Bk CY2006

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
1. vvEit�C/QNTRACTOR: 47
Well Conh or (Individual) Mane /
j' kV;. /7 /2 /l iL / fre
Well Contractor Company Narne
STEETADDRESScRt2ak %G'�rn�� /'L' •_`
.Ill./ AA✓ /JGi %Z(... . S-"4 L
City or Town State Zip Code
(` tM))- )—Li 3o O
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply ®/
DATE DRILLED ° —LZ 3 -J E•
TIME COMPLETED ,"37- 36)
AMO PM°//
3. WELL LOCATION:
CITY: 40°VC*e.I� /'7 /
COUNTY/ )Lc/17l!2.
lTT,.i5r�J J CL .!2 i--alnictrtbn
(Street NameliFenbem. Cammunity, Subdivision, Lot No.. Prcel, Zip Code)
TOPOGRAPHIC / LAND SE7/L NG:
❑Slope. °Valley ❑Flat 1gRIdge ❑Other
(check appropriate baxc_
LATITUDE 3 Sr `41,al
LONGITUDEg d 7 ' LI7�'7
May be in degees.
minutes, seconds or
in a decimal format
Latitude/longitude source: htC S °Topographic map
(location of well must be shown on a USGS lopo map and
attached to this form not using GPS)
4. WELL OWNER J.
OWNER'S NAME �G,,G4/ f( 7.
Ji- 4 G
STREET ADDRESS .). ejc,c 381
i eno.r I�SG aS(-{S
City ix Tom State Zip Code
LB-7—L3i S
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: (SS_
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: /oCf FT.
(Use+• if Above
1Top of Casing)
d. TOP OF CASING IS l / FT. Above Land Surface
*Top of casing terminated alo( below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
I).. YIELD (9Pm): r (' METHOD OF TEST /tic
L DISINFECTION: Type( �Or%H.IL
g. WATER 2 ES (dep ,
From To
Fr To
Fran/4 $ To %7.5-
6. CASING:
Amount •t T'SS
From / 75 To
From To
From To
Thiclmessl
Depth Diameter Weight Material
From (5 To C Li Ft. 4 t e9 Oj ci
From To Ft.
From To Ft.
7. GROUT: Depth Material
From (5 To Ft
From To Ft.
Fran To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft
To Ft.
To Ft.
10. DRI W NG LOG
From To
CCr
17
/CAS/417
es- _C
Fte ratio D rgltbn
e
Yrn Z T,.its
RECEIVED
MAR 2'1 200b
11. REMARKS:
lshcville Ilcgional Offi
Aquifer Protection
100 HERESY CERTIFY THAT THIS WEU. WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD IHS BEEN PROVIDED TO THE WELL OWNER
Rum E�LL-
SI RE OF CERTI WELL CONTRACTOR DATE
CAA,"
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, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTZON1tECORD
North Carolina - Department of Environment and Nitural Resources - Divisionpof Water Quality -Grow taSsm
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1 / I/en� c- fl l U cie1 )1e -cum lcxnotI s 2 7 e.V
WELL CONTRACTOR COMPANY NAME C f.V PF t i et Jel I.0 e
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT/
(ifspplicsble) (if applicable)
/
1. WELL USE (Check Applicable Box): Residential C� MunicipalPublic ❑ Industrial Cl Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
PHONE s 177 "U" yam
2. WELL LOCATION:
Nearest Town:t/ ✓ County Ln e
l ?so A/'kwrz (n t. e K fo7e
(Street Now Numbers, CommuNH, Subdivision, LotNo., Tip Code)
Topographic/Land setting/
❑Ridge ❑Slope Malley afFlat
(check appwpri.lo box)
Latitude/longitude of well location
3. OWNER:( /'e en/ (OM is1ti4.111 i`S (degra+lmimuedaeonds)
Address /78C /IEU'.0+cr�t/ 4, ry 1 e �nrrs / c,6 t {.atituddlongitude source:❑GPS❑Topographic map
(Streeter Roulo )
(cheek box)
//1/fir/ tl/>v /v C- 2 7 e 3 DEPTH DRILLING LOG
City or Town State Zip code From To Fotma(iaa•Description
Ares code- Phone comber
4. DATE DRILLED Z .�l G 6,
5. TOTAL DEPTH: /a G 17
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO erve
7. STATIC WATER LEVEL Below Top of Casing: 2 00 FT.
(Use "t" if Above Top of Casing)
8. TOP OF CASING IS /?I FT. Above Land Surfaces
flop of cedng termlaated allor below bud surface requbea a
variance In aeeordaace with ISA NCAC 2C A11S
9. YIELD (gpm): 9 METHOD OF TEST TC iPi t"
10. WATER ZONES (depth):
11. DISINFECTION: Type CC' /✓
12. CASING:
Dep
Front TTo . Ft to iy
From To Ft
FL
Ft 4:enat:e/e M
Ft
From To
13. GROUT: Depth
From__. To 20
From To
14. SCREEN:d Depth
From To
From_ T
15. SAND/GRAVEL PACK:
Amotmt /0 L Z
Wall Thickness
or Weight/Ft Material
CPR 2/ /� U
Diameter Slot Size Material
Ft in. in.
o Ft. in. in.
' Size Material
»spur
From r (�/ To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road en ma tees /yg(j
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT ACOPY OFS ECOR�1AsBF ROVIDED TO THE WELL OWNER
Z0(0
SIGNATURE OF PERSON CONSTRUCTING 7f WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. (919) 733-221, within 30 days. GW-1 REV. 07/2001
Pt

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section y,
WEIL CONTRACTOR (INDIVIDUAL) NAME (print) Grit j T vsf' T GE CERTIFICATION # Z I�ma7 `''
WELL CONTRACTOR COMPANY NAME 3U5 fiCe{. Lod C L . 0 r%Li tve) PHONE # PO7t9-A'798
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERM IT#!
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential V.-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: I.2 N l G
1(35 rieo,u Ci,c
(Street Nano. Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: ROtJN,G FRANkLt)U
Address / TWO 64 0 '4wt /Fees €d
(S'reetor Ce No.) 2 Q` `C
County 84/g4
City or Town State Zip Code
)- 217 _ ) 90 1
Area code- Phone number
4. DATE DRILLED 3 - 7 - 062
5. TOTAL DEPTH: sy •
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing: ET.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS /fz. FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ww'th ISA NCAC 2C .011&
9. YIELD (gpm): /5 METHOD OF TEST 41 2
10. WATER ZONES (depth): /S 7 /p 01 Co 4/90
11. DISINFECTION:Typer(,OgiNe Amount Q 0Z.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To tipFt. f L
From 'ii�To SO0 Ft. �Fe�_ _
From To Ft.
13. GROUT: Depth
From To Ft.
From 0 To 20 . Ft. d-y,e / Aiir//de 114. 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:
pographic/Land setting
tdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
PHA/35°3R //d oA/ .ggqw
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Ar/L1"
o-yr
YES 0 NO 57 s945-
Material Method
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road'-',
numbers and common road names.
I DO HEREBY CEIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION 67fA/NDARDS, AND THAT A COPY }S-gECORD HAS BEEN PROVIDED TO THE WELL OWNER
RE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original o the Division of Water Quality, Groundwjter Section,1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

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WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CHAD HARTNESS CERTIFICATION a 2901
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
AIR DRILLING COMPANY PHONE g [phone]
1. WELL USE (Check Applicable Box): Residential M Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Hat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: JAMESTOWN
TURNER MILL
County BURKE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DONALD SCRONCE WELL & PUMP CO. (LOUIS PUTTMAN)
Address 2010 STARTO W N ROAD
(Saar or Route No.)
HICKORY, NC 28602
City or Tow) State Zip Code
Area code- Phone number
4. DATE DRILLED 04-06-06
5. TOTAL DEPTH: 405 FT.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO II
7. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top ofCasmg)
8. TOP OF CASING IS 1 1/2 Fr. Above Land Surface*
`Top of casing termisated at/or blow taut surface requires a
variance to accordance with ISA NCAC 2C .11la.
9. YIELD (gpm): 2 METHOD OF TEST AIR
10. WATER ZONES (depth): 394 FT.
11. DISINFECTION: Type HTH
12. CASING:
Depth
From 0 To too
From To
From To
13. GROUT: Depth
From 0 To 20
From To
14. SCREEN: Depth
From To
Ft.
Ft.
Ft.
Diameter
Material
Ft. GROUT
Amount
Wall Thickness
or Weight/Ft Materiel
PVC
Ft
Diameter
Ft in.
Method
POURED
Slot Size Material
in.
in.
From To Ft in.
15. SAND/GRAVEL PACK:
Depth
From To
From To
Ft
Ft.
Size
Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitudeflongitude of well location
(degrees/minutes/seconds)
Latitude/Iongitude source:❑GPS❑Topographic mar
(check box)
DEPTH DRILLING LOG
From To Formation Description
0' 100' DIRT
100' 405' ROCK
-v
J
LOCATION SKETCH
Show direction and distance in miles from at last
two State Roads or County Roads. Include the road
numbers and common road names.
Brown Alt, Qtrac4
191
diet
16. REMARKS: 1
I DO HEREBY CERTIFY THAT THIS WELL W.
CONSTRUCTION ST
CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�-iD-vlU
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Attn: Information Management, 1617 Mail Service Center -
Raleigh, NC 27699-1617, Phone No. [phone], within 30 days.
N,'7( Rd

V-�
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERTIFICATION # 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Mtnieipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: MORGANTON County BURKE1
LOT #189
(Street Name, Numbers, Conununity, Subdivision, Lot No., Zip Code)
3.OWNER: RONNY NORMAN
Address LOT #189
(Street or Route No.)
MORGANTON NC 28655
City or Town State Zip Code
(828) — 584-4288
Area Code Phone number
4. DATE DRILLED 03/04/06
5. TOTAL DEPTH: 480
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IZ
7. STATIC WATER LEVEL Below Top of Casing: 240 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 6 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 12.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 Ft. 6-114" SDR21 PVC
From ____To ____Ft ____ _
From ____To ____FL ____ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From _ To FL
14.SCREEN: Depth Diameter Slot Size Material
From _To_Ft. _ in. _ in.
From To Ft. in _ in.
15. SAND/GRAVEL PACK:
From
From
Depth
To
To Ft
16. REMARKS:
Size Material
Ft
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at (east
Two State Roads or County Roads. Include the road
number and common names
FROM POLKVILLE GO HWY. #226N. RIGHT ON
TRINITY CH. RD. RIGHT ON DYSARTSVILLE RD.
GO APPROX. 3 MILES. lm DR. ON RIGHT PAST
BURKE CO. LINE. GO TO END OF PAVEMENT.
LOT 8189 ON LEFT.
0
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS CTION STANDARDS, THAT A COPY OF THIVtECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment And Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ROBIN MCNEELY CERTIFICATION # 2567
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # _ ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public 0 Industrial ❑ Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: CONNELY SPRINGS
STARLITR LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DENTON BUFF
Address STARLITE LANE
(Street or Route No.)
CONNELY SPRINGS, NC 28601
City or Town State Zip Code
(828) - 443-3179
Area Code Phone number
4. DATE DRILLED 03/06/06
5. TOTAL DEPTH: 62
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Eg
7. STATIC WATER LEVEL Below Top of Casing: 44 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with t 5A NCAC 2C .0118.
9. YIELD (gpm): 18 METHOD OF TEST STEEL TAPE
10. WATER ZONES (depth):
County BURKE
11. DISINFECTION: Type CHLORYTE Amount 8.28
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 62 Ft 24" CEMENT
From _To_Ft. _ _
From To Ft_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT POURED
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
From 44 To 62 Ft. 78M
From _ To _ Ft. _
16. REMARKS:
Material
GRAVEL
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #18 N. FROM FALLSTON. LEFT ON
RHONEY RD. GO APPROX. 2-1/2 MILES, RIGHT
ON CORN HILL RD. RIGHT ON STARLITE LANK
1/4 MILE ON RIGHT.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS CTION STANDARDS, AND THAT A COPY OF THI RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0
`e� % - a<z' /��// , 6 %% h/Ca ems.- 6 = C-) 6
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. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WRLL CONSTRUCTION RECORD
North Carolina Departmcnt of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION if 2 586
1. WELL CONTRACTOR:
Ashley T. Moretz
Well Contractor (IndivIdual) Name
Moretz Wpll nri111n9
Well Contractor Company Name
STREET ADDRESS 6159
HWY. 10 West
Hickory NC 28602
City or Town State Zip Code
( 704 )- 462-1327
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(if applicable)
STATE WELL PERMITB(a applcable)
DWQ or OTHER PERMIT R(d applicable
WELL USE (Check kcable Pox): .Residential Water Supply
DATE DRILLED -"' ^ © 6
TIME COMPLETED : 3 0 AM.D PM
3. WELL LOCATION:
CITY: /Pei (An f‘. COUNTY
///err
(Scoot Name. A. Commonly,, S11bdMis , Lot Na,.Parcel. Zip Code)
TOPOGRAPHIC y LAND S G:
❑Slope OVaIley ['Flat
(check appropriate box)
Sia046N',/
LONGETUDE� LO a �7
Latitude/longitude source: S DTopographic trap
oration of we/must be shown on a USGS topo map end
attached to this fine not using GPS)
d. WELL OWNER �� /) ,,,{/
OWNER'S NAME ilW%4/ 'PIC�
STREET ADDRESS /6$e (44111 AA f 4e- ale
}Y►+ rg�A dr_ Az, ,2 MSS -
City or Town State Zyr Code
Area code - Phone number
LATITUDE
DOther
Maybeintames,
minutes, seconds a
Ina decimal format
5. WELL DETAILS: I1
a- TOTAL DEPTH: 400 1
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
c. WATER LEVEL Below Top of Casing: It) n FT.
(Use.+• if Above Top of Casing)
d. TOP OF CASING 13 FT. Above Land Surface
'Top of casing terminated alor below land surface may require
a variance In accordance with ISA NCAC 2C .0118. EL
�j
e. YIELD (gpm):- / METHOD OF TEST�7 rr%IirT ,
f. DISINFECTION: Type
1,711
Amount,e/b Q Z
g. WA.TFj t/nZONES ^2(deptth). 77
From nC If To t J From To
Fran To
From_. To From To
From To
6. CASING:
�j Thickness(
From Tohg / Ft 2 er /
From To Ft.
From To Ft
7. GROUT: Depth Material Method
From f 7JP 703(� Fiti0'rk�J�
From r To Ft.
From To FL
8. SCREEN; Depth •iameter Slot Site Material
From T,F in
Fran To Ft.
From To FI.^
9, SAND/GRAVEL PACK:
Depth
From To Ft.
Ft.
Fr
10. DRILLING LOG
F
F— (,00,.
11. REMARKS:
Site
Material
Fop�Tatl�t Delta);
S{a %P
,Iefk
rn
!DO HEREBY CERIFT 'IPW TIES WELL WAS CONSTRUCTED N ACCORDANCE W(M
15A NcAc 2C, WELL CONSTRUCTOR STANDARba. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO "ME WELL OWNER.
Tl 2as� 17
SIG TUBEOF(FERTIFIED WELL CONTRACTOR DATE
5Al ei! O oil
PRINTS NAME OF/PERgSSpOO�NN ONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: InformationtMAgt.,
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. (919) 733•7015 ext 5s5.
bd Wd717:60 900Z 80 'ady ZZETZ9PPOL : 'ON XUd
Form GWila
Rev, 7iO5
UN 01 2006
drone zilaaow : VONA

26832
City or Town Store Zip Cade
Area code- Phone number
4. DATE DRILLED QS-04'-CO
5. TOTAL DEPTH. biDS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0.
7. STATIC WATER LEVEL Below((use TFT
if Aboveop ofCssi
8. TOP OF CASING IS a FT. Above Land Surface'
•Top of cadet terminated atler below Lad surface regains ■
variance to accordance with ISA NCAC SC .0111I.
9. YIELD (gpm): •o METHOD OFTESTad%rT.si-
10. WATER ZONES (depth):
11. DISINFECTION: Type INT rbs Amount /f47
12. CASING: WallThidmess
or
From_ To /D `ri Ft. ivtz
From To
From To Ft
13. GROUT: Depth
From t To cat Ft. mote
From To
14. SCREEN: Depth
From To
From, _ To
15. SAND/GRAVEL PACK:
Depth
From To
From To
WELL CONSTRUCTION RECORD
North Carolina - Department of Enviromneat and Oka
Refources - Division of Water Quality - Groundwater Section
{;.il(' /7or nesS cERTWICAT1ON Na.
WELL CONTRACTOR (INDIVIDUAL) NAME (print) n �� ���� �s
W
WELL CONTRACTOR COMPANY NAME »iCkC'tf Wei/,)riAt /A. PHONE 0
STATE WELL CONSTRUCTION PERMIT* 00 ASSOCIATED WQ PERMPTM
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential b Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: A407 nit t CountyRar%P
(Street Name. Numbers. Community, Subdivision. La[N,o.. Zip Code)
3.OWNER: Oho' ieetnn
Address 7ZS- lit:p vu/e// Rd.
(Sant& Rome No.) Morrinfmt,lyl(' olgt&5 _
Topographic/Land setting
❑Ridge ❑Slope ❑Valley [Plat
(check swap box)
Latitude/longitude of well location
(denteeendoseducoods) hrc
Latitude/longitude so urce:❑GPS❑Topogmp map
(check boa)
DEPTK DRILLING LOG
From To Formation Description
ismefra Weiaht/Ft Mate[•
Method
*urea'
Ft.
Diameter Slot Size Material
Ft in. in.
Ft in. in.
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. \ o
N .(e
tl
U/
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
Yha/� /Tmr,� /J o5-/7-Uw
SIGNATURE OF PERSON STRUCTING THE WELL. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Maid Service Center
GWr1 REV. Raleigh,0NC 1
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (IIVDIVroUAL)NAME(print) krifi I-Qrtness CERTIFICATION# 01CIDI
WELL CONTRACTOR COMPANY NAME k ie_kn rc�r I /-�'e 1 � ri Ili flc - i E, PHONE A IFi 131'/- L C
STATE WELL CONSTRUCTION PERMIT# U ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential EL Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Tows Morenfhvl County Bur Ire_
Lggo Rkrnhill Orh)rri I.
(Street Name. Numbers, Community. Subdivida4 lot No, Zip Code)
3. OWNER: ken L i&fkins
Address 14Rn Born hi I1 f)rallor-a P.ci
(Street or Route No.)
Morl1r'uptiirm / MC AR(0SS
City or Town Slate rip Cola
(9l0)- 3C9- (os48
Area code- Phone number
4. DATE DRILLED 05-01-OLD
5. TOTAL DEPTH: I (X15
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Tpp o���� rt FT•
of Casing)
8. TOP OF CASING IS 01 FT. Above Land Surface*
*Top or casing terminated atlor below land surface requires •
variants le accordance with ISA NCAC 2C .0113.
9. YIELD (gpm): METHOD OF TEST Tit- fair Ies1
10. WATER ZONES (depth):
3�l
.4 6?3r
Topographic/Land setting
°Ridge °Slope °Valley ❑Flat
(e6eett appropriate box)
Latitude/longitude of well location
(ee)
Latitude/longitude source:OGPSOTopograpl»c map
(check box)
DEMI DRILLING LOQ
From To Formation Description
11. DISINFECTION: Type 'TILT /afar
12. CASING:
From_ To '7 Ft. iorli rtal
Depth
From To Ft
From To Ft.
13. GROUT: Depth Materiel IS
From_Q_To ,W) Ft. rnu÷.
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.
Amount ILE
Wall Thickness
or Weight/Ft Material
M%4- "Nasal
Method
Pat rPcl
0
CD
CP
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
MO6 N s yes
til
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
e.1140(N tAtiw jJ T 115--to-o(0
SIGNATURE OF PERSON C UCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 26 8 3 4
t of Environment and Natural sources - Division of Water Quality - Groundwater Section
North Carolina - Department (T CERTnrlc,►T1oN s� Q/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1. had a j ' PHONE A �uT� �����''3�
WELL CONTRACTOR COMPANY NAME %/t(-L0t (A [p II ' Sri/lint I.0•
tt�� ASSOCIATED TED WQ PERMITS STATE WELL CONSTRUCTIONcable) PERMIT/ (if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential l Municipal/Public ❑ Industrial 0 Agricultural [
Monitoring ° Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI • �urkP
Nearest Town: ICkon County
017/ s F_ l St
(Street Name, Numbers, Community, Subdivision, lot No., tip Code)
3. OWNER (� or 140ir�
Address c '114 EtAP I SL'
(Street or Route No.)5y Co 12
Connell , C�0 lc
City or Town VP Code
(gZg)- -397-' &30
Area code- Phone number
4. DATE DRILLED Ott -o2S -!J'P
5. TOTAL DEPTH' 1/AS
6. DOES WELL REPLACE EXISTING WELL? YES 21 NO 0
7. STATIC WATER LEVEL BeIoat FT.
(wo"+oiAbove
bomBopofCasing)
8. TOP OF CASING IS a FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance m am):... with 15 METHOD OF TEST 3 Air %2,Sf
2C .0118.
9. YIELD (gpm): � _"�j
10. WATER. ZONES (depth):
11. DISINFECTION: Type
TNT Tabs
12. CASING:
Depth
From—.0 To I / 7
From To
From_ To
13. GROUT: Depth
From_ To 20
From To
14. SCREEN: Depth
From To
From_ To
15. SAND/GRAVEL PACK:
Depth
From To
Front To
Diameter
Ft. A-
FL
FL
Ft
Material
Ft PTroak
Amount 79
Wall Thickness
orWeight/Ft. Material
Topographic/Land setting
[Ridge °Slope [Valley [Flat
(check appropriate box)
Latitude/longitude of well location
(dereeVrdrmta6xo°dr)
Latitude/1ongitude source: GPPS0 opographic map
DEnng DRILLING LOG
From To Formation Description
Method
�i areal
Ft
Diameter Slot Size Material
Ft in. in.
Ft in. in.
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
peamisS
of 0
Pl
xis
ova/ g
m
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 1SANCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WFI1 OWNER
DA
SIGNATURE OF PERSON a STR G THE WPJ I
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center
i RRSVgh, NC 1
27699-1636 Phone No. [phone], within 30 days.

326837
WELL CONSTRUCTION RECORD
DepartmentNof Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL Carolina -
WELL CONTRACTOR (INDIVIDUAL) NAME (print n run IZEE E: CERTIFICATION #L.
WELL CONTRACTOR COMPANY NAME
f licaicable if l'cable
Applicable Box):Residential EIC Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump
1. WELL USE (Cheek Water Injection 0 Other 0 If Other, List Use
Topographic/Land setting
Midge OSlope Malley OFlat
(clerk appropriate box)
Latitude/longitude of well location
(Jegr oonhemods)
Latitude/longitude sounce:OGPSOTopographic map
(check box)
D Dlita,ING LOG
From To Formation Description
PHONE # -
r R7A 3235
STATE WELL M
HIQ OV W j . Tt1Tf T TM'; W. _
CONSTRUCTION MUMS ,ASSOCIATED WQ PERMIT#
2. WET T LOCATION:
Nearest Town: T F^)TR County FIIRICF
(Street Name Numbers, Cemmmrar, Subdivision. Lot No., Zip Code)
3. OWNER: J. HALYYII MTTTFR
Address 741F, Warn) VTSPA
(Street or Route No.)
T ENDIR, NC 28E45
City or Town See Zip Code
( R7R)- 77o coV
Ana code- Pbme number 4. DATE DRILLEDS-(yi
5. TOTAL DEPTH; 175
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO RY
7. STATIC WATER LEVEL Below Top of Casing: 7n FT.
(Use ^✓' if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
*Top of caslua terminated at/or below land surface requires a
variant be accordance with ISA NNGC 2C .01111.
9. YIELD (gpni):OD OF TESIRY ATR TEST'
—
10. WATER ZONES (depth):
11. DISINFECFION: Type
12. CASING:
Depth
From 0 To Y+
From_ To_
From_ To--
13. GROUT: Depth
From 0 To_ L_ Ft.
M B TARS Amount 27
wan mckneaf
16�FvCoeter alweight/Ft MaosiaCl
Ft x asTl
Ft.
Material Method
r7YITT TriPFT)
From To FL
14. SCREEN: Depth
From__ To
From _ To
15. SAND/GRAVEL PACK: Size Material
Frorn____Toh FL
From To Ft.
16. REMARKS:
Diameter Slot Size Material
Ft in. in.
FL__�n• in.
LOCATION SKETCIi _
Show direction and distance �m�mils m om the roadtwo State Roads or County
numbers and common road names.
JUIG/
N
�Iva.�- gf 6O/jb -9 o
!�� ' < iSTA
ou (r/E6 xi
0061t -11
—
m ei
N 0PI
0 we, cr.en
> e
-C
S
tow
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF • S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERS
UCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service CenaW i REV. 07 2001
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Envionment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) NEUL PAIWt)E CERTIFICATION # 2609
WELL CONTRACTOR COMPANY NAME HIQZRY FEIL ER= W. PHONE it f ) 828-324-0035
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
cif applicable) (if applicable)
1. WEI i USE (heck Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ° Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Townz M7aMim County EURKE
ThSARIVIIIE RD
(Street Name. Numbers. Community, Subdivision, Let No., Zip Code)
3. OWNER MEM HlvESNICHkEL CCSINER
Address 319 CARBQ9 CrY RD.
FCRWA: Ithula1C
City or Town State Zip Code
Area coda Phase number
4. DATE DRILLED CQ-03-C6
5. TOTAL DEPTH: 365
6. DOES WELL REPLACE EXISTING WELL? YES 0NO
7. STATIC WATER LEVEL Below Top of Casing. 50 FT.
(Use"!" if Above Top of Casing
8. TOP OF CASING IS 2 FL Above Land Surface'
flop of casiq terminated attar bebw land what requires a
variance In aeenrdaaawab ISA NCAC 2C AliL BY AIR 11!.Sl
9. YIELD (gpm): 15 METHOD OF TEST
10. WATER. ZONES (depth):
11. DISINFECTION: Type Rill TVS
12. CASING:
Depth Diameter
From 0 To 100 Ft M'
From To Ft
From To Ft.
13. GROUT: Depth Material
Froar D _To 2) Fr. GRCUT
Amount 66
Wall Thickness
or Weight/Ft. Material
A](: HASTM,
From To Ft
Method
HIRED
326845
Topographic/Land setting
°Ridge °Slope Malley t7Flat
(cheek appropriate tau)
Latitude/longitude of well location
m
0
(deginu7mimoatseeaads)
Latitude/longitude sou rce:°GPS°Topographic map
(cheek box)
13EPTH DRILLING LOG
From To Formation Description
14. SCREEN: Depth Diameter Slot Size Material
From To Ft._ia io.
From To Ft,____in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
J
N
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
CONSTRUCTION STANDARDS,
THAT A PY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G hie, 4 02-09-06
SIGNATURE N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
>0
rn_
oft(
Cr
r

WELL CONSTRUCTION RECORD -
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) NIL PAREUE CERTIFICATION # 7E09
WELL CONTRACTOR COMPANY NAME EIIQKC Y WELL I1{UJNG QJ- PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 2( Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: cram Tv cPRTN;5 County iI iRKF
7085 (T NUT. Ri).
(Street Name, Numbers, Community, Subdivision, LotNG., Tap Code.)
3. OWNER: PAT M HARPOR (Th&/iW TT.
Address 1261 E1.11 70 WEST
treet or Route
NEWICN0 NC 28613')
City or Town State Tap Code
Arca code- Phone number
4. DATE DRILLED 02- -C6
5. TOTAL DEPTH: 265
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO SY
7. STATIC WATER LEVEL Below Top of Casing: 50 FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
`Top of casing terminated at/or below Ind surface requires a
variance to accordance with ISA NCAC 2C AWL
9. YIELD (gpm): 6 METHOD OF TEST BY AIR 1E51
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
From 0 To 111
H[H TPFiS
From To
From To
13. GROUT:
From__ 0
From
14. SCREEN:
Front
From__
Amount 45
Wall Thickness
SCALP. St
Depth Method
To 20 W FFD
To Ft.
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
R. Veter
Ft.
Ft.
Material
Ft MCC
15. SAND/GRAVEL PACK:
Depth
From To
From To
Size Material
Ft.
Ft.
Topographic/Land setting
Midge DSlope ['Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
C
0,
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
((/�/.C' Ofr '!/.0 .( l 02-16-C6
SIGNATURE OF F.RSO 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

326S4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
TT
WELL CONTRACTOR (INDIVIDUAL) NAME (print) NE, WRITE CERTIFICATION # 2609
WELL CONTRACTOR COMPANY NAME
HICKEY .B1 iRT11INE (1). PHONE / Y"'R1 34-0035
STATE WELL CONSTRUCTION PERMIT/ _ ASSOCIATED WQ PERMITS
(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:
Nearest Town: NI3?NICN County PIR(E
6714 NC 181
(StreetNaaKNumben, Community. Subdvmaa, LotNo., Zip Code)
3. OWNER:
Address
ETIZG RALD NURSER(
6214NC181
(Street cc Route No.)
MTYANI(N, IT, 28655
(828 City
n43wn3107 Town State Zips
Area code- Phone mambep,,, ,
4. DATE DRILLED U O t0O 5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ° NO gt
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "t" if Above Top of Cuing)
8. TOP OF CASING IS 2 FT. Above Land Surface`
'Top of wing terminated atler below load surface requires a
variance la aaordalsp wltb ISA NCAC 2C All&
9. YIELD (gpm): 90 METHOD OF TEST BY AIR MST
10. WATER ZONES (depth):
11. DISINFECTION: Type HIHlY
12. CASING:
Depth
From 0 To 66
From__ To
From To
13. GROUT: Depth
From 0 To
Fronk_ To Ft.
Amount 102
Wall Thickness
or Weight/Ft. Material
(Env. S1H1.
20
Diameter
Ft�
Ft.
FL
Material
Ft. CId [Tr
14. SCREEN: Depth Diameter
From To Ft_in.
From To
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From_To Ft
16. REMARKS:
ethod
MMURED
Topographic/Land setting
❑Ridge °Slope Malley °Flat
(check appropriate box)
Latitude/longitude of well location
(de
Latitude/longitude sou ce:°GPS°Topograpbic map
(cheek box)
DEPTH DRTLLINO LOG
From To Formation Description
Slot Size Material
in.
in.
Material
LOCATION SICETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
®r 6l'WaG
s
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION ST¢NDARDS, Ate THAT A COPY e F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
P anday
SIGNATURE OF
03-15-( 6
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # rr�3i
1. WELL CONTRACTOR:
oO�dRLus el 1
e
Well Ceo(Inal)
Ku_sseIi
(.lull tt't It As jiUc.
Well Contractor Company Name nn rr/
STREET ADDRESS �4'7 L I b e r t-y (� gd
ay /0 it5 1.1 I IC .)-glc+81
City or Town State Zip Code
(g s) &732-3(0fl
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#pn applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply (Er
O DATE DRILLED 4— - 06
TIME COMPLETED / : OO AM El PM 9.-"
3. WELL LOCATION:
CITY: e AALcL COUNTY ,� !/
,gym,/
(Street Name Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
laBkTpe °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box) /
LATITUDE �• a • 6.57
LONGITUDE jil ( / .�R. 9,53-
Latitude/longitude source: E tPS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER
May be in degrees,
minutes, sands or
in a decimal format
OWNER'S NAME -�%iffi/rt.y0/
STREET ADDRESS j t a Bi� (Qa-tc.
eb-)L-1XL l , 4 th-cp 7'1C .2R b (2-
City or Tam c State Zip Code
(Q54L)- 66123- 6339
Area code - Phone number
5. WELL DETAILS: (J
a. TOTAL DEPTH: 4 p S '
b. DOES WELL REPLACE EXISTING WELL? YES ° NO 82--""
c. WATER LEVEL Belau Top of Casing: 7s () FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / 12 FT. Above Land Surface•
'Top d casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. 4 e. YIELD (gpm): METHOD OF TEST L2t///
_.y
f. DISINFECTION: Type /4 %/-I Amount /-'/:L ~7""
g. WATER ZONES (de/Apth):
From P'7
o To OS From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 1) To /alp FL P V C
From To Ft
From To FL
7. GROUT: Depth Materiall Method
From D To 020 Ft. flit _____ _
From To Ft
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRIWNG LOG
From To , Formation Description
p - /,20
S/3?5' 29-a‹,
11. REMARKS:
0
C
ma
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSIRU(. itU N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
I i /ie"\Ylv/1wEac 1G -/7-(4,
S GNA E OF CERI FIED WELL CONTRACTOR DATE
1 J�%ws5 7/
PRI
(1NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL coNSTRUCTtoN RECORD
North Carolina Deparuneot of Environment and Natural Resources- Division of Water Quality
WELT CONTRACTOR CERTIFICATION # 3a1l
f. WSINFECTION: Type Cllf- %qhS Amount
g. WATER ZONES (depth);
tn"1 I From 7;JE% To .� From To
W� Contractor Company � 0rcilrn 'tp)f', From To From To
/ arneJ Fran To From To
STREET
��ADDRESS
)�l3 a "Kr J4wnc i n 6. CASING: ThcI ess/ , '� Mari iui/!L nr. +'�5iI7 r From Depth
_Ft 4J SD111 `W
City or Town State Zip Code From To Ft
( .7041- �Wia."ire% From 'iTo Ft
Area code- Phone number
1)-2. WELL INFORMATION:
SITE WELL ID Mir applicable)
329559
i 4-
'$ eph f3ci1P/�
Well Contractor Individual) Marne/
1. WELL CONTRACTOR:
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Boor): Residential Water Supply e
({G"
. DATE DRILLED 'C6.'-G6'
TIME COMPLETED 3 (!C) AM PM
3. WELL LOCATION: (//
cTTY: elver 'tj :,✓�'—� coupny 4U )F I \Y/�
/
nr, 15 3wd/4Iv';it
(Streetme, Numbers. Community, St06Ns.on No., Parepj, Zip Cadeet 1
TOPOGRAPHIC! LAND SETTING: IJU.�'%Fr`�
Slope OValley ❑Flat ❑Ridge ❑Other
(check appropriate bo,)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal fomut
IatitudeRongitu wee: DO'S Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS) �
4. WELL OWNER /�/� I/
OWNER'S NAME OQK(,00cS /-1 )
STREET ADDRESS
NNn+, �i/
State Zip Code
Area code- Phone number
7. GROUT: Depth Material ,(� Method
From To )3 Ft (M Liar POUT
From To Ft.
From To Ft
8. SCREEN: Depth 7in.
Slot Size Material
From To Ftin.
Fran To Ftin. in.
Fran To Ftin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To FttFr
Form To F
10. DRILLING LOG
From To Formation Description
U--(/ / Re 5,7I S
Qom- &%S'
5. WELL DETAILS: -� / 11. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: '5Cf FT.
(Use -+•#Abase Top of - 0�)
d. TOP OF CASING 1S /. FT. Above Land Surface•
'Top of casing terminated altar belwv lad surface may require
a varialce in acmdee with 15A NCAC 2C .0118. j
e. YIELD (gpm): ,, � '_ METHOD OF TEST Cg L ,1
tl
,57
gran
cb
..,;
t,
et,
n••
Yr
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�T 91 `j ni" O4T; ad.
SIG'jA`T�`�UR POF C I/fI WELL CONTRACTOR DATE
•
PRINTED NAM F _ (F N E OF PE SON STRUCTMG THE WELL
Submit the original to the Division of Water Quality within 30 days. Atilt: kiformatlon Mgt, 1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05 •

RESIDENTIAL WELL coNsTRuC ION RE oRn
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
329558
1. WELL CONTRACTOR:
*1'ph 134i1PV
Well Contractor Individual) Name
�7 k (Jell Or:/I:n4 • -Ai_
Well Contractor Company Name
STREET
���ADDRESS
J,,/3 . 1'rTr glen, ne / j)
Mari U)(K '7 ♦I
City or Town State � Zip Code
L7.0,:qi- $.ni mba-tt
number
Area code. Phone number
-t. WELL INFORMATION:
SITE WELL ID *it applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT A(dappliicable) / r- (/GJ( R,1
WELL USE (Check Appficble ,Residarns Water Supply
DATE DRILLED
TIME COMPLETED
3. WELL ATION:
CITY: ifilln la ill
89 �
(Street Name, Numbers,
AM ❑PMQ
) COUNTY i.�(n�.l! i I\CJ
7
murery, Srm6xsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley DFla ❑Ridge ❑OOra
(check appropriate box
LATITUDE 3
LONGITUDE
May be in degrees,
mums, seconds or
in a decimal format
Latitude/longituurce: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and )?
attached to this form gnot using GPS)
4. WELL OWNER A r
OWNER'S NAME (5ah r✓foil Yin"
STREETADDRESS
/A`Ciity or Town / State LP Code
Area code - Phan number
5. WELL DETAILS:
a. TOTAL DEPTH: ((14
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p�
c. WATER LEVEL Below Top of Casing: S (j FT.
(Use'+- if Above Tap of ' )
d. TOP OF CASING IS Fr. Abe Land Surface
'Top of casing terminated at/or below Iald surface may require
a variance inaccord ,ce with 15A NCAC 2C .0118.
e. YIELD (gpm): ? METHOD OF TEST -Gil AL7,
f. DISINFECTION: Type CU. %965
g.WA'IERJrE (den
F d /
From 1,5 To ! l From
From To From
From To From
Amount j. 16-
To
To
To
6. CASING:Thidmess/
DWeight Atonal
Fran a To Ft tv yDR91
From To FL
From To FL
7. GROUTl.. Depth Material
From 1 To of Ft. ChM [.(Yir
From To Ft.
From To FL
6. SCREEN: Depth Slot Size Material
From To Ft `�� in, in.
From To % Ft ;y in. in.
From To Ftlf inin.
n Method
WOUr
9. SAND/GRAVEL PACK:
Depth
From To
Fro T
From
10. DRIWNG LOG
From To
Material
Formation Description
Lllr� RA S u /cif ,
42 /65
11. REMARKS:
°'(4/ii r GrcQ�
CJ
ti-
d rf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WMN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG
tR' P4 / Jaa! _%C
TUR OF C0471F WELL CONTRACTOR DATE
PRINTED -NAME OF PE SON Cf 1STRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568-
Form GW-la
Rev. 7/05

327531
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JERRY WATKINS CERTIFICATION 1t 2452
WELL CONTRACTOR COMPANY NAME AIR DRILLING COMPANY ?HONE q (7341872-7614
STATE WELL CONSTRUCTION PERMrM ASSOCIATED WQ PERM1T/I
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: MORGANTON County
WILLOW TREE ESTATES
BURKE
(Street Name, Numbers, Cpmmmity, Subdivision, Lan No., Zip Code)
3. OWNER: ASHLEY MORETZ
Address 6159 HIGHWAY 10 WEST
(Street or Route No.)
HICKORY, NC 28602
City or Town State Zip Code
Area code- Phone amber
4. DATE DRILLED 05-19-06
5. TOTAL DEPTH: 265 Fr.
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LB
7. STATIC WATER LEVEL Below Top of Casing. 45 FT.
(Use "+" if Above Top of Caamg)
8. TOP OF CASING IS 1 1/2 FT. Above Land Surfaces
flop of easing terminated at/or below Ind surface requires a
variance V axvrdaneewith ISA NCAC 2C .allR
9. YIELD (gpm): 4 METHOD OF TEST AIR
10. WATER ZONES (depth): 246 FT.
11. DISINFECTION: Type HTH Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 84 Ft PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. GROUT POURED
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material _
From To Ft. in. in.
From To Ft m. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GAS❑Topographic mg
(check box)
DEPTH DRILLING LOG
From To Formation Description
0' 84' DIRT
84' 265' ROCK
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. include the road
numbers and common road names.
Good„ v, L k. �d
w, tlms Tree
ESttres
o t.
w-�w Tree
0
n
rn�
o rr
Cc
err
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, 2$D THAT A 0191, OF LL HAS BEEN PROVIDED TO THE WEOWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Attn: Information Management, 1617 Mail Service Center -
Raleigh, NC 27699-1617, Phone No. [phone], within 30 days.

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 223 I
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
u.ssE!I W4I t IIin.31Nc
Well Contracts Company Nane I /� L
STREET ADDRESS .44 7 Liner1 -y /) "RQ/
�ylbrsin Ile NC (-)468i
City or Town State Zip Code
(W-2.9)- 6.3a- 3(.qS
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Nit ppbcable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT SO applicable)
WELL USE (Check Applcable Bar) Monitoring ❑ Munk ipal/Pubkc 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
g ( Imgation[ Other kst use) T LS-V-1
DATE - DRILLED _S�=`/ 0
?
TIME COMPLETED s� . 3 () AM _ PM (Y-'
3. WELL LOCATION: y� Any
CITY: / / (81a utril. COUNTY 481/
am!' C
(Street NNumbers. Community. Subdmsion, Lot No, Parcel. Zip Code)
TOPOGRAPHIC�/ LAND SETTING:
IgL,lope [Valley ❑Flat ❑Ridge [ Other
(check appropriate box) LATITUDE ?Lu �y '�,f° / / d (
LONGITUDE Li) O b,c A-1/
Latitude/longitude source: 63/GPS ❑Topographic map
(location of well must be shown on a USGS opo map and
attached to this fora a not using GPS)
4. FACILITY. is me name of ere mmness where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY LPL
STREET ADDRESS , ca/ViA-L
May be in degrees,
minutes, seconds or
in a decimal format
City or Town �St"atel . /J Zip Code
CONTACT PERSON 77-04,.a. u6 , Rain)
MAILING ADDRESS wo g Ai y Jar eat
`7V),becl ,_ 1-1/70 .2Rd..4 5
City or Taw State Zip Code
( r28)- 439-966s
Area rode - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 4 a2S
b. DOES WELL REPLACE EXISTING WELL'?/ YES [ NO
c. WATER LEVEL Below Top d Casing: 4O FT.
(Use's' if Above Top d Casing)
d. TOP OF CASING IS % i/., FT. Above Lad Surface
-Top of casing terminated allot. below lard surface may require
a umlaut., in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHODGQ
+ OF TEST 4
f. DISINFECTION: Type tt ( Fr Amount /Y1Gc*p)
WATER ZONES (depth).From 46 To YoZs From To
From To From To
From To From To
g.
6. CASING:
Thickness/
Diameter Weight Material
Fran To,_._.3. Ft PVc_
From To FL
From To Ft.
7. GROUT: Depth Material Method
Frmm� To ,�D FL C!T �'t d p.nti.c
From To Ft !1
From To FL - __._.....
8. SCREEN:
Fran
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From To
From To
Fran T
10. DRILLING LOG
From To
o S3
Diameter Slot Size Material
Ft.
FL
FL
in.
in.
in.
in.
in.
R — CT?
Size Material tV
FL
FL
r.1
o FL CY3
Formation Description; I
0144
5" 3' 4.2S .2e-ut
11. REMARKS:
C
G7
r—
I DO HEREBY CERTFY THAT -THIS WEII WAS CONSTRUCTED al ACCORDANCE WITH
ISA NCAC 2C. WELL COrS1RUCTgN STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN TO THE WELL OWNER
g-/5G4
SIGNATU E OF CER RED WELL CONTRACTOR DATE
r�LtsaLI
PRI NAME OF
PE
RSON CONSTRUCTING THE WELL
J
Submit the original to the Division of Water Quality within 30 days. Attn: bNomtation Mgt,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568-
Form GW-lb
Rev. 7/D5

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # »-%S ,,� ,(,�
f. DISINFECTION: Type 6 4 'b`''4/4V`Amount RL ot(
1. W LL CONTRACTOR:
a to U
to (Individ al) c-ante
rt r.c, (,)ay1V)^r) \ 11-.0C.
Well Contractor Company//��C
++Name
STREET ADDRESS `�I L 1) ) 4 r
City Of Town State Ziptoae
(5 )-41)- 3 a Oa G ;
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(M applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if awry -able)
3. WELL LOCATION: ,
CITY: •- • CO•
3 n 3 lei
WELL USE (Cheek
Applicable Box): Residential Water Supply ID
DATE DRILLED a�.5 V— QC�
TIME COMPLETED AM D PM 0
M 66 X_451-01•110
(Street. _ -, - mbe . unity. Subdivision, Lot No., Parcel, Zip Code)
T OGRAPHIC / LAND SETTING:
Slope ❑Vatey ❑FIat ❑Ridge ❑Other
(check appropriate twig
LATITUDE 3
LONGITUDE
Iatitudeflongitude source: oGPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to th' Ionn In 4 u ng GPS)
4. WELL OWNER •/p'��sjp",�` � t ea/
OWNER'S NAME /_(I
STREET ADDRESS 1: D p Cor 7 e rim i
nrssir
May be in degrees,
minutes, seconds or
in a decimal fonoat
Mos-CM.ca 4 ern_, n-C.
City a -Town State
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH.
b. DOES WELL REPLACE EXISTING WELL? YES CI
Nod
c. WATER LEVEL Below Top d Casing: \ o FT.
(Use -+• if Abc'1. Top d Casing)
d. TOP OF CASING IS 1FT. Above Land Surface*
'Fop d casing tr s/ortielaw land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Igpm): 1 C METHOD OF TEST CA t I bi 0
g. WATER ZONES (depth).
From 3 3 &To , ) 3c Fran To
Ran To From To
From To From To
6. CASING: Thickness/
From Depth
To LA (30. Ft. f , C ameter ht -.Aitt
Rom To Ft.
From To Ft.
7. GROUT: Depth
From d To)-b
Rom To Ft.
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
Material
Ft. (
Method
Diameter Slot Size Material
FL in. in.
Ft. in. in. 7>
FL in. in. =
Gu
t•,:/
Size
From . To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
(✓o
NC. god
-c 6 2.cyr)
rn 3Ssj
Material
Fonnatbsc',ion
N.1
11. REMARKS: 9
tote we
/,Co G ,
1 DO HEREBY CERTFY THAT THIS WELL WAS CONStRUC1ED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF 111E
REC,BRDM(S :17PRO'JpED TO THE WELL OWNER.
RE OF CERTIFl t4&. CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
G7
ry
cri
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 276 1617 Phone No. [phone] ext 568. �t Cd,I0.woo caA4-11-/rajems.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
-. North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
Well Contractor (Individual)
C,
Well Contractor Company Name
1 h�
STREET ADDRESS 9%a J .
`only N 7�02.
City or Town State Zip Code
L .3�_2oorb
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(Happlirabie)
D WQ or OTHER PERMIT (kt applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED
TIME COMPLETED
---�_ AM 0 PM p
3. WELL LOCATION: CITY: y�r c—Cf-C1Y`{ ��DUNTY > L
(Street Name. Numbers, Community. Subdivision, Lot No., Parcel. Zip Code
TOPOGRAPHIC / LAND SETTING: )
❑Skrpe °Valley ❑Flat ❑Ridge ❑Other_
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to the form gnot using GPS)
4. WELL OWNER
OWNER'S NAME Si(XC.,
STREET ADDRESS
City
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 DO
b. DOES WELL REPLACE EXISTING WELL? YES ° NO EL
c. WATER LEVEL Below Tap of Casing: _ ld
(Use'+• IfAbove Top of Casing) �.
d. TOP OF CASING IS . ___ FT. Above
Tcp cI casing terminated at/or8. below lend surface ay Surface -
'Top
a variance in accordance with 154 NCAC 2C .0118.require
t
( e. YIELD (gpm)OF TEST41 41
Ls
'Itr
ubmft the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
17 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
i DO HEREBY CERTIFY THAT THIS WELL WAS
15A NCACni2pCS. WELL CONS1RUCT,DN STANDARCNAJDD 1HTACKNCE
mmi RECORD / BEEN PROVIDED TO THE WELL OWNER
tr.
J0 v c J
Foam GW-la
Rev. 7/05

1. ELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #
STREET ADDRESS i h I �J S+f f *'� C t6
City or Town State Zip Code
( (Orb
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#(a applicable)
STATE WELL PERMITit(e applicable)
DWQ or OTHER PERMIT #01 applicable)—_
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION: (�
CITY: /1ic} Y 9 c _-\ v.�UNTY tJ L] Q
(Street Name. Nunbers, Canm—unity.Subdivision. Lot No., Parcel,
Zip TOPOGRAPHIC / LAND SETTING: Cede)
❑Slope OVaaey ❑Flat ORidge ❑Other
(check appropdah bat)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ['CPS OTopographic map
(location of wet must be shown on a USGS fopo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City
State Cade
Area code - Phone number
5. WELL DETAILS: CC �l
a. TOTAL DEPTHS 0
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOEj
c. WATER LEVEL Below Top of Casing FT.
(Use-' itAbove Top of Casing
d. TOP OF CASING _ J FT. Aye Land Surface`
Top of casing or below kind surface may require
a variance 1, accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): L( METHOD OF TEST r a W
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
`�5 7
f. DISINFECTION: Typ
g. WATER ZONES (depth):
Fran To
100 HEREBY CERTFY THAT THIS WELL WAS
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS,C�D' ATAACpp1 NOS T>
RSEE PR OV WTO THE WELL OWNER
Foim GW-la
Rev. 7535
3 j

RESIDENTIAL WELL CONSTRU
North Carolina Department of Environment and Natural Resources -
WELL CONTRACTOR CERTIFICATION # ' 7
1. VIMLL CONTRACTOR:
l /
}Tell Contractor (I ) Name
f'i ,,(.,P.)) )?rj'1►Ike, Inc
Well Contractor Company Name
STREET ADDRESS 96a L2 ft. S+rce-i- SCE
to (icor"1 ("C a�GU
City or Toren State Zip Code
(gad > s27.Ode `>
Area code" Phone neater
2. WELL INFORMATION:
SITE WELL ID #(if approcle)
STATE WELL PERMIT/kit eyebath)
DWQ or OTHER PERMIT KW appficade)
WELL USE (Check Appfrcable Bad: Residential Wafer Supply ❑
DATE DRILLED ) " 2 7 - 06
TIME COMPLETED ); Oh AMID PMp
3. WELL LOCATION:
CITY: (hnrso, nTTAYl COUNTY
I�. L A-1 r i-C, Dr
Name. Numbers, Caim udy, S+benacion. to No. Parcel. ZIP Code)
TOPOGRAPHIC/LANDSTING:
['Slope OValey OFtat Ridge ❑Other
(check
LATITUDE 3
LONGITUDE
May be in degrees,
atoms, seconds or
in a decimal format
Latitudc/longit7de source: ❑GPS ❑Topographic map
(bcaaon of wet must be shown on a USGS fapo nap and
attached to thislogn usiig GPS)
C. WELL OWNER 1/I- /j/-14, .
{tl
OWNER'S NAME fr)c&rl \ (,phi
STREET ADDRESS
Dem rc, c >CC -Cc
City or lawn Stale rip Code
(`lax >_ 3`)l47°1l
Area code - Phone amber
5. WELL DETAILS: ']
a. TOTAL DEPTH: 3 D
h. DOES WELL REPLACE EXISTING WELL? YES 13' NO 0
c. WATER LEVEL Below Top of Casing: L1(1 Fr.
(Use 8 Above Top of Casing)
d. TOP OF CASING IS) 'a. . FT. Above Lad Surface'
'Top dcasing 7 land swam
a variance it accordance wtlh 15A NCAC 2C .0118.
e. YIELD (gpn): 1 0. METHOD of TESToo r Li c NJ
33C: 1
N RECORD
of Water Quality
f. DISIIN�F/rEE • Type (55✓444'€21- Amount �S
g. T
From pl'bv �. /
From To
Fran -. 30 6 i'llgarn To
Fran
& CASING:
From To
Thickness/
Fran () T. `11 3 Ft r hlja
Fran T. Ft r
Fran T. Ft
7. GROUT:
From n
Frail
From
T.DO
T
Material Method
FLlerol7 poor irirc
FL
FL
8. erUPFN: D'anaer Slot Size kdaerial
From T. Ft in.
Fran T. Ft. _ �_ In. C�
From T. Ftit in.
r8
9. SANDIGRAVEL ' CK: - "'/
Depth - Ste Material r
From T Ft ,
Fran Trr—Ft
From
10. DRILLING LOG
From To
CY 6
11. REMARKS:
Description ; Fo��^ ,,,,�,�1
h", j i J e c) r r-1
S0+4Ftn� Y2eKCh
c-
N
0
1001EREBY CERTIFY 711A THIS WELL WAS COfStm/Cn®MACCO Mnrs wmi
15A MAC 2C. WB.L CONSIRUC'ICN STANDARDS. Alp V 1AT A COPY OF THIS
RECORD HAS BEEN PROMpEDloTE WELL OMER
. e i- .2,7-vc
SIIIi��aNNNPPA..TLIRE OF CERTIFl WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: infounatlon Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext F66.
Fan GW-la
Rev. 7I05

ciio
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1.WELL CONTRACTOR:
STEVE PRICE
Well Contractor (Individual Name)
DEWEY WRIGHT WELL & PUMP CO., INC.
Well Contractor Company Name
STREET ADDRESS
P. 0 130X 308
BOONE NC 28807
City or Town State Zip Code
( 828)- 284-2851
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT #(d applicable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑ X
DATE DRILLED 5/1 006
TIME COMPLETED 10.00 AM ❑ )PM ❑
3. WELL LOCATION:
CITY: MORGANTON couNTY BURKE
BARRIER RD. OFF 181 OFF 221
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat O Ridge ❑ Other
(check appropriate box)
LATITUDE 3 36 57597
LONGRUDE 081 ;3418
Latitude/longitude source: ❑ sirs ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4.WELL OWNER
OWNER'S NAME IOHNNIE L SHF'LI
STREET ADDRESS 7665 SARRIFR AVE
E)AA AN N 28957
C or own D State C Zip Code
57
( (8216- 733-1075
Area code - Phone number
5.WELL DETAILS:
a. TOTAL DEPTH: 245
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO D(
c. WATER LEVEL Below Top of Casing: 50 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118
e. YIELD (gpmj• 1 METHOD OF TEST Air
327520
2878 060248
f. DISINFECTION: Type HTH Amount 40
g. WATER ZONES (depth):
From taro 191 From 23A 231
From To From To
From To From To
6.CASING: Thickness/
Depth Diameter Weight Material
From flro12Vt. 8 1/4 _188_ fALV
From Oro (rt.
From To Ft
7.GROUT: Depth Material Method
From 00 2 t. ( Onion, Gravity Flow
From To Ft.
From To Ft.
&SCREEN: Depth Diameter Slot Size Material
From To Ft. in in
From To, Ft in. in
From T Ft. in. in.
9.SAND/GRAVEL
Depth Size Material
From To Ft.
From _To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 115 MI D
its inn GRANITE
ig0 ig1 GQANITF
191 'O
GAANtTE
230 231 QUARTZ
231 245 GRANITE
�I
1 —;1-1
11. REMARKS:
0 5 GPM 190 -191 0.5 GPM 230 - 231
0 GPM - 0 GPM -
0 GPM - 0 GPM -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC gC, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
H F CERtFFIF ELLLL TRACTOR s - SIGDATE
STEVE PRICE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

3. 0
Address or _
/17/9MM)gults /V c
CJwsass IS
Ammer Item
4. DATE DRILLED i-2 OI
S. TOTAL DBPT& co 5—
NNIBIi.7 YES 0 NO
6. DOES M LREPLACEE>arm
r ,l
3 i
WELL CONSTRUCTION RWOPD
Nam Carolina -Deponmemt of Enviers* ad Nair& Remeaee.- Division ofWain Qesiity-atoueawJerSection
wtlbeorrratAc7CetplmWmauwtwQ a•e !tin �- Kind Y"1 mrrmaAnons�,Z `/
nu. canteen ooss a mein__ wee t�R / rho#JI 1 �i 'PPM • __ _ ___
20
3GTZWILL Ca OONestel0lm "aOa TED MUM
Ofesalioddel
1. WELL USE (Cheek Applicable Hack Raridadid IbmicipallPublie 0 bdmuid 0 Apicultund 0
1tamYering 0 Ieoovery 0 Beet Pump water *aim 0 Other 0 DVSs, List Use
2. WELL LOCATION: tea ski
Nana* T �
.C9am* ape
bedLatiludeareihnde of well location
479
Moen Ns Nemses, aairl. MOMS 1ae?Y, Zip Cade)
1
22 75t
Zip CS
(Igemais oloomeer)
2 7S1, iAritedednigiads eomwe:0GPSDTapap apbic mop
Sotbaa)
Famdi=Description
From To
7. STATIC WATER LEVEL Below Top attr iar /242 m.
�1 (Orewarms Tee maeld
S. TOP OF CASINO IS /& PT. Abon Land place
*Ts daemesenlned eere. SYd at soda a
.eelseeYe.wdree.a...at1CAC2CAI* --/yl tr.(
9 Y>ffi )Soak_2_➢armoa t= /.
10. WATER ZONES (depth):
11. DISINFECTION: Type CCO
12. CASEIO:
Pt* �air./Z K Z M' Vri N UG
pa® Te w
13.
14.
Feem To m-.
TTo '2n � otete,h
U,es, Te P .
Ts- SlotBhr
TPtels-
w,.,., To Pl.--fa- is.
15. SANDORAVELPACIC:
Do. Sim NSW
Prom f To m-
Pron To Pt
100 111211BY CHEWY THATT=WELL p
C ve1> 'i STANDARDS, — —
SIONATIME of
1)
Lormagriangi
Atom' /n en Show direction and distance in miles Rum at lean
Wdllbidaem two Stile Reads atCounty Rads.Include the reed
Bombes and ------mod some..
DIACOORDANCGB WIIH 1SAWCAC2C. WELL
RECORD HAS Blila1PROVVWUD TO INS MILL OWNER
�-'2--G‘
CONSTRUCTING THE WILL DATE
EOhmptae... to Roe Ebibn etWalsr Quay, Gnimadotater Sett 11116 Me Seiko Cesar- Iblitsb, NC
3709-1esR.msNwffMUM oddi al Sea OW-1 REV. 022001

gmit_9TDo`S5- Ft. �.L.._
has To Pt
Froma To Pc
I3. oltOtlt: Dept )ins:it/
PresL / To 7i0 Pt,�rr i re f u'e Mei
Prom_ To Ili
14. SCREEN Dap! DINS Sam Nodal
Proat,. t. To lit .. --ix m
1710A-- TeL F ia. in
IS. SANDVORAVE.PAC&
Ai Daps! Ski >A sia'
Prom To P1.
Fram To Ft,...---/
16. MARKS: Ili 0 AeA y — 111'O S 1'plit
1DOHUSSY fflWYTAASTOW WILL WASODNE1'AUC1iia)HACCORDAN IWIIBISA1iCACIC,WSIL
.,;i'47I
e;3
WELL CONSTRUCTION RECORD
North Carolina -Dapanneeto(E_,it mnaraaidNot e&Er--..a;DimofWaterQuality-GroundwaterSection
_NANA, % • ! �.� o eitymicATI011 / L2 1/
wnt coirr+rr.'tntaatteas eV room r am kw-09k)
irAnwfsaan socncnriwwli M/OCtA4tmWQroam
OfaroSee_l.l ,,% lua1
1. WEL USE (Check Appioabh Bm Raaidele" m " O bilabial ❑ Acietdaral
MageariosD Reemrory 0 Beet Pimp Waslmjst D Other D HOW, Lba Ike
2. xWELLLOCATION:
1 /3/ 20 Z 7rc
l•••rewa e...1..*midi a.,tatwa,raoam)
3. 5en)4 aMiffe
Addis /3 Buffer S&C-a" d/740
M/firb v ti . 2FS7S`c0
OrysTan Se Si Cede
As ens webs „
4. DATE DRILLED l-n -06
S. TOTAL DBPTHL 5 C� S
6. DOES WELL REPLACE mainly WELL? YES 0 NO a-
7. STATIC WATER LEVEL Bobo TapatCeriew qp PT.
i, weber rns.w'e perawa
& TOP OF CASING IS /r PT. Above Lend Sate
weee=to selsalik $&NC CfCAnL
9. YIELD (op ! . METHOD OF TEST T/r 7eil
10. WATER ZONES(dep00:
11. D131NPSCtlotttype tG/f Aso* /O 0?
12. CASIN): wmRiiblsas
rn UG
Midge Blimps Malley MIN
(d••ceprr.pdesb.a)
LarkedeAriastbade of wall location
LitltatkAo /Md.sower DIPSOTcpapsplaiccoup
WNW bet)
From To F Deacriplion
f Sr'?
nr
Show dbfetioi aid thrice in mike from at lank
two SW. Roods or Camay Ronde Web Ilia
Embus end alma reed res.
we//
•
STArIDUIOi, TA OF :I.. :•• . wow BIM wimp DTOT1i=WfLOWISIR
CaaT//- v�
f P �.c. C I —
.........,w.eamr, DATE
sibeteltSaMOStoeaMSS anger gully, GemmitwaterSae1Ns,Sa vmSinks Casks -Rd*ii.NC
t?dl9-t®6Met NsNBi?y3,bti.wain >r Allyn ow-1 REV. mom

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Cents - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
^, f: Q rb
v4/tfui:
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MORGANTON County: BURKE
5033 SILVER CRK CH. RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER HEATHER AVILA
Address 5033 SILVER CRK. CH. RD.
(Street or Route No.)
MORGANTON NC 28655
City or Town State Zip ('Me
4. DATE DRILLED 08/21/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
*Top of casing terminated alor below land surface requires a variance in accor-
dance with I5ANCAC 2C.0118
10 YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 55 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft.OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS: .
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #226 N. FROM POLKVILLE. LEFT ON HWY. #64 E.
LEFT ON SILVER CRK. RD. RT. ON SILVER CRK. CHURCH
RD. 1ST DRIVE ON LEFT PAST TOMMY LANE.
Co")
4-0
ry
to
o a
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
O ,/ i//AD F o%lt%llT r o? ". ,i / G
IGNATURE O PERS CONSTRUCTING L
riginal to Division of Water Quality, Groundwater Section within 30 days
rr'
DATE
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR ROBIN MCNEELY
WELL CONTRACTOR CERTIFICATION #: 2567
STATE WELL CONSTRUCTION PERMIT #:
I. WELL USE (Check Applicable Box): Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: MORGANTON County: BURKE
5033 SILVER CREEK CHURCH RD.
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER HEATHER AVILA
Address 5033 SILVER CREEK CHURCH RD.
(Street or Route No.)
MORGANTON NC 28655
City or Town State Zip Code
4. DATE DRILLED 09/27/06
5. TOTAL DEPTH 30
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES O. NO
8. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use"+'r if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
slop of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: S I tEL TAPE
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.6
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 30 Ft. 24 CEMENT
From To Ft. _
From _ To___ Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. CEMENT POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To Ft. _ inin.
From To Ft. in in
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From 20 To 30 Ft. 78M GRAVEL
From To__ _ Ft.
17. REMARKS:
DRILLING LOG
DEPTH
Formation Description
cl, n " '3
t ) J FJ 0
RECEIVED
OCT 17 2005
Asheville Regional Office
A fifer Pre,tertic,n
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #226N. FROM POLKVILLE. LEFT ON HWY. #64 E. LEFT
ON SILVER CRK. RD. RT. ON SILVER CRK. CHURCH RD. 1
ST DRIV EON LEFT PAST TOMMY LANE.
RECEIVED
DN. OF WATER QUALITY
OCT 0 6 2006
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TIIISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
i moo.
S NA OF PE
Submit original to Division of Wa
n7430
ONSTRUCT1NG WELL
ty, Groundwater Section within 30 days
7 2—a b
DATE
GW-1 REV. 12/99

1. WELL CONTRACTOR.
David Braswell
Well Contractor (Individual) Name
Braswell Welldrilling
Well Contractor Company Name
STREET ADDRESS —PO Box 70
—Newland NC 28657
City or Town State
Zip Code
Area code- Phone number _733-2602
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if appliwble)
DWQ or OTHER. PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED_11/2806
TIME COMPLETED-1:00
3. WELL LOCATION.
CITY: _Johnus ridge COUNTY Burk
AM ❑ PM %
_sunny drive upper creek acres
(Street Name, Numbers, Communiy, Subdivision, Lot No., Parcel, Zip
T�IPOGRAPHIC / LAND SETTING: Code)
ope OValley ❑Flat GRidge r Other
(check appropriate box)
LATITUDE _3�y' — _57.380-_
LONGITUDE-081— _52795
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ,PS L Topographic map
(location of well must be shown on a USGS lopo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME_JamesHeaton
STREET ADDRESS _sunny drive upper crk
johnus ridge NC
city or Town State —��
Zip Code
(_828 )-__964-5142
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:-420
b. DOES WELL REPLACE EXISTING WELL? YES G
c. WATER LEVEL Below Top of Casing: —100
(Use "+• if Above Top of Casing)
NO CI
FT.
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2 METHOD OF TEST_Blow down
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #_2133
f. DISINFECTION: Type hth
Amount-10oz
9. WATER ZONES (depth):
From_230 To_233 - From To
From To
From To
From To
From To
6. CASING:
Depth Thickness/
P Diameter Weight Material
From -1 To Ft.
From To Ft. _ 188 _gal
From — To Ft.
335'801
7. GROUT
Material Method
From 0 To 30 Ft. —net cement
From-30To 18FL —gravity
FromFt
To_—P gravel
.
SCREEN: Depth Diameter
Slot Size Material
From To
From Ft.in. ____ _ in.
To
From To Ft.___in. __ in.
Ft. in.
in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To
From To
From To
Ft.
Ft.
Ft.
10. DRILLING LOG
From To
Formation Description
_0-180 limestone
180-230 _granite
_230-233 _shale 2gpm
233-340 granite
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY O
RECORD HAS BEEN PROVIDED TO THE WELL aNNER IS
1 �� ✓l
SIGNA IR OF CE IFIE. L CONTRACTOR
DATE
David Braswel
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617
Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

Henn Cae*ia . Depwertent of Scrawnier* end Natural Meourt:ee - [Salon el WMN OuNiy • WotmdwNtl Section
1131 Glee $rods Coen • Rahlak N.C. f70F/e34Fhena (11I} 7334221
WELL CONSTRUCTION RECORD wou. CONTRACTOR. /9:212' c eK,gits • i f/A-17
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT.:
1. WELL. USEIPIMI Anna lsa)t Rsddanda Eck —Wilkins' CI Induwal 0 A9rkukwsl ❑ Manner„, 0
knows Li Hem Pump wstn In)eelbn 0 Outer 0 It UtMt. LW use.
z. WELL LOCATION: (Show IkHch of Ms baton below)
Hansa Tonne �/7p.'9, LGe•7 Crony '- �E e^
card Amy Moen oaratiy, sr asts n and tea Ng DRILLING LOG
3. OWNER t �—^/ r 2Ztim Is
Adana /D oraL 1�.1 �
%' ,c /r`� a� iset e_
delt
Cmat�
4. DATE DRILLED fD
3. TOTAL DEPTH /YSS'
S. Curi1NOS COLLECTED YES CD NOB--
r. DOES WELL REPLACE EXL$11HG WELL? YES ❑ NOD--
S. STATIC WATER LEVEL Maw Top of Cuing: FT.
(UN'a' a Mae TW a Cane) eV\
E. TOP OF CASINO IS / ',nit FT. Above Land Who'
A&F WELL DRILLIN&
AND PUMP SERVTCtT
911 Hwy. Busir.es:
__Qa1 TH Bostic, NC 21, •
FearaAnDueryws+ 828-247-?7
\I
RN seam wnu*. rd Haw Yew MIS sedan repwarsiee a wars IF MOW'�©
donee wM 1SA NCAC $C VIII
It '(IELD (Open): O MEDIOD OF TESY,*'
11. WATER ZONES (depth): /+i.fs'
TOFF
1z.CHLORINATION: Typo EAALi%•an_ NlgYnl/n4d•lek_ It additional apnea Ymead me WAN Iccan
17. CASINO: 7o
W$ TNWre.
Depth Dams a Waste t. Maeda
Fran To -.' = FL 4'= ice/ 1 e1
Froln To Fl.
Fran To FL
14. GROUT:
Nadal
From r/lea TO as r PL t sr7✓.,/"se-
TO FL
1S. SCREEN:
Depth Dinar Slot Ski Maledd
From To Ft Ir1. In.
From ..__ To FL_ In. In.
From _._ To FLIn. In.
1E. SANOIORAYELPACK:
Depth Size Mahal
From . To F1.
From To FL
17. REMARKS:
Molhod
LOrallgeiBISIELEa
Paw dksdhn and Samna km at Immo Ewe
Roadster Darr reap rdeenoa pal RO
A&F WELL DRILL
AND PUMP SERVIC;` .>;C
911 Hwy Busint,.
Bostic, NC 280 ' o
828-247.17
I PO HERESY CERTIFY THAT THIS WEU. WAS CONSTRUCTEO *1 ACCORDANCE VAIN ISR /CAC IC. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OnhErt.
FOR OFFICE USE ONLY
Owd Na
aedr Me.
—44-0 ..a-- -7.Le / 6 <'-- C
*o$IAT PRE Of PE CONPTPUCTIrG INS W1tl OD 13
Eabrtn.SMn+N Mkt d Welu as Oillea s. "MOO t1MtY170 C*rf pm FIEY. OM
-24-2B0.3 110 11: 31RM ID:
PAGE:I

WELL CONSTRUCTION RECORD
North Carolina - Departrnent of Environment and Natural Resources - Division of Water3 ') 4 a 2
Quality
-GroundwaterSection/a 6 )
WELL, CONTRACTOR (INDIVIDUAL) NAME. (print) CERTIFICATIONN Zrf.7Z
WELL CONTRACTOR COMPANY NAME III CPS at I �/e l/�2,-��� d. PHONE # (W) 52V-OO C
STATE WELL CONSTRUCTION PERMITS _ o ASSOCIA Q PERMIT'S
Of applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential P Municipal/Public ❑ Industrial O Agricultural ❑ Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIQN:
Nearest Town:///Otr/�0Ytfl Coamy,S(erkp
N29 3 `J.�Liroe Y'ri✓e
(Street Name, Numbers, Community, Subdivision, lot No., Zip Code)
3. OWNER / rpCn
Address 'L93 3r1 ✓e (degmea/mimoea/a000ndr)
_ Route No.) Lantude/longnude source:OOPSOTopograp)uc map
City or T
Morgtn s �►C pt&'(p (d�ek box)
awnJ Zip Code QUM D do 1N s T O(}
(R28 )-tf(o0- ?725 From To Formation Description
Topographic/Land setting
Midge °slope OValley OFlat
(cheek appropriate box)
Latitude/longitude of well location
Area Bodo- Phone number
4. DATE DRILLED 07-2(a -GY$
5. TOTAL DEPTH: 7C5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IN
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING IS if (Use "+" if Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated atlor below land surface regains a
variance in accordance with ISA NCAC 2C .011t
9. YIELD (gpm): / METHOD OF TEST By IQi r Tcs*
10. WATER ZONES (depth)::I,,
11. DISINFECTION: Type E1444 Yak
12. CASING:
, Diameter
FrorrLQ_ ToDDepth
Ft. (p
From To Ft.
From To FL
13. GROUT: Depth
From 0 To 20
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From T
16. REMARKS:
Ft.
Amount
Wall Thickness
or Vilveiet/Ftn!
Ft.
Diameter Slot Size
Fk in, in.
Ft. in. in.
!� Mnhc
Material
Size Material
Ft.
o Ft.
LOCATION IETCH
Z'7 Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
vt/ 6,
wEw
t
E�
ave.
ve (I4 V ORECEIVEDWTR ALITY
s
NOV 1 4 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND AR7�, AND THAT A COPY OF THi RECORD HAS BEEN PROVIDED TO THE WELL OWNER
G5Glace 107,7 a6,
TURE OF PERSON ST1rU O THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Semite Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

Material
Ft. Milip
Wall Thiclmesa
or Weight/Ft. Material
GALD sma
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:
Method
Fr7 I2Fi1
(deOea/miouow/aewade)
Latitude/longitude source:❑GPS❑Topographic map
1�EPTH (check box)
From To DRILLINr LOG
Formation Description
LOCATION SKETtJt
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
(oil Al
"Iio
"nF,v`TEr QUALITY
NOV 1 4 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT PY OF THIS I CORD HAS BEEN PROVIDED TO THE WELL OWNER
Lied
SIGNATURE OF PERSON STR1 G THE WELL
:334
WELL CONSTRUCTION RECORD 61
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CRAD HARThESS
WELL CONTRACTOR COMPANY NAME maw war, MU M CO. CENT2 2931
STATE WELL CONSTRUCTION PERMITS PHONE N B2R) 7R1 324-0035
(if applicable) OCIATED WQ PERMITS
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: MIt4NItN County EKE Topographic/Land /L end setting
5708 FISHHATCI-M R&D ❑Ridge ❑SlopSlope Malley ❑Flat
(Street Name, Number, Community, Subdivision, Ina Nn r.. r.,.r.. Latitude/longitude
_ (check appropriate box)
3. OWNER: FOBIRLE WRITS
Address 4405 SU'1IW RD.
M.awe
Nt or Route No.) , IC 28655
City or Town State Zip Code
( 828 )- 584-2026
Area code. Phone number
4. DATE DRILLED
5. TOTAL DEPTH: +5~
6. DOES WELL REPLACE DUSTING WELL? YES ❑ NO W(
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING IS 2 (Use "F" if Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated at/or bete, land Barba requires a
variance la accordance with 1SA NCAC 2C.011t
9. YIELD (gpm): 10 METHOD OF TEST BY AIR TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type HIH TABS Amount 65
12. CASING:
From 0 Pot 1cIPt. Jr
From To Ft.
From To FL_
13. GROUT: Depth
From 0 To 70
From To
QS-71-cK
DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ouices - Division of Water Quality � Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME print) `1 Y' 4C SS CER7•r?ICATIOpr}a
WELL CONTRACTOR COMPANY NAME Hickory( Weft 2.-/ //i i• 4B PHONE # JVP) 7 4li3)
STATE WELL CONSTRUCTION PERMIT# (f ASSOCIA�''1�ED) WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residentialb Municipal/Public 0 Industrial ❑ Agricultural O
Monitoring O Recovery O Heat Pump Water Injection ° Other ° If Other, List Use
2. WELL LOCATIJOONN•
NearestTown:2('Qrd Countya/irkp
7342 Knox Ave. 4802
(Street Name, Number, Community, Subdivision, Lot No., Zip Code)
3. OWNER:JQSSQ{Z r ffder ti. pi4rit�nt
Address fo/7.San% ,3hfrin0
�rQQ aRouutte No.)
City i rt t lolo e 48(oSS
Tap Code
Area code- Phone comber
4. DATE DRILLED 0% 20-061
5. TOTAL DEPTH: US
1tp 461 G`
Topographic/Land setting
°Ridge OSlope °Valley OFlat
(check appropriate box)
Latitudes/longitude of well location
-Re4/25,14 a (droaa/mimdehmonde)
Latitude/longitude source:OGPSOTopographic map
(sheet box)
DRILLING Lon
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES O NO El
7. STATIC WATER LEVEL Below Top of Casing:. (60 FT.
8. TOP OF CASING IS ...9 FT.
" if Above Top of Casing)
FT. Above Land Surface*
*Tap of casing terminated atAw below land sorbet requires a
variance In accordance with ISA NCAC 2C Am.
9. YIELD (gpm): 20 METHOD OF TEST.'.kr 7eve-
10. WATER ZONES (depth):
11. DISINFECTION: TypefT
12. CASING:
From O _ TDo %'3S Ft. girt
From To Ft`__
From To Ft
13. GROUT: Depth Metuod
From C To 20 Ft. on re mired
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Size Material
Amount (00
Wall Thickness
or Weight/Ft Mataie]
Bnl✓. _
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Depth
From To Ft
From To Ft,
iV
J4r
J1FfDD.CITY
0Li12 /ZIDEE LFIr
�NOV 1 4'22006
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 RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON.CONSIIRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mal) Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 R 4 4 2
North Carolina - Department of Environment and Natural ur - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME L,ha (rite S CER7VICATTON as -20/
WELL CONTRACTOR COMPANY NAME /TI elconj / ri //f a. PHONE s 621137/
STATE WELL
CONSTRUCTION
PERMITS ASSOCIA WO PEWIT*
(if applicable) of applicable)
1. WELL USE (Check Applicable Box): Residential S' MtmicipaIPublio O Industrial D Agricultural D
Monitoring O Recovery O Heat Pump Water Injection D Other Q If Other, List Use
2. WELL LOCATION:
Nearest Tt :M n. CountyJ3urKp
LhoU, n n
(Street Name, Numbers, Commedtj, Salitrbion, Ica No, Zip Code)
3. OWNER: l Xl n/r
Address
(Street oRouts No.)
Mnrrtnnfow WC (055
(Sty&Town Saba Zip Code
WO' ACTS
Topographic/Land setting
ORidge DSlope OValley OFlat
Wyk eppmpSte con)
Latitude/longitude of well location
(sue)
Latitude/longitude source.: OPSD opographic map
o
DEMI DRILLING LO(;
From To Formation Description
Ana code- Phone wwmm
4. DATE DRILLED/1lj
b�grr__
-/V-D '
5. TOTAL DEPTH: c zi
6. DOES WELL REPLACE EXISTING WELL? YES El NO O
7. STATIC WATER LEVEL Below Top of Casing: 900 FT.
Wee "e"ifAbove Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
*Top Madan terminated Mier below land autos rotten a
rarlonee In accordant* web ISA NCAC 2C .011a.
10. WATER ZONES (depth):METHOD OF TESTR1,4 - T &
11. DISINFECTION: Type H7W Totes Amount
12. CASING: Wan Thitess
Depth
Fronti_Q_ To93 Pr G'tF" tlitSt
C�
LOCATION Sln?TCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Fromm___ To FL S /
From_ To FL /�
13. GROUT: �t mat
From D To o 2^�
D FL 0 27 1-to
From To Ft.
14. SCREEN: Depth Diameter Slot Size Ms/trial
Prom_ To FL__in, in.
Front__, To Ft in, In,
15. SAND/GRAVEL PACK
Depth Size Material
From To FL
From To FL
47,77
s
Div RECEIVED (DUALITY
.- NOV J 4 2006
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTFH ISA NCAC 2C, WELL
CONSlRUG?)ON.SIANDARDS, AND THAT A CO =jOyF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
l/116(4
SIGNATURE 0 e 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. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD `'
North Carolina - Department of Environment and Natural Rego es - Division of Water
WELL CONTRACTOR Quality - GroundwaterI Section ��
ONnlvmuAla NAME Q rfn1P,�S n CER77PrcATION d nS'Xl/
WELL CONTRACTOR COMPANY NAIMI 4IC.knrw (M e /1r ri11inq. (x,
STATE WELL CONSTRUCTION PERMITS Q18DPHONE s JP�t132 -po3z
(ifappliable) ASSOCIA WQPERMrl1
ffeppliable)
1. WELL USE (Chec( Applicable Box): Residential (It. MtmicipaYPnblic 0 Industrial CI Agricultural 0
Monitoring 0 Recovery 0 Heal Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town �n Di,{'Q YI County Topographic/Land setting
.S'74' Jet fj sn , (D a ORidge 031ope OVallay OFIat
risto boa)
(Street Norm, Numbers, Cammimlt, Su Lot No. Tip Cab) Lstitad(ldlongitudebeck of
well 3. oWNER:.n $ Chr-i sly ec✓y)er- location
Address21 `! froMn eunice P.de
(Sacco ar Route Na) Latitude/longitude sou ce:OGPSOTopographic map
/KOr g. mj-en Art t boa)
own Stye Z'Cbds F MTo D
Formation DDRILLTGLOG
escription
Ana code- Thom
4. DATE DRILLED (18 2414
5. TOTAL DEPTH: 625'
6. DOES WELL REPLACE EXISTING WELL? YES la-
7. STATIC WATER LEVEL Below Top of Casing:
8. TOP OF CASING IS 2(We "he if Above Tap ofCasba)
FT. Above Land Surface*
'Top at taunt terminated she bow hail whet require a
mime be saordnaa/� ISA NCAC 2C Ala
7
9. YIELD(gpm): METHOD OFTESTOyAir TeS1
10. WATER ZONES (depth):
FECTION:OCATION sic r[�tr
11. DISIN
Type jt-77-1 Tnbb mama I/O//0 Show direction and distance in miles from at least
12. CASING: Wag Thickoea two State Roads or
a1 numbers and common road names Roads. Include the road
Depth
Fromm_ To47 Ft.—i2A_ gDiareter � /4 OS�if.
From_ To FLU_
From__ To
13. GROUT: Depth A/IMaterial
Fro
Front_Q_ To 20 FL flr0/!l- ell VFLL
To Ft.
14. FrontSCREEN: TDepth Dimmer er Slot Size Material 6 ag //tux thy
Prom To Rio in.
k E
15. SAND/GRAVEL PACK
From Tip FL Size Material `yea AP • .. //Ipo9 b
From To FL r RECEIVED
S DIV OF WATER QUALITY
16. REMARKS:
NOV 1 4 206
I DO HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTIONSI:A/WARDS, AND THAT A COPY OP THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
eCt i� SIGNATURE OF PUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone Ne. [phone], within 30 dsye.
OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvironment and N lurid
WELL CONTRACTOR (INDIVIDUAL) NAME (prW
WELL CONTRACTOR COMPANY NAME . 1 r.KO
STATE WELL CONSTRUCTION PERMIT'S
(ifapplicable)
n /ng
,ASSOCIATED � raRMrrs
(if applicable)
- Division of Water Quality - Groundwater Section
CERTIFICATION af,/.Zt1G1 ;,4a
PHONE 1 fA7 .32W'W33)_t'S.3
fit
1. WELL USE (Check Applicable Box): Residential iff. Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 other 0 If Other, List Use
2. WELL LOCATION:
NearestTowir MOCQ.444/ 1M . Cotmty3i .0 rite
�iw y ) 2/ (Aforr-k..
N Sundt
(Street Name, bets,CcmmmdtA ivi�don,Lot Non
(�Zip Cede)
3.OWNER:i��IY1 earned $o/! 'Pnfer)-(-
Address 1'r� . ' 1 (43(0
(slr etaa�pNo.)
Mnrgiti.4srta Nip c8Lo55
City or Stele Zip Cade
(•)-
Area code- Plane number
4. DATE DRILLED 1 0- i `i -0(0
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES C NO 11.
7. STATIC WATER LEVEL Below Top ofCasing: 70 FT.
(Use '4** if Above Tap of Casing)
8. TOP OF CASING IS 0Z FT. Above Land Surface*
*Top of ragtag terminated ova blow lard surface require a
variance In morda work ISA NCAC 2C .0113.
9. YIELD (gpm): METHOD OF T'ESTZy Air 11S l-
10. WATER ZONES (depth):
11. DISINFECTION: Type NT Ioks Amount
12. CASING: WafltVTMdmefa
Depth Diameter Q
oriWe�� f)C 7 numbers and common road names.
From To /0 FL WV"
Topographic/Land setting
°Ridge °Slope °Valley °Flat
(meek appropriate box)
Latitude/longitude of well location
(degree+/)
LatitudeAongit uie soarce:°GPSDTopographic map
(eke* boa)
DEEni DRILLING LOG
From To Formation Description
RECEIVED
DIV. OF WATER 9l IALITY
JAN 0 S 2007
Front_ To Ft.
From To FL
13. GROUTL Depth /1Material
Front al To 90 Ft &rru (-
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.
LOCATION SKETCH
Show direction and distance in miles Rom at least
two State Roads or County Roads. Include the road
6'
Method {,
rtnod
VY
IW L
5
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT
�ACOPY O'F/TIES RECO' a 1145 BERN PROVIDED TO THE WEIL OWNER
r
I..kett,1 .412-/- A /D-360(0
SIGNATURE OF PERSON CONSTR i THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center-RaMgb, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
Nardi Carolina - Department of Environment and Natural Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME /I (pit i / rf11 eS S �� CERTIFICATION x 2901
WELL CONTRACTOR COMPANY NAME klckct//(Drr/t'iny e//��). PRONE d fk2f )32i-ee as -
STATE WELL CONSTRUCTION PERMIT ASSOCIATED WQ PERMIT()
if applicable) (if linable
i t
1. WELL USE (Check Applicable Box): Residential CB Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring O Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: Nearest Town:.blotyantOr�rt County `,�urke
Sit its el Ter .4✓e.
(Saner Name. Numbs , Community, Subdivision, Lot No., Zip Code)
3. OWNER: dREP pit Masser
Address .57t ft, 'Bee 7?et iVp
(Street or Rout No.)
an #O*1 AIC a8eo65
City Os own Stale tip Code
( rat )-Erfee,•�1OrF7
Ara code- Piece camber
4. DATE DRILLED 12 -04-e4s
5. TOTAL DEPTH' 3/o6
6. DOES WELL REPLACE EXISTING WELL? YES El NO 0
7. STATIC WATER LEVEL Below Top of Casing: /69 FT.
(U.e's- ifAbove Top of Canes)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of cuing terminated ettor below Ind surface requiem ■
variance In srcordnct with 1SA NCAC 2C Ala
9. YIELD (pm). /.Z MET1ieri OF TgcT 3/ 4
10, WATER ZONES (depth):
11. %ISiir.hTivk. Typo 12. CASING:
Depth
From 0 To I/O Ft.
From 1'o Ft.
From To Ft
13. GROUT: Depth
From 0 To 22
From To
14. SCREEN: Depth
Front— To
From______ To
15. SAND/GRAVEL PACK
Depth
From T
From To Ft.
/Ji/4 Tc4r2.0 A...enint AZ,
WAR Thickness
ocWdg t _Matmiti
'We riqsftr
Mattfal
Ft. t} r liar
Ft.
Mathod
rtr
Topographic/Land setting
ClRidge ❑Slope ❑Valley ❑Fiat
(check appropriate box)
Latitude/longitude of well location
(depeealm mrmrseeoods)
Latitude/longitude source:OGPSCITopographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
Diameter Slot Sim medal
Ft m. in.
t_ F.___in. in.
Size Material
o Ft
16. REMARKS:
t Oc�T1ON SKETCH
Snow di-et.ion and distance in mifles from at least
two State Roads or County Reads. Include the road
,n .e,o and common read names.
RECEIVED
OF WATER QUALITY
.GPM 0 5 2007
I DO HEREBY CERTIFY THAT THIS WELL WAS C QNSERUCTED IN AWJRDANCE WITH I SA NCAC 2C, WFI 1
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIE WELL OWNER
n� .dJJ /a-//-c;
SIGNATURE OF PERS CONSTRUCTING THE W st f DATE
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Serice Center - Raleigh, NC
27699-1636 Phone No. [phone], within 3aJ days. f3 W 1 REV. V. OMNI

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELLCONTRACTOR:
Nair- Motx-s
W e66 Contractor (Individual) Name
4cLjgnecJ vo2tt. ; r.S%i(lA
Well Contractor Company Name (,
STREET ADDRESS a a a t P arrte Recki
City or Town L cs ko 9
p Code
(gag} al t-43°o
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #prapp*cabtel
STATE WELL PERMIT#(Dapparat,e)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check AppfictleElea): Residential Water StpplycV
DATE DRILLED/a -/ % -0t0
TIME COMPLETED AM CI PM or/
3. WELL LOCA719pN�•
CITY: ([/t/2) COUNTY
l"1SO l altv3antes Cr tc.r{':NDpehi25
(Street Name. Numbers. Community. Sublri.ision. Lon No.. Pandit Ira Code)
TOPOG_RA)p$fIC / LAND SETTING:
❑Sbi
pe 38Vaiey OFM ❑Ridge ❑Other
(Check appropriate bog _ /
LATITUDE 3 16 IA;
y� J jI
LONGITUDE, I O 55
Iatitude/longitude source: PS OTopographic map
(location ofueimust be sham on a USGS topo map and
attached to This fora+ !not using GPS)
4. WELL OWNER ),"
OWNER'S NAME G/%/
cc CI
c"no-to ttJar_ ri sao t
City or Town State/ Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS •( ECK \ 003
(?bt( - 3ta-3t45
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: )ioc
b. DOES WELL REPLACE EXISTING WELL? YvYES L3 NO (
c. WATER LEVEL Below Top of Casing L[ FT.
(Use '+• if AhOVe Top of Casing)
d. TOP OF CASING IS i VZ FT. Above Land Surface•.
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .011&n\
e. YIELD(gpm): a- METHOD OF TEST A.,r
3a3c\
(pot 3
f. DISINFECTION: Type 1tT7-1 Amount r.a-ix,Wd-3
g. WATER ZONES (depth):
Frain L/L/l/ To r<0 From To
From 960 To Q/2 From To
From To From To
6. CASING: Thiclaiessf
Depth _ Diameter Weight
From %j To / 7 Ft,
From To Ft.
From To - FL
7. GROUT: Depth Matey
Ram 0 To (i Ft Cb,
% .cwGsc �" Method
FromPa,.�rLq
From To FL
From To Ft.
& SCREEN: Depth Diameter Slot Size Materiel
Foam To FL in. in.
Fran To FL in, in.
From To Ft in. it.
A SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
From To Ft
10. DRIWNG LOG
From To
O• lie)
/'eoC Orly pas tion
o'.S— / 0 _ ..
MOO p tie nrAylt
11. REMARKS:
REL,tivtL
UI%. OF WATEk QUALITY
JAN 0 G 200?
WOHERESY CERIFYTWINS WELL WAS CONSWUCIEED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCII W STANDARDS. AND IINTA COPY OFT9a
RECORD BEEN PROVIDED TODIE WELL OWNER.
SIG ‘URE OF CERTIFIED WELL CONTRACTOR DATE
Clear ICS M05CS
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, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL. CONTRACTOR:
Char i eS , f `o seS
Well Contractor (Individual) Name
OtA) T e 1i ett I r; ii;
Well Contractor Company Name STREET ADDRESS a a a t (lump Rot tl
owakoo,�k\C' f$(ooci
City or Town $�} Zip Code
aLl1-1430d
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #fdappliaae)
STATE WELL PERMIT#frtapplicable)
DWQ or OTHER PERMIT #fd applicable)
WELL USE (Check Applicable Box Residemial Water Supply8r.
DATE DRILLED IO2-�/
/
TIME COMPLETED //J f 6& AM p PMpt
(7)t(> 3ga-3R15
Area code - Phone number
5. WELL DETAILS: joJ --
a. TOTAL DEPTH: /
3. WELL LOCATIO - ,,�
CITY: (/ z- 'J COUNTY f3 A- t
(Street Name. Numoars Communay, Subdmaion, Let No.. Parcel. rip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flot ❑Ridge ❑Other_
(check appropriate boo .. /
LATITUDE 3 S^ter VS:L(/
LONGITUDE' c 5 _
Latitude/longitude source: fllth' °Topographic map
(location of weltmust be shown on a USGS tops map and
attached to this farm foot using GPS)
a. WELL OWNER ' JJ
OWNER'S NAME (pre .; dent/L.
STREET ADDRESS D . Ecic 1.003
CLRnr� �t-te .2 T 1
City or Town e aOZi C
try Code
May be in deems,
minors, seconds or
in a decimal format
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Vel
c. WATER LEVEL BelowTop of Casing: <-t/Q FT.
(Use if AboverTop of Casing)
d. TOP OF CASING IS / ) J .
FT. Above Land Surface*
'Top d casing terminated et/or below land surface mayay require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1(3 METHOD OF TEST k i
3a39
f. DISINFECTION: Type t4-1--p Amount
g. WATER ZONES (depth):
From 1/20 To
Fran 1P /d3 To _fan_
From To
B. CASING: Thickness/
Depth......./1 Diameter
From 0 To /
From To Ft
From To
From
Fran
From
7. GROUT: Depth
From V To
From To
From To
B. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
To
To
To
10. DRILLING LOG
FrompTo
L/ .a 0
�D Lit
dlx+C7
0
7p ?e1
-79
A.°
420
11. REMARKS:
FL
To
To
To
Material Method
Ft -it Pta,.irC-Ik
Ft
Ft
Diameter Slot Sine Material
FL in. In.
FL 41. in.
FL in. _ in.
Size Material
FL
Ft.
Ft.
Poplar n
r_LI et',
DIV, OF WATCR QUALITY
IAN 0 6 2007
WO HEREBY CERTFYTHAT1MS WELL WAS CONSTRUCTED NA nANCE WmH
ISA NCAC 2C. WELL CONSIRUC nON STAIMARna. AND THJTA COPY OMB
1148 BEEN(P50VKD®TOTINNE WELL OWNER
J ) �/
((f11/�-4J-- .% n2r �0)-)/-, #
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
C4ar itS m ses
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-1a
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 8
.3 3�
333848
1. WELL CONTRACTOR: -
UR0.r, es i t0 S
Weir Contractor (Individual) Name
(dvq.nc el W sit . r; Masa
Well Contractor Company Name
STREET ADDRESS a a a t PU-mp Roca_bWba aNIC, ct (oo'1
City or Town Stag Zip Cale
(gay, a4 (-4300
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mir applicable)
STATE WELL PERMITS(a applicable)
DWQ or OTHER PERIWT!(d applicable)
WELL USE (CheckApp�r�iSla Box): Residential Water Supply
DATE DRILLED !�—L��L)�•
TIME COMPLETED /1/4 60 AM WI;
3. WELL LOCA1ITI - /�, /l
CITY: /Y e.50 COUNTY 614- ^/\+-
/ /�`JO Go,/IC ,3',,ne5weal es
(Street Name. Numbers. Cwnmrnny. 6ubdvis a. Lot No, Parcel, Zip Code
TOPOGRAP)IIC 1 LAND SETTING:
cslopo gvaaey UFIat ❑Ridge ❑Other
(them appropriate box
LATITUDE �33 .7 opc' I/5 >70
b
LONGITUDE Lo J Jr (r�-�
Latitude/longitude source: 1E PS °Topographic map
(location ofwell must be shown on a USGS topo map and
attached to this form snot ushg GPS)
4. WELL OWNER
OWNER'S NAME crecenk
tJG
STREET ADDRESS r.0 . 8QC 1. 003
Cketrlc 14c-a&l0I
Cityor Tcwn State Zip Cade
( 70Y)- 38-31S7
Area code- Phone number
May be in degrees,
minutes, seconds or
in a decal format
5. WELL DETAILS:
,
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YE
c. WATER LEVEL Below Top of Casing j Z� FT.
(Use if Above )Top d Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing Mutated at/or below land surface may require
a variance in as darcewith 15A NCAC 2C.0118. (�\
e. YIELD(gpm): [m5j/ METHOD OF TEST f-br
f. DISINFECTION: Type l- {'l3 AmarMa___¢,Wrj3
g. WATER ZONES (depth):
Rom 215 To _2 ctt) From To
Born 9d 0 To G / (;) From To
From To Fran To
6. CASING: Thicbress(
Weight Er
From Depth Diameter
To
Framf_To_ Ft
From To Ft
7. GROUT: Depth !1 Material
From 6 To —FL emn.C: G,e.
Fron To FL
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
Ram To FL in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
Foxe To FL
Ram To Ft.
From To Ft.
10. DRIUJNG LAG
Fro
m O'}D
4 O !/
!a0 earS
O
25 c
(Ev %inS
11. REMARKS:
Size Material
Formation, pe ep
/'eta el.rf -tion
e- rtn •
eke
t(tt.tIVEu
inn/ rip WATER QUALI
JAN 06 200?
WO IENEBY CEmffYTNAT MIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA WIC 2C. WELL consmucnota
STANDARDS.
ANDAOWNER.
N AND THATACOPY Or NW
SE
RECORD HAS EN
SI-TURE OF CERTIFIED WELL CONTRACTOR DATE
Car Its (yioses
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-1a
Rev. 7105

*kW RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # D-dS 7
L CONTRACTOR:
T
Well Contractor (Individu Name
r t.e, t)L-A\ 0Tvl\tbv)
Well Contractor Company Name
STREET ADDRESS f1 Ei a `, — S--) reoc3 5-
N 1 L \U t' � r3-y, C,o \•
City a Town State Zip Code
(I)`n>-i)7- 0a-Gb
A a code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(# applicable)
STATE WELL PERMIT#(# applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring D MunicipeWublic D
Industrial/Commercial 0 Agricultural 0 Recovery Injection CI
Irdgationo Other 0 (list use)
DATE DRILLED 5- )-3 - [':c,
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY: I(F T
r
tg�e
COUNTY l.v;e
(Street Name. Numbers, Community, Sobdletelon, Lot No.. Parcel, Zip Code)
\TOPOGRAPHIC / LAND SETTING:
Slope [Valley [Flat ❑Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. FACILITY -is We name of the business where The wet l loaded.
FACILITY ID #(0 applicable)
NAME OF FACILITY
May be in degrees,
minutes, seconds or
in a decimal fonnat
STREET ADDRESS
City or Town
CONTACT PERSON
MAILING ADDRESS
111
City Town State Zip Code
Area code - Phone number
S. WELL DETAILS:
a TOTAL DEPTH: 2 U O
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: C 0 FT.
(Use's if Above Top of Casing{
State Zip Code
6)410
,g4 c.* ' 4. e/15
a,
33 :65
e. YIELD (gpm):
t. DISINFECTION: Type
g. WATER ZONES (depth):
From y7/ TOTo t %From To
From /r l' (i To From To
Fran Y To From To
6. CASING:
d. TOP OF CASING IS ,}- FT. Above Land Surface
'Top of casing ter atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
METHOD OF TESTj1J
1± !/Amount r3 Cl / S
Thickness/
Dept f�Iameter litleight Material
From To Ft. L-I C .,j ,(.I•
From To Ft. i
From To FL
7. GROUT: Depth ` Material
From 0 To}-0 FL U`ftf L;l ipc,Ck
From To FL J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. _ in.
From To Ft in. ___ in.
From To Ft. in. In.
9. SAND/GRAVEL PACK:
Fran To FL
Fran To Ft.
From To FL
Method
10. DRILLING LOG
From0 5 7
Size -_. Material _
. Fo(matioft DeessCOyytiption
U 16ys.,
3c� 50{-.
-R(10 . (\Qi 3-(-NC ti-4,1 t"
VCIN
lilt re '
11. REMARKS:
RECEIVED
city, of I.FR Oh1Ht
7-TU 2 tj 19U/
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C. WELL CONSTRUCRON STANDARDS. AND THAT A COPY OF THIS
PR) ED TO THE WELL OWNER.
if l vS • A
elipNATURE OF CER IFIE?W ELL CONTRACTOR DATE
ihi&b�s�\ _ e, >t
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
fY
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-tb
Rev. 7/05

WELL CONSTRUCTION RECORD
Notth Carolina - Depanmatt of Environment andpIszal RnO1tw ivisiom of Water Quality - Orouodwata Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1S 0) (Y 1 j rc., C/L. COWtunon sai)S 7
was coNTawcroa.CoaWANYMOM PRICF WELL DPILLIN„ INC. Tama a $29 327 02E8
STATE WELL CONSTRUCTION PERT TI I RSOCIATED WQ PRRarrre
Of applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential E Mwicipal/PubUC 0 Industrial O Apiednnal O
Monitoring 13 Recovay ❑ Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATRi
Nearest Town: /. 42/d1 .,e
Cmmty 4 1,'—.e
(Seas Name. Numbers. Comsmir. Slitetfim. Lot Ne.. 11e Code)
3. OWNER•—C -5-4 r
Address ty (/. /g'i ity4
, r.�.>(b4 -c ag--6,r5
ty
Ana code. Pbsw maba
4. DATE DRILLED I (l - % R
S. TOTAL DEPTH: u fl5
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing:
Nitro' if *ben Top dCubt)
8. TOP OF CASING 1S 1-4j FT. Above Land Surface'
Kap fleets tasdeaed suer haw lad etas roan a
vaebou In aemreeme *MI ISA NCAC 2C .0111.
9. YL•Z!'(gpm): td' T.t',.o.OFTEST
It WATER ZONES (depth):
11. DISINFECTION:Type.
12. CASING:
Froo�_ToD)S
From __ To
From To
13. GROUT: Dealt
FrotrfaTo 'a-C1
From_ To
14. SCREEN: Depth
Erato_ To
From To
13. SAND/GRAVEL PACK:
Depth
From_,_To
Horn _To
Wall Thickness
Ft Ft err cati 9
Ft
FL�r?ant Mahod
Pt
Diameaer Slot She Mandel
Ft—ht. in.
Ft.
FL
Sire Material
JT opographic/Land setting
Ridge OSlope OValley OFlat
(cheek 1pp/omit s tea)
Latidtddloogimde of well location
333171
Lsdludeilottgimde sourc PSSOOTopographic map
(dock bin)
DEMI DRILLING LOQ
From 0 ! To0 S ForRi6�9 PtiOn
I Cc 'L00
w3e> LQ 5
LOCATION SKEIC$
Show direction and distance in miles from at least
two Stara Roads or County Roads. Include the road
numbers and common mad names.
1Le'7
RECEIVED J
}IV OF 1NPTFR Q11R1M
`-EI3 ? 0 n07
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2G WELL
CONSTRUCTION STANDARDS, AND THAT A COPY 193 BEEN PROVIDED TO THE WII1.Ow�
SIGNATURE OF ON cO /ONC�,S/RUCTING Ti WELL DATE
Submit the original to the Division of Water Quality, Groundwater Seet io■,16.36 Mao Service Caner - Reletgr, NC
27699-106 Prone Na (919) 7313221, within 30 days, GW-I REV. 07n001

WELL CONSTRUCTION RECORD
North Carolina - Department of Encirmunatt amp Res - Division of Water
I Quality • Groundwater Section �f
WELL CONE/ACTOR OWDIV/DUALi NAM (pith Q / J tosyt t CERTFICATIONs 95S
watt coNTRwcroaconstant matt PRICF WELL DPILLIC„ INC. rRONar(929 327 026.
STATE WELL CONSTRUCTION PERMITS j esOLTATED WQ PERMIT'
re applicable) j (if?Ilable)
1. WELL USE (Check Applicable Box): Residential Mtmicipal/publc 0 Indashial O Agieulnnal ❑
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIODAL• " ke
Nearest Town: 15 () v \ C . CountyWY) Y) n c,l 11 �rI nSsrgxu tii�d stating
Hwy �$ Sat.�h ) �d � � �
i ga OS Ices
Dew Noakes. Ceaaaaoy. Subdtvhim. Lot No.. Sp Cads)
I.mntdr2laogimde of well location
3. OWNE& 3 n— r . c s
Address b9ri`t 1rw'I
ec�^^ill (S.wwRaeaitio
1 j2y1nC5 Nc- .-%61,1
$7N-1Jl5
Zip Cab
Are ado- Moo aster
4. DATE DRILLED i - 11- Cc
S. TOTAL DEPTH: t� 3 h
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 111
7. STATIC WATER LEVEL Below Top of Casing: tO Fr,
8. TOP OF CASING IS 1 -. FT. Above Land Surface*
nap daft torsional aver Wow had' inn mote a
rubles r aeardnee with USANCAC 2C AtlL • ``
9. Nan (gym): 13)Cl O OF TEST r.A (LiC i..i-1
TO. WATER ZONES (depth): R4N't. � ?0 N.eput
11. DISINFECTION:Type.6*-0n fog Amount 3 647 S
12. CASING: Wall Manus
Depth Diameter agvdght/FL MurielFro To % O5 Ft ice% f2�_ 1'1 vL
Fromm _To R-
From_ To Ft
13. GROUT: Depth Maria/ Method
From () Tflfl Rey ((+c.'C-10rX.4-
Front____ To Ft
14. SCREEN: Depth Diameaes Slot SS Mania!
Fanny T4_ _ it A ice.
From_ To Ft. in. in.
1S. SAND/GRAVEL PACK:
Depth Sine Menial
From____To FL
Front To Ft
16. REMARKS•
neatere ataeahews)
Latitude/laagitode sourecOGPS0 opogtaphlc map
(cheek boo)
DEPTH DRILLING LOG
From To
D Io$
i v s
«f, trr ktSATER OIJALV'
f- r b ZOO?
LOCATION SICHTCII
Show direction and distance in miles from at least
two Sala Roads or County Roads. Include the road
numbers and con non mad
lb�
typo - 40 A-
1 DO HEREBY CERTIFY 'MATING WELL WAS CONSTRUCTED IN ACCORDANCE WTI! ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OP THIS RE RD �iAS BEEN PROVIDED TO THE WELL OWNER
LCA5Ut- 1� I\ re('
SIGNATURE OF PERSON CONSTRUCTING IRE WELL DATE
Submit the PhogNa
original
of the Division Water Quality, Groundwater Section,1636 Mall Service Center - Rale" NC
p17) 731]211, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and nutral Rdosns - Division of Water i
WELL coNrLACroa (mmvmaAL) NAME Quality -Groundwater Section
(pwt.r) tS J� P,Y`I I cot) t L`'� CaMIcwnoN a 341) -5
w[LL CONTRACTOR COMANY mum PRICF WFLL DBILLIfi� �. INC.
reonE a p 2 ii 327 026,3
STAIR WELL CONSTRUCTION nanny
Of applicable) I9➢OC fifwp wet sable) an]'p
Cif applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural
Monitoring 0 Recovery Cl Heat Pump Water Injection 0 Other 0 If Other, Lim Use
2. WELL LOCA L4/df ie �A/4.
Nearest Town Topogslop c/Land setting
ti —Tin ru W %G, ems• GGddSlope Malley l�lat
(Boat Nene Numbers. Comm* Suede/sites for Ne.. Iip Cade) (check tudeappeof C well
Ladialddlaogihtde of well location
3.OWNER: ,fs&cn4 Gor4y-
Address (cascade)
(Saw flea ) Latitude/longitude source: OGPSOTopogrnphiomap
(drdc bw)
tlE
%m etToon Star Zippy DNLUNGLOO
O �l1 a��1 I Fo { °pDeaaiptro°
Are ads. flaw maw 11u OVO o
4. DATE DRILLED) LI --06 ✓ r
S. TOTAL DEPTH: `? h_ J Theo RD S Y -
6. DOES WELL REPLACE BUSTING WELL? YES 0 NO GV
7. STATIC WATER LEVEL Below Top of Casing fl
1 (Usee-v ifMese Top of Cult
S. TOP OF CASING IS 1-12- FT. Above Land Surfaces
'TM aaetea twelsased War below Intl sancta require a
mime Is werduw with ISA?CAC 2CA111. 1,
9 YRZ» (8?m): SA_r* O. OF TEST Y I lU tt.rl
:
10. WATER ZONES (depth):,� 001/
11. DISINFECTION: Type
12. CASING: ��� Wall Thiclmess
epth
From ('� To (ymot--
"� ' eam ra[hr/Ft. Material
—
Fes_ To FL
From__To Ft.
13. GROUT: Doh Maeda tbod
From rl To a{) R ter 0 t ' 0 LY"
From To It
14. SCREEN: Depth Diameter Slot Sim Madni>1
in.
F&pro �._ Tom_ �m. -__ i n.
IS. SAND/GRAVEL PACK:
Depth Size Material
F_____To Ft.
From To Ft.
LOCATION SKETCH(
Sbow direcdon and distance in miles from at least
two State Roads or County Roads. Include the road
mrmbal and common road namm.
69
RECEIVED
DIV OF WATER OlIALITY
!_�(? 0 200i
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITR ISA NCAC ZC, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BERN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUC7IN(- TIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Settles, lei Mall SaNee Coma- Raleigh, NC
27691-1636 these Na [phone], withal 30 days,
Gw l REV. Innool

3317E
- Division of Water Quality - Groundwater Section
WELL corrra,&croa mIDlvmuAL) nubs tp.t.r�K l� he , r� = eC.. a c-. mTDcunon e a hS
WELL CONTRACTOR COMPANY MAHE PRICF WELL DPILLItINC. eaom#/32it 327 0261.3
STATE WELL CONSTRUCTION PERMIT, ASSOCIATED wQ ztnwra
Ctf appligble)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
(if applicable)
1. WELL USE (Cluck Applicable Box): Residential @' Municipal/Public 0 Industrial 0 Agricultural O
Monitoring a Recovery ❑ Hat Plump water Injection 0 Otter 0 If Other, List Use
2. WELL LOCATE 4n*2-- eerh/F`
Taws County L
SQLRow )—.-
9A-+
aaeYa h rhW
o YLcT_n (wm): 1 % ramOF TESTOII t bloc -fee
I0. WATER ZONES (depth):
IL DISINFECTION: Type
12. CASING:
Frva� To 5 Ft
Fumy__ To Ft
Fromm To Ft
13. GROUT: Depth A3/�aaflt�t�d
Froto�To `-A- \ Ft. Cr rot.-\
From_ To
14. SCREEN: Depth
Fr
om,_ To_
Froin to
IS. SAND/GRAVkiL PACK:
Depth Sire
Fror�_To Ft.
From To Ft_
Ars cods. Shooraesbaa
4. DATE DRILLED Ja)() C)E
3. TOTAL DEPTH d
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IA
7. STATIC WATER LEVEL Below Top of Casing: a-LI It,
( Miro. A:I cTap or Gains)
8. TO? OF CASING IS I PT. Above Land Surface*
`Tap dtang tenUYawd wet Woe Iran ante eeq* a a
es sew a with l5 NCAC C 2C.011a
Topographic/Land setting
•dga OSlope MalleyMalleyUFlat
fleck apprenrisae ban)
Iaiatddlaog1tulocatione of well loon
>Z` (apwMtsesaaw*)
LatitldeAongitude srnacr.OGPS0Topographie map
(chide tan
� DRI LrNG LOG
From r To , Forgutiy�h Description
Amount
Wall Thickness
�cies
Diameter
Slat Sim Matadal
in.
Material
100
3
LOCATION SKETCH
Show direction and distance in miles from at least
two Stem Roads or County Roads. Include the road
numbers and common road names.
f 1CLCi tics_
DiV, ()F WATER OUAL1 iY
?Eli 1) MP
16. REMARKS
1 DO HEREBY CERTIFY THAT THIS WEIL WAS CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A Y HE RECORD HAS BEEN PROVIDED TO TWELL OWNER
n > in - f rl-U6
SIGNATURE PERSON COMMtJcrm THE WEIL DATE
Submit the original to the Division of Water Quality, Groundwater Stenos, ICU Mali Service Center. Raleigh, NC
27014636 Pbone No. [phone], within 30 days, GW 1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2)S0
el. el µ' C'r 28
ti t. d t; t'.1
1. WELL CONTRACTOR:
Cow' ,I.J5J C,e
Well Contractor (Individual) Name
kkII DY:)1. ,qq
Well Contractor Company
ntcis LJS
Name �rJ
STREET ADDRESS 7S 7O Wes?
Yt&r-'bn W.C.'2$752
City or Tasn State Zip Code
(S2, »l2q-4/548
Area code. Phone number
2_ WELL INFORMATION:
SITE WELL ID kif applicable)
STATE WELL PERMIT /R )
DWQ or OTHER PERMIT #(y appicabie)
WELL USE (Check Applicable Bat): Residential Water Supply i
DATE DRILLED )a51-040
TIME COMPLETED ) 07 :00 AM 0 PM @/
3. WELL LOCATION: 77�� �L
���,CITY: I"i(oCq,i✓NT
hriCOUY UUr te.
5aocn T 1204-0.1
(Street Name. Numbers. Caontatny. Su66rieron. Lot No.. Parcel. rip Code)
TOPOGRAPHIC/ LAND SETTING:
❑Slope rivaiiey OFlat ditidge ()Other
(check --
LATITUDE J 2. 73 Ai
LONGITUDE SC ./ SO. 92
Latitude/longitude source: ❑GPS °Topographic map
(locator' of tang must be shown on a USGS Sopo map and
attached to this Armand using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS- • I R4 a6], PIA . l% L.iDr_
City or7o`amUt S ,1>1 C sla S 03
Zip Cote
(7a'( y Loci- % ,38
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH: I
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO te
c. WATER LEVEL RelowTop d Casing S' #O
(Use •+• BAbove Top of Casing)
d. TOP OF CASING IS ) FT. Above Lad Surface'
'Top d casing terminated al/or below land surface may require
a valance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): aQ METHOD OF TESTA' t
-
FT.
May be in degrees, I
minutes, seconds or
in a decimal iomat
f. DISINFECTION: Type C,)Oi,'np Amount Q'r,z
g. WATER ZONES (depth):
From To From To
From I i0 To (YC From To
Fran To From To
6. CASING: k
DeFrom d To / I FL (, ni o
To73 Ft. fn/t(
From To Ft.
Fran 7/
TNclmess/
Weight
.185; f,MfV
7. GROUT: Depth Material Iho)�
From 0 To .26 Ft Ty ) (�Ul'n; ry
From To Ft.
From To Ft
8. SCREEN: From
Depth Diameter Slot Size Material
in.
Ran To Ft it it
From To Ft. at in.
9. SAND/GRAVEL PACK
Depth ' Size (Mel
From To Ft.
From To Ft
From To Ft.
10. DRIWNG LOG
From To
Q' dog
Gq
11. REMARKS:
Formation Description
01 a4- 1'/Ca..(c.
,
6- iZ4,4'xv,'7=_
RECEIVED
Mks. t rFV W;i 7 QUALIT}`
JAN $ Ant
I DO HEREBY CERTFY
HIS ELL /S DONSTRUCIB)N
15A NCAC 2C. WEU.
X,NSIR
RE4Y,RO HAS BEEN PROVIDED TO THE WELL GINNER. NIUID711ATR COPYGViCE WRH
SIGNATURE OF C FIED WELL CONTRACTOR 17
DATE
LI LANETUS 416
PRINTED NAZI OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON #0 510
1. WELL CONTRACTOR:
Cori) u
Well Contractor (Individual) Name
Sus -if a usjl Dr,')I;ns
Well Contractor Company Name
STREET ADDRESS 350/ 55' US %c iv
City or Town State Zip Code
(S28 )- 7r2y-I/59g
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(8 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p9
DATE DRILLED /O —r=0 — O G
TIME COMPLETED ) 2 :0 0 AM O PM 2'
3. WELL LOCATION:
CITY: l%1O/7044' */-/
/ Y [ /C/Z/f2 ci /e r /4/
(Street Name, umbers, Community, Subdivision, tot No., Parcel, Zip Code)
TOPOGRAPHIC / _ALAND SETTING:
['Slope DValley ®Flat ❑Ridge ['Other
(Cheer appropriate box)
LATITUDE SI; '/t .17`1ell
LONGITUDES i c' 9% i.3/ w
Latitude/longitude source: IiGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNEROWyy// 1 ET'S NtdE�!/f)(t YlWI� // %)1
STREET
ADDRESS
_uJ
STREET / 45 Ned _ s
iJe6c) �C 49/6/
City or Town State Zip Code
1'b te5q- 3 t21t'1
Area code - Phone number
COUNTY 80/1"--/ke.,
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: Z 2 .s'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: W 0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated or below land surface may require
a variance it accordance wdh 15A NCAC 2C .0118.
e. YIELD (gpm): 2 0 METHOD OF TEST 4/C1-
3 3 —5' &5
f. DISINFECTION: Type es/6 r,')t F Amount r{O7
g. WATER ZONES (depth):
From To From To
From /SO To /16 From To
From To From To
6. CASING:
Thickness/
Depth. i j i _. Y Weight Material
From To Ft. Y '�—
Fron _ To 13/ Ft. % %0 Vt (,
FronV11 To133 FL(1d ,)Q% t° Alv
7. GROUT: Depth Material Method
From To Ft
From 0 To 2. e
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in. in.
From To Ft. in. in.
FL 41itA�j
9. SAND/GRAVEL PACK:
Depth -
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0- (20
/20- L49
200- 2Zf
11. REMARKS:
Formation Description
fined
C]d r),u/ 7-a
u.41 ITV
JAN 2 6 200?
I DOH
15A
RECO
R CERTIFY THAT THIS WELL WAS CONSTRUCTED eI ACCORDANCE WNH
/ . WELL CONSTRUCTON STANDARDS. AND THAT A COPY OF DAS
BEEN PROVIDED TO THE WELL•
i ce. i'//.� �>•� /o-L O-o
S GGNA ' RE O • CERTI a WELL CONTRACTOR DATE
�1�21 1u54-;�G
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05