Bu 1 CY2006

RESIDENTIAL WELL CONSTRUCTION RECO:iD
North Carolina Department of Environment and Natural Resources- Division of Water Quai ty
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Wet Contractor (Individual) Name
c cic2 ' 641..1 e{S VS
Weil Cr L.rly Nu r:.
STREET ADDRESS 11%3\ A \NAZI aO9
- dsrp43
City or Town site ' -Zip Code
3a91- to(os- aoaaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID A(d apd¢abte)
STATE WELLPERMITMe.a.tee)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply Vet
DATE DRILLED - 7-72
TIME COMPLETED Sr AM O PM
3. WELL LOCH iat
G � / COUNTY / //[[o...7r '7�P
deri /ei
{Sbset Name. Numbers. Community. Subdivision, Lot No_ Parcel, Z)p Code)
T9POGRAPHIC/ LAND SETTING:
i,Pe OYse' fRat D Ridge DOyer
(cheek appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitudt source: OOPS DTopographic map
Pecan ofwelmust be shown on a USGS topo map and
attached to t't form Onot twig GPS)
S. WS.L OWNER
OWNER'S NAME
ADD( SS
(
Area code - Phone number
(1N
Cale
5. WELL DETAILS: / �'
a. TOTAL DEPTH: �t0�
b. DOES WELL REPLACE BUSTING WELL?
YES 0 NOt 7
c.. WATER LEVEL BdoNTOp d Casing &(T) FT.
(Use •+` if Abwe Top d Casing)
d. TOP OF CASING Is 1 FT. AbO+e Land surface
`Top d casing terminated *Jot below land surface may rewire
a variance in accordance With ISA NCAC 2C .0118.
e. YIELD (Wpm):3t ) METHOD OF TEST fR• u
3ke
330710
1. DISINFECTION: Type4' \ l.$ Amount /3
g. WATER ZONES (depth):
From To
From To
From To
From To
From To
From To
6. CASING: Thickness/
Dept Dig Weight Material ,
From To /C.ti Ft. t0 L1
From To FI.
From To F .
7_ GROUT:c� Dept Material Method
From 0 To a0 ' F. Center . 9'r . re c
From To Fl.
From To - Fl.
8. SCREEN: Dept Dangler Slot Stine Material
From To Fl. • in. in.
From To P. in. in. .
From To _ P. in. in.
:S?
9. SAND/GRAVEL PACK:
Dept
• From To
From To
Frorn To
Ft.
Ft
Ft
Sae Material
10. DRILLING LOG
From To Formation Dn
/ 6? ,74 r Ern-li iP
11. REMARKS:
C _ -
cn n
0
0'
I DO HEREBY t.tnr rY THAT THIS WELL "'AS CDNS RIMED N ACCORDANCE Wfh
SSA NCAC 2C. WELL CONSTRUCTDN: SUNDAES* ANT` THAT A COPY OF ltS
RECORD HAS BEEN PROVIDED TO TIC VIES OWNER.
SIGNATURE OF CERTIFIED V ONTRACTOR DATE
#ce C.►t i-LeaFy 6c3.vb-re
PRINTED NAME OF PERSON aONS+RUCTW'THE WELL
Submit the ity
in 30 days. Attn: Informa
IA jt,
Service original Center— Raleigh. NC 27699-16117 el Phone No (9 9) 733-7015 eat 568.�
1617 Mal
Form GW-Ia
Rev. 7)05

RESIDENTML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water QraLt
WELL CONTRACTOR CERTIFICATION #. 0416
1. W61 CONTRACTOR:
L.1 QAT:Os_ 19tQr....'ki"k `•3'^l2.SS
Wee Contractor(bdMdeal) Nane
Q\>, a& • 6O.s.J^f C-t S '
Well Company nape
STREET ADDRESS %%NOES \S aCiQ
t-ko-sr c'c21 NC-- a8'�'-�3
City or Town .. �Zrp Cale
Sate)- tobS— acaq-
Area code- Phone mmrber
2. WELL QEORMA710tt
SITE WELL iD #(dappeoable)
STATE WELLPERM IT#(eeppri able)
DWQor OTHER PERMIT #(d app6eable)
WELL USE (Check Applicable Sad:
Residential Water Supply J
DATE mum 7-/&-le
TeaE COMPLETED ai d a AM O Put Er
3.Wt31 LOCATION:/I
CITY: /$c)i /N.vt/ - coura-Y ELireosb�
rt%nDJ 43wr1 R6 Lot No_PaRtl. Zip Codet
Aster Nane. Numbers. Camu�. Subm�isioR
TOppGRAPHIC f INC SETTING:
C>� OVaaay QFIat ❑Ride ❑Od'er
(chedcaop•WroR be 4
LATITUDE _
LONGITUDE_
Latitude/longitude source: QGPS °Topographic map
(boon owe/ nwstbe shown on a USGS tops map and
attached to this form lnot using GPS)
IMay be b degrees,
orimaes, seconds or
in a decimal flame
4. WELL OWNER
OWNER'S NAME
/AN•1
Art (/R� its
Slate
or Town
(Saar wit- S ns
Area code- Phone number
41 P tP
Zip Code
6. WELL DETAILS: „ e �S.
a. TOTAL DEPTIt Pc
b. DOES WELL REPLACE E7CST1NG WELL? YES Q
NO sa7
c. WATER LEVEL 9eloaTopofCasing: lD 0 FT.
(Use N' dAbmeTop d Casing)
d. TOP OF CASING IS i . FT. Above Land Surface'
*Top of cooky asi.atad atlor blow lad surface may
lequite
alaiace b m: WeeWtth 15A NCAC ZC.0115.
•
c YEA(ggpm): Ci METHOD OF TEST P"
41/4
t. DISINFECTION: TypeS.) L5
g. WATER ZONES (depth):
330711
Amount AO
From To Faun To
From To From To
From To From To
6. CASING:
Depth
FrornSL To 751
From To R.
From To F7.
7. GROUT: Denth
xThiiccknW9isobeesis/
.S+4-1
.,��}} M Me
thod
From 0 To OC© fljrn .•Pcit. pi tie d
From To Fl.
From To R.
8. SCREEN:
From
From
From
Deed+ Dianeter Skit Site Materiel
To R. in. in
To F. in. in
To R. in. it __ _
Ca !
9. SAND/GRAVEL PACK
Depth We Material
' From To - FL C. c
From To FL
From To FL
10. DRILLING LOG
From To Fornraton
79 Qvs
11. REMARKS:
r-1
00 HEREBY CERTIFY THAT THIS WEL WAS CONSiRLL'IE9 a ACCORDANCE YIrrH
1SA NCAC 2C. WELL WNS1RUCTON UTNCOMS. AlC71W.TA COPY OPINE.
RECORD NAS BEEN PROVIDED TO 1N: V. BLOWIER
SIGNATURE OF C WEI, DATE
DNTtit4CT'DR
•bece. X bki20.F)y 6G1J7tet3
PRINTED NAME OF PERSON X4RUCT#NG THE WELL
Submit the original to the DivisionNC of
Water
i a Phone lfty within
(0 days. tn: P.Jit� MIL,
1617 Phan Service Center-�d9h,
Fam GW-la
Rev. 7)OS

RESIDENTIAL WELL CON CTIONRECO:2D
North Carolina Department of Environment and Natural Resources- Division of Water QuaLty
WELL CONTRACTOR CERTIFICATION # 13�
1. WELL CONTRACTOR:
Q cc: c k "irkpc. 3/4 Sao a'/es5
Wee Contractor (Individual) Name
Well cats company Na'+e
STREET ADDRESS \"'%Z S \Nta7 a0C1
Ho't 5i. c\c ), NC . Lpg8't.43
CitCode
y or Town
wos- acaa -
Area code- Phone number
2. WELL INFORMATION
SITE WELL ID8(d.W )
STATE WELLPERMI Tf *pp cable)
DWQ.or OTHER PERMIT 8(ff applicable)
WELL USE (Check Applicable Box): Residential Water Supply V
DATE DRILLED 7-02 2-4-
TIMECOMPLETED 3, d U AMO PM B-
3. WELL LOCATION:
cirt C.-4 sing-^ .. coUNTY strc l4
'We." Crer
{Sheet Name. Numbers. Ca wnurary. Ste. Lrt. No.. Parcel. me Code)'
TOPOG H1C i IAND SETTING:
❑Sipe aney DEW DRidge De Oth
( appropriate
LATITUDE 3
LONGITUDE_
Iatitudeflangttude source: DGPS OTopographic map
(bratiOn of we/Mustbe sham on a USGS topo map and
ached to (omit It using GPS) (Lit /J- %�
4. WELL OWNER (�/O!/L �- �/1
OWNERS NAME - { .�'✓!1L
May be in degrees,
minutes. seconds or
in a decimal font
City or Town
Area aide - Phone number
aSi nt5
2w Code
5. WELL_ DETAILS: n
a. TOTAL DEPTH orZoir...-)
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOile
c. WATER LEVEL Beim Top of Casing as FT.
(use •+• d Above Top of Casing)
d. TOP OF CASINGS \ FT. AWN. Land Surface'
'Top of casing *minded agar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD imam)*!co�p 0 METHOD OF TEST (t'3
330718
f. DISINFECTION: Type4: t IA5 Amount / /
g. WATER ZONES (depth):
From To From To
From To From To
From To Fnxn To
6. CASING: Thicinesst
Depth
Diameter Weight Material ,
From 41. 7G F1. IntoCki
From To Ft. /
From To Ft. .
7. GROUT: Depth Material Method/
From 0 To ao Fl. CentP/tt. In4t"P d
From To R.
From To Flo
8. SCREEN: Depth D"arate: Sbt Ste Material
From To Ft.in_ in.
From To R. in. in. ..
From To R. in.
9. SANDfGRAVEL PACK:
Depth Sire Malarial
• From To' Ft. From To Ft a
From To Ft c-i
10. DRILLING LOG
From To
r Sr(
'771/467'
11. REMARKS:
in.
Formation n
at).
C- iite
-
0"
1 DO HEREBY t,txc rY THAT THIS WELL WAS CCSIS1RLCTD N ACCCRDANCE waif
ISA NCAC 2C, WELt CONSTRUCTION STANDARDS. AFTYrhATA COPY OP TOG
RECORD HAS BEEN PROVIDED TOME w 131 OWNER,
SIGNATURE OF CERTI 'yam+'+,
ec . tic%Aft4'k^� sbINGa
PRINTED NAME OF PERSON %ONS T RUCT WELL
—1,2,/
DATE LLcc
Submit the orighlai to the Division of Water Quality within 30 days. Attn: Information 1.13t.,
1617 ball Service Center —Raleigh. NC Z7699-1617 Phone No. [phone] ext 563.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quoinn
WELL CONTRACTOR CERTIFICATION # • 0416
33u 19
1. WELL CONTRACTOR: -
R Ct`: ek t�o� 1. Sri.3�JeCS
Wel Contractor (IndNiduar) Name -
Wen Cditlactor CompanyNarhe
STREET ADDRESS \'\%% \NAZI aog
%Ao-4 51c.h4S 1 NC oLS'1'-►3
City a Town a -Zip Code
eios- aoa
Aim code- Phase numbs
2. WELL IWORMATIOtt
SITE WELL ID #fif app cable)
STATE WELLPERMTTS(e appacabie)
DWQ or OTHER PERMIT Wr appb:able)
WELL USE (Check Appfgable Bcer): Residential Water Supply Ey
DATE DPoILED
TIME COMPLETED / d) AM❑ PM 9/
3. WELL LOCATION:: /�
CRY: ,Ka nl94*-� .. COUNTY 0/?c,sin- P
{SSeaSNaaw. Numbers. Canmaroty. S+ibMwon. lot No.. Parcel. Zip Cam)
TO HIC / LAND SETTING:
OValley ❑Fiat DRidge ❑Otter
(c appropriate box)
LATITUDE
LONGITUDE
Lanlade/Ion10t4e source: OGPS OTopographic map
(location of eel must be shown on a USGS topo map and
attached totes farm snot using GPS)
4.WELL OWNER
OWNERS NAME
S'tR/F1,,i ,AD,9 ESS
1 S.Ll A`�C1City or Town State
�e
}
Area code- Phone number
May be in dcgcm,
minutes, seconds or
ism decimal fmmt
dtvn G
Tip Cade
S. WEU. DETAILS:
a. TOTAL DEPTH: Pc 0 DOES S /
b. WELL REPLACE EOSTING WELL? YES 0 NOSY
c. WATER LEVEL. ES NTcp of Casing SO FT.
(Use '+' ff Atom Top of Casing)
d TOP OF CASING IS st FT. Above Lard Snrrace"
"Top d casing tanliabad aVa below land surface rTay require
a variance in a eordwce With 1S.A NCAC 2C .0178.
e. YIELD Wpm): A) METHOD OF TEST R•3
t. DISINFECTION: Type4 . %S Amount /f-)
g. WATER ZONES (depth):
From To From To
Rom To From To
Rom To From To
6. CASING: Ti'
Depth Maur ker eyoght 1+
Fran To /O d Ft. la n sA72
From To Ft.
Rom To P.
7. GROUT: Depth
Depth Material Method
Rom Q To D'Z© Fl. &W rit f " Y] tic d
From To FI.
From To P. ... _ .._ -.....
8. SCREEN: Depth Diameter Slot Siie Materiel
Rom To Ft. in. in.
From To P. in. it.
From To Ft. in, it.
CI :ii
9. SAND/GRAVEL PACK: N.
Depth Sire Material C i
. From To - Ft.
From To Ft
From To Ft v>
10. DRIWNG LOG
From To Formation
f /6 � )I�
a7o5
11. REMARKS:
E-n j +t
G
0
r
u
1 CO HERESY ttxrrY THAT THIS WEL L 'PAS CONStPIYRW N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION :TANDAP.DS. AF1)714ATA COPY OF 116
PROVIDED TOTRii =-- OWNER.
SIGNATURE OF ' -• - 1 - ' OR DATE
DATE
e eC.C. CV- }{QOl .b 3e.sA'yRl3
PRINTED NAME OF PERSON X.NS7FIUGTING 711E WELL
J
Submit the original to the Division of Water Quality within 30 days. Attn: Information M It.,
1617 Nail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

.RESIDENTIAL WELL CONSTRUCTION RECO:3D
North Carolina Department of Environment and Natural Resources- Division of Wars Quail;
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Q.-\\ eke. ' 'r6o .A 1E{S k'Sbn
Welt C ur Company Nape
STREET ADDRESS \3\%% \\j c aOCS
Ho 4 5?r:h s, NC- -
City or Tarn Zip Code
a.ln(OS- aaaa_
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID #fdwpIrable)
STATE WELLPERMIT#(vwpF ble)
DWQ.or OTHER PERMIT #(d 8pp/cable)
WELL USE (Check Applicable Sock Residential Water Supply 5
DATE DRIL]..ED 7'ct" S�
TIME COMPLETED .516 J AM 0 PM m�
3. WELL LOCATION: rJ
CITY: r Lt//.r7c.e- COUNTY / 5 c, #11
Ole
e
{Saes Name. Numbers. Cam tray. Su &s ion,
Lot No.. Parcel. 739 Code)
T9POGRAPHIC / LAND SETTING:
ISs7We °valley OFlat ❑Ridge ❑Other
(men epprOgria t box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decal forgot
Latitude/longitude source: °GPS oTopographic map
(location of »el must be shown on a USGS fopo map and
attached tothisform I Fnot ask-g GPS)
4 OWvi/ENER'S
NA / / 20554/Ld
OWN.eR'S NAME 1. rG EET ADDRESS `--/li-SS '/ ,
!E- `-'' d
re l ele /l C
City orTown State Zip Code
(,Qg)- lolen- Q`Ia%
Area code- Phone number
S. WELL. DETAILS: O�,CJ _
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?/YES 0 NOs/
c. WATER LEVEL Beim Top of Casing cO 0 FT.
(User" CAbove Top of Casing)
tt TOP OF CASING IS 1 FT. AbeLand Surface'
_ 'Top of casing terminated at/or below land surface may require
a rime 6u accordance YAM 15A NCAC 2C .0118.
e. YIELD Wpm): '20 METHOD OF TEST R-3
330721
r. DISINFECTION: Type4 .115 Amount / y
g. WATER ZONES (depth):
From To From To
Etun To From To
From To From To
6. CASING:
Thickness/
DepthD" Wl$99tIt
From
//K FI. -schla
From To R.
From To R.
7. GROUT: Depth Material Method
0 To OCO Ft. iYr1rof .. rfe
From
From To R.
From To
8. SCREEN: Depth Da peter: Slot Ste Mmefal
From To R. in. irL
From To R. in. in.
From To - R. in.
9. SAND/GRAVEL PACK:
Depth Ste
•From To- Ft. r.r)
From To Ft.
From To Ft.
c
r
C.,1
10. DRILLING LOG "" g
From To ggr �] n
//Cs 1-rr J'4 4O
11. REMARKS:
rV Cr- n:
o r
o --
r
I DO *RA- Lel rrY THAT TW5 WEL L V'AS CONSTRLVIW NACCORDVCE »'TM
15A NcAC 2C. WELL CONSmUCTON i Th NVNSS. Ale TNT A CCW OF MIS
RECORD HAS SEEN PROVE/ECM TM OWNER.
SIGNATURE OF FIED N - CONTRACTORDATE
`�l c c't \- tli-ti' . iaLuV Cc3
PRINTED NAME OF PERSON X'NSTRUCT G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC Z7699-1617 Phone No. [phone] est 558.
Fan 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 + 0
I`]A
1. WELL CONTRACTOR:
Rewbv'n C` L &ive} l
Well Contractor (Individual) Name ' h C
Ruia3 C, \aude.0 Dr; 111 ns 1
Weil Contractor Company Namet�p
STREET ADDRESS 36 1 Ne'� "Lek des+t 1.11.
kshev;kW, �C, a3So6
City or Town State Zip Code
Sag » 9,54 - 353 4
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #be- applicable)
STATE WELL PERMIT#W applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check A li le Bo : Residential Water Suppty I13�
DATE DRILLED -% �13 ) �O to
TIME COMPLETED ac • �" o AIM PM (S/
3. WELL LOCATION: a(A.11GOM�
re&VO A/I Ile COUNTY
�1 a,p n A t� ; I I ;tb &C .
(Street Name. Numbers. Community. Suedesmn. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑Slope OValley Brlat ❑Ridge ❑Other
(check appropriate box) A
LATITUDE 3 5 1-5 act 3 T
LONGITUDE ` 33 I
Latitude/longitude source: (oQ'PS Topographic map
(location or wel must be shown on a USGS topo map and
attached to this form I not usng GPS)
t
May be in degrees.
minutes. seconds or
In a decimal format
4. WELL OWNER D G 1\'V lC
OWNER'S NAME " A 15
STREET ADDRESS t9C l 11ti0 • t t I l 4
We ervi1lle tic 92'ON
City a Tim State Zip Code
(SI% 65g—aalto
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? VEERS O NO
c. WATER LEVEL Below Top d Casing: 195 FT.
(Use-+ if Above Top d Casing)
d. TOP OF CASING IS + FT. Above Land Surface'
'Top et casing terminated aria blow land surface may require
a variance in acrc�ordance with ISA NCAC 2C .0118.
e. YIELD (gpm):
p-D METHOD OF TEST R'I'G ✓ Al t-
i
a�
f. DISINFECTION: Type mount
g. WATER ZONES (dgpth).
From
Ib`t To 'a
From To
From To
6. CASING:
From
From
From
From
From
From
Depth ()pryer
To L1- I Ft. 6 /b
To Ft.
To Ft.
7. GROUT: Depth
From 1 To orb
To
To
To
Thickness/
s0�1ta(E �yy7l
U
�. �M,atterriaal�
Ft. rrT "o"'f
From To Ft.
Fran To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ftin. in. -'
From To Ft. in. in. ,.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From 4 To /
Ibq`r 1 1Oif
o'- a4s'
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
FturnaIio Desscnpt'2
OU g F-t U L-U f3 "r C
— aD*PCY
'co HEREBY CERTIFY THAT THIS W ELl WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Q-CLICL‘liZ9-.g
SIGNATUREF CERTIFIEDWELL CONTReCTOR ' DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ity
in 30 days. Attn:
4 C47 h itthe
ROW/ire Center- al Raleigh, NC 2 699-16117 Phone hNo (9 9) 733 7015 exttInformation Mgt.,
568.
Form GW-la
Rev. 7/0

ESIDEA'TIAL WELL CONSTRUCTION tiF.COI2U
R 3307 2
Nonh Carolina Department of Environment and Natural Resources- Division of Water Qualiiv
WELL CONTRACTOR CERTIFICATION # a 1 4-
1. WELL CONTRACTOR:
Qeu_1?IQ%n Co-Ad.uie-1I
Well Contractor (Individual) Name
Re..o2berl Cal &wet l Or; 1(; A5 I It c .
Well Contractor Company Name
STREET ADDRESS.3 JI 1•Q.L/3 - CeS- er
(ishev;(12 rvc a8g'oG
City or Town State Zip Code
( -g> a64 -35 25 I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(a applicable) 2O8I0' d! 5(07
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box). Residential Water
DATE DRILLED �/ - rJ ¥ - LS to
TIME COMPLETED 1: SO AM D PM ]�
3. WELL L ATION:
CITYj4 in/a V I (J e
supply V
/�
COUNTY -3d0 }IAv 9
k 1 Uf PP Wall �QQ, ///g4PY4SC
(Street Name. Numbers. canmun ubd von. Lot �rll heC
Parcel. bp Code)
TOPOGRAPHIC / LA,ND SETTING:
❑Slope OValey &Tat ❑Ridge OOther
(check appropriate box)
LATITUDE 5 4- a -16 6qq
LONGITUDE $ a as 4is
• q e
Latitudellongitude source: OePS OTopographic map
(location of well must be show on a USGS topo map end
attached to this form 1 nor usng GPS)
4. WELL OWNER
OWNER'S NAMEfn II i-(]) UfV1 1DOC'D���s
STREET ADD•RESS. �/ !1.S;,ITe r n(/ R
G e;corllP ff Le?off
City or Tows Stale Zip Cade
(9:71--K 7/3 -o?co
Area code - Phone number
May to in degrees
minutes. reads or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
7
b. DOES WELL REPLACE EXISTING WELL? YES O
Not
c. WATER LEVEL Below Top of Casing 0. C. FT.
(Use -•- if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top d casing terminated allot below land surface may require
a variance is accordance with 15A NCAC 2C .0116. ^
e. YIELD(gpm): 1 METHOD OF TEST Rt�-A1R.
f. DISINFECTION: Type /+` '%OAmount
g. WATER ZONES (depth)
From / L. c To p/46
From !I_ 7 ! To F 7 c,
From To
6. CASIIUG:
Depth
From .4-) To 7' FI.
From To Ft
From To FI.
7. GROUT: Depth
From O To FI
From To Ft.
From To Ft.
From
Ff am
Frorn
To
To
To
/1
Thickness/
Drapetpr
erelt5UyW�j �alerial
Material ,.Method
6. SCREEN: Depth Diameter Slot Size Material
From To FI. in. in.
From To Ftin. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Frpm To /"
3
.�-3t-be
((e o - ilo(o z
1t:,6/- e-1S'
'a--L-^3a5>
II. REMARKS:
Ft.
FI.
Ft.
Size Material
F(rmation Description
D V t50-6\4LOB'•
.._.,.......
6eit rJ 1T tS
C(tSV' l CAC - `j V Cl11
C�Ci+-v-s CV'C
tG6 - t o
tee Lt
'V Irv.
C
m
� G•r
sop REHEAT CERTIFY THAT THIS WELT WAS CONSTRUCTED N ACCORDANCE WTI
)SA NCAC aC WELL CONSTRUCTOR STANDARDS AHD THAT A COPY OE THIS
RECORD HAS PEENPROVIDED TO THE W Elt OWNER
f
SIGNATURE OFCERTIFIEDWELL CONTRACTOR /D 7E
@, t (.-4t`� ti3 AS t4
PRINTED NAME OF PERSON CONSTRUCTING 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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and � Naturalp�xrr�Resou ces - Division of Water Quality - Groundwater Section
zz
WELL CONTRACTOR(INDIVIDUAL) NAME (print)1-��ZIO' d'I, CERTIFICATION bilks
w,ELLcovrnACroa CON PAN\' NAME R?PaLAQhraNilk 1I V° DMI/Nj PHONE # (gold J-1 a
0 ei
Jk"1
STATE WELL CONSTRUCTION PERM ITN ASSOCIATED WQ R NIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential Ili' Municipai/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT N: ;���,���
Nearest Town: �lQrt Couniy3A C e:
(Sued Name. Numbers. Community. Subdivision. Lot No.. Zip Code)
OWNER:OktJ $?'tfcrF;Q D
Address 1£ T44Di AN;A 4k vc
(Street or Route No.)
A ahcvi lie NC
City or Town State
2 I roc,
Zip Code
Area code- Phone number
d. DATE DRILLED c»fIq-/aG
5. TOTAL DEPTH: 5-0
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: I Ge O FT. •
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
Topogra 'c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
3L tilysi °t i edf 'o `fi
(degreeshninutesiseconds)`t rr° � (
Latitude/longitude source:OGPS❑Topographic map
(check boa)
DEPTH DRILLING LOG
From To Fotmiation Description
*Top of casing terminated at/or below land surface requires a
variance in accordanceal I5A NCAC 2C .0118.
9. YIELD (gpm): 6 7 METHOD OFTEST&7R'1'- COLTS t'{Q
ID. WATER ZONES (depth): 5
II. DISINFECTION: Type 1i4 Itt Amount AZ
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From& To'ci Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From To /3 Ft. 6 CZ(
From 1 o ! 9- Ft., gri__r
1-1. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From 10
From To
Slot Size
in.
in.
'Method
nU�
Material
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from al least
twc&taikRpads or County Roads. Include the road
nutxtbers and common road names.
1
v
tv
0
c•-••
0
0
16. REMARKS:
1 DO HEREBY CERTIFY HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRJTION STAND RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DAT '
S
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

13. GROUT:
From
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED .,
5. TOTAL DEPTH:
6. DOES WELL REP C E STING WELL? YES D NO Cd
7. STATIC WATER LEVEL Below Top of Casing: L 0 C) FT.
(Use u+ if Above Top of Casing)
8. TOP OF CASING 1S ' FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accord n�ith ISA NCAC 2C .0118.
YIELD (gpm):ME O OF p 5�
11. DISINFECTION: Type (SO LQ,F Amount
12. CASING: Wall Thickness
Depths Diameter or Weight/Ft. Material
From - To_/� Et.
From To Ft.
From To Ft.
Dept
To F
from 10
1-1
Material
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 10 Ft.
From To Ft.
Material
WELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and Natural Resourc s - Division of Water Quality - Groundwater Section
�Q
QQ rs,,, lath
�1,� (; CERTIFICATION to
rx'ELL CONTRACTOR COMPANY NAME/'pnA� t14N WdL'( ( St1 ret PHONE#(DaQ Goa-IaafJ
WELL CONTRACTOR (INDIVIDUAL) NAME (print GA .y V
STATE WELL CONSTRUCTION PERMIT#
if a licable)
.P r •
ASSOCIATED IFQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ if Other, List Use
2. WELL LOCAT N:
Nearest Town: A11 VZIA./
County WA-6'(C
(Street Name. {Numbers. Community. Subdivision. Lot No.. Zip Code)
3. OWNER: iC� Q5(XT wII
Address alb -rvve B—R K T i l
jtrrur eet or Rcu_im No.) ��ci
ti
Topogra Ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
�L t'�• /l nitt o ` � a ^29 3O
(degrees'minutes!seconds) G �EU • a3 tur
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
9. (TS TEST �7HL. W V 4dlli 1
0. WATER ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from at Ist
two State Rba'd' ortiiunlyRoads Include theeroad
numbersand common road namas. •,-
c *^
>c •
1 -t:--.
—J rri
N
P•
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTIJSION STANDARD, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DAT
Submiyf le 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

3t.::s
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource's - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1 Wen
\YELL CON!R.\CTOR CO\IPANS NAME /1 ppP /4Ch; to `H%!/ 0441 r
STATE, \YELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
CERTIFICATION k ago 0 3,
PHONE # (UT) 623-724
I. WELL USE (Check Applicable Box): Residential M btunicipal/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 Town: La4CC5+t?
County stabatQ'Me7. ,
(Erect Name. Numbers. Community. Subdivision. Lot No.. Zip Code)
3. OWNER:<Stt'C11Aiy C6�
Address %33- N•Mus C`y Yrt .
(Street or Route No.)
LttA �, 4-tir121r &k c C2 4/1" S
Cin' or Town State Zip Code
( )-
Area code- Phone number G�7
4. DATE DRILLED as 6� _
5. TOTAL DEPTH:
6. DOES WELL REPLACE CE EXISTING WELL? YES ❑ NO
Topogra is/Land setting
DRidge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/I eitudc of well Igca i
N35* 39,tto oa 4� .0�.�s3�.
(degreesiminuteslsecondsidCy` cQs 9b
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
7. STATIC WATER LEVEL Below Top of Casing: 16 n FT. ,
(Use "-" if Above Top of Casing)
8. TOP OF CASING IS ) FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accordant 'ith l5A NCAC 2C .0118.
9. YIELD (gpm): METHOD F TES1€7 C" l.:O.l r(gt)I.LQ2
I0. WATER ZONES (depth): Dr I
11. DISINFECTION: Type
12. CASING:
FromDepth
To WO/ Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To
From
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size Material
1-rom Io Ft.
From To Ft.
Amount a
Wall Thickness
Diameter or Weight/FL Material
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
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
16. REMARKS:
1 DO HEREBY CERTIFY T AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRU TION STANDA DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL�OWNER
( B' Zf/66
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

crWELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and yNaatturral Resources - Diviisi�on�o1f,Water Quality - Groundwater Section
IA ELL CONTRACTOR (INDIVIDUAL) NAMME (print) rd J�(S.0 i I'')I Siq /CS +TvbaA ``II
\\'ELL CONTRACTOR COMPANY NAME Rjrti&kctl()}N iiii1 1�i ll/r{,
CERTIFICATION #sg'ai
PHONE # Vkt)(033-9a2A
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED \\`Q PER. IT#
(if applicable) (if applicable)
WELL LSE (Check Applicable Box): Residential le/Municipal/Public ❑ Industrial D Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATION: 2�"�',�����Rn�
Near t Town:Fat¢U ICW Counly&kie Atg)
Is Qnot Rs . 2 f5 4 3 o
(Street Name. Numbers. Community, Subdivision. Lot No_ Zip Code)
3. OWNER:ED tdt\ t s31.•\
Address
(Street or Rowe No.)
Ciry or Town Stare
(
Zip Code
Area code- Phone number tr
4. DATE DRILLED GI 4 OCp
5. TOTAL DEPTH: 5O5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO C3�
7. STATIC WATER LEVEL Below Top of Casing: { 450 FT. •
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
Topogr• is/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: UGPSLITopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accords with 15A NCAC 2C .0118. nn--
9. YIELD (gpm): Lt METHOD OF TESTGA(• l Ff� INC,c
10. WATER ZONES (depth): flO
DISINFECTION: Type iarC562-11— Amount 7C
Wall Thickness
Dep Diameter or Weight/Ft. Material
f-rot & To Ft.
From Io Ft.
From -1 o Et.
13. GROU'j Dep
From
Fron1� To t=t 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
1I
12
CASING:
From To Ft.
From To Ft.
i n 9 ti
utioldutr
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.
c7
J
0
(-a
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE'
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Q]
Resources - Divisionrl7Tof Water Quality - Groundwater Section[
7 WELL CONTRACTOR (INDIVIDUAL) NAME (print) )a tich 5�kc3 L(a CERTIFICATION#t2--i
\\'ELL CONTRACTOR COMPANY NAME Air\ (p.. i .MAN QJ1 TD 1L (I (.sERty PHONE # Ogg)) GS3- 9'Z3
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W'Q-PEERMIT#
(if applicable)
(if applicable)
Ct l r, t\
a kia
I. WELL USE (Check .Applicable Box): Residential Od' Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: '��"�'-'��_��''.
Nearest Town. a aix 'Eal N County( mAcomEc
l2 171R. ?s a2�1Z L(
(Street Name. Numbers. Community. Subdivision. Lot No.. Zip Code)
=.OWNER: fActrol5 ( c5
Address Fall J /liCNt?ecCf ece- .
J3140(Set orRo� p) �3-7((
City or Town A/ State Zip Code
Topogr is/Land setting
❑Ridge @Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/Ion itude of well location
)J35 ,3a. it ° W 1,2 (q- *5' (degrees/minutes/seconds) E(.E✓, .2,p7/ /
Latitude./longiWde source:LJG PSLJTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
( Area code- Phone number
4. DATE DRILLED Coos/boo
5. TOTAL DEPTH:, /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO CY
7. STATIC WATER LEVEL Below Top of Casino: GO FT. '
(Use if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface`
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15.A NCAC 2C .0118.
9. YIELD (gpm): Coo METHOD OF TESTG I (- Cc rE&C t mlc
10. WATERZONES(depth): yO, (00, (ary
LOCATION SKETCH
ll. DISINFECTION: Type Ia6(Q,f5 Amount r7'
12
Depth Diameter or Weight/Ft. Material
From a To 'Fe) Ft.
prom -I o Fl.
From to ht.
13. GROUT: Depth r� �Material,^ Met od
From "e' To 3 Ft.LL.IIL
From To 1� Ft. 6thri-01-Q C- b\J.
14. SCREEN: Depth Diameter Slot Size Material
From To Fr in.
From To Ft. in.
15. SAND/GRAVEL PACK:
CASING: Wall Thickness
From
From
Depth Size
To Ft.
To Ft.
in.
in.
Material
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
a
1✓
r
tV
c.i;
Ct-
C-7
I
J
0
C,
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
C UCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
i - /
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE'
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division` of Water Quality - Groundwater Section !r-
WELLCONTRtCTOR(INDIVIDUAL)NAME (print) ll ro os..1 CERTIFICATION th5fa'T
STATE WELL ACCOTOTtCOMPANY
NAME
PERMITS/
fl(gcA/-rY ��1SS:�ATEtDi PER\1IT# PHONE # acpc63-WA
I ifapplicable) I I (if applicable)
1. WELL USE (Check Applicable Box): Residential 13Municipa1/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: fa Nearest Town: (_ ✓IQ__✓ County
33 C-La t»ia \ ¥aifv7ON) Sr3c
(Street Name. Numbers, Community. Subdivisions, Lot No.. Zip Code)
3. OWNER:.��53gi -WIC-{ u
Topoggraa is/Land setting
❑Ridge lope ❑Valley ❑Fiat
(check appropriate box)
Latitude/Ion tude o W I ocati n
11135",' - 2e2 , csa 6,46l p�
(degrees/minutesisecondse / gQ
Address SAMQ- Latitude/longitude source:LJGPSUTopographic map
(Street or Route No.) (check box)
}JL DEPTH DRILLING LOG
city or Tour State Zip Code From To Formation Description
)-
Area code- Phone numb h. 62
4. DATE DRILLED
5. TOTAL DEPTH: 1-1-0,
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO [dam
7. STATIC WATER LEVEL Below Top of Casing: end FT. ,
(Use "_" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface' -
*Top of casing terminated aUor below land surface requires a
variance in accord ce h ISA NCAC 2C .0118.
9. YIELD (epm):( •.7 MET OD OKTEST Celt Colisi Qa5
10. WATER ZONES (depth): 117ur t ( V
11. DISINFECTION: Type )d'(4-, Amount /2.
P. CASING: Wall Thickness
Depth C Diameter or WeighVFt. Material
From D i 9 ) F[.
From I o Ft.
From l o Ft.
13. GROUT: Depth
From To 3 Ft
From To /7 F
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
Slot Size
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
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.
1
CZ
J
p r rail
O 172
ci
ice'✓
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST CTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONTRACTOR COMPANY NAME 1%DA/AchjigA4 IJ,VC
STATE WELL CONSTRUCTION PERMITU ASSOCIATED WQ PERMIT)
tit ap usable) tit -applicable)
licable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources( - Division of Water Quality - Groundwater Section
WELL CONTRACTOR ()INDIVIDUAL) NAME (print) ,lpUI 0 51 4.4p IQ
Q r•/
CERTIFICATION :siAR I
PHONE II fb'd$)�3-97,d3
1. WELL USE (Check Applicable Box): Residential 0 MunicipaUPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: j QieQ.34C.5 County$*,µciant&
Le+ * 1f, Farw64wn -TCk. 28-7(-g
(Street Name. Numbers. Community. Subdivision, Lot No.. Zip Code)
3. OWNER: f `t dMkRom•F3tt.4k y,s..
Address Stata ka.b.t.DQ•'1.5)14CIIQ., 2nP
(Street Or Route NO.) F kt4ck`cc.l-C i'4C - e2 873 a-
Ciiy or Town State
Zip Code
Topograplfic/Land setting
❑Ridge dope ❑Valley ❑Flat
(check appropriate box)
Latitude/lonnitude of well location
u35 -t .353r X Pflg e
(degrees/minutes/seconds/REV. 0227,2 2
Latitudcrlongitude source:❑GPS❑Topographi6' map
(check box)
DEPTH DRILLING LOG
From To Formation Description
( )-
Area code- Phone number
4. DATE DRILLED Si Ica PG
5. TOTAL DEPTH: 5(PS r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: Coo FT.
(Use `+' if Above Top of Casing) •
S. TOP OF CASING IS I FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C AI1S.
9. YIELD (Rpm): .2 METHOD OF TESTA At-. Wts‘ti-tLiC
10. WATER ZONES (depth): WY-5
LOCATION SKETCH
11 DISINFECTION: Type 7Weiet Amount oZ Show direction and distance in miles from at least
12. CASING: Wall Thickness two State 1taads-orCeun ty-Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.:;
From d To Ft.
From To Ft.
From To Ft.
13. GROUT: Depth M.at'erial/_ Method
From To 3 Ftn .Q.TG k.t'
From To / 7 FL%tN1oitAc
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SANDiGRAVELPACK
:
Depth Size Material
From To Ft.
From "to Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATEY
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Marl Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-J REV. 072001

WELL CONSTRUCTION RECORD
tit et r.., _. Q
ciJt-.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL COIYIRACIOR(INDIVIDUAL)NAM E (print) DFiOib 54 C'+4 t4
u ELL CONTRACTOR COMPANY NAME A (RLh7 t4 -{+lull De; Ili N9
ST ATE WELL CONSTRUCTION PE RAI ITS ASSOCIATED \VQ PERMITS
(tt applicable) (itapphcable)
CERTIFICATION `$ ' a)
PHONE r cos )43. MA3
i. WELL USE (Check .Applicable Box): Residential E Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring C Recovery ❑ Heal Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: Fcry eV County&4A3CMN3Q.
MN. egg Slatbtt� a”5t3
(Street Name. Nul.ibers. Community. Subdivision. Lot No.. Zip Code)
3. OWNER: 13C#I.I 6, Nl-h.
Address Si 3.c&yt Dr
(Street Sr Route No.)
-11(QunaatStOhLTI t Nis.
City or Town State
agl9a
Zip Code
Arc _ code- Phone rummer
4. DATE DRILLED 7 /S OCo
5. TOTAL DEPTH if
6.
7. STATIC WATER LEVEL Below Top of Casing: MO Ff.
(Use "+' if Above Top of Casing)
S. TOP OF CASING IS 1 Ff. Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .at 13.
9. YIELD (gpm): I.1 METHOD OF TEST C R (.C4.ftSbtr�
10. WATER ZONES (depth): .,`OO'
Topoggra c/Land setting
❑Ridge L4Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/lonailude of well location
N35 ;2E.5`fO'WOSX a5516
(degrees/minutes/seconds)E.IEV. 228I
Latitude/longitude source:DGPS❑Topographic map
;check box)
DEPTH DRILLING LOG
From To Formation Description
DOES WELL REPLACE EXISTING WELL? YES 0 NO gry--
1 I. DISINFECTION: Type7481Q* Amount v`
12. CASING: Wall.Thic:ness
Depth Diameter or WeiehttFt. Material
From C) To Ra FL
From To Ft.
From To Ft.
13. GROUT: Depth Material -,y Method
From To 3 FtCSa' 1-1Cc k Fbu-r
From To /+ Ft/?R,u4ON;'i-Fi Thar'
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Prom To Ft.
trom To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LOCATION SKETCH
Show direction and distance in miles frczAat I t
two State Roads or County Roads. Include the road
numbers and-eommon'Toad names.
J fT'L`
N — ^f
o r—
_
c
r
SIGNATURE OF PERSON CONSTRUCTING THE WELL
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

It . ('. .)
i)VJ0
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalatResources - Division of Water Quality - Groundwater Section
{1
WELL CONTRACTOR (INDIVIDUAL) NAME (print) AVV;b .` /Tt3/�("("O�i! ,�/ CERTIFIC�AAgTrI[ON 3 1
\YELL CUNT R:\t.rDtt COAli'ANl'N:UtE /%�n�k CI i441 {'�/Q./' DT/II(/�,O PNONEr psi J4+M3
STATE WELL CONSTRUCTION PERNIIT# ASSOCIATED WQ PE2\tIT�
nt applicable) (It ao?hcable)
1. WELL LSE (Check Applicable Box): Residential Qd h'runicipaliPublic 0 industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 1f Other, List Use
2. \k'ELL LOCA-fI N: y{n �P���p J�
Neare own: Qi '_/i Count) .I/ C •M15Z
095 'Clt r. ol 606,
Sri Name. Numbers. Community. Subdivision, Lot No.. Zip Code)
3. OWNER: /QM �y'li�t0hE
Address09 eC M1 I4 hr
(Street or Route No.)
�Sheurne, NL Riga(,
Ciw or Town State Zip Code
Area code- Phone number
4- DATE DRILLED 04 VI °
6. TOTAL DEPTH: (0 if Jr- f
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /Oa FT -
(Use "+' if Above Top of Casing)
S. TOP OF CASING IS i FT. Above Land Surface*
*Top of casing terminated ator below land surface requires a
Topograptfictand setting
❑Ridge lope ❑Valley ❑Flat
(check uppropriate box)
La
i� (35 °tiC3&. OXC9 GJ(1 �
ofaQ°C3q, 5�0
(deg ees/minutes/seconds) t (EU. �1 L: 1
Latituderloneitude source:❑GPS❑Topographic map
J
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accordance with 15A NCAC 2C .nt 18.
9. YIELD (gpm): 1 ME LgQQF TESTQAI t� EC5[%(0q
10. WATER ZONES (depth):
r
H. DISINFECTION: Type 1 C1tZfrt Amount rX
12- CASING: Wall Thickness
Depth �.7 Diameter or Wei^_htFt. Material
From V To /MS Et.
Ft.
Ft.
From
From
13. GROUT:
From
from
To 1q
14_ SCREEN: Dcpth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
Horn To Ft.
from 10 ht.
Slot Size
in.
in.
Material
:Material
LOCATION SKETCH _
Show direction and distance in miles from at east
two State Roads or County Roads. Include thgoad
0
numbers and common road names. a --7
CT)
0
co
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONST CTION ST NDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
s/ /cco
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE-
S u bunt 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

4orth Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
636 Mail Service Cana — Raleigh, N.C. 27699-1636 — Phone [phone]
NELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
r C�, r\ f
3 il.401
1. WELL USE (Check Applicable Bo:): ►: Residential ❑ Municipal ❑ Industrial 0 Agricultural 0 Monitorin
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
Z. WELL LOCATION: (Show sketch of the location below)
4earest Town: OLD FORT County: BUNC
CLIFFSIDE TRAIL -LOT #19
;Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER PAUL BUHL
Address CLIFFSIDE TRAILL.OT #19
;Street or Route No.)
OLD FORT NC 28762
City or Town State Zip Code
4. DATE DRILLED 07/21/06
5. TOTAL DEPTH 985
6. CUTTING COLLECII I) ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 985 FT.
(Use `+^ if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surfaces
'Top of casing laminated at/or below land surface rcquves a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 25
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 40 Ft 6-I/4" SDR21 PVC
From To Ft. _
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 FLOUIKRETE 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: CUSTOMER WANTED TO GO DEEPER IN 605' DRY WELL..
DRILLING LOG DEPTH
Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and diaanre from at least two State
Roads, or other reference points)
HWY. #9 N. FROM BAT CAVE. RT. ON OLD FORT RD.
APPROX 3 MILES, LEFT INTO HIGH CLIFFS AT ROUND
MOUNTAIN. 1.1 MILE UP HILL ON RIGHT. LOT #19.
c
c;)
J
0
0
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.
urt--)
at -LE
SIGNATURE PERSONONSTRUCIINGIHE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

Vorth 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 JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Bo:): ® Residential ❑ Municipal 0 Industrial ❑ Agricultural U Monitoring
0 Recovery 0 Heat Pump Water Injection ❑ Other If Other, List Use:
2. WFJ.T LOCATION: (Show sketch of the location below)
Nearest Town: OLD FORT County: BUNC
CLIFFSIDE TRAIL -LOT #19 DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To
3. OWNER PAUL BUHL
Address CLIFFSIDE TRAIL -LOT #19
(Street or Route No.)
OLD FORT NC 28762
City or Town State Zip Code
4. DATE DRILLED 07/15/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 605 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface°
'Top of casing laminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 0 METHOD OF TEST: ARD
11. WA ILK ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 16.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 40 Ft 6-1/4" SDR21 PVC
From To FL _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 FL OU]KRETE POURED
From To FL
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From To FL in. in.
From To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
17. REMARKS:
DE
Formation Description
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. #9 N. FROM BAT CAVE. RT. ON OLD FORT RD.
APPROX. 3 MILES. LEFT INTO HIGH CLIFFS AT ROUND
MONUTAIN. 1.1 MILE UP HILL ON RIGHT. LOT #19.
Cr)
N
c
I DO CERTIFY THAT THIS WELL WAS CONSTRUC1'tD IN ACCORDANCE WITH I5A 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.
NATURE 0P'PERS0F CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
•

3 2i'7fi7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturalan/�((Resources
' ^-- Division of Water Quality - Groundwater Section
�� n
Vali. C'ONTRAC'TOR (INDIVIDUAL) NAME ( rint).. �!.F)Q(/j/_ W�N� CERTIFICATION #. �7 �C7
WELL CONTRACTOR COMPANY NAME _ 6/scent. .eras L mP PHONE # ( )
S'IATE WELL CONSTRUCTION PERMIT# /t Q 2 ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
I. WELL USE (Cheek Applicable Box): Residential IV-Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring O Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
LL // Topographic/Land setting
Nearest Toµn:_ V LL Cc, County �neamhz ❑Ridge DSlope OValley Wf'lat
(check appropriate box)
Latitude/longitude of well location
(Street Name, Numbers. Community. Subdivision. lot No., hp Code)
3.OWNER: 5&phen /) veto
Address D neea ((„
(Street or Rome No.) "]
&he "IM NL z&8oy
City ot Town State Zip (ode
(Q2g)- 2-59 - aNj
Area code- Phone number
4. DATE DRILLED ,1-1'
5. TOTAI. DEPTH: S 05 r
Di op A!'t. . 'I Ilk! AX III I't VLL 1 1N
7. STATIC WATER LEVEL Below Top of Casing: 7j7J/ET.
(Use"4' if Above Top of Casing)
R. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 13 METHOD OF TEST Z H0CJ2c
10. WATER ZONES (depth): 3D54
76,5
i I. DISINFECTION: Tvpc grit Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. M tcrial
From 0 To y ti Ft. b (' /
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 2-0 Ft. pleg 1-0p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To
15. SAND/GRAVEL PACK
Ft. in. in.
Depth Size Material
From To Ft.
From To Ft.
I6. REMARKS:
1 DO HEREBY CERTIFY TIIAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST.9rN*OARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
Idegreesminutesiseconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To For bon Description
a ,T
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and gommon road names.
r
w
0
C,
C.7.I
SIGNATURE OF PERSON CONSTRUCTING fliE 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 WELL CONSTRUCTION RECOAT/
North Carolina Department of Environment and Natural Resources- Division of Winer Quality
WELL CONTRACTOR CERTIFICATION # 0416
1. WELL CONTRACTOR:
+�Qcc;ck Y\ec t,
W eR Contractor (Indi ival) Name
Q.VJ c Q 64t..in-c s
Well Cat -actor Company Nara
STREET ADDRESS " 2)) S
\tl0/C S('ivtt,'9. - /JC
City or Town State
(aa%,. lo+ciS- a�aa
Arun code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Cd arpiicable)
STATE WELL PERMITA(a appaoble)
DWQ or OTHER PERMIT S(d applicable)
WELL USE (Check Applicable Boxy. Residential W Stec Suppy'fu'
DATEDRILLED S^3
M-`O ]�
TIME COPLETED /
Li'•rd 0
3. WELL LOCATION: /�
CITY: Fie fro %E. kl cowry 64 K
S0.w-less
kson
Qo4
ace-N-7,
‘Zip Code
AM PMid—
/lien;IjS Co OC. ta.
(Street Name. Numbers. Commrnray. Sub6rision. Lo No.. Parcel. rip Code)
TOPOGRAPHIC / LAND SETTING:
rope OVaaey DFat D Ridge !Daher (check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/Iongitude source: 0 GPS DTopographic map
(boohoo of well rust be shown on a LJSGS topo map and
attached to this form it not using GPS)
4. WELL OWNER
OWNERSNAME et%,S '012c c_a\_
May be in degree;
minutes, seconds or
in a decimal format
STREET ADDRESS 31 -fl'e' V .A\'S co,' a
v.e._ >J c aQrc1c3
City or Town State Zip Code
r lo2'- stCa
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: - O
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOt -
c. WATER LEVEL Below Top of Casing: 70 FT.
(Use •+' 8 Abue Top of Casing)
d. TOP OF CASING IS . \ FT. AbOse Land Surface-
. `Tap of casing *emanated allot below land surface may require
a variance on saardance wWi 15A NCAC 2C .0118.
e. YIELD (gpm): /0 METHOD OF TEST -S
f. DISINFECTION: Type 1?; \ \ j
g. WATER ZONES (depth):
327612
Amount /n
From To From To
From To From To
From To From To
6. CASING: Thy/ _
Depth Diameter Weight M
From -}� To �/ Ft b lc, F /�1
From To Ft.
From To Ft
7. GROUT: Depth Matra Method
From 0 To ao a rot /Oc.„-c
From To Ft
From To Ft
8. SCREEN: Depth Dior rater Slot Size Material
Fran To FL in. in.
From To R. in in.
From To Ft iR kt
9. SAND/GRAVE-PACK:
Depth
From
From
From
To
To
To
10. DRIWNG LOG
From To
/ //a
//a a oS
Ft.
Ft.
Ft.
Sim Material
Forma'ion Description
() (7E+^ ,<.rril- h
n
N
RZCEWED�
AUG2 ) tCL5
11. REMARKS:
C ri
1
I DO HEREBY Y TNT THIS WELL VAS CCtSRL'CTED N ACCORD ICE WITH
15A ?CAC 2C, WELL CONSTRUCROR S A CARDS. AND 111IT A COPY OF THIS
RECORD HAS SEEN TO THE VI. QWNER.
SIGNATURE OF CERTIFIED W EI€CONTR
DATE
tett'.0- \ tO-k'tx. 3c sz tic
PRINTED NAME OF PERSON CONSTRUCT WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Id;t.,
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fon GW-la
Rev. 7/I6

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 02143(4
1. WELL CONTRACTOR:
"..6 es- c-,el< 'Nec w\r, MCW? es s
Well Contractor (Individual) Name
C\ ycie e 1cs d- So c\
Well Contracts Company Na
STREET ADDRESS \\c:\ Ps S : "I -`Lay go q
'Hot t cinc PC QB143
City or T LJ Stake 'Zip Code
( &a,ay (ohs- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID IRK applicable)
STATE WELL PERMIT/Nit applicable)
DWQor OTHER PERMReft( applicable) 05-0\5"1O
WELL USE (ChecklApplicable Box): Residential Water Supply
/
DATE DRILLED 7 -/2—r!Bo
TIME COMPLETED _21 d O AM 0 PM
3. WELL LOCATION:/
CITY,:: /45
O t/l
,dtk/ /'lPac.luS /9G/
COUNTY 64hC0en t
(Sheet Hare. Numbers, Community. Subdivision, Lot No.. Parcel. Zip Code)
2TO GRAPHIC / LAND SETTING:
bee OValey ❑Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS oTopographic map
(location of wet must be shown on a USGS topo map and
attached to this form 7 not usrrg GPS)
4. WELL OWNER _ '\
OWNERS NAME ,3e3Se TntoiNCTrl
May be in degrees.
minutes. seconds or
in a decimal format
STREET ADDRESS 3\ \\a9tz Fable Ccx.LC+
« e v,t\e 1JG 28%05
City s Town State Zip Code
( 8a2))- ?-'c2r- 3091
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ia2p?5.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1
c. WATER LEVEL Below Top of Casing: Cr FT.
(Use --1" if Above Top of Casing) -
d. TOP OF CASING IS FT. Above Land Surface'
'Top d casing terminated a la below Land surface may require
a variance in accordance with 15A NCAC 2C .0118.8.
e. YIELD(gpm): 3CD METHOD OF TEST EtI.
327613
f. DISINFECTION: Type 0 +, \S
g. WATER ZONES (depth):
From To From
From
From To
From
6. CASING:
Amount //
To From
To
To
To
Thickness/
From ` Depth Diameter Weight M
/3d FL ;� StW $ p/st;'
From To Ft.
From To Ft.
7. GROUT: Depth Material Method e From 0 To g0 Ft eme v't QGttACeLA
From To Ft.
From To Ft
8. SCREEN: Depth Diameter
From To FL
From To Ft.
From To FL
9. SAND/GRAVEL PACK:
Depth
From
From
From
in.
in.
in.
Size
Scot Sic Material
in.
To Ft.
To Ft.
To Ft
10_ DRILLING LOG
From To?S'
in.
in.
Material
Formation Description
cr es
/ .7 a C-reanae
11. REMARKS:
Fri
-.
-- .
rn
r-
0
r
i
AUG 25 2.5;;S
Arm.fit
I C lice
11(1
A O D
1SA CAC2C. WEU. CERTIFY THAT CONSTRUCTION
WELL WAS STANDARDS.
A'FITAN COPYRF111S PATH
RE NCAC2C.WELL PROVIDED
ETANDAOW.F`E+THATACOPY OF T19S
RECORD HAS BEEN PROVED TO THE WF,IagOVVNER.
SIGNATURE OF CERTIFIED W CONTRACTOR DATE
tect,cK l'acce', '(jqa.�+) '2C S
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ,2143(
1. WELL CONTRACTOR:
�ecc-.c-tc lkec w S6-
3,3y-ec
Well Contractor (Individual) Name
C� ycae 5o.s, ecs •or-5o('
Well Contractor Company Marne
STREET ADDRESS "ERRS .1-\cr, ao q
'Not 5 c• get?nc - »C g8'43
City orTan tjSae - -Zip Code
(Sass (orbs- a DD.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Alfapplicable)
STATE WELLPERMIT#(a applicable)
DWQ or OTHER PERMR #('d applicable)
WELL USE (Check} / Applicable Box): Residential Water Supply
Y DATE DRILLED �es7
TIME COMPLETED 5;'0 AM ❑ PM
3. WELL LOCATION:tS�/f/
CITY: /aY6
COUNTY Ue.,,n rwfj,"
sdree ' if'iP.ccws /Per
( Name, Nwnben. Community. Subdiesion. Lot No., Parcel. Zip Code)
TO RAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude./longitude source: DO'S ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form 'not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME ��rr��
STREET ADDRESS ratESM tttty clPCSonv:tle
HSheV.\\e t4C a0a03
City or Town State Zip Code'
(ties%>_ -oak$
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: o2o25-
b. DOES WELL REPLACE EXISTING WELL? YES
YES O
c. WATER LEVEL Below Top of Casing 6 ()
(Use.' if More Top of Casing)
d. TOP OF CASING IS FT. Move land Surface'
'Top of casing temenafed at/or below land surface may require
a varience in a wderc., with 15A NCAC 2C .0118./
e. YIELD (gpm): /O R METHOD OF TEST
NO V
FT.
f. DISINFECTION: Type 0 1\S
2,27614
Amount /j
g. WATER ZONES (depth):
From To - From To
From To From To
From To Fran To
0. CASING:
Depth From "in /mod
From To
From To
Ft
Ft
Ft.
/
Thickness/
Weigh Mr4a�S�w
S-LR 21 /31 s '
7. GROUT: Depth�1 Material
o� From 3 To Q FL ee'ClPfl-�
From To Ft
From To Ft
Method
Pauced
8. SCREEN: Depth Diameter Sat Sire Material
From To FL in. in.
From To Ft in. in.
From To Ft. in. in-
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To
Ft.
From To Ft.
10. DRILLING LOG
From To
1 /JO
11. REMARKS:
Formaicn Description
°ales t.3jA.ctIO,fl
Crcan
i
N r-:
a
r.--
i=
+I
7
Q.
R'Et.'EivED _<
au(T s rc2
pi r�gr1 D',i14, r7P-l•
1 DO HERESY ChN tMY THAT TMS WELL WAS CONSTRI MED N ACCortmeCE WIT4
ISA NCAC 2C. WELL CONSIRUCTR)N STANDARDS. AND TNATA COPY OF TM
RECORD HAS SEEN PROVIDED'ro INE WELL OWNER.
SIGNATURE OF 'ER1IF1Eb ` LL CONTPACTOR DATE
tiecc.c - 1leske'. Saar/ e c s
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

327815
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envionment and Natural Resources- Division of Water (hulk,
WELL CONTRACTOR CERTIFICATION # • 2t at.
1. WELL CONTRACTOR:
(Lie: e An.. :Sa-•-•J'^fac
City or Town State
(Wa.93)_ a0a
Area code- Phone nuMber
2. WELL INFORMATIOtt
SITE WELL ID 170 eneficable)
STATE WEU. PSILMMIklf appricabS)
DWQ or OTHER PERMIT are ape/cable)
WEU_ USE (Check Amicable Box): Residential Water Supply t%
DATE DRIU.ED
-nate COMPLETED ? 0 AM ID PM fir--
3. WELL L05.1)TION:
CRY: UGC" "144 COUNTY at...4 Cenoll
WeR Contractor (Individual) Name
CL4a.
Well .C.Sta.Mr Company Noche
STREET ADDRESS "‘2)(2) S nt‘LA•i Qoi
\Not ))C.
4-Zip Code
6-to.3e m
(Sawa Name, Numbers. Community. SubdMsion. Lot No.. Pal. Tra Core)
TOPOGRAPHIC / LAND SETTING:
*Slope ClYarley ORM DRIdge 13 Other
(cheat appropdata berg
LATITUDE
LONGITUDE
Latitude/longitude source: POPS OTopographic map
(location of nettmustbe strum; on a USGS topo map and
attached to this form (not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4.1/VELL OWNER
OWNER'S NAME a en 5 ii•acte‘n
STREET ADDRESS 115 -C1nCiR ye_ 3tcrti .5"Ci
c.nnctiNo„cx9271n8
City or Town State Zip Code
(gala )- nen' Webb
Area code - Phone number
5. WELL DETAIL&
a. TOTAL DEPTH: P70 C
b. DOES WELL REPLACE EXISTING WELL? YES 1:1 NO12---
c. WATER LEVEL &SOW Top of Casing FT.
(Use if Above Top of Casino)
d. TOP OF CASING IS • FT. Above Land Surface"
'Top o casing teminated atter be'lowland surface may rewire
a variance in sccordance with ISA NCAC 2C .0118.
e. YIELD Wpm): 7 METHOD OF TEST (-4,•3
f. DISINFECTION: Type cl; k.5 Amount 10
g. WATER ZONES (depth):
From To From
From To From
From To From
To
To
To
6. CASING: Thickness/
Depth Diameter Weight Material
Frorn41 To <7 FL _Ws" -5,04)( )thALL
From To Ft
From To Ft.
T. GROUT: Depth Mataia Method
From 0 To a a Ft. Cases A Plc,fle i
From To Ft
Flom To Ft.
• • •
1
8. SCREEN: Depth MI neter Slot Simi . Material
From To FL 'n. ___I in.
__________
From To Ft it ____ j
From To Ft. TI.
it ..-
_
i -
0. SAND/GRAVEL PACK:
Depth
aorn To Ft
From To
From To
Size
10. DRIWNG LOG
From To Formation
24 QQor
r74
1
Cr
9‘. &OS feria sr fie
na rnuj
ar'
11. REIvLARICS:
I DO HEREBY LttC /14-Y 'NAT THIS WELL V'AS CONSIRLCTED 11ACCORDNCE WITH
15.s NCAC 2C. WELL CONSTRUCTS* Sm'ANDARDS, atal, THAT A COPY Or THIS
RECORD HAS SEEN PROVCIED TO THE t. ELI. OWNER
5-1-6
SIGNATURE OF CTIFIED CONTRACTOR DATE
beret 0' 11-1.20.4h.
PRINTED NAME OF PERSON C CNSTRUCTst a WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Infonrnation
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. (919)733-71715 est 568.
Form GW-la
Rev. 7705

.RESIDENTIAL WELL CONSTRUCTION RECO.1D
North Carolina Department of Environment and Natural Resources' Division of Water Quality
WELL CONTRACTOR CERTIFICATION #- 04 aka
327616
. WELL CONTRACTOR:
Qve: e rcNeNte.C..th Sp w�te is
Well Contractor (Individual) Name
evd42. So.a ItCC
Well cdta tar Company Nate
STREET ADDRESS ‘M2)aS
SOn
�.�.r aos
riot Sic v`ss - IJC as-1trk
City or Town State =tap Cade
(8a9,)_ solos- aoaa
Area code- Phase number
2. WELL INPORMATIOet
SITE WELL ID #(it app66able)
STATE WELL PERNITfRgaoorcaae)
DWQ aOTHERPERMIT#(d appkable)a(.UTJ 03769
WELL USE (Cheek AppirabieHad: Residential Water Supply
DATE DRILLED 5- 8—C
TIMECOMPLETED Ar 3o AMO PIA a--
3. WELL LOCATION:CITY: feavvi1/Cr' COUNTY Ilk x or2 ref
•
ck leci,
tsb, lear.,e, Numbers• Cwaara�'�Su Lot No.. Parcel. TA Cale)
TOPOGRAPHIC t LAND SETTING:
tfSlope °Valley Qlrt F°Ridge °Other
i (deck apprcpriae bag
LATITUDE
LONGITUDE_ _
Latitude/longitude source: DUES oTopogTaphiC map
(locator, of *el rmust be shown on a USGS topo map and
attached to this fan, 7no( sting GPS)
4 WELL OWNER fy� rr++
OWNER'S NAME tfo c (rcCWT C2y
STREET ADDRESS Q osxc i4 C--/SVQ.
CacyG``715
City or Town ) State /go Code
(8aA) (is- 3tc°
Area cede - Phone number
May be in degre,
minutes, seconds or
in a decimal format
5. WBL DETAILS:
a TOTAL DEPTtt ,30 J
b. DOES WELL REPLACE EXISTING WELL? YES ° NOi3—
c. WATER LEVEL BeimTop of Casing - FT.
(Use "+' ii Above Top of Casing)
d. TOP OF CASING IS FT. AbO a Land Surface'
`Top of casing terminated altar bduw land surface may require
a variance in exonlalce with ISA NCAC 2C .0118.
e. YIELD Wpm): —5 !MOD OF TEST (R-�
t. DISINFECTION: Type i t$
g. WATER ZONES (depth):
From To From
From To From
Fran To From
6. CASING:
Fromn� Toth ( 1 . Ft
Frorn To Ft.
From To Ft.
Amount /S
To
To
To
Thickness/
7. GROUT: Depth ��ll�� Material
m Fro_ To ..,r) Ft re Ain
From To Ft
From To Ft.
Nettled
�4av,l
I. SCREEN: Depth Mr nester Slat Sze i Metflrfai
From To Ft. in. In. y 2Y
From To Ft. in. in- i o
From To Ft in N. i Sji
9. SAND/GRAVEL PACK:
Depth
From
From
From
To
To
To
10. DRILLING LOG
From To
6U
11. REMARKS:
Ft.
Ft.
FT.
Size
(glacial
{
G
J
i'T
Formation Dee...14,54i
' Over &'Jr„ L
C
U
rri
I DO HEREBY t,tesr PY 'MAT THIS WELL V 'AS CO1S1RLETED N ACCORDNCE nrarH
15A rest 2C. WELL COrSrnuCDON S) CARDS. AK, TINT A COPT OF TICS
RECORD MS BEEN PROVIDED TO THE • ELL OWNER.
,i �l
SIGNATURE OF r.T• W CONTRACTOR DATE
CX a. - • i JC.eJ�vr+�
PRINTED NAME OF '�' a CC.NSTRUCTwIG Tlt WELL
If ft
cnt
(l ,9
Submit the original to the Division of Water Quality within 30 days. Attn: information id It.,
1617 Mali Service Center— Raleigh, NC Z76991617 Phone No. [phone] ext 568.
Fam GW-la
Rev. 7d05

R
IDENTIAL WELL CONSTRUCTION RECOR D
North Carolina D
WELL CONT
anment of Environment and Natural Resources- Division of Wate' Quality
CTOR CERTIFICATION # aL134
327627
1. WELL CONTRACTOR:
1 rriC pt 44 Sc iy{,r5
Weil Contractor (Individual) Name I
C I CC .Sat& fs 4 Soul
Well tractor Company N me
6/ // n ry
STREET
/ADDRESS y/ V t) nO �) /74` f� 20 9
City or TS 4nq Stitt v . C , %/ZI t� 3.7
(`S
e
3 GIFS-2Oc
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(rf applicable)
STATE WELL PERMIT#(8 applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Resider,Water Supply
DATE DRILLED Vr-z /'- Ce
TIME COMPLETED //it co - AAm/ PM
3. WELL LOCATION: jJ /
CITY: C4 47.E. ..- COUNTY eeDw et/ re44
P'a 47 19, /a f A
( Name. Numbers, Community, Subd shoo. La o.. Parcem, Zip Code)
POGRAPHIC / LAND SETTING:
Slope °Valley °Flat ❑Ridge ❑Other
(check appropriate box)
May be in degrees,
LATITUDE 3 _ . minutes seconds or
LONGITUDE ina decimal format
Latitude/longitude source: ° GPS ❑Topographic map
(!cation of wet must be shown on a USGttopo map and
attached to this form Inot using GPS)
4. WELL
N ER
OWNER'SNAME 1 o kg').tl ,I ) tSkirS
STRE RESS
1
C ty or Town State
( 69/- 9as7
Area code - Phone number
5. WELL DETAILS: 2
a. TOTAL DEPTH: 0_2
b. DOES WELL REPLACE EXISTING WELLI YES E NO j—
c. WATER LEVEL Below Top of Casing: 3 O FT.
(Use '+• if Above Top of Casing) ,
4. TOP OF CASING IS / FT. Alive Land Surface*
'Top d casing terminated at/or below land urface may require
a variance in accedence with 15A NCAC .0118.E
e- YIELD (gpm): 2C) METHOD OF .TST K/ O
f. DISINFECTION: Type P i 1 5 Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
From / DToth Y Ft.! Meter Det
ight
From To 'Y Ft.
Y
From
From To FL_
/0
7. GROUT: Depth n Material Method
From ) To `tc% Ft 1-r rarsLr gnu M.1
From To Ft
From To Ft.
8. SCREEN: Depth Diameter SW Size Matilrial
From To Ft. in. in. ,
From To Ft. _in. in. t From To Ft in in. I.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To FonnatioDescription
O
yv c2OS rant -e
r-�
11. REMARKS:
-n
•
N O
r-
1 DO HEREBY CERTIFY 'HAT THIS WELL WA: CONSTRU..IED N ACCORDANCE WrrH
i5A NCAC 2C. WELL CONSTRUCTION STAHL ARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PR VIDEDTO THE Et L OWNER
SIGNATURE OF CERTIFIED CONTRACTOR DATE
f-LT ‘.5tt,)l/,o.1
PERSON CONSTRUCPNG THE'WELL
^p I
PRINTED NAME
Submit the original to the Division of later Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

I
rr,c r
Wel Contractor (ndrvmu3) Nare J I I 8• WATER ZONES (depth):
C -5-From To From SOh F To
Well retractor Compare Ana ro"' Tc From To
From
70_-. From to
84-17-'06 11:55 FROM-NCDENR ASHEVILLE HO 82(Cyullp'J
1.WELL CONTRACTOR.
1 DISINFECTION: Type
T-dm PLIZ/Lib U-DL_1C
S ENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment Lind Natural Resources-o
Division D. Water Gunli:y
WELL CONTRACTOR CERTIFICATION IS a ll3 Le
STREET ADDRESS Clyde Sawyers & Son Well Drilling
14885 Hwy 209
"v a Hot Springs NC 28743
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID t(dapyf;atia)
STATE WELL PERMITS& applicable)
DWQ or OTHER PERMIT treapplicable) oiCOlo ` C1 �Ci\lp
WELL USE (Check Applicable Sect. Resident®! Water Supply%
DATE DRILL eb /a___
I TIME COMPLETED yrJd
----- Am Frnei
2. WELL LOCATION: City``. 4 r/�y COUNTY
// Qy rN I
nry .tirrrl. eed �r !
(Sheet Nam*. Kumbers, Community, Sublumon, Lot No., Parcel, LP Cod.,;
��T//OPOGRAPHIC 1 LAND SETTING:
77LSlope °Valley ❑Flat ❑Ridge CCther
toned( anpnarlate boo
LATITUDE j. _ I May be in degress,
rn% edes. Seconds es
• LONGITUDE in a decimal refloat
Latitude/longitude source: ° GPS Topographic map
(locatnn ofwer must be shown on a USGS topo map and
attached b this Vann not using CPS/
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
T-
rwev c'N
City or am
�OO�PC Tt'1 C10 d'Q
— e Sate aolg'7P l
le Zlp Cone
Area code - Phone hamper
5. WELL DETAILS:
a. TOTAL DEPTH:�-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO A2--
c. WATER LEVEL Below Toe of Casing: •---/ 111.__FT.
(USe``'ifAboverep ofCasino)
3 TOP OF CASING IS / FT Abee Land Surface*
lop a casino terminated atvr below land surface may require
a variance in accordance with 15A NCAC 2C C118
7 ,
e YIELD (carol' 30 METHOD OF TES /[-_C{
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt
1617 Mail Service Center- Raleigh, NC 2769E-1617 Phone No. ($1$) 733.7015 ext 568.
327338
6. CASING:
hj lac*1
FEW /— To Depth� C� From. To rt %iariieter lM4tayt PA ell.
Pram/-+���- .sc�a
TcFL
T. GROUT: Cepit
Fran,_ To PC
From_,_ To
Fromm To
Material f
Ft a 14+
Ft
FL
S. SCREEN: Depth Oiemoier SW; Sir roe
From To Material
FranTo._..,,.,, FLin. i�.
FL
Fran To
—_ in. H.
F�.'n. rt
a.. SAND/GRAVEL PACK:
Dew Sire Material
From • _To Ft..
From To n. - -.
Frx;____,—to Ft.___-
10. DRILLING LOG
Frpm To
/s0
1
I
1
I
I
I
II
II
11. REMARKS:
Amount
Fwma;ion DesrSDtion l
nt1Dr !iL
I DC 11ERE9`r CERprn triATT!IS WELL WAS CONSTRICTED N ACC :RDa.1CF WITf
1S1 NCAC 2C. WELL CONSTRVCTIN STANDARDS, AND THAT A COPE OR tugs
RECORD MS BEEN PRCNDEC TO 1NE WEIL OWNER.
SIGNATURE OF CERTIFIED
Crr: k
PRINTED NAME OF PERSON ONSTRUCTIN THE WELL
,D)
Pam
Rea. 7
1 n
Lco
Crrs
CJ

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-�7Division of Wate. Quality
WELL CONTRriCTOR CERTIFICAT ON #' oC u&
1. WELL CONTRACTOR:
Nrrk k iktu, SGWyr$
Well Contractor (Individual) Name
CiNicLC .S4.o rs 4 C or\
Well tractor Name
STREET ADDRESS / ( D I )
p „ �t-ey 920 $
Sp C T4oPm , Statr v . r •e Zip ode tk i
LPL- G6c—ac5Q
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID #idapplicable)
STATE WELL PERMIT/Rif applicable)
DWQ or OTHER PERMIT #Cd applicable)
WELL USE (CheckApplicableBox): Residential Water Supply 7 DATE DRILLED —7/S C VV
TIME COMPLETED it's!) t) - AA O PM IBA
3. WELL LOCATION:
CITY: C4:riri//' - couNTit
"cff /%7L
(Street Name, Numbers, Cammunty, Subdssion, 1M No., Parcel, Zip Gode)
OGRAPHIC / LAND SETTING:
Slope DVafey ❑Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oGPS oTopographic map
(location of we9 must be shown on a USG5lopo map and
attached to this form IT not using GPS)
4. WELL OWNER P�
OWNER'S NAME gl'
ST EET ADD SS
i,e
U� P n
T_ AO_
( Ca r�} bState
9/—qr&sl
Area code - Phone number
c
C'kb4,
Code
5. WELL DETAILS:
a. TOTAL DEPTH: Aff
b. DOES WELL REPLACE EXISTING WELLtc YES ❑ NO Q.--
°SC FT.
(Use'+• if Abae Top of Casing)
d. TOP OF CASING IS / FT. Atbue Land Surface*
?op of casing a for below land Surface may require
a variance in accordance with 15A NCACVC .0118.
e. YIELD (gpm): / C METHOD OF 'ST r
E
Submit the original to the Division of 4vater Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 28699-1617 Phone No. [phone] ext 568.
c. WATER LEVEL Below Tap of Casing
6. CASING:
327 628
f. DISINFECTION: Type P r US Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
Thickness/
Depth Ciimeter Wei M M al
From I To 7 ,n Ft..p 4 _ 5 p/oC ar
From To Ft. bit
From To Ft
7. GROUT: Depth Material
From ( To Q.C% Ft. Ce mt.t7'
From To FL
From To Ft.
Method
8_ SCREEN: Depth Diam der Sin' Size Material
From To Ft in. in.
From To Ft in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
To Ft.
To Ft
Frorn
Size
Material
To Ft.
10. DRIWNG LOG
From To. Formation Description
I 8' () t )e r
11. REMARKS:
I DO HEREBY CERTIFY THAT THS WELL WA: CONSTRUCTED N ACCDR7i
15A NCAC 2C. WELL CONSTRUCTION STANC ARDS. AND THAT A COPY OF
RECORD HAS BEEN PROVIDED TO THE WFjJ, OWNER.
SIGNATURE OF CERTIFIED
/W C/ONTRACTOR
fierrr rC ACC f `r'7 W ��//1qr±=
PRINTED NAME CPERSON CON STRUCTNG THEW: L

04-17-'06 11:55 FROM-NCDENR ASHEVILLE HO SLS29S704',
1. WELL CONTRACTOR:
rrr
r a
We Contractor f /Vciiwd/NI Name
_J&W Vim'
Ci&a
dd f.GS-ezea2
Area coda Phone number
2. WELL INFORMATION:
SffE WELL IC kit apoitaga)
STATE WELL PERMITS\vapplia6iei
DWI) or OTHER PERMIT tit applicable)
WELL USE (Check Applicable Bar). Reaidental Water Suppir
DATE DRILLED
TIME COMPLETED(/: /SU
-----_ AM C3.--fiM 0
3. WELL L TON:
CITY: r/ COUNTY
! r
E
poem Name, Numbers. Community, Subdunort La No.. P®cy..Tip 4.Cods)
OPOGRAPHIC, ;AND SETTING:
Slope OValley ❑Flat ❑Ridge OCRs
toileck enomprlapa box)
LATITUDE
LONGITUDE
T-S18 P12/b7 U-nob
.._ GO,Y�Ei�EN77AL WE r CONS TRUCTION RE ORD
North Carolina apemen' ofEnvxonmenr and Natural Rceourtcs. Division of Water C
WELL CONTRACTOR CERTIFICATION # ?3 Lo 2ualiy
W
t— rS
Son Well Drilling
STREET ADD Clyde Sawyers &
c4 1 14885 Hwy 209
Hot Springs NC 2
8743
M*y bi in dsarets,
mules, seconds o:
in a decimal formai
Latitude/longitude source: ❑ GPS C Topographic map
(location of wad roust las dime/ton a USGS topo map and
attached to Mis form! not Laing GPS)
e. WELL OWNER
OWNER'S NAMES�
STIr 1 IT D1 SS
aM prTwm 11State . Zlp Cole
Area code- Phme number
5. WELL DETAILS:
a, TOTAL DEPTH:.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
e. WATER LEVEL Below Top of Cam's.
Ff.
(Use `r'` if Above Top of Casing)
d. TOP OP CASING IS FT. Above Land c
*fop of casing terminated ator ur require
below Cf 01 may retjuir9
a variance in accordance With 1SA NCAC 2C .G718
a YIELD (gpm)' METHOD OF TEST /_.[iq
o1LS
L DISINFECTION:
g. WATER ZONES (depth;:
From To From
From To From
From To Fran
6. CASING:
Depth Diameter
Fran_,__ To S FL,4 _
From„��
FromTo Ft
7. GROUT:
^ Ceps,
Frrjn L, To
From To
Fran To
MatenN 1
O FL en1
Ft. -
_� FL
Amount
327829
MettMO
6. SCREEN: Depth Diameter Slot Sia
Frarrl To_...-.. Ft in. M
From To
_ FL PLin. in.
From To
FL__•in. �_ er, ,
!.. SAND/GRAVEL PACK:
Depth Size Material
From • ToFt.
Frro�ro�_ R— �.
W. DRILLING LOG
IC7Cr
11. REMARKS:
Meteroi
Formation Des;'ytro^ C
nUPr /SL
O
7T,4�r �'
yC?
-ti-r)
Tv 2<
O rL
1
-G
}
I W HEREBY aeon' THAT Tin WELL WAS CONSTRUCTED N ACC:ROAN=
16A . WE'L CONSTRUCM7N STANDARDS. AND :HATA rosy OP 7Na �''
RECORDORD HAS
HAS BEEN?ROMEO TO THE WELL OWNER. �'
SIGNATURE OF CERTIR
_I err: k
PRINTED NAME OF PERSON
Submit the original to the Division of Water Quality within 90 days. Attn:lnfnrmation Mgt,
1617 Mail Serrice Center - Raleigh, NC 27698.1617 Phone No. (919) 7334816 ext 668.
sue_
CONTRACTOR LATE
THE WEIL ! a
C)
Farm GV
Rev.7r'8 2
OJAI

04-17-'06 11:55 FROM-NCDENR ASHEVILLE is'U 818L99/04
1. WELL CONTRACTOR;
'1'y18 P112/05 U-D41p
�T ESIDEVTL4L WartCONSTRUCTIO RECORD
North Catalina Deparnnent of Environment and Na ural Resour
res- Division o.r
Water Qualm•
WELL CONTRACTOR CERTIFICATION # OZ LI3 4
Wel Contractor (ndrv;nuy NOT*
C/lrge Sn. r..V..0 4, .Fn},
I.
s Clyde Sawyers & Son Well Drilling
14885 Hwy 209
sod aa�3__—
Area code- Phone
number
2. WELL INFORMATION;
SITE WELL 10 afd epplatie)
STATE WELL PERMITaul applicable)
DWQ a OTHER PERMITI(d applicable)
WELL USE (Check Applicable Sox). Rwsidentlel Water Suppir
DATE DRILLED
TIME COMPLETED /6; O U AM N 0
Hot Springs NC 28743 gs
Jolla
S. WELL LOCATION://
CITY: nd(r �'
COj1VNTY�{
(Street Nemec Number. Community, Subdot/h. Lot No.. Parcel. Zip Code)
TOP GRAPHIC f LAND SETTING;
°Valley ❑Flat °Ridge Cether
toned( cNopdere tau
LATITUDE
LONGITUDE_, _
Nay be in ,
minutes, seconds a;
:n a decimal formal
Larttudenongitude sourtt: ❑GPS �Topogrophid mop
potation W waym et be shown on a USGS topo map and
attached to this fan m f not using GPS)
a. WELL OWNER
OWNER'S NAME
S T ;Ey ADDRESS
CAI/ or 7°rrn Stale
jai
izaL t'OS/
Area code - Phone number
5. WILL DETAILS:
a. TOTAL DEPTH: a O S
Zip Cod
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO P—
I
e. WATER LEVEL Bebw Top of Casing. a0
(Use `«^ if Above Top of Camp)
d. TOP OP CASING IS 1 FT. Above Lad Sunaaer
'Top sing terminated alter blow tatatsurface m
ay require
of casing
a variance In accordancevet 15A NCAC 2C .011e8
YIELD (morn): 6 METHOD OF TEST !.. _ �t_q
L DISINFECTION: Typo
9. WATER ZONES ;depth):
From Ts
From To
From To
8. CASING:
Depth meter
From_ To5Domeier
p Ft_64_
From,-___- To..__ FL--..._._...
From To___FL
327630
Amount /D
Fran To
From To
Frm_—_ To
Th tkz essi
ght
sIREfl
7. GROUT:
�r� Capin Ma:eiat
FFrom To aO FL e nT
To Ft
Frgn To
PAoten
Malted
8. SCREEN: Depth D;aITIRI • Slot S"
From To at Materai
Fan '----_ FLin. R.
F
_ To FL in. n.
Fran_ Ta�-
Ft._____ln. lI. ______
9. SAND/GRAVEL PACK:
Depth Sae Ma lanai
From • Tc.,.._.,_, Ft.
From T4 Ft.
Frorn_,To__ FL_ -----
110. DRILLING G LOG
F, m To
Formation De9c' an
SC) /
SO '7p,f � C
Iorri
2
GI
11. REMARKS:
FT. IISA DO HERE9Y CERTIFY `rLATTH9 WEU. WAS CONSTRUCTED N AC::ROANCE
I RECORD NCAC 2C.
BEEN FRDVA.0 TO THEN UOOWNe�:ETA COP (CPT THIS
.GNATURE OF CERTI
3err. _
PRINTED NAME OF PERSON ONSTRUCT;N
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center -Raleigh, NC 77688.1617 Phone No. [phone] ext568.
CONTRACTOR Ca.TE ICPT
THE WELL tj
Form GVJj ( 1
Rey. 70°'._
rig

4. WELL OWNER
04-17-'06 11:55 FROM-NCDENR ASHEVILLE Ni EIZYZ*104',
1. WELL CONTRACTOR
'1'-y18 t"i Z/Uj U-7Uo
SI ENTLQL WELL CONSTRUCTION R CORD
North Carolina Department ofEnwonment and Nature) Resourccs. o Division D. Water Quality
WELL CONTRACTOR CERTIFICATION ti a tI3 L
Well
Contract** (Mfividual) Nero
Well
CL e `SawYrrS $ soh
STREE
C4
Clyde Sawyers & Son We11 Drilling
14885 Hwy 209
Hot Springs NC 28743 r
Area coda Phone number
ber
2. WELL INFORMATION:
SITE WELL ID apt spaced
STATE WELL PERMIT/ligappliablei_
DWQ or OTHER PERMITBWV applicable)���
WELL USE (Check Applicable Sox). Reaklentiel Water Soppts'�1
DATE DRILLED_
1 TIME COMPLETED / i O„_ O
12. WELL LOCATION:
CITY:/yam.
Ant ❑ FM C/
COUNTY Q__ Ac�I
(street Name embers, Community. Subaaaion, Lot No.. ParpH, Lp Cade)
TT POG HIC / LAND SETTING:
°Valley ❑Fiat ❑Ridge CCther
tctEck Mpmpnate bar)
LATITUDE
LONGITUDE_, `
May ba in degrele,
mlmxea, seconds o:
:n a docimal fonoa'i
Latitude4ongituda 3Ou1OC: °GPS :Topographic map
(locator of Weimust tic shown on a USGS ropo map and
attached to this form 1 not using GPS)
OWNER'S NAME 9
STREET((ADDDD�?RFEIb$GS
Stale Zip Cie
P
. (. (�C/- S
A'ea code- ,hone number
S. WELL DETAILS:
a. TOTAL DEPTH:_______
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V--
e. WATER LEVEL Beim Top Of Casing:
(Use".' if Above T OfC �"'FT.
1 Top Casing)
a TOP OF CASING is Fr Above Land Surface 'Top of casing termi•Talea ator below iant surface may requir9
a viviartrg in accordance with 1SA NCAC 2C ,0118
a YIELD (gpm),___C__ME7X00 OF TEST /- C
t
f. DISINFECTION: Typo / Amount
�—
9. WATER ZONES (depth);
From To
From To
Fran TO
8. CASING:
Depth/ Diarrtefer
Fran_1— TOse
FromTo Ft.
From To Ft�...._.
T• GROUT: Cell/2: Maredal
en�
From_. To Re F
From To Ft
Froro ____ To__.
8. SCREEN: Depth Diameter Slot Sag
Fnyt..
'._,...._ To_.�.-. Ft.,. in.
m FroTc__ FL in.
Frail__ To____ F M.
L____-'n. et,
9, SAND/GRAVEL PACK:
Depth Sze Ma renal
From • TO Ft.. -
Fran To
From Ta
Frnm To
Th akinecQ
( dalerla!
327631
/O
Method
Material
From To Ft
IFrom______To Ft.
10. DRILLING LOG
iEngel To Formation Des;ytwn
,Ls
11. REMARK'S:
c
N_.
100 HEREBY CERTIr'y `NATTHS WELL WAS CONSTRUCTED N ACG-
ISA NCAC 2C. WELL CONSTRWRON STANDARDS, AND ..R04VOE WITH
RECORD HAS BEEN PRONOEC TOTHE}LaL OWNER. KArA co.WPr4. 7H9
SIGNATURE OF CERTIFIED
err: r_
PRINTED Nf.M_ OF PERSON ONSTRUC T iN
CONTRACTOR
S .fc �
DATE
Submit the original to the Division of Water Quality within 90 days. Attn; Information Mgt,
1617 Mail Service Center- Raleigh, NC 27698.1517 Phone No. [phone] ext 558,
THE WELL
.O
Ram G W-1
Rev.7,105
c

04-17-' 06 11:55 FROM-NCUENR ASHEVILLE id) 82e29V704'l
1. WELL CONTRACTOR:
m;
We Gunboats'(ndmdrab Nara
Sl��e S er,c � doh
Clyde Sawyers & Son Well Drilling
14885 Hwy 209_
Hot Springs NC 28743
We'
STF
as s- aoa�
Area coda Phone number
2. WELL INFORMATION:
SITE WELL ID tar aaapicada)
STATE WELL PERMIT/kr appuicaafe)���
DWQ or OTHER PERMITS -Of applicable)
WELL USE (Check Applicable 5wt): Rtaidentiel Water Supply
DATE DRILLED
TIME COMPLETED., 30 AM D
1. WELL LOCATION:
CITY: C4h7.✓__ y-
COUNTY
FM L--
(Street Name, Numbeia, Community, Subduamm Lol No.. Parcel. Lp Codsi
()POD PHICl LAND SETTING:
°Valley ❑Fiat °Ridge :Other
anent aperopite a box)
LATITUDE J.
LONGITUDE
May br in 4tart t.
minutes seconds ne
in a 4ecitnal format
Latitude/fungitude source: p GPS :Topographic rrap
{locator or war mutt be shown an a USGS topo map and
attach d fa Mk tam ?nor using GPS)
4. WELL OWNER
OWNER'S NAME
SrET-a 5 IIIrSYJ��%>a
Or Team state
Area code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: aS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO S -
c. WATER LEVEL Below Top of Casing
Zip Code
STENTdAL WELL tQO'NSTRUCTtON CORu
North Carolina Depamnent ofEnwran rent and Narural ResourccS. Division of Water Qualm•
WELL CONTRACTOR CERTIFICATION N a L/3 4
'1'-y1E PLL(bS U-70b
L DISINFECTION: Typo t S
9. WATER ZONES (depth):
From To
From To,
From To
B. CASING:
From_ 4 _Depth
�s7 FL / ianmater
FrmrTo FL`_
From To Ft.
7. GROUT: Cwt. Helena
Frwn To 2O Ft tit_
From To FL
From___ To FL
S. SCREEN: Da
Fran DSb; Sat
Fran__.. To F1. L�......i-..._-. in.
To_ FL in.
Fran To
in.
f, SAND/GRAVEL PACK:
Depth Sae
From • TO FL
From TeFL
Fran ToFL
327832
4 mount�2._
From To
From
To
Fityn To
Th cgk, qau
Wt
SctK2t
Aafen
MOWS
DRILLING LOG
11. REMARKS:
ei,
Ma 5arial
Formation Dec ion
fVI
DO HEREB' CER1ifl -NAT THIS WELL WAS CONSTRL'C7E12 15A NCAC 2C, WELL CONSTRI TAN STANDARDSA CO^r• ; 114 Wt
RECORD HAS BEEN PROVIVEC TO THE ELL OWNER
Ta CC^r O•T,A$ i
SIGN'iATURE OF ERTIREA
/3err: L k
PRINTED NAME OF PERSON ONSTRUCTIN
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Canter - Raleigh, NC 27699.1617 Phone No. [phone] ext 568,
(Use `tv' itAboye Top of Casino)
a TOP OF CASING IS FT. Above Lard Surface'
`Top of casing terminated abor blow fad surface may require
a variance In accordance with 15A NCAC 2C .elle
YIELD fontMETHOD OFTEST Ct
L CONTRACTOR
CATE1.3
`G
S
SHE WELL
Form Ga1aC)
McV.7r 5 0
rt
ro
m
--t
If
rn
7
0
rq
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Cm
it

04-17-' 06 11:55 FRCt1-NCDENR ASHEVILLE sU
1. WELL CONTRACTOR.
T-18 FIiZ/05 U-BUD
ENTIAL WELL co STRUC TTny R CORD
North Cazolina Department or Environment and N&ural Rz&ou/rces. Division of Watcr Qunlity
WELL CONTRACTOR CERTIFICATION if OZ9 3 C
Wo1 Contractor t ridj Name
cue . La t s 4 Sor,
Well
STREE
Clyde Sawyers & Son Well Drilling
14885 Hwy 209
Cc Hot Springs NC 28743 S
Area coda Phone number
Z. WELL INFORMATION:
SITE WELL ID SOI weloa e)
STATE WELL PERMIT/MI applicable'
DWQ or OTHER PERMIT *applicable)
WELL USE ;Check Applicable Gas):
DATE DRILLPD g a {_
TIME COMPLETED V
3. WELL LOCATION:
CITY;
Residential Weler Supply y'
AM 0 FM Q- mil
COUNTY .Q 42 .
e rQ1
{Seem Name, Numbers, Community. Subevaan, Lot No., Pratt Zrp Code)
T POGRAPHIC I LAND SETTING:
SIOPe °Valley ❑Flat [(Ridge COMET
(theck,waopiabbox)
LATITUDE 3
LONGITUDE_, `
May 61 in auras,
mmmte s, seconds a
in a decimal form
Latitudefongitude source: 0GPS :Topographic map
((ocaren of wellmustbe 'nano on a USGS topo In aid
attached to cols form l not uskrp BPS)
e. WELL OWNER
OWNER'S NAME S ! _ Q p; ill
STtjEET AD SS (o1s : C
oeo
City or Term t Wit._ asp —33� e. Zip CateArea code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: QS-
b. DOES WELL REPLACE EXISTING WELL? YES 9 NO 12--
c. WATER LEVEL Bebw Top of Casing- __/ o
(Use`r• if Above Top of Casing) �•
t1 TOP OP CASING i5 1 FT.Above Land Sure
'Tap of casing terminated attr blow lend Surface m require
a variance in accordant wth 1SA NCAC 2C
a YIELD (pomp .j METHOD OF TEST A G
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27899• 917 Phone No. [phone] ext 568.
327333
f, DISINFECTION: Type r S amount
9. WATER ZONES (depth): �-
From To_^
From To_�
From____ To
S. CASING:
Fram_i _ To
Frorr.� To
From To__-
7. GROUT: Dept;
F__Q___ To a0
Prom__ To
To_
I. SCREEN:
From
From_
From_
Depth
Te_^T
To
To
From TO
From To
From To-
Thicknesal
Diahat
Fi a el l
Ft
Material II
FL a nT
FL _
FL
M�eetn'o�y
Diameter Slot Sac Meterlat
in.
FL in. Lit.
S. SAND/GRAVEL PACK:
Depth Sire Ma ieriel
From • ,ToFt,
Fran Tc FL
FrorL_Tos_ FLU___
10. DRILLING LOG
Frgrn To
Formation Dew-. tan !�LfRr
Io
1
3•Mierwm•••••.•••fl.....••=•
To �
- or.
11. REMARKS:
SIG' SIGNATURE OF C TIFIED L CONTRACTOR
/Jeri; k s
PRINTED NAME OF PERSON ONSTRUCTA THE WI, J EI2
m
DO HEREBY CERTFY 'HAT THIS WELL WAS CONSTRUCTED N ACC;ROA'YCE
ISA MAC 2C, WELL CONSTRUCTOR STANDARDS, AM) RECORD HAS BEEN PROVIDED TOTHE WELL OWNER. rNTA Wrt O: 7Ma
GATE• C"!
rn

04-17-'06 11:55 FROM-NCDENR ASHEVILLE Mi
1. WELL CONTRACTOR:
rn;
W M Contractor ( Norte
C/de Sawwrs
Well(
&Z8Zy,51U43:i
T-J18 PL1Z/1d5 U-7410
ENTIAL WELL CONSTRUCTION R O D
North Carolina Department ofEnwonment end Natural Acacia
-COS- Division of
Water GualiD•
WELL CONTRACTOR CERTIFICATION f a 13 La
y . lAh
STRE. Clyde Sawyers & Son Well Drilling
14885 Hwy 209
Cc Hot Springs NC 28743 / s
Area coda Phone number
2. WELL INFORMATION:
SITE WELL ID afd applauds)
STATE WELL PERMJTSdfappipde)
DWG, or OTHER PERMIT t(d appiicabte)._���
WELL USE (Check Applicable Sox): Residentml Water SuppiX
DATE DRILLED C -S
TIME COMPLETED irl AM O FM V--
3. WELL LOCATION:
CITY, n /
COUNTY /7rr �re r1.vt rep
;Street Name , el Community.
ilti
• - LanunRy, Subdv>uon• Lot No, Pawl Lp coo.)
TOPO s, r
PHIC ! LAND SETTING:
OVaiiey CFlat Oer
Ridge CCNfO. DRILLING LOG
mheca actor odem box, I Ftzlm To
LATITUDE $
LONGITUDE V _
3217335
1. DISINFECTION: Typo r S Amount
9• WATER ZONES (depth):
From Tc
From Ta
From To
i. CASING:
Depth Diameter
FroFrom
To..
Prat To--�_FC
7. GROUT: Ceps;
Frwn Q To
Fran_--_ To
From_ __ To
Materiai II
FL a nT
FL
_� FL
�r�..,,•��Method
II. SCREEN: Depth Diameter Slot Sin Material
From To
FLin. .
Fmm
To FL in. h
.
FranTo F i
I. SAND/GRAVEL PACK:
Depth Size Materiel
From To _ Ft.
From To R,
FroniTo—_ PL------.__
Miy br In degrees,
mmZIes, seconds o:
in a decimal format
Latitude/lono nude sczrvt: ❑CPS :;Topographic map
(location of wermost be show, on a USGS ropm reap and
attach&to this farm r not using GPS)
4, WELL OWNER
OWNER'S NAME
ee
STR7 TADDR SS
E �1 knps
Cdy or Teton
A -ea code - Phone number
S. WELL DETAILS;
a TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO pa—
c. WATER LEVEL Below Top or Casi.
T9 _(e_Q____FT,
Stale
(Use "." if Above Top of Casing)
d. TOP OF CASING 16 ' F1. Above Land Surface*
Top of casing terminated abor blow land Burfaoe may require
a variance in accordance with 15A NCAC 2C .0116
& YIELD Mont METHOD OF TEST
Zip code
•
I1. REMARK'S:
From To
From___To_
From
Ouft /i
Formation Dose— f
DD HEREBY CERnn.'HATTHS WELL WAS CONSTRUCTED N ACCCRDA.:C`a: WITH
15A NCAC 2C. WELL CON5INL7 DN STANOAROS, A•w) Tn,TA COP ro: thy^
RECORD HAS BEEN FRQypcc TD'ME Wytj DWNER,
SIGNATURE OF CERTIFIED FIED WW
0erk s
PRINTED NAME OF PERSON ONSTRUCT:N THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center - Raleigh, NC 276994617 Phone No. [phone] eat 568.
CATE
Fain GW-1m
Rev. 7)D5
--1
t
t

04-17-' 06 11:55 FROM-NCDENR ASHE'VILLE RU 828291d/W4!1
as G s- aoa�
Area coda Phone Phone b�
2. WELL INFORMATION:
1. WELL CONTRACTOR:
rn,
W�ol )C`ontrail« (hen;dual).Name
C'_
Clyde Sawyers & Son Well Drilling - L 1
14885 Hwy 209 i LS C,
Hot Springs NC 28743 / S
Code
SITE WELL ID eOt eas :able)_.
STATE WELL PERMIT/Airapplicable'
DWQ or OTHER PERMIT kg applicable)_
WELL USE (Check Applicable Bar); Residenfol Water Supply Q.
DATE DRiLLPD_
TIME COMPLETED y r AM ❑ FM
11. WELL LOCATION:
CITY: Cgs I rr r COUNTY
(Buret v not, Numbers, ConimunitSuet* nig%Lot No Parcel yCCode'
TtIP°GRAPHIC) LAND SETTING:
lope OValley ❑Fiat ❑Ridge GCther_
tthecif bleu
LATITUDE
LONGITUDE
May Win deargt
al tos, seconds or
inn denims/ formai
Latitude,Nongitude source: ❑CPS :Topographic reap
(locator/ W wermue/bs shown on a USGS tom map and
attached to this form rnot using CPS)
e, WELL OWNER
i OWNER'S NAME
•STR,T ADDRE
i
City or Town ....e
Zip Code
Ate code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:s _
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL 6e{arTop of Cosby: 3
(Use if Above Top of Casing)
d. TOP OF CASING IS � FT. Above Land Surface'
'Top et casing terminated at or below laid surface may require
a variance in &coon/oncewt 15A NCAC 2C .0118
•
it new (Dpm)*JMETHODOFTEST /" C _ __
NOQ—
FT,
_SENTL4L WELL C
North Carolina Department ofEnvironment and Natural Resour
tes• Division c.r
Water fJualiy
WELL CONTRACTOR CERTIFICATION II ay3 4
T—y18 P112/b5 U—Dbb
327336
L DISINFECTION: Type r S mount,,_,
9. WATER ZONES (depth):
From Tc
Fran To
From To
From To
From To From To
S. CASING:
Th:,Icm&
Ftom�D7TFo rt th 4._ W6�� 2 t
F,an �+<i=-
From
To Ft
7. GROUT:Mfi
Depth Material /
From_Q__ To aO Ft CP_ n._en_.T �,,•_-r
From To FL
Fromm_.__. Too, Ft -----__
3. SCREEN: Depth Dia„neler Slit
From To Sat Material
Fray. To FL�.,�,....i6m.
Fran FL in.
. __- it
TO FL____.in, m
s. SAND/GRAVEL PACK:
Depth Sae Ma tenet
From • To _ _ FL
Froth re FL -----
From_____To FL
10. DRILLING LOG
Fran To
_/T
II. REMARKS:
Formation n
Deso:ytq
n�V-e c
eso l I
100 HEREBY CERUFY RUT7HS WELL WAS CONSTRUCTED N AC: CROAVCE %
ISA NCAC 2C. WELL CONSTRU. nON nTANDARDS. AND rn TA corva= *r!a j,
RECORD HAS SEEN PROVIDED TO THE WILL OW PR.
SIG ATURE O CERTI
/Jett; t k
PRINTED NAME OF PERSON ONSTRUCTOI 7HE WELL
Submit the original to the Division of Water Quality within 30 days, Attu Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699.1517 Phone No. [phone] ext 668,
Far
Rev, 7j05
O
-7177
Y <-u
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iTt
O rTl
cc
r
r
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G-,
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94-17-'36 11: 55 FRCt-tcDENR ASHEVILLE a) 8282 .9710a3
e. WELL CONTRACTOR:
rani / a, r^S W el Cont a t°, ( Moat) Noma
.Sa S4 S 4 So r.•
STREETAooi Clyde Sawyers & Son Well Drilling --
14885 Hwy 209
coda Hot Sprint,s NC 28743
I aa'
Area coda Pima number
=��LY
2. WELL INFORMATION:
SITE WELL ID Kaaaplcaba)
STATE WELL PERMITIldicpplicalsor
DWQ or OTHER PERMIT adrapplcable
WELL USE (Check AmdlocHt BW: Raalda,t:d Water Supply
DATE DOLLED S_p- —
7lMECDMPLETED Y,oU AM PM Lt.--
I. WELL LOCATION: I �
CITY; ftr'.- osh�`
I--____ COVNIY
(9Deet N Nunbaa. Commratry, Sabdyygn Lof No_ Proot.
OPO HIC / LAND SETTING:
COaaty ❑RM DRdge °Other
(coo* smi oppaa MN
TTTUjE
_ I �.� a'sr°rR
LON
_a_
toby In
a
GITUUE in a deewl fonaai
Latitudeacinsjtude 3Ontt: OOPS
:.ZoDOC'aPhio map
pooaaon of boat most to Shan, on a USG& repo map and
attached to this hem not using GPM
4. WELL OWNER
i OWNER'S NAME
ST ET �ODRE381i%-�j'
City_
Asa y'/
Ards code- Phase number
a. WELL DETAILS:
a. TOTAL DEPT►t ?Car
9p Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO gam
e. WATER LEVEL Below Top of Clang. 90 FT.
(Use `." ((Above
Top of Casey)
d. TOP OP CASING la t r FT. Above Land Surfacer
'Top of canig tarrnmated abwbeloYlaid surface may move
a mince in accordance wilt 16A NCAC 2C .C1188
a VIEW (OPmkt-mot,_ AMMO OFMST /C,q
"1'—y18 YtiZ/Ob U—OWb
E.NTIAL WEL CONip UCTION Rtr 0 D
North Cookie Depanmax ofLTaviroameot and Natural R
e€ources- Divlaion o.e
Water Quality
WELL CONTRACTOR CER77FICATION t a t%3 CD
1
327624
f. gaRfFECTION: Typr, r .i Amount__
g. WATER ZONES (depth);
From To
Flom
Fran To
$. CASING:
fief
Ft
From To F,
From To Fes_
7. GROUT: Depth
Fron:Q_ To RC
Fran_ To FL
F1O'n_____ To FL
SCREEN: Depth O1amater Sot Sim
Frail To^�„�FL
Fmen To FL
Fran To
Frar...ea__ To
To From To
From To
Th*nisei
.1G'A fc
MOMS
S.$ANdfRAVEL PACK:
tBP1h sirs Mab-ie!
From
From ' Tcc R --
M&m!N
FLSPrtie n4.
Notarial
Fran�lTp�_- Ft._
j f0. DRILLING LOG
F?1 To Formation Des4-tort
2.27
1►
/?4 Sazs -
11. REMARKS:
f 00 SERE9F CERIay TAUT R/d WELL WAS CONSTRUCTED N ACCCliDioteg
mS.NCAt 2C. WELL CONSTRUCro STANDARD'S, APO rnSTA COPY JF TNa
RECORD NAB BEEN PRCVCIED TO111E WELL OWNER;
ri
SIGNATURE OF CERTIFE1
�C'-Y.Lk I) NTRACTOR a OA7C?'�
yer ` L'
PRINTED NAME OF PERSON NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn; Infonnason Mgt„
1617 Mal Service Center -Raleigh, NC 214150.1017 Phone No. [phone] ext 658.
L"
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Fain
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327623
RAIIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Deartment of Environment and Natural Resources- Division of Wate' Quality
WELL CONTR.ECTOR CERTIFICATION #' ay34
1. WELL CONTRACTOR: J'
!Jerk % i4T'h Sat/5
Well Contractor (Individual) Name
C L ac •SGwyer5 $ S ,<n
Wei or Company ,Nlb{,a6 /' c7 O
STREEET ADDRESS1,S ! 7 0 ?< /7'i:t y ocO 6
C' TWm^4J Stater C, /Z a7te
e
( 32f )_ G 6C- o209,2 •
Area code- Phone nlmlber
2. WELL INFORMATION:
SITE WELL ID AV approble)
STATE WELL PERMIT#(Irappiicabie)
DWQ or OTHER PERMIT #(ff applicable)
WELL USE (Check
,Aw pplble Sox): Resid
DATE DRILLED 7 4r.`^ `P
TIME COMPLETED .2 30 -
3. WELL LOCATION:
CITY: C/4i714/
- CO
Numbers, • T unity. Subemslon.
TOPOGRAPHIC / LAND SETTING:
*lope °Valley °Flat ❑Ridge °Other
(check epptopdate box)
LATITUDE
LONGITUDE
Latitudellongitudesource: oGPS ❑T
(bcaakn of wed must be shown on a USG
attached to this form T not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
C0-ndWs
City or Town
0 PMQ---
No., Parcel, Zip Code) ..
graphic map
map and
mr.tel P.: e Rd
NC- riIS
State ' zip code
L }
number ,
Area code - Phone
iL WELL DETAILS:
a. TOTAL DEPTH: 05—
b. DOES WELL REPLACE EXISTING WELL rTES 0 NO El
ra r
e. WATER LEVEL BebeTop of Casing e) FT.
(Use '+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Move Land Surface'
Top d casitg terminated a (or below land aoface may require
a variance it accordance wlh 15A NCAC .0118.
e. YIELD (gpm): '3 METHOD OF ZEST rJ
f. DISINFECTION: Type {)-e 115 Amount .3 0
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
From / Depth
7 Ft4p /r J,(J(J�}� err
From To Ft '^i'—
Frorn To Ft
7. GROUT: Depth Material
From 1 To Q.C3 Ft Cy. mcAl`
From To Ft
From To Ft
Method
fnttn-d
8. SCREEN: Depth Dian. rier Sbt Sae Material
From To Ft in. in.
From To Ft in. m.
From To Ft it in.
9- SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft
To Ft
To Ft.
10. DRILLING LOG
From To
?O
Ten
11. REMARICS:
Material
Ibrmatioi Description
furor C4i1
Asheville Regional (ice
PAnuifer Protect
1DOHERESY CERTIFY THAT THIS WELL WA: CONSTRICTED N ACCORD NCE WIN
ISA NCAC 2C. WELL CONSTRUCTION STANC ARDS, Aldh THAT A COPY OF THIS
RECORD HAS BEEN PROVDED TO THE WEI L OWNER
SIGNATUREiOF CERTIFIED Why ONTRACTOR DATE
Vfrr. te_ ra f,%) .SW y,oar
PRINTED NAME irPERSON CONSTRUCTVIG THEWELL
Submit the original to the Division of
1617 Mail Service Center- Raleigh, NC 2
later Quality within 30 days. Attn: Information Mgt.,
99-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD?
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 14
Q_04CLo 0I
Well Contractor (Individual) Name
P& to Q o..\ LLet t Dr; \ t ;,t5 t I n c.
Well Contractor Company Name
STREET ADDRESS 351 IvEt.,3 ket ceSltf
f shev,tit NC
ag8'o6
City or Town State Zip Code
( 2,54-35I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 40 applicable)
STATE WELL PERMITO(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applic/�ble Box). /Residential Water Supply
DATE DRILLED b/ 1 q I o 1p /
TIME COMPLETED -3-- o 0 AMO PM[y
3. WELL LOCATION: '''�/nLLt�� /�
CITY: ASH €.4 L<-� COUNTY 0�� COMQg
tk a o1-b LaG6iNG 0-zA.D
(Street Name, Numbers. Community, Subdmsion. Lot No., Parcel, Zrp Code)
TO GRAPHIC / LAND SETTING:
lope [Walley ❑Flat °Ridge ❑Other
(check appropriate boa)
LATITUDE 3 5->r t1^ 1QQ
o
LONGITUDE
Latitude/longitude source: GPS ❑Topographic map
(location o/ wel must be shown on a USGS topo map and
attached to this lam l not usig GPS)
4. WELL OWNER t1�\
OWNER'S NAME })'AL$ AMrYv A/35
STREET ADDRESS * a 01--OGelt3 O fl-
May be in degrees.
minutes, seconds or
in a decimal format
f15(4E`(\Ltt tJC- a_?YD
city or Torn State Zip Code
()- 3%\—oogi
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S D 5
b. DOES WELL REPLACE EXISTING WELL?/ YES 0 NO�(
c. WATER LEVEL Below Top of Casing: D FT.
(Use'+' 8 Above Top d Casing)
d. TOP OF CASING IS 1- FT. Above Land Surface'
- 'Top of casing terminated allot below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): IS METHOD OFTEST (ZtC3—AI
at4-a
f. DISINFECTION: Type
g. WATER ZONES (depth)2
From 4 ,; To 4b 4'
Fran To
From To
Amount
oft? ("
rr0 C
From To
From To
From To
6. CASING:
Depth
Fr n 1 ep �1
, Ft. b((
Franaep
To Ft
Fran To Ft.
Thickness/
SDI tistt
7. GROUT::( Depth Materialy
From 1 To a, tt FL /n� W An “
From To FL
From To Ft.
Method
eau2aD
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
From To FI. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From . To
From To
10. DRILLING LOG
From , Totv a
q2,0- 463'
4-b3'- 464'
4t14/ - SoS`
I1. REMARKS:
Ft.
Ft.
Ft.
MatSbal
a
Sl <
C
CD
m
Size Material; p t= •
ID 7
i0 O
Formation Descria
OJ $ QJc OL>_b
n
m
n
C126VtC€— 15 E9ry
GRAN rt
en R-A N to
I DO HEREBY CERTIFY THAT THIS WELT WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PRONDED TO THE WELL OWNER
&u,LLQ,e,tre_J3 dwe.i . �C1416b
SIGNATURE/�'F CERTIFIED WELL CONTRACTOR DATE
kS\LL.1t fah3f4
PRINTED NAME OF PERSON CONSTRUCTING 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-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Recourcec. Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti oa (¢
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
ellbenCD0d.wd1 brok;Ac (\ C
Well Contractor Company Name
STREET ADDRESS ' JI fkIQUJ FEt CeS.r 1'TWY
iishev,Ile fvc ag 8' 0 G I
City or Tam State Zip Code
( 1P1)- a54-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID opt applicable)
STATE WELL PERMIT#IB applicable)
DWQ or OTHER PERMIT a(if applicable)
WELL USE (Check Applicable Booj): COesidential Water Supply id
DATE DRILLED ID/13/ c
TIME COMPLETED
3
AM0 PM11(
3. WELL LOCATION: (/�j
CITY: �AtP4013 COUNTY ti (Z/vISC
(03o ,)pP6-rz CSC-usi4 CI-J‘k $.
(Street Name. Numbers. Communrty. Subdmuen. Lot No.. Parcel. Zrp Code)
TOPOGRAPHIC /LAN SETTING:
°Slope [Valley t31'Ia1 °Ridge °Other
(check approopnale boon '1
LATITUDE 3 aJ 3)-1 qi
LONGITUDE 1 si• 9\31
Latitude/longitude source: L»61S °Topographic map
(location of wel must be shown on a USGS repo map and
attached to this foam 1 not using GPS)
May be in &greet.
minutes. seconds or
in a decimal Formal
4. WELL OWNER (' ,/�/� �j
OWNER'S NAME A `a I MOO lOO et
STREET ADDRESS W. o , e>ti< 13 t1
FAitiVl43,Q t a3o
City or Town State Zip Code
(83S). AIC -°t< a3
Area code - Phone number
5. WELL DETAILS;
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (OY
c. WATER LEVEL Below Top or Casing- Z r C FT.
(User" if Above Top at Casing)
d. TOP OF CASING IS G FT. Above Land Surface
'Top of casing terminated aUer below land surface may require
a variance in accordance with 15A NCAC 2C .0118.� i� Cn!
e. YIELD (gpm): CQ METHOD OF TEST 1'I `v ^ 41 -
a c",
c; 6: 6 d ci
f. DISINFECTION: Type 1' I (4 E" C)CfiAmount I l OZ'
g. WATER ZONES (depth)
From To From To
From To Frorn To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight
From To FI
From To Ft
Frorn To Ft
7. GROUT: Depth
From To FI.
From To Ft.
From To FI.
Material
Material
Method
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To FIin. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Ft.
From To Ft.
10. DRILLING LOG
From j To /
24-5 — 70S
rr
J 0
0
0
Formation Deseri n
L
r—
N
0
11. REMARKS:
�fil5 WIs1� i4tk3 80-�
Ot\lL_Le 0 pat -floe ritto4-/
245'— -I05'
r DO HEREBY CERTIFY THAT THIS WELL WAS CONso nCTED N ACCORDANCE WTI
'SA NCAC 2C WEltCONSTRUCTION STANDARDS AND THAT A COPY /OF /T/ /NI
RECMDNAS PEE iO TN WELT. OWNER
VQi�"Y\WI1&(3 0
SIGNATURE plfCERTIFIED WELL CONTRACTOR ATE
Su—L_Ig P�A5i-I
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] est 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanmcnl of Environment and Natural Rrsourc co- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H
al4-a
328030
1. WELL CONTRACTOR:
aut.:0 A I C of ck a z\ I
Well Contractor (Individual) Name
kLL,ber La. \CLwct1 Dr;\t;n ln�
W ell Contractor Company Name` ' I
STREET ADDRESS 3 JI tku% ( ceS-Fer
j\shev,(IC NC ag $'o G
City or Town State Zip Code
( K 1 a64 -_15IS I
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID NOT applicable)
STATE WELL PERMITN(f applicable)
DWQ or OTHER PERMIT NV applicable)
WELL USE (Check Apo'? able ©I L1J
x) Residential Water Supply '
DATE DRILLED Co / 1 / o
TIME COMPLETED -- 7 O AM PM i
3. WELL LOCATION:
CITY: C;1L N A Lie
Q-e A's)
(Sveel Name, NumberslCanmunrty. Subdivision. Lot No., Paicel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley 0tat DRidge pother
(check appropriate boa) LATITUDE yT 5 1, i . 4-54
LONGITUDE ei 2, C - SO- Ct
Latitude/longitude source: isi( PS °Topographic map
(bcafion o/ war must be shown on a USGS lopo map and
attached to this loan ( not usig GPS)
COUNTY v3 Cet
1^CI A 1 O k_O � et1-1 NL
May he in depees.
minutes, seconds or
in a decimal (oral
4. WELL OWNER
OWNER'S NAME
eL LA Di LJ re, atIL.D89-S
STREET ADDRESS al (An) -re OA4 (LcAt
ASj1fivtag763
City or Town Slate Zip Code
( Sir "It3—c9ov
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p ND Lbf
c. WATER LEVEL Below Too d Casing v FT.
(Use -a- if Above T d Casing)
d. TOP OF CASING IS - FT. Above Land Surface'
-Top of casrtng lermmafed at/or below land surface may require
a variance in accordance A cordance with 1 SA NCAC 2C .0116.
e. YIELD (gpm): et METHOD OF TEST Q,AG MIL
f. DISINFECTION: Type ('sl t,AeAmounl p DC
g. WATER ZONES (de h)
From 1m qq To 0 l' FroTo
4-0 6 To 4-e ( Frorn To
To Frorn To
Fr cm
From
6. CASING:
Depth
From \ To -*kJ
From To
From To
Ft
FI
FI
Thickness/
Ditteter Doh Malpaial
7. GROUT: Depth Material Method
From . To ail) Ft. !_.C(Y0SNT /to i
From To Ft.
From To FI.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ftin. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG /
From d Ti ,
1%1"
Ti $ 1
- 4-o ( '
4-ob `- 4G'I'
40.1.� 4-as'
Ft.
Ft.
FI.
Size Material
F
(i
ormatio
n
DeSCriptionl l
e .&-' (tAtve C - -1 erri
C.* 0t4+-N-r-G-
c_fits4 Lr - tet Geri
2A-,,1 v-r
EIVj o
G 2D aos
Asheville Reg;
I
tecti
11.
'"" • 'A ua 8r Rroian
ice
I CO HEREBY CERT/FY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS a f{ N PROVIDED TO THE WELL OWNER
Lod 4 4/r31196
SIGNATURE OF CERTIFIED WELL CONTRACTOR
g(Luje N-4$1*i
PRINTED NAME OF PERSON CONSTRUCTING 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-Ia
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:
Rewbevt Ca.1amJe(
Well Contractor (Individual) Name
RUtl.ben Ca.1diveti S)r;1IteKu (Inc •
Well Contractor Company Name
STREET ADDRESS .75) M n i& k1C.e.stey 6tJJ.
AsheAritle.- ro c
City or Town State
Area code- Phone number
2. WELL INFORMATION:
SETE WELL ID #(if applicable)
STATE WELL PERMIT#id applicable)
a8%o6
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): __Residential Water Supply'
DATE DRILLED (G/ a / b 6
TIME COMPLETED 9:- ('3 a AM p PM V
3. WELL LOCATION: //��
CITY: t)gj44t3 4, t.l$ COUNTY €U fa QOM&
(Street Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC/LA D SETTING:
❑Slope [Vatleylat ❑Ridge OOther
(cheek appropriate box)
LATITUDE 3 S 4- 4 - u 33
LONGITUDE 9 a 33 -9 0
May be in depees,
minutes, setondt or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(bcalbn of wet must be shown on a USGS topo map and
attached to this form t not using GPS)
4. WELL OWNER
OWNERS NAME
lOfQ le— ()V1`'LIL
STREET ADDRESS 1)' e a �( a oc_O O
A S 4 t t 1/4.l_ (t% cLr C a- g Z
Zip Cade
City or Town State
(cal} '117--6gSo
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH.
3¢5'
b. DOES WELL REPLACE EXISTING WELLL? YES ®•- NO ❑
c. WATER LEVEL Below Top el Casing: t D FT
(Use -+ it Above Top,,t( of Casing)
d. TOP OF CASING IS `1. FT. Above Land Surface'
-Top of casing terminated aura bearer land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): Go METHOD OF TEST 9,16 — Ai2
t¢°
1. DISINFECTION: Type }.)r 07; Amount
g. WATERppZONES (depth).
d
From I4 To 3aa From
From To From
From To From
6. CASING:
323031
To
To
To
Thickness/
From 1. DepthTob a Ft. 17 Trier
fl(L.d 1 tV IG.
From To Ft.
From To Ft.
7. GROUT:Depth ��11
From A To D10
From To Ft.
From To Ft.
8. SCREEN:
Frorn
From
From
Material
Ft CA NNE(�1
Depth Diameter Slot Size
To FI.
To Ft.
To Ft.
Method
In. in.
in. in.
in. in.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
FromT_To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From/ Tq 3
315'
3(q'- 33-o '
3ao'— 34-5
Formation Description
ataITC
LC€ — 50 Gvr"
G a a lTc
Reg;onell Office
H? r Protection
11. REMARK_—`"`
t DO HEREBY CERTIFY THAT THIS WELT. WAS CONSTRUCTED N ACCORDANCE wmt
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
2Q.hS*A eadLZAR321
o6
SIGNATUR OF CERTIFIED WELL CONTRACTOR E
eel \ 6 0 iks
PRINTED NAME OF PERSON CONSTRUCTING 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-fa
Rev. 7/05

',.. SAATZ's%
RESIDENTIAL 1VF,LL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural-Rramreee- Diviainn of Water Quality
WELL CONTRACTOR CERTIFICATION k 1 r D
1. WELL CONTRACTOR:
LtAedtet Lo kd,ae,t I
Well Contractor (Individual) Name
Re,beh Qn\Cott t Or; k;„�(\4c.
Well Contractor Company Name
e\ 1,,
STREET ADDRESS JI 1u L3 'Lei ceS+e-r )44,01 .
shevttIe Nc asgo6
City or Town Stale Zip Cale
(? )- a64-35$I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT a(if applicable)
WELL USE (Check Applicable B/gi) Residential Water Supply 0
DATE DRILLED toil /0 6/
TIME COMPLETED 11'e S 0 AM?J PM 0
3. WELL LOCATION:
-/ ►(Cj
Y` A ( ill -NI tt-1r-) COUNTY elk.) yJt1)/T%a
CITY:
Q)
era, c-A t LA fv
(Segel Name, umbers, Community. Subdmaron. Lot No.. Parcel. Z,p Code)
TOOP GRAPHIC / LAND SETTING:
L4wpe ❑Valley ❑Flat ORidge ❑Other
(check appropiale box)
LATITUDE y1 5 3 a . 1 15)3
LONGITUDE 5 a a1• is 1(4'
May be in deem.
minutes. seconds or
in a decimal fomui
Latitude/longitude source: Q6PS OTopographic map
(location of we! must be shown on a USGS topo map and
attached to this form ! not usng GPS)
4. WELL OWNER OWNER'S NAME L
STREET ADDRESS f - 61
F'ArAJ)Yw pc__
City or Town State
( ga.g -t (� - 533a
Area code - Phone number
5. WELL DETAILS: q�
/
a. TOTAL DEPTH: 30 [U
I1
a8,st
Zip Code
b. DOES WELL REPLACE EXISTING WELL7 YES 0 NO [9`
C. WATER LEVEL Below Top dCasing-
0 FT.
(Use -. if Above Top d Casing)
d. TOP OF CASING IS FT. Above Land Surface'
-Top d casng terminated ava blow land surface may require
a variance in accordance...Oh 15A NCAC 2C .0118. �-
e. YIELD (gpm): Ip METHOD OF TEST {-1.lT A ti0 es
I. DISINFECTION: Type IA
g WATER ZONES (depth)
Flom C) To 0' 1
Fran L(04 Tp2,b�
From
6. CASING:
From i
From
From
To
From
From
From
Amount % t!Z
To
To
To
Thickness/
Depth
h+I Ft. Da
To ter Seieghhta( t.�lgrili
To Ft
To Ft.
7. GROUT: Depth Depth Material Method
Fran 1 To 9'"-A Ft Cf reteNT 6'D JycESt
From To FI.
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
From To
Diameter Slot Size Mi(gerial
13
Ft. in. in.l> rp
Ft. in. in. a -
Et. in. in. p (0 C 0
PI,A3
H Cro]
Materia o 5
From To
From To
10. DRILLING LOG
Fro 4To3 / b Formation Desaipli0
Co - q o' G (2-4 -r.)1 `E- 15
of O I - 4 I CAtc
ac't\- -Ra6h45' cGCc'.e3-r-C1546 GP
9,65'- 3e5/
f; rn
N
Ft rn
Ft. W cr 0
C2' bd
FI.
Size
0
n
II. REMARKS:
Gem
`J
yL-
:
r—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WTI
ISA CAC 2C WELL CONSmucnDn STANDARDS AND THAT A COPY OF THIS
RECORD HAS PEEN PROVIDED TO THE WELL OWNER
SIGNATURE F CERTIFIED WELL CONTRACTOR
b
DAT
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ear
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 56B.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rcarrc cc- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
\aeh 'Q c d..,ae,l l
Well Contractor (Individual) Name
Q.e.A.L,ben �..o.\&We(l Or;11;nc ( Inc-.
Well Contractor Company Name
STREET ADDRESS 3 J1 flew 'L& c2SrC,t'
6shev;tle_ NC agg"0G
City or Town State Zip Code
139-g} a64-35$I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(II applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appli
DATE DRILLED (2i /
TIME COMPLETED glee ° AM ❑ PM Ee
3. WELL LOCATION: (� �yLy��
CITY: FA/�tA) COUNTY FvvA)ce-
oa): Residential Water Suppfrmfl/
O b
\-nrr-. A S -a& (Zo'A
(Street Name. Numbers. Community. Subdmsion. Lot No.. Parcel. try Code)
TOPOGRAPHIC / L 9D SETTING:
❑Slope DValley Slat ❑Ridge pother
(check appropriate box)
LATITUDE 30.191
LONGITUDE" a a
6a361q
May be in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: OGPS °Topographic map
(location or weI must be shown on a USGS topo map end
attached to this form l not ushg GPS)
4. WELL OWNER
OWNER'S NAME l `i(t Ip
t r1 br.t CYO
STREET ADDRESS s 0 eerwo OdL cx1 ve
As)1ev';Ile tJt-- ag U Ds
City or Town State Zip Code
1 cgaK > a,4%— 3S5'I
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3o5J
b. DOES WELL REPLACE EXISTING WELL?rr YES ElNO/
c. WATER LEVEL Below Top d Casing- Y.' FT.
(Use'+ if Atove Top of Casing)
d. TOP OF CASING IS 1. FT. Above Land Surface'
'Top or casing terminated SJcx below land surface may require
a variance i1 accordance vdth 15A NCAC 2C .0118.
e. YIELD (gpm): t O METHOD OF TEST RIG` A t l
al4—a
328333
I. DISINFECTION: Type tatAmount 10
ciG _
g. WATERry -Z-OtNES (depth
Flom '�1 L. To yl" From To
Frl n a 1 a To a 113 From To
From To From To
6. CASING: Thickness/
Depth1 4ialTleter S e{aryll al mist
To t� FI Ei� �' ( �
From 1
From To Ft
From To FI.
7. GROUT: Depth p�
From To r',L,.O FI. Cwm1 i fL)8—tSa.t.)
From To FI.
From To FI.
8. SCREEN
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From To
From • To
From To
10. DRILLING LOG
From To 9
pi'-`T
Rs• - akia'
a1a'- a',3 •
&73"- 305,
t
I1. REMARKS:
FI.
Ft.
FI
Material Method
Diameter 51o1 Size
in
in
Ft.
FI.
Ft.
in.
in.
in.
in
'D
Size Material O 5'
D D
<) iL
V
4
C)
0
CI3A1303a
6 I-4-A s_71-re,
e,tu-dtca — 4- GBa�
G Q-as-T'-rg
extant ice - b Gen-.
r
_
LG T
Frri
a
I DO HEIFER" CERTYY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C WELL CONSTRUCT/0N STANDARDS AND THAT A COPv of THIS
RECORD HAS PEEN PROVED TO THE WELL OWNER
1 ze,"_ CADcLAQS1is /13/0 (O
SIGNATURE OF5ERTIFIED WELL CONTRACTOR ATE
La ILL. (g 0..3 ASjJ
PRINTED NAME OF PERSON CONSTRUCTING 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-1a
Rev. 7/05
Tr
T

327'7 '77
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource7s_- /D'ivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) R.O &Ai U C bL CERTIFICATION # 2972
WELL CONTRACTOR COMPANY NAME _Arad € 6/6S. W el i til— Pah2i) PHONE # foie 4, g9g3,17a
STATE WELL CONSTRUCTION PERMIT# ,7 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential l7—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 Town: Fa I(dl et,) County 4J/1
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 352 "Poi eto co- Vi ezAJ
(Street or Roino No.)
(fantlrA- NC -
City or Town State
(Kier 622-79V7
28734(
Zip Code
Area code- Phone number
4. DATE DRILLED 52 2/0 (�
5. TOTAL DEPTH: ,?415'
DUES \il.LL REPLACE L:XIS HNC WELL? YES rI NO 1S
7. STATIC WATER LEVEL Below Top of Casing: Q 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): as -METHOD OF TEST Z Gff )I-S
10. WATER ZONES (depth): Zb5'
3YS'
11. DISINFECTION: Type %f%/7t Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From ( To /05' Ft. (t I PI/G
From To Ft.
From To Ft.
13. GROUT: Depth Material MethodD
FromCeMP� %^O l
0 ` To an Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From _ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Material
16. REMARKS:
Topoophietand setting
❑Ridge EISlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From Os
>T ,5 r Form ion y,Description
10(0 ' 3y5' rvdtie
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.
AUG 2 5 20BS
con
L
C
N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA[lb7�RDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
.441,402 (_
SIGNA U' OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
0
0

North Carolina . Department of ErMronment and Natural Resources - Division of Water
1030 Mall Service Center- Raleigh, N.C. 27699.1636•Ptone [phone] aunty - Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C1prYLA 'rat'
r
WELL CONTRACTOR CERTIFICATION #: a 113
STATE WELL CONSTRUCTION PERMIT#:
1
1. WELL USE (cheek Applicable Ibex); FiesidentlaICK Municipal ❑ Industrial ❑
Recovery[] Haat Pump Water injection ❑ Other II Other, List Use:
Agricultural 0 Monitoring 0
2. WELL LOCp rst..:(Show sketch of the location below) Yl D
Nearest Town: T7t " �
(Ylnk.t l Counts tJ( AJfl(nrn flo
(Flood Name end Numbers, CcomurNy, or Subdivision and Lot No)
3. OWNER VOW I Ann FCX Gn
Address I0, 1 `L 1L I e star+Sin er e
Fck
Ia . ZU-Cn4
DRILLING LOG
From To
1—q
-ca30P
Stale 2 p Code 1 •_ 4 1 '� t+(l
4. DATE DRILLED l X t?)t-ItTh ^SOS
6. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOj
7. DOES WELL REPLACE EXISTING WELL? YES 0 NQQ
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I ryes -+' a Above Top el casing)
FT. Above Land Surface'
'Top of mina terminated avor below lend surface requires a variance In meow
dance with ISA NCAC 2C .0111I
10. YIELD (gpm): I S METHOD OF TEST P ICI
I
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount
13. CASING:
Deptin
From _L-_---To I C
From To
From To
14. GROUT:
Deptll,^Material Method
From To O(O FI (k (Mien+
From To Ft
15. SCREEN:
11 additional space Is needed use back of form
WalTNdowss LOCATION SKETCH
sr Wawa _Material ,Stow direction and distance from at least two State
(T�`t`(zT ��1 Roads, or other map reference points) ,26 9
,_�L \
0
Depth Diameter Slot Size Material
From To Ft In In.
From To FI In In.
From _ To ___ FL In. (n
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
��C\o
1\\06
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS EN PROVIDED TO THE WELL OWNER.
i 6-36-00
SIONA�YURE OF PERSON CONSTRUCTINQ THE WELL DATE
Submit edokW to Division el welr Duamy. Omuowater swan within 30 days
0w•1 REV. 12/99
FOR OFFICE USE ONLY
Cued No:
Serial No
i

From To
From To
14. GROUT:
Noah Creme' Depraved of Environment and Ward Rssowcse • Mark t et Water OwMy • Groundwater San
,e3e Msi Sena Claw - Rei"N.C. 27S99.1113s Phons (91.) 733-3221
WELL CONSTRUCTION RECORD au_cowwctow• OA CO-f(A n r
WELL CONTRACTOR CERTIFICATION F. 113
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE ad sAFpllatl� H ftsds N911Q Munlc1tl � Industrial ElAprlou)hir9I MonitoringRecowsty C]Heat Pump Water k jsollon D Omer p if Other, List the
2. WELL LOCATION: (Shaw sketch M 9is location bJuw)
NeweetTowrt: lAleCuiervi I l.P gamy- I5r-cornriC
ploed tan IS P tsn, wd tat NO DRILLING LOG DEPTH
Familial 3. OWNER sj j f Th �C %1Pft Fwm To realOeovyewF
Address 14 pc -A I- (Cu"3‘1 c1 C 1 t t i
n,enventi 1►P Of
t� ' a�s �s�� �n tq Cr
CllyrTown WY ZbCode I qCi - •CY'�
4. DATE DRILLED St- 3t-�xo f - 3
5. TOTAL DEPTH VI' ) S
S. CUTTINGS COU.ECTED YESC NO
7. DOES WELL REPLACE l7GSTIN0 WELL? YES p Nola
I. STATIC WATER LEVEL Below Top al Casing: FT.
Wu •• Mows Top el thelsol
9. TOP OF CASING IS I • FT Above Land Surface*
'Top et Cants loradrteted 'Sr Slaw Ned whoa npha a radr.a N more
damn wit 19A NCAC2CA9t1e
10. YIELD (gpm): l C METHOD OF TEST 1 C7(
11. WATER ZONES (depth):
12. CHLORINATION: Type Arnaud V addaorW spoor S needed we bade of lam
13. CASING:
WS Manna
LOCATION SKETCH
Depth ONmwF1 r orMO . i iarra dk . (Shaw adbn end dolma born at lost Poo We
tn�To S
FroO() FL k 0 Y( I C Roads, a other map Sanwa pah a) 't
FL - c_
FL r ;yr"
n Ft. C'.LYI MaterielDepth Method
From To a
From _
15. SCREEN:
To FL
Depth Diameter Skd Ski
From _ To _ Ft In In.
From _ To _ FL _ In. In.
From To FL_ in: In
113. SANDA3RAVEL PACK:
Depth Sin Malarial
From To FT.
From To FL
17. REMARKS:
Dt C �nfi-u ?,r.1 of
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRICTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPJ( OF THIS RECORD III<B BEEN PROVIDED TO THE WELL OWNER.
c-3/-O
FOR OFFICE USE ONLY
Cued Ea
Sod/ Na.
On PERSON CON5TMJCreiO THE WELL DATE
Submit orIgInd k OrddrtOWNS Duey. ONudedar Sudan wilts 30 days
11W4 NEV. 12/ee
1

North Camino •
Natural
•
1.35 Malt Sena Cott- RSA" N.C.
s 167bPhanR nrew111) � el Water QMNy • Groundwater a�bn
3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C-1 9an ccekc-1—
WELL CONTRACTOR CER VWICAT1oN t: & t 13
STATE WELL CONSTRUCTION PERMIT*
1. WELL USE Mom* depend* Se* RIMd. 0Jt2 Mur d ❑ Indunis ❑ Agricultural 0 Mantap 0
Recovery p Heat Pump Water Irreoton 0 Direr ❑ B oter. LW Use:
2. WELL LOCATION: (Show ukelch of Os loaaeon bibw)
N.a.&Torn Y---0\te 11 lle C,,,ry. . ` Y-'(lures
Mood Nome 3. OWNER .fie � � :V \ C C. end Let Ns.)
k-7 1
lysrTeen ale 2SCedr
4. DATE DRILLED
5. TOTAL DEPTH 14+
6. CUTTINGS COLLECTED YES[] NOQ
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO(Q-
& STATIC WATER LEVEL Below Top of Cluing: FT.
piss •••• Nene Tepee Caine
S. TOP OF CASING IS. FT. Above Lend Swims'
'Top et .nMg Madnaled ether bean bed swtan re.dree a valance 1n near -
donee w t 15A ?CAC 2C AT e
10. YIELD (qpm): _ 1 METHOD OF TEST 1 CI
11. WATER ZONES (depth) -
DRILLING LOG
Fan To
—Sett
Lilac -
'+-O-'4'43-
12. CHLORINATION: Type Amount
13. CASING:
15i
o.
From To 13 FL
From To FL
From To FL
14. GROUT:
Wee TNcbwr
erWwgraiR
Dsp1h ��� M�e_� Method
From ( To eC R. l_.4J 7 K' 1
From To R.
15. SCREEN:
Depth Dire Slot Ski !Medal
From ___To Ft _ In _ In.
From _ To _ F1 _ kt. _ at
From _To_FL_ M. In
16. SAND/GRAVEL PACK:
Depth
From To
FL
From To Ft.
17. REMARKS:
Stu
Maeda,
t editions! spice b needed use beds of loon
LOCATION SKETCH
dteiwon sed Sterne twat ne lam et least o Se
Roads, or other map reference per)
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A MAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
TINE OF PERSON CONSTRUCINGTHE WEL DATE ..
Sabra edebwt b wren erWrier aunty. Ora anemia Sean *thin 30 days
ow.t REV. 121ea
FOR OFFICE USE ONLY
and Nix
Sea tie.
2023
1

North Carob* • D•paranrt of En drone t and Natural Rnoinss - Olvtdon al Water Guilty • Graadwabr Section
103E Me Service Center • Raleigh, N.C. 27IS$163S-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. ago.4'jrlfr'�E.4 P
WELL CONTRACTOR CERTIFICATION 6: 471) 3
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (a sak Applied* S. p ReSdunld 12 Munkbtl 0 IndwpW ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water ktpoibn ❑ Ober [] II Other, Lbt Use:
2. WELL LDCA sloth of lie baba bibw)
Neres'Tomt lbabao
c51'lCV o it l , only -
(Rood
3. OWNER VI 1 Cyr
Address
rTa•n Neb
4. DATE DRILLED 5-15-0
S. TOTAL DEPTH at15
6. CUTTINGS COLLECTED YES[] NOE(
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
6. STATIC WATER LEVEL Show Top of Casing: FT.
(Dare a Abate Tape) CakW
S. TOP OF CASING 1S 1 FT Above Lard Suha•
1\rf1and tot Nat)
9-c1,
GRILLING LAG DEPTH
1- y1 Te
J cf-1- anQ
eoCi
r304-
21sOede
r
Rep of earning brodrabt floe Sew land stag rgrdra • vubrbe b ease G
dare• Walt 15A NCAC 2C,MM S
10. YIELD (gpm): ITh METHOD OF TEST
11. WATER ZONES (Spat
12. CHLORINATION: Type Amowd
13. CASING:
Depth
From To
Frcn To
From To
14. GROUT:
FL
FL
r
—trfl
r •
t addUart epees b ended use beck of Ida'r
Wee TNtbwa LOCATION SKETCH
r WapreFr. �6 (Show dIredlon rd *amp from at bast two Slab
L-• :beds, orother rap Snow points)
Dept Meteciai From I To rZt) n. CePaCn"�"< Method
From To FL
15. SCREEN:
Depth Dhrrreier Slot Siti Mabst
From To _ FI _ In In.
From .To. FL In.. In.
Rom , To FL In: In.
16. SANWGRAVELPACK:
Depth Size MebdS
From To Ft
From To Ft.
17. REMARKS:
R
uo
FAIReliew
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPyIOFTHIS RECORD kIM SEEN PROVIDED TO THE WELE OWNER
FOR OFFICE USE ONLY
Cal Nat
SSA Ns.
TIME OF PERSON CONSTA CIIN6 THE WELL DATE
Subma MODS bdwYaEWA*OrrS% Orsndaar Nara Wes 30 days
GYM REV. MIT

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Ocpvoncnt of environment and Natural Kcsourtc - Di. urun of w' atcr Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Small
WM Contractor (Indmdu&) Name
Green River Well & Pump Company
W ea Contractor Company Name
STREET ADDRESS PO Boa 204
East Flat Roe. NC 28726
City or Town State Zip Coda
828 )- 693-1200
Ares code- Phone nurtoer
2. WELL INFORMATION:
SITE WELL ID BPI awrcaoa) ✓7
STATE WELL PERMIT/At app adq .2.no(0 -01 18 /
DWO or OTHER PERMIT Et appiobS)
WELL USE (Crack Applicable Box). Resioentoi Water Supply 0
DATE DRILLED 7 3 ID (O
TIME COMPLETED
AM ❑ PMp
3. WELL LOCATION: "� _f
CITY. (7 COUNTY C.AFrICQ�Ie
1—Mfia4 ) ekd e.
(Street Name. Numbers. Cammunry. rnsan, Lot No Parcel Zoo Coble)
TOPOGRAPHIC / LAND SETTING.
[g'Sope OValay ❑FM ❑Ridge 000w
laau epbgqr meal bap
LATITUDE �jjyc9 I
0
LONGITUDE )7
Latitude/longitude source: tiCOPS OTopographic map
(bcsron awe/ must In shown on a USGS mpo map and
attached to the tome I not tarp GPS)
May be u, degree.
minima, woods a
w a decimal format
4. WELL OWNER OWNERS NAME 1 1 � 14J -Re e waft'
f
STREET ADDRESS 7bS7inme o,112"'
r`31�c nkt-wca<.i<, EL -
Cry a Town . Sate Zip Coon
ak,- c�s i('4
6.
WELL DETAILS: 0 1
a. TOTAL DEPTH: .( 7
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [}r--
c. WATER LEVEL Babe Top d Gawp'. ¥DO FT
(Use •: E Above Top d Guano)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
Top d casino temenated at/or below land surface may require
. rnnce n with 15A NCAC 2C .0118.
I
e. YIELD (Opn) L- METHOD OF TEST Am
33o;4 3 q
f. DISINFECTION: Type HTR
g WATER}ONES Ioepplln)
From fi o To 4di From
From To From
From To From
e. CASINO:
Depth
From 1 To ff ij Ft
From to Ft
From To Ft
Amount
D,erreter
To
To
To
Thickness)
Wepht
l/"G
7. GROUT: Depth Motional �J
From 0 To 3 Ft SkA.Rg1K
From '3 To 2 0 Ft 13,ectam,,bi-
Fran To Ft
B. SCREEN Depth Diameter Slot Sae
From To Ft n
From To Ft n
From To Ft n
9. SAND/GRAVEL PACK
Depth
From To Ft
Fran To Ft
From To Ft
10. DRILLING LOG
From To
Sae
terwl
1/fC�
Memoo
M ty 1-a& r
n
Malelral
Material
F rmauo scnpuon
0 !S 50� / %i y
0 - /_ / S4+d Sit) rc,Tr
/6 f — 07 (�mt tv
II. REMARKS
N C'TI
L__
I DO NEREBY CERTIFY THAT TN6 wE It WAS CONSTRUCTED w ACCORDANCE wee.
I •sA NCAC PC wElt CONSTRUCT°. STANDARDS *NO Thai A COPn OF TH6
RECORD I S BEEN PNOvOED(9TNf WELL OnNER
S,GNATURE OF CERTIFIED WELL CONTRACTOR DATE
8 Riptit t'&, i"tiL
PRINTED AME OF PERSON ]CQ .IS.UQ_LNQ THE WFI L
In torn aSscii CgL a r: D
Submit the original to the Division of Water Quality within 30 days. A c
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. (919) 733-701 i ex! 568. AUG 25 glluJ
Form GW-la
Rt. 7/05

c1
RESIDENTIAL WELL CONSTRUCTION RECOD
North Carolina Department of Environment and Natural Resources- Division of W ter Quality
WELL CONTRACTOR CERTIFICATION # 7J
1. WELL CONTRACTOR:
i7ecc',CK 11eCt�n �QvJyec3
Well Contractor (Individual) Name
C\ yrt •3Q.1.l12C5 IcV7o C\
Well Contractor Company Nalne
STREET ADDRESS \\Wit:\ .l-Mary aoq
1-10*-310C:r1G'S A>C. .743
City or Taden State Zip Code
( Bas» (o(OS- ao 1a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID p(if applicable)
STATE WELL PERMITfRr applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3 `c
TIME COMPLETED t-1 d t7 AM p PM Di--
3. WELL LOCATION: CITY: Wee o&' ✓,` //P - COUNTY 4Calitc-+t 4<
Lot.Aer, /' // (r-e.. �(` AV.
(Steel Name. Numbers. Community. Subdivision. to No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge °Other
(dry appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: °GPS °Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form Onot using GPS)
4. WELL OWNER
OWNER'S NAME Cf. C\c,c i-cn
STREET ADDRESS 3-9O vPpec Ktat Ccat . ('
.,Jr=C.N env;Lce 9T'I 61
City or Town ) State Zip Code
(S1e, )- ts`iS • Lt4a'-i
Area code - Phone number
May be in degrees,
minutes. seconds or
in a decimal format
5. WELL DETAILS: /
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES ° NO Er
c. WATER LEVEL Below Top of Casing: . 0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS FT. Alcove Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .011l8l.
e. YIELD Wpm): C3 0 METHOD OF TEST R.
f. DISINFECTION: Type 0
g. WATER ZONES (depth):
From
From
From
6. CASING:
From �\
From
From
To From
To From
To From
Depth DiameterTo 3% Ft. Cc, 'Y/
To Ft.
To Ft.
Amount Cf
To
To
To
Thiclmess/
Weight M erral
, aI
7. GROUT: Depth r1 Materiel
ct From 0 To 0 FL eel -TIP -CIA
From To Ft.
From To Ft
Method
Pouch
8. SCREEN: Depth Dix meter S-it Ste Material
From To Ft. in. in.
From To Ft. in. in.
From
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Size
Ft.
To Ft.
To Ft.
Material
10. DRILLING LOG
From To
97
1
I OS
Formatiin Description
_C;vec
t3 ctioto
sccan ile_
11. REMARKS:
0
n
1 DO HEREBY CERTIFY THAT THIS WELL I /AS CONSIT CIED PIACCORDANCE WRN
ISA NCAC 2C. WELL CONSTRUCTION ST/ NOARDS. AI In THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE V ELL OWNEF.
SIGNATURE OF CERTIFIED WE _L CONTRACTOR DATE
S�fC.CK dMO.}1. .`°' i GC S
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.
Fonn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualify
WELL CONTRACTOR CERTIFICATION # 24 N,
1. WELL CONTRACTOR:
tHt c 1A \k. 6(a4Stef s
Well Contractor (Individual) Name
C\�de SQw ecs k S011
Well ontractor cornpahy Name
STREET ADDRESS 1y2R S Kta; 2°9
Kos, ` rq5) NC
City or T nState
( 848 )- (03(4S- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(it applicable)
WEU- USE (Check ApplicableAfBox): Residential Water Supply ❑
DATE DRILLED a a 7- 4
TIME COMPLETED g ;30
3. WELL LOCATION:
CITY: /i4o Liao Or//
S.1ti3
Zip Code
AM ❑ PM 0�
COUNTY 617COM IC
c ccackc .ec e Lace Lek i><z-
(Street Name. Number,Community, Subdivision, Lot No., Pame& Zip Code)
—TOPOGRAPHIC / LAND SETTING:
pyaw✓✓pe °Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE ._
LONGITUDE
Latitude/longitude source: °CPS °Topographic map
(Iocation of we/ must be shown on a USGS topo map and
attached to this font 7not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
So n e.S McCc
STREET ADDRESS ..sCpac'.a.1 uceY`e Lak %z
l�`QC.cu Cs,1,1Le 1%18r1
City or Town State Zip Code
( b'%} IOrJ�G'" tab �7
Area code - Phone number
S. WELL DETAILS: {�
a. TOTAL DEPTH: 7� /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO e
c. WATER LEVEL Below Top of Casing: r 'Q FT.
(Use -+' if Above Tap of Casing)
d. TOP OF CASING IS , FT. Above Land Surface'
'Top at casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gam): 2r./ METHOD OF TEST (R.Q
f. DISINFECTION: Type p` I l S
g. WATER ZONES (depth):
From To
From
From
To
To
Amount /2
From To
From_ To
From To
6. CASING: Thickness/
Depth - iarf er WZk ( 0A eri
From To-6Q+ f/-- FL li(/(xa� P/o f�/C
From To Ft.
From To Ft.
7. GROUT: Depth
Material
From () _To 'io Ft. L'CMQQt
From To Ft.
From To Ft.
Method
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 To Ft.
Size Material
From To Ft.
From To Ft.
10. DRILLING LOG
From To
f/
ECEWE
Arz,h,,„tille gpniorr.i
11. REMARKS:
Formatio l Des ription
75 t-er 04 e :has
4- retie r TG
CJ
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTON STANDARDS, ANC THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED W{E/LL CONTR/.CTOR DATE
PRINTED NAME OF PERSON CONSTR CT NG THE
HE 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 CERTIFICATION # at{?(o
1. WELL CONTRACTOR:
Dtz ctti. 8ota ecs
Well Contractor (Individual) Name
C\yde Sa 'jecs a- SOn.
Well ontractor Compatiy Name
STREET ADDRESS MSS S Kam) Cit:1
Ik
�S NC
City or T n Slate
(8a8 )- (o(eS- aoaa
a8"ly3
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #{if applicable)
STATE WELL PERMIT#(k applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3
TIME COMPLETED / ,13CD AM ❑ PM B---
3. WELL LOCATION: ��?? t! CITY: 29 ,[]t ceS �' COUNTY ,! to/44
erc/' CP-me /C 4'/
(Street Name, Numbers, Community, SubdMslun, La No., Parcel. Zip Code)
TOOROGRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May he in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oGPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNER'S NAME ' Dtta Q.).Ctcty
STREET ADDRESS t 31 TCC \ tS E IN
ue.ce5tec ti)C
City or Town State Zip Code
( 2i4 lya- tQto
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 76S
b. DOES WELL REPLACE EXISTING WELL?
a 13 YES 0 NO '
c. WATER LEVEL Bela7y Top of Casing: C) FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING 1S 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): % METHOD OF TEST iZ,Q
f. DISINFECTION: Type 9% It S Amount 3.S
g. WATER ZONES (depth):
From To From_ To
From To From_ To
From _ To From_ To
6. CASING: Thickness/
From Deph ght Materiel r
Tot /6Y Ft. & ym .52761I/ 7%Q6
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From () _To 2O Ft. CemQ rut ?OLL Cea
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter SI>t 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. DRILLING LOG
From To
/C t
Formatiol Description
0tm/• Qs Pi
/d ? 70S rfra*//c
4 —
Achnuiflp fleginrai 0
.taj r^110{eL.tiD?
11. REMARKS:
C:)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, ANT THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE �OF CERTIFIED /C .CTOR DATE (L
PRINTED NAME OF PERSON CONSTRUCT NG 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(.1 I,
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
{Ze.ole,h Ct&A laLwe, l
Well Contractor (Individual) Name
Pabel4 Qaidweti 1 Inc -
Well Contractor Company Name
STREET ADDRESS JS se,W �I ceder Itwl
agro
Zip Code
Askey; Ile NC
City or Town State
(sag)_ a54--35gI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/Re applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 1
DATE DRILLED 6/ 15 0 6
TIME COMPLETED AM/PM❑
3. WELL LOCATION: n M��7
CITY: FA I Rf) tS f/N) COUNTY QV svf C.OQt
aG Q ALtatat a DO— •
(Street Name. Numbers. Community. Subdiasion. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT NG:
❑Slope DValley 0Fia1 Ig4idge ❑Other
(check appropriate box) ^ H
LATITUDE 3 5 3 0• g Q b
LONGITUDE 3_ 3 a-1 • a9'd
Latitude/longitude source: fittPS OTopographic map
(location of we/ must be shown on a USGS fopo map and
attached to this foam 7 not usig GPS)
4. WELL OWNER �\
OWNER'S NAME if3) L•. i3 A R•:•ON
May be in degrees,
minutes, seconds or
in a decimat format
STREET ADDRESS at V ALL<jy cj2e mF b
ASFt(JI�..Le r' c- / arjo3
City or Town State Zip Code
( Bag )- aqq-q-103
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH: 4 Y15
b. DOES WELL REPLACE EXISTING WELL?r YES 0 NOt4
c. WATER LEVEL Below Top of Casing: � 0 FT.
(Use if Abwe Top d Casing)
d. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. (�
e. YIELD(gpm): D METHOD OF TEST kica"A1r"
►4�
t. DISINFECTION: Type HHTil d Amount f 01
g. WATER ZONES (depth..::
From 1 11 To I1 IFrom To
From 4a`t o To ' A t- a1 From To
From To From To
6. CASING: qyE Thickness/ �r�1
From ± DToth4 co Ft ia"/$r S.e1 1 7aYV
From To Ft.
From To Ft.
7. GROUT:
..1I Depth �1 Material (n� Method
From 1 To ao Ft. C P€$t 1t0051242b
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth
From To
From To
Ft.
Ft.
Size Material
From To Ft.
10. DRILLING LOG
From , To 0
0' 1—I-7i
\
\�F / aol
ao/-oat'
at'- 4-ss'
formation Description
o V eN302D150—I
G «,t.-3li
C2rEV t CIF - Geri.
cc, artt.a Yrs o
cRit-vt - `1 Gem:c
C-d2-A.7a -r€ Z O
3a
JUN Oh 2006
11. REMARKS:
cza0rei
Cles r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
{p,Q_AlibeAn. cL(,17eQQ 5
SIGNATURE OFg ERTIFIED WELL CONTRACTOR
I L.L..(la OA S-4
DATE
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

r
• .
Notes Cabs .Dp.rnw.taMrra.ewrend Need Reeewee.-CMS=elIRS Ore14r-o uw it won
WELL CONSTRUCTION RECORD nu.. cow1RA.YD1a C. to riA ni4_f'
WILL CONTRACTOR CSRTIPICATION r a i t 3
STATE WDISO01n.INIDfn11 PBM*Irs
1. WILL Ip11±oi.e1rppe...s. p_ de elder wYrdr
ethel eI dO Apw lwCI rba thibm
Recovery O Heal Pomp SINS .lesion o Other [3 110ther, ISM Us
2 NewelT H N'r fl ""1'�L'"'e.M."a Can" F`7L� imh.P.
Eked Nomod rewin eeMYw medial Nal OIW1EIli LOO DEPrn
a ants liltXY11Y\ 1vi s Rae Te
Adding Ito Ilia t I1 (lea 4a (k
Me nos *Olt
4. DATE CALLED
5. TOTAL DEPTH
S. mamas =O ACTED TEED ND®'
7. DOES WELL REPLACE E%Isis10 WW2 vas 0 NOE(
A. STATIC WATER LEVEL Below Tap e1 CAME FT.
Nor" glen Tome .eeid
P. TOP OF CASING IS. I FT. Abyss Land Srerroe•
nip oeSIN MSS of errWwIwMaimw*in.wMr..ww-
amee l.lEANCA.2C
10. Yap bps: n METHOD OF TEST 19,11
11. WATER ZONES (doper
12. CHLORINAT10N: Typo Amount
1a. CASPI t
1 Fmm l Depth
1Q� FL am
them—. To FL
From Te FL
14. 6ROL/T:
Finn L Tb
From To
la SCREEN
Depth
Rae To
From _ To _
Flan TO
1a SANWORAVE. PACK
.D TOth
_ To_
From —
From
17. rr.t W
FL
Sroldthod ep.oeamead umbeck elthen
'MI =dins
srWrywe art
Made Method
fVtylPYi+
Memoler SIN Sao MOMS
F1 In.
FL ie In.
FL Ir[ U.
FL
FL
Sin MISS
LOCATION SIO?TCII
plmwiethenone S.weon elken Ore thee Js4
.e. Re.red.rmwrdww..pelt) CA at
ttl
td
0
m
iOONER..aCERTIFY THATTIMNIE1.LMfMCCIIS1R IC18D'RACOO MCIM11TNIM NCAC>C.Wel
CONSTRUCTION STANDS AND THAT ACOPY OF RSOORD NMISEEN swam TOTHE WELLOWNER
S/7
FOR OFFICE USE ONLY
online
wN.
/Mareorlgrmeora.the non. an
Submit Went* grwne/MMwderl Ilam n.er.eram Sit 30 Sys
WM NEV. IS
JU 0 v LUuu
r
•

• North Cribs • Depenmert
MM Sabo Rof th N End Wound liesouress
11S6PhRr 7- 0MSo Weer WMOust • O(awdwlSectionr S
IWO
WELL CONSTRUCTION RECORD WILL CONTRACTOR: C. kin IRK Y tz r
WEU. CONTRACTOR CERTIFICATION r. ci 1 1 3
STATE WEU.CONSTRUCTION FERMIT1:
1. WELL USEthed# AFpIreMU awe): Residential Er Municipal 0 Industrial 0 Aprbulbnl 0 Matting
g 0
Recovery 0 Heat Pump Wafer Solon 0 0 . 0 If cow LW LSW
2. NWELL eaesl T Oj .j&aw I 1' of the location c x-X, O.I"Y11, 3P
Merl tine and. «SrbdbwRIL.LIPIG L DG
OWNER 1an end tar Na) O
9. OWNn1 raver Lj Rem To
llon
Mid R-d 1 a�
Address 1 O , • i . Fon
\Men\leaned Q Mc a$1US1 urA O V�
CaeerRowe Sub 2MCode 4 _ Li S_
4. DATE AL DEP ED �1 12
5. TOTAL DEPTH t
S. CUTTINGS COLLECTED YES 0 NOG''
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOta
S. STATIC WATER LEVEL Below Top of Cam
Woo •+• I Above Teo a Cone
9. TOP OF CASING IS 1 FT. Above Land Soda'
'Too N neM. lor._eled Woe Skew Mod seises reltAree a indents In swop
deem MO 1SA NCAC SCAMSMETHOD OF TEST
10. YIELD (gprn): 9
11. WATER ZONES (depth)*
DEPTH
kr
12. CHLORINATION: Type Amourd S addNoel spew b needed use beck k Wm
19. CASING:
From j D oOCo 8
From To
From To
14. GROUT:
YMI Things
minor R WoWel L
FL ' Vt-I
FL
FL
thod
Ram TToo Gbh F1. i PpYl�lit !Slth Materiel y
From To FI.
15. SCREEN:
LOCATION SKETCH
(SSow dndon end drlra Mom M Is Iwo Sub
Roads, or other new refers ee pokes)
0
-...1 —1
0 C
Doplh MIRAN Slot Ski Malarial
X �LOCi i) I t1[ fk
Fran To Ft InIn.1v —i
From To FL In. In. -<
From To _ FL _ In. In
15. SANDIGRAVELPACK:
Depth Size Malsdd
From To FL
From To FL
17. REMARKS:
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A OPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER
-rnoriet.`. v/irIaa
_._._.TUE DF ram* 00Ns hUCTa1OTWe WHL DATE
EASE DIO S b 12ddon of Wale oat oeendrMer ese vain 30 deys
FOR OFFICE USE ONLY
Ousel No
Sedsl tN
JUN 0 o 2005
oM•I REY. rage

North Cress • DpemM.d of Em4anrM and NslwS Resources -Melon el War QwS7. Groundwater Seallon
111311 Mal San a Cyder • Rod" N.C. $TSIS•1UFFhrw pip 733+7121
WELL CONSTRUCTION RECORD WELL CONTRACTOR• r tan\ n icy
WELL CONTRACTOR CERTIPICATION F a ►�
STATE WELL CONSTRUCTION PERMITS:
326816
1. WELL USIEwasa Appeal. SNor R.rdflS O/ Municipal 0 Industrial ❑ ASt4Wr& ❑ Monitoring ❑
Rocovary Flag Pomp Water InNolbn ❑ Quit CI N OSEr, LW Urr
WEu LOCATION how Ntob elf Om location bilow) it t
Nearest Tows ��c�` WAS NI 11 y 7l
(Rood None and Nabors, Cawnun��{ r a�ulebellllm rod Leo Ile)
3. OWNER rrn(1 fl IQi 7 c' w —S'Rom To
Address ,,\\,,
Cl yeTsen Sloe
4. DATE DRILLED _I 1
S. TOTAL DEPTH .Qa.
e. CUTTINGS OoLLECTEO YES Q no Cr
7. DOES WELL REPLACE EXISTING WELL, YES 0
IL STATIC WATER LEVEL Solow Top of Casing
Os y' II Phew Ted of Casrgl
S. TOP OF CASING W FT Above Land Surface
`Top of seeing Mndnasd Sec Slew laird surface oaf re. a Names In ewer.
dosseWMNNAfICAC2Cqi1-a
10. YIELD (gamyK . METHOD OF TEST 1
11. WATER ZONES (depth):
•
2` cede
ite
DRILLS/CI LOG
-9 0-c r1r
12. CHLORINATION: Typo Amoud
13. CASING:
From 1 D To ' R, M
From To FL
From To Ft
14. GROUT:
Dradli From J_1-- Tol Fl
WM TrWeN
awela rt
From To FI.
15. SCREEN:
Ram
From
From _ To _ FL
16. SAND/GRAVEL PACK:
Depth
_ To
_ To
From _
Fear _
17. REMARKS:
Depth Diameter Slot Ski
To Ft In In.
_To_FL_ In.
In.
FL
Ft
Method
{rand
Malarial
Is1.
rl.
DEPTH
S addling pees la needed use boas d born
LOCATION SKETCH
(Show dnden and dolma Isom M Mal two SIr.
Roads, or other romp relrrea pores)
LetaS
i DO HERESY CERTIFY THAT THIS WEUA. WAS CONSTRUCTED IN ACCORDANCE WITH 1SA MAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
Sal/9A
FOR OFFICE USE ONLY
Ors Nac
apN�TIrE OF PERON CONOTMICnNO THE WEL DATE
Subrra .4a nS W 01rMr4a a WrerOwar, onneessr seem ,*In 30 days
GW4 REV. 1219

Nome Crolas • Doponnunt al Fn*omwnt and Nest Room.. • ft.ISon olWrr Quay • Onsurdw.lr Salon
1e30 MS Soria Comber • RSslgh, N.C.176f-IS3S-Phcns (.1.) 733.3221
WELL CONSTRUCTION RECORD �aCO`I1y
CONTRACTOR N II: 011
STATE WILL CONSTRUCTION PERMITS:
326815
1. �usyE0 Heat W E wasps nther O It Otis i Agricultural 0 Maggio*" 0
2. WELL L owa IN %U .1 S vr i 11 I landau
r - U ` flY\ .
(Red Nana and Numbers, Coneseel...bAryan and Del Na) GRILLING LOG DEPTH
3. OWNER rnor1 Shfi 9/ _ Ran To rn ci-c�\ �+
Address i-C��
► NC
agrrTarM ' GI a►
Cede
4. DATE (*PLUMkf �V
5. TOTAL DEPTH >.
6. CUTTINGS COLLECTED YES Q NOLO'
7. DOES WELL REPLACE t7DSTING WELL? YES D NOQ'
8. STATIC WATER LEVEL Blow Tap el Casing: FT.
(h. Y•. Abets Top SD WN
9. TOP OF CASINO IS ` FT. Above Land Surface
'Top .r may tonnIn.ld 'Yoe brim aM .eran minim(aaan
."nire* be .
10. s YIELD
ISA m): 3C 1I 1� METHOD OF TEST ) r�
11. WATER ZONES (depth$
12. CHLORINATION: Type
13. CASING:
(van FP
rY-rvVe_
cgarmve
Amount I addllbralspan Is needed us* bode a( arm
vwllTabeaa LOCATION SKETCH
i panm�w ea Mho"droalon end darn Mom a1 WI Iwo We
From D TO «� Fl. Ip '/ � r � Roe* or of W ramp reNwra5 PeI1)
Frain To FL
Front To Ft.
Sure GROUT: ctcl {�
Depth
From To
15. SCREEN:
FI.
Depth Diameter Slot Ski Material, 4i1I-
From To Ft In. In. ram/ FT
From To Ft In. • kr . a o
From To _ FL _ h1 _ In. r-
18. SAWD/GRAVELPACK: —r
Depth Size Mslsrll -<
From To Ft.
From To FL
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PRONGED TO THE WELL OWNER.
�rOIMTUNE OF PERSONDIE WELL DATE
Submit Mdnd a ddb.e el WaleO.a4 Bwm Mace vain 30 days
ow.1 REV. ISM
9
0
FOR OFFICE USE ONLY
Gad No
EMS N.
JUN 06 2035

North Carolina • Depend at Environment and Natural Rmauaa • 0MNon of Watt Ouab - Groundwater Salon
Itss M S 6rdoo Curter • ASIIhI, N.C. 271M-10311Plio a (91f) 7859221
WELL CONSTRUCTION RECORD � : CONTRACTOR C IRTI CATION F S 1
STATE WELL CONSTRUCTOR PERMIT!:
32681i
1. WELLUSE0 � a D M� O If Oter, i Industrial t� Agricultural O Monitoring
CI
2. WELL LOCATIQI'1Mow ww *Matdr el to bar Sim)bw)
NSW Tame NS C .J i t (Q a9Co. dye A �NSW
(R.wN.n*,ond Rumen cumn.dlr.rl�4..ndtoWa) aabsrORI INGLOG DEPTH
9. OWNER 1 l *hi A m n nre. Fen, T.
Address i C•3 G -4p '1'+
isne n lit. dSkOin A -Aug
OW or Tear the a"' Obi -`{(].�
4. DATEORILLED 4 _20_QtD
s. TOTAL DEPTH 30S
6. CUTTINGS COLLECTED YES 0 NO®Y"
7. DOES WELL REPLACE EXISTING WELT YES 0 Noe-
S. STATIC WATER LEVEL Below Top d Comp: FT.
(W. •P 1 Air. Top d Coro)
S. TOP OF CASING IS. ‘ FT. Above tad Surface
nap at mane lerdreled ad below lend .swam rgdn a rrk.ee Ni mosey
donee wM/MNC2 METHOD OF TEST �1 Cj
10. YIELD lOPm): S
11. WATER ZONES (d.pM$
12. CHLORINATION: Type Amount V additional spice Is needed use beck d ionn
19. CASING:
Duplh
From To Ft.
Fmm . To FL
From To Ft.
14. GROUT:
WM Twiness
creeds/AWL 420,_,SLCI C
Depth Mated., •
From \ To Oa Fr. cement IYI Method e\
From To Ft. I-40 V\lest
S. SCREEN: Diameter Slot Ski Materiel &IS,Cr"1epth � i
From To Ft In. In. d
Fran To R. in, In. 5�
From To _ FL _ In: _ In. \
Depth 16. SANDIGRAVELPACK: �;� �7GUgeS
Size MOMCrCY.
From To FL
From To FL
17. REMARKS:
LOCATION SKETCH
Mow dY.d a. end dlelra. from at lent two Stole
Rod., or other map reference pobd.)
t 00 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH iM NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A OF THIS RECORD WAS SEEN PRONGED TOME WELL OWNER.
°.�.. ci/ ,.d/oG
TUNE OP PERSON CONSTRUCT W O THE WELL ONE
WNW oddnd a OMrda at War Outs owud.atsrSwabs wain 30 days
OW1 REV. raw
FOR OFFICE USE ONLY
Ord Na
S.ds No
UJNa

DATE DRILLED �1 Ck�'i
TOTAL DEPTH C)T-
CUTTNKTSGOLLECTED YES NOQr
DOES WELL REPLACE EXISTING WELL? YES Q NOD
STATIC WATER LEVEL Show Top of Cuing: FT.
(lN.•a' II Abe. Tay a Col*TOP OF CASINO IS FT. Above Land Sudan'
'Top al may leradnelad Scot bdsw land .edam maim avurnce In new
10.eVIELD(waft g sn): ICI METHOD OF TEST QMCrA
10. VIEW (Spm): I.
11. WATER ZONES (Split
Math Cron. • D.prbrwnt of Erwborrrrd and NNret Reea.ae -awbkn a War Curly • oror.dwerr season
1E35 tTA srvke Cray • ROW% N.C. s7NN•Nft even. (9/p 733-SUl
WELL CONSTRUCTION RECORD WELL CONTRACTOR. C' CCr'if'fir
WELL CONTRACTOR CERTIFICATIONS: 113
STATE WELL CONSTRUCTION PERMITS:
326813
1. WELL USEUSE_Lawsk APOIcaN Sr* Rssd.m.tE( Murdaba 0 Indll9blsl0 Aonown.M 0 Monllorbiy O
Recovery a Heat Puny Water hlerdlort D ON'r p R 01her. Lb1 Use:
z Man* LOCATION:sketch of toe location
)I"Y' rr-)hc,
Malld OWNER ' "r Sa r)d. MN.1 DRn UNOLOG
To
"limn 43, ri-a,414-11-\, `LEN
Ulati
crnwTea sla. cede 11 LA VAS-
tis- aLS
•
12. CHLORINATION. Type Amount
13. CASING:
D.plh
From To 1S
Rom--- To
From To
14. GROUT:
Depth
From To ,D
From To
13. SCREEN:
N eddleord pew b needed us* beak of tam
LOCATION SKETCH
pyyptar w MEW C(ffiww dkedand Wm d Steno a leer Iwo stele
Ft. lL Y (1till . or other mop relerenee pts)
FL
FL
Materiel
R
FI
mats
Thoth orator s Slot Slte Material
From To fl In In.
From To F1. In In.
From To FL In: In
16. SAND/ORAVEL PACK:
Depth Ste* MSdS JUN () 6 206S
From To FL
From To FL
17. REMARKS:
56
0
CT
I DO HERESY CERTIFY THAT THIS WELL VMS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WB.L
CONSTRUCTION STANDARDS. AND THAT ¢OSI{Y OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.`
FOR OFFICE USE ONLY
Arad Ns
Bald*
Not
'S O*4ATUNE OF PERSON CONSTSUCitA THE WOI. DATE
S Ara NNW a DPW eWarw C1US tbrnd.aer Sudan Met 30 days
OWl NEV. INN
6

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resour es - Division of Water Quality - Groundwater Sectionio
tdi CERTIFICATION #OS
WELL CONTRACTOR (INDIVIDUAL) NAME (print)j�rtr. Lyf 11/�O�
p4k1c%74W WEfi b ui1y PHONE # '2X67,3--9a2.3.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifl%able) (if applicable)
WELL. comitt ACroR COMPANY NAME
326778
I, WELL USE (Check Applicable Box): Residential Y Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: �QJQ'. 11--6 CountyTBUF.:e k&
ate-foesf RAT Di, Cc--F' 1- 2flOG
(Street Name. Numbers. Conn ity, Subdivision. Lut No., Zip Cale)
3. OWNER: DPAIi5 ROMPd
Address !Sb «RC5M;t Cs+ .
Stre Route
C ho l��` u c, No.) ggq-1 --
City or Town State Zip Code
( )-
I
Area code- Phone number
4. DATE DRILLED As? 6L
5. TOTAL DEPTH: J"r
6. DOES WELL REPLACE EXISTING WELL? YE$ NO Q
7. STATIC WATER LEVEL Below Top of Casing: II 0 FT.
(Use - " if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
Topogr is/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/Ion itudeofwell to ati n
N3S'36:565'G '37:(cor
(deereesiminutes/seconds) E,��/'r a Roo
Latitude./longitude source:❑GPS❑Topographic ntydp
(check box)
DEPTH DRILLING LOG
From To Formation Description
*Top of casing terminated atfor below land surface requires a
variance in accordance with 15A NCAC 2C.0118. // n_
9. YIELD (gpm): AH
P ME ODOFTEST e�fl(,eat telV”
10. WATER ZONE depth):
I I. DISINFECTION: Type 2 Amount p2--
12. CASING: Wall Thickness
FromDepth Diameter or Weight/Ft. Material
To 8a Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To .3
From To/ F
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size
Material
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.
JUN 06 2La
m
d
J
0
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 LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE' /
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

326777
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturrral,�Resorce�- Division of Water Quality - Groundwater Sectionio/�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (�.� yy Qi /� �.cJyn CERTIFICA ION #�t�tJOl
IN CCONIPANY NAMEONTRACTOR�^,t N
STATEWELLCO.NSTRUCIION PEIWIT# ASSOCIATED W Q PERMIT#
(if a licablc) 1 (if applicable)
1.. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATTION:: .(�
Nearest Town: L2 CQ� t `aiS
> -4- QSS *I tta t�s DDe
(Street Name. Numbers, Community, Subdivision
3. OWNER:'D,?*
Address (3.1%..
et or kstte No.)
County 3LbJt CI-0
, Lot No., Zip Code)
City or Town State
( )-
Zip Code
Arca code- Phone number
4. DATE DRILLED ¥ 0 to
5. TOTAL DEPTH: ( .
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: Mt FT.
(Use "+" if Above Top of Casino)
8. TOP OF CASING IS � FT. Above Land Surface*
Topogra tc/Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropriate box)
Latitude/lough �11 or t' • r
N ;� s "to. a `'40r'��3
•
(degrees/minutes/seconds) E`E V ,
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
*Top of casing terminated at/or elow land surface requires a
variance in accord} nfe� ith ISA NCAC 2C .0118.
9. YIELD (gpm): iIVIVOLI OF TESTer/t l /
. CG►V fcIt fl c
10. WATER ZONES (depth): `t
11. DISINFECTION: Type tt-�01ivC- Amount (C
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To NW) Ft.
From To Ft.
From To Ft.
13. GROUT: Deptlyl,
From To
From ToTU F.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
A <t
8111...TIlkn' Wit
Slot Size
in.
in.
15. SAND/GRAVEL PACK: JLJly 06
Depth Size Material
From To Ft.
From To Ft.
Metho
Material
PHONE t'r) 683-7AaO.1
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:
ten
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTR : TION STANDARI.. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0 VNER
NATURE OF PERSON CONSTRUCTING THE WELL
9 66
DAT
mit 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 WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of W:I:er Quality
WELL CONTRACTOR CERTIFICATION *I- 0411.4
1. WELL CONTRACTOR:
QaCt to.'a`Jecs
Well Contractor (Individual) Name
Q..*.J a'e ' 64�
Well Contractor Company Nate
STREET ADDRESS ‘'9)5 S
\dot S�r:v,ys, ./k3C.
City or Town State
(8a`b} tots- aoa
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID A(d applkable)
STATE WELL PERMIT#([applkable)
DWQ or OTHER PERMIT #(d applicable)
'1�aa.r QoS
as7v3
-Zip Code
WELL USE (Check Applicable Box):
DATE DRILLED y- a y- Co
TIME COMPLETED 02i .3() AM O PM —
3. WELL LOCATION:
CITY: COUNTY L3r�n��w+6e
C
Residential Water Supply 0
/5; COce ik
.(Street Name, Numbers. Canmuney. SubdF-sion, Lot No.. Parcal. hp Code)
TO`pOG RAPHIC / LAND SETTING:
mttowe Ovalley ❑Ftat ['Ridge ❑Other
(check awn". box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑ Topographic map
(location of weff must be alnnns on a USGS topo map and
attached to this form 1 not using GPS)
4, WELL OWNER
OWNERS NAME `hags %AV;N3S3on
STREET ADDRESS 1 vie 41 Ccebt O;We
CanavQ< /Je 98115
City or Town State Zip Code
(Watt )- (obs' ']semi
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: /
a. TOTAL DEPTH: 7(c
Ja-
b. DOES WELL REPLACE EXISTING WELL? YES ID NO
c. WATER LEVEL Below Top of Casing: 70 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 (gpm): 076 METHOD OF TEST -
eR "97
f. DISINFECTION: Type 9; % t$ Amount O
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth, Jt. S Weight M
From A-t To ( -Ft Dio1 in -S
From To Ft
From To Ft
7. GROUT: Depth Material // Method
From 0 To.2U Ft. (Oren-" Poare /
From To Ft
From To Ft
8. SCREEN: Depth Diameter Slot Size Materlal
From To Ft. in. in.
From To Ft. in. in.
From To Ft in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Fl.
From To Ft.
From To Fl.
10. DRIWNG LOG
From To
/ �(
Formation Description
O0€r Q4e den
G, 1 /4 f 6-ro?',te
JUN 06 2006
11. REMARKS:
->~-
A
-J-
rV Ci l
C
rn '�
r
100 HEREBY CERTFY THAT THIS WELL M'AS CONSTRICTED N ACCORDANCE WITH
15A NCAC EC. WELL CONSIRUCTON ST NDARDS. ANDTHAT A COPT 0F THIS
RECORD HAS SEEN
PRPROVIDED
TO THE n ELL OWNER.
y<-
SIGNATURE 0 CERTIFlE Il CONI"RACTOR DATE
`tet '. Ck 41'Qe-tr 6e,,A c3
PRINTED NAME OF PERSON C C NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MS.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-Ia
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-�sDivision of Water Quality
Dc
WELL CONTRACTOR CERTIFICATION # 73(4
1. WELL CONTRACTOR:
�eC .CAL -Heaton SQWyec"
Well Contractor (Individual) Name
50.sz4QcS
Well Contractor Company Warne
STREET ADDRESS \ NAP) S .1- \ ta-y a0 CI
'Hot 5y<trigs, NC 08'7 H'3
City or ToLn LJ Site - Zip Code
( 9a8} (o(o&' oa Oa'�
Area code- Phone number
2. WELT INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWG/ or OTHER PERMIT #(l applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3 _a 7 - 4
TIME COMPLETED a ;SO AM ❑ PM ®/
3. WELL LOCATION:CITY: {'GF/'Uvlr/ COUNTY /56,7Ces/74
rant rep'
(Street Name. Ntnnbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope 0Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE_
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we must be shown on a USGS topo map and
attached to this form l not using GPS)
4. WELL OWNER Q,�.,,
OWNER'S NAME M•Ki 'al
STREET ADDRESS 35 lbw.* liecro i tin+e
May be in degrees,
minutes. seconds or
in a decimal format
FltteMec NC
City or Town State
(Rt )- ats- sass
Area code - Phone number
aconaa
Zip Code
S. WELL DETAILS:
a. TOTAL DEPTH: 3 S5 /
b. DOES WELL REPLACE EXISTING WELL? YES
YES 0 NO 1
c. WATER LEVEL Below Top d 7 Casing: 0 FT.
(Use ".1-* it Above Top of Casing)
d. TOP OF CASING IS 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): _(_6_ METHOD OF TEST R__J
n � d 9 3
1. DISINFECTION: Type D .1 \ Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth „J Diameter Weight M erial
From`� To %10t6Z Ft. (v 4 .5M2J sL
From To
FL
From To Ft.
7. GROUT: Depth Material
�7
From D To d`Q FL CRrnent
From To Ft.
From To Ft.
Method
(�©uc>
8. SCREEN: Depth Diameter S'd 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. DRILLING LOG
F1n To
�c?i
iae2 3 $S
Formation Description
p vtc t.3v ctLo f1
rJ
Gratz kto
7-
a
c
JUN 06 70116
11. REMARKS:
ra cm.l
cr. 3' C7
I DO HEREBY CERTFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OrCERTIFIED
3 a2 o
R4CTOR DATE
DeCf.CK 1k420.t'4' 5 NA, tc S
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

RESIDENTIAL WELL CONSTRUCTION REco:2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #- 0436
1. WELL CONTRACTOR:
a rc; e k Yiec ?&% `x w,te cs
Well Contractor (Individual) Name
�.�\ 4e.3 Q-c S *Son
Well Calfracthr Company Narhe STREET ADDRESS "WAS = lc\..», Qo S
iAot Sic; .gs) A3c. a�TIVA
City or Torn State -Zip Code
(Wort)} toles- ' (3aa
Area code- Phonenumber
2. WEU. INFORMATION:
SITE WELL ID Mil applicable)
STATE WELL PERMIT*? applicable)
DWQ or OTHER PERMIT Mb' applicable) »or(0" O0 stub
WELL USE (Check AppIabie Bate Residential Water Supply e
DATE DRILLED "►"'d'1-bb
TIME COMPLETED 4.00
3. WELL LOCATION:
CITY: /ee/telee-/
SXe—/1/ ,Crt
.tSbTeet Name, Numbers. Co mmondy. Suede/aim. Lot No., Parcel, Zip Code)
TO/POGRAPHIC / LAND SETTING:
QSkye CIVeliey ❑Flat ❑Ridge ()Other
(check appropriate box)
AM ❑ PM IV
LATITUDE 3
LONGITUDE
Latitude/longitude source: OGPS °Topographic map
(location of suer must be shown on a USGS topo map and
attwtmid to this tom? f not using GPS)
COUNTY Zfrr4Gaat.e
May be in degrees,
minutes, seconds or
in a decimal format
a WELL OWNER
OWNER'S NAME 1S6OY tXS•Oea.S.
STREET ADDRESS w511-74a' t7.e0a Rea d
Ashes tie NC. .�84pb
City or Town State Zip Code
(8a4> )- a' blob
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: nS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOMB--
a. WATER LEVEL BebwTop of Casing: rd FT.
(Use '+' S Abode Top of Casing)
d. TOP OF CASING IS 11 FT. Above Land Surface"
"Top of casing to/Hail ld at/or belay land surface may require
a variance in accordance wYh 15A NCAC 2C .0118-
e_ YIELD (gpm): 3 d METHOD OF TEST ("g
67 94 G
f. DISINFECTION: Type T; 1. Amount Ammt / f
g. WATER ZONES (depth):
From Fnam To To
From To From To
From To From To
6. CASING:DThcb,eas/ Materiy
From_4- \ To -5 Y - Ft -- F�-=rLc"
From To Ft
From To FL
7. GROUT: Depth Material
From 0 To ,U F2 Oir.
From To Ft
From To Ft
8. SCREEN: Depth Dia neter Slot Size Material
From To Ft. in. in.
From To Ft in in.
From To Ft in in
Method
ea. c✓r ri
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/ s
s/ 3 os
Formation Descriptiono
Ouer• LJr.-' eZ
J-
-et
s(T)
3L J
�t me
JUN 06Mb
11. REMARKS:
o F0
r
I00 HEREBY tern r ry THAT ha WELL V AS CONSWLCTtD N ACCORDNCE WUN
taA NCAC 2C, WELL CONSTRUCTOR S? NDARDS. AND THAT A COPY OF THS
RECORD HAS BEEN PROVIDED TO WE V. ELL OWAER.
r DW C' a��
SIGNATURE OF CERTIFIED W:- CONTRACTOR DATE
7Qi (: Cx }{to ties. *�
PRINTED NAME OF PERSON C (HMV CT{ G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information 14It.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-la
Rev. 7/85

WELL CONTRACTOR CERTIFICATION #-
1. WELL CONTRACTOR:
� Q.rc: e k >Aec_t1,
Wen Catal u (Individual) Name
Q"Uri.{L ' SS
Well Contractor Company Narhe
STREET ADDRESS " %$ S
tint Sir v`gs) )JC
City or Town State
(8a%)- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ifre applicable)
SSct...a�re.c`\
k Seim
%.aya04
ae7v13
Zip Code
STATE WELL PERMIT#(eapplicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED — G
TIME COMPLETED I U AM PMQi
3. WELL LOCATION: nn //--
CITY: (Gary/Art - COUNTY /)G intern Vic
ere.- /oe 4- Or . 28'Jt S
(Sheet Name, Numbers. Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope Salley ❑Flat °Ridge pother
(cheek appropriate box)
LATITUDE 3
LONGITUDE_
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ° GPS ❑ Topographic map
(location of well must be shorn on a USGS topo map and
attached to this form Int using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS OV ItC 10014- aD O.a
tart Me_c N C 28 vi\rJ
City err Town State Zip Code
{ Pala)- 7L30- wart
Area Code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ,3 O S
b. DOES WELL REPLACE EXISTING WELL? YES NO ti__
c. WATER LEVEL Below Top of Casing S7 FT.
(Use'+' d Abwe Top of Casing)
d. TOP OF CASING IS st . FT. Abdve Land Surface
'Trip of casing temenated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / C) METHOD OF TEST 0:•3
RESIDENTIAL WELL CONSTRUCTION RECo:2D
North Carolina Department of Environment and Natural Resources- Division of WI I ter Quality
ay3ka
• 326793
f. DISINFECTION: Type f; 11$ Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Tjrhickness/
DiaMeter
D
From_1TT_.Ft le)Cy. 5(LYw7(
Vp/G2`r'
From To Ft
From To Ft.
7. GROUT: Depth
From 0 To oge
From To
From To
Materkr
Ft (toaten4-
Ft
Ft
Method
1/7o «a
8. SCREEN: Depth Diu peter 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 FI.
10. DRIWNG LOG
Frorp To
Format bn Description
6,3 Ot9Q,- at, .(,b
G� SOS Crre a,. c
MN 067fiP-R
I1. REMARKS:
—c
v
,)
100 HEREBY CERTIFY THAT THIS WELL Y 'AS CONS RLCTED N ACCORDANCE WM1
15A NCAC 2C. WELL CONSTRUCTION SPNDARDS, AND THAT A COPY OF THIS
RECORD WAS BEEN PROVIDED TO THE OWNER.
SIGNATURE OF C D W c ONTRACTOR DATE
�QC[t. CV- \4tG4c1.1. 3c A eS
PRINTED NAME OF PERSON C C NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information IA lt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Foin GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 8, 0436
1. WELL CONTRACTOR:
�acc:cc 1/231eC.-'h
Well Contactor (Individual) Name
a Q Sa.a'jje-c s
Well Cadractor Company Narhe
STREET ADDRESS WW2) S
\Nov,SS) X3C.
City or Town State
So-No-j -CS
Son
'.a.r aog
I.Zip Code
(8:l9» (otos- aoa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID /(dapplicable)
STATE WELL PERMIT/ rapplicable)
DWQ or OTHER PERMIT /(d applicable) /
WELL USE (Check Applicable Box): Residential Water Supply Ell
DATE DRILLED J /-!/ Co- `
TIME COMPLETED 1/aO AM PMr
3. WELL LOCATION:
hl A�TIO/N:
CITY: 4 f K COUNTY U t PecacKdTe
6rO' e bU nK4-
{Sheet Name, Numbers. Community. Subdivision, Lot No.. Parch. Zip Code)
TOPOGRAPHIC / LAND SETTING:
t dope Dvalley ❑Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/ion:gitude source: OOPS DTopographic map
(location of we/ must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNER'S NAME toNtd Myt45
May be in degrees,
minutes, seconds or
in a decimal famat
STREET ADDRESS 3aQ Woee11oL1nd 'D't JC
S Ws,nftatte A- , NC a$eiat8
City err Town State Zip Code
(eas )- an- 11b'79
Area code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: i co S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO L7—
c. WATER LEVEL Bea., Top c( Casing: -30 FT.
(Use i< Abate Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): (2.6 METHOD OF TEST R.'OJ
CI 6 32792
f. DISINFECTION: Type 9, t \$ Madam
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thiclwess/
Weight ,MO /
/- c c/ '
Vie
From DTPori.L12 Ft Diianper
From To Ft 10'�.
From To Ft
7. GROUT: Depth Material Method
From 0 To a o Ft CPNten C - PO rste L
From To - Ft
From To Ft.
8. SCREEN: Depth Dia riater Slot Sox Material
From To Ft in. in.
From To Ft in. in.
From To Ft. in. i1.
9. SAND/GRAVEL PACK:
Depth SiSize Material
From To Ft.
From To Ft.
From To Ft.
10. DRIWNG LOG
From To
9a
Formation Description
Duey ,'r6F#1
CJ
' //lca
rrt
LILL 06:2GQ6
11. REMARKS:
Cr
o+
u),I
3
I DO HEREBY CERTFY THAT THIS WELL Y 'AS CONSIRLCWED NACcORDN CE WRN
15A NCAC 2C, WELL CONSTRUC1AN S,DS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE U. OWNER.
SIGNATUREOF D CONTRACTOR DATE
berctcv- 1ske6.Ft, 6c,vor_13
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information IJ41t,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:3n
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
326
91
1. WELL CONTRACTOR:
a st ; eV- Y.ec.3&. Sa..w-jecs
W efl Contactor (Individual) Name
Q1.\9 tto ' EJ Qiwiyy�{S �.?On.
Wea C Company Narhe
STREET ADDRESS ‘`4%SS - 'fit,3%.( oQOS
\�v{ S ci..-03S) ))C ca' V1m-7,
City or Tam Stare Zip Code
($atb). toes- 'Qua
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Cif ■ppiicmle)
STATE WELL PERMIT#(uapplaabre)
DWQ or OTHER PERMIT #(d applicable) /
WELL USE (Check Applicable
/B/racy: Residential Water Supply g
DATE DRILLED .5 V' 4
TIMECOM•PLETED 2130 AMO PM[3�
3. WELL LOCATION: /�
C1TY: I'7-'6, LfTr' -. COUNTY j3u „icon -Lie
Laden Chet C veL
{Shea Name, Numbers. Cammumty. Subdivision, Lot No.. Parcel. ZIP Code).
TO OGRAPHIC /LAND SETTING:
lope )]Valley OFl t ❑Ridge
(check appropriate b
LATITUDE 3
LONGITUDE
Latitude/longitude sotTCe: ❑GPS ❑Topographic map
(location of we/ be shown on a USGS topo men and
at htO to this firm I not using GPS)
4 WEIL OWNER
OWNER'S NAME 'Dt' 41nn W:ttacoin
STREET ADDRESS Crest Cf% Catt %t. Rd
Fa:curt..) ) Nc acrl3o
City or Town State Zip Code
($90 )- (flS' tb3to
Area code - Phone number
❑Other
May be in dam,
minutes, seconds or
in a decimal format
S. WELL DETAILS:
a. TOTAL DEPTH: 1
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO'E--
c. WATER LEVEL Below Top of Casing. 3 t FT.
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface`
`Top of casing temi abed aUCT below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST 0..`3
f. DISINFECTION: Type 9; 1 t$ Amount /.3
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
sT ' D-�1er W - M
From To -Ft to -4-:, !i
From To Ft.
From To Ft.
7. GROUT: Depth MaDrrii
From 0 To or10 Ft 'c.zlen it
From To Ft
From To Ft
Method
f
/.1`)1.,..1. G
8. SCREEN: Depth Dia meter Slot Sim Material
From To Ft in. in.
From To Ft n. in.
From To Ft _ fl
9. SAND/GRAVEL. PACK:
Depth Size Material
From To
From To Ft.
From To
10, DRIWNG LOG
From To
sy
Formation Description
CV QGS n
11. REMARKS:
n
Dc 7)
-�:Erg
- —or,
✓
o C
✓
100 HEREBY CERTIFY THAT 7211S WELL M IAS CONSTRECTED N ACCORDANCENMI
1SA NCAC 2C, WELL CONSTRUCTION S PNDARDS. AND THAT A COPY OP THIS
RECORD HAS SEEN PROVIDED TO THE HLL OWNER,
SIGNATURE OFNTFaCCTOOR DATE
1IMTED N . Ck P te-la C oc`aN THE
PRINTED NAME OF PERSON C ONSTRUCTI G WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information 101L,
1617 Mal Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:AD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 04 3t
1. WELL CONTRACTOR:
Q-cc; e k "NekQc.?& Sctw fe cs,
Well Contractor (Individual) Name •
Q.\' J4a1^((Ccc.
Well Cdthactor Company Nari
ta
Kai.
City a Town State
(8a53). (0toa s- a0a
Area code- se Phanumber
2. WELL INFORMATION:
SITE WELL ID #fd applicable)
STATE WELL PERMIT#@epvtiable)
DWQ or OTHER PERMIT #(d applicable) a�5-Ca3i-i-
"
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED S' « e
TIME COMPLETED J I i CIO AM IQ' h'M El3. WELL LOCATION:naf�/
CITY: Bird, JC t-^' - COUNTY VL vDCO
S i (sVA0seT —
.(Sheet Name, Numbers, Community. Subdivision, Lot No., Parcel. Zip Code)
TO/POGRAPHIC / LAND SETTING:
1560pe Valley DFig ORidge DOther
ck (cheappropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ()CPS DTopographic reap
(location of well must be shown on a USGS topo map and
attached to this fonn /not usarg GPS)
4. WELL OWNER
OWNER'S NAME 'S9-50n 41,tae•
STREET ADDRESS Lb S5 S�.u.aton4 tacos
a1:0 l t
A SOFT
STREET ADDRESS "yeS S 1i1/4.4.1 a (I
\,\ot S(';v'99) ASC. oriel r;
=Zip Code
May be in degrees,
minutes, seconds or
in a decimal fames
4L�0c& Th4n, I3t
City or Town State
(82.8)- ass- bRsq
Area code - Phone number
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: /O S
b. DOES WELL REPLACE EXISTING WELL? YES D NOIR--
c. WATER LEVEL Below Top of Casing: /0 FT.
(Use --I.* if Above Top of Casing)
d. TOP OF CASING IS FT. AblNe 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): 3o METHOD OF TEST R•3
326790
f. DISINFECTION: Type 9; t \S Amoum
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thiele -less/
Depfi Vytla( ewMaterial
Fran_To_(n�7 Ft .3 j(
From To
Ft
From To Ft.
7. GROUT: Depth -1., Material
From 0 To r2) Ft. (<n. eel f-
From To Ft
From To Ft
Met d
puny
8. SCREEN: Depth Dia refer Skit Size Material
From To Ft in. in.
From To Ft. ill. in.
Fran To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
From To Ft.
10. DRIWNG LOG
Frpm (Tot
Formation /D1esorption
D� L�t.r`C(44
rs•non,t�
O
0
JUN 06 2(IB6i-
11. REMARKS:
J
C)
mrn
N Ofr.
O LJ
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRIICT/3N S4NDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TOME w ELL OWNER.
(
SIGNATURE OF CERTIFIi 211,CONTRACTOR DATE
be 'zit, 4kt3A-iti 6goZi-e_43
PRINTED NAME OF PERSON C CNSTRU:TING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information wig.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev 7/05

• NarlrCoot •DontWontetS L.nnn Manta untII—M-OMAtena1WNMOHIO OrankeSeen
ISIM Md lads OS • NSW N.C. SI SDISTOPlooa pp1772401
WELL CONSTRUCTION RECORD WSLLOCAOfO11r £+ A
NRRe 'AA-ANk
WRLCORRRACFONCININFICATNEta -J1-15
!TAT! WILL COIMTINICTION FrRMRis
C647
1. M
wrLLUel,,Po�NIO a41 WSW D NOHOW rcdrabo l❑ wlwbo0
Roan"LJ Hod Pram WNW Ieslol0 Odor[] raw,LMLIur
2. WELL LOCATION: (tow obok♦r of Ws bd Oon below)
-i n flit
N +r Wentoer iOki
reen 9- rV\e.-
4.
5.
0.
7.
0.
M.) a- o II
Address
oATE DRILLED l l t)V0 I fl - if
TOTAL DEPTH a oS
CUITINGSCOLLECTED rasp Noe
Donna RERAOE EXPIRED WELL? YES 0 NOef
STATIC WATER LEVEL Wm Tap of CaMF FT.
Mire Ran Tip SICab.
E. TOP OF CASING IS I FT. Above Lord Sudan'
'Too WHobo Iwoin- saoorInks bog seinew St rrL losssr-
Ynt1/11 !CAW
10.YIED l _METHOD OFTET tet
11. WATER ZONE! (MO*
r PC re �'la7 P+
aracnsI a - ! 4r Ft N; env' Kw
Om Taw lMr 79 6144
12. CHLORINATION: Typo Amount
13. CASINO:
From _To. �� R (l0 1%
From---- To FL
Fran To FL
14. GROUT:
WlaMows
epayoorL
From I T 1.�� R. i' P I 1" �� MNiod
From To FL
1S.
DMpt OWNS !lobo Eki IMMO
From To In. b.
From To FL In. In.
Frain To FL b: In.
10. S NWORAVEL PACT:
From
From
17. REMARK*
I to MAW CERTIFY THAT TRW WRL WAS CONSTRUCTED ACCOIobIMICE WITH ISA NM TO. WELL
CONSTRUCTION STANDARDS. AND MAT ACOPY TIMIECORD WEN PYIOEDTOTIEWELL WINEI
DEPTH
S07rnitlIrt
salami moo b sodod off be* et Mon
JaCCMULagral-
AsSwimdt _ionrk Sloslib
Rboda, or aenr mop nwowo pf llq
Ooper
To
To
FOR OFFICE USE ONLY
Sold Ns.
Sze mol ns
FL
aSmaw mason amsnanOs9Trfmat DATE
&toeaaiprRroww.IWrrOat ewrdwwWS=MOM SOdays
ear-+leY. taw
JUN 06 261313
•

•
• North Orin -Osprananta Smfrommed and i MRosa,-amaSMisrOa r•crouna..itt to
,5I5Ri5Swam Wear* RSA. N.Q.uwFlasrna.ptpTSS• en
WELL CONSTRUCTION RECORD WEILCOQRACTOIM Oti-111 t . T
Win CO IRACTOIICEIIwtCATIONM , I1.3
nu WRLOONSTIUC7gN /BMrrit
326646
1. Win Wiltesk A,rM+.age adddfat0 WSW D MOMS CI AEAarlwal0 MaINosYp0
R000.wy Hal rump W.Fw h jooMn D Ober D Mots, LW UNE
2. wal LOCATIOrt pow Mal* of 5N bunion LL4 )
N'l nce (\n r t rS 1-4-1a ca• 5l kP 1C G (Yl
1-orrwhS r Mt e ct
Adat... in c y 5f. 4p+ .
\\I PR Prim 1 ,, i\74 Q-� I
q*Twn mum II `f1 >f
4. win___
5. TOTAL DEPTH U
R CUTTINss COLLECTED_ vaswoEr
7. DOES WELL REPLACE SOWS Walt YRS NO
t STATIC WATERLEVELt a TapdSMm Dew FT.
Eire II Min bpelOrb.
I. ITN' OF CASINO R ( FT. Above lad Ibutoo '
Rqd sap Ismed.Trr bike Mal aaaow SIEVIAINICACIE 10.Ma METHOD AI 10D (Wrr*
11. WATER ZONES (dope*
DP,
12. CHLORINATION: Typo Amount
fs CABSIM
From J_To~�1 FL t P '»'4
From__ To R
From To FL
14. GROAT:
Rem t
From
15. SCRIM
To n p,
To R
Medd Method
Cerne nF- f
Dplh Clumsier BM lhi NSW
Fmm To Ft _ b.
From To FL
From To R. Nt kg.
15. S NDIORAVEL PACK
Owls
From To FL
from To FL
81T. LIdnY
npainnOsitanor
5 oddrordq.et M no.ara use bong d Ann
Ventiores an.
PC Rosao,orMow mgsans pots) �\l
/ W{
�VwS
7l�'1
17. fR*
t OO,ERSCERMY THAT 7M$ WELL WAS COMIERUC1EDN ACCOR WICS %WM ISA NCAC W. WSL
CONSTRUCTION STNAAtD4,AND THAT ACOPVOFTpRECO Dl1MfSIIFIgNOEDTOTEWELOWE.
/t�I, 11fROfrslaaraoommiu ..ODi watt OSTE
OS* v dr_Mr taIlVArOr�mr,-_—_Swtrnwhir20dins
sum REV. MI
FOR OFFICE OM ONLY
memos
JUN 0 6 20U3
r

326645
Nowcfarr • O,F.«on+ol M.Yo.notand wud Moms -ate War only. amud..lf $Gwen
1Eee mL SueboOar • IWO" NLA ETee►te/Erlwr Mtp Mat
WELL CONSTRUCTION RECORD wmscommerce: ( Pf yvvi
WILL CON,RAC ORCWITMLCATON1h (91 I
STATE WELL OONSTINICIgN PERIMTes
1. WMLl. 1011WOOse Anemia to Raeldw___ the epol0 Ln - - bl ❑ ApSMeel E MrdrHna ❑
r•oeM+ral Hod
�r��n4%Valn►P;:.0 Ole fl Mdw.LWwt
z IV frA" it ele.booiwa (k� i
waitrear1conr
-nr IhS CP e d i 1
pbsaanw ltfl_. seaie bl eW •�RILLIDLn. 0TM
• OWNlLL en n�iAl��r Desallai
I2\ ,e _ 0 rr ,r vt� � l
CIDATaa err ate
4. one ammo_q-;414LQL
S. TOTAL DEPTH a
e. COMMIS cougars) yeses. tier
7. ODES WELL REPLACE MOOTIN�AlaL? YES 0 Hoc(
e. STATIC WATER LEVEL Slbf Tap el QS* FT.
Halm ••• l arum Top or Oeay
O . TOP OF CASING IS_'_ FT. Above Land Sudler
'TAW seep lendelnd Die Dim SS sod.agAe.e.(o�A.a.banus.
10. ▪ TAD Y1E) fop* K METHOD OF TEST r I 0
tQ YIe<D fop* �C
11. WATER ZONES SWIG
12. CHLORINATION: Typo
1S. CASINO:
Amount SeOdroolwoo to rand nsMakdbun
Wailli A,..e LocATIDN SIIETCH
From I MIS /„CLE, 0 . R. { TT l %bales e..J mop ._poY.s
14nnlor
oer To n.
ii
From To FL
14. MOLT:
Rom _ T. c9d R. r, 0 re` )-
From To FL Molhod
16. SCRIM
Depth olr,mler Slot Ski WSW
Ram -__To_ Ft _ In. N.
From To R. In. It
Rom To R. it In.
1e. SAND/GRAVEL PACK
Mph Woo PASS
To R.
From
From To
17. I119IAPER
100HEROIN CERTIFY THAT Tie5WELLwASOgIIRI CTWMACCOIOANC11 N14A HMO IC, WELL
CONSTRUCTION STANDARDS,AID1HATA00PxOFTI1S_SlQIPROVIDED TOTIHEWRLORI6L
FON OFFICE MI ONLY
amm rc
wrrrrecossmntarenOTam VIOL DATE
JUN 06 2lu3 DST Nit ,eT
•

Not Crabs •Copenn+alias.n.rand Naiad e..ww-aweaaWar Quay Oa.na.wrs.am
IOW NbaOenia0wiw•SS4 ..N.O.VVsuF1aiPk apta)7sISSNn
WELL CONSTRUCTION RECORD railCONIRActON: Cr\VIRIe.r
WILL CONTRACTORCUIMPIONIN)Ila•. A V\
326644
STATE •OLL OOIMNNIOIION FBNS18s
1. WELL MEE addRIAN swls RsrOnaa V Mea0a10 NOBS 0 Aptedbm10 MaiabO ❑
Reassey uHial Pomp Visor laNdbieo Leo Id IG like se
2 WBd 1AG►T1 n.st ( J
T.nac.l��i s'°s(bh1td 11'Ie
�sai�--�,1, 2 Cr ccrnrP
sr Norm owl MwMb Clariuturehdriloballion se IW
3. OWNER '1\1\fl 5+1�1_ll
Addle \Cu'SI a1(
pna.WINO Vey
CgmTea as
4. DATE VW IT
a. TOTAL DEPTH
& CUTTINGS cougars:, resQ
7. DOES WELL nowt E>OETI WS.I. raO moo'
& STATIC WATER LEVEL Wow Top Stabs FT.
O. TOP OF CAMS W I FT. Men Lana Solos'
Mind soft Iwn hnreieskr kaewbus ewbeo mgkwneeA•web eeuw
dam me
scaW APES
10. YIELD �/ METHOD OF TEST
ern*
11. WATER ZONES (SOW
ne..rreLCA
/2-
44-/00 f .
11,0 - /n / Ff
t►Osee
12. CHLORINATION: Typo Mwwi
I& CASINO:
DEPrH
(s rF
Crrvi(ee
brfi zit Fe
fe1�
Iaim' rpm bmsiatoo bark ofboal
Wall Tains
From i Copt Oa FL .WaMaR ww
Fran--iF ew n To FL e���.
From To FL
14. GROUT:
From / I:tip FL Or mt MNwd.�
Fran To FL
13. SCREEN&
Do. Dlmglw ENr Slot Me MS
From Ts _ Ft _ b, h
From _To FL_ In. k
From, ,To_R._ Inc In.
It SANWORAVELPACK:
Dopes Elie Many ;
From Te FL
Reno To R.
17. TEIAARIW
100HERS CERTIFY THAT TIMSWELL WAS CONSTRUCTED MACCORDANCE WITHNIA MAC WC,SILL
CONSTRUCTION STANDARDS, AND THAT AOOPrpF REIN FROVOTOTNEWELL OWIER.
LDCATayj SKEICN
Mow Awdoneni Seratom aImo too lose
Roofs, stalls amp rslreapails)
FOR OFR= WE ONLY
s10(rtumor new 000lelunislug OWL MiS
SwekSad" lweeaTNaRgeni s SwendawanM TAW EO don
UN 0 6 7003
SIKI NEV. Mg

Nett Ones -OpNernreetas__. wiaand New. llrwer.rt.... Nast Osip •O.swldaelerEeaeal
1SN Me2Mds ONiM- PINS%N C.1/Ai1SMFle ns pity TAfIN
2 wai.LOCA
8
WELL CONSTRUCTION RECORD w lm cowc,oltt f A kilt ru ;ctitr 3 G 6 3
WMLCOMMON co11iwiCATIONp: <SI(3
SMTSwaLOONSIMUCia N FENMSTpM
1. WELLUU�aww awerboey.ReeMN1YW IMM ❑ Yid llal❑ Apl - nlD - 1.1,D
Aeeor.rrjHeel Paw Waist S,Nolan D Other f N°e1..LUtUse:
the losei• W) lfl
jun
eZ .�
.'.;.•tr�rt •Tt4rja �
Pishotliao
SS None Nan Crwardly..;
3. OWNER l Q51u(y D .IQC:
Address OV-k �l y ► ,.40
Ale xCtra eNwNinrC
My floe 4. DATE maw niQ 110
a. TOTAL DEPTH 1 US"
a CUiTNOSCOLLECTEy res0 NDQ'
7. DOES ram p e va VOSTNO watt? Peat 0 NO®^
•. STATIC WATER LEVEL Eels. Tap N CeabF FT.
w s Pen be stone.
E. TOP OF CASINGIS I FT. T.Above Land
'Top eameg iINailie aabwlr.ldeerbwnanan
o obeeeer
dor10. YIELD (yak L METHOD OF TEST w l i Cl
11. WATER ZONES (Spa*
anser Cat nDQ
.dSrag
toeth
DIRlSI6 LOO DlTIH
Raa Ts laNiwlen teeeUw.
BONA
12. CHLORINATION: Type Moats
13. CASINO:
Flea _.__To 'toa FL n "a
Fran._ To R.
From To R.
14. GROUT:
seddeadwee mad me beak al bon
1nelNaYw=
nowt ��aw�rre�,C
Dept M INS MOW
Fora I toa'Q_R C nFnI
Fran To FL
15. SCRIM
Dspw Drat Sol Sbi MOWN
Fran __To_R In. In.
Fran To FL In. In.
Fern _To_R. la In.
10. SAND/GRAVEL PACK
Doper Sloe MISS
From To FL
From To R.
Stint.
plewdbeeaen.rellmos ion reb.RaeoIra
Hatt* ante temp re_ odds)
17. RSJINA.fl
1DONIRACERTIFY THAT THIS watwAECaaWT*OCTeDNACCORDANCE WITH ISA NaAOSC. WELL
CONSTRUCTION STANDS ANDTHAT A COPY arm Iacono wesemi RgAIDEOTOTHE WELL OWNS&
'` h2 1J.
sprit UNS FFEiNaNCONIMIUM lallRVat NM1E
autos flournawrNgaaFEwaMererNlMFat00days
FON °FRCS USE ONLY
aea/Nee
isa
1
7UN 06 f
EWd NN1Y. row

e. YIELD (gpm):
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-DivisionDivision of Water Quality
WELL CONTRACTOR CERTIFICATION # au ` -v
1. WEIA. CONTRACTOR:
ev (QQ-av 6461°efl
Well Contractor (Individual) Name
/
t4.42--fAba'VI CCLA0k. t Qrl(1.n5 t knC .
Well Contractor Company Name
l
STREET ADDRESS 351 c t \-Qi ce-Eter Nwl
N short (le t'c e--B" \ro e
City or Town Stale Zip Code
( Sag » a54- Sig
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED el /—I /
TIME COMPLETED 4 - 0 6AM ❑ PM @'
3. WELL LOCATION: r Q/�
CITY: fW l�r�v/,*t COUNTY I/G'1�\ �va3C®YY�p1c
rr)be I DC, e P� -
(Street Name. Nu rs, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTJNG:
❑Slope ❑Valley ❑Flat idge ❑Other
(check appropriate box) n
LATDL 3ci 2.41
LONGITUDE 3 L I S J
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wen must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER
OWNER'S NAME �71 M- rid: t-(�-e XZ_�
STREET ADDRESS 5 7 a-0 r,*tT fl59CiZ.
t.)tt�+�sGDo�-SaLtsM NC 10(o
City or Town Stat t Zip Code
( io)- q(t- I�t4
Area code - Phone number
5. WELL DETAILS: �O`
a. TOTAL DEPTH: Ta
b. DOES WELL REPLACE EXISTING WELL?YES 0 NO/
c. WATER LEVEL Below Top o?f Casing: ° FT.
(Use "+" it Above Top
of Casing)
d. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
/J
METHOD OF TEST QIG-Ri1L/
6. CASING:
11 Depth
From .1 To 5't
From To Ft.
From To Ft.
7. GROUT: Depth
Amount
326520
f. DISINFECTION: Type L I
g. WATER ZONES (depth):
From 11 (C To 114k From To
From 311 To 'MS From To
From To From To
Thickness/
Ftby er sgphl� Pa)EI
,t Material n Method
From 1 To FL r'YB �? 1 `J`T� ��
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG Dint
From/ T5a oNl (3a ro U�p15N
6a'- n%'
%-VK 7 -- i -i 9
1ct.ct'-nytv
eat,t�
\Cb — i9 frv\
v"TE)
cize4`\C.6 - a GPm
'art& i— foe5() 11 E,
11. REHIARKS:
a
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
JAibeAA Cc',L-.&OQ
SIGNATORE OF CERTIFIED WELL CONTRACTOR / mATE
Q.i A S f
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. JUN 06 200E
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:
Rev -bet, Caldwell
Well Contractor (Individual) Name
2tLLbeh Ca(dwet Dr;(1iv<g Inc•
Well Contractor Company Name s
STREET ADDRESS 35) Ae-) ^"' CeStty Plug
Asheville NIc- aggoCo
City or Town State Zip Code
( ) 9,54- 35/S1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 4/a7/o
TIME COMPLETED 2'-Oo AM PM(1T-/
3. WELL LOCATION: CITY: 6 9-.0,/�a Ad 1—t Nit e(2-- (J
COUNTY Q�C-oine6
14 tGr( CLIFFS
(Street Name, Numbers, Community, 5ubdiNsion. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAW, SETTING:
°Slope °Valley a -fiat ID Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 3 a43 aS
LONGITUDE % a 411 . 59
Latitude/longitude source: F C`ipS °Topographic map
(location of we# must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER ^
OWNER'S NAME the MLper IflLSr O{ aoob
t.TREET ADDRESS P- D Qos 43 k,
ai M Qe4�h fl- 34g91
City or Town State Zip Code
Area code - Phone number
May be in degrees.
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: 1 1051
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 61
c. WATER LEVEL Below Top of Casing: 4-0 o Fr.
(Use -✓ if Above Top of Casing)
d. TOP OF CASING 15
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): METHOD OF TEST (I,IG-AIR,
326519
f. DISINFECTION: Type 4TN Qo%` Amount X O 2-
g. WATER ZONES (depth): ,
From Cis' STo Io05 From To
From To
From To
6. CASING:
Depth
From 1 To 50
From To
From To
From To
From To
Thickness/
Ft. Pieter
S ei L
Ft.
Ft.
PMaterial
7. GROUT: Depth Material Methodhf��
C From a To r& Ft. GMt W'F POUR�L
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To FI. in. in.
9. SAND/GRAVEL PACK:
Depth Size - Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
4-5
4S4t5'
ettS'- t oo5'
t oos' - (1 05'
11. REMARKS:
Formation Description_
oJSRB4.4deri
r�jLr4GP e-
a
a {
—C
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC ?C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OW NERn
Qw :tQ;Q 5 3 D!o
SIGNATU F CERTIFIED WELL CONTRACTOR / DATE
LLL,‘tr OAS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05
JUN 06 2035

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department or Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a t 4• t%
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Ret&ten Q0.1(,we(I Drilling IhC
Well Contractor Company Name\\,^, � ,,
STREET ADDRESS 'SI I�IN' ' kiCesier 14(k)(1
AshevyO_- lac agtoo
City or Town State Zip Code
(gE » a64--35gt
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check AppJ icable Box): Residential Water Supply ❑
DATE DRILLED 4-1 '1/0
TIME COMPLETED t `- 3 a AM[( PMEV
3. WELL LOCATION: //(1 �
CITY: CAROtaLei- COUNTY 4oDt-P1(_OMr��ylltz
CR%-tEK R-v,A t3S-tA-r 5 y1 LDT ts-
(Street Name, Numbers, Community, Subdivision, Lek No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT1NG:
❑Slope °Valley ❑Flat Q4idge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: gt;PS °Topographic map
(location of we% must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER OWNER'S NAME c J I R.V 1 C Q3\ Ih${ne. f t CAR
STREET ADDRESS
City or Town
Slate Zip Code
Area code - Phone number - -- - -
5. WELL DETAILS:
a. TOTAL DEPTH: a-0 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
741/
c. WATER LEVEL Below Top of Casing: !T 0 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS 4 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. A
e. YIELD(gpm): 3b METHOD OF TEST 1`nIG-At((-�
1. DISINFECTION: Type Thl . o Amount
i'6
6 0Z,
g. WATER ZONES (depth):
From j ¢'z To (4 y From To
From To From To
From To From
To
6, CASING: Thickness/
Depth, Di eter c�W'eei�i��rht��1 �{aL
From To t+1 FL ,"'rr'( r `+I`
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material Method
From 4 To tit Ft Ce?n(NT PO Lhe-e !'
From To
Frorn To
Ft.
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 To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From 1 To ir
i ']
t4 1- arts
11. REMARKS:
Formation Descri La
0 \)bn3oft-D 1")
cf.toftCb - 5 o C ern
y <
P'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF MS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE�AF CERTIFIED WELL CONTRACTOR / WATE
tt) (I—u6 . N AS1f
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgA� v���
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. JUIVI�LJ
Farm GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a 14- 0
f
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
Fe-u-(Oe'M C.9�\cLi t l £ r •1\ t 5 `LA C
Well Contractor Company Name
STREET ADDRESS 351 p3 e' Cesk t
Aw st\ito JC axle to
City or Town State Zip Code
( gag» a54 - 35g
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT Cif applicable) � WELL USE (Check Applicable oz):Residential Water Supply Ly/
DATE DRILLED l D 6
TIME COMPLETED 3- o `I AM O PM gni
3. WELL LOCATION.
CITY: t Ft €J t `t_ 'V COUNTY "V "C-Omaig
G 3 14 = s1.164 Ickeshl
(Street umbers, Commukity. Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT G:
❑Slope CValley ❑Flat N.rAidge ❑Other
(check appropriate box)
LATITUDE 3 5 1 % . 6'
LONGITUDE 1 "N. 4 D • 101
Latitude/longitude source: DGPS °Topographic map
(location of wet must be shown on a USGS topo map and
attached to this foram if not using GPS)
4. WELL OWNER
I �iCJC 6 �ti5 LS8.._!
STREET ADDRESS atS0 j.\€ }) le:cesier ticht
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
AS(-ttilL.L. e a-t 14 if
City or Town Slate Zip Code
(�a� , tOS3— 4466
Area code - Phone number
5. WELL DETAILS: �
a. TOTAL DEPTH: r365 '//
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS + FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. �7
e. YIELD (gpm): 100 METHOD OF TEST RAG Ate'
f. DISINFECTION: Type iJ (74 -wo Amount q 0r-
g. WATER ZONES depth
From 3 31 TD.5.3 From To
Fran To From To
From To From To
6. CASING:
Depth i3
From To 110 Ft.
From To Ft.
From To Ft.
7. GROUT: Depth From 1 To �--••�a
L'D
From To
From To
Ft.
Ft
Ft.
Thickness/
eter $ I-01
Pax
Material Method
06. r Po4?-,b
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in
From To Ft. in. in
From To
Material
Ftin. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From ,' To
`13S3t — '`J3n
3-3�%
3
11. REMARKS:
Size Material
Formation Description
\}bP— z-66of
J
o•
ON t
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC SC. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS ,BEEE,N,PRt`OJV1DDED TO THE WELL OWNER. n
SIGNATURE OF CERTIFIED WELL CONTF%ACTOR DATE
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.
i;SV J(j arm GW-la
Rev. 7/05

• North Garr•o I.aMbwr..e.A.ndNrralNommo..•Obtl.roIWebrOS-Srowera.swtalm
na (M S.s. Oontor • INS N.C. 2/500•/11154Tons nip Mal
WELL CONSTRUCTION RECORD WatOONTRAcTON: C kcAn\'CLkr
MOONIIMC1p11CIINTwCA1ION11: 41 C3 RL
STATE veal OONSISUCTION PBISTS:
326851
1.
2.
2.
4.
a
0.
7.
0.
WELL LNIE A/r — sap Rwdonlil ( IMES o bdnbbl 0 AIIklis 1 o Maiming
Reoeeay Neon Pomp Wdr I joollon o Other o EOINK Di Ikuc
wea. L.00A
pbrd N
OWNER
AWNS* P C)
ySSA \A 11 P beMar `Xl(Y`'YYI
( 't'' 1"1 fat
to it
Wen\ erv\ / Ivc
ORRLMU DEPTH
Narw „ ,11 Fewrerro.stla
CUITMwSCOLLECTED YES[] NOd
DOES win REPLACE Ex1MiMID wall vas 0 NDer
STATIC WATER LEVEL Biwa Top N Cosby FT.
Mee 11Plan TiFaO.ry
1. TOP OF CASING IN. I FT. Atom Lard SurNor'
Kspelslag Irmr.ldoVe Jew I.rrsets maw Amin asop
ItYIELD (ppm): �tLETH0 M00FTEST V 11swap PA C�
11. WATER ZONES *pet
OP/ aTWO s.a
DATE GRILLED
TOTAL ovrll
12. CHLORINATION. Typo Amount
13. CASINO:
1belWrwo
To
From
I.(Olourer ____ t
Fan To FL
Fran To FL
14. GROUT:
Depth /AMISS Maid
Fan I To of FL (NC rAU
From To FL
1S. SCREEIk
Depth Dlomobr Slot Ski MebrbT
From To Ft b. b.
From _To_R. tr In.
From _To_R. In h
10. BANDIGRAVEL PACK:
Depth
Rom To
From To R.
Stu
a
MSS
eddf.nl peso b modal um roar S bon
phaud oubnandA.woranaloseaofees
Rost, or Se mop ro/..wpubs)
er 0015
-c
J
0
m
17. HNEI.tfl
100 HERS CERTIFY THAT 1)1111 WELL WAS CONOTK JCTED IN At:CONDANCE WITH ISA ICAO IIC, Ma
CONSTRUCTION STANDARDS. MO awHAS EIS MIOVDEDTOTNENIEU-OWNEIL
FOR OPRC! USE ONLY
Oval Me
ISM AL
lunar nowannr.lament IOIMai van OATS
Sloe oyrabaISSVIaa.owy:Ovird1ra. ANS sal So days
d114NEV. q7N
!JN 06 2u35

326649
Not Coes • Dq...r. of SI.r..ma and N.M. Rre.aao - Skidoo. we Mar O.N..a..r Salon
ICM Med Smoke POW - SSW NCO.117NsHNsnlsr 01114104111
WELL CONSTRUCTION RECORD Wn1. CONTIVATOOk CJ �ct\KW Ver
WELL CONIRACTOII Ca1TWICA11011e 1 1 3
STATE WELL OONOTINICf10M PEIYETds
1.
2 WELL LOCATq»t
Tome
t ri
3. OWER ¥c
Mead )duann N.awa, awSdi - .WLMC iIW
NC s Ncx sfl
Address -con nn vP.
AIe azs-ibi
Mow Toe Shia SOPS
4. DATEORN.LED
6. TOTAL DEPTH �l o
0. CUTTENOSCOu.EOrED trap NOEr
7. DOES WELL REPLACE MOM. WELL/ YES ❑ NO[J'
A STATIC WATER LEVEL ears Tap elP&p FT.
(4er se, aMemTeo alasp
I. TOP OF CASINO E FT. Above t.d S.
'Top .also I.ai.bf.NrES= tone nesrois+waa lmsI.aaraF
dam as WIN= ICSIS
10. YEA (pp* METHOD OF TEST
11. WATEIZONEs SO*
WELL 11111Lckeet Itholbeit seep RAJ IMMO* ❑ Ind_MYl ❑ Av1.drNEl O Maa-.iy 0
Bey Hal PompWager In0 Other CI WOW UMUs
c M, bake - t-xinaMI)e,
aLSI6 we
Cr1r.S. P 4
Th
uT -%fl
74Y
DEPm
r+we.r. o.ayd edlr+
�tti$ auS (ijttr11If'
12. CHLORINATION: Typo AmoMd
13. CABsIt
S.ddM..ltwo Y aoudad
Doan t From To FL "1) _ 421.QS.D.0
Rem To FL
From To Ft.
14. GROUT:
From
From
1s. SCRIM
T Oepri
FL �Werke ntin fi Method
To FL
Depth OL ..Yr aM Ski MSS
From To In. M.
From To FL L1. In.
From To _ R. Yr. In.
I& SANDIORAVELPACK
Dope
From To
From To_
17. SMARM
FL
Ft
Mows dkoeSm red Olen* io.. Ya.1ae S.ee
Rasa or elle onop akin* pone)
✓4
100IERESYCERTIFY MAT THIS MULLWAS C ETR CTED
CONSTRUCTION STANDARDS, AND TINT ACOFJy OF MS
FOR OFFICE USE ONLY
O.eN.
WON&
ACCONDICI WM. IVA a SC. MU
TOME WELL OW►E .
nomonsi1MmeemiollMlllfRM emu. MTE
Ommloaskmeeommeenederemim theme one oat SOdoe
OW4 NEV. OWN
JL'N 06 2E3

15. SCR®k
Dept Dl.rmalor Slot Ski Rad
Fmom._To_Ft In. kt.
From To FL In. M.
From _To_R. b In.
141. SANDIORAVELPACK
Dept lira, Molmbl
From To Ft
From To FI.
• •Noah Cabo •DtpatwwadSmrkwwwntdN.dttloawoa•OMd..SWarOaaaf•1#wadn.ar5aaam
IPSNMI Swan Om* - RSVP, N.C.17MF10iFlwrONp7R ei
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C' in- A C1�'.`f I i;r
mm.00 =4%03RCENTrwcATIONd & I IA
STATE WILL OOIMTIWCTION PERIM
326648
1. wms us A/MnMA�as al woo 1:3 SSW CI Arlan' D NaANY� ❑
Rocovory Yenta Ole1311OOw/.UNWcp� 2 WILLIDCATtOtk nbr' I rba/wr (1) �-�l om I Q
NNrwlTamc V�1F' aVf Yl P� Jl
Lower F It* CM.trcr im (V�1
Aed.» p C ( Y\t,
CywTam INS
4. DATEORILLEO -l'"-
5. TOTAL DEPTH
S. CUTTINGS COLLECTED yes HOC
7. DOES WELL REPLACE EXISTMO WELLY vas Q moth
IL STATIC WATER LEVEL Mow Tap N arbor FT.
la WI fin Sep el ChuSeI yr %
R. TOP OFCAeslsR. I FT. Above lardIMame
Asa IMMO SS RIM
Map N mobs ►rorko a Mho bars YMswam posh nvatsSaw.w 74,
10. TIM (Wm� METHOD OF TEST i
11. WATER ZONES Wool*
12.CHLORINATION: Typo Amount RSINS mm lomad too book orbent
t115LaG tag
11. CA5N&
Wall Was
From To C A FtI_
Fiaw To FL
From To FL
14. GROUT:
Ira
IMPS Mothod
From . I To aD FL C(Irvw1'lir
JrcATt i SKETCH
Wks amiss derma San al kw* oSi
Rosa or oho mop ratww.opubis)
Fran To FL �?
0-
17. REMARKS:
100HEMP CORitFY TNAT nos WILL WAR COHSTROCTRD W ACCOR DNICE WITH 15A NCAC SC, W61
COta7TRUCTICNSTAND 0S. AIOT1147ACOPY ,QFTIRRMOM 1M1sSN1wIpYICWTOTE WELL OWNER
FOR OFFICE 115E ONLY
aarNs
San.
CPrRllkaNaalM ISClalmTHE Wail OATS
Sub* go d ShistiosIWalwalles SissmlivIer Sollst Win Naps
Rwtla SIM
UN 06 2005

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resour
WELL CONTRACTOR (INDIVIDUAL) NAM (print)
"pA 11°.t
WELL CONTRACTOR COMPANY NAME
SPATE WELL CONSTRUCTION PERMIT#
(if applicable)
s - Division of Water Quality - Groundwater
Section
CERTIFICATION #Z-0
01
(11 PHONE # Advq°k.3 ASSOCIATED WQ PERI IF
(if applicable)
WELL USE (Check Applicable Box): Residential DV/Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCAT N: train
Nearest Town: V County Flogatat
(Street Name. Numbers. Community. Subdivision. Lot No.. Zip Code)
3. OWNER:
/ss
AddressI
efIRRA
C,3t±
(Street or Koute No.)
N\•1
City or Town State
)-
Area code- Phone number
4. DATE DRILLED
Topogr phic/Land setting
DRidge lope ❑Valley ❑Flat
(check appropriate box)
Lant de/Ion itude of all a
I`r�Yi�lr 4Q tat r R N, ' ' • a.5 c �9 .� .
�V x (dea ees/minutes/seconds) tie/ d%„T'
Latitude/longitude source:❑GPS❑Topographic map
(check box)
a �4 DRILLING LOG
Zip Code
W
DEPTH
From To
5. TOTAL DEPTH: . T
6. DOES WELL REPLACE EXISTING WELL? `qil6NO fB
7. STATIC WATER LEVEL Below Top of Cosine: (( FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in actor yyc--e.w__ithA NCAC 2C .0118.
9. ZONES vIETHA BEST
10. WATER ZONES pth): � j�5
I I. DISINFECTION: Type 1.l31 i
12. CASING:
Depth Diameter
From To $I Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To „?
From To
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft. in.
Amount OL
Wall Thickness
or Weight/Ft. Material
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.
1
JUN 06 20i3 1
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU ON STAND • RDS. A `.1 THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH WELL
•
SIGNATURE OF PERSON CONSTRUCTING THE WELL
WNER
4
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 CONTRACTOR(INDIVIDUAL) NAMES (print)_
w e:L.I. CONTRACTOR COMPANY NAME 1 ppi
STATE WELL CONSTRUCTION PERMIT# 1
(if applicable)
326504
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources p Division of Water Quality - Groundwater Sec-tiioon�ii. /
ylb},,//��,, l`c' %ert-it CERTIFICATION iNt 1
ItT(y fV ell i
ASSOCIATED WQ PERMIT
(if applicable)
PHONE # [phone]aaA
L. WELL USE (Check Applicable Box): Residential le Mtmicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ lfOther, List Use
2. WEI L LOC.ATI N: t
Nearest Town: QA.1l1 �CL Count,}._
(Street Nmne. Nmnbers. Community, Subdivision, Lot No.. Zip Code)
3. OWNER 1k N�1Art ebtuf •/p611.14 4'4
Address D a694 l03 f
115047
c'V �lc (Street
ttor��Route No.) IR seg k-
City or Town State Zip Code
( )-
Arca code- Phone number
4. DATE DRILLED
,9/60)
5. TOTAL DEPTH: 7-$y�11
6. DOES WELL REPLACE EXISTING WELL? Y NO I
7. STATIC WATER LEVEL Below Top of Casing: �0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
Topoggrpphic/Land setting
DRidge Slope OValley ❑Flat
(check appropriate box)
Lat'ion nudeowel locaLiesaa1a/N36e'a( NO
(degrees/minutes/seconds) EGV•9 t
r
Latitude/longitude source:❑GPS❑Topographic malt)
(check box)
DEPTH
From To
9. YIELD (ZONE ('At METHOD OF TEST!Y •C.Ot `V1
10. WATER depth):
€r'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
variance in accord a with 15A NCAC 2C .0118.
I I. DISINFECTION: Type N Amount
12. CASING: Wall Thickness
FromeDepth �/
" To 11 T Ft.
From To Ft.
Diameter
From To Ft.
13. GROUT: Depth
From To
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
t.
Diameter Slot Size
Ft. in. in.
Ft. in. in.
or Weight/Ft. Material
From To Ft.
From To Ft.
Size Material
Material
DRILLING LOG
Formation Description
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COr'$tgUCTION STANDARDS. AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
620706
SI NATURE 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

326502
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Res;ur es - Division of Water Quality - Groundwater Section/Q
WELL CONTRACTOIt(INDIVIDUAL) NAME (print) rttA �e I CERTIFICATII(ON##1g6O3
lt'ELL CONTRACTOR CO�N1PANYN.aN1E A Dpiklr's IINV /t/&I� bt1`iI PHONE# Vp)�OOI�?224
STATE WELL CONSTRUCTION PERMIT# 1 r ASSOCIATED WQ RMIT#
(ifa licable) (if applicable)
1. WELL USE (Check Applicable Box): Residentia Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other O if Other, List Use
2. WELL LOCATIO
Nearegt Town: V I(t Cou h e5ABIZ
ecTohf5c, k1M - catst4) 211S(if
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LetUtSJ
CFA
Address Pc 130x. S F
IVA
Street or Route No.)
LA VC%V Ila, tilt
inn
City or Town State Zip Code
( )-
DATE DRILLED 3 eZ6(
Area code- Phone number
4. n
5 TOTAL DEPTH: raTCo
Topogra 1c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
atitude/ n itude fwel l etio
N5'. �9��fr35'P,?
(Jegm(�es/minutes/seconds) 14,e, r
Latitude/longitude source:❑GPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES�. /❑ NO I�
T
7. STATIC WATER LEVEL Below Top of Casing: O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS N FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordansri, v}:y h 15A NCAC 2C .0118.
9. YIELD (gpm): LJ• b METHOD OF TESTI lAl• eAN t�l
10. WATER ZONES (depth): /bd
11 DISINFECTION: Type 14Amount pZ
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To 1Ft.
From To Ft.
From To Ft.
13. GROUT: DepthMaterial
From To 3 Ft.
From To II
14. SCREEN: Depth Diameter
From 'To H. in.
From 7-o Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Slot Size
in.
in.
Method
ll.
fvlaterial
From To 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.
,ll1N06`l'u
16. REMARKS:
I DO HEREBY CERTIFY THAT HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUC ION STAND RD AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH • ELL OWNER
SI ATURE OF PERSON CONSTRUCTING THE WELL DAT
Subm' 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

32@500
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resou -ces - Division of Water Quality - Groundwater Section
WELL CONTRACT012(INDIVIDU.AL) NAME (print) LS - " Q[j-� CERTIFICATION 4Ga3•
WELL CONTRACTOR COMPANY NAME
f•A«I Vet 1 3 PHONE # f~/. /QR�i
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT#
(if a. Iicablc)
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIIIO�''N�::�� ��,,((��,�,
Nearest Town: 4.� iQ t t.C.
It'n Sttafty -COU
(Street Name, Numbers, Community, Subdirisi
3. OWNER: K
Address Pd
/' cts
rIVA
253a
14ire t or Roio�
City or Town State
1 )-
Area code- Phone number
4. DATE DRILLED 1 I J iP
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YE NO
7. STATIC WATER LEVEL Below Top of Casing: _ FT.
(Use "+'• if Above Top u&Casing)
S. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
Couny .l4pt--
a8n-Nsc
Lot No., Zip Code)
Witis
02a 4t g
Topogra fc/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/Ion it de of well Iocati2n
N5h` 3X.i�Wfl -\/Ba[ �3�°�1-GY3'
(degrees/minutes/seconds) -fa • i `l5 r
Latitude/longitude source:❑GPS❑Topographic aap
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accord c with I5A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TESTAi CO % 5'
10. WATER ZONES (depth): /7-0
11. DISINFECTION: Type JP 15 ]IS Amount
12. CASING: Wall Thickness
Dept Diameter or Weight/Ft. Material
From To Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material _/— Met - d
From To 3 Ft. CTK
From To i' Ft
14. SCREEN: Depth Diameter Slot Size Mate tal
From To Ft. in. in.
prom l o Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To 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.
Jut) 06 ^3rCN,.
i
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
06
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

3264g9,
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and �/Naa1turaalql Resour `e,s'-`Division of Water Quality - Groundwater Sectiioon��x
WELL CONTRACTOR (INDIVIDUAL) NAME
(priinnt) [s/�/1'R(j/! t1� CERTIFICATION#aces
WELL CONTRACTOR COMPANY NAME / ppA/ALLI/e4ti 2'V e // vl�; I`I N O PHONE # arelnla�$'Qa'{o"i3
STATE WELL CONSTRUCTION PERMIT# (1 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Cheek Applicable Box): Residential ZMunicipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT ON: ^�
Nearest Town: CZ5 County \rait(itL. r.At
44 bIpit c9<) !4i xiDC1 -2830 f
(Street Name. Numbers, Community, Subdivision, Lot o.. Zip Code)
3. OWNER: a66 Sloe-Mf4i' Cot
Address X 3q0 9
(ow^IStr_eet gr,Rout7N ) as 4 31
City or Town State Zip Code
( )-
Area code- Phone number,*4. DATE DRILLED 7 jdip
5. TOTAL DEPTH: If n{
6. DOES WELL REPLACE EXISTING WELL? YE ❑ NO L�
7. STATIC WATER LEVEL Below Top of Casing: 70 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordancyywith 15A NCAC 2C .0118.
9. YIELD (gpm): W METHOD OF TEST
10. WATER ZONES (depth): I��
1I. DISINFECTION: Tvpe ieve1-if Amount
Wall Thickness
or Weight/Ft. Material
12. CASING:
�N Depth//q Diameter
From V To lP / Ft.
From
From
To Ft.
To Ft.
13. GROUT: Dept Material Method
From To Ft.enne.'
From To'9- Ft sN& (.—
I 4. SCREEN: Depth Diameter Slot Size Materia
From
Prom
Te Ft.
to
in. in
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size Material
Topograp c/Land setting
❑Ridge ope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/Ion nude of well location
N364-l. a`? (.3 gag' t3,�9.3(3
(degrees/minutes/seconds) EICV ..2170
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
C— (•Cmrfetinq
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.
`f M! r
Ju S 1,•0
v
0 •
ON
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND/\RDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OW
�3)3
1ER
dc$
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONTRACTOR (INDIVIDUAL) NAME,sprint)),/
WELL CONTRACTOR COMPANY NAME / 1ppFCA ;A
STATE WELL CONSTRUCTION PERMIT#
HE' heable)
32.6498
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resous - Division of Water Quality - Groundwater Section
re t3
Wei 'Y111
CERTIFICATION����#oyfrOTl/.�Q..
PHONE # Also) 6a /�( 23_
ASSOCIATED WQ PERMIT#
(if applicable)
I . WELL LSE (Check Applicable Box): Residential I Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest own: fiSrR.✓I a-4W County
q5 StLt.SMBlc5 ?ce. $730
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 1 (t zrK Spies. z Address ] -FP431
L (Street or Route No.)
t-� rv: CO ,(IC
City or Town State
agY-3o
Zip Code
)-
.Area code- Phone number
4. DATE DRILLED , 3 /
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LY
7. STATIC WATER LEVEL Below Top of Casing: ?C) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of easing terminated at/or below Land surface requires a
variance in accordan with ISA 2C CTRL l A\
9. YIELD (gpm): OF METHOD OF TEST
10. WATER ZONES (depth): 2f0 7 p?*D
-
11. DISINFECTION: Type 1 (- Amount-
12. CASING: Wall Thickness
Depth Diameter or WeightFt. Material
From To /615(Ft.
From To FL
From To Ft.
13. GROUT: Depth.
From To F
From To / f Ft
14. SCREEN: Depth Diameter Slot Size
From To Et. in. ill.
Prom .1 o Ft. tn. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topogr le/Land setting
[Midge Slope ❑Valley ❑Flat
(check appropriate box)
Lat de I n ude of I ocation
� �4�. ` s. T. .576
(degrees/minutes/seconds) EIEN/ . a/Fa�
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.
JUN 06 2036
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TH WELL tIWNER
r
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
6
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Nlail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

326497
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Res
/�gjjurcgs - Division of Water Quality - Groundwater Secttiioon^�
WELL CONTRACTOR (INDIVIDUAL) NAME
(print)'At At�/�+��//I11,4 , p CERTIFICATION
142` 601 s. �s �.
WELL CONTRACTOR COMPANY NAME 4�O%/AIy /Y(,(/ %11I ax.CR PHONE #af\Op�/c2OV
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
tifapplicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Fd" Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2 WELL LOC.A N: 1� 2
Nearest Town: /lU(It..4 Countvi / Jco
Skw.t ac6id 29T/6-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: U'�l %{c,u A5
Address V /sN_ ,C^- K
C getor ANP/i e No.) e ?/�
City or Town State Zip Code
)-
Area code- Phone numbe
4. DATE DRILLED t
5. TOTAL DEPTH: l8J
6. DOES WELL REPLACE EXISTING WELL? YE 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a `'
variance in accurdp�r�rich ISA NCAC 2C.0118. 1 ci(. /�, IU1� YIELD e m: J TH D T w
1
Topogr is/Land setting
❑Ridge Tope ❑Valley ❑Flat
(check
�appropriate
booxx) pe�t1 Nita IooSdt:pf , IWeiofr e
(degrees/minutes/seconds) \-ILv • c
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DRILLING LOG
Formation Description
DEPTH
From To
UCH
9. (gyp )
0. WATER ZONES (depth):
11. DISINFECTION: Type /tre1 k Amount ea-
12. CASING: Wall Thickness
�� Depth Diameter or Weight/Ft. Material
m l.T FroTo 41-d Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To 3 F
From To / -q
14, SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From "fo Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Size Material
Material
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at lea
two State Roads or County Roads. include the rc
numbers and common road names.
JUN 06 Lu:.J
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDA DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE \ ELL OWNER
:g°s 2 3/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
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

32S444
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - /Div'son� of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)('A V; J�______ ��.h'/�l t/ l/�\p ,t� CERTIFICATION #l�9-(a�/�7�
WELI,CONTRACLotCO;MPANYNANIE APIP (LAVi10iN (Yg4L (JA'I�t1\1 PHONE #iS%Cog3 /pcpz
SLATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERM
(ifa .licable) (ifs.. licable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATI N:
Nearest Town:
3(P� V
C
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:�P�1
Address 3W IGI l'�
iiil u5A( cet cgcNod
City or Town State
Zip Code
Area code- Phone number /�� 0
4. DATE DRILLED pu..l �� Y1
5. TOTAL DEPTH: t /
6. DOES WELL REPLACE EXISTING WELL? YES NO UV
Topogr m/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
�trde{jon ti5{,e ofwe of ic.Gs 3
(degrees/minutes/seconds) Ct.�, ,, 37 0
Latitude/longitude source:❑GPS❑Topographic map)
(check box)
DEPTH DRILLING LOG
From To Formation Description
7. STATIC WATER LEVEL Below Top of Casing: IOQ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires'a
9. (gpm): METHOD OFTEST-41P tit
variance in accordsn 02 With 15A NCAC 2C .0118.
YIELD m:
10. WATER ZONES (depth):) - (9.0J—r� ,
11. DISINFECTION: Type IV,t@\t4C Amount
12. CASING: Wall Thickness
From To Dc Diameter or Weight/Ft. Material
Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To
From To
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
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.
tl ei r Onr
JV'i� k.J0 Lud:,
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 OWN
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
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 NaatturalrRes`ourceess - Division Jof Water Quality - Groundwater Section Q
WELL CONTRACTOR (INDIVIDUAL)NAMIE (print) DAVV J`j��iJ I�C1'-14old CERTIFICATION
p3Q4'�/"/jn �,t
Ir'ELL CONTRACTOR COMPANY NAME App>�IRch li�l d� YY'CI( DR; Ii PHONE # J�QIO)VAV./PYNoL
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PEI IT#
(if applicable)
(ifa slicable)
1, \VELL USE (Check Applicable Box): Residential D Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCA: Lei e 5 }
Nearest Town: LSft C�r.t,l Count
a� Ale cuNer- Fkrrn6 C41/44 Ca 3
(Street Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER: Z%4 l M�esst.-t.i
Address 1553 R(�yAr �ct
1' suct3 -Creel or Kou_te No.) Ati14-5
City or Town State
(
Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
6l�
Topogra is/Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropriate box)
143e 3i.d i gcW6Htt(231.,. g1,.
(degrees/minutes/seconds) Eti,
Latitude loneitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
6. DOES WELL REPLA E EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 186 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
`Top of casing terminated atlor below land surface requires a
variance in accorda re with I5A NCAC 2C .0118.
9. YIELD (gpm): t METHOD OF T eiwi l„ dc(T eiurw„. 1
10. WATERZONES(depth): (3a3, ,3�eJ I
l I. DISINFECTION: Type 'note Amount o'
Wall Thickness
Depth Diameter or WeightiFt. Material
From 0 To (64k Ft.
From To Ft.
From To Ft.
13. GROUT Depth
Fromr To
From To
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.
12. CASING:
3 2 t 4 9 3
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 6 L, i;_.v
a
cre
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 0
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ER
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

326492
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturaluResources - Divisionvi`'of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) I 50,l.b 64" cr-t- oP( CERTIFICAATIO/Ny#S�rai
SS ' ELL CONTRACTOR COMPANY NAME �' } 31 kehi(iN Welt ?Illl(v Cl PHONE # (�`KI(Ss3- /01pa>
STATE WELL CONSTRUCTION PERMIT#
Of tlicable)
ASSOCIATED WQ PEIt%IIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential i Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI N:
N31c1* low&n t"'4� County
�f�P.Y �r ,
(Sneer Name, Numbers, Corn unity, Subdivision, Lot No., Zip Code)
3. OWNER:"551/ MNC,C\?�
Address Rt(1.,t Nsk
Qtree Route No.) rali%f it#3
City or Town State
)-
Area code- Phone number �(
4. DATE DRILLED IT
Zip Code
Topogr rc/Land setting
DRidge Slope ❑Valley ❑Flat
,,11 r1 (check(c aapproprriiate box)Latituglocationf well
(degrees/minutes/seconds)Rc ', 02.,r ps-`
Latitude/longitude source:❑GPS❑Topograpfiic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1
7. STATIC WATER LEVEL Below Top of Casing: I COFT.
(Use "=•' if Above Top of Casing)
S. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accorday4c with 15A NCAC 2C .0118.
9. YIELD(gpm): lMET-IODOF TEST C1A(•QCNILkeik 1
10. WATER ZONES (depth): p2p1
t I. DISINFECTION: Type
12. CASING:
Depth p Diameter
From To 77 Ft.
From To Ft.
From To Ft.
13. GROUT), Depth
Frown (-) To 3
From- _ - To / 7-- F
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Amount r%
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
Material
LOCATION SKETCH
Show direction and distance in stiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JUN 06
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
s-
DTE'
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

326491
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and � Natural,//Resourcess --[/Division of Water Quality - Groundwater Section
/J
WELL CONTRACTOR
IS (print) bPi
ATION *91101'i
\%ELL CONTRACTOR COMPANY NA MEYippPs IR�\'R �.\ ill LJ2tt lit PHONEt#fCW�')�as /RD�
STATE \WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifa llicable) (ifa. licable)
L WELL USE (Check Applicable Box): Residential r Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 if Other, List Use
2. WELL LOCATION:
N arest wn: VS I
c5tft� C 2878'
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code) Latitude/Io itude V Il location
Topogra c/Land setting
County�.Ad8l.0-& ❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
N3 o3 � $ •
3. OWNER: �Pcn�� Jy�1-tgUL � (degrees/minutes/seconds)C.KA aaG 9
Address I 3 6_4 faMC,, Latitude/longitude source:❑GPS❑Topographic (nap
City or Town State Zip Code
( )-
Area rode- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: •per' ;
6. DOES WELL REPLACE EXISTING WELL? YES ❑NO 1N'
7. STATIC WATER LEVEL Below Top of Casing: tO,EFT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S ( FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): L A * METHOD OF TEST C.-1AL
10. WATER ZONES (depth): 02 30
11. DISINFECTION: Type ((;61C-4 Amount .2—
12. CASING:
Wall Thickness
FromDepth ��JJ Diameter or Weiehr/Ft. Material
Toy 0 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth, Materi ,,,J��
5 Q nq .
Fromm To 11' Ft,151,__ 1 1
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Material
From To Ft.
DEPTH
From To
(check box)
DRILLING LOG
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.
It "
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR 'TION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DAT
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) NAN (print
WELL C(ThIRACTOR COMPANY NAME j'f1C47fR1
SLATE WELL CONSTRUCTION PERMIT#
(if applicable)
326487
c\o D CERTIFICATION Alt/
IrN
d/
1
PHONE #,1NB)GXt3-7aat3
ASSOCIATED WO PERMIT#
(if applicable)
1, \VELL USE (Check Applicable Box): Residential Municipal/Public 9 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. W Et L LOCAT
Nearest Town: *rvaY;IIrok
c
nja to jo(IAc2�7NIP a8lici
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3 OWNER Cgilkato
Address C / .
��
,\ ICiw( tit (Streeta. rite No.) Des3c*
City or Town State Zip Code
( )-
Area code- Phone numhe
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? Y
7. STATIC WATER LEVEL Below Top of Casing:
(Use "-' if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordan' h 15A NCAC 2C .0118.
9. YIELD (gpm): e s'. METHOD OFTES�
10. WATER ZONES (depth): /t'3a
11 DISINFECTION: Type l
eitcr
12. CASING:
Depth
From To I % Ft.
From To Ft.
FT.
Diameter
From To Ft.
13. GROUP:
From
Fror.. .
14. SCREEN:
Depth
To� Ft
To Ft
Ft
Depth Diameter
From To Ft.
Materi
in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Amount o�
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
Method
Size Material
Material
Topogr lc/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
(degrees/minutes/seconds) c�j/' �a�
Latitude/longitude source:❑GPS❑Topographic nfap
(cbeck box)
DEPTH DRILLING LOG
From To Formation Description
ue?
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.
J
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONNECTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL BATE.
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

gF esc t*6 utcAY, (T[ o1 cn/gD
5t`6a a.� tko tw�a , l
WELL CONSTRUCTION RECORD
3ZVI5.6
North Carolina - Department of Environment an Natural Resources - Divi irn of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM (print)y�Y V '`yob
\YELL CONTRACTOR COMPANYPt NAME I' ` f't 1 ] /y
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
/ CERTIFICATION
l •,�� PHONE
W PER, IT#
ASSOCIATED
Q
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ 1fOther, List Use
2. WELL LOCATI
Nearest Town
r� o $ Ple &.
Vali;Coun AJ kY\4&
Lmse16rnbutY4 25 , aB7 7-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
tStrret or Koine No.)
City or Town State
( )-
Area code- Phone number n /\ /
4. DATE DRILLED `�J/(�
5. TOTAL DEPTH: 6
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Cpd FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordat c with 15A NCAC 2C MDR9. YIELD (gpm): METHOD OFT •S `• Gil
10. WATER ZONES (depth): 10hr �T
Zip Code
I I. DISINFECTION: Type—TAISICe Amount
12. CASING: Wall Thickness
Depth , 7 Diameter or Weight/Ft. Material
From To 3 Ft.
From
From
13. GRO�i�Ty Depth ra ��M�aterr al��/ _r,-�yjtethod
Froth CJ To Ft.
Depth T �l.l.�
From To7T-Ft. &6.4,51Wf t/Q 1)6 r
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
To Ft.
To Ft.
Topogr hic/Land setting
DRidge Slope Malley DFlat
(check appropriate box)
Latit de to t of e locatio
N t�s� E 'NOM °° qq.
(degrees/minutes/seconds)re , CPO'
Latitude/longitude source:❑GPSDTopographic rlfap
(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.
ll I„
.J',Jla UU
a
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 WE L OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

T V \u,.• 1t .fl V v\LLJ
11. DISINFECTION: Type 176/t'- Amount r2
12. CASING: Wall Thickness
Depth_ Diameter
Froi To �0 Ft.
From To Ft.
From To Ft.
32649.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
�rNatural
,�Resources -�rDivision
of Water Quality - Groundwater Section
{j,n
WELL CONTRACTOR (INDIVIDUAL) NAME (print) DRL) �,l 1i7Mt��y CERTIFICATION#tJ(-05'
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMED/ ASSOCIATED WQFERMIT#
(if applicable) (if applicable)
PHONE #
1
WELL USE (Check Applicable Box): Residential CI bfunicipal/Public 0 Industrial 0 Agricultural ❑
Monitoring D Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
WELL LOCATION: p,(����p yy�� 22 ,,��z�
Nearest Town: 3 LPPC,kl M�nTiCounty 5 (-4cr `VJ
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER f
Address A, C(dnvvvl, r
(Street or KOutC N0.
C noia.. Uc a��lS
City or Town State Zip Code
)-
Area code- Phone numb
4. DATE DRILLED
5. TOTAL DEPTH: /
p
6. DOES WELL REPLACE EXISTING WELL? YES0 NO L9'
7. STATIC WATER LEVEL Below Top of Casing: ! d FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accord9neecthNCAC 2C.0118. ,, ` t* ,,,
9. YIELD (gpm): � a4"�J MET OD OF TEST evil. 2a"t AL(Gl�j
la WATER ZONES (depth): cj
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.
Topogra c/Land setting
❑Ridge ope DValley ❑Flat
(check appropriate box)
N3s�a36. d e Coo NN-.,.`200
(degrees/minutes/seconds) C� V , 2, 3-
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
DEPTH
From To
or WeightiFt. Material
l3. GROU:k Depth? Material ,/
From (J To V J F LAG
_'.- To 1� Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
I . SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
TAM
Material
in.
in.
Formation Description
-c
—c
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR CTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE ELL OWNER
Vep
GNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 16361Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 2 6 4 8 4
North Carolina - Department of Environment and Natural Resourcesur- Division of 'Water Quality Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
� (print) bf V1�tyl�r�� 5'E� t, [L�\ly 1 t,, (I
\YELL CONTRACTOR COMPANY NAME F�?p A `� c3r ,l �(y (Li I y..�-t\,`\1�ty PHONE
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCATI N:
N arest Town. Mg County
3o3 w $�r
(Street Name, Numbers, Coi mmnity, Subdivision, Lot No., Zip Code)
3. OWNER: 1e,R, 6 D 14A I t
Address toEsirct 'Fb(K
(Streeto RouteNo.)
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH( 51
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1)V
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in aceordan e,j�r{h ISA NCAC 2C.01I8. ,�l / ////,,,�. ``//
9. YIELD (gpm): L/ METHOD OFTES"I�ri`•W TClt/l�
ID. WATER ZONES (depth): p2�1
Topogra i /Land setting
❑Ridge @Slope ❑Valley ❑Flat
(check appropriate
e,box) }
�3 Latitude/longitude
ti`'f L)./Sa�ad`S7—
(degrees/minutes/seconds) etJ 3�s
Latitude/longitude source:OGPSOTopographic lap
(check box)
DEPTH DRILLING LOG
From To Formation Description
l I. DISINFECTION: Type
12. CASING:
Depth .p Diameter
From 0 To /tl O Ft.
From To Ft.
From To Ft.
13. GROU Depth
From To
From To
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount r%
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
Material
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.
nc
O
T
16, REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CIjUCTION SJ'ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL / DAT
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mai Sf[y'ice\ ,r Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. JJ, �IVV VVOitiR.EV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prin
t)__ I Ad o L� CERTIFICATIONS 2`, /bn
WELL. CONTRACTOR COMPANY NAME _iLe'&`,e_ Gros N%, � 4-40w PHONE II 6 iS-300
STATE WELL CONSTRUCTION PERMIT# J L 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 2 Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection ❑ Other O If Other, List Use
2. WELL LOCATION'/_1`
Nearest Town: /�s.1r1 (/^1
County B&nc6mbe
(Street Name, Numbers, Community, Subdivision, Lot No., Lip Code)
3.OWNER: /*0/ Ton'o y0
Address 7g13 Dint Citek-1
Oef(Street or Route No.) 2'875Z
(:ity or Town State Zip Code
CS5)- "In-'7
Area code- Phone number
4. DATE DRILLED 44D -0
5. TOTAL DEPTH: '7 06
C. DOES V1E1.1. REPLACE EX!STING WELL?
tifitAed
YES (,_I Lu) e
7. STATIC WATER LEVEL Below Top of Casing: /2-0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface`
'Top of casing terminated at/or below land surface requires a
variance in accordant with 15A NCAC 2C .0118.
9. YIELD (gpm): '/J2_ METHO,D OF TEST 2 MD't('
10. WATER ZONES (depth): 305 - y0$'
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.
Topogra ic/Land setting
❑Ridge lope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
01 " 7o'
7 l' - '05' Gra.,(
11
12
DISINFECTION: Type
CASING:
Depth Diameter
From 0 To 7 0 Ft. 61l
From To Ft.
From
13. GROUT:
From 0
To Ft.
Depth
To 2.0 Ft.
From To
14. SCREEN: Depth
From To
From To
15
Amount
Wall Thickness
or Weight/Ft. Material
pvc-
Material
Grout'
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Method
10)
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
JUN 06 2085
CO
N
C>
w
16. REMARKS:
1 DO IIEREE3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONST C ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a4 1—a 0-o--- gala
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 Na 1Resources (- IDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) VIr 'J•NL�SAe.N/.! CERTIFICATION #2•/O-f
WELL CONTRACTOR COMPANY NAMEoft€JI ei,/D.S1 PI/e€Z f une PHONE #IBA %yB-3 // O
STATE WELL CONSTRUCTION PERMIT# I j OZ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
0 0
1. WELL USE (Check Applicable Box): Residential 12{ Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection D Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town: Lamiet
County 3000/nit
(Street Name, Numbers, Community,✓Subbdivision, Lot No., Zip Code)
3. OWNER: bra d //46./_- (degrees/minutes/seconds)
Address { / Leh ( CMf (arc Latitude/longitude source:OGPSOTopographic map
/j' (Street or Route No.) (check box)
Yl� het/6 {� t NG 2 $ Q 05 DEPTH DRILLING LOG
City or Town Slate Zip Code From To Form mtiin Description
(8Z)- 5-45 -15/1p' 3.5'
Area code- Phone number , 361 •/D0,5' �fC(/Ifi-C
4. DATE DRILLED iinz {0
5. TOTAL DEPTH: /0i2S
1Y)I:s• tan:I I REPLACE EXIS r:NNG WELL? YES Li NO t
7. STATIC WATER LEVEL Below Top of Casing: 80 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS { FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accord qce with ISA NCAC 2C .0118.
9. YIELD (gpm): '/4 METHOD Of TEST �%�
10. WATER ZONES (depth): 305 r' VO3 '
11. DISINFECTION: Type /4-fll Amount
12. CASING: Wall Thickness
Depth Diamfter or Weight/Ft. Material
From 0 To 3.5 Ft. lit PV C
From To Ft.
From_ To Ft.
13. GROUT: Depth
From Q To 2-0 Ft
From To Ft.
14. SC'REEN: Depth Diameter
From To Ft. in.
Ft. in.
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Material
Slot Size
in.
in.
Material
Material
Topographic/Land setting
[Ridge It7thlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
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
C
ca
CC -t
- 'c .0
1 zrn
co
• n
C.,
CO
JUN 06
16.REMARKS:
1 DO HERE CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTR CT ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

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: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
326124
1. WELL USE (Check Applicable Box): ® Residential 0 Municipal ❑ Industrial ❑ 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: ASHEVILLE County: BUNC
795 OLD HWY. #20 DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER SHERRY SCHWARTZ
Address 795 OLD HWY. #20
(Street or Route No.)
ASHEVILLE NC
City or Town State Zip Code
4. DATE DRILLED 04/17/06
5. TOTAL DEPTH 605
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 30 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
"Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 6 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 16.5
13. CASING:
Depth
From 0 To
From To
From T
14. GROUT:
Depth
From 0 To 20
From To,
15. SCREEN:
Depth
From To
From To
From To
16. SAND?GRAVEL
Depth
From To
From To
17. REMARKS:
To
Wall Thickness
Diameter or Weight/Ft. Material
40 Ft. 6-1/4" SDR.21 PVC
Ft.
Ft.
Material Method
Ft. QUILKRETE POURED
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.__
Ft. in. in._
PACK:
Size Material
Ft.
Ft.
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)
I-26 TO ASHEVILLE FROM COLUMBUS. TAKE I-40 W. TO
EXIT #44. LEFT ON PATTON RD. LEFT ON HWY. #63 a
INGLES. RT. ON MT. CARMEL RD. a INGLES. BEAR LEFT (al
FORKS ONTO OLD HWY. #20. 2 MILES ON RT.
O
crn
o,
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.
? �GNAT[IRE OF PERSON WELL DATE
Submit opgtal to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99
JUN

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Dcpanmcnt or Environment and Natural Rcxnuccc- Division of Water Quality
WELL CONTRACTOR CERTIFICATION it & t 4" D
1. WELL CONTRACTOR:
i•JA.-1eh 0_04C A3€,1I
Well Contractor (Individual) Name
R.e.tA,ben Q.a1 d,ltet t br; \ r,A5 f Inc .
Well Contractor Company Name
STREET ADDRESS '3J) t tu) ; Ces+2,r Novi
Ashev\tle rvC
City or Town State
( •)- %64--35%I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #{if applicable)
asgo6
Zip Code
STATE WELL PERMIT#(a applicade)
DWG) or OTHER PERMIT Rif appkcab e)
WELL USE (Check Applicable ): Residential Water Supply (tj
DATE DRILLED "I 5 /0 6
TIME COMPLETED L t'- S q AM (V PM EI
3. WELL LOCATION:nyT��4/\C p
CRY: Li(1 AJS IS- R COUNTY aV,con`Bg
GR-ao1L5 Co, .OAC
(Slreel Nang. Numbers. Community, Sulam Lot No.. Parcel. Zip Code)
TOPOGRAPHIC !LANp SETTING:
°Slope OVatey C&'Fiat °Ridge °Other
(cheat rgpopriate bow)
LATITUDE _a_ s 3 4 - 3 as
LONGITUDE is a
source: PS O
Maybe in depees.
minutes. seconds or
in a decimal format
Latitude/longitude
Topographic map
(location of wet must be shown on a USGS topo map and
attached to this loan 7egt using GPS)
I. WELL OWNER
OWNER'S NAME to NI 10 tea O 04
STREET ADDRESS 'rL
3 t-(L(Z'I e tC P L P
AS 16\fk.L_LE roc tt 8-g%t Co
City or Thom State Zip Code
(B3-%)- a'3o— )064—
Area code - Phone number
. WELL DETAILS:
aos
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOo
ig
c. WATER LEVEL Beton Top d Casing: b FT.
(Use -+- if Above Jop d Casing)
d. TOP OF CASING 1S rt1 FT. Above Land Surface'
'Top d casing temfled aUor below Next surface may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD(gpm): 3o METHOD OF TEST 2LG-�L�
f. DISINFECTION: Type
9
say
D Amount
WATER ZONES (depth)) /
From 14-1 To 14i(
From To
From To
From To
From To
From To
6. CASING: y Thickness/gh�
DTolnp t) Ft. i7i�r�tgler SDngh_ % Met
From `/ (pri t i0
From To Ft.
From To Ft.
7. GROUT: Depth rI Material
From 3 d l-+T> To Ft Mts0T.
From To FI.
From To Ft.
Method
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 To FI.
From To Ft.
From To Ft.
10. DRILLING LOG
Frgm ' To '
1 - 9O
-to 14-7'
t4-'(/- 14g/
t4g'- ao5 '
11. REMARKS:
Size Material
Formation Description_
O\( K.6)ttae I�
C.9 0-a
cites! tat 3t, CiY,*T
a as...) \--fis
E_
r
Q
100 HEREBY CERTIFY THAT MLS WELL WAS CONSTRUCTED el ACCORDANCE Wan
ISA NCAC 2C WELL CONSTRUCTOR STANDARDS AND MAT A COPY OF TICS
RECORD HAS EN PROVOED 10 THE WELL OWNER
1/7/oG
SIGNATURE OF RTIFIED WELL CONTRACTOR DATE
tt-L,L6 NA$14
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit the original to the Division of Water Quality within 30 days. Attn: Intonation MgL,
517 Mall Service Center— Raleigh. NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-ta
Rev. 7I05

RESIDENTIAL \FELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 1/
1. WELL CONTRACTOR:
Lev- Q_
Well Contractor (Individual) Name
Re—LL,beh Qs.\&wetl Or;\l;nb 1 Inc.
Well Contractor Company Name
STREET ADDRESS 351 teu) 'Lit c25f'e r Ww�
Nche\AtIt NC aglie o6
City or Tarn State Zip Code
( 391"» 1,54 -35S 1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Kit applicable)
STATE WELL PERMITe(a applicable)
DWQ or OTHER PERMIT e(d applicable)
WELL USE (Check Appli ble B xg Residenliat Water Supply u
DATE DRILLED % ( 0
TIME COMPLETED 4 > O Amp PM 1 /
3. WELL LOCATION: //l�
CITY: it-6 b� (+ COUNTY JIs1 CO/nleE
1t d4f-& PA .l /W0146 pVwDa+ r be- -
(Street Name. Nernbers.Communhy. Suberx.ion, Lot No, Puce. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVafey �F ut ['Ridge ['Other
(check appropriale box)
LATITUDE 2_ 5 i .1 `
LONGITUDE ( e7. 3-1, 154
Latitude)longitude source: pGGPS ['Topographic map
(bcalon of we/ must be shown on a USGS fopo map end
attached fo this form I not usig GPS)
4. WELL OWNER +I+
OWNER'S NAME V30t41•1 i4A NSSA
STREET ADDRESS-7)09 SCAt i fl11(26(L- Gr
AMS6 PS C— a%lei 4-
City or Town Stale Zip Code
( wa-L t54— S )54
May be in degrees.
minutes. seconds or
in a deeinul Amite
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Q b 5
b. DOES WELL REPLACE EXISTING WELL? YES 0
No
1 c. WATER LEVEL Below Too et Casing. D D Ff.
(Use- it Above Top el Casing) j
d. TOP OF CASING 15 +— FT. Above Land Sudace•
-Top al casi,g terminated at/or Debt/land surlace may require
a variance i, accordance with 75A NCAC 2C .0118.
e. YIELD (gpm): / C7 METHOD OF TEST F-+G — Ant'
2
4-
3
33t) 1
1. DISINFECTION: Type lila (,mj6 Amount O (-'Z •
g. WATER ZONES (depth)
From lCl To t00 From To
From r3o To 1_ From
From To From
6. CASING:
,AI Depth Qw eler JWe{a
From t)(
1 To it Ft
(0 05r�,L(
To
To
From To F1
From To F1
Thickness/
aleriarel
7. GROUT: Depth �Y Material Method
From S. To Zo FI. C.. /v1/46 AT ppo 2a b
From To Ft.
From To FI.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
From To
From
Form
To
To
10. DRILLING LOG
Diameter Sbl Size
Ft.
Ft
Ft
Ft.
F1.
F1.
in.
in.
in.
in.
in.
in.
Material
Size Material
From / To f Formation Description
5 O a Rom'✓P-Og .J
�5I et ' GILA N\ >✓
OLC(!' too
too '-%la'
v30'- 13' '
- a_d51
I1. REMARKS:
CfLg•f Lee - 1 O
(..
c(26Jlc - ao
C,2AtJsTC+
C
>n,
trot/ERERY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ADDORDANCE WrnT
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED 10 THE WELL OWNER
Ra :k. CACCLQUe4 7 °
SIGNATURECERTIFIED WELL CONTRACTOR DATE
S Cc -,LA. 6 t% $St1
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: information Mgt.,
1617 Mali Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fenn GW-la
Rev. 7/05

tJ
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resource;- Uivi;ion of Water Quality
WELL CONTRACTOR CERTIFICATION tl
at4-o
1. WELL CONTRACTOR:
i.e u ere vt 04CLoCp
Well Contractor (Individual) Name
frLLben PO Coto (3r;)t;n5 (\ C
Well Contractor Company Name
STREET ADDRESS 3SI tQ-lt) -et Ce S1tr 1-1141
shev;tft r'.0 erg go 6
City or Teem Stale Zip Cafe
(3K)- 154--35$I
Area cafe- Phone number
2. WELL INFORMATION:
SITE WELL ID a(II applicable)
STATE WELL PERMITSIir applicable)
DWQ or OTHER PERMIT a(il applicable) J
WELL USE (Check ApplicableplB/q+�): rR_esidential Water Supply [Ld
DATE DRILLED `..t/ I g / O l7
TIME COMPLETED I (a. S a AM O PM a/
3. WELL LOCATION: ,�{{77"�
CITY: vs'a Al -X 0COUNTY 1..)°,43C-It-rnitk
gyLag-s C541:. LOA O
(Street Name. Numbers. Community, Subdkvon. Lit No.. Parcel. Zip Code)
TOPOGRAPHIC / �LApJ6 SETTING:
°Slope °Valley Q'Flal °Ridge 0Other
(check appropriate boa) ,,
LATITUDE yT 534- • nb
^ LONGITUDE t 4OL• 5 6`T
May be in degrees.
minutes. seconds or
in a decimal runner
Latitude/longitude source: QGPS °Topographic map
(location o7 we/ must be shown on a USGS lopo map end
attached to tha form not usirg GPS)
4. WELL OWNER jel
'�`/ r� `
OWNER'S NAME A eivki /L b J1'
STREET ADDRESS 1.0 I fl,o iG 6
g 3i<� fsc-' ly�lag
City or Town Stale Zip Code
(1as)- cne-1— -Dal
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
Nod
c. WATER LEVEL Below Top et Casing. IA) t% FT.
(Use'•' if Above Toed Casing)
d. TOP OF CASING IS /l FT. Above Land Surface
'Top of using to me aced at/or below Lad surface may require
a variance inlagl/yarrda+ce wdh 15A NCAC 2C .01118. /� 'n(�
e. YIELD(gpm): 7 I ✓ METHOD OF TEST 'tab' f\11
16-7
/. DISINFECTION: Type Amount
g. WATER ZONES (depth)
From To From
Firm To From
Fran To From
t
To
To
To
6. CASING: Thickness/
/ORplh Diameter Weighl Material
From G /To FI.
From To Ft
From To Ft.
7. GROUT: D[plh Material
From L/`yTV Ft
From To Ft
From To Ft
Method
8. SCREEN: Depth Diameter Slot Size Material
From To FI. in. in.
Fran To Ftin. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From . To FI.
From To Fl.
1100.rr1DRILLING LOG
Rowe To rmation Descripran
C
>is
rrs
rn
N = -c
0
r
11. REMARKs:
Ei Wt1-Lif-D t J ttL 1 -
Fe—e-vvti- 'a.a S I ba 5 -'
too "eerily CERTIFY 114AT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRN
L SA .CAC lC WELL CONSTRUCTON STANDARDS AND TIAT A COPY OF THIS
RECORD HAS B N PROVIOED TO ME WELL OWNER
QPItiCiAja
7/1
SIGNATURE oFt81ERT)FIED WELL CONTRACTOR DATE
(J t t-4 € r)--AS4
PRINTED NAME OF PERSON CONSTRUCTING 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

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of !Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
a14-D
1. WELL CONTRACTOR:
�e L)_ ate v1 CtA-kc LAi o
Well Contractor (Individual) Name
REAL,ben L\dw€it (Jr; 1;nc(nc..
Well Contractor Company Name
STREET ADDRESS 3 J I fku3 C254'-.r )441
%sheNAlle NC agg06
City or Town State Zip Code
(10-g>- a54-35isI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID H(il applicable)
STATE WELL PERMIT/(n applicable)
DWQ or OTHER PERMIT //Of applicable)
WELL USE (Check Appii ble or). Residential Water Supply 7
DATE DRILLED /' ((O 0 G
TIME COMPLETED /-- S° Am PMp"
3. WELL LOCATION: t
CITY: Ask J Lt,..lr{ COUNTY 6vrace-era
&am--b-ILA J1 \, S-tt. iesitN J G
(Street Name. Numbers, Community. Subdrc.aion. tot No., Parcet, Zip Code)
TOPOGRAPHIC /LA/p. SETTING:
❑Slope OValley L9Flat °Ridge OOlher
(cherJk appropriate box)
LATITUDE 3 5 3 S - 04 5
LONGITUDE a 3-D6 q1
May he in dcpees,
minutes. seconds or
in a decimal format
Latitude/longitude source: QCrYS °Topographic map
(bcetbn of we/ must be shown on a USGS tope map end
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME (n`Lzv t r✓�fR
c'C4^I V/c;l
STREET ADDRESS 16 4- O q-» 'e-- ('i 11.-.L- E) -
N SR 6-/\1-1. t- ra C- aCii I o CO
City or Town Slate Zip Code
t�a.5()_ 2,55-- %Vol
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
tiD5
b. DOES WELL REPLACE EXISTING WELL? YES O NO'
c. WATER LEVEL Below Top d Casing' 1- FT.
(Use'+ if Above Tt d Casing)
d. TOP OF CASING IS �}(, FT. Above Land Surface'
'Top of casitg to mu aced aVor belon land surface may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gpm): 3 0 METHOD OF TEST 11G -'e Pk `
f. DISINFECTION: Type ill /b Amount
g. WATER ZONES (depth)
epth)
From ill To 11Q From To
To F, pro To
To Frorn To
From
From
6. CASING:AA
-i
Fran
From
From
Depth To e C
To
To
7. GROUT:,�(t Depth
From 1 To aP
O
Thickness/
pt Teter Wei
ghhtt / Mpa�ITenal
Ft. b g SDt g...9( J,v
Ft
Ft
Material Method
Ft. O_AnnAtt-IJT O n u ✓g.
From To FI
From To FI
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To FI. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Fri To a f
fin` ^ 1 1 1 1
�IV- 11 -
11ay- 18S'
11. REMARKS:
Ft.
Ft
Ft.
Size Material
Formation Descript p
e,l
L`- -
n�1C.cS 'S b &ern
G -A . rClJ
t_
fV
CO
0
czr.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WTI
ISA NCAC ]C WELLCONSTRtrCnoH STANDARDS AND DOT A COPY OF THIS
RECORD HAS BrEEN PROVIDED TO THE WELL OWNER�����d t
SIGNATURE OF CERTIFIED WELL CONTRACTOR DA E
PRINTED NAME OF PERSON CONSTRUCTING 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-1a
Rev. 7/05
CjcL

RESIDENTIAL WELL coNSTi1UCT1oN From)
North Carolina Department of Environment and Nanual Reapurcec- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11
at4-o
1. WELL CONTRACTOR:
q-e-v-Vtean Q o~..l&1/4.0ct I
Well Contractor (Individual) Name
Q,e,u,ben Lk\&we.tl Dr;\t;I,5 t Inc.
Well Contractor Company Name
STREET ADDRESS 351 t4u3 Vet ceSLar '"IW .
Pshevitl2 Nc ag806
City or Town State Zip Code
cfg>• 1.54-35$I
Area code- Phone number
2. WELL INFORMATION:
SRE WELL ID fair applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT aril applicable)
WELL USE (Check Applicable Box): Residential Water Supply c)/
DATE DRILLED 6/( /b tO
TIME COMPLETED \ 0 c AM V PM
3. WELL LOCATION: (�
CITY: gARP A20SVILit COUNTY 6°N L-bdY\e
%uc AQ NI..L. %&TA-vt, S
(Sheet Name. Numbers. Community. Subdmarm. Lot No.. Parcel. Zrp Code}
TOPOGRAPHIC / LAND SETTING'
lasknpe OVaney ❑Flat ORidge OOther
(check appropriate box)
LATITUDE j �15 46 .0a1
o LONGITUDE% , a8 •569
May Fe in depots.
minute. seconds or
in a decimal Format
Latitude/longitude source: ‘2LiPS OTopographic map
(bcatbn of well must be shown on a USGS fopo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
rnMk- efica.uS.0l-‘"
(Bays }. -Ala- g5
STREET ADDRESS 1 b L/t Nil-- Cet-tit a
AS146'tlt-t€ NC. at& 03
City Of Town Stale Zip Cafe
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
105
b. DOES WELL REPLACE EXISTING WELL?( 4
c. WATER LEVEL Below Top cf Casing a
(Use -: d Above Top of Casing)
d. TOP OF CASING IS
YES ❑
a
NO(
FT.
FT. Above Land Surface'
-Top d casing %e anated aW beige land surface may require
a variance in accordance with 15A NCAC 2C .0118. ff p
e. YIELD (gpm): b` METHOD OF TEST tt6 - T (1-
f.
0
DISINFECTION: Type VITA Re/ Amount
WATER ZONES (depth)
From 3 to To 3 at
From To
Firm To
6. CASING:
I Depth
From g To 30
From To
From To
FI
Ft
Ft.
7. GROUT: Depth
From i To aiii° Ft.
From To Ft.
From Tv FI.
8. SCREEN: Depth
From To FI. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From y To i
— aS
a5- 3ao '
3eLo nt-sal'
3ait- 7os'
11. REMARKS:
Ft.
FI.
Ft.
0
From To
From To
From To
Jeff
Thickness/
Material
Lwmerrr
Method
010•'a213 6
Diameter Slot Size Material
Size Material
Fo mation Description
CoaAw\-nzs-
aAc�rT
er n
LUOJ
0
0
•
co r 11-11
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WRN
ISA *.CAC 2C WELL CONSTRUCT**. STANDARDS AND THAT A COPY OF THIS
RECORD NAS BEEN PROVIDED TO THE WELL OWNER
eacLudi 06
SIGNATURE OF CERTIFIED WELL CONTRACTOR
�iLtt� L4kS
PRINTED NAME OF PERSO 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

RESIDENTIA L WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Rcarurcec- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON IS a (Y D
1. WELL CONTRACTOR:
f,e-,..levt Q_D-AcLuie,1l
Web Contractor (Individual) Name
P.e_u.bQn Qc \&OCAt Dr; \1;A t Inc.
Well Contractor Company Name 1 - y
STREET ADDRESS 35I tieLa t Ce-S e
%shevltle NC
ag$0G
City a Town Stale Zip Code
Iin)_ a64--35`sI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID RR applicable)
STATE WELL PERMIT#(d appbcable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable 8/ox):) Residential Water Supply [d
qn7/ 01,0
TIME COMPLETED a._ 30 AM0 PM
3. WELL LOCATION:
DATE DRILLED
CITY:
COUNTY VVfJ co/Nt66
\ o t 3 e 2 (2 (LJn1 CRC 6 C
(Sbaet Name. Numbers. Conmunrty. Subdrwnon, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAN SETTING:
❑Slope OValley anal ORidge OOther
(check appropriate box)
LATITUDE yT 5 ag. y 3g
LONGITUDE 3 a A6
May be in dopers.
minutes. second,a
in a decimal format
Latitude/longitude source: 13LTvS ❑Topographic map
Oration of wel must be shown on a USGS lopo map end
attached to this form 1 not usi-g GPS)
4. WELL OWNER
1r1` ((� p ,� C
OWNER'S NAME Q/ °PO IL-`T 4 rU Oi -Z611
STREET ADDRESS I�t0 CA1 &1-DTCg \Atka/
AStibt(,t_>—e rsc._ a o�
City or Town t State. Zip Code
- 7 0ci'%
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: So 5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (�
c. WATER LEVEL Below Top of Casing. 1.0 FT_
(Use...L Casing)
d. TOP OF CASINGNG 1 IS FT. Above Land Surface'
'Top 01 casing terminated ata below land surface may require
a variance in accudance with 15A NCAC 2C .01118.
e. YIELD(gpm): METHOD OF TEST RIG"'
DISINFECTION: Type b-at i c 0 Amount
g. WATER ZONES ideptIll
From 178 To )1
Ernm 44 ?) To 4a4-
Frem To
From To
From To
From To
6. CASING:
,A1 Depths arh
From
1 To O 5 FI.
From To FI
From To Ft.
7. GROUTA:{ Depth .�
From 1 To r Ft.
From t� To FI.
From To Ft.
Cr
Thickness/
Materialiaay,p
CA or 1
Method
et L.tQ t
8. SCREEN: Depth Diameter Slot Size
From To FI. in. in.
From To Ftin. in.
From To
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
Frog - jt) .0 jf 0
Ss'- (7b'
libr_
h lam- 4a3/
4-a.3' - 4 a -at
5o5/
II. REMARKS:
Ft. in. in.
Ft.
Ft.
Ft.
Material
Size Material
Formation Description
0 \T$tzU-v1bt e3
-(> Irv+ c6 ?Z G ern
cFzsV� — —i G Pm
Cb:LA e-'C .
r—
IV
0
I DO HEREBY CERTIFY THAT DRS WELL WAS CONSmut Ito N ACCORDANCE WTI
ISA NCAC 2C WELL CONSTALICTON STANDARDS AND DIRT A COPY OF TMS
RECORD HAS BEEN PROVIDED TO DIE WELL OWNER
Ra. Q 5416o i
SIGNATURE OF CERTIFIED WELL CONTRAC R DATE
e)11-,LL6 NA
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
0
-
r

WELL CONSTRUCTION RECORD 6 6 4
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
wax. cONTRAcrOR ONDIVWUAL) rum / i to crittincsT1oN s 2 7 g g ,
WELL CONTRACTOR COMPANY N w tE e w ajt!r (at/ / 7 Axes ptHONE s gin) 6V4'-ono
STATE WELL CONSTRUCTION PZSMTrs ASSOQATID WQ nsnrr#
(if applicable) (ifapplicable)
1. WELL USE (Check Applicable Box): Residential InfuoicipaIPublic D Industrial O Agricuhuml O
Monitoring D Recovery D Heat Pump Water Injection O Other D If Other, List Use
2. WELL LOCA N:
Nearest ?own: T:AV4RVtU.1✓ county $UrMEAPa
[)UL#' GE2P17
(SeeaNanx,N®bem Community, Sobdtrielm, lot No, nit Clods)
3. 0
Address air ot.D
(sue a Rote No.)
VISAVa9111the, NL zinc Caper Town Susi
Area cede- Phsoe amber
4. DATE DRILLED I 1 ^ 2'2,-010
5. TOTAL DEPTH: 3 ZS
6. DOES WELL REPLACE EXISTING WELL? YES NO _0
7. STATIC WATER LEVEL Below Top of Casing
(Use sr (AboveTap dCasg)
S. TOP OF CASING IS / 8 FT. Above Land Surface*
'Tap dwho; terattar below irdsarraee replan a
variance le with ISANCAC 2C .0112.
9. YIELD (Aron): (00 METHOD OF TESTZI MED
10. WATER ZONES (depth):
21"31131
Topograghicaamd setting
DRidge V of ope °Valley EIP Stt
(star apptopthde Mal
Latiwdellongitide of weft Location
( )
Latitude/toogitude source:l GPSOTopograpbic map
(eliedc tee)
DEFT$ DART ING LOG
From To Formation Description
11. DISINFECTION: Type CL.1-1-
12. CASING:
Amount 10 o , Show direction and distance in miles from at least
Wall Thickness two Sate Roads or County Roads. Include the mad
Depth Dieu err Weigbt/Ft on numbers and commmad names.
From QC To go Ft !n'/4 221 iNL V.I.-11. 7-182-
From To Ft
From_ To Ft `, I 3 JCS 1711 F t,3
13. P om. ': , Tom. Material Ft �Di\X y 1 /k2r� '�, IP P
'r'•y,`••',`FroTo Ft t) aZ c ✓`�.
14. SCREEN. Depth Diameter Mot Size Material
From (5 To Ftin. in.
From To Ft. in. in.
15. SAND/GRAVELPACK:
� Depth Size Material
From ( To Ft.
From To Ft.
16. REMARKS:
oFF =` Z (r.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST IP,t•P•, AND THAT ACOPY OFTHIS RECORD HAS BEEN PROVIDED TOTHE WELL motet
Qic ohiii— 7' //tt D (p
-- -- OF PERSON CONSTRUCIINGTEEWELL DATE
Subndtthe original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 41 6 6 3
North Carolina - Department of Environment and
�Natural R - Division of Water Q�ualitity-- Groundwater Section ,r
WELL CONTRACTOR (INDIVIDUAL) Epa_ nC1�nip Iys � resarrnoCATION. z 787
WELT. CONTRACTOR COMPANY w �e a us �4 J�� // Nolte s & ct1 b 5-ft8CD
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT*
(if applicable)
(Rfapplieable)
1. WELL USE (Check Applicable Box): Residential lr MiScipaVPublic 0 indnsrial 0 Agricultural 0
Monitoring El Recovery t7 Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCA O :
Nearest TOWIC WEAVE-17 V ILLE.County/271 AN( InMff
1}ULA SPILI l.11.$h.
(SheetName.Nambem• Community, Sabthele a, a 2tp Cede)
\ AILS
3 Address M L a LI.o •
or Route NO
1n41%AVetVILLE, NC- Zs3181
CayatTown Sense Tap Code
Ateacode. Phone meber
4. DATE DRILLED 4-Z�.Old
5. TOTAL DEPTH-IPS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO la-
7. STATIC WATER LEVEL Below Top of Casins / / Fr.
(Use 'Ws if Above Top of Cathie
8. TOP OF CASING IS / S FT. Above Land Sur6ee•
'Top ofeaelng tembeated atter below leadsarfee rgs4eea
mitten to eemrdaneewWt ISA NCAC 2C .8118.
9. YIELD {gpm): I5 METHOD OF F TEST TIMF�
10. WATER ZONES (depth):
Topographic/Land setting
Midge OSlope Malley li3Fiat
(chhe k appreprielebox)
Latitude/longitude of well location
6iesteathnirattethereestO
Latitude/longitude smac a:OGPSOTopographic map
Nheekbo:)
DRILLING LOG
From To Formation Description
11. DISINFECTION: Type r1»
12. CASING:
FromDepth
_To Ft 0
From_____ To Et,
Front___ To Ft.
13. GROUT: Depth Material
To 30 FtCIiNael IP'
TFmm_ To Ft
14. SCREEN Depth Dianna Slot Size Material
From P To Ft. --in. in.
From, To Ft_in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From (/ To Ft
From / To Ft
Amount !(i02_
Wall Thielmess
g�Wd
Wr-
/ LOCATION SKETC$
Show erection and distance in units from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT TEO WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
CONSTRUCTION STANDARpS 2 DTHAT A COPY OF s t RECORD HAS BEEN PROVIDED TO THE WELL OWNER
WrV
)1-zz-ob
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Caster -Raleigh, NC
27699-1636Phoae No. [phone], within 30 days. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 341665
North Carolina- Department of Environment and Natural Resoo7mces - Division of Water Quality - Groundwater Section WELL COMACTOH(INDIYWDUAL)NAME , / n t fl{IDQv's Z. CEMMICATION 0 z 7 O Q
Y.;
s
WELL -CONTRACTOR COMPANY .... _ to a .• /' , u a ihal) b Y9'-0r/&o
STATE WELL CONSTRUCTION PE*MIID ASSOCIATED WQ PERM*
elfappliesbie) iifapplicable)
1 WELL USE ((heck Applicable Bali Reai l MtmicipaVPublc 0 Industrial 0 Agricultural 0
Monitoring Recovery 0 Heat Pump Water Injection Other 0 IfOther,List Use
2. WELL LOCATION:
Nearest Town: F&tZNt avJ County a
(SneetN allot mbea.Camtaaoiry, SIM MS% Lot Tip Code)
3. OWNER: TtMMV Cs...oWnE.F_
Address
Ppw4? llevd, NL 28i730
CXayorTown Side 2q Cade
Ann oode-Mow =mbar
4. DATE DRILLED II-1461--
5. TOTAL DEPTHI i05
6. DOES WELL REPLACE EXISTING WELL? YES O NO E
7. STATIC WATER LEVEL Below Top of Casing SET.
., (User if Above Tang Casing)
S.TOP OF CASING IS / 8 FT. Above Land Surface
*Top amass tendaated atlas Slew bad surface spurna
vyiume to acoontratit Mgt 15A NCAC 2C .911S
9. YIELD (gpra it 2,. METHOD OF TESTTI).4EA
10. WATER ZONES (depth):
Topographic/Land setting
ORidge alley DFlat
(chedcrppropriatebax)
Latitude/longitude ofwclllocation
()
Latitude/longitude sotuce:DGPSOTopograpbic map
(ahedcbea)
DEETS DRILLING LOG
From To Formation Description
11. DISINFECTION: Type (LA+
12. CASING:
From (/) Tom/00
From_ To
Fromm To
13. GROUT Depth
Front_ To_
From__ To
14. SCREEN Depth
From _ To
From To
15. SAND/GRAVELPAM:
Ft. (v'/4
Ft
Ft.
Amount I D07
Wall Thickness
or Wdgbt/Ft.
��T71Z: ZI
M`• P Ft. ('NEA
Ft
Diameter Slat Size Material
Ft._in in.
Depth Size Material
From To Ft _
From._To 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.
F-LaV . 2434,1
35a 30.31 0
14/Li p 82? 23. BZS
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH 15ANCAC 2C, WELL
CONSTRUCTION ST a ' . THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
OF P CONSTRUCTING THE WELL DATE
Submit the orlglnat to the Division of Water Quality, Groundwater Section, 1636 Mail Service Cater -Raldgb, NC
27699-1636 Those No. [phone], within 30 days GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 341666
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION 0 Z 7 S V
sow s /10) 6VI-ono
vim. coma/wrote (Ransoms) NAME
WELL CONTRACTOR COMPANYN ... _ ee - .• i' -
STATE WELT, CONSTRUCTION PERROT, ASSOCIATEDWQ rH Mru
(if applicable) cdapplieable)
1. WELL USE (Check Applicable Boa): Reuel 0--Municipal/Public ❑ industrial O Agriculhaal 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
z Nearest �. — . Ll E ails .bkli
port . - `y' B�DG
(SueetName,Nw�eo, Comte Snbdwbiao, LrNt. Z4Q Code)
3.OWNER C fl- e. ?l4Mg•o'.
Address
(Suuta Rose No.)
2.P-%O9
(Say or Town Sloe Tip Code
L� _
4. DATE RWLED //' / D (p
5. TOTAL DEPTH: 225
6. DOES WELL REPLACEEXiSTING WELL? YES NO @-
7. STATIC WATER LEVEL Below Top of Casing:
(User if Above TopatCese�
& TOP OF CASING IS i �3 FT. Above Land Surfaces
atop of easing tnutdYd alter Lehr Ind suttees requires
wow* Y aeconkaet_plat 15A NCAC 2C .911t
9. YIELD (gpm): _(¢ METHOD OF TEStT1 MAD
10. WATER ZONES (depth):
Topograpbic/Land setting
Midge (Mope Malley °Flat
( N� b
Latimde/longitdde of well location
(dam)
Latitude/1=0We somce:OGPSOTopographic map
(shedkbos)
DRILLING LOG
Fotw:tion Descript19n
QII3
i FrTo
11. DISINFECTION: Type PEA- Amount //) n Z.
12. CASING: Wan Thiamess
13. GROUT: Depth Matetiai
"Watt Me
From To 25 Ft
From_ To Ft
Front__ To Ft
Fmmt .TozQFt CrN 2
From�_TO Ft
14. SCREEN:r� Depth Diameter Slot & Material
From / To Ft in.
From To Ft in. in
15. SAND/GRAVELPACK:
Depth Size Material
From_ To Ft
From To Ft
LOCATION SKETCH
Show direction and distance in miles front at least
two State Roads or County Roads. Include the load
numbers and common road names.
. SV. — z 1o22.- Ft•
N. 35° th• 38%
VJ v 8 Z° 26 • Di 4.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wf1H 15ANCAC 2C, WELL
CONSTRUCTION STANDARBS ATIDTHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
eelO,L? lI 9 D{o
OF112120N c0NSTRUCTINGTHEWEI.L DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 ?Mae Na. (919) 733-32221, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
LI
Quality
North Carolina -D tofEnvironmentandNaturalRe -Division of Water y
WELL CoNTRACTO*(ND1VIDUAL) NAME / It to D" GBAIIFICATton a 7 S ti' •
WELL CONTRACTOR COMPANY N LO e e (N /4 hr WV/ ' mpTIONE S fhm t; `✓g-o 0
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ Ply
fiifapplicable) (ifapplicable)
1. WELL USE (Check Applicable Box): Residential cr MmicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 IfOther, List Use
2. WELL LOCATION:
Nearest Town; k A LV 1 U.ECounty/3U NLWMPF
la) Alfs i'ph1=
(SdeetNeaa,Nambeq Cmeoeraj, Sob&virioo, Lot Na, r4 Coda)
3. OWNER R.O N EC I ' 1 .L.
Address _E?P to pP ,ir ba
(SaeetorRone No.)
W EA yg V l LE, N(_ 2.5'1 t3-1
Caper Tam Sow Tip Code
C—�
Meacods Thaw somber
4. DATE DRILLED FL— 1- 9 to
5. TOTAL DEPTW E
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO f
7. STATIC WATER LEVEL Below Top of Casing Z b
Ware If Above TopofCase&
8. TOP OF CASING IS 1 B ' FT. Above Land Statues
*Top ofedagteedaWd attar bWw Wdmew requires
ndnce m ateordsote w1y 13A NCAC 2C A11&
9. YIELD (gpm): 1. 5 METHOD OF TssrliM &17
10. WATER ZONES (depth):
InCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and ton mad names.
Topographic/Load setting
ORidge °Mope Malley Mat
(dock appoptieabox)
Iatibrde/longihide of well location
(daptaahaiamedaecoods)
Latitude/longitude source:OGPSQfopographic map
(dock boa)
DEEM DRILLING LOG
From To Foonattion beset"' tion
11. DISINFECTION: Type r LJ44 Amount In o7..-
12. CASING; Wall Thickens
Depth . Front (jl To J Ft. r.0' L Weight/Ft
~ t t.
From__ To Ft
From To Ft
13. GROUT: Depth telot
From / ToLo To Pt GMauVLEF-
Fmm Ft
14. SCREEN: Depth Diameter
From, $ To Ft in. in.
From 7 To Ft in. in.
15. SAND/GRAVEL PACK
Sim Material
Ec 1• —Zlos
In l N - 751)
o -`aZ° a5•Z30
Slotsrne Material
From�,.epm
To Ft
From rr To Ft
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL VMS CONSTRDCfED IN ACCORDANCE WITH ISA NCAC 2C, WELL
UCFION ST 1 e .41. AND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-LURE OF CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 4 1 6 6 8
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL coNTRACTOR EimI VmaAL) NAPE / n to c urrnrlcsnom / 2 7 S'' .
Well, CONTRACTOR COMPANYIN/g fee- l q /Td.neraoNE it On 65s9-o6'So
STATE WELL CONSTRUCTION PERaMTTY ASSOCIATED WQ PERMIT/
(if applicable) (ifapplicablc)
I. WELL USE (Check Applicable Box): Residential B--Mrmiegxi1PubRc 0 Dial 0 Agricultural 0
Monitoring 0 Recovay 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town IftW PIN EI?-VILLE-County )U NCOME .
f i ,P't\ r 12-e-E lc
(snectName,Naanbers,CommnosxSubdivision, tatNo., Zap Code)
3. OWNER:
Address 1T E K
Motet arRoata No.)
kAiEA flflIL( NC 28781
attar Town sure Tap Code
Arm ads- Pace umber
4. DATEDRIILED I g--Olp
5. TOTAL DEPTH: 1155
6. DOES WELL REPLACE EXISTING WELL? YES Q j40 E-'
7. STATIC WATER LEVEL Below Top of Casing_FI
(user iEAbote Topetcmeas)
8. TOP OF CASING IS / B' FT. Above Lead Surface*
'Top Madan to minted attar below tadswr6ee reg lea a
variance In accordance with ISA NCAC 2C Ala
9. YIELD (gpm); 2.5 METHOD OFTEST -TT MsD
10. WATER. ZONES (depth):
Topographic/Land setting
Midge °Slope Malley CIFist
(check aapprapainlebox)
Latins'dede/longitudeofwell location
mieverstmireaseemete
Latitude/longitude source:OGPSOTopograpbic map
P 'M DRILLING LOG
From To , Formation Description
11. DISINFECTION: Type i! 14 . Amount /0 o7.-
12. CASING:( Wall Thidouss
From ([J Too 36 Ft Por 21t t l
From__ %%%tTo Ft /�
From_ To Ft.
13. GROUT: �_
FmTT25 Ft �'N
From T To Ft
14. Depth Dimeter
F To Ft_in.
From To Ft`_in.
15. SAND/GRAVELPACK
Depth Size Mateial
From To Ft
From To Ft
Slot Size Material
in.
in.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
rumbas and an road names.
LEY. Z3a2a
1tiJo Sz° 3•q &o
16. REMARKS:
I DO HEREBY CERTIFY THAT 1. WELL WAS CONSIRUCTFD IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRl]CIION ST e r THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OF UCIINGTHE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phase No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
"A"670
tr-
North Carolina- Department er/ ofEnvir nmentandNat/uralResoources-DivisionofWaterQuality-GroundwaterSection
WELL CONrRACr'OH (INDIVIDUAL) NAMB�e(atl/�` L/ n I� f XD to S ZT cornmeAT[ON s 27 t)
p
WEAL CONTRACTOR COMPANYAaa Liz e e J" tN /¢ jLr l .9 r"ORO= s t m) b frjal) 0
STATE WELL CANSTROCTIONPEEN= ASSOCIATIDWQ PERMIT*
Of applicable) (applicable)
1. WELL USE (Check Applicable Box): Rol la-- Mnnieipalpoblic 0 Indunria! 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water injection 0 Other 0 If Other, List Use
2 WRI r LOCATION:
Nest Town: to lt%(4fft l I L County (t a.
P,a11%1V-1l—f_ t)wtar The
(StrmtNw4N®beer. Cmme S�bdnioa4 Lot No, Tap Cam)
3. OWNER e G }} � MD
Address pr.3j1 Ivy- 'I' _ i '�v"i �,PR.
«Roue No.)
kJ J -tV I W i 1JCa
«Tow° Sure
(`� 231— 72(o S
Ann cods-thaamber
4. DATE DRKLED �Z d (p
5. TOTAL DEPTH* 4
6. DOES WELL REPLACE EXISTING WELL? YES NO B-
7. STATIC WATER LEVEL Below Top of eosin'
(Ute"M'wArn Top ofcs ig)
& TOP OF CASING IS / FT. Above Land Surfaces
'Top of casing tnmYasud atfor bow bad saes requires
rename b has aaneo wh! 15A NCAC 2C .011t
9. YIELD(gpm): Z METHOD OFTESTT/MP13
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
From 0 IT
251g-i
Cede
Fr o
From_ To Ft.
13. GROUT: Material
From To Ft C
Front__ To Ft
14. SCREEN• Depth Diameter Met Mae
From 0 To Ft�in.
From To Ft in.
IS. SAND/GRAVEL PACK
Depth Size Material
Ft.
From To Ft
o �b FL 0'¢
Ft
Amotmt /0 b 7
Wall nudeness
a Weight/Ft.
GDLZI
Topographie/Ltmd setting
°Ridge 0Slope Malley Flat
( ben)
iatidtddbngiuide ofwell location
(dam)
Latitude/langidde solace:OGPSOTopographic map
(cheek box)
DEEM DIMLINGInq
From To / Formation Description
Material
in.
in.
Fro To
F
Show direction and&stance in tunes from oncost
two State Roads or County Roads. Include the road
nnmbea and common road names.
e LEA/7291vo
N .. ° 3Z.3Z7
W6 82.° zo 39z
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
aut-s-," J �..d� /2-12 -{109
OF CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
21699-1636 Phone No. [phone], within 30 days OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD e ry q
North Carolina - Department ofEntvo®nment and Natural Resources - Division of Water Quality - Groundw tea Section
I 1
WELL CONTRACTOR (IDDivmUAL)HAKE / n C je?At0 0s Zr c'earEnctuoNa 2 7 S I' .
WELL COn Cron for ww w e e w /4 fee- Oita 40 # " NE a taalkaanio
SLATE WELL ccNSIgvtloNIERanTn ASSopATpwQ PERMIT*
(if applicable) (tfapptieable)
1. WEIL USE (Check Applicable Box): Residemial II MmicipaUPublic 0 Iodation] Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water injection 0 Other O If Other, List Use
2. WELL LOCATI914: Topographic/Land setting
Nearest Town ill -At -t ConntYlaate, E.midge°Slope °Valley 0Flat
(Meth sppiapdamboa)
(Street Nam, Mambas, Comemosxsubdieisi, Lotblan DPCada) Latitude/longitude ofwell location
3, OWNER: DAVID juaNEn-
Address
mien et Rome No4
01 Mj N(. ZS11l
Myra LOOM Snore Tap Code
Area cads -Phone amber
4. DATE DRITLED -13- O 1p
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O ,NO a
7. STATIC WATER LEVEL Below Top of Casing # 1
•
/ (Use *above TopoWQ6eg)
8, TOP OF CASING IS / sFT. Above Land Surfaces
*Top ofesslag tenalward War below Issadsurfses remakes
Is �rtme 15ANCAC 2C Alt
9. YIELD (Rpm): Lit) METHOD OFmime TESIJ JZ-
10. WATER. ZONES (depth):
meareerawastemareene
Latitude/longitude sake:OGPSOTopogtapbic map
(boa)
8� TAHT.ING LOG
From To Formation Description
11. DISINFECTION: TypeSze____ ,I-)- Amount-/7c
12. CASING: Wall Tbicimeas
(}i R, . r
Front 7' ToaFt O' L G�t ! -
FronL__To Ft
From__ To Ft
13. GROUT: QA Malaita.
Front_ To � Ft en uti 7r
From / To Ft
14, SCREEN- y Depth
From T To
From; To
15. SANtWG3tAVELPACK
Depth
From To
From To
Diameter Slot Sze Material
in.
in.
Size Material
Ft
Ft.
LOCATION SKETCIj
Show Nit etion and distance in miles from at leant
two State Roads or ComtyRoads, Include the road
number; and common toad names,
&-ay. Z8z)
N. &5° £Y .Ob)
Wu. 8z° -qBq
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTITi ISA NCAC 2C, WELL
CONSTRUCTION ST ThATA COPY OF ThIS RECORD HAS BEENPItOVIDED TO THE WELL OWNER
01)M "5 �dAr£-hit)
OF wrrmr OF CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 flame No. [phone], within 30 days. GW-1 RSV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Dement of Environment and Natural Rem - Division of Water Quality
wELL CONTRACTOR (INMVIDUA1) NAME ,. / /1 f to
WELL CONTRACTOR COMPANY . ye
STATE WELL CONSTRUCTION PERMITS
inapplicable)
3 4 I 6 7 5
- Groundwater Section
onamICATIost e 2 7
NE s 6 Yt-C p
ASSOCIATES'WQ PERMS
inapplicable)
1. WELL USE (Check Applicable Bon): ResidentialEf Mtmicipal/Public O industrial 0 AgricrthuralO
Monitoring Recovery O Beat Pump Water Injection Other If Other, List Use
2. WELL LOCA aN:
Nearest T
r ,
(StiatName, Nus CreatmLLj, SWAM**, Lorna+ riP Code)
3. OWNER: PILiiPtlaD
Address 12.T) (1 eez.. . 1-n "TR D
12-1 or Rib)
�tx , NC. 2431 I
Cop orTowa Sur rip Code
Araooda Phase =Ember
4. DATE DRILLED 12,- -Dip
5. TOTAL DEPTHVaS
6. DOES WELL REPLACE EXISTING WELL? YES O NO e-
7. STATIC WATER LEVEL Below Top of Casing. 2,4 FT.
(their if Top °Mob&
8. TOP OF CASING IS / f �� FT. Above Land Surfaces
'Top admiea tertu sad attar kiln brdaaafa rpa ra
variance bt aaordance with ISA NCAC 2C Ri1S.
9. YIELD (BPm): L METBOD OF TEST -11I1/44ED
10. WATER. ZONES (depth):
11. DISINFECTION: Type
12. CASING:
From Too jg(l
setting
[Midge alley Offlat
Oakappm boa)
Latitude/longitude of well location
O
Latitude/longitude somce:OGPSD opogtaphic map
Diami DRILLING LOG
From To Formation Description
it,14
Finaq__T0 Ft
From_ To Ft.
13. GROUT:
od
From ._To 2.0 Ft( IA MAY
Fron_____To Ft
14. Depth F To Ft _ _in•
Diameter Slot Size Material
in.
From To Ft,._in. in.
15. SAND/GRAVEL PACK
(%/ Depth
Ft Size Material
From Y To
From To Pt.
Amount /nc7
Wall Th�idmeas
rid
Show direction and distance in miles foam at least
two State Roads or County Roads. Include the road
numbers and common road males.
Lev . I"121p
IV .b .:J4'5—I
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND THAT ACOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
, 3tx--/ /2-/R-0lp
OF P.,
CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 7333221, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvironmentand Mauna Resources - Division ofWater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME _6, a l�.'n �' i pliios .J g CYaTIFIcaTtox e 2 7.O
vent CONTRACTOR COMPANY
STATE WELL communion PERMrri ASSOCIATED WQ PERMIT,"
(rfappliS,le)
(if applicable)
1 WELL USE (Check Applicable Box): Residential 13 Mtmic ipal/Public ❑ Industrial 13 Agiwiwtal ❑
Monitoring Q Recovery Q Heat Punt Water Injection ID Other 0 If Other, List Use
2. WELL L. t'
LOCATION: ✓\ : QR
Neatest Town: 4.,u✓,rta. County 6,A„,A, R:+'It1t
13a Did J, S B�� cL Rd. atilt(
(ShatNme.NimMu. Community. 9obfivieiaa. LON°, Zip Code)
} OAddress ID. () \ w �6L Rci
(SmmtorRoute No.)
.Swnnnnv.cr. &J.(,. 208
toyer Tama Stem Tip Cade
(.?apt } a S- r I I S
Area code- Plume number
4. DATE DRILLED 9-6 a -6 %
5. TOTAL DEPTH: f $ 5
6. DOES WELL REPLACE EXISTING WELL? YES 0/NO 0
7. STATIC WATER LEVEL Below Top of Casing: _PT.
� Wert" if Above Tap of Cedes)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Tap ofwing tend - tad alter below laud madam regdresa
mimes b awrdaaee web ISA NCAC 2C .allt ,
9. YIELD (gamy as METHOD of TEST ./ 0. e
10 WATER ZONES (depth):
Topographic/lad setting /
Midge tSlope [Valley PJFlat
(Meek appropriate box)
Latidtde/longmide of well location
( )
Latimdellongitode sounmOOPSI3Topographic map
Wm&boz)
PlEra FRILLING LOG
From To Formation Description
11. DISINFECTION: Type ((1 j Anent /d) 07
12. CASING: Wall Thiciaeaa
From toTo 3 U Ft j 50R I Matneter or t YUC
From_ To Ft
____---
Front_To Ft
13. GROUT,: Depth Material
rrum y_To a0 Ft. (nnt(ttc
From To Ft
14.
Method
Ott rvt
FroSa j Depdr Diameter slot give Maoerial
Fmm (Q Ta Ft -in. in.
From__ To Ft_in.' in.
15. SAND/GRAVELPACK:
Depth Size Material
From f To Ft
From To Ft_ 0\‘'
16. REMARKS:
01
337440
NE a. 6 Y9-oy�p
JAN 2
LOCATION SKETCH
Show direction and Banc a in twigs from at least
two State Roads or County Roads. Include the mad
numbers and common road BMWs.
us'1 0
1DOiiEF
CONSTR
!l ry
Y CERTIFY THAT THIS WELL, WAS CO
{7ON STANDA1WS AAjb THL4T A COPY
c
c'SicavAnmE�- (.�
OF P CONSTRUCTING THE WELL
IN ACCORDANCE WRH 15ANCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Man Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 3 r
North Carolina - Dt.paetua nt of Enviro,Environment and Natural Resources - Division of WaterQuality- Groundwater Section �
WELL CONTRACTOR (INDIVIDUAL)ANAME / PI11AM1ZN eCERTIFICATION# 27p/
11 '7
WELL CONTRACTOR COMPANY* W ee w/¢ -' Q// q A.vvioPRONE R I cn 6Y%O �o
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT*
(if applicable) (if pplicable)
1. WELL USE (Check Applicable Box): Residential lVMumicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ° Heat Pump Water Injection ° Other 0 If Other, List Use
2. WELL LOCATION: t] yy�l 11
Nearest Town- S W r. w nart f.. County y„e o..4.(.
(Street Name,Numbas. Community, Subdivision, LocNo., 21p Code)
3. OWNER: Life('Fn." ct
Address
Sw (Sued or Rome No.)
vUC 2b11Y
fly or Town Stale Tap Code
(.__}
Am code- Phone number
4. DATE DRILLED O-31-0C
5_ TOTAL DEPTH. 4 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ie
7. STATIC WATER LEVEL Below Top of Casing a 1 FT.
� (Use"+" if Above Top of Caviar) r
8. TOP OF CASING IS / 3' FT. Above Land Surfaces
lop of casing tamSated at/or below Ind surface requires a
enfant in atmrdauc jt t iSA NCAC 2C .a11&
9 YIELD (gpm): .S METHOD OF TEST Tenn a a(
10. WATER ZONES (depth):
Topographic/Land setting
Midge °Slope Malley C215at
(cheek appropriate bca)
Latitudellongit ide of well location
()
Latitude/longitude source:°GPS°Topographic map
(chin( boa)
DEPTH DRILLING LOG
From To Formation Description
11. DISINFECTION: Type
12. CASING::
From W ToDDepth () Ft. /
From To Ft
From__ To Ft.
13. GROUT,. Depth Material
From 20 Ft. Contfttt.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From 0 To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From m To Ft
From __To Ft.
LOCATION SKETC)j
Amorist Show direction and distance in miles from at least
Wan Thickness two State Roads or County Roads. Include the road
or Weight/Ft Material numbers and common road names.
5DR-21 vci 0"6 (
Method
t'sF it"
t
.veil
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUt,lru IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSIT C ION STANDARDS T A COPE OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE C 1'ERSONCONSTRUCTING THEWELL DATE
D
UNITY
)07
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Depadment of Environment and Natural Resources - Division of Water Quality - Groundwater aeclio?t 429
WELL CONTRACTOR (INDIVIDUAL) NAME t . / /I oQ /V'S Zr CERTIFICATION S Z 7 O V'
WELL CONTRACTOR COMPANY Nr 14/e// rHONE / &'m 6Yf%onco
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ PERMIT*
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential $ Mnnicipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town- 05 r u 1 L County sePIM C 0141.
fa_ Re..., 1; t a kal
WOW NUM, Nambe s. CQmmimdy,'Sobdivima, Lot No., Zip Code)
pp
3. OWNER: Dot) & r to
Address Sa Rsw bringg Rs 4Sc RJ.
(Saes a Routello.)
/ seJ;Ile, i11L 2not/
Cayce Town State rip rode
C—�
Ara code- Phone number
4. DATE DRILLED /v-2le' OL
5. TOTAL DEPTH: / s'S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ll
7. STATIC WATER LEVEL Below Top of Casing: / S FT.
(Use + if Above Top of Casing)
8. TOP OF CASING IS 1i'' FT. Above Land Surface*
wrap of ®leg terminated attar Wan hued surface requires
corium In accordance with ISA NCAC 2C .911&
9. YIELD (gpm): YO METHOD OF TEST eitt e
10. WATER ZONES (depth):
11. DISINFECTION: T
12. CASING:
From , To 30
From_ To
From_ To
13. GROUT Depth
From^To a
From To
14. SCREEN: Depth
From_0 To
From To Ft. in.
15. SAND/GRAVELK PAC
Ks,
Depth
From // Ft.
From To Ft.
Topographic/Land setting
DRidge (3Slope [Valley [Flat
(the* appropriate hat)
Latitude/longitiide of well location
Latitude/longitude smuce:OGPSOTopographic map
(check but)
DEPTH DRILLING LOG
From To Formation Description
et N Atmunt /o'=
Wall Thicimesa
D�am�erer or WeigbtlFt. Material
Ft 6 %v X)R-21 PVC
Ft
Ft
Material Method
Ft. Conetett we f ruiur
Ft
Diameter Slot Size Material
is
in.
Size Material
LOCATION SKETCH
Show dirxtion and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
R4
m.{lie 3 h!
.p.
REC ED
DI . OF WATE.' QUALITY
ION e� 3 211U7
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRULIW IN ACCORDANCE WITH 15A NCAC 2C, WELL
CO FTION STANDARDS THAT COPY OFRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Catti�
.1.,t ( i.it., t� —EP I ` //9 — 26 -Ci
SIGNATURE OF P CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

237428
WELL CONSTRUC1ION RECORD
North Carolina -Department of Environment and Natunrl Resources - Division of Water Quality - Groundwater Section
antmlaTioN It z 78 hi
WELL corrntacioa« nivmtuL)NAME
WELL CONTRACTOR COMPANY
STATE WELL CONSTRUCTIONPERMITE ASSOCIATED WQ PERMITS
(ifaonlicsble)
NE • aggi lire io
fifapplicablc)
1. WELL USE (heck Applicable Box): Residential l M al/Public O Industrial ❑ Agricukwal ❑
Monitoring O Rccovay 13 Heat Pump Water Injection O Ober O If Other, List Use
2. WELL LOCATION:
NeatesstTown: Ti5LeJ, tt Camay (�:,rco,+� t
!q !twin-. [ter Imo. Uf, ,,MITTS
(SintName,Ntmbm.Community. Sabdivideo. Lot No,. Tip Cede)
3..OWNER: `t1cNr.rs 1 CAV<II
Address `l 7 /r mrn rec. i. �r
Seater Route No)
6r'4ncl\tr NC
ay or MAID state
Ara code- Pbooea t
4. DATEDRILLED�O-Ig-Dti
5. TOTAL DEpPg•3�a /
6. DOES WELL REPLACE EXISTING WELL? YE$O NO LH
7. STATIC WATER LEVEL Below Top ofCasing: S FT.
Q (User if Above Top of Casing)
8. TOP OF CASING IS I U I FT. Above Land Surface
nap ofming .edited below Wed mace rewires a
verbs* h aeeerdasoe with ISANCAC 2C Ailt
9. YIELD (grin): S' METHOD OF TEST %t t+ ed
10. WATER ZONES (depth):
11. DISINFECTION: Type /t Ii Amowit 10cZ
12. CASING: Walt Thickness
or Weight/Ft. Material
Fmm V2 Two 7,')
From__ T
From To
13. GROUT:, Depth
From 10 To : �.1/
From To
14. SCREEP4 Depth
'SIIS
Tap Code
TopoEgk�d setting
ORklge Malley OFlat
(checieppmpos' btu)
Latitude/longitudeofwelllowiion
{ )
Latitude/longitude somce:OGPSOTopographic map
(dteekbox)
PATS DRILLING LOG
From To Formation Description
Ft
Ft
Ft
Material
Ft
Ft
Diameter Slot Size Materill
From To Ft _in. in.
From__ To in.
15. SAND/GRAVELPACK:
Size Material
From V Two Ft
From To Ft
Diameter
Method
16. REMARKS:
LOCATION SKETOI.
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Lew,Cn4t1k, (o
e//
b. RECEIVED
"" DIV. OF WATER QUALITY
riot
Kt- -)51
,MAN 2 3 Z00?
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SANCAC 2C, WELL
C0�IJC IONSTAND *ID TACOPY miS RECORD HAS BEEN PROVIDED 10 THE WELL OWNEE.
CUL
SIGNATURE OF P CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 3 7 4 41
North Carolina -Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
ward. Conflation prconinnald NAME w
WELL CONTRACTOR COMPANY
STATE WELL CONSTRUCTION PERMITS
ofaaatieable)
4/ h."r/ �z CERTIFICATION 2 7 3 h
W Q// 7 h iar oNE a f1kfr3 6 Y� 04/&0
ASSOCIATED WQ Fttnbfffa
Ca,plicable)
1. WELL USE (Check .Applicable Box): Rcsideatial Ei Municipal/Public 0 Industrial ❑ Agricohmal 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Ocher, List Use
2. WELL LOCATION: p(l ii
Narest Town, County pvox/ ;ply t
Z z s /C 4' SA<vu .ir/
(Street Nato; Cammmutr, Subdivision, Lot No, Zip Code)
3. OWNER: R cC (AWL
Address 1.r11 LA.�q
(Street oars No.)
AiVeJint VA
C:AyorTawn State Tap Cade
Area code. None lambert,
4. DATE DRILLED 1-I
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO PI
7. STATIC WATER LEVEL Below Top of Casing: ti FT.
u (Use 'rifAbove Top of Casing)
3. TOP OF CASING IS I' FT. Above Land Surface*
flop of easing eked atter below lodaaaan requires a
mina 4 acarduoewtlb ISANCAC 2C.011S.
9. YIELD (gpon): _L METHOD OF TEST i . ,M t�
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASINO:
FT'70
Fmm�To
Frost_ To
13. GROUT: Depth
From V To 3O
From To
14. SCREEN: Depth
From 05 To
From To
15. SAND/GRAVEL PACK
From � Tow
From To
Topog9phic/Land setting
°Ridge <1151ope DYtitey °Flat
(tbeckappropriate box)
Latitude/Mastoid's of well location
( )
Latitude/longitude sowce:0GPSUTopograpbic map
(check boa)
DRILLING LOG
From To FormationDescription
cc H
Diameter
Ft. / fv
Pt.
Ft
binetirl
Ft. (s':1tie Lc
Amount /D az ,
Wall Thteiness
Ix Weight/Ft. aeowiat
50R -2I ?VC_
Ft
Method
wet irk Ix
Diameter Slot Size Material
Ft _io in.
Ft_in in -
Size Material
Ft
Ft
tJ / (h-R Ott
LOCATION SKETCI(
Show direction and distanas in miles from at (east
two State Roads or County Roads. include the road
numbers and common road names.
t lc.b
t)`
Thz
Y
16. REMARKS.
1 DO HEREBY CERTIFY THAT THIS
CO NSTzta now STAND
7,
el r L-G
St PERSON CONSTRUCTING THE WELL
WAS CONSTRUCTED IN ACCORDANCE WITH ISANCAC 2C, WELL
T A C0 1t OF THIS RECORD HAS BEEN PROVIDED TO WELL OWNER
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Moue No. [phone], within 30 days. GW-1 REV. 07/2001

337439
WELL CONSTRUCTION RECORD
North Carolina - Department ofEnvironment
t�andNaturalResources-DivisionofWaterQ Aity-GroundwaterSection
wires, co mtAcioR�ntvIUAL)� � n tl nacos 3 caRrlFICATIONr� 2 7 3 V
WELL CONTRACTOR COMPANY N r.� e e w n Ae/' tt/e// 4 Arno= a Ina
Y9= p
STATE WELL CONSLAOCTIONPfRNMY ASSOCIATED WQ PERMIT*
Ofapplicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I: yUmicipal/Public ❑ Industrial ID Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: n 11
Nearest Town: F.. k a ra.,ml I. County LLI CO MI 7e
i I &Ili Al ctn.," Or x119I s
(Street Name, Sabdivition Lot Ida, Tip Code)
3. OWNER: Reef OE
Address 31 R,,p►,n 9 Strca Dr(fta•- or Rabe.
CrAlrr N c . AY? I5
city orTown Sew Tap Cade
L�
Area code -Taw ameba
4. DATE DRII,LED I I'Q I- o
5. TOTAL DEPTI- 1 SS
6. DOES WELL REPLACE EXISTING WELL? YES 13/NO O
7. STATIC WATER LEVEL Below Top of Casing: FF.
#� N
8. TOP OF CASING IS 16 FT. Above Land Surfaces
'Top Weeder terms attar ban Iaad attar remakes a
;wince la aecordatee with ISA NCAC 2C AUL .�
9. YIELD (gpm): t C METHOD OF TEST / r nn
10. WATER ZONES (depth):
I1. DISINFECTION: Type
From U/ Two `40
From_To
TopoE setting
ORidge ovaEeyey Mat
SASE apprepade box)
LatihtdeAongitude of well location
Olesternanierecemeceann
Latitude/longitude source:OG SSD opograpbic map
DEEM PRILLING LOG
From To Formation Description
et 14
From_ To
13. GROUT- Dew
From 0 T d 0
From To
14. SCREEN. � Depth
From w To
From To
15. SAND/GRAVEL PACK:
Diameter
Ft �✓
Ft
Ft.
Amount /O °
Wan Thies
S R-or 21� YUI.
Material
o FL rearrrtc
Ft.
Diameter
Ft_m.
Ft. in.
Method
we f gnu(
Slat Sire MMeaat
in.
in.
Depth Size Material
From 9 To Ft.
From To 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.
33\
-S RECEIVED
AV. OF WATER QUALITY
,IAN 2 3 2007
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1111 15A NCAC 2C, WELL
^'ON STAND A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CONSTRUCIING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636Pboue No. [phone], within 30 days. GW-1 REV. 07/2001
4,4
12. CASING:

WELL CONSTRUCTION RECORD!
337438
North Carolina - Department of Environment and Natural Resourcesso- Division of Water Quality - Groundwater Section Q //
WELL CONTRACTOR (INDIVIDUAL) NAME4,Nt) nif fel ( PAD e t"s Zr CERMICATION#Z 7U /
WELL CONTRACTOR COMPANY N W e Q 7i`J Lon be" �Q// �J ArRONE # i2g 6 Vg o fl0
STATE WELL CONSTRUCTION PERMIT# AOCIA7'F,D WQ PERMITS/
Of applicable) (rfapplicable)
1. WELL USE (Check Applicable Box): Residential Be MtmicipalPubiic ❑ Industrial 0 Agricultural ❑
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO ^^
Nearest Town' AICZ7 /T/// County l8vnc o»+be.
(Sheet Name. Numbers, Cammrmuy, SobdMsioo, Lot Nov Zip Code)
3. OWNER: (oxt.c F''o.ne s
Address 388 Conrad. Rd..
Y/[tee (Boat err No.)
NC
My or Town Seine
(820-'n-c,ry
Area cob -Phone number
4. DATE DRILLED /0-03-06
5. TOTAL DEPTH: 3 0 f
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IW'
7. STATIC WATER LEVEL Below Top of Casing. T,
rr (Use' W' if Above Top of Caring)
8. TOP OF CASING IS 13 FT. Above Land Surface*
`Top of caste' terminated ater below bud surface requires a
variance In aemrdance with I5A NCAC 2C .9118.
9. YIELD (gpm): / 0 METHOD OF TEST / rr e+er�
10. WATER. ZONES (depth):
11. DISINFECTION: Type
From
S
Frame_ To
From__ To
GROUT:
From To 3 O
Qf
From To
12. CASING:
0Toter!
13. Depth
14. SCR: Depth
FroTo
FrontEENTo
15. SAND/GRAVEL PACK:
A From C/ Depth
To
Zip Code
Topographic/Land setting
❑Ridge OSlope Malley Mat
(cheek appropriate boa)
Latitude/longitude of well location
(degceolmimud/ee )
Latitude/longitude source:OGPSOTopographic map
DEPTH (check box)
DRILLING LOG
From To Formation Description
Cc H
Direr
,Ft
Ft
Ft.
Amount /0 o z
Wall Thickness
or Weight/Ft. I4atenat
SOR-d 1 /'U�
Material Method
Ft. COnurfe Oct MAX
Ft.
Diameter Slot Size Material
in.
Ft in.
Size Material
Ft.
From To Ft
16. REMARKS:
LOCATION SKETCIl
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
ntnnbers and common road names.
folk) rJ{ JQV
I DO REREBY CERTIFY THAT THIS WELL WAS CONSTRULtat IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARD AND THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P ON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center-Raleigb, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 2
7
4 3 w
3
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME ) 4// ti C fi {A045 ZY CERTWICATroN # 2 7 O/r
WELL CONTRACTOR COMPANY N w +e a iiiJ Witt 4er Phil 9 .wpPHONE 0 thni 6 0
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
of applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Er- Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town. F%/Ao/CCJ County QKett am6r
(Street Name,Numbea, Community, Subdivision, Lot No., Zip Code)
3. OWNER: i ts5e S Et.„("
Address /'D C j{c3'&11a l- hi7//fir.,
�. (Sneea Route No)
f'Alie in ,cJ /VC -
city or Town Shoe Tap Code
Area code- Phone amber
4. DATE DRILLED /0-01-01
5. TOTAL DEPTH: ?nC
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Mr-
7. STATIC WATER LEVEL Below Top of Casing: -.4/2 FT.
(the`W" if Above Top Casing)
8. TOP OF CASING IS / j' FT. Above Land Surfaces
'Tap of easing terminated War below had surface requires a
variance in accordance with ISA NCAC 2C .611&
9. YIELD (gpm): 2 METHOD OF TEST Tien d
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
From teToinV
From__ To
From To
13. GROUT: Depth
From V To a D Ft
TopoPhuJLand setting
QRidge OSlope Malley DFlat
(dwelt appendase box)
Latitude/longitude of well location
Ne /mi weet/eaewol0
Latitude/longitude source:OGPSOTopograpbic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
From To Ft
etH Amount /v oz
Wan Thickness
Diameter or Weight/Ft Material
Ft 6iv soR-a L Puc
Ft
Ft
Material Method
tonrrt ft Litt "tilt
14. SCREEN: Depth Diameter
From a To Ft,_jn.
From To Ft in.
15. SAND/GRAVEL PACK
Depth Size Material
From 9 To Ft
From To Ft.
Slat Size Material
in.
in.
16. REMARKS:
LOCATION SICETCR
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
no fie N; I I Rc�
r
i
I DO HEREBY CERTIFY THAT THIS WELL
CON UCTION STANDARDS
AS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
THA A COPY O THIS RECORD HAS BEEN PROVIDED TO THE WELL, OWNER
LW." c 14, e--y-0l
SIGNATURE OF P 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
UALITY

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Divisionwlity - of Water QGroundwater Section
C�
WELL CONTRACTOR (INDIVIDUAL) NAME ) iQ// n h 0 Lf/os �,1 CERTIFICATION # 2 7 a �/
WELL CONTRACTOR COMPANY N wee > Wafer' we// q ! U.wPHONE no
STATE WELL CONSTRUCTION PERMITe A SOCIATED WQ PERMLT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential fri Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection [ Other 0 If Other, List Use
2 WELL LOCATION: /t
Nearest Town: Foir'vit,J County Urnc...,6c
(Street Name, Numbers, Commmay, Subdivision, LotNo., Tap Cam)
3. OWNER: Rntlb;t r 4 �'t
Address 3 L Orckdr d Hail Lwn t
(Suitt or Rome No.)
ri to -be n/c as'i32
Cray or Town Sore Zip Code
Area code -Phone number
4. DATE DRILLED / 0-//-04
5. TOTAL DEPTH: 20 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0'
7. STATIC WATER LEVEL Below Top of Casing: / 2. FT.
/./ (Use '4'9fAbove Top of casing)
8. TOP OF CASING IS � g FT. Above Land Surface'
"Top of easing umlauted Mir below herd surface requires a
variance In accordance with ISA NCAC 2C A11&
9. YIELD (gpm): 10 METHOD OF TEST TiM ei
10. WATER. ZONES (depth):
TopogqphidLand setting
[Ridge L Slope [Valley DElat
(cheek appropriate box)
Latitude/longitude of well location
(degton/mmnea/see is)
Latitude/longitude source:[GPS[Topographic map
(ebeek boa)
PEPTH PULLING LOG
From To Formation Description
11. DISINFECTION: Type £ C H
12. CASING:
pc Diameter
From W Tom/O Ft is
From__ To Ft.
From__ To Ft.
13. GROUT: Depth / Material Method
Front._ To 20 Ft
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From 0 To Ft in in.
From To Ft. in in.
15. SAND/GRAVEL PACK:
Depth Size Material
From (1 To Ft.
From To Ft.
Amount /00Z
Wan Thickness
or Weight/Ft. Material
39R-21 PVC
16. REMARKS: (o t4cL i Us <
I DO HEREBY CERTIFY THAT THIS WELL W.
CONSTI$U9T ION STANDARDS,
rcid IA it. Iled
LOCATION SREFOj
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
rj •wcl
well [ticerr
CONSTIWC tet t IN ACCORDANCE WITH 15A NCAC 2C, WELL
PY OF r t S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
N CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Man Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. OW-1 REV. 07/2001

WELL CONSTRIIC PION RECORD
North Carolina -Depart nait ofEnviromneat and Natural Resources - Division//of Water Quality Quality - Groundwa$ r �iot 5 0
WELL CONTRACTOR �m]YIDItAL) NAME / IIt° V CERTIFICATION 0 Z7 g V
WELL CONTRACTOR COMPANY W �e w/ AertilQ// ' ' .,. h?HONs s 6Yq-O41,0
i
STATE WELL CONSTRUCTION YERMTO ASSOCIATED WQ PERbIITO
fifanalieable) Clfapplieable)
1. WELL USE (Check Applicable Boxy Residential tI MMnnicipaYPublic ❑ industrial 0 Agriculnual 0
Monitoring ❑ Recovery 0 Heat Pinup Water Injection 0 Other O If Other, List Use
2. WELL LOCATI !1
Nearest Town• In County 9tr.coMbc
Io- %(-t Al i r1. .25380c
(SaatName.Nwnbo. Cdosemaky, Subdivision, la No., Zip Cade)
3. OWNER:- ll r, n iici
Address I n'z r AI-/ut) M t
(Sneerq goats No.) _
ltsktth I 4- IV.0 • Z L15
Citrate Town Seine Zip
Atnrnde-Phew somber
4.DATE DRILLED IU—a�/-f):<r
5. TOTAL DEPTH: y A s
6. DOES WELL REPLACE EXISTING WELL? YES Q. NO Er
7. STATIC WATER LEVEL Below Top of Casing: a 5 FT.
1/ (Use '4^ifAbove TapofCesing)
& TOP OF CASING IS ) ¶ FT. Above Land Surface*
`Tap ofeadaatee-Vast Wee below laud Mt! regains a
mace V warden web ISA NCAC 2C Ailt
9. YHIID (gpm): a6 METHOD OF TEST 'Tined
10. WATER ZONES (depth):
setting
Midge laSlope Galley 13at
(cheek appropriate
La6nxte/longitnde of well location
( )
Latinuic/longitude sowcefGPSOTopograpbic map
(e bez)
DEMI TRILLING LOG
From To Formation Descript—ion
11. DISINFECTION: Type CC H Amount) Oo
12. CASING: Wall Wetness
Diameter aweigbt/Ft. Mattai
Flo To __ Ft 6Yv SOR-? I Per;
Froal_To Ft
From__ To Ft
13. GROUT• Depth Mlaterisl
From yi To 30 a Iaetc ccft
From To Ft.
14. SCREEN- Depth Diameter Skit Su Material
From 9 To Ft )n in.
From To Ft in. in.
15. SAND/GRAVELPACK:
, wSize Material
From (!/ To Ft
From To Ft.______
Method
W ix
LOCATION SKEiYS1
Show direction and &Mum in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
Y CERTIFY THAT WELL WAS CO
ON STANDAR)]�THAT/A DOPY
tAvC ri' / 1, ��/
SIGNATURE OF P
CrED IN ACCORDANCE WITH 15ANCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 072001

WELL CONSTRUCTION RECORD
North Carolina- Dot ofEnvuonmeat and Natural Resources - Division of Water Quality - Gnormdrvata Section
WELL corm/wive wwwvmuso NAME
WELL CONTRACTOR COMPANY
STATE WELL CONSTRUCTION PERETTC ASSOCIATED WQ MEMO
Efappliable) (,fappiicable)
Z CERTIFICATION 8 2 7O
ee wn J4tr bill 9 . sap
a & 6Y9-oygo
1. WELL USE (Cede Applicable Box): Residential lSI7Mmicipavpnblic ❑ Industrial 0 Agriculnual ❑
Monitoring 0 Recovery Q Heat Pomp Water Injection El Other CI If Other, List Use
2. WELL LOCATION:
Nearest Town: Fair✓(cU Comity swccMW€-
36 OrrLn..r4 Neil RA aD73).
(SinnNmae,Numb,a, Cammimag. Subdivision, LonNa, rap Code)
3. OWNER 1.; ..not LA Qvngg
Address Ott ckur4' {-(; II KJ
City orTown State Z. Code
(—?
Area code- Pima amber
4. DATE DRILLED j 0-1 . -
5. TOTAL
6. DOES WELL REPLACE EXISTING WELL? YES Id NO ❑
7. STATIC WATER LEVEL Below Top of Casing 1') FT.
(User if Above Top of Casing
8. TOP OF CASING IS I% ri FT. Above Land Surface'
nap ofeasing tandaated alter below bad ssrSa requires a
variant Is aeoordace ash ISA NCAC 2C Alta.
9. YIELD (gpm): j /1 METHOD OF TEST 'I ,a e J
10. WATER. ZONES (depth):
Topograpbic/Land setting
PSfope Malley DPISI
(dmekappropriate boa)
Latitude/longitude of well location
( )
Latitudttlongitude source:fGPSfTopographic map
(checkboa)
Pam' i DRILLING LOG
From To FommtienDeacription
11. DISINFECTION: Type it lei
12. CASING:
DFrom 6 To� i?()
13. GROUT: Depth
From () To 30
From To
Direr
Ft At
Front --To Ft
From__ To Ft
Material Method.
Ft Concrr)c Wet mix
Amount /n a
Wan 'Maness
orweight/Ft Material
5Di4i At
Ft.
14. SCREEN: Depth Diameter Slot Sze Material
From /% To .2. t'! Ft`ia. in.
From__ To Ft in. in.
15. SAND/GRAVEL PACK
Depth
From To Ft Size ManualFrom
From To FL
337449
y
LOCATION SKECH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road names.
Ov%ttAlo 5 Grain,
fig RJ
16. REMARKS:
I DO HERi BY CERTIFY THAT WELL AS CO C)ED IN ACCORDANCE WI R 15A NCAC 2C, WELL
ON STAND �° THAt}�A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r �,�,iilti e AIRS
(,ti /C9- /'L-
SIGNATURE OF P CONSTRUCTING THE WELL. DATE
Subtnit the original to the Division of Water Quality, Groundwater Section, 1636Mail Service Center -Raleigh, NC
27699-1636 Phone Ne. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Dot of Environment and Natural Resources - Dmsion of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME / /r �tc CERTIFICATION e Z 7 O Qpt/
wELLCONTRACTOR COMPANY wee wabr. (a// # " .rppsoNE a t 6Yg-ovl0
STATE WELL ccNsrtocrtoN FEResrrs _ASSOCIATED WQ Man*
ofaaa>;able) CIfapplhabie)
1 WELL USE (Checks Applicable Bunt): Residential IS/ Mmicipavpublic 0 Dial 0 Agricultural 0
Monitoring 0 Recovery O Heat Pump Water Injection O Other 0 If Other, List Use
2. WELL LOCATION:t-'//��
Nearest Town: iAlrul(U% County 6l4eta; 'el c
a&s !O.tky f A ROI
(StittName.Nami Comm-. Lot No, riP cede)
3. OWNER 12..A55r \ 1 5t Inro cI eat f Co L f e)
Address I3S Fla p red
(Sava RaaeNo.)
l&tTuitwe, IUC )%130
(Sty orTown Stare Tip Cade
(_._)-
Areasodo- Maas number
4. DATEDP.UTPn (L)-D ()C)
5. TOTAL DEPTH; tfn C
6. DOES WELL REPLACE EXISTING WELL? YES,NO Id
7. STATIC WATER.LEVEL Below Top of Casing _AFT
rat Wore trAbareTap of Cesium)
& TOP OF CASING IS 1 b FT. Above Land Surface'
`zap of easing teradaated attar below tad wrier eee afa o
variant Y accs with ISA NCAC 2C .alter.
9. YIELD (nun) 3 METHOD OF TEST Tovuj
10. WATER ZONES (depth):
337448
Topographic/Land setting
Midge 09Cope Malley QFIat
(ehe*appropriate box)
Latitude/longitude of well location
Mesenemeautewseemeo
Latitudelwrgitude sourcenCIPSOTopographic map
pima box)
DEPTH DRILLING LOG
From To Formation Description
11. DISINFECTION: Type CC I-1
12. CASING:
From CP To�Ri /vim t Ft. 6
From To Ft
From_ To Ft.
13. GROUT:Depth Material Method
From a) To iL) Ft. CoAcr{ic a e fi rtt,s
From To Ft.
Amount Ih vZ
Walt Thickness
or Weight/FL wow
SOR �I C
14. Dapdt Diameter Slot Sii Mauna(
F To Ft,_m in.
From To Ft. in. M.
15. SAND/GRAVEL PACK:
From 0 D roFt.___ Sue Material
From__To Ft.
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad names.
0 well
RECEIVED
OF WATER nOAI_ t s
16. REMARKS: blf 2. ``/_UU7
IDO YCERTIFY THAT
ON STAND
CC ll C
WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C., WELL
A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CONSTRUCTING THE WELL DATE
Submit the original to the Divirion 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 Natunei Resources - Division of Water Quality - Groundwater Section �+ WELL CONTRACTOR @'m1VIDIAL) NAMEy )4//�/i C fAC It"S DA mammon a Z 70 V.
WELL CONTRACTOR COMPANY N W e e TTT/ w n be'e// 7 A,,,y HONE s 129Z) 6 Yg-o, So
STATE WELL CONSTRUCTION PERMIT; AaeOCIATED WQ PERMITS
(ifapplicable) of applicable)
1. WELL USE (Check Applicable Box): Residential �Municipai/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town- a t IIe County
4q & IYyy .N l A PCitr✓ins DA lia
(Street Nato; Noma Cantrafaity, Subdivision, Lot Non TJp Code)
3.OWNER: i9 ,Jrac.Mc
Address 1 1 n i I. R tar/ €
rAlet,�rw (Street et CRan Na) 903,2
City or Town State Tip Code
Area coda Phone number
4. DATE DRILLED 9-tot -n 6
5. TOTAL DEPTH: a OS"'
6. DOES WELL REPLACE EXISTING WELL? YES( NO le
7. STATIC WATER LEVEL Below Top of Casing:.
FP,
/r (Use"+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of easing terminated atior below lead serfage requires a
nrince l itecorthwee,witb ISA NCAC 2C All&
.. j 9. YIELD (gpm): ) METHOD OF TEST Tt M e t.1
10. WATER ZONES (depth):
Topographic/Land setting
QRidge Mope (Valley (Flat
(dteek appropriate box)
LatituddlongiUide of well location
(deweetenbitacskeeond0
Latitude/longitude source:(GPS(Topographic map
(the& boz)
REM DRILLING LOG
From To Formation IAa,r;ption
11. DISINFECTION: Type et H
12. CASING: I��oe
From _To 6)' Ft. (n car
From__ To Ft.
Front To Ft
13. GROUT: Depth
From V/ To ) D Ft
From To Ft
Amount (Dnz
Wall Thickness
or
ght/Ft Mataial
A.E UC
Material Method
hintwzf :nix
14. SCREEN Diameter
From 0) Tom Ft__in.
From To Ft. M.
15. SAND/GRAVEL PACK:
Depth Size Material
From 0 To Ft.
From To Ft
Slot Size Material
in.
in.
LOCATION SKETCH
Show direction and distance in miles from at bast
two State Roads or County Roads. Include
numbers and common road names.
circ.
hue
WATER OUPOSiv
�,\t °"i 3 alt17
RF9Y
lOCTI tvuN nNDARl I}ND T COP OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
{I �( J/��//(SIGNATURECONSTRUCTING THE WELL � ATE
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
16. REMARKS:
I DO HEjREEYCERTIFYTHAT THIS WELL WAS CO STRULIED IN ACCORDANCE WITH ISA NCAC 2C, WELL
0 PERSON

WELL CONSTRUCTION fltORD
North Cardin - Dopartaaet of EnvItimmorit and Nonni ResotRas - Division of Wart Quality - Oaoeudwser Section
wau ooler+Acroaonmvaumsrums *bo�//en r Rhod's
west coerrr*croecolo*nnat)c*i7PP t.cR/ e/ We// / het)" sears apxsl6Y9evec:
SrATEwoo,00tanwatOtrensure .411100A711nwQPSIAM170
)_
carvrcATlota 0772 2/
1. WELL USE Pack App!eebb Back Rasidaodal lfl4Sc palIPnblic O Statrid C Apkdaad O
Meottories 0 Reoovay D Erat Prate Ws Wooden 0 Other D IfOtbar, Lit Use
2. WELL LOCATION;
,117�� T / U, cam' CaountyU ,cc *c
Dyp FA zV7 h
pa.tstemrr.+.aCron* rttI LLa,lotrle,zip c•dN
3. owNER: i�'`,5, kym(i g
Addis•D We /aNate arm Ple.)
d'><' /irI
l" Elle tact i'UC 2 :7 6C'
OceorTees Se 7;—
As Pie _I_
4. DATE MUM 1-�_L.�
S. TOTAL DEPTH: 305`
6. DOES WELL REPLACE EXISTING WELL, YES Jp7 N0 iD'
7. STATIC WATER LEVEL Bebw Top ofemiag
(Ilan Ns BMWs Teo of Oat
S. TOP OF CASING IS / 0 PT. Above Lead Smeeee
`Sap dr onesitaaYrWow Stads roods •
Taws r miweema.w 1OANCACIC AUL
9. YIELD (spun)- 5 METHOD OF TEST 72meet
10. WATER ZONES (dope):
11. DISINFECTION: Type C /# Amount /C o 7
(2 CASD'0: wdMobs
� ,,yy Dew aWdr/
rrom_ ____To �9 Sot 2( iftiL C
Prom-__ To it
Pto�_To Pt.
13. GROUT: Dap! AWN
Prmt__e—_T0 20
Prom To Pt
Pt rvicie
14. SCREEN: Dope Derr- Sint Soo _.tidal
Prom_ To Pi._to. S. cc
Fmk --To Pt.....--ia. in
15. SAND/GRAVELPAQL k
�r
Dope Sass Mattis& \
PinII
Pt
Prmt__To P
DIMP flair DbIley Mat
Toponprielad muss
(ebaeaappeeprs bat)
I+IWads4ras Sde of well locution
Nensieheireseessan
Lotiordenospbodo .0O a mop
(at ONO
DIEM DRSLUffila.i
From To F
Ktv R D NVCC( f
F 44i
LGGd11agaSnai
Show arcs. sad detanee ia miles from at Isom
two State Roods or County Rods. Include tbo teed
raaban end ooa®8iesolid ram:.
16. REMARKS:
Q� I
t
l DO HEREBY CERTNYTBATnos WELL WAS CONSTAUCIED
OOHS i1KIp1ON STA1bARDS. AND IBA t►4 Y �Tfiw , _
&dot tbo original to tie Dada flair it Quality, Gertndwnter Sretlese 106 !4t One con -as" NC
ream rum 1k fly& l,wYiY30byr. OW -I REV. 07/2001

WELL CONSTRUCTION RECORD
Noe* Caroline -Department ofBrsvhewmat wad
MILL COMEACTOt atainumm1.) NANt
WOL CONTRACTOR CpRAIW
ern WYL COIIJ1kUClbM
: V* fll
iv_ald
333534
))
Reeorea - Dividers 9f Weer Quality - Groundwater Seeded
c RAC Cif' 5 �!Y,E' t�rrurecanowe27? /
NMrR,'I.�PPT'LW07 Ye' u-'.' // 9 `tAmf rtptat s Wieici 6Y9-vvhc,
Anoc m wro Bolan
(lfaealievltlal
1. WELL USE (check Applicable Boos R.eaeatiel t'MovicipeYPnblio D Lbettial D Agricultural D
Maaitorhg D Recovery D Heat Pump Water legeeoaa D Other D If Other. List Use
2. WELL LOCATIOTE
NeaestTowm /95/1Ui// sty. , .v
pw.rlteaNreaes, Cm•r% a+r tsi aLrNa. no awe)
3. OrdMddk... Z' ?s A c�
A5Atri fie {tie 2d 75-`1
d4•rTerre Orr SO.e.
1 '1-
AaadrPae•.soWr
4. DATE DRILLED %- / (
S. TOTAL DEPTH / xr
TopocaphielLand setting
CUM. 0111ope Malley Witt
(tit "peplos bat)
L a&lossitude of Well location
w..Waie.e.rweaedv)
Latitsdarkniteade ewc&D(PSCITopopraphic map
(Not bet)
DIEM PVT r nary rr
From To Formation Description
6. DOES WELL REPLACE warm WELL? YES NO Ll
7. STATIC WATER LEVEL Below Top otemini
(Us 4e•taboo Top dadad
3. TOP OF CASINO IS % C It Above Led Smace•
•'TTedarias nisi Sr Ws teed Nts owls
mfrs. r arre..wwaa ISA NCACIC.ats.
9. YIELD(npenR 12_ METHOD OFTEST 7. i -re/
10. WATER ZONES (depth):
11. DISINFECTION: Type rr /1 Amount / O c' Z Show dheodon and distena in mike from at lent
12. CASINOS Well Thine two Sew Reads a Coemy Rends. Include the rood
Frost TDo°gc — SD thistelPt aid
L-'C sanbas� rim
Fran_ To Ft \L
w
Prom__To Pt,__,
13. GROUT: Nit M.hdd/ M ee ° I f_ I0.__ fry / �` > 7
Pmeq, _To 1- ' IV MItres/r if rkl�( i �__..: `�
From_ To Ft
14. SCREEN. Depth Dimmer Skit Sias Metrkl
Pram 9C To Pt_in in.
From_ ToFt,._in. in.
U. SANDA3RAVBLPAL
Ns Medal
Pus_ To Pt.
Ftam To Ft. \=-
16. REMARKS:
IDOHEREBY tRIMPYTHATTRIR WELL WAS
CCNRnUCHON S/ANDAEDR. ANOTBATAAI
lu C
SIONATURE OP PERSON
ACCORDANCE WITH ISA NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER
THE WELL DATE
t.LJI Os aslant W the Miss dWakeQuaa%Groundwater hoeWt,1A16 MaaSinks Csala-Raleigh.NC
270114634Ma Ns. Mg) A133t1,within SOEnt OW-1 REV. 07/2001

333530
Near Cora. -D men* enaera- ad
WIIILLOOPIMACM110111111011104111611111.
inn collaal.7atea aMl
KAMM Cim M 1011
li�l1_
LImam
EalidaltiMINCIIIRLISDAR
17RIOi
�!i
Recess - MSS Selies
lir L it/tildes te crA�ona7tY
C) ff r1:A�re we// -I Ito nose s d vnQ
/�
AMOQADH
SS
1. wlaLPie Maidssilid trilmidslitillis0 l.ra-u 0 NOW'
MSwigo ia.ny o lislwDwMeatdso Orsrn Mat Mum
t SYBIL LOCATI
�t TeeaK / U.0 tt caw &Leto/s, 4
2`( &',Ar �yr tab c .2Z 7(y
1Ranuse leas,Cr•esal►L1t+YsJrMe,;Cede)
3. owe .T19Ines ghtiu_q/9/
ALL_ 7 4 J3, i,4r' UA
Fry/.Mite a jvc 2?7Gc
aineh a rs Spas
as Srless,ern -3° CG
s. DAT! team - C
S. TOTAL. Dirt tarn
6. DOM MIL INIPL CIIUMSO MILL? Yir 0 NO Er
7. S1AI1C NAM LIMB. Isbw Top °tClnN SIPT.
tellakoneitaske
a. TOP atCAw101J1 /0 4 Pafl.A s.1. •
M4etee0streesWeewes teaseesps.e
—iolossNres SSN AMCSli
S. MD Op* > s4 lis'MOrxtt$i[ 7:/n er�,
I& wAT1Ri'J Zee (AS
11. DIMMICTOVISpit rG ht /L? c> 7
U. CAS&
19,MOM Deb JEW&
111_,ZaJR,r Qhcrfl -r
pos--_.10 _h
14. IICRIMIL, Dok Daiir Iltrbe iinMYt
15. RANDURAMI.PACX
Ae1 Jd
tr.eraltly
anet
freitsran
ladalsearit0lRso
ofnilloslin
appasesso
risisAm toe sonOCIPSOrsesphia NIP
any
r. Ma=
Mee to NMsdltraee__yes
riX
UiCitatCi
•er*SW ail Sion b tali but
San Beat et Cosy bads. Wale doe mad
MMtrtet 416 ems read ee.aa,
16. SWAM 1
1DO_-_rCl71Y711ATt1161WILL NAtCOMrRIJCSIDDIACCORDMI MIIHANCAC2C,,nz.
CWLR 11014 AMRl 11ir IWM®1VIENIMIVD701f1tWELL 0,111*
llfiOfp a/itp /1SSISM 'Sap. mem RMV.4710001
lCc/

IMILMigintgawnscosk
333528
Nat draft -______ tat_ rien.uta.t lass -nl.w..&W rrSyr-Or—j..d.e.elios
lealLtritt*A!.'Iaeaftive •,tya at In G nodes ,'R es'„ramzga?7F V
nag fon WATSWILL CeNni4t.11atISS 41110001111111
- -TA G
dhaieile
EfallmIAL
I. WILL M6(C h & ANISiolks) Voidsoils1137111.111pillteloD ISIBI Ms.Mr.IlitabadissO
D M0°'af D 1621 Pap Was 1S ..0 Oar VOW, Lit Use
2. WELL LOCATMOk
Uir.lt /- / pew, tees (�
l7 0 +'wn D 6r
(!bender NAiroOrsMrYglielN ,OS*
s. o+wlrIR n$ frl9a %r�
mks7 oa /t.,Y. / /Z
pee.eetterelte.
54'/"1t4rw "VC 0
Areia se *et
L�
as mina
a. DAIS I*V.W b ` - 3 -o
S. TOTAL 1311PI t; -tc
d: DOS WWL [1RR,ACEII IS111m IOW Yn 0 ND r
t STATIC WATER LIVt. bit Top salmis WG' nr,
L top or ram /b PT. Ma Lod sw5.ee
moo oreg.eerneeMresso.etamoro t a
eeeleerr eeeee.eeer.la NANCACI CJIII
t Y11Ila(pa . /Z ,i M=OFTMIT /,>ntd'
l0. WATER .'ECREM(lyOk
11. IDottMUCTUt 2jp f t Ia. Aata_t /iv e
12. CUING: WMWinn
Ptss W ivr hi=ar / Ul
.aad..ditr
Irwtw�l,p �
a11gll.de afar[! leeetle.
lkonesSolos
LsilloSilosiomorooCIONC7ropogoiplik.o
oloalon
To
attairga
•.r i.eM.s�arl�aims Sim be at hest
toe tiltstask atCe ykatbelietheatd
ankisadeomarsal arms.
13/kt:
13, mOt�,d Dook
Aaat�._Tn w tt(one/e t� wet m/X
act ye,
'
C'(
\SP� RQU
14 Ira I_ Visas dse MS KIPE
ReiL a_Tit— Pt +e in. J OF
0
13. IAN VOIAVi.PAOC: OC 1.
Oge Ws SS
•
lt< RldARlxs:
IDONS'tJl71Y711AT11Irin WAS CONOTRUCEID mocOMOADMISMII WINGIC1C. lYIIL
••tu, STA/MAMMAISTIr AlIPY MHOS MSIPRdYR�TOWN TM. OWNER
IIIMM7[MIORMOON ME win OATH
ISO Ile MOSIs lb Slain flair ea. Oralivirrf.MIn.MIMS einbaCtoor-IIe-e114me
MISM fAeroN.pMl1 W.weoMays. ONtd RNN. t17/1001

Nast Candies - Dopiness dSa.ismatad
VOL Capraac'Naat1110lary C
flan arts. carnoCTION ass
dtsalkerth
333e2/
Pas - Data at Wait Quality -Gre a_Satios
tel cm„cs'na,.27 E r
,1alocuTla awp nos .1� 1 Sy -Ono
aleammursiers
1. WSLL U111(MakAll elkaklhoWMWil It erfa Ai s0 la* p Mia •D
Marie 2.4 0 assay 0 1110Pap Water lajtosal Ode 0 VOiMM Lit ilia
2 WILL LOCA /
NaasTm 5 ic" //e- pro, /3u.�coF,�
?As Loki x Anil .7426,
Sue taa icau sCo sl*,110161atbett...>raty
3. owa //2/42- S Jr('R/r 4)-,
Ades 34 q�w./t' k £��,< �j7 w,
/l St�d�/,�i t n' C Z F>G C.,
Oae7a are
anabas
4. DAfl CitILUED i,
t. lora nuts;
t Does Meu. ReNL atinam to MRCS Tea 0 NO er"
7 STATIC MAUR LEM. balseltiramisgr5 .*,
t TOP OPCAMINOII hf" irf AM re
astasaaamisala at *WIC SAL —
MILOup /4- .1Q'IAODOPTUT /"L—
et MAT1l ZOI (*IS
Tatra
W
ORM._aley 017at
Lailmialso id. dna imbue
Malna-
LadlidMt akratOOPSDramptpik amp
Bras Te pasamiam Daarlptios
Saab
11. C� ---,wt yAssert Jei ot�Zy
e ve Pt� 5A ' -21 c'C
iheal_ Ta w___ —
19. (11101t DU.„r, Dq* —
rtai_1,To Zfi Ittow c/'el/�
SSW Brags ad don la ail= be at rat
two SeBeak atGamy task kakis dwwad
aaitaaaid arms tied ain
Iul),k teeac ere'
It SCRSia Doh Des iltfiw 111ta1.1 ; ilr
Pas 9 Te Pt.__ .S. to
Pkaa
15. SASINGRAVILPAM:
bolut•.. eel
1t UMA*K&
1DOSSSa. a PTIIIATIMPWILL WAS
00l*lKAamall �► aein*%
4J1!
S13001SlSOPPSRS011
w1 }t't't
1MACOODDAWCII I atIleac 2C. Nat.
[!Ir Hal XIS 1S(1YINID OTIMIWULt1 PS
1111 WILL DATS
laksltt#aMSS lalkaMSS dWSQardkhOrandir/Mr Met 111d11.SMttMOaar-- i.r NC
XII iasPa.a.I . 011,15$4111.trrb days. ow-i RSY.07/200i

h
00
Topoospidotand setting
laid. Maw OVelley Dist
(iwtgpawt+be)
Ialibthetk Matto dwell Wow
boarsionwwwwild
Lalnddla.&Nede etarecO PSC1Topc pphic map
Oast boo
Fat To Faemalioo Daacdptios
4. DATE DRILLED fo -q_0
S. TOTAL DEPTH: 0.5-
6. DOES WELL REPLAC8100STINO WELL? YES 0 NO L�
7. SrA7TCWATER LEVEL
pBan Top d (9D FL •
8. TOP OF CASINO IS Io 1/ r �d Ff. Rion Lend Smtlee•
flipdeeft*v• - SWba4wYNeaaareresokee
flatb—dmw 1MA: CACMC.MI$.
9. YIELD (. _ wallop OF TEST n%M en'
10. WATER ZONES (dep6):
I1. DISINFECTION: Type CC Y Amount /f� ore
12 CASING: W Il'Gle es
WWSONSTRUCTHON RECORD
Naati Centias-Downma °Parchment sod
WnIA. COrrffC7Ce@muvinat lsues
WEIL OONnaACTOs COMPANY NAIR Sil
StATI WALLCONel1 CTION MOSTA
((faeaAcalla)
of Water Qodlty - Grounds Section
Cprru7CAWON•Z r
�mi1# hunts a Oa
Of adkobb)
I. WELL USE (Chia Applicable Halt): llaidaeaW liV iealaird/Public 0 hedge S 0 ASeiadlmal 0
Mceiario3 0 Recovuy 0 Heal ramp wear *ohm 0 Other 0 If Ober, Lid Use
' n ^;
1 z' 2i
2. WELL LocAnoitk
unTown / (-iea, c
.3XZ o/ / Z 7
(aste.OWN%Cam* -valetalas,.toads)
3. cyfeid sl t7
f/i/iut Leil✓aera 114%eJ - 7 X 7$
Ob•clime err �V WAWA
AsaeerPisarb
Tof�1�L lQry am
Fran_ To
Proat___,__To ik
13.OROUT;Ac Dept Mrpod
Froat�To 2Q �G'JG/'r!J49 (c:(9°A ;chit
Print_ To Pt
14. SCREEN: Dept Dire- SkISin lwdel
Plow O To Ft,-__�s is
Fmk_ To Raja,
IS. SANWORAVELPACK:
Mott Sim Magid
From / DeTo Pt
From__To Pt.
16. REMARKS-
UrcaliatigiaCH
Sbow dinettes ad dimmos ie miler tom at but
two SIM Roods or County Roeda. Implode lbw road
moobms rod apmmm road ans.
7
1 DO may C®t'IEfYTHAT 11113 WELL WAS CONSTRUCTED>N ACCORDANCE an ISANCAC 2C. WELL
srANDARD`� COPY • MOM HAS BEM MOWED TO TIE WELL 09/NER
Sla(ATUtj ,1: _ .. r COPaTRflf0 THE WELL DATh
c i//
Sawa (bs original to Sr DMA* ofWear Quality, Gnodwaer Seelig,1636 Mai Sevin Car a a sh. NC
27N1.1N6Plea Ns.pif)733-3331.mMiY30days. OW -I REV.0712001

d46
9
WELL V¢NSTtVCnON RECORD
Noah agars - Detp..tst of Eaviranweet.oan Ramerc.. - Division cf Weer Quay - Oramdnrr section
wsu.oa r mAcmnpmevmum.)maa�sh i !/'1 C odes 3'e cuinnCATto(.Zn y
war. carntscroacoaQMWmesa JU.)et' wWA/ arse/! 7 naols. gathiZ-vim.
STATIC N LLCONSTRUCtmltri..QD A.IOC7ATIDMO
(If.mii.Eid
1. WELL USE (Cheek App ied:6 Boar Rs.id.otiat a Nmidp.YPnhlic D Ld..trial Q Aariapsd Q
Q *loony D Best Pep Wae.lejewkt 0 other 0 If Others rs Lit Use
2. WELL LOCATI
Nerakr
DCA Z 7rff
ob.rNanNwe. Cars.l4,Wa/�t'ti..._t{.rft.arc,ay
3 OWNBR.ropArrn y OPfriv O�%9 Addrea jf,r�nvtWV&
/th44'e7/P /it 7fie
Dias as, ZI air
L�
Awed Ws sear
4. DATE DRII.I� 7 /'%-o6
5. TOTAL DEPTH: 70;
6. DOS WELL REPLACB mamma WEIL? YES 0 NO lir
7_ STATIC WATER LEVEL. Bebw Top Stains fir.
Wire Mari Top seOsi sd
& TOP OPCAS1NG IS /6" PT. Above Land Slada•
*Top •ties waged enter lull r arm noires ■
fl. b.wrireS IM NCACIC AIM
9 YIELD (gad: xenon OF TEST 7,31-e,..-1
10. WATER ZONES (deputy
11. DLSIHFBCIION: Typo (C1'}t Amount A 0 7
12. CASING: Dt�y,r Wan Thaws
or WSW. Maid
Prom f Tod/C Ft tin SOP 4 /'UI
Prow__ To Pt: _
Prow_ To Ft
13. GROUT:
Fro t_ -ToS. A Ft (S H
Prom_ To Pc
14. SCREEN- _I TDepth Dion.- Matttiae een.e
Prow rO"I Pt..__m. in.
Fret To Pr _i. In
15. SAND/GRAVEL PACK:
Depth sae Mari
Pro.L-k_To Ptr_
Fron`_To Ft`_
16. REMARKS: rvfl
I DO mousy THAT TRW W8L WAS - --
DXM�fsi'AT10Y1RDl. AND t70PY
C
—1005
Toposhin/Lind newts
=did ark,. Malley t
(doe appaprine
Lalhoddloesihtda of well Radon
Latitodalowskads QaPSQT)oposeaphie seep
Rises Seal
MEDI 1mtttIWOrm
From To pj
aroaKRULIGUS
Show dit.oda. sod flan at lset
two smla Ronde or Costly Rands. WAS the toad
Emboss and mama road Crows.
�l
IN WITH ISANCAC2C, WHIZ
•RAS WIEN PROVIDED TO7 111V/13 LOWN OWNER
admit tw.rient to des Dlada.OWN* Qndb, Groundwater sstla., 1686 Mal R..te. Cagier -RISS NC
3769-1l6Pisa N.P19 fit, wilds 30days. GPM REV. 07/2001

fr""FRUCTION RECORD
North Carolina - Department of Etwironticat snd Natural Resources - Division of Water
/f X / Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME��prts�t) 4I/1n tom,/ fi ties � CERTIFICATION g 2 7 0 "/
WELL CONTRACTOR COMPANY *Asir' W ee T eon Aer �8// e I.wptHONE 0 nsj
STATE WELL CONSTRUCTION PERMIT* DISSOCIATED WQ PERMIT*
(if applicable) l (irappliable) r
v,i:�*� ti LSE 'husk Applicable Box): Residential OrMumicipal/Public 0 Industrial 0 Agricultural CI! , -n
h) P. bavny Cl heat Pump Water Injection ❑ Otter 0 If Other, List Use• a
2. WELL LOCATION:
NearestTowneau'r u, l�e County £t,1 c
(Street Nuae, N,mt s, Community. Subdivision, La No., Zip �) .7_ % J y
o4ad't > ..hL. c /�rl
Csa..+.A v lu ales`
/4 Ci/ 1/l {bC. 2'75`i'
City or Town Stun Zip Code
( }-
Ares code- Moue mamba
4. DATE DRILLED Z-/6 -06
5. TOTAL DEPTH: -GC5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO (�
7. STATIC WATER LEVEL Below Top of Casing: 35`o FT.
one ice* if Above Top of Cason)
8. TOP OF CASING IS / 11 FT. Above Land Surface*
'Top of casing tersuLaied atter bete* Ind sarfste requires s
varlaote is accordance wnb ISA NCAC 2C.O118.
9. YIELD (gpm): 0- 3 METHOD OF TEST /t nnYed
10. WATER ZONES (depth):
11. DISINFECTION: Type C. C /J( Ammmt /d
12. CASING: Wall Thickness
Depth _ 2>/g a Wd t.
From � To 20 Ft. :.�_ S
From__ To Ft.
ium To Ft.
.3.. TROUT: Depth __Material "/
tom 0i To Zv Ft. C op,cnfl
Pram -... To - - Ft.
Sit itraz mi to Dittman Sim Size Material
't0 i `r -...,, Ft, m in.
Pa+`ttt a x1 ,...y,._, •. Ft. in. in.
15. SAND/GRAVEL PACK
„( Depth Size Material
From(
To
t tn( Pen r j? �(� v DIZ a,� fe
Front To
Ft.
FL
^z
Material
PL'c
T wasithic/Land setting ' ' 7
❑Ridges at Slope CiValley ❑Fiat
(dbeck wwupt+ne boa)
Latitude/longitude of well location,
Neerewmimaedseroada>
Latitude/longitude source:❑GPSDTopo
(cheek box)
DEPTH
From To
Formation Description
tv
CD
LOCATION SKETC1j
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad names,
16_ REMARKS:
1 DO HEREBY CERTIFY THA THIS WELL WAS CON UCTED ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAt�t)4S, AND THAT A •a •ram' S Rj ORD HAS $ir:EN PROVIDED TO THE WELL OWNER
AT REG 2 `/F-G�
G THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone Na [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 09
0 r 4 ��
North Carolina - Department of Environment and N Resources - 7�!(tv/SSion ofWaterQuality- Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) r�/ i & JJ (. N /t C'cs "J - CERTIFICATION ## 2 / (2,,d/
WELL CONTRACTOR COMPANY NAME. J (A) E,F. I- t;; Filer t /R t „ c f/ T P. ,7�2 PHONE a C '' i LJ 7/) e
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PE
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential e2 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATIO
Nearest Town: Y ? ,%>,zr / County/�iwltt iisi
-Ft (?Qtt r.' >r i/'/titer//r fry- 7 7,:e:'
(Street Name, Numb/as, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Rd Nil tire/ lie
Address//it //72 6 /
/ye,37��6//t (Steer a RoutefrbNcio.)
City or Town State
Area code- Phone number
4. DATE DRILLED / ^3( . `(` t!
5. TOTAL DEPTH: I/Z i'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO La"'
7. STATIC WATER LEVEL Below Top of Casing: 9/' FT.
(Use"+" if Above Top of Casing)
8. TOP OF CASING IS 6 ( FT. Above Land Surface*
flop of casing terminated actor below land surface require a
variance in accordance with ISA NCAC 2C .0118. • /
9. YIELD (gpm): 'Z METHOD OF TEST / i /i1 t/f
10. WATER ZONES (depth):
-7»? 'c 7Z(.5—
Zip Code
11. DISINFECTION: Type (C-//
12. CASING:
Fro ToG Ft'
From To Ft
From To Ft.
13. GROUT:sx Depth
From t To i. C
From To
Amount /i �'-
Wall Thickness
e1;ht/Ft Material
Material
Ft( C'ir•?Ci
Ft
14. SCREEN: - Depth Diameter
From 7' To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
�Y! Depth Size Material
C
From To Ft.
From To Ft.
Topogrjp �c/Land setting
❑Ridge E lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DE
From To
a
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.
M /
Lam'" /77i /s
Slot Size Material
in.
in.
-
(tilt f`
16. REMARKS:
aC EE <
c CDn
3
'11� cc
ry m g
N
a. at o
0
o p Cl'
7
m
a3AI333a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTR. CT1ON STANDARDS A COPY OF 'RECORD HAS BEEN PROVIDED TO THE WF.I I OWNER
'�� L'‘ i ( -16 -z- _ I _ , ._C 6
SIGNATURE OF PE 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

RECEIVED
MAR 2 7 2006
Asheville Regional Office
t t P cparn ion
imeat of Environment and Natural Resources - Division//of Water Quality - Groundwater Section Q �/
WELL CONTRACTOR (INDIVIDUAL) NAME rtst) fir n C 8 X DCI Los V (4 CERTIFICATION # Z 7 O "/
WELL CONTRACTOR COMPANY N W € e iii/� eu r4 /rr' jA/e// /L.I,a.w�,PxoxE A
STATE Wr3L.!. CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT#
',,,,„a.�;,;�'_ _/ fifapplicable
k Ap plir ab a Box): Residential L7 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring [ Recovery 0 Heat Pump Water Injection I] Other 0 If Other, List Use
LL CONSTRUCTION RECORD
2. WELL LOCATIOpec
Nearest Town: PM, lit County et-usceva
Rio j3/u.c /fco,ti J)2 2S'ls-y
(Stied Name, Numbers, Community, Subdivision, Lot No, Zip Code)
3. OWNER: "Ai? Se/
Address eo u(�r .oi. DR
(Sneer ir Route No.)
frea'v/e"�L 2$7Sy
City or Town Stitt Zip Cade
( )-
Ana coda Phone number
4. DATE DRILLED / ' Z �' -O6
5. TOTAL DEPTH: 7 `/'S"
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ir
7. STATIC WATER LEVEL Below Top of Casing:.30C) FT.
//(Use "+" if Above Top of Casing)
F. TOP OF C: SINCI IS /$`�� ry'T Al --we Land Surfaces
*'3,4 . cad»,/, tt4u4, .t r,^ . - bgv).r }Pitt e?te \ti requIns ■
Noserdike 41th i?A NCA 7x € /
g r y cr§wg, i LL. Mtn,nrt G TEST /i /- r
10. WA(nit CONES (depth):j
11. DISINFECTION: Type C C %/ Amount /0 0 2
12. CASING: Wall Thickness
y( Depth or Weight/FL
From !v To %� Ft_�t Spa / C
From To Ft.
From,,,,. To Ft.
13. GROUT: Depth / Material
From 1 To 20 Ft/ /1/7Ceen
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From fill To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From p To Ft.
Msdad
Wei
Topographic/Land scttin
!]Ridge [Slope [Valley
(check. not# box) t"-.)
Latitude/longitude of well location
mesmeaminaraameenda
Latitude/longitude source:DGPS❑Topographic map
(cheer ea)
DEPTH DRILLING LOG
From To Formation Description
J.00ATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common ro:.. ,, s.
.._.._._. NCAC 2C, WELL
IV' Iit::tr' SSiuvi3Ai d�' ii T" T A (V'Y Uf ' ill C(7RD HAS 13E l PRUV1DEp TO THE WELL OWNER
SIGNATURE OF 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

e rt
15. SAND/GRAVEL PACK
Ai Depth Material
From Alf To
From To Ft.
r--, injection O Other D I
Nearest own: i/Y/ ///1oC& ICounty47t CpiHA
4/3 B/err &lam OK P9h way r,g43
(Street Name, Numbers, Community, Subdivision, Lot No., 7iP ode)
3- OWNER: l.vi'////4f i co,//t,eC
Address .3_n/1ltt.+e /Jlr/As9l /�
(Brie[ or Rome No.)
/C/f/i'tT, tcd MJC -z.874 3
City or Town Stoat yip Cote Area code- Phone Lumber
4. DATE DRILLED / ' 2 0 —0
5. TOTAL DEPTH: 3M S`
6. DOES WELL REPLACE EXISTING WELL? YES D NO E
7. STATIC WATER LEVEL Below Top of Casing: /CO FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS / S3 FT. Above Land Surface*
'Top of casing terobated Wow below land surface requires ■
variant la aecordsoct with ISA NCAC 2C .0118. 9. YIELD (gpm): 2. METHOD OF TEST /: 'n ea(
10. WATER ZONES (depth):
1 I. DISINFECTION: Type CC/f
12, CASING:
�f
Off 10 ';..(a ly
From $ To 70
Frcrn Tc•
d t i“ 2A1eif5..,;
Amount /0 az
Wall Tbiclmess
or Weight/Ft. Material
5&tz/ IUC
RECEIVED
MAR 2'7 2006
Asheville Regional Office
u a Prate GOD
t ORD
of Environment and Natural Resources - Division of Water Qua'.
WELL CONTRACTOR (INDIVIDL) UANAME t) at/eel C PAC /WS D—
WELL WELL CONTRACTOR COMPANY N in e / Lunt fee" jjl/e// r /
STAT! wt+l t rONSTR(tCPO PFreirT#tsst..^k"=74+It-c.
rt,cn F) xt 1
c? cl
- Groundwater Section �Q+/�
CERTIFICATION V 2 7 0 /
,.PRONE e 2IK6 Y9'-aygo
TiG i art; atial ❑ Agricultural I�
Other, List Use
Topogn}phic/Land setting
°Ridge 51ope DValley DFlat
(check aprmptine nor)
Latitude/longitude of well location
(degreesbnimiscrisceonclO
Latitude/longitude sotnce:DGPSOTopograpidc map
(check box)
PRILLFNG LOG
Formation Description
D,EPTI-I
From To
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.
n�/C�e}/e WP 1' rrrl�
Slot Size Material
in.
in.
Size
Ft.
e 4'
16. REMARKS:
11)0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON SZ CTION STANDARD THAYA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P
CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceater -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
c e s :;xc' k.4 ncp-ys 3 e z. ' snvimormtent andNaturalResources - Division of Water - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME J nt) /'1 / l�n C _Ph D e d'SCERTIFICATION # 2 7 O 17
WELL CONTRACTOR COMPANY N to€ e iif LA) /R )4 t' We!// V /4 9 /[-f'4AvvPRONE a io Fi Y c;)
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential lei Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Rewvery 0 heat Pump Water Injection 0 Other 0 1f Other, List Use
2 WELL LOCATION;
. nar?"-s* ,-„x R r County )7u+tetrw6
gtsy&vss cleRf zS7.5-9"
: 1e-tt7— n .:t,' :n 4aa. Community, Subdivision, Lot No., Zip Code)
3. OWNER: Z0%l(7 /16'k ',�5.4r
Address 4' lvt°.- -' .., A Al
(San or Race No.)
LA) art) 4en/i' m iv e_ 2875-V
City or Town State Zip Cade
( )-
Ara code- Phone comber
4. DATE DRILLED / -4)-0 'O 4i
5. TOTAL DEPTH: 2a r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 30 FT.
(the -4-- if Above Top of Casing)
&. TOP OF CASING IS / 4/ .t FT. Above Land Surfaces
*Top of aWag terminated attar blow tad *arfasa require* a
variance in accordance with I.SA NCAC 2C .0118. _
9. YIELD (gpm): 3 C2 METHOD OF TEST /r %f•Yn7
10. WATER ZONES (depth):
11. DISINFECTION: Type eC/><
12. CASING:
From__9 Too 0 Ft
From To Ft.
"et.
Mysod
zi .. n erE ._... We it`s/jr
Flom io
Topagzy1ffdLand setting
[Ridge Olive Malley °Flat
(check append/de Mx)
LatitudeAongitude of well location
(degtera niauteUaecceds)
Latitude longitude source: OGPSOTopographic map
(check boa)
DRILL1NCLLOG
Formation Dce..ri 4ton
DEFLU
From To
c
N
).00ATION SKETCR
Amount /0 as 7 Show direction and distance in miles from et least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/FL • numbers and co ..... road names.
Sp A' uc
weJ/ �`a-
•
tar
14. SCREEN: _4, Depth Diameter
Froat__LG_ To Ft. m.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From, 5 To Ft.
From To FL
Slot Size Material
in.
in.
16. REMARKS:
RECEIVED
MAR 27 2006
ah®viny Re yiui ial Office
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 7r Muller Protection
roNSCPJFCrt^! STAND p , NZ) 7)C A COT' nr THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
k,
CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality. Groundwater Section.16.36 Mail
`"k * TP as N;i..%s e 33-1,,ii, wfats 3e itari,
DATE
ice Center - Raleigh, NC
GW-1 REV. 07/2001

c't
t_i i ©
WELL CONSTRUCTION RECORD
Nadi CaMUM - DepitfilSEHt Of EibritOtiiikbt $lid llittrAl Reaoulces - Divis n of Water Quality - Groundwater Section c /�
nu. Cbtfttut: n oinstvInta414A It (yic43 J - --_ �+�'}- -- —1 --- CERTIFICATION A Z7 �l
WELL CONTRACTOR COMPANY NAME S�J-� P P INA fir LAW/ 9 Pi.tt f" PRONE a «2i?) G,5'9 -04730
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT*
(if m,plicable)
Of applicable)
1. WELL USE (Check Applicable Box): Residential L7 Municipal/Public 0 Industrial ❑ Apical
Monitoring LI Recovery ❑ Heat Pump Water Injection ❑ Other O If Other, List Use
2. WELL LOCATIO
Town: �1__
ni /y/0A i Ue !r, Ui` Y -Mot
T &Land :. w
QRidge C7Slope QValley ,t
(check apptapdate box) r-+
(street Naar, Numbers, Community, Subdivision, Tat No, Eip Code) Latitude/longitude of well to io
(de) ! 5
Latitude/longitude source:DGPSOTo
(aback boo)
3. OWNER: (/4/4%% /
Address (y 4 fR2iior lexeiti iciar
or Route No.)
11951i /i%!Y NC 7 flc/
City or Tower Sale Tap Cade
Area code- Phone number,
4. DATE DRILLED y'Z-(J-'06
5. TOTAL DEPTH: .3n —
6. DOES WELL REPLACE EXISTING WELL? YES NO S—
t STATIC WATER LEVEL Below Top of Casing: � I3
2 FT.
/G/r (Use"+" if Above Top of Casing)
8. TOP OF CASING IS / 0 Ff. Above Land Surface*
`Top of cadag twt ad Misr below land mutate requires a
Mann L asmrdaece with ISA NCAC 2C A1111. /
9. YIELD (gpm): S— METHOD OF TEST /, fene'e
10. WATER ZONES (depth):
11. DISINFECTION: Type r C /
12. CASING:
From__ToS Ft .1W
From_ To Ft.
From_ To Ft.
13.. GROUT: ����soc�� {
Fro®_ Too 2D Ft. (psY_/'�lG cie /Y/ii
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
Fronx_t_ To Eton. in.
From To Ft_in. in.
15. SAND/GRAVEL PACK
Amotmt /0 o
Wall Thicimess
or Weat. Material
/ tot
DEPTH
From To
Depth Size Material
Fron�To Ft.
From To _ Ft.
16. REMARKS:
1 DO HEREBY CER THAT THIS WELL WAS a a NSTR
CONSTRUCT[ ARDS, AND MAa •, OF •a .: HAS BEEN PROVIDED TO THE WELL OWNER
Formation
c map
oG
LOCATION SKEFCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
umbers common road manes. o
• 2
cle1470,77,
Poe
Q.
CZ
RDANCE WITH I5A NCAC 2C, WELL
SIGNATURE OF PERSON •a, STRUCIINGTHE WELL
DATE
Depth
Submit tie original to tie Division of Water Quality, Groundwater Section, 1636 Mail Service Cent -Raleigh, NC

WELL CONSTRUCTION RECORD
Nadi C h i1M - Deps-tli flt of EH9iiciiiiietlt Mid N
WELL tbtttli ttt%A 11It) WiitW) NAME (�
WELL CONTRACTOR COMPANY NAb1Er5LOV /
STATE WELL CONSTRUCTION PERMIT#
(rfappiieable)
i•
Resai rc s-Division of Water Quality - Groundwater Section
-'-le ASes- --T /? -. _ CERTIFICATION • 272; V
er well Y �tnip
ASSOCIATED WQ PERFIITw
(if applicable)
327794
1. WELL USE (check Applicable Box): Residential BrMnnicipa1/Public 0 Industrial ❑ Agricultural ❑ 1 ;>
Monitoring D Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use If}�r
`A CD
2. WELL LOCATION: n
Nearest Ton lAretc tfi/hff County lJj.t,1LGrpI
$ Z 13or1/27,- 5/rc< vale a i l 5`9'
(suet Name, Numbest, Cmmoony, Subdivision, rat No., Tip Code)
3. OWNER: /l Cb IJ9(LS Ley
Address !) Z nnn/" /J//a/ 7 /)/e
twat ow (Street
! I1,RoteYC
2 7-7S-9
City a Town Sue Tip Code
(^ -
Ares cods Phone number
4. DATE DR/LED ' -7-c 4
5. TOTAL DEPTH: '7 (n Z
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cr
7_ STATIC WATER LEVEL Below Top of Casing: �T.
i( (Use ^+" if Above Top of Cants()
8. TOP OF CASING IS / X FT. Above Land Surfaces
*Top of easing taw:heated atter below laud surface requires •
variance a aeeord•ace with 1SA NCAC 2C Alrt. -�
9. YIELD (gpm): / 5 METHOD OF TEST / i /Y+ en(
10. WATER ZONES (depth):
11. DISINFECTION: Type PC44 Amormt /(i G Z
12. CASING: Wall ThicknessFrom , n,, /�a�'
..i Depth
To FL_D74 gp,e l t_
Ft 1S
Fromm_ To
From To
13. GROUT: Depth
Ft� To ZD
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
Ft.
Ft 448417,11
Ft
Diameter Slot Size Material
Ft_in in.
Ft_in. in.
r1'opogaphic/Land setting
d Midge OS ope BValley tl
(cheek appropriate box) -U LD
Latitude/longitude of well Iocation\'Gr 75-
Latitude/longitude somce:OGPSEITopogra qc
(check box)
DEPTH st GiOGm
From To Formation Desc 'prion
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.
Ft.
Size Material
From To Ft.
16. REMARKS.
r
U
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCr1ON STANDARD AND T A OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c— — 7"dK
SIGMA OF PERSON CONSTRUCTING THE WELL DATE
rrl
0
rn
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Submit the original to the Division of Water Quality, Groundwater Section, hail Service Center - Raleigh, NC

3 9 'IS 7 8
WELL CONSTRUCTION RECORD
North C oli1S3 - 1,€08ftit&t bf E6Vfttifsitibht 6tid N84aa1 Rei;Ouroes - Di on Of Wafer Quality - Groundwater Section
{V$1.1.. tidittlealtilt (ff>briffit1AL) NAME . CERTIFICATION # i e,1".
WELL CONTRACTOR COMPANY N at->!it1l�:t1 ' / ' � U / PHONE # (7ZR1 /o Y9o.cfl
STATE WELL cONSTRUcrfoN PERMIT./
(if applicable)
ASSOCIATED WQ
(if applicable)
1. WELL USE (Check Applicable Box): Residential Cr' Cmicipa1IPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery D Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 4 i County,
3.
7670 r / Subdivision, /41/3- //) z€7s3
OWNER 6.�?/�y i a(
Address 7 D' Mk
riiniS it NC , 2-7err 3
Topographic/Land setting
�e OVailey
DRtdge (cheek appropriate box)
Latitude/longitude of well
Megmesfritinuteshecoods)
Latitude/longitude source:OGPSDTopo
(deck box)
DEPTH
City or Town Stale Tsp Code From To
Amu cods Phone amber
4. DATE DRILLED ci
5. TOTAL DEPTH: 2- 4/5-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: / Z „FT.
(Use '4" if Above Top of Casing)
8. TOP OF CASING IS /5 °' FT. Above Land Surface*
'Tap of caataa ter daaead Wier below pad surface requires
mimics d aewrdsace with ISA NCAC 2C DIM /
9. YIELD (gpm): 1 5—METHOD OF TEST /f 'n re
10. WATER ZONES (depth):
II. DISINFECTION: Type tcC/S( Amoumt /0 CJ'7
12. CASING: tar;
Wall Thickness
Frost_ To _Ft lP %'f C/7K'l/
From_ To Ft.
From To Ft
13. GROUT Depth Merciful /
From To 20 Ft.C_/I/1l./'tl`l
From To Ft.
N
S
CD
c
CD
0
c rn
c
Formation Description
LOCATION SKETCH
Stow direction and distance in miles from at feast
two State Roads or County Roads. Include the road
numbers and common road names.
Wf, YA% 1V
14. SCREEN. Depth Diameter Slat Sim Material
To
From To Ft in.
15. SAND/GRAVEL PACK
Depth Size Material
From 0 To Ft.
From To Ft.
16. REMARKS:
/n
six
I DO HERESY CERTIFY THAT THIS WEIL W . CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, ;s! ' THAT :/' a ' Y OF TyHS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CO
7f 0O
SICiNATURE OF PERSON CONSTRUCTING THE WELL DATE
W
0
m
Submit tbe original to the Division of Water Quality, Groundwater Section, Mall Service Center - Raleigh, NC

804 CT ,r Y
WELL CONSTRUCTION RECORD
North Cit6US - Digit bf EhY>#gtthiebt rind Na' Reimers - Divin of Water Quality - Groumdwater Section �/
WILL tam-tutus& ('1l'tfitVlbtlu) S t % ' / 0 C kItt2 es .5W LeatTlFlC[A.G1 T,IION X7� L
/
nu. CONTRACTOR moment NAME u)PP jA )� err (,U eIf / la%�'! PHONE t VK 6 9 -Ci %!Jy�
STATE WELL CONSTRUCTION PERMIT, ASSOCIATED WQ
Cif applicable) Cif applicable)
I. WELL USE (Check Applicable Box): Residential l"Mmticipal/Public 0 Industrial O Agricultural ❑
Monitoring O Recovery 0 Heat Pump Water injection O Other 0 If Other, List Use
2. WELL LOCATI' /
Nearest Town: : ?U /e( Co . Qttele. tti
Zt?
(Sena Name, Numbers. Coamway,
tat No, Zip Code)
3. OWNER: Soc /11r h A/'ii Ck
Address 7n95- P Pi?
(Seen or Rave No.)
n'52 4ite ` AU_ 2?7/$—
City at Town State 2p Cade
Ana code- Phone amber
4. DATE DRT. r ED $ O 4
5. TOTAL DEPTH: 2 S`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO its
7. STATIC WATER. LEVEL Below Top of Casing: 3 0 FT.
(Use' f" if Above Top of Caning)
8. TOP OF CASING IS /or /r FT. Above Land Surface*
"top of eaaiag tenanted oar blow bud mace napalm a
Mua a accordance ale ISA NCAC 2C .01111. /
9 YIELD (gpm): ZS— METHOD OF TEST 4rr!e
10. WATER. ZONES (depth):
Topoghic/Land
t7Ridge OSlope DValley
(check appropriate box)
Latitude/longitude of well I
(dnp—miainewewmdo
Latitude/longitude source:OGPSOTo
(check box)
DEPTH DRILL
From To Formation Description
I I. DISINFECTION: Type CC/>/
12. CASING:
From__ Tom 0 0
From__ To
From To
thter
Ft b %F/
Ft
Ft
Amount i/ a 7
Wall Thickness
nit
13. GROUT: Depth .Maw
From (5 To 20 Ft ( l ltea r/ 6Q r
From To Ft.
14. SCREEN: Depth Diameter
From To Ft_in.
From To Ft in.
15. SAND/GRAVEL PACK
Depth Size Material
From 0 To Ft.
From To Ft.
Slot Size Material
iD.
in
car
relic map
Show direction and distance in miles from at least
two State Roads or County Roads. y • the road
numbers and common road names.~..
a ✓tI/
('Ut9i°5
c
G
w
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WEIL WAS CONSTRU IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST S, AND THAT OF RD BEEN PROVIDED TO THE WELL OWNER
s-3d--cC
SIGNATURE OF PERSON CO CTING THE WELL DATE
0
U
Submit the original to tbe Division of Water Quality, Groundwater Section,1636 Mall Swig Center - Raleigh, NC

(1
u t
WELL CONSTRUCTION RECORD
North Cato lllsd - Dipltt alt Of Efl itotthient Mfl Natjral Resources - Divisi of Water Quality - Groundwater Section
WELL I.`#iNtLi.CItillanntIMIAL)NAME (del (dFS-- tAstIMICATIONp
WELL CONTRACTOR COMPANY NAMEc(U P 'W -% tV P /1 % U,N /l PHONE *
STATE WELL CONSTRUCTION PERMIT* ASSOCIATED WQ
(if applicable)
(if applicable)
1. WELL USE neck Applicable Box): Residential ri4umicipal/Public 0 Industrial ❑ Agricultural E
Monitoring ❑ Recon y 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nearest Town: i � County eit/t/i/at {7
4O9Z ((rX.C/n (or) 7$76e0
(Street Na Numbers, Cammuciq', Subdiriaaallo, 2. tat N, Code)
3. OWNER DCN'S R/74vr /S
Address 603Z Cur izen r im P Rot
� (Street or Rowe No.)
City or Town State Tap Code
Arta code- Phone comber
4. DATE DRILLED V - 4.7- U C
5. TOTAL DEPTH: / 6 S
6. DOES WELL REPLACE EXISTING WELL? YES 0 .NO EY
7. STATIC WATER. LEVEL Below Top of Casing: / /e FT.
R // (Use "+" it Above Top of Caring)
8. TOP OF CASING IS / O FT. Above Land Surfaces
'Top of cooing terminated at/er below tad surface requires a
wince lo accordance with ISA NCAC 2C Atrt. �^
9. YIELD (gpm): z- METHOD OF TEST 7 7;Th
10. WATER. ZONES (depth):
11. DISINFECTION: Type Amount
12. CASING: Wall Ts
!jm tr or Weight/Ft _KILL_
From O TowDepth
Ft_��_ %G/ $D/Z'Z/
From_ To Ft.
From_ To Ft.
13. GROUT: Depth Material M
Form (� To 2� Ft( p!4 tte, se X
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From4_ To Ft_inn. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
Frog To Ft.
From To Ft.
16. REMARKS:
Topographic/Land set -
❑Ridge ❑Slope ❑Valley.
(check appropriate box) CD U 7
Latitude/loagitude of well IOD
oc4
°
(degneeshni>tim/aemads)
Latitude/longitude source:❑GPS❑T
(check boz)
DEPTH FRILL
From To
CST
0
`0,
ogre�tic map
'NG LOG
Formation Description
Show direction and distance in miles from at Feast
two State Roads or County Roads. Include the ro
auumbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCIED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUON STANDARD THA A COPY THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SICONATURE 0 ERSON CONSTRUCTING THE WELL DATE
Cap
c
03A1333E
c
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC

327792
WELL CONSTRUCTION RECORD
North wont - Spiih:seitt bf Elfv ttitihieht knit blityral Reboiirces - Di of Water Quality - Groundwater Section
WILL CONDUCTOR ONIRDIsv u l NAM -� /G�- RAO 4e5 )7A, - iX TIFTCATTIoN.27E51
M WELL CONTRACTOR COMPANY NAZSLUPto CANWatr LA.9e// ? ,4 . raoNE / (cSZI& i0 41p-cn&1
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ P
(rf appireeble) (if applicable)
I. WELL USE (Check Applicable Box): Residential V Municipal/Public 0 Industrial 0 Agicultural 0 co
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIgrz ro
onij
Nearest Town: /-/�/� v/ t='t-ll County a �
/236 6Rrr*av Creek pi 73o
(Sestet Name, Numbers, Cammmiry, Subdn Soc. tot No., 24 code)
3. OWNER: f so / Pre-%#
Address 1734 &4'ren cEeeg t
(Streeter Route No.)
Ft9m/tu/et ,uc
2273 D
City or Towu State Tip Code
Area code- Phone camber
4. DATEDRILLED S -/6 `04
5. TOTAL DEPTH: '305—
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO el/
7. STATIC WATER LEVEL Below Top of Casing yD FT.
4 (Use ice if Above Top of Cuing)
8. TOP OF CASING IS / D tt FT. Above Land Surface*
`Top ofedng terefiamd atfar bdow hod sodas* requires ■
tnLaw to asmrdesee wnb 1SA NCAC 2C Ai1i �-
9. YIELD (gpm): /0 METHOD OF TEST / /M ea
10. WATER ZONES (depth):
11. DISINFECTION: Type rl; //
12. CASING: -,
Fmm 0 To /% D Ft (Q 7�
Fri_ To Ft
From To Ft
Amount / CJ 0 7
Wall Thickness
a Weight/Ft
5,942-z/ jell c
13. GROUT: r /
From To, ZD FL( nits- tr
From /!!//! To Ft
14. SCREEN:
F
Depth
T
From To
15. SAND/GRAVEL PACK:
Depth
To
To
To
Diameter
Ft_ia
Size
Ft.
From
From
Method
10--?et Yh/
Slot Size Material
in.
in.
Material
Ft.
Latitude/longitude source:OGPS0Topo
(chat tax)
DEPTH
From To
7-
TopC35lope �Pb�ic/Land setting
ORtdgeOVaney to
(dreck appropriate box) l o �Ei
Latitude/1ongitudeof well location . z
ley w
'0 O
c rOp
co
Formation De:
JKEATION SKETCH
Show direction and riidaert in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
cIkc
%23‘
&Lott40°5e
jk) ( t
(r'0 Dri`ty
16. REMARKS: taV
4
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH 15A NCAC 2C, WELL
CONSTRUJTION STANDARDS, ; u . T COPY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c
1,
TURE OF P ' aN CONSTRUCTING THE WELL
5 /(O oc
DATE
r
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC

43 )-) Mc,9
�rut((-)
WELL CONSTRUCTION RECORD
r461th earwig' - Dtp*tt/lif t Of Ehv1F6Sttefit Iiid Fla(/al Reaomceess pivitiiiin of Wider Qtatlity - Groundwater Section
t1 gLL difttLittaS �Ni1tVt tl u j to �j . . 1 // 07-e— /C Ao e6 `✓ e LAin tICATIONLrtZ G� c
V
WELL CONTRACTOR COMPANY N W� PP (VI9 Lv to// f . _� PHONE a (Sz(9 C'Y2oo
STATE WELL CONSTRUCTION PER61X111 ASSOCIATED WQ
Cif applicable) Cif applicable)
1. WELL USE (Check Applicable Box): Residential BiM®icipaVPublic 0 Industrial 0 Agricultural
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATI N: //
Nearest Town: W/'4/14/1X.V9 Cony �i tntroty%
3o-z /1/2w,r a.-t A/.%/ Die "F76 3
(Street Name, Nambaa, Canmtmity. Subdivision, to No, Tip Code)
3. OWNER: ///14 /A4rice
Address 30 7 h/19r/t/Sn.,t Me /.)*)
(Stria or Rome Nod
Ci) A/u;4/cXo,' TUG= 2 a-7'6 2
City or Town Sage Tip Code
Arca tab Phone number
4. DATE DRILLED 5 =/D - c4
5. TOTAL DEPTH: / V5'
6. DOES WELL REPLACE EXISTING WELLS YES 0 NO 0"
7. STATIC WATER LEVEL Below Top of Casing: / 7 FT.
p ( if Above Top of Casing)
8. TOP OF CASING IS �(tin+' O FT. Above Land Surfaces
'Top M using terminated atter below and surface require
mince In accordance with 15A NCAC tC A11i. '7— /
9. YIELD (gpm): 3 C) METHOD OF TEST / / enee
10. WATER ZONES (depth):
11. DISINFECTION: Type C C /y'
12. CASING:
From To i C Ft
Amotmt /0 d7
Wall Thickness
or Weight/Ft. Material
OP-2/ PVC
Topo d seal
tige Eli Walley
❑RilY]it
(check appropriate box) CD
Latitude/longitude of well loci ck_
v 0 ram-,
(depu tlmmaelwwnth)
Latitude/longitude source:❑GPS❑Topogthphic map
(cork box)
DEPTH PRILL NG-Eee
From To Formation Description
From_ To Ft
Ftnn1—To Ft.
13. GROUT: Depth �Mate�ial
From_ To 26 Ft4ncrek (.t>P- r7t/
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
Fri To Firma in.
From To Ft.in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From 7 To Ft.
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include 'i; . ad
numbers and common road names. `j
P i it
i�.
see
16. REMARKS:
T DO HEREBY
TWICTION CERTIFY THA STHIS WELL WAS PY OF THIS RECORD HASONSTRUCTED IN SBBEEN PROVIDANCE WITH ED THE WELL OWNER
a� �� S =/O-0
S1GNA OF PERSON CONSTRUCTING THE WELL DATE
•
Submit the original to tie Division of Water Quality, Groundwater Section, 1636 Mali Service Center - Raleigh, NC

e M4
WELL CONSTRUCTION RECORD
North catmint - bit tif$ht+itFiibtkNt N" lb-M:6ucea /- Division of Water Quality - Groundwater Section
Wei itSlhlll(LiI31E( IttiBiubiRaft .11° h Ttos Ji('- CflT1r1CA•IONaZ7R
WELL CONTRACTOR COMPANY NAME St U QC Kr, 1.t% PLL 7 /311 A - PHONE /
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ
(1i applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ids Mmucipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injestiou D Other O If Other, List Use
2. WELL LOCATI : 7
Nearest Town: 0.4/Ut9 nip 4-County /S utin:rl /1
b37 5cP,u/c. u/i°W 01 -7R7/7
(Stec Name, Numbers, Community, subdivision, pat Nt, Tap Code)
3. OWNER Atnion b 17)
Address 16 37 5r e/Ot L• / e w 04'
(faucet a Rase No.)
5.4:44,w9 /unaf /V G 2 -e 7(p 7
City a Tara Sure rip Code
Area eat- Plume somber
4. DATE DRILLED 5 ��
5. TOTAL DEPTH: l 5`
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er'7. STATIC WATER LEVEL Below Top of Casing: % FT.
cif (Use ^+" if Above Top of Casing)
8. TOP OF CASING IS l 0 FT. Above Land Surfaces
*Top of easing terminated aHor below bad surface require a
misses In aeons+ midi ISA NCAC 2C Ala /
9. YIELD (son):S% METHOD OF TEST / / !)'t re
10. WATER ZONES (depth):
11. DISINFECTION: Type l r
12. CASING:
From To Ft fl / f
From_ I2/9 To Ft
Front_ To Ft.
13. GROUT: Depth .//
From t9 To 7-0 Ft Ch f tt WC /7*/X
From.... To Ft
14. SCREEN: Depth Diameter
From cif To Ft_in.
From To Ft. in.
15. SAND/GRAVEL PACK
Depth She Material
From To Ft
From To Ft.
t�
T
0 <
Topoggtap�d setting =. tD
DRidge BSlope Malley Iikatm
(check appop:iate box) :U to
Latitudellongitudeofwell Iocat* i v'
(dep hnimontlsecaods)
I.atitudelleagitude source:OGPSOTo
(cheek box)
AEPTH
From To Formation i 'p
Amount 47 07
Wan Thickness
or Wei-Z/ RUC
Slot Sim Materiel
in.
in.
CZ
c-�
cr(
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:
I DO HEREBY CERTIFY THAT THIS WELL W
COTCON STANDARDS,
ICJ
CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
T • • • OP IIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF
N CONSTRUCTING THE WELL DATE
Submit tie original to tie Division of Water Quality, Groundwater Section, 1636 Mae Service Center - Raleigh, NC

327707
WELL CONSTRUCTION RECORD
Nosh Caitlin - Depitdftiift Of Eliltbatithitit laid N$ttaal Reectucss - Division of With Quality - Groundwater Section
WELL butn'It# tt$k intnwusu,u) ti 1Ik a itti /fsi C flrrr c PO'S - .. aK ... ctrttr canon eZZILY
WELL CONTRACTOR COMPAICY NAME S t:1 v f I.uiiIYV c ell % lit. PRONE s iglint.V510
STATE WELL CONETRUCflON MOOT/ ____AESOCIATED WQ PERMS
Of a.Pltcsble
(NaaEIta41e)
1. WELL USE (Cheek Applicable Box): Residential 2 iitmicipal/Poblic ❑ Industrial 0 Agtiooit al 0
Monitoring 0 Recovery Cl Hest Puma Water Injection O Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
21 Lisa lr ,;, lent,
(Serer [al
Craumnity
3. OWNER: !J01 d
R/S e
Address 7 / r Lt aa X i ^ fr
te Nos
Zip Code)
LAYx)r` )0An Az. 7'37‘1
76Z
err a Town Mrs Tap Code
ManAs tear Eton amber 4. DATE DRILLED Jr- 5-- j
5. TOTAL DEPTH: 47) 5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er'
7. STATIC WATER LEVEL Below Top of Caring 8O FT.
// OM ^9iWAbon Top dCasing)
8. TOP OF CASINO IS % Do FT. Above Land Surface'
'Tap state aradan4i tow blew hod marten nealra ■
mYaas r amwdaa with ISA NCAC tC AEU.
9. YIELD (gpm): _ METHOD OF TEST / r ern Al
10. WATER ZONES (depth):
11. DISINFECTION: Type r (/5"
12. CASING:
From pi To Depth_
Ft /a l;J
Fran_____. To Ft.
From To Ft
13. GROUT: ar Depth.
Too eo
From To Ft
14. SCREEN: Depth Diameter Skit Sim Marital
Fro _ To Pt_ jn is
From . To Ft is ia.
15. SAND/GRAVEL PACK
Fram._�To Pt.
Frua To Ft.
•
T c /Laid setting
°Ridge�p pe0Valley OFIst
(duct atererboa)
Isitiadellongilude of Well location
Latitada l giarde wmce:OGPSOT
(mob)
)
From To Formation Deacri
et
c
c a)Co
m
PP-.O
CD n
o 0
LOCATION SKETCH
Amount _62_10 ' Show direction and distance in miles from at least
Wan Midmost two State Roads or County Roads. Include the road 7
err wtr Mtttervi imam and common ttatnes.
ca
(/ IG/f��r
W L°X dh/i/
16, REMARKS
Sim Materiel
I DO HEREBY TWFY THAT THIS WELL AS
STANDARDS,
SIGNATURE OF P
UCTW ACCORDANCE WITH 15A NCAC 2C, WELL
OF TIi1S
HAS BEEN PROVIDED TO THE WELL OWNER
t5 (
CONSTRUCrINQ THE WELL DATE
1
Srbait the original to tie Divider of Water Quality, Grsodwalar See*",1pti Mal Sarah Cain -RAMIS NC

WELL CONSTRUCTION RECORD
Nonh Caton* - D*tettlent bf Eilvitiitiuietltlota Ni
WELL C*PT171ActOR dialtVmY414 N4.18$
WELL CONTRACTOR COMPANY NAME S(.0 e
STATE WELL CONSTRUCTION PERatrra
(aft)
___ASSOCIATED WQ
(if applicable)
Resources - Dyvision of Water Quality - Groundwater Section
LautwlcA.TciioN/ 8
e7
IO�.F Y
PHONE $ g9-e%Y2c.
1. WELL USE (Check Applicable Box): Residential eMonicipaVPublic 0 Industrial 0 Agriwlturai ❑>
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: / /
Nearest To : (JH7 tot � `(e ` > County ��ttrt(
3/g [ n i S 7ts754e
(tram Halt, Numbers, cammmiey, Subdivision, la Na, try code)
3. OWNER: Cnvt Xr 0-4 er
Address 3/S /4L art /Jf7/;
(Stir 9r¢ Route No.)
Wee1C9r'PV;fir tI 7_?%S"51
CayorTown Stain Zip Code
Aria coda Iwme =sober
4. DATE DRML D .7 —7 -Ld 6
5. TOTAL DEPTH: 7 $s
6. DOES WELL REPLACE EXISTLNG WELL? YES jig _NO B
7. STATIC WATER LEVEL Below Top of Casing: �� FT
�� (tlac ter' if Above Top of Caring)
8. TOP OF CASING IS l� FT. Above Land Surface*
'Top of easing teradubd attar below bold whim nga4n a
Twines ta amrdaacc with ISA NCAC 2C Alta.
9 YIELD (gpm): 3 G METHOD OF TEST /i rYt C/
10, WATER ZONES (depth):
11. DISINFrECTION:Type C t /f Amount /O 07
12. CASING: Depth, �yra �, Wor Weight/Ft. Material
all Thickness
From d To S!2 Ft5b,
From To F
From__ To Ft
13. GROUT: Depth / Materal
From 9 To Z(: Ft. Cneti,r'J G
From To Ft.
14. SCREEN: Depth Diameter Slot Sim
F� To Ft Jn in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Sire Material
From Al To Ft.
From To Ft
J'{
Topod
r7Ridge t]Valleyro Fiat
(duck appropriate bon) v ,
Latitude/longitude of well
( 5
Latitude/longitude source:QGPS
(check box)
DEPTH
From To
tin
hie map
0
LING TOQ
F• •• • • Description
Show direction and distance in miles from at least
two State Roads or County Roads. Include the a road
numbers and common road names.
fit/ iftd/0/0{N
Q^�
0
16. REMAR :S:
PUP
IN ACCORDANCE WITH 15A NCAC 2C, WELL
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P n' "a CONSTRUCItNG THE WELL
1,
m
C)
rTl
C
0
DATE
Sutrtoit the ortglnl to the Division of Water Quality, Groundwater Section, 1636 Man Service Crater - Raleigh, NC

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # t-,f'w
1. WELL CONTRACTOR:
/Z 'J .<//er1
Well Contractor (Individual) Name
_Lew s,,r 6'Qtr)�-.1Tr Ll:n
Well Contractor Company Name
STREET ADDRESS
2 Yi r /
fic-if e I it-
vc_ p Code
City or Town State Zip Code
( L3J )- 67. — Sefr
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
STATE W ELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applic ble Box): Residential Water Supplyrp
DATE DRILLED O �`t-,4
TIME COMPLETED /((' CC} AM [l/pM
3. WELL LOCATION:
CITY: AS bPVV. Ile COUNTY )t.A. V1 C. (In la
N4,
�YL`}A)l ��•
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley at DRidge ❑Other
(check appropriate box)
LATITUDE f�3 S//"j/ ,SS )V
LONGITUDE P/ 5 /00 W
Latitude/longitude source: �iPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form it not using GPS)
4. WELL OWNER '
OWNER'S NAME O- itY) Rig -.
STREET ADDRESS,. a r Lam' O.77
•City or Town State Zip Cade
(S s'8)-777— 79a?9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Vor
May be in degrees,
minutes, seconds or
in a decimal format
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing:
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS ._L FT Above Land Surface"
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): 5r METHOD OF TEST %r-,J
f. DISINFECTION: Type ,%/ y Amount 6 o>
g. WATER`ZONES (depth):
/
From / ` , 6 To / s' r From
From 3 vO To c 3 ei CI From To
From To From To
6. CASING: Thickness/
Depth '/ Diarrneter Wei hlMaterial
From 0 To / y Ft. C, ie G y( )/
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To
.7r'i FL ncr
From To Ft.
From To Ft.
To
Method
8. SCREEN: Depth Diameter Sbt 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. DRILLING LOG
From To Fgrmstion Description
.r h cif 5--A ,vc.
JUL
11. REMARKS:
frerfirli
(w-v)
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # • 3.)9 6:-
a. ,
0
t. WELL CONTRACTOR:
r>,!, r r
Well Contractor (Individual) Name
• etall 1):
Wed CollinractorCompany Name
STREET ADDRESS -;;
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply (�
DATE DRILLED (j/g/ /oh
TIME COMPLETED : 00 AM p PMX
3. WELL LOCATION: �/ /�
CITY: .SAeL/(i/!P COUNTY A//7C'(J6,%fi
tStreet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SET/7ING:
❑Slope CI Valley CI Flat Wnidge ❑Other
(check appropriate box)
LATITUDE 35-17 S2A7
LONGITUDE if ! r-? [//
Latitude/longitude source: APS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME If
STREET ADDRESS
City or Town State Zip Code
Lp)- 776 -30/
Area code - Phone number
May he in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL R EXISTING WELL? YES ID NI
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
-Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
/' A
u. YIELD (gpm): r3V METHOD OF TEST/
EPLAC
f. DISINFECTION: Type /zn
g. WATER ZONES (depth):r`
From_ a To ,zl __ From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diam ter Weight_ Maten
From (� To /OOFt. kVjA 5442/
al
From To Ft.
From To Ft.
Amount
oz
7. GROUT: Depth Material Method
From { To A .' Ft. (r`-; t'>'af 1it...::Lri
From To Fl.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From T
11. REMARKS;
2
Fprmation Description
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.
Xr •ALJ/L .Q . .L�.�Y�Cdz� goifth00
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
,ark .S . /4//en
PRINTE 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION fl -'1 ).1.) G�.
I. WELL CONTRACTOR
Well Contractor (Individual) Name
WellConbactor Company Name gg fj )J
STREET ADDRESS .X do l �: d✓ 2.-, f c 11 MIL-
/
t/.fr.
City or Town State
(' J )- • _
Area code- Phone number
2. WELL INFORMATION:
SEIE WELL ID #(it applicable)
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply G
DATE DRILLED -
TIME COMPLETED I% ('x`L AM ❑ PM try
3. WELL LOCATION:
CITY
Zip Code
COUNTY
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SET G:
❑Slope OValley ❑Flat idge ❑Other
(check appropriate box)
LATITUDEv5/,
LONGITUDE P-
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longituiie sou ce: 1QPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME rr�i'zed
STREET ADDRESS J/2 Cyr�r AlesAj
`e, hte ire- a2d79-y
Gity or own State Zip Code
(22/ )- bfl-396/
Area code " Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES d NO O
c. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS 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): 3 METHOD OF TEST
f. DISINFECTION: Type /1"� Amounto?£7oc
g. WATER ZONES (depth):
From 0.764 To ca-'c O From To
From To From To
From To From To
6. CASING: Thickness/
From O DToth�l� FL Dja9 ter
From To Ft.
From To Ft.
Weight Material
JFd7_7/ Li
7. GROUT: Depth Material
From To
sa Ft. (r`i"r,�
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Method
.41
in.
in.
in.
Material
Material
10. DRILLING LOG
From fT�ov7 Formmation Description
trea
Gbh
11. 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.
--D>r
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
"loge k
PRIN ED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
16'17 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7)05

1. WELL CONTRACTOR:
:Mgelc Alli0
Well C- ontractor (Individual) Name
Y"_•Crt)(rsnai 1Ale)1 Dr,}lr'hy
Well Coddtractor Company Name
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON 8 a Si V'
STREET ADDRESS c.9 Y,?
Le•ceskr AA'
City or Town State
($JV )- 073 —9Vr7
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
1/1,1*ir eS/Ty
Zip Code
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (CheckJ/Applicable Box): Residential Wateruply. Sp
DATE DRILLED /P - e?"' _ 0 C
TIME COMPLETED 11 • cw
3. WELL LOCATION:r�fr CITY: ftT.tV, I
AMLC}-• PMD
COUNTY )3440 cc+t(,¢
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAflb SETTING:
❑Slope DValley Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE 0//a f✓
LONGITUDE 72/4/0/3('
Latitude/longitude source: p. S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME L.6.),{t /fr44
S Rob -L
• • r' intki tatnJ ter Krr-
AM' and," ,tC
City or Town State Zip Code
Area code - Phone nuero
m
STREET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: 7l
a. TOTAL DEPTH: 700
b. DOES WELL REPLACE EXISTING WELL? YES p/ NO D
c. WATER LEVEL Below Top of Casing: FT.
(Use "+• 1 Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .011188.
e. YIELD (gpm): ) METHOD OF TEST
f. DISINFECTION: Type /% 7,1] Amount
g. WATER ZONES (depth):
From To Di,/5 l.-- From To
From To From
To
From To From
To
6. CASING:
Depth Diameter
From fl To 741 Ft. _
From To Ft.
From To Ft.
• n
• a
Thickness/
Weight Material
SPUN f
7. GROUT: Depth Material Method
From () To c',i Ft. (''h a/z $.2:441,¢-rp
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. __ in.
9. SAND/GRAVEL PACK:
Depth Size Material
From
From
To Ft.
To Ft.
From To Ft.
Material
10. DRILLING LOG
From T Formation Description
971/ ���•Y•v r(irt:+jt,
9
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CER /9-ay tf
�•/ CONTRACTOR DATE
Pr( E Fer 'aS00'
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
IFIET DWELL C
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 CERTIFICATION # 3-21'67
1. WELL CONTRACTOR:
/y%ri'j.
Well Contractor (Individual) Name
re: ��i.(A'.V t• LI UY: ir,a j
Well Cdrrtractor Company)) Name
X r ++ }
STREET ADDRESS .;j' Y Hit jL' Z ,1 i" I h, l
Leicey e, Li Y2 y,f
City or Town Stale Zip Code
( '" )- L , / 5'�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT SW applicable)
WELL USE (Check Applicable Box):7Residential Water Supply¢
DATE DRILLED / -/37 Cyj
TIME COMPLETED /L) .' 4zc AMe-1PM ❑
3. WELL LOCATION:
CITY: j1wris/y,4,40-/ COUNTY Roil C. evn
(Stree Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
T OGRAPHIC / LAND SETTING:
Slope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 S '-#^/
Latitude/longi(ude source:S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form T not using GPS)
4. WELL OWNER / ,/
OWNER'S NAMEX,6 j2 /ye;71.2.rh1,9
STREET ADDRESS .I L/ l,} [,UQ,r/Y7 00E1
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
.StutX.71Qar1. Nc
: V 71,g
City or Town Slate Zip Code
mod)- - Ss-9
Area code - honene number
5. WELL DETAILS: — I
a. TOTAL DEPTH: C.55
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: FT,
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordancerdwith 15A NCAC 2C .0118.
e. YIELD (gpm): /V METHOD OF TEST
f. DISINFECTION: Type 41// Amount / reie
g. WATER ZONES (depth):
From .21iC/ To e.,2‘O From To
From IC) To .3 c7/) From To
From To - From To
6, CASING:
From
From
From
�1 Depth Diameter
c) To S' c)- Ft._
To Ft.
To Ft.
7. GROUT: Depth
From ( To
From To
From To
;n(; Ft.
Ft
Ft.
Thickness/
Weight erial
c
Material
(o rcrr
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/7 ,2o
1. REMARKS:
Method
t�
in.
in.
in.
Material
Material
Formation Description
iney
(rel3
6-fyin le_
L:1
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
z
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 4'C7
_ CONTRACTOR: rLA) k. LI/iv ES
I Contractor Individual) Name
r � � �+
iejocQNS 111E11 axcz wnp, A.!-t_.
ell,$ontractor Company Name '!
MEET ADDRESS
/'lt-siEL /Y C • a€7 7Lf P
City or Town / State Zip Code
(daa )- 35&-- 8L19Cz
Area code- Phone number
f. `NELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT1t(if applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply c
DATE DRILLED
TIME COMPLETED 3; 30 AM El PM[(
3. WELL LOCATION:
CITY: %✓cry V, //C COUNTY ..r .acc n O
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
la'Slope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r .25 37y/
LONGITUDE 3 Z. 3r 077
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/Iongitude source: c DS ❑Topographic map
(bcation of we0 must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER J�Yf�1,^/
OWNER'S NAME a4I: { lus )4byit{j
STREET ADDRESS 0 O T /2 /
n jn
City or Town State Zip Code
(gas )- (o5&-aa9V/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ryr
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: YD FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS - / FT. Above Land Surface
'Top of casing temtinated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): "r METHOD OF TEST
f. DISINFECTION: Type C6 t.
Amount 27 pJq,
g. WATER ZONES (depth):
From 820 To From To
From ,i/o To From To
From To From To
6. CASING:
Depth Diameter
From Q To 23 Ft.
From To Ft.
From To Ft.
Thickness/
Weight Material
51.p.7s/ ,'•' c_.
7. GROUT: Depth Depth Material Method
From F2 To a0 Ft CoficrcjC "11jr�Ltfinij
From To Ft. J
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
From To
From To
From To
10. DRILLING LOG
From To
0- Is,
/6- - 23
11. REMARKS:
Ft.
Ft.
Ft.
Size
Material
Formation Description
Ch.r
SG1/
tJ
0 t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
F- /rl-ct6
SIGNATURE OF �EERTIFIIEDWELL CONTRACTOR DATE
rtAN /). GU, Ne5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Suhrnit 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.
Fomn GW-la
Rev. 7105

RESIDENTIAL. WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
yyRlI Contracts (Individual) Name
Er coti.) a Jen ant CI amp
Welllontractor Company Name /
STREET ADDRESS 3731, to LetedIm' ii„y.
JX/'(-SiEe- /r, C • aSTT
City or Town / State Zip Code
(2,R8 - La5& 8'i4(r2.,
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/Nil applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED V- /)'-
TIME COMPLETED /9. OG AMA PM
3. WELL LOCAJJON:
CITY: %ants of Ivy COUNTY . [.4nA.
rX, L- 1:. ,4wsr
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT NG:
❑Slope OValley ❑Flat 2Ridge ❑Other
(check appropriate box)
y� /
LATITUDE 3 r •r7.1:e
J
LONGITUDE S— 1— Z, %W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: arGek ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME jj� lift (,-IJ {j'q,(,iie
STREET ADDRESS r L O f /s
bfc44/e/t47/P AtC A878
City or Town State Zip Code
(a?S )- 7/3-979/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Vyr /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c. WATER LEVEL Below Top of Casing: G FT.
(Use -+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): .r METHOD OF TEST
I,
i
/
'ID
f. DISINFECTION: Type C<oeto{ Amount 2zr
g. WATER ZONES (depth):
From 11D To From To
From )4 a To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To e 2 Ft. ( /Zf $ tt#' ,mac_
From To FL
From To Ft.
7. GROUT: Depth
Depth vi Material Method
From P To No Ft. Concrete- //i7L/th% j
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 Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
0 r! C4.
2 Ile K
11. REMARKS:
N c
t'1
J
o•
c
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED el ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
v//ad nt %Jives
RINTED 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

4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
�0,
n- n ,1 ,q
oU1 f Y4
1. W CONTRACTOR:
43hh WI PO
W 1 Contractor lnrljvid al) Nam
KGlf(So#s WE1l &wit
Well ntractor Company Name
STREET ADDRESS (a /1
Lei« ga ACCI a874
City or Town ( State
s
ksn p( L-C.
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#0i applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED Ss 04
TIME COMPLETED 2. D
3. WELL LOCATION: F(t it h
Cr'
CITY:
AM ❑
PM [�
COUNTY BQPU&I C
eenlry Privc
(Street Name, lrumbers. c€mmunity, Subdivision, Lot No., Parcel, Zip Code)
TOP J3RAPHIC / LAND SETTING:
2Sooppe ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
I. ATITUDEVac
LONGITUDE 1420r
Latitude/longitude source: 13.6-1'S 0Topographic map
(hcation of well must be shown on a USGS topo map and
attached to this lone IT not using GPS) nn--
CS X/fCfl 4hC✓•lld.
rail" 'L, p1r tiler '.
May be in degrees,
minutes, seconds or
in a decimal format
IX %le own State✓C
(gslg)- CIS x —44099
Area code - Phone number
5. WELL DETAILS: r
a. TOTAL DEPTH: 70S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (]r
r
c. WATER LEVEL Below Top of Casing: Q FT.
(Use'•' if Above Top of Casing)
d. TOP OF CASING 15 / . 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): 172, METHOD OF TEST ' i)jl�q �n,etr
f. DISINFECTION: Type Cl1 (04%•N C Amount /VtTL
9•
From
From
From
6. CASING:
WATER ZONES (depth):
To r.24 From To
To From To
To From To
Thickness/
Depth Diameter Weight Material
From w To_ (.0 FL ( t A 24 r/a15 fo'c Sl1A
From To Ft.
From To Ft.
7. GROUT: Depth Material�r1M,..,,ett�hod,
From 0 To �fl Ft.6en QEJf
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From . To Ft.
From To FL
From To Ft.
10. DRILLING LOG
From To
-- US
(1l -�G/0
bG - »C
11. REMARKS:
Formation Description
Clntl/
SO n/S`tYtrt1C
1?-or
6-re air :f
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WDH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE-ti% IFIEDt f CONTRACTOR DATE
a )y0-Lfs „
PRINTED NAME
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 CERTIFICATION #
1. W CONTRACTOR:
Lam{ Ii r- a s
V2,11 CCoontr (hdlvidyal)) Nam
t 0#5 WE tz (tM I _C.
Well F)ntractor Comp''aa1nyyNane
/
STREET ADDRESS ti7 3 / /►µ„Gi 1.
I fire5tER A(C ag9
Zip Code
City or Town r State
(SPAR )- ;58— f94-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
PM p'
3. WELL LOCATION: nn
CITY: /KCU/ /1- COUNTYfJ4(/JMOI
toI'm ditrs,Zit 27
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
ope °Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE/j 3 S ± S 2 rqa.
LONGITUDEJ[/g'$ c /
Latitude/longitude source: PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to Nis form snot using GPS)
4. WELL OWNER
WELL USE (Check Applicablg Box): Residential Water Supply [3�
DATE DRILLED
TIME COMPLETED A,00 AM O
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME 3419-C R kf1-/G
STR�j ET ADDRESS jao4C.r4nb'/_adt nr
f-kden nr 0,R76y
City or Town State Zip Code
(qt4 >_ a8S-�bao
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: }oS /
q /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [L
c. WATER LEVEL Below Top of Casing: 6() FT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING 15 [ FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. �j
e. YIELD (gpm): i METHOD OF TEST�IJ
t. DISINFECTION: Type ChtkAtVC Amount 7d Z
g. WATER ZONES (depth):
To
ASS From
To
From To From To
Fran To From To
6. CASING: Thickness/
Depth Iameler Weight Material
From 0 Toj2 Ft, r /a7S OdoSnA
From To Ft.
From To Ft.
7. GROUT: Depth9 MaterialMethod��` Method
From 0 To to Ft. &iced J/tlJ(/Qi,49
From To Ft. T'^�JY
From To - Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft.._ in. in.
From To Ft. in. in.
From To Ft. in.
9- SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
a /A
/X—z7
- 32.
3A ��r7S
11. REMARKS:
Material
Formation Description
SOn errYAaK
lea V(
rT�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
PRINTED
F PERSON CONSTRUCTING THE WELL
3
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-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wafer Quality
WELL CONTRACTOR CERTIFICATION # 2o- Q
Ft 7
v y
1. W CONTRACTOR:
b h �tI
O
Vi II Contractor�I,f(lividyal),.Nam
ii 0//41 S WE I1 afrid Pa pi J_LC
Well ntractor Company
JJName �(
STREET ADDRESS G1 Ie..�1 /Ic I.
Ifi«sfa A! as14Q
City or Town 1 - State Zip Code
(,WAR )- 158-I9&
Area code- Phone number
WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(k applicable)
s
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appl fable Box): Residential Water Supply(]
DATE DRILLED 7
TIME COMPLETEDY /tr3j6 AM B' PM❑
3. WELL LOCATION: �/
CITY: (x/ cc -Si Cr COUNTY/lij w,Vf AC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lope 0Valley 0 Flat ❑Ridge 0 Other
(check appropnale box)
�F
LATITUDE'1 [ /, 30 .3l
LONGITUDEig2ra 5, o r
Latitude/longitude source: S ❑Topographic map
(bcatbn of well must be shown on a USGS topo map and
attached to this fore l not using GPS)
4. WELL OWNER OWNERS NAME &<Qhe.n (Myi/i3
STREET ADDRESS L p Mt((a.t(
t. r.I a rft.-l-e• NC ag ci
City or Town State Zip Code
(462-`4)- 301. to a 2
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: /� 1
a. TOTAL DEPTH: /6 Cr.--
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 12 0 FT.
(Use'+' B Above Top of Casing
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .011 B. `
e. YIELD (gpm): jaiMETHOD OF TESTlJ/)�gil
f. DISINFECTION: Type (r/4l ,yam (. Amount /0 it
g. WATER ZONES (depth):
From To 200 From To
From To 330 From To
From To From To
6. CASING: Thickness/
Depth Di eter 2Wight Material
From 0 e
oC�/) Ft. /b&lh snaA!
From To Ft.
From To Ft.
7. GROUT: Depth Material Method,t
From 0 To lfl Ft. (.;ClCp,��,
fgjr J
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To FL _, in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
FromTo Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 /5
(5 — 35
35 —YCi
vc —330
11. REMARKS:
Forma+�pn Description
(10 y
Sa S*e./e
/ZOC
Gyr.Oe) • •ir C
rn
-V
O
UT
I oD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WE •WNER.
SIGNATUR •F '•TI • T CONTRACTOR
PRINTED NAME JDF 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 *3
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / TO
1. WELL CONTRACTOR:
"'Bk./;fN LU' /V ES
I�II Contractor Individual) Name
ErrSO h1.=11awdrump /LC'
W elltractor Company
Name
STREET.ADDRESS 73J �w 1
Z i'7fs-/E_ /lY • r87i/P
City or Town / State Zip Code
(gdR )-;52- $g912..
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #01 applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply l
DATE DRILLED `%-/J- Di• p�
TIME COMPLETED //..JJ AM IZIPNI
3. WELL LOCATION:
CITY: k,--v7-:4/4- COUNTY 0.,,, i.e." ix
�//'"t /7es<r..- s Let /T ZJ
(Street Name, Numbers, Community, Subdihsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:❑Slope ❑Valley ❑Flat GRi/dge Other
(check appropriate box)
LATITUDE 3 :f v/
LONGITUDE rZ Jrr?S/7'
May he in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DP¢S El Topographic map
(locaton of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME ? E_ 172i//l,i
SJR%EET ADDRESS 4%'7,y�d,97� e.//,t ,Pn'
a-1€41/ert4.1/r. // L --387f y
City or Town State Zip Code
(Rag } (, t1 s-u973
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
�D )
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q
c. WATER LEVEL Below Top of Casing: Y J FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / 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): 3 `O METHOD OF TEST
f. DISINFECTION: Type [r4'-/..[ Amount P Pic s
g. WATER ZONES (depth):
From f'0 To From To
From //a To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 2t Ft. G./rr r�'eri i'...c._
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
/�
From ,ram To . 0 Ft. CO/icrejc p/Oj,(f7ry4
From To Ft. J
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 -- 27 C htt
Zz. tar- C.„v-
11. REMARKS:
10
{
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1//..4"im ..r 7—�1-0c
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
plAN A X /U' Nee
RINTED NAME OF PERSON CONSTRUCTING THE WELL
a
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 Netural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
Bk ''f-N k. Ali A ES
J t4t SaNs /.dell a#cz JRtrp TLC.
Well,$ontractor Company Name / �,-!�1 J/,
STREET ADDRESS 3 3/,ME& LEIf.G�/EQ J'(Ll/U.
I Contractor Individual) Name
.C%lffske, , / i • a0 'Iqg
City or Town / State Zip Code
(CR �- ;452-- g491,2_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 2/
DATE DRILLED - c- - OF
TIME COMPLETED /D 10 AM PMp
3. WELL LOCATION:
CITY: 4,etf it.' COUNTY /r c,,, tiers4A.
/ A 4f
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ['Flat IAHidge ❑Other
(check appropriate box)
LATITUDE 3 r 31r -74f '
LONGITUDE 3' L 33.,r70'
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: Q 'PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER A[/
OWNER'S NAME /21" Anc/a? - e.diyie.
STREET ADDRESS T.V £n4k7 M
Atevq/c_ fie a88ob
Zip Code
City or Town Stale
(gag »a5a-4099
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 j'%
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: L 0 FT.
(Use-+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aior'below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): - METHOD OF TESTAPa)jyj-RO
f. DISINFECTION: Type Cirri i
g. WATER ZONES (depth):
From ZCO To
From
From ,7i0 To From
From To From
,)'f:(A
v r tier
Amount /..? 4.35
6. CASING:
Depth Diameter
From O To // L Ft. 1:-il!
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth Material Method
From fi To a FL CoNcr%#c 7)(pur;tv
From To Ft. J J
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.
9. SAND/GRAVEL PACK:
Depth Size
Fron, To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
- /J7
/07- //Z
//Z- Pkr
Material
Formation Description
C46/
.r ,0/1 .ao.,R
nrn
L. !. ZiiooU
11. REMARKS:
1J
rT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W rIH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/L-04
SIGNATURE OF �CEERTIFIIEDrWELL CONTRACTOR DATE
D/ A-N / 1. / 0, /l+e� 5
RINTED 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

e. YIELD (gpm):
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / *0
1. WELL CONTRACTOR:
W
pall Contractor ((Individual) Name
.E,ec�cr SONS It tell card tiorrp
Well ontractor Company Name ��{ j,.
STREET ADDRESS 3y3/ Ay Ef6E�JEKL &Ay•
/.S/(ESjfe ,'C• a875�P /
City or Town f State Zip Code
(g,R)3)- a5&-- 849Gz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply R-"
DATE DRILLED 7-2t/-0.
TIME COMPLETED 3 :LW
3. WELL LOCATION:
CITY: Le Cej/e- COUNTY .C.CO.•p it
AM PMp
Gil. S ACC 44 Al ,, j
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:`
❑Slope [Valley ❑Flat prgidge DOther
(check appropriale box)
LATITUDE 3 r 1y 7if
LONGITUDE Y L 3k 07c/'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: t36PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form dnot using GPS)
4. WELL OWNER QQ
OWNER'S NAME 4i/fa
STREET ADDRESS /tt
Cr/41v,,a id. R./
Askcuivic /✓'e Asrfd6
City or Town State Zip Code
l a K)- 41e 5- V426,3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 ar
b. DOES WELL REPLACE EXISTING WELL? YES[ NO♦.J
c. WATER LEVEL Below Top of Casing: G 0 FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING 1S / FT. Above Land Surface*
'Top of casing terminated aUor'elow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
712 METHOD OF TESTT)thirti)-RJ
f. DISINFECTION: TypeCiar• •.w
g. WATER ZONES (depth):
From en To From
From ge To From
From To From
6. CASING:
Depth
From 0 To 71 Ft
From To Ft
From To Ft
7. GROUT:
From P
From
From
Amount r /Cfy
To
To
To
Thickness/
Diameter Weight Material
6/2.T
Depth Material Method
To ao Ft. COACrIfIG ?DUtirr4
To Ft. J
To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. - in. in.
From To
From To
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
Ft.
Ft.
Ft.
Size Material
10. DRILLING LOG
From To Formation Description
O 4.7 City
L 7- 74.
72- 20r G ¢
N •
'
J
,.._. _. ��G3CD
Cr.
11. REMARKS:
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
ISA NCAC 2C. WELL CONSTRUC LION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
emu: v. 7-20Vo‘
SIGNATURE OF �EERTIFIIED�WELL CONTRACTOR DATE
PiA• -N / 1. /.(J, /d es
RINTED 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

e. YIELD (gpm):
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / %C
1. WELL CONTRACJTTOR: /, /
II Contractor (Individual) Name
Eego scAi) b J Il add zurip ,CLC,
Well ontractor Company Name /
STREET ADDRESS 37G 31 �j iti LE icEsiticIkUy.
ir-i/eS]ft C • aa?
City or Town / State Zip Code
(8RR )- 2452-- 5g912.-
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/tor applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water SupplyQ-
DATE DRILLED %- 2 f —J(e
TIME COMPLETED 3 . 00
3. WELL LOCATION:
CITY:
AM 0
PM I:V/
COUNTY ��c.,,,..„,y
g 6 ./.,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat UATdge ❑Other
(check appropriate box)
LATITUDE 3 -- TJ• 0Or
LONGITUDE 41' t SO, 5-4/4/'
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: DOSS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME ?e'/pee%. �j/$J/i ot/ f A
ST ET ADDRESS J9'5 /f ,a%a, ig 64.41fll "
tad e
City or Town State Zip Code
( 7443 )- 707-073/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 v
�C' 9R/a
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO gr"*.-
c. WATER LEVEL Below Top of Casing: 4/0 Fr
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated at/orbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
3 c' METHOD OF TEST,?jj/Vat:dr" r J
t. DISINFECTION: Type CGS• •K- Amount/5— hfs
g. WATER ZONES (depth):
From Co To
From 27Q To
From To
From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To ?L/ Ft. G.--Li Sot' i .�,e_
From To Ft,
From To Fl.
7. GROUT: Depth Material Method
/�
From , To a Ft. Concrete- 1(plffi/YQ
From To Ft. J
From To Ft.
8. SCREEN:
From
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From
From
To Ft.
To Ft.
10. DRILLING LOG
From To
0- 21
25- JY
3v- for
11. REMARKS:
Formation Description
L'f.t
5- 4-0>
v
n 19
p1
m
3
y
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7-2f-oc
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
jSDIAA-N h / INes
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.
Fam GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Env'uonment and Natural Resources-rc�Division of Water Quality
p/
WELL CONTRACTOR CERTIFICATION # 0 vR 2
c) (;�
c/ \)
1. W CONTRACTOR:
VIAYYY %�
obhL{ (,c!
a i3
Contractor dividual)_Nan
EN&SofJ15 1w1EII Odd (mp,
Wellglint-actor Company Nm
2a Name
1/M /
STREET ADDRESS
LpisALL 38
City or Town / State
58-S..F94
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(inapplicable)
STATE WELL PERMIT#(il applicable)
s
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):/Residential Water Supply [ice
DATE DRILLED 7/� /Q4,
TIME COMPLETED / 7I/0 AM [ PM
3. WELL LOCATION:
CITY: F/Y)1r17Ci"
COUNTY �attn0lN G�
(Street Name, Numbers, Community, Subdi4sion, Lot No., Parcel, Zip Code)
TO RAPHIC / LAND SETTING:
Slope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 35 3// /J/.z /
LONGITUDE(J/,tit' Qr. ei PT/
Latitude/longitude source: pc�t'� ❑Topographic map
(k'cation of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME _
SEET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
e kw/ f
ea die i✓o a s8D'
City or Town State Zip ode
( a70- a737
Area c e - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Sys
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO{5"'
c. WATER LEVEL Below Top of Casing: % O FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): //1 METHOD OF TESTIr�j
T. DISINFECTION: Type FA ft/'/N-e Amount /Zff�
g. WATER ZONES (depth):
Fran To 3/i From To
From To From To
From To From To
6. CASING: Thickness/
Depth Iameter Weight Material
Fran 4 To ,TT,' Ft. 74,/2F /0//r 4fl/
From To Ft.
From To Ft.
7. GROAT: 0 Depth Materialat'
From To le/Ft. C /ICeele
From To Ft.
From To Ft.
Method
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 Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 —Jo
3D — So
S-3Y-3-
Formation Description
C/a17
Sp Av :0/,vn_
�aG k
f YAth e '
-'9
S`P i ' 2 5
11. REMARKS:
0'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL NER
SIGN
DATE
PRINTED NAME 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.
A
3
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 # 3 / TO
1. WELL CONTRACTOR: . /
B/LL*) f. LU i iV ES
V,ell Contractor (Individual) Name
r
E,ega sent} /.( fell and ump LIZ,
Well ontractor CompanyName
G / /
S11RR-EE/T ADDRESS 4173) /j..W LEttEs7JEEL /huy•
Ls%rt&}Et Awi�. a lTif /
City or Town / State Zip Code
(2 S )- la52-• 8'-{9iL
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(k applicable)
DWQ or OTHER PERMIT #(it applicable) /
WELL USE (Check Applicable Box): Residential Water Supply y,— �
DATE DRILLED fc - 14- /
TIME COMPLETED 2.OJ AM El PM L}7
3. WELL LOCATION:
CITY: Cl.,trlr-
COUNTY ! ....Sc
Je ,1 4-4, At 41, IS
(Street Name. Numbers, Community, Subdiesion, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ['Valley ❑Flat RRdge DOther
(check appropriate box)
LATITUDE 3 r <eV rrc -
LONGITUDE Y 2- 77. 7D r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: p4dPS ❑Topographic map
(location of we0 must be shown on a USGS topo map and
attached to this form %not usfrig GPS)
4. WELL OWNER p�
OWNERS NAME .Je, • liC 1.4
STREET ADDRESS O B O t/ 10
Etik/a- )VC a87a8
City or Tam State Zip Code
Lxag- 7/Q8—qv3
Area cede- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: �J r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOD,/
c. WATER LEVEL Belau Top of Casing: 6.0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. /H
e. YIELD (gpm): 3 METHOD OF TESTAIpjVj rjG-KKnn, O
ti rl 1 tZ 9 0
f. DISINFECTION: Type C/o.•>"c- Amount --,r <<il
g. WATER ZONES (depth):
From Aka To From To
From it) To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 17 To 74 Ft. {."Cr" rtCrl �c
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From P To ao Ft. Concrcfr pnff%/v4
From To Ft. .11
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Ft.
From To Ft.
From To
10. DRILLING LOG
From To Formation Description
0- 7Cl'
7� — 74S%.
74 — 4/00--
O ri
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wrnl
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-Z'1- - 7 /y 17 i
SIGNATURE OF CERTIFIED rWELL CONTRACTOR DATE
Dr A-N hi, Ne5
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

s
D Ahe Boyd
e. YIELD (gpm): i10 METHOD OF TEST
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 490>1
1. W CONTRACTOR:
r O
Obh!✓lfy Namgg
%
W II Contractor `ndjvidcal)
f�R f(So45
WE �l cupid Ptcmp/ LL .
Well Qpntractor Company Name
7
STREET ADDRESS
LE rEsia ACL an4
Zip Code
p� City or Town / State
(09X )- 58—N94_
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(H applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED
TIME COMPLETED AM 0 PM p�
3. WELL LOCATION:
CITY: Ijr y�[� COUNTY %idwrozst AL
net CPC Cie
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
°Valley ❑Flat ❑Ridge ❑Other
(died( appropriate box)
LATITUDE ALIF '3 d.r 3 /
LONGITUDE OM_ /r. 3,59/
Latitude/longitude source: PS °Topographic map
(location of weft must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
STREET ADDRESS 53 4CC�iec. Di •
ljsir-AS C t1vte of �294/G/
City or Town State Zip Code
IV }A7o-5"Vs4
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
yos
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p�
c. WATER LEVEL Below Top of Casing: It) FT,
(Use if Above Top of Casing)
d. TOP OF CASING IS ( FT. Above Land Surface'
*Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
R 9
f%
t. DISINFECTION: Typef'A b/iw) C
Amount /A n t
g. WATER ZONES (depth):
From To 17 AO From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To cr5 Ft.(i, 2j 2/4, /AS OGt SA A/
From To Ft.
From To Ft.
7. GROUT:,r� Depth Materialrr/�p/I �1 , Method
From 0 To �fl FL%OIL.0 tr J/Yl(Iit_
From To Ft. T�^Jl
From To Ft.
8. SCREEN: Depth Diameter Slat 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. DRILLING LOG
From To
Formation Description
0
- D �a„ortio,A<
to - S .tot
swc — OS pay
11. REMARKS:
—O n
J
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wrn1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THEW LOWN!
SIGNATU- eF ER 'FIED ONTRACTOR ATE
PRINTED NAME PERSON CONSTRUCTING THE WELL
5,
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 CERTIFICATION #
1. W CONTRACTOR:
O S
50 Contractor (hd1irvidyal)N=aml
MR &So7n'5 ((tif(!, fiord tit
Well ntractor Company Name
STREET ADDRESS
Fire#E
7
City or Town / State
58-j9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(inapplicable)
p. LLC•
r
as149
Zip Code
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(H applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 5/ : (A /
TIME COMPLETED 72, rOO AM 0 PM [�
3. WELL LOCATION:
F¢t�ui cft)
CITY:
COUNTY PI Acnvc/ 4C
(Street Nara )iumbers.rCommunSubdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
lope DValley ❑Flat EIRidge DOther
(check appropriate box)
IATITUDEN 3,\ 3A r 3^56
LONGITUDE r 'U /g r e_C sq ,
Latitude/longitude source: nTiYS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME %I/r/ SC1Ar
STREET ADDRESS Q / 050 2 S
.si cv. %(f' /✓c 0?88/3
Ity or Torun State Zip Code
(gab ) 777--5577
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: bo S /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q'
c. WATER LEVEL Below Top of Casing: (00 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 (gpm): U METHOD OF TESTTB6, l—Ihr1
Jai 109
f. DISINFECTION: Typeziliteiv_E. Amount
g. WATER ZONES (depth):
From To SIY From To
From To $ YQ From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From__ To (// Ft.
From To Ft.
From To Ft.
7. GROUT: Depth Material )) �1�� Method
From 0 To 10 Ft. e.AlaGY'r J lii2_
From To Ft. �"�"�
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
//•d
11. REMARKS:
Formation Description
may
S A�ti�
t -
v
I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WaL OWNER.
afi rr
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1619 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 #
1. WCONTRACTOR:
abhi/{
ell Contractor (perid al) N
J I
ER' r(5on's E it tz*.A
Yla L�L 3} Lrr Ir�
103 Wh's% r�firl^'ptsili.
e. YIELD (gpm): /0J
Well ntractor CompanyName
STREET ADD/RESSS pI
ER
City or Town / State
Xis )- :s�- 9.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Lsn pr LLC.
�'ir��lEKI
Zip Code
STATE WELL PERMITS/tit applicable}
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED (f/p�H /
TIME COMPLETED /,'//(/ AM PM[{'
3. WELL LOCATION: /�/
CITY: e /KA (r
COUNTY R 1 COmm4G
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN -SETTING:
❑Slope Di Valley tat El Ridge ❑Other
(check appropriate box)
•
LATITUDE/Va _ 2Qr
LONGITUDE/('%�f L 3s,Slb
May be in degrees,
minutes, seconds or
in a decimal format
e'G
Latitude/longitude source: 15 ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
ncl arsonu \ke pc
CI or Town State Zip Code
)- (a a -_sa
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S QS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q"
c. WATER LEVEL Below Top of Casing ' 0 FT.
(Use `+- if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
METHOD OF TEST
67, 9 n hry
c: 4_ i d 0
t. DISINFECTION: TypeC4/Aa/AJC Amount /,6jD7
g. WATER ZONES (depth):
From To 4/ea From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From Q To //2 Ft. t 2 2 246 /Z S •,..91/6 SOIL /
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material Method
From To fl Ft. d' la de
From To Ft.
From To Ft.
8. SCREEN:
From
From
Depth Diameter Slot Size Material
To Ft. • - in. in.
To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
Size Material
To Ft
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 — Sv
— /4'?
/vz— //.
//A - Eds
11. REMARKS:
Formatio Description
("%y
St4/15Sid c,C
cn
CJrinu7r
12115
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO WELL OWNER.
CONTRACTOR DATE
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 t' 310
ct 2 ✓rw4
e)v i
1. WELL CONTRACTOR:
�lz;>t-N /illN EFS
I Contractor Individual) Name
Err11.16 s l� Ie/I a.rd P141,1p
Well ontractor CompanyName
G / l�-r1 �(
STREET ADDRESS riI73/�/..(t} IPteEsi ? iltuy.
i /teskt KC • a0751
City or Town / State Zip Code
Ig.3R )- ;7152 Sg912.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED 7'./— C7%
TIME COMPLETED 7/ .•00 AM dPM
3. WELL LOCATION: p
CITY: (c.,//tr COUNTY p.... z i,a lc
eaes roe- f J24 h.s
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Sbpe DValley ❑Flat ❑Ridge ❑Other
(check appropnate box)
LATITUDE 3 )opill 0%/ r
LONGITUDE Y L lig Or'
Latitude/longitude source: DOS ❑Topographic map
(bcafbn of well must be shown on a USGS fopo map and
attached 10 this form if not using GPS)
4. WELL OWNER /I/`�`
OWNER'S NAME - ae Cons rL(f-1rAN.
STR T ADDRESS L C\J. / 7J 2
y nk A- tIC aR7aA
GI or Town State Zip Code
LCKa-`d 1- le 7n- Rol 3D
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: 3Of
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO a-
c. WATER LEVEL Below Top of Casing: TrO FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
r
e. YIELD (gpm): 70 METHOD OF TESTZ)pj/Jltr15 RJ
f. DISINFECTION: Type r/0. r,r Amount /7 /841
g. WATER ZONES (depth):
From MO To From To
To From To
From To From To
From RCc,
6. CASING:
Depth Diameter
From D To P7 Ft. (.,'jr
From To Ft.
From To Ft.
Thickness/
Weight
SOKZf
Material
.174/ci
7. GROUT: Depth Material Method
From N To SO Ft. o/tt-rete. 7j/0ltr;a1
From To Ft. /
From To Ft.
8. SCREEN: Depth
From To
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
To
To
10. DRILLING LOG
From To
0—r2-
n_P1
F7 — 3'cr
11. REMARKS:
Diameter Slot Size Material
FL in. in.
in. in.
in. in.
Ft.
Ft.
Ft.
Size Material
Formation Description
C'w
fi/i
LOu
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W ml
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Y'//—OG
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
J�J(W4AI 1 12J Ne 5
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
`licit x 7/-a;—.e
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
161 ( Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Form GW-la
Rev. 7/05
7
23

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /'T3
1. WELL CONTRACTOR:
—B/r,1-A)bilAes
.� 1 Contractor fr.vidual) Name
tEe r cems It le/I a d ?wnp /,.LC,
Well ontractor Company Name .r
STREET ADDRESS t�73w
/B/'(.fs]pt /K C • 07871f 2
City or Town / State Zip Code
(8,•>3 y L35 2-- 84912..
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED -%' / -04
TIME COMPLETED .7: 10 AM (7
3. WELL LOCATION:
CITY: Le;e Ale,"
1+�1 rc 1 ,7,/ c
PM Or
COUNTY e„Y 4e
(Street Name, Numbers, tommunity, Subdivision, Lot No., Parcel, Zip Code)
TOpOGRAPHIC / LAND SETTING:
:Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 f. 77. Yr7'
LONGITUDE r L 77, WI'
May be in degrees,
minutes, seconds or
in a decimal fomat
Latitude/longitude source: DoPS ❑Topographic map
(location of web must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER /y� , n•
OWNER'S NAME /�.(.Ci�/c/i ( n bT (L(.ay, JZ
STREET ADDRESS / 5 Vv li� pa /L e NC,
Anaty. %/c /VC a B P a 6
City or Town State Zip Code
(Sfg
Area code - Phone number
5. WELL DETAILS.
a. TOTAL DEPTH: Z%%--
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: 40 FT.
(Use'F' 8 Above Top of Casing)
d. TOP OF CASING 15 , 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): Ga METHOD OF TESTAigitJh15_ h1
e7 .1 3 0 O Q
f. DISINFECTION: Type (in-c. Amount Z'' '1%5
g. WATER ZONES (depth):
From % f ' To From To
From )tt' To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight
From 0 To 63 Ft. G. ier S.flz'
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From ,0 To ,i10 Ft Corir rote 7Amtinj
From To Ft.
From To Ft.
Material
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
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
-.1--i Cht
rr- LI
Material
L7- yar 6--7A
ST
11. REMARKS:
-"1-tear,
n
I
100 HEREBY CERTIFY THAT mis WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TEAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7-
SIGNATURE OF ERTIFIE DWELL CONTRACTOR DATE
PALA, %U, Ives
PPRINTED 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

Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / TO
1. WELL CONTRACTOR: �"
h
-at ES
1 Contractor Indk &t
ividual) Name
Erja /V.5 lb le// a/rd tamp PLC,
W ellontraclor Company Name
STREET ADDRESS 373/,4' w LE!eE JER /ky,
Lcu sJE - N(• a879� /
City or Town / State Zip Code
(8,RR )- a52-- 84191.
STATE WELL PERMIT#(B applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply d
DATE DRILLED 4- 1,) - 04 TIME COMPLETED 1.00 AM ❑ PM Cr"-
3. WELL LOCATION:
CITY:Or�
JLy,r& COUNTY moo. con3(
9M c /ar 4.4�/
(Street Name. Numbers, Commdnity, Subdivision. Lot No., Parcel, Zip Code)
TO OGRAPHIC / LAND SETTING:
Slope °Valley DFlat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 s- ,i`/. 712'
LONGITUDE r Z (en/
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: r .eipS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER (7,1 y1
OWNER'S NAME I GT<( brs.L1a 5 e
ST!F r`
EET ADDRESS d 7 (, 4,V,IC,e i1.-Ye /t-d
ca-t-C;fi1 fvc afo43
City or Town State Zip Code
V-ii )-305-3/9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 24/r
b. DOES WELL REPLACE EXISTING WELL? YES ° NO (
c. WATER LEVEL Below Top of Casing: 4122 FT
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated auorbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): Ito METHOD OF TESTTJ )WtljhJ-R1
3a30r1
f. DISINFECTION: Type (' b.. t. Amount /l hcil
g. WATER ZONES (depth):
From 2r To
From Zr3 a To
From To
6. CASING:
From
From
From
From To
From To
From To
Thickness)
Depth Diameter Weight Material
0 To SV/ Ft. f_-yf -Cate �aY
To Ft.
To Ft.
7. GROUT: n Depth Material Method
From N To No Ft Conrrrcck ?Duchy,
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
in.
in.
in.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 - y S C/cf
5 f.-
C'/- 2 ger
11. REMARKS:
Cn
'V
I •
ON
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W rn1
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
G 7o-cc
Si' ERTIFIIED.WELL CONTRACTOR DATE
PRI�i/fN W. Ne5
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
GNA URE O
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-ta
Red. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /410
1. WELL CONTRACTOR: /' `
Ar ES
Wftll Contractor (Individual) Name
tEeWell cNS lciel1 a.vd u/,1p
!LC
Well ontraclor Company Name
STREET ADDRESS 373/ /Y.EW LEI'eEsIEQ /{dirt/.
iti-ske, dee • a875/2 /
City or Town / State Zip Code
(CR )- ;452-- Sg91.4.
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Lr
DATE DRILLED % -ZS-Ot
TIME COMPLETED /.2 :TO AM 0 PM I
3. WELL LOCATION: CITY: SAa.n 4 nc.),, COUNTY 6,.
vy
pia-.1!
A/ y o
( beet Herne. Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley OFlat tFRITI�dge ❑Other
(check appropriate box)
LATITUDE 3 r
LONGITUDE ir 2 2C. jy'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: CTGPS ❑Topographic map
(location of wen must be shown on a USGS topo map and
attached to This loon if not using GPS)
4. WELL OWNER
OWNER'S NAME �h at) S cad to r-x
STREWA ORES L • eV/)� yrr
At 77
City or Town Slate Zip Code
(S;t g y
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
4/vr
b. DOES WELL REPLACE EXISTING WELL? YES In NO p✓
c. WATER LEVEL Below Top of Casing: /O FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated al/orbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Z METHOD OF TEST/1bithr1 J—! // 5
•
el^
J x T3`b6
f. DISINFECTION: Type Os Amount /t i-cs.,
g. WATER ZONES (depth):
From Yip To From To
From 2vo To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 70 Ft. 4/2r SD•eAr/ -"tic_
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From ,v To 20 Ft. Concrctc 7#2LlliN4
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To FL • 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. DRILLING LOG
From To
b-4r
4r-70
70 - YDr
11. REMARKS:
Formation Description
Cry
r-n
m
a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
t *.<.... G -t i-- 04
SIGNATURE OF EERTIFIIED�WELL CONTRACTOR DATE
D�hN k GU, NeS '
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / i0
1. WELL CONTRACT/OR:
&/
1,fN Jj. Ut'Nes
1 Contractor (Individual) Name
E,e4aseMs b Jell aitc/Rmp uc
Well ontractor CompanyName
�/ / n�-tt1 %,,
STREET ADDRESS 3 3i hid LE/&Gs / E(C /lzzy,
/.c/�(fl].E,� K C . a78 7ef 2 /
City or Town t State Zip Code
(48 1- 35 &-• S 49 (Q
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 03 06 l - 6 O 74
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p—
DATE DRILLED y - 7-OC -/
TIME COMPLETED '.IV AM ❑ PM �T
3. WELL LOCATION:
CITY: L/.zv/ya-
COUNTY AZ.. e+ it
.S/4spC. os&C .Pa"
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope Bycalley ❑Flat DRidge ❑Other
(check appropriate box)
LATITUDE 3 f'" )v. S/zi
LONGITUDE r C L/D, C'$'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 06.PS ❑Topographic map
(bcation of well must be shown on a USGS tops map and
attached to this form d not using GPS)
4. WELL OWNER 1
OWNER'S NAME Nesle S I©r+la m nb
STREET ADDRESS 3 11 S lu de ,}�( a
c_cis-)re t N 'L511��
City or Town State Z p Cale
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: its
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 00
c. WATER LEVEL Below Top of Casing: j 0 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): 20 METHOD OF TESTA)b(,f)'11 j-RQ
f. DISINFECTION: Type (1/a-.Jt
g. WATER ZONES (depth):
From or To From
From ./10 To From
From To From
6. CASING:
Depth Diameter
From a To42 Ft.Girr
From To Ft.
From To Ft.
7. GROUT:1� Depth
N To so Ft.
To Ft.
To Ft.
From
From
From
Amount 7.4.6
To
To
To
Thickness/
Weight
rstea•
Material
�.L
Material Method
Concrete. ph, ;u rig
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0 -,ice
n- -2
S/2- /b!
1L REMARKS:
Formation Description
ire.. 74-
r%7
-
-v
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF EERTIFIIEDWELL CONTRACTOR DATE
DihN !1. LCJ. AteS
RINTED 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. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
20 9
;'$7
1. WEL� CONTRACTOR:
/,I/ %�
fO U h �djvitl)j�'al I1' 11(- so
a l(SOfils WE11 Ord
Well ciontractor Company
/Name /t!
STREET ADDRESS(} 3 / / f t-L
S
(kin p, U—C-•
Lficesi R hit( aslzie
City or Town / State Zip Code
($3' )- 5840A_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) c j O d s 6370 7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
TIME COMPLETED /,W) AM 0 PM
DATE DRILLED
3. WELL LOCATION: //��
CITY: f/� P!✓I-e COUNTY L7i/A CGM be
17/ ('i r/)./ /B
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA ETTING:
❑Slope °Valley Btiat Et Ridge ❑Other
(check appropriate box)
LATITUDE /V 3 S= dS / SAS r
LONGITUDE/LIQQA /ttc�
[?Gips
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source:
❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER [/
OWNER'S NAME J,/ G0Zr// 7i(%�' tail
STREET ADDRESS Q • U6 b �S
eiricAei iV A8730
City or Town Slate Zip Code
(9Ya2 )- L k 4- 3 3 72
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
&(D1
b. DOES WELL REPLACE EXISTING WELL? AYES El NO p�
c. WATER LEVEL Below Top of Casing: rX l/\t/ FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING 1S 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): METHOD OF TESTTB jJfg)I}—Rry
L DISINFECTION: Type ChaWific Amount 4),O2—
g. WATER ZONES (depth):
From To ,gee From To
From To From To
From To From To
6. CASING:
Depth
From To //j)
Thickness)
Diameter Weight Material
Ft. 6„ Z5 2/6,,'a pr! s.&z7
From To Ft.
From To
FL
7. GROUT: 0 Depth Materialat�
From To no Ft. dAir_eEte
From To Ft.
From To Ft.
Method
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 Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
O —'rip C'(0 y
80 /OS s,,Ali rYoeK
/Ot - //d /Lock
11. REMARKS:
6 51C
a/Y
SIT. r' 1Quu
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W MTH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
III%�/C
SIGNATURE 0 CER IFIE CONTRACTOR / 7 DATE
GI, o
PRINTED NAME F 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
A

1. WELL CONTRACTOR:
/.7
te/A-N /..47Y
Contractor Individual) Name
E:�l/SONS I/ IEII c2NQM /
Well ontrada Company Name /
STREET ADDRESS rfl73I N,�10 L
%G63)Ea NC"• 0?87YP
City or Town / State Zip Code
8�R )- 5 2 S'-f9 IL
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
e3oo5— 0o15b"�a
STATE WELL PERMIT -Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply /
DATE DRILLED 'y - 7— 04. TIME COMPLETED /I;LO AM p7 / PMp
3. WELL LOCATION:
CITY:- {/, COUNTYia.,..,,52
CR, Ir7rrc
(Street Name, Nuinters, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley ['Flat ❑Ridge ❑Other
(check appropriate
''box)
,,
LATITUDE 3 vY Ch27
LONGITUDE P Z ZY, Zr6 •
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DthS (3 Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER
OWNER'S NAME
ST EET ADDRESS
CiSheili Ye -
City or Town
Area cod)- (p l0 5 - Lito 603
Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 Ur
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
c. WATER LEVEL Below Top of Casing: yV rr.
(Use'•• if Above Top of Casing)
d. TOP OF CASING IS / 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): 7 METHOD OF TEST
6. CASING:
RESIDENTIAL. WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Divaion of Water Quality
WELL CONTRACTOR CERTIFICATION N 3 / 410
3 Y j 6 6
f. DISINFECTION: Type Cis 'Y
Amount /4 .k ,
g. WATER ZONES (depth):
From rr To From To
Fromii'v To From To
From To From To
Depth Diameter
Fram To G'2. Ft 6.2.
From To Ft
From To Ft.
7. GROUT: Depth
From ,v To ao Ft C0tcrcfc ?jp1U!Thij
From /� To Ft.
From To Ft.
Thickness/
Weight
SPAC c/
Material
8. SCREEN: Depth
From To
From
Material Method
Diameter Slot Size Material
Ft. in. in.
To Ft. in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From • To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
/7- LZ .f'Cs-L/
11. REMARKS:
co
t
tr
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wr1H
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
«-d -06
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
piA-AI k GU, ales
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / /PLC)
1. WELL CONTRAC
jT
�OR: , /
Z1C/�FN fit G)NiNES
I Contractor (Individual) Name
HMV b fell and imp cat
Well ontractor Company
Name /
STREET ADDRESS r 7.3/ /j' & L
City or Town / Stale Zip Code
( )- . 58I/9le.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Or applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED 3-,30 'BOG
TIME COMPLETED 3. 7O AM ❑ PM L'
3. WELL LOCATION:
CITY: 4. i111.,.
COUNTY Jet• en..., /t
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETANG:
❑Slope ❑Valley ['Flat seRidge ❑Other
(check appropriate box)
LATITUDE 3 r t/3, Yt f
LONGITUDE )" 2- Li/, %TY
May he in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: tPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER /�
OWNER'S NAME (Lk\&(1CS eti1
STREET ADDRESS 41/ Aft fop Roa 1
��P L! Wr• /✓� un
City or Town State Zip Code
3 37-59s5
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: -?fir
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C(
c. WATER LEVEL Belau Top of Casing. CYOFT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING 15 ' FT. Above Land Surface*
`Top of casing terminated attar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): JO METHOD OF TEST
hp(/)drtj,-�O
r. DISINFECTION: Type (' 4 .
g. WATER ZONES (depth):
From Jr/To From
From JJ.f To From
From To From
Amount Ar i£fi
6. CASING:
Depth Diameter
From LI To CJ Ft. /../L/
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth Depth Material Method
(.i From To r.` Iri Ft. COacrctc 70Uf;
From To Ft
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.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Y-`
ar- u
Material
Formation Description
C
Sk //
sT- 3 rr
11. REMARKS:
U1_
-0
i •
O
2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3-3a-dt
SIGNATURE OF /ERTIFIIED�WELL CONTRACTOR DATE
P/4/1) /l. G(Jr NeS
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.
Fonn GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 1410
' -5 6 4
e3 Ei Y 1
1. WELL CONTRACTOR:
---afzik/L) 12 y NES
I1 Contractor Individual) Name
f.Ez i/CeN lz IEII a/ amp, Ike,
Well ontractor CompanyName
STREET ADDRESSy7 /3 rE& L
/✓�_ /'(eS fee- /Vi L • a87gg
City or Town / State
24X )- �5 &-- g te.
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT Cif applicable) /
WELL USE (Check Applicable Box): Residential Water Supply Q'
DATE DRILLED Ls. -31- Oi
Zip Code
TIME COMPLETED / : 0 J AM D PM I2r
3. WELL LOCATION:
CITY:-�.
Le. t/ i)1 - COUNTY A../,.t,je_
✓`/ /C d..l COt.4. z /
(Street Name, Numbers, Community, SubdiNsion, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:�
❑Slope OValley ❑Flat Et dge DOther
(check appropriate box)
r
LATITUDE 3 r .17.37!
LONGITUDE Y L 44 / tl /
Latitude/lonei[ude source: S
May be in degrees,
minutes, seconds or
in a decimal format
❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER !/•,
OWNER'S NAME Li' .4thlr _�(Sbn c .7A )46/yte",
STREET ADDRESS SOr r41c COO. el
1;c{ti�u.'li
�� IfC 23,88nc)
City or Town State Zip Code
(Alai- l.e(o5- 44'&
Area code - Phone number
5. WELL DETAILS: _
a. TOTAL DEPTH: 2 r' ) /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [+D
c. WATER LEVEL Below Top of Casing: FT
(Use `+• if Above Top of Casing)
d. TOP OF CASING IS ( FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0•�11 B.
e. YIELD (gem): 3° METHOD OF TEST A)huil1G—RQ
f. DISINFECTION: Type r/ •:_ Amount t lV1/i
g. WATER ZONES (depth):
From //0 To From To
From /[ 0 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Materal
From 0 To S2 Ft. 4./2r f/.z& / "-At
From To Ft,
From To Ft.
7. GROUT: Depth
p Toa0
Material Method
From Ft. Co/Ic_fcfe pjotich
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
Ft. in.
Ft. in.
Size
To Ft.
To Ft.
To Ft.
in.
in.
in.
Material
Material
10. DRILLING LOG
From ' /To Formation Description
y7 (Icy
y7 - .r2 .rlt //
r2-
11. REMARKS:
m
-d
t
Q•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3-3/-04
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
n;A-A, l7, f2L /Ves
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION */ 3 / 440
1. WELL CONTRACTOR:
Loki.;411) Atli
(/ i /V ES
I Contractor Individual) Name
asams /.t tell awc/Rmp PLC.
Well ontractor Company Name
ST,REET ADDRESS
Z_/EFS/EEL /V C • aY r7'gg
City or Town / State Zip Code
8 03 )- ;352-- 8q912_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 4 - ZZ-oG
TIME COMPLETED //:.742 AM ErlpM
3. WELL LOCATION:
CITY: lutes As- COUNTY
5 4-r-YC
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
f3Sclope DValley ❑Flat ❑Ridge ❑Other
(check appropnale box)
LATITUDE 3 i 71.• 614
LONGITUDE r L 3T 7414:7'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: c PS ❑Topographic map
(Iocaton of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER rt
OWNER'S NAME Ka„
(S$(TREET ADDRESS .& f 7 S
`%PAC
City or Town State
(Sa8)-71/3-68a8
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 D �J
1 84 p'
dei ras (1Rd
a8 7qf tR
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO f7
c. WATER LEVEL Below Top of Casing: l/O FT.
(Use'+• if Above Top of Casing) /
d. TOP OF CASING IS f FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0116
e. YIELD (gpm):
's METHOD OF TEST tlth:rj5-R1
eti
o 01 i
f. DISINFECTION: Type `4r%#G
g. WATER ZONES (depth):
From "-Cr- To
From J2r To
From
6. CASING:
To
From
From
From
Amount / Air>
Depth Diameter
From J To /oJ Ft. 4./2r
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth Material Method
From tv To a Ft. Cone
/� rcfe "D%p llfi/YQ
From To Ft. i .J
From To Ft.
6. SCREEN:
From
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
Size Material
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0- cr C/4.4
QY- /..3
Formation Description
rSs w./J/.n-i
/DJ- 20r 6 _,-4
11. REMARKS:
20U5
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
.le r.✓..� G-tit- 04'
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
r A -A, 1< GU, /V 5
RINTED 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.
Fonn 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: /
t(/h.rs
AL
yll Contractor Individual) Name �
/Fleq�wAls GIE1l amid "Pump
Welll ontractor Company Name /
STREET ADDRESS 4g731 A w LEf(E&/EQ /h y.
NrC• 018751S)
City or Town / State Zip Code
2. 5? )- ;52-- S�fq lit
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(8 applicable)
D WQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply [t
- /2-04
DATE DRILLED
TIME COMPLETED ,7 :Da
AM ❑ PM p'
3. WELL LOCATION:/.
CITY: /S.. Vrs/ COUNTY
S/p %C &T / iewi cl tin ,
(Street Name, Numbers, Community. Subdivaion. tot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
aitlope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r 3e. tzr
LONGITUDE Y L 21. Z'/s-
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 12(6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS 1
a11Lti uzA,) 1( d 73D
City or Town State Zip Code
(C6a% >. l ag 3Lf71
Area code - Phone number
5. WELL DETAILS: y
a. TOTAL DEPTH: ✓ ( r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l7'
c. WATER LEVEL Below Top of Casing: 2 0 F7,
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. i�
e. YIELD(gpm): .3 METHOD OFTEST� oth' t'dj_ q
3/4'C
1. DISINFECTION: Type Cio-.
Amount 227 ASi
g. WATER ZONES (depth):
From /20 To From To
From 2F4) To From To
From To From To
6. CASING:
From 0
From
From
7. GROUT:
From f�
From
From
8. SCREEN:
From
From
From
Depth Diameter
To '/S— Ft. d,er
To Ft.
To Ft.
Thickness/
Weight Material
Depth Material Method
To ,NO Ft. Concrete ppjtf7!tl4
To Ft. J
To Ft.
Depth Diameter Slot Size Material
To Ft. - in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
-vim
yr— 24t 6-wrtc
S 2 ae tr7
J
11. REMARKS:
0
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC EC. WELL CONSTRUE. IRON STANDARDS. AND THAT A COPY OF THIS
RECORD WAS BEEN PROVIDED TO THE WELL OWNER.
6-i2-06
SIGNATURE OF ERTIFIED�WELL CONTRACTOR DATE
P/;nl ti, /2IIves '
RINTED 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.
Fonn 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:
_Btt;4-10 (' CU;At a
iipl Contractor Individual) Name
yoncif3A.s a/El/air ¢ amp /-.I.�.
Well tractor Company Name G / 2
S/TRREET ADDRESS 3731 Aid LE/ tz Ja �u y.
L
City or Town / State Zip Code
l 2A )- 5 & -• S i9 &
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 21
DATE DRILLED -6-
TIME COMPLETED AM ❑ PM [
3. WELL LOCATION: ``,,
CITY: fccey,'I el COUNTY �t%mn �t
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC��/ LAND SETTING:
D81ope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r- 31.110
LONGITUDE Sr L
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ETOPS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached fo this form 7 not using GPS)
4. WELL OWNER
OWNERS NAME t.U?r��e/rl( CI
STREETADDRESS (T% e -Y-' 7645
��a /7() 28S/S
City or Town State Zip Code
(Xa )- (e(v t1-15f 8
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
thr
b. DOES WELL REPLACE EXISTING WELL? YES [ NO
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use'✓ if Above Top of Casing)
d. TOP OF CASING IS ( FT. Above Land Surface*
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): L METHOD OF TES
TA)e1/)laAti-�O
f. DISINFECTION: TypeC'orr .-C Amount -C' '4t
g. WATER ZONES (depth):
From 3-1"o To From To
From r-- /jl To From To
From To From To
6. CASING:
Depth Diameter
To r%o Ft. C/tr
To Ft.
To Ft.
From 0
From
From
7. GROUT: Depth
From 4 To 0
From To
Frorn To
8. SCREEN: Depth
From To
Thickness/
Weight Material
Material
Ft. cone ref c.
Ft.
Ft.
Diameter Slot Size
Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
- -r
7J - YO
Method
1101.(fiN.Zi
in.
in.
in.
Material
Material
Formation Description
av-por dr. ,k
c/)
ri
-'D
CD id
J
SEZQJC
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF EERTIFIED�WELL CONTRACTOR DATE
PIA AI n. II ivles "
RINTED 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 G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:.
ell Co��r(h d Namg
,ERG, ik. o/1.s WEIL CAA fum p, LLC•
Well intractor Comp
an
y
JName J� f /
STREET ADDRESS (a /� / Xt (,
teSFEa ACC 387
Zip Code
o' City or Town f State
(0) 5,s'—/94_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
S
STATE WELL PERMIT#(i1 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [J
DATE DRILLED $(S4G
TIME COMPLETED /2;ov
3. WELL LOCATION:
CITY:
�f/f (//eta COUNTY 44Caw,Q[
AM PMLr
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI
❑Slope [Valley ❑Flat idge DOther
(check appropriate box)`
LATITUDE,/ 35' 3 C fr
LONGITUDE/ OA AA ars ?!
Latitude/longitude source: Del5S [Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER {/�) J_
OWNER'S NAME KJl;A-� A./ Q�GI
STREET ADDRESS // / %,y-8e� _
l d.�P 11C 23go/3
City or Town State Zip Code
(__2)2_ - „R5 t Lig
Area code - Phone number
May he in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: �1
a. TOTAL DEPTH: 7Q $
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ir-
e. WATER LEVEL Below Top of Casing: n 0 FT.
(Use '+• it Above Top of Casing) rJT
d. TOP OF CASING 15 / FT. Above Land Surface•
'Top of casing terminated at/or t elow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 50 METHOD OF TEST 'h fl,' tl hirN
20-1
43
f. DISINFECTION: Type('h/g/._w/C Amount $20 L
g. WATER ZONES (depth):
From To MO From To
Fran To From To
From To From To
6, CASING:
Thickness/
Depth _ f iASler Weight aterial 2 /
From To Ft. t �,as
From To Ft.
From To Ft.
7. GROUT: Depth Material
0 To AI() Ft. eAlreeie
From
From To Ft.
From To Ft.
Method
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 To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
v Ye
Formation Description
/A
Y(l -si s•.rYear
s3 - carto c k
sr - 3os $r..al Ye.
cn
rn
J
0'
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THEW 0 NER
U'E OF ERTIFIED CONTRACTOR
NAME F PERSON CONSTRUCTING THE WELL
ED
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.
ATE
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 # 3 / 410
1. WELL CONTRACTOR: /"
Ek, *N X. /J /y ES
II Contractor (Individual) Name
EEgQ C %(Jc1l and nano LIZ-
Well ontTactracta CompanyName/ �,-!1 /%
ST,R_EET ADDRESS 3731 ,M'w LEI LL,1E( fihti/.
Z /•(ES jet 41,C • r�8;Ng /
City or Town / State Zip Code
(CR )- 352-- 8g91.2-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 40OS — b 3 (Pi,
STATE WELL PERMIT#tilappliicyca1b�l,e,,,)),
DWQ or OTHER PERMIT#(it ap—plicabT((e)• .3DO 5 - 03(6 I
WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED /-G -Q(p
TIME COMPLETED /D: Sir
3. WE'LL LOCATION:
CITY: Ze•Zeu/r-
1 /a - Fe11h
AM 2PM
COUNTY...cf.. ![
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope [galley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 Sr 75.2¢n
LONGITUDE - Z ?k.2Lr.
May be in degrees,
minutes_ seconds or
in a decimal format
Latitude/longitude source: ESOPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER /r WAYNE,
OWNER'S NAME es 4 P!+(•N•A`4Rhr it 11 rn,J)
STREET ADDRESS 15
P\eitw;llP N(, al8n(o
City or Town State Zip Code
(5aed )- a5a - (o099
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 417r
b. DOES WELL REPLACE EXISTING WELL? YES C NO
c. WATER LEVEL Below Top of Casing: Pa FT
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or Selav land surface may require
a variance in accordance with 15A NCAC 2C .0118. rr(�
•
e. YIELD (gpm): /2 METHOD OF TEST1j01)tarly- /
f. DISINFECTION: Type(Aur.>tr Amount 20 4 .
g. WATER ZONES (depth):
From kC To From To
From Sic,— To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To Z Ft. 4./Zr f-.Pi' /LC.
From To Ft.
From To Ft.
7. GROUT:Depth Material Method
From (9 To 20 Ft. Concrete ijp(.(ftN�?r
From To Ft. J
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To
FromTo
From To
10. DRILLING LOG
From To
D' 2I
2/- 2c
Liv - L/LCC
11. REMARKS:
Ft.
Ft.
Ft.
Size
in.
in.
in.
Material
Material
Formation Description
CAT
err'Cr.7pn6
1 OD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Blot, '7% '1,7-4r.G / -6 -Gt
SIGNATURE OF CERTIFIEDU/�WELL CONTRACTOR DATE
r;i i /)• /Cl, /yes
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / %1(,
1. WELL CONTRACTOR:Vel/,
1Co L(Narne
Contractor (Individual) Name
I ES
r aL--
WeeG(utaNC �pl Jell air d un+p
Well ontractw Company�yName /
STREET ADDRESS 37.3 AD LEtdE -E(C y•
lit- M, (' . rc3B 19P /
City or Town / State Zip Code
(8 ) 5Sy9lz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED r-/d' O6
TIME COMPLETED /r% '. OU AM Er -PM 0
3. WELL LOCATION: p�
CITY: ee, et y% COUNTY at: el ern d/
irOtis clei
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ['Valley ❑Flat D.Kldge ['Other
(check appropriate box)
LATITUDE 3 S ,74-. JEW
LONGITUDE 7 L _ay %J'f '
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EroPS ❑Topographic map
(location of waif must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER //--
OWNER'S NAME P @ rJ tits h ne.c
WREET ADDRESS (p� ThnsiaC ,\vd..
het).11e, tv C 2go
City or Town State Zip Code
qaR )- 5LJ5- 3a1!�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Z©xr /
b. DOES WELL REPLACE EXISTING WELL? YES [' NO [1(
c. WATER LEVEL Below Top of Casing: VC FT
(Use `F' if Above Top of Casing)
d. TOP OF CASING IS / 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): f METHOD OF TEST
1 n ., (;
1 ti
f. DISINFECTION: Type C/a—.:wG Amount / 4 s s
g. WATER ZONES (depth):
From PC To From To
From 0"5/D To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 7v Ft.
From To Ft.
From To Ft.
7. GROUT: Depth
Depth Material Method
From (� To NO Ft. Concrctc 7),our!!✓Oi
From To Ft. J
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
FAoom To Formation Description
v-•GJ_ C/.",
I r- 7O s4,i
11. REMARKS:
C11
m
-o
O c )t
en
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
i/+N it
Dn. it/ iVes
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 40
1. WELL CONTRACTOR: ��
;+N IndiLU i /V ES
DOContractor vidual) Name -�
tfjocOmn L! fell and J"amp, ki_C,
W ellsontractor Company Name
STREET ADDRESS guy in; LE!eEsJER IIbi /.
%iffsjEt /V,(1 • a87/1P
City or Town / State Zip Code
( <)- .2352 S4glrz
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(I( applicable)
STATE WELL PERMIT/kit applicabie)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply I3`r
S'rir
DATE DRILLED
TIME COMPLETED /✓ : 0 D AM Er —PM!:
3. WELL LOCATION:
CITY: M,-, /.
n.:T //<// .���✓✓jj
(Street Name, Numbers, Commubity, Subdivision, Lot No., Parcel, Zip Code)
T9POGRAPHIC / LAND SETTING:
gliSlope ❑Valley ❑Flat ❑Ridge ❑Other
(cheek appropriate box)
LATITUDE 3 f 4'7. //
LONGITUDE it L 72. 317'
COUNTY /S y„rman ,Iz
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 0f6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME find
ISTR,,EET ADDRESS n t q �la' s.14�
l/ kath to, lie_ NC- ,-2R7u7
City or Town State Zip Code
( S > 1,45-50Y3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: f Dr
b. DOES WELL REPLACE EXISTING WELL? YES El —NO 0
c. WATER LEVEL Below Top of Casing: 447 FT
(Use -+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated at/or betov land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / 2— METHOD OF TESTA Jpltlu1Q'R9
f. DISINFECTION: TypeC/+r:-.1e.. Amount IY„ 6S
g. WATER ZONES (depth):
From . J'- To From
From J9ir To From
From -7 ro To From
6. CASING:
To
To
To
Thickness/
Depth Diameter Weight Material
From 0 To 7%-- Ft. 4e/er fdjdL .....6-C..
From To Ft.
From To Ft.
7. GROUT:/} Depth
From (.i To ro
From To
From To
Ft.
Ft.
Ft.
Material Method
Conte. refs •J)li7ltf%N t4
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 Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
- 7J
Material
Formation Description
cv
/3-1J S/til.c —s{t//
Tr-
11. REMARKS:
rn
"0 c'
'
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wrm
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S--f- 06
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
�P/4JJ W,ives
•
RINTED NAME OF PERSON CONSTRUCTING THE WELL
1
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 # 3 / 410
1. WELL CONTRACTOR: .
&Ln/ k I J' ES
1 Contractor (Individual) Name
EKgU CONS h Jell and 1''amp) !LC,
Well ontractor Company Name ��-!/e C(L/� t1Ul/
STREET ADDRESS rfy�yylJ1,VU,I LEt± —.
LEi/fs]Et i('• ai741P /
City or Town f State Zip Code
(2A 52- SLf9Ce.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
A006- 00,5OD
STATE WELL PERMIT/SW applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply V
DATE DRILLED f cV Oo
TIME COMPLETED -: it, AM ❑ PM g�
3. WELL LOCATION:
CITY: ZC „„A.-- COUNTYd' dontc.
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND IDilope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 .f yl 7f0'
LONGITUDE - Z- 40:7r
'�
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME /L
eS-FrCtli 110 U II
STREET ADDRESS 7?s - ray arrot_P;� {1
a s hail n (' Vs 3
State Zip Code
City or Town
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Zo6'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO tZ"
c. WATER LEVEL Below Top of Casing: ea FT,
(Use `+' 1 Above Top of Casing)
d. TOP OF CASING IS , 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): V METHOD OF TEST QJj)p%lilif J'R9
0
f. DISINFECTION: Type C/,
g. WATER ZONES (depth):
From )-O To
From
From
eev4% To
To
6. CASING:
From
From
From
Amount erne
To
To
To
Thickness/
Depth Diameter Weight
From a To .TY/ Ft. 4t• 7i Ingr.
From To Ft.
From To Ft.
Material
�c c
7. GROUT:n Depth Material Method
From F� To r 0 Ft. COX rCie. 7/OW.201.
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0- s C-"er
44- sd fir."
PI- e'er C--,
Fn
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
vil+N I< GU, Ne5
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 440
1. WELL CONTRACTOR: �"
-3/6.4-N 71 /./1/ES
IITA
I Contractor Individual) Name
igitS6Ns 111e11 aird limp) /_LC.
Well ontractor Company Name
STREET %CADDRESS 373/ AO LEI cEci C� f1,y.
JE/SJEe- AY. /'1d-
Cqy or Town / State Zip Code
()- ;73 5 & -- g Lici /z.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID trot applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED .7 2- QC —/
TIME COMPLETED 3Do AM ❑ PM ❑'
3. WELL LOCATION:
CITY: ,c fC.�r... -, { COUNTY A - 4a ,.o /P
4. is C. • A .Y,i
(Street Name. Numbers, Community, Subdition, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Dope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 e crF'
LONGITUDE T 2- /y ?°2'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ca 5 ❑Topographic map
(bcatbn of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME /7al( Ene4/r let
STR T ADDRESS 7 U rn) hc-I'nP�C r
L i d p� h C arm cj.
City or Town Stale Zip Code
(%;S)- to.%.4— S33.
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
h. DOES WELL REPLACE EXISTING WELL?YES ❑ NO Er
tL
c. WATER LEVEL Below Top of Casing: f o FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS ( FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST
n
L DISINFECTION: Type rip.- • . < Amount 9 i-q )1.9
g. WATER ZONES (depth):
From /2° To From To
From -e4> To From To
From To From
6. CASING:
To
Thickness/
Depth Diameter Weight Material
Fran V To 17 Ft. /_/!r S.oi'en Ad(
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From iv To o Ft. Cone rctc /W id thV Ot
From /� S` To Ft. J
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.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size
Material
10. DRILLING LOG
From To Formation Description
0 -Zz C/cy
22- 2, .34N
27 - Jor (� k
n
11. REMARKS:
i!
n
GU
cn
o
Off'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CrERTIFIED WELL CONTRACTOR DATE
plAgN / 1. UJr Ne 5
RINTED 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.
Forrn GW-la
Rev. 7/05
t

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 l 410
1. WELL CONTRACTOR:
ZZ/IM) 2L i/vES
II Contractor Individual) Name
.Ef s6N> b ie// adc Pamp
Well ontractor Company Name
STREET ADDRESS j..& LE/?±SJEQ iltuy.
/ lESJE� /Y C • 0?875/g /
City or Town / State Zip Code
(SCR r 5&-- ghee
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT/SO( applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [3
/
DATE DRILLED ' ' 2 J 'OL
TIME COMPLETED a'J AM O PM ar
3. WELL LOCATION:
CITY: le re) ice
COUNTY 4-ward(
(Street Name, Numbers, Community. SubdiNsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope DValley ❑Flat ❑Ridge oOther
(check appropnate box)
LATITUDE 3 � 4. it '
LONGITUDE Y' L 4/2- rot
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: e6PS ❑Topographic map
(ocaton of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME �) /
STR T ADDRESS lie)1Y'O (-b fad
C ITTl own h StateZipCode
(,, a3 ctf q O `Jr
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ULf
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 01
c. WATER LEVEL Below Top of Casing: ,/zD FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / . FT. Above Land Surface*
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 30 METHOD OF TESTAP)ifiirfy'/)rj
C i F i
v -L 4
f. DISINFECTION: Type Owe ,:,- Amount /l—A4 .
g. WATER ZONES (depth):
From /,30 To From To
From </i10 To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To l,L Ft. 6-/tr SoArJA c,
From To Ft.
From To Ft.
7. GROUT: Depth
Depth Material Method
From (� To c?` O FL Cots rctc )/OIAfiN L}
From To Ft. J
From To Ft.
B. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
in.
in.
in.
Material
Size Material
From To Ft.
10. DRILLING LOG
From To
D-/07
//Z
biz - 42.
I. REMARKS:
Formation Description
C'1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY Of THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
'Std.:. -7 -1/,...... YLLY.nae
SIGNATURE OF ERTIFIIED�WELL CONTRACTOR DATE
nfAaN Id Ne5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
a
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 70
1. WELL CONTRACTOR: �� //
/•fit'
� Lnu W ES
yy�II Contractor Individual) Name
Er'UuIN3 It fell a#d J"u,1p /1.C-
Welll ontractor Company Name r
STREET ADDRESS 4.1731 ��GLI LI / t.,r✓�E�L %(Gll�.
JP/'PtS/Et a • aY7gg
City or Town / State Zip Code
(248 )- 9 5 & -- S y9 Le_
Areacode- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED dot 2-D--66
TIME COMPLETED /L > G AM ❑ PM
3. WELL LOCATION:
CITY: C:v.dr•,
COUNTYA:e.e
" ,ne `%, i , y i✓<// �i ` S
(Street Name, Numbers, Community, Gubdivision, Lot No., Parcel, Zip Code)
TOPPGRAPHIC / LAND SETTING:
L_d'S /lope DValley DFlat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3 Y -W. 7d-
LONGITUDE 7- L4y'
Latitude/longitude source: p'l;PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER , �,)
OWNER'S NAMEn 0 `I'-{Le(r S pCl<5C--6�U.zr)-
STREET ADDRESS 54L3 \A)ttl, �•J
%79
May be in degrees,
minutes, seconds or
in a decimal format
U hdpfSlshU,le NC
City or Town State Zip Code
cz8'7- 4 41 L
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2�--
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [
c. WATER LEVEL Below Top of Casing: ro J Fr.
(Use `i if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
`Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2° METHOD OF TEST
f. DISINFECTION: Type [ h.-4,c
g. WATER ZONES (depth):
From_d To From
From 15-s' To From
From To From
6. CASING:
Amount %y !;S,
Depth Diameter
From 0 To 7Z Ft. G,/If
From To Ft.
From To Ft.
7. GROUT: Depth
From P To ND
From To
From To
8. SCREEN:
From
From
From
To
To
To
Thickness/
Weight Material
Material Method
FL Concrete- ?/Ol.f ri/y
Ft. l
Ft.
Depth Diameter Slot Size Material
To Ft. -. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From • To
From To
Size Material
Ft.
Ft.
From To Ft.
10. DRILLING LOG
From To
— 17
6 7 - 7Z
7z — Zrr
11. REMARKS:
Formation Description
CA
r4,,
1 '
cn
I 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.
V-a -at
SIGNATURE OF EERTIFIIEDWELL CONTRACTOR DATE
KA-Ai 2< Id Ne5
bPRINTED 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 569.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CEkTIFICATION # 3 / 410
,. Q1
c• J Y f U 1
1. WELL CONTRACT/OR:
B/t/,1`N r, /.PAVES
1 Contractor (((Individual) Name
/ %le// a.ri
Eecru Sa orC amp, lL C,
Well ontractor Company Name /
ST,R�EET ADDRESS 4173/ ba) L516E JEQ jh„y,
.//(t%]p, - /ic• off?7'SFe /
City or Town / Stale Zip Code
(2a8 ,- 352-- gq9&-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#pl applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q'
• DATE DRILLED r-'2. - p(. /
TIME COMPLETED dr/:ro,P AM PMEf
3. WELL LOCATION:Cl
CITY: (//<r
COUNTY.a...,..,,1, /t
Lc. 7 </r .,,/ ,9 TO
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat D4idge ❑Other
(check appropriate box)
LATITUDE 3 T Zr rt.?
LONGITUDE )- L /I; ZG)•'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: er6i)S ❑Topographic map
(Iocation of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME
SET ADDRESS
t'QJY/q h
(�C'liyThor T}dvn (QState
Area code - ((- /✓ Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 14 s
b. DOES WELL REPLACE EXISTING WELL?
YES❑ NOCf
c. WATER LEVEL Below Top of Casing: 3 co FT
(Use'+- i( Above Top of Casing)
d. TOP OF CASING IS , 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): / METHOD OF TESTT Jhinittly Re
t. DISINFECTION: Type ('/✓....e
g. WATER ZONES (depth):
From -1-70 To
From
From
6. CASING:
To
To
From
From
From
Amount 29c "4_6 ..
Depth Diameter
From 0 To /041 Ft. x:./tY-
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
Utz/ Ali:
7. GROUT: Depth Material Method
From ,/i To No Ft. e/1Crefe. iioitri/vor
From To Ft. J
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.
9.
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D - 5-s-
Material
Formation Description
Cky
ft- - /v:, .f4
11. REMARKS:_. _.
TVT/I
--o
1
O
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wml
15A NCAC 2C. WELL CONSTRUCTON STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S Z 04
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
nfA�/d fid, we s
RINTED NAME OF PERSON CONSTRUCTING THE WELL
'ems.
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 CERTIFICATION # J / ¥CJ
1. WELL CONTRACTOR: /'
�. (i(/, /VES
Contractor Individual) Name
a" lice/Vs Lt fell 626 u/,-lp lLC,
Well¢onlractor CompanyName
�/ /
STREET ADDRESS t /J/ //Fr(} L I /LEEK Ikuy.
City or Town / State Zip Code
(21-a 52-• Si{9Cz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L,
DATE DRILLED J -I- 04
TIME COMPLETED Z =a., AM ❑
3. WELL LOCATION: vp
CITY: 4, cer COUNTY f r-- •+'.y/{
�c��CCyys �9 �• I�4
(Street Na/ne, Numbers. Community. Subdidsion, Lot No., Parcel, Zip Code)
T01,0 GRAPHIC / LAND SETTING:
lope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 T C'P. C))
LONGITUDE Y L '/L 4/f5-
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Etth-S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
TREET ADDRESS 1 rQ
�.uerLder�:l Ie c Ag78 7
City or Town State Zip Code
('KO43» 015-7836
Area code - Phone number
.5. WELL DETAILS:
a. TOTAL DEPTH: LO��
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p'
c. WATER LEVEL Below Top of Casing: ✓, 0 FT.
(Use `+• if Above Top of Casing)
d. TOP OF CASING 1S / 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): % METHOD OF TEST
r
001009
f. DISINFECTION: Type C6--nc. • Amount S i .C,
g. WATER ZONES (depth):
From /3% To From To
From no To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From O To YU FL G/zr ra1Ps/ C2_
From To Ft
From To Ft
7. GROUT:/} Depth Material
Method
From N To N0 Ft. COncrc,/e '))/;t/jhiry±
From To Ft. J`�-"""
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Formation Description
74-ry
11. REMARKS:
„ 2035
N
rr
-13
1 .
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3-s-c�
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Pi44 /1. Ill. Ne5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
'Y?
5
a
9
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
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 N 3 / "TC)
1. WELL CONTRACTOR: // �1:4-n1 /U .iv ES
III Contractor Individual) Name
/ Ezrt� Cent') /L JF/J and 1"amp) an
Well9ontractor Company Name / J/
ST,RREET ADDRESS d 73/ AGO LE/ (ESJEtZ j(Z1Jr7
MiC ' a8 E'IP
City or Town / Stale Zip Code
(8.8 X Lf9 G,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 3- j-Ot
TIME COMPLETED S/;DO AM PM.p-
3. WELL LOCATION:
CITY: 6refw COUNTY rd.-, fe
Jf./sn ii,fec .G.aT 0 2Z
(Street Name, Numbers, Community. Subdresion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT NG:
❑Slope °Valley °Flat [(Ridge ❑Other
(check appropriate box)
LATITUDE 3 r M. (.2.4
LONGITUDE t L 35 ?Li
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 0 PS ❑Topographic map
(bcatwn of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNERS NAME r Sit
STREET ADDRESS
J ai c eS4 iY C a' 7 (12
City or Town State Zip Code
( 8a1g > 7& S-'iai3
Area code - Phone number
5. WELL DETAILS: -7
a. TOTAL DEPTH: c �>
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
/
c. WATER LEVEL Below Top of Casing: Y 0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / . FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
elZf r ()'1 -.
E• 0 1' 0
f. DISINFECTION: Type(YJ-..a
g. WATER ZONES (depth):
From Zr To
From /SA" To
From To
6. CASING:
Depth
From 0 To CO Ft
From To Ft
From To Ft
Frorn
From
From
Amount g
Diameter
To
To
To
Thickness/
Weight Material
7. GROUT:/} Depth Material
From 0 To 30 FL Corfu-fe'.tc
From To Ft.
From To Ft.
8. SCREEN: Depth
From To Ft. in. in.
From To Ft. in.
From To Ft. in.
Method
?burin, j
Diameter Slot Size Material
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
p - rr
s r 6o
11. REMARKS:
in.
in.
Material
Formation Description
eft
S1 9y
c/9
.1
1 '
J
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
SSA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-3-p j
SIGNATURE OF EERTIFIEDjWELL CONTRACTOR DATE
P/A-A/ ) IL 1, Ne5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
1
Q
a
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. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ,3 / 410
r n n
�)1CD33
1. WELL CONTRACTOR: J/� �
%Z.1#,Q l.0 r /v ES
Name
fe
ll Contractor. Individual)
/ ( / Liz Well olCCn/C li yN1�uNll liln/
Well Companyr/Nam)e / /
•
STREET ADDRESS 373 Au) LE/7CesIEg y.
/ tts jft M. (' . ; 879g /
City or Town / State Zip Code
(2R8)- 5&-- 8y91,z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i1 applicable) 4,e)es - 6 /g6 3
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED 1-Zr- Ob
TIME COMPLETED 2 . jo AM ❑ PM Ly7
3. WELL LOCATION:
CITY:
L✓evz: 4•i/e NCOUNTY �rn.�•tst
C` carc C/ /o:j
(Street Name. Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPl GRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 r '%/ 706
LONGITUDE *5- L. Jy, Dee
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2.6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS 2
State Zip Code
LKaR)- 7/ 3 - 979
Area code - Phone number /
d41x /5
bign.Uerd.11y NC A17t7
City Dr Town
5. WELL DETAILS:
a. TOTAL DEPTH: 22r
b. DOES WELL REPLACE EXISTING WELL? YES ElNOp
��
c. WATER LEVEL Below Top of Casing: Lie Fr.
(Use 'tit. if Above Top of Casing)
d. TOP OF CASING IS
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): 70 METHOD OF TEST I r - r
T. DISINFECTION: Typr(4 .c Amount // f
g. WATER ZONES (depth):
From /2a To From To
From /00 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 8 To C/ Ft. /I/'r Sgr<i '—C
From To Ft.
From To Ft.
7. GROUT: Depth
Depth Material
From f� To 30 Ft. CotscrCfc'
From To Ft.
From To Ft.
Method
?/D it thil
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
Size
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
1- P6
r/- 22r
11. REMARKS:
Material
Formation Description
C.F-
9 2006
d''
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
PI k!J J 1, ILL N
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 G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 20.E Q
332
1. W
L CONTRACTOR:
( tf r o S
W,����Wal)fNamg
vid
in40So...11lll lIs WElI o A P mpg Li—C.
Well tabntractor Company Name
STREET ADDRESS L 771 Nt�
Lri stEg JV c. a87zfg
City or Town / State
(N)- a58—&G9&.
Area code- Phone number
1. WELL INFORMATION:
SITE WELL ID Stir applicable) _Oa5- 03
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
Zip Code
Net/ AM D PM p'
CITY: fj/iV/ CM/ COUNTY bdACBM D C
112111cr M/vc ES /d1 C 1 lq7*7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTJN6:
°Slope °Valley ['Flat atRidge DOther
(check appropriate box)
LATITUDE4) 3 5 1.4 rtit'
LONGITUDE t) On '
Latitude/longitude source: S 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 'not using GPS)
4. WELL OWNER^/��
OWNER'S NAME Gf y7'atm nVro'Na
STREET ADDRESS T <Q%1r^(/4N Cotner Zest"
a'/✓,'ar.., /YG 23tt73o
City or Town State Zip Code
(8.7%' )- &toy- 71/1
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES ° NO Ef
c. WATER LEVEL Below Top of Casing: 30 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 .011 B.
e. YIELD (gpm): f METHOD OF TEST�rJ
6D s
L DISINFECTION: Type C{t /// /yam A. Amount /t'j 4 p.
g. WATER ZONES (depth):
From do To //5 From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Dia eter Weight Material
From 0 To 3 Ft. r r 2./6. /a25 fvc sad.&
From To Ft.
From To Ft.
7. GROUT: FLC .n Depth //1t Material
V
From To iijll nice 1(e
From To Ft.
From To FL
Method
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
a —�S
Material
Formation Description
A
/5 —3) Ss.l%S xilNi
33 ^39' 'tar/T
3fl --EoS fs.a.v, Yc
11. REMARKS:
0,
'
2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THLS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNA�RE OF
PRINTED NAME
Y'
RTIFIEDj
CONTRACTOR
F 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 # ,3 / 410
1. WELL CONTRACTOR:
X /[./ i /V ES
r4uSe lI 1e/I add Pwnp /1C.
I Contractor Individual) Name
Well ontractor Company Name
STREET ADDRESS a/3/ j w LE/ LESJE1 fitur•
.E (ES t / (' • 78 r7gg /
City or Town / State Zip Code
(2- >3 )- La52-- Ky412,,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID tail applicable) 4RPO 6 - 4,0073
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply Er
DATE DRILLED Z: Z7-C(:
TIME COMPLETED / :.7 AM ❑ PM O-
3. WELL LOCATION:
CITY: //C-//e.
•
COUNTY
(Street Name, Num rs, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat a'liidge ❑Other
(check appropriate box)
LATITUDE 3 3 -- 7/, Trr'
LONGITUDE P Z 4/7 ati'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: (?tiPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER r� f
OWNER'S NAME,rrdri.r_% Wes fr
STREET ADDRESS 796 S'$taireis ;dr Dr.
Orden ar7041
City or Town State Zip Code
%a g )- 74 r 51e55
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ror-
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO G-
c. WATER LEVEL Below Top of Casing: u ,2FT
(Use -+- if Above Top/of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): /2 METHOD OF TEST.11)cithay-R•
:31331
(. DISINFECTION: Type (4. -'r Amount Zf
g. WATER ZONES (depth):
From /Up To To
From f j J
To
From To
6. CASING:
From
From
From
Depth Diameter
From C To %O Ft. r: ✓1r
From To Ft.
From To Ft.
7. GROUT: Depth
From P To ao
From To
From To
To
To
Thickness/
Weight
Sp4.;T
Material
Material Method
Ft. CO/It"_rcte piditiinf
Ft.
Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To
T
From To
Size
Ft.
Ft.
From To Ft.
in.
in.
in.
Material
Material
10. DRILLING LOG
From To Formation Description
0-rr 0/cy
5-r- - so
$4i!
SD -"Dr G:24.c,
Cr)
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
✓�r.r//L 2-.L7-of,
SIGNATURE OF 10ERTIFIED WELL CONTRACTOR DATE
P. A -A) !f, /fI, AfPS
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.
Form G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2Dasl.
1. W
L CONTRACTTqOR:� Wd�0 b Iividya- I)rNa j j O .s
(E 1LSONS WE II odd t'(tm PLC•
Well t)ntractor Company Name P/
STREET ADDRESS f�/ /ftL
l fltes/Eg c as p
City or Town / State Zip Code
( gag )- 258-2f9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED .2 - 2) - Day
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: kit 1/24,4 COUNTY..htn a, Q
/,W(ela4 fle/i,fs
(Street Name, Numbers, CommunigSubdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley CI Flat Of dge DOther
(check appropriate box)
LATITUDE 3 f 24, 69.E
LONGITUDE Y 2_ 01 iJ/ r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DfdPS OTopographic map
(bcation of well must be shown on a USGS tope map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME mberf- J/.a t
STTEET ADDRESS W 6k4»j fa� � �..� J�
City or Town State Zip Code
( 8.28)- 777-.39o0
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 20 C
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c. WATER LEVEL Below Top of Casing: .O FT.
(Use'+' N Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance With 15A NCAC 2C .0118. a e. YIELD (gpm): JD METHOD OF TESTS r./
f. DISINFECTION: Type (/,. nC Amount r%S.,
g. WATER ZONES (depth):
From /Jr To From To
From /317 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To $'r Ft. ‘ / - $*', , /'-'e-
From To Ft.
From To Ft.
7. GROUT: Depth MaterialreMethod
From 0 To In FI. CC°Il1Eir
From To FL
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
a- sl
(3 - Sor
Sb — 20r
1. REMARKS:
Formation Description
Us..
t!)
v-'-
J
it
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD , BEE P. •EDTO E WELL E
C'NTRACTOR DATE
& ), toffs
PRINTED NAMEpF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
7617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON tt 20 v3 Q
Onf,
1. W
L CONTRACTOR:
0bh W./ o
1501 Contractor (rttirvid al)m NaR'qkso4.s E 1 t @Id
Well ntractor Company Name
STREET ADDRESS
C
l(E4Ea AK c. as 14'
City or Town / State Zip Code
( 7? )- .ot 58-8(191,2.
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID If (if applicable)
o`)DO (o - 060 a
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED pr — D D -Qb
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY: COUNTY //A A/(1M6<
deny / k Lo
(Street Na Numbed Community, Subdiesion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat frkidge DOther
(check appropriate box)
•
LATITUDE 3S 2.6 r7QL
LONGITUDES , AS ' _
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER //' /�/-
OWNER'S NAME \ f4 irO n0.. C)(-(I,Y..('A rrta I't
STREET ADDRESS rs ( 00 j-- coilki
{Ed€ttt l) P a)g7a H
City or Town State Zip Code
( tor% l- a75_ Cle 6
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal formai
5. WELL DETAILS:
a. TOTAL DEPTH:
7S
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
c. WATER LEVEL Below Top of Casing: Are FT.
(Use'+• If Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated aVa below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST / Jial(j R'q
f. DISINFECTION: Type qA 6 ti ti r
g. WATER ZONES (depth):
Amount /sj t-
From ).2e To 74/0 From To
To k,s From To
From To From To
From ix)
6. CASING:
Depth
From 0 To $/r
From
From
Thickness/
Diameter Weight Material
Ft./ r/AS 2-4, )5 /PC 50,14/
To Ft.
To Ft.
7. GROUT: Depth �t ,Material
0 To Alo Ft. CDir_eti
From
From To Ft.
From To Ft.
Method
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
From
From
From
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
��
0 _ Nr
z.; - yr
vs-sO
11. REMARKS:
Material
Form tion Description
P0V
f� a 5S/ra�G 1
rn
Prl
"9
1
-t
ririnh
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCT/ON STANDARDS, AND THAT COPY Of THIS
RECORD HAS BEEN PROVIDED TO THE WELL��OOWW/NER.
SIGNATURE OVCERFIE CONTRACTOR DATE
&I, 1)05 '
PRINTED NAME F 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
.11
trl

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanmcnt of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # c 6:1 A 9
0 CS i C(r 7
1. W CONTRACTOR:
Q-4- vs
obh/v,' (,cI
VS/all Contractor (,nldjvidyal) Nam
R'qll,SoJJJI/ is W E Il &r cl icm p. Ur -
Well ntractor Company �NQa jme J(!
STREET ADDRESS q lam/ I' f 1
City or Town l State Zip Code
( gag )- �52-X9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) .0306 5 - a 392 £(
STATE WELL PERMIT#(ll applicable)
DWQ or OTHER PERMIT #(A applicable)
WELL USE (Check ApplicablelBox): Residential Water Supply Efe
"
DATE DRILLED 2 - -QG /
TIME COMPLETED /J � ,3i) AM [ePM 8
3. WELL LOCATION:
CITY: -.Sc.
COUNTY .4C,i C.....f,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley OFIat dRidge ❑Other
(check appropriate box)
LATITUDE 3 ! J/. fin
LONGITUDE r 2- 22 . rig
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: m(PS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
Xe6eti Ala y/✓er
,y
ST7T ADDRESS y 8 .300 /a 0 6
ia!✓v.�w /✓L ,-nFS73 d
City or Town State Zip Code
($a )- 2 75--yeyv
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: fir
b. DOES WELL REPLACE EXISTING WELL? YES I NO ET
c. WATER LEVEL Below Top of Casing: � FT.
(Use `+• if Above Top of Casing)
d. TOP OF CASING IS I 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): 4,04, METHOD OF TEST'BOF TEsTiikifit�p,ry
f. DISINFECTION: Type C/st-
Amount /7 Aft
g. WATER ZONES (depth):
From /2. To From To
From IA-. To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From rr/ To f t Ft. (. -'?r' tdd4'2' /'✓<
From To Ft
From To Ft.
7. GROUT: Depth � M,a�/t.e�riatl/I Method
From 0 To 2() Ft. efinat'iL'
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
- Y7
F2-qz
sz - rev-
11. REMARKS:
Material
Formation Description
.fief/
A
rr
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2-17-.0 r
SIGNATURE OFCERTIFIED W♦-.I.L.CONTRACTOR DATE
61, 1'01-{s
PRINTED NAME 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.
Fonn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /
1. WELL CONTRACTOR:
k,.it-N A. bil/./fr ES
I Contractor (Individual) Name
—ed+111sc.tj5 /JJFll dui hunio !1r,
Welljontractor CompanyName
,1w / r
STREET ADDRESS 273 LE/[EcJE-(Z Neu''•
ZE/ /'fs j t K. (' • • 8192
City or Town / State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable) c3006 - 00Oil
STATE WELL PERMIT#(ii applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 2 " u- :,
TIME COMPLETED 2'Ia
3. WELL LOCATION:
CITY: 4, cij /ci
,L T1rr c%,,>
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ['Valley ❑Flat 314idge ❑Other
(check appropriate box)
LATITUDE 3 r e/L• ZYr
LONGITUDE i a- </1. rq/
AM ❑ PM [�
COUNTY ifi�eaoy Ii
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 3-6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form it not using GPS)
4. WELL OWNER OWNER'S NAMECQLLf41f1 IJ��lo(AXfse Vu$rii
STREET ADDRESS 440 ii et
wile NwI'
eratic,orAk N ( ;1879 /
City or Town State Zip Code
($s0v8 )- �tn%
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Jar-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 13.
c. WATER LEVEL Below Top of Casing: Mo FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or billow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /L METHOD OF TEST
f. DISINFECTION: Type Cbr.AY- Amount /,J AS?
g. WATER ZONES (depth):
From J2 ' To From To
From /40 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From L1 To tY Ft. G"rlr f{yj2/ /avL
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From P To r"O Ft, Co/Icrefc ?iour%iY$
From To Ft. .l
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D
Formation Description
63- 8t- J4r
$d'-2Or
11. REMARKS:
'UV
rrt
en
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/a "U G
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Ate S
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 7�
1. WELL CONTRACTOR:
-B7,1110 1i / /{ ES
ell Contractor Individual) Name --�
tat/ SaNS a Ie// add any LIZ
W ellijontractor Company Name
STREET ADDRESS 3731 Aid id LEtdE JEI l(/.
City or Town if State Zip Code
(8-ZR )- 35&-- 8g9l,z
Area code- Phone number
2, WELL INFORMATION:
SRE WELL ID #(if applicable) Aeo 5- deg 7?
STATE WELL PERMIT/tor applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply L"
DATE DRILLED 2 - /V'0 (• /
TIME COMPLETED /2 t AM ❑ PM p'
3. WELL LOCATION: J
CITY: -r,-. 4l ,. COUNTY /J.. r„-s fl
.z .t w/L 4I./4
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope [Valley [Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 i
LONGITUDE r 2 Sr.4
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: ttrOPS ❑Topographic map
(location of weN must be shown on a USGS topo map and
attached to this form N not using GPS)
4. WELL OWNER //
OWNER'S NAME We ''q C//,ST!/t
ST EET ADDRESS 1/103 ✓r G v%C(Ycc
City or Town Stale Zip Code
(AMU_ -25a - 5 g.s 3
Area code - Phone number
5. WELL DETAILS:
a, TOTAL DEPTH: a-'1-
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q
c. WATER LEVEL Below Top of Casing: to rr.
(Use -+- if Above Top of Casing)
d. TOP OF CASING IS f 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): 7 METHOD OF TEST
ei3 r J 4 0
f. DISINFECTION: TypeO4-..ye'
g. WATER ZONES (depth):
From /767 To
From ft" To
From To
6. CASING:
Depth
From a To io Ft.
From To Ft.
From To Ft.
From
From
From
Amount /V ArSis
Diameter
To
To
To
To
Thickness/
Weight Material
J4k'1/ P✓t
7. GROUT: Depth Material Method
From /9 To 20 Ft, Caticizte. pouchy,
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
r city
.f4
-G/i,- L._..k
>t' GUue m
-o
t •
11. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THis
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
fRIpfa� /)• L , Nes
NTED NAME OF PERSON CONSTRUCTING THE WELL
fl
"3
4
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
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ,,3 / 410
1. WELL CONTRACTOR:
�!G !.911.) L(/ i Ai ES
III Contractor Individual) Name
.Exc�aceth /iJ=/1 aNd cmp
Well ontractor CompanyLILT
yy,? w LName 1
ST,RREET ADDRESS 3731 EIS-E2 MI •
City or Town / State Zip Code
(IA} 5&-• 8y9G2_
Area code- Phone number
2. WELL INFORMATION: SITE WELL ID #(ir applicable) 2,00 �t
STATE WELL PERMIT#(ir applicable)
- c23 /Sa.
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p''
DATE DRILLED % - Fi -06
TIME COMPLETED J ; O J AM ❑ PM p/
3. WELL LOCATION:
CITY: 547 �„v/ COUNTY •-•el+nc---P-4
(Street Name, Numbers, Community. Subdivnsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
['Slope ['Valley DFIat DRidge ❑Other
(check appropriate box)
LATITUDE 3 �' Z7, Tr: re
LONGITUDE ( L 3r. 137'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: azGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER CC� /n�,,•����',,,�,,JJ/
OWNER'S NAME Culp/i (.L Pew `L�'yji�tC eV-,
STREET ADDRESS / Glen �d/Y `,'n'
�1(ncan /")C' a187eq
City or Town Stale Zip Code
( 4f> zq73-.iS6/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2& v-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p-
c. WATER LEVEL Below Top of Casing: 2 a FT
(Use 1 Above Top of Casing)
d. TOP OF CASING IS J FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ` METHOD OF TEST
°c c21
f. DISINFECTION: Type C/J.. w.- Amount Al hts
g. WATER ZONES (depth):
From /TJ To From To
From Zf o To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From D To .T</ Ft. l /21- -C/�i'2r ,4t.
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
/�
From [i To r.0 Ft Cotcrcf prout7n5
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
C
Ty Stem
JY -Zjr
11. REMARKS:
LP,
0
-'O
1 '
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2- (D-op
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
r,RN LD, Nes ''
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION t♦ 3 / %t)
Lj T :' 3 / 0
fi J 1 �.. N
. WELL CONTRACTOR: /' /
I;/ 0 [,(///yES
W II Contractor Individual) Name
r --�
re
Et tents /j J j/ a#iRinio II r.
Well.�ontractor CompanyName/ /
S/TRREET ADDRESS;�I73 /1W LE/ EJE/Z itT.
City or Town / State Zip Code
(2)8 )- 353'-- Xy9tt
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) 6 OO 6- 0 3 /57
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box). Residential Water Supply [}�
DATE DRILLED 2#L C:
TIME COMPLETED Z. : C12 AM PM'
3. WELL LOCATION:
CITY: S,Cy,E�/
(Sheet Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
'Sllope ❑Valley ❑Flat El Ridge ❑Other
(check appropriate box)
LATITUDE 3
e7. bz /
LONGITUDE 43 t- J . /c r
COUNTY
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: o'CIIS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER OWNER'S NAMEc(i �_ Foci< as (,e(ii.QAU
LI P
ST ET ADDRESS
e n IU C 76tf
City or Town State Zip Code
Li _)- A73- 055/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
2G5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing '✓J FT,
(Use `+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): .7) METHOD OF TEST £ w
f. DISINFECTION: Type( t-•:..- Amount/1Aic fy
g. WATER ZONES (depth):
From 70 To
From 230 To
From To
6. CASING:
From
From
From
To
To
To
Thickness)
Depth Diameter Weight Material
From 0 To „t Ft. 44.14r SOw'u �O✓c,
From To Ft.
From To Ft.
7. GROUT: Depth
Depth Material Method
From 0 To 30 Ft. Concrete. 7 )/oup;n1
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Size
Ft.
To Ft.
To Ft.
Material
10. DRILLING LOG
From To Formation Description
0-.T1
?A-- ZCS G--> At'
Ab
£3
S`, iu 711i15
11. REMARKS:
1 DO HEREBY CERTIFY THAT THLS WELL WAS CONSTRUCTED N ACCORDANCE WRN -
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
"eats,
2-2-c�
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
DIRE !?, AL
RINTED 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
r.+
r
v

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION it
1.WELL CONTRACTOR:
II Contractor Individual) Name
Er G'Ill ccsAPs It Le a#t(/Limp F 1 r.
Well ontractor Company Name
STREET ADDRESS
/ ^ 373 E 16EifiC /it
/KK C' • a:
City or Town / State Zip Code
(2- S c 5'•- 8g962._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT S(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply. Q/
DATE DRILLED -
TIME COMPLETED 3 : 34 AM ❑ PM R-
3. WELL LOCATION:
CITY: Ze.tCOUNTYa.,c�+.,,(L
(Street Name, Numbers, CommunbdMsion, Col No., Parcel, Zip Code)
TOPOGRAPHIC�/ LAND SETTING:
Igatope °Valley ❑Flat ID Ridge 0 Other
(check appropriate box)
LATITUDE 3 r 37, 52
LONGITUDE P z . 777
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Q PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER
OWNER'S NAME
STR T A7DRESS 00
diryz
City or Town State Zip Code
(8aR )- 12625- /-!(e 03
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 30.1—
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO CzS
c. WATER LEVEL Below Top of Casing: o FT
(Use'+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated ator below and surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): METHOD OF TEST I - r 5
f. DISINFECTION: Type CAE...A- Amount 21 fcfj
g. WATER ZONES (depth):
From 'Zit To To
From airTo To
From are0 To To
6. CASING:
From
From
From
Depth Diameter
From 0To 2& Ft. 40./4-
From To Ft.
From To Ft.
317
Thickness/
Weight Material
Wee? v.-c
7. GROUT: /} Depth Material Method
From (.i To ao Ft. Concrete. Ni.if%Nr2
From To Ft. /
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From T in.
From To in.
o Ft. in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
•
From
From
Size
To Ft.
To Ft.
To Ft.
Material
10. DRILLING LOG
From To Formation Description
1x-.eir" Le....t+
11. REMARKS:
O
0'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/:tV (x
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
➢i 1><N LU,EiV 8 S
RINTED 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-ta
Rev. 7/05

s
AM PM
K COUNTY awn cos be_
(Street Name, Numbers, ICommuniy, Subdivision, Lot No., Parcel, Zip Code)
TOP PHIC / LAND SETTING:
lope oValley ['Flat ❑Ridge DOther
(check appropriate box)
LATITUDE -lid- ) /,5 7 (
LONGITUDE al 17, 24(
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME _
STRErrtADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2O,r1 Q
L CONTRACTOR:
obi) IV, Po
W 11 Contractor dividual)fNamg
fg/
g4Q, d s W E I ( Qard Pwn A u. L.
Well QpntractorCompany N2a )me
/ Mr / +
STREET ADDRESS Q fe�1
firesiEg 1✓C. age
Zip Code
City or Town / State
258-&I9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 100.5-o 7 /
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 7 ;ro&
TIME COMPLETED
3. WELL LOCATION:
CITY: Ca.t%eat
City or Town State
12R» o 5-9/7g
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: K Q FT_
(Use `t' 8 Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface•
•Topof casing terminated al/or Below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a METHOD OF TESTIJ rii
Orz
31
f. DISINFECTION: TypeCh /O/50/A/ C Amount
g. WATER ZONES (depth):
From 3 t{Q To3470 From To
From To From To
From To From To
/Q z
6. CASING: Thickness/
Depthm ?$' Diameter Wei hi Material
FroTo f, Ft. 2/L) f ftr$t1
From To Ft.
From To Ft.
7. GROUT: Depth n7 ,^Material/I Method
From 0 To 20 FL CPICPETe
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
o —,r
2S—sV
39—YkS
11. REMARKS:
Formation Description
clan
r
-13
ICU;
0
yr
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WM1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE W LL 0 NER.
• SIGNA U' , CER I IED m CONTRACTOR DATE
D'
PRINTED NAME 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] eat 568.
Form GW-la
Rev. 7/05
iD

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. WELL CONTRACTOR f. DISINFECTION: Type
yp
/�IZi4FIt) 4Q11 LV i /1, ES
W I Contractor Individual Name
7=Sopi li fell add tune L,Lz',
Well .ontractor Company Name / A
STREET ADDRESS vJ ,3)A w LE f sJE(c llk
E//tskt Ks(' • a8'7ig)
City or Town / State Zip Code
()- s -- S g91,z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
4006-.034,78
STATE WELL PERMIT#(if applicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q"
DATE DRILLED ///' ZG -04. /
TIME COMPLETED / ,�O AM ❑ PM E
3. WELL LOCATION:
l CITY: -y//r.-
COUNTY 4_rc--1-4
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
TOROGRAPHIC / LAND SETTING:
Ise -Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 rr .7Y or?
LONGITUDE P L l'4 74.8
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ffraPS OTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME
10 at Ala
ST ET ADDRESS i /Q nazi_
eitwatailLt, WC 2879 i
um
( IC
�Cit�tyy� or Town
O�7 �/ State
�/ Zip Code
Area code} Phone n7 be"! L 1 T
5. WELL DETAILS:
a. TOTAL DEPTH: 2 ✓r
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NOV
c. WATER LEVEL Below Top of Casing: r�0 FT
(Use "+• it Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST
g. WATER ZONES (depth):
From /fO
From ZQO
From
To From
To From
To From
6. CASING:
From O
From
3C Si 1
Amount /2.Es5
Depth Diameter
To Cc Ft. li-/Zr
To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7f t2i [
7. GROUT: /� Depth Material Method
From /i To S0 Ft. COncrc1c IjJ 11 fiNOi
Fr
From To FL
an To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 - $t
6 - Cc
-wrr
11. REMARKS:
in.
Material
Formation Description
kJ
1
fj
ion;
CUUi:
cy
21
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W rIH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/Zu-4
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
i r
PALAJ LU> fve5
RINTED 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

IZ /9-iV / r A ES
}y�II Contractor Individual) Name
GYGit SGnts (J II a#J / 1(In IC,
Wellijontractor CompanyName
it" ,I
STREET ADDRESS j/3J ,4 w CEJthy'
y'
lr/'Vfsf/=t Al..(• A8'7qts'
City or Town / State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) c500.5—1 g3T ‘V
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply Q"
DATE DRILLED /' 1 r-C (� /
TIME COMPLETED 3 . 4;0 AM ❑ PM 0-
3. WELL LOCATION:
CITY: C,.,//ems
,4, `5-Ct.S !i/cy '<e/ fl
(Street Name, Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ErStope DValley ❑Flat 0Ridge ❑Other
(check appropriate box)
LATITUDE 3 r
LONGITUDE rZ
COUNTY4 ,ter.,,,/./
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Ert,PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form B not using GPS)
4. WELL OWNER
OWNER'S NAME
STET ADDRESS
City or Town State
r as;-(co9`j
Area code - Phone number
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: -761 r
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .011B.
e. YIELD (gpm): /r METHOD OF TEST
STA
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # / 410
L CONTRACTOR: f. DISINFECTION: Type C1/409K
9.
From 23 0
WATER ZONES (depth):
To From To
From25D To From To
From To From To
e14
c) S
Amount /5".4 t
6. CASING: Thickness/
Depth Diameter Weight
From O To,' W( Ft. Z /Ar S/..e2/
From To Ft.
From To Ft.
Material
/IV&
7. GROUT: Depth
Depth Material Method
From 0 To at) Ft. Cone relc pbtfiiyy, Or
From To Ft. 11
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.
9. SAND/GRAVEL PACK:
Depth
From To
Ft.
From I. To Ft.
From To Ft.
Size
Material
10. DRILLING LOG
From To Formation Description
/r%S- /9/41 Sk//
icK/— 30 r
11. REMARKS:
N '1
—0
1
rT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/-rr-e4
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
'iAN 1< AI Ates
RINTED 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
r9

RESIDENTIAL. WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:
(W 1 CCoontr (�Idjvid al) Nam
RQ(i.. (0/� is WEII 'd whip. LAX.WellC./infractor Company Name r
STREET ADDRESSG77� 1 xci1i C
hotstEg Jlr� a87414
City or Town / State Zip Code
( Y R > a58-Z(9&
Area code- Phone number
. WELL INFORMATION:
SITE WELL ID #(if applicable) o3 O65- 6A 9 4'?
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED /72 6
TIME COMPLETED ,z t190
3. WELL LOCATION:
CITY: ,/Fit i(G%1'Cr` COUNTY SBACan OC
prtta y /r"A 41- '37
(Street tia-me, Nembers. Community, Subdidsion, Lot No., Parcel, Zip Code)
TO RAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 13$' 3/ S7D
LONGITUDE _ea. 77,2gt e
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
d. WELL OWNER
OWNERS NAME rs/y30 D eau: Ck
STRF T ADDRESS 74/ SILK* . id
Atka_ 11C 4.3876f�
State Zip Code
( 8aA)- 2- 9 Sg9
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
City or Town
5. WELL DETAILS:
a. TOTAL DEPTH:
AM ❑ PM.E
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: 1 0 FT.
(Use-+' if Above Top of Casing)
d. TOP OF CASING IS I . FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /00 METHOD OF TEST
c} 1310
f. DISINFECTION: Type cA/ 44 c Amount b 1/2
9•
WATER ZONES (depth):
From
From
To J/LD
To
From To
6. CASING:
Depth l
From_ To 3!)
From To
From To
From
From
From
To
To
To
Thickness/
Diameter Weight Material
Ft4,A, 2//. /d5 Ft'c$AN/
Ft.
Ft.
7. GROUT: DepthMaterial Method
From 0 q e(A._.0To 4J0 Ft. Ei%
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size
From To FL
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
0 15 C(ar
I - 2S raw A Xswrc
AS - 3a (t'e, A-
34 - (TS tine, 74(
11. REMARKS:
to
SPE
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELDS WNER
SIGNATU
PRINTED NAME
CONTRACTOR
DES
F PERSON CONSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
16i 7 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
aD-
Lj 9
0 0
812
1. W CONTRACTOR:
(W Il a�ctor(hd�vid�'al)fNamg
ER'qu. o/1S WE/I OA Ptunp.
Well ntraclor CompanyName
STREET ADDRESS l
fite.ER 11�C ag7gg
City or Town f State Zip Code
( > �52'-819�-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable) A005 a a 36 /
STATE WELL PERMIT#lit applicable)
s
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED /l?yob
TIME COMPLETED t Qv
AM ❑ PM p�
3. WELL LOCATION: ,yI JJ LL
CITY: ,(3/'w/JMJO472t/U COUNTY Ate hc.
10q%"kcik N.
(Street Name, Numbers, Cammuniy, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI .
❑Slope OValley ❑Fiat tdge ❑Other
(check appropriate box)
LATITUDE 4tE P e'3 /!S jq z
LONGITUDE// SA.
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS p Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME /y�tl/
// y pLLGrV
STRjFi�r.�A•/DD'RESS J �/ pax to �7
O ion k PIC 287//
City or Town State Zip Code
(Z25t)_ &L09-9iia4
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Rt7S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rf
c. WATER LEVEL Below Top of Casing: 20 FT.
(Use-+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. �j
•
e. YIELD (gpm): AO METHOD OF TEST rJ
i. DISINFECTION: Type_ Ch (0/'/.vc Amount
g. WATER ZONES (depth):
From /769 To From To
From,Q4 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From(f_ To 3PI Ft. 4,Z5 zed, as P?C spa; (
From To Ft.
From To Ft.
Ra z
7. GROUT: Depth�j /1 ,Meatt�eririal �1�` Method
From 0 To �l� Ft. Go/I_2Eir J/fl(JIi Qj _
From To Ft. �. �^Jl
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 — /0
/0^71
Formation Description
Clay
saedsXoa)e
3A. - 2 OS ayvu)/114
1. REMARKS:
r!5
1
t
- s 2G06
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATUREitSF CERTIFIED
PRINTED NAME
/ 1 0
CONTRACTOR ATE
OHS
F 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 CERTIFICATION # 3 / 40
1. WELL CONTRACTOR: f. DISINFECTION: Type (/o.. ,F
NfZ/+N /illm ES
II Contractor Individual) Name
El°caN; 8 le/I ud)amp 11
Well onlractor Company Name /
STREET ADDRESS
a7731 /kw LEleehE2 thy.
'41 teska I C • a87z/Q
City or Town / State Zip Code
(�R - a5--- 8z19G2._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
'OS -6a816q
STATE WELL PERMIT#(ir applicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q—
DATE DRILLED /— 211- O(s
TIME COMPLETED / 1-10 AM O PM p' /
3. WELL LOCATION: ��>>
CITY: el,/b- COUNTY
L
(Street Name, Numbers, Community. SubdMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
O8lope °Valley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3 < Jr, Oat
LONGITUDE Y L SO 2t7'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: °GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME lv e5
ET ADDRESS 75
[Ai MC
City or Town State
Sag )- a5.2-6094
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Sol
ePb
d ,2R26(o 1
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
c. WATER LEVEL BelowTop of Casing: Jo FT.
(Use `+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface
'Top of casing terminated ator bblow land surface may require
a variance in accordance with 15A NCAC 2C .0118. 3
e. YIELD (gpm): METHOD OF TEST
g. WATER ZONES (depth):
From /jam✓ To
From Z71° To
From To
From
From
From
n
O 3
Amount /.' /6Js
6. CASING:
Depth Diameter
From 0 To 74 Ft. Z,.12r
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth Material Method
From 10 To a Ft. Cot)crc 71-p uIiiv L4
From To Ft. .J
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0,7/
in.
in.
in.
Material
Formation Description
Ciy
7r-7G f!.#
74-
11. REMARKS:
0 t3
rn
cA
� T
tit
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WIT1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Di4N tJ Nes
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / .510
1. WELL CONTRACTOR: /, `
l3/Z/4"/0 L(l i /Y ES
III Contractor Individual) Name
fEll 0 tan/,s b JRll a# Rmp
WC1 C,
ell onlractor Company Name v
STREET ADDRESS Afl31,Mw LEI ESJEIZ ITG;t/
�►,C" • a879P
City or Town / Stale Zip Code
()- 58q912_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) Z 4 - is yg
STATE WELL PERMITS/(if applicable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED /' 7J —400
TIME COMPLETED 11/ . iO AM Er/PM ❑
3. WELL LOCATION:
CITY: iP.<eff:, COUNTY
(Street Name. Numbers. Community, SubdMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat p'Itidge ❑Other
(check appropriate box)
LATITUDE 3 r 0 t/fJ
LONGITUDE t 2 if 7Jy
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: LeGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form (not using GPS)
4. WELL OWNER J \r /
OWNERS NAME Joe %SA;U e 1
ST EET ADDRESS
City or Town Stale
(ZtS_) ? l fi - '{:. / 3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Vor
C/
28ug
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top or casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): J METHOD OF TEST
f. DISINFECTION: Type(/v
31809
Amount 0AIx
g. WATER ZONES (depth):
From goo To From To
From 3.rzr To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From D To ri Ft. G./ar SP,ezi .t.Z
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material Method
From (0 To NO Ft. CcAcretc. J/pj,Tr;Nr?r
From To Ft. J
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. DRILLING LOG
From To
O c'-.7
sr; - re-
.r-r- UDr
11. REMARKS:
Formation Description
(/(y
Iii //
ON
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
�/14NNes
RINTED 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 G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 4o
1. WELL CONTRACTOR:
&,11+N I.J./11 ES
II Contractor Individual) Name
Feciii (,Gn,5 Tr h L i)/1
w L
1 an, dinp fAin
SREET ADDRESS r j73/ A f /'c E fER ility,
Well ontractor Company Name
,
-tins je,- /Y. c - 28 %Y4)
City or Town / State Zip Code
.3. ?i >- 35S'a gy9lL.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box). Residential Water Supply [j
DATE DRILLED /- "rr" O(,
TIME COMPLETED 2 1J✓
3. WELL LOCATION:
CITY: Alecre-N//t
AM ❑ PM p�
Lug .#7
(Street Name, Numbers, Community. Subdiwsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
D Slope ❑Valley ❑Flat pRidge ❑Other
(check appropriate box)
LATITUDE 3 f 3S. LA/J
LONGITUDE P L %r,ore'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: gtPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
ST`_ T ADDRESS Y D ,4 /d/'/g
or Town Q / S)2( �Ro/4
City Zip Code
L /- g46 8- -.1a9�f
Area code - Phone number
5. WELL DETAILS: _
a. TOTAL DEPTH: ) Z'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q"--
c. WATER LEVEL Below Top of Casing: rJ O FT
(Use `+• if Above Top of Casing)
d. TOP OF CASING 15 ( . 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 (gpmy: C %L METHOD OF TEST
e: ) 0 7
f. DISINFECTION: Type ('t✓� ,. ..
g. WATER ZONES (depth):
From .3 St: To From
From v6O To From
From To From
Amount LL AS>
6. CASING:
Depth Diameter
From 0 To 44 Ft. G /Ir
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
%L1Pli iLt
7. GROUT: Depth Material Method
From To NO Ft Cow2refe- /�J1fiNJ
From To Ft. -1
From To - Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. - in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
Size
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
P
I// -
7/6- r-
11. REMARKS:
in.
in.
in.
Material
Material
Formation Description
f4 //
rn
230E
e
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/r-off
SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
A / r
P1A-4 . L(J, Ales
RINTED 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

(1.2g.—)- 7i 3 - 979/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3Dr
RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / 410
1. WELL CONTRACTOR: `
Z(r."/fri) , (�(i i Ai ES
well Contractor Individual) Name
ElteDNS h J II add R.unp C1 rr•
Well ontractor Companyy, Name �)
STREET ADDRESS an Alp LEt(.ESJEIL C(Ll-
City or Town / Stale Zip Code
(52-- 5q9�
Area code- Phone number
2. WELL INFORMATION: L/
SITE WELL ID #(if applicable) 6005. 03 70 (5'
STATE WELL PERMIT#(if applicable)
D W Q or OTHER PERMIT #(N applicable)
WELL USE (Check Applicable Box): Residential Water Supply ©v
DATE DRILLED / 'Jj- Ob -/
TIME COMPLETED .4' , VD AM ❑ PM L7
3. WELL LOCATION: p�
CITY: L.- of I✓y COUNTY ib;./zunJ[
.<o: ,e, o f J2 titres
(Street Name, Numbers, Cornmunay, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
g81ope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 f yd %'Ii'
LONGITUDE J- Z. ?2 .
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: C56PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME
STREFTr
ADDRESS /
&041� 0?87S7
City or Town State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO H
c. WATER LEVEL Below Top of Casing: b-O FT.
(Use `+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface
'Top of casing terminated alor belay land surface may require
a variance in accordance with 15A NCAC 2C .01'j118.
e. YIELD (gpm): /2- METHOD OF TEST )611)if1/'/ ), 9
0
f,
305.
1. DISINFECTION: Type/'/0,...,4. Amount "V /cf,
g. WATER ZONES (depth):
From 5-0 To From To
From lie To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To -70 Ft. L , /LC 10.17I /t✓(-
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From ,v To SO Ft. Co/ICrcfc ?to Lee; v
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
0-Lr (Vey
ds -7D 5-4./
70 - Jar
11. REMARKS:
a
LU,UF
N
t•r
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W rlH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
A �
%) l A-/t) / /V e S
RINTED NAME OF PERSON CONSTRUCTING THE WELL
0
es
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 G W-1 a
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 310
1.�WELL CONTRACTOR
��
iZ/44 AA Air ES
1 Contractor Individual) Name
Er a SaN, it isII a#d r' mp)
Well ontractor Company Name
STREET ADDRESS 573I Al.) IEt(ESy-E!L I,,
tsjet N,C • a8712
City or Town / State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Rif applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 4/
• DATE DRILLED TIME COMPLETED 1/ : JD AM Q/ PM ❑
3. WELL LOCATION: pp
CITY: W6/e-v.)de COUNTY L .,,a61
2Y Tt, C 3/4-r 41.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 -f L/D F-T7
LONGITUDE $ L ZY }t7'
May be in degrees,
minute, seconds or
in a decimal format
Latitude/longitude source: CI�rPS ❑Topographic map
(Iocation of well must be shown on a USGS topo map and
allached to this form A not using GPS)
4. WELL OWNER 'j'
OWNER'S NAME L/L��/c',+ A-470(444<
STREET ADDRESS fl 172. Ao C€n
City or Town State Zip Code
(k x > to V5 4'59 3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 Zr
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: /Q FT
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS / . FT. Above Land Surface'
'Top of casing terminated auor below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): 30 METHOD OF TEST
f. DISINFECTION: Type (
g. WATER ZONES (depth):
From /IC To
From /CO To
From To
6. CASING:
From &
From
From
U r1 .. n a�
e1 O G 0 3
Amount ,/3 A fA
From To
From To
From To
Depth Diameter
To 23 Ft. 4,/7r
To Ft.
To Ft.
7. GROUT; Depth Material
From /� Tor 0 Ft. COACrctsm j `VOLUM/
From To Ft. J
From To • Ft.
Thickness/
Weight Material
$o4'L) A'✓c
Method
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 •
Size
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
p From To
V-/t%
/F- TI
Material
Formation Description
y
s421
Z9- 22s G•,,. {e
11. REMARKS:
rn
V
Lu
O
a•
DO HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
I5A NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-X. -t✓-uceL J-12 -0
SIGNATURE OF ERTIFIE DWELL CONTRACTOR DATE.
PiA-II A I.U,NP
PPRINTED NAME OF PERSON CONSTRUCTING RUCTING THE WELL
w
h
A
3
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / T
1. WELL CONTRACTOR: �" /
/V
2.%N /(!r�•ES
W II Contractor if.
Name
From t7D
Er4GSCA:5 tJcii amid limp ,i.�.C-
Wellsontractor Company Name
ST,REET ADDRESS J73 ftG.) LT/•CFJE{Z f'CLi:
-
City or Town i State Zip Code
(2. X )- �5&-- gg9Gz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) c Des 5 - 0 3/6 7
STATE WELL PERMIT#(ii applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED eir TIME COMPLETED.// y" AM
/ PM❑
3. WELL LOCATION:
CITY: Czid/(i COUNTY4
ij. /ri 1755
(Street Nanle, Numbers, Community, Subdivision, Lot No„ Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
QSlope DValley ❑Flat ,pRidge ❑Other
(check appropriate box)
LATITUDE 3 - 2S col"
LONGITUDE n' ? 'i«i 39r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: F7GPS ❑Topographic map
(Iocation of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME /hh Y SdLJG,ar/
STRT ADDRESS �)U!'- ,�j .c5 "1-6 ne Jd
Nwn4crs✓.JIe /1'c o go 78
City or Town State Zip Code
(lay )-875-/l.s7
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
2cr •
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q
c. WATER LEVEL Below Top of Casing: ?° FT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS / . FT, Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): I O METHOD OF TEST
9 n
t_b ?b
f. DISINFECTION: Type ke...4. Amount /0 ,tcsi
g. WATER ZONES (depth):
To From To
From if0 To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To 70 Ft. (./er sac/ , c_
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
/�
From /� To NO Ft. ConerCC ?Duchy.,
From To Ft.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From • To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
F om To Formation Description
d zi_ C,
J0-2ct-
11. REMARKS:
cc)
rTi
-v
t'
rn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTIH
15A NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CCEERTIFIED�WELL CONTRACTOR DATE
P/AAN R /L N&5
RINTED 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
9
r.>

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / TcJ
419
ti
00
1. WELL CONTRACTOR: /.
�IZr.4/IJ L(J, /I ES
Vg�II Contractor Individual) Name
he' /( IEII arwd fie,
Well ontractor Company Name
STREET ADDRESS 'an Aid LEteE lig thUy•
l Ei'ftss jsa N, c • �87gP /
City or Town / State Zip Code
(S )- 5 2 -- 8 q9 1,2_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) �005 --
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply (�
DATE DRILLED / rj -06
TIME COMPLETED L : Oa
3. WELL LOCATION:�
CITY: C<.,a4.-
AM ❑ PM 3
COUNTY-e-a,.z
41' f'%ae /2^ey /2 //
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPQGRAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 s' jJ. 7.1'
LONGITUDE Y 2- do! 12 P''
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: G' PS ❑Topographic map
(location of web must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME G BeiPj-a r
STREDDRESS
(Do 0.1c•L4rie
Cityw� State C 8Zip � iri
L.7A-(0901
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 10 e
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
c. WATER LEVEL Below Top of Casing: L 0
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
METHOD OF TESTAhab 1]_R/
e. YIELD (gpm): 3v
6. CASING:
t. DISINFECTION: Type ('&OP-..e Amount b' Ass.
g. WATER ZONES (depth):
From /3O To From To
From kV To From To
From To From To
Thickness/
Depth Diameter Weight Material
From fi To r/ Ft. /./lr fixL
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material Method
From (..i To r�` O Ft. CO/trek ?OttNor
From To Ft. .J
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.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft.
To Ft.
To Ft.
Material
10. DRILLING LOG
From To Formation Description
D - dJ C/p
oe
ro , rr SG /
P.f_ ear'
11. REMARKS:
to
1 '
'd 41116
!DO HEREBY CERTIFY THAT TMS WELL WAS CONSTRUCTED W ACCORDANCE W rTH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIOEOTO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE 1/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Pt A-N
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

e. YIELD (gpm): /
d. TOP OF CASING IS
.cr'° LUGRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION q 2O S
--- T..
1. W CONTRACc TOR:
/Iv.. .{ WA aks
w II Uontract�({td/vid al) Nam
ER t(S01115 WEI( QIJJ toner LLC.
Well ntractor Company Name
STREET ADDRESS 1 r („
i(esf a C 38 74g
City or Town / State
(gag )- asp �k19Lz
Area code- Phone number
2. WELL INFORMATION: �.'�77
SITE WELL ID #(if applicable) pJOps- 0 a.2V7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [jam
DATE DRILLED .5/ O (j
TIME COMPLETED 2 ((%D AM❑ PM Q"
3. WELL LOCATION:
CITY: rp/ikSrrtcO
Zip Code
COUNTY1//7t(nM 6C-
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA SETTING:
❑Slope OValley Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE A/ 35' •33, 2,50
LONGITUDEb)Qr i j y
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS logo map and
attached to this form ifnot using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
S/TEET ADDRESS
7 (e
aothSucokef/y
R7 /Gyr/nv's flt/c.
/V C 7/ rvo
City or Town State Zip Code
T) ) 4J 4,-'P133
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: �!/� FT.
(Use'+' if Above Top of Casing)/
//lJ
FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
METHOD OF TESTbr,
I. DISINFECTION: Type de /tA 4J t Amount /t JL
g. WATER ZONES (depth):
From 5nt To / From
3 To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
Fram__a_ To FL l )5 /(/C S/1Z.2
From To Ft.
From To Ft.
7. GROUT: ,Ar-�tT Depth ,Material
V
From To lfl Ft. CDfkC_QEjr
From To Ft.
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.
Method
' J
9- SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
60lc,
KY
$ y -7n5
11. REMARKS:
Size Material
Formation Description
C /a7Stir �S
4rei.1 f
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDEDDETO THE W L OWNER.
SIGNATl7R OF CEPofIFlED CONTRACTOR
-'-Zt,tib4 1,), ohs
PRINTED NAME F 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

'AnRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID //Of applicable) Apd6- 0.o3o fl
1. WELL CONTRACTOR: �fc>�fN G(li ES
W.ell Contractor Individual) Name
L Iel1 a m1 l LC
Eels on S6NC p)
Well.Sontracla Company Name /
STREET ADDRESS 3731 ,M & LE et—S.EQ 111(/,
tots- E,� ht.( . �87Yg 7
City or Town / State Zip Code
EaZ3 r 52-- 8q9[e
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED �" �L- 0¢
TIME COMPLETED %l . 00 AM lar--PM
3. WELL LOCATION:
CITY: L 540tik/ COUNTY 17, Ca., {�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
[Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 S- ,J.3..
/7VJr"
LONGITUDE of-Z. Y� ryr'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: &CPS ID Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER /
OWNER'S NAME ( /7/ {)/A (y epb 7
ST�j E�T ADDRESS 361 e, (rid p . t>cl
cller /v Cg 227/S
City or Town State Zip Code
(S;% (e&7-o8(7
Area code - Phone number
5. WELL DETAILS: l�,,�/
a. TOTAL DEPTH: 21/r
b. DOES WELL REPLACE EXISTING WELL/ YES ❑ NO IT"-
c. WATER LEVEL BSow Top of Casing: Z 0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface"
-Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): I: 0 METHOD OF TESTAkai1 R
r rY ' 0 1 r
f. DISINFECTION: Type C a..-....c Amount /i lc()
WATER ZONES (depth):
From Gr To From To
From 2.10 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 40 To «/r Ft. 4./1/ tarp,( /'c-c
From To Ft.
From To Ft.
7. GROUT: Depth
From I0 To O Ft.
From To Ft.
From To Ft.
Material Method
Concrcte 7fourlro j
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-4/t/
in.
in.
in.
Material
Material
Formation Description
W- t
11. REMARKS:
O
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
-j:4c-. 7-,4-oc
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SDr/4N T). /LLAte s
RINTED 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 56B.
Form GW-la
Rev. 7/05

e. YIELD (gpm):
"-�✓ _ C is- ?ES/DENT/AL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3 / .� ,0
1. WELL CONTRACTOR:
& kA) k ll/;W ES
I Contractorndlvldual) Name
E�lawN; 1pIE11 a.rd�u/,1p
Well ontracla Company Name � /
STREET ADDRESS 373/ AUJ IElersiaz
/ �,
itt--S-/E -a /i C' aY 7ef g
City or Town / State Zip Code
(8 } 58•- 8L/91,2
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) ai005 - 0 5 .f % 5
DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box): Residential Water Supplyy� J
DATE DRILLED ?` />- pL /
TIME COMPLETED /C- ' JJ AM 0 PM
3. WELL LOCATION: pQ
CITY: (twit- COUNTY ,0tnrs'7.IC
Iries t CIrect Zs/ /r/ e3'
( et Name, Numbers. Community. Subdivision, Lot No.. Parcel. Zip Code)
TO OGRAPHIC / LAND SETTING:
Slope ❑Valley DFIat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r 33 .7/Y
LONGITUDE I 2 (/3. 777'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: g(`rpS ❑Topographic map
(location of wed must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
R-rdph he P8r/1aq
City or Town State Zip Code
da2_)- (&8(f—Io37'-f
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO/
c. WATER LEVEL Below Top of Casing: ‘ D FT
(Use'+- if Above Top of Casing)
d. TOP OF CASING 1S / FT. Above Land Surface-
. 'Top of casing terminated allot below land surface may require
a variance in accordance with 15A NCAC 2C .0118. ,fly
L° METHOD OF TESTA/Mill-Rs/
f. DISINFECTION: Type CY , •74-
Amount /T {,
g. WATER ZONES (depth):
From sly To From To
From -70 r To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight
From 0 To 1 / Ft. L/C/ coal/
From To Ft.
From To Ft.
7. GROUT: Depth Material
From ,r.� To No Ft. Cone rcfc
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
To Ft.
From To Ft.
From To Ft.
Size
Material
Method
/oittSfy/
Material
Material
10. DRILLING LOG
From To Formation Description
D 44 Cie.
`/L - r/ Sic(/
r/ - 72r e _-, ;E
11. REMARKS:
c
I DO HEREBY CERTIFY THAT TMS WELL WAS CONSTRUCTED IN ACCORDANCE WOH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PRROOVIVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE r
RINTED 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

RESIDENTIAL WELL CONSTRUCTION RECORD
Scyr.,.
tNonhiCarofBrM. panment of Environment and Natural Resources- Division of Water Quality
ELL CONTRACTOR CERTIFICATION # 20,ol 9
CONTRACTOR:
S
W 1 Contractor ( djvidyal)rNam
E� 1(,Sons kTE 11 2ad )amp. LLC.
Well ntractor Company Name �/'rc r
STREET ADDRESS Gl I�/ /I'IC.Ij l�
Zip Code
City or Town State
(Ya >- 58-8(194-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED /(�//f6
TIME COMPLETED (00 AM PMg /
3. WELL LOCATION: ;;11
CITY: �l/rUL.c u COUNTY VO/tCom bA-
(Street Name, Numbers, Community, Subdiesion, Lot No.. Parcel, Zip Code)
TOP PHIC / LAND SETTING:
lope [Walley ❑Flat ❑Ridge ❑Other
(check appropriatesbox)
LATITUDE rl ; 23-aS
LONGITUDE(LIQ,? )6,'6 7
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS oTopographic map
(location of well must be shown on a USGS tope map and
attached to this form 7not using GPS)
4. WELL OWNER 'J ./-/
OWNER'S NAME k4"- e lee t t r4//A/
yf"t
STREET ADDRESS ], o /3 of aS a $
l,s� �✓.' /✓ C al >43 0
City or Town State Zip Code
(XXX & -17da
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 60 S
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
e. YIELD (gpm): J
(Use -+• if Above Top of Casing) D
d. TOP OF CASING IS ' FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
YES NOp
FT.
METHOD OF TEST
343
f. DISINFECTION: Type (smnfr,Ot
g. WATER ZONES (depth):
From 'Sq To 650 From To
From To From To
From To From To
6. CASING:
Amount
Thickness/
Depth Diameter Weight Material
From n To' :" Ft. b.aS 216,/.25' li/c 5/)tk(
From To Ft.
From To Ft.
7. GROUT: Depth /1 ,Material Method
From To an Ft. ePiC_eE/e
From To Ft.
From To Ft.
8. SCREEN:
From
From
Depth Diameter Slot Size Material
To Ft. - in. in.
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. DRILLING LOG
From To
O — //
— Zi
?Yp -6O S
11. REMARKS:
Formation Description
('(a
Zetil /t7NC
c K
CXen,.,,71C
• en
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND iyp,T A COPY OF THIS
RECORD HAS BEEN Pp°VIDEO TO THE WELL OWNE
006.
CONTRACTOR E
PRINTED NAME pF 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 Wate[ Quality
WELL CONTRACTOR CERTIFICATION # 2o. Q
K 200E
441
1. W CONTRACTOR:
obhf �,cl, io-�-Ls
(EIZQW 11 Contractor (5ivid al)rNam
IISor�s W E ll
Gird in p
Well gjfintractor Company Name
STREET ADDRESS/Q !�/ Xt& L
Lpie.eskfe w ( ag7
City or Twin/ State Zip Code
($v4» .258 -SO &
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable) pj 065- D3773
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED ,•,l/0//t," /
TIME COMPLETED ( ('�/ AM ❑ PM Q
3. WELL LOCATION: ,✓/
CITY: a/Q (k /dID44 ? (4) COUNTY hit(Dh h
(Street Name, Numbers, Community, SubdiMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT/
❑ Slope ❑Valley ❑ Flat idge ❑ Other
(check appropriate box)
LATITUDE W 3 S' 3 1 ail
LONGITUDE 10411.r 14
Latitude/longitude source: aeg ❑Topographic map
(Iocation of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME X( B04� ten,
STREET ADDRESS /Oa (o/d (>eet ei4Cr b7
Raj NAM /YP 27//
City or Town State `� Zip Code
(as » 776-3577
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: L�
a. TOTAL DEPTH: 7QS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO/
c. WATER LEVEL Below Top of Casing: 2-0 FT.
(Use "e A Above Top of Casing)
d. TOP OF CASING IS I 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): /5 METHOD OF TESTI1kij J rq
f. DISINFECTION: Type CA /IA„VE i'' Amount
g. WATERZONES(depth): __
From To /?(/ From 23S To Zi%
Frain To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To ,St Ft. k, 7.5 2/6,/d S Poe- (we.? I
From To Ft.
From To Ft.
7. GROUT: Depth MaterialatMethod
From D To lfl Ft.Cnnotr_eti f�' 1I24L5
From To Ft. T---'-J-1
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To FL • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From_r__To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
YJ - S3
SS - S F
sT - 4,05
11. REMARKS:
Formation Description
Saawelchfmc
Rock
6447 rat Ye
t'1
-
o
rT •
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND L A COPY OF THIS
RECORD HAS BE PROVIDED TO THE W LL 0
RTIFIED 0 CONTRACTOR D V,3/or-6
aJ, Olt
PRI TED NAME • F 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

v 1 J
,`r WELL. CONSTRUCTION RECORD
North Carolina .-. Department of Environment; andjlanral Resources - Divisi., of Water Quality - Groundwater Section /I
1VPLL CONTRACTOR (INDIVIDUAL) NAME (print) 1 # • / i a CERTIFICATION #126C
Wth.0 CONTRACTOR COMPANY NAME 1 C O/J S f Q N• U Nip) LLI'_ PHONE 4.Sa5 '- 249(_
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I MunicipaWPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: Nearest Town: Ft r Cal tr County live( am be.
• ►)vary .9at/c !may- /3/
(Street Name, Numbers, tommuniiry, Subdivision, Lot No., Zip Code)e)
3. OWNER: Qpn 61S�IdQ6ck�
Address 7 400-n a.ls. <51 ie.
(Street or Route No.)
Ordtn /V r 3S76 y
City or Town - State Zip Code
(fie)- 77-sq6/
Area code- Phone number
4. DATE DRILLED 0� 3 0 — 3 S
5. TOTAL DEPTH: QZ) C — 4,es
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: a FT.
f (Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with I9.A NCAC 2C .0118.
9. YIELD (gpm): Sr METHOD OF TEST2(01.1)Nq—ki'q
10. WATER ZONES (depth): 3rd 1.J JJ
Topograp and setting
❑Ridge ape DValley ❑Flat
(check appropriate box)
Latitude/longitude of ell location
Nis. ab4',tp0i✓�8z'37,5� a
(degrees/min s/s�e onds)
Latitude/longitude source: QlPS❑Topographic map
(check box)
DEPTH - DRILLING LOG
From To Formation Description
za r/ay
?(% - 30 sarti3)(!N�
6.,entent/ TI C
LOCATION SKETCH
11. DISINFECTION: Type CA/OttVC- Amount /%tQ7 Show direction and distance in miles from at least
i2. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth C Diameter or Weight/Ft. Material numbers and common road names.
From i) To3J Fr. 6,.-5 V ./AY Nairn
From To F.
From To Ft.
13. GROUT: Depth n Material
From () To a ii Ft. l �oitC-P—E]-E
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
U. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Method
Mini" au< (mot#/&i
c 'tri/VC
rn
J
CA at
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUL LED IN ACCORD
CONSTRUCTION STANDARDS, AND THAT ,A,COPY OF THIS
SIGNATURE OF
ITH l5A NCAC 2C, WELL
BEEN PROVIDED TO THE WELL OWNER
CTING THE WELL
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