Ya CY2005

WELL CONSTRUCTION RECORD 00 306895
North Carolina- Department of Environment and Natural Resources-Division of water Quality-Groundwater Section
N'ELL CONTRACTOR ONDIVIDUAL)NAME (print)--ii �QS�-f �y CERTIFICATION#��
IF ELL CONTRACTOR COMPANY NAME .�s%�Y. IBC(,l �PHONE #
STATE ht
WELL CONSTRUCTION PERMIT# aSSOCIATED%VQ PERI
(i f applicable I (if applicable)
1. WELL USE(Check Applicable Box): Residential unicipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection O Other❑ 1rOther,List Use
2. WELL LOCATION:
Nearest Town:, Z21!C4 L/1 "(4(r County �ib„at�_'.v Topographic/Land��•n8
Il�� W-AEf<�y�a W��S• _r_ �i ORidge OSlope @Valley Flat
(check apPmpriatc box)
(Strccl Name..Nuumibem Community,Subdivision,Lot No.,Zip Code) Latitudellongitude of well location
3. OWNER_ \6�3�i.. ��G (degreesfminutesrsecoads)
Address i` ttp v yxt;R RlizixgQsCwL Latitude/longitude source:OGPSOTopogmphic map
(Street or Rome No-) (check boa)
—ex;l2W—.A &l DEPTH DRILLING LOG
c ny or Torn Sate Zip Code From To Formation Description
Z5 Cu Cy— tl'Z�i p
Area code-Phone number �— -•_ `�
d. DATE DRILLED �' S'^' f)S r/Z / K.f
5. TOTAL DEPTH: /b.S
6. DOES WELL REPLACE EXISTING WELL? YES O NO W
7. STATIC WATER LEVEL Below Top of Casing: YO _FT.
(Use"+^if Above Top of Casing) — s
8. TOP OF CASING IS FT.Above Land Surface" z
*Top of casing terminated aVor below land surface requires a
N ip
variance in accordance with 15A NCAC 2C.011&
9. YIELD(gpm): /?— METHOD OF TEST A/ f O r
10. WATER ZONES(depth):
LOCATION SKETCH
11. DISINFECTION:Type O rfW Amount PC)Z, Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depot Diameter or WeighUFt. Material numbers and common road name.
From To Ft.
Fromm—TO Ft- ���
From_To_L _Ft. 1--Lc U p '^
13. GROUT: Depth Material Method /•31
From To Ft. (S
From t To Ft � c. i� ! Gw/A¢ff t) `o0l'P6�l ��
14. SCREEN:: P�Depth Diameter Sloi Siu Material
From To Ft. in. in.
From—To—FL—in. in.
I5. SAND/GR.AVELPACK: A(_?1„�j.)�
Depth Sim Material rE.Q
From To FL I r
From To Ft-
16, REMARKS: fF1 �Ow
1 DO HEREBY CERTIFY THAT T S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C.WELL
CONSTRUCTION STANDARD , D THAT A PY OFT IS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1
kJ7r--'<—
SIGNAT@REO ERSONCONSTRUCTINGTHEWELL DATE -
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh;NC
27699-16,16 Phone No.[phone],within 30 days. GW-1 REV.07/2001
y h r, - E 2005

- -- . .... - - --
� 11235
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural o.-^••--- of Water Quality-Groundwater Section
WELLCONTRACTOR(INDIVIDUAL)NAME (prloe) (;I i_L1(5 ~ AS •` CERTIFICATION a a—/I I
WELLCONTRACTOR COMPANY NAME REUBEN CALDWELL DRILLING, INC. PIIONEY-t8 �54-3581
STATE WELL CONSTRUCTION PERMtTe 1 537 ASSOCIATED WQ PERM ITa
ife licable) (ifa licable
1. WELL USE(Check Applicable Box): Residential Municipal/Public❑ Industrial ❑ Agricultural ❑
Monitoring❑ Recovery ❑ Ileat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCAT1, N: Topographic/Land setting
Nearest Town: C)U �S� I I- -e/' County A N ❑Ridge ❑Slope ❑Valley ❑Flat
11< n
S GI.K(;IL- /-0 AP (check appropriue box)
(Sveet Name,Numbers,Conwnwity,S/u�bdivision.W No.,Zip Code) LatitudcAongitude of well location
3. OWNER: ` hips IY la: ')(--s 1-4 (dcyw/minuus/wcmde)
Address '� D Cl O, Latitudeflongitude source:❑GHOTopographic map
(L (Sweet a Rowe No.) (check box)
V.9)Un)$U I t_-h' AT C., a-91 DP.PTH DRILLING LOG
CitywTo n Sum Code Fro T / Fo tion Desert do
941) 8� — b 301 ,p f - �q .ln6 6L U
Atv coda Phone number '`.3' 'iit ' -VIE
4. DATE DRILLED 0 5 3 C� Lei - r^
5. TOTAL DEPTH: 3 3 10 s 3 D r C,aAtj t
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [$ C
7. STATIC WATER LEVEL Below Top of Casing:%—FT.
(Use-r-if Above Top of Cuing) _
8. TOP OF CASING IS I FT.Above Land Surface* � ,•,
•Top of cuing tocmlaated at/or below]mod surface requires a _ ,y
varlance In accurdmlth ISA NCAC IC.011g.a w pp
9. YIELD(gpm): METHOD OF TEST
10. WATER ZONES(depth): '3 o Cam— O
LOCATIONSKFTCH
11. DISINFECTION:Type (4 0 o Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the roa
De th t [� ��jjyy��ff���t�o or Wei YR. a a1 numbers and commi n road names.
From To yT FI. O`/K C k
From To FL V.1l�5cra S
From To Ft. �� C e r1`-(A+'e-�
13. GROUT: Depth Material Method
From�To 0-0 Ft. 0F3 "P1' Qou"o J (L W t,-S0r( r..p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material f , s yti
From To Ft. in. in.
From To Ft. in. in. +
15. SAND/GRAVEL PACK: `SAC K- S
Depth Sim Malcrial "tSk314-
From To Ft.
From To _ Ft.
w (°(
16. REMARKS: r
I DO HEREBY CERTIFYTIIAT TIiIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I SA NCAC 2C WE-LL
CONSTRUCTION STANDARDS,AND THAT 4,qOPY OF THIS REC IIAS BEEN PROVIDED TO THE V14LOWNER j
SIGNATURE OF PERSON CONSTRU NG TIIE WELL D TLr -I ! -
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mall Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 RLV.07/2001

ilua `)
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N■ntanl D.•^••—_. 'f Water Quality-Groundwater Smtioon,
WELL CONTRACTOR(INDIVIDUAL)NAME (prlw) ••/ � t^�1� rJAS4 CERTIFICATIONS -I
WELL WELL CONTRACTOR COMPANY NAME REUHEN CALDWELL DRILLING, INC. P110NE4 8 �54-3581
STATE WELL CONSTRUCTION PERMITS 1537 A -OCiATED WQ PERMIT/ r-- - - ----.�:
Ira linable ifa liable t-_-
1. WELL USE(Check Applicable Dox): Residential 63 MunicipaVPublic ❑ Industrial ❑ Agncult4ki !
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCATION: TopographicAmd Sdtfin�
Nearest To �V�IV$y I LL County "Ce ❑Ridge ❑Slope ❑Vail, ZI
A r i(.S (rbaek appeopnere bo=y- Flat
, �-- —'
(Street None,Numbers,Canmtmity,Subdivision,let No.,Zip Code) I-atitude/Iongitude Orwell�loc_atl'on
3. OWNER• C C ti rJ-r-0 S
Address a. Isl CI O� LatitudcAongitudesotuce:❑GPS❑�. opogmphi�p_ -? a
(Street or R a No.) T (check box)
aVP-f�S*k-'LSN ►.1 fokgII PPPLH DRILLING
try or Town tale Zip Code Frp To FomutiorklDescri it
Area Bodo-Phone number aDT r,y V-T 6
4. DATE DRILLED 4 aS 0 , C e� ( , ien
5. TOTAL DEPTH: [ S�_ 5 o r [7 C ;py
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 'L C FT. cs
-c
(Use"+"if Above Top of Cuing) � rs
8. TOP OF CASING IS FT. Above Land Surface.
'Top of cuing terraluted at/or below lad urface requires a
Varian"In acwrdsel wllb ISA NCAC 2C.011 a. pLa
9. YIELD(gpm): 1 METHOD OF TEST PJG O 1�1`
10.WATER ZONES(depth): $ 5 y " 1 u F'Y''� Ln
LOCATION SKFTCH
11. DISINFECTION:Type L D Amount E Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.include the road
Dept Di ter or Wei VFL Tyke,�j+� numbers and common road names.
From To y Ft. $fl l y"-' !
(�
From To FI. I)AV S JS
From To Ft. J ! Loa yDS
13. GROUT- Depth Material Meth f'
From I To aD Ft. C�rrl(3N-1' PaJP°b PAP
From To Ft.14. SCREEN: Depth Dismctcr Slot Sire Material
From To Ft. in. in. t
From To Ft. in. in. tti'tc S
15. SAND/GRAVEL PACK:
Depth Sim Material C/LV kSJ i!,
From To FL
From To Ft.
16. REMARKS: u'NlciI
1 DO HEREBY CERTIFY THATTIIIS WELL WAS CONSTRUCTED 2N ACCORDANCE WTfli ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND TIIATA PY OFTHIS 7GRD IIAS BEEN PROVIDED TO THE 1Wrl—pWNER
4116
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE I 5
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mill Service Center-Raleigh,NC
2769 9-1 63 6 Phone No.[phone],within 30 days. GW-1 REV.07/2001

� 11 � t� 7
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Natural Resources- ivision of Water Quality-Groundwater Sectiioon{C��
\YELL CONTRACTOR(INDIVIDUAL)NAME (print)_gQkJ.`I ��� `56/l� CERTIFICATION`# y )
WELL CON'I RACIOR COMPANY NAME P3 '7ched l 001 kKr �l�i�� PHONE # (r ) 7K�/Z�- T/If
STATE WELL CONSTRUCTION PERM[TO ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box): Residential LPl Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other, List Use
2. WELL LOCATION: tt � � Topo_gra Ic/Land setting
Nearest Town: 3�AaJSy. I .( County C�/_ ❑Ridge Wlope ❑Valley ❑Flat
&9d-1.r 15.LC fC tr Rr Cqe' 77A I� (check appropriate box)
(Street Name.Numbers,C mmunity,Subdivi on,Lot No.,Zip Code) Latitude/longitude of well location
3. OWNER: 7kzXXL Rev, (degrees/minutes/seconds)
Address f)(e3� 5. Latitude/longitude souace:❑GPS❑Topographic map
(Street or Route No.) (check box)
Mi«Qrtir YI, DEPTH DRILLING LOG
City or Town State zip Code From To Formation Description
525)-(ca57—C)G20 D - 10dZk
Area code-Phone number
4. DATEDRILLED 5 ID"�5� Jq G:
5. TOTAL DEPTH:_ D. ,_,/
6. DOES WELL REPLACE EX TING WELL? YES ❑ NOrI� ^� «-'•.t
7. STATIC WATER LEVEL Below Top of Casing: i0c>' FT. C
(Use"+"if Above Top of Casing) a
8. TOP OF CASING IS FT.Above Land Surface*
*Top or casing terminated at/or below land surface requires a N
variance in accordance with ISA NCAC 2C.0118.
9. YIELD (gpm): D, METHOD OF TESTA i.Z
10. WATERZONES(depth): lt.a�01 A O
LOCATION SKETCH
11. DISINFECTION: Type c ,'a-C.-._ Amount m7 Show direction and distance in miles from at leas
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names. -- —
From 0 ToLFt. sch RUC.. _ --
From To Ft.
From To Ft.
13. GROUT: Depth Material— Method.
From d To 'a ..e.�s+c Ft. cn -
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 FL
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION ST INDARDS D THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
s t 5- / 10 -- d-,57—
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV. 07/2001

31141- 3
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) I r '4 h 11, CERTIFICATION#a--,&. /p
WELL CONTRACTOR COMPANY NAME IC,C."SQA; WEll IN�ill�na PHONE OP41 Ie V3 -9T/r/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 1;V Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use'
2. WELL LOCATION: Topographic/Land etting
Nearest Town:73 �wMv./�i. County ya a ❑Ridge ❑Slope t]�alley ❑Flat
eon. 6r"CA (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) L�a�ti��de/Ig9t] irude of well I catiyn
- S� S6a• OB�Z/ V)
3. OWNER: 6 (degrees/mmnutes/secc nds)
Address O. er 5G Latitude/longitude source:❑GPS❑Topographic map
a7 (S [or Route No) (check box)
,!-.I All �9y��' DEPTH DRILLING LOG
Ciry or Town soul Zip Code From To Formation Deserip[10 _
j&?a- b y�= a/53- r) a 5 UZI 4- G
Area code-Phone number - n/„ ,S'(y ry S�p/G(/
4. DATE DRILLED � — (a - C75 � � },�, 1
5. TOTAL DEPTH: q_5 , (a3 (L-q
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ra
7. STATIC WATER LEVEL Below Top of Casing:0O FT.
(Use"+"if Above Top of Casing) 71
8. TOP OF CASING IS f FT.Above Land Surface* r
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118. n O
9. YIELD(gpm): _METHOD OF TEST
10.WATER ZONES(depth): SAD
LOCATION SKETCH
11. DISINFECTION:Type Amount 6z- Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads,or County Roads. Include the road -
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To Ft. L�Y 4AIR_V -P
From_(. La To �o Ft. (0'9 /fip 51'�el
From To Ft.
13. GROUT: Depth Material Method
FromTo 2t)_Ft. IbnCra6 pOu�¢�
From To Ft.
lA. 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. ,/� � /,_A [./rC�C/f
16. REMARKS: ti V41'�AZ A��
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
y7aIal � /- ( - c 'T-
SIGNATrJRE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

WELL CONSTRUCTION RECORD 311404
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �p
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i44, E' ,4llp h CERTIFICATION# q
WELL CONTRACTOR COMPANY NAME r 'I ; PHONEd -Qj Ia V.?-,95��/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential B"/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: -8 ,w b v.)to County 1)onLe y IBKtdge []Slope ❑Valley ❑Fla[
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of well 10gation
3. OWNER: C. SCaRLd L /dengT1 PI m-ion�uAtaes/se ciosna
Address Jy-rap� .7T
�3 uJ
Lafirude/longitude source:mFrPS❑Topographic map
(Sheet or Route No.) (check box)
ova { NC ds7yo DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
(�& G7.s• �1Go9 0
Area code-Phone number -
4. DATE DRILLED Z - C) _
5. TOTALDEPTH: .3b:K' (�-/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Qr�
7. STATIC WATER LEVEL Below To of Casing: d FT.
P e �—
(Use"+•'if Above Top of Casing)
8. TOP OF CASING IS I FT.Above Land Surface' _3
°Top of casing terminated at/or below land surface requires a W
variance in accordance with ISA NCAC 2C.01 IS.
9. YIELD(gpm): & METHOD OE TEST f�i9 Ul Q
10.WATER ZONES(depth): a b'5 -�
LOCATION SKETCH
11. DISINFECTION:Typ Amount /S OZ. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road_
Depth Diareter or Wetght/Ft. Material numbers and common road names.
From 0 To S"0 Ft. & -P _ ,Spkll VL
From To Ft. '
From To Ft. -
13. GROUT: Depth Material -
From---6 To (Z Ft. Lr nc ro 6 p A
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. - -
15. SAND/GRAVEL PACK: --
Depth Size Material -
From To Ft.—
From—To—FL �•�` /�d -
16. REMARKS: esn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I-,2f-()
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

311395
WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) A r /4I t,to CERTIFICATION k /p
WELL CONTRACTOR COMPANY NAME We'll hr"111 e. PHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE(Check Applicable Box):Residential �/ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water In)ection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town�ZVKV U County 1-P V midge ❑Slope ❑Valley ❑Flat
5664 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latt de/loppgitude of well I��CaIt
3. OWNER:
I . 3 ZYhS'A/-Bf4�1la u/
I fJ UOC6 id gree�eco ds)'
Address -e *S O ArT/et;gi.m ;F ( LadtudMongitude source:BeP90Topographic map
(Street or Route No.) (check box)
/�Uewse"//e Nlt dl P71 DEPTH DRILLING LOG
City or Town State Zip Code From To Fonnation escrjp ion
�- R�♦ 870 9 3d �J
Area code-Phone number r7
4. DATE DRILLED - sl
5. TOTAL DEPTH: ;Gar
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO U' 0
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use"+"if Above Tap of Casing)
8. TOP OF CASING IS FT.Above Land Surface* .x
*Top of casing terminated at/or below land surface requires a _
variance in accordance with 15A NCAC 2C.0118. "s
9. YIELD(gpm): a6 METHOD OF TEST'y
10.WATER ZONES(depth): aL�
LOCATION SKETCH
11. DISINFECTION:Type f/ 7-f/ Amount 67. Show direction and distance in miles from at least'
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth is eter or Weight/Ft. Material numbers and common road names.
From To SOS' Ft. 6-W-2i PjC
From To Ft
From To Ft
13. GROUT: Depth Material Method - -
From_To al)_Ft. fonif ra �e
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. - -
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.0712001

WELL CONSTRUCTION RECORD
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) '4a r �- hY i yl)k CERTIFICATION it,
WELL CONTRACTOR COMPANY NAME Ft tr."So a1 J./ell -hrilj,j PHONE(VP-0 /o V3—/n
SPATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) ��// (ifapplicable)
1. WELL USE(Check Applicable Box):Residential p� Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town:Zia"w '> County ilAE� ❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latirude/lo gitude of we locatig n
s/.sy�5>1 o8a��� /S eCw
3. OWNER: f "3 - (degrees/minuteatseconds)
Address - o Latitude/longitude source:❑GPS❑Topographic map
(Sn r or Route No.) ,/ (check box)
��7�3' DEPTH DRILLING LOG
City or Town Suite Zip Code From To Formation Description
&�- to'9-=-
.Area code-Phone number
4. DATE DRILLED
6� Zl
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO a- ij
7. STATIC WATER LEVEL Below Top of Casing: FT. ZI
(Use'•+"if Above Top of Casing) t
8. TOP OF CASING IS=Z FT.Above Land Surface*
c 5
"Top of casing terminated aUor below land surface requires a
variance is accordan with/SANCAC2C.011#. 61
9. YIELD(gpm): _METHOD OF TEST R,
10.WATER ZONES(depth): /fin O
LOCATION SKETCH
11. DISINFECTION:Type H 7 fL_ Amount 6Z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From_0 To '71 Ft. &r I (7t/C� _
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From_Q_To a!) Ft. 62aCro 6 Pnug�
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. ; /�/�, Are
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S�% e Z4-_ �2 y> o
SIGNATURE OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

311392
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i4(tr P /'C/ 1tn ✓\ CERTIFICATION#32-6
,/ /q
WELL CONTRACTOR COMPANY NAME C' Sa j) tA/ II Tc­ill.na PHONE Gt$'!j Ie 1r3—S�Tr/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential Municipal/Public ❑ Industrial ElAgricultural [IMonitoring ❑ Recovery ❑ Heat Pump Water njection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town:$u.cn11s''v�lif. 1' Counry GV ❑Ridge ❑Slope ❑Valley ❑Flat
( IS CY`Li ,w (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) La[1 de/1 ❑gitude of w 11 location
P a �a G t✓
3. OWNER: 'e& degrees/minutes/.,econ s)
Address /�4 s�10.24 Latitude/longitude source:❑GPS❑Topographic map
// L (Street or Route No.) (check box)
�Ar7n//'ke fni fr 4 S FL liga1 y�� DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
( -4 9.4-- y'q 5/9 o ao Clars
Area code-Phone number
4. DATE DRILLED .3 — 2V ' OtS
5. TOTAL DEPTH: V015
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO B--
7. STATIC WATER LEVEL Below Top of Casing:AFT. t
(Use"+"if Above Top of Casing)
S. TOP OF CASING IS FT.Above Land Surface* w
*Top of casing terminated at/or below land surface requires a
r
variance in accordance with 1>A NCAC 2C.0118.
9. YIELD(gpm):5_METHOD OF TEST
10.WATER ZONES(depth): .3G
LOCATION SKETCH
11. DISINFECTION:Type H 7 fL Amount (o Oz. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Rcads.,Include the road'j
Depth Diameter or Weight/Ft. Material numbers and common road names. -
From 0 To ya FL G %v snRal f VC, -
From To Ft --
From To Ft. -
13. GROUT: Depth Material Method
From__Q_To at) Ft. 1bnCro �e P6LXCJ
From To Ft. -
14. SCREEN: Depth Diameter Slot Size Material - -
From To Ft. in. in.
From To Ft, in. in. - -
l5. SAND/GRAVEL PACK: _.._,-... .....,.
Depth Size Material -- -- - -- -- -
From To FL
From To Ft.
16. REMARKS:
Co/�cfr aecd; A(f
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days, GW-I REV.07/2001

01 3 , 13
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (print)--A, f-t 11, CERTIFICATION
WELL CONTRACTOR COMPANY NAME f r+"S ) ide' I T)rill�na PHONE{i V) Io Y_3-S�S�r/
STATE WELL CONSTRUCTION PERMIT# �� ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. 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: graphic/Land setting
Nearest TownI&Cn'jV: e- County 4 tdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(.$beet Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitu e/lon itude Of Well locayfion
a is
3. OWNER: (degAes/mmutes/se ands)
Address ?/ ?5/ -2p 74 // �� e-A11 /7dLatitude/longitude source:❑GPS❑Topographic map
(SrAfet or Route No ./ (check box)
d 2i a� Nr a X/�Y DEPTH DRILLING LOG
City 010fown ssjate ep Code From To Formation Description
.Area code-Phone number
4. DATE DRILLED y
5. TOTAL DEPTH: &rjf)
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface*
•Top of casing terminated at/or below land surface requires a �.
variance in accordance with 15A NCAC 2C.01 la. —�
9. YIELD (gpm): t) METHOD OF TEST N7
10.WATER ZONES(depth):
LOCATION SKETCH O =
11. DISINFECTION:Type H 71-1 Amount Oz. Show direction and distance in miles from Aeast A
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 //ti Ft.fn 'y t P.�/ -
From To Ft. -
From To Ft. - -
13. GROUT: Depth Material Method - -
From�To a0 Ft. &nGro k? pQure.� r
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in. - - -
From To FL in. in. -- -
_ 15. SAND/GRAVEL PACK: _ .
Depth Size Material -From-To-Ft.-
From-To-Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTIOQI,STANDS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
IrKl
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

z1i �' �
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section —,
WELL CONTRACTOR(INDIVIDUAL)NAME (print) i , E- /L'��+ ✓b CERTIFICATION# Y-/(p�9�
/q
WELL CONTRACTOR COMPANY NAME s ,J We.11 TrillCna PHONEW41 493-9Tr/
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: / 1� _ Topographic/Land setting
NeareLTown: 13WrtS V1�(e County /F1(1 ❑Ridge ❑Slope ❑Valley ❑Flat
r'{'n� - (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latirudg/l rlgitude of w 11 loeatioty
r / / �DY/07t4- QA� atr�a'+1u�
3. OWNER: Gf U(-. ,[ Fiid///a'.r/ (degrees/minutes4wonds
Address Latitude/longitude source:❑GPS❑Topographic trap
v (Street or Roure No.) / (check box)
`JQui, I o,,,//� . W� 'C�8?/;/ DEPTH DRILLING LOG
City or Town Suite Zip Code From To Formation Description
(g�- G RR - 9/// b /S Shwl�
Area code-Phone number
4. DATE DRILLED 3 Q ks-
5. TOTAL DEPTH: 3 r_l
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EE:�
7. STATIC WATER LEVEL Below Top of Casing: FT. 3 ry
(Use"+"if Above Top of Casing) ?
S. TOP OF CASING IS_�FT.Above Land Surface+ e
i
*Top of casing terminated at/or below land surface requires a W
variance in accordance with 15A NCAC 2C.0118.
9. YIELD(,-pm):�_METHOD OF TEST R+T r0 P
10.WATER ZONES(depth): 2'm
LOCATION SKETCH
11. DISINFECTION:Type f/ 7f/ Amount 6Z. Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth _ Diameter or Weight/Ft. Material numbers and common road names.
From To S/ FL.�i s d
From To Ft. ' _
From To Ft.
13. GROUT: Depth MaterialMethod
Fromm To 26_Ft. 6p oc ra �-e Q Lk
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 F[. 40
16. REMARKS: •�-t�� /�C-.:
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
�Iya/ &,Z-- 3230/05
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-I REV.07/2001

WELL CONSTRUCTION RECORD
311387
Noah Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section �--����pp��
WELL CONTRACTOR(INDIVIDUAL)NAME (print) , � t h CERTIFICATION#,
WELL CONTRACTOR COMPANY NAME WeAl ZIr II:.-•n PHONE FtA Io�Y3—�5��/
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential 0i Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other,List Use
2. WELL LOCATION: ii Topographic/Land setting
Nearest Town: IZwmy'1Ie County _ W4r3ge ❑Slope ❑Valley ❑Flat
(check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/10]glmde Of ell location
s�lf�td.p LaAI r
3. OWNER: T ( egrees/minuuNsecon s)
Address '� .pvf2 (/n:eo (Jjrrtn � Latitude/longitude source:❑GPS❑Topographic map
( nter or Route No.) (check box) _
�1/C DEPTH DRILLINGLOG
City State Zip Code From To Formation Description
( - /e 7/_ - xw O 70
Area code-Phone number 71 AO
4. DATE DRILLED/sf os Jr., /OB
S. TOTALDEPTH: t�" /Qb
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (ate
7. STATIC WATER LEVEL Below Top of Casing: FT. —e
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS FT.Above Land Surface* "G
*Top of casing terminated attar below land surface requires a CJ s.
variance in accordance with ISA NCAC 2C,M IS. �i
9. YIELD(,-pm):11_METHOD OF TEST_
10.WATER ZONES(depth): /SO
LOCATION SKETCH
11. DISINFECTION:Type f/ 7 fL Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth - Diameter or Weight/Ft. Material numbers and common road names.
From_. 0 To //.SFL A SDY J 1 pY! -
From To - Ft. -
From To FL
13. GROUT: Depth Material M
From_ To a 1) FL ('0nG ro �-e p
From To Fr. -
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 FLy_74,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION STANDARDS,z AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
- - z5�
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section, 1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

3154u5
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and N3 tral Resources- 'vision of Water Quality-Groundwater Section
%�p��
WELL CONTRACTOR UIiDiVIDUAL)N (pAct C8R'r1FICATION t+�.G.(17
WELL CONTRACTOR COMPANY NAME / O� PHONE K�{l )
STATE WELL CONSTRUCTION PERMTfKA/, ASSOCIATED WQ PERMM
Of applicable) ofaeolicable)
I. WELL USE(Check Applicable Box):Residential IR MunicipaltPublic O Industrial O Agricultural❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 13 Other O If Other,List Use
2. WELL LOCA71 :
Nearest Town � Y� Topographic/Land setting
CRidge Mlope [Valley 0171at
(Street Name.Numbczk Conpmpmy,Svlidinis oq Lot No.,tip Code (cbwkopnse Latin�e/longi ai pwo of ebbelolt location
3. OWNER: �%�^'�Li�liG� JtYoysf (de�ae/mtmt�+tx�mds}
Address a Latitudellongitude sotuoe:OGPSElTopographic map
.) (ehedtboa)
L° 7/ DEPTH MU ING LOG
City ar Towo Stye Zip Code From
To Formation Description
Atee code-Mani:comber
4. DATE DRILLED. 211O,
5. TOTAL DEPTH: ',2.2.5
6. DOES WELL REPLACE EXISTING WELL? YES O NO C5
7. STATIC WATER LEVEL Below Top of Casing-_Z4_FT.
, ` (Um"+'if Above Top of Casio _
8. TOP OF CASING IS Ge+1'Ff.Above Land Surface• h
'Top of Basta;termLated JWw below lead surface requim a C
vwimm to aaa wltb 1SA NCAC 2C All&
9. YIELD(Spin): METHOD OF TEST r_
10.WATER ZONES(depth):
LOCATION SKETCH iJt
11. DISINFECTION:Type Amount Show direction and distance in miles from at leas
12. CASING: Wall Thickness two State Roads or County Roads.Include the r'oed
From__T��D FL L «#1/ L numbers and common road names,
From—To Ft
From_To FL
T3. GROUT: L j�fiblethod
From 4_To FL
From To FL
14. SCREEN: Depth Diameter Slat Size Material O
Fro a
Fty_in. in.
Fro To FL in. in
15. S /GRAVEL PACK:
Depth Size Material
From To Ft.
Fro o Ft. `
16. REMARKS; y
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,WELL
CONSTRUCTION ST AND T PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNA F P NSTRUCTTNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Man Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001 —

A w r r
WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natoo I Resources-/jJ�xion o[f Water Qu/alliity-Groundwater Sectiioyn7 WELL CONTRACTOR(INDWIDUAL)NAME (print) t��I i L- f� !t +(/F". /� CERTMCcA'110N#22(' /
WELL CONTRACTOR COMPANY NAME�ll F'e �f" L'�F' '� {�vJ9/'7`�PRONE # Co
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMtt#
(if applicable) (if applicable)
1. WELL USE(Check Applicable Box):Residential®-�`Municipal/Public❑ Industrial❑ Agricultural❑
Monitoring❑ Recovery ❑ Heat Pump Water Injection❑ Other❑ If Other,List Use
2. WELL LOCA N:
Nearest Town, / . County �CPt Topo cJLand setting
Z rviSSt 1'.12 %n f�c/ ) 7// ❑Ridge lope ❑Valley ❑Flat
(check Wroptiate boot)
(S are,Numbed,Cmummity,Subdivision,tot No.,Zip Code) Latitnde/►ongitude of well location
3. OWNER: /S/i�/ /C /y S
Address r7' Latitude/longitude sotuce:❑GPS❑Topographic map
tree[or Route No.) c (cbwk box)
dy/;V.l Y,r 6(/ Z O 711 DEPTH DRILLING T-Fx
City or Town state zip code From To Formation Description
L�-
Atm code Phone otunber
4. DATE DRILLED ? _/ ` .U S
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
7. STATIC WATER LEVEL Below Top of Casing:- �Fj', j
(Use"+^if Above Top of Casing)
8. TOP OF CASING IS /�FT.Above Land Surface`
'Top of caatng terminated at/or below land surface requiro a C-3
variance in actordame with 15A NCAC 2C.0113.
9. YIELD(gpm): l S=METHOD OF TEST /i /?�f1 c
10.WATER ZONES(depth):
I�OCATI_ O__N SI�CII cft
11. DISINFECTION:Type C C Amount /U v'Z Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.include the road 's
FromDept t/Ft numbers and common road names.
To_JL_Ft 1
From To Ft
From To Ft
13. GROUT: Depth Material M
othod
From To�Ft e- C & C C r" fry1 5( h 1 i
From To Ft vY
14. SCREEN: Depth D teeter Slot Size Material -
From To Ft in. in.
From To Ft in. in.
15. SAND/ SACK: Size Material l� ►.!
From To Ft
From To Ft.
I6. REMARKS:
I DO HEREBX CERTIFY THAT THIffAC7SOCP(Y
A N UCTED IN ACCORDANCE WITH l5A NCAC 2C,WELL
CONS ON STANDARDS, F THIS RECO HAS BEEN PROVIDED TO THE WELL OWNER
-�5
SIGNATURE OF PERSON COWRUCIlNG THE WELL DATE
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 bays. GW-1 REV.07/2001

OA - ay A
`jnrm. r:arolina Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
'S.te Man Servlce Center. Ralelgh.N.C. 27699-1636-Phone[phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: /76A'Wd DA.a< %.vy'
WELL CONTRACTOR CERTIFICATION # : Y5b4
STATE WELL CONSTRUCTION PERMIT# :
WF I L USE (Check Applicable Box): Residential Municipal ID Industrial❑ Agricultural ❑ Monitohnc(_!
Recovery ❑ Heat Pump Water Injectio ❑ Other❑ If Other, List Use.
Nl- I 1 OCATION (Show sketch of the location below) 1
Nearest town. I?yAo1l5ei,A.i Count, y.4n/C,x
�4�ao L)()U 6.4 a 1L/414cl5 Rd
c'-,'Name and Numbers Community, or Subdivision and Lot No DRILLING LOG DEPTH
'�VVNER &WAA' d From To Formation Desrnruo"
DA
(Street or k<OUte NO.
9VA'Virc% Lt NC.. ,? >iii'
Town State Zip Code
I)PTF I)RII.1
-a, UFPTH /:26
T"NGS COLLECTED YES Q NO®
DOFS WELL REPLACE EXISTING WELL? YES 0 NO[]
STAT!C WATER LEVEL Below Top of Casing. $� FT .
(Use"+"if above Top of Casing)
TOR OF CASING IS 13w-" FT. Above Land Surface'
%r -" .asigg terminated at/or below land surface requires a variance in accor-
dance with $A NCAC 2C 0118
vF!1it (GPM)_ �:Z* METHOD OF TEST .OhlLSh
WATFP 70NES (depth) ' L
(�P!NATION: TVpe ��r/-! Amount _ If additional space is needed use back of form
- .o�IN Wall Thickness
flenfh Diameter or Weight/Ft Material
To 4s Ft G .27, G PA45%!2' LOCATION SKETCH
,n r To R (Showdirechon and distance from at least twc S'stc
P
Roads, or other ma reference points)
t ,nrr To ct
1C/3T7 5
Depth Material Method �
' - To Ft I ='
^ To FI
rU
.^ SCREEN.
Depth Diameter Slot Size Material
to Ft in in
To Ft in. in.
- _ To Ft in in
1F. SAND/GRAVEL PACK'
Depth Size Material
a To Ft
To Ft
FM�,RKS
! DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL.OWNFR
FOR OFFICE USE ONLY
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Serial No Submit original to Division of Water Quality.Groundwater Section within 30 days
GW-1 REV '7'r8