He CY2006

RESIDENTIAL WEu, CON SIRU'CT IO'' RECORD
North Carolina Dcpartmcnl of Environment and Nature) Kcwsrc.cr Dt.!,l..a ,a a *ICI (Bann
WELL CONTRACTOR CERTIFICATION N 257'
1. WELL CONTRACTOR
Bryant Smtn
Wed Cunene. (Inon+Ouaf Naar
Green Einar WWI & Pump Company
Wei Catnap, Convsny tarns
STREET ADDRESS PO Boa 204
East Flat Roca. NC 26725
City or Town Sara Zip Coda
( 826 ). 593.1200
Ain cede Phone nur Cw
2. WELL INFORMATION'.
SITE WELL ID WO alwwowl y�[
STATE WELL PERMITaul ap0eaa oal 051 CO//54 "'f�7
DWG or OTHER PERMIT WI sppacaaa)
WELL USE (Cn.ca AD Raman' c.bM Boat RamM' W.tw Supply
Q
DATE DFULLE0 - r 3 / 0 to
TIME COMPLETED 1 I ' O<) AM g PM
3 WELL LOCATION:
Sa(LA.C4
CRY
COUNTY 44L4ndikSall
I t D LAi14 S Lake (31 ud
(Worn Name. Numbers Community SuCawaan Lot No Pato& Zip Code)
TOPOGRAPHIC) LAND SETTING
OSiop• OVSMy 0F1n De. OOa.w
(Chia •PCWOO rr 00a)
LATITUDE .15°_L51
LONGITUDE L220,72/ 3a.43
LautLadeAongludc SOIPCC &3PS OTopogtaphlc nap
(bo•lgn d wd must W anown on a USGS repo map sod
•IlacMd to at. loan /not sang CPS)
M.y too w o.pm,
miwwa. mode a
.. dccmal formal
4. WELL OWNER T OM/� I . /
OWNER'S NAME ' De LXEY-1 1�(1�� Wilt
&DA ny
STREET ADDRESS l l0 Ea St WGL1 tek Sf}'eet
cq St -Flat ZOCICIIAI( -24519---
Csy a Town Sas Zip Code
(ice ). (09to-5(cas
Ares md• - Phorr nufDw
6. WELL DETAILS:
a. TOTAL DEPTH: 505
• DOES WELL REPLACE EXISTING WELL? YES O NO p'
c. WATER LEVEL BWo.Y Top of Catania FT
(Up,•'•' I Kea Top d Caarg)
a. TOP OF CASINO IS 1 FT. Apov. Land Surface
`Top d canny terminated Woo Debt. and auA.ca rimy require
• wawa n aoay gno• vain ISA NCAC 2C .0118
• YIELD town) c10 -- METHOD OF TEST Am
1. DISINFECTION. Type man
cL WATER ZZONE S oepin ,
From '90 To `I5C
From
From
Amount
From
From To
To From To
5. CASINO TN.canny
D•po Dar Rrer Vvvoni
/ ll
From To /.t7 Ft _Lit-6L..—
From I _ Ft
From 10 FI
7. GROUT aptn M.tenal�L
From 0 To 3 Ft S/Pkiw7K
Fran 3 T. _ Ft J9,,Jt.1,M
Fran To FI
8. SCREEN
From
From
From
lei pi
./cam
mehoo
/Mc a Ast
Doom Dsnrtm Slot Sun
to Ft n
To Ft n n
To Ft in n
9. SANDn:RAVEL PACK
aptn
From
From
From
10. DRILLING LOG
From To
O - 20
20 ' go
To FI
To FI
To Ft
-/1v
/iv -) Or
Maroon
S¢e Material
11. REMARKS
m
*+1
tmC
fl
!DO
MEREST
]C CELL CO.STNLCTO. STANDARDS AND MDT A E:f➢• CE rw6E wit
RECORD RAS BEER ARCNOE D ' E w E.E.(./. Ow RE R
SIGNATUR OF CERttFIED WELL CONTRACTOR
PRINTE
DATE
AME OF PERSON CONSTRUCTING THE WELL
submit
original
Waterw11days. Eta eon MaL.
11ail a Center Raleigh. NC 26996117Phone No(91733-7015 a568
Dim GW
H I/D5

r n
t
WILL CONSTRUCTION RECORD
8!
North Caulks -D s1oentofBawhemednod Resew*-, . ofWater Quallty-chtsmdneerSection
wIa.CONrwACTOt(mmnmuAL) 7` r I, 2 cnnussornow • Z 7 a ./
WELL CO.rRACT0000MPANY meat s 1.521A/5/9-09" )
flat vita CONf itHcst NMIMS AMOCUTROWQ
reikeble) d
WELL 0feasiiesbi
1. USE (PeaApplha6ie BunO: RMideslhtl 13/ Mmicipettebbc o ___ D Apicultund 0
Masitoring 0 Recovery 0 Eat Nap Wetter h jection 0 Other 0 If OOmr, Litt the
2. WELL LOCA,
Newest J,'//rccsy e
lC% d/sl jinn[ nu, /4 1
Wins Nus,NwekegCat orestLett. 74CMS)
3. ownaR:9044Y h'e z/9/'U
Address od iMW /in,Pedaw..0 IIO
plus NOW, a)
/Ali c �v tT, �r 121 '!1 N1. 75 792
ag•ctsus ass WipCds
Aasair Its ar4 _
4. DATE DRILLED /3 '0 6
3. TOTAL DEPTH:
6. DOES WELL REPLACE EXIStlNo WELL? YES O NO
7. STATIC WATER LEVEL BakwTop Basin&.,, ,FT.
a. TOP OF CASINO is /0J Ff. Above Lad sar4kes
"Rs erriterwwrA ee4r bin Si she nods a
welnrY sSISAMAMAS*
9. YIELD (w®a •_ METHOD OF TEST // into./
10. WATER ZONES (depth):
Topolpiptiotanci setting
CIRidpMope rn alley, ovler
(ebrkgsapdeataa)
Iatl4d.Jogplade dwell location
Ia4HaggS4 soinC/OlsOr tladapoptgphic map
(en kea)
Front To Pacrosei�m Duce_
11, DISINFECTION: Type CChi Minn /O o
I2 CASINO: ( / WeVid =
Prom /�'/ To die Pt I 7`%
Paow __To Fc
Prom__ _ To Fc
13. GROUT: a, bkmtY
Prot Or To 2) Pt. a e )yje l
PreaL_The Ft
14. SCREEN:_, Depth Dineen slur Sae Monk!
Proeq—S. Pt,�jR deer
From_ To_ Pt._)e. in.
15. SANDGRAVELFAC
� ,�1� Depth Sin MerinM.w
rroa. _�To Pt.
Pront__To Pt
LwJ
too'
Show direction and Enos in mike how st Meat
two state Roads or County Reeds. Include the rood
ambers ad common road Ines.
16. REMARKS:
I DO N111UBSYC ERTIPYSHATTIBt WR1L WAS
STANDARDS, AND A
44
a.. 1�
:♦S
• • • WITH I SA NCAC 2C, WELL
HAS BEEN PRi7VMED TOTES WELL DWNER
a
SIONA7iIREOFPERSON • • • THE Vila DATE
i
Sedtdt theoriginal is the Divides Mt Weser Qgalig.Greadwder Section, 1636MallService Color - NC
27410401Pbaatt.(110)Man, within 33days OW-1 REV. 07/2001

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1 636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
9 9 ri n
•3 0 -V 0 f
J
I. WELL USE (Check Applicable Box): ® Residential 0 Municipal U Industrial ❑ Agricultural U Monitoring
0 Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WET T LOCATION: (Show sketch of the location below)
Nearest Town: HENDERSONVILLE County: REND
1380 OLD DANA RD. DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER LINDA BANKS
Address 1380 OLD DANA RD.
(Street or Route No.)
HENDERSONVILLE NC 28739
City or Ton State Zip Code
4. DATE DRILLED 08/23/06
5. TOTAL DEPTH 305
6. CUTTING COI.T.FC:IhD ❑ YES NO
7. DOES WELL REPLACE EXISTING WELL? ® YES 0 NO
8. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 IT. Above Land Surface`
*Top of casing terminated atlor below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10 YIELD (gpm): 50 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 7.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 105 Ft. 6-1/4" SDR.21 PVC
From To Ft
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
From _ To Ft in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft. _
From To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #26 W. FROM COLUMBUS. RT. ON EXIT 49 A (BAT
CAVE EXIT). RT. ON SUGARLOAF RD. RT. ON HOWARD
GAP RD. LEFT ON OLD DANA RD. CROSS BRIDGE. GRAY
HOSUE ON RT.
cn
rn
1
0
m
I DO CERTIFY THAT THIS WFJ.I WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WFI.1
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE N CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ►AA Residential 0 Municipal 0 Industrial ❑ Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection 0 Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the Location below)
Nearest Town: HENDERSONVILLE County: REND
33 CORLIN DR DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER MIKE ROBERTS
Address 33 CORLIN DR
(Street or Route No.)
HENDERSONVILLE NC 28792
City or Town State Zip Code
4. DATE DRILLED 08/08/06
5. TOTAL DEPTH 205
6. CUTTING COLLELTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 10 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 20 Ft. 6-1/4" SDR2I PVC
From To Ft. _
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 FL QUILKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From _ To Ft. in. in_
From To Ft. in. in
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From _ To Ft.
17. REMARKS:
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #26 W. FROM COLUMBUS. EXIT #53. LEFT ON
UPWARD RD. TURNS INTO N. HIGHLAND LAKE RD. LEFT (
DEAD END ON GREENVILLE HWY. RT. ON LITTLE RIVER
RD. 3.8 MILES. LEFT ON BEREA CHRUCH RD. LEFT ON
HOLIDAY DR ERT. ON CORLIN DR 1ST GATE ON LEFT.
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNATURE OF N CONSTRUCTING THE WELL DATE
Sulitufit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/95

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 —Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: HENDERSONVILLE County: REND
OWENSBY RD. (LOT #9) DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER CABIN DREAM HOMES
Address OWENSBY RD. LOT #9
(Street or Route No.)
HENDERSONVILLE NC 28739
City or Town State Zip Code
4. DATE DRILLED 08/22/06
5. TOTAL DEPTH 305
6. CUTTING COLLECTED ❑ YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Caging: 80 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 1SANCAC 2C.0118
10 YIELD (gpm): 6 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount 7.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 55 Ft 6-1/4" SDR21 PVC
From To Ft
From To Ft
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft
15. SCREEN:
Depth
From _ To
From To
From To
16. SAND?GRAVEL
Depth
From _ To_
From _ To_
17. REMARKS:
Diameter Slot Size Material
Ft in. in.
Ft. in._ in.
Ft is is
PACK:
Size Material
Ft
Ft.
If additional space is needed use back of form
LOCATION SKETCH
• (Show direction and distance from at least two State
Roads, or other reference points)
HWY. #26 W. FROM COLUMBUS. RT. ON EXIT 49 A (BAT
CAVE EXIT). RT. ON SUGARLOAF RD, RT. ON BLUE HOUSE
RD. GO TO DEAD END & LEFT ON RIDGE RD. RT. ON
OWENSBY RD. LOG HOUSE ON LEFT.
Co,
rrl
-t
tV
0
m
I DO CERTIFY THAT THIS WELL WAS CONSTRUE 1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
SIGNA OF O" CONS UCTINe 1 WELT DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99
rr

Nabs es Depamst lbalmmet end NOBS Has -atw.aMar o.w-Oma Oman Sot
1001 Sent* PISS N.Q12v1150-0150as w MI5 Mal
WELL CONSTRUCTION RECORD wa s i-30mo s' (barZ /cr
wou.00irmAa tce.r ATaowr. o)//3
iMTE wtaLOO,MTRUERIOa PERIMh
1. VMS usr 1.110beve ROSS'S� Mai+*e1 CILwMYUs D frownD Mselosrq
Rseo.ay0AHat Pimp wasrr nD Ober D VObrl,LMUse
2. was. t.00A M the sleds e boAew bibw)
missTam: e.1.deR5ll;Lail t on-': Alle27/.ierelon
pbseNa. sawrrl.rte NYDIEt,S10 1D0 BEM
a. OMNI C/r.Yr� D Zet Fa n w�.M.o�r�.
Addis / s— gig. , rani O� - 6Gl./7C�f i�l
r 7 , ;.: J l raf7 /fC
A ir're .�r 2?75i2- a4-�6,7) •gref
areas el
eYle3pCeb
4. OATEORIIIED�r '-Sv(- �/'�ri��!
5. TOM. DEPTH
s. CUTIINis CCUJCTeo YESQ
7. DOES WELL REPLACE Ekaslsls WEtL7 TES 0 icc
& STATIC WATetLEVEL 'lbw Top 0Ces w FT.
µe•• wR IAipelDube
P . TOP OF CAMNO 111 / FT. Pas Land SlrYer
elm M•emYmeariamWow hat aim muds e.r- YSwF
10. YIELD 1 rETIIODOFTEST
11. WATER 2OIs!S:- *par
12. CIAOIWATION• Typo Armed Isd-Nelspa nordtlenSEE bsm
12. CASINt
Dods d olwr1rrn ple.Eal.amM.rereeal..rsae
FEN / To VFL /c' C :drde•arsrrmep._I___ ores)
To FL --
Flan Ts Ft
14. GROUT: �) z
/ Depth
Fmm
Meade Mescal
To et O R og1//r i
From To FL
15. SCRIM
Dpls atrnsL Sol Uzi SAWS
Ram _To _ b. In.
From _ To Ft._ In. In.
Rom _To_R._ rs M.
111. SAND/GRAVEL PACK
Ds* Slew Meld
From To PI -
From To R.
17. t*M RICK
w ,
-lam • F
x14
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CON0110)Cnn011STANDARD& NED THAT A COPY M
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FOR OFRBE UEE OWiA -2. v-o
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WELL CONSTRUCTION RECORD WELL CCINTRACTOR: C &z r nit/ l
R WELL CoNnat ow CeE7CAT10N d: //3
MAU NULCONGIRUDTKIN PERMIT
1. MU. Ulikerst Appeal, mom RimMorw' Jd asked o wr-w0 AprIrw.s0 tworno0
Raao.ayCIO Hal Pomp wenIrprelo^0 Other CI NORM LMtMr
a WELL sholeh wra
re,"Illanollteon aRsa)cmine� /1enintrDn
~
!L
d.
7.
1.
MI
DATE ° ED - �� pis �C
TOTAL DEPTH
curnNOs COLLECTED YESD P101 tan(
DOER WELL REPLACE warm WELL? vas O
STATIC WATER LEVEL s.Yr. Top otOmerEY wane De WEDS
FT.
s. TOP OFCASINO IS / FT. Mows la Cuhoa"
'Top of sly Mdn.Yd aarr balm kw/ aim w!~aavote Maa.ar.
dmaaoM/MNCAClOAttN
10. YIELD (opo): 1 rMETHOD OFYERT g/r,
11 WATER ZONES (dops*
Pod Ns Ds* Nay OM.LSIO LOS
OWNER gill MOO re To
Add/ » /00 imsfrari!.a�� tfaw.4s "emir
Month- /Uc .2R7O2 / S! /. r
DV gas Deb Z►OMr
DEPTH
?tan/ ;v
rfreencc
rek.en
1zCFLOIW4ATICN: Typo Amount /sand spore bneeded um, be* dbon
13. CAsseO:
Dolph
Rom 1 .Jar
Fam To
Fare To
14. GROUT:
Rom / To a FrD
From To
14. SCRIM
Depth
r.rlur n LflCA1 ORagan
piny gals Mei.�n,1� ��0ridrraril MS Ins Soo ea
FL V'7' (o[lc or Ser asprei OM)
R
WSW R Moiled
R
Dims* Woe "Ith
From _To_ Fr_ In. _
Rom -_To_FL_ In.
Frw _To_R_ let
10 RAND GRAVEL PACK
Doplh Sao
Ran To Ft
Rom To R
17. REMARK&
MSS
In.In.asas
fn.
Li 1
Kt-T 3
0
100tans cosy TWIT na WILL WAS OOraia1Craoet A00011W NKE nm is so 110.144.
CONSTRUCTOR 'INtMDTHATAOO OFTI� D YI{�PROV�TI 7OEWELL OMER.
FOR OFR= WI ONLY rf �d ii -23 —O G
onntin
DONATUNEOFFENPONICIONIRMIXMODINE flt aas
OAS SOW rarYrnradeDidtsw.d.NnESA ell a das
OM NEV. noa

o • '
Address Sa PX j _ 05
wrrvk1T
City or Town aaN-1
sale Zip Code
4. DATE DRILLED-DI-04
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Q NO
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO' '
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS ' (Use if Above Top of Casing)
FT. Above Land Surface'
?op of using terminated atior below land surface requires a variance In accor-
dance with 15A NCAC 2C .0112 f1
10. YIELD (gpm): ) at METHOD OF TEST P-
11. WATER ZONES (depth)-
1©3 - y4q
4UG - 4SZ)
45n - Sec
North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone] ,,, - .,� �,,
WELL CONSTRUCTION RECORD WELL CONTRACTOR• l /1 u S
WELL CONTRACTOR CERTIFICATION it: c—) 113
STATE WELL CONSTRUCTION PERMIT#:
tI }: t) ! 6
1. WELL USE (check Applicable Box): ResidentiaiD Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑ Recovery Heat Purnp Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCAT
Nearest Town:
: (Show sketch of the
QN ecconvi �bcallon below)
t�y1(l County:PYY1 Qi'SO(l
(Road Name end Moroen, CommuNty, or Subdivision and Lot No.) DRILLING LOG DEPTH
OWNER ern From 7o FonnatirDa peer
12. CHLORINATION: Type Amount If additional space is needed use back of form
13. CASING:
Wak Titaness LOCATION SKETCH
FromDepth
To Ft. (Dierr or Weight/FL Matenai . C (Show direction and distance from at least two State
'1 Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
From D� M,�atterriia�' Method
To C.) Ft (aQ ri f 1K? '�
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From _ To _ Ft. _ in. _ in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
�INU7'"41 GPI1-
rci Fairview
1-1-t0 E
1 DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Cued No:
TORE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12199
Song No.

WELL CONSTROCTION RECORD
North Carotna-Dope s of Eaviras000tsad
MIL CONTRACTOR( OWINDAL)rWe�
WUL CONI'RAC70RCOMPANY C
STATIC WILL OOteTIUCTIOn NUM
(K"gable)
1. WELL USE (Cheek Applicable Hoek Aaideriel DNreiolpSUPublic O Lewin O Ap iaWol 0
Monitoring 0 Recovery O Hest Plump water chop 0 Other if Other, List Use
333531
Ramose - Di ' ' of Wit Qua Quality - Oreemdwater Section
7 c KIic� a' S Sf csmvtcATdorr s 2 72 `/
NNaasWP W WP/f 9 1,4�vs/t9 now d(3286L79-c'/n0
AMOCATID WQ rflaaTs
Of aawfwe k)
.4
2. WELLLOCATINewest T • / tt 4
13o of �s,. / crr f 2$793
(arm Na Naha Caw* Mita Leak, No Cede)
3. OWNER: f20-P If>i' ,a#fin/
Address Lk, oid ra,%/ NV? RI
/1/2/2 i o Gatee itiz 2179 3
Cipaatax Lev ZipOub
�ai►Aeaoaaer
r.
4 DATE DRILLED _ -v 6
5. TOTAL DEFOE: _2. S
6. DOES WELL REPLACE mania WELL? YES ONO 0--
7. STATIC WATER LEVEL Rdaw Top Coins / Z FT.
(lis "er Ab a► reSatCded
S. TOP OF CASINO IS / 6 PT. Above Lad Sallee•
torofcoy assise.aaraata.1st saMa.yreeea /
.rinaIELD ere : 2- 1/037110D1A 9118. TEST %/ it-e r"A
9. YIELD So):
10. WATER ZONES (dope:
11. DJSDGEC I ION: Typo (• C. 4' Amaral / a
1Z CASING: Well 'adobes
Pmg_To 30 FL /C%H Dfairpr at
Prom To FL
From_ To. 14
13. OROt1f• Dept ., Merodefir WOW
_To m. nook/F/Y WF'1 /h//
Pros` To Pt._
14. SCREEN: Daps Dwrbr Slaw Medal
Proot._ To Pt,_ie. in
Prang_ To Pt m. in.
15. SAN IVORAVEL. PACK:
Dept Sias 1Utrial
Pn a _Ter— Ft.
From To PL
16. REIMERS:
1DOBMW CRRTRTYTHAT THIS WEL WAS
CONSIRUC170N AND THAT
e` PERSON
T
ORS.ORbriny. Malley Mkt
(aesiaAegaYrsbon)
Ltifadoilmgitude of well location
(Ypal inhmaib)
Ladwe •agipds soavtO(l?SQTapopyrhie amp
(dock bee
J1BTt T r1V: T
now To Formation Description
Bpi
LaGtaXaggagi
Show &edict and dins* is runes from at Inc
two Stab Roods or County Roads. include the rood
swiss sod coRsars rood ass.
L
ACCORDA1C W11115A NC1C 2C, WELL
DEI ll PROVIDED TO TIM WELLOW!ffit
Saba Ms *Opal to iM Didion of Wt/ae Quallly,Gnendwider Sadism, M06 MSS Santee Omer - RaMlply NC
27490.464 ass No. POI 73l3 21.1rltldR30dsys. OW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
Noah Carolina -DeStselmeet ofBmhosuntInd Naomi Resourcesr/ - Division of Warr Quality - Oronsdwaex Section
C CONTRACTOR MOIVIlOAy Rad Fri G KL Gees CirrincoTIDM s'27'4i
WELL COnrnACrOaCCOunnv NAME �aNee wAiet iv e6/ 4/ Lint note s gm6`19 -c,L/ECi
ITATi WILL CONtTRUCW ON Pr.AaOc3Ati0 WQ tUM
(N.oa)iosbld
"n3N
1. WELL USE (Omit Applicable Book Reiddeetial O lic 0 hard a Appeal 0
LL_1L d.R O Recovery 0 Hat Pomp Water lgadiao n Other 0 If OthQ, List Use
2. WELL LOCATI r / _/
N17 Csmy%Ye/X /..3 �
/76 pik, r r C R f 2S 79 J
(Wow W.e.r■ .CMS*ailalikaLeitio..2 Cods)
3. OWNat 79,"e 5 9)4z # udn
Address l74. /yvn,e, ..1[r. cbt,rI,, la
(r k.teelit)
i3a'e v�4/' c� p 271,
t7yor Tess am a►Cidr
Maui
4. DATs DRILLED 7-21-C'6
5. TOTAL ran* 2 Y
6. DOES WELL !MACE MISTING WELL? YES O NO B--
7. STATIC WATER LEVEL Below Top otCrieg 25 PT.
w'
4, (drVMoatgC add. -
S. TOP OF CASING IS /6 Fr Above Land Sot*ee•
"Top Mae. owwYOm - nMr nerweass NOW nines ■
rnhartsnowirmswW ISA NCACteAIM
9. YIELD (sok `_ METHOD OF TEST 1 ii'-t e
10. WATER ZONES (deplhk
11. D13INPBCf1ON: T c CC /5l _ Amount l0 o z
12. CASING: Wan tidbits'
111/4"1-4—TDeplh PL ni�eer t. Son
Pr _ __ To Ft.
FrOM _To Pt`
13. tiROUT: Dept
Frote` To 7/) FLS SIC/C y
PIM To P1.
14. aDep6 Dies Slot Sin laid
To FL Jo,is
PromL_To FL_h. in.
15. SAND/GRAVEL PAC]C
Depth Sae eel
Pr;lgli To P1.
Pane Te P1.
T Land setting� � ovalley ORS
(obetswipe ken)
Latt ddiae0imde amen location
Lelydell eyieede( searoe:OGPSCITcpograpbc map
(ts tea)
j1RII !Min Ur
From To Poteuntia l Description
DEEM
F
IigATI4L IMICH
Show dmea4en sod diatoms in Sias from at lent
two Star Roods or Canty Roods. Include tho toed
mmbas and common toed tomes.
16. REMARKS: 1
I DO 1lmtBRYCRR7PY TEA. THIS WELT. WAS
CONSTRUCTION ST AND TRAM ' . OF
t�
DI ACCORDANZE WYDI ISA NCAC 2C. WELL
RECORD IIM BSI PROVIDED TO TIM WELL OWNER
7-7/1-Y.
.7/-C; .
THE WUL DATE
SmhmitSsmad is tbs Disida et WaterQasy, GrssdwaterS.clka,106 Mal anvteeCie -Retslpb,NCC
27Al-3OSNat Naet"73$.Mil.. 311dya OW-1 REV.0712001

wZLL CONSTRUCTION RECORD 3 3 3 5 3 5=
Nome am}iee • Dop eImet of Bavieearr led
welt CdrrRACrOR tAlNYmOAW
W* LaonrtMCloeCOMPANYKAas
Rssowoes -Di is 9 of Wear Quality - tiromdweter Section
C f I'�*. cid 5 :Tie csinvlcATIOm .7 7 Z s/
Wr''// o l r�1 f' Mors a fign E 99-G'/2:6s
STATE Wff11.00RTaUC17@I Puma ASSOCIATED WQ PERMITS
OhesYrble)
(lfalio ble)
1. WEIL USE (C/sedi Apia:ebb Box) RmMnlial 2 Neis .Wublc a bird) Cl Aeia.Md a
MoeimA4S 0 Recovery 0 Hatt Pump Water Warden 0 Other 0 If OlSr, Lbt Use
2. WELL. LOCAa
Nearesterwtr , ' Coady '`� N
/32 SUQ C xci '79 2
(S_.etteee. Oarmeee,b.t*d4_.GtNs,DpC *
3. OWNER: dPL L°- gee( I mar e
ANN. /3'Z 5 to- Jot / .Cc
/i/1
'Rnr.
Pr)4evcrat' t L ZF79'7
ant Tee - *OS
As sir Ste
4. DATE DRMLED 7--et
S. TOTAL DEPTH: 2.0E
6 DOHS WELL REPLACE EXISTING WELL? YES 0 NO D-
7. STATIC WATER LEVEL Below Tap of Cagier 3Q PT.
(tMe'v`YAee.Top de mkt
S. TOP OF CASINO IS % 5 „ PT. Above Led Swine*
nip ea. Brad eedt bales h d meths ee,Su e
veewee Y MEMOA MACE OF net �i%N t`C!
9. YIELD
IEfa (Wax
10. WATER ZONES (1W10
!hire Miley Oast
Sisk "papas bit)
Iatiduda4ayiteds of well location
( afe.e. is)
Latimddl - -' : swrde:001112Tepopapbio amp
Wade sea)
DEILI to r ums
From To Formation Description
11. DISINFECTION: Type / /' /5!
l2 CASING:
Froo G _Tole C
Firm To..____ Ft
From To Ft
13. GROUT: DevittMetrlel
preun_�_To 2r Pt.Lperele Wf is ' Q.
\
Proem..To FL
14, 8CR8E{Nr:� Deph Die
Y' To Ft._Jn
Prom........_ To- 10
13. SA)IDxtAVELPACK:
Dap& SirsMariaPtom it Tet_ i
Feint To Fi
O
the 12LAIErsIL
Amami /! c. 7 Show &radios and distance if miles from at least
W.0 TWon Tlithases two Slate Reeds orCounty Roods.Include1bsrood
or WeiebVR MNrlel members and. sass ie wad aan aa.
sp f-2/ Pc)C
r/ (krtr,,; 4V e //
Slat Sisk Wade]
if. SN%/9
tom.
3‘/
i
16. REMARM
I DO BMW CERTIFY THAT THIS WELL WAS CONSTat1CIHD
CDIngiR11COONSTANDARDS, V, THAT ADOPT Of
r
WITH ISA NCAC 2C, WW,L
RAS PROVIDED TO THE WEIL OWN
SIGNATURE OF PERSON THE WELL DATE
•
iieiesie sine eeiRissi se pis uirair ei+WeetrQWIy. G ertdwair S.ctioa ItDS AIM area own -Asielsl. NC
27015-106Pb aI.p1!)7316221,wleda3Odaps OW-1REV. 0712001

33v529
SIOLSUMECIIMI
1isYOman -Damao ottimsasgtsti Dsse..D1.1ma flat goal* - Camber Baton
iIiIL melattlellar.OW/ltta..t In C R s _'!s` allifat:Allon.27 •`1
'atr.LCONI:ACKSCOMPS e we/I , L ss�c- run i ai E %p-Ono
MUMILL COMMIIX11011 MArOCMt8040
albillillasse
L WELWS(Omsk AM$41611#1IIMimW[DiW iio0 IBitidn saw
Nes11dg0 Wsrtgr 0 But Pap Thlrlj Ss0 Oier0 If Clistattls
2. MU. LOCATf01k 'I /
Nail! r' r— "eneirser
J7_ 5- OR m/! i P4'cr tido h%t 271nd,
(wratrr.ltesa.r. Carmatttsu_r,t.ar.;ae
L Met; 7 in /Qlexi
Adis • -7 :jai
ler
fit re >w
CS IS le Brain
4. DA111TI M-2/_06
3. TOTAL t So s
6, Does "sus 31au=mama way m G 110 a--
7.3TADCWATTStAYN.edeTopstail.p San.
,, iprwrn.ul+atyt
CANING a
B. TOrOFCA11, /t PT.AimLedBul..•
a7l+arasDertrrta/asrkesSSsee spara
wAar f a aaesanraO at Mae Alt
t VWD(ffs*a_z__,1111IuHODoriaa %/i"E�
It WATQ100M(AIl11:
11 amencnottECGN Awns JO cr
U. CAtOKk >IYDTYt>•rs
�.-
13. ,IC —
14. BL23111* — r---r /RBIs16.
NrrW
0Te h is
15. WAND iAVW.TAM.
Del Us IirsY
Tompipkieuad ins
ON* asipe Mat
tsbIdareeppoudwte balder
Laidennerb isseirDOICtimpopit mop
adtbso
INCIN
1n0
P1ss Ta pL
iaz
tllt.r t-ta18es eti�irsla b oft l• at tart
esa bile last atCaw PaN1, Weis the wood
slaw
w"i1r,/X
mith levee,
,UC;`fi.
m�lT
16. ISAllllt
ID01111>1/iC RTMUTAT11116letWAS • • . „ , • • BMAOens=um ISAICACE was.
annUenagittrearg*
COY - T108 SAS )v1�VID 1TOttie 1.oMt®l
t ?-Z cE
OPPERM! TSSORL mu
Weft awn imNebo .twesrWay.Ctwrit ist Soda 1111161116 Ihrdom Cusur-arerl►MC
reuwn aa1r.aMQ w481bstillsBOitl0s.
OW-1 116V. te7/2001

Math CN ..-ap rrisdllw,ma,rtW p,aa1e
WELL COM 'AeIMa.a..wwNs : to
Ina aMMLICTON Mean
ran •o&caurarcmr___ --
Ahnr.r.a ...__.,�wQ
L WEL UNUOrdtioNeene __n ial ErvidosidpoWalaso
NINSIekg 0 t+rr 0 Ns Pep Misr Woks 0 os o Id* LINO*
2. MILLQCA •
' a i�1M 4.!7i;
333523
csannetnew.27 F
Haas. azzeo„
T
twr.l.ea,larmtio,sti tolba oy ,ails ids sips �oYkg CPIs
L i.afwf~ balls.
1 Owpafj(i1 T C&ifiler
Mice it Peitz A- I9u e W " "
Claw .r. ion alaiitajaa
Rae To Paarioa
Dasedpeks
4. Dews ant '5 /`/-o6
3. TOTAL torm C V5
6. DOC WILL IOLA=UMW WI LI YU Q NO 0-
7. STATIC WATSIntlirTCpCabs J60 rr
IL 11�ORC.Al�lfiis / 1� OD M,,Atwtapecet.d
!?. Alas Iasi 6telra•
nip ascraterbisti“ min
vtiar.naau.e.uaaa SA11CItlC.a1L
9. 17wNIP*. -, swims ormar /%i7-?e-ot
to. WATER >'la M0011*
11. DiNNPELTIaN:7ya. G, d _ A�
It CAN& w11T__
1A by Yb.
/
ris_z_sro NI on cre
14. SONNINk, Di. Etas MS Ns last
13. SAND/OMAVtLPACR
Nadi
1 mMINIM _TIP_THATTrwrr, WAS
amentu.Blow • .. AN INAT ..•-
t%" ± Ilia diaresie Min Rae at Iss
ta.aieaela.e.e��we.ir. Rtd.ilitap.d
alma
'� • , . sAcandaiwan»ToUR WILLoMwt
INNAIIIIROP PIMP INS WILL DAM
-/V-C
Odialt Nit I frawwu'VIPS OSSA asININNIN. u.s MAIM wr,isc _-_- 'a c
mi -_ OW 11llV. Mom

E)t)
A LL ONS'T'RI;CTION HE( ORD
1 WELL CONTRACTOR
Bryant STTN
Well Concocts (V1e1. us1) Noma
Given Rani Wed E Pump Company
Wr CorarW' Canpeny Name
51 RUT ADDRESS PO Baa $M
Eat Fat Roo. NC 25725
CGT a TINA Soto
Et ID i• 09]•1�
And ooe. Pnon • n✓•o•1
1 WELL yNOSMATION
SITE WELL ID Ha swami
n(� 1�1n1D(o�
STATE WELL PER MIT N• Mppwo•I
D1n/p a OTHER PERMIT Ill 9Ppms060
WELL USE (Ch.,M f cas Boy) . roWRl WIR SWWY
DRILLED
DATE DLAiD __ 11 III/
TIME COff ►CITED
3 WELL LOCAAJTION'. AS.X/
CITY / 1 t (Onla" COunTi_41.
j511Y1alack.)
lRn/ NdenM. Hymns Comm
TOPOGRAPHIC i LAND SETTING
Eyg01'Pc DVS7 OF ()Rape ❑Oew
(i,p. Maaoarae oa.)
LATITUDE _2_7—II�'
LONGITUDE ,Q5522
1 of Lnlfronm•nr NG NMnN Kcfu.rcc. 'J r
..i .ten V„un
Noma Groan. L7eper111MR
WELL CONTRACTOR CERTIFICATION • 2-711
1. pSINF EC TION TTp•
9, WATER ZONES ao'__
Flame. ,c ,5 F (Om
rom
From
1p Code
AM (J PM {y
5.po front Lad No Par Zip Coo•)
L WIUCTC bny°+da Souris e6PS OTopoWeptuc map
tec•ten Of r•F "al two Nown on • USGS rope map •np
•Fi•aIW ro Oa roan / not w•fp CPS)
4.
OWNER'} NAME�
/3
STREET ADDRESS
WELL OWNER JO 1` O
7irton;a )3Gn't) o
CO of Town
State Zip Coo'
•015
•J .rt . Phone mantes
E. WELL DETAILS: /7 � �j
•. TOTAL OEIFTN:---y."'— NO
O CCES WELL REPLACE ExISTW+O WELL7 YES 0
F1
O WATER LEVEL s•ow Top d Coup
(Lisa '•• T Ato.. Top d Cuing)
FT Atom Lard Suffice'
t TOP OF CASsIS ��War Lwow w000 M OIMce r•.T ISQ..•r•
'Tap d carp
IS"N•1 wN ISA NCAC 2C .011E
• •ea.nc' n •owro•nc.
METHOD OF TEST
• YIELD 1pM11
SubRYI p1.OfWrl to Ow DIVSIO"of Wale( Q lity within DO clayl. Arm nap
n Fna
From lo
e CASINO L{yrF
From
DI / F
From— to
Hon_ lo—
7 GROUT Depth Maenad
From D 10 _ Fi
Fromi0,V Ft _
ROT f/ Ft
F mp
Amount
To _�
to
Tn.cMaffr
9 SCREEN
Fromp
Flan
ra_
f n
_
..
Cmoin Dnber •Jg15.D
lo_
FT �n
on
q —n
_._
10_ —n
SANDq RAVEL PAC^
D•an
From From
From
IQ
i,
To_— Ft
10
5u•
Main .4.
10_ DRILt lnG LOG Formaoon O.Scnpuor,
From To _.
—ZS Rt7lk n SS /( —
Tyr
ter
II REMAHhs
Irua 712.]0+5 •A15
Center - Ra1Mpn. NC 276E9. 1117 Phon• No. (919)
1617 Mail Servlpe
w
_ 1„ A.5 CO.TII.ICRDn•CCCnw..Cd ry ^•
I� .S..[1C Wen',
a[ 00.S.�5, )rO•..51...D DDSS • •0 M r • COr.O rn6
ReCOSO•AS ME•..
V 7Q
S.ONA7dsLCR Of CE R 0 `"w[II CO�R
IJF�AK N ,
PRmTEDN Of PE ''Son e"•Ruc in( WELL
o,m Gv.
e rv»
DALE
...,„RECEIVED
Asheville Regional Office
lifer Prot9?tl.,„

o 4Y "_L i o
8ES/DENTIAL WELL conSTRucTlo% ItEC OR
Noah Can bn. Urp✓an•ntol tnvlronmcnt and NaWrL Rcr.+srccv J
WELL CONTRACTOR CERTIFICATION f 2571
1 WELL CONTRACTOR
gryant Smut
WM Cavana (00•10u40 N•ns
Groan Rivet Well f Pump Company
Wd Cau180101 Cwny Nan*
STREET ADDRESS PO Bo.20.
EGA! Ft Roo. NC 25725
City or Toaar SSW
( 523 1. 693.1200
Zs Coo.
Noe o00► Phone Nampo
2. WELL INFORMATION
SITE WELL ID Na •00c•CNI
STATE WELL PERMITI(F•pp•wpq o loof /a Di 1046L9
MVO a OTHER PERMIT NI appicaoul
WELL USE (Chan Applcan* Bonn Ron:NnNW Wna Srppr 0
DATE DRILLED 91 lei O p
TIMECOM►LETED 3:30
3 WELL LOCATION'.
CITY ZI rccn tCA_
Ala la -el Geer IAiM) Dvgc ft.
151r Wm•. NJrroa• COMMON 7 SOaa.'w' LDI Pc Parcel Z'p Coal
T OOPPOC MPH IC 1 LAND SETTING
Galopc OVeit/ CPS oR,Op• oOP'•,
la*a .wwwna■ pa,
LATITUDE 25 �O 141 36A.I
LONGITUDE ^PZo nLLt `i 1
41
LauIUCdiongisssiesorrIsouce C{CPS OTopolgaptuc map
lac.mn W *•N owe W *frown on • VSGS tope m.p one
Owned ro tor. loan F not vary GPSI
A. WELL OWNER �h I• Ltnskn Ntchalsa n
pWNER�3 NAME `
STREET ADDRESS PO 60K 24429
A2rvnU1 ASt?Y.U:(le AK_ fly?9Z
Cry. Tw.n State Zip Code
LQ28 z - 3369
Ann coo. Phone rwnw,
f. WELL CIETAILS: I
•.TOTAL WIN. !��
o DOES WELL REPLACE EXISTING WELL? YES O NO
c WATER LEVEL beam Top 01 Cana
al Cleft
•.• F Move Top
o TO/ OF CASING IS
FT AWN Lyra Sunac•
-Top or o••'0 tartwu0 auto Wow w'0 •urea troy r•VVn•
• .so w n•omro✓.ce afar ISA NCAC 2C Mil
• YIELD I9W I MR3100 OF TEST Orr
AM ❑ PM'
COUNTY f ""'
May a . mgrs.
Wary sends a
.. aactaaal fam.I
t. 01SINFECTION T7 p• ^TH
y. - WATER IONES ,a•w
F,am 90.1e 99C
F,om ro
F IOen t o
f CASINO
7
Fiem
Fiom
From
Amount
0.vl^ p D,a IH
Flom�q
_ le DO Ft E.
F,on le_, fl
Fran lo__ Ft
OROVT O•Pn Mal•Mi 1 �M••U'OG
From / To /0 Ft SAl#t/ v ,I s.'l s4ae
rp
to
0
T nK J*aY
Wort M.I•tal
a/. L
Fran To_ co
horn IQ FI
f SCREEN D+. D.,n.i.Son5'ot 5M.IM W
Flole le fI n n --
'tom To Ft n on
F tom to FI n
f SANCvORAVEL PACK
0.NA
f ram
From
flan
10. DRILLING LOG
From To
e
ll
o F1
To FI
II REMARK'
R
A.
RECORD MS at I,. ✓.P Ut'
So•
Mat•n.
FOrrnaDOn D•sonptra„
n•.
OCT-
A.,,
S,GNATVRE f CERtFpEG 1Eu CONTRACTOR DA
PRINTED E Of PERSON CON tRuClirIC Ted nsE
original to the Division of Water Duality wttnln 30 Days. Arm nrr' ror•oon Mut.
SUomlt Sonia
ysnlu C•prr-R+la/9n, NC 27fff•Lf17 Phone No. Iflv)77240r5 OA
68
0 m CW 1a
SIX

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION it 2571
f. DISINFECTION: Type ff7 /7
1. WELL CONTRACTOR:
Anthony Bryant Smith
Wel Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PC) Box 204
East Flat Rock, NC 28726
City a Town Stale Zip Code
(828 )_ 693-1200
Area code- Phone numbs
2. WELL INFORMATION:
SITE WELL ID a(a applicable)
STATE WELL PERMITS(if applicable) D51 a o 1 1322r
DWQ a OTHER PERMIT a(if applicable)
WELL USE (CheckQApplicabe Box): Residential WMer Supply 0
DATE DRILLED ! - 1'Z - d G
TIME COMPLETED 3 % 3 5
3. WELL LOCATION:
CITY:CriA,0 -C
624-(n-11in m.
AM ID PMB�
COON �1�
(Street Name, Numbers, Community. SubdiWaion, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
6Scope DVSey ❑Flat ❑Ridge p Other
(o weii apprroopnate box)
LATITUDE 37 g.S A%Ab
LONGITUDEO_Le.r /DW
Latitude/longitude source: ❑GPS ❑ Topographic map
(bcattn of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER &Lila_4. " n �%„�
OWNERS NAME �r Q C. ICX nwid S an -
STREET ADDRESS i bSC 1S€
Cd tic-gU/ (1e_ M C. 2S 7a-7
City a TovaaJ State Zip Code
( ) &PS - a2(007
Area code - Ptarte number
May be in degrees,
minutes, seconds or
in a decimal formal
& WELL DETAILS:
a. TOTAL DEPTH: 1 05
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOR"
c. WATER LEVEL Below Top of Casing: O FT.
(Use'+' if AUo a Top c( Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below lard surface may require
a variance in accordance rdance with 15A NCAC 2C .0118.
e. YIELD (gpm): /t METHOD OF TEST AA
Fran
6. CASING:
Depth
From 1 To Me.
g. WATER ZONES (ddepth).
Fran fD To Sr From
From To From
To From
Amount
From To
From To
Di er
Ft. L
Ft.
Ft.
To
To
To
TNckreas/
Weight Material
X1C PYc
7. GROUT: Depth Maalenal Method
Fran 0 To 3 Ft. 5:ii—A EAF
Frames_ To :i D Ft. 13420tfh M, y atilt
Fron To Ft.
IL SCREEN: Depth Diameter Slat Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
B. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Fran To Ft.
From To Ft.
10. DRILLING LOG
From To
Q — /D
Formation Description.,,..
DIYt *"
l o - 2.1 otra� 5t"F/1
as- - 3D Rt-
ae - Cos ,Rft sjs+IE
11. REMAR
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
I SA NCAC 2C. WELL CONSTRUC STANDARDS, AND THAT A COPY OF TMS
RECORD HAS BEEN PROVIDED T(l E WELLRWNER.
13,n
SIGNATUR OF CERTIFIED WELL CONTRACTOR DATE
eii)it t,SN111.-�t
PRINTED E OF OF PERSON CONSTRUCTING THE WELL
1617 Malmit l Sery Service Centeroriginal to — Re aleigh, NC 2 699.16117 ivision of Water Quality
Phonewithin
No. 9 9) 733-7 6 ext 568 ion Mgt,
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 # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Narne
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 ). 693-1200
Area code- Phate number
2. WELL INFORMATION:
SITE WELL ID #(a applicable)
STATE WELL PERMIT#(it applicable) 010 I 0 011 z41' (45'
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED 9 -Ho
IO
TIME COMPLETED I . 30 AM ❑ PM
3. WELL LOCATION: •
}ke.,
CITY: YSM0II I€ COUNTY--t_AAd..GI�-SO r
LQ 1 Lkknott.lviuTrai
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
QSfope ❑Valley ❑Flat ❑Ridge DOther
(check appropriate box) A'
LATITUDE i5,L)j
LONGITUDO&2-V Jlnr tO
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: r2617S ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this four, I not using GPS)
4. WELL OWNER /�
OWNER'S NAME Li) frll "'ZUcR�rn t_715
STREET ADDRESS '7Sz AJ • West - ( Sir Q G-f
Alan i ltr.. F— 33317
City or Turn State Zip Code
SV7- 2so1
Area code - Phone number
5. WELL DETAILS: /
a. TOTAL DEPTH: (o
b. DOES WELL REPLACE EXISTING WELL? YES I - NO ❑
c. WATER LEVEL Below Top of Casing: 3 Q D FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
*Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a METHOD OF TEST Air
.. rT
1. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
Fran L/U Tag-- From To
Fran To From To
From To
From To
6. CASING: Thickness/
Depth Di�rT�er Weight Material
From / To 23 Ft. D '2I.L P —
Fran To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 3 Ft.. /s
From 3 To O Ft.
From To Ft.
8. SCREEN: Depth
Fran To
From To
Fran To
Method
Diameter Slot Size Material,
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From Tg,- Formation Description
/ _ pY r
5 S hat/ AscL.k
/C - C46 i?/Fti l-
n •
n '
�E
1I. REMA
RKS:
OCT
Asheville Regional Office
Aqt pfnr Prntontinn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION ANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO WELL OWNER.
SIGNATURE OF CERTIFIED
ELL CONTRACTOR DATE
S A?yn-& 5417,'l i
PRI T€D NAI(IE 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 CERTIFICAT ON # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City err Town State
( 828 )_ 693-1200
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) STATE WELL PERMIT/Of applicable) n t//
0 / 0 D / 1 Z(en 7
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ID
`I DATE DRILLED —I / Q
TIME COMPLETED ,2! 50 Akio PM IK,
3. WELL LOCATION: ', LII.p_,r �JyIp��!1
/�.RYS81/4.) 1,1,Q-.I COUNTY 1 1 �"`ie4 r
13 W; llo41 R-�i airel
(Street Nam .ambers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY:
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley ❑Flat L'(dge ❑Other
(check appropriate box)
LATITUDE° I Q a 11
LONGITUDE .056Z033 a 01 (A)
Latitude/longitude source: q .GPS ❑Topographic map
(bcatbn of well must be shown on a USGS topo map and
attached to this loam Inot using GPS)
4. WELL OWNER
OWNER'S NAME Q..- Chard Ja hnson
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS P 0 2 29
cled-12orL. /dr-
Ci Town L�aatte
(gzsa )_ 657-'fzs3
Area code - Phone number
8?31
Zip Code
5. WELL DETAILS: r� , /
a. TOTAL DEPTH: 622,5
b. DOES WELL REPLACE EXISTING WELL?yYES,I NO ❑
e. WATER LEVEL Below Top of Casing: 10 FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
*Top d casing terminated at/or below land surface may require
a valiance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): t^° METHOD OF TEST Air
27
f, DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth):
Frain /9l� To 2 DC From
From To From
From To From
6. CASING:
Depth
Fran / To U
From To
From To
7. GROUT: Depth
From G To .-
From 3 To 2O
From To
8. SCREEN: Depth
From To
From To
From To
To
To
To
Thickness/
Diameter Weight Mqterial
Ft. L.to 2/4
Ft.
Ft.
Material Method
Ft. 54AR h''I. 3'
Ft %?ll✓r17Tv�. /M1i I' 1L Glt
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
Size Material
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/— /
/ t' — rt2
S D 5-
11. REMARKS
Formation Description
/2.4012 at,
RECEIVEg1
OCT
Asheville Regional Office
Aquifer Prater -firm
1
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.. 0 THE WE OWNER.
SIG TU OF CERTI IED WELL CONTRACTOR DATE
/3/�n r,r-+5»1 y-i,
PRINTED E OF PERSON CONS RUCTING 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.
Fomt GW-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well .3 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(x applicable) /, y7
STATE WELL PERMIT#(il applicable) % UQ l C / ()
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
{ DATE DRILLED - .24 -0 6'
TIME COMPLETED 2! 44S AM O PM I"il.
3. WELL LOCATION: Z
CITY: I freed 151`-' COUNTY`
ifs /3roam-- 2wa-redge lio(•1- 14.ockeitfit
(Street Name, Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley DFlat anidge CI Other
(check appropriate box)
LATITUDE ° I1 30A/
LONGITUDE(2$2° '39 r OG '3
Latitude/longitude source: ❑GPS 0Topographic map
(location of wet must be shown on a USGS topo map and
attached to this tam 1 not using GPS)
4. WELL OWNER
OWNER'S NAME 146.14I`�1K..GL�
ST EET ADDRESS ? ZL-} ]h0 S! . gig/
(Stint) filed ti C 2 @ q2-
City a Taw; State Zip Code
( zf�)- L 5G -bc,26
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: / (,'(
b. DOES WELL REPLACE EXISTING WELL? YES 0 N 0
c. WATER LEVEL Below Top of Casing: g o FT.
(Use "+• if Abae Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST Air
Ptc.
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
From /%U To lit
From To
From To
Amount
From To
From To
From To
6. CASING:
Depth Diargeter
From / ToCS Ft. L- 7
From To Ft.
From To Ft.
7. GROUT: Depth Material
Fran To_ Ft. sjr r
Fran 3 To 0 Ft.( - z
From To Ft.
Thickness/Weight tt
A/ n'.-.-
Method
�yod<
& SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To _
/— 3
/
6-0 - G0
Co -/L5
11. REMA
Size Material
Formatior,Qescription
RECEIVED st
i
CC7 ' ; 2:3
Ks.
Asheville Regional Office
Aeuifer Prnta 1j
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT] STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T E WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VA ONS
PRINTEDDOF PERSON
ERSONNCONSTRUCTING 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 Quaky
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Wed Cumracta (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
State
( 828 Cty a91200
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID OM appease)
STATE WELL PERMITa(x appease) 0 Lo 12O (CIL) d
DWO or OTHER PERMIT a('d applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED Y ii %. ' 0:2‘
TIME COMPLETED %. 00 AM 0 PM ID'
1. WELL LOCATION: � I n �,, ,�.
CITY: 2l rc (,�1 cL CQ(;INTD.LUL &I((i -
07%e9(POrS 11,01 �l c ` tat --(tb -
(Street Name, Num Com nary, Suooinsion, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
C35lope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)�
LATITUDE f.L 7 3 / 4"
LONGITUDWIL'S' a 02 4/
Latitude/longitude source: g2PS ❑Topographic map
(bcafatn d wen must be shown on a USGS topo map and
attached to this form / not usig GPS)
May be in degrees,
minutes, seconds or
in a decimal formai
4. WELL OWNER
OWNER'S NAME
�10-rc �_S.c STr n / J
STREET ADDRESSOISZ1C ' IKV1 /`Led
%yYc.'JYLtc- tJL.Z%ice,O
City or Tuan State
Area code - Phone number
Zip Cade
6. WELL DETAILS:
a. TOTAL DEPTH: 3
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ir.
c. WATER LEVEL Below Top d Casing: L 0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top or casing terminated ass below lard surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): 3 METHOD OF TEST Air
1. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From •T G0 To .Z() From To
From To From To
From To From To
8. CASING:
Depth D) er
From / To YA Ft. L
Frcm To Ft.
From To Ft.
Thickness/
Weight aterial
ALLr1C
7. GROUT: Depth Material Method
From 0 To� Ft. _ M J
Fran 3 To 1 i� FL /Z— i fit
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/0
0
F mlation escription
F,4 lr
T sF SJa q i
Oh, fnlgler.
n
s
11. REMARKS
f ECCIVw.
)CE
Ashpville Regional Officc
Aquifer Prntertinn
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE q't"a THE WELL OWNER.
0 CERTIFIED
YeA 3 ,74
SIG ATUR OF CERTIFIED WELLL CONTRACTOR DATE
PRIli
NTED N70.IE 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.
Fam GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (IndiMdual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(if applicable)
STATE WELL PERMITN(ifapplicable) n io (nOlO OAFS
DWQ a OTHER PERMIT /$(4 applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED I - 2.1.0 - 0
TIME COMPLETED I Z. 3 O AM ❑ PM
3. WELL LOCATION: I"f��,�,,,`
CITY: I )O�n0., COUNTY 4-44'/'ILr
903 QJ?{Q--e. 2n�
(Street Name. Num rs, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley 13FIat ❑Ridge DOther
(check appropriate box)
LATITUDE 5 ° an' 30W
LONGITUDt LZf .2I w
Latitude longitude source: B;ZPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form tnot using GPS)
4. WELL OWNER
OWNER'S NAMETOM
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS POQa k 2- 3
De-r a tic.- 2g 12
City a Town ' State Zip Code
((ZSf1- 685. kSs(i-
Nea code - Phone number
5. WELL DETAILS: GG ram_ l
a. TOTAL DEPTH: 1 0 5
b. DOES WELL REPLACE EXISTING WELL? YES Lq NO ❑
c. WATER LEVEL Below Top of Casing: 1, 0 FT.
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
*Tcp of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): (ea0 METHOD OF TEST Air
f. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth):
Fran trs To /60 From To
Fran To From To
Fran To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 1 To lFf0FL Cry 21.L PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 30 To 3 Ft.�
From 3 To � 0 Ft. oo/Ocrf� PI ir *WOO
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 Sue Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To rrF�prmation Descnpjion
— 0 JAwdv Se,
3
11. REMARKS:
RECEIVED
JCs 3
Asheville Regional Uttice
Aquiter Nrotection
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/jHE WELL OWNER.
9-27-°'
SIGNATURE GF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
W d Contractor (Individual) Name
Green River Well 8 Pump Company
Well Canlrecta CompaTy Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Tam Stale Zip Code
( 828 } 693.1200
Arse code- Phone number
2- WELL INFORMATION:
SUE WELL ID #(8 applicable)
STATE WELL PERMIT#(a applicable) D 5- / aL.) / /J22a
DWQ a OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED Cf a8 -0 6
TIME COMPLETED I . 30 AM pi PM ❑
3. WELL LOC'C-ATION:A ,, , I
CITY: 1'\O-�-t scn1)LI t-CCOUNTY �{C-radJ 3CT\
I 5-4 m (Val ( 5h'2np 1-
(Street Name. Numbers. Community, Subd.nion. Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valet' OPCIat ❑Ridge ❑Other
(chock appropriate bag
LATITUDE 7 _2,9_ 8 / SS
LONGITUDE T &af aS r (ffi w
Latitude/longitude source: aGPS oTopographic map
(bca#on of we/ must be shown on a USGS topo map and
attached to this form I not using GPS)
4. WELL OWNER —�- �•
OWNER'S NAME 1�n r'igIl0(
STREET ADDRESS I7 S Me "Wit- Pa
May be in degrees,
minutes, seconds or
in a decimal format
-LkaYse sink_ ►J CS) -
City a Tan State Zip Code
(%ur)- `�9o-2-3 (t
Area code - Phone number
Cu WELL DETAILS: •�
a. TOTAL DEPTH: 3 Y- 6
b. DOES WELL REPLACE EXISTING WELL? ArYES 0 NO d�
a fJ c. WATER LEVEL Below Tap Casing: 3 FT.
(Use'*' If Above Tap of Casing)
d. TOP OF CASING IS l FT. Above Land Surface'
'Tap a casing terminated M/a below land surface may require
a variance In Accordance Wth 15A NCAC 2C .0118.
aQ
. YIELD (gpm): I b METHOD OF TEST / N r
1. DISINFECTION: Typo ifT
g. WA ER ZONES (depth):
Fran a/ITo 323
From To
From To
6. CASING:
Depthn D�nfer
From � To 7i i� Ft. err
From To Ft.
Fran To Ft.
Amount
From To
From To
From To
Thickness/
Weigh,
7. GROUT: Depth Material
From 0 To � Ft.
Fran— To 2 0 Ft.
Fran To Ft.
✓G P4
Method
e
4�ye� 4
�fraaTC
8. SCREEN: Depth Diameter Sla Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
A SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To F1.
10. DRILUNG LOG
From To
0 - 2
3— /0
/0 — TV
q ffV
40 —.35ny
Formation Description
s•
1I. REMARKS:
RECEIVES
Asho 1illa Regional nfficn
Aril lifer Prntor'tinn
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
1SA NCAC 2C. WELL CONSTRUCTION ANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO WELL OW ER
SIGNATURE CERTIFIED ELL CONTRACTOR DATE
13t( ,►.at- Sri r)-t1
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 Canter - Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form G W-1 a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571 / �
f. DISINFECTION: Type / - I Amount
g. WATER ZONES (depth): - Xi
Pan
From (%+0 To / 2,7 r From To
Frain / 70 To / 7.typrefern To
From To
Thickness/
W ht
1. WELL CONTRACTOR:
Anthony Bryant Smith
Wd Gateau (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City a Ton State Zip Code
(828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(a applicable)
STATE WELL PERMIT#(ir applicable) /
DWQ a OTHER PERMIT #(N applicable) 0 to /ON / O
WELL USE (Check Applicable Box): Residential Water Suppty 0
DATE DRILLED q vG ? -o W
TIME COMPLETED / U : ()(J AM4M 0
3. WELL LO1''CA__TION:' e^�I��,�,,�- IImon,
CITY: 4-lam Cfr SO/i OUN
34 g S �r�a-44, �d
(Street Name, Numbers. Community. Subdivision. Lot No., Parcel, Zlp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat [?Ridge ❑Other
(check apprcpnate box)
LATITUDE ji! ! / o (I
'AJ
LONGITUDE 2-° 33 r 0 (a GO
Latitudes/longitude source: S GPS °Topographic map
(location d weI must be shown on a USGS topo map and
attached to this lam / not using GPS)
4. WELL OWNER maT
OWNER'S NAME Yna51"y/ , adr) n✓J
ST EET ADDRESS .391 S Cc/a-A-a-, 1
{ �cL�ISGI-tvf`/(e uL .? 73 1
City or Town State Zip Code
(P2K)-�93s/�cs
Area Code - Phone numbs
May be in degrees,
minutes, seconds or
in a decimal format
6. WELL DETAILS: _
a- TOTAL DEPTH: 20 3
b. DOES WELL REPLACE EXISTING WELL? YEESS 0 NO Eh
c. WATER LEVEL Below Top d Casing: S f/ FT.
(Use 6 Above Top d Casing)
d. TOP OF CASING IS / FT. Above Lad Surface*
'Tap d casing terminated a /a below land surface may require
a valance In accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): METHOD OF TEST r
5
From To
6. CASING:
Depth _ ?Ter
From / To fS Ft. L
From To Ft.
From To Ft.
Wattled
PI/C.
7. GROUT: Depth 3Matee.`rii'al�`/��' Method
Fran 3 To 3 F/S C
Fran Tom Ft.
y 1.1 r ✓1` Oc-2
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. in.
Fran To Ft. in. in.
From To Ft. in. in.
9, SAND/GRAVEL PACK:
Depth
From To
Fran To
From To
10. DRILLING LOG
From To
D— 25
) 5'- `FS
I DO HEREBY CERTIFY THAT
15A NCAC 2C. WELL CONSTRUCTOR STANDARDS. AND THAT A COPY OF
RECORD HAS BEEN PROVIDED T E WELL OWNER.
SIGNATU{TURR�E OF CERTIFIED WELL CONTRACTOR
Size Material
Ft.
Ft.
Ft.
Formation Description
d2,i2 /-
DR)* * '64// AiDe,-F
1
4,
9�r7oG
DATE
Rit Itsr,f--5.�,)41
PRINTED E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Serv1ee Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

(&9
2'•
a.r7
r
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prin()
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT: ASSOCIATED WQ PERMIT#
(if apnticable) (if applicable)
ca
CERTIFICATION O 2, 50
PHONEY yj Z?v-4,7'ff
1. WELL USE (Check Applicable Box): Residential 13 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: Flie ION: t
Nearest Town: H Peletso/Utj; Lie CountyAli viscid
�dq3 i'AAfte. ±u to rti
(Street Name. Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: p 5{»ice
Address 9Q rel.4'e Zit/ IA
�,(Street or Route No.)
arOit. jarttLCv /DC
City or Town State Zip Code
(8$)- 777—o344
Area code- Phone number
4. DATE DRILLED g' 15-Ott.
5. TOTAL DEPTH: Z2
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Or
7. STATIC WATER LEVEL Below Top of Casing: 40 FT
(Use "+` if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
'Top of casing terminated at/or below land serrate requires a
variance in accordance with ISA NCAC ZC .0118.
9. YIELD (.gpm); 20 METHOD OF TEST A j 2
10. WATER ZONES (depth): ..Z09ia /Iq. Z 0d'
11. DISINFECTION: Type t(Oa;)t)c_
12. CASING:
Depth
From 0 To 410 Ft_
FromTo R.
From To Ft.
13. GROUT: Depth
From To Ft.
From 0
q
Tucd.k E Lei ea b f. Lc;
Amount b (�
Wall Thickness
Diameter or Weight/Ft. Material
(04 4o PwC
Topo�gphic/Land setting
0Ridge Mope ❑Valley ❑Flat
(check appropriate box l
Latitude/longitude of well loc tion
3SZb•og3N o€Z�(°tAl
(degrees/min,u.,t(eyyaseconds)
Latitude/longitude source:CIGPS❑Topographic map
(check box)
DRILLING LOG
Formatio
� n
Description
bIt2 t
DEPTH
From To
e- ;e
30- 7-z-5 t+.tf-CL_
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Material Method I• �,1�
To 36 Ft. Tt/ r.2 1 -PO oh re / 1111`"` Y
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK: 01
Depth Size Material
From To Ft.
From To Ft-
16. REMARKS:
IdNtTA- Ka
CEIVED
OF WATER QUALITY
4 4 -6' 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA jDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0
St NA IRE OF PERSOl4 CONSTRUCTING THE WELL
RECEIVED
Submit the original to the Division of Water Quality Groundwater Section, 1636 Mail Se
27699-1636 Phone No. [phone], within 30 days.
OCT 1 < AL
DATE
ice Center - Raleigh, NC
GW-I REV. 07/2001
Asheville Regional Office
Aquifer Protectinn

N'rr J u
7(1s� O(5,S v Z WELL CONSTRUCTION RECORD
Carolina - Department of E nviroranent and Natural Resources- e�sources- Division or Water Quality - Orotmdwaser Section
W ELL CONTRACTOR (INDIVIDUAL) NAM—E-(prbt)6 r, rU \ US-f ;Le_ _ CERTIFICATION c )56
a' ELL CONTRACTOR COMPANY NAME UU S/.atC:C i. fej( D II' r. rh,
STATE WELL CONSTRUCTION PERMmTa ASSOCIATED WQ PERMIT*
life icablc)
...............,.,.,,..u�.i...,,,....,:,_.,..:..s-,g.: n _.... if cable)
yi0
3. OWNER: 71 0 Tiiik 4 L/�� 5 n
Address tj%2n L7r�tlou r ( hn�1
Bj „� (Street Cr Rome Ko) Latitude/longitude st)tueo• PSOTopographic map
est ecs, A)v. tie paI: (cheek box)
.,,,,,,.City Sane DEPTH{ DRILLING LOG
T4Cde
(I"7 J- nip. - 4 2 C3 From To Formation Description
Area code- Phone 4- DATE DRILLED $ - I G -, 0 4 O - & O
br✓{{
5. TOTAL DEPTH: 4'6;1f
6. DOES WELL REPLACE EXISTING WELL? YES 9 NO !nO - Z 7 5 (� l3Aw t t Q--•
7. STATIC WATER LEVEL Below Top ofCasmg: </Q }T.
(Uav-iraboya Taper
8. TOP OF CASING IS '
FT. Above Land Surface*
'Tap al casiaa terakad attar beam bad surface requires a
rartante is accordance with ISA NCAC 2C-0I1&
9. YIELD (gpm): TO METHOD OFT..�EST A'f'L
10. WATER ZONES(depth): �rt Fes* [�� / 2 ©p
11. DISINFECf10N:Type (`Ihr:nP Amotart LOCATION SKETCH
11 CASING: % n a Show direction and distance in miles from at least
u r WWII Thidmea two State Roads or County Roads. Include the road
From—_ To 7 2 Ft.j. % t/O or n/fL numbers and rid Herres_
From 72 To 7`/ FL La Ye./ ,J2cA le (t�r)ud
From To /� 0
13. GROUT: Depth 1 RECEIVED
WATER QUALITY
PHONE s DWO72e' «SOS
I. WELL USE (Check Applicable Box): Residential Qi M'unicipalfiubiic 0 Industrial 0 Agricultural ❑
Monitoring O Recovery 0 Heat Pump Water Injection ❑ Other O 1 f Other, List Use
2. WELL LOCATION
Nearest Town: Qpi etef Seta Li: Is tat County i'arle r kik Topognr phic/Land setting
q'atA) y'�t�: q'o*t#u KW? ORidge Eck pa OVbo) OFlaf
(Street Name. Numbers, Community, .. LotNo. % Cade) Mock of hint)
Latitude/longitude "tudeaf�welllocation
35%11.793P(( 0&2°ao.t7/W
From Ci rain FL_2 s / PIS.„yid OIV OF
From To FL �CT Q S
14. SCREEN: Depth Diameter Slot Size Material 2006
From To FL in. in. To �i>C^1
15. SAND/GRAVEL PACK:
FL in in.
Depth Size Material �(!
From _.To Ft.
^/7 '"1
From To FL
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
CONSTRUCTION STANDARDS. AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
K1b ,-
-SIGETATURE OF PERSON CONSTRUCTING THE WELL n DATE O
Submit the original to the Division of Water Quality, Ground-aaty 4��,�s�
27699-1636 Phone No. [phone], within 30 days p`ala[.l�(ce Center -Raleigh, NC
GW-I REV. 07/2001
OCT 1 7 2OCS
Asheville Regional Office
Aquifer Protection

r;
owwrn 41 We' O skW • GNNrdweer Sr^
1311,1411 Sr,rlepNNrr- lump, roc. =romMs7owhrNw pm mant
YELL CONSTRUCTION RECORD nu. cows Acton
-, >� H
L cot4TPACTOR gFT1F note r.
•
t.
fl -
STATE WELL CONSTRUCTION PERMITS:
rG]/�NdclFdo IIIcuaddv t e 0
WILL US Ekes* HeWow IN4K+a^ D mar CI u Ofm• LW Up,. --
Roewwl
WELL LOCATIOtt (ehsw dlsl>>+ � Isogon broom)
NumMITo+R
3. OWNER
FdQ
ClIft
4. DATE QN'U.I1 ��,�
5. TOTAL DIPTNND
7. CossW sLR E.P VOTING WSW YES 0 OO9�
7. ST TC ve TER LEICSial CromMW�
S. t2TATICWATMISYRMI T sums -e Moroi ■Coln.
P. TOP OF CASINO 10. -'. VT. mw Land Strome
SS rwNe1r "SINS I eeew-
'1N el �•�7I'•MI4 dNrr lei —
10. YEW ypw2:METHODOF TEST
11. WAT1112ONU$ ISPfl _
CNL0IMAAT101t TspeMuourd
13. CASINO: /7 di ' •
A&F MP SERVICE, ELL N INC.
G
911Hwy
AND PUMP Business 74
1�5 Bostic, NC 28018
• •ter r ainti 828-247-1773
ti.
•1
rfeasNM Ss_s- Wbodies:a
Flmll �lL.To - f
From To fl
14. Gi1OUT:
we TS.
10141014. MOM g1+edIrseddearrF—MIMC1wiO7' rat 1
Mead W J
FAIN '� T�+� FL SBL-
From _ _— Tip Ft
15. Kamm sumo Marro
OM+
u rom ..._To R. h _—_ h
From _.--To R. h h
is. 8M41OFMVELflat Mu MISS
D�
From -- To R•-
O. ISEW 17 A
TNATTMMweawas CON$T1werso AcCD11D�1NCer ram BA Fatc•waL
conurecnca+ pp PENEITI rosevpl,APEDTHAT*Cori OF'PIS RECORD IWIM TOM MLL00'd
meia1CMswswlat (
sls11A7+s+sd roman
FOR OFFICE I SEOM
Oral Ns
s�wo>,•
-24-20E'3 'ni 11: 31A1 ID:
JI 4
;!---
AO WELL SERVICE, INC.
AN
911 Hwy. Business 74
Bostic, NC 28018
828-247-1773
I141441*Mai deit WNW AS essiNaNW 11M5174 GI:3 Wm
Fat all
PAGE:1

From: Scott Gantt 7044347212 To: Stephen's Wilson
Date: 10/18/2006 Time. 9.57.08 PM Page 4 of 4
333845
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT CANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial .Agricultural ® Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION: Topographic/Land setting
Nearest town: County HENDERSON ❑ Ridge ❑ Slope ❑ Valley ® Flat
129 FAWN VALLEY DR Latitude/Longitude of well location
(Street Name, Numbers, Community, Subdivision. Lot No,. Zip Code) 35.23.345 / 82.34.562
3. OWNER JEFFERY CLOUD (degrees/minutes/seconds)
ADDRESS 129 FAWN VALLEY DR Latitude/longitude source: © GPS ❑ Topographic map
(Street or Row No.) DEPTH DRILLING LOG
HORSE SHOE NC 28742 From To Formation Description
City or Town State Zip Code 0 60 Clay
Area Code - Phone Number
4. DATE DRILLED 9/22106
3. TOTAL DEPTH 200
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES 0 NO El
60 FT.
ph( -a- If Above Top of Casing)
8. TOP OF CASING IS 2 F E Above Land Surface`
*Top of easing termmatcd at/or below land swfase realises a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 15 METHOD OF TEST ARDM
to. WATER ZONES (depth): 120
11. DISINFECTION: TYPE HYPOCHLORITE Amount
60 200 Consolidated Rock
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 69 FL 61/4" SDR2_1 PVC
13. GROUT:
Depth
Material Method
oz
From 0 To 20 FL GRAVEL MIX GRAVITY
14. SCREEN
Depth Diameter Slot Size Material
From NA To FL in. in
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DIV. OF WAPC R
TER -QUALITY
OCT 1 9 2006
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.
10-1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
131:.
GW-1 REV. 07/2001

From: Scott Gantt 7044347212 To Stephanie Wilson
Date: 10/18/2006 Time: 9:57:08 PM Page 3 of 4
333844
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL, USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest lawn' ZIRCONIA
MOUNTAIN VALLEY CH. RD. ZIRCONLA, NC
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER DANNY MAYBIN
Topographic/Land setting
❑ Ridge Ej Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
35.13.007 i 82.30.255
(degrees/minutes/seconds)
ADDRESS p0B 337, MOUNTAIN VALLEY CHURCH RD. Lahtude'ongitude source: 0 GPS ❑ Topographic map
(street or Rowe No.) DEPTH DRILLING LOG
ZIRCONLA NC 28790 From To Formation Description
City or Town Sate Zip Code 0 46 Clay
.Area Code - Phone Number
4. DATE DRILLED 9/20/06
5. TOTAL DEPTH 205
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WAIEIt LEVEL Below Top of Casing:
YES ❑ NO El
150 FT
(Ilse +" If Above Top of Casing)
8. TOP OF CASING 1S 2 FT Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9_ YIELD (gprn} 10 METHOD OF TEST ARDM
m- WATER ZONES (depth): 180
ti. DISINFECTION: TYPE HYPOCHLORITE Amount 5
46 205 Consolidated Rock
12. CASING: Wall Thickness
Depth Diameter or Weieht/FI Material
From 0 To 54 FL 61/4" SDR21 PVC
13. GROUT:
Or
Depth Material Method
From 0 To 20 FL GRAVEL MIX GRAVITY
14. SCREEN
Depth
From NA To
Ft
Diameter
Slot Size Material
in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From NA To FL
16_ REMARKS
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
DIV. OF WATER QUALITY
OCT 1 9 2006
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.
10/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
Vs,"�.)1 0
; 1.3
GW-1 REV. 07/2001

From: Scott Gantt 7044347212 To: Stepnenie Wilson Date: 10/18/2006 Time'. 9.57.08 PM
Page 1 of 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT #
(if applicable)
1. WELL USE (Check Applicable Box) : Residential
Recovery ❑ Heat Pump Water Injection ❑
2. WELL LOCATION:
Nearest toxin: FLAT ROCK
110 HARRISON CREEK RD
ASSOCIATED WQ PERMIT #
333842
(if applicable)
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Other ❑ If Other, List Use:
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER PALTL JOHNSON
ADDRESS 110 HARRISON CREEK RD
(Street or Rout< No.)
FLAT ROCK
City or Town
828-674-6833
NC
State
Area Code - Phone Number
4. DATE DRILLED 9/25106
5. TOTAL DEPTH 600
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC W AlhK LEVEL Below Top of Casing:
28731
Zip Code
YES D NO D
10 Fr.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated at or below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm):
METHOD OF TEST ARDM
io.WAIER ZONES (depth): 380
Topographic/Land setting
D Ridge ❑ Slope ❑ Valley 0 Flat
Latitude/Longitude of well location
35.17.429 / S2.33.100
(depees/minutes/seconds)
La$mdeilongitude source: © GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 75 Clay
600 Consolidated Rock
u. DISINFECTION: TYPE HYPOCHLORITE Amount 30
12. CASING:
Depth
From 0 To
13. GROUT:
Depth
From 0 To
1u. SCREEN
From
Depth
NA To
Wall Thickness
Diameter or Weight/Ft Material
80 Ft 61/4" SDR21 PVC
20 Ft.
15. SAND./GRAVEL PACK:
Depth
From NA To
16. REMARKS:
or
Diameter
FL
Ft.
Sae
Material Method
GRAVEL MIN GRAVITY
Slot Size Material
in.
Maternal
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DIV. OF Wq EIR Q JAI !Ty
OCT 19 2006
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.
Gam" 10/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Daze
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
NOV 03 2006

RESIDENTIAL WELL CONSTRUCTION RECORD
North Camlina Depanmeni of Environment and Natural Resources- Division of Water Qualm_
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR
Bryant Smrth
Well Contractor (Indiddua0 Name
Green River Well & Pump Company
Well Contractor CompanyName
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City a Town State Zip Code
821 6 1. 693-1200
Area code- Prone number
2. WELL INFORMATION:
SITE WELL ID #rir applicable)
STATE WELL PERMIT/tor applicable) (9y' / OD /la 7 0
DWQ or OTHER PERMIT #(i1 applicable)
WELL USE (Check Applicable Box). Residential Water Supply ❑
DATE DRILLED I 0/2 (.�C1 G
TIME COMPLETED 471-'G AM PM
3. WELL LOCATION:
CITY. S.1.�-1�..�,;,1 COUNTY i-lj'KI(-'1,06
IbSt1 51 Pa,)l3 j2d
(Street Name. Number. Community Subdivision Lot No Parch. Zip Code)
TOPOGRAPHIC / LAND SETTING
;Slope , i Valley Offat ❑ Ridge ^ Other
(check appropnale box)
LATITUDE _ Jyx'
LONGITUDE C82°
Latitude/longitude source: *PS ❑Topographic map
(location of wel must be shown on a USGS tope map and
attached to this form H not using GPS)
4. WELL OWNER
May he in degrees.
minutes. seconds or
In a decimal format
OWNER'S NAME J� (Il,l( S
STREET ADDRESS
City or T1 Slate
Zip Code
-'� )- l- CilC Z1
Area code - Prime number
5. WELL DETAILS:
a. TOTAL DEPTH: 157) 5
b. DOES WELL REPLACE EXISTING WELL? YES NO ❑
c. WATER LEVEL Below Top of Casing r759 FT.
(Use -*" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface"
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm). METHOD OF TEST Air
9. SAND/GRAVEL PACK
Depth
Fran To Ft,
From To Ft.
From To Ft
HTH f. DISINFECTION: Type
Amount
334352
g. WATER ZONES (depth).
From /fa To /96 From To
From To From
To
From To From
To
6. CASING:
Depth Diameter
From / To 7, tl Ft._
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To j
Frcm3__ To 2 0
From To
Thickness/
Weight
2/L
Material
Material
` Method
Ft. 5,tk4J /r ,4.ir`ffnxja
Ft.�iAr M ig7250.1
Ft.
8. SCREEN: Depth Diameter Slot Size
From To FI.in.
- in.
From To Ft. in.
in.
From To Ft. in.
__ in.
Size Materal
Material
Format)QQPP Descnption
Red `l
10. DRILLING LOG
From To
O - 5'
CG— . //�' — zaU. SSFi7
/�D -22>
II. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCN,QN STANDARDS. AND THAT A COPY OF TINS
RECORD HAS BEEN PROVIDED T.,THE WELL QWNER
�j E OF CERTIFIED WELL CONTRACTOR /C DE
P INTE AME 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 566.
SI
ATU
0-7
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualm
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City a Town State Zip Code
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SRE WELL ID #(it applicable)
STATE WELL PERMIT#(If applicable) O C 0, U O L/J ( 3
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED I t'hS hi C
TIME COMPLETED Li � ' AM ❑ PM El
3. WELL LOCATION:
CITY. I COUNTYFirirki el -se Y1
9,1 dia r [(t kS 01
(Street Name. Numbers, Community, Subdivision. Lot No., Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING.
OSlope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropnate box)
LATITUDE 3 5 ` �i'7' ) 3ni
LONGITUDE LAID 19'
May he in degrees,
minutes, seconds or
m a decimal format
Latitude/longitude source: fdGPS ❑Topographic map
(bcaton of wel must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME L- CZH S IT-viE= 3L t kQ�YS
STREET ADDRESS 1 r2 O C/L(C(Q)/ia jk I ( ()r
tCLr)R L 4 tN,i L 25-a-'j
City or Town State Zip Code
`6 ).`6 )- (,kyGLi
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
( ((.`7
b. DOES WELL REPLACE EXISTING WELL/?YES 0 NO
7 L�
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.
(
c
e. YIELD (gpm): — METHOD OF TEST Air
I. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth).
Frcm /'IO To /?) From To
From To From To
From To From To
6. CASING: Thickness/
Depth Di meter Weight Material
From / To 6 Ft. 7-'� )/ G iic'L
From To Ft.
From To Ft.
7. GROUT: Depth
Material Method
From 0 To _1 FL S Ffj((Jy fr /, v
From 1 To,? O Ft. /3c-iutow, fir /i1/4 gLj)'c'r2
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Frcm To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK
Depth
From
From
From
10. DRILLING LOG
From To
b— /5
/) - ? (J
? o — 8v
al— /c>
To
To
To
I1. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Descnphon
IJri7 t-
R My; t IT'
(/.i/N1vf
REUE"fEC
DI`/ (-if WA(
DUTY
NOV 0 & 2 Or1R
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wiTH
ISA NCAC 2C. WELL CONSTRUC N STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED THE WELL OWNER.
TUR OF WELL TRACTOR f0 DATEC
t?✓n.7f 517,/-j1
PRINTED'NAME OF PERSON CONSTRUCTING THE WELL
SIGNA CERTIFIE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Departrnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION a 2571
1. WELL. CONTRACTOR:
Anthony Bryant Smith
WeM Contractor (Individual) Name
Green River Well & Pump Company
Weil Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(H applicable)
STATE WELL PERMIT/0 appicable) & , 1 I D
DWG) or OTHER PERMIT/(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 1 D Ia .} I O ic,
TIME COMPLETED I Z CI
3. WELL LOCATION: CITY- I-�L'�C� 1 v'1U 111' COUNTY --/leirS/fl
AMO PMEr-
�Ix Y
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 s
LONGITUDEr .�o,r'7' )U.•t,k3
May be in degrees,
minutes, seconds 0
in a decimal format
Latitude/longitude source: ptPS ❑Topographic map
(bcatbn of we/ must be shown on a USGS topo map and
attached to this form 3 not using GPS)
4. WELL OWNER
OWNER'S NAME
f. DISINFECTION: Type -i or Amount_
g. WATER ZONES (depth).
From / 7 C To / % 7 From To
From To From
To
Fran To From
To
6. CASING:
Thickness/
Depth Diameter Weight Material
From To Ft.
From To FI
From To Ft.
7. GROUT: Depth Material
Method
From To Ft.
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Material
Ft.in. in.
From To Ft in.
From ---� In.
To Ft in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FI. _.
From To FI —.
From To Ft. --...
10. DRILLING LOG
From To
1I. REMARKS:
7 Li /CC'
Formation Descnption
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDF♦O1 TO THE WELL OWNER
SIGNAAJJTW2E OF CERTIFIED WELL CONTRACTOR DATE CC
fJi2 G A^h-x 1r S77 PRINTED EU 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 668.
i r e l r1/4/ e
STREET ADDRESS c
�uSl {ot2z NC 2 cc'72i
CM or Town State
Zip Code
L J W1 -q q j
Area code - Phone number
5- WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Blow Top of Casing: 3 C/
(Use'.' i1 Above Top d Casing)FT.
d. TOP OF CASING IS /
FT'Top d casing terminated at/or below ' Above tsurfaee' Surface
a variance in accordance with 15A N AC 2C .0115 nay require
e. YIELD (gpm): (0 METHOD OF TEST,
Fenn GW-la
Rev. 7/05
J%

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
334342
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SRE WELL ID #(B applicable)
STATE WELL PERMIT#(if applicable) (2 /a / no/d3Q07
DWQ or OTHER PERMIT #(it applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED t oI�1/1�1 O 4,
` TIME COMPLETED T : 4)0 AM ❑ PM Il "
3. WELL LOCATION: ff
CITY: �Y$c S VIoe
38 1ta1-on/2c)
(Street Name, Numbers, Community, Subdijsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC�/ LAND SETTING:
❑Slope latalley ❑Flat ❑Ridge ❑Other
(check appropriate box) /
LATITUDE .i 5 Val Z r 22A
LONGITUDEQS:2° 34,1 54L4)
COUNTY / ✓t(fri
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EaPS 0Topographic map
(bcation of we/ must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER
OWNER'S NAME .42// ; IE ebC'(�(�i._ $5-et I
STREET ADDRESS 3R ::b ( fun teal
�r,tseShow kc,2'-7ya
Ity or Town State Zip Code
('ter )_ g°f('? I
Area code - Phone number
5. WELL DETAILS: _ 1
a. TOTAL DEPTH: / Z 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [g--
c. WATER LEVEL Belau Top of Casing: / 5 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): 17 (] METHOD OF TEST Air
f. DISINFECTION: Type Hill Amount
g. WATER ZONES (depth):
Fran /OOTo /U5 From To
Frail / z 0 To / 2 i From
From To From To
To
6. CASING:
s. Depth Diareter
From / To ii4 Ft. Z.
From To Ft.
From To Ft.
Thickness/
Weight Material
2 /. L PVC
7. GROUT: Depth Material Method
Ili 0 To , Ft. Nr>AfQ--rrrr4 fl'nr.=
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
/ — }
4-- 3
0 - 5r0
szo - /A f
II. REMARKS:
Formation Description
thy
4 ' (f/.n
S.F.vr Y- er,E Radm
iir7Awi t fT
RtCEIVtii
DIV OF ',<.-•-- • gLI1Y
NOV II 0 ?MR
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRU N STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE q' THE WELL JiWNER.
fiettSIGNAT RE OF CERTIFIED WELL CONTRACTOR DATE
g Rtf Ittif'sm.jj
PRINTED/NAME OF PERSOINJ 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 8
fit a
4 4 •
1. WELL. CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )_ 693-1200
Area code- Plane number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT7(Aapplicable) O(P / 20/n9 7
DWQ or OTHER PERMIT Y(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED ICI (p /0 7
TIME COMPLETED L:O J AM ❑ PM
3. WELL LOCATION:,/ ,�/�
CITY: 2.5'�' r a_fe r-
COUNTY I-kJYI
Il7Ta orf&o-J cfi.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
atSIope OValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE° /tor 33/✓
LONGITUDE _C212° 2-3r SZ Lt.)
May be in degrees,
- minutes, seconds or
in a decimal format
Latitude/longitude source: ioaSTS ❑ Topographic map
(location of wer must be shown on a USGS topo map and
attached to mks form not usbg GPS)
4. WELL OWNER � "
OWNER'S NAME AAt cka PI I..l.l
STREET ADDRESS 3 al e
l f wr)(d. NC ZS140
City or Town State
( $S )- 51-7 7 �%
Areacode- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: .2 `(' -1
a
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: f D 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.
a. YIELD (gpm): G METHOD OF TEST Air
f. DISINFECTION: Type NTH
Amount
g. WATER ZONES (depth):
From 7. /? To 2 AiL From To
From To From To
From To From To
6. CASING: Thickness/
Fran j Depth Disa.,n er Weight Materiel
To SX Ft. L �j 2/•C PVC -
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From O To 5 FL 544JGi,> At y V tkle
From 3 To Z 0 Ft. .ev2ohr.,/c Al :if 1-/i7inil
From To Ft.
& SCREEN: Depth Diameter Slot Size Material
Frcm To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0 - /D
<O — 30
a°-70
'7n - a7s
11. REMARKS:
Formation Description
/y sO,P
RErI�/;:
rvuv_a f2u06
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO v)E WELL OWNER
SIGNAAnTUR1�{OF CERTIFIED ELL CONTRACTOR 10 DATE �
PRINTED NAME OFPERSONTHE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR
Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #01 applicable)
334344
STATE WELL PERMIT#(ir applicable) Ota% 00l (')q 332.
DWQ or OTHER PERMIT #(rt applicable)
WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED IC /30 { /0 (0
TIME COMPLETED
'3 30 AM PM;
g_
WELL LOCATION: T�
CITY IJ O,v\(ti.. COUNTY i-E-2Y,ciQKCn
(gn8,Tusfi�t Fh'iIs /7hite2
treat Name Numbers, Commumty Subdrwsron. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope nValley ❑Flat 2Ridge OOther
(check appropriate box)
LATITUDE 37c/1)5//�
LONGITUDEQ$.2° a(' 331-()
May be in degrees.
mrnwes, seconds or
in a decmal forma[
Latitude/longitude source: IC GPS ❑Topographic map
(bcation of wel must be shown on a USGS topo map and
attached to this fore A not using GPS)
4. WELL OWNER ^� r,
OWL1
OWNER'S NAME 0.71 T- V) k)e_
STREET ADDRESS P O P),-) X )0'3g
pcx_inq tvC Zar7?
Crty or Town State
( CC2SC- )- 6 S— — 1091
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ) T5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing. (s 0 FT.
(Use -+" if Above Top of Casing)
0. 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): RJT.c METHOD OF TEST Air
r. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth
From / % j To / 3 ;,) From To
From To From To
Fran To From To
6. CASING: Thickness/
Depth p Darter Weight MAtenal
From L To L If Ft. L df %/ L Y//L
From To FI.
From To Ft.
7. GROUT: Depth Material .L Method
From 0 To 3 Ft. SAkgra-1 M;) ryo<
From To FI.
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.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
—
O30
3 0 •'
b`5 - `t3-
II. REMARKS:
Formation Description
?w4 sc'f
? Sr0.JF
R d'4r fIC
RECFIVED
Div or WATE r 1 hALI I Y
NOV 0 6 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTIO ANDARDS. AND THAT A COPY OF THIS
RECORD
HAS BEEN PROVIDED TO WELL 0 ER
i t . if LNG 1a 30--0(
SIGNATURE CERTIFIED WELL CONTRACTOR DATE
/3 Ry 4-ct—Sni•'71-4t
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.
Earn GW-1a
Rev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality I/
0
WELL CONTRACTOR CERTIFICATION # 2140
1. WELL CONTRACTOR:
Reuben Caldwell
Well Contractor (Individual) Name
Reuben Caldwell's Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 351 New Leicester Hwy.
Asheville, NC 28806
City or Town State
( 828 )- 254-3581
Area code- Phone number
2. WELL INFORMATION:
Zip Code
SITE WELL ID (f(d applicable)
STATE WELL PERMIT#(( applicable)
DWQ or OTHER PERMIT *Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply II
DATE DRILLED 10/ 3. V e (42 /
TIME COMPLETED 3 - ''' �? AM O PM ET
3. WELL LOCATION:
/ iy,, ' �^
CITY: 'L W"8 ry i� 1 L 1. le-" COUNTY T`�la bt (25E
31 i n -r t,.,Aa't3 e_Ctfg-
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SE NG:
❑Slope DVafey ID Flat Oidge ❑Other
(check appropriate box) /�1^
LATITUDE 3 5 R \
LONGITUDE 2 � r� (1 - I O t
Latitude/longitude source: GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this font not using GPS)
4. WELL OWNER l
OWNER'S NAME ^'AIA,N)A
STREET ADDRESS 31 Se INIT.
May be in degrees,
minutes, seconds or
in a decimal format
Arts lv pt-CSor-1 \i
City or Town State
( n1. 1-11- A4 1A
Area code - Phone number
reN t i- C u.
L_/4/(l.3 L_ Qo'4L
Zip Code
5. WELL DETAILS: 0 /
a. TOTAL DEPTH:5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: YJ 0 FT.
(Use "+" if AboveTopof Casing)
d. TOP OF CASING IS , FT. Above Land Surface
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. /f
e. YIELD (gpm): 1 METHOD OF TEST QI(, . A i tt_
t. DISINFECTION: Type 1.714 qos/ Amount o ,✓
g. WATER ZONES (depth):
From 5 6 0 To 3 b From To
From To
Rom To
From To
From
To
6. CASING: ( ( Thickness/
Depth A qo'/ Wjal VM
Fromht
To to, -A. �l- ti
From To Ft.
From To Ft.
7. GROUT: Depth ff� Material /� Method
From -. " FL CETo a-(n6NFb
= otter7
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To R. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Front — I31
3`1'— '36o
r36 D `- 365 `
4CS'
11. REMARKS:
Size Material
Ft.
Ft.
Ft.
Formation Description
(,-a (L.ir-) ITS
C44s4l C.E _._ —1 Gen,
C (LAre- E
re-.[e• rvr..�
int;.Tcp
UK tO ZOO6
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d en, � u,
I Q 3 0 6
SIGNATU E QF CERTIFIED WELL CONTRACTOR D E
(h1163 q3f1/43
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
JAN 0 2 2Rpv1 7/05

North Carolina - Department of Environment and Natural Resources - Division of Water
1636 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone] Quality - Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Box): ® Residential ❑ Municipal ❑ Industrial 0 Agricultural E] Monitoring
❑ Recovery ❑ Heat Pump Water Injection ❑ Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: SALUDA County: HEND
399 OLD MTN. PAGE RD. DRILLING LOG
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To DEPTH
3. OWNER MARK BEDDINGFIELD Formation Description
Address 399 OLD MTN. PAGE RD.
(Street or Route No.)
SALUDA NC 28773
City or Town State Zip Code
4. DATE DRILLED 11/09/06
5. TOTAL DEPTH 205
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? ❑ YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15A NCAC 2C.0118
10. YIELD (gpm): 15 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 4.5
13. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 80 Ft. 6-1/4" SDR.21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. OUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft. in. in.
From _ To Ft. _ in. in.
From To Ft. in. in.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
r, r
33
If additional space is needed use back of font
ft n
731
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #26 W. FROM COLUMBUS. LEFT ON EXIT 59. RT. ON
HWY. #176 W. LEFT ON GREENVILLE ST. LEFT ON OLD
MTN. PAGE RD. 3RD. DRIVE ON LEFT. (391 ON BOX)
RECEIVED
DIv OF WATER QUALITY
DEL i' 2 2U06
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
ask . //-
IGNATURE O1,PERSON CONSTRUCTING THE {MELT, DATE
ubmit original to Division of Water Quality, Groundwater Section within 30 days
GW-I REV. 12/99

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or Town
( 828 )- 693-1200
State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(tt applicable)
STATE WELL PERMIT#(d appl¢ade)
o 40 ao/o Mk LIL%
DWO or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED l - 31 -0(
TIME COMPLETED y 4 i 00 AM PM ❑
3. WELL L,S
OCATTION:^��
CITY. }-kflid-In1111 k COUNTY0 9ASUn-)
19.0 ihcklen MeoviS Lt5 Tom&
(Sweet Name. Numbers. Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:❑Slope ❑Valley ❑Flat l94ldge ❑Other
Ichech appropriate box)
LATITUDE && I 0 (ON
LONGITUDE 1)1L° .21' 53 L(
Latitude/ongitude source: %GPS ❑Topographic map
(bcation of wel must be shown on a USGS topo map and
attached to this tam 1 not using GPS)
4. WELL OWNER /^
OWNER'S NAME I(-s_.k P;iLA-r5i S
STREET ADDRESS QSC, o E44ge QiI
del, C'YSCY1U 111�, i� _2-
City cr Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
CAS- 32E 5
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH:
ab5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO1g
c. WATER LEVEL Belau Top of Casing: � FT.
(Use -+' if Above Top d Casing)
d. TOP OF CASING 15 I FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST//\
335479
f. DISINFECTION: Type Amount
g. WATER ZONES (depth) Z
From / C 0To /!..j From
From . 5 0 To -"If7 j. f From
From To From
6. CASING:
Depth
From / To Z 1 FI
Diameter
L �
From To Ft
From To Ft.
7. GROUT: Depth Material
From Ci To 3 Ft. S
Frorn •3 To t' Ft
Fran To FI
8. SCREEN: Depth
From To
From To
Fran To
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
To
To
To
Thickness/
Weighs Material
1, 1 . E P l /C—
Diameter Slot Size
Ft. in.
Ft. in.
FI. in.
Ft.
Ft.
Ft.
Sae
yI Method
At; t' co
in.
in.
in
Material
Material
0
IND
en
t�
-J
Formation Description
/ — /2 — 54k.'cly 5C,,
PI-- 2 7— GW/1v( hi:
25 — 'IS 9,)2t—
II. REMARKS:
RECEIVED
01 6 ?n06
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITh
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TQ E WELL OyI),ER.
H iZ L.�, -04
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
411I'4EOFPE547,,ONS
PRIN ED fN E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mali Service Center — Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
Anthony Bryant Smith
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division ni Water Quality
WELL CONTRACTOR CERTIFICATION # 2571 3 3 5 4 7 2
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Teem Stale
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *of epphwde)__
STATE WELL PERMIT#(if applioade) Dip) ?-O I (Jar-/ 3
DWQ or OTHER PERMIT #(if applicable)_-
WELL USE (Check Applicable Box): Residential Water Supply (EJ
DATE DRILLEDZ'7 - OG
TIME COMPLETED D . (/ 0
3. WELL LOCATION: �" CITYHt itcL(Jci•nu,t(e COUNTY 41-+ioL(I`i.e, 1
Lc i S��i�C','i-Yornr Sl,�l'X(.v trur�
(Street Nome,Numbers. Community, Subdivision Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope oValley ❑Flat C3Rfdge El Other
(check appropnate box)
LATITUDE 35171 ' 3/4/
LONGITUDE(
Latitude/longitude source: L..6PS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to th/s form 1 not usng GPS)
4. WELL OWNER
OWNER'S NAME T FLdu- .cWS-f-yR CH Cr
STREET ADDRESS 5(rye S FCY vn' LQn
Zip Code
AM PM
May be In degrees,
minutes, seconds or
in a decimal formal
City or Town State Zip Code
AZsl )_ L9L - rd03ra'
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 05
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO c
c. WATER LEVEL Below Top of Casing: S,O FT,
(Use -+- if Above Top d Casing)
d. TOP OF CASING IS / FT. Above Land Surface•
-Top a casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem). /t METHOD OF TEST Air
f. DISINFECTION: Type HTH Amount
9. WATER ZONES (depth).
From % 79 To yyp Fran To
From To From
To
Fran To From
To
6. CASING: Thickness/
Depth Dta ter Weight Matenal
From / To 5-.57 FL
From /.L
To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 _ To_FI.SrT, k%•
From To_ Ft`i
. a,ofewith
From To Ft.
8. SCREEN:
From_
From
From
Depth
To
To
Method
.
Diameter Slot Size Materal
Ft. in. in.
Ft. in.
To Ft _ in.
9. SAND/GRAVEL PACK:
Depth Size
Fran To Ft.
Fran To Ft.
From To Ft.
10. DRILLING LOG
From To
-iv
Ii ` YG
4,0 — AOi
11. REMARKS:
all.
In
Material
7\^
rJ
Formation eescnption
ire]
DEC06t'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED (r9 THE WELL OWNER
SIGNATUFCERTIFIED yyE NTRAC70R pq O{
E
rJ S r
PRINTED NARIE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
335473
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City a Town State
( 828 )- 693-1200
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) //
STATE WELL PERMIT#(if applicable) O(Q / (W)/ /610/
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED //'%f Ts -e.
TIME COMPLETED /2 100
AM g- PM ID
3. WELL LOCATION:.
CITY. FICA ( , COUNTY
ac? hodowbrook--1riup
07?
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
E Slope z<aIley ❑Flat ❑Ridge El Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS O Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this forth if not using GPS)
4. WELL OWNER _
OWNER'S NAME-OVbtVt : QY1-i11, rcL6.2
STREET ADDRESS QZCI Slb(ioW b vocc- Dr.
Flaf?o c4 1t C, c??6 13
City or Town State Zip Code
(S;Z8 )_ 4v9%-0g53
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2 /
b. DOES WELL REPLACE EXISTING WELL? YES g—NO ❑
c. WATER LEVEL Below Top of Casing,
(Use "+- if Above Top of Casing)
90"
FT.
d. TOP OF CASING IS / FT. Above Land Surface'
-Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / 0 METHOD OF TEST Air
f. DISINFECTION: Type HTH
g. WATER ZONES (depth)
From 2 0C To 2 440
From To
From To
6. CASING:
Depth
From / To /2 r Ft.
From/25- To/ 24 Ft.
From To Ft.
Amount
From To
From To
From To
Thickness/
Diameter Weight
7. GROUT: Depth Material
From O To 3 Ft.
Fran 3 To Z O Ft.
Fran To Ft.
Material
6/x-tt%
Method
8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. in.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
29�
D
-90
Flo -zcs-
11. REMARKS:
in. in.
in. in.
Size Material
C
Fg;:--01 nUI )Lion
firSn4 `I
Or t
AEF.k Rock Y-414-7
dhwrfF
RECEIVED
nIV. OF \NA%ttn CAJAL'T
OEC 9 6 71101)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 20, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDEO THE WELL OWNER.
75
SIGNAT� E OF CERTIFIED WELL CONTRACTOR DATE
/f ,-4.t�f
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Bryant Smith
Web Contractor (Individual) Narne
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or Town State
( 828 j. 693-1200
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if apWcebic)
STATE WELL PERMIT#(if applicable) ZC. laa 35
DWQ or OTHER PERMIT $(if applicable)
WELL USE (Check Applicable Box). Residential Water Supply ❑
DATE DRILLED I I - l (7
TIME COMPLETED WOO AM l:? PM ❑
3. WELL LOCATION: 1 _ ��
CITY.-kn--4.QJe "5d nOiI�COUNT? Liter ,Seill
r221 Peace-ktl Ortjti t Dr.
(Street Name. Numbers. Community. Subdivision. Lot No.. Parc
TOPOGRAPHIC / LAND SETTING
Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box) - /
LATITUDE ° of II Q 11\
LONGITUDEOSZ0 aI I o(.L)
Latitude/longitude source: 1si3PS ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER 1 /� I ,,
OWNER'S NAME �14-Ci F�T1LrV e j
STREET ADDRES5Z1p tb 1-0-f"7LVJY )�/I e(V
Zip Code)
May be in degrees,
minutes. seconds or
in a deamal formai
�erlrLQ nl)i I lc' IJC as'79Z
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
V
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 13'
c. WATER LEVEL Below Top of Casing. 6 L' FT.
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm). IOC r METHOD OF TEST Air
3354'74
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth).
From q25 To 1-30 From To
From To From To
From To From To
6. CASING: Thickness/
Depth !� Diameter Weight Material
sj
From / To (Ft. C. ? i4 /4 A/C -
From To Ft.
Fran To Ft.
7, GROUT: Depth Material Method
From 0 To 3 Ft. 5,,k4Et& rM� :: y St-Pdt, /c
From ,� To 2(7 Ft. r3 A,rvlan.`FJ /+tij%Pen4
From To Ft,
8. SCREEN: Depth Diameter Slot Size Material
Fran To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft. p
From To Ft. (D
From To Ft. ITT
cm
o
---a
10. DRILLING LOG
From To
0— 20
Formation Description
%R r
Cc- L O n'E1v✓ $/rn/�
-/t 3n ?RAiurfx
II- REMARKS:
REC.FIVED
DIV OF 1AMATFR QUALITY
DEL 0 b 200UI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED 30 THE WELL OWNER.
SIGNATURE OF CCERTIFIED WELL CONTRACTOR DATE
13AHA-m%—r5n/r J
PRINTEDISIAME 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 or Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
3 354:75
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(if applicable) 04'/00037"W.
DWQ or OTHER PERMIT #(A applicable)
WELL USE (Check Apricabllox): Residential Water Supply 0
DATE DRILLED
TIME COMPLETED L DO AM ❑ PM V
3. WELL LOCATION:
CITY- ,'�-� S1)
nn11Y��1It I-e
c H Lash I ryn.T n ^' t
COUNTY
'Sp
(Street Name, Numbers, Community, Subdivision. Lot No.. Parcel, Zip Code
TOPOGRAPHIC / LAND SETTING:
❑Slope galley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE
3 h a at r �l(pni
LONGITUDE%%2° aot 1g110
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 6 ;PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
Larnj gy'acPS
STREET ADDRESS Q'I-! I /?cf1n fail
K)2 � to
.lry or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
_I
S
b. DOES WELL REPLACE EXISTING WELL? YES CNO 0
c. WATER LEVEL Below Top of Casing: I / FT,
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 15 METHOD OF TEST A. 7
9.
f. DISINFECTION: Type r' f4- Amount
WATER ZONES (depth).
From 350 To-f 07 From To
From To From To
From To From To
6. CASING:
Thickness/
Depth 7 Diameter Weight Material
From To �7 Ft. G per Ate'. r(rG-
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 3 Ft. S,apafa gt.'y4.1thJ� q
From 3 To 7, Q FI.J toc. yj,- pl,Ty
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
rlq
Sf D
9D— fO
11. REMARKS:
F-
O
ion Description
nix/ OF RECEIVED TAU I Y
UEC o ?nnr
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
:SA NCAC 2C. WELL CONSTRUC N STANDARDS AND THAT A COPY OF THIS
At
RECORD HAS BEEN PROVIDED O HEWELL
�OWNER
. J1,
14
SIGNATUR OF CERTIFIED WELL CONTRACTOR DATE
/3/7, r,7L s/itil
PRINTEONAME 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 # 2571
335476
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) 0 S7 ?.o/) P 1 1 1
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED I I H I O —C (.°
TIME COMPLETED 1 I 30 AM C§ PM ❑
3. WELL LOCATION:_ �'"
CITY: j AO.Xl'SO 10 tl.I2. COUNTY -r /yrS(Di
4114k,1K_L TA4s,(}Q(. radJuidsDew/ow/J- :ln ,)
(Street Name, Numbers, Community, Subdivision, L 1 No., P rcel, Zip e)
TOPOGRAPHIC / LAND SETTING:
p8fope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)' "
LATITUDE 35° cZ (o Oy-rv77
LONGITUDE OD° 1 q I
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: IcGPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
leI•chau4 ? `i STREET ADDRESS ZO 5 L, /yM S t' ( OOP eI
�
Ft air -r/ A)C 0413� /
City or Town State
(Sa )-108LL%"(1Q3k
Area code - Phone number
Zip Code
5. WELL DETAILS: t
a. TOTAL DEPTH: ( r-7 45
—
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [7
e. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface`
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 0 METHOD OF TEST Jn r
f. DISINFECTION: Type / Ft- _ Amount
g. WATER ZONES (depth):
From To From
From To From
From To From
To
To
To
6. CASING: Thickness/
From / Depth
if Ft. 2/ Dia er Weight Mot. prial
o4r�J eC--
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 3 Ft. S#Lgiil ALWA-ky)
From ,3 To 2 0 Ft. &-r/vn,ir- /FL`
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
3>
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
6 - / ,R f
/doe
11. REMARKS:
O
iV
0
Formation Description
DIV. OF WATER�JD ALITY
nEr: 0 B 200C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TRAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TITHE WELL OWNER.
1S/z� �DxL`rl' 1/ -/3-OC
SIGNATUiy�ER OF CERTIFIED WELL CONTRACTOR DATE
it
th
PRI0.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 N 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Web Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State
( 828 )- 693-1200
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID Rif applicable)
STATE WELL PERMITY(if applicable) O Lo I ao 10 9 Szs
DWQ or OTHER PERMIT Rif applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED //— .3 -- U C
TIME COMPLETED /, C'c AM 0 PM I]-
3. WELL LOCATION: ,, Q ���
CITY: y-�J dxr5ef) II li COUNTY \° r ram`^ ciln
Lot a'i rn+n meadows, tea_
(Street Name. Numbers. Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC/ / LAND SETTING:
elope DVaUey ❑Flat El Ridge
(check appropnate box) . I
LATITUDE _LS",70r 0/AiI�f
LONGITUDE (�Lt al u 53W
Latitude/longitude source: tGPS ❑Topographic map
(bcafion o1 wel must be drown on a USGS topo map and
attached fo this form l not using GPS)
4. WELL OWNER �/ �,U OWNER'S NAME /CL l I'nnt@essJ
STREET ADDRESSAS(OO e KII
l—ktfl _PXSO71UL te, KJ(2 C q9,9
City or room State Zip Code
(CL )- ass-
Szf5
Area code - Phone number
❑Other
May be in deuces,
minutes, seconds or
in a decimal format
& WELL DETAILS: �//,,,,
a. TOTAL DEPTH: 1—r17.5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 6
c. WATER LEVEL Booed Top of Casing: 5 10 FT.
(Use -+ if Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST 4-1 Y
335477
I. DISINFECTION: Type f 1 Amount
9.
WATER ZONES (depth)
From / fa To /85 From To
From 3 %(' To 377 From To
From To From To
6. CASING:
From
From
From
Thickness/
Depth Diameter Weight enal
u To Y FL L $ / (;
To FI.
To
7. GROUT: Depth
Fran
From
Fran
Ft.
O To 3 Ft. 5
3 TD -1 C Ft.
To Ft.
Material
Methodet
(1J7 c1
8. SCREEN: Depth Diameter Sid Size Matenal
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 ^2,C
T --SL
5_ J -- 7C r r
11. REMARKS:
`Formation Deescnp ion
VA7-waily SO
. v S 't�.r; r=
Dv, Q WATER QUALITY
nEC 0 F 200E
I CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTIQN STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED r,OIrHE WELL OWNER.
Ott 1/-?'0t
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTEDSAME 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 # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City a Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable) O(o / aQ (OZb to
/
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 11
TIME COMPLETED 57 00 AM ❑ PM p-
3. WELL LOCATION:I,' II .'
CITY: 44t,.('i11�Yr1)I)le COUNTY 1te4cLtrsvn
Ci +141rfdtsc 114gacnw'sA7bt(o, Darn,
(street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge E0ther
(check appropriate box)
LATITUDE 3S°_LD r 0TA/
LONGITUDE D Z" .21 r 5 314)
Latitude/longitude source: BOPS OTopographic map
(location of we/ must be shown on a USGS topo map and
attached to this form if not using CPS)
4. WELL OWNER / (2��
OWNER'S NAME I, UL0ieCS
STREET ADDRESS aS1o0 l .P Oaf
Lie-I')ctuisunu \le, UC_a€' R2.
City a Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
(`62e)- 60€5-3Zbs-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Toy/
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO-liej
c. WATER LEVEL Below Top of Casing: 80 FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a valance in 1
a�ccc-dance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST it
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
-
335-478
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From /LC To /!oi From To
From y y0 To 1-/ ' 3 From To
From To From To
6. CASING: Thickness/
Depth Iameler Wei®pt t feral
From / To L $ Ft. 21.4 /'LC
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To ) Ft. -a_
From 3 To v Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Matenal
From To Ft. in. in.
From To Ft. in. _ in.
From To Ft. in. in.
22,
G
d'‘,D
ry
Formation Description
5•gice(y &T, @f�)ftsr I� '
t/r;%
7 (D Hrcei Sroltdr
11. REMARKS:
RECEIVED
rift OF WATER uuALITY
OEC 0 6 ZOOS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED ,TV THE WELL OWNER.
-04
SIGNATU ER OF CERTIFIED ELW L CONTRACTOR DATE
I PRINTEDMAME OF PERSON CONoTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR
�. �cc•eko �� Saw feet
Welt Contractor (Individual) Name -
42- ' in. _- } 9n
Weil r ,hacla Company Nn
STREET ADDRESS _,yy_ $�, '�4—
oC:nit Air - o o'1t-13
Area code- Phase number
2. WELL INFORMATIObt
SITE W ELL ID are applicable)
STATE WELL PERMITB(aeporcabe)
DWQ or OTHER PERMIT #(rf applicable)
USE (Check Ap sewe goes): Residen(iat Wes Supply
DATE DRILLED - 9- yam_
TIME COMPLETED C� • AM 0 PM
3. WELL LOCCAATTION:�
Cam: a e'Jr.ciai�y %4 COUNTY
City a Tovm a -Zip Code
311Gdora Cm" L-°+
4. WELL OWNER
OWNER'S NAME - Cae) Cl1,0E4-6
STREET ADDRESS
RESIDENTIAL WELL CONSTRUCTION REC0 2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # - ati 3to
•
•
Cooley .
{Sheet Tame, Numbers. Community. Subdboisicet. Lot
�TO1ppG RAPHIC f LAND SETTING:
4W1Ope °Valley O Flat ❑Ridge 0 Other
(cheek appropriate boxx
LATITUDE j
LONGITUDE_ _
Latitude/longitudesrnace: CUPS CT
(location of wed must be Topographic amnd
sit using
on a S) topo map a d
attached tothis form not usbrg GPsj
—BSnAtraanv• t\e A)C gg'tq o1
City or Town tale Zip Code
(Rah > (085- Varn
Area code - Phone number
A WELL DETAILS:
a. TOTAL DEPTH: o_
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO r-
c.. WATER LEVEL Below Top of Casing:
(Use'+' d Above Top of Casing )
d. TOP OF CASING IS
*
'Top of casing *minotedr�a below land s�urffaceLaW Surfaceayr
a variance in accordance with 15A NCAC 2C .0118 require
e. YIELD (gpm):/_ METHOD OF TES__T R•ti
t. DISINFECTION: Typ._ia
9. WATER ZONES (depth):
From To From
From To
_ From
From To From
6. CASING:
Depth D�'1a_ne4
Fran�± To1.. Fl._—�-5i
Fran To Ft._
Frorn To Fl•
T. GROUT: Depth ma
enal
F
�� To Ft.
=—'s From To Ft_
From To Ft.
8. SCREEN:
From
From
From
Depth
_ To
To
To
9. SAND/GRAVEL PACK:
Depth
From To__
From To
From To
10. DRIWNG LOG
From To
11. REMARKS:
To
To
To
Th
`y
L
•�''MetthhodJ
Yam'
Danner Slot Size Material
FL_ in in.
R. __in in.
FL
FL
Ft_,
--T
Size Material
Formation Descript 0
IDO HEREBY t.ax ,vY THAT THIS WELL WAS COekitRUCIED N ISA NCAC 2C. WELL CONSTRUCTION; IA NDARb6. AND TNATA ACCORDANCEOrrin
TVl1l1
RECORD WAS BEEN PROVIDED TO TM:%ELL- - OF TITS
RE OF CERTIFIED WELL C .- CTOR DATE
ere Ck He0.4}:+- e..
PRINTED NAME OF PERSON „ONSTRUCTI G E WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information NIA,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
S1 NAT
Form GW-ia
Rev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #- o[l ate
1. WELL CONTRACTOR: -
2 e;cic xACc. h Saa11ayecs
Wen Contractor (Individual) Name
QV) CIA- " StXL t-C 5 % S,o rl.
Well Cohrractor Company Narita
STREET ADDRESS \1�G3% S vc.A..17
�9
Hoh S?c;�ngS) NC- olZ 43
sCity or Torn e -Zip Code
ppVa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mif applicable)
STATE WELL PERMIT#(reppricabie)
DWQ or OTHER PERMIT 4(8 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED t-io'C
TIME COMPLETED /.30 AM FMB--
3. WELL LOCATION:
' ♦�
CITY: , e, v/ arc heat COUNTY i ._ etst
Sbset Numbers.
unity.
{ Subdivision, Lot No.. Parcel, Zip Code)
T9*OGRAPHIC / LAND SETTING:
Slope °Valley ❑Flat .°Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE__
May be in degrees, I
minutes, seconds or
in a decimal format
Latitude/longitude source: °GPS °Topographic map
(location of wet must be shown on a USGS typo map end
attached to this form snot using CPS)
A WELL OWNER
OWNER'S NAME Mac x 'ac.0b6
STREET ADDRESS (%a \ ' KCct (Zoo,a
'Hence 6onv:L.e. j1c asi9a
City or Torn State Zip Code
( Sae. >_ (099- Star)
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: C OS
b. DOES WELL REPLACE EXISTING WELL? YES °
NO
c. WATER LEVEL Below Top of Casing: �d0 FT.
(Use+' if Above Top of Casing)
d. TOP OF CASING 1S i . Ff. Above Land Surface'
Top of casing temktated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
r
e. YIELD (gpm): O METHOD OF TEST (4:•3
t. DISINFECTION: Type...a_ Amount
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
DapB+
From_ki To - Fi,
From To Fl.
From To Fl.
From,
From
From
Diaryr
To
To
To
Thickness/
7. GROUT: Depth Material Method
From Ct 0 To 20 Fl. tiejeg � jam. a j
From To Ft. i"`�s—
From To__ FL
8. SCREEN: Depth Dia peter stir Size Material
From To Fl. in. __.. n.
From To Ft. in
n.
From To Fl. n. in.
9. SAND/GRAVEL. PACK:
Depth Size Material
From To- Ft..
FranTo Ft —�—
From To FL -'--
10. DRIWNG LOG
From To Formation ,Plu
-t9 Gas- _=
11. REMARKS:
5
�s ITY
_000
1 DO HEREBY CERTIFY THAT Tay WEL L Y'AS CON1Rl'CTED N ACCORDANCE WITX 1SA NCAC 2C. WELL CONSTRUCTION STA NDAROS AND TWA COPY OF THIS
RECORD HAS BEEN PROVIDED TO Thai IA °Wee
SIGNATURE OF CERTIFIED W
'beret Ck %-►E44y 6r'. uvree5
PRINTED NAME OF PERSON ;ONSTRUCTING THE WELL
e9' •?cr
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: intonna
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568,
ion M -'„a
*arm GW-raj
Rev 7/05
DEC 12 2006

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of A'a:er (Nally
WELL CONTRACTOR CERTIFICATION #. 3k
1. WELL CONTRACTOR:
►� Q�C; a k, NAewh 'a&w•^1tcS
W r Contractor (Individual) Name
�.� rice_ 'J era. .y Ed' S * t1 n
Well Cr attar Company Nate
STREET ADDRESS \‘3\liSeB '�1w1 24q
%Aok TC'e4S) NC - a8'lui3
City or Town mete -Zip Code
(8a;)- (a(os- aaaa,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #fdappa b1 )
STATE WELL PERMIT/KO applicable)
DWQ or OTHER PERMIT S(d applicable) /
WELL USE (Check Applicable Box): Residential Water Supply f
DATE DRILLED 9' G- C
TIME COMPLETED /�, Or) AM gg---1!)
3. WELL LOCATION:
CITY44•141, v4 COUNTY e(%t
&yy
9ca.4 T1
{Stet Name, Numbers, Camanurdty. Subdnision, Lot No.. Parcel, Z9 Code)
T9POGRAPHIC / LAND SETTING:
lope ❑Valley OFTat ❑Ridge ❑Other
(theee appropriate bar)
LATITUDE 3
LONGITUDE
May be in degrees,
minute, seconds or
in a decimal format
Latitude/longitude source: ❑GPS O Topographic map
Oration of wet must be shown an a USGS topo map and
attached tothisform /not usig GPS)
4. WELL OWNER �u
OWNERS NAME :Ira
Lai tact
STREET ADDRESS a2 awl` on,e Son Si- Ceti
? endeds°nv:tiej Ak a8r792
City or Tom State Zip Code
(gas ). (o8`3/4- TIo a
Area code - Pawn number
5. WELL DETAILS:
a TOTAL DEPTH: (OS
b. DOES WELL REPLACE EXISTING WELL? YES O NO E)i'
a WATER LEVEL Below Top of Casing: 4/1/i0 FT.
(Use'+' it Abwe Top of Casing)
d. TOP OF CASING IS . FT. Above Land Surface"
'Top of casing tenured aVar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / METHOD OF TEST (4.•3
3352a7
1. DISINFECTION: Type ;;. t 15 Amourr JQ
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: - Thedmess/
Depth DtIer Weight nt f'//r
rial
Fran To Fl._ be
From To
Ft.
From To FT.
7. GROUT: Depth Material / Method
From 0 To gel FL [FleNte.r /0Foreeirere
From To R.
.._. _ _.
From To F1.
8. SCREEN: Depth Dior Halm Slot See _ Material
From To Fl.
From To P. in.. in. t7
From To Fl. in. in. IT1
9. SAND/GRAVEL PACK: r✓
Depth Size Malarial iC
From To - FL N
From To FL g
From To FL '
10. DRIWNG LOG
From To Formation Description -
/ 3�(p OUP." adero of
»t; 605"
11. REMARKS:
G�oeeTete
1 DO HEREBY CERTIFY THAT THIS WELL Y'A9 CONS1RL'CTED N ACCORDNCE WRX
15A tA:AC2C. WELL CONSIRUCTION l:TA NDARDS. AND THAT A COPY OF DOS
RECORD WAS BEEN PROVIDED TO 714.10)LL OWNER.
SIGNATURE OF
CONTRACTOR DATE
ble Cr. e-W \AtO j1 6‘20Anc3
PRINTED NAME OF PERSON X'NSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mal SeMee Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ia
Rev. 7105

.va STAB 8
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
May be in degrees,
LONGITUDE(OI/W minutes, seconds or
j in a decimal format
Latitude/longitude source: PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME /gyp
EET ADDRESS
vven t ntractor Company Name
STREET ADDRESS 1 N f (I ' y/
SfE tale
City or Town State
Area code- Phone number 2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable
Sox): Residential Water Supply p'
DATE DRILLED____/ /„'_---
TIME COMPLETEDD
AM ❑ PM
3. WELL LOCATION:
CITY: %.ar )(yh t"' COUNTY��/�
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE iIsf�
r
City or Town State d /
Zip Cade
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: SSC'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I:
c. WATER LEVEL Below Top of Casing: F��/
(Use `+- if Above Top of Casing) ' —�'
d. TOP OF CASING IS r
'Top of casing terminated at/or below land surfacenmS requirer
a variance in accordance with 15A NCAC 2C .0118.E
e. YIELD (gpm): � METHOD OF TEST y
f. DISINFECTION: Type,�.��e��r�""
-t4-_ Amount_
g. WATER ZONES (depth)
Thickness/Depth Diameter Weight
MaterialFrom_, T�e"ala,nFrom To Ft. From
8. SCREEN:
From
From
From
SAND/GRAVEL PACK:
Depth
From To
From To
From Tn
Diameter Slot Size
Ft. • in. in.
Ft in. in.
in. in.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WE • W ER.
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext568.
Form GW-la
Rev. 7/05

r/t COUNTY_1�
(Sheol Name, Numbers, Community, Subdiv
ision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC /LAN TTING:
OSlope OValley lat ❑Ridge ❑Other
(check appropriate box)
LATITUDE fU-=!' / r
_ May 4 in degrees,
LONGITUDE (Q I�� minutes, secalds or
in a decimal format
Latitude/longitude source: PS ❑Topographic map
(location of we/ must be shown on a USGS top° map and
attached to this Than "not using GPS)
4. WELL OWNER
OWNER'S NAME
S ' EET ADDRESSI
S
City or Town State
L++�'��LI-- c�c� Zip Code
Area code -_Phone number 6 8
5. WELL DETAILS:
r
a. TOTAL DEPTH: `nS' .
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use -+• if Above Top of Casing)
d. TOP OF CASING IS
*Top of casing terminatedFT. Above Land Surface*
War below CA surface may require
a variance in
accordance with 15A NCAC 2C .0778
'0
e. YIELD (gpm): 2rMETHOD OF TEST
,. SFATe
1. W CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION North Carolina Department Environment and Natural Resources- DivisioRECORD Water
of Quality
WELL CONTRACTOR CERTIFICATION
W II Contractor a x ( djvW ap Nam
r + 1
O l'
Well •nlractor Company Name
STREET ADDRESS
sN�LLStrR /V C. �7
(SAL-
or Town Stale
(N-A7_J- 201 9 Zip Code
Area code
Phone number
2. WELL INFORMATION:
SITE WELL ID #tit applicable! .v
STATE WELL PERMIT#(it applicable)__
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appli
DATE DRILLED .L
TIME COMPLETED
3. WELL LOCATION:,
CITY:
t, DISINFECTION: Type a
g. WATER ZONES (depth):
From To 217n
From To
From To
6. CASING:
8. SCREEN:
From
From
From
Depth
To
To
To
•335183
Amount
From To
From To
From To
Thickness/
arrneler Weight Material
&- 4)
Method
J
r
Diameter Slot Size Material
in. in.
Ft in. in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth
From TO FtSize Malarial
.
From To FL
From To Ft.
10. DRILLING LOG
From To Formation Description
a
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND RATA ACCORF THIS WIN HAS BEEN PROVIDED TO THE ELL + . 7NATA COPY OF THIS
SIGNATU- OF ERTIF' a r CONTRACTORink
�/ 2
IA
the PRI TED NAME •F PERSON CONSTRUCTING THE WELL
1617Submit
orgialoDivision
Quality within 30 days.
568.
Don Mgt., I Sett h gh, NC 27 916Phone No. (919) 733-715 ext
Form GWta
Rev. 7/05

RESIDENTIAL WELL
North Carolina Department of Environment and Natural TDOision o f WORD
ater WELL CONTRACTOR CERTIFICATION
Quality
q_,�'o�
n..
even r ntractor Com
partyyName
STREET ADDRESS
City or Town State
Q]t'J .-C�v('/jA/ Zip Code
Area code- Phone number`i`�
2. WELL INFORMATION:
SITE WELL ID kirapplicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Su I
DATE DRILLED ///��/�i ppy�
AM ❑ PM [L3'
3. WELL LOCATION:
CITY: ai°i !'
COUNTYN
�eCCr"t
try Numbers.1t��/5 / Community. S btl sion, Lot No., Parcel, Zip Code)
TO,OGRAPHIC / LAND SETTING:
Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE E& 2
LONGITUDE,-
d. r �J
Latitude/longitude source: PS °Topographic map
(location of weB must be shown on a USGS lopo map and
attached to this form d not usin GPS) 4. WELL OWNER Marlow /1'1 e 5 o /` r�k
OWNER'S NAME V2 A G/
FirJ' nrAf
STREET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State eZ
Area code - Phone number T—
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO •
c. WATER LEVEL Below Top of Casing:
(Use'+• if Above Top of Casing) ----FT'
d. TOP OF CASING IS _L.__ *Top of casing terminated at/or below and surface m ySrequire
a variance in accordance with 15A NCAC 2C . require
e. YIELD IS__ 0718-
(gpm):METHOD OF TEST I' r
From
From
From
6. CASING: r v
Thickness/ Depth
From_ j� TD_- Diameter Wight �aterial
.� 2I-1djrasa?,
From To
Ft.
_ 7 Ft
From
f. DISINFECTION: Type. ., G
Amount
g. WATER ZONES (depth)
:
DTo___2 j From T,
To
9. SAND/GRAVEL PACK:
Depth
From
From To__
From
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL NER.
PRINTED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05
CD
2�:

RESIDENTIAL WELL CONSTRUO
North Carolina Department of Environment and Natural Resources- FDivisionn of CW RD
WELL CONTRACTOR CERTIFICter Quality
CERTIFICATION
n..
F. DISINFECTION: Type
g. WATER ZONES (depth):
From ToJ JL
From To
City or Town State �...
a'i ill
Area code- decode-- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMITS/Of applicable)
DWQ or OTHER PERMIT //Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED /Q G/
TIME COMPLETED a
AM PMa�
3. WELL LOCATION:
CITY:
GG-- GCOUNTY_Lzaksw
(Steet Name, r
Numbers, Community,
y Subdivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LgNpsFTTING:
0 Slope 0 Valley Iat ❑_ Ridge 0 Other
(check appropriate box) —�
LATITUDE(433 r ✓fi„ ,,S,„!.7/
3SMay be in de&ecs.
LONGITUDEL�Q ` ' in a des,se<ondsor
12 6 / in a decimal fomrat
Latitude/longitude source: QQ_—�
(location of well must be shown a U GS t0 , m is anddp
attached to this form if not usingtopo map
GPSJ
City or Town
Litn j- IF g�7
Area code - Phone n----umber
5. WELL DETAILS:
a. TOTAL DEPTH: 2j__ �s
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO G
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing) ---FT.
d. TOP OF CASING IS FT.
'Top of casing terminated auor below land
Above Land Surface'
a variance in accordance with 15A NCAC surf ace may require
2C .0718,
e. YIELD
(gpm)'METHOD OF TEST�J
9. SAND/GRAVEL PACK:
Depth
From To
From
From
I OD HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, A COPY OF HIS WITH
RECORD HAS BEEN PROVIDED TO THEEND HATA COPY OF THIS WELLOWNER.
PRINTED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05
3351
S

STATE
RESIDENTIAL WELL
CONSTRUCTION
North Carolina Department of Environment and Natural Divionn of WaRD
ter Quality
WELL CONTRACTOR
CERTIFICATION 267
#
even ntractor Company Name
STREET ADDRESSLL
I.
City or Town State
Zip Code
Area code-
a ber
Phone number
2. WELL INFORMATION:
SITE WELL ID #tif applicable) 00
( pp 3
STATE WELL�9
PERMIT# if applicable)
D WQ or OTHER PERMIT #(if applicable)_
WELL USE (Check Applicable Box
Residential Water Supply
DATE DRILLED
TIME COMPLETED —/
3. WELL LOCATION: AM 0 PM LT
CITY: _glit
Ali_ COUNTY -ram
Numbers,
/a Y �'fTy
Community, Subdivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LAN ING:
❑Slope 0 Valley lat ❑Ridge ❑Other
(check appropriate box) -�
LATITUDE 4/3S / f l' /
LONGITUDL�.1J�Lr
Latitude/longitude source:
PS Topoic
(location of well must be shown on a ❑USGS fopgraphO map ndp
attached to This form (not using GPS) and
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town State
V )-�4 I' Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: _____y_
(Use -+' if Above Top of Casing) —FT'
d. TOP OF CASING IS
*Top of casing terminated ator below and surfacemay Land y rerequiquir
a variance in accordance with 15A NCAC 2C .0778re
e. YIELD (gpm): --fV/____ y
METHOD OF TE5Tlladaji
l
Submit the original to the Division of Water Quality within
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No.
May be in degrees,
minutes, seconds or
in a decimal format
3351 75
f. DISINFECTION: Type j /jr/
r �L?� Amount /Jn>
9. WATER ZONES (depth):
From
From / To y' From To
From From To
To
6. CASING: r °
Depth Thickness/
Diameter Weight Material
From To Ft. Z✓/./aS n.�1 J
From r __
10. DRILLING LOG
From To
i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED A ACCORDANCE WITH
NCAC 2C, WELL CONSTRUCTION STANDARDS, AND
THAT
RECORD HAS BEEN PROVIDED TO THE WEB OW ER. COPY OF THIS
PRINTED NAME aF PERSON CONSTRUCTING THE WELL
30 days. Attn: Information Mgt.,
[phone] ext 568.
Form GW-1a
Rev. 7/05

w STAY
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
n °
vveu Cpntractor Company Name
STREET ADDRESSL
City or Town State
SA:e�. Zip Code
Area-
codee-Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Wat
PPYB�
DATE DRILLED
TIME COMPLETED /
AM ❑ PM ❑
3. WELL LOCATION:
CITY: COUNTY HY O
IZ
r name; b Numers,u"'�
Community. Subdivision, Lot No., Parcel, Zp Code)
TOPPOGRAPHIC / LAND SETTING:
ar'Slope [Valley DFlat °Ridge ❑Other
(check apprppriate box) �---
LATITUDE 4V 3 S ! aJ / /73 / May be in degrees,
LONGITUDE6a$h.° �'/` rJ/ 111e`�•onds or
in a decimal format
Latitude/longitude source: S
(location of we# must be shown on a UUSGS 0 map ndp
,
attached to this form # not using GPS) po and
4. WELL OWNER
OWNER'S NAME lnq T / v
STT ET ADDRESS _ t_ U
rn
"t�^' ore the NC City or Town State 'Z ��
Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTHS
b. DOES WELL REPLACE EXISTING WELL? YES[ NO 'r
c. WATER LEVEL Below Top of Casing: r�
(Use'+" if Above Top of Casing) FT.
d. TOP OF CASING IS FT. Above Land
'Top of casing terminated at/or below land surface maySace*requir
a variance in accordance with 15A NCAC 2C .0176require
e. YIELD (gpm):
METHOD OF TESTb
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From To
From
335163
Thickness/
Depth
From_ To Ft. D r We�ig�hhtj' aateeriialn,
From To Ft. —� p"- 'ac"^ /
From__. To 1=r
7. GROUT: Depth
From iI Material
To Ft. I22:
From To Ft.
From To cr
9. SAND/GRAVEL PACK:
Depth
From To
From To
From
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED NACCORDANCE WM1
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND
RECORD HAS
BEEN PROVIDED TO THE WELLAWNER. TiATA COPY OF THIS
PRI TED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. (919)733-
Y
7015 ext 568.
Form GW-la
Rev. 7/05
CD
f-rl
Li
(ND
0
0
rn

STATE
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Dep
artment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
vven pfntractor Company Name
STREET ADDRESS�7
City or Town r Stale
9
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID kit applicable) �0 1
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Su I DATE DRILLED pp
�/
TIME COMPLETED
3. WELL LOCATION:
CITY:
�)/ISP IyJQQ
—`--�_ COUNTY
-7/51
(Street
Name,Numbers.
Com unity, S btl rtsion, Lot No., Parcel, Zip Code)
TD5.1pGRAPHIC / LAND SETTING:
rest -lope ❑ Valley 0 Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE tt/ 3�C, /
LONGITUDEJ/BQ r-
r
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME
City or Town
c Q�.�, �x r—t State Zip Code
Area code /2 hum r 0_ R <(0
Phone number
5. WELL DETAILS:
a. TOTAL DEPTH. </ 7/��
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO /
c. WATER LEVEL Below Top of Casing: !,/ 9
(Use `+• if Above Top of Casing)
d. TOP OF CASING IS
'Top of casing terminated at/or FT. Above Land Surface*u
a variance in accordance with be w land surface may require
/,., SA NCAC 2C .0118.
e. YIELD (gpm):-4i=____ 7311/
Pi
I
METHOD OF TEST
May be in degrees,
minutes, seconds or
in a decimal format
f. DISINFECTION: Type
g. WATER ZONES (depth):
33Si
Depth Thickness/
Diameter Weight Material
From_ a _ To_�._FL4� Z Weight
r leeCS of
From `�'�4/
To Ft.
9. SAND/GRAVEL PACK:
Depth
From T __
From T __
From
I15A NCAC 2C, WELL CONSTRUCTION STANDARDS, DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
AND THATA COPY OF THIS
R CORD HAS BEEN PROVIDED ID THE WELL OWNER.
Submit the original to the Division of WaterPRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit
1617 itil Service Center — Raleigh, Quality within 30 days. NC 27699-1617 Phone No. 919 733 Attn:tInformation Mgt.,
( 1 7015 ext 568.
Form GW-la
Rev. 7/05

COUNTydrithaika
SOLI Ca." cal
Community.treet Name, Numbers. Subdivision, Lot N o Parcel.
TOP RAPHIC / LAND SETTING: 1
lope [3Valley 0 Flat ID Ridge ❑Other
(check appropriate box) -�--�
LATITUDE r
,y y' min ce in degrees,
r ,� minutes, secoMs or LONGITUDEgr in a decimal format
Latitude/longitude source: 4;;IISE'S ❑Topographic (location of well must be shown on a UGS topo map ndp
attached to this form Anot using GPS) and
4. WELL OWNER
OWNER'S NAME
TREET ADORE
gator Towns� �f 9 Sate
gL O
atj- 12 7.-X'r t%j Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL pEPTH: ')jam
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO P
c. WATER LEVEL Below Top of Casing:�z�
(Use'+• if Above Top of Casing)
d. TOP OF CASING 1S _A__
'Top of casing terminated at/or below and surf ce may reqLd uire
a variance in accordance with 15A NCAC 2C .0118. dt
e. YIELD (gpm): %,S METHOD OF TEST r
RESIDENTIAL WELL CONSTRUCTION North Carolina De RECORD
Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H
n
vven e ntraclor Company
STREET ADDRESSL
sfxe n/
City or Town State
[/� Zip Code
Area code. Phone number en
2. WELL INFORMATION:
SITE WELL ID #(if applicabe) ('
STATE WELL PERMIT/Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable ox): Residential Water Supply
DATE DRILLED 9 � PPY 0
TIME COMPLETED-
3. WELL LOCH//TTION:
CITY:
f. DISINFECTION: Type
g. WATER ZONES (depth):
From Toa
From To
Diameter Slot Size
Ft. in. in.
Ft.
SAND/GRAVEL PACK:
Depth
From T
From
From
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND
RECORD HAS BEEN PR • r ED TO THE WELL OWN 7HATA COPY Or THIS
PRINTED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
335150

N..a SrA F'
.RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and Naturra Re ouurces- Don of Water
ECORD
WELL CONTRACTOR CERTIFIC WELL
CERTIFICATION
n,.
CL4Ciy or Town C� (1�State
1- S.3 `d`i / ZtP Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#lit applicable)
DWQ or OTHER PERMIT #(i/ applicable)
WELL USE (Check Applicable Box): Residential Water Supply t• DATE DRILLED,_-_? fabeB)--
TIME COMPLETED '
r—T-- O� —_ AM ❑ PM [L3�
3. WELL LOCATION:
CITY:
rrCv/1 �e
--�-�_ COUNTY
(Street Name,
Numbers, Community. Sub lesion, Lot No., Parcel, Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley 'Flat ❑Ridge ❑Other
(check appropriate box)—�-�
LATITUDE /0 3 S 19 . C�
LONGITUD�,("kr `jam=�3.—
Latitude/longitude source:
S ❑ topo
Topographic mdp
(location of Wei must be shown on a USGS map and
attached to this /orm trio( using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: a. TOTAL DEPTH: 2
b. DOES WELL REPLACE EXISTING WELL? YES 17 NO
c, WATER LEVEL Below Top of Casing: c�1-�r/�
(Use'+• if Above Top of Casing) -AFT.
d. TOP OF CASING IS _._
Ld Surface*
*Top of casing terminated at/or below lad�ace ma require
a variance in accordance with 15A NCAC 2C .0118.
y gwre
e. YIELD
(9Pm):—_ METHOD OF iESTii' ' '' . )
335148
V. DISINFECTION: Type ( a o Lr
--j-s/1Lea Amount
g. WATER ZONES (depth):
From To
From To� From To
From To
7. GROUT: Depth
/t nMaterial
From
To_Q Ft.
From To
Ft.
From To
6. CASING: °
Depth Thickness/
From Diameter Weight Material
FromToo_ Ft.Ll
To Ft-4L//o /21S Ptl/
SAND/GRAVEL PACK:
Depth
From To
From To
From
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS,
RECORD HAS BEEN PROVIDED TO THE WELL AND THATA COPY OF THIS
�1WNER.
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. 919 733-
Y
( ) 7D15 ext 568.
Form GW-la
Rev. 7/05

STA:
RESIDENTIAL WELL
North Carolina Depanment of Environment and Naturale Resources- DivisionONofWaRUter
u WELL CONTRACTOR CERTIFICATION # Q abty
r r r f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
Area code_ Phones ne number
2. WELL INFORMATION:
SITE WELL ID kit applicable)
STATE WELL PERMIT/(if applicable)
DWQ or OTHER PERMIT (if applicable)
WELL USE (Check Applicabl
Box): Residential Water Su Er
DATE DRILLED_ Supply Li'
TIME COMPLETED r
3. WELL LOCATION: (L AM
CITY: __L`l) )O Il /
-"------�_ COUNTY � �
(Street Name, Numbers, C emmunitY. SubdiNsicn, Lol No., Parcel, 2 TOP PHIC / LAND SETTING:
lope °Valley °Flat ❑Ridge °Other
(check appropriate box) �---
LATITUDE g. 3S - /j '•y„ r� / May be in degi
LONGITUDEWOU Sr y r minutes,suon
m a decimal foi
Latitude/longitude source:
(location of well must be shown on a UUSGS Topographic map map
to this form if not using GPS) 1p and
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS .0
a Of
City or Town Sfate
> izz 790 Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: %5 ..
b. DOES WELL REPLACE EXISTING WELL? YES ° NO
c. WATER LEVEL Below lop of Casing: ____�) f
(Use'+• if Above Top of Casing) ' -"�' -FT.
d. TOP OF CASING IS
'Top of casing terminated at/or �' Above Land Surface'
a variance in accordance with 15A NC land 2Csur.01 may require
CAC 2C .0118.
lkaaisji
e. YIELD (gpm):
METHOD OF TESiI
I DO HEREBY CERTIFY THAT THIS WELL WAS CE CON
1SA NCAC 2C, WELL CONSTRUCTION STAND , DTHA A COPY OFIW RECORD HAS BEEN PROVIDED TO THE WELL OWN ROiTA COPY OF THIS
4,
SIGNATURE OF CE • IFIED - C rr' TRACTOR
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

even t�ntractor Compa
STREET ADDRESSy
City or T0wn State
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
TIME COMPLETED /
3. WELL LOCATION: AM p' ❑
CITY:
COUNTY edi ,E,J i
(Street Name, Numbers, Com ,Q
^unity. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI
°Slope °Valley ❑Flat Q( idge °Other
(check appropriate box)
LATITUDE AI 3 5 • (,�
"fiT
Z
LONGITUDE WO 57 7/i
Latitude)longitude source: ° PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME_
y5rTf2EET ADDRESSai •i 1--_ % �--'ITS
City or Town State Y eZ
-,� T rP %�_/fir/ ZIP Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: C _
ACi
b. DOES WELL REPLACE EXISTING
�WELL? YES NO p'•
c. WATER LEVEL Below Top of Casing: �j�j7
(Use "+• if Above Top of Casing) '�—�'
d. TOP OF CASING IS
'Top of casing terminated al/or below land surfce ma require
a variance in accordance with 15A NCAC 2C . y
e. YIELD (gPm)'—?�� METHOD OF TEST.
J g1itydail
18, ffjt
ny Name
May be in degrees,
minutes, seconds or
in a decimal format
RESIDENTIAL WELL
North Carolina Dean CONSTRUCTION RECORD
P ment of Environment and Natural Resources- Division of Water Quality
WELL
/CONTRACTOR CERTIFICATION-4
` f. DISINFECTION: �YP� <b
g. WATER ZONES (depth): a Amount > L
From To
Fro To
From To
'335128
Depth Thickness/
Diameter Weight Material
From
Te Ft..zzadday a1,A To Ft.
From r
7. GROUT: Depth
Material
From Too Ft. GOI
From To
Ft.
From To
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE
T5A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND
RECORD HAS BEEN PROVIDED TO THATq COPYpIWITH
lA r THE WELL OVYlJER.
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL Co
NSTRUCTION RECOD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
City or Town *—State _
Zip Code
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(N applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED_y,� C/ —
TIME COMPLETED r
AM 0 PM p�
3. WELL LOCATION:
CITY: %` /�/
r —.-c__ _COUNTY { - Z
(Street Name, Numbers, Community, Subdivision, Lot No., parcel, Zip Cotle) TOP PHIC / LAND SETTING:
lope 0 Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDELI/_
LONGITUDEgg r S y se
Latitude/longitude source: , S ❑Topographic map
(location of we/ must be shown on a USGS tope map and
attached to this form d not using GPS)
4. WELL OWNER
OWNER'S NAME
ST• ET ADDRESS
City or Town
State Zip Code
)-_ 1c8s- r9as
Area code - Phone number�—
5. WELL DETAILS:
a. TOTAL DEPTH:_�s
b. DOES' ---�--
WELL REPLACE EXISTING WELL? YES � NO ■
c, WATER LEVEL Below Top of Casing: (Use `+• if Above Top of Casing)
d. TOP OF CASING IS FT.
`Top of casing terminated at/or below and surface mnd ay require
a variance in accordance with 15A NCAC 2C .0118, y
e. YIELD (gpm):
METHOD OF TEST r
May be in degrees,
minutes, seconds or
in a decimal format
f. DISINFECTION: Type //1/4.1
g. WATER ZONES (depth)
From TD
From To
6. CASING:
Depth Thickness/
From__ Diameter Weight Material
Ft.taa_
From Ft. 2/ ,/dS f/U.4
To
335129
9. SAND/GRAVEL PACK:
Depth
From To
From To
From
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WM1
I5A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY Or THLS
RECORD HAS BEEN PROVIDED TO THEW WELL OWNER.
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

_at COUNTY kew
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box) �---
LATITUDES/ 33I 2.y T May be in degrees,
LONGITUDt I 5".r minutes, seconds or
in a decimal format
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNERS NAME_,'
�f r
STREET ADDRESS.n F.'e ..• _
5. WELL DETAILS:
a. TOTAL DEPTH: os
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c, WATER LEVEL Below Top of Casing:
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS _I__
FT. Above Land aces
*Top of casing terminated aVor below and surface may require
a variance in accordance with 15A NCAC 2C .0116.E require
e. YIELD (gpm); r' METHOD OF TEST
ecT;t4 STATEq
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #Q
n
vven r ntractor Company
STREET ADDRESSr 73 1
City or Town State
.OYYfJ�C'yr",� Zip Code
Area code- Phone nuumberrt 2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/Mt applicable)
D WQ or OTHER PERMIT #(%applicable)_
WELL USE (Check Applicable Box): Residential Water
DATE DRILLED—_ "�g Supply ❑
TIME COMPLETED 4�'n AM[C pM❑
3. WELL LOCATION:
CITY:
I. DISINFECTION: Type
g. WATER ZONES (depth)
From
335139
Depth Thickness/
P Diameter Weight Material
From — To Tontr— Ft(j4at 7J6./JS &f
Ft.
Diameter Slot Size
Ft. in. in.
Ft in. In.
in. in.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
i5A NCAC 2C, WELL CONSTRUC DON STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL. OWN
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # O,a�
vveli tipntractor Company Name
STREET ADDRESSr7,1
LFi� PSBR /►✓ c
City or Town State
-5�-__
Area
code- Phone number
2. WELL INFORMATION:
SITE WELL IDShitapplicable) (/0 /GOq
STATE WELL PERMIT#of applicable)--
DWQ or OTHER PERMIT #(i( applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETE 1 ��
AM❑ PMQ�
3. WELL �!LOCATION:
CITY: ! k C/.
`__ COUNTY
(Street Name, Numbers, Community, Subdivision Lot No., Parcel, Zip Code)
TOP PHIC / LAND SETTING:
lope ❑Valley ['Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE -3i=r-r-_a_.
LONGITUDE( ((' 7 C t,. s r
May be in degrees,
minutes seconds or
in a decimal format
Latitude/longitude source: ❑GPS
(%ocation of well must be shown on a USGS to o ndp
attached to this form d not using GPS) map and
4. WELL OWNER
OWNER'S NAME �y
syT)tEET ADDRESS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: LO L3'
(Use'+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type ik O/y� r� Amount /O o
g. WATER ZONES (depth):
From To 100 Frnm
335190
Thickness/
Diameter Weight Material
FLjtnd,_ j /iLf &s a ig
Ft.
7. GROUT: Depth
Material
From To_ `2Q FLt
From To Ft.
From To R
Diameter Slot Size
FL in. in.
Ft in. in.
in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To_
From
10. DRILLING LOG
From To
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
PRINTED NAME • F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
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WELL CONSTRUCTION RECORD wax cO ITRAcroft 17-pi :e/c
«Itt CONTRACTOR CXPTWICM10N O. U�/
STATE WELL CONSTRUCTION KIIMITF.
1. WELL USE AS
ork (MUd.ni O IRoidpal ❑ Inawsa � #g.sMm od � iNYy ❑
11.....•T 1a HnI F.Iir Ws ki•o-• 0 ob er 0 It Oise UM Um:
2. WELL LOCATIOFk Mow Waldo of gm loedan below)
Naar Trwc ,�./ j J.)&t <nit ). t. f accent (y"4e h.'-c ct)'
•
Tyr—Irr+wrNw�wa�'4 a,..iSubsMiwand Nej orIwNOLOG
3. OMEN cilo AC-,,r 1; ,'c7Z - / Figs T.
Ad*s �, „ [ ' 3 /
Y
iU,y�/t's 17. <r c ✓ 7!�
war Awe err rine -
4. DATE COMM (
5. TOTAL DEM af
I. CtMTINO t COLLECTED YES v
T. 000WELLNWLACIImosw welt YES NO
A (�
STATIC WATER t tv�L arm Tap as FT.
Mire a mono w awe
S. TOP OF CASSIA Is!jy' ` FT. Men Land flee
ems wbraamad .eJlwwi.Sd.wMa•rwwr- ps.••w..e�.uvhC
IDY ) p METN000FTEST /��.. C�`--� � 10�� �'� 7C\Qb
A&F WELL DRILLING EIN
AND PUMP
BERness 74
�xq�R1
Fame iMllli -1773
1L atom aim Typo 14/n. - r I4' Msfl ,/'C'.d WFi
13. CASI & 9_ 9
cG n ,7t.1Pt
i1.M.4ll ape I• midst we is*.l Eonn
w•. t•rr.r ►DTSATION SE7C11
f O.plh ^`N tarn eW.ylsf 01e.4 IPnWants NW Senn Swnbums Seas
Fora. ' .Te . . FL.GL .= 742c'2.-C. Roods. vMrrsnip San F.M!
Fa.. Ts F.— p
Flew To Fl.$) ,y
Ts. GROUT;
c
AMISS �8s� �O1 . ALSwe y'� �
From % To . FL S r9-u/n /te a/4::
hem _ To Ft /
15. SCREEN
Des Dle..•1.. Slot Slt. M1M.dSI
Few Te FI h h
Fntiw,__TO_FL_ h In.
Finai _. To __ FL_ In.
IS. SAFOIYIIAVELPACK
Omit Mu M.Ifl
From To
From . To
17. 10MW! E:
\
A&F WELL D
AND PUMP SE'::'
91.1 Hwy. Bu_.
,»Bostic, NC
828-2d
;'.s
100 HERHEY CEITIFYTHAT THIS WILL WAS CON$TSICT1O P4 ACODRO4NCE NTH ISA NOC K Val
commons STANDARDS, MO7NAT ACOPT OF MS RECORD HAS BEEN FRONDED TOM MU OS.
PCNOFIRCEUSIONLY
0... Ne
ewN..
uaNATWIEOF IMMO meTTaleelie we eat Ong
bilmemlipbeto OISM Wale asses tworn .InnNW&31Iens
S.•I flV..2t1
J
t
-24 -20E'3 ION 11: 314^1 ID:
PAGE :1

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section •
C" CERTIFICATION itaes 4
¢KY ota:nite., PHONE # Sa3 4g3-9ag
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME IOW b
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential f MunicipaVPublic ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:�eJ�'trt,,(_'
Nearest Town: l�.il.
County ILI..) 56Pr
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ili Li4NL. thhaM�
Address +RI Cr' Ave.�h/lyI�
(Street or Route No.)
14ell3ZC-r5C114t et Vs() We__
City or Town State
( )-
Zip Code
Topographic/Land setting
❑Ridge ope ❑Valley ❑Flat
(check appropriate box)
Na,at'dein'4i fwell locationAq'�(
(degrees/minutes/seconds) Et cV, a4 rO
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Area code- Phone number
4. DATE DRILLEDrt{O' o4' O(o
5. TOTAL DEPTH: T(D 51
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO N
7. STATIC WATER LEVEL Below Top of Casing: 200 FT.
(Use "+-" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .011S.
9. YIELD (gpm):3rtr'iS. METHOD OFTESTeA(.QJ sk It
10. WATER ZONE epth): i C
1 I. DISINFECTION: Type'8r)(4.)1., Amount R
12. CASING: Wall Thickness
De Diameter or Wei t/Ft. Material
P Weight/Ft.
From d To J� Ft.
From To Ft.
From To Ft.
13. GROUT: Depth �1 Material
From To 3 Ft.Or�,f' Q,
From To ) 7 Ft.rtill OMI'(t
14. SCREEN: Depth
From To
Diameter
Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Slot Size
Material
in.
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRU DN STANDATI(DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/O —0cp,
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division u( Water Quality
WELL CONTRACTOR CERTIFICAT ON # 2571
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Irx k dual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) 05) Z L II LT (. L I
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED / Z -.4 59--L`
TIME COMPLETED ) r 3 0 AM ❑ PM [ -
3, WELL LOCATION:
CITY. C-Gt3-CdSC11UIIle
II�� ry ,, COUNTY '(C6/7
%vl : / (tJ7-rl r rt-T[/! KL / Z.QL-) V I I) -e
(Sheet Name, Numbers. Community, Subdivision, Lotjo., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING'
RSlope ❑Valley ❑Flat ERidge OOther
(check appropnate box)
LATITUDE 3C12/1 17 DN
LONGITUDEb ?' ' /A (.c)
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: [BPS ❑Topographic map
(bcafron of wel must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME STREET ADDRESS((I O C aN) I/77 p
--k-/. 4 n L2 l l )_ t N C2 4c/7c a
City or Town / Slate Zip Code
r7
1 ry cmlctieiie v?1crl013
Area code - Phone number
5. WELL DETAILS: '
—
a. TOTAL DEPTH: 7.4. 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO R—
c. WATER LEVEL Below Top of Casing: FT.
(Use -+ it Abo a 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 valance in accodance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 0 METHOD OF TEST Air
I. DISINFECTION: Type HTH Amount
g. WATER ZONES (ddepth).
From '7d0 To 7/7 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Dia ter Weight Material
From / To (v Ft. C r At‘ if✓C .
From To Ft.
From To Ft.
7. GROUT: Depth
From �/ To ,3 Ft
From 3 To 2 L% Ft.
From To Ft
Material
8. SCREEN: Depth Diameter
From To Ft.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
C� / 5—
/5- - 44Q
4-to '_ j C/
7 L1 - 7 % 5 (5A-24 A; , {-,:
II. REMARKS:
Method
Slot Size Matenal
in in
In. In
In. In.
Size
Matenal
Formation Description
erric
!J'7tr
RECEIVED
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO 1PE WELL OWNER
LU'
SIGNATUR OF F CERTIFIED WELL CONTRACTOR
t31�m PERSON CONSTRUCTING THE WELL
/R-- 3>
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL HELL CONSTRUL rlu\ RECORD
North l arolina Department of F.(.trainmen' Lulu Aaturul kexi n,Icc.-1)...,,
N ELL CONTRACTOR CERTIFICATION n 257'
1. WELL CONTRACTOR
Arinony Bryant Smith
NeII Contractor (Individual) Name
Greer River Well R. Pump Company
:Veil Contractor Company Name
STREET ADDRESS PO Box 204
Nast Rai Rock NC 28726
Ciry or Town State Zip Code
62u 693-1200
Area _ode- Phone number
2. WELL INFORMATION:
SITE .VEAL ID Apr applicable)
S1 A!E WELL PERMIT#til applicable) G Y" / �n / / �. 96, (
DWQ w OTHER PERMIT #(d applicable)
WELL USE ICneck Applicable Box) Residential Water Supply 1.
(2-/ZO/0�
DATE DRILLED
TIME COMPLETED /2 ct AM _I PM
3. WELL LOCATION:
k.t.&��— COUNT 3 (SO>2
/2;t(91%lucecfo�,(a
t vet Name Numbers Community. Subdivision Lot No Parcel Zip Coca)
,POGRAPHIC. LAND SETTING
Slope Valley -flat u.RIdge ..]Other
Driven appropriate box)
I JuE 35°IS' 091U
JNGITUDE oaZ° z Z ' J 5s it)
.Ma, he in Jewess.
minute 1C0l1nd„ii
m u Jeional ibi mai
_ulnuie luneilude source: =GPS __Topographic map
bcaton of wen must be shown on a USGS topo map and
attached ro this form A not using GPS)
4. WELL OWNER
. :NE P a-, NAME
_ roe- Sip-earr�
ADDRESS sfc Ol a+ia�& d
o. _tack, ;kJ(zi 73 (
Town Oldie LIP I,UIC
t rYI_ (c 2 /egZ
%aea code - Phone number
5. WELL DETAILS'.
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO -✓
c. WATER LEVEL Below Top of Casing t) (/ FT.
,Use if Above Top of Casing)
d. TOP OF CASING IS 1 FT Above Land Surface'
"op of casing terminated auor below land surface may require
a ,ariance in accordance vwth 15A NCAC 2C 0118
e. YIELD (gpm) 3 METHOD OF TEST J I 1
336531
I. DISINFECTION. Type /-T Amount
g. WATER ZONES djebit �r1
From 2,)OTd Z3)— iron ..
From To -roil 1
From To From
6. CASING: Thickness;
Depth, Djameter(r.Weight Material
lx Frn To F' Y
From
From
to
7. GROUT'. Depth Material Meir'nx
From C:) : .3 r; 5.4/14 /i. M,i3,�/'16X
From 3 IL�.(J FI / _142 ..J eft" /f1.7`�/isti<
From To F;
8. SCREEN
From
From
From
Depth
To
To
9. SAND/GRAVEL PACK
Depth
From
From
From
Ts
To
To
Diemeter Slot Size
1Anito ai
Size i..., )M4teribl ...mot
Ft
10. DRILLING LOG
From To
U /J
/5- - i0
tar- Sf/i
5'!7 - 9D5
Formation Description
ais) /.
s.7„ IsTtir.r
chitI/
II. REMARKS:
RECEIVED
DIV. OF WATER QUALITY
JANfl4ZOO?
DC riEREHy CER'
%L<iayt ✓ Z0 /2 2/'iS
S GNATU OF�CERTIF JED 0EL'_CGNI RACTGR
S,77.- L/
PRINTW NAME OF PERSON LaNSTRUCTI NG Tr16
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.

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualir
WELL CONTRACTOR CERTIFICAT ON # 2571
336530
1. WELL CONTRACTOR:
Anthony Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Twin Stale
Zip Code
/ 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir appiwbe) /
STATE WELL PERMIT#pt applicable) 0 f ax) I / 32_) 1
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED /
TIME COMPLETED H', 00 AM ❑ PM J-
3. WELL LOCATION:
CITY
a-- COUNTY Jrt-C1-IGC-i(1C-
PI 5 k cc(
(Street Name. Numbe Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING.
L2 Slope ls7'Qalley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3j
LONGITUDE j j ' 49/ L('
May be In degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2CPS 0Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
STREET ADDRESS fL% /kQ ekcl CYlI L (2c)
6 dct IJG 21s'7%3
City or Town State Zip Code
E2S )_ iv rji?-20'7D
Area code - Phone number
OWNER'S NAME
5. WELL DETAILS:
a. TOTAL DEPTH: z} 1
b. DOES WELL REPLACE EXISTING WELL? YES C NO (—
c. WATER LEVEL Below Top M Casing: 0 0 FT.
(Use'+' if Above Top Of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
-Top d casing terminated allot below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /0 METHOD OF TEST Air
1. DISINFECTION: Type HTH
g. WATER ZONES (depth).
From %2z) To )2.)-
From To
From To
6. CASING:
Amount
From To
From To
From To
Depth _ Diameter
From / To / j `/ Ft. L
From ! J j To / .70 Ft. Z. r
From To Ft.
7. GROUT: Depth
From L/ To
From 3 To-C-
From To
8. SCREEN:
From
From
From
Depth
To
To
To
Thickness/
Weight M7ittenal
/fir,
/ f9 5/ /2=i -/
Material method)
7
Ft. i�,r oAu..:, fr Arey9zt 7{
FL
Diameter Sid Size Material
Ft. in.
Ft
Ft. in In
9. SAND/GRAVEL PACK
Depth
From
From
From
10. DRILLING LOG
From To
O - 3>)
3 _ c
60 - 7C/
'61 - / %(.t
l 7c> 2 Li ‘2-
To
To
To
Ft.
Ft.
Ft.
Size Matenal
Formation Description
lgr 4 C1/4 y
54,, / SL, /
4-",7 .--, 4 5,9,4)
RECEIVED
DIV, OF WATER OLIAL%TV
1I. REMARKS:
IAN n 4 Z00/
I WHEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE vans
15A NCAC 2C. WELL CONSTRUCTIONSTANDARDS. AND TtAT A COPY OF MI5
RECORD HAS BEEN PROVIDED TO E'WELL OWNER
%Z±T1La" 4/6i )� -/ -r-C
SIGNATURe''}OF CERTIFJ,ED WELL CONTRACTOR DATE
PRINT BEAM OF PERSONFCONSTRUCTING 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 SW�e
Rev 7 05

Well Con(racto (Individual) Name
r
6te-OLnt I[ /
Well Contractor Company Name
W
LkCo(Town State Zip Code
�,-M 4 4 -/-(`a
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- De rs n n V, aler (,luaht.
WELL CONTRACTOR CERTIFICATION H
1. W L CONTRA ToR.
a
STREET ADDRESS
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID #(if appucaore)
STATE WELL PERMIT#(rtapplicable) (D(1001 I LS'72_
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box)'. Residential Water Supply Cy --
DATE DRILLED a//4 I O
TIME COMPLETED LP, J0 AM ❑ PM
3 WELL LOCATION:
CITY Zr V d c.,rQ COUNTY
7 (. pet C'e- LIDO (2.Cf
Street Name. Numbers Community SA/moron. Lot No Parcel. Zip Code)
TOPOGRAPHIC) LAND SETTING'.
3' lope Walley ❑Flat ❑Ridge DOther
knock appropriate box)
LATITUDE 35 13 6'3A1
LONGITUDIi3?2-` .c7' L%2W
May be in degrees,
minutes. seconds or
m a decimal format
I aunulc/longitudc source- 6CiPS ❑Topographic map
l *ace ton of wet must be shown on a USGS repo map and
attached to Hra form if nor using GPS)
4. WELL OWNER
OWNER'S NAME
=-t1°LC rs U 1'L-
— act) oil Sirkl-z n
STREET ADDRESS AQr7+ Pacer._ Cenr1e1Z'yy24
-21l CO,,rcL, NL,8i'a
City or Town State Zip Code
b'2g (a9(,.., -4%1
Area code - Phone number
5 WELL DETAILS:
a. TOTAL DEPTH:
c`
0 J
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er---
/
c WATER LEVEL Below Top of Casng. ` � FT
(Use'«- If Above Top of Casing)
d TOP OF CASING 15 / FT. Above Land Surface-
'T. op of casing terminated aUor below land surface may require
a variance rn accordance with 15A NCAC 2C 0 18
e. YIELD (gpm). L'G METHOD OF TEST_
f. DISINFECTION. Type
g. WATER ZONES (depth)
From 2 45 - To; 7t:7_. From
From To - From
From To From
6. CASING
Depth Diameter
From / To 4, Ft - 4,
From To Ft
From To Ft
336529
Amount
To
To
To
Thickness
Weight Mayerrai
7. GROUT: Depth Material
From To Ftjd�l.� `
�7 l!-
From 3 To/z Ft 47,41GrLr<'i:%r
From To Ft
8. SCREEN: Depth
Method
ikiyiettlarc
Diameter Slot Size Material
From To Ft
rn in
From To Ft in in
From To _.. Ft n in
9. SAND/GRAVEL PACK.
Depth Sze Material
From To Ft
To Ft
To Ft
From
From
10. DRILLING LOG
From To
O — 2 5
Z:) -- 547
c Gr
(l7 —(3i
I . REMARKS
Formation Description
D, ,$)r
(>/-?/jir..)i FIT
S/»' L'r-
G,: �w,i0 ci- %„r
4-., rr
t tGEivED
IDIV, OF WA I EH QUALITY
JAN 0 4 2007
DO HEREBY CERTIFY THAN IRIS E NAS CmgrR cTEC IN AL OR _
15A NCAC 2C WELL CCNSrRUC ST ry `ARDS ANL 'HA' a ;-Cx a
RECORD HAS BEEN PROVIDED TE AE.. N
21 -c C
OF CERTIFIED WELL CONTRACTOR DATE
IZ(1 /}k.Frsdl
AME OF PERSON CO 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.
f'dr1n7G W - l
R@ e b. -05

11. WELL CONTRACTOR
Bryant Smith
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department o(Euvironment and ,Natural Resource,- Ih, o l.ol u1 Ak.iicr Clu,d in
WELL CONTRACTOR CERTIFICATION # 2571
bell Contracts (Indiadual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
Fast Flat Rock NC 28726
City or Town State
328 )_ 693-1200
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMIT#)dapplicable) (3 Ls I p20 / U 5 7UO
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box). Residential Water Supply 0
DATE DRILLED 1241 3 1 0
TIME COMPLETED 3. DO
3. WELL LOCATION
U1� 4C(AciQy YrvLiik_
AIM ❑ PMX
(� COUNTY` TLE.Sl n
Street Name Numbers. Community Subdivision, Lot No. Parcel Zip Code)
OPOGRAPHIC / LAND SETTING
Slope Valley _'Flat 4Idge ;Other
neck appropriate ocx; /
%I. UDE 37 VIS/ /p/�1
ONGITUDE`' • LiT U7LCA
M.n be in dap ec
mmuas, seconds or
n a decimal format
.aliwde longitude source: GPS CTopographic map
(bcatan of well must be shown on a USGS topo map and
attached to Mrs form if not using GPS)
4. WELL OWNER •
OAVNERS NAME \J)E ivIc&
STREET ADDRESS -PC ore xA
_fast FLct- --?ct- NCZss72(—
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES T. NO TX
c. WATER LEVEL Below Top of Casing //%L7 FT
'Use Tx.. d Above Top of Casing)
d. TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated ads below land surface may require
a variance In accordance with 15A NCAC 2C 0118.
e. YIELD (gpm) METHOD OF TEST Air
1. DISINFECTION: Type HTn
336528
Amount
g. WATER ZONES 'depth'
From 2, %C Io .L ')0 From
From I o From
From To From
6. CASING.
Depth
From I :5/L FI
From To FI
From r.c Ft
8. SCREEN
From
From
From
Diaer
0
10
Thucoiess-
Weigh Wet .1'
244 Li,`
Meths:
P11 Ycol iL
Depth Diameter Slot Size Material
To Ft In
To FI In In
To FI
in
9. SAND/GRAVEL PACK.
Depth Sze
From To FI
Fran To FI
Fran To - Et.
10. DRILLING LOG
rrom To
-3v
i �e) - 5`i
- '7C1Lc -5
11. REMARKS:
DOd¢REat L&Rrft
RECORD
NCAC2C NE..
ORD -LAa BE Fn x2;.;
SIGNATU
�11
F all n escnpllur
l5Hfz� kir/,4
�r1-+.dy Or
I(1-A.Z1
KfCEIVED
F7lV Ot VVATER(1(IALITk
JAN 0 4 2997--=
OF CERTIFIED WELL CC
PRINTED CAME OF PERSON CNSTRUCTING THE
TRACTOR
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,
12.-It_tt

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2571
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State
Zip Code
(828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) 1�
STATE WELL PERMIT#(it applicable) .0 /a0 J04I g
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED I24I6 j 0 tr.
TIME COMPLETED I OU
3. WELL LOCATION: l
CITY: +�QrtSOriU I(1e COUNTY`��-�'y�f/-rS 0-7
LI-1j«hoxneti I ICfs'Watts Ut1/.e
(Street Name. Num rs. Community, Subdivision, Lot No., arcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Ddope ).Valley ❑Flat ORidge
(check appropriate box)
LATITUDE 3 Be 59 N
LONGITUDE n%c, lq/ 2l7 Cc)
❑ Other
AMcY5 PM
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: (9'QPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this loan if not using GPS)
4. WELL OWNER ,
OWNER'S NAME �(L1 n eV K
nut r. E -fps
STREET ADDRESS y'I
-31 f C{ /- 'it r�?
��Y�/Clw��rNC J•J)Ss--
City or Town State rP Zip Cade
(fig )3-S/<D0_3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
S I
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO La/
c. WATER LEVEL Below Top of Casing: co / FT.
(Use `+" if Above Tap of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST Air
336527
f. DISINFECTION: Type HT"
g. WATER ZONES (depth)..
7%U To
From
From
To
From To
Amount
From To
From To
From To
6. CASING:
From t To Depth Ft Diameter
From To Ft,
From To Ft.
Thickness/
Weight Material
7. GROUT: Depth 3 Material
From 0 To Ft. prt -�trL
From 3 To . L FL
From
To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From
From
From
10. DRILLING LOG
From To
0
30-/0
(0 3t,l
To Ft.
To Ft.
To Ft.
II. REMARKS:
Formation Description
/%54t i // /C /)r',t
(_� i5I}Wr/r
r-
RE,E� R QUAtcry
f)1\/- OF W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRU •N STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE THE WELL OWNER.
oar
SIGNATU E OF CERTSFIFzD WELL CONTRACTOR DATE
?tin frOf
rnN?ED4JAM O PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PER:VIIT8
Of applicable)
(if applicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and /Nattural Resources - Division of Water Quality - Groundwater Section
WELL g /�
WELL CONTRACTOR (INDIVIDUAL)NANIE'(printt)) J_R3.,y- One CERTIFICATION
ttd663.
%VEL.L CONTRACTOR COMPANY NAME /9 {�r/ (J JQ, rV I l�'S� C PHONE # Ip/to) p33 VR
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: (l Countyliabel-5(� .J
193 l�rtiuc,�)c . (� al z
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
titufle to nude w II Joc'tion
3. OWNER: e<-.0rna-3 (k n�t%5 ao� ga a It7-,I
(degrees/minutes'seconds)£(e4 2,27,�l
Latitude/longitude source:OGPSOTopoeraphic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
R:
Address Ic; L5Jkllecikl CR rQ,
(Street(ior Route No.)
City or Town t StatetI
C�de � �
Zip Code
Its*Area code- Phone number 4. DATE DRILLED leg ((0 R36
5. TOTAL DEPTH: „2 t
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO E'
7. STATIC WATER LEVEL Below Top of Casing: I Gb FT.
8. TOP OF CASING IS I (Use"+^ if Above Top of Casing)
FT. Above Land Surface*
'Top of casing tertninated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): a0 METHOD QF ESTC'1AM Ie)6I' fa( C('
10. WATER ZONES (depth): ) 2 0I N5
i
LOCATION SKETCH
11. DISINFECTION: T ,.d r l ( - Amount mount ,2 Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road DepthDiameter or Weight/Ft. Material numbers and common road names.
from e' Et.
From To H.
From To Ft.
13. GROUT: Depth
From To
From To
14. SCREEN: Depth -
P Diameter Sloi Size Material
From To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK: n.
Depth Size Material 1(ll;v
From To Ft.
From To Ft.
Topograhtc/Land setting
❑Ridge 1dS ope ❑Valley ❑Flat
(check appropriate box)
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Stfhmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
/6//71CSG,
DAT'
c
C+;

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality, -
WELL CONTRACTOR CERTIFICATION # ;77 %
336525
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 L. 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) 0 CI 00/1 3 CI I
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED / 2- -e - O C
TIME COMPLETED /O % 3 0 AM 0 PM i7
3. WELL LOCATION:
CITY: p(%[Jxt$ c ntole COUNTY tkr-'^fr 1
(o3O Surf-jSF=
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
ripe ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE ° er40 / 6 g.
LONGITUDE 0 2- 3/ r )/ k)
May be in degrees,
minutes, seconds or
in a decimal format
Latitude longitude source: Lt:04S ❑Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER //�� /� Bon); n� II �1
OWNER'S NAME M I"K he 11te /r/USS9(A, iC
STREET ADDRESS co 3 U SUL J /) C Dv. L t
1- -t,c -vSovlvli (P, IvJC zE%9r
City a Town State Zip Code
u2 ')- I"261
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
d4s-
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q-
c. WATER LEVEL Below Top of Casing: (r9 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): 5— METHOD OF TEST Air
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
From 2,),0 To 2, 2,7 From
From
From
6. CASING:
From
From
From
Amount
To From
To From
To
To
To
Thickness/
Depth D'atpeter Weight enal
To2g Ft. [ter
2/,( C,
To Ft.
To Ft.
7. GROUT: Depth Material Method
From 3 To 3 Ft. S/a/kJ 1t#
From 3 To ?v0 Ft. �7F. NfDo/jT»
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
Fran To
Fran To
Fran To
10. DRILLING LOG
From To
0 —
3-- if
/s?-2&s-
11. REMARKS:
Ft.
Ft.
FI.
Size ,Matefiaf,
Formation Description
5 // %{O
ariLth `fir
RECEIVED
u%V. OF WATER QUALITY
JAN 0 4
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 T WELL OWNER.
/
3
SIGNATURE OF CERTIFIED WELL CONTRACTOR
73 /7Ay OF PERSON Sm, `frt
%l-2-O(
DATE
PRINTED N E 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

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMIT #:
1. WELL USE (Check Applicable Bor): ® Residential ❑ Municipal
0 Recovery 0 Heat Pump Water Injection 0 Other
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town. SALUDA County: MEND
ORCHARD LAKE RD.
(Road Name and Numbers, Community, or Subdivision and Lot No.)
3. OWNER LOUISE MCCLURE
Address ORCHARD LAKE RD.
(Street or Route No.)
SALUDA NC 28773
City or Town State Zip Code
4. DATE DRILLED 12/15/06
5. TOTAL DEPTH 185
6. CUTTING COIJ.FCTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ® NO
8. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(Use `+" if Above Top of Casing)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated al/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.011 g
10. YIELD (gpm): 20 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3.5
13. CASING: —
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 42 Ft.6.1/4" SDR21 PVC
From To Ft.
From To
14. GROUT:
Depth
From 0 To 20
From To
15. SCREEN:
Depth Diameter Slot Size Material
Ft.
Material Method
Ft. OUIKRETE POURED
Ft.
From To FL in.
From To Ft. in.
From To Ft. in.
16. SAND?GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
17. REMARKS:
m.
in.
in.
Material
❑ Industrial 0 Agricultural 0 Monitoring
If Other, List Use:
DRILLING LOG
From To
DEPTH
Formation Description
If additional space is needed use back of form
Ct
lea
00
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
I-26 FROM COLUMBUS. TAKE EXIT #59 LEFT TO SALUDA.
LEFT ON GREENVILLE ST. LEFT ON MINE MTN. RD. LEFT
ON ORCHARD LAKE RD. DRIVE ON RT. JUST BEFORE
PAVEMENT ENDS.
OIV. OFFWATER O 4LITy
JAN 0 5 2007
I DO CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
A
FOR OFFICE USE ONLY
Quad No:
Serial No.
�0--7„ ,
SIGNATURE PERSON CONSTRUCTING THE WELL`DATE G / � - T s
Submit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina — Department of Environment and Natural Resources — Division of Water Quality — Groundwater Section
1636 Mail Service Center — Raleigh, N.C. 27699-1636 — Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: JEFF MELTON
WELL CONTRACTOR CERTIFICATION #: 3417
STATE WELL CONSTRUCTION PERMTT #:
1. WELL USE (Check Applicable Box): ❑ Residential ❑ Municipal ❑ Industrial ❑ Agricultural 0 Monitoring
❑ Recovery 0 Heat Pump Water Injection ® Other If Other, List Use: IRRIGATION
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: FLAT ROCK County REND
156 ARROWHEAD HILL LANE DRILLING LOG DEPTH
(Road Name and Numbers, Community, or Subdivision and Lot No.) From To Formation Description
3. OWNER LARRY STEPP
Address 156 ARROWHEAD HILL LANE
(Street or Route No.)
FLAT ROCK NC 28731
City or Town State Zip Code
4. DATE DRILLED 12/16/06
5. TOTAL DEPTH 185
6. CUTTING COLLECTED 0 YES ® NO
7. DOES WELL REPLACE EXISTING WELL? 0 YES ®NO
8. STATIC WATER LEVEL Below Top of Casing: 60 FT.
(Use "+" if Above Top of Caging)
9. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in accor-
dance with 15ANCAC 2C.0118
10. YIELD (gpm): 30 METHOD OF TEST: ARD
11. WATER ZONES (depth):
12. CHLORINATION: Type: CHLORYTE Amount: 3.5
13. CASING:
Diameter Slot Size
Ft.
FL
From To Ft.
16. SAND?GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 50 Ft. 6-1/4" SDR21 PVC
From To Ft.
From To Ft.
14. GROUT:
Depth Material Method
From 0 To 20 Ft. QUIKRETE POURED
From To Ft.
15. SCREEN:
Depth Material
From To in. in.
From Toin. in.
in. i11.
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
I-26W FROM COLUMBUSRIGHT ON UPWARD RD. EXIT #53
GO PAST HOWARD GAP RD. 1/4 MILE. RIGHT ON JACKSON
LOOP RD. 1/4 MILE RIGHT ON ARROWHEAD HILL LANE.
GO TO END.
RECEIVED
GIV. OF WATER QUALITY
JAN 9 5 2007
I DO CERTIFY THAT THIS WELL WAS CONSTRUt.1 ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY
Quad No:
Serial No.
e�//< r cs" i.l /' I �'�/B/?T� is -� t -ii
IGNATIJRE yyIIFF PE N CONSTR G TIHE WELL DATE
ubmit original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

North Carolina . Department of Environment and Natural Resources • Division of Water Duality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636•Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION COI I3
STATE WELL CONSTRUCTION PERMIT,
CAP
CAS
cn
txi
c*e
1. WELL USE (Cheek Applicable cox): Residentiate
ReeovaMunicipal ❑ Ier List al❑
rY ❑ Heat Pump Water Injection [� Other 0 If Other, List Use:
2. WELL LOCATION:; e�tp o4of the location below)
Nearest Town: I A
allitaur
County: J-4Pnderan
`(Read Name d Numbers. Covn nuNty, or Subdivision and lot No.)
3. OWNER �'
Address
City or Town Stab
4. DATE DRILLED I-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES El NOB2y
7. DOES WELL REPLACE EXISTING WELL? Y � NOI2
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS t (Use •: a Above Top of Case')
FT. Above Land Surface'
'Top of casing terminated aver below land surface 'SWIM variance In accor-
dance with 1SA NCAC 2C .e to
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
ToWall Thickneu
thi ` i ter or Weeigtiwt M,tetiai
FromFt j
From To Ft
From To Ft.
14. GROUT:
Depth t� n Material Method
From __1__ To' Ft. t -Ol(Y1or)l
From To Ft. -+�—++--
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft _.__ M. In.
From To _ Ft _ in. __ in.
From To Ft In in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft
17. REMARKS:
Agricultural ❑ Monitoring ❑
ft additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at oast two State
Roads, or other map reference points)
RECEIVED
DIV. OF WATER QUALITY
JAN 0 '5 2007
re-
rL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECORD H BEEN PROVE D TO THE WELL OWNER.
Cued No:
FOR OFFICE USE ONLY /jtai /6' - 3 / - ei �o
SIG RE OF PERSON CONSTRUCTING THE WELL ((DATE
Submit original to Division of Water Ouailty, Groundwater Section within 30 days
GW-1 REV. 12199
Genet No

f`Lr 20.07
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 21 38
1. WELL CONTRACTOR:
James W. Camo
Well Contractor.(IndhAdua6 Name
Camp's Well & _Porno Co. Tnc
Well Contractor Company Name
STREET ADDRESS P 0 BOX
Ellenboro NC
City or Town State
(828). 453-7322
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #0t appacable)
STATE WELL PERMITW applicable) / I 11,, 11,,
DWQ or OTHER PERMIT 1/(if applicable) 01,0 16011 L to 'I t1
WELL USE (Check Applicable Box): Residential Water Supply❑
DATE DRILLED 13 . i g' 6 L
TIME COMPLETED 2• tij AM O PM
3. WELL LOCATI N:
CITY: COUNTY \ i%AIADIA Len.
429
28040
Zip ode
Macs_Aln*• L C
(SheetNumbers, Community. ubdANsion.Lot No.. Parcel, Zip Code) _
TOPOGRAPHIC I LAND SETTING:
IGIS pe OValey O.Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE .a$_ t I, 2 a ei
LONGITUDES)._ en t l FC
Latitude/longitude source: aG1S OTopograpbic trap
(location of wel must be shown on a USGS typo map and
attached to this lone 1 not using GPS)
4. WELL OWNEW$N A �( 'A 1 t
OWNER'S NAME n 1 vt Ly
STREET ADDRESS Y D R o X 10613
May be In doped'
minutes, aecads or
in a decimal Lmat
cA.)Nax lL— O(2 113
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 L S
b. DOES WELL. REPLACE EXISTING WELL? YES p N0 BY-
c. WATER If Above Top of Casing)
((Usef Casing: ki 0 FT,
d. TOP OF CASING IS 1 FT. Above Land Surface'
Top d casing tem:hated atM below land surface may requh'e
a varianceIn accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):__U)_— METHOD OF TEST ILA
339739
f. DISINFECTION: Type chlOrine Amount )C-
g, WATER ZONES (depth):
From To From To
From To From To
From To - From - To
6. CASING: Thickness/
tIb sir MarneW Weinht Material
Rom 0 De
Jo Ft. 6* SDR21 PVC
From To Ft
From To R.
7. GROUT: Depth Material Method
Fran. To 20 FL Sackrete Hand
From To Ft.
Fran To Ft.
e. SCREEN: Depth Diameter Slot Size .Material
From To Ft. in b.
From_ To Ft. In In.
Fran_ To FL In. In.
9. SAND/GRAVEL PACK: Depth Size Material
From To_ Ft.
From To Ft.
Fr' n To Ft.
10. DRILLING LOG
From To
0• 3S
11. REMARKS:
r� eriptIon
'AN (1 200?
I DO HEREBY CERDFY'MATINS WELL WAS OONSIRUCIED N ACCORDANCE WITH
16A NCAC 20, WELL CONSTRUCTION STANDARDS. AND IHATA COPY OF THIS •
RECORD HAS BEEN PROVIDEOTOTHE WELL OWNER.
slGNA
f, M lP L) Mn -�-a 1 EICERTIFIED.W LL'C RACTOR DATE
T OF
James W. Camp
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division ol,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
TY

1. WELL CONTRACTOR
WE
V QAf; ck ‘Ne .»h '"fecS
Well Contractor (Individual) Name
Q\i cliQ ' 6ta2t.^f e-rS : Sfl.1.
Well Contractor Company Ndt,.
•
STREET ADDRESS ‘1/431C3$'=j ,\kt.Ay aOC2
No-! 5 c;tnNc as'-v-l3
Stale City or Town e1. -zip Code
($s� tabs- aoaa -
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Maapprcable)
STATE WELL FERMI -Mgr applicable)
DWQ or OTHER PERMIT tiff applicable)
WELL USE (Check Applicable Box): Residential Water Supply 01/
DATE DRILLED //-/,-o .
TIME COMPLETED 9730 AM PM�/.
3. WELL LOCATION: CITY: /74.0Zcrsr544n,-;A:
r� 4r1 U ifs/ 1 .0,,
{ Name Numbers. Cmm ug ty. 4't•n"'e nn, La No.. Parcel, Ztp Cede)'
TOPOGRAPHIC / LAND SETTING:
islope °va➢ey ❑Flat ❑Ridge Dotter
@lees apProonate box)
LATITUDE 3
LONGITUDE
COUNTY /44�r.-s07
IMay bemdegrees, I
minutes, seconds or
in a decimal format
Latitude/lomgtude source: oGPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME IO ;eh MLA 4'1 DI t-k
STREET ADDRESS /(c f,a1P Tnt ye
ncipn Nc f•P7CN
City or Town/ State Zip Code
(P_AaP - (094- C,CS4
Area code - Phone number
A WELL DETAILS:
a TOTAL DEPTIt .•) 7C
b. DOES WELL REPLACE EXISTING WELL? YES 0 Novi
c. WATER LEVEL BelowTop of Casing: [ C)
(Use a+ if Above Top of Casing)
d- TOP OF CASING 1S l . FT. Aboe Land Surface
'Top of casing terminated atfor below land surface may require
a variance in aecadance wdh 15A NCAC 2C .0118.
e. YIOA(9Pm): Sd METHOD OF TEST e-:•Si
FT.
RESIDENTIAL WELL CONSTRUCTION RECOAD
North Carolina D.Parbnent of Environment and Natural Reso
urces- Division of A-ata Qual-ty
WELL CONTRACTOR CERTIFICATION #- ale
337507
f. DISINFECTION: T ----r
ourrt
g. WATER ZONES (depth):
From To From
To
From To Fror*,
- To
From To From
To
6. CASING:
Thickness/
From 4- Depth
if%. Ft.. D ipts WeightMaterial ,
From
To Fl, -"] ?(
FroTo Fl.
7- GROUT: Depth
r�Jm Material
From Q To ptt7 P1,
From To F1.
From To Fl.
)ht tee
& SCRFFN: Depth Dia Haler Slot Size Material
From To P. In. in in
From To Fl. in_ .
.
From To P. in.
9- SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft
From To Ft
10. DRIWNG LOG
From To
e--7 '770
II. REKARICS:
P6nFormation
iigi ink wArrcu. nil
T
!Do Y THAT INSWELL WAS CONSIRLVTED NACCORDga.CE Wrmm
15A NCAC 2C, WELL CONSTRUC1gN MP HOARDS. An, THAT COPY OF TWS
RECORD HAS BEEN PROVIDED TO TM: w ELL OWNER.
SIGNATURE OF CERTI PACTOR DATE
t ci-
e.0- Wee&1y 6C.4' 13
PRINTED NAME OF PE
RSON ..C'NSTRUCT$G THE WELL
Submit the original to the Division of Water Duality within 30 days. Attn: Information Mgt,
617 Mall Service Center— Raleigh, NC 27599-1617 Phone No. [phone] ext 558.
Form GW-la
Rev. 7I05

RESIDENTIAL WELL CONSTRUCTION RECIalD
North Carolina DyxirRnent of Environment and Natural Resources- Division of A'ater Quality
WELL CONTRACTOR CERTLFICATION 8- OM,iO
1. WELL CONTRACTOR:
0-cc -eSo,.a-ees
Well Contractor (Individual) Name -
i'.\ 1Jat Sc..aye- - fir *Son.
Web Cohtracta Company Nar reQ
STREET ADDRESS V �aoC3
i-\o-! 5RC:mis) NC airy-13
City or Town slate -Lip Code
8a%)- ce(o$- aoaa -
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID SM applicable)
STATE WELL PERMITreMar.,Ai.a
DWQ or OTHER PERMIT 11(1 evialt,dAc)
WELL USE (Check Applicable Box): Resid Rial Water Supply di
DATE DRILLED /7/2
TIME COMPLETED a�AMD PM
3. WELL LOCATION: / ��
CRY: 4iy �Pi'GYI w/iW COUNTY ,4l 1 e r_xosr
{Sheet Name, N. Cannrwtty. Subcavcion, Lot No., Parcel, Zip Ccae).
TOPOGRAPHIC / LAND SETTING:
®Slope Ovaliey ❑Flat ❑Ridge ❑Other
(check gronaaiste box)
LATITUDE 3
LONGITUDE
May be in degree;,
minors, seconds or
in a decimal font
Latitude/lomgitudesource: DGPS nTopographicmap
Vocation of wer must be shown on a USGS topo map and
attached fords ram fnot using GPS)
4. WELL OWNER
OWNER'S NAME Ro ir7 t1
STREET ADDRESS N'A S to
1-4Nrldgre,onv:Ile
City or Town State
t 8aPj- 943- 12i4i9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Po-Vte c
4:11.;,-n nPy RtDCVL (Zri
,Oc 0.`1'1
Zip Code
b. DOES WELL REPLACE EXISTING WELL?
7 YES O NOt 7
c WATER LEVEL BdowTop of Casing: oC a FT.
(Use ^*' ff Above Top of Casing)
d. TOP OF CASING LS ' , FT. Above Land Surface'
'Top of cling terminated a (or below land surface may require
a variance in accordance with 16A NCAC 2C .0118.
e. YID (gpm): /5 METHOD OF TEST lit•
337506
L DISINFECTION: Type. , % t$ Amount / D
g. WATER ZONES (depth): _
From To From To
From To From To
From To From To
6. CASING: Thy
Depth Diamr Weight
From- To_ R. 10 TC 1C
From To Fl.
From To R.
7. GROUT: Depth �r Material j.
From 0 To aCI R. (ear/1 f
From To Fl.
From To P.
nr tee
8. SCREEN: Depth Dia meter Slot Size Material
From To Fl. in. in.
From To R. _. in.
From To R. vr. in.
9- SAND/GRAVEL PACK:
Depth Size Material
From To - Ft
From To Ft
From To Ft
1D. DRILLING LOG
From To
% 7
a 65
11. REMARKS:
A.Fizrertionek.pct De.>4a
i\e'. 2 e ,?Liu/
100 HEREBY CERTFYTHAT 114S WELL V 'AS CON37Rvc1ED N ACCORDANCE WIN
15A NCAC EC. WELL CONSTRUCTION :TPNDARDS. N:DTHATA COPY OF THIS
RECORD WAS BEEN PROVIDE TO7Hr ..sQ • 14E&
SIGNATURE OF CERTIFIED w
//7-F
ONTRACTOR DATE
bete. Os- }{42O.rb £C.al
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568-
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:2D
North Carolina Department of Environment and Natural Resources- Divof II atc QuaJ ty
WELL CONTRACTOR CERTIFICATION # - 2i ate
1. WELL CONTRACTOR:
ter(:: ec a . ao-.arte.cs
Wen Contractor (indMdual) Name
Well Coihbactor C
ompN
Company
STREET ADDRESS VatlV V sJ \\uS' 20(1
H0A c J3C. art'43
City a Tam She •.. -rip Code
(8D2)- ta(oS-aced ,
Area code- Phone numb
2. WELL INFORMATION:
SITE WELL ID #fd apprioable)
STATE WELL PERMIT#(?apP cat1e)
DWQ or OTHER PERMIT #(9 app6cate)
WELL USE (Check Applicable Box): Residartiat Water Supply V
DATE DRAIED 44: /f" _ /
TIME COMPLETED 9 i. AM I( PM 0
3. WEU. LOCATION: //
CITY:7j A/ ril erv!?-. COUNTY/in4orI�GJ
Name, .(SbeetName, Novae& Commoray. Sub?raron, Lot No_ Parcel. Pp Code)'
TOy OGRAPHIC / LAND SETTING:
¢dove [Valley ❑flat [Ridge ❑Other
(check app'opteate bar)
LATITUDE 3
LONGITUDE
Latitude/longitude source: EDGES OTopographtc map
(bcation ofwelt nustbe shown on a USGS topo map and
attached to torn fnot using GPS)
9. WELL OWNER ��77
OWNER'S NAME 'Minh'. csA' .S• i.J ('. r \-
STREET ADDRESS aN73 C5. -Nettle C.SCAM or N kz'
?iendecYx, nv' lie A c de70
City or Town State T-iP Code
May be in degrees. I
minutes, seconds or
in a decimal format
(89E )- LE7 aCISS
Are ode - Pion number
5. WETS DETAILS:
4;
a. TOTAL DEPTH:, .v
b. DOES WELL REPLACE EXISTING WELL? YES O NO"{y
e_ WATER LEVEL BelowTee of Casing: /0D Fr.
(Use'+' #Above Top of Casing)
d. TOP OF CASING IS it FT. Above Land Surface'
*Top Of casing routed aVa below lard surface may require
a variance in ar.uatia ...-with 15A NCAC 2C .0118.
//�
e. YIELD (gam): /b< METHOD OF Ito} {.S
337518
f. DISINFECTION: Typt . \ ! $ Amount
g. WATER ZONES (depth):
From To From
From To From
From To From
To
To
To
6. CASING: Thitlmess/
D';a� W?.igFR_
From $�, ,�� R. - ft,I".Fran To Fl.
From To Fl.
7. GROUT:ss••�� Depth n�T Maher
From V To JCQ FI. (eat. nL
From To FL
From To Fl.
a. SCREEN: Depth Dancter Slat Sire Material
From To R. th. From in.
R. iv.. in.
From To F. in. in.
9. SAMDIGRAVEL PACK:
Depth
Fran To -
From
From
Size
Ft.
To FL
To Ft.
10. DRILLING LOG
From To Formation Da
�0 7�L3et' ter•
11. REMARKS:
a
Gan-
af ?
1 DO HE ereHY CERTIFY TNAT Tf ate wa I WAS CCM-17.LLMED N AGARDN!CE ROTH
(EA NCAC 2C. WELL CCNATRDCRON I ;Tp THAT A COPY OF TNS
RECORD HAS SEEN F DEV TOW NELL
1_
SIGNATURE OF CERTIFIED WELL .. TRACTOORS DATE
iC'. Cx ;s1£D.Or1�.T�THE PRINTED NAME OF PERSON ;ONSiF.UCTM . G WEU.
Submit the ty within 30 das. Attn:
1617 Mail Semite Center nal to r-- Raleigh, NC 27699-161e Division of Water �7w1 Phone No(9 9) 733-7015 a t 5 8 non
NF;t
Form GW-la
Rev. 7It5

RESWENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Meier Qua;ty
WELL CONTRACTOR CERTI FICATiON # - ate
1. WELL CONTRACTOR:
Weil Contractor (Individual) Name
Z.\ JJt1.42. 'JQa.3"I ter' S itSi4 Pl
WeR CdWactior Company Narhe
STREET ADDRESS C.V75 C1 S \: ua'y 209
%io'r S r:h') Js3C - atry3
City or Town a '.. -Zip Code
D im cnios- acsa.�
Area code- Phone number
2. WELL INFORMATION:
SITE W EU- ID WUapprrcaNe)
STATE WELL PERMITStaapp%eatee)
DWG aOTHER PERMRSCetifi atk)
WELL USE (Check Applicable BOXY Residential Water Supply r$'
DATE DRILLED / .77. -�6
TIME COMPLETED ,2 13e) Anti] PM D-
3. WELL LOCATION-
CITY:
r _ !?c/i9"Soge7r couNne
�
2 � /,A5
.(Sbinetme, Numbers. Coen purely. Sd?droror, Lot No_ Remet TT Code)'
i2ROGRAPHIC / LAND SETTING:
lope 0ValleY Cat ❑Ridge ❑ahe,
(cheek apropriate box)
LATITUDE 3 _
LONGITUDE
Latitude/longitude source: °GYS °Topographic map
(L.ati n ofweImustbe shown on a USGS topo map and
cashed to this form 'not uskg GPS)
4. WELL OWNER
OWNER'S NAME Qi'.l \tie 1 CcaS
STREET ADDRESS t01 C.y?ceSS &S4sate6 'LgnQ
if€ndecst,yt'Ile /it a "i4 a
City or Toren )State Zip Cade
(8a8 )- (d b - %ASS
Area code - Phone number
May be in degrees,
minutes seconds or
in a decimal fanner
S. WELL DETAILS: _.•"�/ S
a. TOTAL DEPTH: C at°
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL BelowTcp of Casing /0
(Use '+' ff Above Top of Casing)
NOt7
FT.
sL TOP OF CASING IS \ . FT. Above Land surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAG 2C .0118.
e. YIELD(gprn): LP METHOD OF Itbl ec.3
33751i
t. DISINFECTION: Type4.I. %$ Arncunt /3
O. WATER ZONES (depth):
From To Fran To
From - To Fro^ To
From Top______ From To
6. CASING:
From 4 To Depth//3 Fl. ID'C.�
From To FI.
From To Ft.
Thickness/
Weight
iSi
7. GROUT: Depth tt11 Material etrslod(
From 0 To QC) FI. i&n r4-. the, x!
From To Ft.
From To R.
8. SCREEN: Depth Dia peter Slot Size Material
From To Ft. in. in.
From To R. iv.. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To -
Fran To
From To
Size
Ft.
Ft
Ft.
Material
10. DRILLING LOG
From To Formation Dn
//3 71O ieti t
//3 a 6-5 Gm,.'
11. REMARKS: ,
100 MEREST CERtIFYTHAT THIS WEL L Y'AS Cou$iRI:Cfan N ACCOaDVW.CE MTH
15A "CAC 2C, WELL CONSTRUCTON I:TA NOARDi. AND THATA COPT OF TWS
RECORD HAS BEEN PROVIDED TOTS: N E 'tER.
SIGNATURE OF CERTIFIED v"El Kf'ITRACTOR DATE
iC-1. 4G.4 . 6c.iA C3_
PRINTED NAME OF PERSON CONSTRUCT. G THE WELL
Submit the original to the Division of
Water at 6a ai ty withinone No- 30(9days.
7Q15 InformationexM
1617 Mali Service Center—Raleig558.
h, NC
Fan, GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCDON RECO D
North Carolina Ds.parbnent of Environment and Natural Resources- Division of Water Quaiiry
WELL CONTRACTOR C b. TIFICATION # oc 1 ale
337524
1. WELL CONTRACTOR:
Q-Ve: c Nk0-0..Tt1 Les-recc,
Wen Contractor (individual) Name
c1
WSI CatacWr -CompanMaimQQS.
STREET ADDRESS �yV C):j -aoct
HoAr 5ccn%) Nc fain i3
City or Town state . -. -Zip Code
(8at} (e's- aaaa .
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Altappliahle)
STATE WELL PERMITS(dapp&cable)
DWQ or OTHER PERMIT Siff applicable)
WELL USE (Check Applicaable Ba): ResSupplyiiai Water Supply
DATE DRILLED /r J ?.. 6
TIME COMPLETED 3 i 3 a
3. WELL LOCATION:
CITY: lien <'Pr.Sdn thli4.
66r ej,
AM PMfl -
COUNTY $a diet--50
{Steel Name. Numbers. Cerwawsty. Subbasipn, Lot No.. Parcel, DP Cede)
T%POGRAPHIC / LAND SETTING:
&Slope Ovafey ❑Fitt CIRidge ID Other
(check appropriate brat)
LATITUDE 3
LONGITUDE
Latitude/longitude souse: ❑ OPS °Topographic map
(location of nel must be shown on a USGS fopo map and
ached to this form Snot imam GPS)
4. WE'LL OWNER OWNERS NAME a3,-ka{^O.
STREETADDRESS e GtV.e •' {ccA
" ev cjikc5c--w. ite >1JC g.) r,, `
City or Town State Zip Code
( 8L`33 )' Q`15-'] i 5y
Area code- Phone number
5. WELL DETAILS: / / a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
cWATER LEVEL SeimTc !JBof d Fr.
(Use'+' llAbate Top of Casing)
May hem dam,
minutes, seconds or
in a decimal Format
•
d. TOP OF CASING IS ± FT. Above Land Surface'
'Top of casing to tnaled atfor below land surface may require
a vaiance in accordatcewhh 15A NCAC 2C .0118.
e. YIELD(gpm): / METHOD OF TEST fRsc
L. DISINFECTION: TYpe4>11.5 Amount rQv
g. WATER ZONES (depth):
From To From To
From To Fron To
From To Frain To
6. CASING: Thickness!
Depth Diampte Weight
From_ To 9d - R. 1. t
Fran To Ft.
From To R.
7. GROUT: Depth
Depth �nMaterta
From 0 To ao R. (earn —.
From To Ft
From To
Method
RN tie 4
8. SCREEN: Depth Dia neter Slot Size Material
From To R. ir . th.
From To P. ir.. in.
From To FL Ir. in.
9. SANDfGRAVEL PACK:
Depth Size
From To' Ft.
From To Ft -
From To Ft.
10. DRILLING LOG
From To
/ 96
90 Yes
11. REMARKS:
Formation D
&r'f
&1a•t
YS4:VLIVC:.Li
nrp. tiF w;TATER ('jUAL.i i
JAN 2 h 2907
100 HEREBY l.eN TRY THAT THIS WELL VAS CONSWF.LOIED N ACCORD,Q CE W'TTH'
15A NCAC 2E, WELL CONS RUCTVN STANDARDS AM'TNATA COPY OF THIS
RECORD HAS BEEN PROV VED W TMi OWTEF,
SIG TURE OF C Fi
PRINTED NAME OF PERSON CONSTRUCTING THE WEU.
N CONTRACTOR DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mat,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/tS

337432
WELL CONSTRUCTION RECORD
North Carolina - Department of Enviromnent andNaturalResources - Division/of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME 4giat) n i, ,/ .. d Q to p ,r
CERTIFICATION # 2 7 O
WELL CONTRACTOR COMPANY N /i,o'ea (a(4 i(L'/' tliQ/AArpPRONE # i` fr) 6Y9'-oyg0
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1 WELL USE (Check Applicable Box): Residential 13" Mmicipal/Public 0 Industrial 0 Agricultumi 0
Monitoring 0 Recovery 0 Heat Pump Water Injection O Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Ht.u&tfun yijIA. County 4enclea et
4,/0%.1/twli.. Kk
(Street Name Numbers, Community, Subdivision. LaiNo., Zip Cam)
3. OWNER: Tlee.+Le( Aif1nn�.r(
Address 690 R; lc..+L iel (ease
(Street a Rome No.)
M;\11 Rids( N
Topographic/Land setting
ORidge 0Slope Malley MEfat
(check appmpmtebox)
Latitude/longinide of well location
(degteafmmuas/aexmes)
Latitude/longitude source:OGPSOTopographic map
(check toe)
City orrawn Ste Zip DRILLING LOG
Zip Code From To Formation Description
An code -Phone number
4. DATE DRILLED /0-25.:-OG
5. TOTAL DEPTH: 2 S �/
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q
7. STATIC WATER LEVEL Below Top of Casing: / S FT.
(Use 'kr- if Above Tcp of Caneg)
S. TOP OF CASING IS I8 - FT. Above Land Surface*
flop of casing terminated at/or bobw land surface requires a
variance to accordance with ISO NCAC 2C Lill.
9. YIELD (gpm): /0 METHOD OF TEST 1 t'., tot
10. WATER. ZONES (depth):
11. DISINFECTION: Type
12. CASING:
DepthFrom P To la
90
From__ To
From To
13. GRO
TTo 30
From To
14. SCREEN: l Depth
/�
From Y' To
From To
15. SAND/GRAVEL PACK:
Depth
From ♦' To
From To
Cc 11
Diaimeter
Ft inn
Al
Ft
Ft.
Amount 10Oz-.
Wall Thickness
or Weight/Ft Material
5 A-21 Pvc
Material Method
Ft. Pone(ttc. Litt rtIR
Ft
Diameter Slot Size Material
FL in. in.
Ft. in in.
Size Material
Ft.
FL
LOCATION SKEfCI{
Show direction and distance in miles from at least
two State Roads or Cotmty Roads. Include the road
ambers and common road tames.
5w «i via <r At1
16. REMARKS: C
w
I DO HEREBY CERTIFY THAT THIS WELL WpS CONSTRUCiw IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, f+NDITHATJ COPY OF t S RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CI tttAL r
CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
ITV

RESIDENTIAL WELL CONSTRUCTION RECORD
Nonh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
1.W CONTRACTOR:
//�, a s
W II Con Contractor 91djvld aam
tE k� ofs ktii owd Lun 1
Well Vntractor Company Name �/'�c / P�
STREET ADDRESS r?/ 3j /f A„�j,) l��j(7� ki
ir�sfxR 14�t a871/Q
City or Town �f �Sttaatte Zip Code
(SLA�'rya5A)`(1/
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L�
DATE DRILLED
06
TIME COMPLETED 1/049 AM El PM L
3. WELL LOCATION:
CITY. CITY: L`'Di)Q4 COUNTY Hul/trsn ,
.b UNA'CR /59
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE AI 3.5 ' 2,b,bg3
LONGITUDES O p%L _w
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: S ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) /
4. WELL OWNER 4/6///Il. y �
y
rrnQ &(q QyL5
OWNER'S NAME if./.4if./.4Mf J{Q' /t ten A�
ST ET ADDRESS g, 5a-c 5 775
sAca //p ArC a gg/3
City or Town State Zip Code
(gab )- th9/- 670/
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO2
c. WATER LEVEL Below Top of Casing:
(Use -+• i1 Above Top of Casing)
4 O
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0115. [1
e. YIELD (gpm): La METHOD OF TEST N
2OA
3s211
f. DISINFECTION: Type di iftMaN C Amount Q e
g. WATER ZONES (depth).
From To 2f'O From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From__ To_fO Ft. bl a45
2/4445 /IIC fait
From To Ft.
From To Ft.
7. GROUT: Depth /7nMaterial Method
From 1) ToLn Ft. l'%cet{e
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft... in. in.
From To Ft in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
7a —2 5'
11. REMARKS:
Material
Formation Description
dray �t�
S/illt /17KZC
Roc
rNYdir%C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1 SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HASB N. ROVIDED TO THE WELL QWNFR.
SIG ATUO' CERT
PRINTED NAME
CONTRACTOR DATE
�1 i, OHS. „
F PERSON CONSTRUCTING THE WELL.
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON #
CONTRACTOR:
u L{ o4
W II Contractor (hdjvid al) Nam
(Lc0 a"5 �tfEIl (a d
Well ntractor Company Name
STREET ADDRESS f rt,
City or Town / State
(g:i')- 5S'4fl �
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
C
S
a►ns, L-C•
as149
Zip Code
la
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box). Residentia
DATE DRILLED 14/04)it
TIME COMPLETED 7 AM
3. WELL LOCATION:
CITY: fifoot e/5/44 //C COUNTY
I Water Supply p'
❑ PM Er
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lope ❑Valley ['Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE ALS
pp' /q,3QG
LONGITUDE 10011A 1L0 �y]'
Latitude/longitude source: EIC S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER OWNER'S NAME /J/ 6 ( P4 , e//
lY
May be in degrees,
minutes, seconds or
in a decimal format
P
T EET/tDDRESS .0 L/lt/4'
eende(cmvil e /VC 287i
City or Town State
Lam)- leX-7- '{V7W-1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
56s'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: tie FT.
(Use "t' if Above Top of Casing)
Zip Code
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 4% METHOD OF TEST JII.Yi1W 4^
20
T. DISINFECTION: Type C4/0$ vc.
Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weighty r fialerial
From 0 To vs Ft. 4,As Z11e.Ldl `/,0-0,0j/
From To Ft.
From To Ft.
7. GROUT: Depth �7 Material
J •�, Method
From 0 To 1O Ft. LCiCETg a.P.Url
From To Ft. �'�'�
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in, in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0 -30
30 -
vs -54S
11. REMARKS:
Formation Description
C/ay J�
S'/ Alf M Ne
jot
(innw1'ltc
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 NER.
SIGNATURE OF ERTIFIE. - i CONTRACTOR ATE
It 1, oats n
PRINTED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
IS

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
L CONTRACTOR: P
W� ontrctor,Ftddvid at)fNam ®
f k' t(So`JJJ,g WEli aid umpf LLC.
Well ntractor Company�yName %I/�c /
STREET ADDRESS ra /�/ /�X.�i.� l�
ACC asizig
City or Town / State
( .R ;)6S' 9&
Area code- Phone number
Zip Code
2. WELL INFORMATION: /f
SITE WELL ID#tit applicable) ✓ e/OQ//o 99
STATE WELL PERMITS/Or applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED /,(/ltI/b
TIME COMPLETED Ze d0
3. WELL LOCATION:
CITY: uvula h
AM ❑ PM @'
COUNTY h'(/4Q VW4,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
DSlope alley ❑Flat ORidge DOther
(check appropriate box)
LATITUDE)(/ 340 rr e f,3Q/ t
LONGITUDEU)9V.& r� Wd'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: att.§ ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
d. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town State
( 82r8 )- 89 I- (e rl 1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 305
C. 9
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L7
c. WATER LEVEL Below Top of Casing. YO FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm) y METHOD OF TEST���r�j
f.
9.
• M 1 9
DISINFECTION: TypeCAP/s'C Amount 70 L
WATER ZONES (depth):
From To
From To
From To
6. CASING:
From
From
From
Depth Diameter
From__. To_17_ Ft. { rap
From To Ft.
From To Ft.
7. GROUT: Depth From 0 To 10 Ft.66/ e /f
From To Ft.
From To Ft.
8. SCREEN: Depth
From To
From To Ft. in.
From To Ft. in,
To
To
To
Thickness/
Weight ip aterial
Material Method
Diameter Slot Size Material
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
o—YU
Ss — POS
in.
in.
Material
Formation Description
ehif
St#141Drvc
ieeLIk
t Nr 1/4-
11. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL � NER.
SIGNir OF
RTIF
ONTRACTOR / DATE
©i/5
PRINTED NAME F PERSON CONSTRUCTING THE WELL'
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD of r 2 3
North Carolina Department of Environment and Natural Resources-rc�Division of Water Quality
OI
WELL CONTRACTOR CERTIFICATION # 0.A.S
1
W CONTRACTOR:
Wcb J• W, a
II Contractor1 `►rdjvid}'al))Nam
[ENIL& ONS W E it &kid
Well clntractor Company Name
y
STREET ADDRESS (a
Zip Code
o� City or Town / State
c WAR - SW -- 9L2-
Area code- Phone number
2. WELL INFORMATION: n
SITE WELL ID *Of applicable) /0 41
STATE WELL PERMIT#(il applicable)
p, !_-LC.
of5// 6,07
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED
TIME COMPLETED 6 r I/// AM ❑ PM
3. WELL LOCATION:
CITY:, / c rC4G/s COUNTY Hc.i no.li
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP PHIC / LAND SETTING:
ope ❑Valley ❑Flat ❑Ridge OOther
(check appropriate box)
LATITUDE/MI" 3" J ;7(yr
LONGITUDE(fiV j' XS(�(/
Latitude/longitude source: nrGrc ID 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 ��4r
OWNER'S NAMEGi.
STREET ADDRESS IA3h�( a(D�y Cgs leer•
F1 CityAckor State c• aVZip / 3
de
Qa8)- (trig--ago-a
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
"it
h. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [3"
c. WATER LEVEL Below Top of Casing: r12/ FT.
(Use `+• if Above Top of Casing)
1
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): .Z METHOD OF TEST,,
f. DISINFECTION: Type (ryn kik ale Amount Zv� Z
g. WATER ZONES (depth):
From To_- From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From_ To fjf Ft. 6 AS 4/6,W Pvcrplj
From To Ft.
From To Ft.
7. GROUT: 0 Depth //Materialatk�Method
FromTo 1i0 Ft. u]]Cfreei
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft, in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK
Depth
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
M 'y3
) O
ce4t
11. REMARKS:
Size Material
Formation Description
Cfa
sarnisle�K .ve
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL ,CO�NSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEgN pnOVIDED TO THE Wfl LON
SIGN
PRINTED NAME
CONTRACTOR
OHS„
PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7)05

e. YIELD (gpm)
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON #
L CONTRACTOR:
AJ(
W� Coontr Lindjvidy lirNam ® S
fEk' &(5off s W E ]L & drPum p, U__C.
Well ntractor Company yNamejj�/'�c
STREET ADDRESS r'A Sj /it- 1.
IF11E4 R Ar, (' aS74Q
City or Town I State
(Ds) 5S'-W9
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
Dle/ap/0785/.2
STATE WELL PERMIT#(ir applicable/
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED b /
TIME COMPLETED ( ?IAD AM ❑ PM Q
3. WELL LOCATION: /
CITY' ia4 cyv/r/( COUNTY mini testa/
Sogetrka4' Alto, Q1
(Street Nam umbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box) /
LATITUDE W 35 31 r 3d9
LONGITUDE UIOS%lr C/4
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this ffoorrm'''' A not usi CPS) ' /
4. WELL OWNER h/V D,a-&F0 F'd
OWNER'S NAME Oberf- iarme.r
SC7FE�EET ADDRESS to Y&inmP��
9'fer, krsoh v, //e NC 879
City or Town State Zip Code
(n 8 )- (e85-9-5a8
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: YDS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [J
May be in degrees,
minutes, seconds or
in a decimal format
c. WATER LEVEL Below Top of Casing.
(Use -+" if Above Top of Casing)
d. TOP OF CASING IS
FT.
FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. fq
METHOD OF TEST a
t. DISINFECTION: Type C//QO.f(f/t Amount
g. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
From
From
From
To
To
To
Thickness/
Depth Diameter Weight Material
From /) To -To Ft. b, � W4M,) /y/tOQA/
From To Ft.
From To Ft.
7. GROUT: DepthMaterial
0 To �j f
�J0 Ft. doWiErr
From
From To Ft.
From To Ft.
8. SCREEN:
From
From
From
Method
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From
From
From
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
(7 "50
'D-NS
y5 -- SD
.So - SIDS
11. REMARKS:
Material
Formation Description
e/ay ,/
,SaNs tDan
„cads
Gntw.'re
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG
TORE O CERl1FIED WaL�CONTRACTOR
PRINTED NAME
& L lofts
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

-ors.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. W CONTRACTOR:
L hi/ Wr r) S
W 11 Contractor Wvidyal)-NCam�G J�
it- 60f5 jL)/ tJ GZ'a tunp, LLC
Well cjntractor Company //Name ld
STREET ADDRESSr�I> 5 /
fiEit/ia X cl s ag
City or Town / State
(yds )- L-5s'4f9&
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #lit applicable) Qth % : ) O/ D 9 £'5 2
STATE WELL PERMIT#0r applicable)
DWQ or OTHER PERMIT #(i1 applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
AM D
PM r
CITY: toctety ufI('fC COUNTY Hen t/CSeY
544mn' I1M Dr,
(Streel Name, Numbers, Community. ubdivsion, Lot No., Parcel, Zip Code)
TOPOSFtAPHIC / LAND SETTING:
lope OValley ID Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE$) 3 A __b AA 30, Y
LONGITUDE',QO i_ 2/19
Latitude/longitude source: (ImQtC�_Y.�❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
May be in degrees,
minutes, seconds or
in a decimal format
REETADDRESS _
Son
(%City or Town p Stated(,
a<8 ,- lSl O 5 - as;i
A ea code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
30S'
)ivrh Nv
d.
C a879L
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES IDNO pr
c. WATER LEVEL Below Top of Casing:l) FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. qy
e. YIELD (gpm): i 2. METHOD OF TEST r J
r2O
at
0
r. DISINFECTION: jekitthis Amount
g. WATER ZONES (depth):
From To lib From To
From To From
From To From
!ao=
To
To
6. CASING: Thickness/
Depth Diameter Weight Material
From__ To 35 Ft. 4.)5 'dew' PUCS0$1
From To Ft.
From To Ft
7. GROUT: 0Depth �7 Material�oMethod
From To 10 Ft. CD/reti
From To Ft.
From To Ft.
Pawl
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FI. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
o -1%0 clay
1.0 -30
- SsYl,ac
3a 3 S �/
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1 SA NCAC 2C, WELL CONSTRUC110N STANDARDS, AND THAT A COPY OP THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON #
1. W�EInL)L CONTRACTOR:
W II Contractor ( ddvidyal))Namg
Mk? ONN`S ttliell &id t"amp,
Wet ntractor Company Name
STREET ADDRESSL IS/ NlbJ C
i<-esfER C. 3874g
City or Town r State Zip Code
( 83JR )- 5S'-f9Gz
s
Area code- Phone number
2. WELL INFORMATION: /,
SITE WELL ID Cif applicable) D(��^, J a V/ b 5 0 Y3
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT tiff applicable)
WELL USE (Check Applicable Box): Residential Water Supply !]�
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
1110146
/' DO
CITY: LdAtyUi n"L
AM ID PM[
COUNTY /4n Jt�`SDAI
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT]
❑Slope ❑Valley ❑Flat idge ❑Other
(check appropriate box)
LATITUDE ita,5 Q„(4iLDYA
LONGITUDE: e
Latitude/longitude source: PS
May be in degrees,
minutes, seconds or
in a decimal format
Topographic map
(location of well must be shown on a USGS topo map and
attached to this form #not using GPS)
4. WELL OWNER r1
OWNER'S NAME 4iA-UI.
arnb
SfitEET ADDRESS l 15 (T re renhrrr 1O r LQ.
r W �Sonl 0:11e. SC_ rl96Q 86
City -or Tbwn State Zip Code
($k )- S7 I- as JV
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
LOS'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: /DO FT.
(Use "+" if Above Top of Casing)
I
d. TOP OF CASING IS FT. Above Land Surfaces
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. qq
e. YIELD (gpm): / METHOD OF TEST J
20 g
3
L DISINFECTION: Type 4M, Amount
g. WATER ZONES (depth):
From To /e
From To
From To
From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From_ To/a.$' Ft.bp..A$ ZjSa21
From To Ft.
From To Ft.
7. GROUT: 0 Depth Materiale�ri!!!'''11T24h4
Method
From To 410 Ft. &laat/ J 11
From To Ft. TJ
From To Ft.
8. SCREEN: Depth Diameter
From To Ft.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
O —
Yf-/OD
140- Les Ask it
Anna re -
Slot Size Material
in. in.
in. in.
in. in.
Size
Material
Formation Description
tier
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BE PROVIDED TO THE W OWNER.
F CE : IFIED CONTRACTOR
Luc offs
PRINTED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
237

WELL CONSTRUCTION RECORD 3 4 a 6 6 2
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section WELL coxTRAOTOa pra1VIDUAu NAMEpelafl I n C . ©eit�s CERTIFICATION s 2 7 O Li
WELT. CONTRACTOR COMPANY xee�—mow ee f t.u.Q.,�t/' Q// 1 /-�.r,�,Paoxe s tPstl� 6Y9oY8o
STATE WELL CGNSTRUCEION PEUWU
(if applicable)
ASSOCIATED WQ PEleans#
(ifapplieable)
1. WELL USE (Check Applicable Box): Residential r Municipal/Public (3 Indutial El Agricultural ❑
Monitoring E Recovery Q Heat Pump Water Injection E Other 0 If Other, List Use
2. WELL LOCATI
N T • CAV g- Comty4-1ENDE:EftN
[4NvE 1Zasel> — ( KF1.nIa AcwyS.
(Scat Name, Nmnbe . Cammaouy. Sebdbicoo, Loa Na. rip Code)
3. OWNER: I•1
Address _Mt P h17 17=. •i�Aly E .
(Sweet a Fora No.)
atyorToam Sean Tap Code
Ana code -Phone mother
4. DATE DRILLED IJ;ZO-Olt
5. TOTAL DEPTH- 4 05 •
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO 12'
7. STATIC WATER LEVEL Below Top of Casing: 22- FT.
(11se'4, UAboveTopoW Sg)
3. TOP OF CASING IS / 5 FT. Above Land Surface*
*Top of cuing # ndmaad War below land mutes requires a
vartasee h, eaordaacewfl LSANCAC 2C.0119.
9. YIELD (gpm): /2. METHOD OF TEST11L4 t>
10. WATER ZONES (depth):
11. DISINFECTION: Type /, ,1 / Amount in Az
12. CASING: /• Wall Thickness
From I� Torig° D� f
Fromm, / To Pt
From_ To Ft
13. GROUT: Depth Material
To 7-0 Ft. CD KY L
TS.
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From,_ ( To Ft --ill. in.
From To Ft, in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
From To Ft
Topographic/Land setting
(dock appropriate Nod
Laiiwde/longibide ofwell location
( )
Lat tude/loagihaie source:lGPSEITopographic map
(Medan()
DEEM DDRIIJ.ING LOG
Ftom To / Formation Description
'1 i:rr$4.._
Show direction . • distance in miles from at least
two State Roads or County Roads. Include the road
rumbas and common road names.
- 40 a 10 elcitabAlg. KD
N 05° bZ..•(002_
\&t 0 SZ.° o3 . bEA
REV• IIBS'
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WEIL
CONSTRUCTION ST ' , AND THAT A COPY OF min RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SICiNAWRE a /• a• e' CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mall Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nature) Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION q 2571
1. WELL CONTRACTOR:
Bryant Smith
Wsl Contractor (Individual) Name
Green River Well & Pump Company
Well Contractor Conpany Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Ton State Zip Code
( 828 )- 693-1200
Axes rode- Phone number
2. WELL INFORMATION:
SITE WELL ID ft(if applicable) STATE WELL PERMIT/(f applicade) 0 is co list S-
OW() or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED // 23- aL
TIME COMPLETED ?; 70 AM ❑ PM 3-
3. WELL LOCATION:
CITY: ¶✓FeCIO COUNTY
,2iDIL GA-x-a'L em,i,)CC�
(Sreet Name. Numbers. Community, Subdivision. Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ['Flat ['Ridge OOt er
(check appropnate box) �
LATITUDE3je -' Y(3//
1
N
LONGITUDE yg2-V Z'd90
Latitude/longitude source: I1.rPS ❑ Topographic map
(locatbn of wort must be shown on a USGS topo map and
attic/NKr to this form 1 not using GPS)
4. WELL OWNER
OWNER'S NAME
May be in dcgrew,
minute& seconds or
n a decimal format
STREET ADDRESS Pc FJ Ol<T
City or Town State
g2' )- tog Z-831PZ
Area code - Phone number
6. WELL DETAILS: _
a. TOTAL DEPTH: 0 S
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Q-
c. WATER LEVEL Below Top of Casing: 3 0 ' FT.
(Use '+' if Above Top of Casng)
d. TOP OF CASINO 15 1 FT. Above Land Surface'
'Top of casing teminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
a. YIELD (gpm): 3 METHOD OF TEST Air
f. DISINFECTION: Type HTH
g- WATER ZONES (depth)
From //0 To //) From
From To From
From To From
8. CASING: Thickness/
From / To g1 FtDepth EN/niter Weight
. C. 2/.4
Amount
From To Ft.
From To Ft.
To
To
To
Material
P✓r:
7. GROUT: Depth Material Method
From D ToS_ Ft. 5,4)E%ir
From ,? To 2U Ft.QK„.j tor:,//,v
From To Ft.
8. SCREEN
From
From
From
Depth
To
To FI in
To FI 11
Demeter Slot Size Material
Ft m m
9. SAND/GRAVEL PACK
Depth
From
From
From
To
To
To
10. DRILLING LOG
From To
D—
I 3
3n—o
Co —.7
2 5-- 2 c5-
11. REMARKS:
Ft.
Ft
Ft.
Size Matenal
Formation Description
1'/Zt
5�<!y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrrH
ISA NCAC 2C, WELL CONSTRUCT1CN STANDARDS, ARO THAT A COPY c$ THIS
RECORD INS BEEN PROVIDED TO WELL OWNER
C VPOC
SIGNATU TRACTOR DATE
CERTIFIED
R OF CERTIFIED WELL CON
:z�rrr� r S art. kitPR NTED AME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Atbl: Information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Re"Sources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Rew�p,� Q e/'t
Well Contractor (Individual) Name
f-e,D.,be.A 0 o .&weAA 1'tv 8 ( lac .
Well Contractor Company Name ''nn
STREET ADDRESS 351 IV e 1ec co s+CY
k sikeA 11e- NC- (o
City or Town State Zip Cade
(g3$'). &54-36s1
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID UMapplicable)
STATE WELL PERMIT#(i1 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Appjicable Bpx): Residential Water Supply/
DATE DRILLED
0G
1(
TIME COMPLETED -�
3. WELL LOCATION:
CITY: R...ACC-i4(612.----
AM g/PME
COUNTY
IA 5 Mu -(cis rv'—t -
1,f)15-42S 0-4
(Street Name, Numbers. Community. Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND S�ET/-pNG:
[(Slope [Valley DFlat ❑Ridge ['Other
(check appropriate box)
LATITUDE 3 . 5 q 4 -O t b
LONGITUDE 1 of agA 1 C1
Latitude/longitude source: r1 I'S ❑Topographic map
(bcatbn of wel must be shown on a USGS topo map and
attached to this form 7 not usng GPS)
4. WELL OWNER (� 1'
OWNER'S NAME GtfaaI fl oaAS}4
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS t9.5 NJ-C.[(
1-b—ce--€4 Nc,
City or Town State
( q) 3aq-4►)1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Ue e
Zip Code
b. DOES WELL REPLACE EXISTING WELL?/ YES 0 NO
L9tS
c. WATER LEVEL Below Top of Casing: - D FT.
(Use -+" if AboveTopofCasing)
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. a pT
e. YIELD (gpm): a. METHOD OF TEST ^ -G
/. DISINFECTION: Type NIN Qt7 Amount
g. WATER ZONES (depth):
From Z t O To z I) From
From
From
From a- 3 6 To 4-31
From To
6. CASING: f Thickness/
,A/ Depth 6 I D�m/Rer C e paJya
From 1 To Ft. i
To
To
To
From To Ft.
To Ft.
From
7. GROUT: Depth
,( �1 Material
From d To 0.s+ Ft ce%Ylitsr%r
From To Ft.
From To Ft.
Method
6)00K-aD
8. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth
From
To Ft.
From • To Ft.
From To Ft.
10. DRILLING LOG
Frpm / To e
auO' al( '
436 4-311'
— (o05 '
11. REMARKS:
Material
Size Material
Fprmation Description
o-J ta' &U a b-S dJ
e e-t3Y L Cs 1 e Vain
G(LA aLTC
C�vLG��n — U' ern
�-� Ol-A .a T'-fF>
."1-7
r— jr7
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WI T4
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND 'THAT A COPY OF THLS —<
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
2Q.u.Q9 4.% CAP 4-�(4joco
SIGNATURE 0 CERTIFIED WELL CONTRACTOR D FE
tt l li5 c.--)AS}4
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTTAL WELL CONSTRUCTION RECORD
North Carolina Depart/mart of Environment and Natural Reswaces- Dnaioo of Water Quality
WELL CONTRACTOR CERTIFICATION # - Zta
1. WELL CONTRACTOR . .
t-ve: 'f cuka JQCS
Wel Contractor (IndMdual) Name -
e.‘ ate_ " SQswiit-CS *SOn.
Well Cohtrac . Company Naugle
STREET ADDRESS ♦�%%S .Y<t,J j acci
t\o* c;h ) Nc. - a8'vy3
City or Town she -2rp Cafe
(8M)- t (oS— at)g ,
Aree code- Phone number
2. WELL INFORMATION:
SITE WELL ID aWearr4ctk)
STATE WELL PERMIT#(saapec rde)
DWQ or OTHER PERMIT #(C eppewble) /
WELL USE (Check AppfaWe 8ac). Residartial Water SupplyI
DATE DRILLED 6 -2 (-G.
TIME COMPLETED A G CJ AM O PM t3�
3. WELL. LOCATION: /
CITY:: Are-+1 sem-'•'4�r.. COUNTY /4„ clar_nh
/'tr icerd, Qc/
4Seaet Nape Numbers. Cam -witty. Sutaabin, Lot No.. Pare* ZIP Code)'
T�Lp=WIND GRAPHIC AND SETTING:
*Tope Ovaiey ❑FIS ❑Ridge ❑Other
(check aurora box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: (JOTS 17Topographic map
(location of wet must be shown on a USGS fapo map and
afached to this form Foot osig GPS)
May be in *great,
minute; seconds or
Bra decimal format
0. WELL. OWNER
OWNERS NAME
XJ6 k01 &e M a
STREET ADDRESS Pc '(3bx t3.WIO
City or Town State Zip Cade
( %as )- 768•baoo
Area code- Phone number
5. WEII DETAILS: /L/
a. TOTAL DEPTH: / -r
b. DOES WELL REPLACE EXISTING WELL? TES ❑ Novi
c. WATER LEVEL Beim Top d Casing: 3O FT.
(Use`+' iT Above Top d Casing)
d. TOP OF CASING IS 1 FT. Ab(re tad Surface'
'Tap of easing ffiminated eVor below land surface may require
a variance in accordance �77 with 15A NCAC 2C .0118.
e. YIELD(ppm): a7CJ METHOD Of TEST f:•3
329325
f. DtSINFECl7ON: Type41,5 Amount 7
g. WATER ZONES (depth):
Fran ToFrom To
From To From To
Fran To From To
6. CASING: Tbttiessr
Depth D VSeigfnt
Fran 41 To S3 R. .`94.2I n iC
From To Ft. /
From To
R.
7. GROUT: Depth
DeptlaMaterial Method
From 0 _To 2© fl. Center* tee,1
From To R.
From To R.
8. SCREEN Depth Da peter Slot Site Material
From To fl. in in.
From To R. uv. in.
From To R. in. in.
9. SANDIGRAVEL PACK:
Depth - She Malawi
From To- Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
s 3 /1/S
11. REMARKS:
aaForrnaton
ILacr &I`
i' 9rrl
cn ._ V
-i
I00 PERUrf CERTIFY THAT THIS WELL Y'AS WNSTR1'1RED NACCORDANCE YRm
15A NCAC 2C. WELL CONSTRUCTION MP CARDS. AND THAT A COPY CF'MS
RECOR(R16S BEEN PRWDEDTOTR: TIELLQWsffR.
(
SIGNATURE OF TIEDNr ',TRACTOR DATE
See. c-x \teams 606A nos
PRINTED NAME OF PERSON X'NSTRUCTING TiiE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: kaformatton ten,
1617 Mai Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Faro GW-la
Rev. 7/05

329324
RESIDENTIAL wELL CONSTRUCTION RECO AD
North Carolina Department orEmaonman and Nadia' Resources- Division of Water Quality.
WELL CONTRACTOR CERTIFICATION # 04 ILI
1. WELL CONTRACTOR: Dace; C lk Nc‘ii£Ca% 'r •.' ,ecs
Wel Contractor (lndMdvai) None •
na.�V eke_ /J Q1.a Q t- s 1 "S t3 e7
Well Company Name
STREET ADDRESS \yV 8 \\LA./ atiq
t-\o4 5c:h4S NC a8'1`-i3
City or Town Mae - .. -ZrPCode .
($D8). tiVOS- aCiaPA-
Area code- Phone nwnber
2. WELL INFORMATION:
SITE WELL ID #fdapprrcable)
STATE WELL PERM!Trl(rnookable)
DWQ or OTHER PERMIT S(f apprcable)
WELL USE (Check Applicable Sox): Residential Water Supply id
DATEDRILLED -020 - F
THAE COMPLETED 3 r a ci AM O PM it
3. WELLOCATION:
CITY: 12iyarcvr o• 1/4 ..
COUNTY Alen le-C. c>#1
/)rr�yy/e/' f re) et r
{Steel T't.NNumbers. Carenurdly. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Bdopa ON/alley OFat DRidge Doter
(check appmpdate box)
IATTrUDE 3
LONGITUDE
Iatihde/iongitude solace: O GPS O Topographic map
(location of re/mustbe shone on a USGS two map and
attached for8us firm fnot using GPS)
May be m dogma,
minutes, seconds or
in a decimal femme
a WEIL OWNER
OWNERS NAME
STREET ADDRESS tO
Fktctvet r)G
City or Town State
(BAR )- to$ M- who
Area code - Phone number
8A 'Het%est -A ny: tte aa&
asn3a
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: (o--)
b. DOES WELL REPLACE EXISTING WELL? YES D
c. WATER LEVEL BebwTop d Casing gib
(Use+'i(Above Top of Casing) -
et TOP OF CASING IS 1 . FT. Abort Lard Surface'
Top d wsig tenineted attar below and surface may require
a variance it accordance with ISA NCAC 2C .0118.q
e. YIELD(gpm): a o METHOD OFTEST > •e.,D
NOS7
FT.
f. DISINFECTION: Type4 L 13
Amwnt2C--_
g. WATER ZONES (depth):
From To From To
From To - - From To
From To From To
6_ CASING:
/ �G :Tl+idoxssl
epth Client Weight
From_DTo1.r1._,? Ft_ ADS. -5ii a I
From To FI.
From To Fl.
7. GROUT: Depth Ma�WOWAtatlra
From�_To Oc0 FL ( {ylyp/1'�" 0 C/re
From To - FI.
From To FI.
•
8. SCREEN: Depth That Slot Ste Matertai
From To Ft. in. h
From To R. it in.
From To R. _ n. in.
9. SAND/GRAVEL PACK:
Dept - Size Material
From To Ft
Fran To Ft
From To Ft
10. DRILLING LOG
From To Formation
<3k 3acr fir.
/3 fe -14 s- &iv. *
11. REMARKS:
c n
•
rC
r-
I DO HEREBY "MAT VC WELL V'AS COMSIRLCIEDNACCORDUI Wmf
15A NCAC 2C, WELL CONSTRUCTION .TPNO* D3. AND THAT A CCP' OF Tes
RECORD HAS PI 1OTS:HELL OWNER.
SIGNATURE OF CERTIFIED WEIl CI�ITRACFOR
PRINTED NAME OF PERSON ;ONSTRUCT!NG -a WEU.
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: information Mai,
1617 Mali Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

329323
RESIDENTIAL WEue coNSTRucTtoN REa):2n
North Carolina Department of Environment and Natural Reacto a Division of Wat QuaBty
'PFEIL CONTRACTOR CERT I ICA'IION al• ai
1-WSJ_ CONTRACTOR:
tom.. Qxe:tk "NAPC .2 N &a'- ,tVS
Wd Contractor (Indtsktuat) Name
QCitiaQ C ^let's k'SGn
STREET ADDRESS \"1VSS VILLaV aoq
Ho4 6?(C 14St ix.. - a2 i3
Ctty or Toren Stele-ZP Code
(8M)- t 5(06- aciaa
Area code Phone number
7. WELL INFOP MATIOtt
SITE WELL ID A(f eppr able)
STATE WELL PERNaf4(reophaue)
DWQ or OTHER PER &PT p(C applicable)
WS.L USE (Check AppRwble Sacs Residential Water Supply 1
DATE DRILLED 6 •/1"-
77AECoieptEtuD /r`30 AM d PM9-
3. WELL LOCATION
CRY: ,ir.7rk/'lonne Mr
COUNTY XeHetl.^SXih •
fr Marne, ,(onNim*ms, toamem)r smONrkn to No.. p«tt. Zt Cade) ..
T OGRAPHIC 1 LAND SETTING
Wane; QFka oRidge (other
ice* romomimo e°°e ?day be in degrees.
LATITUDE 3 miens number
inadedmei format
LONGITUDE_ _.
Latibtdeflongitu3e son f OPS OTopogtapbie magr
([ocatioe, of well must be shown on a t1SG$ two mop and
stitched to this tan fnot GPS)
0.WSLOWNER
OWNERS NAME n e h J 1 �{ .Pi'e-SS
ctrt on fr ADDRESS fc5coa R;date
Nettchesowv:ile, ac a lq
Cfty a Tam Stele fl Cade
(Sera 3%8- \7la
Area code- Phone number
5. WELT. DETAILS: t
a TOTALDEPftt ✓--�
b. DOES WEU- REPLACE EXISTING WELL? YES ❑
e. WATER LEVEL Below Top of Casing 5 6 FT.
(use +t'iitAbele Top el Casing) -
d. TOP OE CASING Is FT. Pbae Land Surtax*
'Top d casing te,N.ated at/or beber lend surface may require
a variance In scram=with 15A NCAC £C .0115.
s. TIB.D(spm): CPO METHOD OFTEST r�•
t. DISINFECTIOtt Tyfl4 . %$
g. WATER ZONES (depth)
From To Fran
Rom To From
From To From
6. CASING: Dirt
Fran4_To R._ 1e .
Ilognitl
From To R
Depth
From To R.
T. GROUT:. Depth Materiel
From0To_29_Ft. Cents, :
From To • Ft.
Fmm To • R
I/
To
To
To
.Thkanessh
fhttie
A SCRES't Depth Diane . Slat Slav Materiel
From To R in. R
Ftom To R. In. R
Fmm To R. in. is
•
9. SANDIGRAYEL PACK:
D
From To- FL
From To Ft
From To Ft
Sae Maerid
1ft. DRTLUtiG LOG
From To Forrmafnn
t 7J 11 to C A..
78 ;Os *
11- REMARKS:
r
F.D •
Fes
o le
100 ?EMS( GUMP' ma THIS wal.T'A6 ramI TEONACCOROetCE won
NSA ICAC2C. WELL CONSTRUCTION UThO*1)I. ANDINITA COPT OFTra
MECORO HMS BEN pRuWDEOTOTIa¢walOra
SIGNATURE OF CERTIFIED r
ate c-e ck \AtO.4j3, Acerb 73
PRINTED NAME OF PERSON X .M5 G WELL
— ram "
Submit the original to the Division of Water Quality within 30 days. Attn: InfonnaHOn 9R3t
1617 alas! Service Center— Raleigh, PC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 71g5

RESIDENTIAL nu. CONSTRUCTION REarzD
• North Carolina Departmolt of Environment and Natural Resource- Division of War Chalk;
WELL CONTRACTOR CERTIFICATION #. of i Zto
1.WELL CONTRACTOR -
o`l. arc; e k ae.c 2th rJo.�3�lf' cs
Wd Contractor (httflviduel) Kane
Wd Cate.Sr Coni ,w.' Mahe
STREET ADDRESS ak.t.Se Y 129g
Eck gv:ny Nc. aa't,43
City or Town .. -Zip Code
(8M)- tn(oS- aoaaa
Area code- hole rumba
2. WELL RNEMtATl0tt
SITE WELL ID sof impac Na)
STATE WELL PERMTSoraorFrable)
MCI aOTHER RERMIT£(Wapplicable)
WELL USE (Check AppGiable Bw. Residential Water Supply lS
DATE DRILLED G17-le
ram coMPLETEDa;a0 AM PM
3,WES LOC/p_71001t `/
CCTV: /TC�P`cork alit COUNTY Neerc4r'Sah
Oil ZIA /Ter!.
.(saem Name, misname, comnunar. suedmaion, Lot Iyo.. Parcel. zP Coder
TRAPHIC t LAND SETTING:
9e oWdley OF 0Ridge ❑Other
(cheek aprreerlata h04
LATITUDE 3
LONGITUDE
•
IMay beind I
minims,secorldsa
in a decimal formal
Laimdd(ongitnde son o 3PS DTopogtaph c map
(bcabon of wet must be shown on a USGS tapo map and
*Ruched to fhb tort f not using GPS)
4. WED -DEWIER (�
OWNERS NAME - h 1J U.R.4 is &
olNtti ADDRESS a5&do A:d�P Road
_, u
liender son^e:Ilec v 98192
Cltya TOwtl State rep Code
(8aA ,- 388' 1710
Area code - PhOne comber
& WELL DETAILS:. '
a. TOTALDEPikt 1%as
b. DOES WELL REPLACE BUSTING WELL? YES B
C.WATER LEVEL BdoeTWdCasing -90 Fr.
(Use^*' II Abate Top of Casing)
d. TOP OF CASING Ls FT. AbO.e Land Surf*ce'
'Top d Cosby lnm&latad *or below land surface rney require
wronawe In act °NaCemittl t5A NCAC 2C .0118.
e. YIELD (gpin): f/ MEMO OF TEST i
329322
_. DWrWECTIOtt Type4.1 N5 Amount
g WATER ZONES (depth):
From To Fran To
From To _ From To
From To Fran To
6.
f/.
CASING:
Flom__}j_�To 72 .Ft. b=If Dtbiter
�rr .
From To R.
Fran To FL
7. GROUT: Depth Meerid
Fan0Toa Fl. (f/11rn4'.
From To , Ft.
From To P. .
•
puttee d
& SCREEt Depth Diameter Slot Ste Maedd
From To FL in. h
From To P. in. in.
Rom To P in. In.
S. SAMGRAY0. PACK
Depth Ste MSW
Ram To- FL
From To Ft
From To Ft
t& DR'WNG LOG
From To nor oton
72 blurt v
73 P2S %3•n+r.r
11. REMARKS:
C)
r~
'1
t00 HERESY CERTFYTlMrnaa WELL WAS CONSTRLC7®NA NIM
RSA NCAC 2C,WELL CO,StRUCPYI IMIMARDS. AND m,NTACarr pFWs nf4
BEEN PR0V01910 HLGMIIER.
SIGNATURE OF ":�• . CONTRACTOR DATE
^tete, tk \Neck*j0 6Q5,I'TeEs5
PRINTED NAME OF PERSON X NSiRUCfING THE WSJ.
y within 30 days. Attn:
rmation Mgt.,
16177 Mservice Center Raleigh. NC 27599-15117bmit the original to the Division of Water � Phone No. [phone] exces
ali s
69.
Faro GW-la
Rev. DOS

329321
RES,IDENTJa WELL coNSTRVCTION REco:xv
North Carolina Department of Embomnent and Natural Resources- Division or Waco Doak)
WELL CONTRACTOR CERTIFICATION #- 2 ats
1. WELL CONTRACTOR:
-irtzh
WS Contractor (h v1duaf) Name
S CJ1 cQ Madre
+ S G rI
STREET ADDRESS 141
NSZ)US -WAY 20Q
1.10 k tjTC 112, 1NC - a8'v-43
Cdy or Town spa -Tip Code
(8 %» loos- °aa -
Arm code- Phan number
2. WELL morons A7Wtb
SITE WELL ID Weapplicable)
STATE WELL PERNMTB(aanpacable)
DWQ or OTHER Pew #(dapplicable)
WELL USE (Check Applicable Eke): Residential Water l� Supply
DATE DRILLED (0-A ` to
aptETEo L/ . .
vats con ,' o a. AM o PM E
3. WELL LOCATIOtft .•(P CRY: rneSC
mac. at\
Dpanbaa,
-Wass Community. SubStsion, La No_ Parcel Zip Code) ..
T POGRAPHIC f LAND SETTING:
OYediey One oRidge ❑Other
(check appropriate b
LATITUDE ,y
LONGITUDE_
Tatiarde longitu a source: OG?S 0Topographic map
gocaton of wet most be shorn oa a USGS typo map and
attached to Mb flan (not us^g GPS)
4. WELL OWNER
OWNER'S NAME
�htcttr ADDRESS a5
?(eeaeteonv;tie , ac-
City or Town State
( 8a8 ). 38g• 1'110
Area Dade - Phone number
A WEU. DETAILS: : • / 0 S
a TOTAL DEPTtt SO,.,/
b. DOES WELL REPLACE EXiSTRNG WELL?YES 17 NOV
c. WATER LEVELBeim Top of Casing 9a FT.
(Use `•P 9Above Top of Ca Ing)
d. TOP OF CASING is Fr. Above Lad Surface
'Top of easing branded aVa below teed surface rosy require
a variance in scram. with 15A NCAC ZC .0118.
e. YIELD (gpm): METHOD OF TEST f t"
May be in degrees,
azioner, seam:her
m a decimal famer
LU.Z 4 eSS
stay cais
a8r19
tip Code
f. Dr31PFECTION: Typed% L$ Amount x J
g. WATER ZONES (depth): .
Fran To From To
From To From To
From To From To
6. CASING:
Depth4 T79 • R. D` .9
Pram 4441
From To R.
Fran To R.
7. GROUT:[ iai
Depth Maw
0
From Ten R. Ceritault.
From To - P
Fran To P.
8. SCREEN: Depth Diatteter Slot Slue Maeial
From To R. in it
From To P. in in.
From To R. rn. Si.
9. SAND/GRAVEL PACK:
DepD1
From
From
From
To- FL
To Ft
To Ft
tR DR'UJNG LOG
From To
J 79
79 ins
11. REMARKS:
Sizo Material
?1aGr
corron
L
r
n
r—
tDD HEREBY CERSEYTHAT THIS WELLWAS CC.$IRLCiEDNACCORDPOCF wm1
15a NCAC2C. WELL WNSlRUC110t.4IW WtDS. NSDNTACCP?OFTNS
RECORDWAS SEEN PROVIDED TOT)B'eat OWNER.
S)GNATURE OF C@:11flED 1RrEli CONTRACTOR GATE
t*cC.ex #to.A-6oa7ms
PRINTED NAME OF PERSON XNNSrRUCTRIG TiiE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Wormatlon Nf 3L,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone Ho. [phone] eat 568.
Form GW-la
Rev. 7)

From: Scott Gantt 7044347212 To: Stephenie Wilson Date: 7/10/2006 Time: 6:06:44 PM
Page 3 of 7
From
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
WELL LOCATION:
Nearest town: EDNEYVILLE
231 GRIFFIN DR
County HENDERSON
(Street Name, Numbers, Community. Subdivision. Lot No,. Zip Code)
3. OWNER CHRISTI ELLIS
ADDRESS 231 GRIFFIN DR
(Street or Route No.)
HENDERSONVILLE
City or Town
NC
State
Area Code - Phone Number
4. DATE DRILLED 6/2/06
5. TOTAL DEPTH 85
6. DOES WELL REPLACE EXISTING WELL^
7. STATIC WATER LEVEL Below Top of Casing:
YES NO
60 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
°Top of casing terminated atlor below and surface requires a variance in
accordance with 15A NCAC 2C0118
9. YIELD (gpm): 18
la. WAIBR ZONES (depth):
11. DISINFECTION: TYPE HYPOCHLORITE
METHOD OF TEST
70
ARDM
28792
Zip Code
Topographic/Land setting
❑ Ridge ❑ Slope ❑ valley ❑ Flat
Latitude/Longitude of well location
35.23.677 i 82.24.464
(degrees/minutmseconds)
Latitude/Ioneitude source: ❑ GPS ❑ Topographic map
DEPTH
From To
0 22
DRILLING LOG
Fomlation Description
Clay
22 85 Consolidated Rock
12. CASING:
Depth Diameter
From 0 To 28 FL 61/4"
13. GROUT:
Depth
From 0 To 20 Ft.
14. SCREEN
Depth
From NA To
1s. SAND/GRAVEL PACK:
Depth
NA To
16. REMARKS:
Amount 3
Wall Thickness
or Weight/Ft Material
SDR 21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
FL
Size
Ft,
Slot Size Material
in
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
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.
7/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- ul vt titer Quality
WELL CONTRACTOR CERTIFICATION P 2571
1. WELL CONTRACTOR:
Bryant Smith
WM Contractor (ndMdwB Name
Green River Well & Pump Company
Wee Conmaga Company Name
STREET ADDRESS PO Box 204
East Flat Roca, NC 28726
City or Towel State Zip Coda
( 828 ). 693-1200
Ares coda- Plane nurroer
2. WELL INFORMATION:
SITE WELL ID S f apptuae)
STATE WELL PERMIT/Stir appsara) Dl0 000 )D 5?‘9.
DWO or OTHER PERMIT Sy am:Acabta)
WELL USE (Chats Ap/ylcaba Box). Residential Wster Supply ❑
DATE DRILLED /.Jr c /o %
TIME COMPLETED /0:00 ,yid IM PM
3. WELL LOCATION:
CITY. ,V-1-1E-6-4 COUNTY w
ASu
Lot,''l 61oo.H:ng(awe St 1:vtiL:n r 39 y LAte/Hsi
(Strew Name. Number" Canmunty. Suodrwswn. La No . Pincel. Zip Cone)
TOPOGRAPHIC / LAND SETTING:
&cape OVway ❑Fld ❑Ridge OOolw
(meat appropriate mix)
LATITUDE _LS° 13' 3L N
LONGITUDE{j2° ZIS' 3 I W
Latitude/longitude source. 7PS ❑Topographic map
(bcalon d waif must be shown on a USGS Copra map and
.Rachad to M tomn 7 not rang GPS)
4. WELL OWNER
OWNER'S NAME Sh
STREET ADDRESS 530 Shur rLc'1 Mtn ti"'
May be in dogma.
minute, scalds a
b . decimal formai
&M rock. U
1-1-t-kd,i_7corn oi Ile hiC LY'15 I
Cty or Town State Zp Code
lIZ zt)• 1aq-9)�I-S
Area code • Pnaa nurn°sr
6. WELL DETAILS: c
a. TOTAL DEPTH: 3 S5 (
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOl¢],
c. WATER LEVEL BeSOW Top of Casing . i FT.
(Use •: If Above Top of Clang)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
lop of casing lennrated sva below and surface may require
a variance in accordance with 1SA NCAC 2C .0118.
e. YIELD (gpm)' lT METHOD OF TEST Ail
1. DISINFECTION. Type H1H Amount
g. WATER ZONES (depth)
From 3/5 To 32D From To
From To From To
From ` To From To
8. CASINOThickness,
Depth Di rT)e16r Wepm male'sl
From To�3 FI $ 2 /, C. t,
From To FI
From To _ Ft
7. GROUT' Depth Matenal Memos
0 To Ft S 7
From
From A To 2 3 (J_ Ft O rf'ti 1Y� OQn
4
From To Ft
8. SCREEN' Depth Diameter Sat Sae Material
From To Ft n n
From To Ft on on
From To FI in in
9. SAN[YGRAVEL PAC
Depth Sae Material
From To Ft
' From To Ft
From To Ft
10. DRILLING LOG
From To
II. REMARKS.
F/S /Z'CY n jilla1nption:
�tr/l ✓lot&
(-ID
err
AUG
1 ZU if)
i CO HEREBY CERTIFY RNA I THIS w EL L OAS CCNSTRvC1ED IN ACCORDANCE W nH
1'aA ICAO 7C WELL CONSTRuCTOn STANLWiOS AND THAT A COPY O' M6
RECORDP.AS BEEN PROvOED r0 ft WELL ONNER
SIGNAIUR OF CERTIFIED WEI }CONTRACTOR
PRINTED7SAME OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Duality within 30 days. Ann: Information Mgt_
1617 Mall Service Center - Raleigh, NC 27899.1817 Phone No. [phone] ext 568.
Form GW•la
Rev 7/05

RESIDENTIAL WELLCONSTRucTION RECORD
North Carolina Department of Envumnmcnt and Narunl Resources Dw isb n ..I water Qualm)
WELL CONTRACTOR CERTIFICATION a 257 /
Wel .. w (IndMduel) Noma
Ghee'-rl ?Iver l.,Je1
Well Contractor Company Nana
STREET ADDRESS ?U Pj OX a0't
Cast Plat -ko(-K- Ki( ot(SgQ(o
City a Town State / Zip Code
tR ). 693-)Z00
Area code- Plane nunter
2 WELL INFORMATION:
SITE WELL. ID a(u appraoul
STATE WELL PERMITNd appbaole) 0 Le I COOO5Z 1
MVO or OTHER PERMIT a(I appecal4)
WELL USE (Check cable ResidentialBox).Residential Water Supply E
DATE DRILLED 14. Zee l 0
TIME COMPLETED lf• 00 AM ❑ PM%
3. WELL LOCATIO(NN�:� � ��f
CITY 5Gly-M a-
-
1Zv9 Pau"
(Street Name Numoere. Community, SutAlwean La No Parcel Zip Covet
TOPOGRAPHIC / LAND SETTING.
❑Stop, °Valley °Fit ❑Ridge °Omer
len•Ck apaopNa Port
LATITUDE s J2 / S7'V/
LONGITUDE.Q Z° XLi
Lautudelongnude sotucc. SOPS DTopographic map
(location of we/ must b mown one USGS topo map and
attached to no foal Y not any GPS)
a. WELL OWNER r
OWNERS NAME 1011 rT�Is,
STREET ADDRESS IF" l.-Lr1L (.PI3
M ou_9 h6-U' k ( k.) L Z4'7Si
City cc Town State Zip Coda
(cjlR r L092-DI lQt
Area code • Phone nurrter
COUNTY I�`""'""S' '
May be to deem.
mmuta, ands a
m a decimal format
6. WELL DETAILS: �T
a. TOTAL DEPTH: 605
b. DOES WELL REPLACE EXISTING WELL? YES
YES ID NO 67
LEVELa
c. WATER Beaty Top d Casing:3 0 Fr
(Um •: I Above Top d Cang)
d. TOP OF CASING IS FT. Above Lard Surface
Top d casing %ernnated Mid below and surface may require
a enrolee n accordance meth ESA NCAC 2C .0116.
a. YIELD (9pm): 3 METHOD OF TEST r
t DISINFECTION'. Type 'ill • Amount
g. WATER ZONES roepm,
From 2I/5To 2 0 From To
Fran To From To
From To From To
6. CASING. Thrckrwss
Deptn Diameter Weight Maw teerral
From / To GI FI Lt ZLG 1y�`
From To FI
From To Ft
7 GROUT Depth Matenal MetTrod
From 0 To� FI SA RA
From 3 To_ag Ft 7n✓scfam;ifr M&i4
Fran To Ft
8. SCREEN'. Depth Diameter Slot Sze Matensl
From To FI n n
From To Ft n n
From To FI n n
9. SAND/GRAVEL PACK
Depth Sae Material
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To Fgrmapon�escnon
C9 — y� flan saline
1�� 5O
co - GO
Co— .521-
11. REMARKS:
a•
C •ram.
n1 r'r
N
c err am';
r
I DO rtEREBT CERT•FT' ThAT n'i5
tN NC. C x wEt. CO+S-THLC'
RECORD MS BEEN PROVIDED T
tt WAS CONSnuCTED IN ACCORDANCE wr
STANDMDS AND TWAT A DDP' Da Tics
W ELt QpNER
SIGNATURt'OF CERTIFIED WELL CONTRACTOR
s--(-0t
DATE
PRINTED OF PERSON CONSTRUCTING THE WELI
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.
1517 Mall Service Centrr- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW
Rev 7Ia5

RESIDENTIAL WELL consrRucr►on RECORD
_North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Wel Contractor (IndMdual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or Tov.n State Zip Code
028 )_ 693-1200
Area code- Piton number
2. WELL INFORMATION:
SITE WELL ID flit appecaMe)
STATE WELL PERMIT/Re applicable) D ('/2CIO 5 &
DWG) or OTHER PERMIT e(7 appiable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 5110 I cc,
TIME COMPLETED ( I. 00
3. WELL LOCATION:
CITY: f;y�. L94.moiiI
AM ❑ PM )11.
COUNTY
l-ct I. Min Intdel ou&S - I J1c1cdowsDr
(Street Name. Numbers. Community. Sunditesion. Lot Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
L3Sbpa OValley OFlat ❑Ridge ❑Other
(check appoprate box)
LATITUDE �T3S �o/ non.'
LONGITUDEraitSA 1 5 Z LI]
Latitude/longitude solace: SOPS ❑Topographic map
(bcetbn of wet must be shown on a USGS topo map and
attached to this form y not using GPS)
4.WELL OWNER OWNER'S NAMEml Kt_'7 a Anc ✓Icl-- /Vlt( ll/f'r
STREET ADDRESS L: '7`I /£L(P YS 0.4--ruz P4
al: �scx
May be in degree,
minutia, moan& o
in a decimal format
\ SC?1U11IMF (..��jl7ft
City or Town State Z4 Code
Area code - Piton number
5. WELL DETAILS:
a. TOTAL DEPTH: I P
b. DOES WELL REPLACE EXISTING WELL? YES O NO
Cli-
c. WATER LEVEL Below Top of Casng: 70 FT.
(Use -+' 1 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Solace'
-Top d casing terminated at/or below land surface may require
a wrong in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): I 0 METHOD OF TEST Air
I. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth)
From /%+!i To / 2.'2From To
From To From To
From To From To
6. CASING:
Depth _ Diameter
From / To 9 A/ Ft 6 ..
From To Ft
From To Ft.
Thickness/
Weight Material
7. GROUT: Depth Material Method
From C9 To -? Ft. 5n.4)2/2/ /J1 : y j /%id
From 3 To ; Ft.l3. win .. h' /11:) ]z /"✓e`
From To Ft.
8. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
From
• From
From
Diameter Slot Size Matenal
Ft. in. n.
Ft n. in.
Ft n. m
Sae
To Ft
To Ft.
To Ft.
Material
0. DRILLING LOG
From To Formation Descnptnn
—_2c /7,J2t-
27 -
11. REMARKS:
O Lam-..
C
r—
I DO HEREBY CERTIFY THAT TNiS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
I5A NCAC 2C, WELL CONSTRUCTOR STANDARDS. AND THAT A CORM OF THIS
RCW1D HAS BEEN PROVIDED Tgf{IE WELL OWNER
/�rafra.�% // "ii(
SIGN UREm ERrtIFIED 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] est 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL cos srRucrloN
North Carolina Department of Environment and Natural Resources- Division at Water Quality
WELL CONTRACTOR CERTIFICATION p 2571
1. WELL CONTRACTOR:
Bryant Smth
Wei Contractor (Individual) Name
Green River Well 8 Pump Company
Well Contractor Company Nana
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or TOWn State Zip Code
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Lit applicable)
STATE WELL PERMIT&a amicable)
DWQ or OTHER PERMIT till applicable) D ca 10 n! 13 3 40
WELL USE (Check Applicablepox): Residential Water Supply p
DATE DRILLED `S// / / 0
TIME COMPLETED 30 AM ElPM t'6L
3. WELL LOCATION: /
CITY: 1a Llvs WI V)11? COUNTY
64 Sugcuv n , (2d
(Street Name, Number's. CommunteSubdiesron. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / �LANN D SETTING:
❑Slope °ValleL7 y rrt °Ridge ❑Other
(crack appropnate box)
LATITUDE _LS: I' G r W
LONGITUDE CBZO »-' D7tt1
Latitude/longitude source: rsQPS ❑Topographic map
(bcaton 0! veal must be shown on • USGS topo map and
attached to the form % not using GPS)
May be is degr .
minute, woods or
in a decimal format
4. WELL OWNER
OWNERS NAME
(Adair re_vi (-ewe I 1
STREET ADDRESS PO (30 K SD&'+
4^cLut w /-1 (e, NC_ a (6'.)G 3
City or Town State Zip Code
('izCS /- 6,' '7 - Z, G
Area code - Plane number
6. WELL DETAILS: S
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
YES 0 NO Q-
c. WATER LEVEL Below Top o( Casng: •! 3 FT.
(Use -+' 1 Above Top al Casng)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top d wing Laminated at/or below land surface may require
a variance in abcordanc. twill 15A NCAC 2C .0118.
a. YIELD (gpm): 15 METHOD OF TEST Air
f. DISINFECTION: Type HT Ft
g. WATER ZONES (depth)
From /17To / (✓ From
From To From
From To From
6. CASING:
Amount
To
To
To
Thickness/
Depth Diameter Weight Material
From To'7/ Ft. f b Z/•/. PLC -
From To Ft
From To Ft
7. GROUT: Depth Matenal Method
From_C To_l_ Ft. > ri%C % M. Si-i..<
From 3 To IitC FL•i J..r71DN.ix Al.i.fliklrt
From To Ft.
8. SCREEN: Depth Diameter Slot Size Matenal
From To Ft in.
From To
From To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
—
.2h
2j—^5
D (. Sr
G 5 - /4 /T
Ft.
Ft. in.
Size
Ft
Ft
Ft.
Material
1L REMARKS:
Formation Descnption
/.7-ri'r
Clry
n.vr.1 `rL-n3ti
i2Gw.✓ 5 1 ,f
1 bn
N
0
rT7r2
^' <
I DO HEREBY CERTIFY TWO 71115 WEL
15A NCAC IC. WELL CONSTRIx. Ix1
RECORD HAS BEEN PROVIDED TO T
WAS CONSTRUCTED IN ACCORDANCE W nH
ANOARDS. AND TAT A COPY OF 1 W5
ELL OWN
� /Z,d�Ou'/ ,�(f ✓/ C' D - 11 -C
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
gRayiess- Sen, 'ri-7
PRINTED N14+IE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Aim: 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 Dcpamnent or Environment and Natural Resources= DtWsion of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Wel Contractor (IndMdual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rode, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID a(it applicable) /1
STATE WELL PERMIT#(e appcable) 0 Ip l a 0 0 3/ 3 S
DWQ or OTHER PERMIT CI applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 6-- /Z - 0
TIME COMPLETED r 3 (^0 AM p PM -
3. WELL L ATION; /
CITY: ?C-.E-4SO11�?ll� COUNTY i�I `,-r_`-A-A-'"k'U
3srL� eet NaInse. , Sd teerCommunity. Sub . Lot No. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley aPral ['Ridge ❑Outer
(check appropnate box)
LATITUDE .2i12 /7kA/
LONGITUDEe_ti(A A9r,J
Latitude/longitllde source: 3}6PS ❑Topographic map
(bcaton a war must be shown on a USGS tope map and
attached to this tam, 7 not using GPS)
6. WELL OWNER
AME F/mrrl./
OWNER'S NA(Q4aj-L
S REETADDRESS 4 -7
ScmuI(1e, /10/2
n / rest
City a Town State Zip Code
(o 8 5-- 3 3(.O
Area code - Phone number
May be in degree,
minute, second. or
m a decimal format
6. WELL DETAILS: '�T1
a. TOTAL DEPTH: / 1 L S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO WY
c. WATER LEVEL Below Top of Casing: _2 0 FT.
(Use -+' t Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top d rasing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): %1L METHOD OF TEST Air
1. DISINFECTION: Type HTH
g. WATER ZONES (depth)
From 2 3 ✓ To J. 3 i
Fran To
From To
6. CASING:
From
From
From
Amount
Depth Diameter
From / To /L 0 Ft. 2, Q
From To FI.
From To Ft.
To
To
To
Thickness/
Weight Material
Pat-
7. GROUT:Depth Matenal
�l
From V To Ft 51i '( /Z—
From_3 To Ft./7iC,J1C.✓;ter
From To Ft
8. SCREEN
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK:
Depth
From To
• From To
From To
10. DRILLING LOG
From To
/ /o
3 0 - 3Ci
fo
II. REMARKS:
Darnels,
Ft
Ft
Ft
in
m
Method
filly
Slot Size Material
n
in
in
Sze Material
Ft
Ft
Ft
Formaton Descnpoon
R2cl L Ar
lJ;fir
S,nJct/ n r / 9 ccJ;t-A-<
5<,=// ,' c/ k
Hz? n.r, l T,
t
,
CT, 1
•1
' c
V
I DO HEREBY CERTFY THAT THIS WELL WAS CONSrRUC1ED IN ACCORDANCE W nH
15A NCAC 2C, WELL CONSrTtllt.lUN STANDARDS AND THAT A CQ'Y OF DNS
RcuntD HAS BEEN PRO✓IDED THE WELL OWNER
f,2 zr - 1 /3 E'S
SIGnNAT E OF CERTIFIED WELL CONTRACTOR DATE
yTj/7wfi
t /Fin
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: 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 $ 2571
1. WELL CONTRACTOR:
Bryant Smith
Wel Contractor (Inditdua8 Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rods, NC 28726
City or Tom State Zip Code
( 828 ). 693-1200
Area code- Plane number
2. WELL INFORMATION:
SITE WELL ID i(it amicable)
STATE WELL PERMIT/Art ewer:able)
TIME COMPLETED Z7 0 0 AM p PMX
3. WELL LOCATION: �fjj �
CITY ft U) I j'e' COUNTY -ie7"LieYSon
L-Ofa0 Gn'ilram Wads
mtx> (Street Name. Nua, Community, Subdivision, Lot No., Parcel, Zip Code)
TO RAPHIC / LAND SETTING:
lop° ❑Valley ❑Flan ❑RiOge ❑Omer
(check appropnale bar)
LATITUDE _15°,-2ar 00/4
LONGITUDE LJ o / % r 5<7�
DWQ or OTHER PERMIT I(/ aapplicable)(J v
cable) P /r-2 01 I0 ¥ZC
WELL USE (Check Applicabe B/px): Residents Water Supply CI
BATE DRILLED 51/ / 0
May be in degrees.
minutes, seconds or
in a decimal format
Lam-ode/longitude source: ET,OPS ❑Topographic map
(bastion awe/ must be shewn on a USGS bpo map and
attached to MIS form I not using GPS)
4. WELL OWNER rk ,, I. L`/�
OWNER'S NAME N(c k- 5I c/ra^y: oce
STREET ADDRESS 3 I I Low 1 Ied
L-ti c sg�Vr1le-,�t)(lz042
City or Town State Zip Code
?Z5‘)-
Area ode - Phone number
6. WELL DETAILS: l.(/ tP \
a. TOTAL DEPTH: J
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOT
c. WATER LEVEL Below Top of Casing: / 3 0 FT.
(Use •,• t Above Top d 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.
a YIELD (gpm): I METHOD OF TEST Air
t. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth):
From / g47 To / 7 5 From
Fran
From
6. CASING:
To
To
From
From
To
To
To
Thickness/
Depth Diam{eter Weight
C Y
From / To L Ft. / 1 I C
From To Ft.
From To Ft.
Materal
7. GROUT: Depth Material(�( Mev�mod
From 0 To S Ft. 5Alk'!%%TG M'=.%:4/C43?
From .3 To .2 C Ft. 'Ja rao»t-4 rsi 1t±ne
From To Ft
8. SCREEN: Depth Demeter Slot Size Matenal
From To Ft.
From To Ft m in
From To FI m In
SANDfGRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
From To Ft
10. DRILLING LOG
From To
3
'2, a — 53—
i7 -LCy-
II. REMARKS:
Formation Descripbon
t7, r?
Ul/Jr Ski r4 Str. z&
r- v
n; 7
c
I DO HEREBY CER11FY TM&T THIS W ELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUC nON STANDARDS, AND TNAT A COPY OF 1HS
RECORD HAS BEEN PROVIDED TO'TNE WELL OWNER
SIGN R OF CERTIFIED WELL CONTRACTOR
CC
DATE
' ficurr PRI EDNAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form.GW-la
.Rev 7/05

MP WELL DIMUJNG
Minh cases •Mw r_�wir.O_l__se�rO��.r�rr � AND PUMP /IG
nal, l+raw llener-swill >lA� inla 911 Hey 74
Bane.
WELL CONSTRUC ION RECORD WILL. sM7alaclole 91-114•1)6"/C1 - , 7-mnonnons
Mlloolnose 11C�il.w1Ci11o11a: AS
Manfa>tLOOI I�R
1.
a. WELL LOCATOR w el 11101imesiebilli4 /
►Mtr.MT m ' '-" ling' E; n ifs / ' .mod (Ad- Sn Al iJ / 14P
/7 ;5: r �iTl2Q ti\mv 4 CJ/
wItMsswair- r- lr �1lrl•La
i. OMNI adiaramsa s is
reeadzgaPant ,� - /lc� G.C..e/4-)!
4. OATIEDIOLIAID
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RESIDENTIAL WELL consTRucTior. RECORD
_Worth Catobni Department of environment and Natant Kc,ou roc,- `• •tor Vann
WELL CONTRACTOR CERTIFICATION a 2571
DISINFECTION Type HTH
1. WELL CONTRACTOR:
Bryant Srntn
WM Ca*ss (IndMduall Name
Groat FINa WM & Pump Company
W ea Convector Company Name
STREET ADDRESS PD 6°A 204
East Flat Roo. NC 28725
City a Twin - Sane
( 828 )- 693.1200
Ana cods Plane numbs
2. WELL INFORMATION:
SITE WELL ID 6(t Eppnoacl �1
STATE WELLPERMITNEappscwe) G(a) toil '7 7 �
DWO or OTHER PERMIT NE app cab,)
WELL USE (Check ?pinta Bo ). Rwwaxal Weta SoWY 0
l
DATE DRILLED /
TIME COMPLETED
3 WELL LOCATION:', �- C.'' II,, I
crir i' 1nt IC It L OUNTYTi�"t tinct!
Zp Cod,
00
AM 0 PM/4
Ia 5 (' rxt4i nuke l IX.
(Sire, Nana. Number, CammuMP. SVaaeaon. Ld No PEW. Zip Coos)
TOPOGRAPHIC t LAND SETTING
pabw ❑Vallry OFI, 0Rd9• 000-ss
Ir-_ apaoata. mu)
LATITUDE 35c IS'C',A)
LONGITUDE CiZC ass /'6 w
L.auulde longlfide solace b)OPS O Topographic reap
(peen W wM mum a storm on s USGS mpo map and
artac7ad to au ram 1 not uang CPS)
May be is era.
'Comm, .coda a
R a decimal format
4. WELL OWNER
OWNERS NAME(f' /I
STREET ADDRESS C'X'
�latcL'. NL-Zs'"3I
Cty a TO•111 Sate Zip Cob;
Laskin
Avon cods • Ptona narrow
6. WELL DETAILS: 1
a. TOTAL DEYTH: 513 D. DOES WELL REPLACE EXISTING WELL 7 YES 0 NO
c. WATER LEVEL Baaw Top d Going 5-0 FT
(Um '✓ 6 Attoe Top d Cams)
d. TOP OF CASINO IS I Fr Abases Land Surf au'
Top d caasm0outlook rmnin ng sdcr below lard outlook may require
a versa n epoyrdanC,e .At ISA NCAC 2C .0118.
• YIELD Wpm) METHOD OF TEST A'r
1.
p. WATER ZONES t°ppm,
From
From
Fran
To
To
To
Anautt
From To
From To
From To
6. CASINOThoansaSi
% 0.pinh Dramala Wpm
From 1 To i Fr
From to Ft
From To Ft
7. GROUT
Fran_
From
From
Depth
To Ft
To FI
To Ft
Matartat
Mil ai
Mstrad
8 SCREEN Depth Dunwlei Sal Sae Mauna*
From
To Ft ^ ^
From
From
To Ft n ^
To Ft
6. SANCVORAVEL PACK
Depth
From
o FI
From To Ft
From To Ft
10. DRILLING LOC
from To
3Q)
Sae
MOW 'al
roimason (SR
(
n
it 11... _ 3.2K fir S-_2
'
0O*CREST CERTIFY not nteS WElr *AS COrSTRVCTEDwCCV DACCC*u QE son.
Cr Le 15A 0r IC tan ca.sTsverCs. D YQ t. so ELP+Nos AN
D THAIRECORD rr15 BEEn PRO*
SIG ATURE CERTIFIED WELL CONTRACTOR
DATE
A A S
PRINTED . E OF P RSON n• • 'SLTRUCTING THE WEL
Y AUG1 f,
SubMit Ma original lo Ina Division of Wafer Quality within 116 1 Mali Sarvlos Camas- Ralalgh, NC 27699.16117 Poe No, 0Y19) 733-7015 eato E boon Mgt. G 2 5 LULL Rte. 705

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Lkparvnant of Envnronmcnt and Naurrsl Kcaou run- Dr. i).un .0 ta aicr (Juan!,
WELL CONTRACTOR CERTIFICATION a 2571
1. DISINFECTION Type HT rI Amount
0. WATER ZONES t atom,
From
9iis ign
From To
From To From To
From
To From To
1. WELL CONTRACTOR:
Bryant Smtn
Wed Catrecax (Incandua0 Nan.
Green RNer Wei & Pump Company
WS Catreaor Convsny Horne
STREET ADDRESS PO Dos 20e
East FIa1 Roca. NC 28726
City or Town - Sate Zo Cape
( 828 ). 693-1200
Area coat Phan marrow
2 WELL INFORMATION:
SITE WELL ID Dept swarm) ^ - j
STATE WELL PERMITRg spawat) (7 &,' 2010, 31 3
DWO or OTHER PERMIT Nd appacebS)
WELL USE (Chest �Ap/lima. Boat. Rwaato Wets Supply 0
DATE DRILLED `r ra s JO TIME COMPLETED 3 . cc AM CI Rw4) -
3 wEU. LOCATION: ] �� �,-, ,J
car Zt rc Cn((a, COUNTYR1-41CiJ
el-SCr%
Si o oid fl t-. Clruei 2OCEC(
(StnS Name. Numoeta Commune,/ Sutlaw.an Lot No Parw1 21p Coos)
TppgGRAPHIC I LAND SETTING
LBS/aW OVWry Ort ORape 000001
(Meat .prop.(. pot)
LATITUDE 3SL J 3 r zoti
LONGITUDE C is 47' 0 (otO
Lsutude/Iolg&lude sotacc L,OF'S ❑Topographic map
(option d wig Plus( Cr shown on • USGS mpo map and
manned ro ma brut ! hot uang GPS)
4. WELL OWNER
OWNER'SNAMEDaL,td (xt
STREETADDRESSSIOCkd n&t-Gifu erf2d
21rconC& A_i C ZS)750
Cty a Town Site Zp Coo•
1 ) ggo-1330
Ares code - Ptrav number
6. WELL DETAILS: 1
a. TOTAL DEPTN: 7 I `�
May be u de6rea.
mieula, wands a
a a dcmal format
o DOES WELL REPLACE EARTINO WELL? ``YES O NO Cie
J
c. WATER LEVEL Bobo Top d Casino p FT
(Us• -: 1 Atom Top d Casing)
d. TOP Of CASINO IS 1 FT. Mon Land Sudan
'Top d ca+n 'amnestied flat Wow land surface nay toques
• swa In a cores a tart ISA NCAC 2C .0118
• YIELD (9ptn) 0 — METte00 OF TEST Att
6 CASINO Tnakn•ev
1 Depth lO Disc a We ni M 1el is!
From to it 4 Y A/ c /5't
From To FI Disc
From To Ft
7. GROUT'. Depth f / Mean& /� Memo
From Toys__ F1 7 y' ALy � ,�,,�,,4,�
Fran Toaa.. Ft r / r h= At y C gat
From To Ft
8. SCREEN Dupin Denwta Sat Site Malaui
From To_._ Ft n n
in an
o Ft
From
To Ft n n
9. SANDIORAVEL PACs Maau.
Dean SD*
From To Ft
From To Ft
From To F1
10. DRILLING LOG
From To
11. REMARKS
F q�naoor) Descnouon
Port 'J—
{„% J117ck
Ua, w.1- -
0
O
r
Don/REST CERnh nMl n.1S w' *AS CC..SIR UCTE Dw ACCORDANCE tom
ISA !CAC 2C vat L CCMS-TNI C,,,',,,�,��...tEEppp��l SIANOARDS AND MAI A CCP. C. n.6
RECORD
WAS BEEN PROvOED TO *Et. Owm(R
9.7DATE
EEx
DATE
SIGNATUR OF CERTIFIED WELL LCONTRACTOR
J�rT
OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: ntorjnaoon 11pt;.� y M1 J Earn GW • 1.
tst7 Mall Service Canter- Raleigh. NC 27699.1617 Phone No. [phone] ex t 568
Re. 2,05
AUG 25 200S

/i
RESIDENTIAL WELL CONSTRUCTION RECOr1(D
North Cambria Department of Environment and Natural Kesou Her DPI uwn of w ate( Quality
WELL CONTRACTOR CERTIFICATION M 2571
f. DISINFECTION'. Type NTH
g. WATER ZONES I deem)
From l (/(% To /45
1. WELL CONTRACTOR:
Bryant Srnd1
W M Contractor (Indladua0 Name
Green Rnet Well & Pump Company
Weil Contractor Ccnpny Name
STREET ADDRESS PO BOA 20e
East Flat Rock. NC 28726
City or Town Slate Z4 Code
L828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID soi estate) p { /l
STATE WELL PERMITge appkcable) OLP 1 W I053 u
MVO or OTHER PERMIT Et appicates)
WELL USE (CheckApplicableBoa). Residential Water Supply ❑
DATE ORJLLED I - o 0
TIME COMPLETED 1 '0 0 AM ❑ PM,jy,
3. WELL LOCATOR:
CITY hoe
I tursctS 1" Roc
COUNTY
q 3 c_ara.(l ire }-b- l l s r
(Las
(areal Name. Nurnps's. Community. Sub:Dusan. Lot No Potosi. Zip Code)
TOPOGRAPHIC 1 LAND SETTING.
❑Slope Pt/alley 13'FlaI ORldpe 00n1er
(check approonale boa)
LATITUDE .,SD__1.9 r 061 "J
LONGITUDE
Q 2 321 5`/z/u)
Laulade/ tlongitude source q&PS OTopographic map
(bceton d wei musl be ohown on a USGS nano map and
snitched to CIa form / not tang GPS)
4. WELL OWNER 1 I�.U✓'
OWNER'S NAME-DUO6
STR ET ADDRESS 3 r4 A Cf/ 16
May be in Sera
Sagas, moords a
o a deci oral format
Cty or Town Stale bp Cone
(03r1-993i
Ana code - Phan numoer
6. WELL DETAILS: /��1 1
a. TOTALDEPTM: AOS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 3
c. WATER LEVEL Below Top d Clang 0 FT
(Use -: f Atone Top d Casng)
d. TOP OF CASINO IS FT. Above Land Surface'
'Top d casing temrenats] Wor below lard surface ray require
a rename in soPor4lance wan 1SA !CAC 2C .0116
e. YIELD (gem) METHOD OF TEST AR
Amount
From
From To Flom
From To From
To
To
To
0. CASINOThickness/
Depth Diameter Wegh} I yr!
From To_k� Ft ! L'
From To Ft
From To Ft
7. GROUT: Depth Matenal Method
,I
r
L
From 0 To FtI µlr1 7rcIre
2 From 3 To O Ft Ma'? l-/r"C<
From To Ft
8, SCREEN Depth Demeter Slot Sae Matenal
From To Ft an n
From To Ft n _ n
From To Ft n n
9. SAND/GRAVEL PACK
Depth
From To
To
From
From To
10. DRILLING LOG
From To
lQ - 5�
5-0 — Z GO
II. REMARKS.
Ft
Ft
Ft
Sae
Material
Fco.rnabon Descnpbon
4 42*
D!(% 1 I7/l7 }it:
i3pPied ;7
Lr
CO rr —
CAI
O•
I DO HEREBY csorne r no I rats W EL
ISA NoAC X WEtt CO4STRUChoN
RECORD NAS BEER PROVOED to TR
WAS CONSTRUCTED IN ACCORDANCE cam.
? AAPS AND TINT A COP, CC TM6
Et' CAN I{R
/J Zt o {
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
PRINTED E 0 PERSON CO ST$UC11 LNG THEWELL
Submit the original to the Division of Water Quality within 30 days. Ann: Infiarmabon Mgt..
AUG 2 51(10j
1617 Mali Sonia Center— Raleigh, NC 27699.1817 Phone No. [phone] eat 568.
Form GEE la
Rev 7/D5

V
RESIDENTIAL WELL CONSTRUCTION REC°i\RD
North Caitlin Department of Environment and Natural Kesourcc - Dr%i nun ui w seer Queen
WELL CONTRACTOR CERTIFICATION a 2571
1. WELL CONTRACTOR:
Bryant Smith
WM Canbactor (Individual) Name
Green River Wall & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 2De
Ent Fast Rau. NC 28726
City or Torn State
( 828 ). 693.1200
Arse cods- Phone number
Zip Coo
2. WELL INFORMATION:
SITE WELL ID If aencael l r/ , I�
STATE WELL PERMITS( awe:O Q•7C I001 ( 221
DWO or OTHER PERMIT NM applicable)
WELL USE (Check A ylcabil Boat. Rn.oantt Water Supply 0
DATE DRILLED ' I I g 1 O t0
TIME COMPLETED
3. WELL LOCATION: ��� JJ
CITY. Ofrse Shoe. COUNTY 14-4'GFXSYn
Frovii m; I I Tr.
I'•3U
AM O PM12(
(Strom Name. Numters. Community. Suochne.n. Lol No. Parcel Zip Cope)
TOP'OGRR-A'�P/IIIC / LAND SETTING.
❑Slope lyearey OFtn ❑R.Og. OOther
(aec. •paeahae Gila)
LATITUDE ()gar)
15n1
LONGITUDE()ALr IL/-u)
Lautude/longitlde source: b0PS oTopographic map
(boatman d wa1 mot be shown on a USGS topo map and
attached to Ms loam t not wag CPS)
6. WELL OWNER
OWNER'S NAME D0L�1��j1�J1k�tpYYI—
q,
STREETADDRESS r�^tvA`"1 Ladswr5 ri✓(c) )yt I
ticrseSheL A)C.ZSco 2-
C9y a Town f State Zp Coo
May be in meow
manta, aeon& a
n a dc®al formai
Sszs-)•cep I-soSq
Ate* coos - Phone manes(
6. WELL DETAILS: C G 1
a. TOTAL DEPTH: D-7
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO✓
c. WATER LEVEL Below Top or Clang . (S FT
(Use'✓ E Abo* Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land 5o 1 c
Top d easing.ternermtS eta blear land .udace may !equine
• wawa ✓ nalccordance ova ISA NCAC 2C .0118
e. YIELD (9pm): O METHOD OF TEST An
.'.
1. DISINFECTION: Type r/TH
Amount
g WATER
ZONES loeptnl
Fran 'nilk To /5— From To
From To From To
From To From To
6. CASINO: Thickness(
1Depth ,f ,2 FI Dia� ter !p N�arr®I
From To S_C
From To FI
From To FI
7. GROUT: Depth Maternal Method
From 6, To FI ,S t
From .2, To FI r
From To FI
8. SCREEN. Depth Demeter Sla Site Material
From To Ft n n
From To Ft n n
From To Ft n n
9. SANDORAVEL PACK
Depth Sae Material
From To FI
From To Ft
From
To FI
10. DRILLING LOG
Frgm To FVfmaton Description
(a ` 1.5 IL y
15- D S 4dd - Cd k Rock
si0 - 9S' (dRA4ibc o
0
r-�
C7
Cr,
r
I1. REMARKS
I COHERES', CERTNv TNAT TeS WELL WAS CONSTRUCTED II ACCORDANCE yarn,
ISA NCAC 2C wEll CONsTRuCTOr STANDARDS AND TWO A COPS Or nits
RECORDNAS BEEN PROvOED Is-.( WELL W.NER
SIGNATUR&'OF CERTIFIED WELL CONTRACTOR
13,NAME
PRINTSE NAME OF PE SON CONSTR CTING THE WELL
7 -20-0(
DATE
Submit the original to the Division of Water Quality within 30 days. Atm: Infomiabon Mot., form GW-is
1617 Mail Servlu Center- Raleigh, NC 27699-1517 Phone No. [phone] ext S6$ ; I,-,r Rev nos

RESIDENTIAL WELL consrRucrion RECORD
North Carolina Uepa tram of environment and Natural Resources- Di' Isemn of ater Quail!)
WELL CONTRACTOR CERTIFICATION a 2571
1. WELL CONTRACTOR:
Bryant Smat
WN Contractor (k.dMduai Name
Green River Wall & Pump Company
Wen Contractor Company Nana
STREET ADDRESS PO Box 201
Eaar Bel ROOK. NC 28726
City or Tann State Z9 Code
( 828 )- 693-1200
NM code- Phone numb(
2. WELL INFORMATION:
SITE WELL ID 6(d applxape) /
STATE WELL PERMITLr apWaDe) 01-0 IRn)n 3844
DWG or OTHER PERMIT flit appicebs)
WELL USE (Check MRlcabM Box). RnWmttl Water Sappy 0
7 /
DATE DRILLED " (1 771 Q
TIME COMPLETED 'a:00 pm AMO PM%
3. WELL LOCATION: ,�,Q 0. ,E 1,
CITY. �at a. COUNTY 1U-vA`S'n-'
lot Lz n'i+n Meadows, Atbiergreacku Dr-
(Straet Name. Numbers. Community, Sutwl+ann. Lot No. Parcel. Zip Codel
roy RAPNIC/ LAND SETTING.
aSbpe OVaIMy Offal ORgpe ❑door
(Owe sopoona. box)
LATITUDE aDr O7N
LONGITUDE sji Zo 1 I / sc Lt)
Lautudd/longift c solace: C(GPS OTopographic map
(bcsCun d wN must In shown on a USGS topo m•p and
attached to ale loan( / not Nato GPS)
4. WELL OWNER ,�..1-
OWNERS NAME Matt -he -La l 120 F-C�
STREET ADDRESS p. Ts [✓ 1(t YYL
mot rso-Q \ e, 60C-6zWICZ
Cty or Town Slate Zip Code
May acre dam.
minas. seconds or
in . decimal format
LRzu )- LAS-oy7&a
Nee code - Phone number
•6. WELL DETAILS: G 1
a. TOTAL DEPTH: �1 �f0.J
O. DOES WELL REPLACE EXISTING WELL?? YES 0 NO
c. WATER LEVEL Below Top Of Clang' G D FT.
(Uses I Abo a Top d Camp)
d. TOP OF CASINO IS 1 FT. Above Land Surface•
*Toed casino tannrated aVa Wow land surface my require
• ~lance n accordance slat 1SA NCAC 2C .0116
e. YIELD (9pnl). I L METHOD OF TEST A•
1. DISINFECTION: Type r4TH
Amount
. WATER ZONES l aeon)
y
From ( Dd To / p ) From
From To From
From To Flom
6. CASING
Depth Deter
Fran L iamTo_ -" Ft -r
From To Ft
From To Ft
To
To
To
Thickness,
Wept) erel
2I.0 dG
7. GROUT: Depth Mat nal
-7
From 0 To 3 Ft
From To 2 0 Ft S9XIQJ SAE
From To Ft
8. SCREEN. Depth
From To
From To
From To
Diameter SI01 Sure
Ft
Ft
Ft
9. SANDIORAVEL PACK
Depth
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
b - %5—
/s —'SO
'AO-2O5-
IL REMARKS:
n
Size
Metnoa
I Z
rr yP
en
n
Material
Material
For.mpon
scnpuon
LT/22j+U/ter
�. 71
I
CO i
I CO NERVE! CDR TICE THAT 1t.iS wELt WAS CONSTRUCTED II+ACCORDANCE wm.
ISA NCAC 2C WELL CONSrRuCTIOr STANDARDS AND THAT A CCYr Cr n.b
RECORD rnS BEEN PROvDED TE oda OWNER
SIGNATURE CERTIFIED WELL CONTRACTOR DATE
r5
R
PRI TEDVAME OF PER ON MRS 2KLJLIfNG'TnPWE'ttr—`""""'"'
Submit Nth original to the Division of Water Quality within 30 days. Attn: Intortnapon Mgt- Form CW.la
1617 Mall Service Center- Raleigh, NC 27699.1617 Phone No. [phone] ext 568.I • ` R•.v 7/O5
AOC) 2 5 2C J

RESIDENTIAL WELL conSTR urrlsN RECORD
North Cambria Departncnl of Environment and Natural Resources- Doi 'stun of water Quabry
WELL CONTRACTOR CERTIFICATION M 2571
1 WELL CONTRACTOR:
Bryant Smith
W M Contractor (Irdr dua0 Name
Green River Well & Pump Conpany
War Contractor Company Na
STREET ADDRESS PD BOA 20e
East Flat Rodr. NC 28726
City or Town State Z9 Code
828 ). 693.1200
Ara node- Phan number
2. WELL INFORMATION:
SITE WELL ID Ha appratae)
STATE WELL PERMITHI apWn7�
caae) 0 �.s I IN/ V a 5I 9
DWG or OTHER PERMIT CI appiwae)
WELL USE (Check calIa Box). R& Water Supply ❑
DATE DRJLLEO r71 L lll o aloem
TIME COMPLETED 1 0 o AM O PME2
3. WELL LOCATION:
CRY 1-kac IscTNU1 tie couNTY cL s.nn
0 I .I> -Id To p7)rl'1et (EA-K4-9u ID
(a., Nemf Numbers. Commenty. Surdenvol LaTb . Par Zip Code)
TOPOGRAPHIC 1 LAND SETTING.
O Slope O Valley O Fill O Rdge °Other
(door approonfl not)
LATITUDE j$024.l C9,,(
LONGITUDE t a 3 r 16 u%
Latitude/longitude source: rifff3PS °Topographic reap
(bcataan d wag must rw snowman a USGS tope map and
artacMd to Or/ bin if not asap GPS)
4. WELL OWNER T �r
OWNERS NAME ie-+7)es (±CRATE i
STIR ET ADDRESS //1Z55-- C00 K-/'^'
May ea io depm,
miaula. .®odor or
m a.dcimal format
scrnulite C-Z81 t
CO Or Twin State ZIP Code
/-LAS-35if
Aram code - Phone nuntar
6. WELL DETAILS:
a. TOTAL DEPTH: 7 AS
b. DOES WELL REPLACE EXISTING WELL? YES O NO Q�
c. WATER LEVEL Below Top d Camp_ 2 OD FT.
(UM -✓ I Mow Top d Could)
d. TOP OF CASINO IS 1 FT. AI»w Land Surface'
Top d casing 'emanated Mica Wow lard surface rray require
a avarice n .Lmlynce with ISA NCAC 2C .0118
e. YIELD (ppm) QN METHOD OF TEST Aa
1. DISINFECTION. Type HT II
p. WATER ZONES ineptnl
n
From >Go To 345-
Fran
From
To
To
6. CASINO
/ Depth
From ( To_J FI
From To FI
From To
Ft
From
From
from
0,
4 z
Amount
Di!riter
To
To
To
TNCKINs.
Wapm
2/,C
M%le!®i
7. GROUT'. Dept) Matimal Merino
From To 3 FI 5.44QC/h` M;y iL L
From To AC Ft /3ir,i .twilit Al, Y f- Oc1<
From To FI
0. SCREEN
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PAC Pc
Depth
Fran To
From To
From To
10. DRILLING LOG
From To
z
29 -35
3ti - `15-
4f-42S
11. REMARKS.
Demeter Slot Sae Malone!
Ft n n
Fl n n
Ft n n C
GJ t
Sae Malena
Ft
FI
FI
0
rl_
DONERESY CERnh THAT Ibis WELT WAS CONSTRVCTEDINACCORDANCE WET},
ISA RCAC 2C WEtt CPISTRLCTIOv STANDARDS
TA D DS AND flM1 A CO' C% NITS
RECORD nAS BEEN PROVOEO
47-!d 'a
SIGNATUR OF CERTIFI`D WELL CONTRACTOR DATE
/A
PRINTETE
D 1XM OF PERSON CONSTRUCTING THE WELL
1617 Mall Servicemit the Center- RalMgh, NC 2 699l to the Division of -16117�IIPhonee No. 919) 733.7015 eat 568.
spore Mgt_
Form GW-I•
Re. 7/05

From. Scntt Gantt 7044347717 Trr Stephanie Wilson
Datr. 31fi100fi limp 3 21 18 PM
Pa0r 3 nffi
(if applicable)
1. WELL USE (Check Applicable Box) : Residential lE
Recovery ❑ Heat Pump Water Injection ❑
2. WELL LOCATION:
Nearest town: HORSE SHOE
33 HILDA LANE
WELL CONSTRUCTION RECORD '- b. `' 4
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable)
Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Other ❑ If Other, List Use:
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER CHRISTOPHER McMAHAN
ADDRESS 33 HILDA LANE
(Strca or Rowc No.)
HORSESHOE
City or Town
828-257-1258
NC
State
Area Code - Phone Number
4. DATE DRILLED 7/17/06
5. TOTAL DEPTH 245
28742
Zip Code
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ID
7. STATIC WATER LEVEL Below Top of Casing: 55 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING 1S 2 FT. Above Land Surface'
'Top of casing terminated atror below land srfacc recites a variance m
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 5 METHOD OF TEST ARDM
10. WATER ZONES (depth): 155
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley fl Flat
Latitude/Longitude of well location
35 23.126 /82.34.412
(degrees/minutesseconds)
Latitude/longitude source. 0 GPS ❑ Topographic map
DEPTH
From To
0 100
DRILLING LOG
Formation Description
Clay
100 245 Consolidated Rock
11. DISINFECTION: TYPE HYPOCHLORITE Amount 10
12. CASING:
Depth
From 0 To 108
13. GROW':
Depth
From 0 To
14. SCREEN
Depth
From NA To
Diameter
FL 61/4"
Wall Thickness
or Weight/FL Material
SDR 21 PVC
Oz
Material Method
20 Ft GRAVEL MIX GRAVITY
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Diameter Slot Size Material
FL in in
Ft,
Size
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
a
G")
J
_N
0'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
871/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1jREV. 07/2001
AUG 25 2E5
1

From: Scott Gantt 7044347212 To: Stephenie Wilson Date: 8/6/2006 Time: 3:21:18 PM
Page 2 of 6
WELL CONSTRUCTION RECORD J j:
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section .._
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check .Applicable Box) : Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
2. WELL LOCATION:
Nearest town: EDNEYVILLE
HAWKS WOODS SUBDIVISION LOT4
County HENDERSON
(Street Name. Numbers. Community, Subdivision, Lot No.. Zip Code)
I. OWNER REPLTABLE BUILDERS
ADDRESS 22 APPLE BLOSSOM LN
(Street or Route No.)
HENDERSONVILLE
City or Town
845-856-2853
NC
State
Area Code - Phone Number
4. DATE DRILLED 7/14/06
5. TOTAL DEPTH 300
6. DOES WELL REPLACE EXISTING WELL°
7. STATIC WATER LEVEL Below Top of Casing:
28792
Zip Code
YES NO ['y
70 FT.
(me "t" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a valiance 1
accordance with 15A NCAC 2C.0118
9. YIELD Omni): 7 METHOD OF TEST
10. WATER ZONES (depth): 120
ARDM
Topographic/Land setting
❑ Ridge Slope 0 Valley ❑ Flat
Latitude/Longitude of well location
35.26.098 / 82.19.774
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS ❑ Topographic map
DEPTH
From To
DRILLING LOG
Formation Description
0 80 Clay
80 300 Consolidated Rock
it. DISINFECTION: TYPE HYPOCHLORITE
12. CASING:
From 0
13. GROUT:
From 0
14. SCREEN
From
Depth Diameter
To 90 Ft 61/4"
Depth
To 20 FL
Depth
NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
.Amount 12
Wall Thickness
or Weight/FL Material
SDR 21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
Ft in
Ft,
Size
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15.A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
8/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the erighlai to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. `--
GW-1 REV. 07/2001

32 7 805
WELL CONSTRUCTION RECORD
North carats - DepattlSat 51 Etleltiiiiit eat khd Na Res—otitees = Division of Water Quality - Grotmdwater Section
WILL t:Oktii itwttbii Fi u E "' 61 vtt as. _ --T/7 LciifcA raTloN # 2 7X V
WELL CONTRACTOR COMPANY NAME `7t11 t� P j�l,t9/�--eRh
{�/ l u e// ry /h PRONE w ��� sT c 9-�i� iG
STATE WELL CONSTRUCTION PERMITS ASSOCIATED WQ PERMIT#
(if applwble) (if applicable)
1. WELL USE (Check Applicable Box): Residential L micipalIPublic ❑ Industrial 0 Agricultural 0
Monitoring Q Recovery 0 Hat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO : ff�/ //
Nearest Town: ( �/'L.15 O County geni!�/SGiee/
Z/$ : 72ri r )}R 2.T710 5 —
Staeer Name, � . Sabdivideq ixa No., Code
( C®muahy '/ Tip )
3. OWNER /Jr,,pp��'' e, e/s
Address 2/ t E4V e ?fce
(Swu & Rase No.)
u,ij , 0 Fl/ G
City at Town Stale
-'? 76 C
Tv Code
Ana cods Phone somber
4. DATE DRILLED 3-366
5. TOTAL DEPTH: / er
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO FY
7. STATIC WATER LEVEL Below Top of Casing: 7 FT.
1/ (use'M" if Pawn Top of Casing)
, 8. TOP OF CASING IS / FT. Above Land Surface*
*Top of cats terodaaad at/or bebow had satiate requires a
ndaace h1 aemrdaaee wnh ISA NCAC 2C MIA
9 Yffii D (gpm): 30 METHOD OF TEST /, re/
10. WATER ZONES (depth):
11. DISINFECTION: Type L r
12. CASING:
Fron_ Too/ Ft Dar
Fromm To Ft
From To Ft
13. GROUT: Depth ial
From ier To 212 Ft ( ./1GPt2i /'e
From To Ft
Topographic/Land setting
❑Ridgy °V ope Ovalley LlFlat
(check appapri.a: box)
Latitude/longitude of well location
(degmeshminonee+waode)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH FRILLING LOG
From To Formation Description
Amotmt /0 a > Show direction and distance in tiles from etWast
Wall Tlticimeas two State Roads or County Roads. Include theLL;oad
or Weight/FtG
and common road names. 7
/ Sh2Z
Method
Luefr/12/.
14. SCREEN Depth Diameter Slot Size Material
From To Ft _in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK
Depth Size Material
FroTo Ft.
From ( To Ft. AUG 25 20U3
RECEIVEDAL
16. REMARKS•
r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCrB Sath Sr i15A.NCAC 2C, WELL
CONSTRU STANDARDS, AND A OF THIS s a RD HAS BEEN PROVIDED TO THE WELL OWNER
c- L7--3t
SIGNATURE OF PERSON r.aNSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Cep - Raleigh, NC

WELL CONSTRUCTION RECORD -
Mott WORM - DBptitEllont of>idWiptilf;eiit ibd N Raoid e - Iliivision of Whit Quality - Groundwater Section s
WELL ets►rttiert It ENM VIIMIAi I Nish tt fn G fM ere9 Ye. CERTIFICATION r�ZL�L/
wtu. CONTRACTOR COMPANY NAM/ SI Orr t.ut4l�i'i' tit// , iltertp2 PEONE r (A (p 31:9-Z2VerC,
STATE WELL CONSTRUCTION PRRICTN—ASSOCIATED WQ roman
(if appitrsble) (if alnlwbk)
1. WELL USE (Check Applicable Box): Residential ErMWoieipaI/Public ❑ Industrial ❑ Agricultural ❑ D
Monitoring ❑ Recovery D Heat Puny Water Wanda' ❑ Other 0 If Oder, List Use x>•
t
o"(I) C
( r V.!
TopogT setting I) 2 N..,❑Ridge ❑VaDey 7. cn
(chat app edete btu) ro c.?
Latitude/longitude of wellloceti$a
1,9., O v>
r4_ -141144,
roomy
Z7
City Of Torn sae Zip Code
ma soar- Pbraa ersmb _
4. DATE DRILLED S -�S O L
5. TOTAL DEPTH: S-C.)
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO '
7. STATIC WATER LEVEL Below Top of Casing: 719 FT.
C /r (Uu^V"*Meow Top dCwi g)
8. TOP OF CASING IS /D FT. Above Land Surface*
*Tee et Liam Madauud ■ a' beta lira eraha requires a
wets le aasudsass Ub ISA NCAC 2C .01111.
9. YIEL) (w m): C- METHOD OF TEST 7 irlen(
10. WATER ZONES (depth):
11. DISINFECTION: Type CC %J" Amoamt /G n 7
12. CASING: Dye Wall Thickness
Punt-A-T°o_ D Ft, 6 Ys/ S
or Weight/Ft.
From__ To Ft.
From To Ft.
13. GROUT: Depth ,„-,Material Mqb°
To 2 Ft(/)in o Y% Os thank
From.__ To Ft
14. SCREEN: Depth Dianna Scot Sia Mostai
m. Frof To Ft --in- in.
From_ To Ft_m. in.
1S. SAND/GRAVELPACK
�( Depth Size Material
From f�' To Ft.
From To Ft.
2. WELL LOCATION -
Nearest Town:
4-7 {nary
Nowt Nis*, Nana . .. , samba's. la No, IIn Cade)
3. OWNER: Di t /Ica me/ �.�''�'
Address 5- K
f// L/` Latitude/longitude )
/ e-di/Ac.ru`a A312. 7 z73z DEM (Soh WO
From To
map
Formation Description
laCtilEESIEELCli
Show direction and distance in miles from at feast
two State Roads or County Roads. Include the road---7
mambas and common mad names.
w
rV
0
0
16. REMARKS•
1 DO F1IDtFBY CERTIFY THAT THIS WELL WASCONSTRU
STANDARDS,
t t ,tr
IN ACCORDANCE WITH 1 SA NCAC 2C, WELL
RECORD HAS OEM PROVIDED TO THE WELL OWNER
CI 757-0
DATE
rn
0
r:ri
i
Subunit tie original to the DIOS* of Water Quality, Grsodwatn Section, lei Mali Service Caner - Raleigh, NC

0Nin) 79fl
WELL CONSTRUCTION RECORD
North
CMiohiSf- `1ff1t tilThitlbt UAL) / t maid rRnoutca . . . of *Runt Wilk),- Oramdwater Section
/ c le es Tti- ctxTtriCAna4Q7Ell
to i/ r s
wcu coefTaAcroa conr*n NASA Sl> P e wr9% t.: .. p rasa a az§ -O no
STATZ WELL CONSTRUCTION PERKITS _,ASSOCIATRD WQ POMITn
(if a pliab►e)
(if tppiieeble)
I. WELL USE (Check Applicable Box): Residential O1MimicipsYPublic 0 industrial 0
Monitoring ❑ Recovery 0 Fiat Poem Water [ideation 0 Other 0 If Other, List Use 5
�= 0 G
2. WELL LOCATION -
Nearest /�
Tom,: Tor (1Y/6GYl/
7J —$h ((cry � re R1 -2
Stet Nam, N®LVL . SabetriUm. La Na. DP Cot)
3. OWNER: /9. 5}1/ /A — / ;Ti C e
Address ?5 ShAY[x..V fiat,
(Snort a Rana Nw)
h/CC car / t C Z a-7 5 Z.
City at Tara Stet Zy Code
As code- Phoae.ambu
4. DATE DRILLED SVie'UG
5. TOTAL DEPTH: i y5 6. DOES WELL REPLACE EXISTING WELL? YES Q N_O (3"
7. STATIC WATER LEVEL Below Top of Casing: 7l� FT.
set, (the *4-- if Nave Top of Cosies)
8. TOP OF CASING IS / 0 FT. Above Land Surface'
'Top of saaiaa to mirt.d t)ce law bed ameba rgaha ■
vuSsa Is aawdoee wish RSA NCAC 2C atla. -
.0-0/
9. YIELD (gpm): '« METHOD OF TEST //flt 1't/
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
From_it To 3o
From__ To
Froth To
13. GROUT: Depth
Frost__ To_O
Front To
14. SCREEN:. Depth
Front. To
From To
15. SAND/GRAVEL PAM:
r CAC Amoco _61 a
D�. W ll Thitineat M r,.�
Ft !o/A/ 5D2 % f'(/C
Ft
Ft.
Moral
Ft(etu"el�G (A.4%h,>
FL
Dimmer Slot Size Material
Ft_in. in.
Ft. in. in.
Depth Sire Material
From 10 To Ft,
Finat_To_ Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS
CONSTRSTANDARDS, AND
'Lt4 C,.
SIGNATURE OF PERSON
C]AidSe AA441looppee
TopoQSiopic/Land
L7V
Meat tppmpiatehve){f0 J
Iaotnrdedlahginrde of well
(deytameSo lmis odt� O
Latitude/longitude somoe:LDOPS
(that a
PEELER D
From To Formation Description
L
V
()CATION SK7FQj
Show direction and distance in miles from at last
two State Roads or County Roads. Include the road
numbers and common
l6p
STRUCTE) Ltd ACCORDANCE WIIN ISA NCAC 2C, WELL
THIS .. a'.. t HAS BEEN PROVIDED TOT E WELL OWNER
$ =//- (
rt1
rn
V
Submit the original to the Division of Water Quality, Groundwater Section, ISM Mail Service Center - Raleigh, NC

orth Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
536 Mail Service Center- Raleigh, N.C. 27699-1636 - Phone [phone]
VELL CONSTRUCTION RECORD WELL CONTRACTOR: RODNEY ROBBINS
WELL CONTRACTOR CERTIFICATION #: 2785
STATE WELL CONSTRUCTION PERMIT #:
. WELL USE (Check Applicable Box): ® Residential 0 Municipal
0 Recovery 0 Heat Pump Water Injection ❑ Other
. WELL LOCATION: (Show sketch of the location below)
fewest Town: EDNEYVILLE County: HEND
LUE ROCK RD.
load Name and Numbers, Community, or Subdivision and Lot No.) F
. OWNER HELEN SUGGS
.ddress BLUE ROCK RD.
itreet or Route No.)
:DNEYVILLE 'NC 28727
'ity or Town State Zip Code
. DATE DRILLED 06/13/06
. TOTAL DEPTH 205
. CUTTING COI IFLIED El YES El NO
. DOES WELL REPLACE EXISTING WELL? 0 YES El NO
. STATIC WAIE.R LEVEL Below Top of Casing: 20 FT.
Ise "+" if Above Top of Casing)
. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
Fop of casing terminated at/or below land surface requires a variance in accor-
ance with I5A NCAC 2C.0118
0 YIELD (gpm): 40 METHOD OF TEST: ARD
1. WATER ZONES (depth):
Fr
2. CHLORINATION: Type: CHLORYTE Amount: 4.5
3. CASING:
Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 130 Ft.6-1/4" SDR21 PVC
From To Ft. _
From To Ft
4. GROUT:
Depth Material Method
From 0 To 20 Ft.OUILKRETE POURED
From To Ft
5. SCREEN:
Depth
From To
From To
From To
6. SAND?GRAVEL PACK:
Depth Size
From To Ft
From To Ft.
7. REMARKS:
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
Material
❑ Industrial 0 Agricultural 0 Monitoring
If Other, List Use:
DRILLING LOG
DEPTH
To Formation Description
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other reference points)
HWY. #64/74A W. FROM LAKE LURE. LEFT ON HWY. #64 (d
BAT CAVE. APPROX 1-1/2 MILES LEFT ON EDNEY INN RD.
LEFT ON BLUE ROCK VALLEY ACROSS BRIDGE. FOLLOW
BLUE ROCK TO LTO ON RT. NEXT TO PASTURE.
DO CERTIFY THAT THIS WELL WAS CONSTRUC1 E'D IN ACCORDANCE WITH 15A NCAC 2C, WFI.r
'ONSTRUCTION STANDARDS, AND THAT A COPY OF THISRECORD HAS BEEN PROVIDED TO THE WELL OWNER
0
c
r
rn rri`:
o C`
r
FOR OFFICE USE ONLY
Quad No:
Serial No.
��a4 e ,.4 Ito , �� A3-0
SIGNATURE OF P CONSTRUCTING THE WELL DATE
original to Division of Water Quality, Groundwater Section within 30 days
GW-1 REV. 12/99

04-17-'66 11:55 FROM-NCDEHR ASHEVILLE RU SLif2`Jy'/N43
1. WELL CONTRACTOR:
M„
r
Wet cartes( -
C/t,4e Sc ..,ems
3SLA2l fIElVTIAL WELL Coo TsucuoN CpI D
Nona Carolina Deparan at otEn*on uat and Natural Rcaourcos. Division *Maw Quay
WELL CON1'RACCOR CERI:FICATUON k o2 t/3 4
`� Soil
Clyde Sawyers & Son Well Drilling knecf.
14885 Hwy 209
Hot Springs NC 28743 /S
a)- c G s- aoz2
Area code. PaonanurMj
Jolla
2. WELL WFORstATlcK
SITE WELL AD ✓ CPeatotte)
STATE WELL PERNvf3(rt�
DWG or OTHER PERMIT' AV applicable" `�
WELL USE (CheckApp� Bad: Rasinott7 Water SuPPN3
DATE DRILLED
Tide cOMPLl7el 3 ' IS AM ❑ PM e-
2. WELL LOCATION:
G7TY: *. a.., • IA COUNTY 44-04rr-50 t
C.tld- Fe-S e rit
I(Seat Nana. Nesters. Cvrmawry. gaedyerart totilot PrcwLiip Code)
POGRAPHIC! LAND SETTING:
Siope OW* DFlat ❑Rdge cOther
Iwet asaraMHS Mao
LATITUDE I May Po al Pogrom
GANG aim. sammd,
nm ar
LONGITUDE I ma&cird format
Lwmdenon itude ro'uot: ❑ an cTopOSTFMNo map
(kos&r, afaeAmuWee shown on a USOS tope tow and
atxANto Ws fire Itot using OP,
A, WELL CANNER
OWNER'S NAM
STR
Cepop
Area Gods- Phone
WELL PCTAli,b
a. TOTAL
ICIJIG ?awl,
6.
cstpwc2L5L__
b. Does VI/ELL REPLACEWSTINGWELL? YESp
I e. WATIERLEVEL BebeTopofGISMO; 36a
(Use w iA6we rep of Cans))
a TOP GP CASING IS
'Telt daring ter asl aka Won Leos.
terminal
a may maim
sedate In accordance with ISANCAC 2C.0148
' YIELD Spa* 3 NEMO OF TEST IV/3 ...».. .a...`..`....
NSTRUCTf WELL
1617 original to the Division of Water Quality Within 30 days. Attn: IrformsVan Mite
Service Can* -Rablgh. NC 27'6994917 Phone No. [phone] exi SSS.
L DISINFECTION: Type
9. WATER ZONES (depd):
From To
Fenn To
From ._ To
S. CASING:
Fra n_ T Dar�
from To
ua
Town__ Ta
7. GROUT: Depth
From S To tO
Fan, To
32'7320
PL /bb U-DIdo
t 5 —
�.�.
Fro.._ To
Frain To
From To
o < Fti.4_ g i
Material mewl
FL Cry_
Ft-
Fvm To Ft.
S. SCREEN: Depth Dint' SL+2 SPA
Fitts To Ft�h, in. atateriet
Faro Tom
Ergo__ FC Y. kb.
Ti F�pt. h.
L .SAtDt4RAVEL PACK
�t Sea Mato*
From-T�....-...'�R�
rron� _To
tt. GRILLING LOG
ran To
F
-�?7
7 1 S
NO Ir
FT.
1
i Do Went mon' 1MNCACt` TSW WELL WASOpl.MR; NA=CROWJ(¢ WOW
RECORD NUS aEENP gHE lazy w.rn aaarcoFTMe
�dOnOEDR RSANttowraw
Fain GW-1q
Res. 7275
Ica

04-17-' 06 11:55 FROM-I4CDENR ASHEVILLE i U
1. WELL CONTRACTOR:
1_ /C rr, c, .k 7 fits'
W el Connector ( ndmdual3 Ne:mo
.la C -L .Tna
Wet ---
Clyde Sawyers & Son Well Drilling
STR 14885 Hwy 209 race {-
C Hot Springs NC 28743 - 5-
T-916 YLiZ/ids U-D00
LL SLDENTL4L WELL CONSTRUL4i0x Rb'CO
North Carolina Department otEnvuenaent and Natural Rtsourt La- Divieicn of Water Quaiiy
WELL CONTRACTOR CERTIFICATION tit a 113 4
aa- J.- .Pc)..../
Area coda Phone number
2. WELL INFORMATION:
SITE WELL ID eitappacads3
STATE WELL PERMiTff rapptiaeiel
DWQ or OTHER PERMIT it(f applicable)
WELL USE PCheck Applicable Stack Residenfai Water Supp& ti
DATE GRILLED -C o26 - G
TIME COMPLETED VI 0o AM 0 PM r
1. WELL LOCATION:
erTY::3///fdr,-4n"SrrtO24 COUNTY 144 ry"Pr cor1
(Street Name, Nunbei. Community. Subdaaion, Lot No.. P. by Code)
TOP GRAPHIC f LAND SETTING:
ClVaIIay ❑Fiat QRbge CCrer
(check appropriate boy
LATITUDE _ May to in degree,
ounirtesseconds or
LONGITUDE :n a decimal *epee[
Latitude/longitude source: OGPS ,-,Topogaphiomap
(locvton o`waemust bs sham on a USGS typo map and
attscheCto This form P not using CPS)
s. WELL OWNER
OWNER'S NAME Our' &ci C
STREET ADDRESS 33 Ye. now Rocic oqd
7tee.ocsciet It mac. aR,7sa
Gay *crown sue& Lp Code
9.;aQ73- i1-18 i08%
Aea code- Phone number
S. WELL DETAILS:
a TOTAL DEPTH: / O S
b. DOES WELL REPLACE EXISTING WELL? YES D
e. WATER LEVEL Belay Top ce Casing: 20
Mee' if Above roe of Casevi
4. TOP OF CASING IS I FT. Above Land Surface•
'Top U casing animated atAtr baav land surface may require
a worts in accordance with 1 SA NCAC 2C .0110
a WELD (spiny /1", MrHCD OF TEST
NO 62•-
FT.
`i t
j'
II
327325
L DISINFECTION: Typs r%S ?mount
9. WATER ZONES (depth):
From Tc
From To
From To
6. CASING:
Fran/, Dee
om J F FL_ 4er
From. To FLU,
From To Ft
7. GROUT: Dim:
Fron._Q__ To e
From To
Frog To
From To
From To
Frall To
Tt. tlnesO
`.TL: (
Material ff
Ft,`
Ft.
metheo
P4
a. SCREEN: Depth D;mne& Slat Sa
Frog _____ To Ft In. H.
Fran To FL
at in.
Fro i To Ft`,M. ___ n.
1. SAND/GRAVEL PACK:
Depth Size Matscir
From . TcFt,.
Frain Tc FL .
From _To Ft..
10. DRILLING LOG
Fr To
sO
11. REMARKS:
Meteroi
Formation Desejotion
nu.er fjcQn�eh
&-rc .: 4•c
i Co HEREBY CERW'y!HATTHS WELL WAS CONSTRDCTEO N Ac:CROA CE fyITH 1SA NCAC 2C. WELL CONSTRUCT ION Or MAN,rtATA CO'r'J% TMa ;
RECORD HAS BEEN PRONOEDTO THE HA'N . WNER 3
--.---.CTOR DATE
�err1c k f 1:,
PRINTED NAME OF PERSON CONSTR�wGr s i 2-
JCTiN THE WELL ,0
Submit the original to the Division of Water Quality within 30 days. Attn: krfonnaton Mgt
1617 Mall Streit* Center- Raleigh, NC 27699.1617 Phone No. (919) T334015 ext 568,
SIGNATURE OF CERTIFIED
Faro GY/aa S
Re.'. 710! Ci
tD
0
IND
CI7
0
0
cro

04-17-' 06 11:55 FROM-NCDENR ASHEVILLE id) SaL9y'tI74U
1. WELL CONTRACTOR
Wall Contractor (TNodal) Name
. .t_
Clyde Sawyers & Son Well Drilling
STREET 14885 Hwy 209
C4v Hot Springs NC 28743 3-
Well
Chr
Area code_ Phone number
2. WELL INFORMATION:
SITE WELL ID $(a appioalia)
STATE WELL PERMITSsif applicable/
DWQ or OTHER PERMIT eft applicable)
WELL USE (Check Applicable Sox): Residential Water Supprr
DATE DRIL&MS)
TIME COMPLETED o? VS -
AM O FM II--
1. WELL LOCATION:
CITY: A J-'t_T as » COUNTY e o
C—oALCC Qj
(Street Name, Numbers. Comnu ny. Subdvsion, Lot No.. Parcel ZZp Cody
TOPOGRAPHIC! LAND SETTING.
°Valley ❑Fiat ❑Ridge CCther
tchect wuropriate boy
LATITUDE _.3_
LONGITUDE_,
May bs in dearest
Emotes, seconds o
in I decimal roman
Latihde/lonetude soarct: DUDS Topographic map
pocaton of well most by shown on a USGS typo map and
attached to this form not using CPS)
4. WELL OWNER
OWNER'S NAME
ST•c TADDRESS
sum
o293-sroaD
Wee code- Phone numb
5. WELL DETAILS; Saca. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Or
WATER LEVEL Bebe Top of Casing.
Top of
(Use'.= it Above T9` f.
Casing)
a TOP OF CASING IS FT. Above Land Surface'
'Top of Casing terminated aVor below lard surface may require
a variance In accordance with 15A NCAC 2C .CIIC
a YIE-0(gpm)' S METHOD OF TEST i_q
Zip Code
ENTIAL WFLI CONSTRUCTIO
•F-91if YLSZ/05 U-nub
CORD
North Carolina Depamnent ofSnvuonment and NeruntRcsourceS• s
Division a. Water Quality
WELL CONTRACTOR CERTIFICATION tt tl3 6
t. DISINFECTION: Typo r S amount__21,
9. WATER ZONES (depth):
From Tq
From To
Fran To
B. CASING:
Depth "A:Wxsd
Froin_� To__4� FCC
1VsiggJlm�
From -� .SC,Kmt
T FL
From To
FL
From To
Fro^ To
From To
327634
7. GROUT: Deter MatenN / Method
Frocr. ToFrm To aO FL erl#
FL
Frvr , r, —FL
5. SCREEN: Depth Diameter SLY, See
FL-__..... Ma twist Fowl To ---. in. Ln.
Fran
To FL in
Fran To h.
Ft.-.�!n..�_ rt.
I, .SANDIGtzAVEL PACK:
Depth Size Material
From • To__•___ Ft,
From TC FL ---.—_
Fran _To,_ FL__ ----
10. DRILLING LOG
From To
11. REMARKS:
FDrma c: Dos
_ n c m o.- t - G
•
00 HEREBY CERTIFY THAT THS WELL WAS CONSTRUCTED N ACCtRDATOR
ISA NCAC 2C, WELL CONSTRLOTON STANDARD$, VC THAT COP ICIT THa
RECORD HAS BEEN ?ROVAEO TD THE WEL, OWNER,
81oNA UREURE O CF CF
err: c_
PRINTED NAME OF PERSON ONSTRUCTIN THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1817 Mail Service Center -Raleigh, NC 27899.1617 Phone No. [phone] eat 568,
O
Form GYJ� 1s,;:
Rev.7,5 c�
yyt7 t
41
rn

LONGITUDE
R4SIDE'NTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wate - Quality
WELL CONTRACTOR CERTIFICATION #' ay36,_
327317
1. WELL CONTRACTOR:
{
Ikrrtrk /4cJ4 S0.Wyr5
Well Contractor (Individual) Name _1
C '1c c vciflye!`S 2 -S prl
Well Cohtractor Company Name
STREET ADDRESS / 7 FP(
A i4 t/ 0020 D
�O 'S%or Token State c/J yN.
C.
. ' /Zip o 4/.3
a8 G Gs'- e2Oa,2
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #('d applicable)
STATE WELL PERMIT/he applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check' Applicable Box): Residential Water Suppty'O�
DATE DRILLED 7 �� - t-Q. J�
TIME COMPLETED a. DO -
3. WELL LOCATION: ''//
CITY: /1(G/)e/r/t°Av://� - coursingfi�i/'so.t
/ / %J./c. (tee of— Lo} l am\
(Steel Name. Nunbers, Caumunity. Subdivision, lit No., Parcel, Zip Code)
` TOPOGRAPHIC / LAND SETTING:
gl Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
ASD PM lg.—
May be in degrees,
LATITUDE 3 _ € minutes, seconds or
in a decimal format
Latitude/longitude source: DGPS ❑Topographic map
(bcation of wet must be shown on a USG:,.topo map and
attached to this bun 1 not using GPS) 4. WELL OWNER A
OWNER'S NAME t\e-e.Ct I tiOc \e?. (5fo U.P InC.
STREET ADDRESS t 31 6ouk- 'Reece- 'v.
City or Town State i Zip Code
(aa)- SC11-eo
Area code - Phone number
5. WELL DETAILS: �T
a. TOTAL DEPTH: k�COCS
b. DOES WELL REPLACE EXISTING WELLS YES ❑ NO IDi
c. WATER LEVEL BelowTop of Casing D 0 FT.
(Use '+• if AboveTopof Casing) ,
d. TOP OF CASING IS / FT. AhCve Land Surface'
`Top of casing temhv,aled at/or below land Surface may require
a variance in accordance with 15A NCAC .0118.
e. YIELD (gpm): a f METHOD OF *ST 4.1 q
f. DISINFECTION: Type VI 1 5 Amount /1
g. WATER ZONES (depth):
From To From To
Frain To From To
From To From To
6. CASING; Thickness/
Depth/� C iameter Weight From / To 92 Ft.4 /r sDct 1() cPC
From To Ft "Y� /
From To Ft
7. GROUT: Depth Material Method
�l
From 1 To QLC% Ft. Gunk, i- enti 1-4
From To Ft
From To Ft
{{
8. SCREEN: Depth Diann ?ter Slot Size M�teriai$-'-
From To Ft. in. in.
`
From To Et. in. in. `...
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft
From To Ft.
Size Material
:I7
C J
10. DRIWNG LOG
From To Formation Desch tan
/�1 9-1 O �� (- . ��, r%
$ c? e2S ____G ',ail: ft
11. REMARKS:
0
c
C
1 DO HEREBY CERTIFY THAT THIS WELL WA I CONSrRVc,ED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUICT/0N STARE ARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEL L OWNER
SIGNATURE OFi:ERTIFIED
ONTRACTOR DATE
412-err, [ /7`r0
PRINTED NAME O PERSON CON3TRUCTNG TH(?'WELL
Submit the original to the Division of *later Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:2D
North Carolina Department of Environment and Natural Resources- Division of Wa_er Quality
WELL CONTRACTOR CERTIFICATION # • 0416
1. WELL CONTRACTOR:
9--Cc; c w-ge.{s
Wee Contractor (Individual) Name
e...'at' Sc,.a(ec4, A-S0n
Wee Czhractar Company Nathe
STREET ADDRESS \"\9$ 5 \\t.S7 20S
No* 3vC \0 ) NC - as-kui3
s
City or Town e 'Zip Code
(8a%)_ cobs- aoaa
Area code- Prone number
2. WELL INFORMATION:
SITE WELL ID 401 eppfcable)
STATE WELL PERMR#([eppliable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Cheek Applicable Box): Residential Water Supply Lrl�
DATE DRILLED g" V- 6
TIME COMPLETED 3i co AM ❑ PM lg-
3. WELL LOCATION:
CRY: / ..eilehr$am Lt• tile
h/d A4mc ,okcc
{Street Name, Numbers. CaMmunity. Subdivision. Lot No.. Parcel, TN Code)
TOPOGRAPHIC! LAND SETTING:
alepe DValley OHM ORidge ❑Gamer
(cheek appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: O GPS O Topographic map
(location of wed must be shown on a USGS topo map and
attached to this form 'not using GPS)
4, WEI..L OWNER
OWNER'S NAME 1-4) , I 1 i tot_ 6 . {16)+r-•"
STREET ADDRESS \yy O\ A fko..,e p W lit 1/4.4+‘t
eaAerene.vMe , Ne �8'14d
City a Town State Zip Code
(82% - S51.8,t3
Area code - Phone number
couNrr /Slp�o�a r
May be in degrees.
minutia, seconds or
m a decimal font
A WELL DETAILS: .IDS a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NO
a L. B WATER LEVEdaaTop of Casing: /a° FT.
(Use WE Above Top of Casing)
d. TOP OF CASING IS N. FT. Ab4 ve Land Surface*
'Top of casing terminated aflor below lad surface may require
a variance in accordance vat! 15A NCAC 2C .0118.
e. YIELD (gpm): 1 METHOD OF TEST R•3
330723
f. DISINFECTION: Typed \ \S Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
.%DiThickness(
FromTo h9b FI. �a �vit21
Deght
From To R.
From To Fl.
7. GROUT: Depth
M
_ Material / Method
From 0 To o2 O F. Cemen/ CA'is..e d
From To Ft. T
Fran To F.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To F. in, n.
From To FL in, in.
9. SAND/GRAVE4. PACK:
Depth Size Maeda
Hai
' From To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From TA Formabon Description
/ Y$ Out"' /ga
9? aZC irrAtzfrt.
11. REMARKS:
n r:
c - -
I DO HEREBY utK etY TAINT MC WEIL M'AS CON3WRL'CTED N ACCORDNCE WriH
15A NCAC 2C. WELL CONSTRUCTlON:trANDAROS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVDED . H ELL OWNER.
SIGNATURE OF CERT1 - 1
e. 2Ct°.8-
to. 'SC.1d'yes3
PRINTED NAME OF PERSON ;ONSTRUCTING it WELL
OR DATE
Submit the original to the Division of Water Quality within 30 days. Attn: information M ;t..
1617 Mali Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fors GW-la
Rev. 7f05

RESIDENTIAL WELL CONSTRUCTION RECOA3D
North Carolina Department of —Environment and Natural Resources- Di. o:vn of W a:er Quality
WELL CONTRACTOR CERTIFICATION #- 04 aka
330722
1. WELL CONTRACTOR: .
(Lit ;e &. Y+ec.-k), scatarrecs
Wet l.urua..at (Individual) Name -
Q' NfaQ • 6o.t.,'ye.�S k s0n.
Wee Wiwer.aa Company Nate
STREET ADDRERSS \y%UQ !'y., FJ to 7 avq
vita-Ci't\ i\)c y - -`- Code
3
City a ,5T Fate
loos- SZoa.
Area code- Phase number
2 WELL INFORMATION:
SffE WELL ID S(d makable)
STATE VYELLPERMIT#(a aopeoMt)
DWQor OTHER PERMIT MU ape/able) -//
WELL USE (Check Applicable Box): Residehtal Water Supply a3
DATE DRILLED 1^02- C
TIME COMPLETED %d(t AM0 PMf
3. WELL LOCATIOtt[�/�//�� ,/ /
CITY: festatP✓Soh u• (lc _- COUNTY /�C�ic1A-7-450(i
L'ZIVE /Vn vs c 4r'
{:awe! Hare: Numbers. Caemwn'dy. Sum Loot. No.. Paetl, Zb Code
T9POGRAPHIC ( LAND SETTING
1t> oVatey DFIat CI Ridge ❑Oeer
(check
LATITUDE 3
LONGITUDE
Latitude/longitude source: t7GPS OTopegrapbic map
(bation of wet must be mown on a E/SGS typo map and
acacieed teat form Inot usig GPS)
May be in degrees,
minutes seconds or
in a decimal format
A WELL OWNER
dig
A.
OWNERS
OWNERS NAME
STREET ADDRESS a5
, �JC
City a Town Slate
($a8,. erg(-3ato%
Area ccde - Phase number
Hcltrxukals
M ergot.\ of eve
olio'
rip code
5. WELL DETAILS:
a TOTAL DEPTIt 9o'x
b. DDES WELL REPLACE DUSTING WELL? YES 0
NOS/
c. WATER LEVEL Below Tap of Casing JO FT.
(t)se "Le !Abate Top d crone)
eL TOP OF CASING IS IV . FT. Abeam Lard Surface'
'Top el caning terminated nated aka beton lad surface may requite
a Yuan+ in moordancewith 15A NCAC 2C M118.
e. YIELD Wpm.): / METHOD OF TEST ii'3
f. DISRNECTIOtt:Typo a\\$
g. WATER ZONES (depth):
From To
From To
From - To
6. CASING:
From
Amount a0
To
From To
Fran To
Thi4ness/
Dp D*rMet Weight
Fran _To�(n/ R. iota 1
From To Ft.
From To R.
7. GROUT:Depth�T Meteriat
ss'�,, pC
From v To d F. Cer Geist.
From To Fl.
From To Ft.
Methodpiste
8_ SCREEN: Depth Diameter SIot&le Material
From To F. in st.
Flom To F. 12. in.
From To F_ in. in.
9. SANDIGRAVEL PACK:
Depth Ste Material
'Fmm To FL
From To Ft.
From To ft
111. DR!.WNG LOG
From To
�9
G yos
11- REMARKS:
Formation
,3E
I DO HERESY CERTIFY THAT THIS WELL WAS NOXIED MACCORTINCE mama
15A ?CAC 2C, WELL CONSIROCnnrt.:V MS1lNTA COPY OF IMPS
RECORD HAS BEEN PROVIDENT°'ME OWwttt
SIGNATURE OF CERTIFIED In comrascroa DATE
PRINTED NAME OF PERSON x'NS`:RUCT WELL
Submit the original to the 'Division of Water Quality within 30 days. Attn: 5177 f#sil Se Center —Raleigh, NC Z7699-16177 Phone No. (919) T33-7015 ester 568.
Fam GW-la
Res 7/OS

WELL CONSTRUCTION RECORD
2 uc 108
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Brendan M. Brodie
WELL CONTRACTOR COMPANY NAME EarthCon, Inc.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
CERTIFICATION # 3297
(if applicable)
(if applicable)
PHONE # [phone]
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 21 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Hendersonville County Henderson
103 Estate Drive, 28739
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Singleton & Jordan Environmental
Address 70 Woodfin Place
(Street or Route No.)
Asheville NC 28801
City or Town State Zip Code
( 864 )- 225-8959
Area code- Phone number
4. DA 1 E DRILLED 6-6-06
5. TOTAL DEPTH: 18 feet
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 13
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF ZEST
10. WATER ZONES (depth):
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 8 Ft. 2-inches PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 6 Ft. Portland
From To Ft.
14. SCREEN: Depth Diameter
From 8 To 18 Ft. 2 in
From To Ft. in
Slot Size Material
0.010 in. PVC
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 6 To 18 Ft. F x 50 Silica Sand
From To Ft.
16. REMARKS: Monitoring Well MW-1
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ®Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0-18 ft. Orange Brown Clayey
Silty Sand
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THISAND
WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONA
ARDS, THAT A OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
✓ arty`/ 6-15-06
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Attn: Information Management, 1617 Mail Service Center -
Raleigh, NC 27699-1617, Phone No. [phone], within 30 days.
GW-1 REV. 09/2004

331170
Me 1 Salk. twat - N.O. M ►r'•a4wn..�s wwwRIO aww•owr,�. aI«IAs■wr3�0 1V
ranni
WELL CONSTRUCTION RECORD nu. corm ACTOR : d-/r Gt.)(27 ll/S/i e' `j-
WELL CONTRACTOR CEP TWICATION.:.,i 1
STATE WELL CONSTRUCTION MINIM n %3
'/,n l /n 5 js
I. WELL IN E Molt -I oak Gooklonlalir Mutielpol 0 Induslsl 0 Aprbtal MoriaY4
a.ee..q p 1qa PUMP Ws r j.olan 0 Wet ❑ U Ober. Lit u«:
2. WELL LOCATION* Mow Oath M IM Wagon below)
Nano Wes ,4164-> E•. $ ntJr/,//tt Owrrbr /lGva/el" S' nis
> r-• ,.rep >4/t rJ,- 4A.
SW len was Islet Ownsais SASS and la) DRLLING LOG
3. OWNER .a d,` .r' / ,. ,,Ors-, Fier. 10
Ad*ssa -3 9 - /,4 i—' p
09/
eAPC,c A - r
mewTw. ,� wr•ono
At. DATE DRUID `'_
6. TOTAL DEPTH is is ' SbS
S. CUTTINGS COLLECTED YES > ti
T. oasv'LLR9PLACSEx WE19 YES NO a--
S. STATIC WATER t.EVSI.Saks Top ulCoster j FT.
r, o/Na 'es so W CIWW.
P. TOP OF CASING ISAb
�,x._ FT. .nlone Suds.'
'To N tee la, . al OW Wiwi 11./ swift* 14 .. • ••Www• M •ssr
alies Wit IM Naat ID Spa
10. VIEW (opn METi$0D OP TEST 4 let 13/aruz0
1I. WATER ZONES SINS 2`f /
A&F WELL DRILLING
ANDPHwy BuRnesE'7)C
DE 0 tir (1C 28016
FaW1n Osilar -
1773
12. C4.OISNATl01t Typo C •ke-T- "' e Amu r+ +r oldocom smog b moiled woo Mete form
O. CASING: 3 9
AM IN+nsM SIMMS-
Depth
��� moos •W. SFt. MSS (Wm Owes ridSonWelimbicre Moo
YMAI 'To..`+ ��R - " /C,' C:J/ A: > C-- Roods. or oho mpssbrww. PRO
Maur., __ T. N r-.—
?N mr Ai
Rom To
1 e. GROUT:
Flom /7
Rots _ _ To FL
15. SCREEN
Ppm
Ftom _.".To__
i+'a'Ta a,. ,aTO�
From d — To
13. 110F40160AVEL PACK
Do*
Form To
Flu To
FL
Dept i M.Mda
OIwr.Nr Maio MANN
Ft _ h
R. h b1. _
R_ h h
as M ONIS
FL
FL
11. REMARF r 'A
cn
c
I so Knew awn TINT TMY WIU. WAS coNST* CTso of occo DANCE MSTN ISA NOC KC. vim
cow TIMUMN$ ANDFAINI.NVTHAT ACDPYOFDOS RECORD MN MEN g O IDEDWIIEWSflOmar.
F 11OPPVI*MSEOW,
Ned
a.w.a.
24-24213 'ION 11:31R1 ID:
/.r)1 !0 tattle—
MONancvMOISar��INIURICTflMat Ssw[
wNotoWnrrCMOs Wit oOSAotelr.>t•r.6.M.rtWSacop
304 rev. OM
A&F WELL DRILLING
AND PUMP SERVICE, INC.
PAGE:1

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of -Water Quality
WELL CONTRACTOR CERTIFICATION # 2 i J3 N
1. WELL CONTRACTOR:
J0.iKes �•ea_ lMP
Well ontractor (Indi i ual) Name /1
rAYifLOs f e II t P�mP 1_p
Well Contr for Company Name j�
STREET ADDRESS I 0 2 D x 4 2q
I
IlebonD j C 2VbLib
City or Town State Zip Code
( }
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply V
DATE DRILLED 7 -11- a o,
TIME COMPLETED ,5 : �7 O AM O PM V
3. WELL LOCATION:
CITY: nGICOUNTY He YiQ e r5Oo.
9i to_ Rd. 1- !Aden_ IVIi0.r✓nh)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC /D SETTING:
❑Slope ❑Valley t Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 16 2o, 0gig
LONGITUDE .S_ao 4I • S' -5
Latitude/longitude source: ( PS oTopographic map
(location of wel must be shown on a USGS topo map and
attached to this form 1 not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
WELL
ER
4 OWNER'S NAME D0.)10.5 �0.-i-)1 Well
STRE ADD Pt 13 el / rk/ I'{T�p e L
eneCuotilil e (\JL 0 g'7q
City or Town State Zip Code
Area code - Phone number
S. WELL DETAILS: DS
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p,
c. WATER LEVEL Belau Top of Casing: 3 O F r. 1
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS ) FT. Above Land Surface
'Top of casing terminated atlbr belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1 S METHOD OF TEST a ✓
331246
f. DISINFECTION: Typecklo ✓i rye
Amount i cu/,
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth _ Diameter Weight M fiGnnal
From D To `5g FL ip SOR21 rvc
From To Ft.
From To Ft.
7. GROUT: Depth Material Mpthod
From 0 To �o Ft. Sat Krefe [la ',Lid
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
D S8
58 2
SC/?
11. REMARKS:
dirt 5a-n
evt)tso)i dated yo Lk�
n
CIT
•
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a/.ea. k)• (4L 1 4 g-1 g D6
SIGNA RE OF CERTIFIED WELL CONTRACTOR DATE
\Awtes Ii.Ca
PRINTED NAME OF PERSON COhis TRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1611 Mail Service Center— Raleigh, NC276991617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 S'
331247
1. WELL CONTRACTOR:
Janes Lit)
a
Well Contractor (Individual) Name
a )1414 5 L/ )t I) r co
Well Contra or Company Name ;��11''
STREET ADDRESS I L) BOX I a
rIfenitre, NL t-o
City or Tam State Zip Code
gA )- c3-73a�
c•
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(inapplicable)
STATE WELL PERMIT#(ln applicable)
DWQ or OTHER PERMIT #(if applicable) , /
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED tl I L1 _ c (O
TIME COMPLETED AMO PM[V/
3. WELL LOCATION:
CITY: 11eeV/ - (' COUNTY -FP Jeri() ✓--
I✓aw K <ee,n'su1 d -
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAirD SETTING:
❑Slope ❑Valley Qtlat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 1 -224 L�
LONGITUDE � ) q . gig
Latitude/longitude source: VaPS ❑ Topographic map
(location of wefl must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER .n
OWNER'S NAME 11A l(a5 AYYI. vtytIJ
STREET ADDRESS I FDLN± 1 - e 1.n•
IFn l..;,E N 27ga
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
)-
Area code • Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Ict
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOj4
3 s FT.
c. WATER LEVEL BelowTop of Casing:
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. an
•
e. YIELD (gpm): .!� "l METHOD OF TEST r
f. DISINFECTION: Type C 444Y1 N e Amount )
g. WATER ZONES (depth):
From To From To
cup
From To Fran To
From To From To
6. CASING: Thickness/
Depth Diameter Weight MTV
From 0 To 6,0 Ft. SL&Z/ YYC
From To Ft.
From To Ft.
7. GROUT: Depth LMaterial
From 0 To -2.0 Ft. Jac kr efe
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From • To Ft.
Fran To Ft.
10. DRILLING LOG
From To Formation Description
D lro ciir'C San el u
P3
/.o 155 el, f6D/;rl4'le d ro C
'1
11. REMARKS:
N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF TNIS
RECORD )&AS BEEN PROVIDED TO THE WELL OWNER.
SIGNAXLJRE OF CERTIFIED WELL C
OLWieh kJ. i�a mg
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
RACTOR DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

',.,,RESIDTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTO('t CERTIFICATION # 3 / 41 )
'jJ )42
1. WELL CONTRACTOR:', /
& 'A-nl LU /v ES
EII Contractor Individual) Name
t4 Sate /J Ju 11 ard �"ump, / 1 C,
Well ontractor Company Name
J
STREET ADDRESS r� 73/ AO LEt(E IE2 kq,
5/'PG S/Ee„ /% C' • ag ilyg
City or Town / State Zip Code
(S.R?3 )- 252-- 8g91,_
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID #(if applicable) Q 5/ rt2 eV Q'/ Z% 2
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply U
DATE DRILLED 3 - /r? - 0 TIME COMPLETED /-,(D AM ❑ PMQ /
3. WELL LOC/pTION: ��
CITY: /f �a/r�sa. v.//t COUNTY /1� f.%v
.,ae. "I c A. it t 7
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOEOGRAPHIC / LAND SETTING:
Slope DValley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE 3 r-- /C C 5 j'
LONGITUDE r Z n - /6-O '
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2dPS ❑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 ``l\.,� ( /--
OWNER'SNAME abatilt�ri £YWlaSQ Utled *y
STREET ADDRESS 5 `f/3 asheu,//p Arc y
nthou/mdd% Nr 2,87j/
City or Town Stale Zip Code
VA )- 487-a883
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2°f
b. DOES WELL REPLACE EXISTING WELL? YES NOW
c. WATER LEVEL Belau Top of Casing:
(Use'+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
?
e. YIELD (gpm): J 7 O METHOD OF TESTj1,011!i tir/ r 4
4/0
FT.
f. DISINFECTION: Type(&, .-:c Amount 7 AS -Bs
g. WATER ZONES (depth):
From SO To From
From /C 0 To From
From To From
6. CASING:
Depth Diameter
From o To r 7 Ft. e,../2"-
From To FL
From To Ft.
To
To
To
Thickness)
Weight Material
S3'!/ �L
7. GROUT: Depth Depth Material Method
From 42 To a" Ft. Cone:rcfe. 1101.ffiNOi
From To Ft. ..JJ
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
r7- 25r
11. REMARKS:
cn
rn
o•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W rH
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
/VeS
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 3 / 410
1. WELL CONTRACTOR: /. `
jW� II Contractor Individual) Name
re
Sees l,1 l�—II and t�1/n� 'LC,
Well jontractor CompanyName/1 //
STREET ADDRESS ;iJ /3/ ,4' w LE (E t E(Z I fLu
/(5Sk t /KC• at?
City or Town / State Zip Code
(2;(8 )- � S y9 &.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) r9 5/. O / c 9a 8 7
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (CheckDApplicable Box): Residential Water Supply Q'
DATE DRILLED ar •-/U - 1)4
TIME COMPLETED -?.DJ AM El PMQ
3. WELL LOCATION:
CITY: e c/i-fo•- v //1 COUNTY / �.h
L,4 -944,4 .C.t, 3
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Slope ❑Valley ❑Flat DRidge ❑Other
(check appropriate box)
LATITUDE 3 -' IS. 7/I
LONGITUDE r 2- J0.
May be in degrees,
minutes, seconds or
in a decimal formal
Latitude/longitude source: L7GPS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
Te�2f'fT, 7,/9e,So//
STRR jT ADDRESS vat, 726re // U€it
C.44d/tr Al ,,8V5
City or Town r State Zip Code
(t?n)- So&-5aa/
Area code - Phone number
OWNERS NAME
5. WELL DETAILS:
a. TOTAL DEPTH: .2 ?g /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L7
c. WATER LEVEL Below Top of Casing: 47/0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): C D METHOD OF TEST
09s1 S 4®
f. DISINFECTION: Type (1/+->'K Amount. .2 Aft.
g. WATER ZONES (depth):
From /30 To From
From DSO To From
From To From
6. CASING:
Depth Diameter
From 0 To 62 Ft. 4,/1r
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight
5D/jt/
Material
�✓L
7. GROUT:I� Depth Material Method
From 0 To ,i�0 Ft CO/1crctc
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From —T—To Ft.
From To Ft.
10. DRILLING LOG
From To
r%_if
5l- 6c
Fe—
Material
Formation Description
CA./
-12
J
G EI:r 1J0
11. REMARKS:
C*'
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.
Cc
3-/a-CL
SIGNATURE OF CTERTIFIED WELL CONTRACTOR DATE
r A
pf A!J
t
•/yc'S
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt_
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
•

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division otWater Quality
WELL CONTRACTOR CERTIFICATION # r'O ?
n < isHr
0 E) Y !
1. W CONTRACTOR:
Wabhid, a
11 Contractor ( djvid}'al)rNamg
RQJLSOn/5 WE I G `d �ump LLC•
Well cfintractor Company Name r
STREET ADDRESSA 7$J N,rw It r/esl2Ncrfy
i(2s-E 2 AIL' 38149
City or Town l State Zip Code
(YR
S
Area code- Phone number
2. WELL INFORMATION: /
SITE WELL ID #(it applicable) ID62 AO ( op 3 a.5"
STATE WELL PERMIT#(i/ applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED 4:E' 9
AM O PM
3. WELL LOCATION: /
CITY: ; ginoytLY�! COUNTY f/C/r//(VSpp/
(Street Name, Numbers, Community, Subdidsion, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING'
❑Slope ❑Valley ❑Flat dge DOther
(check appropriate box)
•
LATITUDE r/ 3 S Y. a f/i
LONGITUDE(() d$d. tS
Latitude/longitude source: ❑GPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
d. WELL OWNER
OWNER'S NAME //Ancy �)/ry'�f Pryd
STREET ADDRESS jOs a D /d..
May be in degrees,
minutes, seconds or
in a decimal format
Cud, m.n a
ud •N C—nr' -121-- 36St'R
City or Town State Zip Code
93a-a)4a
rea cotle - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
7DS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): — METHOD OF TEST
r./
f. DISINFECTION: Type v/ 4n /N C. Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From O To J, j Ft.b.dY 2.(/,/.2S MA" 5OeF7 /
From To Ft.
From To Ft.
7. GROUT: Depth ,Material
From D To 10 Ft. C°I(etie
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
f T/C
-AZ
<L— 2- 7
2i —7a
11. REMARKS:
Q
0
trn Formation Description
(/ay J sv
cies. S?/da/L
/64.-
/5 ate, 7c
2035
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W nH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE dECEf2TIFIED CONTRACTOR 7W
her &I Yours'
PRINTED NAME/ F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form G W-1 a
Rev. 7/05

RESIDENTIAL, WELL CONSTRUCTION RECORD
North Carolina Department of Env'vonment pjd Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2O ? Q
st n
�i f} 11
1. W CONTRACTOR:
rV', `1�' ' o S
(W II CCoontract tylridyal))Nams
E�u.SOJllr 15 W G /I &Wrd T amp, LLC.
Well Vantractor CompanyNamee Arai
/ r
STREET ADDRESS Id! Arai (�EJ(1Esiia(fir(/
L (eSieg ACC 38149
City or Town State Zip Code
( 5J3?) :58-549&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i/ applicable) ®/'C /De 7.:1
STATE WELL PERMIT#(i/applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply (
DATE DRILLED //7
TIME COMPLETED// 6 AM ❑ PM
3. WELL LOCATION:
CITY: &JM -Cy V///C. COUNTY ("i(,Aia3-6 N/
(Street Name, Numbers _Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAP / LAND SETTING:
❑Slope alley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 13_;Z, `/(2b5 /
LONGITUDE A)O'nA 7 C '
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town
May be in degrees,
minutes, seconds or
in a decimal format
/(i4ccra / zv!r//
2'Q 5®< q
/7e A 87,-9,
State Zip Cale
(Rak)- 329-7051.0
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use**- if Above Top of Casing)
d. TOP OF CASING IS 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 (gem): 5 METHOD OF TESTTHh J�gl�-f)fr`j
ZD FT
f. DISINFECTION: Typ4,'h 0t/AJC Amount /A It Z
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From r7 To 02, Ft. 6,2 5 24, /,23 A/¢ 5$>ZZ I
From To Ft.
From To Ft.
7. GROUT: 0 Depth �1 Material Method
Fran To �j� Ft. &frith
From To Ft.
From To Ft.
J
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
0 ^ 60
lG —n
sr - 92
11. REMARKS:
Formation Description !2
a
SH/(�Tifd�ve
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE O CER l D
PRINTED NAME
G 1,
CONTRACTOR DATE
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
20 1
1. W CONTRACTOR:
`till O
(W 11 � r� vidyyal ffNam
EkQ&LSoit SUEll @'d Pta p. L.L_C.
Well Chnhactor Company Name
STREET ADDRESSr7/77.1 p �/''n
iffEEs-I-E ,V 1 L aO /`CX
City or Town /— State Zip Code
('3J7 >-5�-Wj`)G�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
etil01oo /0309
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply L7
DATE DRILLED Y/2 L`yi,Q
TIME COMPLETED/ /, 3a% AM ❑ PM
3. WELL LOCATION: ' /
CITY: i4 c,yo,r//C ry COUNTY e/Lier-V4)
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOP RGAPHIC / LAND SETTING:
Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE() 35 e 2,6 is-4'
LONGITUD
r
source: S ❑
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitudeTopographic map
(bcation of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME
47(sea
LPa^Ve
S,,T%p�EET ADDRESS 3 7 2 &fel et ,
?their-yseivvale fiC a871 a
City or Town State Zip Code
(8a 81-a7-a438
Area code - Phone number
5. WELL DETAILS: �1
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [�
c. WATER LEVEL Below Top of Casing: %J) FT.
(Use'+- if Above Top of Casing) -
d. TOP OF CASING 1S r . FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accorda9ca with 15A NCAC 2C "1141
e. YIELD (gpm): (-7 METHOD OF TEST
f. DISINFECTION: Type Cp/,7/i14(Jt
Amount /y&Z
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
Depth Diameter
From / To a FLA./Qy
From To Ft.
From To Ft.
To
To
To
Thickness/
Weight Material
2/6r/2 /i/C 5240A /
7. GROUT: Depth Material
From 0 To lfl Ft. d'etritiff
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. - • in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Ft.
From To
yMeethhoodd
J
in.
in.
in.
Material
Material
10. DRILLING LOG
From To Formation Description
0 — is Ci/may
— Ss
GI) =315
11. REMARKS:
SAAp SIds✓c
rT1
—o
t
CP-
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PR 9VIDEO TO THE WELL OWNER.
SIGNA
PRINTED NAME
RTIFIED WSkL�CONTRACTOR
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
ATE
r-
e
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2D 9
1.W CONTRACTOR:
{tb q `/ - a-t
tW II ontract thdjvitl al)Nam
k'QQ<o'.s WG it ola
Well Vintractor Company Name y
STREET ADDRESS / f
L4cieteS#Gg ,C
City or Town f State
( 83H >_ a 58-Wt94
S
um pr . LL.C.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) Q S'/ao i/o a 4 4,
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED 006
/�
TIME COMPLETED /((/(/ AM PMEr
3. WELL LOCATION: /
CITY: f�l/1 er-U7(( COUNTY / /y-etl(t.5)4/
pads/ups (tan} - 7. /5
(strectilame. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/LAND TTING:
❑Slope DVafey ffrial ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3S # 2 \ r S S Z.
LONGITUDE L5 037. r/
Latitude/longitude source: S oTopographic map
(bcation of well must be shown on a USGS topo map and
attached to This form if not using GPS)
4. WELL OWNER
OWNER'S NAME Ati' PZp eif, eC
STREET ADDRESS /5 9 m25 6rare_ td
eicAGr /11 C- A?7:3
City or Town State Zip Code
(S)S6 )- t,WIC -99O7
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CIK
c. WATER LEVEL Below Top of Casing: ^/ FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING IS i FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): S METHOD OF TEST rJ
9gsr
sr,.. ,
':0 d3U
I. DISINFECTION: Typed , In/li'RGc Amount / Zo z
9. WATER ZONES (depth):
From To 2W From To
From To From To
Fran To From To
6. CASING: Thickness/
Depth _Piameter Weight Material
From 0 ToTK Ft.(!/25 7.1I, 2 frC /1--R/
From To Ft.
From To Ft.
7. GROUT: Depth �1 nMaterial/
From 0 To �0 Ft. L1'l ,QEpr
From To Ft.
From To Ft.
Methodod
' rJ
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
Ft.
Ft.
From To Ft.
10. DRILLING LOG
From To
ice/
�5Z —qz,
94. -YQS
11. REMARKS:
Size Material
Formation Description
S�t� Sf we
�o(k P
S?.
21135
N
-O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG
14U2
ATURFT.OF CERTIFIED WGbLCONTRACTOR / DATE
PRINTED NAME
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
W CONTRACTOR:
0bh Id' 1�� s
tW II Contractor ( tljvidu. al)_Nam� �u(n
Q Li_<,oi s (V E 1 (Livdj� p LLC.
Well Qpntractor Company Name Jt/ 1 r
STREET ADDRESS r� (cal / CbJ i
Lci s-fga /VL 'Pig
City or Town / State
( Slag )- 5F-249/L.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply El
DATE DATE DRILLED /Jfp /
TIME COMPLETED
APO AM D PM p'
3. WELL LOCATION:
CITY: ,E. jt¢t/U/V4 `Sp
'/ COUNTY fit/tie r✓
CA esY4M
(Street Name, Numbers, Community, lubdivision, Lot No., Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING:
lope ID Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 0_ILO e SW
LONGITUDE0 9X P Ir 33�6
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: BliPS 10
Topographic map
(location of well must be shown on a USGS topo map and
attached to This form d not using GPS)
4. WELL OWNER q � �r�
OWNERS NAME 1 f3 5 C-
ST ET ADDRESS 7'�r)ryt6Altr a (ic -} _i1
SkeU plc hcJ �V6bb 1
City or Town State Zip Code
(Kai )- a5 a- (QOS
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
30s'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Pf
c. WATER LEVEL Below Top of Casing: C..O FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):
445
METHOD OF TEST
i c L -.
s c) a v 0
f. DISINFECTION: Type C/1D,,,ciir_ Amount /p�Z
g. WATER ZONES (depth):
From To_$(2From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To c/aFt.1_ ZL ddy ,"Ur 5.2)10,,/
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material Method
From ��)) To In Ft. t-."n�ireele
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. - in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 —I5 (Cloy
3f S B�s
AV
YO —ZOS /-,r)v/ 54,
1,
11. REMARKS:
cri
ri
-• 3 r
•
-J
Q1'•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED II ACCORDANCE WRH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATUATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

1.w
I �
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
CONTRACTOR:
City or Town / State
(gam) 5S-,g4
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) 0 (AO 10369 7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q
lI .
/L� H S
fW II Contractor ( djvidy'al) amg
.�P9,4-<0# 5 WE II Oki Kan p. .,.0
Well ypntractor Company Name
STREET ADDRESS r 77 1 NN1� C
cry
ler ie_ESfER 11;C an/Pi
Zip Code
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
CITY: yrlUnnd
66
%OO AMO PM�
COUNTYh' elf f/rer
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/LAN TTING:
❑Slope [Valley at ❑Ridge ❑Other
(check appropriate box)
LATITUDE /U'''' II � / r;
LONGITUDEwOSa,'10- rV''
Latitude/longitude source: QGPS [Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 0 not using GPS)
4. WELL OWNER ,/ 'Jr'�
OWNER'S NAME gar. (d C & '/e 'J
STS,EFT ADDRESS 7? °midi,e •rrje
rcl,° h h c 21g70
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal formai
rose )- a73-ifSs
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO De
c. WATER LEVEL Below Top of Casing: /O FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
*Top of casing terminated at/or below land surface may require
a variance in accordance�1with 15A NCAC 2C .0118.
e. YIELD (gpm): {..(/ METHOD OF TEST
5ry
30 s r
From
f. DISINFECTION: Type Q/ Amount
g. WATER ZONES (depth):
So z
Fran To 22O From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter WeightMaterial
r) To PO Ft. 6,2 i 2/6r/r ' d )
To Ft.
To Ft.
From
From
From
7. GROUT: Depth Material Method
Fran D To ao Ft. &table t '
49 From To Ft.
From To Ft.
6. SCREEN:
From
From
Depth Diameter Slot Size Material
To Ft. - in. in.
To Ft. in. In.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
U 7,0
70 — $S
ss - PD
—JOS
J'=
11. REMARKS:
Ft.
Ft.
Ft.
Size Material
Formation Description
r1/4 y
sa S atra/C,
ai-.fd./lAC
1 Qy
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE W fiH
15A NCAC 2C, WELL CONSTRUCTON STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWN
SIGN
PRINTED NAME
CERTIFIECONTRACTOR ATE
al, 1'os'
PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 20 Q
1. W CONTRACTOR:
Wyk tract (hdjvid�'al) am
/cingtl<c) s kEIlPump LLC.
Well �Cbbntracla Company Na
me
je
yr
STREET ADDRESS 'J1 /�/ /Y5/LJ 1.
LEi -'eSf g f C 3g 74ig
City or Town / State Zip Cade
( "Ng )- 57-Sei9A.
Area code- Phone number
2. WELL INFORMATION:
SITE W ELL ID Riff applicable) b fp / no /0 5 7a yr
STATE WELL PERMITS/Or applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
.DATE DRILLED 5/954
TIME COMPLETED
3. WELL LOCATION:
CITY: Eiji trvi/d/c.
AM El PMI
COUNTY fly r11.. f /yQ
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETT
❑Slope ❑Valley ❑Flat QRldge ❑Other
(check appropriate box)
LATITUDE /✓33, pi 5 / r
LONGITUDE/P5'A r
Latitude/longitude source: PS ❑Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form ifnot using GPS)
4. WELL OWNER c
OWNER'S NAME- /04 fiber �)�OLV(`G,('e 45m
STREET ADDRESS 5 r51 / 3 `1. %w/J / fp /,Lw
Pn4',b
rio nc �s7q/
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
S f
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EY
c. WATER LEVEL Belau Top of Casing: D// Ff.
(Use-+• if Above Top of Casing)
1
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): V METHOD OF TESTlotidithillr
J
t f 9
0 J t
f. DISINFECTION: Type Cheidue
Amount q6 r-
g. WATER ZONES (depth):
From To 2-4"0 From To
From To .32.0 From To
From To From To
6. CASING:
Depth /�
From D To Sv Ft
From To Ft
From To Ft
Diameter
6,2,s
Thickness/
Weight Material
2/6,/AS AiCS/7,42,/
7. GROUT: Depth Material
From 0 To ao Ft. CtfICQd
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Size Material
Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
o —61)
%Sg75
11. REMARKS:
Formation Description
san
iirD.vt
'04-
C' R7r%LY
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARQ8: AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO 1HE W EL NER.
SIGN
PRINTED NAME
CONTRACTOR
F PERSON CONSTRUCTING THE WELL
83
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division -of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W FL.� CONTRACTOR:
bobhf jdr ��--I-s
fW Il Contractor djvid}'al))Nam
i &SCf1'S WEI1 aw'el wnp LLC•
Well Cntractor Company
yName /•
STREET ADDRESS AraiLE/ ces
Lpiites-t g if c . S8149
City or Town / State Zip Code
(' )- .)58-.?9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) Q (e/.0 /04.1 3 7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
7/6
TIME COMPLETED
AM 0
PM
3. WELL LOCATION: J/
COUNTY He i1�/2/ eri
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTIN
❑Slope DVailey ['Flat idge DOther
(check appropriate box)
LATITUDE N3,c,f) %32/
LONGITUDE [MA.' Zaa,Q�J�/v
Latitudeflongitude source: ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 3 not using GPS)
4. WELL OWNER c 1
OWNER'S NAMF&Kj-&rpfh c�Y) .LOCC+C•p ),CS; rL5
REETADDRESSRCgf 3 Q.skau,t(e,
—
ChdrPrsbfdO.I(e he a 7 1
City or Town State Zip Code
S S)- is2g7-ags3
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
3(S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: f 0
(Use'*- if Above Top of Casing)
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gram): b METHOD OF TEST J)kYil•rq
2o;
f. DISINFECTION: Type C. jQ/y/UQ, Amount Q. e Jj
g. WATER ZONES (depth):
From To .Z4 From To
From To 3 20 From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To ,5 9 Ft. 4,2S 2/G,JV /`FC S/k /
From To Ft
From To Ft
7. GROUT: Depth L.//77 Material
From 0 To 10 Ft. eireti
From To Ft.
From To Ft.
Method
apjazii
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
p -- r 6
ad -7S
7S. —50
SO - 26S
11. REMARKS:
Material
Formation Description
C Jay
San el, ?'dam
jb r /s firs
..0
4
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 BE PROVIDED TO THE WELJyOWpER
.S/' /
CONTRACTOR DATE
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
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 #
2o-.1 2
c 1"1 cc
U J i i :J
1. W CONTRACTOR:
Lf %r O
W 11 �Q (hdjvid al)Namg
tE2g4<oit E ak'd
Well Untractor Company Name
STREET ADDRESS f�/ /ftlti L
LFir% sigg n(c a874g
City or Town / State
( y3R) 5s3—s 9&
s
umpr L.C.
Zip Code
Area code- Phone number
2. WELL INFORMATION: /"
SITE W ELL ID #(if applicable) t le / to 1 D LE R (o 3
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
06
TIME COMPLETED
,2i0o AM El PMQK
3. WELL LOCATION: /
CITY: (;/, /7 Cf/#///f1 CDUNTY/y{MJCti"
(Street Name, Numbers, Community, Subdidsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SET
❑Slope ❑Valley ❑Flat Ridge ❑Other
(check appropriate box)
LATITUDE/1) 3-S Al, 71/r
LONGITUDE
Latitude/longitude source: DC PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this,I Horn",
Snot using/�' GPS)��/C lT
4. WELL OWNER porn1PC atrnrj�t/„�ol... (Sf�.rth
OWNER'S NAME 11'7 2 YUiX
STREET ADDRESS 7s /'t'L^k Rtcr•k 411
QShP11IfP We eQ8R
City or Town State Zip Code
(Cie% % aS.a_62699
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO2///
c. WATER LEVEL Below Top of Casing: 2-0 FT.
(Use -+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated auor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST-Yu/lit, gt)
aos
t. DISINFECTION: Type (r% /044)-( Amount Sh?
g. WATER ZONES (depth):
From To 7/0
From To / jp
From To
From
From
From
To
To
To
6. CASING: Thickness/
Depth /� Diameter Weight Material
From 1To ((// Ft. 6/25 Z((o,/25 A//( S/%ea)
From To Ft.
From To Ft.
7. GROUT: Depth ��11 �nM!aa�ieriorial)) .� , Method
From D To a Ft. li"fa_Ce7e O..liQ r_
From To Ft. ��
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To Formation Description
—YD P/a
Va - 55
s5 —bDD in/A
Ie0 —US /97ANP7L
rn
r*!
t
SE P 1.2 2UUS
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONTRACTOR s DATE
Olt
F PERSON CONSTRUCTING THE WELL
T
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 # 2O- 9
rt n., ✓yon
t: rj y i ti
1. W CONTRACTOR:
W II Co tract (krd vid al) Nam
fER'Q&son15 %Eli �w-d
Well ntractor Company Name y
STREET ADDRESS ,�i1 i,
s
umpr U.X.
itesf g /IT L a874 9
City or Town / State Zip Code
(3'3g)- 5"Y -St194
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable) 64, / oo /0 1/ ag5
STATE WELL PERMIT#(Ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):
DATE DRILLED s/00
TIME COMPLETED f [ ! D t/
Residential Water Supply -If
AM ❑ PME
3. WELL LOCATION: / / //
CITY: cf f CJL1/��t COUNTY NfA (/Id Ai
(Street Name. Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAP C / LAND SETTING:
❑Slope alley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE/as o2Jr gs
LONGITUDE t1aiA �xII
Latitude/longitude source: CIGPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
d. WELL OWNER
OWNER'S NAME SQr L'{-.114, r C1%n(: rot, Gl 441S�rs
STREET ADDRESS SC`) 3 le J. Ile 1
T to.nSont(r nt /V C. 5S79 1
City or Town State Zip Code
(En )- (0%1-%.,y
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: a�S
b. DOES WELL REPLACE EXISTING WELL? YES I2 NO ❑
c. WATER LEVEL Below Top of Casing:
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118. rI
e. YIELD (gpm): / T\ METHOD OF TESTrJ
T. DISINFECTION: Type (r . lQ t,&i[ Amount 0 7
g. WATER ZONES (depth):
From To //Q From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 1//2 Ft. 6,A5 v /ir gaii/m/z e
From To Ft.
From To Ft
7. GROUT: 0 Depth 1 Material Method
From To 10 Ft. G' Il EIP Algol
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
O Uay
�rerd s
?,S --17
Y.a«.
- y2 /zo C.
72,—arts
11. REMARKS:
G/era7.:,74-
L'u Uli
I00 HEREBY CERTIFY TNAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEL rW R.
SIGNAT CONTRACTOR TE
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
b b
a S1. WELL CONTRACTOR:
W II ContrI/rdvdyal)fNamgfR &5o,v5 W E II fcrrJ Wn p. LLC•
Well C)ntractor Company
jName A� {/
STREET ADDRESS ra / 3 / /YtIJ l�&J [7ES'la
L piiesA g w a87ei4
City or Town / State
( 8.M )- 52—Wfg&
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<
DATE DRILLED
TIME COMPLETED
3. WELL LOCATION:
CITY: g/< �2 her
31)
AM PM[j
COUNTY /tq�{/Np/
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAP C / LAND SETTING:
['Slope Valley ❑Flat ['Ridge ❑Other
(check'/appropriate box)
Jy LATITUDE 3 S if 9t?, C1Q �y
LONGITUDEt5).r 2.6/o1r
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Qe PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STR)rET ADDRESS 1,1
City or Town ate
(Ca,g)- ogy—gi5/
Area code - Phone number
Zip Code
5. WELL DETAILS: /'y
a. TOTAL DEPTH: L15
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO B"
c. WATER LEVEL Below Top of Casing: FT.
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): a METHOD OF TEST `/ raj
f. DISINFECTION: Type /Q^/o(J ( Amount A Q Z
g. WATER ZONES (depth): r
From To 220 From To
From To From To
Fran To From To
6. CASING: Thickness)
From 0 DToth, /pjameer Weight pat
From To iFL
S_/
To Ft.
From To Ft.
7. GROUT: Depth �1 n'�Material l!
From 0 To an Ft. aE{r
From To Ft.
From To Ft.
B. SCREEN: Depth
From To
From
From
Method
Algol
Diameter Slot Size Material
Ft. in.
To Ft. in.
To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
in.
in.
in.
Size Material
10. DRILLING LOG
From To
o—ce 'VP
Formation Description
r (47
ram 64.& -c
/0 A3 /rrc4
11. REMARKS:
9
l
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
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 Envlronmsnt and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 20 Q
1. W CONTRACTOR:
ah/it Af 14s
f'ill Contractor („p1djvidyal),,Na ;�g
Rg4Sois WE It of ismp LLC•
Well ntractor CompanyName
A
STREET ADDRESS I I
LIFie sfEg Ar,C a874g
(J,� �7City or Town p/ State Zip Cale
( '1�rS F S3 -S49
Area code- Phone number
?. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED S
TIME COMPLETED
3. WELL LOCATION:
CITY: prp F4I/,-Chtr,
AM❑ /PME3
COUNTY 7-f{�QC/SDAV
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
TOPOGRAPHIC / LAND SETT'
❑Slope CValley ID Flat idge ❑Other
(check appropriate box)
LATITUDE/(_ z/, Q77.
•
LONGITUDEgap' 1 bp(5Y,565
Latitude/longitude source: S
May be in degrees,
minutes, seconds or
in a decimal format
❑Topographic map
(bcafion of well must be shown on a USGS topo map and
attached to this form 9 not using GPS)
4. WELL OWNER n
OWNER'S NAME 4Clyyto
STREET ADDRESS coo tabd"1.G' a.
/ K ,i/Mm1 ,,,n, lC ,, s City or Town State Zip Code
6zj' >_ to 57--zly747
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO -IV
3D5f
c. WATER LEVEL Below Top of Casing: AO
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
'Top of casing terminated aVa below land surface may require
a variance in accordance with 15A NCAC 2C .0118. �]
e. YIELD (gpm): f 2, METHOD OF TEST�rJ
FT.
T. DISINFECTION: Type QrL.v C Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
•
Depth Diameter
From 0 To Co Ft.
From To Ft.
From To Ft.
Thickness/
Weight Material
,UCS®QR
7. GROUT: Ft
Deptho/�jll //!! ��Matteeerial II
From 0 To .V'((LEjff
From To Ft.
From To Fl.
8. SCREEN:
From
From
From
Method
Depth Diameter Slot Size Material
To Ft. i in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
AS —
is ^So
vJ — 74S
Formation Description
Sat Pas Yo4✓ C
1 z
� 2PD6
11. REMARKS: - -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE wan
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, Ay0 THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL 0
SIGNAT
PRINTED NAME
CONTRACTOR / BATE
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
19i T 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- Divisi3n of Water Quality
WELL CONTRACTOR CERTIFICAT ON #
2& P
1. WFL4 CONTRACTOR:
•L{ (/x, 13 s
W,�II Cone (Indjvidya�l)(r'Nam
(�?u<c WE11 OA dump LLC•
Well ntractor Company ya- L.
Namej/I� / /
STREET ADDRESS OI I�/ /Y
Lit(esfif Al, c . a8 V
City or Town State Zip Code
($3,X )- 58 -WO 4_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q---
6-//- o 6
DATE DRILLED
TIME COMPLETED AMLE- PMET--
3. WELL LOCATION: Flt n[n `
CITY: COUNTY y{dt'eso Ay
417-
(Street Name, Numbers, Community, Subdivision, Lol No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI G.
❑Slope 0 Valley 9-Flat yrKidge ❑Other
(check appropriate box)
LATITUDE 3S1 `Z,(1p207
LONGITUDWfl Ai 2.0 I517'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER /'// /,,,-_
OWNER'S NAME Hanuo t bt4/-rti
TREET ADDRESS
City or Town State
( '? $ )- ( K7- /fq7 /
Area code - Phone number
Zip Code
5. WELL DETAILS: �L
a. TOTAL DEPTH: ,/ Os /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [f
c. WATER LEVEL Below Top of Casing: ---/ FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING 1S / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
J8r/
e. YIELD(gpm): ID METHOD OF TEST
f. DISINFECTION: Type CIA/Dr/i1/C Amount Qr Gi
g. WATER ZONES (depth):
From To 20.0 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To'7j%1 Ft.(v,a.S 24,/1T PVCSLYPA/
From To Ft.
From To Ft.
7. GROUT: Depth ��77 nnCL
Material Method
From 0 To �() FL jjff
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in, in,
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
o --/S Cat �r�
IS - 3, san✓s/D,--e
33.0( - 35' Ile, f
-4S - 30 5.- G+bA✓, fc
11. REMARKS:
I DO HEREBY CERTIFY THAT THLS WELL WAS CONSTRUCTED N ACCORDANCE Wrm
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
S
SIGNATURE OFJCERTIFIED CONTRACTOR ATE
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone. No. [phone] ext 568.
Form G W-1 a
Rev. 7/05

kr-
1
c
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 20 9
L CONTRACTOR:
hi) •(.Jr rod-�-s
W Contractor)dwid yal)�.Namy
k'q&Sola's LUEII 0 adrPtunp Li—
ntractor Company Name Y
STREET ADDRESS 7� /► %ti l,�►(')ES
�FfrES#ER n�C a81412
City or Town ) State Zip Code
( '4 )- 58-9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
S
TIME COMPLETED 6Z AM ❑ PM p'
Z.
3. WELL LOCATION: /
CITY: F,p�ncyL2/rll•( COUNTY 74.I�/rVI)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANQ.SETTING:
❑Slope DValley Flat El Ridge ❑Other
(check appropriate box)
LATITUDE N3y a/ sr 7‘
LONGITUDEp0�r r
Latitude/longitude source: reCPC ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
May be in degrees,
minutes. seconds or
in a decimal format
OWNER'S NAME Mien GS O,r,Grr•CCc+
STREET ADDRESS 10 / 0 Ab2nuT "4
JP¢,lttacyAnt { 17f7 a87J
City or Town State Zip Code
Areacode -'Phone'8
7 7y
VV
5. WELL DETAILS:
a. TOTAL DEPTH:
tog
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing 2 O FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. `
e. YIELD (gpm): �z% METHOD OF TESTI»/)�0)5-i'y
f. DISINFECTION: Type Coil A/G Amount 0
g. WATER ZONES (depth):
From To ISO From To
From To From To
From To From To
6. CASING: Thickness)
Depth Diam er Weight Material
Frorn_0_ To Q Ft. 4g2/b./.2Y /lc s-v a I
From To Ft.
From To Ft.
7. GROUT: 0 Depth /1 ,Material �1�� Method
From To �fl Ft.dMI(fjj 1/W ►/2rrr_
From To Ft. ",T---"'-J7
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in, in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 ^70 C/ay
30 "V7 Stith* i<
4,7 — sa . ,c
SA — *OS eir-errw.'7ff_
11. REMARKS:
I •
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED
1SA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND
RECORD HAS BEEN PROVIDED TO THE WE WN
SIGN
PRINTED NAME
CORDANCE WITH
A COPY OF THIS
CONTRACTOR
U�t IDES
F PERSON CONSTRUCTING THE WELL
DATE
2 9
c
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and t. al Resources - Divisi
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
of Water Quality - Groundwater Section CERTIFICATION8.2)W
PHONE tiL1210.52-5494_
WELL CONTRACTOR COMPANY NAME f r L—rk,cO
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 17 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: 44.bh 'SDNtI / lie County //MO eri-M
lta/ley Y/iu! Pan/KS
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
Alen al eicema,.//e- Nl a8
ity or Town - Slate Zip Code
gaE)- 4792 -aW-41
Area code- Phone number
4. DATE DRILLED or n6
5. TOTAL DEPTH: vas
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO VH'
7. STATIC WATER LEVEL Below Top of Casing: /5 FT.
(Use "+" if Above Top of Casing)
FT. Above Land Surface'
*Top of casing terminated at/or below and surface requires a
variance in accordance nh ISMETHOD
NCAC 2C .0118.
9. YIELD (gpm):METHOD OF TEST
10. WATER ZONES (depth): /D/ 3 t/7
11. DISINFECTION: Type Ch!Dt ff/t-
12. CASING:
8. TOP OF CASING IS
From n
From
From
13. GROUT:
From 0
1
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 13 at
(check appropriate box)
Latitude/longitude of well location
e sS'26,p / thrs2'. 37.567
(degrees/minu s/s nds)
Latitude/longitude source: 2GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
C/a}� �NJc
DEPTH
From To
0
- 3
7 3 — 7Y
Depth Diameter
To �t Frk,AS
To Ft.
To Ft.
Depth n Material
To a (i Ft. (DIit2.E4-E
From To Fe.
14. SCREEN: Depth Diameter Slot Size
From To Fr in. in. From To Fe. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
5 /ee/
Method
ThuUrfa)
Material
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least rAt
two State Roads or County Roads. Include the road 8
numbers and common road names.
mT.
-t7
t rt
a
.14
p 1 �[ o
Qb x
U4/et LL ew Farms
f DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND T)L T A COPY OF AS BEEN PROVIDED TO THE WELL OWNER
OF PERSOI9 CO TRUCTING THE WELL ATEv
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

{I(SJ W CONTRACTOR:
W I Contractorridvd aI)IV
a
mI
L
Well ntracta Company Name
STREET ADDRESS I
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2O ? 8
n I+ A
V rj [ t
CEOrd
rr
L, fIC:es-EE2 ACC.
City a Town ) State
($:'>- a58-. 94_
am p/ LLC.
a8 AV
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable) 067 a 6 /1733 /
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED
TIME COMPLETED 2,}Q
AM ❑ PM @�
3. WELL LOCATION: /
CITY: ionq COUNTY *41QC/rtf4i
�j rfOloti DPut.-9, L.1` 7
(Street ame, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP PHIC / LAND SETTING:
lope QV -alley ❑Flat ❑Ridge DOther
(check appropriate box)
LATITUDE /(%
Zl1. 15f
LONGITUDEVQ Qa. ?.(,SO;
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 5611S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
REET ADDRESS
S
OWNER'S NAME 'r•7 Aor- -Zc/ty
D B o Sc 337
Laic �W.re nc a)87�4,
City or Town State Zip Code
(B;�f > IDa5-42isq
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH.
146
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p�
c. WATER LEVEL Below Top of Casing yo FT.
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS ' FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
714129
-
T
EST
e. YIELD (gpm): METHOD OF TES
f. DISINFECTION: Type C4 le.ai:v it Amount /QOL
g. WATER ZONES (depth):
From To WO Frnm To
From To From To
From To From To
6. CASING:
Thickness/
Depth Di�ams1€r Weight Material
Fran 0 To vA Ft.6i,25 2/L,/2 7 Pet 5-044
From To Ft.
From To Ft.
7. GROUT: Depth )) //Material
Method
From 0 To nfn Ft. r-+OICeETe
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. _, in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
To Ft.
To Ft.
Size Material
To Ft.
10. DRILLING LOG
From To Formation Description
/ 7 — 37 cQaOS-Attr
37 — YR Io r CS
W. 2VS errvu%?IC
11. REMARKS:
t17
T
a
z2
-'O
t L�
J
O
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUC11ON STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO 1HE WELL OWNER.
SIGNATURE
U / /y
F C TIFIED WFL�CONTRACTOR ATE
PRINTED NAME
F PERSON CONSTRUCTING THE WELL
4-
5
9
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
20
4 J Y j 0
1. WFLJCONTRACTOR:
ebbrV,' Wrtlr
tW II Contractor (rrdjvid��'al)rrNarn
TllsonIs ailEI odd icmp. U_C.
Well idiot/actor Company
jNa jme %�% LEI
STREET ADDRESS/1 /3/ Hai LEI CES aHay
LT1(.5- g Nc as149
City or Town / State Zip Code
(,X R » 58-,5(19&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(il applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p'
DATE DRILLED '///,?70(7
TIME COMPLETED! a 1r () AM ❑ PM
3. WELL LOCATION: f%
CITY: j/Isi o V l)/(//o COUNTYYiO/A (iiA .tl
041 ('/ear Crf ek Jif),
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC/ LAND SETTING:
rfli lope [Valley ❑Flat ❑Ridge ['Other
(check appropriate box)
LATITUDE ,(J 3S a3, /147
LONGITUDE(.J,7fjL ) 1I//5-1
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Den ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form l not using GPS)
4. WELL OWNER /- /1 _ /f I1
OWNERS NAME 7grs(1'LaS nrAfftr4 ctaJ ANC J/
ST EET ADDRESS 560 r� All Clear, ere(r/c
Idr rso,Ulrlfe_ hC p.179 a
City or Town State Zip Code
Rau (C15-995S7
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Z/y5 /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p-
c. WATER LEVEL Below Top of Casing: /Qd FT.
(Use ele if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. e. YIELD (gpm): d METHOD OF TEST/W.105Ey
6.
L DISINFECTION: Type Cti t0 /vn. ( Amount ,r/ Z �.
g. WATER ZONES (depth):
From To %J)/D From To
From To From To
From To From To
CASING: Thickness/
Depth Diameter
From Q To 5 Ft(a, ?.)
From To Ft.
From To Ft.
Weight Material
2((,/2s v/C,r.2/7s/
7. GROUT: Depth Material/ Method
From 0 To In Ft. matte
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
,•? — UO
r(O — 67J
11. REMARKS:
Size Material
Formation Description
R
r /l 0
SQ7 tie.rit
rr
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WIm
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT QDPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATULE OF RTIFIED CONTRACTOR / ATE
-2ft)btir & Lh+ls
PRINTED NAME'DF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. W CONTRACTOR:
abh fV', w as
1,11 Contractor (h-�-�
djvid al) Nam
Well Vintractor CompanyyName /
STREET ADDRESS / t („
l i(tes-Ft2 V C. a8748
City or Town / State
Area code- Phone number
Zip Code
7. WELL INFORMATION: SITE WELL ID #(if applicable) 06/00 /oc 41/25
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED /3/Q6 /
TIME COMPLETED ^rj Q7f AM ID PM p
3. WELL LOCATION:
CITY: ,i_ //jre// I,. /7C COUNTY J tt:t // eTSD�
Y &O<o14 1( • i tW LS%�{. SC5 U% /5
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TO RAPHIC / LAND SETTING:
Slope [Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE/U 3S
LONGITUDE/DOfl /7, 'Pr
May be in degrees,
minutes, seconds or
in a decimal fomai
Latitude/longitude source: 136IS-- oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS)
4. WELL OWNER
OWNER'S NAME• v T �/ /q/ (To y
STREET ADDRESS � 4, 3 CO,yn /' TN /
yid >ess oln.0 . I Uc_ n e- a ?et a
City or Town State Zip Code
Li)- kR3- �a73
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
7ys(
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 7_0 FT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface•
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. `�
e. YIELD (gpm): 30 METHOD OF TESTl /ii pla-/)iry
2019
4' 'il
09 T. ,: L 6 5
I. DISINFECTION: Type CAlQ /'/CA) C Amount / nz
g. WATER ZONES (depth):
From To 70 From To
From To From To
Fran To From To
6. CASING:
Depth From (7 To C/c
Ft
From To Ft
From To Ft
Diameter
625
Thickness/
Weight !naterial
716, /Z5 t✓C' 2
7. GROUT: Depth ��11 �,M.avt�enriallI �1 Method
From D To a FL Lam" tette l/ei QIr_
From To FL 7�'�
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
Material
10. DRILLING LOG
From To Formation Description
0 —13 C/Lr�l�,
73 -V3 So!(1'i/Bv-c
Y3 - tit 417' Acre
y9 - 5915 6„kou) 1 / r
11. REMARKS:
Cr:
--O
r T
& 1006
on
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
T5A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND TNATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG ''�R �- CERT ECONTRACTOR? DATE
(11, o+/s '
PRINTED NAME aF PERSON CONSTRUCTING THE WELL
C)
2
rr
titt
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 # 001
s` n 6O' ti i $
1. W CONTRACTOR:
6 /L) id
ACTOR:, S
/W 1 a tractor vidyal)Nam(
R 1(SD .5 WEII t d Writ), P. uC•
Well Qtntractor Company Name
STREET ADDRESS77 1 NCAJ C ,
L,Fielests 1V. C as lw
City or Town / State Zip Code
(gag » 258-&f9&-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply LT
DATE DRILLED /�j,/6j —/
TIME COMPLETED a, Oo AM ❑ PM L�
3. WELL LOCATION://
CITY: NLL>C/504/C(
COUNTY fircni ,294.l
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTIN :
❑Slope ['Valley 0 Flat fp-Ridge 0 Other
(check,,cfappropriate box)
LATITUDE N 3 5 eS'SOPS
LONGITUDEWO YiZ l'Fj gvr
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 2.61:rc ['Topographic map
(location of well must be shown on a USGS topo map and
attached to This form d not using GPS)
4. WELL OWNER //•�
OWNER'S NAME (alu/(}}�•� Lz/�
it a4--r1r1 qp i-R7
(J
STREET ADDRESS II a be-N NQ lrq 2cL
`'� qtr.h e a ccl 01
City or Town State Zip Code
gaX )_ (p7'f-638
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: r!O_S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p�
c. WATER LEVEL Below Top of Casing: f�,/� FT.
(Use `+` if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
/
e. YIELD (gpm): r METHOD OF TESTTBb/Jjpl5--Ei
f. DISINFECTION: Type r'/.40,K€ Amount h.0z
g. WATER ZONES (depth):
To /YO From To
To From To
To From To
From
From
From
6. CASING:
Depth
From 0 To t«5
From
From
Thickness/
Diameter Weight paterial
Ft..2/6,/25 ✓VICSJkAI
To Ft.
To Ft.
7. GROUT: Depth Material Method
From 0 To �fl Ft.CPICCt{e
From To Ft.
From To Ft.
B. SCREEN:
From
From
From
Depth
To
To
To
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To
25 - Yj1
tip —Y5
11. REMARKS:
Formation Description
rya se
SPX/ 2, C
1 '
SEP J. 9 21106
O
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD I4AS BEEN PROVIDED TO THE WELL OWNE
SIGNA
PRINTED NAME
CONTRACTOR DATE
(a it doffs
PERSON CONSTRUCTING THE WELL
g
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-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR: n
III Co U h �cyvid Nam
/y.ERqul ok E it Odd Pcun pi U_C.
Well cfintractor Company Name
STREET ADDRESS 771 Nt- L
lti(:esfe2 ACC aril/9
Zip Code
City or Town State
( 8)- 58-2(19&
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 Supplyg
DATE DRILLED
TIME COMPLETED 2 . j0 AM ❑ PM 00".
3. WELL LOCATION:
CITY: S4 tweet COUNTY Nuittgola 41
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOiat RAPHIC / LAND SETTING:
lope °Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE AV alp I S /
LONGITUDEtS 2Q.I.S1
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ,PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form Anot using GPS)
4. WELL OWNER M^
OWNER'S NAME (_/� af./ 1-1 tvtw `w
STREET ADDRESS
nal% ct NC
City or Town State Zip Code
SaW F1n93
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
S
Yin /
b. DOES WELL REPLACE EXISTING WELL? YES ° NO p�
c. WATER LEVEL Below Top of Casing: 40 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated alor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /0 METHOD OF TEST�� r
5
2D6,1
ei+Ll r . Ci R1
f. DISINFECTION: Type ih 4 pit(
g. WATER ZONES (depth):
Amount a
From To 3qO From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From_p_ To3_ FL`,A5 Sint pecaDAA'
From To Ft.
From To Ft.
7. GROUT: Depth Material �, Method
From 0 To 21Q Ft. (cfa /e 1/1t)(/'P_, _
From To Ft. "J�'�J
From To Ft.
8. SCREEN: Depth Diameter Sbt Size Material
From To Ft. in. in.
9.
From To Ft. in. in.
From To Ft. in. in.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
11. REMARKS:
Formation Description
chsy
Sanhpplrr c
gete1
vs
rn
-'D
SEP 2LOC
O '
CT,
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WrTH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
U RWOF CERTIF
It I,
CONTRACTOR ATE
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05 : ,

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
abck
1. W CONTRACTOR:
(,cI o s
(W 1 Conlraclor lndjvicirtNami
E (ZSo4s I.UEII Ct�'� Qmp, U__C.
Well (J'ntractor Company Name
STREET ADDRESS7 / Nt C
Lf1 es-FEg NC- as7
City or Town p/ �yS�tate
( FAR)- ia5 '4 /at&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#(ilapplicable) 0leico > 6/7w
STATE WELL PERMIT#(il applicable)
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED TIME COMPLETED' �'Z.DO AM 0 PM}7 J
3. WELL LOCATION:�
CITY: ► /C G.,. COUNTY /tr/a/Y••j/N
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, Zip Code)
TOI2GRAPHIC / LAND SETTING:
lope ❑Valley DFlat ❑Ridge ❑Other
(check appropriate box)
LATITUDE //3,5 A4, y7
LONGITUDE/a' !,t, /Si /r
Latitude/longitude source: 3GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this !am if not useg GPS)
4. WELL OWNER
OWNERS NAME ThIMt"���L,/ ifa y/
STREET ADDRESS //S O(t(Nes Alin Ed
Nc ' t373
City or Town Stale Zip Code
2.2 (05/-bly--
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH:
5.5r /
3D
b. DOES WELL REPLACE EXISTING WELL?. YES ❑ NO p"
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): b METHOD OF TEST )jp7p��lrp
f. DISINFECTION: Type Vl/04UC Amount IVOL
g. WATER ZONES (depth):
From To do
From
From
6. CASING:
To
To
From
From
From
To
To
To
Thickness/
Depth Diameter Weight pMaterial
From 0 To), Ft.4,ar7/t/.Z�fVtfMA/
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material /
From To ao Ft. i�'IL.CETe
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 —/i
/4 z
33 0,2,5
11. REMARKS:
Formatiign Description
c /o
Sesryail
Rey k
Gnq wiYc m
O •
' J 'phi n T
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTPN STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNAT RE OF • RTIFIED ' CONTRACTOR ATE
PRINTED NAME F PERSON 1ctohs
OCONSTRUCTING 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 #
L CONTRACTOR:
%� WIPOS W Cotrf?r I)m
'gizSoill.s IENaIl end
Well Contractor Company Name
STREET ADDRESS7 1 Neii C
L,F!(r�SfR /IBC 2874/Q
`''City or Town • State
( 8.Nf )- 5? 4f9&
Zip Code
Area code- Phone number
2. WELL INFORMATION: ^/1
SITE WELL ID #(i1 applicable) 04J /00 / 01
/ 3
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED /714
TIME COMPLETED if /D AM PM ❑
3. WELL LOCATION: //
CITY: bowie COUNTY/7y/I arktitom/
trid/«I A.�t..rs C./
(Stree Name. Numbers, Community. Subdivision, Lot No.. Parcel. Zip Code)
TOP PHIC / LAND SETTING:
lope °Valley ❑Flat ['Ridge °Other
(check appropriate box)
LATITUDEN 3 b.- •
LONGITUDE O u• (47
Latitude/longitude source: BGVs °Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form r not using GPS)
d. WELL OWNER
OWNER'S NAME 4 ZL I-2ei�S
S REET ADD ESS f] o )c. 3 3 7
>rc a 87y6
City or Town State Zip Code
(Ra$ )- rDa5- U8(!y
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
. WELL DETAILS:
a. TOTAL DEPTH:
I 45
b. DOES WELL REPLACE WELL? YES ❑ NO (aJ /
c. WATER LEVEL Belau Top of Casing /00 FT,
(Use -+' if Above Top of Casing)
(
d. TOP OF CASING IS 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): METHOD OF TESTl ry
f. DISINFECTION: TypeCht M•rAie Amount
g. WATER ZONES (depth):
From ToLY'J From
From
From
6. CASING:
To
To
5
From
From
20o.
om To
To
To
Thickness/
Depth Diameter Weight Material
From_p__To) ALLyt.�i2,T _[[___
From To Ft.
From To Ft.
7. GROUT: ,,nc� Depth Material l
From D To �Q Ft.GC'at/E
From To Ft.
From To Ft.
Method
B. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0^/0
!O —if
xY-3S
11. REMARKS:
Formation Description
cry y
s, fsiism
Roc
6aM Ye
I
J
20476
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WALL OWNER
•j40
SIGN
TURE
CERTIFIED W bLCONTRACTOR
r)J
lO 1, 0-Hs
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- DivisiaiLaf Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:di
r O
gbh �,cf
W I Contractornvidyal)rNam
tE k( o4U 115 WE J I Oki cunt), LLC.
Well nlractor Company Name
yJt�r f
STREET ADDRESS q !�
a.cc
Li/Les-kg /Il C
a87s/
City or Town J �}/Sttate Zip Code
p
(.4V } 50p-?i9lz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID OW applicable)
s
STATE WELL PERMIT/4a applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply I�
DATE DRILLED /o/AJ/OG
TIME COMPLETED 3 ,QQ
3. WELL LOCATION:
CITY: H-t'tJte;»wit1
AM ❑ PML7
COUNTY IHYAir itti
6-tired%ti Lwp 47--Ij
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TO .GGRAPHIC / LAND SETTING:
lope 0 Valley ❑ Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE /✓ 3 S 2 I (7/y
LONGITUDFj0'Js'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: C?i�iPS ❑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 (^ 014-1,gan r/��,� gu_z ,j e_
34STREET ADDRESS 5413 f'iStc s i'e
"42,des) 6na:11e rrc_ agi9 1'
City or Town State Zip Code
82-Clg )- (43 7 22t3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Yo-s-
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO r
c. WATER LEVEL Below Top of Casing: 490 FT
(Use "+- if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface"
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): METHOD OF TESTlkj)j8j- j
33'G84
L DISINFECTION: Type Oh !Q/t//{-e Amount ,1 O2
g. WATER ZONES (depth):
Fran To 2 [40 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From /'f To 4/7 Ft. 6,25 zJ6i25 fill 57)el )
From To Ft.
From To Ft.
7. GROUT: Depth Materialp
From 0 To an Ft. G'DtICeti
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot 5
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From.
From
From
Size
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
Method
" J
e Material
in.
in.
in.
Material
Formation Description
o -AA eta
yR-97 fork
97 — crs `male tfC
11. REMARKS:
FF1
-u
v
3, 2203
I DO HEREBY CERTIFY THAT TMS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND 1HATA COPY OF THLS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
al SIGNATURF�bF CERTII/FIEDNTRACTOR
PR�EEDDhNAME,DF PERSONLL 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.
Fain GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
pJ
WELL CONTRACTOR CERTIFICATION # O 2
L CONTRACTOR:
WM1 Contra fndjvidu�al)r,Nam
R uSolnis WE/I aw'iRu)npy LLC•
Well Clintractor Company Name
STREET ADDRESS 7 ie C
E1 E.E.YER A!c'. asi
City or Town / State Zip Code
( 3R )- 58-24-9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Er( if applicable)
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED V;'J/Q6
TIME COMPLETED 3, 3/7 AM ❑ PM L�
3. WELL LOCATION: J
CITY: f-(tgp�f rriq; IIC COUNTY tifit/.l Y/C'61t/
6i/te#/ /—avj 4fra�v
(Street Name, Numbers, Community, subdivision, Lot No., Parcel, Zip Code)
TOP RAPHIC / LAND SETTING:
lope oValley ❑Flat ID Ridge ❑Other
(check appropriate box)
LATITUDE/'/ 3S ?%t
LONGITUDELtk3.Z I a $1raL /
Latitude/longitude source: pliPS ❑Topographic map
(location of wet/ must be shown on a USGS lopo map and
attached to this form A not using GPS)
4. WELL OWNER `
OWNER'S NAME VlA4i'(( it NIG(,(/(,
TREET ADDRESS 541 3 +Mt sail A ItAlimi
.etsbraqt \v c 28711
City or Town —State Zip Cale
4a,_ Lt77- a??3
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ycs
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: ac 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): /0 METHOD OF TEST
f. DISINFECTION: Type4 iitom'G(/e Amount /%f(/`
g. WATER ZONES (depth):
From To 47) From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 1 To 99 Ft. bf.7‘S 7/6.12S fiC.5IWA)1
From To Ft.
From To Ft.
7. GROUT: ,c� Depth Material �1�` Method
From Fh To 10 Ft. i �i�Q�}e dA(___
From To Ft. T'�-J�
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/9 —59
39 —Y31
vv — YOS
11. REMARKS:
Formation Description
C(0t/
a— wove
&rani/ 'Yt
V7 w
m
—O
0
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
f S
SIGNAT F •ERTIIFIIED W CONTRACTOR
a it
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
TE
Form GW-la
Rev, 7/05
a
a

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # �.*+� Q
r` n n J eCI i ~! 4 El i
1. W
L CONTRACTOR: %�
&ooh Lr o
(W 1 Contractor ( cad al)rNam
E o On/ kTE I a'd - n pi ux.
Well C)ntractor Company Name
STREET ADDRESS Q 77 I N5C
LF, es-tER 14C as7w
City or Town �7' State
(.9p Ai�} 2. 5S'4J9Ze
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
S
Zip Code
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply
7/$7o6
TIME COMPLETED /Q. 3b AM 1.7 PM O
3. WELL LOCATION:�
CITY: i t vWtT Ci COUNTY 1—feet leyed
DATE DRILLED
(Street Name, Numbers, Community, Subdivision, Lot No„ Parcel, Zip Code)
TOPOGRAPHIC/LAN ING:
❑Slope ❑Valley lat ❑Ridge ❑Other
(check appropriate box)
LATITUDE�� e Cliff
304 r
LONGITUDE ` 2 ..!
Latitude/longitude source: t3�it'S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this loon 'not using GPS)
4. WELL OWNER
OWNERS NAME ��/""`e'(/�
E ADDRESS
ry
T
May be in degrees,
minutes, seconds or
in a decimal format
w,a
STR
f-" -41 7 r C-
#
City or own State
a-K)- 159I-7310
Area code - Phone number
//er
ae
87a9
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: Sys /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (�
c. WATER LEVEL Below Top of Casing: //Q v FT,
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): /j METHOD OF TEST Dpkipilµ jrp
f. DISINFECTION: Type c 4 ffPj4't Amount
g. WATER ZONES (depth):
From To.4, From To
From To From To
From To From To
6. CASING:
Depth
From r) To i7
//Diameter
Ft.j ./-
From To Ft.
From To Ft.
Thickness/
Weight Material
7/4ells ps'c54/72
7. GROUT: Depth Material Method
From 0 To no Ft. &/C2Ejff
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in, in.
9. SAND/GRAVEL PACK:
Depth Size Material
From - To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From To
—�/�
Yi7 -sz
Sx -57
57 - /V5
11. REMARKS:
Formation Description
a2At651dg/c
or /S
A
n
m
I ,3
i
i-
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
ONTRACTOR ' 'DATE
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Farm GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 420, 9
1. WF(J. CONTRACTOR:
a b Li
W I Contra (lldjvid�al)Nam
E USo4s Ell Ltd
Well (pntractor Company Name
Po
STREET ADDRESS I3/ /►e
S
tLmp/ LLC.
C
if/testa /IBC a874Q
City or Town / State
( R3,R - a 5F-i9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(itapplicable)
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applica�,le�BBox): Residential Water Supply Q�
DATE DRILLED 7/ L(/�OgI
TIME COMPLETED 2. vO AM ❑ PM
3. WELL LOCATION:
CITY: gig tyt//(,'/( COUNTY N Cr5ebe
/ /Mu)/S CArC,
(St�Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANDSETTING:
Slope [Walley at ❑Ridge DOther
(check�appropriate box)
LATITUDE 1j! L9/7,20/ / n
LONGITUDE((/ 1 f CiO.O_/!r
Latitude/longitude source: p45PS 0Topographic map
(location of we0 must be shown on a USGS topo map and
attached to this Mon (not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME 197,2 h a.ddr Rope /'ies
STfn��ET ADDRESS/S/h aICIt rJi/OJ .Whrl
Ncrriey-sari v, /(e /✓e a8 79/
City or Town State Zip Code
(icaR >• 5S/— 3.Z6 '1
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: /D FT_
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): f/U METHOD OF TESTl)Y/)jp)f(—.eq
3,3 i700
f.
9.
From To / CPO From
From To From
From To From
DISINFECTION: Type_ehijzz/ Amount
WATER ZONES (depth):
r
6. CASING:
To
To
To
Thickness/
Depth ammeter Weight Material
From /9 To///% Ft. 9�%s /(rr/u' /
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material �^ Method
From To an Ft. &Irft <e
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Material
Formation Description
//h �70, a/`PR//7(A
11. REMARKS:
LO
C.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THER.
SIGNATUI E Og CERTIFIED CONTRACTOR ATE
_�PERSONSTRUC
PR ED NAME F 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 Natyral Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
W CONTRACTOR:
v o4
abh/ �cI
fW II Contractor t#rdjvitl ap Nam
ER it. On( %E it �Id
Well r)ntractor Company Name
STREET ADDRESS71 ,Ytj
Lfi/'zsiEg JIW C a87
City or Town f Stale Zip Cale
)- 5JC'-4`�yI &
Area code- Phone number
7. WELL INFORMATION:
SITE WELL ID #(if applicable)
s
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT //Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED 7(w/j6
TIME COMPLETED ,/"O0 AM 0 PM Z
3. WELL LOCATION:
CITY: £d t jc LOC COUNTY NL//�/�U
/ Fe ! * It-5
(Street Name. Numbers. Community. Subdivision, Lot No., Parcel. Tp Code)
TOPOGRAPHIC / IAND 3E7
"Wre
❑Slope °Valley ❑Flat idge ❑Other
(check appropriate box)
LATITUDE iy 3 S r !' "! b r
LONGITUDE
r
May be in degrees, i
minutes, seconds or
in a decimal format
Latitude/longitude source: BCiPS ❑Topographic map
(bcaton of we® must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME
T EET ADDRESS of / �Q .'teen - ed
. end ei
City or Town
(Sdx )_ 977-6 7sy
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? YES El NO pV
c. WATER LEVEL Belau Top of Casing: 24) FT.
(Use-+- if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. �
e. YIELD(gpm): ( METHOD OF TESTTBJ�6)Ij�%�'rp
�D kt#,+e
State - Zip Code
70 sf
n
v v
0 3
t. DISINFECTION: Type ('Atd/ ue.
Amount 2_(I PJ2.
g. WATER ZONES (depth):
From To LW From To
From To From To
From To From To
6. CASING:
Depth 4
From p) To SO
From To
From To
Thickness!
Diameter Weight Material
Ft. f„J.g 24./.15 "'coal
Ft.
Ft.
7. GROUT: Depth Material
From 0 To an Ft. &tacl
From To Ft.
From To Ft.
Method
—6. 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
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To Formation Description
0 _ 9S C/A",
sanalr AteeT
VS r53
D
Cr-r,
11. REMARKS:
Art*
%l/iw rfL
CFI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WDH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE ELL OWNER
SIGN O ER I IEa ^� CONTRACTOR r
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
SATE
Fam GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
o2Oa Q
' 0 04
1. W CONTRACTOR:
W
F�,I
1 Contra '„yrrdjvid al) Nam
2pl(S D!d S WE I1 cold
Well ntractor Company Name
STREET ADDRESS31 Nt
rriesEeQ ACC a814g
Zip Code
City or Town / State
( S51? )- 5S'—W9&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
p,1.-LC.
STATE WELL PERMIT#(il applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 7I�- 0,
TIME COMPLETED /`,f ;Oa AM ❑ PM ❑
3. WELL LOCATION: j
/
CITY: Fie Idler COUNTY kill na,t/
s g 101blftQf Dr
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT
❑Slope ❑Valley ❑Flat idge °Other
(check appropriate box)
LATITUDEN 35 17, 0.3/'
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this tom) if not using GPS)
4. WELL OWNER ��%f-�� �{�/;
OWNER'S NAME pdry/:}es 4mn tr,/ re-kher
TREET ADDRESS 80/0 /Shcvrile- �44G � rcor,ll: Ile Tf r aV/ y
79
City or Town State Zip Code
Aral )- loa7-tfy'rY
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Belay Top of Casing: 10 FT.
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type(/ file./.le. Amount
g. WATER ZONES (depth): r
From To 050 From To
From To From To
From To From To
?vz
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 50 Ft. b JS 2/4,22.$ /VC (4.4 /
From To Ft.
From To Ft.
7. GROUT: 0 Depth �7 Materialat/ ,'� ` Method
From To AjD Ft. (!"Yr.CG&ff .!/Y/(/IZIr_1Q
From To Ft. �'"'�JI
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From To
From To
To Ft.
Ft.
Ft.
Size
Material
10. DRILLING LOG
From To Formation Description
D^3b
PO — YS
LIS — to
so —2'a
11. REMARKS:
C/ay
saAels*ve
Ax%s
6,044
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
PRINTED NAME
CONTRACTOR 1 (GATE
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05
A

RESIDENTIAL WELL CONSTRUCTION RECORD "
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
20,.
7' 2
F.LL CONTRACTOR:j�
GOh �, o s
1' Wf. DISINFECTION: Type C/ AD A./WC Amount
rI Contractor ` ncli vt id I) N
a amg
.ER t(Scnls E �l Oki
Well �ntrada Company Name
STREET ADDRESS ri7 I
py LLC.
�i(esfE7 /V,C LSI44
pp City or Town �71 State
( f1-R)- :2151(}/194_
Area code- Phone number
2, N/ELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(il applicable)
Zip Cale
DWQ or OTHER PERMIT #(ff applicable)
WELL USE (Check Applicable Box): Residential Water Supply
• DATE DRILLED i(9
TIME COMPLETED_ ' AM D PM p�
3. WELL LOCATION:JAgiber-COUNTY ' / //
CIITnTY: Z,vi ( M, YIS kt./1ex'Cr5FJQ
PeltA/S /i✓aMi4,tMNZe tr3
(Street Name, Nybers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ['Ridge ❑Other
(check appropriate box)
LATITUDE Alt.' 2q, lvfD r
LONGITUDE i
❑
Latitude/longitude source: PS
May be in degrees,
minutes, seconds or
in a decimal format
Topographic map
(bcation of well must be shown on a USGS topo map and
attached to this form 1 not using GPS)
d. WELL OWNER
OWNER'S NAME
STREET ADDRESS
:/Hs r, Let' /ifC 2 875
h or Town State Zip Code
(8as()_ 69(' (ndr6
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
S
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing. L%Q FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 / . FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST13)1)je7 (1/Ifry
/7
g. WATER ZONES (depth):
From To 3/20 Fran To
Fran To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight Material
From y7 To tin Ft. 6,AS Z/6i/,25 _____A
Fran To Ft.
From To Ft.
7. GROUT: Depth Ma�tearial
From 0 To an Ft i✓Oia`Ltle
From To Ft.
From To Ft.
8.
Method
SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From
From
Size
To Ft.
To Ft.
10. DRILLING LOG
From To
glf - (LC
!OS — //.0
//8 �50c
11. REMARKS:
Material
Formation Description
C/a v
SO�i�S)10rtir
r4
`}roiv •i-T
Tie
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WM1
15A NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL NNER.
///•� <y/�� Off/; 0
SIGNATURE OF4ERTIFIED CONTRACTOR % DATE
10,
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit be 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

d. WELL OWNER
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2oA 9
6J. i 3_
1. WELL CONTRACTOR:
(✓'' r
WI Contractor.1( c id Nam
f r i(SCJJJJIl77al)s 5 /! Qa'd
Well Cpntractor Company
/Name �% /
STREET ADDRESSI �! /►t- 1
irmsi-EQ lV �.
City or Town State
(Y'.1R
as74Q
Zip Cade
Area code- Phone number
. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 00".
DATE DRILLED fill
TIME COMPLETED • /CVO AM D PM [T
3. WELL LOCATION:�
CITY: l /q 'car k COUNTYjr�.flar
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SET15Ge-
OSIope ❑Valley ❑Flat oRidge ❑Other
(check appropriate box)
LATITUDE 446 ' 3r 0617 /
LONGITUDE tt) 011Ar
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GAS)
OWNER'S NAME CA�[na /��! (T. s7l, 6 65
ST BEET ADDRESS 373/ Jreent6We.. b'fuy
74 fir S27a/ /
City or Town State Zip Code
(saB )_ l0g4r325/
Area code - Phone number
May he in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
a. TOTAL DEPTH: Ye 5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L3'
c, WATER LEVEL Below Top of Casing: Av. FT.
(Use-+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Z
METHOD OF TEST kibv 5-k
f. DISINFECTION: Type Ch Intl a s Amount 12 a 7
g. WATER ZONES (depth):
From To 7-iSe From To
From To From To
Fran To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From /) To2 00 FtfprfS 2/6 /fl f6C cam+,
From To Ft.
From To Ft.
7. GROUT: Depth /l Materialr�ri
From 0 To 410 Ft. U..OIt.c,th
From To Ft.
From To Ft.
'j), ��MMethod
J
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. _. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
San/ s'Xi*/e
p — 1s
— 2/
V — A.b
Al rQc
11. REMARKS:
- /s-/mgi, `let.
fn
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
OP"CERTIFIED WLLLCONTRACTOR / ,DATE
.hbr 1 J, .i'o fs
PRINTED NAMEDF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

e. YIELD (gpm): 7
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 424005'1 Q
CONTRACTOR:
W II Contractor ilividyal)fNarn(ER u.So/r's WEII Odd damp Li-C.Well ntractor Company^yName ,r r
STREET ADDRESS 1 A,
fi esiER //C a8V
pA✓1 ' JCity or Town C/ State
(.'1} 2)53'W!-at&
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
Zip Code
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable�'plBox): Residential Water Supply
DATE DRILLED yi�/p (, /
TIME COMPLETED
ii Sea AM O PM p"
3. WELL LOCATION::[[
CITY: P. /r /%I r,— COUNTY Hr/10 Y/`SDw
Chtraty £s4cic3 Lr#7
(SUeet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LANU.&ETrING:
❑Slope ❑Valley rrflat ORidge ❑Other
(check appropriate box)
LATITUDE Al3 S r 1q y fa s
LONGITUDEu) Off 2%1 D, ,3r 33S
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: BLYS ID Topographic map
(location of well must be shown on a USGS topo map and
attached to this form A not using GPS) / /'
4. WELL OWNER w Tg4,,5�') rr2cr_a e_Afr.cl-w'V
OWNER'S NAME TAw1t5 Vta'/Da)
STREET ADDRESS 6.54/
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ClQS /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (]'
c. WATER LEVEL Below Top of Casing: #/ FT
(Use -+• if Above Top of Casing)
r
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.
METHOD OF TEST��(j
31
f. DISINFECTION: Type CGI /0r 1AJC Amount 40 Z
g. WATER ZONES (depth):
From To ,2 ,C From To
From To ;,e)0 From To
From To From To
6. CASING:
Depth
From 0 To /%.n
From To
From To
Thickness/
Diameter Weight Material
Ft.4,.2‘S /as fc- 2 qA)
Ft.
Ft.
7. GROUT: ,,nT� Depth �] Material
From v To le Ft. dieir_eti f
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size
To Ft.
To Ft.
To Ft.
Material
10. DRILLING LOG
From To Formation Description
0 °"9D C/a%
ID ^in SearlioAvc
f9J - Vet 5 Cwait/Lc
11. REMARKS:
CnrPc
T
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATU OF CERTI IF ED CONTRACTOR 5 DATE
PRINTED NAME
((if erHS"
F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt_
1617 Mali Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fotm GW-la
Rev. 7/05
3

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 20003
el- '23
1. WEL[7/L CONTTR`ACCTOR:I✓,�''J(�
AContractor (�Itllvidyal)�Nam a� S
K 4Sos#s %Eli otici turn LLC.
Well C)ntractor Company Name P/
STREET ADDRESS73) /Yt1U C
L.Fiesf a N, C a8-frig
City or Town 1 State
( 8. R)- 2.1 53 —WO 4-
Area code- Phone number
?. WELL INFORMATION:
SITE WELL ID 4/(if applicable)
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED
TIME COMPLETED ' ,'O/% AM TI
3. WELL LOCATION:
CITY: f lD &a / COUNTY frAft/R1/ e/P..7/
/iulter Aloe A. "'it (Street Name, Numbers, Community, Subdivision, Lot o., Parcel, Zip Code)
TOPOGRAPHIC / LAND,SETTING:
❑Slope ❑Valley anal ['Ridge ❑Other
(check appropriate box) /
LATITUDE `(// 3giut/
S
LONGITUDE.
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ Topographic map
(location of we9 must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER / --f
OWNERS NAME ctr j,�, —4/yGe',
ST
s7ir
Stale Zip Code
($2R ��;rr;//,,tt�� sq9�
Area code - PhMe u ber
T ADDRESS
41Yeile r
City or Town
5. WELL DETAILS:
a. TOTAL DEPTH:
;2 QS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: /0 FT
(Use'+' if Above 1 Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. ffr�
e. YIELD (gpm): Y O METHOD OF TEST r
f. DISINFECTION: Type UI %/Q/ye(ti Amount 'n
g. WATER ZONES (depth):
From To_2 9 From To
From To A 9s From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 47/) Ft. b,%l5 1&./1,S At Sae?
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To An Rep/cede
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From , To
From To
Size
Ft.
Ft.
From To Ft.
10. DRILLING LOG
From To
Q
�S— 3S
SS—y0
yo
11. REMARKS:
J
in.
in.
in.
Material
Material
Formation Description
Clay
Sar-bir )(acdC
2or 4
nrv' 7T
114
v
CI, to
m
ey
-v
0-
•
•
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wmt
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OSIER.
SIGNATUR
OF C
�[J
TIFIE CONTRACTOR
l� �/ Coifs'
F PERSON CONSTRUCTING THE WELL
A E
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 20 aa1 •�
O .Z f 2
rJ .3ti
1. W CONTRACTOR:
II Contractor al) Nam
Mk' /:(Sons �tf(EIl f(''d j�JUm P � _C•
Well C)ntractor Company Name
a
y
STREET ADDRESS, /�(
LIE i SfGR /Il C ag
Zip Code
City or Town / State
(A' ')- a58—WO
4.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 8�
DATE DRILLED
TIME COMPLETED rU AM PM❑
3. WELL LOCATION: /J^
CITY: ,CJrM ,'i//(( Zit,- C/' COUNTY/-0V (/'SJ t,'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
TOP RAPHIC / LAND SETTING:
Slope :Valley ❑Flat ❑Ridge DOther
(check appropriate box)
IATITUDE(13 5 I )C/, 4 /
LONGITUDEO,.� t r
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER OWNERS NAME Oh1'1'/S, ,gQ.-/eA "A„
STREET ADDRESS fee /S.✓e/Loa
�
%%/3 , i'e / NC o1775
City or Town State Zip Code
May be in degrees,
minutes, seconds or
in a decimal format
c 2)- 69/- ko2o
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
ZyS
b. DOES WELL REPLACE EXISTING WELL? YES: NO
c. WATER LEVEL Below Top of Casing: 2„O rr.
(Use -1-* if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated aior below land surface may require
a variance in cc/accordance wdh 15A NCAC 2C .0118. �
e. YIELD (gam): METHOD OF TESTljY/J� 4 j?5
f. DISINFECTION: Type (rfl I0^/41 C Amount 5? y
g. WATER ZONES (depth):
From To &V From To
From To From To
From To From To
6. CASING:
Thickness/
Depth jI ter Weight
From 0 To6.2 Ft. OI T Z/0,/a5
From To Ft.
From To Ft.
7. GROUT: f-� Depth Material
From L� To () Ft. &IcQEjff
From To Ft.
From To Ft.
Material
S/Je.(
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
—/D
�(U -
SQ 6
62 — 2Y1e
11. REMARKS:
Formation Description
Gr
San/f)4iur
Pr/S
G-n:ac' 7 c
m
-o
0 •
tT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
tar
SIGNATURE OryL`ERTIFIED/W U,.0 TOR 1/ :ATE
ILL aHs-
PRINTED NAME PERSON CONSTRUCTING THE WELL
rt
t
Submit the original to the Division of Water Quality within 30 days. Attn: Information MgL,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

-
RESIDENTIAL WELL CONSTRUCTION RECORD.
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:
L-{ 1(11
WW�II Coontract (ilcpvid al) Nam
iSoJfd,s JEJl l"ER d
Well Untraclor Company
S l Na jme J1! /
STREET ADDRESy� / A t-,
4Fi�-esf g 11(C a8liN
City or Town ( State
(�a5S'—W9&
Area code- Phone number
2. WELL INFORMATION;
SITE WELL ID #(it applicable)
p/ LLC.
Zip Code
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply E
DATE DRILLED
TIME COMPLETED 3 , 00
3. WELL LOCATION:
CITY: Owe? A
AM❑'/ PM
COUNTY �7T/((/er94/
(Street Name, Numbers, Community, Subdiision, Lot No., Parcel, Zip Code)
TOPOGRAP / LAND SETTING:
❑Slope Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE/f/ 5 e 1 q, 9(5'
LONGITUDE/d r 56 f qy7'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: Et(5T ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form 4not using GPS)
4. WELL OWNER L / 11
OWNER'S NAME ALAUP/jG / /a
STRET ADDRESS 4;32
itAsol va /iC ar R 79 /
City or Town State Zip Code
f1g }fo0/,-1763
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 0 5 /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO'[]
c. WATER LEVEL Belau Top of Casing: L/© FT.
(Use-+• if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): I 5 METHOD OF TESTlJJ)JNq-.r4,
9.
u
f. DISINFECTION: Type 0l1/0Z'hA/C Amount S-OL
g. WATER ZONES (depth):
From To Lpv From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To Q// Ft. , e1 S 2/6,/as PYc' 09 A'
From To Ft.
From To Ft.
7. GROUT: Depth ;7,Material
From 0 To p�0 Ft. eo f(Ceejff
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Fran To Ft.
10. DRILLING LOG
From To
7-7a
70-?/
-4G
YF -305
11. REMARKS:
Formation Description
C/a r
ca.-m/sYr94f
a0,/S
actr,c', lc-
O
tT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. ANDTIAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATI' E OF ERT' D CONTRACTOR ATE
Olt
PRINTED NAME PERSON CONSTRUCTING THE WELL
4
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
20-;?
8 3 Y a 2 8
1. W CONTRACTOR:
L� ILL a-1
W I Con ({Tchvidual)Nam
I q <on' S kfs lI O'd
Well Qpntractor Company Name
STREET ADDRESS
/ / A/!
/(teeF /. 1
City or Town / State
(i ')- :)52 -Sti94_
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable)
STATE WELL PERMIT#(i1 applicable)
S
amp, . LLC.
as7
Zip Code
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED
TIME COMPLETED 5 AM�M p
3. WELL LOCATION:
CITY: L£Q, /t e l/V, (//L
COUNTY -eKP C/YO(!%
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND,SETTING:
❑Slope DValley pf at ❑Ridge DOther
(check appropriate box)
LATITUDE $3 5 a Lift"
LONGITUDE/1205)_e r r
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS fopo map and
attached to this form d not using GPS)
d. WELL OWNER p
OWNER'S NAME �?Lo11 t,/i�r.C:.�r�,
Y £z , i.,bac
STR ET ADDRESS S7QS 0 / mere /�
Pft tly he n�
City or Town State Zip Code
( q.QA)- S'9)- y105
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: y(%S/
b. DOES WELL REPLACE EXISTING WELL? YES D NO EKZ
c. WATER LEVEL Below Top of Casing: CO FT.
(Use-+• if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3/7... METHOD OF TEST1)/YatlN—ir4
i. DISINFECTION: Type.(h/pehttt Amount $Q -
g. WATER ZONES (depth):
From To 220 From To
From To 3OS From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To z//J Ft. (p, 223 ?jL/.Ts ftrc1Dea/
From To Ft.
From To Ft.
7. GROUT: Depth /1 ,,Material Method
From 0 To Alo Ft. Ca e
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. • in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 V-
A 5 'IS
35 - YD
— `7l/S
11. REMARKS:
Formation Description
C4Y
S6hdS74DA✓t
tor
�}/bn/! tit.
QS
—o
I •
J
0'
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wfn/
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY Or THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE
RACTOR DATE
olafs '
PRINTED NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division.Of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. W CONTRACTOR:
obi) W/ r
MWall o tracts flntid al) Namg
I? itSofis W E it Oki
Well ntractor Company Name y/
STREET ADDRESS 7 r (�
L,Fisftg me
City or Town 7 State
(' 5S' -394
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(it applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Q'
DATE DRILLED s,47o�,
TIME COMPLETED 7 3 r 00 AM PM ❑
3. WELL LOCCATIION:a
CITY: i lfniY/SONW (/� COUNTY /—/0/(I t/`SD 0
.S'1-oyf riff £ -Ie5 Lo
(Sheet Name, Numbers, C unity, Subdivision, Lot Nu., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTI
❑Slope ID Valley El Flat edge ❑Other
(check appropriate box)
LATITUDENt._1S r 2-St 63S /
LONGITUDE(il_CRjr
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS ❑Topographic map
(bcaton of welt must be shown on a USGS topo map and
attached to this form Y not using GPS)
4. WELL OWNER I /
OWNERS NAME / l�je An
ff7
/n� acCctn4-
STREET ADDRESS /1 Bo/ 4T 75
'LazL(t) YIl' �, X73 o
ity or Town State Zip Code
� k 6,2R- a/4/�
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IV
5,st
c. WATER LEVEL Below Top of Casing: 60 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface•
*Top of casing terminated at/or Selow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): aN METHOD OF TESTitYthe
lry
20
n
ti a d
738
f. DISINFECTION; Typej` A tothifC Amount /3 tea,
g. WATER ZONES (depth):
From To/ 40' From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From D To - Ft.4 as 2/4, /A5 Pee' S»4 t/
From To Ft.
From To Ft.
7. GROUT: 0 Depth Material Method
To ljf Ft. CDIICeeie
From
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To Formation Description
� — 2a
7 eon 01.14-
Z.55d.—SOS 1 (y,,,unft
CI
11. REMARKS:
N
tr
CIS
I DID HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCT/0N STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
'/I��'1/ 1V ,CP s
SIGNATURE OF ERTIFIED WFI.LCONTRACTOR DATE
It 1, I'ol-is
PRINTED NAMEpF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

6 Jia6k)
RESIDENTIAL WELLCONSTRUCTIO' RECORD
North Carolina Uep.rvnanl OE Lnvfronmcnt and Natural Kexrurcc> Ui. ,.I .. alal V‘..5n
WELL CONTRACTOR CERTIFICATION s 2571
1 WELL CONTRACTOR
B yam SnUf
WJ Cbrtraaor (nanfaaaa0 Name
Glean RNr WJ 6 Pump Company
W J Contractor Compny NAM*
STREET ADDRESS PO Bo. 204
En Fat Roa. NC 28726
Cty a Town Slue Zp Cod*
( 628 ). 693-1200
Nee oar Phone mercer
2. WELL INFORMATION'
SITE WELL ID 901.Pac.5•e1
STATE WELL PERMITNt app.aae) 0 LI (00) Q 55 % 0
DWO or OTHER PERMIT RI appaaor)
WELL USE (CMC* Apgar/_ Boa/ RMnWaal
.oaral WaSappy
DATE DRILLED 0 31(J Io
TIMECOMPLETED fl'a0
Am Pm
3 WELL LOCATION:
c)TYhP/-{U) Lea- couHTT 1(I
a2s Eg0/tuivictl
iSas Name. Namara Comment;. Suatieon La No Paral Zs Coo.l
TOPOGRAPHIC I LAND SETTING
s.s`roe OVolley Ono ORope DOo1.r
Iaeca ecorwq.Y aoa)
LATITUDE •35° iS` ZUFJ
LONGITUDE Q 2±. ZIalit)
Laun,dn:Aongmde watt QOPS °Topographic map
(mcaaot W wed mar a drawn one DSGS mpo map .na
*Nana to Oa Ran I not wag GPS)
a. WELL OWNER J� nnn`
OWNER'S NAM^I E nn L2J-n 2[ -
May 0e M apa,
mart, a10fdf a
m a decimal roan
STREET ADDRESSa,44 I3k0-8..L %(ba) F-O
,ltdp.(scnu‘dle-)luGZB?9L
CR a Tan Sale Zp Coa
QzAt,. (Az •3o 2-
Area ooa. - Prone rfurnDer
6. WELL DETAILS:
•. TOTAL DEPTH: I Lk)
o DOES WELL REPLACE EXISTING WELL? ��Y1TES Er NO ❑
c WATERLEVEL 8.QWToPa Cary 'U FT
(Use ••• E Above Top d CMnp)
P. TOP OF CASINO IS 1 FT Above Lard Surface'
'T ap d aaaap Mammal l a9a Caen land *alma nay aqua
a wawao. m .c�ojr7a.arw wan 1SA NCAC 2C 0118
• YIELD (ppm) Of-f) METHOD OF TEST Air
1. DISINFECTION Type "ITN Amount
p WA TER ZONES ,De Pln
From 95— I 100 From is
From /30 To /33— From To
From To From To
6 CASINO Tnelrwea,
From 1
From
From
19111
To$7 Ft Depth
lfLryr•. r.L
to FI
To Ft
7. GROUT D.pfn MaI.n.I
Fron_0 To� FI 544Z fe
Fram_� To2.O Ft Bor ah30r fi:
From to FI
8 SCREEN
From
From
From
D•un,
To
To
To
9 SAND/GRAVEL PACs
090 n
Fran
From l o
From To
10. DRILLING LOG
From To
0 Z5
2r —ff0
40 -•/ri5
II REMARKS
�M awe
ai22A
Asti
Oral•, Sal Su• Male' a
Ft
Ft
Ft
Ft
Ft
Sa.
Forma n DesCnpuon
N
P1
O
•co II RES• Winn fly! 0-tabi
A5 COrsTRtCTEO w acCORDa..Ci nn*
1St .CC 7C nEtr CO,STM VCOMROS An0 mAr. Gems me,
RECORD BEE. mg>a0 f.. Per
SIG ATURE 0 CEATIFIE WELL CONTRACTOR
DATE
PRINTED k'AME OF PERSON N$TRUCTING THE WELL
Submit the original to Ms Division of Water Quality within 30 clays. Arm nronna non Mgt.
1417 Mali S.reic. Center - R.IJpn, NC Z7699.1617 Pnon. No. [phone] .al 558
o.rnCW I•

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Ueparvnent of tnvuonmcnt and Natural Know roc. !I.,.n n,rcr y...bn
WELL CONTRACTOR CERTIFICATION s 3571
1 WELL CONTRACTOR:
Bryant Stoat
We. Contract (enalwOreO Nam*
Groan RNw Well li Pump Company
ors Contractor Company Naar
STREET ADDRESS PO80s204
Earl Fief Roca. NC 25725
Cry or Town
( 626 ). 693.1200
Air code- Phone narrow
Stile Zp COO.
2. WELL INFORMATION:
SITE WELL ID ROI.ppleaa.l
STATE WELL PERMIT«. appeaser U(44 rROJ (g
DYVO or OTHER PERMIT Sy app.abw)
WELL LSE (Chan AAMcacr. Boa) Rrrwntai WaterSLpp,y tjiZ
t
DATE DRILLED u / Z2-/ o Le
TIME COMPLETED 12:oo AM ❑ PMVI.
7. WELL LOCATION
CITY v{Mrkipsc Ylv l f C-
O Crihbs (Z.oacL-
(9r.. None N.,Dw. Carnmun y SOOLoo, Ls No Pwal Zip Coo.)
TOPOGRAPHIC / LAND SETTING
OSIap. OVWey tTFLt ORro9. OOOnw
nava s aapree W.,
LATITUDE _�2r5�:0 Sio�
LONGITUDEQf2° 23r D54.4)
Laun,acAonsiade source I GPS OTopograptuc map
r.c.r.n or wN mot co mown on . vsGS rope map and
.h.cMd to OM Ann f not uwg CPS)
A WELL OWNER OWNER'S NAME TO -✓L G ,L s
CouNT 41-f'�Lwr
I.Ly ha a Osaw.,
oiwla, aeoa16 or
.. dcoal format
STREET ADDRESS CI?14V 7l1 1 I lDr .
}-4A1rtg rsrnL)I lle-i(
428Toon Sun Zap coo.
,• CAC- efos9
t
Ann coos - Phone neater
6. WELL DETAILS: _ t
a. TOTAL DEPTH: al 2 0
o DOES WELL REPLACE EAISTINO WELL YES O NO CC
c WATER LEVEL Sewn Top of Clang 4 0 FT
(use'✓ E Above Top d Caerq)
a. TOP OF CASINO IS 1 FT Above Lana Surface'
lop d warp lobs aMd Woe WOOS' lend maroon hey require
awe m .ctmf rGt1a Lrr91 15A NCAC 2C .0116
• YIELD l9prn) 1 METHOD OF TEST A•
1. DISINFECTION Type n7n Amount
. WATER ZONES loom.
J
From ( N To 2 00 From 10
From To From To
From To From to
6 CASINO
Dow D7rtor
From_L 10 getFI 2
From To Fr
From To
Thiclale.Y
Weg1l
7. GROUT Doan Manner
From o To 3 Ft Fi
F,om 7 To 20 fl gy Sc,}r
From -To Ft
Mellott
Pat
Mona]
�00
S. SCREEN Drprn Damara 5ar Sae MalwId.
From To Fi n n
From to Fr n n
From To GI n n
.. SANOVORAVEL PACn
Dean Sa• Mannar
From
erom 10 Fr
From To I
10. DRILLING LOG
From T
o-30
30- ,3Sr
2.15
II REMARKS
r
O I
r DO rKAEar CEanh nv.i n.S Ln%t.r. WAS ccn ntLC1Eo w ACCO CMrCL Wines
n5A ,CC 7C WEIL CO'.SrrlLCr S1A.DMDS AFC M.1 A ClCPO nits
RECORDnAS BEE. PRO.. OE D' rnEO*sfR
T= -
S,GNATLR FCERT�r bevy DATE
nfu./CONTRACTOR DALERyinE
dr
PRINTEPWAME OF PERSON CONSTRUCTING THE vvEt
Sutbrr&t the original TO the Division of Water Quality within 30 days. ATVI- information Mgt.
1617 Moil Service Cotter - Raleigh, NC 27699.1617 Phone No. [phone] eat 56e
Cam CW I
... „U5

RESIDENTIAL WELL CONSTRUCilON RECORD
North Carolina Department of Environment and Natural Rcsourus- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Wet Contractor (IndMdual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rocs. NC 28726
City or Town State
( 828 )- 693-1200
Arse code- Plane number
Zp Code
2. WELL INFORMATION:
SITE WELL. ID e0f applicable)
STATE WELLPERMIT#(rtapplicabe) J00/0g9aC
DWG or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply
d [gam
DATE DRILLED --/6-Via
TIME COMPLETED J r 3 0 AM ❑ PM (.]-
3. WELL LOCATION:
,,
2i
CRY: 4-k-PLdsa tub lie COUNTY ArtSOY)
ewcrOd xn0) 1Ihr-
(Street Name. Numbers. Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat aRfdge ❑Other
(check appropnate box)
LATITUDE /7i'� 4'!N
LONGITUDE :r 4u10
latitlde/longitlde source: 9-PS ❑Topographic map
(bcation of waf must be shown on a USGS topo map and
aftschad to this form 7not using GPS)
4. WELL OWNER
OWNERS NAME Mani CI J leave r
STR ET ADDRESS 38$ Pre.ot x.J rr)oc( Dr'
ilk, NC- a 3`l yf
Cry or Town State Zip Code
(gam)- fag? - S$ 30
May be in degrees,
mlmita, seconds or
in a decimal format
Area code - Phone number
6. WELL DETAILS: —
a. TOTAL DEPTH: 3 A)
b. DOES WELL REPLACE EXISTING WELL? YES O NO p�
c. WATER LEVEL Beim Top d CasFp: 70 r FT.
(Use'+ f Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or blow land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gam): ! METHOD OF TEST Air
3R l
315
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
Ix From pi% To Z 93 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From / To % O Ft
From To Ft
From To Ft,
7. GROUT:
Frorn
From
From
Depth
To Ft
To Ft.
To Ft.
Matenal
Method
8. SCREEN: Depth Diameter Slot Size Material
From To Ft.
From To Ft
From To Ft
9. SAND/GRAVEL PACK
Depth
n.
n
in
Sae
Frorn To Ft
From To Ft,
From To Ft
10. DRILLING LOG
From To
/55 -32
n
n
Material
Formabon Descnpbon
a'?tf-tv+%-
-21
1 '
CT 4
O'
rarisi fir`/I Pew"( 185 tv3-?C
I CO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W mi
15A NCAC 2C. WELL CONSIRUCT10N STANDARDS. AND THAT A CCPY OF THIS
RECORD HAS BEEN PROVOEQrIP THE W EL} OWNER
SIGNATUI€ OF CER IED WELL CONTRACTOR DATE
& >tLTL 6m, t 4
PRINT 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- Raielgh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev 7/05

31585
RESIDENTIAL WELL CONSTRUCTION RECORD
North C.robn. LNaartrnatt of tnnronm.m .rd N.DrN Kno•r c .ttl O,.e,n
WELL CONTRACTOR CERTIFICATION 9 2571
1 WELL CONTRACTQR.
Bryant Smin
WM Caaacv (MwriMW) Nacre
Green Fiver Wee 6 Pump Company
W M Corancta Carp.ny Nara
STREET ADDRESS PO Boa 204
Esc fat Roo. tie 28726
City or Town Slat.
( 020 ). 693.1200
N.. axle- Phan MOODS
2. WELL INFORMATION:
Zp Code
SITE WELL ID IN .OPua•) STATE WELL PERMITS(' Nam) bi' I OoIoS p0 `G
I
DWO or OTHER PERMIT 9(F .ppkabw)
WELL USE (Chock A(plc s Boa) RMtoa9al Water Supply 0
DATE DRILLED 110 Io
TIME COMPLETED n-I'C'� AMY7 FlaQ
0. WELL LOCAT)ON: F� /_ 1. 1
CITY F1 at-Rc'cC COUNTY-f-}tNdt0nri-
La33FeImr+earx/ 2±73I
Mums Nan.. maws. Can/aunt, S.roawwn La Na Pwwr Zip GOO.)
TOPOGRAPHIC 1 LAND SETTING
Q'Srop. DVal.y DEW ORcW DOVI..
(crew apptoa.a Wa)
LATITUDE isUbr 554
LONGITUDE AILa3 1 ti 1.3
Laurttddony0+de solace *PS OTopograptuc map
(Moan W vial mW D. atone or • USGS tope m.p end
.N.Cn.p ID era Form / rn1 wog GPSI
M.y t... tiro..
airy, mond' a
a a Saimaa! Ean.I
a. WELL OWNER L A 1I^ ,�1
OWNER'S NAME NT l ent-S I
STREET ADDRESS 4c LL�1 Ic4cA &.d KYes
)=-1 r- N G 2-03
Cry a Town �/ Slat. bp Coo.
822' . (DSY-4333
Arse vide - Phorn morrow
6. WELL DETAILS: I
a. TOTAL DEPTH: 55&5
D DOES WELL REPLACE EXISTING WELL? YES ❑ NO is
c WATER LEVEL boort Top at Cum FT
(Via'✓ • ADO.. Top d Cun91
a. TOP OF CASINO IS 1 FT Above Land Surface
'Top of cam tamnrt.O Woe D.ow I.rte .tat.os may 'qua.
• evince n .ocwUaros Non 15A NCAC 2C 0110
• YIELD(9Wn)
0-0 METHOD OF TEST Aa
I. DISINFECTION Typ• 'an
9. WATER
ZONES worn,
Trs-
Fran J 10 cf.
Fran 10
Fran 10
• CASINO
D•pin
Flom ...:J�a-lo 10 FI
From to FI
From o FI
From
From
From
AMMO tall
q. p.l.r
It;
o
io
Thokn•aar
Weight Met No
2/.6
7. GROUT D•Pn MN•MI
Flom 0 To 3 Fl S,rk.E4
From_ To AO FI Agit ba//r
From I Fr
6 SCREEN
From
Fran
Fran
Dawn Di.rnrl.r Sot S.t.
Io FI n n
10 FI n n
10 Fr n n
9. SAND'ORAVEL PACK
Dean S.
From 10
Fran io Er
Mai...a.
Maher u'
10. DRILLING LOG
From To Formation Descrpoon
11 REMARKS
I11
O arn [j
too num.. n. rtC/G CV n Co.nOCC?.STK.r(' 1v. 51 ..0 Da nv. . C• Oar
m
K E
rvrTM
RECORDra5 Of EK RHov Dr.NER
2-// 'et
SIGNATU OF CER n41ED WELL CONTRACTOR DAZE
PRINTED E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Watsr Duality within 30 Gays. Ann• nlorrna000 Mgt..
1617 Mall Unless Center- Ra1M9n. NC Z7699.1017 Phone No. [phone] •a1 568
ram GW i.
) r r5

9 ^ ~ C
RESIDENTIAL WELL CONSTR L'CTI O", RE( ORD
North Cawobn. O•pervnau of tnwlronmenl and N•mra1 KcSUurccr J., etc,
WELL CONTRACTOR CERTIFICATION s 2571
1 WELL CONTRACTOR:
Bryn) Strain
W1 Costnceor (noNwusi) Noma
Groan Rnw W W 6 Pump Company
Woo Contractor Company Nam•
STREET ADDRESS PC) Bo'20•
East FMI Roo. NC 26726
CAN or Town Style
L 6 1 62. 693-1200
Zv Code
Noe ocean Phone mac..
2. WELL INFORMATION:
SITE WELL ID Ca•ppcow) /
STATE WELL PERMITA% wp•wuq D�o�al,D ida(o ,cq
DIO or OTHER PERMIT a(• 5pprape)
WELL USE (CMct Applroot Su) Ronan•, Wotw Sari ❑
OATEORILLED SI(%L(0
TIME COMPLETED 7 ' 00 ASA 0 PM Fi
3. f. WELL LOCATION:
µ
CITY 14VICIS/SC"IU II (C. COUNTY 4-4./K{Lll?S(1L'
3`/,>0 4eCicifuhtliutdows .1 (" (fl is 021 ik CeicrkS
MONO W. NumUwa Communry Swwawn LP No Peron Z,p Coo•)
TOPOGRAPHIC X LAND SETTING
O Slope OT/W y OFt ORrope OOP.?
(Fn•pT< eoprpprr. Doa)
LATITUDE _25t20 1.0
LONDITUDEft.2.k. SI E.J
May be M deem.
O&a.ia monde Of
e • Wiwi Formal
Launde/longlude solace ETCPS OTopog7aptuc map
(Onion of war muw ce WIuwn on • VSGS rope mop •nor
•a•CM4 n Ma loan F nor wnp CPS)
a. WELL OWNER OWPI ER'S NAME J I�
e4-i-. 64-4
STREET ADDRESS Q 7/JC -I el yyPe l�(-L
CCttvTo2i'T:;ife l)Lz 2cit
ry or Tow Strt. Zv Coos
Arlo cods - Prone nunaw
6. WELL DETAILS:
•. TOTAL DEITH: r� `)
o DOES WELL REPLACE EXISTING WELL7 YES O NO a'
c WATER LEVEL Brow Top at Cung ID FT
(IA• / Ater* Top d Gang)
• TOP OF CASINO IS I FT AOo.t Lana Surface'
-Top A COHN lemanotael War Wow IwC surface may r.Qulr•
• wrono• n wzaro•noe yam ISA NCAC 2C .0156
•. MELD loom/ (d METHOD OF TEST Ns
I. DISINFECTION Type 'ITN
p WATER ZONES (poor,.
From Zoo 'c 00 r(ont
From to Flom
From to Grom
• CASINO
From
0.to p0 p1,s/p ?rpal•r
/ Gi J�
From o
From o FI
7. GROUT Dept,
From Q To 3 FI
From .A To30 Ft
From To FI
Amount
To
To
T nlcRn•ar
Wpnl
MateMl
.54kants
Asafnear
li Z
M .plop
Mr7 �O /
B. SCREEN Ovum Drn.t. Slot Sue Marwo.
From To FI n n
From 10 FI n n
From To Fi n n
SANO'ORAVEL PACK
Pepin
F'om t
From I Fi
From Io FI
10. DRILLING LOG
From To
e —3S
1 REMARKS
Sae
Mabuw
F rnaDo71 Descrpuon
.4m!/ )R.o�
8
C,1 -
Or-1
a
,00nERCST CERnn nV.l Ini5 at„ YEAS CO.STM!C*CD.. 'CCO DA. Ct ER.n.
ESA 'CAC 7C wEtl CONSTR VC SIA.OAROS ARO DEAl A CO coma
RECORO.%
to.4 Min PROnCko! I Mt, tM+FR
SIGNATUR OF CERTiFiE wEu CONTRACTOR
r3rm n7;9-k
PRINTED NAME OF PERSON CONSTRUCT INC THE WELL
DATE
Submit ttla original 10 the Division of Water Quality within 30 days. Attu Information Mgt.
1617 Mall S rvlu Caner- Raldpf, NC 27099.1017 Phan, No. [phone] tAt 566
pm CA le
+RY

n ,1
t 1 t y c f
7
RESIDENTIAL WELL CONSTRUCTION RECORD
Nona Caro4r. Ucp rvn nl of tnvllonmcnl and NwN Rcauu roc n .Icr Qt alrn
WELL CONTRACTOR CERTIFICATION R 257'
t. WELL CONTRACTOR:
Bryant Smth
WM Corpscaar (Inor.Wual Herne
Green Rrvw W W 6 Pump Company
WM Contractor Company Name
STREET ADDRESS PD B01 204
East Fist ROO, NC 28726
City or Tom Son.
828 ). 693.1200
Nt. moo Pone Marts
2. WELL INFORMATION'
SITE WELL ID NII appoecor
STATE WELL PERMITN, applpp.) 05
2ro Coo•
l00117,2
DWG or OTHER PERMIT Nf ap9eapj.l
WELL USE (Chace Arcata, Boa) Rwlcernai Wow &rimy O
DATE ORJLLED g S kg"
TIME COMPLETED ( J C AAI O PMyri
3. WELL LOCATION:://'�/
til50rIV, He_ COUNTY `I'-'E-j1Lu-9Sw'l
��l��Q�C4S fl i Zi / rl Kea rl
!Sired None. Numbs(. Conrmo.n SutdMwn Lot No Pupal Zip Dow)
TOPOGRAPHIC / LAND SETTING
O'sbp. OVMry Ono °Rape ❑Dow
Iww .p9"OPo••. ppc)
LATITUDE ,.. 2CI D'/&
LONGITUDE j2-�cl) 5714-%
CITY
May be to dcprm
masa monde a
or a decimal format
LaUnrdeAonynde so'acc ¢GPS OTopogaptuc map
(oc.mn W wog mat De Mown on a USGS opo map and
att&CM4 to f'e kraal / not uaaq CPS)
a. WELL OWNER Q,�
OWNERS NAME k '� µ- s
STREET ADDRESS a5L0O £'C ete
34-, j.ISOn (1 i (te- 2 `'S'7 ?
Cry Or Tov.n Sate Zp Coo.
tag -I?l0
Noe md.. Pare nutrias(
6. WELL DETAILS:
•. TOTAL DEPTH: !A " 7
0 DOES WELL REPLACE EXISTING/ WELL? YES D
NO gf
it
c WATER LEVELbean Top of Cunp /00
(Us( '.-f Above Top d Cunp)
d. TOP OF CASINO IS I FT Move L WIW Surface'
'Top d casing I.rrrsn.W nor tam and soilage nay redone
a manor in ffaccordana m' 15A NCAC 2C .0110
• YIELD Wpm) MET..00 OF TEST Ae
FT
I. DISINFECTION Type 'IT"
D WATER ZONES I o.pm,
From J.j) To ZCO
From To _
From To
6 CASINO
From
From
Flom
Amount
To
To
To
Th.csneatr
0.p"n D.. w W2t
From to Q Ft (i
From I Ft
Fran To Fi
7. GROUT Degn Ma1wI
From 0 To 1 Ft
From 3 To/O_. Ft //461,diis
From To Fr
6 SCREEN
From
From
From
()won Dummy.
to Ft
e Ft
to Ft
/. SAND'ORAVEL PACs
D.pn
mom
From 10
From To
10. DRILLING LOG
From To
'-t o - 7s�
7c R c'5-
11 REMARKS
Sim' Sc.
n n
Maiw et
P_�.
M.0 tic
t%tio o0 2
M4 tP2r
Sq./ M.IVNi
Matwut
..Fr
F-))ormaoon Descrpbon
V /?
S6,r)/ Rook
g /Mao:fa
rn
m
8
f?
100nEREsr CERnn ilea rwS at
rev NC,C PC MELI CO.Smc.0 PO.
RECORDnAS BEEN orro.a D 'C •
n.5CO.SmRVREDn ACCONO•Kt von-
ANDSPDS AnD n-or . CO., CO A.d
n[.. O..N
SIGNATURE cfr CERTIFIED WELL CONTRACTOR DATE
ARyAokSank
PRINTED NAME OF PERSON CONSTRUCTING TnE WELL
_J
Submit the original to the Division of Water Quality within 30 Days. Alen nform.00n MIL.
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] .AI 566
o.m Go., la
we. hOS

RESIDENTML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rcsourccs- Ihvcslon of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR
Bryant Smith
Wel Contractor (Individual) Naar
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rodc, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Plane number
2. WELL INFORMATION:
SITE WELL ID a(d applicable) ,r1 n ���� ((/n� I �/
STATE WELL PERMIT/Of applicable) no Mai oLta
DWG or OTHER PERMIT SR applicable)
WELL USE (Check Appplicable Box): Residential Water Supply ❑
DATE DRILLED O y OC
TIME COMPLETED 't; •; a
3. WELL LOCATION:�� "
CITY: 130%Lr tik COUNTY h am-'
z14- rme Numbers,
(Street Name. Numbe, Community. Subdansion. L No.. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
C36topa OVaINy OFlat ❑Ridge ❑Other
(check apprWnate box)
LATITUDE _btc' 0-7
LONGITUDEQQ(C_4,(h '' QC.%
Latitude/longitude source: Q6PS ❑Topographic map
(location W wet must be shown on a USGS topo map and
attached to this form 1 not using GPS)
MID PM Q'
Lo -10
hay be in degree,
minute, aecondr or
in a decimal format
t. WELL OWNER y�/�
OWNERS NAME `�L3.0 (1 I-P rl�l
STREET ADDRESS (q JJJ !_��L P w,.c./1fr�'
4e,�tdk.vasonta(l\�� 7�(_ 42-
City or Town State 1 Zip Code
ids Z' 3J8b
Area code - Phone number
6. WELL DETAILS: _
a. TOTAL. DEPTH: 3 L 3
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 6---
c. WATER LEVEL Below Top of Caskg: L O FT.
(Lisa '+' 1 Above Top d Csng)
d. TOP OF CASING IS 1 FT. Move Land Surface'
Top of casing terminated actor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpWO: L O METHOD OF TEST Air
1. DISINFECTION: Type HTH
Amount
9. WATER ZONES (depth): fCC •h
To 33D JJFrom
To 3CO'y) jHom
From To From
From 3 3✓
From
6. CASINO:
Depth
Frorn / To 9g. Ft.
From To Ft.
To
To
To
Thickness/
Diap�rter Weight Maaterel
From To Ft.
7. GROUT: Depth Material Method
From 0 To Ft M �_/C�cl
From, 3 To do Ft «..D /t{ty
From To Ft.
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
Frorn To
From To
From To
10. DRILLING LOG
From To
a— �o
hto - cfrif
s?D 3 t r
11. REMARKS:
Diameter Slot Size Matenal
Ft in. n.
Ft
Ft
Ft.
Ft.
Ft
m
m
See Matenal
Formabon Descnpton
r�I-
- 1trot;' #ag7'
5ie// flzc[C
(4 #ill tI
CO C!
I • I
-13
Cr.
T
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
13A NCAC 2C, WELL CONSrRIX. man STANDARDS, AND THAT A Cam' OF THIS
RECORD HAS BEEN PRO/IDED HE WELL OWNER
-Lt.
S NATU yE OF CERTI WELL CONTRACTOR DATE
PRINTED KAME OF PESNN CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: 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 Depanunent of Environment and Natural Resources- Division Ul N atcr Quality
WELL CONTRACTOR CERTIFICATION N S- 7
AN
Wes ( Dan
Gree-n %VPr lt/21\ ' Kink/0
Wed Contractor Company Nam.
STREET ADDRESS Po O)C a
�aSt ijat -Rock M( a€%a(o
City or Tenn State Zip Code
( )- 693-J2_0o
Arse coda Phone number
2. WELL INFORMATION:
SITE WELL ID Cif appcade)
STATE WELL PERMITS(. applicable)
(o% leg
DWO or OTHER PERMIT 6(f applicable)
WELL USE (Check Applicable Box)): Residential Water Supply
RI ❑
DATE DRILLED— /G — oO
TIME COMPLETED 17i . 3 V AM O PM C3 .
3. WELL LOCATION:
CATION: ,, '
CITY: ,,d-F.( SLM uii I-E- COUNTY 1"\t`-'^�"'`S�
le i- I P7_ t r i-et s l Oalcl.Ln9
(Street Name. Number. Community. SubdiNeion, Lot No.. Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
oslope OValley OFSt laR`dg.
(check appropriate box)
LATITUDE _21/5 q /V
LONGITUDEO�jjl
Latitude/longitude source: 0PPS (7Topographic map
(foc.tnn o( w.1 must b. shown on . USGS fop* map and
.n.cn.d to ets form I not using GPS)
4. WELL OWNER OWNER'S NAME yyQuit U zt
May be in de®mk
minute, seconds or
m a decimal format
TREET ADDRESS 4144,0 O ugLL&Ioo+cL'
cAQ Jn�SUY)uvC7-e li ( l-(‘n92_
City or Town State Zip Code
t'i Z--c )- tPR z -Frei'oS
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: G 0 6
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E '
c. WATER LEVEL Below Top of Casing: / S C% FT.
(Use'+ I Above Top d Casatg).
d. TOP OF CASING I5 % FT. Above Land Surface'
'Top d casing terminated actor below land surface may require
a variance n accordance wet 15A NCAC 2C .0116.
e. YIELD (gpm) / METHOD OF TEST fp /S.
1. DISINFECTION: Type (J ref Amount
g. WATER ZONES (depm)
From 200 To 3 05 From To
From To From To
From To From To
6. CASING: Thickness/
Depth Dia tar Weight ,�}riel
From To /Z Ft
L. �, / L v
From To Ft
From To Ft.
7. GROUT: Depth Material
From C~% To 2 (% Ft. Stf-k '/!-/117+-
From To Ft.
From To Ft
8. SCREEN: Depth Diameter Slot Size Maternal
From To Ftn. n.
From To Ftn. n.
From To Ft in in.
9. SAND/GRAVEL PACK:
Depth Sae Material
From To Ft
From To Ft.
From To Ft
10. DRILLING LOG
From To
O— /5-
0
iFrmaton Descnption
7/2t
�.?AwifF
RECEIVC-D
J
Ashexille-.Segianal-Offiee
Aquifer Protection
II. REMARKS:
I DO HEREBY CERTIFY RNT THIS WELL WAS CCNSTRUCIED IN ACCOtOANCE W nH
I5A NCAC 2C, WELL CCNSTRUCTfl STANDARDS, AND MAT A COPY OF THIS
RECORD HAS BEEN PRO/OED Tq'JNE WELL OWNER
! -/7-06
SIGNATUR OF CERTIFIED WELL CONTRACTOR DATE
13Rvmt &mrrk
PRINTED N E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1817 Mall Service Center- Raleigh, NC 27899-1817 Phone No. [phone] ext 568.
Form GW-ta
Rev 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carotins Department or Environment and Neural Resources- D1S u.un .d w alnr Qualm
WELL CONTRACTOR CERTIFICATION a a 5 '7 I I
1. DISINFECTION Type t-1-f 1 1'F- Amount
g, WATER ZONES r aeoni
From YL7 To l From To
1 WELL CONTRACTOR
Web L444aw/ (IrdMdual) Nam.
Gies ver LAJe\ v Roy°
WWI Convect*. ecta CorrpnY Hans
STREET ADDRESS Po R] oX ao
Fast f lar(lc Ni( a€7a(C
City a Tova1 Slat. Zip Cod.
695-)zoo
Area coder Phone nunt.r.
Z. WELL INFORMATION:
SITE WELL ID 6pl awaD.) n
STATE WELL PERMITS(' eppnraCl.l t 1iD Ia`lJ' I5 14 1
DWD a OTHER PERMIT 6(6 .p96cad.)
WELL. USE (Check AppEaol. Boil: Residents' Wader Supply 0
DATE ORiLLED I I i 7�tI c %
TIME COMPLETED r/-'3 0 AM 0 PM
3. WELL LOCATION:
C
I
TY- I/-�t'�U�(�-CAI SIJYtullll-/�C
OUNTYLOk.Ca,tin
7 1Pi (l.d) I inn e goct- F d.
(Seel Name. Numbers. Community. SuakwMan, Lot No Parcel. Zip Coot)
TO:r•GRAPH IC I LAND SETTING.
t glop• OVWM Ong QRKIge QO61.r
(men appropnalt pail
LATITUDE 35�11r 317J
LONGITUDEQS2` Ig 21 LT)
Laaludelonwtude source. IabPS ❑ Topographic leap
(Qcaton W we/ most De Shown one USGS repo map end
enricher/ Co 6r rain / not uaelg CPS)
4. WELL. OWNER `1
OWNER'S NAME Net-I�`� iriJ(4-271
STREET ADDRESS PC va
I30-Caukl OC.9%1JO
Cry or Town State Zip Code
(`62-S). (pKS--r)SX
Are. code • Pion novae.
May be is degrees.
minuto, monde a
m a decimal normal
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ikt"--.
c. WATER LEVEL Below Top d Casing: 2 0 F r
(um •✓ 6 Mon Top d Cans)
d. TOP OF CASINO IS I Ff. Aoo'a Land Surface'
Top d wing t.rmnsted .ua Wow land surface may require
. v.raance n accordance whit ISA NCAC 2C .0116.
.. YIELD (9prn)': METHOD OF TEST & I r
Fe ,R Fq
ha'.Y
From To From To
From To From To
6. CASINO. Duct -nest,
Depth Dran.ter Weight Materiel
From / To 2Z Ft / 9 Rte.P2C
From To FI
From To FI
7. GROUT Depth Material M,J.7d1od
From G To AO Ft SreREtc Mry�'/c&/e
From To Ft
From to Ft
8 SCREEN D.ptn Dsrn.ter Slot Sae Malarial
From To Ft n 11
From To Ft n n
From To FI n 'n
9. SAND/GRAVEL PACK
D.pm $u. Material
From To Ft
From To FI
From To Ft
10. DRILLING LOG
From To
- /O
/0— /Z,
RECEIVED
fd71
MAR 08
Fo abort scnPoon
a. I Fir
-�t
A he -villa -Regional -Office —
Aquifer ProteLtion
II. REMAR KS.
7
J
a
CONCAVE/ CER11 l n T rni5 WELL an AS n�l�= LCTED MOT i ACrt ACCORDANCE Wm,
I5A NCAC 7C W ELt COSSTRLCMr 5r
RECORDw1S BEEN PROS Of 0 TO WEtt OWNER
SIGNATURE F CERTIFIED WELL CONTRACTOR GATE
/3%A NAME �n,NSTR
PRINTED N E OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of ty
hin
Water
(9) Information Mgt.,
11177 Kali Service Center— Raleigh, NC 276996117PhoneNo. 19733-7016
Form GW-ta
Rw n05

RESIDENTIAL wELL consrRuc-rion RECORD
North Carolina Deprtrnent of Environment and Naval Resources Di.,y,un „l ales Quabn
WELL CONTRACTOR CERTIFICATION N 2 5 % I
1 WELL CONTRACTOR:
-pThcalai-Sm
(Individual) Nana
Crean Ztver tALC\ o ko„f,
W W Convector Cormpeny Name l
STREET ADDRESS PO OR av'F
�QS+ Flat +ZOCaL N (a 6 7a (G
Cary or Town State y Zip Code
)- (093-Izoo
Area code- Prone nurrlv.,
2 WELL INFORMATION:
SITE WELL ID srepocad.)
STATE WELLPERMITS(. applaa.) 051 00 1( 3 I -S
DWQ o OTHER PERMIT 6(. app0cabie)
WELL USE (Check A/ppable Boa). RnMnts Water SWpty 0
DATE DRILLED II'^-'L'L'
TIME COMPLETED 11 ; 0 O AM & PM LJ
3. WELL LOCATION:
errs t 9 TtidaAScsflGlite COUNTY`-F-��CIJilSur1
%'7 CSrQatd Cafes ph at
(Suss Nam.. Notion. Communsy. Subdlw.on Lot No Pwal. Zip Coo.)
TOPOGRAPHIC/ LAID SETTING
O Siege [Weary O FSi aiK39. O ovwr
Icneeh apPopnaA oak) . 1
LATITUDE _L551 / a-il /J
LONGITUDE
QZ° l0/ DO (a)
May be in do6rm.
simile, .words or
in a docalml formal
Laotudenongiwde source: S(GPS ❑Topograptuc map
Vocation of war rust be .hown on . USGS tap* map and
aracb.d to vac lam I not Lang CPS/
4. WELL OWNER D /j (�,
OWNER'S NAME Iryry��I ailit I'@(�V-�l(ij r300 ken
STREET ADDR ESS ate Lt /F1L1rfot.u.e_
f"f th--her Ne-aCr132_
CEy or Town State Zip Code
In - Ala s-
Nee pod. • Phone nuro.r
6. WELL DETAILS: 1
_
a. TOTAL DEPTH: 7 0
b
b. DOES WELL REPLACE EXISTING WELL? YES O N1do
B c. WATER LEVEL ElstonTop of Gulag. t/ C ag. it FT.
(Use '•' If Above Top d Crag)
d. TOP OF CASING IS ( FT. Above Land Surface'
Top d wig ternrat.d aeon blow and .uAaoe fray require
• vara n .o ardarlee wql 13A NCAC 2C .0118.
.. YIELD (gpm): I METNOO OF TEST TL i r
DISINFECTION. TypeityJf Amount
9. WATER ZONESloepml `II
From /e0 To /6% From
From To Flom
From To From
6. CASINO.
Depth
Flom % To 614[' Ft
From To Ft
From To Ft
7. (ROUT.�,�7 D.pin
C
From To .2O FI
From To Ft
From To FI
8. SCREEN:
From
From
From
Depth
To
To
To
O)r11.ar
mane'
To
To
To
Thickness.
Wepht
21.4
p��
Mgt/lea
Cornets Sol Stze Mal.nal
FI n
Ft n n
Ft n n
9. SAND/GRAVEL PACK
Depth
From To Ft
From To Ft
From To FI
10. DRILLING LOG
From To
— /v
/o - 3O
7a 'I
Soo
Material
Formation De.crpoon
0/4
54t;/ Aioc>k
&It/ tXE///ref}
• time tc
RECEIVED
200
I
Asheville -Regional Office
Aquifer Piotection
11. REMARKS.
0
0"
, CO nEREBy CERnFv nor nuts -eat WAS CONSmLCTED w ACCORDANCE win,
I'.A NCAC 7C. WELL CO,STRuCTI6, STANDARDS AND THAT A CCPvv CE TNS
RECORD rM. BEEN PROy Of D rOY E WELL O: V,ER
1-z
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
,SRga-'t- Ste, t-k
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Duality within 30 days. Ann: InformaDon Mgt.,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rey 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # - 2 M 3l0
1. WELL CONTRACTOR:
Otcc.ct4, -kilo. v\n ia7+a^tSL.c-s
Well Contractor (Individual) Name
CA 1 aQ SQa 2-C6 ,lo-r+ w%.1.
Well Contractor Company Name
STREET ADDRESS \ •Lyp.b i0a`1 aoq
HOs a43C:1R t NC.
City or Tom tat
(daSS t0toP - ao zz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID (Kif applicable)
-Zip Code
STATE WELL PERMIT/Mrappkoable)
DWQ or OTHER PERMITS/Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED f-�%+ (c
TIME COMPLETED / e 60 AM ❑ PM ILL--
3. WELL LOCATION:
CITY: e1e/r-ton r..// COUNTY flea-s.✓...rpsr
L-ocr.s>'- Grote.. ,Qt.
.(Sheet Name, Numbers, Community. Subdivision, lR No.. Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
3'`ope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 _
LONGITUDE
May be in degrees, I
minutes_ seconds or
in a decimal format
Latitude/longitude source: °GPS °Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form (not using GPS)
4. WELL OWNER C
OWNERG
'S NAME tA9Q�(elte GebKa..
STREET ADDRESS 1233a Letu.S} 4/cove ttta,
liendesserv:Ile, Jac_ awnt
City or Tovn State Zip Code
(Sz8 )- (095-7ota
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: ? OS - b. DOES WELL. REPLACE EXISTING WELL? YES 0 NO g/
c WATER LEVEL Below Top of Casing: Pc FT.
(Use'+• if Above Top of Casing) .
d. TOP OF CASING IS \ FT. Above Land Surface`
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): Si METHOD OF TEST
f. DISINFECTION: Type_ Amount /..i
g. WATER ZONES (depth):
From To To
From To To
From To From To
G. CASING: Thickness/
Weight Matenal
From
From
Depth Dieter
From / To %(. Ft. At'
From To Ft
From To Ft.
7. GROUT: Depth Material Method
From 0 To c Ft ern ,,' { ,t,�rd(
From To Ft. - �"�
From To Ft
8. SCREEN: Depth Diameter SS Size Material
Frorn To Ft in. la.
From To Ft in. in.
From To Ft. in. in.
9. SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
From To FL
From To Ft
Kt. DRILLING LOG
From To
7G
Formatio-1 Description
Ov don
7 . -Co-t Gso n
RE(FIVEn
MAR U 8 2U06
Lev lit Regionai-Office--
Aquifer P
11. REMARKS:
otectjon
rn
v
1 DO HEREBY CERTIFY THATTHS WELL WAS CONSTRUCTED N ACCORDANCE WITH
1SA NCAC 2C. WELL CONSTRUCTDN STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PRODDED TO THE Fr OWNER
/-l7s
SIGNATURE OF CERTIFIED EL NTRACTOR DATE
1�tcc:c.k. 'ek 0,^1. So& C-',S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

3726°?7
6
North Carolina — D WELL CONSTRUCTION RECORD
WELL Carolina
Department of Environment And Natural Resources — Division of Water
CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINSmty Groundwater Section
WELL CONTRACTOR COMPANY N CERTIFICATION # 2785
STATE WELL CONSTRUCTION PERMIT # PTCTMAN WELL BORING LLC
( applicable PHONE # (8281 4S3 n���
(if ) ASSOCIATED if pgRMIT # 061�70
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/public
Monitoring 0 Recovery 0 Heat PumpOtherOther, Industrial
2. WELL LOCATION: Water Injection Other 0 if p�� List Use
Agn
Nearest Town: HENDERSONVILLE
155 LONE LAUREL DR County HEND Topographic/Land setting
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) ❑ Ridge ❑ Slope 3. OWNER: TASON LEONARD Vey ❑ Flat
Address 155 LONE (check appropriate box)
LAUREL DR Latitude/longitude of well location
(Street or Route No.)
HENDERSONVILLE NC 28739 (degrees/mmutes/seconds)
City or Town State Latitude/longitude
(828) — 272-9726 Zip Code ngit°de source: 0 GPS ❑Topographic map
Area Code Phone number (check box)
DEPTH
4. DATE DRILLED 01/27/06
5. TOTAL DEPTH: 205 From To
_
6. DOES WELL REPLACE EXISTING WELL? YESNO
7. STATIC WATER 0 ® DRILLOG
LEVEL Below Top of Casing: 40 FT From To
8. TOP OF CASING IS 1-1/2(Use + if Above Top of Casing)
FT. Above Land Surface*
'Top of casing terminated at/or below land LOCATION SICE CH
variance m accordance with 15A NCAC 2Cs.0 surface requires a
9. YIELD (gPm): 10 Show direction and distance in miles from the
least
WATER ZONES METHOD OF TEST ARD Two State Roads or County Roads Include the road
(depth): number and common names
11. DISINFECTION: Type CHLORYTE MTN.#64 W. FROM BAT CAVE. LEFT ON PILOT
12. CASING: �— Amount 4.5STRAIGHT 1 STOP SIGN. LEFT ON
Wall Thickness RIDGE RD. STOP SIGN. RT. ON LONE LAUREL
Depth Diameter or Weight/Ft Material DR LOT #15 ON LEFT.
From 0
To 140 Ft 6-1/4" SDR21
From To Ft PVC
From To Ft
13. GROUT: Depth Material
From 0_ To 20 Ft. UfE Method
From To Ft --- POURED
14.SCREEN: Depth Diameter Slot Size
From To — F1 Material n
From — in. in. to
15. SAND/GRAVEL PACK:
To Ft' in.in.
From Depth To Ft Material MAR 08 2006 001
From To _ Ft. Asheville
Regional OffiCe
A uifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A O • Y •F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/
SIGNATURE OF P • TON CONSTRUCTING THE WELL
DATE
27699-1636 Phone No. [phone], withindays.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center — Raleigh, NC
GW-1 REV. 07/2001
16. REMARKS:

WELL CONSTRUCTION North Carolina - Department of Environment And Natural Resources - Division oC0 ter WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS
WELL CONTRACTOR COMP Quality - Groundwater Section
ANY NAME PITTMAIV WEL OBL�RING I,LC CERTIFICATION # 2785
STATE WELL CONSTRUCTION PERMIT #
(if applicable) ASSOCIATED WQ PERMIT # PHONE # (828_ ) 4_p662
1. WELL USE (if applicable)
0 Recovery Applicable Box): Residential ® Municipal/Public
Monitoring ry 0 Heat Pump0 Industrial Ll
2. WELL LOCATION: Water Injection 0 Other 0 If Other Agricultural
Nearest Town: BAT CAVEList Use
308 BLUE ROCK RED County HEND.
(Street Name, Numbers, Community, Subdivision,Topographic/Land setting
3. OWNER: MARSHALL SEAY Lot No., Zip Code) ❑Ridge ❑Slope ❑ Valley ❑ Flat
Address 308 BLUE ROCK (check appropriate box)
(Street or Route No.) �u1llOtude of well location
BAT CAVE NC
City or Town State 28710 Latitude/long(degrees/°P°graphmc
minutes/seconds)
(MI) - 978-0434 Zip COS rigitude source: 0 GPS 0 T
Area Code Phone number
(check box) map
4. DATE DRILLED 01/19/06 DEPTH
5. TOTAL DEPTH: 265 From To
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: D� L— INCr LOG
g 40 FT. [a From To
8. TOP OF CASING IS 1- (Use + if Above Top of Casing)
*Top of 1/2 FT. Above Land Surface*
m8 terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. LOCATION
9. YIELD (gpm): 15 METHOD OF TEST ARD Show direction and distance is miles 10. WATER ZONES Two State Roads or Countyfrom at least
(�) nut and common nams Roads. Include the road
11. DISINFECTION: T FROM RUTHERFORDON
12. CASING: Type CHLORYTE CAVE, MILE.
#64/74 TO BAT
Amount 6 LEFT ON HWY. #� 1 MH E, LEFT ON
Depth Wall Thickness EDNEY INN RD, LEFT ON BLUE ROCK
Diameter or Weight/Ft Material #23 ON RIGHT. RD. LOT
From 0 To 160 Ft 6-1/4"
FromToFt SDR21 PVC
From To Ft
13. GROUT: Depth Material
From 0 To 20 Ft. UH{RETE Method__
From To Ft �� OURED
14.SCREEN: Depth Diameter Slot Size Matte From To
Fromo Ft in in.
15. SAND/GRAVEL PACK t
;n.
From Depth Size Material
To Ft
From
ToF[
16. REMARKS.
-Tm
i-J
RECEIVED
MAR 08 2006
Asheville Regional Office
Aquifer Protection
I DO HEREBY CERTIFY THAT THIS
DO CTION STAND WELL WAS CONSTRUCTED IN ACCORDANCE �S, AND THAT A COPY O THIS RECORD HAS BEEN PROVIDED OCTHE2C, VVELL
WELL OWNER
SIG ATURE OF PER �
ON i NSTRUCTING THE WELL
DATE T
27699-1636 Phone No. [phone], within30 days
Submit the original to the Division of Water Groundwater Section,1636 Mail Service Center- Raleigh, NC
GW-1 REV. 07/2001

cram: Scott Gantt To: Stephenie Wilson Date: 2/14/2006 Time: 8:28:14 PM
Page 3 of 3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: FLAT ROCK
OLE TWO TOPS LANE, OFF GARRET RD
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER TONY HILL
ADDRESS 168 OLE TWO TOPS LANE
(Street or Route No.)
FLAT ROCK
City or Town
828-685-3917 S0
NC
State
28731
Zip Code
Topographic/Land setting
❑ Ridge ❑ Slope 0 Valley 0 Flat
Latitude/Longitude of well location
35.19.105 / 82.21.841
322594
(deg-egg/minutes/seconds)
Latitude/longitude source: 0 GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 50 Clay
Area Code - Phone Number
4. DATE DRILLED 1/18/06
5. TOTAL DEPTH 125
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
YES ❑ NO 121
60 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
*Top of casing terminated atior below land surface requires a variance in
accordance with 15A NCAC 2C.0118
9. YIELD (gpm): 20 METHOD OF TEST ARDM
io. WATER ZONES (depth): 125
D. DISINFECTION: TYPE HYPOCHLORITE Amount 3
12. CASING:
Depth
From 0 To
13. GROUT:
From 0
14. SCREEN
Diameter
56 FL 61/4"
Depth
To 20 Ft
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
125 Consolidated Rock
Wall Thickness
or Weight/Ft Material
SDR 21 PVC
oz
Material Method
GRAVEL MIX GRAVITY
Diameter
Ft. in.
Size
Ft,
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
2/1/06
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001
RECEIVED
MAR 0 8 2006
Asheville Regional Office
Aquifer Protection

brom: Scott Bantu lo: tephenie Wilson
Date: 2/14/2006 Time: 828:14 PM Page 2 of 3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box) : Residential ❑ Municipal E Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: HENDERSONVILLE County HENDERSON
1426 FRUITLAND RD
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER ALAN HORNE
ADDRESS 1426 FRUITLAND RD
(Street or Route No.)
HENDERSONVILLE
City or Town
828-693-9750
NC
State
Area Code - Phone Number
4. DATE DRILLED 1 / 10/06
5. TOTAL DEPTH 125
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
Zip Code
YES NO lS1
70 FT.
/Use "t" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface"
'Top of casing termvatcd at/or below hind surface requires a variance in
accordance with 15A NCAC 20.01I8
9. YIELD (gxn): 20 METHOD OF TEST ARDM
10. WATER ZONES (depth): 56 120
u. DISINFECTION: TYPE HYPOCHLORITE Amount 4
12. CASING:
Depth Diameter
From 0 - To 53 Ft 61/4"
13. GROUT:
Depth
From 0 To 20
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL, PACK:
Depth
From NA To Ft,
16. REMARKS:
FL
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley 3 Flat
Latitude/Longitude of well location
35.22.620 / 82.24.736
322593
(degrees/minutes/seconds)
Latitude/longitude source: E GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 10 Clay
10 22 Consolidated Rock
22 38 Clay
38 125 Consolidated Rock
Wall Thickness
or Weight/Ft. Material
SDR21 PVC
oz
Material Method
GRAVEL MIX GRAVITY
Diameter
Ft in
Slot Size Material
in
Size Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service c
27699-1636 Phone No. [phone], within 30 days.
1/10/06
Date
nter- RiveeE'
�1 MAR 0 8 2006
Asheville Regional Office
A•uifer Protection

Depth in Diameter
From -& To I A D. Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Materiale�� Meth
From To Ft. fCIZ,[2 OC.t.
From To li-q Ft. /
14. SCREEN: Depth Diameter Slot Size Materm
From To Ft. in. in.
From To Ft. in. in.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
Resoour/C.ree�s-IDivision of Water Quality - Groundwater Sectiionn
WELL CONTRACTOR (INDIVIDUAL) NAME (print) LAE?. tt LAIC 11.3 CERTIFICATION NA (DOA
WELL CONTRACTOR COMPANY NAME AppAIAchl P N Well 3) 1 G u.3 PHONE # (X )6S5 9Ra.3
STATE WELL CONSTRUCTION I'ERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential /Municipal/Public O Industrial O Agricultural ❑
Monitoring ❑ Recovery O Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT'IO,rN:
Nearest Town: ryQAVQZ.111 1\c,County lv abi.$0l4
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:I 1 115�I17� bJP1 1 ccriH b4 lxt
Address $$ ((�� J5C ►�
t� N Un a �(St1ree,t or Route No.) �9 ry
1Nst-.rt tt t� V 1 W M C_ O l
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 1-0 CO
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES O NO 0'
7. STATIC WATER LEVEL Below Top of Casing: GO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith ISA NCAC 2C.0118. l __ (j
9. YIELD (gpm): 7 METHOD 9F TEST 1. C. oh-l�k
10. WATER ZONES (depth): l# (0C)
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
or Weight/Ft. Material
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
From
From To Ft.
Topogr tc/Land setting
DRidge Mope ❑Valley ❑Flat
(check appropriate box)
La:51p�
N35 �ttieS3gituwga de of e14c�(et
(degrees/minutes/seconds) ,N(. a left
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
4J
Gl.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARVS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
tiSl- (VP
SIGNATURE OF PERSON OONSTRRE4 rcIEI1,E D DATE
Submit the original to the Division of Water Quality, GroundwateLSection, Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. FEB 1 3 2006 GW-1 REV. 07/2001
Asheville Regional Office
Aquifer Protection

From: Scott Gantt lo: Stephenre Wilson Uate: 3/L52000 lime: 9:42:44 PM
Page 1 of 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1_ WELL USE (Check Applicable Box) Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: EAST FLAT ROCK
KAY RD, OFF HWY 25
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER GENE WALTERS
ADDRESS 1250 PINNACLE MTN RD
(Street or Route No.)
HENDERSONVILLE
City or Town
828-696 2186
NC
State
Area Code - Phone Number
4_ DATE DRILLED 2/11/06
5. TOTAL DEPTH 340
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28790
Zip Code
YES ❑ NO Ei
180 FT
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface'
"Top of casing terminated at/or below land surface requires a valiance in
accordance with 15A NCAC 2C0118
9. YIELD (gym): 2 METHOD OF TEST
M. WATER ZONES (depth): 140
u. DISINFECTION: TYPE HYPOCHLORITE
12. CASING:
ARDM
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley Flat
Latitude/Longitude of well location
35.15.95 / 82.23.919
(degrees/minutes/seconds)
Latitude/longitude source: 0 GPS ❑ Topographic map
DEPTH DRILLING LOG
From To Formation Description
0 40 Clay
40 340 Consolidated Rock
Depth Diameter
From 0 To 45 Ft. 61/4"
11 GROUT:
From 0
I4. SCREEN
From
Depth
To 20 Ft.
Depth
NA To
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
Amount 8
Wall Thickness
or Weight/Ft. Material
SDR 21 PVC
oz
Material Method
GRAVEL MIX GRAVITY
Diameter
Ft in.
Size
Ft,
Slot Size Material
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
RECEIVED
MAR 27 2005
Asheville Regional Office
Aquifer Protection
GW-1 REV. 07/2001

rI UN I. 6cou Gantt o: 6tepnenie wnson Date: 3/8/2006 Time: 9:42:44 PM
From
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Ground
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTI
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # (704) 4
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PEI
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box) : Residential ❑ Municipal ❑ Industrial ❑ Agicultura
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
2. WELL LOCATION:
Nearest town: EAST FLAT ROCK
KAY RD, OFF HWY 25
County HENDERSON
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
1. OWNER GENE WALTERS
ADDRESS 1250 PINNACLE MTN RD
(Street or Route No.)
HENDERSONVILLE
City or Town
828-696 2186
NC
State
Area Code - Phone Number
4. DATE DRILLED 2/11/06
5. TOTAL DEPTH 340
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28790
Zip Code
YES ❑ NO ID
180 FT.
(Use'.+" If Above Top or Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top or casing terminated at/or below land svGee requires a variance in
accordance with ISA NCAC 2C.0118
9. YIELD (gpm): 2 METHOD OF TEST
10. WATER ZONES (depth): 140
ARDM
Topographic/L
❑ Ridge ❑ Slope
Latitude/Longitude
35.1592_5/
(degrees/mii
Latitude/longitude source: E
DEPTH
From To
0 40
40 340
II. DISINFECTION: TYPE IIYPOCHLORITE
12. CASING:
Depth Diameter
From 0 To 45 FL 61/4"
18. GROUT:
Depth
From 0 To 20 FL
14. SCREEN
Depth
From NA To
15. SAND/GRAVEL PACK:
Depth
NA To
16. REMARKS:
Amount 8
Wall Thickness
or Weight/Ft. Material
SDR 21 PVC
Oz
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in.
Size
Ft,
Slot Size Material
in.
Material
LOCATION SKET
Show direction and distance in mi
two State Roads or County Roads
numbers and common road names
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC. 2C, WE
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service ce
27699-1636 Phone No. [phone], within 30 days.
RECEIVED
MAR 27 2006
Asheville Regional Office
A•uifer Protection
D1

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) STEPHEN SLOAN CERTIFICATION#2854
WELLcoNrRACTORCOMPANYNAIa GEOLOGIC EXPLORATION, INC. Thom ,/ [phone]
STATE WELL CONSTRUCTION PERMIT,/ ASSOCIATED WQ PERMITN
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: HENDERSONVILLE County HENDERSON
3202 MAGNOLIA DRIVE
(Street Name, Numbers, Coaummity, Subdivision, Let No., Zip Code)
3. OWNER: BARBARA GERTHER RESIDENCE
Address 3202 MAGNOLIA DRIVE
(Street or Route No.)
HENDERSONVILLE NC 28792
City or Town State Zip Code
Areacode-Phone Dumber
4. DATE DRILLED 01/27/06
5. TOTAL DEPTH: 265 FEET
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing:6.0 FT.
(Ise "+" if Above Top of Casing)
8. TOP OF CASING IS 0.0 FT. Above Land Surface"
'Tap ateartq flashed attar below had mime requires •
variance in amwda cewai ISA NCAC 2C Alt
9. YIELD (gpm): N/A METHOD OF TEST N/A
10. WATER ZONES (depth): N/A
11. DISINFECTION: Type N/A
12. CASING:
Depth Diameter
From 0.0 To11.5 Ft. 2INCH
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0.0 To2.0
From To
14. SCREEN: Depth
From 11.5 To 26.5
From To
Amount
Wall Thickness
or Weight/Ft Materiel
SCH 40 PVC
Ft. Portland Bentonite
Ft.
Diameter Slot Size Material
FL2.0 in. .010 in. PVC
Ft. in. in.
Method
Slurry
15. SAND/GRAVEL PACK:
Depth Size Material
From too To 26.5 Ft. 20-40 FINE SILICA SAND
From To Ft.
16. REMARKS: MW-1 BENTONITE SEAL FROM 2.0 TO 10.0 FEET
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(dcgacdminutdaccooda)
Latitude/longitude source:❑GPS❑Topographic mar
(check box)
1=if DRILLING LOG
From To Formation Description
0.0 10.0 FILL
10.0 20.0 GRAY SILT
20.0 25.0
GRAY/TAN SANDY SILT
25.0 26.5 PARTIALLY WEATHERED ROCK
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common mad names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA I ARDS, AND TJI COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON . . dm I. ' Y.I WELL DA
Submit the original to the Division of Water Quality jAttn: IRoeuGE Rent, 1617 Mail Service Center -
Raleigh, NC 27699-1617, Phone No. [phone], with 30 days.
MAR 2 7 2006
Asheville Regional Office
Aquifer. Protection

•
RESIDENTIAL WELL coNSTRucc) on RECORD
North Carobn. Department or Environment and Netun) Resources- Dn won oI W o'er Qu4Lry
WELL CONTRACTOR CERTIFICATION s a 5 %
1. WELL CONTRACTOR:
}-rc n� S80214-
Wei (YWM0ua6 Nun
Gres-n ?1ver iA \\ ' �kyro
WWI Contractor Company Nun
STREET ADDRESS PO P3 O)C al `f
CGSf Ylattic- 7
I( o-i€aCo
City or Toywm Sate ZV Coda
( Pc6 )- 61 S-.zoo
Ares code- Phone number
2 WELL INFORMATION:
SITE W ELL 10 Ha aoaaaorl
STATE WELL PERMITHI appeoae) 05102 0lO0 416
DWO or OTHER PERMIT $(I appkwble)
WELL USE (Check App4'c3bI Boa). Rn.O.tnrl Wino Supply 0
DATE (FULLED a' I I ��17 O (O
d� TIME COMPLETED -00
0. WELL LOCATION: ' I
CITY 4X.y p�RA5cm) (Ile- COuNTY`t 0\GktASCJt
LofLfgGrLJ oaks1�ytu2
(Strom Name. NambrS. Community. Subde..on. La No Prot. Zip Cooel
TOPOGRAPHIC I LAND SETTING.
OSlope OVslley ❑FS1 ORaW D06wr
Wreak apprapnte Mu)
LATITUDE J5da7) ?IN
LONGITUDE j?2 d /41 3g&
LaatudeAongitude source: -IS�OPS °Topographic map
(Mcapon of wW must D anewn on a USGS top* map and
snatched to h bnn 1 not reap GPS)
4. WELL OWNER
OWNERS NAME in-Ct IADhe#5i1ne-
STREETADD ESS ?CS t50K.I40
hn kay.&r FL 3a414-
ty a Town State Zip Code
5()). 7b4 -(aµµ)
AM ❑ PM ct
May ba in deems
mime, womb a
o a decimal format
Arse code • PNorr nvrrOw
6. WELL DETAILS:
a. TOTAL DEPTH:
goy
b. DOES WELL REPLACE EXISTING WELL? YES 0
N
c. WATER LEVEL Below Top d Cheap: FT.
(Uw -e- I Above Top d Casing)
d. TOP OF CASING IS I FT. Abow Land Sunoco'
Top d cooing tennrated et/or bebw land surface may require
a nice n donee e W01 ISA NCAC 2C .01116.
e. YIELD (gprnr LU METHOD OF TEST Act' I^
Submit the original to the Division of Water Quality within
1617 Mall Service Center - Raleigh, NC 27699.1017 Phone No
From
6. CASINO.
I. DISINFECTION Type .{- Amoune
WATER ZONES roeornF
Flom To From To
From To From To
To From To
NM Du tar
From_ To A740 FI G tr
From To Ft
From To Ft
T Maness
Weight
;V. L
1. GROUT Depth Material
From 0 To 2.0 Ft bcf-jy;a1
From To Ft
From To Ft
8. SCREEN: Depth Dorrreter Slot Sue Malenr
From To FI in in
From To Ft in n
From To Ft n n
9. SAND/GRAVEL PACK
Dean
From To FI
From To Ft
From To FI
Soo
Material
10. ORILLING LOG
From To Formation Descrpoon
,5_ !7r)2
av ant,
t, ye7/i.v,tr,
ID— TO.,-144'.E��ihsea
II. REMARKS
W
co HEREBY CERTn Tv, r TM15 WELLPELL WAS CO4STRLCTEO W ACCORDANCE win.,
rSA PVC 1C. PELL CO.Srn,.0 TO. STANOARDS AFC THAI A COPY OE rN6
RECORD HAS BEE. PROVOE THE wELI Gone
SIGNATU OF CERTIFIED WELL CONTRACTOR DATE
n2a,y�twr.5i-4
AME OF PERSON CON
PRINTED RtCIIV tb
30 days. Alt: InforrmaTson Mgt.. Fair GW•la
[phone] eat 568.
MAR 2 7 AOOE 705
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELLconsrRUCTIO;. RECORD
North Carolina Ucptrvnent of Environmcnl and Natural Ka -scum -as P' slon ,n w AIR, QuaL f
WELL CONTRACTOR CERTIFICATION M a 5 '7 I
WM Caulaca (edMduai Naar
Cree-n ?tver LA Ik ' ?Any:,
WWI Contractor Company Name
STREET ADDRESS p0 jO)C aU
ELst YlAtkocJc. M( a€7a(o
City or Town Sent. / Zip Coda
( G93-)2.00
Area code- Phone mans
s
2 WELL INFORMATION:
SITE WELL ID ILO, acpoae) /� L+L
STATE WELL PERMITB(I aopwapel C C49- 0 113
OWQ or OTHER PERMIT Mr appicabS)
WELL USE (Check App/jiab&F Box):
DATE DRILLED 4I / //01
TIME COMPLETED 1/:CO
3. WELL. LOCATION:
1 I� COUN
CITY leo' /
Residential Water Suppry 0
AMAl_ PM 0
I c t4 Grab (ticks
(Suva Name Hunters. Community. Suoolwwn. Lot No Piaui. Z p Coos)
TOPOGRAPHIC // LAND SETTING.
BSww 0Valley Vet °Rage OOenn
(caeca appropnaw boa)
LATITUDE 3�7t 1 0 til
LONGITUDE OgLScl. (9' /f Itil
Laorude/longifde solace gtGPS °Topographic map
(bp.aon or we/ nap b. Norm on a USGS ropy mop .nd
.tfach.d to Gee bnn / not bong GPS)
4. WELL OWNER
OWNERS NAME fl�'A-t'�� P- 01 b1/12-X)
STREET ADDRESS Pb 1300-/a7
May be in degree,
misuse aordr or
m a decimal format
Ctyocei I&sta 11
C6y a T _ State Zip Code
czic ,- I95'S'QBU
Nee coo. • Phone norrcer
6. WELL DETAILS: �� 5 /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES D NO
c. WATER LEVEL Baow Top c1 Curio /O D FT
(Vas '•' E Above Top of Casey)
d. TOP OF CASItq IS I FT. Abo+e Land Surface'
'Top or caning tennrated eV or below land surface may require
a ~once p a000rderw vat ISA NCAC 2C .01/1�0.
.. YIELD(9pn): / METNOO Of TEST H"(Y
r. DISINFECTION Type TI -r Amount
g. WATER Z ONES I ospthl
From / j 9 To ! j From To
From To From To
From To From To
6. CASINO: Theeuasas
Depth D miler Wepm Mal.rel
From ` To 510 Ft Z 1•C file_
From To FI •
From To Ft
7. GROUT'. Depth Mai.ral M.tnod
From 6) To 20 Ft SAsrne ft M. 4?Cu(
From To Ft
Flom To Ft
8. SCREEN: Depth Darner Sloe Sae Mal.n.l
From To FI in in _
From To Ft n n
From To FI n n
9. SANDORAVEL PAC'
Depth See Maleral
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
0-- rp
is--4d
rQe - Qc
II. REMARKS:
r .>
l W AEA EBY CERnE> n*r n.15 W Ett WAS CONSrR.CTED Al ACCORDANCE on.
16 A IC*C 2C. WELL GO.STRI.CTO+ STANDARDS ANC TKO A COPY O TN6
RECORDrsAS BEEN PROVOEO rO DIE yt ELL OWNER
,2odT 2-9r-Cc
SIGNA(TTUUURE or C_E�RTT.IIFFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CON STf tale Mt
Submit the original to the Division of Water Quality within 30 days. Atm: Information
1617 Mail Service Center - Raleigh. NC 27699-1617 Phone No. [phone] ex r 568.
Mgt.,
Form GW I•
MAR 27 28W&D5
Asheville Regional Office
Aquifer Protection

RESIDENTIAL WELL coNSTRUCTIon RECORD
North Carolina Uetertncnt of Environment and Natural Kesourccs- Dia n,on m N E'er QuaLp
WELL CONTRACTOR CERTIFICATION IY oC 5 '7 I
1. WELL CONTRACTOR:
•
WN (ksdmdua9 Name
Gre.e,1 ever IAJ& ? KeND
W e9 Contractor Company Name
STREET ADDRESS Po Pa 0)C al)
Fas+Flat -Rom- M(ae7c2_
City or Town State y Zip Code
( ). 13-)zoo
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 10 LW appcaole)
STATE WELL PERMITI(d Appiaap Q61 V O/I2 ib I
DWG a OTHER PERMIT Kim Applicat a)
WELL USE (Check App cable Box): Residential Water Suppry O
DATE DRILLED a'r I o
r4r /
3
TIME COMPLETED . 3 0 AM 0 PM*
3. WELL LOCATION:
Cm: tAvW a.lA-
COUNTY 0=4141-4SCTr-
1 3 Lid Il)i(io[J
(Street Name. Nflrs, Community, Subdwaion. LA No . Parcel. Zip Coal)
TOPOGRAPHIC / LAND SETTING:
'Skip. OVolly OFMt °Ridge °Other
(Check appropnale boa)
LATITUDE 35 J 02.1j
LONGITUDE QQZ° 33' 42-ta
Lauttde4ongittde source: deGPS ❑Topographic map
(Ocean awe/ must be shown on a USGS typo map and
araohed to tar form 1 not carp GPS)
4. WELL OWNER r^ �-{,
OWNER'S NAME SAY L at fRr eleti S'Y1
UC41pp
STREET ADDRESS I rV2S Fig-✓M / ne
t-1-e_rrtusn S (I 1e1 IJL zv) a9
City or Town State Zip Code
J. (+lb-8033
May be in &Pta.
nausea, seconds a
n a decimal Lamar
Arse code • Phone number
6. WELL DETAILS: .' C
c7
a. TOTAL DEPTH: T
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO%
c. WATER LEVEL Below Top d Casing: L 0 FT.
(Use ••• 1 Abow Top d Casng)
0. TOP OF CASING IS t FT. Above Land Surface'
Top of casing Marinated Ala Wow Tend surface may require
a ~once in accordance When 15A NCAC 2C .0118./�
e. YIELD (gpm): I D METHOO OF TEST si I-
9
From
L.2CI To
From 139-To
From To
DISINFECTION. Type 44-ri-f- Amount
WATER ZONES (aepm) . pfe n
[ 2 s From
[ yo'fls YFrom_
From
6. CASINO:
Dean
From I To //,1 Ft
From To Ft
From To FI
�L
Darr/Mar
V ll
7. GROUT: Depth
From i' To 2 0
From To
From To
6. SCREEN:
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
From
From
From To Ft
To
To
To
Thickness
Weight Wral
2l.L do
(Mittens'
Ft. J?/.tLL7 rfriE
Ft
FI
Method
M.'v K Porte
Diameter Slot Size
Ft n n
Ft n n
Ft n n
To FI
To FI.
10, DRILLING LOG
From To
© —30
Sae
Matanel
Material
Formation Description
30— f L7 54kr` fr R
`!all Lfoc/C
do0 - [in" JI?✓f-ro r)'F
S`O foci
II. REMARKS:
W
V
100 HEREBY CERTIFY THAT nos WELL WAS CONSmuCTED W ACCORDANCE wail
ISA ROC 2C. WELL CONSTRLCTp4 STANDARDS. AND 'EMT A CCPT CF 1NRS
RECORD RAS BEEN PRO. DE TO THE WELL OWNER
/3/747 �> 2-/Y-Otf
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
/J
/� ,y I
a Vm.o Jn7r/J1
PRINTED NAME OF PERSON Content tr.)
Submit the original to the Division of Water Duality within 30 Days. Ann: Informs
1617 Mall Service Center- Raleigh, NC Z7699.1617 Phone No. [phone] ext 568.
on MgL,
Form GW 1a
MAR 2 7 200fe• 7/05
Asheville Regional Office
Aquifer Protection

U.'
RESIDENTIAL WELLconSTRUCTIO' RECORD
North CuoLrw LkpWnent or Lorirooment and Natural Resources P.'>..+n ..I •• flier Vu.Lf
WELL CONTRACTOR CERTIFICATION s a 5 %
1 WELL CONTRACTOR'
W W t.a .wx (Wdrridua0 Nome
/
t <Sr ?,ver IAIZ11 ' -ko.if)
Well Com-oam Company Name
STREET ADDRESS POjo1C air+
t=lat iCocc nJ(ae(o
Cory or Town Some r Lip Code
(Pis ,. P15 -)L o 0
Mee code Phone nunwr
2. WELL INFORMATION:
SITE WELL ID WI appao-.) STATE WELL PERMITgr apprppel 0 5 la 0 1 I 10 I EC
DWO or OTHER PERMIT 1(1 applicable)
WELL USE (Check AppAcatee Bo.). Ragents Water Suppy 0
DATE ORILIED t ` I O CO
TIME COMPLETED '' 00 AM ❑ PM.tC
5. WELL LOCATION:
CITY. 21 r (AS-inLVA. COUNTY axe
I LH o\G A& I A3( .C4 Z%'1 90
(Wee Name Nematode. Commoner. Subdewn. Lot No . Parcel. Zip CogI
TOPOGRAPHIC 7 LAND SETTING.
Slope (Oran °hot °Ridge °Over
(Ova epQ NSW nprl
LATITUDE 35c it
'I� 5$N
LONGITUDE 03Ztl..(TI S9(A)
May be ia dcpw.
mimeo, .mon& or
'MI a decimal Gomm
LaotLede/longlttdc sauce 9.9PS ❑Topographic trap
()coon d wN nwat G. shown o1I a VSGS rope map aeq
art.pnW ro U. aem F not rang GPS)
4. WELL OWNER
OWNERS NAME
STREET ADDRESS briSq
t—BI Z-oc)C_ ILK- 2 W? 31
cty a Town Sate Zap cos.
jns,. (D93--(03S7
Ara card. - Pna.. nwTlp.r
6. WELL DETAILS: .. TOTAL DEPTH. (DOS
D. DOES WELL REPLACE EXISTING WELL? YES D NCit
c. WATER LEVEL BOOR Top d Gating: FT
((tee -e- B ADO.+ Top d Caring)
d. TOP OF CASINO IS f FT. Abort Les Surface'
Top Or wing l•nnrvMd ago b4ow lead surf We rely rWwr.
• .aeon• n eoco ran 15A NCAC 2C .0116.
•. YIELD(gpM) t ia MET/4000F TEST . r
f. DISINFECTION T7pe FT / 4-{- Amo✓`r
g. WATER`) ZONE 5'oepin,
From ;975 To ).9t9
From
From
To
To
From
From
From
To
to
10
0. CASINO. Tacmes a.
Dept) Drac ter Weight Mawr el
From % To L y Ft L 11,1 PVC-
From To FI
From To Ft
7. GROUT Deter, Material NMp..V'00
From_ To�_ Ft <i4ktF/Lr µ;fig9O/?
From To Ft
From To FI
B. SCREEN Depth Drrnner Sue 5¢• Maun&
From To Ft w el
From To FI n et
Fran To FI n n
B. SANOORAVEL PAC
O.pn S. M.Wnai
From To Ft
From to Ft
From To Fe
10. DRILLING LOC
Formabo Deecrpoon
0dm /1D R.c�) Cl y
to - 35— Dhit*
ti e 0C C3a lfc 5 :/1
II. REMARKS
0
tCF
�'W ns. � 7C wEn CO.SmrrCnO.,t nA3 STAROMOSANO TNAT A COPY vOTED of M 11.6
rem,
RKORD rAS BEET. PRO.010 '^E NEu Or.RE.
R-/%:0G
SIG ATUR OF CERTIFIED WELL CONTRACTOR DATE
SR �Aw m'tl'
PRINTED NAltE OF PEPS0.. COR'S1
ECEIVED
Sutxnit the original to the Dlvlslon of Water Quality Within 30 days. Arm. Inform DOn Mg . Faro GW • la
1617 Mail Service Center- Raleigh, NC 27699-1017 Phone No. [phone] eat 566 R MAR 27 20067q6
Asheville Regional Office
pni lifter Prntprtiff

RESIDENTIAL WELL CONSTRUCTION RECORD
North Cuobr. Department of Environment and Natural Knourccs Dlr.,...rr .•I ..elcr Vu•Bp
WELL CONTRACTOR CERTIFICATION It a 5 '7 l
1 WELL CONTRACTOR'
lmrgn-u- Scn 4\4--ki
Wet Lur wear (Inuewwl) Nun.
Gr'e 11 Iver I 11 ' ?kr'tp
W W Contractor Con -pony Nan.
STREET ADDRESS POOtt. o.vf
4st i-latocK_ M( a�7.2.�
C.y a Ton Sm. Zip Cod.
(06)- 695-)Zoo
Ara cod.- Phone numo.r
2 WELL INFORMATION:
SITE WELL ID alit apaop.I
STATE WELL PERMITga .opraa.) 057 pc /,S f6'l
DVVO or OTHER PERMIT L(1 applicants)
WELL USE ICb.c. App.:aW. Boa). Raa.ntel Arno Supply 0
DATE DRILLED 3raitLa'
TIME COMPLETED Li co
3. WELL LOCATION:
crrr 14LthctinsCrot(r-a
AM o Pmgt
COUNTY hwu:'1 S0
itt Fi (j)(C'Or uAq LaLtf e
I5V..t Name N.-enters . Canmontry Suoaaucn. La No Parcel Zrp Coal
r OPOGRAPHIC / LANO SETTING.
OSlope DWhey OFII ORg9. DOR»r
(a.ca mycon.. to.)
/v
LATITUDE S_63r 3tr l
LONGITUDEQZC over 3ZLJ
May b. a anginas
oa atato. e•oadn a
in a dccwl formal
LaonY7c/Iongrludc source SOPS OTopographic rnnp
(paamn or wW mink M Mown cans VSGS typo map end
anti d ro ow loan / no( pang CPS)
♦. WELL OWNER p�>
OWNERS NAME �1O- v i, cek- UL-n-'1--GLgx a-
STREETADDRESS J3C <> Ili- YKkm (244
4 iLd-rosis'iUi1e, 0(zYrl7I
Cry a T on Stan. rip Cato
Air COCA . Pnon. nwrc-
6. WELL DETAILS:
a. TOTAL DEPTH: (o4 5
o. DOES WELL REPLACE EXISTING WELL? YES 0 N003V
c. WATER LEVEL B.ow Top or Coney. /00 FT
(Uri '•' 1 Aoc../Top d Cary)
d. TOP OF CASINO IS 1 FT. Above Land ono
'Top or carry t.nnn.E.d Ma Cato. land .url.dt fray r.pulr•
• .trance n eccoroanaa win, ISA NCAC 2C.0116.
• YIELD(9Prn) /' METHOO OF TEST
I DISINFECTION Type Ti
9. WATER ZONES .Hprni
From /4' 0 To /Ua7 From
Frain To
From To
B CASINO
From
Ftom
Arno writ
to
To
To
Tnrc•mrsa.
D.qn D n)ele, Micro aur.I
From—_ To 6 ,' FI a -- 2/.4 ✓c-
From To Ft
From To FI
7 GROUT Deom Material �f M.UoO
Z Flom 0 To 0 FI S//-kakil{/'
K E;y1 ),)
From To FI
From To Ft
6. SCREEN D.PIn Demeter Slot Str• Matenal
From To FI n n
From To FI n n
From To Ft n n
9 SANLYORAVEL PACa
Dean Soy Matsu...
From To Ft
From To FI
From To FI
10. DRILLING LOG
From To
o-3J
: 0 — 72
Ayra
R€D
MAD O6
F ormauon De.cnpoon
PitZr
-S1TOt.'is
IC
Asheville Regional Ottice
-Ae ife--Protection
II. REMARKS
r oOnEREB• CEann Thar TwiS r.ELL ry A5 CONSTRUCTED �E rrn.
rya RCCK+NEL, CPST-OuCT%T SIAr,DW1nARO^.ti S
RECORDn.5 BEE,. owPIXC(I T^f '* LL pVOIER
S NATURt OF CERTIFIED WELL CONTRACTOR
PRwitaJt— 5, /iti
PRINTEDNAME OF PERSON CONSTRUCTING THE WELL
2-22-06
DATE
submit the original to the Division of Water Duality Wtthln 30 days. Aral. information Mgt..
1617 Mall Service Center - Raleigh. NC 27699-1617 Piton. No. [phone] .AI 565
orm GW• la
Re. 7/05

Carolina Department of Environment and Natural Resources- Division
North of Water Quality
WELL CONTRACTOR CERTIFICAT ON # 24 Nei
1. WELL CONTRACTOR:
De v:.c_V\SatAyecs
Well Contractor (Individual) Name
CAVA. 6a.ayecs Son
Well Gontractor Comply Name
STREET ADDRESS 1,t 5 'Kies) aW
11“)-
�ncsNt
City or Tdwn` St7ate
(eat)- toes- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(Happlicable)
8" 93
- Zip Code
STATE WELL PERMIT#(8 applicabie)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED a /s— re
TIME COMPLETED V / 6 O AM i] PM fr,V1
3. WELL LOCATION: ee
CITY: A--,c4, Sc.+ p, _ COUNTY ///Mr2.4r1-1:3#7
cd oV" /# c 6 Mc<
(Street Name, Numbers, Community, Subdivision, tot No., Parcel, Zip Code) ---
TOPOGRAPHICOP1/ LAND SETTING:
agape ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE $
LONGITUDE
May he in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: OGPS ❑Topographic map
(location of wen must be shown on a USGS topo map and
attached to this form 7not uskg GPS)
4. WELL OWNER
OWNER'S NAME YZOsQC Cc.c?Q cl%Qr
STREET ADDRESS '%5 WQ.t\.ca Vtoda
1-lacseShoe 0c. aSri tit
City or Town State Zip Code
(1:;Q8 > 8CX\— (o(daa
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: . 30-5—
b. DOES WELL REPLACE EXISTING WELL? YES YES 0
c. WATER LEVEL Below Top of Casing: 7
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS , FT. Above Land Surface'
'Top of casing terminated agar belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): J METHOD OF TEST aZi
NOtg'
FT.
RESIDENTIAL WELL CONSTRUCTION RECORD \/" 3 A stt (�
3 2 4 3 eD O
f. DISINFECTION: Type P' II Amount /5
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
From / Depth
/.3% Ft do AFrom To Ft.
From To Ft.
Weight Mat
SIJ.PIII Ps94c-
7. GROUT: Depth Material Method
From 0 To aO Ft. C..tMQat- ?Ouch
From To Ft
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
From To Ft.
10. DRI W NG LOG
From To Formatim Description i ?% d u[r Liter, f .
/3 7 ?cl`S ,.o-, , S�
11. REMARKS:
RECEIVED
,: 1 7r1_'
\ A 1 LJLII
lifer Protection
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WE WNER.
i/6'6""
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
cpt />la zl —54tvY s-s
PRINTED NAME OF PERSON CONSTRUCT NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #- 2y
324337
1. WELL CONTRACTOR:
ecs;c11‘ \. 50ssecs
Well Contractor (Individual) Name
C\wde h Son
Well dontractor gompaby Name
STREET ADDRESS tM2 5 W.TA' ao9
lloi ics?NC 98-143
City a Town, Siate - Zip Cade
(8a8)- (otes- aoaa'
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#fdapplicable)
DWQ or OTHER PERMIT #(8 applicable)
WELL USE (Check qD•p likable Box):
DATE DRILLED of /4 -c
Residential Water Supply ❑
TIME COMPLETED 3 .3 t. AM O PM 13-"-
3. WELL L CITY::u# Qm(NyCC� n hl. /la COUNTY llei'tdP^SC/1
(Street.JV2
Name. Numbers, Community. Subdivision, Lot No., Parcel. LP Code) -
T9POGRAPHIC / LAND SETTING:
lope ()Valley ❑Fiat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ()GPS Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form snot usig GPS)
4. WELL OWNER
OWNER'S NAME IQ 0CV1sa +M'.\\pc
STREET ADDRESS ` 1c (o QSc7\54 O`!1 Na7
\Aoc4e oi,oe yjC a87 L.td
City or Town "State Zip Code
( Bag > t3c1° Stoa
Area code - Phone number
May be in degree;
minutes, seconds or
in a decimal format
5. WELL DETAILS: a. TOTAL DEPTH: 3 O d
S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LR'
c. WATER LEVEL Below Top of Casing: \_5-4° FT.
(Use "4." 8 Above Top of Casing)
d. TOP OF CASING IS ` FT. Above Land Surfacee
'Top of casing temmrated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): SO METHOD OF TEST (1.7.Q
f. DISINFECTION: Type pi IL 5
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
Amount / 9
From To
From To
Fran To
Thickness/
From / Depth
(nS Ft.
.� eter .Sne,(/o11 batsipi.
Fran To Ft (a�/YY �011 �e��
From To Ft.
7. GROUT: Depth Material Method
Fran1_ To 2O Ft e..CfrteL ?cu.cec\
From To Ft
From To Ft
8. SCREEN: Depth Diameter Set Size Material
From To Ft. in. in.
From To Ft in. lo.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft
Size Material
10. DRILLING LOG
From To
S-
a, s J 8J-
11. REMARKS:
Formaticn Description
nOre %c.olen
(,- t.T%h-
Asheville Regional Office
ro ec ion
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, No THAT A COP! OFT IS
RECORD HAS BEEN PROVIDED TO ,T>R WELL OWNER.
o2/`-
IGNATURE��vOF CERTIFIIEWELL CONTR'-.CTOR DATE
l2er//cif !it'-X c&&yP/'S
PRINTED NAME OF PERSON CONSTRUCT14G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

North Campo. . Deprtnent of ErwIrorvnant and Henna! Reaoracea -Melon of Wet a+eAty . Groundwater 8aoI$on
163E bALN Sevke Cantor • RWlph, N.C. 27600.1696Ptone (ftq 723-3721 WELL CONSTRUCTION RECORD WELL CONTRACTOR. g'4,-/4/ri-le2 ,
WELL CONTRACTOR CERTIFICATION 6: 7 /73
STATE WELL CONSTRUCTION PERMITer
49q
1. WELL USE Can);
nwek Applicable SReefderNW Dblp Munal 0 indwbiel 0 AErloulIural 0 Moneeenp 0
Recovery [] INN Pump Wetter Injection ❑ Olwr it Other, UN vac
2.
WELL LOCATION�� pkelsh of tore location below)
al//c_ rage •Pc/.
,raw Name and Nu rAws , r 01rbdINrkn and Let No.)
3.
OWNER 7%%W ,P/�
Address //�(�t 6ae(, ftpraa h'67/ L¢.
F7� C,JCL N•c
City et Town Stale
4. DATE. DRIU.ED 3C
5. TOTAL DEPTH
e. CUTTINGS COLLECTED YES Q NO
VD Cede
Nearest Town. courd r /?oo d e,e c rW
DRILLING LOG DEPTH
From yyTo
4y- 2 5'
'A
Z4TD-2Szr °fee,/ee,
Z2i-31:1c Ac
7. DOES WELL REPLACE EXISTING WELL? YES [] NOCK
S. STATIC WATER LEVEL Below Top of Cramp: FT.
(Use •••IAben Topel Crag)
9. TOP OF CASING IS / FT. Above Land Surface
•Tee of enl g atmlnated Wet below lend nrteee requires a vsslrw In eeeew
donee with 1$A NCAC 2C .ot1S
10. YIELD (0pm)• METHOD OF TEST
11. WATER ZONES (depth).
12. CHLORINATION: Type Amount
13. CASING:
WY ttM, n
From I Dopib To W7 n Dflr r Wald
From To FL
From To Ft
14. GROUT:
Dspih
From / To Go Ft
Motorist
Corn e14''
Front To Ft
15. SCREEN:
I1 additional apace Is needed use beck of Item
LOCATION SKETCH
(Show direction end distance from a1 Nut two State
Roads. or other reference points)
)C
Method e // 7t/Rd 0; d d / ,Rd
dgPct eve, A'4-
©v
Depth Diameter Slot Size Material
From To Ft In. In
From To .__ F1 In __ In
From To _� Ft In. _,_ In
10. SAND/GRAVEL PACK:
Depth Sire Maerial
To FI
To Ft.
From
From
17. REMARKS:
/ A1#%
t DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 20, WELL
CONSTRUCTION STANDARDS, ANO THAT A COPYF THIS RECORD I1A$ f FEN PROVIDED'!�O THE WELL OWNER.
FOR OFFICE USE ONLY
Cued Net
Seals' No
UIRE OF PERSON CONSTRUCTING THE WELL DATE
Sabra odanat te drlNen of Water ouay. Omundr.Wr seem within 30 days
_0w4 REV. ISNM
RECEIVED
AshevWC Ren,ionE O Zit e
fti^'a tr Pion I =9"

RESIDENT/AL WYLLCONSIRUCTION RECORD
North Carolina E)cpvmwnt of Environment and NMUN Kcsaurccs 1> u.un 'A .Icl (Jualin
WELL CONTRACTOR CERTIFICATION e
1 WELL CONTRACTOR'
VVM Cw;.smr (MWNtdual) Ne ne
61 e. C-r11ver kJe\I Vile/..o
W W Contracts Company Names
STREET ADDRESS Poriloic aU4-
Fast Flat +Zoc.K- NC a€7'(o
Cry ce Toen
State / lie Coo.
Nee code- Phone nunO.r
2 WELL INFORMATION:
SITE WELL ID Wr .poorn.l
STATE WELL PERMITN/ tiWiwa.) 075'+J
DYA or OTHER PERMIT 6l6 applocade)
WELL USE (CMcit AppicaW, Boa). Rn d.rltial Watts SLQply 0
DATE DRILLED 3h�3/0La Lt TIME COMPLETED o 0 Nd 0 PM 14
3. WELL LOCATION:
,�,� 77,���
Cm' 4--e-aI1So i0;11- COUNTY 42-4p��cn)
Uta A(e(4fr k CSlakSi 2&Qe4k'OOC,
(SINE Name. No mb re. CanmuMy. SuDanton Ld No P.rael. Zip Coo.)
�TOPpG RAPHIC/ LAID SETTING.
t9d0pe oValley oflat ORadge 004»r
low° 199100nele Dag
LATITUDE u /'/ 3oA/
LONGITUDEQ 2 jo' cZ3A)
L atinliG/Idngilade source GPS OTopogynphic rnnp
nowiton d we/ in de Norm on . USGS topo meP .rW
.R.ch.d ro ON loan 1 not wag GPS)
e. WELL OWNER
VO5 r (o93 -4to7/
N» cod. • Ptton. nwno.l
May be in &prow
miaula..eowrdt or
it a deccn.l format
OWNER'S NAME li6EAA I rla'VSctalI
STREET ADDRESSa(AO I0 _1(p-ne lOL led
44.2&CLc.4,curtu(i/P, "IC- -?5737
City or ro..n Sut. Zip Code
6. WELL DETAILS: n r
.. TOTAL DEPTH: ia `( �
b 00ES WELL REPLACE EXISTING WELL? YES O NO tia
Topd c.. 5� FT
c. WATER LEVEL I SeigleAbove Top Of CasiN)
N
d. TOP Of CASINO IS I FT. Above Lang Surface
'Top d wing tearenated silo/ Coign Ind surface may require
• wwraae in accordance a.an 15A NCAC 2C .0111T0.
.. YIELD (ppm) METHOD OF TEST t'TI r
a5'71
r DISINFECTION
q. WATER ZONES ;aepin,
From /-1r7
Fran / %C
From
6 CASINO
From /
From
Flan
10
To /91
To
0.pin
o E FI
To FI
To FI
7. GROUT Depth
Fran 0 To.110
From To
From To
6. SCREEN NON
From io
From To F
From To F
832
Amo Wrl
From to
Flom To
Fmm To
T neon —was
Celiiner Wapnl Mat*rwI
aL F'�
M.l.n.l
Ft 5arnatP—
Ft
FI
9 SAND'ORAVEL PACK
D.pn
From
From
Fran
10. DRILLING LOG
From To
O -4
To
To
O
1S'- .34-
DP.mlrSue melons!
F
6-0 — '7D
%0 - Zat?
II. REMARKS
n
4RECEIVED
n n
See Malarur, a...
rl 4shevllia Rg;ffic
Ft Jiquitcr Protection
F orma bon De9Crpoon
kd) Ubty
Rao,- - SR// Reek
53.�/i Raj-
CMAJ /fe_..
0
�---
pA NC#C nEREBY ?1hL C .sr rui5 En. was ID.5 ANCCTEO A ACCCOPY 1,O w
RECORD nAS BEE,. PNO+SOft) rr. i`.ETAEi OS. ERd TMrAC�v CoO'rwS
SIGNATUR
PRINTED N
oc
DATE
OF CERT IFS IED Vv ELL CONTRACTOR
E OF PERSON CONSTRUCTING THE WELL
y
in
0
ys. Ann
11,17�Myl Service Center- Raleigh, NC 27 99-to the Division of 1611 Phone No.3j919) 733-7015 'xi 565 tton MqL.
Fam GW• la
R e. 7 i05

324S i
RESIDENTIAL WELL CONSTRUCTION RECORD
North Cool n Ucpvvncnt o1'Environment end Hanel Kwourcco Dv. no it . 0 '^ •Im' L1u41r
WELL CONTRACTOR CERTIFICATION a oQ 5 %
1 WELL CONTRACTOR'.
VVM Gad— (Inaaduill Noma
e_n ?Ives We11 ,Kip
Won Caw.cta Coepany N✓"
STREET ADDRESS Po rJ O$- al)
4st Fick t +Zoc x r� C ? V 7a c0
Cory a Tosn Sat. F Zip Co&.
(06 ). 693-1zoO
Area cods Pram numbs
2 WELL INFORMATION:
SITE WELL 10 Nit appa.I �//n7
STATE WELL PERMITN• alwroaa.l 3 fl9 n / I /c(ar,
DWG Of OTHER PERMIT N1 appiaW.)
WELL USE (CMCK Appl abM Goa). Rnisna Wns Suppry 2—
CATEDRIUED 3-1 t -06,
TIME COMPLETED o2. 30
3. WELL LOCATION: I I' ,,
CfTY f a.-t.LL-' COUNTY TM1dJ .sc>7
09 JL( 41.t4. Milsbr(
(Strom Nam. Nonc.m.. Canm.Ny. Sucanon, La No Parcel Zip Coast
TOPOGRAPHIC 1 LAN SETTING.
(41o130 VWay Ong ORIdp. °Otna
Ionia .opropn.Y pa)
LONGITUDEQZL air Lk t4
LAT IT D DE
AM ❑ PM (5L
May b M dspaa,
miasma, awards a
o a d.emal format
L4atudcAonglwde solace OOPS °Topographic crop
(averse of wool nag D. .newel on a VSGS typo map .n0
.4nh.0 to gm. Vern / not wp GPS)
4. WELL OWNER
OWNER'S bo`M 'S NAMEHittk-I
STREET ADDRESS PD rapY 036"
-D o 4». 0., n3 c a cs
Cry or Torn Sat.
fa IC I. io g r - o t1L
Zap Cod.
6. WELL DETA4LS: 1
a. TOTAL DEPTH: Ja`
o. 00E5 WELL REPLACE EXISTING WELL? YES 0
C. WATER LEVEL Satyr Top d Carp. 3 0 FT
(U6. ••• 1 ADota Top d Carp)
d. TOP OF CASING IS I FT, Above Land Sutac.'
'Top d wing terminated .Mai ISACAG merino' Wow 1.50 A116. y r.pu.•
wn
a arty. coatdanw
NOS
.. YIELD (gpm) 5 0 METHOD OF TEST A - fir
I. DISINFECTION Tr p. if-%T(
Amount
g, WATER ZONES !o.Urni
From /GO 10 /03- from to
From to From to
From To From To
6. CASINO 7Notifies r
Depth D'a tot W.pnl Maliral
From / To n Ft G f 2/ C. /rC
From To Ft
From To Ft
i. GROUT D.oln
From Q To a Ft
From To Ft
From To Ft
6. SCREEN
From
From
From
9. SAND''ORAVEL PA
0.pin
From
From
From To
10. DRILLING LOG
From To
M[[ah on&
rria�/T(11E'fH
M.Voc
tScct
ev;Ile Regiulial 0fiIce
er-Protectiol
Fomuoon O.acrpoon
7-
it O - 3 D tNSF// Rock
SO /2 C l7RA-v tr
r — 4D
710
II. REMARKS
CO OEREar CERTIFY TMr nos S ANO CONSm0CTEg • CCOO cl fl, f wen.
RECORonAS aEEIN PRPSOED r (TnELOnNERDS O mMTaur.d MS
3 -I,C-CC
51GNATVR OF CERTIFIED WELL CONTRACTOR GATE
y2 Irctt r 41/ )
PRINTE
AME OF PERSON CONSTRUCTING THE wEu
Submit the
Division
days. 30 6oon Mpt.
1Mall 5.ice enter - RSlalp, NC Z76991E17Phn. No(917337015 a II 58
F wen GW•1a
Re, 7A5

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Ucpvtncnl or Environment and Natural Kcvourccs P. I>i..n •" .. cicr ()Wail)
WELL CONTRACTOR CERTIFICATION N a 5 '7
I WELL CONTRACTOR'
? ela-I1 t5m
WeilIA. 'car (bdMduat) Nana
Grey-1 tV P( 14)" �k/ J�
Wet Convect. Cor '.ny Nana
5TREET ADDRESS PO Imo. OS- aU
St Y lA r +Z0CK iv a is 1‘2, c�
City a Town Sato r zap Code
(Pis ,• 693-)2_oo
Ana cods Piwna numbs
2 WELL INFORMATION:
SITE WELL ID Nd sopaata•)
STATE WELL PERMITINO apprww) 061 oo (/ 5 5 0 3
DWG a OTHER PERMIT a(/ appfwoN)
WELL USE (Chock Applcade Box). Radwnal Wctat SWAY 0
OATEDRILLED /5-0(0
TIME COMPLETED
S. WELL L ATIO��N: ee��[��pI /,,
CITY-,(.LI-UI SE5 i V I I I I' COUNTY" l e L\Ct�'-IS 61'1
3OOSabi /0-ho7,OYI
(Seam Nam,. N✓nMf. Comm 'My. Sutdiuson. lot No PMMI. Zip Cooal
TOPOGRAPHIC I LAND SETTING.
OSrop• OVWry rut ORdW DO6ar
(Enc. app.-oprLala tug) •• II
LATITUDE 0L•lr l7N
Laoluddlongiadc source VOIDS ❑Topographic reap
(Eleamn d we1 naNl D• shown on a VSGS rope map ena
•neNrea tv ma ban F not wag GPS)
4. WELL OWNER
OWNER'S NAME ULC\ (°. VQh� JO SOI1
STREET ADDRESS a. (Li" Snail OYI %2C7
sir)nv (ik-ei NC zS''ii
cey a Town Sato bp Code
$2'6 ,. to9S 5 Lico
Nee code . FTon• nurrite
LONGITUDE
i;od
May la in dcp a.
minute, tccaldt 01
o • d¢wl rermat
6 WELL DETAILS:
a. TOTAL DEPTH: 3 0 5
o. DOES WELL REPLACE EXISTING WELL? YES O NO
G Cl FT
c. WATER LEVEL Baas Top d Coati).
(UM1 APP." Top d Caen?)
Toe OF CASING IS , FT. Above Land Surface
'Top at casing tennrated Slot Mika" and ,utlace may rebut,
• anent* n eocoraance wet ISA NCAC 2C .0116/.y
aO METHOD OF TEST � I r
•. YIELD (9pm)
6.
I. COSINE ECTtON Typ• 47/ iil Amount
9. WATER ZONES !prom:
From. To 2 7J From To
From Io Flom Io
From Io From To
CASINO T moan••
Dam.i,l WYpnl Malarrl
Ft L zic Pdc-
Ft
FI
Oman
From / To Lte?..3
From To
Flom To
7. GROUT Dvpin
From U To D Ft
From To Ft
Flom To FI
6. SCREEN' 0.pin
From To
From To
From To
9. SANO'ORAVEL PACn
D•pin
From To
From To
From To
10. DRILLING LOC
From To
D— /5
/5-- to
f(jo- jo
7O - gos
II. REMARKS
Mal.Ml M• ,00
SASS<io: M;jtiMe
Ornvtei Slot Su• Malanel
FI
Said
MalaOi/'
Ft
Ft
Ashev!Ife Heg onal Orfice
Amite/ Protection
F ormaoo Deecrpoon
Rod C/y
5e4Al 73Sc %L /
53i,r!/ /Sac,/*
Rn,oi r
-n
rvm.
r0 HC.0 e7CC C'EL, CP.sTH,C T S1AnWAP5on01M1 A CO 0,5E
5
AECORO nos fn Pep. Of ' of PELL OrvnfH
LL
S IGNATU E OF CERTIFIED WELL CONTRACTOR DATE
/fSin /
PRINTED
A COME OF PERSON CONSTRUCTING TIE AELL
Submit
Watera11days. ` Forma Dort Mgt..
$1Mall Servlc. Center Ralel91, NC n990117Phone No(91733.7015
F a m Cw la
R.. 7,05

24829
RESIDENTIAL WELL CONSTRUCTION RECORD
North Cambria Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N rX 6 '
CONTRACTOR:
attta
Wei Camadto' (Individual) Nam.
Geer, er IAJe11 l.tO
Well Contractor Company Name
STREET ADDRESS PO P OX a'U
�ast mist -ROcjc.. N( ag7a_(�
City or Town State zip Code
IPSS )- P15-)2-OO
Area code- Plane number
2. WELL INFORMATION:
SITE WELL ID sit applicable)
STATE WELL PERMITsa awncabIe) 0S/ :ZOI oz. /rc
DWO or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply tr
DATE DRILLED 1 -/ 2 -06
TIME COMPLETED Y', 3 0 AM O RM a
3. WELL LOCATION: ��// II
CITY' EfiaidgkeS0t7Uili.� COUNTY kifiddrrLSOW/
(Street Name. Numbers, Community. Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
(gSkrpe OVallay ❑Fit ORkOge ❑❑ter
(check apWopnate box)
LATITUDE
Zt2 ' 4/ W
LONGITUDEOI2"ZQ' bOxi}
Laotude/Iongitude source: ErGPS ❑Topographic map
(Gabon awe/ must be shown one USGS topo map end
attached to US torn 1 not tang GPS)
May be in dogma,
minutes, seconds or
in a decimal format
4.
WELL OWNER
'SADDAMR EES�./J S :C�varC,✓1inr��/Ud '1let.L4t't4OW
ell
SRNEEERT
2.4 5U t-e, nL2 '%?
Cryaart State
Zip Code
Area code • Plane number
6. WELL DETAILS:
a. TOTAL DEPTH: OJr
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO B"-
c. WATER LEVEL Below Top of Casing: /5 F FT.
(Use*** 1 Above Top d Casing)
d. TOP OF CASINO IS i FT. Abow Land Surface'
'Top of casing terminated aVor below land surface may require
a wren in accordance with ISA NCAC 2C .0118.
e. YIELD (9prn)' /g. METHOD OF TEST �tIZ
1. DISINFECTION: Type Amount
g. WATER ZONES (oeptn)
From /00 To / 625- From
From /'/ 5 To l f° From
From To From
6. CASING:
Depth Demeter
From / To L 0 Ft L t
From To Ft
From To
7. GROUT: Depth
From (7 To . 0
From To
From To
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
[h — 5—
II. REMARKS:
Ft
To
To
To
Thickness,
Weight Materal
t/.G PdG
Material
Ft Se/Ar?tLf/i
Ft
Ft
Method
AL/SigiVe
Demeter Slot Size Matenal
Ft. n n
n
See Matenal
Ft.
I Ft.
FtAshevilfe Reyiondl Office
_ Aruiter Protection
Formation Description
tar
/rr
Y7l�r✓ r fr
i CO HEREBY
NCAC 2C. WELL CONSUCTxa+ STAND.W DSS AND TRAY TRUCTED IN ACCORDANCE WITH
A COPY OF 'BLS
ISA TR
RECORD HAS BEEN PROYDEq•r0 THE W ELL OWNER
atf
S GNATU ccyyE OFCTSFIED WELL CONTRACTOR 3 �DATE
PRINTED -NAME OF PERON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: Information Mgt.,
1617 Mall Service Center - Raleigh, NC 27699.1617 Phone No. [phone] eat 568.
Form GW -1a
Rev 7/05

3 7 4 8 2 8
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department or Eneironmcnt and Rabat( Amur -us- Prcualrn
WELL CONTRACTOR CERTIFICATION N 4,2 5'71
1 WELL CONTRACTOR:
7-)r(/(Lat t$rn
Vale Cass-w IA)
(tndmow0N�aIn.
6re� eT �tver' ' ar.p
vv.,' Contractor Company Nana
STREET ADDRESS PC (3 DX aDi
fast rIat fCoc.K- M( oZ€%02(o
Stet. 7 zip Goa
Cary a Town
tgA,• 693-1200
Are code- Rhona number
2 WELL INFORMATION'.
SITE WELL 10a<1 apvowl / n/-�
STATE WELL PERMITS(. apµwor.)0 (0/Qo /
CPWD or OTHER PERMIT P(1 appac.d.)
WELL USE (Crock Ao tae Boa,
Rri0ontal Watts Supply❑
DATE DRILLED o�-t Oi (p
TIME COMPLETED
0. WELL LOCATION:
crrY j1a-64SonUI(I-F_ COUNTY
.3:00
Amo PMlpt
(AT oiltne(`rap 12�
(Snot Name. Numb 's. Canmpnay. SuodwtRm. Lot No Pwc.I Zip Cool
TOPOGRAPHIC / LAND SETTING.
QSlop. OValtry I& Ridge GOWN
(ass aPPrWMtr op•,
LATITUDE _acJS ii
LONGITUDE .Q$Z a 5 ' Oka]
Laarudn/bngltude source GPS oTopograptuc map
()w.Ppn of wet mu* a Yell on . USGS topo mop .no
.Ncn.0 to 61. Form / nor owl) GPS)
N. WELL OWNER /`C C 1_.. �,L�
OWNER'S NAME CCC 1 (1 � �IC'_ f
STREET ADDRESSI' O laTt7vk' 3
May b. in &p a.
casino, aide a
IT • d•c naI tonnat
plat 00ct NC_ $"731
Cty a Town Sat. Zip Cod.
Ct ?b 1. (0 61 a/ 13
Aar cod. • PTon• nwro.r
6. WELL DETAILS:
a. TOTAL Dcp'TN'. r? LC S
b. DOES WELL REPLACE EXISTING WELL? YES G NO\i4
c. WATER LEVEL Bolan Top or Caws. / CO FT
(Van -•' 1 Aoo.. Top d Casino)
d. TOP OF CASING IS FT. Above LMd Surface'
Top of cawing I.rmng.d s'or blow and soda may/Nuns
• wiarw n .ecoyr\d.no. writ ISA NCAC 2C .01I6.
I
YIELD (9pm, IIv METHOD OF TEST A r
I. DISINFECTION T Tp. ./.1-1 TI Amount
WATER ZONES 'arpm,
From Z AT) To 2#.0 From To
From To Fiom To
From To From To
6 CASINO Tnrcan.>s.
Non Da tar Wapnl M.jwral
From To !Da FI / zi,c i`G
From 10 FI
From To FI
7 OROUT D.pin Maim& maraca
MmaracaFrom 0 To 2 D FI SltkaatA: Atli -ttoct
From To Ft
From To FI
6. SCREEN D.ptn
From To
From
From
To
To
Sloe C.
I all
9. SAND/GRAVEL PAC
GREAT,
From To
From To
From To
10. DRILLING LOG
From To
/— /0
r
FI Cd if G LJ —I
FI n n
So• ... .. Mal.nar� ...
t
FM1Wiire Regional Office
FI Aquifer P rntectinn
F ma6on .cryDon
, ad rIety
nIR*
L2oc600- S 4.=/l
t3l
DO '<Afire CAS corisTnuCTtO
its NCAC TC n En CP.SmrL•C$rYnaEr�tBt'anMRPS OTuATrn CORY Or SACCOE0ANCE nm.
RECORD rr.5 BEEN YAP. Of 0'0 'V nEtt t ER
SIGNATUR OF CERTIFIED WELL CONTRACTOR GATE
1 izy ituif 6o / 9 h
PRINTE AME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Watw Quality within 30 Clay.. Ann: inrom,aoon m9 t,
1617 Mall Service Canter- Ral.rph, NC Z7099-1017 Pnon. No. (919) 73.3-7015 .al 506
am GYV,11.
R., 705

NPD 32 4 2 l
RES/DENTIAL WELL CONSTRUCTION RECORD
North Cavan§ Deportment of Environment and Natural Kneurccs D '> r. . _err Quality
WELL CONTRACTOR CERTIFICATION N a 5 %
t WELL CONTRACTOR'
WM Cartkactinr (MWMdual) Nara
6rec 1 Aver keel ?uyND
Wed Cawsaor Company Name
STREET ADDRESS PO j3 OsC a0"4-
Fast Flay -kocx- ( g 7.2Jc
City Of Torn Sate r ZIP Code
(4 ). 695-Izoo
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID Co appaDr) _n p
STATE WELL PERMIT/(a apywael h% /001035 /
MVO a OTHER PERMIT INV applicable)
WELL USE (CNeca Appocatno BOR). Rn ama Weer Supply (y
DATE°FULLED 3/a 'fl 0 fo
TIME COMPLETED I.0 0
AM O PM*
3. WELL LOCATION:
crry 1/4I-2.Incl 5 (.1-7143/ 1.1-140UNTY(-C,(4.0WSOrl
6 31p g0.st & Led ai ci yz
ISnet Name, Number a.tomm✓ey. Sleanaon. Lot NO Parcel. Z,P COCA)
TOPOGRAPHIC t LAND SETTING.
0 Slope OVMIey OFIa 131�&d9a 00tt1er
lawn aPP..bI��''Wnale owl
LATITUDE }�'ppF2Cli
LONGITuoa•[iei t 33 GJ
Laotude longnudc Source OOPS °Topograptuc map
(onto., d.•M must TAP a1pmrl on • USGS tope mop ono
anima to we tom I not rang CPS)
4. WELL OWN fr
OWNER'S L J--r 13
L a a-
NAME
ST EEry T ADDRESS ed
t sYtill t/ l ? ? izip. '19Z
May In is &roe
CILIA/WA wood& or
u • decimal Format
ry a %me State
tQ4)- (oS'371.111
Alva MOO - Prone numanst
6. WELL DETAILS: a. TOTAL DEPTH: 4615
D. DOES WELL REPLACE EXISTING WELLY YES O NO g"
c. WATER LEVEL Below Top d Gawp: 540 FT
(Uw -e- 9 Alwve Top d CASINO
d. TOP OF CASINO IS / FT. Mow Land Sunoco'
Top d coming tstlnnat•d Wa °Mow land aunoa may reoua•
• ae~MAGA al accordance mat 15A NCAC 2C .0116.
e. YIELD(9pfn1 2 METHOD OF TEST A;rZ
t. D&SJNFECTION Tips
g. WATER ZONES cJRpini
From To
From to
From to
e. CASINO
Dawn y
From 1 To 2 / FI
Fran To FI
From To FI
7 GROUT Deptn
From 0 To 20 Ft
From To Ft
From To Ft
From
Fiery)
From
o ant•I
Arno urn
To
to
v
1MCaness.
Weight
Ma tonal Mepwd
SRkRS% nl.y 9r Poo,e
6. SCREEN Demon Demme, Stet Sue Mal•nai
From To Ft n in
From 10 Ft n an
From To Ft
9. SAND'ORAVEL PACK
Dawn S
From To Ft
From To FI
F IOM To Ft
10. DRILLING LOG
From To
RECEIVED
Ma Wnal
Asheville Regional Jfl
Protection
/ C 5 -'Qti ORM° t�
cl
o,
I Paco/ pc' to yYS'
,:gym gticr/*"ytIII
if#5— '2 poi
W nC AC 1C Worn
LL Co.STR *Ib. S1ANO 0SAm0 Poi e.OE mom.
w °OPT of
NECONO nAS aE En PRO.OEO rOI NELL OmIER
51GNATV OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
SuDmlt the original to the Division of Water Duality within
11117 Mail Service Center- Rale4gh, NC 27699.11117 Phone No
30 clays. Attn'. Inrormaoon Mgt..
. [phone] col 566
Form GW• la
Re. 705

312482$
RESIDENTIAL WELLconsrRucrlO' RECORD
North Carolina Department of Environment and Natural Kcsourus DIN uiun .n w sl cr (funbn
WELL CONTRACTOR CERTIFICATION M a 5 % I I
r. DISINFECTION Type'/ Amount
1 WELL CONTRACTOR'.
jbrv/La ttTryi
Wad Can le Stag (9tdAMdu&) Hart,
6rectn?IverWe\\ 1lyy.0
Wall Conwaclu Cat'pany Nan,
STREET ADDRESS pO o)C ao
aS+ Y ea ( a (SgQcc,
City or Town State F LP Coda
,• 693-lzoo
Area Gods Phase number
2 WELL INFORMATION:
SITE WELL ID MI aoPl aael C/�/
STATE WELL PER MIT6(a appacauel ©5/a0)0 b'`('z2'
DWG or OTHER PERMIT s(s applicabS)
WELL USE (Chace APWPDS Bowl. RgIWMY W r
DW ATE OLl.ED 3 �/ /0 Co
ate Supply 0
TIME COMPLETED 2 i 3 0 AMC} PM i•
7. WELL LOCATION:
cm `einuAJJt`IlC
j9? ¢t d. lnct KGout- g-d
COUNTY
S vr7
(Strew Name Numoere. Community. Sutom ot, Lot No
TOPOGRAPHIC / llW D SETTING.
❑Slope [Valley OFlat i'JRIQW DOV'K
(a,a app.wna, DOS)
LATITUDE _g °aG I 3 3 Ai
LONGITUDE QS ,x0 Z Z 42
Laattdeilottgaudc source- CiccPS [Topographic map
(»eetcn ofwN net D• shown one USGS top. map and
attaUrW M rta form / not pang GPS)
Parcel. ZIP Cow)
May be in &gran.
Sans, seconds a
e a decvul format
e. WELL OWNER j-
OWNER'S NM4EJ a -VI FC1S�?k ry lII�ZC.�ILa/L A-1-) """k1
STREET ADDRESS' `£,
t L-G�*'�tt.�r t'cr'`Y
--9tEd lair NC zS132-
Cry or Town Ststa
cts-25"). ia�iii -O.3699
Nee code • Phone nunt*
Zip Code
5. WELL DETAILS:
a. TOTAL DEPTH: Ca05
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ()L
c. WATER LEVEL Below Top d Crimp. / OO FT.
(Us'✓ 9 Above Top d Caan9)
d. TOP OF CASINO IS FT. Above Land Surface
Top d casing commuted atya allow land surface may rogue's
a.arance n accordance WMt 'SA NCAC 1C .01118.T,
•. YIELD (gpn). t METHOO OF TEST r
9. WATER ZONES iwpini
F tom Z g5 To 3 V(% From
From To From
From To From
6. CASINO. Thickness.
Depth DoIp tar Waprn tylstersi
From / To '/O Ft e 9 7./.4 raC
To
To
To
From To FI
From To FI
7. GROUT Depin ./ /JT�
From 0 To x4 Ft P,Gdr±E — 'r(
From / 7 To .Z a Ft crfaeaaRO75s Allae
MateMl Me01oo
Fran To Ft
8 SCREEN'. Depth 0annme Slot Sae Matanal
From To Ft n in
Fran To Ft in n
From To Ft n n
9. SAND/GRAVEL PACK
Depth
From To FI
From To Ft
From To Ft
10. DRILLING LOG
From To
0- 30
3o-��
Sot* CO
GO- /_DS-
Sae Malone!
Formaaon Deacnpoon
54 6/1 lCo
Iv
gionaLOf ice
'fotecttoiT--
II. REMARKS.
ISA KRCAC 7C CvEt[ CO.STRvCTC tSTANDARDS AND TIV.T * CCPv CF 7KL WAS CCWWCTED W q wm.
RECORD AAS BEEN PRO* DEC rO WetI GAMER
3-30-o<
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
t San(tit
PRINTE AME OF PERSON CONSTRUCTING THE WELL
Submit to the
Division n9) Information Mgt..
1617 MallService enter - Ralelh, NC Z799--1617Phe No(917337015 ex588
Four C 4 le
Re. 7N5

324408
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalyyResources - Division of Water Quality - Groundwater Section
T WELL CON TRACOR(INDIVIDUAL) NAME
��(print)L_ L?tR
WELL CONTRACTOR COMPANY NAME I-}j}IJF�J�IR 1lN4
(LIB CERTIFICATION A403.
ell DC PHONE # (pp4417•9.01afa.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
i. WELL USE (Check Applicable Box): Residential G Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest TownF ^D�N�C1YV+«QQ County}r t „'`5SN
773Th/V..
(Street Name Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: VI.5+t'
Address``s'm ' i 5 N. /yr/ he M riorA-
�" �SJUoWlzsbevliIUNo.is C s.194
City or Town State r Zip Code
( )-
.Area code- Phone number • ` 0
4. DATE DRILLED �)Y
5. TOTAL DEPTH: j OO
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L
7. STATIC WATER LEVEL Below Top of Casing: (DOD FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface`
`Top of casing terminated at/or below land surface requires a
variance in accordapce with ISA NCAC 2C .0118. /1 / n�,- ��
9. YIELD (gpm): / METHOD OF TESTC_G_I • A
10. WATER ZONE epth):
11. DISINFECTION: Type__ Amount �-.......
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From T Ft.
From To Ft.
From To Ft.
13. GROUT: Depth@ Material method
From To J Ft, *4
From To /. Ft I lina.g«
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From l o Ft.
Topogra ic/Land setting
DRidge lope ❑Valley ❑Flat
(chheeck approoppyriate box)
Latitude/lonaitud
welljocatiorit is(
si
(degrees/minutes/seconds) Olf., v. ?'+'I ./
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
Asheville Reniona.i Office
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND • • o S, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Q Co
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Su mit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION IMCORD-
North Carolina - Department of Environment and Natural ResoUrces - Di
• - RT ROlion
WELL CONTRACTOR (INDIVIDUAL) NAME (Print)//7/LA) /41 L 1(� 0 `P S YR - - - -CERTIFICATION # 27 ail t/
WELL CONTRACTOR COMPANY NAME Sire )L ,PP Loci 9 a) PHONE PHONE#CIA) b`1%-C)`/ 8()
STATE WELL CONSTRUCTION PERMITS _ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential n Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO / > / /
Nearest Town ii!vein'1 County/%r/94'i�iseni
7793 Tic is f osn /><w 217 6 It
(Street Plante, N(ou beti, Cmmwo . Subdivision, Lot No., Tap Code)
3. OWNER /9li-efivgii e N1 u s/ n
Address '72 93 Rey/ski-7 //y ui
(Soot&Route No.)
//Cr;N S tr)-t /vt 2 t` 7 61
City or Town State Zip Code
Area code Phone amber
4. DATE DRILLED -- _ ZZ- U (n
5. TOTAL DEPTH: 4'c 5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO EK
7. STATIC WATER LEVEL Below Top of Casing: %O FT.
p (Use"+" if Above Top of Casing)
8. TOP OF CASING IS / /t `/ FT. Above Land Surface*
"Top of easing terminated at/or below land surface requtra ■
variance he aaordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3 METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type C C. fi
12. CASING:
��� ((( Depth Diameter
From r/r To Ft
om F /_ To Ft.
From To Ft.
13. GROUT: Depth de -Material i
From p To 7n Ft tYir tt le
From To Ft
14. SCREEN- Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft in. in.
15. SAND/GRAVEL PACK:
��( Depth Size Material
From YJ To Ft.
From To Ft.
Amount / U en
Wall Thiclaess
or Weight/Ft. Material
16. REMARKS:
Topogrgphic/Laud setting 'a
❑Ridge p tope Malley ❑FI)'
(cheek appropriate box)
Latitude/longitude of well location u
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH. DRILLING LOG
From To Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or -County Roads. Include *end
numbers and common road names.
r2
DLs-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W1TH 15A NCAC 2C, WELL
CONSTRUCTION STA$DARDS, AND Tlifvj' /) COPY CJF THIS RECO)b HAS BEEN PROVIDED TO THE WELL OWNER
z-zzo6
r n-r
SIGNATURE OF PERSON CONdrTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

From: Scott Gantt To: Stephenie Wilson Date: 4/4/2006 Time: 8:37:16 PM
rage [ 014
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment, and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) SCOTT GANTT CERTIFICATION # 2584
WELL CONTRACTOR COMPANY NAME CAROLINA WELL DRILLERS, INC. PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ® Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0
Recovery ❑ Heat Pump Water Injection ❑ Other D If Other, List Use:
2. WELL LOCATION:
Nearest town: EDNEYVILLE County HENDERSON
HAWKS WOODS SUBDIVISION LOT 4
(Street Name, Numbers, Community, Subdivision, Lot No,. Zip Code)
3. OWNER REPUTABLE BUILDERS
ADDRESS 22 APPLE BLOSSOM LN
(Street or Route No.)
HENDERSONVILLE
City or Town
845-856-2853
NC
State
Area Code - Phone Number
4_ DATE DRILLED 3/2/06
5. TOTAL DEPTH 600
6. DOES WELL REPLACE EXISTING WELL?
7. STATIC WATER LEVEL Below Top of Casing:
28792
Zip Code
YES ❑ NO D
240 FT.
(Use "+" If Above Top of Casing)
8. TOP OF CASING IS 2 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a variance in
accordance with 15A NC AC 2C 0I18
9. YIELD (Rpm): 1 QT METHOD OF TEST ARDM
360
10. WATER ZONES (depth):
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
Latitude/Longitude of well location
3526.072 / 82.19 746
24682
(degrees:minuteNeeconds)
Latitude/longitude source. ❑ GPS ❑ Topographic map
DEPTH
From To
0 25
DRILLING LOG
Formation Description
Clay
25 600 Consolidated Rock
u. DISINFECTION: TYPE HYPOCHLORITE .Amount 117
12. CASING:
From 0
13. GROUT:
Wall Thickness
Depth Diameter or Weight/Ft. Material
To 40 Ft 61/4" SDR21 PVC
Depth
From 0 To
la. SCREEN
Depth
From NA To
20 FL
15. SAND/GRAVEL PACK:
Depth
From NA To
16. REMARKS:
o= LOCATION SKETCH
Material Method
GRAVEL MIX GRAVITY
Diameter
FL in.
Size
Ft,
Slot Size Material
in.
Material
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
•
4/1/06
SIGNATURE OF PERSON CONSTRUCTING THE WELL Date
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. f-------.--
GW-1 REV. 0712001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
CO t LWt(I
Well ContractorI,(Individual) Name
1 e a.h€11 @ ekte.1 l Or i 1. n g ( AC"
Well Contractor Company Name ((��
STREET ADDRESS 351 NIea. 1-ei Cesi-er 11LUN,
Ah2v'(I\e NC a% y to
City or Town State Zip Code
a54- 3s%
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT *Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3 /a 3 /0 6
TIME COMPLETED I a AM ❑ PM
3. WELL LOCATION: �1 I I
CITY: r \-CTG1
4 K. COUNTY 16 N Ov SJ A
r l o o r� I tJ G LAu PP-e b P tc La (-It q
(Street Name. Numbers. Consmuniy, Subdias,on, Lot WO. Parcel. Zip Code)
TQPOGRAPHIC / LAND SETTING:
Slope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 5 a 3 • 49 1
LONGITUDE R a3 •4
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: gy4PS °Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form 7 not (nbg GPS)
4. WELL OWNER 1 (�
OWNER'S NAME v ?Nike r I -
STREET ADDRESS a a Lv) f,C 0 fJ �L-A n
Rstit V13-1-e NC aSy05
City or Town State Zip Code
(`3a% } als-9 o11
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NQj]
c. WATER LEVEL Below Top of Casing: 10 FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING IS A1• FT. Above Land Surface'
'Top of casing terminated aUcc below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
4a5'
e. YIELD(gpm): " METHOD OF TEST '• C- 13l'?.
a14-
1. DISINFECTION: Type t 90 /p Amount 0 CZ-
g. WATER ZONES (depth):
11�
From 111 To
From To
From To
6. CASING:
From
From
To
To
From To
Thickness/
+ Depth_at Di eler Weight Ma Ial
From .! To O Ft. b�/% SpQo-t1
From To Ft.
From To Fl.
7. GROUT: i Depth Material Method
From To '�' O FL Cb ME N Tt✓' LE(�
From To Ft.
From To Ft.
8. SCREEN: Diameter Slot Size Material
From - Ft. in. in.
Ft. in. in.
From
From
Depth
To
To
To
Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
Frorry To y
- -I l
\ , - t-1'J
(-1-1 — 1-1$
1-1%' -
Ft.
Ft.
Ft.
Size Material
11. RENIARKS:
Foirmation Description
asRfl j:JCLOea'1
C, CLA+.1\TC
Cteg LCe - b ccry.
LZAr=t-tC
l-3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WON
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1' r•'nn1Inn
SIGNATUR�p F CERTIFIED WELL CONTRACTOR,
PRINTED NAME C' PERSON CONSTRUCTING THE WELL
ob
AT
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] elit 568•i,
Form W-la
i.(aev. 1(05
{

RESIDENTIAL \\'ELL CONSTROCTION RECORD
North Carolina Dcpanmcnl of Environment and Natural Rcsourccs- Di%ision of Water Quality
,A1
WELL CONTRACTOR CERTIFICATION # 1 `T 0 (T' (y �J/
I. DISINFECTION: Type I' "1 lb /u Amount 0 e 1-
g. WATER ZONES (depth)
From 1 D l To (b From To
From To From To
From To From To
6. CASING; ppa� Thickness/
From
DepthTo 50 FI. E�Y iS er WelsSo`11 P✓Mat�I
1. WELL, CONTRACTOR:
��.E,-;6=,Ln, C._ALntuC 1-L
Well Contractor (Individual) Name
RuVC2)LTN') CAL.nt,_ev_�
Well Contractor Company Name
STREET ADDRESS -' l t�t_w' )S.: is \Z tit- lit.+)
�S I,C,JIL_L` NC 3-'tYcL
City or Town Slate
(vZi ). Q-34- -3Scdl
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable)
Zip Code
STATE WELL PERMIT#(II applicable)
DWQ or OTHER PERMIT #(d applicable)
CoWELL USE (Check Applicable B/qx):Residential Water Supply (3)1/DATE DRILLED 3 j'a. t / 01
TIME COMPLETED 1t 0re AMt2" PMQ
3. WELL LOCATION: /� 1
CITY: F1, 1 C.t'1 e 1Z COUNTY �N'7L ERSot-)
)-oT (1 I 6i-ootn)(CG )-Ae&E 1—
(Street Name, Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TpPOGRARHIC/ LAND SETTING:
Slope QValley ❑Flat °Ridge °Other
(check appropriate box)
LATITUDE 3 5 a 3 . 5 09
LONGITUDE 3 a a 3 ,4/1)
May be in degrees,
minutes. seconds or
in a decimal format
Latitude/longitude source: gCPS oTopographic map
(location of wet must be shown on a USGS top° map and
attached to this form l nor usig GPS)
4. WELL OWNER
OWNER'S NAME c--11 TVL I 1 N e- e
STRS5it((EET ADDRESS dQ (,./ wo op& {`DAD
fJC 0.0% S
City or Tam 1 State Zip Code
(gag» 't5-9011
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES O NOV(
c. WATER LEVEL Below Top of Casing' " FT.
(Use's.- it Above Top of Casing)
d. TOP OF CASING I5 - FT. Above Land Surface
'Top d casing terminated agor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
305
e. YIELD(gpm): 1" METHOD OF TEST R(G-Ai&_
From To Ft.
From To FI.
oci-D
7. GROUT:AA Depth Material Method
From 1 To CZC Ft C,embcur CDJ?-E.1)
From To Ft.
From To FI.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FI in. in.
From To FIin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From , To a Formation Description
1 — li'5 ON/Btt i./2.0aita
+5'- to'7' CarzAw/TE
1o'l'._ log'
I0("- 3o5'' BIZA:-.,IT6
11. REMARKS:
c2 J I c-- - 1 o Urn
I DO HEREBY CERTIFY THAT MIS WELL WAS CONSmuCtto N ACCORDANCE WM4
ISA NCAC 2C. WELL CONSTPUCM)N STANDARDS AND THAT A COPY OF 111I5
RECORD IUS BEE PROVIDED TO THE WELL OWNER
5Laykiv, Led2cLuidk 3/a7/o 6
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON COtTRIySTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Infonnaton Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Ram GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RecoRI)
North Carolina Dcpanmcnl of Environment and Natural Resources- {Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ) I i- C'
1. WELL CONTRACTOR:
R(:.> 3L:„. C (tuDt.JT L__
Well Contractor (Individual) Name
,
NC c. f j N C /l g L-LkrJG I IJC.
Well Contractor Company Name
STREET ADDRESS 361 NEW yam. {E6 Sib -
�SI\es/ c(
City or Town State Zip Code
(u_Zk)- X34-347Kl
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #pl applicable)
STATE WELL FERMIT#pt applicable)
DWQ or OTHER PERMIT #(ff applicable)
WELL USE (Check Applicabl$ Box): Residential Water Supply ElDATE DRILLED S I i 6/ ei (c)
TIME COMPLETED -1.-` cAMO PM g'
3. WELL LOCATION:
CITY: \IL.L.S �1 VIE C--COUNTY I`Itfvele � S j'vN
1t 11 &LA6 Iceilvo cr-Ag{y S
(Street Name. Numbers. Community, Subdmsron. Lot No.. Parcel. Zrp Code)
TOPOGRAPHIC / LA50 SETTING:
oSlope 0Vailey ingLat ORidge ❑Other
(check appropriate box) ,^,
LATITUDE 3 5 94 '4 14
LONGITUDE 1_ 3Sr;4-q
May he in degrees.
minutes. seconds or
in a decimal format
Latitude/longitude source: OGPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this form I not usig GPS)
4. WELL OWNER
OWNER'S NAME
JAA*e% UIZS113
STREET ADDRESS P ?( 18
City or Town State
( gam } 1 1 1.(a9 0
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: /
b. DOES WELL REPLACE EXISTING WELL? ES O NO (q
c. WATER LEVEL Below Top of Casing. 11 l A FT.
(Use -+- if Above T cl Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.p
e. YIELD(gpm): 0 METHOD OF TEST kto —11
Zip Code
II05'
1. DISINFECTION: Type i{Tly cNi., Amount
g. WATER ZONES (depth).
From t�(_J/o/1/4 From To
Frorn To From To
From To From To
(; L t
6. CASING: Thickness/
Depth Diameter Weight Ma(etial
From To 3� Ft. 6/� SO I yrV!✓
From To Ft.
From To Ft.
7. GROUT: Depth Material (n� Method
Frorn .1 To rk° FI. L-ennbic,-I tyLJP ()
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
Frorn To Ft. in. in.
From To Ftin. in.
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To FI.
From To Ft.
10. DRILLING LOG
From : TO
1 $
AS' — Itc5'
11. REMARKS:
rot -motion Description
Cr +t4
-7
r-1
g:-1 IS :SAS.CA LL/ hi -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRE/C OON STANDARDS AND THAT A COPY OF THIS
RECORD PIA BEEN PROVIDED TO THE WELL
�ILOWNER
2, 1/�!
SIGNATURE F CERTIFIED WELL CONTRACTOR DATE
iSII,l-I(; 'CAS El
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn
1617 Mall Service Center— Raleigh. NC 27699-1617 Phone No. [phone]
Info iIo
ext 56 .
Farm GW-la
RSV. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORC�
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 24 ?Lo
1. WELL CONTRACTOR:
O ecc,c'u� !\. 6etsyccs
Well Contractor (Individual) Name
C.\e 512. Yecs SOT\
Well Gontractor Compalw Name
STREET ADDRESS V-ACIR 5 WCJ a M
Kot 4nr an s rc r 2 8.-P-► 3
City or T `' Stale - Zip Code
( Bat)- (otas- aoa'a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID dt(if applicable)
STATE WELL PERMIT/tfd applicable)
DWQ or OTHER PERMIT #(I( applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 2-°2p TIME COMPLETED .230 AM 0 PM Er--
3. WELL LO[CJ/�TTIO/N: / '/-
CITY: /JGIi et•ois6nY. l(r - cowry /`y4'�! cler-ah
Alo c c' Cc KI.
(Street Name. Numbers, Canm nity, Subdivision. Loa No., Parch, Zip Code) -
T9POGRAPHIC / LAND SETTING:
I3Sl0Pe OValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ID GPS OTopographic map
(location of wet must be shown on a USGS topo map and
attached lodes form 7not using GPS)
4. WELL OWNER
OWNER'S NAME OOLLQ Thant-,P r
STREET ADDRESS 'PO (& X Lfl'A
3Bile o
Zip Code
May be in degrees,
minute', seconds or
in a decimal format
‘aa, NC
City a Town State
(T - )- v - \ t0'i3
Area code - Phone number
6. W ELL DETAILS:
a. TOTAL DEPTH: 076 /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [Y
c. WATER LEVEL Below Top of Casing: ...CO FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS �_ FT. Above Land Surface'
'Top d casing terminated atior belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): (! METHOD OF TEST lit.
f. DISINFECTION: Type 9:Ik Amount
g. WATER ZONES (depth):
From To
From To
From To
/O
=rom To
=rom To
rrom To
6. CASING:
Depthn DU meter
From / To 76 Ft. l,ti
From To Ft. _
From To Ft.
7. GROUT: Depth
Fromb_To 2O
From To
From To
Thickness/
7/141I
1aterial
Ft.j. Siz nt
Ft
Ft.
Melhod
?ouceA
8. SCREEN: Depth Diiamet er Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To Ft.
.)ze
FL
Ft
Material
10. DRILLING LOG
From TYO
F )rrnatio'T Description
o'er �r.YtlrR
r;
11. REMARKS:
0
u1
10O HEREBY CERTIFY THAT THIS WELL WA: CONSTRUZ TED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTVN STANt BARDS. ANC -HATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO T)rf, WEI L OWNER.
SIGNATURE OF CERTIFIERLL CONTRA .ITOR
Are, a t ,4IEafs/lWEf! nJ
PRINTED NAME OF PERSON COh STRUCT MG THE WELL
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mg1.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
WELL CONSTRU(
"-CTIONRECORD Basin Code
DRILLING CONTRACTOR: iL pt3107,04 Header Ent
J / STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 02 130 PERMIT NUMBER:
GW-1 Ent.
1. WELL LOCATI (Sh w sketph of the loca'on below)
Nearest Town: `fl)4ery 0n yt County ilkn ip
(Road. Co ni ' or Subdivision andjaitt No.)
2. OWNER ( c�j� ofn r% %%
ADDRESG /'/
(Street or Route o.)
City or Town State! L Cod
3. DATE DRILLED y'S O4USE OF WELL ';;��f
4. TOTAL DEPTH 7/4,/
8. CUTTINGS COLLECTED YES F NO❑
6. DOES WELL REPLACE EX1STIN WELL? YES Q NOZ
7. STATIC WATER LEVEL Below Top of Casing: ' FT.
(Use '+ if a Too o Casing)
8_ TOP OF CASING IS S°77 ove Land Surfac
• Casing Terminated at/or below land surface Is Illegal unless a variance Is Issued
In accordance with 15A NCAC 2C .0115
9. YIELD (gpm): — METHOD OF TEST
10. WATER ZONES (depth)*
DEPTH
From To
11. CHLORINATION: Type — Amount
12. CASING:
2,69
DRILLING LOG
Formation Description
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
?? �, depth 6 Diameter orWeight/B.�M riai (Show direction and distance from at least two State
Frorrr�'�9 To Ft. —Lg— '"� yC Roads, or other map reference points)
From To
From To
13. GROUT:
Depth
From • S To -3
From To
14. SCREEN:
Depth Diameter Slot Size terial
in
in
Ft.
Ft
Material Method
Ft. 4i vrAeit efilEct C7k�1li�i
Ft
From To Ft in.
From To Ft in.
15. SAND/GRAVEL PACK:
e Depth l/� Siz Materials .
From To / Ft. dO
From o Ft
//y e �f
16. REMARKS: i 7 L" ! % /' � LI / . - 1bn- Y X5 r i C VC CIEr
' • X2 X`y '
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU TED I ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r� �1jL
SIGNATU�
CONTRACTOR OR AGENT DATE
GW-1 REV. 991 Submit original to Division of Environmental Management and copy to well owner.
in
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Bostic, NC 2e013
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JUN 06 2006

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso rces - Division of Water Quality - Groundwater Section
(�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1N, C/ y� CERTIFIC�jA(TIIONN #pg6'v/
WELL CONTRACTOR COMPANY NAME ]itpPL A -A I%j'/tI di L?1 JI1 /3 PHONE # ` )i983-q�p40t
STATE. WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) / (if applicable)
326! di 9
1. WELL USE (Check Applicable Box): Residential /Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ 1f Other, List Use
2. WELL LOCATION:
yokiNearest Town: E n y {-(��(�Q
(Street Name. Nut ers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ft (A ?-it
Address ( ((0
a
r {TG
EltawaAvee[or��ddou[e No.)
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED 02,3��Co
5. TOTAL DEPTH: (0 5'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: POO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
a1<?a9
Zip Code
opographic/Land setting
idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitygie/ o gitude of well location
N35 %t./VD' �n/a�a°3%.37�5
(degrees/minutes/seconds) G ��l% 2 AR i/
Latitude/longitude source:❑GPS❑Topographic mac)
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
9. YIELD (gpm):)pint METHOD OFTEST C'jA{ WA-IitoT/G
I0. WATER ZONES depth): cQco
11. DISINFECTION: Type 16(3(ert
12
CASING:
Depth Diameter
Diameter
m T
FroTo Ft.
From To
From To
13. GROUT: Depth
From
From
14. SCREEN' Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From To
16. REMARKS:
To 3 Ft.C)AfCt all C/,
To q Ft. hC%L-t=3"1
Ft.
Ft.
Material Method
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Amount a
Wall Thickness
or Weight/Ft. Material
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
A
r
0
0
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCTION STAyyDARS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�,a
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECO:2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 921136
326s8J
1. WELL CONTRACTOR:
Q�rc; c \ Qc..tin-W^tect
Well Contractor (Individual) Name
��44JJc 2 ' 64,.3yy4&-4-S k Son
Well Conttactor Company Nathe
STREET ADDRESS ay.C2)42)S %..;' j aos
‘Not S�r:v,s >Jc aw-N-2,
City or Town State ^Zip Code
(Sato)_ iolos- Qo'aa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #fdapplicable)
STATE WELL PERMR#(ifapplicable)
DWQ or OTHER PERMIT#Of applicable) Die s OD t Oe'l %elel
WELL USE (Check Applicable Bak Residential Water Supply O
DATE DRILLED 7 -'26.- -
TIME COMPLETED 210 U AM O PM 19
3. WELL LOCATION: '
Cifl::)� 4'etarSon ulie -... DcouNTA/ �tc' Y e e/Son
,tnIC.d
(Street Name,Blumbera. Co mnunay, Subdivision. id No.. Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING:
l CValley ❑Flat ❑Ridge DOther
(theca appropriate box)
LATITUDE .. _
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we! must be shown on a USGS typo map and
attached to this form 'not using GPS)
4. WELL OWNER
OWNER'S NAME P..Chace &cues STREET ADDRESS Wirt Kranvjs *brt*tt4.
"{endecs,ntn.t:tte Mc ?Nick 2
City or Town late Zip Code
(SU) ). b'74-9t3�
Area code - Phone number
5. WELL DETAILS -
a. TOTAL DEPTH: 3 G S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO E—
c. WATER LEVEL Below Top of Casing: 7'0 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 1S FT. Above Land Surface•
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 070 METHOD OF TEST R•3
f. DISINFECTION: Type ; 1 LS Amount / 9'
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From To
6. CASING:
From
From To Ft.
From To FL
Dh �lThicglahiesslI
.} }, /O. FL Dialer f/i ( ;<a t c
7. GROUT: Depth Matertri. Method
From 0 To ;CJ FL Ce flo4Vdl
From To FL
From To Ft
8. SCREEN: Depth Dianeter Slot Ste Material
From To Ft in. in.
From To Ft in. in.
From To Ft in. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
Ft.
Ft.
Ft.
Size Material
10. DRIWNG LOG
From To Formal ion Description
/Of O tie-- 4r/r
/0C 3G $ (17/"Cn/ke
v
JUUN CKr 2C6 )
11. REMARICS:
0
r
r DO HEREBY CERTIFY THAT THIS WELL Y'AS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION rat HOARDS. AND THAT ACOPT OF THIS
RECORD HAS BEEN PROVIDED TO THE N ELL OWNER.
7'�
SIGNATURE OF CERTIFIED CONTRACTORE
DATE
•
be CV, kkeek 6c: *-
PRINTED NAME OF PERSON C C NSTRUOTi G T E WELL
the original to the Division of Water Quality within 30 days. Attn: information I# It.,
Ail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7I05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # -al 4
1. WELL CONTRACTOR:
e k.1»eV\ 1d0 ell i
Wes Contractor (Individual) Name
Well Contractor Companyny�Name �yc� Owl
///
STREET ADDRESS56$ pleb.) 1ice�tit
Ash€;ile NC, actge i
City or Town State Zip Code
(sag y a54 - 3651
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Ap licaablox): Residential Water Supply
DATE DRILLED y 4 /a k0
TIME COMPLETED 10 t. 3 o
3. WELL LOCATION: /�
CITY: T LC'�G4 g, R- COUNTYH.E'4 ©+SI1SOoal
t
Lot i{ 1 t plopdv\t 6•1G 9A94(
(Street Name, Numbers% Community, SubdiNsion, Lot No.. Parcel. Zip Code)
TOPOGRAPHIC / (Aya SETTING:
❑ Slope ° Valley fiat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 5 a3.535
LONGITUDE 3 a 23.Sa6
AMd PM
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: t�GPS °Topographic map
(/ocatbn of well must be shown on a USGS topo map and
attached to This form ifnot using GPS)
4. WELL OWNER
OWNER'S NAME R(CAL j`/1R ).�--L5 l� Jcco
STREET ADDRESS 9. D - Y�Li �L ,4-b 5
AsLb�a� Nc aw o4
City or Town State Zip Code
(%a? 4a63
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
A-6 se
b. DOES WELL REPLACE EXISTING WELL? YES
c. WATER LEVEL Below Top of Casing:
(Use'+- if Above Top of Casing)
FT.
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .011�18...
e. YIELD (gpm): ) 5 METHOD OF TEST R(V - A P
f. DISINFECTION: Type
?ITN CA 05:Amount
g. WATER ZONES (depth):
From 43b To 431 From
From To From
From To From
6. CASING:
3-
From
From
From
Depth
To Si
To
To
Ft
Ft
Ft
g oz.
To
To
To
Thickness/
6/Dia%ter 5 ei (i
,(YVGti3terial
7. GROUT: Depth Material /� Method
From To a0 Ft. l;}�(T ;3-t PC
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Fprmation Descript' n1a �� & /- 43t,° C,aA sr-ft
31 c
r
- ° .12T toil- - �5 l� s� i3
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF MI5
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
ColaLAQ
SIGNATURE OF CERTIFIED WELL CONTRACTOR r DATE
u�tLL-t .pAAS1J
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. 6 q()(-Form GW-la
JUN 0 LUl ev.7/05

WELL CONSTRUCTION RECORD
North Carolina - Deparnnent of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL).NANlE (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
Cytpthat
lac..htk YVQFtt �/rthis PHONE# A tY83-/�3
326499
ASSOCIATED WQ PERMIT#
(if a rlicable)
CERTIFICATION t
1. WELL USE (Check Applicable Box): Residential J Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: /
Nearest Town c vine. Coun
f35t (Anti � ;r� e( r ace 7
(Street Name, Numbers, Community, SSuubdivisi n, Lot No., Zip ode)
3. OWNER:-dal&41f < Y6u,&
Address V
(Street or Koine No.)
u Xq1�
City or Town State Zip Code ( )-
Area code- Phone number /?6/gyp
///yyy���
4. DATE DRILLED �'/p
5. TOTAL DEPTH: ((( r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO YX
7. STATIC WATER LEVEL Below Top of Casing: (phi FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated atter below land surface requires a
variance in accord ce vith ISA NCAC 2C .0118.
9. YIELD (gpm): • METHOD OF TEST
Topogra c/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
�rz/lo i d�of weLl alYa ark 7 ty
(degrees/miinutes/seconds)Gee� ^I[�� ??
Latitude; longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH
From To
��-Cuu fr xICf
10. WATER ZONES (depth): h (S) a L`(�
l 1. DISINFECTION: Type
12. CASING:
Amount /7—
Wall Thickness
DRILLING LOG
Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
Dept i Diameter or Weight/Ft. Material numbers and common road names.
FromG To F
From To Ft.
From To Ft.
13. GROL[k. Depth
From To 'R Ft
From To ( . Ft
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material ,II,i O f) 2E113
From To Ft.
From To Ft.
3
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CON CTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL WNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-32_21, within 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL coNnurrton RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
/ (Indiidual) Nana
Core_ arl gtL/ er 1-0e) Pj,oL. rJ
WWI Contractor Company Name , l
STREET ADDRESS PO CX LRYU
S±; tat oEX- NC ag7a(el
City or Than State 7 zip Code
(R )- 61S-)ZOO
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID eV applicable) STATE WELL PERMITII(n applicable) 06f/ 00 /03Q 1n
2
DWG) or OTHER PERMIT /{9 applicable)_
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 3 -?.3 / - 47C
TIME COMPLETED 3 : 00 AM ❑ PM IEL-
3. WELL LOCATION: II'�
CITY: �5c3)1 a II) �. COUNTY HC_,(, d tXsLXJ
3II5s Thr L-R-
(Street Name. Numbers. Community. Subdi.nion, La No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
OSlope ❑Valley DFlat ❑Ridge ❑Other
(check appropnate Dos)
LATITUDE OAI✓
LONGITUDEcleiQ /% Ls'
May be in &pro,
minutia, seconda or
m a decimal formal
Lautude/longitude source: ID'CPS ❑Topographic map
(beaten or wet must bit shown on a USGS tops map and
attached to the form % not Mang GPS)
4. WELL OWNER L
OWNERS NAMED I Y\a_Q ci A)
STREET ADDRESS (Ogg &Paid a jO(A/9 t.
o-n u i) ( Z4'/q L
ty ex Town State Zip Code
LK). (�98 0-7g
Area code . Phone number
6. WELL DETAILS: �1_
a. TOTAL DEPTH: L3 o S
b. DOES WELL REPLACE EXISTING WELL? YES (y NO ❑
c. WATER LEVEL Below Top of Casing: G O FT.
(Use •: M Abow Top d Casng)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
'Top d casing terminated at/or below and surface may require
a variance in accordance with 15A NCAC 2C .011,8. /T e. YIELD (gpm): I METHOD OF TEST i i2
LI C.
1. DISINFECTION: Type (1 Amount
g. WATER ZONES (depml
From ''S1 To J35
From To
From To
6. CASING
From
From
From
To
To
To
Th,cknessr
Depth DDarraler Weight
From / To %z Ft 4, L,e
From To Ft
From To Ft
7. GROUT Depth
From D To /7 Ft
From 17 To A 0 Ft
From To Ft
8. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACN-
Depth
From To
From To
From To
10. DRILLING LOG
From To
0-z0
2 0 -/-7
L D — 3 In—
i
I1. REMARKS:
Material
a eTatcPue.47
StivegOie
Material
Pile -
Method
M,y Se' /e/Z
„Ai/ 9f_pa0lJrZ
Demeter Slot Size Matenal
Ft. n. n
Ft.
Ft in in
Ft
Ft.
Ft
Soe Material
Formaton Descnpbon
per+
S.ae.dA,}5eAtTi Digs
1/2424-40/
u62U
'2 Z1m
c 1
70.c
N
O
Crl
Go,
i CO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN ACCORDANCE wrni
15A NCAC 2C. WELL COeSrHuCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO TWELL OWN
Li -I -04
SIGNATURE (iF CERTIFIED WELL CONTRACTOR DATE
/3 Ryfri- - 6m •'tit
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1817 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev 7/05

RESIDENTIAL WELL coNsrhuc no` RECORD
North Carotins Usparpiront of environment and Navin) Nnourtcs pi, our. " .A aLC Vuaun
WELL CONTRACTOR CERTIFICATION N
1 WELL CONTRACTOR'.
WN (.ARkaA..rn (ItCMWual) Nara
Gnat cf-n ?tUer Lc)(\\ k/9,10
odes corw.aa Caipeny NWT.
STREET ADDRESS pOY301C a 1.
0.s7 filar +Zocic t�C aY7Qto
Cary at Tts.+1 State / Zip Code
Lg ,. ,15-2o0
Awe coon Prone nuatw
2 WELL INFORMATION:
SITE WELL ID gp.pp<aD..l
STATE WELL PERMITa(a woe:am) rJ IOOI O 5(o9a
DW0 a OTHER PERMIT I(1 app6abS)
WELL USE (Check Soar. Reagent* Water Supply 0
DATE DRILLED 11410Co
TIME COMPLETED )' AM O PM If
J. WELL LOCATION:
CRY UYIU RA Stit COUNTY n i
(�331INi daker'7r, Zg�3`1
(SAn.I Nw.. vnpw.. Commonly. Suoawron, La No Parcel. Zip Coal
TOPOGRAPHIC / LAND SETTING.
❑slop. cr aWy OFat ORS OOttwr
lama epvoprlav Po&l
LATITUDE �/•j 119' 3o
ri
LONGITUDEQ6.2 31 ' a ?-1/3
LautudcAony0Ldc soLca Ls,OFS OTopographic map
(*sawn of wag must p• wrown on . USGS typo m.p .n0
.Riches/ to .A. loan 1 nal wag GPS)
a.O NAME I I
ER
OWNHERER'SS NNArl 692/-4 I:JUI Iciers-plb F1f'oii
/���"�' -%'Tt/ 7�
STREET ADDRESS Y? e0v131r""�✓rle
. tncatson Mile NG2-8T39
pCry a Town Oat. Zo Code
laali ). Gob-$ba?
Arse coon . Pion. nurrcw
May b. in Mimi,
mwala.. cod• a
e . dmieul fennel
6. WELL DETAILS: r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EYOST1N0 WELL? YES 0 NO fl
c. WATER LEVEL S..A.r Top d Gawp. L QF7
d Ca.°p)
(Dos '✓ 1 Atom! Top
1 FT. ADo.. Lad Surface'
0. TOP OF CASINO IS Top d owing tnwwaNbob",bob",l o.leld surfacer uH, surface may rq
• .a,a n apcord.npe .al ISA NCAC 2C .01/110.
• YIELD(pp ) ME 1-100 OF TEST t'CI
I OISI NE EC TION T, pc__._ Arno unl
g WATER ZONES ce ptn,
0 10 /`.7/ Flom 10
From a%G
10 From to
From
From
o From To
I moo- n a
6. CASING
D.qn Dames( Weight M�7a�s/nl
Fram� To �OFI 21.L _±t
From To Ft
From To Ft
Mal.rml Mph
7. O 0.I � __toys
Frroom �% To
to 2 D Ft li .'iF l7k//L ar.
From To Ft
From To Ft
n Demeter Sae San Malenel
6. SCREEN D.etFrom T To FI _O
From__
o Ft ^ -- n
From
To Ft o in
6. SANOYCRAVEL PACK Soo Material
D.pin
from To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
0
Lo
II. REMARKS
F orma000, Deccrlpoon
1 Tyl
a4
N pT1
d
r-
IISA NSA NEARCE x CERTIF.,
Fn Dp.SrnpCllp.tL ise•5 51ANDAROSAND m%AI A C d n.ucTro we q w
RECORD.v,S BEEP PRO?OF'O In( wEtt prnER
E OF CERTIFIED WELL CONTRACTOR
PRINTED AME OF PERSON CONSTRUCTING THE WELL
in 30 ys. Ann
111117�Maill 5.rvlC. C.nlr - Rally o the Division
NC Water PhowfNo. 19) aoon M9
733 7015 .*T 5 0mgt.,
am OWI.
R.. 7;05

326353
RESIDENTIAL WEL.CONSTRLCTIO's RECORD
North Carobna Ocpvm.cnl or Envtronmcnl and Nonni Hrnnoorc<s 0" '•- ' <
W ELL CONTRAas
CONTRACTOR CERTIFICATION t 5 '7
t WELL CONTRACTOR
tmrq of $r
W.t L.. raix (xwAwd.&) Nfl
Greta. .vrr tA-1 \ K./re
?AS Corwt.Qa Corny Marne
STREET ADDRESS POY3 DX
CnSk YIAt�oCK
City or Tara; Sat.
k , 615-)2.00
au(
� a�gait)
Ea Cod.
Area Logy Prone non -of
2 WELL INFORMATION'.
SITE WELL IO NB &waWl
STATE WELL PERMITN1.ponc.a.I 063 /CO/oz9/3
DWG a OTHER PERMIT Nr .p$ab4)
WELL uSE (CN.c. App.ca0M Boa). Raro.rnW W.l., 519P7 0
DATE DRILLED -Orr
TIME COMPLETED .23 V
3 WELL LOCATION.
CITY 1.-1-Q^a rS UYI in Il-CCOUN TY `t-{iYir,Uy4jn
1�7 6loornlngAale_.Dv,,t
(Stu N•m., NlrrNre•r.. Cantu SAWwwn. Lot No Pwo.1 Zip Cool
rOPOGRAPNIC / LAND SETTING
O Slops Q1/aary (a1 * ❑Rqp. Ooa»r
IONIC% apprDpn.l. w.)
LATITUDE J'ZY' oil IV
Lo«GITuovig Jr rill
l�Da2flon&nd< so cc OGPS OTopow.ptuc map
(°yawn of wed nag D. Now% on . ()SOS Iopo mop Ina
.NraNrod to rue l nn / nor ....r0 GPS)
.. WELL OWNER ,.,1
OWNER'S NAME COL 4311a id Bu! Ids, Tx.
STREET ADDRESS PC r Y-w 5
Fletcher-/' NC- 2-t73Z
Suns Zap Cod.
Ch a Twin
AM ❑ PM ar
May ba is dcgroa.
mavalac .am.d. a
F . 4 .n4l formal
LzC( ). 721 --40l ig
b. WELL DETAILS'. y�h/
a. TOTAL DEPTH.
o. DOES WELL REPLACE EXISTING WELL? YES O NO3y
i •j
a. WATER LEV(1).. I v. BAw Typo d Carry)
,
(Uw'•' AdoTop
d TOP Of CASING 13 FT. ADow Land Sur1Ka'
Top d once; to nnm.d a'w D.W.• Lena sue iwoe May 'aqua*
• Aran .o• n .ocord.ny. win ISA NCAC 2C .011.8..
• MELD (Op(n) � METHOD OF TEST
FT
I DISINFECTION Try.
g WATER ZONES
From
Fan
From
7(0 To
Io
I
B CASINO
I
Arno r.nl
F,om
F,o,n IO
Flom Tv
1 Norma& A
Organ DNnVI.r W.rpm
From / 10 4,9Ft 44 2/.L
From 10 Fr
From To Fr
Mat./ a
✓C
1 OROu1 Ding n Mal.nallMite
Frew._ To 2 f� Ft S1* ado5 Mite'Ei e
from 10 Ft
From To
S. SCREEN D.N
n D.m.t•r SIo15.a• Mat•n•i
From
0 Fr in n
From io Fr n •r
FI n n
From to
9. SAND/GRAY EL RAC
Choir
Fran To_
From Io
From Tv
10. DRILLING LOG
From To
P i
11. REMARKS
Fr
FI
Fr
So. MaI•r id.
gad1.I oon
iy
flout 54 1(
74 fr o
1,
1
1
�Do CEC?C CEAnh r>Yr •>.0 .rrA.,0RD T.OTsAl• DOPY 01 '5
rN NICK K ry [ r. LP )-i.r,.0 n0. St.NO.A PS an0 M�. • GO.. d
xeCORO MS B.En PAPG C 'O '^I MPr O.+nC•
rJ lr. r
S rGNATuftOF CERIED WELL COniftAC TOR DARE
' Lys 7� fNS
PR INTE D`nAm( OF PERSON CONSTRUCTING WELL
ty within 30
rm wi
11617MMall S.rvlc Center - Ralrgb,l to the n of Water NC P 99 117 Pilont NO. 919) 733.70 5 C ro508 oon MpL..
FormGf I.
R.. ]NOS

326352
RESIDENTIAL WELL CONSYRLC'riu, ,,, oKD
North C.roLo. Ucpvmrcnl of Environment and Natural Rnourtcs 1
WELL CONTRACTOR CERTTFICAT1On R oR % I
, WELL CONTRACTOR
?veil Cock>,cia (Inorv.OmN) Awns
("r;r-r ? ver IA)f11 „o
rev oil Cor.a.aw Ccc p.ny N.rn.
STREET ADDRESS IFoa,os
aSt roCK A ( a€702.to
C.y a Ivan Sot. 7 Lp Coo.
). A3-)L00
Ai w 000.. Paw* nvno.
WELL INFORMATION
SITE WELL iD WI.oaoa.: 0
STATE WELL PERMITRN .pp,wa.l (0i 00 /0 R53-8
DWO a OTHER PERMR F(1 .pp.corW.)
WELL L15E (C'.n ,A 9dc4otI� Bp.I Rwwnar Wn« Slgp} O
DATE DRJLLi0 LEI I I O(
TIME COMPLETED
3 WELL LOCATION. �' ,�-1,,
c cry-lLudvlsa/1UI(le COUNTY `lT_"'-/�I0-0-NfSd?)
,'• 3
O
AA 0 Pm*
BIZ I �Y I anS `% L-t0 -Dr(
ISV..I morns N.a.Coof s Cantu ✓My Soto.....an la No Pwon Zip Coo.,
T(WOG RAPnlC, LAND SETTING
34.0099 push Of la ORa9. 0O7mo
I area .PP-W^. I. Coil
LATITVDE ZS°old' D&Al
LONGITVDEaZe1 7 7 Si U...)laun.kno14JD.4c Eotcu *PS 0Topogaptuc map
(OO.mn d w.9 mvN o. ✓+o,.n on . VSGS repo crisp .na
.n.wrra ro T. roan / 1101 „wp GP5)
4. WELL OWNER �•, � p
OwN ER'S NAME J IYYI roart.
STREET ADORES-5 II 2-13R�N-
Q-Vk&I SiTnuLEtof(NCZ_F6rliL
C.y w TOwn A.I. ZD Coo.
,. 15a-1'707
Nso coo. • Paw..
May b. o /cyrvo.
m+n.Y.. Axonal of
m • d.CaYI (onn.I
E WELL DETAILS:
.. TOTAL DEPTR:
o DOES WELL REPLACE EX/5TTN0 WELL? YES 0 NO E1C
WATEA LEVEL Boom Top of Cuing Igo
FT 7
(uw'•' 1 Apow Top d Grand)
o TOP Of CASINO IS I FT. Goa.. Lana Suns.'
'Top of wand t.rmroa.d odor Moot, .w4Mc. my r.luu.
• „rl•„w wnw n ,ora....n Moot,ISAA NCAC IC .0118
• YIELD(9Pnn) MET..00 OF TEST 4 r
: asiNF EC T ION ff-T
p WATEH ZO,.E> >..
Flan Lei° c ,�/{/J
F,o
From
1 CASING
D.vrn
n flaTo •O �/p
Ft
from to
F,wn r:
OROVT Cmn'
om 0 l0 2
From to
from :o
B SCREEN
Flom
From
F: orn
ri om
Arno un1
7.
Tn,c.n..s.
D,alrvIrn Yv.gnl !dr�`
G 2✓•G i
M".�I .`n'.' .F, MJJ�W
y.C/Y AL `n i Y.1lOafe
Dv pm D.,..n., SRr S.r. M.:.,..
a__
F. n
to F: n n
9 SANODRAvE'L PAC,-
D.pn
From
from
From
t0 DRILLINC .00
From 7o
0 - C
e - 3O
3o- ErO
di -a -jz5
.`UN 06 2013
11 11ENIA HHS
Su.
Forma Don Da.c ton
Pmeit
t
co
i & nC.#C 1C CE(n CO`>'TM.,CSrO,41 mf0,AOS FAO IMT . C� 5( nn..
RECP'r0,u5 bt(•✓+Ptn 'O n(, On+E.
y
SICnA VRE FCEH,fD/.F.. CONTRACTOR DATE
---fir
PRINTED n E Of PERSON CON TR VC Tine lnE rvEl.
ty
Sr./Di-nil
Mall S.rvIc original C.nld/` R+INQ , NC Z7999- 417 Phone
ho I. No. (919) 733.70 5 ea, 50a oon mg
k.. ,0W

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina L)cpumlenl or Environmcnl and Nano n) R nou reds TT
WELL CONTRACTOR CERTIFICATION a a 5 % )
326351
1 WELL CONTRAC TOR'
7Tha
W M (Iran.• •I) Name
Orre-n ?1vPr L e11 ' -Ra/E,i0
W W Cano.aor Carpany Nam•
STREET ADDRESS Po os. LD,U'f
`Cast Ylar-koctC. NC oZES%p�(o
Sat. / Zip Coo.
Gaya Torn
t tis ) 693-izoo
Ns. c40r INson• naro.r
2 WELL INFORMATION.
SITE WELL ID lid appop.•r
STATE WELL PERMITNr aptRgow ion /o15'(oZ
OWQ or OTHER PERMIT M(1 .pp1cADM)
WELL USE (Chock Appir.ol. Boa, Rwant* Ha SLoppry ❑
DATE DWU.E0 r/S —o
TIME COMPLETED idAt90 AA/(] PMQ�
3 WELL LOCATION'. 1 1_
Cm 1-}A-iAd 0A5(iioitt-e000NTy L✓Cson
319 ka9ikta- blip,o 2-ci
(SUM Nw.. NMno.r.. CanmWLy 5VCG1,W1. Lot No Potosi Zrp COO./
TOPOGRAPHIC 1 LAND SETTING
O'SVAm OVsuay DFIn ORC9. 00 ..
Iowa appr00N4 loon
LATITUDE _y CL/ OS/y
LONGITUDEQ/2Q
Lautudc/Iongtadc soured p@f5S OTopogr.phc mop
t4o•mn d we, ewr Dv .norm on • VSGS typo mop •n0
•lMur.o to we roan / nor ,..+p GPS)
A WELL OWNER �f /,
OWNER'S NAME t/�-}S-,Q(�,fl/-• `
ST EET ADORE55 aA� I�C-FKS"aIe 4.c.
kP&cUASowOt11�I�C Zo'Yz
Scc. r°slog 2 - (03c, Cs bp COO*
Cry a
May to . ora,
IRIIWIOI, WOOS ea
s . d.cvul formal
Ace. wa. • Prat. n✓com
• WELL DETAILS'.
•. TOTAL DEPTH:
D. DOES WELL REPLACE EXISTING) WELL? YES 0 NO e
c. WATER LEVEL &wow Top d Cwnp. 90 FT
(Uw'•- / Above Top d Camp)
a TOP OF CASINO IS / FT. ADon Land Surface•
Top d Dowry, WrmnM.d Wow o.fo.r Nand malice troy rector•
• Mnae n acccr0•rc• vC, I S A NCAC 2C .0116.
• . I'LLDIgptn) METHOD OF TEST A; it
I DISINFECTION 1,p.
g WATER ZONES Aso',
From Z9f lc 300 F,om
Ftorn T., Foom
From to from
1 CASINO
Down
From / To Ay-
Fom to
From To
7 GROUT D.p
F rem 6 T
From_ T
From
1. SCREEN
From
From
From
Anon(
T nrcrn•. a
W.prn MaWt.l
2/,! P./G
In Mil•MI M• 190
03 FISkRe-, Po
o 2.� Ft �rBAJ7LD.'0/iri J-•r/� /Z
O Ft
Depin
To
To
To
N. SAND/GRAVEL PAC.
D•prn
From
From
From
10. DRILLING OC
From To
/z
/7 — y5_
Io
Io
To
/5- — 315r
0.rnvtn 51a SIa.
Fr
Fr
FI
Ft
MYI•na
Sofa Maoris?
Forrnaoon Desorption
S •Stms)r_
i2
JUN ®6 2E1
11. REMARKS
--C = € 9l
L'C)
CO- r-1 rt
.00 riffle B. CER nn fl rrw.5N(61 ow! CO.51ALCTE0n*CCOIDr•,.CG n n.
I A ,.CAC 1C +. f L Co R•.CTO. amoMps AND OAT A COr co rn3
RECORD ,.A5 Bf E• PAD. O(0' O r nE„P+
SCNATURE F CERrE /r EL( CONTRACTOR
t
TR t Snit ;1
PRINTED NAME OF PERSON CONSTRUCTING THE ,VELL
if/l3 dt
DATE
SuWNl me original to the Division of Watw Quality within 30 days. AEI' information MQL..
11117 Mali Servlu Cantor- Raleigh, NC Z7699-11117 Peon. NO. [phone] lit See
Fwm CW I•
N.. Ltd

RESIDENTIAL WELL CONSTRUCTION RECORD
North Cuotirui Dcgentmcnl of Environment and Natural Rc»urus Th. ^ aIr' Vuain
WELL CONTRACTOR CERTIFICATION N
I WELL CONTRAC TOR
Wel (...4w.wI�77(awNW..M) Nutt
GrP-t-n ,YFr ltlZ1\ ? kyn.{J
W.1 C.ornaronot Company Name
STREET ADDRESS Po �DX r;NO
a5t , 1A r -.ocac M (a Y1Q (
City or Tow, sm. 7 zq Coo.
(o93-)Loo
Arlo war Pion. nuntw
2 WELL INFORMATION'
SITE WELL 10 Ha .pacaaq c �
STATE WELL PERMIT/0 apWoo.)©t/ ' I DO 10 p Z-b
DWG Of OTHER PERMIT all app6c.a•)
WELL LASE (CN.ct �.6. 1Muol. boa) Reagents' Warts/ Suppry ❑
DATE DRILLED 111EJ I 0 1a
TIME COMPLETED 4- o (IJAQ Phi*
3 WELL LOCATION.
CM( 14-t4&c .ScrY%J(IIecouNTY Pre.-►'Y& 5' Yt
I( liar -Per lad a FOCI&
I WaA m N.., ,/moo.. Cantnooly. Suoaw.cn. la Na Paean Z,p Cowl
TOPOGRAPHIC 1 LAND SETTING
O SCP. OVwry OFIN ORCS*
Io,KH, appropr M• co,/
LATITUDE _S °Z3 O17�
LONGITUDE emu? °° Rs"o0
Lauttalc/long+ttdc sotacc SOPS OTopogaptuc map
(upamn of NW tmat Do *noon on . USGS ropo map arta
mooched CO in. Arm 1 ne1 owg GPS)
a. WELL OWNER
OWNER'S NAME Ilf0.t/�It--�0--r��J ^"'(-""y
STREET ADDRESS I I r 9 1p--)L ���7L
1-a-�-nd._UtStrn0If! N ( Z
Cry or To,.n sat. Zip Coo,
062-53 ), ocCs• 31t5
N• pe0.. Pnon• nunv w
May be A Cognac
aumno., ,cowda a
o a acanl tonal
6. WELL DETAll.S:
a. TOTAL DEPTH. /
o. DOES WELL REPLACE EAISTY.O WELL? YES fT NO 0
T ofCoup. P1
c. WATER LEVE(I,. BI AD op d C.a"p)
(Uw '•' 1 Atone Top
a TOP OF C o•rng IS
I FL Alan Lang Surface
'Top d w tartt+lMtaa .La Wow anal .w1.w may 1.puR•
a anoa n aoLoyynw ran ISA NCAC 2C .011�6
YIELD (9P^') K.
METNOO OF TEST I r
1 Dl5INFECTIOn Irw first A(fl0 I
p wAT ER 20NES xor^
Flom /55 To le From
to Horn le
F,om —
From
To Fiom io
n.cu»as
• CASINO Yr ar
m
o.,an n /j
Der�rter W.pm
Fro10 L(/ Ft 2/.GL u
F1ornTo Ft
From To Ft
7 OROLFT D.prn Molnar
Flom —L1e J F, /.�� -
Fromf.4— to !.�% FI r,� k✓Jiklif
Fran to F1
6. SCREEN Doan O.mwsr Sol Sue
F IOM 10 Ft n n
from
0 Ft n n
From to _ Ft n ^
M CThc
Ars' lake
tottfeart
Ma lanai
SANDYORAVEL PACs
0•an Sa. Mat/Rio.
horn IJ Ft
Fran 0 Ft
Fran u Ft
10. DRILLING LOG
From 10
F orma oon Descrycon
414f 0-G� Biel
—2UUU
J
r
II. REMARKS
n r... • r•••s RE, A +,A3 CCNS'TR UC FED +. ACCOI CA^<E ono.
00nEMEB+CnEPn CC.. ;S,.n0An0 n.A1 A COP'.C. n.S
RECORD
,>A IFD Of M,P5 x E,. MS ME• cx D. Of r^E 0EnEa
FIED WEL. CONTRACTOR DATE
Il
AAiE OF PERSON TnE WELL
SQWNt the original to the Division of Water Quality within 30 Gays. Ann inform. DOR tagt
Te1T Mall Service C.nt.r - Raleigh, NC 27699.1II17 Phone No. [phone] cat 568
Tom GW 1a
R.. >os

RESIDENTIAL WELLconSYRUcrlu• 'Lc ORD
North Caron. Dgwvnmt ol'tnvwnment .nd N.NN Nnocrca+ fl• •
WELL CONTRACTOR CERTIFICATION c2 7 %
326348
WELL CONTRACTOR
7 r y.un
W
./ (... ..r (pl0rw0u4l) Nome
W.Y Caveat Conp.ny N✓n.
STREET ADDRESS IP0? OS. aU't
Fast r)ar o(.K. 1�1C oZ eta (0
San. Zp Coo.
Cry a Torn
(RA ). G93-jzoo
Ain cow- Pnww Furrow
2 WELL INFORM AMO1x
SITE WELL ID h'l.Paawl -T //
STATE WELL PERM' TR..oacaaq '05 Ic..0 `QG )96
OVA a OTHER PERMrT F(1 .ppic.o..)
WELL USE (C11.0 rage Bo.) Rmiasmal Wow S.9p17 0
CATE ("LUC l' a0/U
TIME COMPLETED 3:30
3 WELL LOCATION.
c(n I4et4LvSonu11IL
AM
COUNTY 4-0\0 '••DUX'
4a6- Lu4Le� CreeK Dr((Ae
t Svgw Nano hanDM. Comma) SWa..wn La No
Pwo l 2rp Cow;
TOPOGRAPHIC r LAND SETTI G
C Slop. OVMry OFM Cop. OOv.w
taiga WaOONM Owl
.,LTITUDE 35° 17' I3if
LONGITU DEaL° .3Y' z+uJ
LLon+odbngrcuck Iotuu 11GPS OTopograptUc map
(00•WWt1 a wN nm..r 0 Now on . (.1SG5 mpg map .na
.r..an.a ry s.. rOnn F nor wp CPS)
.. WELL OWNER
Own ER-SNAME TO LIQI-ujkr q�
STREET ADDRESS IG10 (�I(.�4-1e-✓YIIOc C. ar+
f \45"1'at S5Y10Itse, NG z$n35
Cha fawn Slate ZQCaM
e6 LS ). (0c - a o %
ALy bc w Ocilla.
m-amma, .wade
o . decimal forms.
Ai es MC* • Pnen. r sT
11 WELL DETAA.S 3 25 r
a. TOTAL DEPTH .
o DOES WELL REPLACE EXIST -ISO WtU.7 YES O NO Ifr...-
c WATER LEVEL Bev. Top a C..ng. (0 n
(UN '.' I Apo.. Top a C•Ang)
o TOP Of CASIfs0 15 I FT. ADO.. Lana Surf t.c.'
'Top a wvq Iwww,.t.o Wee a..ow Lord .vl.cs rr.y e.Guw.
. whence n .aacoree o• van ISA NCAC 2C .0110,,�I
YM�Wen) A('T METH00 OF TEST • r
I CHSl NEEC•,. 1474 y-T' Am O.nI
9 WATERZOr.t
L] .+...
Ficen
Fium _ f.wm_
Fran 'o f•om
1 CASINO Iroc..n.s T.
ig, VVITnt
From
1 ao /el r, 21.g1 /31>G
F ewn To Ft
Flom To
OROIfT 0.1)"' q M.I.ryl
Fran 2FIE
Egon) ,'� Ic d fI
Flom
1 SCREEN 0.mn D.mn.n Sro15.r.
f.Gm Iu fi n n
from
From o
i SANCYORAvE, PACT"
O.pin Su. mu.Fs.
Fran " --"-- -
Flom 1 ,
from
10 DRILLING .00
From To Forma D.•cnpoon
o D.a
CI
' RA.Vr i'2
0
✓ YT:J
to
Oa /11'
co .
IUll Oh 2055
tl„
11. REMARK]
oont RED,_nC..0 XCnf rCO. TT LA: ,., 05 O Fn.., ., co S(nn..
fECOxo M S bt En >wo.UC' 0 t nA. Op n[x
SCIIATUR&'OF CER,.F•ED .ALL CO
a 4LJI g 1,14-11
PRINTED AME OF PERSON CONSTRUCTING THE WEt.
4 -21-QL
TRACTOR DATE
SUtMLI me original to Ins Division of Walw Quality wrttlln 30 Day•. Ann nror1 .Don mot
1117 Mail S.rvlc. Center - Raleigh. NC Z7099-1117 Pfon. No. (91f) 733-701 a cal )tle

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N 2571
326347
1. WELL CONTRACTOR:
Bryant Smith
We$ Contractor (Indidual) Name
Green River Well 8 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 2°4
East Flat Rodc
NC 28726
City or Taws State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Cif applicable)
STATE WELL PERMIT/kV applicable) nS / a U I / (0 7 Li`I
DWQ or OTHER PERMIT R(W applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 4s I O
TIME COMPLETED 3,00 ANq0 Pk10_
3. WELL LOCATION: L l . ' ,
CITY: &aa)LA.dOL f'Y COUNTY /Iscfri
It33/ Pack Rd
(StreetName, Numbers, NamNumbers, munity, Subdi.sion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope UWelley ❑Fat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 35 jz '71Lkk)
LONGITUDEUSZ°aar 0
May be in degrees,
minutes, seconds or
in a decimal format
Latitudefongitude source: jtGPS ❑Topographic map
(location of weg must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER �" /
OWNER'S NAME Q ualt4r Monies ,D( (4.2{j)-naiat
STREET ADDRESS /441, Ozor)e i7v/U.0 _/
Q-tLtda K)C 74/773
City or Town State
-3o33
Area code - Phone number
Zip Code
6. WELL DETAILS:
a. TOTAL DEPTH: ,/q
L%-1-
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: `, Q FT
(Use `+` M Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
'Top of casing terminated at/or below land surface may require
a variance in accordance With 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST Air
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth):
From / 3.f To it° From To
From To From To
From To From To
6. CASING: Thickness/
/ Depth Dia ter Weight MaterialFrom 7�f Ft. /, 7 R/. C Y✓e
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 3 Ft. S/rh�1geie
From_ Tom_ Ft. Sa oA, 'Ar
From To Ft.
Method
/111.1OvZ
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in.
From To Ft. in. in.
9. SANDVGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From T Fgrmationpeecription
o - p / rid Crt.c
- - flvr'(U z�al--
4�
S-O ix/ 6/co .
S-- 344- (RAsat&
O
;C
Q
•lam
—t 1
.r)
JUN Oh 406
Il. REMARKS:
0
c'l rr1
`z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W rlH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO T 1 WELL OWNER.
SIG ERTIFIED WELL CONTRACTOR DATE
art ,9-r4f-b m, ;f4
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
NATUR F C
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na ral Resources-- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME ((print) o In, Ul ebb CERTIFICATION #ZN/8
WELL CONTRACTOR COMPANY NAME (Af/atiLer ;boas Lust 4-- Pt% %✓te
STATE WELL CONSTRUCTION PERMIT# 1 7 o 2-- ASSOCIATED WQ PERMrr#
(if applicable) (if applicable)
PHONE # 6328 W18-3/20
1. WELL USE (Check Applicable Box): Residential B Municipal/Public O Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATION: N,/_t (,, /
Nearest Town: I�f e?k County
(Street Name, Numbers, Community, Subdivision,�Lot No., Zip Code)
3.OWNER: 6r Webb
Address • AC 3 3
(StreetC- or Rnn�e1N Ft either
_ .ZB 73 2
City or Town State Zip Code
($& )- 6B(4-6go8
Area code- Phone number
4. DATE DRILLED ,y�fr6 '0 6
5. TOTAL DEPTH: 'Jo5
D,p:S WELL REPLACE EXISTING WELT? YES LI Iy) el--
7 STATIC WATER LEVEL Below Top of Casing: ise b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance pgith 15A NCAC 2C .0118.
9. YIELD (gpm): 02- METHOD OF TEST 2- Hoot-3
10. WATER ZONES (depth): 2-Z5
11. DISINFECTION: Type Hsi
12. CASING:
Amount
Wall Thickness
/� Depth Diameter or Weight/Ft. Material
From_D To BO Ft. it,twt
From To Ft.
From_ To
13. GROUT: Depth
From 0 To ZD Ft.
From To Ft.
Ft.
Material Method
mrnn - ere P
14. SCREEN- Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope OValley Otlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Fotrrjtion Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JUN 06 20U3
r-
L 6. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C'ONSTRUCjT)ION STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
oC
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

326123
WELL CONSTRUCTION RECORD
North Carolina — Department of Environment And Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RODNEY ROBBINS CERII1•TCATION # 2785
WELL CONTRACTOR COMPANY NAME PITTMAN WELL BORING, LLC PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT # ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential N Municipal/Public ❑ Industrial 0 Agricultural
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: EDNEYVILLE County REND
70 CYPRESS ESTATE LANE
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: DON RICHARDSON
Address 70 CYPRESS ESTATE LANE
(Street or Route No.)
EDNEYVILLE NC 28792
City or Town State Zip Club
(828) - 692-3819
Area Code Phone number
4. DATE DRILLED 04/13/06
5. TOTAL DEPTH: 305
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO N
7. STATIC WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1-1/2 FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 6 METHOD OF TEST ARD
10. WATER ZONES (depth):
11. DISINFECTION: Type CHLORYTE Amount 7.5
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From 0 To 130 Ft. 6-1/4" SDR21 PVC
From To Ft. _
From To_Ft.
_ _
13. GROUT: Depth Material Method
From 0 To 20 Ft QUIKRETE POURED
From To Ft
14.SCREEN: Depth Diameter Slot Size Material
From _ To _ Ft _ in. _ in.
From _ To Ft. _ in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To_Ft.
_
From To Ft
16. REMARKS:
Topographic/Land setting
❑ Ridge ❑ Slope ❑ Valley ❑ Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minuics/seconds)
Latitude/longitude source: ❑ GPS ❑ Topographic map
(check box)
DEPTH
From To
DRILLING LOG
From To
LOCATION SKETCH
Show direction and distance in miles from at least
Two State Roads or County Roads. Include the road
number and common names
HWY. #64E. FROM HENDERSONVILLE. RT. ON
LAYCOCK RD. LEFT ON N, RIDGE RD. RT. ON
CYPRESS ESTATES LANE. ter LOT ON RT.
JUN 06 20:3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OFF;HISSRECORD HAS BEEN PROVIDED TO THE WELL OWNER
_tor
SIf GNATURE OF PERSO CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
)r4- . -1/4/ 4 -So
DATE

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Lbpartment or Environment and Natunl Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION M 2571
1. WELL CONTRACTOR:
Bryant Smith
Wet Contractor (Individual) Nana
Green River Well & Pump Company
Well Cantracta Company Nan*
STREET ADDRESS PD Box 204
East Flat Rock, NC 28726
City a Town State Zip Code
( 828 )_ 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID S0lappcabie) �//
STATE WELL PERMIT$(a applicable) 0 1 0010 gen / b
DM or OTHER PERMIT kit applicable)
WELL USE (Check Applicable Box). Residential Water Supply 0
DATE DRILLED (o (t / O L
TIME COMPLETED I 1 -00 AM ck PM 0
3. WELL LOCATION:
CITY: F-K.tA6UYP)1 I(2
IT 13ns+L i� I-rruq,
COUNTY 4t-& SO1v
(Street Name. Numbers. Canmunity. Sub:Meson. Lot No . Parcel Zip Cooe)
TOPOGRAPHIC / LAND SETTING:
2SCIoW OValley ❑Flit ORidge ❑Other
(Creekappmpnaie box)
LATITUDE _g at. 2-1 19 N
LONGITUDE0S2O 3O' IT/ LO
May be in desnies,
minutes, sands or
m a decimal format
Latitude/longitude source: Q/GPS ❑Topographic map
(location W wail must a shown on a USGS topo map and
attached to the tone 7 not asap GPS)
4. WELL OWNER
OWNER'SNAME Leo MCCrc.LJ
STREET ADDRESS PD fob a'19
TIN D LLM l fl.cx e. y hl C? Y s S'
Cty a Town State Zip Code
)NI( )- !p 9 4 -e><I 2- 5
Area code • Phone nunta
6. WELL DETAILS: I
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO D—
c. WATER LEVEL Below Top of Casing: 7' 0 FT.
(Use': I Above Top d Cun9)
d. TOP OF CASINO IS 1 FT. Above Land Surface'
'Top d asing terminated ago below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST Air
1. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth)
From 2, 490 To Z CrFrom To
From To _ From To
From To From To
6. CASING: Thickness/
Depth Dia ter Weight ktaterel
From � To '74 Ft L 2/.4 Pvr
From To Ft
From To Ft
7. GROUT: Depth
Matenal Method
From 0 To 3 Ft 6aa4'A'az//r Aft; rt3 ,i7)t)sW
L
From 3 To20 Ft /ic&ai 144ij S-lrnit
From To Fl.
8. SCREEN: Depth Demeter Slot Size Matenal
From To Ft n. n
From To Ft n n
From To Ft n
9. SANDIORAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
0 - 71 2
2 - 40
qo j0
CD 40
Et) — Z.C>
11. REMARKS:
Ft
Ft
Ft
Soo Material
Formabon Descnpuon
pi a
in V
C/1A.,
I1RU..vw,:hn�(
0
—:1
mil
DO HEREBY CERTIr r THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W ITN
ISA NCAC 2C WELL CONSTRUCSTANDARDS AND THAT A C(PY Cr THIS
RECORD HAS BEEN PRO.OED lb r E WELL PLANER
S)GNATUR'E 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: Intormadon Mgt,.. .. !kJ
1617 Mall Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-la
Rev 7/05

) 0 x _
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quahty
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well 6 Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Hit amicable/ �-7 2
STATE WELL PERMIT#(d applicable) 05! 0D I/ l `/y ' 13
DM o OTHER PERMIT CI applicable)_
WELL USE (Check, icable Box): Residential Water Supply ❑
DATE DRILLED 026 "O iv
TIME COMPLETED t f..0() AM ❑ PM ('oc
3. WELL LOCATION:CITY: f--k-nJO t2/1U 'l1-7 I IIf. COUNTY -J,.Gtk-2.)ll
1--01-,24Gr&4 dd(Dais, 640 Cncc0,1 Oats cr.
(Street Name, Numbers, Community, Subdiwson, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
IgSlope [Walley ❑Flat ❑Ridge 0O6ter
(erode aperopnate box)
LATITUDE j t 'l' /VI
LONGITUDE02C f fr a? id
Latitude/longitude source: OGPS °Topographic map
(location of wei must be shown on a USGS fopo map and
attached to this form 7 not usrp GPS)
4. WELL OWNER ;;J] ,f
OWNER'S NAME ties UU;)Ses/ ThL
May be in dcgrms,
minutes, aecodr or
in a decimal format
STREET ADDRESS /a-LD Oaic)a1d 14- (I (EY-
Pfau & t N L?w7?
City or Town State
Area code - Phone number
6. WELL DETAILS: �7 I
a- TOTAL DEPTH: / 0 D
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO lc
c. WATER LEVEL Below Top of Casing: 2 0 C7 FT.
(Use -✓ if Above Top et Casing)
d. TOP OF CASING IS 1 FT. Above lard Surface'
-Top of casing terminated 'Nor below land surface rrny require
a variance in accordance Kith ISA NCAC 2C .0118.
e- YIELD(gpn»: J METHOD OF TEST Air
f. DISINFECTION: Type HTH
g. WATER ZONES (depth)
From '2 C 5 To 2 70 From
From To From
From To From
6. CASING:
Amount
To
To
To
Thickness/
Depth Dipmleter Weight lerlal
From/ To 2TQ Ft. 21. _ / _
From To Ft.
From To Fl.
7. GROUT: Depth Matenal Method
•
From 0 To 3 Ft. 5 r.qj .r r y 8- A Z
From 7, To � 0 FL �/...��Yr.niil�
From To Ft
8. SCREEN
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
From To
From To
' From To
10. DRILLING LOG
From To
gyp — •70
17t) - 795
II. REMARKS:
Demeter Slot Size Matenal
FL n.
Ft n.
Ft m
Ft.
Ft.
Ft.
in
lo
Sze - 'Materiel
Formation Descripbon
5/'fi�t'cl /-e4 -
O
r
1 =1^
w
1-
1 DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN Ar ' ROANCE W r1N
I5A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY CF THIS
RECORD HAS BEEN PROVIDE 91T0 THE WELL OWNER
S T FCE VIED WELL CONTRACTOR DATE
B /7_ m.a r6vn. �'L(
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1817 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolrla Lkpertmcnl of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION q 2571
1. WELL CONTRACTOR:
Bryant Smith
Wer Contactor (Individual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rods, NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Hit applicable)
STATE W ELL PERMITF(it applicable) C&' / 00 I0 3S 73
DWO a OTHER PERMIT t(i applicable)
WELL USE (Check Appl ere Box): Residential Water Supply ❑
DATE DRILLED �I(c o
TIME COMPLETED I n IY O O AM y_ PM ❑
3. WELL L ATION:
CITY: L %(lil1(-e COUN
acJ3atn1 (stile, bloc ow/c(I �-e j Pk a-t
(Street Name. Numbers, Community, Subdlw . Lot No.. Parcel. Zip Code)
TOO GRAPHIC / LAND SETTING:
(dope °Valley ❑FW °Ridge ❑Other
(check appropriate box)
LATITUDE _$LT Z-3 321
LONGITUDE Licallic 3,1 i)
Latitude/longitude source:GPS ❑Topographic map
(bcafbn of we/ must be shown on a USGS topo map and
attached fo Mit form 7 not using GPS)
4. WELL OWNER �, {
OWNERS NAME (1 0 *Tones. Mc_
May be in degree,
minutes, seconds or
ie a decimal format
STREET ADDRESS pc ram[% tC `f I�
/VI ES NC, al f(oO
(gzg)- eagi-&(0z3
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
5
Zip Code
b. DOES WELL REPLACE EXISTING WELL?YESSX NO °
c. WATER LEVEL Below Top of Casing: / 0 FT.
(Use '+'1Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top d casing terminated actor below land surface may require
a variance a accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 4,0 METHOD OF TEST Air
f. DISINFECTION: Type HTH Amount
9. WATER ZONES (depth)
From 6.3 To 73, From To
From To From To
From To From To
8. CASING: Thickness/
Depth /// n Dia er Weight Aerial
From / To /, Ft. 2/, C lCi
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
Fran Q To 3 Ft.. r At 2y,tt'oe
Fran 3 To2,O Ft Q r /1t;/¢%pwt
From To Ft.
8. SCREEN: Depth Diameter Slot Size Maternal
From To Ft. n. in.
From To Ft.
From To Ft.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
, From To Ft.
From To Ft
10. DRILLING LOG
From To
tb — !D
to
46 - SO
11. REMARKS:
n1
;"-
;IDr,
0
r
_t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W mH
16A NCAC 2C, WELL CONSTRL rp,H STANDARDS, AND THAT A COPY OF THIS
RECORD TINS BE D TQTN OWNER
S NATURE OF CERTIFIED WELL CONTRACTOR
-2-0c
DATE
BR gm/f11
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 Uccartncnt of Environment and Natural Resources Division of Water Quahry
WELL CONTRACTOR CERTIFICATION N 2571
1. WELL CONTRACTOR:
Bryant Smith
WM Contractor (Individual) Name
Green River Well & Pump Company
Wail Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock. NC 28726
City or Town State Zip Code
( 828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Mil applicable)
STATE WELL PERMIT#(e applicable) 0 :S /0'01 iy e
DWQ or OTHER PERMIT e(t applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED C - $ '- o
TIME COMPLETED /!. CI
AM R'PM❑
3. WELL LOCATION:
CDTY: `Ca Sr Floc/nocou G h i& dt-
(Street Name. Numbers, Community ITOiisan. Lot No , Parcel. Z:p Code)
TOPOGRAPHIC / LAND SETTING:
DSlope oValley ❑Flat ❑Ridge ❑Otter
(check appropnate box) /
LATITUDE r ? / ry
LONGITUDEOQoff 05 tJ
May be in degree,
minutes, seconds or
n a decimal lomniat
lautude/longitude source: isCPS ❑Topographic trap
(bcatbn of wet must be shown on a USGS topo map and
attached to this fonts % not using GPS)
4. WELL OWNER
OWNER'S NAME l ,,,, ���%
2EET ADDRESS I ( S� (J �; AC W
S
CIud
ak-t5
ru n (-l-- l- Loc i-iz)
City a Town State Zip Code
(- Sg23
Area code • Phone number
5. WELL DETAILS: _
a. TOTAL DEPTH: G 0 S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er-
e. WATER LEVEL Below Top d Casing: / 2 0 FT.
(Use 'F' y Above Top d Casng)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated ator below land surface may require
a variance in accordance web 15A NCAC 2C .0118.
e. YIELD (gpm): ,Z METHOD OF TEST Air
t; ! i
I. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth) rr
From 3 90 To 31From To
From .5 3 3- To 5--'5q7 /9 a iFiom To
From To From To
6. CASINO:
Depth
From / To/33 Ft. Sartater
From To Ft. Defter
From To Ft.
7. GROUT:
From 0
Thickness/
Weight /Mjternal
2J•C- /JL
Depth Matenal Method
To .3 Ft Sn-kR,i a n;, sd %%
From 3 To .2 0 Ft. ,B/Cp/ioa,i& M;7 Y 1Pooi2
From To Ft
8. SCREEN: Depth Demeter Skit Size Material
From To Ft. in. in.
From To Ftin. in.
From To Ft in. in.
9. SAND/GRAVEL PACK
Depth
From
, From
From
To
To
To
10. DRILLING LOG
From To
C7 -- gD
80 -90
o- /2�-
11. REMARKS:
Ft.
Ft.
Ft
Sae Material
Formation Descnption
D 1� t
L✓A/ex .Ldn,✓,4
&Rave/ 34 //
co TT.
I DO HEREBY CERTIFY T -WT THIS WELL WAS CONSrRuclto IN ACCORDANCE wnH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPT CE TH6
REUMD HAS SEEN PRO IDEO.70 THE WELL OWNER
SIGNATURE OF CERTI IEF D WELL CONTRACTOR _/DATE
Ry mut 5,77;elk
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone] eat 568.
Form GW-la
Rev 7/05

- RESIDENTIAL WELL ConsrRucT)on RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CERTIFICATION p 2511
1. WELL CONTRACTOR:
Bryant Smith
Well Contractor (Individual) Name
Green River Well & Pump -Company
Well Contractor Company Name
STREET ADDRESS PO Box 206
East Flat Rock. NC 28726
City or Tory State Zip Code
L828 )- 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 1(11 appaade) I 1
STATE WELL PERMITel6 applicable) e /o Dl jN
DWG) or OTHER PERMIT all applicable)
WELL USE (Check Applicable Box): Residential Water Supply Cl(n
DATE DRILLED / 0 G
TIME COMPLETED 3 • oo
3. WELL LOCATION: G
CITY: ji' St I0. tCOUNTY
'f`)Ytint j124
(StreeteetName. Numbers, Com miry, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope OValley ❑Flat ORidge ❑Other
(crack appropnale box)
LATITUDE Ski 30i./
LONGITUDE/m a,}' 0R(4)
Latitude/longitude solace: (7.6PS ❑Topographic map
(locatbn of wog must be shown on it USGS topo map and
attached to this tam) / not using GPS)
6. WELL OWNER
OWNER'S NAME
AAA ❑ PM 2--
May be in degree,
minute, seconds or
m a decimal format
�=b �tct'a,1dSan-f
STREET ADDRESS 143.15 N- (,3.( 67'44(1 j1/4-'
M e CI 1 L+D 15 3 C, rj 2
City or T State Zip Code
(.2(0)- 51 L
Area code - Phone number
6. WELL DETAILS: _
a. TOTAL DEPTH: 3 05
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO @-
c. WATER LEVEL Beknv Top of Casn9: / 00 FT.
(Use -✓ 6 Above Top d Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
'Top d casing teminated at/or below land surface may require
a variance in accordance Mth 15A NCAC 2C .0118.
e. YIELD (gpm): / 0 METHOD OF TEST Air
t. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth):
From 2 7 To 2, go From To
From To From To
From To From To
6. CASING:
Thickness)
Depth Dia er Weight tercel
From / To /AO Ft. 6* ZLC __
From To Ft.
From To Ft.
7. GROUT:
From 0
From 3
From
Depth Matenal Method
To 3 Ft. 5.MMg,JS At1 f r l$ofe
Ft. 131041,•4/xc Pt ;IV floor
To Ft.
8. SCREEN
From
From
From
To 20
Depth
To
To
To
Demeter Slot Size
Ft. in.
Ft m
Ft in
in
in
In
Material
9. SAND/GRAVEL PACK:
Depth Sae Matenal
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
0- 50
50-6J
Lo -iCr
/PS - 305
11. REMARKS:
Formaton Description
DRt
1.),;(ef ,BRvxxineS 4 mil/
C
0
-c
1 DO HEREBY CERTIFY THAT THIS W ELL WAS CONSTRUCTED IN ACCORDANCE W iTH
ISA NCAC 2C, WELL CONST U“ STANDARDS, AND THAT A COPY OF TH6
RECORD HAS BEEN PROVIDED E WELL OWNER.
SIGNATU1 E OF CERTIFIED WELL CONTRACTOR DATE
FIh
ty-
PRI TECKNAM OFPERSONCONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Atm: Intormanon 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 Lkpvuncnt of Enwronmcnt and Natural Kcsou rocs- DI D !stun ul Wate( ()eaat>
WELL CONTRACTOR CERTIFICATION tr 2571
1. WELL CONTRACTOR:
Bryant Stith
W el Contractor (Indradual) Name
Groan RIYer Was & Pump Company
Well Contractor CompenY Nan*
STREET ADDRESS PO Box 204
East Fat Rock, NC 28725
City o Town Sat. Zip Code
( 828 )- 693-1200
Area cod- Phone number
2. WELL INFORMATION:
SITE WELL ID 801 Meade)
STATE WELL PERMITD( 'policed.) 0 Le) 00/053k2.
DWO or OTHER PERMIT aft appfobls)
WELL USE (Cheek Appli ata Box) Resldentol Water Supply 0
DATE DRILLED es=1I2_ID&,
TIME COMPLETED 3 •.00 AM ❑ PM
3. WELL LOCATION: ^ I
CITY YconYi
(0.— COUNTY 1.-1d--0-"CrI°
c 3g air 124 II_1- 9-
(Street Name. Numbers. Community Suodmsan Lot No . Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTIN -
oSlopa OVNIey Oral dga 00V1e
Knack appropr*a bowl
LATITUDE • .
LONGITUDE
May be iR degrees,
mioub, a000tlh Or
n a decimal format
Laurude/longitde source: °GPS °Topographic map
(»talon of wW must to Mown on a USGS rope map and
atach 0 to Ono tonal I not yang GPS)
4. WELL OWNER II ,�,
OWNER'S NAME W15
STREET ADDRESS &3 Sin -Hot 5- kti
Ff-c_fic-her, n ( z-W)34
Cty or Town Stara
(C ). lag -I14-0C
Nee code • Prior* nunbr
zip Code
6. WELL OETMLS: Q /
a. TOTAL DEPTH: O�j-
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO EL
Bakes
c. WATER LEVEL Top dat Crrg: AO FT.
(Use • t Atone Top d Casing)
d. TOP OF CASING IS 1 FT. Atom Land Surface'
Top d casing terminated at/or below and surface may require
a stance in .cw0.no. ...an 15A NCAC 2C .0116
e. YIELD (9pm). 10 0 METHOO OF TEST Orr
I. DISINFECTION- Type HIM Amount
g. WATER ZONES loepthl
From 5 Tr To ea From To
From To From To
From To From To
0. CASING-. Thickness,
Depth Da le; weight M Ierel
From / To 3y FI �L A IL Me
From To Ft
From To Ft
7. GROUT: Depth Material
from o To 3 Ft 5?Ak/dele
From ,3 To .ZO/%4A'
FI 71Parr.t'S.
From To FI
�Men2�a,�
m'Y
Mini .<
8. SCREEN. Depth Demeter Slot Sue Material
From To FI n n
From To FI n n
From To FI n
9. SANDIGRAVEL PACK
Depth See Mateia:
From To Ft
• From To FI
From To Ft
10. DRILLING LOG
From To
/ — /5
/4 — 25
" — 573-
11. REMARKS
Formation Descnpuon
ayR /-
S'js// 80C1€
6 athoife
rn
1
i CO nEREe'r CERnFV TM I THJS nELL nA5 COOSTRUCTED In ACCORDAnCt W'Th
ISO M.1C 2C WELL COnSTRCCTIO•. SU :CARDS AND 1hA1 A CCPY O rn¢
RECORD NA5 BEEN PRO.OED TCyI).f n ELL OnnER
SIGNATU
C/7e2
OF CERTIFIED WELL CONTRACTOR DATE
13ay A,-,»T 6..' L
PRINTE NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Arm: inforrnatlon Mgt_
1617 Mall Service Center — Raleigh, NC 27099.1817 Phone No. [phone] eat 568.
Form GW-la
Re. 7/05

A
RESIDENTIAL WELL CONSIRUCTIO RECORD
North Carolina Department of Environment and Natural Resources- Division of Water (Nary
WELL CONTRACTOR CERTWICATION N 2571
1. WELL CONTRACTOR
Bryant Smith
WeY Contractor (Individual) Name
Green River Well 8 Pump•Company
Well Contractor Company Nana
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
weld l
Z4 Code
SITE WELL ID kit applicable) p �, /
STATE WELL PERMITNt appwabL Q (0) 00 / 0 p 3+7
DWQ or OTHER PERMIT S(% applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED C
TIME COMPLETED / 6 0 AAA PM Er
3. WELL LOCATION: JJ ,J �
CITY: gala( P� COUNTY4- t: IS(!!-)
qn IJ nU-n p
(Street Name, Numbers. Community. MSIOO, Lot No . Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
°Sipe ❑Valley ❑Flat ai1'dge pother
(crack appropriate box)
LATITUDE Jr/2r Ts✓
LONGITUDE %i '15 rJ
May be in demo,
minute, woods or
m a decimal format
Latitlde/longitude solace: g6TPS ❑Topographic map
(bcaatn of we must be shown on a USGS topo map and
attached to this Awn % not using GPS)
4. WELL OWNER OWNER'S NAME fI�`( 1I P
ST EET ADDRESS.? /'Y-
a— nett7'73
City or Town State Zip Code
(4� ,- q( -573(0
Area code - Phone number
6. WELL DETAILS: /7 _
a. TOTAL DEPTH: LDS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er.
c. WATER LEVEL Below Top or Casing: 3 00 FT.
(Use's- 4 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below and surface may require
a variance n accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): t METHOO OF TEST Air
f. DISINFECTION: Type HTH Amount
g. WATER ZONES (depth)
FroTo? From
m 3 C To
From To From To
From To From To
6. CASINO: Thickness/
Depth pp Dia er Weight Materal
From / To /p Ft. /__, 2/4C Pee.
From To Ft
From To Ft.
7. GROUT: Depth Matenal Method
From 0 To 3 Ft. S AC/ 7Agic
From 3 To aD Ft. H Ai V S-POrw
From To Fi.
8. SCREEN: Depth Demeter Slot Size Matenal
From To Ft. D. n.
From To Ft in m
From To Ft.
9. SAND/GRAVEL PACK:
Depth See Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
O - I4_
`J
11. REMARKS:
F/? g, i Desorption
ne
RmArtk_ n
.-Y
r
o —
7
I CO HERESY CERTIFY TINT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrTH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A CCPY OF THIS
RECORD HAS BEEN PROVIDED %p THE W ELLOWNER.
6
SIGNATURE OF CERTIFIED WELL CONTRACTOR
DATE
l3rs / err S,77 th
PRINTED AME 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 al Water Quality
WELL CONTRACTOR CERTIFICATION tl 2571
1. WELL CONTRACTOR:
Bryant Smith
Wel Contractor (Indiidual) Name
Green River Well & Pump Company
Well Contractor Company Name
STREET ADDRESS PO Box 204
East Flat Rock, NC 28726
City or Town State Zip Code
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:WA-I 1 40,
SITE WELL ID Cif appcable)
STATE WELL FERMIUM applicable) n l 0 En ?0
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED e a —O4
TIME COMPLETED #...7 0 AM ❑ PM Qr
3. WELL LOCATION: I
CITY: J da- COUNTY S191
Pa-t
(Street Name, Numbers, Commun Subdivi
TOPOGRAPHIC / LAND SETTING:
Efdlope OVelley ❑Flat ❑Ridge ❑Ot er
(check appropriate box)
LATITUDE far 5 2 h/
LONGITUDEQ$262I' ra
Lautlde/longitude source: ROTS ❑Topographic map
(Wigton of wH must be shown on a USGS topo map and
attached to the form 7 not usap GPS)
4. WELL OWNER
OWNER'S NAME Ph
Lot No., Parcel. Zip Code)
May be in degrees,
minutes, seconds or
in a decimal format
� 51& &!ej
STREET ADDRESS (.^ e
I mrtflr-y St•
S'aQurtct- tJC.3-8773
City or Town State Zip Code
Area code - Phone number
6. WELL DETAILS: _
a. TOTAL DEPTH: ?x 4 5
b. DOES WELL REPLACE EXISTING WELL? YES B-- NO 0
c. WATER LEVEL Below Top of Casing: Lt0 FT.
(Use -+' t Above Top d Casing)
d. TOP OF CASINO 15 1 FT. Above Land Surface'
Top d casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 7 METHOD OF TEST Air
f. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth).
From /20 To /3r From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Dia ter Weight
From 1 To g3 Ft :7 21,C
From
From
To Ft
To Ft
7. GROUT: Depth
From 0 To 2
From_ To 2 0
From To
8. SCREEN
From
From
From
Depth
To
To
To
9. SAND/GRAVEL PACK
Depth
From To
From To
From To
10. DRILLING LOG
From To
d - �0
/n - 6o
60-70
'70 - "7 S
75f #r
11. REMARKS:
Material
/ ✓L
Matenal Method
Ft. Sfrica .- M1ry 1- dew(
Ft (J'dat,1A- Miy $POog
Ft
Diameter Slot Size Matenal
Ft n. n
Ftn, n.
Ft
Ft.
Ft
Ft
Sae
Matenal
ppFormation Descnption
nF_1J ciris,
.S1,4R
.14 1f 4Oc-k
r.1
0
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrin
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THe
REGARD INS BEEN PROVIDED THE WELL ONNER
C—/1-cc
SIGNATRUOF CERTIFIED{WELL CONTRACTOR DATE
`TUnJ 1Heiki grits
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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. [phone] ext 568.
Form GW-la
Rev, 7/05

t, 'J
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Dis ision of Water Quality
WELL CONTRACTOR CERTITICATION N 2571
1. WELL CONTRACTOR:
Bryant Srnth
WN Contractor (Indi idua8 Name
Green River Well 8 Purnp Company
Well Contractor Company Name
STREET ADDRESS PO Box 201
East Flat Rod. NC 28726
City or Tmwn State Zp Code
( 828 ). 693-1200
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID t01 appratae)
Lcs 00 102490
STATE WELL PERMITIOf appicade)
DNIO or OTHER PERMIT t(1 applicable)
WELL USE (Chock Applicable Box): Residentol Water Supply ❑
DATE DRILLED G —2Z—IOC
TIME COMPLETED 1013 0 AMID,'" PM
3. WELL LOCATION: �J�^ ��,,,J �,,�
CITY. SK-x^^+^D_— COUNTY 4--r Il.l•�r �L'n
1H5 i land. Ca &t drg77.3
(Street Namcirtumbers. Community, Subdivision. Lot No. Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
O64ow OValley OFlat ORdge ❑Other
(check appropnaR box)
_g° 1q/ aonl
LONGITUDE al° oral 52W
LATITUDE
May by in degree,
minute, seconds or
o a decimal formai
Latitude/longitude source: SGPS ❑Topographic map
(location d we/ must la shown on a USGS topo map and
attached rc tlrr. form 7 nor uaep GPS)
{. WELL OWNER rLrr (4l c51 iS
OWNERS NAME ,-J J ' ���
STREET ADDRESS .% I La Gt 4G/
faSk-�atQnTr NC2SI)�(P
Cry or Town State zip Coda
Arse code • Purina number
6. WELL DETAILS: Oil
a. TOTAL DEPTH: `O�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO O'
c. WATER LEVEL Below Top of Casing: FT.
(Use •: t Abow Top d Casing)
Q TOP OF CASING IS I FT. Above Land Surface'
Top d casing laminated aVor below Lend surface may require
a variance as accordance with 15A NCAC 2C .0118.
a YIELD (gpn): 0 METHOD OF TEST Au
/. DISINFECTION: Type HTH
g. WATER ZONES (depth)
From To
From To
From To
6. CASING:
Depth? t
From / To
From To
From To
7. GROUT: Depth
From a To .3
From To 20
From To
8. SCREEN: Depth
From To
From To
From To
Fl. 524f01.
Ft l3Qutpr0441-
Ft
Amount
From To
From To
From To
Thickness/
L aTeter Weight Ma7ieral
Ft Weight Marcel
%"LTC/
Ft
Ft
Material Method
Demeter Sid Size Material
Ft
Ft
Ft
9. SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
10. DRILLING LOG
From To
i_0
/0— S�
— 5'0)
11. REMARKS:
Formation Descpo non
ety
5ft'Qa Siv,vr'_
GRd'aJ,'fF- __
C.)
I DO HEREBY CERTIFY TlMT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wrTH
f1L NCAC 2C WELL CCNSrRUC1fll STANDARDS AND THAT A Cam' CF THG
RECORD NAS BEEN PROVIDED E WELL OWNER
SIGNR F CERTIFIED WELL CONTRACTOR
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Intormanon mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] est 568.
Form GW-la
Rev 7/05