Gr CY2006

RESIDENTIAL WELL C0lL mu noNREcORD
North Carolina Department ofFaviomnt andTiaoid Resuem- Division d Water Qaalty
WELL CONTRACTOR CERTIFICATION s
1. WELL COUTRACTOit
/ oTI�
Wsa
y s \"6cn5
gocividlssnNaae
i YCn.V�C.w� We .1 OriUtni,
Wd Cm6aeb Comps yNaa
sTREETADDREss 634 ("(Yelp /a^)."-
t(L614b1 ,\k NC
City or Tom Shia
(69k>. Lit 9- Fl`ifi(
Area coda- Mae number
2, WELIFORNIATOlt
SITE WELL D 661appiriii_
STATE WELL PHO.lna4sseaN -
DWQaOTiEiPERWTe(i )
WELL USE (Cheek Applicata Bag Raidaii WaterSupply Ok
DATE ORRLEO 9 -2,e-0 6
Tait WSPLETED 7=0 0 AMO mast
0` 77 /
Tip Code
3WELL LOCATl\at
CITY: (2r4\,irC✓1�`L COUN1i\ JYTAnLYY\
��o���
R.YdaName. 4-o0asa tnUb..Palest 3.Coss)-
TOPOGRAPHIC I LAIC SEnhlt
o ofMidge Data
trbork
LATnwE � //4' 39.Q"
- w.niWES3° rrio' 3.f'
La iSe/ki nginde saw= 040PS °Topogtp is map
poeat . dtallaatba ad* ana OEMS typo nap and
aided b aia Asml lad stsig APS7
4. WELL OWNER
Mg be odd.
arecadsce
:saved imam
owlElis NAME 8 rev t L.) � . <
biFE£FADORESS a4- (l°Yw
Q�h,r.�v,ll. (SIC aer7 7I
Car or Tan Sale Zip Code
( cn-} 417C- 64130
Area tale- Phone =rarer
&WELLB OWL&
a. TOTAL DEPsit
b. DOES WELLREP1ACE OOSTNG WWII TESO W)
c. %WATEtLEVEL &lasT pd" /0 FT.
(lice` flame TapdCasii
aL TOP OF CASFIGIS / Fr Above Laid Soilae
'Top dtag laaiad norbtialtodsousagIapia
awine isamodio: i ISADCAC 2C Alta.
.. naDtgpaak AO W1IODOFTEST a i r
3cc(2
f. o18REEClfatTypa Firm Amount 30Z
g. WATER ZONES (daphk
Flom (C)' To $ O Fnen To
FIm ' To From To
Fran To From To
6 CASNG: TRi lmecsf
Depth
Fan 0 SS R. AAY fi Rom To R
From To Ft
7. GROUT: Dept
From n To g0
From To
Foa To
laelaid
Ft Cnf-
Ft,
R
'r1
6 SCREE* Dept Oiantler Sum Saj lagerisi
From To FL in. f i
From To Ft _
From To
s Sa1pRRAVELPAat
Depth Sines . .v
Fa■�_To R ti
From To n `''
--
it SLUNG LOG
Ron To
11. REMARKS:
CO
0
r—
r
IODIESVO rW17fina6tSOaaNc®aAOCamllNCEttmt
a=lNine WC ile NItivadaQ�NOWAOOPrOFL6
IBaCn16 a®Itt0tICIEW7a71EtIBIAaaaR
�o *rwcs rat 7 E
SICIIM OF isaen WEL DATE
trklA ceps
Penal
Subsoil the original to the Division of Water Quality within 30 days. Alec IWornnation rlgLr
1617 (Nail Service Cantor— Raleigh, NC 27699.1617 Phone No. [phone] est 56S.
Form CIW-1a
Rev.7A5

RrswEl11 m4L WHO, CONS UC ION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR C�ICATION. 33 0,
1. WELL
crux
5f r. 0\4\Ceti
WaSsonermicr (krdmrdua4 time
Vvt,\v.w 'JeA\ Ors\1c.
Wd Cadraeter company time
STREETADDRESS (n34 1-174e To r (4401.
bbC,6,;11.
Ceps Tam Shia Ep Code
c40(t)- (d?q- Fs1-16
Area code- Phone umber
2. WELL WORIBATDtt
SITE WEILmfsoiodarl
STATE WELL PERIRTSW emito
DWG or OTHER PERMIT!(iappiohk)
WE3LISE (ChedlAppreabb8* MASS Water Soppy 01
DATE ammo -7'427-n6
Tam caso Eta in: no AM04 Pit
3.W&LLOCATlalt r^,
CITY_ Rion r v.tr✓;11. CDUWTTl. ► „rnnc,.
! o o. r r a YRfU'eViL V-CrA
Mee tarra.raemam.Om merlM rtem.insane-Past]7'Oad4-
TOPOGRAPHIC NAND SE.!rTs,s,�G
Sk Ot Maley ant *age Maw
pees pap leam0
tATTTIDE ,Q aa SC. D
LowccrwE.13° 3t ' Wt 3"
LathuckAangibidesoucc ROPE OTopogaphiomap
(ban Ghee awns shown at a USGS Apo amp and
Mated Weis doo7aoTa io en;
4.WE3.LMINIM TT OWNERSNNkE ,(� Joey K e1 i�Ti r.rf1
STREET c, cr n efr..nr M nee)
Pc)bbits'i11. h[C_ OCr%7I
City or Tan Sire rip Cade
c Rz81- 1-79 - 60 'Bs
Area axle- Phone ante
WDke indigos.
simmer. scab at
inadread Das
i watrcTAIL&
a. TOTALDEF•T1t 3 O
b. DOES WELL REPLACE Exisfintig 'IB? YES NOdr
c WATER LEWatidonTePdCedar —80 FT.
(Use`e flare Top deeming)
d. TOP OF CASNIG E 1 Swine
nip Maas lasmaalelrlrh ssladswats ern apes
a varaceia aniOrlarteallISUCAC2CATM.
a TEED Spof S METIIODOFTEST o.i r
L DflECIIOItType MrH Amount 13or
g. WATER ZONES (dept.*
Ran 30 To :330 Fran To
From To From To
From To Fan To
6. CASMIG:
iameter
Rom n To Do Depth
R. 6Yq
Fret To R
From To - Ft.
Tallness!
igtit
SD Wit;
7. GROW: Dew Weld It
Real V To 940 RC...ecM- T Jcrtrin4
From To Ft,
From To R.
S. SCN®t Dew Diameter Slot sus Msyial
Ram To R In. in.
Rem To R S. _ it _.
Rom To R In. _ ia.
a SAIOIGRAVaPACK: v
Dear Sir trrm T 1 tip?
Rom To R. CJ1
Fraq_To FL ,; r..)
PIM To FL __ r..,
10. Mimic LOG
Rom To
11. REMARK&
G
1
o ,
c-.
100140/31T lasLWASOmENea®raoWImnCEamn
l amxar watemawrcocna tm .WAcvvaFlms
® nnommOEE IIra IDEDIO mEwaLwaamt
vA1^- oo CroR7 a7-U6
S16N1► ^F WEII HATE
rip t60(hntfi
PIWT®T OF PHN r TTEWBL
Subs* the odgOWl to the Division of Water Quality within 30 days. AThn: Information Mgt.,
1617 Meg Senna, Center -&Sigh, NC 27690-1617 phone No. [phone] est 56L.
Fmm t3W-la
Rae 7A5

RESIDENTIAL ww. c(NtSIRUC71ON RIPCORD
Nash Cambia Department a-EnvironmentnodNa .IReso�uo--
oDivir Division Water
WELL CONTRACTOR CERTIFICAT ION i ci 3'6 b
6 ij
1. waL CONTRACTOR
wi.i4�-1�c)pS
1
G 2�ew (QAt CtDW's
Wei i:orarador Compaq Name
STREET ADDRESS 639 H 7T6,4,‘
�tr.trwttp 6ic ac77/
City or Tom Stale T9 Code
Lis '-171- @1st(
Aao coda- Pan mamba
2WELL IN ATIat
Sloe WELL D ISaaelalr)
STATE WELLPERISH'S►
DWQaOTHER PERIMRif rnnieahtd
WELL USE (CliedrAppkableBam* Rwiderii WatrSiletik
DATEafXED 7-2S-!'?�
TECCHaaEIW 4 r ob ARO FYI
SWELL LOCATOR
CITY: �4110s stir. la COUuY6b, bend
DIC Gait, Red
*seertlarimhasConracl -.—Yra rtle.Pim a$coma-
TOPOGRIPFiC(LA�N�DSETTIR£Dal*Dpe MayMayjmrW DNS Maw
tdhasrepeaiaramd
Lana* s & 'va. 3"
LONGITUDE Y3° 39' L:a.f)
Latioxidicogiindesow= kelps oTopopaphicrinp
gran dmdaarten a.maUsGSkyompamd
afaraedloHYu6rImtamiq BPS)
4. WELL OWNER
owners NNE \ ?ct.r Sn% !!
sstiffr AttORE= I.J�I f,�Q eFC ex.CA,
'IGi )C)Div'6✓. t l� fl\(C 2'c77 /
Mryleindopes.
throb, some or
:,deed amet
CilaoToon Side Zip Cade
( Qak t- 7.3 g- / q-0 7
Area ale - p,na r
a WELL OWL&
a TOTAL LEPER 1 30
b. DOES WHLREPLACE EXISLNGWBl7 NERD NOD(
e. WATER LEVEL DelorToeflaky 40 FT.
Mare lAhaaTap ofCaeiip)
d. TOP INCASING EFT. Abate LemdSatre
'rapor cap Immhradl Sheba bad sedum wag mar
aamine a aeoadeaodh ISA IMO= Arta
a. YIELD 30 EMODOFTEST C•I r
T. OBINFECIlOtt Tape H rH Mom[ a{ oz
g. `-i WATrR zad* Ea (dee,
RomRomo ' Tot 30 Fran To
From To Fam To
From To Fan To
t CASING: 1 '—
Rom 0 TeoaDiameter Weiiie
LOff'FL OKI Ca? AL vC.
Fan To FL
Fan To R
7. GROUT: Degas Illmid *Mod
Fan f? To a,0 R Cfanvrnl- "Ne rr
Fnar_To Et
Flan To R. �
a SCRE3t Dept Ciianeler Sid S® AYYlrid
Fos To R in. io
Fro To R. In.
Fan To Ft to _
S. SNOGRAVEEPACK:
Depth Sze
From To R.
Fla�_To R
Rae To R.
IS. DRILLING too
Foxe To
11. REMARKS:
Font Delorpim.__.__ _,1--_J
0
100111EIEBT0311MISITUSIIIMILLIMPSCIONSOWIEDIMPDXPONCEIMMI
lSAIICO :ac.walCO�. cmmsoaormevaonaTACCIPrmFnr
merovoanae®rtnwm®m vmalorrea
.frig WS.LG s OR7-a5-o6
SfGNA CELIFED WELL DATE
O,,Ah, , (this S
NNEOF P6I60N �
PRRIT® THE Mai.
Submit the original to the Division of water Quality within 30 days. Ater Monnatioo Mgt.,
1617 Mail Setviee Cantor—Raidgh, NC 21999-1617 Phone No. (919) 7334015 sat 569.
FaniGW-te
Rev. 7/05

RM]DENTTAL iYFILCONSTRUCTION RECORD
North Cat Deputised of& miasm to aodNaoaal Resource- Division of Water Quaftn
WELL CONTRACTOR CliltTDTCATION# 3? 6
1. WELL CONTRACiOit
rps
ar V.\ o «ti v.0
Wd Gor6atr CfMae
/ r-77a J
STREET ADDRESS (24 urs'e 7-01^,✓. "0
�bbl aU{ 9Yc, 9*771
CLYa1Tom Stile Le Code
( (04"). y7Y ts4614
Are code- Peon melba
2 WELL I FaRIIATIOW
SITE WELL DWSW
STATE WELL PERINTSITIW aeei
DWQ or OTHER MOAT SS applicable)
WELL USE (Check , pfolleBap Raeidefd WaesSupply Fl
DATE as.LW 7-ear7-04
TIME COMPLETED //: 00 I ap PIM
&WE LLOCCATIak
CITY: %_`bblrvb viI//i Cotn 6amKscM"N.
w0I; CTrfK ROE,J
Meet xr llooEao.0 movomEa8Mr. eatLa.PallaPOESi-
TOPOGRAPHIC /LAID SETTING
OS/Tr Ma! pRA OW71 Daher
nett appepereee.0
LATRTDE s j° & t W 6. 6"
LONGITUDE «3 ° 2,Y' L/a- !
Latitude/knewsort mCiPS °TopograWirrmp
O ar=d lam dbe silt tan a USGS Lcpo my and
a4dzsdWes tailwind* GPS;
4. WB.LOWIER
OWNBts mat 6/-even P
STREEiAOORFSS U)a1 (,rt (2aknaa
2r1.b1.44✓ )Ie NrC. 2.rc77/
Ilgte leaves.
.ioiecro alrer
leaab>iF fors
Sly erTea Sidle Zp Cede
( 1-315-02y3
Arse sods - Home anise
5.WBLDETA/I4 a O
ff
TOTAL Dame D6�
b. DOES WELL REPLACE EXISTINGNELL? YESO NO DI
c WATER LEVEL adaTapclCaablg Fr.
(Ilse"" SAW.. TopdtCaeca
d TOP OFGSMGR 1 FT. Arse Laid Sashed
_ 'Tap Maas Imielid hlacirdsoar )tt90 e
avadaeM amadacea/1 IS IGC 2C .Ot18
e. 711311(gpat UMW WIEST QC
Tram
6. CASING:
aa, 4 ,21
L DISINFECITOttTTp NrH Amount 2!
9• WATER ZONES Wet*
Fun -A0 To sc S Fran To
Fiat To From To
To Fran To
Res To 76
Fan To
Roo To
Threw/ �I
FL 66 Kra ,CY.Y<d1 ,
FL
Ft
7 G Uf: Dept WSW Resod
Rm1 7) To a0 FL <arm* `EEJorr,pit3
Ran To Ft,
Fos To R.
8 SCR®t Deph Dander SdSae ", ile•sol
fyan To R_ m b1.-. Tw ,
Fst To Ft M -____ S. t,:.
F4an To Ft IL _ EL
.' o
t
i SAIDIGRAvaftct
Dept She
FranTo FL
Frog To R
Fs To n.
c
ET:
a :>
to. mill*a LAG
From To
Tl Rpa&AfKS
Formai= Detoipdon
f
a
cn
Ni
r
-ti
is NEMOVOIONV1ISTIIISIVIEL WISOOSIECIEDISACEOFIOANCEEOM
1a11GCSONELLCDIOOMICallOTUOflflfACCPfOMB
1aEao me a®/mwIEDIOTEaBLOMPER
7 as-o6
DATE
0yg4 , riIl6�o s
PTIMIED NALEOF PERSON rlaHcrMs THE WELL
Submitthe origilai to Ole DIVISION of Water Quay within 30 days. Att: bLmelon Mgt,
1617 MIS Swim Ceder -Rabigla, NC 27599-0617 (None No. [phone] sad 565.
FarGW--ta
Rec. TA5

RES7D NnAL TIYWd.coPS1ROCnoN RECORD
North Cs060a Depurator ofEor"iromett rod Natural Rammer Divmm of Warm- Quaky
WELL CONTRACTOR CERTIFICATION 1 3t6
1. waL
Q kA 1-1r tih.6 CArS
Wei (Ingra al)Name
vb.A l3QV
WdConba la Cempeername
STREET ADDRESS 63'1 I - We 7-0-4h 12pe.C/l
Rabb r€vjI14 NC. at-77i
City arTon ".deb lbtd
Ka-sr). y>a - £su Sv
Arn cods Mow mem
2.waLMATOtt
SITE WELLD eff ma*
STATE WELL PERNITNRWthm Rel
DWI or ODE2 PERMIT ON appfoNei_
WELL USE (Check Rw rabbFat Erna edWSW.*ra
DATE women 7-go-o4
TaIE COMPLETED / {? ' OO MIA PIA \O
CIIt
CITY: 1 S7 Alin v-4, v/6l laa�� COUNTY Crc non-
NeaalNre..ram
jy loa 'Oe�..Bisi iY41 irataP
TOPOGRAPHIC / LAND SETTI1G:
OSIalm MAW! DFLWI wedge pots
(deaigRaa rs LATITUDE � 97.3, '
LONGITUDE rr_ 1- f 3a•6"
Iatituddloogihdesew= Stt3PS nTopogaphieasp
0omam d Ndamd le sham al a L6GS l:po mPR and
aitdadb as bmlad aely GA4
4. WELL COWER
OWN13S PROF IOrr. (J rt) r't-. Y
Se a
ebbI "-SidlIt lac" 4 77/
Noy b itdegas.
minim stash or
bated fame
ADDRESS 6ill C :90 (2aaei
Cigar Tom -Sate Zip Cods
(7a.7 )- lin- n 1GD
Are aide- Paine ranter
S.waLDETAISu !
a. TOTAL DEPTIt b05
b. DOES WELL REPLACEEXISTING WELL? YES° Nook
c. WATER LEVEL adosawarCedg 9r) FT.
(Wear IMom Tap dOmit
d. TDPOF CASING S / FT. Above Load Seefat
TapeealylmaleidSlrSalmi mdomgmmma
avm®ceb accordance 15ANCAC2CAlta.
a. YIELD bp* a L1ER000FTEM G, r
4 4 1
L Da tannottTree HTH Amount as
g. WATER ZOIESideptx
From -4 0 `To 6 oc7 Fain To
From To Fein To
Rao To From To
6. CASIN:
Tbieboaf
Few O rho lrk'Ft. 66/w S at
Faaa To Ft
From To - Ft
Hbwid
7. GROUT: Dept IMmid WNW
From 0 To SO a C 4ne Gump 1'%
Foe To FT.
Form To Ft.
I. SCREE/t Dept Dian-'-- SW Sze I/laaid
Face To Ft in.
Rom To Fi M.
Rae To R. h _ Ire`
G -
S. SANDAIRAVVELPACK:
Dept Sze NSW
Flom To FL
Fmi To FL
Fs To Ft
DRl1l4G LOG
Fwat To Faineant
11. RRLIARER-
O
11001ENSIV0311WrINATINISIVELLWASOONIMCEDIECONDMICEaam
USA COGS.sa3LOaiilIIICameaml_ag/am7AAOPReCF1m
— -- INa6egOrtEDTOne LOae
Sl AINFIEOFwin asWELLc IIAeCTOR DATE
2 a-, frhaI I(6r.yO
PRINTED NAIEOFPERSON CONSTh TISTIEC
Submit the original to the Division of Water (W.ay within 30 days. Ater Information Mgt,
1617 Midi Semite Cents —Raleigh, NC 270111-1617 Phone No. (!19) 733-7015 ext 666.
Fein Gw-1e
Rea TAN

J c 'U l
RESIDENTIAL ntcous Ru notN RzcoRV
Noah Carotin Department of Enviroment and Natural Rmaoacar Dives or Weer Quality
WELL CONTRACTOR CERTIFICATION II
1. WELL
Noma Or1`\Ins
Wd trans. campsatent
'AI
SW ADDRESS 6?I /1106P ✓cir ► t
, b N;isva ll< fur ak771
City or Min Skis tip Code
(nt )• '179- Trig
Area axis nommom
tWELL a ORMATwlt
SHE WELL ID SIr1PPaa>W
STATE WELL pBasllMar* a
DWQaOTHER PERMIT faa pIcabk)
WE.LUSE (ca nAggrotl-Sag Rmdnofi WatrSoppy/'t
WTE MUSED %-/3-06
TWE count —nip ) a: 00 ASO PNy$
&WELLLOCATlft If ta171
CRY: (Zii't�p i.n4-4/4 COY l7 nYZ.Y‘tr-.
(lnonf r� 1 drI2 el— oud
(Sag Il_w.Jamtroes m�}.9�ia�4almdMa_PbalLaN•Caae}
TOPOGRAPIECf UNID SETRIIt
[Mono Waal OF ORYba DOSS
LATtrucE G o-SC
LOSGnu 3 9 ( Sf� 3
Latituddionginde some FI(YS °TopographicmP
Thai=ofalI sibsaitaonaUSGStoponep sod
tad bbfrAAinotwigGAS)
0. WELLOaW6R •
OWNERS MANE SQ C y N y c d-
S1 I ADDRESS i' IOU tl!-t,., r L,o., Lire L Ob..
413r 4110 lnrr. ?gin'
City oToan
Nay to fa arc
siedgat ber
ielrsa Meet
Sure Zip Code
r teat )- Y SA - fro t1a
Area code- Phone Maar
S.WELlETAltc
a. TOTAL CIEFIlt 1 h 0 5
b. DOES rIE.L REPLACE SUMS WELL? 'MSG ►Otp
c WOOER LEM.BdoeTape"ably goo FT.
(liar gAbase Top etCaine
d TOP OF CASING IS ) FT. Above land _ae
Tap a cabs Imni esdNaarbras1.a5.lrmwaolmen
a vaaiace i larldmm-i ISA *CAC 2C A116.
e. YIELD Ia WETIIODOFTEN' Ca
1. DISINFECT1Ott Type
s WATER ZONES ldopbl:
Ran 8'0 O To, DOS i From To
Rom To Fnao To
Fro To Ran To
G. CASING: Tbi�iicesal
Depth �6�rrd
Rom0 To 3fi' R 6'//y SA(0.1 J�Y�_
Run To R
Fran To Ft
7 GROUT: Dept
Fina 0 To a0 R Carnet*
Amount q oz
Ram To
Faso To
Ft,
R
Naledd MOS
i SCREEtt Depth Camelot Slat Sat NSW
Rom To FI. lit M.
For To Fi. S. i$.
Frteq_To R In. i► "
e. EaawRAVELFACK: - of
Dope Sire WISP 0
Rom To Ft.` s
RomTo R c..,
Fs To R.
Fiea To Fomleion DesoQBoo
11. RVMAAKS:
(29
r--5 c:
,J-
1ma®rWITEaIIIQDaiwIIL WASCISICEDIUCCORDANElml
15N=7CnC.16LCOl 0a0 r Ona4NDLI IACCI fOF76
1a0OYDMIB lHVaDYd®W111EINELLOWNER
ala-IC def.,
SKIM OFCBCrF7®vIBL DATE
4 1m1L16 s
PRIEM M OF PERSON DE WELL
Submit the original to the Division of Water Duality within 30 days. Ater: Infoaaaeon Mgt.,
1617 WI Service Center— Serials, NC 2160-1617 Phone No. [phone] s:t 566.
Fam GW-1a
Rev.7A5
0

1. WELL
RESIDENTIAL veni.cONSBUCI10N RECORD
..-_ Nato Carotin Deputmoa ofEaviomrm and Natural Resuaas-DivvWion of Water Quality
WELL CONTRACTOR CERTIFICATION i 3 3 T1 b
CTOIt
v6d i r. 1 ' 11`16t:,es
Wen eye (hldiadl>gNaee
Wen Oatsla OcanpamyN:
1lcttl ADDRESS 644 Hroat %n 20c•CI
i24 D .sv,1 to Nrc- ac771
City or Tam Stale Zip Code
(tot&}Y73'‘svS`1
Area aids Phama mama
2. WBLaaalatATIOlt
SITE WELL ID GdraPPWWWL-
STATEWELPBOAMPPapa-
DWQ o OTTER PERMIT Alf appi.ehte1
WEILISE(ChedcAppfrddatod: Rmiba6d Wawa**
DATE ORII.tID -7-.3-06
tma COMPLETE 7 30 AND PNIZ
1WELL LOCATION
CI
�
CITY: IZI )�wcvi Ie' -- COUNTY V roinc
Lpt.Je_r &-CGa.t1 bJ
MemMaine.Mntas.ammeaa>1dnamme.acme- Panel 2pcool-
TOPOGRAPI DC / LAND SER VI&
0Ele a Map fklfiet Dlaodl caw
(mom mompambi4
I owcincEaL tins 4 Y.8r"
May beindegas.
mimaQ.a0aldeor
iadoskill tisaa
Iatiwdeilorrimde smtacc {CBS oTapograptic mop
pheafao d wI wstbe shoo an a IISGS Taro map sad
addmdlo6blkna lda tin6PS7
4. WELL OMER OWNERS NNE raw" ire K�✓1 Saes I
i ADDRESS / rk.-,pc r5+-ecaC$\ 'Zc c i
14\9 s-cvl�e MC. o%G77(
CityorToam Slue rap Code
(r-rs } 979-91 8
Area ode- Phone amber
t?JELL FETAL& ��,
a. TOTAL DEVIlt
a DOES SMELL FELICECOSTINGWB.L? YES 0 NOgl
n WATER LEVEL adm.TpdCarr r,t0 FT.
Rae wMies TapdCai j
1L TOP OFCAMSIS ( Ft About Land Sather
Topdawing leaideda baba bud aabalS nit
avalance to a oardm-aalb ISA/CAC2C.a11t
e_ YIELD gip* 30 wricoaFTEST c I r
R n
ei J
L taGINFECTIOR Type HrH Mama I3n7
g. WATER ZOIESNor*
Flan r7.v To 330 Ram To
Rat To Ran To
Rom To Roo To
G. CASIta
wweed
Run TToo12,I at Z aI
Rom To a
Ram To a
Thicknnd
Makitial
PvL
7. GROUT: Depth Wisitl Melba
Fnm_Q_To AO a CCnren*
Rom To Ft —
Four To a
L SOREEtt Deem Ditmelr Slot Sze bysmiial
Rao To a im. _ n __i:
Rom To FL in. - in. CZ
Rom To a In. _ hi.
Ji
A SNOBRAVELPACK
Depth I.me Ilenai-I -.
Rom To a
F1ohL_To a
Foos To a
16I mum LOG
Flom To
1L REMARKS -
A nefmDescription
tv
r .a
G:
o
IODIRIBICEIMWinaraoa®LtamWmwcmEDSICClmmMICEwt
1i11UIGSNELiOm1iIMUMIIIMEISa7aRACQ16}6
i40mlDMS�a®1MOYCemW71EIIBl.00ami .
OFCBiutniWEL RACfOR DATE
.Vusf,r tort; il60 s
PRRTBI IWEOF PERSON CONSIIWCItLSBE Wl3L
Submit the original to the Division of Water Canny within 30 days. Attn: b *Imadon Mgt,
1617 MI Smite Center—RaNigh, NC 27690-1117 Phone No. (g16) 733-7015 wit 666E
Farm ON -la
Flea 7A5
9

OWNER
I?ESIDENTML 1VGLL CONSTIIUC'i'ION RECORD
North Carolina Department of Environment and Noland Resumed- Division or Water QUalily
WELL CONTRACTOR Ull CERTIFICATION N
1. WELL CONTRACTOR:
tedy/jeep
ell ml acla
W C (Individual) Name
MILLER WELL DRILLING, INC.
Wee Conhscice Company Name
STREETADDRESSp•0• BOX 567
HAYESVIILE, N.C. 20904
Clly or Tam Stale Zip Cale
( 028). 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID epi .policable)
STATE WELL PERMIT/IN applicable)
DWG or OTHER PERMIT sir applicable)
WELL USE (Check Applicable Sox): Residential Water Supply O
DATE DRILLED 7-01-O4
TIMECOMPLETEO AM I] PMLI
3. WELL LOCATION'
CITY:
COUNTY t/"/'4/14Ot
/44 Clcr/e4ter id
isbnl Ram.. Number. Community. Subdivision. la No.. retest. Lp Code)
TOPOGRAPHIC 1 LAND SETTING:
Igytlope L)Veeey t]Flal t711Idge L1OIher
(check spp,op,lats box)
LATITUDE _a_ /L. yes
LONGITUDES 2 Y7' /0'
Lalilude/iongilude source: IgMI'S pTnpngrnphic loop
(Inca/fort of wnt most be shown on a USGS Iopo mop end
elleched lo (his fort 'not mho GPS)
4.WELL OWNER /
OWNER'S NAME 6Qv'd dr
STREET ADDRESS 311-3 Floyd Cu(Fe nl-err&tL
&obbihsv;ile. NC- aY771
City a Town Stale Zlp Code
L—E
Area code • Phan number
Msy le In deem%
mbants, secmds a
Ins decimal Pinion
IL WELL DETAILS: �Oz
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1:r
e. WATER LEVEL DetonTop dCasino. Z° FT.
(Use''• a Awe Top d Casing)
d. TOP OF CASINO 19 ` FT. Above Land Suttee&
'Top of casing leremled Mice below lard sul ece may rtpuke
a valance M uceadalce eelth 15A NCAC 2C .01188..
•
a. YIEtD(gprn): 8 METHOD OF TEST ACV
330704
MWO
NC ✓
1. DISINFECTION: Type f{Tlt Amount iiV w/
g. WATER ZONES (depth):
From /fr to /e^6 From To
To From to
To From To
Fran
Fran
6. CASINO: Thickness/
benlh Dlameler Wel td Material
From 0To s26 FI. 6.21— _CAeefl /°VL
Fran To Ft.
From To rl.
T. GROUT: Depth
/�Maa_te'riel Method
Ran 0 To 3 FL ro`rri/atfi u d
Fran_? To ;LC P1. //11M 14- �'*r✓` ,
Nan To
FI.
S. SCREEN: Depth blameler Skit Site Matelot
Ftan To rl. In. In.
Fran - To rt.In. _ id.
ham To rt. In. In. c•
9. SANDIORAVEL PACK:
Depth
Tian
Flom
From
To
To
To
10. DRILLING LOG
From To
Gam" goy
11. REMARKS:
Fl.
Fl.
ri.
Size
Material r"
Formation Desc 1ptbn
0
0
0
100 r1Enrev CWT./IN/it MS Welt WAS voHSttWCir0 N ACCORDANCE rend
ISA NCAC 7C. W Ett COWSIROC1ON S1ANDARDS. AND MAI A COSINE NW
RECORD INS SEEN PROYDED TO WELL OWNER.
SIGNAT EOFCER�WELL CONTRACTOR DALE
//my /eecc
PRINT elp NAME OF PERSON CONSTRUCTING DIE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,
Fam GW-1

RESIDENTIAL WELL CONSTRUCTION ILECORD3 3 (° cQWNER
J MvrD
Ninth Caroline Deportmcul of L•nvkonmeul turd Natural Resources- Division or Wales Quality
WELL CONTRACTOR CEUTIPICA I' ON N 2�03
1. WELL CONTRACTOR:
/7 i2eeCt
la Individual Nan
Cord
WeeC (Individual) e
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P.O. BOX 567
HAYESVILLE, N.C. 28904
City or Tam Slate Zlp Code
( 828 )- 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID Hill applicabe)
STATE WELL PERMITeis applicable)
DWQ a OTHER PERMIT 1(11 applicable)
WELL USE (Check Applicable Box):
DATE DRILLED G -2S-06
TIME COMPLETED 2 '6O AML7 PM
(-
2. WELL LOCATION:
CITY: /l02/4(4 Yle-
Residential Water Supply (9''
COUNTY G/'ihy^'
Golf Ce'wse 4ad
ISbeel biome. Number. Cmmunay. Subdivision. Lai No.. Parul. Do Code)
TOPOGRAPHIC 1 LAND SETTING:
(elope (Valley (]Flat °Ridge °Other
(check appropriate box)
LATITUDE j. £ Z/- f7Z0
LONGITUDE
Latitude/longitude source: gOl'S oTnpogrnphic map
(kcalbn of we/ must be shown cm a USGS lo)w mop end
.inched to Ns farm 'no( using GPS)
4. WELL OWNER
OWNER'S NAME ,%', 571€4 s/(
May le in dimes.
mllnllm. month or
1n a decimal format
STREET ADDRESS 2.92. &a—
R044.wsd.l; rice
city or Tosco ` Slate
I Afie). Y1''i - 8888
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: Vi?
02 771
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
e. WATER LEVEL Bekm Top d Casing. C 0 FT.
(Use's' 'Above Tap d Casing)
d. TOP OF CASINO 19 / FT. Above Lad Suttee?
*Top d rasing terminated aVa below had 'unlace may lequhe
e valance In accordance wl11115A NCAC 2C .01•
1e.
e. YIELD (gpm): 2 METHOD OF TEST /Sir
1. DISINFECTION: type
O. WATER ZONES (depth):
From &00 10 20 7
/ rr Amount
From To
From To From To
riom 7o From To
C. CASINO: Thickness)
beplh Diameter Welghl
Fran 0 To Fe rt Gies' .Saza
From
Fran
To Ft.
To Fl.
NC
Mpterhl
v�
T. GROUT: Depth alefd / Method
To. 4' Ft. a/'��46y _
Fran 3 To ao FI. Qv/If'9 c
From To FL
It SCREEN:
ftom
From •
Depth Diameter Slot Size Material
To Ft.In. In.
To Ff. In hr.
Flan To rt. In
9. SAND/GRAVEL PACK:
Depth
Pram 10
From 10
Size Material
Ft.
Fl.
From To FI.
10. DRILLING LOG
From To
0- PS'
3 v z
1 I. REMARKS!
Formation Desctiptbn
cloy
/r/pen- *a
c
c
100 IIEntay COI MT lilAt 111! wEtt WAS COrtstmdctto N Accorumct whit
ISA NCAC 2C. wEll CONSTRUCTION SIANOMOS. NlU INAT Atari Ot MS
NECORO ILAS BEEN mummy TOWN WELL OWNEtr.
S,,,r�,r< 7-oy-0ff ,
SIGNATU E OF CERTIFIED WELL CONTRACTOR GATE
Arty "acee
PRINIEDMAME OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Inlolmetion Mgt.,
rmm r1W.1

Se)
RESIDENTJA4 WELL consrxacrwK sicatut
Nord+ FaoiFaDepman of&.-.- a ent aid Mount awes- Diva Si Waat QmSity
wall, catrnucaoR caerinct norn . -2 470 /
33C364
t. well CONTRACTOR:
ratio 1Z imiLn
nesCanartrs Kpwwmd}oma,.
I,viIA.6n bell r1r,`u,n
weGn atConpralUaa
STRIET ADDRESS c_S '5/6 /,c )RCl,
ictss�aa N Cr90a
fly or Taan State Tip Cain
t v- -' .K3 T- Q41r3
aoats— Pa nap I. aYteiO1allAtint
ens Ia1 tO ea
STIRSMeth FIRMITI PaFoleydal
DWI re OTHER Peet et/wa.tt
TruiMIEtaloatsag* Rasa wreallorMgi .
MTh MUM 7- l ?-z ,
TIMSOkMtMEM -2 ?o •
CITY: (ail n b h 1 ✓I { v; (I a COUNTY GM kv-t i
Ion prtOn ,
sane...1........osonteaUteb.*aa4 aptlaey
AM❑ PN�
T flak SETTS*
rAiarap;aaraal
tAITTUDE
LONOMJOE
May it antra,
mist a to nta
haaaatiama
fAlialggigudg— van oaosailit:aotp
Aaaaf a daatanta as as a Date mop and
rite -_warier OPS)
aMELLaMaBe _ I
arts at L._ ne Wl,•nTr
:�QDOLTADDRESS F. c^ -R c K 73 4
AOMilli/ i/ie her, & ? 7 7 I
CaraTq.n Sra 73pCod,
t_--. -
Aaaeade• Pa ease
a WELL DETAILS:
n TOTAL Dtlm qs'
t DMMILLIMPI CEE7Ei,MMIL? YES ❑ NOD —
a. WATOt Una as Carr JD L . FT.
(doe•. *Mom Top Wi tan
d.TO►PIC11.Dar, I • FT.Aaaalaadfact
144 onerl. ._- na aaa aaa an wo raa_ada
ovwaa•wtaaiatioai`a 1aA MAC 2C..EHt
!Cr* c?O ITMODOF1ST 121,/Z
t COMFtCTIOst Typo PN 11 P 6 r- it
Y. MATER zo1B ldapthl:
Fos To Fran To
Fran To Fran To
From To Fran To
O. COMM
Dent Das
Rom To Ft.
Rao To Ft
7. (MOUT: Onah
Faa_h_ To
Fua3` Tc
Thicker*,
Weigel aarar
•11.
S. =MEM Dada .lamer *Ma Mai
hem_ R. i. in.
Tam_ To Ft • i< - in.
Fan To Ft m in.
it - SAtOptIWEL PACK:
rapt Sao tin a
Finn To Ft
Ftara�To FL
iaaaa To, Ft
:1140ittme Los
Fa To
- lc'
- ter'
enf - 14S'
II. PZIMMIitS:
Vhay en 't1Qc.k
rotoGarcan}rrwarTtaaaataaaaaglaaa ggi iCaga i aanr
wnc asaatLna..aCt.ar--- i.nrarnitCartnreg
atraoanoawnS 1OTauwaa.GSM
aC'AlvY,Pn/} Ain7-/.
S SitIPIE FCEIMPIEMwell • • •
1 vtn vvt (A3, tSOv'i
s_/oFPiA•DMCCs?rinuGT THE mat

RESIDENTIAL WELL CONSTRUCTION ItECQJ?kt V i U
North Caroline Department of L•nvhonnlenl and Natural Resources- Division or Wale Quelhy ,
WELL CONTRACTOR OR CEIL1'IF•ICA 1'ION N
1. WELL CONTRACTOR:
P-Cr eece,
Well CanIr l/Ca tlndlvkivatj Name
MILLER WELL DRILLING, INC.
Well Contractor company Name
STREET ADDRESS PAL BOX 567
HAYESVILLE, N.C. 28904
City or Town Stale Zip Code
( 828 F 837-2997
Area ccde- Phone number
L WELL INFORMATION:
SITE WELL ID Apt applicable)
STATE WELL PERMITA(e applicable)
DWG or OTHER PERMIT A(II applicable)
WELL USE (Check Applicable Doa): Residential Water Supply ()/
DATE DRILLED 7-(1-- 64
TIME COMPLETED //200 AMIerMU
3. WELL LOCATION: /
CITY: Mail e/14 COUNtY 6%a-4A'•
CAt'tweY
'SOWNema.1 umbeu. Cammunrly. Subdivision. Lol No.. Perch. hip Code)
TOPOGRAPHIC 1 LAND SETTING:
OSlope IEKidiey TIFIa1 ORIdge (jollier
(check appopilale box)
LATITUDE . / i. rvs"
LONGITUDE . 3__ 9 7' 83
Lalilude/longillde source: t9G1'S ❑Topographic ulnp
(kcalbn of web most be shown on a USGS Tope map and
stretched to This fort rnot usk,g GPS)
4. WELL OWNER // / 1
OWNER'S NAME Tdh/l CfJe/"ely7 eh
STREET ADDRESS 7S1Z Mfbb/4A Car1�,4-7
l7 o/4...n Ale (Pit /
City a loam Slate Zip Code
May be In deplore.
minting. seemah ne
bra decline? Mimi'
2Z3-174)7
Area code • Phan number
S. WELL DETAILS:
e. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er
e. WATER LEVEL BrlowTop of Casing: FT.
(Utter II Above lop d Casing)
d. 10P OF CASINO 19 / FT. Above Lad Surface'
*Top d casing lent,ded BUM below lard eu,Ince may require
e variants h acccldance Wilk 15A NCAC 2C .0116.
e. YIELD Wpm): /2— METHOD OF TEST /9//-
1;-fo 3
OWNER
MWD
NC ✓
I. Df91NFEct1ON: type #% [7 Amount
g. WATER ZONES (depth):
From ,Z70 To 27/ From To
From To
Fran To
6. CASINO:
From
Fran
beplh blameler
Ran 0 To /67 Ft 4-As"
r,an /07 To l.Ly FI. /e. AS'
From 10 FI.
To
10
ihlcknessl
Weight Maleld
$a421 /4/G
./9Y 5Ace
T. GROUT: Depth le
,�Ma,Jal / Method
Fran3To 3 rt. /'oft(�
From 3 To rt. �ei7u#t -ice rfj y
room To PI.
B. SCREEN: Depth Diameter Sid Size Material
From To rt.
From_
Fran
To F1. In. ko.
To Fl. In. __ In.
B. SAND/GRAVEL PACK:
Depth
Prom 10 FI.
Size Material
F,an 10 FL
From To FI.
10. DRILLING LOD
Ftom To
D - /2-e
�Z0' ,212
11. REMARKS:
Formation bescrlplbn
41/
Tan
c
r
co miner CEP ITT 1NAt bits WELL WAS CO,gtRUCIte N ACCORDANCE WMI
?SA NCAc 7C. nit CONITIIUC110N B1A110ARDe. PhD TKO A COPT Or nets
RECORD H AI BEEN PROVIDED 10 Mt WELL OWNER
7-/z-a6.
BIGNATUROF CERTIFIED WELL CONTRACTOR DATE
ArryAec2
PRINTED NAME OF PERSON CONSTRUCTINO TIIE WELL
Submit the original to the Division of Water Quality within 30 days. Alin: Mtomls tion Mgt.,
ram OW.1

338 698
RESIDENTIAL 1VELL CONSTRUCTION RECORD
North Carolina Department or Environment and Natural Sesuurcei-- Division of Water Quality
WELL CONTItAC'TOIt CEILTIFICATION A 2`I01
1. WELL CONTRACTOR://�
/dozy
ezc
Well Canlracla IImdlvldual) Name
MILLER WELL DRILLING, INC.
Well embitter Company Name
STREET ADDRESS P•D• BOX 567
HAYESVILLE, N.C. 28904
City or Tam Stale Zip Code
828)- 037-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Ipl ervncsble)
STATE WELL PERMITIINeppacable)
DWO or OTHER PERMIT I(II applkable)
WELL USE (Check Applicable Box): Reskienlal Wale' Supply 01
DATE DRILLED 7"a"D6
TIME COMPLETED Sye D AMU PM W-
3.WELL LOCC�/y,TION%J•
CITY: /IOr4F ;n5 i%Yle
tear Cr zit( foC*aP-
(SbaN Neme. Numbers. Community, Subdivision. Lel No.. Parcel. Zip Codel
TOPOGRAPHIC I LAND SETTING:
LgSlope t7Veley Oriel (3Rldge ❑Oilier
1chedt spproptlale bon)
LATITUDE ..L r /2i7
LONGITUDE I_ L ¥3. 0 5 3
Latitude/longitude source: 106PS EtTopngrnpliic mop
(bcalbrt of wet most be shown on a USGS Iopo map and
eneched Lo Ihb form r not using GPS)
4. WELL OWNER �J
OWNER'S NAME /(Ode? Sc /are
COUNTY 6rei-eXa
May 1e In delreet.
ndinnes, second, a
In a decbuel liemal
STREET ADDRESS 31 Beetr Greek 11rive_
RobbinSutlle_ A/c ZfS77l
ClyorTown Stele
t �z� F Sb? - 1�3tt
Area rode • Phone number
Zip Code
&WELL DETAILS! a. TOTAL DEPTH: 3 (�
L d
b. DOES WELL REPLACE EXISTING WELL? YES O NOg�
e. WATER LEVEL Below Top ot Casing: S 0 FT.
(Use '1* I Above Top d Casbg)
d. TOP OF CASINO IS / FT. Above Laid Surface'
gyp d casing lermkated ego below land eaiece may require
a valance h accordance nth 15A NCAC 2C .01111..
•
a. YIELD Wpm): / T METHOD OF TEST /i 7-
OWNER
MM./
NC l/
1. DISINFECTION: Type
V. WATER ZONES (depth):
From e210 10 ZS)/ From To
From 32t To 722 Fran To
r,o,n To From To
6. CASING:
Amount
YAP
Thkkrressl
Depth / Diameter Weight Miterlal
Fran 0 To 6 Fi Ft. b-zJ� Satz I I C
From To Ft.
From To Fi.
T. GROUT: Depth Material / Method
Fran 0 To _ FI. Aline "gin ��
From J To D_.rt. Je�i6nYG .e
From To F1.
R. SCREEN: Depth Diameter Sbi Stze Material
Rom To FI In In.
From , To F1. In. in.
From " To rt. In. h.
a. SANDIGRAVEL PACK:
Depth
Ran To F1.
Ran 7o FL
Size Male,laT'
From To Ft. !'
10. DRILLING LOG
From To Formalbn Description
0 -- sS C74y
5 5-- 34(0 CryvaHe-74't
11. REMARKS!
C—
c
100 HEREBY CERTIFY THAT PAS WELL WAS COURtnOctto N eccorrU*NCE MIN
1SA NCAC TC. WELT CONSTRUCTION STANDARDS. Ar101)TA1 A COPT OE De
RECORD INS BEEN PROVIDED TO THE WELL OWNER.
_ e -D4` —l)-fl ,
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
ct
PRINTED NAME OF PERSON CONSTRUCTING 11IE WELL
Submit the original to the Division of Water Quality-wIthln 30 days; Attn: Information Mgt,
. _.....
Form CW.1

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2045
0 €
1: WELL CONTRACTOR:
James B. Brown
Well Contractor (Individual) Name
Hedden Brothers Well Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 73 Holly Hills Vista RD
Franklin. NC 28734
City or Town State
(828 )- 369-9591
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
Zip Code
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply g
D DATE DRILLED • AlO�1t • 0 Le
TIME COMPLETED &: oo
3. WELL LOl,AT10N:
AM ❑ PM)0
COUNTYb12.11a /71
(Stye Name, Numbers, Community, SubdAision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
[Slope [Valley ❑Flat (0 Ridge ❑Other
(check appropriate box)
LATITUDE4 0984
�y
LONGITUDE Rat, tLIIA7
Latitude/longitude source: IKGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this (omit not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4 WELL OWNER
Ant
STREET ADDRESS -P +•OX. Loi I
en1J m anLO a 4 ownState 028771
city or Zip Code
Area code - Phone number
5. WELL DETAILS: , fnr
e. TOTAL DEPTH: _3�j(-J
b. DOES WELL REPLACE EXISTING WELL?�
?�
YES ❑ N0
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use'+' if Above Top of Casing)
P. TOP OF CASING 15 2 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): 00 METHOD OF TEST 131°W
f. DISINFECTION: Type H T H Amount 160Z
g. WATER ZONES (depth):de
From 5 �1,:�
5 To °15 From To
From To From To
From To From To
6. CASING: Thickness/
Depth OO Di meter Weight Mate ial
From Q To Ft. �0 C
From_ (61 To Ft. re - �e'
From To Ft.
7. GROUT: Depth Material Method
From 0 To 20 percent & benonite p
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. In.
From To Ft. in. In.
9. SAND/GRAVEL PACK: it
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
9 LLY3
Formation Description
clay & sand
granite
CA
m
-0
rn
11. REMARKS:
Eec.I I1 ¢d i.�'1Lorga0b J& xed
U.a�m5 (/ICO'
D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ATURE OF CER i ED WELL CONTRACT[ DATE
James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION, 2045
1. WELL CONTRACTOR:
James B. Brown
Well Contractor (Indirvic uatName
Redden Brothers Well Trilling, Inc.
Well Contractor Company Name
STREET ADDRESS 73-Holly Hills Vista RD
Franklin, NC 28734
City or Town State Zip Code
(828 )- 369-9591
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) �a.
WELL USE (Check Applicable Box): Residential Water Supply!\
XI
DATE DRILLED 9..�s
TIME COMPLETED - M-VV AM ❑ PMk
3. WELL LO TION: -
IT� COUNTY�NU4I[!//i r
eet Name, Numbers, Community, Su Nolan. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
;-.Slope °Valley °Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE .J ,y0,
LONGITUDE 2 01,�
Latitude/longitude source: iiGPS °Topographic map
(location of well must be own on a USGS topo map and
attached to this form if mot using GPS)
4. WELL OWNER
OWNER'S NAME
"RED ET ADDRESSL]L7C )
IIICity or Town - State
Area code • Phone number
May be in degrees.
minutes, seconds or
in a decimal format
?ern —
Zip
Code
5. WELL DETAILS: �L'D
a. TOTAL DEPTH: ']
b. DOES WELL REPLACE EXISTING WELL? YES ° NOK
c. WATER LEVEL Below Top of Casing: Ca CD FT.
(Use •*• if Above Top of Casing)
d. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
o. YIELD (gpm): AD METHOD OF TEST Blow
U u i el 0 0
f. DISINFECTION: Type H T H Amount 1 60Z
g. WATER ZONES (depth):
From A03 To 3105_
From aa0 To A07
From To
From To
From To From To
6. CASING:
Depth DI m�er
From O To 103 Ft. ( o
From 103 To_JQ(Q-Ft.LC r(Se
From To Ft.
7. GROUT: Depth
From To 20
From To
From To
Thickness/
Weight Material
Material Method
pement & benonite pumped
Ft.
Ft.
8. SCREEN: Depth Diameter Slot Stze Material
From To Ft. in. in,
From To Ft, in. In.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Frofn To Ft.
Material
10. DRILLING LOG
From To
Formation Description
r1Ry & sand
g1-art.LtP
c..,_r �, L.;..
11. REMARKS:
EBC! 1A101.0
w
rrl
-13
1 , ...
O
tir
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO0. SEEN PROVIDED TOT E WELL OWNER.
ATURE OF CERTIFIED WELL CONTRACTOR DATE
James B. Brown
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 WSIA.CONSTRUCTION RECORD
North Cmo6Da Department of animated and Nedra Rnaaees-Divmm of Water Qudiy
WELL. CONTRACTORCP7CnfiC4TIONs 6
1. WELL CONTRACTOR:
o/�Uat,�1aKr ♦ �Name e e, <igp S
7l 1! 1h.C.nr. �2Q�U ri�Il'ZS
Wei Contractor Canon Name �nn
sTRREEET ADDRESS ` 5 LI H vcie Lc-) n \`a ci
i �f\'1tl:r5✓i1 le VC, SCj7/
City oTann Slate Code
(_€ a- . Litt - g-ti Sy
Area code. Rom inmost
2 WE.LWOR1eATIOlt
SITE WELL O till reoloale)
STATE WELL PERIIITINapoicaras1
DWQ or OTHER PERMIT 3(Iapplca61e)
WELL L$E (Chedc Appirids Batt Redd..&I w>dor Soppy 0(
wic
DATEo DRILLED Y—.3n -AL-
T'BIE COMPLETES / /f 00 Aug na O
3_WRLIM TIOIt ^ 1
CITY: i•1b}rinS✓1ilia COUNTY%1 TNUW�
.Pc,raol.r5e go»cj
Menet Ne ne..nium++- Oemserer.BWd.Ybo.Lettie.. parcel zip Cai}
TOPOGRAPHIC / LAND SETTING:
OSlope Malay OFW AU* Man
Woe&apaapdalbd
LATITWE 3c r r 13-8"
LONGTatAE, OH.5 (
May tc in dope,
mimes, stands ar
Ma &eel foe
Latitude/longitude sw= ORS °Topographicn
(bat= d wei met be shone an a USGS tope map and
dadrd l Si fatal not aft t'
4. WELL CANNER
OWNERS NAME V 06 I E'. a cr-)
} :ADDRESS Pox, (Yicp 12ce,r'I
bir5;rur Air �fs7l
(ill or Town Sege rip Cade
(ids1- 1-/79'—c&9'
Area code - Phone number
SINES DETAIL&f
a TOTAL ° nt h C.c
b_ DOES WETS REPLACE FLQSTis wa.L7 YES O NO Q(
c. WATER LEVEL Oda, Tap dtn.S O FT.
(Use*** iAbele Top avian)
d. TOP OF CASIGI , FT_ Mae Lae StStancescagey"Tap d cagey Maeatrrbmwbad wYcarelsNga:a
atv)saer exeercealla 15A ICAC2C MM1d
e. YIELD We* O METNODOF TEST CAI r-
3i1J28
L IDISINFECTIOtt Type I -I T H Avant O
g WATER ZONES (dap*
Fain To
Rum To Fmm To
From To From To
e, CASaaG
0�p�r Thickness/
Fmm�_TToo % FL (� i it?2(
Rom To Ft
Rom To • Ft
7. mail: OgS
Faia e) To i
Ram To
Fan To
8. SCR®t Depth
Fan To
Fqe To
MSS Itrsrm
Ft CQ O'tnd- per" inns.
Ft
Diameter Slog Mamrid
FL id d
FL s. _ is
in.
i SAIOIBRAVEL.PACK:
Death See IMeti•
Rom • To R.
Foe To R.
Root To R.
16. °RILING LOG
Rem To Formal -.Desolation
m
[,Li
11. REMARKS 7 ✓
111011BIEIWOMFTINIUMISWEILITASCCOMINICIEDOIACCOPIYJICEINCH
asArwer .wHLm67FamtS NMOMES.Aroana rwae
IEeaWtNaONMPIC DEDloaEwHLaw6t
9pNTlO'E�0¢:C6TIF�'
DATE
�,('�rI5-ce i
PRIiT®IMIEO6t8ON COs1!►�I1CIlI6 THE W131
Submit the original to the Division of Water Quality within 30 days. Attn: MomuBon Mgt,
1617 Mall Service Center —Raleigh, NC 27699.1617 Phone No. [phone] east 5611.
Foe moV-1,
Rat7A5

Rw»ENITAL WELL COlSPROC170NRECORD
Nash Gotta Deparmemt atEavioomeot and Natant Resaaacs- Divisim of Water Quality
WELL CONRACTORCERTIFlCATTONF 33C6
1. WELL CONTRACrat
I/154n:• ►A/VM fir
W arm. Ortivideaa tt Nana
Wd Damian CsgsyNaoe
ST(REETAD 63 I tide thM' '(1�
ICU11Di-,5414 Are �y167%1
SS or Tarn Stele �` Code
LC )• - gS43LI
Aran and.. Paaasoamer
2.1'4E11RFORNAT101t
SITE SELL ID NT age
STATE WELL PB INTINesidoldeL_
DSO a DTtei PERINI8(iamicable)
waLUSE (ChedcA/p'piubbaaaX Roamed walrSgepyO
DATE mum t 91- 06
Tare C0167.ET o 2 ( ) PAI Pei I:4
SWELL LOCATIOlt
CITY: f2e b,:.E,f 14 COUNTY Glett
0 Doe r T),tkkoo -eee. aoae,
(saeetNeenteeeeaa.naa code- ..
TOPOGRAPHIC I LAND SETTS
DStpe Oar OF gHIdge °Other
appapbb
Seelbad
tATtrIDE .r`�LI A 3ci.9,r
LDNGITUO g3f IiLI' 9 r1
LatitudSkmgimdesaice OTepogapermap
phcaeoedrdasaetbesteno oeaLEGS tow amp aal
a`ciadbisAnt oink gGPM
4. WELL OWNER
oWtaBtStUaE (Lr,01C, 't I" ley n -I
ar •ADORSS ire
Vu5 CeirEP ICeaagni
CigaToon Slab Zip Code
((et )_ 147F- 3g46
Aran ode- Phone number
'Am Min :peek
in admire Seat
S. WELL DETAILS ��
a. TOTAL Dente
1ti DOES WELL REPLACE EXISTING WELL? 'YEESO NO
c s WATER LEVELOdTwpetCedar `?J FT
(Datum lamaTop dCa toot
d. TOP OF CAZRS IS 3' FT. Abase land Skirts"
'Top desagtaatoaaaaaabets Sod sec rim rerple
adame fa aocada aoeaaah ISA!CAC 2C ANL
e. *GSM (ipae); / 0 auET11000FTEST Ca r"
e n
6.3 i.41
L DSEECtloltType Firth Airman! 707
g.
ROMli ZONES (deplbr
Fame
Fran
To Fare To
To From To
To From To
G. CASING: o Twliielmessi
Rom O Two IIS FL 6S4i VIZ
Rum To Ft
Fraq To Ft
7 GROUT: Dept WSW
From 0 To 90 Ft C nerem )-
Fm_To Ft.
Fa To R.
Udall
8. SCREEtt Dept Diameter Sld Sam PANGS
Faro To Ft. in. in.
Rea To R. S. _ R
Rom_To Ft In. M.
s. SNORRAYaPACK:
Dept Sze 'Medd
Fan . To Ft.
Fa�To R
Fon To Ft.
it SLING LOG
Fan To Famaimveaopian
SF.P 1 22C5
11. REMARK&
r
•
tit
IaD,6Brt8Rr7evlatwaaLaeespaiNC,maaavom�aaor
aaaaaaleaaalalLUMMUCdeSma0e0RALFmmAC@TWINS
NECOIpMma®IPROV®W IeENBLOWIER.
CrIAZ /474,/' c cc-AI-0
.FIE OF CEITIWIEDWEIL CadDite TORmairsid1TE
1 J54-,i. 1 r ts,1 rN OF FERMI TlE WELL
Submit the original to the Division of Water Quality within 30 days. Amu. b(anpUon i18t,
1617 Mal Service Center —Raleigh, NC 2f6uS-1617 Phone No. [phone] ext 588.
Ram OW-1a
RaL71W

RESIDENTIAL WELL oomsmucnow RECORD
Nat cat Deparrmmt otEavi0000t and Natural Resources- Division of Water Quality
WELL CNTRACTORC1lCATLW133�s6
cTott
Wd stales
(Yldvfa+4 Name !
stales
YYivv* O LJe\,\ rt1,t„a
Welcandor Compaq/ Mama ''j''
STREETD ADDRESS i'134 it yae Ton .
PClboa-n5✓nu#_ Afc- 9. 711
On orTom Stoke Cede
�l79- etigq
Anna— Pboeesama
2. WELLUftOREATCOnt
SITE WELL D IptaactoNH
STATEWELLPBOIIIIpapdaatl .
DWQmOTHER PERMIT IR ppi'a+4
WELL USE (ChedcAppberdieBath Reddened Wane Sop* IR
DATE DRILLED a/e 04
TINE COLLETED I a = QCi AM❑
SWELL LOCATIOW
/ `
lieetd rive
(Sheol as tiumbaeOe leil dhign eataae-PaaOoaa}
TOPOGRAPIIC / NAND SETntIG:
OSlupe Ova OFIet redge Mew
tam* appmpas24
LONGDWE±a° Li ' n7,0'.
Iatitade bade some Mips OTepOg apmt awp
&COM d set %sat M show am a lASGS ipo mp and
aaa3adwFia doaa7ad-iq CPS)
4.VMS 0111ER
OWNERS WALE OQar\ rn"r1 1 rc.
silt! ADDRESS Sere ° i de
y
I G[J,4 r'., )Ie. /YG -.9e77 /
Cey oToan Zip Code
( tio7 } CIO- "3°1 O l
Area code- Pharr mmiha
der beidogma.
inthies,seambor
isade led lima
SWELDETAL&
a TOTALevitt b S�
b. DOES WELL REPLACE DUSTING TNE.L?//YY�ESO NDg
LEVEL
a WATEtLEY6darTgd' t /KV FT
(User 'Abaft Tap dCane
d. TOP OF CASING IS ( - FT. Above Land Sand
Wog dtag tmalne_der bast lad sodas nri ego e
eater in amadameti SA NCAC 2C Alm-
a. YIELD Set 1 E7(IODOF1ST our
9 rk
0 F}
t OEECnmftType NTH
g WATER ZONES (NOW
Fran 1401 To ,CSS
Root To
Flan To
Fran
Foam
Amount act OZ
To
To
From To
6. CASING: q� Ttciweov/
Farr O Depth
A l a Ft b q%4'aea =
Forma To FL
Foam To Ft
7 GROUT: Dept eeahedd
Fam t) To 90 Ft �f
F+as To Ft,
Ram To FL
Metod
pOrnplAs
a SCRW1t Depth tame Slot Sian idatoai
Fan To R. in. d
Fat To FL in. in
Finaq_To P1 In. In.
!L sMcopA1aPACK:
Dept Sze Yataaie
Faro . To Ft
Faati_To_
Fan To R.
It ORlll-IlG LOG
Eno To Fenton Dasaip ion
SCP
11. REMARKC-
L
en
Roam conwroornswessocNfssonaAtmam eerWI
ErrWxsw9LCOI CWnEVWamm.AM7eRAOlprffl6
PECOamwm i®aNIW a®W 111Ewatam6l
A: 0_
Sate OFCERMEDWEl1 LLIACrOR DATE
Pnfl tI;In V rtl ` t dF PERSON �1{SfAII RNG THE WELL
Submit the original to the Division of Water Quality tallith% 30 days. Ants Morn edion Mgt,
1617 Mel Service Center — Raleigh, NC 27699-1617 Phone No. [phone] sxt 561.
Fam ON -le
Rat 7105

RESIDENTIAL WELL con3'1'ROcfloNRECORD
North Cathie Department of Environment and Natant Resaaca - Dlvaim of Water Quaiy
WELL coven ACDOR CiDC nocr70N 0 33 6 6
n 9 1 +' P
eluJ27
1. WB1
US+,n 1'Itttd'Grs
We( ant aobr(idaiWill Name R 1
11Cn\fw,vv. I ,)e11 rtains
WMCa,aador Sam M aura /J
STREETADO'j"'RESS C341 Tcd9 + o^�'12e d
>lab,-.c;,Ij-e (Yc 9 7r 1
Cit7 erTOM Sii Tip Cede
(SOt- tJ71- Fs41b`l
Area Cods- Rae number
7../111ELL INFORIU.1101t
SITE WELL D DIapplala)
STATE WELPgaOfilpapeatarl
DWO or OTHER PERMIT Ea mpicable)
WELL USE (ChadcAppidi Bats landed"' WllerSrWle*
oATEomum it ),S-- 0 6
TONE COMPLETED 31") AMP PM9j
WELL
1 CITY: Mit�I rK. its
d-e C00,1\ NC/pats
lacteal Name.nessnees. Caxesellyalabassissalla.PalestIIpOaeN-
TOPOGRAPHC 1 LAND SETTING:
oalope Way y oFlal DM* Dag
(ebse
LATRIDE Se Vt%, 6 t "
LONGUtDESat t//90•firt
Iatituddkogitldcsow= &CAPS oTopograpiicmop
(Ica fa
alrJ&I MrIns
fad saissGPM Ar9
0. OWlBtS NAME V �I �--"�"7
bi IADDESS 'FPfnq)n
1 bC.��tile fv2 s-'1/
City or Tow Side a Cede
t tat i- 4'1 T - 8-7 0
Area code- Phone amber
A YYiw�
Way Sistine;
alma eQadror
iadesiod Oar
& W610ETAlt
a. TOTALOEFT1t 30
his DOES WELL REPLACE masons Woe, YES NO Of
c. WATER LEVEL OdoaTapmCasig in FT.
(Derr NINosTop dCain*
d. TOP OF CASING IS / . FT. Arm Lad Sarin`
. 'Tap dcalm tmaleidagar bean bad mafd-o/m9mie
avimcai aooaiaoi 15AICAG 2C A111
e. YBDISP.k An METHOD wTEST al T-
L pSaFECnatt Type HTH Mae! ) 0 nZ
g. TRITER ZDSF8Napa*
Front /0 t Toad From To
Flint To From To
From To Fran To
6. CASING: Tlidmmd N1
ROM 0 Depth
e FaAC/ FL f .7.) f�i
Farm To Ft
From To Ft
7. GROUT: Dept
Velar Meld
Fain 0 To ao Ft Ce rnw4- ()VIM pas,
Frain To Ft,
Form To Ft.
a SCREETt Depth Diameter Sloe Um Material
Fe® To Ft. in. in.
Flats To FL fa _ i.
Fmq_To FL in in.
L SIIMKIRAVELPACK:
Dept Mee Malarial
Fls__To Ft
Fio�_To R
Fs To FL
1l ORl1R4G LOG
Flom To
Formeioo Dtaoipion
CO
SEP 9 200
1L REMARKS:
Ve
O
4
IOmw TWIELSCCOlmam-e®mAtNOsaAame
191aSCICON HLe016aaCIMISmaOmReaaHAACOPrOF71a
I6V mmrs ®r�ROp®W 71evaed
t1t/ jelet
sigarauft — / aLcairiyso e jr m
iT_4 OSTE
an) Ss to Y htt6 il�l°G .5
of PERSON oolLSTwlc
THE
PRIMED NNE WELL
Submit the °Vital to the Division of Water G1oSKy within 30 days. Ann: information Mgt,
1617 Mall Service Cants—Ra1N0h, NC 27609-1617 Photo No. [phone] etct 660.
Farm GW-la
Rao 7R05

RESIDENTIAL WELL aarismucrioNRECORD
North Carolina Dgatraoat dEsau meoi aodNmord Rea aaetg Dion of Wier Quay
WELL CONTRACTOR C R 1FICATION, 33"ivivisi
1. WB1t �tONIRACTWt
Iic*ln VkI\t6r.r05
W l r lNina
An� rill
rrw, We t.
WelCanter CmapaoyName
STREET ADDRESS 631 klri? TAX ``(J
1Z)bbkned," e IYc 9r677/
City or Tow SW* TIP Code
t IOC 1- 1171 - *4 K4
Area ad. Phwsaoaaa
2.WELLNFORMATION
SITE WELL D 1(iam@mlel
STATE WELL PEOMTeRappuY -
DWQorOTN62Pt3tMTi(ia ]_ y
WELL USE (Check AppidigBog BuddedWafer
+ WaSappy(
DATE DRILLED / - C 6
TONE COMPLETED /: 6fi
] AM❑ PMg
LOCASOlt CITY: A 4-) n<✓11 � ¢ CDUNTYV YcAnter
re-d.0 Q.V\ 200 J
(Went Nisi taries.Ooreirgentht leAlstrb_Iwatamorist-
TOPOGRAPHIC HAND SETTIM
OSG R MOON Grit Midge OOma
imam ' ° LATITUDEonga'/a-9"
LONGItIDE.3 41 ' 54.7'
Lati W ddlaa®mde coals KGPS °Topographic map
tbcataldaa/alrtheMom w a USES kw amp ad
Sada'baibs)not oft APS)
Meg bed degas,
sialga®dsar
Ma total tea
aWELL 'Wle'
OWNERS NAME
6Ab Poker
s•tuADohms ` -ecc1Tl, (lz.tJ
,W,rs.41. Nt- b*77/
Ott or Tors Side TV Cade
(r)-SS7- 0781
Area cede- Phone iambs
S. WELDE:TALs_
a. TOTAL Dann / SS
b. DOES WBIREPLACE EISTINGNELL? YESO PC
f,
c. WATER LEVE.adosTapd' g La FT.
(Use^PiAtone Top(Staabg)
d. TOP OFCASING 6 / - FT. Above Lend &Wad
. Wo d cadre InelsOdriskelolaudaaamFaspire
anodise itasidiDai 'MCPC2C DM
o_ WELD _ r'>Zi •Encoarnesr 00 en
L DISINFECTION Type I-1 TH Mast
g . WATER ZONES (doll*
Rom ti Si To / 5S ran To
Run To From To
Rom To Flom To
6. CASING: Tbictne+sl
Weiglt
Flom 0 Two /0' FL �� /� SORIA'
Rom To FL
Rum To Ft
7. GROUT: Dan tumid M lhad
Rom 0 To ao FL ( ,ntF poVhp;s
Rao To FL O
Fl
Root To FL
L SCREE* Depth Dla obir Sid Sae Materiel
Fm To FL I. in -
Fa To FL S. _ is
Ran To FL In. in
L BNOIBWNELPACK
ONO Sze Medial
From . To FL
rml_To FL
Rom To Ft.
1L DRILLING LOG
Fan To
11. REMARKS:
Fermata DeaoiplioR
to
I
IWIENER C1311,w—lp EIL ItACCOONCEaril
6RWIC2%1I131CO IRMUCIEinswaerrm ma no ACOPYffaD
Ia:ODsaa OEM MOVIDED10 1a8s.OMER
7944
sigwa Lc `t 1E
OFCEiIFEDWELCONTABCiOR DATE
00 'In al; c�pS-
PARRED IMIEOFFEWON CONETIWCIWGTIE INE L
Submit the original to the Division of Water Quality within 30 days. MSc tenon Mgt,
1617 Mall SNvice Center- RalSgh, NC 27699-10N7 Phony No. (915) 7334015 cod 56i.
Fam GW-ter
Rst-TA5

RESIDENTIAL vita cot SI'Rucnoti R&CORA
North Carolina Department orEavioomat mediated Rws urco- Divan'
ivmm d Water Quality
WELL CONTRACTOR CERTIFICATION
GONTRACTOit
ji/N
WW.0 ndhxtr praivihd) None
IG�Yrlvvl trall �i'1
Wd Cama:aor CompaWPl e I
STREET ADDRESS 63`I 1-1 yCE y e / ov,\ 1ZccJ
t blr.s,i'Ik Mc ac77r
City or Tan Stele Bp Cork
( tdu )- `/7' — St(5t1
Area axle- Phone inneber
2. WELL NPORMATIOIt
SITE WRL ®fl Mamma)
STATE WELL PEiiIT'PS)
DWQ ur OTHER PERMIT 6(i appicatle)
WELL USE (Check Ap elke RW earet waerSappqfil
DATE MEWEDb el
THE COMPLETED ( 0 AM❑ Rig
iwELLLOCATE* /�
CITY: I�\- ,;r ✓;11e COUNTY�_7)2 \tN'v
Via L' ego( i2ectel
Calmat Wwa Iteadwei Como ely_Sd liala4SSUte. pascal aF
Coda) -
TOPOGRAPHIC/ LAND SETTNC'
agape Maley Dna Owes Daher
peek
LATITUDE 3 S0e ' `i 3. 7 di
Latioude/loagitdesou= *WS °Topographicmap
(!Deaf= d eweratrd60 shown an a USES kw nip sad
a 6 dm d la Mt Tomas d wing GPSy
4. WELL COINER
OWNERS NAAEGLACE ,'//er
STREET ADDRESS folk ('r✓cd 12c(--tj
12dtibivIc --ll- N a-77' l
City aToai Stab Zp Cade
( )- 3— SO4 7
Area code - Phone number
May kbider;
robolekaexo•irar
:ade:Srt limos
5. WgtDETAY.S:
a. TOTAL. Dint 30D
b_ DOES VSL REFUGE BOSTN6 WELL? PEED NOM
e WATER LEVEL Odor Tom dCaewg FT.
(Urev Nano Top ctCasing)
d. TOP OF CAGING lB-FT. Above Land Sorbet
-Top d ramie kmioeetdWorY4doerdsame row mere
avalance iu..wJ. a 15AICAC2C.O11e.
e. YIELD Newt I METHOD OFTEST air
L osancnwt Type )-I iH
3`f 524
nz
g• WATER ZONES Wept*
From Lc- To Sid? From To
Rom To Fran To
Ran To Rom To
6. CASING: Taieessl
FED O To IO Ft ,sier WA( PV'
Rm To R
Roes To R
7. GROUT: . Depth MMtlwia Method
FED ID To au R Cs2.-r.¢nd- P"le
From To Ft,
Ran To Ft
L SCREIt Depth Diameter Not Om Melad
Feat To Ft. In. in.
FED To f _ia _ ie.
Ran To R in. M.
S. SNEIGRAVELPACK:
Depth Sze WSW
Rom To R.
Faol_To R.
Rom To R.
i9
to Munn LOS
Rom To Form:tooDesuption
SEP ± 9 2P73
1L ItEhlARKS:
1=wes19:01111rma-e BVIELL mua:ataa®ewmaeAorvmtrFwwn
ItAlCiriIt--m. S.NM.'matm LCONEUR tIMIES /�IaRACQP7a5 rO
aeoom5 eEENPRO®m1lEIMELLOwwet
cZ2 k 7141� ii-06
! �OFCBait®Vwsl DATE
QJi/fi.- 'Thus �p <
FRAME IMAEOF PERSON GOIISIZdICIIasliE WELL
Submit the original to the Division of Wader Duality within 30 days. Atlas: Mar a&oe Mgt,
1617 Mail Service Center — Raleigh, NC 27609-1617 Phone No. [phone] eat 561.
From Oi -1a
Rey. TAS

WELL CONTILACI OIt crit'1'IPlCA LION M
1. WELL CONTRACTOR!
Wee CtnlricI t'IndMdual) Nome
MILLER WELL CHILLING, 1NC.
Wee Cod, ado' Company Nome
SifEETADDRESS p.0• OOX 5G7
NAYESVILLE, N.C. 28904
City as Town Stale
i 020 L 037-2997
Anea code- phone number
2. WELL INFORMATION:
SITE WELL ID 11d ariacebh)
S TAT E W ELL pERMI t l l applicable)
DW0 or OtNER PERMIT Hill applicable)
WELL USE {Check Applicable Dolt Nesidenllal Waite Supply 1W
tateoniLLED 8-0 06
1IME COMPLETED /7, OO
S. WELL Lociti N. (/�
CItY: �a //Jv.
zip Code
AMUA'MU
COUNTY 6.774-41,1.
f/ai-el 0-et�t
Mies, Neme. Numbers. Cwmm nay. Subdivision, IA No.. re,cal. Zip Code)
10POGnAPNIC t LAND SEt1INO:
Mime UVaeee UFIal tinldoe 1:101her
Ichac& sppnop,lals boa)
LAtItUDE 3 IS-733
LONGITUDE 1. 3 411, i'5 q
isliludellnngiiude source: tlal'S i7litpogrnplde ump
fixation rt c al to Mk form bt nol oak p GPS)
e shown on n G S IIXIo map end
Mee be In detues.
mb airs. mouth at
In a decimal awned
1. vial OWNER
OWNER'S NAME Noy,/ ` /t '
S1REEtADDRESS L047 14vxrf S Cork RA
l�o66';nsu,ll,e NC Zg77(
City ce Them Slate Zip Code
L�F
Ain coda • Phone number
R WELL bETAILS:
L totALbtPtN: .192
b. DOES WELL REPLACE EXISTINO WELL/ YES p NO
e. WATER LEVEL nelow Top d Cesing. / rt.
(Use's' A Above Tzp d Coskp)
d. 10P OF CASINO 19 / rt. Above Land Sudan'
*top d toting IetSmted ova below land sotines may lequhe
mine In sccudalice Mtn iSA NCAC 2C .011E.
e . YIELDIgpm): MEt14000r1ESt
RESIDENTIAL
t
,l\L'SiDENTIAL 1VELLCONS IADCI"ION RECUR')t
North towline llepanmenl or Embroilment mod Nalmd Ittsomeel• Division or Wild Quality
21o5
OWNER
MWD
NC
I. MSINrEc1ION: typo hi t
u. WAtER ZONES ideplh):
roan 730' to rtom
roan to roan
Flan lo room
I. CASINO:
Amount '4' Lys
To
to
lo
Melons✓
DDimwits
Welool�11 M erw
Fran 0 teptho P% P1. (r.— -/bY• S ere /
Fran to r1.
than to ri.
1. oROUt: Depth Maletid
From d to 3 rt.
roan 3 to.?-B tt
Flom to Ft.
I. SCREEN:
From
Fiat,
Fian
bepth
To
to
To
Method
/Hamster Slot Size Materiel
rt. kh.
PLIn M.
PL
v. SANOIORAVELPACRI
Depth
Fran to F1.
From 10 Fl.
Fran To F1.
10. MILLING L0O
From To
Size MalerIai
ram:anon besctlplbn
Q - 7S'r Cly- ay-4, e
75-- 39L (bran i%a2-
11. REMARKS:
• 0
c
fV
w fT.
N
sop writer WI lit that 1411 "MINAS COIISMUCIta N ACCORDANCE NW
tea NCAC 2C. WEII CONIIIIUCtbN SlN1OINIA. 010 THAT Atori oe 11M I
mast HMI BEEN MOvtE0 tO 1NE NEM OWI*N.
910 / E OF CER1iFIED WELLCONiRAC1OR DAME
k1 tr teeec e
PR iED ME OF PERSON CONSTRUCIIN01IIE-WELL
f
Submit Ills otluinni to the Division of Water Qunllly WINO 30 dtys. Alltlt kt$oMuitleil Mal.,
rtnn OW11

RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroldia Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
W eK Contractor (Individual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY
NC 28906
City or Taus State
( 828 )- 837-8008
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/(d applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 17
DATE DRILLED 09l28/06
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: ROBBINSVILLE COUNTY GRAHAM
SIDNEY LANE LOT#19
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat �l Ridge ❑Other
(check appropnate box)
LATITUDE 3 5
25.325N
LONGITUDE 8 3 43.905W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: GPS ❑Topographic map
(location of wee must be shown one USGS topo map end
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME JOHN KIPP
STREET ADDRESS 11307 PELICAN LAKE CT.
RIVERVIEW FL 33569
City or Town State Zip Code
( 813 )- 476-6331
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 800'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO RI
c. WATER LEVEL Below Top of Casing: — FT.
(Use •+• if 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 aaith 15A NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST AIR
3 e3 n r( 4 S
f. DISINFECTION: Type CHLORINE
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
From
From
Amount 100PPM
From
From 0' Depth
To 60' Ft. Diameter
From To Ft. 9
From To Ft.
7. GROUT:
From 0
From
From
Depth
To 20
Material
CEMENT
Ft
To
To
To
Thickness/
ess/
58021 Material
To Ft.
To Ft.
Method
CIRAYITY
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 Sae Material
From To Ft.
To Ft.
To Ft.
From
From
10. DRILLING LOG
From To Formation Description
0' TO 2' TOP SOIL
7 TO 12' BROWN CLAY
12' TO 43'
BROWN DECOMPOSED GRAN
43' TO 800' GRAY GRANITE & WHITE QTZ
11. REMARKS:
((c»�r
C.1
1
BIT SIZE 6.025
1 DO HEREBY CERTFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W nH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TOT1E WELL OWNER
SIGNATURE OF CERTIFIED 09/07/06 E11bO 7RRACTOR DATE
to-.6-R Ls Pic V
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
SEP 2 200G Rev.7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
Wel Contractor (IndMdual) Name
CHEROKEE WELL DRILLING
Well Contractor Company Name
STREET ADDRESS PO BOX 1007
MURPHY
NC 28906
City or Town State
( 828 )_ 837-8008
Zip Code
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 08/24/06
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
Cry. ROBBINSVILLE COUNTY GRAHAM
LAKE VIEW ESTATES OFF OF YELLOW BRANCH
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
KSlope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 26.191N
LONGITUDE 8 3 43.759W
May be in degrees,
minutes, semnds or
in a decimal format
Latitude/longitude source: t9GPS ❑Topographic map
(bcatbn of we/ must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNER'S NAME BULLSEYE BUILDERS
STREET ADDRESS PO BOX 58490
ROBBINSVILLE NC
28771
City or Town State Zip Code
( 828 )- 479-1265
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 500'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 200 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
'Top d casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 7 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
g. WATER ZONES (depth):
From 200' To 300
Amount 10OPPM
From To
From 460' To 480' From To
From To From To
6. CASING:
Depth
From O. To 68
From To
From To
7. GROUT: Depth
From 0 To 20'
Thickness/
Ft. 61/8 m 1812i
Ft.
Ft.
Material
Ft. CEMENT
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
PVCrial
Method
GRAVITY
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
0' TO 25'
25' TO 55
55' TO 500'
11. REMARKS:
Ft.
Ft
Ft.
Size Material
Formation Description
BROWN DECOMPOSED GRANITE
BROWN GRANITE
GRAY GRANITE/WHITE QUARTZ
BIT SIZE 6.063
I DO HEREBY CER 1FYTHATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A CCPY OF THIS
RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
)I I.09/0706
RE CERTIFIED WELL CONTRACR DATE
- P 2-1.1).
TIED N ME OF PERSON CONSTRUCTIbly 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.
.s; f
Form GIN -la
Rev. 7/05

..,RESIDENTIAL WELL CONSTRUCTION con);\
North Carolina Department of EnvirOhMent and Retinal Rascal:S. blVIslod ttr Wit* Quality' -11
WELL CONTRACTOR cERTHoleAlriOrill 2 4.0 rn" 11 1:4 ri
I. DISINFECTION: Type AMbunt glair°
Prom y/e To 3/9 From "1"4."To
I From . to Prom _ To
Prom To Front to
- r r
G.
CASINGI •• .•
Depth
Front 0 - To ac Pt teArl a sae i--•
Diameter VVetobleu Malone'
.viEu.:4TRActon: _
ivet-r57" --Azec•e
Well Contractor (Indivklual) Name
Wel Contractor Company Name
STREET ADDRESS Of/ar
Geyer Tram State Zip Code
• Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID.Olapplicable)
STATE ViELL PERMititil aptomd.)
bWQ or OTHER PERMIT Mil Operable)
WELL USE (Check Applicable ga): "Residential Water Supply Eke!
DATE mitten
1104E COMPLETED 3 ‘fg. "1 Am d pm t
• i WELLLOCATION! •• '•
n fit •
WY: 4.11 eft COUNTY 101411"r.1"
• 1770i/4 14 /Of E,4 X
nn (Street Mum Numbers, Community, Subdivision. Lot No., Parcel, ZO Gods).
toPoGRAPHic i LAND Sttritio: • 1 st.tr
4,T. Slope tiVainy Drag sago poth•r
• (tick ammo,* bto
LATIUM .tit eZ i•Z
1/4.1_r
toke,truntrf4r •ViTif
"4.
Latitudenongitude source!' CAPS- iiTopographic map , - • .
pocatbri at WS must be ISM USGS tope map end
•4 attached to lhat form fatal Usho OPS)
May be In &peek
minted, iecondl 11
lit decimal connate-
.'•d:4:13WNER'S NAkte ' Polin 9/- "Ye f
StREET ADDI1ESS pcpBox
I -R;WiAsu;11,t, MG 7,977 I
CHT or Town . • . Stale Zip Coda
I. WELL bEtAlLt:
t
tovAL 13Errit 1512
• • la. DOES VAL REPLACE EXISTING WELL! YES CI No 0--.....:
WATER LEVEL Debi Tag of Canny /0 ° FT;;;;; ';;;,,
1- "nvlt:.,T,Cti,P ell?4117P,t,i_tising) 14- , ir.ti TR dew.
d. tos cc cAti140 IS "iiiM Of : Above Lend Surface ' '
*Top ct eating laminated war Sow land Surface may NON "et 1
7t# ' e Wailintalt It aderdinci eel SA FIC.Ac 2c .011s.: / A rre).114-.
t. bliab WNW: f RONDO or tat nit
• ' 1 -,. z i.:!;.i.rn4 lic-nr.'...;,;:ii. it „ F'.-111,,1`
From To Ft
• From To I.
trrr‘t•-.% urrn
,7. GROUT: Depth •tt ittni4y ‘1600:1,-1,
From To 3 PL
t From 3 Tb Pt
a m 41,0o-400W :a
S. SCREEN: fr Depth .1 Ski Size 1-;064Aeteitil 411110
tont_ g
I Frorn To Ft In:
From To "
v. SANOioaAViL PACK:\ • h•-°- 1J c rsr.".1
Depth size • mien
From • TO ' ' tin
From • to Pt.
From To 91/..:
ki4 #:/riartter0/142). ain"*”
10. DRILLING LOG le'fift I if mys, F
From- To FOnnailtiniltiarMbri'd
C14
•.7Le-
II
I
1 i
IDO SEREST CERTIFY THAT MS WEL1WAS CONSTRUCTED Si ACCORDANCE MN
SA WAG EC. WELL CONSTRUCIPZIN STANDARDS. AND MT A COP! OF TM I it sr
RECORD HAS BEEN PROVIDED TO THEWELL ,,„,,,,,, 3,.:,,,, i,.,. 1
''''- . • t-, -0 -di,
1 SIGMA E OF CERTIFIED WELL CONTRACTOR'. DATE
iI 14>%/V! i je4-' 4411444/1tileit*A40A NW ASA .
.: PRINTED IE OF PERSON CONSTRUCTING THE WELL ' '
- - -
kttS
fl
7,.RUbitilt the original to the Division of Water Quality Within Ril digt, Attn: ittorthatioh Mats 4. ittliftle, • `1•140 e
41417 Man Service motet- Raleigh, NC269V1C1t7hoM Wd. 00.0.7.314pii 11 sits*Sis •;:rew•st itt rre,070:19,0,sit
•

33449
RESIDENTIAL WlsLb,cUNstltUcriON IIECUitb .
North tetanus (lepahueet of teekamlehl Nrd Nelmd Ktsnmtek- blvklod et Wetet Quaky
WELL cUNt11AC11)11 CE1ttir1CA'110N N 2-4 0 3
1. WELDL CoNtnACtbat
/crry /•eta
Wes Conhfetor (kdMduab Name
MILLER WILL bHILLING, INC.
Wes Catatonia Company Kane
S1ItEETAbbRESSp.O. faX 561
NAYESVIILE, N.C. 28904
city te tuwn Stale tip Cale
.A 928} 837-2997
Axes code- Phone ndmbit
i WELL INFODMAtION:
but WELL I1t 10 epplkeUel
S1Alt WELL PE(Dttlp applicable)
bWO a Ot11Ea PERMIT 1(S w$IcaWe)
WELL USE (Check Applicable bog: D,wlde tld Water Supply L3..'"
bAtt MILIEU el -2.�. 0 (o
'TIMECoMPLEtEO S-S� AM IS' t•MU
1. WELL IbcAtloN:
CCDT:/� Desennlle
coUNtY orrwwas-
fcaeft✓attr
Oren None. Numbest. Cemmesey. tebsltlol. LW No.. 1•eseel. Zip Cods
toPooMPHIC 1 LAND SEttINo:
gout* (1V W tllbl tlildpe bother
(check M*'W"'1' kkt1
tA111UDE 1 Co •231
LbuoltubE.$ 3 WI .9 Ls—'
t1111todellohghthle woke WISPS tltbpeghlphle Illnp
(bcelbn et het most be ehottd on s USCS bpo map Md
&Itched b orb htth 1 tint hskq GPS)
L WELL owNETI DD L
• b1NNEa'S Tame I `/77 `war
• StatttAbbfrf9 &fl- C..t._ L.sG1 ea')`' ad'
fLoL►...av'•Lla Nc 2-%77I
cm, to use, Slate Zip Code
'._. t ti } 1(- 9- 60(,l
Awe tads • Plante mmmbel
i WELL bEtAtl9:
L totALOEPt* /4r
b. tgfi WELL REPLACE EXISTING *ELLt YES [i No i -
t. wMrA LEnEL below top d Casing: 2Y Pt.
(Uee'a' i Above tw M CskiM
d too Of bASIN019 / Ft. Above lad st*loce'
'top d Leine tooinmed Whet bekhv lend twin mq ilkolke
e *Oro Is eeeadante *ids ISA NCAC 2C.011e.
0.'WU) OO: 25 Met WO OP trill' ,1'r.
Ably le In depots,
ndane*.'torah to
Ina decked laud
1. bI51NFEc1IoN: type h27rt Amount tog
u. WAtUD ioNES (debdll:
Fran 43 ,to /Pi Fran
Frain lb Fran
From to Fran
S. CASINO:
to
10
to
tltcknenel
beplh Diameter Weight Miners
trap 0 to //V Pl. .L 2 ./Yf' J>S _l
than to F1.
Flan _te F1.
t. ofloUt: beplh stale)
than 0 to 3 rt. r�inri
Fran_�_to o Fi, �f . • e
Flan to Pt
e. ccltttN: bepth
Flan To!
Fran ' . to
Pion to
e. SANDIW*AvELPACK:
Depth
hew_
Flan_
@tan_
Method
tkethslet SIo1 Otte
F1. M. M.
F1. In. M.
FL M M.
1e PI
to FL,
to. Fl
1tl. bf1111No Lots
Prom to
/cL . .—Gr11er-1
11. lttMAItk5t
Maleld
Sete Materiel
ro ms(bn bestnplbn
OWNED • f:
t°liii'
Mwo ;�
NC t'.
;
8.
1,
,f
u
tin:
oN pck '6 2p06
Ibd 'lentil onion 1NAt MI IttlL WAS tWNtMIClte M ACCONIIAItCt MIN'
ISANCACat.Witt tonstine:lbeSWIWMbS.NN1IRO AConotlles I
Mort KASNENPNWStO$lNSWMtrivia
9 ;i/-d6
SN3NAtURE OF CET WIEU WELL CONTRACTOR DATE
h..,_
.� l /eet c'C
PRINIEU NAME of PEADOtl CONETRUCIINO TIIE flat
r�•
1..
a
i.
SubSIll'lid btlgMei 1e ihp !Aviators of Water duillly wNhi 13d din. AID+: WehNWon Mgt.)
ar.a+u.nher. ).♦Moan -ttelnlnit NC7TRS0.1S11 Numb Nd.ivtoitii.109IKt11111,
Fan tEV li
HM.IIOS *'"

RESIDRESIDENTIAL
ENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resumed- Division or Water Quality
WELL CONTRACTOR CERTIFICATION M 240 3
1. WELL CONTRACTOR:
/r
lr a Irtdivlduai Name
Well Conk Co
W 1 )
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P•0. BOX 567
HAYESVILLE, N.C. 28904
City or Town State
( 828). 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Apr applicable)
STATE WELL PERMIT$(a applicable)
bWQ or OTHER PERMIT 11(0 applicable)
WELL USE (Check Applicable Box): Residential Water Supply t(3)*DATE DRILLED 2 —if- d I+ /
TIME COMPLETED /f .0o AM - PM 0
3. WELL LOCATION) CITY: /70106- 41 Z'• fl= COUNTY 6call4 0.1'
Code
fillet cy a/ranch
ael Name N bars, Community.
Subdivision,
(Sa ly Lot No.. Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
tiSlope []Valley E}Flal r]Ridge ❑Olher
(check appropriate box)
LATITUDE .. / 9. 66
LONGITUDE Q 3 S 0 - 116
May he in degrees.
minutes, seconds or
in a decimal rennet
Latitude/longitude source: DOB ❑Topographic map
(bcetbn of wet must be shown on a USGS topo map end
attached to this form I not ushg GPS)
1. WELL OWNER /J /
OWNER'S NAME BOLA i4 if e3
STREW ADDRESS. 2- ?- Aims.) kh-.844
C41fR,�/e�t ,
City or Town
Stale Zip Code
(87-16 »79-6`73y
Area code - Phone number
S. WELL DETAILS:
TOTAL DEPTH: 5 0 0
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO lY
e. WATER LEVEL Bdow Top of Casing: 7 0 Fr.
(Use';' 8 Above Top d Casing)
d. TOP OF CASINO IS / FT. Above Land Stelace'
'Top d casing terminated aga below land surface may require
a valance an accordance with ISA NCAC 2C .0118.
•
e. YIELD (gpm): / METHOD OF TEST gx>"
OWNER
MWD
NC
I. DISINFECTION: Type lilt Amount yl'i G cP
g. WATER ZONES (depth):
From Nlg To From To
Fran To From To
From To From To
6. CASING: Thickness/
bepth QQlameler Weight Material
From 0 To 4I$ FI. d ).S5 Spezl QjJc
From To F1.
Fran To F1.
7. GROUT: Depth Material
From 0 To_e_ Ft. film/
From 3 To VYY F1. />'&IJ avy- —c-
From To Ft.
IL SCREEN: Depth blameter Slot Size Material
From To FI. In. In.
From To Ft. In in.
From To Ft. In. In.
9. SANDIGRAVEL PACK:
Depth Size Material
Flom To fl. From To Ft.
From To Ft.
10. DRILLING LOG
From To
v-31
31I -so 0
11. REMARKS:
Formatbn Description
NJhf
nb
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPT OF 7MS
RECORD HAS BEEN PRWIbEDTOTHE WELL OWNER.
aeeicz S -a-06
SIGNATURE OF 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] est 58A.
Form GW-le
Rev. 1105

RESIDENTIAL wm. CONSTRUCTION REcoitn
North Crorna Department of Farvinenicat and Natural Resaaces- Division of Water Quickly
WELL CONTRACTOR CERTIFICATION 0
1. WELL CONTRACTOR
Oc'S 11'62,5'
Wd Contractor (Insa rdaW Nr
tine
STREETADDREss 6314 R ycte T )n 1'lex,d
bh; :,Ids ?sit 7/
City or Town Stale z4
c tad} tin— 'VS (I
Area code- Phase number
2. WELL WCI YATIOIt
SRE MaL m a(aeaMo'-
STATE WE9LPt3iMTapapaorq
MVO Of OTTER PERMIT SW amicable)
WELL USE (Cheek AntallDot Rasidaid War Sapp* ))C
DATE DRUID 9-92,D 4
rawcCMPLETW //;00 AM14 Rap
3. WB.LI tW
CITY:
TOM
hin5„110 CDUNTY a•v-Vabn
e, ..a-.
a Pnel 'cosr
TOPOGRAPHIC I LAND SETTING:
Clace Maley )eht Ol a Daher
rcheeteReePWraeol
LATITUDE a.
IDNWUtE sir N7' aQs"
Latitudedongitude soa=: YtGPS °Topographic map
16cafoe d.damtbe shaman s USGS Iwo map earl
alledtedbi(aia rmitamigW'
A WELL owner
OWNER'S NAME €rice Cl le(r
be r ADDRESS r L L; 1-ci k i�ti.d
f hl,; „1/. Art'. a%77/
Coy rTam Stale Zip Code
I F Q/7`?— 67,(
Area code. Phase number
IMay be in dedaes, I
Stara svaadsr
:aicied fan
. 16 ' 31.'-/"
S WE3LDETAIL& e_
a TOTAL DEYfl t W
b. DOES WELL RACE EXISTING WELL? 'YEW NO till
c. WATER LEVB.edssTapatCasimir S FT.
(Uses*" IMeseTap et Cabo)
d. TOP OFCASINO 6 / FT. Mcrae lad &dace
Tap oft cleft irmieslalattw Westad warn wayeatpit
a vaaros in armadas= Sit ISA ICAO 2C AI16.
s YIELDS S MEMO OF TEST GiIT
Submit the original to the Division of Water Dually within 90 days. Attn: Information Mgt.,
1617 Mali Servlce Center— Raleigh, NC 27699-1617 Phone No. (91s) 733-7015 eat 558.
Frm OW-1a
Rev.7A5

RESIDENTLIL wm.corantuci7oN RECORD
North Cast Department ofEnvironment and Natural Rcsur s- Division of Water Quarry
WELL conTRwcnk CERTIFICATION I 3 3?s6
" 3 121
1. WELL CONTRACTOR
We
netAkces
re-Anorv. W e \1 Q
Campanyl'laae
STREET ADDRESS V L34 Pyle
(2nbb,b;;lie kit
Contractor
Well
City orTown stele
t gat ►. tJ19- 8-ggsq
Area cods Pharr numbs
2WELUNFORNATIOtt
SITE WELL ID TMa,oeatlN
i\,401
ats77/
tap Code
STATE WELLPBNiTINTagaeaN4
DWQ or OTHER MOAT Rif applicable)
WELL USE (Cade/in
tull�sIke Rridenilet Water Sappy"(
DATE DRILLED ' / "`('- b
TOE COMPLETED L/:00 AMQ FMK
3. WELL LAGOON
CITY: 1 e.4-42 viC ICE COUNTY 6 rejko ,,.
G.el had-I-er (Zeus.)
Mks* Nana titiabms.CammaktikbdidaimWore.Prod.2Ftesa/-
TOPOGRAPtUC /LANND SETTING:
Mitre Maley OFit ledge oO9ts
(dadcapptapsbbag
LATITUDE sif 16'53 r,
LONGTIME/s 4/r3C,9"
May be in domes.
mask ar
iadada fort
Latitude/longitude sa rcd *NS °Topographic map
dnafmratna onistbeahttananaUSGStporeapcad
aMmdb pklh}s-imtetaig O,//i��
aWELL OWNER
OWNBrs NAME /—rnr�iP 1 er
si I ALADD ) Le%d'hor (Cec /
(CCCity( at
Tam Slab Zip Cade
( 305)- 791— 9;,.5
Area code. Phamnurnher
& WELL DETAL& �� i
a. TOTAL DEPTR
b. DOES WELLRELACE E7aSTN3 WU.L? YES O ND Qr
c. WATER LEVEL Oda Top dCaring 6o FT.
(Use' ' 9Aimee Top dCenion
d. TOP OF CASING I FT. Alone Land Sofas*
'Top et calla tamiseddbrhobo land em(ceaaey monist
a variance in aaodateaoti ISA 'CAC 2C d110.
e. YIELD War / 0 tETNODOFTEST CU C
A viler Pr
nosennerconsvmerossvin
URN=2C, laHLCa6mwCHONSIANISANDINWACOM
REOoaa tree BEEMwn mw'mE 1ee3t011mBL
i4 s c
/{
SLGNAOFCERTIFIED INEcONRACfOR ATE
V/)1-1v1 rnt� li r 5
PRINTED NAIEOF PERSON 001115TRUCTING TIE WELL
OISanCTOttType HrI A4mtN a5
e. WATER ZOMBI (depl*
From 60 To 45T' From To
To Fan To
To Rom To
Fan
Fan
6. CAMS:. Tire/ N�etd
Film 0 Two 7e/ Ft. ,SUnbar aga ll� c
From To FL
From To Ft
7. GROUT: Depth Mash Meted
From n To &' Ft f rrlvnl• Jvn
Rom To Ft,
For To FL
0. &a...t Depth Diameter Not gore Material
Roam To Ft it In.
Form To R, in. . in.
Rom__ To Ft`_K ln.
0. WINDIeRAYELPNCK:
Depth Size &Medal
Fan To FL
Fatl__To R,
Ream To Ft
10. OR9.LRIG LOG
Rom To FatenefonDesorption
11. RBMARBs: OCT
—4
Asheville Rogi nal Offit,e
Submit the original to the Division of waiter Quay y within 30 days. Attn: telonnatlon Mgt.,
1617 Mall Service Center— Raleigh, NC 27599-1617 Phone No. [phone] ext 569.
Form GW-ta
Rev 7A5

RESIDENTIAL nu. RECORD
Noah Cantos Department ofEnvironment and Naemai Rcsaum--D�Diviioa of Water Quaky
WELL CONTRACTOR CERTIFICATION i F S c6
1.
tirn. L1e\l 'Qri1\
Cornet CmpmyName /� '7-
STREET ADDRESS 6311 14yele IaAr• afkcil
(2A4)%ftvil l e SIC, at771
aty Or Tom Slab ras Code
lJ3fr >•Y79 459
Area code. Phone numm
7_ WELL OFORYATaa1t
SITE WEI L m Weaepreaete)
STATE WEU.P9muTWtanio -.
DM or OTHER PERMIT*,apLicaNe)
WELL USE (Chair raidse* Rmiderr/d WaterSappyW
DATE DRILLED — 1 I "- 06
TaIECOMPLET'® / 'OD AMU PM4
3. WELLnrAITIDIt
CITY: grid% f11lt
RA
Meat Y cl icrlarl
TOPOGRAPHIC I LAND SETTING:
OSope Maley DFbt WWI oOM
(dadrapwPeretra/
LATITUDE° ,'/6
LONGITUDE_ a.0 �1Si'43P£f'1
tatitudetiongitudesasct J GPSa °Topographic map
(baton d mdemdbe *hoar on a USGS eiPo mp and
SAW odefarmlootariaBPSJ
OWNER'S NAME �r fins ef5
INM� � I
minim. pewee or
ins triad *ram
i2nr;ea
Se a ADDR�S Ytkr
r
lltsit+r ✓i �,�PCC77
QV or Tom Slab ro Cris
( i(�Sr> Ll7`/— ? act 1
Area code. Phone amber
S WELL DEEMS r r
a. TOTAL DEPnt e'7 QO
e. DOES aal.L REPLACE oasTIIG WaL7 YES O NOa
c. INKIER LEVEL adoNTgrdOwing 71' FT.
(Us "e' 'Mama ma Tap d Cam)
d. TOP OFCASSIS 1 FT. Abase tad Solace'
'Top Maxim landmeodapmbabrbd=damns/ moire
avariance b aaeadrmNi 15A ICAC2C AIM
e. YIELD Igoe* / METHOD OF TEST CV% r
L DISINFECT1Oft Type N TM Arnow* 1907
g. WATER WIPES *oft
From 7,S' To cr)c`
Rom To
Fans To
Fran To
From To
Rom To
6. CASPIG Thirties*/
Ram O To Co
o 7` RamR M a PYC
it
From To R
Fen To • R
7. GROUT- Mob ___
From O To 9NO R. C€nw 4-
Rnm_To R
Ram To P1,
t S'att* Dgdh
Ham To
F1sem To
FmrL__To
To
ILsnc AvapAoe
Depth
Frog
To
Rom_
__To
10. DRILLING LOG
Ran To
11raNdpomp in,
Diameter Sid Sins Ihrord
R ia, ha.
F1 k - m.
In.
Site ilrNid
R
11. REMARKS:
R
Fornmaon Desablim
R8
uCT
Ice
rtOn
ll0O.. a,wlILVEWOCW�'Waa mtOCaoa IMIIS
NECORDNASN BIPROI �W71EN9LOVINER.
D11aQAC?l tIFLB
TL>s� /rs 9-f Fa
SISTA JJ-��OFt CONTRACTOR DATE
`UcSdn.% (�%iiILR
PRNTED NAME OFPERSON CK `� a THE WELL
Submit the original to the Division of Water Duality within 30 days. Atm: information Mgt.,
1617 Moll Service Canter —Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Rim SW -la
Rev.7N5

RESIDENTIAL wnL CONSTRucnoNI RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CIOMP1CATION f v 3 E(6
1. WELL C ONTRACfOIt
1�S;i r r it Irk IliA,60,05
WsRteakaatar (etividua Clam
1 `,A v" ( J.0A\ V A\ YES
Wel Cariaela Campayini ,n
STREET ADDRESS AZ `t M yJe 1 'fin 1'\c7-11
0c7G"}Di ns✓,IIe &1s-77(
all orMOM Stab iyCade
( iafs ). 179-'47/,e c/
Attu coda- Phone timber
2wax ero RtAnoIt
SITE WELL O eVappaahte)
STATE WELLPERMD'fpapeaakb
DWG Of OTHER PERMIT MIappirahle)
WELL USE (CbdcAppirideStet ReaidaSI WalaSaredy
DATE DRILLED G- 7f'O6
Tam cowmen / /: 3Q AMA PIA CI
S. wattecaTION
CRY: KnkhfVine COUHTTCr�n':f/.i^✓,
wee oskeecee
Meet Nene.Nmems. 0amr>,t,a" meet tails.. Paaat iCade- -
TOPOGRAPHJC / LAND SET�TNM
pip
Dame °Maley OFid DOME
ahem eme[ p�robtap
tannins L 4L- ac `lea.
LORGRUOE1a° Li0' 07.1„
Lathudenongitude soma Apt °Topographic map
(beaim dtdmd he shown an a (/SG1S hpo map and
aatdaadbaitgam mind aft 6
0. WELL OWNER
OWNER'S NAME 1-1..rn1J io\nnoo.n.
6-MEET anomess Low�er 1t kee se
a i-t✓;/�e /1YL Pr77/
(sat or Tam Sble Zip Cade
(ile3CI-47�i- �7f7
Area code - Phone number
May to in degree;
o®ta,moods or
inaidal fume
5. WELL DETAIL& "G SC)
TOTAL DEPDt
b. DOES WELL REP LACE EXISTING MELD ,Y�ESO NOW
C. WATER L.EVELlidoaTapafcait¢ �f v FT.
(User XA6areTap dCatn)
d. TOP OF CASING IS / . FT. Above Lad &Mace
-'Sig athoentor emirs
avalance ir amdaoesi RSA CAC 2C AWL
a YIELD Input row METHOD OFTEST Gil r
e
e0it0i`.1n)
L vusn CTIOtt Type /-/ 7- El Asmwtt I ri na-
g. WATERC/ZDrES(dina
Fran L O To Li H2O Ram To
Fan To Rom To
Fan To Ram To
6. CASING:
Fan 0 Two 1
From To Ft
Ran To Ft
7. GROUT: Drab 'Maly.-. Method
Fos f) To an R (ewwnd- to
Faq__To Ft,
Firm To FL
a Wet
Ram
Rom
Fri
Depot Dane Gat Om Retarid
To Ft in, kL
To R. S. _ to
,To F_h in.
0. SARp6RAYaiMCR(c
Owls Sias ilraii
Fak_To__ Ft.
From To Ft
Rare To R.
10. COALING LOG
Ram To Fonta6t Deeap6on
11. REMARKS:
52
1
Iv
Asheville Regional Office
Aquifer Protection
a75SM ie.waLCannenm aAoamOlaRwow
tEC0ania6 Ba1PaW�W LEWELLaatlwa/11DT11 VACOPIf CFTn
(hz;(16.j,x- Ct-Li _06
SIGHA CERTFIEDw@L COIiTRAC GR DATE
C'/vSh,
PRIDED NAME OF PERSON COIISIfaICTil6 ME WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Sonnauon Mgt,
1617 Mao Service Center - Raleigh, NC 27699-1617 Phone No. pis) 733-7015 ext 568.
Fant GW-la
Rev.7/05

RESIDENTIAL WELL cob ntucnom mcoiw
North Cal Depmbaeot oEoviaanat and Natural Resources- Division of Waaer Quality
WE LCONTRACTORCERTTPICATIoNft Da tS C)
1. WELL CONTRACTO
W Caldk
6s-rr_410.vrl 1 tlel/ Ariiii,,,ry
Wee fansrador C.ampayNaos fe
STREET ADDRESS !0 3 tf AS J e
1Q�Twat 5 1/s LG AftSlab ct -7-7/
Area code- none must&
2. WELLINFORNAT1pt
SITE WELL ®d6ta,oiauy
STATEWELL PERMTfl .. garde
DWQ or OTHER PER/MTS(isppiwds)
VEIL USE (cMdcAPPthBo* ReddaeldWater Sag*
DAttmatED 9-29-/16
THE COMPLETED 1 . AMP Mil
1WELLL AT
cm: jr$A7�Ip,'r, c u ll a coutmr liar hO, m
T betre. ^ bro. rich -77!
(4DYattlanotorm aa.O rromay 6aa6Wa.Lana. $Co/y-
TOPOGRAPF6C 1 LAND SETTNCG
(]Elie Malley Cat SRNs, ODaw
(dlaatappaptlsat
LATITUDE Sf F'A.4 W. Eft!/
LOMMUDEa. rl 7'KG. Ens!
Latitude/Mogan'de solrc= O(S'S oTopognmhic map
Ana..doralmrtbshows onaUSGSIrmo saw rod
added 'GPM
4. WELL OVRER
OWNER'S NAME r1A Yn(cn Lh, new
S r ADORE= et. n bit In re; c
ritl
j�p 1 ns L,: t J�� tf!: 2 I
Ciyor mei Slab Da Cods
( sra* 1- tin
Area code- Plane amber
tiny bs in rlegrees.
mmma,aaras bor
bra drama fen
iwnI DECAL&
a. TOTAL DEPnt 06-
b. DOES WELL REPLACE EXISTING WELL? YES CI NO13
C. WATER LEM-OolaaTo,oCosby Mill FT.
(User Nitta Top old/SW
d. TOP OF CASNSK 1 FT. Above land Sorbet
'Twat calm baoiaabdatlrbetaabdaa(om wagwgda
Marisa --m amadaeea 15A NCAC 20 Aia
e. tlaD / METHOD OF TEST cu r
f. vRREECllott Typo Hr/f Amount /D.aY
E. WATER HIES (dqS
From yin To ScilS From To
From To Flom__To
Rom To Rom To
6. CASaxt niches* �6�1
Fm P, ePthTo Ft.inst. SW" "/ i''VP
Rom To -Fr
—
Fran To Ft
7. 6NOUT: Dap! Mafedd Mdlmd
From ll To M Ft [PM,onT nnktpilie Fraq_._,_To Ft
From To Ft.
IL 5 as t Depth aanetr Slat Sze Mahaid
From To FL M. is.
Flaw To P1,__i. _ in
FnTo Ft IA it
S. SAlO0RAiaLPACK:
Degb Sae Wail
From To Ft
From To Ft
Ron To Ft
16. oakum L.OG
Rom To Felnmial Desoipeal
1. REMARKS;
RCCCIVC
OCT
Asheville Regional Office
Aqurrer Fir ntectiOn
I00 .IFr7latflfl LrASOp aaCCOMMICEaww
7Sta2C.711H10maARC®SSSaaa DIVA HYRACOPIOF1a
wEsbmlae®1FROYm®1011E /111LOWIaaa
WELL CONTRACTOR DATE
PRINTED NUEatf CONSTRUCTING THE WELL
Submit the original to the Division of Water Qualty within 30 days. Attn: information Mgt.,
1617 Mali Service Center -Raleigh, NC 276994617 Phone No. (81t1) 733-7016 eat 558.
Form GW-la
Rov 7105

tLS1DE[v j jAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # tifH —
1. WE CONT
SYLVA
City
621 8 )- 586-5550
Area code- Phone number
2.
WELL INFORMATION:
rs
Wen Contractor (Individual ae
AAA GREENE BROS. WELL DRLG. OF SYLVA, INC.
Wen Contractor Company Name
STREET ADDRESS
1800 SKYLAND DRIVE
NNE
State
28779
Zip Code
_ J
ieade)
SITE WELL ID #08 eppf
STATE WELL PERMITS/(if applicade)
DWI] or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED_____AM PM [�/
TIME COMPLETED �"
3. WELL LOCAT N� 171
CDUN iv (14,/
CITY:
(Street N me, Numbers, ammunity, u• iNsi •n, Lot No., Parcel, Zip(Code)
TOPOGRAPHIC / LAND SETTING:
[Slope [Valley ❑Flat Midge ❑ Other
�—
(check appropriate box) May be in degre
LATITUDE — minutes. seennd
N a decimal for
LONGITUDE_ __ o a hic map
Latitude/longitude source: 0GPS ❑Top gr P
(location of wen must be shown on a USGS topo map and
attached to this form it not using GPS)
4. WELL OWNER
OWNER'S NAME
STET ADDRESS
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOy
c. WATER LEVEL Below Top of Casing: Za FT..
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS _J�—FT. Above Land Surface'
'Top of casing terminated agar below land surface may require
a variance in accordancej�with 15A NCAC 2C .0118.
_SC—
e. YIELD (gpm): _—METHOD OF TEST__-1-12--
f. DISINFECTION: Type
g• W TER ZONES (depth):
From To
ilgli
From 3 S To_a
7. GROUT: Depth
Frain_(_ To_i— Ft.
From_3_To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
To—FL--m' -- in.
From From To Ft.in.
_m .
From To Ft in. — in.
022
9. SANDIGRAVEL PACK: Size
Material
Depth
From To Ft..
From To Ft,
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
I HEREBY CERTIFY THAT PIS WELL WAS TED
CORDANCE
15A CAC 2C. WELL CONSTRUC110N STANDARDS. ANDIN
DTHATA CDOPY OF THIS WITH
RECORD BEEN PROVIDED THEW NER
/gam
SIGNATURE OF CERTIFIEDTE
r WALL; 1� Jvu_R AP
PRINTED NAME OF PERS• CONSTRUCTING THE WELL
in
Mail he
Center - Raleigh, NC 2 699 1 17 aliP o IehNo. (9 9) 733 7015 enxt 568.tion Mgt,
161730 days. Attn: I
Form GW-1a
Rev. 7105

ENTIAI wv� .
- CONSTRUCTION CORD
Nona Carolina Department of En vionaaent and Natural Re
sources- Oivitiob of Water Quality
WELL CONTRACTOR CERTIFICATION it O S_Q
(Street Name. N,anyern Ccmmunity-subditisba.Luta. Parc* Coc
TOPOGRAPHIC / LAND SE77a1G:
OSape OVaaey anal *Rite iOeaar
(back appapatebmd
LATITUDE _3 _10 =,`� (/ • 9/ 2 1r mS is d
LONGITUDE a_ a Z' - ,5":" odrar
IatitudeAengiprdcsource: IMPS °Topographic map
action dwdawl be alma an a USGS Iwo map and
attached b this font / n o t m in/ GPS)
A WELL OSTER
OWNERS NAME
STREET ADDRESS /tea;/Nn P n-rl,v r•rF. k
City Or TawnArea code - SIS 2rpcma
Phone number
5. WELLDETAR.S: /
a. TOTAL oErrll_[p3()r
b. DOES WELL REPLACE EXISTING WELL? YES0 NO
SI
c. WATER LEVa&kmTop ofCaiar
Nse^t'/Above Tap Casing)
d. TOP OF CASNG IS AboveLard
Surface
Top of casing tetnialed affix below and nay Kiddie
aScein accardanceniaa 15A MAC OM
Submit the original to the Division of Water Quality within 30 days. Attn: Intonnatlon Mgt.,
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. (919) T33-7015 ext 568.
c. 3 4 2 7
Form GW-1a
Rev. 7A5

RAIMEfflitgnascaeustcpm
North Carta toa Deprtaad of Eaveonmaa and Natant Resources- Division of Water Quality
WELL COMxAcroR CERTIFICATION r_
1. WELL CONTRACTOR:
ry'71,ca, ajle&s
W ei\-t,n. LJ.e 11 ail l
we, CatOne, Naze
STREET ADDRESS 6 3 ( 1--1 tiviv\ re ,77
e.l
City orTem Slate Tip Coda
(S52,53- t>7y-g-vc/i
Area cad. Phone MOW
2WELL OFOtlIATIOtt
SITE WEU.ID ela;eiarNei
STATE WED-PEWaTtaf____
DWQ or OTTER PENNINE
WELL USE (ChedtAppeeatiaSo* Ttesidsii MMxSupply cf
0117E DRILLED_
TSE COMPLETED 0 ALTO PW El
3.1NHLi n` TOW.
CITY:
0. WILL OWNER
OWNERS NAME �`�nzer
STREET ADORERS
1 bhl�
'' ��City``orT-one Stile Zip Code
'`uPhone number
S. WELL DETAIL& ri
a TOTAL DEPTIt o p__
b. DOES WELL REPLACE SUSTNG NELL? YES❑ NO 1t
a WATER MVO_ Bee Top alCalls
�_�
(Use it AbaseTape/Caeag)
d- TOP OF CASING IS / FT Above Land
Surfaces
mer cattle �abtrbetovfond swi regime a isoordanoe WS 15A NAC2C.0111.
a na.D(Wmj��TitOpcFTEstaic___
Submitthe original to the t Service w
1817 Division or Water Quality within 30 days. Arne: nrom,atn„ ice.,
Raleigh, NC 276994617 Phone No. [phone] ext 568.
re-
lIDtreeN
tlble rnbers. ea ll-M-IM PaRat aPCeee}
TOPOGRAPHIC / LAND SETTING:
nape MEW OFW AITidge Maser
One* andatelszei
t���
LATITUDE .�st_ ay ' n i '/
LONGTR10E ff 3 °4L2Liqj»
tatitdellotgitt4c source: ACiPS OTopogmpbic map
owero a onelina ntbe sis,as a WalkuoaNP and
MachedioAElFeaeiaalaig
Fame GW-1a
Rm. 7/05
A j7

4. WELL MINER
RESIDENTIwI
North Caofra Department of Environment and Natural Resources- Division of Water Quaky
WELL constacrent aciamcanon
Meet Name timbaa'Careas-tea la4rs.. Pap. ZIP Cod*
TOPOGRAPHIC /LAND 8ETT/1QQ
DSeEllwr WF oolar
(the* appropriann
LATITUDE S � 9Th' 536 �t aam
totaxruoE 8132Ecatbn
ahoenonaUSES p mego end
adede_ba irfannlaotriny CPS)
Submit the original to the Division of Water Quality within 30 days. Attn: tnforma0en Mgt.,
1617 ball Service Center_ Ra1Neh, NC 27666-0617 Phone No. [phone] ext 666.
Form GW-ta
new DOS

RECORD
NashCantata Department ofEnvironment amNatural Resources- of Water Quaky
WELL CONTRACTOR CERTIFICATION
U3e..1l
Commuter toalpawNaae
STREET ADDRESS v3�� YI YCdP 'ti 1 v, Oct/
r �c,nnlrnV1 l2 (V C 77/
City or Tom Shea TP Coda
Ares en Peens sans
n 'i,sy
2. WELL INFOWt1Tnnut
SITE WELLID staaapaeabla)
STATE 1MN3L PHO/Tep
DWQ or OTHER PERiITSDappal:Ed*l
WELL USE (Che int:aft13a* Restinar w,NarSappy,h(
DATE DRUM_ /n=^n.o__
TIME COMPLETED--%-( ARtO PMj
3. WHL LOCAT101a;
CITY: 1`�r, hl:_ _ _ COUNTY E n
�r!-s Crk
TOPOGRAPNIC1LAND SETTING. taeNa. Pima BPooaa}
DSpa Malley DR; frifladisr Mahar
swwwswastave
LATITI nE _oZ •O tr
LONGITNNDE is' a L—a)
LatiudeAcingitude aPmelon of car DTapog ap)tie'�
agmbedNvMkkm*taotaeitgM USGS 4aornvoand
0. VASSOYWNER ----
OWNER'S NAME e-H-er
STREET ADDRESS ✓, ,
5. WRXDETAIL&
a. TOTAL DEPTItZi 5
b. DOES WELL REPLACE memo WELL? VERO ROA1
c WATER LL�-ado_Tapdt]siq��(2! �C
(Mew Kahn Tap dean)
d. TOP OF CASING g / FT. Above Laid SlaFace
rapof cannaIasi agar babslond sanatenny taquie
a variance in J/azaahnosidlt15ANCAC2CAM
e. YEW(gpmt LL_MEDDOFTEST_.Cy1 r
submit the original to the Division of Water Quality within 30 days. Attn: M onnadn„ Mgt.,
1617 Mao Seiviae Center_ Raleigh, NC 23889-1817 Phone No. [phone] txt 558.
Form GW-1a
Rer.7105
334274

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION #ie
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contractor (IndMdual) 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)
DWQ or OTHER PERMIT #(t applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 10/10/06
TIME COMPLETED AM El PM ❑
3. WELL LOCATION:
CITY:
ROBBINSVILLE
COUNTY GRAHAM
HARD SLATE ROAD (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope Valley ❑Flat 0 Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS ❑ Topographic map
(location of wet must be shown on a USGS topo map and
attached to this toms Ifnot using GPS)
4. WELL OWNER
OWNER'S NAME STEPHEN L. WRIGHT
STREET ADDRESS 412 HILLCREST ST.
TALLAHASSEE FL 32308
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State Zip Code
L850 )- 566-4197
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: BOD`
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO IX
c. WATER LEVEL Below Top of Casing: 200 FT.
(Use "+" if Above Top cf Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST AIR
333728
f. DISINFECTION: Type CHLORINE Amount 100 PPM
g. WATER ZONES (depth):
From 780' To SOD 39P°a From To
From To From To
From To From To
6. CASING: Thickness/ t,,t to
From ' Depth 6 ��8 SDK21 PVCrial
0 h30'
From To
From To
7. GROUT: Depth
From 0 To 20
D meter
R.
Ft.
R.
Material
R CEMENT
From To Ft.
Method
GRAVITY
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To R. in. in.
From To R. in. in.
From To 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' BROWN DIRT TO BLUE GRANITE
20' TO 30' BLUE GRANITE
30' TO 800'
11. REMARKS:
BLUE GRANITE
OIV. Of wq I ER QD ALITY
OC I 1 8 2008
5ACELNSTUIS IOANDCONSTRUCTED
ANTHDIA E WITH
15A 2, WELL CONSTRUCTION WELL
THAT�OFTHIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
641
10/13/06
IGNATURE A0.CTR
IGIINATUREO QC�EE �tTIFj ELL CONTRACTOR DATE
'IJILLIAML( b2AbIEj In015
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 27699-1817 Phone No. [phone] ext 508.
tf r/ n r,
)t
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 # 3368
334055
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Web 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
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply I]
DATE DRILLED 10/12/08
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY_ ROBBINSVILLE
COUNTY GRAHAM
OLIVER ORR ROAD
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
*lope OValley Flat ❑Ridge ['Other!-' (check appropriate box)
LATITUDE 3 5
LONGITUDE 8 3
23.800N
50.720W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EnGPS oTopographic map
(location of we,Imust be shown on a USGS topo map and
attached to this tor, #not using GPS)
4. WELL OWNER
OWNER'S NAME SETH MILLSAPS
STREET ADDRESS PO BOX 338
ROBBINSVILLE NC
28771
City or Town State
( 828 )- 479-2798
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 200'
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: — FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance vith 15A NCAC 2C .0118.
e. YIELD (gpm): 30 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE
Amount 100PPM
g. WATER ZONES (depth):
From 160' To 180' From To
From 180' To 200' From To
From To From To
6. CASING:
Depth D' ter
From 0' To 85 R. 8'l%°
From To Ft.
From To Ft.
7. GROUT:
From 0'
From
From
Depth
To 20
To
Material
R. CEMENT
Thickness/
V58I
R.
To Ft.
Material
Method
GRAVITY
8. SCREEN: Depth Diameter Slot Size Material
From To FL in. in.
From To Ft. In. in.
From To R. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
From To Ft.
10. DRILLING LOG
From To
0' TO 20'
20' TO 40'
40' TO 60'
Formation Description
SAND/BROWN DIRT
BROWN DIRT TO DARK BLUE SLATE
DARK BLUE TO BROWN SLATE
60' TO 85' BROWN TO DARK BLUE SLATE
85' TO 200' DARK BLUE SLATE
11. REMARKS:
RbCEYJE
pt iALk 1
ply .QF VIFC(
1;ii\f 2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 20, WELL CONSTRUC 1CW STANDARDS, AND THAT COPY OF TiIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER,
sw ze4
SIGNATURE OF CEIR4RED WELL CONTRACTOR DATE
I)t1.UAL1 ))1ahb L rolls
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
10/18/06
Submit the original to the Division of Water Quality within 30 days. Atttt: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 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
( 828 )_ 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#() applicable)
DWQ or OTHER PERMIT #(lf applicable)
WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 10/13/06
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: ROBBINSVILLE
COUNTY GRAHAM
YELLOW BRANCH ROAD
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
OPOGRAPH IC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge pother
(check appropriate box)
LATITUDE 3 5 25.126N
LONGITUDE 8 3 43.474W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: wGPS ❑Topographic map
(location of wel must be shown on a USGS top* map and
attached to this form snot using GPS)
4. WELL OWNER
OWNER'S NAME SUSAN KIRKPATRICK
STREET ADDRESS 96 YELLOW BRANCH RD.
FONTANA NC 28733
City or Town State Zip Code
( 828 )- 479-4779
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 220'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO121
c. WATER LEVEL Below Top of Casing: 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): 2D METHOD OF TEST AIR
334054
f. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From 180' To 200' From To
From To From To
From To From To
6. CASING: DepthThickntesc/ N�
From 0' To�, R. 6 I�6 er 181Eli PVCrial
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0' To 20' R. CEMENT GRAVITY
From To R.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0' TO 20' BROWN DIRT
Formation Description
20' TO 40' BROWN DIRT
40' TO 60'
60' TO 80' BROWN DIRT TO BLUE GRANITE
80' TO 90'
90' TO 220'
11. REMARKS:
BROWN DIRT
BLUE GRANITE/SET CASING
BLUE GRANITE
RECEI" nut i 1Tv
F WAMR
OCj 2 ulnb
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA CDPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
{''r tz <ter.; 14.:r 10/18/06
SIG ATURE OF CERTIFIED WELL NTRACTOR DATE
IX9ILU t'j .a). \\LN' 1 Eta II
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL
322
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N Z f0 3
OWNER 4:'r"
MWD
NC
1. WELL ONTRACT9
COnlrfierla OR:
ell Individual
Name W ( )
MILLER WELL DRILLING, INC.
Well Conlraclor Company Name
STREET ADDRESS P • 0 a BOX DO7
HAYESVILLE, N.C. 28904
City a Town Slate Zip Code
( 828 } 837-2997
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID 901 applicable)
STATE WELL PERMIT$(a applicable)
DWQ or OTHER PERMIT 9(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED / a - C6- 676
TIME COMPLETED .?-..j0 AMID PM Er
a. WELL LOCATION:
/j04t,?fv '//C
G/cI Cd-t-cd
COUNTY Ura//t7"-
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
lc/Slope °Valley OFlat ❑Ridge IJOlher
(check appropriate box)
LATITUDE S •2,3, // 7
LONGITUDE I 3 SI- lie
May be In degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: L':rvl's ❑Topographic map
(locatbrl of we/ must he shown on a USGS logo map end
attached to this form r hot using GPS)
4. WELL OWNER
OWNER'S NAME 01G 147 err
STREET ADDRESS (,LtS 6-Ia da,eJ)S Grk k d
RObbIhSL/;Ile- NL 2g77,
City a Town Stale Zip Code
( }
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / `' 2
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 6r
e. WATER LEVEL Below Top of Casing. rt.
(Use -4- II Above Top of Casing)
d. TOP OF CASINO IS / Pr. Above Land Surface'
'Top of casing terminated atfor belay land surface may require
a variance In accordance with !SA NCAC 2C .0118.
•
e. YIEL.D(gpm): /S� METHOD OF TEST /fr/
1. DISINFECTION: Type /7T(t Amount 'tree,
g. WATER ZONES (depth):
Prom /31 To From To
From To From To
Ran To From To
6. CASINO:
Depth Diameter
From ZT To _33 FL 6.2J-
From To FI.
From To FI.
Thickness/
Weight
544,E /
Material
7. GROUT: Depth Material /� %�%
,✓ Met�hoodd
From 0 To .F1. 7ya4c1 ____ ', .
From ,3 To 2 O FL. 1Xi/7` ":, /'v
From To F1.
11. SCREEN: Depth Diameter Slot Size Material
From To PI. In. In.
From To FL In. In.
Ftan To F1.
9. SANDIGRAVELPACK:
Depth
Prom To F1.
From To Ft.
Prom To Ft.
10. DRILLING LOG
From To
C- /O
/ a - "Y2-
11. REMARKS:
In. In.
Size Material
Formation Descriplbn
C/4/
Grail, re
nr.iftCtt..
9E(_ ll S L\
I DO HERESY CERTIFY THAT RIM WELL WAS CONSTRUCTED N ACCORDANCE rant
' ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
/0-0(—c6
SIGNATT E OF CERTIFIED WELL CONTRACTOR DATE
/CPLcL
PRINTED NIE OF PERSON ERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Alin: Information Mgt,
161T Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 668. '
Form GWta
Rev. 7/05

RESIDENTIAL nu. cot•STRUcnpN RnnnRD
?lath Cat Department ofEaviaeneot and Naoeal Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION. 'S 3
335394
tcMRACTott;
CCthr (1r \5(�-ols
wel Contractor (neiviAd) j
Wdf.Mracdr��vv� Ord i ns_
Carripayltaae
STREET ADDRESS (. 3 L I i' t `fC r4 I a4,' I Cc��J
n,.;}J,. :I6 At'c 771
CiyarTaa Stole rip Cade
( L(7ci c)•L1,5C-(
Area coda. Plronemmla
2. vies NrORMATIoet
SITE WELL D SRappeeaaaj
STATEWELL pg ISTRW ,,. rrly
DWO or OTHER PHtYTa(Iappim6M)
WELL USE (Mack Applicable Ike RaidmidwaaSapyp
DATE DRILLED / %— J —06
TWE COMms= a) AMO PM
3 WELL t ar-AM*
CITY: COUNTY Tr„ l�c m
18aamNr . �h(Nir5e -in,: in
4-moona-tiara lato m.. Pad 21Pcostal- _
TOPOGRAPHIC T LAIO SETTING:
°Skim CVt CFW Meese COIa
won sppaplmbad
LAT(IUDE .a c! 2.3 ' o o.y."
- LOMdRDE 83° 37o6,8"
sorts p$OPs °Topographic man
s'_Te aadmatteahaenaaaR9GSIpomanad
aaca'Aedblob knits; rssIng
4. WELL OWNER
ow Clem- C<-5t
kW be fadeouts.
ann. eurly
iota drama Marc
STREETADOTtESS ig hTr -,e Se- rt
ar,%t��✓ ),;11;- 5VC. sr771
auorr TaSaar Cat
(rI-zit7t'-( �r6
Area code - Phone march
awB1DETAa&
a TOTALDEPTTt rl�
M. DOES WELL REPLACE EXISTING WELL? TES o NOItt
c s
WATER LEVEL Tap dCasks 7 5" FT.
Mae'. EAnaaToperarrra)
d. TOP OF CASING IS ( FT. Above Lund Safr"
Top a cameo teadatad ara bet,, Amp model
aaereein aeoadsrai 15ANOW2CAla �
ir
a YEW(swot / METHOD OF TEST C7Ur r
t olsaeuott Type J-I rd Amount i 3na
a WRITER ZONES Omit
Fran 75' To Li 0 c Ram To
Front To Rom To
Ram To Rao To
6. CASING: Thidatesat
we n
Fan I`) Two ri 7 Ft. E 5i.Y1b11 tetanal-
Rom To Ft.
Rao To Ft
7- GROUT: INS Medd
Rae n Tot Qr Ft reme-A-
Rae To Ft
Awn To FL
IL SCRIM* Depth Diameter Skit Sze Mash
Fn. To R. __:a
Ron To Ft S. _ a
Ra t__To Ft nt In.
O. SANDERATELPACK:
DW6 Size MOWN
FmA,__To R.
Frott__To Ft.
Fun To t3.
Tq"
1a DMus* LOG
Fe* To Fps DeaaSn
II. REMARKS:
UMW
tISSIMIC2C. acoMMINCI onSsare* a Am
rewrr rrmc
aaoaaowl a®nwawm®lonleacae.orrrat
vi,s
( i1-/-OC
SIENA OF CERTIREDWRE CONTRACTOR DATE
PRIMO NAME OFrPERSON cotaTRUCTING
TIE WELL
Submit the original to the Division of Water Quality within 30 days. Atlas: Sormat
km
1617 Mali Service Center- Raleigh, NC 27699.1617 Phone No. pie) 733-7015 eat 668. Mgt.,
Fad OW-1e
Rev. 7105

RESIDENTIAL nu, corantocnot►REcoltn
Noah Carotin Deparnead oEavioomaa and Neural Resources- Division of Water Quality
WELL corrneAcroacEanncsncj 1 �6
1. WELL
CrOR:
Nan. Ncifes v
Well TIndeddudi
72'n CA2\t 0(IL)rS
Wd Cate*, C--1--- 'vlase ) I 9 ��l/ 1
STREET ADDRESS 6��4 �lyclp °sin „e..�C. �l
1lXh,--nct;)L2 fVC Qc.77/
aim Tomo Shale hp Code
cam.1/7f- ss1.Cy
Perna Leda. Pis number
2. VIEU-IWORIIIATIOlk
SITE WELL D Sreveiaity
STATE WELL. pBtaaTpapdaaay
DWQ ar OTHER PEWIT f(f appLeaile)
WELL USE (Cheek Agitate/ Sag ReddenedWeist3uppleR
OATS DlaLm //— 3 -OE
raw com 7.ETED • On mu PIA
3. WELL LOCATIDt
Goan 6 ANcy v
'— 0 /i P, OIC Syr 1Ca
(Street naaa.. ULM, Pa aLZipCoae)-
TOPOGRAPHIC t LAND BETTING:
Dape Maley °Fit *Sp °Oast
(drada.pePN+•ia)
LATftt1DE .62 .9n i /:5 F. e"
Lamm* 631OSly n
Lauds sans q(Rs [Topographic tap
gota ion dneIamtbs shown as a 115GS101,oRae and
afNedraaa adsloarestDap GPM
4. WELL OWNER
OWNER'S WOE - „ll 1 ' lPPdEr�.�/1��
t7 1 ADDRESS ye Ph . r I ,or anC V. t
City ,rTarn Side Zip Cale
RC/lC`). FCi-- (J2;55(7
Area code - Pawn aunts,
S.WEILSEMIS ,
a. TOTAL OEPnt `3 UO
Ithy odorm
eineen same or
isadeci•l ism I
h. DOES WELL REPLACE EXISTED WELL? TES° ROA
e. WATER LEVEL adaaTapdrearier / at) FT.
Wan ethos Tap dealing)
d. TOP OF CASING B / FT. Move Lad Surfeit
'Tcpof caging lattialeddear baba land suds, ins regret
sadauaxie azorder eani TEA NCAC 2C AIM
O. YIELD(apak METHOD OF TEST o'4r
3 35395
1. ohs mutt Type H TH
Amami /bc,
g. WATER ZONES (dupe*
Fan g To di.rl Jr Fran To
Fan To Tian To
Rao To Fan To
B. CASING: Tti___ wpee�t
Ram To Ft.
Frain To Ft
7. GROUT: napes alaieLd WSW
Fun f) To 9Cr) F _o"e4- Jl
Fea i_To Ft
Foe To Ft
S. %REFS Daft Dimmest Slat sae Salami
Foos To —
Ras To
p._._In. _ it.
Ftai_To FL it _ h
S. SAIdCRAVELPACK:
Dot Sias
Fran To Ft
Pic qFL
Raw To FL
10. DRILLING LOG
flan To
1I. REMARKS:
Fennelae Deataiplion
err'^
v'JP?
nEc: ZOOS
BELL Sp�palaiaaa 1ACMOFINS N
RECO.inaa9eaea1MEDWI ENHLOrem
n ti_l_ 1r•�CIS�. //_ T.-
S161M OFCETiiffl®Wnj a�ON4OR DATEPRINTEDcf/US,?_et� ✓�I)tSC��l!11
PRINTED NAME OF FERBON COIISTR JCTIIGSitE WELL
Submft the original to the Division of Water Quality within 30 days. Attn: bSormaeon Mgt,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Fain GW.la
Rev. 7/05

RESIDENTIAL nu. c rnvcnor,RECORD
North Cambia Deportment of Environment and Natural Resources- Division of Water Quarry
WELL CONTRACTOR CER��5"WTIFICATIONs `' 6
S 1. W8WHmACTOft
on VIVA cr
Contractor (inaradua6 Nana ern'
re -anon L\c U trim'
wes eiaaetor Coapuetame
STREET ADDRESS (L) 15Z�
\) \tvw"7,vi I NtseaatomTam se
i,`S�fi} Cj74- 9115V
Area ea Prone mister
Z WELL INFOTI>rATIMt
SITE WELLD WORO ,lb61
FO-" 1 `f GC;
77/
As Cade
STATE WELL PERNIDINS,_ end
DWQ r OTHER P60fTEX operable)
WEL USE (ch.&sppfarda Ike Reetlnid WatrSuppyjk
DATEfls /.)- (- 06
nueccsasensa Li O3
Pap PMef%
iWE LLOCATIOR
CITY: c .%. - COUNTY
{,J2_re-1.v,C✓vim
tiv e k7U C 17 11..
Meet remo..tam6a6Coramo s aaaaiire,teUtr.Parc*aPteeei-
TOPOGRAPIaC / LAW SETTNIa
OStme May ORA Wigs OOthr
west Fparpdreseab
LATITUDE s " i�r ' C/ 3.1 1/
torawrDE 5):53!c3..E��
Tali4deAorrgipdealnocc tpPS °Topogaphicnap
poaa8m dwell ba almumcn a USGStypo amp and
e tchedk IikAmmlmtemho BPS)
4.WELL OMER I
OWNERS NAME i C ke,P L-. t /6 ;h�.i v-An
STREET AODI�s West- Ibti4-Led o i�o(c/
bb iv? a -77/
CilywTara Stele rpCode
(7 70 l t-Q'o - 0-32- 1
Area Cade- Phone mamba
Ibaby thodgpres,
milam_asaba
iedaiml ism
L WfLLDETAL&
a. TorAL one /
b. DOES WELL REPLACE EXISTING PE L? YESO rick
c MAIM LEVEL Dakar Tap e easier -2 ) FT
pooreaAbyss TopdCram)
d. TOP usmien 6 / FT.AbateLaid Soboa'
'Tap dcasing taioladaYtrbel rbadaa(aoemayaspie
wham* in asainoei 15A !ICAO r nne.
e. YIELD lan /5 METNODOFTEST (*Air
f. DISINFECTIOttTina (-f T N Amount '7ne _
g. WATER Vie ploplA
Rom an To From To
Foe To From To
Rom To Ram To
6. CASING: Tbielonesof
D�a Wa t reel
Fran 0 Two �' 'f R Cr Ycr 5/1GC� it v7.
Ram To R
Rom To R
7. GROUT: Depth Mandel
Flan (7 To, W' Ftr Perw"d-
From __To R
Rom To R
a SCREE* Depth
Rem To
Ram To
Ran�_To _
i SANDIBRAYtiPACK:
Diaa.ter Slot Sim Melair
R h. b.
R. IA _ Se
PI- i0. is
Depth Slat Menial
Ram To R
Finaq__Tq_R
Fan To R
is. DRILLING LOCI
Foot To Feunafo. Deea(plim
1L REMARKS:
RECIVCCI G iri 0 lAl 1 e "
IaN,!
aCa1113/1 1H1 i '11it is NAOMmMeEMn
amaanaSSEINPmemnlO7aE�L aamnNTAOtorOF'B6
�// l�+ _g��l^ / ���1_C � i/-1-(6
SIGNATURE OFcett., WEIL comma& DATE
Ous);n AilC
PRINTED NNE OF PERSON CDMftTNG TIE WELL
Submit the original to the Division of water Quality within 30 days. Attn: information Mgt.,
1617 Mali Servite Center- Raleigh, NC 276994617 Phone No. [phone] ext 568.
FamGW-le
Rev.7A5

RhsmENTML nu.conSTRocnoN RECORD
North Cants Department orEnvhaoeot and Nuad Emmaus. Division of Water Ovally
WELL CONTRACTOR CERTIFICATION 1/3 3 5- sv
1. WELL CONTRACTOR:
O.;F-t+n �'hi11c :ejc
Wren,
a.4ecfl � call € 41 T-I
IIIIdTi.riadpr .l
CreepoW
STREET ADDRESS bay /4Sp
Pe1ab;v:Csi I l-, 1Vt aCia /
CayaTo.a Slav Tip Cade
( f-1- 75 - 55YI ��1
Area Code- Plimemmmr
2.WELL I FORMATott
SITE WELL D art app- i ,
STATE wet pe atadfpspsats1
DWQ or ODER remeTarePPr . hied
WRLUSE (ChedtArrahbrag Redder* Walreagp yj'i
oxre DRILLED l / -/l%--nG
Tam cowmen / :a 'On Aim Pug(
3.WELL LOCATION -�
CRY':: �flh;rv*JjlipcoutrriVti \nc
r 100r +r, r\ C(ktjc r �iic4li
leaeet time. .rommas.0e yonLo. Pink ZIP034,1
TOPOGRAPHIC /LAND BETTING:
Dare Maley OFht train Maw
Wow OOD
LATins* .ESL nli a n 5-a
LONcrruot, 3 O5.7 er
source a,GPS °Topographic mop
realmewe, west beshown enaUSGSt iomaraid
Madam' tlrTsue notwip GPM
0. ws.LOYIN ER
OWNER'S NAME no r O tUU Q 1(
b, M irkJ ,v� C'rea&T P<•�c:C
5 7 r Az. :9477 /
City erTown Slab IpCab
(S:3t 1E174-41(59
Area coda- Phan manta
1167 he ideates. I
winas.scent a
i.aduel* rat
S. WELL DETAIL&
a. TOTAL DORM ( c
b. DOES MU -REPLACE EXISTING WELL? PESO Hog
a WATER UMELSalmTop d ashen /o5 FT.
(Uarrier Mors Tap elCadre)
d. TOP OF CASING IS FT. Above Land Sabot
'Top den, lamiEladWar below land aura our require
a variance nadmdsrsosugh 15A CACffiANIL
it YIELD(gpmjv /,R 11011000FTEST C%L1(l
t DnotTyp. 1--+77-1
Amount % c&•r. z
g. TATERZONES Pep*
. Fran 1 C,fi To .;()5 Fran To
Fan To From To
Rom To Fran To
S. CA.SING: Thameser
Foe 0 Two (7 FL C.W.- 4at Mt.
From To Ft.
From To • Ft
7 GROUP. Da* atebdtl
Fun fl To 9) FtCJ?mo.'d
Fmti_To Ft,
Fie To FL
I SCREE* Depth Diameter Stet See Material
Rom Fi, in. in.
Feu To R. S. _ b.
Fom_To Ft to M.
I SMOGRAYRPACK:
ENS Siam Raerhl
Ftoel_To_____R
Foe To R
Finat,_To R
Method
IS. MiA.ic toe
Ram To Formica Dmoiplion
11. REMARKS:
GEC.4LIaCib
I iC.mletaoawR.Cm aAacao
• RDImeeIno e®1enEelRL llplllln'ACOPIOF7IIS
16
EIL
tAct1_ c
( s I1-/c--c4
�TUft OF was,_�RAR DATE
dQosti✓1 1 hii1sc s
PRINTED NAME OF PERSON CONSTRUCTING TIE WELL
Submit the original to the Division of Water Quality within 30 days. Atet: dntoneaeon Mgt,
1617 Mail Service Center- Raleigh, NC 27599-1617 Phone No. [phone] at S RL
ram GW-la
Rev 715

RESIDENTIAL WELL CONSTRUCTION Rz,oxo
North Caofao Departing of Eavi000tat and Nadaal Resaota-Division of Water Quality
WELL CONTRACTOR CERTIFICATION i «33`.--(
1 3
1. WELL
TRACTOR:
vy11l (cC s
kContraolof(baividual) them
rr.-k(Je11 (I
WES Caatrador Compayt
STREET ADDRESS 6 ?q N �Yk �ri�--�n aor<ci
Arc_ acs77/
CAT or Tam Serie rip Cale
t `(9s i. Li <-1-,3Cl
Area ones- peons number
2. WELLINFORMATmIt
SUE WELL D /Gaafe die
STATE WELL PHlyTipfyppryeq
ONO aOTHER PEI C Neppi_U )
WELL aE(aredrActiatbprbrid waterSa t.
DATe omu.so l-/q-06
TRtE CONFLETED y= Or} AMP FINK
WELL
a CITY: 7bb: ) iI
alc� (1QnS l CQd
listen rrrlr..r�w, Coewe .—. trom r Poem, Spate.
TOPOGRAPHIC 1 LAID SETTING:
OSbpe Mar Atilt ORNy/ Daher
ldsrteppsgmre ee
LA-nrunE $ s]_ , X.3/ 6ci, 5
Lonenum_f cc
Latitude/longitude sow ,ems OTepooaphic map
Amara=dndmmrbe Warm ara USGStgaoarmand
Medal beifotal atesbeer4
d.WB.LOMER
OWNS SWILE 'J(1)'1ny v��l,v S ..//))
Atx71'a�S ( ,�,< (ri> wzrrk d`0cJIq
Zip Cab
Mmhe ideas.
mials.seeaba I
iaderat team
City or Tam Sale
)- 73, Q (/
Area code - Phone rant r
SWELL OEMs a. TOTAL DEPTIt OPP 66
b. DOES WELL REPLACE EXISTING Walt VISO HON
c- WATER LEYB.BdoraopMeasly t!/) FT.
meow Above Top demi@
d. TOP CIF CASINO IS L FT. Above Land Sodas
'Top et calm loalwedakabobslnd wboes ap, ,sle
aratarcei acc a oneealt 15A MTAC 2C AUL
a WELD 3'P METHOD OFTEST CA t (`
•
t costracecntet Type H 7 H
tF UeRBtZONES (NPaz
Farr 6 b To .acc
Ran To
Fan To
Amount 9 c
Fan To
From To
Fan To
6. CASING: Ttddwsl
Wee
Ran t� Depth
To 1 FL(D%y�W 2i) & ivC
Ram To R
Fmq__-To R
7. SNOUT: Dept Mataid Method
Ran r^, To: W R ('
Frro_To Ft,
Foam To Ft,
S. =REM Depth Oimaler Um Ms Melrid
Ran To FL —In. i.
Haar To R.-.--b. it.
Ron To Ft, h h
L SANWORAwLPACK:
Dena Stae llderit
Ram To R
Frml__To R
Ram To R
14 oeLLING LOG
From To FemmiR-Desojdion
IL REMARKS:
REL�y�� 1UHt,'
,ay.7F PEEP
�� 1, 20,1
•
iaoar®r1 OMFV9arlas IEU-MIronWrc®rACCORWa,Emn
15AM C=IVE LCaf1amlrCDor=WISNAW na COW MOM
MOODRASMErVROM� LOWIE�1r�er.AJrrrrt 7
J2,614; /v4l'/L7�i� ,/-/cf-0
SENATUREOFpEtTITFED WEN_ OONiitllcToR
DATE
25.1-An Liekl nec sn THE was
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center -Raleigh, NC 27666-1617 Phone No. [phone] ext 666.
Farm GW-ta
Rev. 7105
398

1. WELL CONTRACTOR:
James B. Brown
Well Contractor (Individual) Name
Hedden BrothersWellDrillin Inc,
Well Contractor Company Name
STREET ADDRESS 73-H011Y Hills Vista RD
Franklin, tdC ZA7Rd
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMITS/Of applicable)_
DWQ or OTHER PERMIT #(if applicable)• ,
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED :
TIME COMPLETED
3. WELL LOCO 10
CIT l .1
AM ❑ PMM
reet ame Hu • -en, Community, Subdivision, Lot No reel, Zip Code)
TOPOGRAPHI /LAND SETTING:
G Slope °Valley ❑Flat ❑Ridge °Other
(check appropriate box)) �--
LATITUDE Jffi� 03
LONGITUDE. rM(,
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
S REETADDRESS
City or Town Ste
Area code • Phone number
5. WELL DETAILS: �ay1,I /TT
a. TOTAL DEPTH; —4 '1
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES1 0 N0,
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing) FT,
tl. TOP OF CASING IS i
FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance In accordapce with 15A NCAC 2C .0118,
e, YIELD (gpm): —•L2 _ METHOD OF TEST B10W
RESIDENTIAL WELL C NSTRUCTION RE ORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #2045
f. DISINFECTION: Type H T H _ Amount_
g. WATER ZONES (depth):
From To From
From To
From To - _ .:..
From ,��Q To
-'�+-4r— To From 70
6. CASING:
Thickness/
From��Depth f
To fir ' Ft Dla afar Wei Ip Mat
From To Ft. v
From To Ft.
7. GROUT: Depth Material
From 0 To 20 Method
Frcerne11 t benonite p
From To
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To_
To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
Diameter Slot Size
Ft. In. __ In.
Ft in. In.
Ft. In. In.
Ft.
Ft.
Ft.
Size Materal
Formation Description
r•la� R c^ d
ranifa
11. REMARKS•
Material
I D0 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO:O HAS BEEN PROVIDED TO THE WELL OWNER.
r _
NATURE OF TIFIED WELL CONTRACT R DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Su@mit the origtnatto.the Division of Water Quality within 30 days, Attn: Information Mgt,
161 Mail Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
DEC 12 2006
a
DEC ]F ��''/�i08

1. WELL CONTRACTOR:
RESIDENTIAL WELL ONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # _2045
•
James B Brown
Well Contractor (Individual) Name
Hadrian Brothers Well Dr.illin
Well Contractor Company Name
STREET ADDRESS 73Ho11
Inc:
Hills Vista RD
Franklin N q
City or Town State Zlp Cotla
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(It applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply lam'
DATE oRILLED a 7�
TIME COMPLETED =— L_ AM 0 PMX
3. WELL LO TION:.
CITY: COUNT
an
(S(reet N;17.rfbers, Com unity, SubdMsjon, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
: Slope :Valley ❑Flat :Ridge ❑Other
(check appropriate box)
LONGITUDE
DE
Latitude/longitude source: )(GTE,
(location of well must be shown on a USGS tope malp andc : attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAM
STREET APDRES
City or Town Sta e
i men )--i_221
Area code • Phone numbeer
5. WELL DETAILS:
a. TOTAL DEPTH;b_
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [
c. WATER LEVEL Below Top of Casing:_
(Use •*" If Above Top of Casing) FT.
tl. TOP OF CASINO IS 2 FT. Above Land Surface*
'Top of casing terminated at/or below and surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem): __ METHOD OF TEST B1
z
May be in degrees,
minutes, seconds or
in a decimal format
p
Code
335113
it. DISINFECTION: Type
Amount 160z
g. WATEA ZONES (depth):
From Tor From
-.1�7--.-_To
o.qqQO'�To.._ _
From
From TO
From To From
To
6. CASING:
Depth
From o Thickness/
a eter Weloht
To �� DI
From To Ft
From To Ft
7. GROUT:
0
From
From,
From
6, SCREEN:
From
From
From
Depth
To 20
To
To Ft
Depth
_ To_
To
To
9. SAND/GRAVEL PACK;
Depth
From To
From To
From To
10. DRILLING LOG
From To h
V r
`N ) r I
11. REMARKS:
Material Method
FGement & benonite p
FL
Diameter Slot Size Material
Ft. In. in.
Ft. In. In.
Ft In. in,
Ft
Ft.
FI.
Size Material
Formation Description
rlati R ¢^nA
nranit
r.-m-7.trifttgfRaLIALIM—
I I D0 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC EC, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RcC AS BEEN PROVIDED TO THE WELL OWNER.
ATURE or RTIFIED WELL CONTRA DATE.. p
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] eat 568.
Form GW-la
Rev. 7/05
•

City or Town
CrD
RESIDENTIAL WELL CONSTRUCTION RECORD :"
North Carolina Department of Environment and Natural Resources- Division of Water Quality < a
WELL CONTRACTOR CERTIFICATION H 2- ° 3
OWNER 12-6'oh
MWD
NC
1. WELL CONTRACTOR:
Contract Individual Name
Con (Individual)
MILLER WELL DRILLING, INC.
Well Contractor Company Name
STREET ADDRESS P• 0. BOX 567
HAYESVILLE, N.C. 28904
city or Town stale
( 828)- 837-2997
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(e applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply —
DATE DRILLED /D C‘
TIME COMPLETED /c, CC AM 0 PM 0
3. WELL LOCATION://�
CITY: .4 2,75 ✓'//e. COUNTY on,i4rn
/J' /d5
(Street Mahe, Numbers. Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
['Slope glley OFlat DRidge ❑Other
(check appropriate box) r
LATITUDE 3 S IS, 2-a°
LONGITUDE 3 1-Hi 928
Latitude/longitude source: kGPS Topographic map
(location of wet must be shown on a USGS lopo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS _5 27-0. tali Ash rt4,
May be in degrees,
minutes, seconds or
in a decimal Formal
/n /.erg- lit fers eel
Rebb;14stidie ,Uc-
State Zip Code
Area code - Phone number
6. WELL DETAILS: 1 t
a. TOTAL DEPTH: F
2?77(
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: a>Z C FT.
(Use 8 Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): l G METHOD OF TEST ,'
1. DISINFECTION: Type /17171/ Amount
g. WATER ZONES (depth):
From /7C To From To
From To From To
From To From To
6. CASING: Thickness)
p Depth Diameter Weight Material
From GI To /4' Ft. -2,5'- ; /331 f 2 /
From To Ft.
From To rt.
ilYc
7. GROUT: Depth Materriiaal Method
Rom 0 To 41 Ft. ..4r/%rrc %U:-. --2,c/
From 4 To ✓ D R. 4,-;/ - /-'r A"}"e 7
From To Ft.
8. SCREEN: Depth - Diameter Slot Size Material
From To Ft. In. In.
From To FL in. in.
From To Ft. In. in.
9. SAND/GRAVEL PACK: - 1
n
Depth Size Material CO
From To FL txn
From To FL i-'
From To Ft. ^'
-3
10. DRILLING LOG
From To
Formation Description
/ 4-,Y aria ii . )4-,.
11. REMARKS:
RNA biv. EIVED
TER % ALITy
(AN f) b 200?
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL. CONTRACTOR DATE
6rvice Ta�7/or�
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] eat 568.
Form GW-ia
Rev.1105

North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 403
1. WELL CONTRACTOR:
/-er!y ✓f2 ec
W e0 Contradtor (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 Code
( 82B 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT IV applicable)
WELL USE (Check Applicable Box): Residential Water Supply Er -
DATE DRILLED /0 -f_sr" C6.
TIME COMPLETED 3-" AM PM13'
3. WELL LOCATION:.
CITY: /Ii'/J 416..,- (l¢?
(Ai
COUNTY !3:^aH �`"
iSlreel Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
lag./Pe ()Valley ['Flat ID Ridge 0 Other
(check appropriate box)
LATITUDE S 2(- 7 S1 r
LONGITUDE g 3 1p3. S-fl '
Latitude/longitude source: 11(GPS ❑Topographic map
(location of well must be shown on a USGS tope map and
attached to this Ions 7 not using GPS)
4. WELL OWNER /
OWNER'S NAME ,)Ldn U4.t,yt/-
May be in degrees,
minutes, seconds ar
in a decimal formal
STREET ADDRESS PO Box z5/ Z
Robi14iS r I)e NL 2MO
City or Twin State Zip Cade
( 1-
Area code - Phone number
5, WELL DETAILS: 7
a. TOTAL DEPTH: vc 6 2'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 6 U FT,
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS l FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ' METHOD OF TEST .""
CA
C,J.Z OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD c'^ MIND
.,:3 NC
Ix+'
I. DISINFECTION: Type grit
Amount i' /-
g. WATER ZONES (depth):
From d25 S" To From
From To From
From To From
6. CASING:
Depth
From0 To .23 Ft
From To Ft
From To Ft
Diameter
G,:cs "
To
To
To
Thickness/
Weight Material
.weal /t.'-
7. GROUT: Depth Material
From 0 To 3 FI. ✓ar&h/
From 3 To2_b Ft. .G'ewt2-
From To Ft.
Method
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
Size Malarial
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
p-70
/'U.-242
11. REMARKS:
Formation Description
-.J
71v CirlwwAt(vFn
FFR [QUALITY
JAN 0 R lnp7
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
J 5k Lohq
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No, [phone] ext 568.
Farm GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envionmat rind Natural ResomoesDiv'rioa of W� Quality
WELL CONTRACTOR CERTIFICx
AT[ON it 2 J p 4
1. WEU, (C,Q lTR&CTOR:
d 'Ults--N il'Kontractor 'r(�s 1
ri
WelContaelorCompanyNameQ_�t / l�ih�
STREET ADDRESS 037 ?.C./P l-� TI ,,. atoll
(2& c ills. Nit ara-il
City or Term Slate rip
( (�r3g'- Ci7r1- @ictI
Area code- Row rumba
2. Wa1IFO1GIAT101!
SITE WELL ID bit appiu k)
STATE WELL PERMITSWararbrke
DIM Of OTTER PERMITS(lepp ale)
WELL USE (ChedcAppide-130* Llridwrld wakr$appl)rN
DATE DRILLED / a-. /5—o 6
Ta1E COMPLETED %Ti AMO PM Dr
3. WEJ_LACATIpt
aim (2 kjr•svA1(A coueryGc4v,rr.
Lrr,)er E Fro Cr�edc
iSlraalllerne.11ueaees. IALeb..Pard.$Oub}
TOPOGRAPHIC t LAND SETTMIC:
DSlope DYE Mat Kiley D06er
LATITUDE s &b RE r /C,p "
LctaILlwES QO' 3a.9„
Ialit deila git de soot= AGPS ['Topographic map
(kcabbndNei mentheshown anaUSGStypo smpad
sled edSo lislbma ladmig GPSJ
4.WELL OWNER
, (�
owners WANE k�vi r\ Oer -O l"\,
STREET ADDRESS Ln,J-Qr 6,.0-Jyer( Creek
bcbh, ,c4fl. (Vc_ &c,77
Odya Town Slab ZIP oath
May be it degrees,
ai_s meantor
isa&r>.L haat
S. WELL DETAIL&
a TOTAL DEPnt -S(4)5
b. DOES Mat. REPLACE EXISTING WELL? YES CI NO„
e. WATER LEVEL fiebeTapofCasing 41 cc FT.
Warr if Above Top d Casing)
d. TOP OF CASING is / . FT. Above Lad Surface•
Tap at casing-miafcdagar below bdadaoesnay sagsse
avariance aara.adarraemilt 15AN AC2CAIBA
e. YIELD On 3'O METNODOFTEST Call f
E. OISINFIa[.TIOtt Type NTH Amount / 0 oz
g. MAMMIES Iambi
Fmmn.S To ;Uc7 From To
Fran To From To
Ram To Ram To
6. CASING: Titaness(
Fan ri Two Ct/Ft CCRR{ fa3t?2 PVC
Rom To Ft.
From To Ft
7. GROUP Depth
Fret fl To at)
From To
Rem To
Serb
Ft C mere v -
Ft
R
a SCRE9k Depth Diameter got Sze Material
Frm_To R N. a
Ram To R M. _ a
Fan To Ft. b. it
S. SAMMEIRMiELPACK:
Depth Sin Muriel
Fmm To FI.
From To R
Rime To R
ie. DRtUNG LOG
Pam To Formal n Daaolp6on
11. REMARKS:
tttG_.
r)LV. OF WATER AUAL►r
rnOIBBYCHIIFY7Ia7Mtw8LNAsCOrM12EDWAC :NONCEWrrrr
151110C2C. CCINSTRUCOONSTANDAMS.A1DAYN<ACOTOFWO
RECORDrrrS NN®Iwsaea®9o71E WELL OWNER.
nil/Sk
SIgM jjf�.�FF��DERTFED WEL DATE
PRINTEDMEOFPERSONcO C DEWEI .
Submit the original to the Division of Water Quality within 30 days. Attie: Information Mgt-,
1617 Mao Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fam GW-la
Rev.7105

RESIDENTIAL weu, coEsraucnoN RECORD
Naar Canto Department oFavimmlaa and Natural Reanras• Division of Weer Quality
WE L£ONTRACTORCERTIFlCATIONl ,�3C-6
t. WEU.
CTOR:
Wel contractor Met
Y1ll4r j/'
\t r.1nt„r t)p \( Ian l ( '
WdCaeractor Conpaa m / � h<
STREET ADDRESS ,//i ?(.1 14, Ae �aav, (lac, )
Q24)b61:s.,;1ii, Ivc ae6-77/
City orTown Slate rip Code
Ar
}Ras—(cti
2 waLIFoIt' nnolt
SITE WELLID sptemlimwe)
STATE WELLPERIEW,,
DWQ or OTHER PERMIT IR ePPliable)
WBLIIE (ChedrAWiotle Ba¢ Rariaerir WaerSapplyq'
DATE owls l a-
TWE COMPLETED tflfl AMID wok
3. WELLLOCATiOtt
CITY: % h h i n5v,'LCOUNTY \ ) rbSflc rv,
LSi Y'L,%l t On CA ,.
tared Nara tkeeb-.-[ r.SreeaiebateLtai. Pared. 'code}
TOPOGRAP)IC / tAtC SETTING:
Daim ovaaw AEU ORilbe ooemr
(meek apor aimmord
tATITUGE ya sc° j6 1 / a 6' n
tonornmEn71 01 t"
I May bepagues.
I
minks, roods
Inaadcad Mauna
LatitudeAongitudesomca A tf5 DTtpogtaphiemap
Oran aleel west be shaman a USGS kpemap and
aaaaleaieOTabarTmtaatq BPS)
4.WELL OTMER r -
OWNER'S NAMEn
STREET � S.v,a.Jh;cc?
12n\nbIICVT 1. M V -77/
City or Town Slate Zp Code
( Ydrr}73 t-3 a
Area carte- Pharr number
S. waLOETALt a. TOTAL DEPn�c7r
t S
b. DOES WELL REPLACE EXISTING WELL? YES Q Now
c. WATER LEVEL BdaaTepelCasing it FL
(Use"t lamas Top etCadre)
d. TOP OF CASSIS IS / FT.Abow Land Surfaces
Tope( aabgfeaiohdalabelow hod surface may spire
a vaame m meat art 1511BCAC 2C AIM
e. YIELD(fl 'p.(°. It1EMOOFTEST etI_'�'�
t DISI FECiWIt Type fi rH Amount 6. A,
g. WATER ZONES (depa*
From /(7/ To XIS ' From To
Ran To From To
From To From To
6. CASING:
Tidelaressf
Fran l Two 26- Ft r c5j2e2,1
From To Ft
Rom To Ft
7. GROUP Dues MalrGd
Farm n To `d0 Ft tr ni—
Fraa To Ft
Farm To Ft
it SCIEBt Depth Diameter got goo Material
From___To Ft k a
Farm To Ft. --it. u.
Ram To Ft. it it
t SAM/GRAVE.PACK:
Depth sae Me di
Rom To Ft
Fna __TaL_Ft,__
Frem____To Ft
10. DIMLING Lou
Fmm To FonneVon Deaoipdolt
11. REMARKS;
RECE%VEU
tjiV OF WATER MALI fV
JAN °9 5 ZUC17
rts�rIICAC2.WHLCa6meeeen�l'�eaameel®aAOWOFAIS n1
a®mmWS IPIWMEOTOTEMRLOa et AYRAO�/QFAE
.4,114s )213-0c
SIGNATURft. CERTIFIED WELL/Cc TOR DATE
PRINTED NAME WEIL
geRf rU I iSrlJs
Submit the original to the Division of Water Quality within 30 days. Ann: Intonnaton Mgt,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Pam GW-la
Rev. 7105
CAZ
ca
cad
C)
r

RESIDENTIAL wicu.caoNsrRucnoN RECORD
Noah Cambia Deparlmaa of Environment and Natural Resources- Dm' lake of Wata Quaky
WELL CONTRAcroRCEDTIF1CATIONf
CIS
eta
1. WELL COMRACTOM
w v�� ,�1�16��4
vc`\r`ti�r ( 1c� l l ()nll i1;\
eO Ca drackarenpa yNana .r g
STREET ADDRESS �l�Y /VI c/Q /,71 ,..v. 1 A✓� da C(
r7C�7%�
Zip Cade
City
Po i orT lnn � le
( kn3t t- 97,- .kv53'
Area cafe, Rase Meter
2. WELL M ATIdt
SITE WELL ID fpaeaieaen)
STATE WELLPERNNTff/aprbera0
DWQor OTTER PHiMTMIappIkable)
WELL USE (OtedtA s-naSaak Reddened Water Suppry
DATE muu.ED /.�- ti — 06
�C
TIME COMPLETED AMO PM Cr
3. WELL LOCATION: �
CRY:jhl�,� v21L cumin vehjit
L.r P 6nc.),.)\eirri
tweet nuehaa.O—emebfnram.taaao.. Pared. 7a.cod.)- .
TOPOGRAPt4C i LAND SETTYIG:
Oscpe Maley ORt Sri* Darer
tohanansuPdabamd
ta-rrr m $.a /9 r h /S "
Lonemice_E _,561 y n
tatitde/Iomitdesour= ACIPS OTopogaphicnap
(bastion dfar must be shain an a USGSSopa monad
Waded Ions Iona Inot atm GPS)
0. WBSOWNER
OWNERS NAME ant4t 1 GAG ZG h :S
STRgTADORea5s 1-,1-j-IP g exib,✓Y
62c1oh1r.SiIIL, /ler at-7
Gay erTonn Sale Tip Cade
( 797 I- 77/ S` i
Area code - Phone number
5. WBIDETA0g /
a t�rs� TOTAL Cyr S
b. DOES WELL REPLACE EXISTING WELL? YES O NOA
c. WATER LEVEL SdmrTapdenting •bp ` FT.
(tM.W SAWA: orCatag)
d. TOP OF CASING IS / - FT. Above Lend Surbst
'Tend aisle taaiaaedalarbek abdaadaoemgWane
variance it mazdanatath 15AMAC 2CAnt
e. YIED(gpmk t NEMNODDETE.ST a. ;IN
IMay to in doom
o aaombor I
teadroaal knot
f. DISIMECTIat Type r, TN Amount f .6 n'�
g. WATER ZONES (dope*
Faun 15 r To 0 (N.0 ` From To
From To Rory To
From To Rom To
S. CASING:
DepDiameter
ROMd To�7 71 Ft 6
Ran To Ft
Flom To Ft
Thinnest/en�dt1t ,d
,71,1 Nub
7. GROUT: Depth Wail What
Fran t7 To ar3 Ft CPwuzni- ,fl',.,.�pi
Rag__ To Ft, I� -7
Free To Ft
S. SCREEN: Depth Diameter Slot Size ii. Material
Ran To Pt. In
Fran To PL M. is
FraILTo Pt M. kt
S. SAN DIGRAvanAce
Depth Site MOM
Rom To FL
FraR_To Ft
Fmra___To Ft
10. OWlalG Inc
Ram To Formrmn Description
11. REMARKS;
RrCFIVFD
GIB. or WATEP QIJAI @'
•
IAN sl L00/
lea MdC2C.IVELLCOMMUCTIONSIMMAMMMI
R ®1OW
MASO BIPROYaE WHLOW/NEIR. 9uaACaMOF9at
SNaYNATtAtE J . ' v/'IL6ks
WELL FOR DATE
Q�t1S�in V7i1 IKc,,��JJS
PRINTED OF PERSON cons -Michas TIE was.
Submit the original to the Division of Water Quality within 30 days. Ann: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1817 Phone No. [phone] ext 568.
FarmGW-la
Rest 7/05
r_,
ry

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3041
1. WELL CONTRACTOR:
PAUL BRYANT BRUCE
Well Contractor (Individual) Name
MA GREENE BROS. WELL DRLG. OF SYLVA, INC
Well Contractor Company Name
STREET ADDRESS 1800 SKYLAND DRIVE
SYLVA NC 28779
City or Town State Zip Code
( 828 )- 586-5550
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 8/10/06
TIME COMPLETED 5:00 AM ❑ PM
3. WELL LOCATION:
CITY: ALMOND COUNTY GRAHAM
TOBACCO BR. OFF HWY 28
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat O Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ID GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this (onn if not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME JOHN LUKE
STREET ADDRESS 1176 LAKE BREEZE DRIVE
WELLINGTON, FL 33414
City or Town State
( 561 )_ 512-4564
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 650
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 120 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): 3 METHOD OF TEST AIR
338056
I. DISINFECTION: Type HTH Amount 29.25 OUNCES
g. WATER ZONES (depth):
From 500 To 503
From
From
6. CASING:
From 610 To 613
To From To
To
From 0 DTot82 Ft "Voter
From To Ft. B 7�4
From To Ft.
7. GROUT: Depth
From U To 3
From 3 To 20
From To
From To
Thickness/
SFi�Z7
Material
Ft.CEMENT
Ft. BENTONITE
Ft.
Matrial
Method
TOP
PUMP WITH TRIM PIPE
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-73
73-500
500-503
503-610
610-613
613-650
11. REMARKS:
Formation Description
CLAY
GRANITE
CAVITY
GRANITE
CAVITY
GRANITE
DIV, OF WATER ML; I v
FEE) I L 2001
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.
NATURE OF CERTIFIED L CONTRACTOR DATE
PRIN NAME OF PERSON CONSTRUCTING THE WELL
✓t-.0
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina I)
t of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3368
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Wel 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
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 101 applicable)
STATE WELL PERMIT/kir applicable)
DWQ or OTHER PERM FT I(ff applicable)
WELL USE (Check Applicable Box): Residential Water supply 0
DATE DRILLED 01ro9N6
TIME COMPLETED AM 0 PM ❑
3. WELL LOCATION:
CRY: ROBBINSVILLE
COUNTY GRAHAM
453 OLD YELLOW BRANCH RD.
(Sheet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
TitSlope °Valley ❑Flat 0 Ridge ❑OBher
(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 wen must be shown on a USGS topo map and
attached to this tam (not using GPS)
4. WELL OWNER
OWNER'S NAME JOHN LOVIN
STREET ADDRESS 453 OLD YELLOW BRANCH RD.
ROBBINSVILLE NC 28771
Cdy or Torn State Zip Code
( 828 )_ 479-3095
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' 'Above Top d Casing)
d. TOP OF CASING 15 1 FT. Above Land Surface'
'Top d casing terminated ator below lard surface may require
a valence it accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST AIR
1. DISINFECTION: Type CHLORINE
Amount 100 PPM
g. WATER ZONES (depth):
From To From To
From To Rom To
From To From To
8. CASING:
Depth
From D To BP R.
From To R.
From To' Ft
Thickness/
8 piret a 184Y1
'PVC
7. GROUT: Depth Material Method
From d To 20' R. CEMENT GRAVITY
From To R.
From To R.
8. SCREEN: Depth Diameter Slot Size Material
From To R. In. h.
From To Ft. in. In.
From To R. in. F.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To R
From To Ft
10. DRILLING LOG
From To
G TO 20'
20' TO 40'
40' TO 60'
6D TO 80'
80' TO 605'
11. REMARKS:
Formation Description
SAND & DIRT
SAND a DIRT
SAND & BLUE SLATE
BLUE SLATE
BLUE SLATE
:n
I DO HEREBY CERTIFY TWIT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPYOF THB
RECORD HAS BEEN PROVIDED TORTE WELL OWNER,
01/16836
NA RE 6F`CERTIFIEV'WELL CONTRACTOR DATE
6.)%wnu 2w Leu)t
PRINTED NAME OF PERS ►ROCTB I'H� �yELt
RECEIVED
Submit the original to the Division of Water Quality within 30 days. Attn: lnfornatlon Mgt,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 5j8.
Form GWAa
FEB 07 2006 Rev. 7J05
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina lkpartnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3368
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Wet Contractor (IndMdAa4) Name
CHEROKEE WELL DRLLING
Well Contractor Conpeny Name
STREET ADDRESS PO BOX 1007
MURPHY NC
28906
City or Tone State Zip Cods
( 828 )_ 837-8008
Area code- Phone number
2. WELL INFORMATION:
SITE WELL IOW applicable)
STATE WELL PERMITI(i applicable)
DWQ or OTHER PERMITIV applicable)
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED 01/10/08
TIME COMPLETED AM ❑ PM 0
3. WELL LOCATION:
CITY: ROBBINSVILLE
COUNTY GRAHAM
453 OW YELLOW BRANCH RD.
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC! LAND SETTING:
❑Slope ❑Vaaloy 04 Fat ❑Ridge OOther
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(beatbn of wel must be shown on a USGS fopo map and
attached to this form not using GPS)
4. WELL OWNER
OWNER'S NAME JOHN LOVIN
May be in degree,
minutes, ecaonds or
in a decimal format
STREET ADDRESS 453 OLD YELLOW BRANCH RD.
ROBBINSVILLE NC
28771
Cly or Town State
( 828 )_ 479-3095
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 366.
Zip Cods
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M
c. WATER LEVEL Below Top of Casing: 100 FT.
(Use'*' if Above Top d Casing)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
`Top of casing teminated atlor below and surface may require
a variance In accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): 20 METHOD OF TEST AIR
8. CASING:
Depth
From D To 831 R.
From To R.
f. DISINFECTION: Type CHLORINE Amount 1(K)PPM
g. WATER ZONES (depth):
From 320' To 340' From To
From To From To
From To From To
Thickness/
61/8 SDR21
'PVC
From To R.
7. GROUT: Depth Materiel Method
From 0' To 20 R. CEMENT GRAVITY
From To R.
From To R.
8. SCREEN: Depth Diameter Slot Sae Material
From To R. in. n.
From To R. in. In.
From To R. in. in.
9. SAND/GRAVEL PACK:
Depth Sae Material
From To FL
From To Ft
From To Ft.
10. DRILLING LOG
From To
C TO 20'
20' TO 40'
40' TO 60'
60' TO 80'
80' TO 93'
93' TO 365'
11. REMARKS:
Formation Description
RED DIRT & SAND
SAND TO BROWN SLATE
BROWN SLATE/SAND
BROWN TO BLUE SLATE
SLATE
SLATE
I CO HEREBY CERTIFY THAT RAS WELL WAS CONSTRUCTED MAr O'RDPIPE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A CCPt OFT IS
RECORD WAS BEEN PROVIDED 10 THE WELL OWNER.
'ul a-Lr)/1/Z • �.(`[ to bf T 01/16/08
SIGNATURE OF CE TI ED,W LL NTRHCOR DATE
Ab% 1..E s
PRINTED NAME OF PE I RM A rob Inc WELL
RECEIVED
Submit the original to the Division of Water Quality within 30 days. Attn: Inform Mon Mgt,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 566. Form GW-tor
FEB 07 2006Rev7105
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
Noah Carolina Department of Environment and Natural Resources
-DDiivision of Water Quality
WELL CONTRACTOR CERTIFICATION 8 3 i V `o
I. wFr t coNrRAcroR 1}'\\16 _S
W
WContractor
Ai2\actor+(kividual) Name
`5 G/1
Well
Na es. 1Of\%\i'
STREET 661nsv te Nec'de at77 �
City Or Toan Stab Zip Coda
(C >. `f 71 —1-1I6t1
Area code- Phaie mew
2. WELL INFORMATION:
SITE WELL ID /kd applicable)
STATE WELL PERMITIgaPoll ace)
OWQ or OTHER PERMIT Mil appicaMe)
WS.L USE (Check Amicable Bar): Thiskkormil Wage SW* tit
DATE DRILLED 1 o-ph
TWE COMPLETED -300 AMp PM(;
3. WELL L TtOlt ^- `
CITY: �p�[1 NK,n � 6 COUNTJ�7 Y b
(if-vp rne6 C dc-
(Street Nome..to.were. Camanay St6nkierc Latino.. Parcel. Z, Code)
TOPOGRAPHIC / LAND SETTING:.
°Slope °Verity ORM p tidge toiler
(check apprCapdals bad
LATITUDE 3 )2C ► 1,57. 6"
LONGITUDE ff aD tl 5
IMay be in degrees. I
alsates. seat or
inadecimal boot
LatiotrkAongitude source: 4GPS °Topographic map
potation Owl nas & Shan, on a USGS Nape n:sp and
attdaed b iris Rrmlnot using GPS)
4. WELL OWNER
OWNER'S NAME
(7rprie-
rTe
city or Town Sate
(tae I-CI741-6A►D
Area code - Phone number
rip Code
3
5. WELL DEMOS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rf
c. WATER LEVEL BarsTop of Casing „9,5. FT.
(Use 'a' ifAbove Top ci Casing)
d TOP OF CASING IS l FT. Above Laid Su aces
'Top d casing leniNled aUar below beid surface may require
a variance in accedence vier MA NCAC 2C.0118.
e. YIELD(ginx tin de / METHOD DETEST CLt I'
I. DISII.WECTIOItType Lei.1 Ff
g. WATnEERr 2,NES (depth) ,
From Oc To 1 OS From To
Fmm To Fran To
From To From To
6. CASING:
From i) DToo ra() Ft 6 YYu
From To Ft.
From To Ft
7. GROUT: Depth
Rom f1 To a0
Fran To
Fran To
Amount t/ 0 7
Ter:Mess/
sat
Materiel
Ft rt1n.cS -
Ft.
Ft
Me6md
PJ"^Pt;%
8.SCREEN: D a
Depth neler Slat Size Material
From Ft in. in.
From To Ft Si. - n
From To Ft in. in.
A SAND/GRAVEL PACK:
Depth Stott Material
Fran To Ft
Fran To Ft
Rom To FL
ID. DRILLING LOG
Flom To
11. REMARKS:
Formamwl Description
1001610y CenFT'TUTTIi WELL WAS Cna1acTa RACCOR wow
ISA ICAO 2C. WELL COIATRULMON STANDARDS, AND TAT A COPY OF Ta3
RECORD HAS SEEN PROVED TO THE WELL Gana
SIGNATURE OF CERTIFIED WELL fCOATIACrOR / 3 DATE
6- 6
ck,
PRINTED NAME OF pFR801j THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

RESIDENTIAL W1311. CONSTRUCTION RECORD
NacthCant Depraeart ofEntioteraat a S Nino! R Division of Water Quality
WELL CONTRACTOR laTtnCATION 8
1. TRILL CONTRACTOR:
Vacated/or ,1s05
Wel maci ► 1 `1� ,11t;"(S�
STREET Nand
ADDRESS 4.3 trcierm IN Ref -A
�cZhb�rsrde !7 /
CAN FrM to 20046
( 42tj- L) 77- `6tlbk
Aria cods Phan anew
7-INELLIRFORISAUTO1t
SITE WELL IDSO-ppaawl
STATE WELL PERM/TIN appate)
Maar°TIER PEREITttapplca ie)
WELL USE (Choi Amiable Scot ResdaW Wear S 0(
DATE°MAD /-a7- ob
TIMECOMPLETED ili50 AMp PIA cc
3.WEL 4WIt,
DM/ f >obi•svi I IR COUPaTY.
e C f e1t
r9eatarn. Oamoggiatoonedatosua.ProcelEordood
TOPOGRAPHIC) LAND SETTING: ..
QSCe.�jVley OFit DRUB* Doter
LATITUDE, ...A apparels*
C) /,. "
LONGITUDE S se gel ` L131Ci
tafibierionsiGide sctn VPS orcevenetsc amp
Onadbrr flee maltb shown on a USGStcyonapard -
aaadad to to him 7td odq GPS!
a COMM
OWNERSNASE 0 ()DLittry
ADDRESS &'e Gi. C nee
►� we 77
City or TOM S
f(C9t)- 4474- with
Ann rode- Phone number
•t!,k-•ericz,
— swords or
Ina doled kart
S. WELL DETAIL.
a. TOTAL rut /n5
b. DOES .te.LREPLACE EXISTING wa,.o VES NOW
e. WATER LEVEL Saba Tap do rig aO FT.
Mare
d. TOP OF CASSIG E l . FT. A royo lad Suds/
Teo dieing term W td dM below Ind surface now name
amime to aoortnoadh15AWAG 2C.otta
a V1aDtoper• 9.0 METHOD OF TEST Cu r
1. asewuc ottType I-iYF{ Aemas q 02
y. WATER ZONES (depth):
Run 90'To '„ra From
Ram To From
Fran To From
To
To
To
Mtn/
Moat an D DT t Li.� Ft 6 j I
Fr1
From To Ft------
Fran__Ta..__F4_
7. GROUT: Depth u.tait reeeS
Ran 0 To go Ft Cerye.Pj- t\nei%
Fmm To Ft 1
Fran To Ft
IL D6r . Caret ad Slaw Matata
Ran__ TO.---- Ft, —it In
Ran__ To Ft it - it
Fron_To Ft it it.
I. SANS/GRAVEL PACK:
Diva Sao Maria
Fea�_Ta R.
Fran. To A.
Frar1_To Ft
10. DRIUR(G LOG
From To
Fama6on Desaytbn
RECEIVED
MAR 08 7nnH,
Ash@VFBe ReC9itd!ld? OFFILe
Aguifar Protartion
11. REMARKS:
r
u
WOHEREeY CBnPr7HAT110WELWASaaa1aRCIEDaA000RDAI CEWhir
MSC SC.WEU Calaal%RO bnl.l IMIL MOnaTACQt CIF VS
RECORD MUMPS t.WhLEDTOME.rOLOn.6t
/-ay-o 6
DATE
d\>si-;n Vfl14 ;,,Dc
PRINTED W WE OF PERSON CON5TRUCi1NS THE WELT.
Submit the odginai to the Division of Water Quality within 30 days. Ann: Information Mgt,
1617 Mali Sennes Cantor - Raleigh, NC 27699-181T Phony No. [phone] art 568.
Fam GW-Is
Rev 7A5

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- �Division of Water Quality
WELL CONTRACTOR CERTIFICATION I 33O b
1. WELL NTRACTOR:
(S-I-inn_ (K(tLcit
Wd(ki3wdual) Name
) Y e,�.,rY. 1-10k pn 110:ne
Well Coa actor Ca npa y14amie
STREET ADDRESS G 6 y`I li ),cie TY
("r), '5 t€ k77 II
City or Town Slab Zip Cale
(Han Lin -Si1St/
Area code- Phone rumba
Y. WELL NIFORMATIOtt
SITE WELL ID Weappsu"e)
STATE WELL PERMRatiaieWan )
DWQ or OTHER PERMIT S(Y appfieahle) Sumba(
Wal USE (Check Applicable Bed Rraidatira Walla Supply(
DATE DRILLED / a3- o
TIME COMPLETED ZI t. d 0 AMO PM IX
3. WELL LOCATIOI&
CITY: � Ni;ASOil8 COUNTY Crr WNC--'rv.
kovotr Cc.IRpkc
(Street Nana Numbers. Camn.My-Suhdniston. Lot No.. PaceI. Zp_Code)
TOPOGRAPHIC 1 LAND SETTING:
°Slope Maley OFIM FkRidge OOiher
(check appropriate boa
LATITUDE L 2 /I%/ O(.,,O14
LotIGRUDE e a_ `7 7' I rr
Latitude/longitude source: I(OPS [(Topographic map
(bcalbn d and *raSbe shorn* on a USGStapo map and
albehed to Nis yam 1' not using GPM
4. WELL OWNER .�
OWNER'S NAIVE 1' ,I)Ictir5k(J 6p2C-.CS
STREET ADDRESS �. 'piker V XYi-rnilr ccesc
a Town Tip Cade
May be in area
drates.asamdsar
in decimal Erma
Area code- Phone number
S. WELL DETAILS: f
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ElNO
c. WATER LEVEL Below Tap of cast; 1 q 6 Fr.
(Use 4-NAlloaeTopdCarng)
d TOP OF CASING IS 1 . FT. Above lad Surface'
'Top d casing /aninfed guar below lend surface nrr require
a variance in aecadneewith 15A NCAC 2C .0118.
e. YIELD(gpmg %/7 METHODOFTaiT air
ie
/ to i
L WSIPEECBOtt Type I`1 1-H
Amount 16 OZ.
g. WATER ZONES (depth*,
From /Uri To rfiOS From To
Fran To From To
From To From To
6. CASING:
Thickness/
France _n_Ft tK i 4 6116231 sae_
Weight Material
Depth
From To Ft
From To Ft
7. GROUT: Depth eems�...� MaterialFran�To 9 0 Ft r4N'e '
From To Ft
From To FL
8. SCREEN: Depth Diameter Sit Sae
Foram
From
From
Material
To Ft Si. R
To Ft Si. _ in.
To Ft in, in.
9. SAIO/GRAYa. PACK:
Depth Sae Maaisl
From To Ft.
Fran To Ft
From To Ft
10. DRILLING LOG
From To Formation Deserglon
IVtD
82
—r,
rn
evi e • egional Ofrica
-- ote
11. REMARKS:
mD HEREBY t9mWYTMT1fISW U- WAS OaamaJCIED a ACCOROWCE Wmr
15A IOC 2C. WEU. COf4S7mrna1 SDJCAR05, AND THAT COPY aFlaa
RECORD HAS BED* PROVIDED TO THE WELL OWNER
NRIG Ad_ ,c6
/ 3-cas
SIG RE t>F CERTIFIED CONTRACTOR DATE
d)051-1
r1 0 I ICONSTROC ING
PRWIED NAME OF PERSON THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: brforrnatlon Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
Noah Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 3Z V,
1. WELLCONTRACTOR:
_tTI`^ �,I
c,O_S
Nana
(indAnldDaq
E;Cre-1,0,r, 001 On) t Ih%
Wed Contractor Camay
///` /l Tc�JY
Name [ ,
5 , \ ADDRESS j f NR04J
D1Oietyi �eNrc -77 /
City or Town Sale Tip Cade
(?off} CI7°1-1s1!69
Area code- Phone amber
2. WELL It CRMATIOtt
SITE WELL ID apt appreciable)
STATE WELL PERMITI amplca eel
DWQ a OTHER PERMIT l(d appIc Ie)
UfaL USE (ChairAppccmle Bag Residential Weber Supply gt
camDRUM "04
THE COMPLETED c6 ` 30 AML3 PMClit
3. WELL LOCATIttjjj 11-_ _�
CITY: �04)i nsv )t COINTRre-ANG INN
&moL. `Orr Qec ct
(Street Nane..tombers. C ±y.&Nkbn CatNo.. PROSE Z. Code}
TOPOGRAPHIC LAND SETTING:
°Slope Marl anal OM* palter
(o1Nr1 appropriate bad
LATITUDE iy cam° /6-1 ,51. �7
LONGrrutm 3° 61' '-11,6,1
Latitude/longitude source: OOPS °Topographic map
pocalon dadnNmtbe slam on a USGS Iwpo map and
aladredberrs foam I:sat n g GPS)
4. WELL OWNER
OWNER'S NAME ice 6( chetr APN,
SI ADDRESS 6t) 1 Cp1GU
AADt t\Svl d i. i\fc o�ic77 /
May be in degea,
Mom; maids or
or Town Slab Trp Code
( 67C). 333 - (,56
Area code- Phone number
5. WELDETAtS:
a. TOTALDEPTIt aS
b. DOES WELL REPLACE COSTING WELL? YES ° NOgt
c. WATER LEVEL Below Top d Casing ac7 Fr.
(Uses + ifAbove Top d Casing)
d. TOP OF CASaq 18 / FT. Abram Land Surface
'Top d casing Laminated aWar below lad surface may require
a variance En a/cc�ordancevith 15A NCAC 2C .0118.
re. YIELD n) `7 0 METHOD OFTEST C i r'
f. DISItFE(TIOtt Type ai rl-(
Amount 4 oz
g. WAT�EvR�ZO►ES (depth):
Fran lJ.D 1 To job d From To
Faro To Fran To
Fan To From To
6. CASING:
Thickness/
/ Diameter Weigel Material
Fan_ODToo raja_ Ft % � era)
From To Ft
Fran To Ft
7. GROUT: Depth r Materiel
Ran 0 To 919 Ft. Cerra,
FOR To Ft
From To Ft
Method
p4;
8. SCREEtt Depth Diana SM Size Material
Fran To FL W. M.
From To FL R _ in.
Fran To Ft. In. in.
8. SAIOIWtAVEL PACK:
Depth Size Material
From To Ft.
From To F.
Fan To FL
.�T.__
10. DRNJNG LOG
Raw To Fomaalon Description
11. REMARKS:
RECEIVE
D
evi a egional Office
Aquifer Protection
100 HEIST wun 1NAT1aB WELL WAS COBISMUCim ACCORDANCE ram
ISA/CAC2C. WELL CONSTRUCTION STANDARDS, AND 1MTACOPT Ones
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
h /%zlu aNTRAcr / - l 6-06
SIGNAH (NRt af CERTIFIED WE oR DATE
cPRINTED
HAWOFPERsoNf N6� THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GWla
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resmaces• Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2045
1. WELL CONTRACTOR:
James B. Brown
W kII Contractor (Individual) Name
Hedden Brothers Well Drilling, Inc.
W ea Contractor Company Name
5-MEET ADDRESS 73 Holly Hills Vista Rd
Franklin, NC• 28734
Cityor Town State Zip Code
( 828 )- 369-9591
Area cods Phone number
2. WELL INFORMATION:
SITE WELL ID Mill applicable)
STATE WELL PERMITC H applicable)
DWO or OTHER PERMIT NW applicable)
W1 . JSE (Check Applicablle,Boox)):: Residential Water Supply0
O.: E DRILLED 4^^n
7 Vll Ua
TIME COMPLETED rX r(% I AMC PMi
3. WELL LOCAT
CI
P
eD f4 (2 J
C
OUNTY
jSuael , Numbers, Community.
Lot No., Panel, Zip Code)
Tr 1 OGRAPHIC / LAND SETTING:
D DVelley ❑Flat DRidge DOther
(check eppr6priate box)
L'.'i*UDE
LC'JcsITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DGPS DTopographic map
bcatbn of we! must be shown on a USGS topo map and
attached to this form M not using GPS)
4, WELL OWNER
OWNER'S NAME
ST(t_ RE5S Po
ovii
City or Town State'
(11ZJ- ¥79 data
AI e. a;de - Phone number
5. WELL DETAILS: ���
a. TOTAL DEPTH:
1•
71r
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO
e. WATER LEVEL Below Top al Casing: x10 FT.
(Use's' H Above Top of Casing)
d. TOP OF CASING is 2 FT. Above Lend Surface'
'Top of casing terminated agar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. 4 :LD Wpm): 'cW iceMETHOD OF TEST Blow
c; 0
1. DISINFECTION: Type H T H Amount 168z
g. WATER ZONESy(de th):
From % O! To From To
From /0 a 'To g jtl' From To
From ) D'To 13g' From To
6, CASING: Thickness/
Depo
th
From ToFL Dlametfr
From r To Ft. s I�
From To Ft.
Weight M�leflal
Yf _
7. GROUT: Depth Material Method
From 0 To 20 Ft. ceme It & barite wiped
From To Ft
From To FI.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. In.
From To FL In. In.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
Clay & sand
Granite
1
3,
I1. RWEM,{L-RKS:, a,
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wml
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
REC9RCf1AS BEEN PROVIDED TO THE WELL OWNER.
Ler
ATURE OF E TIFIED WELL CONTRACTOR -
�
James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
RECEIVED
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
1617 Mall Service Center — Raleigh, NC 27699.1617 Phone No. [phone] eat 568.
MAR 08 20r7/06
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
James B. Brown
Wet Contractor (Individual) Name
Hedden Brothers Well Drilling, Inc.
W i' Contractor Company Name
STREET ADDRESS 73 Holly Hills Vista Rd
Fr n�klin,
City or Town State Zip Code
L$28 )• 369-9591
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
ST-TE WELL PERMI T #(0 applicable)
Dx OTHER PERMIT #(if applicable)
VIEi.L USE (Check Applicable Box):
Residential Water Supply ❑
D.\T2 DRILLED I '4..010
TIME COMPLETED T r 6 AMC PM 0)✓
3. WEL L LOC TION:
CITY: 11/1-1 COUNTY ThALAmn
( o tr deg/mg )
(5 rest Na e, N be Community, SubdINaIon, Lot No., Parcel, Zip Code)
TO?UGRAPHIC / LAND SETTING:
❑Sic as [Valley ❑Flat ❑Ridge [Other
(check appropriate box)
1, 1 ', DE . 2/Q n%Al
f At UDE 011 gill'
..siitude/longitude source: Q PS ❑Topographic map
(beafbn of well must be shown on a USGS fops map and
attached to this form Ifnot using GPS)
4, W aL OWNER / //�,,
OWNER'S NAME �(..I, _I /L,yA7CCr
STR'EETAD RESS y.y
May be in degrees,
minutes, seconds or
in a decimal format
Iy or Town stile
4n- is/51
Area code - Phone number
Zip Code
5. Wfi:.t. DETAILS: n
a. TOTAL DEPTH: ca 9C)
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX
e. WATER LEVEL Belau Top of Casing: 5-10 FT,
(Use 'v If Above Top of Casing)
d. TOP OF CASING IS 2 FT. Above Land Surface -
'Top of casing terminated at/or below land surface may require
a variance In accordance with I5A NCAC 2C .0110.
e. YIELD (gpm): CJ METHOD OF TEST B1CW
2045
1, DISINFECTION: Type H T H Amount 1 66z
g. WATERO ZONES (depth):
From / A4 r To From To
From /95 ,To
/ From To
From To From To
6. CASING:
Thickness/
Depth Di meter Weight tgrial
From To Ft. V
From �J ' To Ft. .IRii
From To Ft.
7. GROUT: Depth Material . Method
From () To 20 Ft 04IHit & bannite mire
From To Ft.
From To Ft.
0. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. In.
From To Ft. In. In.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 Al(Clay & sand
tfl' 4i ' Granite
11. REMARKS: &PPWI)
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WDH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
REC9IC)IAS SEEN PROVIDED TO THE WELL OWNER.
/
WELL CONTRACTOR DATE
James B. Brown
PRINTED NAME OF PERSON Cinches ayr w$r FVG `^LGLL
Subs st the orlglnal to the Division of Water Quality within 30 days. Attn: Information Mgt.,R E C E I V E D
191R.
� ,Nall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Form
7/05
MAR 0 8 2006
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2045
1. WELL CONTRACTOR:
James B. Brown
Well Contractor (Individual) Name
Hedden Brothers Well Drilling, Inc.
Wei 7ontractor Company Name
=Er ADDRESS 73 Holly Hills Vista Rd
Franklin, NC' 28734
City or Town State Zip Code
( 628 )- 369-9591
Ares. code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(It applicable)
S. F WELL PERMIT/hit applicable)
C I ; ...sr OTHER PERMIT Cif applicable)
try..- USE (Check Applicable Box):Residential Water Supply p
DAI DRILLED .7' bl�I.CI�
TIME COMPLETED .-q f AJ AMC PM
3. WELc-LO T �, J ,`
CITY: P. D L4 ) COUNTY/TI oi9
t t � nu y/�J1
ry. S iioneot No., Parcel, Zip Cods)
rael Name, N
TOPOGRAPHIC / LAND SETTING:
❑Slope (Valley ❑Flat ❑Ridge ❑Other
(check appr5prale box)
LA! '..'DE
iGITUDE
L&r.tude/longitude source: 0GPS (Topographic map
(location of wel must be shown on a USGS topo map and
attached to this loan r not using CPS)
4. WELL. OWNER
May be in degrees,
minute, seconds or
in a decimal format
OWNER'S NAME
STR T DpRESS l
(. or Town State Zip Code
($Z1- 2179-93 9
Area code • Phone number
6. WELL DETAILS: `
a. YOTAL DEPTH: 9,) l�} '
b. DOES WELL REPLACE EXISTING WELL? YES NO,
c. WATER LEVEL Below Top of Casing: (-90 FT.
(Use'+' 6 Above Top of Casing)
d. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated ador below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. {IELD (9pm). 540 METHOD OF TEST Blow
1. DISINFECTION: Type H T H Amount 168Z
g. WATER�ZONES (depth): [
From (b r To_ t From / 5�7 To
zit) • To i From r From To
From /.47 To From To
6. CASING: Thickness)
0 Depth Dlameter Weiggjjyy Matgrial�.
From To 57 Ft. /0 r' r ,nS SfP
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From_ Tot- Ft. Oee t & t unite Reeled
From To Ft.
From To Ft.
8. SCREEN: Depth Dlameter Slot Size Material
From To Ft. in. in.
From To Ft. In. In.
From To Ft. In. in.
9. SANDIGRAYEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To - Ft.
10. DRILLING LOG
From To
0 �.
L.a5 1 ri l)I
Formation Description
Clay & sand
Granite
EIVED
MAR 2.7 i015
1
0
0.
et Mlle Regiorlai Offlue
1, REM
wra
f�r Pr tection
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECO'„ A5 BEEN PROVIDED TO THE WELL OWNER.
NAT RE •F ERTIFIED WELL CONTRACTOR DATE
James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Stet 1.it the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1 s 11 Mall Serviee Center— Raleigh, NC 27699.1817 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resouunxs-Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:,n-
W aitracTar�(bi& idua )Y, `\`V(uS
ire.\/\r..nn tie\ OM\1r�
ell Contractor compsry Nana
STREET ADDRESS 6t. 41 cie y(�t,�Y\ �or.-kci
Zt'nwY'�irllla (\IG 477/
City a Town Stale Code
( )- CI ry— k q,44
Ana rnrle Phom Tanta
2. WELL RFORMATIOIt
SITE WELL ID 0(lf _. S aNs)
STATE WELL PERMrrstlapparaat)
DWQ or OTHER PERMIT MI aparra 1 )
WSJ. USE (Check Applicable Bat¢ Rmidaw'i Water Supply
DATEDRILLED 9,�2l3-0 6
TIME COMPLETED 4/ :3O AM O PM I$
3. WELL LOCATIOtt
CITY: i bb1.'S;He coINTYGrtAlfwrY.
l.ousfSt CS ( ,reek
(Street balm. C .t S arnision..InlNo.. Parcel, apt Code) -
TOPOGRAPHIC / LAND SETTING:
❑Sipe OI/atey field ORidge OOlher
OM* appoo'pistsawUO
LATITUDE 3 I cl a -L /37. 7 "
Lotarwe j 3° y/ ' 24,9'r
Latitude/longitude sauce: KGPS OTopographic map
(beafion of wet muslin shown on a USGS lope map end
needled to #his nemVnot using GPS)
4. WELL OWNER t� ((�� I
OWNER'S in
r (2)1. C��4-,elct
Maybe inaepea.
®ernes. seconds or
Me decal Tones
SJRttn ADORFSS I..0 for f c.. iwa y€rS C'.feeic
:lnsvJle M� asr77/
City or Stab Tip Code
( 770} yG� /31r7.
Area tide- Phaie mr,ta
R. WELL DETAILS:
a. TOTAL DEPTIt / ,f n'
b. DOES WELL. REPLACE EXISTING WELL? YES NO14
c. WATER LEVEL Below Top dCasiag /0 ET.
Men' if Above Top et Casing)
d. TOP OF CASING M /_FT. Above Laid Surface*
Tap d casing laminated ate below beat ssfse r my esquire
e variance in AaccordancewRs 15A NCAC 2C .0118.
e. YIED(gpm)_ o METHOD OF TEST f')1/41 r
33 €'4,
f. DISINFECTiottType HrH
g. WATER ZONES (dear
Fran I h / To Ito'
Fran To
Fran To
Amount 7 c1
From To
From To
Fran To
6. CASING:Depth
Thickness/
Fmm_0_ To p"lp Ft Wett
From To Ft
Fran To Ft
pe ill
7. GROUT: Depth MaterialUdhod
From 0 To i9,0 n. CprnorJ- ()omen's
Fran To Ft
Fran To Ft
& SCREEtt Depth Diameter Slot Sim Material
From To Ft in. in.
Fran To Ft it _ in.
Fran To Ft in. in.
& SAMMORAVEL PAQC
Depth Sim Material
From To Ft
Fran To Ft
Fran To FL
10. DRILLING LOG
From To Formation Dal
R►-CFIVFn
fr AR
/ /UUb
Aohoville Rogional Offi
Aquifer Protection
11. REMARKS:
I OD HEREBY IBnFYT W 1T T6 wan. WAS CCa6Tnic1w a ACCamsaE WITH
15A a 2C. WELL CONSTRUCTION STANDARDS. AMMO COPY OF Lea
RECORD NUS aff I PROY:EOM111E WELL OWNER
SIGNII J � h a-23-06
OF CERTIFIED/WELL CONTRACTOR DATE
T T\lG
PRINKED NAME OF PERSON TtE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: IntonnatIon Mgt.,
1617 Mali Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Fam GW-la
Rev. TI05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
-33Fr6
1. WELL CONTRACTOR:
W 3sa- en 1(hj IsSer
Orthitadtlag Name
, v`onhaYur C npaty Name\ 1 lQc i l :. S
Wei C
STREET ADDRESS 639 4 XcIe 1a i?/j
Dced
eels\ vrue (\t as77/
City or Tatn Stale Tip Cale
). ( 82t975 - ei/69
Area code- Pltme mopes
Z WELL INFORMATNMt
SITE WELL ID A(Napor - )
STATE WELL PERMRi(fapprcaae)
DWQ or OTHER PERMIT Kt applicable)
WELL USE (Check Applicable Beg RaeidenS Water Supply
DATE DRILLED
TatE COMPLETED .OO AM O PM tit
3. WELL LOCATIOtt //��
CRY: y2t4h w ,1 f I Io COUNTY \ l n'. \ YY1
Tht°Y.murn
(Street Name. Community.. Lettlo, Parch Zp Code}
TOPOGRAPHIC / LAND SETTING:
ID Slope OVa/ey OFTat Wedge Mahar
(cheat eppm_rials��bad LATITUDE S A aS I ? b 2N3 .'
LotiGrruu€4 L 95' 5 6.9 11
Iati W de/longitude source: j49PS °Topographic map
(location dud met be shown on a USGS tap[ map and
aladed bit brmknot using GPM
4. WELL OWNER yn f nn
OWNERS WILE CJr`I1 ((*iarc4S
STREETADORESS TIo L.c.rcdtr
2ebbwn rl l le SSS Z Code7/
7a729113
Area code - Phone number
May be in degas,
minutes. moodsor
bra deed fart[
S. WELL DETAILS: /
a. TOTAL DEPrt
b. DOES WELL REPLACE EXISTING WELL?` YES 0 NO Y
WATER LEVEL BdowTop of Casing 50.5 FT.
(Use at' I /thoseTop d Casing)
d. TOP OF CASING 1S / FT. Abode Land Surface
Tap et easing beniaded War belowlard surface may expire
a arsiatce it accordance %eh 15A NCAC 2C .0118.
et. YIELD(gpmn* �� METHOD OF TEST CLI r
1. DLSRFECTIOIt Type MTr 1 Amount 7oZ.
g. WATER ZONES (dope*
From S, AS r To 7051 Fran To
Fran To Fran To
From To From To
6. CASING:
_ Thicbtas/
To Fran To3?Ft- ' c ,SLJ«�,i rtel
From To Ft.
From To Ft
7. GROUT:
Depth Material Method
Fran 0 To an Ft ("Server* Ptht I-nnb.
Fran To Ft 1_
Finn To Ft
8. SCREEN: Depot Diameter Slat Mae Material
From To Ft is iL
From To Ft in. _ W.
Fran To Ft it in.
9. SAND/GRAVE-PACK:
Depth Size Malarial
Fmm To Ft.
From To FL
Fran To Ft
10. DRILLING LOG
Flom To
Formation Descs Ibn
RELEIVED--
MAR z7 2006
Asheville RPgionai office
—Au°ifai Proteeti
11. REMARKS:
r 1
I OD ICY an/ DKr 11e WELL WAS COISIMICIED el ACCORONCE Mei
15A'CAC 2C. WELL CCNSIMICIGN STANDARDS. AlpTiATA COPY OF 1H6
RECORD aAS BEEN PROVIDED TO 111E WELL OWNER.
SIGNAi ORt OF CERTIFIED WELL CONTRACTOR DATE
moraytl- I C\ V h L (hl5'T uyriN-
OF PERSON CO THE WELL
Submit the original to the Division of Water Quality within 30 days. AUn: information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 558.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resource- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
/v
/ .w. COO Nnnll1v.‘�
Wet Contractor Company Name
STREET ADDRESS 6:3LI Nyrle i-ntar Yzcccl
(2r4 l:,wille Nit gts77I
City or Town Stele Bp Code
(.Y2Y} 775 —
Ar n code Phone number
2. W91 nWORMATIOtt
SITE WELL ID t(damiable)
STATE WELL PERMITi(rappacatm/
DWQ or OTHER PERMIT ikif *gamble) ar(
WELL USE (CheSAppicable Bo¢ Reaidrr9d War Supplyg
DATE DRII r ED g— S- O6 PM'aS
TIME COMPLETED 5: CO AM ❑
3. WF1L LOC TlOft
CITY: YG ibirc v; I le cot, (4Ac t
)e<llow ffbr.eie, rend
(Street Marne. MMus. Ca munly_9dad*Ion. Lath.. Parcel. BP Cede -
TOPOGRAPHIC ILAND SETTING:
°Slope °Whey OFLd flRMge OOter
(check appmpMa6m�)
LATITUDE . SS AS r�'(.L3 '
toldsfrlATEl a7 Gr. IC, "
May be in degrees,
adage; seconds oh
isadesirolSet
Latitude/longitude source: jatITPS °Topographic map
pocatan dwet maf be shown on a USGS topo map and
atlschedSothis coma not wary GPM
4. WELL OWNER n2 ,�/
OWNERS NAME I V-Al r t1 r r 1
ST�tEEr ADDRESS Yl o(r) F6rt+.c.�r
bbMvat trS, "de77
City r Town Zp Code
(fff ). t/7c 5-93a
Area code- Phone anther
5. WEi.L DETAILS: / ,
a. TOTAL DEPTFt Y
b. DOES WELL REPLACE EXISTING WELL? YES CI NOR
c. WATER LEVEL Below Tap at Casing / ,2S Fr.
(Use'+' I Mae Top d Casing)
d. TOP OF CASING $ i . FT. Above Land Surface
'Top d casing lammed aVrbelow land sodas may roar
a variance in ac :ordancewslin 15A NCAC 2C .0118.
e. YIELD(gptw): /a METHOD OF TEST (]i i r
f. D$MFECTIOtt Type f-f rH Amount 151) 2
g. WATER ZONES (depth):
Frain i ,its' To 4fr9' From To
Fran To From To
Fran To From To
6. CASING: Thidmess/
al
FanbTToo 3A' Ft. 6 5allgeter aaaI PVC
From To Ft
From To Ft
7. GROUT: Depth Ma edd Method
Frain 0 To a.O Ft rpneAk p1/4)MArnm
�` Fran To Ft.
From To FL
0. SCREENt Depth Diameter Got SS Material
Fran To Ft in. in.
Rom To Ft in. in.
Ran To Ft hi. in.
9. SaNWORAVB. PACK:
Depth Sim Material
From To FL
Rom To Ft
Flag To Ft
10. DRILLING LOG
Fern To
Fomlaon Descrpfon
RECEIVED
27
Asheville Regional Office
Aquifer Protection
11. REMARKS:
0
1 a)16a9Y EY1 W1TMIS Wel WAS GOraewhC1® MN:0a1CN CE Wml
Ma CPC 2C. WELL CONa1RUCIDN STANDARDS. AlODNTACOPYOF 1Na
RECORD INS MEN PROYOED TOTE MU -OWNER
OF CERTIFIED Wel CONTRACTOR DATE
[�d*tn Y)-li 1c5cp
PRINTED NAME OF PERSON CDatSTRUCDNG THE WELL
Submit the original to the Division of Water Quality within 30 days. ATM: Infonnatfon Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

' . .
• WELLCONSTRUCTION RECORD•
••
::: t :.
North Ca(oltna - Department of Environment and Natural Resources - Division of Water Quality-- Groundwater Section
was coNTRACTOR (INDIt(IDUAy Otb4'fnJS /4n 11 :A,i. • 'ativprentit4
MtIlia
. -otfiyo
WELL CONTRACTOR COMPANY NAr•I�.pylt S '�eMo r4 Ilia1I1y.11-u 'Kt_-' •Puol r $t S. Li 2-4 O
STATE WELL CONSTRUCTION PRRMITD ast5Aten wtPreihrrri
Crappliabk) .(ifapplicable) • .
1. WELL USE (Check Applicable -Box): Reswential lE icipalPubllc ❑ Industrial 0 Agricultural CI
' Monitoring Cl Amor" O • Hat Pun, Water Injection C Other Cf If Other, List Use ' - •
2.-WELL LOCATIQN:
Nearest Town: /YOehn5v,17r; County,0-i4itAn) •
SNOW EitD R'177
(Sweet Na Numbers, Comma*,uav, Sub6ridoo, Let He. rip Cade)
3. OWNER: Arr1 et? r C c-`s 1-1-o no Ike 4- .
Address 3 35 t1/ p t e. Lnor '
(SaeetoiRomeNo.) •
FRttatti j/G a g43 "-/
CityorTowu State - - Zlp Cods
6t.5- 3't4-o490 ..
Arca code Thom number
4- DATE DRILLED 3 — oi' — o" fe
5. TOTAL DEPTH: 3 QS' •
•
g[aptd setting -
dge ClSlope Malley Crat
(cM tapprapsiambw0 a
LatitugeAorigitude efweli location •
(*t alaatearaaaonm)
Latitude/longitude sourecOGPSCITopographic map
(eheeltbox)
DEPTH ' DRILLING LOG
From To - Formation Description
6. DOES WELL REPLACE EXISTING WELL? YES CI No.
7. STATIC WATER. LEVEL Below Top of Casing FT
(Um `Y RAbow Top ofCadog)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of gulag termio■ted odor tutor Batsman rpalrSs a . - - "
virtue* la wordeots wRb"ISAT$CLC2C MIL
9. YIELD (gprn): -r% METHOD OF TEST tJ1Fe
M. WATER ZONES (depth): To) /30 " a/ S ' (/
LOCATION SKETCH
11. DISINFECTION: Type H-/14: Amount TEl-A S Slow direction and distance in miles from at least
12. CASING: - Wall Th cknen two State Roads or County Roads: Include the road
• Depth or WeightlPL numbers and -common road names.
From Q • To (5./ -
From_ To FL -
From Tp FL
13. GROUT:. Depth - Materiel Method
From () Tra FL &4r art pay.° ,
m .
FroTo Ft
4. SCREEN: Depth Diameter . Slot Size : Material •
From To Ft.in in.
From To FL_ja in.
5. SAND/GRAVEL PACK: _
Depth Size Material
From To FL
From To Ft.
6. REMARKS:
i
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCFED IN ACCORDANCE WITH IS/. NCAC2C, WELL -
ONSTRUCTIONSTANDARDS, AND THAT A COPY OF 'no RECORD HAS BEEN PROVIDED TOTHEN/ILL OWNER
3-aa04- .
SIGNATURE -OF PERSON CONSTRUCTING 'THE WELL . DATE -
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
n699-1636 Phone No. [phone], within 30 days. - eve -I REV. 07/2001
0

North Carolina - Department of Envhonaaid and Haag Resources - Division of
WELL CONTRACTOR (INnn UAL) 6 (prlee)s.h-11 PI I
WELT. CONT[LACTOa COMPANY NAM -""'rC i�n1IA,�.► 11) JIAtr411
STATE WELT. cona'rnucrtow runt, AsaocNTLD WQ'PSRMrr1 -.t -
WELL CONSTRUCTION RECORD -
star Qtta((ty_ Qroiiadwater Section
i�•"i��„neL CL�TZRIC/[710D1i 2fl4 •
2151g
:ruoi t i.
ftrappliable) {ifappliable) • -
I. WELL USE (Check AppticSSk Box) Raideatia(>�M mi ipawPublic 0 Industrial CI Agricuthuld
' Monitoring0 Recovery Cr Heat Pomp Water Injection ❑ Other CI Ifodic; ListUse .. •
Taila/ --3 b
•
•
1
2 `WELL LOCATjQN: (T - . V, j'
Nearest Town: O1Ss•NI11e ' Cott* AI•fAZ'f
Sitio id_Ri)e j Rd 01 81'1 /
Moot Name. Numben. Communiy, Subd eisioo. tat t)o. Zip Code)
3. OWNER4Th?R i.(��'S !l0%Y1 �P� IOC Q.
Address ' 3- 3 S %I tZ, L- Lao
T,o?rero)
aty'wTown Stye rip Oodo
(Fag). 39-9-D c7Q/) • . lS'
Area Thomea code- ome number - . -,
4. DATE DRILLED 3 — a % —0
5. TOTAL DEPTH- 4, O) '
6. DOES WELL RBPLACBEmma WELL? YES N.O 44-
7. STATIC WATER LEVEL Below Top ofOasbng: 300 F:
(UserN bwwTopofcadao)
8. TOP OF CASINO IS / FT. Above Land Surface'
'Top or ashy( trrmtoated agar bola 1pd.m4aapaka a
various** ucsrdauawldfla fCAC2C A11a. •
9. YIELD (gpra): METHOD OF TEST_ J)%IU/7/1 .
ID. WATER ZONES (depth):SYo0' (1 - •
` VOCATION SKETCH
11. DISINFECTION: Type fF-to- Amotmt a TA• 3 5 and
12. CASING: - - Wall Tbiduwa • _ two State Roads or County Roa s:Include the road
Depth D a err Wd»tlPt numbers and -common road names.
From_ 0 . To % Ft._�=S ;11W
From To. FL - -
Froi _ Tp Ft.,---,_
13. GROUP_ Depth Material. Method - -
Frorrt_ _ToFt. e0tr PC»0
From To it. -
.4. SCREEN: Depth Diameter - Slot Size - • Material
From To Ft..__ -_in. is
From To FL in. in. - j
S. SAND/GRAVEL PACK
Depth Size Materiel -- -
From To Ft.
From To Ft •AshevWe R :ni- `ti ice
AC' ?
6- REMARKS: .
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISAi4CAC2C, WELL -
tNSTRUCTIONSTANDARDS, AND THAT ACOPY OFTH(SRECORDH SBEENPROVIDEDTOTHE-WBILOWNER
+'FQ,�`,t
gragpiP7Lsnd seiting -
-
•
Ridge OSiope C1Valley QAat
(disc.& ppmpdibebor) •
Ceti(udellougitude of well location •
, (depnwhatuads)
Latitudellongitdde sonrce:OOPSOTopograpbic map
• (dwdtboa)
r*PTH - DRILLING LOG
From To ' .Formation Description
-
3-:a0tO Co -
SIGNATURE-OPPERSON CONSTRUCTING THE WELL - • DATE - -
submit the original to the Division of Water Quality, Groundwater Section,1636 Mali Servlee Center -Raleigh, NC
.27699-1636 Phone No. [phone], within 30 days. - GW-1 REV. 07/2001
Z
0
u

RESIDENTIAL WELL coNsnRucrloN RECORD *
North Carolina Department of Environment and Natural ResourcesDivision of Water Quality
WELL CONTRACTOR CERTIFICATION # C7 ou�7 6y
1'
1. WELL
Well C
RACTOR:
i k+<�
1t
ta6(Nndtviidueq Name
CANE)(-1,. (i3 t14
Wed Contractor Company Name
STREET ADDRESS 6 34 Hide]
fecyptrK vfle N(c 771
Iy or Tam State Zip Code
(4'"} C/ 71 cct/F19
Area code- Phase numbs
2. WELL INFORMATION:
SITE WELL ID #fd appdcable)
STATE WELL PERMITT/Aidamiable)
DWQ or OTHER PERMIT 1f(8 applicable)
WELL USE (Check Applicable 8ac): Residential Water Supptyg
DATE DRILLED -1 6 _ C 6
TIME COMPLETED /C)
AM ❑ PM*
3. WELL LOCATION: j f //_'�'(
curt 8-2, b N l A i` V ' COUNT) rGi11Cwn
(Street NlRoc-La one Numbers. C nau dy- im. LUNG.. Parcel, Zip -Code) -
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley gnat ❑Ridge ❑Other
(check appropriate bad
LATITUDE �-S7 osos h�(.
j� (
LONGITUDE D CJ b C'I Q' it
Latitude/longitude source: OOPS °Topographic map
(location ofwe/ must be shown on a USGS topo map and
attached to this term I not earn GPS)
4. WELL OWNER L�
OWNER'S NAME / IP(-Kk I 1' 1C-Caee
May be in degrees,
acmes, seconds a
in a decimal fame
ST ET ADDRESS Arc
City
State
c)- ciyam,- 6773
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: `l Co
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO4
c. WATER LEVEL Beim Top of Casing: / v.S FT.
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS / FT. Above Lad Surface*
'Top at casing terminated a for below lad surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): -5 METHOD OF TEST Cn.('e
f. DISINFECTION: Type i-i tr( Amount �T?
g. WATER ZS (drnh):
Fran 11
`;. To Ci n / From To
From To From To
From To From To
6. CASING: Thickness/
Depth tsar
W ' Material
Fran b To Is'a FL .6 (y PVC
From To FL
From To FL
7. GROUT:r� Depth Material Methode
Fro1 m l To r' FL r�vr*- r�'S11 .'YTt�i rv,
Fran To FL
Fran To Ft.
8. SCREEN: Depth Diameter Slot Size Material
Fran To FL in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
Fran To Ft.
From To FL
From To FL
10. DRIWNG LOG
From To Formation Description
flizu V
11. REMARKS:
T 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WTH
15A NCAC 2C. WELL CONSTRUCTOR STANDARDS. AND THAT A COPY OF TR
RECORD HAS SEEN PRODDED TO THE WELL OWNER
Cr 1VS /9 d 5 3-1d -04
CONTRACTOR DATE
SIGNATUREJrC a ERTIFlED WELL
``)ln 1 , \t I S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL -CONTRACTOR:
Well Contractor (Individual) Name
ackk cr-r5
Well Contractor Company Name ` �, Peel
(1�
STREET ADDRESS 6Pry m L�IA%h 1 eel
(..)Q * `t, Jf11\\ i rr\
b*'s le NC a -7i 1
City or Torn State Zip Cale
Area arch Plnon
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMIT#(dapplesde)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Boxy Residential Water Supply (jai
DATE DRILLED n -- 0 (--
TIME COMPLETED Soo AMID PM ill
3. WELL LOCATION: ,r
CITY: \�Q� .F(l7//� COUNTY Y ____\
(r- f�amer i' . t-VJL ir,c
(Shoe( _Numbers. Cammasea.SobdMsim. LotNo.. Parcel. Zip Cade)_
TOPOGRAPHIC f LAND SETTING:
❑Slope OVatey [Mat 'gRidge QOther
(check appropriate hod / A
LATITUDE 3`' /os(i /i.•g
LONGITUDES r u `—I 7 r tcl Are
Latitude/longitude source: JkGPS Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this tom I not into GPS)
4. WELL OWNER
OWNER'S NAME I VVv\
STREET t ADDRESS Lcr C-JYP
nt/itvs/4 NC es771
City a Town State Zip Code
,A7'1O- 01Ih
Area code - Phan number
May be in degrees,
minutes, seconds or
m a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: 94 0
b. DOES WELL REPLACE EXISTING WELL? YES CINO a
e. WATER LEVEL Below Top d Casing: ) C S FT.
(Use '+"d Above Top d Casing)
d. TOP OF CASING IS ( FT. Above Land Surface`
'Top d casing terminated abbe below lend surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1 5 METHOD OF TEST rk l in
f. DISINFECTION: Type M T r Amount 7 c 2-
9. WATER ZONES (depth):��]LLtt��
From ( D 5 To__y� From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight
Fran—_ 6 Jr Ft b nt «izM iil'-'
From To Ft.
From To FL
7. GROUT: Depth Material Method
From 0 To 'at) Ft f arnAnf imti vter
From To FL r
From To FL
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 FL
10. DRIWNG LOG
From To Formation Description
hI/
r'
AchcvWC (1Cy»On
ii,,nu ter Prates:
11. REMARKS:
100 /EREBY CERTVY THAT TIES WELL WAS WNSRNCIED el ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER_
72 /ems 3 1 n ®G
SIGNAT OF CERTIFIED WELL CONTRACTOR DATE
d71» t n h (T CONSTRUCTING
S
PRINTED NAME OF PERSON CONSTRUC NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD V"
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL ONTRACTOR:
•
We!f.�ntractopr (individual)N Name 1 1
Well Writ-actor
Company UO �\ On V\\Y1r
STREET/�ADDRESS 63 t ride Todc:�RC.J
►�t,+iinlbcr%;Me �fc_ 4 77 t
City a- Town tffie Zip Cade
tf sr Phone` et - ftM 4
Area code- numbs
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(iapplwhle)
DWQ or OTHER PERMIT «if applicable)
WELL USE (Check Applicable Bee): Residential Wale Supply 1'
DATE DRILLED 3 — 9 -- (1(.
TIME COMPLETED R3:t70 AM PMK
3. WELL L TIDY: j
CITY: \43 1 rill COUNTY
C OVP 2t>rio1_
t Numbers. Ca ewalY_SabdiNaaa4 LatNa. Parcel. Zip -Cade}
TOPOGRAPHIC! LAND SETTING:
❑Slope ['Valley ❑Flat »Ridge ❑Other
(rhea appropriate box
LATITUDE _.SI" rACI az
/
LONGITUDE 3° `77 �S6`C'
Latitude/longitude source: ikGPS ['Topographic map
(location d wel must be shown on a USGS topo map and
affached to this lam Ind use.* GPS)
May be in degrees.
min secant or
in a decimal bent
4. WELL OWNER
OWNER'S NAME
$TR ET ADDRESS
e
City or Town
c a) ti7%- 9177a
Area code - Phone number
hr.I 1tl€ \
State
S. WELL DETAILS: r
a. TOTAL DEPTH: 156
Zip Cone
b. DOES WELL REPLACE EXISTING WELL? YES
YES 0 NOM
c. WATER LEVEL Below Top of Casing b c� FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above land Surface*
'Top of casing terminated arks betel, lad surface may require
a variance in accorda'nce with 15A NCAC 2C .0118.
e. YIELD (gpm): ias METHOD OF TEST O, i `i'
f. DISINFECTION: Type H 1 fi
Amount 4 07
g. WATER ZOtES (depth):
Fran f i To/ r5 1 From To
From To From To
Fran To From To
6. CASING: ThicWresd
^ W'
From ( ,9L) Ft. Di %t( � ..� O VY
Fran To FL
From To Ft
7. GROUT: Depth Material
Fran b T
From To FL
From To Ft
Melt*
•o �.O Ft can -vent le i Ini;
8. SCREEN: Depth
From To
From To
From To
Diameter Slot Size Material
Ft in. in.
FL in. n_
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To FL
From To FL
10. DRILLING LOG
From To Formation Description
Zito
7`I
Ash=vile® Regional t3fi;L,e
_-�AtuIfee'r Protection
11. REMARKS:
r CO HEREBY CERTIFY THAT THIS WELL WAS CONSIRUCIED N ACCORDANCE WnR
15A ICAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS eEENPROVIDED TO THE WELL OWNER ,OW.
SIGNATURE s i`iERTIFlED WELL CONTRACTOR DATE
4. ). -;., tMt lfic,
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-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:
Well traacctm (Individual) Nane
r�• .r..\ OP\V
Well Contractor Company Name
STREET ADDRESS
t1';nw;UP G r S77I
C' a Torn Stem Zip Code
(etdk )- LI Yy 6ti
Area code- Phone Norther
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#fda amicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Bak): Residential Water Supply lX
DATE DRILLED 3 CI] ` b 6)
TIME COMPLETED + 7 CO AM ❑ PM Pis
I. WELL LOA ,+ O. t
CITY: 111111``jj e 1!\� �InP COUNNj�TY Ir�W\Y_Y.iV�
(Street Namben. Cann dty..Subariabn. I.at.No.. Parcel, ZIp.Code)-
TOPOGRAPHIC 1 LAND SETTING:
❑Slope OValey ❑Flat Ridge ❑Other
(check appropriate bag
LATITUDE C3� 66 QC] 1 3(i-) if
LONGITUDE e7 a LT, (�(.711
Latitude/longitude source: **PS oTopographic map
(location dmet must be shown on a USGS tapo map and
attached to this lone Ind using GPS)
May be in degrees,
minutes, seconds or
in a decimal font
4. WELLONtNER
OWNER'S NAME
Pre6tor\ UJo,y(� (�
STREET ALTDRESS (Xr C' a7��? .�r .CV
R 4 <v,l�e 'NC EA7X1
City or Town Stele Code
( Cd.ee- 7e a-24 a
Area code - Phone number
5. WELL DETAILS: + rr
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 6 (`) FT.
(Use "4" it Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface*
'Top of casing terminated atlor blow land surface may require
a variance in accordance wlh 15A NCAC 2C .0118.
e. YIELD (gem) / METHOD OF TEST Co e
f. DISINFECTION: Type 1-'1 T H
Amount I n7
g. WATER ZONES (depth):
From_ij t To i s6r$ A Fran To
Fran To From To
From To Fran To
6. CASING:
Diameter Thickness/
Fran DTomCT FL 6 'lt( W71 )51'?( I `L
From To Ft.
From To Ft.
7. GROUT: DepthMaterialMaterial
Fran To 90J Ft CarY�'1i';v
From To Ft.
From To Ft.
& SCREEN: Depth Diameter Slot Size Material
Fran To Ft in. in.
Fran To Ft. in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
Fran To FL
Fran To FL
Fran To Ft.
10. DRIWNG LOG
From To Formation DesaRtbn
F{EttIV
0
O
Ac hpville Regional OEii
t..i Pfoteofio
11. REMARKS:
n 00 HEREBY COMFY THAT TH S WELL WAS CONSTRUCTED N ACCORDANCE WITH
iSA NCAC 2c. WELL CONSTRUCTION STANDARDS. AND TINT A COPY OF VMS
RECORD HAS BEEN PRWUED TO THE WELL OWNER
L
TOR DATE
SIGNATUR OF CERTIFIED WELL CONIC
PRINTEDCNAMEVOF PERT SON 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

RESIUI:N11/11, WELL colvs I ItUt I ION REan )
Meth Cnrolinn Ucpmtmcnl ui- Ent irunntcnl mid Nnitiral Ittsuuicca Division of Wider Quality
\YE1,1, (TON'IItA(71 It CEILI'IEIt'A•1'I(IN 8
OWIIER
MWD
NC
1. WEL); CONTRACTOR:
ry
Wei Crnbncla (bdivMual) Nano!
ee,c t
MILLEN WELL DRILLING, INC.
Wall Cool,xla Company Name
SI REET ADDRESS11.U. DUX 5137
IIAYESVTLLE, N.C. 20904
City off lovat SInle
029 ). 1337-2997
tip Uotln
Alen mfr.- Pharr nm„ba
2. WELL INronMATlorl:
SITE WELL ID Cu .preraN.)
S !Alt WELL rERMITMoi errec.biw)
DWO a OttIER PERMIT Milt applicable)
WELL USE (Check A)q,lknbla flox): Rrsidential W niri Supply ICJ/
UAI E DRILLED 0.2
71ME COMPLEI ED f. t'�) AM IJ PMli;!/
3. WELL LOCATION:
CITY: 1. Z4us(1'/e: COUNIY (4irl lie l4"-
(Cc`i443 Creek #220
(Slow, Item., Nanbwr., Crnnnunity, SubdlNnlon, Lel No. , Pomp!, Zip Code)
TOt'OGRAPIIIC f LAND SETTING:
bee DVanry OTlal TlRklgn UUlltet
(check .pproptIal. box)
LATITUDE �- S .Z3- Say
LONGNUUE 8 3 5 /- e.30
Lalihnle/lot,giludc source: Lakll'S UTupnFtnpltic mop
(i cnlin of nor Hurst he shmttt on n (ISGS lope mop nod
ellnched to This rant 1 nor unity GPS)
4. WELL OWNER
OWNER'S NAME 7trry / XC/I
May be le Agora,
ininu,rs, ,erundi or
In II drrbnnl Gmnnl
SIREET ADDRESS 'Po (30x t3or(-
-LBG-NAr., Jaw, gala, , L 32oss—
city a 1 own Stole Zip Cale
(9 (Pi }.5_1'I-239`7
Agra code • Plnne nun,bw
S. WELL VET AILS: 9
a TOTAL DEPTH: .2 t' C
b. GOES WELL REPLACE EXISTING WELL? YES IJ
NUL•Y
e. WATER LEVEL Rnl'w I op or Casing .1 t I' I.
(Use '4' 0 Above Tot d Casing)
d. TOP Or CASINO 13 / FT. Abner Lend ,^,uda;e•
•Inp of easing Inminnled ante below land nunnre may iequlte
valance to Retaliative wilt, 15A None 2C .0110.
e. YIELD IOPnt): / d 0 METHOD OF TEST
0,
I. DISINrEC NON: I yo. /t r17 Atwood Alcui.9
u. WA I ER ZONES (depth):
Fiore .25T In .25'5 Fran To
Fran To Fran to
Nolo to Fran To
CASING:
Fran_ D
room
Ran
Urollt
In 2'
To
10
FI
r1
rl
[Hameln
I lddne9 n/
W el Id
54S2 )
7. GROIN! (truth Mnleilal
Flat, e to / rt.
flout '/ 10 rl 4',*9. R-
atan to rl
Mnlerlal
Method
>'rrcl
0. SCnrr4I: Urpllt Ulmneler SIu1 Site
Ran 10 rt. ht. _ to.
flan 10 ri. In. Yt.
rim to F1. In. In.
9. SANUIORAVEL PACK:
Droll;
Flan To FI
room In rt.
Fan To FI.
Size
Material
Material
10. 01111.1ING TOO
Rohl l o F(tmalion Desctlplbn
y-•2E0 lrrYl fL
RECEIVED
t nr) 'i
J u•-
shevtile Regional Ofiik,b
Aauirer Protection
0
I L. REMARKS:
I p(n ItPrft cr niwv 111.1 11119 Wf lA W A9 COI)IfUCiln 41 .cconngrrr woo/
i?A N(' Al: VI. W rt.t CNIIS IOUCI 111 0T»IP$nrt9 RIM fNI A CO4T Q De
ftCOiW IU9 BE FN rnVY113Eo 10INE WELL OWNER.
�Z�ZC-L•� Z -.Z S/'CV'
UN OF CEIi 11FiEU WELL CONT RACIUIT UAIE
SIGNA 1
PRIN 1 ED NAME OF PERSON CONS, RUC I INO It it W F lt.
11
^; 111.
•ii
Submll the Dllgllinl to the DivIRlou of Water Du:Ally within 30 daytt. Alln: h/rottnnllon
1S17 ht:7U rrrvrr Coulter - flatrlglt,!IC 27699.1017 rftono M. [phone] 9x1508.
ramrW1s
110Y, ifs Is Ir;

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment raid Natural Resources- Division of Water Quality
1VELI, cONTRACToll cEIETIFICA•tION a
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
MILLER WELL DRILLING, INC.
Well Contracla Company Name
STREET ADDRESSP•O. BOX 557
HAYESVILLE, N.C. 28904
City or Town Slate
( 828 y 837-2997
Area code- Phone number
2. WELL INFORMATION:
Zip Code
SITE WELL ID Aft opplicatIe)
STATE WELL PERMITA(il applicable)
DWQ or OTHER PERMIT 11(11 applicable)
WELL USE (Check Applicable Box): Residential Wale; Supply CU—
DATE DRILLED •7 -,Z if- °
TIME COMPLETED /d' O'n AMU-- PM❑
3. WELL LOCATION: /
CITY: /'ID 6'6"2S�I/6 COUNTY (i%:../r•OL.
(Sheet Name, Numbers, Cormnunily, SubdiNdon, Lot No., Parcel. 2ip Code)
TOPOGRAPHIC I LAND SETTING:
OSMpe Malley f7Flat URTdge OOlher
(check appropriate bole)
LATITUDE 3 3-- 23. ..1g/
LONGI1 UDE 5' 3 S i, VJY
latitude/lonf:ihole snorer Lifil'S Olbpogrnphic nap
(brnlkan of an/ meet be strewn err n USGS (opo nap and
allachnd to this lam /nor using GPS)
4. WELL OWNER OWNER'S NAME //o/li»•e ,/, c c'-4C
STREET ADDRESS PO ff0 x76I
�i ,Ast/lie, NG 2-6
May be in degrees,
mimntee, «coeds m
in a decimal formal
Citya Town Stale Zip Code
lets )_ 7779-9yY8
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: C/ 2
b. DOES WELL REPLACE EXISTING WELL? YES O NOIY
c. WATER LEVEL Below Top of Casing / D Cd FT.
(Use'+' A Above Top al Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top el casing terminated allot below land surface may require
a valance In accordance with 15A NCAC 2C .0118.
•
e. YIELD Wpm): b METHOD OF TEST /1 /-
' 1
_OWNER
MIND
NC
I. DISINFECTION: Type
Amount �yC✓`
g. WATER ZONES (depth):
From .1 4/0 To .Lr{ / From
From To From
From To Fan
6. CASING:
From D
Fran
From
Depot
To J/5 FI.
//3' To /A Ft.
To FI.
7. GROUT: Depth
From 0 To 6
From /y
Fran
Diameter
-,1I"
To
To
To
Thickness/
Weight
ix"?'
/SS
Material
FL f`��,"1`/n old
To ;IC) FL %1gie4 /G
To FI.
8. SCREEN: Depth
Flom To
From To
Material
5/ecn/
Method
"CO
Diameter Sid Size Material
FI. In In.
F1. In. M.
From To Ft. M. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
0 l,2s'
/Ad - 3L1
II. REMARKS:
FI.
Ft.
Ft.
Size
Material
Formation Description
1K
-/ frc
r`T
O
I DO HEREBY CERTRY THAT one WELL WAS CONSTRUCTED el ACCogoAncE WRH
ISA NCAC 2C. WEI.( CONSTRUCTION STANDARDS. MIDDAY A COPY Or INS
RECORD IDS BEEN PROVIDED TO THE WELL OWNER.
1
v' ' jt'',7/06<— ) -� 51-06
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Intonation Mgt-,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] axt 568.

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION li 3388
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contactor (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 PERMIT7(7 applicable)
DWO or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED 03/06106
TIME COMPLETED AM ❑ PM Q
3. WELL LOCATION:
CITY: ROBINSVILLE COUNTY GRAHAM
SHEPPARD'S CREEK RD.
(Street Name, Numbers, Commonly, Subdiesim, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
['Slope tpValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 5 22.260N
LONGITUDE 8 3 46.780W
May be in &grew,
mimics, seconds or
in a decimal format
Latitude/longitude source: 19GPS ❑Topographic map
(location of wel must be shown on a USGS topo map end
attached to this form /not using GPS)
4. WELL OWNER
OWNERS NAME RICK SADOWSKI
STREET ADDRESS 914 CASEY COVE DR.
NOKOMIS FL 34275
City or Town State Zip Code
( 941 )- 504-1177
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 545'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing: 30 FT.
(Use'+' 7 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3/4 METHOD OF TEST AIR
1DISINFECTION: Type CHLORINE
Amount _ 100 RPM
g. WATER ZONES (depth):
From To From To
From To From To
From To From To _
6. CASINO:
Depth Diameter
From 0' To 35 Ft 6 114
From To Ft.
From To Ft.
Thickness/ �1a�{s
SD�41 M
7. GROUT: Depth Material Method
From 0 To 20 R. CEMENT GRAVITY
From To R.
From To R.
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 Sze Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0' TO 20' BLACK/RED DIRT TO BROWN SLATE
20' 10 3S BLUE SLATE
35' TO 545' BLUE SLATE
11. REMARKS:
O"
I DO HERESY CERTIFY THAT 111I8 WELL WAS CONSTRUCTED IN ACCORDANCE WIM
15A NCAC 2C, WELL CCNSTRUCT1C4 STANDARDS, AND THAT OCPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEII. OWNER,
03/10/06
SIGNATURE OFCER IFIE L NTRACTOR DATE-.
SI� PRINTED NAME OFMtat �aCTnI,IG Rt vv@LY"'^'
RECEIVED
Submit the original to the Division of Water Quality within 30 days. Attn: Infomlatioii Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Form GWts
PK 7/05 ,
?Will.
Asheville Asheville Regional Office
AauiferProtection

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Kcsoumcs- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 3366
1. WELL CONTRACTOR:
WILLIAM BRADLEY LEWIS
Well Contractor (Individual) 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 tr(6 applicable)
STATE WELL PERMITO(if applicable)
DWQ or OTHER PERMIT 5(7 appk able)
WELL USE (Check Applicable Box): Residential Water Supply Ni
DATE DRILLED 03/07/06
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: ROBBINSVILLE
COUNTY GRAHAM
HWY. 129 BEFORE CASTLEWOOD
(Street Name, Numbers, Community, 3ubdi)Asion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DA/alley ❑Flat ❑Ridge ❑Other.
(check appropriate boa)
LATITUDE 3 5
LONGITUDE 8 3
20.705N
49.266W
May be in degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: BOPS ❑Topographic map
(location of we/ must be shown one USGS typo map and
attached to this form i not using GPS)
4. WELL OWNER
OWNER'S NAME BOB SCAHILL
STREET ADDRESS PO BOX 2605
ROBBINSVILLE NC
28771
City or Town State Zip Code
( 828 )- 506-4708
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 225'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO L3
c. WATER LEVEL Below Top of Casing: 80 FT.
(Use •+• 1 Above Top or Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated atfor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 10 METHOD OF TEST AIR
f. DISINFECTION: Type CHLORINE Amount 100 PPM
g. WATER ZONES (depth):
From 180' To 200' From To
From To From To
From To From To
6. CASING: TWhickness/ N1�tar
From 0' TDeppt75' Ft, 6 �(4ISI 805i PVG d
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 20' Ft.CEMENT
From To Ft.
From To Ft.
Method
GRAVITY
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. F.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0' TO 20' BROWN/BLACK SAND GRAVEL
20' TO 40' BLUE GRANITE
40'
60'
75'
TO
TO
TO
60'
75'
225'
1I. REMARKS:
BLUE GRANITE.
BLUE GRANITE
BLUE GRANITE
u
0
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT CCPY OF 11119
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
L, 03/13/06
SI NATURE OF RTIFI L CO TRACTOR�DATE
L
)luakA-k al2ADl.81 r1-CCl1S
!
PRINTED NAME OF PERSON CONSTRUCTING TNEGVELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information I4iI.E C E I V E lormGyy-
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 5618. Rev. 7435
P.PIP,, 1 2U36
a
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL CONSTRUE RECORD
IJU1111 Carolina Department of Environment mid Natural Resources- Division or Willer Quality
WELI. CONTRACTOR CERTIFICATION H 2- L 0 3
1. WELL CONTRACTTOR:
W NI Contractor (Individual) Name
MILLER WELL DRILLINGy INC.
Well Conlralor Company Name
STREET ADDRESS P.O. BOX 567
RAYESVILLE, rj.C. 289U/
City n Town Stale Zip Crate
828). 837-2997
Area cafe- Phone numb*,
2. WELL INFORMATION:
SITE WELL III tta apnlicabe)__.
STAI E writ. PERMIINQI applicable)
D W O ry OTHER PE FT MI f p(il applicable)
WELL USE (Check Applicable Dnr) Resideldial Water Supply f ✓
DATE DRILLED J -/5 —C
TIME COMPLETED - .L,(, AMII PM(LI--
3. WELL LOC9; TION: �
CNY: /i c /'/. / c.<' e'
/Or/
CDUNJ'Y__`9.__:L
ISlreet H e. numbers. Crnnnu uly. Subdivision, Lol No , I'alcel 2 3' lode)
TOPOGRAPHIC I LAND SETTING:
°Slope ovnney r)Flal Midge ❑Other
(check Ppproptiml. box)
blar Ie in depress,
LATITUDE 3 S- / %' e7 minuleq strands or
LONGITUDE 4 yS . S O i in s hind rammt
LaIiludcllongiludc source: li(il'S ❑Ibi ograplric map
(krnlion or twill nnrsf be shorn ern n USG S Irma tune nod
nitache(' In This form 2 not using GI'S)
4. WELL OWNER f
OWNER'S NAME ��4//1' /i el/-i t'.1
STREET ADDRESS f
2'lAi ( p �rdo E;;_.
City or 1 own State
LLLt) BSI-L1��-
Area cafe - Phone number
5. WELL DETAILS:
a. TOTAL DEPT II: "
Zip Cale
b. DOES WELL REF9.ACE EXISTING WELL? YES T.1 NU F1-�
c. WATER LEVEL Rnlnw Top of Cacing• <2 &i
(Use'+' it Above /lop of Casing)
d. TOP OF CASING IS / FT. Above 1 and Sullace'
'Top at casing letminaled ally below land sudann may require
a variance hi accordance wlh 15A NCAC 2C .0110.
e. YIELD (gpm): / 6 METIIOD OF TEST /, /
I. DISINFECTION: Type
g. WATER ZONES (depth):
nom'j In 76
r nan/_LO In
rlorn In
6. CASING:
Depth
Finn ('I to G>:S FI
from fo FI
Flom 10 FI
1. GROUT: Ucplh
r nun L) 10 } FI
nun _i to. ,J rl
Flan to rl
8. SCREEN: Depth
From In
faun In FI_
non To Ft
9. SAND/GRAVEL PACK:
Depth
nun to
FromTo
Flom to
From
From
OWNER
MWO
NC t/
Amount /Yy'v'
To
To
From To
Diamelet
G.IS"
1 hicimessl
Weight Material
sZ'/4a /'t'C.
4
Method
i L•r y-'e (Z
()imitate; Slot She
FI In In.
In. In.
In. In.
n.
FI
Ft.
Sire
Material
Material
10. [TRILLING I. OG
From To Fotrnation Description
D - 6U L/,t1y�
C c , /( k C".'••%`-. frC.
II. REMARKS:
r7
I ROl4nrnY crmlrY IRA erns WELT WAS CONSTRUCTED F1 ACCORDANCE WRN
n5A rlCAr. 2C. WLLt COIISTRUCION STANDARDS ATTU THAT A Cry! OF 11115
RECORD IIAS PEEN enciv DED 101HE WELL OWNER
SIGNAIUR OF CERTIFIED WELL CONTRACTOR DATE
:'y /C r _
PRINT ED (SAME OF PERSON CONS1 DUCTING 111E WELL
Submit the original to the Division of Water Quality within 30 days. Alin: kitormation Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
rrrm GW.te
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2045
1. WELL CONTRACTOR:
James B. Brown
Well Contractor (Individual) Name
Hedden Brothers Well Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 73Holly Hills Vista RD
Franklin, NC 28734
City or Town State
( 828 )- 369-9591
Area code- Phone number
2. WELL INFORMATION:
Zip Code
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#0f applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply O
DATE DRILLED . ' 30.O(O
TIME COMPLETED
Y./ELL LOCCC��,ppATI NJ,�� •
CITY: _AA/I/Y
3.16 AM ❑ PMK
COUNTYikh'dL(11
(Sire Name, Numbers, Community, Subdieslon, Lot No., Parcel, Zlp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
jy '/y
LATITUDE p,�4 DAJ
LONGITUDE pl •/ (03?i)
' atitude/longitude source: 4GPS OTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
s. WELL OWNER /0e.
OWNER'S NAME
STREET fD,DRESS 5-Le TAiL/*dadj/G :9S'1i/
City or Town 'State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
(�> 4 /9 -/0900--)
Area code - Phone number
6. WELL DETAILS: l�O
a. TOTAL DEPTH:
DOES WELL REPLACE EXISTING WELL?/ YES� 0 NO
MM
e. WATER LEVEL Below Top of Casing:. / (�. FT.
(Use'+' If Above Top of Casing)
d. TOP OF CASING IS 2 FT, Above Land Surface•
'Top of casing terminated at/or below land surface may require
a variance In accordancec�with 15A NCAC 2C .0118.
e. YIELD (gpm): at) METHOD OF TEST Blow.
f. DISINFECTION: Type H T H
g. WATER ZONES (depth): �1
From jjl1�3y
�yy To / r From 46340 Qfo,i
FromTo /J3 From - To
From To r From To
6. CASING: JJJ Thickness/
From Depth
Ft. Diameter W C t /)
From—��LT-To Ft.//J,
From To Ft.
Amount 160z
7. GROUT: Depth Material Method
From 0 To 20 Foement & benciatumped
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Sze Material
From To Ft. In. in.
From To Ft. In. In.
From To Ft. In. In.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10, DRILLING LOG
From To Formation Description
clay & sand
grani t-a
S
11. REMARKS:
O is
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOB3'NAS BEEN PROVIDED TO THE WELL OWNER.
NATURE OF CERTIFIED WELL CONTRACTOR DATE
James B. Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
R17 Mail Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
IUN 05 2UU6.
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 # . 2045
1. WELL CONTRACTOR:
James B. Brown
Well Contractor (Individual) Name - -
Hedden Brothers Well Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 73 Holly Hills Vista RD
Franklin. NC 28734
City or Town State Zip Code
(828 )- 369-9591
Area code- Phone number ,
2. WELL INFORMATION:
SITE WELL ID #pl applicable)
STATE. WELL PERMIT#(If sppilcable)
DWQ cr OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED AMZ,i,\PM 0
3. WELL LO 'j'(��
GTTY: A 1��.�F1 M Q�A':OUNTY &i'l
(Sit et ems, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE , 7i
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on e USGS topo map end
attached to th/s loan Hnot using GPS)
4. WELL OWNER
OWNER'S NAME
PRE)5tDDRESS
May be in degrees,
minutes, seconds or
in a decimal format
t Ma City or Town d
( ). 4/9i
Area code Phone number
Zip Code
6. WELL DETAILS:
a. TOTAL DEPTH: e l)C)
b. DOES WELL REPLACE EXISTING WELL? YES ° WOK_
c. WATER LEVEL Belau Top of Casing: 1 00 FT.
• (Use -+" If Above Top of Casing)
d. TOP OP CASINO IS 2 - 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 (gamy c ^O METHOD OF TEST Blow
f. DISINFECTION: Type H T H
9. WATER ONES (depth):/
From 7 'To 75
From .Q0.51 To . fis
From To
6. CASING:
/ Depth
From_r_,7- To
From /07 To
From To
7. GROUT: Depth
From 0 To 20 FGement
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
From
Amount 160z
To
To
To
Thickness/
Dlame)er Weight Mahal
FI. !r ye
FL
Material
Method
& benonite
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From1a'?(1
s
�)r t
Material
Formation Description
clay & sand
granll-a
-c
11. RRFjARKS: ^ w4Lugh
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W ITN
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD) HAS BEEN PROVIDED TO THE WELL OWNER.
GNATURE OF CERTIFIED WELL CONTRACTOR DATE
James B. Brawn
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW-la
JUN 05 2PY. 7/05
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 668.

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
Wen 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 Cif applicable)
STATE WELL PERMIT/(it applicable)
DWQ or OTHER PERMIT •(w applicable)
WELL USE (Check Applicable Box):
DATE DRILLED 05/19/06
Residential Water Supply El
TIME COMPLETED AM ❑ PM
3. WELL LOCATION:
CITY: ROBBINSVILLE COUNTY GRAHAM
SANTEETLAH ROAD
(Street Name, Numbers, Community, SubdMsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5
LONGITUDE 8 3
20.103N
53.495W
May he in dcarca,
minulee, aecmrda or
M a decimal framer
Latitude/longitude source: EIOPS ❑Topographic map
(/ocatbn of we/ must be shown on a USGS topo map and
affached to this loan Ynof using GPS)
4. WELL OWNER
OWNER'S NAME RON JOHNSON
STREET ADDRESS 3094 SANTEETLAH RD
ROBBINSVILLE NC
28771
City or Town State Zip Code
( 828 )- 479-8400
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 380'
b, DOES WELL REPLACE EXISTING WELL? YES 0
NO DI
c. WATER LEVEL Below Top of Casing: 75 FT.
(Use'+' n Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated auor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 75 METHOD OF TEST AIR
r. DISINFECTION: Type CHLORINE Amount 100 PPM
g. WATER ZONES (depth):
From 100' To 200' From To
From 355' To 357' From To
From 370' To 375' From To
6. CASING: Thickness/
From 0' DTooth
BlT R. 6im NHS HS Mrs'
From To Ft.
From To Ft.
7. GROUT:
From Cr
From
From
Depth
To 2(7
Material
M CEMENT
Tn Ft.
To R.
Method
GRAVITY
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 Sme Material
From To Ft.
From To Ft.
From To Ft.
AlN 0 6 2006
10. DRILLING LOG
From To Formation Description
0' TO 6' RED SHALE
6' TO 35' BROWN SANDSTONE
35' TO 45'
BLACK SLATE
45' 10 55' BROWN SLATE
55' TO 160' GRAY GRANITE
160'
163'
355'
TO
10
TO
163'
355'
357'
FRACTURED ROCK
GRAY GRANITE
d
FRACTURED ROCK
357' TO 380' GRAY GRANITE
11. REMARKS:
BIT SIZE 6.029
.x:
Tr
--G
Ca)
v
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRULI KM STANDARDS, AND THAT A CCPY OF THIS
RECO D HAS BEEN PROVIDED TD THE WELL OWNER.
J
05/22/06
S ATUR • CERTI- DWELLCONT-AC OR DATE
i}AR-ror) tL L. IrKrr
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 588.
Form GW-ia
Rev. 7/05

3(p, ar rt
e l 6
I?EswENT'LIL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division or Water Quality
1VELL CONT'RAC"l'OIt CERTIFICATION H Z 1 0 3
1. WELLLPONTRACTOR:
/ .f /eece
la
Well Cash
(Individual) Name
MILLER WELL DRILLING, INC.
Wee Contractor Company Name
STREET ADDRESS P•0• BOX 5B7
HAYESVILLE, N.C. 28904
City or Town Slate Zip Code
( 828 } 837-2997
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID elil epplcable)
STATE WELL PERMIT ilapplicable)
DWQ or OTHER PERMIT H(if applicable) �/
'
WELL USE (Check Applicable Box): Residential Water Supply Ly
DATE DRILLED ! -V- 6 6
TIME COMPLETED 3. 10 AM❑ PMI;1--#
2. WELL LOCATION: // /
CITY: (ID %/-Alv.'(�'e- COUNTY 6-C4 41
Ze (Lie 540 6- /4
(Street Noma. Numbers. communlly. Subdivision. Lot No.. Pa¢el. Z4 Code)
TOPOGRAPHIC l LAND SETTING:
['Slope I]Valley OFlal '-Mtge ❑Other
(check approprlala box)
LATITUDE .l S' /Y.,1VS
LONGITUDE r 3 75' • 9/2
Latitude/longitude source: ta!',PS 0Toi ographic nmp
(location of well most be shown on n USGS lopo mop end
attached to This form I not uskrg GPS)
1.
WELL
OWNER'SSOWNER
OWNERNAME �✓C C '
May be in degreet
minutes, seconds or
in a decimal format
i
STREET ADDRESS b‘2. oI l i e crk (:c1
Robbilisu'ille Pc- zW77/
City at town State Zip Cafe
1-
Area code • Phone number
S. WELL DETAILS: (/
a. TOTAL DEPTH: 392
b. DOS WELL REPLACE EXISTING WELL? YES 0 NO9-'
e. WATER LEVEL Be1owTop of Casing: 6 0 FT.
(Use'4' If Above Top d Casing)
d. TOP OF CASING IS / FT. Above Lend Sullace'
'Top d casing letmblated atior below land surface may require
a valance In Decadence with 15A NCAC 2C .0118.
•
e. YIELD(gpm): 2— MET HOD OF TEST /9°�
(�' OWNER
MWD
NC t/
1. DISINFECTION: Type /2/7/2 Amount
g. WATER ZONES (depth):
From 32-0 To 3.2 ! From To
From
From
To From To
to From To
6. CASING:
Depth Diameter
From 0 To 63 Ft. 4-Zs--
From To FI.
From To Ft.
7. GROUT: Depth
From 0 To3
From .1 To,Zb
From To
'Thickness/
Weigh) Malerial
SRC 1 • Arc
B. SCREEN: Depth Diameter Slot Size
From To F1. In. In.
Fran To FI. In. In.
Fran To FL in. In.
Material
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
7o FI.
To FI.
From
From
10. DRILLING LOG
From To Formation Descriplbn
D — f-f"
SS 3YZ
1I. REMARKS:
otu
/r/dr. f2
'i IN 05 20Dn
I DO IIETIER Y CF.mFT 111AI THIS WELT WAS CONS mum O 1* ACCORDANCE WITH
ISA NCAC 1C, WELT CONSTRUCTION STANDARDS. A110 Bt*T A COPY Or MS
RECORD IIAS BEEN PROW1E010111E WELL OWNER.
gyp Y it o s
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTE�D((NAME OF PERSON CONSTRUCTING Tilt WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center - Raleiah. NC 27699-1617 Phone No. (9191733-7015 exl 566.
FormGWID
nn tmc

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL NTRACTOR:
Jt (-I 1N l `kcif
W rQ.C.Ttractor (Individual)) Name
3C4\ Hiatt ()rah;
Well Contractor Camp S`:3/a yyNaame� ( '�'_ //
STREET ADDRESS 7 r/' Q ?SedeL
(ZCI6:VStfl[e age /
City or Town State Lp Code
4171- t> 45tf
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID am applicable)
STATE WELL PERMR#(uapplicable)
DWG! or OTHER PERMIT #(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 9 - 7- 06
TIME COMPLETED 3 In 0 AM CI PM
3. WELL LOCATION: �.Y�`
CITY: 1 `()pp11n I 6 Y/1(I Q COUNTY
/lu -•c,rs Creel.
(Street Name.. Numbers. CommWNry._Subdinsion, LotNo., Parcel. Zip Code}
TOPOGRAPHIC / LAND SETTING:
$lope °Valet ❑Fla[ ❑Ridge ['Other
(cheek appropriate �boox)) ��,�
LATITUDE _y.o (r�r .°
• LONGITUDE O 3.° 0�7 3Q-/'/
May be in degrees,
minutes, seconds or
in a decimal brat
Latitude/longitude source:/tGPS °Topographic map
(bcafbn ofwe#mast be slpWn on a USGS tope map and
attached to this form #not usig GPS)
4. WELL OWNER
•
OWNER'S NAME V/ nCeto Jc rn!Lr(C„,
STREET ADDRESS II wd!-�el"'i'hG.(� 5 C reek.
leer\A__V rSil le I L air77 /
City or Town State Zip Code
(kat)M79- iei
Area code - Phone number
5. WELL DETAILS: oW
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES CI NO
c. WATER LEVEL Below Top of Casing: A •y FT.
(Use '+• if Above Top of Casing)
d. TOP OF CASING IS t _ FT. Above Land Surfaces
"Tap of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Igpm): 3 0 METHOD OF TEST G I r
33ca
326390
f. DISINFECTION: Type
Amount \ 07
g. WATER ZOkIES (depth): /
From as To ate From To
Fran To From To
Fran To From To
6. CASING: Thickness/
Fran_a_ ,Ft �ianeter Weight Material
-11 7 %y sot? at t°+c
From To Ft
From To Ft
7. GROUT: Depth
�T Material Method
From P) To 90 FL enYta,nd- 1- OThejn&
From To FL
Fran To Ft.
8. SCREEN: Depth Diameter Slot Slze Material
Fran To Ft in. in.
From To Ft in. _ in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To a
From To FL
Material
10. DRILLING LOG
From To Formation Description
11. REMARKS:
0
o7)
0
x<
100 HEREBY CEHmmYTHATTHIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTOR STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNA OF^F CERTIFIED WELL CCONTRACTOR DAT©o
VOS4-Ir �l
PRINTED NAME OF PERSON CONS R ING 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 # 3s-6
1. WE ONTRACTOR:
trarpor (Individual) Name /
0 ttspfrvw. Ina[ 1
Well Contractor Companyy Name / T n
STRF�T ADDRESS h3Y /y1rJQ / a- n /G BC,c/
//`/ ,g7/
City or Town Stale Zip Code
( t2 -). 1179- +55'
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
�tASYak N(C_
STATE WELL PERMITB(dappliicabe)
DWQ or OTHER PERMIT #(9 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
,
DATE DRILLED Li—v—b6 "1
TIME COMPLETED Li: aid AM 0 PMyr
3. WELL LOCATION• "l
CITY; t1QFtt mEYI I e COUNTYVr ( cAyv--
Jsr tC°LI a
(Street Warne. Numbers.�groowVty...thdh eron. LotNa. Parser. zip cafe)
TOPOGRAPHIC / LAND SETTING:
❑Slope DVSs/ ❑Flat Midge ❑Other
(check appropriate
tboxx)
LATITUDE 3 c7 ° Ob((r 04,5 "
LONGITUDE f 3` V e 37-a
Latitude/longitude source: %iPS °Topographic map
(location of net must be shown on a USGS topo map and
attached to this loom 7not usng GPS)
WELL.
4. OWNERSNA ^�€ r k- 1 k L
OWNER'S NAME � nY{� r
STREET ADDRESS Fags.' /3IIhM 10
t?obb,:.s,111Q arc atm
City or Tam State Zip Cede
({cal). 7,?5 - 1253
Area code - Phan number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: '7 05 "
a. TOTAL DEPTH: 3
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOf(
c. WATER LEVEL Below Top of Casing: 7S FT.
(Use '+• if Abate Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface•
'Top d casing terminated at/or below lad surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 5 METHOD OF TEST ON. r
326389
f. DISINFECTION: Type 0-7 771 Amount ion?
g. WATER ZONES (depth):
From 75 ' To 205 • From To
From To
Fran To
6. CASING:
From 0
From
From
Depth tt-- Diameter
To V/ Ft(i
To Ft.
To Ft.
From To
From To
Thickness/
6at
7. GROUT: Depth Material
From 0 To ao Ft. CemQni-
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft in _ in.
Fran To Ft. in, in.
Method
9.
SAPID/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To FL
10. DRILLING LOG
From To
Material
Formation De.r.iptiun
OnPi
11. REMARKS:
CO
0
0
C
r
I DO HERESY CERTFY THAT T IS WELL WAS CONS1RUCIED w ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRL)C 1ON STANDARDS, AND IHATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNAT CERTIFIED WELL CONTRACTOR �- D 0 6
E
Car6-1h o't lskCpps
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL ONTRACTOR�/::1n 1
c ,tth r, r'n1lly pc
W;j ontrtlor (Individual) Name 11
tfira.� 1..-, it,\ell 0nil ) r.%
Well Contractor Company Name
STREET ADDRESS ( 3)/rJ yd." 7-01,37-N fienj
`7) w�1YK✓)le j%( d ir77 /
City or Town State Zip Code
( tale)- L179- ey5y
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 0(if applicable)
STATE WELL PERMrrly[dappricaae)
DWQ or OTHER PERMIT Nit applicable)
WELL USE (Check Applicable Bad: Residential Water Supply R
DATE DRILLED Li-- 3-0 6
TIME COMPLETED I a; 30 AM ❑ PM (4
3. WELL LOCATION:
CITY: Rt]BXDI✓511, ►It COUNTY Craknvy,
/G),., Anne k kuuy aCC
(Street Name. Numbers. Community_Subdiis'Ion, Lot Na. Parcel. Zip Code).
TOPOGRAPHIC / LAND SETTING:
OSbpe OVaky ID Flat )(Ridge ❑Other
(check appropriate bad / //
LATITUDE 3 S //a�� /a O
LONGITUDE $ 3 0 7, t 16,6 r v
May be in degrees,
minutes, seconds or
in a decimal knaat
Latitude/longitude source: BOPS °Topographic map
(location d well must be shown on a USGS tops map and
attached to this form t not using GPS)
4. WELL OWNER ^( U1L
OWNER'S NAME AVn /7eV1 i C,�ise l'�
STREET ADDRESS ,/let/QW h Ica -At Hwy a-'
Y4126.14414 (\[C ac-77)
City or Tarn State Zip Code
( era-t). 7.3s - a o
Phone Area code - numbs
5. WELL DETAILS:
a. TOTAL DEPTH:
%OS'
b. DOES WELL REPLACE EXISTING WELL?/YES ❑ 13 NO)
c. WATER LEVEL Below Top d Casing / 4 FT.
(Use+-11 Above Top of Casing)
d. TOP OF CASING IS ' FT. Above Land Surface'
'Top d casing emulated ayer below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): I METHOD OF TEST a 1 (1
326388
f. DISINFECTION: Type la tf-I Amount'ra4 n7
g. WATERZONES
?OS
(depth):
From 1 bc7 ' To 7Ot From To
From To From To
From To From To
6. CASING:
Fran
From
Fran
Thickness/ 'Atli
O T°Teti87 Ft 61/q ( WV(
To Ft
To Ft.
7. GROUT: Depth'^ Material Method
From a To C�N.J Ft. CQynee.t f)r„ {. rp I
Fran To FtT r ( 1 a
From To Ft
8. SCREEN:
From
From
Depth Diameter Slot Size Material
To Ft in. in.
To Ft. in. In.
Fran To Ft in. in.
9. SAPID/GRAVEL PACK:
Depth Size Material
Fron To FL
From To FL
Fran To Ft
10. DRILLING LOG
From To
Formation Description
1 ' d 06 ENS
11. REMARKS:
m
co
-i
1 DO HEREBY CERTIFY THAT TIC WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONS1RUCRON STANDARDS. AND THATA COPY OF MIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATU
0%7,u✓ y- -lob
OF CE IFIED WELL CONTRACTOR DATE
I�057-1Y1 ,II Cettas
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 WEILCONSI'RUCTION RECORD
North Camara Department tFSviooma t and Natal Resources- Diroim of Water Quality
WELL CONRACTORCERTIFICA1ION6 r<
1. WELL CONTRACTOR:
WeeCenamor 7y garcon
tame Li �7
STREET ADDRESS /t* 7 Tl;+W‘ 1 C /7f't ar-
(21nb,,,,l io £VC r Y77H
City or Tam Stria Tip Cade
Area cods Pea mortar
2 WELNFORNATIDIt
SITE WELL ID amiable)
STATE WELL PR AITOI -:
DWQ or OTHER PERANTi(i we:—nd
WEILUSE (ClredcAppiralie Batt Rae.id NNW Soppy 51
DATE DRILLED 6, / 'S" t)
TBIE COMPLETED fn AM❑ map(
3WELL lINSATICSt
CITY: J•{f)iih,/cc; e
it <Kec eP.
tame Nara Nomeaa.'+
TOPOGRAPHIC J LAND SETTING:
OStpe DWI, OFbt Wrist Meow
(data paif
LATflWE S atl 1;,4 •5 v
LONORUDEs;�L L��' nes
Latitude/leggiestaaa= WPS DTopograpbicamp
poea6ad daafaaatMsaioaa ea a USGS epoaep aed
alladadbdibr dlaafr6g6PSj
COUNTY of r" : NY\
reca lea.
ea.PanelDpOea d-
May le odogras,
aeon snoods or
boa admit is
4.WELL OVINER OWNERS NATE Lo--: j ne_ i {`;,1 \i
STREET Ammo ky PJ eer C&! ([ re S
L���
� rC 1 AI. V� l
,l Gay or Tam Slide T.p Code
( H3). 46, - L{757
Area code- Plume mate
5.WBLDETAI.S: /
a. TOTAL air nt . y n65
b. DOES WELL REPLACE EXISTING WELL?
/PESO NON
c. WATER tan. orTapdCNig I .1-7 FT.
(Mee iAtom Tap diCaaq)
d. TOP OF CABNGS 1 Ff.Abate lard Seise Tpacair bad audimo we isgdre
arasab a cadaemerah TSII'CPC 2C AHI.
e.VMS bp* 1 METHOD OF TEST CA,f
L OBRFECif101t Typa 1-1 rH
g. WATER2;0 (dope*
ROM Yb ' To 4 i ^- Fran
Fan To From
Fes To From
6. CASING:
F,� C.'oft/ Ftt
Ham To Ft
From To Ft
Amount
Dinar
To
3p2.
To
To
THifoeGsl
Vaasa
Zl 1C
7. GROUT: Dapb naiad*
Ram V To ;-j'b Ft r O -r* —
Rom To Ft
Rom To FL
Malhad
s. SCR®t Deport names Skt Sze Mobil
Fora To Ft in. R
Forme To FL in _ R
Rae To FL In in.
i SA/OBRAVELPACK:
Dort Size Wien
Rom . To FL
Fmot_To R.
Rom To Ft
nt`
10. DRIlAIG LOG
Rom To Foimafm De—a(plion
1L REMARK&
a
N
0
r
IODIEIEM OSIN9LIVASCORNC®INCOM I ENem
ssaatxa-wetaaawcmaSw0amtatoaQaamroFws
tr®aieadi®epnoea®W TIEraLpaeBl
OF CERTMEDWELL GATE
PRIMED :OF PERSON Y • tiSIRUCTS31IEWELL
Submit the original to the Division of Water Quality within 30 days. Min: Nfonnabon Mgt,
1617 MA Sondes Canter— Raleigh, NC 21699-1617 Phone No. [phone] ext 568.
Fam GW-1a
Rev. Th'E

RJ
RESIDENTIAL Was. t nnvcnoti RECORD
Nods Camino Depa9aeot oEnviaiment and Nan RawaaDiv s-ision of Water QualityWELL CONTRACTOR C19C1incATION C $ 7 3
CONTRACTOlt
rh4laec
w . o ri
�� rrarr. Cyr I ,ll+'v3
Comm
WOTANMa m -/mName
STREET ADDRESS ("?7 %CZ,
(�C rYt`-I. cj7! SUS
-qy or Toro Ss
/Mare nuMber
2 WEB- I Fq�A,DIt
SITE WELL DENa pi -My
STATE WAS P9 UIfl p[io- -
-9477/
Bp Code
DWQ or OTHER PERMITXiapprmabiN
WELL USE flack AgiaWaLog Raligned WaferBtWA
DATE DRILLED 6-- 04
TWYE COMPLETED r-. C/, AMO PMO(
S.Yd LLOCATION
CITY Rr`inb4/- COurttTYGr-i/Y.r,�
5d CF ,')c Ia'� l r.^.-�a)C� 7L_eC-13
Mama MaM Mabee. l3ao-Pamal$coda}
TOPOGRAPHIC /LAID SETTPIt
OWN* ovAe, VA OW* ooaw
(dee*appagi bbr)
LA -arum s 2 .-,ia' /d-31
- LONGITUDES =i L[ t/ ?.;:C
Iatioddlaogibdc sour= AGPS oTopogatpbic nap
POGROM d load bs shown ar r USGS two wend
Madrid folk kfatTam!asks BPS)
4. WELL OWNErt /^ I
OWNER'S TIPAE ( C-YhC^• re /�
SiREETA00[tt3'S r�es r Y. �n I
4I9 IVC,
gMIE a Tort �''77 [j SGtre/
( �1G1 } 6,a7— / /0
Area code- Phone reeler
MarbeodQa,
irer,aswdsa
deeimi fiat
&W LDETAL& �1f I
a. TOTALDEPRRt / (/J
%1n.-ic -Ch-_\
r aPec f et-,0
777
Code
b. DOS WELL REPLACE EISTNGWREIL? VESO ND '
c. WATER LEVEL BdawToporCoder /S FL
(Daum"Abaft Top dComo'
d. TOP CIF CASING IS / FT. Atom LordSaisr
. Typal easily dwbradWar bin Ind maga maympnr
aname kaomiasi SANOAC 2C AR&
o . WELD 116 ETNDDOFTFSr at r
L OTRDat Type H iil Amount W
g. WATER ZaO Omar r
Fran 5 To l f
Fnm To
From To
Fran To
From To
Rao To
6. CASING: Ttilaraase/
Depth treed1 Material
Rae r' To .6 /5 R 6 gi / tr 5-t-ee
From To R
From To Ft
7. GROUT: Dapla Yalsai
Rom n To aP R C
Ram To Ft,
Rom To R
larthod
& SCREE& Depth Diameter Ski Sae Malarial
Faso To Ft. M. io.
Faa To R. M. _ M.
Faun To Ft_ M. In.
I SMEDRBRAVELPACK:
Dap* Size Medial
Rom To R
Ftat�To R
Rom To R.
10. ORILENG LOG
From To
11. REMARKS:
Formica
10011801Y0311WellairmetvEurascasecelliDetACCOIVIWCEwmi
SSMGCrSaae11em6waC110nSsawan6 MW RalACOraF76
.naw el4 eaatOWEDmTEMa1ORaBt
SIGNATURE OF CERTt7ED WELL CONTRACTOR DATE
'r.J-i� __ ll
E t1�11EOFMOONCOe19TnnnT)EWELL
Submit the original to the Division of Water GuaYty within 30 days. sun: bMEmadon Mgt.,
1617 Mall Service Center— Raleigh, NC 27666d617 Phone No. [phone] ext 668.
Fame GW-ta
Rat MS

RESIDENTIAL weu,00NSTRUC-n0D RECORD
North Cno4m Department etEnvironment and Natal Resomea-Division of Wain Quality
WEU. COII1'RACTOR CERTIFICATIONS
1. WELL COIRRACToft
ti; t+rR 011
Cantraclo (baferidmth..—...
r%C taraBll7 n g�
sTnREET ADDRESS F, ` 'LI 47Cfe / (Yi'w•earl Li
�7�hirs- I10 r C .Y77/
City or Tam Stele re Cade
tes t} Lin c iS /
Area code- Maenneate
2. WELL INFORMA710It
SITE WELlmdlleppaed!)
STATE WELL P£HYTdRepafaMy
DWG aOTHER PERMIT did appF ' )
WEILUSE (Cho*AppiaMa Bo* yIthale i+Wds Stipp l PA
Dra
m 6` 30" or
TIME COMPLETED S ('J AM❑ PM �.
3. WELL LOCATOR /-�
CITY_ / <C.+) /7 COUNTY
a' <ff <j (J7,.r i cox
Meet at Wome.Oumomeaedhehtniem.LamaPumaaPCaee1
TOPOGRAPLIC / LAND SETTT
MS OVSw Ond �TaOs comer
(dark wrapartss
LATmiDE IC 51 (i // q
SIDE_E,i.` `> 1, t/3 `(`t
Iatiatdellat de sou= MOPS °Topographic map
(baton dsal ass Ibestain anaUSGSlopei ad
Mediae oIds *we 7sNeaig@PSi
twat OWNER
OWNERS NNE Li ar v"e C
May Lenders.
himEeeaasor
iadated fst
S 1ADDRESS.
/? " S rr✓e IGr'Ur�
l" �CAy cameo SYb Coda
4-17
A lac t- Rale cumber
5. WaLDETAti&
a TOTAL Dente ei f .5
Y. DOES WELL REPLACE EXISTING WELL? VERO NOR
c. WATER LEVEL Mew Top of Casing (0 Ft
(User NAlaaTap deabns
d. TOP OF CAGING IS / . FT. Above Laid 8ofse
"Twee exam le die daMs4dYodsmdaosdymoire
avoleb scoonrnmi 1SANCAC2CA/M
a TRWSP* E7NODOFTEST 4 i r
L iiratirEcoott boa 1477-1 Ant*
g. SINTER ZG ES ("NIG
Rem /,(1 To From To
From To
From To
S. CASING:
From To
Fran To
Fm0 To//s FL /-`/�r
Depth
Ram To
Ft
Roo To • Ft
7. GROUT: Depth
Fm rh To 4.)
Fiw To Ft
Fm To R.
Dirt' most
s a l f tt
l/aladd
Ft (. rz'*b'
Mime
1
a SC et D.vm Diamto Slot Sim Matadi
Feat To Ft is ix.
Ron To R. M. _ in-
Ron.To Ft h in.
9. SAIMIGRAVELPAoe
Depth Sate Medial
From To R.
Fonl_To R.
Fs To R.
1t ORa1HCG LOG
Fan To Fonoaron Desaiplion
1L REMARKS:
c
J " -
C
u
J
niter
tooln®rarnmIN TNawetrmlMan-Nc®raooaor ICEami
eatatehWGe101CO SIMILCmtiaa0l®e a D1RWACCPyOR76
natamissMEER TOTEMHi'Of
CERTF®r11B.L P10NiFdICFOR 736)
DATE
MUTEDMtOFPERSON THE vial.
Subml Elie original to the Division o1 Water Quality within 30 days. Attn: Monnadon Mgt,
1617 Mall Semite Center — Rah**, NC 27519.1617 Phone No. [phone] tact 568.
FamGW-1a
Reis 7A5

RESIDENTIAL W EIL crorisrRucrnoN ncoiw
Nadi Carrion DepaIemt of Environment and Natural Resousoes• Division of Waist Quaky
WELL coNrRAcroR Ct aims-nom 9 -ivio
C( 15d-i CI
Sconnacfa ( kil Nana
• Wd CotacContactorCompany Name jI
S ADDRESS 6 3 /IJ l f 0-3?1 r c-4
k \ iIL ifs- s 77I
My a Two Star Zp Cade
� 7`j-4
Ans Dods• plme mama
2. WELL a FORIBAT1Oft
SITE WELL D d(f ae ical kf
STATE WELL PERSIDIRInona.
DWQ or ODER PERI/Mgtappf®hle)
WELL USE (ChmfiAppL U.. Bet Rattlafal WdaSappl l@
OATS DRILLED -i =7" 6 A
commute) 7) PUst
TOTE COm•' O AN❑
floss tItcATIOIt
I
CITY: J�Ib ,rt=✓IIIP /^� / counntGailL-r-,
t m r �i AC.r,t 1
MeetNaaz.Nieaa 1stN0. PatwtaPoadaF
TOPOGRAPHIC / LAND SETT W G
OStpe DNS i@Fki DRidaa DOME
1r8dcaypmparat 4 U
/�l LATITUDE 3 1
llafr
L waT DE Li ' ��: >-
Latiadt tde sour= RGPS oTopogra phic non
&ca reafsdoathssham on USGStop* amp and
a0ad® mdloWstttadraj GPM
WE
LL (m 1I
OWNER'S NAME /:.\ n yre.)..( er{
.SIttASS t�..n t —lf iiJ CcCi!7
NC 3417/
My OrTann Skin Zip Cods
(7 Oil ..3t1-iy6S
Ae® c9de. ttmttbe
May bee degrees.
aimn4aaaadaa
.adec al list
S. WE.LDETAM.&
a. TOTAL OEFTIt i to
b. DOES WELL REPLACE EXISTING VEIL? VIES NOOt
c a WATER TSOsita L/t7( FL
(User InheeTapdCalks)
d. TOP OFCASNG t8 / FT. Above Land Smfsd
*Tap dasingimameala bisbsYsd am--naasaoke
a*mince it acmdacei , JI is&C 2C101t
at. MELD foot ) A METHOD OF TEST Cti
f. DIBI FECT1Ott Type El Amount 707
a WATERZOIE5 (nape*,
From t)h To /ftO
From To
Fran To
G. CASING:
Froar_Q__To -[
Rom To R
Fom To Ft
7 GROUT: Depb
Rom 0 To 3.0
Ram To
Foxe To •
From To
Rom To
Ram To
1t L.sa/
R I D t tefar WeLgd lhfevr"o
! Wirral %
aaeieaFd
Ft
Ft,
Ft.
a. SCREE* Depth Diameter SWSas fAiaid
Rao To FL In. i.
Rea To R it _ in.
Faso__ To FL la In.
i SANW RAVEL PACK:
Depth STae Mt
Ram To Ft
Rom_To
Rom To R.
7a. Datums Los
Roo To
11. RZMARKS:
Ftuadott pesnpion
N
aama33101r o-osaaa.sascasntctmascmoar�ataI
ssnaarxS. .taamacassamsaawo>.osaCCMafem
aamotsse®nrwN®mnEwatamaat
%- j j/-L.� c 6- 7-06
OF CERTF� WEELLL,CONTRACrQ DATE
+)1 r ' 1�
NAME ME PRINT® WEIL
Submit the original to the Division of Water Quality within 30 days. AtUE Momutwn Mgt.,
1617 Mall Senriea Center —Meth, NC 71699-1617 Phone No.1910) 733.7016 tat 56E.
Ram GW-la
Rev.7A5

.RESIDENTIAL WELL core'aocnoN RECORD
North Cunha Departr.ont &Enviannbt and Natural Round DMbi m of Water Quality
WELL CONTRACTOR CERTIFICATION ! J0to
CONTRACTOR:
-th
WdCalaame trnithriasr) tear ,n
Y, LiQ\l Vllf��� C� /
STREET ADDRESS %. 'RLi /�1,C12 TC).J;\ 12exd
air orToro Stile ZZCole
(-ntg). L17ei- 5 159
Area coda- Rase
2. WBSWORMA71DIt
SITE WELL IDa(raWiable)
STATE WELLP9ivi*Raplulb)
DWQ or OTHER PERMIT Nit pploable)
WELL USE (CladcAppirabb Boit Iaailmid Wain Sunni
DATE DRILLED i .7 1`nth,
THE COMPLETED 6 fl?) AM❑ PMMW
3_ WELLtO�CJATfl1t
ern,:!`C()L4 1✓c 4II comet"kJ
1n i k-d'le 6 ry b'rrl (cc.A
Pelmet tine. nestemCm_eg tolidialsglatao- rivet aPCadet-
TOPOGRAPHIC 1 LAND SETTNG:
osq,e Malley OFIet * mother
Muck appepriniMid
LArrruoe 8_ 2: O t ,r
Iatitde/otgihdcsamcc nips Crimpographicinap
Pain d Eistiawat S shown as a USGS ipo map and
addmdbait fon7notran GPM
4. W13.1.Oplct // C
OWNERS NNE A�l ✓� V n-047
ASS G.tt19 <,r1CLih '1 I f2*tr
, vIl1't, ad7y�
a
thy bbdopers.
Mink; s r
:edeeimil ism
( r(3)- ffl`i - (*5 1
Area code- Rom mere
5.WE L DETNS
a. TOTALDEFIF! r.l�
b. DOES WELL REPLACE EXISTING p .LY YES El 110
WATER LEW&OtioaTmp FT
(Use'F iAkre Tap etCato)
d. TOP OF CASING (B i FT.Abae Land Sabot
. 'Toper oasis Yermitel Marhel stelsadooe-lanpie
eamazeboatoda ewi 151 CAO 2C Alta
a YIELD Went . D rErxaacFTesr CA (r
L CisiteCnott Type HtH
a. WATEtZOTFS (depldri..
Ram -�CC To < n
From To
Rom To
a CASING:
Rom Two .5 6 Ft
RomTo Ft
From To Ft
7-GROUT: Depth
From() To m
RamTo
oa FiTo
Rm aTo
Rao To
From To
�p1a Tbidt ijemss/
:41111 r °Mr s
Ft (Q.-r�z��_' pentMMUS C?il;�
Ft 1
FL
a SCREEtk Depth Diameter Sloth Material
Rain To FL it in.
Res To FL S. _ it
Ram To Ft. to. In.
a. sMOIB AvtiPAM:
Depth size Wend
From To FL
Rm_To FL
Firm To FL
n. DRYIWG LOG
RCM To
1L REMARK&
Folnraim Desorption
?CJ
1Wa®VCEIO 7g76a9LWaWi1111CIEDaARORMICE lm1
6ma91CSsVIIBL eau W CIOMSTMOSIDIAwD WZACaPY °File
11ECOmalsat BIPmoVwm7o9EINELLLama[
14714
t;1sNAti1irtEOFCERTFEDWEtLCOITRACTOR DATE
•
K�En V-h; l5
PRNT®INIEOFPHLBON THEW131
Submit the origbld to ttta Division of Water Quality within 30 days. Amer: information Mgt.,
1617 MN Sarin Canby —Raleigh, NC 27699-1117 Phone No. [phone] at 568.
Form ON -la
Rev.7ATs

RESIDENTIAL WELT.CONST ocnoxRECORD
North OranDepartment etEaviroome tandNatmdResaaoa-DivmndWater Quality
wend, CONTRACTOR c ipic noNi
1. CTOit
c I
wet 'aMor (o wn dName I ` `'y� �S1
( JI, ih \C\\ ktir
Wd Cmdr ‘miiTalytianas
STREET s v&
City orTam Stale, 2 ). Li 75- £r' q
wo♦ Arta coda- Rrsraais
b;
/Y
I �P �<�c...+nfC rd
rip Code
LWELL IN ATELt
SITE WELL Dti0appsrsbLq
STATE WELL PERMIrnapsida)
DWQ or OTHER PERMIT Vain)
WELL ME(CheekAppirs"- BoM Rana Water Stank
DATE maw ,-- nC,
THE COMPLETED i / : ,On MAX Pup
3. WELL tick at
Cam: ref biz ;:-.4Val o NT atark -
l
reneZerNotnenenoonermey.9ear.kalmne-mannaapmatel-
TOPOGRARBC / LAID SETLNG:
COMM ovsay prat DM* mew
easeurnisesse
LATTttmE _a_ s2_ 0 2. E
L i E_SiLig 1 i7" 94
May teoderma.
isadeeard fee r
Ialmaddbr de sow= %PPS OTapograthierem
gorAfaadaeimrstbe shownma USGStop* asp and
aMadsed task fo m la d asip GPM
4. WELL OMER
OWNERS NAME f"£-.UJ 1 / ' 1 or;C4r\ �/f
AOORmS ��i Ll..i,J l nt4' (CCU r
rhnrc .;1I ic c;e77/
oar State rp Code
( 6-34- , i 71 - 36 0?
Area erde- Phone marts
5. WELCETAt& _
a. TOTAL DEPTtt iT
b. DOES M .LREPACE oeStiltG WELL? YES CI NO
e. WATER LEVEL RdasTopdCaaier 30 I.
Fr
Warr of Casing)
d TOP OFCASING IS / FT. Atom Land &oboe
. 'Top of mileleminiddllrLi WMmien neyamie
avarimee noaxdrecandh15ARCAC20MILL
a. YIELD 7 METHOD OF TEST G. t f
t. OBRFEGTIOtt Type H T/y Amount /3 r-
g. RAWER ZONES (a4 *
Fran �O To kC'5 Fan To
Ram To From To
F1m To From To
6. CASING: Thdmess/
Tm` Dinineler Wii Material
Roar G o&. Et .0ht�.L:-._
Ram To R
From To R
7. GROUT: Dept Matsial Method
Fm,12_To tD RGen.e,,l-- pl,,,FA6
FlaTo Ft,
Rom To R
8 SCREOt Drpli Diameter Slat Sam Material
Roar To R Si. in. _
Rom To R it _ ir.
Rom To R h in.
8. satdBITAVELP/tCK:
Daps Sze Material
Rom To FL
Rum To R
Rom To R.
nt`
10. DRILLING LOG
ROM To
11. REMARKS:
Famren DesoyYon
e
o .-
noon®r031Erffi1sw6LmeaoasaacameAofSaoa CENme
Lana/eeS.N9LOm SIMUCm11Sm10a alai TACOR'eF16
REC oaMa®1NW1 D1011 \19Lam6l
OF WELL COMaTOR OI1TE
r
TILE
NAME PERSON
PRIMED WELL
Submit the orightal to the Division of Water Quality within 30 days. Atha: htiomu5oa Mgt,
1617 Mail Semite Center— Raleigh, NC 27580.1617 Phone Na [phone] nt 568.
Fam GW-la
Roe AM

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Deperbnent of Envimmnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION f! 2261
1. WELL CONTRACTOR:
CHRISTOPHER L. DICKEY
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 n(Ir applicable)
STATE WELL PERMIT/CI applicable)
DWG or OTHER PERMIT t(Y applicable)
WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 05/17/06
TIME COMPLETED
3. WELL LOCATION:
CITY: STECOAH
AM ❑ PM ❑
COUNTY GRAHAM
BLACK BEAR LOOP
(Sheet Name, Numbers, Community. Subdivision, Ld No., Parcel, Zrp Code)
TOPOGRAPHIC / LAND SETTING:
Id Slope ['Valley ❑Flat ❑Ridge ()Other
(check appropriate box)
LATITUDE 3 5
LONGITUDE 8 3
23.093N
39.010 W
May be in denims.
minutes, seconds or
in a decimal fwmzt
Latitude/longitude source: r]GPS ❑Topographic map
(bcetbn d wel must be shown one USGS topo map end
attached to this foram l not using GPS)
4. WELL OWNER
OWNER'S NAME VICTOR HEIN
STREET ADDRESS 8250 NALLE GRADE RD.
NORTH FT. MYERS
FL 33917
City or Town State Zip Code
( 239 543-3098
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 800'
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 150
NO13
FT.
(Use Y' 1 Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing laminated. at/or below bind surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST AIR
1. DISINFECTION: Type CHLORINE Amount 100 PPM
g. WATER ZONES (depth):
From 360' To 380' From To
To From To
To From To
From
From
6. CASING:
Thickness/
From 0' DTot41' R. fi tr8 of Salt'2t rl
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 20' O CEMENT
From To Ft
From To Ft.
8. SCREEN:
From
From
From
Depth Diameter Slot Size
To Ft. in.
To Ft. in.
To Ft in.
9. SAND/GRAVEL PACK
Depth
From
From
From
To
To
To
Ft.
Ft.
Ft.
Size
Method
GRAVITY
in.
In.
in.
Material
Material
10. DRILLING LOG
From To Formation Description
0' TO 18' RED & BROWN SLATE
18' 10 135' BLACK SLATE
135' TO 600'
11. REMARKS:
L
r-�
GRAY GRANITE
. n i"'
<
N G771
0
BIT SIZE 6 088
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACOCRDANCE Irani
15A NCAC 2C, WELL CONSTRUCrx1N STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED ID THE WELL OWNER.
Z.T OF T ,EL0N1 05/23/08
NATURE OF ERTIFIED WELL CONT TOR DATE
c11il1)IC TliJ L. I
RINTED 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 27899-1817 Phone No. [phone] ext 588.
Faro GW-la
Rev. 705

03123D
RESIDENTIAL WELL coremucnos RECORD
North CmormDgrtment of Eoviamed and Natant Resmce.- Division of Water Quaky
WELL cot/nut-ma c:sirrincAnom s 33V6
1. WELL CTOft
Tnrthe �U arne
rZ,m%',r vr. f „ �Q r t�'1 iy%
WdConnecta Gown Name ��) /�- y— �//
STREET ADDRESS 6• D i C %44 / (},.lv\ IC 1
122\16nbvll C, -77/
Ciyr orTaan Stile De Cato
( cg -). 4-f 75- Ss4 S'1
Area coda. Mono swan
RAVELL WFORSIA1101t
SUE WELL D tllapperaSS)
STATE WELLPHoITiapat
DWQ or OTHER R3WITi(1 g era:die)
WELL USE (Cloak Appkanie/Bodo Reeidafal wssipplr�
�
DATEWSLU rrj/�/ Ob
Toe/ COMPLETED a.-(7b AND RSA
3. MatLOnCATIOHt
CITY: (2;6b;i l le ••
&rt,n s Crv4L Vo
Meet The..tam6ees_Ca mipr_9eeade. .- ...
TOPOGRAPHIC /LAN) SETTING_
Claim ovary oat DRidae maw
fdlockappaprit
LATITUDE al_Q k'w33,r
LONGITUDES 3y J6' at/.6„
Iatiwddlangit de sancc KC>PS oTepographie tap
fixation al agar aaaal b tan an a USGSS two sap sad
aaaden ieba/laotaate BPS)
A WELL. O ER
OWNERS NME \ JV. iG. RCS
.71 i ADDRESS 1 -r 4s.6 C r ek )2.c
�bC,.:lle cvc 2�77t
MyoTom SYIe Zp Cade
t04f-).(175— L!603
Area code- P1lamramber
IIeCade}
be is arm
senarear
Sedeaiod Tama
S. WELL SEMIS A
a.
TOTALDEPTet O�cso
E. DOES WELL REPUUM OUSTING MELLT PESO NDAt
C. WATER LEVELERS/Taper Claw 60 FT.
((laze`+ flare dCeetag)
d. TOP OFCASSf.6 1 - FT.AhoreLaedSues-
. Taper tmliellmi rbids Sad aaada nnmake
• oakum eamadanoemaISAWAG2C.n11t
a.YIELD lip* A ammo OF TEST et1ee
327546
L ussFEc1FoltType I`f l H Amount I re) a
g. =TELMOIEa McFaU
Tian 60 To 'rX*f) Fran To
From To From To
Rae To Ram To
S. CASING: TN:M sa
Idiaterial
Fan n DTor'i? / Ft Tar MI I p
Finn To Ft
Ram To Ft.
7. GROUT: Dori ISMS Mebd
FromCm To -315 Ft. C ei,i - p, Ann F) ✓ n
Ram To FL
Tim To FL
1. SCREEt Derah Diameter Slat Sox Mahal
Ram To Ft. is IR
Tim To FL in _ a_
Ham To FL in. in.
1. SAeD/GRAVELPAM:
Detpll Size ISMS
Foam ' To Ft.
PC° FL
Rom To FL
to maim Lou
Fmm To Formica
11. REMARKS:
c-1
CO. ' .-47
val
S'ti
-C
IODIEMBIVOENAMWINSIOBLISSCONSONCEDIOACCORIDANCEVifili
tsnmx2:adlCOiBrcmrSpeDaQAmINCwcQraFeeS
aeoaoaaa®1eaOV®W71EINInC aaat
i t
SIGMA1 _Iniuw1ED WELL
CI �Fd-/%‘
PRNT®l6WFOFPHt60N WE WELL
L
Submit the original to the Division of Water Qualty within 30 days. Amt bfmasSon Mgt.,
1617 Mail Ssavke Center —Raleigh, NC 27699-1617 Phone No. [phone] es t 565.
Fam GW-1a
Fan 7A5

Ofic
RESIDENTIAL nu.00rxsntocrwN RECORD
Nash Groan Deportment dFsvimtm e t and Naiad Re sci raess-Division of Water Quality
WELL CONTRACTOR CERTIFICATION if ,? �.4
Wd-Canaria
hams
k.r.vn L)p\ IQ11117,16.
Candor ComploarNa t
STREET ADDRESS (l 3y Hyde ✓ a.1v,
(2 \ rsvi'jlr CVc 2Sr771
City aTam Stile Z4Code
($dec1- (I7i ^V459
Area Rude- Pita PUMPS'
2. WHl/WRIIIATIOIt
SITE WELL ID apt ■pae -"el
STATE WELPERMTasanaeaMel
DWG a OTHER PERIATti(e Wpiat*
WEIL USE (Meek #r picdGte Lk*Reidried Wader
WaSop*Ef
DATE DRILLED A:- Q- D 6
TYE meri T o (-I? DO AMO NA pz
1 WHLI rtnolt % ^1'^_�- �
CRYM_ 11!(4bbirtst(J. ( T''t'�
lc�iu\irin C (QPaC
Theettene. _.0oeealp_fBWiia6g1-10-14. Pow& DaCadM
TOPOGRAPHIC / LAW SET1Pc
ODIRm Math OPW NM & DOME(
teat*me ice
LATITUDE _ tc2 oZO'L%(l-S"
LitIdefongibdcsmtcc 4GPS OTopogaphiemap
Paean d meI mast bets on a USGS ergo imp and
aaadadb Oic no twig
4. WELL OW►ER '
omasNAe&/'/o unirAin �.Ceek_ Ji r[ rs
AOORE55 nurtss:, Cruet
bcosville Arc
CeyaToswo Stole Code
( <<- 1- 73E- lasso
Ana code- Rune number
May le is demist
minim s tau
Maeleit forms
5. WELL DE7At& a. TOTAL DEPTIt (Or
I DOES WELL REPLACE nentarsE11.7 YES NON
c. WATERLEVR. Dakesaimdf tim crg FT.
(Uasw• ■AleaaTop d Casing)
d. TOP OF CAMS IC 1 - . FT -Abate Lord Sorbet
_ Toped =doisitredaWbelow MOmdCempnob.
avai__ ameimoasi WANCAC2C ANI
e. WED Wet / S RELNODOFTEST C N-%
327547
L O*ECII0It Type l`i 'f-N Mama ig c' Z
D. CUTER ZONED (dolor
Fran ' To 'y c,t-� Foam To
Fear To Ram
Real To Feint
To
To
6. CASR M Rarest
Rom 0Depth
o°a7 R. f. I Darr-ClW D Material
Rom To R.
From To Ft
7. GROUT: Dept MEW t iad
Rom i) To `dvO Ft C.2+veni- )
Faso To Ft
Fiola To Ft
C. SCREE* Depth Diameter Slot She Material
Farm To Ft is it
Rom To FL is _ it.
From To Ft h it
S. SsdwRAYaPACK:
Depth Sine MAeii
Rom ' To R.
ROM To Ft
Fos To Ft
70. tRIILING LOG
Fmn To
11. REMARKS:
Fossedal' Dasoipfmn
N 0 r,
r
mosaasvcsur oar asmaLWISCwsOrca®mAmmmra,eemx
IMICI C7gteELCIINSIieCKetSMIMAII RAtmlmmAfA)PvCFam
HEOSID1MSBEENPAW WllElP a/prey
SaaLA OFCERTB$WE11 DATE
P'RMi®NAME OF PERSON THE WEIL
Submit the original to the Division of Water Gunny Within 30 days. Attn: bto.matlon Mgt.,
1617 Mel Sento Center— Raleigh, NC 27699-1617 Phone No. {619) 733-7015 eat 56S.
Fmm GW-la
Rot 7A5

RESIDENTIAL nu, t rts-raucno •I R&CORD
Node Ca thn Depatamt of Environment aodNatural Resources- Dirvmon dWaa Quaky
WELL CONTRACTOR C RTMCsnONt? 3 3�s6
w caatraaa Oraoieati9 ware
5ah-w (A)Q \t Drtijl a;•>a
Wd Careralor !celerol awe , I
STREET ADDRESS 1 3 q N p,;/e-r,,.>r /2hd
t?��hbl Y11asc-77i
City aTam Stele Mc Cede
(.8:94-} 6/ 79 -Cii5 /
Area as Rhona t
2.wt3.LIFOPnATlOIt
SITE WELL D f aaai _)
STATE WELL PERMITS. antheld -
DWQ or OTHER PEW/TNTappirahk)
WELL USE (CheckAppiurhJ Do* Reodrril Water Swot!
DATE mum
To1E COmPLEIW a:D0 AMP PM
1 WES LOCATIOIF ry'l
CITY: r4 ko V11IB COUNTYGNY4K'.v.rN
WI et^ ( ck d
Oonneek .9iaea- .risCodoi-
TOPOGRAPHIC/LAID SEITOIM
osepe Malty OFlat 001Idge 0011wer
(dark pan at lla,
LATITUDE s�� , n'L//..4
LONGITUDE. sr_ yic'k3-Sr"
Latitude/longitude sow= AGPS cfropographic map
& cafoo d d mist M shwas an a IISGS two map and
adrJadMoak boa adasidpGPS)
4. WELL OwI@t /��
OWN82S NAME 0. intl rl)6 /� rne5
I ADDRESS _ Cn6LCnrl growl, 0,�,4
trite Mr at77�
City aTONI Sale Zip Code
((km )_7,� /--71Rh(
Area code - Plume saber
My Ix adepts;
vairaekatandscrt
ina axial Ewan
5. Val DETAILS: cf
a TOTAL OEPTIt 7C- )
b. DOES Val REPLACE MUTING WELL? VEND NOg
c WATER LEVEL De eacieeai Cr % LID FT -
(User" flame Top cif Casing)
d. TOP OF CAT NIS 7 - FT_ Above Land S.r®ar
Toth et cage tee i heddt►habwidaadiosaspnode
ava®memscadaraavialC C7Cdl%
e. YISD(gpe* / ETH000FTEST C. (•
327548
L DBRFT3CnottTypo H7�H Aame 5 o7
g. INTER Z —&p r
From NO O To 7D5 From To
Rao To Run
To
Fos To Rom To
& CAS9IG Thickened
Ras t) Two ?5 a 6 Dinner 40 t ight ZVV .
Won To Ft
Ram To Ft
7. GROUT: Dept Nataatel tlesaod
Flan h To "PC) Ft C f)l )1'r.0lrc
FoxeTo Ft l
Fos To Ft_
S. SCR®t Dada Diaaehe Slot See Material
Faro To Ft is d
Foos To FL it _ R
Fin To FL it la
9. SAIdORAVE.PACK:
Depth Slav HAe id
Rem • To FL
Fraal_To FL
Fas To R.
1e. DRILLING LOG
Fan To
II. REMARKS:
FameFame= Des rpeon
J
•
rn
1
ImnaayaitirraarcanaaLaaa-zaewie-®ursamoaaxaea
IMIC/CaGaaLmaiwCOORSIroaaayellIM CC.PMFTS
RBCaaaaee®nrpaa®TOI EelHLaaaaat
OFCl3iIF®MIBL =ACTOR WOE
PRM®NAIEOF PERSON oot6T�Ici
IRE WELL
Submit the original to the Division al Water Quality within 30 days. Ater Ibt—tlon Mgt,
1617 Meg Service Coiner —Raleigh, NC YTN9.1617 Phone No. [phone] nd 566.
Ran GTHI-la
Rea 7N5

,RFSIDENTL4L nu. c0#tsnucnoN RECORD
Noah Gramm D OtoEnvionmedandNa,ralReesonrce-Divbim�of Water
WELL CONTRACTOR CERTIFICATION f ?C.-6
aiLD
327549
CONTRACTOR
(,Jell ►ell\ hg
WelCOWMAN CootPmff Woo
STREET ADDRESS
/24-AcesQl IL rvt ` a4-nr
City orTore Stele rip Code
( } LI 79- gy69
Area code- Maenads
2 WELLNFCRWATIOlt
SITE WELL ID WIapp@aile)
STATE WELL PERMITIFapaorm)
DWQ or OTHER P6a/Tf(f/mini e)
WELL WE (ChertAppiatlaEke Re.HNir WSSaplysi
DATE DRILLED
/ 7- 04
TWE C0UPLETED
/a: OD ato Pllpl
3. WELL
CITY: 0 �!')Q7h irrvi "�
't'Gi try
Meet Nonatad.
/ LAHD SErmc
Dann Maim fVRi Abdo, Maher
men appgawkem)
LATTNDE _a_ g° aa'S/.p r•
LONGITUDES o �r 1 ' / a.a l'
Lalihdefiorgmdesew p(GPS °Topographic map
Ore m) afsal astto shaman USGStwo ®pend
ahedarbah tislaatasilp BPS)
aWELL OWNER �/
OWNER'S NA)E Erl e Kj-e6 /� nn
STREET Nat aflan 5 C!'L/o. 2r,c.C.e
ON-CSvi71e tie ,Q477/
(�yorTma 7r (With7/ Ip Code
-a 1-LIrJ+ ( !b
Area code- untie
tl9'be inamen.
eid^Nesdto
Ina derail `m
S. WELL DETAILS: r
a TOTAL DEPttt Jrc
d DOES Vat REPLACE EOSTfG 1rBl7 YES ND g'
c. WATER LEVEL BaraTpdCamber 6.5 FT.
(Usev- if Mom Top dCaailJ
d. TOP CIF CAMS IS 1 _ FT. Above Land Smfaor
_ 'Top claming aka: dbbaby Sod maim mlpwgie
vNomeaaoma_meiWA CAC2CM EL
a YIELD fount I Ti LtETNOor= co 7(`
L. DISINFECTIM Type 4-1-/j
a- WATER ZONES Napa* /
Fain 6cc ' To Ki S..5 From
From To From
From To Foom To
Tpi tnessl
Depth DiameterDiameterwh le< yip `tat
Ram I") To l u3 R A V4
d asot
To
To
Front To R
Front_To R
7. GROUT_ Dept i Weir Whorl
From n To 9O R_r 4-,e-A " 0.1x a...a
FromTo Ft �T
From To R
L SCREE* Dept Diameter Slot Dze efet rir
From To Ft in.
Flom To R k _ it.
Fine To FL
bl
be.
t SAtd6WWELPACK:
Dept Size ItAtetr
From ' To
FrN�To Ft.
Fawn To R
1e. Oi31Ra6 LOG
Fmn To Formation Demo(plion
1L REMARKS:
0
r T
C
rn
/10111311111“131WrilliffINIBIMELLVINSCOMMINCIEDIRACCOPEIMCEIMBH
ISA NOC2C3VELLCONSIIILIMISIMEIAIMS.Mai7117ACOP/ OFIIIS
,BONDISS®eNICY®WINE NNLCawEtt
/ 72s r - /7-0�
a9rmuntoF CERIFED WELL CONTRACTOR DATE
cc sd-r n ommw0-0 Sys
PRNTED NAVE OF PERSON WNSffaICiBG THE WELL
Submit the original to the Division of Water Quality within SO days. Atm: information Mgt.,
1617 MN Service Canter —Raleigh, NC 27689-1617 Phone No. [phone] ext 568.
Fam GIN -la
Rest DOS

1. WELL COIRRACIOIt
RiESIDEWTTAL wa .cowsnwawri =cow)
North Combo &proms JTEari aamadmodNtladNeam-DirtaTWar Q, ,
WELL CONTRACTOR CEEeTlrlcsjwttS d t a'D
fi
Was :ate LaaanalAparP
ra _n tyn t✓e // d r, //, r� o
Wd Calmar CotaroWoe Ot
STREET ADDRESS 63 / //OA ib/n RJ
Rnti%LlirtN ths Nc 2P77/
City aTotn Sire Dodo&
L 979- BAAV4'
Ponds Paaa number
SITE WELL DSpmosse
STATE WHLP9ICR,;e S
D WQ a OTHER FEgB S(S tppiahkj
VA31. Idest?naabb&Kt P_LI 4WSrSao*II
CATEOR rIO s-y -04
TaN COMPLETED 3:3o man FM®
taEtlt,OFJGt�p�It I
c TV I[ab h;rl fL'-' a cowry Gr -LO J+!
7Thart rl hre. n-A r9*_27/
centtfaa6.lai cemassaassara Lama a. aLbe.} ..-,
TOPOGRAPW ICtIA1DEETTN6e
oav+e May oFra asp Koss
LOs tipodioleq
LA BTUGE 3sr �011/7r••
LalornlaEt 3e . ,3or S"
lauoddlaetde as nt MOPS olbpavwd ie es4
Ma--dtslltadla Staama LAi6Slpoasp sod
aDslWa 6itIan&sksOw
itallosER
owlets NAME a/4n En m.n-
STREETADOPE= %sl Aare- es A rn nrh
Ro J-.h;rzsioWd, IV,* 771
City or Toth SeY Zip COI
Mayte kites.
Ya�riar teattt
1-
Ara code- Phone eat
tWELL D TAa$
a torn tame Gfl,s
b. DDEB WELLIELALE EUSTIMD WELT YES° NOW
=TERLEVEL 0 nT•pdClay /aO FT.
(IMwitat rTtpdC
d TOP OF CASINGS / . FtA6aoLad Seder
- 'Taper cadre etaalsaiawlndMsbennask
aarea lariereat 1511? CRC tO Alit
a. YLane y ■ETNOOOFIEST Q
327551
t 0I8111FBCTIOItTypa %%TW Arns* Q`,_ oz
Fan l a r, To LOd'
Rat_
Rom To
�cAST03:
Fan To
Ran____To
From__ To
Taros,/
Depth OSm. WES MraLI
Fin n :re Al Ft L,1 Snr ! pvc
Fan To R. 4
Frown To Ft
7. GROUT: MOM Mon
Raa_Q_TO ` _ F!, rNMPnT
Fat_To Ft
Esuar2;
Awe__ To R.
t SCREW Oat Ma ar SIBS MOM
For To Ft, it tb
Fla To Ft, K _ K
From Te FC, r. h
t M LPACSO
Dae Sea Haab
F oL__To FL
FaL_Tq__9.
tt vnam LOG
From To Faa_onDea_Ip_on
tL RINIARKS:
CO
0
IDDea stain taco_ 3_ smsDMIEDIaotada[wnr
mhMaC7C.e®.LODtiaACODDIUMI IDO DIHEACC raraW
IECDn)Ite a@/r/Ratatm W TM anL Olaet
SICNKNaEOFCHtIiitDWBLCOtciMCrOR DATE
'T 4 1v
PRIMED NONE e50IWISTRICIN6THE Wm.
m
cD
TX
*n
D 0
-4--
c,r1
cr
r
Eahaaf the original to the Division of Water Quality within 30 dam at niata eaon WO
1617IlilSark* Cooly -Raleigh. NCVVW-tm PhwnlMo.OM) 7S1-7015mita.
Pas GW-ls
Rot 7A6

RESIDENTIAL WELL CONSTRUCTION RECORD
North Camfw Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION R Da SQ
1. WELL CONTRACTOR:
;;: A&
Wel Guarantor pompous, Name
62ra.%Tam LAIN/ oar,%/e
Wd Ca4ator Company Name
STREET ADDRESS o J4i #7107;t✓n RBI
R4hbinsv,Y/e He .2.877/
City or Town State 2p Cafe
L179-9-4/6171
Area code- Phase number
2 W914FORIlATIOtt
SITE WELL ID e(aapp urale)
STATE WELL rnauT/RIanginas)
DWQ or OTHER PERWT i(d alatthr hle)
WELL USE (Check Applicable Sae Ras7dedrl Water Sappy tat
DATE DRILLED rS /Q-o6
TIME COMPLETED 9,'3(J AM PM (Q
i WELL LOCLOCATIONIIO
CITY: Rnhb[')75 de %/e COUNTY t rr( /n
TijnCro ragca.ne-J 2St771
(Street Name, timbers.alANo.. Panora. Ws Code) -
TOPOGRAPHIC /LAND SETTING:
OSbpe OValey ORat NJ Ridge Daher
(rust eppnpia-bmd
LATrnii€ s £° P3 '111 r) a
writ/rumFL a3° 3a'/�, 6"
Latimddlongihdd so rca ❑GPS OTopographic map
(location Maul I mat be shown an a USGS lupe snap aid
agr/od b leis form Ind rapt GAS)
4. WELLOYMc gel
OWNERS WANE h`aralrl o neinutt.1S
STREET ADDRESS tilacnn hr1a.nrA
0lei %ins a/Wet' /✓e Df77/
City or Tarn Sbte 2p Code
1-179-1
May le in drgss,
nines, seconds a
in decimal foot
Area code - Phan number
5. WSJ- DETAIS:
a. TOTAL OEPTEt
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOM
c. WATER LEVEL Below Tap of Casing n FT.
(Use‘4' *AhweTop of Casing)
d. TOP OF CASING I6 1 . FT. Abaa Lad Surber
'Tap of cathg Em.edSur baba lard surface aw rapier
a vansie it azadarmaan 15A NCAC 2C .0110.
a YIELD (gm* h METHOD OF TEST (A,t
CUPID
327552
f. DISRFECTIOtt Type ()
g. WATER ZOIES (depth)
From_ � To 0)
Fran To
Fnni To
Fran
From
Fran
Amount n
To
To
To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To lac Ft 64 5nr2i J%VG
From To Ft
From To Ft
7. GROUT: Depth Material Medod
From A ToQ_ Ft (.efna r1r -211221p4
From To Ft.
From To FL
It SCREE* Depth Diameter Slot Slim Material
Ran To Ft. in n.
Fom To Ft in. _ M.
Rom To Ft. 6t in.
9. SANINGRAva PACK:
Depth Size Material
From • To Ft.
From To Ft
Fiore To Ft
10. DRILLING LOG
Flom To Formation Daaipfion
11. REMARKS:
0
0
0
WAN T be gyao. raT/ro
Ian HEREBY C9rrFYTNTTaaWELL WAS CCNa1a1CIEDaPCCCrD Ja tam
15A HOC2C. WELL commons STM A be. /db1a1TACtlM CFTC
RECORD WS BEEN Ranlrp®TOTE WELL LL OWNER.
c /C) tea
SIGNATURE OF Vial. CONTRACTOR DATE
J p AQ
MINTED NAME OF CONSTRUCTING THE WELL
1
Submit the original to the Division of Water Quality within 30 days. Attn: InfonnaOon Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Finn GW-la
Rev. 7/05

RESIDENTIAL ww. COtnucnori RECORD
North CaaraOtaortmeat olTartionmed ad Natal Rooms- Ohbbt af Wun Quad
WELL COTRACTORC'LIIFICATION
rQn (co
327553
1. WELL CONIRNC,TOlt
w 6Swae
�ro,ham OM! drs'J//n
wsConia or Os ie vin
STREET ADDRESS �0 W ,',Lsj, tin RC[
Rnii%i nSyi/al Air p 77/
City aloft Slat /*Code
I92Srm- W79- $'QQS'/
Arm fl Wars ante
7_ WELL OVORrATLOW
SITE wai D alrapsdnH
STATE WRL pslTflaptaeatcy
DWQtrOTHER PER.. *PI tpph j
WQLUSE fChi t/paka bGa8 Radeteaa Wsbattl oYf8
DATE on= .- /a-46c
Ti aNbP.ET® l/;ir ALLk wo
3. WELL LOCATIpat
art Polak ntj/ilb OOUNTY_Sr! A ,
Poky zhp r CreAK as-77 /
Paw oat., orm os. lei>lathe. watt apas}
TOMO:W MfLAND WITINEt
Mbar Mai MN tondo Does
*Me warble kid
LATTnSE 35a fl 47.41',
LONG ax.2_er 37'3y 9"
Lalituleilanginde Fount •OPS DTuPoptplicabap
tAcalett ofaadsat Is dace m d WAS kg* awn'
icdadteRiok /ndabafpNW
Nay In bean
aYoetasaba
imaam.' iota
4. WELLOIR@t
011011305NAM %rp1/y anckrews
slaw ACERB= elviT}t.or rr,oel
Rn,b-)insv,l/e Nt. 'aS477/
t.p� City cmTan Salo ZOCab
Am tab- Pharr umb go �f7/
5.WELLOEP.1Mb �J
a TOTAL -OEM* 130
b. WEENIES REPLACE E OME&WBi? T66D NOto
c. WATER LE fl.8t oTopdcathtc / 22 FT.
Nas^a"FAss Tiveros bye
d. TOPOFCALNNta / _ FT. Nay tad Salatr
• epnda baaduwaaa 161LM NCAC a
a YIELD bpi* NEn0oniw CA, / r
1. DISP EcrtoltTypo /7/7--/ Annan /Y at
g WATER zees max
F n, n To c3o ffRan To
To Face To
Rem To Far To
&
ThianpW
Fn1 n To /2a Ft, r CCirtiI PVet
Rao To Ft,
Fran To FL
7. MOM Oast awed NOW
Raq 0 Tq ,2ri FL (*torn earn" lOr/mplir
Fosti____To R
Am To li
io011133t Dope n__a_ Oa Site aaaa-r
Faro To_ FL Ic. h
Fm Te Ft b. _ h
Form To Ft_____k as
1. SANsaWWBPAdC
Dept Stew Redd
Flan To____R.
Ran To R
RasL_To Ft_„__
IL MOIRE LOG
Rai To
IL REMARKS:
Fenton Dereplon
c
C
a..
T iN
C?
C%
sonearrawarrunrussamteseaseactolucasomeavani
draloae'X.aattiana taCiMatsltosta moo>a rocs raja
tlCaYaaa4Yartaaradp7sLlpaaata,Bt
Tti4F ria .S /2_n4
SIGNATURE OF WEILCONTRACTO( DATE
V FT 1 rP
PRIMED N1hE y9160N CAIaTRUCT.c THE WED.
1 7Li1 Sabah
Il i.ctService aCeathe se Division of Water Quayvtlhln all days. Attic bdaamttma (sat.,
H. NC 276*1617 Phone No. (0114 733-701 6 ant St
Fan IIYV.1a
Rea 7As

RESIDENTIAL WELL CONSIRUCITON RECORD
Noah Guerra Department ofEnvioement and Narral Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # (CO
1. WELL CONTRACTOR:
c-roP-A- de
W/ef+Contractor Name
t,✓e// cir: ll :rig
Well Contractor company Naa {�
STR/E�ET ADDRESS A31/ " , # 77tr n R
/Crk
a hhi'vlsv,iid /VC e2 '77/
City or Tam Stake rip Code
1179 - S<N.(N
Area tale- Phan number
2. WELLHFORMATIOtt
SITE WELL ID Alt aR6table)
STATE WELL PBOMTiNalw n)_
DWQ or OTHER PERMTT4Cd appimhle)
WELL USE (CherkAppiolb Bask Residual, Wader Sup* 2
DATEDRI rED S-/G-•estf
Time cum temp 7: on AM ❑ meg
3. WEL LOCATIONt CITY: Ro6L; VIC If/WA COUNTY (;noirvin I
Pam 7-h,r r reek as, 77/
Meet Name. leathers. Cmaeoaa-Sb6idao.a Para 24 CedeF
TOPOGRAPHIC / LAND SETTING:
OSlam OVel ' OFIN MSS Oahe
Meek appropiarebad LATITUDE is S 0.7 rent. u T'r
LONGUu0El 3° 37 '32./"
tsliaddkaagivaicSotto ®GPS OTOpoglaphlcniaa
( Cell of sal oral be short on a USGS apo map and
aaahed b 166 fat Ind mug GPS)
4. WELL CURER II,,
OWNERS WANE (�l �/C YI O 2 Hna-T
s} �tamer ADDRESS Pis vs 'rho r Crepk
T / n 7tAVi it° IV!, 25i'771
City or Tam Stale 2p Code
(�(�$-).L/74- ayo7
Area code - Phone number
May a in degrees.
minutes, mmdra
a a deml fount
5. W13L OETAIS: -f J
a. TOTAL DEPnt 70.
b. DOES WE.. REPLACE EXISTING WELL? YES❑ NOM
c. WATER LEVEL BebaTop ofCaaiE n FT.
(Uses" 1AbamTop d Cad%)
d. TOP OF CASING E / FT. Above Laad Surface*
Tap of snag tandmairt gar below Ned statemay regale
a wane in amens ma 15A NCAC 2C A11t
e. YIELD(gplak /5 METHOD OF TEST r'wi r
327554
f. O1SIPFECTIOIt Type Q Amount fl
g. WATER ZONES (depth)
Fran (i To re Fran To
From To From To
From To From To
6. CASING: Tt* nts&r
Depth DiaLne We6N
Fran n To y(f Ftf a SOni T/r.
Fran To Ft
Fran To Ft
7. GROUT: Depth Material
Flom To Ft
Fran To Ft.
Fnm To FL
Method
a SCREEN Depth Daneter Slot She Material
Fran To Ft. m. in.
From To Ft a _ R
Fran To Ft. in. in.
A SANDIGRAVB- PACK:
Depth Size Material
Fawn . To FL
Fran To FL
Rom To Ft
10. DRILLING LOG
From To Formation
11. REMARKS:
e -:
1 pCI
Co rr ir!
o �r
tr.
_LA)/U7/ Yo O,° Nyei /C,Turto
I 0011211ESTSCrIEInFY1WITTNBW61WASCOa AIM TAT
ACCamDW NMM
ISAaC/C2C, WELL COMIRU:O11 SW. AID TATACCPt OF1MS
RECORD INS MEI PROVDEDTOTE WELL Ow16L
SIGNATURE OF WBL CONTRACTOR DATE
PRINTED J,h AI ONPCOlISTIiIICING
NAME OF TIE WEU.
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 GWla
Rev. 71O5