Above TuP of Casing) J R. TOP OF CASING IS ( FT.Above Land Surface' -Top of casing terminatde allor below land surface requires a CJ7 ..1 variance in accordance with 15A NCAC 2C.0118. — 9. YIELD(gpm): 6 METHOD OF TEST ie 4, C 10. WATER ZONES(depth): _��(7fl LOCATION SKETCH 11. DISINFECTION:Type Fitl Amount_L;Z c Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diaracter `o'r�Weight/Ft. Wren nat numbers and `commonk road names. } From To_��_ From To Ft. From To Ft. le i ()rvi-o 7'? I . GROUT Depth Material Method tU_,.� �e��- �,�{O 7'O✓>` From O To_20 _FL (l2V,,en - PLJrn txs5r ��^^ !! II r OC �e �ci 5 From__.—To___ Ft. __ - __.___ `�0 '7 ,t7r ;. 11<S 14. SCREEN: Depth Diameter Slot Size Material ,/�1 - From To FL _in. _ in. (�'� lJ f tY¢ O`` ..((( /�✓t.+I'+S' From To Ft. in. in. �VYn �1� CID '2 Y\c+� dr ,Or,V',e- 15. SAND/GRAVEL PACK: Depth Size Material lJx Uh e �- From- To Ft. From To__Ft. ---- I6_ 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 SIGNATUIM OF PERSON CO TRUCTING THE WELL DATE Submit the original to the Division of Water Quality.Groundwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. .GW-1 REV. 07/2001 WELL CONSTRUCTION RECORD North Carolina - Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section �Y/rl•LM G CERTIFICATION 4y?•1 \VELL CONTRACTOR(INDIVIOUAL)NAME (print)/' )^f- � � � t,, l.. W 'I PHONE p R'ELL CONTRACTOR COMPANY NAME yJ CC �S YYy �- S"I"ATE WELL CONSTRUCTION PERM ITN _ASSOCIA'TED WQ PERMIT# (ifapplicable) _ (ifapplicable) I. WELL USE (Check Applicable Box): Residential OL Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ if Other, List Use --- 2. WELL LOCATION: 4 Topographic/Land setting Nearest Town: {�l('rfZnnR1��`�" --County V5 ON V-- ❑Ridge []Slope ❑Valley ❑Flat Gt b6�Yl Icheck apprupnme box) A. Latitude/longitude of well location (Street Name,Numbers,Crnnmuuity.Subdivision,Lot No..Zip Code) 3. OWNER:—y,V�� � ' f�-<< ldegreesoninums/seconds) Addres.a _(11 b - talitudcllon, nude source:❑GPS❑Topographic map — — Icheck (Sveo or Ro we No-) e46--r�0 If,�� iq'L .��Ut 3 _ DEPTH DRILLING LOG Cilyor Town Smte Zip Code From To Formation Descripl ion Inc- C/M Area code.Phone number 4. DATE DRILLED — 5. TOTAL DEPTH: r 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO W I _ T STATIC WATER LEVEL Below Top of Casing:_ 1 SFT. (Use"+"if Above Top of Casing) 0 � R. TOP OF CASING IS I FT"Above Land Surface* --- 'T'op of casing terminated at/or below,land surface requires a "3 variance In accordance with 15A NCAC 2C.01 IS. 9. YIELD(gpm):_".30 METHOD OF TEST 10. WATER ZONES(dep(h): I L,O r LOCATION SKETCH 11. DISINFECTION:Type .A r H Amount=r2, J 7`, Show direction and distance in miles from at least 12, CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weighb'Ft. Material numbers and common road names. From_Q �_ "To .Q_Ft. 61 _4_. 60CRA _PTC-- d- ar, 4�1111Ywl P0, �C �•�m1�P5 �'(Jrr1 From To Ft. lec�T10� 7 1 E c % ..� rn�l�$ ',}li(✓1 From To Ft.11 GROUT: Depth Material Method �i��Nb- DYN G'i1ason O r� or J From_n Togo 1l (� From To----Ft.___--- - — -- �rl V A-e5 dr, t.le\l (�Y\ IP9� 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Marerial From To FL— From—To- FL . 16, REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT COPY OF THIS RECORDHAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE "!ELL DATE Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1616 Phone No.(919)733-3221,within 30 days. GW-I REV. 07/2001 WELL CONSTRUCTION RECORD V W North Carolina- Department of Environment and rural Resources-Division of Water Quality- Groundwater Sect`i�oni��/ WELL CONTRACTOR(INDIVIDUAL)NAME (print) ( CERTIFICATION#L7Ul� WELL CONTRACTOR COMPANY NAME_ U cVw,/�Ada Tu//. PHONE # 9-4—ia STATE WELL CONSTRUCTION PERINIIT# ASSOCIATED WQ PERMIT# (if applicable) (inapplicable) 1. WELL USE(Check Applicable Box): Residentialr- Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use 2. WELL LOCATI N: Topographic/Land setting Nearest zown: t County C�—UW4110 ❑Ridge ❑Slope ❑Valley ❑Flat l breL47 C44G (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: �.r2f4IgL r t n (degrees/minutes/seconds) Address 2s ,i/f! Latitude/longitude source:❑GPS❑Topographic map (Street or Route NoJ (check box) �1 a�if4 AIL �i�/3 DEPTH DRILLING LOG iEyorlf own State zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED 9-dJ'O S 6�A 5. TOTAL DEPTH: (PSS` 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 Z—FT. Above Land Surface' -Top of casing terminated atlor below land surface requires a variance in accordance with 15A NCAC 2C.0118. 9. YIELD (gpm): as1 METHOD OF TEST__ 10. WATER ZONES (depth): _ LOCATION SKETCH 11. DISINFECTION: Type Amount ._ Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth, Diame� r or Weight/Ft. Material numbers and common road names. From t9 To NO Ft. From To Ft. _ From To Ft. 13. GROUT: Depth Material Method _ From—D—To D=P Ft. ('D_/4A/� From To Ft. 14. SCREEN: Depth Diameter Slot Size Material - _ From To Ft. in. in. o Ul From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft.- From-To-Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL CO TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER Zd SIGNATURE OF PER`O�QONSTRUCMG.THE.WELL. DATE Submit the original to the Division of Water Quality;Ground)jale• S,getionl-1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days j6$ GW-I REV. 07/2001 i j aF�+TAh o . RESIDENTIAL WELL coNSTRUCTIoN REcoRD North Carolina Department of Environment and Natural Resources-DivWmm of Water Quality WELL CONTRACTOR CERTIFICATION If 1.WELL CO11NN.T CTO I. DISINFECTION:Type Amount 2 �ND g. WATER ZONES(depth): We1�C`ontractor�(Ind' ulal)Name / From_T0 J� From To (9r /:L jz/ &A-)// �Y NNI/,'r/d Frain To From To Well Contractor Company Name { -� Lx �f From To From To STREEfTADDRESS 6(3y & Ann/d/✓YI /Cj G. CASING: Depth p� Thickness/ RQ�IIHYICUaNIl� 1Vc d5(77/ FTAn�To�Ft(ner Weight Material City or Tarn State Zip Code From To Ft _ (RQ1•I�.,• ' 5 if Fran To Ft Area code- Ptlane number 7. GROUT: Depth Material Method 2.WELL INFORMATION: Fmn_To %0 FtP-MP)`IT Nh SITE WELL ID#(if apgicate) From To FL STATE WELL PERMIT#(/applicable) Fran To Ft DWQ or OTHER PERMIT 9(d applicable) 8. SCREEN: Depth Diameter slot size Material WELL USE(Check Applicable Box): Residential Water Supply 1I Fmn To Ft_in. _in. n / From To Ft_h in. DATE DRILLED,(I-�Ln/�7'dJ Finn To Ft._in, in. TIME COMPLETED I aC. 3a AM❑ PM M 9. sANwGRAVEt PACK: 3.WELL LOCATION: Depth Sim Material From To Ft CITY: A If t r COUNTY1 Finn To Ft ` , F1 Ctl//r.S' tC�L oC�7 From To Ft (Street Name.Nwnbera.Cmenundy-Subt iasion.Lot N .Parcel.Zip Coae)- TOPOGRAPHIC t LAND SETTING: 10.DRILLING LOG - ❑Siope Ovaley oRat ORidge 000ra From To Formation Description (cheek WprW iate boo May in . LATITUDE 3 >�`: ao L3'S, n devem minus ,��or LONGITUDE y� U'!- 49tt ma deeinral4mat Latitudellongitude source: ®GPS oTopographic map (bcation ofael must be sham on a USGS topo map and &fftW dfo Ihz/arm/notusig GPS) _ 4.WELL OWNER -:.. OWNER'S NAME(a3-M R"CA✓11ord ` - t i STREET ADDRESS (-Ullts r 1tv,son Ct'7L AIC oy71 3 � b9 C' or Town State Zip Cale p.„ Area code- Phone number - 11. REMARKS: S.WELL DETAILS: a. TOTAL DEPTH: _ b. DOES WELL REPLACE EXISTING WELL? YES❑ NO It 100 HEREBY CERWYTHATTIea WELL WAS CONSTRUCTED N ACCORDANCE Wrim C. WATER LEVEL Below Tapd CaeirTg: _FT. 15A NCAC 2C.WELL CONSmrtcmN STANDARDS.ANDTHATA Cart O'lets (Use'tom If Above Top of Casing) RECORD MS tB�EEN PROVIDED TO THE WELL OWNER ove d. TOP OF CASING IS I . Fr.Ab Law suame' `�AY t /"f'Y/A P [6^02 7.•q5� 'Tap of casing terrtrlffied attar below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE a variance in accordance,with ISA NCAC 2C.0118. eta. YIELD(gpm):�METHOD OF TEST QS J`_ 11YA to PRINTED NAME OF PERSIN!CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Fa 1617 Mail Service Center-Raleigh,NC 276994617 Phone No.(919)733-7015 ezt 568. rmw-1a G Rev. G d..r SrAiFo V ('w RESIDENTIAL WELL,CONSTRUCTION REcoRD U 5 yl - North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION M cl3s'e 1.WELL —rCONTRACTOR: / E DISINFECTION:Typo Amount ��p.ro•G e - g. WATER ZONES(depth): Wen Contractor(lnd'Wtd me Na Fran .'1D To��jr From To �r�F�GIm Ljell r'�YYn���y�p From To From To Well Contractor Company Name '/ �— From To From To STREET ADDRESS J/h3� �,�p T ajn Rej. 8• CASE: Thickness/ materialWeWM b rTown i'/�E /VC a,f177/ F�n_�T��ps�FtZr Rnr:]I PyeG City a Town State Zip Code From To Ft _ (579 re } L 2E /•yrj!� From To Ft Area cod Ph. Ph nwrnber 2.WELL INFORMATION: 7. GROUT. Depth Material �U�Method O SITE WELL ID e Cf applicable) Fmm1}_To�_Ft C,64jenr From To Ft STATE WELL PERMITIry applicable) From To Ft. DWQ or OTHER PERMIT#(f eppGeable) g, SCREEN: Dept, Diameter Slot Size Material WELL USE(Check AppWaWe Bwo: Residential Water Supply M From To Ft_m. _in. From To Ft_in. _in. DATE DRILLED 4/--(X'5� From To FL_in. _ in. TIME COMPLETED � �rZO AM❑ PMIS 8. SANIYGRAVEL PACK: 3.WELL LOCATION: Depth Sim Material m — CI)•Y: / COUNTY<Sl._J/Lrry1 From To Ft thrriL ',uY Tier' Zk FmnL TcL FL (Sheet Name.Numbers,CaarRcWly.SWdnision,Lotlh.,Parcel,Zip.Code)- TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG OSbpe pValley ❑Flat OtRidge 00ther From To Formation Description (check appropriate 1304 LATITUDE 3 � mianes,secarnds a LONGITUDE Q a '6 Y,,f" in a dsiool Gormm t ;. Latitude/longitude source: MGPS OTopographic map o (location d Walmustbe sham on a USGS logo map and bleached to Ors fare l not as ft GPS) s 4.WELL OWNER —' OWNER'S NAME L• STREET ADDRESS f�rv.con e/4V I✓G `.1Sr7f _ C 0 Town State Zip Code Aran code- kVLuimb,�'Q 11. REMARKS: 5.WELL DETAILS: �N a. TOTAL DEPTH:JC.Ii� b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 1 DO HEREBY CERIFYTHAT7W WELL WAS CONSTRUC1ED IN ACCORDANCE wmt c. WATER LEVEL SeloNTop or Casing: FT. 1aA NCACW.WLL E CON5IRUCTDN STANDARDS.AND IHATA COPY OF met (Use'+'If Above Top Of Camp) RECORD HAS BEEN PROVIDED TO THE WELL OWNER d. TOP OF CASING IS_I Fr.Above Land Swface• � ` T/yAo ,^ 'Tap Of casing terminated allor bn9mv land surface may reamer SIGNATURE OF CERTIFIED WELL CONTRACTOR 5 a variance in accordance with 1SA NCAC 2C.0118.e. YIELD(gpm): _METHOD OF TEST Gi!Y' X J441JJ0 PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Farm GW-1a 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.(919)733-7015 ext 566. Rev. 4 C RESIDENTIAL WELL CONSTRucnoN RECORD y! North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION If_Q O(r<2 1.WELL CONTRACTOR: I. DISINFECTION:Type Amouat We �e L/aH - 9. WATER ZONES(depth): n Contractor(Ind'rvid W) ame From 1 To 10 From—To— From—To From To Wei Contractor Coer rpry Name I From To Fran To— STREET 'ADDRESS a / vZL TAG✓/j // 6. CASING: Thickness/ n R/fhhiJ1S(JirI�1 NC iSX771 From�To_��Ft� Weight Anrgl VC (amity or Town State Zip Code From To Ft _ (rb2a )-.(��y^ —GyrsL� From To Ft Area cods rTP I�wie nu 66''nt. 2.WELL INFORMATION: 7. GROUT: Depth Material Method - SITE WELL ID fipf appfirabw) From Tc FL STATE WELL PRMITJIV applicable) Fran To Ft DWQ or OTHER PERMIT 0(0 applicable) B. SCREEN: Depth Dianeter Slot S'¢e Material WELL USE(Check Applicable-Box): ResrdNNial Water Supply® From To Ft_in. _ in. From To FL_in, _ in. DATE DRILLED ��/3�-C3.S� From To Ft_in. _ in. TIME COMPLETED 7 i tad AMD PM NI 9. SAND/GRAVEL PACK: 3.WELL LOCATION: Depth Sae Material From Ta FL CITY: ff C r 11 COUNnTY tS/,,/to,YI From To FL (.-h•.ua.5,oti /arc TN j R,� z I Fran To Ft ( Nam4. bars. .Suhdi*im lot .Parce9�Co&y _ TOPOGRAPHIC I LAND SETTING: - _ 10.DRIWNG LOG OSkpe WVatey OFId ORKIge ❑Omer From To Formation Description (caeck apprapdate bm) May be inLATITUDE �,�� r mNa tes.Bowels or LONGITUDE�„aO t .s>sti.la r n a decimal farmat Latitude/longittde source: MGPS OTopographic map (IocataT of welmustbe shown on a USGS topo map and attached to this form T not usng GPS) _ 4.WELL OWNER ccc�� _ OWNER'SNAME�USS I,�s,Se1Y STREET ADDRESS71.3 �s-YEi1.S'P V !")V•a)Y� er' r'� r n C' a Town a State Zip Code Area code- Phohe ntmhber 11. REMARKS: -. S.WELL DETAILS: a. TOTAL DEPTH: ! � - b. DOES WELL.REPLACE EXISTING WELL? YES❑ NO III c WATER LEVEL Below Top of 100 HEREBY CERTFYTHATTNS WELLWAS CON6mUC1ED NACCORDANCE WRH lip Casing: FT. 15A NCAC2C.WELL CONSTRUCTION STANDARDS.PNOTNATACOM OFTwS (Use'+•0 Above Top d Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER d. TOP OF CASING IS _FT.Above Land Sudxe• `�'(;c,,, \/!A *Top d caskg terminated of below lend surface may TWudTe SIGNATURE RE OF CET ElD1W ELL CONTRACTOR —D" ATE a variance inaccordance with 1SA NCAC 2C.011 S. e. YIELD(gpm): METHOD OF TEST Ft.l r PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, w-ter Fo 1617 Mail Service Center—Raleigh,NC 276994617 Phone No.(919)733-7015 ext 568. mtG Rev. G e«.sTArto RD V t� :J YS l tit ESIDENTIAL WELL CONSTRUCTION RECORD W North Carolina Department of Environment and Natural Rasrmuc c Division of Water Quality 4m«.m WELL CONTRACTOR CERTIFICATION ii_ r90 J y 1.W�EELLLL CONCONTRACTOR. I f. DISINFECTION:TYPe _ Amoum� 2 �/.,4 A g. WATER ZONES(depth): Well��or(I�ud)Nam 1 Fmm�L Toadl� From To CTi r Jdm (ll y/� l/l t����i'Hfi From To From To W el Contractor Cornpa y Name d� t Fmm To From To STREET ADDRESS �.� f� zl J RBI S. CASING: Thickness/ BA y 11 S'wn t//lid /1�C 771 From�_TToo?/ Ft2r sn 1-31 r /c- h Weight material City a Town State Code Fmm To Ft R y5-y From To FL Area code- Phone number 7. GROUT: Depth MaOerial Method 2 WELL INFORMATION: Fran_.,�,,,_To_�a _FLCPrYlOY1T +f-J,y..•,W n' SITE WELL ID tf(0 applicable) From To Ft STATE WELL PERMIT"appkade) Fran To FL DWO or OTHER PERMIT#(if appiicaW & SCREEN: Depth Diarnater Slot Sias Matael WELL USE(Check Applicable 8ac):. Residential Water Supply 51 From To FL—in. _ in. From Tc FL_n - in.r DATE DRILLED AI-22—O ra .S� Fn To FL_bL _in. TIME COMPLETED Ili : .3O AM® PM 9. SANDIGRAVEL PACK: 3.WELL LOCATION: Depth size Material CITY: Rneletk2 ell COUNTY"3&✓0L'k A7 Fran To FL /�'a TT Fmm To FL is/ eat ed �1rnnG�I Ate From To FL eet Name.- SAGoion.int Nw.Pakml.Zip.Code)- TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG ❑Slope oValey ❑Flat MRilge ❑Omer From TO FomlabDn Description (dwc k appropriate bond ,ice az,�„ May ems,smartrem ndso LATITUDE wautes.eecarLLs a LONGITUDE jL 'f a1 a °W Tenet Latitude iongiwde source: 1pGPS OTopographic map (location of Wei must be shown on a USGS topo map and p atlached to 0ris reran Ind us►g GPS) 4.WELL OWNER F. OWNER'SNAME C� S STREET ADDRESS nc�t U'1 �rvSOn C. C r Tam State rN Code La2j:}grrs- /93S Area code- Phone mBnber 11. REMARKS: S.WELL DETAILS: a. TOTAL DEPTH: 7kS b. DOES WELL REPLACE EXISTING WELL? YES NO Id I DONEREBY CERTFYT TTIS WELL WAS CONSTRUMED INACCORDANCE WoN c. WATER LEVEL BdaAr TopdCasng: C1 FT. IAA NCAC:O.WEu OONsmucuoN STANnARDS.ANDTHATAC Or Tit (Use'+'gAbare Top of Casing) RECORD HAS BEEN PRUIOEOTOn E WELL OWNER d. TOP OF CASING IS I_FT.Abae Land Surface' ^j HV �� 'Top d Casingin ccormled aVorv.M belay lanCA surface may requie SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE a vaiarce n accordance with 15A NCAC 2C.Ot 18. e. YIELD(gpm): METHOD OF TEST L i!C ;TA LZ 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.(919)733-7015 90 568. Fam FormGW-ter7105 ".w STATta 411 4 RESIDENTIAL WELL CONSTRUCTION RECORD `' t North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION#_4,5'Q 1.WELL •CONTRACTOR: f. DISINFECTION:Type T Amount�t�p Tea ea�P &JIV g. WATER ZONES(depth): Well Contractor(Ind ual)Name From2�_To-aj([5-_ From-To- 6 iv;"CR M L✓Nzz r I// From To From To Well Contractor Company Name o From To From To STREET ADDRESS 6 �0' �[�f j7 ��r.� 6. CASING: Thickness/ R^ Depth Diameter Weight Material R4 tv�T lam. //ta e 77/ From Vj Ft. (; �; sutal Py�_ ry a Town Stated Zip Code From To Ft. T ( t From To Ft. — Area coda- phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method From_Tom Ft.CcrMAhT SITE WELL ID"I applicable) From To Ft. STATE WELL PERMIT#(d appacable) From To Ft. DWO a OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Sox): Residential Water Supply Q( From To FL__in. — in. From To Ft. in. _ DATE OMLLED_�d From To Ft._in in. . _ TIME COMPLETED in. !) AM D PM® S. SAND/GRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: /'VsOn CA COUNTYA I h From To FL From To Ft- 0-r:5!lif o y b Fran To Ft. (Street Name,Nufnbers,Carnmundy,Subdivision,Lot No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope OValley ❑Flat ®Ridge ❑Other From To Formation Description (check appropriate box) LATITUDE 3 '�� �-f! May be in degeeO minutes,seconds m LONGITUDE� 3O l/ in a decimal format Latitude/longitude source: wGPS pTopographic map (location of we#must be shown on a USGS topo map and attached to this form 7not using GPS) Y 4.WELL OWNER J OWNER'S NAME I2?�Cr�C'V STREET ADDRESS V-/� ^ SJI"thSUYI C m Town ' State Zip Code c�'25t )-�firSf'- I9.�S Area code- Phone number 5.WELL DETAILS: 11. REMARKS: a. TOTAL DEPTH: (S�_ b. DOES WELL REPLACE EXISTING WELL] YES❑ NOR c. WATER LEVEL Balm Top of Casing: .�(�(J FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH (Use`*'B Above Top of Casing) RECORD DHAS BEEN PROM ED TO WELL OWNERRDS . THAT COPY OF THIS d. TOP OF CASING IS I FT.Above Land Surface* `I N I op of casing terminated atia below land surface may require SIG ATURE OF CERTIFIED WELL CONTRACTOR a variance in accordance With 15A NCAC 2C.0118. ,U/ DATE e. YIELD(gpm):�_METHOD OF TEST�b f /^ �2r. 11YA P PRINTED NAME OF PERSON CONSTRUCTINCf 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.(919)733-7015 ext 566. Form GW-1a Raw.7/05 r' L 1 L - .'- RESIDENTIAL WELL CONSTRUCTION RECORD f 4 North Carolina Department of Environment and Natural Resources-Division of Water Quality _ WELL CONTRACTOR CERTIFICATION N_Q Q,-�Q 1.WELL CONTRACTOR: f. DISINFECTION:Type // Amount je- k� 4A g. WATERZONES(depth): Well Contractor(individual)Name o From 4Za5- To,�J.s From To S�/1�Y✓J L✓Pd �A r f�y/ /?g From To Frain To Wed ContractoTCompany Name '/ From To - From—To— STREET ADDRESS r 37 FA�y�p T wn R� 6. CASING: Thickness/ lye, From Depth To(�Ft. Diameter g13r_jf Material or Town State Zip Code From To Ft. _ Fran To Ft. Area cade--PhorNj number 2.WELL INFORMATION: 7. GROUT: Depth Material Method SITE WELL ID#(if applicable) From O 7oy?Q__Ft Cdrrp;ohr At,- From To Ft. STATE WELL PERMIT#(9 appiicablel Fran To Ft. DWQ m OTHER PERMIT 9(g applicable) E. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Bail: Residential Water Supply 2j From To Ft. in. _ in. DATE DRILLED Fran - To Ft in. _ in. �D--3^CJS� Fran To Ft In. in. TIME COMPLETED ��r�G AM"® PM O 9. SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: /,�p,(� n e-,'Ty COUNTY�Ir.J�_ Fr°m T°' Ft 7— Fran To Ft. !/ SdDYi�flG Rr,, as'r v2- From To Ft. (Street Name,N re. unity, ubdiftion,Lot No.,Parcel,cp code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG (check appropriate box) Slope pValley ❑F6t ❑Ridge ❑Other From To Formation Description P LATITUDE 3 �� ` '�i� M ay minutes, LONGITUDE� a° 29'?9. 9" Latitude/longitude source: gGPS ❑Topographic map (location of web must be drown on a USGS topo map and attached to this form 1 not using GPS) 4.WELL OWNER OWNER'S NAME c /^ STREET ADDRESS C or Town State Zip Code Area code-hone number 5.WELL DETAILS: / 11. REMARKS: a. TOTAL DEPTH: N el la. DOES WELL REPLACE EXISTING WELL? YES NO 10 c. WATER LEVEL Below Top of Casing:_ //J(J FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wmt 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THATA COPY OF Tlaa (Use'+-tf Above Top of Casing) RECORD HAS BEEN PROVIDED To THE WELL OWNER. d. TOP OF CASING IS.I FT.Above Land Surface- �� op ri Dosing terminated with beloISA land surface may require SIGNATURE OF CE IFIEAD WELL CONTRACTOR z r =DA E s a variance in accordance with 15A NCAC 2C.0118. e. YIELD(gpm): 41 METHOD OF TEST t'Jl,t r✓' —LJ E-1- !7r V�p 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.(919)733-7015 ext 568. Form GW-1a Rev.7/D5 D.,',.SrA1Ty RESIDENTIAL WELL CONSTRUCTION RECORD ' North Carolina Department of Environment and Natural Resources-Division of Water Quality 9 ' WELL CONTRACTOR CERTIFICATION A 2045 IOU 1,WELL CONTRACTOR: I. DISINFECTION:Type. H T H Amount 1 68Z James B. Brown g• WATER ZONES(depth): Well Contractor(Individual)Name From�{1nU , To 22 From To 'Hedderi Brothers Well Drilling IrrC. From s To— •• From To Well Contractor Company Name From To From To STREET ADDRESS 73 lolly Hills Vista Rd 6. CASING: Thicknesst _p_, F 'LT /„.� Dl�rne:er .100 z10 FYankl i n N(` 28734 From To Ft. _ w0 City or fawn Slate Zip Code From To Ft. ( 828 )- 369-9591 From To_Ft. Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method From_�To 20 Ft. catHlt & t]BYn1tE RIIpH3 SITE WELL ID#(if applicable) From To Ft. STATE WELL PERMIT#(ii 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 0 From To_Ft. in. _ In. O From To_Ft.—In. _ In. DATE DRILLED From To Ft_in. _ In, TIME COMPLETED 3• AM❑ PM ff� g, SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material From To Ft. CITY: AAgg&_� //1I COUNTY from To Ft 1, )(,t,1 Wj 1� (i"fi From To Ft. (Street Name,Numbers.Community,Subdivalon,Let No.,Parcel,Zip Code) - TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope ❑Valley ❑Flat ❑Ridge OOther From To Formation Description (check appr6prlals box) e in r Clay & Sand LATITUDE May minutn,seccondsonds or f- r - r CIr ni o LONGITUDE in a decimal fomist Latitude/longitude source: ❑GPS ❑Topographic map (location of wet must be shown on a USGS topo map and attached to this form l not using GPS) C7 4.WELL OWNER r OWNER'S NAMEppJJ ''- S-f EET ADDRESS jVd fie J9713 City cam /xLf State Zip Code Area code• Phone number 11. REMARKS: 5.WELL DETAILS: a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX 100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH C. WATER LEVEL Seim Top Of Casing: FT. 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS (Use•+•If Abam Top of Casing) RECO HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASINO 18 2 FT.Above Land Surface' 'Top of Casing terminated at/or below land surface may require NATURE OF CERTIFIED WELL CONTRACTOR 'DATE a variance in accordance with 16A NCAC 2C.0118. e. YIELD(9pm):4—METHOD OF TEST BloW James B. Brown PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt:, Form GW-la 1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.(919)733.7015 ext 568. Rev.7106 } RESIDENTIAL WELL CONSTRocTION RECORD \ V� , '� North Carolina Department of Environment and Natural Resources•Division of Water Quality WELL CONTRACTOR CERTIFICATION N 2045 1,WELL CONTRACTOR: f. DISINFECTION:Type H T H Amount 166Z James B. Brown g• WATER ZONES(depth): Well Contractor(individual)Name From-.JL Toa69' From To He(ki n Brothers Well Drilling Inca From Abl' TO� From To Well Contractor Company Name From To From To STREETADDRESS 73 Holly Hills Vista Rd S. CASING: Thickness/ Depth Diameter Weight Material F'ranklinF N 8744 FromATo�.9 Ft. " C Cly a Town State Zip Code From To a�Ft. loN ( 628 )- 369-9591 From To__Ft. Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method From To 20 Ft.9n3t & ill.tE EgMEd SITE WELL ID#(If applicable) Fran To Ft. STATE WELL PERMIT#(if applicable) From To Ft. DWQorOTHERPERMIT#(ifapplicable) S. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply O From To Ft._in. _ In. From To Ft._In. _ In, DATE DRILLED I O -ZG •Q5 From To Ft._in. _ in. TIME COMPLETED �J�sO�AM❑ PMp/ - 9. SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: COUNTY_�tJQf.•o. From To Ft. Fran To Ft _S do From To Ft. (street Name.Numbers,Community,eubtllN•lon,Lot No.,Panl,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope OVallay ❑Flat ❑Ridge OOther From To Formation Description (chock apprdprlste box) May t 3� , Clay & sand LATITUDE r r ..3. _ minutes, in s,seconds o or Rrani fa LONGITUDE_ _ In a decimal fomut Latitude/longitude source: OGPS OTopographic map (location or wep must be shown an a USGS tops map and attached to this form#not us/ng GPS) e.WELL OWNER - OWNER'S NAME STRE ADDRESS , City or T#vn ale Zip Code O c R28 ,• 488 — 9503 Area code• Phone number S.WELL DETAILS: 11. REMARKS: �7 e� a. TOTAL DEPTH: 3DO r b. DOES WELL REPLACE EXISTING WELL? YESO NOA - c. WATER LEVEL Below To of Casing: �� 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED m ACCORDANCE WRH p Q O FT. 1SA NOAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS (Use'+'If Above Top of Casing) REcc AS BEEN PROVIDED TOTHE WELL OWNER. d. TOP OF CASINO 18 2 FT.Above Land Surface' 'Top of easing terminated aVor below land surface may require q E F C R'E WELL CONTRACTOR _ ■variance In accordance with 15A NCAC 2C.0118. e, YIELD(gpm): _METHOD OF TEST B31_QW James B. Brown PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., 1617 Mali Service Center—Raleigh,NO 27699.1617 Phone No.(919)733.7015 ext 568. Form GW-la Rev,7/05 d y � RESIDENTIAL WELL CONSTRucnON RECORD G North Carolina Department of Envunnment and Natural Rmourca-Division of Water Quality •� �• WELL CONTRACTOR CERTIFICATION If 1. Fa a CONTRACTOR. C DISINFECTION:Type l —Amount y r �z t\Cnpsi 9. WATERZOIES(depOrY ;,]p Cmtrada(Individual)Nam Fmm LDD To—&r1S— From To `I��x Fmm To Fran To Wel Contractor CnmperwNwo Fran To Fmm To STREET ADDRESS �a4 `�'"�KI 't F S. CASING: .` ,^, Tforimess/ Fmn�uTo_ FtL Y._ _ City or Toes Stale Zip Cade From To FL (RJR}c„lL , g1yS� From To - Ft— Area code- Prram RBarnber 7. GROUT: Depth Material Madvid 2.WELwELL 3#mapp Frcmf_To�G Ft CO Ma;� 11[11 11 SITE WELL ID a(a appi®hb) Faun Tc Ft ~ STATE WELL PERMFr#g ppfoab) Fmm To Ft DWQ or OTHER PERMIT aid appicable) 8. SCREEN: Depth Diane(a Slot Sbm Material WELL USE(CheckAppirahle Bat): Res erfml Water Supply) From To FL trL in. Flan To FL f =in. DATEDRILLED�r�`�7�(�.'] From To Ft in in. TIMECOMPLETED L4�:t Jf) AMO P(R A SADlGRANB-PACK: 3.WELL LOCATIONt Depth S"me Material CITY: COUNTY E�Wc4i mrs FarR_Tc Ft From To FL C'T'P ek 0AGc Fran To Ft TOPOGRAPHIC/LAND SETTING: _ 10.DRILLING LOG ❑Slope OVatey OFlat ANdge OOBIa Flom To FoMMIDn DearJQtldn (cbem r� bmd ' May be in demos, LATITUDE tea— may,_C�y mi 1Lab3 admae.aecmdsar LONGITUDE o a,. ri nadec®Ifamt Iatitude/longitu�sotnce: XGPS OTopnV*ric map (/ocal ma or"mmus(6e Show"an a USGS 40o map aad adwiaed to a is farm 7not rasing GPb7 4.WELL OWNER OWNER'S NAM f /^�,!,^I,I lr,:i STREETADDRESS „��_( CJE'Pr`. f1 E Ors G , WC_ ok:z J.-�3 fN CiIVorTom State q7 Cade ( Phan Rxernb> � m —er�1 1111 N Area wde- 11. 5.WELL DETAaS: S e1%ille Regional a TOTAL DEPTH: '� uifer Protectio b. DOES WELLREPIAM E LISTING WELL? PESO NOjq G WATER LEVEL BelowT d IMNEMYCERWTMT7MVARLWA5CONSRW WmA=RnANCEwrm ap Csitg:-a�FT. tSANCAC WEUCONSamlCar WMMAFMS.AMIMITACapr OFMM (llse-+•IAbma Top d Casing) RECORDHAS BEEN P ROVDWT07M WELL MINA d. TOP OF CASING 16 I FT.Above Lad Surface' Tap of casing tarrrimlad ago bdm Wad surtaee may require SIGNA E�CERTI WELL CONTRACTOR DATE a variance is aeeardemarwM 16A NCAC 2C.01 18. !1 a YELD(gpmJ 3Q METHODOFTEST�_ C a i:.-A ONI&ggTIf WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GW-1a 1617 hail Service Center—Raleigh,NC 276994617 Phone No.(919)733-7015 ext 566. Rev.7105 y ypae� v . 4 RESIDENTIAL wELL coNSTRucnoN REco" 3 2 13 3 0 North Carolina Depmtmrn(of Envimtment arld Natural Rcswrce -Division of Watts Quality @ � WELL CONTRACTOR CERTLPICATION III U 1.WELL RRACTOR: E DISRWECTION-Type _Amount AZ g. WATER ZONES(deift Weer Conuacbr(kldividuaq Nw a Fam 1 QO To / Fmn To C-AVtYham From To From To Well CadracW Company Name11'' f Floret To From To STREET ADDRESS 16 `llU(�Q �`,q\ cn 'id _ j �� D 1 1 & CASING: Tltrgtmsf y A Abe . 1U a 1 Fran O Tod Qq_Ft S = ) City err Taus Stale Zip Cafe Fmn To Ft _ Ama co }4-- 1 A4 4 Fmn To FL Area codes Pttdne romtha Z WELLI FORMATION: 7. GROUT: Depth Meterel Method SITE WELL ID 0(dappacame) Frdm�To Ft STATE WELL PERM(TN(iapp6rede) From To Ft DWQ ar OTHER PERMIT OR applicable)_ & SCREER Depth Diameter Sk[Size Kletual WELL USE(Check Applicable e B Raiderdial Wafer SlQpyp( Fran Tc Ft_n. _ fa From To Ft_kL in. DATE DRILLED Fran To Ft R _n. TMECOMPLETED ,Fi .Q AM❑ PMPQ 9. SAlClTiRAVEL PACK: 3.WELL LOCATIOW Depth Sim Matem CITY: TY COUN Fmk To FL �� �,� Fran To FL P'r "' f a-1 eroy(1 From To FL (Sew Naule.-Members.CoaUw0y Sdx1Md^latNa-PaeG ZVWda) -- TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG - ❑Slope OValky oF(at )ridge DORM From To Formation DcScripfon (dNwk VPoPft*bwO UTfTUDE 3 J G'/�h�l��I ,I' inMaybe nut�, Q LONGITUDE_gaC 7�,E �/ madxmWfamat Latiaddlm&xle summit~ 03PS (370pogtaphie map fbcafbn o/etelrmrsI be shown an a USGS kpo map and . aaadled to sus form Ind wV GPS) c, O.WELL OWNER - -_ OWNER'S NAME 1 t+ STREETADDRESS T I —Stab Code I�C r C aTwm I IF2i�- } *2 3 A- y ism_ Ansacade- n JAN 301006 11. REMARKS: &WELL DETAILS: m TOTALDEPnt �� ° - ewe Re TOT) c. DOES WO.LREVLACEEXISTINGWELL? PESO HOB UIerP 1DOMtMY CEgWYTMTTNs WELL WASCONMNUCIen N el WATER LEVEL BebwTop of Cacitg: /'0a__FT. ISAW-#C .WaLmtSYRU:nwsTAMARD& rOATACowOrTM (l/se-+•ff Abwe Tap d CmiW F03XMHAS DMI PRWoE0707M WELLGVWWR d. TOP OF CASING Fr.Above Land Surface' /'/4ak' �05 "Top d castg aVd Ilebw kwtd surfew may revue SINNA 17�E�F CERTIFI®Wt31 CONTRACTOR DATE a varbrce it acoardarm w1h 1SA NCAC 2C.01118. e. YMM(gpm). /0 METHOD OF TEST_ 11 PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt, Form GW-fa 1617 Mail Service Center-Raleigh,NC 27 6 9 9-1 61 7 Phone No.(919)733-7015 ext$68. Rev.70 RESIDENTIAL WELL coxsrRDcrloN REcoR* 3 ,91329 4: ✓yr North Carolina Department of Environment and Natural Resources-Doi/vis/ion of Water Quafny u. -r.P- , �w.d WELL CONTRACTOR CERTIFICATION# T 1. CONTRACTOR: f. DISINFECTION:TYpe Amount 4 ez tl i r` M I I L n 5 a. WATERZONEs(depth): Wen Contractor(Individrai)Nan From jjt To��y- From To t / r1.1r1 oq (JO l k rr�l l�n From To From To Well Contractor Cwqmw Name ( - �} V Fran To From To STREET ADDRESS l"1 r� J�Yf. rF�l..ri I4`v,,Cq 6. CASING: TNdmessl .T, W ' L h rail jyL y771 Fmm_0_ Two-3a—� City or Tom Stale Zip Code Fran To Ft - -` a'-Cl' y From To FL Areacode- 4ab 2.WELL INFORMATION: 7. GROUT: Depth Material Method Rom__ToZ_FLLPjn� ' iN i SITE WELL ID/fdappacable) Fun Tc Ft STATE WELL PERMITA101apparablel_ Fran To Ft DWQ or OTHER PERMIT OR apptrable) L SCREEN: Depth Diameter Sid Sbe Material WELLUSE(Chedt Appirable Bark Resndenlial Wa�Sup*01 Fran To Ft . _In. /� Fun To Ft m en. _ir. DATED LLED /.- )a— S Fran Tc Ft m. at TIME COMPLETED , -Of) AM❑ PM Q(; — A SANOIGRAVEL PACK: 3.WELL TIOIk << Depth Sias Material CITY: C.Ol1MY f )(,V C^i Y\ Fran To Ft. Y. Fran To FL TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG ❑Slope oVatiey oFld ARidge pOerer From To Formation Descrom I . a/ Maybe it degrars, LATITUDE ,ys �1 �. 7 m�sa,uoomkor LONGTn1DE�� r/ ma decimal format Latitude/longitude samca )IGPS OTopogaphic nop (ftadmofi"nwdboalimmonaUSGSkpomW&id altedmd b Ois Tam Ind usig GM �1= 4.WELL OWNER -'� 1 . OWNER'S NAME ♦)c7 Y\ W e6 I OIU STREET ADDRESS 256.4 1.PG rza- 1= C' aTawn Slake Zip Code (�. 3flt i - 3j�3 Area code- Phone mmnber 11. REMARKS: A WELL DETAILS: a TOTAL - b. DOES WELL REPLAN OWTINCa WELL? YES❑ NO� IDDMtM CMMTNl1TTI6 WELL WAS WKtnldPCIED NACCORMNCEVMH e. WATER LEVEL A aw Top d Cacing: �FT, tSA nGC=WEIL WNSimwUTna SUNMROS,ADT 'FA COPY OF Tian (Use-+-IAbaie Top dCasirg) RECORD MS BEEN PROVIDED 70 WELL OMnBt d. TOP OF CASINO Is _FT.Aboae land Safao e . -Top of causing kerriNkPa War bdw land saface may requre S RE OF CERTIFIED WEEL CONTRACTOR DATE ava'. inacoadanceweh1SANCAC2C.0118. e. nELD(epmY-4—METNODOFTEST C ✓ - CONISTRUCTW.THE WELL Submit the original to the Division of Water Quality with n 30 days. Attn:Information Mgt, Fam GW-ta 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone o.(919)73j-AfjS2?:q SA5 Ron.7/w Asheville Regional Office Aquifer Protection „a STATLo 961 20489 $5 � t- S RESIDENTIAL WELL CONSTRUCTION RECORD •.�� '� � North Carolina Department of Environment and Natural Resources Division of Water Quality _ 3�3�h WELL CONTRACTOR CERTIFICATION# _ 1.WELL CONTRACTOR: 1 L DISINFECTION:Type Amount�$�� V /L'(Sd-1 r, 1�IF:Q,GI-5 g. WATER ZONES(depth): Wetl ntrxtor(Individual)Name From STD , To d From To Uo1 � WPAI AA,f-e j h From To From To Well Contractor ComPiny Na/m'e y- a 'fran To From To STREET ADDRESS JQ[�,9f4 'e /--C1 A r\ ”" S. CASING: `Thickne1ss/ I�Ohbl✓CYrlle UV /7c 7 FramQ_:To ATth DI t �561 (E)VS City or Town /State Zip Cade From To Ft. Fran To FL Area code- Phone number 7. GROUT: Depth Material Method 2.WELL INFORMATION: Frao�To 9N0 FtCevv_1Q_r\�' lY' SITE WELL ID#(if applkable) From To Ft r STATE WELL PERMR#(d applicame) Fran To Ft DWQ or OTHER PERMIT#(if appricable) 8. SCREEN: Depth Diameter Slot S¢a Material WELL USE(Check Applicable Box): Residential Water Supply p Fran To Ftin. _in. From To Ft_in. _in. DATEDRILLED �! —rX/-/7 From To FL_m. _in. TIME COMPLETED AM❑ PM(L S SAND/GRAVEL PACK: 3.WELL LOCATION: e Depth size Material CITY: r COUNTY VLjCA" h From To FL C^7IDrV / ' 1 rM From To Ft (Sheet Name.N omm bees.Community-Subdiasion.Lot No..Pemet Zip Code)- - _ _..___.-... . ice_ TOPOGRAPHIC I LAND SETTING: - 10.DRILLING LOG ❑Slope pvaley ❑Fla KRidge ❑Other From To Formation Description (check appropriate box) U LATITUDE '/7, / rI minutes. or LONGITUDE cK &3 0' /( ma decimal format Latitude/longitude source: ACPS oTopographic map (location of we/must be shown on a USGS fopo map and a#acbed to Bus lam snot ushg GPS) i 4.WELL OWNER OWNER'S NAME 7t?S p STREET ADDRESS r ' r'<7� State Zip Code Area code- Phone number 11. REMARKS: 5.WELL DETAILS: e a. TOTAL DEPTH: 6,130 _ b. DOES WELL REPLACE F_)OSTING WELL? YES❑ NO g( 1001ERESY CERIFY THAT TM WELL WAS CONSTRUCTED NACCORDANCE WITH c WATER LEVEL Below Tap of Casing:_202�__FT. IM NCAC M.WELL CONSTRUCIM STANDARDS.AND THATACO"Or Ties. (Use•+•if Abce Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER d. TOP OF CASING IS I Fr.Above Lana Surface .—DDT •Tap of casi o termi aed a/or below land surface may require SIG URE OF CERTIFIED CONTRACTOR DATE a variance in accordance with 15A NCAC 2C.0118. e. YIELD(gpm):L_METHODOFTEST OLI r j��S PRINTED E 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.(919)733-7015 eltt 568. FormW-1a G LL 4;;3 Rev, G c ' - RESIDENTIAL WELL CONSTRUCTION RECORD �J 3 2 Q �.� North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION 4 '�a,�Y-d 1.WELL CONTRACTOR: U DISINFECTION:Type NTH Amoultt_� g. WATER ZONES(depth): Well Contractor(In�—uall Name /t France To�_ From To r `v rCgYfn-Yvf IA)ell Cty"//./na From To From To ell Contradar Company Name Fran To Fran To STREET ADDRESS CD3�lYYto T/./H R 6. CASING: Thickness/ Depth Qi;lrleta Weight Rn�inry:!!.o N'G ' Sr77/ Fran__j�__To_2a_Ft. SQr�L City or Town State Zip Code From To Ft _ Ida }'�' ysw From To Ft. Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method From__To QQFLCEmM:* ;Jh't SITE WELL ID 0(il appicable) From To Ft STATE WELL PERMIT4fd applcabte) From To Ft DWQ or OTHER PERMIT 0(d applicable) 8. SCREEN: Depth Diameter Slot Sze Material From TO Ft—in, _ in. WELL USE(Check Applicable Bar): Residential Water SupplySJ From To Ft In- _in. DATEDRILLED �f ���{^/7� From To Ft in. in. TIME COMPLETED O AM❑ PM 1' 9. SAID/GRAVEL PACK: — 3.WELL LOCATION: Depth Size Material CITY: /jgn n COUNTY Fmrrl_TcL._Ft From To Ft cS k l/ Ca i/A 9,Fr JI From To Ft (street Na�,Conuntmay,.SlAmuision,Lct7Vo..Parcel.ZT.Code)- _- TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope oVaky ❑FIM MRidge 0001er From To Formation Description (check appropriate bmQ - s�` �`Ysi'Y May lniumide�' LATITUDE Donate;secalds or LONGITUDE$ .30 t3Q'08.!y loadecimalbnmt Latitut&Aongitude source: 5tGPS ❑Topographic map - (bca8bn of well irmsf be shown on a USGS loon map and aftectred to ants form Ind using GPS) 4.WELL OWNER --�Y-- / OWNER'S NAME uci r T /Qk)/Y/cCI't fJ� STREETADDRESS cSICV COVeP rvS�sn Ceti7V rMe- �A71 CX aTown ' State 744 Code `;-sr Area code- Phone number 11. REMARKS: 5.WELL DETAILS: n TD a. TOTAL DEPTH: O Fyoz b. DOES WELL REPLACE EXISTING WELL? YES❑ NO0( �q I ODHEREBYCERTFYTH MS ATTWELLWASCOSTMXIWNACCORDANCEWTIM C. WATER LEVEL Bellow Top of Casing: ( .I FT. 15A NCAC 2C.WELL CONSTRUC1ON STANDARDS.AND THAT A COPY OF TM (Use'+•a Abom Top d Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER d. TOP OF CASING IS T FT.Abae Land Surfacee �lTp �HP. /�^ `Top d casing tertTima[ed aVa below land surface may require SIGNATURE CERTIFIED WELL CONTRACTOR DA E'� a variance in accordance with 15A NCAC 2C.0118. e. YIELD(gpm):�_METHOD OF TEST 1 I� &t' PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL, F=GW-1a 1617 Mail Setrvice Center-Raleigh,NC 27699-1617 Phone No.(919)733-7016 ext S68. I i 2 4 LLvO Rev.7105 -6^c STAIt'v 320487 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION N tQa522 1.WELL CONTRACTOR: I. DISINFECTION:Type Amount (L_ 0.O-Vp "P - 9. WATER ZONES(depth): Well Contractor(Indwilluall Name )/ From___( -_Tom_ From To m !Llee// a .r/r/! / /![) From To Fmm To Well Contractor Gomp//ary Name 1 1 From To From To STREET ADDRESS If�3-L 6W e Town RA S. CASING: Thickness/ 1�Q� /rng Vi l�F NC �77/ From� om � ndatelial _T Ft C Cdy or Torn State Zip Code From To Ft _ (�l-�q-61 q6"I From To Ft _ Area code. Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method SITE WELL ID H(d appucawe) Ftan_j0_To_Q(Q_Ft hY r` From To Ft STATE WELL PERMIT!(Yappaeade) From To Ft DWQ or OTHER PERMIT C(if applicable) S. SCREEN: Depth Diameter Sid Size Material WELL USE(Check Applicable Bmc): Resrdmlial Water Supply b] From To Ft—in. — in. DATE DRILLED lJ�— (� Frain To Ft_m. _ in. 61--"� From To Ft._in. —in. TIME COMPLETED y2 c3(5 AMD PMjg S. SAND/GRAVEL PACK: 3.WELL LOCATION: Depth Size Material fFrom—C([I'T�Y: (/S� O J9 C,i�Ex COUNTY_c1a I.✓C�,/}? F� To Ft tnn 7ana ��E,v T Q� 713 From To FL (Street Name.Numbers.Cmenunty_Subdivium,Lod. w,Pared,Zip Code} _ __.._,_- _.. . --.. TOPOGRAPHIC I LAND SETTING: 10.DRIW NG LOG ❑Slope OVa&,y ❑Flat MRidge ❑Other From To Formation Description (Check appmprlate box) 'e ,�t"7 N /1 May be in dew LATITUDE 3 �0�,�. � mioutes,umrldsv LONGITUDE$,,,, o /! in a decimal format Latitude/longitude source: ®GPS OTopographic map (bcatba of we/must be shown on a uses topo map and attached to M form Jnot usig GPS) 4.WELL OWNER J� � OWNER'S NAME) ,f Peerkins _ STREET ADDRESS - C1n20Jlgr_ �' TY 7/Jl� C y err TownI State Zip Code Area code- Phone numbs 11. REMA S: S.WELL DETAILS: ems/ 1_0 a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES❑ NO la G WATER LEVEL Blow Top of Casing: IUD HEREBY CMlFYTHATTMWELLWAS CONSIRocica NAC DgXE WITH 0 FT. 15A NCAC=.WEU COr'ISUILICT N STANDOUMS.ANDTHATA Cow OF TM (Use'+'I Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER d. TOP OF CASING IS.I FT.Above Land Surface J'DATE QN 'Top of casing ternailated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR ,J a variance in accordance with 15A NCAC 2C.011B. .-� I� {- L/ e. YIELD(gfm): h METHODOFTEST 0,1'r tl� -P !TV11'd PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, FarmW-ter G 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.(919)733-7015 ext 568. k , 2 4 LuOBRev. �a.F STA�o RESIDENTIAL WELL CONSTRUCTION RECORD 485 4". North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# F o�(:�) 1.WELL CONTRACTOR: f. DISINFECTION:Type Amount 1,202 g. WATER ZONES(depth): Well Contracts"(IRdiividual)Name Rom-)k0) To S O From To Pek et i," 0 El i l f"i��r hn From To From To m Well Contractor Copany Name r1 Fran To From To STREETADDRESS (��r y�do TIAJn lCr� 6. CASING: Thiclmessl I Depth er Weight aerial nbh/`»SV/l�B /UG a2771 From 3/ Ft nra City or Torn Stale Zip Code From To Ft _ 41Z?- �6Lf Fran To Ft Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method Fr pia an_�To�Ft('.a h1 F�YI T SITE W ELL ID#(d applicable) From To Ft STATE WELL PERMIT#(F applicable) From To FL DWQ or OTHER PERMIT#(if applicable) R. SCREEN: Depth Diameter Slot Size Material WELL.USE(Check Applicable Box): Residential Water Supply R From To Ft—in. _ in. From To Ft_in. _in. DATE DRILLED !/t -nS Fran To Ft_m. _in. TIME COMPLETED a y IS AM[I PM® g, SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: ,t z] 4, r2 C_ COUNTY S(AI�1�/`� FmnL _Tc FL nn From To FL /[f�n YY ,0k.Y- me rY 7�� From To FL (Street Name.Nmabers.Commmrily.SUbtinniM L C416X.Parcel.Zip Code) _ — -_ . .;9_—_.__._ —__ - ___ -- TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Skpe OValley ❑Flat ®Ridge ❑Other From To Formation Description (check approptlab box) LATITUDE '� .pe c r - �r May be in dcBas, si mintamsaondsm LONGITUDE-?-am '1*3�/-4.c{11 ma decimal format Latitude/iongibude source: MGPS ❑Topographic tnap (location of weI must be shown on a USGS topo map and attached to this Ibm;7not using GPS) 4.WELL OWNER ..� - OWNER'SNAME John tS/QTer STREET ADDRESS &nZh,0/' 13r�sar, .`ram fl/GSr7/3/3 m RC a Town Slate Zip Cale (R�sr l--tf5rsr� 9Soa Area code- Phone number -v 5.WELL DETAILS: 11. REMARKS: a TOTAL DEP'TH: _ b. DOES WELL REPLACE DUSTING WELL? YES❑ NOR 1 DO HERESY CERTFY THAT TM WELL WAS CONSTRUCTED N ACCORDANCE WITH C. WATER LEVEL Below Top d Casing: FT. I'M NCAC 2C.WELL CONSmucTEN STANDARDS,ANu THATAC,,M TM (Use'+'#Abom Top of Casing) RECORD HAS BEEN PRCNEEDTO THE WELL OWNER d. TOP OF CASING IS I _FT.Above Land Surface 'Top of Casing termiiated land atior below d surface may require SIGNATURE OF CERTIFIEDG0- WELL CONTRACTOR DATE a variance in accordance with 15A NCAC 2C.0118. e. YIELD(gpm): _METHOD OF TEST r&/e rJ � ItI (/ PRINTED NAME OF PE SON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-la 1617 Mail Service Center-Raleigh,NC 276994617 Phone No.(919)733-7015 ext 566.J,',;v 2 4 2006 Rev.7/D5 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION N 2045 1.WELL CONTRACTOR: 1. DISINFECTION:Type H T H Amount 166z James B. Brown g. WATER ZONES(depth): 1 Well Contractor(Individual)Name From To._ A iZ From To iden Brothers Well Drilling, Inc. From To From To Well Contractor Company Name From To From To STREET ADDRESS 73 Holly Hills Vista Rd S. CASING: Thickness/ �Dep'7 7 Diameter Wglp(t1� Ma Brie/ Fr ankl y,� N(, 28734 From To l O 1 Ft. _1.2_ 11 Db City or Town Slate Zip Code From_To_Ft. 369-9591 From__ToFt. _ Area code- Phone number 7. GROUT: Depth Material Method 2.WELL INFORMATION: From -_To 20 Ft. CE[Hlt & bErinil be WIPE SITE WELL ID d(If applicable) From_To_Ft. STATE WELL PERMITIl l applicable) From__To Ft. DWO or OTHER PERMIT ill applicable) S. SCREEN: Depth Diameter Slot Size Material From_To Ft—in. _ In. WELL USE(Check Applicable Box): Residential Water Supply p From_To Ft._in. —In. DATE DRILLED L From__To_Ft._In. _in. TIMECOMPLETED AMO PM S. SAND/GRAVEL PACK: 3.WELL LOC TION• Depth Size Material From To_Ft. CITY: COUNTY From To_Ft. From To Ft._ (Strae a ,Numbefa, ommunity, ubdlNsion,Lot No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope ❑Valley CiFlat ❑Ridge ❑Other From To Formation Description (check spDrdpriate box) 0 10 Clay & sand [ins n dearea, 1 1 1 Gran i E LATITUDE _ seconds or LONGITUDE mal format Latitude/longitude source: ❑GPS OTopographic map (location of well must be shown one USGS tope map and attached to this form,rnol using GPS) 1.WELL OWNER OWNER'S NAME STRE TA DR SS, _ i on NC City or Town f Stale Zip Cale �1 ( S'ZE. 49-A& U4189 Area code- Phone number O -_ 11. REMARKS: 5.WELL DETAILS: - a. TOTAL DEPTH:_�.51SL b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ 100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH a WATER LEVEL SolowTopof Casing -- . NX) T. I 15ANOAC C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS (Use'+'O Above Top of Casing) FRECS BE EN PROVIDED TO THE WELL OWNER. d, TOP OF CASINO IS 2 Fr.Above Land Surface-'Top of casing terminated at/or below land surface may require RE OF CERTIFIED WELL CONTRACTOR DATE a variance in acpadance with 15A NCAC 2C.011 S. a. YIELD(gpm): 1 METHOD OF TEST B1(7W James B. Broom PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1a 1617 Mall Service Center—Raleigh,NO 27699.1617 Phone No.(919)733.7015 ext 568. Rev.7/05 21028 WELL CONSTRUCTION RECORD Nonh Carolina-Department of Environment and Natural Resources-Division OfW ater Quality-Groundwater Section WELL CONTRACTOR(INDIv,IDUAL)NAME (print) J� fI PI I S ! 1 t tt� '� CERTIFICATIOON M�n /�-Jf `P WELL CONTRACTOR COMPANY NAM PHONE mill —S2 4-3 A(b 0 STATE WELL CONSTRUCTION PERMIT{ AWOCIATEDW ERMrm (if applicable) (if applicab10) I. WELL USE(Check Applicable Box):Residential' unicipaVPublic❑ lndustiial D Agricultural Q Monitoring❑ Recovery 11' Heat Pump Water Injection D Other Ef If Other,List Use 2.',WELL LOCATION: AidLand setting . Ne st Town: County SCO It t21 dge DSIOpe DValley DFlat U CIC )'Ll )L (check appropriate box) (Sues Name.Numbers,Community,subdivision,Lot No.,Zip Code) L stitudstAongitude.of well location 1 OWNER: SA ya-fisl2rn— lq-,e v o-R . , (depaca/minutet/aecondt) Address t r m, 1 --eraser- lT t Latitudrllongittidasource:DGPSDTopographicmap (Slrw or Rowe No.) t - (check box) C/; 4' A,, -,7/� DEPTH DRILLING LOG City«Town S - Zip Code ,Fro Formation Description Ara code.Phone number _ 4. DATE DRILLED 1 � -36 -� Z7 �nrt' /U � �illm%4Q> 5. TOTAL DEPTH: 6- DOES WELL REPLACE EXISTING WELL1 YES D NO 7. STATIC WATER LEVEL Below Top of Cuing: Gil FT: (Use"Y'if Above Top of Casial) 8. TOP OF CASING IS FT.Above Land Surface* 'Top of radon termtoattd actor berate Iwdsurfaee requires a - variaaa to aceordauca Wftb-ISA 14CAC 3C,011L 9. YIELD(gptn): . METHOD OF TEST 10.WATER ZONES(depth): I.35- 971-) (l LOCATION SKETCH 11. DISINFECTION:Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Reads,Include the road Depth Di tar .of We�VFL Ma numbers and'common road names. From To�Z FL�saw' From To FL From To_Ft. t_ I3. GROUT: Depth Materiel n�Method,- From Tc,-cSP--FL—a From To FL .4. SCREEN: Depth Diameter . Slot Sim Material o From To FL in. in. Q' From To Ft. in. in. S. SAND/GRAVEL PACK Depth Size Material From To Ft. From To Ft. 6. REMARKS: DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL ONSTRUCTION STANDARDS,AND THAT A COPY OF/� S RECORD O BEEN PROVIDED TO THE.WELL WNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE 5-ubmit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh;NC - 17699-1636 Phone No.(919)733-322I,within 30 days. OW-1 REV.07/2001 n : 4 S RESIDENTIAL WELL CONSTRUCTION RECORD. r North Carolina Department of Environment and Natural Resources-Division of Water Quality - - �� WELL CONTRACTOR CERTIFICATION# 2045 1.WELL CONTRACTOR: I. DISINFECTION:Type H T H Amount 166z James B. Brown g, WATER ZONES(depth). Well Contractor(Individual)Name From LLLTo 19 3 , From To f3eri�en $rothers Well Drillintx, Inc. From To 0 From To Well Contractcr Cornpary Name From To From To STREET ADDRESS 73 Holly Hills Vista Rd 6. CASING: Thickness/ FYanklin� NC 28734 _QD th T0--Z-4 D� lFr Wejgn� Matgrial� From op OQ _M , inn City or Town State Zip Code From To Ft ( 828 1- 369-9591 From To_FI. Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth Material Method FromQ_To 20 Ft. carErt &hgxnii Ed SITE WELL ID#(it applicable) From To Ft. STATE WELL PERMIT#0f applicable) From„,To_____Ft. DW Q or OTHER PERMIT al applicable) S. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply❑ From To_Ft._in. — In. 'O D C From To_Ft._In. _ In. DATE DRILLED J From To Ft_in. _ in. TIME COMPLETED AM❑ PM 8. SANDIGRAVEL PACK: 3.WELL LOCATION; Depth Size Material CITY: � COUNTY _ From To_Ft. from To Ft. From To Ft. (Street Name,Humbert,Wrnmity,SubdrYsion,Lot No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope OValley ❑Flat ❑Ridge ❑0ther From Tlg,7 Formation Description (check apprdproto box) r __Clay & Sand May be in degrees, r t Cran i Le LATITUDE �}- _ minutes,seconds or LONGITUDE in a deciml format - Latitude/longitude source: ❑OPS ❑Topographic map (location of weif must be shown on a USGS fopo map and ;-1 attached to this form IF not using GPS) 4.WELL OWNER M4 )AvAJrn OWNER'S NAME r S'fR ET ADDRESS ON City or to Zip Code - ►SAS Area code• Phone number 11. REMARKS: S.WELL DETAILS: a. TOTAL DEPTH- b. DOES WELL REPLACE EXISTING WELL? YES Cl NO,e/ �.�/� IOO HERESY CERTFCONSTTHIS WELL S WASAND CONRDS,AND THAT IN COPY OFACCORDANCETHIS WITH e. WATER LEVEL Below Top of Casing: q00 FT. ng WELL CONSTRUCTION'AN STANDARDS,OWNER, TMATA COPY OF THIS (Use'+'If Above Top of Casing) RE D 5 BEEN PROVIDE TO THE WELL OWNER. d. TOP OF CASING le 2 FT.Above Land Surface- 'Top of Casing terminated aVor below land surface may require gTURE OF ERTIFIED WELL CONTRACTOR DATE a variance in accordance with 15A NCAC 2C,0116. o, YIELD(gpm):—Cz—METHOD OF TEST Blaa James B. Brown PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., For,GW-la 1617 Mail Service Carl Raleigh,NC 27699-1617 Phone No,(919)733-7015 ext 568. Rev.7105 RESIDENTIAL WELL CONSTRUCTION RECORD v North Carolina Department of Environment and Natural Resources•Division of Water Quality I A WELL CONTRACTOR CERTIFICATION 0 2045 1.WELL CONTRACTOR: 1. DISINFECTION:Type H T H Amount 16OZ James B. Brown g• WATER ZONES(depth):I Well Contractor(individual)Name From—aALI TO !!5l From To Heiden Brothers Well Drilling, Inc. From To From To Wall Contractor Company Name FrOrn To From To STREET ADDRESS 73 Holly_ Hills Vista Rd S. CASING: Thickness/ Depth Di msler Wei ht Maenal Frank I' NC 28734 FrOnITO�,Ft. , City or Tawn Stale Zip Code From_To Ft. 828 369-9591 From_To Ft. Area code- Phone number - 2.WELL INFORMATION: 7. GROUT: Depth Material Method From—D_To 20 Ft, CISlHit & hffa to RI[ABd SITE WELL ID#pf applicable) From_To Ft. STATE WELL PERMIT#(Il applicable) From_To Ft. DWO or OTHER PERMIT#(if applicable) S. SCREEN: Depth Diameler Slot Size Material WELL USE(Chock Applicable Box): Residential Water Supply❑ From_To_Ft._in. In. �1 �q From—To Ft.—In. _ In. DATE DRILLED 9'a3o5 From_To Ft. in, in. TIME COMPLETED 3',T-5 AMO PM4f 9, SANDIGRAVEL PACK: 3.WELL LOCATION- Depth Size Material CIT COUNTY, G3 - From To Ft. 4From To Ft. Qf( From To Ft. (Street Name,Numbers,Community,Subdivalan,Lot No.,Paul,Zip Code) ` TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG _. ❑Slope ❑ ❑Flat ❑Ridge ❑other From Formation Description - (check apprdpdale box) D ' __Claw & sand May be in degrees, r (,Tani to LATITUDE � _ minutes,seconds or LONGITUDE in a decimal format Latitude/longitude source: ❑GPS ❑Topographic map (location of we#must be shown on a USGS topo map and allached to this form#not using CPS) 4.WELL OWNER - m OWNER'S NAME ( _ STREET ADDRESS YO FJD,IC I-7of(e •� _—RA14SrM &-t-, NC Z97 B City or T n 510 Zip Code tgZ� ). 73te -SL 36 Area code• Phone nunfilber 11. REMARKS: S.WELL DETAILS: a a. TOTAL DEPTH: iaoo Is. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH - c. WATER LEVEL Balm Top of Casing:- �FT. 15A NCAC3 ,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF THIS (Use'+'S Above Top of Casing) RECOR BEEN PRO ICEOTO4tE WELL OWNER. d. TOP OF CASING IS 2 FT.Above Land Surface' 'Top of Casing terminated allot below land surface may require S ATURE OF CERTIFIED WELL CONTRACTOR DATE a variance In accordane,with 15A NCAC 2C,011 S. e. YIELD(gpm): v METHOD OF TUT pl-gw James B. Brown PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form Gw•1a 1617 Mail Service Center—Raleigh,INC 27699-1617 Phone No.(919)733-7016 ext 568. Rev.7/05 WELL CONSTRUCTION RECORD. North Carolina- Department of Environment and Natural Repurces- Divisi'n of water Qua]it -Groundwater Section N1'ELL CONTRACTOR INDIVIDUAL)NAME (print) �+ - "�- '1, -1 CERTIFIC)A>TIIOyN--ILK V,ELL CON'rR:1CTORCONIPA.Nl'NANIE kY N)4-�nO O � 11 ) `2 ^-^PRONE C (Oo4� S-rATE[CELL CONSTRCCTION PERM ITp ASSOCIATED NyQ PERMIT: (ifapplicable) (if aoolicable) 1. WELL USE(Check Applicable Box): Residential blunieipal.!Public ❑ Industrial ❑ Agricultural ❑ ` � „i Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use 2. WELL LOCATION: Topographic.'Land Setting �rzstTown: � County ❑Ridge ❑Slope ❑\'alley 0 Klat (check appropriate box) (S:r :Name. N_wnb;ri.Conimunity.SSub^division,Lot No..Zip Code) ar - Lah[lld5'%longitude of well location 3. O1\'NER:�i�✓Y. Pn' �� ��/-'� —D (dcontti ininur:&'seconds) r\ - as'TD�i L—" 1��� Latitud.'longitude Source:❑GPS❑Topographic map (Si:ee[0 RJu:e ) ) 33 v (Check G(\ 1L DEPTH DRIRI LLING LOG a Sole C7��� ,Co.l. ",7Fom do zs^.ription Ace.:;oe.Phone r.::n'h� � \(—T. DATE DRILLEDS. TOTAL DEPTH:6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO � 7. STATIC WATER LEVEL Belo.y Top of Casing: Io AFT. (Use`�'if Above Top o€Casinel CA S. TOP OF CASING 6 FT.Above Land Surface' 'l y of casing urminared at'ur betv,s Land surface requires a C� variance in acco,6rc,•svith I5A NCAC 2C.0113. T 9. YIELD (epm): _METHOL) OF TEST I — 10. WATER ZONES(depth): j �� �— LOCATION SKETCH I I. DiSI\FECTION:Type G-)T i:J Amount Sho',v direction and'distan.e in mils from at least 12. CASING: �T\gall Tirekness wo State Roads or County Roads. Include the road Depth Diameter or Wei.h.Ft. ax)•e��lmbers and� blJ comm From _To Ft. S ,e Fro;: To Ft. Fro Ft. ^ - 13. OROC De T: o:b \la:zrial � Method From To FLs,` Frors_�_To ,.Ft. f i�F�-•r �� L4L) ta. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. —1 V From To Ft. in. in. 15. SA\D GRAVEL PACK: Depth Size Materal From To Ft.— From—To—Ft. 16. REMARKS: 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELLCONSTR CT10N STANDARDS.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER 5.,i� , Mi C um 2- .1L oS SIGNATUREOFPERSONC DATE Submit the orivinal to the Division of N1 ater Quality, Ground„ater Section, 1636?tail Scrvia Center-Raleigh,INC 27699-1636 Phonc No.(919)733-3221,,,'ithin 30 days. ----- G1%-1 REV.OT2001 RECEIVED t FEB 0 7 2006 Asheville Regional Office Allyffer Protection `YELL CONSTRUCTION RECORD . North Carolina Department of E viromnent and Naw al Resources-Division of Water Quality (n l5 �- wecccoNrRncroR(i`mrv>nvAL)tveMX .� CERTIFI whoa# _ WELL CONTRACTOR C06IPJLNY NAME o- PHONE # U STATE WEL&CONSTRUMON PERyIIT# ASSOCIATED WQ ER1D'C# . (tfappheable) "(ifappticable) L WELL USE(Check Applicable Box):Residentialf37 Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: TDpograpilic/Landsctting Neaz Town: Covaty - Midge `Slope ❑Valley ❑Flat G��r7y (check appropriate box) (Street Naux,Nudgms,Communi ,Subdi /✓ ,Lot No.,Zip Code) Latitudetionginideofwell location 3. OWNER•��"I �/Q�-��1� (degrees/miaureshecoods) .. A ress Fyp ,, tit/ LatitudeAongimdesource:❑ map (Stree[or Rouen No.) (checkbox) bEP ITT DRILLING LOG City or Town Stare Zip Code From To Formationl)escription Arca code-Phone number - 4. DATE DRILLED rf — 74 0 5. TOTAL DEPTH: c 7G 6. DOES WELL REPLA EXISTING WELL? YES❑ ji0 d 7 6 Z , 7. STATIC WATER LEVEL Below Top of Casing: (Jr FT. (Use"+"if Above Top orcasiug) 8. TOP OF CASING IS FT.Above Land Surface yi -Top or eating terminated at/or below land surface requires a variance In accords c with 15A NCAC 2C.0I IS. 9. YIELD(gpm):.r METHOD OF TEST G P--- y 10.WATER ZONES(depth): 260 c t LOCATION SKETCH o 11. DISINFECTION:Type `{ / Amount how direction and distance in miles from at-last12. CASING: !Yatl'rb-cS;ness �. ' tivo State Roads or County Roads. inchide the road liop Diamfh; or Wclzl,✓FL 1,iaicn-1 nr,a-rs -..j.cm:uo:. r04.:it.::.c_. .. From t7 Tc SZ FL (o �✓ $O [ 2/ �u From To Ft. From To Ft. 13. GROUT: Depth . Material Method From 0 . To---I_FL. -�=- Fromm �,�_To_ FL. ° 14. SCREEN: .Depth Diameter Slot Size Material - From - To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth. - Size Material . . From To FL From To FL 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARD,$,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER /U O � �rnrl / I SIGNATURE oFkkSON CONSTRUCT G THE WELL DATE Sui:;,:it the crioinal to tP:e iirisiun of Water Qua;ity,Attu: lu`ormation i4lanagemcut,1617 Riaii Service Ceater- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. L ED GW-lREV.09/2004 005 al Office ction WELL CONSTRUCTION RECORD CNp North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIYD)UAL)NA.� (print) �T < CERTIFICATION# 21 WELL CONTRACTOR COMPANY NA.NI6 )A:21A ¢�" z Z'd eC-�( PRONE#(Er-� S STATE WELL-CONSTRUCTION PERMIT# - _ - ASSOCIATED WQ PERWT# (if applicable) - - (if applicable) I. WELL USE(Check Applicable Box):Residential lk Municipal/Public❑ Industrial❑ Agricultural❑ - Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2 WELL LOCATION: Topographic/Land setting Nearest wn. County ' ` ❑,?dge ❑Slope ❑Valley Mat oi��ZL (check appropriate box) (SoccrN umbers,Co 'ry,Su 'vision,L No,Zip Code) Latitudellongitude of well location 3. OWNER• KA��Je (degreWmiames/secoods) Ad ess - D _ i-7� _ Latitude/longitude source:❑GPS❑Topographic map - (Sneetor m ) (checkboa) - - {` DEPTH DRILLING LOG City or State Zip Code From To Formation Description U` -ho `Y a 9 sxS - -- Area codedc-Phone number . 4. DATE DRILLED 7— m -O ( 2 S 5. TOTAL DEPTH:�. L _z 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO,)@ 7. STATIC WATER LEVEL Below Top of Casing: `3 FT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS�_FT.Above Land Surface' -Top of easing terminated at/or below land surface requires a variance In accordan a with ISA NCAC 2C.0il& 9. YIELD(gpm): _METHOD OF TEST 10.WATER ZONES(depth): ag a LOCATION SKETCH 11. DISINFECTION:Type-] Amount Show direction and distance in miles from at least 12. CASING: Wall Thicknes 7two State Roads or County Roads.Include the road Depth Diameter or Weight/FL Wterial numbers and common road names. From-0 To Ft ( / IYU �+� From To Ft. &� /vl, From To Ft. 13. GROUT:�t Depth Material Method From (l To�,3 Ft - _ From To J Ft. - - 14- SCREEN: Depth Diameter Slot Size Material Z _ From To Ft.—in. _ in. From To Ft. in _ in- D/ ACK. 15. SANGRAVELP url Depth Size Material t�From To Ft cr 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 CONSTRUCTEN T) WELL DATE Snomit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- Raleigh,NC 2 7699-1 61 7, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 RECEIVED FEB 0 7 2006 Asheville Regional Office Aquifer Protection r r WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section (� WELL CONTRACTOR(INDIVIDUAL)NAME (print) � C CERTIFICATION# 2 /O-& WELL CONTRACTOR COM PANY NAME-A" 1 PHONE #f5� -Sd STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PE MIT# (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 N: Topographic/Land setting NeargstTown. County_ ,f / ❑Ridge JRSIope ❑Valley ❑Flat S", '(i'v C 28'7! 7 (check appropriate box) (Street Name,Numbers,Community,Sub Msion,L,,[No\.;Zip Code) Latitude/longitude of well location 3. OWNER:��.JK�1'l�"k —`.NS-(A-3�.� -. / (degrees/minutes/seconds) Address -'d?J21) Latitude/longitude source:❑GPS❑Topographic map (Street��Ro�yw{e No.) �/ - - (check box) " I�cJC� C' 4 6 71_S DEPTH DRILLING LOG t o Town Stare Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED R 2-U O 5. TOTAL DEPTH: r Ilk' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO a51 f/8- Z �p 7. STATIC WATER LEVEL Below Top of Casing: teZFT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS�_FT.Above Land Surface" •Top of casing terminated at/or below-land surface requires a variance In accordance with 15A NCAC 2C.0118. }, 9. YIELD (gpm):_ 7 j METHOD OF TESTA I �_ — 10.WATER ZONES(depth): I 1 S LOCATION SKETCH 11. DISINFECTION:Type T ount _dhow direction and distance in miles from at least 12. CASING: Wall Thickness j two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material numbers and common road names. From-To Ft. Lt/� IPP(r From To Ft. From To Ft. _ 13. GROUT: Depth Material Method G ' From 0 To FL � From—,3 _To Ft. . " 28`� W��^',�,"��q 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. _ From To Ft. in. _ in. _ 15. SAND/GRAVEL PACK: N Depth Size Material 1 r-n From To Ft. From To Ft: Cn 16. "EMARKS: ()JO HLtiLE3Y CL.I It Y THAT THIS ",LLi-WAS CON...I UC'6'i ^CC'.Fl) n"L�'.IT \1v9v:^. 2C,V,ELL-- - CONSTRUCTION STANDARDS,AND THAT A COPY O S RFfQRD HAS'B jPROV�ID_ED TO THE WELL OWNER W;1[-�E �/—(� Submit the original to the Division of Water Quality,Groundwater RAotT,ISII is AU"vice Cent r-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. - G� 1 REV. 07/2001 FEB 0 7 2006 Asheville Regional Office Aouifar Protection WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- ivision of Water Quality-Groundwater Section WELL CONTRACTOR(INDtVIDUAL)NAME (print) CERTIFICATION# WELL CONTRACTOR COMPANY NAME " A'L'L- ?� PHONE # SX'lo �SS'S' STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PER!IT# (if applicable) . (if applicable) 1. WELL USE(Check Applicable Box):Residential#,j Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ - Other❑ If Other,List Use 2. WELL LOCATI /� Topographic/Land setting Nearest To L-t f ounty, ❑Ridge [tope []Valley ❑Flat (check appropriate box) (Street Name,Num ers,Community,Su/ivision,Lot ho.,Zip Code) Latitude/longitude of well location 3. OWNER���//1-�f'�_1/li (degrees minut<s'seconds) Address 04 Latitude/longitude source:❑GPS❑Topographic map Ro (check box) 0 (Street or ute No. "s DEPTH DRILLING LOG ( �/ tyogown6 !tap, Zip Code From To Formation Description Area code-Phone number dd"" 4. DATE DRILLED U U p 5. TOTAL DEPTH: ��"" 6. DOES WELL REPLACE EXISTING. YES ❑ NO q y Z 7. STATIC WATER LEVEL Below Top of Casing:� T. Z p 17 Z 0 I (Use'W'if Above Top of Casing) � d S. TOP OF CASING IS FT.Above Land Surface* v Z G -Top of casing terminated atlor below land surface requlres variance in accordance with A NCAC 2C.01M n 9. YIELD(gpm): / S METHOD OF TESTA I /� _ 10.WATER ZONES(depth): 010 / 7_ O _ k-0 LOCATION SKETCH 11. DISINFECTION:Type- l-1 %/4-- Amount '_t Show direction and distance in miles from at least 12. CASING: I Wall Thickness —two State Roads or County Roads. Include the road Depth tlmeter or WeighVFt. Material numbers and common road names. o_From 0 T .rr��//,�Ft.(0 5 D 2 41 600 C, CA, To Ft. __ �)'o`D'ri', From To Ft. t 13. GROUT: Depth Matenal -f —-Mei od From To Ft.From / mm_To Ft�--�`= [<J 1. ���}...� 14. SCREEN: Depth Diameter Slot Size Material (! r— 1 <= From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: ry Depth Size Material OJT '.. From To Ft. 1 o From To Ft. a 16. REMARKS: "'. l DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL"= — -- --- -. -,T A :'Y OF T,!!S BEEN.f.2OVIUI D TO THE WELL O,:i:ER SIGNATURE OFIPE?LSON CONSTRUCTING THE IVEL.. DATE Submit the original to the Division of Water Quality, round RErN GEUVE Do Sen1c Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-1 REV. 07/2001 FEB 0 7 2006 Asheville Regional Office Aquifer Protection , WELL CONSTRUCTION RECORD North Carolina Department of Enviro en t and Na 1JI wurces-Division of Water Quality /) WELL CONTRACTORWiDfvIDUAL)NANIE (print) /`l"� ��'' CERTMCAT10Np �.Ja. Vi WELL CONTRACTOR COMPANY NAA� � :. W � ONE i {SR&I `rd2 SSS a STATE WELL CONSTRUCTION PER.NIITp ASSOCIATED WQ PE R p (ifaPPhpble) _ - - (ifawliicable) 1. WELL USE(Check Applicable Boz):Residential Muni'cipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use - 2. WELL LOCATI Nearest Town: ` Countydge 0 lope 'Land setting � ❑Ridge LJ81ope ❑Valley ❑Flat (,� (chackapimpr��) - (Skeet Numbers,Community,Subdivuio Lot No.,kP74--oka .7/3 Latitude/longitudeof well location 3. OWNER: /J 44C e4li :a.J (d<gn:edminueesheeonds) Address 0 /3oV a; V/ Latitude/longitude source:❑GPS❑Topographic map /j (Streetor Rou,�N_o3 (check box) _ f n � n k y7l, DEPTH DRILLING LOG t ry oa a////nnnnG s ate ,p c c From To Formation Description -- — 8-970 Area code.Phone number 4. DATE DRILLED 3 as o 0 5. TOTAL DEPTH: _ 3 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 97 - 7. STATIC WATER LEVEL Below Top of Casing: ZP7 FT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS FT.Above Land Surface' 'Top of rising terminated at/or below land surface requires a variance In accordance with ISA NCAC 2C.0118. 9. YIELD(gpm): I—METHOD OF TEST, 1 10.WATER ZONES(depth): 3� , t2�'�' LOCATION SKETCH 11. DISINFECTION:TypeI Amount A ' show direction and distance in miles from at least 12 CASING: two State Roads or County Roads.Include the road Lcpu: lliamC.r ur :4aght/i L Male;.,, Co!;. i i w .a.nc— From To_3) Ft. Vlt ypp— Zl _JeU C, From To Ft: From To Ft. 13. GROFrom b Depth Material Method 9 ,^ A From To FL �� / f'/�[4 From_3_To�FL-�sge>xse.�f+--� co�7z"" 14. SCREEN: .Depth Diameter Slot Size Materia �-. From To Ft. in. in. From To Ft. in. in. — 15. SAND/GRAVELPACK: _ Depth Size Material ry From To Ft. Ln From To Ft. - C3 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrm 15A NCAC 2C,WELL - CONSTRUCTION STANDARDS,AND TIIAT A COPY OF TM OCORD HAS BEEN PROVIDED TO THE WELL OWNER - nATURE Or PERSON CONS IRUC E G THE WELL "y llATE T, SCr...i Raleigh,NC 276994617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 RECEIVED FEB 0 7 2006' Asheville Regional Office Aquifer Protection `YELL CONSTRUCTION RECORD A `� NOrth Carolina Department of Environment and Natural Resources-Division of Water Quality / WELL CONTRACTOR MDIYIDUAL)NA.'VIE (print) - CERTIFICATION M WELL CONTRACTOR COMPANY NAME PHONEa B�) 5� (y_sSSd . STATE WELL CONSTRUCTION PERNtITp _- -_ASSOCIATED W Rh Q E _DTa - - - (if applicable) - 1. WELL USE(Check ApplicableBoz):Residential Mtmicipal/Public❑ Industrial❑ Agricultural❑ 'r , Monitoring O Recovery O 'Heat Pump Water Injection O Other❑ If Other,List Use 1 +. 2. WELL LOCAT To phic/Land setting ' Nearest fot County ORidg Icpe,OValley ` OFlat V'Y11C4-ryn{7Gt1� L-_bl d" 7� check (Street Name,Numbers,Com unity.Subdi ton,Lot No, i Code) Latitude4ougitude ofwel location 3. OWNER: »u t ,' (degteWminu es/sccoods). - Address n -43 (11 ��— Latitude/longitude source:OGPSOTopographic map IS io Route No.) (check box) C, 24 7/ DEPTH DRILLING LOG t ci or own State 1 Zip code From To Fomtatton Description - Area code.Phone number 4. DATE DRILLED /0 $ " D 5. TOTAL DEPTH: 242R 6. DOES WELL REPLACE EXISTING WELL? YES O NO Or 7. STATIC WATER LEVEL Below Top of Casing: /.(_ FT. 2� y� �f ov -•Y�3 (Use"+"if Above Top of Casing) S. TOP OF CASING IS FT.Above Land Surface` -Top or casing terminated atior below land surface requires a _ variance In accordance with 1SA NCAC 2C.011& 9. YIELD(gpm): _[_METHOD OF TEST I k- 10.WATER ZONES(depth): �y o LOCATION SKETCH 11. DISINFECTION:Type 1 -]'��---Amount�jS.2 is, '/Show direction and distance in miles from at least 12. CASINrJ: - Will Thickr.-cs Y Itvo State Roads or County Roads.Include the road - Lcp�l Dtr.retcr or tiVe7jJJt't ?.leten_, "�h".. 'd e�.;;m n z_ue>_ From O To 7 Ft- From- From To Ft: - - From To FL !� - 13. GROUT: Dep�! . to al Method � d r r e From 0 To Ft. From__a_To_, FL (,Lj�-�i,n�..� L 14. SCREEN: .Depth Diameter Slot Size V '!"�. Orr`= 11- From To FL in. in. N From TO Ft. in. in. is 15. SAND/GRAVEL PACK: Depth Size Material s From TO FL From TO FL i 16. REMARKS: -- t I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANnA •'�^^•'-, ._._ .r-AtACOPYOF TfUSIECORD HAS BEEN PROVIDED T0 THE WELL OWNER SIGNA i u kjT- F PrRSON CONSTRUCTA?G THE WELL - DAT= - Raleigh,NC 2 7 699-1 61 7, Phone No.(919)733-7015,within 30 daye RECEIVED Gw-I REV.09/2004 FEB 0 7 2006 Asheville Regional Office Aquifer Protection NVELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality .WELL CONTRACTOR(LYDIVMUAL)NA.MIE (prlat) .. C9G�ts e=' .,� CERTIFICATION# WELL CONTRACTOR COMPANY NAbIE — PHO`!E It - STATE WELLCONs'TRUCrION PERMIT# ASSOCIA D W PERMl1T# (ifappheable) _ .. . 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 LOCATI N: Topographic/Land setting Nearest Town: County b ❑Ridge lope.-❑Valley OFlat (check appropriate box) - Community,Name,Numbers,Commu ,subdivision,Lot No.,Zip e) _. Latitude/longitude of well location 3. OWNS (degrees minutcs/xcoodT Address Z� - Latitude/longitude source:❑GPS❑Topographic map Street r ute W) I - (check box) DEPTH DRILLING LOG ` ryor smm - .Zip code From To Formation Description if 9-f0 i .. Area code-Phone number 4. DATE DRILLED 0 J 5. TOTAL DEPTH: 69 Z� 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Tz 1�y 7. STATIC WATER LEVEL Below To i : — �v T 78 P of Casn g �_FT. (Uu"+"if Above Top of Casing) 8. TOP OF CASING IS FT.Above Land Surface' •Top of casing terminated itlor below land surrace requires a variance In accordance with 15A NCAC 2C.011& ^a 9. YIELD(gpm):�_METHOD OF TESTA 1 J 11 10.WATER ZONES(depth): f 20 tcy LOCATION SKETCiI — 11. DISINFECTION:Type tAtnount,�? ,C� ow direction and distance in miles from at least _ 12 CA SING: � ill Th;�l nas � hvo State Roads or County Roads.Include the road L) pit FiiarneC i m %Vcigh JYL n Matcat t-'.Hour s -nd cc_;ron i•„aL nc-i.c,. From_Q—T0 Ft. 6 " 2 /1( �/C— From To Ft. _ "`�(, _ From To Ft. (% �` /) / ) 13. GROUT. Depth F.taterial Method (t�1,L From�_To _Ft. - _ ` I Z From_To_�-eZ Ft—J� (f 7� n,r — 14. SCREEN: Depth Diameter Slot Size M' atetial► From - To Ft. in. M. From TO Ft, in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. d` 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 TEiLSJ,tECORD HAS BE CIVIDED TO THE WELL OWNER C f NA_. OF PERS STRUCFING THE WEPL DATE Lorne,S� le th 0: Walct Quahl,Attu:luformution Rlat:21eme0t, 1.17 Mail 3ctvice Ceuler- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 RECEIVED FEB 07 2006 Asheville Regional Office Aquifer Protection WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natuiml Resources-Division of Water Quality P/ ` WELL CONTRACTOR(PIDIVIDUAL)NA3fE (print) ��"" CERT'Q'ICATIONN ,.. . : WELL CONTRACTOR COMPANY NAME PB0_NE ff fS2A STATE WELL CONSTRUCRON PER-NUTg ASSOCIATED WQ ERNUT11 . (if applicable) 1. WELL USE(Check Applicable Box):Residentla� Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ '-Heat Pump Water Injection❑ Other❑ If Other,List Use 2 NELL TOwrt:� County Topographic/Land setting )(Ridge ❑Slope,'[]Valley [Mat (cheek appmpriate box) • (Sneet Name,(Numbers, unity,Subdivision,Lot No.,tip e) - Latitude/longitude of well location 3. OWNER 1 (dogmalminute l.acconds) Address Sl, v -__B.L- _ _ / Latitude/longitude source:❑GPS❑Topographic map (Scltit ute N '�//�.- 310 Z 7 DEPTH (check�J t t 4y�- (Q _ EPTH DRILLING LOG �ptq or Town$ Sr r `o Zip Code From To Formation Description " t G Arcs code-Phone number b 4. DATE DRILLED ' 6 O I 5. TOTAL DEPTH: VV a _ 7a 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO P( 7. STATIC WATER LEVEL Below Top of Casing: 4," FT. (Use'*"if Above Top of Casing) - S. TOP OF CASING IS_ FT.Above Land Surface• -Top of casing terminated atlor below land surface requires a variance In accordant with ISANCAC2C.011& ^ 9. YIELD(gpm): METHOD OF TEST_hJ l V 10.WATER ZONES(depth): 72 f r I OCATION SKETCH 11. DISINFECTION:Type 7/-t— Amount r i,a o Show direction and distance in miles from at least 12 CASINc. V Y nvo Sole Roads or County Reads.Include theroad llcpll: Li -:-..r o 1'i roi] iL. hia[cr al t .,;;bcr. �u C:nu! !of' •._{.._:-a.;. From_Tom Ft. p Z U C_ From To Ft. From To Ft. - - 13. GROUT: Depth Material Method From 0 TO&:.. Ft. I From 3 To.-Zd) Fc .,. &I=r . ca ./u, v 14. SCREEN: Depth _ Diameter Slot Size Mate ' 1 From TO FL in. in. o From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To FL 16. REMARKS: ( I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND COPY OF THIS CORD HAS B PROVIDED TO THE WELL OWNER SIGNATURE Or"PERSON CONST,•UCTING THE WELL PATE Sub!ni:tL c o:!eiu;' t.; the cT r - Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. - W-1 REV.09/2004 RECEIVED FEB 07.2006 A heVllle Regional Offioe uMer Protedon RESIDENTIAL WELL CONSTRUCTION RECORD\ North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION#�O�� 1.WELL CONTRACTOR: I. DISINFECTION:Type Amount r g. WATER ZONES(depth): Well Contractor(Individual)Name From To,p To Cfd1/l e GCS-✓'D �/ e Ill i^ �� �t rG. ,,,�.!(I(�- From To From To Well Contractor Company Name J From To �j From To STREET ADDRESS �yp L/',Ql7 s Y(' _ 6. CASING: Thickness/ Depth Ft Di gAer Weight Material r q 1 From d To ` -t yClly or TOw,/nn /State Zip Code From To Ft. ! }�ti?Y- �7_ 77 From To Ft. Area code- phone number 2.WELL INFORMATION: 7. GROUT: Depth TY Material Method Method SITE WELL ID#(if applicable) From �L___ Tq; Ft. [kW ell tL.v-, From_To FL_ STATE WELL PERMIT#(itapplicable) Rcm__"fo Ft DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply From To Ft_in. _ h. DATE DRILLED ��-�� ()� FromTo Ft. n. _in. From To Ft._in, in. TIME COMPLETED qbqD p(v(D. 9. SANDIGRAVEL PACK: 3.WELL LOr�CCATION: Depth Size Material CITY: ;)1'yS:.Ai �-`f COUNTY. 4r i Front. To Ft. ^ma— Fran. To Ft. N i l S' Creek Fran_ To Ft. (Street Name,Numbers,Cormunity,Sobcfiwvc n,Lot No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope OValley ❑Flat ❑Ridge ❑Other From To Formation Description (check apprcrptiate box) P LATITUDE 3 — =inyutM�onds LONGITUDE t:. Latitude/longitude source: ❑GPS ❑Topographic map - (location of we#must be shown on a USGS topo map and attached to this form#not using GPS) 4.WELL OWNER / OWNER'S NAME `AQt(y�/y�� A) ll ��// + STREET ADDRESS tyl� l�rl l/f n�/p " City or Town State Zip Coda �)' _ Area cafe- Phone number S.WELL DETAILS: // EE 11. REItARKS: a. TOTAL DEPTH: ID L)J� b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ ��QC> FT. IDO HERES(CERWY THAT THIS WELL WAS CONSTRUCTED NACCORDANCE wml c. WATER LEVEL Below Top of Casing: SA NCAC 2 . CONSTRUCTION STANDARDS (Use-+'if Above Top of Casing) RECORD HAS EENL ROMI ED TO THE WELL OWNER. THATACOPY OF THIS d. TOP OF CASING IS f FT.Above Land Surface' n ���� ( tom 'Top of casing tenated Wor ow land surface may require ` a variance in accordance With 15A NCAC 2C.01 18.rmi bel SRGNATURE OFCERTIF"ICED WELL CONTRACTOR DATE e. YIELD(gpm): —METHOD OF TEST rl ( Y�i-! l_4 yam ._ R ' NAME OF PERSON CONSTRUCTING THE WELL E(�� Submit the original to the Division of OU3teer QualjV kR 30 day . Attn:Information Mgt., 1617 Mail Service Center-Raleigl#,NC 27699-1617 Phone No.(919)7 3-7015 ext 568. Form GW-ta FEB 07 2006 JAN 19 2006 Rev.7/05 Asheville Regional Office Aquifer Protection v.a STArfp� u S RESIDENTIAL WELL CONSTRUCTION RECORD �.� ' r ang North Carolina Department of Environment and Natural Resources-Division of Water Quality .�a.M..m.a. _. WELL CONTRACTOR CERTIFICATION# b /, 1.W L CONTRACTOR: I. DISINFECTION:Type Amount /[k, 0 i-Al).e, g. WATER ZONES(depth): Well Contractor(Individual)Name From To From To From To From To Well Confr ' tt s Fran To From To 248 CRANE CIRCLE -- STREET ADDRESS FRANKLIN, NC 28734 6. CASING: Thickness/ //'' Depth Diareter Weight Material From v To Ft City or Town State Zip Cafe From To Ft. - � ��-y ,6 From To Ft. Area code- Phone 2.WELL INFORMATION:number 7. GROUT: Depth �r Material Method From O To�Ft.C „`7Lth[yi SITE WELL ID#(if applicable) From To Ft. 7 STATE WELL PFRM:T#(if8pP1ic8b1e) From _10 Ft. DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply 0- From__To FL—in. — in. ) FromTo Ft. in. _in. DATE DRILLED CAS From To Ft.—in. _ in. TIME COMPLETED AM❑ PM[] 9. SAND/GRAVELPACK: 3.WELL LOCATION: Depth Size Material II CITY: �,ff1S�Yv C T6/ COUNTY�SLIKII. Y AEI From To Ft. J� ,lam J Rom From_- To Ft. ieATo_Ft. (Street Name,Numbers,Community.Subdivision,Lot No.,Parcel.Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ❑Slope ❑Valley ❑Flat ❑Ridge []Other From To Formation Description (check appropriate box) — — May to in degrees, LATITUDE 3 _ minute,seconds or a �f LONGITUDE in a decimal format Latitude/longitudesource: ❑GPS ❑Topographicmap �? (location of web must be shown on a USG topo map and -- attached to this/orm ff not using GPS) 1 4.WELL OWNER OWNER'S NAME U k e,,.pp�✓)es ,sue STREET ADDRESS Z-,X YNab C:-I"Y !✓L a F71 3 City Town I State Zip Code Area code- Phone number 11. REIMARKS: S.WELL DETAILS: / a. TOTAL DEP /TH: o� b. DOES WELL REPLACE EXISTING WELL? YES NO I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRUCTED INACCORDANCE WOH c. WATER LEVEL Below Top of Casing ,7 V FT. 15A NOAC 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 / FT.Above Land Surface' 'Top of casing terminated aVor below land surface may require SIGN TUBE OF RTIFIED WELL CONTRACTOR DATE fo a variance in accordance with 15A NCAC 2C.0118. e. YIELD(gpm): _METHOD OF TEST Y C- ` { A11, ����� PDDRM+bLD AME OF PERSON CONSTRUCTING THE 13 Submit the original to the Division r�f Water E h y W. Mint .ays. A n: Information Mgt., Form GW-ta 1617 Mall Service Center-Raleigh,NC 27699-1617 Phone No.(919)733-70 5 ext 568. Rev.7ro5 FEB 07 2006 JAN 19 2006 Asheville Regional Office Llifer Protection a„w SrA Eo �y } 11 r'1 lei. 4� RESIDENTIAL WELL CONSTRUCTION RECORD - ' North Carolina Department of Environment and Natural Resources-Division of Water Quality Via ':>ag 7 _ WELL CONTRACTOR CERTIFICATION# J L' 7/ 1.WELL �CONTRACTOR: /? I. DISINFECTION:Type Amount t l 1,�A A,n ! l /lQ-M t' g. WATER ZONES(depth): Well Contractor(Individual)Name From_ To From To From_ To From To Well CorLtr1�911111"W"ELL DRILLING, INC. From To From To STREET ADDRES 48 CRANE CIRCLE 6. CASING: ✓ Thickness/ rial From 1/ Depth Ft. Di mf r Weight 0611 p' City a Town Stale Zip Code FromTo Ft. p(0' )- 6 �2 V-q y;� t' From To FL Area code- Phone number 2.WELL INFORMATION: - 7. GROUT: Depth Material Method SR Fran C) Tc��U Ft. EWELLID#(ifapplicable) Fran-_To Ft. STATE WELL PERMIT"#(itapplicabie) From To Ft._ DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply 9 From To Ft.—in. _in. A From To Ft._in. _in. DATE DRILLED 16 .26-6, Fran-To—Ft.—in. _in. TIME COMPLETED _ AM p PM p 9. SAND GRAVEL PACK: 3.WELL LOCATION: Depth Size Material From To Ft. CITY: COUNT�L'L)L1, N From To Ft. nv ti F1r t JK!d From, To Ft. (Street Name,Numbers,Community,Subdivision,Lot No.,Pamel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILL NG LOG []Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description (check appropriate box) May be in degrees, LATITUDE 3 _ minutes,seconds or LONGITUDE in a decimal format A J Latitude/longitude source: ❑CPS ❑Topographic map(location of of we#must be shown on a USGS topo map and attached to this form I not using GPS) -- 4.WELL OWNER OWNER'SNAME NAhth2 6rine-c- v - STREETADDRESS PL7. BC)( j—L CD City o Town State Zip Code Area code- Phone number 11. REMARKS: S.WELL DETAILS: /�✓ a. TOTAL DEPTH: J J b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑ c. WATER LEVEL Below TO IDO HERES)CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH P of Casing: ..� FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS (Use'+•if Above Top of Casing) RECORD W S BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS FT.Above Land Surface' 2�e� WELL 'Top of casing terminated agor below land surface may require a variance in accordance with 15A NCAC 2C.0118. 9�LI —A OF CERTIFIED CONTRACTOR/ DATEe. YIELD(gpm): c .Q METHOD OF TEST 4,ri1,�� --- PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of WatQu t days. AI n: Information Mgt., Form Gw-ter 1617 Mail Service Center—Raleigh,N 27699 9)733-7 16 ext 568.JAN 19 2006 .Rev.7105 FEB 07 2006 Asheville Regional Office WELL CONSTRUCTION RECORD North Carolina Department of En�v}{'Juo t Natural Resources-Division of Water Quality WELL CONTRACTOR(INDWD)UAL)NAOI/E��(,prta`ty s/� . yam y /� CERTIFICATION# aL.0 / 1 WELL CONl'RACrOR CO.NPA,NY NAb A IE g1 r?^_Q I .--r p -��t' PHONE # ( ). STATE WELL CONSTRUCTION PEILNUT# - ASSOCIATED WQ PERNDT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential N Mumcipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCAT Topographic/Land setting— Nearest tT�q�wn County, ❑Ridge M81ope ❑Valley �at f 7u(�v.-JL�. O �.I _ /1r_�S;y`( tch`ec'k app op^ate box) rV - (Saeet Name ,Community,Sub di ision,Lallo.,Zip e) n/ )Latittidrllongimde of well locatkH ' 3. OWNE .� ll (degn:es/auautes/secoads) L� Address 33 LatitudcAongimde source:❑GPS❑Topographic reap . (Street rRo to No.) \^ (checkbox) - - f ` o� LS 7!3 DEPTH DRILLING LOG City or Town State Zip Code From - To Forinatio—nW n Area code•Plume RILLaD _ Q� - 4. DATE DRILLED / tY 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO �5q 7. STATIC WATER LEVEL Below Top of Casing:_ta y I. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS_�_FT.Above Land Surface' 'Top or casing terminated aHor below land surface requires a tT variance in accordance v4fb 15A NCAC 2C.011& 9. YIELD(gpm): METHOD OF 1ST H �l� 10.WATER ZONES(depth): S LOCATION SKETCH 11. DISINFECTION:Type -)' Amount _ Show direction and distance in miles from at least 12. CASING: Wall Thickness Fwo State Roads or County Roads.Include the road Depth Dialtteta or Weight/FL _Material numbers and common road names.` p From To_�f� �o� Si—1 (1PJ Gray From To Ft.t. From To Ft. 13. GROF.rom ��ii Depth Material ethod From (i To_�FL From_ To fit) Ft. W 14. SCREEN: Depth Diameter Slot Size aterial From To FL in. in. From To Ft. in. in. 15. SAND/GRAV Depth Depth Size - Material From—To—- FL— From—To—FL 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF S NCORD HAS BEEN PR059#D TO THE WELL OWNER - 10 1 S OS SIGNATURE OFTERSON CONSTRUCTNG THE WEI IL- DATE Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. --- R E C E I V E D G -1 RFV.09.i2004 LFEB 0 7 2006 sh�eville Regional Office ifer Protection WELL CONSTRUCTION RECORD .North Carolina-Department of Environment and Na al Resour s-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) CERTIFICATION# ;�d Y WELL CONTRACTOR COMPANY NAME I PHONE # STATE WELL CONSTRUCTION PE&NIIT# ASSOCIATED WQ PERSIIT# (if applicable) (ifapplicable) 1. WELL USE(Check Applicable Box):Residential Munipipal/Public❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATI Topographic/Land setting Ne rest Town: ounry �L� ❑Ridge lope ❑Valley ❑Flat - (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lo o.,zip Code) Latitude/longitude of well location 3. OWNER: C (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (Stre t or Ro to N (check box) airez-. 0 �� 7/ DEPTH DRILLING LOG de - From To Formation Description Z1S� Area code-Phone number y — Ay L 4. DATE DRILLED 2 " 5. TOTAL DEPTH: Z" — ZO Z 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA 20 Z—2Z v 7. STATIC WATER LEVEL Below Top of Casing: (/� FT. 2,70 —Z72y (Use"+"ifAbave Top of �� v ��� R. TOP OF CASING IS�_FT.Above Land Surface* C— -Top of casing terminated attar below land surface requires a - iarianceinaccordanqewlth ISANCAC2C.0118. -'' 9. YIELD(gpm): / n METHOD OF TEST t r" N 10.WATER ZONES(depth): 2,4T-22 'Z77 d e1#11 LOCATION SKETCH o 11. DISfNFEC110iv "1 ype Amount ,E Z� _ 'now direction and distance in miles fitom at least 12. CASING: I Wall Thickness o �w'o State Roads or County Roads.Include the road Depth Diatcletzr or L Materi l numbers and common road names. From d To , O7 Ft. From To FL From To FL 13. GROUT: Depth Material - .Method w vw From (7 To FL From— _Top FL (-C7 at 14. SCREEN: Depth Diameter Slot Size b�—laterial — swry...- From Tc Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material 1 From To Ft. - - From To Ft. 16. REMARKS: ID TTEREEY CERTIFY THAT THIS WELL 1VAS CONSTRLtCTED TN ACCORDANCF- WITH 156 NCAC 2C,V,'ELT. CONSTRUCTION STANDARDS,AND THAT A COPY OF CORD HAS BEEN PROVIDED TO'FHE WELL U�'-NER S iIiNATURF CT FPt'.S ON C^NS TR UC:T1 NG THE��L-rC PAT F Submit the original to the Division of Water Quality,Gr undwaft-rS ali 63 alyi►Service Center-Raleigh,NC 27699-1636 Phone No.(919)733.3221,within 30 days. 1''ff CC CC VV CC LL�J GW-1 REV. 0712001 FEB 0 i 2006 Asheville Regional Office WELL CONSTRUCTION RECORD V ~v North Carolina-Department of Environment and I Resources Divisi of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NASIE (print) '�� ' CERTIFICATION#�3� � /' WELL CONTRACTOR COMPANY NAM to NE # ZX .a Z-8-�, eJ STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ ERM T# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residential S"' Municipal/Public❑ Industrial❑ Agricultural O Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2: WELL LOCATI Topographic/Land setting Nearest Town: County, ❑Ridge ,Slope ❑Valley ❑Flat rj - I (check appropriate box) (Street Name,Nu rs,C munity, bdivi n,Lot No.,Zip ) Latitude/longitude of well location 3. OWNER: 's" Cs a (degrees/minutes/seconds) Addres - Latitude/longitude source:❑GPS❑Topographic map (Street or��99ute Np� ^�� (check box) (�A , / l ��c�7/3 DEPTH DRILLING LOG City o own Stat4, Zip Code From To Formation Description 2Y Area code-Phone number 4. DATE DRILLED ` 0 � 1 6 —RT S' 5. TOTAL DEPTH: 01 _Q-7 S_ 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO - 7 8- > SZJ 7. STATIC WATER LEVEL Below Top of Casing:�FT. (Use"+"if Above Top of ;sing) S. TOP OF CASING IS�_FT.Above Land Surface* -Top of casing terminated at/or below land surface requires a variance In accordancej Nth�15A NCAC 2C.0118. y 9. YIELD(gpm):_—f9—METHOD OF TEST 10.WATER ZONES(depth): -,;:I 7 � _ so LOCATION SKETCH 11. DISINFECTION:Type _ 'Amount Lf+ how direction and distance in miles from at least 12. CASING: Wail Thickness two State Roads or County Roads.Include the road Depth`''/ Diameter or Weiet�htttFt.� M to ' I numbers and common road names. From O To X 4 Ft. 1. YtlG� From To Ft. From To Ft. 13. GROUT: Depth Material Me hod FromTFt. From To Ft. ry J W 14. SCREEN: Depth Diameter Slot Size Material �.,..A.z.yr--�� From To Ft. in. From To Ft. in. in. - '- 15. SAND/GRAVEL PACK: Depth Size Material - y From To Ft. N Ln From To Ft. C] v 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONS..,uurioN ST.,,.N UAP.DS AND T; :11'A COPY "r]!S RECORD HAS.KEN PROVID"D To-i iE V _LI.0\""'FR 0S S70A,ATURF OF PI7 R S,tN CONSTRUCTING THE\YELL D.4TG Submit the original to the Division of Water Quality, Groundwater Section,16,1§llWLS� Se/C"� [ Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. R E C O Y �sSYJI REV.O'7/2001 FEB 0 7 2006 Asheville Regional Office Ant Mar Prntaetinn WELL CONSTRUCTION RECORD (� North Carolina-Department of Environment andANatural Resources-d ivision of Water Quality-Groundwater Section a(print \\"ELL CONTRACTOR(1SDI\'IDCAL)NA>IE / '� � CERTIF[C/A�TIO\: N E LLcOS'FRAc'rOR COMPASYSA\IE HONE R CIS �c�S e) STATE\\ELL CONSTRUCTION PERMIT- —ASSOCIATED WQ PE NIM - :(ifapplicable) - (if aoolicable) I. WELL USE (Check Applicable Box):Residential Ntunicipal.'Public ❑ Industrial ❑ Agricultural ❑ Monitorin.-❑ Recovery ❑ Heat Pump Water n3ection❑ Other❑ If Other,List Use ' 2. WELL LOCATION: Topo;raphic/Landsetting Nearest T w unt r ❑Ridge ❑Slope ❑Va11zy jzmat ' r 7 7. `j (check appropriate box) (Strcat\ane.Numbers,torunsunitq.Subdi,is" n,Lot N ..Zip ode) Laafitude%lonl'itude of well location - 3. 0WNER. Lt� (dee ee 'minu¢z seconds) Addrass 5 3 AJ f-- DZ 1 1 Latitude longitude source:DGPSDTopo raphic map - //�(S eet or ou-NuJ -� n (check box) z iitXt� �� 3 3.3 v DEPTH DRILLING LOG Crn�or Tu„n St� ? Zip Coue From To Formation Description r�rir 'Etrd Area code-Phone number a. DATE DRILLED .6 S. TOTAL DEPTH: a 1 ! K 0 1 K3 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA 7. STATIC WATER LEVEL Below Top of Casing:- 15i-p_171. (Use"+"if Abocc Top of Casing) S. TOP OF CASING IS i FT.Above Land Surface' "Top of casing terminated at'ur belusv land Surface requires a rarian,c in acc.rdencwftq ISANCAC 2C.0I IS. y� 9. YIELD (eon): ' \METHOD OF TEST r� — 10.\PATER ZONES(depth): ( LOCATION SKETCH 11. D!S!NFECTION:Type -" Amount Show direction and'dis!anee in miles from at least 12. CASING: %l all Thickness mo State Roads or Count} ROads. Include the road Depth Diaole;• r or Weigh:Ft. \la e,bI number and common road names. From 0 To 10 Ft., &Y/ if - Front To 'FI. From To - Ft. V 13, GROUT: Depth \la:rr:a! Method ✓ Fron) S _ To Ft. CfI„-Ly- From 7�) FL �s✓3J r 1-l. SCREEN: De Depth Diameter S'ot Size p a:erial - Frorn To FL in. in. From To Ft. in. in. ° Ul 15. SAND GRAVEL PACK: o Depth Sze - \lateral From To Ft. �Fron; - Tc Ft. " 16. REMARKS: I DO HERESN"CERTIF) THAT IS\\'ELL\\'AS CONSTRUCTED IN ACCORDANCE R"ITH 1i.A\CAC 2C,WELL COS'STR 'CTION STANDARf��.AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O%k NER r- - --__--- - -^SIGNATILIJ lit P LI .iON 6K STPUC-i`ING TEE Vd ELL DATE Submit the original to the Division of\Cater Quality, Groundwater Section, 1636:Vail Service Center-Raleigh,NC =v..hin3U 'i,. '-. --- --; -rr 1". 07;''00! RECEIVED FEB 07 2006 Asheville Regional Office urfer Protection NC _ -- UIVNEN U WELL CONSTRUCTION RECORD Notch Carolina-Department of Enviromnenl and Nat�yyyJJJal Resouuirces-Division of Water Quality-Groundwater Section WELL CONTRACTOR(IN a1VAD UAL)NAME (pimp /C`/� !C'�e't��'- CERTIFICAl10NN�_02 WELL CON TRACTOR COMPANY NAME 7/L/l� PHONE N STATE WELL CONSTRUCTION PERAHIN_ ASSOCIATED WQ PN.RAITIN (if npplicnble) (If appl icnble) 1. WELL USE(Check Applicable Box): Itesidenlini k-l-'Municipal/Public U Industrial U Agsicu)lural U Monitoring❑ Recovery U I leal Pump Water hljecliou❑ Olher U If Other,List Use 2. WELL LOCATION:// !! Topographic/Land sctliug Nearest Town: CGI�rC(�CL Counly UlUdge ❑Slope []Valley UFlat _ (clink appeoprinle bon) (Suctt Name,/Number,Caurnwlily,Subdivision,Lot No.,Zip Cale) Lalitudellongilude of well location 3. OWNER: C,!?1+/-lefroJ2 yeD�J'e- (derrece)minnlee/rnnnds) Address a,?> Latitudellougilude source:UGPS❑"fopogtnphic nmp (Sueclor Roule No.) (clink bon) - u� M1LLjNQ_4QCi City or Town Slate Zip Coale From To ForniationDeseliption Area cote-Pbone number 4, DATE DRILLED —!��S'� �D— TSJ— S. TOTAL DEPTi1: )is is ne 6. DOES WELL REPLACE EXISTINOWELL7 YES ❑ NO W RECEIVED7. STATIC WATER LEVEL Below Top of Cnsiug: X-0 FT. i (Use"+"Ir Above lop or Cnsina) 8. TOP Or CASING IS l Z 1'1. Above Lnnd Sin race* •Tap or ulna lennlnded eUnr blow Innd eurtace requires a MAR 08 63 •silence In accordance with ISA NCAC 2C.0118. 9. YIELD(gpnl):�_METIIOU OF TESL' shaville Regiopal e 10. WATER ZONES(depth): 1/�6 I OCAl It. DISINFECTION:Type 117tT Amount � P Show direction and distance in miles from at least 12. CASING: Wnll Thickness Iwo Slate Roads or Comity Roads. Include the road ocpth Diameter of Weight/Fl. Material numbers and conunon road names. From To_J�J Fl. From To FL From To FL y� 13. GROUI': Depnr lac I)al Mediod }f rrerll Dom_Ted_Ft.. 7 From 1 To2,9 Ft. S,<y,{ao ff v,.n j41 14. SCREEN: Depdr Diameter Slut Size Material FtOnT To FL-in. in. From FL in. in. C3 15. SAND/GRAVFI.PACK: Drptll Size Mnlelial From Tor Fl. Ftom To FL 16. REMARKS: I DO IIFREBY CERTIFY TIIATTI[IS WELL WAS CONSTRUCT OD IN ACCORDANCE WITIi 15ANCAC 2C,WELL CONSTItUCtION STAN DAMS,AND TIIAT A COPY OF TIIIS RECORD IIAS BEEN PROVIDED TO TI JEWELL OWNER SIUNAILIAE OF PERSON CONSTRULMNO TIIE WELL DATE Submit (he original to file Division of Waler Qualily,Groundwater Section,1636 Mail Service Corder-Raleigh,NC 37699-1616 rhuue No.(919)733-3221,within 30 dnys. UW-1 REV.07/2001 �r � IIVs►\vYIVJ�/]T rf R �� c F? C e OWNER E �t s RL,sn)EN7lAL 1VELL CONsrRl1C'r10N Rl;cou0 ' f ( MWD 's,. �{ North Carolina Uepannrenl of Envilonmenl and Natural Resources-Division of Wi ler Quality NC WELL CONT-RAC'I Olt CER'FIFICA7-ION it I.WELL CONTRACTO � f. DISINFECTION:Type �./T 1 -Lc Amount e II. WATER ZONES(depth): WeII Conlracla(Individual)Name EEMILLER WELL DRILLING , INC . r-ian ��o Tp—From / LuZ From To Well Conhacto Company Nanm From To Fran To Fom Ta STREETADDRESS P. O . BOX 567 C. CASING: Thickness/ Fran DepthDiameter Wei hl material HAYESVILLE NC 28904 City or Town Stale Zip Coda From To ( 828_1- B 3 Floor To Fl. Area code- Phone number —_ 2.WELL INFORMATION: 7. GROUT; Depth Palelial Method SITE WELL ID#pf applicable) From 0 To .5-- Ft.A." 14yer' ze, Fran S_ o ax�.lt Ft. - faai�c v STATE WELL PERMITe(il applicable) From T To FL DWQ or OTHER PERMIT H(n applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box: Residential Water Supply 6� From To Ft—in. k,. DATE DRILLED , ,- - - Fron To FL__b, In. Flan To Ft In. _ in. TIME COMPLETED .� '0 d AMU PM� 9. SANDIGRAVEL PACK: �.WELL LOCATION:, Depth Size / Material CITY: CLier- ea COUNTY.f[.r14 r*It Fran To FL From To Ft. IShe.l ama.Moorhen.Commm�lly.SubdiHelon.Lot No.,Parcel,Zip C oe.) Fran ' TO FT_ TOPOGRAPHIC/LAND SETTING: ❑Slope 11Vaney Offal ORid a 10.DRILLING LOG g []Other(chlrck appropriate boa) From To Formation Description LATITUDE JT S_ -?3.4Z ti May be in degrees, �f minul6,w, ands or __I �' _�`4 4ue LONGITUDE 9 3 /C �8L in adechral kmnal 11Zf .70L Latilude/longitude source: UCfps OTopographic slap _ 000RIb"or wee most be shown on a USGS logo"lop and attached to this form 7 not using GPS) _ 4.WELL OWNER //// n OWNER'SNAME _ f4ir/r?k XWfiry 8 STREET ADDRESS C7C till nalona Ice City a Town Stale Zip Code rot Area code• Phone number 6.WELL DETAILS: L I. REMARKS: a. TOTALOEPTH: tr. DOES WELL REPLACE EXISTING WELL7 YES O NO E�- c. WATER LEVEL Below Top of Caging /`-- FT I DO REREBY CEn pry THATneS WELL WAS CONS7RVCIrD NACCOnDnTICE WrrN OP g) RECORO INS BEEN pit SI UCTIOND TO EWNDAROSELL En. THATACOPYOPTIaS (Use'+'II Above TI d Casio d. TOP OF CASING IS / FT.Above Lend Surface- �/� 'Top d casing lerminaled al/or below land surface may require —� - 7Z� a variance In accordance with 15A NCAC 2C.0118. StUNAI LIKE OF CERTIFIED WELL CONTRACTOR DACE e. YIELD(gpm): 112-0 METHODOFTEST ;r / 'eli- A�2e c e- PRINT ED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: 11110rma0on Mgt., 1617 Mail Service Center—Raleigh,NC 27699.1617 Phone No.(919)733-7015 ext 668. Form 0,448 Rev.7/05 STA1[v ~ S RESIDENTIAL WELL CONSTRUCTION RECORD OWNER North Carolina Department of Environment and Natural Resources-Division of Water Quality MWD WELL CONTRACTOR CERTIFICATION# NC F,�NTIRIACTOIR:ACTOR: f. DISINFECTION:Type �7/r!t{ / y �EZti� Amount(Indlvldual)Name g• WATER ZONES(depth): From `ll�ct ToFrorn To WELL"DRILLINGNC . proor Company Name To Rom To From To FrwnRESS P . O . BOX- �iR7 TO S. CASING: Depth Thickness/ H A Y E S V I L L E N C 2 8 9 0 4 Fran L p Diameter Weight Material City w TOwn Slate TO j�Ft. L ..r r l '✓G Zip Code From To Ft. 28 837- From To Ft.Area code- Phone numberumbw 2.WELL INFORMATION: 7. GROUT: Depth Meter ad Method SRE WELL ID it(if applicable) From L' To J Ft. ,-Jr'af/� ',� STATE WELL PERMIT#(itapplicable) Fran -7 TO -Ft-,/s'�i>f�"'}� zj;....� From To Ft. '"�=�'�-�• DWQ or OTHER PERMIT#(if applicable) a. SCREEN: Depth Diameter Slot Size WELL USE(Check Applicable Box): Residential Water Supply From To Ft.WELL FY __in. in_ . DATE DRILLED ,/�y=_ FrOrn To FL-_in, TIME COMPLETED in. From To Ft. in.,Z•�C O AM 0 PM[C.� _ in. 3.WELL LOCATION: 9. SAND/GRAVEL PACK: CITY: c..//,e.��(Z Ec'� L COUNTY W�.'� From To Ft Depth Size Material C r S ��re'e/G Fran To FL an Fr To Ft. �— (Sueet Name•Numbem,Community.Subdivlslon,Lot No.,Parcel,Zip Code) ----�_ TOPOGRAPHIC/LAND SETTING: ❑Slope 13afalley ❑Flat ❑Ridge ❑Other 10.DRILLING LOG (check appropriate box) From - To Formation Description LATITUDE 3 .7 7, J/Z Maybe in degrees, minutes,secondsor LONGITUDE b' ,3 .�, j//ry in a decimal fomut S' s-/L Latitude/longitude Source: ErGPS ❑Topographic map —'-- (%cation O/wer must be shown on a USGS topo map and attached to this/orm if not using GPSJ E 4.WELL OWNER OWNER'S NAME T. r/G i�-,/,a� l�•,.vf f �QO _ p STREET ADDRESS MAR City a Town State Zip Code tl$i ice c� t > ecti Area code- Phone number �----- 5.WELL DETAILS: 11. REMARKS: a. TOTAL DEPTH: .S_/O It. DOES WELL REPLACE EXISTING WELL? YES Cl NO Ey C. WATER LEVEL Below Top of Casing: If J FT. I DO HEREBY CERTIFY THAT THIS WELL WAS C (Use'+•if Above Top of Casin 1SA NCAC 2C.WELL CONSTRUCTION STANDAR ONSTRUCTED IN ACCORDANCE WITH AND THAT R COPY OF THIS DS. g) RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS / FT.Above Land Surface' *Top of casing terminated attor below land surface may require n7.7���Z� a variance in accordance with 15A NCAC 2C.0118.e. SIG AT�UR OF CERTIFIED WELL CONTRACTOR DATE YIELD(gpm): .L. METHOD OF TESTi' PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt., 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.(919)733-7015 ext 568. Form GW-1a Rev.7/05 i OWNER RES/UEN'I'/�1L \vrt.l,cons!lDMICn Rl:couD r T 3 No,th Cal ulina Dc ranmmnl of Envilm menu and Natural Itesourccs-Division of Water Quality NC MWD \TELL CUNTILA('1'UR CI?ILTII'ICA77UN ll 1-W ELL CONTRACTOR: 11;-y eece I. DISINFECTION:Type / fe ZC .__ Amount /y "ell Cadmct Onmrvxmaq Name 9• WATER ZONES(deplh): Cr, MILLER WELL DRILLING INC . Fmm 1E1 Tn From To — lion From To From Well Contractor Conspany Name To Ran To From To STREET ADDRESS P . 0. D 0 X rJ 6] G. CASING: Thickness/ H A Y E S V I L L E N G 2 D 9 0 4 _ From Depth/�, Diameter Weight Material City a Town Stale - O To Ft.� ,A? SAZ e.l Zip Cudo From To Ft. A) 8 3 7-mb-M Ram To Fl. -- Area code- Phorre nunumbs 2-WELL INFORMATION: T. GROUT: Depth mat at Method SITE WELL ID#tirappncable) From O To41 Fit lv d X STATE WELL PERMIT#Idapplkable) Fron�_To,�l Ft. //7`ar•1'e Fran To Ft. DWQ or OTHER PERMIT#(if applicable) -/ B. SCREEN: Depth Diameter SW Size Material WELL USE(Check Applicable Box): Residential Water Supply R Fromr To Ft__in. _ in, DATE DRILLED //-11-e3' From To— _- In. TIME COMPLETED ,3.•CO AM❑ PM p� Rom To FL__In. 3.WELL LOCATION: 9. SAND/GRAVEL PACK: �lC / fW4r/! Depth Size Material CITY: Chi lf'Q e COUNTY- Fron' To Ft. C COr1 Qi From To FI. (Bbeer Neme,Nomben. i From To Ft Ca -n n r y,Sobtll Nelon.Lol No.,Parcel.Zip Cotlel ' TOPOGRAPHIC/LAND SETTING: 13slope Valley pFlal pRldge []Other 10.DRILLING LOG (check approprlale box) From To Description LATITUDE y nrinores,sttrnsds a lc /4(iQ �� LONGITUDES.J 15, 3>3 in'decimal firmal Lalilude/longit tide source: ell'S ❑'ropogiapll(c map ' (bcation or we#must be shown on a USGS Iopo neap end -- attached to This tarn Anot using GPS) - 4.WELL OWNER O 8 �l - OWNER'SNAME A'6re,,7 fPeee,4 a - STREET ADDRESS SSA 71`4e / g1 t - Pro City Or town Slate Zip CWe O"T ( F Area code. Phone number S.WELL DETAILS: It. REMARKS: a. TOTAL DEPTH: �O p X IT. DOES WELL REPLACE EXISTING WELL? YESO NO B�-- e. WATER LEVEL Below Top of Casing FT I DO HEREBY CE R MY THAT THIS WELL WAS CONSTRDCIFO NAC[IMDnnCE WIfN p 9) RECORD HAS BEEN PROVIDED TO THE WELL OWNER, D nNT4COPY OE ileS (Usa'�'it Above To d CasioWELL CONSTRUCTION STANARDS d. TOP OF CASING IS / FT.Above Land Surlwe' 'Top of casing terminated al/a below land surface may require a variance in acc dance wllh 15A NCAC 2C.01118, SIGNATURE OF CERTITIFIED WELL CONTRACTOR GATE a. YIELD(gpm): T METHOD OF TEST /`� /"r-"rrY /Ce e e e PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Met., 1617 Mall Service Center-Raleigh,NC 27699-1617 Phone No.(919)733-7015 9xt 568. Fmm G7V-19 Rev.7105 d°T► OWNER r RESIDENTIAL WELL CONSTRUCnoN w RECORD MWD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# NC V 1.WELL CONTRACTOR: f. DISINFECTION:T HT y YPa ���f Amount Vr(c,• ee e C g. WATER ZONES(depth): well Contractor(Individual)Name From r16 To .Z`J 7 From MILLER WELL DRILLING , INC . From To— TO W ell Contractor Company Name From From To To From To STREET ADDRESS P . C . BOX 567 G. CASING: Thickness) Depth Diamelor Wei hl Material HAYESVILLE NC 28904 From O To e? Ft. 6-4r S4�?/ Oc•c City or Town State Zip Code From 4? To_,ee Ff828 . }_ 837-2997 From To FI. Area code- Phone number 2.WELL INFORMATION: T. GROUT: Depth �alleer1'al Method SITE WELL ID#(If applicable) From L9 To 3 Ft. r-- From -� To�Ff. J/}!1 7 0,V,{e STATE WELL PERMIT#p1 applicable) From To Ft. DWQ or OTHER PERMIT x(if applicable) 8. SCREEN: Depth Diameter Slot Size Malarial WELL USE(Check Applicable Box): Residential Water Supply O From To Ft. In. _ in DATEDRILLED ��-�f -�f� From To Ft—in. _ in. From To Ft.—In. _ in. TIME COMPLETED AMp PM el' 9. SANDIGRAVEL PACK: 3.WELL LOCATION: // Depth Size Material CITY: C7 ew J(/ee COUNTY - 61M From Ta FL _�e'�lOatJ /Ti�I From To Ft. From Tc FI. (51reEl Name,Numbers.CMM Ry,SubdiAslon,Lol No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG R191lope OValley ❑Flal EIRidge ❑Other From To Formation Descri lion (check appropriate boa) P LATITUDE 0Z Y�s_ Maybe in degrees, LONGITUDE gI zfo�y in a decimal formal Latitude/longitude source: ujbTS ❑Topographic map fbcetbn of Weir must he shown on a USGS lopo map and to C/�G 1 /F attached to this form I net using GPS) <.WELL OWNER OWNER'SNAME _�jr`L J/JBd'Q % �/'�(J�i/COIpJ MAR OUM06 STREET ADDRESSlis- v Cr or Town _ eV a( O - lY State Zip Cade CtIO ( } Area code- Phone number S.WELL DETAILS: 11. REMARKS: a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YESO NO L9- e. WATER LEVEL Below Top of Casing, ( I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH g ✓ FT. TSA NCAC]C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF NeS (Use**'if Above Top of Casing) RECORD HAS BEEN PRODDED TO THE WELL OWNER. d. TOP OF CASING IS FT.Above Land Surface' 'Top of casing terminated aUm below land surface may require a variance In accordance with ISA NCAC 2C,0118. SIGNATURE OF CERTIF IED WELL CONTRACTOR DATE is. YIELD(gpm):— ___METHOD OF TEST �i/` /'P!/'(� Weecz PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. ARn: Information Mgt., 1617 Mail Service Center-Raleigh,NC 27699.1617 Phone No.(919)733-7015 ex1568. Form GW-la Rev.7105 4r S RESIDENTIAL WELL CONSTRUCTION RECORU a �r OWNER North Carolina Uepartmcnt MWD of Hnvironment and Natural Resources-Division of Water ualily � "' .:� 'm a..,.....• WELL CONTRACTOR CERTIFICATION# NC 1.WELL CONTRACTOR: 7 L DISINFECTION:Type,_[ Tf� Amount�yCv 4 ec e. Well Contracla(Indmduap Name U. WATER ZONES(depth): MILLER WELL DRILLING INC . From f�� TO �� From Tc Wea Contractor Company Name From To From To From To. From STREET ADDRESS P.D. BOX 567To 6. CASING: HAYESVILLE, N . C . 28904 De Depth Thickness/ P Diameter Weiiphl Material ".Y Or I own State From Q To %G Y Ft. 6.-L,rJ- 1/Zip Code From i C --`=— ( 828 )- 837-2997 Z-To SiLFL r s Area code- Phone number From To FL 2.WELL INFORMATION: 7. GROUT: Depth Material Method SREWELL ID Stir appNwNe) From r To Ft. 1:�.,_ T%a_ i7� :`�h7/rrC STATE WELL PERMIT#(irapplicable) Fran 4 To '✓`" Fig i/Yes;>��i' From r� DWQ or OTHER PERMIT k if To Ft-( applicable) WELL USE(Check Applicable Box): Residential Water Su B• SCREEN: Depth Diameter PPlY E3�' From To FL Slot Size Material DATE DRILLED */-74r 'CS' From In. �, To Fl.-_—la �— From To �.TIME COMPLETED _� °_ '_p_ AMO PM� Fh---In' in. 3.WELL LOCATION: 9. SANDIGRAVEL PACK: � I Depth Size CITY: _!J/J'lL�i C_ i•!_'� COUNTY .'Wes_ -i%_ j _ From To Ft Material From To Ft.(S"et Names,Numbers,Community,--vurAAlon,Lot No.,Parcel,Zip—Cod,) From - TD Ft.. _ TOPOGRAPHIC/LAND SETTING: ❑Slope DValley 0171al ❑Ridge []Other 10. DRILLING LOG (check appropriate box) -- From To Formation Description LATITUDE 3 ,� d,y' May be indegrea, ----��- minutes,seconds LONGITUDE in a decimal format e -5— 7/k(/ Latitude/longitude source: E GPS ❑Topographic map (location Of wey most be shown on a USGS topo map and attached to this Corm 1 not using GPS) City or Tam 4.WELL OWNER . MoE OWNER'S NAME STREET ADDRESS ZSlate ip Code =Arl*levRa Ol s e'rnei i O _ Area code- Phone number Cho S.WELL DETAILS: 7IDOHEREBYCERIIFY a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES❑ NO p- C- WATER LEVEL Belau Top d Casing: F HIS.WELL WAS CONSTRUCTED N ACCORDANCE WITH (Use'+•N Above Top d Casing'— T. T`5A`NCAC 2C,WELL CONSTRUCTK)N STANDARDS.AND THAT ACOPY OF nes g) RECORD HAS BEEN PROVIDED To THE WELL OWNER. d. TOP OF CASING IS FT.Above Land Surface' *Top Or rasing terminated atior below land surface may require • a variance in accordance With 1SA NCAC 2C.o119. SIGNATURFr OF CERTIFIED WELL CONTRACTOR J DATE e. YIELD(gpm): J METHOD OF TEST_ �//y _/��/f�/(e'c'� c ' 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.(919)733.7015 ext 568. Form GW-Ta YELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CoNrmCTOR(I rVmUAL) CERTIFICATION M r_ - 626 566.5550 n WELL CONTRACCOR C05[PANY NAA[E AAA OREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE ,M ( ) STATE WELI.'CO-Sf[tUCTION PER.MTa ASSOCIATED WQ PERJIIT% _ .- (tfaPPheable)' - 7-7 (if applicable) 1. WELL USE(Check Applicable Box):ResidentiaA Municipal/Public❑ Industrial❑ Agricultural❑ <- Monitoring❑ Recovery',[],.Heat Pump Water Injection❑ Other O If Other,List Use 2. WELL LOCATI , Topographic/Land setting Nearest Town: - • _ County n ' pRidBe _]Slope OValley ❑Flat L (cbeck appropriate box) . . (Sweet Name,Numbers,Commumry,Subdinston,Lot No.,Zip ode) LatiNde/longitudeof well location (degn:es/minutestseconds) 3. Address - Latiru&Aongirude source:OGPSOTopographic map _ I cc r Route N - (check box) 3 Z 77 3 DEPTH DRILLING LOG Cary or wn State ` Zip Cade From - To i - Formation Description Area code.Phone number - :- C) Z O 4. DATE DRILLED 11/1-7 /D 5. TOTAL DEPTH: T'7T 7fd' 9/ i 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 5r 7 Y t - 75-y 7. STATIC WATER LEVEL Below Top of Casing:—La-0—FT. (Use'•+"if Above Top of Cuing) 8. TOP OF CASING IS FT.Above Land Surface' *Top or eaing terminated actor below land surface requires a variance to accordance with ISA NCAC IC.0113. /) 9. YIELD(gpm): J Q METHOD OF TEST A I Y-, 10.WATER ZONES(depth): 7/D LOCATION SKETCH 11, DISINFECTION: T r Amount_,� Show direction and distance in miles from at least 12. CAS(yi G: m• 1Y�II Thic}-m /J�_(vo Smtc Roads ut Cowity Roads. Inclu..': the read Depth Diam ter or%Veight/Ft. Dtat: numbers and common road names. From j2 To Ft. 5D/L From To - Ft. •� _ _ Q �Cfc,c.� From To FL 13. GROUT: Depth hlSten� [ethod From 0 - To 3 FL From 4 To Ft: . (A) W -14. SCREEN: Depth Diameter Slot Size :Material -. From - To Ft. in. - in. From To FL in. . in. - '- i5. SAND/GRAVEL PACK Depth Size" Material From To Ft. From - To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED1N ACCORDANCE WITH 15A NCAC2C,WELL ' - ` .CONSTRUCTION STANDARDS,AND COS" RE HAS SEEN PROVIDED TO THE WELL OWNER _ Submit the original to the Division of}V[pter Quality,Attn: Inform�it��fl�$ � Idr17 plait S 'ce Center- Raleio_h,NC 27699-1617, Phone No.(919)733-7015,1ri[hin 30 days. /tom Asheville Regional Office AatJiferPrCtfectian : A `YELL'CONSTRUCTION RECORD ai , 5 Noah Carolina Department of Envlt ent and Natuial Resources Ihvtston of Water Quality -� a> WELL CONTR>C[OR(LYDIMUAL)NAS[E (prlat); Ouy ii..N� `�. s HCERTIICATION a _ OS. ....:':..is �w� .�, ..:!'+' },'t✓ s+. -R'ECLCON7RAC[OR CObIPANY NAS[E APt\GREENE BROS: .'Lr.r WELLDRLG.OF SYLVA•INC PHONEM 828)5a6-5350 STATEWELL CONSTRUCTION PERHIT% ., ASSOCIATED WQpERtiDT% OPlicable) . .(ifapplicabitA 1 WELL USE(Check Applicable Box) Residenhaa Mdnicipal/Pubhc❑ • Industrial❑ Agncultuta!❑ ` Monitoring❑ ,Recovery ❑ ,Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WE L LOCATI Y ' ~ ' Topographic/Land s------ Neares Town Coon[) X/� ❑[LdgSlope ❑Valleyr OFIa[ r check appmpnate box) F' R (S=t Name Numbers C?m Uf� S vision, Na Zip Code) - Lahtude/IOngiC�de Of well loeati n;r 3 OWNER: Address n. Latitude/longttudesource.OGPS❑Topographtcttap't. ui '�"^`; ,(Sweet or Route),[o) , -(checkbox) .;, ' " `� a ZS 7f DEPTH - , DRILLID G LOG -;" �: City or L wn Sane - , Zip Code From To Forrnanon Description(828 Area code-Phone oumber ' - 4. DATE DRILLED 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTNG WELL? YES j7 NO QK 7. STATIC WATER LEVEL Below Top of Casing: riJ FT. 7 yy _ 7yz (Uu'+"if Above Top of Casing) 8. TOP OF CASNG IS FT.Above Land Surface' 'Top orcmin;terminated actor below land surface requireaa vactance lnaccordan with l3.>NCAC 2C.0118. /) 9. YIELD(gpm): METHOD OF TEST 10.WATER ZONES(depth):_�(o O y O LOCATION SKETCH 11 P( (�'LCT[0� 7 yp< Amo�r.t — , Shoe dictction and dun_ncc in milts from at least 1. CAc1NG: 1VaI ..ickress o State Roads or County Roads. Include the road Dept - is er or Weight/Ft. A t ria numbers and common road names. From� To Ft. O�V From To Ft. From e To- 13. GROUT: Depth Depth � Md[erial - _ (ethodFrom 0 To 3 Ft. 14. SCREEN: Depth 'Diameter Slot Size Material From To Ft. '_in. in. - From To Ft._in. in. 15. 5.4N5/GRAVEL TACK: Depth '''Size '. Material From To FL From To 'Ft. _ 1 16. REMARKS: i: ` - e I DO HEREBY CERTIFY THAT THIS LL"WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC 2C,WELL Nil ' CONSTRUCTION STANDARD DT A OPYOFTHI RDHASBEENPBDVIDEDTO THE WELLOWYER z - 'Submit the original to the Division of Water Quality,Attn:Inforfolit"(U Iail Se ce Center- ;thrn30un--'�S 1`iG '�L/ - L , J Asheville Regional Office Aauifel Protection WELL CONSTRUCTION RECORD o�Ctrati,� North Carolina Department of Enviro e�nt and Natural R sources-Division of Water Quality , WELL CONTRACTOR(LYDIVTDUAL)NA.�fE (print) ;Gf/r�(i(. A , CERTIFICATION# �d .WELL CONTRACTOR C05IPA.YY NAbfE AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE M (828)588-5550 - STATE WELL CONSTRUCTION PER.ABTX - - '- ASSOCIATED WQ PER.NDTN (if applicable) (if applicable) - I. WELL USE(Check Applicable Box):Residen«al MunicipaVPublic❑ Industrial O Agricultural❑ Monitoring❑ >Recovery ❑ :Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WEI I LOCATIO L Nearzst ur: ' Count j Top o�a{ra�phic/fand setting, /n �. t ❑Ridge fZr;'lope OValley ❑Flat 3-mc, MIn� I�_i _ (check appropriate box) (Strtt[Name,—' a ,Commumry, ubdrv1sion, No.,Zip Code) La«tudeflongitude of well location 3. OWNER:Y (dag ees m oums seconds) Addres r Latirude7longirude source:OGPSOTopographic map (Sage[or oWc N ), (check box) `. Gc. 8 DEPTH DRILLING LOG 54'e.�o CChy or Toowwn Sn[� �Z Zip Code From To Formation Description Area code-Phonc nusnbc r X;_J " 4. DATE DRILLED l v 1710r 5.-TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES O-NO, Z Z - L STATIC WATER LEVEL Below Top Casing:� (Use"+'if Above Top of Cuing) 8. TOP OF CASING IS FT.Above Land Surface. *Top of easing terminated stror below land surface requires a variance in accordance with 15A NCAC 2C.0118. - 9. YIELD(gpm):�_METHOD OF VS: - I (/ 10."'ATER ZONES(depth): l I12 LOCATION SKETCH 11. DISINFECTION:Type Amount_ how direction and distance in miles from at least IZ. CASIPiGr l4hil Thickness two State Roads or Cour•ry Roads.inelud_ the road Depth Diam ter or Weighu'Ft. Ma 'a( numbers and common road names. - From d To�Ft.b t�-' - �OQ.Zf From To Ft. From FL De _ ('{ 13. GROUT: Depth M113terial lethod l'-A_jx.J�/i1t From_Tom_Ft.- a�4C may, — From_To��Ft. --`��C 'Y�- r''2-�-"C (�(J�-v,.�/J /�•�- '`7il 14. SCREEN: Depth Diameter Slot Size - Material From - To 'Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth -.. Size Material From To Ft. _ From To Ft. _ .16. REMARKS: ) - I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND F THIS RECORDHAS BEEN PROVIDED TO THE WELL OWNER Sllw 1"fURF OF PEKY':: ONSTP U(.(P!G Submit the original to the Division of Water Quality,Attn: Information rVIAnagemprit 1617 ryla rvice Center- Raleigh,NC 27699-1617,. Phone No.(919)733-7015,Within 30 days. - j RECEIVED Asheville Regional Office Altai#el pro#ectirn WELL CONSTRUCTION RECORD NoNt Carolina Department of Environment and Natural Resources-Division of Water Quality .-.,. L / WELLCOYCRACTOR(CfDIVIDUAL)NAME (p�int)!/(t'..Le-C /� J�L--Lti CERTIFICATIOYp30�f / WELL CONTRACTOR COdIPA-VY NASIE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # (828)586-5550 ' STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PER4t1T# (if applicable) (if applicable) I. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other O If Other,List Use 32428 ( 2. WELL LOCATI \:. Topographic/Land setting NearestTo%& - C—o-u—minty- ❑Ridge OSlope OValley�lat �V \ JG yt,2 4 r- ,L '..� s Nl �}. _ (check appropriate box) (SwcetName.Numbers.Community,Subdivision.-Lot No., i�� Latlrudellongitudeof well location 3. OWNER: (�ltN✓� --�'L'/'2.F�,t!.y„ C'�� ��> (degrces/miautes/seeands) Address t >' D 6' Latitude/longitude source:OGPSOTopographic map (Sweet or Roure No.) (check box)_ I a a X 71 DEPTH DRILLNG LOG City or.own State Zip Code From To Formation Description Area code-Phone numbe 4. DATE DR[LLED S 5. TOTAL DEPTH: 2� 7 _ V 6. DOES WELL REPLACE EXISTING)YELL? YES ❑ NO .�r 7. STATIC WATER LEVEL Below Top of Casing: 1 u FT. �� Z _ 3O (Use"+"i(Above Top of Casing) -� 8. TOP OF CASING IS FT.Above Land Surface' -Top of easing term in aced ao'or below land s urface requires a p z 7 J ti sariance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm):7%� METHOD OF TEST I 10. WATER ZONES 5 , LOCATION SKETCH 11. DISINFECTION:Type - Amount Show direction and distance in miles from at least 12. CASING: - Wall Thickness two State Roads or County Roads.Include the road Depth Da etzr or WeightTt. Mat al numbers and common road names. From _To: 4.zI Ft. SO ✓G From To 13" FI. From To Ft. 13. GROUT: Depth Material Method Fram�_To 7 Ft. From=Z To L.L, Ft. 14. SCREEN: Depth Diameter Slot Size Material From To F[. in. in. CUpL,Z;r 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 ST �ARDS,AND THATAT AF THIS RECORD HAS BEEN PROVIDEOTO THE WELL OWNER SIGNATUREOFPERS' N-CO'Lq VtT.TTHEKELL DATE Submit the orisinal to the Division or Water Qualirv,Attn: Information hianaae ail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,µithi RECEIVE® GW-I REV.09/2004 7Aa Asheville Regional of ice lli#e ; eCti011 n Lo 307955 WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) _ (if applicable) 1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other❑ if Other,List Use 2. WELL LOCATI N Topographic/Land setting tetNam rest bwn: County ORidge ❑Slope OVallx) ❑Flat (checkitude of ell Numbers,Couanuniry,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location _ 3. OWNER: (degrees/minutes/seconds) Address Latitude/longitude source:OGPSOTopographic map /i Str et r Aoute ) (check box) n�c 1987J9 DEPTH DRILLING LOG try or T �/ to Zip Code From T r Formation Description 828 / - 0 �� clay it sand Area code-Phone number granite 4. DATE DRILLED ' 10'QS 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES O 7. STATIC WATER LEVEL Below Top of Casing: (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface" .Top of casing terminated et/or below land surface requires a variance in accordsmaswith 15A NCAC 2C.0118. BLOW 9. YIELD(gpm): A ME)T�O t0 � ��___ 10.WATER ZONES(depth):�� LOCATION SKETCH Show direction and distance in miles from at least 11. DISINFECTION:Type H T H Amount 16 oz 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth ��n��p(pppp(�� Di meter or Weight/Ft. terial numbers and common road names. From 0 To Ft. _ ca From=To Ft. From To Ft. 13. GROUT: Depth Material Method r" „2 From 0 To 20 Ft. 6enonite&cement pumped -or" From To Ft. a% "^ 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. _ in. �o ena From To Ft. in. in. W o� 15. SAND/GRAVEL PACK: Z Depth Size Material �t7 From To Ft. n From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDA S,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER ���. Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 k'ELL CONSTRUCTION RECORD 307248 North Carolina-Department of Environment and Natural Resources Divisi WELLCONrRACron"UIVlOUAL)NAME [Print) *-� on of Water Quality-Groundwater Section CONTR WELL COMPANY NAME / l CER2'1PICATION MHO SPATE WELL CONSTRUCTION PEttMITq ' (ifa licable PHONE d �_ ,,�Sl SSOCIATEO{yQ PERMiTa WELL USE(Check Appl 1 icable Eox).Residential 1� Monitoring❑ Recovery tf ltcable 0 Heai Pump Water Injection Pal/Publie❑ Industrial❑ Agricultural❑ 1 Other 0 If Other,List Use z• WELL LOCATION: Nearest Town;�iU<eU<e �<�; County_ TOPographic/Landsetting 1 ORidge OSIO CommunAy,g bdrno Pe MalleyOFlat on,Lot Ho.,ZIP Code) (check appropriate bet) 3. OWNER: eL n .( Latitude/longitude of well location Address I 'ectOr Route Noj Latitude/longitudeseSOUM EI PSD opographicmap. �n,itnn V A14C vm Shoe 7e3�i•� (chat boa) q ` cy79� 17— J ZPCade DEPTH Rato To DRILLING From 4. DATE code. D_t� Formation Description 5. TOTAL DEPTH:__, Q ---�� 6. DOES WELL REPLACE EXISTING GWWELL? -- 7. STATIC WATER LEVEL Below Top of Casing:� s) S. TOP OF CASING IS (uSe"+"if Above Tap ofCaai,i g)n crop of MslnB wrmin d attar bFT.Above Land Surface' variance �� ald elow land surface regal,■ --' to accordance with 15A NCAC 2C.01,a. 9. YIELD(gpm): -"--� ZONES(depth); 10. WATER -�-METHODD FTEST i) 11. DISINFECTION:Type —' I2. CASING: Amount�p..;9 LOCATI`S CH o Show direction and distance in to Depth Wall lluclotesr two State Roads or miles from at least From Diameter ar Weight/FL Material a tubers and co Coanly Roads.Include the road From To��Ft' � --- _ y� mmon wd"�nn To FL _ Y ro M rAJ on� NO a. From To -r- u Go J.$'JY7 r'JBS 13. GROII'i': FL /UY/'J TOE 77 epth From Material M-- 1 6 G-O Sr3 m,`IPS . FromhT Q g Gr �. T �7 8ryr5oac: 14. SCREEN: Dc th Ft.—` -'�761Luo GO � T ' D /� From To Diameter Slot Siu hd— 0� lT s a s�p T/+rn /',t�r/T�O From Ft. m. N�fir Sj10 Jr�(hT Gd S L To Fl. in. V` Trat..rahr IS. SAND/GRAVELPACK- in. in. /Nm L Depth sift ` �'Ies Turn R',hT o n S/tleA , From F.to —Tom FL Material ree(C Go. p,,2 MJ'Je S T rn A, ti �' Ftl � h WQ��C.f'al/9B Ord. Torn 16. REMARKS: `'b�hr�o T Tp o¢ h,�� Lt�Prl Oh I DO HEREBY CERTIFY THAT r r CONSTRUCTION STAND , WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC WELL - ARDS,AND THAT A COPY OF THIS RECORD HA S BEEN PROVIDED TO THE WELL OWNER SIGNATURR O-4 ERSO _JedLUNSTR U it Submit the original to the Division of W CT1NG THE WELL DATE 27699-I636 Phone No.(919)733-3221,within t30 days. Y,Groundwater Section 1636 Mail Service Center Raleigh,NC a GW-1 REV.07/2901 r 0 0 tr No Ci ) WELL CONSTRUCTION RECORD North Carolina-Department orEnvironment and Natum� esources-Division of Water Quality-Groundwater 3 307249 17 2 4 9 LL CO WE NTRACTOR(INDIvIDUAL)NAME (prtat al on WELL CO\-TR,tCTOR COMPANY NAME CERTIFICATION#�C1 STATE WELL CONSTRUCr10N PERMIT# W t , 60 PHONE # .)yPq� (ifa irable) ASSOCIATED WQ PERMIT# ifs livable I. WELL USE(Check Applicable Box):Residential goMonitoring❑ R Municipal/Public❑ Indusecovery O Heat Pump Water Injection❑ Other O If Other, trial❑List Use Agricultural O 2. WELL LOCATION: Nprest Towny[j &, ��'. '_ '�_ Coun � Top09raphic/Land setting tt�lako r- h t�T,ac nR�) DRidge OSlopa Malley Mat c, nmercn,Cam nrty,Subdtws.on,lot No.,Tap Cade) (check appropriate boa) 3. OWNER: C- 60 Latitude/longitude of well location Address ` —� (degreea/minuteyseconds) l7� � (StreNorRoutsNo.) Latitude/longitude source:OGPSOTD o.r�YSan 6 P &raphic map Crtty orTowa ip— DEPTH (check box) S ZtPCode DRILLING LOG (�l-�Yr- /bW From To Formation Descriptiq�,t tD Area cads'Phanc numbv 4. DATE DRILLED -./�_ — < 5. TOTAL DEPTH: �S,A 6, DOES WELL REPLACE EXISTING TI WELL?7. STATIC WATER LEVEL Below Top of YES O NO Casing: �G?) 8. TOP OF (Use"+^if Above Top afC FT. CASING!S �FT.Above �r -- ---- *Top ofcarin8 tertaloated at/or below land,,fate ��SUrfaCe �� varlante la accordance with l$A NCAC3C.0118. require"a `�_ 9. YIELD(gpm):�_METHOD OF TEST 10,WATER 70NES(depth): Qp ��_ — I1. DISINFECTION:Type �- 12 C Amount IACATIO__ N SKc r CASING: ,rN Show direction and distance in miles from at least FroDepth K'all Tidckness two State Roads ar Diameter or WeighUFt. Material mbers and w County Roads.Include the road Fromm T--Ft. L-- .S,Qx moron oad names. To l-Y� ya. Fm o�lmondk 'Do G.a From To Ft.� /- 2 13. GROUT: Depth �G'7"Tdn 7yf� or.3m,%f'Sr Material '�' From__To...�_FL-CE'�E»T method fern 1467-a n -]kLn74 a q IU From To yw'r7 �N f 5 �G S 14. SCREEN: FL-- ��l� t, a From Depth Diameter Slot Sirs M—j " `� 7 �r/ems TvYI7 /l,8?h T 06'1 To From To Ft- in. in. pnTahe /oop 11/ovT/7 (r 2 yn„�3 15. SAND/GRAVE FL in. iR• 4 . O, Depth �PACK: T7JYN )4.gtir On rSaI, ' n From Size Material Y, rH r G-d From To Ft. �,� Qr 171,'Ie X en R'bT Ta GJell 16. REMARKS: on Ie.'r, I DO HEREBY CERTIFY THAT THIS WELL WAS D IN ACCORDANCE WITH CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS�RECORD HAS BEEN PROVIDED NCTC2 G WELL O .� A TO HE WELL OWNER SIGNATURE OF PE ON CONS'fRUCTINC THE WELL Submit the anginal to the 33 32 1, i Water QuaOty,Groundwater Section,1636 Mall Service Center E 27699-1636 Phone No.(919)733-3221,within 30 days. Raleigh,NC GW-I (SEX.07/401,, C WELL CONSTRUCTION RECORD � � � � � � North Carolina-Department of Environment and NaturaJl�Resoure -Division of Water Quality-Groundwater Section WELL CONTRACTOR tINDIVIDUAL)NAME (print t WELL CO\TRACTOR COMPANY NAME CERTIVICA77ON 92ao STATE WELL CONSTRUCTION PERMIT# r , PHONE # ti7S)t/75�.SfY�CL (iFa licable) ASSOCIATED WQ PERMIT# wmmmwmpnaaaa�(ifa licable 1. WELL USE(Check Applicable Box):Residential Municipal/Public O industrial p11000111 Monitoring❑ Recovery ❑ Het pump Water Injection❑ Other c !f Other. Use Agriculture(❑ 2. WELL LOCATION: Ngarest Town: �� t " TopographiC/LRDd setting F CountyL WnNn Nome,Numbers,Community,Subdivision,tat Na,2ip Code) edge 17$lope i]Valley OFlat (cheek appmpriata b") 3. OWNER: tPrLv yh N� Latitudeflongitudeof well location Address intep � T�C (degrcea/miwtevsxonds) (siren er Route No.) Latitude/longitude source;OGPS17Topographic map . ity rTo r:T_ci h C:.,,N To:;r, �� Y 7Ff7/_��� DEPTH (check 6mc) '' �� ZiPCode From DRILLING LOG A,-coae- To er Formation Description 4. DATE DRILLED ------ r 5.. TOTAL DEPTH: {REPLACE EXIS GN WIT ELL? LEVEL Below To YES❑ NO pff 7. STATIC WATER 6. DOES WELL of P Casing: p`FT S. TOP OF CASING IS � Nse +�'PAbove Top Of Casing) 'Top of caring rermlmted Wa--r�'aFFT.Abovad surign, e Land Surfa es variance In acmrdance with ISA NCAC 2C.01 IS. gMnsa —_ 9. YIELD(gpm):�_METHOD OF TES y �-- 10. WATER ZONES(depth); s ------- It. DISINFECTION; --'—Type LOCATION KETCH 12. CASING: Amount IS,k/ Show direction and distance mites from at least DepthWall Thickness two State Roads or Court ty From Diameter or WeightlFt. Ma-� umbers and common road na a es.s.include the road From To FIX 41 6Ar.21 `�. A� From TD Ft. 7YOYY) Al))fQt? NO GO /.F 'rn ye's To Ft. 13. GROUT: Depth Tvrn leo Pion 71/� Go 3 FromMaterial Method r Fom`�--o-t �.Fl-_CeJnig r f,,,n '•� jY1"lNS 'Turn /N.�`T on Or/7-ah7- 14. SCREEN: FLU— // �P'h Diameter slot size — /a" F�SZKTPS � 3,7 M,'/v T,1-r; From To FL Material ^ L From Ft.—in. in. {1 hT_ U n -4On;Rn To Ft. in. ©l VE'r'L✓ Gt� I5. SAND/GRA VEL PACK. in. 9 nn Depth Sim 0-,j Mules 7a-en Al ' h r0f) Tkr P From To Material y From Ft. T I�ATI7 Go, Q,lm,'JeS 7v�n /e�T o Ft. r on l�rr'i% WeLys F.✓ell On t\r l7T 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAg CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE�WELL WELL OWNER P SIGNATURE OF PE NCONSTRUCTINGTHEWELL ram' Submit the original to the Division within Water Quality,Groundwater See rE-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. tion,1636 Mail Service Cen er GW-1 REV.07/2001 WELL CONSTRUCTION RECORD � � � � � nvironment and Natural IResources-Division of Water Quality-Groundwater Section North Carolina-Department of E WELL CONTRACTOR(INDIVIDUAL)NAME/(+print) t t WELL CONTRACTOR COMPANY NAME�`r C.1,1t�1M / ' CERTIFICATION#2'a-50 STATE WELL CONSTRUCTION PERMIT# r I i j� PHONE #�52Sye f-S-4S—y (ifa licable) ASSOCIATED WQ pERMIT# (ifa licable) I. WELL USE (Check Applicable Box):Residential C4 Municipal/Public ❑ Monitoring❑ Recovery ❑ Heat Pump Industrial El Agricultural ❑ Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Nearest Town: Court Topographic/Land Setting Id l"ge" " (� '�7 B�Aet me N„ f]5rr/�Rn nty� ❑Ridge ❑Slope ❑Valley ❑Flat b s,Co munity,Subdivision,Lot No.,Zip Code) (check appropriate box) 3. OWNER: LatitudeAongitude of well location Address �, IeL del (degrees/minutes/sm nds) (Street or Route No.) Latitude/longitude source:❑GPS❑Topographic map ��sSnn r T 11'r � 4 �J Z (check box) �i ry Tow Sete Ztp Code DEPTH DRILLING LOG (s.c69)-�- , S l e From To Formation Description Area code-Phone number �- 4. DATE DRILLED / 7-in 5. TOTAL DEPTH: Wn 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO ❑ — 7. STATIC WATER LEVEL Below Top of Casing: (Use"+"if Above Top ofCuing) --�� Ql 8. TOP OF CASING IS'_FT Above Land Surface* CG *Top of casing terminated at/or below land surface requires a variance in accordance with 15A NCAC 2C.0118. --�- 9. YIELD(gpm): I_METHOD OF TEST_ ------ -- 10. WATER ZONES(depth): 11. DISINFECTION:Typed y LOCATION S— 12. CASING: T Amount n�_ Show direction and distance in miles from at least wo State Roads or Depth Diameter OrlWight/Ft Thickness aterial t umbers and commonounty o d names Include the road From a To 'ld Ft. cnr n t f From To Ft. Pdt✓I CJJNOYIC' PG) (rU j.�fYh•t/G'$ %vYi9 From To Ft. 011 7 C 13. GROUT: Depth Material 1� Froma_Tom_FL, �� �,, Method /L�r" R je yj% CU frl r'T�� From To FL �� r (. 3rykln c;'i y 14. SCREEN: Depth Diameter GO 770 STaP S:ggn 77;1/) 1e,; (G-U 7U From Slot Size Material i _ To Ft. in. �Sj p it r// 7-4,rn �IC�)1 CO From To in. _/- 15. SAND/GRAVEL PACK: FL—in. in. C _ Depth .Sn/O Jp /t�h F /+ f/rn % l �C 7-0 From To Ft. Size Material 7err1TeV70. RGN.L^ t!�T �' I�J77r%G� T,pN From To Ft. �— 'C t, �7 r �t P') 44a-,,--� f 1. c�S rC''Y't'el�` Gd , O,(c /ht�/Et 16. REMARKS: T'1• 1 /E7 %vr) �YdcRS Rd, Cp, o I 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORD CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER i:. �rF+r ANCE WITH ISA NCAC 2C,WELL SIGNATURE OF PERSON WNSTRUCTING THE WELL Submit the original to the Division of Water Quality DATE 27699-1636 Phone No.(919)733-3221,within 30 days. Groundwater Section,]636 Matl Service Center MAR - 8 2�'�lii Raleigh,NC GW-1 REV. 07/2001 Tic --- - - O6dNER -- -- � 3 0 81 OD - - WELL CONSTRUCTION RECORD Nor lh Carolina-Depai tucnl of Environment and Hat pfffral Resources-Division of Water Quality-Groundwater Section/ WELL.CUNT RACTOit(INDIVIDUAL)NAa.E .../..y...r.r ' -// C6Ge CERTIFICATION Na WELL CONTRACTOR COMPANY NAME L��IIE'�^ PHONE a WW) fi'I2.'�.ssl STATE WELL CONSTRUCTION PEINITTN ASSOCIATED WO PERMITN (i f nppl icahlc) (i f applicable) - 1. WELL USE(Check Applicable Boa): Residential 9'�Muuicipa/Public❑ Industrial❑ Agricultural❑ :Y Monitoring❑ Recovery ❑ heal Pump Water Injection❑ Other❑ If Other,List Use -� 2. WELL LOCATIOM// �/ Topogmphic/Land setting Nesfest,//T�own: d2C��L�Q Cooly Sr'U�r /t ❑Ridge ❑Slope ❑Valley ❑flat __Z,c fn✓e• (check approprisle box) `- (Clrrel Namq Num" bee,,Gnnmunily,$nbJivision,Lul No..Zip Ci.Jr) L,atiluddlongitude of well location "` / y" w0SJ, fS 06 0" 3. OWNER:_ )fL)u�` U C�f (Jeyee✓minumcx rreonJx) Address Q_T1,6� laliludellongitude source:❑CPS❑Topographic map ($noel m Rome No.) (check box) illl.'1'Tll I2BlI.L1NS'L1dLSi City or Iown Sr,re Zip a..1, Floor To Fomfalion Description Arm arse-Phone muuber 0— 60 C/p ra✓i 4. DATE DRILI.FD d -0,"';' to U- 26L 6 nn.'tt 5. TOTAL DEPTH: 2O. 6. DOES WELL REPLACE EXISTING WEL.1.7 YES ❑ NO a 7. STATIC WATER LEVEL Below fop of Casing: 7_FI'. (Use"r'•if Above Top of Ceeing) 8. TOp OF CASING IS �'� FT.Above Land Smface• •Top of caslna tit mingled.1h r Moe land mrh ee rrrpdrn a varlmee Ia scxordanre,rlih 15A NCAC 7C.0l la. 9. YIELD(gpni): 6 MEfiIODOFIT.SI' /r 10. WATER ZONES(depth): /7s LOCATION SY.ETG.►I I. DiSINFEC"YION:"Type �ZAlnuunl_��yc 1.P Show direction and distance in miles from at least 12. CASING: Wall llmicknevs two State Roads or Coady Roads. Include the road Depth Diameter or WeighUFt. Material numbers and common road names. Front O To 6 4 Ft. G"')*- ,/,YP S7frF From To FT --- Flmm To FL 13. GROUT: Dcplll M I rinI lelhod Ff onLr� i 7k,"To Ft. '? 7^rfI/vim _ From--S' To 02/:' FL c'r.''/_'i�e _ ✓P.JjUv� 14. SCREEN: Drpth Dimucler Slot rim taalcrial Front To F[.—ill. in. From To Fl. in. in. CAA 15. SANWGRAVFLPACK: Drp1I1 Sim Mxlclial From To FL From l'o PI. ---- 16. REMARKS: 1 DO IIpRFUY CERI[FYI[TAT THIS WFLI.WAS CONS IROCIIID IN ACCORDANCE Willi 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,A14D THAC A COP 'OF'I HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER 1���E— SIGNATURE OF PERSON CONS I RUCIING THE WELL DATE - Submit the original to Ibe 1)ivi5ion of Water Qunlily,Gromuhvater Section,1636 Mail Service Center-Ralelgh,NC 27699-16.16 Tlrnnc No.(919)733-3221,%vdihhm 3O days. OW-1 REV. 07l2001 m NC OWNER _ MWD WELL CONSTRUCTION RECORD 3 North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) �i�/�� /LeeCP' CERTIFICATION# ^�� WELL CONTRACT OR COMPANY NAME i,/ill�� PHONE N STATE WELL CONSTRUCTION PEM11TN ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residential QK Municipal/Public ❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Ileat Pump Water injection❑ Other❑ If Other,List Use 2. WELL LOCATION i tom TopographiefLand selling Nearest Town: C��C`" Couuly s H'�r ❑Ridge ❑Slope ❑Valley ❑Flat %Coy �rPpc( (check appropriate box) , (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cale) LatitudcllonRilude of well localiorl,, n�33"';j, +/8'3 crlOgd`a2/' 414.,f 3. OWNER:-AR/7 ///V/— Lae (degreedminutedrecomb) Address Lid ?Y,'ba/ 6001 Latitude/longitude source:❑GPS❑Topographic map (Street in Route No.) (check box) I)LPT'll DRILLING LOU City or Town state zip Cale From To Formation Description Ara code-phone number 4. DATEDRILLED 2-/0 'OJ� lzEt- 610 5. TOTAL DEPTI L• 6/0 ' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lk 7. STATIC WATER LEVEL Below Top of Casing: 0 Gp Fr. L (Use'4-if Above Tnp of Casing) . g. TOP OF CASING IS /L Fr.Above[.and Surface* T *Top of rasing Irrminalyd aUor below land surface requires■ cart once In accordance nilh 15A NCAC 2C.0119. 9. YIELD(gpm): ? MET[IOD OF TEST 10. WATER ZONES(depth): l,0C " rr r LOCATION SKETCH Ln It. DISINFECTION:Type /�1� Ainounl f/r/f Show direction and distance in miles from at least 12. CASING: Wall'Ihickness two State Roads or County Roads.Include the road Depol Diameter or WcighUFI. Material numbers and common road names. From D Tb L?2 Ft. 6-;f3' -$AetI man From /.?Z Tn ZL�_Ft C. Ls- _/eh, sf4- From To Fr. _ 13. GROur: Depth I Iy'ytI tedrod From Q To y Ft. 0,17%."� Ftont 'Y Tom Ft.� p4!c var s 14. SCREEN: Depth Diameter Slot Size Material Front Tor H.-ill. in. .. From TO,—Ft. in. in. 15. SANEVORAVELPACK: Depth Size Ma(crinl - From To Ft. From To FL 16. REMARKS: 1 DO NEREDY CERTIFY T11AT THIS WELL WAS CONS FRUCFED IN ACCORDANCE Will t 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PLRSON CONS'rRUCI1N0 THE WELL DATE Submit the oriLinnIto the Division of Water Qua lily,Groundwater Section,1636 Mall Service Center-Raleigh,NC 17699-1&i6 Phone No.(919)733-322i,wNhin 3U dnys. OW-1 REV.0712001 WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) Russell S Taylor CERTIFICATION#2187 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery O Heat Pump Water Injection❑ Other O If Other,List Use 2. WELL LOCATI N: ' SG�1 1— Topographic/Land setting Nearest Town: C tnty ORidge ❑Slope OValley ❑Flat (check appropriate box) (-Street Name,Numbers,Community,Subdivision, of No.,Zip Code) Latitude/longitude of well location 3. OWNER: / 1 (degrees/minutes/seconds) Address n� Latitude/longitude source:OGPSOTopographic map r r�(Street or Route No.) ' ' (check box) Al� < DEPTH DRILLING LOG City or Town Zip Code From T Formation Description 828 _ to 0 .5J clay&sand Area code.Phone numbe Q granite 4. DATE DRILLED 5. TOTAL DEPTH: 0 r (( �� 6. DOES WELL REPLACE EXISTING WELL? YES NO 7. STATIC WATER LEVEL Below Top of Casing: T. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface" -Top of casing terminated attor below land surface requires a variance in accordanee wi h ISA NCAC 2C.0118. 9. YIELD(gpm): V. METHOD OF TEST BLOW/ IO.WATERZONES ept ): $7' 1:37 LOCATION SKETCH 11. DISINFECTION:Type H T H Amount i 6 oz Show direction and distance in miles from at least 12, CASING: Wall Thickness two State Roads or County Roads. Include the road De pth th Diameter or Wet t/Ft. Material numbers and common road names. From 0 To�Ft.= o^. From To Ft. O Grrt From To Ft.__ Gn -4r� P 13. GROUT: Depth Material Method 9 ::o m From 0 To 20 Ft. Benonite&cement pumped �O From To Ft. O o� 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. --1� From To Ft. in. in. (A Zg 15. SAND/GRAVEL PACK: Depth Size Material V, n From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER 7 05 NATURE OF PERSON CONSTRUCTING THE WELL DAT Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service.Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. - R - GW-1 REV.09/2004 309476 WELL CONSTRUCTION RECORD North Carolina- Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (p/rri--n�t)s_L�r 'Ud P CERTIFICATION# WELL CONTRACTOR COMPANY NAME C)— n / ea n'i G./e 11 �fi III 'n�PHONE # &&)!ZZ - Y,T4 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 NJea�resttTown:&)Y&n G.'Ty County S-1&4aj; ❑Ridge ❑Slope ❑Valley ❑Flat /1;AJLd n VV:Osti) , (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of Well location 3. OWNER: & houls7-"n (degreeslminutes/seconds) Address f." ( Z z Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) nr)zsca C,'Tv IVL ).Sr7,12 DEPTH DRILLING LOG City or Town State Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED3^�-OS n 5. TOTAL DEPTH:_31RO � �C 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R 7. STATIC WATER LEVEL Below Top of Casing:_/OD FT. r� t (Use"+^if Above Top of Casing) 8. TOP OF CASING IS_�FT.Above Land Surface* t 'Top of casing terminated attar below land surface requires a r variance in accordance with I5A NCAC 2C.0118. 9. YIELD(gpm):. aO METHOD OF TEST 0.i t^ 10. WATER ZONES(depth): '„1Sr0 LOCATION SKETCH It. DISINFECTION:Type Amount (f„tp Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material n mbers and common road names. From Tom Ft. .S()r ! _fl yc _ ro m cal mo n a( /00 G o O,� m +l l e From To Ft. G From To Ft. on 1�WY aO N /TUYli le4 T on 13. GROUT: Depth Material Method L� From--!;-J_To Q0 Ft. C'.FMen'T (7rr r' JS'if'/) V1,&AJ C-,0 CJ3m") From FL De h I 14. SCREEN: Depth Diameter Slot Size Material �UTI'1 R r� GU 0, MN 7-v.e✓1 From—To—Ft.—in. in. Jd y.�` G' O l mt'le 7tl w6,1fO 17 From To Ft. in. in. lYu / 15. SAND/GRAVEL PACK: Depth Size Material /\ From To Ft. - From To Ft. 16. REMARKS: a I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL _ J CONSTRUCTION STANDARDS,AND THAT Af.COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER r II 7 � F �'O9—Out SIGNATURE OF PERSON WNSTRUCTING THE WELL DATE o 0 cn _ Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh, - 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV.0712001 C 3O94'7 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (paint) /fr CERTIFICATION#�Q WELL CONTRACTOR COMPANY NAME 6 ��rin W,.// I^i�li t/7Lf PHONE STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residential® Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting NKarest Town: 2r)ySc n County .S1 lnlrt i 12 ❑Ridge OSlope ❑Valley ❑Flat -�eja71d4a. lakC fsT T�.t e(S'7/� (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: &nyl abr-,M (degrees/minutes/smonds) Address Th7ay3Ar_14& E,S7yZeS Latitude/longitude source:❑GPSOTopographicmap (Street or Route No.) (check box) -2a S n G'Ty me 2Fr7/3 DEPTH DRILLING LOG ci y or Tote zip Code From To Formation Description Area code-Phone number 4. DATEDRILLED ��9�lr.5" 5. TOTAL DEPTH: 46,S 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® - 7. STATIC WATER LEVEL Below Top of Casing:_7d FT. (Use"V'if Above Top of Casing) 8. TOP OF CASING IS�_FT.Above Land Surface' r1t `Top of casing terminated atfor below land surface requires a y variance in accordance with 15A NCAC 2C.0119. I' 9. YIELD(gpm):�_METHOD OF TEST �Ci i r 10. WATER ZONES(depth): LOCATION SKETCH 11. DISINFECTION:Type, 1777-/7 Amount tr.F� Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material mg tubers mm and common road names. Fro To S1 6t c l' Ft. goral VOm G.lmor1� PO. (7 p -6 From To Ft. _ From To Ft Go c.3 »7 ,tic�s 13. GROUT: Depth Material Method _ r r _ From _To20 Ft. C,,oWar)T Pv-� lurn lC'T 7- 7tl✓ re,%P6L 14ke 6s/ct 7eS Fron To Ft. 14. SCREEN: Depth Diameter Slot Size Material CO, y,7mr`'Ies- Tllr/1 1N�TOrl From To Ft. in. in. IS From To Ft. in. in. 'e �r 0 JrI'I/e � Qa O r 15. SAND/GRAVEL PACK: "t`t Depth Size Material �(!r 9��` � O c) Ve /d t i loll From To Ft. / From To FL on lei T 16. REMARKS: n 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL 3 i �S CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE U c Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigtr,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-1 REV.0112001 WELL CONSTRUCTION RECORD 0-0 309419 North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential O Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCAT1 : Topographic/Land Setting N stTot n: County ❑Ridge ❑Slope ❑Valley ❑Flat (check appropriate box) (Street Name, umbers,Community,Subdivision,Lot NO.,Zip Code) Latitude/longitude of well location 3. OWNER: (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (Street or Route NO. (check box) � � 1.'1 DEPTH DRILLING LOG Ci orTo State ... Zip Code From r Formation Description ( , 770--�i�f'—C95& 0 o clay&sand Area code•P one number � �'/� f granite 4. DATE DRILLED!� " 5. TOTAL DEPTH: —=�L 6. DOES WELL REPLACE EXISTING WELL? YES❑ O )�S 7. STATIC WATER LEVEL Below Top of Casing: FT. (Use"+"if Above Top of asing) 8. TOP OF CASING IS 2 FT.Above Land Surface" W -Top of casing terminated atior below land surface requires a variance In accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): � METHOD OFTEST�BLOW — 1 10.WATER ZONES(depth): 7t7 r y LOCATION SKETCH 11. DISINFECTION:T e H T H Amount 16 oz Show direction and distance in miles from at Itpt 12. CASING: yp Wall Thickness two State Roads or County Roads.Include the road ' Depth Diameter or Weight/Ft. atenal numbers and common road names. From 0 To Ft. „ From_=To Ft. to" ,a$'.. stw From To Ft. 13. GROUT: Depth Material Method From 0 To 20 Ft. Benonite&cement pumped From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From To FL—in. in. From To Ft. in. in. _ 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STA RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER �SIGNAIZRE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center- _ Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REu.`09/200 I i; cam, " 10940 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources- Ivision of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (/pr'int)—J2 - , zAe' CERTIFICATION#99� C7 WELL CONTRACTOR COMPANY NAME l'1-1^c'L�0.Y17 L 'r</I PHONE # Grn'tte)�7 5'1 qx STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT# (if applicable) (if applicable) _ 1. WELL USE (Check Applicable Box): Residential M Municipal/Public❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ 1rOther,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town:. N,;,3n C;Jy County—<,&- 1 ❑Ridge ❑Slope ❑Valley ❑Flat F a . Z42 7 YL 3 (check appropriate box) (Stree(A1�. �m�e,Numbers, ��Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: rhsa A(en, Q (degrees/minutes/smonds) Address Fi°e &—,c R -151 Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) C- .2Ss 7 11 DEPTH DRILLING LOG City,or Town tate Zip Code From To Formation Descriptiory- (F[a`t2-c)-3 91- 3 i :3 Area code-Phone number 4. DATE DRILLED � 5. TOTAL DEPTH: >� � 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ot 7. STATIC WATER LEVEL Below Top of Casing: iC FT. W (Use"+"if Above Top of Casing) 8. TOP OF CASING IS / FT.Above Land Surface' r1t `Top of casing terminated atlor below land surface requires a -��.9 variance in accordance with 15A NCAC 2C.0119. � 9. YIELD(gpm): 6 METHOD OF TEST a-i r 10. WATER ZONES(depth): Q LOCATION SKETCH 11. DISINFECTION:Type L' Amount 6 Show direction and distance in miles from at least 12. CASING: Walt Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material Rumbers and common road names. ' From ! To Ft. _ V� ' ems' 'l�°/ �c�s �.9 '.. 1�L — Tf M c�)net;'A Pe U-� 1, From To F[. ., {-,j On !_ From To FL /L�"j'/) ��'7 �� `Y� + -- 13. GROUT: Depth Material Method 'le h% 0.T From e, 1't2J� �"~)� S T't n r PTO `ayG7 Ft. Et l'+It'%i9T � t �� /Fi i"✓� From To Ft. ) 14. SCREEN: Depth Diameter Slot Size Material n , f_ cze q°s /y7,�es �Lr 1 /1 !6'�7 From To Ft. in. in. �'(Irr/ r _ J From To Ft. in. in. �+-O 15. SAND/GRAVEL PACK: n �' / � Depth Sim Material lT- % '� -� G n U iJ6"`7 From To FL From To FL 16. REMARKS: wicsll �d F! �T�/Area ct TGr zt 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 ON✓NBR SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE —' - Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC a GW-1 REV,4�12001 27699-1636 Phone No.(919)733-3221,within 30 days. - 314939 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-1pivision of Water Quality-Groundwater Sectiion.,q WELL CONTRACTOR(INDIVIDUAL)NAME (print) t '+ - CERTIFICATION# Q° 'I WELL CONTRACTOR COMPANY NAME�"—%"r/.e Piet L✓f L, t&r71/ Cg P.%!r/ri1C PHONE # Ks3.dri)5F7FJ'->rYS y STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residential I& Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCAT N: Topographic/Land setting NearestTopwn: - �:� C�r County-!L-�C�.ril ❑Ridge ❑Slope ❑Valley ❑Flat f a ';:I A C R ak ac 7>i (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: 1'7 (degrees/minutestsmonds) Address e e / Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) +II C r7v �( �51 Z% 3 DEPTH DRILLING LOG ny or town te a zip Code From To Formation Description Area code-Phone number "rt 4. DATE DRILLED �/ /l•[75 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO M J't 7. STATIC WATER LEVEL Below Top of Casing: FT. _ ;a (Use"+"if Above Top of Casing) C.A 8. TOP OF CASING IS_�_FT.Above Land Surface* 9 -Top of casing terminated at/or below land surface requires a fP variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): C) METHOD OF TEST D.'p 10. WATER ZONES(depth): LOCATION SKETCH 11. DISINFECTION:Type C Amount /1 Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material nup(rn�bers and common road names. / 9 From_To n�G Ft. S!)l' J � _ Ti'LI y✓) C'J)"ndf7L'� From To Ft. - From To Ft �j-� ��'. - 71/� 13. GROUT: Depth Material Method _ . ./ From Ct To IP FL C,0VZ!UI r �LwA dp )l7 R7�h T' From To FL ` Y, f r y SIG)• 14. SCREEN: Depth Diameter Slot Size Material C -t /1�'�I Zjr Cl�a)��Gc lT�? �a � From To Ft. in. in. --� t i i t � 9y1,'��f /21e/1 From To Ft. in. in. (J 15. SAND/GRAVEL PACK: CA 1r 10 G�I1dG S R . � d' Depth Size Material �( � )„ Eil7eE/' From To Ft. m II JE -r"'-7 1 h -T C7/1 From To Ft / , >/ lo. (�(7. Gl,5r>> /�%.n Rih 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 _ 44.1k SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE c Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Ral gI ,NC _ 27699-1636 Phone No.(919)733-3221,within 30 days. GW I REV.(h07/1001 ; 1093 � WELL CONSTRUCTION RECORD North Carolina- Department of Environment and Natural Resources-Di esion of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print)y ( I #1910 res ho m L� J WELL CONTRACTOR COMPANY NAME ' 1'z�fi Y1�_PHONE # (SN�,y79- Ys 4 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential a Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: '4 County.SWcx.,'n / ❑Ridge ❑Slope ❑Valley ❑Flat Z I ik 4' ST t 9b';zI-�? (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location r- 3. OWNER: [�10 _ (degrees/minutes/seconds) Address Ie.0 t' d r S Te-r Latitude/longitude source:OGPSOTopographic map (Street or Route No.) (check box) Qr SOn Ze NC aS(7/.3 DEPTH DRILLING LOG ny or Town grate Zip Code From To Formation Description (2L)m-2;? -/2f&2 Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q 7. STATIC WATER LEVEL Below Top of Casing P1 FT. rr (Use"+"if Above Top of Casing) 8. TOP OF CASING IS FT.Above Land Surface' *Top of casing terminated atfor below land surface requires a L variance in accordance with 15A NCAC 2C.0118. ~: 9. YIELD(gpm): METHOD OF TEST a i Y f'- 10. WATER ZONES( epth): LOCATION SKETCH i 1. DISINFECTION:Type A Amount n Show direction and distance in miles from at least 9 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material numbers and common``oad ames. From�To_I_Ft.�_ ALL Ayc -yrofn u,lmend �UG6 1f 1�' M.'Ies 'Turn From To FL R C{)T O n 741 From To Ft. T p,� T 13. GROUT: Depth Material Method T,rn R h 4It 4 To STop From_.O- _To �e) Ft. ['PMCnT sJgn 7-Lrn lP�T across a vLor pa msS- Fro To FL O� f. 14. SCREEN: Depth Diameter Slot Size Material T ,s T 'p S, rl Tl/rn Rs�hT d d'1 N4,y )I From To Ft. in. in. From To Ft. in. in. GO a,6 r'i%1�P.S Turn Nj-.on o )d Hwy 15. SAND/GRAVEL PACK: /9, GO To 7t'rs-T /&)-Pr Trrrt IePT Depth Size Material From To Ft. on 13uCknerr 13rclnCh 6-0 a.c' rrlt"1t�5 . From To Ft. 'Turn f aro lour) Branch (4o, q.9m,Yrs. 16. REMARKS: 'jd rn !Y'r r"Y'I r , /, g 1. Turn le-4TonBLm/4Icir -''Q ��� I7F �v.i c � _ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL_ w I CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER ' — �E3 �� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE r� c.n Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC GW-t REV..;07/2001 - 27699-1636 Phone No.(919)733-3221,within 30 days. 31093 "7 WELL CONSTRUCTION RECORD North Carolina- Department of Environment and Natural Resources-Tivision of Water Quality-Groundwater Sectito,n,�- WELL CONTRACTOR(INDIVIDUAL)NAME (print) )fl�� ,�/JP CERTIFICATION#t✓-0 TTTTT WELL CONTRACTOR COMPANY NAME Sr" YY/ t✓'W/ A.-"114 PHONE # 153A41479- SLJ STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential® Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: nrV.12n Cl County- SLJCL r Y/ ❑Ridge ❑Slope ❑Valley ❑Flat -ZMh Ar r- E_ rA%F� 5 7/a (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER:-Paul lr rOC P (degreestminutes/seconds) Address T m c fS%aTiaS Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) Br\/S2il <f 'Ttl IVG .1R7/.3 DEPTH DRILLING LOG Ci y of r town sm a Zip Code From To Formation Description Area code-Phone number 4. DATEDRILLED �/�C�S 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO IR 7. STATIC WATER LEVEL Below Top of Casing: .'31Sn FT. (Use"V'if Above Top of Casing) 8. TOP OF CASING IS�_FT.Above Land Surface* tL_72 *Top of casing terminated at/or below land surface requires a ` variance in accordan a wr[h ISA NCAC 2C.OI18. 9. YIELD(gpm): METHOD OF TEST 10. WATER ZONES epth): .SCI LOCATION SKETCH 11. DISINFECTION:Type Amount D.9d Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material n mbers and common road rfmes. � � From O To�_Ft. I snra l _A yc tr0 M C:+�,11YM d 17 !f'1 �-o From To Ft. 1e* T U.T 'cJc"-r' `c�. E-Vt 1 T From To Ft. - 13. GROUT: Depth Material Method p/ (,Jio 'TQ s 76)ra Ricohr Fromm To 'LQ Ft. P PYI'r i From To FL r1 pn c..krkc� 14. SCREEN: Depth Diameter Slot Size Material C From To Ft. in. in. �Ur /�/ah Qyj �;y6•lberC."S�R�c"5 From To Ft. in. in. /+ 15. SAND/GRAVEL PACK: G d O, g m t t S TUrY) fp Depth Size Material -1 L�f- j� ]� �+ O� From To Ft. on m f'V`f� 7 h AA , U'U 0, 3M"le From To FL l ureple�7 6o % Top O� V6) WEB,' 16. REMARKS: elr;-- I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL L - CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE ry 1 Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC,07 1 REV.. 12001 i - - 27699-1636 Phone No.(919)733-322I,within 30 days. GW-1 -" ��1 3111 E► �7 WELL CONSTRUCTION RECORD North Carolina - Department of Environment and Na�turraal R�esouur'ccess-Division of Water Quality-Groundwater Section �J WELL CONTRACTOR(INDIVIDUAL)NAME /(j'rin0 l rfGr t_�Y 't- CERTIFICATION/ �J WELL CON"fR:\C"f012 COMPANY NAME l�Ir'rf1 wSi PHONE # szy-��/.� STATE\YELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE (Check Applicable Box): Residential,FJ�unicipat/Public ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: " � Topographic/Land setting Nears (Town: Countyc�lt1�1�At ❑Ridge ❑Slope ❑Valley ❑Flat - 1O'+-�GeJ (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location. -- 3. OWNER:J��'N /l,{1[n Jr}S�N (degrees/mimnes/seconds) Address F.rl d0y A.fS"7 Latitude/longitude source:❑GPS❑Topographic map (Stree^to�Route No (check box) - /rL oZQ�� DEPTH DRILLING LOG City or flown Scat Zip Code From To Formation Description Area code-Phone number — /2; 4. DATE DRILLED :7 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES El NO ❑ - 7. STATIC WATER LEVEL Below Top of Casing: FT. a (Use"+"if Above Top of Casing) 5j1 8. TOP OF CASING 1S�_FT.Above Land Surface* to " *Top of casing terminated at/or below land surface requires a variance in accordance with 15A NCAC 2C.0118. 0 9. YIELD (gpm): 'a,0 METHOD OF TEST A' - c-n 10. WATER ZONES(depth): LOCATION SKETCH It. DISINFECTION: Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Di r or Weight/Ft. Material numbers and common road names. -- From P� TohZ FL DVG From To Ft.From To Ft. 13. GROUT: Depth Material Method From D To �..() FL aG s) From To Ft. i r 14. SCREEN: Depth Diameter Slot Size Material - L eo From To Ft, in. in, N I From To Ft. in. in. -` 15. SAND/GRAVEL PACK: — Depth Size Material - From To Ft.From To Ft. - 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CON TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER :te e_f� LSD 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)733-3221,within 30 days. GW-I REV. 07/2001 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and oral Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) �Cp Q CERTIFICATION#ao-3 WELL CONTRACTOR COMPANY NAME �A/IC L�)/US y PHONE # f � STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT'# (i f applicable) o r appl icable) l. WELL USE(Check Applicable Box): ResidentiaKT�Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other, List Use �. 1: 2. WELL LOCATI N: = Topographic/Land�settlrlg Nearest Town: County SL& �s I �q ❑Ridge ❑Slope ❑Valley,,,❑FIa4 ��� �lr/s.✓��ye K,.1 (check appropriate btra) (Street Name,,�Nuumbcrs.Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location ( o- j 3. OWNER: ✓ - (degrees/minutes/secokds): Address -y't3 1 Ar-Q T21 Latitude/longitude source:❑GPSt�fo'pographic mat (Street or Route No.) (check box) _ nA/y 2% n/L 7 A 7 DEPTH DRILLING LOG City or Town State Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED J�-'y-05- 1D _-• — 5. TOTAL DEPTH: y Tp 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ - - 7. STATIC WATER LEVEL Below Top of Casing: 30 Fr. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS- FT. Above Land Surface* c � •Top of casing terminated at/or below land surface requires a 9 - variance In accordance with 15A NCAC 2C.0118. c17 9. YIELD(gpm): I ' - METHOD OF TEST_,44 r 10. WATER ZONES(depth): _ LOCATION SKETCH 11. DISINFECTION: Type Amount _ Show direction and distance in miles from at lea's[ 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diamfter or Weight/Ft. Material numbers and common road,names. From To &0 Ft.�t� From To `- From To FL 11. GROUT: Depth Material Method From O To � 6 Ft. CeAZ& Z± rr From To Ft. 14. SCREEN: Depth Diameter Slut Size Material "'! cn - From r To Ft. 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 CONSTRLNTION 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.(919)733-3221,Within 30 days. GW-I REV. 07/2001 WELL CONSTRUCTION RECORD �,,/ ea 3, -L x " v North Carolina-Department of Environment and Natural Resources-Division of Water Quality- Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print)�d"'t al46C CERTIFICATI`ONN+gt3d19/ WELL CONTRACTOR COMPANY NAME! 2b:jee/I/S /�e�/�H L G y�L PHONE H Lo g 47�YY�z STATE WELL CONSTRUCTION PERh11Tt1 ASSOCIATED WQ PERAIIT'p (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residentialfl'Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use 2. WELL LOCATIRN: Topographic/Land setting Nearest Town. Coun(ySlr/� /_ ❑Ridge ❑Slope ❑Valley ❑Flat —I— (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitudeilongitude of well location 3. OWNER: Ed �VG�tcIIP_ (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) — S y Al DEPTH LRILLING LOG City of Town state zip code From To Formation Description Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH: SD5 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I] 7. STATIC WATER LEVEL Below Top of Casing: 101) FT. (Use"+"i(Above Top of Casing) _ 8. TOP OF CASING IS / FT. Above Land Surface* "Top of casing terminated at/or below land surface requires a e"T A variance In accordance Milt 15A NCAC 2C.0I18. , 9. YIELD(gpm): S-(a-METHOD OF TEST AY In s 10. WATER ZONES(depth): _ LOCATION SKETCH IL DISINFECTION: Type Amount _ Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Dianleter or WeighUFt. Material numbers and common road names. From To-r,�Ft. to /v ,�✓� From To Ft. From To FL _ -- 13. GROUT: Depth Materia Method — From �To-0dD Ft. if2/!st From To Ft. 14. SCREEN: Depth Diameter - Slot Size Material From To Ft. in. in. rid From To Ft, in. in. = I ' 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 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 Alaler Quality,Groundwater Section, 1636 IV1aH Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GWA REV, 07/2001 WELL CONSTRUCTION RECORD ,) �16c North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) 16 �J✓K.�-��F CERTIFICATION k WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OP SYLVA,INC. PHONE # (828)586-5550 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 LOCATI N: Top?gaphic/Land setting Nearest own: 9 L� County. ❑Ridge X]Slope ❑Valley ❑Flat (check appropriate box) (Street Name(,Nuu�r4crs,ConarnunitA Subdivision, Lot o.,)Zip Code) wl Latitude/longitude of well location 3. OWNER: (degmes/minutes/seconds) Address ' u J Latitude/longitude source:❑GPS❑Topographic map (Street oWVa No,�3 35, (check box) i —TL- DEPTH DRILLING LOG City or ro Zip adz From To Formation Description o� Areacode-Phone Dumber ,/ _ �+ 4. DATE DRILLED /L�S_�yttC/�_ 5. TOTAL DEPTH:-7 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO et 7. STATIC WATER LEVEL Below Top of Casing: FT. 75 (Use"+"if Above Top Casing) 8. TOP OF CASING IS FT.Above Land Surface* -Top orcasing terminated attor below land surface requires a variance In accordynce with 15A NCAC 2C.0118. 9. YIELD(gpm): I METHOD OF TEST (V� 10.WATER ZONES(depth): `JS LOCATION SKETCH 11. DISINFECTION:Type Amount 3 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 CO To��j/ Ft.�f From To Ft. _ From To Ft. i 13. GROUT: Depth Material Method From d To Ft._� � I From 3 To t�L FL 14. SCREEN: Depth Diameter Slot Size From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH 15A NCAC 2C,WELL CONS N STANDARDS,AND THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER �i D c7 r SIGNATURE OF PERSON CONSTRUCTNG THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Lenten..__.._.._.___.. Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. 6W71 REV.0�12004 WELL CONSTRUCTION RECORD 1. -1 5 ( a North Carolina Department of Environment (�and �iNatural Resources-Division of Water Quality WELL CONTRACTOR(LNDIVH/UAL)NAME (print) CERTIFICATION p _ 0 Ll/ WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE p (828)586-5550 STATE WELL CONSTRUCTION PERNIITX ASSOCIATED WQ PMNnTM (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 N: Topp�r�phic/Land setting Neare tTown: C unty ❑Ridge lope OValley ❑Flat `/_'+� � (check appropriate box) (Street Name,NLLurnbcm,Community,Subdinsio i,Lon o.,Z Code) �eatitude/longitude of well location. 3. OWNER � (degmes/minutes/semnds) Address ���-� LE�r✓ Latitude/longitude source:OGPSOTopographic map (Scree[or Rgptq No.) ` b t (check box) DEPTH DRILLING LOG City or Twn State e�,•n'Code From To Formation Description 8L) 4- E O — Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH:����''�} y 6. DOES WELL REPC7 CE EXfsT NG WELL? YES ❑ N0 00 7. STATIC WATER LEVEL Below Top of Casing:_f�} FT. (Use"+"if Above Top ofCasing) _ .�� 8. TOP OF CASING IS FT.Above Land Surface' 'Top of casing terminated at/or below land surface requires a variance in accordan with 15A NCAC 2C.0118. 9. YIELD(gpm):�METHOD OF TEST l 10. WATER ZONES(depth): ',-)d T4= � LOCATION SKETCH I I. DISINFECTION:Type Amount�Nlato*a how direction and distance in miles from at least 12. CASING: Wail Thicwo State Roads or County Roads. Include the road Depth Diameter orWeighumbers and common road names. From To Ft. �� From To Ft. From To Ft. 13. GROUT: Depth Material Method From b To Ft. _ ^ From To Ft. 14. SCREEN: Depth Diameter Slot Size Nf terial 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 CERTLFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONS TRUC STANDARDS,AND THAT A COPY IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER '5' /D-0S SIGNATURE OF PERSON CONSTRUCTRN THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV, 09/2004 3 115 WELL CONSTRUCTION RECORD North Carolina Department of Enviro �ent and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) 8 � CERTIFICATION# WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # (828)586-5550 STATE WELL CONSTRUCTION PERMITa 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 N: — Topographic/Land setting Near Cou tytZQif `' ORidge ❑Slope OVallcy7Flat x ii( ii /itJj Q y� (check appropriate box) (Strcet Name,Numbers,Commum �,Subdivision,Lot No Zip Cod VIC> Latirude/longirude of well location 3. OWNER: (degrees/minutes/seconds) Address pe Latitude/longitude source:OGPSOTopographic map (Street to o.) r( /� (check box) 1. t� 9 11 DEEPTH DRILLING LOG Ciry o iown State Zi Code From To Formation Description Rc C ?b £5 — 'S �� Area code-Phone number Q 4. DATE DRILLED � ,) —- rj 5. TOTAL DEPTH: U 6. DOES WELL REPLACE EXISTING WELL? YES , NO Jq 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 accordanc5 with 15A NCAC 2C.0118. 9. Y f 1, 10.WATER ZONES(depth): 0 U r LOCATION SKETCH 11. DISINFECTION:Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the roads®`�,; Depth) iaSneter nL rial numbers and common road name �1 t From O To Ft. , From To Ft. From To Ft. I �'• ' ,, _,(,/y�Q� 13. GROUT: Depth atenal Method _ -.=( ✓�t��`�' "r—z"f — From Q To Ft- From } From_To Ft. -�CJ n 14. SCREENS Depth Diameter Slot Size Material ,4y.--r— From__ -To � _Ft. in. in. ' I From - To_�, Ft. in. in. 15. SAND/GRAVEL PACK_ Depth Size Material If From To Ft- From—To Ft. S -C C 1 16. REMARKS: r\3 } .a I DO HEREBY CERTIFY _HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL o CONSTRUCTION ST RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNED /U Clelql- SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn:Information Management,1617 Mail Service Center - Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. -- 'i j Gar,l E V 09/2004 i , WELL CONSTRUCTION RECORD �til *i North Carolina Department of Environment and Nam 1 Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (pri."T—"i & CERTIFICATION#-!z•—� WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # (828)586-5550 STATE WELL CONSTRUCITON PERMIT# - (if a livable) ASSOCIATED Wt2 PERMIT# (if applicable) qq rr 1. WELL USE(Check Applicable Box):Residential Municipal/Public❑ Industrial❑ Agricultural❑ Y u Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Nearest To (/_ C un trt(q.� Topographic/Land setting ORidge glElope ❑Valley ❑Flat u L - check a ro(Street Na ,me Numbers,C' sunity,Sutldivision,Lot No.,Zip Co e) ( PP Prete box) Latitude/IongiNdeof well location 3. OWNER: Q or Address (degrees/minutes/seconds) (Stye or Route No. Latitude/longitude source:OGPSOTopographic map �- �'Y` DEPTH - (check box) city or State Zip Code DRILLING LOG � - �wo y/ _- 3 S-A _ / �7 � From To Formation Description Area code-Phone number 4. DATE DRILLEDS- 5. TOTAL DEPTH: $ f�;V 6. DOES WELL REPLACE EXISTING WELL?WELL? YES ❑ NO J� 7. STATIC WATER LEVEL Below Top of Casing: 1 '4 0 FT 8. TOP OF CASING IS (Ilse u+-if Above Top of casing) (✓ V l FT.Above Land Surface" C Top of casing terminated atfor below land surface requires a - r, variance in accordance with 15.A NCAC 2C.0118. -- 9. YIELD' m 3L I Z ) _METHOp OF TEST , V- 10.WATER ZONES(depth): 7j d ------ �T N 12 11. DISINFECTION:Type LOCATI_ON SKETCH 12. CASING: Amount , �,. Z' $flow direction and distance in miles fromcDleastg Depth Wall Thickness _"--two State Roads or County Roads.Include�f a roa� �ameter or Weight/Ft. Material numbers and common road names. From To- F[. From ' To - Ft. From Ft. De 13. GROUT: Depth Material /t� ! From i To ethod l t�l. L`-x4(.�. From To 7�1 Ft. ` 14. SCREEN: pe th 4' P Diameter Slot Size aterial .��t r7'P-r fi-L From - To - Ft. in: From1°' To Ft.—in. in. _ 15. SAND/GRAVEL PACK. 2�/ - Depth .Size Material / - From ToQ_�, From To F[. 16. REMARKS: /p `�J I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION�STA�fN7DARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center- - Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. ! GW-1 REV.09/2004 !!C ' -�✓ till I/I !t _ - )11111 11'IsLI., CONSTRUCTION RUI,'1'AU[V ItEI,UIZII 11 `i 't0 NOI III Cm III I - DrPat A ncn1 of IJI1 vi to l it l lC l l(1111d 14n III I I Itcs�o/l It Ccs- Uivisiun of WIN(Ct Quality-GI(It I l ldws l cr Sec A ioII II'FLL CON I It A CI OR(IN III VI II I IA I.)NAME (pr Int l / / /C t'ec e- -_-- 'CFill If I CAI IM I RjZ Of too z5f7 II'F 1,1.CUIJ 1 IUCI Ull l-(rpn-ANY NANII?-_— SI-AIFIF FAA.CONSI IInCIl(IN 1'EIIn117M____."___--"-----ASSIICIAI Ell WI)I'FII6117 M it n r dicalrlc I. No.I;1 1, 1ISL'. (L'6rck Applirahlc I n1): Itcsidrulial it: U bulusidril I.t Aglicullwal U r.iouitoting LI Rcvcimy LI Ilcal I'tiugr 1Valcr 6rjcclino U lJihct U If Ulhcr,List 2. \\'Pi 1, 1 UCA 110I' : // I'upogrnphi✓l.Mld scllinl; IJc/n'lcst/'ful(cic_�Jj�'fe/) Cl;lupc I_IVnllcy I Ill:d V/f6rl VJ(�!l_./[C - - _ . .._ __ . (drtrk npl•rtgnino--ell (Start Nn nr.N�nnbn Cr:nnn:niy ¢d L,kion.1 I IIn_;;I,('rYlr) I,n(iludc/longiAtitle OFNN localinn 1. O\1 Add(css s er I hltprerJminulyd. ..... 360 A — n(iludeluogtuosoulc PSIJ IQf o pngiapl:ic nl 14 Mu) (St:r1ti ap ILmIE Nn.) U-Intioll it, or J.", SInG ip c'.•.Ir Fonntiuu IJcscnplion A,,nil•-PLC nr nunA•rr — -- d .1. IL\TR Ulilla I'U G. 1)IIPS \1'P.LI, Itl!I•LACIt I:AIS11140 \V1:1 13 ITs LI IJr) h — — 7. S Pr\I IC 1VA I FR LliVlil, licluw.1'Ill' of(':r^•in{:' _- 0_ __I'I'. _ ----------- (if., Alnvr l.q.or 1'n•iupl -< rq L — N R. l nl' UI' CASIIJG IS I_ L _ t-1. ADavc Lnnd Slnlacc' •l rI.nl nrL�p bnnlnnlnl nl/•n Irrinn Irnd nninrr rrqulrtr ,ntlrntr In uvn dn:tr nhh ISA N('AC 1C.III Ifl. tl 9. 1'llil.l) (gpnQ: _ S__ �1P:fIl000h'll!Sl'_ rr — 10. WA I Clt O1JES (dclrlll): �� ---- ---- L(LCALIULJ M_lCi /1T Anlmin _��y�_— Shim dilecl1011 gild lllstallce ill illtlrs IIOIn nt Icntl I I. UISIIJPISCJ1U11:'I}Pc—/I Iwo SIniC I(On(Is llf COIIII(y ROnc1s. IIICIIIdc Ilic load 12. G\SIIJCi: Wall thickness 11•pIJ, Uimnc�r ur\VcighVhl, hlntcrial numbers and couuuon load mmics• — 1'nnn 11. GR(IUF: I)rpill M1 Ile(II (I A 11- SCI:IiI:N: hrpUl Uimncicr SlotSiro hlatclial Pion) I'lom___. 15- SANIIftiILAVI'I. PACI: 1 Ilrplh :�i�r Llnlninl IG. RIir.1r\lit;$; _--_—_—_-- I I(U IIf l'.I Ill"CLltl il'\"I HAT I III'; WITI,WAS('01JSI12,11C1 P.0 Ill ACCURUAIWT Wit 11 15A IICAC 2C,WELLCOLTS I RUCI TUN S I'Al IPAI(DS,At U I HA I'A CUI''i 01 '1Ill!;ItuCORD HAS BEEN I'RUVIULiU'fU ll lt!\VII,LL UV I IFT, -- — W) ( ----- -------._—__—SIA1IIII!OFI•P.IISUNCONSIAUC111,10.11it!WI'.1,1. UA'11. Sulnnil Ihr o11l;in 11 lu the Nhidull lit Wn(rr l)nalily,GI ullndl(mtcF Secllun, 1f-)fi Mall SmIce Crlllrr-Rnlrlgh,Nf' -��� (cvlp .❑rr!,..("I")"nl !`rl,n ,1�rr. (i1V-I ltl'sV. 11l/)1 lthln 'i! 1O1 NC t/ OWNER MWD WELL CONS'i'RUCTION RE;C01W 3 North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) P/-�j' O�GGL�' CERTIFICATION/ a2yd.3 WELL CONTRACTOR COMPANY NAME_ /�/'��'� PHONE / ( 81J-2SSA STATE WELL CONSTRUCTION PERMITM ASSOCIATED WQ PERMIT, (i rnpplicame) (if appticnble) I. WELL USE(Check Applicable Doz): Residential B— Municipal/public❑ Industrial❑ Agricultural❑ Monitoring ❑ Recovery ❑ I►cat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATIO`N:`elO�G� Topographic/Land setting NearestTown: ff21 County sw•r,'r7 ❑Ridge ❑Slope ❑Valley ❑Plat d' Cove Look (check appropriate box) (Street Name,Numbers,Community,Subdivision,Len No.,Zip Code) Latitude/longitude of pwell loc9lion 4L//4I' / Stukq[ I is- 5i-5i „ 3. OWNER: b � (degrte✓minmteileernnds) Address �_T�,ba/ ('oa11r, VO&x 547 Lalilude/longilude source:❑GPS❑Topographic map (Street m Route No.) (check box) CNtraket NC Z8715 DEPTH DRHAdNOLQQ Ciry or Town State Zip Gmk From To Formation Description A"Colo-Timm,number 4. DATEDRILLEDyo��— 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL7 YES ❑ NO to 7. STATIC WATER LEVEL Below Top or Casing: /F 1`r. r (Use"t"if Above Top of Casing) 8. TOP OF CASING IS i' Fr.Above I.mu1 Surface* •Top of ruing Iermlmird War below Isn'tsurface reyoirel a vsrlsort In accordance with 15A NCAC 2C Al 19. 1 !` 9. YIELD(gpin): e25— htETl top OFTESTr 10. WATER ZONES(deptli): 2�r 7.3 LOCATION O 11. DISINFECTION:Type T Amount VC ,O ,Show direction and distance in miles from of Ic,sl 12. CASING: Wall Thickness two Slate Roads or County Roads.Include the toad Depth Diameter or Wci hUFI. Material numbers and common road names. Florvi 0 To /oS )a, 6 9J •/$N Sfee I From To rt.- From To FL ..- .. 13. GROUr: Depth tnlggt'nl . tcihod Front O Tom_Ft. oiT�d�d y� ed From To}49 _ 14. SCREEN: Depth Diameter Slot Sizc Material Front To Pl. in. __ in. From To Ft.—in. in. 15. SAND/GRAVEt.PACK: _ Drplh Size Matcrinl j From To PI. _.. From To FL 16. REMARKS: I DO HEREBY CERTIFY THATTINS WELL WAS CONS"I'RUCIED 1N ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND�TI AT A COPY OF I ILIS RECORD I►AS BEEN PROVIDED TO THE WELL OWNER . SIGNATURE 01:PERSON CONS]RUCTING THE WELL DATE Submit Ole original to the Division of Water Quality,Groundwater Section, 1636 Mall Service Center-Raleigh,NC 27699-I06 Phone No.(919)733-3221,wilh(n 30 days. OW-1 REV. 07/2001 i WELL CONSTRUCTION RECORD 3 1 Q J 9 6 North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) WILLIAM BRADLEY LEWIS CERTIFICATION#3368 WELL CONTRACTOR COMPANY NAME CHEROKEE WELL DRILLING AND PUMP COMPANY,INC PHONE # (828)837-8008 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) - 1. WELL USE(Check Applicable Box):Residential Q� Municipal/Public ❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water njection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: BRYSON CITY County SWAIN Midge []Slope ❑Valley ❑Flat ON RIGHT JUST BEFORE ALARKA EXIT (check appropriate box) - (Street Narnq Numbeta,Cammumty,Subdivision,Lot No.,Zip Code) (check of well location 3. OWNER: WILLIAM KENNER (degrees/minutes/seconds) Address P.O.BOX 1866 LaUtude/longitude source:❑GPSOTopographic map (Street or Rome No.) (check box) BRYSON CITY NC 28713 DEPTH DRILLING LOG atyorIovvn State Zip code From To Formation Description 88j-488-5263 0'TO 20' BROWN DIRT Area code-Phone number 20'TO 40' GRANITE 525' 4. DATE DRILLED 2005 40'TO 525' GRANITE ; 5. TOTAL DEPTH: 525' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g 7. STATIC WATER LEVEL Below Top of Casing: 100 FT. { (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 1 FT.Above Land Surface* -Top of casing terminated after below land surface requires a a� variance in accordance with 15A NCAC 2C.0118. S 9. YIELD(gpm): 6 METHOD OF TEST AIR 10. WATER ZONES(depth): NEW BIT Fit LOCATION SKETCH 11. DISINFECTION:Type CHLORINE Amount 100 PPM Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include die road Depth Diameter or Weight/Ft. Material numbers and common road names. From 0 To 40 Ft. 6 1/8' SDR 21 PVC From To Ft. �50� From To Ft. G 13. GROUT: Depth Mateial Method From 0 To 20 FL CEMENT GRAVITY From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in, From To FL in. in. 15. SAND/GRAVEL PACK: �I Depth Size Material l From To Ft. From To FL )/ 16. REMARKS: rt I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECO HAS BEEN OVIDED TO 711E WELL OWNER `zt3 SIGNATURE OF PERSON CONSTRUC G WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-I REV.09/2004 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural R sourcesiv'sion of Water Quality-Groundwater Section ,�� WELL CONTRACTOR(INDIVIDUAL)NAME (print) T�->�- ,/STY / CERTIFICATION#DI, O WELL CONTRACTOR COMPANY NAME (TY'A,�r:74�( N/t + �l rl2�PHONE # bZnV A! V STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE (Check Applicable Box): Residential ® Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: 4( C .— County S Wo-, Yl ❑Ridge ❑Slope ❑Valley ❑Flat Si %Z6 r J7 " a (check appropriate box) (Street Name,Numbers,Community,Subdivisi oon,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: LO.ValeA /tA:J/BY. (degrees/minutes/seconds) Address Sr'jVet- yn_nv r� Latitude/longitude source:❑GPS❑Topographic map tt�� (Street or Route No.) (check box) _sat)eSon Gr,7�v< 1\f�' �Fi 713 DEPTH DRILLING LOG ity or Town iJla zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED D,-F�-o 6 5. TOTAL DEPTH: z/OS g 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO R 7. STATIC WATER LEVEL Below Top of Casing: 0 FT. 1 (Use"+"if Above Top of Casing) 8. TOP OF CASING IS_�FT.Above Land Surface* *Top of casing terminated it/or below land surface requires a variance in accordance with I5A NCAC 2C.0I18. , 9. YIELD(gpm): K) METHOD OF TEST c�, Y 10. WATER ZONES(depth): O LOCATION SKETCH 11. DISINFECTION:Type n Amount h Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material n tubers and common road oames. G 7 rki From ToQe Ft. In k+ r ram al mo nck Po , (,-'-a l� o From To Ft. ) /' From To Ft. �h �i�Yl L ✓1 I /q S Go 13. GROUT: Depth Material Method J T From � ToaO _Ft. (coWlEr17T U + � m .%1S 7,,n /C`� ` p _ .._ From To Ft. yp Y1.� •Jam, 14. SCREEN: Depth Diameter Slot Size Material Szi f v&C r m r'n& From To Ft. in. in. From To Ft. in. in. %vr,.n n �, eGtT 15. SAND/GRAVEL PACK: Depth Sim Material /� U Jr'l�. . `/r-;�i�tit From To Ft. (j'-�J LC From To // FL 1 - I` 1A� — - 16. REMARKS: L�!`t �� T �� it Yn TYG (' TUY E V�or 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 T(YTHEWpj) C� ICO k AIV, SIGNATURE OF PERSON CO STRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV.07/2001 WELL CONSTRUCTION RECORD 308528 North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # (626)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential El Municipal/Public ❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOC t. Topographic/Land setting Near t own: County72110 . ❑Ridge ❑Slope ❑Valley ❑Flat (check appropriate box) (Street Name,Numbers,Commodity,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: (degrees/minutes/seconds) Addre Latitude/longitude source:❑GPS❑Topographic map Stre t or owe No. (check box) ' - � DEPTH DRILLING LOG ny or wn struirl, Zip CUde From To 1 0 clay&sand Formation Description _ Area code-Phone number�t ,`��___,�Q� 4. DATE DRILLED A-t�-N granite 5. TOTAL DEPTH: /'JQb 1. 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO , 7. STATIC WATER LEVEL Below Top of Casing: //DQ FT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface' `Tap of casing terminated allor below land surface requires a variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): METHOD OF TEST BLOW 10.WATER ZONES depth): LOCATION SKETCH 11. DISINFECTION:Type H T H Amount 16 oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the roay Depth Di eter or Weight/Ft. Material numbers and common road names. From 0 To Ft. '� PVtz From To Ft. (p" T From To Ft. a 13. GROUT: Depth Material Method From 0 To 20 Ft. Benonite&cement pumped c From To F[._ o rr 14. SCREEN: Depth Diameter Slot Size Material Ln From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material J_ L�'. 17 L, From To Ft. From To Ft. MAR 2 1 2005 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCgC 2C WELL;" CONSTRUCTION STANDARDS,ikR)D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNEW SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-I REV.09/2004 �� 34g52, 1 WELL.CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources.D'Yisipn�l of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (fp*ried 1 T �/�J1( 0O CERTIFICATION#225O WELL CONTRACTOR COMPANY NAME _ G'rC1r16..Yh JA1 (( �w a/I `tnc PHONE aagayz?_& " STATE WELL CONSTRUCTION rERMITN oc— ASSOCIATED WQ PERMITf (ifatmliabie) (ifapplinbk) I. WELL USE(Check Applicable Box):Residential 14 MunicipatiPublic❑ Industrial❑ Awiculh=1 O Monitoring❑ Recovery O Neat Puny Wa(cr Injection O Ouher O If Olhor,List Use 2. WELL LOCATI N: Topographir/Land setting Ncarcsl own�1 - ` County SJLLa.�a OKk%C (i7Slope OVallry DPW 7/ Sl 2 .pp.ovi; m.) (Saeel Nanrc,Nu bem Cap --4,Subdvi%; ,La Na Tip Cede) latitude iengitude of well location 3. OWNER: \V't'm /-- - Address _15r4/tioa7 hrnneh ]atitudeAongitudaao� PS❑'fopographiemap (Star w Raau No.) (cheek bus) ar <t,rr C a'T)e Iye- 2,P 7/1 DE PTH EPTH DRILLING LOG ( Irys'Town -/ a zip cede From To Formation Description rt Arcs rode-Pause aamler 4. DATE DRILLEp /.�7— 5. TOTAL DEPTwH: p 6. DOES WELL REPLACE EXISTING WELL? YP.S O NO IS 7. STATIC WATER LEVFL Below Top of Casing:-ao--Ff. (.p ' (Use'+`if Above Tap arCaww 8. TOP OF CASING IS�_FT.Above Land Surfacox 'Tap of caing tannin Ind atrw bdow had tarfaee re4ulree s �..f n rarl"M k umrdaaee with ISA NCAC IC.0113. 9. YIELD(gpm): QK- _METHOD OF TEST G r 10.WATER ZONES(depth): /.2S LOCATION SKETCH - 11. DISINFECfION:Type Amount 0.go- Show direction and&smnccinrniics from atleast t 2. CASING: Wall Thieknesa two State Roads or County Roads.Include the road Depth Diuneter of Weighfft- n mbca and common road names. From,�_To�[_FLSp*_ cDr2) PV6 o,]monA ISO GO l+9' In"ICS From To FL From—To FL,— I Urrl T GU q, rz 1n,VCf 13. GROUT: Depth Material it yd, From n To�`�_FL r�+m�+nr p _ TO £nr'T Gil ,BrySan Ct"Ty GU To S Tom From To—De Ft S ' /9 Tvrn /ePTon ✓eTrnrs 931V& 14. SCREEN: Depth Diameter Slot Size Material `t� From To Ft ;n. in. (r p T RCo ?I/ h 7- � -Prc,Yi k I r h ronL _To FL,in. in. � D p 15. SAND/GRAVEL PACK-, 6l �k-ove C uJ,r /(oac7l (j 0 It3 Mrt/CS Depth Sire Material From TO FL_ T �O(/SC a✓) l�>tT L✓ea�� 01) let T From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED M ACCORDANCE WITH I SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OFTHIS RECORD HAS BEEN PROVIDED TD THE WELL OWNER SIGNATURE OF PERMN CONSTRUCTING THE WELL DATE N Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-RaleiLh,M6.1, n, 27699-1636 Phone Na(919)733-3221,within 38 day% G W-1 REV.0711$0}, o �l �� 3p8522 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) 1 e-p- CERTIFICATION 9946-6 r,M WELL CONTRACTOR COMPANY NAME h 1'1/l I, w ,as(( N.tIIrIYI(w PHONE x MAO g79'H/S'Lf STATE WELL CONSTRUCTIO O N PERMfrd ASSOCIATEDWQPERMrr# Off licable) (ifapplireble) I. WELL USE(Check Applicable Box):Residential 19 Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other 17 If Other,List Use 2. WELL LOCATION: TopogtaphicfLand setting Nearest Town: IZMV San Gr T County r5 t✓e..'✓1 {� —� �'- ORidge ❑Slope ❑Valley ❑Flat �lEw.b,D Grf.,x../r /Q� DSr773 (check appfopdne box) (Street Natne.Numbers,Community,Subdivision,La No.,Zip Code) Latitude/longitude of well location 3. OWNER: Z:).annt't ca/A 're (degroealminvles/semnds) Address -D&CR Gr.a, k RA- -- Latitudellongitude source:OGPS❑Topographic map (Street or Route No.) (check box) 13ty n ;Ty Tfc 2571 DEPTH DRILLING LOG ny of Town 'State Zip code From To Formation Description CRJz- 7X-e)9a3 Area code-Phone number 4. DATE DRILLED :� _ 5. TOTAL DEPTH:. NOS 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO M G7 7. STATIC WATER LEVEL Below Top of Casing:-20 _FT. (Use"+'•ifAbo{ro Top of Casing) � 8. TOP OF CASING IS / FT,Above Land Surface' 'Tap of casing termlmted atlor bttuw lend rurfam requires a GO 74 variance In aemrdam with ISA NCAC 2C.01IL 9. YIELD(gpm):l METHOD OF TEST i r O a 10. WATER ZONES(depth): R35 LOCATION SKETCH IL DISINFECTION:Type Amount Q,_,T'a Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the mad Depth Diameter or Weight/Ft Material ran ets and common road names. From_�_To_ZFt k� Sorge �YG Tror� �l -OPA Po bra /,9- 16"5 From To Ft. Tfirn le- TO» 7y 13. GROUT: Depth Material Method ��.� 04,'7- ('p7 60 Td STaNr 640 From--0 _To rL0 _Ft- rCMPnT u ' From To Ft. 721, n /NET a 0 To S 7"/0 /i�h T 14. SCREEN: Depth Diameter Slot Size Material -�� A-r O 7O )'1 &AT S7a/0 From To FL in. in. 721 l h0 h TO From To_Ft. in. in. �' f-jT Turn /6'�7- G-0 T `� 15. SAND/GRAVEL PACK: (� / /�7t /e Tvrvl Depth Sirs Material 0 STreeT From To Ft. ef° GrPe'k Go /,�/m.'�CS Tura From Tc Ft (ra O.� 16. REMARKS: ��+T ! O✓I0/ry STon� =nN oUdr 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 PERSdN CONSTRUCTING THE WELL DATE N Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NCB ro - 27699-1636 Phone No.(919)733-3221,within 36 days. GW-I REV.07ir1U61 0 rD 308523 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Scotion WELL CONTRACTOR(INDIVIDUAL)NAME (print] 1 T/ {fy/�P CERTIFICATION WELL CONTRACTOR COM PANV NAM E�xi" 1i JOJJ r�.r s��t In�j PHONE8 STATE WELL CONSTRUCTION PERMITB sSSOC1ATED WQ PERM[T8 (ifaonlicable) (if applicable) L WELL USE(Check Applicable Box):Residential N MunicipaUPublic❑ Industrial O Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other O if Other,List Use 2. WELL LOCATION:N asT over: Z .iSon7 CountySWht TopographirJLnd setting dge OSlope OVallcy O Flat � tiR'" CN f 5 jGsT.a (chak appropriate box) (Strew Home,Numbers,Community,Subdivision,Let No.,Zip Code) LatitudeJlongitude of well location 3. OWNER- I PSS®� Idegrees/minu[eslsetonds) Address c / ,o s'CTnTA Latitude/longitude source:OGPSOTopogmphic map (Sheet or Route No.) (chock box) I�iS�P1 TZ& ,r1Sr7/'Z DEPTH DRILLING LOG —y or Town gura Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED rz— 5. TOTAL DEPTH: S'�Q 6. DOES WELL REPLACE EXISTING WELL? YES O NO 10 7. STATIC WATER LEVEL Below Top of Casing: 190 FT. T (Use"+"if Above Top of Casing) 8. TOP OF CASING IS I FT.Above Land Surface* t `Yap of"Sing terminated ado,below land surface requires a CO Variance in accordance with ISA NCAC 2C.0118. 9. YIELD(gpm):Z—METHOD OF TEST t& r U1 10. WATER ZONES(depth): N 7/5 LOCATION SKETCH 11. DISINFECTION:Type Amount o,gg 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 WeightfFt. Material no mbers and common road names. Fro k To Ft._To 7.� Ft. SOr2! _P ve From rm calmonck Po GO h g' ,w les From To FL T rrJ le-PT orl To 7y'E Go 93, 13. GROUT: Depth Material Method il T Ha lakr From_Q_Toter O FL !'.oYr1N HT L ,'Y1e m��G`rS cli o rn 7G�T T From To FL £S7A7-05 00 S.�/ M le'S 72/rn R IR ' h7- 14. SCREEN: Depth Diameter Slot Size Material �VO r CTO, From To Ft. in. in. O)� 7, j-r,.na 100� T`I t, 1 From To Ft. in. in. Rt�hT F Or 1aRf$.�/e 15. SAND/GRAVEL PACK: 0,3 tl,'I�' Turn Depth Sin Material 104MT X4—6T Art`vd an R�h7 70` rom Tc Ft. From To FL 16. REMARKS: Vv I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER n2v 7�� e ��1Y of - SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC - o - 27699-1636 Phone No.(919)133-322I,within 30 days G W-1 REV.07J200i u, J. f WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION It 2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE if (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential 0 Municipal/Public ❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATI Topographic/Land setting Neq�'��pp//gqstTmvm County ❑Ridge ❑Slope ❑Valley ❑Flat y,_ y (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot�No,��Zip Code) Latitude/longitude of well location 3. OWNER: �.QxLIC! (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (Streetor oum No.) (check box) _) ,3 DEPTH DRILLING LOG City or Tqjva State Zip Code FroJ� /�pn� Formation Description 6L2�e 7 __ (J ,Q Clay&Sand Area code-Phone numb�eer -OI—lO-001 Granite 4. TOT L DEPTH: ED(o•9 0 5. TOTAL DEPTH: ' �,{ 6. DOES WELL REPLACE EXISTING WELL? YES NO X 7. STATIC WATER LEVEL Below Top ofCasing: FT. (Use"+"if Above Top of asing) 8. TOP OF CASING IS oZ FT.Above Land Surface' -Top of casing terminated at/or below land surface requires a variance in accordance dh 15A NCAC 2C.0118. 9. YIELD(gpm): METHOD OF TEST BLOW 10.WATER ZONES( pth): LOCATION SKETCH 11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road hh Depth D}}}}}}'ame�er or Weight/Ft. atenal numbers and common road names. From To F[ YC From 0 To Ft. e i7 From To Ft. 13. GROUT: Depth Material Method c— cl From 0 To 20 Ft.Benonite&Cement pumped From To Ft. IV in 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. O From To Ft. in. in. 15. SAND/GRAVEL PACK: �yy Depth Size Material 3T From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C,WELL - - - CONSTRUCTION STA RDS,AND THAT A C PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE— Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. - GW-1 REV.09/2004 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natuurra Refssources- tvision of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAMES (priut)_;14;T' CERTIFICATION8 (Z WELL CONTRACTOR COMPANY NAME CT-mi.126,N W'611 PHONE # )475+- S4S'N STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) L WELL USE(Check Applicable Box):Residential Ild Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATI N: Topographic/Land setting Nearest Town: p County S A&2J n ❑Ridge ❑Slope ❑Valley ❑Flat l�7h o e-!! nA_ D a.7 a.. (check appropriate box) (Street Na_�umbers,Community,Subdivision,Lot No.,zip Code) Latitude/longitude of well location 3. OWNER: A2!n7_ C�oy('hra„Y7 (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map Street or Route No.) (check box) �Yv�yjy, !iTr! ha 'E7J_3 DEPTH DRILLING LOG ellyor7ovn ��d zip Code From To Formation Description Cx0- �r/7-(c 7 Area code-Phone number 4. DATE DRILLED 5. TOTALDEPTH:�OS t 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ca 7. STATIC WATER LEVEL Below Top of Casing:—Yd _FT. —� (Use"+"if Above Top of Casing) st3 8. TOP OF CASING IS_�FT.Above Land Surfaces �- -Top of casing terminated at/or below land surface requires a variance in accordance with ISA NCAC 2C.0118. 9. YIELD(gpm): METHOD OF TESTS 10.WATER ZONES(depth): //•s LOCATION SKETCH 11. DISINFECTION:Type Amount U-`W Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Di meter orcnr21 Ft. Material_ npembers and common road names. / From To /n9 Ft. ( -hron C.1MOr)A !"o Cre /i�JnrtJes From To Ft. T r y.) le,. T o n 7/� ) From To Ft. 7 r �7'G� �y,�/9'1,t/fo-s 13. GROFrom To Depth Material FL C� at�al Method ytZ p T r,n R f From To Ft. M— 0T ,•<es T rn RI�hT on S&450T-0p,rM5 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. L°reek GO ' , 15. SAND/GRAVEL PACK: f '/s/77i IeS Trn o Ort Depth Size Material t�.C71✓enTvre 'jj^Q,rr� �`�ry�O�CI.Od11d ACA From To Ft. /C� From To Ft. l!—!� O/I jrr y)I t � /o T T r,r J��Ton 16. REMARKS: '`�� well 40 ),4fy 7y I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE O PERSON ON CONSTRUCTING T� HEW L,L - 1 - DATE Submit the original to the Division of Water Quality, "water Section,1636 Mail Service.Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV.07/2001 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �� WELL CONTRACTOR(INDIVIDUAL)NAME (print)— T / # CERTIFICATION#yg,bs_ WELL CONTRACTOR COMPANY NAME O"YL'l"7N Lt,f,VII A f I`21, PHONE # fAJW79:C1Wy STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (ifapplicable) (ifapplicable) L WELL USE(Check Applicable Box): Residential 14 Municipal/Public❑ Industrial ❑ Agricultural ❑� J Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting- 1rest Town: County9`ilwte i y7 ❑Ridge ❑Slope ❑Valley ❑Flat j CAn l/M4 6jw✓p 987/3 (check appropriate box) (Street Name,,NWnbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location r I 3. OWNER:mew.Ylf SGhI� (degrees/minutes./smonds) _ Address li vio fz~-k J2 i Latitude/longitude source:❑GPS❑Topographic map` (Street 8F Route No.) (check box) rysv CJ,T)e IVC 2g7/3 DEPTH DRILLING LOG City or Town Zip Code From To Formation Description (Uk)- 7.34-/?/3 Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH:�Q s 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO B 7. STATIC WATER LEVEL Below Top of Casing: ,SS FT. c. (Use"+^if Above Top of Casing) r 8. TOP OF CASING IS�_FT.Above Land Surface' t 'Top of casing terminated at/or below land surface requires a am variance in accordance with 15A NCAC 2C.0116. :+ 9. YIELD(gpm):�_METHOD OF TEST CS.t'r' O CA 10. WATER ZONES(depth): S' LOCATION SKETCH' It. DISINFECTION:Type Amount d.99 Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Di meter or Weight/Ft. Material eumbers and common road names. From_To Sig Ft. — -,:;'pr,%I P✓e- 4norn 6.)rodn J / Ga �.frrt.'/des "Tbrpn- 1 From To Ft. fro71 DIES TUr l') i 4j�' 1EkT an 75' ' GQ From—TO Ft 13. GROUT: Depth Material Method aT 4;-X"T ee q &C' To Zop e From_0 To 0 _FL CFmearr'T V ` ........���� Sr 11 urn �F T � GCPCSS From To FL /d S TD�V pq 14. SCREEN: Depth Diameter Slot Size Material Over pCks5 -re $TaP sr n �U-+'% JZrti7 From To Ft. in. in. /9 6!-Cy From To Ft, in. in. 15. SAND/GRAVEL PACK: le-)�T aT STap 1i hT G•Q • G7• a n''r`JNS Depth Size Material Yd 7 � From To Ft. hYavf �" From To Ft. YtAYt�(It'Yt�s Grove AA -6 2Altv"''re-S 7-01-01 16. REMARKS: 1� r Well on RIa11lr. 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 PEf SON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV.07/2001 Q f `F WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural sourc - ivision of Water Quali -Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAMES(print) CERTIFICATION#� G WELL CONTRACTOR COMPANY NAME Q. //'1 L1e-01 ar"11"kw PHONE #kjay1��'�r' -f STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable_) _ 1. WELL USE Check Applicable Box): Residential M Munici al/Public❑ Industrial ❑ Agricultural ❑ ( PP P Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use i r i 2. WELL LOCATION: Topographic/Land setting T Nearest Town: CountyrSfsa # ❑Ridge ❑Slope ❑Valley ❑tlaf,, 'o1F17/3 (check appropriate box) 1 (Strect Name. umbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well locati6fr o- 3. OWNER: T P (degreestminutes/seconds) _ Address f.w'7Jn,/e en,e,c* d6l Latitude/longitude source:❑hPS❑'opogmpht`map _ (Street or Route No.) _ 2-P7/ 3 DEPTH DRILLING LOG - -- ty or Town s to Zip Code From To Formation Description_ /44r3 Area code-Phone number 4. DATE DRILLED - 1 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d L 7. STATIC WATER LEVEL Below Top of Casing: I�QFT. (Use"+••if Above Top of Casing) 8. TOP OF CASING IS_�FT.Above Land Surface* 'Top of casing terminated attor below land surface requires a �c•A variance in accordance with ISA NCAC 2C.0118. rY°1 9. YIELD(gpm): �6 METHOD OF TEST 0.f`r 10.WATER ZONES(depth): LOCATION SKETCH 11. DISINFECTION:Type-A _ Amount A.:,(G Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material iturabers and common road names. From�_To�Q_Ft.�_ :_Oral Pyc r�ir" cid a')OI)A /- 6 Go 1,Ymr ��s From To Ft. •�-' n J From To Ft. / Y1 �caT O✓I 7y� `�- 13. GROUT: Depth Material Method �-- Air From_To d _F[. Tor j Nb L Yr) �l r``I T �T E�(�) 7 r7e2 L✓h t ]TFy From To FL �-0 Cj,� r2•/,`/E �Urr1 f P� T 6ZO 70 ST f 14. SCREEN: Depth Diameter Slot Size Material y, From To Ft. in. y- in. 5 t`q y) �„n leT O A (Alt,7—(f+r, From To Ft. in. in. C / 15. SAND/GRAVEL PACK: VC�Oa RQv V"O• Un' Depth Size Material From To Ft. o 1A f3ry sejo c/Ty /\1.11 • Cj-G) e,//)1 i le -�- ^ From To Ft. r"YI) lf7T 0on Ceynte-We e-ek av, 16. REMARKS: r)r 1 ry,, 6 t};,�VT t1 n /`��y 6 urn s I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PER 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.(919)733-3221,within 30 days. GW-I REV.07/2001 WELL CONSTRUCTION RECORD O < North Carolina-Department of Environment and Natural_Rgsourceg��ivision of Water Quality-Groundwater Sectiion . WELL CONTRACTOR(INDIVIDUAL)NAME (print) V P E CERTIFICATION 11,2651-0 WELL CONTRACTOR COMPANY NAME r-p" ''r✓t lt'Pr akalr'n#PHONE # (¢lfil t179-5'S'Sz/ STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box): Residential 6d Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: : Countye�SL✓n',w ❑Ridge ❑Slope ❑Valley ❑Flat 1 ��/r S%!a Aft'7/.3 (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: Rob Alo ke (degreesminutes/seconds) Address Cv/1/SiAk IRA Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) CqZ /ly Z2 10[ A�713 DEPTH DRILLING LOG or Town s ate zip code From To Formation Description Area code-Phone number •3 4. DATE DRILLED 1'—7-©6" 5. TOTAL DEPTH: fro S' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® C T STATIC WATER LEVEL Below Top of Casing:-��FT. (Use"+"if Above Top of Casing) cn t =� 8. TOP OF CASING IS FT.Above Land Surface• 'Top of casing terminated atlor below land surface requires a variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): METHOD OF TEST0y r 10.WATER ZONES depth): LOCATION SKETCH 11. DISINFECTION:Type Amount Q,yQ Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Di meter or Weight/Ft. Material i(umbers and commoq road names. From�To�Ft 56r AL/G +ro)v? e.lmonCl PQGa /,g'm1/ Tvrn /,Pp From To Ft. Cin 7 E ` R oy,t, E - O,T From To Ft. v,� m' l�s Turn f xi'T �lj alork 13. GROUT: Depth Material Method STo� 5, n 1�rn From To ed.0 FL Gf�Mf-Y/i R nth T d n �,lovkac, a1, �a�l .3,5r in I PSFrom To— '?i✓N 14. SCREEN: Depth Ft Diameter Slot Size Material Ai�h7 o n Deep t~aP Ac,,p(a-o , Q,9- rn,'/PS From Tc Ft. in. in. 7vrn Rtgh an /��. GU , U, a2 From To Ft. in. in. 15. SAND/GRAVEL PACK: M,'/PS TUrn lei 7 erl �j``b / eLV1s'4 R Depth Size Material lT/',o h7 m 7�S -rLi-M 4'0L Ton To, From To Ft. / From To Ft. d)-I'(/1-1 WAY 4,7N1/ do R+�hT, 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 u SIGNATURE OF PERSON CONSTRUC=G THE WEI{I. I' r ( IIJA0vi 1- i. Submit the original to the Division of Water Quality,Groundwg�der`Qic—tion,1636 Mail Service Ceti ri-, sleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. i 1 'i t 1 2 0 ,�r�f C1 -);REV.07/2001 Jiv s I I J t � , WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling,Inc PHONE # ( )369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential ID Municipal/Public ❑ Industrial ❑ Agri_cu_ltural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATIO I:, Topographic/Land setting Ne stTown: Countys � ❑Ridge ❑Slope ❑Valley ❑Flat `, rG/ (check appropriate box) (Street ame,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (Stre or-Route No) '`Q (check box) �l1 AF ;7 DEPTH DRILLING LOG C;ny or T wn Zip Code From T , Formation Description T(0� 0 Clay&sand Area code-Phone number t !p ^� Granite 4. DATE DRILLED J ' /0'06 5. TOTAL DEPTH: (OOO' 6. DOES WELL REPLACE EXISTING WELL? YES NO ❑ 7. STATIC WATER LEVEL Below Top of Casing: FT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface' "Top of casing terminated at/or below land surface requires a variance in accordaa with 15A NCAC 2C.0118. 9. YIELD(gpm): METHOD OF TEST BLOW 10.WATER ZONES(depth): �a tf �— LOCATION SKETCH 11. DISINFECTION: Type H T H Amount 16oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Di eter or Weight/Ft. Material numbers and common road names. From 0 To_�Ft. .IS 8 From it To Ft. ;y From To Ft. L 13. GROUT: Depth Material Method C_ From-0 To 20 Ft.Benonite&cement _pumped From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. From To Ft. 16. REMARKS: - I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL [ "- CONSTRUCTION STA RDS,AND THAT A C Y OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O n r _ r- SIGNATURE F PERSON CONSTRUCTING THE WELL DATE -_ Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Cep ! o Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. �, I GW 1 R1 V.N/2004S0 J i L WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural t.Resources /-Division of Water Quality-Groundwater Section ,�`� WELL CONTRACTOR(INDIVIDUAL)NAME (print) // -TES-/'" /tyr 18 CERTIFICATION#JQaYO WELL CONTRACTOR COMPANY NAME GPJJ&tzl L:Jell' Yf�PHONE # QFr)Y79-S'VSr� STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (ifa licable) L WELL USE (Check Applicable Box): Residential 5d Municipal/Public ❑ Industrial ❑ Agricultural _r='.� C7 Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ if Other,List Use v �fU 2. WELL LOCATION: Topographic/Land settin T r Nearest Town:13ty 6 • 7)1 CountySLJa,'iJ ❑Ridge ❑Slope ❑Valley .fat �" H9 D YC,2J,-fI 2s�7i 3 (check appropriate box) .'-' -� _n c— (Street Nat e,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well loco fgn� - i--n / =t G•o 3. OWNER: GYl Lz//-' ro--Y1� jT� (degrees/minutes/seconds) Address /� m, 6-n'1/J.c.�y— Latitude/longitude source:❑GPS❑Top �k 'c map (Street or Route No.) (check box) art 13r ki9 ! 1VC `L� �73 DEPTH DRILLI G LOG rty,or Town grate te Zip Code From To Formation esc [[,���t���� 3 Area code-Phone number 4. DATE DRILLED ��lb S t� 5. TOTAL DEPTH: AMA' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® 7. STATIC WATER LEVEL Below Top of Casing:�__FT. (Use"+'if Above Top of Casing) Q r 8. TOP OF CASING IS� FT.Above Land Surface* -Top of casing terminated atlor below land surface requires a ` variance in accordance with ISA NCAC 2C.0118. 9. YIELD(gpm): 46 METHOD OF TEST 0-1i1- 10.WATER ZONES(depth): LOCATION SKETCH 11. DISINFECTION:Type Amount�� Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. _ Material rbelYand�c/ommon rgad es. From_0—To� Ft. 64 5yral { y5.� he TU G v ' F/"J From To Ft. fjT Cn �� tTU I/r From To FL /u�'n / 13. GROUT: Depth Material n Method ./�S- -�v�-�/ /Ge'�T on m Fro _To r Ft. ('FYl2 �' I' +• J From To FL RO,C•L 6-0 14. SCREEN: Depth Diameter Slot Size Material t. From To F in. is On ��/ /7�9/'l� �T0.,rs �G lT�• r From To Ft. in. in. n1, �S /flrn ��: r'®n Gamp 15. SAND/GRAVEL PACK: Depth Size Material From To Ft. fir 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 99 OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PER90N CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GWA REV.07/2001 : 1: WELL CONSTRUCTION RECORD V f i 1". 6 ') North Carolina-Department of Environment and Natural Resources- Qivision of Water Quality-Groundwater Sectio�n'`�' WELL CONTRACTOR(INDIVIDUAL)NAME (print) l�A T� ?Ylf/d CERTIFICATION Ag�y}� WELL CONTRACTOR COMPANY NAME 6i- eA. I t 1 LAN✓I r,' Iir✓/. -PHONE # �rc1479-S�S'cf STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residential 18 Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town: G/ ry County SLe,f�o'Y! ❑Ridge ❑Slope ❑Valley ❑Flat t7 rr ,0,0,0 (/"D 'ast)J3 (check appropriate box) (Street Nfune,Nuum ere,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: R/1 .�7 /�Cw (degreWminutes/smonds) Address I r,♦ Latitude/longitude source:❑GPS❑Topographic map (Street ol Route No.) (check box) L_tv ,yn r,1je A16 �2R77 DEPTH DRILLING LOG uy or town race zip code From To Formation Description Area code-Phone number 1 4. DATE DRILLED 7-a,?-aS— 5. TOTAL DEPTH: 21t7 7 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 12 ( on, 7. STATIC WATER LEVEL Below Top of Casing:l z) FT. (Use"+"if Above Top of Casing) 0 8. TOP OF CASING IS�_FT.Above Land Surface* cis *Top of casing terminated at/or below land surface requires a y variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): IA METHOD OF TEST Ol.r'r 10. WATER ZONES(depth): 1,617 LOCATION SKETCH 11. DISINFECTION:Type Amount a e Show direction and distance in miles from at least 12. CASING: Walt Thickness two State Roads or County Roads.Include the road Depth Diameter or WeighVFt. Material n mbers and common road ame�y ! /%,S, From To /f 7 Ft.y / _ _%C�'L pLtrtl CLjrl�47Pj /1z0 6 From To Ft. .�'^ 7 G�From To Ft. �4 7% T r� ILA / _ 13. GROUT: Depth Material Method r l 5' T,,/? 4110 / I C ..1 From '0 To 16 Ft. t',cYn,-g A�xa, Gd rJ' m From To Ft. )64'1 y U-'0.%"�'�(,.t 6:o To V /4lo 5 ton 14. SCREEN: Depth Diameter Slot Size Material 1 [[�� II _ / �T From To Ft. in. in. lure /�41' oe 3, ?177de/ /wn'n From—To—Ft in. in. 7 �►i on Dec-17 Cr YD RL GU Q'q 15. SAND/GRAVEL PACK: -T n Depth Size Material A, ,leoS /Urn Ri�hTvti / ickril cockIre. From To Ft. Qa -�- From To Ft. ROent.dyo, 0 ,�!>7 E /o,-A R1� j�'O 16. REMARKS: 2d eild� R")CkA` I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT 1A�COP�Y/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,Groundw ctiorhO96 TjI SCrnFe Ceryten-Raleigh,NC �u 27699-1636 Phone No.(919)733-3221,within 30 days. qW=Y V.07/2001 WS, J 1 5 J 1 U WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources,-Division of Water Quality-Groundwater Sectiio''n''��'''' WELL CONTRACTOR(INDIVIDUAL)NAME/('p+r�iint) )_ Vi�/r' CERTIFICATION#.�cy� WELL CONTRACTOR COMPANY NAME G[q[,j- &m Li eii !�P ,CV-PHONE # aS� 74:?1<<J STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box):Residential 0 Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: --- Topographic/Land setting Nearest Town: Cournty S tje)-i n ❑Ridge ❑Slope ❑Valley ❑Flat e7 (check appropriate box) (Street Name.Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: oL�) (degrees/minmes/seconds) Address itt t0 Latitude/longitude source:❑GPS❑Topographic map (Street or Rd6te No.) (check box) r zf n CiT iVG $5r7/� DEPTH DRILLING LOG ilyoState Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO GO _.' 7. STATIC WATER LEVEL Below Top of Casing: Q FT. (Use"+"if Above Top of Casing) F'.. 771 8. TOP OF CASING IS FT.Above Land Surface* en -Top of casing terminated at/or below land surface requires a LA variance In accordance with ISA NCAC 2C.0118. 9. YIELD(gpm): D METHOD OF TEST G.i r " 10. WATER ZONES(depth): C/ LOCATION SKETCH 11. DISINFECTION:Type C) Amount e) Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material numbers and common road names' From `5 To 1 Ft.lr, I Knr2) � _Pre Pi o. l rovJ Po G® G.-Cr" 55 From To Ft. (� 11 11 From To Ft. ROB. % R(IL'Yr�A TP RCA, 13. GROUT: Depth Material Method (+ _ From e_To�_Ft.4:,o mu FiT It " o. d+ om t SIN,./$ .� n �� f 65Lo From Ft.De ,T /U�r U I4. SCREEN: Depth Diameter Slot Size Material /O /}O From To Ft. in. in. From To Ft. in. in. rahf . 15. SAND/GRAVEL PACK: — Depth Size Material F- m i Fro To Ft. From To W1 � Ft._ 16. REMARKS: E'D[ /7�/C) �TU/� j LU05 i I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL-;— — -� CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE1�L r ; to -�S- SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater S_ection,.1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. I GW-I REV.07/2001 Gh? i wu I� t IN ASHEInIt Rr(-IJ+ r i T 9 r . WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natura Rgsources-.Di ision of Water Quality-Groundwater Sectiio��nn�, WELL CONTRACTOR(INDIVIDUAL)NAMES (sprint) �—t CERTIFICATION#.�fb WELL CONTRACTOR COMPANY NAME t 7- AL[s—M 'L✓i�%// t PHONE # a2ai� -:S%'r `/ STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box):Residential 19 Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting Nearest Town 1r? G County6a.F:;'r9 S ❑Ridge ❑Slope ❑Valley Mat�,:�}h P111 2 g-:V'3 (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No..Zip Code) Latitude/longitude of well location 3. OWNER: /�, !/ a////75 (degrees/minutes/seconds) Address Y e e Ta a RIL Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) 1 py n6, T�e )t/C a'�t17i3 DEPTH DRILLING LOG ityor Town State Zip Code From To Formation Description (")- - �25-9'o Area code-Phone number _ 4. DATE DRILLED 7`/ -c7SJ 5. TOTAL DEPTH: 6i rl l;' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R 7. STATIC WATER LEVEL Below Top of Casing: QGu FT. G (Use"+"if Above Top of Casing) 8. TOP OF CASING IS�_FT.Above Land Surface` ~ t. r *Top of casing terminated atlor below land surface requires a variance in accordance with 15A NCAC 2C.OtlS. � :p 9. YIELD(gpm): METHOD OF TEST C'ti: d' Ln 71 10. WATER ZONES epth): ��� `qa LOCATION SKETCH '-3 11. DISINFECTION:Type T Amount Cl___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. atenal n tubers and common road names. /' From_6 To��Ft.� 'C',nr L 4 Fret 't �j.l Y) o n A /"O V o 1 S r M/1&C From To Ft. From To FL I Ur E'h � }-T On 7 6-0 313^ k 13. GROUT: Depth Material Method From C) Tom_Ft. C rim an j F( s- From—To— 14. SCREEN: Depth Diameter Slot Size Material n i rl.T CI n �q/`T/CJj� From To Ft, in. in. QQ From To Ft. n. n. 6-() 6,f m ikc LA/d P r il« Caleb p 15. SAND/GRAVEL PACK: n Depth Size Material 44-__-. .. .- _... 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 TH,EWELL 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.(919)733-3221,within 30 days. GW-I REV.07/2001 314814 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources Rr�esources-IDivision of Water Quality-Groundwater Sectiioon.1 , WELL CONTRACTOR(INDIVIDUAL)NAME (print) .�IFY"� V/A q(y - CERTIFICATION# cJ WELL CONTRACTOR COMPANY NAME CJ-7YAkk Lti/A/J tG,;�Lna PHONE # W.J!2 -�'/,�S•,i STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box): Residentiall3l Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION: Topographic/Land setting NearestT wn: County1Sj„&&24 ❑Ridge ❑Slope ❑Valley ❑Flat .11 - cip �( r�ji�Z/-- (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER:�%5 Z e—!�S<Vlc (degrees/minutes/seconds) Address ,ein V,. , ) lt� Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) O Rlgl l�/G 7AI DEPTH DRILLING LOG ny or TC�—�tata Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED ti 5. TOTAL DEPTH: � 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO T STATIC WATER LEVEL Below Top of Casing: 6C _FT. a (Use"+"if Above Top of Casing) r 8. TOP OF CASING IS I FT.Above Land Surface* 'Top of casing terminated at/or below land surface requires a mac variance in accordance with 15A NCAC 2C.0118. r "} 9. YIELD(gpm): I METHOD OF TEST ri,i r t 10.WATER ZONES(depth): yl a LOCATION SKETCH 11. DISINFECTION:Type dTAI Amount 41, Show direction and distance in miles from at least s 12. CASING: Wa11.Thickness two State Roads or County Roads.Include the road, Depth Diameter or Weight/Ft. �M'atterial numbers and common road names. Fromm To�i-Ft /nT $;fJC'Zv� -C P 6 -ho II'I <;11mo ne3 Pd G`U , c), mt os From To Ft. From To Ft. uI, /6 ' Um /�17 J �n 13. GROUT: Depth Material Method �/f Ltl From__Toter 0 Ft. 6eLne+/1r n J� / /_G"n� t/ From To Ft. V' t/ NS �UI"f'! l� oS�h T 14. SCREEN: Depth Diameter Slot Size Material ))Y3 a / From To Ft. in. in. _ _ 7O (q,/f�C on From To Ft. in. in. 15. SAND/GRAVEL PACK: Depth Size Material - -- ' From—To—- Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORbANCE 1YITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT /A�CO'PY/OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PE SON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 27699-I636 Phone No.(919)733-3221,within 30 days. GW-I REV.07/2001 V rR� z314 � J WELL CONSTRUCTION RECORD North Carolina- Department of Environment and.Natural IR�esoufrgges-Division of Water Quality-Groundwater Sectiio�n,,� WELL CONTRACTOR(INDIVIDUAL)NAME Cr /P.1 T Cf tG CERTIFICATION#$SL�U WELL CONTRACTOR COMPANY NAME Craw ,�.rFl W LJI J Art' Js T PHONE # 4 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) I. WELL USE(Check Applicable Box): Residential Dt Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use 2. WELL LOCAT N: r Topographic/Land setting Near s� wn: County LIIO.,t)� ❑Ridge Mope ❑Valley ❑Flat >s Yl )/i°pui (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Cade) Latitude/longitude of well location 3. OWNER: N (degrees/minutestsmonds) Address ft� (,eJ Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) R- (n$ - 11LG 9,?7 JG5,n2 DEPTH DRILLING LOG City or Town star Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED 7—C—6,S _ 5. TOTAL DEPTH: 7,o S' 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO {R 7. STATIC WATER LEVEL Below Top of Casing:_!�06_FT. v (Use"+"if Above Top of Casing) S. TOP OF CASING IS I FT.Above Land Surface' r.' -Top of casing terminated attor below land surface requires a - variance in accordance with 15A NCAC 2C.0118. ''s 9. YIELD(gpm): J 'r METHOD OF TEST n_j r 0 10. WATER ZONES(depth): 60S— LOCATION SKETCH "t 11. DISINFECTION:Type_ _ Amount en.1AQ Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road — —Dep _ From To Ft. Di�agt(ter or ,5 W Ft. aterial numbers and common road names. From To - Ft. y P G tr0 rn 0,)n4 vnA /� C li d O./ M.I'/Cc From To FL O✓1 �,fj N mourn 1� T tsn Nfn 13. GROUT: Depth Material C� Method From_p_To�_Ft. e ,oY».o»T From To Ft. Yv %P(� ROO 60 3 fYl j(N S Tu r n 14. SCREEN: Depth Diameter Slot Size Material I C t�h _C �j'v /d �,S 7T (/dti From To Ft. in. in. From To Ft. in. in. l/"G•�V On 1 eel Gat �.. 11'l i l e 15. SAND/GRAVEL PACK: ? Depth Size Material /IQ � )l O tt' r' 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 �����- C-, _O .S-, 0 _ SIGNATURE OF PERSON CO STI�UCTING THE WELL DATE Submit the original to the Division of Water Quality,Groundi�etlC6ectiko63,J Mailt�l ice 4g ler t Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. I�GW-D REV.07/2001 - - 6" WELL CONSTRUCTION RECORD 3 .p 4 5 6 p North Carolina-Department of Environment and N tural Resoun:es - Division of Water Quality- Groundwater Section WELL CON-"RACTOR(INDIVIDUAL)NAi\IE (print) iG CER'FIFICA-ION4 WELL CONTRACTOR COMPANY NAME CRANE R OTHERS ELLiRiCLfA6;Fi'bZ, PHONE N ( ) STATE WELL CONSTRUCTION PERAII-"p FRANKLIN, NCA7 \TED\VQ PElil\II"FN (if applicable) (if applicable) I. WELL USE(Check Applicable Box): Residentij40'Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use 2. WELL LOCATION- Topographic/Land setting /Neeaarest Town: l� 4- County i n/ ❑Ridge ❑Slope ❑Valley ❑Flat `-�Y r� EMA _ (check appropriate box) (Street Name,Numbers.Community,Subdivision, Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER's de so cci:EJGPSE]s) Address /t',.) fir✓ Latitudz:or�gitude sourcea7GPSCTopographicmap ko (Street or Route No.) (check box) ,�Ly 25I C o?-W DEPTH DRILLING LOG Ci or-"own /State Zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED /o2—t� !!� to Lv � 5. TOTAL DEPTII: 103� 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ ea 7. STATIC WATER LEVEL Below Top of Casing: QD-5 FT. * (Use-+-if Above Top of Casing) 8. TOP OF CASING IS_�_ FT.Above Land Surface* r 'Top of casing terminated al/or below Land surface requires a '- variance In accordance with 15A NCAC 2C.0118, _ 9. YIELD(gpm): 10 METHOD OF TEST 4 Y 10. WATER ZONES (depth): _ LOCATION SKETCH 11. DISINFECTION: Type Amount _ Show direction and distance in miles frotnt least 12. CASING: Wall l'hickness two State Roads or County Roads. Include the road Depth Diamvl r or Weight/Ft. Material numbers and common road names. Frotn_-6_To 10 FL � L From To FL From To FL c_q 13. GROUT: Depth Material, Method t. From To—ZA_Ft._IfZ — _ ��{ Zll y L'� z rL From To Ft. 14. SCREEN: Depth Diameter Slot Size MaW,aL " v: From To Ft. in. in. r' �� — N From To Ft. in. in. L `� z 15. SAND/GRAVEL PACK: y G.�� _ Depth Size Material —D > From To Ft. 1n From To Ft. � a L� 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CO RUCTION(STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER L t va, l —,2o SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of ItValer Quality,Groundn aler Section, 1636 (Nail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-1 REV. 07/2001 3 f r. ry � WE LL CONSTRUCTION RECORD _ ( - North Carolina Department of En(vonment(and Natural Natural Resources-Division of Water Quality - e� WELL CONTRACTOR(LNDIVIDUAL)NAME (print 13)buG � # CERTIFICATION# WELL CONTRACTOR CObrPANY NAbIE AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. PHONE # (828)586.5550 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) -_ (if applicable) �(•_�\IC/`)l I. WELL USE(Check Applicable Box):Residential 12<Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Punp Water Injection❑ Other❑ If Other,List Use 2. WELL LOC N: f ToPP,ow�r�aphic/Land setting Nearest Tow ' Coum; ❑RidgeJfSlope ❑Valley ❑Flat YYIIIKttttteck appropriate box) (Street Name,Numbers,Community.Subdivision,Lot No.,Zip Code) Latitude90nglrude of Well location lIYA 3. OWNER: YY+ (degrees/rnmuxs scconds) Address Latitude/longirude source:❑GPSOTopographic map meet or Ro Vo. (check box)a-8 DEPTH DRILLING LOGS City or T Sdt pCode From To Formation Description - Sk -e? Area code-Phone oum .�7 — 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 f FT.Above Land Surface` 'Top of casiag terminated aobr below land surface requires a sariance in accordance with 15A NCAC 2C.0118. n 9. YIELD(epm):�METHOD OF TEST 10. WATER ZONES(depth): ;Z<2:l — O / LOCATION SKETCH 11. DISINFECTfON:Type-- Amount Show direction and distance in miles from at least 12. CASING: %Val[Thickness two Syate Roads or County Roads.Include the road Depth iamet�r or Weigho'Ft. Materia number and common road names. From 0 To 3 Ft. R S�Z) From To Ft. From To Ft. 13. GROUT: Depth Material Method From 0 To -3 Ft. n 1 Froms�To�Ft. R r !d. SCREEN: Depth Diameter Slot Size Material From De Ft. in. in. From To Ft- in. in. 15. SAND/GRAVELPACR 00 Depth Size Material - 0 From To Ft. From To Ft. , 16. REMARKS: I DO HEREBY CERTIFY TYAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION ST ARD AND THAT A WY OF TH S BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTrt5THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Mansgementj 1617 Mail S;rvice Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. • - - ,QW-1 REV.09;2004 I ' WELL CONSTRUCTI N`RREECOMY F North Carolina Department of Env nment and Natural Resources-Division of Water Quality WELL CONTRACTOR(LNDIVIDUAL)NAME (PrInM• (t,I�(JYYCLt' CERTIFICATION d . WELL CONTRACTOR COMPA.\Y NA-,fr AAA GREENE BROS.WELL ORLG.OF SYLVA,INC. - PHONE N (828)586-5550 STATE WELL:CONSTRUCTION PERbIIT$ ASSOCIATED WQ PER),tlTA. - - (if applicable) (ifapolicable) 1. "ELL USE(Check Applicable Box):Residential MunicipaVPublic ❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATI Topographic/Land setting Neare Ctmyn Ridge ❑Slope alley ❑Flat -1 (check appropriate box) (Seca Name.Numbers,Community,Subdivisi n,Lot _Zip Code) Latitode/longirude of Well location 3. OWNER: `� (degrees/minutes/seconds) Addre s Latitude/loneirude source:❑GPS❑Topographic map Sureetor uc o.) ma ') (cheek boa) 4-&r %L -/y` C.��'7�� DEPTH DRfLLFNGLOG` Cin Town Sate a Zip Code From To Formation Description , c 7. . ' - Area code.Phone number r f 4. DATE DRILLED — I -7 5. TOTAL DEPTH: 7 , 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 19 _ 7. STATIC WATER LEVEL Below Top of Casing: A r? FT. Jz)!5- _/c.� (Use'•+-if Above Top of Casing) S. TOP OF CASING IS FT.Above Land Surface. -Top orcasin.terminated at'or below land surface requires a sariance in accordrnce w'th 1>A,CAC 2C.0118. 9. YIELD(gpm):LC7 METHOD OF TEST 1 t/ 10.WATER ZONES(depth): fOS LOCATION SKETCH 1 I. DISINFECTION:Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. include the rorad Depth Diameter or Weight'Ft. Materi numbers and common road names. (7 From Q To Ft. / From To Ft C From To Ft. r- 13. GROUT: Depth Material Method tv ' From To 7 Ft _i - / 00 From To�Ft. Lc� .. 14. SCREEN: Depth Diameter Slot Sizz (aterial ' Ln From To Ft. in. in. From To Ft. in. in. U. SAND/GRAVEL PACK: Depth Size Material From To Fr.— From—To—Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CON STR N S ARDS,AND COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATURE OF PERSON CONSTRUCTIN WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,Within 30 days. r ri I 6 r1) Is REV.09/2004 i WELL CONSTRUCTION ECORDO f 6 1 5 ,." North Carolina Department of Envir9k,�ent and Naturalles^ources-Division of Water Quality / WELL CONTRACTOR(INDIVIDUAL)NAME (print)*.Y�GGCN . ILYLUI Cab CERTIFICATION# V! WELL CONTRACTOR COMPANY NAME AAA GREENE BROS.WELL DRLG.OF SYLVA,INC. PHONE # (828)586-5550 _ STATE WELL CONSTRUCTION PERSHT# ASSOCIATED WQ PER:NIIT#(if applicable) (if applicable) L WELL USE(Check Applicable Box):Residentially Municipal/Public❑ Industrial❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. ELL LOCHwn N: Topographic Land setting NearesW tTo 0 n� Z ❑Ridge Slope ❑Valley ❑Flat - Uy cbeckappmpria[ebox) (Street Name,Numbers, mmumtyy,,SubdMsioonn,,�L'& o.,Zip e C Latitude longitude of well location 3. OWNER: q./1^ //�( (af�iL�I L �� (degre *oinutes/seconds) A dress _•� .ie�( d'✓�.. T Latitude/longitude source:❑GPS❑Topographic map (Sq°e[or Ro to o. (check box) l )�/fK�rL �7y � DEPTH DRILLING LOG' City or T wn Scat e ' J2tp o/de From 'To Formation Description 628 -_ `` . r^7 Area code-Phone oumber 4. DATE DRILLED '5'— C-) 5. TOTAL DEPTH:: 6. DOES WELL REPLACE EXISTING WELL? YES NO 7. STATIC WATER LEVEL Below Top of Casing: 0 (Use'•+-if Above Topo acing) 8. TOP OF CASING IS FT.Above Land Surface- •Top orcasiog terminated at/or below land surface requires a variance in accordan a with 15A NCAC 2C.0118. 9. YIELD(gpm): — THOD OF TEST 6 f I0.WATER ZONES(depth) `S r U ZC U- - LOCATION SKETCH It. DISINFECTION:Type T Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or WeightTt. Matanal numbers and common road names. From To gFt. 5D. Z! _ — / p� From To Ft From To — .t. 13. GROUT: Depth Material Method. From 3 To Ft. (.L_ From To F[. � L 14. SCREEN: Depth Diameter Slot Size Material s C From To Ft. in. in. ~�� ro From—To—Ft.—in. in. •" 15. SAND/GRAVEL PACK: t� Depth Size Material � From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCT19NS S,AND THAT AA COPY OF THIS CiO` S BEEN PROVIDED TO THE WELL OWNER SIGNAT-URf-OFTSRSON CONSTRUCTING THE R ELLS DATE Submit the original to the Division or Water Quality,Attn: IDformation hfanagegienr„t6T7 Mail-Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days: QW-I REV.09;2004 AJr 2 314521 WELL CONSTRUCTION RECORD W North Carolina- Department of Environment and N ral Resources-Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) i.& & ,fie CERTIFICATION WELL CONTRACTOR conlPANr NAME CRAM BROTHERS t°JELL DRILLING, INC. PHONE # STATE WELL CONSTRUCTION PERMIT# FRANKLINA"%Mf p WQ PERruTs (if applicable) (if applicable) I. WELL USE(Check Applicable Box): Residentials' Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other ❑ If Other, List Use 2. WELL LOCATION: Nearest Town: CounA ❑ty� Topographic/Land setting O Ridge ❑Slope ❑Valley ❑Flat ��� ^ (check appropriate box) (Street Mine,Numbers,Community,Subdivision,Lot No.,Zip Code) /i Latitudeilongitude of well location 3. OWNER: Nil(C ' o Address (degrees/minutes/seconds) Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) DEPTH DRILLING LOG City or Town State Zip Code From To Formation Description Area code-Phone number n 4. DATE DRILLED 5. TOTAL DEPT'H:�- 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ 7. STATIC WATER LEVEL Below Top of Casing: Q A)) FT. (Use"+"if Above Top of Casing) r" ^ 8. TOP OF CASING IS FT.Above Land Surface* N3 *Top of casing terminated at/or below land surface requires a variance in accordanfe with 15A NCAC 2C.0118. O ... 9. YIELD(gpm): 1/a METHOD OF TEST ,eA' its 10. WATER ZONES (depth): LOCATION SKETCH 11. DISINFECTION: Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Dia r�e er or Weight/Ft. Material numbers and common road names. From To-L_FL_ ptyr- From To Ft. From To Ft. 13. GROUT: Depth Material Method From D To 020 Ft._�d//2e� From To FL I ,rtr 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. =! From To Ft. in. in. 15. SAND/GRAVEL PACK: Size Depth Material DeP From To Ft. o I From To Ft. `r 16. REMARKS: 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CON TRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOTHE WELL OWNER nn 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)733-3221,within 30 days. GW-1 REV. 07/2001 WELL CONSTRUCTION RECORD � � 1 4- 0 31 North Carolina• Department of Environment and Natural /Resources- Division of Water Qua dy- Groundwater Section l WELL CONTRAC"I OR(INDIVIDUAL)NADIE (print) /—✓Q�f l,y`�-„J�_ CERTIFICA ION#J62 WELL CONTRACTOR COMPANY NAME PHONE p -ENE BROTHERS ,L D� h STATE WELL CONS"fRUCT10N PERAIITN - ffigI6r 1VQ PEIiBfITp (if applicable) �aat,,,,t a,,, � -� (ifapplicable) 1. WELL USE(Check Applicable Box): Residentiao Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Beat Pump Water Injection ❑ Other ❑ If Other, List Use 2. WELL LOCATION: Nearest Towtl:B 7) Topographic/Land setting lam_County� �}_ ❑Ridge ❑Slope ❑Valley ❑Flat (Street Name,Numbers,Community,Subdivision,Lot (check appropriate bon) No.,Zip Code) 1 Lalitudeilongitude of well location 3. OWNER: id2bb (degrees/minutes/seconds) Address A4>i*i IlIe Latitude/longitude source:❑GI's0'ropographic map r (Street or Route No.) (check box) LA ' u'S4.A C oZ !`R � DEPTH DRILLING LOG City or Town State zip Code From To Formation Description Area code-Phone number 4. DATE DRILLED 6S 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ 7. STATIC WATER LEVEL Below Top of Casing: _7_FT. / (Use"+"if Above Top of Casing) 8. TOP OF CASING IS—L_ FT.Above Land Surface* r "Top of casing terminated at/or below land surface requires a N.y variance In acenrdance with 15A NCAC 2C.011 S. - 9. YIELD(gpm): _METHOD OF TEST .Q,r 10. WATER ZONES (depth): _ _ LOCATION SKETCH If. 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 �V Depth Diameter or Weight/Ft. Material numbers and common road names. From([_To ,3, — FL (o yq From To Ft. 7� i----, From To FL ➢ _ l 13. GROUT: Depth Material Method Er F1 J FromTo-,�?�Ft. 2/ t �/ From To Ft. / - c 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in, ry 15. SAND/GRAVEL PACK: 0 cs Depth Size Material �"z r- J From To FL - <>From To FL 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSS RUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER t 7/le�� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit (lie original to the Division of Water Quality,Groundwater Section, 1636111eil Servdce Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV. 07/200I WELL CONSTRUCTION RECORD �W 3 14 5 ' 2 North Carolina-Department of Environment and Natural Resources- Division of Water Quality- Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) CER'rIFICA77ON k� WELL CONTRACTOR COMPANY NAME CRANE BRQTupoz F°''Fs l )1RILLING. INC. PHONE q � -I STATE WELL CONSTRUCTION PEIL11ITq 248 Cri,+''[. CIRCI,Fc (if applicable) RAWKLIw, rep. coro-r OCIATED WQ PEIUNII'# (ifapplicable) 1. WELL USE(Check Applicable Box): Residentiat.91 Municipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use 2. WELL LOCATION: Nearest Town:- Topographic/Land setting y _county; il) ❑Ridge ❑Slope ❑Valley ❑Flat �� A/lLLLs 5 (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: 1qr-1-'d;e4,- (degrees/minwes/secmrds) Address 0 613x � �y Latitude/longitude source:❑GPS❑Topographicmap (Street or Route Nu.) (check box) lq/r"Aa P,I K Z O a DEPTH DRILLING LOG City or Town Slate Zip Code From To Formation Description Area code-Phone number 4. DATEDRILLED I?-LO—OS L) 5. TOTAL DEPTH: 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ 7. STATIC WATER LEVEL Below Top of Casing: _ U FT. (Use"+"if Above Top of Casing) S. TOP OF CASING IS FT. Above Land Surface* f— 'Top of casing terminated atlnr below land surface requires a r "' variance In accordance with 15A NCAC 2C.n119. N 9. YIELD(gpm): 1 -r_METHOD OF TEST 4 r _ 10. WATER ZONES (depth): o LOCATION SKETCH 3 11. DISINFECTION: Type Amount Show direction and distance in miles from- leas( kn 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Dian r or Weight/Ft. Material numbers and coalition road names. From To Ft. UL From To Ft. From To Ft. 13. GROUT: Depth Material Method 1 From 0- To.20 Ft.--L..,�-- - � From To Ft. cc- 1) , 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. -: From To Ft. in. in. — <. r" 15. SAND/GRAVEL PACK: o Depth Size Material From To Ft. From To Ft. r i 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,WELL CON/S34UCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER —4—a-I&Z C4 o �(J C�— SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to (he Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-I REV. 07/2001 OIVNER M11D WL LL CONSTRUCTION RECORD t�io 14433 NorBl Carolina-DepalIntent of Enviromncnl mid Nay al Resources-Division of Water Quality-Oroundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (pFird) l� /Leecc. CERTIFICATIONM �1.l�zr WELL CONTRACTOR COMPANY NAatE PHONE M ASSOCIATED WQ PERMITM r- ' STATE WELL CONSTRUCTION PERa11TM (If applicable) — 1. WELL USE(Check Applicable [lox): Rcsidelloal 0-,Muuicipal/Public❑ Induslrial Cl Agricultural O Monitoring O Recovery ❑ ►feat Puulp Water Injection O 011rer O If Other,List Use 2. WELLLOCATION:" 'Fopographic/Lamdsetting I-' — - -� County �O`'' l ORidge OSIoPe []Valley ❑Flat lei l�an NCarCsl Town:Cie (check appropriate box) laliludc/longilude of wcl�loc"lion (Sueel Name,Numbers,Courmudty,Subdivislar,Lot No.,Zip Code) !1/35 S2 7 �X r"k,'693 ,21 .5 " — (deareealminutes/seconds) ' �. -- 3. OWNER: ,S4j1aac.z Je X,'',fS Address `' T�b�/ Ca1t Latitude/longitude sourcc:OGPSOTopograPhic neap (check boa) (Street or Route No.) DEPTIf DRILLING LOB. zl Code Front To Formation Description City or sown StateP Area code-Phone number 4, DATE DRILLED f 5. TOTAL DEPTII: 6. DOES WELL REPLACE EXIS"fINO WELL? YES ❑ NO 7. STATIC WATER LEVEL Bclow T-op of Casing: .220 Fr. e (Use"+"Ir Above Top of CaninM) — �`• S. TOP OF CASING IS i IT.Above Land Swfacea = ry *Top of esJnr terminated at/or below land surface requires a variance In accordance with 15A NCAC IC.0119. n 9. YIELD(gpm): "S METIIOD OF TEST 10.WATER ZONES(depth): LOCATION SKETCII T Amount (� Show direction and distance in miles from at least 11. DISINFECTION:Type Wall lunickness two State Roads or County Roads.Include the road 12. CASING: numbers and common road names. Depth Diameter or Weight/Ft. MLletial From To 142 Ft. e-.2j- 001 O From 4L:Z To G3 FL s,sf" lSS� Sfee! Front_ To FL 13. GROUT: Depth ate to] Method, FromTo Ft. cr�` vas d Front_ To FL 4 a 14. SCREEN: Depot Dimnelcr Slot Size Material From To Ft. iu, in. From To Fl. in. iu. IS. SAND/GRAVEL PACK:Depot Size Material Fron'L To Ft. ___--- Pram 16. REMARKS: I DO I IEREBY CERTIFY T►lATTIIIS WELL WAS CONSTRUCfED IN ACCORDANCE WIT[( 15ANCAC 2C,WELL CONSTRUCTION STANDARDS,AND TUAT A COPY OF TILLS RECORD I(AS BEEN PROVIDED TO T IE WELL OW14ER SIGNATURE OF PERSON CONSTRUCTINO TILE WELL DATE Submit the original to the Division of Water Quality,Groundwater Secllon,1636 biall Service CeOroer'RCVgh,C 27699-1636 Pboue No.(919)733-3221,wilhhl 30 dnys. 22 WELL CONSTRUCTION RECORD l am' 4 e� North Carolina-Department of Environment and Natural Resources- Division of Water Quality-Groundwater Section WELL CONTRACTOR(INDIVIDUAL)NAME (print) T 5A1— ��" CERTIFICATION�/ WELL CONTRACTOR COMPANY NAME PHONE # ��f� STATE WELL CONSTRUCTION PERMIT# 248 CRANEMW ATED WQ PERMIT# (if applicable) "'—�`Yif applicable) 1. WELL USE(Check Applicable Box): Residential.12- N micipal/Public ❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use 2. WELL LOCATION: Neares�Town:"Kl�.SSO I / 4 County e 4±/ Topographic/Land setting � �� �— ❑Ridge ❑Slope ❑Valley ❑Flat 4A (check appropriate box) (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location /S�q A" 3. OWNER: r11 I (degrees/minutes/seconds) Address , A. !4J X_/O$L Latitude/longitude source:❑GPS❑Topographic map (Street or Route No.) (check box) Y d Al C V202, DEPTH DRILLING LOG City or sown State Zip Code From To Formation Description Area code-Phone number// 4. DATE DRILLED 5. TOTAL DEPTH:_�SS 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑ — # 7. STATIC WATER LEVEL Below Top of Casing: Z! d FT. (Use"+"if Above Top of Casing) C 8. TOP OF CASING IS�_FT. Above Land Surface* r -Top of casing terminated at/or below land surface requires a variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm): _METHOD OF TEST_ �/__ n 10. WATER ZONES(depth): — LOCATION SKETCH =Ta 11. DISINFECTION:Type Amount Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or WeighuTt. Material numbers and common road names. From 0 To.� Ft. lo% From To Ft. From To Ft. 13. GROUT: Depth Material ^� [ r _ - -'r) i From U To .2 Ft._ Method L(L�.i!/S n i.- I From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. n. rc From To Ft. in. in. 15. SAND/GRAVEL PACK: c Depth Size Material From To Ft. "":�I o From To Ft. OFF,71 J —_- 16. REMARKS: - rt 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.(919)733-3221,within 30 days. GW-1 REV. 07/2001 WELL CONSTRUCTION RECORD G,)W 3 15 7 2 North Carolina Department of Environment and Natural Resources-Division of Water Quality - WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B.Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc PHONE # ( 1 369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential ID Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATION- Topographic/Land setting Nearest wn: County ❑Ridge ❑Slope ❑Valley ❑Flat f A. (check appropriate box) (Street ame,NuW= ZipCode Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: (degrees/minums/seconds) Address Latitude/longitude source:❑GPS❑Topographic map (check box) R?ov- DEPTH DRILLING LOity or Toe From To r Formation Description (8m oSaoB 0 125 Clay it sand Area code-Phone number Z071 �_ Granite 4. DATE DRILLED 'IS'OS 5. TOTAL DEPTH: O� 6. DOES WELL REPLACE EXISTING WELL? YES❑ NO 7. STATIC WATER LEVEL Below Top of Casing: gOd T. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface* -Top of casing terminated it/or below land surface requires a variance in accordance with 15A NCAC 2C.0118.9. YIELD(gpm): 1.5 METHOD OF TEST BLOW 10.WATER ZONES(depth):_& � . LOCATION SKETCH 11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Diameter or Weight/Ft. Material numbers and common road names. From 0 To Ft. (o,• FromTo Ft. From To Ft. 13. GROUT: Depth Material Method .' From 0 To 20 Ft.Benonite&Cement pumped From To Ft. 3 , al 14. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. 15. SAND/GRAVEL PACK: ;¢ Depth Size Material CCJ) From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STA RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER �Y e)6 SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 10 3 � 6 '7 WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE # (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential El Municipal/Public❑ Industrial❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATIO TOpographic/Land setting Neare own: �. County&dl)2( ) ❑Ridge ❑Slope [ Valley ❑Flat jD�� (check appropriate box) (stre8t ame,Numbers,Community,Sub/division,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: .[f /�{ (l/J/� (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map / ( tree[or Route a. �— (check box) 'p` (((yLLL---��� DEPTH DRILLING LOG �ty or Town to zip Code From To Formation Description B(�a)- ���_ �+� 0 r Clay&Sand Area codeine number ���M' — Cl Granite 4. DATE DEPTH: 5. TOTAL DEPTH: � 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO)( 7. STATIC WATER LEVEL Below Top of Casing:_I/50 FT. (Use"+"if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface* *Top orcasing terminated aVor below land surface requires a variance in accordance with 15A NCAC 2C.011& 9. YIELD(gpm): �ME17ZF TEST BLOW I0.WATERZONE LOCATION SKETCH 11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth Di eter or Weight/Ft. Mgcrial numbers and common road names. From 0 To Ft. � From�ToFt. From To Ft. 13. GROUT: Depth Material Method From 0 To 20 Ft.Benonite&Cement pumped i I I From TO Ft. is -'� -- - --- - �l 14. SCREEN: Depth Diameter Slo[Size Material Crl From To Ft. in. in. ?J1,� O From To F[. in. in. - - 15. SAND/GRAVEL PACK: O - Depth Size Material --From To Ft. From To Ft. 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER SIGNATU F PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management, 1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 r� 1 r. A 7 , s1 WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR(INDIVIDUAL)NAME (print) James B. Brown CERTIFICATION#2045 WELL CONTRACTOR COMPANY NAME Hedden Brothers Well Drilling, Inc. PHONE # (828)369-9591 STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# (if applicable) (if applicable) 1. WELL USE(Check Applicable Box):Residential 0 Municipal/Public❑ Industrial ❑ Agricultural ❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use 2. WELL LOCATI N: Topographic/Land setting Nest^ Tto n: County il. l ❑Ridge ❑Slope ❑Valley ❑Flat SIICLI.W (check appropriate box) treet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well location 3. OWNER: (degrees/minutes/seconds) Address Latitude/longitude source:❑GPS❑Topographic map �. /,(,�(S'tre t or ARoute No.) (check box)l �lT 31VI DEPTH DRILLING LOG a y Town �1 S zip C de From To Formation Description 6 _�—go _ Clay&Sand Area code-Phone number 9 66 ___ / , Granite 4. DATE DRILLED -/ 5. TOTAL DEPTH: /OM, — 6. DOES WELL REPLACE EXISTING WELL? YES NO 7. STATIC WATER LEVEL Below Top of Casing: F (Use"+^if Above Top of Casing) 8. TOP OF CASING IS 2 FT.Above Land Surface* -Top of casing terminated at/or below land surface requires a variance in accordance with 15A NCAC 2C.0118. 9. YIELD(gpm):�_METHOD OF TEST BLOW 10. WATER ZONES(depth): 335 r LOCATION SKETCH 11. DISINFECTION:Type H T H Amount 16oz Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads.Include the road Depth-r„ Diapeter or WeigOht/Ft. Material numbers and common road names. From 0 To�.- Ft. (O _./8(L �h�G 'L __. ....._ _... .._ .... . _.... From R To Ft. ' } From To Ft. 13. GROUT: Depth Material Method i From 0 To 20 Ft.Benoni[e a Cement pumped From To Ft. 14. SCREEN: Depth Diameter Slot Size Material From—To—Ft.—in. __ in. From To Ft. in. in. tT 15. SAND/GRAVEL PACK: 9 Depth Size Material O From To Ft. _ From To Ft. Ln 16. REMARKS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION ST RDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER -G-D SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE Submit the original to the Division of Water Quality,Attn: Information Management,1617 Mail Service Center- Raleigh,NC 27699-1617, Phone No.(919)733-7015,within 30 days. GW-1 REV.09/2004 ( a 1 WELL CONSTRUCTION RECORD North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section W ELL CONTRACTOR(INDIVIDUAL)NAME 1print)_ _/4t CERTIFICATION#..1�{!t'C WELT.CONTRACTOR COMPANYNAME C,! NF �>7^s Jf '/ lr r PHONE # ($�,� lo STATE WELL CONSTRUCTION PERMIT# �Y 6 z k� (if applicable) ASSOCIATED WQ PERMIT# 00000000(if applicable) I. WELL USE(Check Applicable Box):Residential 13-"<Iunicipal/Public ❑ Industrial ❑ Agricultural❑ Monitoring❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use 2. WELLLOCATIO Nearest Town: r County _ TopograylTic/Land setting — aela —rrWePI ❑Ridge &Kope ❑Valley OFlat (Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) (check appropriate box) Latitude/longitude of well location 3. OWNER: � [- Address _ (degees/minutes/seconds) :R/ P or Route No.) Latitude/longitude source:OGPSOTopographic map (Street 32 1 9 Q (check box) Up or Town state DEPTH DRILLING LOG Zip Code From To i Format' Description Area code-Phone number 4. DATE DRILLED 5. TOTAL DEPTH: 1,66 5- , (; v1(_11-1 Si` 11VLI_I REPI-ACI 1_YIC'I'I NrI: WL a YES 0 NO W 7. STATIC WATER LEVEL Below Top of Casing: 0'06 FT. K TOP OF CASING IS (Use +"if Above Top ofCasing) 'Top of casing terminated at/or below land .Abrfaovre Land a urface• variance in accordance "it/h 15A NCAC 2C.0118. ' 9. YIELD(gpm): METHOD OF TEST s 10. WATER ZONES(depth): (a nS_ Qd S a 1 1. DISINFECTION:T e LOCATION SKETCH YP 11TH Amount /9 -1-61�% Show direction and distance in miles from at least 12. CASING: Wall Thickness two State Roads or County Roads. Include the road Depth Diameter or Weight/Ft. Material From To ap Ft. numbers and common road names. __—. (p /I �.� From To FL From To Ft 13. GRO[JT: Depth Material w From D TO—"—Ft. /r r _. . .. �- Method _ _------- to From _To pth Ft. 14. SCREEN: De From To Ft Diameter Material , . in. Slot Size M 1, From in. To Ft._in. in. L l'. CK: .'l,I f n ���i5, 15, SAND/GRAVELPA "='� From Depth Ft th Size Material I — `_j =e From_--To Ft. 16. REMARKS: I DO IiEREBY CERTIFY THAT 1-I1IS 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 - U— 6 S SIGNATURE OF PERSON CONSTRUCTING THEWW DATE ELL Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC 27699-1636 Phone No.(919)733-3221,within 30 days. GW-1 REV.07/2001 rl OWNER RESIDENTIAL WCLLCONS•FIIUCT1ONRECOI(l) C& MWD North Carolina Department of Environment and Natural Resources-Division of Water Quality NC WELL CONTRACTOR CERTIFICATION # 1.WELL CANTRACTOR: I. DISINFECTION:Type T Amount Ktc, Z�e/ /-/ {C e g. WATER ZONES(depth): Well Cont for(Individual)Name From_To 0?h / From To MILLER WELL DRILLING , INC . From To From To Well Contractor Company Name From To From To STREETADDRESS P . O . BOX 28904 6. CASING: Thicknessf Depth Diameter W�e�i�h_l� Material HAYESVILLE , N . C . 28904 From�_To�Ft.6. s f( City or Torun Stale Zip Code From To Ft. t 828 } 837-29 77 From—To—Ft.— Area code- Phone number 3.WELL INFORMATION: 7. GROUP: Depth Materi f MelhoV From C To_j Ft. r/ �- SITE WELL ID#(il applicable) From To FL zl c ; STATE WELL PERMIT#(a applicable) From To Ft. DWQ or OTHER PERMIT#(if applicable) ,, B. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Boxj. Residential Water Supply 111/ From To Ft.—In. _ in. `�—a�`�3 From To Ft.—In. _ in. DATE DRILLED From To Ft.—in. _ In. TIME COMPLETED AM PM p/ e, SAND/GRAVEL PACK: 3.WELL LOCATION, / ` Depth Size Material CITY: �'C ��EQ COUNTY �cJ trv�7 From To Ft.— From—To—Ft. From To Ft. (Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) _ TOP GRAPHIC I LAND SETTING: 10.DRILLING LOG L3ePDpe oValley ❑Flal ❑Ridge ❑Other From To Formation Description (check appropriate box) LATITUDE a d 9• yA • May be in degrees. minutes,seconds or LONGITUDE F 3 0 /L/ S�) in a decimal format yo Yyz L Latitude/longitude source: g611S ❑Topographic map (location of we#must be shown on a USGS logo map and n attached to this loan#nor using GPS) 4.WELL OWNER OWNER'S NAMESTREET ADDRESS Ln City or Town Stale Zip Code L Y Area code- Phone number _- 11. REMARKS: 5.WELL DETAILS: ,/ / a. TOTAL DEPTH: 2 TZ b. DOES WELL REPLACE EXISTING WELL? YES❑ N04a- - e. WATERLEVELBeIowT of Casing: ((� I DO HEREBY CERTWY THAT THIS WELL WAS CONSTmfCED NACCORDANCE WITH W g: U FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT ACOP.Y.OF THIS.. (Use'+'If Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER, i. d. TOP OF CASING IS L FT.Above Land Surface' 'Top of casing terminated allor below land surface may require SIGNATURE F CERTIFIED WELL CONTRACTOR / DATE a variance in accordance with 15A NCRC 2C.0718. 11 e. YIELD(gpm): J METHOD OF TEST 17'//~ / PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form Gw•1a 1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.(919)733-7015 ext 568. Rev: OTA, RESIDENTIAL WELL CONNorth Carolina De artment of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# & in,5 0 1.WELL CONTRACTOR: f. DISINFECTION:Type Amount-1 Q� /TY�•f g. WATER ZONES(depth). T-- Well Contractor(Indlvld ai)Name From_!V1Q To_,R&)_ From To I Y)A From To From To Well Contractor Company Name oe From To 'J From To STREET ADDRESS fp37 �y�N T/,2rj 8,4 6. CASING: Thickness/ Depth Fila meter Weight MatenW nhh>`Y16 lfr'��id IVY p2577! From,_To_6q Ft.Ln.}� tnr4/ Pt/c City or Town State Zip Code From To_Ft.TT Fran To Ft. Area code- Phone number 2.WELL INFORMATION: 7. GROUT: Depth �, Material Method SITE WELL ID#(if applicable) Fr�—Q—Toms —Ft. !'oiL7P11T p n,!).'na From To Ft. STATE WELL PERMITIA#aiwlcable) From To Ft. DWQ or OTHER PERMIT#(it applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply 04 From Tc Ft. in. _ in DATE DRILLED From To_Ft._in. _ in. q-aG -o _ TIME COMPLETED AM p PM 04 from TO Ft._in. in, 9. SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: Js' COUNTY 61W. n Prom Tt Ft. Fran To Ft. _L7riAn7'A1 1PY` !V� regL'� arcel, p Fran Tc Ft. (Sbee me,Numbers,Community,Subdmsion.Lot No.,P Z ) TOPOGRAPHIC I LAND SETTING: 10.DRILLING LOG ❑Slope NValley ❑Flat ❑Ridge C)Other From To.. (check appropriate troz) - Formation Description LATITUDE 3 to �9 J�a•�,",r Maybe in degree; f- minutes,seconds or LONGITUDE 2 .6 U�ea .9/r ina decimal format Latitude/longitude source: ❑GPS []Topographic map n (boation Of We9 must be shown on a USGS topo map and attached to this form 1 not using GPS) - tT 4.WELL OWNER _ OWNER'S NAME J a $ � STREET ADDRESS 1 ' /��D �O1 <C 1�Pt/Cnn CJ T J 11ze a61-'�.� C or Town r State Zip Coda Area code• Phone number - 5.WELL DETAILS: ��11 csr� II. REMARKS: a. TOTAL DEPTH: K Of j r In. DOES WELL REPLACE EXISTING WELL? YES❑ NO c- WATER LEVEL Below Top of Casing:�U _FT, I DO HEREBY CERTIFY TNAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WMi W Casing) RECORD HAS BEEN PRovn ED TO THE WELL OWNER.2C.WELL CONSTRUCTION STANDARDS D THATACOPY OF THIS (Use if Above,T d Cali d. TOP OF CASING IS FT.Above Land Surface +f"�y //, 'Top of casing accordance with below Land may require IGNATURE OF CERTIFIED WELL CONTRACTOR DATE a v 2C.01 S variance in accordance with 15A NCAC 2C.011g. e. YIELD(gpm): METHOD OF TEST_ ,%/' �/� '7' /r'7rj/�to 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 27699-1817 Phone No.(919)733-7015 ext 568. Form GW-la Rev.7/05 SrATEo f:. 4 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# C106-d 1.WELL CONTRACTOR: f. DISINFECTION:Type Amount �pz g. WATER ZONES(depth): was Contractor(Inds Iduap Name From f10 To 7.�h_ From To rci ha YY1 (g q y y ( M '�� 'tn f From To From Well Connector CompanyTo Name From To From / To STREET ADDRESS In` �E! T(,rJyl R� 6. CASING: Thickness! ?tyri Depth ,_5 D_i7meterWeighto i y O�bIY)Cvy1�E `V� �$77/ From� - _To < ,.,_FL(n _ � G�cCitty or/Town Sta'te1 Zip Code From To Ft. _ (�- `�79- $y� / From To Ft. Area code- Phone number -- 2.WELL INFORMATION: 7. GROUT: Depth Material Method SITE WELL ID#(if applicable) From-0 To�_Ft �PlY1Cy(T 1012mI12` , From To Ft. Of STATE WELL PERMIT#(itapplioeble) Fram To Ft DWQ or OTHER PERMIT#(8 applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Check Applicable Box): Residential Water Supply X From To Ft._in. _ in. DATE DRILLED /}"as C,1� From To Ft. in. _ in. From To Ft. in. in. TIME COMPLETED_ .,3 Q AM❑ PM 10 9. SANDIGRAVEL PACK: 3.WELL LOCATION: Depth Size Material CITY: PY/GiJ7 Ci TV COUNTY r�Ie�Li n From To Ft. /— From To Ft. 1»hr.o QJR-7 From To Ft. (54ee1 Name.Numbers,Caomunay,Subdmswn,Lot No.,Parcel,Zip Code) TOPOGRAPHIC/LAND SETTING: _ OSklpe ❑Valley ❑Flat ISRidge ❑Other 10.DRILLING LOG (check apprroopdats box) From To, Formation Description LATITUDE 3 50 .ZI Z/ =indegrms,�9-��f+(J--LONGITUDEg 29/07.,q Latitude/longitude source: ®GPS OTopographic map (location of W e9 must be shown on a USGS topo map and attached to this)orm7not using GPS) 4.WELL OWNER t OWNER'S NAME A O STREET ADDRESS _CJPE+' 1Jnn ryd "� CC or Town SWe Zip Code Area code- Phone number 5.WELL DETAILS: 11. REMARKS: a. TOTAL DEPTH: 7 _ b. DOES WELL REPLACE EXISTING WELL? YES❑ NOgr C. WATER LEVEL Below Top of Casing: 1/0 FT 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH (Use'+•A Above Top o/Casing) RECOROC 2C.EEN d WELL SI U TC O TIE WNDARDS RO THATA COPY OF THIS d. TOP OF CASING IS�_FT,Above Land Surface' 'Top of casing terminated allot below land surface may require ---- 'Z41A to a variance in accordance with 1 SA NCAC 2C.0118. SIG�N-A I U 1Kt OF CE�R/TIFIED W ELL CONTRACTOR DATE e. YIELD(gpm):--a METHOD OF TEST 1I Y'-7 /yr i0 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 27 6 99-1 61 7 Phone No.(919)733-7015 ext 568, Form GW-la Rev.7/05 yya'aa STATEo \J RESIDENTIAL WELL CONSTRUCTION RECORD " -( t <F North Caroline Department of Environment and Natural Resources-Division of Water Quality -. WELL CONTRACTOR CERTIFICATION# .6 Sa _ 1.WELL CONTRACTOR: I. DistNFECTION:Type�Zt Amount PZ�j 9. WATER ZONES(depth): Well Contractor(Individual)Name From—S�,s To YC,S From To From To From To Well Contractor Company Name W 7 / From To From To STppR��EE/T ADDRESS /n ) fytv�.0 7t f / C CASING: Thickness/ Lrl1Y)�i>7Si/r`�fSs Cl Depth Diameter Weight Material uC?l'77� From O To 9 Ft. snra) Pvc- SIgg—ary a Tovm State Zip Code From To Ft. _ tv3L!- t'1L ' kZ/Sy From To Ft. Area code- Phare number 2.WELL INFORMATION: 7. GROUT: Depth Material Method SITE WELL ID Happlicable) om_#( FrS2_To `r FL C't-rnyn 7' PU From To Ft. CK STATE WELL PERMIT o (#applcanle) From T FL DWQ or OTHER PERMIT#(if applicable) 8. SCREEN: Depth Diameter Slot Size Material WELL USE(Chock Applicable Box): Residential Water Supply QI Front To__Ft. in. _ in. DATEDRILLED_7'—/�—Q S� FTDm To— Ft.__in. in, TIME COMPLETED_ Z AM p PM® Fran TO—FL_in. _ in, 3.WELL LOCATION: 9. SANDIGRAVEL PACK: Depth Size Material TY' C COUNTY (S�i�i/-1 From FromT —Ft. From!T To Ft. -�"t✓T�» �!ieCP PC 'Jf From Tc_Ft. (Street Name,Numbers,Commundy,Subdmamn,Lot No.,Parcel,Zip Code) TOPOGRAPHIC I LAND SETTING: ❑Slope OValley ❑Flat GIRidge ❑Other 10.DRILLING LOG (check appropriate From To box) Formation Description LATITUDE 3 ,� ' / MayLONGITUDES , !! Latitude/longitude source: ®GPS oTopographic map - (location of Well must be shown on a USGS topo map and - attached to this form/not Using GPS) - O :_s 4.WELL OWNER OWNER'S NAME ,rr7 C rJl r� r STREET ADDRESS fir. cn n •'- . date Zip Code � Area code- Phone number S.WELL DETAILS: 11. REMARKS: a. TOTAL DEPTH: ta. DOES WELL REPLACE EXISTING WELL? YES❑ NOS( c. WATER LEVEL Below Top of Casing:_ 9'r FT 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH (Use*+'if Above Top of Casing) RECORD 2C.WELL BEEN PROVIDED CONSTRUCTION STAND OWNERDTHATACCCORD OPY OF TMS d. TOP p CASING IS�_FT.Above Lend Surface* Tim )� r IA& 'Top of casing terminated at/or below land surface may require � I f- /Y a variance in accordance with ISA NCAC 2C.0118. SIGNA I URRE OF CERTIFIED WELL CONTRACTOR DATE e. YIELD(gpm):A.METHOD OF TEST QLi/ 7'p /yam110 MIN I tv 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.N0.(919)733-7015 ext 568. Farm GW-ta Rev.7105 UIMER DWI NII'D _------ WLLL CONS'1'RUC'I'lON IU�.CORD Not Ur Carolina-Dcpalttucnt of Luvitmuncul gild Nfrt I"Itcsoufces-Division of Waler Qpolily-Uicuudwaicr Section �� Ge��c- ccnnFR:ATIunNv7 °.S \YELL COniMCFOR(INDIVIDUAL)NAaIE (plul) /yyj lleee rlloNE N 'r WELL CON I MCIOR CoNt PAN V NAME / ASSOCIATED\YQ rEM11TN STATE\YELL CONS IRUCIION rEMl1'IN I f p,rilcnblc if n �dicahlc 1. WELL USE(Check Applicnble llox): Residculial p3 1MmdclpnUPublic Ci Indualtial d Agilculluial❑ Monitoring❑ Recovery LI Ilenl Pump Witter Injecdou U Other Q If Older,List Use / / TopogrnphicJLmld selling 2. \NULL LOCH"TIONc - Coun Je•o/uety S"�'n ❑Ridge ❑Slope t]Vnllcy ❑Mal Ncolcsl'l owiv (check ppp upilme bon) CO'/e Laliludeilotlgilude of well lucalion (Sbtel Nnw Nmnba I.Cmnnuudly,Subdivlslar,WI Nu.,7.Ip Crnle) Q iiW Qsf GIl `Vc/ t c (delltedndnulec/recnnd Q 3. O\VNL'slt: 5ii4 eZet L4ti Latiluddlougilude s0urcc:C7OPS0T01)oglnphic lllap Address C"V—71'eb`—'t C�"�� (cb«k Mn) (Stteel er Route NO.) 13�11 111 aq LLINstLQSi nation Dcscripliuu City Of Town State Zip Code Ftoul To Cum Art.m1e.Thuile numbei 4. DA'I U DRILLED r_/sQS R3 /�� 3. I0FALDEVI-I1: /Xg 6. DOES WELL RI;I'LACI!UXISI'INO WELL') I lJ NO 7. STATIC WATER LL•VEL Uclow'fop of Cgsiug: (Use"F"If Above*full or Cnnlnp) B. TOT'OP CASING IS � FT.Above Lnnd Sultuce• -lop of aging lennlndrd pilot below lend surface requlrn a enlance In accordance with ISA NCAC 2C.0111. 9. YIELD (gpnl). /S' NIUlT1OD Otr'1"EST' — IU.WAI"ER ZONES(dcpol): !70 j,�CIONSKCIC)f �y'T ouut �a� Show direction and dislance in miles from al least 11. DISINFECTION:Type Aul _____—Wall I bickncss Iwo State Roads or County Roads.Include We road 12. CASING: Dcptll Dialucter of Wei hurl. Maeell uuulberN end couunon load names. Prom 07b !oS' 1:1. C- cS' r MY Flom To_R. 4 Ftom r,"rFI" to 13. GROUT': Depth io�lgria� edlod rn oil ru+ a e� From—To To rt. n V• p rronr 14. SCREEN: Depth Diwoeter Slot Size Matelinl o r_ rron, lu. rnn,1 fo rl, lu. J 15. SAND/GRAVI'si.PACK:Depth Size MislaidSEP 2 6 L 0J rronr 'I"tl Ft. From Fo rl. __--- 16. REMARKS: I DOIIUIiUUY CERfIFY1-1IATTIIIS WELL WAS CONS l'KUCI EDIN ACCORDANCE WITII I5A NCAC 2C.WELL CONSIIiUCTION STANDARDS,AND TIIAI'A COPY Or'f1IIS Ill'CORD IIAS UUUN PROVIDED TO1'lIL WELL OWNER RD SIGNAL URg ol'. I L•I(SON CONSI RUCTiNO T11C WELL DATE Submit (be of IglRal Ill 111e DIvIsInR Of 1Vnler Qunll(y,GCUUlldt7ater Secllou, 1636 AImil Service Ctilr'IILVgli,NC . ,,..,.,+.., ,,,r ...1tt.L. 111 .Im•t �t' a f (IIVNEH rl FIII'0 ------- -_-----._ Il O s r �' WLLL CONS'1'RUC'1'lON 1tl;CO1ZD Nolth Cniolina-Departlucut of Linvirouutcut and Nnl�u al ltesourccs-Divislml of Walcr quality GEITI IOAT ION undwater Rliul� WELL CON YIIACIOII(INDIVIDUAL)NAME 011111) / "��y ��tL� �L= WELL CONT IACIOtt COPIpANY NAME Y/e.- ruonE � (b'Zb'1 9�s � ASSOCIA'IED Will PEMII"Ia STATE WELL CONS tRUCIION rEM11Ta if n h dicnblc if n Jicnblc 1. WELL USE(Check Applicnl,le Box): Itesidculint Ellh1uuicipal/Public CI hldusllinl ❑ Agdcullwal U htonitoting U Recovery U ►lcal Pump Water Injection U Other U Irodier,List Use 2. W ELI.LOCATION- 'I'upogrnphit/Land selling 1 e�Ghee County �Jai�I []Judge ❑Slop Cl e Vnlley UFlat NcaicsL Tuwll: /t (check tpp,tgninre boo) a y Comic Latiluddlongiludeofwclllycslion (abet—IN�n�h4 Nmn1•<u.Community.Subdi,him4 Lot No..Zip Cule) N�,,,1,���°'6..W�jTf'(s— ��. y��• 1 °) ` Tn'6.-� C°q)7` (drarteelndnu,elltecnndQ ). OWNER: �e y Latitudellougilude source:UGPSUTopogiaphic nlap Address (check box) (Spent Or Roule No.) 11L►'�1'll Lai Lum LM, Zip Cale From To pots alion Dcscliptiou City or TOwn Stale Airs ta1)e-rbone number f �'"H✓b 4. D/vI DR ILLIiD fe 5. -to rALDEI.1.1I: AOZ• G. DOGS 1VELL RLPLACL EXISTING WELL? YES I 1401L3' 7. STATIC WAKI"GR LEVEL Belo U'e0�`UIf A10ve9'I: afCmbnp) 8. TOP OF CASINO IS �LZ I"1'.Above Laud Sul face* •Tap of tninr tnndnartd sUor btlotr Ia11.1 tuners requites a rnlsnce In accordance with ISA NCAC 1C.01Ip. 9. YIELD(gpnl): > METHOD OF TEST— III.WATER ZONES(dept l): l`/� �1. ) A1IQC1�`t1S�LG11 /1/r _ Auwtud c Show direction and distance lit miles from at Icast 11. DISINFGCfIUN:'rype Wall Thickness two State(Loads or County Roads. include the road 12. CASING: numbers and collutloll road mm�cs. Ucpth Dianeter �yOf WeighUFt. Mec Flora( li l l2_-To pL E,zs y Flom ro FL Front To FL McWod� cry 1nle lal m U. GILOUr: Depth Front O To _Ft. c� t♦°"d -.3— �— Flom 3 To 1:1• r 14. SCREEN: Depdr Diameter Slot Size o lrL Malcrial _ ul rlont lb Fl. rmUL FI. In, in. - .. 15. SANDIGIIAVELPACKt Size hlnlnlnl Depth SEP 2 6 2(i0� From To Ft. . From To FL 16. REMAIUKS: I DO 11EItEDY CERNFY 77tATTIIIS WELL WAS CONSIIIUCIED IN ACCORDANCE WITII 15ANCAC 2C.WEL►• CONS IItUC17ON SIANDAIWS,AND T11A1'A COPY Or'11IS Ill CORD IIAS ELGN PROVIDGDTOT 1 WELL OWNER CONS yip — DATL SIGNA7 UIW OF 1'L'IISUN CONS71tUCI1NG 771L WELL Sulnnll th e orlginnl to (he Dlvlslml of 1Valer Qunilly,Groundlraler Secllml,1436 pLll Service C(Wrl REVgU 2UU1 11 . mtn1711lilt "Illtln '111dnPe. y Pfll'D __ v' U IVN H2 ---- li WELL COmlg,nP1lC'l10N RECORD Nol01 Cal 01ilia-Dcpal Intent of Env irmu lent and Nat���� u�s-Divisiml of Wolcr_luality-Groundwater Section a 1,, eCGC CEI11IFICA1 IIONQM7' WELL Corl MCI-oil(INo1VIDUAL)NAME (pillar; _� _P11pNE 0 19'�1_. 1T�Zy�� w'EI.L CON mCjotk coasrAMY NAbIE /�'`��/� ASSOCIA'I'EIl JVQ PERMIIN STATE WELL CONS FRIIMM PEM11T11 1 f p t dictiblc if np licnblc I. WELL USE(Check Applicable Ilox): Resitleldinl l Mumlcipal/Public ❑ hldusltial ❑ Agricultural tj Mouiloling❑ Recovery ❑ Heat Pump Water Imjeclion U 0111cr❑ ifolher,List Use 2. IN ELL LOCH"\'IO�Nt [ Topographic/Lnnd setting Ncatcsl'Fown: Cfte%°ryze' County S./4 !/ ❑ ❑V RIdge LISIOpe alley UFlat �GOL' (check epphlgnlele boe) ��i—. LatituJdlungilude Orwell location', (Sueel Ne lie,Numbar,Cununmhily,SuLJivlelal,Lot Nu.,7.1//p twists) ��C4Thse0, ?D TiN� ��r ' (deQleedntlnine✓recnndh) ), OWNER: Laliludellmtgiludesource:❑CPS❑fupoglnphicurap Address _.----- (check box) (slmet of It.-le Nn.) )&M M11-1111ALLOU zi Cwle hrenl To PorumtionDcsctiptioti City Of lbws StateP (---) Ara Bede-Phone number 4. DATE DRILLED y- 5. To rAL DEI''I'I I: 6. DOES YVFLL Rlil'LACI!EXISI'INO WELL? YES ❑ NO 0- 7. STATIC WATER LEVEL Delow TOP of Cnsiug:�—Er. (use'•J•"If Above"I bp of Casing) S. TOI' 01:CASINO IS Z V l% Above LnOd Silllitcc• •Top of rising toudrOded eVnr below lend Bullies rsqul,rs e ♦mince In ar,Odellte with 13A NCAC IC.011a. �r - 9. YIDI.D (gpnt): _A4 71000FTEST to.WATER ZONES(depth): Ig-L ` ] OCAjION SKC7 A Show direction slid distance in miles ftomt sl least it. DISINFECTION:Type_Z7� Wnll'IbicknessAnwuut �ly��G Iwo State Roads or County Roads. Include Die road 12. CASING: g numbers gild collunon goad names. Depth Diameter or Weei hUFI. Malellal From To E3 F1. *�R�- l / S h?( Cn rT1 Front To From 'TO FI. A13. 0ROU F: Depth In c}tar McWod c.n p I o—�`--Ft. D/T7s�d e d o <z Froth �, From 6 Te _rI. ���,�fxr,te lit r' 14. SCREEN: Deptli Diameter Slot Size Material yi Front To Ft. in. im. In. Front 'Ib__Fl, In. 15. SAND/GRAYFL PACK: Depth Size Mnletlal Front To—FL -- --- S_' 2 6 LJOJ Front i.uFL 16. REMARKS: 1 DO IIEItEUY CERTIPYTIIATTIIIS WELL WAS CONSTRt1CN?D IN ACCORDANCE WITH ISANCAC 2C,WELL CoNsTILUCI ION STANDAIWS,ANDI IAT A COPY OF'r111S IIECORD IIAS BEEN PROVIDED TO �WELL OWNER SIONA ME 01:I'EItSON CONS'IAUCINO 111E WELL Subndt(lie of lghtal to the Division of\Valer Quall(y,Groundwater SeclloR,1636 Atoll Service Ca`yr'IILVth,C ,,.. . . ., ..h.. .,. rr.. m1m 111 Jill ..ithhl 111 do Y7.