Cl CY2006

RESID Ni'L'IL WELL CONS TI(UCIION REcon»
Noll; Unrolioa I /rpm lnrenl of linvhonn,eul nod Natural Remitter.- Nivhlun or Waler Quality
%VIE,I,1. CONTRACTOR CE12TIEICA'l ION H
23 S3
OWNER
MIND
ITC ✓
1. WELL CONTRACI OR:
Kt (-Hi AA l 11-z1
W e6 Contender (b,divIdual) Nano!
MILLER WELL DRILLING, INC.
Well Coolrncla Company Name
SI NEE ADDRESS P•U. DUX 9(37
IIAYESVILLU, N.C. 20904
City a Town Slate Zip Colo
l R20 ). 837-2997
Ain cede- Phone nun,be.
2. WELL INFORMATION:
SITE WELL ID Cif smile *l.q
S I Al E WELL rERMI I IIII .ppnrehln)
DWQ a UTITER PERMIT 1(11 npplicallIo)
WELL USE (Check AprlicM le Dow): Residential Wale, Supply Cl
DATEURILLEU 36 -04,
TIME COMPLETED ?no
3. WELL LOCATION:
CITY: PG ✓C$ U(HF
AMII PMLI
COUNTY Cla Y
ISI.ni Ovine. Nur..bete. Co.mnuNny, Sobdiv,.loo. Lol No_ 1'n,c.l, Zlp cone)
T OrocRArllic 1 LANO SETTING:
!eve UVnary LIRA IlRWun ❑011ier___
(chedt .ppropnat. box)
1 "lily he In drprtet.
�"�
LATITUDE _j1 _'"I .11'2(minute,. ternotIct fir
LONGITUDE-5 • I1111 In a drebnnl famml
Latitude/longitude snun-e: UIiI' S 1-ITopopraphie amp
(I rrtlbn W one most inn shnntr fin n I/.SGS loan amp and
ellnrhnd In Ills Aleut/ not using GPS)
t. WELL OWNER 1
OWNER'S NAME CbY,5h ly1 Zy(C
SIREEUADDRESS LitI o(LLI zl cl-
M�tri-eif21
City a lover Stale Zip Cole
A1ea code • Phone nundnr,
S. WELL DETAILS:
a. TOTAL DEPTH: 3 ('
b. DOES WELL REPLACE EMI Rio WELL? YES U
e. WATER LEVEL Retwv lop o1 Cochin _
(Use •+• 0 Above lop of Casing)
d. TOP OF CASINO 15 P F T. Abnvo 1 and Sistine.?
'lop of tattoo leandnnlnd nlht below land ptu Inc" nmy requite
a varla.Ce In accordance with 19A NCIAC 2C .0110. •
!IOU
e. YIELD lyre) : ,�(] ME1110D OF TEST Ai-
h olsl lrtcllo : Typo Amount 1 Cup
p. WATER ZONES (depth):
nom /28' To /gee
rla,l , eye
From
To a93 Fran To
From To From
To
6. CASING:
flew, U
Q.
UrpII,
To /5 _FI
non To rt
non to FI
Diwneler
7. GROUT: Depth Motet rat
Town In El.
from to rt.
nom to rt.
To
T IacIo.ts/
Welyhl MaleiW
I88 stst/c-
Method
6. SCnrEN: Depth Dlwneler SkA Sire 1.13404
non 10 rt. In. In.
Flom To rt. In. k,.
Twin I El. In. In.
9. SANt1IORA9EL PACK:
Depth Size Material
man Io rt.
non Tn rt.
rlon To rt.
10. DIALLING I DO
now l o
/<Sb• 3,2e1
// Fonnallon bescliplion
L.irdlSiene /Grcn, fr
RECEiVFD
0
Asheville Regional Off
Aquifer Protection
I I. REMARKS!
ct
Ion moony cro'er filet min watt. wee CO,Utnucitn N PCCOIM rrE AIM
I tftAr: 1r. WELL COMM einlpnln,. Pt a1A1 A COrr Or 1,13
nECrMOIlAS BlrEN rnovvE fir
SIGNAIUI CI CENIIFIE WELL CONrRACICHI
UAIE
IEick -L7khL ..
PRI I ED NAME OF PERSON CONS) RUC NW; 1 nF W r ll.
I{;b1
:II
t;a
f, (l
Snhnlll Ihn orlOhlal in Nip Dlvlglon DI Miler Quality within 3U daya. Mitt. Inlmnrallon MOT.,
1517 tt,li 4nrrl• " Cenirr - flalrluli. NC 27G79 1617 rliono No.19191733.7015 QM 558.
rr.mnw.1p -,.,f
11.- tree

RESIDENTIAL WELL CONS' TRUCIION RECURU
North Camber' Uepnllnlnd of En 11unnieul nod Natural Ittsotitcct- Divlshm of Wiley Duality
WELL CON.' RACIT /It CERTIFICATION N -�/ 5 15
OWNER
MWD_
11C
1. WELC,CONI RAC T OR:
gelg
Well Cad la (hnlTvklunl) Name
NI_LLEN_WELL DUILLING, INC.
Wea embalm Company Name
ST REF AIILIRESSP•U• DUX 567
IIAYESVTLLE, N.C. 28904
City a Town Slate Zip Cain
Stole
E 037-2997
Ale, code- Phone number
2. WELL INFORMATION:
SITE WELL ID Om arrl'r nhl.)
SIAI E WELL Purim applicable)
DWG a OTtIER PERM1r 1(11 applicable)
WELL USE (Check Applicable Doh): ResIdenlial Wale' Supply 1/
DATE DRILLED "-// 71 6
TIME COMPLETED /7.'C)C) AMID I'MN
3. WELL LOCATION: /l
CITY: iulf'S/)i//e COUNTY
[Shan° Nona, Metric Cvnnnnily. Suhdidnlon, lot No , l'iucel, hip cab)
TO OGRAPNIC 1 LAND SETTING:
Slope [Valley TJflat (.1Ridgn ()Other
(check appropdaia boa)
LATITUDE _3_ : CI • it/
LONGITUDE i ce/" �12 3'
Ltliluddlongiltide solute: (I(l8'S III (pop atillic
1NOp
(i'cn4rn o/ sr/ matt be slrouro nil n USGS two map add
effm hed to lint khan / iror using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
t0.75
May he In &peer.
miuulrS, reromh ter
bn n decimal Pound
City o{ 1 own
Sew' 6oa.utit-
Po ao,)L $2H-
(le-, me _ 289oce
Stale Zip Coln
g26 »309- O15"3
Area code • Phone number
S. WELL DETAILS: cQso ,
a. TOTAL DEPTH(:
b. DOES WELL REPLACE EXISTING WELL? YES U NO U
r-
.) Fr
e. WATER LEVEL Rnhry Trr' of Cnsing 1
(Use '4' 9 Aloe Top ol Casing)
d. 10P OF CASINO IS Zoo/ FT, Abnvnt. mid Sudan,'
'Top d casing tamhmled nllo helm land sul torn nrny tequlie
o valance In accadxice with 15A NGAC 2C .0118..
e. YIELD(gpml: 40 MEINUDOF1EST
f. DISINFECTION: Type I+TN
p. WAT En ZONES (depth):
Flom �t irl,`/I'd •
Fronr�%• To27a"�
From
From
From To From
Amount I atP
6. CASINO:
, U"pllr/1 Diameter
from 0In 9,?' rl /r,
Ran To rt.
foam To FI.
7. GROUT: Depth Material
rran To rt.
Ran To P1,
rran To rl.
To
To
To
Thlcinetst
Wright ale7W
sn>.z► Y N, Ct .
Method
1. SCnrEtu: Depth Diameter Sid Size Material
• From To r1. tn. _ tn.
from To rt. In. ki.
Ron To P1. ,In. ki.
9. SAND/GRAVEL PACK:
Deplh
'' rran To PI.
Ran to El.
Ran To FI.
19. DRILLIIJO too
Fl01t1 70
0 36 •
Size Main Id
Fonnnliion Denoiplbn
/7 /
OMd r°
ln.ws Trfnr' / 14161 1./P
RECEIVE
Pelievilie-Regienal 0
Muller Pt' ectio
0
11. ItF.ltl4qItli
rSc° t r P7 NO i(Nu) &r
fihoel) ? r5dL c/t'r 7r')a r'
/-.nn.S C PTV i niid.3
'PO ianrnt crnMIFy nu�trryn1aC9 MIXwM cfy,is,nucirn n Eccrmoarw'E wins
rsnon p 11•
nEc00oirl� EENPn oVlgro101TM VIE �iMENuIACOPy Ur MIS
02/7
SIGNATURE OF CERIIFIEU WEL CON IRACIOR UAIE
Oork nth*
PLAIN EU NAME OF PERSON CONS(NUClltlri 11,11 WELL
Sidinill Ihn r'rlgInal 1111IIP DIvlSluti of WnInr JItnll1y wlllih 30 days, Alto! httointaIIon Mot.,
in17r!all Cnn'Ira renlrr- Ralntnit. IJC 77G991G17 Phonn N0- f9191731.701`S ea1568.
ramr; /.;....
n�- nnr_

I?iis'1111iNI iAL WELL CONS I RUCTiUN ItLCUiiu
Ninth Carolina Iltpmboutl ur 1'atvhuunicul mid Natural Reconvert- Division or Wale( Quality
C(IN'ERACTtIIt CERTIFICATION II t Yd5
OWNER
MWU
NC
1. WELL CONTRACTOR:
Well conks -odor (Indvkloal) Name
MILLED WELL DRILLING, INC.
Well Co ine:Iry Company Name
SIREET ADDRESS 11• U. DOX 567
IIAYESVILLE, N.C. 20904
City or Town Slate Zip undo
( 020 ). 037-2997
At ea code- Phone mmmlnt
2. WELL OIFORMATIOU
SITE WELL ID 9ill nn•arM.l.)
STATE WELL rERMIT Rpl.prltcable)
U ma or OTI TER rERMI r %(It nppllcahle)_
WELL USE (Check Applicable Dux) : Residential Water Supply CI
UAIE DRILLED (2`/-0
TIME COMPLETED p.b0
3. WELL LOCATION:
CITY: NA ✓C'5VI1''P
AM I PM J t
COUNTY_/2)1
lSl. l Norm- Nard..I.. Conitnunuy. Si,bdid.bri, lot Nn , 1`..c.I. Ilp Cod..)
T OrOGRAPI ITC I LAND SETTING:
USkge [Volley Krill URldgn UOthet
%clunk eppropdal. bold
LAIITWE _3 S 64' 3�
LONGITUDE 5 3 4;, 39ro'
Latitude/lmigitode source: ULii'S 01(Imp apltic imp
(Irntkvt o/ ar/,mist bn shown nrt n NSGS lolio nmp mid
eflnrhed In fhb Imo roof ink; CPS)
4, WELL OWNER /�
OWNER'S NAME IIMMUfry r kbos
STREET ADDRESS —3507 t- Cola' Eretta R.0
wIIo �L4D9
F Ivy he In dry, re..
totn,nn, Sen.nH nr
In a drrhunl Gmnnt
N C.
C yo Iovn Slate Zip Code
Alpa code - fleets number
S. WELL DETAILS: oo��
a TOTAL OEPTII: p Do '
b. DOES WELL REPLACE EXISTING WELL? YESH NU L]
e. WAI ER LEVEL Rehm Tcpd Canino So • rt.
(Use'+' 0 Alcove Top d Casing)
d. TOP Or CASING IS P__,' FT. Abnvn Lend Suriore'
'I no of casting I .Mnnted MUo below lard sudnce cony tequila
e vwlarice I nccodarice Wilt ISA NQAC 2C .D 118.8.
••
e. YIELD Wpm): c -b METHOD OE TEST Hi it
1. UISINFECIION: Type H,o H
Atnomd
C u�
u. WATER CZONES (depth):
Ron /6o$ to 17a ' Pon To
Ron lo From To
Floe lo Ron lo
G. CASING:
Ron0
rn..n
rton
'tenth 0imnelei
to 6"
To
In
T. CROU I: Depth
room In
room 1n
Ran Io
rt.
rl
ri.
ri.
Pl.
MRletial
lilrtnessl
Weight Mnlerial
S>i-I-I Y', U.Q
Mellod
fl. SCRrEN: Depth OIwnelnr Slot Size
RIM, In rt, In. In.
Ron 10 rt. In. In.
Ron lo PI. In. ln.
9. SAW/GRAVEL PACK:
Depth
roam To
Ran To
Ran To
10, NRI(.LING LOG
r font To
Ft.
rt.
rt.
Material
Size Marrrlal
Forrnnlbn Uescslpllon
C,)" 86' Swirl /Clay j°21A
k0' p,00' Lime%no e
---R E C E I Y ED
Ashevi""e Regional Offi
Rtl�ifel f'rotcction
II. ItE.HMAILI(S! L r�
Dent �S ri pump dbL/D I.J /rod
lanirr Arms a,O AO/sir 7'i)r/
I PO nrnrnY crntlrt II IA ling wEtt WAS COIN tnwCIrO W ACconO.Nr:E. WM.
ISA NCAC 7C, WEI,1 CPUs I'WC11WN SISIMAnn9. AM IHAI A COPY Of I/q
RECORD 11AS SEEN rmovotO IO)1/E WELL pvvPER
(9/-06
SIGNAIUI �IEU /�{ L 1�R�Cton UAIE
PION EU I'IAME OF PERSON CONSI RUCtRV) 111E WELL
•
r.:
tit
Sn1,ndl Ihn o091111I In the fllvlalon of Walvr (flintily within 30 clays. Alhtt Ittfoimallon Mgt,
1517 Mill Srrvlcp Crider— Ila!eluli. NC 27699.1017 thong No. (9191733.7015 ex( 568.
rtvmOWta '.'„
11ev rin4 '.,,

RESIDLN1LLI/. YELLCUNSIItUCI UN RECUR -
Nottli Carolina Drpn linen) el Envhonmenl null Naito -al Ittsonicct- Division of Walet Quality
WELL CONTRALTI Olt CIOL IEICA-I'I/IN Nye)705
OWNER
MWD 'or'.
NC I/ 1 s;'
T. WELL CONTRACTOR:
Well Cadrncla (Individual) Name
__PALLED WELL maim INC.
Well Cnnitactte Canpmly Nam.
STREET ADDRESS P.O. DUX 6137
IIAYESVILLE, N.C.
209UA
City or lova, Stale
( 02(3 ).037-2997
Atea cow).- Pisan. number
2. WELL INFORMATION:
SITE WELL IU apt em•nrxhi.i
np Cate
S tATE WELL PERMIUpi.ppllceblrI
DWO a oil ER PERl.11 r apr nppricabin)
WELL USE (Check Apr
/Jicnlde D//�x) flesidenlial Wairt Supply Fit
DATE DRILLED 1 ! / b(0
TIME COMPLETED D 0
AMU I'MA
3. WELL LOCAIIOU:
CITY' i--1.y<°sv;i)C' COUNIY Cly o
yu5-CL I
(She.i None, Ninntere. Community. SnhdiN.lon, lel No., hovel, Zip Code)
TDroGRADltir 1 LAND srrnNG:
gysilnpe UVaeey (Jrht 1ifIdge ❑Olhm__
Ich.ck Tptol^lab bot)
LAmUDE 3_ S Ln.17731
1ON011ttDE B 3 57. P�"
L,IiUnIcllongiluJr stuns: LI GI'S LiTnpoglnphic nrnp
(T,cntiwt M not ours" hx shorn on n USGS (opt mop and
etteched to Ibis Amor (rtol usity GPS)
4. WELL OWNER
OWNER'S NAME
May le h, drptn.,
n,iomrt, trrm,tlt err
Ina drrinrnl rmnwl
Jt'ar. es
SIREETADURE.r•S, 8 Y L (KPUIe Dr
IFnyeSv'ft£ /VC Zgoy-
C,ly to 1 own Stale
F
Area Code • Phase number
S. WELL DETAILS: 7
e. TOTAL DEPTH: 7 L A)
Zip Coda
b. DOES WELL REPLACE EXISIIND WELL? YES U
NO 119
e. WATER LEVEL PelrwloppfCntkig 3nO rt.
(Use'*' 11 Above Tot of Casing)
d. TOP OF CASINO 19 FT. Above 1 and Molars,'
•lop a catkin Imminnled allow bolo." land swims, may require
o vim lance kt accadwtce will, 15A NOAC 2C .0118.
n
e. YIELD Wpm): s] ME1110D OF TEST AI!
1. DISINFEC)ION: Type CJ,Jy (Ip e Amount f Go..
0. WA EN ZONES (devils):
Fran «%la lb `77v7"
flan {o yp To !, 9•5"
Ftatl To
Evan
From
Fran
To
To
10
6. CASING: Ibltknetsl
Urptb
roan 0 In (07" rt.
non To rt.
rta„ to rt.
Olarneler Welyhl MnteiW
T. GROUrr Devils Mntetial Method
rttxn Tn rt.
ntxn To rt.
non to F1.
e. scnrrtl Urp111 Dlnnelnr Slot Sire Material
non to El. In. _ In.
non To rl. In. In.
frown to FI. In In.
9. SANDIORAVEL PACK:
DNA Size Malachi
non to Fl.
Flan_ To rl.
Fion to FI.
10. DRILLING LOCI
From To
55' 750 Lime 3 'to .1 e
Formation Descilplbn
REDEIV-ED
A,lltryttlC !1C
T3
Office--
Aouite, Protection
n)
0
LEI
II. (REMARKS!.
LaS11,"Yls rnirk4 br
(ibern
)rn k,n5 11
too ritor err crmirY our one WELL WA, CONININC0n tr ACCOPnNx-E MEM
ISA NUM: it eat t PottstnUClnt elu/nnnne. NV IWU A COPT Of era
ntconu lug eEEN Pnovor LIME I+RL OWt1Ee
SIGNA v Iii IFICU VY Li CO TRACTOR UAIE
Jac j1'l r I4dk)
1'Iuitil Eli NAME OF PENSON CONS1 RUC11110 1Nr writ_
• i
•
1
G`!
1
1
4."ii
.1
Submit the Ptlttlnnl In MR DP/Igloo DI Water Quality within 39 clays. Attu hitornitlllatl Mdt.,
1E17 ?WI r.nrvtrr. rrni^r - R:IlrlNit. ►IC 27E99 III 17 Phnnn Dn. (91y1 /11.701e oil 5SR
rr.rn meth,"idl:

RESIDENTIAL, TVELL CONS I RUC77UN ItECU,1D
North Carolina Depmlutcul of bit 11hnnicul on I Natural Ittsotite�rr.,. Divisln„ of Wailer Quality
WELL CUN'I RAC7Olt CEII'I'IFICA'1' (IN N /OS
OWNER __
MIND_/
NC
1. WELL CONTRACTOR:
Well Cadlncla (iodivkltlal) Name
NILLEII WELL Of1ILLING, INC.
Well Cad, actor Company Name
STREET ADDRESS 11 •U. DUX
567
IIAYESVTLLE, N.C. 2091)4
City a I own Stale Lip Coln
0128 } 837_2997
At ea cafe- Phone mamba,
2. WELL INFORMATION:
SITE WE1. L ID Apr .pel'r,Ne)
S I AI E wrll rrfMl1 Rhl erellrpt,to
OWO or O111ER FEITAIII 11(11 writable)_
WELL USE (Check Appliraldn Dox). tlesWenliai Wale' Supply
LL11
DAIS DRIED 04,
TIME COMPLEIED 3; 0d
AM(_) I'M,)J
3. WELL LOCATION:
IIII �1
CITY: He yr.su ULc COM, Y_cl.C�y
5yv-.
S l,fel Lw. Nnnnl•ea. Crnnnurlly. Subdlvl.lon, tot No., 1`nvl. ZIP Cade)
T�OPOGRAPIIIC I LANK SETTING:
elope uVnney I11-ht
(check eprnprl.l. box)
May Ire In drprta.
U(T ITUOE _a_ J Co .IS 8 al llmen, arrow?, trr
/ In la ran 'Inrn! la,nml
LONGITUDE 2, S � z$�2
LatiluJdlongiWJr source: 0(il'S r_i-Topoglaplric nap
(irnNan of Hermits( ion shoes, m,, n VSG$ fo)et ntnp wad
Mlachrd 10 llris fool f tad using (3PS)
4. WELL OWNER 11 `
OWNER'S NAME DOC c�nilh
STREET ADDRESS. (6L(4keUI'CW Df
ITrIYPSVi��Y lt/C ZPIOLI-
City or I ow„ Stale hip Code
A,pa code• Phone number
S. WELL DETAIL S:
.i. TOTAL c7'
)
b. DOES WELL REPLACE EXIS rINU WELL? YES U N0.iq
c. WAT ER LEVEL Drk'w lry 01 CneImr 50 r
(llee'r' 0 Abrva Top of Casing)
d. TOP or CASINO IS /. 1O// _ FT Abnvr irn,d Sudan!'
•Imp d rnsknq lermkwlnd Runs below land lint lawn only requke
s vwlance In rrccadaltce wi1D 15A NQAC 2C .0110.
FL
e. YIELD Iupm)t /3 METHOD OF TEST /T/r
1. DISINFECTION: Type Nr2 R
0. WATER /ZONES Wand!):Flom G' 7 to fog From To
Fran lo From To
Amount
Fran
G. CASINO:
flan 6
u
Foam
Fiona
T. OROU l :
rnrn
man
to
Depth
toO' rl.
To rl
lv rt.
Depth
1n
In
rba,n lo
0. SCIlrEfl:
From
flan
rtan
Depth
10
to
To
rt
rl.
r(.
Fran To
Tldr:knessl
Dlatnelet Weluht Malerlal
e
Melanin!
MMlnd
(Animator Sktl Sin! LiMnli
FI. lo. In.
El.
Ft.
9. SANDIORAVEL PACK:
Depth S12e Male,lal
flan 7n FT
Nam to rt.
Foam 1n rl.
10. fall: LING 1 DO
Frorn l o
39. /5d-
/S O" Co"
clog"90
( 7 .
Formation Description
LJ•/TIes/onr
/-Zw4fc
1- nirj j'cnr
5 revilte Reyional 0
Aquifer Protection
II. )tENIAI(I<S:
1J12)` °nLL toe LC Orly dryer
31J )o1' s CaAtte yvu4 of hi!f
1 oo air nrnr ermiry mM mantra WA! ctxlltnlCnn 11 eCCrinrlai,w;p Wino
ISA uCAr, JC. WI CI cotr inuxnIn , C1l s, irtsnp7 A,n) A Cony or its
REC0110 It09 0EE0 rumor lair WELL OW11ER.
SIGIJA
C1S � ()cl dry
PRINT EU NAME OE PERSON CONS! RUC1Nr wrii.
fr
t,.
'' 3
t
1 IFI U L CO TRACTOR U E i''.;
tiit)
+$1
submit trio of Iylnal In Ow Dlv1vlon of Water quality wltldn JD days. Alin. It,lo, naflon MgI.,
1517 Rbll Cnrvtrn r enlrr.- Ralrtuti. TIC 27f77 iC 17 Montt No. 11191733.7U]5 ax1 568.
ram OWL,
n... /Mid

(Art
3303
RESIDENTIAL WELL CONS FRUCITUN RECORD
MWO
North Carolina Department of Environment and Noland Resources- Division or Weitr Quality NC _/
WELL CONTRACT UIt cIItTIPICA'I ION N
1. DISINFECTION: Type %iT µ
0. WATER ZONES (depth):
From /Le To /45-' From To
From 10 From To
From To Flom To
C. CASING: Thickness!
Depth, Diameter Weight tetlS
rm rttb° Toes ' FI. %" ,VC
1. WELL CONTRACTOR:
W eA Coniteclor tlydhridual) Name
MILLER WELL DRILLING, INC.
W M Canitaelot Company Name
STREET ADDRESS P.O. BOX 567
HAYESVILLE, N.C. 28904 _
City ot Town Stale Zip Code
( 828 I. 837-2997
At ea code- Phone numbs'
2. WELL INFORMATION:
SITE WELL ID a1R enolteable)
STATE WELL PERMIT/pi appeceblel
DWG or OTHER PERMIT "(If applicable)
WELL USE (Check Applicable Sox): Residenllal Water Supply ig
DATE DRILLED 7-1 '-06
TIME COMPLETED 5,'o 3 AMU PMtgl.
3. WELL LOCATION: I /�
CITY: / /L/ yr5lii'1 e COUNTY l /0/
(,0r/3
%Sbnl Nnm. Numbs. Canmallty. SubdIMIon. id No.. Parcel. Zip Code)
TOPOGRAPHIC I LAND SETTING:
RSbpe LTValley °Flat ORldue UOlher
(check epprornlale boa)
LATITUDE ,. C 00' in V
LONGITUDE -fa 4-47y.2/0
Lsliludeylongi(ude source: RHII'S Iflopogrnpltic mnp
(kcelbn of welt must be shown on a USGS lopo mop end
elleched to Ihis form ►riot esaq GPS)
4. WELL OWNER IZ0 box-t La5)i me- +To to my ec,t)tr'
OWNER'S NAME N;nbah P\uyal ) tic �Bnter
STREET ADDRESS 2-330 ilin-Er n Ge&eC Sd-
1401q(Su tl\P ro,c, aR4'ny
CII or Tam Slate Zip Code
May be In deyrtn.
ttthnrin,'erten), Or
bt • decimal Remo)
}
Area code • Phone panther
1L WELL DETAILS: /1� a. TOTAL DEPTH: ' , /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (1L
t. WATER LEVEL DelowToro( ening: /5 - FT.
(Use's' II Abase Top d Casing)
d. TOP OF CASING IS / 3' / FT. Above Land Surface'
'Top d toting laminated see below land tutlece may requlls
s tart M aceordante YAM 15A NCAC 2C .0118..
•
e. YIELD lupm) /o(' METHOD Or TEST /I r r
Fran To F1.
Flan To F1.
Amount /5,rriCf'S~
7. OROUt! Depth p Material'^� Method
Fran 0 ` To O- Ft.&'aldardrCrt.,ed P,c5L.rcrn
i From To F1.
i Ftom To Ft.
O. SCREEN: Depth Diameter Slot Slze Matelot
Fran 10 Ft. In. In.
Ftom To F1. In. M.
Ftan To Pl. In. kt.
9. SAND/GRAVEL PACK:
Depth Slze Material
From 10 rt.
Fran to Ft
Pion to PI.
10. DRILLING LOG
From To
�" Vs'
43 /7D ,
Pon -nation Descriplbn
no/ JraueG
,n,ec6ne
IL ItEMAKKSs--_
144$1— 773 6,7
AIMS O 00424-
100 Hen er Cr WV THAT MI WELL WAS cotrsinUCltDN ACCOAOANCE MIN
ISA NCAC IC. yyE11 CONAN* sn�`AN ARDS.M MAI A COPT OF NM
RECORD M ¢NPR
7-19-06 .
BIONATURE OF CERTIFIED WELLCONtRICTOR DATE
QrL mChi&
PRINTED NAME OF PERSON CONSTRUCT WO DIE WELL
Cnhtnll llte nrInInnl In The Division of Water UualIty within 30 days. Attn: kltonne8on MgL,
Frnn OW.I

RESIDENTIAL WELL CONSTRUCTION (RECORD
North Carolina Department of Environment mid Natural Resources- DIv1loN or Weis Quality
WELL CONTRACTOR CEitl'MICA mot N
1. WELL CONTRACTOR:
Well Contractor 'individual) Name
MILLER WELL DRILLING, INC.
Weil Contractor Company Name
STREET ADDRESS P• U• D O X 5 6 7
HAYESVILLE, N.C. 28904
City or Town Slate Zip Code
( 828 ). 837-2997
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID apt applicable)
STATE WELL PERMITala applicable)
DWQ or OTHER PERMIT 1(1 applicable)
WELL USE (Check--! /Appllicaable Box): Residential Wolof Supply
/ ($
DATE DRILLED -0'/P
TIME COMPLETED y.DC.) AM Li NH4
3. WELL LOCATION:
CITY: a C
%Sbel m, Nee, N�'s. or . Subdivision. Lot No., tineei, Zip Codel
COUNTY C/n.v _
TOPOGRAPHIC I LAND SETTING:
!Skipe I:Walley LTFIal °Ridge °Other
(check appropelale boa)
LATITUDE _3_ �oa� 7o7"
LONGITUDE es3 p ti I7tt
Laliluddlongilude source: YAPS (TTmpmgrnphic map
(kcalksn or welt mist be shown on a USGS logo map and
attached to IM1is form 1 rtol usl'g GPS)
WELL OWNER 5a gd1r�A Rtry'Y tk Son
OWNER'S NAME hint -On Rarat 1 •if€ hen k(
Mny le in dopers,
nibs Iles. seconds Or
la a dedmal ilnmal
STREET ADDRESS 233O Iilnbnn Gen tt'Y ( CA
7IGyeSI)II�P )(O • o2OlIJte
coy o iixn Slate Zip Code
Area Lode • Phone number
8 WELL DETAILS:
a. TOTALbEPTH: 116D.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NON
t. WATER LEVEL Below Top d Casing: pa'b' Ft.
(Use's' 8 Above/T pop d Casing)
d. TOP OP CASINO 19 !0 " FT. Above Lend Surface'
'Top d easing terminated War below land satire may teqube
valance h eaadaice with ISA NCAC 2C .0118,
a. YIELD (ppm1: Jilt_ METHOD OF TEST A•
r r
•
:s Q sqNp ER
U
MWD
NC
1. DISINFECTION: type Hi ll
V.
WATER ZONES (depth):
Amount /fd`,nfl /S
From / 70' To / 72 ' Flom To
From /%S' To / 71- Prom to
From To Ftom to
6. CASINO: thicknesal
, Depth Dlaneler Weight Melerlal
Fran 0t To %/' FL (n , U,c.
T.
B.
From to Fl.
From To F1.
GROUT: Depth Material Method
From D" to VCY Ft. on (r/Cr7e.` list ti..N.
From To F1.
From to Pi.
SCREEN: Depth Diameter Slot Size Mateital
Han To F1. In. kr.
Aon , To PI. In. In.
From To rt. In.
9. SANDIORAVEL PACK:
Depth
Flom To
How To
From To
FI.
F1.
Ft.
Size Material
10. DRILLING LOG
From TO Fottilaeon Desciiplbn
0" ndet rare I,
fop' nteS'itine
C)
N
6
r—
I1. REMA1tK�j
j' "SP- o'/z3/2a7`�e
/M) to '7 424
I DO HERESY CERTIFY INAt WSW welt WAS cprtsmuClrD N ACCORDANCE WITH
tSA NCAC 7C. It CONSIflUC1 S1ANDMDS. MD TINT A COPT Or /NO
macaw IIAS EN PR VOWNE
7-lW-o6,
BIGNATURE'6F CERTIFIED WELL CON fftACTOR DATE
`Sat^E no/a
PRINTED NAME OF PERSON CONSTRUCTING 111E WELL
Submit the original to the Division of Water Quality within 30 days. Allnt intonation Mpt.,
Farm Gw•1,

z� i 300
J
J?GSIUGNrI4L %VILLI C_ONSTIWslIUN IIECUIW
Nunh tooling Department of L•nvkonuterd and Netted Ittsuuteet• blvlslof or Wald Qudhy
WELL CONTRACTOR CltltlIl 1CA 11UN N
1. WELL CONTItkCtOR:
Wel Corti/ado IheAvldual) Herne
MILLER NELL DRILLING, INC.
W el Cant eclat Company Name
ElREttAbbRttSPM. Dux 557
NAYESVILLE, N.C. 28904
cay a town Stale zlp Cale
( 828 ). 837-2997
Nea tilde- Phone nunbet
L VeELL INFORMATION:
brit WELL ID Id ersecsbel
StAlE WELL PORNNIlle applinble)
bW0 or bttlER PERMIT Apt applicable)
WELL USE (Cheek AppAcdde boxy ResMenlld Walet Supply pi
bAtE DRILLED i 3 - f
tIME CoMPLtttb't f 3D
!. WELL LOCATION:
Ott: 14cVt=cui1)e
(fleet Hume. Hornbill. Community. Bublaaalon, la Ne.. l'weet hip Code
AM,QQ PMU
couNty (lay
t 000011 111C I LAND SEt11NG:
't Sbpe tIvelley t1411 t7RM0e t1011br
(check eppt•piele box)
1AtItUDE ,,LS.1L iSi
LbNGItUDt 85 2 34 I
hlitudeiIohgihtde source: tIOPS tltupogrnpltie tunp
pocallxt ut veal hm'st be stmwet on a USGS lorw map and
abeebed t0 Ihls Mon E nd uslp GPS)
4. WELL OWNER
OWNER'S NAME LAIaxyne -5GIt2
STREETA3DRESS Z333 13(Anker Kill 1?d
I3I4lr5Vllle kA 305/2.
Car or town Shele Zip Code
Net wit • Phone mike!
R WELL brtAlls:
A. totAL bMPtN: In
b. boES WELL REPLACE EIUStINO WELL? YES 13 NO*
is WAtErt Witt below top d•CnMU: In t) a Ft,
ma... II Above top d Caskq)
d. for OP CASING IS ( g r r Pt. Above Lad Sudare'
stood teeing It,NSI d aba belay lend Wire may ►puke
s relents M steads*, Mgh ISA NCAC 20.0110.I
e. YIELD (ppmJ: r ) MEtNoO OP tESt f-I itP
May be M &pees,
'Amite, Item h ne
In • declnul Aemal
OWNER
MWb ,
NC_ ✓�
40i
I. bISINr ctIoN: type /-117 N Amount :VS/hrck4
U. WATER ioNts (depth):
horn r,IRSS•to ,.Sb' Ftom 3 V3"to 3YV'
horn y. lotto Poi" Flan to
Flan ,'tJr/: to 3n 4," horn t0
s. CASINO: tbktnKN
berth blanheleh Wetgld pot
i
Than to PI.
Flan to PI.
1. GRoUt: berth Material
Fran, 0 " to DO' k`I._F3errin,,;fekt.,k„f .17
Eton to F1.
Atom to PI
e. SCREEN: bepih
Than to
Than •. to_
Fran to
it 3ANUIGRAVEL PACK
Depth
Fitton 10
Ftan to
Fran to
Method
rrev,.
(Memel* Slot Slze Ma1esWoi
FI. M In.
P1 M. M.
PI In M.
PI.
FI.
FI.
Size Matetlal
10. b ILL111G Lou
Front to _Formanes Desetiplbn
,o,. a' op .Coif.
Go' ('/p✓
46 /36 • ' C Icy $lcfr tit t V
13A' R/_o' Ll ni rt.3 An
11. IttNIAItKS
2"'3
N
CJ
5 sP - &'/Z3/7.407 41.1
73/Arts 2-3
1 ba hhtnter CEptfl1NA1 the! Waal WAS to'SlnvCltb N ACCORDANCE tatty
15A Ncat 1c. wEL( tvwlruct ON SIANDAntM. AROMA) Atom or NO I
Ream , Ell PN0,01011je1NEMELIMott
SIONAl ►' F ER1
9-06
lOR b111E
T n rk msrn)
PRINTED NAME OF PERSONCONSTRUCTING IIIE WELL
rs....n d.e ..sinl.,d 1.. the hlulalni nl Wslar 0I1a111e Wltlilll 3d SAYS. AM! b11u11NhUt►d MdLL
Pee.., rtw_la

RESIDRESIDENTIAL
ENTIAL WELL C_ONStIIUCtTON ItECUftU
Noah booths* liepathaenl of L•nebmmieid IOW N.Wrd Ittsubitel• Uirklal Of Wile Quality
WrLL CUt4t'11AClt)it CFit'I'IPICA 1'IUN N 735-3
I, MitLL contRActof:
Well Coldacla lkidMdual) Nam
MILLER WELL DRILLING, INC.
Well conkacla company Name
S1REttADbftSSP•D. DUX 567
ITAYESVILLE, N.C. 28904
coy is l own Stale
1 828 T. D37-2997
Uses axle- Phone number
L WELL INN:TI MATION:
SLUE WELL ID bpi ayoncSel
SIAtE WELL PE1Nitetteppeeablel
DW0 a OM ER PERMIT 6'A appEcabk►
WELL USE 'check Applicable boat Resldedld Wolof Supply (SI
bAttDRILLED 9-096-0G,
'TIME COMPLETED 51-OAMU rut:
1. WELL LbCAt10N:
city: MGye'SUIIIP cOUN1Y Clay
Lor TePres Q
IseeM Name, Nxnke,e. Camnaaq. aab*leloi. UM No., reel. Zlo codas
t oPoDRAPNIC ?LAND Ott/IND:
hb Code
Wkps Maki t Plat tlfldW boll er
Wm* eppop'lale box)
LATITUDE •i_ 01 • 130'
LONGItUDE ea 3_ .i • 7 3$ '
tilfludestohgillhfe enure: 1.41.1's tltnpurtephic limp
1 slbri Pei met/ be chsd Toe* form tool us►on 0 G51opo mop end
p GPS)
n
4. WELL owNER
OWNER'S NAME Lv Co (
stfEEt ADDRESS S5 01,1 6 4 t4J
FEuyy�s,�,lle NC. Z`3104
1 Slew Zip Code
May le in der eft.
Minnie", !mink Of
M e decimal Amami
CNy
Pnny SwansDh
1 239E 253 - g'v to
., Ana code • Plonssamlbe
1 WELL bttAIL9:
a. tbtALbrPt* �nh
k NOES nu. RePIAct Milstein WELL? YE9 ti NO
t. WAtER LEVEL belowtop of thin : S o ' It.
'USY4• 11 Above top d Crbp)
d 101410 CAttNO 19 1 ? n Pt. Abose Lad Sudaet'
'topd Wry Iamllaatld Wa bests bid Ilalsce may Ielpae,
a Wawa kl rxudalcewit NSA NOAc tcAD le.
6.'Habig*: /5 MEtilobDP ltst H ir'
OWNER 41
FAVYU ���1
•
NC I, ,'
.d
I, bISINrrctION:Ammon( o`
u. WAttf ZONES Idspth):
klom /?7' toll?hors to
rico,,103' tb 0Y' Isom to
Pram to Isom to -
6. CASING:
beplh ukuleles
tlnn 6 '' to G:2' PI. /e "
Fran to rt.
bum to Pi.
r. oaoUt: berth Mie.id
Ilan 0" toa0' PI. 8nria;ic cotes/
Pram to PI.
Flan to II.
tldclnef✓
Weigh, dead
Method
l Irnj L,Gm
6. sO WEN: beplh blamelot Mot Slta Malell
Flan to kl.M. __ In.
Flan • to PI. M. M.
Plan to St In M.
6. *ANOIGRAVELPACK:
Depth
Plan to Pi.,
Pram to ` Pt
Pion To - PL,
M. brill been LOG
From to
:1"
an' rSd'
,Sn' man'
1:
Site Mesabi
Formaton beaetoton
;TA, so;(._
r�y
C nysklr anIX
SAci' L.IMrc-Ione
•
RNtAl? pb
0
OCR
Ir ftMA_SP—es f 23Jz0d7 -444
1 bl oD¢7z
/ iu S
IDu$tllfll CEk$Rt 1RAt tle6 WELL WA/ to+nNm10itb N AtCONOAN:E MIN
ISA MAC It PIMA CONE IIANbMda. ANb atilt Atom as
Wow BEN MI NIl--
SIGNATURE
mac
PRINTED NAME OF P
q 25-06 :
JOR DALE
CONSTRUCTING NNE WELL
Submli 11te btldhNei to the Division of Watet 00*111I witilhl id ds . Mei! bioN11IU1tN Mg
_.... .. e... "nee: ed,,.sa►I., Mai tll_tniNtelklL '.'
hem OW1i
has I

RESIDENTIAL WELL CONSTRUCTION RECORD . '
North Carolina Department of Environment and Natural kesourcet- Division Pt Watet Quality
WELL CONTRACTOR CERTIFICATION 0
1. WELL CONTRACTOR:
Wee Ira w(Individual) Name
.g. vveilkut
Well Contractor Company Name
j STREET ADDRESS ? Booc Jtv
( t x //e StaleLk- Zip
cod0 y Hy
( fizz -2997
I Area code- Phone number
2. WELL INFORMATION:
SRE WELL ID Slit applicable)
i
STATE WELL PERMIT/Nil applicable)
i DWQ or OTHER PERMIT #(0 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED t_/( o •
' TIME COMPLETED /lit 3 AM14 PM
3 WELL LOCATION: ' I
CITY: �0. J (NI)1►I P n COUNTY l ' lay
(Street Name, Numbers' community, Subdivision, Ln1 No., Parcel, Zip Code)
TOPOGRAPHIC l LAND SETTING:
slope °Valley ['Flat ❑Rage °Omer
(check appropriate box)
LATITUDE 4_old 'fa I
'LONGITUDE 3 Z`
Latitude/longitude source: PS ❑Topographic map
! (cation of we/ must be shbMt on a USGS topo map and
, attached to this lam? no/ using GPS)
4. WELL OWNER fI �I� IJ 1
(OWNER'S NAME TYainSTREET ADDRESS 32,7 Scn 45NS
}TcT�IPCoIIIP N.C, 2�7oy
C ty Or Town State Zip Code
(g�g).3E`i- 160i
Area code 4 Phone number
(
8. WELL DETAILS:
L TOTAL DEPTH: �0n
May be in degrees,
minutes, secondi or
in a decimal f nnal
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
,
6. WATER LEVEL BelowTop of Casing: 3n FT.
(Use'+' 8 Above Top of Casing) : .. .
d. TOP of CASING 1S 1 io r FT. Above Land Surface'
'Top of casing terminated allot below land surface may require .
a valance In accordance wllh 15A NCAC 2C .0118. • '
I. YIELD(gpm): /'5 METHOD OF TEST !1lr
2353
a 2za1S
I. DISINFECTION: Type N Ti, Amount Id rat/
g. WATER ZONES (depth): /
From /,$9 ` To /44 ' From To
From /8(e' To /ft?' From To
From To From To
,8. CASING:
Thickness)
Depth Diameter Weight Material
Fron6" To YFt.jolt_ P. d, C,
From To Ft.
From To Ft.
7. GROUT: Depth Material
From n„ To VCI ' Ft Zralaa.irifrnr.t
From To FL
From To - Kt
8. SCREEN: Depth
From To
From To
From To
Method
Diamelet Slot Size Material
Ft. In. m.
Ft. In. In.
Ft. In. In..
9. SANDIGRAVELPACK:
Depth
From To FL
Size Material
From To Ft.
From To Ft:
10. DRILLING LOG
From To
6": 09'
9n'
;cp. ate,
11. REMARKS:
Formatidn Descriplbn
T y Coil
re 101
5cr✓/ Mud ('lny m1K
6imr Irma
I4N U 2 2009
-,(‘nt't
I DO HEREBY CERTFY THAT THIS W
15A NCAC 2C. ELL CONSTR
RECORD HA 9 EEN PROVIDE .
LL WAS CONSTRUCTED IN ACCORDANCE WRH
STANDARpS. AND TINT A COPY OF THIS
SIGNATURE'OF CERTIFIED WELL CONTRACTOR DATE
TfVk /P7r/4oa.)
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 . Phon6 No. [phone] ext 566r < , , t)
FormGW-1a'...
Rev. 7105
THE yf170. OW

North Caroline Department of Envkollnaul end Natural Resuurees• Division of Water Quality
1VELLCONTItACIUII CEIttlflcA PION M Y, 3
1. WELL CONTRACTOR:
Wee Conhoc(y( IlndbAduali Name
MILLER WELL DRILLING, INC.
Well Counselor Company Name
STREET ADDRESS P•0. BOX 567
NAYESVILLE, N.C. 28904
Cily a Tam Stale Zip Cale
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID Ala eeplkable)
STATE WELL PERMITIts applicable)
DWQ or OTHER PERMIT /(il applicable) /
WELL USE (Cheek Applicable fax). Residenlal Water Supply l$"
DATE DRILLED 2 I D t'
TIME COMPLETED / AM L7 PM)
3. WELL LOCATION:
rite' COUNTY (% /
CITY:
7-t N
Minion Nema. Numbs's. Community. Subdivision. tol No., Pncsl, Zip Code)
TOPOGRAP IC I LANG SETTING:
LTSbpe VSIey Mflat °Ridge °Other
(check apprep,lata box)
LATITUDE 3 5- as . )d
LONGITUDE 92_ 3_ , tom�( 70
tatitudellongilude sauce: Mvi'S °Tnpngrnphie map
(Iecnlbn of wet must be of ro,vn on n USGS Icpo mop end
attached to lhls loot /not osier; GPS)
4. WELL OWNER 14441I Lo46sr.,L 4/0OWNER'S NAME 44 I ntOn% Cod Y %
STREET ADDRESS . 2330 [};at -on (phief RA
G / eesv I P YUC. 110V
Ciry a lawn Slele Zip Code
Area erode • Phone nm,bet
May be In &peek
nannies, Wmxh m
Ina decimal Oxman
IL WELL DETAILS: �l
a. TOTAL DEPTH: POD
b. DOES WELL REPLACE EXISTING WELL?YES ❑ NON
e. WATER LEVEL Delve Top d Casing: th) • FT.
(Use'r' S Above lop d Comp)
d. TOP OF CASING 19 l6 FT, Above Lend Suttees'
gap d easing Ierrrlkmled nVa below lard surface may leqube
a variance In accadarice with 15A NCAC 2C .0115.
•
e" YIELD Wpm): /(D METHOD OF TEST Pi
1. DISINFECTION: Type J/711 Amount /
g. WATER ZONES (depth):
From /,26 1via?'
Fran /66 ' Too 03
Fran St' To /S.
S. CASINO:
Depth Diameter
Fromm" to 67' Pt G
Fran To P1.
From To PI.
Prom
Prom
Fran
To
OWNER
RESIDENTIAL WELL CONSTRUCTtom RECORD 3 3 0 5 9 60No
NC_
rfs
I
10
Thkknessl
Weight erii
T. GROUT: Depth Material Method
Fran n' To,2/)r Ft. Ctnrror1/6b24..7- /2/D-Aern
Fran To F1.
Rom To Ft
S. 9CREEN: Depth Dlemeler Sblsize Maledal
Prom To Pt. In In.
Fecerr to Pt In. kr.
Noon To F1. In la. -
G;7
9. SANDIGRAVEL PACK:
Depth
Tian To Ft.
Fran To Ft
Sloe Maledat
Prom To P1.
10. DRILLING LOG
From To
O "
Formation Description -
/LI 50 r L
L/4
end / roue(,
L,nrrs4nr
lizspoo
A
This 201°D40E :
r—
11. REMARKS:
(DO IIEn1:9Y crntsT that 1leS 'Maras consmucrt0 N ecconoMIct MIN
ISA NCAC IC. W,IANDAnwS. AIA TINT A cof OF THIS
NECOnp HAS N N %CHIDED lI1E yyEll ImNEn.
SIGNATURE 11
dart /!7t//dn)
PRINIED NAME OF PERSON CONSTRUCTING T1IE WELL
7-I 4 -0 6 .
CTOR DATE
Submit the orininel to the Division of Water Quality within 30 days. Attn: Inhumation Mgt.,
r..... nW.I.

/1 v
RESIDENTIAL! WELL CONSruUC'rIUN itEcultb
North Cnrnliva lkrnluncnl ul Li,vhunuteul mrd Nnlwnl Nesourcrt- Division of Water (Jualiiy
%SELL CON IItAC'11JR CIsll'I'IEICA'1'IUN N
1. WELL CONTRACTOR:
W ell Canhnclor tbulivklual) Name
fIILLEn WELL DRILLING, INC.
Well Ca,hacla Canr ely None
STREET ADDRESS P.O. DUX 51;7
IIAYESVtLLE, N.C. 20904
City a 10V01 Slalo ZIp Lode
020 )_ 037-2991
Atea code. Phone on
2. WELL INFORMATION:
SITE WELL 10 Ppl.rrnrnN.l
S I AI E WELL PERMIT /III arrllrebie)
DWQ ce OTIIER rERMIr Itl1 npplicnble)
WELL USE (Check Applicable Bowl* Residential walnr Supply eir
DATE DRILLED 2--zj-06
TIMECO)APLEIEO /�3(:)
AM IJ I'M (IO
J. WELL LOCATION: 11 /
CITY: 1t'S 1(2Jvll)"e CLIUNIY (.,1'Qy
(Street Home, Nnnbete, Community. SubJi Lion, Lol Ilo.. 19lrel. Zip Cod')
TOPOGRAPHIC I LAIN) SF. TTING!
(B.Sk.fe EIVnlry Tiflal F1RIdun uolhel
trh.rk 'vrrordata ho.)
LATITUDE _a_ s bl 4313 y
LONGITUDE R 3
kt,y lo rlrpirec.
nlinntel, .rrr nt !, in
bl a drrbend rnnnnl
alilndcllonpiludr touter: k.TT i1vs If!ii.rititttpaphic rn:q,
(l rnfhn of nrl roost hn S110140 a, n (ISGS Alpo Molt nerd
alfarhed 10 O,1t Alm ION !Sig GPS)
4. WELL OWNER
OWNER'S NAME if I (AM Cali(
SiREEt ADOIlleS -33C) III f '1 Cejd -r tZtit
PSt)tIl A L Zg90 t
city a 111 Slate Zip Ctxle
At ea code - I'hra,a nunlhn
5. WELL DETAIL S. -
e. TOTAL DEPTH: �UC1
b. DOES WELL RErLACEEXISRIJUWELL/ YESU NDU
e. WATER LEVEL Rnl'w lop el Cnsint FT.
(Use'+' 8 Above Top of Casino)
d. TOP OF CASINO IS fr i FT. Abnvn 1 nitd Sultan?
•Toll d casing Inndnnled albs below lard 'wince mny laqulte
P valance In accordance with 15A NDAC 2C .0118.
•
P. YIELD (gpm): lr) METHOD OF TEST /) %
OWNER
MIND
'IC
I. OISINrEC11011: Type 7-1 T p{ A,nouul iclUt'
u. WATER ZONES (deplli):
Nam r;%S to Og0)
Flan To
tram To
Flan
Fran
Flan
E. CASINO:
Urplh Dlarneler
from 0 / lo 50 Ft !a"
fnan To rt
non 1b rl.
7. GROUT: Depth
Ipso Tn
nom to
man In
rt.
rt
rt.
To
To
To
1DIrin.ssl
Welpld Meterid
SS-4 tJ'C
Meltad
1. SCREEN: Urrlh 171nn,eler Ski Size Malerlal
man 10 FI. In. kl.
from To FI. In. In.
Flan lo rt. Iri. k1.
9. SAND/GRAVEL PACK!
Depth
non To Fl.
non In rt
flan To FI.
10. PPRLING 100
rroln To
fix• OR'•
Size
Material
ronrtalbn Desaiplbn
yn,es At i
RECEIVE
FF.egional
ou Fier Protect'
11. DEI JAltEst
�r� l r t i) d — LT)) &)
Ion ninny crn'FY mat peg WEIL WAS COM tomtit el acenrloarre yam
ISA Nt1Ar: tr„ WELT MIS tettour N e tflpAnps IVIO MAT A COPT Or INES
nECOMO IN 9 PEEN envy to 111W WELL OW EA,
SIGN
L O'IRACTOR UAIE
iu & C-M AI
PRIN I Et) NAME or PERSON CONS I nuc T IIIt; 111E writ
t-em
VOL
Std11n11 the of Iuinal PI (he Division ut Water Quality w(llth; 39 days. AIIII! Worntntlott Mgt.,
1e 17 11,1 c..,n.n rrr.l n. _ RntnbJ, tlf` ]ir.nn IC 17 !loon NM P1101 ill Vitt evt 51111
nem ow -is
1

331 301
I?ESIDCNTJ,I L wtLL CUNSTRUCI ION RECORD
North Carolina Department oFL•nvlroimrertl aml Natural Resources. Division or Water Quality
114t,LL CONTRACT Olt CEA-IT ICA•1'ION 1T c,353
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
MILLER WELL DRILLING, INC.
Wee Conbaclo Company Name
STREET ADDRESS P•0. BOX 567
HAYESVILLE, N.C. 28904
City o Town Stale
( 828 } 837-2997
Zip Code
Atea code- Phone number
2. WELL INFORMATION:
SITE WELL ID IPI evollcable)
STATE WELL PERMITIIII applicable)
DWQ or OTHER PERMIT I(S applicable)
WELL USE (Check Applicable Box). Resklenllal Water Supply 1J
DATE DRILLED 7- -54o
TIME COMPLETED , :bb
a. WELL LOCATION:
CITY: yc5ullle
AMO PM01
COUNTY l la y
ISInni Nadia. Numbers. Community. subdivision, lel No., Parcel, hp Code)
TOPOGRAPHIC 1 LAND SETTING:
j4sbpe OVe0ey ['Flat Orildge C)011ier
(check apprep,lals boa)
LATITUDE _3,5kg 240
LONGITUDE 51{ 0410
Latitudellongilude source: OOI'S oTnpogrnplilc nlnp
(kcalkn (gem/ must be shown on a USGS Iopo map and
attached to This lam trio) uslrg GPS)
1. WELL. OWNER 11ff ` I
OWNER'S NAME L11Yl\b, OP nArc- I _ _ s7 1
STREET ADDRESS 2-330 µ; nton triter RA
iiccs o,11 c vuc a fsVa
City o Town Stale Zip Code
May It In &pen
miuuln, secants a
In ■ decimal hnmal
}
Nee code • Phone number
3. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NOM
e. WATER LEVEL Rei mToro( Casing: FT.
(Use '+' II Above Top d Casing)
d. TOP OF CASINO IS /8 " FT. Above Lmrd Sudety'
'Top d casing terminated aha below land •ounce may tequhe
Ti tabrlce In accordance with 15A NCAC 2C .0110.
•
It. YIELD Wpm): /5 METHOD OF TEST 19tr
OWNER
MIND
NC
1. DISINFECTION: Type NT )4 Amount PMedibils
g. WATER ZONES (depth):
From /DO To /dot From To
From /(e6 To ((o/' From to
Fran ,205' To ao%' Ftom To
S. CASINO: Thickness/
Depth Diameter Weigh! Material
From O" To 6,3' FI.
Fran To FI.
Fran To Ft.
1. GROUT: Depth Material Method
Fran 6 " To20 ' FI. F�rnian � i � .,� d.�/csl.rom
Fromm To Ft.
From To Ft
B. SCREEN: Depth Diameter Sid Size Metalal
Ran To rt. In. In.
From •. to Pt.M M.
From To Ft. In In.
9. SANDIORAVEL PACK:
Depth Size Malerld
From To F1.
Fran to Ft.
Ft.
From To
10. DRILLING LOO
From To
o,. a,
; ipD.
Pa' 91
VW a,Pa
II. ItED1AILKS:
Formation Description
/010 Sdi L
cQ f0
L ern PC di n•2
N
N flr-,
0
Ito urnreT Grittier 1NAt
1SA NCAC 2 Ell CORSI
RECORD EEN Pf0V
welt WAS coustnuetrf N ACCORD oca Willi
DS.IdtD DATA COPY OF VHS
7 Z6-o6 .
BIGNATUR OF CERTIFIED WELL CONTRACTOR DALE
Tack dipl'ln.l)
PRINTED NAME OF PERSON CONSTRUCTING IIIE WELL
Submit the orlginnl to the Division of Water quality wind 130 days. Alit: Information Mgt.,
Form OW1

RESIDENTIAL WELL CONS TTLUCT ION RECORD
North Carolina Department of Env ironmcnl and Natural Resources- Division of Water Quality
WELL. cONTItACFUIt CERTIF• ICAT ON II 3 5 3
1. WELL CONTRACTOR:
T+^ ftvilpeu
Well Co,tracld)(Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•O. BOX 5 G 7
MAYESVILLE, N.C. 28904
City a Town Stale
L 828 )- 837-2997
Al ea code- Phone number
Zip Cale
2. WELL INFORMATION:
SITE WELL ID Npl applicable)
STATE WELL PERMITNIir applicable)
DWQ or OTHER PERMIT N(if applicable)_
WELL USE (Check Applicable Box) Residential Water Supply 1]
DATE DRILLED 3—Q i• 020
TIME COMPLETED / 0 6 AMU MLA
3. WELL LOCATION:
CITY:
� taco( s)Ji COON I Cla 1/
(Slreel Name. Numbers. Community. Subdivision. Lol No . Parcel. Zip Code)
TOPOGRAPHIC I LAND SETTING'
tikSlope [Valley DFlal ❑Ridge ❑Other
(check appropriate box)
May he in degrees.
LATITUDE 3 5 00. 0y6 minutes. gerunds nr
LONGITUDE H. •J ,� A7/g s in a Jrcinnal Formal
Latitude/longitude source: %il'S ❑Topographic map
(km -alien of we%most he shown on n USGS forgo map and
attached fo Ibis hum I not using GPS)
4. WELL OWNER
OWNER'S NAME
•
c Sri, rk
SI RFET ADDRESS Sti I dkeJlfw llr_uc
T1) e 94lioel
COY a I own Slale Zip Code
(13ZS I- 38i5— 'Si
Area code • Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: f 90
b. DOES WELL REPLACE EXISTING WELL? YES() ITO2S,
c. WATER LEVEL Below Top of Casing Jt,Q FT.
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS /6 FT. Above land Surface'
'Top al casing terminated al/or below land solace may require
a variance in accordance will) 15A NCAC 2C .0118.
e. YIELD (ppin): / METIIOD OF TEST Av r
OWNER
MVVD
NC 1/
T. DISINFECTION: Type !7 TN
g. WATER ZONES (depth):
From r l r7 Toc2r.. 0 From
Font' To Frail
F101n to From
Amount f5
To
10
To
6. CASING: Thickness/
Ueplh Diameter Weight Material
From 0 •. To /.3 Ft. /sr .r Stc-rc
rran To Ft.
From to FI.
T. GROUT: Depth ^� Material � Method
From (7 ri To cy,� FIc-et.T^rri-/mmIsl/r Jberrn
From To FI.
Fran To F1
R. SCREEN: Depth Diameter 51o1 Size Material
Fran To Ft. In. In.
From To FI. In. in.
From To El. In. In.
9. SANU/GRAVEL PACK:
Depth Size Malerial
Fran 10 FI.
From To Ft.
From
To F1.
10. DRILLING LOG
From To
/PCB 306
Formation Description
FK lire,/ L,Tllesit I
r�riL'Ls � (.tor MIA 41"014c11
It. REn1AltKS:
It s.. Ca ..
7
_3
'2
100 llFROIIY crnhey 111AT 11119 WELL WAS cOrlSlROCRO el ACCORDANCF WITH
IAA NCAC 2C. CIA CONSIfiJ N S1Ai D.nOt A THAT A COPT Of THIS
RECORD IIAy)sEENPROVIO O LLOW
3 9 O6
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
�SzsAlne. i41'3
PRINT EL) NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. AIM:Information Mgt.,
1911 Mail Service Center — Ralolah_ NC 27699-1617 Phone No. [phone] Dxt 568.
Form GW-Ia
Tlnv nos

I?ESIUEN'1-LI L 1VELL CONSTItuC I lON RECORD
North Carolina Department ol Environment an I Natural Resources- Division of Water Quality
1VIiI.I. CON FItACIOIt CEItTIFICA'P ON If ,�I_v�
1. WELL CONTRACTOR:
-eK 04.RR&c
Well Conn acltsO(Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•O. BOX 5G7
HAYESVILLE, N.C. 28904
City or Town Slate Zip Cole
l 828 F 837-2997
At ea code- Phone number
2. WELL INFORMATION:
SITE WELL ID d(If applicable)
STATE WELL PERMIT/hit applicable)
MCI a OTIIER PERMIT flit applicable)
WELL USE (Check Applicable Dox) Residential Waler Supplyy)
DATE DRILLED
TIME COMPLETED :!OO
3.
WELL LOCATION:
CITY: t7j7f'SLi7/C" COUNTY ( /Q/
AM LI PM jk1
(Sheet Name. Number. Community. Subdivision, Lol No . I'a,cel. lop Code)
TOPOGRAPHIC I LAND SETTING:
154 Slope [Watley ❑Flat DRidge UOther
(check appropriate box)
LATITUDE 3 6.0,• Qinn ia(0 z
LONGITUDE LJ 3 8s p
latitude/longitude source: t rl'S rTopogrnpllic map
(kv:nfinn of wet most be shown on n USGS (opo map and
attached Io this loon f not uskrg GPS)
4. WELL OWNER
OWNER'S NAME
S T REET ADDRESS
�}u yye- u J) r ,Vc. 2_
City Se 1 own Stale Zip Code
May be in degrees,
minutes. seconds or
in a decimal fonnnl
(Area code Plicate number
5. WELL DETAILS:
a. TOTAL DEPTH:
nor Jones
era I1L►L r
SYD
b. DOES WELL REPLACE EXISTING WELL? YES❑ NON
e. WATER LEVEL Delow Top of Casing � FT.
(Use'T.' it Above Top ol Casing)
p .y
d. TOP OF CASING IS /3 FT Above l and Surface'
'Top of casing terminated alien below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ,3 METHOD OF TEST ft r
OWNER
MWD
NC /
nom
Run
6. CASING:
I. DISINFECTION: Type fi TV/ Amount 9 11///r�5
g. WATER ZONES (depth):
Fron, VC) To V7,2 From To
To rl an To
to Fron To
Depth
Ran U To
From To
Rom 10
7. GROUT:
From 0-
Fl
rt.
FI.
Thic ness/
Diameter Weigtt Material
Depth ^ Material Method
O'
To U Ft. Cen,rn1/Sent,,j-r /-)4 r)wr,m
From
Ron
9. SCREEN:
From
Ftem
Fran
To Ft.
To FI
Depth
10
To
To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
/
/O' 3OCA Crr1CST,I
dne
Diameter Slol Size Material
FI. In. In.
Ft. In. in.
FI. In. In.
rt.
rt.
F1.
3co " ,3.5e •
Imo' $Yo
II. REMARKS:
Size Material
Formation Desctiplion
1\CC
L7n,estc,. p
L/meSlone /S(le/t° ni,,.
Ioournrpyc rRIFT111AI THIS
15A Near. )r, Ell CONstn
RECORD ll FEN rnCN 1011Jfj,4 ttt
E1.1. WAS CONSIRUCITn el ACCORDANCE wIIN
ION 1 0ARDS. A IO nut A Cory of IRIS
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
%17 e // LJ
PRINTED NAME OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Atha: Information Mgt.,
1517 Mall Service Center -Raleigh, !IC 27699-1617 Phone No. [phone] ext 566.
Form GW-17
fire. 7/05

RESID NTL I L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources• Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
(53
3 2, 6 7 W30NER
MWD
NC
1. WELL CONTRACTOR: n^
/V �4a
W ell Contract (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•O. BOX 567
HAYESVILLE, N.C. 28904
City or Town State Zip Code
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT/4a applicable)
DWO or OTHER PERMIT a(if applicable)
WELL USE (Check Applicable Box): Residential Wale' Supply
7 DATE DRILLED —5
TIME COMPLETED 7/ e 0 AM® PM13
3. WELL LOCATION:
CITY: (eV Cliff COUN I L-G ty
(Skeet Name. Numbers, Community. Subdivision. Lot No., Parcel. Zip Code)
TOPOGRAPHIC f LAND SETTING:
laSlcpe OValley OFlat ❑Rkige El Other
(check appso tiale box)
LATITUDE J> 02•5227
LONGITUDE ;._S • Y3a7
Latitude/longitude source: jti'S °Topographic map
(kxarbn of wr7 nnwf be shown on n USGS fopo map and
al:ached to this form 1 not using GPS)
4. WEII OWNER '/
OWNER'S NAME a y b/bkt NI an 3-0"'
STREET ADDRESS t sb (2-1th.ertt, tS f �'
t—i-�.n(k2 gfC' 2e8 LSl51
City a 1 Stale zip Cale
t 328) 589-6o21
Area rode • Phone number
Mny Iv in desrer s.
'Moults, seconds et
In a decimal format
S. WELL DETAILS: �0 ,
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES* NO ❑
c. WATER LEVEL Below Top of Casing: _ 50 FT.
(Use'+• 8 Above Top d Casing)
•r
J. TOP OF CASING IS 0 p FT. Above Lend Sothic?
'Top of casing terminated ago below land sutlace may require
a variance In accordance with15A NCAC 2C .0118.
•a. YIELD (gpm): l0 METHOD OF TEST'L/r
t. DISINFECTION: Type 27 711 Amount Peer/kfs
g. WATER ZONES (depth):
From /S'O' To/902' From To
From) Ff6 To)8J From To
From yo . Tel 7 e- Flom To
6. CASINO: ThIcknessi
Depth Diameter Weight Material
Fran O„ To L2:• Ft. [.," Ktic
Fran To Ft.
Fran To FI.
7. GROUT: Depth 17 Maletial ;� Method
Fta1142: To Fl.&aL./c/cn of D/cir€4••,
From To FI.
Flan To FI.
S. SCREEN: Depth Diameter Slot Size Material
From To FI. In. In.
Ftorn To Ft. In. In.
Fran To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Ran To Ft.
Ran 7o Ft.
From To Ft.
10. DRILLING LOG
From To
AO' AN
aoo. gP8b
11. ItENIARKS:
Formation Description
`TM ten P
r"3 fiche //imecAne ri y x
,JUi 6 2005
1130 I!ETIESY CEnt 111AI n119 WELL WAS caanntnuCtm() tl ACCORDANCE WIN
15A NCAC 2C. • I t COMM SIANOMIDS. AND MAI ACOPY Or MS
RECa1D HAS EN PROVIDE f*NEZ4L OWN
4-5-06
SIGNATURE sFCERTIFIED WELL CONTRACTOR DATE
Tack Mee//seJ
PRIM E° NAME OF PERSON CONSTRUCTING THE WELL
Submit the oriulnal to the Division of Water Quality within 30 days. Attn: Information Mgt.,
Form GW1a

OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD 3 6 7 1 9
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION N p/`�, j,�
1. WELL CONTRACTOR:
Well Cordracla (Individual) Name
MILLER WELL DRILLING, INC.
Web Contractor Company Name
STREET ADDRESS P • 0. BOX 507
HAYESVILLE, N.C. 28904
Cily a Town Stale Zip Cale
( 828 } 837-2997
Area tale- Phone number
2. WELL INFORMATION:
SITE WELL ID I it applicable)
STATE WELL PERMIT/(e applicable)
DWQ or OTHER PERMIT I(il applicable)
WELL USE (CheckApplicable Box): Residential Water Supply
,
DATE DRILLED L[ —I 4-0 0
TIME COMPLETED !Igo AMIa PM❑
2. WELL LOCATION: y �{
CITY: I'1G,ytrsUlll'e COUNTY l In/
(Sheet Name, Number. Community. Subdivision, Lot No., Parcel, Zip Code)
TOGRAPHIC / LAND SETTING:
lope °Valley OFlal tIdge OOther
(check appropriate box)
LATITUDE ,3 QZ•970r
LONGITUDE a 31 • bt3'
Latitude/longitude source: il'S UTo( ographic map
(bcnlbn of well must be shown on n USGS logo map and
attached to this lone roof using GPS)
4. WELL OWNER
OW NEWS NAME ?er. cT?F'n or
STREET ADDRESS. cle-' N- ,.✓Arae 4A2-
TAg rnA- Ft. 33 b0y
City or Tolman Slate Zip Code
(s[ 3} 9bao -Ofs3/
Area code • Phone number
Mny le hi drpiece,
minutes, second.' or
In a decimal formal
S.WELLDETAILS:
a. TOTAL DEPTH: 7O'
b. DOES WELL REPLACE EXISTING WELL? YES U NO I]
e. WATER LEVEL Below Top of Casing: ) f ' FT.
(Use •4• 8 AboveTopof Casing)
d. TOP OF CASING IS h 0 FT. Above Land Sutlace
'Top of casing Terminated fluor below land surface may require
a valance In accordance with 15A NCAC 2C .0118.
•
e. YIELD Wpm): Sr) METHOD OF TEST RI I'
NCt,
I. DISINFECTION: Type k7 f% Amount a,2OpP/lc'f
g. WATER ZONES (depth): Y
From, ' To I 's • From
From
From
To
From p,.20 To paii' To
From To To
6. CASING: Thlctnessl
Depth Diameter Weight M lerlai
Fran 6" To/Q ' Ft. "
From To Ft.
Flan To Ft.
7. GROUT: Depth�t �"�-1 ��rr
;From /) if Torf0 . Fl.00ITbn rir G., .,J 1�19al1rc41
From To FY.
From To Ft.
Material Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In in.
From To FI. In. In.
From To rt. In. In.
9. SAND/GRAVEL PACK:
Depth
Fan
Fan
From
Size Material
To F1.
To FI.
To Ft.
10. DRILLING LOG
From To
3'
gs�' /00'
//)o' a 'O'
11. REMARKS:
Formation Descriplbn
/a saiC
I e-s'{dnr
Iv'; lie
.11. N1 06. 2003
100 HEREBY CEPTKY TMMA t 11119 WELL WAS CC/inlet/CND et ACCOROAN0E woe
ISA NCAC 1C. WELL CONSifuCtION SIANOMDS. AND ANT A COOT OF TM
RECORD 11A511lEEN PROMO 0 111E yyELL OWNER.
—06
SIGNATURR�OF CERTI D W LL RACTOR DATE
eI�dr3
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
Form GW1a

330399
RESIDENTIAL WELL CON STItUC'I'ION ItECOItD
Nunit Carolina bepanmcrd or Environment and Neural Resuurees• Division or Weltr Quality
WELL CUNTRAC I OR CERTIPICA PION N r- 3S
1. DISINFECTION: Type
{(, WATER ZONES (depth);
From /47
From l�� To /&J' From
Prona/14i To2ki'
C. CASINGbe aFr•
1. WELL CONTRACTOR: �V—
anlr�
llvfdual' .
e
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•0. BOX 567
HAYESVILLE, N.C. 28904
City re Tam Slate zip Code
1828 ) 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID hill eppncable)
STATE W ELL PERMIT/0 applicable)
DWO or OTHER PERMIT NUJ applicable)
WELL USE (Check Applicable fox): Resldeeid W aler Supply RI
DATE DRILLED 7'7�116 "6 IO
TIME COMPLETED d n 15O AM O PM ei
3. WELL LOCATION:
CITY: t'10.n/PC giVft
COUNTY Mar
ISbni Name. Numbers. Community. Subdrdalon, Lot No., Mittel Zip Code)
TOPOGRAPHIC I LAND SETTING:
(Slope I:Watley []Flat ORldge ❑Olber
(check appropriate box)
LATITUDE . 0! 5W8'
LONGITUDE 0 3 in • 3I�e
Latitude/longitude source: lalil'S nTopogrnphic mnp
(bcnrbn of time most be shown on a USGS Iopo mnp and
attached In Ibis /ontl /nel uslre GPS)
4. WELL OWNER GeerieErv', M
OWNER'S NAME h Fu ,1- tjo (eIL./B r
STREET ADDRESS f.441I`A RfSocjp.ks,l+290 Hwy 6RW
•
-- M' � A/C- 2. 'SSA 04
Mny IT In depees,
ndnntrs, setnlnllor
In a decline) Formal
irya tnml Stale ZlpCode
101-V F S,' $fin
Area code • Phone number
S. WELL DETAILS: 3b
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES i] NOS
e. WATER LEVEL Below Top til Casing: 1, FT.
(Use's' II Above Top of epilog)
d. 7OP OF CASINO 15 �� PT. Above Lad Sunlece'
•Top d ceskng lennlrndled Wm below land enlace may requke
e valence In accordance Wnh ISA NCAC 2C .0110.
e. YIELD Wpm): (D iJ METHOD OP TEST 91 r
OWNER
MWD
NC
Amount ram` ,ll1•fS
From 3,6
Fran
Deplb Dlarneler
From 0 " Trigg' Ft (e " ,
From To Ft.
From To F1.
to
To
Thickness:
Welphi Material
.U,C.
T. GROUT: Depth Material ;� Method
From n '• T�r5' FI n aR-r CFrrni !Dir OliOn Qvni
r From To PI.
! From To FL _.........
S. SCREEN: beplh
From To
From to
From To
Diameter Slot Size Material
Pl. In. In.
Fl. In. __ in.
rt. In. In. i
e. SANDIORAVEL PACK:
Depth
Ran To
Ran to
From To
10. DRILLING LOG
From v,
n,y
6d CD'
Ao' ,3re0'
I I. REMARKS:
Size Material
FI.
FI.
Ft
rormalbn bescrlptbn
Idpp sat
Lrt�i(you t-C
AFrin l/nec Ne_
LLL11�f... omPc% one .
100 HEREBY CERISE 1HAT MS WELL WAS CONSDIVCTrn N ACCORDANCE wml
ISA MAC 2C. WELL CONS]nUCDION /1*NDMOS. AND TINT A COP! OF MI
VECOR(/IW BEEN V WELL • NER.
SIGNA RE OF CE IFIE 1 E
ins (i1rT.0
PRINTED NAME OF PERSON CONSTRUCIINO 111E WELL
7-II-06 •
NTRACTOR DATE
w..L.—n d•� ...I..L. nt I.. II.w Merle inn nr Welar Os1alIIW WIIhlit 30 don. ANTI: Information Mgt.,
rmm rlW.lr

North Carolina Department of Environment and Natural Itesourccs- Division of Water Quality
TVELL. CONTRACTOR CERTIFICATION 8 gg55
1. WELL CONTRACTOR:
444 /
Well eclat (Individual) Name /; f
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•O. BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale
( 828 ). 837-2997
Area code- Phone number
2. WELL INFORMATION:
Zip Cale
SITE WELL ID Obi applicable)
STATE WELL PERMIT/Or applicable)
DWQ or OTHER PERMIT OW applicable)
WELL USE (Check Applicable Box): Residential W aler Supply
DATE DRILLED 3 -�1� t1 - 0
oc TIME COMPLETED •OO AM O PM 121
3. WELL LOCATION:
CITY: I-Layrsv 111,e_ COUNTY 0 Lay
Smoky ?lsP
(Street Name. Numbers. Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC ( LAND SETTING:
(Slope (Valley ['Flat ()Ridge ❑Other
(check appropriate box)
LATITUDE _,T $ Otte/. Ott
LONGITUDE 8 3 J v•7(8f
hliludc/longitude source: sdot's ❑Topographic map
(tnca(ion of wet mast be shown on a USGS fopo map and
attached to this fom, f not using GPS)
4. WELL OWNER j� �` II I
OWNERS NAME D?C. SmI*k
May he in degrees,
minuses. seconds or
in a decimal format
STREET ADDRESS SF fake U tely Da v e
µnyesQille NG Z$RDfi-
City or Town Stale
Pt% )- 3a5 - 657(
Area code - Phone number
5. WELL DETAILS: (,
a. TOTAL DEPTH: w aO'
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO QT,
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' 8 Above Top of Casing)
i
d. TOP OF CASING IS ()
/ t FT. Above Lend Surface'
'Top of casing terminated aVor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
• •
e. YIELD (gpm): Q METHOD OF TEST R 1 C
()6c;, r WNEN 3^ZZ-O6
RESIDENTIAL WELL CONSTRUCTION RECORD'
MWO
NC
1. DISINFECTION: Type N 771 Amount e„) Cud g. WATER ZONES (depth):
From `a%p5' To 96/�7' From To
From a57f0 To 34/3' From To
From To From To
6. CASING: Thickness(
Weight
Depth Diamgler
From 0' To (el F1. [n
Frorn To Ft.
From To FI.
Malerial
P,V,C
7. GROUT: Depth f1 Material Method
From (0 • To PO' Ft. pnninrato f enrCalcabam
From To FI.
From
To F1.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From To F1. In. In.
From To F1.in. In.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft.
To Fl.
To F1.
10. DRILLING LOG
From To
145' c9bo•
'OD' q Po \nn. Jane
Material
11. ItEMARKS:
Formation Description
S%no'L,nirsi one to K
AiN 013 203
I DO HEREBY CERTIFY UTAT NOS W F.tl. WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, W CONSTRUCT �prN7 STANDARDS. AND HMIS
A COPY OF S
RECORD HAS pgE N PROVDEty14iHE WW. OWNER
319 0
SIGNATURE OF CERTIFIED WELL COHTflACTOR DATE
Jack me Ile it)
PRINTED NAME OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
I P11 n,._-_ u_ mini vli rn+e -..r ace
ram GW to

RESIDENTIAL WELL EONS ratty 'f1UN ILECUItU 3 3 3 4 5 r
North Cerelhit bepalmeul ar Envhonrueul mid Nelurd Ittluuree!• blvlslou or Wrier Qusllly
writ, cowl -tumult CEIt1'IPICA'I'IUN N
1. WELL coNthActon:
W ell Conlrecla $Indlvlduall Nome
HILLtA WELL bfILLING, INC.
Well Gadrscaw Company Nome
STREET AbtstSSP.0. BOX 567
(IAYESVILLE, N.C. 20904
City a Town Slate ZIP Cod
( 028 } 837-2997
Area code- Phone number
L WELL INPORMATION:
SU W ELL ID hill applicable)
9 Mir W Ell PERMIt1p applicable)
brill or DINER PERMIT 1111 applicable)
WELL USE (Check Applicable fax): Reeldenlld Wake Supply (A,
bAtE DRILLED 9 - 7 -01
1IME coMt'1ETEU 3I.n a AMU PM(r
3. WELL LOCATION!
CITY: 140.1 ego/ 11 P COUNTY Cloy
ISbeei tieing, Numbers. Conenimny. Subdivision. lop No., parcel, Zip Code!
tOONOGRAPNIC I LAND SETTING:
;lope bVahey brio) fRbpe bonier
(check sppopiple boa)
LATITUDE ,.,1_ °C • Apr
LONGITUDE 8 ` 713
Leliludefnegiltde Source: i 'S b1'upngrnphic mnp
Tbcelbn PI wee most be shoed or, n USGS Iola map erld
sflsched birth yam►not snip GPS)
4. well OWNER
OWNER'S NAME Toe Mv.rra
sl11EElAbbnEssJ2(33 Saln'e/ CO Vt Rd
14nyyes,l; Ile EL 2-R9o4-
enicr love Stale Zip Code
1.
Ales code • Phone nundrer
May I< In Jepcet
rnlann, seeaiJi ht
In a tledi al Oemd
E. WELL bEtA119: i/ 'l
a. TOTALbEPtlb Tin°'
b. boE9 WELL REPLACE EXISTING WELL? YES b NO b
e. WATER LEVEL eelowtop d casino. ico• Ft:
Wee*** II Above Tsp W Ceske)
d. TOP OP CASING 19 i» " Pt. Above Lad swine,.
•to r d task° Idn*mled Mid below lend ealpce may Iedukd
• reline* In ectoldsice With ISA NCAC 2C .et It• -‘
•
I. YIELD10pm): /5 METHobDEtEst I -)if
(. birnNPEctioN: trot /1 TH Amount 9yd fp[(ds
p. WAt1ER zoNtI (depth):
Fpom / /3Y' to Y34 1 hem to
Piom VW,' to Y$o' F,an to
Fran To
Flom 10
6. CASINO:
Depth bla,rele,
Flan C>" to Co `/' ra.
K,an to rt.
F,an to rl.
thlcsnesel
WelplJ MsIe,id
V.Oc
'7.ONobt: beplh Material
Fran b" to ?0FLBenlee)1'T/ce.,t.,t
Fran to PI.
' Klom to PI
O. SCREEN(
Klan
Kran •.
Method
J7,CS1.esn.
beplh blame's, Sbi Sire Malald
to Pl. In. In.
to ri. In. b.
I. Pram To rt. to b.
I. SANUIofAVELPACK!
beplh Site Male,lal
rlan 10 -P1.
P,mn 10 PI.
Nom to rt.
10. bnKLI11G lop
Rom To
v0'
Uo' S
11. ItEAtAItKS!
Potmelbn bescrlplbn
/ap so,�.
cl„.y
S%fc
i rie si•oee
1 eo tenter CEfliFY n1At nuS W Elt WAS t0,minuCrto a ACCORDANCE With
• RSANCAC 3C.)YELI CON7IR p_ l.pN011NtAC0►r c►THE
NECDaOIIA EEN PR ELL ti
ei19-06 .
SIGNAT IIRRoF CERTIFIED WELLCON1RAC1OR DATE
-VGA_ fin e !1�' o
PRINTED NAME Or PERSo CONSTRUCTING 111E WELL
5ubmll Rho origins! to the Division of Water quality nllhtf 30 days: Mho Information Milli
tram b4411

OWNEN '
I SIllENTIAL WELT; cUNsrltuctION RECORD q '''I
Noah Ct uois Department otL•nvhmr ieid Mill Nona' twines Division ot Wain Qi3ll J 4 4 8'"""°
NC tom."
WELL CONTRACTOR CEllt'IrICA'T ION N �, 3$�_
1. WELL toutfActon:
W el Canhacla (hhdlvUuat) Nome
MILLER WELL BHILLINOh INC.
Wel Caner/eke Company Nana
i1REEt AbbntSS P.O. 110X 567
NAYESVILLE, N.C. 20904
City to Tam Slate
t 828 T. 837-2997
A'ea code- Phone mamba
1. WELL INPonMAtlou:
WE writ. ID etc applkiWt)
STATE WELL 0E1 MIt rls applicable)
DWG a DINER PERMIT e(r ap*Ieable)
WELL Use (cheek Applicable Rust Residential Wolin Supply IJ
bAtrbnhLLED 9/-b1
Zip Code
TIMEcoMPLEtEt 3'.O6 AMID PMp(
!. WELL LbCAtloN:
C11Y: casein t COUNTY Clay
terns Naar. Numbs's. community. Subd illon, Lot Net, I'arca,. Zlp Code)
tOPOGNAPNIC I LAND SEttING:
tlSkye tIveketh brat bfklpe CiOlher
(clrtA hypneMl'Ila but)
LATITUDE
LONGITUDE
ilitiludellongiltnie solace: IN61'S bit' mgrnplile amp
tbealbrt of Mar most be *lawn one USGS boo map end
attached to ids tome / naught) GPM
I. wrll owNER
bWNEP'SNAME Cobge Sahe,Oai 4-Mrkt
Aley le M /epeek
ndtNna, seconds Of
M e decimal ewaat
STREET ADORERS PO nx [221
14Ati2Stitlit, tit, 2 890LV
City of to nl Slide Zrr Code
t_^}
NN code • Phase Isom
1.WELL DETAILS:
L toot burnt 7 ri)'
b. DOE51rtll hEPIACE EXISTINd wELLt YES t7 NU g)
t. WAttlt Levet below be d•Ceekp- Pt,
Woo •r' a Abase tog d Caskp)
d. TOP br OASINd 19 / f " Pt. Above Land su,In'
good WTI lSn*uded MIS below had swim may Iepu*e
ittrine (neeeSlrbneeWih15ANCACtC,et1t,
C.
YIELD lepmh I.2 ME11I00 DP'Est Ar r
ni,
1. blslNrrctloN: type Amount
u. WAt Eft zoNEl (depth):
Thom 7 /3 to y/5' rian to
khan V&7' tb V29ham to
khan to rran to
I. cASINd:
„ berth blsttelet
rn u b /OIL PI. ( '
ham to rt.
bon to PI.
t.OnoUte beplh Molerld
horn 6 " to,2ri' PI. Bandon/-r
than to PI.
Plant to Pl.
thickness/
Welpld
Materiel
skr/
� Method
,t/isilsram
e. ScfrEN: booth btnnels SW Slat Mderd
Ran to rl. M. M.
• Ran , to P1. M. M.
krona to Pt. In M.
e. SANtSollAVELPACIt:
beph Size Mderlal
Phan 10
Iran to
ham to
10. MILLING LOG
Born to
0 ., 0'
.rl.
PI.
PL
.3911e r;'
II. ILEMAItICSI
rolmalbn besdblbn
7ep Sn,L
C /o ✓
l rau e
Lr lines inn e
•
`c jE Josd
Rirtssa
61 I-
I Co tenter teams tom Tsai Well WAS t000moo to M Accvnu*ct woo
htconblN/ aces OLpfNfIr10 i eLLAtrpAnOl fND 1tNtACO►ia INN i
�s�ErL i
//c `:/ill?' 9-f2-06
BIGNATIIR OFCERTIFIED WELL CONTRACTOR DATE
_ —(11 ale thik)
PION I EU FIAME OF PERSON CONSTRUCIRIO tilt WELL
Submit the WOW() the bit/Islets et Water QUilily WIlldil 30 days. Atilt! Istenntllotl Mgt.,
rani oW.h

7c 2O/
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater SectionWELL CONTRACTOR (INDIVIDUAL) NAME (print) M(Chfad (Y' CCAu.$C CERTIFICATION#3%14.Il
WELL CONTRACTOR COMPANY NAME -inc` 'v --t` 12-91thO11 arc PRONE It(U)1 O" 4
STATE WELL CONSTRUCTION PERMIT# _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential'( Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Wateidnl%ction ❑ Other ❑ If Other, List Use
2. WELL LOCATIO
Nearest To,�7 v I ii County
'v9Qs01 S Ttc. CJ
(Street Name, Number, Community, Subdivision, Lot No., Zip Code)
3. OWNER: -DC:3\N\ £
Address (.o fZ 4iaC �t Ott.
(Street or Route No.)
City or T State Zip Code
Cfli)- 20 ?\SS
Area coda Phone number
4. DATE DRILLED I,2',( Cl - O &
5. TOTAL DEPTH: PIO
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS f FT. Above Land Surface*
`Top of casing terminated ar)or below land surface requires a
variance In aceordaaee b ISA NCAC 2C .0118. //JJ /��
9. YIELD (gpm): METHOD OF TESTA i^ I�t') e''"�
10. WATER ZONES (depth): �f
3Wr1
11. DISINFECTION: Type i .t ‘1) E; r , At Amount
12. CASING: Wall Thickness
Depth, Diameter or W,qt' t
From+I To Pelli Ft. 6 id 15/716.
From / 5 To 3Q Ft (i,, !J S
From To Ft.
13. GROUT: Depth Material
From (3 To 3 FL) 4.;,i. j (twfe..] t
From_ To ,x; Ft. ) jEi l ic.1 t kF
14. SCREEN: Depth Diameter Slot Size
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
Method ,^
?ctirin
From To Ft.
From To Ft.
❑Topographic/Land settin
Ridge ❑Slope ❑Valley Flat
(check appropriate box) ���////// ������......
L�.aatitude/1Sagitude)of ll location l /
JV354oil Ib.q 1 n y9•3,, y
(degrees/ seconds)
Latitude/longitude sourcPS❑Topographic map
��i��i (cccccdll�����teck box)
DRILLING LOG
Formatign Description
DEPTH
From To
Llto
5.91
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
DIV. OF WATER QUALITY
JAN 1 8 7007
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL W.
CONSTRUCTION STANDARDS, ?FHAT
ATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

33330t WNERr15-06
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
MWD
NC ✓
1. WELL CONTRACTOR:
OPetrie-�
(Individual) , L e—
Well Contra w Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P.O. BOX 5G7
YESVILLE, N.C. 28904
City or Town State Zip Code
( 828 y 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(8 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED —! S -- 6
TIME COMPLETED .Z tali AM ❑ PM I3
3. WELL LOCATION: /
CITY: COUNTY C`C7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
°Slope °Valley ❑Flat ❑Ridge °Other
(check appropriate box)
LATITUDE 3 S &3- 925
LONGITUDE b' 3 s Y- 6 t
Latitude/longitude source: La8PS ❑Topographic map
(location of well must be shown on a USGS topo reap and
attached to this form 1 not using GPS)
4. WELL OWNER OWNER'S NAME Ai, 2T`/
CA-
STREETADDRESS )Ct-I- 5CPN drC Or;iv-e
May be in degrees,
minutes, seconds or
in a decimal format
it-Lr�e sr)1 Ile A/C Z.89olt
City or own Stale Zip Code
( >
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: 0 �q
%5"
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 2l� FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 6 METHOD OF TEST /1/!�
t. DISINFECTION: Type /r ! V Amount %leIt/
g. WATER ZONES (depth):
Rom To From To
From To
Ran
6. CASING:
rom 6
To
From
From
Depth giaMeler
Io 32 a -01J
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To J
From 7
From
To
To
Thickness/
Weight Material
f �.0
allee,r?I Method
Ft. e/1709d d
To eld Ft. t'c4, 4&-
To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To R. In. in.
9. SANDIGRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
74'— rir -
II. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Description
e-ft
Gaon, fe--
RECEIVED
N\/ f iF VVATFR OUAt..11 V
FEII 2 2 ZO07
I DO HEREBY CERTIFY THAT IRIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
r7GJ/z 1/4
/2/..-
DATE
d(
PRINTED NAME OPERSON
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
rm., Tint

337580
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) \tvl
DIVIDUAL) NAME (print) , /- S' � CERTIFICATION a1
WELL CONTRACTOR COMPANY NAME ��'(3v 1tJ LSaL 1 LI1CPHONE a PrlaD r —CO
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential ElMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCA
Nearest T
(Sheet Name. Number, Tom vision, Lot No., tip
3. OWNER. b
Address .np�t��fo `1
City or T
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES [1 NO l0
7. STATIC WATER LEVEL Below Top of Casing: T.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 ET. Above Land Surface*
'Top of wing terminated actor below land surface requires a
variance In accord.n.,eit�iw�iith ISA NCAC 1C .Olga.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): \'ir1
i eAtt o Zip Code
11. DISINFECTION: Type
12. CASING:
lit
�P(� er
From —To 13 Ft LOW.
From To Ft.
From_ To Ft.
13. GROUT: Depth
From_ To `\D Ft.
From To Ft.
Slot Size
Amount
Wall Thickness
or Wei tat. Mal
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.
Material
16. REMARKS:
in.
in.
opographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreea/mivuroaleaonds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRf.r_ING LOG
From
To Fotm*tion Description
\t r `3O2
3AN E:' (i LU'.1!
LOCATION SKETC}(
Show direction and distance in miles from at fei
two State Roads or County Roads. Include the r
numbers and common road names.
‘4,
4
LE
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRN 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 Mall Service Center - Rslelgh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

)7 5779
Y.4 k
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalS Resourc ivision of ter Quality - Groundwater Sectia
WELL CONTRACTOR (INDIVIDUAL) NAME (priim))C (;) CERTIFICATIONN OPKIp
WELL CONTRACTOR COMPANY NAME `` EItl ��-� AU4 Ck PHONE # J�1310 I1-C-5—
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1.
WELL USE (Check Applicable Box): Residential Ca' Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Nearest To
County.
(Street Name, ti ben, Corrirawi , Subdivision,, Lot No., Zip Code)
3. OWNER:
Address
treet orN
tate Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: (..4 /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO l
7. STATIC WATER LEVEL Below Top of Casing: (GB FT.
(Use "4"' if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface"
'Top of casing terminated at/or below land surface requires ■
variance In aceordan with ISA NCAC 1C .0118.
9. YIELD (gpm): METHOp OF TEST rot
10. WATER ZONES (depth): ``i`t
11. DISINFECTION: Type Valk Amount
12. CASING: Wall Thickness
r or Weight/Ft. Material
From 0 To Ft. (�4" c9p IC--
From To FL
From To FL
13. GROUT: Dep$j i renal
From D To at FL G
From To FL
14. SCREEN: Depth Diameter Slot Size
From______ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft.
16. REMARKS:
Material
Topographic/Lagd setting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
IN
DEPTH
Fr To
5-L l
-1m. Cots'
Fo
RtGEt'�turA1�S
np.; r iroP '' ......
e U)1 r
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County oads. Include the road
numbers and common road r es. gn awa . LX1UC Afro.\
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TkiE WI LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
So 0(0
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

33'7578
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) C4t).1,—S la C�t CERTIFICATION peril'
WELL CONTRACTOR COMPANY NAME Wicei tom".4 "-'- WtL' -, (�'1 t. PHONE I 31(1 g/55
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMITS(
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 3' Municipa1/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
City
Ara�rode- Phone mmtbet
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L�
7. STATIC WATER LEVEL Below Top of Casing:T
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS _ _ FT. Above Land Surfaces
'Top of wing terminated at/or below Ind surface requires a
variance In aceordamc with ISA NCAC 2C .0111L
9. YIELD (gpm): METHOD 10F TEST 'Alt
10. WATER ZONES (depth):S
•
11. DISINFECTION: Type WTtk
12. CASING:
FroTo FL L.r
•
From To Ft
From To Ft
13. From_ Dept s Mat 'a1
Ft.
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
Front___ To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
r eirl
lerial
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCc ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL WNER
0,4delt \ VG Up
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Topographic/L etting
❑Ridge ❑Slope alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formatjon Description
DEPTH
From To
0'
'T5t (oPzt
le '1 (4-1
QUALITy
JAN '!', ( 21107
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.
semflattb u01:Yi t s_
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

3. OWNER
Address
ls„V,y of
-t•
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: �— /
6. DOES WELL REPLACE EXISTING WELL? YES f J NO EI
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface'
'Top of wing terminated at/or below land surface requires a
variance hi accord mwith ISA NCAC 2C .011a. `�
9. YIELD (gpm): l/U METHOD OF TEST rt 1
10. WATER ZONES (depth): 11D'
WELL CONSTRUCTION RECORD
7-?
North Carolina - Department of Environment and Natural�Resources1c- Division of Water Quality - Groundwater Section
jQ
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CN1'c"'e es:t9---2(U CERTIFICATION Nam/✓1
WELL CONTRACTOR COMPANY NAME ‘StkfereSALLE USEL - PRONE N (Si-'q/S
STATE WELL CONSTRUCTION PERMITN ASSOCIATED WQ PERMTIN
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I( Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCA
Connty0_
(Street Name, Nurt)bdp, Community, SubdIWUm, La No., Zip Code)
VAL
Zip Code
11. DISINFECTION: Type
12. CASING:
Depth
From_ To .?�' o
From To
From To
13. GROUT:
Frottt—� To
From To
14. SCREEN: Depth
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft.
Wrt-f
er
Ft.
Ft.,
Ft
Ft.
Ft.
Amount
Wall Thickness
or Wei � . ,Af\taI
terial
16. REMARKS:
Diameter
Slot Size Material
in.
in.
Material
Topographic/Lan�" setting
❑Ridge ❑Slope Malley ❑Flat
(check appropriate box)
Latitudellongitude of well location
(degreealminuteileeconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Forma 'on ription
O 11
( aQ
ad t 0:35'
Ciltt. , i� uAff-R MUAIM
JAM ( 21107
J.00ATION SKETCI;
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 WNER
/.r r/t(.0 f All t� c� 1lJ oto
9 SIGNATURE OF PERSON CONSTRUCTING THE WELL DAjE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

; e C e
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcr`.Division of Water Quality - Groundwater Section
CERTIFICATION
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
tr rintt),,,t`� `"/""'�
WELL CONTRACTOR COMPANY NAME tteS t PHONE u
STATE WELL CONSTRUCTION PERMIT# _ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ErMunicipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
(Street Name
3. OWNER:
Address
mbar*, Commun
Subdivision, Lot No.,o.`Zip Code)
Street
Ytsl.)
tate Zip Code
ldLZY-
Area code- Phone number \`
4. DATE DRILLEDat
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: \So FT.
(Use "+" if Above Top of Cuing)
8. TOP OF CASING IS \ FT. Above Land Surface'
'Top of wing terminated at/or below Ind surface requires a
variance le aceordan with ISA NCAC 2C .01111.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): \ S0
11. DISINFECTION: Type {'(fir
12. CASING:
Depth Diameter
From O To & Ft. GA4 "
From _ To Ft.
From To Ft.
13. GROUT: Depth Ma real
From O To_ FI.
Frorn To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ftin. in.
Frog- To Ft. in in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
ecbAmasiount
Wall Thickness
or Weittift.HIatS4a1
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC�TT�ION STANDIDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED T THE
H D LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Material
/Topographic/Land setting
&Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degre&mimne✓seconds)
Latitude/longitude source:❑GPS❑Topogfaphic map
(check box)
))
Fo a. a sc .tion
GGCIvitv lAl n v
„,‘„,„,TER
JAN 2, a zo97
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the ioaa
numbers and common road names.
v
k)?IThE
,i
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
e' 'tr i
North Carolina - Department of Environment and NaturalRS �urc s - Division Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME ((ppriintt) Q> `,-',lt t't�t�-a_. CERTIFICATION
0997
WELL CONTRACTOR COMPANY NAME Wee 1\l.W WT• PHONE a SSC
STATE WELL. CONSTRUCTION PERMIT% ASSOCIATED WO PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCA • a
(Street Nemo, N - Comm i• yl, Subdivision, Lot No., Zip Code)
a- etainiStaat
3. OWNER:
Address
fertutwagte
City or T• State Zip Code
Area code- Phone number 11.^� 1
4. DATE DRILLED \\'ai I btp
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I�3'
7. STATIC WATER LEVEL Below Top of Casing: %D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of callus terminated at/or below land surface requires a
variance la accordan�ee with ISA NCAC 2C .011S.
9. YIELD (gpm): `fS METHO? OF TEST Y�
10. WATER ZONES (depth): \'%.
11. DISINFECTION: Type WT1A Amount
12. CASING: DeP Wall Thickness
or Weitt/Ft.
From To (3 FL torte t .{<
From To Ft.
From To Ft.
13. GROUT: Depth
From () To 1.23 Ft.
From To Ft.
14. SCREEN: Depth
From_ To FL in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft
Diameter
G•Lr: •
Slot SizeMaterial
in.
in. n'
Material
TopograpM sag
❑Ridge ❑Slope Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreedmluutesheconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fotmatipn pesckiption
D_EP_TH
Front To
0 lDl
10' (p31
ATER QUALITY
JAN ?, 6 inro
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 STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO WE OWNER
( 6112,'" 1.4,Ikol'7 Dlo
1GNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

1 p 3
eD�+d
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and�wRRees� Resources - Division Water Quality - Groundwater nderOSectionA
WELL CONTRACTOR (INDIVIDUAL) NAME ``N D '�
WELL CONTRACTOR COMPANY NAME t3itu� L43 P—LLUtC) PHONE a ) ql--S
ASSOCIATED WQ PERMIT/
STATE WELL CONSTRUCTION PERMrTa (if applicable)
(if applicable) /
1. WELL USE (Check Applicable Box): Residential L� Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
3. OWNE
Address "Ng
Address• (Street ctRoutine.) 2����,,
x�G.RA.U4. l-114 ✓b15-4t'
Zip code
flp
Area code- Phone number
4. DATE DRILLED6. DOES WELL REPLACE EXISTING ,
WELL- YES NO l3
5. TOTAL DEPTH:,
z❑n
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Top of wing terminated at/or below land surface requires
variance in accords" th 1SA NCAC 2C .0tla.
9. YIELD (gpm): METHOD QF TEST ; TZ
10. WATER. ZONES (depth): 7y5
11. DISINFECTION: Type l Amount
12. CASING: Wall Thickness
r Wei t/Ft. a5 t,rial
DsP t`yn_.
From t Te kp FL it/teFt.
To Ft.
From To Ft.
13. GROUT: Depth
From b To3� Ft.
From _ To Ft.
14. SCREEN: Depth Diameter Slot Size Matenat
From To Ft. in. in.
From* To Ft. in. in.
15. SAND/GRAVEL PACK Size Material
DeP�
From To Ft.
From To Ft.
7. STATIC WATER LEVEL Below Top of Casing: FT.
Topolrr8phic/Land setting
❑Ridge p lope []Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreadmimteelseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DIEM DRILLINGLOG
F D T) Fo on Description
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC'k1ON STAND AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOITHI OWEWNER
j DSTED
/SIGNATURE OF PERSON CONSTRUCTING THE WELL
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.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceen`tteer, RREV g , N2C(Il
27699-1616 Phone No. [phone], within 30 days

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
Natural Resources - Division of Water Quality - Groundwater Sec 'o
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Ah\ 11 RAC 5, I �S CERTIFICATION ter/
WELL CONTRACTOR COMPANY NAME
3 3 7 5 8 4
VrV\e��V1Uk, PHONEN)�(`(I
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential E Municipal/Public Cl Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Nearest T
1
(Street eNumbberrss, Cammun
3. OWNER F^�
Address d`1a% C—ps I mt�(Streator Route tiL 4.1 City or, Taw _State I Zip Code
Subdivision, let No., Zip Code)
Area code- Phone cumber 1
4. DATE DRILLED I1 \Oct Ole
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use "+" it Above Top of Casing)
8. TOP OF CASING IS ` FT. Above Land Surfaces
'Top of easing terminated at/or below land surface requires a
variance 1n seeerdsgee with 15A NCAC 1C .0118.
9. YIELD (gpm): l D METHOD 9F TEST Ykra---
10. WATER ZONES (depth):
11. DISINFECTION: Type v\"—(Fk-
12. CASING:
Amount
p r Wall Thickness
From d TI Dept, LO''/4 SI �t. Material
Ft.
Y'
From To Ft
From To Ft.
13. GROUT: Dept'', Mat al
From O To Ft
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft__in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
Material
Topographic/Lantetting
!Midge ❑Slope °Walley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To \ Folp)$tion Description
O 10
\b' ? 3'
,-
nv ii rTFp n11AL1TY
JAN (; 2007
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.
*Li ia
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU ON ANDARD , AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OWNER
,ate 1\ OLP
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
f Environment t d Natural Resotrc ivision of Water Quality - Groundwater Section
North Carolina - Department onvtronmen an
On/''
WELL CONTRACTOR (INDIVIDUAL) NAM�411 Cj
E (mint) CERTIFICATION #
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
VoictLf,,\f‘tit, ustu,_braw
PHONE #o
1. WELL USE (Check Applicable Box): Residential l3/ Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
Nearest
(Street N e, Numpen, - ity, Subdivision, Lot No., Zip Code
3. OWNER:
Address
�h
\ (,, -lor Router I
City gr T.1C State 1 Zip Code
(fl14)-4q • —3OCO
Area code- Phone number
4. DATE DRILLED \\ \ DLp
5. TOTAL DEPTH: 1 `
6. DOES WELL REPLACE EXISTING WELL? YES/ �❑, NO
(Q
7. STATIC WATER LEVEL Below Top of Casing: D FT.
(Use "*" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface"
*Top of wing terminated at/or below land surface requires a
variance ie(gpm): .bOh ISAMBTPAC 2C OF TEST �'V`(J.-
0118.
9. YIELD (gpm): � (TIT�O{�I
10. WATER ZONES (depth):
11. DISINFECTION: Type mil-% Amount
12. CASING: t1� p Wall Thickness
b _ To "lli Ft. Us"i(er g UFt. at 'al
From To Ft.
From _ To
13. GROUT: Depth.,
From To l t)
From To
14. SCREEN: Depth
From To
Ft.
MM*�renal_
FtCu-rw'cN
Ft.
Topograpbic/Lansetting
❑Ridge OSlope EValley ❑Flat
(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 I esci ption
C.' CI 0'
'310 `loth
()R° t_1F 161ATFR (1liAl�( e
Jo '1 c ?CIO/
Meth
tta
Diameter Slot Size Material
Ft. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
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.
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 WELL OWNER
� �Ibcc
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

33'7587
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �a
\
WELL CONTRACTOR (INDIVIDUAL) NAME (print) S\\ U.Y, `` S - I S CERTIFICATION a U/�/
WELL CONTRACTOR COMPANY NAME LUC IY ELu�'Qz.ILL1.WC- PHONE #A)
STATE WELL. CONSTRUCTION PERMITI ASSOCIATED WQ PERMIT/
(if applicable) (ifapplicable)
1. WELL USE (Check Applicable Box): Residential 13 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLL
a ij oN:
b. .S County
O
;4
(Street Npme, umber, •_ , Subdivision, No.,
3. OWNER: ---
Address �V i1�'� i —s SeiL�•'I
Code)
ice—) `61
Area code- Phone number 11
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
7. STATIC WATER LEVEL Below Top of Casing: 7 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Top of wing terminated at/or below land surface requires a
variance bt aecerdi np with ISA NCAC 2C .61111.
9. YIELD (gpm): I MERIOD OF TEST
10. WATER ZONES (depth): ,
11. DISINFECTION: Type �" ('rt Amount
12. CASINO: tt� Wall ibielmess
From 0 To \DS FL (Dazneer
µ/ " Wei t(Ft. jateal
From To Ft. (� ��C�
From To Ft
13. GROUT: Dep(h _ Mat 'al
From d To 1 b5 Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft. pp
16. REMARKS: U-k-L\151(A-R -
Zip Code
Topogr)s¢hic/Land setting
❑Ridge OiSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
@egreea/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From (o Fo on Description
tttl,kivrit,
Oh) OF \4I4,TFP QI 14l It
IAN 9 g 2007
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and co' . on road p@me, s.,
Material
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CON ST U TION STAND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE W$LL OWNER
g pea 11\apt
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRICTION RECORD
Divis on of W ater Quality
Carolina Department of Environment and Natural Resources-
WELL CONTRACTOR CERTIFICATION # 3368 —�
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
W eU Contractor (IndNidua9 Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
PO BOX 1007
STREET ADDRESS 28906
StateNC
Zip Code
MURPHY
City or Town
82( 8 ) 837-8008
Area code- Phone Hunter
2 WELL INFORMATION:
SITE WELL ID #(rf applicable)
STATE WELL PERMIT applicable)
DWQ or OTHER PERMIT #(it applT WELL USE (Check Applicable Bad: Residential Water SuPPIY
DATE DRILLED 09113106
TIME COMPLETED_
3. WELL LOCATION:
Cm,. HAYS
munity. Subdivision, Lot No., Parcel. Zip Code)
(Street Name, Numbers, Com
TOPOGRAPHIC 1 LAND SETTING:
11Siope 0Valley ❑Flat l7 Ridge ❑Oliver
(check appropriate box)
LATITUDE 3 5 02.0
8 4 09.907W
Letitudenbnt
LONGITUDE— PS OTopograptuc map
fTwsoiree:ceshownmap and
(bcation oof we/ must be shown on a USGS topo
attached to this torn 8 not using GPS)
4. WELL OWNER LEHARRISON
OWNER'S NAME PO BOX541
STREET ADDRESS
NC
City or
HAState
City
or Town
8( J. 389-4290
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 30° EXISTING WELL? YES ❑ NO
El
b. DOES WELL REPLACE
..
c. WATER LEVEL Below Top of Casing:
FT. Above Land Surface
C
d. TOP OF*Top ci casing terminated Uora—below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
CHLORINE
f. DISINFECTION: Type—�'—
g, WATER ZONES (depth):
From 180 To 20 Fn
Fri
From To
2� Fr
From
6. CASING:
AMO PM
COUNTY CLAY
WEST GUM LOG RD.
(Use'+' d Above ve Top of Casing)
28904
Zip Code
e, YIELD(9PrnY
50 METHOD OF TESTAIR_
�— Information Mgt-,
Submit the original to the Division of Water Quality Within 30 days. Attn.
1617 Mall Service Center— Raleigh, NC 276994617 Phone No. [phone] ext 568.
FT.
Material
Ft. CEMENT
Ft.
T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
BY
FY
I RECORDO D
A BELL CONSTRUCTION
STANDARDS, AND THAT a CCPr OF THIS
RBp HAS BEEN PROVIDED 1O THE WELL oWt4ER.
wnaos
Form GW ..1 a
Rev. 7105

WELL CONSTRUCTION RECORD
RESIDENTIAL Division of Water Quahty
North Carolina Department of Environment and Natural Resources -
WELL CONTRACTOR CERTIFICATION # 3368
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contractor (Individual) Name
CHEROREE WELL DRILLING
Well Contractor Company Name
PO BOX 1007
STREET ADDRESS
MURPHY
City or Town
6zf 6 1- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Of applicable)
STATE WELL PERMITIrof applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply px
DATE DRILLED 0911� 0
PM 0
TIME COMPLETED--
AM
3. WELL LOCATION:
CITY: HAYESVILLE
CALDWELL ROAD
(Sheet Name, Numbers, Community, SubdiNsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
❑Slope °Valley ®Flat °Ridge °Oter
(check appropriate box)
LATITUDE
LONGITUDE__ —�— hicrnap
Latitude/longitudesource: ❑GPS ❑Topo graP
(location of wee must be shown on a USGS topo map and
attached to this form Hnot using GPS)
4. WELL OWNER
OWNER'S NAME WINDELL ANDERSON
STREET ADDRESS 1425 BURNT SCHOOLHOUSE RD.
28904
HAYESVIL State Zip Code
CRy or Too NC wn
82( 8 )- 389-8986
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES C NO
IX
c. WATER LEVEL Below Top of Casing: FT.
NC
State
28906
Zip Code
cOUNTY CLAY
(Use et" t Above Top of Casing)
•
1 S F( Move Land Surface'
*Tod. TOP p of casingASINGterminated l or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST AIR
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
CHLORINE
g. WATER ZONES (depth):
From 160' To lea' Fm
From• To 280' Frc
To Fn
0j 0 tj
I DO HEREBY CER11FYTHAT THIS WELSrPNSCOSTRUTEDTINCYo�TM CE Wm1
15A NCAC 2C, WELL CONSTRUC
HON RECORD HAS BEEN PROVIDED TOTHE WELL
OWNER.
09t20/06
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev. 7/05

RESIDENTIAL
WELL CONSTRUCTION RECORD
North Carolina Departme
nt of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3368
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Wee Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007 28906
MURPHY NC
City or Town
State Zip Code
82( 8 )- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(! applicable)
DWQ or OTHER PERMIT #(if applicable)���
WELL USE (Check Applicable Box): Residential Water Supply ID
DATE DRILLED 091211—
TIME COMPLETED_
AM ❑ FM
3. WELL LOCATION:
CITY: HAYESVILLE COUNTY COY ----
OFF OF SHORES DRIVE parcel Zip fie)
(Street Name, Numbers, Community, SubdMsion, Lot No.,
TOPOGRAPHIC I LAND SETTING:
aliSlope ❑Valley ❑Flat ❑ Ridge ❑Other
r(check appropriate box) is degees,
01.071N nvoutea exuada ox
LATITUDE 3 5iaadecimal format
LONGITUDE 8 3 43.218W
Latitude/longitude source: NGPS ❑Topographic map
(bcetbn of wet must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME D.M. REESE CONTRACTING
STREET ADDRESS PO BOX BBB
NC 28904
HAYESVILLE State Zip Code
City or Town
82( 8 )- 389-3388
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 220' 7 YES ❑ NO
b. DOES WELL REPLACE EXISTING WEU-
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" If Above Top of Casing)
1 ET Above Land Surface*
d. TOP p of casingAng CASING
inatedorbelow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
50 METHOD OF TEST AIR
e. YIELD (9Pm):
f. DISINFECTION: Type CHLORINE
g, WATER ZONES (depth)
From 180' To 200
From 200' To 220
From To
6. CASING:
From U'
From
From
7. GROUT:
From 0'
From
From_
8. SCREEN:
From
From
From
Depth
To ZO
To_
To
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From
From
From_-
10. DRILLING LOG
From To
0' TO 20'
20' TO 40'
40' TO 220'
11. REMARKS'
From-
From -
From
Amount 100 PPM
To
To
To
Thicknessl
R. 6118 ar
Material
FtCEMENT
Ft.
Ft
Ft.
Ft.
Method
GRAVITY
Material
Material
Formation Description
RED SLATE
BLUE SLATE
BLUE SLATE
IDOHEREBY THAT UICS LMONSTANDARDS, AND THAT A CCPY OF THIS L WAS CONSTRUCTED IN ACCORDANCE W ml
15A NCAC 2C,, WELL WELL PCR RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ED EL OONTRAI
S NA URE OF CERTI f I
4 i' >�`��>f.C'_I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mali Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
09/25106
DATE
Form GW-1a
Rev. 7(05

WELL CONSTRUCTION RECORD n 0 "
Ce J .v .J .
North Carolina - Department of Environment and Natural Resources DiviioRof Water Quality - Groundwater Section
forya�/� eso -/ � y
/! f 4414 lU' --/ ^Y'j� CERTIFICATION # 3 0 r6
WELL CONTRACTOR (INDIVIDUAL) NAME (print) J� t C. PHONE #D(%� 7 3 �` /7 y
WELL CONTRACTOR COMPANY NAME S CAM- O PANS U/r
STATE WELL CONSTRUCTION PERMITASSOCIATED WQ PERMIT## (if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION1:( r
Nearest Town: city Yvi I1 t County Ct
(Street Name, Numbers, Coom rim itty, Subdivision, Lott No., Zip Code)
3. OWNER: JZICJLt " 1j o ` l,
Address OYY ftti-f6f ``VI
(Street or Route No.)
,.s„J6te /\/ri ;frfi ti/
Lily Town Stale Zip Code
(—)-
Areacode- Phone number6p / A U {-
4. DATE DRILLED `7� 7 v
5. TOTAL DEPTH: 3 0 7
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO C
7. STATIC WATER LEVEL Below Top of Casing: tFT.
., (Use'•+" if Above Top of Casing)
1
S. TOP OF CASING IS . V FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires •
variance in accordan ith 15A NCAC 2C .0118. XX
9. YIELD (gpm): _—. METHOI2 OF TEST
10. WATER ZONES (depth): a l V
11. DISINFECTION: Type iiiii Amount
12. CASING: Wall Thickness
/1 Depth/ , Diameter or Weight/Ft.
From 40 1/10I2
'/Ft.6.r WO
From To Ft.
From To Ft. ethod
13. GROUT: Depty,k,__ �ja
From 6 To NV- Ft. li
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
Material
L
Topographic/Land setting
Ridge 0Slope OValley [Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LQG
From To Fo"on Description
0— ld
/a-3o
30— 3(17
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 an,d1``
\.rP
common road names.
n
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND rTHA' A rOPY OF THIS RECORD HAS BEEN PROVIDED TO/THEWELL OWNER
7
DATE
ON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center, REVgh 2001
27699-1636 Phone No. [phone], within 30 days.

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 33s6
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Weft Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC 28906
City or Town State Zip Code
( 828 )- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMIT/kit applicable)
DWQ or OTHER PERMIT #(it applicable)
WELL USE (Check Applicable Box): Residential Water Supply px
DATE DRILLED 09/18/06
TIME COMPLETED AM El PM CI
3. WELL LOCATION:
CITY: HAYESVILLE COUNTY CLAY
REBEL LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
-Tit,Slope O Valley ❑ Flat O Ridge ❑Other
�("" (check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we/ must be shown on a USGS typo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME MICHAEL RUSK
STREET ADDRESS 19440 N.W. 10th ST.
PEMBROKE PINES FL 33029
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
( 954 )- 435-3927
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 800
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use'+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST AIR
(. DISINFECTION: Type
CHLORINE Amount 100 PPM
g, WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
Depth 6 titrmeter
From a To 8 R
From_, To R.
From To R.
7. GROUT: Depth Material
From 0'
To 20
R CEMENT
From To R.
From To R.
6. SCREEN: Depth Diameter Slot Size Material
From To R. in. in,
From To Ft. in. in.
From To R. in. in.
To
To
To
Thickness/
SD�27
Material
Method
GRAVITY
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
0' TO 20'
20'
40'
60'
TO
TO
TO
40'
60'
80'
80' TO 800'
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Description
RED/BROWN DIRT
BROWN SLATE
BROWN TO BLUE SLATE
BLUE SLATE
SLUE SLATE
IV -
Us
Q r
Olt
115AHERESY CERTIFYTHATTHIS NCAC 2C, WELL CONSTRUCTION STANDARWAS ODDSS, CONSTRUCTED THAT
IA COPY N CF THIISwnrl
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L
09120/06
IGNATU RE OF CERTIFIED ' CONTRACTOR DATE
LUAN1 C )21 ")Lt4 �L L l
P TED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mail the
Center— Rae alivision of leigh, NC 276994617 r Quality within eNo. 9 9) 733 7Attn: ext 568.gon Mgt,
Form GW-la
Rev. 7/05

AR
NOV 03 21106 y�
l�ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3131
1. WELL CONTRACTOR:
Law biLLA20
Well Cadractot (bdhrate° Name
9ya2s {(JELL DRILUN6 rNL•
Wel Contractor Corpaiy Name
STREET ADDRESS /267 »vF,RIirC- ytuV
2 //2S Vfa0512
City orTovai State Zip Code
(7X2)- 745-21(0,6
Area code- Phan: numbs
2 WELL INFORMATION:
SITE WELL IDAN applicable)
STATE WELL PERMIT#(aappauble)
DWQ a OTHER PERMIT f(if appieable)
WELL USE (Check Applicable Hot): Residential Water Supply lg"
DATE DRILLED /0-'/3- 000
TIME COMPLETED S LO AM ❑ PM Igo
3. WELL LOCATION:
CITY: EdY6Sva-c& couN -CQ?V
S(1LIE V1t�12n Lrfr/n3 O2g9Oq
(Sleet Noma, Numbers, Canmunay, sitdltion, Lot No., Purcell, Zip Code)
TO GRAPHIC / LAND SETTING:
re&Mie OValley Ong ORidge ❑onw
(check appropriate bred
LATITUDE /`/moo dG . 038 /
LONGITUDE (A/ QS3 o y3. 37Z
Latitude/Longitude sours: t06fPS OTopographic map
(bcatbn of wet must be shown on a USGS tcpo map and
attached to this Tam 7not usrg GPS)
4. WELL OWNER
OWNERS NAME BILL f 7 ALcr j WA ccv,/
STREET ADDRESS 5500 v. cara9e Walk
A\ re 4 a G A ooc
orTown State Zip Code
( %01D )- 78)- 0 4''5
Area code - Phone matter
May beindegrees,
minutes, =roods or
in a decimal foment
& WELL DETAILS:
a. TOTAL DEPTH: 32S
b. DOES WELL REPLACE ETaSTnNG WELL.? YES 0 NO
c. WATER LEVEL Below Top of Casing: '5 Fr.
(Use --re If Above Top d Casing)
d. TOP OF CASING IS ca. FT. Above Lad Surface*
'Top of casing terminated aver below land strface may require
a weave In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a METHOD OF TEST a //Z
L DISINFECTION: Type /7177/ Amount
g. WATER ZONES (depth):
Frun To From To
From To From To
Fran To From To
& CASING: Thidmess/
Meterjal
From O Depth 73 Ft. ,� Weight
7.��& /�c-,RU�C_.
Fran 7? To !L3 FL 5D� Pvc.
Fran To FL
333852
/$oa
7. GROUT: Depth Material
From 0 Tc %2 FL C�-$446/v —
From To FL
From To FL
Method
G2aV%rY
& SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. in.
Fran To FL in. in.
Fran To FL in, in.
& SAND/GRAVEL PACK:
Depth
From
Fran
Fran
' Sim Material
To Ft.
To Ft.
To Ft
10. DRIWNG LOG
From To
H S'
R7 /OFC
((bx U-4 5
/q/S Is5
/SS /(e1
40/ 0
/70 /�`.j O
QL'{p 3 LO
3in ?,as
11. REMARKS:
Formation Description
I�,ED Gil?
72i2ouN chfr
ait24r G.IEep&c-D Rock
LAC,Ic 5L2.4-‘
Lacs .5 Larc
%gaAV?' WJ catiC>T"
.Scars
6 /3(?1_ec Zat.& w/G..te
to✓2A-vrrcd/6,OIPA/G T—
a2/el-alJr /ZoGh '-y,a47
/�
RFCERIrn
n!V O . C vVIED ni If' ITv
OCT 2 0 2006
I DO HEREBY CERTFYT AtTHIS WELL WAS CONSTRUCTED N ACCORDANCE WtIH
15A NCCC. WELL CONSTRUCTION THAT COPY OF MIS
RE BEEN PROVIDED
TURE OF CERTIFIED
Pe -re V/cO2
—/6:1_2G
ELL 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 Canter — Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-1a
Rev. 7/0S

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3463
333733
1. WELL CONTRACTOR:
GREGORY M. FRENCH
Well Contractor (IndMduag Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Town State Zip Code
( 828 )- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMITit(if applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 10/12/06
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: HAYESVILLE COUNTY CLAY
GRAND LAUREL IN LAUREL OAK ESTATES
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
%Slope ❑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 hum I not using GPS)
4. WELL OWNER
OWNERS NAME LAWRENCE "KEN" BEAL
STREET ADDRESS
119 BREEZY BROOK
HAYESVILLE NC
City or Tam State
( 828 )_ 389-4680
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: `'N'
28904
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 21
c. WATER LEVEL Below Top of Casing: — FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4 FT. Above Land Surface
'Top of casing teminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 71/2 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
g• WATER ZONES (depth):
From 110' To 111'
Amount 100 PPM
From To
From 295' To 296' From To
From To From To
6. CASING:
From 0' °To 7th 1' R. 1D/8 er
From To R.
From To R.
7. GROUT: Depth Material
From 0 To 20 R CEMENT
From To R
Thickness/
From To R.
8. SCREEN:
From
From
From
Method
GRAVITY
Depth Diameter Slot Size Material
To R. in. in.
To R. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
10. DRILLING LOG
From To
0' TO 6'
Size Material
To Ft.
To Ft.
To FL
6' TO 48'
48' TO 320'
320' TO 335'
335' TO 440'
440' TO 500'
Formation Description
RED SLATE
BROWN SLATE
GRAY GRANITE
WHITE QUARTZ
GRAY GRANITEAYHITE QUARTZ
GRAY GRANITE
RECEIVED
Iv. Ur WATER QUAI ITV
OCT 18 200G
11. REMARKS:
BIT SIZE: 5.998
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND1HATA CCPY OF THIS
REGARD HAS BEEN PROVIDED TO THE WELL OWNER.
4
SIIGGNATTI RE CERTIFIEDWELV L CONTRACTOR 10/1 DATE
(\-1gN1E14 N1 FPEJO
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 # 3401
1. WELL CONTRACTOR:
JOHN ARTHUR CHASTAIN
Well Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Town State Zip Code
( 828 ). 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(if applicable)
OWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 10/20/06
TIME COMPLETED 5:00 AM ❑ PM 121
3. WELL LOCATION:
CITY'. HAYESVILLE
COUNTY CLAY
WEBER WAY WELL #3
(Street Name. Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope :Valley ❑Flat X)Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May he in degrees.
minutes, seconds or
in a decimal format
Unit Ude/longitude source: ID GPS : Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME RAY NEWCOMB
STREET ADDRESS 93 ROCK RIDGE RD.
MURPHY
NC 28906
Crty or Town State Zip Code
( 828 837-7849
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 600'
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO El
c. WATER LEVEL Below Top of Casing: 500 FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1/2 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From To From To
To From To
To From To
From
From
6. CASING:
Depth Di meter
From 0 80
To ' Ft- 6 118
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To 20
Ft.
From To Ft.
From To Ft.
8. SCREEN:
From
Depth
To
To
To
From
From
Material
CEMENT
Thickness/
18921
Material
Method
GRAVITY
Diameter Slot Size Material
Ft. in. in
Ft. in in
Ftin. in
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
0' TO 15'
Ft.
Ft.
Ft.
Size Material
Formation Description
YELLOW DIRT
15' TO 30' RED DIRT
30' TO 70'
RED DIRT
70' TO 80' GRANITEJS ET CASING
80' TO 600' GRANITE
Ra-CENFD
D( ,1)(7 IMA.1pR Q�IALIT(
90V l� 2 2006
11. REMARKS:
BIT SIZE: 5.973
LL
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.
r 11/ 1 t-1t at "\t 1l { Li
SI NATURE OF CERTIFIEDWEL ONTRACTOR DATE
«aL; !tt Its
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
10/27/06
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form G W -1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3401
334210
1. WELL CONTRACTOR:
JOHN ARTHUR CHASTAIN
Well Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Town State
( 828 ). 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(f apphrable)
DWQ or OTHER PERMIT #(d applicable)
Zip Code
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 10'18/06
TIME COMPLETED 1:00 AM PM 2
3. WELL LOCATION:
CITY: HAYESVILLE COUNTY CLAY
WEBER WAY WELL #2
(Street Name. Numbers, Community, Subdiasion, Lot No., Parcel, Zrp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat El Ridge ❑Other
(check appropriate box)
LATITUDE 3 5
LONGITUDE 8 3
03.798N
55.984W
Islay be in degrees.
minutes, .seconds or
in a decimal fomlat
Latitude/ongitudc source: DGPS ❑Topographic map
(locator of wet must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME RAY NEWCOMB
STREET ADDRESS 93 ROCK RIDGE RD,
MURPHY NC 28906
City or Town State Zip Code
( 828 837-7849
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 200'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use "+" if Above Top of Casing)
d, TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm): 50 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE Amount 100 PPM
g. WATER ZONES (depth):
From 0' To 70'
To 140'
From 70'
From To
6. CASING:
Depth
From 0' To 50'
From To
From To
Ft
Ft
Ft
From
From
From
To
To
To
WThickness/
61/8 afar S(�o27t
7. GROUT: Material
From 0 To Ft. CEMENT
From To Ft.
From To Ft
Depth
20'
8. SCREEN:
From
From
From
Depth
To
To
To
Material
Method
GRAVITY
Diameter Slot Size Material
Ft. in. in.
Ft. in in.
Ft. in. in.
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
Ft.
Ft.
FL
Size Material
10. DRILLING LOG
From To Formation Description
0' TO 20' RED DIRT
20' TO 30' RED DIRT
30' TO 50'
30'
GRANITE/SET CASING
TO 200' GRANITE
RFCFNED
_-Icp auAUTY
2 MI6
11. REMARKS:
BIT SIZE: 6.037
2086
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 SEEN PROVIDED TO THE WELL OWNER
1 H
E-ti'l i—A, i\-.0'4;'I ( 1 10127106
'IGNNNAT`�U-R1E OR CCERRT7FlED WELLLCON�TRACTO�R DATE
PRINTED NAME OFI 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 # 3401
1. WELL CONTRACTOR:
JOHN ARTHUR CHASTAIN
Well Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Town State
( 828 )_ 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
Zip Code
STATE WELL PERMITWIf applicable)__
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply Ox
DATE DRILLED 10/16/06
TIME COMPLETED 1030 AM Xj PM E
3. WELL LOCATION:
CITY. HAVESVILLE COUNTY CLAY
WEBER WAY WELL #1 LOT #101
(&reel Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat i Ridge ❑Other
(check appropriate bus)
LATITUDE 3 5 06.766N
LONGITUDE 8 3 54.815W
May he in degrees,
minutes, seconds or
in a decimal format
I utittide/longitude source: pGPS ❑To} ographic snap
((ocaten of we! must be shown on a USGS fopo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME RAY NEWCOMB
STREET ADDRESS 93 ROCK RIDGE RD.
MURPHY
NC 28906
City or Town State Zip Code
( 828 837-7849
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 400'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
Di
c. WATER LEVEL Below Top of Casing: 700 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm): 72 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
g. WATER ZONES (depth).
From To From
From To From_
From To From
6. CASING:
Depth
From 0' To 100' Ft 6 1/8 eter
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 20 FL CEMENT
From To Ft.
From To Ft.
B. SCREEN
From
From
From
".2�9
Amount
100 PPM `n F.
to
To
To
To
Thickness/
PC Material
Method
GRAVITY
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in in.
m
To Ft. in, in.
9. SAND/GRAVEL PACK
Depth
Flom
From
From
To
To
To
Ft.
Ft.
Ft.
Size Material
10. DRILLING LOG
From To Formation Description
0' TO 40' BROWN DIRT
40' TO 80' RED DIRT
80' TO 100'
GRANITE/SET CASING
100' TO 400' GRANITE
0
j ECDVEP
c �'ATEG QI IALiTY
tsl0\P u 1
11. REMARKS:
BIT SIZE 6.047
2e0
I DO HEREBY CERT FY 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.
1027/06
SIGNATURE OF CERTIFIED WE L CONTRACTOR DATE
ti c�aLIPI Nt ,.1,'
PRINTED NAME OF PER 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

n 335d12
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resin/red- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H Z it O 3
1. WELLjONTRACTOR:
fe.fConk la 2/ /eece.
IndNklual
Name
( )
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P• O. BOX 567
HAYESVILLE, N.C. 28904
City or Town State
( 828 } 837-2997
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Apt applicable)
STATE WELL PERMITI(s applicable)
DWQ or OTHER PERMIT a(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED. /l d /- 0 C
TIME COMPLETED /7 60 AMP' PMD
3. WELL LOCATION: / /
CITY: 8rtt fIT<oW1 COUNTY Cloy
5eJ-fawb" , a
(Street Norma Num n, Community,
(S ty, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
I91(ope tjValley ❑Flat ID Ridge ❑Other
(theca appropriate box)
LATITUDE , ii ,: 02, sc
LONGITUDE 8 3 S 7, /(V
Latitude/longitude source: BCPS (Topographic map
(bcalbn of we/ must be shown on a USGS fopo map and
attached to this form l not ash) GPS)
4. WELL OWNER yyII
OWNER'S NAME Oav, d ,7/�C/'Qr;O/I
STREET ADDRESS PO 2 O.Y. 35
May be in degrees,
minutes, seconds or
in a decimal format
Arc� 55&OWn.N6 2$a02
City dTown State Zip Code
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: a2
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOS
c. WATER LEVEL BelowTop of Casing: ✓ 0 FT.
(Use '4" H Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Sudece•
'Top at casing terminated eUor below land surface may require
a variance In accordance with 15A NCAC 2C .0118,
•
e. YIELD (gpm): ,S—U METHOD OF TEST , /
OWNER It In b6:4...
MWD t`T.;
NC. \/
L DISINFECTION: Type /7 fir Amount "eCi‘ 949
g. WATER ZONES (depth):
From 2‘.2- To From To
From To From To
From To From To
6. CASING: Thickness)
Depth Diameter Weight
From o To 27 Ft. 6-2r • /n
From To Ft.
From To Ft.
7. GROUT: Depth Material
From e To 3 FI. lAVI
From d Tom Ft. fur• -
From To Ft.
Seed/
8. SCREEN: Depth Diameter Slot Size Material
From To F1. In. In,
From To Ft. In. In.
From To FL In. In.
8. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Front To F1.
From To Ft.
10. DRILLING LOG
From To
D -es
FS--.2 6s ,
t;
11. REMARKS:
0
Formation Descriptbn
r/a y
014,
R L;5E4221AUT
r
.-a u'',
v
100 HEREBY CERTIFY /HAT TWS WELL WAS CONSTRUCTED N ACCORDANCE WIN
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND TMATA COPY OF lips
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
!/ Oi-aC
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
`Jack Long'
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 OW-1a
Rev. 7/05

RLSIvcNTJ4L WELL CONSTRUCTION RECUR& 3 5
North Caroline Department or Environment end Metal Itesumccs- Dlvklon or Wain Qualky
WELL CONT'ILACTOIt CEittIPICA'I'ION N -aye ,S
1N 006OMWD
NC
1. WELL CONTRACTOR:
IIp Rec«
W eit Contractor (Individual) Name
MILLER WELL DRILLING, INC.
W M Cailracta Company Name
STREET ADDRESS p.0. BOX 567
HAYESVILLE, N.C. 28904
City of Town Stale
828 F 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID apt applicable)
Zlp Code
STATE WELL PERMI T91e applicable)
DWQ or OTHER PERMIT HUI applicable)
WELL USE (Check Applicable Box): Resklenllal Wolof Supply 11
DATE DRILLED /D /4 -66.
TIMECOMPLETED /iDO AMU PMLYI�
3. WELL LOCATION:
CITY: ,711976-07/c. COUNTY C .,6-/
f4gt4e Poirv%
+ISWat Name. NumWD, Community, Subdivision Lot No., Intel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
(7Slcpe (]Vevey keg OHldge [I011ier
(Chet, pproprtale box)
LATITUDE ,.,'Z sr_ 0(a/77
LONGITUDE ±.3 `'!`c YYa
Latitude/longitude source: L'OI'S t flopogrnphic limp
(Rcnibn of vent most be shown on n USGS Inpo map and
attached M Ihb form t not usbp GPS)
WELL OWNER n�
OWNER'S NAME N0 r -t •v'i-5(
Mny 1e 1n Jcpeee,
rnhnice, germ), or
In a decimal Enmat
STREET ADDRESS
, C9A
City or Town Stale
Cleq )• 7;3 - 743
Ales code - Phone number
EL WELL DETAILS:
I. TOTAL DEPTH: jOO
b. DOES WELL REPLACE EXISTING WELL? YES 0
e. WATER LEVEL Delon Top of Casing:
(Use '+' N Above /Top d Casing)
d. TOP OF CASINO 19 ` FT. Above lorid Melee,'
'Top d casing Laminated eVor below land surface may requke
a valance In accordance wllll 15A NCAC 2C .011115,
•
e. YIELD(ppm). Q METHOD or TEST 17//Q
3.,,, (orb
Zlp Code
1, DISINFECTION: Type MTh?
u. WATER ZONES (depth):
From
Fran
Fran
6. CASINO:
To
Tb
To
Depth ,
Fran St To 9? F1,
From To FI.
From To F1.
T. GROUT: Depth
Fran 0 To 10 rt. PORT/AI-at gin
I From To FI.
i Ftom To FI.
B. SCREEN: Depth Diameter SkA Size Material
Fran To rt. in. In.
Nom • to P1. In, M.
Fran To rt. in. In.
9. SANDIORAVEL PACK:
Depth Size Material
Amount fZ Crlto
From To
From To
From To
Tldcknesd �
bla�n9lRr r5 2te Material
FOI C..
how To F1.
From To F1.
Flan To F1.
1e. DRILLING LOO
Front To
I1. REMARKS:
Maledal Method
Formation Description
CG"cR 0k-Irt ?
r�F :ru•
)t.: a9l"
0
v
1ooHERESY crltr.Y 114A1n
ISA NCAC TO ELT constt�t��ry�qqq
RECORD! 7. EEN PROV�t
Wet! WAS tong tniltMO N ACCORDANCE ysml
ioN 1 DSIO THAT AcopTO !He
TO ELL pYypta.
/a -4-o6
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
P4Y/4,Peace— '
PRINTED NAME OF PER80N CONSTRUCIING TIIE WELL
10,
t •
li
r
rtr,
1,
Submit lie original to the Division of Water Quality within 30 days. AHn MfonnrtIon Mgt.,
161T Mali Service Center- Raleigh, NC 2T699.1617 Phone No, (919) 733.101S'Xt 66A.
Formaw•ta ,►
Rev, Ng5

OWNER 11-^17-06
RESIDENTIAL WELL CONSTRUCTION RECORD 3 5 6 0 7 MWD
North Carolina Department of Environment and Natural Resources- Division of Water Quality NC ✓
WELL CONTRACTOR CERTIFICATION H .2 7 03
1. WELL CONTRACTOR:
rei7 s&et
Well Contractor (individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P.O. BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale Zip Cale
( 828 y 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID Of applicable)
STATE WELL PERMITBOI applicable)
DWQ or OTHER PERMIT k(H applicable)
WELL USE (Check Applicable Box): Residential Water Supply E''
DATE DRILLED /7- 0 - 06
TIME COMPLETED 2 - C0 AM D PM 9--
1. WELL LOCATION:
CITY: �Cti✓/ wC- COUNTY L/4/
tent& &lec / / 1ea0(0tAiS
(Street Name, Numbers, Community. S dMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p8fope °Valley DFlat ❑Ridge ['Other
(check appropriate box)
LATITUDE S! e..i'.Td'
LONGITUDE 3 Y. 2-1‘
Latitude/longitude source: oepS ❑Topographic map
(bcation of wel must be shown on a USGS logo map and
attached to this tom 7 not using GPS)
4.WELLOWNER Mand4 Eller
OWNER'S NAME /0//; f2 rcw CE//z'ei - Z o
May be in degrees,
minutes, seconds or
in a decimal formal
STREET ADDRESS 2.330 t+; n+DnCegfet' Rd
-Pay -es v'kIle NC- Z BR0It
City dr Town Slate Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
/22
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 2'
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 o( casing terminated aVor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): /..r— METHOD OF TEST /9r7
I. DISINFECTION: Type fr T r/
g. WATER ZONES (depth):
From //S To
From
From
6. CASING:
To
To
Amount 1; y')
From To
From To
From To
Thickness/
Depth Diameter We�lyhl Material
From To Ye Ft. 6-.ZS S.GYc'2I y''QC
From To Ft.
From To Ft.
7. GROUT:
From 0
Depth Material Method
To .3 Ft. /a'r /4n1 r •>+y'e2
From 3 To 2 0 Ft. %je,/rei, i-
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From To FL In. In.
From To Ft. In. In.
Front To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
D 2J'
as-- /22
11. REMARKS:
c._
D
ZV
N
O
Formatbn Descriptbn o0
C/`/
I-cc-n. y'L
ceGt-; crOWN"''N
rt
100 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 PROVIDEb TO THE WELL OWNER.
%��i< l / -el- a(
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
!J/. v LG 7-k%74r ..
PRINTED NAME OF PERSON CONSTRUCTING STRUCTING 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] oxt 568.
Form GW-la
Rev, 1/05

5 8 (p NER -In O-O6
RESIDENTIAL WELL CONSTRUCTION RECORD d MWD
North Carolina Department of Environment and Natural Resources-(rDivision of Water Quality
WELL CONTRACTOR CERTIFICATION N 2y-03
NC
1. WELL CONTRACTOR:
/=Icy het-.
Well Con actor (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P. O. BOX 567
HAYESVILLE, N.C. 28904
City or Town State Zip Code
( 82B). 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(B applicable)
DWQ or OTHER PERMIT in applicable)
WELL USE (Check Applicable Box): Residential Water Supply (]-
DATE DRILLED /1- 07 - 01
TIME COMPLETED ..S--C AMID PM 9
3. WELL LOCATION:A/
CITY: /-fhy€3c<'(le COUNTY (- L
C r r t e,' ere z J o f s-64/e 4.. 7tfr j 5
(Street Name. Numbers. Community. Subdivision, Lot No., Part I. Zip Code)
TOPOGRAPHIC I LAND SETTING:
13SIope °Valley ❑Flat ID Ridge ❑Other
(check appropriate box)
LATITUDE - - 5 6° ' 243°
LONGITUDEQ 3 sY. i&r
Latitude/longitude source: 606PS ['Topographic map
(location of welt must be shown on a USGS topo map and
attached to this form 7 not using GPS)
4. WELL OWNER �f Cr,L
OWNER'S NAME CirAS e ✓ba✓( . C#t74S0
STREET ADDRESS to r Ise Gr "G4,....„ •e5
City or Tam Slate Zip Code
( C/O V;RtaKCen ✓,233OLe for at
Area code- Phone number Hayes(); IIQ1JC
zs50 �{
5. WELL DETAILS:
a. TOTAL. DEPTH: / 42
May be in degrees,
minutes, seconds or
in a decimal format
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O
c. WATER LEVEL Below Top of Casing: 9 FT.
(Use'+' 8 Above Top al 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): ,.ZJ METHOD OF TEST /% /"
L DISINFECTION: Type // T17/
Amount /y / �7 A
g. WATER ZONES (depth):
From / //- To From To
From To From To
From To From To
6. CASING: Thickness)
Depth Diameter Weight Material
From 0 To 63 Ft. 6-.25-- ac.Z/ Y't'C-
Fran To Ft.
From To Ft.
7. GROUT: Depth Material /
From D To 5' Ft. 12Vartnit
From _7 To 2C Ft. j/{/ti,;c Ye
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In.
From To FL In.
Method
From To FL In.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Fl.
From To Ft.
kr.
in.
ln.
Size Material
O
'CV.;
0
10. DRILLING LOG
From To Formation Description
11. REMARKS:
rcOem aNI
r u r
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
I5A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF Tray
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ft
SIGNATRE F CERTIFIED WELL CONTRACTOR DATE
70..54 Lcn --
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-ta
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORO " e 2 0
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 2 t tO 3
1. WELL CONTRACTOR:
/4-isC 4€ecLe
Well Contr for (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P.D. BOX 567
HAYESVILLE, N.C. 28904
City or Town State Zip Code
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID rips applicable)
STATE WELL PERMITri(II applicable)
DWQ or OTHER PERMIT a(II applicable)
WELL USE (Check Applicable Box): Residential Water Supply g/
DATE DRILLED — Z "6
TIME COMPLETED 2 0 0 AM ❑ PM la,
3. WELL LOCAT)ON•
CITY: t%,veJ c'" & COUNTY l-!C
Tlls v: tete—
Nama ben,
Commun
ity, nay, Subdivision, Lol No., Parcel. Zip Code)
TOPOGRAPHIC !LAND SETTING:
❑Slope °Valley p3'tlat °Ridge ❑Other
(check appropdare box)
LATITUDE , r D* 114.
LONGITUDE 6' 3 V6' P-61
Latitude/longitude source: ECPS °Topographic map
Potation of well must be shown one USGS tow map and
attached ID thtt form / not using GPS)
4. WELL OWNER Sr [ / /
OWOWNER'S NAME 6 �enec%61
May be in degrees,
minutes. seconds or
in a decimal formal
STREET ADDRESS t80 TtAsrt a Fittf GYk )` k
1yeSLitt )P A/L aceaO '
City 6r Town Slate Zip Code
( }
Atea code - Phone number
S. WELL DETAILS!
a. TOTAL DEPTH: 2 6 2i
b. DOES WELL REPLACE EXISTING WELL? YES I NO Ia
c. WATER LEVEL Below Top of Casing: / D FT.
(Use '+'11Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surlace'
'Top al lasing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0t 18.
e. YIELD (gpm): ./ METHOD OF TEST /li /^
1. DISINFECTION: Type /)' Tit
g. WATER�/Z�ONES (depth):
From 2,2D To
From To
Fran To
Amount 41Y6-ra
From To
From To
From To
6. CASING: Thickness/
Depth Diameter Weigh! Material
From 0 To 6a Ft. G-.1.$ so,e;z/ i'.'C
Fromr, To �� Ft. ‘-2S Ter Sfee
From To F1.
T. GROUT: Depth 1ei Method
From 0 To 3 F1.
From ? To ?S ,Ft.
Fran To F1.
6. SCREEN: Depth Diameter Slot Size Matelot
From To P1. In In.
From To Ft. In. h.
From
To F1. In. In.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
To F1.
From
From
Size Material
To F1.
10. DRILLING LOG
From To Formation Descriptbn
Fs- -zCy
f;
11. REMARKS:
t°rcC,Q4t-n91).1.‘C
ttot
JAN 02 2007
100 HERESY CERTIFY THAT 111IS WELL WAS CONSTRUCTED N ACCORDANCE WHO
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND 1HAT A COPY OF INS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
��uu// (/sece j-,,39-06.
SIGNATURe0 CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON
CONSTRUCTING
STRUCTING 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. '

335621o\NER 1
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and NalUrai Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N • 2.4 0 3
1. WELL CNTRACTOR:
er ry feeet
ontract Individual Name
WeeC ( )
MILLER WELL DRILLING, INC.
Wen Contractor Company Name
STREET ADDRESS P • O. BOX 567
HAYESVILLE, N.C. 28904
City a Town Stale Zip Code
( 828 } 837-2997
Area coda- Phone number
2. WELL INFORMATION:
SITE WELL ID Ilpl applicable)
STATE WELL FERMIUM, applicable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply El,
bATE DRILLED y `'2 7- G
TIME COMPLETED e{•-ao AM[] PM(
3. WELL LOCATION:
CITY: it eiryt J lit COUNTY
Al // te st
• (Street Name, Nun e, Community, Subdivision, Lol No., Parcel, Zip Code)
Cloy
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Vafey gPGI ❑Ridge ❑Other
(check appropriate born
LATITUDE _3_ jj: C/, 3 z.0
LONGITUDE 3._ V0,2.5j
Latitude/longitude source: 13G1'S L]Topographic map
(bastion ofWel must be shown on a USGS topo map end
attached to This burr Inot using GPS)
4. WELL OWNER OWNER'S NAME rrvi,)/ BUSS €, /
STREET ADORESS 2330 Ilinhn Lanier Ed
gvt)esu',IIf NC 2f0t
City Town Stale Zip Code
Moy he in degrees,
minutes, seconds or
Inc decimal format
( }
Area code - Phone number
S. WELL DETAILS:
a. total DEPTH: 3 72
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: A D PT.
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated allor below land surface may require
a variance In accordance with 15A NCAC 2C .011e.
•
e. YIELD (gpm): S— METHOD OF TEST .1:1-
MWD
I. DISINFECTION: Type /lil/ Amount 1X-ic cir"
g. WATER ZONES (depth):
From 32J' To From To
From To From To
Fran To From To
B. CASINO: Thickness/
Depth Diameter Weight
From 0 To Vo FI. d• r23` SO,T/
From To Ft.
From To Pt.
Material
7. GROUT: Depth Naterjal Method
From 0 To 20 Ft. �rodoit e -_��'�
From 3 To 20 FI. Qri%i.
Fran
To Ft.
S. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From To F1. In. In.
Fran To Pt. in. In.
O. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
o-
e 3Y1
Tr
11. REMARKS:
Size Material
Ft.
Ft.
Ft.
Formation Descriplbn
G/k/
/Ler
O
ry
0
100 HEREBY CERTIFY THAT MIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. ARO THAT A COPY OF fM5
RECORD HAS BEEN PROVIDED TO THE WELL OWNER -----
Zde�— f�2b o6
SIGNATUR OF CERTIFIED WELL CONTRACTOR DATE
/ /tr let c'e
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No, [phone] eat 688.

• ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
(-1 335444
'-WELL CONTRACTOR CERTIFICATION #
a
1. WELL O.T
ELL CONTRAOR• i
I DA I 1and
Well Contractor (Individual) Name
ex5 W61 9rti\itt1g
Well Contractor Compan Nam
tD C 5�D
STREET ADDRESS
rsvi 11e CSA ;10
`'City or T State
('70&>_ TZJ5-alt,L.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL FERMIT#(g applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public e
IndustrialCommercial ° Agricultural 0 Recovery 0 Injection (
Irrigation° Other ° (list use)
DATE DRILLED 1 ^"t ^ O CP
TIME COMPLETED 51. 614 AM ° PM LS
3. WELL LOC ION: /} I /y, --1G�CITY: Imo/ Ar11 [a (� COUNTY L�Gai
3J_Gr VQ1k1.4 LJCl[1`/;S,t_i'v\ 1
(Street Name, Numbers, Conimunity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat °Ridge ° Other
(check appropriate box)
LATITUDE/ Si zfg4
LONGITUDEt ,3°,J 3 , itta
4
Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 1(3PS ❑Topographic map
(location of we9 must be shown on a USGS opo map and
attached to this form Inot using GPS)
4. FACIUTY• is the name of IN business where the web is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Ivor VtztttL S ' v Stm\
STREET ADDRESS fl,V -1 _/44'4v 1
W cos- n t.) C—
City or Town State Zip Code
CONTACT PERSON IJ p^ rO(,trd-q;tn
4AIJNGADRRESS 9 12g kJ as-4- L(kt, k
r
y\L64- m—DeCutel Pt —
City or Town
State Zip Code
(•-CIS I). S3r\_-7205
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
LD Qt3
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EW
c. WATER LEVEL Below Top of Casing: LO 0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4 FT, Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118/.t
e. YIELD (gpm): 2— METHOD OFTEST $t'1V
f. DISINFECTION: Type F 1 44 Amount 1 t b
9.
WATER ZONES (depth):pt
From tee To ry I From To
From To From To
From To Rom To
6. CASING:
From 0
From
From
Depth
to
To
T
Depth
To63
To
To
7. GROUT:
Thickness/
Dia�(rester I.% ( serial
F1. t0 ani
Ft.
o Ft.
((�� Material J ., Method
From 0 Ft.0144141 .>1p,t— _
Fran Ft. t
From Ft.
8. SCREEN:
Fran
Depth Diameter Slot Size Material
To Ft. in. _ in.
From To Ft. in. _ in.
From To Ft. in. _ in.
9. SAND/GRAVEL PACK:
Depth - Size Material
Q
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
¥i nw n
PQn&#r
a ri 7
- 4.oc C'
21to > —Co
11. REMARKS:
Formation Des 'p
L •:
a
rntX0
r
AID 02 2007
ONSTR
CO
0
0
0
w
D W ACCORDANCE WITH
TA COPY OF THIS
t7 - of
SIGNATURE OF CERTIFIED WELL CON RACTOR DATE
ro t-L 5 Rtlian
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
CERTIFY THAT THIS WELL WAS
2C, WELL CONSTR •,;! N ST
HAS SEEN PROV
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
1

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
S
WELL CONTRACTOR CERTIFICATION # 3131
335443
1. WELL C.ONTRAO.TAR: 1
Lon' ti 'lard
Well Contractor (Individual) Name
ers WeII-Dr'IIi' Inc
Well ontractor Compel Nam
STREET ADDRESS Vo Dv* 580
1 ke GA 30514
tity or
Town
Stattee/ Zip Code
t-rNO- 445 2-1
jL
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) Monitoring 0 Municipal/Public p�
IndustriaVComrnercial 0 Agricultural ° Recovery 0 Injection 0
Irrigation° Other 0 (list use)
DATE DRILLED I (- 5-cxv
TIME COMPLETED Z-: SU AM 0 PM,O/
3. WELL LOCATION:
cry. W grf2 COUNTY e..iay
becrVa(leg SLAhr4ivi5lsrt
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHICAP�// LAND SETTING:
❑Slope e7valley °Flat ❑Ridge 0 Other
(check appropriate box) �r
LATITUDE,/ . 72I
LONGITUDEinLejf
Latitude/longitude source: PS °Topographic map
(location of wee must be shown on a USGS opo map and
attached to this form not using GPS)
4. FACILITY- is the name of the business where the well is oared.
FACILITY ID #(if applicable) Q
NAME OF FACILITY I C-er Va I ICV ..x orti v i von.
STREET ADDRESS bcap Va ICAAC'-
Wa.rflt. Iv CT 1
City or Town State Zip Code
T
CONTACT PERSON y brl Okfn4l/0.i
Wes-�l�a (micach FL3.
hr—
May be in degrees,
minutes, seconds or
in a decimal format
City or Town Stale Zip Code
t > 833-- 2_7-DS
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: to 25
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Fr
c. WATER LEVEL Below Top of Casing: 25 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): 2.. .4
METHOD OF TEST - r
f. DISINFECTION: Type I4T14 Amount 1 lb.
WATER ZONES (depth):
From 30 To 4 O From To
From To From To
From To From To
6. CASING:
9•
Depth ,Dimeter ei ht �`'lplariat
Fram C) To i-o 5 Ft. Lo WI i-PP (
From To Ft.
From To Ft.
7. GROUT: Depth Material) L Method
t.0
From p To Ins Fern en - .Dump
From To Ft. r
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft:
From To Ft.
From To Ft.,
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Thickness/
10. DRILLING LOG
From To
0 _20
-
g I
105- Zoo
2ZO - Z5c1
?b
FRS — (oUo
(orr-N -(oZcl
11. REMARKS:
in. _ in.
in. in,
� N
Size Material>tl.lO
dr
Lei
Formation Description
g(Inv.) 11 I
rpwn I�U
ran i ic._ ttbr-}7 ,r,1i (
1- el
r1
irand—c C1xv;
Ian ri-2 rnli
t t •1
artrite
tat
0-+ran i is
'era n 7 l t 2 Ru A rk-
L
I DO HE
15A N
SIGNATURE OF CERTI D WELL •NTRACTOR //� TE
Mark S RO (and
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
CERTIFY THAT THIS WELL - CON - CIED N ACCORDANCE WITH
WELL CONSTR DON -. -^. THAT COPY OF THIS
BEEN PROV • rt - �'�
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

STAry
Y
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION to Z 1 C 1
Well Contractor ividual) Name
Well Contractor ompanny Name—'��--
STREET ADDRESS 1�
L2a2 1555
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *of applicable)
STATE WELL PERMIT#(Rapplicable)
DWQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED ) )_[_-
TIME COMPLETED
--�_ AM 0 PM 0
e la
City or Town State Zip Code
3. WELL LOCATION: rr,
CITY: �P _ COUNTY&
(Street Na berg. CoMmunity, Subd.s ion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC ND SETTING:
❑Slope aley ❑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 weft must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME �A
STREET ADDRESS
SJ IG.Xf St�l ��� r
City or Town State
(70l0»_fi- x347.5
Phone number
Area code - r
5. WELL DETAILS:
a. TOTAL DEPTH:_
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing:_
(Use -+• if Above TopTo^yof Casing)
�'l
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
Zip Code
•
W L.J
n
f. DISINFECTION: Type
=�1w
g. WATER ONES (depth):
From To
From To
From
6. CASING:
To
Depth
From.._ To '& Ft.
From To Ft.
From To Ft.
Amount
To
To
To
Thickness/
iamater Wight tit_
-MLA
From
From
From
7. GROUT: Depth Material
From C7
From
From
To.PS� Ft `C
To Ft.
To Ft.
8. SCREEN: Depth Diameter
From • To Ft. in
From To Ft
in
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
' uu
11. REMARKS:
Method
Slot Size Material
in.
in.
in.
Size Material
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTON STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU
7♦
OF CE f IED WELL
COT RACTOR .,.,. DATE
PRINTED NAME eF •. RSRI a_ Alto It
ON Cs' ST' UCTING HE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Inform$tion Mgt., DEC 1 2 2006Form GW-14
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 560i.
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
3(75
1. WELL CONTRACTOR:
FRP(az 2. V(cro
Well Contractor (Individual) Name
GYP-RS CAu0.-LO t(LIN6 CNC.
We® Cantractar Campaty Name
STREET ADDRESS 1747 a UG,2tDGs 11.w y
J21LA!RCN' luy- GeQ 30312
City or Town State Zip Code
Li( } 745 - 2t.
Area code- Phase number
2. WELL INFORMATION:
S&FE WELL ID fa appiada)
STATE WELL PERMIT4h2applicable)
DWQ or OTHER PERMIT f(t applicable)
WELL USE (Chedc Applabie Ba4: Residential Water Supply ®�
DATE DRILLED l I— I y— O 6 -/
TIME COMPLETED I21'3O AM PMe
& WELL LOCATION:
CITY: (dr-IR N E country C(2W
4%2 1 L CnvL o2890%"
(Street Naar, Numbers, Community, Subdi aicn, Lot No., Parcel, Zip Cods)
TOP RAPHIC / LAND SETTING:
OVatey ❑FRM ❑Ridge ()Other
(d,.dc appccpdate bad
LATITUDE/4.1g ° S4. (o yG `
LONGITUDE AL .Q33 ` 52. 74'5
Ialtude/Iongitude source: elfIS OTopographic map
(bastion ofwarmust be shown on a USGS topo map and
attached to this lam trot using GPS)
4.WELL OWNER ,7
OWNER'S NAME 6 D U... 15 LaliZ
STREETADDRESS 466 l7SLL C'QVE
w c- WC 2 a 40
City or Tout State Zip Code
(yoy)- Ss4..- 9'297
Area cede - Phone comber
May ne in Mayas,
minutes, seconds or
in a decimal fotmet
5. WELL DETAILS: //
a. TOTAL DEPTH: (� 25
b. DOES WELL REPLACE EXISTING WELT.? YES 0 NO eV
a WATER LEVEL Belay Top CICasi g: I n FT.
(Use •+• If Above Tap at Casing)
d. TOP OF CASING IS oZ FT. Above Lad Surface*
'Top of casing terminated aver bdav lad surface may require
a valance In accordance with 15A NCAC 2C .0118.
e. YIELD(gTm): / METHOD OF TEST afIC
f. DISINFECTION: Type >gni Amount .2 /65
g. WATER ZONES (depth): 7
From
From
From
To
To
To
Franc
From
Fran
To
To
To
6. CASING: Thiclmess/
Depth
Froln_.S2_ To z o Ft telt Tr, Mit
From To FL
Fran To Ft.
7. GROUT: Depth Material
From (') To c » Ft CI ievtEi T 1 )2P l iirvr
From To Ft.
From(,__ To Ft.
Method
& 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
Fran To
Fran To
From To
10. DRIWNG LOG
From /To
b c^
5 7
7— . ,27
427 - 37
37 -75
75 - So
Aga yos
Al o s — 'Y53
11. REMARKS:
33-(v2s
Size Material
Ft.
FL
FL
Formation Description
.&Cou,,,r r,Jc-arri&rzec Rc'c&
i&ac.e_ Sta r�
Giza& rr
C,aAZT?
Cog 1/7
©va2Tz.
.0LeCsc Ste
©ud errc --a
Gflaw,r
r. 1
lC2cr* Set 4/4'O
tr
einititrz-
Secs- Sc2A;
eaa
I DO HEREBYCERIFYTHATTJS WELL WAS CONSTRUCTED N ACCORDANCE WM1
iW NCAC 20 WELL CONSTRUCTION STANDARDS" AND THATA COPYOF1HIS
RECORD HAS BEEN PROVED To THE A
WELL.�LO¢OWNER, //
(N YamTE
SIGNATURE CERTIFIED D WELL ONTRACTOR i('�DDATE
FiC& vz P. l/ /GTa z
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit theoriginal to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] eict 668.
Form GW-1a
Rev. 7/05

3934 gd7
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
`Natural Resources�- Diivi�sionn o�f�Water Quality - Groundwater Section a��7
WELL CONTRACTOR (INDIVIDUAL) NAME (rInnt) t'hU ` t v9 1\tc' r'.S CERTIFICAATTI(ONr#__ G�_
WELL CONTRACTOR COMPANY NAME V ^ `6 V kU-C �1'i'_" `OVA t-J"` A PHONE # J avo i3Ol - 1 1SS
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential El Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: County`E
'S eikiPCI-1) '2GAk
(Sheet Name, Numbers, Community, Subdi 'elan, Let No., Zip Code)
3. OWNE
Address
ter- o)- ,� St a,� Zip Code
her-‘)- } 71`Ihr-(
Area code- Phone mmeber I
4. DATE DRILLED 1u
5. TOTAL DEPTH: fl 5'
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO I9'
7. STATIC WATER LEVEL Below Top of Casing: 1-1:C FT.
(Use "+^ if Above Top of Cuing)
8. TOP OF CASING IS I 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): �7 METHOD OF TEST VkAQ-
10. WATER ZONES (depth): GA
11. DISINFECTION: Type Vt? Amount
12. CASING: Wall Thiclmess
From_ (� To (9o1 Ft. Cot Depth D!s�nrt�o(Weigh t. Ivfalerial
From To Ft. D��l V��
From To Ft.
13. GROUT: Depth Ma 'al
From(3 To (eck Ft 'E
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.
From To Ft.
Slot Size
in.
in.
Material
Topoggrp�pphic/Land setting
❑Ridge E lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/mimdes/aeconda)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forman Description
DEPTH
From To
0 Sell
31' (eo'
lob' `1`15'
REc:t.r v c.
n1V OF �NHTER QUALITY
Nov 0y2
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.
/ • �l,.�,
16. REMARKS: taza
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDMMS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO L OWNER
strip te(p“,,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources,n- Division ofaWater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
&t t( f GY c�' 11c .t,1 ` _ CERTIFICATION # 015/
WELL CONTRACTOR COMPANY NAME W t U-CT 1.S� � PHONE # 1�°"?) S"I .9I S
STATE WELL CONSTRUCTION PERMIT" ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential !B-/ Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Neare Town:
un
(Street Nam Ne, unbar,
3. OWNER:
AddressW L5
nrtT
No., Zip Code)
City Town
Org>
State
Area code- Phone number
4. DATE DRILLED -
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES P NO
7. STATIC WATER LEVEL Below Top of Casing: 4 b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surfaces
*Top of wing terminated at/er below land surface requires a
variance In mordent. with ISA NCAC 2C .0118.
9. YIELD (gpm): Id METHODI OF TEST ten 2-
10. WATER ZONES (depth): \s'a
11. DISINFECTION: Type \AAmount
12. CASING:
Depth Diameter
From b To Si, Ft. G.f ke
From '-3.' To f R` Ft. 1.6-'/1"
From To Ft.
13. GROUT: Depth �� Mitqteria1
From b To r19, FL��t`a
From To Ft.
14. SCREEN: Depth
From To
No.) c602340r.i
Zip Code
Diameter
Ft. in.
From . To Ft, in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Wall Thickness
or Wylabt/Ft.
Slot Size
in.
in.
Material
16. REMARKS: S'n 3 ' zF)LL
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 TH8 WELL OWNER
SIGNATt7RE OF PERSON CONSTRUCTING THE WELL
Topographic/Laujsetting
❑Ridge ❑Slope IIBVValley ❑Flat
(check appropriate box)
Latitude/longittide of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To F..:ti.n a sc (ption
0
'5' 5?'
Slrlel
r\9l 1 c 4'
IT`S
NUV U 9 2000
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Incluthe road
numbers and common road names.
l�f�o2<C
Material
DATE
334508
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
,9.
451
North Carolina - Department of Environment and Naturaltu1Resources - Division of Water Quality - Groundwater Sectionon2�
WELL CONTRACTOR (INDIVIDUAL) NAME
�(prrint))2( /Kith)( t —GEms,"" Q CERTIFICATION��TI8'13
WELL CONTRACTOR COMPANY NAME W TTT i s ILA , t ts. r M2i U-A t'Vy PRONE 8 l0io) FA " I 1 SS
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS{
(if applicable) (if applicable)
/
1. WELL USE (Check Applicable Box): Residential H Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI :
st To
(S • e, N unity, bdivtsioo, Lot No., Zip Code)
3. OWNER:
Address
City State Zip Code
Areacode- Phone number `a 1 p
4. DATE DRILLED 11 16 co
5. TOTAL DEPTH: V /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO l
7. STATIC WATER LEVEL Below Top of Casing: lb FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS � FT. Above Land Surface*
*Top of cuing terminated at/or below land surface nqulres a
variance le accordauc ISA NCAC 2C .0118.
9. YIELD (gpm): \ MFQ>) OF TEST
10. WATER ZONES (depth): g6
11. DISINFECTION: Type Vag
Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Mal
3 k From b ToFt. (o'IW' �YVC�
From To FL
From To Ft.
13. GROUT: Dept Material
From To Ft.-t'�ad<t
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
From To
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
Slot Size
in. in.
in.
Material
16. REMARKS:
/Topographic/Land setting
Entidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutealaeconda)
Latitude/longitude source:❑GPS❑Topographic map
(check tax)
DEPTH DRILLING LOG
From SI Foao De ription
S'
p,v pl
p,nV 0 2 1S
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road niLmel.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE.IVELL OWNER
t:4 cz
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DA
0(0
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

„e., / T P 1 S - Zip Code
Ana cods Phone manber �o
4. DATE DRILLED �1Q �(P
5. TOTAL DEPTH: LA i
6. DOES WELL REPLACE EXISTING WELL? YES Q NO "IV
7. STATIC WATER LEVEL Below Top of Casing: ID Fr,
(Use *r^ if Above Top of Cuing)
8. TOP OF CASING IS t FT. Above Land Surface*
'Top of cuing terminated at/or below land surface requires ■
variance In accordauce.S11 ISA NCAC 2C .011a.
9. YIELD (gpm): /0 U METHOp OF TEST
10. WATER ZONES (depth): V7-3
11. DISINFECTION: Type
12. CASING:
u TDo
th
From�Ft 4
From To Ft
From To Ft.
13. GROUT: Mgt
From f _ To 20 Ft al
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
From To Ft.
- `T Amount
Direr Wall
lThickness
b'( YW t. jytr
Slot Size
_ in.
in.
16. REMARKS:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and` Natural Resources Division of Water Quality - Groundwater Section
�)
WELL CONTRACTOR (INDIVIDUAL) NAM (print) w Iu'`�� SCr t' Y( t-�.YYkS CERTIFICATION Ran (-fib
WELL CONTRACTOR COMPANY NAME 4 T U.E Labrl I, ICZ-. U..i.NLC, PHONE •Ies'o)r(SC-.
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ef/ Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
(Street Name, umber, r • m , ity, Subdivision, Lot
3. OWNER:
Address V.5.1ikAS(
., Zip Code)
a ',It— DEPTH
Topographic/Land setting
❑Ridge ❑Slope p alley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
(depeedminutea/aeroods)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DRILLING LOG
From T4 Fongption Description
441
Nat
DIV. O c WATER DIJALITI
NOV 0 9 2006
LOCATISKEMLI
Sh.w direction and distance in miles from at least
State Roads or County Roads. Include road
numbers d common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
CONSTRUCTION STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OWNER
\SST, i�c,2
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
.B

WELL CONSTRUCTION RECORD
rtt ♦i (`
Yle
ja f:
North Carolina - Department of Environment and Natural Resources �-�Diivvision
n�of�Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) C`(Q 1 k° an ` ik�' • "'^'�Z� CERTIFICATION # 0' ✓/
WELL CONTRACTOR COMPANY NAME �i �,ALLZ t.ACLL 'baAll-(D-ial PHONE # ivr) 311-`l, SS --
STATE WELL CONSTRUCTION PERMITS/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er—Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use _
2. WELL LOCA ON:
Nearest Town: t .aLLr" county an
`OCilk*ibla A \f UDA)S
(Street Nanpe,�Numben, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 1fl2i . ((AP
City or Town S
(rib (1)- . % —!a
Ares code- Phone number `1
4. DATE DRILLED
5. TOTAL DEPTH: J
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L�
7. STATIC WATER LEVEL Below Top of Casing: t) FT.
(Use'*+" if Above Top of Casing)
8. TOP OF CASING IS FT Above Land Surface*
'Top of wlag terminated at/or below land surface ngolres ■
variance hi accordance with 1SA NCAC 2C .011&
9. YIELD (gpm): \DO METHOD F TEST 1a\t
10. WATER ZONES (depth): \`1i1
3tti'
Zip Code
11. DISINFECTION: Type �}f(F! Amount
12. CASING: Wall Thiclmess
�(�eter or Wei t. Iy�
From 0 To Ft. to'/4' kit From To Ft
From To Ft.
13. GROUT: Depth �_�_,�""""" M����44�44te-��-tia•��•1����}}}...►►►,,......
From d To $a Ft.
From To 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.
)ropographic/Land setting
BIMdge ['Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forma: De cription
DEETII
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 STANDARDS, AND}HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ooge /A/ ee&_
SIGNATURE O PERSON CONSTRUCTING THE WELL
DATE
1 244ID/p
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
334504
North Carolina - Department of Environment and Natural Resources -
Di ' ion of Water Quality - Groundwater Sectioonyn
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ' AWS GU CIE CERTIFICATION 8 , ft
WELL CONTRACTOR COMPANY NAME 'td ,V LLC (,S€"i. - 12--ILU Pic PHONE It "en
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQPERMIT/I
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential i / MunicipalPublic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Nf1Llk,
---1)c-rWetturftth O&M
CountyC VW
(Street Name. Number, Community, Subdivision, Lot No., Zip Code)
3. OWNER: \ Ltt &.k( —
Address 3'1oa
C�NIQIs ir883JLreet «CC
City or Town State
P
Zip Code
(DO- `mil¢ - csigS1
Ata code- Phone number
4. DATE DRILLED `0� De
5. TOTAL DEPTH: '� I /
6. DOES WELL REPLACE EXISTING WELL/ YES ❑ NOI7
7. STATIC WATER LEVEL Below Top of Casing: 1 tsb FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS \ FT. Above Land Surface'
'Top of teeing terminated at/or below land surface requires a
variance in accordaoiqe with ISA NCAC 2C .el I8.
9. YIELD (gpm): 4-10 METHOD OF TEST Att.
10. WATER ZONES (depth):-0
11. DISINFECTION: Type * (kk Amount
12. CASING: Wall Thiclmess
Depth„ Ihiyneter o Wei t tt. p4atylial
From b To 3 Ft (o/�.' NVC..
From To Ft.
From To
13. GROUT:,_ Depth
Frorn_ I_ To Loa
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size Material
From To
From To
16. REMARKS:
Ft.
Ft.
Slot Size
in.
in.
Topographic/Land setting
natidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formatfon`DesFription
DEPTH
From To
0 5
51 (G3'
(03' edSl
tJONi Q 9 Lp06
LOCATION SKETCH
Show direction and distance in mil
two State Roads or County Roads
numbers and common road nam
from at least
lude the road
teak
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OWNER
002 ,e p4 icke4. oca
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
� Ig

WELL CONSTRUCTION RECORD g3463
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pram)' `3"5• vi
APWV • io��-1 t�,r‘S \� �,,I CERTIFICATION, >�t77 �l�a
WELL CONTRACTOR COMPANY NAME w N�I Ca , �.� U.1 NI() PRONE e
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT,/
(if applicable) (it -applicable)
1. WELL USE (Check Applicable Box): Residential 111 Municipal/Public 0 industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT
N
To leaIP�'t..ir
•
(Street Name, Number,
3. OWNER:''
Address
Subdi Lot No., Zip Code)
City or'.'' State . Zip Code
)-
Area code- Phone mnnber
4. DATE DRILLED -1
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO LDS
7. STATIC WATER LEVEL Below Top of Casing: 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 accordan with ISA NCAC 2C .0118.
9. YIELD (gpm): METHQD OF TEST'2
10. WATER ZONES (depth): 5b --
r15' — \c.
11. DISINFECTION: Type 1 Tvk Amotia)t
12. CASING: Wall Thickness
Depth
Diameter or Weight/Ft. pp��aat(er�rrral
From CI To �l Ft. I0 74 t�Y221.(P COY C.
From To Ft.
From To Ft
13. GROUT: Dept__
From 0 To Ft
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.
From To Ft.
Slot Size
in.
in
Material
16. REMARKS:
Topographic/Latii setting
❑Ridge ❑Slope Walley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To
O
2, V-81t
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,
CONSTRUp'[ON ANDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 50Z-
North Carolina - Department of Environment and
�Natural
� Resources - Division of Quality - Groundwater Section ��/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) l �,1 / 7 9 1 , T2.tu- L. CERTIFICATION p�7Cl /
WELL CONTRACTOR COMPANY NAME tA ` 5± V 1L l� U., 1 I Q- UJ PHONE II q/ 5S
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 2( Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOC TION:
(Street Name, Numbers, Comm , u • ' Sion, Lot No., Zip Code)
3. OWNER: S •- ..
Address
No.)
Cm' • T ' Zip Code
'
Area code- Phone ttmrber
4. DATE DRILLED
5. TOTAL DEPTH: rr /
6. DOES WELL REPLACE EXISTING WELL? YES NO [Id
7. STATIC WATER LEVEL Below Top of Casing: FT.(Use "+" if Above Top of Cuing)
8. TOP OF CASING IS ` FT. Above Land Surface*
Top of wing terminated at/or below land surface requires a
variance In accordance with ISA NCAC 2C .0118.
9. YIELD (gpm)• 0 METHOD OF TEST Ma-
10. WATER ZONES (depth):
11. DISINFECTION: Type (�
12. CASING:
From To
From To
13. GROUT: Depth
From Z L To
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Front To Ft.
Amount
Wall Thiclmess
From b To Ft. npiapvt4l (fir Weight/Ft. atpyal
Ft.
Ft.
_ Maqterial
Ftel_ty4—t
Material
/topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/mint/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
FormaDescription
DEPTH
From To
b \D`
\b' 4W'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and co .n road names.
Advimift I2J
- ,*,2 i6-\--3Ytag,
16. REMARKS�2`19aE — e ]1-qmi'1 it l L, \A'? c-k
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTR CIION STANDII S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO WE OWNER
e at
A.
t la
SIG ATURE OF PERSON CONSTRUCTING THE WELL ` A
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
3 345o 1
North Carolina - Department of Environment and Natural
1 Resources - Division of Water
,Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CY 1� (1Et `v�l�' 1&Q p.€tU CERTIFICATION
o ,39
WELL CONTRACTOR COMPANY NAME v`�` ` 1 r`�Vl �� - Q-1 LUM PHONE A 6I,SUW - //
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# �1
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
(Street oi-R No.)
.i tip Code
�rCity T `sue l ,
Armcode- Phone number
4. DATE DRILLED I
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 19
7. STATIC WATER LEVEL Below Top of Casing: t7) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
'Top of cuing terminated at/or below land surface requires a
variance In accord nee with 1SA NCAC 2C .0118.
9. YIELD (gpm): S THMD OF TEST'2-
10. WATER ZONES (depth): \
t
11. DISINFECTION: Type
12. CASING: Dept•p,e Wall Thickness
o`�o '.O' S" -��.l t. p4acyw.
From_iT F[ F'Vl.
From To Ft
From To Ft
13. GROUT: Depth M�(eriaLkEi
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.
Dia
Amount
11 Topographic/Land setting
Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH
From To
0 kD
6
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County R�ag,,lnclude the road
numbers and common ro
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO LL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD ; 45
North Carolina - Department of Environment and NaturalaResources - Division of Water Quality - Groundwater Sectioniri
WELL CONTRACTOR (INDIVIDUAL) NAME
p,((pprint;\raLt-LP (`5'0A-01' ( I € En CERTIFICCATTIIO2NcPtel?gO
WELL CONTRACTOR COMPANY NAME WCl (C5"h L-L E W 'LL�`u U� �di PRONE a S )8o iL I) 5
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential El Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL
Nealsst
(Street N
3. OWNER:,
Address
or Rpnge;(o.)
County ``4,3
City or ma
Zip Code
Ara code- Phone number
4. DATE DRILLED \ DIP
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: ST3 FT.
(Use «+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of wing terminated at/or below Ind surface requires a
valiance In accordan with ISA NCAC 2C .0118.
9. YIELD (gpm) MP,ZIiOA pF TEST Q--
10. WATER ZONES (depth): n
11. DISINFECTION: Type * k
12. CASING:
From 0 To 21;, Ft CP rtger
From............... To Ft.
From To Ft.
13. GROUT: Depth
Froth L7 To� FL
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK
Depth
From To Ft.
From To Ft.
Size
Amount
Wall Thickness
or tit. atisal
Slot Size
in.
in
Material
/ Topographic/Land setting
Midge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degreeshn tutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING J.O()
Formation Description
DEPTH
From Tp ,
40'
3c'
\I O \NN\�� L
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road : s es. , 1
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION A COPY OF THIS RECORD HAS BEEN PROVIDED T�� VyEL[. OWNER
1° ID(10
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Ratelgh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural 1RaAessoMourc�es^ Division of Water Quality - Groundwater Section
y
WELL CONTRACTOR (INDIVIDUAL) NAME p(prinnt�)\r•S)`i- ls`l&'`t3W� t��i5 CERTIFICATIO�Nga(l�//
WELL CONTRACTOR COMPANY NAME \`k t l 1 �� ���1= 1 - �. i PHONE a ) O� /
STATE WELL CONSTRUCTION PERMITS _ ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCA
Nearest.
County.
(Street Name. Number, Comm
3. 0
A
hy, Ybdi
ddress
•
ye1nt owe 'Stele
' tia 11
Zip Code
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES p NO D-
7. STATIC WATER LEVEL Below Top of Casing: lo0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t ET. Above Land Surface'
'Top of rising terminated actor below land surface requires a
variance IN accord nee with ISA NCAC 2C .011S.
9. YIELD (gpm): METHOD OF TEST t
10. WATER ZONES (depth): �aO
11. DISINFECTION: Type"( Amount
12. CASING: '' Idar4tPr 'c b WallaThickness
From U TTo �`l-% FL . aeL(A Mal
From To FL
From To Ft.
13. GROUT: Dep'TttI NN
FrortiQ To `Y'h Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Zip Code)
Slot Size
in. in.
in.
Material
16. REMARKS:
4
Ole
1
"Topographic/Land setting
Ridge ['Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTR DRILLING LOG
From To Forrr{Qtion Description
rt c.ci punL1TY
ow, or
NOS R
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
"-t '-( k4 `cam
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 OWNER
C 5)F,S SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE O c
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
(a

WRI.L. CONTRACTOR:
\leiWteA I.A7);k6Y-1
I Wad Catiracn Mdmrsua4 Mona
tet)1/(00 )pi Pritti 1. c
I WIN Cooninn Cards
nc
STREET moires 3TO /0/1/4-6,7,
7ra<s4ni.nn Wei
City ce Torm State
I 2101 g fc3 7 - 096Lt.
Aas NNW Piton* numbs
2. WeilailltORNAllOtt
SITEWal 10 MP nollials1
SIVE WELL PERMS. nona001...
IMO orOTHER Meat eff
al USE tcn telteaNO4bota NotadradmWS 544701 0
OAT; ORRLEO j/ - /4- 404
rionaporunsb 3;06 • ou 0 PNI
S. INEtIASICNIKON
art 14 gsv; It e «meat( My
"Rva;rt /vas <p r'inrAc
otoidonoi, soloorio.OmmononosonsoittaNs tAk twat
(Tar= 101: alas trOiiir
tobOdooPOPSobt be*
LATINS*
LOIENTUDE
R9c,r)
Zap CaR
Mop be latttomet.
Mint1001. en* or
litadolontban
Looseikaostido OOPS oTopogaphic map
andionaf alfamotb• stes too • USG:Stapp onda and
OisSodiribile I retsio OPS)
t VIIELL OMEN
OWNER'S WO/E-K II WO Pr
OMIT ADDRESS 3Q/O peed, cb-
141gfrori.+4k-64
36•Vor
re Cot
11/4g a2/3'- x4'I
Amea ado • :Moro stem
11. WELL VETAILS:
ma TOM terns /66 '
DOES WELL IERVICIE esp. WUXI NIS o NO I:I--
e. WAS LEVU. Odom Roof Cawing AO FT.
Wore Ansa to Ott:Rat
d. NIP OP IIASSISII / Ptptcw,LsdSflW
good amino iondondiRotbdos rods irdd tea
indrestin insiodennovei ISA IICAC 2C Mt
o. TRW Way .2 mamma% Tarr Ai?
RESIDENTL44 cothistR venom RECORli
North ("mama Depadmeart of Envenom= and Natural Racconts- Division of Weer Qtt$y
WELL COKIRACTOR CERTIFICATION * °WY
v. IMMIFECTIOOt fps ldfIet ?el Ito Ia
• INATER ZONES (depth)
Fora To
horn To
From To
• coomet
Doran Orstodso
Pn 0 To Cebt ft. 67 tag
From To Ft.
Ran To ft.
T. an: Depth
frathb_
Frog g TO •-)in
To Ft
S. SCREW Dopii aset amatte
nos To Ft IN. tn.
•From To R. in.
Front_ To. Ft _in M.
3 3 6 3 9
maws I S
From To
Pram To
From I o
Thickness/
Weir MOM
<nrM
401412104101•11. PACK:
Dapth st NSW
From To R.
Son TO R.
; *SG LOG
From To FoomationOsoaiSSOS
Ste) - 5n
10 — an Aknqe
0 - 1 h
CO C-.0 CI C
SA tig rrrnr1:I
IL REMARKS:
RFCFIVFfl
niv riF INATFR Qum rry
114 4p nn irk
ODHOURy MOW MAT 110 1NR3/4 IRINPRVCRON MCCOWN=
OA IOC RC Mkt cOIRMINCOMENHOMin. moan COPY tree
latosralai sumnowasso nine Rata sae
(latinera ardiareoett =6thclote at462e
i\VVIVI4Niate,C\ ISEltr)
PRINTED OIF PERSON CONETROCIIIIS VMS

RES,LAENTIA emu. cons-nown0m atoms
North Camara Dtyrtment of Eaestem as and Natant itamtavere Uivtdar Of Water Quoit)
wasCONTRACTOR CERTIFICATION a a 4 0 y
336397
t I. WELL cOWTRACTOR:
I V,I�yNQS tZ WI)Sign
W*a Caviar tmtnwta¢Nom
1 (�s e11 r��l�.ng
STREET AOC*ES& SRa 1,4 <nri
ljcnsstntan r^ t 02 89Da
Gya Twat State Code
t`basj•- 5sX7-0910_3
Monde- Asa twitter ,
a ROLSPORMATatt
tiff WILL 10 QeeteMsatstl -
STATE WI LL PlIMIFpeyaboo q
DWQ rOTfER PIFIRTietthearealtel
TALL ME tete* Aare+eaaa): iiaauaair *air Opp"
arswalla ll-as'-ola
TIIIEOOmetenes if6 - map Fuer—
ieelt. WCATIOek
cm: Weir Y1re. couvrr(Ji t1
�p� rn�Jn Zdt
sameata, tesepleetartatel. Let Ile_ food. De Ceee1
TOFSPORAMOD /tAND SETIDtE
`bat dos. t]S hit
i Aineg as boo
LATITUDE 3towOrvuos
_
Moy be htderer ,
mitrw ono* or
TatlleiNtee�Yn►SRI; OOPS OTOPROPMCwt4
Artdiaaiadw atilt ll SC*•Ulteis iqr imp and
atl dietteMebiiemIMOIMMEIPS
4. WBLOSIMER
OVRIER'S NAME
STET ADDRESS
G14a Twin SiMe
t >•
Ana ache • Phu* aunts
s wtus DETAILS:
TOTS& tent ► ta6'
Zip Cade
r. DOES MILt8PnmwaL? 'VESO NO la --
a mats Lava armag,f cassis,. Sin r FT.
(UN•. temlip vale
a. Tap orCA ts+i / , FT. AWNS land ataUer
Teri ese /11iSerblewbadsassesevysrgae
ataeleltaeli twoaaMa.4l. 1M IICAD .MIR
e. mare: 020 ■EIMCOOFTfTJ4,'4Q
L 0s*1Fc4npt Type
MOIR IMES Nepal.
Feats Ted
From To
From To
4 CAROM
Aat.ak 1 n
Run To
Fran To
From To
7tieNtessl
jitRug f Two QS' et ofparrrr ? VC
Fran To R.
Reat__To FL
7. GROUT: . Depth
To3L
Etna (3' Toto?,)•
MOS
PCs nit 4)
IL SOIREM t1ees Dies atalla Men
Ras Tea - R P. tn.
Fpy,_,__Ta Rom. is - h:
Erato - To Ft ia.
I. %AflZIYGRINEL PACK:
Depot Sae uraad
Fast To R
Pant ----TO- Ft
Fie Ta. R
1.211LESSILJOIS LO6
fr ei To
0 10' C1lot
Ip� - 4n, frt.-idI <-l-nne
1(6' - flats' Srrrivtl4-e
I T. REMARKS:
Formate Oaitaipson
V
IAN
9 S 2liU-
mop vn 7or st
10041MOOtONlAtrwatt tttiteaLtwpptrataeRoaaoe7Nara=Ma
SWAM Wins' atirtadao n. NOTaRFcor rflm
ammoiea MINTRONINITO moat n�rir
QR.(1�l l "�R�
17 ep
Tone OF CERTIFIED eK1.CCM�R1iCT0fe PATE
, iiVOW f.);IsArt
PIMITED RAKE OF IMMIOR CONSTRICTSKI itE v as

pas mamba. Cramentr,
Tn.- WOW (LAND SETTS*
tors ono doer coats
oiatoPrildebboO
TATTTWE
LONGITUDE_;_,_
LatibieAlearsssuae DON OTOFEPPMe waer
ttmettsoles aSMPip*resWOErepoarpend
aUtodedtark ISO It net eMy@Ps,
L. WEJ. ovate 1 t -"
Ctrs NAME ] : } A-�' G (l 4'
STREET ADDRESS 1C)Lv4 QU�iI
CitinP_ NJ,
iNWerTown SIM
(soa- htn`t
Am arts• Thaw arer
t. WELL CONTRACTOR:
`w,,4r r�
frrocctnt cindmaugt
(,i:ken JAVA Dr:Ilt�nc LLC
WO CaamoN. Company Name
1 flirt AOo(ResL5 &') / <ti n AV
�rcaSS1�W(l IY•C t 02690a
Citr a Tarn State 2sp Code
is?Kt- - D9&_
Armmria- Phony numbs
a. WILLINF RMATIOR
EITE WELL ID sari
STATE WEILPROMO here ti
9WQ re OTHER PERIOr vflcshte4
%situUSEtC M* Resioner Water Slap*
QY
s.weiLLW�C1ATxrc
GitY: LO A rf1 .
wort CIA CI
)-Qr°t 1�f'h. trial ear
wNo Poona toCron
►ry be to deport,
minus . mends or
krlieh eStart
rat
covet'LQ.
or .
i WEns. SETARS:
a TQTAI, perm,20.Ct
b. DOFF wdL wtMtfnFEnsee18*&tt YES❑ NOC C. WATER LEVEL Oster Ile dCarat ode, f FT.
!. TOP at amen / rt. AbateLend U 4ce•
'Trod anWApirrlaimtOM( Mew loaderten rare sere
arams* awarder inttISANCAC2C..MIR
.. WILD Spey. 5t ttETtooatnewt i�it i2
RESJDENTIUL WELJa Ns7RCCTIONRe oiw
Noah roman, Department of Eavnoemcaa and Namara Raw- ttividor of Water Quality
WELL CONTRACTOR CERTIFICATION * _ __
o CTRat 1 ype41i'11 Pt' 11 as/WM 15
336392
p. MATER ZONES Nape..
Fe. To From To
Fran To from To
Flom To From 10
S. CAROM
From d
From
Ran
�Tihielmmen/
twin
TO `%7' Ftln St 1
To Ft.
To Ft.
7. GROUT: Depth
Cram To
Fran. 32 To 2D' FL '
Ran To Ft
Pec
SS MEW Cmpit .DNS - art
Fes To Rt. 1n. in.
From - To "Ft M. - in. From To Ftbo. to
a SAttNORAYSL PACK:
Depth Sian
From To Ft
Front To Pt.
AS. h. R.
004.0413 LOG
Fran To
--s'
5'- tott
Gao/ „2CS'
REMARKS:
Forma* teach tton
4n€q S{-on
trran11 E
KEYED
D1u tFWAtQUALITY
IAN 0 8 2007
444 f Cn fiAck
toomasvca t ntat nenu. raw operroc#oatracramrNcshNlfn
+asIOC 2PWWI t NCIWOirMrearri ,AprIvoAetPatorIW
Sobs etgrMAIM TO Italia
ErWATUNE OF WELL C'CtNtNCTDk
���nnwtt t.C1i1<e f
PAINED RIME Of PERMS CONsnwCIWR THE waL

FEB 9 1 2CU7RES/DENT7AL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3175
1. WELL CONTRACTOR:
i72i PtJZ.. ik \ (CTn2
Well Conracter (Individual) Name
J3�Cf�S CAC-LL Dail,.(_( KCa 1 MC
Wd Contractor Company Name STREET ADDRESS t2(ol ail �" Caro 14 kJ 14.
JNalP_sv(LLc- a
City orTaan State Zip Code
c70G)- 744S —Z(��
Ares ode- Phab number
2. WELL INFORMATION:
SITE WELL ID 80f appiublo) r 2
STATE WELL PERMfW(Wapplicable)
DWQ a OTHER PERMIT ipf appceble)
WELL USE (Cheat Applicable Bap: Residents Water Supply ❑
DATE DRILLED 6,-Z2 Oca 2 11-Z/(=i(D
TIME COMPLETED (0 I.30 I AM br PM El
S. WELL LOCATION:
CITY: W elZ 4 e. CDUNTy CLBY
-E>2 VicJi
30Sty
(Sheet Nam., Numbers. Community. Subdivision. Lot No., Parcel, ap Code)
TO RAPHIC 1 LAND SETTING:
%Slope °Valey 10 Rot ()Ridge ❑OUmr
(chedcapp.opdate boo
LATTrUDEtL g 1.
LONGITUDEQ_Cr, 3e 2 S
Latitude/longitude source: 0Topograpbic map
(bca/bn of sef must be shown one USGS typo map and
attached Joints Torn Ind asig GPS)
4 WELL OWNER j''� j.,, 1
OWNER'S NAME Don -'DL�L_ nIj- n
STREET RESS Z n _Sntrl4n ni Ki L ri. y
4 (,41-PI GL 3 of 1
City or Tam State Zip Code
( Sbl )_ g -2-2o5
Area codePhone number
-
May be in degm,
mimics, seconds or
in a docket Erma
5. WELL DETAILS: �
a. TOTAL DEPTH: KJ////
b. DOES WELL REPLACE EXISTING WELL? YES ElNt)
c. WATER LEVEL Below Top of Casing: . / 5FT.
(Use •1" P Above Top of Casing)
d TOP OF CASING IS OC FT. Above Lad Surface'
'Tap of casktg terminated at1a below land surface may refire
a v dance In accordancewith 15A NCAC 2C .0118.
e. YIELD (gpm): 4 METHOD OF TEST aR
ncrenz,e lo 7,25pm
33$513
L DISRffECTIOMType �i7/7AArnount nl /6
g. WATER ZONES (
Fray)/!.f, To A GPM From To
Fran. _To From To
Fran To From To
6. CASING: TNcMess/
From-Z Depth _c-O 14ntr Material
From To FL �� ??ll
Fran To FL
7. GROUT: Depth
From 0 To -Co
Fran To
From To
al Method
R. t£ban2uct De'MIt,o
FT.
FL
a. SCREEW Depth Dander Slot Stu Material
From_ To R in. In.
From__ To FL In. In.
Fran To Ft in. In.
A SANDIGRAVEL PACK:
Depth Slze Material
From To FL
Frm(-,_To Ft.
Fran To FL
10. DRIWNG LOG
From To
0 Cl
dS /an
11. REMARKS:
Formation Description
7 ✓ Se.tnlaer--
[ L, Lzasz. _S o v4 / Aewe
+22,/ o/Ferf-SCc 1 ✓Lne it
ago Anr-
e2iawir�
D2ltac M22y Geacrr
ZzcierGe7 V 0 OW'
flail c ra d/
azio drbrC
bark yea r
RECEIVED
OIV. OF WATER QUALITY
0H
1 DO HEREBY CERIFY1HATTIS WELL WAS CONSTRUCTED N ACCO1OANCE WITH
lea NCAC 2C, WELL CONSTRUCTION STi1NIDAROS. AND THATA COPY OFT S
79EBt TO WFIL OWNf4i
-0&
SIGNATURE CERTIFlEDW CONTRACTOR DATE
PRI NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Intonation Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7106

FEB ? 1 2113E
.RESIDElVTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Envbonma t and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION it .3t / S
1. WELL CONTRACTOR:
TrReu� P. j(ct Utz
Wet Contractor (Individual) Name
.I ct2s WPt c_021Ct (rta MN!'
Wel Cadraiar Company Name
STREET ADDRESS J2(27 lL0612C:Yoe (awV
atasauk G2. 3©5(4
City or Tam State Zip Code
)- 745-aura
Area code- Phone nut
2. WELL INFORMATION:
SITE WELL ID is applicable)
4/
STATE WELL PERMITWIrappliwge)
DWQ a OTHER PERMIT egf applicable)
WELL USE (Check Applicable Bat): Residential Water Supply
DATE DRILLED (,,—(20-0C fa-J?-64o
TIME COMPLETED /2 15 AM ❑ PM rY /
A WE LL LOCATION
CITY: (t JSQNE COUNTY CL 2.Y
De.ciz V2.wty
(Street Nave, Numbers, Community, SubdMdon, Let Na, Parcel, Zip Code)
TOPOG / LAND SETTING:
°Slope aley ❑PI$ ORfdge ❑Other
(check eppopdm bag
tAirruos/Q 8 ° 511. 49140.
fv
LONGrruDLJ Os3°5%, /y]
Latitude/longitude sconce: airGig.
❑Topogaphic map
(bastion of welmustbe sham on a USGS topo map and
attached to this tan tnat ushg GPS)
May be is degrees,
mamba, seconds or
in a deal lamer
(Tn1)- 833-220�
Area code - Phone number
5. WELL DETAILS: /_ Li5
a. TOTAL DEPTfh (O `I /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p7
c. WATER LEVEL Bei mTop of Casing: SD FT
(Use +• IAbove Top d Casing)
d. TOP OF CASING IS FT. Above LaSurface'
'Tap ef casing iun or below land surface may require
e
a valance in accordance with 15A NCAC 2C .0115.
e. YIELD(gpm): / C� / METHOD OFTEST a(!(
1 /iG/ en ri .b (n&55pM
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 668.
336511
L QSINFECTION: type Fr -n-I Amount oZ /
g. WATER ZONES (depth): 7
Fran To - e From To
From To Fran To
Fran To From To
IL CASINO: Thickness/
WIlaMaterial
na(t2 T% I`t/Z�FL in*g
From To FL
Fran_ To FL
O'er.
7. GROUT: Depth , TtMaterial Method
Fran d To SAL / FL p0211-aMD
From To FL
From To Ft,
tL SCREEN Depth Diane, Slot Size Material
Fran To Fttn. in.
Fran To FL in. in.
From To FL ID. In.
9. SANDIGRAVEL PACK
Depth Size Materiel
Fran To Ft.
Fran To FL
From To FL
10. DRILLING LOG
Fr
om -7
l�7 ►a7
I Cr leo
10o ILC
lis tart
(89 &5S
5S 3,7o
370 .SOS
4O .S/ 0
S!pp ,64S
Jo45 - Ibb5
Formation Pro as/ Description
7214 52NA /Zack
GRtV atntnzso gout
GR PA/iT-
Qua nil
GRSN(T
Doll PR a.Y r✓/cir>, t IWCB
&car SR2 o /crz # M/oB
aaac Geo,/ aoc+c
?)ar/c o/2ay+ Peck.
A..rlt- r7 y r40..&
KtlatIVEL)
11. REMARKS: DIV OF WATER QUALITY
JAN 0 4 2007
100 HEREBY CERTFYTiATTHR WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND TNT A COPY OF MIS
HAS BEEN PROVIDED TO THE WELL OWNER.
7.f cw f� U[ IJ�dL 6 20-d6
la OF CERTIFIED WELL CONTRACTOR DATE
A7 8/42 /7 V/croQ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
4. WELL OWNER T� Nr�+
OWNER'SNAME DOr> t-omn4Ttin
STREETADD RESS 2500 araitl V1xit. C4i*)
)/1/4%S+F1!ilrrL T F1-- ?3c40 l
City a Town State Zip Code
Fenn GW-la
Rev. 7/05

RESIDENTIAL nu. ° pris1RGCTION RECORIi
Nadi rarokta Department ofEwrsarucat and Naomi ttssncuar- lAvisicat.1 Wars ter
WELL CONTRACTOR CERTIFICATION a 2Ci c t
333678
1 1. WELL CONTRACTOR.
V , c_3,(\ylsnn
I (.)Jsnn tJ,t311 Dr; ll:nq
I woo coursers tod u$ dames
YHA Cann Company Nan
STREET ADDRESS 6 S& IA); sty, id
? r.sshuan 14. r s94.2
obi a Tam State Zs Code
r �6a2iS AN 7 - 09cd,X,.
Aso uade- Passe numbs
LIMA INFORNATldat
MERU ID sae sarraad
STATE WEIL. PIER MRNe welaMaL_
MR ofEMER PST Rlrepviaael_.,,
WELL MELDING; Appldalea«rk Reeaeaoee War Swe'y I3
OATEMOUSO
Trlotanwa, nej rrt7A
+rM0
SWIRL IMMO*
CTTn: )4h} yes Vi /lee Cbti nrr&My
Wires rpoek 1titoits L.n.
karearsmoi aa..tfaandowrsr.raea..fre.09 coast
TOPO<IRAPNIC f t1V10 OE7TM$u ..
aka trolornilm I7RNpi SEisr
(tl i pr8s akbad
LATITUDE _3_ —
LONGITUDE
Loshodolloogibob Ma DOTI otopo ookic map
tbrantimietawstat statnai us UEGStape map and
MYeMdts/Mr ban tassYy sass
4. NEU OMERI '�
OWtERSNAMElrllrt C ntn n<An
STREET ADDRESS
May br lsderes
Minato% sawn* or
iaasaled beard
CItaTon 9Me
L--.�-
Are®oide- Phil* aunt ar
rep Cats
SWELL DETAILS: -f�
a. TOTAL WPMAS r /
b. DOES WELL1 LACE EDITING VIEW TES Et NO P,I
e. WATER LEVELBibsTop dCads WI' FT.
Woe'*' # AWN Tip tattONT0
d. TOP OFOA:IIIER 1 rt. AOastadSsr4oe
•Trap d Ism amtmow omromm rasago mo ntlSo
awAar.sp atiewlaa.e ISA CAC aC SITE
s. Tian two: / %a KETlIooaFTEST 4,(2
t DISINFECTIGat ryp.►r4k ?eii a1s Aswaat I S
y. WATER ZONES (depth).
Flom
To
From To
From To
it CASPER
Ds D nder
e) Fart E) To 1' saFt (Q ras
From To Ft
Fan To Ft
T. GROUT: Dept
Few_ To a '
Flan .fir Tom_
F_To Ft
S. =let Des* OINKS SWIG* MSS
rat__ ce?t 'It ia.
Rom To Ft t 6r.
Fmk To Ft in.
From Te
From To
Fran To
Ttwd«esst
Weij«
S12foL/
IL SNWAVEL PACK:
t)prpr Sze USN
From To Ft.
From TqFt
Fran To. Ft
:OIWii412 LOG
From To
0 - In
In'- IA'
R Q' - .ZtoS'
I. REMARKS:
Fomo areOmaiplion
Siv% Ito
RRFCEIVFD
u11/ OFF IAMTER QUALITY
408 007
Mop nn 2,ar•k
r meow can laws naieweMsOOssaNeCe®«aoatrss+ar«tr
11A CC=MIL COMMUCIOISIMOMEM— TWA 05PlaS
swam we yeainontaoron*ir scams.
QtOF oo R. (.�� 11at COMMUCTOO - No
< \;.\:lsaO
PRINTED s4i OF PERSON CONSTRuCTING 14E WELL

RESIDENTIAL WELL CONSTRUCTION RECORD
CAD
OWNER 1Z-"6'Ob
North Carolina Department of Environment and Natural Resources- Division of Water Quality a
TVELL CONTRACTOR CERTIFICATION # rte..?
T`t
MWD
NC
1. WELL CONTRACTOR:
"etr
Conlrac Individual Nam
W eli a (Individual) e
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESSP.O. BOX 5G7
HAYESVILLE, N.C. 28904
City er Town State Zip Code
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#Iil applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Ea --
DATE DRILLED //-,2Q-06
TIME COMPLETED %--DO AM ❑ PM
3. WELL LOCATION:
CITY: ibile d.- 1(e" COUNTY
ate. G 5 9 S
(Streel Name. Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
OSlope Qtlalley ❑Flat ORidge OOther
(check appropriate box)
LATITUDE 3 .1- D 2, 0 9?
LONGITUDE 5' 3 36 G,j'I
Latitude/longitude source: pal'S ❑Topographic map
(location of well must be shown on a USGS fopo map and
attached to This form I not using GPS)
4. WELL OWNER nn OWNER'S NAME ✓/G.v; J 6t.'pr T
May be in degrees,
minutes, seconds or
in a decimal formal
STREET ADDRESS t!/25!L
e--(cI /21-
Ale C/A- 5Cr-
City or town State Zip Code
(011)- it? --765,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ✓Z 22
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO er-
e. WATER LEVEL Below Top of Casing: 2 (2 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 6 METHOD OF TEST 'r
f. DISINFECTION: Type /7 The Amount irk
g. WATER ZONES (depth):
From .2 dU To From To
From To From To
From To From To
6. CASING:
From ei
From
From
Thickness/
Depth Diameter Weight Material
To /05"`Ft. C-•ZJ ..i7t )Aze./
To Ft.
To Ft.
7. GROUT: Depth Material { Method
From 0 To 3 El. G nc Te l*2
From To 20 Ft. v /+-f
From To Ft.
8. SCREEN: Depth
From To
From To
From To
Diameter Slot Size Material
FI. in. In.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
0
Zs` 95-
95-2ZL
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
`tt
rT-
-r
Formation Description
v. /
Clap
f �=
RFCEIVEn
DIV. OF WATER QUALITY
)AN 0 5 2007
I DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN ACCORDANCE W ITN
I5A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
fir Teiphir
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
// z/--06
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
4C4 Ax.1, c...-.r..., r.ntne_ fleininh HP 77RQB-1A17 Phnnn Nn. t919t 713-7015 xt 568.
Form GW-Ia
D..., 7mS

J� 1 7, Aivv 3 2 2 5' 5 OWNER RESIDENTIAL WELL. CONSTRUCTION RECORD
North Carolina Depotlinen' of Envilunmcnt and Natural Resources- Division of Water Qualify
WELT, C/JN'I'RAC'I'L)R CERTIFICATION N
1. WELL CONTRACTOR:
(14I1Ler
Wen Corrlracia (Individual) Name
_ FALLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P . O. BOX
HAYESVILLE, N.C.
City or Town Stale
L 828 ). 837-2997
Area code- Phone number
5 G 7
28904
Zip Crxfo
2. WELL INrORM AT ION:
SITE WELL ID s(a applicable(
STAT E WELL FERMI UM applicable)___
D W Q a OTHER PERMIT N(IF applicable)
WELL USE (Check Applicable 13ox): Residential Water Supply
DATE DRILLED I / q Applicable
TIME COMPLETED 2100 AMU PM(gj
3. WELL LOCATION:
CITY: rrr•`7eSrili[e COUNTY CLt9
ISlreel Neme, Numb.,,, Cnnnnuniry. SubdiNslon, Lol No., parcel, Zip (;ode)
TQPOGRAPNIC I LAND SETTING:
VSlope OValtey orbit llRIdge (jollier
(check reproprlale boa)
LATITUDE _3_ C
LONGITUDE g 3 'tit .'7' r
May I'e in cores,
mirknlr,. ,fr'ona, err
In A decimal hoot!
Lafitudc/longitude coerce: LIGI'S LJTbpographic reap
(}miner of nni must be shown on n IISG S tom mop and
effnchnd In This 'burr I trot using GI'S)
4. WELL OWNER
OWNER'S NAME lZlerl,l-i t.2t ._,5€.--,
STREET ADDRESS 64 w
City a I am 5 �l�y—_.LaL.t�_. z
Zip Crx)e
Area axle - Pbake number
S. WELL DETAILS:
o. TOTAL DEPIN: G D /
b. DOES WELL REPLACE EXISTING WELL? YESL1 NON
c. WATER LEVEL Pekes Top of Casino' 9
(lice •4• H Above Top of Casing)
r y
d. TOP OF CASING IS
FT. Above bud Smlaca'
•Top of casing terminated ntla below land surface nray require
• variance In accordance with 15A NOAC 2C .Otto.
e. YIELD Wpm). LyfpiMETIJODOFTEST tTr
FT.
S3
1. OISINFECTION: Type
0. WATER ZONES (depth):
Fran /S{/l • To _
•
MWD
NC
V
a Amount i n
From
rran ,2?% )n x To 2201 From
Fran edc.2.5' to a2 .. From
6. CASING:
Depth Dias t r
rran_, 1c/JJ EL
rirmr To FI.
rran To FI.
To
To
To
1ldclmess/
Weiglrl Material
5D2xt ATG
T. GROUt: Depth Material
IAa
from ToMethod
a3` /r
trnrn_�� _To D; IA y-
Flan To FI.
6. SCREEN: Depth Diameter Slul Size Material
Fran To FI.N.
In.
Fran To rl.In. In.
Fran To El. In. In.
9.
SAND/GRAVEL PACK:
Depth
From To rt.
Ftan To rl.
From To Ff.
10. DRILLING LOG
From To
//3' l95'
/.)5' /8a
/Po. 720i)'
,*ho•,--)9v
VE
MAR 0 ti 200
_Ashavill.e-Regional
tecti
I1. ter.mnItJtS:
Size
Material
Formal' n Description
I bO I Irnrey croon TIIAT erns WELL WAS CafslRucTro N ACCOROM/CE WITH
ISA NCAC 20. Ell consul ON SunRAIMS,q 1IIAI ACOPT Or Tlq
RECOnn 14A fEEN PROMO O /DELL QWyER.
I CI 06
SIGNATURE F CERTIFIED
WELL CONTRACTOR DALE
pJ"' EU NAME Of PERSON NS1 IJr, 111E WELL
Stilnnit tiro oi!ginal In the Division of Water Quality wllhlli 30 clays, Attn: Information Mut.,
1517 h1i0I "rry!rn Center - RD!c!yll, NC 27699-1617 Phone No. [phone] ox1 SOO
Form OW fa

OWNER',;
RESIDENTIAL WELL. CONSTRUCTION RECOIMWD
L 6 1 6
North Caroline Department or Envlrbnmenl end Natural kesourcesa Division of Waterr Quality
7 NC
WELL CONTRACTOR CERTIFICATION H 236 3''
`:1, WELL CONTRACTOR: .
Well Contractor (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET AbDRESS P .0e BOX 567
HAYESVILLE, N.C. 28904
City or Tonn Stale Zip Code
( 828 y 837-2997
Area code- Phone number
& WELL INFORMATION:
SITE WELL ID dui applicable)
STATE WELL PERMITAIe applicable)
bWCI or OCHER PERMIT Leta applicable)
WELL (1SE (Check Applicable Box): Residential Water Supply
DATE DRILLED /O-2-O(€,
TIME COMPLETED 7.)'.Oci AMP
S. WELL LOCATION:
j CITY: Fla jesu,(l0
PM El
COUNTY C. 10.E
(Seer Name, Numbers, Community, SubdMslon, Lot No., Parcel, Zip Code)
- : TOPOGRAPHIC 1 LAND SEttING:
taSlope Walley Timm OFildge bother
(Cheek appropriate box)
LATITUDE O`f° 179V'
LoNGltUDE 0 3 tie ' 93 3 r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source t IOPS tTopographic map
(bestial o1 Wet must be shown one USGS tom map and
attached to 11* form I slot ushg GPS)
4. WELL OWNER
OWNER•SNAME V_ n/SbJnnsa
STREET ADDRESS 5-5 O Id h LI UT
(-t-
elly oo(( Toren State Zip Code
Arse code. Phone number
6, WELL DETAILS;
sl TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 Hoa
e. WATER LEVEL below Top d Casing: Ls d FT.
(the '+• ll Above Top d Casing)
d. TOP OP CASING Is 1 g "
. PT. Above Land Sodom'
'Top of easing terminated Rua below land surface may require
o valence In accordance with 1SA NCAC 2C .011 A,
•
e, YIELD Wpm). 3 METHOD OP LEST A r r
1. bISINPEctIoN: type 4T 1-1 Amount _ cto �l
g. WATER ZONES (depth):
Prom 4485' Ta fl 2From to
Fiorn2-5/7' to 5/R' From. To
From To From To
6. CASING:
Depth , blamefer
Prom d To a. PI. c, "
From toPi
Thickness/
Weigh,
Material
LhC-
From To Ft
7. OROUt: Depth Material {� Method <'+
m, Prar' To,' P1. 19rddon17 W /r0,1- fIC yLcr •
Fran TO PI. --4 :>
• From to F1.
a, SCREEN: Depth Diameter Blot Site Ma s (
Frain To M. In M.
Prom To F1. In. Itt a'
Fran To FLIn. __ In.
6. SANDiGRAVEL PACK: z
Depth Site Malsial o
Front to ri.
iV
From ttl FL
From To . EL
1o. DRILLING Loci
From To
0" .
11, REMARKS)
Formation bescrlplbn
%OP Soil
r
.5 cal
Slci� L I r iec-inne
C PAL"
I Do HERESY CENTPT 114At
' I5SNCAC2' WELL CONS'
NECORb r = SEEN PR.
WELL WAS CONStaUCTEb N ACCOr(CANCt WIIN
20 ; E OSJVrO 1rN1 A COP(' OF /N6
!' 0-4-06
SIGNATU E OF CERTIFIED WELL CONTRACTOR DATE
-Loki .1,
T�ck Mel"
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: (nfonnation Mgt,
1917 Mall Semite Center - Raleigh, NC 27699.161? Phone No. [phone] bet 5B6,"'

CA32J695
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 0 c A5- 3
OWNER
MWD
NC
1. WELL CONTRACTOR:
r Kok N I le -
Well Contractor (LJ1Tdividual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P.D. BOX 507
HAYESVILLE, N.C. 28904
City or Town Stale Zip Code
L 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID !pl applicable)
STATE WELL PERMITI01 applicable)
DWQ or OTHER PERMIT SW applicable)
WELL USE (Check Applicable Box): Resldenlial Water Supply
DATE DRILLED -3--) (Y-O6
TIME COMPLETED �'O 0
3. WELL LOCATION: CITY: IaajeSVt 11 e COUNTY e In )/
l D /1 n li.yl'C ti $S Ld/In'Va..
(Sheet Name. Numbers. Community. Subdivision. Lot No., Parcel. Zip Code)
TOPOGRAPHIC I LAND SETTING:
tl‘Slope °Valley °Flat °Ridge ❑Other
(check appropriate box)
LATITUDE 3_ f of • 301
LONGITUDES $ .7&?
L atitudcllongitude source: %CI'S °Topographic map
(location of we/ most he shown on a USGS lope map arid
attached to This fans I nor using GPS)
4. WELL OWNER
OWNER'S NAME L I e WET l� e
STREET ADDRESS %Falnnllarbrn t3L101iwy 14
Marble
City a Town Slate Zip Cafe
to tit
AM O PM (o
May he in degrees,
minutes, seconds or
in a decimal loan)
Nc, Z81o5
( 432% } 599
Area cafe - Phone number
5. WELL DETAILS: (J
a. TOTAL. DEPTH: ! 1
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO,aI
c. WATER LEVEL Belau Top of Casing:
(Use if Above Top o1 Casing)
FT.
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a valance In accordance with 15A NCAC 2C .0118.
e. YIELD Wpm): ina METHOD OF TEST Air
1. DISINFECT ION: Type f-/7// Amount laipxyds
g. WATER ZONES (depth):
From 3l3ppToflc( From To
To From To
To From To
From
From
6. CASING: Thickness)
Depth Diameter Weight aleriS
From Q '. To 38 FI. (.0' , D.0
From To F1.
From To Ft.
7. GROUT: Depth Material Method
Fran n" To rQf' Ft. &MINIlfe/rrnrd% D143hrc,r
From To FI.
From To F1.
8. SCREEN: Depth Diameter Slot Size Material
From To FI. In. In.
From To Ft. In. In.
From To FI. In. In.
9. SANDIGRAVEL PACK:
Depth
Flan
From
From
To rt.
To F1.
To F1.
10. DRILLING LOG
From To
09/6
9i0' D$0"
�80 ' 3 Yo
39-o 500'
500" 8fn"
Size Material
Formation Description
nncslo/le
StioIc
Cirri Cs4au
5) 4e
0
L i nnri4nn e
f
rNSP— /Z/z7/0
ry
.Ij/h!5 toflt00/0
I I. ItEM1ARKS:
r.�
yz
H
1 DO HEREBY CF.RTWY THAT DRS WELL WAS CONSTRUCTED a1 ACCORDANCE WITH
I5A NCAC 2C. WELT fONSTRUC1TON 8 NOARDS. AND MAT A COPY OF MS
RECORD HAS BEE ROWED TO WE j!J"ITIER.
Lt-t0-ob
SIGNATURE OF RTIFIED WELL CONTRACTOR DATE
-Jack OTh to
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the Drduinal to the Division of Water Quality within 30 days. Attn: Information Mgt.,
ra,m nw_ta

RESIDENTIAL WELL CONSTRUCTION RUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION t) (..353
OWNER
MWD
NC ✓
1. WELL CAI TIJ,ACTOR:
Ct (411_
Well Con
actor (I Q '. oat) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P • 0. BOX 567
ITAYESVILLE, N.C. 28904
City or Town State Zip Code
(. 828)- 837-2997
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID Otil applicable)
STATE WELL PERMIT/NI applicable)
DWG) or OTHER PERMIT a(if applicable) "`
WELL USE (Check Applicable Box): Residential Water Supply LY
DATE DRILLED 3-3o-0 to
TIME COMPLETED / D() AMU PMjljl
3. WELL LOCATION:
CITY: f—C,iyeStit 11e
licorice R•A
COUNTY eIC y
1/ t Neel Name. Numbaa;Q mwdly. Subdivision. Lol No.. Parcel. Zip Cade)
TOPOGRAPHIC 1 LAND SETTING:
Slope [Valley ❑Flat ❑Ridge [Other
(Check epproprlale box)
LATITUDE 3 C- Of• 01"71/
LONGITUDE .6 ,3 w, Zy0
Latitude/longitude source: VIl'S ❑Topographic map
(k.cntbn of wet must be shown on n USGS topo mop and
attached to this form f not using GPS)
4. WELL OWNER
OWNER'S NAME z)err/Iy '�LJC _l i
STREET ADDRESS D 0 erik 1231
NC 28404-
City or own Stale
Area code - Phone number
May he in degrees,
minutes. seconds or
in a decimal Snood
Zip Code
5. WELL DETAILS: a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO PS,
c. WATER LEVEL BelowTop of Casing: /P6 F1.
(Use'•' if Above Top of Casing)
d. TOP OF CASING 1S FT. Above Land Surface'
'Top d casing laminated al/or below land sutlace may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD Igpm):,.20 METHOD OF TEST 19Tr
1. DISINFECTION: Type 117// Amount 376, Pet/r/s
g. WATER ZONES (depth):
From 1700. To 7c); From
From 1/46 To z%/%. From
From 4130 To 4133 . From
To
To
To
6. CASING: Thickness)
,, Depth Diameter Weight terial
From 0 Tov2 V' Ft ( lJ,c
Fran To Ft.
From To FI.
T. GROUT: Depth�1 Material
From/ " To rXn Ft. Crmen 7 L
Fan To Ft.
Fran To FI.
Method 1
IL SCREEN: Depth Diameter Sid Size Material
Fran To FI. In. In.
From • To Ft. In. In.
Flan To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Fian to FI.
10. DRILLING LOG
From ToFormation Description
��. 70' (Jn rs741n
700• ,3)' S/ci'r/Slook' nilx
,36 720• Shale LoarSjnnP reitx
s U e Rec,t ,r_1 Oates
An,.l.<x G• :e,`?r,,
11. REMARKS:
I DO HEREBY CERIWY THAT THIS WELL WAS CONS!PUCIrO e1 ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. ALA) 111AT A COPY OF 1115
RECORD INS BEEN PROVIDE OTI THE W EL40W NE
_Jack Me/kid
PRINTED NAME OF PERSON CONSTRUCTING 11IE WELL
I
Submit the original to the Division of Water Quality wllhl 1 30 days. Attn: Information Mgt.,
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW1a
flee_ T105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3368
326274
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contractor (Individual) Name
CHEROKEE WELL DRILLING
Web Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY
NC 28906
City or Town State Zip Code
( 828 ). 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT8(e applicable)
DWQ or OTHER PERMIT •(C applicable)
WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 05/02/08
TIME COMPLETED
3. WELL LOCATION:
CITY: HAYESVILLE
AM ❑ PM ❑
COUNTY CLAY
'OUR DRIVE' OFF OF CHATUGE LANE
(Street Name, Numbers, Community, Subdhision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
®Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate boa)
02.711 N
LATITUDE 3 5
LONGITUDE 8 3 45.203 W
May be in degrees,
minutes, seconds or
in a decimal foment
Latitude/longitude source: POPS ['Topographic map
(bcation of wet must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME STEVEN SWISHER
STREET ADDRESS 381 RIVER OAKS DR.
HAYESVILLE NC
28909
City or Town State Zip Code
828 )_ 389-8752
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 565'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use air 9 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing teminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm): 50 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From 540' To 560' From To
From To From To
From To From To
6. CASING:
From 0' Depth
250' Ft. D1/4
iameter
From To Ft.
From To R.
T
h
ic
kness/ Mapa��a
.186M STEEL'
7. GROUT: Depth Material
From 0 To 20' R. CEMENT
From To R.
From To FT.
Method
GRAVITY
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. In.
From To Ft. in. in.
From To R. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Ft.
To Ft.
To Ft.
Size Material
10. DRILLING LOG
From To
0' TO 20'
20' TO 40'
40'
TO 80'
80'
TO 100'
100' TO 160'
160' TO
200'
200' TO
220'
22D 10
O
.L'
Formation Description^'
BROWN DIRTeo
TAN DIRT
BROWN DIRT
BOULDER & BROWN DIRTcay
BOULDER
BROWN DIRT
BROWN DIRT & GRANITE
260 BLUE GRANITE
260' TO 565
11. REMARKS:
BLUE GRANITE
Jo Th
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W I1H
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT CC1PY OF T S
RECORD HA5 BEEN PROVIDED TO THE WELL OWNER.
,fr '- 05/03/06
SIGNATURE OF OERTIFI D W LL C NTRACTOR DATE
JI«14Ili P�"� Di EV La «
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ltU
Submit the original to the Division of Water Quality within 30 days. Attn: bltonnatlon Mgt,
1817 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
o rd \--\ctm
Well Contractor (Indi id 1) Name
Rio t - p\& U3aV Lo.
Well Contract& Company Name
STREET ADDRESS IGGa f- S.OA 2 v A.
i3l&.cs6At 6f` 3 5I
City or Town State Zip Code
( Da) 7 t/5—)5L5
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#M applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED c b_o?2
ox4
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION: CITY: COUNTY C I QLA
CI, AC. e Crea3 Lc ne.
(Street Name, Numb , Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPH / LAND SETTING:
❑Slope itealley ❑Flat DRidge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form /not using GPS)
4. WELL OWNER
OWNER'S NAME The_nrva ter Tit� er',y
STREET ADDRESS Mao? Z CY,'Gr-
\ C1\P,5tr f VA r2R(n().3
City or Town State Zip Code
(540)- 3a1D— 91193
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
645
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [3�
c. WATER LEVEL Below Top of Casing: FT.
(Use '+"1 Above Top of Casing)
d. TOP OF CASING IS IP FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance//__with 15A NCAC 2C .0118.
LP METHOD OF TEST .BICA. %L
e. YIELD (gpm):
3151
5'32
f. DISINFECTION: Type "7"1 i t-t Amount
g. WATER ZONES (depth):
From ln0 To ra%D
From
FromJain To From
From To From
To
30 oz
To
To
6. CASING: Thickness/
• Depth a DiarpeterIllggght Material
From () Togas Ft. (o %t f 1M1Y1 PUG'
From To Ft. i11Gi.`
From To Ft.
7. GROUT: Depth Material Method
Rom n
From To Ft. r e Aertr
From To Ft.
To ao Ft. POLAO,Ysc, (Ire 4L11(C
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
Ft.
Ft.
Ft.
Size Material
From To
Formation Description
� 1145C�C1'
�
FE
Aallwi,5; )Tec c ri
PC' ca j
11. REMARKS:
occian
VC &r' ke.
Vi
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.
EOFC I EDWLLC T, 'J-4)
SIGNA RE OF C IFlED WELL C TRACTOR DATE
Ftard• 1�n
TE NAME O RSON CONST UCTING
PRIN TcpE 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 Caroline Department or Environment and Natural Resoureef• Division or Water Quality
WELL CONTRACTOR CERTIFICATION N 2-14. 0 3
1. WELL� �CONTRACTOR:
/er''5/ Aece
Well Contractor (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•0. BOX
567
HAYESVILLE, N.C. 28904
City ot Town Stale
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Slur arpllcable)
STATE WELL PERMIT e(e applicable)
DWQ or OTHER PERMIT A'(11 applicable)
WELL USE (Check Applicable Boa): Residential Water Supply
DATE DRILLED 3 - 0.2- 0 6
Zip Code
TIME COMPLETED -7-.00 AMO PMlr"
3. WELL LOCATION:
CITY: MY" o.de
11-4 e
(Sbeat Name. Number, Community. SubdrNslon, Lot No., Potosi. Zip Code)
TOPOGRAPHIC l LAND SETTING:"�
°Slope °Valley °FLat 'Idge ❑Other
(check tom optlale box)
LATITUDE _.3_ S ea. ss 2-
LONGITUDE ' ,1 V9' ;220
Letiludellongilude source: I9Cl'S oT'oi ographic mop
(location or wet must be shown on n USGS lope map and
attached to lids form I not using GPS)
4. WELL OWNER /
OWNER'S NAME CO"'r i0G1!
COUNTY c icy
May I'e In dealers,
inbuilt.; seconds or
In a decimal Fermat
STREET ADDRESS 32- Ora. ice R \ A9-C )AITe
tF6(y2S,/iIIe i[L 2-941611-•
City or Town State Zip code
} 30s- 53/
ea code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 96
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Le
e. WATER LEVEL Below Top of Casing: 02 U0 FT.
(Use '4' 11 Above Top of Casing)
d. TOP OF CASING IS / FT. Above Lend Surface'
'Top of casing terminated allot below land am lace may require
a variance In accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): -1 METHOD OF TEST ry r
u. WATER ZONES (depth):
From 300 To .30 / From
From 670 To (7" From
From To From
6. CASING:
Depth
Fran 0 To 17 F1. 6
From
From
To Ft.
To FI.
OWNER
MWD
NC
1. DISINFECTION: Type dine- Amount /5Y( {'
To
To
7o
Thickness/
Diameter W.we.ze PSG
el lit Material
.;r -
7. GROUT: Depth Material/
From To .y FI. //�aaw/
Fran 3 To2O FI. Otr7n/n: t�
Fran To FI.
Method
O4-
a. SCREEN: Depth Diameter Slot Site Material
From To FI.In. In.
From - To rt. In. In.
From To F1. In. kr.
9. SANDIGRAVEL PACK:
Depth Slze Material
From To Ft.
From To FL
From To F1.
10. DRILLING LOG
From To
0 — 60
0- it
11. REMARKS:
Formation Description
Grit//. l e-
JUi
c.
u LUud
I DO IIEREBY CERTIFY THAT THIS WELL WAS ccnsmm.1ra N ACCORDANCE WIM
ISA NCAC LC. WELL CONSTRUCTION STANDARDS. N10 THAI ACOPY 13F 1M5
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATGRE OF CERTIFIED WELL CONTRACTOR DATE
4rry Reece
PRINTED NAME OF PERSON CONSTRUCTING TIIE WELL
•
1
Submit the original to the Division of Water quality wind 1 30 days. Attn: Infonnatlon Mgt.,
.�».. .. .._ ..___.__ .. _._._.. .... .e.. cu_—_.. s _ mini ell 7nat.sr tee
Form GWta
I

326
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envimnnicul and Natural Resources- Division or Water Quality
WELL CONTItACIOlt CERTIFICATION N P /O3
1. WELT CONTRACTOR:
Conk to
erz Aee
Indivklual
Well (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•O. BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale Zip Cale
(. 828 ). 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 001 applicable)
STATE WELL PERMITRpr applicable)
DWG or OTHER PERMIT AQI applicable)
WELL USE (Check Applicable Box): Residential Water Supply IDS
DATE DRILLED / 0Y'0
TIME COMPLETED 1."0
3. WELL LOCATION:
CITY: (Ykf rreS4/. ((e-
(lc/ T•Ce- CU✓e- X •
(Sleet Name, Numbers, Community. Subdivision, Lot No., Parcel, Try Code)
TOPOGRAPHIC !LAND SETTING:
C3' epe ❑Valley anal ❑Rldge ❑Other
(check appropriate box)
LATITUDE 01. 135
LONGITUDE 83 53 69'j-
Utitude/longitude source: OCI'S UTo; ()graphic mop
(location of we/ must be shown on n USGS Form map and
affached to This fort I not using GPS)
AMO PML?
COUNTY C` atio/
May be in depen,
minutes, sernnds or
In a decimal romal
4. WELL OWNER
OWNER'S NAME 7017 Gr'fi C;C?/" '"1 U/v Ito Idlis
STREET ADDRESS ISCreek5idr (JrLIC#8
I-faye 5vtlJQ A/C
-
City a Town Slate
t
Area code. Phone number
zgel OF
Zip Code
S. WELL DETAILS: Per
e. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO EY
c. WATER LEVEL Below Top of Casing: L' 0
(Use's' 8 Above Top of Casing)
d. TOP OF CASING I5 / FT. Above Land Surface'
'Top of casing 'emanated al/or below land swine may require
a valance In accordance with ISA NCAC 2C .0118.
•
e. YIELD (gpm): } METHOD OF TEST /9/7
FT.
1 } OWNER
MWD
NC t/
1. DISINFECTION: Type //71! Amount QYZY'
g. WATER ZONES (depth):
From 9'0— To 397 From To
From To From To
From To From To
6. CASING: Thickness/
Depth / Diameter Weight Material
From 0 To 26 FI. C tS" sl!t, V - Aie.,
Fran To Ft.
From To FI.
T. GROUT: Depth , „Material
From To 3 FI. ii/714-1/
From -3
From To FL
To,jo Fl/ie.: ; 14t
Method
/
tie lei
8. SCREEN: Depth Diameter Slot Size Material
From To FI. In. In.
From • To Ft. In. In.
From To Ft In In.
9. SANDIGRAVEL PACK:
Depth
Fran To F1.
From To Ft.
From To F1.
Size Material
10. DRILLING LOG
From To Formation Description
lag - was •
1 I. RENIAItKS:
;,, 0 ii 2035
100 tit RtBY CFPIFY T11AI MIS WEIL WAS CONSTDUCITO el ACCORDANCE WIN
15A TICK 2C, WELI CONSTRUCTION STANDARDS. AND MAT A COPY or TM
RECORD INS BEEN PROYDEO 10 THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
471, I/4zeLe.
I AME OF
PERSON
NN CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
.----- .._ — ... .... .w.. n,.___x,_ mint a awl cell
Form GW-Ia

326 e uvii;;
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2-1+03
1.WELLCyNTRACTOR:
/merry Ae�
Connacfar Individual
Well (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESSP•0. BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale Zip Cale
828 y 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Old applicable)
STATE WELL PERMIT/is applicable)
DWQ or OTHER PERMIT ►(II applicable)
WELL USE (Check Applicable Sox): Residenlial Mier Supply
DATE DRILLED ,S' 0%0 6
TIME COMPLETED /0. C'O AM Ira` PM Li
3. WELL LOCATION: l/
CITY: GJ4rr/e COUNTY C- 42/
,t,, e /49 c%01e-4 EY
)Sheol Name. Nuon.9ert Community. Subdivision, Lot No.. Pncel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
OSlope Crisdley Oriel ORidge 001her
(check appropriate box)
LATITUDE ,3 I" 94'6
LONGITUDE b 3 59 - ;2.6.9
Latitude/longitude source: FTPiI'S ❑Topographic map
fbcafbn of wet most be shown on a USGS lopo mop and
attached to fhb lam it not using GPS)
4.WELL OWNER cD
OWNER'S NAME St'7 /e/i J7//»v/-
STREET ADDRESS 6Z1T SW 7th Ave
wit 5F-on FL 326q�
City CeTown Slate Zip Code
Area cafe • Phone number
hley le hi de►rees.
minter!. seconds or
hn a decimal Tbrmal
IL WELL DETAILS:
a. TOTAL DEPTH: /22
b. DOES WELL REPLACE EXISTING WELL? YES O NOIr.
e. WATER LEVEL Below Top o( Casing: .5 FT.
(Use '4' 8 Above Top of Casing)
d. TOP OF CASING 19 l FT. Above Land Surface'
'Top al casing terminaled attar below land surface may require
a valance In accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): 2S METHOD OF TEST AT
OWNER
MWD
NC
I. DISINFECTION: Type /7 Tr! Amount CS' Lof/
g. WATER ZONES (depth):
From /7.5— To //6 From To
From To From To
From To Flom To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To C? Fl. 6,21 sod/ R'c
Fran 6 ? To i'/;" Ft 6-15- .l Ale Site /
From To Ft.
7. GROUT: Depth Material Method
From 0 To.3 ri. r/TRnc iA ed
I From 3 To ne l9 FI. eevi w4`e ri,- el
From To FI.
e. SCREEN: Depth Diameter Slot Size Malarial
From To Ft. In. In.
From • To rt. In. M.
From To Ft. In. M.
9. SAND/GRAVEL PACK:
Deplh
Fran To
From 7o
From To
10. DRILLING LOG
From To
D—?s
/2 Z.
11. REMARKS:
Ft.
FI.
FI.
Size
Material
Formatbn Description
clay
lrr.-n,'t e
1 DO THEREBY CERTIFY THAT n119 WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCIEN STANDARDS. AND MAT A COPY OF 111 S
RECORD HAS BEEN PROVIDED 70 THE WELL OWNER.
S'-oy o6
SIGN,ATTURE OF CERTIFIED WELL CONTRACTOR DATE
/rr/ "flee `e-
PRINIED NAME OF PERSON CONSTRUCTING DIE WELL
,
Submit the original Io the Division of Water Quality with! 130 days. Mtn: Information Mgt.,
4917 Mnrr Camden rnnlsr— mninlnl, NC /roan -Cott Pinner Ain. 10101 711a111R sat SRN.
ramcw-Ia ,,t

32r700
RESIDENTIAL WELL cons -tau LION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CEIt I IFICA PION 11 Z V" •3
OWNER
MWD
1. WEL CONTRACTTOR:ter-% /eter.
IndNldual) Nam
Well Conk la(
e
MILLER WELL DRILLING,
Well Contractor Company Name
STREET ADDRESSP•O. BOX 5G7
HAYESVILLE, N.C. 28904
INC.
City a Town Slate Zip Code
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID lin applicable)
STATE WELL PERMITIIa applicable)
DWQ or OTHER PERMIT IV applicable)
WELL USE (Check Applicable Sox): Residential Water Supply I
DATE DRILLED 6 -go - 0 (
TIME COMPLETED 22. 00 AM PM
[-
3. WELL LOCATION:
CITY: cydcode
//// COUNTY C47
Ai cw45Jcc /Ci l/C/" ,e
ISbeN Name, Numbers. Community. Subdivision, lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
['Slope WI ley ['Flat ORIdge OOlher
check approprlale box)
LATITUDE 5— 0?' 7/V
LONGITUDE f 3 -r6 - 2 74
Latitude/longitude source: Etdr5 ❑Topographic nap
(bcarbn of we/ must be shown on a USGS Iopo map end
attached to Ibis faun 1 not using GPS)
4. WELL OWNER
OWNER'S NAME J.'a� e/-
STREET ADDRESS .24 21'7 Wnnc (DE T errq Ce
Palm f}arbnur FL .4- 8-5
City or Town Stale Zip Code
Area code - Phone number
Mny he in degrees.
adnrn, socnnds or
In a decimal formal
S. WELL DETAILS:
a TOTAL DEPTH: 22
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO L-
e. WATER LEVEL Below Top °teasing. 2- d FT.
(Use '4" 'Above Top d Casing)
d. TOP OF CASINO IS / FT. Above Land Surface'
'Top d casing Iermkteled atlor below land surface may mqulre
e valance In accordance with 15A NCAC 2C .0118.��
•
e. YIELDIgpm): ` METHOD OF TESTr1??/r77
1. DISINFECTION: Typo /T Amount 7c/C
p. WATER ZONES (depth):
e2.16 To A./(
From
From
Fran
6. CASING:
Depth Diameter
V To0_ Ft. f-AS--
To F1.
From
From
From To FI.
To
To
From To
From To
From To
Thickness/
Weight Material
54(21 v�
7. GROUT: Depth Material
From 0 To 3 Fi. 4/"x�^?i
i From 3 To Xo FI. z07bv-Se
I From To Ft.
Method
6. SCREEN: Depth Diameter Slot Size Material
From To F1. In. In.
From - To FI. In. In.
From To rt. In. In.
9, SANOIGRAVEL PACK:
Deplh Size Material
rran To FI.
From To FI.
From To Ft.
10. DRILLING LOG
From To Formation Descriptioe
D b' clLy
- ZQ2.
II. REMARKS:
ar
c O
nT
100 HERESY CERTFY THAT THIS WELL WAS CONST/rUCTED N ACCORDANCE YAM
ISA NCAC 2C. W Ell CONSTRUCTION STANDARDS. MD THAT A COPT OF THIS
RECORD HAS SEEN PROVIDED TON* WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Ay Ea LC •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
- ramcW-Is

329698
RESIDENTIAL WELL CONSTRUC r1ON RECORD
North Carolina Department of Environment end Natural Resumes- Division or Weld Quality
WELL CONTILAC'I'Olt CEICI'IFICA PION N 24 D3
1. WELL /CCfoNTRACTOR:
/a� -4e e-
CU
WeA (IndWidual) Name
MILLER WELL DRILLING, INC.
W ell Co,baclor Company Name
STPEETADDRESSp•0. BOX 567
HAYESVILLE, N.C. 28904
City a Town Stale VD Code
( 828 y 837-2997
Area code- Phone number
L WELL INFORMATION:
SITE WELL ID Hill apolkaWel
STATE WELL PERMITS/pi applicable)
DWQ or OTTIER PERMIT l(9 applicable)
WELL USE (Check Applicable Sox): Reskienllal Water Supply 19--"
DATEDRILLED 6-2G�
TIME COMPLETED el' OD
AM I] PM
1. WELL LOCATION: /
CITY: O/-ksfr1 owy2 COUNTY de/
(rrcEser CreeA-
%Sher Name. Number. Cmrnurly. Subdldelon, lel No.. Pncd. ZIP Code)
TOPOGRAPHIC 1 LAND SETTING:
BS ri*e 17Vnney orb' °Ridge loolher
(check epprvprlale bon)
LATITUDE _, .. 0 / - y19
LONGITUDE 5
Latitude/longitude source: scl'S °Topogrnplde mop
(bcnlbn of wit must be shown on n USGS lopo mop end
eaechad to Oils fans Inol using GPS)
Ally be In dopers.
tubede 1, secreuh o
In a rkdmel Emma
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS PO Bpi 66
Av/
oar,
afasS-Lewrt NC 2'40L
City a loan State Zip Code
)-
Area code • Plane number
IL WELL DETAILS:
e. TOTAL DEPTH:
l3�
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: � 0 PT,
(Use's' M Above Top of Casing)
d. TOP OF CASINO IS / FT. Above Lard Surface'
•top d easing terminated et/or below lad surlece may respire
a ratline In accordance WA 15A NCAC 2C .oi 1e.
•
a. YIELD 19pm): 20 METHOD Or TEST /9i C
OWNER
MWD
NC
I. DISINFECTION: typo hit Amount At Cr,
g, WATER ZONES (depth):
From 16e5 To 7e6 From To
From To Fran To
Prom To Floes to
E. CASINO:
D
Fran
From To Ft.
From 10 FI.
Thickness/
Depth blamel$r Weigh! Mft/'vc.Idfen-to !FI. /e. l{Z
7. GROUT: Depth Ma%eerial pMd
From 0 To 3 Ft Xi-,7 c? /✓pre.
1 tmitt__ To ?O ,Ft. i!1j%vJ7Ce- fbn1Ye,
Plom to P1.
e. SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. kr.
From to Ft. In. In.
Prom To rt. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
Fran To M.
From To FI.
From To Pl.
10. °RILLIILG too
From To Formation Description
d — 0 Clay
9o_ iVO b n- f�
I I. REMARKS!
2
cc
c
0
I oo llEREOF CERIay /NAt Oro WELL WAS CONS IIWCItD N ACCOSIONe:E rani
ISA NCAC TC. WElt CONSTRUCtION StMDMt1S. A11D 1WT A COPT of Del
RECORD INS SEEN PIIOVbEO 10 WE WELL OWNEN.
ee.L� G-2 off,
61GNAT V E OF GERIIFIED WELL CONTRACIOR DATE
/try ec1
PRIN I ED NAME OF PERSON CONST RUCI INO II IE WELL
•
Cuhmll Ilia nrinlnal to the Division of Water Quality within 30 days. Attn: hitonnatlon Mgt,
- rim owls

3
RESIDENTIAL WELL COUs'AUCTION kEcoi D
Nord' Carolina Department of Environment and Nalurai Resources. Division or Weler Quality,
WELL Cunt/knoll CEILT'IPICA I'IUN N
24 a3
OWNER f
MWD [�
m,
NC t
1. WELL CONTRACTOR:
et /leect
Wee Cuntteclat pndboduall None
MILLER WELL DRILLING, INC.
Wel Conlraclm Company Name
S1REETADDRESSp•U. VOX 567
HAYESVILLE, N.C. 28904
City or T own Stale hip Cole
( 8213 } 037-2997
Area code- Phone numbet
2. WELL INFORMATION:
SITE WELL ID pa spplkeble)
STATE WELL PERMIT/pi applicable)
DWO or OTHER PERMIT 9(e applicable)
WELL USE (Check Applicable fox): Residential Water Supply EV
DATE DRILLED G -21-06
TIME COMPLETED 3-.CO
AM IJ PM I I-
3. WELL LOCATION: /
CITY: //GyeJ4)/'l`e— COUNTY U4V
Sorel/S 4, L4-#S 14.not., Ivk
'Stint Name, Wombats. Community. Subdivision. Ltd No., Pncel, Zip Codeld
TOPOGRAPHIC f LAND SETTING:
w8Eope (Valley ClFlal (Ridge ❑Other
[check epproptlate bin)
LATITUDE � S� t003, 010
r
LONGITUDE e 3 ! Q' /2 7
Latitude/longitude source: trd'S nlu) ogtnphic mop
lkcalbn or wnl mast be shown on a USGS Iopo mop and
enriched to Hs fort tool uslig GPS)
A. WELL OWNER
OWNER'S NAME .2-}'a/1 Ben 14'•E ie
May 1< In Jerre,.
mIr,Ule}, leeaidl N
In • decline, Emma!
STREET ADDRESS 750 PO 1 k S'r
Mat' e ft- 6-4 3004, 4
CIF( aTown Stele
}
Ales rode • Ptnie number
S. WELL DETAILS:
a, TOTAL DEPTH: 2 I[ 0
b. DOES WELL REPLACE EXISTING WELL? YES L NO l
e. WATER LEVEL Beam Top ofCasing. e U P1.
(Use's' a Above Top d Cesbg►
d. TOP OF CASINO IS / FT. Above Lad Surface'
'Top d easing Ietntnled sum below land enlace may require
a variance In accordate with 1SA NCAC 2C .011 e.
a. YIELD Wpm). b METHOD OF TEST /¢/r
•
Zip Code
/
1. DISINFECTION: Type // 7r I
g, WATER ZONES (depth):
From 720 To 3-Z I
Amount
From To
From To From To
' Fran To From To
S. CASING:
Thkknnef
Depth Diameter Wel lht Material
gran 0 To 76 FL 6.2r. SpeZ I .. i90 6
From to F1
Flom to Fl.
?. OROUT: Depth Mal/R
eti l p Method
From 0 To.7 F1. /1,i/"d ,e, 'red
i rran _Togo .rt. 2oz4Li-t4-- ». eti
From To F1.
R. SCREEN: Depth biomeler Slot Slze Material
From To Ft. In. In.
From to F1.In. M.
Fran To FI. In. In.
9. SAND/GRAVEL PACK:
Deplh Slze Malerial
iron To F1.
Prom to rt.
Prom To FI.
10. DRILLING LOO
From To
D - GS'
�r3Ya
11. REMARKS:
Formation Descriplbn
n
*CC
—
1 VO IIEnFel VERITY THAT IRS WELL WAS CONetnUctto N ACCORONN;E MrN
ISA NCAC IC. WEu CONSTRUCTION SINn/MOS. AND NW *COPT OF MI
RECORD HAS BEEN PROVIDED TOME WELL OWNER
SIGN OF CERR1I ED WELL CONTRACTOR
•
C-2)-e1C
DATE
PRINTED NAME OF PERSON CONSTRUCTING 111E WELL
Submit llle orlalnal to the Division or Water Quality within 30 days. Alit1! M,onnalion Mgt,
FamOw•U

32V.6o
RESIDENTIAL WELT: CONSTR. non RECORD
North Carolina Department of Environment and Natural Resources- Division of Wider Qualify
WELL CONTRACTOR CEItTIFICK! ION N 2 vo f-
1. WELL CONTRACTOR:
PJ//?; A'recc-
Well Canlractcw (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•0. BOX 567
HAYESVILLE, N.C. 28904
City or Torn Stale Zip Cale
( 828 } 837-2997
Area code- Phone number
t. WELL INFORMATION:
SITE WELL ID pu eppllcable)
STATE WELL PERMIT/dr applkable)
DWQ or OTHER PERMIT 1(ff applicable)
WELL USE (Check Applicable Sox): Reskienlial Water Supply
DATE DRILLED 6 -/3 -19rp
TIME COMPLETED /DiDO
AMA PM ET
3. WELL LOCATION: /!
CITY: 4ireSvilie COUNTY Ci�j
(Sbeat Name. Numbers. Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC t LAND SETTING:
❑Sbpe OVasey (Vial ❑Ridge ❑Oilier
(check epproprlale box)
LATITUDE ,jIJ2 , .3117/
LONGITUDE 3311 q) 0'
Latitude/longitude source: OOPS ['Topographic map
(bcefbn or war must be shown on n USGS topo map and
attached to this form I nol using GPS)
A. WELL OWNER p�1q. ,y� /�
OWNER'S NAME / ///'��//-/z
play he in degrees,
nduates, second. or
in • decimal formal
STREET ADDRESS PLACA. 6103
Il-A esvilkt_ N(, 2-ggo4�
Gil or Town State Zip code
}
Area code - Phone number
S. WELL DETAILS:? /
a. TOTAL DEPTH: rJ J
b. DOES WELL REPLACE EXISTING WELL? YES p NO0
p
e, WATER LEVEL Below Top of Casing: o Q F1.
(Use'+-11 Above Toed Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top d casing *urinated aVa below land surface may require
a valance in accordance wlih I SA NCAC 2C .0110.•
e. YIELD Wpm): 3O METHOD OF TEST f/R
OWNER
MWD
NC I/
1. DISINFECTION: Type 7-., Amount .92..-CL/JG
g, WATER ZONES (depth):
From /8i To z-cr
Fran r70O To 37.9
From To
From To
Fran 3s0 To 366 From To
6. CASING:
From
Thickness/
Depth Dian ter Wei h1 Material
0 TORS. FL /o% 5af �a
From () To 3vtd' F1. y" ,Srfi 1O fat
From To F1.
7. GROUT: Deplh Material Method
From 0 To_,n_ FI. PoatrAywd ,R
i Fran 3 To Do' ,FI. ee.t srvr lie vR
r From To F1.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From - To FL In. In.
From To F1. In. In.
9.
SAND/GRAVEL PACK:
Depth Size Malerlal
From To Ft.
To Ft.
To Ft.
Fran
From
10. DRILLING LOG
From To Formation Descriplbn
fV
11. REMARKS:
1 DD 11ERE9Y CF.RWY 111AT Rlq WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 7 WELT COTESIRUC110N SIANDARDS, A11p 1HAT A COPY Of 1N6
RECORD 1M SENT PROVIDED 701HE WELL OWNER.
0g
BIGFIATURItf'OF CERTIFIED WELL CONTRACTOR DATE
fk r Keec c
PRINTED NAME OF PERSON CONSTRUCTING TILE WELL
Submit the original to the Division of Water Quality within 30 days. Atln: Information Mgt.,
- Form Ow-1s

329393
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resource,- Division or Water Quality
WELL CONTRACTOR CERTIFICATION IY 93/4,
1. WELL CONTRACTOR:
A/kr iCAreilii
ell Contractor (Individual) Name
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•0• BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale hip Code
( 828 } 837-2997
Area code- Phone number
L WELL INFORMATION:
SITE WELL ID SW appl cAble)
STATE WELL PERMITIte applicable)
DWQ or OTHER PERMIT e(if applicable)
Residential Waler Supply (tt
WELL USE (CheckApplicable Box):
DATE DRILLED 1p
TIME COMPLETED /t . CO
3. WELL LOCATION: i/ CITY: yC 7/77
M P
COUNTY C1/7f/,
(Sbeal Name, Numbers, Community. Subdivision. Lot No., Parcel, hp Code)
TOPOGRAPHIC f LAND SETTING:
V5bpe LTVafey ['Flat ORidge (3011ter
)check appropriate box)
LATITUDE `•a 980
LONGITUDE 83 - 030
Latitude/longitude source: DGI'S ['Topographic nap
(bullion of welt must be shown on n USGS logo mop end
attached to this form I not uskig GPS)
4. WELL OWNER 7—
OWNER'S NAME r/ iOf /OA'9
May le in drying,
mibetc,, vermeil m
In a decimal kmmat
STREET ADDRESS
City or Town Stele
L_}
Area code - Phone number
5. WELL DETAILS: 7l� /
a. TOTAL DEPTH: t! .
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES p' NO LJ
e. WATER LEVEL Below Top of Casing: 80 FT.
(Use's' II Above Top d Casing)
d. TOP OF CASING IS / FT. Above Laid Surface'
'Top of casing lermhurled eVa below land surface may require
■ valance In accordance wilh 15A NCAC 2C .0110.
•
e. YIELD (gpm): .Z J METHOD OF TEST 4/4
1. DISINFECTION: Typifier,
OWNER
MWD
NC
Amount it e4d0 '
a. WATER ZONES (depth):
FrornsTo From To
From Cif To From To
From To
Franj90 To Syr
S. CASING:
Thickness/
Depth D ter Welaqhl Material
From 0 To /en Ft fain" />UC
From To Ft
From To F1.
7. GROUT: Depth Material
From 6 Tom FI./Mr///Na.i .96<>
From To F1.
From To F1.
Method
S. SCREEN: Depth Diameter Slot Size Material
From To FI.In. In.
From To Ft. In. In.
Fran To FL In. _ In.
B. SAND/GRAVEL PACK:
Depth
Fran
From
From
Size Malerlal
7o F1.
To Ft.
To F1.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
i DO HERESY CER1TY tHAt THIS WELL WAS CONSTRUCIID N ACCORDANCE WIM
ISA HCAC 2C, WELL CONSTRUCTION S1ANDARDS. AND 11N1 A COPY OF MS
RECORD HAS BEEN PROVIDED tO THE WELL OWNER.
SI �N /e t_
RE l�'tl
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
fl4,/, o RCCIe-
RIME NAME OF PERSON CON
p STRUCI ING THE WELL
Submit 111e original to the Division of Water Quality Wild 130 days. Attn: information Mgt,
- Prim uw•1a

/) 'Tn
,IIESIDENTIAL WELL CONS1'IWUCi1UN ItECUlttJ r 2 9 8
Nadi Catalina Department of Envkmunehl bud NaAWel Resume*. Division of Welet QUellly
WELL CUN'TItACTOlt Ctiti'IrICA I1UN
I. MSINFECIION: term%d Amount 7Y
WELL Corn MCI
/oft
A.,-7 dC 2 Gc
c
Cone i edwlduall Nome
WMC
MILLER WELL DRILLING, INC.
Well Contractor Company Name
S1REEtADDRtssP.O. BOX 567
NAYESVILLE, N.C. 28904
Stale
Clly a town
828 } 837-2997
Area tole- Phone numbs
. WELL INFORMATION:
SttE WELL IV kid emecablel
St Al E WELL PERMIT NO'potable)
Ma or OTHER PERMIT NW applicable)
WELL USE )Check Applicable Dot): Residential Wale! Supply 1S
bAtemaiEb 8 —C
tiMECoMPLEttb ,2- oO
l.WELLlOC/AtioN: / I/
C►iY: //arefu /t't coUNtY c/a/
Zip Code
AMU PMl4
Ailey l041
IS►.N Nam% mnb.,t. Community. Nubdideton, tot No., Point. h4 Coos)
t OPOGtAPNIC 1 LAND SEt1ING:
( bVeeey Orb, tlnldse Mlles
Wendt tipper's% Doe)
LAtltMME 3 S_ 03- f2 ?
LoNGItUDE g 3 9 . 59 7
Lr+liluddlongihtde source: w61'S blbpbgtapltic tnnp
lineation emit Must be shoot on s USGS lopo Map end
attached Id kids form tad uskp GPS)
4. WELL OWNER 1_
OWNER'S NAME M eW 1
Statm'Abbfts9 ?OBOX 2_93
�,, V-esv'lle Alt 7fOq-
IC' loam 51ele Zip Code
May It In depro,
mhmita, necN4i m
In cdccloal sons
i
}
Nee code • Mims mmibet
S. WELL brtAlls:
A totALbEPlN: /22
b. GOES WELL REPLACE EXIStINO WELL/ YES U NO 1
E. WATER LEVEL below top d.land: S0 F1,
Woo w d Above top d Cakp)
d. for OF CAsPNo 19 / rt. Above lad Stelees'
°top d eakq Iesn*Wed *Vet below lad Melon May tetra
e vahrice M eceotdenee ttldl I5A NCAC 2C .O1111.
e. TIEltIkpnh .20 MEtHoDUFtEST /f r
OWNER
MWb
NC
k. WAttR ZoNEs ideplit):
F1ont /00 to /4/ From to
From to Fran to
horn 10 From to
c. CASINO: thickness)
beplh - bangle, Welpld M edal
horn 0 to .ZY FL 6-A5— (' fat
Fran
Nom 10 P1. •
T. GROUP: Depth ;etetyl , Meslod
hoe 0 to 3 El
Fran 3 to -to , PI
Flom to P1.
I. SCREEN: bepilt blamelet Slot Size Matehi
Fran To PI. In. __ In.
Fran , to FI.h1. __ M.
Fran to FI. In. __ M.
I. sANUIORAVEL PACK:
Depth Ws Morten%'
tan . to Pt.
From 10 Fl.
Fran to P1.
to P1.
10. MULLING LOU
From To Formation besetiplbn
s— i L GY
tL
I i. REMARKS:
T
c __
ram.
CI i 3 LUUJ
N :P
r—
[
ri
n
I NO NINNY CEntet sHMt llal VALE WAS cdatnUcttO N AceuetrA Ct vm$
' is E It )1_� tAet7►y of iNN
NECOCAI EEN Pn 10 NY�EIE rl r
S=12 -06;
81ONA7lii OF CERTIFIED WE
CONTRACTOR DATE
lov erf CY
PR TED NAME OF PERSON CONSTRUC11N0111E WELL
......__ ...._,m.. ...Nish IN afros All..' LdniwNillNN NI_.

'Altr
1,wttl oNtttActott:
ee
?.11 WENTIAL 111EL1, I.►
Nunlr Dublbm beperlmenl at Ii nvkoouteM nod Nelms( Knott* Dleboloto of WileQdelny
rya Conk la (b,dlvlaudl
NILLEn WELL
Wee Conbacla Comb
StffltAbbatSSp X 5G7
NAYESVILLE slate
Uril 7
a
Coy a 1 own
Ave* Phone number
L WELL INFOKMAtION:
511E W ELl ID e1e ersbcablel�
STATE writ PEnMt Ile WnM°able►—.�-
DWO a otMtn PERMIT Ire applicable)__
U E ICI eek Applicable boa): Residential Meet Supply t�
AMU pmIJ'
RE
WCLLCON TIIACI4 Olt I. tNSIN 3
y. ype
WATER ZONES Wool*
Ftom�-to
Nuns Flom — lb
GNI LING INC • Footo
enyNorm s. CASHIERG. GG From D
N.C� -- Fran.
Fran
WELL S r !g„g 6
bAtt bnititU
tIMECOMPLEttD_�-
N.WELLLot: tION: // �GL
A ave l(e COUNIY_�
Ott:/J /
et * d
Thieete slam
15aN Nana.N
tl tiS
dNa, Learel
IOPOGNAPNIC ASEENO:
EIS o Iselt tlbET Winter
Kind
apMorlon boa)
S' 02•17L
In1NubE .�- 3 5/7- o � �
LONGItU®E — 1S y „I,ngrophie mnF
L>tliluJcllongihrde source: led lIttelbn of rsol most be thew' rm n USGS Iq,o mop rod
eneehed M Vbb roml t tool ON UPS)
A.WELLOWNER `a 2!1 LCw.'S
OVyNEWS NAME h
StttEEtAbt?ttEss 5D 28g0
Stele
NIp Coat
Zip Cale
Clef la town
Areecode • Plays woke
S, wtll bfh AILS!
[L 101ALOEM* 3�
b DOES Visa IttrlACEEXIS1INGWELL? YES II NOte
e.TIMER LEVEL?eke toodcoo* 0 -rt.
Wte'1' N Above top d Casing)
Ft. Above Letd Sotoce'
d. tor or CASING%n algid_ e be ow leie MO loco tntp WOO
top d eetlntl
e,rorynteMreeotdetttewllhf6ANCAC2C.S1 A.
t'tau Wpm): 1Z--MOH® ortESt /¢_
Ahoy le In diner!•
Hertel, steeds a
le s decimal rate
t o_
1 onoU : t Depth
to
Lill_
From_
Fran,
From
Depth tean,elel
to JAL
to FI.
FI.
Amount
da d
_Ft. Ze
Fran�._teal, FI.
Frana� _te —Pl.,� --
Flan —
i
to
to
to
tllctono/
Tv,'
Mded
Wel IA
sizl�
O. SCNEEN: be110
Fran
Fowls •__to.�
Flan ----
t. sAtitontffiVELPACKt
Depth
France to
From To
Flan_ ttl
10. DRILLING LOG
Front '10
11. IIEMAILK51
blander ski sivi
rt._M.
F1.__M.
t1.,
FI.
Site
In.
M.
MaterM
1"s
Fonnalbn beserlplbN
tdN HNroMos. Ne111N1 Ator of Me
too metro teflon'Met flits welt MI OS CdrolnUCttn N ACCOrlrletti tpfi
tootsiloUc
p8 oKee o0041le ENFFROu10E0101tlWWI OWNER.
91
NA1
FIINIE
AME OF
p_7o-n6
EOF CER1 IED vial NNAG10R lE
•
tect
EN80N CONSINUCt LNG 111E WELL
dlblt Mel.,
row GVl
Hri. ilea
settSubm the oike1C,n,tt - lDivision DI Inlel& "HO 2T599 {o17 alllMon* No. 1911331015 i1116 M.
self malt Strike Wirt

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resource!- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H d yO re
1. WELL CONTRACTOR:
Wen Contractor (Individual) Name
MILLER WELL DRILLING INC.
Well Contractor Company Name
STREET ADDRESS P - D t BOX _ —
HAYESVILLEI N.C. 28904
City or Town Slate
g( 28)- 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID N01 applicable)
STATE WELL PERMITN(a applicable)
DWG or OTHER PERMIT N(i( applicable)_
WELL USE (Check Applicable Box): Residential Water Supply Dy
DATE DRILLED 80
TIME COMPLETED ram— AM fir<M ❑
3. WELL LOCATION:
CITY: a4Yc S�//G
I �4Kuc / /3r ' f o /'emit
Obese Name. Numbers. Community. Subdivision. lot No Parcel. Zip Code)
TOPOGRAPHIC I LAND SETTING:
t °Valley riFlal El Ridge oORher
(check appropriate box)
LATITUDE j_ C O( ' / b(
LONGITUDE /D
U 3
Latitude/longitude source: (md,PS OTopographic map
(bcalbn of warms( be shown on a USGS Iopo map and
attached to this Ism N not using GPS)
4.WELLOWNER //��
OWNER'S NAME KOrxgr H1/4-Kf
STREET ADDRESS 3o Zz— N<< (k+A/t/ (xq._
Zip Code
COUNTY cif,/
IMay be In degrees.
minutes, seconds or
in a decimal Format
City or T
eSO. )'I)1/('. Z $`q
Stale Zip Code
Area code�Phone number
B. WELL DETAILS: i
e. TOTAL DEPTH: �
b. DOES WELL REPLACE EXISTING WELL? YES o NO E�
c. WATER LEVEL Below Top d Casing: LT 0 FT.
(Use "e' 8 Above Top of Casing)
l
d. TOP OP CASINO IS 1 FT. Above Land Surface'
'Top d casing terminated elks below land surlace may require
e variance In accordance with 15A NCAC 2C .0118.
e. YIELD 19Pm):__ojt_METH000FTEST / 2
•
OWNER
MWD
tier'
1. DISINFECTION: Type Ifni Amount 7Z Cal'
0. WATER ZONES (depth):
Fromm g s To 97 From To
From 2 IPS To Z C From To
From to From To
6. CASING: TNcknessl
Depth plaiteler Welght Material
From O To FL ra 4' SORZ/ OOG
From To FL
From To PI.
7. GROUT: Depth Material Method
Fromj__To 3 FI. cIPTln�d /i/2
From 3 To ZO PI ', e 79,112
From To FI.
8. SCREEN: Depth
From To
From
From
Diameter Slot Size
F1.In.
To PI. In. _ M.
To Ft In. In.
9. SANDIGRAVEL PACK!
Depth
From To
From To
From To--
10. DRILLING LOG
From To
11. REMARKS:
Size Material
Fl.
Ft.
F1.
Material
Formation Description
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W1r4
TM 14CAC 2C. RECORD HAS BEELL CONSTRUCTION STANDARDS. 11fRWIDED TO)'WEU. OW1ER. ilNiACOPY OF THIS
SIGNATURE DF
q-1-o6
DATE
�h�lln Rae« '
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 566.'

? 3 en v0
o,
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envkontnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION SI ? 1
1. DISINFECTION: Type
WELL CONTRACTOR:
Reece/
Well Contract (Individual) Name INC
MILLER WELL DRILLING
Well Contractor Company I
ame
STREET ADDRESS P.O. BOX 567
HAYESVILLE, N.C. 28904
City or Town
Stale Zip Code
BL?8 - 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mil applicable)
STATE WELL PERMITN(a appllcablel
DWQ or OTHER PERMIT 1(il applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED___
RILLED AM 0 PMlu
TIME COMPLETED
3. WELL LOCATION: /IO COUNTY G
CITY: f} t P 1-1�-----
to 9 .c mu subdivision.
t-
(Sheet Noma, Numbers, Community, Subdivision, Lot No., Parcel, Zp Code)
TOPOGRAPHIC 1 LAND SETTING: a❑Other
de []Valley ❑Flat O 9
(check appropriate box)
LATITUDE 2. � r
LONGITUDE � •� o ra Iric Wrap
PS nTop 6 P
Latitude/longitude source: map and
Vocation
toµlll must be shown on a hb fain f not us Ig GPS) GS lotto
May 1x In degrees,
minutes, seconds or
Inc decimal format
A. WELL OWNER CKf
OWNER'S NAME a bra— t302-� A'�
STREET ADDRESS ) Z s f O
-e
City n ov+n
Area code • Phone number.
S. WELL DETAILS:
a. TOTAL DEPTH: �'� NO
b. DOES WELL REPLACE EXISTING WELL?
YES
S 0
c. WATER LEVEL Below Casing.
b Top d Casing)
(Use'+ N Above lop
d. TOP OF CASINO IS FT. Above Land Surface'
'Top d casing terminated atla below land surface may require
a variance In accordance vdlh 15A NCAC 2C .0116.
Slate Zip Code
g, WATER ZONES (depth):
Fran�To�__
Fromig_—. To�
Fran To
6. CASING: Depth� //�1
From_ Tom'-= Ft..
From To Ft.,
From To Ft.
From
From.
From
OWNER
MWD
NC�'
Amount
Material Method
T. GROUT: Depth
From
© To2_FI.
flci_ Mfg
Fran3�T_ To 20 FI. c av r
From To Ft.
a. SCREEN:
From
From
Fran_,
T
e. YIELD (gpm) METHOD OF TES
n 30 days. Attn:
tIon
Submit the r0vf ice Center- Raleigh, NC 2 699 1617 Quality
lPhone No. (9 9)133 T015 ext 558. Mgt.,
Depth
To
To
To
9. SANDIGRAVEL PACK:
Depth
From To
FromTo
FromTo
10. DRILLING LOG
Ftom To
11. REMARKS:
Formation bescriplbn
IHEREBY CEA?Enits W,
ACCORDANCE
ISACAC2C. CNIR RIM &CWTor
THIS
RECORD HAS fN VROVIDE E OVINE
SIGNATURE OF Gtnt rrrc • • -- -
PRINTED NAME OF PERSON CONSTRUCTING THEW WELL
FrnnGW-ia
Rev. T105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3327
1. WELL CONTRACTOR:
CALVIN ROSE
Wen Contractor (IndMdual) Name
ROSE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS 7621 NEW HWY. 68
MADISONVILLE TN 37354
City or Town State Zip Code
L423 )- 442-3431
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID t(if applicable)
STATE WELL PERMITII(if applicable)
DWQ or OTHER PERMIT#(if appncable)
WELL USE (Check Applicable Box): Residential Water Supply ❑x
DATE DRILLED 01/05/06
TIME COMPLETED 2A0 AM ❑ PM El
3. WELL LOCATION:
CITY: HAYESVILLE COUNTY CLAY
LOT 63 CHATUGE HEIGHTS
(Street Name. Numbers, Community, Subdivision, Lot No.. Parcel, Zip Cede)
TOPOGRAPHIC / LAND SETTING:
g(Siope ❑Valley 0 Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 02.665N
LONGITUDE 83 45.933W
Latitude/longitude source: EGPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL. OWNER
OWNER'S NAME PATRICK TUCKER (D.M. REESE CONTRACTING)
May he in dcgrm,
minutes, secondsm
in a decimal format
STREET ADDRESS
HAYESVILLE
PO BOX 883
NC 28904
City or Town State Zip Code
L828 )_ 389-3388
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: g00'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO pl
c. WATER LEVEL. Below Top of Casing: FT.
(Use '4" I Above Top of Casing)
d. TOP OF CASINO IS 1.5 FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance it accordance vith 15A NCAC 2C .0118.
e. YIELD (gpm): 1/3 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/htf�Iyf�r
From 0' Depth
93' R. 6 nu ter 5��21 PVC ial
From 93' To T00' FL 6 /14 .188 STEEL
From To Ft.
7. GROUT: Depth Material
From 0 To 20' Ft.CEMENT
From To FT.
From To F.
Method
GRAVITY
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. b.
From To Ft. in. in.
From To Ft. in. In.
9. SAND/GRAVEL PACK:
Depth Sae Material
From To Ft.
From To FL
From To Ft.
10. DRILLING LOG
From To
0' TO 75'
Formation Description
DIRT/GRAY SHALE
75 TO 100' GRANITE
100' TO 900'
11. REMARKS:
GRANITE
CS7
G
I CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUC1U4 STANDARDS, AND THAT A COPY OF THG
RECORD HAS BEEN PROVIDED TO THE W ELL OWNER.
S 2hv, 4/2+'
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PFRSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: IhfonnatIH K E I V E D
1617 Mall Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ert 568.
FEB 07 2006
01/09/06
Fenn 3W-1a
Rev.:105
Asheville Regional Office
A:nuifer Protection

ESIDENTIAL WELL CONSTRUCTION RECORI
North Carolina Dcpan , ..,,t of Ens it°, lent and Natural iesourrr_s-
WEi L CONTRACTOR CERTIFICATION # ,)4'o 4
S. WELL CONTRACTOR:
)QwfPS i�L L& \Son
WWI Contractor (kWivldLvd) taame.
l&lilsnYt\ U Q1l
Well Contractor Company Name. t
EET ADDRESS ,cOn 1 3..31 1 SOY) RA.
cci-DLnn 'PLC , s s49a
City or Town State.. hip Code
+ �a8 )- -046
Area cote- Phase number
2_ WELL INFORMATION:
SETE WELL ID Hit applicable)
STATE WELL PER:IAT#(tl OppUcabe)
DWQ cr OTHER PERMIT #Qf appir Se)
WELL USE ,Check Applicable Easy Residential'Hater Supply yi
DATE DRILLED .1 I D + 0
TIME COMPLETED I ) DO AM.❑ PM.—
3. WELL LOCATION
�7Tv.$FQSTtI LOA counTrf' eir4
Civ1Pl
(Striae .. - s. Community, Subdinion, lat No.. Para, ZIP
TOPOGRAPHIC !LAND SETTING:
❑Slope °Valley ORES Page 0 Other
(check apptinalesetoai
LATITUDE 3
LONGITUDE
May tx in degr
minutes, S< O
in 9 decimal fn
LatitudetIongimde source: OUPS °Topographic map
(location of reel must be shown on a f1SGS fops map end
attached to 1hi form d ndrusing CPS)
4. WELL OWNER Wilt
\ (t
OWNERS NAME W ilt GI Wi
STREET ADDRESS.47$ 14is
Syacc,- 4Y) N.G ,)Srrro)
City or Town State
( sr r S SI -5yaa
Area code - Phone number
5. WELL DETAILS: 7�cc
a. TOTAL DEPTH: .lts1J ,
b. DOES WELL REPLACE EXIST'
e
Zip Code
LL7 YES ❑ NO [Y
c. WATER LEVEL Below Top al Casing: G„D'
(Use'*" rf'Abom Top of Casing)
d. TOP OF CASING IS I. FT. Above Land Surface'
'Tap of easing Selntitated at/or below land surface may require
a variance in accordance with SSA NCAC 2C .0418.
e. YIELD(gpm): 4 METHOD OF TEST Ill`rQ.
L. DISINFECTION: iPpe lj ,f �Q Amount
g. WATER ZONES (depth):
F•an To Fran To
From 1'o From
From To _ From
6. CASING:
To
To
Depth Diameter
Flan- 0 To I SSOL Ft. 6,36
From I St r To _p_q__ Ft..i9iQ __
From To Ft. _
Material
7. GROUT: Depth
Frwn 0 To. 3 ` Fi. %0 L.
cren ,:S' To at' Ft ii w l ■•
Frost To FS
Thickness)
Weisel Material
S42% t'c
�14y 5*t'et
SCREEN: Depth Diarnate S't$ize
Front To Ft in.
From To Ft in.
Front To Ft in.
Ca RAVES PACK:
Depth
From To Fr
From To Ft.
To Ft.
O. DRIWNG LOG
From To
Size
method
PressorQ_
?nr SS(A rQ
m
Formation Desaiptann.
%eA. clay
(Intl Poc i1 CtC1'
Gran'A e
-RECEIVED
Asheville Regional Office
--Aquifer-Protection
. REMARKS:
0
BY CERIWYTNAT THIS WELL WAS CONSintCTED N ACCORDANCE WRN
2C, WEU. CONSTRUL NUR STANDARDS. Ate NEAT A COPY OF THIS
E;CORO HAS SEEN PROVIDED TO THE WELL OWNER
- I 0-1262
TUR£ OF CERTIFIED WELL CONTRACTOR DATE
LSc-fvncwiles) n
PRINTED NAME OF PERSON. CONSTRUCTING THE WELL
2 14j 0/WM

RESIDENTIAL WEY.t. CONS l atot I
North Carta Depanmact of Envit',rae un and Naomi ltcsotrcct- Dtvisirutr of'katet Quality
WILL CONTRACTOR CERTIFICATION is 4240q
i 1. WELL CONTRACTOR.:
DC]V✓laS IR uJiltnn
Weil Ceram: u h twtuati Nam?
it`1 �J� _LX\o 11 D ;11
Well Contractor Company Name
STREET ADDRESS ...61) G),/Srsn R J
74-r ss+'Ft.3a N.C1 2 Cr
City orTo.vny /State Zip Code
SS2S1-
T/�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ant apatitabie) STATE WELL PERMITMc applrcawe)
DWQ or OTHER PERMIT /kV sppg abWe)
WELL USE (Check Appboable Bex): ReSdental Water Supply 03�
DATE DRILLED I - I -ineo
TIME COMPLETED LI:Oo AMO PM
3. WELL LOCATION:
CITY: V�.svl II $
c. s+
0 tar 4
Clu”
(Shoat asmbarx. Community, Subcerowo,
TOPOGRAPHIC / LAND StI INC:
IMSrope °Valley ❑Flat IRidge: ❑Other
(check appropriale box)
LaTtTUDE 3
LONGITUDE
Q. Parcel, Zip Cpda!
May be in degrees,
minutes. tons or
in a decimal format
Latitude/longitude source: QGPS °Topographic map
rotation of ettql must be shown wt a L'SGS top° map and
attached to this form f not using GPS)
4. WELL OWNER T
OWNER'S NAME CORP / ocik - y
STREET ADDRESS tlacf., L:h p5fp�fed
Vol P4 3f)s1 a
City a Teem State - Zip Code
( 70(4)- 7Sr/- ,2702/ -
Areacade. Phone n:taw
5. WELL DETAILS:
a. TOTAL DEPTH: 1 SJ t
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ele-
c. WATER LEVEL Behw Tap d Casing. 4201 FT.
(use '*• if Above Top of Casing)
d. TOP OF CASING 15 1 FT. Above LAM Surface'
'Tog of casing terminated at/a below land surface may require
a variance in accordance with 15A NCAC 2C .0118.fr
e. YIELD (gpm): 1,5 METHOD OF TEST4
f. DISINFECTION: Typal:nigh a Amount gm
g. WATER ZONES (depth):
From To
F-rn To
From To
6. CASING:.:
From To
From To
From To •
Thickness)
Depth t Diarneter Weichr Materlaa
From p To 40 FL(, 025 S01-21 PYC
From Tn Ft.
From _ To Ft.
7. GROUT: Depth Material
Fran 0 To_.:IL • FtWe
r m,,�1
From 3c To .Q'. Ft,a. e
Flan To Ft
8. SCREEN: Depth Diamewr.:..
From To R.
Front To Ft. - in.
From To Ft. in.
Method
See
tn.
in
9. SAND/GRAVEL PACK:
Depot Size
Fran To Fi.
From To Ft.
From To. Ft.
ie. DRNUNG LOG
From - To
MAR 0 8 2UU6
to
er r Tectio
Modal
Formation Desu'rytic n
MARKS:
O1
I ODHERE mY CERTFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WIFE
t5A NCAC 2C, WELT CONSTRUCTION STANDARDS, MC THAT A COPT:OFTi95
RECORD HAS VEEN PROVIDED TO THE WE' .OWNER,
STA.0 /z74.`l0n- 1 a/ flip
TURE OF CERT/FIED WELL CONTRACTOR - DATE
VYL I<An
PRINTED NAME OF PERSON CONSTRUCTING THE WELL

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resou
s --�Division
of Water Quality - Groundwater Sectiosj
WELL CONTRACTOR (INDIVIDUAL) NAME
.(print) & at • I t't' erL._AS� CERTIFICATIONO�•
WELL CONTRACTOR COMPANY NAME 4 "t U' U bQ LL 'L' —, PHONE a rr of Nq R (
CC -
STATE WELL CONSTRUCTION PERMI # ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I3' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCA
T
(Street
3. OWNER:
Address ,
Community, Subdivision, Lot No., Zip Code)
City orown
Area code- Phone number
4. DATE DRILLED n UP i 'b' cilia
5. TOTAL DEPTH.
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO II
7. STATIC WATER LEVEL Below Top of Casing: a' FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ` FT. Above Land Surface*
'Top of wing terminated atter below land surface requires a
variance In accordam with ISA NCAC 2C Silt9. YIELD (gpm): _ MEIHODl OF TEST "in--
10. WATER ZONES (depth): 'i `s
ographic/Land setting
dge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
aR �(o.) 04
State �jt� Zip Code
11. DISINFECTION: Type 'tom Amount
12. CASING: ]]����;ee Wall Thickness
Weight/Ft, rial olt
From 0 To
tip3 Ft. tDrtrr 7.( numbers names.
From To Ft.
From To Ft.
13. GROUT: Depth
From C) To Cn% Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft.
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Foription
DEPTH
From To
O So'
WV
16. REMARKS:
•
LOCATION SKETCH f'
Show direction and distance in miles from at Est
two State Roads or County Roads. Include theoroad
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, A'''��N``,D///T/HAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE OWNER
4.7 c_ SIGNATURE OFPERJON COgT$lam15LL DATE
Submit the original to the Division of Water Quabty, Groundwater Section, 1636 Mall S nice Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days MAR 2 7 2006 GW-1 REV. 07/2001
Asheville Regional Office
9(3 DID

0
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
nnNatu,rr�a1l1''Resource DivisionofWater Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME. (print) 1.:.4�1 -S G . 1-LL CERTIFICATION
�/�!✓/
WELL CONTRACTOR COMPANY NAME t31t1YG sht.LE a' YtU. U PHONE M 30- 9/&C
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
f1
t
1. WELL USE (Check Applicable Box): Residential R"Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
3. OWNER: '�
Address 6-%0 "or Ro
I�11[siitil-(,0'`` v�7n..o
e�
City or
Area code- Phone number ..,,I
4. DATE DRILLED
y40%
5. TOTAL DEPTH.
State Zip Code
/
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 t FT. Above Land Surface'
'Top of wing terminated at/or below land surface requires ■
variance in accordance wit ISA NCAC 2C .0118.
9. YIELD (gpm): MET(iQD 9F TEST
10. WATER ZONES (depth): 11((0.0
"Topographic/Land setting
IBRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DRILLING LOG
Fonnajion (description
DEPTH
From To
0 5
S' 23
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
@p er or Wei t/Ft. atf�lal
From 0 To Ft. i SDl?� 4 C v
From To Ft.
From To j� Ft.
13. FroO�To To £ "0 FL t
Malarial
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Slot Size
in.
in.
Material
Size Material
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WIT WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,
CONSTRUC3'ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WE OWNER
7i49A�/1.-�
SIGNATURE OF PE
ON C
9TEl i
SATE
Submit the original to the Division of Water Qu lity, Groundwater Section, 1636 Mall erviee Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 da s. MAR 2 % Zn(�� GW-1 REV. 07/2001
Iheviiie Regional Office
Aquifer Prntor+i.,..

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�Resource,s - ivissyioon�oof Water Quality - Groundwater Sectiioonp!
WELL CONTRACTOR (INDIVIDUAL) NAME
(p-rr�i,nt)�t)` ^C.\ C)4° �. `j't eF-yam-. CERTIFICATI{ON#2?
WELL CONTRACTOR COMPANY NAME WitiL"��•u� WE1.k" Ws) PHONE # y{v of 3g9r41
.55
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential L9' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
N .. To
(Street Name
3. OWNER:
Address
City
Am codnumber ?Dt
4. DATEE DRILLED a� `�
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO H
7. STATIC WATER LEVEL Below Top of Casing:�I•.
(Use '4" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
"Top of cuing terminated at/or below land surface requires a
variance In accordan a with ISA NCAC 2C .0118.
9. YIELD (gpm): 5 MEjOR OF TEST
10. WATER ZONES (depth): `' 1�{
Subdivision, Lot No., Zip Code)
State Zip Code
11. DISINFECTION: Type t t M Amount
12. CASING: Wall Thickness
t¢, Dialect; o W t/Ft. All
From.Q_ To bd-1 Ft. l0 / 4 g .
From To Ft.
From To Ft.
13. GROUT: Dept Ma
Frown b To \ri Ft.
From To Ft. i
14. SCREEN: Depth Diameter
Frottt To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Froth To Ft.
From To Ft.
Slot Size
_ in.
in.
Material
16. REMARKS:
/ Topographic/Land setting
ttidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH
From To
0 at
15-1
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Includ the road
numbers and ommon road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARD, AND THAT A COPY OF a RD HAS BEEN PROVIDED TO THE LL -
,t0 A-5 it i4 r114,._-_
/ SIGNATURE OF PERSON 1 ONSTRUCTING 'C " n a ATE
Submit the original to the Division of Water Quality, a roundwatHttRctMri,1 $fail Servlc Center -Raleigh,
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 0"
Asheville Regional Office
Aquifer Protection

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - ivission1 of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME `` (print) `` 'r4r C-� . ` \ CERTIFICATION tlr/
t�i
WELL CONTRACTOR COMPANY NAME i. `u� l-.h"�.l._%> ^1C-) PHONE s MAce1 9 \SS
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential a Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL ' ON:
kriat
(S e, Numben, , 14'. Subdivisi • Lot No., Zip Code)
3. OWNER: ,►
Address
or Rea,�o.
1�'V)rym$o n_%ci�0 Zip Code
Area code- Phone number �� 1 p
4. DATE DRILLED `
5. TOTAL DEPTH: POST
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO LI
7. STATIC WATER LEVEL Below Top of Casing: (.ot) FT.
Wee "+" 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 1SA NCAC 2C .0118.
9. YIELD (gpm): \ MET, OD OF TEST 1O SU
10. WATER ZONES (depth): \%
LA
11. DISINFECTION: Type
12. CASING:
UN"
S
From b To FL 4
From To Ft.
From To Ft.
13. GROUT: Depth
Mceilal
From 0 To n S- FCC Ink A-- E
From To Ft. I
14. SCREEN: Depth Diameter Slot Size
From To Ft. in in.
From To Ft. in. in.
15. SAND/GRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
r Wei (wfp rl}
Material
16. REMARKS:
Topographic/Land'setting
❑Ridge ❑Slope p alley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH a It 1 aA
From To Formatio 1. on
D bi 1
,h' 1S' n41:1 l.!
fls' ems' ,�.„,
O
n
O-1
LOCATION SKETCH
Show direction and distance in miles from at 1 ast
two State Roads or County Roads. Include th mad
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE—L
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO WELL OWNER�
E ("Si gg5 L /4,tJ e �Z.. 0(
SIGNATURE OF PERSO CONS - - - Tl'IIE WEII. DATE
Submit the original to the Division of Water Quality
27699-1636 Phone No. [phone], within 30 days.
GroundwetVettlprlTMail Se
Asheville Regional Office
Aauiter Protection
e Center - Raleigh, NC
GW-1 REV. 07/2001

RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # _� I : 3 I l
1. WELL CONTRACTOR:
Lon 17l i IarcL
Well Contractor (Individual) Name
We adracta Company Name
STREET ADDRESS 14I1%r7 l3L(("_ I& gt_ L)LI
ctlrfviIt9 6A 3L )l.2
City or Town State Zip Code
( t7 (AO* r isk -- Q (tr (n
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(a applicable)
STATE WELL PERMIT#(ifapplicable)
DWQ or OTHER PERMIT#(x applicable)
WELL USE (Check Applicable Bole): Residential Water Supply X
DATE DRILLED .9 - r3 i -CCP
TIME COMPLETED 3 . 3C) AM 0 PM V
3. WELL LOCATION:
CITY: Nr}Kf('/l/iL COUNTY C//1Y
vJgc C.h2,crt Rt iia 2 lz� z
(Street Name, Numbers, Community, Sub: 'on, Lot No., Parcal, p Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope :Valley ❑Flat :Ridge ❑Other
(check appropriate box)
LATITUDE et. Via'
LONGITUDEC+:B'm°5mJ .'% -') -3
Latitude/longitude source: 'PPS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER -� �// �r--/pj
OWNER'S NAME 1L�a l far /.ilo/
rnt
j$TTREETADDRESS 170 I ��t&i- r i k_rt
T'4trkkuy{ rL
May be in degrees,
minutes, seconds or
in a decimal format
City or Town / State Zip Code
(9S(( )- c19V• 3orr"
Area code - Phone number
5. WELL DETAILS: +�) — I
a. TOTAL DEPTH: 6oL 3
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO J
c. WATER LEVEL Belau Top of Casing: Gv FT.
(Use'+n if Above Top of Casing)
d. TOP OF CASING IS a. FT. Above Land Surface'
'Top of casing terminated at/ar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1, ' 1 METHOD OF TEST /Y'i
f. DISINFECTION: Type N%H Amount o2 (( 02
g. WATER ZONES (depth):
From 2or 79 /6PA` Fran To
From _fe4rr le .T6F-- From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To if Ft.
From To Ft
Fran To Ft.
7. GROUT: Depth
From 0 To 2 •
Fran To
From To
8. SCREEN:
From
From
From
Material Method
Ft. Cr0frirL'' GOy.< 77'
Ft.
Ft.
Depth Diameter Slot Size Material
To FL in. in.
To Ft. in. in.
To Ft In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
Fran To Ft.
From To Ft.
11- ' From To FL
10. DRILLING LOG
From To Formation Description
/3 .t q 7o, fpf
2r Go H-n?f (2 fact/
a• Jo
N4rO 6,89 f ors
16 .2m1'" Nf+ro erny it+GY
Tor 3oe.
S:> -41- o
G.`eHY trny dCxFf
L:OH t- non /teGy'
2/` A4r/r troy 'Caw°(
11. REMARKS:
AEELI-11F°
2
HSf)c�/Illc; t'te IUl Idl nice
4:7uifcF r r t-CtiOII
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR0HAS BEEN PROVVEOfW THE WELL OWNER
3-/3 w'
NATURE OF CERTIFIED WELL CONTRACTOR DATE
MI9t la // f$Z/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

..+STATE.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Faye°, intent and Halm) Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # eh,
1. WELL CONTRACTOR:
an ua . J�m"se n
Vaail Contractor (Iran atuat, Name
Well Contractor Company Ncime
STREET AOOR��(N SS .�V r /S�/i!- red,
/�2fsS Bi ten ,QY, a
City or Tarn State Zip Code
tX'1—OQ63
Area code- Phone number _
2. WELL INFORMATION_
SITE W ELL ID Mt applicable)
STATE WELL PERMIT/Be amitotic)
DWQ or OTHER PERMIT #`(if v.-cant.)
WELL USE (Check Applicable Box) Residential Weser Supp fy m,/
DATE DRILLED . 4—(j (o
TIMECOMPI,ETED 2; 3a
3. WELL. LOCATiCN:
Ctil (-Oft couNTYdac._
Greo s4}/� Cc-eQk
(strew Name. Nude n, Community, Subdivision. Lot No.. Parcel, Zip Code)
^TO,�POGRAPHIC / LAND SETTING:
213 J ❑Valley :°Flat DRidge. cOther
(check epprerpriate box).
LATITUDE 3
LONGITUDE
0 PM.-
May be in dogreex. 1.
minter. coronet or I
in a decimal foment
Latitude/longitude source: ❑GPS OTopograplltc Tuap
(bcatk,n of weir/oast be shown en e USGS tope map and
attached toll* form not using cos?
4. WELL OWNER
OWNER'S NAME 4A),ac . a
STREET ADDRESS
City or Torn State
Area rode - Priem n Jrn✓Y
5. WELL DETAILS: ^^/
a. TOTAL DEPTH' 1 (/5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO by
c. WATER LEVEL Top d Casing: 64) r FT;
(User" it Above Top of Casing)
d. TOP OF CASING IS. 1 FT. Above Land Surface'
'Tap of casing terminated aUor bee* land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 6 METHOD OF TEST U4 f2
f. DtSfNFECTION: TypeichlWalpisAmrnent f
g. WATER ZONES (depth):
Freon To Fran To
From To From To
From To
From To
6. CASING:.:- Thickness(
Depth Diacnne r Wekmt Material
From 0 Tour FLrne2S SDri4 p1/(.
From To Ft
From To Ft.
7. GROUT: Depth
From 0 TO gnr� Ft;
From .7j To tie) F
From To
8. SCREEN: Depth (Diameter,-. Sbt52e--
Frotn To Ft. in. : in.
Fmrn To Ft -. in. in. From To Ft in in.
9. SAND/GRAVEL PACK:
Depth
From To FI.
From To Ft.
From To. Ft.
10. DRILLING LOG
From To
tfl'
tor`— 31'
3) r
et
Size Martel
Format n Des
IQ(
?-Erin
RECEIVED
2
Asheville Regional Orrice
Aquifer Protection
11. REMARKS:
� d roc 1
100 HERESY CERTIFY THAT THIS WEU, WAS CONSTRUCTED el ACCORDANCE WIP
iSA NCAC 2C, WELL CONSTRUCTION STANDARDS AND 'NA'rA COPY: OF ' NS
RECORD HAS SEEN PROVIDED TO THE W EIL OWNER
CERTIFIED WELL CONTRACTOR
ram`
l Sr Milwai IA'iIcon
PRINTED NAME OF ttERSON CONSTRUCTING THE WELL

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envitnt and Natural Resnirces- Division of Water Quality
WELL CONTRACTOR CERTIFICATIONS 290 (1
1. WELL CONTRACTOR:
:Twos 140)1 SCt111
Wed Cortractoru pndivcfuai? Name
1ADSCIA wen t7r,Il: nOk
Well Contractor Company Nine 1
STREET ADDRESS S SC L x V son Ti Ct t
13mcSTOtir1. t1.e s40a
City or Town State Zip Code
' 3t—t)G&3
Area code- Phrase number _
2.WELL INFORMATION:.
SITE WELL IDk(Happlicabe) STATE E WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(it ate atilt)
WELL USE (Chem( Applicable Boxy Residerrtlal Water Suppty O/
DATE DRILLED,Q -Pc.- 04,
TIME COMPLETED t Oc AM PM rr
3. WELL LOCATION:
CITY: 17rQSS f COUNTY`/t
14-
(Sweet Name, wwnnbjj• Community. S zbdknan, Lot No.. Parcel, Tip Coda]
TOPOGRAPHIC t LAND SETTING:
❑Slope: CIValey °Flat °Ridge: °Other
(check gpnipoats box)
LATITUDE 3
LONGITUDE
May be in degrees,
mini es. exoner or I
in a decimal farina(
Latitude/longitude source: OGPS °Topographic map
(I cation of wed must be shown on a USGS topo map and
attached to thi' Jmm I not used CPS)
4. WELL OWNER
OWNERS NAME jAV , - 11
STREET ADDRESS
City or Tcn*n State - Zip Code
Area code - Phale nurn:Dr.
S. WELL DETAILS:
a. TOTAL DEPTH: p q S r
b. DOES WELL REPLACE EXISTING WELL?
YES NOp/
c. WATER LEVEL Below Top d Casing..170 FT.
(Use "+" if Above Top d Casing).
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Ttp of casI g temilnated ails bete* land surface may require
a variance in accordance with 15A NCAC 2C. .0116.
S. 'nap (gpm): ,QQ METHOD OF TEST 4.R
f. DtStNfECf)Ott Typea2elleb
g, WATER ZONES (depth):
From To
From To
From To
From
Prom To
10
From To
6. CASING: Thickness/
Depth Diameter
Fron b To I X FL (0, .35
From To Ft.
From To Ft
7. GROUT: Depth eriai
From. l To r F •• ��
From Sr.,. To r2Qr Ft �F.+ifK 4 e
d
Fran To Ftt.
to jI Svc
Method
P
D.
B.-SCREEN: Depth Diameter:: Slot Srzr
From To Ft. in, _ n
From - To. Ft. in in.
From To FL in in.
S. SANDIGRAVEL PACK:
Depth Size Material
Frain To Ft.
From To - Ft.
:. From To. Ft.
10. DRILLING LOG
From To
- I r,
F rmathon Description
Re� (.Iv a
"rand 1-�va
Ito
Ih' '
t to - j k5' 'raft
RECEIV
APR1 t ;tn
rtr;'. lawn
Asheville Regional Qfficp
tect
I. REMARKS:
I DO HERESY CERTIFY THAT 114S WEtl WAS CONSTRICTED N ACCORDANCE Wrn4
ISA NCAC iC. WELL CONSTRUCT/ON STANDARDS. AND INAT A CORY.OFTWS
RECORD HAS SEEN PROVIDED TO THE VEVA/OWNER.
Qa Q . Lt_1 C.arvt\. a -o 6
SI UR£ OF CERTIFIED WELL CONTRACTOR DATE
rM I0,'SCIn ..
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
4

6
1. WELL. CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Enveonment and Natural Resources- Division of Water Quality
WFT.T CONTRACTOR CERTIFICATION #
Me.u2 P. 'L I arc@
Well Contracts (Indhidua0 None
YEPS wc-c_c_ D2(C1-IMG INC.
Wel Canada Company Nane 'r
STREET ADDRESS 12C7 RLcIEQQDG . I4UV
j A-(2SVILL C2 (I
City a Togo State Zip Cede
006 )- 74 S 2.160
Area code Phone manber
2. WELL INFORMATION:
SITE WELL ID #(a applicable) 43
STATE WELL PERMR#(eapp icase)
DWQ a OTHER PERMIT #(if appicable)
WELL USE (Check Applicable Bap: Residential Water Supply ❑
DATE DRILLED (r23-c6
TIME COMPLETED S ro AM 0 PM (9'
3. WELL LOCATION:
CITY: GJ 2.1214 G cowry C L-8i/
T )C R vat( C_y
(Sheet Name, Number, Community, Subdivision, lot No., Parcel, Zip Code)
TOP IC / LAND SETTING:
°Valley oF)at ❑Ridge °Other
(check appropriate boot)
LATITUDE �ILLC1 ° S?. SY 7
LONGITUD(LvO23 a C2, /
Iatihtde/longitude source: °Topographic map
(bcatbn of we/must be sham on a USGS typo map and
attached to this form #not using GPS)
4. WELL OWNER jam
L OWNER'S NAME on E'ouV\�r;,i it
May be in degrees,
musts, seconds or
in a decimal format
STREET ADDRESST1e
�G4-44z\m csan WI- 01
City or Town Staid ZIp Code
(hlDt) %3?,-2a.(--
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Beim/Top err Casing: fr O FT.
(Use •+• B Above /T/o'�p of Ceara)
d. TOP OF CASING IS OL FT. Above Land Surfae
"Tap of casing terminated atkr below lad steam may require
a tralatce In acconlance with 15A NCAC 2C .0118. /1
e. YIELD (gpm): 2 METHOD OF TEST
f. DISINFECTION: Type ,4 /7# Amowtt
g. WATER ZONES /,
From✓dam) To (d om To
From To From To
Fran - To From To
6. CASING:
Depth r
From`t2 To SO Ft
From To FL
From To Ft.
Thickness/
Material
s'r�--
7. GROUT: Depth Material Method
Frem_2()___ To S] Ft oQTt240,3± U1H,Q C2
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Sid Sae Material
Fran To Ft. in. In.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK
Depth
Frain
From
From
To FL
To Ft
To Ft.
Size Material
33
10. DRILLING LOG
From
-
S`4.e, — rats
/S
11. REMARKS:
Formation Description
Cte-sr)
-7aa1 SaAka flack
CPRQ 6.k_nFn /ixle
PM( Fr29.f/ w/a,a4rm /c2
4 r /2.e �-ccr w/2.DA fici
)?A!&
2xZkB2al'.f B wrfni,cq
£D p K c 2p
ro f. ._
:i
100 HEREBY CERTFY "MATINS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUC ON STANDARDS, AND THAT A COPY OF THIS
BEEN PROVOED TO THE WELL OWNER.
Ai/1
SIGNATURE CERTIFIED CONTRACTOR
PRIN�NAME OF PERSON CONSTRUCTING THE WELL
( f l-o6
DATE
Submit the original to the Division of Water Quality within 30 days. Attu: hrfonnatlon Mgt,
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fam GW-1a
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3175
1. WELL CONTRACTOR:
i=.2P�J7 VtC-To2
Wet Caaractar (Individual) Name
eYCRS UJC-LL tt dLU MCC C
Wel Contractor Company Name I
STREET ADDRESS \2(i 1 U E1� 21E f -i iJ Y.
NattzSv(LLe Gs& 30sty
City or Town Stale Zip Code
()- 7VS -216'2
Area code- Phase member
2. WELL INFORMATION:
SITE WELL ID$(d applicable) 2
STATE WELL PERMIT7(eappiable)
DWQ a OTHER PERMIT KW applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED CP -22 -Qc,
TIME COMPLETED I C/ : 30 AM ❑ PM ❑
3. WELL LOCATION: CITY: L� e2N-LUN
E cowry CL.S1 r'
2T R V i CY
(Sheet Name, Numbers. Community, Subdivision, Lot No., Parcel, Zp Code)
TO IC / LAND SETTING:
Slope °Valley °Fiat ❑Ridge ❑Otte
(eked( appropriate bat)
LATITUDE /' ,�•. S/6•
LONGITUDEC/I�la ° S2. .S9
Latitude/longitude source: ❑Topographic map
(bcatbn of we must be shown on a USGS topo map and
attached to this tam snot using GPS)
4. WELL OWNER
OWNER'S NAME DO n 1"ULt t1ln
STREET RESS 2w T/ 1 SbUDi at Hwy
Ime3Pach rL 35401
Citya Than State Zip Code
( 5tal). g33 -2265
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: /
a. TOTAL DEPTH: L/ /
b. DOES WELL REPLACE EXISTING WELL? YES ❑/ NO pJ
a WATER LEVEL Debi: Top of Casing: /.7FT.
(Use WIT AboR Tap of Casing)
d. TOP OF CASING IS a FT. Abase Land Surface'
'Tap of casing laminated at/a below lad surface may ren ie
a variance In accordance with 15A NCAC 2C .0118.
0. YIELD (gam): 4 METHOD OF TEST aR
L' 0 •
t DISINFECTION: Type �i77 7JAmount •,! /6
g. WATER ZONES (depth):
Fru /(9'2 • To I/ G3 From To
Fran To From To
Fran To Fran To
6. CASING: Thidmesa/
Weight Material
Fre n"ta To ' v Ft. ( rile r
From To Ft
From To Ft
7. GROUT: Depth Materiel Method
From 0 To -Ca a {b fzn2.0 /2U/Y(%R-uo
From To FL
From To Ft
& SCREEN: Depth Diameter Slot Sae Material
From To Ft. in. in.
From To Ft. in. in.
Fran To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
Fran
Fran
Sae Material
To Ft.
To FL
To Ft
10. DRILLING LOG
From To
0 Cr
11. REMARKS:
Formation Description
gE1J G(252
"7"P Ai SRAnI.Pma.,
6 2S'I etigeTFIeccl1 ✓t2c K
OPA/n—
eppJ eac.4- wlA
6� 2r10,,A
02,2 ec cagy/ X4C.le s,c=
, ,-c.ra 7035V t
Dast•e Zack-
1 DO HEREBY CER1FYn1AT1HLS WELL WAS CONSIRUCIED N ACCORDANCE W mI
15A NCAC 2C, WELL CONSTRUCTIONSTAANDARDS, NC 'P ATA COPY OF INSS
REC BEEN PR 0�OWNER
SIGNATURECERTIFlE
CONTRACTOR DATE
'vz&V/C
PRI TED NAME OF PERSON CONSTRUCTING THE WELL
e
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Servico Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Farm GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Inveoameat and Natural Resources- Division of Water Quality
WF.T.T CONTRACTOR CERTIFICATION it 2 ! 75
1. WELL CONTRACTOR:
V-Qestz, P. Ni(oto
Well Contractor (Individual) Name
BYERS Wet ( 021(LI NC, IrM(
Wei Caltracta Company Name STREET ADDRESS 1261 r ilieatt0c (44.)Y
TL212SV(L(k G2. 3©5(C�
C)ly or Taws State
(Tao } 7L15-aIGG
Area code- Phase number
2. WELL INFORMATION:
SITE WELL ID Mir applicable)
Zip Code
STATE WELL PERMIT#Qr apgicase)
DWQ a OTHER PERMIT 9Qf applicable)
WELL USE (ChecicAppbca lle Ba): Residential Water Supply 0
DATE DRILLED ICAi—IX0-0C
IME
TCOMPLETED /2�l5 AM PM
3. WELL LOCATION:
CITY: (()ENE COUNTY CL2
De---C-1 Warr-y
(Street Name, Numbers, Community, SOWavision, Lot Nov, Parcel, Zip Code)
TO ! LAND SETTING:
❑Slope aley ❑Fiat ❑Ridge ❑Other
(check appropriate bap
LATITUDEI`1_l_q 5 9 /i0
LONGITUDLW O'63524 //J7
Latitude/longitude source: &Kg Topographic map
(bcatbn of Wei must be shown an a USGS topo map and
&/acltedto lit form snot usig GPS)
4. WELL OWNER
OWNERS NAME npi1 rpm -fair,
May be in degrees,
minutes, seconds a
in a dccimal format
STREET NDRESS 2500 aLS'i b i x i . Fk.O9
W9S+440(irn PVCd1 FL ? U)I
�
City aTavn State pp Code
(` .01) 833-�2_055
Area code- Phone amber
5. WELL DETAILS: / 1 i C
a. TOTAL DEPTH: 'J /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Al
c. WATER LEVEL Belot/Top of Casing:
(Use '+• If Above Top of Casing)
d. TOP OF CASING IS FT. Above Lad Surface'
'Top of caskg S7a below lad striate may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (epm): / METHOD OF TEST Pik
SO
Fr.
From
From To From To
From To Fran To
6. CASING:
[ION
IO / Dial"Fran"ta To 7�IhL Ft �
From To Ft
Fran To Ft
ZS •J
G D191NFECTloN: Type I [ Amount
g. WATER ZONES (depth): 7
To • From To
(} 4 k
TN�clmtess/
W 13Tf Sat_
7. GROUT: Depth , �'7 Material Method
Fran Ci To S/ 4. Ft Y
From To Ft.
Fran To Ft
& SCREEN: Depth Diameter Slot Sae Material
From To FL in. In.
From To Ft. in. in.
From To FL in. in.
9. SANDIGRAVEL PACK:
Depth
Fran
Fran
From
Sae Material
To Ft.
To Ft
To Ft
10. DRI W NG LOG
From
To
7
Formation Description
Re ct&)
f % Ta i 52No mock
19
GRP 41 Wfe,GAZto £ocH
100 FRa rrr
lOo
ILS QuaRTZ-
L
ItS 18C1 GRawr w/
`89 355 '172RtrGR2Y (Tam t f1` r 1
655 370 liner Aim./ lope rz t 8tcA tr `
370 .4oC blink Ge.RLe Coc e c)
Quart-
.SlD Zaric Pr2?y is tc c�-;
505 5/0
11. REMARKS:
I CO HEREBY CERIFY 'MAThaS WELL WAS CONSTRUCTED N ACCORDANCE W rti
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IGNATIE OF CERTIFIED WELL CONTRACTOR DATE
avz P 1//croe
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality with n 30 days. Attn: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Fam GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -
Division of Water Quality
WELL CONTRACTOR CERTIFICATION # JOy y
1. WELL CONTRACTOR:
ell Contractor (Individual) Name
Well contan$g4Tiy!t-demeitat bRILLht3, L' .
243 Cr, APIE CLRO' E
STREET ADORES 'v^ LT .A.,
City or Town Stale Zip Cale
( ).gay—L99 ,
Area code- Phone num er
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMITS/(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply$ --
DATE DRILLED (40--- I —o b
TIME COMPLETED AM ❑ PMD
3. WELL LOCATION:
CITY: I- fgLSL)1IIe_-
COUNTY LI'H4
eiv,rtl%
(Street me. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat ❑Ridge ❑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 A nor using GPS)
4. WELL OWNER
OWNER'S NAME .J N eat.
STREET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
c5J; )ice a asp ity or own State Zip Code
Area code - Phone number
5. WELL DETAILS: r
a. TOTAL DEPTH: 3 cs
b. DOES WELL REPLACE EXISTING WELL/ YES 0 NO -Et—
c. WATER LEVEL Below Top of Casing: X V FT.
(Use'+- if Above Top or Casing) ly
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in aacccadande with 15A NCAC 2C .0118.
e. YIELD (gpm): d, METHOD OF TEST ✓
2 "822
(1 V
1. DISINFECTION: Type
g. WATER ZONES (depth):
From To From
From To From
From To From
Amount
To
To
To
6. CASING: Thickness/
From ( DTolh �/ Ft. Di(0 Weight Materialr
From To to Ft. !OJ f
From To Ft,
7. GROUT: Depth Material Method
From 6 To - FL `�rAtAas.- -- pdizA
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 FL 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 r;
0- 2/b
11. REMARKS:
elAY
_?
C�
r-2
c.J
JUL 20 2006
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrrH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
Arbics
SIGNATUJR OF CERTIFIED WELL CONTRACTOR * DATE
vI'
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 CONTILACTOIl CERTIFICATION N 3 7/
1. WELL CONTRACTOR:
d�nni Qr»&e_
Well Contractor (Individual) Name
LKANt KROIAI.KLaS
Well Contractor Cort2nYai } E CIRCLE
FRANKLIN, NC ";; 4
STREET ADDRESS
City or awn Stale
%jo
(d dd )_ q
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID fl(Ir applicable)
STATE WELL FERMI I M(il applicable)
DWQ or OTIIER PERMIT #(it applicable)
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED (r L"-
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: {�At1est/1
ecU////
COUNTY i
(Sheet ame, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPIFIIC / LAND SETTING:
['Slope [Valley [Mat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GI'S [jai ographic map
(bcation of well must be shown on a USGS fopo map and
attached to this form rT not using GPS)
4. WELL OWNER
May be in degrees,
minutes, seconds or
in a decimal formal
OWNER'S NAME
STREET ADDRESS
City o' own Slate
Area cafe - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
c--
30,5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES p NO ❑
e. WATER LEVEL Below Top of Casing: /r0 FT.
(Use -*" tl Above Top or 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 .01188../
e. YIELD (gpm): METHOD OF TEST 0l//7.-
1. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
From
From
323821
Amount
To
To
From To
Depth Dame,
From 0 To (p.5—FL
From To Ft.
From To Ft.
Thickness/
Weight Material
7. GROUT: 6 Depth Material
From T rt. `n $I'A,-
Nor To Ft.
From To Ft.
8. SCREEN: Depth
From
From To Ft
From To F1.
9. SAND/GRAVEL PACK:
Depth
Fran
From
From
To
To
To
10. DRILLING LOG
From To
Diameter Slot Size
12.(414
rr Method
1 ul
To FI. in. in.
in. • In.
Ft.
In.
Material
Size Material
Ft.
F1.
Formation Description°
0— to ST ('Jr7
Let- 3
11. REMARKS:
G
JUL 20 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. W ELl CONSTRUCTION STANDARDS, AND THAT A COPY OF 71115
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SI
IbA
ATURE 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 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD 3 2 9 8 8
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
Well Contractor (Indtviduai) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHV
NC 28906
City or Town State Zip Code
( 828 )- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(if applicable)
STATE WELL PERMIT/Ur applicable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable BoxC Residential Water Supply El(
DATE DRILLED 07/07/06
TIME COMPLETED AM ❑ PM ❑
3. WELL. LOCATION:
CITY:
HAYESVILLE
COUNTY CLAY
COLD BRANCH ROAD
(Street Name, Numbers, Communes, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ri/alley ❑Flat ['Ridge ❑Other
ll((check apprapdate box)
LATITUDE 3 5 01.900N
LONGITUDE 8 3 44.127W
May Fc in ddorcev,
minute, eaxmds or
in a decimal format
latitude/longitude source: e9CiPS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to th6 form root using GPS)
4. WELL OWNER
OWNER'S NAME RUBY WORLEY
STREET ADDRESS 251 COLD BRANCH RD.
HAYESVILLE
NC 28904
City or Town State Zip Code
( 828 389-4527
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 20°'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO fA
c. WATER LEVEL Below Top of Casing: 75 FT.
(Use'+' A Above Top o( 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 vAth 15A NCAC 2C .0118.
e. YIELD (gpm): 550 METHOD OF TEST AIR
f- DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From 180 To 185.From To
From To From To
From To From To
6. CASING:
Depth Diagmeter
From Cr To 90' Ft. 61/4
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 20 Ft.CEMENT
From___ To Ft
From To Ft.
Thickness/
105S Kt
Method
GRAVITY
8. SCREEN: Depth Diameter Slot Size Material
From To Ftin.
From To R. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOC
From To
0' TO 15'
Formation Description
RED SLATE
15' TO 75' BROWN SLATE
75' TO 130'
BLACK SLATE
Q
130' 10 200' GRAY GRANITE 8 WHITE QUARTZ
CD
I1. REMARKS:
Y(1
C-11 r ni'i
—
BiT SIZE 6.019
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCIXt0ANCE WnH
1 A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THLS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
07/10/06
SIGNATU- •FCERTI EDW LLCONTR' TOR DATE
C
1 I�STftHE.� �t� KE I
PRINTED NAME OF PERSON CONSTRUCTING T E WELL
Submit the original to the Division of Water Quality within 30 days. Attu: Information Mgt,
1617 Mail 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
WELL CONTRACTOR (INDIVIDUAL) NAME(�print) W,\t_fl w�Re. * �� S CERTIFICATION ISOC/`�D
WELL CONTRACTOR COMPANY NAME Nt c9. LLt. uS ..L u-� PHONE �1 '_i_7_SS
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMITS*
(if applicable) Of applicable)
0°rap ry
V r
1. WELL USE (Check Applicable Box): ResidentiaM Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
=:
(Street Name, Nuumb�er,�
3. OWNER: i
Address kn
City or own State
riCit -bi70
Mea code- Phone comber
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
7. STATIC WATER LEVEL Below Top of Casing: CET.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface*
'Top of twang terminated at/or below land surface requires a
variance In actordaiI th ISA NCAC 2C .011& Q
9. YIELD (gpm): 5C) METHJD OF TEST
10. WATER ZONES (depth): 25
1ct
ubdividoq Lot No., Zip Code)
1)(p
Zip Cade
11. DISINFECTION: Type \k l l� Amount
12. CASING: Wall Thickness
Deptl<k , Dlatpeter h UFt. atttial
From b To rj'l Ft. (9_�./ •(, �G
From To Ft
From To Ft.
13. GROUT: Depth Material„
From D To al Ft L 2SL
From To Ft.
6
r.M...net
14. SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Material
Topographic/Land setting
❑Ridge ❑Slope %Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
(degrm/minuteaheconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From Tot Fo 'on Description
A' 10!
LOCATION SKETCI;
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. c—
r
t rI
=t
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 TIjE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
\S Itic)
ATE
0
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

;+ :J 0 4 �g
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (�prlC 1nt) C, Crt�RV- - CERTIFICATIONt rthcl
WELL CONTRACTOR COMPANY NAME Wer(IMX.f PHONE 0 &X) 384.-9/SS
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 LOCA +N:
N Town: county
eff fir.. Itt��1�rrI
Nam
(Street Nabar, Community, Subdivision, Lot No., Zip Code)
411
Street or Ro
3. OWNER:
Address
2 G4
Zip Code
(Cl - ' 19 -4.51.,
City Town State
Area coda Phone number
4. DATE DRILLED 1`t bit?
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: LAD FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface*
'Top of wing terminated at/or below land surface requires a
variance In accordant with ISA NCAC 2C .0118.
9. YIELD (gpm): METODIOF TEST
ZONES
��(o
10. WATER. (depth):
11. DISINFECTION: Type %c k'1% Amount
12. CASING: Wall Thickness
TDeoth pi9> er or Weight/Ft �tatenal
From Ire Ft (o'/4t' '1•!a �1(C.
From To Ft.
From To Ft.
13. GROUT: Dept]?"
From b To la Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
Topographic/Land setting
❑Ridge ❑Slope ]Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation r *scrip ' on
b lb'
lb' taro'
2° t
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers an , common road name
e
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDT,S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OWNER
(2e0 S C OP
SIGNATURE PERSON CONSTRUCTING THE WELLDATE
c_
c+
N
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

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CONTRACTOR (INDIVIDUAL) NAME (print) \ ``+'I 1 F` X y S •� TCEYV�S CERTIFICATION // K 73g
WELL CONTRACTOR COMPANY NAME Fy+^lf•SV‘LL% l '�yLS•-), NA PHONE # {0")a87-9 Ass
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA
N
(Street Name, Number,
3. OWNER:.
Address
County.
(Street 4=.) 2�1 I
City or''T''I
(flJ34. L
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO El/
7. STATIC WATER LEVEL Below Top of Casing: en O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of wing terminated st/or below land surface requires a
variance In accordancvdtb ISA NCAC 2C .0I111.
9. YIELD (gpm): . METHOD pF TEST
10. WATER ZONES (depth): \2 C
Zip Code
11. DISINFECTION: Type ¥( fi
12. CASING: �PTo�}
From b eD Ft
From To Ft.
From To Ft
13. GROUT: Depth
From To
From To
14. SCREEN: Depth Diameter
From To FL in.
Ft.
Ft
Slot Size
_ in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
From To Ft.
From To Ft
Amount
Wan Thiclmess
or c-z 4 12\
Material
"Topographic/Land setting
Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degnxs/minutes/wconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formg(ion Description
DEPTH
From To
4'
4' Br),
So' 17' l
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.
61--•D CD4
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2G WELL
OWNER
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO
Co l l to
SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 072001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourc - ivuion of ,Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CC 12t,� �
WELL CONTRACTOR COMPANY NAME VIS r't J I U-E I.AS U I (2 1 -� /�kC
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# 1
(if applicable) (if applicable)
- Groundwater Section
CERTIFICATION 0 .29.37
PHONE # 3.69 i/CS
1. WELL USE (Check Applicable Box): Residential L9" Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCA
N
(Street Name, Numbers,
3. OWNER:�C&Jt
Address 10S0
(Shot or
} m
Town
Lot No., Zip Code)
,^4511U"
No.) y
L UO(cZ-'
hJ
Zip Code
4. DATE DRILLED
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Fact
7. STATIC WATER LEVEL Below Top of Casing: can FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ' FT. Above Land Surface*
'Top of wing terminated at/or below land surface requires a
variance In accord& ce with 15A NCAC 2C .0118.CU-`
9. YIELD (gpm): _ IvT,THOD OF TEST
10. WATER ZONES (depth): ?t 2
1�1�10
11. DISINFECTION: TypeAmount
12. CASING: Wall Thickness
Depth,10ter or Weight/Ft al
From b To 3 FLLL" .<o PVC-.
From To Ft.
From To Ft.
13. GROUT: Depth Mtrciai
From_ b__ To ctS FC.g-r,
From To Ft. XLl
14. SCREEN: Depth Diameter Slot Size
From To Ft. in, in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FL
Material
Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Forma .n ses•Ution
b 7o'
(POI cis'
9'2' ..01'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Rgad$. elude the road 2-
numbers and common road s
kakt, f (fly
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO OWNER
C 14%LIL c.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
�Rees�ourc Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMEt �(prin�,t�)) Lae"
C= � CERTIFICATION
WELL CONTRACTOR COMPANY NAME W ^ tC7\La ( --A U--( PHONE # pc) 2539 /5c
STATE WELL CONSTRUCTION PERMIT/ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential l"Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA {O
Netyl�J County.
(Street Name, Num
3. OWNER;
Address
City or own State
(-Ou} c6q — isles
Asa ado- Phone number
4. DATE DRILLEDb(P
5. TOTAL DEPTH. 'an '
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO B"
7. STATIC WATER LEVEL Below Top of Casing: \ 00 FT.
(Use "f" 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 accordant(with RSA NCAC 2C .0118.
9. YIELD (gpm): 1 A METHOD OF TEST Q
10. WATER ZONES (depth): Ci11 I
Zip Code
11. DISINFECTION: Type
12. CASING: �P,
From 0 To t4
From To
From To
13. GROUT: Depth
From C To 94 Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK
Depth Size
From To Ft.
From To Ft.
Slot Size Material
_in.
in.
Material
16. REMARKS:
Amount
Wall Thickness
Ft (so
a n pt. _Material
S�We gh��V
Ft
Ft
Topographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degRWminumhecouds)
Latitude/longitude souroe:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fo ..:tio 8 c .lion
DEPTH
From To
b
r14' tf
LOCATION SKETCI;
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road 2
numbers and common road names.
CJ1'a (41 ' tl,sj (n
I(QktI DO HEREBY CERTIFY THAT THIS WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TOOWNER
ESL /,4 A- l eti.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
0(Q
a'
0
c
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION IF c{ V0 y.
1. WELL CONTRA t,1 VK:
CYO VIA es R. ()3; so v-)
Well Contractor (Individual) Nam_
Cikti Son LAP-M. DI v13
Well Contractor Company Name.
STREET ADDRESS ji lcO GC); 1-50n. R
3rCaSstpr.nn NLL', 2290a
City or Town State- Zip -Code
(k2s - 'rS5`t-cxrhb2
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *it applicable)
STATE WELL PERMIT#(v applicable)
DWQ or OTHER PERMIT #(IT applitte)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public a-
Mdustriaiternmercial0 Agricu turato Recovery 0 lniectan 0
lrrigalion0 Other
0 (list use) •
DATE DRILLED / tuX - 3C1-oar
TIME COMPLETEDL? /6'O
3. WELL LOCATION:
CITY: Flaye i1;I)e- -.
(09
(Street Game, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC-/-LAN_-SEfl4NG--
DBrope aVailey ❑Fiat .0Ridge 0 Other
(check appropnate box
AM CI PMW.--
COUNTY (?Jc /
LATiTU27E 3
May beindegsees.
minutes, seconds or
WNGITUDE _ - in a decimal format
Latitude/longitude source: DO'S ❑Topographic map
(location awe/ must be shown an a USGS topo map and
attached to this tom: d no! using GPS)
4- FACLITX- is me name ettesbusiness heremwell is lamed_
FACILITY in A(it applicable)
NAME OF FACILITY?! yl P (rft`N if..-1- Cakti th
STREET ADDRESS tog
limy esvfl/e N.c, as5ov
City or Tom State Zip Code
CONTACT PERSON ,ek . 6 k
MAILING ADDRESS//.<S ? Zit
/1i1111414tSe eWas
City a Town State
( 'O6 )-SQL-ly/(
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 4:56r
b. DOES WELLREPLACE EXISTING WEti? YES Q NO We'
c. WATER LEVEL -Below Top of Casing: 4' N FT.
(Use `+• if Above Top. of Casing) _
7. GROUT:
d. TOP OF CASING IS FT. Above land Surface'
'Top of casino terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): -5METHOD OF TEST 42,/
I. DISINFECTION: Type{//A rest. Amount CP
g. WATER ZONES (depth):
From To
Rom To
From To From To
From To From To
B. CASING: Thickness/
Depth Diameter We(ctt T�t Nial
From D g?)` R. la,.2S Si1r2/ P I/ (-
from To Ft.
from To Ft.
Depth
Fran f&) To gt Ft
From < r To 26) r Ft
From To Ft.
E. SCREEN: Depth Diameter Slat Size
From To
From To
From Ta
9. SAND/GRAVEL PACK
Ft.
Ft.
Ft
in.
in.
in.
Depth
From To Ft.
Rom
From
in.
in.
in.
Malarial
Sivo __ Material
To Ft.
To Ft.
10: ORLLI.'G LOG
From To
0 - tb`
1 b - `ID'
'10 .sist
11. REMARKS:
nnap Fin bock
O
O
Fjormation Description -n
KQA clay,
prClvn�il� a rot it
rT
C_.
1j N
r,.
0
o6
I CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
154 NCAC 2C. WELL CONSTRUC1SON STANDARDS, AND "'RATA COPY OF this
RECORDeMS BEEN PROVIDED TO THE WELL OWNER.
C'r%;vtet a- P,t � . 5- h(e
SIG 4ATURE OF CERTIFIED WELL CONTRACTOR DATE
OF PERSON CONSTRUCTING THE WELL
tnn
PRINTED
Submit the original to the Division of Water Quality within 30 days: Attn:Information Mgt,
1617Mail SeeviceCopier — ,NG27699-1617 Phone He_ (SIB)733791SsrtS&L
Form GW-1b
Rev.7

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
rHL'J6C
1. WELL CONTRACTOR:
WHIC " ontractor�(In •wdual)N�ame C)n
A asn an We\\ (n -
Well Contractor Company Name
STREET ADDRESS 1 "'17GY C • (Ai(
3lc(5o\\\e. GA 3a�')a
City or Town State Zip Code
1555
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 rJ ;a 6(O
TIME COMPLETED AM PM
3. WELL LOCATION:
CITY: COUNTY C \ CA-3
5ceri,c k�catic J
(Street Name. Numbers, Community. Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
la Slope [Valley ❑Flat ❑Ridge ID Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we0 must be shown on a USGS topo map and
attached to this form Bnot using GPS)
4. WELL OWNER
May he in degrees,
mints, seconds or
in a decimal format
OWNER'S NAME
Pn.c %rtaa\\
STREET ADDRESS
City or Town State
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Gy5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use'+' if Above TopTo^of Casing)
d. TOP OF CASING IS d FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
Li e. YIELD (gpm): i METHOD OF TEST • •\D
f. DISINFECTION: Type t L I'l Amount a? OZ
g. WATERnSZONES (depth):
From ,Q D To From To
From LI Db To From To
From To From To
6. CASING: Thickness/
From b Depth
Tol� Ft. Cs fly ter Weight �Materiel
From To Ft. C__.
From To Ft.
7. GROUT: Depth Material Method
From O To Ft. f WeSSLtt-c,
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Ma)prial
From To Ft. in. inrh
in. " p
in. IL �i�<-
(D CD
9. SAND/GRAVEL PACK: -p CD
Depth Size (0 /N
-.3 (Li
From To Ft.
From To Ft.
From To Ft.
From To
From To
10. DRILLING LOG
From To
Ft.
Ft.
in.
in.
Mated
n
a - .SS C,0. Formation Descriptjon aT
'r ,• rtAxAa-
ato- /
L�vnaiAr a 6PO1
g
fori5 i 45
11. REMARKS:
r
•
.� m= 6PJn
o Cm
Cr. �C
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
th-J O
CONTRACTOR DATE
PRINT D NAME • - RSON CONSTR CTING 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

RESIDENTIA4 nu. CONSTRUCTION RTC 0 ItU
North rarohca Department oflammancat and Natural itacrunms- 'Avalon at Wt. Quaky
WELL CaNTRACTCIR CERTIFICATION *
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Fran ' To Ft
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—
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IlliCtliDNAt NNW MOMONDT011411MILL SAM
+444124 e, papw- 06
TIME OF CERTIFS." WELL
1,•1/4.) LSO VI
rem wok of PERIM CONSTRUCTS THE WELL
c
4.-- •

M.Acridn JIFG
City or Toon State rip Col
te) 7- 0963'
Amos* Prow ROWS
a WALL 1111PORIMIllat
MISWELL 11.1111~14
SrAltlina. mans as)
swo ar OTHER Rear AV 'pork!
WILL ME Latecit Auplakkamec Rmiastei Wow Sap* El<
GAMMA) 4- AK- 6
Tatearuned A` /50 • awn- Pal 0
clrr
naLtOCOMICIlk
ye< Late
Pluise Ref
Mantalsto task
TOPOORAPIEC /ONO SETIMit
OSSIOWRostrrit vireo
lansidisbne
Lamm _a_
tairucE •
RESIDENT1,44 WELL CONSTRUCTION SWORD
tlst Camara bowman ofEmmousacut sod Hamm' kaloatars- Limas tif Wait Quality
WELL Ca/flake-MDR CERTW1CA1701.4 * c2 q
1. WELL CONTRACTOR: L 011MFECTIOW Tya Past
)(IMPS I CAM SO in ti. WATER ZONES SWAN.
ves caters Ondoots* Nam
JAM snn c-;11 :43
Wd Corantlor Company Noma
STREET sac) toilson
counrehy oisasa.679ae4
May le depot%
mama mom* et
lasdalwitheit
Lodmisinglimb arm DON oToporpimbicamp
reMortoremilamotim ort talitirpo imp and
Witallsaltaiik tuattatt GIPS
4. MILLIWINER
Women wam penny ,Wo-$S
STREET ADORERS
(Atli Twin Es Coda
Ama tad, - /Maw tatorse
EWELL DETAILS:
a. rout tent 705 '
h. 001111WILL Sr° EITERWS UMW YES NO
C. WATER LIM Ilimaat Cathy FT.
ware Erna Twi STORWEE
11. TORO, MINNIMIS / Nowa Lard
laud 000.1011041111110slailmil asks moysoprim
WOK= aC mitt
. . arse*Yyressicoonarlik,
Rom To
Rom To
Rom To
it. CASIIIM
336380
/ 6
Rom To
FFOOI To
Fran To
Thorns,
Foam b re (16 IFL YO,r von._
Rom To Ft.
Rom To Ft
7. GROUT: Dupla
Rai To
Flat Xi Teat) I.
IL EMS* mph •Ms itt Wm Malint
PIS To; R.
•Ram To Ft. ia. irt.
ROM To Ft la in
I. ifeigliORAVEL Mac
•Dapla
Far' To Ft
Fliam__JTOFL
Frao To Ft. -
ti...allittOS toe
From To
0
ib-
,-.<0 .7es
11. REMARKS:
Size
Mts.
Foffillibft
.Z:0 VI
(77/2 flTP
1"--3
map An I
ttearalliarr 111111111111111VIABCONSWIIIMILIC031110/INCES
IM 1101C VIOLLISILOINISTAIDailloWID IOW Cartergle
SOCOVIONAO INIONMIOCIOMMEVIlisame
gi=ciainviewatii6A-46
TcromeirlThevA cm PA.); ey1oitassucnie
ova ERSON MENEM

RESIDENT1,44 w jut. cot+snevenotr weft
North Camino DgrmOent orEimisnwt and Naha) iiesown - STirito a df war QerthMy
WELL CONTRACTOR CERTLFICATIONa .,%S!D</
t. WELL CONTRACTOR
�a►n�� cZ. A' IkOfl
rem Canaacpr (n wrnii lime
(A)1I i ° CA i( rtrfll.',13
WM Cote Camay Nero
STREET A0°s 5 8 0 Lt,ilisn4
c7 w Al,(1 Erie.)
Ca a Town Stale lip Cade
tga.fsr1-otea
Ara a Photo numbs
•
a MlwiM+ORrATKOt
tiTTEwak c ofertnwetq
STKIEVI LLPfNfHPaedaeAa
DNIQ4rQT1FR P[A tlOt ppiee6lej
FALL OIMLams W* KerinsWrerSopear
TNNL001R! w 4.'et c&O • Auto PM9-
iwtBLLQCAnnt 14/4
/
cm: a
tree, Ieerine.Oee�
To-OK1 MMC/LAM nit
OWEI4 &Aar DEW mks OEM....
IMN•Qd- -
atnttE y —
cbutt /C oc/
Loonies
Dean
fToy k6lport
mina; oast or
iaaesrit
Istlerlsitssid4 *ewe; o7 s
liesl+aetbseaw, o sW
-wo/aa
aMNlapbaetr AS A resrMt
l IIRLa INIER
ernes NAME Penny fl/o ss
=TIIeET ADDRESS
OWorTow 81Ne
Meade- P7ra+e alas
E WELL OETAas:
s TOOL 0 'TIt /025'
h. mat#:Lmum E>oonsMLL? veep Noit
c. WATER Lava. OeriasP Casit /on r, FT.
tam inn SEP IMMO
▪ TOPGPa / • FT. MostadSolo
'Tad -Mlrimi nMspMrUrnre/ •M41.e4we4+t
ouslesrr isMilrf sSM 1M MAC IC. Mit
a 1'M7$4.44* 20 ttt?TNODT1p TRAVI4
L ONNIFECTIOSt Type
s WATER ZONES (depth):
Facet To
Faro To
From To
A. CANES•
R 6; ll f.
JJU0 il
Asm a
From To
From To
From )o
Dense
Fnot h To SO `Ft the eaC
From To R.
Rom To Pt
7- GROUT: Depth
Five To
Rat To ,. #:.
Thiamin
worsol
✓C-
MOS
rturvt
u n4
i met rapt . Moe Mita lAma
Fear Tq_„__ Pt In. Aa.
hook_ _To Ft is
Fiat ___ ToR_r.
%A1OHIRAVEL Mac
Oct Sze Maid
FoaTo R
T R.
Foes To. R
:Sea Los
Ram To roman Dtt s
- l©` C'la
11. REMARKS:
c
Plop Ann 3 cc
/mNNtir TrwTw.Nta7111SCS tICIND.epoteoe01Vand
sIrJC= astanscasti414.1141441,441711mTaairterTMO
AtCOowit telaRaiAomaawA..ame
ikploa + ir`t�wn.Lo OINK �ofr-,WITEE�
WM OF
m+I (A�rIS14 ® ntN1BL

l I. well CONTRACTOR
L C \cn fl
Welt Can n cbSq S} Nora
USLIcluel. t A30.1( Cli't u;
IWe.Caaetfacertpar_Nete
8TR6Eiw°refets 5 g J /3/ /</ n A>r)
3I'-ggstea1I? JV/1 Q2g9
car or T mi ate Zoo Code
1x1x1- 1-69
�ESIAENTIA: WELL CONSTRUCTION WORD
North Caobat Dept- n Arent of mod
d Natural Rants- LtivvSah if Was (Malty
LCONTRACWIR C ERTW1CATIOR.r2'VGC/
33C6'7S
Traci F Poops *Mao
iRIOLEINPCFNIAllONt
WREwEu SO IleoraYN
Malt MR/PENMS•01gobs*
DNQorOT ERPERIET ,s spoons)
wtatORE tcneAApptidraaa: Roils _-. NnwStn*o
ant mule 6 /j--DG
Ttrtnwc3.'36 All❑ Peer/
I, NRLta`C�ATION
art fli4 do.Sd)//a Loiter//may
NJr(7
I�erUsra,letsrew UNe.,YeeeL by two
/LlMO!tR:�
cos*
Saw-Dfle caw
s0NIRRboo)
yams* 2
Losolnume
Itrkits
SIWM . reto &ar
lutist Los
aswewdtsiaSdi Shaheen • USGSltpe>s and
ritW sedieknest 11114tIa1gPS1
l wat.ormen
oWt*WSNa1EDroiany MPS.S
STREET &MESS
(AyaTrot
MerCde• Phan stems
SWELL DEUS -}
a TOTAL atsflt.,! D.S
h. Don tr timer atans Nan rasp Non
c. WATER LEVAL BobsTantesifa FT.
Nee• ittosTlpdtca .)
19IPdafrillif urSkreerbraereboeoar4e
RONIONatIsmtlfGielwtIRMA 1C.SKIS
isTear ETRODOr tar
t ormawacricapt Tppe%r h Pplo toe lb
op. WATER ZONES (depth}:
RIM To
From To
Fran To
I CANNCANNIERN
Free
Front
To
To
m Fro To
Di
ham p Too no' Ft Go
tornobot
Frown To Ft.
fan To Ft
T_ LROVT: Ooplh
qvo �jj; To3'' _,_
Tticknessi
WeirWINO
S.7CllElt DSOs . asosist-skttlfte
from To R. it. tn.
w To Et is it:
Flow To Ft. M.
M.
- -
MSS
W
S. iobRwlB PACK:
Dept stow errraet
Foam' To Ft
Fetat To Ft
Fish TO. Ft.
ta-gOisms LOG
Roca To
10- Chi
bn — ,PCX
lie Rattans:
Fasten
Phi V
DeCrhkrfad RAP
Tos
t_
Map D/? .a4e.
to
ne foramo t a.awopr w..aare_oae:OMeQMM
*MOM ankf tnufIINISIef oaff MIDIwaittartnFaes
SCOW alsaouleewt _ aaaoi.owtot
TUNE Of Val CIONIMICTOlt
oden • ntifIWOr Milt/soh 0 t a.iN. news!.

RESIDENTIAL w$uCONSUL/OWN R CORD
Mont faolma Dcprveent of Enviontocal and Haunt kssomca- Divaian Si Wier Quolily
WEU. MOINTRAC-MR antrunCATiowt * ago y
9'1'
UOVOit
,. Well CONTRACTOR:
1 JDen AS R lam, ISnn
{ yes C1atein, asyneeNem
�1
11f15nn u e(1 1D.r,11:n0.
yea Cantata Coney Nwe J
1 SiwonCMESS 6V Ltd./Son• /'l4
GO' or Tavn State Zdt Cat
r8as'gcY-DC'a3
Aldan.. PROM. nab.
1 wIILISC OATIOrt
WE WEIL ID Ilitnalo}
PATE MEILPERMITe sw talin
DWQ or OTHER now s(1t wi:.lanj
veal USE /Cha's Palest la8sa Rssiarnns *star Soiil' [�
DATE DRUM (ro-/9-O(to
notyOM1at1. /: 30 . • unto PIA
iMIBt.LpCA4lplt
cm: HAy P S V 1)P amain C 4.
f2u3QaLLd" �' QYsslalae,►orast L "tMsn.LMlb.,PnI,&ca s3
Toppompiectuvenot
i3vag and DMit Dolan
o tewi;+bee
um. _.3. _
unarms _
1W be IndeMee%
mina omit or
isatiolonl Snit
Liana melbor-- Ochs amempagoec map
Assen.rresta bwam. LEMtro asp and
aiitatoosb tool rar daty ens
OWNERS NAME i OSS, e n
snort *mass /3. n d vygr .cte
/iM/acv;/7e - f/G n2899V
01110f Tam sate ao Cab
Mote
-
f+tae mace
tWERR DETAILS:
a. TOM. DlTR 242
b. Does Mu wean none MIA VES 1ao
e. wont LEVEL EidanTap ti Caw 60 FT.
Akre *Atblsa Top (flee
d. TWO? P M f - Ft. Atsa tnlrllstr
Kanofcati11s*Slllrtilasl it srhaiai rlrplsa
opal aanatm-e 76A MCAO 7C..M^^7t
a 111Deur /0 aET1bDt7F7nT �t1IQ
R Cgsncil01t T1ps,},Th V'Pll oLS —_-tt lb
WATER ZONES (tiepint.
trove To
From To
Run To
t. rAtrttE
For To
From to
From 3o
Non Dont
Nan 17 •o_ 3_Qkt,ln
Fran To Ft
Frye To FL
7. QRoUT: OettIn
Fran__ To
Hang( To
Peale To
S. SCRUM Dsprl . &iaainar 8t1[ilZtit - _slam
Asti To R In.
Rom To Ft! is
Flaw To Ft
Titaness/
lataiobt Man
Alin L
1. SMEtAVEL PACK.
Dort
Ham To Ft
Futon To FL
loan T1a. - Ft
Size tasa.isl
'>X'iJtlfi LOG
From To
0— ID
In - lone
Ieb' - lade
Nan - ass'
1 i. REIKAnS:
Fontana otiaiol/on
c' — '.
Sin? on $ask
ICol fly la was moscoposcn«n000brRiIOW
Ilk CC ItMat e0tirla..s*.16YIta, Mr VAT KCOPY LIMO
at -vllK SINS to000701f.aLLCnaa.
l—t
7011E opC18t',reo �.rn-/QTE
p Y1114 nt Cz�i�SF1/1

RESIDEN774 WELL CONSTRUCTION ItEcONAt
Nash Carolina Doyerunent ofEnvintmerat zed Name) knouices- Division of Was:Quid*
wait awritscrom corturicatom • a go V
. t, Intl CONTRACTOR.
wed omen Oinkonsai} nen
(A)1,SC)),) LA\ IA cirltncj
:
STREET mouss S SID /4 7ison ,'4brass1ncn N. C,
or* or Tim) Nate rep Cede
IVg tS7 -6 2e0S
Ass cods- Pope aunts
& !NOLL INFORNATIOtt
SIM WELL ID ON eielesees1
STATE WIRA. PSI,* awn*
DWG reCTNER PIIINST IRE enpliseinel
Val USE Owen hypiesbialin* Reedineniel leiniat Soggy
OM ONUS) P- a) -06
TINIECONIUMID /SD • WO PS —
U.1:1_,snr\
cif?: 1.4 I( RS (.1 He cart( h4 I/
111 Q_ nq
Pensabailineste.Cesalionelmosen.latb..Peseot spoons
ToPoSSeNic / ONO SETTS*
QOM GS ON* corair
aposserge
Limn _3-
tONORLIOE
/Sty it kern
memist
Issilmist hot
LadeSsiglut OCIPS CIISPINFIPISc NEP
AtattestemPargie skanta USGStqw men and
alabslibiNtesa twas•NrOPS,
4. NEU. ORINER
OVRIERTi NAIRE
STREET MOSS
ante Town
Ann ado - Phone rota
F. WELL DETAILS:
Tout earns 3(:).
b. MIS WILL MIRAN ISOSTINS USW warp NO IV
e. WARR UM. IC Toni Calm 4 MI # FT.
(kfte+-• AWN Tip ttOINOR
• TOPOP case rr same taw SuPooe
lopoltanyinwee Mee SO oodles fillynnlin
Wen irmolsona RR ICAO 2C AM
.. War* 5 SKIIIINIOP UST 414
t3 Lts
)7.,#
OINNFECTIOet Type 6-I-Velle4-ssawn ID
o. WATER ZONES (6tpett
Flora To Rom To
Fs= To From To
Rom To From To
t. CASIMIR
T. GROUT: Not
rom_a_ To_yit
Rom 3
•Rae To Ft:
& SCRIM 0•46 OSist INNS*
room To R. N.
•Ron To Ft rn.et.
Rom To Ft in
&• SASIONIRAVEL PACK:
OPP% Sze
finet To Ft_
INSSI
Ft
Flan
7.11SRIONASS LOG
Scat To
I I. REPRAEKS:
FoffisioNtOusisios
< ,ha/
)7ran /- -
Y1).
C.
0
0
C)
ylitop nry-cle
scanner mow 'not InSVICL VMS CONNNOCIONIMOOSIDINIOTM
RAMC= %MILL COMINSUCIONSWINNIMS MOstOOPrOrSit
ROOM SIAS SINN /110.1011DTOINENSIL ONNIR
t (At Qtrokir
PERSON
THE 9461.

RESIDENTLIII nns commit -roam atcat»
- Noah Carols Dec ruaan otEa.wnmea[ awl Natural Rmoaors- Divides W War Qus ky
WILL CONTRACTOR CERTIFICATION f a4'o
1. WELL CONTRACTOR;
�14irlie$ �L6Ison
Wei Camaetry OnOn Mac
LO hen Q.0 rd 1-;1 I �S
Wa Careaaor Oros, time
nET MDRies S&' /J)'j.s2 n Pe)
3M<C1-QC'\t1 hit('_.
ayoTomo ale
�Ica fr4$3>-094z
• mos.- `Amax wads
1 WILLOWOPIOATIOM
N TSV/81tDiasions i
SATE NMI Pain.ewomai
owaironee. fl Ts(Egpas6k)
wtt we tc wwwww. asiy Awes was swore smarm - 03 - n [p
nweci 4: on • Amp -Petra/
c sEt>.toc& st
ciT:grt,.SSirVA,n
gr(Qsg-,r
at.sIaan.
Toreamuctone CS*
OS* SNOW - is t71Dyi OC/iar
oistowestbs$
LATIIIDE 1 _
LONOMIDE_ _
twt.iMtrra.r s.iaac DOIS o1i4o ik wart
lieaimdmtbaaattoasswaa a ilE63tlmomp and
attitMa�Mwir /war149Ps
4. wtiOMSR
OYMiSC6 WO& KIrK r]Un 10
erne TrtatemsS invi roost/ edit Pc1
Cif OfTa.r Side Zip Cob
1-
Aria sags- Prong an
t atr..fientt4 Cray
Mrybrhtrec%
roMmor. monk or
Ya+Arrtmw
d WPLL OETAtLs:
a. TOME. DI TR Icis-
k DOB SS1ti1t1NMCE wen tRite ns0 ROOD
a Srte taus. anT ot Caw cS0 r FT.
leire IOW* Tip *Collo)
a TOPOF c W / • Ff.Ataiatadsmrop
'Ty oosiiiinots/Mrioloo ens iniersimin
race baarSa�i� IIIMAC IC Milt
Ma.* .3D ESIMODOFTiSIT 44
a a mtcTtoetTwohth Pellek Anna. Po
9. WATER ZOIS (tlgp ).
Fre. To From To
From To Fran To
Rom To From To
NoloS. CAIOlik Theban
Flan; (9 To S(Q'Ft D wSDI hir ?VC
Rom To Ft
Fite To Pt
s GROUT: . Depth
Fioit ' TO
Fro. ` Toc2-6'
S. SOMIElt Illom000r Shctm' MSS
ROO Tq Ft ti. r.
Fag - - To Ft in in.'
Fern To R
r^
L iatDIORAVE . POCK:
Soo mrn d
For To R
Fork____To_____ FL
Fast To. Ft
C.t
1clwoeat.OG
Rom To Fommlio t Doom hmt
0 - )t1'
® - PA
lF
4es / S, itirmis iP
II. RSR[ARIES:
Ma ,ez /tr/l
menteraPOIPoAsa00.fmYC.pmn000 one uww
sIntr. MmeottIIIIMCpepsti ams,mo tornoonorT e
emCaoers sswewwMOIDTO MOu.o art
_.0
THE OFCentro lieu.
vvivn�( (.1;Isesn
OF PERSON COIICRi1CTMS Tt(Ettigt

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
Wel Contractor (Individual) Narne
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY
NC 28906
City or Team State Zip Code
L828 )_ 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID S(if applicable) _
STATE WELL PERMITS(? applicable)
DWQ or OTHER PERMIT =(i(appicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED 0607106
TIME COMPLETED AM ❑ PM O
3. WELL LOCATION:
CITY: HAYESVILLE
COUNTY CLAY
BEACH COVE RD.
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
Slope OValley OFtat ®Ridge
(check appropriate box)
LATITUDE _3 5
LONGITUDE 8 3
00.884N
❑Other
54.185W
May be in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: (gGPS °Topographic map
(location of wen must be shown on a USGS topo map end
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME KIRBY SHAW
STREET ADDRESS 990 NORTH KINGS HWY.
FORT PIERCE
FL 34947
City or Town State Zip Code
LT72 )- 216-7868
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2138'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (8
c. WATER LEVEL Below Top of Casing: 40 FT.
(Use'+-1 Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordance vat 15A NCAC 2C .0118.
e. YIELD (game): 30 METHOD OF TEST AR
0 gi
088
1. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From 125' To 121' From To
From To From To
From To From To
6. CASING: mat Kate
Thickness/
Kr
From 0' DToot119' F. 6 �6 of Sa021
From To F.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 20 Ft CEMENT GRAVITY
From To Ft.
From To F.
8. SCREEN: Depth Diameter Sid Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Sae Material
From To Ft.
Frorp To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0' TO 1Z RED SLATE
12' TO 105' BROWN SLATE
105' TO 200'
11. REMARKS:
CD
BLACK SLATE
O
t_
v T'
N o'-7i
0 -
—1
BIT SIZE 6.038
I DO HEREBY CERT1FYTUAT THIS WELL WAS CONSTRIR.I eu INACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUL niN STANDARDS, ANDTHAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TORE WELL
2/06
A r RE OF RTIFI D W LL CON - CTO r DATE
LalesaER 1 , Dick
ED NAME OF PERSON CONSTRUCTING THE VILL
Submit the original to the Division of Water Quality within 30 days. Attn: intonation Mgt,
1617 Mali Service Center — Raleigh, NC 27699-1617 Phone No. (919) 73S 7015 ext 568.
F0111 GW-1a
Rev. 7835

RES!DENT,AL v.nt CONsrRucnoN wow)
North Cxolma Dgonmem of Emr<anmoa and Natural Racraces- Division et Walt Quell)
WELL CONTRACTOR CERTIFICATION P o2 ova
a. WELL CONTRACTOR
P Vi n
TartTartCatrarta onontlwq name
1 +Xi snrj kf Or; no�
i\ Company `1
tmaiADDRESS 5W) I�r IS on 'Rd,
Cam Than State Zio Coda
Amax*. nu be
I. VIGIL NoPoPIIIATENt
SITE WFL;gMIS -
STATE WELL P9RfiN aioYeaelo)
flWQer OTHER PEWS fl - -wple)
WELL ME tCHeac.AmieeeiBm* Rasiam.ne War Supply _
DATE DRILLED 5- .- 0 G
Aar CI mall
1. WRLtO�/CATIDet
CITY: PAy0,.‹V; P. cotnrr /ray
f ss < /l/Tlro�te
♦ ttmYme.omar I,C-leedlom W RW..Pmmr.*comb;
TOPOSIENNOCf LAND SETT.*
ORS tnIiy aria ORS* Stieir ..
taniataardirdeatad
LATITUDE 3 _
iorrOrnME
Iiity be k rat%
mimes stconds
batiks& belt
IAtisatAaleeileitearer DtWS OToporoplafcmap
Sat tiv eieastbe lfinewm a LOSSikir map and
e/eteUbaee lam IweroYgelPS
4 Mil ONeER :harts 5 NAME -Rail C n ct1_1.[.1 M flatt-c..
sneer ADDRESS I(0a3 Pea -ekes -Is /'/>UP Ee
jLQwQSSrp 30 96
firma Tram Sae top Cab
17h/ )- *94 - z/9Ycl
Arne ante- Phan pprS
S WELL DETAILS:
a. TOTAL cent '65
b. Dard swans aet*ct eravau YES o ta)B�
e watt Lava. 8cTop t Caters • a b r FT:
wove Loom T.ptc j
d TwPOPC MNQli ( • FT. Pease Lel SW4oer
*hod mobs MoromotarNrom oL mob*womaim
avioraHa o.+er.+wr ISA IICAC2G.eTffi
s. Tlirz uq SD ■ETTRDOatMI "
L DENTIFECITOtt TlrpeWI V GLPk Parse IN
9. WATER ZONES (depinj.
From To From To
From To Fran To
From To Fran To
1. CAMAB:
Dean .// DamTair
Fran; 0 To 44 Ft Cc,
Fran To Ft.
Tian To Ft
7. GROUT: Depth
Fraln_� To_y__
Flvno �` To a D i
. Gran To
1 sraifflt Depri tiormor: illy ___
From Tq R. i .. h
Fern To Ft a ti
Fran To Ft m. is-
Themessl
A - SNORiRAVEl PACK:
Depth Sea ►meal
From ' To Ft.
Frew To R
From To. R
Slase LOG
From To
C? - 'es'
�n — a4 r
Footman Desedpbon
a rTcnvQA
- <-S ' 4-/rint7`1^
II. RPM OTITIS:
rDtrrcmeTsv THAT 1011111MItt 0;1101111CIPIDNACCONOMICIE that
TsnCSC 1C.war dream mersOWIliaACanerneS
�WOODTMa twr+aanoaD eosowe eriaa.ow.
eal-
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lion Wet (c�,` Sbn
HAI E � TIE waL

RESIDENTIAL WELL CONSTRUCTION RECORD ! i :: r: 8 h
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3368
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Town State Zip Code
L828 )- 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(! applicable)
DWQ or OTHER PERMIT #(it applicable)
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED 08/07/06
TIME COMPLETED AM 0 PM ❑
3. WELL LOCATION:
CITY: g9ds5`ill''R; COUNTY CLAY
PINE LOG
(Street Name, Numbers, Community, SmdMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Ial Slope (Valley OFlat ORidge ❑Other
7� (check appropriate box)
LATITUDE 3 4 59.826N
LONGITUDE 8 3
56.205W
May be in degree,
minute, seconds or
in a decimal format
Latitude/longitude source: p GPS 17 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 SKIP MCLEAN
STREET ADDRESS 220 ARTHUR AVE.
COCOA BEACH FL
32931-4004
City or Town State Zip Code
( 321 )- 34343988
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 240
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use ‘1"' f Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top d casing terminated at/or below land surface may require
a variance in accordance vdth 15A NCAC 2C .0118.
e. YIELD (gpm): 50 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
if
From 2W' To 220' From To
From To From To
From To From
6. CASING:
Amount 100 PPM
WATER ZONES (depth):
From d DTo�80 Ft 61'8 er
From To R.
From To Ft.
7. GROUT: Depth Material
From 0 To 20' Ft. CEMENT
To
Thickness/y
V'e
SD 21tPVcrel
From To Ft.
From To Ft.
8. SCREEN:
From
From
Depth Diameter Slot Size
To Ft. in.
To Ft. in.
From
To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
From
Prom
Size
To Ft.
To Ft.
To Ft.
Method
GRAVITY
in.
in.
in.
Material
Material
10. DRILLING LOG
From To Formation Description
0' TO 20' BROWN DIRT TO BLUE SLATE
20' TO 40'
40 TO 60'
60' TO BO'
BROWN TO TAN SLATE
TAN TO BLUE SLATE
BLUE SLATE
80' TO 240' BIDE SLATE
11. REMARKS:
v
Pr tt,
r
CD L7
1
I DO HEREBY CERTIFY-MATTHIS WELL WAS CCNSfRUClED IN ACCORDANCE W rlH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND 1HATA COPY OF THIS
RECORD/Ih��'l�HAS BEEN PROVIDED TOTHE WELL OWNER.
"Jib; ✓j 09/11/06
SIGNATURE bF CERT(SS(jED WELL CONTRACTOR DATE
iittifAM ktr i L-bi;IS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1817 Mail Service Center— Raleigh, NC 27699-1617 Phone No. (919) 7337015 ext 568.
CGS
Form GW-la
Rev. 7/05

f 1. WELL CONTRACTOR
I „Q r% p,c R. (A); knn
lWail Conan, 1kW. koli Wra
wes Css.cto carps va
STREET ADDRESS C8P) L4) i /G!)/7 RJ
3rrASS\-n(1n C S°/�
City or Tovn to Cale
QS" “t7-OG1n2
Amosd► Praia Ours
1 WILLIM O1MATIOIt
MIEWELL seiwpreet
mirth eaniRiilipeplas
DIYQeranaaperaergrop4ebiq _.
eealtUSE (Pack App9slY`as* Firir.r.ease•ie+rO�
MEDIUM 5( -I/ - !n
TstECCIIRtRD ,3i0 & • Awo nui9-
3-flLUM101t
Cm: ilea_ COutertecky
�eRteetemo isawwtitotte.oeaek*pC l
TOPOSIRP.MCtIADien! _•
461101Y Vale of** Cant
illian;rtru.l
SATTTUDE 2 _
141RkRME�
May b enders
Mesa mow*
i ilidedlirt
snr acku jrr. w. OOPS ulracci tplikaap
eaei.de./ __ 1te..swoLefer ipemeaid
sias / asliceI.Ilrii raps
lMaas
cwnleesnaa g g r inn 4 rn5 Ed
sneerADONEs5
Qfet Tem �1ee zrrcoiY
Menede - Mat .m S
treELL rat
Tara tent '
L nos 1 Caret ctasisINlpatt reap row'
e MATS WAIL sstopaail a 10 FT.
Plerr Tien reefing!)
d. seTOPIC COMOICI I - tT-Aa.wtaelasAiaet
Kupontedepierabandkrilieramderkeesvieriouraim
taineietkiniemeaminalti4110ADIDLitti
..appr3f TaTlT11DDOFTOTitjQ,(T
RESIDEN77.44 wzu.cowl-Rocnom
North random Depettment ofl..as.eeet and Want Reemaccs- t)iviian if rir.Tjtieity
WELL CONTRACTOR ct9RrlslcATlolt p o y
kMINSFIC1101t Type
a. STfl( ZONES (depail:
Res Ts
Ron To
Ram To
IL DANS
Aeeaett 1D
Rem To
Rem To
Free To
(MS
Tliceeael
F in 0 ToDitinn7' Ft ( f C , f Per
FRO To Ft.
Fms To R
T. GROUT: . Depth
Fiu..-cr TO
RttiL�_ Te
.Fisic Tq Pt M.
Rate ...To R. - in. it.
Foe To Ft io - -
sr. -sm WB PACK:
haw To R.
Rem To Ft
Fst TO - Ft
ISMS
Sias Nll.f�
Sas Loa
Fain To FantWWtOlsaaott
icS _DAS` &rani TP
RtLtivt.._-
DIV. OF VvitTtr< LtuMLI f Y
OCT 11 2E6
i4t p on tar IC
.oelSraMR,nog ts at vasr0tswig esmatfsotnafs.
parson vs soma mainswas
mD or r R. m�camunnwk !I
J WIYVtk (l) seI SF1 n
Rs pWill OFmow coestrRDtsTHEMBl

RESIDENTLA WELL CONStRUCnOHReam
North Catoboa Name* ofEmikaamcn sac Natural knoaca- Devito al WEN
rveu, CONTRACTOR CERTIilcAtloa R ,,2 yo
9 9 6-1
P Pi c..
1. was. CONTRACTOR
1/4-\i4rvtiA �. uIIIann
wwo:ne . macs* wain.
Iw O urieweet C sa In � ., q
rasa moues 6 T3 /.c./kb,1 1l J
X c.. S1/4z.Jn N. r, a?179Dc)
City to Toon Rift 2. Cade
IXaz> tS7-n44_3
Aaaaaoe- Pears rmthe
i WILL wi ORWRRot!
unvie1:fewlaaa.• A
STA1E r,6 . Mann weieael
WI trifle PRAM ERappWiedel
WELL DIE pin aprawaiewawaSop* r-
am 1 tlS %Os- o4
TelEDel slat & Ja • Alit CI Flier
iriELL
DRY:
P. (la.. e Raginata
I
Or�as�sess tw1e.. no.tip isW.T
FOretierec ampsnot
.
ails 4s a cave See
1iiolte O tweeae
LAMBE 3
Lossvtioe
Gan Cbt1NT r C 114 V
MgbrSepia,
mime monk or
W+ twist
Latedatisoile sear o(s Cfrop woo
(inewdaeraantie Wan a UPCS1wo sip and
AaallwbweIr arnoes,ene
s. watOrrER
%wa staat I-uka brerclIe_
STREET ADDRESS
CW or Tort aloe
Awawds- Pont ammo
&WELLDETAILS:
TO1m eernt 1 451
t O@E MI. SACS ENNRur ME St `+EEO Fo(y-
e. WATER Lava anTop 'Mamas .20 r FT.
$Tee't imiseTweftoMp}
o. rope empas / FT. Aaetaw/___
T4s9ew1Ei istStrM4ei.r spin weaves
owdmoi11molrri IN 1101E 2C. Mt
a Mare /a2 ortic arreEvrie
P.
L areETEcnaat T,ps&i 4 Po 11 v 1-4 Aeesall I S
e. sten ZONES Owed:
Fae. To
Eton To
From To
e. CAROM
For
CAM
Te
To
Frail To
DISTIde
Rees O ° mo' Rfp
Fen To� Ft
Fan To R
T1Oress7
Air
snral c!
7. WIOtJt: tan
Farms, CCFive 37
To
t sc 1a M. . aims.-E11tIke
Feso __ To R. tin '
. how To Ft - it
Fran To R. to
Mewed
i IANDI_ .&b6 PAC:
Depth size fee Biel
hen To Ft.
. Caw To. - R
.:.... 1�If TLOG
From
O - In CJau
'4a✓l
In - Sn'
.cfi ' - 4,15r
11. REIlARXS:
6
Pours's%Goonip ou
RECEIVED
DIV. OF WATER II 'Pan
OC I 1 t 200C
Mot nn -Kock
Tawe.rran*rrnwr111Swtawrapi. Namnaoaw-Re i
a11111 as a.li. seeoaIIRA +{• aneentGOsrerne
1eCa101104 ISw�Y�T011117SLaagR. i
ii194R. S_n5 dl +
OFtERTERR CbNFIECTOR DATE 1
I
1,0: 13n4

RESIDENT/4 WELL cons-Dux-nowitecoaut
Nord+ Caoeea Dgntmdn ofEnWeint aoif Nand ROMOCCP. MASON et %War Qua*Y
wFu casrrRACIDR ctRTIFICATIOR s 024D 41
t. na CONTRACTOR:
5 Z- W11 sun_
me Gnat/ Oogovionie
VIM Cant Ma
9T.Erti ADDRESS ,S R7) (,t );/</1 /i Rr1f
3 missin, �n l.e. ds a
l a Tann
lan 3- Ss3`j-n9:G3
Aarredo. Pocoa +tunes
1 a taro a sanatt
UflEwa t B MitaleeoAlN
IRWIT WELL RlMIEteiMoMN
DWG roT1ER POW a(f appeos0le
MILL u9Enon losabo ioa.t AS1S Nit s.p*�
OR'([ORLLR�j¢9 - .t)G li/o
TMEO�1l 11�a2ed9- AMQ PMW-
INIRLUMAIf0k
art (A)nrnp
d (� cOtltnn'(JM1?
vto tanoe..+.ip:.. saute._.... l4ebe.T
TOPOGRAPHIC R.APID Ei1ENE.
LATITUDE A.
LOOMITUDE
be kdae;
mascot — ot
ita+r-entA ieK
LoiteMisiluds rimer" Dan Oroccip>wtbicmop
Ile ttniamleatie Reston• LLEGSS ale and
011itOildnr two Iflt ySP$
4IIIRLCMS
sitienPsua onij Gyrr•
9TA9ET ADORE83
I<lebma
OWN Tian
N . t' . �909'
aueCoil
t tay -39oy
Anna- Pbcsientillat
I. WELL 0ETAtis:
a. Tomm. arm `. M6'
r OM LMMLfa..-..-.nn YES ND Er
G SIS LEYit.9losFopOCA % 'ZS FT.
cuss %i sTepecs,
d TOPSQaIERME f rt. Nretd___
TeRaTg brio otA9rMrMbo Ind ofloorwounito
o lemolo alma alloISAi c c=M.
e. TORbisoKt In aRHOltrUIR 14i2
L paiiiitnat Isin 4A Pei) a i-m fees IS
it. RATER MIEs *Pit
Fe To Rain To
From To For To
Fun To From To
CONNet
Thiclolmy
n Co Ft Cps
WOolo
F s ( TiL
ROM To Ft
Nan To Ft.
7- OMIT: Ooplh
Faatt_� re_ at
Feint .R+ To e26'
Rs : To '.Ft`
t CHEW t1.p9i Da-- . i1N91ot - MONS
1To R b. To
Foot_ To Ft. .
FM To R. in in.
IL 4/01011WAVIL Mot
Ron To FtFla
I
FNutTa Ft
To. a 1
>i LOG i
Ran To FoenrhnD000dm on
o - in+ V
eo - �' r t:
�S a74CS' /Piro/ e
S
DiVW�EF F [:` 11
I
II. REMARKS:
tvtap on Sark
tin+ersrc�eloewola sautrwotNwer:lolwamaaopwrn+ I
tooter o4meL7srAne.Me{, sto aaa>tCareOr/Itt
alto orate 011ausora9To11eetrLLon
Epgl,Tq OMM) Vat
Q. ua-a qTE
J CADItsotei
tt�ElerEu oFmoon CoNttIRcrEgI+ilivies

RESIDE/YHA nu. coNSTRucnourcolut
NOVI11 Crina DCP.Mitlit canna* and Piatutui itesoma- DM** sr Vier Oiciabo
WELL CONTRACTOR cERTincATtor4 s 24o4
2 3. 3 !I 4 S
1. MILL CONTRACTOR:
CjElhiesS____a_LaiLSO4
wet CaNzetrz Qnolooluac More
DO:l son _wok firattvls
Wel Conleekr Conway Ma
STREET ADDRESS 5Rn Wavy-) kei,
CS/ or Toon Sze
(WIC SS 7- bct fat
mama Pilo* MISS
1 SILLNECIFileATIOlt
WERIELL filiaiwess4
Yriass4bLan t4.0 , s241.?
STATE 1/43.1. • poband
DWG ',OMER maw, .raj
Ma USE IONS( AmimbloaNO Far Si ANS Some GL-
IM% MUM 9- 0 -
TIManimmi 570.0
1.11MILLIACAllat
COY: P courrnr/gy
.calarishis.t.ato 'Lent* canal
Torteeric WV
lust,
ADAC PM a-
calintivast PW dale oils
ISRSIERIRSEIbbso)
LATITUDE
LOMORTUDE
1 kW Illairom
Aiwa. swat or
las ads* be
lalebinglaa se ORM pitaporiplie Rap
Pato altaioNlat as tin • USGSltise mop and
Aso trelle•OPS
4. NELL OMER
owes NAME vvrelinto I Kg Ovid -
SWEET ADDRESS
arta SIMS awe root
Motet - Peale as
neva trots:
Tara. awn* 366
MEI LULL IMILME EINDIND RILL? WM 0 NO 0-
o. WATER LEVEL Odinainf Gang FT.
MN -nano TRIKONME
i. TROOP MIKOMIL FT. Mataid DO°
ifitallilests subs se Nos warns
ovilialinuninsialeMili CAC EC A116.
TIRSKIINO- MEMODOFTWAT kit
r.camipecnat Tye_ pas15
g. votteR ZONES Nopini.
FAIRS To Frown To
Fenn To gem To
Ran To From To
A. GSM
Theisen
DeNn Dienes Weele Mattel
Fir 0 To 46' Ft 6,as pVC
FAN T •
Run To Pt.
7. air: NOR
Rent 3' To a0
IL ICINIEM Dipli amiNer Slat
Flan T9 R. in.
R. in.
Roo To R in in
S. SANDIGISAVEL. Mac
Depet Size Mamie
Fees t To FL
FL
Ft
.,:: Statme LOG
ROM To Familial Dastaipser
0- ID' f 114y,
ID - 5r) sioi•-w. a4fun 42_
5D - ZDS ' 6-ittiel : tP
II. REMARKS:
9.tCCSo1.11-1/41-r
Div. of `Sr -
°CI 11 2°)
rAnp On Trick.
itosimeromerwia wenn soasuraiosnocariosaloonon
scat= leakconsicianammillit vniernoomortge
seconows 6161111INONOODIAnniesinion
2. liatiODAA. ?It-Y.:104�asnn 0
OF MUM, WEM •• • • GATE
cirer( ISCil
RIME OF PEROPAOPOITIWCTIS Tit WELL

I 1. MOLL CONTRACTOR:
J 14144a.5 t., t, )‘. \Ann
wait cant,. <er } kini,
kAtkon k AQ1 Ort`Ili r\a Lfc.
We. Caarwr Cortmriy tree
RESIDENTIAL flLL CON$TRtrcrrom stcoav
- North Cavan" Dcprtsent eon-s and Natural Hrsawo s• Davisr of Watt ()Wit) <
WILL coirrRAcroit cin- ,cnx i a „24/0 ci
3 s 3 3 3 4
C�
qr II
smatammo S86 AV set n & J,
igracci-rAZn PA .r r a 291o0)
rIran- `S37-n9(a.3
Arr ma► Pooh* naves
4 ratrta}peOISAn10tt
onto ak to oat ss-
trot watillgussuasoms
DWG tre7 eMUIRsrlepptaeter
at ow tC Iei froolo iaaraf Fart tears s..pit.O�
atn aiaLa, Ora
rsaEaFsltl7� /:OO • mot] Rotr3�
S. WELL
CITY:$tan cota.rr(i 19
cat a Tenn T.0 Cade
c
somaa,
WHO ..fseaLnp Cnte:
TGr_f_i c/LIMOSET/1111It
0�4rSeem bad D St4e Mae
f iim+wtros+er0
LATITUDE _T„ _
talq ODO
Laidofi'yutr"am DOPS cfropoiniicirop
p oasrrrtwsta.ti.abso se.r*GGStteomoptra
rrMMtftomit Non psrrint
4. MELONS _
OMlERSMiddJ•WA:- onn;a Stow
gnawAa 2/50 w;/S Riot:, f.ay (Aviv
C4Wt i tr 11 a Teem • .2Re16J7i
Zip Cods
t r ¶cS-S$KI
Ansa*• Plow an
EWILL DETAILS:
a Tom wpm
b. oats vas imPocanompos wow rasa worm
a moat unit wooTsdG R 4.0' - FT.
en;abasTortcat
`Tatar WOO / FT.ASssumoswAor
ligtoloossostionstoial000moosrawsooripo
•t- . *1s lassMF1st/ICAOMt
IL MM.*/n2 orrNoaarnarr4..O
Mimeo mom&
ies+rntSmin
r. rleteSSCOOst Trash - WI Pell ei.s is lb
o. syr ZONES *Ohl
Fa To From Ta
(-sea To Croat To
Foam To From 7o
t. DAS Taiebrsrsi
m War
F+agI Two )Y6Rloa , 5:area 1 M.
Fran To R. _
Frost To Ft
7. WIOUT: Ca
Flint To. a r
Frue_, Toa
AIM To R.
S. S-:pfflt fl+Pw . Dimas - msYe
Fiala Tit _ R
- Foam To Ft itt. - ti
From To FL in. �.
a n RAVEL PACK:
Dept Ciao
taer�
Fmk To R
Frra___To Ft
. Fasv To. R.
?Ml- tiot LOG
Flom To
lf�- jbnr
ICV'C I70(
ryn-aaS
11. REMARKS:
Formsfea O.se+io`aa
RaA
.
of
TaR°UP``
oTv11 -
iMap ion l3a ck
t oaatmv aion nea wove' vow oprwreep.comas sr
iso star atskaaatiu:rraderra.arim t000ararnr
ssooears ssrraeeate.aw.aatrw.Orarr.
4erniieoFtntAvocce f D co
on
Paths ac "i' Iop�t006.11W11141111
iltCffp t�yt�Tie pes1