Bu 2 CY2006

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturalat_Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_5erDuvtI I CERTIFICATION#_,33.5q
WELL CONTRACTOR COMPANY NAME _ a (tentAr&S. vita .L Punip PRONE # (82a 0/93170
STATE WELL CONSTRUCTION PERMIT/4__4f1 O 2- _--___-ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential le-Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: QdlCait County BdnGlIW16L
(Street Name, Numbers, Community. Suhdivision, Lot No., hip Code)
3. OWNER: Ted- L 1.
Address 2
( angler
City or Town
(Stree rr Route No.)
State hip Cock
( )--g2.4„-42 5 a 0
Area code- Phone number
4. DATE DRILLED
5. TOTAL. DEPTH: Sb5T
6 -Li -aC,
Topographic/Land setting
❑Ridge ❑Slope ❑Valley It
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O - KQ _
7. STATIC WATER LEVEL Below Top of Casing: TO FT.
(Use "t.. 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 accordanth 15A NCAC 2C .0118.
9. YIELD (gpm): H METUOD OF TEST ZNOU2s
10. WATER ZONES (depth): bi t
11 DISINFECTION: Type PI VP Amount
12. CASING: Wall 'Thickness
Depth Diameter or Weight/Ft. Material
From 0 To y0 Ft. b "
From To Ft.
From To Ft.
13. GROUT: Depth cMatcrial Method
From 0 To Zo Ft. l-e ne _a __
From To Ft.
I`
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15_ SAND/GRAVEL. PACK:
Depth Site Material
From
From
16. RI(MARKS:
To Ft.
To Pt.
C7, en-
-42
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the r9d
numbers and common road names. -`
c
r
CJt ri :
N
nt
I DO HEREBY CERTIFY THAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE W'TTH I5A NCAC 2C. WELL
CONSIRUCFI Is STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TILE 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. 072001

W1/4) J2n861
WELL CONSTRUCTION RECORD
North Carolina - Department of F.nvironment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prin0_ _ �� CER'CIFICA'rION#
N'ELI. CONTRACTOR COMPANY NAME- 6 teent- fos watt/ Pain Je PHONE # bat
STATE WELL CONSTRUCTION PERMIT# I `P02— ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Puhlic ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: weal &'vt [Ft County & ncnn be -
(Street Name, Number}., Community. Subdivision, Lot No., Zip Code)
3. OWNER: "Terry (c
Address 1 Norman trcvad...
(Street tfr Route No.)
aa'odlCX »C..-- 2_8-c5
City or Town State Zip Cade
Bala)-qz,I-64co
.Area code- Phone number
4. DATE DRILLED
5. TOTAI. DEPTH: 7785'
!)()Lc,, `A .i 1 REP( A( i. LYICI (F(. U:LI i o YELiLF
7. STATIC WATER LEVEL Below Top of Casing: y O ET.
(Use"+' if Above Top of Casing)
H. TOP OF CASING IS FT. Above Land Surface`
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
9. YIELD (gpm): 6Q f METHOD OF TEST ItDc t$
10. WATER ZONES (depth): 7bS
Topographic/Land setting��
❑Ridge ❑Slope ❑Valley OFF-lat
(check appropriate box)
Latitude/longitude of well location
( degrees, minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D'41y( t
Cog, - '](.S L c
11. DISINFECTION: Tvpe h ni
12. CASING:
Depth Diameter
From 0 To kg Ft. b•
From To Ft.
From To Ft.
13_ GROUT: Depth Material
From D To JO Ft. Ceinem
From To Ft.
Amount
Wall Thickness
or Weight/Ft.
14. SCREEN: Depth
From To
From To
I . SAND/GRAVEL PACK
Depth Size
From To Fi.
From To Ft.
Diameter
Ft. in.
Ft. in.
16. REMARKS:
Material
P✓ c-
Method
Top
Slot Size Material
in.
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
C
7r c
nsi
a
0
_'
I DO I IEREL3' /YY��C,ERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
('ONSTR(.l<C,ttvN STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
net - /
d�Q 60 t� 1T rp L
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

�N4S59
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
\AEL.l. CONTRACTOR (INDIVIDUAL) NAME (print)___1Z. e(`Duvac/. Il f CERTIFICATION #5(/
33
WELL CONTRACTOR COMPANY NAME - 6reeveprowli V)a4-1 (� PHONE #(f32e)4V8;30Q
STATE WELL CONSTRUCTION PERMIT#-H O2- ..__ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ®Municipal,/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION::''
Nearest Town: yv)µ4Lef ✓l(' !c _ County
comb
(Street Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER: ! efry Lrzct) ke
Address l Or4/N lira/lc/1 1 ES+.
(Street or Dote No.)
Ck/1t�lte,- A1.- 2R7ic
City or Town State Zip (ode
1 .1-. �?,�L:-is3 0 a ----.-
Area code Phone number
4. DATE DRILLED 6/7��06
5. TOTAL DEPTH: 9ZS
n„rc WE:;.' tE.ni ..r •(. (. c!_ i rn;(. WE! i ., YES (i NO L!'
7. STATIC WATER LEVEL Below Top of Casing: if 0 FT.
(Use '* ' if Above Top of Casing)
K. TOP OF CASING IS / FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): y0 METHOD OF TEST 2-Heo2S
10. WATER ZONES (depth): Mg
11. DISINFECTION: Type 1-17 Amount
12. CASING:
Depth
FromTo 35'
From To
From To
13. GROUT: Depth_
From d To'.
From To
14. SCREEN: Depth
From .Eo
From To
15. S.ANDGR.AVEI. PACK:
Depth
Front To
Wall Thickness
Diameter or Weight/Ft.
Ft. _
t
b
Ft.
Ft.
Material
Ft. Cie t?a� _
Ft.
Materialn
Yv/t
Topographic/Land setting
❑Ridge ❑Slope 0Valley It
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Form tion Description
31'
R25'
Method
Diameter Slot Size Material
Ft. in. in.
Ft. \\ in. in.
`Size Material
Ft.
From To Ft.
16. REMARKS:
I DO HERE
C'ONS1R
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
21135
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE 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
q

3297'74
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural �) Resources-�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Q-A RA.+ I1 Ga. ('I r.- I / CERTIFICATION1$15e2
WELL CONTRACTOR COMPANY NAME 0e-t t L( (NPLL D L.- I el PHONE x t )lay-ysgQ
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMIT,/
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 1. unicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATOONJ I'
Nearest Town: YTS �Ut u--e- County ilJNI GOM
90 N,cnlots_ R k.
(Street Name. Numbers. Community. Subdivision. Lot No- Zap Code)
3. OWNER: Nth
h
Address 110 No L t %I
•
(Street or Route No.)
�r�.a�.G�! I�iC a-SrP)ti
City or Town State TAp Code
(Fait)- D 3 n - Sect
Area code- Pbooc nuathey
4. DATE DRILLED / 9/ 0 (u
5. TOTAL DEPTH: 41O4 J
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO tH
7. STATIC WATER LEVEL Below Top of Casing (OG FT.
(Use "+^ if Above Top of Casing)
3. TOP OF CASING I5 FT. Above Land Surface'
'Tape of twin terminated at/or below bud surface requires a
variance in accordaw with ISA NCAC ZC .0118. /1 n /�-+h )
9. YIELD (gpm): METHOD OF TEST l t/ (,F
10. WATER ZONES (depth): -2cjr pw) Ll y ?5o
11. DISINFECTION: Type tier, , e I Atnount
12. CASING: Wall Thickness
w Wdgbt/Ft. Material
From
From O
From -45
13. GROUT:
From
From C.)To 20
14. SCREEN:
From
Diameter
FL
To g-` Ft. b Y(i , ,L'� (,' c.
ToS7 Ft. b .j J ISY� �j /:1 �
Dep Material
m To FL
Ft. ,Y<,\
Depth Dianleter Slot Size Material
To FL in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Et.
Depth
To
16. REMARKS:
1 DO HEREBY CERTIFY THAT I
Method
Topograpiatc/tand setting
❑Ridge t1751ope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
°;f JP. o ltit o 45Z r,/ 3. tq6 tr•
(deg es/mioutes/ )
Latitude/longitude source: PS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
tart
©-51D
50-y0c (A/1'1✓i' .
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
c
Q - C '; .,e
n-)
numbers and common road names.
N 4
Cni ; je
itjot:ers olu l) t7 till toy. 41
ELL WAS CONSTRUCTED IN ACC
CONSTRUCTION STANDARDS, G1aL THAT
COPY OF 7HI
0 PERSO
Submit the original to the Division of Water Quality
27699-1636 Phone No. (919) 733+3221, within 30 days.
Group
E WITH I5A NCAC 2C., WELL
PROVIDED TO THE WELL OWNER
DATE
ter Section, 1636 Mail Service Center -Raleigh, NC
i.a; 1.4 iul;J
GW-1 REV. 07/2001

3 2 V i ,1 3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL. CONTRACTOR (INDIVIDUAL) NAME (print) Cplit4 sOS-r C.E CERTIFICATION# 2Sb
xvELL CONTRACTOR COMPANY NAME fi
Jus{—c6 L�Io (C
STATE WELL CONSTRUCTION PERMITd ASSOCIATED WQ PERMFTTII
(if applicable) (if applicable)
PHONE S
1. WELL USE (Check Applicable Box): Residential 1Y 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: S � County gLhutiv'
L-4-2 seQl� }A 'RILL ts
(Street Name Numbers. CC Subdivision. Lta NO-.^Zry GOO 5eh
3. OWNER: B� V �1 �� P• 1�
Address 3EQu,oya1. yiU-s
(Street or Rowe No.)
Ptekiote rut 28732
City or Todd State rep Code
Area code- Tone number
4. DATE DRILLED ;li13I °(a
5. TOTAL DEPTH: ` 6.05
6. DOES WELL REPLACE EXISTING WELL? YES NO 0
rQ
7. STATIC WATER LEVEL Below TopofCasing:� FT.
(Use "+' if Above Top of Casing)
3. TOP OF CASING IS FT. Above Land Surface*
'Top of casing tenanted aIim below had suntan requires a
variance is accordance with ISA NCAC 2C .S11&
9. YIELD (gpm): METHOD OF TEST /4l2
10. WATER ZONES (depth): 2Sr nr e goo'
11. DISINFECTION: Type etOm;Np. Amount 2 OZ
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From To FL
From U To 77 Ft. ''t7tiler
From '7 % To 7 rt Ft. CO / b f j g
13. GROUT: Depth
From To FL
From_ To_Z FL NL7 / red
14. SCREEN: Depth Diameter Slot Size Mat al
From To Ft. in. in.
From. To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
35e5H,oDifr o 9z° 13,(022 t✓
( minntes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
C�- 70 //Zd"
70-go r ist/Linc bo
16. REMARKS:
Material Method
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. include the road
numbers and common road names.
6.
1 DO HEREBY CERTIFY THAT WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS .1THAT RP 1RD.HASBEENPROVIDEDTOTHEWELLOWNER
SIGNATURE O;(T:'?= I N CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section,J636 Marl Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07200I

09-17-'06 11:55 FROM-NCDENR ASHEVILLE iU 86L(2y97043
1. WELL CONTRACTOR
rr;
Wee Contractor
Well tractor Company are
r-y1Lr
SI EN7Z4L WELL CONSTRucTION RCOf D
North Carolina Department efEnvironment and Na.urel Reaourccs- s
Division D. Waco Qualip•
WELL CONTRACTOR CERTIFICATION N a I3
STREET ADDRESS (/ O AL/L L _ _ L.
cAl tr.
City 'orTcwn Sate
Area code- Phone
nee number
ber
2. WELL INFORMATION:
SITE WELL ID *jr amicable)
STATE WELL PERMITSat applicable?
DWQ or OTHER PERMIT *(d apSicable)�W_
WELL USE (Check Applicable Eat). Residential Water Supply
DATE DRILLED___- f/
TIME COMPLETED -7i do
1. WELL LOCATOR:
AM ❑ FMg- I
CITY: - T+' -, COUNTY %J'4,.-.
(Street a
et Name, No. Community, Subdvaioy Lot No.. Racal. Lp Gods)
I T OGRAPHIC f LAND SETTING;
slops OVatky ❑Fiat ❑Ridge CCther
tcheck anemones b*
LATITUDE 3
LONGITUDE_„ _
May br in d$srto,
antes, wands a:
in a decimal format
Latttudeng (t enale scarce: D GPS zlopographic map
pocaton ofwaif mu (bit show?or, a USGS mopo map and
tta ached to WS firm A not using UPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS Rb wn
�Qh mi\ t t fJc
C o+ aState Zip Cede
;52.11jI •.5isa
A'ee code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: -3_
b. DOES WELL REPLACE EXISTING WELL? YES
Goer 4L__ �a
a67l5
NOS
c. WATER LEVEL Betow Top of Casing. Zf
(Use `r'R'Above T R.
Too Of r �l�)
d. TOP OF CASINO IS 1 FT Above 'Try of casing terminated attr Land Surfacer
Wow 2c el may require
a variance in accordance with SA NCAC 2C .M+.B
e.YIELD tgpr)! Y METHOD OF TEST IfF3
FU2Jb5 U-Nb
329332
t. DISINFECTION; Typo r -S amownl,1��
9• WATER ZONES (depth):
From
From
7c
To
From To
1. CASING:
Depth
s FL C � er
m From To______ FL
Fro
o Ft
7. GROOOT:CamCa
Fron_Q- To Re
From To
Fra;L_..._ To
From
From
From
Material
Ft LPz/L.
FL.
To
To,
TA tlaaj
IA eri
1. SCREEN: Death
Diameter Slut Size. Material
From _ To
From ---_ FL in. n.
To__TFL, jn kt.
I. SAND/GRAVEL PACK:
Depth Sae Morena!
From ToFe______
From To Ft
FPXTI .—To FL—
S0. DRILLING LOG
Fula T},
11. REMARKS:
Formation Desc`ylton
n U.Pr /S4 mutt
DO HEREBY CERTIFY 'NATTKE WELL WAS CONSTRUCTED N AC2:Ai LWVCE WITH
ISA NCAC 2C. WELL CONSTRG:TON STm3ARDS, AND :NATA COP (OF WWES
Rom` EEN PROVIOEC TO WELL OWNER.
SIGNATURE OF
/J Crr; . , S
PRINTED NAME OF PERSON ONSTRUCTint THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt,
1617 Mail Service Canter-Raloigh. NC 77699.1617 Phone No. [phone] ext562.
Form GW-la
Rev. 7105
s a
C)
c_ �

329331
,RESIDENTIAL WELL CONSTRUCTION RECO 3D
North Carolina Department of Environment and Natural Resaaea- Div:,ti,t of N atc Quality
WELL CONTRACTOR CERTIFICATION # oc Z 3�e
1. WELL CONTRACTOR:
O¢iC:cx. '.ems % 4a,,vtecs
W el Contractor (Individual) Name
Well Company
STREET ADDRESS NyV9S Ns% ZCIq
Ho-! Sic 21 NC - a8ti143
City or Town S e -Zip Code
(8a%)- (p(os- oaf
Area code Phone numbs
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMT8(a.,.wr
DWQ or OTHER PERMrr 41(d applicable)
WELL USE (Check Applicable SSoxx): Residential Water Supply I/
DATE DRILLED < /D Cn
TIME COMPIT_TED S.56
3. WELL LOCATION:
oft
AM PMg -
COUNTY Qc.nCoy%x
Sc/V 1d
.(Stet Name. NFxttben. Community. Sub&M4QA, Lot No.. Parcel. Zip Code).
TO7OGRAPHIC f LAND SETTING:
ipbclope ovafley PR* DRidge OOther
(chock
LATITUDE 3
LONGITUDE
Latitude/longitude solace: O GPS O Topographic !nap
(bcation of eel mvstbe showman a USGS tapo map and
attached to this form snot ussg GPS)
May be m degiea,
minutes, seconds or
in a decimal format
4. WELL OWNER Get e �
OWNERS NAME J_ ftAtkL'
STREET ADDRESS at 3 ajt 401
en.adlec , Pt 28115
City a Town State Zip Code
(928 )- 112-515Z
Ana code - Phone number
5. WELL DETAILS: 3 I S
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O
c WATER LEVEL B&avTop of Casing: YQ
(Use •+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top or casing to hinted at/or bebw land surface may tequite
a variance in =order= WPM 15A NCAC 2C .0118. tip
e. YIELD(9Prn)' Y METHOD OF TEST P.'�.J
NOSV
FT.
t. DISINFECTION: Typed l\S Amount / rl
g. WATER ZONES (depth):
From
From
Fran
6_ CASING:
To From To
To From To
To From To
Fmm Depth"
1 / From To
From To
Thido tell
Diameter Weight
-6114,24
Ft.
Fl.
7_ GROUT: Depth Ma'aial
From To�Fl. Cep-ire/4-.
Frain To - Fl.
From To Ft.
8. SCREEN: Depth Da natter Slot Size Material
From To Fi. in in.
_ From To R. in. in.
From To FL in '6L
f t�
9. SANDLGRAVEL PACK:
Depth - Size Material
From To- Ft
Fran To FL
Fran To Ft
10. DR!WNG LOG
From To
I .39
»FLater. orrlatbn/�
lr.
3, ,BLS &.ry.)fv
11. REMARKS:
O
0
C r
o`''' t7
r—
I00 HEREBY %.a(ItY MAT MIS WELLY AS CONS'TRUClm N ACCORDAMCE WITH
15A NCAC 2C. WELL W NSTRUCROH ..TA NMRD3. AtS MAT. GAPY 6 his
RECORD HAS BEEN PRCNDEDTO THI,1% ELL OWNER.
SI ' ' TURE OF CERT! oat 'Ell CONTRACTORS DATE
17e tf . Gx vvecorb.IN t1t
PRINTED NAME OF PERSON XiNSTRUCT G I WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7A5

329330
RESIDENTIAL WELL CONSTRUCTION RECO:10
North Carolina Department of Environment and Natural Resources- Divisive of N a:er Walt,
WELL CONTRACTOR CERTIFICATION #- 3j 3L.
1. WELL CONTRACTOR: -
Qcc; e_c. ec �. .•-ire cs
W eW Contractor (Individual) Name
WeA Cdlhada Company Notate
STREET ADDRESS CyVQt \�t.J�r ar3ci
'
1-\o-t 5cc \Q 1 NC - LWV-i3
City or Town s� - -zip Code
(83S>_ cocps- aoa _
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERM -Tea app➢oble)
DWQ or OTHER PERMIT a(ff yy6 aLA) /
WELL USE (Check Apppricable Bon):Residerrtid Water Supply Lq
DATE DRILLED ! —�� (
TIME COMPLETED I, Oo AM PM
3. WELL LOCATION: ,[ )
CITY: LI:CPl/{" counn31tnrd462
Name,ter Numbers, et1
Write,Nu_5 SW®Wlon. Lot No.. ParceI. at Code)
TD9OGRAPHIC / LAND SETTING:
CI WWI CI FIN ❑Ridge ❑Dee
(check appropriate box)
LATITUDE 3
LONGITUDE _
Latitude/longitude solace: ❑ GPS °Topographic map
(location of weir must be shown on a USGS tapo map and
attached to Pia tom l not using GPS)
6.Wt3LOWNER
OWNER'S NAME U � A
STT T ADDRESSeStesI RC
S
t
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
(8.1% )- tot ct-o1aa
Area code - Phone number
& WELL DETAILS: '
a. TOTAL DEPTH: - &
b. DOES WELL REPLACE EXISTING WELL? YES ❑
Nov
c. WATER LEVEL Saw 7Cp of Casing n FT.
(use •+' 8 Above Top Cf casing)
d. TOP OF CASING Is FT. Above Land surface*
'Top of casing Ventilated at/or below land surface may require
a variance in accordancewWn 15A NCAC 2C .0118.
e. YIELD (ppm): C. METHOD OF TEST iJ..•3
f. =INFECTION: Type_g NS Amount 10C
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From To
6. CASING: Diatipter Weight
Thickness/Fran }) To nJ/S-Fl._ '° I
From To FI.
From To FI.
7. GROUT: Depthn Material
a From 0 To C) R. (te11'+4-.
From To Fl.
From To - R.
Meacd
fhtePcf
8. SCREEN: Dep'J1 Diann& Skit Size Material
From To R. in. in.
From To R.
From To R. vr. In.
9. SAND/GRAVEL PACK:
Depth - Size Material
From To' Ft. _.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Fotatbn Des
j /is fimter Pk.
//s 0791'
11. REMARKS:
L.
r-
1
m
100 HEREBY' CERTIFY TRAT THIS WELL MILS CONSIRL'1.1tDN ACCORWICE WrM
ESA NCAC 2C. WEU. CONSTRVCT ON nTANOMDS. AMC' THAT COP. CR/HS
RECORD HAS BEEN PROVIDED TO THI: W ELL OWNER.
SIGNATURE OF CERTIFIED WELL NTRACTORRDATE
72 Cf. Os-VAG. s'S73
TAE
PRINTED NAME OF PERSON X1NSTRUC? G 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.
Farm GW-la
Rey. 7/05

329329
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Di of Rater Quality
WELL CONTRACTOR CERTIFICATION #- aM 3t.
1. WELL CONTRACTOR:
2-c: e lc 1?.e✓�►, Sam tef�
Well Contractor (Individual) Name -
�.�4))dQE-Cc r)
Well Cd drool Company �Narpphe
STREET ADDRESS '\%% \NAAS/ aog
Ho-4 Sec nca , Nc a8'�`-i3
City Cr Town Ste -2m Code
(8a%)- (0(95- aaaaa_ -
Area erode- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/ W.vv%..bL)
DWQaOTHER PERMIT#(9wv L) /
WELL USE (Check Applicable Sad: Residential Water Supply (f�"
DATE DRILLED 7- 8 -.C.:
TIME COMPLETED J r CT AM 0 PM a--
3. WELL LOCATION:
CITY: La of Qtr t.''4 ..
a S/7n
{Suer Name, Numbers, Canmuney. subdivision, Lot No.. Parcel. Zip Cale)
TOPOGRAPHIC / LAND SETTING:
pSlope ljVafey CFI CI Ridge ❑Other
(cheek st box)
LATITUDE 3
LONGITUDE
COUNTY O,e1r o *f4P
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longittte source: GGPS °Topographic map
(location of welmustbe shown on a USGS tops map and
affected to !his form Inot using GPS)
4. WELL OWNER _ J 1
OWNER'S NAME O-M AQS T'TtS
STREET ADDRESS ( SH err err Sk.
'Aehsv:%t tJc 288a'1
City or Tavn • State Zip Code
(%a% )- a toYt‘
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTIt o7 d S
b. DOES WELL REPLACE EXISTING WELL? YES CI NOV
c. WATER LEVEL Seim Top of Casing 07CD FT.
(use'+' d Above Top 0f Casing)
t TOP OF CASING IS i FT. Abehe Land Surface'
Top of rasing terminated aUa blow lard surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (glom): ✓ METHOD OF TEST 0i''3
f. DISINFECTION: Type4:11S Amount J()
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth / Dlot Weigh
Frn�i To �-Fl 4, " -ca .yina, at
From To FI,
From To R.
7. GROUT: Depth Ma'eria
From 0 To ao Fl. (--en)tent
From To - FL
From To Fi"
8. SCREEN: Depth Diner Skit Size Material
From To FL in. in.
From To R. in. in.
From To P. in. in.
9. SANDiGRAVEL PACK:
Depth Sae Material
From To FL
From To FL
From To Ft
10. DR!WNG LOG
From To Formation
> — 40cr i
11. REMARKS:
ram •
—
t— -,-1
100 /SEREST CERTIFY THAT 114S WELLY AS CORSTRLCIID N ACCORDANCE vim
15A N .AC 2C. WELL CONSTRUCTOR STANDARDS. Alan nNT A COPr De T45
RECORD HAS SEER PROVIDED TO THE W -
a - O
SIGNATURE OF CERTIFIED WELL Ca '1 OR DATE
DATE
` +C(`. t.% \At6.4rjy 6C.1.4 '�¢C4
PRINTED NAME OF PERSON XNSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information hi3L,
1617 Mal Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fam GW-la
Rev. 7/O5

329326
RESIDENTTAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of M ate Quality
WELL CONTRACTOR CERTIFICATION #- OM ate
1. W
E
LL CONTRACTOR:
Q.l \ • c eL Nrker-r.ltim 'S0.W'lQCS
Wd Contractor(4ldvldual) Name - - -
t.�ijdQ ' 'S 0.s.177Q4'S * sofT.
Well Cdrtractor Company Nate
STREET ADDRESS \yCSU rJ .M Laura
4'10.4 1-Ctn°N J C - i LW-143
City ce Ta n sswee -Zip Code
(87%» (0(05-0aa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mae
STATE WELL PERMITfl...hcaUe)
DWQ or OTHER PERMIT S(ff amicable)
WELL USE (Check Applicable Bog: Residential Water Supply g
DATE DRILLED Cn Thais
TIME COMPLETED 3 rO 6 Amp PM U /
3. WELL LOCAT1Ott
CItI TY: Can/ir .. COUNTY 5r. H lO/7tee
Cur` ,.f (reek
.(Sbxet Name. Numbers. Cammmay, Subdhbirn4 Lot No.. Parcel. Zrp Code)
gT POGRAPHIC / LAND SETTING:
Slope OVaNey ❑Fitt ❑Ridge ❑Other
(vme*'pP"pdate box)
LATRUDE
LONGITUDE
May be in degree,
minutes, seconds or
in a deeimal format
Latituddlongitudcsolace: GPS Topographic map
(barbs of wetrrarsf be shonrt on a USGS topo map and
aexhed to this form f not using GPS) �r
4. wet. OWNER (� (AJIJ(,�J
OWNERS NAME (batS
Sutttr ADDRESS 4I00 V:Sta. Loewe. Ctn.
Cana‘ec , 'at
City or Town Stale
(828 ), 33'l • Sig a
Area code - Phone number
S. WELL DETAILS: '
a TOTAL DEPT}t •1 9 d -l-
b. DOES WELL REPLACE EX STING WELL? � YES 0 NO
a. WATER LEVEL LEVEL. Below Top d Casing r /C'/ FT.
(Use*' if Above Top of Casing)
d. TOP OF CASING I 1•
FT. AbOwe Laud surface'
Top d m easing rirw[ad aVor bel land surface may require
a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): -IQ METHOD OF TEST R'AJs7�
29.11.5
Zip Code
f. DISINFECTION: Typ.4L%%3 Amount 3 c)
g. WATER ZONES (depth):
From To From To
Flom To From To
From To Fran To
6. CASING:
papthesaf
From }i DToth/3�-Fl. Drier I
From To Ft. .7:.
From To FI.
7. GROUT: Depth Matvia Method(
From To_sa3_,_R. Cenral. I�/mF c4
From To Fl.
From To Ft.
8. SCREEN: Depth Diameter Slot Store Materiel
From To Ff. _in. in.
Fran To F. 'vr.. in.
From To R. _ivL in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To FL
From To Ft.
10. DRILLING LOG
From
To „formation
J/3S nacr
/3 S K oS
11. REMARKS:
4" tz
r,
10O HERESY CERWY 'MAT THIS WELL r"Aa CrONSTRLCTED N I.CCORWAGE NRm
1Se Nut 2C, WELL CONSTRUCTOR ]TANDARDS. M31TH4ATA COPY OP Tors
RECORD HAS SEEN PROVIDED TONIC NELLQ
Comer F
SZ*NATURE OF CERTIFIED WEI� RACTtiR DATE
'bete. 0' 944to.kt:S
PRINTED NAME OF PERSON X'NSTRUCTINGG THE
Submit the original to the Division of Water Quality within 30 days. Attn: information kilt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. (919) T33-7015 ext 568.
Form GIN -la
Rev. 7105

assz
RESIDENTIAL WELL CONSTRUCTION RECO3D
North Carolina Department of Environment and Natural Resources- DIof Warr Quality
WELL CONTRACTOR CERTIFICATION #. I
1. WELLCONTRACTOR:
..tve;,2tec_ •N
Wel Contractor (td*1Ual) Name -
Q.\>.))ate. ' 6c.a'y2-CS *.son
Well CJi a k. Company Nada
STREET ADDRESS .lyV G15 .YCi...iY o�)q
b10it c n 1 1')C. - da8'i'-13
City or Town .. -Zip Code
(8 n- tn(bS- oaod
Area code Phone number
2. WELL INFORMATLOIt
SITE WELL ID Art applicable)
STATE WELL PERtt9Tif(rapp caNt)
DWQ or OTHER PERMIT Elf app&able)
WELL USE (Chedt ApptwWe Box):/Residential Water Supply(/'
DATE DRILLED V -G ce
TIME COMPLETED . O o AM p PMge-
3. WEB.- LOCATION:
Cirr/: Er/ 4/t'f4/-
( i( <dr %G/
.(Sbse frame, Numbers. Community. Srbrdirion, Lot No.. Parts, Zip Coder
TOPOGRAPHIC f LAND SETTING:
QrSlope DVS ❑FM ❑Ridge ❑Other
<check appropriate eery
LATITUDE 3
LONGITUDE
COUNTY /JL ht'owt 4
May be m degree,
minutes, seconds or
in a decimal format
Iatitude/iongitude source: ❑U'S °Topographic map
(location of wet must tie slrorm on a USGS typo map and
ached to MC form fnot usig GPS)
4. WEIS OWNER
OWNERS NAME LL
STR rCP:CeS%i'.sc
City or Town /State
Area code - Phone number
Zip Code
S WELL DETAILS: a 5TOTAL DEPTIt 0-5-
b. DOES WELL REPLAN EXISTING WELL? YES ° N017
c. WATER LEVEL BS wTap of Casing SU Fr.
(Use ^*' f Above Top d Casing)
d. TOP OF CASING IS 14 Fr. Abae tad Surface'
Top of casing terminated at/or blow land surface may require
a variance F accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF -TEST R•tJ
329318
t. DISINFECTION: Type*, t %S Amount vc S
g. WATER ZONES (depth):
From To To
From To To
From To To
From
From
From
6. CASING: Thickness/
Depth ,, DiameterWeight
From,_To /O6 R. tot. .9t()42I
From To FI.
From To FI.
7. GROUT: Depth Material Mklha
From 0 To&o R. CPoitelt pri• ( hP
From To - R.
From To - Ft.
8. SCREEN: Depth Dat meter Slot Size Material
From To FI. in. in.
From To R. m.. in.
' From To R. m. it
9. SAND/GRAVEL PACK:
Oeptt - Sae Maseisi
From To- FL
From To FL
From To FL
10. DRIWNG LOG
From To
j • ia�
Formation Description
oacr dreii
I b 8 SdS Lr `{e
11. REMARKS:
Cr
to
—:
r—
I OD HERESY CERTIFY maiYRS WELL Y'AS CO*SIRtCIED N ACCORIW CE WITH
NSA NCAC2C. WEU CONSIRUCnON hTANDARDS. AFTTVITACOPY OF THIS
RECORD wS SEEN PROVIDED TO TM: P. EU. OWNER.
SIGNATURE OF
'terc.cx Henkb. SxsA7Q 4
PRINTED NAME OF PERSON x'NSTRUCiINGG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information MIL,
1617Maii Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 56S.
Faro GW-la
Rev. 7/05

North Caroline • Daps%.p t a ErMan ent and Nein Ibeor.aee - ONMon a W.* overly •Gror.dw.br Season
1636 Mal Service Center - RIM N.C. 27599.1S311•Pbone (11H) 733.3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: a C tacri-LI“X
WELL CONTRACTOR CERTIFICATION d c9 113
STATE WELL CONSTRUCTION PERMIT6:
1. WELL USE (WadtApplesbt• SRR Narldflu j3 Muic% 1 0 Industrial ❑ Apdoulk:nl 0 Monforbp ❑
Recovery 0 Haat Pump Water Wedge: 0 Ddrsr 0 E Oder. Ust Use:
lirlt
z Harm TO:l JMof the locallon Slow)
I I Cwer 1'2lk n(trn')(0,
(Rwrd wlrb wmrwey, or aabdrlrlon.d La No.
3. OWN � �Cvt 1fl n m-tn NrrnQ7
Address
Cry at Tern Sob
H ,r
4. DATE DRILLED
S. TOTAL DEPTN
6. CUTTINGS COLLECTED YESQ Ndp'
7. DOES WELL REPLACE DUSTING WELL? YES ❑ ND9'
6. STATIC WATER LEVEL Below Top of Cuing: FT.
9. TOP OF CASING IS , FT Above Lad Surface'
Krp of DAM b.drr.Led sWe Wks bit w.bea require.. aarbrr.o M radar -
dunes RNA ISA LILAC 2C MIS
10. YIELD (yprn): 17 METHOD OF TEST
it. WATER ZONES(dpthr
aai5"3
21D Cads
DRILLING LOG
inen To
4;('Yn- ROC
12. CHLORINATION: Type Amwd
13. CASINO:
Well Tanen
Dap91 CL._ .r arWMyaFt
From 1 To G� Ft. (OT
From To FL
From To FL
14. GROUT:
Depth Metsdd Medved
From 1 To at)
FL CC XYI.QYL±
From To FL
15. SCREEN:
Depth Dbene*r Slot Ski Material
From _To_FI In. bt.
From _ To _ Fl. !n h.
From To FL_
16. SAND/GRAVEL PACK:
Depth Stare MdedS
from To FL
From To Ft.
17. REMARKS:
DEPTH
•Ia • a
crn
crn n1
d addM 'W pace b needed use beds of bnn
LOCATION SKETCH
1�(Mdamerm drecaon andame PromMPS swots. o
Roads. orother mop retererbepokes) rC-- I
IG 3 N
cis
rnorpn\\
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH ISA CAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD,
SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / r r"�v�L 5- 25-000
Oard NC TURE OF PERSONCONSTARRNO THE MILL DATE
Suave GROW bMRSNWFSOrwNlc Ownbodbr SWIM wN11rt 30 days
OW1 REV. Ifl
Sand Ns.
1

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Dcpanmcnl of Environment and Natural New t:met- Division of Waite Quality
WELL CONTRACTOR CERTIFICATION t$ a ( 4-
1. WELL CONTRACTOR:
g,e tx le )n Q._ckA ek.,a e,11
Well Contractor (Individual) Name
Q L, w Qx &well ©C';11;nc4 t i+tL-
WellContractorCompanyName
STREET ADDRESS 3 GJI f\P-LO F.'t Ce-SrC-L, r J"Irtl�
(ishev;tle- rvC
aggo6
City or Town Stale Zip Code
(fig)- a54-35�1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT x(if applicable) �/
WELL USE (Check Applicable J7ea) Residential Water Supplye
DATE DRILLED b
/"
TIME COMPLETED'' P I i- S V AM y� M p
3. WELL LOCATION: Cr Q
CITY: L ICESyLSQL- COUNTY tJv N � m�`
1 o-r M `3 \ �om.e.s % C&1 K gr#-rj-5
(Street Name. Numbers. Canmunrly. Subbbb mewl. lot No.. Pincer, Zip Code)
T OGRAPHIC / LAND SETTING:
lattope °Valley °Flat ❑Ridge °Other
(check appropriatebox)
LATITUDE 3 5 3qq • l 1�
LONGITUDE a. 4J • 6 S p' O
Latitude/longitude source: OGPS °Topographic map
(location of wel must be shown on a USGS lopo map and
attached to this loan 1 not using GPS)
May to in rkpreek
minutes. seconds or
in a decimal format
4. WELL OWNER OWNER'S NAME 4ft S 1 L U( I c' S% A K
STREET ADDRESS 61 6S: C(
1stasjt'. Lid AQT 3-6
ASI.4 -J .L€ t'uC a - gob
City or Tarn State Zip Code
( e a8 r a.. y 0
Area cede - Phone number
5. WELL DETAILS: ,1 p y
a. TOTAL DEPTH: 4 b
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
c. WATER LEVEL Below Top c1 Casing- t 0 FT.
(Use -✓ if Above Top cf Casing)
d. TOP OF CASING IS /J- FT. Above Land Surface'
'Top o( casng terminated aeer below land surface may require
a variance n accorP(1p
dance with 1 SA NCAC 2C .01118..
e. YIELD(gpm): 15 METHOD OF TEST let V"."
V.
From
From
From
DISINFECTION: Type
WATER ZONES (depth)(
r O% To 10 th1
q 44 To 4-44
To
0 Amount
From
Fran
Frorn
To
To
To
6. CASING: Thickness/
Depth a. • FI. ('()3`$ .SWCA
erg I
Fran J..
From To FI
From To Ft.
7. GROUT: Depth
From To a-13
From To
From To
Ft.
Ft.
FI
material
r `•
Material Method
e r4t A-r
8. SCREEN: Depth Diameter Slot Size
From To FI. in. in.
From To FI. in. in.
From To FI in. in.
9. SAND/GRAVEL PACK:
Depth
Firm To
F rum To
From To
10. DRILLING LOG
From ( To
is
Tycd(- loq'
o9)
4-4-3' - 4 44'
4 4q 1- 465
II. REMARKS:
FI.
FI.
Ft.
Material
Size Material
Formation Description
\I 'rgJ..h'L t t rJ
C ;Lp.
rz 4vc<a `h CJkin
&et';t 1-re
(.tzg.Jlra - t5TV2 GPiv
C_
C_
0
m
r DO HEREBY CERTTY THAT TWS W ELl WAS CONSTRUCTED N ACCORDANCE WITH
ISA 'CAC 2C WELL CONSTRUCTION STANDARDS AND ThAT A COPY Or TMS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE` CERTIFIED WELL CONTRACTOR
tk- \ AC 0 ASIA
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•4617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

v
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a 14—o
1. wWWLL CONTRACTO(t:
to-beil p \d,Ljt11
Well Contractor Individual) Name
Re)A,bevt l' Ot iuue,t I 0r61;,q3 1 I nc.•
Well Contractor Company Name 1
STREET ADDRESS 351 A e t,. Let cesteif0(,(,�
� s he), e_ IJ C ag T o (0 1
City or Town State Zip Code
(cai ) 154-35g1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
DATE DRILLED
TIME COMPLETED Z• 7j D AM 0 PM V'
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Bqx): Residential Water Supply 0
0
3. WELL LOCATION: _
CITY: AL$pI//A NQf�1'�J COUNTY MJU I�r,�/�
E
aumC_.6 ma6 C.30 . LAI 1_
(Street Name. Numbers. Community. Subdtasion. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / L iND SETTING:
ID Slope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 1_ Q-;
LONGITUDE& 2
5 lg3
GPS ❑
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source:Topographic map
(location of we9 must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER R2 nn
OWNERS NAME VV6�JCJ0n'JJb t0 . LA.430 LL
STR ET ADDRESS %5 I ANY -k (J�''AN C{.{ to_
LE AN Osh ,t C/
City or Town State Zip Code
(4S-531k
Area code - Phone number
5. WELL DETAILS: qq �
a. TOTAL DEPTH: `Y"'US
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: Q t1 FT.
(Use'+- if Above Top of Casing)
NO./
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): 1 S METHOD OF TEST I LG -A liv
f. DISINFECTION: Type 1,11.1 Yto/" Amount 0C`
g. WATER ZONES (depth):
From g 1' Ton From To
To From To
From
From
To From To
6. CASING:
From a
From
Thickness/
Depth ci Diameeer We1ohL/ Material
Tom 1 FL (c' . !VI STB(✓)-
To Ft.
From To Ft.
7. GROUT:Depth y/ Material rt. L/Method
From S TOT u Ft.` 'eivlb 7/ t J -i e 6
From To Ft.
Frorn To Ft.
8. SCREEN: Depth
From To
From To
From To
Diameter Sbt Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From • To
Size Material
Ft.
Ft.
From To Ft.
10. DRILLING LOG
From / To /
9 - (3
- -t .
at `e citc
crg/ - 4D5'
11. RENIARKS:
0 Fo,Finatior),DtesCn cAptt ea
�Pack ..)L i
C-a-B4rCb - I G Pn-'
r CIA f`-). t'f t3
c_
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF 111IS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
k>(l,.lrle. rJAS}�
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

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environmcnl and Natural Pccourcco Divirion of Water Quality
WELL CONTRACTOR CERTIFICATION II a ( 4-
1. WELL CONTRACTOR:
fete �2QN Qok0La t
Well Contractor (Individual) Name
P,E,1,413Qn Q . \ &Lott DC; \ k; A5 (14 c. .
Well Contractor Company Name
STREET ADDRESS SS I f'Q.t•l\ et C.eSTe-r J"1NJ�
Nshev\t(t NC ag $'o G
City or Town State Zip Code
( S9-IK 1, 64- -3 51 I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Y(i( applicable)
STATE WELL PERMIT/id applicable)
DWQ or OTHER PERMIT ff(if applicable)
ble Bya): Residential Water Supply
WELL USE (Check Appli
DATE DRILLED TIME COMPLETED I . 3
06
AMID PM'
3. WELL LOCATION: (n� ,o-
CITY: �AtRV' COUNTY (2yl)� CD Mai
"Ti chi% L.A (LO u1 &kI'K (L OA b
(Street Name. Numbers. Community. Subdmvon. Lot No. Parcel. Zip Code)
TOPOGRAPHIC f LAND SETTING:
❑Slope DValley Vat ❑Ridge DOther
(check appropriate box) LATITUDE y1 5 -3S _168
LONGITUDE t a 9,4- . Y> U O
LatitudeAongitude source: cieS OTopographic map
(location of wet must be shown on a USGS (opo map and
attached to this form 1 not usiq GPS)
4. WELL OWNER R ,CSiY( frJ� a,�
OWNER'S NAME tU VW t CAt33•-L
May be in drgtres.
minutes. seconds or
in a decimal fumui
STREET ADDRESS Jai L. U...Al2_0 ClZbei2 (2-o,�=ALti>J\gw ►mac 9-%130
City or Town State Zip Code
($a-% r 69-8 — e2 6 V5
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES D NO Q
c. WATER LEVEL Below Top of Casingb b FT.
(Use -+' if Abate Top o( Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top d casing terminated aUpr below land surface may require
a variance in accordance with 1 SA NCAC 2C .0118.
e. YIELD (gpm): U\b METHOD OF TEST MG -
f. DISINFECTION: Type
g. WATER ZONES (de Ih)
From \31 To 15 From
From To [torn
From To Frorn
6. CASING:
Depth iaueler
From
y To6 Ft. Z/a
Fan To Ft
Fran To Ft.
7. GROUT: Depth ^�
From To ZC) Ft.
From To FI.
From To FI
Amount O
DZ -
To
To
To
Thickness/
Weioht• . Material
.t•tg S e
Material
Cat
Method
B. SCREEN: Depth Diameter Slot Size Material
From To FI. in. in.
From To FIin. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
Ran
To
To
Ft.
Ft.
Ft.
Size
Material
10. DRILLING LOG
From ( To ,
e)
4-5f— si C Pa. tJlr�
131'— 1 3'3 c2ftN(1c it G P11'V
�3g'- a.o5Gan t-r 6
ii. REMARKS:
For ation Description
o -.J -6t.a , A ina
Cv
r
r
I DO NE RERY CERTIFY THAT DRS WELL WAS CONSTRUCTED H ACCORDANCE WITH
ISA NC AC 2C WELL COHSTRt cny. STANDARDS AND THAT A COPY OF THIS
RECORD HAS PEEN RROVOED TO THE WELL OWNER innnn
cLrOJSFy
SIGNATURE Ok CERTIFIED WELL CONTRACTOR
( t.\-1t3- (JASll
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 GW1a
Rev. 7/05
t

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanmcnt of Environment and Natural Rcsourccr. Divicion of Water Qu,dil�
tVELL CONTRACTOR CERTIFICATION 1/a (4-i
a
1. WELL CONTRACTOR:
i.,e u-Alev1 L a-164.0 0 I
Well Contractor (I/�ndividua`l) Name
Re .bent Q.ta1LLLt)ett Dr; 1t‘‘n5 (\ C-
Well Contractor Company Name I I
STREET ADDRESS 3 JI 'Atka t CeS+.r
f\shevltle NC aggo(o
City or Town State Zip Code
( } tam - 3 ”
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #0f appbcable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable 8o Residential Water Supply INK
DATE DRILLED " �B �0 fL-+
TIME COMPLETED a•L •� Amp PM [V'
3. WELL LOCATION: W/�/�
CITY: f3 A✓t4t71 \ �(i COUNTY "- .) Ca ringr
C9 be. -?-a u ,o
(Street Name, Numbers. Cvnmvn' , SPbemHon ,Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OVaeey ❑Flat DRidge :tether
(check appropriate bowl LATITUDE y1 5_ 4-4- •• t f. a
LONGITUDE a. 34- 2-
Latitude/longitude source: jCPS °Topographic map
(location awe! must be shown on a USGS topo map and
attached to this form (not using CPS)
4. WELL OWNER
OWNER'S NAME G A (A P j2
May be in *pees.
minutes. seconds or
in a decimal format
STREET ADDRESS a -a a O L-QS C! 4343 S 9-0 -
l &MitRJt`L" NC aglg1
City or Town Stale Zip Code
(' 2-%')- bent-bas
Area code - Phone number
5- WELL DETAILS:
a. TOTAL DEPTH:
6051
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (Y
c. WATER LEVEL Below Top of Casing t ? J FT.
(Use -+ if Above Top of Casing)
d. TOP OF CASING IS 4- FT. Above Land Surface'
'Top of casig terminated atior below land surface may require
a variance it accordance with ISA NCAC 2C .0118. //� [[ff
e. YIELD(gpm): METHOD OF TEST 1\(v'*t'{
I. DISINFECTION: Type I qtr Amount Zj O Z
g. WATER ZONES (depth)
From 214 To A 7 J
From 51
o To S°4 1
Frin To
6. CASING:
Depth
FromL To 1 oa
From To
From To
From To
From To
From To
DI�
Ft
FI
FI.
7. GROUT: ,At Depth
From "1 To as Ft.
From To Ft
From To Ft
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Deplh
From To
From To
From To
10. DRILLING LOG
From 4 To
-
Gi5f - 1,14 r
a'14-'- a1S'
a-tS /e5tte'
>
QQ'- bb5'
Thickness/
eter Wei h( Mat I
Material
C.ymyr7T
Method
roe-e�
Diameter Slot Size Material
FI.
Ft.
Ft.
FI.
FI.
Ft.
in.
in.
in.
in.
in.
in,
Size Material
Formation Description
r41-11..(61-.5 e-b e i•)
C� 0.A P 3 -t g
ri[., t c - rl-- & rr'
c•.(t aS t — 3 CbQrY�
r�
L T—
r i:
i'ilt7fi — m_
11. REMARKS:
ta A tAa Sl-t` c rJ
tj-e pR.,
LQ�
0
F-
I DO NE PE RY CERTIFY THAT THIS W EIL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NC AC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS RE EN PROVIDED TO THE WELL OWNER
� rra L ems. C oQ CLU JeC ga
SIGN/alit
TEt E OF CE TIFIED WELL CONTRACTOR
R, L_L_1 IJ A Sla
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-Ia
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dcpanment of Environment and Natural Recourccc- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ff a t Y
1. WELL CONTRACTOR:
c..2 \_e v1 Q 0.Ac o o
Well Contractor (Individual) Name
geAL.beh Q,a\ d,WO t Drt k;A5 I n c.
Well Contractor Company Name
STREET ADDRESS 351 fle-LJ t Ce Y"e.r kiwi
%shev\tl2 NC n 0G
City o Town Stale Zip Code
( 3S41 a54- -35f I
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID C(if applicable)
STATE WELL PERMITC(io applicable)
DWQ or OTHER PERMIT k(if applicable)
WELL USE (Check Applicable Bo : Residential Water Supply ai
te
DATE DRILLED CO /a. "3 / o I7 %
TIME COMPLETED 10'•/30 AM[q PM0
3. WELL LOCATION:
CITY: t fAiik•ii'-121!COUNTY eupco L-3
(SUeeI Name, Numbers. Commurt. Subdnnron. lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Fiat °Ridge ❑Other
(check appropriate box) �1
LATITUDE 3 5 4-4--16 vl
LONGITUDE 3._ a 3 L-. ors
Latitude/longitude source: p6PS °Topographic map
(bca(bn o/ wet must be shown on a USGS Pope map and
attached to this fan ITrot usng GPS)
4. WELL OWNER (`
OWNER'S NAME A a -
May to in deem.
minutes. seconds or
in a decimal format
STREET ADDRESS Ora
i/J e AEI g-{LJ 1 L_L_%
City or Tam Stale
lass} 69i- baga
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
(DPP
o t_4 G 164 S RA
c_ atigl
Zip Code
bs�
b. DOES WELL REPLACE EXISTING WELL? YES ° NO Q�
c. WATER LEVEL Bekaa Top CasinBekaad A FT.
(Use's if Above Topic( Casing)
d. TOP OF CASING IS FT. Above Land Surface*
'Top d casing terminated aua befon land surface may require
a variance in accaiance with 15A NCAC 2C .0118.
e. YIELD (gpm): O METHOD OF TEST 6 - A I Q
L DISINFECTION: Type
g. WATER ZQNES (depth)
From 1V
Fran/ To
From To
6. CASING:
A( Depth
From 1 To t DO Ft.
From To FI
From To Ft
7. GROUT: Depth
From
From
From
Amount
From
To
To
To
Thickness/
eter
501khT .at rY Ll
�1 �+ Material
To 0.0 Ft. Ccf n'e-rd r
To FL
To FI.
8. SCREEN
From
From
From
Depth Diameter Slot Size
To FI.
To FI
To FI.
9. SAND/GRAVEL PACK:
Depth
From
To FI.
From To FI.
From To Ft.
10. DRILLING LOG
From e To
— et
II. REMAR 'S:
p Uj L L . sba, L_L.13 1
in.
in.
in.
Size
Method
LOJ_D
in.
in
in.
Material
Material
Fprmatiion Description
tsv ;e7LC� au2e511
e P-A rs1 C—
r
Fr;
np CH
oats .
I WHEREBY CERTIFY THAT THIS WELT WAS CONSTRUCTED N ACCORDANCE wino
ISA NCAC 2C WELL CCOC���ggqTNNNrSmUCToN STANQyiTS A THAT A COPY OF THIS
RECORD HAS BEEN gROJUED EWELL b1�
�C� f _
es-QQ3€r CuLIN LL
SIGNATURE CERTIFIED WELLkCONTRACTOR
A p�\V�1
L4
PRINTED N 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] eat 568.
Form GW-la
Rev. 7/05

NOtTh C S a - Consumed
ss - .maof Entnment and Natural Rarom. - Woke of Waterfib Groundwater Section
ME Ralalpl4 N.C. 27699-1538Phar [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. (`loan n 1r r
WELL CONTRACTOR CERTIFICATION t: 6
STATE WELL CONSTRUCTION PERWT6e
1. WELL USE toed Applbabb6a) R.Nd.ndaft7r municipal I:3 industrial
R.eowry ❑ HsM Pump Water ...won 0 Other p if Ober, Ust Use:
Agllmdlural ❑ Monitoring ❑
2. WELL OCATM (Show
went LToolwr V \ l P QX)Cflf \ IJ! ihe °" 2 .. { aK.,
mood
3. R 'b�iiSCrsi rd Del No(
Address t+t t„' • s - 0E.'e 9-1
I P_ CraiJ
V\i _rU p ' c
Oly Nale ZI►ada
4. °ATEDRILLED-551
5. TOTAL DEPTH 1 at" S
6. CUTT1NGSCOLLECTED YES 0 NOLK
7. DOES WELL REPLACE EXISTING WELL? YES El NOD"-
8. STATIC WATER LEVEL Below Top W Cuing: FT.
(Ua 9Assn Top elQuint
9. TOP OF CASING IS t FT. Above Land Surface*
'Top el nay lordr.Ld odor bus lend maths avubrc.lnwen
dunce wan ISA MAC 2C MIS
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
DRILLING LOG
_AT-4- T.
trascie
( Oct:
12. CHLORINATION: Type Amount
13. CASING:
Rom_D.p
To
From To
DEPTH
V additional pew b needed we beds of loom
Wall Therm
,�srow LOCATION SKETCH
Ora .a. anTWOWrt. 1 4 - , Mreo6on end alrc. banal bat boo ebb
R. _ 1Cz4 ' Roods or other man Moren r petit')
FL
From To FL
14. GROUT:
From ` To r '% Fl
From To Ft.
15. SCREEN:
Method
Depth Diameter Slot SS maths
From _ To Fr In. In.
From To Ft. M In.
From To _ FL _ In.
16. SAND/GRAVEL PACK
Depth Size Materiel
From To FL
From To Ft
17. REMARKS:
(v12"fie kd
Lo
Jam- �Qw)
0
0
T-1
Ur
f ;C1 Ctf
CJ*' }-'.ctQ
C_
100HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS AND THAT A COPY1QF THIS RECORD HAS BEEN PRONGED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Oad NA
nodal Ne.
OF PERSON CONETRUCTaa THE W ELL DATE
Sutra adytar. b OMhra alWain Dualy Owuhdcear eaceen wilt 30 days
OW-1 PET. t21ee
Dui

North Carolina • Depereoaa of EmironmwA and Surat lleeoire.e-OluMon a Ws Onasay. Groundwater Seolon
1C36 Mal Santo Center • Raleigh, N.C. 27699-1676.Phone NI IN Mini
WELL. CONSTRUCTION RECORD wcucoNnucrof. is i O«rt %k _f
WELL CONTRACTOR cMRfFICATION op: r7 ( I .,
STATE WELL CONSTRuc soR PEIMMTe:
1.
WELL USE ApM cater OS Residential Municipal 0 Industrial 0
Recovery ID Hest Pump Water h{eoaon p Omer J NOW, UN Use:
AprbWtnal ❑ Monitoring ❑
WELL LOCATION: Mow Sigh aee Imam bibw)
Waal Tows ton - n (n CA . 1 Yi
3. (Read Ni " er Sabi. . and Lot No.) DRILLING LOG
o(ReadwNeT }C'� J. . Ram
1_1 Ts
SO d—MCA yer Teen erala
4.DATE DRILLED iA I.Q 2oaa 1SO
S. TOTAL DEPTH i
6. CUTTWGS COLLECTED YES Q No(
7. DOES WELL REPLACE EXISTING watt YES 0 NOr
6. STATIC WATER LEVEL Below Top of Casino FT.
(tan •.• I Alas Tee el Casing)
S. TOP OF CASING IS FT. Above Land Surface'
'Toe a nobs lanolnalail svw Wks Ind aurae* piquing a valance b gager-
down sam 12A NCAC2C.pi1a
10. YIELD (ypm): l METHOD OF TEST 2 l t
11. WATER ZONES (depth):
kicks 4 Voht
Fa Iry a v '
12. CHLORINATION: Type Amount
13. CASING:
j Depth
Front t . To f U'Ft.
Fmm To FL
From To FL
14. GROUT:
DEPTH
Ramadan DwayAw
2 eddllona space le needed toe Sit of Iona
Wall ThawLOCATION SKETCH
awsglSFL Mali"dteeaon end L4... a kam at least two 81s1e
• ti Aotls or other map reference ;mk ;mkt)
!!�� Materiel _ Method
Foam I . T Ft. I Q, �� r? 'Ft
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From To Ft In
From _ To _ Fl. kt
From To FL_ In
16. SAND/GRAVEL PACK:
From
From To FL F-lvA.'U `14 Tht. -CL o':e .
17. REMARKS:
Depth Size
To Ft.
Material
in.
I n.
InNSW
pad
0
m ¥" -t
\Y 3
fCA
ci
r 7.7
rn
v 7
by
d
rn
1
t DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. NC THAT A COPYTHISTHIS RECORD SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY film(r 74
Oaf Ma
SION""INE OF PERSON CONSTRUCTING THE oval DATE
Sandi Oral Chiba allN errOaaey Onandasty Sam w wMdn 30 days
Ow•1 REY. 1211111
1

r r •
Nrth Carolina • Depenment of Endorwn.1 and Kant Resources - Ohtdon of Water Oudy - Orasrdweer Sew
193e Md Service Center • Rabbh. N.C. 27699.1636•Phono p19) 733.3221
WELL CONSTRUCTION RECORD Wlat. CONTRACTOR: C-1- QOL4'i Cjc 4 cx
�13
WELL COMPACTOR CERTIFICATION N
STATE WELL CONSTRUCTION PERMIT&
4 U
1. WELL USE neck sededbtt.4 RealdunSfl Muicbd ❑ Industrial 0 Agricultural ❑ MoSorInp 0
Recovery ❑ Heat Pura Water Iri.ollon p Or»r p If MI , Lid Use:
2. WELL LOCA dugch oI tot:don Sow)
Nino unlit Want. erul
ribsd
3. OWNERlfJ-, I nio`1
Address Al
1/4\>(nven/1
as Tan SLYs >»Code
4. DATE DRILLEDS2S3k0
5. TOTAL DEPTH WOO
6. Cl1TTB es COLLECTED YES[ NO
7. DOES WELL REPLACE !DUSTING WELL? YES NOer
6. STATIC WATER LEVEL odor Top of Cuing: FT.
per 'el Nave Tie or Qriyj
9. TOP OF CASING IS 1 FT. Above Land Surface'
?per mine tradrmed wax below Irrd surfs' 'wane • vanes 1n .'err-
drKa wSb 13A /CAC 2CA,piiie
10. YIELD (Wpm): `SO METHOD OF TEST
11. WATER ZONES (depth).
Come Pc--1
12. CHLORINATION: Type Amount
13. CASING:
Dep9i``r
From. To '�w Ft
Rom 7o FL
Ram To FL
14. GROUT:
Foam I T0
From To
1s. SCREEN:
FL
pa.._ pee b needed us* beck of form
was menu LOCATION SKETCH
rvwV•n IoRea}I. ,..� innelon and alines loom al Net Iwo Slate
or other amp Swoon mints)
Depth Diameter Slot Ski
Rom ._ To _ Ft _ In. _ In.
From _ To _ FL In. In.
From _ To _ FL_ In; _ In.
16. SAND/GRAVEL PACK:
Depth
From To
Rom To_
17. AEMARK3:
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 20. WELL
CONSTRUCTION STANDAR)S. AND THAT A COPY OF TMB RECORD BEEN fl OVI0ED TO THE WELL OWNER
FOR OFFICE USE ONLY
Cod rae
SsS Ns.
Crrl
0
DONATteE OF PER IM OON IITIUMtq THE W t3L DATE
Submit viral b Orrere. d flit Owy twunttemer $e Wen W Nlln 30 days
OW -I NEV. 12ee
$

North CrWbwa • Daprbant of Enactment and Nsknd anodes - °Men of Water O.Yy - Omr.dwatr Seddon
1636IMR Sarvloa Carter- RablyL N.C. 27606.163iPhona (9H) 733-3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR. (( t- r
WELL CONTRACTOR CERTIFICATION r
c n
/t
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE pea ipplbabbas* RWdrtlMNJ Municipal ❑ Indu.bS 0 Agricultural E Modlolhp 0
Recovery ❑ Heat iPump Water Infection D Oiler p 11 on»r. UMUse:U
T'
2. I��cA�} CTI tt'°w6°"
Nir.s,Tow lcr'( I I I
IliadNems.aod Nurse, Demmeas, m Suberwm s4t No l . ORIWNG LOG
3. ow,i knCU 151/4„ Di ` S To
Ate. `cp ttiT,kaarbcc Dr ,e el
t—C k r\Dkex° `-+-1Ct
City of Tenn Elsie anent
4. DATEDRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NOE
T. DOES WELL REPLACE EXISTING WELL? YES NO[✓'
6. STATIC WATER LEVEL Below Top of Casing: FT.
(Use .'aNana paCrripl
9. TOP OF CASING IS 1 FT. Above Land Smaha•
'Top of maw tersdrnled'Mr blew tent swims raydraa a n.k. as In meow -
dance wlN ISA 1ICAC 2C Atli
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth)
DEPTH
u OA el
12. CHLORINATION: Type Amanl 6 •jtt. W spew b needed um bee* of form
13. CASING:
From�Dpdh 1
To FIII niL,
Form To FL
From To FL
14. GROUT:
Wan TeNmae LOCATION SKETCH
wwa an. WSW ,($fmowdream and J.I.reken at least two Bub
l Reads, re other mop Mersa* pokes)
Depth .trIN Method
From 1 M
To - D r% p F C �s�C11
From To FL
15. SCREEN:
Depth Diameter Slot Steel Material
From ___ To _ FI _ In. _ In.
From _ To _ FI In In.
From _ To Fla in.
16. SAND/GRAVEL PACK
Depth Sim Material
From To FL
From To FL
17. REMARKS:
L
r
0
0
ern
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. Wf3L
CONSTRUCTION STANDARDS, AND THAT &COPY THIS RECORD FIAS BEEN PROVIDED TO THE WELL OWNER.
/e--lc--
FOR OFFICE USE ONLY
Cued Hs
Sate Ns.
OF PERSON CONSTRUCTING THE WEIL DATE
Ertaraedgbar b OldrnalWOW tbownlaila_Swim WIND 30 days
owl NEV. WAN
1

Frain To
From To
14. GROUT:
From
From
15. SCREEN:
Nadi Carolina • Deprinta of ErniomwM.nd Wound Rsicss - Woke a Water Guilty - cliourdi+.ar Sedan
1036 Mi Wan Center- Ratllh, N.C.276SF1I3S-Phmn 9110) 733-3221
WELL CONSTRUCTION RECORD WELLcoNTRAcron• r -oNni r
WELL CONTRACTOR CENTIFICATION R: call 2)
STATE WELL CONSTRUCTION PERMMTNr
1. WELL USE (aradk*ypinbla a«S ResklenSeIld Muhlapd 0 Industrial ❑ Agdoulturen Monlb.rq O
Recovery 0 HsM Pump Water bk(.otorr 0 Other p Witter, Ust Use:
2. WELL LOCATION: n: (Show Mudd of M locallon Saw) l
Nand TowI L,- 1 CV VA .\ County:
(Road draw *art Numbers. Crmaady, or Eutasion and to Na)
3. OWNER e iarn r 5 C r\Irr r0 1
Agar" Ica (at
) l�CI
FC i rV al) Re r
CayeT.an Stab 2p Coda
4. DATE DRILLED 5 i
S. TOTAL DEPTH It .
6. CUTTINGS COUECTED YES 0 NOE(
7. DOES WELL REPLACE EXISTING WELL'? YES 0 NO'(
6. STATIC WATER LEVEL Show Top of Cukor FT.
(the se Aeon Toy of 0 i
0. TOP OF CASING IS. 1 FT. Above Land Surface*
'Tap et nsby tararfrrlad a*ar below WS aortae ro drea a variance In manor -
donee wNh11*NICAC2CSAto
10. YIELD (ypm): %>t METHOD OF TEST r`1
11. WATER ZONES (depli)
ORILUNO LOG
Fan To
104- JCS
Ioc-3(eS
12. CHLORINATION: Typo Amount t addNb.W aped b ridded use beck of loan
13. CASING:
fFL
Drr
FL
FL
WO Raldo na
rC
teriel
To R. CLn' art
To FL
Depth Diameter Slot Stu
From _To _Fl In. _IrL
From _ To FL In. in.
Ram To FL . In: In.
16. SAND/GRAVEL PACK
Depth Size Malarial
From To FL
Method
MaNrW
From To FL
17. REMARKS:
0
LOCATION SKETCH
(Show dndon indrawn* from at Met two Odic,
Roe* or other map damn points) .,' 0
-\yjO�0 Ck r-_ -Im
r•;-
CD
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH )SA NCAC 2C. WELL
CONSTRUCTION STANDIWDS.AND THAT Acory FTHIS SEEN TO THE WELLOWNEfL
FOR OFFICE USE ONLY
Ord Nei
Sall) Na.
agN11TME OF PERSON CONSTMlCIWO THE WELL DUE
Sutra atafrni b Caw 'Molar GAO . Dwuhdwlr Sadrn whin 30 den
OW-1 LEY. 1E11

RESIDENTIAL 1wu, coNSTRLICTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION d
1. WELL CONTRACTOR:
,U(4 a AL_pw�l L,
Well Contractor (Individual) Name
RAU(Le ti C A11DI.JCLL G in1C-
Well Contractor Company Name �\ 1
STREET ADDRESS 35\ kw Le(ceSiwk 1.4(23
Nsi1e.,J 1‘.-L_C 1.) o 6
City or Town State Zip Code
(cab )- a64 - 3 581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ft(il applicable)
STATE WELL PERMIT/(A applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply D/
TIME COMPLETED 1 3 u AM El PM@'
DATE DRILLED
3. WELL LOCATION:
CITY: I A RV e. LLD
COUNTY 'GUN COM t)
tlu AT CcU2 cryrzcH s'r.
(Street Name. Numbers. Community. Subdivsion. Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley (syr tat ❑Ridge °Other
(check appropriate box)
LATITUDE 3 r7C 5.a011
LONGITUDE 9 'Z ' •A3 • S v5 /
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: tgePS °Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this tom, 7 not using GPS)
4. WELL OWNER / .�
OWNER'S NAME (mot-I(Z1S t, tL1CIL
STREET ADDRESS V /+ TIZA otS aJ /
ASdlt-t-e
aSta5
Slate Zip Code
(QU(‘ )_ by1 agog
City or Town
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOD/
6o
'45
c. WATER LEVEL Below Top d Casing:
(Use's' it Above Top d Casing)
FT.
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): D METHOD OF TEST 11,16- A IFL"
4er
1. DISINFECTION: Type � q 0 u Amount
g. WATER/ ZONES ({d{epth)p.
From } L'l To 1 b'S] From To
Fron To From To
From To From To
O D Z
6. CASING:
AA Depth
From 1 Tom
From
From
To
To
7. GROUT:.I Depth
From J. To ao
From To
From To
FI.
Ft.
Ft.
er
Thickness/
giczi
Material Method
Ft. CIMCST t u12.J;b
FI.
Ft.
8. SCREEN: Depth Diameter Slot Size Material
Fron To Ft. in. in.
From To Ftin. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
To
To
Ft.
Ft.
Ft.
Size Material
10. DRILLING LOG
From ; To / Formation Description
— _tor ov€v-dgci2b 1-�
\b-1 '— \b.% e_g6 — $3 C:L'M
L% a45/ G 12..$1 v 1—rc
11. RENIARKS:
!V
ai
1 DO HEREBY CERTFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCT)DN STANDARDS, AND THAT ACOPY OF T115 .
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(1Z-Z kitRi '1 Q d /cob
SIGNATURE 9F CERTIFIED WELL CONTRACTOR DA E
SIGNATURE/DE
t)ASetA
PRINTED NAME OF PERSON CONSTRUCTING THE WFI I
Submit the original to the Division of Water Quality within 30 days. Attn: Information maEC E IV E FDm GW-la
1617 Mail Service Center —Raleigh, NC 27699.1617 Phone No. [phone] ext 568. Rev. 7/05
FEB 07 2006
Asheville Regional Office
Ani,ifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2.4 "3 to
1. WELL CONTRACTOR: - f. DISINFECTION: Type .1\..5 Amount 20
Decv:CM. tiee'C:-- :1C�4J``2i5 9• WATER ZONES (depth):
Well Contractor (Individual) Name From To From To
CA 1e f a -i£CS jQ('\ VJ@\\QIt:\0:hi\ From To From To
Well Contractor Company Name From To From To
STREET ADDRESS VA.OUS Hta1 aOC\
Not a et.rarNs NC - ace -via,
City or Talm \,$lath -Zip Code
(Cloav,)_ talon- aon.
Area code- Phone number
2. WELL INFORMATION:
SETE WELL ID Mir applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ID
DATE DRILLED /'//— L (y
TIME COMPLETED I i O U
3. WELL LOCATION:
CITY: CO17 cq..pr^ COUNTY
609 Loeoj t toe
(Sheet Nan, Number:, Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC/ / LAND SETTING:
CQSlope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
AM 0
PM
6..0 onr pp
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: OOPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form not using GPS)
d. WELL OWNER
OWNER'S NAME JO%.t CSCC
STREET ADDRESS a9 Eesr 9;tc eda a LQK.e
ti;S),,e. \\e )uC fga05
City or Town i State Zip Code
( Sam )- aag Lkaia
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: VoS
b. DOES WELL REPLACE EXISTING WELL?/ YES 0 NO
c.O WATER LEVEL Below Tap of Casing: Q Fr.
(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)' 3o METHOD OF TEST P.: 5
6. CASING: Thickness/
Depth Diameter Weight Material
From / To/63 Ft (a L.A 1k Z.\ T\es?.,C
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 0O Ft. ePJ nQ�„_ pp used
From To Ft �"�
From To FL
8. SCREEN: Depth Diameter SIA Size Material
From To Ft. in. in.
From To Ft in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRIWNG LOG
From To
/ Jo)
Formatioi Description
Ov QC' (, rdorl
/o3 VaC (7C0.f, tQ
RECEIVED
CO
MAR 0 8 MR
1
Asheville Regional OThce
Aquifer Protection
0
1 . REMARKS:
I DO HEREBY CERTIFY THAT T115 WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTOR STANDARDS, AND NATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
//
SIGNATURE OF CERYI DWELL CONTRA:TOR DATE
DES .CK Hrkt ,n SaWyE-«
PRINTED 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.
Farm GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualit}
WELL CONTRACTOR CERTIFICATION # a`13b
1. WELL CONTRACTOR:
CI CS CZ CM. liea.'s\. ctc.ltCS
Well Contractor (Individual) Name
C\ wales
Well Contractor Company Name
STREET ADDRESS \\A` S wzi Lary
\aot 5 r NC- acely3
City or TdYn �,$tal� --Zip Code
( ,aQT)- tobS- aael
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID #fd applicable)
STATE WELL PERMR#feapplicabs)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED /-
TIME COMPLETED / # 0 U AM p PM Fa9�l
3. WELL LOCATION:
CITY: 'Ejj\-et1.\\' COUNTY &fir"mode
/3-a4057(� S}oore rcye5 Cataa0k\
(Street Na m Marie. Nurnberg. Community. Subdivision, Lot No., Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
QS`lape ❑Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(bcatbn of wet must be shown on a USGS topo map and
attached to this form t not using GPS)
4. WELL OWNER
OWNER'S NAME \' \. ,\ 'T4 innp
STREET ADDRESS PCTThp54 "ooC\
May be in degrees,
minutes, seconds or
in a decimal format
fAsNe t\ v._, l• 28Rn(o
City or Town State Zip Code
(Sas )_ a3\- aslQ
Area code - Phone number
5. WELL. DETAILS: /
a. TOTAL DEPTH: co 0 S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 5fi
c. WATER LEVEL Below Top of Casing: 8o 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): / METHOD OF TEST
f. DISINFECTION: Type O. \\S Amount a
g. WATER ZONES (depth):
From To From To
1/4 ;Sot WQ" pc:\I.aCt Fmm To From To
t� From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From / To 2 7 Ft. (p +a Ltc Z.\ T \ 0.5\'',C
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To b Ft. e FP friC ,
From To Ft.
From To Ft
Method
8. SCREEN: Depth Diameter SIri Size Material
From To Ft. in. b.
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. DRI WNG LOG
From To
37 [„cj
11. REMARKS:
Formatioi Description
Ovtc- (3\Araon
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND 1HATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE W LOWNER.
SIGNATURE 0 CERTIFI WELL iiTRACTOR DA
K 1 Ci So.\JyeAS
PRINTED NAME OF PE ON 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 # 24
1. WELL CONTRACTOR:
tcc :c lK \L. Sotayecs
Well Contractor (Individual) Name
C\4e Saw ecs h SOn
Well ontractor Compahy Name
STREET ADDRESS I48R 5 Kam) 209
kot 4.3 8t)roc 98143
City or T State - Zip Cale
( Bat - totsS- aaaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(, applicable)
D WQ or OTHER PERMIT Skit applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q"
DATE DRILLED t- Ot.P /..
TIME COMPLETED 3..o-o AMO PM p'
3. WELL LOCATION:
CITY: (7-• a M cn3t l• - COUNTY (' triv• es valet.
ry+naYtL �O '9 kcAe (sutra e�
(Street Name, Number, Cacmunity, Subdivision, Lot No., Parcel, Zip Cafe) -
TOPOGRAPHIC / LAND SETTING:
❑Slope Walley 13Flat ❑Ridge DOther
(check$ppropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER
OWNER'S NAME Kt 4, Cats. A
p
STREET ADDRESS C O eNX -)1gtro
May be in degrees,
minutes, seconds or
in adecimal format
S ?t‘.Y, nlc O 1s(0
City or Town State Zip Cale
(RaR )- (,,Q(0 • RBa\
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: tiOS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (.g'
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 aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �Z METHOD OF TEST R.A
f. DISINFECTION: Type P' 1( S
Amount ?8
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Thickness/
FromDe\ TTo t%2 Ft. th ba�eter 4 h;t, Material
Fran To Ft
From To Ft.
7. GROUT: Depth Material Method
From Q To 1O Ft. C.CYwto ?ot>ce..
From To Ft.
From To FL
8. SCREEN: Depth Diameter ShI Size Material
From To Ft. in. in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
5 From To Ft.
10. DRILLING LOG
From To
9a
pia 40S
Formation Description
Oyty Cy+uctiesA
G corn,}e
nccciv
MAR 0 8 20
r'*1
t
A.hevilla Raglon-
otec
II. REMARKS:
0
L)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrnl
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. ANC THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
gb -COD
SIGNATURE OF C RTIFIED WE CONTRACT e' DATE
F1e iO '.So
PRINTED NAME OF PERSON CONSTRUCTNG 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 # •a 14
1. WELL CONTRACTOR:
p
Well Contractor (Individual) Name
\(4.0 n1ka-1 C4\LOW _\—
Well Contractor Company Name
STREET ADDRESS
51164tL_L
Otx.--L-I eJ 6tI+$
36j Feu LBiC Stsi R /
a C a%c6 c (0
City or Town State Zip Cale
(fi yv-34-3cA
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#n: applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED \ — �.i1 ` 0 (0
TIME COMPLETED \ O AM J PM ❑
1. WELL LOCATION:
CITY: COUNTY \w,vi J^^•>L,
OC C(Le,by— kt
(Street Name, N tiers. Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
CI Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 36
D'3L. Q31-
LONGITUDE,j a o 4' • 6a'
May be in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: OIFTPS °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 OAJto � -`
STREET ADDRESS `DLA 4i( l-jC 1:eit OI`r�
LeiCftS-flAaSAar
City or Town
State Zip Code
cba%>- a�5-63
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 O S /!
COb. DOES WELL REPLACE EXISTING WELL? YES 0 NO EJ
c. WATER LEVEL Below Top of Casing: t0 FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING 15 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): '1S METHOD OF TEST rtCti1�
g
y c;
DISINFECTION: Type II lid LtD/c Amount I< 6 Z
WATER ZONES (depth): T/
From VI 0 To 9-kE From To
From To From To
From To From To
6. CASING:.[ Thickness/
From % DTothei Ft. i�riteter SalDhtl Material
From To Ft. // LLdd "( Y
From To Ft,
7. GROUT: Depth Material Method
From To a O Ft. L rip 1/4C^.
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
Size Material
Ft,
From To Ft.
From To Ft.
10. DRILLING LOG
Fron�ny To r Fgrrnation Description
_ 4 a rt t\ b - f rz
- 1 6 d — o11O ' G0_A^11-t•
,ale x'3V1- e72adLCZ — 15 C47'10..-1
an'- 3cs I c2-raNtTE"
RECEIVED
MAR 0 8 2006
A3hcvillo-Regional Office
Aquifer Protection
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.
i �_04u.Qg �- 21-0b
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
\_\kg• (JA
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 it a‘ 4 L"
1. WELL CONTRACTOR:
Re BEN L-A L;e�l_
Well Contractor (Individual) Name
12E,1% 3ti CA t.oi,CL-}.L—
Well Contractor Company Name {{{
STREET ADDRESS 351 i't- Lt (tl 'Sit o ill
Sl fV tJL 3.(t C
City or Town State Zip Code
(sa(,- at4 7)5
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 ('-�. 5 _-
TIME COMPLETED Il - 3 -J AMg PM❑
1. WELL LOCATION: f�
CITY: --u1CA-'S1G1L- COUNTY U;JCOMf�(;
AI%1c( sIL .% 1
(Street Name. Numblers. Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LApD SETTING:
❑Slope °Valley gtlat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 3 t= . S4- I
LONGITUDE j
Latitude/longitude source: stPS °Topographic map
(location of wet must be shown on a USGS topo map and
attached to this foram l not using GPS)
4. WELL OWNER
OWNER'S NAME
May be in degrees,
minutes, seconds or
in a decimal format
(agtt_005 tNC
D D
STREET ADDRESS CaO �1(� el 1- tiNts 9-4)
y.,k3-\ C e 51!3 g--ipl G a1(1 4-4,;
City or Town State Zip Code
(Y > `acic _ 3563
Area code - Phone number
5. WELL DETAILS: ��1T -
(Col,J /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO FJ
c. WATER LEVEL Below Top of Casing: Z 0 FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING IS 11 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. !T
e. YIELD (gpm): METHOD OF TEST 21 � A
a. TOTAL DEPTH:
1. DISINFECTION: Type f 't I k ((O / Amount 1 2 c Z
g. WATER ZONES (depth):
From IV G 1
To O 1..
From To
From To
6. CASING:
Depth Dia
From To aS FLjy
From To Ft. 77
From To Ft.
From
From
From
To
To
To
Thickness/
eter Weight Ma1epal
swat Qv v
7. GROUT: Depth Material Method
From 1 To a Ft Ct v ,N)r -t,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 Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From i
T(�
"). `- 3 0
Lo'—
`h L^ Ifc)
1 1
Formation Description
Cjcaa ,"L-ESba)
tc
C. CLe f 1 C OPin
C� LA 1T L=
RECEIVED
MAR 0 8 2006
m
Aattevllle Regional Office
Q^ Protec
11. REMARKS:
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.
ik_suuLk,e.." Cc.32 .L,L;t4 I 'I OL
SIGNATURE OF CERTIFIED WELL CONTRACTOR DAT
4/21 t__t—i iJ ASA
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 #
1. WELL CONTRACTOR:
\P-)U! C ALOLL) e,L.L,
Well Contractor (Individual) Name
(CLU ae tv C ALb bib LL \-tLt-i13G It.�C..-
Well Contractor Company
Name �J
STREET ADDRESS 351 t4(r3 t1C€JIBk I /
AS 4 E4 ts--Ly; c
City or Town State Zip Code
(c‘31i> 3\64 - 3Sg1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i/ applicable)
STATE WELL PERMIT#(ilappiicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appll able Bo ): Residential Water Supply p/
DATE DRILLED t / I 'a/'O (C
TIME COMPLETED Z - -, o AM0 PM12/
3. WELL LOCATION:
CITY: PA I Pi) 6, b`) COUNTY GNC"t`AU
. C-: LeS ev/w S G"•-c/E
(Street Name, Numbers, Community. Subdisisian, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat ❑Ridge °Other
(check appropriate box)
LATITUDE 3 5 ° jt . S14
LONGITUDE `_ 1,1 • 3 1 b
Latitude/longitude source: DGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
CA L i-1 11RJ) , 1C c t' 42 u` m;',
STREET ADDRESS 41I 4 Cf.D '+1ALJ Caeg Ago
As+RVILLts 14c. asgc5
City or Town State Zip Code
cBaK >_ -31- )Ic
Area code - Phone number
5. WELL DETAILS: /� 1
a. TOTAL DEPTH: 0 5
b. DOES WELL REPLACE EXISTING WELL? YES
YES ❑ NO
b c. WATER LEVEL Below Top of Casing: 0 FT.
(Use'+' i1 Above Top/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): 15 I
ar4o
1. DISINFECTION: Type •1 I
g. WATER ZONES (depth):
From 143 To 144
From To
From To
From
From
From
322G90
Amount 3 1:4z -
To
To
To
6. CASING: Thickness/
4 Depth n0 Di h.1er Weight t�J�dl
From i To °S Ft. �n t5 . D(_ U
From To Ft.
From To
Ft.
7. GROUT: Depth Material
From =i 1 To a u Ft. aemLs r
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 FL
From To Ft.
Size Material
10. DRILLING LOG
From _ T!7
4-3' -t 144
0-1-/- °i o b'
Fohnatio Dec�n
D fJ
GA.Sta4'Tt�
CRcVtCC—I5 GPm
G$ Ar.1iYE
RFC:FIVP0
8 20ub
'1
I,I
r rT
A�t1e1/itle Rdyional O(fi
aui er rotentinn
11. REMARKS:
0
r„
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ei ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER rn
R ,r C4dLt.27/ob
SIGNATURE OO CERTIFIED WELL CONTRACTOR TE
JJI LL € (j S'41
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -AA Division of Water Quality
WELL CONTRACTOR CERTIFICATION # O' I 4- �=
1. WEL((L CONTRACTOR:
S<k'_vG LS.0 CAL -Of L
Well Contractor (Individual) Name
Mt, L j e. iv (LA L.i7t: EA.Ac Og\1/4-1.1tcC I NC
Well Contractor Company Name i
STREET ADDRESS -151 fit :b` Li:: (Le vtdL �iL5
j>,Sju�i�LL r� �b$G6
City or Town State Zip Code
(%_ CS )- am- - 3, M
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 1Box): Residential Water Supply ❑
DATE DRILLED i 1 (1/ 0 L /
TIME COMPLETED \ i - 5 c AM p PM ❑
3. WELL LOCATION: / (�
CITY: i((V5ii%�1 LLF: COUNTY IVL�.nI!i�
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, bp Code)
TO RAPHIC / LAND SETTING:
Slope DValley ❑Flat °Ridge ❑Other
(check appropriate box) q
LATITUDE 3 SI _r" 2)5- I
E % zJ�`F�
LONGITUDU. 321
May be in eleven,
minutes, seconds or
in a decimal format
Latitude/longitude source: dGPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form mnot ushg GPS)
4. WELL OWNER
OWNER'S NAME �—,� S Li L` 0 A � i S
SKEET ADDRESS P. C • c t` ^ 1 -1 (2.,t, ",3-s" Y3
)5Ntti4ILLC 1-A.-
City or Town State Zip Code
(C/ u )- aCf - 6Ci b
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: k c 5 /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
c. WATER LEVEL Below Top of Casing: FT.
(Use N.' if Above Top of Casing)
d. TOP OF CASING 15 FT. Above Land Surface'
rmi 'Top of casing tenatedlat/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118./1(nl /n1
e. YIELD(gpm): METHOD OF TEST i.I I; - I`11v
322689
1. DISINFECTION: Type I- 114 '1C/<-7, Amount
g. WATER ZONES (depth):
From Ja :: To I
From To
From To
6. CASING:
From
From
From
To
To
To
Thickness/
From _L DToth l kp? eler
J Ft 'jprgjd ale jyk�
From To Ft f: UK �I
From To Ft
7. GROUT: Depth i, Material
From To aJ Ft. LC rive 'IC
From To Ft.
From To Ft.
/1 Method
f 4 t: ,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
From
From
To Ft.
To Ft.
To Ft.
Size
Material
10. DRILLING LOG
Fro , To ,r Fprmation Descriptjon
- JAo
Vat:1- a.bo"
3LEi'
i•- C 5'
L&2 tc>l <C
L%SiC� - a C�'.r.
RECEIVED --
MAR O R 2006
T
rn
Asheville Regional Office
--AgeiferPretectirn
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
21-aklan,o�Gi
SIGNATURE CERTIFIED WELL CONTRACTOR DA E
[5 i L1 I e, 13PVS,1�
PRINTED NAME OF PERSON CONSTRUCTI G 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 # o'Z'13to
1. WELL CONTRACTOR: f. DISINFECTION: Type '.\\ `J
0 e ,; ct , it e 0.fih k0.+a`` Q<'S g. WATER ZONES (depth):
Web Contractor (Individual) Name - From To From
C\ 1 de �Snwry,ecs 3/4.son we..\\ 4�C:\4:ny From To From
Well Contractor Company Name �} From To From
STREET ADDRESS \'Aa$.5 \5113. &OCt
\sot S ec:to,S NC. - atevAz
City or T \Stat --Zip Code
(aagJ- Lobs•- aon.
Area code- Phone number
22 WEU. INFORMATION:
SITE WELL ID An applicable)
STATE WELL PERMIT#orappkcable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appbcable Box): Residential Water Supply 0
DATE DRILLED i Y ^ cP
TIME COMPLETED o7i CIO AM ❑ PM 9--
3. WELL LOCATION:
CITY: L--:r_ rat r COUNTY i>b
C t, 09�y be
4\eY o."(AQV (Ya
(Street Name, Numbers, Cmrmunity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
I3Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we#must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER
OWNER'S NAME M; 1(a 1.J Q\\& ("-
'gag (Old Le: ce. -er Hw7
agony
Zip Code
STREET ADDRESS
F\ Stne tit l\e
City or Town
Nte
State
(8a% >- ant 1-14`1%
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: % 427ji C
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing: #576 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.
e. YIELD (gpm): /e METHOD OF TEST
6. CASING:
Depth
Frame_ To y5) Ft.
From To Ft.
Frorn To Ft.
7. GROUT: Depth
From Q To D O Ft
From To Ft.
From To Ft.
/Diameter
V 4
Material
Amount / Q
To
To
To
Thickness/
Weight Ma]terial,��,
"et -S, r f
Method
8. SCREEN: Depth Diameter SITt Size Material
From To Ft. in. in.
From To Ft. in. _ in.
Frorn To . FL in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft
From To Ft.
10. DRILLING LOG
From To
8• S. .2as
Size Material
Formatiot Description
Ov2c (3vrcdor�
(7C AY1• to
__ RF CEIE� V
MAKE 20
AShevdia ' =yiona
• • ote
n
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT COPT OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/ y
SIGNATURE OF CERTIFIED NTRACTOR DATE
& v:CAA. 'tktGet Ns. So.T.„vyc.c6
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

1
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Res
�Qtu' eels Division of Water Quality - Groundwater Section
T
WELL CONTRACTOR (INDIVIDUAL) NAM (prirMM�innt)pi.(-[TkI��( �(7{/w,('VJ��/ ���t�J I, ty `(�, CERTIFICATION�tXpX!10�Vp�
WELL CONTRACTOR COMPANY NAME f% llk✓b'1TIY �l�r at(�l_1..IY�t1Y� PHONE#•�%4 xOAITI
11 ,, ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT#
(if applicable) (if applicable)
9 lc'
its
1. WELL USE (Check Applicable Box): Residential lE Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCAT N:
Nearest n: \C MQ,
3Cv b um
Cot
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: 0.3 t. Z"
Address
lsis14
(Street or Route No.)
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED I-
Zip Code
-O(0
5. TOTAL DEPTH: d5-( /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13
7. STATIC WATER LEVEL Below Top of Casing: Ci O 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 accords ce t ISA NCAC 2C.0118.
YIELD (gpm): �� M T OD OF
Topogra and setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Nat /IQn .RD el, gc�ati
�� U/02� .OHO
(degrees/minutes/seconds) city,cp..��-
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
9. TES G-_ iCi
0. WATER ZONES (depth): �� al d�
11. DISINFECTION: Types-1-1 L e Amount C..-
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To CC% Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Method
From Fo 1-1
From To Fl.SliLi
14. SCREEN: Depth Diameter
From To FL in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From l o Ft.
Slot Size Material
in.
in.
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.
I6. REMARKS:
1 DO HEREBY CERTIFY TH. T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRU TION STANDAijbS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONstttiCetiti$re-
Sumfit the original to the Division of Water Quality Groundwater Section, 116336Mail Ser
27699-1636 Phone No. [phone], within 30 days.
FEB 13 2006
Asheville Regional Office
Aquifer Protection
/
DATE
ce Center - Raleigh, NC
GW-t REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources'/ - Division/of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) .NAME((prriinn/t))♦JcJ f/ %� 1 CERTIFICATIIO/N#pp"'-C�.
3.
WELL CONTRACTORCOMFANY NAME PP ITN-7/l�/v Y` �,J�•Y PHONE # (kt100 (�•lt/tDt
STATE WELT. CONSTRUCTION PERMITS I ASSOCIATED WQ FERMI
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential le Municipal/Public 0 Industrial O Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOC.4TI,ON:rusS{c� �_ Q`
Near Town: �p,„,yy�� tJ Counq te.AJC -
1.0(,3 - ,f1~ANN - -T\. d. -1-'4 K
(Street Name, Numbers, �Coinmunity,, Subdivision, Lot No., Zip Cade)
3. OWNER:NQ)1 ^` � 1�A
Address 135 1-1Q.2.1Z n r,
��/IL (Street or Route o.)
is v_4VWt kJ t4 . aSS Bb (
City or Town State Zip Code
( )
Area code- Phone mmmber
4. DATE DRILLED I. *0 CO
5. TOTAL DEPTH: 05
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L9
7. STATIC WATER LEVEL Below Top of Casing: q 0 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
variance in accordan a with ISA NCAC 2C .0118.
n
10. WATER ZONES (depth). -/
DISINFECTION: Type 1A61.
11
12
Amount �—
CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To I (0 Ft.
From To Ft.
From To Ft.
13. GROUT: Dept
to o Ft.
From Fo 1sk Ft.
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 1 o Ft.
ographic/Land setting
tdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
La[i[u)ies/l o �a awe!! ��A
N 3S Lou Ll W ^p (I(j l
(degrees/minutes/seconds) EtEV, 02 t
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.
CD
u-I
16. REMARKS:
I DO HEREBY CERTIFY THA-�j THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
WC CONSTITION STANDAR , AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c j_zo—d
DATE
SIGNATURE OF PERSON -ea
RECEIVED
Submit the original to the Division of Water Qua ity, Groun water ection, 1636 Mail' crevice Center- Raleigh, NC
YIELD 9. (gpm): METHOD OF ?'.FtST\Sa C. e� %� � ti( e5
27699-1636 Phone No. [phone], within 30 days.
FEB 13 2006
Asheville Regional Office
GW-1 REV. 07/2001

a' 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -I /Division of Water Quality - Groundwater Sectio[n�r
WELL COS'"fRACTOR(INDIb'1DUAL)NAM (print) [A� 1 I{(I� j�j• CERTIFICCA�TIION#�(a6)6a
WELL CONTRACTOR. COMPANY NAME 4p pN Min m t cil i.•%1 \1M PHONE #(\dt>)603 1 aa3
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(ifapplicable) / (if applicable)
1. WELL USE (Check Applicable Box): Residential `ll Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION• Topographic/Land setting
Nje LW idge ❑Slope ID Valley ❑Flat
crest Town: • Coun*9
(Street Name.. Numbers,pCoonnununity,,.(S.ubbddii�vision, Lot No., Zip Code)
3. OWNER: {V�-'v��•"'�!^'��. U�-� (degrees;minutes/second.,) E�
Address 16 �` Latitude/longitude source:❑GPSOTopographic map
(check box)
DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
( )-
Area code- Phone number rrm�
4. DATE DRILLED I— 04
5. TOTAL DEPTH: 3N51
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: CO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
(Street or Route 'No.)
titO; 4 t Rc. actEa‘
oco
"Top of casing terminated at/or below land surface requires a
zvC
variance in accordant rich ISA NCAC 2C.8118.
9. YIELD(gpm): MFjQpOFTES'Il7QL•ebNeirr
WATER ZONES de h
( pth):
(check appropriate box)
I\Lt t tub,14e1V3icsgi‘
10.
11. DISINFECTION: TypS- Amount C
12. CASING: Wall Thickness
y� Dept Diameter or Weight/Ft. Material
Front v . To 2 C Ft.
From To Ft.
From To Ft.
13. CiROUl': Dcpth_s j�V
From To F TC�
From To i'
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From to Ft.
From to H.
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
O
0)
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WWELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTR ! ION STAND RDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCnefe4
Inuit the original to the Division of Water Quality, Groundwater S n, I Service Cc
27699-1636 Phone No. [phone], within 30 days. � � 16 L JUU
li
Asheville Regional Office
Aquifer Protection
ATE
ter - Raleigh, NC
V-1 REV.07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andNatural,ResourcesJ-ID`ivision of Water Quality - Groundwater Section/
WELL CONTRACTOR (INDIVIDUAL) NAME �{print)
� /1-14e, & ` •A�/(�/'11 (S ���� ttt,,, ��` pp'' CERTIFICATION ptoteS
WELL CONTRACTOR COMPANY NAME / l�jJhllT7l.Yl1U� y\t1(, I1, .�/-t l'1\ PHONE# ?:6G GAS- r 3
STATE WELL CONSTRUCTION PERMIT# h / ASSOCIATEU�I.VQ FERN #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential W I nicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA lop:
Nearest Ti}Xn: 1 i 3 Coun
Ak
(Street Name, Numbers! Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 'I
fitsiwu„a (trees prR uQ to 437.16
City or Town State
Zip Code
( )-
Area code- Phone number I
4. DATE DRILLED I-
5. TOTAL DEPTH: (_StoS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO t8'
7. STATIC WATER LEVEL Below Top of Casing: rot 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
torographic/Land setting
agidge ❑Slope ❑Valley ❑Flat
(check appropriate box) �(� p.cj
l`! c )t de/to, nP�ttn e n well ,gr< t is I OD^
(deggre�e(sIJminutes/seconndds)�'ele(%,
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accordan +rh ISA NCAC 2C .01t8. //JJ ,,�)Comt
YIELD !.� METHOD TESTC?'f'l
10. WATER ZONES (depth):
11. DISINFECTION: Type
9. (Spm)
Amount 0-2—
12. CASING: Wall Thickness
�-^� Depth Diameter or Weight/Ft. Material
Frotr�"'�/ To a, Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To_ F
From To —TT Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To 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.
15. SAND/GRAVEL PACK:
Depth Size Material
1-rom to Et.
From to Ft.
16. REMARKS:
RECEIVED
FEB 13 2006
Asheville Regional Office
4)
C71
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCQ61946f lierRiVilarta4t, WELL
CONSTRUCJ'ION STANDA) DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WGE2LLLL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL IYAT/E /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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a. eek-
1. WELL CONTRACTOR:
Vita •mac T C L(i(.'.i L-
Well Contractor (Individual) Name
gtL s k r+ Citi_otGt,L. 041 Lot* 1 It
Well Contractor Company Name
STREET ADDRESS /61 .;b... Is;rs;C/.o Li.,,/
sl�t��; uC-- .3KBe
City or Town State Zip Code
(())- 54 - 350
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Appli le Bo>J Supply Elesidential Water Supply Oto /
TIME COMPLETED ( AM0 PM p'
DATE DRILLED
1. WELL LOCATION:
'2"
CITY: R A Rr`) PI/JVI�€' COUNT
1�n2-I4 g_
y SjvN(�M67c
(Street Name. Numbers. Community. Subdivision. Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SET)IS G:
❑Slope ❑Valley ❑Flat Ridge ❑Other
(check appropriate box)
LATITUDE 3 a 24.1.33
LONGITUDE J 5 Z1-1 .421
Latitude/longitude source: PS ❑Topographic map
(location of welt must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER ri
OWNER'S NAME l7 c r �y1 I k 11 LL�t1 v`�
STREET ADDRESS 1'1 c LU i-(,Z.t-CT i b i4 w `
.5ihVi L a •ggc3
City or Town State Zip Code
( $a'> 9% ►boss
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? �tYES 0 NO
c. WATER LEVEL Below Top of Casing: 14=' FT.
(Use'+' it Above T,op of Casing)
55"
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aUer below land surface may require
a variance in accordance with 15A NCAC 2C .0118. 5 n q
e. YIELD (gpm): METHOD OF TEST
1
f.
9.
DISINFECTION: Type `-({. 1 0 &Amount
WATEp ZONES (depth):
From 0 To (4" I From
Fran To From
From To From
To
To
To
6. CASING: Thickness/
Depth „ pi r$ter Weio&t
From To -1t 5 Ft. L' 1(Soft(
From To Ft.
From To Ft.
7. GROUT: Depth Material
From -I To ''t O Ft. (-Cyr1F,N 1.
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
*terra'
Method
41417
Depth Diameter Slot Size
To Ft. in. in.
To Ft, in. in.
To Ft. in. in.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From/ To,
C
11;/ — i4c '
14-c = i 4 1'
4(''
Formation Description\\
\/'eta }i u,¢a(j ,'1/4J
C nt11 C
Cio✓tC—l5Gr'm
RECEIVED
r-n
L-,J
1J
m
MAW 2 / 2006
O
Asheville Ragional Office
I1. R o ;'fet?rotection
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 _I/
tZsLAAte-Y. CQJ �t/d 3, ° 0
SIGNATURE OF CERTIFIEDIWELL CONTRACTOR TE
l� 1 LL-t a /NJ 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 V
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a r 4a
1. WELL CONTRACTOR:
Re»,betn QkkAL/e \
/Wpell Contractorndivi aI) Nis, {{����
R-,eh ' Ut 1 k ‘ i K Q
Well Contractor Company Name (JJ
STREET ADDRESS S 13 3 }-ti " gy 4k' J
skkaLug- I.Ic 2r8 86(0
City or Town State Zip Code
tea% )- a 64 x. 35 8 ‘
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i1 applicable)
STATE WELL PERMIT#QI applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check App icable x): Residential Water Supply*/
DATE DRILLED
t�roV)
TIME COMPLETED va r3 O
AMD PM/
3. WELL LOCATION:
CITY: J m eM\ LL( COUNTY OAgn
C ewcc'5 C.AA9b1- (;-esO
(Street Name, Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAyO SETTING:
❑Slope DValley mtiat ❑Ridge °Other
(check appropriate box)
LATITUDE 3 1 4-0 r 1 53
a-5a.1e3
LONGITUDE 0
Latitude/longitude source: 'd6PS °Topographic map
(location of wel 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
:7
OWNER'S NAME Olt '° N r " �+ Sp-n s
STREET ADDRESS b5 t41LL t•
AS1Ag\Rt.Lks PAC- aSSoC
City or Town Slate Zip Code
( $9.$ 1,6a— b4-6 5'
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
YES ° NO (i'
c. WATER LEVEL Below Top of Casing (j ▪ FT.
(Use's- 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. /p�
e. YIELD (gpm): (0 METHOD OF TEST Qi 6 - n I it''
From
1. DISINFECTION: Type 14114 Amount Ci I L"
g. WATER ZONES (depth):
From I "i 4- To t 1 S From To
From 3 6^.. To 3 5 1 From To
From To From To
6. CASING: ,A10 Thickness)
From 1 DepthTog t Ft. Dja ter i t I tvJRteO
From To Ft. �J YYYY
From To Ft.
7. GROUT:A Depth �T _ Material
From 1 To Ft. CgMs-NT
From To Ft.
From To Ft.
8. SCREEN:
From
From
Method
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ftin. in.
9. SAND/GRAVEL PACK:
Depth
Frorn To
From To
From To
10. DRILLING LOG
Frorn i To l
r^5i 1Z4j
1'7s'
-(5 / — 35c
35v 1- 351'
3-1'- 41-05'
Ft.
Ft.
Ft.
Size Material
E Zh V at-a)(z_tt63
e.-ev aJ it
tc —5Grin
C2 OAN1 L�
HrC -IVED
ry
MAR 2 7 jnnfi
r7
s
I I. Asio MMiesRegionai Office
Aquifer Protection
I DO HEREBY CERTIFY MAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND MAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO ME WELL O NER.
.g1»4f' c o A��QQ 4n/©b
SIGNATUR F CERTIFIED WELL CONTRACTOR + DATE
itL\F� ,)&Sj
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- Dnisron ..I sicr Quabn
WELL. CONTRACTOR CERTWICATION M a 57'7
1 WELL CONTRACTOR:
Thk-V a±-
WM Gr. ease (Mmduai Name
6ret-n RIver IAle\\ rikrp
Well Contractor Cowpony Name
STREET ADDRESS Po 3 DX a
East Ia r +Zocj. M (a € co
City or Town Stat. 1 Zip Code
(06 . 615-)zo0
Ares oode- Phone nunter
2. WELL INFORMATION:
SITE WELL ID SRI aparwt..)
STATE WELL PERMITRI .ppoade) aw - o 33S /
DW10 or OTHER PERMIT 6(1 appaabie)
WELL USE (Check Applicata Boa): Residential Wn c Supp1y Er-
DATE DRILLED if o W
TIME COMPLETED I. Do
3. WELL LOCATION:
CRY C•/YL n COUNTY B IA.Ll.C.0I4( Iy'
LoraEctUTL& ft1 dke
ISinel Nana. NumOws. Community,
Sw . Lot No
TOPOGRAPHIC I LAND SETTING.
❑Slops ❑Vaary Ong 3(b94 OOna
(alson •PPrOpMW Oda) .I
LATITUDE •,L p7 Q5ry
LONGITUDE pxz.° I� 171 143 li
)
Latitude/longitude 6otace.*FS OTopowaphic map
(kmadon or wet must be shown one USGS tope map and
Much! to Ole toms / not unv GPS)
4, WELL OWNERnn 1.
AM CI RA 0(...
Parcel. Zip Coos)
May be in &Ftno,
mania soon& or
decimal n a decul form
OWNER'S NAME �1
STREET X-ADDRESS q�O 5 Ski LknTwn 1
Ha - Moim .i& tita q
(`6 LSCay a 1- Co€5- - %mil Suit, Ziacda
Area code • Prior norms
6. WELL DETAILS: � ,yr( tc
a. TOTAL OEPTN: -1 V ✓
b. DOES WELL REPLACE EXISTIN0 WELL? YES O NOV:
c. WATER LEVEL Beaga Top d Crane: /&O FT
(Use': 6 Above
Top d Casino)
d. TOP Of CASINO is _— FT. Abort Land Surface'
'Top d wino tarrnneted Wor beaus. NM aafaa tray require
a wean n accordance with ISA NCAC 2C .011 f
YIELD (opm)'3 METHOD OF TEST I 1
.
I. DISINFECTION Type 111-4+ Amount
9. WATER ZONES--�lo.olrn
From /A0 To1141 From
From To From
From To From To
6. CASINO'.
Depart` Dyartwtar
m FroTo p g Ft G t
From To FI
From To Ft
To
To
T hckness
Wegm Maw el
7. GROUTDepth Motional Mamwd
L
From_ To 2L.f7 FI (g1 K
From To Ft
From To Ft
6. SCREEN: Depth
From To
From To
From To
Demeter
Ft
FI
FI
51c4 Sae Matenal
n
9. SANDIORAVEL PAC
Depth Sae Motional
From To FI
From To Ft
From To Ft
10. DRILLING LOG
from To
0- H5
RECEIVE
ForrnaDOn Deacrpoon
DiA7--
s 4 �' p : rAG.2F2;./r -
MAR 2 ' 266a
Ashevi Regional • Ice
.. - atecti:
II. REMARKS:
0
0
IREST CERTIFY
WELHT IN ACCORDANCE yeahn.
ISSA KIG 2C WELL COSm,C STANDARDS an0TAa 6
RECORD RRAS BEEN OROvIDEO r EWEt.L AEA
SIGNATUR
—f sDAtL�d' �-/D-Dc
OF CERTIFIEDWELL CONTRACTOR DATE
PRINTE AME OF PERSON CONSTft ACTING THE WELL
1617 within 30
ys.
Mall SarVICS Canterl to -Ralslph, P C Z7699--1Water
6117 Ptl Phone No. 919) 733.7Attn: eato566a Don Mot.,
Form GW•la
Re. 7,05

WELL CONTRACTOR CERTIFICATION
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
al 0
)' 0ft0
1. WELL CONTRACTOR:
C W.I>t.a LL
Well Contractor (Individual) Name
Gi.eThbN C.ALN1,JELL
Well Contractor Company Name
i� tL.L WOG IOC
STREET ADDRESS 51 r3 tSD.: LE Ic• i:Sl-e Nu.
elf Ip,; C
City or Town Slate
(5 'j8 >• a54 - 3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMITS/0 applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED a. "• ;3 tic 1:
TIME COMPLETED 1 u AM ❑ PM '
/
3. WELL LOCATION:
11..
CITY: tv C. T.. 7 2— t ra COUNTY L�L�a/L..c1v.1� V
�Su 4,;I-6 t"4zArt G talc -AD
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
0Slope ❑Valley El Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 -5 'a":) . S dLj
LONGITUDE, .34 - Gd 3
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: grdPS EtTopographic map
(location of web must be shown on a USGS topo map and
attached to this form i not usfrg GPS)
4. WELL OWNER
OWNER'S NAME 00 AL. i) 0 L.-A Gg.w$
STREET ADDRESS ,1.5L 0eem)
A5vltLl7 TiC 1 ti�4
City or Town ( Stale Zip Code
G
(t33 ) QS9�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: L' 0 J
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: N A
(Use -+- 8 Above Trof Casing)
CASING IS•
FT
,
d. TOP OF FT. Above Land Surface'
'Top of casing terminated ate below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST �t G - A
0
f. DISINFECTION: Type "--
i
g. WATER ZONES,,AA(depth):
From t-i 4
From To
From To
Amount
From To
From To
From To
6. CASING:
A_`7J
From + Depth
abr." ter
To Ft /e
From To Ft.
From To Ft.
Thickness/
s cii ( PIM
7. GROAT: Depth Material Method
From ..Z To (i Ft. (G /Ytbt)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
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
Fr rlTo /
1`(7 1005
Foropgtiog Description
0 v(T 3 :;i—A 4—)
GIZAt•-.)ri
tv
m _
o
I I. RE Srik S:
7
I DO HEREB 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 WNER.
2 r c" (fit c CJ %'
l lr /
SIGNATURE OF ERTIFIED�WELL CONTR�1
ACTOR DA0 k:
TE
f�il_t e. AS.I,�
PRINTED NAME OF PERSON CONSTRUCTINTHE 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
fL6 u CA La.;e L_
Well Contractor (Individual) Name
& T1 CALQw;LL.LrillLoa:), Ir
Well Contractor Company Name
STREET ADDRESS '35 i ICI tit w LE_l C eS t i - Htv;
\S I IL Lin ,.c acC(4
City or Town State Zip Code
(54y a 4--3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(ii applicable)
DWQ or OTHER PERMIT #(i! applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 1 /.3 ty
�:.` TIME COMPLETED / 11.`
AM Fj / PM❑
3. WELL LOCATION: 22
CITY: U.-ALAN &4ILUCC COUNTY i=JLN CL, l s4s
,CC VCLQJ ItBLJ (t AD
(Street Name, Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAy,D SETTING:
oSlope ❑Valley aflat ❑Ridge 0Other
(check appropriate box)
e0
LATITUDE t3 5 x)T
LONGITUDE a ? 6
Latitude/longitude source: 124PS ❑Topographic map
fbcation of we# must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
p
OWNER'S NAME iu Lit II� L?jLchli'S4 l,.i�I61
STET ADDRESS (O J G o 1-4.)V I t; (,)
c.,NE`It i tvas' ci-
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:
b. DOES WELL REPLACE EXISTING WELL? YES NO p'
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
i
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated ador below land surface may require
a variance in accordance with 15A NCAC 2C .0118.r
e. YIELD(gpm): toMETHOD OF TEST its\(3--1`�L
I1
'530,,
f. DISINFECTION: Type {` Ili Lt b Amount d c I
g. WATER ZONES (depth):
From - 1 et To a
From
Frorn To From To
From To From To
6. CASING: Thickness/
! Depth S Di,a� eter Weigh Material
From ? To -3 ' Ft. G 1 �, Cur )— Material
C-�
From To Ft. III
From To Ft.
To
7. GROUT:j Depth
From -t To a Ft.
From To Ft.
From To Ft.
Material Method
L.cA'kb.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. in. in.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
Fro p v Tos
Foci -nation Description -,
ySCI C.;.--f (.
lCi A cX y C ' i IZ-Cti ! LU - :- C 4 0,1
rn
v
11. REMARKS
3 e
Asheville Re. io
0u
A.uifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY Op THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1 t i /. /
v��.� �Y3 G
SIGNATURE OF CERTIFIED WELL CONTRACTOR / DAIE
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 # a i`-D
1. WELL CONTRACTOR:
R€UGB •-1 I--Q(JE
Well Contractor (Individual) Name
City or Town State
gas( » a54- - 3 5y 1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
u 4i i3 N! l /` Lo wt\-L f $U LLI a; G) (gw
Well Contractor Company Name
tt t
STREET ADDRESS "35 I N�w Lii l CsIS T ek Ica /
A51-iischt_LE NC ca--gW D6 /
Zip Cale
STATE WELL PERMIT#(t applicable)
DWQ or OTHER PERMIT #(if applicable)
2-afl�
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / SETTING:
❑Slope °Valley II6Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 3 3 O-4-o3
LONGITUDE S a a--- 009
Latitude/longitude source: OGPS ❑Topographic ma
(location of wel must be shown on a USGS topo map and
attached to this form A not ushho GPS)
4. WELL OWNER �(1
OWNER'S NAME &€CLA tiln GS:J
WELL USE (Check Appli ble B x): Residential Water Supply 0
DATE DRILLED a °1 o (o
TIME COMPLETED AM ❑ PM Net
3. WELL LOC TION:
CITY: VII t RJ to w COUNTY CJ°NCOA'tK
SVGA(: I�ai--h w
May be in degrees,
minutes, seconds or
in a decimal format
p
STR ET ADDRESS )1)S AR CrC• int_cts
t\S J \LL.a C �-n 6 6
City or Town State Zip Code
( 95» `a`I`1 —1SI 0
Area code - Phone number
5. WELL DETAILS: - ,1� /
r
a. TOTAL DEPTH: V -T S /
b. DOES WELL REPLACE EXISTING WELL? ❑ NO Y
c. WATER LEVEL Below Top of Casing: Q D FT.
(Use -+• if Above Tay 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 vnlh ISA NCAC 2C .0118.
e. YIELD (gpm): T METHOD OF TEST Q c3 f I I/
f. DISINFECTION: Type
g. WATER ZONES (depth)
From To 1 3
From 3 10 To .3 i 1
From To
6. CASING:
qq Depth1
From 1 To 10
From To
From To
3 J
Amount
From To
From To
From To
0 1{ £1
yThickness/ '�
Ft. Db /*'e r �Wc<-1 Ole
��,i
Ft.
Ft.
7. GROUT: Depth Material Method
From 4 To am Ft. Qeire N-( Otte 12>
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
Frog) / To
- iO
Fo�'^ation Description
6416v2—Obji
OW. IS D / c3t -1
150'-iSi'
vS1' — It 0;
3\0 � 311.'
t\' — 6+5'
c2eftC6- 3 coPn-,
C92stwLT
l2.-134 C-e — 1 G e M
G(ri.Yt %a1 l
RECEIVED
-71
MAR 2 7 200
--Achevilis-E3egional Office
1 . Rlfr Protection
1 D0 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
R-Q USLA/e Ca�ia��
SIGNATURE
OF CERTIFIED WELL CONTRACTOR DAT
L�1ULI�+ t3AS'4
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 # 24240
1. WELL CONTRACTOR:
17eee,cth H. 3c tAyecs
Well Contractor (Individual) Name
C\vtde Sa•Aecs k Sorg
Well Contractor Comp&iy Name
STREET ADDRESS t48415 ALA) Roci
No} 5ac;ra� 7 NC 9 8 143
City or T&&w"n ' State = Zip Code
(bag> totes- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#fd applicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED 02 '-8-
TIME COMPLETED / r VS AM O PM Et-
3. WELL LOCATION: , //
CITY: 4SAPPi 2? - couNTY/FGre/Co,nL
dereA Greif- %)r, Lei .5
(Street Name, Numbers. Community, Subdivision. Lot No., Parch, Zip Code) -
LTOO�PO���GRAPHIC / LAND SETTING:
lyowpe OValIey ['Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER
OWNER'S NAME 3k'e'e tJ v.ae.0
STREET ADDRESS R3\ -aid (1 fait\cj tkorne
F1iheV'.tte NC- 9SSArItn
City or Town i State Zip Code
(RAP:)- a\5- 2$a5
Area code - Phone number
May be in degrees,
minutes, secondsor
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: b S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO a/
te
c- WATER LEVEL Below Top of Casing: 70 Fr.
(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):.-(0 METHOD OF TEST R.A
324341
f. DISINFECTION: Type er 1 t 5 Amount l 7
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
/ Depth Dia�etN er Weight Material
From ! To FLY Jam(/ f 2" rite,
From To Ft.
From To Ft.
7. GROUT: Depth Material
From () To .aO Ft. C-ctnont
From To Ft
From To Ft
Method
. c_P a
8. SCREEN: Depth Diameter Sot Size Material
From To Ft. in. M.
From To Ft in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Frorn To Ft.
Size Material
10. DRILLING LOG
From To
/ S_
11. REMARKS:
Formation Description
rxr dar (leer
sheville Regional Office
Aouiferr r rotection
I DO HEREBY CERTIFY THAT 1NIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, N1 THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO Tye WELL OWNER
02- F-4
SIGNATURE OF CERTIIFFIELLWELL CONTRACTOR DATE
/Orr.,etc 1t Y&4 .A' S4wyer5
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. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION $f
1. WELL CONTRACTOR:
1� ¢.-Cv c1K \k, Sots`fec
Well Contractor (Individual) Name
pi e Sava e<s k Sots
Well dontractor Compdhy Name
STREET ADDRESS C^18f3 5 Kta7 aGFt
tkot 6c:.t55 y Nc 98-143
City or T Stale - Zip Cale
(Bag )- (0(as- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(5 applicable)
STATE WELL PERMIT#(aapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED oQ -
TIME COMPLETED 7'00 AM 0 PM IW
3. WELL LOCATION:�///
CITY: �t S!'K [l.l� .. COUNTY /SG trr Om'�P
C ecc' (eil /C Z. Lok-(o
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) -
TOPOGRAPHIC / LAND SETTING:
�bpe oValley ['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 fon n:not using GPS)
4. WELL OWNER
OWNER'S NAME Ske'Ve 5t ar)V zr
STREET ADDRESS WM- OW Cou.tt-tc / 1,Ovite
ftotte.f, tte 1r. aRSQ rn
City or Town State Zip Code
( eaa ats- a8OS
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 8-.5-
/
b. DOES WELL REPLACE EXISTING WELL? YES ° NO @'
c. WATER LEVEL Below Top of Casing: 70 FT.
(Use'+"d 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 .0115.
e. YIELD(gpm): 30 METHOD OF TEST lCt
324342
I. DISINFECTION: Type P`ItS
Amount /9
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Depth Diaeter
From / mTo 7,1 Ft. (. 4
From To Ft.
From To Ft.
7. GROUT: Depth
From_ To QO Ft
From To Ft
From To Ft.
Thickness/
7 21 tf7 ale
Material Method
e� Ott. otj cea
8. SCREEN: Depth Diameter S et 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 Topp� Formate' Description
over netre(./2
93 Jcrs
11. REMARKS:
(ra..s ;IT
Asheville Recitanal Office
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AN3 THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED W
TRRCTOR
a-7-(
DATE
Oer.r C� X,c.4 Scttuy C/J
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 RECbRD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 24 no
1. WELL CONTRACTOR:
ecc,c1K\k. 3c cyeSs
Well Contractor (Individual) Name
£1 wk SL.A CCS k Soc\
Well ontractor Comptry Name
STREET ADDRESS 1M8R 5 Wt•s1 aoR
Floc ` c 3 N�C a 8'1L 13
City or T 4-3State= Zip Code
( Bag )- (acts- aoaa-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(aappltcable)
DWQ or OTHER PERMIT #(if appricable)
WELL USE (Check Applicable Back Residential Water Supply O
DATE DRILLED /-30- 4
TIME COMPLETED Vied d AM O PM C-
3. WELL LOCATION:
CITY: G..C/r//�� - COUNTY arrn/
Cree en D.
(Street Name. Numbers. Corrmunay. Subermion, Lo'. No., Parcel. Zip Code). -.
TOyO GRAPHIC / LAND SETTING:
164510pe °Valley ❑Flat °Ridge OOOcer
(ehedc appropaaie box)
LATFRUDE
LONGITUDE
Latitude/longitude source: ['CPS °Topographic map
(bcafrr of wel must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME Vice\stvett
STREET ADDRESS .1\ ove'taotr. Lan
May be in degrees,
minutes, seconds or
in a decimal format
CfsnateC PC- a9P1
City or Town State Zip Code
(RaA > 9-N3- 38'1L1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: CCWS /
b. DOES WELL REPLACE EXISTING WELL? YES CI NO re
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS ` FT. Above Land Surface'
. Top d casing terminated at/or below land surface may require
a variance in accordance with 1SA NCAC 2C .0118. e. YIELD (gpm): T20 METHOD OF TEST Q:.W
324343
f. DISINFECTION: Type Pi lit S Amount / ?
g. WATER ZONES (depth):
From To From To
From To From To
From To From_ To
6. CASING: Thickness/
�i �
From_/To Depth (c/ Ft ("/y W c.'i
From To Ft
From To Ft
7. GROAT: DepthMaterial Method
From 0 To 2O Ft C.Cmr>ttt ?Cu Clerk
From To Ft
From To FL
& SCREEN: Depth Diameter Sat 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
/ G/
11. REMARKS:
Forrnatit n Description
d uie - C3u . dr't
ti'GI de 44
R E
Asheville Regional Offjce
Aauifer Protection
1 °ORERED), CERTIFY THAT IRS WELL WAS CONSTR ICIED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTOR STANDARDS. AN: THAT A COPY OF THIS
RECORD HAS SEEN PROVIEDTOTHE WELL OWNER
MN/�TIME OF CERTIFIE ELL CONTR;CTOR DATE
PRINTED NAME OF PERSON CONSTRUC1;NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mal Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

4 324339
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2y?(o
1. WELL CONTRACTOR:
beoc..tin\k 5o4> yecS
Well Contractor (Individual) Name
CAyat s ecs a- Sot,
Well Gontractor GompelyName
STREET ADDRESS tM%Ri 5 Wta1 Pact
Flo} f6 cz..g4 p)C o8i43
City or Teem U State = Zip Code
(Bali)- totes- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #('d applicable)
STATE WELL PERMIT#(Rapplicable)
DWQ or OTHER PERMIT #(R applicable)
WELL. USE (Check Applicable Box): Residential Water Supply ID
DATE DRILLED «QQ��-/
TIME COMPLETED SS0 U AM 0 PM Q-
3. WELL LOCATION:/
CITY: (c, J6 r"-
COUNTY U4 hC arrs Ot
&ley -vb %:C
(Street Name. Numbers, Co.Tanunity. StrSdiNaion, tat No., Parcel. Zip Code)..-.
_O[TOPOGRAPHIC / LAND SETTING:
4yafope °Valley ❑Flat ❑Ridge ID Otter
(cheek appropriate box)
LATITUDE 3
LONGITUDE
May be in degas,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS °Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form Inot us/ng GPS)
4. WELL OWNER
OWNER'S NAME b'sI'A Cb .Y.2c
STREET ADDRESS , L1 zr-* G Ilea ytp L.1L -
�t 2re'n IJC 0-W1O`i
City or Tom 1 State Zip Code
(1c1 )- il�al- '%S2,1
Area code - Phone number
5. WELL DETAILS: ;Cr
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES ° NO 29
c. WATER LEVEL Below Top of Casing: 90 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 a fordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST R.A
f. DISINFECTION: Type pi 116 Amount 1/ Cr
g. WATER ZONES (depth):
From To From To
From To From To
From - To From To
6. CASING: Thickness/
Diameter W�''gghNi N]ate�I
From / To 2'o? FL G S 5/Jq,,�l Q/a r
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From To 1O Ft (.'csv ijt POLa MI
From To Ft
From To Ft
8. SCREEN: Depth Diameter S'ot 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
j rya
Formaticn D tion
r CL
tp( Gfs.. G. re, ..1,'ft
11. REMARKS:
I DD HEREBY CERTIFY THAT
15A NCAC 2C. WELL CONSTR r
RECORD HAS BEEN PROVIDED TO THE WELL OW
s evii iiee,ional Offi
WELL r totem
R
SIGNATURE OF C$RTIFIE
n2-/O-Q
LL CONTR-ACTOR DATE
Mee.k.of" /4 '4' So r..yert
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.
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 # \ "r 0
1. WELL CONTRACTOR:
kk.n3 t.J CA LP -n-'-- -
Well Contractor (Individual) Name
9 &t� c-ALoweLa_ NALLA Gt 1st,
Well Contractor Company Name
STREET ADDRESS ,351 Ill ti Ie1cesta- �W
City or Town State Zip Code
(gag' )- a54 eS5 g�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMI(#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check A plicable ox): Residential Water Supply Lg
DATE DRILLED a a% 6
TIME COMPLETED I 0 0 AM O PM /
3. WELL L�Qj C�ATION: /
CITY: cA\ 9IU AO 6SJILL6 COUNTY
Qtcot
0 C,1L UJitf> rJ C.44
(Street Name, Numbers, Community. Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA)ID SETTING:
❑Slope ❑Valley ®Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 S 4'1 • 3 I-3
LONGITUDE 3 9, al . o Oto
Latitude/longitude source: [.MPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form ?not usirg GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME (T -
STREET ADDRESS t' , _ G c%� t
QAQ-ta Av_4S\J tL.l Nc a8 Dq
City or Town State Zip Code
( Ra% )_
Area code - Phone number
D 0 J G 4 t R-
5. WELL DETAILS: 4 /
a. TOTAL DEPTH: , O S
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: b re 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.
e. YIELD (gpm): 3 METHOD OF TEST g.),G - A I fl
324293
f. DISINFECTION: Type 'fFl (‘ Amount g' O •
Fran WATERd3_ To (depth"
p - From To
From 14-, To 4 From To
From To From To
6. CASING:
From 1
From
Thickness/
Depth pameler 'vieioh( sl egel.
To 4a Ft. C7 �a 'f�i t7
To Ft
From To Ft
7. GROUT: e Depth
From 1 To 45)
From To
From To
Material
Ft. C't ratiNt
Ft.
Ft.
Method
a. 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
Fr / T
‘41
14 ' ' 1k5'
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
Fo ation Description
C-, rtn r- t-r 5
c.E, a 6PM
C9 $ j4 TJ 1'-t�Fs
LR-ts\t — 1 GPM
G LA-7'3 iTE1
RECEIVED
Asheville Regional Oft -ice
Aquifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF 111I5
RECORD HAS SEEN PROVIDED TO THE WELL OWNER.^nnn
RoAQS Q C a/a306
SIGNATUR F CERTIFIED WELL CONTRACTOR DA E
1 Lug (xi ASd
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
1. WE L CONTRACTOgi
eabgn l�a cLref I
Well Contractor (Individual) Name
ReAxben (..eJclulell OY'i 1 i n3 111nC-
Well Contractor Company Name
STREET ADDRESS 351 03 ew e.'es--er 11w�
i shev'tl(e NC, aBYd
City or Town State Zip Code
(tag > �4-3sS1►
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 Appl'cable Bor/�: esidential Water Supply 0
DATE DRILLED 'a a 4- / 0 bi
TIME COMPLETED 1 • 31) AM PM(/'
3. WELL LOCATION: n
CITY: L C\N O IS.
COUNTY IOU(IC (11
13C
(Street Name, Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA ETTING:
❑Slope ❑Valley tat ❑Ridge ❑Other
(check appropriate box) f-
LATITUDE 3 aq b "Ifp,
3
LONGITUDE j r
Latitude/longitude source: GPS OTopographic map
(bcation of wet must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME Ynn AFK
(LcQ,i.asofa
STREET ADDRESS 3g63 fin tmeIKc 0 b-
C�ln_Is7)�agt.4_G Vt9.C,)Ni( a4-013
City or Town Slate Zip Code
( 54-0_gR.4-3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: jak4 `=
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ci
c. WATER LEVEL Below Top of Casing: tO 0 FT.
(Use '4" if Above Top of Casing)
d. TOP OF CASING IS le- FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .01pp18.r f1 n
e. YIELD(gpm): I11 METHOD OF TEST Rat V fTl„--,
01q-U
f. DISINFECTION: Type
324292
g. WATER ZONES (depth)_
From 110 To II 1 From To
To From To
To - From To
From
From
6. CASING:
4 Depth
From 1 To 53
From To
From To
7. GROUT: ae Depth
From `i To ra
From To
From To
8. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From To
From To
Ft.
Ft.
Ft.
Thickk�nteesss/ ,�I
D;aaterial
met r Ie1S b JTG €.1--
Material Method
Ft. 0--la th x-1 \I 1 fO ugt
Ft.
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
From To Ft.
10. DRILLING LOG
Fro)n1 f To /
O
\10 tt1
11' lit45'
11. REMARKS:
Formation Description
1/Gp—GuRbi�
c1RANI 1 C.
tVtc:s — 10 GPin
C, 2A ro \It
RECEIVED
Asheville Regional Office
I DO HEREBY CERTWY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCHON STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
Lit.—.' g s•-.i
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mai) Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a-\ o
324291
1. WELL CONTRACTOR:
(Zei.Lben Cu-ILA.P2A
Well Contractor (Individual) Name
(tv-beVl (d&wLU Ori\I‘‘ti5 \Nc.
Well Contractor Company Name I
n `I
STREET ADDRESS 351 NQ w Lek IQ -au -kw
Mhev\\IQ OC a_st Co
City or Town State� Zip Code
c4ag a54 _ 35
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ft(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public l
Industrial/Commercial 0 Agricultural ° Recovery C Injection 0
IrrigationD Other ° (list use)
DATE DRILLED 3/I / 0 6
TIME COMPLETED 1 a 1 3 o AM O PMp
3. WELL LOCATION: ��yy""��"
CITY: Weo.Verv%Af\
11Q COUNTY lCOh�—`
a.4- Stitin r. C. Qr v
(Street Name. Numbers. Community. Subdivision, Lot No.. Parcel. Zip Code)
TO9OGRAPHtC / LAND SETTING:
Slope °Valley ❑Flat °Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Maybe in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: M,PS °Topographic map
(location of well must be shown on a USGS opo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(If applicable)
NAME OF FACILITY STREET ADDRESS `a4 ur G��
\Cin nal-
ki,)ew/civ,lle tic 9-414'I
City or Town N State ZiptCode sJ
CONTACT PERSON i/ ekv.te- '"YO 1R�,�0.Wol
MAILING ADDRES a4 1\"A.a\ r o ,IA t�e-
U�en-vervl\ale �.Tc a-g 1g1
City or Town State Zip Code
(> "\�1-44(5
Area code - Phone number
5. WELL DETAILS: ^
a. TOTAL DEPTH: Co 0 5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top al 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 DISINFECTION:
�1 Eet e F m TEST X z 1. DISINFECTION: Type __f(11110 o Amount !1 b •
g. WATER ZONES (depth).
From To From To
From To From To
From To From To
6. CASING:,(p Thickness/
From y DepthToO D Ft Diameter , WYg)tt 5-,Material
e-
From. To FL b(_ I
From To Ft.
7. GROUT: Depth O gbi-regW ff6 _ /y,��
, Material Method
From To Ft. C,rYVb U
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 r
11. REMARKS:
F rmat''ign Description
cAf
RECEIVED
4.^'7) 1, nne.
Asheville Regional Office
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 7C. 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-lb
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W =LL CONTRACTOR:
�eL<bevt Ca(dwe,l j
Well Contractor (1 dividual Name
f,e.(A.t�en .ck\ wiLlk Ori
Well Contractor Company Name
S51 (\kW l'et
STREET ADDRESS
( shevl\lc Pc -
City or Town State
(SAS')- a54-- 35811
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appli ble x): Residential Water Supply
DATE DRILLED 3 3 6 (t/
TIME COMPLETED 3 J AM PMLd
7
3. WELL LOCATION: 22
CITY: Ln)SAV6%OL-LE COUNTY (1,1)4\1f-4fh86
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LA9.0 SETTING:
❑Slope ['Valley eiat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 4 4.05G
LONGITUDE 8 a 3 4• 36
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: egL,t•S oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form Ind using GPS)
4. WELL OWNER
OWNER'S NAME
k, 04-)-- Lj 1-7_,J1-7_,STREET ADDRESS 6 5 I\ 1 LCLI S -r
sN641L_Le tJc alga
City or Town State Zip Code
(gal )- a5a- b4-b5-
Area code - Phone number
5. WELL DETAILS: 1 /
a. TOTAL DEPTH: 4-0 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
c. WATER LEVEL Below Top of Casing: (O O FT.
(Use -+' if AboveTop of Casing)
A
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): qa METHOD OF TEST R(C A (I�'
f.
9.
at4D
324290
DISINFECTION: Type Try `0� Amount ' 6 Z
WATER ZONES (depth .
From "1 1 To a
nFrom To
From 43 a-66 To 3 a C.,From To
From To From To
6. CASING: Thickness/
,A/ Depth ,t Di eter We tt �Qat� I
From 1 To 6 4 Ft. bJ 51 l iZ t
From To Ft.
From To Ft.
7. GROUT: Depth Material
From "4 To Ft. C. M t3T
From To Ft.
From To Ft.
8.
9.
SCREEN: Depth
From To
From To
From To
SAND/GRAVEL PACK:
Depth
From To
From To
Method
Lela ij
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
From To Ft.
10. DRILLING LOG
Frllom, To / Flom -lotion Descripf
Sq O JO�..400a-ob
69i- 21' V116
ek-('- 4-' CP-6vtCE - a.GPry
�1$ / - -6q 5' C2 12-4 ...T L-F6
e 5t- 36U:.' c..aVtCr — t8 (irM
sat, ' - 4 05; C.)ILA ra t-T 6
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A DOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR / D(ATE
kI L-Le 'NJ As1
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

1395)
Note Carokns - Department et Environment and Nadel Resources - ONNten of Water Gusiy - Oroundwayr Seotton
10* Malt Seneca Center- RYelph, N.C. l7e••-163S-Phene (f1Y) 733-3221
WELL CONSTRUCTION RECORD WELLcoNTRACTOR• ClegxwA Je.e
WELL CONTRACTOR CERTIFICATION 0: 2 if 3
STATE WELL CONSTRUCTION PERMIT►:
1. WELL USE (Cheek Appleebls sea): ReeldenBat2J( Munietpal 0 industrial ❑ Agricultural ❑ Monitor) ❑
Recovery 0 Heat Pump Water Injection 0 Other ❑ II Other, LIs1 Use:
2. WELL LOCATION: (Show sketch of the bealon below)
NearestTown: ASkel)i//a cot.* /ju/VGun[.0c_.
Ae/Ce4-1e/2-. /(w
(Read Marne end Nu nben, et SubdMalen end Lot Nei3. OWNER GICpey r e/-
Address /70 Ca,NeA5 t<cwe /34 Lvc»ooc,
Wes( sr Rene ROT
City r Teem Mate 21p Cent
4.. DATE ORILLED 3-
5. TOTAL DEPTH t/ 4/.5
6. CUTTINGS COLLECTED YES [] NOC7"
7. DOES WELL REPLACE EXISTING WELL" YES Q NOt
8. STATIC WATER LEVEL Below Top sl Casing: FT.
(UM •.• I Mere Toe et Carte)
9. TOP OF CASINO IS / FT. Above Land Surface'
'Top of easing terminated ellr Sew lend modem; requket a vrtenre In mum
dance with 1SA ?CAC PC .11p •
(gamy 10. YIELD (gamy(a METHOD OF TEST
11. WATER ZONES (depth)•
CRILUNO LOG
From Te
/—/4.0
DEPTH
i2nneMen DenMpuen
O //r' b SA,) d
rya -360 RN;��
? 60- 3 b / 04 go ./ L-C.
12. CHLORINATION: Type Amount
13. CASING:
Well T?iknsis
Depth Dtrnfar r Welg1VR. WNW
From / .To Ft
From To Ft
From To Ft
14. GROUT:
Depth Materiel Method
From / To 20 Ft
From To F1
15. SCREEN:
C ewe -
Depth Diameter Slot Site Mstsdel
From , To Ft In In
From To _ Ft In In
From _ To Ft M. In
10. SAND/GRAVEL PACK:
Depth Sire Material
From To Ft
From To F1
17. REMARKS:
v
tl addltlon& space b needed use beck of ionn
LOCATION SKETCH
(Show direction and distance Irom a1 Nest two Were
Roods, or other map reference points)
G iF t
c Ai
t.R n.
. *Lip� f
h
Po.s
vFF'<L
Le/C e5 -' eA-- /-fw/
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS�RECORO HAS BEEN PROVIDED TO THE WELL OWNER.
IS
Kek i' e4i6W
FOR OFFICE USE ONLY
owed tla
Swill the.
SIONATUNE Of PERSON CONSTRUCTING THE WELL
Suter* edging' le Division of Wale . , Onwndwaler Socket within 30 days
RECEIVED
Asheville e Regionel G`fice
q Protection
DATE
1 REV. Ibel

Noe Csrollns • Department of Environment and Natant Resource • aWtsbn W Water Cruelly . Oroundw.Nr Section
163/ Mil Swam Censer. RISEN N.C. 27696-1636Ptone (9//) 733 3W
WELL CONSTRUCTION RECORD wtu.CONTRACTOR• r%PJke2/1424
WEU. CONTRACTOR CERTWICATION s: 7 (! 3
STATE WELL CONSTRUCTION PERMITS:
c,9,
1. WELL USE peak App labia soak nciame list❑ Municipal ElIndwoS ❑
Recovery al Heat Pump WMsr Injection 0 Oliver 0 It Olh*r, LIN Uss:
Agricultural 0 Monllort% 0
2. WELL LOCATION: (S)bw skslch of 1M IocaUon below) /
frown- le, _reeks:.. ri0 may:
Cal PrAvis,'
Mad Nene nod ca ..1� m emNbn and
Los Nt) ORILUNQ LOG DEPTH
3. OWNER G9! //�df{[p' ��4R Pt! / Addtns 5/ taw. ied/h0.r l `-C�t'-ioedte z- IF -I/ 7Te ��smrrr,w,ga�1
//7-ZOO (t,4C
pear Tone Stale 2Ip Cada 2t3 - 20/ 84eC/+Cc,
4. DATE DRILLED,3-`7-66 2ci!-2Y•S 4c'iau; t'
5. TOTAL DEPTH Z </ r
6. CUTTINGS COLLECTED YES 0 NOc
7. DOES WELL REPUCE WELL?NO
S. STATIC WATER LEVEL EXISTINGSofasTop of Casing
ES FT.EJ---/ RECEIVED
fun Y' S Alan Tap al Cnbq)
9. TOP OF CASING IS / Ff. Abaft Land Surface'
'Top of ening teradnss.d otter betow tend anion rmgdns a amlanee In neaer. ° f - r")
donee with ISA NOW lC t1e -
10. YIELD (Ipmp METHOD OF TEST RCS
11. WATER ZONES (Split(/ ASi: vaiic{�c9/O:sal Office
Aquifer Protection
12. CHLORINATION: Typo Amount 11 sddk o'W sps o Is needed use book of loom
19. CASING:
VTM Tl nsss LOCATION SKETCH
Depth i Diann er MannISsdr (Show Ortolansod distance lance koel NIwo
o State
From 1 To ...1-1-2 Ft . reed.
Roads, a other nap reference pants)
From To Ft.
From To FL
14. GROUT:
Depth Material Method
From To
Ft Oh CA r<-
From To F1
15. SCREEN:
Depth Diameter Sell Slze Material
From To Ft _ in. In
From To _._ Ft In ___ In
From To _ FL In. ____ In
16. SAND/GRAVEL PACK:
Depth Sirs Material
From To Ft.
From To Ft
17. REMARKS:
l Ic'4'11
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS RECORD W(1/�9 BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY it C4 I�YGL^Xys�� . I gi o t,
Owed Nor SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subma DWI b Olrtden d Water Ousllly. Omse tMerer Salmn within 30 days
oW4 REV. BM
Sethi No.
G

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• 0-l'Ga2GUr i.
WELL CONTRACTOR CERTIFICATION #: 2 l) 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) O
Nearest Town: (. An L� G/'e County h, it. eo As, b o
ticro Wegs 0.,ra.,r, R�
(Road Nameaaotl' Numbers, Community, or Subdivision and Lot No.) DRILLING LOG DEPTH
Np 3. OWNER ` tft,c L i a-r vr ` et , rick From To Formation Description
Address p p %e ' S S 0- ? 4 au.e; (late:Ien
as tkedt-tq- (Street or o.) aews q — 4S' 9 An ca-x:.Z�'
City or Town State Zip Code �0���� ��
t(t� ert
4. DATE DRILLED / _ Uia `O (o a- es `1A
5. TOTAL DEPTH , $ S
6. CUTTINGS COLLECTED YES ❑ NOal
7. DOES WELL REPLACE EXISTING WELL? YES G NO�
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above Top of Casing)
9. TOP OF CASING IS t FT Above Land Surface*
'Top of using terminated et/or below land surface requires a variance in accor-
dance with 15A NCAC 2C .0118 �-i
10. YIELD (gpm)• S METHOD OF TEST R t_5
11. WATER ZONES (depth)*
sheville Regional Office
12. CHLORINATION: Type
13. CASING:
714 Amount a' S 0
Wall Thickness
Depth , / Diameter or Weight/Ft. Material
From e To 7T Ft _ _ r` Ptic-
From To Ft
From To Ft.
14. GROUT:
De t4 Material Method
From 0 To sip Ft t^ -�
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft. in In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECC)4RD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
i %///off
DATE

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- l '?td
WELL CONTRACTOR CERTIFICATION #: Z ((3i
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential czt Municipal ❑ Industrial El Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town• 4-A-VI tJt-t,u) County: (3LG1'LpL-YVv'L¢ .
(-I toy q itozc eck Roz1LCAcK I1t(Lc
(Road Name and Numbers. Co�nity, or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER /4 1 P 7, d'r-: From To Formation Description
Address to y O (R-H To- fwri.) t cl 6 I a b etwitilou,,.(c.., ,
(Street or RouteNo.1 fa7 3G [1iYcxT+iJe
otlaLw�� fed , d�7.3o 30`t— 310
City or Town State Zip Code
4. DATE DRILLED ) — 3 —tr!• 11 f y �) n Oro , Er
5. TOTAL DEPTH QS 4 t?— 4 t3 i", r-2:tvic�LC6. CUTTINGS COLLECTED YES ❑ NO yLI 9 ' a- 0 ant 17. DOES WELL REPLACE EXISTING WELL? YES n NOgj C., 31— /n 22Ctov c t
8. STATIC WATER LEVEL Below Top of Casing: 70 FT. Co '2 3 — 74 0 f2. v a n i 4.-4_,
(use..? II Above Top of Casing) '7a 1— » a. C t -C. v't u
9. TOP OF CASING IS I FT Above Land Surface' .7 O 3 _ --PUS 1- C4 n d 2
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C . 11a
10. YIELD (gpm)- fl METHOD OF TEST R. ?,
11. WATER ZONES (depth)-
12. CHLORINATION: Type -P4—
13. CASING:
Amount • kr 1 If additional space Is needed use back of form
Wall Thickness
Depth r ar We VFt. Material
From To [ a� Ft f�" tt PVC—.
From To Ft
From To Ft
14. GROUT:
Depth /i Material Method
From 0 To 4210 Ft. lrt Thz s4 rn\ 0.404
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 =J
16. SAND/GRAVEL PACK: I IN)
Depth Size Material � r
From To Ft. ,6,L to
c.:n
From To Ft
17. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
c4,12-:,;/41;llosia A
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CQPY OF THIS REC1ORD HAS�I
FOR OFFICE USE ONLY
Quad No:
Serial No.
RECEIVED
ER.
1/3/61(49
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality. GmundwateRSecton, wlthin,3Q days
,h:"( t LiAluki GW
Asheville Regional Office
Aquifer Protection
ATE
REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1 636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR c 'es b-
WELL CONTRACTOR CERTIFICATION #: ZI 17
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town. Lit d a s t- wt'IR.C. County 13
(Road Name and Numbers, Community, or SubdMsion and Lot No.)
3. OWNER Fkflt t Eo (fC—pcn�
Address p1�� r,�� S t)
t p U (Street a HotNo.)
(76,4
,4AceYrt.f� . .
From
From
From
14. GROUT:
a no
City or Town State Zip Code
4. DATE DRILLED a /r dab
5. TOTAL DEPTH C V S
6. CUTTINGS COLLECTED YES Q NCO
7. DOES WELL REPLACE EXISTING WELL? YES Q NO®
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use if Above Top o1 Casing)
9. TOP OF CASING IS 1 FT Above Land Surface'
Top of casing terminated aVor below land surface requires a variance In actor -
dance with 15A NCAC 2C . 18
10. YIELD (gpm)• Tx METHOD OF TEST x ';,5
11. WATER ZONES (depth).
Cf Yl ru-tyubl o
DRILLING LOG
From To
6 9/
9 - -/ 4 S'
c2E/— S'4 O
S'J/ - S1Z
Sa3- s-cq
12. CHLORINATION: Type /4 7N- Amount s S
13. CASING:
Wall Thickness
Depth Diarnp r or Weight/FL Material
To er� Ft yf! 2j Qtit--
To Ft. % 21- Y
To Ft
From 0
From
15. SCREEN:
Depths, Material Method
To 01a Ft. Cv n-4 r-.sue red4te.A
To Ft
Depth Diameter Slot Size Material
From To Ft in in
From _ To Ft — in
From To Ft. in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
in
in
DEPTH
Formation Description
,t4 rkeiat
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
RECEIVED
�
Lun� v' O
Asheville Regional Office
Aquifer Protection
2t. WELL.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 13A NCAC ,
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/JO,U ple/rm64)S 0-21/5/06,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Quality. Groundwater Section within 30 days
GW-1 REV. 12/99
FOR OFFICE USE ONLY
Quad No:
Serial No.

324407
WELL CONSTRUCTION RECORD
North Carolina - Departtnent of Environment and Natural Resou es - Division of Water Quality - Groundwater Section
ELL CONTRACTOR
)
N
\YELL CONTRACTORCODMPA:\Y NLAMEaf�p A�ftclMAy W¢1I51��,i1Lrna PHONE #IC 6t5.� A
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# 88VV
(if applicable) (ifapplicable)
I. WELL USE (Check Applicable Box): Residential td' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2,
WELL LOCAT,ION:
Nearest Town: kisiorefel
County R(Ln{C(j/Ma
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:BC/6AN1*H'
Address 1lot MorFh'
klicto
(Swy
eet or oute
City or Town 1 State
eigt
No.)
Zip Code
( )-
Area code- Phone number AA
4. DATE DRILLED tsid°.0 )
5. TOTAL DEPTH: 44t
6. DOES WELL REPLACE EXISTING WELL? YE 0 NO
7. STATIC WATER LEVEL Below Top of Casing:FT.
/ (Use "+^ if Above Top of Casing)
8. TOP OF CASING IS ! FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accordang with ISA NCAC 2C .0118. (in
-VQi� METHOD OF
10. WATERZONES(depth): p33�.%
11. DISINFECTION: Type i rIO(CC Amount o2
12. CASING: Wall Thickness
y� Depth Diameter or Weight/Ft. Material
From V To 36 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth --22
From To e0 F
From To / Ft
14. SCREEN: Depth Diameter Slot Size Materi
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From - to Ft.
From Io Ft.
TEST
9. YIELD (gpm): L.CX•+'
16. REMARKS:
Topogra c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/Io�q�} u of well loc t s4 n65
Nl'35 cSZS •Li z W s��^.,'/'tom• [77S
(degrees/minutes/seconds)Gte • p2,
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.
RECEit/ED
Asheville Regional Office
At:aIF!"eC i rc:tectlon
1 DO HEREBY CERTIFY TT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTyCT1ON STAND DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
ubmit 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 Re ources -[[Division of Water Quality - Groundwater Section
WELL CONTRAC "rOR (INDIVIDUAL) NAP,t( (print) �R.\. t)Nl tr-}��/V CERTIFICCAA(TjION�#/(9(e�03g2
WELL COSTI2:\CTOIt COMPANY NAME l l f t `i/,AI/a( /�r�l rfl MG PHONE # r )67b'- 2 a
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
324406
ASSOCIATED WQ PERMIT#
(if applicable)
L WELL USE (Check Applicable Box): Residential ty/unicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELLLOCA1
Nearest Town:
6D l7-Rh{ cnnnt)Bcti kSt
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: LiINDr-tY� iitssh
Address f
4 •. e/il teem or owe No.) zne3if
City or Town State Zip Code
( )-
Area code- Phone number nn
4. DATE DRILLED O�'
5. TOTAL DEPTH: CD Cfr
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: 2 EFf.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ) FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .01 IS.
9. YIELD (gpm): /00 t METHOD QF TESTGS l•
10. WATER ZONES (depth): CP ge t
t 1 . DISINFECTION: Type liCINCL Amount car
12. CASING: Wall Thickness
Depth n Diameter or Weight/Ft. Material
From To Kis& Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From to
From To
14. SCREEN: Depth
From To Ft. in.
Diameter
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 'I-o Ft.
Slot Size
Material
in.
in.
From To Ft.
Topograp /Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropriate box)
W i ud 1 n we�
/227
(degrees/minutes/seconds) G A,M3) (p
Latitude/longitude source:❑GPSDTopographic map
(check box)
DEPTH
From To
DRILLING LOG
Fommtion 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.
RECEIVE0
Asheville Regional Office
Acii.ajfer Protection
16. REMARKS:
I DO HEREBY CERTIFY THA THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STA 'D • • • S, A D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
-6-dC
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit tI 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

324405
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment an Natural Resourc s - ivision/Iof Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME(print) � { `5 CERTIFICATION
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT
(if applicable)
PP
i
t�N PHONE # 00tWS1tr.5. 1.3
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential ld MunicipaVPublic 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCH ON: ,
Nearest Town: r1�1Ci, county `-IMO
caanc¢)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:} t1p�
Address _yJ� i .154anc.a Nc(
( re otg Na.)
/.�,�—r CCCIIIVVV//////t\7 /
City or Town State
( )-
.Area code- Phone number
4. DATE DRILLED 0.7a' O CD
5. TOTAL DEPTH:32.5 r
6. DOES WELL REPLACE EXISTING WELL? YFFS❑ NO
7. sTKr1c WATER LEVEL Below Top ofCasing: 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 accordan th ISA NCAC 2C.0118.
YIELD (gpm): METH D OF T
Zip Code
Topogra ic/Land setting
❑Ridge lope ❑Valley ❑Fiat
�,}' �j (cheek appropriate
�'box)
pf ',p'•L/'�/� ?
IV atUd g,3�.d iavYrDtaZ�/7T�j7� r �!
(degreesiminuteslseconds) 0EV, Zt f "
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
9 Q EST�I �%ol�i1y
0. WATER ZONE C�
I S(depth):
a Ka-
l.I. DISINFECTION: Type
12. CASING:
FromDepth
To JI . Ft.
From To Ft.
Diameter
From To Ft.
13. GROUT: Depth Material
From to gL�_. e ' J
From To 4 F. alias'
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From to Ft.
From to Ft.
Amount p2
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
Method
MOT'
as.wwunra.
Materi
Size 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.
RECE
Asheville Regional Office
Agsaifei Protection
16. REMARKS:
I DO HEREBY CERTIBY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST: sIDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/"dla
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 Resourc;s - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM( (print)
WELL CONTRACTOR COMPANY NAME ?pc* `d1� IAA ai Lilh PHONE # (1 •''Rag,
SLATE WELL CONSTRUCTION PERMIT# r r ASSOCIATED WQ P�It_R j{)IT#
(if applicable) / (if applicable)
CERTIFICATION AVG
1. WELL USE (Check Applicable Box): Residential IQ� Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
WELL LOCAT O
r
Nearest Town: had I C. Countyy 7IAtrknt t
f YYCIG
(Street Name. Numbers, Commy, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
)VQ_be/V.
iS WY lW
(Sir or route No.) au//
City or Town State Zip Code
( )-
Area code- Phone number t�
4. DATE DRILLED a- 0 ..65. TOTAL DEPTH: 5-05 ' /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO LI
7. STATIC WATER LEVEL Below Top of Casing: /66 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ) FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. /��, �r
9. YIELD (gpm): ' METHO OFTES"1&31. (V\i l(
10. WATER ZONES (depth): *0
II. DISINFECTION:Type-TAmount
12. CASING: Wall Thickness
Depth Diameter or Weight/R. Material
From —(5- To_ '_ Ft.
From To Ft.
From To Ft
13. GROUT: Depth,
From l o L3 F
From To /q Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
Topo ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location to*
N•3se 3s.s9-ar well 173
(degrees/minutes/seconds) sty: i!3
Latitude/longitude source:❑GPS❑Topographic ma
(check box)
DEPTH DRILLING LOG
From To Formation Description
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From l o Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEWED
Asheviise Regione,i Office
AquAti. Protection
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
0Q- M-O4
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

324402
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources/- DivisionDof Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prints))/{t,✓!T^�jt�(1 /f `�t,'J CERTIFICATIIO/Np#Qt�LQQq �t�
\VELL CONSTRO:TIONY NAME PPR/M1\-711 hladi 71lt1� PHONE# p)t�d3'/p{plp�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W PERMIT#
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential I/ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:'.
154 -Fitt 7b 'Mfu.
County /4NILi'
(Street Name. Numbers, Cmraunity, Subdivision, Lot No.. Zip Code)
3. OWNER: & 42MU/���>>>�%�n(K6g,
Address ( 5 De?" .
46A eta ! trees or Ropte No.) /1 f „ KO
City or Town Cl State�atteO_ZiipUCCoddee
( )-
Area code- Phone number
4. DATE DRILLED OtCO
//
O
5. TOTAL DEPTH: 029-0—* ^/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I;1
7. STATIC WATER LEVEL Below Top of Casing: 6 C FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ! FT. Above Land Surface'
*Top of casing terminated atfor below land surface requires a
variance in accordan with 15A NCAC 2C .0118.
9. YIELD (epm):— METHOD OF TES
10. WATER ZONES (depth):
11. DISINFECTION: Type 843We Amount o2-
12. CASING:
Topohic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box) (�
N 3ettt�3 ' ittSwel�nt'23,iii021 Z.
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
Depth
From"- To Ft.
From To Ft.
From To Ft.
13. GROUT: Dept
From T
From To
14. SCREEN: Depth Diameter Slot Size Mate
From To Ft. in in. From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From '1-o Ft.
From To Ft.
Wall Thickness
Diameter or WeightlFt. 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.
RECEIVED
Asheville Regional Office
An'r e Prn ect crl
I DO HEREBY CERTIFY TH • THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTI CTION ST • tD • ' S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
Sub it 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

324401
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resour es - Division of Water Quality - Groundwater Sectionll
WELL CONTRACI OR (INDIVIDUAL) NAME (print)i_'O2 y hMS CERTIFICATION 4663
ONTCT
WELL CRAOR COMPANY NAME Aprit/�C:{'(r/ll�8.1 v6', fli%ha. PHONE # tdlt0)61s.9a,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(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
2. WELL LOCATION:
Nearest Town: rea stun J ou9ty
CO � �
2 4 D;Ar.& rMwer ; L (CCa f, 1
(Street Name, Numbers, Community, Subdivision, Lot No., ip Code)
3. OWNER (C { jCONCS
Address D �� �O ,
}/_ _ _ - ag43b
(Street or Route No.)
Zip Code
l )-
Area code- Rhone number � /I it
4. DATE DRILLED `,',(''J
5. TOTAL DEPTH:t126
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /00 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 accordan ISA NCAC 2C .01I8. - n
9. YIELD (gpm): .'J METHOD OF TEST4AL, \011414/t,'
•
City or Town State
30
Topogr hic/Land setting
❑Ridge Tope ❑Valley ❑Flat
(check appropriate box)
K Latitucle/longitude of well location
s Sag W3aa 23.053
(degrees/minutes/seconds) E‘E.v. aq-3I"'
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
v
Io. WATER ZONES (depth): 360
11. DISINFECTION: Typelkestek Amount
12. CASING: Wall Thickness
Depth 9 Diameter or Weight/Ft. Material
From'$ To 6 Ft.
From To Ft.
From To Ft.
I3. GROUT: Depth Material
From To 3 Ft. C6hC'iZC%Q.
From To II Ft. 614-tl'Ltt 'S.l
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
l5. SAND/GRAVEL PACK:
Depth Size Material
From 10 Ft.
From lb Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEF ED
Asheville Regional Office
ACI'jiie( Y 'rcteciion
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION S ANL�ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�7/G/id
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of tV'ater Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

324400
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalwResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)sri1 Any Weaj CERTIFICpA�sTIIONilAdl6ggaq
WELL CONTRACTOR COMPANY NAME )1(WAIA C4 Ai / bt�l /if 3 PHONE # l0/tV)64.5 �I//I pt
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:relikfttold County15Ct e1Ql�irt8L
9* -ruts tiltMGtfnbTXG cct 6 2fl36
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip
}-Coder
3. OWNER: Gt(Q. sibtrr 1*wcS, jj c r
Address P61 •% ¥
(Street or Route No.) rs v;euf /3 -1.3-0
City or Town State
( )-
.Area code- Phone number
4. DATE DRILLED
Zip Code
CS',
Topo ic/Land setting
❑Ridge Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
u35'3R.52z.' SW:23.03y�5,�#
Kvt /d
(degrees/minutes/seconds) c02'"
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
5. TOTAL DEPTH:?Z. /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 11"
7. STATIC WATER LEVEL Below Top of Casing: 1250 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 I5A NCAC 2C .0118.
9. YIELD (gpm): 4-1,' METHOD OF TESTeiAt ail&>140
10. WATERZONES(depth): 4Z00 t 3gC) C
11. DISINFECTION: Type—&Q t Amount e2
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
Frome To to Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
FromTo 3
From To
14. SCREEN: Depth Diameter Material
From To Ft, in
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Material
,,,�11..��
FLCA 'tl..�t.
Ft. (yi
Slot Size
From -I Ft.
16. REMARKS:
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.
RECEIVED
Asheville Regional Office
Aau!fek' P c'iectiaf
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTIjj1CTIOST,DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
10
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sub lit 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-( REV. 07/2001

324399
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOIR(INDIVIDUAL) NAME (print) L&W21'I( ita(3 CERTIFICrA.,TyI,ONp#�a033
\YELL CONTRACTOR CONIPANY NAME (tjpflRcb14(4 at D�i11i►a PHONE # topu�C83- 1a�3
STATE WELL CONSTRUCTION PERMIT'S ` ASSOCIATED WQ PERMIT#
licable
) (if a. licable)
I. WELL USE (Check Applicable Box): Residential A Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
7
WELL LOCATQLOt-�
Nearest Town: I'�t`�1 i I(G
Comtty3SCO IL
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
�7i,,,� ""�� .1
3. OWNER:�[6(t i MI ! ;���+
Address U /�Cs (MA(IS� 'G }dt
(Street or Route No.)
(lshekii 11,C) fie, 021(10c
•
City or Town State Zip Code
)-
Area code- Phone number
4. DATE DRILLED .Z�I4/0 Co
5. TOTAL DEPTH: ( 5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 21/
7. STATIC WATER LEVEL Below Top of Casing: COO FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface*
*Top of rasing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
Topoggrr is/Land setting
DRidge ►7Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of w11 ocatio
N36634.255' It%Ma. N.t5t3 Q
t
(degrees/minutes/seconds) elev. a 4r
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
9. YIELD (gpm): „t00 T METHOD OF TEST CIO i • CONtt >.1.0
10. WATER ZONES (depth): 1 `6(>
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. DISINFECTION: Type 1t3(¢•t Amount 2.
12. CASING: Wall Thickness
Depth Diameter or Weigh/Ft. Material
-e-tr" To 70 Ft.
To Ft.
To Ft.
13. GROUT: Depth Material ,/'
N From To 3 Ft. O' ,oat �
From To I' Ft. totgi t
14. SCREEN: Depth Diameter Slot Size
from To Ft. in. tn.
From "Co Ft. in.
From
From
From
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Material
16. REMARKS:
RECEIVED
Asheville Regional Office
Aquifer Protection
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRyCT1ON STANARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0
SIGNATURE OF PERSON CONSTRUCTING THE WELL TE
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

324398
WELL CONSTRUCTION RECORD
North Carolina - Deparnnent of Environment a d//{�Natural Resour
es - Division of Water Quality - Groundwater Section
.Q WELL CONTRACTOR (INDIVIDUAL) NAME (prinJAg rrett� 7y CERTIFICATIONg/lb(rYVOj
WELL CON`FRACTORCOM PANT NAME F' r1TALQh%RN Si Nil tr*(o PHONE #Wi
STATE WELL CONSTRUCTION PERMIT# rr ASSOCIATED WQCPERM 1#
(if applicable) (if appl icable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCA 1 N:
NearestG,Town {t1i'dli �I iiti CountyTh*4 fit t
16 rote Cite", 4 nCoTn+
(Street Name, Nun Community, on, Lot No., Zip Code)
Topographic/Land setting
idge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
3. OWNER: 1464'16M QI (degrees/minutes/seconds)
Address 1(D4' fiv, cec y (tx, Latitude/longitude source:❑GPS❑Topographic map
, (S�ce Route No.)
Q /t u t I I1\\ (; , s p t7 (check box)
w� it �.� 1 pT DEPTH DRILLING LOG
City or Town State Zip Code From To Formation Description
( )-
Area code- Phone numbe
4. DATE DRILLED
5. TOTAL DEPTH:6w C 7 /
6. DOES WELL REPLACE EXISTING WELL? YES NO hd�
7. STATIC WATER LEVEL Below Top of Casing: O 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 nce th ISA NCAC 2C .0118.
9. YIELD ((rpm): C5, METHOD OF TESTql$1, W!V JC( --
10. WATER ZONES (depth): 4.96
11. DISINFECTION: TypeTaJO(ee Amount AZ
12. CASING: Wall Thickness
Depth Diameter or Weieht/Ft. Material
From -& To /7,0 Ft.
From To Ft.
From To Et.
13. GROUT: Depth n
From 'fo V Ft. \y,; t
Frnt» to——i-t t t G,-, RAC &QED
14. SCREEN' Depth Diameter Slot Size Matenal
From To Ft. in. in.
From To Ft. in. in. !
15. SAND/GRAVEL PACK:
Depth Size Material
From to Ft. Asheville Regional Office
From ro Ft. Aquifer Protection
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:
Material
Method
1 DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR 'CTION STANDAkDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL D • E
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
2.7699.1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

324396
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources,- Division of Water Quality - Groundwater Section /,�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) h(tf^7ty�R y� q��j� 1 rt'rs CERTIFICyAt1TQIO/Nt �jAoOL
\YELL CONTRACTOR COMPANY NA\IE llFriAIA I I N YJI t yJ�f j ll� PHONE # /�) Q gcl 'Au
5'fAl'E WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if a licable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential 'i Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: Mb(tF) sSA
� County3
+(antewts5b hZ$. (c.o-{ 9) CON cloit223(5
(Street Name, Numbers, Community, gibdivision. Lot No., Zip Code)
3. OWNER: / 4AtN ll �15
Address 12 A N • taKu ia, VG.
(�sh�.Ar•ilctreet or Route
`Jo, ainod.
City or Town State Zip Code
)-
Area code- Phone number
4. DATE DRILLED �vtR' deb
5. TOTAL DEPTH: 60140-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO @'
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accorrd$nee with 15A NCAC 2C .0118.
YIELD a m : /liAC9(G METHOD OF
setting
❑Ridge ❑Slope ❑Valley lat
(check appropriate box)
Latitude) o strode f e location
(degrees/minutestseconds)EtS(', 2RO?
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
Wi5 a if3.4 3'f
DEPTH
From To
TEST
9. (gP ) EST SA ( 03/10Irill.el
10. WATER ZONES (depth): --
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
11. DISINFECTION: Type- 36(W+ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From—'— To 97- Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To
From To /
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. ill.
From To Ft. In. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
RECEIVED
(.4 £
Asheville Regional Office
Aquifer Protection
16. REMARKS:
1 DO HEREBY CERTIFY T. AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTR '. ION S ND. • DS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
3E
ATE
Su tit 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

324394
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resource - Division of Water Quality - Groundwater Section
pp
WELL CONTRACTOR (INDIVIDUAL) NAME ((prirint)t),, � CERTIFICATION ijpFOCJa
WELLCONTI(AC[OR COMPANYNAME l7(jj,Jl}L(-1 N �VVW( /(Jl)VQ PHONE #��OI
S BATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERM ail
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential QA' Ivlunicipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:1�+ `�
Nearest own: L.¢Iea.SEa, Countyr3UNCAtY3t
94 5h¢RRt Lime tl.Qtcestr ,ZB 7142r
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWN.
Address
P4�IXI�l�u si
(
(Street br Route No.)
Lu ll. E )UCH. rz78'1
City or Town Stare Zip Code
.Area code- Phone number D�/ gIo Co
4. DATE DRILLED 1
5. TOTAL DEPTH:o6 'S
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 90 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 accurda'�f �v th 15A NCAC 2C .0118. /HOD 9. YIELD (gpm): .,METOFTESTCOALCt e
10. WATER ZONES (depth): t SO
11 DISINFECTION: Type
12. CASING:
Amount 0. —
Wall Thickness
Depth Diameter or Weight/Ft. Material
From To -KO Ft.
From To Ft.
From To Ft.
13. GROUT: Depth il,Material
From To Ft. Qf C
From To Ft.
14. SCREEN: Depth Diameter Slot Sizc Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topogra ]c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
L titu.e%g y 4-Y I� I �.o�ao rf-c•
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
rD
Asheville Regional Office
A uifei�Protection
I DO HEREBY CERTIFY THAT 1S WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTR ION STANDARD", AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W 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-I REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2Ly?(o
1. WELL CONTRACTOR:
i)tcc6at.,yecs
Well Contractor (Individual) Name
eAyak .3+ s`iecs k 6oe
Well Olontractor Compahy Name
STREET ADDRESS
Ro}
VA%s Wes) aw
r
"S7te
City or T n State
( Barb )- (0(0s- aoaa
Area code- Phone number
a1M3
Zip Cale
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply IDDATE DRILLED R /7-6
TIME COMPLETED ,Sxr3 c AM El PM(p.•�
3. WELL LOCATION: qq //
CITY: 4 Site U • //� COUNTY/JCzn/C/9M2k
e Ord X'r r
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER
OWNER'S NAME -rilrel t hot4
STREET ADDRESS to A S4, In n C1 c \va
City or Town r State Zip Code
(.1s)- a%5- atoari
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
Cr /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (g'
c. WATER LEVEL Below Top of Casing: 70 FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS t 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 METHOD OF TEST R.A
324350
f. DISINFECTION: Type 9; I t S
9•
From
From
WATER ZONES (depth):
To
To_
From To
6. CASING:
From
From
From
Amount 3s
Depths Diameter
From / To 7 / FLyaa_
From To Ft.
From To Ft.
To
To
To
Thickness/
We t M ria
C
7. GROUT: Depth Material
Frorn Q To 'aQ Ft. Ct-McY1.t
From To Ft.
From To Ft.
Method
ao.>, cea
8. 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 Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/ 9/
9/ 7nC.
Formation Description
6r¢n.,'P
REC gMPCD
11. REMARKS: Asheville Regional Office
Ac,ui'i >ieCi!CI:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
ISA NCAC 2C, WELL CONSTRUCT/0N STANDARDS, AND THAT A DOPY OF THIS
RECO' r)r BEEN PROVIDED TO :r9 ELL OWNER.
eyQ—/7-4
SIGNATURE OF C RTIFIE' LL CONTRACTOR DATE
a'n1 sell- /xr.i .�cc1y,.rS
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
North Carolina D
WELL CON
1. WELL CONTRACTOR:
�PCt:cac \t. 6cooly tts
Wed Contractor (Individual) Name
CAI de 'SGA4-1 Ct d .'Son
Well Caltrador Company Name
STREET ADDRESS t4696 tts..1
ttot 46pc-eo5 NC
City or Tawh OStat�
( (avS e'2otZ
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Ail applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Resid
DATE DRILLED /—a.7- G
TIMECOMPLETED S. 0 0 •
3. WELL LOCATION:
CITY: //e /1Isisc. -co'
15;j4evo (n ue e/1 IC d i
{Street Name. NuMbers Community. SubdMs'
TO OGRAPHIC 1 LAND SETTING:
Intloto (Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE _
Latitude/longitudesource: OOPS OT
(location of wet must be shown on a USG
attached to this form inert using GPS)
IDENTIAL WELL CONSTRUCTION RECORD
ent of Environment and Natural Resources- Division of Water Quality
OR CERTIFICATION #" ? 4 3 h
iJ2\\ OS V sem
goq
Zip Code
Water Supply 0
0 PM8--
,4h Con.IA-
No. Parcel. Zip Code)
A WELL OWNER LL q
OWNER'S NAME (3e- 6--rYJ..
STREET ADDRESS 1QS e), h(Y
1=0..cv:Pv1 %v
City or Tom State
(2a9, 91ob
Area code - Phone number
5. WELL DETAILS: L�
a. TOTAL DEPTH: 7 07 5.
b. DOES WELL REPLACE EXISTING WELL
c. WATER LEVEL. Below Top c( Casing:
(Use '+"rf Above Top of Casing)
d. TOP OF CASING 1S \ FT.
?op of casing tetmineted at/or below land
a variance in accordance with 15A NCA• -
e. YIELD (gpm): R METHOD OF ST Q :Cy
May be in degrees
minutes. seconds or
in a decimal format
graphic map
map and
Cove.
Zip Code
/
YES CI NO93
90 FT.
Land Surface
urface may require
C .0118.
324348
f. DISINFECTION: Type p : \\ j Amoum 1
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Mated
From�_To�� Ft._ts t k J.\_prin3t:C
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From k7 To V Ft (en,e ht _ow1e.k
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Sot Size Material
From To Ft
From To Ft in. in.
From To Ft in. in.
9. SAND/GRAYEL PACK:
Depth
From
From
From
Size Maerial
To Ft.
To Ft.
To FL
10. DRIWNG LOG
From To
� \ 75-
11. REMARKS:
Forrnatic n Description
h N'tt ‘Cisst el o e,
&teal: to
RECEIVED
Asheville Regionai Office
A.ufer Protection
100 HEREBY CERTIFY THAT TMS WELL WAS CONSIR /CTED N ACCORDANCE WUH
15A NCAC 2C. WELL CONSTRUC110N STANDARDS. AN: THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFI D WENTR%.CTOR DATE
V\Qv( ten. \-k.,400,Ayt fa
PRINTED NAME OF PERSON CONSTRUC1 NG THE WELL
Submit the original to the Division of
1617 Mail Service Center— Raleigh, NC
ater Quality within 30 days. Attn: Information Mgt.,
99-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

o}
City or T
RESIDENTIAL WELL CONSTRUCTION RECORD
v
324347
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 24 ?to
1. WELL CONTRACTOR:
i�ecc,clA % 5catsyecs
Well Contractor (Individual) Name
CAS e_ & s'ge(S 3 6011
Well aontractor Compahv Name
STREET ADDRESS t4'dR 5 Wes7 aW
N :.`g%roc
aa�w3
- Zip Code
(Barb )- (o(as- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#fd applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):x)/Residential Water Supply 0
DATE DRILLED �` 4907— c.o
TIME COMPLETED �i va AM ❑ PM D�
3. WELL LOCATION: /J
CITY: to.? t/rrr./ -. COUNTY /JLLA( CNL4.
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING:
Slope [Valley ❑Flat °Ridge °Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ID GPS °Topographic map
(location of welt must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER
OWNER'S NAME tiex\ 5LJ e'ry iC'�
STREET ADDRESS S 15'tev1'•tt5 (�.d tJ4.
hl�eV,t.e. Aar- cZi eko
City or Town ' State Zip Code
( 3-e} ai8- 9uilaz
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: G a S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (1
c. WATER LEVEL Belau Top of Casing: '0 Z5 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS , FT. Above land Surface'
'Top of casing terminated at/or belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST R,Q
f. DISINFECTION: Type 9, i l
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
Amount 3d
From To
From To
From To
Thickness/
Depth Diarpeter W ' ht M
From To Cp ? Ft (o Al M2( p14 ill
From To Ft.
From To Ft.
7. GROUT: Depth
Material Method
From_0_ To 2O Ft. tr .CMfnt' 'ots.ced
From To Ft
From To Ft.
8. SCREEN: Depth Diameter SIX 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. DRIWNG LOG
From To
/ G?
6? 44n
11. REMARKS:
Formation Description
fl— eeon
Grua r' 1e
CEWVED
r
Asheville Regional Office
Anal%i' F'rotectbon
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, ANC THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
e
SIGNATURE OF CERTIFIFpWEELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTNG 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 # ,at{ ?Ls
1. WELL CONTRACTOR:
�cc .C1K H. 5atsyets
Well Contractor (Individual) Name
C\+de 5owjyecs 4 Son
Well Contractor Comp Name
STREET ADDRESS tM2R 5 \J7 Pact
1 oa 5 :cgs 11 p c 98"143
City or T 91ate - Zip Code
(gat (o(aS- aaaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #('rf applicable)
STATE WELL PERMIT#td applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 2-e20'-
TIME COMPLETED y..UC.) AM 0 PM 3. WELL WELL LOCATION: 1
CITY: 7.-.u-rad - COUNTY /3ancvnt4
l/P //s rig tI,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code) --
TOJOGRAPHIC / LAND SETTING:
Nbpe DValley ['Flat ❑Ridge OOther
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME 'KQ•n 'Jen6CYI
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS 5 'anee--. tt - R".d42'CZa-
`AS%.G�I<tte-, Nt✓ .Qigt)JJ3
City a Town St
ate Zip Code
( el a2+ .i� t
qs- i ttca
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH: at oS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [
c. WATER LEVEL Below Top of Casing: it a 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): R METHOD OF TEST R.A
324346
f. DISINFECTION: Type P' 1(5 Amount 3 6 _
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matrial�c
From / To 69 Ft. c /t/ S4Q2j
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 'ZO Ft. C.c*.,Qylt co use
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 FL
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
/ Te9 cDvr/l4n%h
1 c C&. 1
11. REMARKS:
RECEIV O
1
•J
Aaheville lle+c;iundi OTTiLG
AQ':1,to+. Protection
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 TOTH' ELL OWNER
SIGNATURE OF CERT I/END "(1 GONTRF,CTOR DATE
UP/'/. "C C /JPa�'�( _5 4. 1/r/ t
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-ta
Rev. 7/05

39S 324345
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 24310
1. WELL CONTRACTOR:
i7 e.Ct:LW H, So.tsyecs
Well Contractor (Individual) Name
C\',dc. Snwjec5 k SOT
Well infractor Comp Name
STREET ADDRESS t4285 Let POci
Rot Sp-r ..q5) NC... 98' 143
City or Town 4-7 State - Zip Cade
(8a8 d- rotes- aoaa
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID ;Rif applicable)
STATE WELL PERMIT#(Rapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED /1— /—ot
TIME COMPLETED ,./, 30
3. WELL LOCATION:__/
CITY: AK.-[r./.li
AM D PM IDa'
COUNTY 4Gh En44
(Ztoca
(Street Name, Numbers, Community, Subdivision, La No., Parcel, ZIP Code) - -
TO,OGRAPHIC / LAND SETTING:
�Siope ❑Vafey OFlat ORidge pother
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: pGPS ❑ Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form !not using GPS)
4. WELL OWNER
OWNER'S NAME 5JIN'C\e1 CAtar, ne.tS
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS 5'i bit .Can ag0-ci
S\nev t1 e .CSC
City or Town ) State
(sa.tk tntc1-\y5io
Area code - Phone number
Q0G>o
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: aQ0 S /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO l
c. WATER LEVEL Below Top of Casing: o2/0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface•
'Top of casing tennmeted at/or below land surface may require
a variance in accordance with 1 SA NCAC 2C .0118.
e. YIELD (gpm): /S METHOD OF TEST
T. DISINFECTION: Type 9 It S Amount /Q
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING;
Depth Di meter
From / To ti/� FL
From To Ft.
From To Ft.
Thickness/
vWe-i ! [, it,;.
7. GROUT: Depth Material Method
From 0 To aO Ft.
From To Ft
From To Ft
C -t-event cot, tea
8. SCREEN: Depth Diameter S of Size Material
Flom To Ft. in. in.
From To Ft in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth
From
To Ft.
From To Ft.
Size
Material
From To Ft.
10. DRILLING LOG
From To Formation Description
yc- v, w"...Ai?
YS ai) C iF/ue,ft
11. REMARKS:
RFC1-t1P1-D
Refinne) Offico
Protection
I DO HEREBY CERTIFY THAT TM$ WELL WAS ORS triD.. i[D NALLUHuwr.c
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO TH6'WELL OWNER,
SI AiURE/OF CERTIFII-YYECL CONTRL CTOR DATE
FN
PRINTED NAME OF PERSON CONSTRUC G THE WELL
PRINTED
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

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION II al 4 0
1. WELL CONTRACTOR:
Reo1-be4, @jA rcuel(
LContractor (Individual) Name
ell be,a1 P kJ c� w 9 I I Or% 1 1 1 vtr4 t1 v(c
Well Contractor Company Name
STREET ADDRESS 35I t eio LetceSi-elf141
Fshev;ile NC a%%o(o
City (fl'» 354-3SSI
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box) Monitoring ❑ MunicipaVPublic (I
Industrial/Commercial ❑ Agricultural ° Recovery ° Injection ❑
Irrigation❑ Other ° (list use
DATE DRILLED 3/j1/ 0 (O
TIME COMPLETED IQ t 3 O AM❑ PMpJ
3. WELL LOCATION:
CITY: WeO.Jei-vI Ile. COUNTY 'Qt.LIitom bE
-a-A- Shan no, Qr;Je.
(Street Name, Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND�SETTING:
❑Slope °Valley LFlhrat ❑Ridge ° Other
(check appropriate box) LATITUDE 3 5 4- I 50
LONGITUDE 3 a 33 . 3 a4-
May be in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: IfTST 'S ❑ Topographic map
(location of well must be shown on a USGS opo map and
attached to this form I not using GPS)
4. FACILITY -is the name of the business Were the well is located.
FACILITY ID #(il applicable)
NAME OF FACILITY
STREET ADDRESS a4 Qri v e..
Waste-rv,112 nl --
as tg-1
City or Town State ?Oft
f 11 ZipZip Code
CONTACT PERSON Q a.ak`_,, ? ft0-0L.
ail--LINGADDRESS aJrhhh. for; /t
( ea''erJ I Ile ij c-- as `t $ 7
City or Town State Zip Code
(%ag —4415
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Belau Top of Casing: U`f FT.
(Use's' it Above Top of Casing)
bos '
d. TOP OF CASING 15 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). 5 r=L,,METHOD OF TEST D'Aw o0co
�
f. DISINFECTION: Type tkItt 40,/o Amount (4 e2
g. WATER ZONES (depth).
From l o I To I o a From To
From 4 Ocl To 4-1 0 From To__
From To From To
6. CASING: Thickness/
Deptf(., DJam�ter W(e-gty, g�� r
From To �(O Ft Ogg
K m6
From To Ft.
From To Ft.
7. GROUT:
Depth Material
Material o Method
tri-foFrom _ To D 0 FL GCB i')t f (`I reg D
From To Ft.
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
Diameter Slot Size Material
Ft. in. in.
Ft. in. _ In.
Ft. in. in.
10. DRILLING LOG
From To r
— r5
—15'— 101 '
\ oar — ')_cot
4--tA — 4 i o '
*to° — (005
R-EC
Ft.
Ft.
Ft.
Size Material
F�mtatqDescription,
�O
G Rae t'-rt3
e.F—Lc Nit eAc 15 G efs^
cRs l leis - 3 5 GPr"
11. REMjARAsheville Regional Office
N
0
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEDNJ ACCORDANCE WM1
15A NCAC 2C WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
RECORD HAS EN PROVIDED TO WE
1/
SIGNATURERF CERTIFIED WELL CONTRACTOR 'DATE
f5 l4-4_, I tZt. N) ASU
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mali Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05

l i e e.sk
CLI 2_Q2ve__
State Zip Code
( PS- }aIS- -f 3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: r `'
b. DOES WELL REPLACE EXISTIN(l WELL? /YES 0 NOW,
CQ 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 or below land surface may require
a variance in accordanceJwith 15A NCAC 2C .01188... _
e. YIELD (gpm): --7 METHOD OF TEST___Z]L_E_
DtP
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
�
WELL CONTRACTOR CERTIFICATION # q' 71
1. WELL CONTRACTOR:
Ci4/d a 1 jees .San LA)CII OR:
ye S(�w v2- 9�Stnl� 1i I( ik: iG
STREET ADDRESS /'( n$c / / L U U. r4U I
Well ontractor Comp#ny Name
Hof � 2=Anc apm43/
(gag» &45 c2ttza-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(r applicable)
DWQ or OTHER PERMIT #(IT applicable)
WELL USE (Check Appliica�le Box): ResidentialdWater Supply
DATE DRILLED '7 - / -• D ( e
TIME COMPLETED AM 0 PM 0
S
City own State - Zip Code
3. WELL LOCATION:
bCITY—:{ ,G l/K ri I e k. COUNTY --Bane ht�
�1CL.A ,1Q?,/e S4-4,17nes CO
(Street Name, Numbers, Community, Sebdivi , Lot No., Parcel, Zip Code)
POGRAPHIC / LAND SETTING:
Slope (Valley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS (Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form Inot using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
eytlkfl
City or Town
f. DISINFECTION: Type C 0lil (?i A.L j: - mount d
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
From Cd DToepth �s� Ft. DI(O �Y 5/�[�Weightr .'1/ Material
p/9.ST;
From To Ft.
From To Ft.
7. GROUT: Depth Material
From G5 To cal.Ft. i edt
From To Ft.
From To Ft
Method
Da ,Qe
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To Formatioi Desc' lion
/-/ /03 oueiL (.!•tU)GK—d•
/03 _ioS`
11. REMARKS:
J
CD
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, ELL CONSTRUCTION ST DS. AND THATA COPY OF THIS
RECORD HAS EN PROJID$D TO LL OWNER.
SI N TURR,TI/ W CONTRACTORD'' t l�
kce /7et PS
PRINTED NAME OF PERSON CONSTRUC MG 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
Well (Individual) ame

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 02143(4
1. WELL CONTRACTOR:
�eccteu 11ec.n SG.ayecS
Well Contractor (Individual) Name
C\yc+e 6a..-ecs 4-5oh
Well Contractor Company N
STREET ADDRESS
Ho tioc.ncSle
eokJ PC
City or
( Sa,. ldb,s- aoa
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID Ala applicable)
STATE WELL PERMIT#(W applicable)
DWQ or OTHER PERMIT A(d applicable) /
WELL. USE (Check Applicable Box): Residential Water Supply 27
DATE DRILLED 1" ' 2 C
TIME COMPLETED V,r v 1. AM ❑ PM ®/
3. WELL LOCATION:n
CITY: ///e-ck %*117t .. COUNTY aal1c de
843
-Zip Code
t(hdkPY (dde
(Steel Name. Numbers. Community, Subdiwaian, Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope °Valley ❑Flat °Ridge ❑Other
(check apprapdate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER ' Ilea
OWNER'S NAME / �/ 1/, 5 Ilea 5le
May be in degrees,
minutes seconds or
in a decimal format
STR AD�ESS
Elie
City 9r
own
( ; t yr9 — iS `ttl 0
Area code - Phone number
Zip Code
S. WELL DETAILS: r''f
a. TOTAL DEPTH: Y air
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Si
c. WATER LEVEL Below Top of Casing 4-30 FT.
(Use'+' if Move 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
f. DISINFECTION: Type O ,.\S
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
Amount a /
To
To
To
Thickness/
From t-\ DToo5( Diameter Ft. 6, 'MSni221 S ,
From To Ft
From To Ft.
7. GROUT: Depth Material Method
From 0 To PO Ft
C'etnen* eOuc1
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter S:ot Size Material
From To Ft in. in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRIWNG LOG
FrTo
om
S6
.5"G Var
11. REMARKS:
Formaticl Description
Cries tiv.(lkodl
(scon54e
r.,
my
v
u1
I00 HEREBY CERTIFY THAT THS WELL WAS CONSTRL'C1ED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF MS
RECORD HAS BEEN PROVIDED TO NE WELL OWNER.
y- 7-e
SIGNA RE OF CERTTI 9EDti L peNTacTOR DATE
11ecc.c'C MQc.k ' c»A 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-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 02143(4
1. WELL CONTRACTOR:
�evv'.CK A•kec. 'a‘.a?ec S
Well Contractor (Individual) Name
CAt- e Sa.A1eCS'e-5or1
Well Contracts Company N !�
STREET ADDRESS \VIP, S . 1-`tzy 20 r't
'Not 5-to c.ncs PC g8' 43
City or Tthn Stele -Zip Code
( 8a8q_ (otoS- a oat
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT Mil applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED y—‘ - G
TIME COMPLETED e.? AM 0 PM Ec/
3. WELL LOCATION:
CITY: jr. -. COUNTY 6aat0.01�r
Citesax-/ rare A'J,
(Street Name. Numbers. Community. Subdivision, Lot No.. Parcel. Zip Code)
TO GRAPHIC/ LAND SETTING:
lope ❑Valley ❑Flat CI Ridge ❑Other
(check appropriate box)
LATITUDE J_
LONGITUDE
Latitude/longitude source: 0GPS ❑Topographic map
(location of wel must be shown on a USGS topo map ar,d
attached to this lam Inot using GPS)
4. WELL OWNER
OWNER'S NAME ({ f
STJ,ET QRESS 3 -6 L t, r A e r 0l
,f
Coal let , flb
City or Town State Zip Code
(8 Y)- &93-/9s1/
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS: -7
a. TOTAL. DEPTH: of 0S
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO
e. WATER LEVEL Below Top Of Casing ‘0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
'Top d casing terminated atla below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): v(7V METHOD OF TEST R,
f. DISINFECTION: Type 0...N \S Amount /d
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From To
6. CASING: ameter Thickness/
From -3-' , Depth , To 2-? Ft (n 4, weight /J/43Ti!
From To Ft
From To Ft
7. GROUT: Depth �7 Material Method
From 0 To air Ft. CCaiznt Qow M
From To Ft
From To Ft
8. SCREEN: Depth Diameter Snt Size Material
From To Ft. in. in.
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRIWNG LOG
From To
Formaticn Description
°Ne-C tavostio,r
aos C3rafV,te_
11. REMARKS:
a�
I DO HEREBY CERTIFY THAT TH S WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C, WELL CONSIRUCItN STANDARDS. Nt) THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
yG G
SIGNATURE OF WE ONTRACTOR DATE
'neCv \C - 'Fk4o tti 60.30S- 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-la
Rea. 7105

RESIDENTIAL
RWELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 243(Q
1. WELL CONTRACTOR:
s ec e'.eic ''lecANn SaLay ers
Well Contractor (Individual) Name
C\ yde 6o -jQcs 'Sor
Well Contractor Company Nafne
STREET ADDRESS V-Wri P,S .-I-\W,y Qo q
1"10 CH or 4+n . Y1j Stale N• �
( 8a28). lobs- aoa.a.
Area code- Phone number
2. WELL INFORMATION:
08'7 43
-Zip Code
SITE WELL ID #(tf applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT Kif applicable) /
WELL USE (Check Appbca Ie Box): Residential Water Supply el
DATE DRILLED 1-. -(+
TIME COMPLETED "I ;3 e• AM ❑ PM fr
3. WELL LOCATION:
CITY: a/le .. COUNTY &Arno"4
Spt.714 %Koryo, '3'Z4c 4'
(Street Name. Numbers, Comdunity, Subdivision. Lot No.. Parcel. Zip Code)
TO RAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: iGPS ['Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form fnot using GPS)
4. WELL OWNER //�•
OWNER'S NAME ml/// ,,71ryI GiJFJ l,,l�t &
STREET ADDRESS 1' l 1 (1 V ; ST&- ES -Er S
C;,sIIeR n/1/45
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /D-S—
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2'
c. WATER LEVEL Below Top of Casing: /�' FT.
(Use'+' 8 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): av METHOD OF TEST
f. DISINFECTION: Type 0 . t \S
g. WATER ZONES (depth):
From
From
From
8. CASING:
To
To
To
Amount
From_ To
From_ To
From_ To
Thickness/
epth
From t\ DToQ / Ft (. ger S12 a) p/asf>
Fran To Ft
From To Ft
7. GROUT: Depth Material Method
��77 C
From 0 To o�0 Ft. eO%tfk POLLCec1
From To Ft.
From To Ft
8. SCREEN: Depth Diameter S M Size Material
From To Ft in. in.
From To FL in. in.
From To Ft. in. in.
S. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft
From To Ft.
Size Material
10. DRIWNG LOG
From TooC'7
1 /
/oS
t
1
11. REMARKS:
Formaticn Description
prfec 1. Ctio,rl
N
c-3
of
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRt'C1ED el ACCORDANCE Wag
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
s
SIGNATURE OF CERTIFIED W
y S =4
ONTRiCTOR DATE
necv c"c ikracken oc».s- at 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/t5

a
RESIDENTIAL WELL CONSTRUCTION RECO:2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # (214.34Q
1. WELL CONTRACTOR:
ltevv c.c rtkeeem MQwyecS
Well Contractor (Individual) Name
C f4e- 3CINA1 tCS c SC)
Weer Comactar Company Nan.
STREET ADDRESS VAAR S (any ao s
lion 5 ctnc's PC. 081743
City or TcFm L Stae -Zip Code
( eas} cobs- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a fd applicable)
STATE WELL PERMIT* applicable)
DWQ a OTHER PERMIT ; KW applicable)
WELL USE (Check Apo/able Box): Residential Water Supply Q/
DATE DRILLED 3-/2-
TIME COMPLETED V• QU AMci PMJ
3_ WELL LOCATION:
CITY: C4.v,/,Gr COUNTY VL,n Ca*t4C
VOL. Act S Coue #r
4Sbfet Naind, Numbers, Canmunity. Subdivision, Lea No.. Parcel, Zip Code)
TO RAPHIC / LAND SETTING:
lope °valley ❑FIat ❑Ridge ❑Other
(check appropriate both)
LATITUDE _2_
LONGITUDE
Latitude/Iongitude source: ❑GPS °Topographic map
(location of wel must be shown on a USGS tcpo map and
attached to this font trot using GPS)
4. WELL OWNER /ri ((rr l
l� OWNER'S NAME RI STL,
May be in degrees,
minas . seconds or
in a decimal format
CS/
STREET ADDRESS VOL.& . Coy¢ Rd
ea vkaVe Air
O l5
City or Town State Zip Code
( $al)- fofofl-fan 0\
Area code - Phone numbs
5. WELL DETAILS:
a TOTAL DEPTH: fa f
b. DOES WELL REPLACE EXISTING WELL? YES O NO V
e. WATER LEVEL Baas Top d Casing: .SQ FT.
(Use -+• 8 Above Top of Casing)
d. TOP OF CASING IS \ FT. Aloud Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.8.
e. YIELD (gpm): / METHOD OF TEST ft. ___t;
f.
DISINFECTION: Type Q,',\S Amount a.�
g. WATER ZONES (depth):
From To From
From To From
From To From To
6. CASING: Thickness/
Depth Ft 6. i•T(catilDiameter Weigit IriSi'e/
Ft
To
To
From -)r-N, To
From To
From 'To
Ft.
7. GROUT: Depth ��TT nMaterial
From 0 To g0 Ft Ce'en ent
From To Ft.
Method
POucpcl
From To - Ft
8. SCREEN: Depth Diameter S1Sta. Material
From To Ft. in. in.
From To FL in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To - Ft.
From To Ft
10. DRIWNG LOG
From To
1 G8'
(.0 faX
11. REMARKS:
Formati*, Description
f e.c 1�,,.cdo4n
=rra(Ni to
743
ry
0
iJl
1 DO HERESY CERTIFY THAT THS WELL WAS CONSTRUCTED VIACCORDANCE WITH
1SA NCAC 2C. WELL CONSTRUCT/ON STAM ARDS, AND I1ATA COPY OF THIS
RECORD HAS BEEN PROVIDED 70 THE WELL OWNER.
3-/7-E
SIGNATURE OF CERTIFIED W61eCONTRACTOR DATE
fecCACK 'tltctt•
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 # r2143(4
1. WELL CONTRACTOR:
�2cP',CK '\k€02M c-,k.ay es 4%
Wee Contractor (Individual) Name
%/ to 5a�1e cs a So h
Well Contractor Company Na
STREET ADDRESS tyP1P1 S . -\ sy o2o q
1-lot t :ng5 PC ei 43
-Zip Code
City or T S>ae
( 8aS)- (otoS- a op. n
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(iapplicable)
DWQ or OTHER PERMIT #('d applicable)
WELL USE (Check Applicable Box): Residential Water Supply I�
RI DATE DLLED S� 7 - G
TIME COMPLETED e) :30 AM 0 PM
3. WELL LOCATION: //
CITY: eeF/1 5 Crec e COUNTY J re n Coin 5 c-
G/ Ct -.. / /ed.
(Street Name, Numbers. Community. Subdivision, Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope OVafey ❑Flat ❑Ridge El Other
(check appmpdate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑GPS OTopographic map
(location of wed must be shown on a USGS topo map and
attached to this form 1 not usig GPS)
4. WELL OWNER
OWNER'S NAME TY,.wl to LJ.i.YfQt1E
STREET ADDRESS LISCt`Oy ('Cetc Road
May be in degrees,
minutes, seconds or
in a decimal format
t.leovat.r'tse i.Zc_ aria,
City or Town State Zip Cade
(B8>- a'13 115b
Area code - Phone number
5. WELL DETAILS: VS
a- TOTAL DEPTH: 2
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
e. WATER LEVEL Below Top of Casing: cr. 0 FT.
(Use +' if Above Top of Casing)
d. TOP OF CASING IS t FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
II.. YIELD (gpm): CCU 8.
METHOD OF TEST t'
f. DISINFECTION: Type I, % Amount 7
g. WATER ZONES (depth):
From To
From
From
6. CASING:
To
To
From To
From To
From To
Thickness/
From Di"t" � Two /./9Ft (o�!�eter Weigh M
From To Ft. ;era- Sreee /
From To Ft.
7. GROUT: Depth �1 Material Method
From 0 To oZ0 Ft C,2,nnent eow eA
From To Ft
From To Ft
8. SCREEN: Depth Diameter Slot Sae Material
From To FL in in.
From To Ft in. in.
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
Ft. in. in.
To Ft.
To Ft.
To Ft
10. DRILLING LOG
From To
1 //r%
11. REMARKS:
Size
Material
Formation Description
ONec c�, ct►o n
(_ too ice_
rl
>
J
1 DO HEREBY CERTFY THAT NHS WELL WAS CONSTRUCTED,/ ACCORDANCE virus
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, ANC THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF RTIFIE WD EICCONTRACTOR
Decc.c-c MQat4. 5oL„.y ac S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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.
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 # a 4 O
1. WELL CONTRACTOR:
Re VLbet\ Caleu 42-
Well Contractor (Individual) Name
Zt°wbQ#1 C �tc�w€.d Dct U1113 \ c ,
Well Contractor Company Name
STREET ADDRESS 35( 1/4(1 V CO Lei ceS*e
J'\C11QLj\1 ie N C a-1 o b
City or Town State Zip Code
(<6a%4-3s%
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable B9x): Residential Water Supply 01
DATE DRILLED a-4 / ° (O
TIME COMPLETED 1.-- 3 b AM O PM fit'
3. WELL LOCATION: /�/
CITY: U.)e A V e(\J t t l_L COUNTY Igt'e'l Ate ,
C L14LsrvGel"( re--"b
(Street Name. Numbers. Community. SubdMsion, La No.. Parcel. Zrp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley LyrClat ❑Ridge ❑Other
(check appropriale box) r
LATITUDE 3 5 45 .3 D (3
LONGITUDE ? a 34 - 35 p
Latitude/longitude source: I'(GPS °Topographic map
(location of we# must be shown on a USGS topo map and
attached to this form if nor using GPS)
4. WELL OWNER
OWNER'S NAME
May be in degrees.
minutes, seconds or
in a decimal format
C_thas jixiaie ..S
STREET ADDRESS as e--L-C 41.75.33C-)E j7 L t) -
.13 WV! n3s t L-L_ e- I•3- a gi g l
City or Town State Zip Code
(51aK ). (O5'1 - 4 al to
Area code - Phone number
5. WELL DETAILS: ,1
a. TOTAL DEPTH: 3 45
b. DOES WELL REPLACE EXISTING WELL? YES NO II
c. WATER LEVEL Below Top of Casing: 0 FT.
(Use -+- it Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top o( casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): la METHOD OF TEST RtQ - A 12-
/
1. DISINFECTION: Type
g. WATER ZONES (depthh).
From [A D To 9
N(s)
4 CIV6 Amount o Z
From To
From 3 3 (o To 331 From To
From To From To
6. CASING:
Depth
From To i a Ft
From To Ft
From To FI
Diaru ter
ISrr
Thickness/
?RN
Mtateual
YVI�
7. GROUT: 1 Depth Material Method
From 1 To �a Ft. CR fnlaNt (2-To 0
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
From To
From To
From To
10. DRILLING LOG
From r To
- la k
at
\-i % t .- 1-t9 '
\1S'- 3 3(0
336'- .3.9'
--nil- 345
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formmation Description
b \J 6 el &'.) (L O < rJ
G ZA.> C[c
t •`oy tc .- 1 GPM
G a.n a '1-
c to + \ c E - 91 (=t'
C:iatke•a Te,
(13
1 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.
biLACAA Q9-Qd(,a 4bDb
SIGNATURE aCERTIFIED WELL CONTRACTOR
t%r.R; eaftSU
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Into
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 56
ation Mgt,
Rev. 7/05

RESIDENTIAL \YELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality.
WELL CONTRACTOR CERTIFICATION # "L 1 4 1
1. WELL CONTRACTOR:
C - lot' t\ C,ctik1,,,c a 11
Well Contractor (Individual) Name
C oAcLA,t.'P_t\ 71
Well Contractor Company Name
`\ I
STREET ADDRESS '15 I W (t Lea CAS NI"'
4\S 9U l.Q t.iC
State Zip Code
(gag)- ash- -36tt
City or Town
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appli ble Bo : Residential Water Supply
DATE DRILLED v 0 te
TIME COMPLETED c AM ❑ PM
3. WELL LOCATION: L
CITY: � f��;v E� V.1 (lQ COUNTY a�ui
t o C -at 3 't . Q_, C 4 C p 0� 57 r1-C� S
(Street Name. Numbers1Community. Subdinsion. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LANB SETTING:
❑Slope DValley &tat ORidge ID Other
(check appropriate box) LATITUDE 3 5 44- • 'y 7'S O
LONGITUDE 14 . c 3
Latitude/longitude source: prOPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form if not usig GPS)
4. WELL OWNER _
OWNER'S NAME ?It Li4.l.j C.0 NS IR.JC-(I 0
STREET ADDRESS '3QS 1' ` AC Nt) L ;,) 4'-/
1
May be in degrees,
minutes, seconds or
in a decimal format
1
City or Town Stale Zip Code
( Sal )- G,S iC t b 5"
Area code - Phone number
5. WELL DETAILS: JJ y'
a. TOTAL DEPTH: .) 9 .)
b. DOES WELL REPLACE EXISTING WELL? YES CINO I
c. WATER LEVEL Below Top of Casing: 0 C FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING 15 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .01118.
e. YIELD (gpm): 1 � METHOD OF TEST 1\1C7 ' I'I I a-
I. DISINFECTION: Type try Ddi 1
g. WATER ZONES (depth).
From 24I To ;1h)a From
From To From
From To From
6. CASING:
Depth°
From J To `3 '-
From To
From To
Ft
Ft
Ft.
ete
To
To
To
Thickness/
WeighVVeight Material
7. GROUT: II Depth a. MateriaL/ Method
From --1. To hi p Ft (� . C rla'rp _I" roe-' Le
From To Ft.
Frorn To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
9.
From To Ftin. in.
From To Ft. in. in.
SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From, To
Size
Material
Formation Description
.S 't 0- \I ,1-t_;."_.,3e hl
`iS'— 4-4Ig C 1.-La.:rr
k4 11 a '-CI c&' c 4e V 1(✓C? - lb `; PM
a41%- 3D`i' r`, flit cl" .
11. RENIARKS:
I WHEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WrrH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND 111ATA COPY OF THIS
RECORD HA BEEN PROVIDED TO THE WELL OWNER
,€%t eo-Qc ,,,&9 4/3/ 6
/
SIGNATURE-10F CERTIFIED WELL CONTRACTOR / DATE
I /
PRINTED NAME OF -PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Ir
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] e
ormation Mgt.,
t 568.
Fonn �W-1a
Rev. 7 05

OCRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 1434
1. WELL CONTRACTOR:
l% e c-c c (ec torn f G W y et s
Well Contractor (Individual) Name
C\ yc+e iecs so r
Well Contractor Company Na e
STREET ADDRESS \y"\S Fi "NW-1 Qo C1
14o4
« c nqt PC•
ty
( Bag, lobs- aoa�
?87�3
• Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(B applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
L _
DATE DRILLED / /i- C
TIME COMPLETED /,'0 U AM ❑ PM m-
3. WELL LOCATION: �/
CITY: �( li' COUNTY 1 enycoe.Y b'
/ K
(Stree4,Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TO GRAPHIC / LAND SETTING:
tope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitudeflongitude source: ❑GPS ❑Topographic map
(location of we9 must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER ()
OWNER'S NAME 1 e dl- L,
sTg l�Q ss hi(
Li OY VV5L /
(City or Town State Zip Cade
073- 17/2
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a /S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c.. WATER LEVEL Below Top of Casing: 70 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): oc2 0 METHOD OF TEST R. q
t. DISINFECTION: Type cr. \
..\'S Amount /oi
g. WATER ZONES (depth):
From To From To
From
From
6. CASING:
To
To
From
From
To
To
Thickness/
From 1r-\ To 9/Depth C) Ft. , Dian%!er We�9h!a)
From To Ft. Mpla ;.
�Y
From To Ft.
7. GROUT: Depth r] Material Method
From 0 To aO Ft. Cen'1efl{ QouteA
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Sht 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.
Front To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
I go
p.1±-5 ,.ctlu.n
`Ci y 5 (Tccack,ice
1K REMARKS:
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRIXTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
c
NT
SIGNATURE OF CER I IE ELL CONTRACTOR DATE
Decc.c_c M>zat`. 6a3A-// Cc S
PRINTED NAME OF PERSON CONSTRUCTNG 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 # 73(Q
1. WELL CONTRACTOR: - -
ecc•,ctc 1i2C%4t SRWyecS
Well Contractor (Individual) Name
C,\ yde 6CLAi eCS er So h
Well Contractor Company Nene
STREET ADDRESS VyAR S . --- ury 20 q
Not is kngs., PC - 08'7 43
City or Tc+en ,..)Scree - -Zip Code
( 9as} (obs- a co.
Area coda Phone numbs
2. WELL INFORMATION:
SITE WELL ID Rif applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT Rif applicable)
WELL USE (Check Applicable Box): Residential Water Supply I
DATEDWLLED Y'///
TIME COMPLETED V,'OO AM ❑ PM 1<1--
3. WELL LOCATION: / //
CITY: ) S/�y��p6hD COUNTY /,)GA4d Al OP
(r"/,can /Ai Ace £A
(Street Name, Numbers, Carlmunity. Subdivision, Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minute . seconds or
in a decimal format
Latitude/longitude source: DGPS [Topographic map
(location of welmustbe shown on a USGS topo map and
attached to this form foot uscrg GPS)
4. WELL OWNER
OWNER'S NAME fl'1 Riexasi
STREEp ADDRESS /2.1
City of -town State
Area code - Phone number
5. WELL DETAILS:
��
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 11
c. WATER LEVEL Below Top of Casing: 70 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 Wpm):ad METHOD OF TEST R..�
T. DISINFECTION: Type[• ,\\S
g. WATER ZONES (depth):
From
From
From
To From
To _ From
To From
Amount a3
6. CASING:
Depth Diameter
From "d'� To�2 Ft. Cp.'*1
From To FL
From To Ft.
To
To
To
Thickness/
Weight
71s '
7. GROUT: Depth �t /�Mateial Method
Frain 0 To o0r3 FL C er,sn.t pow M
From To F_
From To F:
8. SCREEN: Depth C iameter S'.ot Size Material
From To F . in. in.
From To F . in.
From To F. in.
in.
in.
9_ SAND/GRAVEL PACK:
Depth Size Material
From To FL
To Ft.
To FL
From
F
From
10. DRIWNG LOG
From To Formation Description
1 99
(rlec t3, cctu n
�Y V& C Csccan,te
O
PO
11. REMARKS:
WO HEREBY CERTIFY THAT THIS WELL NAS CONSTRLCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUC ON ST%HOARDS. A. ND THAT A COPY OF tWs
RECORD HAS BEEN PROVIDED TO THE 1VELL OWNER
SIGNATURE OF CERTIFIED WE
R4CTOR DATE
'1' ect' ACK )kern .tom 5cl?Jy 2.0 S
PRINTED NAME OF PERSON CONSTRUCT ;NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Ngt,
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 Wafer Quality
WELL CONTRACTOR CERTIFICATION # 2`I3(Q
1. WELL CONTRACTOR:
Dec(`teu 14ecw, SQ‘ayecs
WM Contractor (Individual) Name
(`
Wen Contractor
cs � `IO C\
Company
pany
STREET ADDRESS k` API S : 1-\t.7sy carp q
1413*
"alf< 1. ast e PC
City or Trri
( Baer,_ fobs- a oar
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Irfd apprrcable)
STATE WELL PERMrr#(Bapplicable) DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply
�t1
DATE DRILLED l /0 - C.
TIME COMPLETED /,4.0 0 AM O PM h'
3. WELL. LOCATION: /n
CITY: lUe4LY/ ti;(/�e .:: COUNTY /3 Cr ramlie
a8'7 43
-Zip Code
2n
(Street N
Do letCan( tiky41
. Subdivision, La: No.. Parcel. bp Code).
TO RAPHIC / LAND SETTING:
lope ❑Valley ❑Flat QRidge ❑Other
(check appmpdate box)
LATITUDE ._
LONGITUDE
Latitude/longitude source: ❑CPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form /not using GPS)
d. WELL OWNER
OWNER'S NAME 1h:t<i Vag.?yy�� P/C
S,TTRR�EET ADDRESS Sao !T ' it tl fir em) s
We4ierablto jl('-
May be in degrees,
'minutes seconds or
in a decimal format
City a Town Zip Code
(2071)_ BSI— /
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH: ri
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1
a WATER LEVEL Below Top of Casing a`//FT.
(Use +' B Above Top of Casing)
d. TOP OF CASING 15 i FT. Above Land Surface*
'Top of casing terminated /or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
/
e. YIELD (gpm): d METHOD OF TEST R.
f. DISINFECTION: Type 0,I\S Amount r
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
From Jr
\ er
o Depth _ FL k
Fran To Ft
From to Ft
7. GROUT; Depth ��n1
From 0 To acO
From To
From To
To
To
To
Thickness/
Schaal
Material Method
Ft ee'o- enj pau.tM
Ft.
Ft
8. SCREEN: Depth Diameter Sot 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
To Ft.
Size Material
To Ft.
To Ft.
10. DRIWNG LOG
From To
1 .3l
Formation Description
3Tcatcn,te
11. REMARKS:
-o
J
0
0v
I DO HEREBY CERTFY THAT THIS WELL w AS CONSTRICTED N ACCORDANCE rine
15A NCAC 2C. WELL CONSTRUCTION STA 'CARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEu OWNER.
//// r tr
SIGNATURE OF CY I1FIED WEl1 CQ TOR DATE
tect`\CK 'KQ.Csth--.:ya.azy acs
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information M(It,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7705

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N�af(U,rall Resources�kb - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) !�/-7Ob /k I[L) (nCERTIFICATION #Z7'/
/%
WELL CONTRACTOR COMPANY NAME ()!r✓,�Ae its (,(,l[.if <[ Porp PHONE # f((,C‘1
VI ATE WELL CONSTRUCTION PERMIT# /t/ J 2— ASSOCIATED WQ PERMIT#
(if applicable) " (if applicable)
1. WELL USE (Check Applicable Box): Residential !DV—Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WEI.I.LOCAT1Ot4
Nearest Town: a/id /P/-1 County
(Sued Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
11 (Street or Rout
Aie No
o
J-t %evd41?
_ L$ ❑y or:I own State
Iff
1 t .t-{
Zip Code
60)- SI l5/7
Area code- Phone number
4. DATE DRILLED 3-Zi-0 1.
5. TOTAL DEPTH: / O O..i
,. DUES WELL U1y:P1 A(•1: 1:VIV'I IMIG Url.l 1 .) VI.I I I NO f I
7. STATIC WATER LEVEL Below Top of Casing: 950 FT.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
'lop of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2-/-/4i
10. WATER ZONES (depth):-6D51-70S
1 1 . DISINFECTION: Type
12. CASING:
Depth Diameter
From_0 To 30 Ft. . '
From To Ft.
From_ To Ft.
13. GROUT:,rDepth
From 0 To 2-0 Ft.
Amount
Wall Thickness
or Weight/Ft. Mptt rial
�V
Material (rirl aA t
From To Ft.
14. SCREEN' Depth Diameter
From _ To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Method
/U�
Slot Size Material
in.
in.
From_To Ft.
16. REMARKS:
Topogra ic/Land setting
❑Ridge QSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forrraation Description
DEPTH
From To
-3 D'
ail - lc(I 5(
Law
rahLP(
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.
rp
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
( ONS I RIK N STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
_ �14 ,Ve? x' � 1 y-5-- 6
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 rall Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) JlLA' J' 1Lb I� CERTIFICATION #2-4fILr
ELL CONTRACTOR COMPANY NAME CI re f/i e b (t-1,,
s. , V �j. Yi v, nl ,
STATE. WELL CONSTRUCTION PERMIT# /' O a- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # lam ') C. (/, 6 - 3 / % C%
1. WELL USE (Check Applicable Box): Residential V Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LO('.ATIO : Nearest Town: ill she 'P County 6t.n'k.t
(Street Name. Numbers Community. Subdivision, Lot No., Zip Code)
3. OWNER:
Address
treet or Route No.)
)s"01kti 1L9L 2871
(iry or Town State Zip Code
it‘cti'C(I&O
Area code- Phone number
4. DATE DRILLED 3" %-O (o
5. TOTAL DEPTH: 42 O .5-
1;. DOES '1;;.l t REP! A(.1. I:v ICI INi(: WELL! o vI. 11 NI1 1 I
7. STATIC WATER LEVEL Below Top of Casing: 20 O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
"lop of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST ZF-yr�s
10. WATER ZONES (depth): 3 bS
11 DISINFECTION: Type Writ
12 CASING:
r-t Depth Diameter
From 1, To 3 Ft. n
From To Ft.
From To Ft.
13. GROUT: Depth
From O To at) Ft.
Amount
Wall Thickness
or Weight/Ft. MAterial
Material
eke e4.'f
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Method
flop
Slot Size Material
in.
in.
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting ze�
❑Ridge ❑Slope OValley QElat
(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
-t a.Y tanck
01-30
31' bc5'
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.
(3
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL —"
(ONS"I RUCTION STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TITE WELL OWNER
1(
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

RESIDENTIAL WELL CONSTRUCTION REC DRD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2L{?Ln
1. WELL CONTRACTOR:
i� zcc :ct !'S. 6c izyec.s
Well Contractor (Individual) Name
C\yde & iecs A- Sof\
Well ontractor Comet/ Name
STREET ADDRESS 14W 5 Kt9 aC
No} 6 c z . qc,, NC 1811-13
City or T " State - Zip Code
(8at3)- (ogs- ;caeca
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #of applicable)
STATE WELL PERMIT/Kir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicableBox): Residential Water Supply 0
DATE DRILLED 1'/--J7" .J 7 ?a
TIME COMPLETED 6 AM 0 PM ED--
3. WELL LO/C'A'�TION:� //JJ
CITY: 67» �'4r _ COUNTY /3prCoel1.S//
P
AMA �J. ?-io' W.As Lck El
(Street Name. Numbers, Community, Slibdiyision, UN No., Parch. Zip Code)
TO1PPpGRAPHIC / LAND SETTING:
6J,SIope ❑Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form /not using GPS)
4. WELL OWNER
OWNER'S NAME QoV QC ieE\C
STREET ADDRESS %fl Ca'cvd\ec EZd
ENSV ev .E\e- y + � G a9Q,o6
City or Town State Zip Code
(?-gie (PPS- C1Ds1
Area code - Phone number
5. WELL DETAILS: u ^ -
a. TOTAL DEPTH: O[ J /
b. DOES WELL REPLACE EXISTING WELL? YES El NC) (
c. WATER LEVEL Beim Top d Casing: 37) FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
. 'Top d casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpmf S METHOD OF TEST R.A
f. DISINFECTION: Type i I\S Amount a/
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/ �^�}
From � ToMDiameter Weight OS F.. L � sWc2 ( f /4 /c c
From To F .
From To F .
7. GROUT: Depth Mater al Method
From n To 'ao F. CS.:Ova} ?OL).Ctsk
From To F.
From To F.
8. SCREEN: Depth Ciameter Slot Size Material
From To F'. in. in.
Fran To A. in. in.
From To Fl. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILUNG LOG
From To
/ 025
Formatio- Descriptio
Cs) UPr" etc. •' h
ai 1 c r bran. /r
11. REMARKS:
1 DO HEREBY CERTIFY THAT TICS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION S ANDARDS, /NC THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE NELL OWNER
SIGNATURE OFCERTIFIED W.1- L CONTRACTOR DATE
per ACC. k
.44/10 S 13y/ft,
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.
Faro GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Valet- Qua ity
WELL CONTRACTOR CERTIFICATION # 24?Lo
1. WELL CONTRACTOR:
\ecc_e.1A\k. 3O4 reC
Well Contractor (Individual) Name
C\ode S>.s'jecs k SGcN
Well ontractor Comp yName
STREET ADDRESS k4 'tR 5 11.J)
]tour:. q5)) NC a 8" H 3
City or Town `-' State Zip Code
( Berl)- totes- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i1 applicable)
STATE WELL PERMIT#(n applicable)
DWO or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3-.2 C.
TIME COMPLETED -/ 13 J AM 0 PM IN---
3. WELL LOCATION:
CRY: 6
/O//c / /c /. 1io\\.j W.ki s Lei V
(Street Name. Numbers. Community. Subdiesion, c4 No., Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING:
0Valley ❑Flat ❑Ridge DOther
(check appropriate box)
aocl
qd�^
LATITUDE 3
LONGITUDE
Latitude/longitude source: GPS OTopographic map
(location of we/ must be shown on a USGS topo map and
attached to this form Inot using GPS)
COUNTY obird/lteC
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME PC) P OCta1-1C �Tf
STREET ADDRESS '1"I �.nd tees icn&. `S
WS1,veNi \tee T ADC ae3Bratp
City or Town State Zip Code
(ea% >_ ( - 9ts
Area code - Phone number
5. WELL DETAILS: i;
a. TOTAL DEPTH: Y
U5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (1'
c. WATER LEVEL Below Top of Casing: .SC) FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS k 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): / S
METHOD OF TEST LZ.)Q
f. DISINFECTION: Type4'a 11S Amount ,a(1
g. WATER ZONES (depth):
From To Fron To
From To Fron To
From To Fron To
6. CASING:
Depth Diameter
From / To a/ Ft. %
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To 20 Ft.
From To FL
From To FL
Material
Thickness/
Weigh Mrattniral/
Method
8- SCREEN: Depth t iameter Slot Size Material
Fran To FL in. _ in.
From To FL in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To II.
From To It
From
To It.
10. DRILLING LOG
From To Formation Description
a / OUP^ dt.,,J.49
a I c16 S Eft an 71-e
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WEL . WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT1ON f TANDARDS, NC THAT COPY OF PBS
RECORD HAS BEEN PROVIDED TO WELL OWNER.
SIGNATURE OF CELRTIFIED�/6. ECLCONTRACTOR DAT
yrC fC /I�r GY _GNe/-.0
PRINTED NAME OF PER ON I;ONSTRL CT-Nd'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 CERTIFICAT ON # 3 / 410
1. WELL CONTRACTOR:
l.C/iJPES
V.ell Contractor Individual) Name
/-.ErlicoNS lb itII and �'uh1p, U--C,
Well ontractor Company Name
STREET ADDRESS 37 / LL(p �E� l/(/. 4 &
J.5/t sjet Nr(. eR87gg
City or Town / State Zip Code
g�R )- a58-- gq9
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(i/ applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED �"1= 27' o c.
TIME COMPLETED ../Z a
3. WELL LOCATION:
CITY:eh
Ocotr�
,44 #Usi' (-evil..0g-
(Street Name, Numbers, Community, Subdiasion, Lot No., Parcel, Zip Code)
TOP GRAPHIC / LAND 041;0Pe DValley ❑Flat Li Ridge ❑Other
(check appropriate box)
LATITUDE 3 r %l nc
LONGITUDE r 2. .2S. Ss 1
AM ❑
PM Er.
COUNTY 4rn,�
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: L3dPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this Corm if not using GPS)
4. WELL OWNER /J
OWNER'S NAME Afteler�sC-04 �7,(z��s,e.
STTEET ADDRESS 40 eiSri tali 5 mJ
ei//e Air AKBa4,
City or Town State Zip Code
t 2_)- 6 65 - 96.6
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ybf
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C3v"
c. WATER LEVEL Below Top of Casing: rD 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): J METHOD OF TEST
n g if
d,i'1i9
f. DISINFECTION: Type C/#.r L Amount /f A%,
g. WATER ZONES (depth):
From Z rip To From
Frain Jr-0 To From
From To From
6. CASING:
Depth Diameter
From %% To for Ft. 4,/7r
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
7. GROUT: Depth
Depth Material Method
From N To NO Ft. Concrete. "))jo/ rmi
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
From . To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
6,- 20 CAL.ti
3o: ?f' Skq
3 r - £,C2
11. REMARKS:
m
-v n
1 ' S
p.�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C. WELL CONSTRUCT/3N STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
•-/7-0t
SIGNATURE OF/ERTIFIEDWELL CONTRACTOR DATE I
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 1410
1. WELL CONTRACTOR: /.i
-BIZ/4,u al Al ES
WA.I Contractor If.
Name
r
Et iSOM3 b Jt I/ add ?w np LLLL
Well ontractor Company
Name r
STREET ADDRESS rQ /J/ /[/.- to
IC • a87Yg
City or Town / Stale Zip Code
(S )- ;352-- gLici .
Area code- Phone numbs
. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(n applicable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply V
V-/r-LYe
DATE DRILLED
TIME COMPLETED L - 3J AM ° PM a
3. WELL LOCATION:
CITY:
C /h.- COUNTY 44tw.Je
/4(014 24•4 elf +/Ira tot /i
(Street Name, Numbers, Community Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 1 JY. SCY
LONGITUDE f L 10. / 7t
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: ErePS °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
OWNERS NAME µd r tan )y//�tSin
i ,es
STREET ADDRESS. �Q5r 42,cse/L1.Jfit
1:44r4e. v NC of 1(73 eg
City or Town State Zip Cale
bas } £Q81-Sy 7
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: VQr
b. DOES WELL REPLACE EXISTING WELL? YES ° NO lEr
c. WATER LEVEL Below Top of Casing: /QO FT.
(Use ifAbove Top of Casing)
d. TOP OF CASING 15 / FTleAbove Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2 L METHOD OF TEST
R n e 4-1
c1v1
t. DISINFECTION: Type C'o. c Amount 7.10
g. WATER ZONES (depth):
From Z 'S-- To From To
From <'70 To From To
From To From To
6. CASING:
Depth Diameter
From 0 To L3 Ft. L ,..,-
From To Ft.
From To Ft.
Thickness/
Weight
ffax' i
Material
Fric
7. GROUT: Depth /ZMaterial Method
/�
From F� To 20 Ft. Concrc1ct ?you j
From To Ft.
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
Diameter Slot Size Material
Ft. Ft.
Ft.
in. in.
in. in.
in. in.
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
Material
From To Formation Description
Ci 54it
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC ]C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF jERTIFIIEDWELL CONTRACTOR DATE
PJAA-N l). UJ, /V65
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 #
1. WELL CONTRACTOR: /' /
fd JC yTA) LUiW�ES
II Contractor Individual) Nam
/let ce �/np,
Well ontractor Company Name
STREET ADDRESS
City a Town / State
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Boxy. Residential Water Supply p'
DATE DRILLED T- Z.r- OG
TIME COMPLETED ?I3J AM ❑ PMQ-
3. WELL LOCATION:
CITY: V4A.A/ COUNTY �n,cn •ii
fa,%,.,
(Street Na Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat i,�Ridge DOther
(check appropriate box)
LATITUDE 3 Y
LONGITUDE �" L 37, 2/40 '
Latitude/longitude source: Er PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this forma not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
STREET ADDRESS * A'ck 4. 1k /few (aNe__
We4.derv,Ne -/✓c / 03878 7
City or Town
State Zip Code
(&a _)- IC 95- #52 41
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 7o'r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l3'
c. WATER LEVEL Below Top of Casing: VO
(Use •+' if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated at/or belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD {gem): ?, METHOD OF TEST
FT.
f. DISINFECTION: Type r'4:1---ve
g. WATER ZONES (depth):
From /VI✓
From Zria
From
6. CASING:
From 0
From
From
To
To
To
Depth
T BP
To
To
Amount /7 4.43
From To
Frain To
From To
Thickness/
Diameter Weight Material
o z Ft. L✓2r -.Glyn
Ft.
7. GROUT: Depth
Ft.
Material Method
From P To Ol`O Ft. COACrcte- 7OL1fiiVi
From To Ft. /
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From . To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0- ri
t7-4z
cz- ?Jr
11. REMARKS:
Size Material
Formation Description
34 i/
N
I•1
-O n
en 4
cri
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WrTH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
�ti-✓ Y-Zr-oc.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
J�D)A/}N I?, /2r'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-
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. W CONTRACTOR: %�
`v'' (/ /N(I PO
W 1 o act (►ldjvid al) Nam
° /S kTE 11 Ord it p, u.._c.
Well ntractor Company
/Name JIjK
STREET ADDRESS GI Ie�1 /i hi 1.
lfr s-f-g ACC- a81
City or Town 7 State
( y )- 52--9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
s
Zip Code
DATE DRILLED
Oia
TIME COMPLETED///V AM ja<IN❑
3. WELL LOCATION: CITY: o,2' �r4 COUNTY 19L/ 1 hr
Caine G//4f 411
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAP / LAND SETTING:
[' Slope alley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE ,1%3.5' 3/ 613/
LONGITUDE10$7. /aa,S�'r
Latitude/longitude source: L��PS ❑Topographic map
(location of weB must be shown on a USGS topo map and
attached to this (omit not using GPS)
4. WELL OWNER /,
OWNER'S NAME/v/'( //
STFj ,ET ADDRESS /73 (2- vat d
.,Gi ire / 7 )q7f/
City or Town State Zip Code
(g2 >_ a73-0766
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: .7QS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL BelovTop of Casing: lD FT.
(Use'+- if Above Top of Casing)
May be in degrees,
minutes, seconds or
in a decimal format
d. TOP OF CASING IS
FT. Above Land Surface'
-Top of casing terminated agar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /S METHOD OF TEST1Shly is 4
33
✓ • .yi f
f. DISINFECTION; Type C (a'/ s-r Amount
g. WATER ZONES (depth):
From To /CO From
From To 21J From
From To From
6. CASING:
roc.
To
To
To
Thickness/
Depth Diameter Wei9ht Material
From To 76 Ft.�Ar%,S 2./G.y�,r P1CCN2Z/
From To Ft.
From To Ft.
7. GROUT: 0 Depth /) Material
FromTo 10 Ft. &4CPEde
Frorn 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
O rVS
95 -7/
7/ - 74
7; ` .S
11. REMARKS:
Formation Description
da
SaeloesYch -
6Zo�K
%t/'w nil 7'
A-
C/f
LLf-:: I Lj
-73
.X
N
ice
CD
tT
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEE PROVIDED TO THE WE .s • NER
CERTIFIED
Jhtih UJ, fla
PRINTED NAME F PERSON CONSTRUCTING THE WELL
O
6
ATE
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 / 70
1. WELL CONTRAC1�TOR:
1 Contractor ((Individual) Name
A L
EZGU caNs 11 fEII .�z.rd Lt�np
Well ontractor Company Name / r
STREET ADDRESS d 31 Alp LE/ 6E -IEC fWy-
LG- ui-s)ea K c • a87yg
City or Town / Stale Zip Code
($.R ,- 58-' 8491z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applica ie)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply D'
DATE DRILLED r'fO — 0C
TIME COMPLETED 'tee AM PM d./
3. WELL LOCAJJON: p
CITY: A I . COUNTY4 4V.-FIf
�tnta il.�f
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOBOGRAPHIC / LAND SETTING:
Slope oValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 f S t -7 23
LONGITUDE r z 440. zarr r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: L3'd S ❑Topographic map
(bcation of well must be shown on a USGS tope map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS %e 4
rc k 6..S
City or Town State Zip Code
> 777 3ct1G
Area code - Phone dumber
5. WELL DETAILS:
a. TOTAL DEPTH: 2'r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO gr"*"
c. WATER LEVEL Below Top of Casing: qr.? 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): /r METHOD OF TESTA)p(IJThy -i?p
63 es, ti v 11
4 (,f
t. DISINFECTION: Type (�Zor-:.c Amount r`r S�
g. WATER ZONES (depth):
From ��o To
From To
From To
6. CASING:
Depth
Frain d To/2r
From To
From To
7. GROUT:Depth
n
From (� To No
From To
From To
From
From
From
Diameter
Ft. titer.
Ft.
Ft.
To
To
To
Thickness/
Weight Material
Jae?"' /'LC
Material Method
Ft. COncrcfe �jp Uf[N4
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 Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D-lea
'7i -'2'
"ex-- zoc
11. REMARKS:
Material
Formation Description
rut,
to
m
t
O
1T
100 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.
7r
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
PrAN k Dives
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Y
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.
Fomt 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 / qC
.. n •• 7 c,
1. WELL CONTRACTOR:
Individual) t(%,vES
I Contractor Name
re4 scN3 /i la /I a#i I"amp /.LC
Well ontractor CompanyName
1 ��C1 Jr'
S1 RREET ADDRESS 3 31 Au LE/ l EQ ('(Lih i•
!J= /'(ts Jet it (• a87gg
City or Town / State Zip Code
(2. R )- 352 Sti9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box), Residential Water Supply Er-
-DATE DRILLED S2S -0C,
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION: oo
CITY: �' K COUNTY /9“— or, se
(Street Narn4, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
�TOO�POGRAPHIC / LAND SETTING:
13 ope 0Valley ❑Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3 3 a' )-yr'
LONGITUDE r Z UD, S//
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: C+1GPS ❑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, [(,/r 44
ST T ADDRESS // / �u ���
�4.�Z, 2 S7/C
City or Town State Zip ode
L2._r �5-(�099
Area code - Phone number
5. WELL DETAILS: ^�
a. TOTAL DEPTH: L r1"
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: to D
(Use `+` if Above Top of Casing)
FT.
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): / Z METHOD OF TESTAJhwif1"— it
f. DISINFECTION: Type 0/Gv--I.P
Amount J s
g. WATER ZONES (depth):
From /Lo To From To
From 2rr To From To
From To From To
6. CASING:
Depth Diameter
Fran 0 To 9r Ft. L!C!'
From To Ft.
From To Ft.
Thickness/
Weight M terial
-Srl.C2( �v L
7. GROUT: Depth
Depth Material Method
From (� To ;�a Ft. CoACrefc ?Du fi/Yq
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.
Material
From To Ft.
10. DRILLING LOG
From To Formation Description
D-co CA/
sr -
r-... �. .)nn•� Tlmm7
1 cJ
oo
d9
11. REMARKS:
J
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 BEEN PROVIDED TO THE WELL OWNER.
41/>-awe
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Pr4N 1< b Nes
RINTED NAME OF PERSON CONSTRUCTING THE WELL
S- 2f-Oc
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. Wgl,) CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Id, Po
1/,11 Contractor ( al) Nam
AR I(S0r1/s fEIl Oki LAX.
Well X.
Well C)ntraclor Company
/Name2)A� I
STREET ADDRESS r Ie%t /1t-
Lpi skg I ACC. a574-9
City or Town , State Zip Cade
( WV )- 58-W194.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(6 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Ir.--
DATE DRILLED 4 C4#
TIME COMPLET D /y/7,1g0
3. WELL LOCATION:
AM PM O
CITY: 4i{ PievA %,'() COUNTY N/nrOrl7ce
Ara.- /vtmgG /x1 r' /3
(Street Name, Numbers, aemmunity, Subdivision, of No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTIN :
❑Slope :Valley :Flat agidge ❑Other
(check appropriate box)
LATITUDE �S ?t VI 93S
LONGITUDEa)OIa. /5476 t
Latitude/longitude source: 2: ES ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form / not using GPS)
4. WELL OWNER ifiL4-4—,
�/OWNER'S NAME WUfe- �j-p-/
STREET ADDRESS3S' �jyy/ x77 ('
(kZ InG.YL/rZt_ %1%e
City or Town State Zip Code
( `L 6,24-r31/
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
JOS
b. DOES WELL REPLACE EXISTING WELL? YES NO
c. WATER LEVEL Below Top of Casing: / VO FT.
(Use '+- if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated al/or below and surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD
(gpm): METHOD OF TESTikbjj ij— 1r4j
2
40.k )
L DISINFECTION: Typef'A kncd C Amount f$Q >_
g. WATER ZONES (depth):
From To /Vr% From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From:To 6' Ft. 6,dS 2/6./25' Pre C4C /
From To Ft.
From To Ft.
7. GROUT: Depth Material /
From 0 To 410 Ft. i fc'PEfg
From To Ft.
From To Ft.
Method�
' J
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
To Ft.
To FL
To Ft.
10. DRILLING LOG
From To
17 - ?o
1p —ss
ss - 60
b° SQV
11. REMARKS:
Size
Material
Formation Description
ea y
c noisid Al c
I-0r�S
--O
c
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 0
PRINTED NAME
CONTRACTOR
DATE
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 fi .3 / 74.)
1. WELL CONTRACTOR: f. DISINFECTION; Type C
/Y es g. WATER ZONES (depth):
1 Contractor (((Individual) Name
!� (t��E� 1i► I C ,
From 17o To
El0ce heGa#�MppL -
Weontracta Company Name From .ZfC To
From To
ST,RREET ADDRESS v/3I AID LEE-E`IIIU
• 070'792
City or Town / Stale Zip Code
(S.R » La52-- 841912._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(II applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p"
DATE DRILLED + yV eG /
TIME COMPLETED Z. /X- AM ❑ PM B�
3. WELL LOCATION:
CITY: // ce,/ti COUNTY �•co�,�
rt erroritif %/s -t !i /3
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat D+<Idge ❑Other
(check appropriate box)
LATITUDE 3 r• OLV/
LONGITUDE f i a). .74
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Cr6S ❑Topographic map
(bcafbn of well must be shown on a USGS fopo map and
attached to this form 7 not using GPS)
4. WELL OWNER (n)
OWNER'S NAME 1 Y I
40,i) s
STREET ADDRESS • .�
L aij /j , X7X7
City or Tam State Zip Code
( KaR >_ 777-0/Se
Area code - Phone number
5. WELL DETAILS: '7
a. TOTAL DEPTH: J t f
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 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 " r
6. CASING:
f 1 A v 1 a 6
Amount %%2 1�
From To
From To
From To
Depth Diameter
From D To 7z Ft. G./e.r-
From To Ft.
From To Ft.
Thickness/
Wpig hl
Material
7. GROUT: Depth Material Method
From f� To 0 Ft. Cascrcfr ?out; N.2r
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 —r—To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
O— .7 COY
47- 7L SG//
72-- 7s-/ '•(,, tr
cn
SEE- ZJC
11. REMARKS:
I
I '
J
;s
r
ri
f 2r-a,
SIGNATURE OF �CERTIFIED WELL CONTRACTOR DATE
N PIAT), UJ, Ives
RINTED NAME OF PERSON CONSTRUCTING THE WELL
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
nct.
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 /
at 9
ff v t u (j
1. WELL CONTRACTOR:��
r,kI) A // i'NES
1 Contractor Individual) Name
firja c iv5 �.l 1E11 gird � .th p, JAC.
Well ontractor Company Name
ST,RR.EET ADDRESS ,j73/Aw LEfeEs-/ER Nw
!� %etSjE4t KC• a8'�'fp
City or Town / State Zip Code
(2.5? )- L 5 & -, S q9 6z_
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [�
DATE DRILLED 3--24/-04
TIME COMPLETED ,a _.DJ AM O PM Er-
3. WELL LOCATION:
CITY: Hc'. C"+4--
COUNTY .o.0--e-y .!`
A%wa.-es t WA...
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p8tope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 . 77, 7d7
LONGITUDE (-//, 2)-7
May be in degrees,
minutes, seconds or
in a decimal formai
Latitude/longitude source: QC:rPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 7 not using GPS)
4. WELL OWNER
OWNER'S NAME
STREE. ADDRESS /
•Siti.cr212/ AL __. fiir)lo
City or Town State
( CA? )- ?76 -3. 3.a
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: rc.. 4fr
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO fe
c. WATER LEVEL Belau Top of Casing: 60 FT.
(Use -t' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated alor below land surface may require
a variance in accordance with 15A NCAC 2C .001Q118. 2
e. YIELD (gpm): 20 METHOD OFTESTNIH/tr1 .../ 1
f. DISINFECTION: Type O'FJ A.
g. WATER ZONES (depth):
From/20 To From To
Amount /D / $J
From L/r— To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To 7d` Ft. C- r .-C--a4 t r`2
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From P To ; O Ft. CON.: fete "))jp LlfiN.9r
From To Ft. J J
From To Ft.
6. 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 %D C/y,
-
11. REMARKS:
V)
-13
L)
3
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WIN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OFRTIFIED WELL CONTRACTOR DATE
�taN k llf ;ves
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 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 / 410
1. WELL CONTRACTOR: Ail
&, N A , /v ES
�yv�o+il Contractor Individual) Name �
lE(ctOteNs l.11E11 a,rdPmp 1.LC.
Well9ontractor Company Name /
S�T/-REET ADDRESS 3731 /�,EW LEfdESIEjZ Iltl:f/.
/t- /,eL-s Ea /i , c • oi0 (q g
City or Town f State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Ef
DATE DRILLED 5-- ZT-oto
TIME COMPLETED `%rho AM PMI�-
3. WELL LOCATION: CITY: Ld�Dicrs fv CDUNTY-ccir jc
Zees, /._ . e e 4,/ . 2-
(Street Name, Numbers, Community. Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ['Flat ETClge ['Other
(check appropriate box)
LATITUDE 3 .f 4* 7ro r
LONGITUDE%- 2 .fit, / V7
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: p GYS °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
STREET ADDRESS '< girl
/7 C i9S7a P
City or Town State Zip Cale
(f,iR )- 76g-1- L/3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2or
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (�
c. WATER LEVEL Below Top of Casing: 64:7 FT.
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS
&8
FT. Above Land Surface'
'Top of casing terminated alfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST
I'I15- r J
f` r` C w V 4
ci A. 1
f. DISINFECTION: Type Ciar.,de
g. WATER ZONES (depth):
From 7J- To From
From Pi To From
To From
From /l-D
6. CASING:
Amount ¥ 'Sit
Depth Diameter
From 0 To (G Ft. G,/Zr
From To Ft.
From To Ft.
7. GROUT: Depth
/�
From (� To NO
From To
From To
To
To
To
Thickness/
Weight Material
SpaeC/ "4/G
Material Method
Ft. CCVIcrcfe C(.ffiN Ji
Ft. J J
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
To
To
10. DRILLING LOG
From To
0-li
G/L
Fc - ear
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Description
CJY
s4i
rn
8
rn
rn -
-72
n
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.
SIGNATURE OF ERTIFIED WELL CONTRACTOR• DATE
PIA -Al A /j ,ve s
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.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nalurak(tesources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11 3 / *0
1. WELL CONTRACTOR: /]�
--an t) l] , IN /,Ai ES
Vfil Contractor ((Individual) Name
Ef4Lf h.( S6N5 fell covet / wnp
Well,9ontractor Company Name
STREET ADDRESS 3731 Ato LE/eEsJE-C ley•
City or Town / State Zip Code
(238 )- 5& 8191rz.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(N applicable)
WELL USE (Check Applicable Box): Residential Water Supply E'
DATE DRILLED
4-2-04
TIME COMPLETED / , 2a
3. WELL LOCATION:
CITY.. 51—aari4v.
AM i] PME
COUNTY Al2eonSt.
(Street Name, Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Qblope ❑Valley 0 Flat ID Ridge 0 Other
(check appropriate box)
LATITUDE 3 r 'AZ Yrr'
LONGITUDE t{_ Z' //14%1
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: l3L,PS 0Topographic 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� qA 1;
4
STR ET ADDRESSf'rf2 ,C7711 '3/b
On ei5ez i1e 1)e 287i 9
City or Town State Zip Code
(.53eAg )_ (Pad— yie2/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ULr /
b. DOES WELL REPLACE EXISTING WELL?t YES 0 NO
c. WATER LEVEL Below Top of Casing: / 0.O FT,
(Use `-r- 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): 5 METHOD OF TEST - r 1
f. DISINFECTION: Type C.'.- .-c Amount A Ato
g. WATER ZONES (depth):
From Zf"O To From To
From .150 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
Fran C To V7 Ft. a /,o— jt c,
From To Ft.
From To Ft.
7. GROUT: Depth Material) Method
�}
From ,v To No Ft. Concrc/C- ?toter?' pi r2
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
1'- T4
7L- y/
Formation Description
rh1
4J/ - yte 6- . •<r
11. REMARKS:
I DO HEREBY CERTIFY THATTNIS WELL WAS CONSTRUCTED N ACCORDANCE Wall
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEE�N�PPRROVIDED TO THE WELL OWNER.
,rediesserr
SIGNATURE OF 51
EERTIFIIEDrWELL CONTRACTOR DATE
DIA-As ji, / fees
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 # 3 / TO
1. WELL CONTRACTOR: �"
Eki>fN GViNFS
VA Contractor Individual) Name
/EtaC6Ns It IE/I a#d inp 1.1C,
W elllontractor Company Name
STREET ADDRESS
L
LEI (EijEt A a
City or Town / State Zip Code
(OH )- 35�'- Pic Ie.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(d applicable) /
WELL USE (Check Applicable Box): Residential Water Supply 2.
DATE DRILLED C'T/-DL
TIME COMPLETED //, .�D AM p''''PM ❑
3. WELL LOCATION:f
CITY: Ace) Arc
COUNTY
(Street Name, Nofibers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC�/ LAND SETTING:
Slope °Valley ❑Flat ORidge DOther
(check appropriate box)
LATITUDE 3 C 34 V-)
LONGITUDE r 2. -VC"
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: CPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Snot using GPS)
4. WELL OWNER
OWNER'S NAME
ST ET ADDRESS
City aTown State
i3 R E ;15- 38o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 of
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ° NO re'V.
c. WATER LEVEL Below Top of Casing: 440 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): �t METHOD OF TEST •
41
f. DISINFECTION: Type Amount fSi}
g. WATER ZONES (depth):
Rom f 0 To From To
From /jD To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From O To 7.: Ft.Ct/L- Si}pi/ -Pitt
Rom To Ft.
From To Ft.
7. GROUT: Depth
Depth Material Method
From /� To xt0 Ft. 0oiCrefc ?totithvj
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 Materiel
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
4r-7.1 14i/
?- 10r [-..., 'st
11. REMARKS:
SC
m
—101
1
0T
100 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.
$ief; x c.. 1 /-04
SIGNATURE OF CERTIFIEDWELLCONTRACTOR DATE
PtA4N n. GU, Wes
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.
Forth G W-1 a
Rev. 7/05

11. DISINFECTION: Type tP tk Amount 2-
12. CASING: Wall Thickness
r r T A R
J a i 0
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section7
WELL CONTRACTOR (INDIVIDUAL) NAME (prii�nt) idet / rah'. .fN,, ,IA,IVit CERTIFICATION #2, 4
WELL CONTRACTOR COMPANY NAME r1�F/A {i�-yT(/l/l ��r11( PHONE # (>',�g)�83-7aa
STATE WELL CONSTRUCTION PERMIT# 1 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential t1 Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: a
Nearest Town: Lcuc&5fce�, Count i °�yv\UQ,
15Q1- 6U>to n-4-8
(Street Name. Numbers, Community, Subdivision,oLot No.. Zip Code)
3. OWNER:TED -�- ANt Mick
Address 15a5
(Street or Route No.)
City or Town ' State
Zip Code
Area code- Phone number t�
4. DATE DRILLED. / 3
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES NO
7. STATIC WATER LEVEL Below Top of Casing: /� FT.
(use"+" if Above Top of Casing)
8. TOP OF CASING IS " FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in actor an wi h 1SA NCAC 2C .o11a.
9. Y IELD (gpm): • METHOD OFT S
0. WATER ZONES I gO
Topographic/Land setting
❑Ridge �dS1ope ❑Valley ❑Flat
(check appropnate box)
Latitude/longitude of we I locaa�ipp '^}D
N35 t4a .3q� `I-(5 0J
(degrees/minutes/seconds) E '/ 2cD g3
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
I{7 .at1/416 46QC
I (depth): n
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the Tog
numbers and common road names.
Depth Diameter or Weight/Ft. Material
From To 7s 0 Ft.
From To Ft.
From To Ft.
13. GROUT:
From
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 Et.
From To Ft.
16. REMARKS:
QT'•
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AN THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T E WELL OWNER
/ 7 7�
SIGNATURE OF PERSON CONSTRUCTING THE WELL " DA F.'
Submit the o :sin al 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

5} C A -
t) 3 l ' I V
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Ressouu�fcess - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) CERTIFICATIONy�SC2Ce)
VV'ELL CONTRACTOR CO\tPANI'NAME /IFH JNkR�IA'N al;�LJ�r �+�� PHONE it Ma..,
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
l if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential CJ VIunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Usc
2. WELL LOCATION:
Nearest Town: Itlbrbflay Countyaik-ICS]N•67-
(Street Nance. Numbers. Communist Subdivision, lot No.. Zip Code)
3. OWNER: \-l[E1.leS
Address ko4-`(4%i 116
,
(Street or Route No.)
ae� Nr 2S
City or Town Scare
Zip Code
Topograp ,Land setting
DRidge ope ❑Valley ❑Flat
(check appropriate box)
Latitu e lonoitudc ofw I1 location
god3 vfo a-`L O,5•'gyp
(degrees/minutes/seconds) EIcv • p1(i / Q
Latitude/longitude source:UGPSLJTopographic map
{check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number J�
4. DATE DRILLED 3" G OCP
5. TOTAL DEPTH: P* n
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ILK-
7. STATIC WATER LEVEL Below Top of Casing: !Db FT.
(Use `+' if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): .'D METHOD OF TEST('Q
10. WATER ZONES (depth): "31.1.
LOCATION SKETCH
11. DISINFECTION: TypeTB3(Qk- Amount .— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From To •wig Ft. _
From To
1-rom To
13. GROUT: Depth Material Method
From To 3 Ft. 1�kQ., __ r
From To VI' Ft. N -tu LA.
t •
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in. o•,nw
Ft.
Ft.
15. SAND/GRAb'EL PACK:
Depth Size Marerlal
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalResourc s - Division/of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) klgn 6/1J CERTIFICATION#Ny 0t3
icy
\\'ELI. CONTRACTOR COMPANY NAME
STA F E WELL CONSTRUCTION PER:\IIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential 2" A9unicipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: ,n �ru2��
Nearest Town: Tai fVi ciA) CountySJ4-CA b
95 C.wac}{eAb Q. VC Qv.) 2 7730
(Street Name. Numbers. Community. Subdivision. Lot No.. Zip Code)
3. OWNER: AIM difINDICIOp
Address LSO ec - ct% 5a
(Street or Route No.)
R;cces05014 -1)x 35033,
City or Town Skate Zip Code
Topogr Ic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(cheek appropriate box)
Latitudilon itude of well location
Nt3S 33•050 -lpfo22 2.0933
(degrees/minutes/seconds) e (Ey, 3oLri
Latitude/longitude source:LJGPSLJTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number
4. DATE DRILLED -- F ' O4
5. TOTAL DEPTH: 505
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l�
7. STATIC WATER LEVEL Below Top of Casing: Mel FT. •
(Use if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated arior below land surface requires a
variance in accordance with ISA NC.AC 2C .0118.
9. YIELD (gpm): R •S METHOD OF TEST C-r(AL•el-1('i3P1.LQ;
10. WATER ZONES (depth):
11. DISINFECTION: Type 17 Isl1 Amount e2
12. CASING: Wall Thickness
Depth Diameter or Veight'FL Material
From 10 flrtFt.
From 10 Ft.
Ft.
from 10
13. GROUT: Depth Material Method
From To 3 Ft. QO7'1CZZ& \liar
Ft. i #3{p}WCfC d-ULu(
From To I 4
I . SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft.
Size 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.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARgS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
bmit 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
A�,gcAi14 Vag oeti u.q PHONE # 62403 /^^

s, 9 e ry ; r
6t L. ice?
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalspResources - Division of Water Quality - Groundwater Section 2
WELL CONTRACTOR (INDIVIDUAL) NAMEnS (print) Filer-9 r oLt6 CERTIFIC,A�TIIONN r#�DZW'b^otL
WELL. CONTRACTOR COMPANY NAME R{�Atl\OLliPst'-1 �I1 1V)f)l.. PHONE # AA 1p a3-�U23,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
I. WELL USE (Check Applicable Box): Residential L7Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring LJ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Usc
2. WELL LOCATN: Nearest Town: h;f>�C ZAP" Countyaiw'riN&&tC).
(Street Name. Numbers. Community. Subdivision, Len No.. Zip Code)
3. OWNER: klib +rbZLVCS11., 5hQ.L+0t4
Address 7(4hr-4 Al<0 'ci
(Street or Route No.)
(�;(,J NC, ag�30
City or Town State Zip Code
4. ,aCp
Area code- Phone number /
DATE DRILLED (( 9
TOTAL DEPTH:
5. r � %
6. DOES WELL REPLACE EXISTING WELL? YES O NO LY
Topograp}ilc/Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropnate box)
rJan de/Ion itude of wel loca�o
. °3A.ot93 SA 5.CGG
(degrees/minutes/seconds) 1CiCti a4-49
•
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
7. STATIC WATER LEVEL Below Top of Casing: 143 FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface'
*Top of casing terminated attar below land surface requires a
variance in accordance with I5A NCAC 2C .0118. /��N //����
9. YIELD(gpm): I. METHOD OFTES1C--7AI•t-Oarf Litz
ID. WATER ZONES (depth): (6D
11. DISINFECTION: Type ) A131,a t
12. CASING:
Depth Diameter
From 0 To 9, Ft.
From To Ft.
From To Ft.
Amount o2
Wall Thickness
or Weight/Ft. Material
13. GROUT: Depth Material U R
From To 3 Ft.
From To FL Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
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.
SEEP _ia L
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 LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the o ;,final 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
n' ,, n 4 4
Li 1 U 1.
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectiono
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L,eIeM 1'/c' i�p CERTIFICATION #7tVOC,�1�f
WELT. CONTRACT OR COMPANY NAME AppALPC�Ir AN Veit ,IJII.I I Is 4 PHONE # {S�1 \PR3- /aoce-
STATE WELL CONSTRUCTION PERMIT/4 ASSOCIATED WQQPERRMIT#
(if applicable)
(if applicable)
1. WELL ESE (Check Applicable Box): Residential O Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring LI Recovery D Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N: \�
Ne rest Town: �(}t,,rr
,d4
Lance
3. OWNER:
Address
County,
2-8 Y
City or Town State Zip Code
)-
Area code- Phone nwnb$sL-.,,
4. DATE DRILLED_rt" 0214-(d CP
5. TOTAL DEPTH: —
6. DOES WELL RE LACE EXISTING WELL? YES 0 NO GY
7. STATIC WATER LEVEL Below Top of Casing: (d0 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
variance in accord. ncc with 15A NCAC 2C .0118. -,�/
9. YIELD(gpm): OOT MEN' O,i.)OFTESICi • ��
10. WATER ZONES (depth): �0(( ��$$
Topogra, ic/Land setting
❑Ridge lope ID Valley ❑Flat
(check appropnate box/
ri35— ;LT. w36 ww r 3�- rso
(degrees/minwes/seconds)
Latitude/longitude source:OGPSopographic map
tcheck box)UT
DEPTH DRILLING LOG
From To Formation Description
a 15�
(Strcci Name. Niimbers. Community. Subdivision, Lot Na.. Zip Code)
(� &LC
(Streerb Rome No.)
IJQM N C-
11. DISINFECTION: Type 1 kt2, Amount era.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material /
From To �0 Ft.
From To Ft.
From To FL
13 GROUT: Depth
From To Ft
From To— Ft
14. SCREEN: Depth Diameter Slot Size
in.
in.
From To FL in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at lea��p�,
two State Roads or County Roads. Include the r numbers and common road names.
t, m
rn
•
Srl C
1 DO HEREBY CERTIFY THAT IH1S WELL WAS CONS I RUC.dLD IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE ELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE'
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECOPY, -
North Carolina - Department of Environment and Natural
R�
esourcesDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) tjr: 4. .417-Li(.3 CERTIFICATION#A�3
w'E IA. CONTRACTOR COMPANY NAME Pi PA(.fl CI4if1-N 1441( Iil�ji (li/�LO PHONE # (C2a$ ( 3-C/12t3
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential/Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring U Recovery ❑ Heat Pump Water Injection ❑ Other ❑ if Other, List Use
2. WELL LOCATION:
Nearest Town: C¢.5'b-K CountyEU
Id.33 OIDf2O a$7a
(Street Name. N/umberss, ((Community. Subdivision, Lot No.. Zip Code)
3.OWNER: IE1't'1') kc.14--oi..f
Address ) U$ O(D 02Th r,' R I
(StreAizam bay, &ouleNo.) 4rf0l
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH_ /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1;1
7. -STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface"
Topo ta ...."c/Land setting
❑Ridge t:Slope ❑Valley ❑Flat
(check appropnaa'te bGox)�5� y
1 ati de/la ggi co--t ac 1/J Vrb `duo (�1 3J(degrees/t/mmiinutes/seconds) SEW. a 1
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
Frain To Formation Description
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C.0I I8. ��++ f�
9. YIELD (gpm): sZn METHOD QFTEST I-11=t4•Q.34-1-E.dl'tC.¢,RN,
10. WATER ZONES (depth): l (a `D) 50
1 I. DISINFECTION: Type I fCBW.Jt, Amount
12. CASING: Wall Thickness
Depth , Diameter or Weight/FL Material
Fron To 1 Og Ft.
From To Ft.
From To Ft.
(3. GROUT: Depth /'�,,,,M,.at�erii�ah(,, Method
From To 3 Ft. ...net- et-C,� -PbIX`e
From To ! Ft. (ZfLI }-4 Ltj - ?5Lki
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From 'Fo Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To
From To
Size Material
Ft.
Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL\WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION SpA' JDARDS, AND THA A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r .20/6,6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATHI
Submit the tffiginat 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

e1 9
0
WELL CONSTRUCTION RECORD
Gi
North Carolina - Department of Environment and Natural
Resources - Division of Water Quality - Groundwater Section7
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (.A2ey VIZ iii y �, rr,, CERTIFICATION Pole ea
WELL CONTRACTOR COMP.ANYNAME A pp 1fa!(A.tAAI ME1I J1 I'll4_ PHONE # gig) i¢KI-9aaA
STATE WELL CONSTRUCTION PERM IN ASSOCIATED WQ PERM IN
l if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential la.---)vlRnicipal/Public 0 Industrial 0 Agricultural 0
Monitoring LI Recovery ILI Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATI N:
44-GIA ref
Nearest Town: AMt) 11 County
(Street Name. Numbers, Community. Subdivision, Lot No.. Zip Code)
3. O Address
1 �ci KiS �11 Qt�120C ,
(Street or Route No.)
City or Town State
( Area code- Phone number
4. DATE DRILLED 7 •02*-"Oxo
5. TOTAL DEPTH:2,2
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13
7. STATIC WATER LEVEL Below Top of Casing: IDE) FT.
Zip Code
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
Topographic/Land setting
❑Ridge l ❑Valley ❑Flat
(check appropnate box)
Latitude/limaitudemf,we,11 location
(degrees/minutes/seconds) € (D �
Latitude/Ioneitude source:0GPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
*Top of casing terminated at/or below land surface requires a
variance in accordance w' ISA NCAC 2C .0118. �1
9. YIELD (gpm):METHOD OF TESTGAL.Q k CA1ct
10. WATER ZONES (depth): / 2ni
r2 �� V
11. DISINFECTION: Type -Witt- Amount 02
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From -01 To Fa. Ft.
From To Ft.
From To Ft.
13. GROUT:
From
From
14. SCREEN:
From
Diameter Slot Size Matena
To Ft. in. in.
From 'To Ft. in. in.
Depth
To 3
To t Ft!t.lY7-C)XL1
Depth
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at le
two State Roads or County Roads. Include the ro
numbers and common road names.
cn
S 7
1 DO HEREBY CERTIFY THAT THIS W L WAS CONS IKUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION TANDARDS, AND ' AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEI 1. ATE
OCO
Submit the t riginal 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

ifiKP
WELL CONSTRUCTION RECORD *3 r 1 ,, :1 9
North Carolina - Department of Environment and Natural/[Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)rLAU _
P'ELI. CON'I'ItACTOit COMPANY NAMI_
E A pi/»c�} /
TWELL
SFAE WELL CONSTRUCTION PERMIT#
(if applicable) (if applicable)
CERTIFICATION #9t4a4
PHONE #
1DAD)&D -a- 2.ga
ASSOCIATED WQ PERMIT#
WELL USE (Check Applicable Box): Residential Fjl/ Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring L Recovery ❑ Heat Pump Water Injection 0 Other 0 if Other, List Use
WELL LOCATI N: 2�,
Nearest Town:�..
al rvIZlA/ County zAkiSe
h+,btu FA1C5), Lt E-5 l S # L9 ,2$43O
(Street Name. Numbers. Community. Subdivision, Lot No.. Zip Code)
3. OW-s NER: oh rJ YnQIiAr�
Address Swu.tt 3gtpc ex -Ea .
(Street or Route No.)
i5kW; Ke. UQ- ,27��
City or Town State Zip Code
( )-
Area code- Phone numb--
4. DATE DRILLED 2$ 1410�
5. TOTAL DEPTH
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: )f.SO FT.
1 (Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface`
Topogra ic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropnate box)
Latitude/longitude oRwe.11 location
N35'29. .55 lip A ,&. c >
(degreesiminutes/seconds)EV, R cif
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
*Top of casing terminated at/or below land surface reclaim a
variance in accordan a nh 15A NCAC 2C .0118. nn .�__ //
9. YIELD (pm): METHOD ES7VnV- • �C7 ,, e/i•,
10. WATER ZONES (depth): lob,
11. DISINFECTION: Type JAI5 t€ Amount _45,__
12. CASING: Wall Thickness
Dep[hc��.r Diameter or Weight/Ft. Material numbers and common road names.
Frorn e' To Ilv Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material -
From To 1 F11 -Qj
From To '� Ft.
14. SCREEN: Depth Diameter Slot Size
Frorn To Ft. in. in.
From To Et. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
16. REMARKS:
r,
TIP
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the rid
21
Cr.
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 WF.I.r.
ATE
Submit th 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

v 3 4 f V (� 8
D i)
WELL CONSTRUCTION RECORD -
North Carolina - Department of Environment and Natural Resd%�{Tces - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) bet-C , L/� , Vci16 CERTIFICATION #�°3
WELL CONTRACTOR COMPANY NAME A-p, AhACG)/�YM1f 'We f�J t Dt;i1 q PHONE # (lia(6 )tD�3'%�d3
SLATE WELL CONSTRUCTION PERMIT# I ASSOCIATED WQ PERMIT#
l if applicable) (ifapplicable)
WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0
Monitoring U Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 4141 Q.IZ,Vi ) lQ,
h1; n.rF +I i i i Roca
Counti&NC OALk
(Street Name. TNuumbers. Community, Subdivision, Lot No.. Zip Code)
3. OWNER: 1iflk�e��`'( Snil`tL�
Address y�D("SCA., A53g,
(S reet or Route No.)
`Q Q ry`rC RC.
City or Town State Zip Code
( )-
Area code- Phone number
DATE DRILLED .
TOTAL DEPTH:r3 �
4.
5.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: ! OO 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
Agricultural ❑
Topo ic/Land setting
❑Ridge Slope ❑Valley 0Flat
(check appropnate box)
Latitude/longitude of well location Q
NSS 4-1 c `Wc$a3� / it& 2
(degrees/minmes/seconds) cc� o2(?
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accorda/nc ^with 15A NCAC 2C .0118. �J� ,,[�
9. YIELD (gpm):1 MEAOp OFT T $C1 -364 3.,
10. WATER ZONES (depth): 3
I] DISINFECTION: Type IASSI(14-5 Amount oC
12. CASING:
Wall Thickness
Depth ^ Diameter or Weight/Ft. Material
From A�t� To �Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To3 Ft
From To i 7 Ft
14. SCREEN: Depth Diameter Slot Size Material
Front To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Matcria
Method
Ll.c�
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include the ro
numbers and common road names.
esne
L, —
I DO HEREBY CERTIFY THAT-TH1S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS; AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOE, WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WF.LI. -.
ATF.'
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 LOCATION: ,,' _"�,,
Nearest Town: .T<I(i Q1AI County3( :fit nt t
LAwrAL, Town:
Lo`ft `j r'gg� 30
3 OWNER O%r1,5 (.;4+sicf( (5A CONS4.11. 40til
sl °? i ! 1 n
L1 r_j i 0 )
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -
Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LA alh1?Uy,, tjJa `1.
WELL CONTRACTOR COMPANY NAME App rMRc4n;AN YVU�� ND,kI
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED W'i7 PERMIT#
t if applicable) /
(if applicable)
CERTIFICATIONp/#o1 a6OraO, 7
PHONE # 619$4g3-bC
W ELL USE (Check Applicable Box): Residential V Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
Topo9 . ahic/Land setting
'Midge %Slope ❑Valley DFlat
(check appropriate box)
(Street Name. Numbers. Community. Subdivision, Lot No.. Zip Cade) Latitude/I itud well location
•
O r�
•
(degreeshninutesiseconds)Etc'/ 93
Address 4 tint¢, P kit tK('(L Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.)
3cskiMUZ, KC, a n of
City or Town Sale Zip Code
( )-
DEPTH
From
(check box)
DRILLING LOG
To Formation Description
Area code- Phone numbl 1 , / 16 f
p
4. DATE DRILLED l �
5. TOTAL DEPTH: !(p'
6. DOES WELL REPLACE EXISTING WELL? YE ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: X0 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. hh,,,,
9. YIELD (gpm): /7 METHOD OF TESTGAt eoarEtt
10. WATER ZONES (depth): LCO I "75
11. DISINFECTION: Type IR S(dE Amount R-
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
Flom To 71- Ft.
From To Ft.
From To Ft.
13. GROUT: Depth 22
From Tobr Ft.
From To ! TT Ft.
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.
Slot Size
Material
in.
in.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the r
numbers and common road names. •
J
I DO HEREBY CERTIFY THAT I -[IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUC,'ION STAND AJ2DS„AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEI.I. / D
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. G W-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources /-/Division of Water Quality - Groundwater Section�/
WELL CONTRACTOR (INDIVIDUAL) NAME
(^^p�Nrint)I,LA2Cy W L/�(I L. II CERTIFICATION #/u aC1. ,
WELL CONTRACTOR COMPANY NA\1EI ippA/ACATA'NiAt( j? t it t kt PRONE # On 3,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential E Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: ��7R�,��
Nearest Town:{-NZU14 J Count tW_Xt�
Mal-4Aflk Eat. LCfs*-5 y a 31.,3c.
(Street Name. Numbers. Community,No.. Subdivision, Lot Zip Code)
3. OWNER: T3fa( Su.;(b/t1 55
Address oR? M0.1*A-► Y; ht4�
(Street or Route No.)
-ksha,Ui Ile- &I ,
City or Town Stale Zip Code ( )-
Area code- Phone numbgr/ % fp&
4. DATE DRILLED
5. TOTAL DEPTH: zc
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I
7. STATIC WATER LEVEL Below Top of Casing: 100 FT.
(Use -4-'1 if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
Topogra c/Land setting
DRidge 2Sclone ❑Valley ❑Flat
tenet( appropnatteb(oox)
LatitN ude WoebVDljo81 /
(degrees/minutes/seconds)E( 33b
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118_
9. YIELD (gpm): I T METHOD OF TES1€ A/. Cd&t [CYttuc
10. WATER ZONES (depth): (0 5.((O5 / c 0
11. DISINFECTION: Type IAI5 La /f Amount a,
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From—e To 5 N Ft.
From To Ft.
From To Ft.
13. GROUT: Depth . Material Method
From To 3 FL h1 C1. hl.>``(
From To_ Ft tii t QM/sr
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From '1-o Et. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THI
CONSTRUCTION1.STANDARDS, AN
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.
WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE LL OWNER
/116 ,0
SIGNATURE OF PERSON CONSTRUCTING THE, WfiLI. D TF'
tq
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

c) n `l
dJ,i51>
WELL CONSTRUCTION RECORD
Nonh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section�//�
\NELL CONTRACTOR (INDIVIDUAL) NAME (print) L_.a/ ,y -Weird CERTIFICATION Pieta
P. ELL CONTRACTOR COMPANY NAME 7-1`� ffIAQ1' (&M WV{ .D511[1. R) PHONE # app iD8L3 I�1 o�c�L
STATE. \\'ELL CONSTRUCTION PERMIT# ( ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential OG Municipal/Pubiic 0 Industrial 0 Agricultural 0
Monitoring U Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town. Fri-r-V'tX/ Countyy'3UMCGYtBC.
1\40.14tdd Es-k . Lc4 28-1
(Street Name. Numbers, Community, Subdivision,tl5\
Lot No.. Zip Code)
3. OWNER: f(Q,X,Smm{ Vt`\L
Address d 63)C
t�Jtr (Sueetq oute No.) a&�
City or Town State Zip Code
( )-
Area code- Phone number Phone number0(6
5. TOTAL DEPTFl3.5r //
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO ItY
7. STATIC WATER LEVEL Below Top of Casing: Q(\ FT.
Topo tc/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropnate box)
1atitkdell� ng le of well location rp
1155 (``deesreevminutes/seconds) elev. av\ p (o
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
N35*a a sa a54-35
(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
variance in accordan c with I5A NCAC 2C AI18.
9. YIELD (gpm): .fi, METHO ES1G/4(C $ 1 P1
10. WATER ZONES (depth): 100, ,-QFJ0�
11. DISINFECTION: Type /f Amount r
12. CASING: Wall Thickness
` Deptb.� Diameter or Weight/Ft. Material
From To X7' Ft.
From To Ft.
From To Ft.
I3. GROUT: Depth
From To 3 Ft
From To 1 f Ft
14. SCREEN: Dept Diameter Slot Size Material
Prom To Ft. in. in.
From 'le Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
t (;
Method
Ih. 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.
SEP
I DO HEREBY CERTIFY THAT HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS/AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE ELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELT ATF'
1
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
n
Oda t}29
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sectionn//
WELL CONTRACT OR (INDIVIDUAL) NANIE (prin/t,), ,,t_- cy 7,WO1« CERTIFICATION 7fAW03.
\VELI. CO\IRACt0R CIOMPAN\ NANIE f ppdAdA AKO "Mall
SLATE \YELL CONSTRUCTION PERMITU I ASSOCIATED WQ PERMIT#
t if applicable) (if applicable)
PHONE 4 ILMD )t11gN- /.daa
I. WELL USE (Chug}; Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural ❑
Nionitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
U'ELL LOCATION: .1_
Nearest Town:11vQ¢.5�-K, County C
-Z—pr1CA) TR�'t9!-a lZIX- 428 4/-g
(S:; Koine. Numbers. Cu1mirmunity. Subdiir+iiission.�}yLot No., Zip Code)
3. Oil,NER:.A 1Vii 1(L L'.1 K4
Address 13 pcf1b7 ?. IAMQ-
tSviwij,,r Rautt i
ag$b�
Ile &
Cnr or Trncn. Stair Zip Code
t
\ree coot- Pnone number 4
4. DATE DRILLED Cov./ (� co
5. TOTAL DEPTH: (•
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: /D0 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
Variance in accordance with 15A NCAC 2C .0118.
Topogra /Land setting
DRidge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude fwelll cation
iS 354- ? cast Latitude/longitude a <03CD
(degrees/minutes/seconds) Elev. V . a la/
Latitude/longitude source:❑GPS❑Topographic map �P
(check box)
DEPTH DRILLING LOG
From To Formation Description
9. YIELD (epm): 4t METHOD OF TEST6,44.CC aiti4'at3a
10. WATER ZONES (depth): / :, 20 JC
11. DISINFECTION: Type 1e76C Amount aR
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To CDC Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Mmcnal Method
Prom I It.
14. SCREEN: " Depth Diameter Slot Size Material
From To Ftin. in.
From To Et. in. in.
15. SAND/GRAVEL PACT::
Depth Size Materia!
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.
r.
16. REMA.RKS.
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN .ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU)LTION STAND ryt2DS. 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

331519
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcess�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) l-PaIN �W/Q•ti'S CERTIFICA•�TIION#a4 of
Akch
WELL CONTRACTOR COMPANY NAME iAb4 UAW )1(ht3 PHONE #j p3)GS, 9 ala
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 0" Municipai/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
NearestTown:FM/ViCA»J CountyRUM-W
1 S35 (.Mich 7Ld� . FAiR W) f i3O
(Street Name, mbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Wi1tilNry
Address 70 13c c. 23 a,
(Street or Route No.)
t-tat/NliCAil N Q a�g�30
City or Town Stare Zip Code
Area code- Phone number !�v 4. DATE DRILLED a• la • CD
5. TOTAL DEPTH: + LP /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ri
7. STATIC WATER LEVEL Below Top of Casing: �O O Ff.
(Use "+" if Above Top of Casing)
Topo c/Land setting
❑Ridge @Slope ❑Valley ❑Flat
(check appropriate box)
N3% 3a %b 4%MitZ G �5
(degrees/minutes/seconds) etc V • 2A 7(�
O I
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
8. TOP OF CASING IS ( FT. Above Land Surface'
'Top of casing terminated atlor below land surface requires a
variance la accordaa�uyce with ISA NCAC 2C.0118. ,/
9. YIELD (gpm): ; •t•in METHOD OF TESTA CbM -a i NCgr
10. WATER ZONES (depth): 3 a 5 M" 3
LOCATION SKETCH
11. DISINFECTION: Type ) P 13IL Amount � Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
From Dep ��� Diameter or Wei t/FtMaterial numbers and common road names.
A FL 1
From To Ft.
From To Ft.
13. GROUT: Depth , Material Method
From To 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 Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD., AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
7- Oco
DATE
ubmit 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: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
n
e+ 7.i 1.rJ Li '7,
1. WELL USE (Check Applicable Box): 0 Residential ❑ Municipal 0 Industrial ❑ Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ® Other If Other, List Use: TEST WELL
2. WELL LOCATION: (Show sketch of the Location below)
Nearest Town: WEAVERVII.I E County: BUNC
ENGLISH ESTATES DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER DON FREEMAN
Address ENGLISH ESTATES
(Street or Route No.)
WEAVERVILLE NC
City or Town State Zip Code
4. DATE DRILLED 07/27/06
5. TOTAL DEPTH 225
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WFJ.T REPLACE EXISTING WFJ.I 7 ❑ YES NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surfaces
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 12 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION:
13. CASING:
Type: CHLORYTE Amount 5
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 30 Ft 6-1/4" SDR.21 PVC
From To Ft
From _ To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in._ in.
From To Ft. in. in._
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #240 W. FROM ASHEV111 F LEFT ON EXIT 4A (HWY.
#19) TOWARD WEAVERVAJ F RT. ON EXIT 19A TO
MARSHALL. LEFT ON MONTECILLO RD. GO TO END a
RIVER & RT. ON #251 N. GO PAST ALEXANDER POST
OFFICE & RT. ON APPALOOSA DR
rn
0
rn
ce
a
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
7-rc
GNATURETURE GOERS COUCTING THE WF.I.i, DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

RESIDENTIAL WELL CONST RECORD
North Carolina Dcranmcnt of I.mironmenl and Natural Resouttrr• I)il it ion orWatcr Orr ale
WELL CONTRACTOR CERTIFICATION a
1. WELL CONTRACTOR:
Well Contractor (Indrvtdual) Name
kabev\ Catdi.bet.I Or; t 1 119 Inc
Well Contractor Company
Name
,,\�
STREET ADDRESS 'IS I 1"e�l cnrcr Hwy
iskSkevc tie_ t3C a\lcga
City or Town Stale Zip Code
(gag) 54—-35S'I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID alit applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT a(il applicable)
WELL USE (Check ApplicablePox)) Residential Wale( Supply L)I
DATE DRILLED °I I % 0 6
TIME COMPLETED Z r . D D
AM O PIA
3. WELL LOCATION:
CITY: LAQNaR4SJ \L€ COUNTY QUN comae
W'v4t—r l6Y\oRZ vts.�NLI1
(Street Name, Numbers. Community. Subdresron. Log Nn _ Primer. Zip Cafe)
TOPOGRAPHIC /L5,1XD SETTING:
❑Slope ❑Valley QJFIat DRidge ❑Other
(check appropriate box) LATITUDE 3 5 4-1 • 3a5
LONGITUDE B a a-1 •1 6 3
May be in degrees.
minutes. wools or
in a dttinvl formai
Latitude/longitude source: Escps °Topographic map
(location of wel must be shown on a USGS Topa map and
attached to this form l not usng CPS)
4. WELL OWNER
OWNER'S NAME
Q0 Los 86
STREET ADDRESS aD .So NtA 1600 ° a
ti3tHER'Jia Nc 3S18I
City or Town Stale Zip Code
(`Sat > barb- aa60
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a OO
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO/
c. WATER LEVEL Below Topct Casing 6 li FT.
(Use -. 8 Above Td Casng)
d. TOP OF CASING 15 1 FT Above Land Surface'
-Top of casing Tenoned et/or below tend surface may regime
a variance in accordance with 15A NCAC 7C 0118
e. YIELD(ppm): ( METHOD OF TEST R►&— A re-
i
at4-D
f DISINFECTION'. Type
o WAT ER ZONES ((resit')
Fenn 14S To 15a
Rom_ To
From To
6. CASING'.
From
From
From
1
From
From
Front
Amount
To
To
To
Thickness/
332 '1
Depth —,
I D Ft D a
Toler C 4 n� t
To
To
Ft
Ft
7. GROUT: Depth M�mil
Method
y Frn�CA
_ To T) Ft. ldI? fkOe,�
From To FI.
From
8. SCREEN
From
From
From
To Ft
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
Frrm To
From TO
From To
10. DRILLING LOG
From ( To y
l- 1 RI
9t'' 153,
tsa'- aoo'
II. REMARKS:
Diameter Slot Size
Ft. in in.
Ft in in.
Ft in in.
FI
Ft
Ft
Material
Size Material
Formation Description
G R-a t0-T"r E
UZ.RVtCS - 7t cern
c
IRO HFPFPT CERTIFY THAT THIS W F I 1 WAS CONSTRUCTED N ACCORDANCE WITH
ISA Ne AC al- W FI t CONSTRUCTION STANDARDS AND THAT A COPT OF THIS
RECORD eeS PEFH PROVIDED TO THE WEtt OWNFP T
SIGNATLIRE OF CERTIFIED WELL CONTP.ACTC
IOLL,t_L1S D,ASA'1
PRINTED NAME OF PERSON CONSTRUCTING
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] eat 568.

Cityor Tam State
( gas } LIS-44-4-3
Area code- Phone number
5. WELL DETAILS:
a- TOTAL DEPTH:
Sr
RES11)F_A'TIAL \\•ELL coNSTR1fCTION RECORD
North Carolina Department of Environment and Natural Recounts- Division of Water Ouali1y
%VELL CONTRACTOR CERTIFICATION a
1. WELL CONTRACTOR:
Rt,,be \ exythulz4i
Well Contractor (Indnnduah Name
Veu•bey, C od.,.uetl ir<<I:Ing Inc
Well Contractor Company Name
STREET ADDRESS % J I t eu.z oe rc r' 441
(ksj trc i(e. t3C 3.7c70 b
City or Town Stale Zip Code
tgag ). a54 -36$ I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID x(il app'cable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT OW applicable)
WELL USE (Check Apo,' 'able 6px)j Residenlial Water Supply/
DATE DRILLED 6�/S1 / 010
TIME COMPLETED ///1Q a3 D AM PM�
3. WELL LOCATION:
1
CITY: CAP4OARUS'J I L1 COUNTY elJ/ai CDmB‘
S QGa-Ic- f-6tL, 8S r it-r65
(Street Name. Numbers. Community. Submearon. Lot No.. Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
argraPe OVafey OFlat ORidge 0Other
(check appropriale boxx) LATITUDE 3 S 4 6.051
LONGITUDES I_ �• t1a
Latitude/longitude source: girls OTopographic map
(location of we/ must be shown on e USGS topo map and
attached to this form 1 no? using GPS)
May be in degrees.
minutes, seconds or
in a decimal unmet
4. WELL OWNER
OWNER'S NAME
1-71lkititti
STREET ADDRESS \ Ste. �IN tin-7a
f\Alk 111 Li N c a 154-
Zip Code
b. DOES WELL REPLACE EXISTING WELL7 YES 0 NO N
c. WATER LEVEL BelowTop o( Casing 1 00 FT
(Use -A- 8 Above /Top of Casing)
i d. TOP OF CASING 15 FT. Above Land Sur -lace'
'Top of casing terminated aVor below land sunace may reoune
a variance in accordance with 1 SA NCAC 2C 0118
e. YIELD igpm): 1 lit METHOD OF TEST %IG-P 1(1,1
a14-D
t DISINFECTION: Type !e a e O Amount
g WATER ZONESO(depth)
Firm 35- To I4-0
Firm
From
6. CASING
From_,1
From
From
To
To
Dents
To_115 Ft
Tv FI
To Ft
7, GROUT: Depth� ,r�
From To(/l.�x Ft
From To Ft
From To FI
8. SCREEN: Depth
From To Ftin, in
From To Ft
From To Ft
9. SAND/GRAVEL PACK
Depth
From To
From • To
From To
10. DRILLING LOG
Frpm( TILD
ISS /r f)4-05
1.4a` — 51,52
II. REMARKS:
n in.
in. in,
Ft
Ft.
FI
From
From
Fr run
3 3
1
!Y
To
To
To
Thickness/ {M�
Pr � pet
Material
n
I•AiN
A Method
eVv l)
Diameter Slot Size Material
Size Material
For -nation ,rI,rrDescription
01i{-rr�& flZ-rsG R
ral
L"t V
G e.. nc-
f
C,
o).
t—
I nO NFRF pv CERTIFY THAT THIS Writ WAS CONSTRUCTED el ACCORDANCE WITH
ISA NraC zo WFIL CONSTRUCTION STANDARDS AND THAT A COPY (][ is
ritconDMAe pcpc FNPROOVOEDTTO THE WELL OWNER
W
SIGNATURE OF CERTIFIED WELL CONTRAC
M Sit
PRINTED NAME OF PERSON CONSTRUCTING
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mall Service Center— Raleiggllc 27698 t607 Phone No. [phone] ext 56B.

RESIDENTIAL WELL CONS U 'CTION RECORD
North Carolina Ucpanmrnt of I-m nonmcnl and Natural Recotocce- Di‘ pion of Water Quality
WELL CONTRACTOR CERTIFICATION e a % ¢ C7
1. WELL CONTRACTOR:
Rethioe.A C.&dt,I it '
Well Contractor (Indwrdua0 Name
kVA—. kV Ca.Aue.Li OnLii11g�lnc-
Well Contractor Company Name,\
STREET ADDRESS 'IS 1 tte U-' \-e�i ce.str Nw�
Pshev\ tie I3Q 2Nw7b
City or Town State hp Cafe
(gad) a.s4 - 3 55'
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID M(if applicable)
STATE WELL PERMITP(u appltcablel
DWQ or OTHER PERMIT e(if applicable)
WELL USE (Check Ap kohlBor�t
DATE DRILLED C% /i / D (o
TIME COMPLETED t 1 •• 3 0
3. WELL LOCATION:
CITY: Weft J6O.J1 `t_�
Rezyenlial Water Supply
AM [M PM 0
COUNTY &rte)W DIyigTa
EP ®S&SQF4L, 62.oA0
(Street Name. Numbers, Communes. Subdrcaron Lot No Parcel, Zip Coyle)
TOPOGRAPHIC / LAND SETTING.
❑Slope ❑Valley 10Lal DRidge pother
(check appropriate box) ( p'
LATITUDE 3 5 44. 5
LONGITUDE1_ (I 31 -513
Latitude/longitude source: DGPS OTopographic map
(bcation of wel must be shown on a USGS logo map and
attached to this cam 1 not usng GPS)
4. WELL OWNER
May tc in &Frets.
minutq seconds or
ma deeinul format
OWNER'S NAME W\\OAAE.L I IIE 1CALr
STREET ADDRESS •l;Lau tl l- 20A O
WGAJeK•►I L-L.�3 IJC
City a Town State
( 8a% » 1-r5. 1343
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH' 305
3g��11
Z.p Code
b. DOES WELL REPLACE EXISTING WELL?�yYESe7
d NO Clc. WATER LEVEL Below Too Casing
g 0 FT
(Use ••• if Abate �d Cain))
d. TOP OF CASING IS FT Above Land Surtace'
'Top or casing terminated aLa onow land sunace may re.2lnre
a varance n accordance wdb 15A NCAC 7C 0118
e. YIELD (gpm) b METHOD OF TEST Q.4Cr'&ttt
DISINFECTION: Type 147
g WATER ZONES Idepib)
Firm i3�r5 To t^^3� From
O
From_ 1 5 To 1 O Fran
Fran To Frorn
6. CASING'
Iron
From
F rrm
1 Depth
To 16 Ft
To Ft
To Ft
7. GROUT: Depth
hem
From
From
Amount ' bZ
To
To
To
Thickness/
eY r
5 T8 n%leeal
Material
3 To a. Ft. (6 1%roT'
To Ft
To Ft
Method
JR%
a. SCREEN: Depth Diameter Slot Size
From To FIin in.
Front To Ft in in.
F rem To
9. SAND/GRAVEL PACK:
Depth
From To
I -tom • To
From To
10. DRILLING LOG
Fro E To
o' \ 35 f
135'-13( '
1361- a-15'
a-TS Pe a-16'
a-16'-305'
11. RF.MAItKS:
Ft in in.
Ft.
Ft
Ft.
Material
Size Material
formation Description
o 'EA-2-134-2-Cnce
Cs CIA E4t�
C-a.64 \OF!. — Ge.r
CO 6t-Aatit
C R-6`r t Cg -. 9L 3 ern/
GRA(\It rG
Li;
CO
IDO HEptey CERTIFY THAT THIS WFLL WAS CONSTRUCTED N ACCORDANCE WITH
ISA Hr AC 2C WELE CONSmUCTton STANDARDS AND THAT A COPY OF TMS
RE Car) HAS sr,‘ FN nq U'AED To ME WELL Ownrn
SIGNATURE OF RTIFIED WELL CONTRACTOR TE
to (L_Lte rc ASIa 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.
SEP ti 2OO8tev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Hevnnces- Di. Minn of Water Quality
WELL CONTRACTOR CERTIFICATION N
1. WELL CONTRACTOR:
ReitA20€A Caukul4l
Well Connecta (Individual) Name
Rea beY\ Ca.\&u.ell Or t I; i 9 114C
Well Contractor Company Name. \
STREET ADDRESS 'S51 tJeu- Le-"(cesttr �w I
fksRev\ Lk, tjC 2.,W7G b
City or Town Stale Zip Code
a5h--352I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID this applicable}
STATE WELL PERMIT#(a appl.cablel
DWQ or OTHER PERMIT a(if applicable)
WELL USE (Check Appli ble x)r_ Residential Water Supply (TS
DATE DRILLED 8 a 0 6
TIME COMPLETED 3 ° AM ❑ PM ii7
3. WELL LOCATION: CITY: WB At M 1 L1-6 COUNTY ink`�Uaoo,n136
4-4-5 6‘31ealra &Tx, ci4 A.0 A D
(Stier} Name. Numbers. Comm candy. Subdma,on, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAD SETTING:
❑Slope [Valley eclat ❑Ridge [Other
(check appropriate box) O '\
LATITUDE 3 5 4- 3 --a IA
LONGITUDE I a '35 . 5``5 (c
Latitude/longitude source: LfeaPS ❑Topographic map
(bcatbn orwel must be drown on a USGS fopo map and
attached to this form f not usng GPS)
4. WELL OWNER r n
OWNER'S NAME . \,1 o�',DC1 �7+fJ COP
STREET ADDRESS Y T J rJ&v S-rock. go AD
(,it'stwtue. r3C erg 131
City or Town Slate Zrp Code
(<3.34). 658— 446°1
May be in dcpces,
minutes. seconds or
in a decimal format
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
a5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO F'I
c. WATER LEVEL Debw Top of Casing G t
(UseNG if Above dCasing)
d. TOP OF CASING IS FT Above Land Surface'
-Too a' caseag terminated acts below Land surface may require
a variance el accordance vnth ISA NCAC 2C Of IR
e. YIELD(gpm). 7 METHOD OF TEST RAG rAI1-1
FT
-at4-iD
I. DISINFECTION: Type I4 d CdAmount
g WATER ZONES (depth}
From 170 To ( Z
Form To
From To
6. CASING:
j Depth
From + To 1- FI
From To FI
Fran To Ft
7. T GROUT.
rn V ^ Depth�
FrrTo /J
From To
Fran To
8. SCREEN: Depth
From To
From
From
Frorn
3 32524
To
To
To
TWhyickness,
gI%%ter cal a ci
Material Method
FI CS YL P)r Pp .i R- y
Ft
FI
Diameter Slot Size Material
FI. in in.
From To FI in in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From To
Fran To
From To
10. DRILLING LOG
From / To f
_ 7a
fl0
t `to'-
t11`—:3GS7
li. REMARKS:
FI.
Ft.
FI.
Size Material
formation
C
� tC t - -7 e ern
C/>
PO
—o •
IDO NF RFRy CERTIFY THAT TINS wFtl WAS CONSTRUCTED al ACCORDANCE WITH
ISA PIC AC )r wat CONSTRUCTION STANDARDS AND THAT A COPT OF,TIS
RECOPO uAs PE F N PROvOEO TO THE WEIL OWNER
eSIQ
SIGNATI!PF Or CERTIFIEDEDE
WELL CONTRACTOR
&Li L/ IO 1 S I I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ATE
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mali Service Center — Raleigh. NC 27699-1617 Phone No. [phone] ext 568.
Form GW-Ia
Rev 7/O':

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Naloral Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 11
522
1. WELL CONTRACTOR:
Resk_ben CoMkkx0 l '
Well Contractor (Individual( Name
Retik.be Co3c ;eLI Oritl; Inc -
Well Contractor Company Name -\Vcasts
STREET ADDRESS %S 1 1`+€" Let
Psh,ev;Lk. 13C 3\W7�6
Zip Code
(sacr a54—
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID %Cif applicable)
STATE WELL PERMITR(d applicable)
DWQ or OTHER PERMIT e(if applicable)
City or Town State
35cI
WELL USE (Check cA'pplll able Bo/a) Res idenlial Plater Suepy CV
DATE DRILLED D/ �/0 6
TIME COMPLETED 3 • $'O AM 0 PM V
3. WELL LOCATION e
CITY: Ats/ATabl&(�. COUNTY gun)
LaT q 3><&AQrai et 1aILL M.
(Street Name. Numbers. Cbnmunrty, Subdrwaion Lint No . Parcel. Zip Code)
TOPOGRAPHIC ! LA)D SETTING'
❑SIope OValley 'Flat ORidge ❑Cther
(check appropriate box)
LATITUDE yT 5 4-0 .D $5
LONGITUDE H a 4•0 • 136 �a
Latitudeflongitude source: ecFs OTopographic map
(location of wef must be shown on a USGS fops map and
attached to this form f not usrg GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
May he in degrees,
minutes, seconds or
in a decimal format
RoG&!L eaoW)J
60 t.oat ease RDA'
I.AAA4a Rai Li, M C age o
City or Town Slate Zip Code
8a% r 331-c14a\
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO lq
c. WATER LEVEL Below Top of Casing b FT
(Use -a' if Above Top d Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing temenated aua below tend surface may fegune
a variance n accordance with 15A NCAC 2C 01118./v e
e. YIELD(gpm) 1 METHOD OF TEST l�:6-AtR-
5'
1, DISINFECTION' Type' IATI4
g. WATER ZONES ('ep1).
From, ( 6 p To QGl
From To
From To
6. CASING
I Depth e
From 1 To CI Ft
FI
Fran To Ft
From To FI
7. GROUT:
Depth /�
From y To ao
From To
From To
O. SCREEN: Depth
From To
From
Front
To
To
9. SAND/GRAVEL PACK
Depth
From To
From To
Frcm To
10. DRILLING LOG se
From = To
1 qo
-
6'r- Ib9'
16af - 3,65,
11. REMARKS:
FI.
Ft
Ft
Amount
From To
From
From
0
D aryelor
To
To
Thickness/
SaKhttll Ma al
e
Material Method
Diameter SIot Size Material
FI.
Ft
Ft.
Fl.
Ft.
Ft.
in
in
in.
in.
in.
in.
Size Material
Palmation Description
o s/ C 93
(9 KH r ATE
C££v1C,ff - 10 GPM
r7
rn ti
0
•
I DO TRRERE CFRTEY TRAY THIS WETS WAS CONSTRUCTED N ACCORDANCE WON
ISA NrAC 2r Wit I. CONSTRUCTON STANDAROS AND THAT A COPY OF Dos
RECORD NAS REFN PROVIDED TO THE W LLOWNFR
(Z � #lob
SIGNATURE OF CERTIFIED WELL CONTRACTOR r DATE
Cr t3
PRINTID NAME OF PFR :ON 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
Nonh Carolina Depanmcnt of Eneimnmenl and Natural FtrsnurcCo- Ihs kiwi of Water Quality
WELL CONTRACTOR CERTIFICATION # a t 4- 0
1. WELL CONTRACTOR:
Rea_beA Cc0AuvLi
Well Contractor (Individual) Name
Reu.bek. C038,4,cU Or t l: AB l ne
W ell Contractor Company Name
F,�
STREET ADDRESS SS t"eU" ct tester Nut
ksh,ev,Lle_ p3Q a.SScb
City or Town State Zip Code
(€3 » 0.Sh- - 3 581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMITS/id applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appl able B x) Residential Water Suppty
DATE DRILLED $a s IO 6
TIME COMPLETED t I •. 3 a AM i PIA D
3. WELL LOCATE/ /�
CITY' AEl- A,r €O�- COUNTY 300c_ornBE
9aA {oaen--Gs 'OIC,tJf
(Street Name. Numbers. Cornmunrty. Subdivision. Lei No. Pincer. 2ie Code)
TOPOGRAPHIC / LAND SETTING.
❑Slope 12/alley ❑Flat ['Ridge pother
(check appropriate box)
LATITUDE 3 5 4-a •ct6a
LONGITUDE (Ic a 3(5 .qq9
Latitudc/Iongitude source: EfiGPS El -topographic map
(bca(ion o/ wel must be shown on a USGS fopo map and
attached to this tom (not usng GPS)
4. WELL OWNER
OWNER'S NAME —IL r' O t 7 6
May he in &pen
minutes. seconds or
in a decimal formai
STREET ADDRESS a6 Et) K-eOglaS IJ+a+
Ay6A,J Qa-/` N-6
City a f own Slate
( fag)- b4'S-66a3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
105/
Zip Code
b. DOES WELL REPLACE EXISTING WELL7 YES iNO fD
c. WATER LEVEL Below Top of Casing i 00 FT
(Use -a• if Above Top of Casing)
d. TOP OF CASING IS de FT Above Land Surface
•Top at casing Terminated abor below land surface may require
a variance in accordance vein 15A NCAC 7C 0118 pp
e. YIELD Igpm) £ METHOD OF TEST Rt6 - R i h
1. DISINFECTION: Type
g. WATER ZgiNES (depth)
From { 65 To t 1 0
Flan
Fr on
6. CASING
From
Frorn
From
To
TO
7. GROUT: Depth
Frm, To aD
Frn To
Fom To
8. SCREEN
From
From
From To Ft
9. SAND/GRAVEL PACK:
OPpm
From To
Fran To
From To
10. DRILLING LOG
From / To /
4- ao
at, - 165
l b5' - 1-10' /
l`to z " -105
I1. REMARKS:
jja aD�i
From
F rrm
From
332520
Amount
e G -
To
To
To
Thickness/
tiler sOr;1
Wenht
Material Method
FL W aoR�i D
Ft.
FI
Depth Diameter Slot Size Material
To Ftin in.
To Ft in in.
in in.
Ft.
Ft
Ft.
Size Material
Formation Description
g2AtotT�
1 c.Li -
Gyp-, ,..
Fn. 7:3
I'r- --
IV .1
IDODORFflx CFRTiY THAT THISwf U. WAS CONSTRUCTfo N ACCORDANCE WFTH
ISA NC ar.)r writ CONSTRUCTION STANDARDS AND THAT A COPY Or nee
RECOnn,Ha; PPFEN PRovQE0 TO THE W1t.I(.LAA
OOWNNFR
P�/(�
`gLIAQ,e t\ QO�ALU O/ 3 A b
A SIGNTDR OF CERTIFIED WELL CONTRACTOR DA E
PRINTED NAME CIF PFR ON 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 GWta
- Rev 7/05
•

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] /� 1 y._,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR- ` A 0anA t Xte
WELL CONTRACTOR CERTIFICATION c• t 1,
STATE WELL CONSTRUCTION PERMIT.:
1. WELL USE (check Applicable Box): Residential' Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch o(the location below)
Marini n
rest Town: eatery)). t Q . County I `)k 1 ITh ninte
(Rued Named Numpe ta,,.,,, „�Subdivisionor and tot No.)
--S.\-'�3. OWNER L/ytJ�l,���f� 1 S
Address
DRILLING LOG
From To
1—r10
arc( ri ( n
4. DATE DRILLED aln—ayS
5. TOTAL DEPTH L4
6. CUTTINGS COLLECTED YES El NOp'
7. DOES WELL REPLACE EXISTING WELL? YES IE NO'
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (tiaa �. ti Afww Top of Cupp)
FT. Above Land Surface'
'Top of casing terminated et/or below land surface requires a variance in accor-
dance with ISA NCAC 2C .0.1.111
a
10. YIELD (gpm): ) METHOD OF TEST I 1 111
11. WATER ZONES (depth)•
(Sif-eatorlot•fE) ---115 tr.Yv envervt 11e Nc ai1S1
City or Town, State Zip Cods
12. CHLORINATION: Type
13. CASING:
Dept Frond .To 10
From To
From To
14. GROUT:
Ft.
Ft
Ft
Amount
Wall Thickness
or Weight/Ft. Material
From Topta 0 Ft. >rQ ,I ' 1i/ 1-1- Method
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in in
From _ To Ft in _ in
From To _ FL _ in in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
DEPTH
Formation Description
tf additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
nv.)u 1`�v\ -ZZ
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A C OF THIS % £CORDD H//��BEEN PPRRQVIDED TO THE WELL OWNERR.. /
71 =L/�t'LLif�1N✓W (� O ' QIO
TURE OF PERSON CONSTRUCTING THE WELL DATE
Sutrrii oripnafto Division or Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
FOR OFFICE USE ONLY
Quad No:
Sorel No.

1'I
WOOmar •Ogmenmaofbmbr..Jend NOS Rama sesame' aver QS•owi.anYrSwim
ISMS NW Gee Omar • Nothla KC. W I.F/MSP eno WIR 75s4121
WELL CONSTRUCTION RECORD WILLomNTEACTDIa G on rt., r
WfiLCCNTRACICR{N111TIMCA1NNIs: cell
RATS WwiCCIwflMIC7r011 gRMITIS
1. WELL uur— A>l.r.oOas Mrde*.I0 b- "O Aodr.aadO M.i.bo0
A.rM.rp `t iPamW u►rj.a0...0 oworp SOW LIM Wolt
2. WELI LD1.ATIOet (Naa. aL+.fl Wee balm }
Ner.Mlb.c WCPOLverV111R
mini woo .�(Naasra,Omrr erthbaM.aalalra► CI SPGLOS OEPTM
s Odds ,fr'vc l�,Ys //tn Adds I- 'f3 ,. .&o.-yR
g 7
ilfrav n"'77P 2 4' 4$ r D ex\sj
awns .r1. was �f.�7- �i � ('Jt��A)�C:Q
4. DATE CI ant - 2 cce Y.ZF - 5/3'!� Q f\tlP
r. TOTAL WWIn V
s. own councils) Yes0 ND®'
7. COES WSL REPLACE Eke .1S WW2 YES 0 NOltr.
s. STATIC WATER LEVEL WON Top Collor FT.
p aro•PaAteeAPor Dee
_
s. TOP OF CASING IS Fr. Min Laid Slater'
1»dsay bra eWeYobarTrodomM-missaw,-.eebeaav
See ee. AMO.rasa
10. YIELD Wok S. METHOD OF TAT R i• 7
11. WA-vawOREEWIPwk •
12. CHLORINATOR- Typo Amount
to GASMMOW
VAS TIMmon
. TO~��✓ FL !%'/ R_ From
To FL From To 1'I
14. GROUT:
WSW Meth
Front / To ao a etneA f od
From To FL
15• SCREW
Depth Ol.rrtr Slat Ski MOMS
Ran To Ft In. b.
Faro _ To FL In.. b.
Front _To_FL Ln In.
It SANWORAVEL PACK:
Duple
From To
Front To
17. REW RILL
r.drmaeopmebNSW a.eWadban
L�CATIONlIWT[a1
We.* osntdtu_.irealksmeaaae
C Rork orWmerpe-mrmpole)
I00HERS CERTIFY THAT THIS WILL WAS CW WWWCTW IN ACCORDINCS W M ISA MAC R. Rea
COMSINIICCCNRA14Mws,AND NWACOPY CP ISRECORD WSWM RO.SIEDTOTHE WELL OMER
FOR PRICE (ISE ONLY / �7 /lyi6 -Z 3 —Q to
arse
...1T.a[a►..rera0lr'TIa1u..ntVIE WM oral
SSW WOW WASTTwrr.r Sam- __ali.R t30d w
s1 Ant. ww

<:;�
o
NISCoes•D..a..odOnst d♦dNSAIt.___r•D1 _SWdwa♦a-Opounik tirSsr♦on
tarMiLlndr.GeM -tL18181 .c.gnowalrmaspop 7$flfll.
WELL CONSTRUCTION RECORD TRILL COMPACTOR: /./1g1--104 Tos
WELLCONi.AOTOR MIIMPISATIONu o3/i 3
STATSNaSO01aia 1OTION 118fIs
1. WILL ua A)!♦rdi8s* n♦desdrl� M - MondpoI ❑ helo♦rtd 0 Apa 0 Moe * 0
n.ao.wyPHoot Pump Wear Ljia-ae❑ Ole o OdsLitUom
2. WELL L:OCATIOttJR*MO .1MRain Wise. 2
toorsslU fa 7•lifi��./vi v,;�r emir.CIUntrrinhl.
WM Nial tbsliss. ONIUMIldrireg Indlabil .dSlls) OltllilOLDO 01011
a OWNER F a rah ,LM Y% %bo ner1' Iry Is Ts 1a..sno.R,prs
Adis ,9lI �-�y fi &i lle SGa 4 ,I 67-,-
F7trvfei.) Alwhrf.NC 297.30 vvg- YS`a ren Ur-
9rf-w41
CysrT♦Rs ♦nr. TV OS a fo - Cf9>' "carp"
Tura ten
DATE ONUS e
W'n*i011 H G/ SoaucrED rtw0 w®--
DOES WELL REPLACE EUSTINO WELL? YES 0 NO0-
STATIC WATER LEVEL Roby Top eh OMrIF FT.
w Hon Too nay
I. TOP OF CASINO18 FwT. Alms Lone St.lro-
ern Se. heal roarben l.dseem tu r.salswor♦ssrr
As .or1M11d MAA S
ALYIELD (gm): 20 METHODOFTEST I y
11. WATER ZONES SAS
4.
A
s.
7.
A
12. CHLORINATION: Two Amount
13. Calk
Fsn / ~ l Y
To
From To
14.GROUT:
e mend son b trseod tus board born
sassL
p.n.Yr
FL iv 7C/
FL
FL
Dept ) _ To ftfl MSS i Lhshoe
From
From To FL
is. ACME*
Du*h
Fan To
Frets To
From To
10. SANDISRAVEL PACK
Mph
Rom To
Ron To_
17. RLMLIIIILS:
Olrnslor N ti
R_ M. In.
FL— In. • its
R._ tit In.
Lh]T.ATIDth SIQTCN
LTte. drab_ and orbs from d trod re ors
Rea or am rdmrsysr+U
1 DO HERMIT COMM 114AT VHS VAAL WAS coon RUC1m 1N ACCOIIDMNCS MIN /M MAC AO. WSL
CONSTRUCT=SrANDMp AND MAT AM" OPTNItin FaMEO TONE Vaal OSIER.
FOR MICE USEONLY
Orme
raYnlnsorf'1111♦O11CarnMl.... ilr ..nt. ♦orT8
SSW sads.OrYmdWrrrdoyt,Sadie Srr!w Shin 30 din
flt IRV.us
GCT 62 Ld J

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. LI lit IA) .Q�
WELL CONTRACTOR CERTIFICATION 0: (-9 I I
STATE WELL CONSTRUCTION PERMIT*:
c. n
1. WELL USE (Cheek Applicable Boa): Residential EgY Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery El Heat Pump Water Injection Other Ej If Other, List Use:
2. WELL LOCATh14511: (Shaw sketch of the location below) tl1� . �nr r�t�
Nearest Town: -1 ) Irwin in4-tm County' 1< U a n xa 1 1l 9.
(Road Name and Nomoe a, Community:or Subvention and Lot No.) DRILLING LOG DEPTH
3. OWNER enri to AA)k P
Address oleo\I Vm From To Fortnatlpn Description
I �
treet or�1 Td t 1 tiro.
aS--1City 11
or Town r, Alai Op Coda
4. DATE DRILLED I _3_L )
5. TOTAL DEPTH ROS-
6. CUTTINGS COLLECTED YES ❑ NO['
7. DOES WELL REPLACE EXISTING WELL? YES NO /
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use Y' il Above Top of Casing)
9. TOP OF CASING IS I FT Above Land Surface`
Top of easing terminated aver below land surface requites a variance in actor. . ".
dance with 15A NCAC ZC .ggt�1e 10. YIELD (gprn): V ,r� METHOD OF TEST � 1 Ct
11. WATER ZONES (depth)- uu
12. CHLORINATION: Type Amount
13. CASING:
14. GROUT:
If additional space is needed use back of form
LOCATION SKETCH
Depth via TNae"n l n Ft Diameter or Weight/FL n Material (Show direction and distance from at least two Sate
From 1 To l \
i�=" C leit Roads, or other map reference points)
From To Ft.
From To Ft
�Si- fYttn . 9_0 �'O �trl ,
a
Depth Material Method
From 1 To Sp Et, C9XYl-PX\ts
From To Ft
15. SCREEN:
1_c� _. m
- 0 ra
_ till
2CA . • 1
Depth Diameter Slot Size Material 0 hill
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:
1Lt { Csi .
Cttc"
NC. Oojt
5cczmcX tcL .
ArrCn
CDI1e3e 12c1.
JII
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECOR0
� H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY � LTA t-4e-0 4
Quad Nt
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Subnit original to %Mon or water Quakty, Groundwater Section within 30 days
GW-1 REV. 1299
Soft No.

North Carolina . Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27599.1836-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• C k Q0 ARIA-O bit
WELL CONTRACTOR CERTIFICATION *: c-i 13
STATE WELL CONSTRUCTION PERMIT*:
WELL USE (Check Applicable Box): Residential' Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection
❑ Other If Other, List Use:
2. WELL LOCATLQN: (Show sketch of the location below) /� I.,
Nearest Town: UC lyTan Y�i , County:I `�1 1 nCflm he,
Agricultural ❑
Monitoring ❑
(Road Name and Numbers. Community. or Subdivision and Lot No.) DRILLING LOG
OWNER l 1 r1CAn ni n7
Address ?Meru- Qt6n0 r SA-. Lot t
Zip c�(Street or testa Ao.
n�-. t L _ Sari a-5 City or Town ` "-'
coda
4. DATE DRILLED " 1-'; -ris
5.
6.
TOTAL DEPTH nas
CUTTINGS COLLECTED YES ❑ NOE '
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOar
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 1 (use ••'• 9 Above Top of Casing)
FT. Above Land Surface'
'Top et easing terminaoM at/or below land surface notaries a variance in accor-
dance oath 15A NCAC 2C XIa n
10. YIELD (gprn): I V METHOD OF TEST 9-11 V•
11. WATER ZONES (depth)•
From To
i n5
�S 15°1
I�G - IloD
ILDn - ,Dac
12. CHLORINATION: Type Amount
13. CASING:
Depth
From To —
From To
From To
14. GROUT:
DEPTH
Formation Description
50.rt \ dA rA-
qrank
Tani FP
If additional space is needed use back of form
D�n,e Wall Thickness LOCATION SKETCH
Ft I °actt'1or or w«gnW. Material (Show direction and distance from at least two State
Ft.
Ft.
cliaDC
Depth Material Method
From I To an Ft. evtnrfk-
From To Ft
15. SCREEN:
From
From
From
Depth Diameter Slot Size
To _ Ft _ in ____ In
To Ft in In
To FL in in
16. SAND/GRAVEL PACK
From
From To Ft
17. REMARKS:
Depth
To Ft
Material
Size Material
Roads, or other map reference points)
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 HBEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY A4Z-1c�1 /7/�/ % -See
Quad No:
E OF PERSON CONSTRUCTING THE WELL DATE
Submit orig1nal to Div4ion of water Outlay, Groundwater Seedion within 30 days
GW-1 REV. 12/99
Sena No.

North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mal Service Canter - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR* 0 1 oarykylier
WELL CONTRACTOR CERTIFICATION e: 13
STATE WELL CONSTRUCTION PERMITe:
1. WELL USE (Check Appticaaa Box): Residential 62 Municipal ❑ Industrial C7 Agricultural ❑ Monitoring ❑ Recovery ❑ Heat Pump Water Injection Other ❑ If Other, List Use:
2. WELL LOCpT��,p�Ntf Row ISLketchnof1 the iocation below)
Nearest Town: t`l I l 1 C rT + MT , County' i g!%/I�tQNjv�t
(Reed Namard Numbers. Conxrunity. or Suockvision and Lal No.)
3. OWNER wm N Cntn
Address 1-'C) Q xRo
Q*.c. Yvan N.; e.
a%-1 11
C y or Town State $ StCode
1
4. DATE DRILLED ll —
5. TOTAL DEPTH S?
6. CUTTINGS COLLECTED YES ❑ NOD
7. DOES WELL REPLACE EXISTING WELL? YES NOL:1--
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Us. �� 9 Above Top of Gagne)
FT. Above Land Surface'
'Top of using terminated atror below land surface requires a variance in accor-
dance with ISA NCAC 2C .e1111 pp
10. YIELD (gpm): S METHOD OF TEST
11. WATER ZONES (depth)-
DRILLING LOG
From To
11c
Ioo -410�i
(4taQ -�41Q
Lk-1 0 -
12. CHLORINATION: Type Amount
13. CASING:
From
From
From _
14. GROUT:
DEPTH
Fomuuon Descrlpbcn
11 additional space is needed use back of form
LOCATION SKETCH
Depth Wall Thickness
_ p 100 FL Diameter
r
To Ft. or W L r,terial i (Show direction and distance from at least two State
'r""0n"' C Roads, or other map reference points)
-
To Ft.
Depth Material Method
From ___I__ To sa...a.Ft. OOnmp; }
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 Sae Material
From To Ft
From To Ft
17. REMARKS:
( GY
Ya-
"?n
Etwy G Cl K. ril+rt .
r
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO Px OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
Asa �,r�( 7-G-0
FOR OFFICE USE ONLY
Quad No:
TUBE OF PERSON CONSTRUCTING THE WELL DATE
Submit oripnal to Division of Water Ouauty, Groundwater Section within 30 days
GW-1 REV. 12/99
Sent No

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR- f2on- l-l%Ci-*CX
WELL CONTRACTOR CERTIFICATION it: c) 11
STATE WELL CONSTRUCTION PERMIT#:
G
f 01
e! <i 4
1. WELL USE (Check Applicable Box): Residential Er Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery O Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Tovm: �tf i\A+n . county rp m Ic nVY\h Q
(Road Name and Numbers, Commonly. or Suoavlsion and Lot No.)
�3. OWNER E LJn (floA VUJCndQX
Address \Q 1c ' }c
Q1nom nn+-rtt"
City or Town &Le
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO (
7. DOES WELL REPLACE EXISTING WELL? YES Ej NO8
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use Above Top of 9. TOP OF CASING 15 FT. Above LandSurface )
'Top of acing terminated ater below land surface requires a variance In accor-
dance with 1SA NCAC2q ¢1ta n
10. YIELD (gpm): I l _ METHOD OF TEST 9-\ \ 9
11. WATER ZONES (depth)
-
aasn 11 12)01 - I L4
DRILLING LOG
From�s To
- -1
Zip code
DEPTH
Fonna9on Desenption
d rt1�r1
C�011 alto
��ll(CQ
12. CHLORINATION: Type Amount 0 add)tionat apace is needed use back of form
13. CASING:
Depth
From \ To 1�
From To
From To
14. GROUT:
Ft.
Wall Thickness LOCATION SKETCH
Ft
Dwneter or Wnphin. i td \- C (Show direction and distance froat least two State
i�\ .#._ rK-P/J11 from at
or other map reference POIntS) m
-v
T
Depth Material Method
From \ Tor .Ft ,00.rlPl1
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:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS EN PROVIDED TO THE WELL OWNER.
g-' q •7-4-ofr
FOR OFFICE USE ONLY
Quad No:
akitE
Opproi.T
rn lei on
Serial No.
SIGNATURE OF PERSON CONSTRU
CTING THE WELL DATE
Sttlxnt anginal to Division of water Quality. Groundwater Sector within 30 days
GW-t REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' C A e LOC- r
WELL. CONTRACTOR CERTIFICATION 0:=D 1 13
STATE WELL CONSTRUCTION PERMIT#:
100
1. WELL USE (Check Applicable Sox): ResidentialMunicipal ❑ Industrial 0 Agricultural 0
Recovery [] Heat Pump Water Injection Other 0 If Other, tJst Use:
2. WELL LOCATION: (Show sketch of the location below) P
Nearest Town: N )PC]\IPrvt II se County +� rr tmcn hp
'(Read Name, Numbers, Community. or Subdivision and Lai NO
OWNER ('l�1.— \AiIIel49
Address P street Rauie No.)
W eavCrV\ I I e NC
City or Tawn slay
4. DATE DRILLED 1-I D-Olo
5. TOTAL DEPTH BIOS
6. CUTTINGS COLLECTED YES 0 NOQ
7. DOES WELL REPLACE EXISTING WELL? YES O NOET
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (� •. • a Above Top a Casing)
FT. Above Land Surface•
Top of casing terminated ator below land surface requires a variance in actor -
dame with ISA NCAC 2C .0115
10. YIELD (gprn): ) ` METHOD OF TEST R (`'
11. WATER ZONES (depth).
Monitoring ❑
DRILLING LOG
From To
(—V-
e; 10 1 aaq -?ram
zip Cote
12. CHLORINATION: Type Amount
13. CASING:
DepthWall Tess
Diameter or We pnVFt Mamial
FromTo Ita. Ft .["C`,'Y"Ui__' (�)(� n1"1
From To Ft. 1" "
From
14. GROUT:
To Ft.
Depth
From \ To av
From To
15. SCREEN:
Material Method
Ft CSYT1Crli-
Ft
Depth Diameter Slot Size Material
From To _ Ft _ in
From To . Ft. in
From To Ft in
16. SAND/GRAVEL PACK
Depth Size Material
From To Ft
in.
in
in
From To Ft
17. REMARKS:
DEPTH
FOmnation Description
Sa(tkd c014
far\1
CLA(C
tt additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at :east two State
Roads, or other map reference points)
Ci
FAct.
e'-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HASBEEN PROVIDED TO THE WELL OWNER.
7--//- d c-
FOR OFFICE USE ONLY
Dead Ne
Serial No.
GM
m
—D
U▪ G
SI iNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original 10 pnjwn or Water Duality, omuwwater Simian within 30 days
GW-I REV. 1299

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:
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• ra cart .DXCC
WELL CONTRACTOR CERTIFICATION 0: rDI 13
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable Box): Residential" Municipal 0 Industrial 0 Agricultural ❑ Monitoring ❑
Recovery Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATI N: Show ski h of the location below)
Nearest Town: VH/ I I I i County ' x )(-1C,-r 1'PC
(Road Name and Numbers, Cormiwxty. or SubOvirion and Lot No.) DRILLING LOG DEPTH
3. OWNER .1-Cup \ flTh.. From To Formation Description
Address (-Q- ) ^rpt ttr reStt°.4� ilea--1 - l9 S ,�1G 4I- CI i r t
{<i5Y1CV\IlP (�«,oAatr. o. c���tDl(� t?v/s� n- LLq9 cr�)
City or Town state Zip Code Jet "'l- F� X�l]iC�
4. DATE DRILLED ��� -OW L-foU - `.j OS 9t n\
5. TOTAL DEPTH �.J _ _
6. CUTTINGS COLLECTED YES NOra-
7. DOES WELL REPLACE EXISTING WELL? YES ED NO[
B. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (�''' a Above Tap a Casing)
FT Above Land Surface*
-Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C .011a
10. YIELD (gprn): LO METHOD OF TEST 1°-1 I q
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount If additional apace is needed use back of form
13. CASING:
Depth Wan Thickish LOCATION SKETCH
P Diameter or Weight/FL Material C (Show direction and distance from at least two State
From I To (pS Ft p r�'t
Roads, or other map reference points)
From To Ft. 4
From To Ft. A
14. GROUT:
ct7 T.
Depth Material Method rrn
From 1 To aD Ft a/MOM t- -
From To Ft �D .
15. SCREEN: t
tT
1C.itG
to ii.
htili Cr
LiLOT
' us<♦bll
Hum 74
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY 0 THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY - (5 -o6
Quad No:
Side No.
SIGNAT1fiE OF PERSON CONSTRUCTING THE WELL GATE
Submit original to Division of Walt Quaky, 0/Dishwater Simeon within 30 days
GW-1 REV. 12199

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636-phone [phone] IS -an
n ^ ,^ WELL CONSTRUCTION RECORD WELL CONTRACTOR- C lQ SUf l x r-
WELL CONTRACTOR CERTIFICATION #:a,II3
STATE WELL CONSTRUCTION PERMIT#:
st n r
6�) 9
1. WELL USE (Cheek Applicable Box): Residenlialla."" Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery [] Heat Pump Water Injection Other If Other, List Use:
2. WELL. LOCATION. (Show .l sketch.of the location below) �j .
Nearest Town: i�%t .l f}1 �I County 1c�:' NeTr1'Ylhc7
(Reed Name and Numbers. Conrnunfty. or Subdivision and Lot No.)
OWNER hrnon W ei.
Address
()-ornlrl� 711E
City or Town Stay
5. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOT:r
7. DOES WELL REPLACE EXISTING WELL? YES NCI
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS ( *.' 9 Above Tap of Casing)
FT. Above Land Surfaces
'Top of casing terminated aior below land surface requbss a variance In accor-
dance with 15A NCAC 2C .0113 ry,
10. YIELD (gprn): Ili. METHOD OF TEST 1'ltt.
11. WATER ZONES (depth)-
•
12. CHLORINATION: Type Amount -
13. CASING:
Depth
From 1 To Ft.
From To Ft.
From To Ft.
14. GROUT:
I Depth
From To an
From To
15. SCREEN:
DRILLING LOG
From To
ass-1oa .•
zip cede (? 0 -Ilir
DEPTH
Formation Descnpbon
mair d- clAr+
If addidonel apace is needed use back of form
Wag Midas' LOCATION SKETCH Nrt
or Weight/FL Material (Show direction and distance from at least two State
P-1C12h1C Roads, or other map reference points) J
CD
a
Material Method
Method
Ft OP n r r2 [r
Ft
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:
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COO OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY /may" / l7—/ 9— d
C �
Quad No:
Setif No.
SipN/1TURE OF PERSON CONSTRUCTING THE WELL DATE
Subrr l original to Division of Water Quality, Grotsto+ater 5ealon within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR* CAXQ.iIA 7 ic-1
WELL CONTRACTOR CERTIFICATION ,: m/ t %'\
STATE WELL CONSTRUCTION PERMIT,:
a
6 a;_ 0 t.t i
1 WELL
USE (check Applicable Box): Residentia?Q'Municipal ❑ Industrial ❑ Agricultural CDMonitoring
RE ❑
very ❑ Heat Pump Water Injection Other 0 If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: toWPavewLli.P County.% 'OrNninp`
OWNER (`]nt'iOff1
"(Road Naar��^od Nunwn, Cannon' or Subdivision and Lot No!) DRILLING LOG
�3. �Qt3 From To
Address 1Q D J t•-ct1
Wearer( k e ►)(- o.2�T � c - 2,04
( 'n- I4o
City or Town btLe Zp Code
4. DATE DRILLED 410 -,Ds- I t }C_
5. TOTAL DEPTH lJ '
6. CUTTINGS COLLECTED YES ❑ NO Er
7. DOES WELL REPLACE EXISTING WELL'? YES N0g.-
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use eve 9 Above Tap of Casing)
FT Above Land Surface'
Kop of using terminated allor below land surface requires a variance in accor-
danoa with 15A NCAC 2C . 1a
10. YIELD ((pm): I METHOD OF TEST Cm/
11. WATER ZONES (depth)*
1
12. CHLORINATION: Type
13. CASING:
From I Depth I Ft `Diameter
From To 1 Ft
From To Ft
14. GROUT:
Amount
11 additional space is needed use back of form
k
Wall Ttidman LOCATION SKETCH O
or WalgrolFt. ^ nit , 1 (Show direction and distance from at least two State r/t -
Roads, or other reap reference points) • n
.,,
DepththMaterial Method
From �_ To _0Ft cil.M1Q.(l*
From To Ft
15. SCREEN:
Depth Diameter Slot Size
From 7o Ft in in
From To Ft in in
From To Ft in in
16. SAND/GRAVEL PACK:
Depth Size
From TO FL
From To Ft.
17. REMARKS:
Material
Material
HS
32,
jPi
eaxfCtrctSVIIt¢
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF /THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ! ` . �V 1l/��%��7 '� 9— 0G.
vD
O• N a
Quad No:
Serial No
TORE OF PERSON CONSTRUCTING THE WELL OATE
Wall original to Division of Water Duality, Groundwater Saaian within 30 days
GW-1 REV. 12/99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh. N.C. 27699-1636-Phone [phone] �y-� �, ,/�
WELL CONSTRUCTION RECORD WELL CONTRACTOR- C/l![l 9.-I u A R,7 V
WELL CONTRACTOR CERTIFICATION 1t: 1 \3
STATE WELL CONSTRUCTION PERMIT*:
239
1. WELL USE (check Applicable Box): Residential (0 Municipal ❑ Industrial ❑ Agricultural 0
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION: (Shaw sketch_ of the location below)
Nearest Town: Ul1PC�UPrV1 County: 'r'Y7'1rYlDQ,
(Road Nameyand bers Num, y. or Subdivision and Lot No,)
/
-.3. OWNER l ,Irc!_1 jc-)eI
Address `kr) 3 ,- ,. e, „ C 1 Q
Monitoring 0
DRILLING LOG DEPTH
From To
1-cko
st'iti/ili? ( N,ah)C d a$s#0.4 450-- Van
City or Town State Zip Code
Il.- NO
4. DATE DRILLED G- I L� - r)4
5. TOTAL DEPTH Lt
6. CUTTINGS COLLECTED YES ❑ NOffl.—
7. DOES WELL REPLACE EXISTING WELL? YES NOE?'
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Usa •. Il Above Top of Casing)
9. TOP OF CASING IS I , FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In actor-
dans with 15A NCAC ZC .,O3 13
10. YIELD (gpm)- 5 _ METHOD OF TEST
11. WATER ZONES (depth) -
12. CHLORINATION: Type Amount
13. CASING:
Depth
From_JTo aV
From To
From To
14. GROUT:
Depth
From . To r-Y)
From To
15. SCREEN:
Formation Description
c
Y addition& space is needed use back of form
Way Thickness LOCATION SKETCH
Diameter or weight/Ft. Matedal . (Show direction and distance from at east two State
en
Ft
1 G.V,1
Roads, or otherrr1
map reference points) -O
Ft
Ft.
Material Method
Ft C' t lr c rvt
Ft
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: -
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 HAJ,S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
4�NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Duality, Groundwater Social within 30 days
GW-1 REV. 1299
Saar No.

North Carolina - Department of Environment and Natural Resources - Division of Water Duality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. t canAnsver
WELL CONTRACTOR CERTIFICATION #: a I t3
STATE WELL CONSTRUCTION PERMIT#:
1 t%
0
1. WELL USE (Check Applicable Box): Residentia)6eiKMunicipal ❑ Industrial El Agricultural ❑
Recovery Heat Pump Water Injection Other ED If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) nn
Nearest Town: \Aic\pyV 1 i I.Q County 1 n-Yin,
(Road Name and Nunbers, Cormimity, or Subdivision and Lot No.)
OWNER Ht 147(mS*,
Address (DcC _>v
WelOWl./� Y�IK tat cif \e d.
City or Town Stale
Qt n,
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOQ
7. DOES WELL. REPLACE EXISTING WELL? YES r4Q9a
S. STATIC WATER LEVEL Below Top of Casing: FT.
Monitoring ❑
DRILLING LOG
From To
ao03- 3
ZiP Cads
(thee': a Above Top of Casvtp)
9. TOP OF CASING 1S t. FT Above Land Surface'
'Top or using terminated atlor below land surface requires a names In seem.
10. YIELD (gpm)• In METHOD OF TEST
11. WATER ZONES (depth) -
dance with 15A NCAC 2C 0113 R( r,t
12. CHLORINATION: Type Amount
13. CASING:
Wall Tbictoru
Depth omits
From I o 1�1 Ft D4 1 t ri orw hWt.
From To Ft. `�
From To Ft
14. GROUT:
f Depth Material Method
From 1 To r� /-� Ft. ) ornaflt
From To Ft
15. SCREEN:
From
From
Depth Diameter Slot Size
To Ft In
To Ft._ in
From _To_Ft. __ in
16. SAND/GRAVEL PACK:
Depth Size Materiuio)
Material
From To Ft
From To Ft
17. REMARKS:
in
In
in
11 additional apace is needed use back o1 form
LOCATION SKETCH
how direction and distance from at bast two State
Roads, or other map reference points)
t4-Z3
tot-
'
\cal+ese lane.
Let µ I
/icitnctrclrvtt)Q
10-Z3U
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF IS RECORD HAS BE N PROVIDED TO THE WELL OWNER.
7— ad
FOR OFFICE USE ONLY
Quad No:
SI iNATURE OF PERSON CONSTRUCTING THE WELL
Serial No.
GATE
Submit olgkW to Pavilion or water Ouailty, Groundwater Section within 30 days
GW-1 REV. 12199

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27599.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR- ( jp c t I Arti A
WELL CONTRACTOR CERTIFICATION It: 01(
STATE WELL CONSTRUCTION PERMIT*:
0 n 0
el 3 .,; c) L., .?
1. WELL USE (Chock Applicable Box): Residential Municipal ❑ Industrial❑ Agricultural ❑ Monitoring❑
Recovery [] Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: sShow sketch of the location below)
NearestTown: h)4110\re rI tLP County. X ornw_
(ROed Name and Numcen. Conmunity. or Subdivision and tot No.) DRILLING LOG DEPTH
3. OWNER MI he Yt e3(t) From To
Address d(D netriv.n ri Vl
�t fittg 1 «1NC, e. a,sDi-F
Ciy or Town Stye Zip Code
4. DATE DRILLED--ov
5. TOTAL DEPTH S9(0 S
6. CUTTINGS COLLECTED YES ❑ NOg--
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO7
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (� '• if Abair Top of Casing)
FT. Above Land Surface'
`Top of easing terminated aver below lane surface requires a variance in accor-
dance wah 15A NCAC 2C .01111
10. YIELD (gprn): IS METHOD OF TEST in
11. WATER ZONES (depth)*
-t4y
(QU1-al
SIG -
12. CHLORINATION: Type Amount
13. CASING:
all Thickness
Depth Diameter or W
From�To u44 Ft 144_
From To Ft
From To Ft
14. GROUT:
Fonnalion Descnption
< t1(-4 4- ct ri-
Cirt'£.I'l t V
C rev ( e
ysn ire
C7
< �)
If additional space is needed use back of form
LOCATION SKETCH
Material (Stow direction and distance from at least two State
,row
or other map reference points)
C-rslcumo, va\t<'1 (203t to enC'.
Depth From I ToS V Ft 0��' e l Mettwd
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material Ordiai 1
From To Ft in in
From To Ft in in.
From To Ft in in F1a+C14
16. SAND/GRAVEL PACK G. < i
Depth Sae Material
From To Ft
From To Ft.
17. REMARKS:
IGS3N)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO%� O� F THIS RE RD H BEEN PROVIDED TO THE WELL/OWNER
✓. / 1
FOR OFFICE USE ONLY /✓'7 d / - Z b
Clued No:
Saw No.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Sutra original to Division of Water Duality, Groundwater Sedan within 30 days
DATE
GW-1 REV. 12,99

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636-Phone [phone] ��."^ WELL CONSTRUCTION RECORD WELL CONTRACTOR• I 1X ruicd-7t ,x
WELL CONTRACTOR CERTIFICATION e:.-?113
STATE WELL CONSTRUCTION PERMIT$:
r) r1 n a;
ti hit , ; ct,
1. WELL USE (Check Applicable ow* Residentia)'' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATIO N: (Show sketch of the location below)
Nearest Town: ��K t�(P_C'l /1 t \t County
12-1 tinerrn
(Rood Name and Numbers,cp�bi ty, or SubcWision and tot No.)
�3. OWNER Jc+nn kr {1 FnSU �
Address Q Q 1b\t
est or u Ro
INIPONervi l e _pa(
Or
d., I - (So)
DRILLING LOG DEPTH
From To
OD
City or Town gay Zip Code
4. DATE DRILLED ?7'cis--(xp
5. TOTAL DEPTH c- Lk S
6. CUTTINGS COLLECTED YES NOD'
7. DOES WELL REPLACE EXISTING WELL? YES [] NO®'
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use s+ a Above Top of Casing)
FT. Above Land Surface'
'Top of using terminated at/or below land surface requires a variance in accor-
dance with 1SA NCAC 2C .01111 n
10. YIELD (gpm): r�O METHOD OF TEST 0-1I Gi
11. WATER ZONES (depth)-
k>I-)qa
jqo-343"
12. CHLORINATION: Type Amount
13. CASING:
Formation Descrtptiorl
if additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth CCi Ft tpyr �m tr or *Diameter Material , (Show direction and distance from at least two Siatv,
From `I ( )�) Roads, or other map reference points) rn
From To Ft
From To Ft
14. GROUT:
From
From
15. SCREEN:
Depth
To �O
Material Method
Ft cornet\1
To Ft
Depth Diameter Slot Size Material
From To Ft in in
From _ To __ Ft _____ in ___ In
From __ To __ FL _ in _ in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD HAS giEN PROVIDED TO THE WELL OWNER.
t0
0
m
FOR OFFICE USE ONLY
Cued No:
Sodas No.
S13NA7URE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouaity, Omundwatar Section within 30 days
GW-1 REV. 12199

North Carolina • Depanmeni of Environment and Natural Resource • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone] WELL CONSTRUCTION RECORD WELL CONTRACTOR• l /1
Affi
WELL CONTRACTOR CERTIFICATION a:al l-23
STATE WELL CONSTRUCTION PERMITS:
2;
ae.,,r
1. WELL USE (Check Applicable Box): Fiesidentialtir Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection Ei Other If Other, List Use:
2. WELL LOCATItQN1 Show sketch of the location below)
Nearest Town: 1-1 Yi(l/ I ivcoun,.
(Road Name pT� and Numbers. CorrmUMy. or Subdivision and Lot No.)
\
�3. OWNER �t�l.'//
Address 1
Fla %,r ( lark
City or Town
4. DATE DRILLED -
5. TOTAL DEPTH 7Oa
6. CUTTINGS COLLECTED YES❑ NOM'
7. DOES WELL REPLACE EXISTING WELL? YES NO(g'
8. STATIC WATER LEVEL I3elow Top of Casing: FT.
9. TOP OF CASING IS ' (U •••• Y Ara Top of Casing)
FT Above Land Surface'
?op of casing terminated af/or Stow land surface requires a variance In acre -
dance with 15A NCAC 2C .Qp$
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth).
ir"13a
Zip Code
No.)
12. CHLORINATION: Type Amount
13. CASING:
Depth
From
�To ��
From To
From To
14. GROUT:
numb"
DRILLING LOG DEPTH
From To
I-in0
lOf -lGiG
d o`10 - cok0
�%-c)- (OS
Formation De - ••ti
if additional spate is needed use back of form
Wall Thickness LOCATION SKETCH
Ft Diameter Of Weight ty C(Show direction and distance from at least two State
Ft 1.14— Roses, or other reap reference rife)
Ft
' Depth Mate Method
From ToS7� Ft. trr
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 Sae Material
From To Ft
From To Ft.
17. REMARKS:
tw} 71+-tit Ek
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY / 8-31 D b
Cued Na
Serial No.
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Oueuty, Groiatdwater Sedlion within 30 days
GW1 REV. 12/99

0 C n, 2 f
North Carolina . Department 01 Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR. l'1 Pan&fituf
WELL CONTRACTOR CERTIFICATION #: C1(i 3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (cheek Applicable Box): Residenti
Municipal ❑ Industrial 0 Agricultural ❑
Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATI�j Show,ti e)Fh of the location below)
Nearest Town: ff �����` Ill II ((5 Count,.Lininre
• (Road Narne rm
and Numbers. Counity. utxxvision and Lot No.)
�3. OWNER M�'Z ,i � t°I 3 . 4'S1S O
Address : 1✓1 FE Y C On U e
�h ChP� Nil rqj r 13g
City or Town •r1. State zip Code
4. DATE DRILLED 'it.... • -0442
5. TOTAL DEPTH Li
6. CUTTINGS COLLECTED YES 0 NO®'
7. DOES WELL REPLACE EXISTING WELL? YES O NOj
8. STATIC WATER LEVEL Below Top of Casing: FT.
(Use M Above Top of 9. TOP OF CASING IS 1 FT. •Above LandSurface )
Top of casing terminated aver below land surface requires a variants in accor-
dant* with 15A NCAC 2C .0113
10. YIELD (gpm)• ip METHOD OF TEST I G
11. WATER ZONES (depth).•
1
12. CHLORINATION: Type Amount
13. CASING:
Monitoring 0
DRILLING LOG
From To
i-Ian
a -°f
s;Rq- ago
ago -qos
DEPTH
Formation • •tleh
If additional space is needed use back of form
C' Wall Thickness
LOCATION SKETCH
Depth d' b Ft x Weight/FL L 17Material • a211 C (Show direction and distance from at east two State
From I) '�`'�'� Roads, or other map reference points)
From To Ft
From To Ft.
14. GROUT:
From
From
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK:
Depth
From To
From To
17. REMARKS:
Deft Material Method
To d Ft (MOM'
To Ft
Depth Diameter Slot Size Material
To Ft in in
To Ft in __ In
To FL in in
Size Material
Ft.
Ft.
4-AC t-
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY 0 THIS RECORD HAS EEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY %f //�G�c�iW ` 0 G
SIONA E OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Grounewatar Section within 30 days
GW-1 REV. 12199
Ouad No:
Serial No.

q n c i1 E •n
el c. 0
North Carolina - Department of Environment and Natural Resources - Division or Water Quality - Groundwater Section
1636 Mal Service Canter - Raleigh. N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR- CUnrtAn r
WELL CONTRACTOR CERTIFICATION #: IS
STATE WELL CONSTRUCTION PERMIT:
1. WELL USE (Meek Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural 0 Monitoring ❑
Recovery ❑ Heat Pump Water injection 0 Other If Other, List Use:
2. WELL LOCATI N:,(Show "lath of the location below) �J
Nearest Town: i-SYIGU t tit Courty� J'7..0 Y Crn g
• (Road Name and Nu m Conwraty. or Subdivision and tot No,) DRILLING LOG DEPTH
Th. OWNER , k VII (APP, From To FomutionDescripuon
Address (Qc.ti(^`1 F\1a- r`ni-n ( D ri1 i C) ca
Ri...i r\A i t� reel or (6-
,c. 1 SO � chi' I_ I
City or Town gay Zip Code
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES❑ NOhO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO®'
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 'I (use'. 9 Above Top of Casey)
FT. Above Land Surface'
lop of using terminated War below land surface requires a variance In accor-
dance with ISA NCAC 2C . 1111 ((�l n
gPm) METHOD OF TEST 1`'11 _ L
10. YIELD (
11. WATER ZONES (depth)*
12. CHLORINATION: Type
13. CASING:
Amount If add)uon i apace is needed use back of Corm
Wail Thickness LOCATION SKETCH
C Depth
To Ft � 1w ter o Weight/FL f)Material
7t i C (Show direction and distance from at Mast two State
From + T__ Roads or other points)
map reference From To Ft
From To Ft CJ1
14. GROUT:
From i TToao Ft i ' Y�'r\t-- th Material Method
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 Sae Material
From To Ft
From To Ft.
17. REMARKS:
VAT
M
v\ ict ' •
tr A
O(d For (0 .
��'iiCf`t F
G FaA rvt eta
Z`4o
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER. �n
FOR OFFICE USE ONLY COi'% d - 30'6
Quad No: s=O4ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of water Ouailty, Groundwater Section within 30 days
Ow-1 REV. 12199
Serial No.

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: lit or) .r,
WELL CONTRACTOR CERTIFICATION a: o
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable Boa); ResidentialQ Municipal 0 Industrial 0 Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 11)
Nearest Town: Courty. trm
'(Road Name and Numbers. CommuNty. or Sub&ision and lot No.)
3. OWNER Ul
Address CXJJY'1
(Street or Rp{d1 No.) _
✓U �' `- 4, r 1" v -� K)(
City or Town Stay rap Code
4. DATE DRILLED -"a t LC
5. TOTAL DEPTH e '-
6. CUTTINGS COLLECTED YES El NO-'
7. DOES WELL REPLACE EXISTING WELL? YES DN0L9'
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING is { fuse •••9 Above Top of Casing)
FT. Above Land Surface'
'Top of casing terminated al/or below land surface requires a variant* In accor-
dance with 19A NCAC 2C .0115
10. YIELD (gpm): l t % METHOD OF TEST I"\ C.
11. WATER ZONES (depth)•
DRILLING LOG
From To
kC'
12. CHLORINATION: Type Amount
13. CASING:
DEPTH
Formation Deserfption
(1\11 lTh ¥
J
If add)bonal space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material _ ` (Stow direction and distance from at least two State
From To Y.1 Ft ` '1i_1
Roads, or other reap reference points)
From To Ft
From To Ft
14. GROUT:
Depth Material Method
From To ..., Ft. '--
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:
CCT
J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COOF THIS RECORD FjµS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Ouad No:
P-2 9-0 c.
Serla No.
SK;�IATURE OF PERSON CONSTRUC11NO THE WELL DATE
Submit original to Division of Water Duality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina • Department Of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Canter - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR' (`) VIA --I An Wit'
WELL CONTRACTOR CERTIFICATION e: `:_ 3
STATE WELL CONSTRUCTION PERMIT/it
3 m ft n, (; p
U
ti v + V
1. WELL USE (check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑
Recovery Heat Pump Water Injection El Other ci If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A C e(l cr I A \ C County t._ r ii7'1 " ;j—`i`
--3.
(Read Name and Numbers, Community* or Sutxtivtuon and Lot No.)
OWNER ICY i'C1 7 [!��" . y y.._ . v r
Address 7-,k ^ (:X )'
(Stuns or Route No.)
Oily or Town Stye
4. DATE DRILLED (XG
D
5. TOTAL DEPTH '-
6. CUTTINGS COLLECTED YES NOt
7. DOES WELL REPLACE EXISTING WELL? YES [] NO7
8. STATIC WATER LEVEL Below Top of Casing: FT.
Zip Coca
Monitoring ❑
DRILLING LOG
From To
1 oC - I'-+
4�'T
9. TOP OF CASING IS ` (Use .• a Above Top of Casing)
FT Above Land Surface'
top of using terminated atior below land surface requires a variance In actor -
dams with 16A NC 2C ,Oita
10. YIELD (gpmCA): r. - METHOD OF TEST ✓mt Ll
11. WATER ZONES (depth)*
12. CHLORINATION: Type Amount
13. CASING:
wag Thickness
From Deeppth r.� Ft Diameter «We . Material
To C i i
From To Ft
From To Ft.
14. GROUT:
Depth Material , _ Method
From To » (- Ft. U-) \1 (1
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From _ To _ Ft _ in in
From _ To _ Ft in _ In.
From _ To __ FL ^ in _ m
16. SAND/GRAVEL PACK
Depth Sae Material
From To Ft
From To Ft.
17. REMARKS:
DEPTH
Fonnallon Description
JJ ✓
J
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
-r
-a
0—o
�, I
1o1-L3N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A Cg OF THI RECOR HAS BEEN PROVIDED TO THE WELL OWNER.
TUBE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DhAslon of water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
FOR OFFICE USE ONLY
Quad No
SMat No.

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 WELLCONTRACTOR• CI eareA -cx-
WELL CONTRACTOR CERTIFICATION a: r=
STATE WELL CONSTRUCTION PERMITa:
67
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) --7
Nearest Town: V\ ?TVPr / t .\\e
County l )
(Road Name and Numbers. Community, or Subdivision and Lat No.)
.a3. OWNER r. )k % Th,e0 '✓
HCXt>e `` rt M ML.
City or Town State Zip Code
4. DATE DRILLED k - - '
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOE(
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (�'�C a Above Tap or Casing)
FT. Above Land Surface'
*Top of casing terminated auor below land surface requires a variance In accor-
dance wah 1SA NCAC 2C AW
10. YIELD (gpm): i Th METHOD OF TEST I • • : j
11. WATER ZONES (depth)*
Address C O gn.r . c"\/
1 pry)-', 1-C1
r9crl
12. CHLORINATION: Type Amount
13. CASING:
Depth ... „ Dianwter
From To L. Ft
From To Ft.
From To Ft.
14. GROUT:
From
From
15. SCREEN:
Wall Thickness
or WaignVR.
DRILLING LOG
From To
C
Gt -a?
2
DEPTH
Formation DesmiPtion
C` tr 1 C
tf additional space is needed use back of form
LOCATION SKETCH
Material ,. (Show direction and distance from at least two State
Roads, or other map reference points)
Depth c. Material Method
Tort) Ft. lI I YY f i
To Ft
Depth Diameter Slot Size Material
From _ To ___ Ft _ in _ in
From _ To _ Ft _ in. __ in.
From _ To _ FL _ in _ in
16. SAND/GRAVEL PACK:
Depth Size Material 's
From To Ft
From To Ft
17. REMARKS:
rnto
-D n
1/40
0` -rT ;lit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF TCORD ' BEEN P OVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY HIS �/ — Z‘ -O
Quad Nix TORE OF PERSON CONSTRUCTING THE WELL DATE
Sabi* original to Division of Water Quality, Groundnut: Sadion within 30 days
GW-1 REV. 12/99
Sell No.

film,'i
14. DepthSlot Size Material
From To Ft. in. in.
From__ To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
16. REMARKS:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ResourcesA- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) GA- 6 �Lfe7i�C CERTIFICATION # AO'
WELL CONTRACTOR COMPANY NAME L %/it ntj PHONE f Pe Cr>Ytce
STATE WELL CONSTRUCTION PERMIT* C ASSOCIATED WQ PERM rill
(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
2. WELL LOCATION: Q(�
Nearest Town: OLn q-4- County IS13AJt°frif)ta
na lA
(Street Name. Numbers. Community. Subdivision. L//ott No.. hp Code)
3. OWNER: �f'I�O �iIYV-44 j
Address 6 VVV )�1 31 Of Foci• Rea-•
ck
City or Town
Area code- Phone rumba
4. DATE DRILLED LI-ZO'-D(a
5. TOTAL DEPTH: `/os /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CY
7. STATIC WATER LEVEL Below Top of Casing: FT.
(User of casing)
8. TOP OF CASING IS / FT. Above Land Surface;
*Tap of casing terahated at/or bebw land surface requires a
variance in accordant' t with ISA NCAC 2C .MIS.
9. YIELD (gpm): at MEET�'HHOD OF TEST �%'/ 3�
10. WATER ZONES (depth): ,i(ggHm �1Lf. Set,'
Street or R No.)ap Code
11. DISINFECTION: Type C i&Z;tior Amount O csL
12. CASING:
Depth Diameter
From_f To
From To
From /0 / To
13. GROUT: Depth
From
To Ft.
Wall Thickness
Topogr�aapphic/Land setting
❑Ridge (lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
e ;:1���/ /782%z.s%% its
3�
(dcgreeshnimnesfsecoads)
Latitude/Iongitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
z//ei' S/iTiti
oak
DEPTH
From To
�-9S
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
or WeightFL. Material numbers and common road naynes.
ert° wire/
/FA vai1/
Material Method
From © To ja Ft. �//P@
SCREEN: Diankter
60.121
0
•
Submit the original to the : n of Water r/ality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
RECEIVED
v '"R QUALITY
OGT.06 2006
RECEIVED
OCT 1? 2eLid
Ashevi - ¢-... •
Asuite( Prntertinn
" an
1 DO HEREBY CERTIFY T t T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WWJTA I5A
CONSTRUCTIONSTANI'S,AND THAT ACOPY OF ■.-RECORD. HAS BEEN PROVIDED TO THE WELL OWNER
41110,
RSON CONSTRUCTING THE WELL
DATE
27699-1636 Phone No. [phone], within 30 days. G W-1 REV. 07/2001
ce
go/ /c C. pesw..-.i
7o9- 7E(c, — SY--

0 2 9 fl
el ti-
12. CASING:
Depth
From To O(
From
From
13. GROUT: Depth
From To
From 0 To 21
Depth
To
Front__ To
15. SAND/GRAVEL PACK:
Depth
From To
From To
14. SCREEN:
From
I6. REMARKS:
1 DO HEREBY CERT)F
CONSTRUCTION
WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and Natural Res�-orurces- Division or Water Quality - Oroundwater
W ELL CONTRACTOR (INDIVIDUAL) NAME (prier) 41y J 4; c / c,(� CERTIFICATION a/CO
WELL CONTRACTOR COMPANY NAME 3 �%Gt: t� Ly,t L W r-t L.L i PHONE a f 7ii!-rig/Er
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT*
tire licab1e) (if Usable)
I. WELL USE (Check Applicable Box): Residential CP.-Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Otter, List Use
2. WELL LOCATION:
Nearest Town: I.S'G(Ur 1-C County &wertinfr e
12$ i .t9(,hbdtz�
(Street Nature Numbers. Canu*„sa�twwo-w rp Co)
3. OWNER: /3ytt 1 15ifrC
Address rZS fieyyLsipPL
(Street or Rotes Na)
4g/,uite NC zb'8a5
City or Town State rip Code
(9?6 __fl5- 2v2e
Anti. code- Pivot mmriier
4. DATE DRILLED Wit 04,
5. TOTAL DEPTH: 'O
Tc-vpograpph c/Land setting
ORidge LStope °Valley Offal
(cheek appropriate box)
Latitude/longitude of well location
35°.sY.JlaJ 4,./4 o Z? Z8..s1.6(A)
(degreeshitioutesisecondO
Latitude/longitude soorce:OGPSOTopographic map
(dial; boa)
DEPTH DRILLING LOG
From To Formation Description
O Rio
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 131C - l S 7. STATIC WATER LEVEL Below Top of Casing 4?47 0 FT.
8. TOP OFCAStNGIS (mac; Wins. Top dCo�)
FT. Above Laud Surface*
'Tap of casing terminated atter below lead surface rtpuhes a
variance to accords with ISA NCAC 2C .91t& ..,.�e,,'
9. YIELD (gpm): / METHOD OF TEST s(/Vd/4(1?
10. WATER ZONES (depth): /t /A Co &or"
11. DISINFECTION: Type C(d),C i MC
Round Eli O 1mom
mct -
Wall Thi
Diaor Weight/Ft. Material
FL 61/9 pin
To FL
To Ft.
Material
FL•
R.2 v(
Diameter
Ft. in.
FL in.
sirs Size
in.
iR
Size Material
Ft.
FL
/2c s 0.14 1.-
facie Oita
!S 705 g'2rbdtt''L_
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mad
numbers and common road names.
��' 4
^
Rim
V. Or RECEIVED
QUALITY
OCT 04 20o6
47JF�
1i°LU`—1
AT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
DARDS. AND THATA COPY ORD HAS BEEN PROVIDED TO THE WELL OWNER
OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality,
27699-1636 Phone No. [phone], within 30 days.
ndtRiEltecViEeatStsv
DATE
Center -Raleigh, NC
GW-1 REV.07/2001
OCT 1??'.i:::
Asheville Regional Office
A uifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CERTIFICATION #
%YELL. CONTRACTOR COMPANY NAME
PHONE # f )
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(ifappliabk)
I. WELL USE (Check Applicable Box): Residential 0 MunicipaVPublic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 I(Other, List Use
2. WELL LOCATIOJ1:
Nearest Town: Faintihew sic County a_.te
(Street Nam:. Numbers, Community, Subdivision, tot No.. Zip Code)
3. OWNER: SQD'i JuMpc.R,
Address / VT I Ar4Y. NMved! IC4
64. , fshect . RouCNo.)
City or Town State Zip Cak
)-
Area code- Phone number
4. DATE DRILLED g - /S_ O
5. TOTAL DEPTH: WO.j
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er
7. STATIC WATERLEVELBeIowTo of �Or lns`
A0.rA'- I`IA+wt11/
Depth Diameter
From To Ft._
From O To //f Ft. (.
From j// To //3 Ft. G
13. GROUT: Depth Material
From To Ft.
From__,._ To�Q_ Ft. '�f / �—
14. SCREEN: Depth Dianxfer Slot Size Ma ei riaP
From To FL in
From in.
To
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
16. REMARKS:
P 6 / FT.
S. TOP OF CASING IS (Use '4 if Above Tory of Casing)
FT. Above Land Surface*
'Top of casing terminated atter below land snrftte reaaires a
variance in accordance with ISA NCAC 2C .011t
9. YIELD (gpm): / METHODQOF TEST /t%5/,1�!
10. WATER ZONES (depth): / 9, /0, e+ aro
1I. DISINFECTION: Type &0A4Ve
12. CASING:
Topo d setting
❑Ridge lope ❑Valley ❑Flat
(check approprtate non
Latitude/longitude of well location
�5°St 9F/, OSz'_ ez/Z y t✓
(degrxs/minutesheconds)
Latitude/longitude sourcc:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description.
0— .ft
0J�oc�
4Dl" � /2mAd
LOCATION SKETCH
Amount (K a Show direction and distance in miles from at least
wall Thickness two State Roads or County Roads. Include the road
or Weight/Fe Material numbers and common road names.
Method
DIV. OF RECEIVEDT
Ft. in. in. QUALITY
OCT 0 6-zoos
ed
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH i5A NCAC 2C. WELL
CONSTRUCTION STANDARD 9!}JD THAT t)J;OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1 1
GAgaal
c neck
IGNAmRF F PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Gr
27699-1636 Phone No. [phone], within 30 days.
ndwatRteeE6ii CaLsenice C nter - Raleigh, NC
W-I REV. 07/2001
OCT
Asheville Regional Office
Aquifer Prntnrtinn
7

RESIDENTIAL WELL CONSTRUCTION RECORD
Non h Carolina Department of Environment and Natural Rrsnurcrs. Division of Water Quality
WELL CONTRACTOR CERTIFICATION tt a t 4 i7
1. WELL CONTRACTOR:
R l✓Lh_b c_cd 1P 4t
Well Contractor (Individual) Name
Reu.bevv Co3cLetj C)ri•tg i lne•
Well Contractor Company Name' \
STREET ADDRESS %S I t e-W l-e..I c.est r Ww�
fksh,tr tk I3Q aNg70 b
City or Town Slate Zip Code
(ea-( )- 3.54-359I
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID aril applicable)
STATE WELL PERMIT#(a applcable)
DWQ or OTHER PERMIT #(i/ applicable)
WELL USE (Check APP Cable B x) Residential Water Supply (V
DATE DRILLED 1/ Oil (1
TIME COMPLETED 3I e. o AM/ PM p
3. WELL LOCATION: p
cry: £Ak,3 tbSV)L.LET COUNTY D-rf51(-4/r
d-'O CG AR. N I Li- V STATES
(Street Name. Numbers. Community. Sobdrn,on. Lot No.. Parcel. hip Code)
TOPQGRAPHIC / LAND SETTING:
itSIFP4 °Vafey °Flat °Ridge °Other
(check appropriate bow)
LATITUDE yi 5 4ta -C 39
LONGITUDE `_ a as.59
May be in deprers.
minutes. seconds or
in a decimal format
LatiludC/Iongitude source: {APS OTopographic map
(bcation of wet must be shown on a USGS topo map and
attached to This form m110i usng GPS)
4. WELL OWNER 2
OWNER'S NAME orb j T1 b12-T2--8t /
STREET ADDRESS 7C SG&a. VA ILL._ nki �L
Ciy or Town State Zrp Code
( 4¢0'7 )- Vat a" Vt30
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 05
b. DOES WELL REPLACE EXISTING WELL? YE,S° NO.A
c. WATER LEVEL Beta Top c( Casing �1ia FT
(Use -e' 8 Above Tr c! C asing/
d. TOP OF CASING IS it. FT. Above Land Surface'
'Top d casing terminated al/or beton Land surface may require
a variance in dance with 15A NCAC 1C 0118.
% F-
e. YIELD(gpm). ,2 METHOD OF TEST QLC.... 1f„
DISINFECTION: Type n t (4 qo% _ Arnount
g WATER ZONES (depth)
From To N/�
From To
From To
6. CASING
j Depth
From 1. To as FI
Frorn To FI
From To FI
7. GROUT- Depth ^^''
From i To ail F1.
From To Ft.
From To Ft
Dra
From
From
From
ei '_ V F. V L
To
To
To
Thickness/
ter We__ 1 °dal ial
12 vz
Material
(..€m r
Method
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
From To F1.
From To Ft.
FromTo Ft.
10. DRILLING LOG
From / To j
r� 1S
Imo'— ) OOS'
11. REMARKS:
Material
Material
F matron Description
b/ G11444.41-0& >�
Ft0 Cr
RECEIVED
DIV. OF WATER (IUALITy
OCT 0i 6 200G
100 NE PE lit CFRTYY THAT THIS WEI) WAS CONSTRUCTED N ACCORDANCE
Wrtll
I SA Nr AC IC will CONSTRUCTION SIAM: AROS ANC) MAT A COPY OF mI RECOn0 N S PEEN PROVIDED TO TILE WELL OWNER
okeLa Si ,-1 th0
StIrNAti, (PIPE OFGERTIFIE0 WELL CONTRACTOR 0 TE
ltl�Ea t3AS
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] eat 568.
Form GW-ta
Rev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural R eav nres. Dis is inn of Water Quality
WELL CONTRACTOR CERTIFICATION tl
1. WELL CONTRACTOR:
Rw ben Cald.uwe41
Well Contractor (Individual) Name
Oeu,bev\ Co`1tLeu1 Ors t L io Inc.
Well Contractor Company Name1
STREET ADDRESS S5 I (Jet/3 € cestr r b1u4
Ps�ev� lie tJC 3,w7c
City or Town Stale Zip Code
(fig) �54 - 3 59
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT/(a applicable)
DWQ or OTHER PERMIT a(0 applicable)
WELL USE (Check Applicable B ) Residential Water Supply off
DATE DRILLED c /cis To 6
TIME COMPLETED 1a 3o AM PM Ey
3. WELL LOCATION: (�-�
CITY: CI.A a N1.-1§YZ- COUNTY gum C-OM
o o tLETYLf& G AP
(Sine! Name. Numbers, Community, Subdn.von. Lot Ho Pucel bp Code)
TOPOGRAPHIC / LAND SETTING
�bpe OVaBcy ❑Flat ORidge OOther
(check appropriate box)
LATITUDE 3 .S 34-.DS I
LONGITUDE g ,_ 4-. 4 as
May he in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(bcaobn of we/ must be shown on a USGS topo map end
attached to this form / not usng GPS)
4. WELL OWNER
OWNER'S NAME
c/k Flc laaUl ..-0
STREET ADDRESS %CL Ic38VV1\ )S e/$415 (Lo
r�ruis1->z- ac. aT-115
Cityor Town Slate Zip Code
b 6s- a69
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
34-5
b. DOES WELL REPLACE EXISTING WELL? YES CI NO
d A
L✓j
c. WATER LEVEL Below Top Casmg O CI FT
(Use'+' it Above Top d Casing)d. TOP OF CASING IS -AL FT Above Land Surface'
-Top or casing temmnaled allot betov lard surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD(gpm): 15 METHOD OF TEST `n`lG —ryly
/ DISINFECTION: Type 4lik 4..0%Amounl
g WATER ZONES (depth
Flcvm i p5 '7To IS
5
Fran I'' To 1. S-
Fran To
6. CASING:
II
From J To Dept 3O
From To
From To
From
From
Frorn
Ft ljait
Ft
Ft
7. GROUT:Depths a�
From 1 To aft Ft.
Frorn To Ft.
From To Ft
8. SCREEN: Depth
From To FI. in. in.
From To FIin in.
From To FI in. in.
$r o1
To
To
To
Thickness(
0°4 lens
Material
C,im13N-I
Method
Qovtc.9
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
F rqm/— IRS /
lays/- 150''
1so, - 155'
t53'- 33u'
330 / - 3 35'
335/- 3.45/
11. REN1AItKS:
Diameter 5101 Size Material
Ft.
Ft,
Ft,
Size Material
Formation Description
C9C24+a tT(s
c_ 2gN/ - 5 G Pr m
(-a rJ VT Ca
Ci0-410$ — to GFm
G (Z.P ra 1 TE
DIV OF WATEK Q;1.
R n
RECEIVED
OCT 17 2005
I DO NEPFPy cFntry THAT TDRS WELL WAS
ISA NCAC ac WWI.). CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAC PF EN PROVIEED TO THE WELL OWNER
Asheville Regional Office
cONsTR AMFN{.1''einRnnjrt. tn.In
SIGNATURE OF ERTIFIED WELL. CONTRACTOR D TE
It-4-1f5 tJAS3J
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] eat 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
Non), Carolina Department of I minmment and Natural Rrcrrnrcec- I)i% ieinn of Water Quality
WELL CONTRACTOR CERTIFICATION id a i 4 c0
1. WELL CONTRACTOR:
Ren-be,N Q-A-wet(
Well Contractor (Individual) Name
Rau be- V\ C LL.e 1I �ri t I:11 g I AC
Well Contractor Company Name
STREET ADDRESS 3S I �1-'Lei (e ter I'1wl
(\shev; t.le tJC a Nicene
City or Town State Zip Code
gLa�r a,s4--3' 9I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMITS/tit applicable)
DWQ or OTHER PERMIT %(if applicable) /
WELL USE (Check Applicable Bos) Residential Water Sorrily DJ
DATE DRILLED (0 / 3 /o G
TIME COMPLETED I'. 3 o AME PIA
3. WELL LOCATION:
CITY: ASIA"•((��(—L �+ COUNTY t1VCOMgp,,!
1J37 If 4 tt Q AREga-tote Su-f36t111510A
(Street Name. Numbers. Cwnmunny, Subdmson, Lot No. Parcel, hop Code)
TO` QGRAPHIC / LAND SETTING:
lifIope oValley ❑Flat ❑Ridge OOther
(check appropriate box) r _
LATITUDE 3 5"3q. Q8(0
LONGITUDE % a 15 . pit
May he in degrees,
minims. seconds or
in a decimal fnrmai
Latitudellongitude source: tCGPS ❑Topographic map
(location of wel must be shown on a USGS logo map and
attached Io this form Ina? usng GPS)
4. WELL OWNER
OWNER'S NAME STIE9r.A S en caJ"IC"
STREET ADDRESS 160 at -rite, U R 0
SwA4/1440p ('A ,3c a8-11q
City or Town Slate Zip Cade
(DA F. IA L- S3tg
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
345
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top d Casing
(Use -r- A Above Top d Casing)
d. TOP OF CASING IS
NO
FT
FT Above Land 5udace'
'Toed casng terminated atla below land surface may require
a variance in accordance walk 15A NCAC PC 0118
e. YIELD (gpm):
METHOD OF TEST t1tG-AIR
ryi 9
el '7 J A
1 DISINFECTION: Type 4T11 "ID /a Amount
g WATER ZONES (deeppl )./
ripen 4.0 To C1 sS
Trim To
r,.n To
6, CASING'.
D
Frpn To
epth $4- El
Fran To Ft
From To FI
7. GROUT: Depth
From 1. To 'ai0
From To
From To
8. SCREEN:
From
From
From
From
From
Fmrn
To
To
To
Thickness/
Qiflfr'pler s eioh6ll [vtatgtial
Material Method
Ft. CS In - AT Oute.D
FI
F1
Depth Diameter Slot Size Material
To FI._in. in.
To Ft in is
To FI_in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From__ To
Ft
F1
FI.
Size Malerial
10. DRILLING LOG
From/ � / To� r F%rmation Description
—
OV @KC,Vt.ia
4-q / - 9 0' C, R.n-01-r6
'o '-Gt.S' c-(LA-Jtoc- n Gen"
ctS/ - 3 4-5' Gft-Aaat-,'e
II. RENIARKS:
RECEIVED
DIV. OF WATER QUALITY
006
R�C F-DIFD
OCT 17 2006
Asheville Regional Office
Acts fifer Prefttrt:..r.
100 HF Rr BY C F RTIFY THAT MR W FIt WAS CONSmUCTFD N ACCORDANCE WW1 ISA NCAC )r WFtL CONsmuCTION STANDARDS AND THAT A COPY or THIS
REcoRo HAS OF EN PROVIDED TO mE WELL OWNER
Layenn eskeLwia _ t olob
SIGNATURE OF CERTIFIED WELL CONTRACTOR
l>.L4F� 1arSii
GATE
pRMTFO NAML 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-1a
Rev. 7/05

RESIDENTIAL 1'ELL CONCTRi'CTION RECORD
North Carolina Department of Environment and Natural Rrvnucea- Di, i:ion of Water (hlalilr
WELL CONTRACTOR CERTIFICATION tt
1. WELL CONTRACTOR:
Re beTA c�dt)4(
Well Contractor (Individual) Name
(Lau -bey. Catd gull OrjtI;tHgInc
Well Contractor Company Name
STREET ADDRESS SS 1 rJe-U. Fes --I cestzr NU..
fksh.ev1 Lie IJC �wgc 6
City or Town Stale Zip Code
(ea() 3S4- 35S'I
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID M(ir applicable)
STATE WELL PERMITD(a applicable)
DWQ or OTHER PERMIT %(il applicable)
WELL USE (Check Ap licabl Bo:) Resdenlia/ Water Supply ly
DATE DRILLED R/ 5/ U To
TIME COMPLETED
3. WELL LOCATION:/ y/�t /�-a!
CITY: AS �tSa1l_L.6 COUNTY UV1JL'I4a-
I ®J AM ❑ PMI/
IPa634 t���s��--1< �++ W 63
(Street Name, Number, Community. 5ubdrepoo„ en No_ P reel Zip Code)
TOPOGRAPHIC / SETTING:
❑Slope °Valley lal °Ridge °Other
(check appropriate box) r
LATITUDE 3 5 3 1, b$ b
LONGITUDE B 2 *tin k
May he in degrees,
minutes. seconds or
m a decimal format
Latitude/longitude source BGPS °Topographic map
(location o/ wel must be shown on e USGS logo map end
elfached to this form 1 not usig GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS AG-3 4 Lff Kees-Zp72. I4"11
1.43- 1 C45 5 Cti — Ps C.-
C.Iy- m�own b%3 Stale56gZip Code
(it) -7
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 6 5
b. DOES WELL REPLACE EXISTING WELL? TES NO 0
c. WATER LEVEL Below Topot Casing g 0 FT
(Use e' a Above Top or Casing)
d. TOP OF CASING IS FT Above Land Surface'
'Too or casing tsv unaIed abor below land surface may "-nt:'e
a variance in accordancewith t 5A NCAC PC 0116 �l
e. YIELD (gpm) CT METHOD OF TEST Q,tG - A !4 --
Submit the original to the Division of Water Quality within 30 days. Attn: Ir
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919i 733.7015 e
a1A c7
f. DISINFECTION: Type 7(t {O UAmount d C
9 WATER Z9NES (depth)
`/
r,p., i 5 To _`� Frorn
To
rrem To Frorn
To
F,..n To Frorn
To
6. CASING.
Depth Di Ate
From_ To S FI.
Fran To FI
Frorn
,m To Ft
Thickness) pre,
ei hysl s te"I
7. GROUT: Depth t� Material
FromTo 01.6 FI Lti ta\6»V1 1
From To Ft
Fro'^ To FI.
Method
B. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To FLin in.
From To
Et in. in.
9. SAND/GRAVEL PACK'
Depth
From To Ft.
From To Fl.
From To Ft.
10. DRILLING LOG
Frorn / T 6( /
SS'- Si)
OtIL___--I / ` 3 oS)
11. REMARKS:
Material
Size Material
Fo mation Description
i. l 15-
Gen-.
C� 1Lsa \a
RECEIVED
UIV. of- WAIER QUALITY
OCT 0, 6 200G
100 HERE ey crnwv /HAT 1M$ WFLL WAS CONSMCTFO N ACCORDANCE MTH
,SA NCAC )c Wilt CONSTRUCTION STANDARDS AND THAT A COPT OF IS
RECono IlAS RFF vnpypFO TO THr WELL OWNFR
SIGNATI Ira['
ERTIFIED WELL CONTRACTOR / p
PUit4 Ff., ru.ME CTr "r'1 r.,h. L.orgb I HVC TING THE WELL
RECEIVED
orination Mgt.,
1565.
OCT 17 2006
Forrr
Rev.
E
GW-la
/05
Asheville Regional Office
AC an/. Penta"!1.«w

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential d Municipal/Public 0 Industrial ❑ Agricultural 0
1
9-061A Ln11,b6
�ro4he!
)tIOZ
of Water Quality - Groundwater Section
CERTIFICATION # 2V /8
P!!)Lp PHONE # (8Z$) Gq8-3170
ASSOCIATED WQ PERMIT#
(if applicable)
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: "
Nearest Town: Cavidler
County 8uncarnh ,
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: N.10 Heal-kan ,JYa.e/I
Address 23'0b O amOle. Lit-
(StreetorRo eNe.)
4,hnl.ille NC 238o6
City or Town State Zip Code
($idl- '7/ 3- 4y 33
Area code- Phone number L
4. DATE DRILLED e 'Z
5. TOTAL DEPTH: 2 65 t
6. DOES `AT I. REPLACE EXIS !INC; V'EIYtLS ❑ NO iJ'
7. STATIC WATER LEVEL Below Top of Casing: S 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 accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 120 r METHOD OF TEST 2 h t/r$
10. WATER ZONES (depth): 2.50
Topographic/Land setting
ORidge ❑Slope OValley Eclat
(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
/7
1 I . DISINFECTION: Type 1-% 77.1-
12. CASING:
Depth
From 0 To 9 9 Ft.
Diameter
(4, f
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
pvc-
13. GROUT: Depth Material Method
From 0 To 20 Ft. Cernerr} 1 op
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include the ro
numbers and common road names. 44
1 '
Cil
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAhIDARDS, AND THAT A
COPY OF THIS RECORD HAS BEEN PROVIDED TOTHEWELL OWNER
//, a c A--r L^Z -O 1s-.
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

From _
From
17. REMARKS:
North Carolina - Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mai! Service Canter - Raleigh, N.C.
g 27699.1636-phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: C 1 ki.Y)kf A Q,r
WELL CONTRACTOR CERTIFICATION it [- ( 3
STATE WELL CONSTRUCTION PERMIT#:
334244
1. WELL USE (checkApplicetue Box): Residential Municipal ❑ Industrial 0
Recovery ❑ Heat Pump Water Injection ❑ Other
❑ 1f Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: (•CAI �Y� 1 O ,tom
County L(l"tfa'a7 Q
Agricultural ❑ Monitoring 0
A3. OWNER VC��Nameind ' ry. or Su sion and Lot No.) DRILLING LOG
�( fl', A k. A�eC,S DEPTH
Address �� _ - From To Formation Descrlotipn
rM Or • n-n e .
City or own St/10
4. DATE DRILLED ID-t�--cLc
5. TOTAL DEPTH _3Dr
6. CUTTINGS COLLECTED YES ❑ NO
21
7. DOES WELL REPLACE EXISTING WELL? YES Nry �{
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS IIFT. (Usep Above Top of
ove Land Surface"
'Top of using terminated at/er below lend surface require a variance In accor-
dance with 15A NCAC 2C .0113
10. YIELD (gpm): In METHOD OF TEST
11. WATER ZONES (depth):
•
12. CHLORINATION: Type Amount
13. CASING:
` Depty
From To I___
From To
From
14. GROUT:
From
From
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK:
Depth
To Ft
To Ft.
Ft.
Ft.
To Ft
t ?10 aaq
zip cod aa.G
D ;lc
If addtbonal space is needed use back of form
Wall Thickness
Diameter aWalghwt. ,^IMteria C
Depth Mate' I
To ct Ft. C40
To Ft.
Depth
To
To
To
Method
Diameter Slot Size Material
Ft _ In. In
Ft .__ in. In.
Ft. _ _ In. in
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A GOP F THIS RECORD H3.S BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
SIG 9(ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or Water Quality, Groundwater Section wfthin 30 days
Serial No.
GW-I REV. 12199

If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Diameter or Weight/Ft. Material
)may �.� C(Sh°w direction and distance from at !east two State
Ft
Ft.
l�-�L` Roads, or other map reference points)
Ft.
—L� Deptc2—Ft. Method
FOR OFFICE USE ONLY
Ouad Na
Serial No.
North Carolina - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.163&phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION S:oS'l t
STATE WELL CONSTRUCTION PERMITS:
44 2
1. WELL USE (check Applicable awn: Residential rer Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection
Other a If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:.��!V t { �P/1�-�� --- County _k�riCsoii bI
(RoadName
3. OWNER
Address
Numbers. Corrmunl or Su... and Lot No.)
DRILLING LOG
From To
J
I Or •
City or Town
Stale 4. DATE DRILLED �`f-i �n 74 Code
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES El NO
7. DOES WELL REPLACE EXISTING WELL? YES (� N ` n 6. STATIC WATER LEVEL Below Top of Casing: FT ��'�('� (.11F�-1TY
(Use'.' 9 Above Top of Casing)
9. TOP OF CASING IS
'Top of eating terminated at/er below land FT.
rfacAe regve Land Surface'
dance wah ISA NCAC 2 Sate rsqukaa • vuLnp in accor-
dance YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13, CASING:
Depth
From. _`To_
From To
From _ To-
14. GROUT:
From
From To Ft.
15. SCREEN:
Amount
Depth Diameter Slot Slze Material
From To Ft _ In.
In.
From
To .__ Ft. _ In. .—__ in.
From To Ft. __ In.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COJPYYJOOFTHIS RECORD HAS BEEN
PROVIDED TO THEyWn'ELL OWNER. /-
SIG OF Nf3 THE WELL — L d D
DATE
K3
Submit original to Division of water Quality, Groundwater Section within 30 days
GWl REV. 12/99

/1a 1e Combs
•Depo"""w�.r._w.rNr.re...., Okede.awlr.o,e-a�.d.r..s..an 3 3 4 2 31
R+elraNA VIIS-Ml.Fl.,e 711341111
WELL CONSTRUCTION RECORD flu. DDRTRACias1WIL
av* WEIL CONSTRUCTER'FL CONTRACTOR it •
1. MU. WEtha..lAwes. meth Ro.ldenINLJ` Mwdrlp.l❑ adman Anon Moodko l,O
Rsssvery Heel Pump Wider Simeon a Odor 0.OrN..I.MON:
2. WELL LOCAnottohs deft dnthes:=Sys)
N.rMITWewe Oe� i
end tn.sMaim Ossmora«...hln.rtat wy
a. OWNl91 117-
Address " lJ s I
'y (sr Tort Se SCI'
4. DATE MILLED-) " ''-'
& TOTAL DEPTH
d. amniaccuacjww vas No0
7. con us.L REPLACE eons Was? YE8 CI 100-
A STATIC WATER LEVEL SeMw Top N Collor
E. TOP OF CASING IS Fn. N _ Iad N FT. Above Lid S& ousse
9.Fdrwr lonmierdeft ld.wMdnp —__
SIM liallette SC MIDnwpl. _ le set.
10. YIELD I.,* METHOD OF TEST ._ r
11. WATER ZONES (*pith
oRlluwn �IH
Rwt T. rio.e.ato..syo..
12. CHLORINATION: NAT10N: Typo Amount
1a. CASM10:
From
Finn To
From To
14. GROUT:
Rem
From
1t SCRODS
Iteddywdtone br.d dwl.dhdh.n
WWI ilidinses
LOl.ATlal SKETCH
14m..r CL .w..r goes t.As,one aims kin rl.ntass ver.
To ct
Reawd.ranpSan robin)
FL
FL
Dept MMNM Method
To c"� R.• t 1 '-r�-MethodTo R
Depth Olson Mel Sbs Maeda
Fa.n To._.R In. In
From � To FL In.' __ In.
Fan To R. h ___h
1d. SAMEORAVEL PACK:
From
Rom
17. RISAMINt
To_
To_
Mr
F!.
FL
Mrdll
1001ERMIT 011Ri1FY THAT THIS WELL WAS CONSTRINTED M ACONIDANCII WITH 1M NGIC SC. WEL
CONSTRUCTION SM1 R NOD THAT A00F1GOFTHIS/�elFROWNED TONE WEILOWNER.
Q2D4
Tay toprlReeronnwarnw.w
IFOR MRCS USE ONLY
amine I
dawn.
SW.asyl„lr ahlwrwrrwwr. .._T .a.w. Wit ro daps ata
ant Mt Van
•

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:
422get c
WELL CONTRACTOR CERTIFICATION,:
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable Sox): Residential❑ Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection
❑ Other ED If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
County:
Agricultural ❑ Monitoring ❑
-a. ,(Road Nang and Numbers. Community. or Sub6vision and Lot No.)
3. OWNER
Address
,,
Ibtrelm or Route No.)
DRILLING LOG DEPTH
From To Formation Description
City or Town Star
4. DATE DRILLED `-P
5. TOTAL DEPTH '_
6. CUTTINGS COLLECTED YES El NO Ea I-��
7. DOES WELL REPLACE EXISTING WELL? YES � NOt=J
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (use '+' a Abase Top of Casing)
FT. Above Land Surface' �g
u
'Top of sing terminated atror below land surface requires a variance In actor- �C'E v 0.�„� 1. dance with 1SA NCAC 2C .o11a
10. YIELD (gpm): METHOD OF TEST 2''' ptn1F
11. WATER ZONES (depth): tit�P �C�a
12. CHLORINATION: Type Amount
13. CASING:
If additional apace is needed use back of form
Depth t3arnetr Wax Thickness
LOCATION SKETCH
a Weight/Ft. Material (Show direction and distance from at least two State
From To Ft
From To Roads, or other map reference points)
Ft
From To Ft.
14. GROUT:
Depth Material Method
From To >' i-) Ft. .
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:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ._ ac
Quad No:
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Sedai No
GW-I REV. t2,99

North Carolina - Department of Environment and Natural Resources - Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: Ca"'w-r kcy,bl1'
WELL CONTRACTOR CERTIFICATION Cc -CA
STATE WELL CONSTRUCTION PERMIT$:
' 04.
et t' t
24
1. WELL USE (check Applicable Box): Residential ' Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) �
County: 21 i(r,) t p tt Y�t�� 1b
Nearest Town:
(Road Name and Numbers. Community. or SubWision and lot No.)
OWNER Skbn �ejn -5e
Address C I CAI �O rt ncl
CA CC
ri, 7\7\a eric C a� i,DG
City or Town State
zip cod.
5. DATE D
TODEPTH
,i�;
5. TOTAL DEPTH ,,��
6. CUTTINGS COLLECTED YES El NO
7. DOES WELL REPLACE EXISTING WELL? YES NO®'
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS. l (Use : il Above Top of Cashel')
FT. Above Land Surface'
-Top of easing terminated aUar below land surface requires a variance In accor-
dance with 1SA NCAC 2C Aytlla
10. YIELD (gpm): X METHOD OF TEST P-1.1(�
11. WATER ZONES (depth): II
•
12. CHLORINATION: Type Amount
13. CASING:
D From___ _t..To M`21
From._.
From
14. GROUT:
To
To
DRILLING LOG DEPTH
From To Formation De
-LIq �(l
4G Gq
QG- tr\C
)00 -I4SS
'Rae
.-tt, ., ,F snit.�� 700h
ft additional space is needed use back of form
Wag Thickness
SKETCH
Di n eter of WeighVR. Materi , (Show direction and distance from at least two State
Roads, or other map reference polnti)'--
FL _
Ft.
Depth Material Method
From I To A Ft. C YY' 2Yli
From To Ft
15. SCREEN:
Depth Diameter Slot Size Matenal
From To Ft in in
From To _ Ft. in. ____ In.
From To _ FL In in
16. SAND/GRAVEL PACK:
Depth Size Material
Prom To Ft
From To Ft
17. REMARKS:
C
j,kr/ Qj,yro d5ViUIC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIStRECORra HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
/6— 2 7-04
TORE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water OuSity, Groundwater Section within 30 days
Serial No
GW-t REV. 12199

From _
From
17. REMARKS:
op casing terminated aver below land surface requires • variance In accor-
dance veldt 1SA NCAC 2C .e11e
1 D. YIELD (gprn): �_ METHOD OF TEST P-» q
11. WATER ZONES (depth):
North Carolina - Depanment 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. CL20 rikntbi
WELL CONTRACTOR CERTIFICATION #: a1121
STATE WELL CONSTRUCTION PERMIT#:
334223
1. WELL USE (check Applicable Sox): Residential2 Municipal 0 Industrial ❑ Recovery ❑ Heat Pump Water Injection 0 Other
© If Other, List Use: Agricultural ❑ Monitoring 0
2. WELL LOCATII�O�,N,: (Show sketch of the location below)
Nearest Town: �P�i 11\p
County:
(Road Name Numtwrs, Community.pr Sub6Nsion and tot No.)
`3. OWNER �j(
From
`y1ion LING LOG DEPTH
To Formation D sal
Address pp €� t ,
+1� ��t or
- a4 e bon
�-y
cay�Tawn 641. Zip Code s -1 - 3 c7h �r ice
4. DATE DRILLED ?��� j - -jic
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO`E]
7. DOES WELL REPLACE EXISTING WELL? YES [] NOc-
6, STATIC WATER LEVEL Below Top of Casing: FT,
9. TOP OF CASING IS I FT.AboAbcvnTopolface' RFrFIVED
•T or FT. Above Land Surface'
r vvF,TER QuAli t
Nay 0 e, zuu6
12. CHLORINATION: Type Amount
13. CASING: If additional space is needed use back of form
Depth Diameter Wall TNeimees LOCATION SKETCH
From J or weightin. Material!(Show direction and distance from at least two Stare
To , Q /4_
From To I C Roads, or other map reference points)
From To Ft.
14. GROUT:
From _
From
15. SCREEN:
Depth
Torte
To
Depth
From To
From To —_
From To
16. SAND/GRAVEL PACK:
Depth
To
To
tenant Method
Ft.
Ft
Diameter Slot Size Material
Ft in in.
Ft. in. In.
Ft In. ___ €n
Ft
Ft.
Size Material
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF THIS RECORD j 1AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Sent No.
/O-/?-0
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division or water Ouatity, Groundwater Section within 30 days
GWt REV. 12/99

FOR OFFICE USE ONLY
Ouad No:
Serial No
From
From
17. REMARKS:
From To Ft.
From To Ft,
14. GROUT:
Depth Material Method
From _L__. To a Ft. ' x 7
From To Ft
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To_
Ft
Ft.
Ft.
Diameter Slot Size Material
In. in.
In. In.
In. in
Size Material
Ft
Ft.
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO F THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
Ater nr O._/Z--66
SIG TURE OF PERSON Submit original to Division of Water Duality. CONSTRUCTING
Groundwater Seq�wlthin 30 days
OATS
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
1. WELL USE (Check
Recovery ❑
2. WELL LOCATI
Nearest Town:
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT.
Applicable Box): Residenttalrt Municipal ❑
❑ Agricultural El
Heat Pump Water Injection industrial
❑ Other If Other, List Use:
(Show sketch of the location below)
\rY'\/tlln
County: i'
(Road Name and Numbers. Communery. or SOdivtyon
�3. OWNER c�F�rN ��1 and Lot No.)
Address
DRILLING LOG
From To
( a o.
or i 4
rot
City or Town State 4. DATE DRILLED 7)--R0 Zip Code
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NOD. 7. DOES WELL REPLACE EXISTING WELL? YES NOP
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (the ��� a Above Top of Casa+01
*Top or casing FT. Above Land Surface'
*Tope with g terminated aver below land surface requires a variance in actor-
1SA NCAC 2C.01111
10. YIELD (GPM): i (> METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
Amount
13. CASING:
Depth Was Thickness
From--.� To ,l Ft. Diameter or Weight/Ft. Material
C
ate • Zr'� 1^
334219
Monitoring ❑
DEPTH
Fomuuon DesafpOon
: -t)CI -f cur
rxtt t f.
YarU tQ
\ �ciRL
cr
If additional space is need a back of loan
LOCATION SKETCH
(Show direction and distance from at least Inc State
Roads, or other map reference points)
GW-1 REV. 12r99

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: f Ars
4 1
( ICO 11 WI A -CI —
WELL CONTRACTOR CERTIFICATION #: c- \ ( 2)
STATE WELL CONSTRUCTION PERMITS:
1. WELL USE (Checkapplleable Bosh Residential Municipal ❑ Industrial ❑
Recovery ❑ Heat Pump Water Injection Agricultural ❑ Monitoring 0
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: t �,rt� i i; ( County:
"(Road Narnq and Numbers, CortrnuNty. or Subdivtyon ano Lot No.)
3. OWNER ` a
DRILLING LOG DEPTH
Address "� I �e From To
���� "0r FormanonDeaMpuon
mar'o. J_.� + ` -1 � .112 no( '-�- C i r"
' i Q_- 1 SS" - ��=i C r rt t\ t 4 R
City or Town star - - ` - CodeI _ 5-Li D 4. DATE DRILLED `-"L � .-Li(i-- DS- (. ?IfO,P
5. TOTAL DEPTH it CI:
6. CUTTINGS COLLECTED YES El NOD
7. DOES WELL REPLACE EXISTING WELL? YES El NO©'
8. STATIC WATER LEVEL Below Top of Casing: _ FT.
9. TOP OF CASING IS (Use A' a Above Top of Cain) AG FT. Above Land Surface* R
'Top of casing terminated at/or below land surface requires a variance In actor- nF 7iSt`
OQO
dance yeah 15A 2C.0115 ,l�J '�
10. YIELD (gpm): —I-a— METHOD OF TEST I r,i AS3 h'
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount It additional space is needed use back of form
Wall thickness
SKETCH
II Depth._, C� Diameter or Weight/FL. Material
From __J.. — (Show direction and distance from at east two State
To I U Ft. (1 1' 1
From To ( Roads, or other map reference points)
Ft.
From To Ft.
14. GROUT:
Depth Material Method
From I To &o Ft. r 1 i'Ylc nit
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:
ri
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF THIS RECORD AS SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
//6 -/3-D,.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Ouaitty, Groundwater Section within 30 days
„CF)ki
Serial No
GW-I REV. 12199

Depth
To
To
To
FOR OFFICE USE ONLY
Quad No:
WV No.
From
From
17. REMARKS:
North Carolina • Department Of Environment and Natural Resources - Division of Water Ouai'dY • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL. CONTRACTOR:
WELL CONTRACTOR CERTIFICATION STATE WELL CONSTRUCTION PERMITe:
33421
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery 0 Heat Pump Water Injection Agricultural 0
❑ Other 0 If Other, List Use: Monitoring 0
2. WELL LOCATI N: Show sk1 h of the location below)
Nearest Town: S
County: X� _
(Rood Name and Numbers,
OWN Community. or Subdivision anti Lot No.)
3. ER 0 i f ry� MC l $C t 11 Sri
Address 5 •�
City or Town State
4. DATE DRILLED _Zip Coos
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO Cr
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (case •'• g'� Top of Casing)
-Top ofeasingtarminNG aUdrba lend surface
Land Surface'
dance with 15A NCAC 2C .0116 requires a variance to aCcw•
10. YIELD (gpm): Ir METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:mount
From Dept. Diameter
To Ft.10�
From To Ft.
From To Ft
14. GROUT:
Wall Thickness
or WeIgii �M}ate�riall
/� .`MTh 1"C
Depth
Material Method
From .1_` To L- Ft. �_
From To Ft.
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK
Depth
To
To__
Diameter Slot Size Material
Ft tn. in.
Ft._ in. --__ in.
F1. _ in.
Size Material
Ft
Ft.
DRILLING LOG
From
To
DEPTH
Formation Description
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least Iwo State
Roads, or other map reference points)
Fker
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 IiAS BEEN PROVIDED TO THE WELL OWNER.
66
TURE OF PERSON
Submit original to Division Water Duality Groundwater ygHo witthhin 30 days DATE
GW-1 REV. 12/99

From
From
17. REMARKS:
Depth
To
To
To
North Carolina • Department of Environment end Natural Resources • Division of Water Quality . Groundwater Section
1636 Mair Service Center - Raleigh, N.C. 27699.1636-Ptwne [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: it 1 Of n n fl 1 gg .r
WELL CONTRACTOR CERTIFICATION,:3II2
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check APPficabfa sox): Residentieer Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, Ust Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town:
County:
Meted Na and �a�nd Numbers. Community. or Subrhviston and Lot No.) M. OWNER '4 aloy�y 1 �i,1or� DEPTH
Address
ry«Town el Stake
4. DATE DRILLED 1 1-6 CAP5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO®'
7. DOES WELL REPLACE EXISTING WELL? YES [] N
Osa
8. STATIC WATER LEVEL Below Top of Casing: P7.
9. TOP OF CASING IS (Use*: s Above Top of Casing)
Surface'FT. Above Land
'Top of casing terminated avebe surfaces requires a varlanp
rIn accor-
dance wfth 1SA NCAC 2C.011e
10. YIELD (gpm): a _ METHOD OF TEST (, ,,
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
zip
ss
Depth' n^n Die peter or eight/ .
From .�To A.ILUL R. tOYLJ ,_ «watgnvFL Material
From To Ft. 'T
From To Ft.
14. GROUT:
1 Depth
From To 6)0
From To
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK:
Depth
To
To
Ft. egialiejaLs—
Ft.
Diameter Slot Size
Ft In.
Ft. In.
Ft.
Ft.
Ft.
Material Method
Material
in.
in.
In. in.
Size Material
DRILLING LOG
From To
Formation Description
r-i
RECttutu tort
v„ \NikkEn.cat
env is ` 2006
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two Slate
Roads, or other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS' OF THIS RECORD AS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Simi No
SIGNATURE OF PERSON CONSTRUCTING THE/O ac,
WELL Submit original to Division of Water Ouafty, Groundwater Section wfthin 30 days GATE
GW-f REV. 12/99

33 216
FOR OFFICE USE ONLY
Quad No:
Sedal No
From
From
17. REMARKS:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town; ...1-P4r\ / as„,
fl(1 I I n County:
(Road Name
3. OWNER
Address
City or Town
Numbers. Community, or Sub6Wyon and tot No.)
4. DATE DRILLED O plo Zip Code
5. TOTAL DEPTH r7C"
6. CUTTINGS COLLECTED YES C3 NOI
7. DOES WELL REPLACE EXISTING WELL? E ❑ NO12"
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use 9 Move Top Of Casing)
ove Land Surface'
'Top of easing terminated at/or be land surface requires a variance In accor-
dance with 15A NCAC 2C .011e (� 10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type —---__Arnount
13. CASING:
From
From
From
Depth
To 4)
To
To
14. GROUT:
Depth Material Method
From L� To ZIG_ Ft. X'n fl n1
From To Ft �-�:L_
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
Walt Thickness
Diameter or Wefgm/R, Mate
Ft.
Ft.
Diameter Slot SIze Material
Ft In. in.
Ft. in. In.
Ft. _. In. in.
Size
Ft.
Ft.
Material
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:
WELL CONTRACTOR CERTIFICATION e:
STATE WELL CONSTRUCTION PERMITe:
1. WELL USE (Check Applicable Sax): Residential Municipal Industrial ❑
Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
Agricultural 0
Monitoring ID
DRILLING LOG
From To
0
DEPTH
Formation Desc tpuon
C11`I eTh �QnU
oaU�
It additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at !east two State
Roads, or Other map reference points)
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO PX OF THIIS,S,,��ECORD AS BEEN PROVIDED TO THE WELL OWNER.
!� //f- i• _ /D- z/- e�
(NATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DMslon of Water Quality, Groundwater Section within 30 days
X
GW-t REV. 12/99

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
We® Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMIT#(t applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Boxy Residential Water Supply 0
DATE DRILLED I 0 /a.0/
TIME COMPLETED 3 a AM ° PM
3. WELL LOCATION: IL
CITY: LE (C�S-fe 7L COUNTY qu NCefTtgb.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SE9NG:
❑Slope °Valley ❑Flat WRidge ❑Other
(check appropriate box)
LATITUDE i. 30 . $ C q
LONGITUDE a 7 i , r-($
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: eraPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form (not using GPS)
4. WELL OWNER �
1 OWNER'S NAME r 1 1 C.4 S e, 1, On A Cr' t% /� STREET ADDRESS 31 C1 Cojote C «_n r5p 1(.i 6
tc.a SZerv_ t.) C, a8141
City or Town State Zip Code
c?a` >- (03
Area code - Phone number
5. WELL DETAILS: J
a. TOTAL DEPTH. 445
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO I1
c. WATER LEVEL Below Top of Casing: O L FT.
(Use'+" if Above Topid 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): ( a METHOD OF TEST 14-1 G - A 11"
4339
f. DISINFECTION: Type 111 r{0 1 Amount
g. WATER ZONES (depth):
From 1 1 S To i Y From To
From To From To
From To From To
6. CASING: Thiclness/
Weigh!
From :- DeTopth,.b Ft. h'/ B� SDR2l
From To Ft.
Fran To Ft.
7. GROUT: Depth Material
From i To a a Ft. C.8 m8 ,v T
From To Ft.
From To Ft.
Method
e u/L$.D
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. In. In.
Fran To Ft. in. in.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
Frpm / To /
- 53
5t'-'15'
\86 44-s
11. REMARKS:
,1
DFqrmation Y �2Br °L'd�E`strN
CiL V t C4 — (✓Z (won
C�2Aa1Tt
Ca t=(�FiVED
Div NATr=R (1OALITY
1
123U6 ._
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS SEEN PROVIDED TO THE WELL OWNER. /
2t-1. �cL i �a 3/©E
DAfffE
SIGNATURE OF CERTIFIED WELL CONTRACTOR
11-1- tz cJ P S 1J
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

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2402
1. WELL CONTRACTOR:
MIKE McCONAHEY
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC.
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC 28625
City a Town State Zip Code
( 704 )- 872-7686
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Of applicable) MW-2
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Box) Monitakng XI Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
InigationD Other 0 (list use)
DATE DRILLED 09/11/06
TIME COMPLETED AM 0 PM ❑
3. WELL LOCATION:
CITyt ASHEVILLE
22 CHURCH STREET
COUNTY BUNCOMBE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Vafey ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE s.
LONGITUDE
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 it not using GPS)
4. FACILITY -is the name dew business where the well Is located.
FACILITY ID #(I( applicable)
NAME OF FACILITY SWANNANOA LAUNDRY
STREET ADDRESS 22 CHURCH STREET
ASHEVILLE NC
City a Town State
CONTACT PERSON NCDENR
Zip Cale
MAILING ADDRESS 1637 MALL. SERVICE CENTER..
RALEIGH NC 27699
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 34.0 FT.
(Use'+• if Above Top of Casing)
334009
d. TOP OF CASING IS 0.0 FT. Above Land Surface
`Top of casing terminated at/or blow land surface may reaWre
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
9.
WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Fran 0.0 DTo 32.0 Ft. """" l(tt PVC
al
From To Ft.
Fran To Ft.
7. GROUT: Depth Material
Fran 0.0 To 27.0 Ft. Portland bentonite
From To Ft.
Fran To Ft.
8. SCREEN: Depth Diameter
Method
SLURRY
Slot Size Materiel
Fran 32.0 To 42.0 Ft2.0 in. .010 in. PVC
Fran To Ft. in. _ in.
From To Ft. in. _ in.
9. SAND/GRAVEL PACK:
Depth Size
From 30.0 To 42.0 Ft. 20-40
Fran To FL
From
To Ft.
10. DRILLING LOG
From To
0.0 1.0
1.0 10.0
100
20.0
30.0
90 0
30.0
42.0
Material
Fine Silica Sand
Formation Description
siRAVFI
GRAVEL FILL WITH TRASH
ORANGE/BROWN/RED SILTY CLAYEY SAND
BROWN/RED SAND
BLACK/WHITE/BROWN/ORANGE SILTY SAND
11. REMARKS:
Bentonite seal from 27.0 to 30.0 Feet.
v0°s 2�06
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF miS
RECORD HAS BEE$ PROVIDE.RJQ''M!' WE OWNER.
. iss_ s 10/09/06
SIGNATURE OF CERTIFIED WELNTRACTOR DATE
MIKE McCONAHEY
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-lb
Rev. 7/05

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2402
1. WELL CONTRACTOR:
MIKE McCONAHEY
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC.
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Code
( 704 )- 872-7686
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(6 applicable) MW-1
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if appfr,ble)
WELL USE (Check Applicable Box) Monitaing El Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 09/11/06
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY: ASHEVILLE
22 CHURCH STREET
COUNTY BUNCOMBE
(Street Name Numbers, Community, Subdi4sion, Lot No., Parcel, Zp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Fist ❑Ridge 0 Other
(died( appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(l)cation of wet must be shown on a USGS tope map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(d applicable)
NAME OF FACILITY SWANNANOA LAUNDRY
STREET ADDRESS 22 CHURCH STREET
ASHEVILLE NC
City or Town State
CONTACT PERSON NCDENR
Zip Code
MAILING ADDRESS- 1637.MAIL SERVICE CENTER
RALEIGH NC 27699
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 46.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NC) El
c. WATER LEVEL Below Tap of Casing: 38.0 FT.
(Use '+• if Above Top of Casing)
6. CASING:
334008
d. TOP OF CASING 1S 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A g. WATER ZONES (depth): ti
From To From To
From To From To
From To From To
Timis
�a�en
Fran 0.0 Depth 36.0 Ft. 2 1 S�r�aO pVC el
From To Ft.
Fran To Ft.
7. GROUT: Depth
Material Method
Frain 0.0 To 30.0 Ft. Portland bentonite
Fran To Ft.
Fran To Ft.
8. SCREEN: Depth Diameter Slot Size
SLURRY
Material
Fran 36.0 To 46.0 Ft.2.0 in. .010 in. PVC
From To Ft. in. _ in.
Fran To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
Fran 33.0 To 46.0 FL 20-40 Fine Silica Sand
From To Ft.
Fran To FL
10. DRILLING LOG
From To
0.0
10
100
20.0
30.0
1.0
10.0
20 0
30.0
47.0
Size Material
N.
Formation Description
C,RAVFI
TANORANGE SILTY CLAYEY SAND
ORANGEBROWN/RED SILTY CLAYEY SAND
BROWN/RED SAND
BLACKMMITE/BRO W NORANGE SILTY SAND
aqrk
11. REMARKS: )\I
Bentonite seal from 30.0 to 33.0 Feet.
,‘,)1)cs Q
1 DO HEREBY CERI1FY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUC TAN ARDS, AND THAT A COPY OF THIS
RECORD 1AS BE7N PROVIIP/F/p E LL OWNER.
t`/( 10/09/06
SIGNATURE OF CERTIFIED WE ONTRACTOR DATE
MIICE McCONAHEY
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-lb
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town Slate
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITS/0/ applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Bold: Residential Water Supply ere'
DATE DRILLED %Q/A5 /O( /
TIME COMPLETED �) T' AM ❑ PM [�
Zip Cade
3. WELL LOCATION: /�
CITY: EA tat t3"4.) COUNTY �Il (.2 CZ rr eS�
\a ( tL-A • t oP /`lira &eA)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LANDLSETTING:
❑Slope ❑Valley Slat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 5 3 D .36
LONGITUDE a 24- 04
Latitude/longitude source: �GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this fonn 1 not using GPS)
0. WELL OWNER
OWNER'S NAME ESA
STREET ADDRESS la 1 FLAT TOP rt 'p -
ag-13
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State Zip Code
( sat )_ 405
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 5 0 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO�
c. WATER LEVEL BelowTop of Casing: ©o FT.
(Use "+" if Above j'ap of Casing)
d. TOP OF CASING IS - FT. Above Land Surface'
`Top of casing terminated allot below land surface may require
a variance in accordance with 15A NCAC 2C .0118.p
e. YIELD (gpm): a METHOD OF TEST 1(q-At9-1
3335538
f. DISINFECTION: Type
g. WATER ZONES (depth):
From 2 U S To al.D
From To
From To
6. CASING:
IV (• -1 c Amount t Z
From
From
Fran
To
To
To
Thickness/
1 DepthTo? 5W Q�.f" From To Ft.
From To Ft.
From To Ft.
7. GROUT: Depth �Maatteriall,` [�,
From Cet' To as Ft. �i ^-'Y t "
From To Ft.
From To Ft.
Method
oite-
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.
Size Material
From To Ft.
10. DRILLING LOG
Fropi / To
Eft'" qo5'
t5'- a i
P.,t0 505
11. REMARKS:
Formation Descri tiioonn
a JLT 1;
q^
�
Cg-le-41' a G 9rn
r. (Li ra try[€
RECEIVED
:-1nr nr 1AL TFR QUAL.UP'
1) a ZII06
IDO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1CuAlaiv,exitLAALO
SIGNATURE OF CERTIFIED WELL CONTRACTOR ' DATE
L.Lf t� itkS 1.4
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 # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
(828 y. 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(iif applicable)
STATE WELL PERMIT#(H applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable
JJJBox/)::�� Residential Water Supply Il
/
DATE DRILLED I I I 3/0 c0
TIME COMPLETED I I . AM f3 PM ❑
3. WELL LOCATION:`J/,,(�
CITY: AUK 7tA0a D COUNTY &MC-1 T4c
Res e1)1// ``A Q-c:DicSarS C.2e A a
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANrySETTING:
❑Slope ❑Valley C3FIat DRidge ❑Other
(check appropriate box)
LATITUDE 4 A •13 9'
LONGITUDE %' ' l'n°
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: , etiPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this tom, snot using GPS)
4. WELL OWNER ���`��
OWNER'S NAME Ms
STREET ADDRESS qS c P A (L°%r • NS 41_0R i>
}\t_ /t .)z.trR
City &r Torn State Zip Code
091 64-5--(ob93
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: to 0 5
b. DOES WELL REPLACE EXISTING WELL? YES gar/NO 0
1 0 0
c. WATER LEVEL Below Top of Casing: FT.
(Use '+"if Above Top of Casing)
d. TOP OF CASING IS A, FT. Above Land Surface
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. ,1 /� '
e. YIELD (gpm): METHOD OF TEST LAG A - i `al
333 5
5 6
f. DISINFECTION: Type l 0 Amount
g. WATER ZONES (depth):
From V-1.S Too From To
From 46 0 To �"' From To
From To Fram To
Thickness/
6. CASING:
Depth Di eke Weight
From o 6a Ft. S0(
From TT:
Ft.
From To Ft.
7. GROUT: Depth Material
From To a_a Ft. C60A1303T
From To Ft.
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
Material
'/C-
Method
eout6 D
9. SAND/GRAVEL PACK:
Depth
From To Ft.
Fram To Ft.
Size Material
From To Ft.
10. DRILLING LOG
Fromr To i
5-f r-
viS `- •80'
t80'-4c0"
4-too "~ 4-65'
4-c-5 ` - 6oc;'
11. REMARKS:
Formation Description N
o J flit-& ka-- t-
7 g�AaYTW
Cs�ILC+S %�In1
f`/GA13-L'fl
rite./ I A -- a. (3 Pen
6P.i1+OZ'T &
RECEIVED
ON OF WAl ER QUALi I Y
DEC 0 7 zoos
I DO HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OFOFnCERTIFIED WELL CONTRACTOR
4g(t-4-\6 t.31154
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
oh
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, �/afJr,2 , Gw-la
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] eat 568. Rev. 7/05

WELL CONSTRUCTION RECORD Groundwater Section
Quality ��/��
N/� LI CERTIFICATION alit
North Carolina - Department of Environment and t tnt)flur=all, RRetssOuurrccess - Division of Water Q 6
WELL CONTRACTOR (1NDIVIDUAI.)NAME (P^�rO ILLS PHONE #
WELL CONTRACTOR COMPANY NAME (7 I Y�1 ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# (if a' .livable
(i a�. Ica �
WELL USE (Check Applicable Box): Residential u
Monitoring 0 Recovery DI Heat Pump Water Injection CI Other 0 If Other, List Use
ah
f f ble Industrial ❑ Agricultural ❑
pM nicipal/Publrc
1.
Topogr p ic/Land setting
ORidge ❑Slope OValley161.1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) o hie map
Latitude/longitude source:O(chPSOTop gra P
eck box)
DEPTH DRILLING
From To
2. WELL LOCATIO : ' ( Cotmty
Nearest Town:
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER:
Address
City or Town State Zip Code
(ezS)- 2 99 9'/411
4 DATE9- -"Gto
/6 5
Area code- Phone number
DRILLED_,____
5. TOES `N EPTH: YES rl NO w/
E. DOES `i'F.I.L Rl';Pl,.^,CF. 1:vIS, !NU h, Zi i't �FT.
7. STATIC WATER LEVEL Below Top of Casing:
/ (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 g m): _L with15 M TH .0118.
D OF TEST?
9. YIELD (gpmY
10. WATER ZONES (depth):
11. DISINFECTION: Type alb— Wall
Am Amount
12. CASING: Depth
From--To� Ft.
From To Ft.
From
To Ft.
13. GROUT: Depth
From__Q—To ZO
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
From To Ft.
From
To Ft.
Ft.
Ft.
Diameter
Ft. in.
Ft. in
Diameter or Weight/Ft. Matepal
ht_
aterial
Size
Method
Slot Size Material
in.
in.
Material
Formation Description
LOCATION SKETCH
Show direction and distancemiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
i '). Z. 2103
16. REMARKS:
HETRUCEW RE WITH C 2C,
AND
ISW THATLLWAS A COPYCONSOF THISTRECORDD HACCOAS DANCBEEN PROVIDEDI5A TO NCATHE EWEL wNER
LO
/ —
DATE aSIGNATURE OF PERSON CO
NSTRU ±
Submit the original to the Division of
within 30 dayslry� Groundw � er Seaton, 16t1713f15etvdio'GW-1Center - r,
27699-1636 Phone No. [phone],
DEC 12 2006
aleigh, NC
EV. 07/2001

5344
WELL CONSTRUCTION RECORD Groundwater Section
Division of Water Quality "
tural Resout'cesL CERTIFICATION #20�
North Carolina - Department of Environment and N l , �� W—
rI y dY1T� PHONE # Qi�aiZ
WELL CONTRACTOR (tNDIv101 AL) NAME (print)
no ASSOCIATED WQ PERMIT#
WF.LI. CONTRACTOR COMPANY NAME cell if a licable)
WELL CONSTRUCTION PERMiT# �
(ifa
LOCATIONS A _ County__
Nearest Town:_ (1" ��_
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
Industrial Applicable Box): Residential-Er-Municipal/Public
esidential unici
WELL USE (Check veP Water Injection 0 Other 0 If Other, List Use
Monitoring 0 Recovery ❑ Heat Pump
T ogra h
STATE W licable
T1 pal Public ❑ ❑ Agricultural
❑
1 ic/Land setting
op OFlat
ORidge f3Stope OValley
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) o a hic map
Latitude/longitude source:O (chPk bxop gr P
DEPTH DRILL
ING LOG
WELL
2.
3. OWNER:
Address
/ (Street or Ro� No.)
Asheftl�e State
City or Tow
Areateize-c--coode- Phone number
4. DATE DRILLED_
5. TOTAL DEPTH:t- r��ta I o YES ❑ NO i�
6. DOES WELL REPLACE EYLS1 . of Casing: �FT.
7. STATIC WATER LEVEL BelowTop "+" if Above Top of Casing)
S. TOP OFof CASING IS
FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires
variance g m): _ accordancewith_METHOD OF TEST L—
AC 2C .0118.
9. YIELD (SPm)�
10. WATER ZONES (depth):
T� Amount
11 . DISINFECTION: Type Wall Thickness
Diameter or Weight/Ft.
Ft.
Ft.
Ft
Ft.
%4c
12. CASING: Depth
From_Q_--To%.3
From To___
From To
13. GROUT: Depth
From_Q.—To Lb
From To
14. SCREEN: Depth
From To
From To___
15. SAND/GRAVEELPPACK:
DeFrom To
FromTo
Z€SQS
Zip Code
venal
Method
Material
Ft.
Diameter
Ft. in.
Ft. in.
Size Material
Ft.
Ft.
Description
To Formation D Pon
FroFro=
1
Slot Size Material
in.
in.
LOCATION SKETCH
Show direction and distancemiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 2006
HAINSD WTEHLALT WAACSOCPOYNOSFTRTUHCISTERDECINOACCORDANCE
PRWOITHV IDED NOATHC 2G
WELL
ER��16. REMARKS:
DATE
SIGNATURE OF PERSON CONSTRUCTING THE CREEL `
Quality, Groundwater Se on, 1636 MaitService Center' REVgh, NC
Submit the original to the Division of Water Q ty+ DEC 12 2006
27699"1636 Phone No. [phone], within 30 days,
LUTY

RESIDENTIAL WELL CONSTRUCTION REC0 3D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION atii3140
1. WELL CONTRACTOR:
wen Contractor (Individual) Name •
e...‘ ace. ' SC.sa7 er'S 1 5'9h
Wen Contractor Compaiy �Na Nate
STREET ADDRESS "\BSE Vitlw1V 204
Hoek 5Tr;nk) NC f a8'1�13
pp��ppCity or Town a -.Zip Code
( 8a )- tQ(O6' aoa
Area code Phone number
2. WELL INFORMATION:
SITE WELL n) #(dappncmle)
STATE WELL PERMIT#(daopnaNe)
DWQ or OTHER PERMIT #(lf applicable)
WELL USE (Check AAppnwblee 6Box)): Residential Water Supply I
DATE DRILLED 7 '/O _ — /
TIME COMPLETED 3 i 30 AM ❑ PM L�
3. WELL LOCATION:
CITYp`Y':: JJ.CtJtt .. COUNTY Ul"
1./?(i� /��.J/4.
{Seat ry e. Nrunbsa. CammuMy. Lot no_ Par ,`[W Vie)
TO IC / LAND SETTING:
lope DVaney ❑FIet L)Ridge ❑Other
(check macerate bmr)
LATITUDE 3
LONGITUDE
Latitudefongitude source: POPS °Topographic map
(beafbn of wet must be shown on a USGS fopo map and
attached luaus fain drat using GPS)
4- WELL OWNER/
OW4 OWNER'S NAME eosvn C3. 1140c 11
STREET ADDRESS aa' cyn (R,dQP r? * s
Aeeet tec -Icode
City or Tam State Zip
( Sat)- 11S- 6*. B
Area code - Phone numbs
May be m degrees,
minute, seconds or
in a decimal format
A WELL DETAILS: 3o.e.
a. TOTAL DEPTH:
b. DOES WELL REPLACE DUSTING WELL? YES ❑ NOcy/-
c. WATER LEVEL. BebmTcp of Casing 70 Fr.
(Use'+' ffAliwe Top d Casing)
d. TOP OF CASING R . FT."Above Lard Surface"
`Top d casing terminated actor bland surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): O METHOD OF TEST
335294
f. DISINFECTION: TYpe4a.\\S Amount /s
g. WATER ZONES (depth): From To From To
From To From To
From To From To
6_ CASING: Thickness/
Depth Dampier Weight
From_alTo /i3 Ft__
From To Ft.
From To Ft.
7. GROUT: Depthn Material
From Tot 0 P. (v'litail -
Frxn To F1.
From To Ft.
8. SCREEN: Depth Da rater Slot Size Material
From To Ft. in. in.
From To R. in.. in.
From To R. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
To -
To
To
Ste
Ft.
Ft.
Ft
10. DRIWNG LOG
From To Formation
/ //3 0Orr
11. REMARKS:
iv
0
0
rn
I?TV
;tr 4 tt._UUt'
100 HEREBY CER7FY THAT THIS WELI.WAS CONSIF.LCTED Al ACCORDANCE WRH
15A NCAC 2C, WELL CONS1RUCmmN r frANOMDS. Ara`'NATO, COPY OF WS
RECORD HAS SEEN PROVVED TO THI: NELL ONTIER.
SIGNA RE 0 RTI I .L CONTRACTOR DA
-vac- .6c0.8yers
PRINTED NAME OF PERSON .X'NSTRUCi1NG VIE 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

1. WELL CONrRACTOFt
RESIDENTIAL welt, coNSTRucT1oN REco: tD
North Carolina Department of Environment and Natural Resources- Di.iaivu of R'a:er Quality
WELL CONTRACTOR CERTIFICATION e• 04 31e
weft Contractor (Individual) Name ooaJe c%
�1Lc�Q
Wen Cointractor Company
STREET ADDRESS ,'1%$ s .Vufr I , g)c
Ho 4 5 r,n 1 NC st-P43
City or Town . -Zip Code
(8a%)- (pros- as .
Area cods Phone number
2 WELL INFORMAT1Ott.
SITE WELL ID SfdapprasNe)
STATE WELL PER1 UT#(aappetable)
DWQ or OTHER PERM ITS[dappricable)
WELL USE (Check A�pDp c*Ie Box): Residential Water Supply rg/
DATE DRILLED .-'O` J= 4
TIME COMPLETED p! lea AM ❑ PM 63�
3. WELL LOCH ON:
CtiY: 4C-aer .4{/L7.. COUNTY n C raw (aP
!.✓oarlli..ni a Tr.e Wood lawaf L • it 5
{Street Name. Numbers. Cannaray. subdivision, Lot No- Parcel, ZIP Care)- .,
TQEOFRAPJA(C / LAND SETTING:
r tee-e OPPOolleY DPW °Ridge ❑Other
(creek appropriate bad
IATTTUDE 3 _
LONGTJDE _
I May be m degrees,
I
minutes, seconds or
in a decimal format
LeLtude/iongttude sowvc DGPS °Topographic map
(location of we/mrutbe shown on a USGS topo map and
attached toil* firm if not using GPS)
A WELL OWNER
OWNER'S NAME NS4 ConS}rLac*:0Y1
STREET ADDRESS Po Box 123 ,
cSoctc min MC Q811‘
City a Town t State Tip Code
caaa J. nn9• (otfas
Area code - Phone number
s. WELL DETAILS:
a. TOTAL DEPTIC 70 s
b. DOES WELL REPLACE EXISTING WELL? YES D
NOV-
c WATER LEVEL 8SowTop of Casing: 47.4. FT.
(Use`•' if Above Top d Casing)
cL TOP OF CASING IS 1 . FT. Above Lard Surface*
Tap of chasing terminated at%or below land surface may require
a variance in accordance wth 15A NCAC 2C .0118.
e. YIELD (gpm): $ METHOD OF TEST (+Z`3
Fran-14-1To L.. Fr_"�
From To R.
Fran To R.
7. GROUT: Depth iris
From Q To pro FL:,e�
From To R.
From To R.
8. SCREEN:
From
From
From
Depth
To
To
To
9- SAND/GRAVEL PACK:
Depth
From To__
From TO
From To
10. DRIWNG LOG
From To
94
9� Vas
11. REMARKS:
T. DISINFECTION: Types„ 3 15 Amount a_
g. WATER ZONES (depth):
From To _ From To
From To - From To
From To From
70
6. CASING:TliNmessl
WOSItt
.t h r1 j
&ioaI
Method
Diameter Sid Size Material
R- m. ___in.
R. —mac.. in.
R. in. in..
Size Matoriai
FL
Ft
Ft.
F�n
7-
DEC 12 LUUb
WO HEREBY kxMnos, 'MAT THIS WEL L WAS CONS1PLCTED N AM:01MM WON
ISA NCAC 2C, W EIA CONS RUCn0N On ROAMS. AND ',HATA COPY OF THIS
RECORD HAS BEER PROYnp{9 TO nor' N WE&
SIGNATURE OF CERTIFIED WEIrv.yevn.ACT,R DATE
PRINTED NAME OF PERSON ONSTRUCT)NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Win.,
1617 Mali Sondes Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO3D
North Carolina Department of Environment and Natural Resoluta- Division of N-am Qualm
WELL CONTRACTOR CERTIFICATION #- ZV
33528
1. WELL CONTRACTOR:
•Z gate; C.31... VteC1,Ti, taw -Jets
Wes Contractor (individual) Name •
Q.VcL'Q ' 'JC'tiswi'jQ-CS * 0n,
Wen Contractor Company Nate
STREET ADDRESS \a513S )sktall 209
Ho,* S?r.h ) Nc d8ny3
City a Term State . . -Zap Code
(8a2a.. tabs- ao� -
Area code- Phone number
2. WELL INFORMATIOtt
SrrE WELL ID o@eoprcable)
STATE WELL PERMITd(:appBrable)
DWQ or OTHER PERMIT#(d astable)
WELL USE (Check AppTaabte Box): Residential Water Supplyl
DATE DRILLED % - y
T1ME COMPLETED //ea AM O PM
3. WELL LODetTTION: ''s
CITY: OrICA /"4..
Gr/o:464L a..
COUNTY ,prnceve he
tame Name, Nwnbma. CammuMy. Substation, fat No.. Parcel. DP Code)
TO RAPHIC / LAND SETTING:
EiVaBey ❑FI Ridge DOBrer
(d box)
LATITUDE 3
LONGITUDE
Latitude/longitude solace: r3GPS OTopographic map
(bea8on of wag must be shown on a USGS two map and
attached loafs tomPlot using GPS)
A WELL. OWNER
OWNER'S NAME -1Th QN 1 d. 1-v9
STREET ADDRESS 3e2.6-'(.J cod toad at':ve
SLaannanoa 3 A)C a8,18
City or Town State Zip Code
( Sae, ). Q'13- 8(0'19
Area code - Phase number
May be in degrees,
mimaes, setts or
in a decimal format
5. WELL DETAILS: S.
a TOTAL DEPfFt fee
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOT/
c. WATER LEVEL Noe Top of Casing SO FT.
(the'' If Above Top d Casing)
d TOP OF CASING tS it FT. Above land Surface"
'fop et case terminated aValow below' surface may require
a variance in at eaalr a wt11 15A NCAC 2C .0118.
e. YIELD (ppmr COU METHOD OF TEST (c.3
1. DISINFECTION: TYPe2.1%t5
g. WATER ZONES (depth):
From To From
From To Fron
From - To Fron
6. CASING:
Amount `
To
To
To
Titaness/
Det721' Des WegM
From_Tot R. tot, � �t
From To Ft.
From To Ft.
7. GROUT: Depth Material
From Q To0O Fl. Center%{
From To Pi.
From To R.
Metal ,
& SCREEN: Depth Diameter Slat Size Material
From To R. In. in.
From To R. n.. n.
Fran To R. _in. n.
9. SANOAGRAVEL PACK:
• Depth
From
To- Ft
Size Material
From To Ft
From To Ft
10. DRILLING LOG
From To
i • 47
47 /(os
Formation
71arr A.rc
II. REMARKS: . DEC 12 2006
I DO HEREBY text mY MAT MIS WELL WAS cOtSIRUZ1m NACEORDVICE Wml
150, NCAC 2C, YYELL CONS1RUC1AN UTANDARDS. MC, n/AT A COPY OF TfS
RECORD W 1S BEEN PROVIDED TO TM: t1 o ER.
SIGNATURE O CERTIFIED WEI CONTRACTOR DATEE
be iAtc.tb. Seozres,s
PRINTED NAME OF PERSON ;ONSTRUCTING THE WEU.
Submit the original to the Division of Water Quality within 30 slays. Attn: (information Mgt.,
1617 Mall Serviee Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fain GW-1
Rev. 7/05

May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: eePro(location of well must be shownU Gs /op map
anddp
attached to this rm if not us USGS !olio map
WELL OWNER / GPS)
��( �// - �0S
OWNER'S NAME
STET ADDRESS1b--i�—
City or Town
State Zip Code
Area code • one number
•-
5. WELL DETAILS:
a. TOTAL DEPTH:____
b. DOES WELL REPLACE EXXISTIINGWE WELL? YES C NO
c• WATER LEVEL Below Top of Casing: (Use -+- if Above Top of Casing)
d. TOP OF CASING IS
*Top of casing terminated at/or below Above Land may
requir
a variance in accordance with 15A land surface may require
NCAC 2C .017B.
e. YIELD (gpm):
METHOD OF TEST
RESIDENTIAL w
North Carolina De WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources- Division of Water u
WELL CONTRACTOR CERTIFIC Quality
CERTIFICATION #
ET
STRE��--+-r�-�T ADDRESS
LaQ] (7City or Town Sttate
? )-2,15a Lp Code
Area code-er
2. WELL INFORMATION:
SITE WELL ID #(it applicable) �0
STATE WELL PERMIT#(it applicable) D ,��3
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Box): Residential Water Su DATE DRILLED___ Supply i
TIME COMPLETED
3. WELL LOCATION: AM PM p/
CITY: FR�Pt i PLV
COUNTY/
(Street N Numbers, Community,
m IY. Subdivision, Lot No., Par
TOPOGRAPHIC / LAND SET dge O
❑Slope ❑Valley ❑Flat Idge ❑Other
(check appropriate box)
LATITUDE 4b3 r y- J ,
LONGITUDEr 3 -
La"
p
335147
T. DISINFECTION: Type - rI/1 ;VC Amount
9. WATER ZONES (depth):
From Toq' T_
From
10. DRILLING LOG
From To
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WRIT
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEL 0 NE
PRI TED NAME eF 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. WELL CONTRACTOR:
RESIDENTIAL WELL Co
North Carolina Department of Environment and Natural CONSTRUCTION o f CORD
Water
WELL CONTRACTOR WELL
Quality
CERTIFICATION
City or Towne Stale
Zip Code
Area code_ Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/tot applicable)
DWQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED i''A-.. Oi
TIME COMPLETED
AM ❑ PM [}i
3. WELL LOCATION:
CITY: G..oh.
(Street Name, NumbeAre
ve
rC munity, Subdivision
TOPOG �f.1 • Lot No., parcel, Zip Code)
RAPHIC/LAND SEG:
_`T7
❑Slope OValley ❑Flat edge OOther
(check appropriale box)
LATITUDE 3 r z7
LONGITUDE Y . ll Sr"
Latitude/longitude source: cj fs
a
(rotation of well must be shown on a UU GS topo ndp
attached to this form lnot using GPS) map and
4, WELL OWNER
OWNER'S NAMEE�t6Sr. �A r
ST4EET ADDRESS
n ti r
COUNTY
CiyorTown
( �q� Stale
f[ 2 - / 9 6
Area
Phone number
5. WELL DETAILS: ' /
a. TOTAL DEPTH: Y /i r
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO
c. WATER LEVEL Below Top of Casing:
O�
(Use'+• if Above Top of Casing) �.
d. TOP OF CASING IS
*Top of casing terminated auor below land y surface may
a variance in accordance with 15A NCAC 2C .0118. squire
e. YIELD (gpm): 70
METHOD OF TEST 1 r
—
Submit the original to the Division of
1617 Mail Service Center — Raleigh, NC 27699.1 Quality within
1617 Pho
f. DISINFECTION: Type C4.nit
g. WATER ZONES (depth):
From 320 To
From VII7 To
From To
6. CASING:
From
From
From
Depth
To 6Z
To
To Ft
7. GROUT: Depth To_i��,
Ft.
From
To Ft
From To
Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To ...
Ft.
From
From
From
Diameter
Ft. ,/ r
Ft.
335149
Amount l
To
To
To
Thickness/
Weight Material
A-c
rM�etthod
#21
Material
10. DRILLING LOG
From To
Formation Description
5-7
11. REMARKS:
Material
I DO HEREBY CERTIFY THAT 11113 WELL WAS CONSTRUCTED M ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEENPROVIDEDTO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONT O�
RACTOR DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt.,
ne No. [phone] ext 568.
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
RESIDENTIAL WELLNorthCarolina CONSTRUCTION RECORD
Depanment of Environment and Natural Resources- Division of Water WELL CONTRACTOR CERTIFICATION Quality
4_, /
Well ontraclor Company
STREET ADDRESS
State
City Dr Tower � ate
Zip Code
Area code- Phone number
2. WELL INFORMATION:
8ao4airs
SITE WELL ID Nit -applicable) ' /
�o�Y -11 3l STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED /'zJ--p( �
TIME COMPLETED 3,
3. WELL LOCATION: AMA PM
CITY: �•//
COUNTY �a
(Street Nam Numbers, Community,
IY Subdivision, Lot No., Porcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope (Iley ❑Flat 0 Ridge ❑Other
(check appropriate box)
LATITUDE 3 f B�Si Maybe in degrees,
LONGITUDE Y' Lsif minutes, seconds or
in a decimal format
Latitude/longitude source: PS 0Topographic map
(location of we# must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER
OWNER'S NAME h r
STTEL�T ADDRESS
City or Town
2_2123State
Area code _ Phone
%— r7
Ph ne number
5. WELL DETAILS:
a. TOTAL DEPTH: 1 i J
Zip Code
b. DOES WELL REPLACE
EXISTING WELL? YES 0 NO p�
FT.
d. TOP OF CASING IS ��
*Top of casing terminated FT. Above Land may require
a variance in accordance with below land surface require
Sq NCAC 2C .0118.
e. YIELD (gpm): Zo
METHOD OF TEST � ;'
Submit the original to the Division of Water
1617 Mail Service Center— Raleigh, NC 27699_ 17 Pho
hu within 3
c. WATER LEVEL Below Top of Casing: 5/12
(Use -+• 8 Above Top of Casing)��
335152
f. DISINFECTION: Type °an:,,,
Amount__
9• WATER ZONES (depth):
From
From 2u _ o�— From To
To From T From To
6. CASING:
From
From.
From
To Ft.
7. GROUT: Depth
Material
From Toa Ft. COrele
Ft.
From To Ft --
8. SCREEN: Depth
From Diameter Slot Size Material
To
From To Ft. in. in.
From To in. in.
Ft. in.
in.
9. SAND/GRAVEL PACK:
Depth
From To Size Material
From Ft.
From To Ft.
To Ft.
11. REMARKS:
P(��Metethod
p -
I DD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED NACCOR
15A NCAC 2C. WELL CONSTRUCTION STANDMROS AND
RECORD HAS BEEN PROVIDED TO THE THATA COPY OF THIS
WITH
WELL pWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR7� .. DATE
ANTED NAME OF PERSON CONSTRUCTING THE WELL
0 days. Attn: Information Mgt.,
ne No. [phone] ext 568.
Form GW-fa
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
Atale Zip Code
ntractor CompanyName
STREET ADDRESS a3/ to LFr•��...�Gn
y.
City or Town S?Q
/ C tate
rea code- number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable) � / 00 a
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply E /
DATE DRILLED St2 /—
TIME COMPLETED e •'Jo
AM ❑ PM 2
3. WELL LOCATION:
CITY: U�rtf.
COUNTY !.
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DCFS
U
(Iocation of well must be shown on a USGS topo map
ndp
attached to this form if not using GPS) ap and
4. WELL OWNER
OWNERS NAME
STREEj DDRESS
(Street Name, Numbers, `� Community, Subdihsion, Lol No., parcel, Zip Code) TOPOGRAPHIC / LAND SETT{N
°Slope 0 Valley ❑Flat [7Hidge ❑Other
(check appropriate box)
LATITUDE 3 -I- S/1 t 7
LONGITUDE ,- L .7r 7
Zip Code
5. WELL DETAILS:?
a. TOTAL DEPTH: 2Qf'
b. DOES WELL REPLACE EXISTING LL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top yam- a FT,
of Casing)
d. TOP OF CASING IS L
FT. Above Land
*Top of casing terminated at/or below land E surface m Surequir
a variance in accordance with 15A NCAC 2C .0118.squire
e. YIELD (gpm): --_ METHOD OF TEST { ,,•
Submit the original to the Division of Water
1617 Mail
Service Center— Raleigh, NC 27699.1617
within 30 da s. Attn:1617 Phone No, 919 733 7o15 ext 568.
Information Mgt.,
015
Method
'ha/Ids-
Diameter Diameter Slot Size
Ft.in. in.
Ft.
f. DISINFECTION: Type _('�:_,�
Amount
g. WATER ZONES (depth):
From_ To
From To
From --4•22 To
From To
From To
From To
6. CASING:
Depth Diameter
From 0 Tot_ Ft.s
From To Ft
From To Ft.
7. GROUT: Depth
From___ Toa Ft.
From To Ft._
From To Ft.
8. SCREEN: Depth
From To
From To
From To Ft
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
11. REMARKS:
Size Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORD
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF TWS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER. �n ACCORDANCE WITH
SIGNATURE OFRTIFr IEp //ELL CONTRACTOR .2/_OL
DATE
p
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 7/05

S. WELL LOCATION:
CITY _fit2t irL/
COUNTYS
(Street e. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TO GRAPHIC / LAND SETTING:
Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE ,_414_1a y
A
Latitude/longitude source:. PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME
STR ET ADDRESS
c
City or Town State
Lacii)-__217-_-__ a
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:
(Use `+• if Above Top of Casing) —FT.
d. TOP OF CASING IS _E__
*Top of casing terminated at/or Above mayLannd surface d require
a variance in accordance with 15A NCAC 2C 0118.requve
METHOD OF TEST. J J
Submit the original to the Division of Water Quality With
1617 Mail Service Center—
e. YIELD(gpm):
STATE
1. W CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Q t7City or Town C' State _.
( iL'—KLZip 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
TIME COMPLETED
AM PM
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From
From
6. CASING:
From
From
From
fl5154
Amount?`
Thickness/
From,_. Depthpth Ft Diameter 'W'`eigh't'f Matatteriaall� '
From To Ft. /'J /
To Ft.
7. GROUT: Depth �^ Material
FroFrom To Ft. lam_
To
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To Formation Description
11. REMARKS:
Material
Method
Material
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 TH1 ELL •WNER.
RE eF CE•TIFIEa +- CONTRACTO
ATE
PRI ED NAME eF PERSON CONSTRUCTING THE WELL
in 30 days. Attn:
Raleigh, NC 27699-1617 Phone No. (919)733-7 15 ext 568. Mgt.,
Form GW-1a
Rev. 7/05

1. WELL CONTRACTOR:
.RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and NaturalResources- of Water
OR
Quality
WELL CONTRACTOR CERTIFICATION
Well ontractor Company e
STREET ADDRESS
City or Town State
Zip Code
Area code_ P �'• f� o
Aone number
2. WELL INFORMATION:
SITE WELL ID #lie applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supplyg�
DATE DRILLED
TIME COMPLETED 2,'.)
AMO PM L�
3, WELL LOCATION:
CITY:-/uy,��
17 COUNTY f .4.4e.•_,y
C ucs
(Street Name, Numbers, Community,
ommunit , Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SE/TTING:
❑Slope O Valley 0 Flat ('J Ridge D Other
(check appropriate box)—��
LATITUDE 3 5— (•/S/ 291
May be in dcgrees,
LONGITUDE V. 2-
Latitude/longitude source: pQrPg
(bcation of well must be shown on a USGS❑ topo
Topographic map
attached to this form if not using GPS) topo map and
4. WELL OWNER
OWNER'S NAME 1
STR7E/ET ADDRESS � a
City or Town
State
Area code - Phone number-r----
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E
c. WATER LEVEL Below Top of Casing: /GTO
(Use •.. if Above Top of Casing) �'
d. TOP OF CASING IS
*Top of casing terminated at/or below land Above Land Surface*
a variance in accordance with 15A surface may require
NCAC 2C .0118,
e. YIELD (gpm):
METHOD OF TEST /
Submit the original to the Division of Water Quality within
1617 Mail Service Center— Ra
leigh, NC 27699-1617 30 days. 01n: Information Mgt.,
Phone No. (919) 733_7015 ext 568.
f. DISINFECTION: Type C# ;1
9• WATER ZONES (depth):3a
From To
From 4-Pr— To
From To
6. CASING:
From
From
From
From Depth Diameter
From To 24 Ft..
To Ft.
From
To Ft.
7. GROUT: Depth
Material
FroFrom To.Q Ft.
To
From To Ft'----'--
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth Size
From To
From To
From To
335155
Amount r�
To
To
To
Thickness/
Weight
11. REMARKS:
Ft.
Ft.
Ft.
Material
Material
Method
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT copy of TIES
WITH
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR -O6
DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW.1a
Rev. 7/05
0

4. WELL OWNER
OWNER'S NAME _
STREET ADDRESS
1. WELL CONTRACTOR:
RESIDENTIAL WELL
North Carolina Department of Environment and Natural e ouurces_TDOiNon o CO
WELL CONTRACTOR ter
Quality
CERTIFICATION # � f��
vvals{ontractor Companyyya
e
STREET ADDRESS
Zip Code
Area code_ Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITitor applicable)
DWQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicable Box): Residential Water Supply C1'
DATE DRILLED_ i• f- U4
TIME COMPLETED %1 _ AM
3. WELL LOCATION:
0
CITY: CE'sr+�
COUNTY
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SET
TING:
FZSlope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box) -�
LATITUDE 3 C 4/.9. /42 ' May be in degrees,
LONGITUDE f L--- minute, seconds or
�7 - in a decimal format
Latitude/longitude source: r?,Do ❑T
(/ocatbn of we#must be shown on a Topographic map
attached to this fora d not using GPSSGS topo map and
a.
C/ City or Town State
Zip Code
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 3''Jd-
b. DOES WELL REPLACE EXISTING LL? YES ° NO
CV
c. WATER LEVEL Below Top of Casing: L v
(Use "+• if Above Top of Casing)'—�'
d. TOP OF CASING IS
"Top of casing terminated at/or below land �' Above Land may Surface*
a variance in accordance with 15A NCAC 2C surface
1.require
e. YIELD (gpm): .?D
METHOD OF TEST 1 '•
Submit the original to the Division of Water Quality within
1617 Mail Service Center- Raleigh, NC 27699-1617 Phon N
335150
f. DISINFECTION: Type 044-,
g. WATER ZONES (depth): Amount
From 2217 To
From 2P� From To
To From
From To
To From
6. CASING: To
Depth Diameter Weight
From O Material
From To Ft. G./es- aiiiieri .R .
Ft.
From To
Ft.
7. GROUT: Depth
Material Froron� ToO Ft. CO�/1C
FrTo
From To Ft
8. SCREEN: Depth Diameter Slot Size
From To FL Material
From To FL ---in. in.
From To in. in.
Ft. in.
in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From To
From Ft.
From TO Ft. �--
To Ft. �--
10. DRILLING LOG
From To
C-
r -4J
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND
RECORD HAS BEEN PROVIDED TO THE IN ACCORDANCE WRH
WELL OWNER. THATA COPY OF TINS
SIG E O RTI� p WELL CONTRACTOR 9'21'0 rs
A RgCTOR DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt.,
e o. [phone] ext 568.
Form GW-la
Rev. 7/05
Method
J
0

1. WELL CONTRACTOR:
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
CO a
STATE WELL PERMIT#(it applicable) ��—
DWQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Box): Residential Water
DATE DRILLED Supply
i�-lJ- CJ=
TIME COMPLETED
`�-- AM 0 PM p�
LOCATION:
A�r. it -/ems
re
(Street Name,
7 Numbero
Community,
�Of
m tY Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat Ltidge ❑Other
(check appropdate box)
LATITUDE 3 r t!P, 4,/1 May be in degrees,
LONGITUDE D- minutes, secorldsor
Z y�� in a decimal format
Latitude/longitude source: Ef6P8
❑
(location of well must be shown on a UGS topo
o map ndp
attached to this form if nol using GPS) and
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
RESIDENTIAL WELL CONSTRU
North Carolina Department of Environment and Natural Resources- TDiivvision of Water Quality RECOD
7
WELL CONTRACTOR CERTIFICATION
Zip Code
3. WELL
CITY:
COUNTY ,t+�.
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES p NO
LBV
c. WATER LEVEL Below Top of Casing -ro
(Use "+• if Above Top of Casi.—FT.
ng)
d. TOP OF CASING IS FT. Above Ld �L
"Top of casing terminated al/or below and surfce may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gem): .paws
METHOD OF TEST r �
Submit the original to the Division of Water Quality within
1617 Mail Service Center —
Raleigh, NC 27699. 30 days. Attn: Information Mgt.,
1617 Phone No. [phone] ext 568.
f. DISINFECTION: Trve/r•`
Amount vZ
g. WATER ZONES (depth):
From 6F-0 To
From.
From i✓. _ To From
From Zd To
From
6. CASING:
From D Depth Diameter
To d1 Ft. E.mr
From To Ft
From To Ft.
7. GROUT: Depth
Fronnn_P_ ToQ Ft.
ToFt..
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
11. REMARKS:
To Ft.
To Ft.
To Ft.
Material
<
Method
To
To
To
Thickness/
Weight
Material
Cone rdc
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WDN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND' NATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
" DATE
q
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 7/05
Z
r—D

1. WELL CONTRACTOR:
Area code- Phone ber
2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT#Or applicable)
D WQ or OTHER PERMIT #(if applicable) Applicable
WELL USE (Check---
Box): Residential Water Supply[
DATE DRILLED
TIME COMPLETED '�a
AM ❑
3. WELL LOCATION:
CITY: 6. c+T<--
>uif
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION t{
1
Zip Code
(Sties/ N b Community, S bd Comm ar 7
hsion, Lot No., "Parcel, Zip Code)
TOPOGR
APHIC / LAND SETTING:
OSlope °Valley ❑Flat pfiidge OOther
(check appropdale box)
LATITUDE 3 , C/=y�•
LONGITUDE i L u_ �� _ ✓
Latitude/longitude source: ❑GPS ❑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 our
STREET ADDRESS 0 J
City or Town` le
a g )- ZiP Code
Area code —�- -b
Phone number—`�
5. WELL DETAILS:
a. TOTAL DEPTH: C�VI'
b. DOES WELL REPLACE EXISTINGC3' WELL? YES ° NO /
(Use "+• if Above T si
op of Casing)
d. TOP OF CASING IS ��-
'Top of casing terminated at/or below land
n Above Land Surface' surface may require
C. WATER LEVEL Below Top of Casing: 4).-0FT.
a variance in accordance with 15A NCA
C 2C .0118.
e. YIELD (gpm).
METHOD OF TEST
Submit the original to the Division of Water Quality
1617 Mail Service Center —
thin
0 days. Attn:
Raleigh, NC 27699-1617 Phone No. 919) 733-7015 Information Mgt.,
( ) 7D75 ext 568.
f. DISINFECTION: Type Ch4-cam
g. WATER ZONES (depth):
From era To
From � <ro To
From To
6. CASING:
From
From
From
From
From
From
Diameter
Ft. 4 ttf
Ft.
To Ft.
7. GROUT: Depth
Fro_ To_ Ft.
From To
From FL_
To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From Ft..
To Ft.
From To Ft.
11. REMARKS:
335158
Amount ps�t_
To
To
To
Thickness/
Weight
salt.,
Material
Methodetho
?� t4
J
Diameter Slot Size Material
Ft.
Ft. in.
Ft in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WW1
15A NCAC 2C, WELL CONSTRUCRON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
.ems)
-04
DATE
SIGNATURE OF ERTIFIED WELL CONTRACTOR /D-
DATE
•P4
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW.1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION North Carolina De an RECORD
P ment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
vven r�ntractor CompanyName
STREET ADDRESS
(SCity or Town C) ���Stttatte
AL o1 S� �J'Y- / 2iP Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #{i(applicable)
STATE WELL PERMIT#(it applicable)
DWG) or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED-.
TIME COMPLETED r �L11
-� AM 0
3. WELL LOCATION:
CITY:
�� COUNTY nco /`
(Street Name, Numbers, Community, Subdhision
TORA,Lot No., Parcel, Zip Code)
PHIC / LAND SETTING:
lope 0 Valley 0 Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE /t/js r 7 $=
LONGITUDEWD$,,r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source:
(location of well must be shown on a USGS topo
amh ndp
attached to this form f not using GPS) map and
4. WELL OWNER
OWNER'S NAME �t
/STREET ADDRESS
City or Town
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /"p t
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p.----
c. WATER LEVEL Below Top of Casing;
(Use "+" if Above Top of Casing FT.
d. TOP OF CASING IS _L.__ FT. Above Land 'Top of casing terminated at/or bet land surface may Surfacerequire
a variance in accordance with 15A NCAC 2C .0118.
Sie. YIELD (gpm): METHOD OF TEST J
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.
335159
f. DISINFECTION: TYPO.t-ra4t- hcCtd a
[._ Amount_
9• WATER ZONES (depth):
From
Diameter Slot Size
Ft. . in.
in.
Ft. in.
in.
in.
in.
SAND/GRAVEL PACK:
Depth
From
From
From
10. DRILLING LOG
From To
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wtnr
1 SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELWNER.
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Fonn GW-1a
Rev. 7/05

"ter/
(Street Name, Numbers, Community, Subdivision, Lol No., parcel, Zi
TOPOGRAPHIC / LAND SETTING: P Code)
❑Slope ❑Valley ❑Flat age Et Other
(check appropriate box)
LATITUDE 3 r !/j`: 227 • May be in degrees,
LONGITUDE L minutes, seconds or
,JL J&a in a decimal format
Latitude/longitude source: eCPS
❑
(bcation of well must be shown on a USGStopo m
amp ndp
attached to this form Anot using GPS)ap and
4. WELL OWNER
OWNER'S NAME
TREET ADDRESS /D.S-.Oh
City or Town State
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH:
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION
RECOD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
W ell/ ontractor Company Name uciz U
STREETADDRESS 73> E10 LF/ FSTEIZ lfZilU.
City or Town Stale
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITS/tit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicable Box): Residential Water Supply 3
DATE DRILLED /O -=—
TIME COMPLETED ,�v
AM 0 PM gr.
3. WELL LOCATION:
CITY: (dNti tr.
COUNTY r �
(Use "+• d Above Top of Casing)
d. TOP OF CASING IS L
FT. Above Land 'Top of casing terminated at/orbet land surface may y Irrresquigair
a variance in accordance with 15A NCAC 2C .0118. re
e. YIELD (gpm): A __ METHOD OF TEST 1
b. DOES WELL REPLACE EXISTING WELL? YES NO
c. WATER LEVEL Below Top of Casing: f0
FT.
335161
f. DISINFECTION: Type '.,,_
Amount st
g. WATER ZONES (depth):
From 71—' To
From
From Z/ /r'
To From
From To
From
6. CASING:
From 6%
From
From
Depth Thickness/
Diameter Weight
-T0-11�'Ft. f. rri'
,
TomY'r++,th'��
Ft.
To Ft.
7. GROUT: Depth
g�, Material
From_R Toal Ft. COAL f
From ToFL
From G
From To Ft
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth Size
From To From
Ff.
From To Ft.
Fran To
11. REMARKS:
Material
C
y� ''t"M� eetth"od_
r J
Diameter Slot Size Material
in.
Ft in.
in.
Ft. in.
in.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTOR STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR S'- Op
- _ A . DATE
A-
V
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-12
Rev. 7/05

AM PMp/
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION North Carolina Department of Environment and N alural RRECORD
Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
Well ontractor Company�a Q
Name
STREET ADDRESS J -&
City or Town Stale
428 -o} ?- 3490
Area code-
Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 0 0 P -
STATE WELL PERMIT#(itapplicable)
do��/�
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED /° —04 ppy `�
TIME COMPLETED Z . 042
3. WELL LOCATION:
CITY: 4;4rv> jpa.
COUNTY •fA
Zip Code
(Sueat Name, Numbers, Community, SubdiNeion Ld No., parcel, Zip Code TOPOGRAPHIC / LAND SETTING:
OSlope a siey °Flat ID Ridge °Other
(check appropriate box)
LATITUDE 3 t.� �4_ May lx in degrees
LONGITUDE Y L minutes, secondsor
�Z in a decimal format
Latitude/longitude source: tae1
(location of well must be shown on a US S topo
m ndp
attached to this form #not using GPS) map and
4. WELL OWNER
OWNER'S NAME
l Lo
S, REET ADDRESS 4,
( r
ASLw A
City or Town State
l ra )- 7i
Area code - Phone numbere,
5. WELL DETAILS:
a. TOTAL DEPTH: ZOr
Zip Code
b. DOES WELL REPLACE EXISTING WELL? Y
c. WATER LEVEL Below Top of Casing:
Casing)
ES ID NO C]�
(Use `+• if Above Topof si
d. TOP OF CASING IS FT. Above
`Top of casing terminated at/or below and surfaced y req require
a variance in accordance with 15A NCAC 2C .0118.
Submit the original to the Divisi
f. DISINFECTION: Type
9. WATER ZONES (depth):
From 9)— To
From //0
From To
3.5162
Amount 3u�r
6. CASING: To
Depth Thickness/
From D Depth
F_ Diameter Weight Material
From To Ft.�s!-ai
From
To Ft.
7. GROUT: Depth
Material
�,1
From To�Q Ft. C04/ c
To Ft.
From To Ft.---
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From. Size
From
From
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
p_ Formation Description
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WM1
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO ME WELL OWNER.
41-eu
SIGNATURE OF ERTIFIED • C•C'
A WELL CONTRACTOR DATE
_ 4
RINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mall Service Center— on of Water Quality within 30 days. Attn: Information Mgt.,
Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
CD
m

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
Well onlractor Company Nameanrd
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT/tot applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply c
DATE DRILLED
TIME COMPLETED -/
AM IS PM❑
3. WELL LOCATION:CITY: .11a4-v. es"
ommunity, Subdivision, Lot No., Parcel, Zip Code
(Street Name, Numbers C
TO5OGRgPHIC / LAND SETTING:
lope ❑Valley El Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE A.1=r,
LONGITUDE J- G 23. atr'
COUNTY �++€_;•y.�
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑gPS
❑Topdp
(bcation of we9 must be shown on a USGS topotopo map and
attached to this form Anot using GPS)
<. WELL OWNER
OWNER'S NAME -Pei/2 fa
STREET ADDRESS
City or Town Stale ' a
Zip Code
�8r-337-�fao9
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:
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS _____I____ FTAbove 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): p METHOD OF TEST 1 ;, I'
-ir4
335164
f. DISINFECTION: Type AG
_ Amount -2 o:
g. WATER ZONES (depth):
From `fig To From
From J,7r> To
To From To
From cite, To From
To
6. CASING:
From
From
From
7. GROUT: Depth
g�, Material
From_-_To--r2� Ft. C0/Icrcle
From To
From To
8. SCREEN: Depth
From To_
From To_
From To
SAND/GRAVEL PACK:
Depth
From To
From T
From To
10. DRILLING LOG
From To
11. REMARKS:
Method
T
Diameter Slot Size Material
Ft. in. in.
Ft in. in.
Ft. in. _ in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED R ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF 11IIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
.x v
SIGNATURE OF ERTIFIED WELL CONTRACTOR - DATE
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.
4 s t/
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 7/05

1. WWWW CONTRACTOR:
r o
W.�II Contractor (1?Jjvidyal)rNam
/ER�k(So;vs WEIlOrd LLc.
Well ntractor Company Name at
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2Oaq 9
STREET ADDRESS a'i1 3 ( Xrbi C
1 flitesiEg me asli12
City or Town ) State Zip Code
(7.H>
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) c O O 6 — 0 17 _ —
STATE WELL PERMIT#(ir applicable)
DWG! or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED // 2/00_
TIME COMPLETED %/ -DO AM ❑ PM p�
3. WELL LOCATION:
CITY: /( /
IJf CCU COUNTY �//I�n�.r M
S
(Sheet Name, Numbers. Community, Subdixision, Lot No., Parcel, Zip Code)
TOPOGRAP-HIC / LAND SETTING:
p6 o�pe DValley ❑Flat ❑Ridge ❑Other
(check apprepriale box)
LATITUD4J I , Z. 2 ela
LONGITUDE oaa r %
Latitude/longitude source: S ❑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
OWNER'S NAME Scn7i ct.QN j
ratEET ADDRESS �,q-M1 (..0....-0. 1.7)r
/7vi-P-w X C a S'7.0
City or Town State Zip Code
Lai- 774-31Ya
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-1
c. WATER LEVEL Below Top of Casing: AO 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): 30 METHOD OF TEA/i'l/f`9j..)
-
4 4
f. DISINFECTION: Type Crf f,inivL Amount /ooz.
g. WATER ZONES (depth):
From To 90 From
To
From To From To
From To From To
6. CASING: fro FL Thickness/
From Depth
Diameter Weight �+ Material
D Torlp i',. 2.16. y PU("/)/9A/
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
' J
From 0 To Wtf) Ft. dAireriff
From To Ft.
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft,
From To Ft.
10. DRILLING LOG
From To Form tion Description
rey
k
nae
/doc
�nng.
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE W 611 ONMFe_
PRINTED NAME
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 / 44)
1. WELL CONTRACTOR: ��
tZ N }f. GUr•AEs
II Contractor
ndividual) Name
Ee cesolt lit!! a.vd
Well ontractor Company Name
STREET ADDRESS
r
» sjee-
City or Town /
Area code- Phone number
10
State
S g91,z
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/Air applicable)
L
tunic, 1J-C,
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0-
DATE DRILLED /a - ,4 - !A Cs
TIME COMPLETED // : AVE( PM ❑
3. WELL LOCATION: p
CITY: .iI'se
COUNTY /l r. c+»te
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat L Ridge DOther
(check appropriate box)
LATITUDE 3 f 7'1/• VZ`/'
LONGITUDE t 2 /7, 3yrr
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 724PS ❑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 w•/
STAEET ADDRESS 5/ (73 Eto4.w,d
(i2nityyv AC A 87/ l<
City or Town State Zip Code
Liar_ J- (e tf 8 - 404 t
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S'.) r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2
c. WATER LEVEL Below Top of Casing: / za 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):
/ METHOD OF TESTA)Ndliti .Rq
f. DISINFECTION: Type %/o: .-sL
g. WATER ZONES (depth):
From . 30 To
From Zi/EP To
From '/70 To
6. CASING:
From
From
From
Amount ? n..
Depth Diameter
From O To Z/L Ft. 4.Z7.-
From To Ft.
From To Ft.
To
To
To
Thickness/
Weigh) Material
sva'r!
7. GROUT: Depth Material
/�
From f� To NO Ft. Concrete_
From To Ft.
From To Ft.
Method
?Dacia)
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 To
Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
©- .7
37- Si.
z/2- rvr
11. REMARKS:
Material
Formation Description
(J Y
$4 t.I
(s<r PC
ir.
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 ERTIFIIED�WELL CONTRACTOR DATE
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
C3
N
Col

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON k
335168
1. W CONTRACTOR:
Well 'ntractor Company Name
STREET ADDRESS
City or Town Stale Zip Code
( , 511-- `&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) CP&Q UQ
STATE WELL PERMITS/Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L,a'
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
CITY: .hCuh�ilad COUNTY
bdn rail he_
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN ETTING:
❑Slope 0 Valley ffflat ❑Ridge ID Other
(check appropriate box)
LATITUDE/j. 3y ' 4
LONGe/longi yam,1r
Latitude/longitude source:so'S DTopographic 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
i
City or Town State
AM ❑ PM f�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:�%_T—S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
FT.
(Use'+• if Above Top W 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.
May be in degrees,
i
m notes, seconds or
in a decimal format
ip Code
e. YIELD (gpm): �/� METHOD OF TEST --
From To
6. CASING:
T. DISINFECTION: Type Amount__S
9. WATER ZONES (depth):
From To V S From To
From To� From To
From To
Depth �Iameter
g_ From 1) TovIFt.&As
From To Ft.
From To Ft.
7. GROUT: Depth Material
/
From 0 To �Q //))nnced
Ft. &i
From To Ft.
From To Ft.
B. SCREEN: Depth Diameter Slot Size
From To Ft.in. _ in.
From To Ft. in. __ in.
From To Ft. in. in.
Thickness/
Weight Ma lariat
Method
9. SAND/GRAVEL PACK:
Depth
From To
Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
o —RS
AS —3t
11. REMARKS:
Material
Size Material
Formation Description
elaV
SA/1 Ittnv.L
ir
rAnuir/i �C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WM/
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OW IER.
CONTRACTOR
6hb1 &I. ib. r�
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.
E
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 / Tt)
1. WELL CONTRACTOR: J.
G(! /zr fN J/A/ES
11 Contractor Individual) Name
jEf4IGSeN5 hIEnic2Nc�amp kitWell ontractor Company Name /
STREET ADDRESS
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable) c OO & - r7 oZ SOQ
STATE WELL PERMIT#(e applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply pe
DATE DRILLED _s"7 - /t-Oc
TIME COMPLETED I :0" AM ❑ PM ®-
3. WELL LOCATION:
CITY: /4v'040-G,e
06(
(Street Name, Numbers. Community, SubdMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat Fkidge Other
(check appropriate box)
LATITUDE 3 t 7Z Y70
LONGITUDE Y L /7, /C7
wL
esjet City or Town / State i Ap odIQ
(8� ode
>- a52-• Sqq&
COUNTY "Cie-a..Il
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: i dpS ❑Topographic map
(Iocatan of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME IN, FS er ides r
STREET AePfe SS 3 3. (1r4cet.i4A r( kiirc-
4412,i,b4 NC a7_26 2,
city or Town State Zip Code
d )- s g a- (only
Area code - Phone number
5. WELL DETAILS: yy
a. TOTAL DEPTH: 6f/
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 57
c. WATER LEVEL Below Top of Casing: rrr� FT.
(Use -+• if Above Top of Casing)
d. TOP OF CASING 15 / 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): /t METHOD OF TESTA) )Niffi - lr 4
33.5169
f. DISINFECTION: Type Creu-_-..a. Amount eir t.
g. WATER ZONES (depth):
From 2/a To From To
Ran 2411.0 To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From To i-p Ft.C.ier r last> ••••`zc
From To Ft.
From To Ft.
7. GROUT: Depth Material
From To �` O FL CO/ICrCJC.
From To Ft.
From To Ft.
Method
peachv�
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- kg /tie
fN- Sit !4a
rs - Zar G=.., h
11. REMARKS:
r
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.
SIGNATURE OF /ERTIFIIED�WELL CONTRACTOR DATE
jSD)"A-A, ) UJ, At es "
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 #
20,E
3351;0
d 144
PO1. CONTRACTOR:
0b
I
W�1 Contractor ( svW iaqNam1(n jreso#)JEO
Mkt ,LLC.
Well ntractor Company Name
STREET ADDRESS ta I eJ 1 /►A,I
L,FiLes-P R nj c. agrAtg
City or Town State Zip Code
(8�? )- 52 9&
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 / t 06
TIME COMPLETED? ) 1 30 AM ❑ PM p�
3. WELL LOCATION: /
CITY: j/f[$r4-cr COUNTY 6()Acorn fic
Conrk S j Ai e- ta7` /
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
lope [Valley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 33 r :.,1, IUD
LONGITUDE(IOn• )..Q /15r'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ¢GYS [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
c
City or Town State
(8aa )-5515-73a(
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a..is
b. DOES WELL REPLACE EXISTING WELL? YES [ NO g'
c, WATER LEVEL Below Top of Casing: Sp FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS 1 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): METHOD OF TES
our t'e r3 o#/ RL
sge4.
Zip Code
f. DISINFECTION: Type Ch /OpiN/(_ Amount 2r172_.-.
g. WATER ZONES (depth):
From To /S From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From C) To Si7 Ft. Jo2 S 2/(r/Ap "de 5D4A
From To Ft.
From To Ft.
7. GROUT: Depth MaterialMethod
From 0 To an Ft. &bat/
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
From
Size Material
To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
35 -YS
cis - SO
3D -R8's
11. REMARKS:
Formation Description
etarSinitA,//'
ide
/1ncK
ant iv. •1
1 DO HEREBY CERTIFY 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.
SIGNdfSRF"OF
PRINTED NAME
ERTI F EI D CONTRACTOR
ATE
(.(i/ O lS
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
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f1(estER AK(11
City or Town f State Zip a 7e
(FA )- 52-W/94z
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #01 applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p/
DATE DRILLED /Q/6 '� g
TIME COMPLETED !j /O AM ❑ PM p'
3. WELL LOCATION: CITY: /Fk /c 4 t— COUNTY 130/CCOh Jr
C©nk S id.v c an EgTat
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
pt-lope 0 Valley ❑ Flat 0 Ridge 0 Other,
(check appropriate box)
LATITUDE /(/3S I 'Z%t y/Q /
LONGITUDE NOtA.1 21,777tt
Latitude/longitude source: el S 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
OWNER'S NAME
ST, EET ADDRESS
GL1npi
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 #
Rod P
335171
1. W CONTRACTOR:
(,A.lf
C)bh�d/vid al)Nam �o5
14610/1.5 WE II @id
Well Ifntractor Company Name
/
STREET ADDRESS 12J I
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO g'
c. WATER LEVEL Below Top of Casing: 5Q
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 .01)18.
e. YIELD (gpm): 3 METHOD OF TEST_�yr
f. DISINFECTION: Type C%i/QAl`N8 Amount art
g. WATER ZONES (depth):
From To 2i(7 From To
From To From To
From To From To
6. CASING: Thickness/
Depth i eter Weight Material
Fran dTo err Ft. 4 r 5 L/ii/ Ilyc;/AA,
From To Ft.
Rom To Ft.
7. GROUT: Depth Materriall
From 0 To �fl Ft. &lade/'
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 To Ft.
From To Ft.
Method
From To Ft.
10. DRILLING LOG
From To
d so
63 -n fine cn /
ere", je
Material
b9' -4VS
11. REMARKS:
Formation Description
-/, Awe,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WNH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD MS BEEN PROVIDED TO THE WELL OWNER.
ONTRACTOR 42ATE`
PRINTED NAME F PERSON CONSTRUCTING THE WELL
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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
if

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -
Division of Water Quality
WELL
CONTRACTOR CERTIFICATION #_Q
r n..
vvemntractor Company Name vu-u r /Yl f�--L-•
STREET ADDRESS
City or Town State
Area
(SAL-
�L�Q Zlp Cotle
Area code- ber /
Phone number
2. WELL INFORMATION:
SITE WELL ID *Of applicable
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED
TIME COMPLETED
3. WELL LOCATION: AM [� FM
CITY: /�rA it n(/tf
COUNTY •y
(Street Name, Numbers, Community, Subdivision, Lot No., parcel,
TOPOGRAPHIC / LAND Zlp Code)
SETTING:
Slope °Valley °Flat ID Ridge ❑Other
(check appropriate box)
LATITUDE & 3 S 30 p' b , May be in degrees,
LONGITUDE(�,r� seconds minutes, sendsor
r in a decimal format
Latitude/longitude source:
PS ❑ topo
Topographic dp
(location of why must be shown on a USGS topo map and
attached to this Corm d not using GPS)
4. WELL OWNER
OWNER'S NAME,__�'U3 (7
S;�6ET ADDRESS
Area code - Phan--- number
5. WELL DETAILS: �1 a. TOTAL DEPTH: p_�
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO r.
c• WATER LEVEL Below Top of Casing:
d. TOP OF CASING 15 f
*Top of casing terminated at/or below Above Land Surface*
with 1 O1N land 2C .01 may require
a variance in accordance
^ • _ a _SA NCAC 0118.
(Use "+• if Above Top of Casing)
f. DISINFECTION: Type
9• WATER ZONES (depth):
From To
6. CASING: 1 °
Depth Thickness/
omT�_ Diameter Weight Material
From— To Ft. _ 2/6• a S P✓ d )
Ft
From
7. GROAT: Depth
From To-�4t,>;L y � I Material _//,/�y�`J//'MQ'e�t'h�o=d{
Ft.()Seek_
J
From To Ft
From To Ft --�
9. SAND/GRAVEL PACK:
Depth
From T =
From To_
From r„
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCT/ON STANDARDS,
RECORD HAS BEEN PROVIDED TO THE ELL O ER. THATA COPY OF THIS
� ER.
PRINTED NAME eF 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. 733-
919
( ) 7015 ext 568.
Form GW-la
Rev. 7/05
vs

May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source:
CPS ❑ topaphp dp
(attache of this
i must be shown on a USGS topo map and
attached to form Toot using GPS)
4. WELL OWNER
OWNER'S NAME A. ,S
S EET ADDRESS iY (O 1-
City or Town
tl State
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO c
ie-
c, WATER LEVEL Below Top of Casing:
(Use "- ' if Above Top or Casing)
d. TOP OF CASING IS
"Top of casing terminated FT. Above Land Surface*
a variance in accordance ago with ISA surface may require
r 15A NCAC 2C .0116.
•
e. YIELD (gpm): U
METHOD OF TESTr
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and NaturaRe osDion o WaaRD
WELL CONTRACTOR Quality
CERTIFICATION t/_ t2
even ontractor Company e
STREET ADDRESS
City of Town' State
Area cod
e- Phone ne number
or `��--
2. WELL INFORMATION:
SITE WELL ID #(irapplicable)
STATE WELL
PERMIT#(ir applicable)��
D WQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicable Box): Residential Water Supply pi DATE DRILLED 4 -)
TIME COMPLETED /Z
3. WELL LOCATION: AM PM
CITY: L!/!vr! M k
COUNTY
(Street Name. Numbers, r �/
Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope 0 Valley 0 Flat . Ridge 0 Other
(check appropriate box)
LATITUDE 3 T- " List_
LONGITUDES Z
Zip Code
f• DISINFECTION: Type CO,
9• WATER ZONES (depth):
From 2s.) To
From ;i 70 To
From To
8. CASING:
From 0
From
From
From
From
From
335176
Amount C //:
To
To
To
Thickness/
Weight
Material
J3z
�� ldetho Method
J
8. SCREEN: Depth Diameter Slol Size
From To Material
From To Ft.
L in in.
--__in. in.
From To
Ft in. in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From To Ft
From To Ft. From To To
Ft. ��-
10. DRILLING LOG
From To
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC
15A NCAC 2C, WELL CONSTRUCTION STANDARDS,
RECORD HAS BEEN PROVIDEDAND iED IN ACCORDANCE WITH
TO THE WELL OWNER. THATACOPY OF INIS
SIGNATuRE OF ERTIFIED WELL CONTRACTOR D/D ATE
T 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. (919)733-
Y
7015 ext 568.
Form GW-1a
Rev, 7/05
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1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
Welll.ontractor Company Name
STREET ADDRESS ,M'w LE/&CS-1E/Z !/
•
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#0r applicable)_
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED / 2 ZC _ O�
TIME COMPLETED // AM ID".. -PM
3. WELL LOCATION: p CITY: J�-�!✓cr, 'C COUNTY de,=_
�c.+a Ls,c rr
(Street N Nurebers. C unity. SubtllHaion. Lot No., Parcel, Zip Code
TOPOGRAPHIC / LAND SETTING: )
°Slope °Valley ❑Flat 0.41dge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE _it
Latitude/longitude source: r{;pg
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 _
ST$EET ADDRESS
Zip Code
City or Town State
(h&j_ --XL9/
City or Town State
Areacode» 77f _ /,a/
Phone number
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: 20 r
b. DOES WELL REPLACE EXISTING WELL? YES NO
c. WATER LEVEL Below Top of Casing: '1/4 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): fa METHOD OF TEST
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.
35177
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From ro To From
To
Fro., To From To
From To From
To
6. CASING:
Depth Thickness/
From O p Diameter Weight Material
Toed& Ft. G,/(r fi,.e-�� h
From To Ft. _
From To Ft.
7. GROUT: Depth Material
From_g_To�O Ft. COS_
G
From To Ft.
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
y�e1sr u'.c�.1M"eetthodhood
r J
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
To Ft.
To Ft.
To Ft.
Size Material
10. DRILLING LOG
From To Formation Description
fret
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ex-
SIGNATURE OF ERTIFIED WELL CONTRACTOR 'AT
DATE
•' /Q- y.
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Fonn GW-la
Rev. 7/05
CD
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CITY: _r,/
---�-�� COUNTY �ic, Lt
(Street Na
Numbers, community, Subdivision, Lot No., Parcel Zip Code)
TOPOGRAPHIC / LAND SETTJNG:
❑Slope 0 Valley ❑Flat idge ❑Other
(check appropriate box)
LATITUDE 3 ,y•-
LONGITUDE k- & ,,
Latitude/longitude source: Et,fS
(location of waif must be shown on a USGS top Topographic anddp
attached to this form f not using Gp topo map
4. WELL OWNER 11 /I nn
OWNER'S NAME�j�yrPt H Q
STREET ADDRESS
City or Town State
Area code - Phone numb f
5. WELL DETAILS: /
a. TOTAL DEPTH: {IsOJ�
b. DOES WELL REPLACE EXISTING LL/ YES ❑ NO
c, WATER LEVEL Below Top of Casing: I�
G
FT.
d. TOP OF CASING IS
. 'Top of casing terminated at/orFT. Above Lanm Suregcer
a variance in accordance with 15A surface may require
15A NCAC 2C .0118.
e. YIELD (gpm):4-
METHOD OF TEST I :'r� Eel
Submit the original to the Division of Water Quality within
1617 Mail Service Center- Raleigh, NC 27699.1617 Phon N
(Use `+• if Above Top of Casing)
Zip Code
1. WELL CONTRACTOR:
-RESIDENTIAL WELL CONS
North Carolina Department of Environment and Natural Resources- TlON RECORD
WELL C WELL of Water Quality
ONTRACTOR CERTIFICATION
QQ�-1ppCity of Towne State
Zip Code
Area code_ Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT/Nilapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply E
DATE DRILLED /0 —
TIME COMPLETED f . DD
AM
3. WELL LOCATION: PM L]
May be in degrees,
minutes, seconds or
in a decimal format
f. DISINFECTION: Type �o.�.,-
Amount J
9- WATER ZONES (depth):
From id a To
From ‘1--goTo From To
From From To
To From
6. CASING: To
From
From
From
To Ft.
7. GROUT: Depth
MaterialFro1
From To_ `1' Q Ft. Cone if L®
To_�
From To Ft. 8. SCREEN: Depth
From T
From To
From To
9. SAND/GRAVEL PACK:
Depth
Size
From
To
From To
From To
10. DRILLING LOG
From To
_ry
,r3�
3'351.79
Method
72"elfi—j-
Material
I n0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED NJ
15A NCAC 2C, WELL CONSTRUCTION S RECORD �DED TO THE WELL
OAND THAT ACOPY OF 1µj1 CE WITH HAS BEEN PR WELL L OWNER.
-
SIGNATURE OF _~r ERTIFIED WCONTRACTOR ELL CONT -SATE
A DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt,
e o. [phone] ext 568.
Form GW-la
Rev. 7/05

1. W CONTRACTOR:
RESIDENTIAL WELL
CONSTRUCTION
ECOD
North Carolina Department of Environment and Natural esouurces-TDivision of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well •ntrector Cam
❑any Name
STREET ADDRESS
ALL .S
City or Town Stale
Area code-
Ph
one number
2. WELL INFORMATION:
SITE WELL ID#tifapplicable) oG)CS 6 _64o
STATE WELL PERMIT#(ir applicable)_
DWQ or OTHER PERMIT # if ( applicable)
DATE DRILLED / 3/a
WELL USE (Check --- Applica le Box� Residential Water Supply
TIME COMPLETED"
AM ❑ PM p�
3. WELL LOCATION:
CITY: F/Ar /)rf, COUNTY /a/.,,
Zip Code
(ScreeSrot1.0° i/ ^ 4) t i101,9,/ . /
Name,Numbers, Community. Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0-SI pe O Valley ❑ Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE/>:/ $ I .3 3/ J,�l� ?
LONGITUDE..(2/1 .2, /
Latitude/longitude source:
(location of well must be shown on a USGS❑topo m ndp
attached to this form Anot using GPS) map and
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town State
t v
St
Area code - Phone number
5. WELL. DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO t
c. WATER LEVEL Below Top of Casing:.
(Use'+' if Above Top of Casing) �—FT.
d. TOP OF CASING IS FT. Above Land Surface
'Top of casing terminated al/or below landmay requisurface requir
a variance in accordance with 15A NCAC 2C .0118. re
e. YIELD (gpm). ?-
METHOD OF TEST
liyahog,
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
L DISINFECTION: Typ,'
g. WATER ZONES (depth):
From
From To
From To
6. CASING:
a335t1so
/ Amount /4+=-i
To 1&) From
From
From
To
Thickness/
height_, ,,, rN�..ttaterial
7. GROUT: Depth
From d x� Material
To_, Q Ft. 7
From To
From To FL'---�--
- 8. SCREEN: Depth Diameter Slot Size
From To
FL in.
To Ft.in.
FromFrom
9. SAND/GRAVEL PACK:
Depth Size
From To
From
From
11. REMARKS:
Ft.
To Ft.
To Ft.
Method
paug4863
Material
Formation Descriptbn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WDH
15A NCAC 2C. WELL CONSTRUCT/ON1STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO
O THE WELL OW ER
1 t ." dd
PRINTED NAME • F PERSON CONSTRUCTING
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. 733-
919
( 1 7015 ext 568.
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
State
Welllontractor Company
STREET ADDRESS
City or Town t I
St t Zip Code
RESIDENTIAL WELL Co
North Carolina Department of Environment and Natural ResourcesTDivision RECORD
Cyan ter Quality
WELL CONTRACTOR CERTIFICATION
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT#(if applicable)_
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water^/
DATE DRILLED /O • �i _ 0�— Supply
TIME COMPLETED
3. WELL LOCATION: AM PM [>'
CITY: eir
COUNTY
(Street Name,
N mb Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Mope 0 Valley 0 Flat ❑ Ridge 0 Other
(check appropriate box) �--�
LATITUDE 3 J-
LONGITUDE #- L
Latitude/longitude source: Q.,PS 0Topographic 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
fee- !2N
STjtEET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
City AIC �87Cityor Town State
Zip Code
3S Area code - phone numbs
5. WELL DETAILS:
a. TOTAL DEPTH: ,JO .7-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
Cr
c. WATER LEVEL Below Top of Casing: 20
(Use'+• if Above Top of Casing) —FT'
d. TOP OF CASING IS FT. Above Ld Surface'
'Top of casing terminated at/or below land surf ce may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Jr?
---_METHOD OF TEST ..rle
Submit the original to the Division of Water Quality Within
1617 Mail Service Center-
0
ys.
Raleigh, NC 27699.1817 Phone No. 3919a733-Attn: Information Mgt.,
( 1 7015 ext 568.
f. DISINFECTION: Type_ — Amounty ij
g. WATER ZONES (depth):
From /ep To
From ty42 From
To From
From To
From
6. CASING:
Depth Thickness/
From_ p i_i FtDiameter Weight Material
From To "'G`�- ?tie
From Ft.
T�Ft.
7. GROUT: Depth
Material
FroFrom To IQ Ft Cone4%
To
From To Ft
8. SCREEN: Depth
From To F mneler Sbl Size Material
From To
From To
9. SAND/GRAVEL PACK:
Depth
Size
From To _. Material
From T
From To Ft
10. DRILLING LOG
From To
Formation Description
11. REMARKS:
Method
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH1 SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELLAT
CONTRACTOR DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 7/05

.RESIDENTIAL WELL CONSTRUCTION REco:u
North Carolina Department of Environment and Natural Resources- Division of eater Qual:.ty
WELL CONTRACTOR CERTIFICATION # 2t 31O
t. DISINFECTION: Typed‘ \S Amount /...�
1. WELL CONTRACTOR:
¢rc: ck Lec, &b SSa. -3-de.C4
Wee Contractor (Individual) Name
Q.\\)1aQ ' SQt..I'7e.-CS j i 4n.
Well Cd.ti sv. r Company \'\Naitiep
STREET ADDRESS SESrJ' WWCIAS'1 20fl
No-tt ��r;n s, Nc - f asin i3
City or Twin Sbte -try Code
(8 %» lo(oS- aoa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mif appliicabte)
STATE WELL PERMfT#(Yapgiable)
DWQ or OTHER PERMIT 4fd applicable)
WELL USE (Check Applicable Sox): Residential Water Supply (aJ
DATE DRILLED
TIME COMPLETED / .100 AM PM[a9--
3. WELL LOCATION:
CITY: /ei c P.r/Pr
COUNTY /71r. 4 .w..Ze
4/e4' P." A C T.- /CC/ .
{Street Name, Numbers. Community. Subdivision. Lot No.. Parcel, Zip Code)'
TOPOGRAPHIC / LAND SETTING:
L4kope OValley OFWt CI Ridge ❑Omer
(check appropriate box)
LATITUDE 3 _
LONGITUDE
Latitude/longitude source: ❑ QFS ()Topographic map
(bastion of wel must be shown on a USGS topo map and
attached tothisform l not using GPS)
4. WELL OWNER 2�
OWNER'S NAME 7etgi'(^te
STREET ADDRESS toJv Qb't
May beindegrees,
minutes, seconds or
in a decimal fonoat
Et d'n'10.tt t1
193D\
R7SMtv:t\C NC
City or Twin) State
(Sas } 350-9o310
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: r,C S~
trg8$\Y
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES O NO B—
C WATER LEVEL BebwTop Of Casing: e0 FT.
(Use •+' if Abate Top of Casing)
d. TOP OF CASING IS \ . FT. Above Land Surface'
'Top o( casing terminated at/or below land surface may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST R• 3
g. WATER ZONES (depth):
Frain To
From To
From To
6. CASING:
De
pth,
R.
Fran To F1.
335298
From To
From To
From To
Thickness/ s/
°Weight
rant-
ry
From To Fl.
7. GROUT: e^� Depth Materiel
From To `2 o F. 0" xc r/�
From To F1
From To - Ft.
Method
"avwr /
& SCREEN: Depth Diameter Sbt Size Material
From To Ft. in. in.
From To R. in.. in.
From To R. in. in.
9. SAND/GRAVB-PACK
Depth
From To Ft.
Fran To Ft,
From To Ft.
10. DRIWNG LOG
From To
/ 5;2
sz o?c C
11. REMARKS:
Size Material
Formation Description
ace.— die/le/es.
i i7A1_Il Y
toFpei 'L ( /_. uuu
I DO THEREBY CERTIFY THAT THIS WELL V 'AS COts>TRUCIED N ArroaDACF NTH
15A NCAC 2C, WELL CANSTRUCTrON::rP ROAR AND TW.TA COPY CF T95
RECORD HAS BEEN PROVIDED TO THE w
SIGNATURE OF CE IFlED WEI
C - QC.. le
PRINTED NAME OF ERSON
Submit the original to the Division of Water Quality within 30 days. Attn: In
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] e
nation
s66. DEC 12 2006
TRACTOR
DATE
Fame -la
Rev./

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTIONRECO:2D
• North Carolina Department of Environment and Natural Resources- Division of K ater Qual:1
WELL CONTRACTOR CERTIFICATION # ali i'
t. DISINFECTION: Typed_\%,S
g. WATER ZONES (depth):
From From To
From From To
From
From To
-
Well Contactor (btdMduai) Name
Well
Company Narhe
STREET ADDRESS 8n`43
City or Town e . -bp Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID SW applicable)
STATE WELL PERMITS(' appricabIe)
DWQ or OTHER PERMIT #(tf appfn:able)�
WELL USE (Check ApN'aab" Sox): Residential Water Supply t2/
DATE DRILLED 9,—
TIME COMPLETED � /� J n o
3. WELL LOCATION: /
CRY: COUNTY
PM E'
Community. Subdivision, fat No.. Parcel, 2q Code)
{yb•rg Name. ambers.
TOPOGRAP IC ( LAND SETTING:
❑Slope alley ❑Fkt ❑Ridge ❑Other
(cheek appropriates boa)
LATTIUDE 3
LONGITUDE _ _
Latitude/longitude source: DGPS CITopograaphic map
Potationowed must be shown on a USGS tops map and
etta,hed to this form Tnot using GPS)
4. WELL OWNER
OWNER'S NAME Pit"�-t{� LC'F.nQ—
/
STREET ADDRESS .L e;)L� '1Q-7 � �
.0W0.1s /3e.
City a Tam
(. )-:
Area code - Phone numbs
a WELL DETAILS: `'�
a. TOTAL DEPTH: J�--
b. DOES WELL REPLACE EXISTING WELL? PEES ❑ NO7
a WATER LEVEL BelowTop of Casing: AFT.
(Use 'anboveTopofCasig).
d. TOP OF CASING 6 FT. Above Land Surface
*Top d casing terminated ova below land surface may require
a variance in e..rada,rr.c with 15A NCAC 2C .0118.
e. YIELD (gprn): S METHOD OF TEST
May be in d.ge-,
minutes, seconds or
in a decimal format
State Zip Code
6. CASING:
To
To
To
Amount
Thickress/
Depth Dianpter Weight
From To �.,i
From To Ft.
From To Fl.
7. GROUT: Depth Materai
From To� Ft._ (entan f .
From To R.
From To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
FromTo
/-5
Dianeter Slot Size Materiel
R. in. in.
P. in.. in.
Fl. Ir. in.
FL
Ft_
Ft_
Size Maw
10. DRIWNG LOG Form't n
From To � � �
' a c.) LL LY[ f 1
flC
11. REMARKS:
C.srt `
`wr F¢,
`19
400 HEREBY CERTIFY THAT OILS WELL WAS tD".STRICXATA ACCORDANCE
COPY rm
TED IN w
RECOtSA RD HAS SEELL CONSTRUCTION N PRWI0E0101MNELL OWNER.
SIGNATURE OF CEfZTlFlED N OIYTRACTOR DATE
r,(c CX �'fL0.Fyy
PRINTED NAME OF PERSON-.
Submit the original to the Division of Water Quality within 30 days. Attn: info
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568
4
;onMgt, Fain9W-la
Rev. 7/05
DEC 12 2006

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quafty
WELL CONTRACTOR CERTIFICATION # 0436
1. WELL CONTRACTOR:
'Zere:ck Seca►,
Wed Contractor (Individual) Name
CNN a.Q ' J Qt.AyyEc s 'SO n.
Well Co?IUactor Company Nad e
STREET ADDRESS \yV85 \dCt S j ao4
Nod 5iCn S) NC - ot8"t.43
City or Town a • -Zip Code
(89%)- co(o8- aoan
Area code- Phone number
2. WELL INFORMATIOtt
SITE WELL ID #fdapprcable)
STATE WELL PERMR#(eeppliable)
DWQ or OTHER PERMIT #(if 1
O
WELL USE (Check Applicable Box): Residential Water sups y
DATE DRILLED Tho2 P�
TIMECOMPLETED S,"OU AMO PMi3�
3. WELL LOCATION:
CRY: Mee ,"/X f ..
4 •C /en JCYn . W'
{Street Name. Numbers. Community, Subdivision. Lorlio . Parcel. tv Code)
TOPOGRAPHIC / LANDSEWING:
❑Slope Ovalle)' ❑Fat IgiRidge ❑Other
(cheek approvers box)
LATITUDE 3
LONGITUDE
Latitude/lOngitude source: OOPS OTopographic map
(option of wait matte shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER ��
OWNER'S NAME ,)tee 3 \
STREET ADDRESS BSIC Min Scenic 14a.J
Ast'ev:tier JSC a tSo`1
COUNTY,/ sr Cowie 4'
1 May be in degrees, I
minutes, seconds or
in a decimal format
City or Town State
(Sae y. Ala-(oSte
Area code - Phone number
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: Z 0 -S.-
b. DOES WELL REPLACE EXISTING WELL?. YES 0 NO E-
c.. WATER LEVEL Below Top of Casing / D U FT.
(Use -.• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top d casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST P-.•�
t. DISINFECTION: Typed 11S Amount 3 6
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Depth
From' Tod.? cf
From To
From To
7. GROUT: Depth
From To.20
Frain To Fl.
From To Ft.
D'
Ft.
Ft.
n.
Thickness/
Wright Material
fail /wifet
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
From To
Material
Fl. Centro/.
Method
/�OLIYt✓
Dianeter Slot Sim Material
Fl. in. in.
R. in. in.
Fl. in. ' irk.
Size Material
Ft.
From To FL
From To Ft.
10. DRILLING LOG
From TO
Formation Description
el acr• ,
c2e ro-o 7 4Ln--. IBC
11. REMARKS:
c r.CP4\17-D
iv ?On
1 DO HEREBY CERTIFY TNAT INS WEL L Y 'AS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSmUC1k1N KRAW��A.Rr�DyS� AND THATA COPY OF Tay
RECORD HAS BEEN PROVIDED TO THIi w "' IER.
s
SIGNATURE OF CERTIFIED TRACTOR
RDATE
t"�2rc.tk HD. ttiiy 5e.%Are
PRINTED NAME OF PERSON :.:ONSTRUCTIftG j13 E WF(.L
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, . +hFain GW-la
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568, Rev 7105
DEC 12 2006
0

RESIDENTIAL WELL CONSTRUCTION RECO2D
North Carolina Department of Environment and Natural Resources- Division of St'a:er Qua)
WELL CONTRACTOR CERTIFICATION # akt 3L
1. WELL CONTRACTOR:
Q-ce: ck
Well Contractor (Individual) Name
QV. J &Q ' 'J4s.Jle.-(-S 3/4-
Well C& factor Company Nate
STREET ADDRESS \'\? s 7131. y a0(;
1-\04 5�c;t\c , Nc 0-8'-143
pp City or Town state . -Zip Code
( Oa%} totos- acaa_
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID fi aNtlicase)
STATE WELL PERMIT*? applicable)
DWQ or OTHER PERMIT R(tappficable)
WELL USE (Check Applicable god): Residential Water Supply
DATE MILLED
TIME COMPLETED 1/442,1/4f..30 AM p PM IDS'
3. WELL LOCATION:
CITY: lgi,1161. .. COUNTY Sirs or qe
n ciOn Co .Q �]
.P �
{Sbi Name. Numbers. Community. $ub n, tot No.. Parcel. Code)
TOP RAPHIC / LAND SETTING:
°Valley ❑Flat ❑Ridge °Other
(ehesi appropriate box)
LATITUDE 3
LONGITUDE
Latitide/)ongitude source: OGPS ❑Topographic map
flotation of eel must be shown on a USGS fopo map and
atfeefnes/ to this firer tnot ushrg GPS)
4 WELL OWNER /
OWNER'S NAME a'+ef,LCLti Aj ye O L16 0414
STREET ADDRESS (0 )00 We kr-5O.n u'ifP
1e11, Qc) N c t, 8173Q
City or Town State Zip Code
93R)• CoS4-$1-1SO
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: o10s
b. DOES WELL REPLACE EXISTING WELL? YES (7 N01;{
c. WATER LEVEL Below Top of Casing: CS U FT.
(Use'V itAbove Top d Casing)
d. TOP OF CASING IS i FT. Above Land Surface"
-fop of casing temestel avor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /b METHOD OF TEST • \
err
IMay be in degree, I
minutes, seconds or
in a decimal format
t. DISINFECTION: Type4 \ 5 _
g. WATER ZONES (depth)_
From To From
From To From
From To _ From
6. CASING:
From
From
From To Ft.
Amount_
To
To
To
kn Thicess/
Depth D'
1 To ff� FWeigM . a
To FI.
1
7. GROUT:
Depth Material Method
From T,� To ao R. (vex.�,�d- pal., r
From To P1 "�"t"-'t i .. �"F d
Fran To Ft.
8. SCREEN: Depth
From To
From To
From To
9.
Daneter Slot Size Material
R. m. in.
F. ire. in.
R. in. in.
SAND/GRAVEI. PACK:
Depth
From To- Ft.
From To Ft
From To FL
10. DR!LUNG LOG
From To
fey a.7os
11. REMARKS:
Size
&tetanal
Formation Descrip ion
DEC 12 2006
1DDHEREBY CERTIFY THAT THIS WEL 4+v'AS CONY' TCTEpH
ISA NCAC 2C, WELL CONSTRUCTOR!;TANDARD9' AN) TMATA �V/rfll
RECORD HAS BEEN PROVIDED TO ME E1=OWNER
NATURE OF CE
be{ —lc CV, %kto.4ta (30,4)itt3
PRINTED NAME OF PERSON XONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information M3L,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. (919} 733-7015 ext 568.
ONTRACTOR
9/se.
DATE
Fam GW-la
Rev. 7/05

Area code- Phonenumber
2. WELL INFORMATION:
SITE WELL ID *of applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT tiff applicable)_
WELL USE (Check Applicable Box
DATED ) Residential Water Supply
KILLED _ r— OG
TIME COMPLETED t J
3. WELL LOCATION: AM O PM p/
CITY: Cote %/C
COUNTY
At 2
/�<<s
['Slope ❑Fl
Slope DVall G"
at itlge ❑Other.
(check appropriate box)
LATITUDE 3 r
LONGITUDE 1"L r,-- r
Latitude/longitude so CPS
source:
1. WELL CONTRACTOR:
RESIDENTIAL
North Carolina De WELL CONSTRUCTION RECORD
partment of Environment and Natural Resources- Division of Water
WELL CONTRACTOR CERTIFICATION Quality
#��^
i
vv ellsrontractor Compaompa-1L
ny Name
STREET ADDRESS
Zip Code
N u Cwn
TOPOGRAPHIC tY Subdivision, L , Lot No., Parcel,
/LAND SETT p Cade)
May be in degrees,
minutes, seconds or
in a decimal format
(location of we#must be shown , USGS to efll p anddp
attached to this form d on a USGS topo map
4. WELL OWNER
not using GPS)
Zip Code
5. WELL DETAILS:
a. TOTAL
b. DOES WELL REPLACE EXISTING WELL? YES O NO c. WATER LEVEL Below Top of Casing: l,/J
if Above Top of Casing)"" —'AFT.
d. TOP OF CASING IS
'Top of casing terminated at/or below land Above Le land surface m Surface'
a variance in accordance with 15A NCAC 2C , ay require
e. YIELD (gpm): Lv 0178.
—�_ METHOD OF TEST
Depth
To
To
To
Ft.
Ft.
Ft.
Material
e t{{` W 4. V 1
6t 4
Amount
From
To_��
From To
From — —�
To
Thickness/
Diameter Weight Material
Ft
—�
Ft. Diameter Wei! Z
Size Material
f. DISINFECTION: Type
C�tiY
9• WATER ZONES (depth):
From X10 To
From /ftp
To
From
To
B. CASING:
8. SCREEN:
From
From
From
From
From
II• REMARKS:
I DO HERESY CERTIFY THAT
ISA NCAC 2C, WELL CONSTRUCT/ONTHIS WELL WAS CONSTRUCTE
D IN ACCORDANCE WITH
PROVIDED TO iHE�EllO AND 7HATA COPY OF THIS
OWNER.
SIGNATURE OF
ERTIFIED WELL CONTRACTOR
Submit the original to the Division of Water
Quality Within 30 days. Attn: Information
1617 Phone No. (919 73 _ Mgt.,
Raleigh, NC 27699-
4
RINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mail Service Center—
3 7015 ext 568.
S-r-roc
DATE
Farm GW-la
Rev. 7/05

RESIDENTIAL w
North Carolina Department WELL CONSTRUCTION RECORD
P ment of Environment and Natural Resources- Division of Water
WELL CONTRACTOR CERTIFICATION # Quality
State
Sae 2SS'--T9i
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)_
STATE WELL PERMIT# ila ( pphcable)��
D WQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Boxy Residential Water
DATE DRILLED__ z , L_ Supply ■
TIME COMPLETED_ —/
3. WELL LOCATION; AM ❑ PM l3
CITY:
even l�ntrac(or Company Name
STREET ADDRESS(L
City w Town g
Zip Code
CS[8u.•: _✓COUNTY
Llaw a _ f
(StreeettP a°me, Numbers, Community, Subdivision, Lot No., Parcel, Zi
TO OP PHIC t LAND SETTING: P Code)
ope ❑Valley 0 Flat Ridge❑0 Other
(check appropriate box) —�--��
LATITUDE A t 3 J = p� / May be in degrees,
LONGITUDE r �L'L-�L� minutes, seconds or
in a decimal format
Latitude/longitude source:
(k)cation of well must be shown on a ❑ USGS lopTopogrmap
map
attached to this form if not using topo map and
4. WELL OWNER GPSJ
OWNER'S NAME
STREET ADDRESS
State
IN or Town
Area '
Zip ode
code} Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:_ L/
I. DOES WELL REPLACE EXISTING WELL? YES p NO c. WATER LEVEL Below Top of Casing: i'efn (Use "+" if Above Top of Casing)
d. TOP OF CASING IS
'Top of casing terminated al/ �n d Above ceLamay dace'
a variance in accordance with 15A land surface require
NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST
�J
335142
f. DISINFECTION: Type r g. WATER ZONES (depth): Amount %/
From To
Depth
From lameter W.
From To� Ft. u
To Ft.
From To
F(. —
7. GROUT: Depth
From Material
From To—�`���,(� '-"� Ft. en
L
To Ft.
From To r.
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND IN ACCORDANCE WITH
RECORD HAS SEEN PROVIDED TO THE WELL OWNER. A COPY OF THIS
PRI TED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water
1617Sub it Service Center— Raleigh, nNWater
Quality wPhone
No 30 days. 7ois Information Mgt.,
1617 Phone No.[phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL
art WELL CONSTRUCTION RECORD
North Carolina Department ment of Environment and Natural Resources -Division of Water
WELL CONTRACTOR CERTIFICATIONWELL q �Q, c")
dr
VVell tractor Dompany Name
STREET ADDRESS
il
(SEQ ] City or Town C' State
J. - la ._i�(r�^� Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#0r applicable)
DWQ or OTHER PERMIT #(ir applicable)
WELLUSE (Check Applicable B
J�///p/o x): Residential Water Supply
DATE DRILLED Q�y/ —
TIMECOMPLETED �`'2 Lrtn /
3. WELL LOCATION: --"Lis-IL_�_ AM O PM p�
CITY: ,fr 1[ .
COUNTY_h�r�a�
(Street Name, Numbers, Community,4t
^ '—�
Subdivision, Lot No., Parcel, Zip Code)
TOP PHIC / LAND SETTING:
lope O Valley ❑ Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE WAS I
YV_� 79 May be in degrees,
LONGITUDE'' r minutes, seconds or
Ltiin a decimal format
Latitude/longitude source:
PS ID (location of wed must be shown on t Topographic ndp
a USGS
attached to this form snot usingUSGS opo map and
4. WELL OWNER GPSJ
OWNER'S NAME 4�
STR T ADDRESS 0 pp s n
.LJtl
ram✓ ///� _ ,
0
City or Town
State
Area ccode
e - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH.
b. DOES WELL REPLACE EXISTING WELL? YES FA NO�
c• WATER LEVEL Below Top of Casing: �(/
(Use -+• if Above Top of Casing)
d. TOP OF CASING IS
*Top of casing terminated at/ FT. Above Land may Surface'
a variance in accordance with 15A land 2Csur.0118.requireNCAC 2C _0118. e. YIELD (gpm): l
METHOD OF TEST.
/
rL DISINFECTION: Type
g. WATER ZONES (depth):
From To�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
ISSA NCAC 2C, WELL CONSTRUCTOR STANDARDS, AND THAT
A ACCORDANCE WRH
RECORD HAS BEEN PROVIDED TO THE WELL OWNER. THATA COPY OF THIS
1
PRI TED NAME aF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality
1617 Mail Service Center— Raleigh, NC 27699-1617
within 30 days. Attn: Information Mgt.,
Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
335149
ti

May be in degrees,
minutes, seconds or
Latitude/longitude source: in a decimal format
f r'S ❑ Topographic map
(location of welmust be shown on a USGS topo map and
attached to this form /not using GPS)
4. WELL OWNER _
Zip Code
5. WELL DETAILS: / J
a. TOTAL DEPTH: y03�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CY
c• WATER LEVEL Below Top of Casing:
(Use "t" if Above Top g)
d. TOP OF CASING IS FT.)
*Top of casing terminated Above surface y Surface*
a variance in accord with below land 2C.01may r accordance with 15A NCAC 2C .0118. Y require
e. YIELD (gpm): /
METHOD OF TEST • '
I�
n STATe
ti
1. WELL CONTRACTOR:
RESIDENTIAL
WELL CONSTRUCTION RECORD
WELL CONTRACTOR
Department of Environment and
R CERTIFICATION #3 ��0
es
Weill ontractor company
Name
13REET ADDRESS
City or Town State
e
(2R) [Tug__rea code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)_
STATE WELL PERMIT# ifa ( Ppbcablel
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Sox) Residential Water Supply p/
DATE DRILLED 1/=
TIME COMPLETED /=
3. WELL LOCATION:
CITY: e. ce
COUNTY
4;7 0,
me, Numbers. Com unuen t
TOPO Y 5 btl N Lot No., Parcel, Zip Code)
GRAPHIC /LAND SETTING:
❑ Slope 0 Valley 0 Flat @f(tdge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE @ : nae'
Zip Code
North Caroli
Natural Resources- Division of Water Quality
f. DISINFECTION: Type Ciw- .,
Amount
9. WATER ZONES
(depth).
.335145
14a
From 2W To
From 3L'f
Frain
B. CASING:
To To
From
From
From
7. GROUT: Depth
From Material
From To Ft. Cale /' LL•
From FI'
To FI.--
8. SCREEN: Depth
From To
From To
From To
11. REMARKS:
Method
) U�jry
Diameter Slot Size Material
Ft in. in.
Ft in.
in.
Ft. in.
in.
Size Material
I DO HEREBY CERTEY THAT THIS WELL WAS CONSTRUCTED IN ACCORD
ISA NCAC 2C WELL CONSTRUCTION RECORD HAS BEEN PROVIDEDTOTE WELL OWACCORDANCE WW1
TO THE WELLO AND THATACOPY OF THIS
OWNER
SIGNATURE O RTIF EI D WELL CONTRACTOR RACTOR
4
Submit the original to the Division of Water RINTED NAME OF PERSON CONSTRUCTING-
1617Sub ittt origvice Cantor— THE WELL
Raleigh, NC 27699 17 Quality Phonehio 30 days. 7oi Information Mgt.,
1617 No.(9tg�733-7075 ext568.
sTE
DATE
Form GW-la
Rev. 7/05

LATITUDE 3S e2fa/
LONGITUDELijo
Cn` • �'
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
OWNER'S NAME��� i7
STREET ADDRESS
City orTown�=
State
('224L) $, ZipZ:p Cottle
Area code - Phone number
5. WELL DETAILS:
a. TOTAL
b. DOES WELL REPLACE—_— EXISTING WELL? YES ° NO
c• WATER LEVEL Below Top of Casing:
(Use `+• if Above Top of Casing�—FT.
d. TOP OF CASING IS
'Top of casing terminated at/orFT.laAbove LandSurface*requir
a variance in accordance with 151A2Csur.01 8. require
e. YIELD �� �/�' 5 NCAC 2C .0118. qf�
(9Pnt). METHOD OF TESTI
vxel �pntractor Com u f IY7
party Name
STREET ADDRESS(]
City or Town State
(AL -
Area code- Phone number
er ��-
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(a applicable)_
OWQ or OTHER PERMIT #(if applicable)
DATE DRILLED---
WELL USE (Check Applic 6le Box): Residential Water Supply
TIME COMPLETEDa______
3. WELL LOCATION:
6�1Z___� AM PM
CITY: L, 1
c:L�' COUNTY_ dU/16
t
Numbers, %r/f� /•
Community,Subdiesion, Lot No., Parcel,
RAPHIC / LAND SETTING: Code)
TOPfflZip
lope Valley °Flat °Ridge ❑Other
(check appropriate box)
RESIDENTIAL WE
LL CONSTRUCTION RECORD
North Carolina De panment of Environment and Natural Resources- Division of Water WELL CONTRACTOR CERTIFICATION20 WELL
1. DISINFECTION: Type
•
g. WATER ZONES (depth):
From
51. ♦1 t" at t)
w
eJ 4� !s ,w
Depth Thickness/
From ) To Diameter Weight ,OM�^atteririall
From To Ft. - ram
From To
Ft.
7. GROUT: Depth
Material
From Tp
From Ft.
To r.
I DO
15A NCAC HERESY CERTIFY BEEN WELL CONSTRUCT/ON STANDARDSSAND THAT A COPY TRUCTED IN ACCORDANCE wRH
RECORD ./L PROVIDED TO E /WELL ER
Submit the original to the Division of Water PRI TED NAME eF PERSON CONSTRUCTING THE WELL
1617Submit
it Service Center h Raleigh, oNf Water
Quality Phone
No.o 309 days. 7Attn:015 Information Mgt.,
7617 Phone (gi g�7�3_7075 ext 568.
Form GW-la
Rev. 7/05
CD
rn
dV

1. WELL CONTRACTOR:
RESIDENTIAL
North Carolina De WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources- Division of Water Q
WELL CONTRACTOR CERTIFICATION # uality
4 55
Well ontractw Company
Name
STREET ADDRESS
Zip Code
May be in degrees,
minutes, seconds or
-� in a decimal format
Latitude/longitude source:
(location of well must be own op a USGs t0 Topographic anddp
attached 10 this form #shown on a USGS (opo map
4. WELL OWNER _ not using GPS)
City or Town
( l728 ) State
(1 code_ Phone numbs T e
2. WELL INFORMATION:
SITE WELL ID #(if applicable)_
STATE WELL PERMIT# f applicable)
PPlicable)
DWQ or OTHER PE
RMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ff
DATE DRILLED - --QG PPY
TIME COMPLETED /f7 ) AM
3. WELL LOCATION: �PM
CITY: %i4.. //<
2 COUNTY
(Street Name, Numbers, Community, Subdivision, Lot No., TOPOGRAPHIC / LAND SETTING: Parcel, Zip Code)
❑Slope ❑Valley 0 Flat Qfidge 0 Other
(check appropriate box)
LATITUDE 3 Y
LONGITUDE T L Jr./ SOZ•
OWNER'S NAME
TREET ADDRESS
City or Town State
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO c. WATER LEVEL Below Top of Casing:
(Use °+• if Above Top of f Casing)
d. Casing)
d. TOP OF CASING IS
'Top of casing terminated FT.laAbove Land y Surface'
a variance in accordance with below land 2C .01 dance with 15A NCAC 2C .0118,aY require
e. YIELD (gpm): /r
METHOD OF TESTS ;' r ••q
I
From
From
From
6. CASING:
f. DISINFECTION: Type el- --a
g. WATER ZONES (depth)
2/0 To
270 To
6. SCREEN:
From
From
From
Depth
To
To
To Ft.
From
From
From
3011 °l1
Amount /y f3
Method
Diameter Slot Size Material
Ft. in.
. in.
Ft
in. in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From To
From Ft.
From To Ft.
To Ft.
10. DRILLING LOG
From To
O- r y Formation Description
11. REMARKS:
SIGNATURE OF
l 44
RINTED NAME OF PERSON CONSTRUCTING THE WELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
ISA NCAC 2C, WELL CONSTRUCT/ON STANDARDS
RECORD HAS BEEN PR N ACCORDANCE WRH
PROVIDED TO THE WELLOWNER THATA COPY OF THIS
ERTIFIED WELL CONTRACTOR
RACTOR DATE
Submit the original to the Division of Water Quality
1617 Mail Service Center Raleigh, NC 2Water
1617
Within 30 days. 7Attn:015 Information Mgt,
Phone No. (g19) 733-7015 ext 568.
Form GW-la
Rev. 7/05
C7

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
Well onlractor Company Name sir
STREET ADDRESS
p City °f Town State
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 r
DATE DRILLED Y-27-04
Zip Code
TIME COMPLETED _
AM ❑ PM
3. WELL LOCATION:
CITY: /ta a
COUNTY
(Street Name, Numbers, Communi y, Subdit7sion, Lot No., Pareel, Zip Code)
TOPOGRAPHIC / LAND SET}'ING:
❑Slope ❑Valley ❑Flat CfRidge DOther
(check appropriate box)
LATITUDE 3 s C//
LONGITUDE 6- L •�, z �•
Latitude/longitude source: Er6pS ❑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--�-7---
rlON
STi/j'EETp ADDRESS
C2�9.r.Jln
��>> City
la Town State
Area
Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: f 'ir
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fiV
c. WATER LEVEL Below Top of Casing: /00
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS __L._ FT. Above Ld Sface*
'Top of casing terminated aior bet and suit ce mayrequire
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (9em): 2 0 METHOD OF TEST -
/
,y
From 170
From To.
6. CASING:
f. DISINFECTION: Type %-�,.�
9• WATER ZONES (depth):
From cLo To
To
From
From
From
Depth Diameter
From_( To i Z Ft. .sec
From To Ft.
From To Ft.
7. GROUT: Depth
om Material
Fr
From_ To p Ft CO nterefc
Ft.
Ft.
w
el
Amount A,A,.c.
To
Thickness/
Weight Material
311(+a/ �C
�� 1retho
Method
J
Diameter Slot Size
Ft. in.
— in.
To
Ft in.
in.
To
Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size
FMaterial
rom To
Ft.
From To
Ft.
From
TO Ft.
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 OWNERVI
SIGNATURE OF ERTIFIED WELL CONTRACTOR
.4 -
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.
Material
e=12-06
DATE
Form GW-la
Rev. 7/05

_r; 51A
1. WELL CONTRACTOR:
1 Contractor
RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and Natural Resources- Division
o f 4QRD
ater WELL CONTRACTOR CERTIFICATIONQuality
Well ontractor company Name
STREET ADDRESS
Zip Code
Area code- Phonenumberem
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 o- ' DATE DRILLED
TIME COMPLETED
AM PM
3. WELL LOCATION:�r�r-7
CITY:
./1,e7 /fit
COUNTY
(Street Name, Numbers, Community,
Subdivision, Lot No. parcel, Zip Code)
TOogOGRAPHIC / LAND SETTING:
lope O Valley ❑Flat Ridge ❑Other
(check appropriate box)
LATITUDE 3 aC yl=i r May be in degrees,
LONGITUDE L x minutes, seconds or
27 3s"y in a decimal format
Latitude/longitude source: p2;PS ❑Topographic map
(location of weff must be shown on a USGS topo map and
attached to /his form if not using GPS)
4. WELL OWNER
OWNER'S NAME
� .lip
ST EET ADDRESS ir�r���lih
City or Town State
- - Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: .TO r
b. DOES WELL REP
LACE EXISTING WELL? YES CINO E(/
c. WATER LEVEL Below Top of Casing: f .r7
(Use `+• if Above Top of Casing)' —FT'
d. TOP OF CASING IS ______L_
'Top of casing terminated at/or belowFT. Above Land and surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): �p METHOD OF TEST 1 ; • 1.1
From
From
From
6. CASING:
'33518
f. DISINFECTION: Type
Amount 1 is ryL
g. WATER ZONES (depth):
To From
To
To
From To
To From
To
Depth
From G To d�c7
From To
From To_�
Ft.
7. GROUT: Depth
g Material
F �_ l Toe Ft. %O� .
T
From To Ft --�
8. SCREEN: Depth From T Diameter Slot Size Material
Ft.
From �In. in.
To
From Ft. in.
in.
To --_
Ftn.
in.
9. SAND/GRAVEL PACK:
Depth Size
Material 1=1
From
From
Thickness/
Diameter Weight Material
Ft.6. ez rva .
Ft.
Method
12"
J
To Ft.
To
Ft. �---n
To Ft.
10. DRILLING LOG
From To
O 7.-
7r' 4.2.1
Fp`_
11. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTEpp 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-1a
Rev. 7/05

1.. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well (l onlractor Company Name
� ry 3
STREET ADDRESS . / co _ L " I�J
Ff /'�C n
' y
City or Town State
L22a j- 5 ' xy9 / Zip Code
Area c `x��—��—.
ode- Phone number
2. WELL INFORMATION:
SITE WELL ID *Of applicable)_00 6
STATE WELL PERMIT/Sot applicable)
DWQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicable Box): Residential Water Supply p
DATE DRILLED H. SS'=_
TIME COMPLETED ; J.;
AM 0 PM
3. WELL LOCATION:
CITY:.�e,'c •S tti
COUNTY ncs
A 1114 v.
(StreetN Numbers. C o di
ty, Subdivision, Lot No. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat pledge ❑Other
(check appropriate box)
LATITUDE 3 C' ,17_ k.LL
LONGITUDE Y 2 J j Ye
Latitude/longitude source: GPS ❑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
SEET ADDRESS 15 l 'c i
Isharr.It- ,Nis
5. WELL DETAILS:
a. TOTAL DEPTH:
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ° NO (j
c. WATER LEVEL Below Top of Casing: Q/
(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): METHOD OF TEST
-,y
6. CASING:
From 0
From
From To Ft.
7. GROUT: Depth
From_ T
From To
From To
To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
11. REMARKS:
�335188
/
f. DISINFECTION: Type --.-ra
Amount yGr
9. WATER ZONES (depth):
from SC To From
From ' z0 To To
From To
From To From
To
Thickness/
Weight Material
�, Material
Ft. Cone
Ft.
Ft.
Diameter Slot Size
Ft in. in.
Ft in.
in.
Ft. in. _ in.
Size Material
Material
TO
ry
Formation Description rn
I DO HEREBY CERTIFY 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 OF ERTIFIED WELL CONTRACTOR // DAT
E
DATE
A a
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. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
II Contractor Individual) Name
Weill ontractor Company Name
STREET ADDRESS /0 L
City or Town State
(gam)- a5 -- XTI
Area
co
de- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) op Q 3 Y
STATE WELL PERMIT#01 applicable)
D WQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L
DATE DRILLED I/ - /=pe
TIME COMPLETED //; alp
-�— AM D--"PM❑
3. WELL LOCATION:
CITY: L///COUNTY
`^ L_ ,his t ts''
(St t N N Numbers', Comm ly, Subdlnsion, Lot No. Parcel, Zip Code)
�TO`�POGRAPHIC / LAND SETTING:
L7SIope 0 Valley ❑Flat ❑Ridge 0 Other
(check appropriate box) �—�---
LATITUDE 3 i
LONGITUDE Y - 77 dNy
Latitude/longitude source: Et6PS
❑Top topo ,n p mdp
(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 r--lJ116
STREET ADDRESS
Zip Code
City or Town Stale
LP!" )- asa_ i
Area code - Phone number
5. WELL DETAILS: �/
a. TOTAL DEPTH: erg f
May be in degrees,
minutes, seconds or
in a decimal format
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(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): / METHOD OF TEST / :'
33591
f. DISINFECTION: Type /p-,-.z Amount
g. WATER ZONES (depth):
From /ail To
From J%., To To
From
6. CASING:
From
From.
From
From
From
From
To
Thickness/
Weight Material
r�ava.
7. GROUT: Depth
Material
Frorn_g_ ToQ Ft. COfc
From To Ft.
From To Ft.
Method
Diameter Slot Size Material
Ft in. in.
To Ft in.
in.
To
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
FMaterial
From
To Ft.
From To Ft.
From To Ft. �'-
11. REMARKS:
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 BEENNPPRWJDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTORAT C�`'
e DATE
4
HINTED 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

de.-.„.4 STATp
1. WELL CONTRACTOR:
I Contractor
RESIDENTIAL WELL CONS
RECOD
North Carolina Department of Environment and Natural Resources- TDiivvisiionn of Water Quality
WELL CONTRACTOR CERTIFICATION #
1
lI. `_
Individual) Name
r
Wellontractor Compan�y a
STREET ADDRESS/�% ryG/rl �r•t�l _
f 7 F-�y E
Citr or Town State
Zip Code
Area code_
Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)xaQQ
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED // ' /i/=—
TIME COMPLETED -7 'DJ
---�__ AM ❑ PM p--
3. WELL LOCATION:
CITY: 4c:e
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code
TOPOGRAPHIC / LAND SETTING: )
Qope ['Valley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE ' i— %/ ; 7m0 May be in degrees,
LONGITUDE I Z. minutes, seconds or
.y(p n a decimal format
Latitude/longitude source: ['.OIS
U
(location of we; must be shown on a USGS to amp ndp
attached to this form snot using GPS) map end
4. WELL OWNER
OWNER'S NAME
�S REET ADDRESS 40 T-i—
�{e!/i/�e
NC n
City aTown State
r ,2 '/��� Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 0 5`
a/rd
COUNTY
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS
'Top of casing terminated al/or FT. Above Land may Surface*
a variance in accordance with below
NCAC 2C 01 require
e. YIELDt18.
(gpm): '7=. METHOD OF TEST 1 h rl
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 60
Fr.
Submit the original to the Division of Water Quality withi
1617 Mail Service Center-
3 3
f. DISINFECTION: Type %a,->
Amount �t oZ
9. WATER ZONES (depth):
From Jed To
From rr f From
To From
From To
From
6. CASING:
Depth
From O ToCG
From
Diameter
Ft. /Qr—
To Ft.
From To
Ft.
7. GROUT: Depth
Material
FromFrom To�` Q Ft. Cone
To n.
From To Ft.---
8. SCREEN: Depth Diameter
From To Siot Size
From To Ft in. in.
From To Ft.in. in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Material
From
From
10. DRILLING LOG
From To
O C,/
11. REMARKS:
Ft.
To Ft.
To Ft.
Formation Description
Ci
To
To
To
Thickness/
Weight Material
Method
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORD
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PR ACCORDANCE Y`'�
PROVIDED TO THE WELL OWNER.
SIGNATURE ERTI WELL CONTRACTOR
DATE
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Raleigh, NC 27699-1617 n 30 days. Attn: Information Mgt.,
Phone No. [phone] ext 568.
F�2
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
vven r ntractor Company Name
STREET ADDRESS- 7 tT C- y
rS O Ic r4
City or Town State
.rn )Phone numb - S Zlp Code
Area code-
2. WELL INFORMATION:
SITE WELL ID #(if applicable)_
STATE WELL PERMIT/Mr applicable)
DWQ or OTHER PERMIT #(if applicable)
WELLUSE (Check Applicabble Box): Residential Water Supply
DATE DRILLED-- //�'*"&_
TIME COMPLETED//, _'7rn ^'$
Tom-+-.c.L—_ AM Ll pM p
3. WELL LOCATION:
CITY:/t/tf%/ G f%
COUNTY At p
t.Tr
(Street Name Numbers, Com nay. Subtlidsion, Lot No., Parcel, Zip Code)
TOP PHIC /LAND SETTING:
lope D Valley ❑ Flat 0 Ridge 0 Other
(check appropriate box) �--
LATITUDES/J..1r
LONGITUDE AAI asSys,.
Latitude/longitudesourcce ert;'S 0 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
S?jEET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
City or Town
State Zip Code
$( ,fone8-Dolo9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: _gQ b. DOES WELL. REPLACE EXISTING WELL? YES 0 NO IV........
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING 1S __L___ FT. Above Land 'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.atthji
e. YIELD (gpm): METHOD OF TEST. 3
DISINFECTION: Typ /
�S 4A[w- Amount-- te2a-
W
WATER ZONES (depth):
m To_,j1�
n To
6. CASING:
Depth n Thickness/
From_ Toad Ft. D/AW-i/tgh;�,5
From To Ft. 5-r r�fccC4
From
7. GROUT: Depth
Material Method
m
FroTo_2Q FL Col _
From To Ft
From To Pr
Diameter Slot Size
Ft. in. in.
Ft in. in.
Ft. in. in.
SAND/GRAVEL PACK:
Depth
From To
From To
From
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'EEN PROVIDED TO ;WELc NE
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
3'J1g3

RESMENHAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
vven r�ntractor Company Name —Y
STREET
'' AADDRESS,
City or Town Stale
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)_
DWQ or OTHER PERMIT #Qf applicable)_
WELL USE (Check Applicable
-Box): Reside,
DATE DRILLED
3. WELL LOCATION:
CITY: M//sfre ! COUNTYCigA--
(Street N
me, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP R4PHIC / LAND SETTING:
lope ['Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE,�3S M , 3n6 _ May he in degrees
LONGITUDE fpnr . minutes, seconds or
in a decimal format
Latitude/longitude source: PS ID 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 S L r
STZET ADDRESS
J�s'ru. a <Ad
City or Town State
+y Zip Code
Area code - Phone number'�'--
5. WELL DETAILS:
a. TOTAL DEPTH: G C—
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO tL
c. WATER LEVEL Below Top of Casing:
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Ld Surface'
'Top of casing terminated at/or bet land surf ce may require
a variance in accordance with 15A NCAC 2C .0118.
e, YIELD (gpm): _bQ_ METHOD OF TESTq
f. DISINFECTION: Type,. ���n ���
{�.� Amount
g. WATER ZONES (depth):
From
From TD--��- From T
From To T From t
To
Depth r Thickness/
Di ter Weight Material
Frorn_SL To _ Ft. t atizaS /I/C SAR.t/
From To Ft.
From To_ Ft.
7. GROUT: Depth
Material
From To_2 Ft.—j.
From To Ft.
From To Fr
SAND/GRAVEL PACK:
Depth
From To
From
From Tn
10. DRILLING LOG
From To
_Isar _
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.
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.
Fort GW-la
Rev. 7/05
S°c94

1. WELL CONTRACTOR:
RESIDENTIAL WELL
North Carolina Department of Environment and NaturalesoRUes DONon o f WORp
ater
WELL CONTRACTOR CERTIFIC ATION$WELL
�
City or Town State
A82code-
3 1 __�z`
Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(Happlicable)�_
DWQ or OTHER PERMIT #(tf applicable)
WELL WELL USE (Check Applicable Box): Residential Water Supply ge
DATE DRILLED �/=
6
TIME COMPLETED 7;-.0O
3. WELL LOCATION: AM O PM [}�
CITY: At:
COUNTY
(Street ame. Numbers. oma, Community. Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Bdlope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) —�
LATITUDE 3 f" .7G, T—r f • May be in degrees,
LONGITUDE y z J7 minutes, seconds or
= in a decimal format
Latitude/longitude source: EATS
(location of well must be shown on a O GS Topographic
andp
attached to this form !not using GPS)• map and
4. WELL OWNER
OWNER'S NAME
REET ADDRESS C L"♦•C7�rl�;i
City or Town Stale
Area cods) Phone _42"`—�0 a
tuber
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use'.' if Above Top of Casing)
Zip Code
Zip Code
YES ❑
42'
d. TOP OF CASING IS
'Top of casing terminated al/or belowAbove Land may Surface*
a variance in accordance with 1 NCA 2Csur.01 require
NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST It ti
From 4.40
From
6. CASING:
0
From
From
From
f. DISINFECTION: Type %av
Amount=i
g. WATER ZONES (depth):
From /2r To
From
T From
To From
Depth
To ✓7
To
To
7. GROUT: Depth
From__ To
From To
From To
8. SCREEN: Depth
From To
From To
From T
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
11. REMARKS:
To
To
To
Thickness/
Weight
rO.P4
Material
„sig.
Diameter Slot Size Material
FL in.
Ft. in.
Ft.in.
Size Material
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONS
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, CONSTRUCTED THAT
A COPY FAHIS WITH
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
..� THATA COPY OF THIS
SIGNATURE OF ERTID• ELD CONTRACTOR i' / ' kir
- DATE
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. 733-
919
Y
( ) 7015 ext 568.
Form GW-la
Rev. 7/05
3v

SgE
1. WELL CONTRACTOR:
Contractor
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well ontractor Companye
Individual) Name
�.rd uh1
STREET ADDRESS-
,3
—t I'
City or Town State Zip Code
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/flit applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 0 /7 QG
TIME COMPLETED y : 0 y�
3. WELL LOCATION:
CITY: %Gory}..
COUNTY r_ ,,,,.
.412
(Street ame, Numbers, Cwnmuni
H. Subtlivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope CIValley 0 Flat r7 r<Cidge 0 Other
(check appropriate box)
LATITUDE 3 r5-_
LONGITUDE P
Latitude/longitude source: tat ❑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-
S^REET ADDRESS
City or Town State
Area code - Phone number —T'--
5. WELL DETAILS:
a. TOTAL DEPTH:
(Use ".' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land
��—
'Top of casing terminated at/or below land surface maySrequir
e variance in accordance with 15A NCAC 2C .0118.require
e. YIELD (gpm):
METHOD OF TEST) .rrl ,ra
"9
AM ❑ PM El -
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c• WATER LEVEL Below Top of Casing: at
FT.
r3351?g
f. DISINFECTION: Type /c; .'x Amount '/2 wt
g. WATER ZONES (depth):
From 7 To
From To
From To
From To
From To
From To
6. CASING:
Depth Thickness/
Diameter Weight Material
From To Ft. L,ik sDht/
To Ft
From To Ft.
7. GROUT: Depth
From__ T
From To
From To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
To
10. DRILLING LOG
From To
11. REMARKS:
���,, Material
Ft. COS%
Ft.
Ft.
y�v�e'' d
Method
J
Diameter Slot Size Material
Ft. _in.
in.
Ft in. in.
Ft. in. in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
0.7
SIGNATU E OF ERT F ED WELL CONTRACTOR
DATE
a4
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. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECOD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
WeIIyontractor Companyyy 3a `!
STREET ADDRESSr/% /t'Cbi 1 ° I JJ
City or Town fat of r1
State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
STATE WELL PERMIT/krapplicable)
OWQ or OTHER PERMIT #(I( applicable)
WELL USE (Check Applicable Box): Residential Water Supply lG DATE DRILLED #4/ Zp 0_
TIME COMPLETED
AM 0 PM 0
3. WELL LOCC�ATION.
CITY: .7/r "Yr. -
COUNTY�t
e„,,4 f e e -
Numbers. Community. l
(Street
6 btl slon, lot No., Pareel, Zip Code)
TOPOGRAPHIC / LAND SETTI G:
❑Slope °Valley ❑Flat Rclge °Other
(check appropriate box)
LATITUDE 3 y e ra May be in degrees,
LONGITUDE i L �— minmes, seconds or
iOt' c a a decimal fortnat
Latitude/longitude source: t? S °Topographic map
(bcatbn or well must be shown on a USGS topo map and
attached to this form loot using GPS)
4. WELL OWNER
OWNER'S NAME
S 'EET ADDRESS
City or Town �
Area State
}am m gd
Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: (.r '
e. YIELD (gpm);
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
er-
c• WATER LEVEL Below Top of Casing: �d
(Use "+" if Above Top or Casing) FT.
d. TOP OF CASING IS FT. Above
'Top of casing terminated at/or below and surfacLand
ma ❑ace'
a variance in accordance with 15A NCAC 2C .0118. Y require
METHOD OF TEST / . + 'l
f. DISINFECTION: Type ete.,- .
Amount
g. WATER ZONES (depth):
From /%'o To
From t :f From
To From
From To
From
6. CASING:
From
From
From
To
To
To
Thickness/
Weight
Material
.wiz.
7. GROAT: Depth
Material Method
From�_Toy-�p Ft. �.O�f�,
From T 4
From To Ft.< T
8. SCREEN: Depth
From To
From To
Fran T
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To
Ft.
10. DRILLING LOG
From To
- SW
11. REMARKS:
Diameter Slot Size MaterialFt.in. in.
in.
in.
Ft.in.
in.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCT/ONSTANDARDS, AND
RECORD HAS BEEN PROVIDED TOOTHE WELL OWNER. THATA COPY OF THIS
SIGNATURE OF CERTIFIEWELL CONTRACTOR / D E
DATE
• A-
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center _ Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
RESIDENTIAL WELL Co
North Carolina Department of Environment and Natural ResouurcesTDivision RECORD u
WELL CONTRACTOR CERTIFICATION g ter Quality
vvensronlractor Company Name
STREET ADDRESS
3. WELL. LOCATION:
CITY: ZeS C e's <si
( COUN7 yr.4,�,y
V 1•tiy
(Street Name, Numbers, Community, Subdivision,
TOPOG LW No., Parcel, Zip Code)
RAPHIC /LAND SETTING:
aSTOpe 0 Valley ❑Flat Cl Ridge ❑Other
(check appropriate box) -�
LATITUDE 3 f—zZ r May be in degrees,
LONGITUDE cr—minutes, sec fonuat
S'cn � in a decimal format
Latitude/longitude source:
❑ topaphp mdp
(location to this
be ofshown on a USGS topo map and
attached to This form Trot using GPS)
4. WELL OWNER
OWNER'S NAME
ST ET ADDRESS
(DnQJ�iI
�Q�� City or Town State
�5 �-' XLl4/ Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#(0applicable)(3DD — /
STATE WELL PERMIT#(irapp6cable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Su
DATE DRILLED . ppty d�
TIME COMPLETED I ; 00
AM ❑ PM [[�
City or i State
Zip Cade
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: y `
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS _1__
FT. Above Land Surface*
'Top of casing terminated at/or be/ow land surface mayrequire
a variance in accordance with 15A NCAC 2C .0118
e. YIELD (gPm).
METHOD OF TEST1F .."
9
Submit the original to the Division of Water Quality within
1617 Mail Service Center-
6. CASING:
From 0 Depth Diameter
From To J4/ Ft. l../lr
To Ft.
From To
Ft.
7. GROUT: Depth
Material
From To_$Q Ft. �:0=c
To
From To Ft ---
335' 98
Amount ✓i
8. SCREEN:
From
From
From
Depth Diameter Slot Size
To
To Ft.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
11. REMARKS:
f. DISINFECTION: Type ride./
g. WATER ZONES (depth):
From___© To
From
From /_ To From
From To
From To
Thickness/
Weight Material
Method
lakcatisi
Size Material
Material
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE MTH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF �I1/EQy ERTIFIED WELL CONTRACTOR DATE
•� 4 �.
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Raleigh, NC 27699- 30 days. Attn: Information Mgt.,
1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourr es - Division of Water Quality - Groundwater Section
•
WELL CONTRACTOR (INDIVIDUAL) NAME
�(print)
\L(L q�
WELL coNTRAcron COMI'ANS' NAME TT W J ,�(/t�l/ft-rL —f�. ,n CERTIFICATION #vYIO et?
(Y
STATE WELL CONSTRUCTION PERMED/
(if a »licable)
(_)-
Area code- Phone number
4. DATE DRILLED K) deica
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O---" -'-
7. STATIC WATER LEVEL Below Top of Casing 4__FT.
8. TOP OF CASING IS (Use -sif Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC IC .0118.--------
9. YIELD (ZON , t METHOD of TES.L�'7A
10. WATER ZONES (depth):
PRONE # US) 03 72a,3
ASSOCIATED WQ PERMIT#
(if a..licable)
1. WELL USE (Check Applicable Box); Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other ❑ tf Other, List Use
2. WELL LOCATION:
Nearest Town: !)li�CG1Z
CD�'iii7�lldl.l County(
(Street Name. rbera, C nity, Subdivision, Lot No., Zip Code)
ortnf�."
3. OWNER: AA
Address Y
1 (Street or Route No.) S
City or Tow State Zip Code
11. DISINFECTION: TypeaX(j(4.
12. CASING: Amount
Wall Thickness
Depth Diameter or Weight/Ft. Material
Prom -6 1 ng_4_ Pt.
Prom 7o Ft.
From To FL
13. GROUT: Depth I Material (.� Method
From To Ft.�T �'='-K LAX -
From To I . F
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.
Slot Size
in.
in.
I6.REMARKS:
Material
Topogra is/Land setting
DRidge t9'Slope DValley ❑Flat
(check appropriate box)
Latitude/longitude of w II 1 cation
N35°L35 cc3� Wo 3, S
(degreesiminutes/seconds)EJ1/ '/05--
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDA .,J S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL /• 6 /O(0
D E
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 clays.
GW-I REV. 07/2001

STATE WELL CONSTRUCTION PERMIT#
(if a> )licable)
). WELL USE (Check Applicable Box): Residential P/ Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection ❑ Other O If Other, List Use
2. WELL LOCATION:
Nearest Town:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CO.N'17tACrOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME rin�` y G(Z �j (+A/� "Tir, CERTIFICoA�TIION#
PHONE # M.) 3-r'fa `�ir
ASSOCIATED WQ PERMIT#
(if at licable)
• ���91urA •
(Street Name, Numbers, Community, Subdivision, Lot No' Zip Code)
3.OWNER:
Address
Street or t e No.)
City or Town Stat
(—_)'
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH
County ctri.{ 1{
Zip Code
Topoggra Ic/Land setting
❑Ridge WS)ope ❑Valley ❑Flat
(check appropriate box)
/0Ion itu0d of II &at' n�,�
(degreeshninntes/seconds)S6v 3105
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
To Formation Description
La
DEPTH
From
6. DOES WELL REPLACE EXISTING WELL? YES O NO CC
7. STATIC WATER LEVEL Below Topof Casing: Ad____FT.
(Use .� " if Above Top of Casing)�---
8. TOP OF CASING IS _ J _ FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NC.4C 2C .0118.
9. YIELD (gpm): � METHOD OF TESTi
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
1 rom—la Ft
From I o
From To
13. GROUT: Dept
From To 0 Ft
From Tor Ft
14. SCREEN: Depth
From To
From To Ft.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To F(_
16. REMARKS:
Ft.
FL
L Co2__ Amount
Wall Thickness
Diameter or Weight/Ft. Material
Diameter
Ft. in.
in.
Slot Size
in.
in
Size Material
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.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STA 'D,ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S 'NATURE OF PERSON CONSTRUCTING THE WELL
D TE
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

Ci/,_ CERTIFICATION # 3
WELL CON'Tli:\CroItcoip.ANyNAME _
(If a> licable) ASSOCIATED WQ PERMIT#
(ifa. licable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL IXI\rRACTOR(INDIVIDUAL) NAAtdE (print)��r%i ��jty
/lw� 7QiZ\�I CR �]
srATE WELL coNsrxLcrloN Pexallr# PRONE # 1r6a8)�o83 as
1. WELL USE (Check Applicable Box): Residential ► Municipal/Public O Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump
9
Depth
From_ to k_ Ft.
Flom 1 o
From To
13. GROUT: Depth
From To
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From To
16. REMARKS:
Water
p Injection O Other O If Other, List Use
WELL LOCATION:
Nearest Town:IzA tie
r3S C-7AY1'1 �1.1 Coon[ (�Cptv�$�
(Street Name. N Subdivision,
ni rCode -�
CC,,��'' Numbers, Community, Subdnsmo, Lot No., Zip Code)
3. OWNER: EbA/i �h•t(
Address
(street or Route No.)
1,1 vtr_L.0
City or Town State
Area code- Phone number
4. DATE DRILLED J062
5. TOTAL DEPTH:
Topogra 'c/Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropriate box)
NtLatitude/I gitude ofw well loc i3°�c,�o8•5.iq
(degreesmtinutesheconds)Elev 2092
Latitude/longitude source: OGPSOTopoeraphtc map
DEPTH (check box)
DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q 7. STATIC WATER LEVEL Below Top of Casing: 6t7 FT.
8. TOP OF CASING IS (Use "+" if Above Top of Casing)
*Topof casing_ L .. FT. Above Land Surface*
terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. -----
9. YIELD (gpm): _[0 M TROD OF TESTrn: ,
0. WATER ZONES (depth): �i• , '� y,cN '---"-�-`I--
11. DISINFECTION:TypeTsi {
12. CASING: Amount Wall Thickness
Diameter or Weight/Ft.
Et.
Matcr" I
Ft.Q Or1Cr ✓'`-tt
— —__
Ft.G `(rpA.l u/t/-
Diameter
Ft. in.
Ft in.
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
Material numbers and common road names.
Method
u
Slot Size Material
in
In.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL U
SATE
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
w'ELL CONTRACTOR (INDIVIDUAL) NAME (print) A �R WnWel/ L/ qq
w'EILCONrRACFORCONIPANy NAME ids r5erv,c 1 I \ CERTIFICATION kp Z(P�eL
-----. a._ WQ Welt PHONE q (O�'�O)l00 U-/�K
STATE WELL CONSTRUCTION PER3IIT6 -7
m..a. - (if licable) ASSOCIATED PERMIT# V'
(ifar.licable) Cy
I. WELL USE (Check Applicable Box): Residential E Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town` AW#fJj 1.�
48A �u cOrmly_Af�f6
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:Ef,l LI1nAsilisp\'5onOl.,
ry
Address
(rect or Route
City or Town State
Area code- Phone number
4. DATE DRILLED_JQL/Q/6CP
5. TOTAL DEPTH:
Topogra /Land setting
❑Ridge ope ❑Valley ❑Flat
(c eck appropriate box)
Latiitude/loonQgittu-d/P VOA
well location
N 3s'II-62.64g YrA'3 .1-/0
(degrees/minutes/seconds) C.tv,267Cp
Latitude/longitude source:OGPSOTopographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 12
7. STATIC WATER LEVEL Below Top of Casing:
Lf:21__FT.
8. TOP OF CASING IS / Oise
FT. if Above Top oSurfCasing)
FT. Above Land Surface* *Top of casing terminated at/or below land surface requires a
variance in accordkagyith I5A NCAC 2C .0118. r� �I
9. YIELD (gptn):jC.ADy- - METHOD OFTESTI'SYYI, ill_ffir (?r)Pie
I WATER ZONES (depth):
1 I. DISINFECTION: Type i Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From .lo ____ Ft.
From 7 o Et.
From To Ft,
13. GROUT: Depth Ma erial
From To Method
Ft.
From FL
14. SCREEN: Depth Diameter
Slot Size Material
From To Ft, in,
in.
From
To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY 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
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, 07/200I
CrZ
C'�

(Slrect or NoT Route
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED jj ZP
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES El NO LIV — 7. STATIC WATER LEVEL Below Top of Casing: FT / —
�.
Use FT. ASurface*
if Top Casing)
8. TOP OF CASING IS Above Land Suace
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
l(depth):
trot LJ
From
From
13. GROUT:
From
From
l4. SCREEN:
From
From To
15. SAND/GRAVEL PACK:
Depth
To
To
11. DISINFECTION: Type
12. CASING:
Amount
Wall Thickness
or Weight/Ft. Material
From
From
16. REMARKS:
Depth Diameter
Et.
l o Ft.
To Ft.
Depth
To
To
Depth
To
Mate al
Diameter
Ft. in
Ft. in.
Ft
Ft
Slot Size
in.
in.
Size Material
Meth gd
Material
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAMEZp „I Q Y-Groundwater Section
(print) R. �11
WELL CONTRACTOR COMPANY NAME
STATE YELL CONSTRUCTION PERMIT#
(ifa tlicable)
ASSOCIATED WQ PER:.IIT#
(if a..licable)
I . WELL USE (Check Applicable Box): Residential - . .
Agricultural ❑
CERTIFICATION #�
Monitoring ❑ Recoveryt nmcipal/Public 0 Industrial 0
O Heat Pump Water In ection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: C,.,,.-e
a�#'a0 (n t+o2
(Street Name. Nonbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER: sI� .Z-C3
Address
Topogra c/Land setting
DRidge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/lon Rude o well location
u 3 g R� Rude,
a€a
(degrees/minutes/seconds) scv A��7
VV
Latitude/longitudesource:OGPSOTopographtc map
DEPTH
From
(check box)
DRILLING LOG
To Formation Description
9. YIELD (gpm) ,rj 42, MF�H�D OF TES �p l
0. WATER ZONES ----__-_.__
LOCATION N SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT f WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AN9 THAT COP° OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit tiie 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
!d Gee

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso
WELL CONTRACTOR (INDIVIDUAL) NAME (print)jjt,l
WELL CONTRACTOt COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if a) [Rabic)
rces - Division of Water Quality - Groundwater Section
ASSOCIATED WQ PERMIT
(ifaicable)
1. WELL USE (Check Applicable Box): Residential n Municipal/Public
Agricultural ❑
Monitoring ❑ Recovery O Heat Pump Water Injection0Other ❑ Industrial List ❑
1 Other ❑ 11'Other, List Use
2. WELL LOCATIION:
Nearest Town:
4_52,Ln
Count
\vt �
(Street Name,Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:,
Address
6. DOES WELL REPLACE EXISTING WELL? YES O NO Q' —
7. STATIC WATER LEVEL Below Top of Casing: O� FT
�.
8. TOP OF CASING [S I (UseFT. bovTop Surfice
land
s r AbovecerLand Surface*
`"Top of casing terminated at/or below land surface requires a
variance in accordan e with ISA NCAC 2C MIS.
9. YIELD (gpm): o METHOOF TESTG[tl _I X4? 10. WATER ZONES (depth): 1 —g
1I. DISINFECTION: Type
Zip Code
Topograp ' /Land setting
❑Ridge ope ❑Valley OFlat
(check appropriate box)
�! /
5 udeoYwlocoti
� i55!'lnor CI,�Q(p�x
(degrees/minutes:seconds) E ei/ b G c
Latitude/longitude Source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
City or Town State
(_)-
4. DrATE ea DRILLEDcode- Phonebe� r I I
5A. TOTAL DEPTH:_(O5
12. CASING:
F rot
From
From
13. GROUT:
From
From
14.SCREEN:
From
From
15. SAND/GRA
From
From
16.REMARKS:
Amount
Wall Thickness
Depth ' Diameter or Weight/Ft. Material
Ib"r37 Ft.
toFt.
To Ft.
Depth3 Mater. I Metho
To Ft.�<
Ton_ Ft
Depth Diameter Slot SizeMaterial
To Ft.
To
VEL PACK:
Depth Size
_To Ft.
To Ft.
in
Ft. in.
in.
in
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION
STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LOCATION
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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
CERTIFICATION �CL-i
HONE # (�.?A)(ai- Z 00
CZ
way
C49

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAN1 (print)
it/
WELL CO:\"I'li:\CrOii COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(ifa. )licable)
CERTIFICATION #ciiou
PHONE # (KAS -9aa�
ASSOCIATED WQ PER,\IIT#
(if a..licable)
I. WELL USE (Check Applicable Box): Residential Y Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATrION:
Nearest Town:
Count)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: a k1 61'€W
A�rtdtdress w1t� ) \Ln /`(•(� In/1 A' t w
Ake'(Slrecl ,RomeNo.)N o.)
City r VVT ''n��LL��YY//de
State Zip Code
Area code- Phone number
4. DATE DRILLED10
5. TOTAL DEPTH:
IVl ao
6. DOES WELL REPLACE EXISTING YES 0 NO EY 7. STATIC WATER LEVEL Below Top of Casing: jo_Q
_FT.
8. TOP OF CASING IS (Use bAbove Top Surface*
land FT.
S r AboveceLand
*Top of casing terminated aUor below land surface requires a
variance in accordance with ISA NCAC 2C.0118. / 9. YIELD (gpm): _I ___ METHOq O TEST `7)1 �/tf �rl---
10. WATER ZONES (depth):
11. DISINFECTION: Type
A
12. CASING: mount.__
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 'Io /_(:)__ Ft.
from to
From To
13. GROUT: Depth Material
From To Method
From Tow e
14. SCREEN: Depth —t�otS Material
ate al
P Diameter Slot Size Material
From To Ft.
in. in.
From To Ft.
15. SAND/GRAVEL PACK: to
Depth Size
From To Ft.
From To Ft.
Topogr is/Land setting
❑Ridge lope DValle
Y ❑Flat
(check appropriate box)
� t�kd,. 6vell ooccaj;oKt
(degreesiminutwes/seconds) Ui v:� / �cd
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
I6.REMARKS:
I.I.
Ft.
in.
Material
LOCATION
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C,
CONSTRUCTION STANDARD , AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
6
ATE
`--
�TE
"
Submit to 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
.12

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalrResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME. (pript) t_.fiez WQ�,1$
/nt w ,(Cv h CERTIFICATION p#B4o �
\WELL CON'rR:\CPOR COMPANI' NAD1E yJ�/! I C� I =Af C r PHONE 1/ B.YD)t003' Jnt/x
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERh/1T#
(if applicable)
fit applicable)
L WELL USE (Check Applicable Box): Residential IB 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: 31 De County
�, qGS
ark
(Street Name. Numbers, Communit,Subdivision, Lot No., Zip Code)
3. OWNER: Q-11/,5��O.;yy i eQ-(
Address PD W(ti 6 t 61
(S reel or Route No.)
�Jslw'1!� NC, p.?8.8/6
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED /%�33/0C,4)
5. TOTAL DEPTH: 5c 'i'r
6
Topogr ic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude pf well location
N55 `33 /53 WierS,2 / m'' (degrees/minuteslseconds)6/EV 25//
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
DOES WELL REPLACE EXISTING WELL? YES ❑ NO CY
7. STATIC WATER LEVEL Below Top of Casing: 1.20 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
variance in accordane vith ISA NCAC 2C .0118.
9. YIELD (gpm): 1. METH D OF TESTGriL ,C:[�A/71'i�(i'
10. WATER ZONES (depth): /2r0
11. DISINFECTION: Type 6IC`tt Amount oZ
12. CASING:
Wall Thickness
Depth, Diameter or Weight/Ft. Material
From 0 Too. ir Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From To
From To7'7" 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.
16. REMARKS:
Slot Size
in.
in.
Material
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 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION S'{AARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA E
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service. Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001
CEJ
elt
eleD

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Lnez/ `rI i(4
CERTIFICATION # ON,
WELL CONTRACTOR COMPANY NAME AW 5111Vt(,e-t3)� C, PHONE #ivs)wS3-t.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT#
(if applicable)
�� (if applicable)
1. WELL USE (Check Applicable Box): Residential L�l Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearet Town:Canaftc
57s(Cbt5tf, 6L,kg n aCounty/ ✓tas> t&Q,
•
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER:
Address
6(kfty . fin aert i1/44
(Street or Route No.)
City or Town Slate Zip Code
( )-
Area code- Phone number /
4. DATE DRILLED I (jb (64
5. TOTAL DEPTH:
Topogra fc/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latit de longitude of a location
N. t35�, .16 /6 l ita. 35 3
(degrees/minutes/seconds) Jey:253z
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: )aa 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 ISA NCAC 2C _011S. /�
9. YIELD (gpm): { 6 ME ,OD OF TEST (Z4/ a/)7 4,
0. WATER ZONES (depth): 1200
11. DISINFECTION: Type P(31f , f. Amount 02._
12. CASING: Wall Thickness
`� Depth Diameter or Weight/Ft. Material
From T7- To 11 A Ft.
From To Ft.
From To Ft.
13. GROUT: Depth ,, Materia
From 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.
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.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL J CP
DA{E
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and atural Resource - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
et Li aI''(-4 CERTIFICATION ##e 603.
WELL CONTRACTOR COMPANY NAME I t VY V sertI 'c,$) ZJUC • PHONE # t�ySo 825'9Attat
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
of applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCH 10 '���,���
Neare r T wn: tealttiG County, ttULufrtM JU/
J(5pd. ?a.
(Street Name. Nu ers. Conintnity, Subdivision, Lot No.. Zip Code)
3. OWNER: �y� . rnC c esA/
Address i3W ( R e Dfl'r,
c4hbfi/l[N (Street Ro_uteno.)
City or Town State Zip Code
( )
Area code- Phone number / �
4. DATE DRILLED a 0 4p
5. TOTAL DEPTH: I.7r
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO (t�
Topogra c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box) {.af Atreia � w I, j _ $X isy
N (degrees/minutes/seconds)E/cr !G'
Latitude/longitude source:❑GPS❑Topograph c map
(check hox)
DEPTH DRILLING LOG
From To Formation Description
7. STATIC WATER LEVEL Below Top of Casing: 16C) 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
variance in accordanceqwit ISA NCAC 2C.0118. n
9. YIELD (gpm): I L7,: METRO OF TESTls7i l• eI I-ainf/t
10. WATER ZONES (depth): / 5 5
t I. DISINFECTION: Type7f4A>IQti+ Amount A
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From C— To 9e3 Ft.
From To Ft.
From To Ft.
13. GROUT Depth Material Method
From To . 3 FI. _ nC (�. iT
From To / Ft SWAM
Y�OL(,V
14. SCREEN: Depth Diameter Material
From To Ft. in.
From To FL in.
Slot Size
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
•
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC 1 ED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
E
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environs
ent and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if a .licable)
ASSOCIATED WQ PERMIT#
(ifa. licable)
WELL USE (Check Applicable Box): Residential 42� miicipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat
Pump
Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
Count c,.nnce
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
City or Town Stare
Area code- Ph
6
7. STATIC WATER LEVEL Below Top of Casing: AFT
8. TOP OF CASING IS I (Use if Above Top of Casing)
FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accord c vith IS.A NCAC 2C .01IS.
9. YIELD (epm):_ MFrTHQROF TES
10. WATER ZONES (depth):
I1. DISINFECTION: Ty
12. CASING:
Depth Diameter
From & To Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Materia
From To�4114
To_t _ Ft A� , f WS etho.
From _ Ft emostii' La
14. SCREEN: Depth Diameter
From To Ft.
From
P
Amotmt �o—
Wall Thickness
or WeighVFt. Material
in.
To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
Slot Size
in.
in.
Size Material
Material
one number
4. DATE DRILLED
5. TOTAL DEPTH:
DOES WELL REPLACE EXISTING WELL? YES 0 NO �----
Topogra c/Land setting
ORidge lope OValley ❑Flat
(check appropriate box)
L tutel tu4S9fyeij 1
(degrees/minutes/seconds) V c CV
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
From To Formation Description
DEPTH
CERTIFICATION pp# 63
PHONE # t2f0'(�) S' MIis.7
LOCATION
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STAN r DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/1
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATa
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
-rt
OC
OC
a1
CC
C

3. OWNER:
Address
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and ,Na, ,tau/ral Resources - Division of Water Quality - Groundwater Section .
WELL CONTRACTOR (INDIVIDUAL) NAME (print) W Frie
CERTIFICATION
N�o#r.a�� , ..
WELL CONTRACTOR COMPANY NAME /VD PHONE # ODlA)`rq�' Irao�
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): ResidentiatV Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Nearest Town:
County_�b
�36 C bj t ' J <A4
(Street Name. Numbers,
Community, Subdivision, Lot No.. Zip Code)
t-6V1hh'1 hnDtcscs j,
ON:
(Street or Route No.)
City or Town State Zip Code
( )-
Topo ic/Land setting
❑Ridge lope DValley ❑Flat
��(( (check appropriate box)La�✓f/,
IV3t5d310.38�ofwkl((g �ty9 9JT
��(QO��Sp�� 77,�''� '
(degrees/minutes/seconds) eel. 2 Q 9
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number
4. DATE DRILLED 11 ) I 0 4
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: f 00 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 ISA NCAC 2C Ai I8. //''11 (�� ,,,/
9. YIELD (gpm): "OD M'TA(1D O TESI� JAI, l OI) i-irc
0. WATER ZONES (depth): � p %�51 Y
11. DISINFECTION: Type //d' C- Amount
12. CASING: Wall Thickness
� Dept / Diameter or Weight/Ft.
Frolx� Tc(� Ft.
From To Ft.
From To Ft.
13. GROUTA Depth
From To 0
From ToI
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
material
Ft. )IL. 20,,((
L, .I7r'
Ft
Diameter
Ft. in.
Ft. in.
16. REMARKS:
Slot Size
in.
in.
Material
Material
Material
T1
rn
1,0
r-•.s
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STAI45»DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE ELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
l/
AT
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Canpany Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 ). 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Br: Residential Water Supply 13
DATE DRILLED 11 [ 07,0 10 /
TIME COMPLETED 11'- 0 D AM LN PM ❑
3. WELL LOCATION: Q
CITY: u� J IL.(--& COUNTY Er Utem 66
CD l-Nklp- 4 d pi-(tsp- R D 4 hlwy A5-70
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN ETTING:
❑Slope ❑Valley at ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 4 4- -q 16
LONGITUDEL31. ab r�
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form i/not using GPS)
4. WELL OWNER r7 "
OWNER'S NAME Qb 3 B P— (/w top-1
May be in degrees, I
minutes, seconds or
in a decimal format
STREET ADDRESS S kb Lb r3 6 6I) Ai e (Z„b
W Cra t;- ,d) L.L(s- NC (Mta)
City or Town State Zip Code
( va()- ‘4-5 — 4-br
Area code - Phone number
8. WELL DETAILS: n
a. TOTAL DEPTH: J 4'5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M1j
e. WATER LEVEL Below Top of Casing: O FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1/ FT. Above Land Surface*
*Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. a YIELD (gpm): METHOD OF TEST t — ry I1n-.
L DISINFECTION: Type 1t1 6 jo Amount
g. WATER 2QNE3 (depth):
From 21 ) To G Z '�
From To
From To From To
From To From To
to 0
8. CASING: ,,/ �t Thickness/ Met
D )(X Zi er St t Met
From To Ft.
From To Ft.
From To Ft.
7. GROUT: Depth
c�11
Material
From '4- To rap Ft. e- 6 pi t
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 FL
From To FL
Method
in.
in.
in.
Material
Size Material
.1
coT
7,\7
10. DRILLING LOG
Front To 13
(13'— R 5
a1,51- aiat'
a313' - 3 -5'
11. REMARKS:
c:s
Fovnation Description
0.14e(-au (tto
4r�V `ce t- 4-0 Gfjn
/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED M ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY r)F THIS
RECORD HAS BEEN PROVIDED TO THE WELL
.PI
OWNER.
/`xRM_^j
P(/f.ERTIFIED WELL CONTRACTOR
SIGNATURE O
rJ IGrute s. A c�t4
PERSON
PRINTED NAME OF PERSON ONSTRU TING 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 # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Indi idual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City a Town State Zip Code
82t 8 ,_ 254-3581
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(Rapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box : Residential Water Supply rV
DATE DRILLED 1( O 17 /
TIME COMPLETED n o AM ❑ PM f9/
3. WELL LOCATION:
CITY: Wat__sRA) ILL f3
COUNTY 6v11 fA^`r00
414 C1-AR-1LS c14Mai I-, At -
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPQGRAPHIC / LAND SETTING:
lope OValley ❑Flat ID Ridge ❑Other
(check appropriate box)
LATITUDE .L 5 4 3 .8'S9
LONGITUDE B a ILA-e_
Latitude/longitude source: Er PS ❑ Topographic map
(location of well must be shown on a USGS tmpo map and
attached to this fine #not using GPS)
4. WELL OWNER �
OWNER'S NAME S CO 1 nn `r rW en. s t t. G
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS
City Tom State Zip Code
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 40 5
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO I
c. WATER LEVEL Below Top of Casing: g 0 FT,
(Use `+" if Above Top of Casing)
d. TOP OF CASING IS FT. Abae Land Surface*
*Top of casing terminated ado below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): _i_ METHOD OF TESTII_G_AI Q.�
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.
f. DISINFECTION: Type
9• WATER ZONES (depth):
From f 5 5 To '1(;j 0 From,
From_33±.1 To 135 From
From To From
8. CASING: Thickness/
Depth D'a er Weightoal
From 1 To I (S6 Ft. yr`
From To Ft.
From To Ft.
6 Amount
7. GROUT: Depth Material
From 1.
From To Ft.
From To Ft.
Method
• J(Lp _D
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. �T
10. DRILLING LOG
Fr e To S / Formation Description
DJ�(�6uG2O$f�
q5=t55S ' �C iraiY(,
1551- 1bo ' C
1 C r'3i't
tg
11. REMARKS:
r�ti r,R .
FEB21 2007
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AN
RECORD HAS BEEN PROVIDED TO THE WELL OWNERO hIATA COPY OF THISr
SIGNATURE OF CERTIFIED WELL CONTRACTOR D E
oRs
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
r
C
0.:
ram GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and Natural Resdurqes/ - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
^(print)
WELL CONTRACTOR COMPANY NAME /1t6JUAl/RAI/1M CERTIFICATION HA�r
S'I :ATE WELL CONSTRUCTION PERMITU Tr
(if applicable) ASSOCIATED WQ PERMIT
3. OWNER: CD lms
Address rg�ta j..(Q(COW L Q-Wej NC
(degrees/minutes/seconds) s`,tp* a5 .3
"�rL Latitude/longitude source:❑GPS❑Topographicmap
af+n IVLJ Zip Code 6- (check box)
City or Town State From DEPTH
To DRILLING LOG
(—.)-Formation Description
Area code- Phone number
4. DATE DRILLED10/3/Oho
5. TOTAL DEPTH:,,' 5" r 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1;
7. STATIC WATER LEVEL Below Top of Casing: FT.
8. TOP OF CASING IS , (use "+^ if Above Top of Casing)
FT Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordanawyikS,h 15A NCAC 2C .0118.
9. YIELD (gpm): a V METHOD OF TEST api/. riwi tAJcP
10. WATER ZONES (depth): 165 '\
(i f applicable)
ONE R (0A 63-7flCeD
to
CY
Crab
1. WELL USE (Check Applicable Box): Residential El-Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring U Recovery ❑ Heat Pump Water Injection ❑ Other 0 if Other, List Use
2. WELL LOCATION:
Nearest Town: et,701)Icbc, County T3oNa, Topo,�gra•Bhic/Land setting
❑Ridge Mope ❑Valley ❑Flat
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code) (check appropnate box)
LaN3S 3/1n 4detoo y necon
r
11. DISINFECTION: Type
12. CASING:
Slot Size
in.
15. SAND/GRAVEL PACK: 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
Material numbers and common road names.
Amount a
Wall Thickness
Depth Diameter or WeighVft.
From e - To 1__aa Ft.
From To Ft.
From To Ft.
13. GROUT: Depth �Maater al
From To 3F I r`X.IL1i.Q,
From To ( Cy F
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
16. REMARKS:
Material
ai! Dr%! ;
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TF AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O'
SIGNATURE OF PERSON CONSTRUCTING THE WELL d v
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 CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CON'TRACTOR(INDIVIDUAL) NAME (print) CILI
a a CERTIFICATION # a(D n
WELL CONTRACTOR COMPANY NAME I ► .(1hi /i!/ /r://' • yq �+rf �t�
_._. PHONE # Igggi:833'�l9a3 STATE WELL CONSTRUCTION PERMIT#
(if applicable) ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential @Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 if Other, List Use
2. WELL LOCATION:
Nearest Town: :� County � P.
(Street Name. Numbers. Community, Subdivision, Lot No.. Zip Code)
3. OWNER:t 11S �i`-r�qM
Address (p
Citab
^ , ^^�¢� (Street or No.)
eg-LetJ ICY V A8l4- g
City or Town Stare Zip Code
( )-
Area code- Phone number
4. DATE DRILLED_
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO .E
7. STATIC WATER LEVEL Below Top of Casing: IN) FT.
8. TOP OF CASING IS I (Use •'+" if Above Top of Casing)
FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordytwjvtth ISA NCAC 2C .01(8.
YIELD m accords
�
Topographic/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longit eofwelll cat'o
la•35' 33. cSB2 tn(�6�, �l.q
3'T
(degrees/minutes/seconds) EIe , '' los
Latitude/longitude source.❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
9. (gP ) METHOD OF TES AI • hi J-
10. WATER ZONES (depth): I (PE a5O
1I. DISINFECTION: Type Ig( 4
12. CASING:
Depth Diameter
From To a(0 Ft.
Amount R
Wall Thickness
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
or Weight/Ft. Material numbers and common road names.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From To 3. �'l'f�
O
From To I�Ft
' Ft���G � 1.1Kt
14. SCREEN: Depth Diameter Slot Size Material
From To FL in.
in.
From
'lb Ft. in. in.
15. SAND/GRAVEL PACK
Depth
From To
From To
16. REMARKS:
Ft.
Ft.
Size Material
1 DO HEREBY CERTIFY THAT THIS \ ELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEI.f. -.
ATE'
Submit the orie nal 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
6
:l
CD
0
rt
cet
eft

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naatuura���l Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) '''W04
WELL CONTRACTOR COMPANY NAME Ap,,,.� �,/Q,(� ���/�f` �- - '\CERTIFICATION k26,04
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
ONE #$4)433- 4,94-
I. WELL USE (Check Applicable Box): Residential lsV Municipal/Public O Industrial ❑ Agricultural O
Monitoring ❑ Recovery O Heat Pump Water Injection ❑ Other O if Other, List Use
2. WELL LOCAT%ON:
Nearest Town: TaWVCei / untyt".S4.1.104SAASL
4S
(Street Name,, Numbers, Community, Subdivision, Lot No., Zip Code)
I'If
3. OWNER: it Et (6 No.,
Address CAA- OVAL�W^v„ei
zmi, . rreet o[ RR No.) p
Y (naJSI State
2 6 l J
City or Town StatZip Code
(
Area code- Phone number
4. DATE DRILLED 41a 8 i6(p
5. TOTAL DEPTH: 11."5/
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IV7
7. STATIC WATER LEVEL Below Top of Casing: 5 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 h 15A NCAC 2C .0118.
9. YIELD (gpm): —� METHQpD OF TESIGAI • Ci A(
10. WATER ZONES (depth): eco, bad (/ 0 t'
Topogr c/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
ud Latitude/longitude ofwe I location, �b oa`� t554-�F
(degrees/minutes/seconds) E L v , 30(.o g
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
11. DISINFECTION: Type—Mt—art/Amount
12. CASING:
Depth Diameter
From To t�( Ft.
From To Ft.
From To Ft.
13. GROUT: 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
Wall Thickness
or Weight/Ft. Material
Slot Size
in.
in.
16. REMARKS:
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.
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 OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA E' V
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 RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140 )
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Cade
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(i(applicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applic e B • Residential Water Supply ❑
DATE DRILLED { 3 C
TIME COMPLETED i - g 0 AM ❑ PM I
3. WELL LOCATION: Q1 CAA�TION: Q
CITY: N tsUjt COUNTY 6E4J a rnigg
3 a k 1tr CtJSW Cz V' ,fcAb
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / ING:
❑Slope OValley at DRdge ❑Other
(check appropriate box)
LATITUDE _t, 5_ 30.5 +a
LONGITUDE a 4 6 454-
Latitude/longitude source: WM'S ❑ Topographic map
(bcatbn of wet must be shown on a USGS topo map and
attached to thk form #not using GPS)
A WELL OWNER OWNER'S NAME J o L. 1 r ryrt� i i) IA-'
STREET ADDRESS 3 c a_ 0 CC U GTis CF es %t„c Aid
&AtD i'jt tn15
City a Town State 2 Code
(51$) b65--a615
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO E
O
c. WATER LEVEL Below Top of Casing: Q P 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 aredance with 15A NCAC 2C .0118.
e. YIELD (gpm): tiE O METHOD OF TEST (1,1G - A le.,
From dD5
From
6. CASING: Thickness/
Depttl Diameter Weight Material
From To 1 t) Jam' Ft.
From To FI.
From To Ft.
`'36508
f. DISINFECTION: Type G Amount n o
-
g. WATER ZONES (depth):
From t 1 5 To i 2 0 Fran To
To a) O From To
To From To
7. GROUT: Depth Material Method
From 1 To a o Ft. C.t••'M k N T Pc u-ee D
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
From
From
From
Material
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
Fro r T r Fgrmation Description
— 0 D 0 V e f-Bv{L.pg 0')
OOr^ t V ' 62q..)tat
ao5r- ato' e AteNStcs - ao Ggm
Ztt ' -- 'a 45' CbRA t-) t`T6
11. REMARKS:
RECEIVED
IAN R) 4 luur
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO 'THE WELL OWNER.
asAibe.A, )a1)g 0,6
SIGNATURE OF�ERTIFIED WELL CONTRACTOR / DATE
1 kLk BJ & 3,41
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

RESIDENTTAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Inclividua) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )- 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID /88 applicabe)
STATE WELL PERMIT#(t applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable B : (Residential Water Supply'g�
DATE DRILLED 1 0 \ ra O 41U
TIME COMPLETED \ - ✓ AM ❑ PM
3. WELL LOCATION: l2ny,�, ,_
CITY: tAY-ODAJ { (rCOUNTY IO�n1C0(n ig
9.`/ (l-sry e
(Street Name, Number,, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley anct :Midge ❑Other
(check appropriatebox)
LATITUDE _3_ 5_ J-j -
LONGITUDE `d. b _ t i (D
Latitude/longitude source: .2.6113- ❑ Topographic map
(location of wet must be shown on a USGS topo map and
attached to this fomr not using GPS)
4. WELL OWNER ,n/ `
OWNER'S NAME 1 Vie-4 - ` G L �j )05
STREET ADDRESS ASa."t ?u4 t' le-- L.LA NE.
N 1/4c-L� Nit, alei 4
City or own State Zip Code
( 1. } ea 6 1_ O (aLA
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
May be in degrees,
minutes, seconds or
in a decimal format
b. DOES WELL REPLACE EXISTING WELL? YES °
c. WATER LEVEL Below Top of Casing:
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS Ai. FT. Above Land Surface•
'Top of casing terminated aVar below land surface may require
a variance in accorpance with 15A NCAC 2C .0118.
NOV"A
FT.
e. YIELD (gpm): METHOD OF TEST (La) -A t
f. DISINFECTION: Type
g. WATER ZONES ((depth).
From SD O Toll
To
From
From
6. CASING:!
ip8),
From - DTo `f FL ?Sra
From To Ft.
From To Ft.
To
Amount
335507
/OZ
From To
From To
From To
Thickness/
7. GROUT: Depth Material Method
From -.. To RID Ft. l'.ticv T Ebt.:9Q
From To Ft.
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To FL
From To Ft.
n.
in.
in.
Size Material
10. DRILLING LOG
Fro a To /
1
:3(0KI
31 '— 4-oS'
11. REMARKS:
Formation Descliptio
o fwr�c3�,
eq, tec?—s' GFrt
n-, LA-r-'-b'T
REGEtVED
ON C* WAiiRQUALIT,
IAN 0 4 2007
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wmi
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD H5Q BEEN PROVDED TO THE WELL OWNER.
SIGNATURE {4yCERTIFIED WELL CONTRA TOR "DATE
al
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
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State
Zip Cade
( 828 )- 254-3581
Area code- Phase number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(Oapplicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Bo/�:): Residential Water Supply r
DATE DRILLED l 3 /f $ / 0 to
TIME COMPLETED I u a AM O PM V
3. WELL LOCATION:
CITY: AS f{ li J k t...` COUNTY gt-nil CD reve6
tt g>3A4cloav- LAc.)G
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN ETTING:
❑Slope ❑Valley at ❑Ridge ❑Other
(check appropriate box)
LATITUDE 5 St-151
LONGITUDE g a 2a • a S 1
Latitude/longitude source: aCPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to thb form #not using GPS)
4. WELL OWNER
OWNER'S NAME CD tp u Rc, e ()PAP F
STREET ADDRESS it 10 DF3AJre. (L O,€4 R tJg
ato4,
May be in degrees,
minutes, seconds or
in a decimal format
lkSNEV'It_L€ t�C.
City or Town State Zip Code
( cga% )- 3 iit- 0 544
Area axle - Phone number
5. WELL DETAILS: -11 ..i
a. TOTAL DEPTH:--.79.5 r
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO
c. WATER LEVEL Below Top of Casing: b FT.
(Use'+' if Above Tirol Casing)
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing tenanted aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118./1kg
e. YIELD (gpm): N METHOD OF TEST K-I6 - A 11`--
6. CASING:
Fran�De
To Ft.
From To Ft.
From To Ft.
336506
f. DISINFECTION: Type hZl Amount - i° L
g. WATER ZONES (depth j
From 2 (g o To 265 From To
From To From To
Fran To From To
/
Thickness/
7. GROUT:Depth r��e Material
^
From r _ To �.� Ft. M1f'A1-fa
From To Ft.
Fran To Ft.
8. SCREEN: Depth
From To
From To
PMethod
Dv��
Diameter Slot Size Materiel
Ft. in. in.
Ft. in. In.
From To Ft. In. in.
9. SAND/GRAVEL PACK: J
Depth
From To Ft.
Fran To Ft.
Size Material
From To Ft.
10. DRILLING LOG
Erin', To i
d jI- ' 601
0.601- a.51
L5i 3 5
11. REMARKS:
lio�n, .D,e�scription
0 J a
RECEIVED
DIV. Or WATER OUAI ITV
IAN04
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W TH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND 114ATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
la
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
'r oV7✓vh� I01(6.11
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

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: e.dt-u cWx
WELL CONTRACTOR CERTIFICATION •: c�12,
STATE WELL CONSTRUCTION PERMITg:
1. WELL USE (deck Applicable aoa): Residentialiar Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection
1 0 Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: P t'y rLYttic
(Read Name and Numbers
3. OWNER
Address
ty. or Subdivision and Lot No.)
1
.. uea\ PirVr 11,( aatorN)G o. ,s-ISC-j
City or Town State Zip Coda oZtCA -aQ.ii
4. DATE DRILLED 10-25 OLO
5. TOTAL DEPTH sz$D5
6. CUTTINGS COLLECTED YES ❑ Nv
7. DOES WELL REPLACE EXISTING WELL? S [❑ NC1
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (use above Top of Cuing)
nd Surface'
'Top of casing terminated at/or below land suFrface requiove res • variance In accor-
dance with 1SA NCAC 2C .0111I
10. YIELD (gpm): j _ METHOD OF TEST —0-1171
11. WATER ZONES (depth):
•
12. CHLORINATION: Type
13. CASING: Amount
Depth Diameter
From__I_To 10 Ft. Wig
From
From _
14. GROUT:
From
From To F1
15. SCREEN:
To Ft.
To Ft.
Waa Thickness
or Weight/Ft. Material
Depth Material Method
—1-- To rf_ FL ('Qt" (1CI1
Depth Diameter Slot Size Material
From To Ft In.
From To .__ Ft. _ in.
From To FL In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
in
In.
in
IFOR OFFICE USE ONLY
Quad No:
Sedal No.
DRILLING LOG
From To
I
te- 2tC
DEPTH
Fonnaaon Description
r plat' n TIYin-
( of C�Q
t+e
.
If additional space Ls needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points}
RECEIVED
DIV, OF WATER OtJAUTv
IAN Q ?UU7
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
i
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quatfty, Groundwater Section within 30 days
GW-I REV. 12199

North Carolina . Department of Environment end Natural Resources - Division of Water Quality • Groundwater Section
1636 Mail Service Center - Raleigh,
N.C. 27699.1636-phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR• t ille.1 /Un
WELL CONTRACTOR CERTIFICATION S: 5
STATE WELL CONSTRUCTION PERMITS
ticT
th
C37
CS
1. WELL USE (Check Applicable Boa): Residentiatll-2r Municipal 0 Industrial ❑ Agricultural ❑
Recovery ❑ Heat Pump Water Injection
0 Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) nn
Nearest Town: H l erhtery l \►Q County: 6'X'rfY1h€
'Plead Name and Numbers. Community. or Subdivision and tot No.)
. OWNER d tr ek,C` SO-rnS
Address YIn.-, x a3D
�
,,�y� rat or Route No.)
t 'il.k1t\tQ. MC,
City or Town Stab Zip as--lo 1
4. DATE DRILLED tO a4-riilQ Cale
5. TOTAL DEPTH i tk7S
6. CUTTINGS COLLECTED YES 0 NO Par
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOC/]'
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (Use' a Above Top of Casing)
ve Land Surface'
-Top of casing terminated aUor below land FT.
rfaceAborequires a variance In accor-
d
ance with ISA NCAC 2C.0118 /I
10. YIELD (gprn): \ V2 METHOD OF TEST CLIVI
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
hickne
Depth Diameter Wor Weight/FLL Material
From.-1_,_ To 103
From To
From To
14. GROUT:
From
From To Ft
15. SCREEN:
DRILLING LOG
From To
-I��
Monitoring ❑
DEPTH
Formation Description
SLTna +dty
sill ni-te
eVtCP
nor-Lni. ie
If additional space is needed use back of form
Ft l yU plait (
Ft.
Ft
Depth Material
To aO . Ft. (11-
Method
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
From To Ft
From To Ft
17. REMARKS:
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Let \ t inn Rc(.
of fled'
RECEIVED
OIV, OF WATER OUAUTV
.CAN 0 5 Z(10?
Fla+CJL.bLi Y
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to DNislon of Water 0ualtty, Groundwater Section within 30 days
Serial No.
GW-1 REV. 12199

City or Town Stab
4. DATE DRILLED "1-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 N
7. DOES WELL REPLACE EXISTING WELL? YES 0 N
Oia
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING tS�-I+-- (use •'• b Axwe Top of Casing)
?op of using terminated aVor below land surfaFT. ce requires a variance ove Land Surfaces
accor-
dance with 15A NCAC 2C .0113
10. YIELD (gpm): .31_113.a METHOD OF TEST T_
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Depth Diameter or Wel hidme..t. Material
From_-_L__To cri (0 Ft. % 1 ____
From To Ft. ` C
From To Ft
14. GROUT:
Depth Material Method
To
To Ft.
From
From
17. REMARKS:
Depth
To
To
To _
From
From
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK:
Depth
To
To_
Ft
Ft.
Ft.
Diameter Slot Size Material
in. in.
In. ____ In.
In. in
Size Material
Ft.
Ft. _
North Carolina • Department of Environment and Natural Resources • Division or Water Quality • Groundwater Section
1636 Mail Service Canter - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Apptuwe Box): Residential Qf Municipal ElIndustrial ❑
Recovery 0 Heat Pump Water Injection [j Other
CI It Other, List Use:
2. WELL LOCATION: Show sketch of the location below)
Nearest Town: P
County:
(Read and Numbers. Community. or Subdivision and Lot No.)
3. OWNER t♦t i ,,� �l DRILLING LOG
Address � ji _ _ 1 From To
a-) - I R C,
CsW
deft
t;Ya
tic,
Agricultural Monitoring ❑
If additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at Nast two State
Roads, or other map reference points)
RECEIVED
DIV. OF WATER QUALITY
JAN 0 5 2001
A a.)).)
100.HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPS F THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
IFOR OFFICE USE ONLY
Quad No:
Serial No
eb
IT, elle,
gJoarc rcb/J Vl1LP
GLA
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit vriglnal to Division of Water Duality, Groundwater Section within 30 days
GW-1 REV. 12199

1. WELL CONTRACTOR:
c rA_ Neke•Wt '• !zo-' Tess
Well Contractor (Individual) Name
ciaz
Well Cd for Company Na
STREET ADDRESS \'a%%%c1 \ l Lai 209
¥ko*# 5?c;n4Sl Nc = a8'v43
City or Town SUS -Zip Code
($mil- ta(os- aeaa.,
Area code- Mum number
2. WELL INFORMATION:
SITE WELL ID Ref aPpicable)
STATE WELL PERMTFS(a applicable)
DWQ or OTHER PERMIT #(d W+1'Ta'+bL)
WELL USE (Cheri Appleable Box): Residential Water Supply V
DATE DRILLED 42-7 G" � ��
TIME COMPLETED 9 '�D AM 'Uo'A4 0
3. WELL LOCATION::
Crn': /lam COUNTY 62m# ,n4L
4
,( Name, Numbers, commuzdy. Subdievsion. La No.. Parcel, hp Code)
T RAPHIC / LAND SETTING:
lope °Valley ❑Flat °Ridge ❑Other
(check appropriate boo)
LATITUDE 3
LONGITUDE
Latitude/longitude source: °GPS °Topographic map
(,location of wet must be shown on a USGS two map and
attached Sothis form dnot usbg GPS)
4. WELL OWNER
OWNER'S NAME CrC ievi .fr Karen a Mc beret
STREET ADDRESS EG tq�i'.'Ce5 Lan
ao lakes .tic nI$1115
City or Torn State TV Code
May be in
mimna, seconds or
in a decimal format
(91aBy (o`7c. e9(7
Area code - Phone number
5. WEL.L DETAILS:
a. TOTAL DEPTH: /2)10s
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV7
c WATER LEVEL Bebe Top of Casing: 400 FT.
(use 'v-' ff Above Top of Casing)
rf_ TOP OF CASING IS i FT. Above Land Surface'
'Top of casing terminated at/a below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Wpm):. 42 METHOD OF TEST (k'S
RESIDENTIAL WELL CONSTRUCTION RECO:iu
North Carolina Apartment of Environment and Natural Resources- Division of Water poetry
WELL CONTRACTOR CERTIFICATION#- 2L
f_ DISINFECTION: Type ?yt 1$ Amount _Cc)
'7 0
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth D'mantaa Weight Material i
From_aT_ UCH Fl. 1o'C. ,
Fran To R.
From To Fl.
7. GROUT: Depth
Depth Materal MCMO
FroTo a(en��d Fl. n{-
m 0 ` r i
From To FL
From To Ft.
8. SCREEN: Depth Da rater Sht Sax Mateial
From To R. _ ir,. it
From To Fs. vr.. in.
From To R. in. in.
•
9. SAND/GRAVEL PACK:
Depth Size Malarial
From To Fl
From To Ft
From To Ft.
10. DRILLING LOG
From To
yd
11. REMARKS:
Formationt` �OLi..
RECEIVED
ITS
AN 11 2007
100 HEREBY CERrFY THAT THIS WEL I. Y'AS CONSIRLCIED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS- AFT'R WT A COPY CF THIS
RECORD HAS BEEN PRIDED TO ELL OWtmR.
SIGNATURE OF RTIFIED N " t CONTRACTOR DATE
PRINTED NAME OF PERSON ;C'NSTRUCTING THE WEU.
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mat,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] eat 568_
Fans GW-la
Rev. 7/05
-T1
r't1
co
rV
0

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division oft Quality
WELL CONTRACTOR CERTIFICATION #- aLt ate
1. WELL CONTRACTOR:
We Contractor (Individual) Name
Wed Coiitracmr Company N ai
STREET ADDRESS \"\88r% :News,/ RoCi
% 43 A--,t2 Ac asp 3
((]]��•.vppCity or Town ssl��ttee F . -rap Code
(8 %)- (D(Ds- aoCa. a.
Area code- Phone number
3. WELL INFORMATIOIt
SITE WELL ID #Idapprrcable)
STATE WELL PERMWT#txevocable)
DWQ or OTHER PERMIT MIT applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED /Y gr
TIMECOMPLETED .3/3d
3. WELL LOCATION:
CFTy: ,,LCgr /`_ COUNTY Q4 rile
cCE“.to C / OOP err/
-(Sneet Name. NUAbera. Community. Subdivision, Lot No., Parcel, 24 Cade). ,
TOPOGRAP 4IC / LAND SETTING:
❑Sbpe I *aley CORN ❑Ridge ❑OBrer
(cheek wwola:sat box)
LATITUDE 3 _
LONGITUDE
May be m degrees, I
minutes, sconds or
Bra decimal format
Latitude/longitude Source: OGPS OTopographic map
(kcabon of welm mar be shown on a USGS topo map and
dta,hed to this Cam trio: usig GPS)
4_ WELL OWNER OWNER'S NAME Ru.tb At'tct
STREET ADDRESS 911 S -60tav atS
AM❑
Cove RA
Ragan
City or Town State Zip Code
(Sae). fo6.1-tab )--
Area code- Phone numbs
cSits.t(e) NC
5. WELL DETAILS:
a. TOTAL DEPTH:_ _ �S-
b. DOES WELL REPLACE;WUSTINGWELL? YES 0 NOV
c. WATER LEVEL Below Top of Casing: /a FT.
(Use +'rf Above Top of Casing)
cL TOP OF CASING 16 \ FT. Above Land Surface*
'Top d rasing terminated at/a below land surface may rewire
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):2(72_ METHOD OF TEST
337
©1
f_ DISINFECTION: Type4 115
Amount 9
g. WATER ZONES (depth):
From To From To
From To _ From To
From To From To
6. CASING:
From - i ToS/ F L W'a -o -r in1 iet t
Fran To R. i �""—'tom
From To Fl.
7. GROUT: Depth
From 0 To aO
Thickness/
Diampta INgighl Material
Material
Ft Cent et
Fran To Fl.
From To Fi.
8. SCREEN: Depth Dia Hater Sbt Size Material
From To R. in. in.
From To R.in.. in.
From To R. in.
Depth
SAND/GRAVEL PACK:
Size
From To' FL
From To FL
From To FL
10. DRILLING LOG
From
/
Sl ft'S
11. REMARICS:
Formation Desorippon
fi,/ OF : ATLR (➢EJ AJ.ITy
.JAN ➢ 20U7
100 HEREBY CERTIFY THAT THIS WELL Y'AS COsistELCim NACrdan°NCE WrtN
15A NCAC 2C. WELL cons -Mc -non ma RoARps. PAT TNATA COPY OF ibis
RECORD HAS SEEN PROVIDED TO THE N •r�R, .
S RE OF C - FIED WEI -- : NTRACTOR DATE
ce Ck Nell it ea
PRINTED NAME OF PERSON X'NSTRUCT)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. 7JD5

RESIDENTIAL WELL CONSTRUCTION RECO W
North Carolina Department of Environment and Natural Resources- Division on "a ter Quail;
WELL CONTRACTOR CERTIFICATION # • 0436
337512
1. WELL CONTRACTOR:
Well Contractor ()rdiv)duaq Name
'Q'. 'f6 CAAA\^J¢.- - s to n
Well GCuuiirbe�.k„ Company Nape
STREET ADDRESS V \% S \ku aeci
City or Tam Slate -Zip Code
(8aa%} iefos- aoaa
Area code Phone nubs
2. WELL INFORMATION:
SITE WELL ID Ma applicable)
STATE WELL PERMIT#(tapplicable)
DWQ or OTHER PERMIT # fit die) G(O ` O.2 3`l S /
WELL USE (Check Applicable Box): Residue Water Supply r7
DATE DRILLED /- 3C) 6
TBHE CONPLETED %/ r fl f) AM girerM
3. WELL LOCATION:
CRY: ct 6/-h/..-elu.//C' COLM'.Y AA. tho4
i Name. Nsabera. Canmurdly. Subcliviston, Lot No.. Panto, Zip Code)
TOPOGRAPHIC f LAND SETTING:
Mope DValley ❑F1at 0 Ridge ❑Other
(check aw wi let% box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
iatitudellongitudesource: OGPS Topographic map
(location ofwe/ must be shown on a USGS topo map and
altwheJ to Iris torn ?not using GPS)
v1- WELL OWNER
OWNER'S NAME \i QC h`:y j\iACt<net
STREET ADDRESS aw3 GC\h _°7iaT C eck
.s inCiceckAO tie ` tic o'1 8rk9
City or Town Stare Zip Code
( "ae } t-j tc$ - 1 \9
Area code - Phone numbs
5. WELL DETAILS: 25
a. TOTAL DEPTH:.
b. DOES WELL REPLACE EXISTING WELL? TES L7 NOV
c. WATER LEVEL Below Top of Casing O O Fr.
(Use •✓ ITAbove Top of Casing)
d. TOP OF CASING IS \ . FT. Above Lard Surface*
"Top d casing terminated dfof blow laid surface may require
a variance in au..adaA... with ISA NCAC 2C .0118.
e. YIELD(gpm): METHOD OF TEST O.'S
t DISINFECTION: Type 2> 11.5 Amount 2
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth
Weight Material ,
iarn
From -4 \ Z(n_ Fl. D g .sCs?i t
From To R.
Rom To R.
7. GROUT: Depth Material
From 0 To afl Fl. (flirt -3rt'�.
From To Ft.
From To
Aletlhod
8. SCREEN: Depth Dia n ter Slat Size Matsu,
From To FI. in. in.
From To R. in.. in.
From To P. _rn. in.
9. SANDIGRAVI3 PACK:
Depth Size Maria
Frorn To FL
From To FL
From To Ft
LB. DRLLLtNG LOG
From T Formation Desuiptian
I -V( aocr
96 Yas
11. REMARKS:
Gnv
k i CEi\FL)
)F lrt4 R onto
l DO HERESY CERTWYTHAT THIS WELL Y 'AS COF+SFFLCfm N ACCORDANCE Watt
ISA NCAC 2C, WELL CONSTRUCTION MA ND.AROO ARV TIARA COPY OF TNS
RECORD HAS BEEN FRONDED W j'yjt N ELL OWNER.
SIGNATURE OF CE ' FLED ' t CONTRACTOR DATE
PRINTED NAME OF PERSON X NSTF.UCT$G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information MTt,
1617 Mal Service Center— Raleigh, NC 27699-1617 Phone No. (919) 733-701 5 ext 568.
Form GW-la
Rev. 7N5

RESIDENTIAL WELL CONSTRUCTION RECO2D
North Carolina D.,p,ubnem of Envuvnment and Natural Resources- Division of Water Qua":t;
WELL CONTRACTOR CERTIFICATION # -
1. WELL CONTRACTOR:
Well Contractor (individual) Name
S0U2i. jC-C'S *'r.?R±r7
Well :actor Company Nape
STREETADDREss \ 1VGItj Astta7 a0Cq
5Tc-,v AK. ain.43
L����p©City or Town Slate • _try Cade
8 (a%)- (o05-
Area trade_ Phone number
2. WELL INFORMATION
SITE WELL ID #QFapprirable)
STATE WELL PERMIT#(Iopploae)
DWQ or OTHER PERMIT #(d opp5t.4de) 0(0- 00805
WELL USE (Check App Ic / Ie Box): Residential Water Supply B
DATE DRILLED /0
TINE COMPLETED 3 r r5 d AM O PM
3. WELL LOCATION: ��
CITY: do.-!-/lrI/U.(/,.. COUNTY�3j �I CC.44,
tro 4tci LC} 5
i -ne. Numbers. Can� nunity. SZbptyt Lot No.. Parcel. Zip Code) ...
Toy0DRAPHIC / LAND SET11NG:
1116-WPe °Valley ❑Flit DRfdge El Other
(check a•r box)
LATITUDE 3
LONGITUDE
May be in defiers,
minutes, seconds oe
in a decimal format
Latitude/loagitude source: ❑ CPS °Topographic map
(location of wet must be shown on a USGS Lupo map and
ettechtU to this form I' not using GPS)
4 WELL OWNER
OWNERS NAME
C:irir;scu £vecet•t-e
STREET ADDRESS _LVg ije ittZ. oral c
l..3ea.tet' nil ,'%Q,•-j
City or Town Zip Cade
(sacs ). '239- oat'?
Area code - Phone number
S. WELL. DETAILS:
a TOTAL DEPTH::/Os
b. DOES WELL REPLACE EXISTING WELL? YES °
NOV
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 ternwtated at/a below land surface may require
a variance in accordance wtlh 15A NCAC 2C .0118.
e. YIELD(gpm): TK) METHOD OF TEST r<-s
i
0436
337511
f. DISINFECTJON: Type4 \ t$
g. WATER ZONES (depth):
From To
From To
From To Fro:- To
6. CASING:
From To
Depth
From 4 To 3?
From To
From To
7. GROOT:ec�� Depth
From 0 To a© n_ ,etf-
From To Ft,
From To - FL
8. SCREEN: Depth Diameter Sht She Material
From To R.m. in.
From To P. _e,_ in.
From To P, b;. in.
9. SAND/GRAVEL PACK:
Depth Size
From To- FL
From To FL
From To Ft
From To
Thickness/
Diary.- weight
R -fir
R.
Fl,
1D. DRILLING LOG
From To
I 37
11. REMARKS:
Materie
Fonration D=n
_a OW �
IHU [')F 1/titiFP 011 rT y
JAN ? c 2007
I DO ItMt r CERTIFY THAT THIS WELL VAS CONSTRLGTID N At fl u rYtrM
15A NCAC 2C. WELL CONSTRUCT/DPI 1?AHDARD3 ANDTHATA COPY CFnHS
RECORD H 1S BEEN PROVIDED TO '.. ELL OWNER.
SIGNATURE OF FLED N - L CO:ITRACTOR DATE
PRINTED NAME OF PERSON :ONSTF,UCT±NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mat,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form OW -la
Rev. 7/tS
i
r

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina D..µ+rbuent of Environment and Natural Resources- Division of VW'arer Quart}
WELL CONTRACTOR CERTIFICATION #- Ott ere
1. WEU. CONTRACTOR:
Q cc: e % ♦3 e-c..m a a'vees
Wed Contractor (Individual) Name
eAlq 442. ' Sa a. ems-s *Son
Wen Contractor Company Narhe
STREET ADDRESS `y V p ¶ .\k( y QQCi
Hohr;ngS NC lo►8'it i3
City or Town Slate •) . -Zip Code
(V?Lp���ppi} (Dios" aoaa.
Area code- Phone number
2. WELL INFORMATIOat
SITE WELL ID;Rd appioMe)
STATE WELL PERMITre(aaiepdraele)
DWQ or OTHER PERMIT ft(if applicable)
WELL USE (Check Applicable 80* Residential Water Supply V
DATE DRILLED M
TIME COMPLETED 7. r3 0 AMID PM EL
3_ WELL LOCATION: /�
CITY: A s/r�,„/� .. COUNTY /944(-G /rr../9
UX r, 3710
{Stet Name, Numbers. Commonly. Slohcbrision, Lot No.. Parcel, Z, Code)'
T POGRAPHIC / LAND SETTING:
Slope °Valley CI Flat ❑Ridge ID Other
(check appropriate bad
IATRUDE 3 _
LONGITUDE
May be m degrees,
minims, seconds or
in a decimal format
Latitude/longitude source: DGPS °Topographic map
Meader? of well mustbe shown on a USGS topo map and
attached to this form drat us/lg GPS)
& WELL OWNER
OWNER'S NAME 'j;rn' Re'n;rl�icc
STREET ADDRESS 3110_, OX CC€CC Ra
(,3e. vecv, (le , Luc 08797
City or Town State Zip Code
(gas } j:L-ls- w31Li
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2oC
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV-
a WATER LEVEL Betow Top or Casing 30a FT.
(Use`*' iiAbove Top of Casing)
c. TOP OF CASING IS ' FT. Above Land Surface.
'Top of casing terminated at/or below land surface may require
a variance in accordance Will ISA NCAC 2C .0118.
e. YIELD (gpm): h METHOD OF TEST R•.4%
i
337510
f_ DISINFECTION: Type 1l 1$ Amount vs
g. WATER ZONES (depth):
From To From To
Fran To From To
From To From To
6. CASING: Thickness/
From -} A, Depth .2 j i. D r Weight _ieef I Matinee
From To R.
Jr"
From To F1.
7. GROUT: Depth Material
From 0 To QO R. iPti(F,
From To Fl.
From To FL
the
& SCREEN: Depth Dia meter Skit Size Material
From To Fl in. in.
From To Fl_ in in
From To FI. _ke.
9. SAND/GRAVEL PACK:
Depth Size Material
From To' Ft.
From To FL
From To Ft.
10. DRILLING LOG
From To
al
RI 9es
11. REMARKS:
Formation n
dt)cr
100
1 OD HEREBY r:F_R11 Y THAT114G WE7L V AS COHS[RLCTFD N ACCORDANCE Wny
15e NCAC 2C, WELL CONSTRUCT/ON LTA WARDS. APTTHATA COPY OF Ter$
RECORD WAS BEEN PNOVDEDTO TM: N ELL OW
SIGNATURE OF CERTIFIE.!!Z . . •ST- OR DATE
•
bece. Ck \Ato. .G,vNrRr-
PRINTED NAME OF PERSON ::C'NSTRUCfiNG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information M3t.,
1617 Mall Service Center_ Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7N5

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Em'vonment and Natural Resources- Division of Water Qual:ry
WELL CONTRACTOR CERTIFICATION 3F • at.
337508
1. WELL CONTRACTOR:
e\ e,G31, Sct-w-jeCS
Wer Contractor (individual) Name -
'!v\t``A2 ' 64..yyyerS n
Well Cdtacta Company Navhe
STREET ADDRESS \' Z S \\1A/ 20q
Ho,* 5e ;'4 I /ac d8'-1-13
City or Town Stae . -2rp Code
(S , t,(os- aoa ._
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 4(4angle: ie)
STATE WELL PERMITS? applirabie)
DWQ or OTHER PERMIT # fepp&Ask.) C600145
WELL USE (Check Applicable Box): ResidantiS Water Supply LN
DATE DRILLED /A.,-6
TIME COMPLETED /ll.i f) AMa..-rM0
3. WEU. LOCATION: /� cousin //��
CIT1': Co, / - coU/lL. y�CYrn 4
64 /42 / 5
.(SteNumbers. Centrafly. Subchizaort Lot No.. Parcel, Zip Code).
TOPOGRAPHIC / D SETTING:
❑5
bDe pV �Firffi �y pRidga
(etweck arpraprralt box)
LATITUDE 3
LONGITUDE
❑Other
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude solace: oGPS uTopvgrapbic map
(bastion of weir must be shown on a USGS topo map and
ettaJ,r:J to Ma Mn l not userg GPS)
4. WELL OWNER
OWNER'S NAME ROIOL?S"i`
STREET ADDRESS 2010 ' 6tcAy ✓Svr Cb 114-
A- ectie r; lie /1C J ar1V7
City or Town ' State Zip Code
<8ae) ata-) 134
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH:✓c''
b. DOES WELL REPLACE EXISTING WELL? YES 0 N017
a WATER LEVEL BSowTop of Casing: ✓7) Fr.
(Use "✓ B Above Top d 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 Wpm): / METHOD OF TEST P.'.
t- DISINFECTION: Type Ci 115
g. WATER ZONES (depth):
From To
From To
From To
Amount 02 in
From To
From To
From To
6. CASING: Thickness/
Depth Diampta Weight
Fran 4' //LI FI.P�T -Sova1
From To FI.
From To R.
7_ GROUT: Depth �nl MaterialFrom 0 To «o R. &Wre.T1'- From To F1.
From To R.
8. SCREEN: Depth Da deter Slot Size Material
From To R. in. in.
From To R. in.. in.
From To R. in. in.
9- SAND/GRAVEL PACK:
Depth
From To
From To
From To
I0. DR:LUNG LOG
From To
11. REMARKS:
Size
FL
Ft
Ft
Formation(' �D
7 Oc,
i-;t:eEVYCD
I DO HEREBY CERTIFY THAT IRS WELL VAS COIIS1RLCTED N ACCORDANCINWTIN
15A NCAC 2C. WELL CONSTRUCnON LTANDARDS. MS`THATA COPY OF DNS
RECORD HAS BEEN PROYDEDTO THE N. ELL OWNER.
SIGNA URE OF CERTIFIED 'Et OliTRACTOR DATE
t -Vet. C1- 4A ° b. 4G' 1J]rtn3
PRINTED NAME OF PERSON .IONSTRUCT*NG THE WEU.
Submit the original to the Division of Water Quality within 30 days- Attn: information tax,
1617 Mal Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568-
Form GW-Ia
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:2D
• North Carolina Department of Environment and Natural Resources. Division of Rater Quality
WELL CONTRACTOR CERTIFICATION a- all ate
337505
1. WELL CONTRACTOR:
12-rc • e
W eR Contractor (Individual) Name
�.'\Jc)1'Q ' 'rS O.awi''yyV�S
Well Contractor Company Na t,eQQ !� r�
STREET ADDRESS �V1 V 9 rj .AN.A.,S y OL©`1
Ho 4 � r;N� } NG e d-8'l*�3
t� City or Town State - -Zip Code
(& %)- tn(os- o�c�--ci�
Area code- Plane number
2. WELL INFORMATION:
SITE WELL ID 4fd applicable)
STATE WELL PERFAITR(a.wfn.ebL)
DWQ or OTHER PERMIT #(
WELL USE (Check Appfcable Boc): Residential Water Supply de
DATE DRILLED /a2
TIME COMPLETED l; c)
3. WELL LOCATION:
�%
CRY: f
{Street Nameetlw bera. Community. S.LS.:+T.t Lot No,. Parcel, Zip Code)
T9POGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat CI Ridge Metier
(check aprrnmerte box)
LATITUDE 3
LONGITUDE
AM❑ PMre)----
COUNTY /3 4 <r CGcn 4
May be in dam,
minutes, seconds or
in a decimal Emmet
Latitude/longitude source: p GPSS O Topographic map
(bcation of veal must be shown on a USGS topo map and
attached to this form Plot using GPS)
4. WELL
OWNER'S NAME 'S�enS�:'e t1:.1Si5a,1 [�
STREET ADDRESS 88ft,
Conches ASc d lls
City or Town State rip Code
(; sag ). (ch t - Sao
Area code - Phone numbs
Si. WELL OF/SAILS: C
a. TOTAL DEPTH: -O S_
b- DOES WELL REPLACE EXISTING WELL?
//YES ❑ NOT/
c. CG WATER LEVEL BelovTop of Casing: CG FT.
(Use sr" iTAbove Top of Casing)
d. TOP OF CASING IS . FT. Above Land Surface'
'Top of casing terminated at/or below land surface may rewire
a variance in accordancewitlt 15A NCAC 2C .0118.
e. YIELD (gam): J i METHOD OF TEST Po.,5
f. DISINFECTION: TYPe4 . % 1.$ Amount / 9
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Weight Material - 21 fit
Depth Diiamgter
From 1 To� R. Io ra
From To R.
From To Fl.
7. GROUT: Depth Materialt� Mater
From 0 To aCI R_ (en1 �{-
From To FL
From To R-
8. SCREEN: Depth Daneter Sht Size Material
From - To R. in. in.
From To Ft in in.
FromTo R. ii r. in.
9. SAND/GRAVEL PACK:
Depth Site MainIS
Fran To- FL
From To Ft
From To FL
10. DR!WNG LOG
From To� Mart
�rFormation/Description
/ art C"1r./Y
11. REMARKS:
RFCEIVEIJ
. % IbTF nilµ -I
jAom
I to MEREST CERTIFY THAT THIS WEL L. Y'AS COFStRLCIED NPCCORDPI CE w111
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. ANT THATA COPT OF THIS
RECORD HAS BEEN PROVIDED TO THI: N ELL OWNER.
SIGNATURE OF CERTIFIED WEI
CTOR DATE
�Q:('. C - 1442O b. 4 c PRINTED NAME OF PERSON .'.GNSTRUCTE N GTRE 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.
Farm GW-fa
Rev. 7/t6

RES/DENTMAL WELL CONSTRUCTION RECO 3D
North Carolina Departtnent of Envwnmcnt and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 04 ate
337503
1. WELL CONTRACTOR: --
etc:ck AQ-CF-T So:eartecs
Well Contractor (In Nidual) Name
eAN.dQ' Sots yQ�S kEOn
Well Co Company Nauhe
STREET ADDRESS \sy V el b :NetV (aOS
o c nc4, NC = f
City or Town -try Code
(� }. (o(os-;can._
Area code- Phone number
Z. WELL INFORMATION:
SITE WELL ID R(d applicable)
STATE WELL PERMIT*? applicable) OWQorOTHER PERMITX(1fq &cLL)�Yy^CU'C2iiaoa
WELL USE (Check Applicable Box): ResidentW Water Supply el
DATEDRILLED ?actS-
TI-ME COMLE PTED / i dc.)
A WELL LOCATION:
AMD PM Irr—
Crfl':- COUNTY ../57k.no arn‘e
L12 VUot Ctie5i 'c VC
{Street Mane. Numbers, Camnmuly. SubBA sSNA, Lot No.. Parcel, =N Code)'
TOPOGRAPHIC / LAND SETTING:
S`ope It/alley ❑FW El Ridge ❑Ottrer
(check aN,.M..;.a bag
&ATITUDE 3 _
LONGITUDE
Iatittde/1ongitude source: ❑ OPS 0 Topographic map
(location of we mustbe shown on a USGS topo map and
attached to this form 'not usig GPS)
4. WEIL OWNER
OWNER'S NAME I HQ'Fe`.A t,Sc.cis \
May be in degrees,
minutes, seconds or
in a decimal forams
STREET ADDRESS 11ci.Mn(v;e Ra.
City or Town State rip Cade
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NOS/
c. WATER LEVEL. Below Top of Casing: U U FT.
(user.* Above Top of Casing)
d. TOP OF CASING IS % FT. Above Land Surface'.
'Pop d casing terminated at/cc below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): �6 METHOD OF TEST____
f_ DISINFECTION: Type4.115 Amount /3
g. WATER ZONES (depth):
From To From To
Fran To From To
From To Fran To
6. CASING:
Thickness/
DeptFrom'-lid- D � i ins-;
From To Ft.
From To Ft.
7. GROUT: Depth
Depth rn1 Mate:'iat Method
From 0 a
To O R. (erne Pf1 f. ` i &4
From To R.
Fmrn To Ft.
8. SCREEN: Depth Dia peter Slot Slim Material
From To F. in. in.
From To R. ir:. in.
From To R. in, in.
9. SANDWGRAVEL PACK:
Depth Size Material
From To- Ft.
From To Ft.
From To FL
10. DRIWNG LOG
From To
/0 2
11. REMARKS:
Formation De.,r.r wrr
,,Formation
tkr AT.4.41
REGEIVED
MAN `L A '/_UU/
I DO HEREBY COMFY THAT nffi WELL V 'AS CONSTRLCTED N Ak'CORDMN15 WITH
ISA NCAC 2C, WEll CONSTRUCTION!MA NDARDS A/C) THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE B. ELL OWNER.
SIGNATURE OF CERTIFIED iTPACTOR DATE
43
PRINTED NAME OF PERSON CONSTRUCTING THHE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mat,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568_
Fain GW-la
Rev. 7/05
y

RESIDENTIAL WELL CONSTRUCTION RECO2D
North Carolina D4pmauent of Environment and Natural Resources- Division of w'a:cr Quoit)
WELL CONTRACTOR CERTIFICATION #- Oli 3k
1. WELL CONTRACTOR:
QC(' e_. \ketA h Set w'jecs
Wed Contractor (Individual) Name -
�� a'Q ' SOsw'1i4-i es * .?On
Well Cdrtracta Company Nate
STREET ADDRESS `'\%S S VS-417 21g
t-\04 5?c,81\) )JG7. o-811.43
City or Tam a -Zip Code
($ )- (ntos- ea.
Are code- Phone number
2 WELL INFORMATIOtt
SITE WEU. ID #fd appinble)
STATE WEU. PERMITS(a applicable)
DWQaOTHER PERMIT #(dappbcabte) Ciao'o2IAa WELL USE (Check Apple** Ga): Residential Water SupplyISJ
DATE DR U.ED / `�
TIME COMPLETED ) i 30 AM PM&
3. WELL LOCATION:/ /�
CITY: CO IcVer .. COUNTY /34 tic any 4t
/K Sic Coop ed
4SbeetName, Numbers. Community. Subdivision, Lot No- Parcel. pa Code)' ..
TOPOGRAPHIC LAND SNG:
❑Slope °Valley 0F6i dRMge ❑Otter
(check appropriate bar)
LATITUDE 3
LONGITUDE
Latitude/longitude source: °GPS °Topographic map
(bcation of well must be shown on a USGS topo map and
attached to.* form 'not using GPS)
4, WELL OWNER n ` 9
OWNERS NAME RCiO% C n 1_cA d IDevoc? s+K.R'F
STREET ADDRESS Y'0 en
R,rlaS
May be in degrees,
misut , secordsor
in a decimal format
Enna l Nc
Cly or Tam State
(R38 ). tdc,5 3(c8�,
Are code - Phone number
Zip Code
S. WELL DETAILS: /�S
a TOTAL DEPTH: 7'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
c. WATER LEVEL BebeTop of Casing: SO FT.
(Use'4• I AboveTop of Casing)
d- TOP OF CASING IS , FT. Abae Land Surface'
Top of casing temtbreted aVa below land surface may require
a variance in accadancevveb 15A NCAC 2C .0118.
e. YIELD (gprn): 0 METHOD OF TEST ft•c
337521
t. DISINFECTION: Type4ii l5 Amount - /
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Thickness/
From $14 1cf l -fi �T.�_ : .VI fir;
From To Ff. l
From To Fl.
7- GROUT: Depth
Depth Matenai Method
From 0 To OCI n. (etlyetif . frl&PP
From To Fl.
From To Fl.
8- SCREEN: Depth Diameter Slot Sire Materiel
From To Fl. N. _ in.
From To Ft ir.. in.
From To P. ir. in.
9. SANDtGRAVEL PACK:
Depth
From
From
From
To FL
To Ft
To Ft.
10. DR!LUNG LOG
From To
4o
11. REMARKS:
Size
»Ft3rp� ormatiotn D
,ry n
P,11_ t1„
RECEIVED
01.IN,1 it
I DO HEREBY CERTIFY THAT 1H6 WELLY AS CONSTRUCTED N ACCORDWCE WITH
15A NCAC 2C, WELL CONSTRUCTION NO NOARD3. AM1DT ATA COPY OF TIC
RECORD HAS BEEN PRaMED TO ,' OWNER.
SIGNATUREOF CERTIFIED %' ONTRACTTOOR� DATE
\b. ecc:Cx \AtC b. 'clac
PRINTED NAME OF PERSON :ONSTRUCTI n G THE WEU.
Submit the original to the Division of Water Quality within 30 days. Attn: Information M 3t.,
1617 Mail Service Center —Raleigh, NC Z7699-1617 Phone No. [phone] ext 568.
Fan GW-la
Rev. 7)05

.RESIDENTIAL WELL CONSTRUCTION RECOIL»
North Carolina Department of Environment and Natural Resources- Division of 18 ater Quality
WELL CONTRACTOR CERTIFICATION # - 31
337520
1. WELL CONTRACTOR:
Q eacr:SG4-3-ir .c s
Well Contactor (Individual) Name
�.��J [�'2 SG.Swiyy EIS .k n
WeI1 (:oiNaetor Company Narile
STREET ADDRESS \y V V % Vti.a j o
Ho* 6TC:1\ s) NC = a8n�3
City or Torn a 'Zap Code
(8n1- (aros—;cap.
Area code- Phone number
2. WELL INFORMATION:
SFTE WELL ID 71(U applicable)
STATE WEU. PERM!T3(rapplioWa)
DWG or OTHER PERMIT fat applicable)
WELL USE (Check Applicable Box): Residential Water Supply iyy
DATE DRILLED (� -f- 6
TIME COMPLETED Seca-0 AM 0 PM (gam
3. WELL LOCATION: /
CITY: L,0('150 , L 'e . COUNTYfLA
4 /CO.?Z4
011/
.(Baser Name, Numbers.
Ckmmuney. Subdivision, Lot No- Parcae rip Code)'
TOPOGRAPHIC! LAND SETTING:
❑Slope 0Vaaey ❑Fiat ❑Ridge °Other
(check appropriate boar)
LATITUDE 3
LONGITUDE
Latitude/longitude source: GPS °Topographic map
Vocation of well must be shown on a USGS fopo map and
attached to Mrs ham Ind usa+g GPS)
9. WELL OWNER
OWNERS NAME !�` t \'c\nrfl(O�nr(VP \'\0.A",.ACA
STREET ADDRESS bSCC) IA4r'�F r"-.0 i1v: 1 \P)Ra.
r iF+kirks ) .aCWI3
City or Town State Zip Code
(Bays). tc:9i'k
Area code- Phone number
May be in degrees,
urinates, seconds or
in a decimal format
A WELL DETAILS: / r_
a. TOTAL DEPTH: (aj
b. DOES WELL REPLACE EXISTING WELL?/ YES ❑
c. WATER LEVEL Below Top d Casing: tGCJ FT.
(Use •+' 1Above Top d Casing)
d. TOP OF CASING IS : FT. Above Land Surface'
'Top of casing terminated attar below lard surface may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD (gpm): —10 METHOD OF TEST f c.c„,
NOV
f. DISINFECTION: Type 4 . % 1.$ Amount
g. WATER ZONES (depth):
From To Fron To
From To From To
Fran To Fron To
6. CASING:
Thickness/
DepthDiiarnr Wei�9M�
From To/03 R. tot ,schal
From To R.
From To FL
7. GROUT: Depth Material
From 0 To ao R. ienrnf
From To R.
From To R.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVE!-PACK:
Depth
From
From
From
Diameter Slot Size Material
R. Ir. it
in.
R. in. i1.
To- Ft.
To Ft.
To FL
Size Material
10. DR!WNG LOG
From To Formation Description
/ /63 30ONA3rc ,
/C39 5/6 _
11. REMARKS:
fl-i, Y)FtNaIER On il..'v
kfl
100 HEREBY CERREY 1NAT THUS WEIL Y CONSTRUCIED^ACCORD WRX
NS1
15A NCAC ZC, WELL CORY/C /1ON . COPY OF THIS
PRWIDED TOWN: w ELL CM 14ER.
t ram, A*•
SIGNATURE OF CE .L NTRACTOR DATE
te:G1A }\Wrb. Co.h tL43
PRINTED NAME OF PERSON .C'NSTF.UCTING THE WELT
Submit the original to the Division of Water Quality within 30 days. Attn: Information Nt3t,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-Ia
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:AD
North Carolina Department of Environment and Natural Resources- Division of V'ter Quaky
WELL CONTRACTOR CERTIFICATION #
337519
1. WELL CONTRACTOR:
t e: gje- aec,, 1', :SCL'a-VeC?1
Wert Contractor (Individual) Name -
' Si rl.
Well C& Company Rabe
�J
STREET ADDRESS \'\% ..Wtfral3CI
IA a* 61 c;c1Stt NG t8'i�3
City or Teen -Zip Code
(8a(6- (e(oS- abga
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #[fiapperatee)
STATE WELL PERMIT'3(AappacatTe)
DWQ or OTHER PERMIT LIfd aPPTrialale _/
WELL USE (Check AppThcable Bar): Residential Water Supply El
DATE DRILLED
TIME COMPLETED /O, Zi N AM L7/#M
3. WELL LOCATION:
CfTY: eke e/A ..
f "a a'r dip.✓ rer!
Ammer earn. Numbers. Cornitur ty Subdivision, Lot No.. Parcel. Zip Code).
TO`gptRAPHIC / LAND SETTING:
;twine
❑Fiat ()Ridge ❑Other
(cheek a,PdP^a:e boat
LATITUDE 3
LONGITUDE_
Latitude/longitude source: ❑GPS °Topographic map
(downon ofwet must be shown on a USGS tom map and
erode..) to fhis form d nor use o GPS)
A. WELL OWNER OWNERS NAME Off, 7:-p- �"
�n nekk
May be in degrees,
mines, seconds or
in a decimal format
STREET ADDRESS PuCGTC. Y SIG t v ve
CA4dlea
{FOR ,. a-at\ok
Area code - Phone numbs
5. WELL DETAILS:
a. TOTAL DEPTH:. or-
b. DOES WELL REPLACE EXISTING WELL? YES ID Nocyf
c WATER LEVEL BebwTcpoCasing: TC) FT.
(User" 7Above Top of Casi g) ..
d- TOP OF CASING IS X .
FT. Abbe Land Surface"
'Top of casing wed aVOT below land surface may require
a variance fir accordance nigh ISA NCAC ZC .0118.
e. YIELD(gpm): , > METHOD OF TEST f.•S
COUNTY amc-nr 6-0 •
City or Town State Op Code
T. DISINFECTION: Type4\\S Amount / Y
9. WATER ZONES (depth):
From To From
From To From,
From . To From
To
To
To
6. CASING: Thickness/
Depth, ^ DiSna(.+a Weght
From 4-1 Ton L R. �P' ., .1 ?tie � C
Fran To F.
From To F.
7. GROUT: Depth rI Material
Rom t1 To ao F. (rn 1. 4-..
Rom To F.
Rom To R.
8. SCREEN: Depth Da peter Slot Ste Material
From To R. v.. in.
Rom To P. __.. 8... in.
From To F. tr,. bt
9_ SAND/GRAVE. PACK:
Depth Size Material
Rom To- Ft.
From To FL
From To FL
10. DR!UJNG LOG
From To
Sic)
Formation
J t)c, Ar,n I
re --
II. REMARKS:
RECEIVED
F )f.)/TG!2 nuAi
1N
I DO HEREBY cat fiT THAT THIS WET. L WAS COtSIF.LCtED N ACCORDNIN WITH
15A NCAC 2C, WELL CONSTRUCTOR sTAHna$T. ASV 1HATA COPY OF TM
RECORD HAS BEEN PROVIDED1'0TNM: WELL OWNER.
SIG • TURE OF CERT! s'f O. - • •^ e. TE
I bece. Ck ' Ato k-'
PRINTED NAME OF PERSON X•NSTFUCTING IRE WEIL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mat,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext S66.
Form GW-la
Rev. DOS

RESIDENTIAL WELL CONSTRUCTION RECO3D
North Carolina Department of Environment and Natural Resources- Div -elms of wa:er Quality
WELL CONTRACTOR CERTMCATION #
337516
1. WELL CONTRACTOR
gate: c- '?te.a let Sa a recS
WeR Contractor (Individual) Name
ScUa C tC * arm
Weft wsLn Company
STREET ADDRESS V4‘932) \\A-47 okici
Hot 5 r;n IAK.Aa8'l' i 3
City or Town state -try Code
( SAS - (a(oS- aoaa,
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID MTX applicable)
STATE WELL PERMIT/(Uappliable)
DWQ or OTHER PERMIT /Td apft
WELL USE (Check Applicable 13md: ResideritW Water Supply ram'
DATE DRILLED
TIME COMPLETED 3 3O AM 0 PM p/
3. WELL LOCATION: CI�/
TY/l: as/ - �y COUNTY GeAcc# .sf&
iats.re\ Lot t
ASbme Name. Members. CammuMy. Swim, Lot No_ Parcel. ro Code)
TOPOGRAPHIC /,Le�` D� SETTING:
OOW/ReySbpe OW/Rey ldi-I= ❑Ridge ❑ eier
(check box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude solace: DGPS °Topographic map
(location ofwet must be shown on a USGS topo map and
attached to this torn snot using GPS)
a. WELL OWNER
OWNERS NAME
cartel-5togt v roc
STREET ADDRESS 10 .a X
41si
*\51tei'i\P NC Q4,8i5
City or Town 1 State 2p Code
(6a£D ). n- 81 li i
Arm code - Phone number -
5. WELL DETAILS:
a. TOTAL DEPTH:. c20 S
b. DOES WELL REPLACE EXISTING WELL? YES ° NOV
e.. WATER LEVEL Below Top of Casing: 6()
(Use a+'TAbo?Top ofCasing) ..
d. TOP OF CASING IS \ . FT. Above Land Surface'
'Top of casing terminated at/or below kind surface may require
a valance in accordance Nth ISA NCAC 2C .0118.
e. YIELD (gpm): 7 METHOD OF TEST PC'S
FT.
f- DISINFECTION: Type4L%‘$
g. WATER ZONES (depth):
From To
Rom To
From To
6. CASING: From h\i Tr R. Dl a
From To
From To
Ft.
R.
Amount_
From To
From To
Fran To
Thickness/
7. GROUT: Depth Materiale
Rom 0 To aQ R. (env`--SL_
From To P.
Rom To R.
a. SCREEN: Depe, Da meter Slat Size Material
From To FI. = in.
From To R. ir. sf.
Rom To R in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
To-
To
To
10. DRILLING LOG
From To
t
nr 2Cs
11. REMARKS:
Silt? Material
Ft
Ft
Ft
Forrrr, alio
Fors- A,Meti
tnreF(\re)i
ow +)CV'I `fFJ fOAI.ii
001$REBY CERTIYTRAT mis WEL LY'AS COrSIF.LCTED NACa RDANCE Wmt
15A NCAC 2C, WELL CONSTRUCTION Ina ?WARDS. Ah�T TNATA COPT Of THs
RECORD HAS BEEN PRWOEDTDTHESELL OW j
to a�
SIGNATURE OF CER1TFIED L^.rEi.0 COOR DATE
PRINTED NAME OF PERSON XNSTFUCTiING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mali Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-Ia
Rev. 7JOS

1. WELL CONTRACTOR: ..
Wee Contractor (Individual) Name
RA* 1Q ' S41aierr J4n
Weer CJAo.M Company Narlue
STREET ADDRESS. caRy5b 2001
Ho*i 6?-c;i\ ) NC -Zip
City or Tam State .
c82 -
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ;TV applicable)
STATE WELL PERMIT/1(f app%cable)
DWQ or OTHER PERMIT S(d le)
WELL USE (Check App3icable Bent): Residential Water SupPty Re
DATE DRILLED (5:-fo a� 4.
TIME///
CONPLETED o C) AMC- 'Mn
3. WELL LOCATION:
i,
art / 4"tie cOw _ ssCOUNTY /.i'u%'YG!n
i.'/Frteji (rt aN\ PaRei\,aLot
ot6
N Community. Subdirawn. Code)
.(Sb��tda=*re. umbers.
TOPOGRAPHIC 1 L 1 SETTING:
❑Slope oVa®ey lanai ❑Rdge Pother
(cheek appromMte bon)
LATITUDE 3
LONGITUDE_
May be in degrees,
smuts, seconds or
in a dei.jl!W format
Latitude/longitude source: OGPS OTepogtaphic map
gocaton of wet must be shown on a USGS two map and
attached to Mks firm 1not using GPS)
& WELL OWNER
OWNER'S NAME eywr-(-= (Q7b CC,
STREET ADDRESS fb e o> S1Ca\
C1.5191eV,ile 3 A)C aeeth
City or Town State Zip Code
(Seats )- rasa— Vita
Area code - Phone number
& WELL DETAILS: 3��
a TOTAL DEPTH:'
b. DOES WELLREPLACE EXISTING WELL?
YES i7 Nowt
a WATER LEVEL '1 Top tCasing:
Above Top
d. TOP OF CASING IS FT. Aboae Land Surface"
,Top d elow casing terminated swot bland surface may require
a variance in m,,.u„iam.,, with ISA NCAC 2C .0118.
e. YIELD (gpm): /p NETHOD OF i tD i %•
RESIDENTIAL WELL CONSTRUCTION REC(rzn
• North Carolina Department of Environment and Natural Resources- Division of Tc otter Qua;ty
WELL CONTRACTOR CERTIFICATION # - 310 f
L DISINFECTION: Type4>\ \5 Amount
g. WATER ZONES (depth):
From To From To
From To Fror^, To
From To From To
6. CASING:
33'7515
Thickness/
Depth D- :er �Wni�g �t i Material
From - To Ft. let" _ ;seE-t
From To R.
From To
7. GROUT: Depth
From Q To Q©
From To Fl.
From To Ft.
Mate
FT. CP.r�.4
Method f(
8. SCREEN: Depth Dia peter Slot Size Material
From To Ft. — . — in.
From To R.
From To Fa. in. in.
9. SAND/GRAVEL PACK:
Depth
From To_
From To
From To
Ft
F L_
Ft.
Sim Material
to Dro n LOG Forrrabbt Description
/ Flom To( 7 — ,.enee)
6, 3a
II. REMARKS:
n r, Li!4\!i•(]nil A! r.
LAN & 21107
I DO HEREBY CERTIFY THAT THIS WELL VAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSiRUC1X*STANDARDTG_ AFT'TNATACOPY OF Tea
RECORD HAS BEEN PROVIDED TO THE NEU.OW'
�e
SIGNATUE OF CERTIhltO WELL CO i' OR
PRINTED NAME OF PERSON ;ONSTF.UCTI__�_
in 30 (lays. Attn:
Submit
Service Center -Rto the aleigh, NC 27699 1617 on of Water QualityPhone No.(9 9} 733-7015 information
Fam GW-la
Rev. 7l05

RESIDENTIAL WELL CONSTRUCTION R.Eco: D
North Carolina D1.pur /sent of Environment and Natural Resources Division of Vi a:er Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Q C CAA- NAO-C,Ztin,
Wei CalbaCtor (Individual) Name
Well GJrb stir' Company Nahe
STREET ADDRESS \'\ARA 1\NA7 20CI
-ko 4 5TC.n ) Nc as1 3
City or Tam State -Zip Code
Lam t@(os- aCa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Wit spareable)
STATE WELL PERMITA(Aapplicable)
DWQ or OTHER PERMIT ;Elf pr tiL)
WELL USE (Check Apgar. aced: Residential Ware Supply J
DA,'E DRILLED /G-ozy G
TiMECOMPLE7ED/J 3a AM0/l'M D
3. WELL LOCATION:
CITY: /-i'v/Pu COUNTY auo.et-Oat 4e
5: Cf/^nH /G G 8lac V. 'C Truster Lek
(S1raiName. Numbers. Community. SubdivisiOn. La No.. EWLV. E¢ code) I!\
TOPOGRAPHIC / LAND SETTING:
[Slope [Valley uthd QRidge 10 Other
(check .w W':At box)
LATITUDE 3
LONGITUDE
Latitude/longitude solace: [GPS [Topographic map
(location of must be shown on a USGS top[ map and
auwiw) to /Ns tom 'not using GPS)
&WELL OWNER
OWNER'S NAME Mail: \ r\:SO aSTREET ADDRESS 1" V X 14
May be in dam,
minutes, seconds o
in a decimal format
e-(ksoactt5va e. 1 A)C 9110C)
City or Torn Stale Zip Code
(P RP )- C 4-031 l
Ara code - Phone number
SWELL DETAILS: _,..s /
a. TOTAL DEPTH:.
b. DOES WELL REPLACE EXISTING WELL? YES D
c. WATER LEVEL BelooTop of Casing 0:$
(Use+' if Above Top of Casing)
d_ TOP OF CASING is \ FT. Above Land Surface
"Top d casing taminalev aVor bek* land surface may require
a variance in wI.ad&nc with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST -G•
NOt/
FT.
04,16
337514
f. DISINFECTION:Type;l lg , Amomtt 7
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness(
Depth Derr,:vvvgtt Material ,
From �i To �c) R. toT:, 112<
Frcm To R.
From To R.
7. GROUT: Depth �} Material Method
Method
From 0 To ao R. cent- n f . [ .l e {/ 4
From To Ft.
From To Ft.
S. SCREEN: Depth
From To
From To
From To
Diameter Slot Size Material
Ft. ir:. in.
R. ir in.
R. _ h;. in.
9. SAND/GRAVEL PACK:
Depth Ste Material
From To FL
From To FL
From To
Ft.
10. DRILLING LOG
From To Formation Desortation
�(� Tile
11. REMARKS:
rxL-nr-lr
,vy1 1CU
1 wr{ O11t41 I T 1(
1 CO HEREBY CERTIFY THAT TiSS WELL V'AS Cditsirt.FrEowACCORDANCE WIN
15A NCAC 2Ct WELL CONSTRUCTION IDANDARD3. AND THAT A COPY OF RC
RECORD HAS BEEN PROVIDED TOTE: W ELL'
1/4"
SIGNATURE OF CERTIFIED 1 COkiRACTOOnRS DATE
C
PRINTED NAME OF PERSON ;C NSTF UCTING TFIE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information M;t.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rey. 7N5

1. WELL CONTRACTOR:
s2.--re;0k ec,00, Sa•.YveCS
Well Contra4or (IndMrlual) Name -
t?io1 ' 6cIL4--cs kS4n
Well Company NWie
STREET ADDRESS \\ARA Vt..1.,11 a%Qq
1-k0 ) AK. - crib}-ia
City or Town S e . — Code
( 8)- to405- as .
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/lcapplirabie)
DWQ or OTHER PERMIT #(-F appbcable) OHO - 0 I'M 5
WELL USE (Cheek Applicable
� �7/Residential Water Supply
DATE DRILLED / a v�0C- �r ,/
TIME COMPLETED /%Jj6 .�AM Er PM ❑
3_ WELL LOCATION:
CITY: 4..'c&44r .. COUNTY �elLtOrs*/ iP
a-/ serif
(Street Name. Numbers. Comnnurmy. subdMsicn, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC i!AND SETTING:
OSlope OVaaey ❑Flat ❑Ridge 0Otner
(medc+Wny.:st. bore)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wed must be shown on a USGS topo map end
attached tothis form d not using GPS)
4 WELL OWNER
OWNER'S NAME at Pi'pr`�`+ 1_ `Lew:S
h
STREET ADDRESS � VaX 11r: V e
Ce;roster 1wn P Zip ode
BVIS
City or To
(CUP) )- (ci7CS,k1C
Area code - Phone nub
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: /
at TOTAL DEPTH: ! Co S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOt
c.WATER LEVEL SeimTgldCasing Cei FT.
(Use •+' BAbove Top of Casing)
d. TOP OF CASING IS FT. above Land Surface'
`(op of casing terminated atior below land surface may require
a variance In accordance veith 15A NCAC 2C .0118.
e. YIELD (gpm):J 2 METHOD OF TEST (�:•�
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of lwasr Quality,
337525
WELL CONTRACTOR CERTIFICATION #' r2Aate
t. DISINFECTION: Type4;. XS Amount ?f
g. WATER ZONES (depth):
From To _ From
From To From To
From To From
To
To
6. CASING: Tladptessf
Depth
.t _ wool, ?Aft;
From � � To Jne[ - Fl. ( C
From To Po.
From To Fl.
7. GROUT: Depth nn Material Method
From�Tpc o d R. Ce artm f f k td'F d
From To Fl.
From To R.
8. SCREEN: Depth Da Hate SIX See Material
From To Fl. in. in.
From To P. in. in.
From To Fl. Ir. in.
9. SAND/GRAVEL PACK:
Depth
From To__
From To
From To
Size
FL
Ft
Ft.
Material
10. DR!WNG LOG From To Formation D
j q _/?Orr atteel
92 /! S C•`
-_ R'CCEWED
i ,it, (lr %A(G cR
*�F odi(lf.(r`P1
11. REMARKS:
--4N 2 al ?or,/
100 HEREBY CERTI • THAT 1ta5 WELL AS Gami ttlto N ACCORDNCCE Win
15A NCAC 2C, WEU. OONS1RUCVN :T, . -, ANT "[HATA COT' OF THIS
RECORD HAS BEEN p�tOVOEDTOTHU W was
SIGNATURE OF CERTIFI 1 GO H'' CTORrrDATE
'�PCC plc \kQO-acyy �a 1.-S�
1T( 4',
PRINTED NAME OF PERSON .'.6NSTRUCTt G WELL
1617Submitthe original to the Division of Water ity
in 30
Ma Service Center alenter- Raleigh, NC 27699-16 7 PhonehNo(9 9)�733-70 6Lion Mat
ext 568
Form GW-la
Rev. 7)05

1. WELL CONTRACTOR:
(A2Y 5u5-�iCE
Well Contractor (Individual) Name
S1i'&i&F Weu
Well Contractor Company Name
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of' Water Quality
WELL CONTRACTOR CERTIFICATION # 21 SO
STREET ADDRESS 3 8u $ 'US 70 i;.".3
UkCi IOIta Zip Code
City
State2'e7SZ
(82B >-'24-45g9
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID *IfappBcable)
STATE WELL PERMITt(u Ocable1
DWQ or OTHER PERMITA if applicable)
WELL USE (Check AppbcaWe Bat Residential Waer Supply ❑
DATE DFULLED !2f 22/01,
TIME COMPLETED AMP PM 0
3. WELL LOCATION:
CITY: &AuA& COUNTY gn& likre
�.°©LCfec K QSh Epi v J(54eNNIneNanasCorwouay. Sadwiaa. int No.. Parcel. ZCo) TO 6GRAPHIC / LAND SETTING: J i).
lope 0Va/ey ❑Flat ❑Ridge °Other
(check appropriate box
LATITUDE 1a 39. ld minutes, sermods or
May te in degrees,
in a decimal format.
LONGITUDE (2 7 a ZB . r y W
Latituddlongihde source: ig4PS °Topographic map
(loca&xr awe/must be shown on a USGS topo mep and
attached to /Ms form inotushig GPS)
4. WELL OWNER ,,11 g1 �y
OWNER'S NAME 'vQHirt ry %na!J'O/ �V10<*vOLI.,f
STREET ADDRESS. (.2( Lap e C&Poin
S L, U' L (.e Vv f. 71 Z
City or Town State Zip Cale
082g a3cs- 30
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Z 2
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
pier
c. WATER LEVEL below Top of Casing: i 0 FT.
(Use if Above Top d Casing)
d. TOP OF CASING IS FT. Above Land Smiacee
Top of casing terminated atfor below land surface may require
a variance in accordance YAM 15A NCAC 2C _0118.
e. YIELD (gpn): 2 0 METHOD OF TEST Ter \ YL.
eD 3 r C53 e rJ
T. DISINFECTION: Type Cl f%K/fte Amount 8 oZ
g. WATER ZONES (depth):
From To From To
From IQo To 170 Fran To
From To From
To
6. CASING:
Thickness/
From Ft.
Diameter Weight Material
From O To ,r+ Ft 10.Eg p PVC
From 3ti To r 2- Ft+-'� it d' A
7. GROUT: Depth
From To Ft
From CO To 3 O Ft.
From To Ft
8. SCREEN: Depth
Fran To
From To
Frorn To
9. SAND/GRAVEL PACK:
Depth
Frc,n
From
From
Material Method
*tire_ 1 pI)meet
Diameter Slot Size Material
Ft in. __ in.
FL in. In.
Ft in. _ in.
To Ft.
Sore Material
To FL
To Ft
10. DRIWNG LOG
From To Formation Description
47— 22S A/2.a-,u'i _
11. REMARKS:
REQEPrED
k 7 (i 2007
I DO HEREBY CEmwY IWIrlHSWBJ. WAS CONSTRUCIID ACCORDANCE Wffli
RSA 2C. MalCONSmUCION
mECOilN "(HATA COPY OF THIS
Ms BEEN PROVIDED -MINE WEIS
SIGNATURE OF
LII t4ALOS�h t�
P OF PERSON
•
f_— ff-2?-ot
WELL CONTRACTOR - DATE
CONSTRUC
TING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attnc Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7A6

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State
( 828 } 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(II applicable)
Zip Cale
STATE WELL PERMIT,r(8 applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Appli able Bo»{: Residential Water Supply El
DATE DRILLED la fa a O 6
TIME COMPLETED a . 0 0 AM 0 PM
3. WELL LOCATION:
CITY: 1.nee5-'Cb !Z COUNTY 6, At Cm-rnU' ir
as 241>s-y (tern o
(Street Name, Numbers, Comm6nity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANDCSETTING:
0 Slope ❑Valley a tat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 S 31. CC 7-z
LONGITUDE `L a 3 et.$ g D
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: aGrisr ❑Topographic map
(bcat/on of wehmust be shown on a USGS topo map and
attached to this form fnot using GPS)
4. WELL OWNER �n c ' /
OWNER'S NAME RO GAR.- S AA I I ti
STREET ADDRESS q R (2y%-v.v _B Is-) 0-? A 0
Ar(If J t � �(g ("C a-cg D fo
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 'd WV
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Belau Top of Casing: V 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 (gam): O METHOD OF TEST RiG -AtR.
32s562
f. DISINFECTION: Type h 1 Amount 115 i
g. WAT?R ZONES S):
From To From To
From To Fran To
From To Fran To
6. CASING:
.+( o fX fJ
Fran J TT-t-'� t. b
o cF
From To Ft.
From To Ft.
Thickness/
Ont aterial
7. GROUT: Depth Material
From 1 To ao Ft. at MB-i'Z
From To Ft.
Ft.
From To
Method
(nvfiED
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Ran To Ft. in. in.
Rom To Ft. in. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
FrL = TooS/
'- 4s
5'
5a
, e
CjgacrJ r"G€
C_t c..fs c — -s a G
CS il.A n.5 f -r
11. REMARKS:
Formation Descriptio
V �L
jA b 25t
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS B{/EN�ENN^ PRO..VIDO0EDDT�TO--THE WELL OWNER. q
SIGNATURE OF CERTIFIED WELL CONTRA DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(irappliable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable : Residential Water Supply 0
DATE DRILLED SaL _ O
TIME COMPLETED t 3 0 AM it PM ❑
3. WELL LOCATION:
CITY: Ylt t t 1'S C4) COUNTY igt! adtfringt
td1/4314 rfltv 6t.. Ci,(2..CLh
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ['Ridge OOther
(check appropriate box
LATITUDE 6 3 ` 6 5 a
LONGITUDE I k A ¢' 6 I b
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ErGfi Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
DIES tr-•r G
OWNER'S'SNAME
STREETRDDRESS 34 t
FntRl6(-ts n`1�so
City or Town State Zip Code
62�-ab3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 5 /
b. DOES WELL REPLACE EXISTING WELL? YES /NO 0
c. WATER LEVEL Belau Tap of Casing: 1 Li) FT.
(Use "+° if Above Top of Casing)
d. TOP OF CASING IS -3 FT. Above Land Surface`
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118./n��
e. YIELD (gpm): O, METHOD OF TEST aft, o I
ki
f. DISINFECTION: Type h
g. WATER ZONES (depth): ,--
From SIB' To 36 5
From 5'7v To '1'
From To
6. CASING:
A1 Der i� ^^
From .+--T`T�' Ft.
From To Ft.
From To Ft.
Amount
561
tZ
From To
From To
From To
/ Thickness/
7. GROUT: Depth
Weighki.
pert
••••••
Material Method
From -5-- To +� Q Ft. cl'Yli I z- `� 9
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 Ft.
Size Material
From To Ft.
From To Ft.
10. DRILLING LOG
Fr9m e To3S /
35l— 360'
J-
3 to
5ZO- 3,-
515f — 60'
11. REMARKS:
Fo cation Description
'r tiY
lC...6
R�+N u-c
C-Ras- `LCC —
rZECEIVED
tuttry
JAN%A 711117
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF Ty IS ,7
RECORD HAS BEEN PROVIDED TO THE WE OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR ATE
v) t) 1
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 # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (IndKidual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City a Town State
Zip Code
( 828 )- 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(if applicable)
STATE WELL PERMIT#1(rapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply W
DATE DRILLED 1 a- 3 D— to
TIME COMPLETED \ o t AM PM 9
3. WELL LOCATION: (�
CITY: b:i EAST Rv 1 u- COUNTY 6 v 13 to rvt 6c
`--,sT AA- 66 vPWPJA C73t)i2.1
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope °Valley ❑Flat °Ridge ❑Other
(check appropriate box)
LATITUDE 3 4-3 a/ 3' —4t
LONGITUDE& a. 35
Latitude/longitude source: °CPS ❑Topographicmap
(location of wee must be shown on a USGS tope map and
attached to this form Inot using GPS)
4. WELL OWNER /� c (�
OWNER'S NAME 1 r 1 G G A(U MO 6 •�"'
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS S-a tr4- ASCtTT Vc+tn1--r C-tR.ag—
AsNedtt_.`si rat- a-%go3
City Town State Zip Code
(%^aX )_ Fri-Cl—ol\3
Area code - Phone number
5. WELL DETAILS: ��5
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ° NO 11
c. WATER LEVEL Below Top of Casing: 4 0 d FT.
(Use "+" if Above T of Casing)
d. TOP OF CASING IS Ter
FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
�^t
e. YIELD (gpm): -1 METHOD OF TEST NYt7 ' P ' Q
f. DISINFECTION: Type IY
g. WATER ZONES (depth):
From Y To %� Front To
From To Fran To
From To From To
560
Amount O o Z
6. CASING: h qI
From Dept
I I J Ft. b
Ft.
From To Ft.
From To
Thiclmess/
7. GROUT: Depth Material Method
From —I To ao Ft. Ctnevifa r Ov6--A
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 Ft.
From To Ft.
Size Material
From To Ft.
10. DRILLING LOG
Fropt ' To l o'
\\ '— Y$5
' �c
t11.039,5'
11. REMARKS:
Formation Descriptio
oJ€1R $tr2lsg n`3
G fLa-roTl tit
ege-4iCie -. `I 3-fYin
:UCLA-ntv'L'F
• lEWvLeVCI-
IV Of WATER'MAU I r
JAIL 2 s [007
100 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 1HE WELL OWNER. /
C,!�d , 13
SIGNATURE OD WELL CONTRACTOR TE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
0
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 # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )• 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #Qt applicable)
STATE WELL PERMITS/(ifapplicable)
DWQ or OTHER PERMIT Staf applicable)
WELL USE (Check Applicable Box)' Residential Water Supply el
DATE DRILLED 11/ 3 a7o (-3 /
TIME COMPLETED '?- v `� AM ❑ PM E9.
3. WELL LOCATION: n5
CITY: A $ a CJ (LLB COUNTY °it) Cjt
Na,.o b t 3 v L-ts l c�-Gat g i.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip ode)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley pilot ❑Ridge °Other
(check appropriate box)-1 LATITUDE 5 .� •69 1
LONGITUDE a ¢a.tra5
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: GT6PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER (t�� �r--
OWNER'S NAME Sun- teU.S%IQ.S
STNEETADDRESS rt. fit. Ar4(eu;S g.ct
1,1rckx) c 4
City or Town State Zip Cafe
($ asc >_ 691- asa`i
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH: 0
b. DOES WELL REPLACE EXISTING WELL? YE S1(7I NO 0
c. WATER LEVEL Below Top of Casing: 8 10 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 vnth 15A NCAC 2C .0118.A
e. YIELD (gpm): —I METHOD OF TEST Q1 G - A Ia-
f. DISINFECTION: Type ♦r tt& q OW/u Amount
g. WATER ES (der"):
From 1 -1 To 1 3 From To
From 84S To3 5£3 From To
From To From To
C..
6. CASING:
) Depth
From a To —1'7
Ft.
From To Ft.
From To Ft.
Thickness/
er s Weight 1
7. GROUT: Depth
From - To r-
From To
From To
Material
Ft. aint ap T
Ft.
Ft.
TjaVe
Method
feottet
8. SCREEN: Depth Diameter Slot Size Materiel
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
Front c To i
— 1a
2a'—
i
"34S0 4o S
11. REMARKS:
formation Description,
c5 1J 72S?SLfl2J t
0.-460
z_ 9 e lLC t -' 6 C t
VTr
QQ L eteRS — "'eh
GGtA-'flg
titltIvtu
ON. (a- WATER QUALITY
JAN 2 6 2007
1 DO HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE O ERTIFIED WELL CONTRACTOR
tCIA14.itc 6 1
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 # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State Zip Code
( 828 )_ 254-3581
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(Napplicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applic
DATE DRILLED
e Bo9: Residential Water Supplyf
a (c
TIME COMPLETED— AM PMfl
3. WELL LOCATION: CITY: �Ac`pn�, ,
f\ike, n.) COUNTY 431%r)csr'grd
233, 0N.-0 € b(Zf �p1J
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat EiRidge ❑Other
(check appropriate box)
LATITUDE 3 5 3a.1 I b
LONGITUDE a ova. 41 to
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Q.6t'S ❑ Topographic map
(location of we, must be shown on a USGS topo map and
attached to this form Knot using GPS)
4. WELL OWNER (� �'^
UAn1 Pay-) g
OWNER'S NAME
STREET ADDRESS r. O , I6b)( &o )
R
AtfLike.I.J NC-- i tC13a
City or Town State Zip Code
(•g3')- 1\3-16Si
Area code - Phone number
6. WELL DETAILS: r1 CC /
a. TOTAL DEPTH: A,J
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
c. WATER LEVEL Below Tap of Casing: 6 i7 FT,
(Use °+• if Above Torf Casing)
d. TOP OF CASING IS FT. Above Land Surface
'Top of casing terminated aVor below land surface may require
a variance in accordance wdh 15A NCAC 2C .0118.
e. YIELD (gM11): St5 METHOD OF TEST RAG A I
33'7585
f. DISINFECTION: TypeAmount
g. WATER ZONES (depthp
From 17° To 17
From To
From To
6. CASING:
/ f�
From 9 D oth ct � Ft. tl I74or sWt
From To Ft.
From To Ft.
7. GROUT: Depth
Depth
From 1 To a-e
From To
From To
i
From To
From To
From To
Thickness/
Material ��Method�
Ft. Cs0 SA71- 4%a L)uW-LA
Ft.
FL
8. SCREEN: Depth Diameter
From To Ft.
From To Ft
From To Ft.
Slot Size Material
in. in.
in. in.
in. In.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
Fro / To /
�- S6
rife' - \"10
t Lp (`I S /
►-ts a45'
11. REMARKS:
Fogpnnanon Description
Q. C19J17-C ES
e4 n(tc-e -as GPM
(.A tc rc 6
RECEIVEp
flu nr ‘40KrrpOl1ALITV
DAI' g 6 2007
I D0 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.
sofa &
SIGNATURE bF ERTIFIED WELL CONTRACTOR DATE
\L.LIL)AS.4
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:3D
North Carolina Department of Environment and Natural Resources- Division of licater Quality
WELL CONTRACTOR CERTIFICATION # N 3L
1. WELL CONTRACTOR:
t: t c e 14- eC L-s '.•a-ie_rs
Well Contractor (Individual) Name -
'
Well Compaq' NappmeQ
STREET ADDRESS \'\ Cl CJ \\ A'j 2oCt
t1.43-! 5RC:nolf) NC a8."1‘43
City orTown state -Tip Code
(8 %)- (DIOS- oaaaa.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #ur applicable)
STATE WELL PERMIT/Kt applicable)
DWQ or OTHER PERMIT tRif applicable)
WELL USE (Check lAppIIctox): Applicable BResidential Water Supply V
/
DATE DRILLED 2-
TIMECOMPLETED JIreY) AM PMH�
3_ WELL LOCATION:
CITY: ,Ad-!/ I;r ..,/ _ COUNTY
/— ;//./4,ima Age/
{Shear Mont Numbers. Canmunny. SubMwsion Lot No.. Parcel, ZIp Cam)
TOLypG RAPHIC / LAND SETTING:
OVailey ❑Flat in Ridge ❑Other
(cheek approPrWte boa)
LATITUDE 3 _
LONGITUDE_,...
May be in d
minutes, seconds or
in a decimal format
i
Latitude/longitude source: OGPS DTopographic map
(rayon of must be shown on a USGS typo map and
attached to ttis torn Inot using GPS)
4- WELL OWNER
OWNER'S NAME C'No-C .tS ( TCovI S
STREET ADDRESS 34o9F 5�,-;o-c �to\\Otl
F4;cv:e.‘a 1Jc- oari3o
City or Town State Zip Code
( Bag ). '1'lS-b5y°
Area code- Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: O
b. DOES WELL REPLACE EXIS11NG WELL? YES ❑ NOV
c. WATER LEVELB 70
Abase Top of Casing)
((Use-4
FT.
d- TOP OF CASING IS it FT. Above Land Surface'
'Top orcasing terminated aVaetow blad surface may require
a variance in accordance vi a 15A NCAC 2C .0118.
e. YIELD (gpm): /0 METHOD OF TEST R•C.
6. CASING: �e� �l i
From._ ,S0°M I Pt* C
Fran To R-
338766 1
t. OtS)NFECT1oN: Type4 a % XS Amount _/ 1
g. WATER ZONES (depth):
From To From To
From To From To
From To _ From To
Thickness,
Depth fl mat Wsiot Material
From To R.
7. GROUT:
ea�� Depth ,,r�11 Matey
From V To otf.1 Fl. (eIY(• of ..
From To R.
Rom To FL -
8. SCREEN: Depth
Fran To
From To
From To
9. SAND/GRAVEL. PACK:
Depth
From
Fran
From
Method (t.
fri
Dianeter SlotSte Material
R. in. n.
R_ in. n.
R. n. in.
To' Ft_
To FL -
To _FL
10. DRIWNG LOG
From To
//
//i
11. REMARKS:
Size Mateiai
Formation D
tealWCu
t�)V OF wAiERQUALITY
MAR 0 S 211tV
100 NEREIT CERTFY THAT THIS WELL V'AS CONSRL'C1ED N ACCORDANCE W M
iSA NCAC 2C. WEIL �COrN�5�mMUCTOR :TP NDAROS. Ant THATA COPY OF THIS
RECORD HAS BEEN PROJDEDTO TNT: N OWNER.
Si NATURE OF
FIEDN 'CONTRACTOR DATE
t0'- \AtO-Ttbi. �.C.3.S 2n5
PRINTED NAME OF PERSON XiNSiRUCTING T E WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information M 3t-,
1617 Mal Service Center -Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Faro GW-la
Rev. 7105

e. YIELD (gpm):
D2WTown
273-S
le
()9562
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: r
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / %O
tfi
24r,
1. WELL CONTRACTOR: �" /
h
ZariyfIt) 1i. al; Ai
II Contractor Individual) Name
E� [r SONS /i fell d d tunicLLC.
Well ontractor Company Name
STREET ADDRESS a731 Aid LEteESiEIZ ll y.
L�/�ln-skt /4(• A?7"/ /
City or Town / State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) .07a 64 - 623 /7
STATE WELL PERMIT#0i applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [),
DATE DRILLED /.. '/j-- 06
TIME COMPLETED S': JO AM ❑ PM I]-
3. WELL LOCATION:
CITY: 4 e 'tots
COUNTY.r'hrn rax it
(Street Name. Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING:
lope DValley ❑Fiat ❑Ridge ❑Other
(chec( appropriate box)
LATITUDE 3 ,r 7S, Ate
LONGITUDE Y Z E/0, r/L
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ptrf'S ❑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 _
STREET ADDRESS
QNP
r'eeti-e% /✓C 7418
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO pV--
c. WATER LEVEL Below Top of Casing: 01'42 FT.
(Use `i' 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.
/t METHOD OF TEST?)bL1)i r19' r 1
f. DISINFECTION: Type eh,:,a
g. WATER ZONES (depth):
From /20 To
From 3 5,:-) To
From To
From
From
From
Amount ,
To
To
To
6. CASING: Thickness/
!'r Depth Diameter Weight Material
From ti To 3Z Ft. &o..ZZY' S.are1J !-(-
From To FL
From To Ft.
7. GROUT: Depth Depth Material Method
From Fr To NO Ft. Concrete. ?buthy rj
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
Z7 ri,
27- .Tz ciejt
rz - sr-Zr
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.
/2-/l-0y
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE L
RINTED NAME OF PERSON CONSTRUCTING THE WELL
X
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 #
CONTRACTOR:
Gbhl Lxf a s
(W 11 Contractor `�rd)vid NCamni
n2 &(oJ4'Is I Mud icmp LLD•
Well lJntractor Company Name r
STREET ADDRESS LI Jaa/ /►p,.w 1.
ag 149
City or Town ( State Zip Code
($ ') 6S'- 9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Skit applicable) 400 6 - 0 3 S' 38
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box). Residential Water Supply [�
DATE DRILLED �I�a /
TIME COMPLETED 91 od AM PM ❑
3. WELL LOCATION:
CITY:' RI/w1 Ct.) COUNTY btAo' tit.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN TING:
❑Slope DValley lat ❑Ridge ❑Other
(check appropriate box)
LATITUDE pb aY/r oc,
LONGITUDE OQfI
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER B#4
OWNER'S NAME/��n//Q/t/
ST ET ADDRESS /9 •I"e 7.):14& �(d1
Alfil ew Ai o`18 73 0
City or Town State Zip Code
(3? 3)- (pa8- I 9 I 9
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 ❑
.v/
c. WATER LEVEL Below Top of Casing: i) FT.
(Use `+- if Above Top of Casing) I
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. CC��
e. YIELD (gpm): (" o METHOD OF TEST)
20 S7
r. DISINFECTION: Typei4/O^IWC
g. WATER ZONES (depth):
From To 2,/49
From To
From To
Amount /19 zfoS
From To
From To
From To
6. CASING: Thickness/
Depth Diameter Weight Material
From_ To /SS Ft. £e2 S 34/2 f fibri tell
From To Ft.
From
To Ft.
7. GROUT: 0 Depth /I Material
From To 10 Ft. &lath
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot S
From To Ft. in.
From To Ft. in.
From To
Method
e Material
in.
in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
Front To Ft.
Size Material
From To Ft.
10. DRILLING LOG
From To
0 —
id — is
30 —155
11. REMARKS:
Formation Description
Cla
544 OrlYetal4
C
noriyc.
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 BE PROVIDED TO THE W El.y OW
CONTRACTOR TE
PRINTED NAMEIDF 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 #
1. W CONTRACTOR:
W II Contractor (drvid(rNam ® /n
,6k' ks oi(.s it cad p, LL.C.
Well C)ntractor Company N22a jme
STREET ADDRESS ai3/
Lgl(xSftR A(C a1
City or Town / Stale Zip Code
(8R )- a5,s'-191,2_
Area code- Phone number
2. WELL INFORMATION: SITE WELL ID #(it applicable) 0?D 6-o.a3/6'j
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED J1 ,'G/_ AM L3 PM ❑
3. WELL LOCATION:
CITY: fib /r(I/ CL!% COUNTY QZ/rrj„xq
(Street Name, Numbers, Community, Subdwision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING'ldg
❑Slope ❑Valley ❑Flat aR/e ❑Other
(check appropriate box)
LATITUDE ,t/33�
_Uj.) 2. t 6 9,7/
LONGITUDEj,Ir(�5/r?✓\, 1J Sr f x
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ia61 ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
ST EET ADDRESS _ ___
%ak ier ae7 n
City or Town State
//r ii 10r 6(
( $)-to5I-R5o(0
Area code - Phone number
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (�
c. WATER LEVEL Below Top of Casing: L(d 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
267.-1
3 215
f. DISINFECTION: Type CI fe teVC- Amount'74/
g. WATER ZONES (depth):
From To 2_0 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weightalenal
From 0 To Ly Ft. 4»k7 j,6,iV d A /
From To Ft.
From To Ft.
7. GROUT: DepthMterrial
iaMethod
From 0 Too Ft. etc
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
iC
/ Q — r
Formatiop Description
c, y4 »4/C
Ly — (is - /.,>�: AC
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 11 ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS,, ND1HAT A. COPY OF THIS
RECORD HA ENP VIDEO TO THE WELLO
SIGNATURE
C,ERTIFIED WFL CONTRACTOR ." {SATE
i, oft
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
3" 214
1. WELL CONTRACTOR:
aCi ,v /r. / i/{i ES
,Vell Contractor Individual) Name
/ieii aivd?unr /LC
Well on S6N5 p�
Well jay
Company Name /
STREET ADDRESS r�/3J kW LEIA(EcIEs ily.
iti tf-Vet IC . aS'7TP /
City or Town / State Zip Code
(2 X )-:52-- 8i{9lz_
Area code- Phone number
2. WELL INFORMATION: SITE WELL ID #(if applicable) Cl if9OS - 0 a 976
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p•''
DATE DRILLED /2 -vcic
TIME COMPLETED -/`l AM 0 PM [�
3. WELL LOCATION: pp
CITY: ,r, c �1 fr.- COUNTY An to. „((
Pie/ A,/ ,, ,fr/ tine "Oe
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
&Slope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 r" It 4I941
LONGITUDE C L. gib dor
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: E.EPS ❑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 NAM
S EET ADDRESS
City or Town State Zip Code
( R )- (353_a54,7
Area code - Phone number
5. WELL DETAILS: 2/�r a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? Y I ES ❑ NO E
�
c. WATER LEVEL Below Top of Casing: 74 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 .01118. 22 e. YIELD (gpm): 4/0 METHOD OF TEST 11JpI1:telQ-/lra
L DISINFECTION: Type C - - d Amount yz't
g. WATER ZONES (depth):
From /GC=' To From
From 3 dip To From
From To From
6. CASING:
To
To
To
Thickness(
Depth Diameter Weight Material
From Jr) To /J9' Ft. C.-P.S .NZ/ A-c.
From To Ft.
From To Ft.
7. GROUT: Depth
Depth Material Method
From N To X30 Ft. CO rcfe. ?%o LlflN4
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
/IJ
iil
-Jr- lit-
11. REMARKS:
Material
Formation Description
Croy
cfee f/
lrvz iG
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.
•�- /2-//-06
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
12f64-,v /7, /Ai Ne 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-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON t/ 3 1 *
1. WELL CONTRACTOR: i/" /
r>fW L{i c N tES
II Contractor Individual) Name
'Er lesanls 1.11E11 aird�`amp,
Well ontractor Company Name
STREET ADDRESS
wL
itns EA Ar,C. aY 7LI P
City or Town / State
($.RJR )- a52-- 849&,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #tifapplicable) ,7(56(t_ 0308i
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Pr
DATE DRILLED / F - 7 ✓ L
TIME COMPLETED 2 : AM [ PM as'.
3. WELL LOCATION: pp
CITY: ken.'y, I COUNTY den lo.Y it -
Zip Code
�.; Ate, ' 4, r /r/ 17
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope [Valley DEWOflLdge ❑Other
(check appropriate box)
LATITUDE 3 r 4/2S1,j'
LONGITUDE r " 3), 7L7
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EK'S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
W
es►
ocN;rJ s;ar Imo•
ue r0 ,ll� NC 72 7
City or Town State Zip Code
($aR)-a9E-89t'
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
,�a r
b. DOES WELL REPLACE EXISTING WELL? YES [ NO Qf
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): ✓ Z METHOD OF TESThML'tt1Q'/lr i
f. DISINFECTION: Type efs i,...,e
Amount -3 .+
g. WATER/ZONES (depth)
V :
From 0 To From To
From Zt J To From To
From To From To
6. CASING:
Depth
From 0 To 24
From To
From To
7. GROUT:
Fro
From
Thickness/
Diameter Weight Material
FL
Ft.
Ft.
Depth Material Method
To go Ft. CCWICrcte. pg7%.ff!!Y4
To FI. 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
0--%i
Ji-T4
Ti- �dl'
11. REMARKS:
Formation Description
C/cJ
3-4$
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.
`g e -`' /2-1-4,
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
ntA-a 4J, iv 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-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
chh�1,l,1. W CONTRACTOR:
a
W II Contractor Nalt�g Qp/(Sofs ``Qwdwp,Well ntractor Company Name
STREET ADDRESS
City or Town / Stale
( Vtg )-5�191�
s
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) ADD J`- • 6 4/ q' /
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [�
100
3;DO
DATE DRILLED
TIME COMPLETED
AM PMET"-
3. WELL LOCATION: [� �L�'
CITY: IY4(4 4114/ &A/COUNTY tWA(het be
(Street Name, Numbers, Community, SubdMsion, Lot No., Parcel, Zip Code)
TO GRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat DRidge ❑Other
(check appropriate box)
LATITUDE N-3S •
LONGITUDE 0 p Ar
Latitude/longitude source: 131PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME -8/1,,
STREET ADDRESS /4921 /d rcek(3ossJj
aci5 i>✓ f1�C aB7//
Ity or Town State Zip Cale
(n 770-3577
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: A6 $
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: Y'1 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 LI/ accordance with 15A NCAC 2C .0118. q
e. YIELD (gpm): METHOD OF TESTrJ
20)3
r� A 10
f. DISINFECTION:Typefg44t - Amount is/ 0z
g. WATER ZONES (depth).
From To /24 From To
From To From To
From To From To
6- CASING: Thickness/
Depth
From___ To Ya Ft.
From To Ft,
From To Ft.
7. GROUT: Depth q
From D To pj0
From To
From To
Diameter Weight Material
4.A4 24,/ds 'PC fait {I
�] Material
Ft. 1retie
Ft.
Ft.
Method
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
2s -3S
35
abS
11. REMARKS:
Formation Description
J#I4 p 5 le/A/c
/Cock
G/wd,'JI
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 BE N PROVIDED TO THE WEL OWNER.
SIGNATUR OF ERTIFIED
PRINTED NAME
ONTRACTOR
0
F PERSON CONSTRUCTING THE WELL
ATE
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 / 7C
1. /WELL CONTRACTOR: )J.. !!
fik1fA) LUi°A,ES
EII Contractor Individual) Name
,ec?v sows % leu add�unlp,
Well3ontractor CompanyName
G ��-(1 �j I/
STREET ADDRESS 373) A.0 LEf iQGsiE/ t y.
City or Town / State Zip Code
(8a )- r€52 Sy9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
06i
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 3
DATE DRILLED /1 •
TIME COMPLETED // :x%J
3. WELL LOCATION:
CITY: p/Irry
AM a""PM ❑
COUNTY X...r r... JC
A .R--/o.s 4-A*5 4.0/ el,ar �
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPDGRAPHIC / LAND SETTING:
lope ❑Valley 0 Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3 r SCj.
LONGITUDE V 1- 2'77-'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oGPS ❑Topographic map
(bcatlon of we# must be shown on a USGS topo map and
attached to this form # not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
State Zip Code
82 )- HI 8 — 8a ! to
Area code - Phone number
r M �
fet.veru1"Ne_ /✓G 28 78 7
City or Town
5. WELL DETAILS:
a. TOTAL DEPTH:
-Ow
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2"
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. �
e. YIELD (gpm): /Q METHOD OF TEST7) 1Witi RI,/
3 A 2220
f. DISINFECTION: Type (r'°- -C Amount '�L
`°1
g. WATER ZONES (depth):
From C162 To From To
From eve To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight ...Metal
From 8 To e Ft. C/ir S.U/S/
From To Ft.
From To Ft.
7. GROUT: Depth Depth Material
,ram From To 6` 0 Ft. Cowry*
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From
From
From
in. in.
in. in.
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
d-/1 C'4
'S - z4vi 5-44/
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.
/z -/r-o4
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
nJAAiN /L[ /ve 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 #
1. W CONTRACTOR:
o-4-1-s
W it Contractor (rrdividpal)Nag
poi of s WE it (aid Painp, LLC.
Well U ntractor Company Name /r /
STREET ADDRESS !
l lcesf 6� /4�c ag7IQ
City or Town ) State
(iv )- 5,Y--sgen`i&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
Zip Code
.4065 - 6a5 o 3
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable_Box): Residential Water Supply
DATE DRILLED /�/L �d6
TIME COMPLETED / 9r 3U AM PM ❑
3. WELL LOCATI 14:: /
CITY: /y!)CCA Gfr• COUNTY �(�N./Afri OL
//,(r�,y(// 6 /1J tot 2C 1a
(Sire- 2, Numbers, Co money. Subdivision. Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lo(}e ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE/ 5
r
LONGITUDE 4,1l0%A,/A S,� e
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to rhis fo if not using GPS)
4. WELL OWNER E ADDRESS /s er'(w/5e/ytR-AJ—/-�
OWNER'S NAME ``G //
STRE\ e Ot-, nq R(icR,ra lop
1. tri ,n lY a $70 v
City or Town State Zip Code
( fag )- 55/- le 4 cis
May be in degrees,
minutes, seconds or
in a decimal format
kit DYb
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
NOftr'77
c. WATER LEVEL Below Top of Casing: 66 FT.
(Use'+^ if Above Top
p of Casing) ���rLLLL
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): 3. 0 METHOD OF TEST��l
f. DISINFECTION: Typ
g. WATER ZONES (depth):
From To ZVO From To
From To From To
From To From To-
6. CASING:
Depth_
From 4 To V
- Amount /242-
Thickness/
Diameter Weight Materi f
Ft.6,27 VIJAY MeC-5*ii
From To Ft.
From To Ft.
7. GROUT: 0 Depth �l Material
From To �iQ Ft. cL fade
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
YO S'
11. REMARKS:
Material
Formation Description
day
f9f,7"nlA
OC
614,4 e
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 - WEL OW
°A5(d6
SIGNATU'T O'CE•' IFIEf CONTRACTOR DA E
PRINTED NAME IF 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:
Gbh ,r, o4--I-s
W II ContractorrVividyal) N�ani
f"c tt1 on S VIER coact Pump, LLC-.
Well ntractor Company Najme
STREET ADDRESS I7 /y7
Lf E.S-bEg Jl7:C 38749
City or Town State Zip Code
-) 5SL_`9&
Area code- Phone number
2. WELL INFORMATION: .yj
SITE WELL ID #(if applicable) 466t/ Qi - 0ar! 5
STATE W ELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable
Box): Residential Water Supply
DATE DRILLED / it/[tider
TIME COMPLETED l(�f,� [[[[[[ AM Er PM 0
ELL
3 W CITY: LOCATION:
ok /'(/f/AA4/COUNTY S,J•COM &--
(Street Name. Numbers, Community. Subdivision, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
O Slope OValley ❑Flat liffrage ❑Other
(check appropriate box)
LATITUDE p 3S / 35.74,4
LONGITUDE OfM
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 �4 L L4
OWNER'S NAME
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS
Mack N. C. 227 I
City or Town State Zip Code
(W )- 777 5349
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ElNO DV
YOSf
c. WATER LEVEL Below Top of Casing: 7 V FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS I 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)-. . METHOD OF TEST 0ry'N ^�'y
20-1
1. DISINFECTION: Type eakMv4. Amount
g. WATER ZONES (depth):
From To )FD From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To/DD Ft. la; 7/41dI /NCs444i
From To Ft.
From To
FL
7. GROUT: 0 Depth ��11 Material j Method
From I.� To .10 Ft. la d/ _�
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
0 — TD
70— 4S
t'S — /OD
11. REMARKS:
Formation Description
Self rc
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 6. E ' ROVIDED TO THE WEL N
SIGNATURE OF ' ERTIFIED -' ONTRACTOR r OATE
ORS kt
PRINTED NAME
F PERSON CONSTRUCTING THE
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.
WELL
Form GW-la
Rev. 7/05
7222

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 440
1. WELL CONTRACTOR. ,
ES
II Contractor Individual)
Na
me
ame
Errant; 11IEI1 a rd Pomp 'LC.
Well ontractor Company Name /
STREET ADDRESS dl �w LE ' thaECL yI/
•
City or Town / State Zip Code
8.Z3 )- a58- 891L
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 67606 - A ate/ 3
STATE WELL PERMIT#(it applicable)
D W Q or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Er---
- %f- 04'
TIME COMPLETED ' `/J AM Q PM
DATE DRILLED
3. WELL LOpATION:
CITY: ‹eie.,S kr COUNTY "Zit p.q-CC
/4�40{/ My'
(Street Nan(e. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat 3*idge ❑Other
(check appropriate box)
LATITUDE 3 r al4 in t
LONGITUDE r: 2- 32• '7719
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: f3(;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 NAME
i al/ �ypvE
ST T ADDRES IP .' 17 g'
City or Town State Zip Code
( Rf )- lag 3 99 a o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Zar'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c. WATER LEVEL Below Top of Casing: . yL? FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated aVo below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
r I e. YIELD (gpm): fir] METHOD OF TESTAIjIj/)drjrj- r q
224
f. DISINFECTION: Type
Amount 2 %< oc.
g. WATER ZONES (depth):
From /f To From
From To From
From To From
6. CASING:
Depth Diameter
From 0 To /01 Ft. 4,4C
From To Ft.
From To Ft.
7. GROUT: Depth
A
From
From
From
To
To
To
Thickness/
Weight
Material
yvc-
Material Method
To a o Ft. Concrete. ")]Q urilyyl
To Ft. J J
To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From T in.
From To in.
o FL_ in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
To Ft
To Ft
To Ft
10. DRILLING LOG
From To C/
fG- /Cif
Size
Material
11. REMARKS:
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED P1 ACCORDANCE WRH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
/2-/T-�l
SIGNATURE OF ERTIFIIED(WELL CONTRACTOR DATE
nPlAAN /JJ' /V e S
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [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 k
1. W CONTRACTOR:
Lhh • lfr
a
W I1 Contractor djvidyal )Namtt-((.vn5 s
WEI Gard Gtlnp, PLC"
Well tntractor Company Name
STREET ADDRESS()yaAjn/i, /
EJ(ES. )Q�(,jy
ir'eSia lV c ar /4g
City or Town l State Zip Code
( )- 5S -W/9&
Area code- Phone number
2. WELL INFORMATION: ^ /ter /
SITE WELL ID #lit applicable) �[J66.— 0 /43 3
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED i/L�rj(s ��11
TIME COMPLETED //too AM PM❑
3. WELL LOCATION: yrk�
CITY: Cowl jf /% COUNTY BOA CO fl be,.
Weaver. S.H.,tth Dn1
(Street Name, Numbers, Community. Subdivision. Lot No., Parcel, Zip Code)
TO GRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge COther
(check appropriate box)
LATITUDE Of 35' 1,44r3q f'r
LONGITUDENQB1•I Y�rC3Lr r
Latitude/longitude source: PS ❑
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 for not using GPS)
4. WELL OWNER
OWNER'S NAME _
SHEET ADDRESS
a iY kZ
te
C4ndle r jrrJ 6727/5
City or Town State Zip Code
( Ratf)- /(027—O2& g
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3/Q 5
b. DOES WELL REPLACE EXISTING WELL? YESI�
0 NO
2
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.
e. YIELD (gpm)t WO METHOD OF TEST JI y.- '4j
3`P225
L DISINFECTION: Type C'GIONr.VC Amount /%7
g. WATER ZONES (depth):
From
From
From
To
To
To
From
From
From
To
To
To
6. CASING: Thickness/
Depth Diameter Weight Material
From Q To MOb Ft. &AS L/i.MS t .S,Qp�
From To Ft.
From To Ft.
7. GROUT: 0 Depth Materialn�Method
From To ao Ft. LC'I LCtte- Axil
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. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
-4S Clay
SS tar steal Dwc
OP' 36 S 6..-wed/ jr-t
11. REMARKS:
100 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 OW R.
SIGNATU E F CE IFIED CONTRACTOR 1 L7ATE
Oafs
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 # 3 / 410
r-t
226
1. WELL CONTRACTOR:
'Br/ALA)/(.//-AES
W II Contractor Individual) Name
E ScNs & Iell and ee fp,
Well ontractor Company Name/
STTRREETADDRESS 37 J fl) (.L/A 7J1E(R (/,
L(
City or Town f State Zip Code
(St R )- a52-- 8yglz
Area code- Phone number
2. WELL INFORMATION: /I /
SITE WELL ID Cif applicable) 4Ot%4
STATE WELL PERMIT#(if applicable)
— 0/A90
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply{
DATE DRILLED /Iet,
TIME COMPLETED IZ -'I v AM El PM Q7
3. WELL LOCATION:
CITY: Lt.C.,F je,- COUNTY 4-,."+ fi
.4/.;t,./..- > cret L. {- .rate //
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:�
❑Slope ❑Valley DEWBttidye ❑Other
(check appropriate box)
LATITUDE 3 s- 7i. 7
LONGITUDE Y L U/- 4,cr—
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: CS6S ❑Topographic map
(location of weN must be shown on a USGS topo map and
attached to this form 1' not using GPS)
4. WELL OWNER
e/%/ter: A/C-- an'c 6
City or Town State Zip Code
( 'nn )- !v to 5 - CQ,e
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3vr
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO (j
c. WATER LEVEL Below Top of Casing: 4/1-0 FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surfaces
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.qtt
e. YIELD (gpmj: f METHOD OF TEST(t'Q(1)Itj3- t
t. DISINFECTION: Type CLe.sti4
g. WATER ZONES (depth):
From wC) To
From
To
From To
6. CASING:
Depth
From 0 To 7r
From To
From To
From
From
From
Amount y kb E+C
To
To
To
Thickness/
Diameter Weight Material
FL ‘"/rr- )1.4CC/ r✓t-
Ft.
Ft.
7. GROUT: Depth Material Method
From F� To `�0 Ft. Co/ILtete 7/7Gfi/YA
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 To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0- 73
73- 7r
it-- 7vr
11. REMARKS:
Formation Description
Uxy
S4/>
t
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/ERTIFIED�WELL CONTRACTOR DATE
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 / 410
1. WELL CONTRACTOR: J� �
Zez.2/N /Ui-IWES
II Contractor Individual) Name
Exc}[e OALs % Jell a#c Pwnp,
Well4ontractor Company Name ter{ /
STREET ADDRESS 73 LEfeES7EGL )kty.
—llrrske- KC'• a77g2
City or Town / State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Or applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box):
Residential Water Supply,g'
DATE DRILLED /2 - 24 - CG•
TIME COMPLETED //;.99 AMP/PM❑
3. WELL LOCATION:/j
CITY: C,C.! ci-s£ COUNTY /v+<s,73'L
(Street game, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope 0 Valley 0 Flat I3' d!ge ❑ Other
(check appropriate box)
LATITUDE 3 r •77 QV 1- '
LONGITUDE Y Z.— ea, Di'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: fj.615S ❑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 ri- //��, /
OWNER'S NAME /)����/�' I��c�est)LT/f4.(j-(O/�/
SxiEET ADDRESS / ✓ / atipo/AdKo CGN2
red,%lr /v C Ag iga o
City or Town State Zip Code
(82R )- 776-353
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2C/1--
b. DOES WELL REPLACE EXISTING WELL? /YES ❑ NO IB-
c. WATER LEVEL Below Top of Casing: 40 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): /
METHOD OF TEST -�q
et
t
f. DISINFECTION: Type Amount .4I o L
g. WATER ZONES (depth):
From /3O To
From j,0 To
From To
6. CASING:
From To
From
From
To
To
Thickness/
Depth Diameter Weight
From D To /010 Ft. tar SP ',
From To Ft.
From To Ft.
7. GROUT: Depth Material
P To ao Ft. CONercjc ?Duci/Y4
To Ft. JJ
To Ft.
From
From
From
Material
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
From To
From To
10. DRILLING LOG
From To
/UT
/Bj`'//Q
//0- luf
11. REMARKS:
Size Material
Ft.
Ft.
Ft.
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WiTH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF uE"RTIFIE�D�WELL CONTRACTOR DATE
P/A/�N /J /t 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 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 # r2e,
3 229
1.W CONTRACTOR:
4�C)bh • WI o s
W II Contractor `ndjvidtlal) Na mi
Fruit
��o/d5 C
lllkf'! &Jbd tan pi I. -LC.
Well U ntractor Company Name y/
STREET ADDRESS I t 1.
1�1(Ps-Mg C.
City or Town ) State
( FM) )-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) o3006 —° r7, ° °9
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED /
Zql/6C?
TIME COMPLETED /4'D AM L3 PM El
3. WELL LOCATION: �I /
CITY:' //11/!(CIL/ COUNTY ISIAcemyAC
PAcep offf
(Street Name. Numbers, Community. Subdivision. Lot No., Parcel, Zip Code)
TOPRAPHIC / LAND SETTING:
Slope ❑Valley El Flat ❑Ridge ❑Other
(check appropriate box) L
LATITUDE N1 3Zr`Q�/fyr
a8riztei
Zip Code
LONGITUDE Win
f
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS ❑ Topographic map
(bcation of well must be shown on a USGS tope map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME p !J
STET ADDRESS 7p T�Je//�(L T 7Ye.
hit/ -/ Lid eu/ NC 2R7.3
City or Town State
(8a18 )- 498.- d 43Cr
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3YS
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [>1
c. WATER LEVEL Below Top of Casing: 4V
(Use "+• if Above Top of Casing)
1
d. TOP OF CASING 15
FT.
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).
/d
METHOD OF TEST
f. DISINFECTION: Typef'4/Q/yk1( Amount /la
g. WATER ZONES (depth):
From To 2l✓S • From To
From To From To
From To From To
6. CASING:
Thickness/
Depth giameler Weight Material
From_p To /pj Ft. 6.2 s 2f6z/27 ',tics -haw
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material
From To 10 FL Ld/Otj
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Material
For a pn Description
day
n1Klvr
if-er6-,-en/7t.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BE 'ROVIDED TO THE WE OW ER
SIGNATUR OF ERTIFIED
PRI
Zr
NTRACTOR ATE
64)11,93
TED NAMF 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 / Tt)
1. WELL CONTRACTOR:
TRACTOR: �� //
/I -A) ZA /Al ES
I�II Contractor Individual) Name --�
Ex ttsaN.s b tell ad Limp) lie,
Well3ontractor Company Naarne G / n,-� % %%
STREET ADDRESS a73 flaw LE/ est i C /jll:II.
/i� C' aY'Reg /
City or Town / State Zip Code
2;78 )- 52- 8i{9Lz
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 g
DATE DRILLED J/'7..-di
TIME COMPLETED 2 L e v AM O PM IS
3. WELL LOCATION:
CITY: Tars/ COUNTY ,6£,..r..Je
Z/T7 40 �rAkc' f
(Street Name. Numbers, Community, Subdiasion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat Idge ID Other
(check appropriate box)
LATITUDE 3 37.4 c1`I.
LONGITUDE r Z' .i C. 78t
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ptiPS ❑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 /ldr kc 68Col ,n
STREET ADDRESS 4(3 ,f7 4i kat -
nes\hawkr\C 818
City or n Stale Zip Code
(`h2•8 )- 45 P._65 I2
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: re} 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 jj
(gpm): METHOD OF TESTA JplL�ijtr
r
r.
2 3 0
f. DISINFECTION: Type e/✓-
''�' Amount -a at
g. WATER ZONES (depth):
From /6t' To From To
From Z,f To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To C S/ Ft. Cite— fl', y/ lwZ..
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From P To a` o Ft. Co/Icicle, `liy uthv4
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 Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0els Lissy
1i - {/r/ s4//
toot- 2i,' /sx..//c
11. REMARKS:
100 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.
leAz1
SIGNATURE OF CrERTIFIED WELL CONTRACTOR
PI A• -
ede,
DATE
/Ve S
RINTED NAME OF PERSON CONSTRUCTING THE,NpT4 . --
"qti `:.
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 / ¥C
1. WELL CONTRACTOR:
-Bkt.4-/1% W /•/F ES
11 Contractor Individual) Name
WellgozSONs 1p(fell and �t�mp
Well ontraclor Company Name G 1 f�-C/ I jI�
STREET ADDRESS 3/3/ Ato LL% L,EJ fEt Ik .y.
-le ske_ /K C' ra8 r7gg /
City or Town / State Zip Code
(S }3 )- 5 & - 8'-i9 Ce
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable) Chi 0 0 (Q - o a v9 s
STATE WELL PERMIT#(It applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply 1
DATE DRILLED 1/ ---A) 04 /
TIME COMPLETED /I; 3c) AM(g PM❑
3. WELL LOCATION:
CITY: he 4/111C
sel fl L'OY-L
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley ❑ Flat I!t dge ❑ Other
(check appropriate box)
LATITUDE 3 $= No. VA
LONGITUDE t 2- 7). qzd'
COUNTY An cuew..
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Er6PS 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 T /
OWNER'S NAME XiN ., (.4/Vie el
STREET ADDRESS T. 0 60 St / 833 /
es.Aev,7fe r)7 agsL-1
City or Town State Zip Code
( _)-213I-l0N
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 2 All
b. DOES WELL REPLACE EXISTING WELL?
YES 0
NOV
c. WATER LEVEL Below Top of Casing: G L1 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 0116
e. YIELD (gpm):
METHOD OF TEST - r7
L DISINFECTION: Type (^✓c. ,a
g. WATER ZONES (depth):
From /�I. To
From 2oJ To
From To
6. CASING:
From
From
From
Amount 2 oz
Depth Diameter
From 0 To J-7 Ft. G.:/L>t-
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
'r"'L!
7. GROUT:n Depth Material Method
From p To p%0 FL ConCrefe. peurin1
From To FI.
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
From
To Ft.
From To Ft.
Size
in.
Material
From To Ft.
10. DRILLING LOG
From To
0- Vr c/y
SO- •.1) .i4ed
11. REMARKS:
Formation Description
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 CERTIFIED WELL CONTRACTOR
P/A/dN h1 L(Jr, ves
RINTED NAME OF PERSON CONSTRUCTING THE WELL
ff-sr-4X
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

City or Town
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # J / T6)
1. WELL CONTRACTOR:
&ii+i wines
I�II Contractor (Individual) Name -�
fEr cOw; h Je/i an d Liz,
Well ontractor Company Name3 ,
STREET ADDRESS 7& LELCS7EC
City or Town / State Zip Code
(8,S )-Stich_
Area code- Phone number
2. WELL INFORMATION: step
SITE WELL ID Of applicable) �D e j 3 Y'l!
STATE WELL PERMIT/SO applicable)
DWQ or OTHER PERMIT #(if applicable) —/
WELL USE (Check Applicable Box): Residential Water Supply LF
DATE DRILLED //-11-196
TIME COMPLETED /�•'•T D AM Y7 PM YID
3. WELL LOCATION:
CITY::41,,iss>'I(i
X//esto/.r /s�11
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:�
Rld
❑Slope :Valley ❑Flat Oge ❑Other
(check appropriate box)
LATITUDE 3 3— 3Y, 4ptr
LONGITUDE r L (-l'4, 4/0)'
COUNTY ,8"-e-s`4
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: &CI'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
S EET ADDRESS
e�llle 4,�grnan lo
�C �880 l
Stale
Lam-)- 7 71c•-19 r
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
44i
Zip Code
b. DOES WELL REPLACE EXISTING WELL? //YES 0 NO Q'
c. WATER LEVEL Below Top of Casing: h FT.
(Use'+' it 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 .001Q118.
e. YIELD (gpm): / 1/2 METHOD OF TESTA InitLrAf.-�r
f. DISINFECTION: Type CJv--'>1 a
Amount cri-
g. WATER ZONES (depth):
From 3c.' To From To
From err To From
From To From
6. CASING:
Depth Diameter
From 0 To /71- Ft. /,,,/L,-
From To Ft.
From To Ft.
To
To
Thickness/
Weight Material
Lik72/
7. GROUT: Depth Depth Material Method
From P To so FL CO/trek. iLlinlai
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
From
To Ft.
From To Ft.
Size
Material
From To Ft.
10. DRILLING LOG
From To
0- /22
/77 /7i
/7t- C-t.r
11. REMARKS:
Formation Description
C/c7
%gHc�.7f+•a t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W nH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
*eta: e4,4400
SIGNATURE OF ERTIFIED WELL CONTRACTOR. DATE
D14A-A, la,;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. 7105

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:
ZerI.4--IJ 706 YES
I�II Contractor Individual) Name �
fEe [r:saNs blel/ add hemp) ,(LC.
Well ontractor Company Name 1/ J
STREETpADDRESS 37031 , & LEteESit &Ey.
City or Town 7 State Zip Code
( )- La5?-- 8'�9Gz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
be& —o12g9
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q'
DATE DRILLED tiod -Of
TIME COMPLETED 3 ..70 AM ❑ PM De
3. WELL LOCATION:
CITY: , ,4 Lai COUNTY Zit:. air
%'red' Gt:a get° Z.,- #/5
(Street an/e, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TO9OGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 f 427.7/3"--
LONGITUDE Y L .77. s/'f'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: oCS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Y not using GPS)
4. WELL OWNER OWNER'S NAME xo4 -/ GSJ �f� J�tk „1/4/d �r' / »
STREET ADDRESS
f/c-kie✓ /Vl c:Q 3ot.
City or Town
(ge2N)-A373�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
State Zip Code
J1 i
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 21'
c. WATER LEVEL Below Top of Casing: Y 4 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.jfin(
‘11-) METHOD OF TESTAibb tirR9
e. YIELD (gpm).
p r 6
f. DISINFECTION: Type �'/m-..Y Amount .2 r/L 6L
g. WATER ZONES (depth):
From 247f To From To
From jJV To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From V To irk Ft. ,saw jP4 4-
From To Ft,
From To Ft.
7. GROUT:n Depth �rMaterialL
From f) To No Ft COWre/e
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
From
From
Method
in.
in.
in.
Material
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
O- �S
ss- LV
Formation Description
Cloy
.q . -7or Colcn.%Y
11. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE$Nm1
1 SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
//.27 -t*
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
r;AA-N ILf 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-1a
Rev. 7/05

Town State
(e Cilia(
1(75 - Q4(.6-
Area node - Phone number
5. WELL DETAILS: ^(n�
a. TOTAL DEPTH: IX ar
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti 21 S0
337549
1. WELL CONTRACTOR:
Can2v S+)S4ICE
Well Contractor (Individual) Name
Jost-icr W e Li. b LL; 6.11
Well Contractor Company Name
STREET ADDRESS .3 DLj 5 VS 7O W
ik,c;corTo�wn Mate 2 R7 z
Zip Code
(eze ). 7211-451
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID Wit applicable)
STATE WELL PERMITWif applicable)
DWQ or OTHER PERMIT tiff applicable)
WELL USE (Check Applicable Box): Residential Water Supply f�
DATE DRILLED I2-20 -Jt,
TIME COMPLETED AM Q PM O
3. WELL LOCATION
CITY: A 1N(,h COUNTY RLLikol_ip{
(Street Name, timbers. Community, Sub6vieron,.LLot No.. FI. 3ceI, ptoae)1
TOPOGRAPHIC / LAND SETTING:
❑Slope fei' ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 .S 32, 97 Ai
LONGITUDE € Z zi,•«6`td
L9titude/longitude source: nQ1 S ❑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 NAM
STREET ADORES Rz4b -C
May be in degrees,
minutes, seconds or
in a decimal comsat
Terra Pr.
i4'K. D N ji C 2 t1 oN
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cr
e. WATER LEVEL Below Top of Casing: y O FT.
(Use'+1 if Above Top of Casing)
d. TOP OF CASING 1S 11lC. FT. Above Land Surface'
'Top of casing terminated N/ar below land surface may require
a variance n accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Ji 0 METHOD OF TEST 14 )ft
f. DISINFECTION: Type CLatellot Amount 8 02-
g. WATER ZONES (depth):
From To From To
From i9O To iqo From
To
From To From To
6. CASING: Thickness/
From Deppth Ft. Diameter Weight Material
From 0 To Bef Ft oik From $.7 To qj Ft. G 1/7 i i1Q 4�2/� 1-�
7 --
7. GROUT: Depth Material Method
From To Ft.
qt.�---ter— -�-�
From ° To �FL YY� 4p 71 �.aw
From To Ft --�'-�
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Ran To FL in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth - Size Material
From To Ft.
From To Ft.
Ran To Ft.
10. DRILLING LOG
From To
d- 80
96- Z25
11. REMARKS:
Formation Description
ID i rz t
airz.-r-
n rt h ltrito
H_;; rtrwATFPnur))ry
/AN F+ h 2007
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTnUC1Ep N ACCORDANCE WON
ISA NCAC 2C. WELL CONSTRUC/IDN STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
rP
URE l9F CE ED WELL CONTRACTOR Z 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 REcau)
North Carolina Department of Environment and Natural Resources- Division of Wan Quality
WELL CONTRACTOR CERTIFICATION #- att aka
337509
1. WELL CONTRACTOR
QA'C; e k VmO —kb. �Risa�1C' C S
Well Contractor (Individual) Nane -
C\,, cL'2 ' &Do..yye{ s$ E G
Well C Company yU V Naraahep
STREET ADDRESS ,5'f aoc
t-‘o4t. 5Tr;hes) Nc a8''t.43
City or Town a -Zip Code
($ } ta(oS— ac.aa,
WELL USE (Check Applicable Box).
DATE DRILLED // o
TIME COFAPLETED /'On AMO PMQ._
3. WELL LOCATION:
CRY::,54/Pe/t /COUNT
Y E577L4,--00,4
{Sheet Name. Numbers, Comm uSub .ion, Lot No.. Pamel, T¢Code)
e)-iY/m w�Gii/j
TO RAPHIC /LAND SETTING:
IOValley ❑Flat ❑Ridge DOOrer
(cheat attar box)
LATITUDE _„ _
LONGnUDE_ _
Latitude/longitude solace: ❑GPS °Topographic map
(bcation of vier must be shaven on a USGS typo map and
attached t0 Ltis four /not psi g GPS)
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mitamplicable)
STATE WELL PERMIT/(7tappticable)
DWQ or OTHER PERMIT 3(ifappfcabte) 05- 03i(cr'.
Residedial Water Supply y
May be in degrees,
minutes, seconds or
in a decimal format
4- WELL OWNER
OWNER'S NAME
?1,1; j ecru
STREET ADDRESS 5Q '& tve'r tLc&:J1L Lc'.vLQ
195'vte Ile \ PC 98B05
City or Town State Zip Code
(R as - ;Th3- iictLk?
Area code - Phone number
R WELL DETAILS:
a TOTAL DEPTH: �`�
b. DOES WELL REPLACE DUSTING WELL? YES D NOV
c. WATER LEVEL (debt Top dCasing: r2'9 Fr.
Nees" if Above Top d Casing)
d- TOP OF CASING IS ' FT. Above Land Sur face
'Top d casing terminated aVor below land surface may require
a valance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): .3d METHOD OF TEST R'S%
t DISINFECTION: Type 1%is
Amount 7
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
.�
6. CASING: o' Thichas
From I Depth
R. D1 -CC.. . eight
From To R.
From To Ft.
7. GROUT: Depth
n Material {
From 0 on
To o R. Centers-
From To Ft.
From To R.
Meted
'thee 4
8. SCREEN: Depth Dia natter Stet She Material
From To Fi. in. m.
From To R. = _ in.
From To R. ir,. in.
9. SANDIGRAVEL PACK:
Depth
From
Size Material
To- Ft.
Rom To Ft
From To Ft
10. DRILLING LOG
From To Formation
yri bore
°
11. REMARKS:
RECE!VEO
Ilitrrrp Fsa)r Li
1 DO HEREBY CERTIFY -MAT TUBS WEL L V 'AS CONSIRLCIED N ACCORDANCE WIN
IBA NCAC 2C, WELL CONS1RUCILIN STA HOARDS. AN.D IHATA COP! OF WAS
RECORD HAS BEEN PROVIDED TO THE ELL OWNER.
Z—�
SIGNATURE OFF I LFIED WELL CONTRACTOR DATE
' SIP sN. Ck iAte.'t b. stA
PRINTED NAME OF PERSON .:CINSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information NIX,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105
',r

RESIDENTIAL WELL CONS, RUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of VW ater Quash
WELL CONTRACTOR CERTIFICATION # - 3t.
1. WELL CONTRACTOR:
�z tee; C. .ems >r. -ie s
Well Contractor (Individual) Name
Z.\ JJc�Q ' 'SGt.a1C-C4 * S n
WSI Culdiai.h+i Company N
STREET ADDRESS V"\2% YtLa7 QOq
1-ko'r c;t\Q a8.1-13
City or Town e -Zip Code
( 8'r (n(oS-
Area rode- Phone number
2. WELL INFORMAT)OPC
SITE WELL ID #(Iif apPnrsble)
STATE WELL PERMMTgaravpiicable)
DWQor OTHER PERMIT tt(d.&i.a) 0B Q15'1t
WELL USE (Check Appr Box): Residentra( Water Supply e
DATEDRILLED M.a(�6. TIME COMPLETED / $Q AM ❑ PM ¢3�
9. WELL LOCJA /
CITY: /t P./�.. COUNTY /cri/C ossl '
Ct 4.7.- ,& ACboCMQC.dC
Lot No.. Parcel. re Coda)
ff
{Sh�Naisre. Numbers. Community. Sr+okL
TORAPHIC / LAND SETTING:
%/Slope OVaRey ❑Flat ❑Ridge In Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS oTopograpinc map
(location of wet must be shown on a MSS topo map end
alrai.h,e,f to this fomr'not using GPS)
IMay beet s,
minuets, seconds or
in a decimal format
A. WELL OWNER OWNERS NAME !� ) ev co Q ,n 1
STREET ADDRESS ti"is4 "M.A.:te'CSM er%v-t fe
Zip Code
City or Term State
(9 213 r -a.3 01- 0 ata<
At code - Phone number
S. WELL DETAILS: .�
a. TOTAL DEPTH: - 141
b. DOES WELL REPLACE EXISTING WELL? YES 13 NO /
c. WATER LEVEL Sela*Top of Casing (20 FT.
(Use •+' 1T Above Top Of Casing)
d. TOP OF cASPIG Is \ . FT_ Above Land Surface'
'Top of casing terminated at/or be 0w!and surface may require
a satiate in ciW.1u^JTa,,,,e wit 15A NCAC 2C .0118.
e. YIELD Wpm):!(/ METHOD OF TEST_2.S--
337513
f_ DISINFECTION: Type 4aI \.5 Amount /Z
g. WATER ZONES (depth):
From To Fran To
From To From To
ROM
To Fran To
Tbiclaress/
Dept Di>" 'g I
o dFl. b
6. CASING:
F
From To
From To
R.
FL
7. GROUT:Depth Mate
Rom tt�� v To r210 FL CerdYt-'F1t
Fr
From To Ft.
From To FT-
8. SCREEN: Depth
From To
From To
From To
9. SANDIGRAVEL PACK:
Depth
From To
From To
From To
Dianeter Slot Sae Material
Fi. = . m.
R. g:.. in.
R. _9. In.
Ft.
FL
Size Mar!
Ft.
10. DRRUNG LOG
From To _ U — Formation Dcs4.4 wig
t AO 6r
11. REMARKS:
.i`'. 2 6 2007.
100 HEREBY CERTWY THAT T LIT 'AS
CO3-CIDi 9mM
15ANCAC 2C, WELL CON5m ' .MD THAT A �
RECORD HAS BEEN PROVVED TO TM: eat OWNER.
SIGNATURE OF CERTIFIED
ONTRACTOR DATE
It
PRINTED NAME OF PERSON _ONSTR:UCT' G THE WEU.
Submit the original to the Division of Water Quality within 30 days. Attn: information
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7N5

- RESIDENTIAL WELL CONSTRUCTION RECORD
Nortb.Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. WELL CONTRACT/OR: .
1 Contractor (`Individual) Name
f
E 0co/VD ./.( fen aacz Uh1p uC.
Well ontractcw Company
Name r
STREET ADDRESS 3 /3J ,E&U L/
/ei'lf&}Ft Ai (1 . .:28 �yg
City or Town / State Zip Code
(2A )- 5 2-- S q{91,L.
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 fl/Appplicable Box): Residential Water Supply p�
DATE DRILLED 7-G-06
TIME COMPLETED S ,-JQ
AM ° PMp
3. WELL LOCATION: ,a77
CITY: Si...Y no AIr, COUNTY Xt. rd.-144.
514-1n/s
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
7Slope °Valley ❑Flat ❑Ridge ❑Omer
(check appropriate box)
LATITUDE 3 t" ?% erg'
LONGITUDE r Z z3,
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 413S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not usurg GPS)
4. WELL OWNER 1 /
OWNER'S NAME C6154( .Lq.sk/1y, GSI 11
STREET ADDRESSA3 LLi I f.(AY �EjEjj,
u\e Y\C acts%s
City or Town State Zip Code
((la%t )- aqerk-34p1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Jzr
b. DOES WELL REPLACE EXISTING WELL? YES Cl NO 0
c. WATER LEVEL Below Top of Casing: G T% FT.
(Use -+• if Above Top of Casing)
d. TOP OF CASING 15 ' FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (grimy.70 METHOD OF TEST
•
� ' A6
eJ v f U8
f. DISINFECTION: Type eh-- Amount 24/7E6
g. WATER ZONES (depth):
From /-(200
,1
From 01) To
To
From To
6. CASING:
From
From
From
To
To
To
Thickness/
Depth Diameter Weight Material
From a To re- FL L. ,Ir San / ..s
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From /9 To A Ft. CO/IC R c. ?Did f;N4
From To Ft. ;Ali
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
To Formation Description
b -J y
r'/-r4 k,/
ra-7zr Gr- ,E
11. REMARKS:
-' i 9 200b
r el
7
t
J
0'
1 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.
476- air
SIGNATURE OF CrERTIFIED WELL CONTRACTOR DATE
D/AA-N / /, L[J,•
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.
Fonn GW-la
Rev. 7/05

7
1a smi.iaOng- . uz.WINOWarm.paeM GI nlional'R"""'°''oa.wUrs.a�on
fr
WELL CONSTRUCTION RECORD WRLOOIIRIADTORr A ttAAan IA 11 JJX
WM.CONTRACTOR GIBITIFIOATION11:A11,E
STATE MU. CONSTR IC710N PEIEE1.s
cos
f.5
cn
1. WILL USEI_Lokerk AR...Y.. o RoskimS fl TA.IdoGY 0 " -i O AplelN..10 rber.rq
A.os.r7O Had Flaw Wan Inpolbn 0 Ole [I IOl er.I* ua.e
a. WIi1. wouret pT:r. bo.rwr OW
N.rTOert m � �r r ?
r..0 rYr rube,
mans 844Nan amrarieratitkiirtlm W wwy
S. OWNen V vi r&f7 CO-21
AddnM l;:3
ZrilADIAJILLQCSImeriAir
gorTww SIMs
4. DATE DRE.LEO l `!
S. TOTAL DEPTH
0. CUTTSIOS COLLECTED YESO NOE(
7. DOES WBl REPLACE EXISTING weu.I YES ❑ N
a. STATIC WATER LEVEL Ws Tap elOM W FT.
S. TOP OF CASINO W T.FT. Above lard S.r1°
9.poraim konbr.ldsettWks ra/swim r.plb.s was km.MF
d.rwa.tt MANSACSCaiM
10. YE ti thpn x an menu) wren
1/. WATER ZONES (Spar
Stldo
<s , , <<,-(.,
sass_
LOG o_rH
I T. s Til (+
ctrrerlon.
Yf III .
SLY%( -Hon
of) `S
12. CHLORINATION: Typo /Amend
13. CASINO:
From1
_TTO r 0I FL
Frmn To FL
From To R
14. GROUT:
VAN Thicrwerr
r WryMR
Flom ___ To �R + W f MMad
Fmm To R
1S. WHOM
Daplb Olomoltr Wol Ski
From . To Ft _ In. br.
From __,To R__ In.. k
From To R. lit In.
it SAND/GRAVEL PACK
Dopes
From To
Ram To_
17. Tie
FL
R
1A.lorltl
T.dnl.rlnon bnordd.Mbook ofbun
1rPITION SIO?TCH
awe tionlon ond bom
Asa or ohr mop
ese
VLLJ
F� (DUAUTV
JAN it 5 2007
on%wIScvn Lei ;city-'L&
1oo mew CERTIFY THAT MG MULL WAS OCINTNII1IED fN AccOmomellWRN 15A WC SG MEAL
COImm,Cn0METAWAlaAND 1HATACTT
OFTHIS16t
INSNENFRONDEDTDTHEWELLOR
FOR OFFICE USE ONLY 0 /f vT7�
air a Mw.
S al
�.w e•lrtw..i1c..r.Irrwru.MiolO deybetinte aTE
.
f1Wd Iler. PIN
tuna.!noona esniu soT1al trpL
FEB 21 2u .`

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Re ou ces - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)NAME _( flat) (/ it s'
WELL CONTRACTOR COMPANY NAME 7J7L /W/ i( CENEIFICATIO�NpY 3'/�tpYpb�te�
Zn(C. PHONE it�28)�%
STATE WELL CONSTRUCTION PERNIIT#
(if applicable) ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential W MunicipaIfPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Purnp Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N: ��"�
Nearest Towt,sw�nnanoa County e>britt;p74_,
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address ( ACO
Its I eal (Street orRouteNo.)
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED 0 ( 66
5. TOTAL DEPTH:
Zip Code
Topograp+lc/Land setting
❑Ridge pSlope DValley OFlat
(check appropriate box)
atitude/longitudeofw'ell,Ioc t'
35 a35. 555 WoX $.,z,
(degreeslminutestseconds) 23 d
Latitude/longitude source:DGPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO I'3
r 1
7. STATIC WATER LEVEL Below Top ofCasing: /60 FT.
(Use "-b" if Above Top of Casing) i\\
8. TOP OF CASING IS / FT. Above Land Surface* �'
"Top of casing terminated at/or below land surface requires a M1
•
variance in accordance with I5A NCAC 2C .0118. /]��� c-)
9. YIELD (gpm): / t'D M, j DDQ ST e7Ai • Codoie�, �'
10. WATER ZONES (depth): a/L�SQQ Gdi
11. DISINFECTION: Type J AK"3ICF Amount z
12. CASING: Wall Thickness
From`— To i 3 r
From
From
To
To
13. GROUT: Depth
From To
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Diameter or Weight/Ft.
Ft.
Ft.
Ft.
Material
•nCre -
Material
Method
u�
Diameter Slot Size Material
Ft. in. in.
Ft. 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.
71jlll-;,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION STANARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ //r P
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/0 _3/ 0 )
D
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
L CONTRACTOR:
&'oh/ V'' (rJr a
tW II Contractor (pdjvidppal)r�Namy
Ekotitsok.s ?U Ell ouct pp LLC.
Well �Cbontractor Company Name
y
STREET ADDRESS L I
LiIteS gg ACC as"71
Zip Code
City or Town / State
(.'Spp
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) 4 00 6 - 0 arsyy
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED
TIME COMPLETED / too o AM ❑ PM L'(
S
3. WELL LOCATION: !L
CITY: StWedW4f/O4j'J R COUNTY iAz1(.04 -C
(Street Name, tiers, C iunity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT!
❑Slope OValley 0 Flat idge 0 Other
(check appropriate box)
LATITUDE A/ 35 r It, 7// ft'
LONGITUDE
latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form "not using GPS)
4. WELL OWNER am /l
OWNER'S NAME I^r)YCh rdf ` rlh-"C-5 S
STREET ADDRESS r7.(5j L'ENt(4I lijez.u._e.
�tAJmnnc.ru•rlle S.C. a,gtFR 3
City or Town State Zip Code
tAD-B >• 71 a-orlgo
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
GOSr
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: /CO 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 (ppm): R METHOD OF TEST
, y
?35167
f. DISINFECTION: Type Cl/erINe Amount
g. WATER ZONES (depth):
From To ` 0 From
From To From
From To From
6. CASING:
Depth
From A To 70
From To
From To
Ft
Ft
Ft
�$Dy
To
To
To
Thickness/
Diameter Weight Material
br%s ftiC5,94 tl
7. GROUT: Depth Material Method
From 0 To an FL&(CfETff
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
& 5 - >D stock
70 — (aO5 O MN/1G
1. REMARKS:
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WfDI
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGN/ E CERTIFIED CONTRACTOR
(dJr` OHS"
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

WELL CONSTRUCTION RECORD
335698
North Carolina - Department of Environment and Natural Resources
//- /Division of Water Quality - Groundwater Sect,io`n,,
WELL CONTRACTOR (INDIVIDUAL) NAME (print) O L1-)�i CERTIFICATION#2'7/8
WELL CONTRACTOR COMPANY NAME Greeno-F/l.ers VG.0 OUOC/ffl % PHONE # fP29)4413'3/70
STATE WELL CONSTRUCTION PERMIT# f90 2—
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential e' Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other [' If Other, List Use
2. WELL LOCATIO : -
Nearest Town: /3)7CVLUC
i cot14-1-1 L.14
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
J3. OWNER: OhI� Eshr' e
Address 34 5#acbwood LI- &>f1.
County (3unc15)Abe-
10
e tit
I M((Street or Ropty, No. )
N(� ze€03
City or Town Stale Zip Code
($Z )- 231- 7575
Area code- Phone number
4. DATE DRILLED // /7.D 6
5. TOTAL DEPTH: $ 65 '
6. DOES N'LLI. REPLACE EXK ! K[U WELL? n o ES lUt nu)
7. STATIC WATER LEVEL Below Top of Casing: /0 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 accordanse with ISA NCAC 2C .0118.
9. YIELD (gpm): -1/Li METHOD OF TEST S /14)UrS
10. WATER ZONES (depth): 305 '
505
11. DISINFECTION: Type /-17/
12. CASING:
Depth
From 0 To 25 Ft.
From To Ft.
Amount
Wall Thickness
Diameter or Weight/Ft. Material
6" PVC
From To Ft.
13. GROUT: Depth Material Method
From 0 To zD Ft. CB/Ylen7 To n
From To Ft. i_
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
['Ridge ❑Slope ['Valley lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
0' Z5'
26' 865' fit
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.
JAN 02 2007
16. REMARKS:
RncvNFEt RE�)rl`[‘,
y IC)Uk'
yki
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/L -‘ --0 6
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 CONS RUCTION RECORD
North Carolina Dcpanment of Environment and Natural Kr gum- Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 24-0
1. WELL CONTRACTOR:
(� ea,-- be Cr- 1d.w e, I I
Well Contractor (Individual) Name
«evLbe,n Caldwell Ori I \;n5 1AC. .
Well Contractor Company Name
e 1e
STREET ADDRESS SS I e W LQ-) (..e.S ter Hui
ShevilIe 1JC at b
City or Town State Zip Code
(Sa`d )- a54 - 55? l
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mli( applicable)
STATE WELL PERMIT/SWapplicable)
DWQ or OTHER PERMIT M(if applicable)
WELL USE (Check A/p�plipable BoJ;):: Residential Water Supply
DATE DRILLED C 1 / 1 %/ OG
TIME COMPLETED t a ^ t t AM p PM t/
3. WELL LOCATION: 2.m` /��
CITY: SWAw1.TA.3 crA COUNTY &a'7"k'�Fi
4-v3 14AcL(LLSbrC 411.,L Rcns
(Street Name. Numbers. Community. Subdivision. Lot Na.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope [Valley ❑Flat [Ridge ❑Other
(check appropriate boa)
LATITUDE 3 5 31, aq/-3
LONGITUDE& D.Q—• 17YJ
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: upCcl'i S [Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER �/ ,.rW�
OWNER'S NAME ON A (t4( G a )
STREET ADDRESS Al413 I' t -el,S OAJ 1-1I ..20
S W A N /J A N.1 6 A 1-Z al -} 1?
City a Town State Zip Code
( )- 686-o003
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 0 0
b. DOES WELL REPLACE EXISTING WELL? YFyS NO ❑
c. WATER LEVEL Below Top of Casing: 1,-) /A FT
(Use'+' if Above Tr c( Casing)
d. TOP OF CASING IS AL FT. Above Land Surface'
'Top d casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .01118. e. YIELD (gpm): ° METHOD OF TEST 9 1/4G --A t f�I
✓
9
I. DISINFECTION: Type e' Amount
WA1 ER ZON (depth)
NY c
From qv From To
From To From To
Fran To From To
6. CASING: Thickness/
From 1
II Depth.,
To OcIIa eter Weigh . �.(vtpelial tt F. _1LLl-_, Y`(
From To Ft.
From To Ft
eft ot <d4
7. GROUT:Depth �] Material et Meth
1
From To r+k,0 Ft. CELM3� r0-1,)
From To Ft.
From To FI.
8. SCREEN: Depth Diameler Slot Size Material
Fran To Ft. in. in.
From To FI. in. in.
From To Ft. in in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Fro t Tt S /
\5`- men ��6r1{a1r
Ft.
FI.
FI.
Size
Material
Fprma�tl�on Descript. n
RECEIVED
DIV. OF WATER f(JALITy
OCT Q
ECEIVED
OCT 17 2005
11. REMARKS:
` euiIl Regional Office
'1'•` 1/1/4 "kg, rif?r Protection
I DO HEREBY CERTIFY THAT m15 WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF MIS
•
RECORD HAS BEEN
jPRROVIID_E�(D %/�
TO THE WWEL�L��O�WN�ERkQQQ
SIGNATURE CERTIFIED WELL CONTRACTOR 1 DATE
It l-bg t S4-.„
PRINTED NAME OF PERSON CONSTRUCT NG 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 \YELL CONSTRUCTION RECORD
North Carolina Dcpanmcnl of Environment and Natural Resources- Dicnitro of \Vatcr Quality
WELL CONTRACTOR CERTIFICATION s
1. WELL CONTRACTOR:
Re been C-alA04(
Wen Contractor (Individual) Name
ZQu 0e �� C-0.l&u,€U cCinf l I l t1g ` 6C.
Well Contractor Company Name- \
STREET ADDRESS J 1 t^L_t" Hwy
(ksh,ev; lie 1JC ���� 6
City Of Town State Zip Code
(gag ,. a54- - 3 58 )
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(it applicable)
STATE WELL PERMITS/Ur applicable,
DWQ or OTHER PERMIT #('d applicable)
WELL USE (Check Applicable (jad f Residential Water Supply (�
DATE DRILLED
o
TIME COMPLETED ' i" 5 C AMR( PM
3. WELL LOCCATIION:/ 1/4T /1
CITY' '1S``6JLt-l-d COUNTY 'N1V Iti C1 fh10E.
3ti (� I u bJ u-at t b r•-(4a
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS S-I W\ 6., LOW CP-tt K Qf-
ASt-teo( n c. aiNO3
May he in degrees
minutes. seconds or
in a decimal format
(Sheet Name. Numbers. Community. Subdwaron. Lot No Pwcel. Z,p Code)
TOPOGRAPHIC! t / D SETTING
❑Slope [Valley gnat °Ridge °O!her
(check appropriate boa)
LATITUDE 3 5 53 305
LONGITUDE ' & Mr.
Latitudeflongitudc source: 1 PS °Topographic map
fbcaGbn of we/ must be shown on a USGS tom map and
attached to this form l nor usng GPS)
Ye-1 i y hl0 u Se- r
City or 'foam Slate hp Code
(5s&% r aD6-- 4-411
Area code • Phone number
5. WELL DETAILS: _
�T
a. TOTAL DEPTH: ola
b. DOES WELL REPLACE EXISTING WELL7 YES 0
NO el'
c. WATER LEVEL Below Top or Casing LI 0 FT
(Use -•' iI AboveTood Casmq )
d, TOP OF CASING IS } FT Above Lard Surface'
-Top or casing terminated aVcz below lard surface may regime
a variance n accordance wnh I SA NCAC 2C 0118.
YIELD (gram) OHO METHOD OF TEST R\G -A led
ak4-D
V.DISINFECTION: Type 0 q 0 A
q. WATER ZONES (depth)
From 115 To i From
From To
From To
6. CASING'.
Dept��]
From 1 To-1 3
From To
From To
7. GROUT:,{ Depth
From 1 To a-b
From To
From To
8. SCREEN
From
From
Frorn
Depth
To
To
To
9, SAND/GRAVEL PACK:
Depth
From To
From To
From To
10, DRILLING LOG
Fro ^ To/ s
RCS'- 115'
115'-(So'
IRD'— aa55'
II. REMARKS:
FI
FI
FI
From
From
3 n 2
r
E��e�2
Amount
To
To
To
ThicNness/
Di�r ,el^r &Urs l� M i C.,
Material
FI. Ceralt01-
Ft.
Fl.
Method
Diameter Slot Size Material
Ft.
FI
Ft
Ft.
F1.
Ft.
in.
in.
in.
in.
in.
Size Material
Foffmation Description
15vsK6V,213t31�
2q 41Tt
(c.e - at G eon
e ALA
d
n
IERJNF RE Rs CFRTWY THAT 1141S WELL WAS CONSTRUCTS(' N ACCORDANCE Wmy
ISA Nrar: Jr WFl 1 CONSTRUCTION STANDARDS AIR) THAT A COPY r DOS
RECOnn ne^. EN PROoOFO TO 04 WELL OWNER
GrooL,4 &ob
SIGNATURE OF ERTIFIED veal CONTRACTOR
S1ti-ug 6JA31-4
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 Natural Resources��- Division of Water Quality - Groundwater Section
\V ELL CONTRACTOR (INDIVIDUAL) NAME (print)/,,^kt?y J'Jtt o( CERTIFICATION =pOCIC s
St ELL CONI R.\CTOR COMPANY NAME F i t7\ War'11 A N thl611 �t ; (`{NC.{ PHONE k ($ )493-9�23,
STATE WELL CONSTRUCTION PERMITS 1 1 ASSOCIATED tC'ERMIT:
(It applicable) bt appl cable)
i. WELL USE (Check Applicable Box): ResidentialMunicipal/Public ❑ Industrial 0 .Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOC.ATI N:
Nearest Town: CNTLY11VPiL 7P
CountybI�tCDNA.
TopograRbretand setting
❑Ridge fl ope ❑Valley ❑Flat
(check appropriate box)
(Saxe; Name. Numbers. Community. Subdivision, Lot No.. Zip Code) Latitude/loneitnde of w II IOCanon
ac,� , N,3°SG���a°a 04
3. OWNER: � (degreesiminuteslsecondstele% o251+
Address �� Fie � Latitudellon_itude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
(Street or Route No.)
Sig hlNrtN6es RC_ 2 7 7g
City or Town Stale Zip Code
1'
Area code- Phone numb
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL9 YES 0 NO E
7. STATIC WATER LEVEL Below Top of Casing: Jac 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 accorda r'with ISA NCAC 2C.0118.
9. YIELD (gpm): METHOD OF TES1C7A �• l ptI i�
10. WATER ZONES (depth): /63_r 33Crs
11. DISINFECTION: Type la CAL Amount ,2
12. CASING: Wall Tnickress
Depth Diameter or Weight/Ft
From To r1-6 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From To 3 Ft
hron1 To Ft
14. SCREEN: Depth
Prone
From To
15. SAND,/GRAVEL PACK:
Depth
From b
t rom
To Ft
Material
Diameter
Ft
Size
in.
m.
Ft.
To Fl.
Material
slot Size Material
in.
in.
:Material
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
SEP -i a 2305
cn
rn
VI
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

324397
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesu'-/Division of Water Quality - Groundwater Sectionti[?
WELL conizACrOR(INDIVIDU.AL) NAME (print) kfllg,Yy Wyit{/(k %� CERTIFICATION#/N�o oG
WELL CONTRACTOR COMPANY NAME A�palAeht AI ^AkW 1irlt{li eij
StATE WELL CONSTRUCTION PERMIT# �•�dJ
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
PHONE # )G23-7RIP
I. 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
2. WELL LOCATI N:
Nearest Townt 5bt t-4UA /VO, IQ County.
Topogr e/Land setting
❑Ridge Slope OValley ❑Flat
(check appropriate box)
H Lartit de/longit deofwell ocatio
3.Scgga�Ao.rnQ
D` ,
(degrees/minutes/seconds) sw. , 5 O co
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
6. DOES WELL REPLACEXISTING WELL? YES NO !Y
7. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith 15A NCAC 2C .0118. Gut
9. YIELD (gpm): / METHOD F TEST ('rt%f. Gut A1€1
10. WATER ZONES (depth): �� _•�
if *si Mott
(Street Name, Numbers, munity, Subdivision, Lot No., Zip Code)
3. OWNER: 9gVl )5eity tcniviholt�
Address 3/ ,t
rt a�Sneet or Route No.)
�(/1! o`'-'}To .•LLLL C a -�
City or Town State Zip Code
( )-
Area code- Phone number at/a/ DATE DRILLED a((QGo
5. TOTAL DEPTH: ' I
11. DISINFECTION: Type IUMW& Amount at
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
Frotn To 9* Ft.
From To Ft.
From To Ft
13. GROUT: Depth
From To 3 F
From To % 7 F _
14. SCREEN: Depth Diameter Slot Size M a1
From 'fo Ft. in. in.
From 1b Ft. m. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
Asheville Regional Office
A uifef Protection
1 DO HEREBY CERTIFY THAT T
CONSTRU TION STANDRDS
S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL 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-I REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Dcpanmcnt of Environment and Natural Rcsmurccs- Divicinn of Water Quality
WELL CONTRACTOR CERTIFICATION N of t D t
1. WELL CONTRACTOR:
c.e_A) 2 V ._04C A)e--1 I
Well Contractor (Individual) Name
fu,bein eo..1d.wt(( Or;‘t;AS 1 \►1G-
W ell Contractor Company Name \ }� �,. �' //
STREET ADDRESS 35t tletti et CeS-1-er )-Li .
(\shev;tie IvC ag8'0(�
City or Tom Stale Zip Code
( %H a54-35gI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(if applicabe)
STATE WELL PERMITN(d applicable)
DWQ or OTHER PERMIT %(if applicable)
WELL USE (Check Appiicjble Boxy Residential Water Supply
DATE DRILLED 1 / 2 /c9 6
TIME COMPLETED y\t'- o 0 AMel/ PM 0
3. WELL LOCATION:
`I/ 2�(��
CITY: 1\5(43 V ( 1.-L�, COUNTY 10 U/3 CO Met -
(Street
YaF (2PIt-5 eS°getL�tsloa
(Skeet Name. ¶4umbers. Community. Subdmsson. Let No.. Parcel. Zip Code)
TO, GRAPHIC / LAND SETTING:
@Sipe OVaee)' OFIat ❑Ridge OOther
(check appropriate box)
LATITUDE 5 aq .a3q
LONGITUDE $ a_
31 _140
May be in deem.
minutes. seconds or
in a decimal format
Latitude/longitude sourcc:S OTopoglaphic map
(loca(bn of wel must be shown on a USGS fopo map end
attached to this form 1 not using GPS)
4. WELL. OWNER ! , `
OWNER'S NAME `Iola 6'7
STIk' EET ADDRESS A- Oq. o r. DLe.� MCA) ao� Pin
F\St-kasA L_l.� &C Le/
0-5-
City or Town State Zip Cade
( gag, a.Gb-- o4-a(o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
4oS
Qvt L De-1—S
b. DOES WELL REPLACE EXISTING WELLL7 YES ❑ NO
c. WATER LEVEL Below Top cl Casing c) 0 J FT.
(Use'+' N Abwe Top or Casing)
d. TOP OF CASING 1S y FT. Above Land Surface'
'Top or casing trmieuled attor beton land surface may require
a variance in accordance with ISA NCAC 2C .0116. (f
r.. e. YIELD (gpinr 1� METHOD OF TEST kik - Al
1. DISINFECTION: Type Nl N •1,D/h Amount
g. WATER ZONES (depth)
Frorn 1 O To 311
From
From
6. CASING:
To
To
1� Depth
From + To 15 FI
From To Ft
From To Ft.
T. GROUT: ,AI Depth
From - t— To ao Ft.
From To Ft.
From To Ft.
From
From
Fran
To
Br6Z•
To
To
Thickness/p� 1e er Weight
o'Zt vvG
Material
e,ta Nta u'f
Method
DU 3D
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
From To
From To
From To
10. DRILLING LOG
Fro i To
/ - 1 0
'10'— 3 (0 '
310'- 3ti'
33 11 1 — 4-0 5'
11. REMARKS:
Ft.
Ft.
Ft.
Material
Size Material
Foqrmation Description
fnJK2$0212tg N
G ,3rVC
Cz 2 A rJ tt6
O
E_
n
r)
i
r-
r
I DO HEREBY CERTIFY MAT TNLS WELL WAS CONSTROCTED el ACCORDANCE WTTH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS. AND THAT A COPY Or MIS
RECORD 14*55BEEN PROVVIDED TO THE WELL OwieuRA M2D /�/
cbtA
eAn
/(43
SIGNATU E OF CERTIFIED WELL CONTRACTOR DAT
tt_&—tra ()As4t
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] eat 569.
Form GWta
Rev. T)05

City or Town State Zip Code
( )-
.Area code- Phone number v to W
4. DATE DRILLED 3 D
5. TOTAL DEPTH: «Q6
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ! FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in aceor¢¢��nrsylith 15A NCAC 2C.0118.
YIELD (gum): m :0(• � METHOD OF T
O. WATER ZONES (depth):oO
11. DISINFECTION: Type 1 Ls Q,
12. CASING:
Depth Diameter
From'-e— To Co8Ft.
From To Ft.
From To Ft.
13. GROUT: Depth . Material aletlutd
From To 3 Ft
From To I V Ft. `L.Y.{�ll r
14. SCREEN: Depth Diameter Slot Size Material
From "fo Et. in. in.
From 'lo Ft. m. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Amount L.
Wall Thickness
or Weight/Ft. Material
From To Ft. .
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso`uurc/�rs - Division of Water Quality - Groundwater Section
\VELL CONTRACTOR(INDIVIDUAL) NAME (print) (U Well
/fS CERTIFICATION#g�QS�)
WELL CONTRACFOR COMPANY NAME 4ppA{f�V it R/� ell 2 ali �
styli WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # (5Ar413-9aa3
I. WELL USE (Check Applicable Box): Residential Ltd' Nlunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI �N'
Nearest Town: 3l'►wtite,
County&.1lCA \k C
Topogra is/Land setting
❑Ridge Tope ❑Valley DFlat
(check appropriate box)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) L titude/Ion rltu f Cl I Cali01
3. OWNER: eivt4i Z DA (s/bAuts &AMt (degrees/minutes/seconds) E(C.�• apa5A
Address 5 (G'laa nim Cr1- Latitude/lonuitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
n°W f . uc., a% I DRILLING LOG
Formation Description
DEPTH
From To
9. (gp ) EST ..QAb2kli Nt4,I`g)
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
IIwI 0�O 2C 3
1
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDA' i S. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE \ LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL D
Submit the riginal 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a t a- 3
1. WELL CONTRACTOR:
Re -bes Cald.we l t
Well Contractor (Individual) Name
Re\ODRA Wei -Ludt tril\i'n CS IAC.
Well Contractor Company Name
STREET ADDRESS 351 N`e.,v-) letck-Ssei i4w(
shev; tie_ c, a b b
City or Town State Zip Code
(gag a54-35-ZI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITa(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applica le B ): Residential Water Supply 0
DATE DRILLED 5 3 Q /
TIME COMPLETED t I)AMI PM❑
3. WELL LOCATION:
A/L�
CITY: AS•I-IS y t L.L. I COUNTY v" VACe 6-
,a 3 Ail°. S{latbttrS
(Street Name. Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA D SETTING:
❑Slope °Valleyat °Ridge DOther
(check appropriate box)
LATITUDE 3 5 3r.85a
LONGITUDES a `t"'g 5l
Latitude/longitude source: • aPS °Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form (not usurg GPS)
4. WELL OWNER �/ K
OWNER'S NAME vl IAL1./ De MIS/UK
STREET ADDRESS '5 clic •.) pPA
May be in degrees,
minutes, seconds or
in a decimal format
Q5.0 Jt t-t-C its c_.
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: �4 r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: b FT.
(Use'+' if Above Tr 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 .01118..' p
e. YIELD(gpm): I-5 METHOD OF TEST „Iv' A)P-'
326518
f. DISINFECTION: Type NW Qua Amount Et-
g.
WATER ZONES (depth):
From ' S To
From `f ✓y To
From To
From
From
From
To
To
To
6. CASING: Thickness)
Depth qI ter _We hhtt Ott
From .i- To ca Ft. b 5•>W*+tl �/
From To _ Ft.
From To Ft.
7. GROUT: Depth Material Method
From '1 To 2 t) FL (tgn 'eccRit.
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
Depth Diameter Slot Size Material
To Ft. in. in.
To in. in.
To in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
FL
Ft.
10. DRILLING LOG
From . To
4,.
4-1'— 2'S
40
.go'
Vice — \85'
as — 245
11. REMARKS:
Size Material
Ft.
Ft.
Ft.
Formation Description
b 4P3C.4U pti
Cr2A al-r6
02-6-fLcs" 6 G err
eut:,t t-rr
G(ze itc_As" 1 a
C,(2.w ) rr
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.
f -tJtM Q-Aaa , 8 ob
SIGNATURE OF CERTIFIED WELL CONTRACTOR ILI l� OAS -
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgtd I nn-„ Form Gw-la
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568. JO jy Li h LJuU Rev.7/o5

RESIDENTIAL WELL coNSTItUCrioN RecoRI)
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
ALDUJe
Well Contractor (Individual) Name
fCUV Cset CAI QHAjCLL Rt1L,1RC7
Well Contractor Company Name - n
STREET ADDRESS 35 \ f` e W Le 1 c6 1'e'uc- N W
Asfb4t1_La tJC. ag806
City or Town State Zip Code
c 3- } 2s4-35E1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
STATE WELL)PLERMIT#(C applicable)
DWQ or OTHER PERMIT #(i( applicable) .Xo3 - 7-6 r 7
WELL USE (Check Applicable Bo ): Residential Water Supply p/
DATE DRILLED t a/�..9 /O S
TIME COMPLETED
3. WELL LOCATION: r
CITY: 4
1 I 3 O AMd PM
COUNTY ►JuN Cc)nCE.
Lis;? Lee (( LL N1aa- K(LQ/ �� -
Street Name, Numbers. C6mmvniy. 5ubdmsipn. Lot No ,Parcel, dp
Code
)
TOPOGRAPHIC l LAND SETTING:
3/Slope ❑Valley ❑Flat ❑Ridge
(check appropriate box)
LATITUDE 3
LONGITUDE
❑Other
May be in degrees
minutes. seconds or
in a decimal format
Latitude/longitude source: 0GPS OTopographic map
(location of wet must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
ItLN oR.ew aleJss
45 ft LA OtnAP
&AN0La S 1 i S
City or Town Stale Zip Code
Area code - Phone number ' / e
5. WELL DETAILS: A E S a. TOTAL DEPTH: L//
b. DOES WELL REPLACE EXISTING WELLLq? YES ❑ NO
c. WATER LEVEL BelemTop d Casing: n D FT.
(Use's" it Above Top d Casing)
d. TOP OF CASING IS -l. FT. Above Land Surface'
-Top d casing terminated avor below land surface may require
a variance in accordance with 15A NCAC 2C .01�16. 1p pp
e. YIEtD(gpm): 6 METHOD OF TEST t.iC TT (p-v
goat- 0
328320
1. DISINFECTION: Type rvT li `D/h Amount 4Z I6-
g. WATER,tZONES (depth):
From 14 % To , 41 From To
From 3 3 To 3, 4 From To
From To From To
6. CASING:
From
From
Thickness/
Depth Dian —Ater Weight_
To J o5 Ft. b SS S-JE-- (
To Ft.
From To Ft.
7. GROUT
From
From
From
Depth Material Method
To a -A {� Ft. C-€111SNT O L.Z
To
To
8. SCREEN: Depth
Frorn To
Frorn To
From To
Ft.
Ft.
Diameter Slot Size
Ft. in. in.
Ftin. in
Ft in. in
9. SAND/GRAVEL PACK:
Depth
From To
From, To
From To
10. DRILLING LOG
Frogr f To, ce/
s4
14g'-14-9'
\erg — 30 3 '
3p 3' - 3t4'
3c4'- 4c5'
I1. REMARKS:
Ft.
Ft.
FI.
OD
Formation Desch p(ion
e (ILA p•-�-s
Cet-E\I1C - -3-
C � 0-41.-.) t`T
C Remit ) Ct — Cj-
vr�nv(-r�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WrM
ISA HCAC 7C, WELL CONSTRUCTON STANDARDS, AND THAT A COPY OF
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Imo, Caateci
a/' 3/z) s
SIGNATURE OF CERTIFIED WELL CONTRACTOR DA
title (V ASIA
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
Sri
0

RESIDENTIAL WELL. CONSTRUCTION REcoRD
North Carolina Department of Environment and Natural Itesourcc . Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
�P u �2V1 Q o4ci.. ut\
Well Contractor (Individual) Name
fwben l..C�\(Lott l br;\l n5 ( \roc,.
Well Contractor Company Namel I
STREET ADDRESS SI NQu3e -eet CeS r Hui
(\shev\ttQ ivc as go 6
City or Town State Zip Code
(3;-K)- a54-35isI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID alit applicable)
STATE WELL PERMIT#ta applicable)
DWQ or OTHER PERMIT OW applicable) /
WELL USE (Check Applicable 1 /,Box): Residential Water Supply (p'
DATE DRILLED a 4 G
TIME COMPLETED 4' `a `O
3. WELL LOCATION: �/\ �rLy/�'ia�
CITY: A5/46 f 1 LL6 COUNTY •`�v N("�"
AM 0
PMQ
b I1. c,R.6c (L CA4 A Pt L. Q-rr AO
(Sheet Name. Waltham. Communiy. 51,b0n-soon. lot No.. Parcel. Zip Code)
T POGRAPHIC / NAND SETTING:
Slope °Valley °Flat ❑Ridge pother
(check appropriate boa)
LATITUDE 3 5 31'8I
Q
LONGITUDE a C‘•t3
Latitudellongitude source: gliIPS °Topographic map
(bcation of we/ must be shown on a USGS topo map and
attached to this form 1 not usig GPS)
4. WELL OWNER `
OWNER'S NAME/ICI( :5 OC
STREET ADDRESS I7 f 7-'/ ix el (trait, 1 Q
e
, 41eOttle n1C �SlgOb
ily or Town State Zip Code
>- 1 t.3 - tflit 1
Area code - Phone number
May be in &pees.
minute. seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
Lt{S
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top d Casing
(Use -e- it Above Top of Casing)
61)
NO 0
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top d casing lemeuled at/or,below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm)_ ago METHOD OF TEST Sktl"—
ai4-D
n r y • i1
.3 Ft.
DISINFECTION: Type N / Pt Dy1D Amount e d c
g. WAT ER ZONES Wapiti)
From (
i 1 l llTo ) G
From To
From To
6'
From
Fr Dm
From
To
To
To
6. CASING: Thickness)
DepthDial eler t ht t+1/leyal
From 4-1 To Tr Ft. //rz/�
From To Ft. _
From To Ft.
7. GROUT:: Depth Material
/�MaterialMeth
From G- Ton, Ft. (.?./.--"Xtity— '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
From To
From ' To
From To
10. DRILLING LOG
From / To
'— Igo
al-5'
1I. REMARKS:
Ft.
Ft.
Ft.
Size Material
Fprmation Descri t n
G (2-/1ITS
,b.., - ab
rr
G"M
1
CD
CPI
r DORFREPT CERTIFY 01*1 TUTS WELL WAS CONSTRUCTED N ACCORDANCE Wrnl!
ISA NCAC 2C WELT CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
R ECORD HAS PE EN PROVIDED TO TM f WELL OWNER
SIGNAT UREs OF CERTIFIED WELL CONTRACTOR
\tJ bShi
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
Nonh Carolina Depanmcnt of Environment and Natural Recourse- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Q,Q,tk QXv
Well Contractor (Individual) Name
Run Qz \&wet) 6r;\t;11b t \ c.
Well Contractor Company Name1 L, I I I
STREET ADDRESS '351 t ` u Kt CQSIC.r Mw-'
(\Shev,tle NC a.ggo%
City or Town State Zip Code
( P'» a54-35FsI
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID aril applicable)
STATE WELL PERMITS/ill applicable)
DWQ or OTHER PERMIT #(il applicable)
WELL USE (Check Applicable B7). Residential Water Supply 5/
DATE DRILLED '-7 /a% / D b —
TIME COMPLETED 3 - D / AM 0 PM Ly
3. WELL LOCATION: r n f
CITY: AS k4C1 LL C4 COUNTY �U 111 Ccvnh
thv
(Street Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC (LAND SETTING:
['Slope QValey 151413I ❑Ridge °Other
(check appropriate box)
LATITUDE % 5 3qi
LONGITUDE%a ASS.a1t
Latitude/longitude source: fIe PS °Topographic map
(location of we, must be shown on a USGS topo map and
attached to this form 1 nor using GPS)
4. WELL OWNER ^/ �J^
OWNER'S NAME " l `" aLe_
STREET ADDRESS 4-5 5FGOKS fnl1L- es)N>g
A5>1gitu.e N c.._ ano+
May be in depees.
minutes. seconds or
in a decimal formai
s 3 b
City a Town State Zip Code
(VZ)- `so-15g3
Area code - Phone number
5. WELL DETAILS: %
a. TOTAL DEPTH: ta O
b. DOES WELL REPLACE EXISTING WELL7 YES 0 NOV
c. WATER LEVEL Below Top or Casing Sr 10 FT.
(Use '•' 8 Above T d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing Iermnaled aVa belon land surface may require
a variance in accordance with 1 SA NCAC 2C .0118.
e. YIELD (gpm): OL,U METHOD OF TEST RA —d t 1-,
at4-D
1.
9
DISINFECTION: Type ry In (.col
WATER ZONES (depth)
From Aa 4- To 'AaS From To
Frrvn To From
From To From
3 3 OY 3
Amount
6. CASING:
Firm
From
From
Depthn
To s'1 D+ FI
To Ft
To FI
7. GROUT: Depth
/ q Material
From 1 Toa`O Ft LAT iNCN I
From To
From To
To
To
Thickktn(ess/
c D( I AAA(e�ial
8. SCREEN
From
From
FI.
Ft
Method
141 r)2-6D
Depth Diameter Slot Size Material
To Ft. in. in.
To FIin in.
From To FIin. in.
9. SAND/GRAVEL PACK
Depth
From
From •
From
To
To
To
10. DRILLING LOG
Frgm C To /
1 — d5
S' - taq-'
a4'-aas •
FI.
F1.
Ft.
Size Material
or ation Description
-t v-PD0P-OVFa
9....14
c, - 211-.) C.,rat
U.as'- ace' BR-ArsCT6
II. REMARKS:
r
N
r CO NE REPT CERTIFY 1NAT THIS Vial WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD NAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DA E
\ —t-E t3A5
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] eat 568.
Form GW-la
Rev. 7/05

Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID b(il applicable)
STATE WELL PERMIT -ay applicable)
DWQ or OTHER PERMIT a(? applicable)
WELL USE (Check Appli ble 6 x) Residential Water Supply (1/DATE DRILLED ' 1 / c 6
TIME COMPLETED
3. WELL LOCATION: r
\_L-
CITY: Ali
51-g t e COUNTY
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanmrmbf I'.ncuonment and Natural Rcsourcer- Ui' iunn of \Valor Quality
WELL CONTRACTOR CERTIFICATION a
ai4-0
n e."),r -
�3: .U.I
1. WELL CONTRACTOR:
Re,L_be,y� C�dL( ,41
Weft Contractor (Individual) Name
Re(,..bek, C d.sucil �rLUo Inc
Well Contractor Company Name' l
STREET ADDRESS •3S 1 t. e.w t-p i cestC r jYa
Psh,evc Lk_,JC 3\W7c 6
City a Town State hp Code
(za a54- - 3 5S' I
3 Eo AM0 PMr(
vluc.c angb
i&c 1-f.JAtr3 ,gee?A'
(Street Name. Numbers. Community. Subdnaron. tot No Parcel. Zip Code)
TOPOGRAPHIC / LAND��SETTING:
❑Slope CA/alleyglut ❑Ridge ['Other
(check appropriate boa)
LATITUDE ..
LONGITUDE j a_ 3 b. i 6 5
Latitude/longitude source: BPS ['Topographic map
(bca(bn of we/ must be shown on a USGS topo map and
attached to this form 1 not vsng GPSI
d. WELL OWNER 1{,t (� ,,,,t/ f�
OWNER'S NAME �W AR. L-e5''}// (• `J`'"'Fed
STREET ADDRESS P.O. act
I t31
3o.53 z,
May be in dopers,
minutes. seconde o,
in a decimal /meat
/4S-V6 �LE tj asap
City or Totten Slate Zip Code
( fag } -3 q
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ^y9‘5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top d Casing
(Use i1 Above Tr of Casing)
ba
FT
d. TOP OF CASING 1S FT Above Land Surface'
'Top of casing lennated WWor below land surface may renuee
a variance on accordance with 1 SA NCAC 2C 0118 qq n
e. YIELD (gpni) 4 D METHOD OF TEST (246-' ry I/✓
1 DISINFECTION. Type 4.IT[t 1t %Amount 3 C G'
q WATER ZONES RI^plh)
r,pn CI I To I,
F,rwn To
Frr n To
6. CASING.
Depth,� e�
From To y-"' Ft
Frpn To FI
Front To FI
7. GROUT.
From
From
Eton
Depth
To airs Ft
To FI
To FI
8. SCREEN Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
From
From
To
To
Eton, To
C}�ar
Thickness/
ter y&% t�{
ell
—
Material Method
rJT eo 4JR b
Diameter Slot Size Material
FI. in. in.
FI in in.
FI
Ft
FI
Ft
n. in.
Size Material
10. DRILLING LOG
Frcyn / To t
37
'1 V- t-ta/
t-ca'- aC.5'
11. RENIARKS:
e its
(3 a..ne°t-re
Lr furruC6-4 c7
RJ4 t'fl t 1d;
C.
L_
Q\
era
0
10) NFRFRY CFRTW Y THAT WnS WFI l WAS CONSTRUCT -TOR ACCORDANCE W rrN
ISA Nr.0 ar WF I T CONSTrUC no« STANDARDS •NU THAT A COPY F S
Arc onoTIFF NrRoworD TO TN WELT OWNER
9 e6
SIGNATT I/FD WELL CONTRACTOR
N-t_t A5 l 1
PRINT Fre NAME, OF PERSON CONSTRUCTING THE WELL
ATE
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.
Form GW-la
Rev. 7/05

RESIDENTIAL AVELL CONSTRUCTION RECORD
North Carolina Department of I.ns ironment and Nairnl Resources. 1)i' ision of Water Quality
WELL CONTRACTOR CERTIFICATION if
1. WELL CONTRACTOR:
Re)Llbeh Cid.uvAl
Well Contractor (Individual) Name
cZeckbe CCdd,weti
Wen Contractor Company Name
STREET ADDRESS SS I Rw
fksh,e'r 1te QC_
1-e.(cesrtl' Ww�
�ggcb
City or Town State Zip Code
%a` » 9.54- - 3 5 S'
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #tit applicable)
STATE WELL PERMIT#(A applicable/
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable B x) Residential Water Supply lif
DATE DRILLED %/ a (
t 1 0 tl /
TIME COMPLETED t0 , 3 0 AMc� PM
3. WELL LOCATION: (' �s Q Q a!
CITY: AS tt(V t 1-Le COUNTY 604 COM6e.
3 Se&TM erkPIE FRoe
(Stieel Name. Numbers. Commonly. 5 A R.e
.on. Lot No Parcel . hT Code)
TOPOGRAPHIC I LAND SETTING.
❑Slope °Valley p�retat ORidge ❑Other
(check appropriate bort LATITUDE 3 z55L 13 .001 %
✓ LONGITUDE % • O3 '
Latituddiongitudc source: DGPS °Topographic map
(bcatbn of Wet must be shown one USGS t000 map and
attached to this form ! not usng GPS)
Ala) he in degrees,
minutes. seconds or
in a decimal format
4. WELL OWNER �/
OWNER'S NAME At, Mil
STREET ADDRESS 3 s Mt-n4 GpavelitiLD t'oA `,
ASa%J')L�C P aT%
City or Tom State - Zip Code
(gad} As-6s54
Area cycle - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a b5
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top d Casing (OV FT
(Use B Above Tad Casing)
d. TOP OF CASING IS Al FT Above Land Surface'
'Top of casng terminated auor benow Land surface may reourre
a valance an accordance with t5A NCAC 7C 0118 p 7
e. YIELD (gpm). i 5 METHOD OF TEST R76' „)r->
NO LaJ
a�4D
331288
I. DISINFECTION Type ti-rg orb •• Amount 8 * 7-
g. WATER ZO ES Id.,rl/hl
Fiore, 11 To I r i7 From
Finns To From
Tmn To From
To
To
To
6. CASING. Thickness/
1 Depth To 51 FI 5 O^^9'VI Dia tnr WDeipht , fj r7e,
From
From
Fr ern
7. GROUT:
From
From
From
To Ft
To FI
Depth �Material Method
To ab Ft. ICAME. Pl. PO OM
To FI.
To FI
B. SCREEN:
From
From
From
Depth
To
To
To
Diameter Slot Size
Ft in
FI in
FI in
9. SAND/GRAVEL PACK:
Depth
From To FI
From , To Ft
F torn To Ft
TO DM(t ING LOG
From j To +
Al a 59
t5'- tt O %gay- absa
II. REMARKS:
Size
in.
in,
in.
Material
Material
Flormation Description
cJQ6Ntc€- I.:7 (5 r (In
•
C'1
0
IDo NENFRV CENT T Tut MOS WFI L WAS CONSTRUCTED W ACCORDANCE WITH
ISA PWAC )C WEIL CONS TRUC TON STANDAR OS AND THAT A CO>r. OE THIS
RECORD NAjPF NPRRO,vp��gEDTO THE WELL DWNERy /Wy1
LAQ
SIGNAT LIRE
r CERTIFIED WELL CONTRACTOR
tit-16 pi15}j
DATE
PRINTrr, 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

RESI4 ENTIAL WELL CONSTRUCTION RECORD
£uuC
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ref 0 9
vv t4C)
1. W ;C. ,;ACTOR: pp
/lbrlJ' H 11N�,
LW II CCoontract `rldjvidyal)rNamg
EI? ?.Sins I ll E II oiid um p. LLG
W ell ntractor Company Name / r
STREET ADDRESS, 771
ifi 5L g I►KC a8i
City or Town f State Zip Code
(gag )- a5S-2(/9&
Area code- Phone number
2. WELL INFORMATION: SITE WELL ID #(if applicable) .4* 6 6 - 60 / 7t!
'y
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q'
DATE DRILLED 3/,1 y/06 /
TIME COMPLETED // 2; 37 AM ❑ PM Et
7.--
WELL LOCATION:
CITY: StlaNNae/ma COUNTY I7OACAA1 be
(Street Name, Numbers, Community, Subdivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC/LAND ING:
❑Slope ❑Valley tat ❑Ridge DOther
(check appropriate box)
LATITUDE// 3S 34,7�zr
LONGITUDEa y
��'"
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form tl not using GPS)
4. WELL OWNER �/
OWNER'S NAME (>f19 TjCST/l4l' IG wsa/ Co -
3EETADDRESS -`: (� ]D6 V.
Wanrtanoo nC ofR7rl
City or Town State Zip Code
(%)_ a'7--6353
Area code - Phone number
May he in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: gS5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q'
c. WATER LEVEL Belau Top of Casing: /p FT.
(Use -+• 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.
r
e. YIELD (gpm) 9.5 METHOD OF TEST
f. DISINFECTION: Type CIA (o.^;,u r Amount /702
g. WATER ZONES (depth):
From To A Sri- From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From_ To 5r( Ft. A_ C/Er siCC
From To Ft.
From To Ft.
7. GROUT: ,,rr�l Depth q �-v Materialat�
From V To Ojt l Ft. 6fCL5fi
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. - in. in.
From To Ft. in. in.
Front 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 Descripticro _ I
—20 /s
20 — 77 jai/ s&t--1
7( — RY A-Or�t .--t
tj V - tT SS Gam../ 1-. O .
11. REMARKS:
1 DO HEREBY CERTIFY 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 /W/EELL�}�/WVNNEER.
SIGNATLREtOF G£RT' CONTRACTORS ( DATE
�hh& & L 1&Hs ,
PRINTED NAMEPF 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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON
.3 / *0
331Ci8?
1. WELL CONTRACTOR: /. !
E�/e/4"N LU i N Es
I.�II Contractor Individual) Name �
hale S6Ns It IEhh anti gmp L1_Ct
Well ontractor Company Name
STREET ADDRESS 573/AID LEME� JEQ Iku/.
E/'(t-SJEt K L' 028 r1TP
City or Town / State Zip Code
8-RR ga52— 8491e.
Area code- Phone number
2. 'NELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMITS/Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 6- e%- OG /
TIME COMPLETED 2 : Qo AM ID PM p'
3. WELL LOCATION:(
CITY: ./Arne c W<
jay.K „Y.// z
(Street Name, Numbers, Community, SubdiMsion, Lot No., Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
[Slope [Valley ❑Flat [Ridge ❑Other
(check appropriate box)
LATITUDE 3 i !i ZS7
LONGITUDE Y z 2r OVT '
COUNTY /.-n[on 4
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: BPS ❑Topographic map
(Iocatun 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 7iel/r1/ )? 'IA /d Lt
STREET ADDI-R,F� S! 6a a ye. 1 9
City or Town State Zip Code
4V? )_ 702- 3g62
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Ze
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 01-0•"
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 atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118. fy�
e. YIELD (gpm): t` O METHOD OF TESTA)bileily )r 4
f. DISINFECTION: Type C
Amount S Ass
g. WATER ZONES (depth):
From 40 To From To
From 2 / 0 To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Maat�erial
From 0 To VS Ft. (/L.1- cram)/
From To Ft.
From To Ft.
7. GROUT: Depth
A
From
From
From
Material Method
To so Ft. Cotlercfe. ?Dj{Di/yq
To Ft.
To Ft.
8. SCREEN: Depth
From To Ft. - in. in.
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
cam'!- c/r
c%S'- 22r
11. REMARKS:
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
Ft.
Formation Description
C/y
s Va
rrs
0
0
-0
• 4v
O
I DO HEREBY CERTIFY THATTHIS 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.
6-z7--cam
SIGNATURE OF �E/RTIFIED WELL CONTRACTOR DATE
PinN if. hives
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

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION 9 3 / 7c)
1. WELL CONTRACTOR: /,
�lz(`14N 7 r•/u ES
yII Contractor Individual) Name
J'Er scNN 1.1 ie11 awd raspy �LC,
Well ontractor Company Name
STREET ADDRESS 3/3/ fQLLE/as{ Ez l tu7•
J/(f&jft • a87ig City or Town / State Zip Code
(CR )- La52-- 8i/91Q
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 6- 23-C 6
TIME COMPLETED I ?J AM ❑ PM
3. WELL LOCATION:
CITY: �";JC COUNTY ALACvh'1C
Sr-mrrt. /�cr..• e
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOgOGRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge El Other
(check appropriate box)
LATITUDE 3 ,� ?re ZTL
LONGITUDE r 2 Z3
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: te6PS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME ( (AJ/, "/✓Gr (.Cj/75Tr/-w(.y'i 61�
STREET ADDRESS 'Sile/ /Q/nf ZQ
,8/LP-/ 41M /YC 3 87//
City or Town State Zip Code
2)8 )- le 9-//33
Area code - Phone number
5. WELL DETAILS: l
a. TOTAL DEPTH: GD% /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0'
c. WATER LEVEL Below Top of Casing L 9 Fr.
(Use `y' A 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): 3r) METHOD OF TESTA)/jj1111/12 7r 9
f. DISINFECTION: Type ��o-•-.r Amountf )Lt SJ
g. WATER ZONES (depth):
From /1 '? To From To
From / ro To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 4o Ft. 4./tf $At P1 "at-C.
From To Ft.
From To Ft.
7. GROUT: Depth �tMateriall,.L Method
From F� To ,20 Ft. Concrete. iwuch„.1
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
0-Sr
Sr -Co
Go - l�li
11. REMARKS:
Formation Description
r/ry/
lkcn;/C -
ti
SEP" 2306
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.
Ze; 5' Z .r G-23-o4
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
v!lN id 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): / V
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:
�/f.�/ /V'' {W O S
Well tract {rlrid al) Namg � )
MINI(Sof5 kTEII odd 1'wwnp. L..-C.
Well tentractor Company yNa jme �/r / r
STREET ADDRESS a /� l ,' ti1i 1
frICeSig Ai.0 67$749
City or Town / State Zip Code
3S ('y aS8-WJ9&-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED /� ee
TIME COMPLETED (( P,3Q
AM PM
3. WELL LOCATION:
CITY: SGJ,Nve Na of COUNTY evA[OM6rE.
1l4fje,v Coot 641
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND ING:
❑Slope ❑Valley lel ['Ridge DOther
(check appropriale box)
e
LATITUDE N. 3S 31:'f
LONGITUDE/44 '
Latitude/longitude source: S ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER
OWNERS NAME _
STREET ADDRESS
May he in degrees,
minutes, seconds or
in a decimal format
or Town State
5. WELL DETAILS:
a. TOTAL DEPTH:
/6S
ip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: ,4 FT.
(Use 0 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
Tl rl
METHOD OF TES
f. DISINFECTION: Typeehr/OriyoJ .
g. WATER ZONES (depth):
From (5 To /00 From
From To From
From To From
6. CASING:
Depth Diameter
From_ To 4,0 Ft.dra$
From To Ft.
From To Ft.
Amount
R f
To
To
To
Thickness/
Weight Material
,/$r $t e
7. GROUT: Depth Material/ �` �!'1^Method
From 0 To�Q Ft 60fI E/f 1/la it69
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 Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0
SS -6D
4p -/4bs
11. REMARKS:
Size
Material
Formation Description
sw-efid "Lc
(/av
"2a,-
a aw, j/e
r.Lt.;r,r `r
C o n
Li,uU t 9
s,
c:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCk WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THg.WELL OWNER
OF CERTIFIED
PRINTED NAME
# 6
,lCONTRALTO DATE
a1, Pthfs"
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 / 440
1. WELL CONTRACT/OR:
�/z�,►N J7, 1ftIvES
I Contractor Individual) Name
r /
CEP 0SONs b IE/1 4ad imps ll e.
Weli ontractor Company Name l� f /I
STREET ADDRESS r� y3J Ait& LEttr±s'feg thug,
City or Torn / State Zip Code
()- ;352- SL{91L
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable) €21005 ,. Q / 9,57
STATE WELL PERMIT#(k applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply [1'
DATE DRILLED /Z - Pt"
TIME COMPLETED /D: Do AM lf(PM ❑
3. WELL LOCATION:
CITY: five,. 9 Cno•yc
COUNTY ,o..e..co,-s Ss.
A a I
(Street Name, Numbers, (..ommunity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
d Slope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 f 3L , yrr
LONGITUDE rP 2. O COJ'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: perrS ❑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 nI
OWNER'S NAME «I1441y-1-�Fet IC.STREETADDRESS l�-J1pb-rn1r.�- �. -
(iiQVthgneQ AC\t= 3g775?
City or Town Stale Zip Code
(g2-K >_ e is- 3 i.b
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / 2r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
c. WATER LEVEL Below Top of Casing: '�'r../ FT.
(Use 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): /r METHOD OF TESTikaistk,
f. DISINFECTION: Type ('/yam. Amount (441s
g. WATER ZONES (depth):
From 4.0 To From
From IA? To From
From To From
6. CASING:
Depth Diameter
From D To 2i Ft. 7r
From To Ft.
From To Ft.
7. GROUT:
From (i
To
To
To
Thickness/
Weight
Material
Depth Material Method
To 20 Ft. Cont'ne. "n�(.(fi/Yq
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 Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-23
Z7 -zr
2Y- iZr
11. REMARKS:
Formation Description
Cly,
5-4),
r*1
-'o
dCC
0
O+
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
` •-t✓-.---
SIGNATURE OF ERTIFIIED�WELL CONTRACTOR DATE
RfAAN b /yes "
RINTED NAME OF PERSON CONSTRUCTING THE WELL
f
4
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-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:
CotrctWfII ConaNydlvid 'e
nRQpI(So4.5 f od ftm,LC-
Wellntractor Company Name
STREET ADDRESSX771
Z,FItffSb R lac' as749
Zip Code
pp City or Town 1 LySttate/
('SU )- .�6S'-Wfl&
Area code- Phone number
s
2. WELL INFORMATION:
SUE WELL ID Of applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED 777 / r e06
TIME COMPLETED 00 AM ❑ PM LT'
3. WELL LOCATION: ,{
CITY: D/QC/4 /400411tt'l7 COUNTY / 7(JOV'&n&t.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley Slat 0 Ridge ❑Other
(check appropriate box)
LATITUDE/JaS r 3 3t. 06 rf
LONGITUDE(t 31j 4E /� r
Latitude/longitude source: PS ❑Topographic map
(locaton of well must be shown on a USGS topo map and
attached to This form 9 not using GPS)
4. WELL OWNER
OWNER'S NAME -.32?/I/j tiet // -L
STREET ADDRESS 3Q Catec 5 CoaP
1e//p. l✓C sASSo
Ctty or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
(tug )- & log- 76as
Area code - Phone number
5. WELL DETAILS: r
a. TOTAL DEPTH: V S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [/f
c. WATER LEVEL Below Top of Casing: 2_0 FT.
(Use-+• If Above Top of Casing)
d. TOP OF CASING IS /• FT. Above Land Surface'
'Top of casing terminated Woe below land surface may require
a variance in accordance with 15A NCAC 2C .0118. `
METHOD OF TEST-1)/6 ft, "War
e. YIELD (gpm): AO
f. DISINFECTION: Type("h 4(/Ntot/C Amount //a OL
g. WATER ZONES (depth):
From To /{/0 From
From To From
From To From
6. CASING:
To
To
To
Thickness/
Depth Diameter Weight Material
From d Tob2 Ft.4,A5 zadIS ljjrsflA/
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To Ft. �C' LC'ILCEfe
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 r To Ft.
From To Ft. _
From To Ft.
10. DRILLING LOG
From To
1 -yd
Z/Q - 5?
sJ-�a
63. -2YS
11. REMARKS:
Forma Description
a
Tnr
CL eQ
ri
rn
5
o $
Cr.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W DH
15A NCAC 2C, WELL CONSTRUCDON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE W ELL.WNER
ONTRACTOR
PRINTED NAMEPF 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. 7105