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WELL CONSTRUCTION RECORD
P I pi
North Carolina - Department of Environment and Na twat Resources - Division of Water Quality - Groundwater Section
WEIL CONTRACTOR (INDIVIDUAL) SAN1E (print) 03tr 39irlf_A... CERTIFICATION # 3354'
WELL ( ONTRACFOR COMPANY NAME Erreenc_ets LOta 4- Puvr-up PHONE 8 (g7A bqe ,3i 2 0
STATE WELL CONSTRUCTION PERMED4 I' i 0 2- ASSOCIATED WQ PERMIT#
(if applicable, Of applicable)
1. WELL USE (Check Applicable Box): Residential Er.4unicipal/Public 0 Industrial 0 Agricultural D
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:_le- County 14-214/ Waif
(Street Name. Numbers. (ommuniry. Subdivision, 1.01 NO., Zip Code)
3. OWNER: j IV a_ A) e ja
Address 43 Di ija-fich any 1_,1.
(Street or Route No.)
AAS Oak, A) c 2 7Q 4,
City or .1.0WII State Zip Code
(121)- -23q- in C
Arco code- Phone number
4. DATE DRILLED_ 1-1/3 i0
5. TOTAL DEPTH:
1. 1119 Pi!" VI- 1.!c 1 i" ? Y!'S
7. STATIC: WATER LEVEL I3elow Top of Casing: Y (--) FT.
it:se "t-ifAhove Top of Casing •
5. TOP OF CASING IS L FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A !'CAC 2C: .0118.
9. YIELD (pm): _ 35 METHOD,OF TEST 2. th9u1c
WATF,R ZONES (depth): 9105
I!.uislNElicrlox: Type_ frig
In. CASING:
Amount
Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To ei Ft. 6°
From. i To
From To Ft.
13. GROUT: Depth aterial
From 0 To ZD Ft. e_at.A.E
From To
14. SCREEN: Depth Diameter Slot Sizc Material
From To Ft. in. in.
From To Ft. in. In.
15. SAND/GRAVE,I, PACK:
Depth Sizc Material
PV C
From To Ft.
Method
TO?
Topographic/Land setting
121fdge 0Slope OValley OFIat
(check appropriate box)
Latitude/longitude of well location
(degreesaninutes•seconds)
Latitude/longitude souree:DGPSOTopographic map
(cheek box)
DEPTI I DRILLING LOG
From To Formation Description
Q ' —gl.'
D 2 '
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.
From To Ft.
16. REMARKS:
I DO IIEREBY CERTIFY triArmis WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A N(
CONSTRIICTIO, .ANDARDS. AND TILAT A COPY OF THIS RECORD I IAS BEEN PROVIDED TO
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service
27699-1636 Phone No. [phone], within 30 days.
'AC 2C, WELL
TIIE WELL OWNER
DATE
Center - Raleigh, NC
GW-1 REV. 07/2001

t 1I
WELL CONSTRUCTION RECORD
North Carolina - Department of F.nvironnient and Natural Resources - Division of Water Quality - Groundwater Section
WEI1 ('O\'TRACTOR (INDIVIDUAL) 4: (Print)_ QoU`t /\, W.. _ ____ _ _ CERTIFICATION # 21/0
WELL (oNrkActoRCOMPANY NAMEiSre,B11_t _ Alps cJUL. 4-Philp _ _.___ PIIONE # f 221117(18-317 o
STATE WELL CONSTRUCTION PERMIT _ /7 °- ASSOCIATED WQ PERMIT# _ _
(if applicable) (if applicable)
I. WEL1. USE (Check Applicable Box): Residential E3.-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I teat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: 60,(14"0/S) County 404t
Street ,Name Numbers. Community. Subtli vibion. lot No.. Zip Code)
OWNER: ken c( G hers
Address __-3D__ +p���
(Street or Ruufe Nat
CanioA 4UC-
City or Town State
(en, 2-3S- 9y93
Area aide- Phone number
4. DATE DRILLED__Q_j
L87lb
Zip Code
5. TOTAI. DEPTH:_3�,$
...)).)4\\Alit RI.nl All. L\t.tIr.t.N).11 \t.l I11r)L,—
7. STATIC WATER LEVEL Below Top of Casing: __tob ,., FT.
1Csc" 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 I5A NCAC 2C .0118.
9. YIELD (gpm): 'ZMETHOD OF TEST 7 f4.'t.S
10. WATER ZONES (depth): 3415
Topographic/Land setting
DRidge ❑Slope ❑Valley PFlat
(cheek appropriate box}
Latitude/longitude of well location
(degrees/minutes/seconds)
latitude/longitude source:fGPSfTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
�8 ` - 36
11 DISINFECTION: Type_ _ ±1777 _ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From- To 27 Ft. fj" �JC
From. To Ft. _
From To
I3. GROUT: Depth Material"
From Q... To 2-0 Ft. Ce-/Ada.
From To
la. SCREILN: Depth I )iantcter Slot Sim Material
From To Ft, in. in.
From To Ft in. in.
15. SAND/GR.AVEI. PACK:
Depth Size Material
Method
Top
From__ To_ _ Pt.
From To Ft.
16. REMARKS:
LOCATION SKETCII
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
IVILEIVJ VJ G0313
I DO I ILK EBY CERTIFY T(AT TEES WELL WAS CONSTRUCTED IN ACCORDANCE WIT!! ISA NCAC 2C. WELL
CONSTRUCTR . STANDARDS,
,AND
�THAT A COPY OF TII(S RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
a IL�Q.--a�-'6 -vL_ i9 "L5'-D 6
SIGNATURE OF PERSON CONSTRUCTINGTI(E WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

(Street or Route No.)
1/0OA/ erWidth ,UL a979�
City or Town State Zip Code
(6z61- Z35 //?5-
Area code- Phone number -1-0
-0 6
4. DATE DRILLED L r
5. TOTAL DEPTH: 7 S
_ IAI)I.51 NCI:, 1 P1.111 k/ 11 l..-ICl lnp.1.I 1 .1 c,.rl LJ�
7, STATIC WATER LEVEL Below Top of Casing: ij FT.
( Use. "4-- if Above Top of Lasing)
X. TOP OF CASING IS / FT. Above (,and Surface*
''fop of casing terminated at/or below land surface requires a
variance in accordance �yr Yh I5A NCAC 2C:.0118.
9. YIELD (gpm): 14 METHOD?: TEST SOUPS
10_ WATER ZONES (depth):
/6
I :. DISINFECTION: Type-_.. Hp/
12 CASING:
Depth Diameter
From 1,To i 9 Ft. 4/
From To
From _ To _ lit,
13. GROUT: Depth Material
Prom— a_. To Z Fi. Cerne._
From To Pt.
Amount
Wall Thickness
or Weight.rFt. Material
L
Method
rop
14. SCREEN: Depth Diameter Slot Size Material
15
From To _ _ Ft. in,
From To Ft. -__—in.
SAND/GRAVE(. PACK:
Depth Size Material
From
From
in.
in,
1b. REMARKS:
To Ft.
To
{ 1 O. ,Fr r-
G tai A
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural [Resoura'e/sr ��- D�ivvision of Water Quality - Groundwater Section
WFIL CONTRACTOR (INDIVIDt1A1.) NAME (print) I' 6TA, Webb-. /_/. __- CERTIFICATION # O/6
WELL ('ON RACfOR COMPANY NAME. -. r✓rCel/t__ei� Wei-`_tl--./_t/lY?___.__._ PHONE k€4 6c ..3120
STATE WELL CONSIRUCfION PERMIT# -_3 O_ y _ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential it Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Beat Pump Water injection 0 Other 0 If Other, List Use
2_ WELL LOCATION:
Nearest Town:__�j,/
County G'J/111,LOQZt
!Street Name, Numbers, Community, Subdivision, lot No., Zip ('del
3. OWNER: lid&a ✓ co b jack Wailyz4A,
Topographic/Land setting
DRidge DSlope ❑Valley EFlat
(check appropriate box)
Latitude/longitude of well location
Idegr esiminutsiseconds)
Address -/ Q__. _.JYV/»_rjte.. s Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
D
- i ttSS 5 •
LOC'.ATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
O
oz
Do THEREBY CERTIFY 'IIIAT THIS WELI. WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C'. WELL
CONSTRUCTION ANDARDS, AND TIIAT A COPY OF THIS RECORD I IAS BEEN PROVIDED TO TIIE WELL OWNER
•
/ t/YtPnat j/beci zs-0 b
S iNATURE OF PERSON CONSTRUCTING TI IE WELI. 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

12 rl P t.1 1 A
cut) WELL CONSTRUCTION RECORD
i Mirth C ar(ilina'= Department of Environment and Natural Resources
-Division of Water Quality - Groundwater Section
p
; WELL ('ON'FRACFOR(INDIVIDUAL)NAME (print) 6e p/ki S,pI�Z/Grnoie .___-_.. CERTIFICATION #3i82
WELL CONTRA('TOR COMPANY NAME_ 6rt412E_,no �€^"' CEP"' (bay PHONE # 03246 ge- 3.0
STATE WELL CONSTRUCTION PERMIT# _Pe 0 Z— ASSOCIATED W'Q PERMED/ _.. _.
(if applicable) (if applicable)
1. WELL LSE (Check Applicable Box): Residential Q' Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WISLI, LOCATION: � "" � �
Nearest Town:4 4CJYc,e rtC County�6C fYX
i Street Name, Numbers, Community, Subdivision, lut No., Zip (ode)
3. OWNFR:
Address _--2-I.15 Piac_cr-cop
(Street or Route N. 1
alit 1e . JC 2-872-(
('itv or Town State Zip Code
(82$- 631-8.5�
Arca code- Phone number
3. DATE DRILLED_ 9"3/'rt £'
5. TOTAL DEPTH: pc(o S—
t I"918111'I.I I U1.nl 1/' 1. I.8I3:198(. 11 1 ','3.c I nI' 1-1—
7. STATIC WATER LEVEL Below Top of Casing: 9 00 FT.
(use "t' it Above Top of Casing)
R. TOI' OF CASING IS / FT. Above Land Surface"
'top of casing terminated atlor below land surface requires a
variance in accordance with I5A NCAC 2C: .011x.
9. YIELD (gpm): METHOD OF TEST 2 i%0/15_
10. WATER ZONES (depth):
yoo'
11. DISINFECTION: Type__ HIM - Amount
i2_. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From0_To 3& FL (an
From To It.
From To
13. GROUT: Depth Material / Method
From 0 To 2-0Ft. a nteA lop
Front To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in,
From __ - To Ft. - in. ---- in.
15. SAND/GRAVE(. PACK:
Depth Size Material
Material
plc-
Fron: To Ft.
From To Ft,
6. REMARKS: _ __
Topographic/Land setting
ldgc ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrcesnninutes,seconds)
Latitude/longitude source:❑GPS❑Topographic map
l check box)
DEPTH DRILLING LOG
From To Formation Description
_O.f- 36'
37' sr
fLG
LOCATION SKETCII
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
a
I DO I IEREBY CERTIFY 'I'IIAf THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITIL ISA NCAC 2C. WELL
C'ONSTRt1CTION 1 T)p.NDARDS, AND TI TAT A COPY OF THIS RECORD I LAS BEEN PROVIDED TO TILE WELL. OWNER
SIGNATURE OF PERSON CONSTRUCTING TIFF 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

rj 1.:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -- Division of Water Quality - Groundwater Section//��pp
—WELL CONTRACTOR (INDIVIDUAL) NAME (print) �Qp'A WeldZ7�
,—____ —___ CERTIFICATION ita
WELLCONTRAc"tOR COMPANY NAME -Lfteilf_..D/tS weft_-- garip.--.PHONE # Q23i6g9-3( 0
STATE WELL CONSTRUCTION PERMIT/4 /' 0 - ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. Wha.l. USE (Check Applicable Box): Residential C Municipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Beat Pump Water injection 0 Other 0 If Other, List Use
2. WELL LOCATION: "�
Nearest Town: r44 7 D& County WQgLOcZY[
i Street Name. Numbers. Community_ 5 ibdivision. Ian No.. Zip Code)
;. OWNER: —Parr,/ Phatiii
Address
(Street or Route No.)
t 1t). orl i\we State Zip Code
(Q !reh fo'1`5f
Area nude- Phone number
4. DATE DRILLED__ _el 5 -d b
--
5. TOTALTOTALDEPTII: 13051
yid)! 1/-I. 1. !_I\ I lh,l. \A'1.1
7. STATIC' WATER LEVEL I3clow Top of Casing: _ZQ FT.
It se "i"if Above Top of Casing) •
S. TOP OF CASING IS I _ FT. Above Land Surface` ---
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118. ' /
9. YIELD (gpn): _ METHOD _ METHOD OF TEST z ikat'S
10. WATER ZONES (depth): 395
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Pflat
I check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
I-ront To Formation Description
Q' _-7QI
1 L DISINFECTION: Type__ jjf Amount
12. CASING: Wall Thickness
Depth ( Diameter or Weight/Ft. Material
From CD To Zo Ft. jort
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From Q_. To 2.0._. Ft- C'Q/Y2B.-
/—
I rem To PI.
15. SCREEN: Depth Diameter Slot Size Material
From To It. in.
From To Ft. in.
15. SAND/(GRAVE(. PACK:
Depth Size
From To Ft.
F rorn---- To Ft.
1b. REMARKS:
In.
in.
Material
LOCATION SKETCH
Show direction and distance in stiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO IIEREBY CERTIFY THAT lII[S WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND TIIAT A COPY OF THIS RECORD I IAS BEEN PROVIDED TO TIIE WELL. OWNER
R72-C-o b
SIGNATURE OF PERSON CONSTRUCTING TILE WELI. 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

9
10
WELL CONSTRUCTION RECORD
327766
North Carolina - Department of Environment and Natural Resour�c�esn- Division of Water Quality - Groundwater Section Q
WE:LI. CONTRA('TOR (INDIVIDUAL.) NAME (prinntt)p_ _ bf i (//V/ v/^!!/// /b/ / CERTIFICATION #zppyt0
WELL CONTRACTOR COMPANY NAME _ 6ree4 c B cos Wed ¥.- Pone PHONE # 16l$ 6 ye -,ji? (2)
STATE WELL CONSTRUCTION PERMIT# p o Z ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
I . WELL USE (Cheek Applicable Box): Residential / Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOC'ATIO : /
Nearest Town: -_2_jJD/L _ County IIay Wb ti
(Street Name, Numbers, Community. Subdivision, Lot No., Zip (de)
3. OWNER: C?aIf-
Address
Address
(Snttit or Route No.)
Car' ,t AVG
p�e''//��City of TowoQ QQStateG
ID)--i0i✓ -43_9 a
Area code- Phone number
4. DATE DRILLED6--(2.-"0 6
5. TOTAL DEPTH: S b5 r
f. I\/\LI UILI I UI.UI A!'1. 4VILi1 nJ_ U'111 I' 1 V4111 Af
7. STATIC WATER LEVEL Below Top of Casing: / 0
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
YIELD (gpm): S METHOD OF TEST Z 110H1is
28 /b
WATER ZONES (depth): 326E
Zip Code
IY
FT.
I I. DISINFECTION: Tvpc i%/
12. CASING:
Depth Diameter
From To ¶ - Ft. L'
From To Ft.
From To Ft.
13. GROUT: Depth
From (% To 2-o Ft.
From To FL
Amount
Wall 'thickness
or Weight/Ft. Marenal
pie
Material Method
Gym cn�
14. SCREEN: Depth Diameter
Slot Sim Material
From To Ft. in. in.
From__ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
I- ram To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley lat
(check appropriate box)
Latitude/loneitude of well location
(dcgrcesiminutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From, To , Formation Description
5yf - 3(a3 r (T7lYL/iGT G
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.
N
m
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION SI:)A ARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIONA LURE OF PERSON CONSTRUCTING TIIE WELL
_g-a(
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No.[phone], within 30 days. GW-I REV. 07/2001

WELL CONTRACTOR (INDIVIDUAL) NAMEn(print) ex 0U /L1�1
WELL CONTRACTOR COMPANY NAME (7 (CBAM
STATE WELL CONSTRUCTION PERMIT# /y0Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N coral Resources - Division of Water Quality - Groundwater Section /
CERTIFICATION # 3355
PHONE #(946V8-3f70
'-as . turd 4 Aim?
I. WELL USE (Check Applicable Box): Residential Er-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: /, /I �
Nearest Town: C.Igd , County /7Qd, WO
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: rM.$ CrC
Address / 29,D
cfircli &SA Welt
i (Street or Route Na) rk
City or Town State Zip Code
(82_4S)- 671/- 9y8&
Area code- Phone number
4. DATE DRILLED f%2-43-0(0
5. TOTAL DEPTH: 3051
. IX,'LS ',VE'L 1. REPLACE EX!sT!NG ''F I •, Yl:S i (( NO ktV
7. STATIC WATER LEVEL Below Top of Casing: go FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
''Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / 0 METHOD OF TEST hf2.Jcf
10. WATER ZONES (depth): / 1S'
Z$S`
l 1. DISINFECTION: Type HMI Amount
12. CASING: Wall Thickness
Depth Di eter or Weight/Ft. Ma rial
From__D To 1/Z Ft. f
From To Ft.
From To Ft.
13. GROUT: Depth Materiala"� Method
From [7 To 2-0 Ft. (come vl 7-3 fl
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft. i "v' -r r�cz. iona —lice
Topographic/Land setting
❑Ridge ❑Slope OValley HFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From / Tor Forgration Description
P3'- 3os' � unvtG
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road o
numbers and common road names.
16. REMARKS:
Material R E C r ` ' D
AUG 2 5 203S
I DU I lEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDS. AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

O\C)
�: R 21 7
� `7 S. 2
WELL CONSTRUCTION RECORD
North Carolina -,Department of Environment and Na al Resources - Division of Water Quality - Groundwater Section
hK/J(�J Weil I 'r CERTIFICATION #1.(// p,
WEL[. CONTRACTOR COMPANY NAME %GeAe.. As. Wei '- Pco'n p PHONE # (Sea 0 V 8 -3/ % O
STATE WELL CONSTRUCTION PERMIT# Jt/ 0
(if applicable) (if applicable)
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
b;ti wel,b
ASSOCIATED WQ PERMIT#
I . WELL USE (Check Applicable Box): Residential EKMunicipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2 WELL LOCATIO)1: I
Nearest Town: Rica fits wells County Hay
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ,add I A -
Address / 02
(Street or Route No.)
10aynesvtclt Nc-
City or Town State
(96- 92.6-6o70
Area code- Phone number
4. DATE DRILLED 5 -2-0 -0 (p
5. TOTAL DEPTH: /2S'
Zip Code
D„'.S \V...... REP'LACE Ex !SUING WELL? YES I I NO Cre.
7. STATIC WATER LEVEL Below Top of Casing: i 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS , FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
sariance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): b 0 METHOD OF TEST Z HOuti
10. WATER ZONES (depth): 1 05-1
11. DISINFECTION: Type y771 Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From -Q To 51 Ft. b" PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 2-0 Ft. Cpa✓/et 4-
From To Ft.
14. SCREEN- Depth Diameter Slot Size
From To - Ft. in. in.
From To
15. SAND/GRAVEL PACK:
Ft. in. in.
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Method
Top
Topographic/Land setting
❑Ridge 0Slope OValley IQ1:lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formatiyp,Description
Q4, 1 ( l c�
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
AUG 2 5 20U5
0
( DU HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCIPcN STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

327783
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section p
WELL CONTRACTOR (INDIVIDUAL) NAMEj (print) QQf) bI /te/ ,,Wr,�'d' �) CERTIFICATION # .zv/O
WELL. CONTRACTOR COMPANY NAME £u,,e4e /t cos. WL't�I W_i✓ np PHONE # SA Z$ �oV8 :'�hO
STATE WELL CONSTRUCTION PERMIT# / q O Z ASSOCIATED WQ PERMIT#
(if applicable) - (if applicable)
1. WELL USE (Check Applicable Box): Residential lE / Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection O Other 0 If Other, List Use
2. WELL LOCAT,iO�N1:
Nearest Town: W a yACSVak'G County One/tuo
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 0 id /9i yy)gl�
Address /t/02 UG!lWoe& Act
(Street or Route No.)
1/OfslitAeoVia{ Nc- L8794
City or Town State Zip Code
O- kb- 4090
Area code- Phone number
4. DATE DRILLED 06 -2. a (n
5. TOTAL DEPTH: 11{5'
V. Dru:C \UT..!, L UI`DI REPLIWI VIC1IAJ: Il/1:1 I;� VI.0 11 NO r�r
7. STATIC WATER LEVEL Below Top of Casing: NO FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 8 METHOD OF TEST Z fdoLt.S
10. WATER ZONES (depth): 5bS' - 145 1
11. DISINFECTION: Type /+TF/ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. MaterQial
From C2 To 419 Ft. 4," PVC. -
From To Ft.
From To Ft.
Topographic/Land setting
0Ridge DSlope 0Valley L3F at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Form tion Description
r
l 41-1
e `- ' NS' 6r to
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
L
13. GROUT: Depth Material Method cr.
From (i To 2-0 Ft._-LtMgy% I p to _
From To Ft. co
I4. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in. j
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
i6. REMARKS:
Material
AUG 25 21:[5
0
1 DU IiEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONS/ DARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
£ni oost- _�is/.1-rn-- ' 3/0 c.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natu al Resources - Division of Water Quality - Groundwater Sectionq
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 6 J /1,.' IW ebb CERTIFICATION #LYLtg
WELL. CONTRACTOR COMPANY NAME T OP'4 . &s WeiCc 44.rQ _PHONE # (D2g) 645-3170
STATE WELL CONSTRUCTION PERMIT# /7 v Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
r; tis
4.4 ki I i 1
WELL USE (Check Applicable Box): Residential L7 Municipal/Public ❑ Industrial ❑ Agricultural E
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELLLOCATIOhj;
Nearest Town: 11 Jn`ft-Abr-
CountyiC
(Street Narnc, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ,(Q LC( I#DI&/oak-
Address 39O/ o/d gi✓er 0-4
(Street or Route No.) 347
- /�� (1 or Town State Zip Code
Pere))- 73`t-€t9°
Area code- Phone number
4. DATE DRILLED S 19'4D 6
5. TOTAL DEPTH: 205
Topogra ic/Land setting
ORidge ope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
31' -Z st a
1)ULS "11 i REPLACE EXISTING WtELT_, YES III NO
7. STATIC WATER LEVEL Below Top of Casing: �/ d FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordant with ISA NCAC 2C .0118.
9. YIELD (gpm): 5 METHODPF TEST z ,How
10. WATER ZONES (depth): /N/5
I I. DISINFECTION: Type /#TN
12. CASING:
n Depth Diameter
From To 30 Ft. 62(
From To Ft.
From To Ft.
13. GROUT: Depth •
From 6 To 2
From
Amount
Wall Thickness
or Weight/Ft. ✓ei
ci l
Ft. daterial
e/nP/Lif
To Ft.
14. SCREEN- Depth Diameter Slot Size
Ft. in. in.
From _ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From_To Ft.
From To
Method
Top
16. REMARKS:
Size
Material
Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
L. ki
AUG 2 5 2Dui
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTRUC' STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
0
0

327780
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N�a,$i,,[d1 Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME ((print) IW$efr fJ u VA-i( CERTIFICATION ant/WELT. CONTRACTOR COMPANY NAME 6rrej2 e 17i0s. tdej / I-- Pump PHONE [phone]'3/70
STATE WELL CONSTRUCTION PERMIT/4 fy 0 Z ASSOCIATED WQ PERMIT*/
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential G}----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: tu/Wfler$VG/i•e County Kay 1.4-0 /
(Street Name, N��u^^mbers, Community, Subdivision, Lot No., Zip Code)
t� 3. OWNER: tsry CO.,-1-/JC.
Address P •O . 431'x 9 C.
"U�1ss.til rRoute NC Z878G
City or Town State State Zip Code
(823 (ayb-Suq
Area code- Phone number
4. DATE DRILLED ,S" ( gyp 4
5. TOTAL DEPTH: 2 g 5-'
4 DoLs WELL REPLACE I .X!ST!!N l(i U'EL ? YkS L1 NO l
7. STATIC WATER LEVEL Below Top of Casing: 10 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 2 0 METHOD OF TEST 7- {}pUt1
10. WATER ZONES (depth): ZZS i
LbS'
11. DISINFECTION: Type (fret Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. M terial
From To by Ft. bit
�j )�ee
From To Ft.
From To Ft.
13. GROUT: Depth Material ` Method
From /2 To 2-0 Ft. C2_nj.C/vi nd
From To Ft. f _
14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
DEPTH
From To
695'- zest rani re
Topoggraa hic/Land setting
[Ridge OdSlope [Valley OFIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
t-i E c "
Asheville s e,<ic -,I
16. REMARKS: C
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STA7 ARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF 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
r_
0
r—I

3 2 f i{ V
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME' ((print),�OfjLje.l I.1/'CAra2G ( CERTIFICATION# 335g
WELL. CONTRACTOR COMPANY NAME SL -e _o s £oaf 4- Pm'ip PHONE # 63a6 6 40 - 317 0
STATE WELL CONSTRUCTION PERMIT# / el O T- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential B Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCAT_ON: /I
Nearest Town: )LJ, . jil tsr (Ile County N .1
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ]* U ti Couaiv1rtf Ca Ash uu)e)N o
Address / S J/J,sep//ah aurf
Street or Route No.)
�r e Juno/usI c N G L S 741s—
City or Town State Zip Code
(8 L'- Z5-6 6
Area code- Phone number
4. DATE DRILLED
y-Z-8-(216)
5. TOTAL DEPTH: 60 5'
(.. DULY,, WELL RFD' ACE EX!S'!lNI: WELL? YES I 1 NO GI"-
7. STATIC WATER LEVEL Below Top of Casing: /0 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): V METHOD OF TEST 2 MO
10. WATER ZONES (depth): 2,0.5
11. DISINFECTION: Type /J'7i/
12. CASING:
Depth
From Q To 24 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 217 Ft. L emPA-
From To Ft.
14. SC'REEN: 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.
Diameter
b"
Amount
Wall Thickness
or Weight/Ft. Material
Pp'C
6. REMARKS:
Method
re?
Topogra ic/Land setting
❑Ridgee OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
From To Formation Description
2qt
2..5' - ISO5'
DEPTH
sec hdE
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
AUG 252003
Asheviiie Regionai 0
Aquifer flrn ,,
1 DU IIERE13Y CERTIFY TILAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION DARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Yn ` /tee coc
3 /,g/o6
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
P)
0
r=

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section op
CERTIFICATION # 2 Wei?
WELL CONTRACTOR COMPANY NAME 6/reed f1%Q,S. WGLL ,D PHONE # (�1 Fi 4/83t 7 O
STATE WELL CONSTRUCTION PERMIT# / `f O Z ASSOCIATED WQ PERMIT#
(if applicable)
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
(if applicable)
PobU'Jebb
i. WELL USE (Check Applicable Box): Residential Eg Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCA_
Nearest Town::atieit
County N4.t/IDod
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
Sr� (Street or Route
,No. )
(:it5 of e Yo—tkne L /V
L9 - 73Y-8613G
Area code- Phone number
4. DATE DRILLED V 2-7-0 6
ZR75/
Zip Code
5. TOTAL DEPTH: 2Z6a
(, t\nt. WELL RL:PLArI-: L:vic'nn:G WELL? Y1:c r I NO L✓
7. STATIC WATER LEVEL Below Top of Casing: 6 e FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS " FT. Above Land Surface"
`Top of casing terminated at/or below land surface requires a
variance in accordant,with HA NCAC 2C .0118.
9. YIELD (gpm): 2/ METHOD OF TEST 2 ilea-5
10. WATER ZONES (depth): 2OS
11. DISINFECTION: Type Writ/
12. CASING:
Depth Diameter
From To se Ft. & °f
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
PVC
13. GROUT: Depth Material Method
From 0 To 2-0 Ft. Cease- /_ j op
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
in.
in.
From To Ft.
Fram To Ft.
16. REMARKS:
Topographic/Land setting
ORidge ❑Slope OValley a:Flat
(check appropriate box)
Latitude/longitude of well location
ti+ (degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Format on Description
l2' 513 Cni
S9 t- 22St ram Fe
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECE J
.AUG 2
Asheville Regional
Acnjjfer i-'rotf.
0
I DO IiEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONAN
DARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER IA
/241,4aer .9
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
0
0

327776
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) toyer Ovi/ 11
WELL CONTRACTOR COMPANY NAME 6stele th fas. JecI 4- Popp
CERTIFICATION # 33.5 Y
PHONE # 02$ { 4' 3/70
STATE WELL CONSTRUCTION PERMIT# WO Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
a/
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
1
WELL LOCATION:
Nearest Town:
yIe
County 140.41(/J0Q1
(Street Name, Numbers, Community', Subdivision, Lot No., Zip Code)
3. OWNER:
Mts /VA-'i ]ew S
Address / /ypiac/£Idire
(Sweet or Route No.)
Ooncanui/It TY
or Town State
75737
Zip Code
( 972. - $ib_ 9 B48
Area code- Phone number
4. DATE DRILLED 5 9/0
5. TOTAL DEPTH: J 0 05'
Cadopographic/Land setting
ge ❑Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From Tot Formation Description
D 3-5
&' -/005' Cmrtl 1-e
OOES \1/L1,1 REPLACE `:X!S:1ING WELL? YES I I NO
7. STATIC WATER LEVEL Below Top of Casing: 1415 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS I FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): ! METHQD(QF TEST Z. WOOLS10. WATER ZONES (depth): ( 0
11. DISINFECTION: Type Jtr#
12. CASING:
Depth Diameter
From_- To j Ft. b "
From To Ft.
From To Ft.
13 GROUT: Depth Material
From 0 To ZO Ft. realt-lf
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
PVC
From To Ft.
Site
Me hod
0
Slot Size Material
in.
in.
Material
16. REMARKS:
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.
REC I
AUG
Acheviile Regional L. Ice
/if I�er Pm recta /
r_
C
W
0
0
C"1
0 r
0
Cr!
rn
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C'ONSTRUCTIO ' STANDARDS. AND/THAT A� COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
A o�--(�GL 4440A,B(4-11--_ .S//8/0 (•
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
321115
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME jprint) P-bje., DWeal CERTIFICATION�ca'p# 33,5y
WELL CONTRACTOR COMPANY NAME (. re ld,$ (D-1 (�id- P(/mp PHONE # y,) 4QB",7/la)
'cen
STATE WELL CONSTRUCTION PERMIT# / `f 0 L ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential t 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 Ton L/iisii.� 0 /lte County 1402,toVc
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: PnM 6book
Address yelg JPnbns ?d
ntreet RouteoANo.)
Caa• r"' n "
City or Town State Zip Code
(Bze)- z 63 - S773
Area code- Phone number
4. DATE DRILLED y-Z6 -e L
5. TOTAL DEPTH: ZZS
,. IX)LS WI..L.l REPLACE EX!S!INU WELL'? ? YES ILI NOl
7. STATIC WATER LEVEL Below Top of Casing: 2 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS % FT. Above Land Surface"
'Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): / 0 METHOD OF TEST 2 F)OQU
10. WATER ZONES (depth): ZAS
11. DISINFECTION: Type
12. CASING:
Depth
Fromm To 9 / Ft.
From To Ft.
From To Ft.
TE/
Amount
Wall Thickness
Diameter or Weight/Ft. Material
Sfee(
13. GROUT: Depth Material Method
From 0 To 2-0 Ft. regle/t %b fJ
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:
Topoggraphic/I and setting
❑Ridge 2S1ope OValley (Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: DGPSOTopographic map
(check box)
DRILLING LOG
Formatipn Description
DEPTH
From To
0' 7l 6 7Zt ZZS' 44//(1Q
.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
{
RECE / r
AUG 25 2GLS
eviile Regional &; ice
i
Lp`aii%r 1. ,t-, .
'Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a. aoa SIGNATURE OF OF PERSON CONSTRUCTING THE WELL
S// 51/a
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
0
0

16. REMARKS:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N rural Resources - Division of Water Quality - Groundwater Section
PHONE # Ism d(/R,3/ 70
STATE WELL CONSTRUCTION PERMIT# ` Q ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 2KMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) f CERTIFICATION # 2 V/(T
WELL. CONTRACTOR COMPANY NAME Ca ram° -(° &os. �� «- abrio
2. WELL LOCATI N. /
Nearest Town: e redel} County �fU�
I Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
ohnQ 6100
ar). 6 4e /Y %S
�r.�t� ($tree��jpo�r Route 7No. )
/T-a35/e_ _. /t) c
1 or own
z8%St
(v"LF704 ow —OD9 / Zip Code
Area code- Phone number
4. DATE DRILLED 511-0 G
5. TOTAL DEPTH: 2!o'i'
1t'LS WELL REPLACE LXIS 11N" WELL? YES ILl NO If
7. STATIC WATER LEVEL Below Top of Casing: bb FT.
II (Use"+" if Above Top of Casing)
8. TOP OF CASING IS L FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accoraapce with 15A NCAC 2C .0118.
9. YIELD (gpm): G 0 METHOD OF TEST Z FIOUtJ
10. WATER ZONES (depth): 2LS '
11. DISINFECTION: Type fi%f1'
12. CASING:
Depth Diameter
6"
13.
From n To 30
From To
From To
GROUT:
From
Amount
Wall Thickness
or Weight/Ft. Material
Ft PVC -
Ft.
Ft.
Depth /�M�,aterial Method
To 2-0 Ft. Cegle�f/-
From To Ft.
14. SCREEN: Depth Diameter
From . .-_ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Slot Size Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley l
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
Of 3 01
3! '- 2-�S'
FUl11fi-r_
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road 0
numbers and common road names.
1
From To Ft. i 1
AshevNfe Rerun_, Gtfice
AcYP ii,`pr Pr.1 . i
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
( ONSTRUCTI TANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
L'nn ei nd I 1 SI/ F31i7 G
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
0
-1

327773
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /2 y Q r DUI/Oa CERTIFICATION��8333V
t ete_ Es *. rns i -A ine PHONE it tea, 4 (18.3 I7 0
STATE WELL CONSTRUCTION PERMIT# /y d Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL CONTRACTOR COMPANY NAME
I. WELL USE (Check Applicable Box): Residential Ere—Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: / _
Nearest Town: V )Q!'�,e ✓U1VG County
awlwood
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. oviNER4tical Pact Alt der 5
Address 780t{ Fliviced 4/70
(Street or Route No.)
CAaid 0 ff zt(o
City or Town State Zip Code
0,S)- 8y?—Zy0 z
Area code- Phone number
4. DATE DRILLED 5 Zy-O (O
5. TOTAL DEPTH: (0 6 S
`. I\()L_S \ir,a I REP' A..UE I-XIS'l ING '.YELL? YES I I NO r,
7. STATIC WATER LEVEL Below Top of Casing: b 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /2- METHOD qF TEST 2 Rodec.5
10. WATER ZONES (depth): 5135
11
12
DISINFECTION: Type brieg- Amount
CASING: Wall Thickness
Depth Diameter or Weight/Ft. M terial
Frum 0 To 3? Ft. (it t C.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To Lb Ft. Ceme,-F Top
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.
Jopographic/Land setting
ge ❑Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Form ion Description
Q 39,
o`-Gos` a.e
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
c_
0
({I
16. REMARKS: `'----
wArc1 ifer
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
C'ONSTRUCTIO ' STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Ul3</Qua
Ile Regional ion.ai `mice
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

lam`- 327772
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION # v18
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Q0161 /V Webb
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
___ 'e- 6roLi_ Lett 4- Anne PHONE # t 8 6(i98170
Z ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential MunicipaUPublic O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: "
Nearest Town: L.:an�/L County a/ at
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Jnhn CraAC-
Address yoga Ng hard ed_
(Street or Route No.)
C'0pip/. MC. 26'i1b
City or Town State Zip Code
(eza)- 24& - 3 4 8 9
Area code- Phone number
4. DATE DRILLED t3-1/-o G
5. TOTAL DEPTH: ZOS
DOES WELT REPLACE : EXIS nn:(: WELT? :' YES I 1 nu) K
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface"
*Top of casing terminated at/or below laud surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): (7 META-] KOD OF TEST2 Hooss
10. W'ATER ZONES (depth): / V J
I I. DISINFECTION: Type
12. CASING:
Depth
From (� To 911
From To
From _ To
13. GROUT: Depth
From o To al)
Had
From To
14. SCREEN: Depth
From_ To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From
Diameter
Ft.
b u
Ft.
Ft.
Amount
Wall Thickness
or Weight/Ft. Materal
Material Method
Ft. Cp./nu/1— 73P
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size
Ft.
To Ft.
Material
16. REMARKS:
Topogra ic/Land setting
ORidge 2Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
o' �L'
15' - 2051 �7ra-t�t""[.
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. o
0
RECEIVE
IAUG 2 2011v
1 Ashev;)ie
ReinDal �= "ce
1 DO IiEREBY 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 DATE
c_
w
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
0- I

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (2,O6In W ei,6 CERTIFICATION # 2'94
WELL CONTRACTOR COMPANY NAME C 1-CV e. Arcs. c -tU 4- Awn()PHONE a Oa 6Y8 3(7 0
STATE WELL CONSTRUCTION PERMIT# /7 0 2 ASSOCIATED WQ PERMITS
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential El Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: /�
Nearest Town: Can40ti County h4t0Oodt
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
Joe_-e
3. OWNER: .,V(
Address /O 7 m,ed
(Street or Route No.)
are ell Viile ,SG 216(c
City or Town State Zip Code
(&)- LPJSsszi
Area code- Phone number
4. DATE DRILLED .6 17-06
5. TOTAL DEPTH: B
(. DOES WELL REPLACE EX!S!!NG WELL? YNO Fel
7. STATIC WATER LEVEL Below Top of Casing: C FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S r FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accorda e with 15A NCAC 2C .0118. /I
9. YIELD (gpm): 0 METHOD OF TEST 2-2/OU, J
I _ WATER ZONES (depth):
bs,
Topographic/Land setting
ORidge ❑Slope °Valley &hat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From , To Forma 'on Description
- / - e s' gra4 ribs
1I. DISINFECTION: Type / 7 Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To Ft. L. t .SfiPp,/
From To Ft.
From To Ft. -
13. (TROUT: Depth Material �
From 0 ToZO Ft. CQ /1)eili�
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
From To
l5. SAND/GRAVEL PACK
Depth Material
Method
Top
Slot Size Material
in. in.
Ft. in. in.
From To
From To
16. REMARKS:
Size
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road r--
numbers and common road names.
FIECETb"F .
U
• i>
Coo)
1 DU HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
CONSTRUCTIOI�r"STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
rxflsraa
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
r_
0
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
7.7
rTh
G _-

32 '70
'3 j
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N/pral Resour s - �Diivisi/on of Water Quality - Groundwater Section �-(�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) IC./J09et vU V�/1 CERTIFICATION #33`5
WELT. CONTRACTOR COMPANY NAME.acese, &-o S weft - l ml PHONE # 02a 6r(te 3/7d
STATE WELL CONSTRUCTION PERMIT# NO L ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential LVl Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: .1.j ut6tc Cotmryirb/ A
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:. f'n�''�`,�, /L.....c+,�,J'•^�p{S
Address /0qI TGJ i/L prAs( kJO,
(Strict or Route No.)
JO/I.e)a/ad(e_ �G �786
CaVol' Town State Zip Code
(SS)- 776 034 fr
Area code- Phone number �
4. DATE DRILLED L5 1 Z •L� ./ c
. IX)LS \ ll1.',[,UE:DI A;'II I: VIC'1'IAII: W E 11 .1 VIa I I NO LA"
7. STATIC WATER LEVEL Below Top of Casing: / b FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance"Rh ISA NCAC 2C .0118.
9. YIELD (gpm):' METHOD OF TEST 2 Rocts
10. WATER ZONES (depth): 22S f ^ SBS /
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.
Topographic/Land setting
ORidge DSlope OValley L7hlat
(check appropriate box)
Latitude/longitude of well location
(degreeslminutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
o I 27 1 t 1,Or(
2 8 - 5851 5ra0N--t✓
5. TOTAL DEPTH: 5 5
11. DISINFECTION: Type
12. CAS1NG:
Depth Diamet
From to To 2 7 Ft. b rer
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 2! Z Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From_ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Sipe Material
H17-1
Amount ?
Wall Thickness
or Weight/Ft. Material
PVC-
aterial
be/tie/Li-
....Ugthod
/OP
Depth
From To Ft.
From To Ft.
I6.REMARKS:
f_
c
CO
N
RECEIVED
.._._..-_�
I DU HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL —,
CONSTRUCTION NDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Atka 2D /OCQ
hevw e Regional Office i
' '%. i f or Prr efitC:,')
�N42Oo tr���. -- 6-6—0
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
0

WELL CONSTRUCTION RECORD 3 2 7 7 v 9
North Carolina - Department of Environment and N tural Resources - Division/of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME rind Ci fl/,I C.0 %1 CERTIFICATION # 335-7
WELL CONTRACTOR COMPANY NAME (reeve tos !Ilea V Vary PHONE # ( )
STATE WELL CONSTRUCTION PERMIT# )g 0 Z-- ASSOCIATED WQ PEANUT/3
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential V Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATI "
Nearest Town: ye.ye.�(L(bratty County__ URJC_
Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: [SA/ /_DA
Address P13 i c4-eA u..)
LStreet or Route No.) 'r
netujl-t /Jc Z ?95'
City or Town State Zip Code
67a)- Qz.h- gs3z
Area code- Phone number
4. DATE DRILLED / 7 -G Co
5. TOTAL DEPTH: 2651
I\t.L:S'r.;F.I. I. ui:oLArI:: L:v1S.r !NU \a/l:l 1 _, v, 1:S 111 njr\ f:Y
7. STATIC WATER LEVEL Below Top of Casing: % (7 FT.
(Use "+- if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 60 f METHOD OF TEST 2-HOOsti
10. WATER ZONES (depth): 2 f%s r
11 DISINFECTION: Type ff?7* Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To ZbSFt. 411 Dec -
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 7-0 Ft. Ce'nia 'ri p
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.
Topograc/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)
DRILLING LOG
Formation Description
DEPTH
From To
p S5(
561 • 2651 6 rant
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. r�
RECEIVED
AUG 2 5 2Q11
sheviVe Regional Office
i6. REMARKS: [ Ar2111fE1* prntE:CI L? i
1 DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRU T ' STANDARDS, AND TI LAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

327768
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater SectionQ
WELL ('ONTRACTOR(INDIVIDUAL) NAME (print) /i We496 CERTIFICATION#?7/4Q
WELL CONTRACTOR COMPANY NAME 6rees. _6rds ji1',%( P(LM P PHONE # (84$ L�/
y g.gb
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential I/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATK/)N7:
Nearest Town: _._Cods /1
County NpyuprxXi
(Street Nuns, Number:, Community. Subdivision, Lot No., Zip Code)
3. OWNER:
Address
ke1 re-M-M;
2G0 rater Trost
I Street or Route No.)
C a .0 4z7n A/L_ 2871b
It)' Or Iowti State
(Rm- 90,0 -92-tV
code- Phone number
4. DATE DRILLED 5- 75d b
5. TOTAL DEPTH: P/S
v tr..; ,tn.I1 01.m Al 1. I. V IS I In.r. U. 1.117 \i'' Mr) LL✓
7. STATIC WATER LEVEL Below Top of Casing: 1ia FT.
( Use "+" if Above Top of Casing)
S. TOP OF CASING IS _ FT. Above Land Surface'
'lop of casing terminated ator below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /J`� METHOD pF TEST 2 //00Cd
10. WATER ZONES (depth): /� /Z.S
II. DISINFECTION: Type km Amount
12. CASING: Wall Thickness
Zip Code
Topographic/Land setting
❑Ridge ❑Slope ❑Valley lafecit
(check appropriate box)
Latitude/longitude of well location
(degrees.minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
I check box)
DEPTH DRILLING LOG
From To Formation Description
D1 7-ZI
23r- I5/5'
Depth Diameter or Weight/Ft. Material
From 0 To 11 Ft. 4f) PVC -
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 70 Ft. Cez' �1 TOp
From To Ft.
14. SCREEN: Depth Diameter
From ToFt.. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16
Slot Size Material
in.
in.
REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names. ct
0
CO
RECEIVED
sheville Regional Office
A.nuiter Gro`eciion
I DO HEREBY CERTIFY TIIAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUI ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
�a-t�-OYo
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. 072001

9 n O
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalYt_Resources - Division of Water Quality - Groundwater Section, 9
WELL CONIRAC'TOR (INDIVIDUAL) NAME!. (print) [yQQ,I__) ijJ - f___ _ _,—___ , CERTIFICATION #Z-7/G
WEIR, CONTRACTOR COMPANY NAME .6Le 4L— /6_OS („Pai 190r)/�PRONE # (acS "93/7
StArE WELL. CONSTRUCTION PERMff# ---__ O 2-- _ASSOCIATED WQ PERMIT,*
(if applicable) _ -�— (if applicable)
1. WELL USE. (('heck Applicable I3ox): Residential B' Municipa(!Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ I1cat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELLLOCATIO/N'':
Nearest Town: (,(__ -140/1
County "_p`""'N-
(Sucet Name, Nurn bers, Community, Subdivision, Ike No., lip Cale)
3 OWNER:
CI Address _ZQ._ !
(c y(4trice
(Strata or Rout • No 1
(o,140A f�L 2437/L
nv ur'town State hip lode
hrea eerie- Phone number
4. DATE DRILLED _Q: -O
5. TOTAL DEPTH: 2.r0S
. I"J:C, U'1.11 1)1. n: A('I. 1.F_1" 111:(; Y1n.1 i'1 VI.l11 N, 1
7. STATIC WATER LEVEL 13eiow Top of Casing: / 3 __FT.
use "'" if Above 'Top of Casing)
N. TOP OF CASING 1S ./ FT. Above land Surface*
*Top of casing terminated ar/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): _jam METHOD of TEST 2-HOC.-S
10. WATER ZONES (depth): b5
I _ DISINFECTION: Type_ _.n/V7 _.
12. CASING:
Depth y .1 Diameter
From _U To 5(0 Ft. er
From To
From To It.
13. GROUT- Depth Material
From_.-___ ToZfl Ft. air/.¢A4*
From To _ Ft. ++
Iv. SCREEN: Depth Diameter Slot Size Materials
From To Pt. in.
From To Pt. in.
15. SAND/GRAVE(. PACK:
Depth Size
Prom To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
From To Ft.
16. REMARKS:
I DO I IEREI3Y CERTIFY TI IAf TI ITS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTIO TANDARDS, AND THAT A COPY OF THIS RECORD I IAS 13EEN PROVIDED TO TIIE WELI. OWNER
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 1
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D' 'o'_
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the ro
numbers and common road names.
L7
t,D
m
-77
r
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL.
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

DS3
WELL CONSTRUCTION RECOR 1
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 0-0b/;1 Litt/
Pimp
_— .__.. CERTIFICATION# /Z� (q,3
WELL CONTRACTOR COMPANY' NAME. Creedt_�! bs CVtt/� Pimp... ..—___PHONE # y6 3_00
STATE WELL CONSTRUCTION PER:MFF# /7 QZ-- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (('heck Applicable 13ox): Residential a Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL 1.i. LOCATION:
Nearest Town: Ca
County HQi,iWOocI
;Street Nurse, Numbers. Community, Subdivision. Ian No., Lip Code)
>. OWNER: J2TG0.. CUT L51P
Address _- eaI/_ U/es[PC.( Sf'
/� I (Street or Route No_I
i .C414DA NC 2-071 (o
ity or own State Zip funk
(gz$)- I- 6 977
Area code- Phone nuns her
4. DATE DRILLED I-IS-0 b
5. TOTAL DEPTH:
1)(m, \A/I:1 1 pi.11l n!'1. V 1.\ 1 It.() kJ�
7. STATIC WATER LEVEL Below Top of Casing: _ __FT.
( t:se " if Above Top of Casing)
S- TOP OF CASING IS 1 FT. Above Land Surface*
Topographic/Land setting
❑Ridge ❑Slope ❑Valley P;Prfat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Form�},gn Description
I)EPTI I
From To
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): _2 0 MET OD OF, TEST Z 4-0S
l0. WATER ZONES (depth): 05
I I. DISINFECTION: Type__ _ Amount
12. CASINO: Wall Thickness
Depth Diameter or Weight/Ft. Material
From_D_ _. To g D Ft. i, f t
From To
From To
13. (TROUT: Depth Material Method
Frain _. 0 . 'To ZO Ft. (1Cmen-1 To j)
From To Ft.
19. SCREEN: Depth Diameter Slot Size
From TO Ft. in.
From To FL in.
15. SAND/GRAVEL PA('K:
Depth Size
i:rom To Ft.
Pram To Pt.
16. REMARKS:
in.
in.
Material
LOCATION SKETCII
Show direction and distance in miles from at Least
two State Roads or County Roads. Include the r 1
numbers and common road names.
C
0
0
I DO 1 LEREBY CERTIFY TI IAT'IBIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII ISA NCAC 2C. WELL
CONSTRUCTION ST 'DARDS, AND THAT A COPY OF THIS RECORD I IAS BEEN PROV [DED TO TI IE WELL. OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL.
g- /—a L
DATE.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone]. within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
n 9 r.
i'
North Carolina - Department of Environment and Natural LResources
�- Division of Water Quality - Groundwater Section r�
WELL. CONTRACTOR (INDIVIDUAL) NAME (print) 0.0b1 , (�'ie_-__D __ CERTIFICATION # z9J,
WELL CONTRACTOR COMPANY NAME &[--_.,6/aS l-G14_Air _.._-_. PHONE # (2'$ ISG-. /7a
O 2_
STATE WELL CONSTRUCTION 1'ION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL. USE (Check Applicable Box): Residential nlunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEI.LLOCATIOppN�:��
Nearest Town:W _ne UGt-c
CountyarFi'
!Street Name. Numbers, Community. Subdivision, tut No., Zip Code)
3. OWNER:,J_Qhfl /(L'P,/L//' �/ O (eC
.Address L.&4 L.Cq'Gl e- LDr
lytreet or Route No.)
Iarpon .S�n/t53 �L 311�B 9
(727)- W — 2-8BS
Arca code- ('none number 7
4. DATE DRILLED 6� 40
Te
5. TOTAL DDEPTH:,�.,��r
DOES ua.t 1 PEP! ♦('1. LYI. i tn.r,. N LI 1 o Vl.c Li NO —Li
7. STATIC' WATER LEVEL Below Top of Casing: /O a . _FT.
I Cse "+" if Above Top of Casingl
S. TOP OF CASING IS / FT. Above (.and Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance wish ISA NCAC 2C .0118.
9. YIELD (gpm): /3 METHOD OF TEST Z fffX�S
10. WATER ZONES (depth): _ 14'5
l Tv or Tow State Zip Code
11. DISINFECTION: Type__HTH _ _ Amount
12. CASING: Wall'fhickness
Depth Diameter or Weight/Ft. Ma 'rial
From b To 4Z H. _&t/PG
From To _ --_— Et.
From To Pt.
13. GROUT: Depth „Material , Method
Front0_.__. io2 Ft. C.eale,&7 To p
From To Pt
14. SCREEN: Depth Diameter Slot Size
From To Et. in. in.
From To Ft. in. in.
15. SAND/GRAVY',(. PACK:
Depth Size Material
Material
From To Ft.
From To Pt.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley CaPtat
(check appropnate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
I check box)
DRILLING LOG
Formation Description
DEPTH
From To
�t �Z I
�13 I
v>Z
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the rtC
numbers and common road names.
(D
1 DU I IEREBY CERTIFY THAT 'HIES WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C', WELL
CONSTRUCTIJa,N STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL. OWNER
SIGNATURE ()I: PERSON CONSTRUCTING TIIE WEI,I. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
0.
an an Ur a a ti
North Carolina - Department of Environment and INV Ltural Resources - Division of Water Quality - Groundwater Section
19,4, Webb_ _ ..
\Att.!. conancroa COMPANY NAME 62 reelit if (21-S. vie.a.. c1.- Po ny PHONE # ( lag Lc18-3I20
STATE WELL cosaraucrioN PEnmErti _NO Z___ ASSOCIATED WQ PERM tt#
i if applicablei (if applicable)
V) ( ()VERA( roR (INDIVIDUAL) NAME (print)
CERTIFICATION # awg
1. WELL USE (('heck Applicable Box): Residential 12K—Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 fleet Pump Water Injection 0 Other 0 If Other. List Use
2. WELL LOCATION -
Nearest Town: Ak11.—
County
60 0 Of
I Street Name, Numbei3, Community, Subdivision, IA): No., Zip Code)
3. OWNER: ()e..-0(5C
Address _ 1-qat-C_
(Street or Route No.
+ FA- 3351.578
City or Iowii State Zip (ode
514 3vt-I&37
Area ,:ode- Phone number
4. DATE DRILLED b -30 —0
5. TOTAL DEPTH:
!)()!.s PEP1 */ !-.81 1 Wh! A? Yl.c, I
7. STATIC WATER LEVEL Below Top of Casing: gip ,,_ FT.
( l:se if Above Top of Ca:,ing)
N. 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 ( imm): 2 METHOD OF TEST 2 /1004J
10. WATER ZONES (depth): /49.5
11. DISINFECTION: Type ..jtr# . Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From b To 6 Et. 6'
From To
crial
From To
3. GROUT: Depth iyaterial Method
From C) To D. Ft. Ue infibt
--
Th
p
From To
Topographic/Land setting
ORidge OSlope OValley flat
(check appropriate box)
Latitudc/longitude of well location
(degrees,mmutesiseeonds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
DEPTH
From To
6
4/11
Forma ion Description
LOCATION SKETCII
Show direction and distance in miles from at le.C..thj
two State Roads or County Roads. Include the mad
0
numbers and common road names.
C)
14_ SCREEN: Depth Diameter Slot Size Material
From To Ft in. in.
From To Ft. in. in.
15. SAND/(iRAVEL PACK:
Depth Site Material
From To Ft.
From To Ft.
Ib. REMARKS:
0
...3"
—
I IX) HEREBY CERTIFY THAT UIK WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTIO, STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OE PERSON CONSTRUCTING TIIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. (1W-1 REV. 07/2001

e) R. a•
a0u00'0
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division off Water Quality - Groundwater Suction
W TA('I ELL(ONROR (INDIVIDUAL) NAME (print) C�L}_dI/,. W1S',,�iretf,t`edo-core _____.. CERTIFICATION # CONTRACTORWELCONTRACTOR COMPANY NAME 6ftewe, eras . noble ...-----PHONE #fgetcyg -317°
srkrt: WELL CONSTRUCTION PERMED(/ 7 02— ASSOCIATED` WQ/YPERMIT#
(if applicable) (if applicable)
I. WELL. USE (('heck Applicable Box): Residential IrMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WI(I.I.LOCATIO.':
Nearest Town: /1nn
County
'Street Name, Numbers. Community, Subdivision, tut No., Zip Code)
3. OWNER: j�C4 Sffa(,USer
Address -.tel. _ _ 86,
(Street or Route No.)
(fle �L 7,R7zl
(sty or l ow is State hip Code
Ste" �g3-I935
Srea code- Phone number
4. DATE DRILLED__ _qTO G -_-_--
5. TOTAL DEPTH: 405'
I)f i.Q WELL Pita! AI t. t.vt%! INy. u't.l EL! ? vt.s i N:')
7. STATIC WATER LEVEL Below Top of Casing: q 0 FT.
use'*" if Above Top of Casing)
8_ TOP OF CASING IS / FT. Above Land Surface*
*fop of casing terminated at/or below land surface requires a
variance in accordan a with I5A NCA(' 2C .OI la.
9. YIELD (gpm): le 02- METHOD OF TEST Z/-hOUQ j
10. WATER ZONES (depth):
11
I
13
14
I
q65'
Topogra/Land setting
❑Ridge I 13S ope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTII DRILLING LOG
From To Formation Description
Q 63'
DISINFECTION: Type__ 1/171
CASING:
Depth Diameter
From Q To 43 Et. 6t`_--
From To _ FL
From To
(TROUT: Depth / Material
From 0_-_-To ZD Ft. Get/2
Frrim To 1=t.
SCREEN: Depth Diameter
From To Ft. in
From To Ft. in
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
6. REMARKS:
.Amount
Wall 'thickness
or Weight/Ft. Material
Method
TO?
Slot Size Material r_
in.
in.
Material
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the bad
numbers and common road names.
0
lD
Issa
Cr
0
0
I DO I IER EBY CERTIFY liiA'I TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCT! QN STANDARDS, AND TEAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No.1919) 733-3221, within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
of Environment and Naral Resources - Division of Water Quality - Groundwater Section
w pit CONTRACTOR (INDIVIDUAL)NAME (print) ger
go
ousattf
CERTIFICATION #335 y
WELL CONTRACTOR COMPANY NAME .6crCfra c & 0 _s Weil et- flivry PHONE 1r fea (c. Y i3.3i 7 CJ
STATE WELL CONSTRUCTION PERMIT# jii 0 2-- ASSOCIATED WOPERMIT#
(if applicable) (if applicable)
33053q-
North Carolina - Department
1. WELL USE (Check Applicable Box): Residential g'Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 !Mat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: ,..,
Nearest Town: _Givitie_
County blafia-)0001
t Street Name, Numbers, Community, Subdivision, Au No.. lip Code)
3. OWNER:
Address 9_79 I Qc re_ JtL
;Street or Roure No.Cfc4t
or 'Llasi State
(SA49)- -(b06— 510
Zip Code
AI ell (ode- Pnone number
4. DATE DRILLED_914.9 _
5. TOTAL DEPTH: 22.45
SA'!“ 1/1.1)I V IC I I I ') N() 42,
7. STATIC WATER LEVEL Below Top of Casing: I/ D FT.
(use o Above Top of ( (bang)
X. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (pm): METHOD OF TEST 2- hi-O(J0—‘
In. WATER ZONES (depth):
2-05'
11. DISINFECTION: Type_ _
i 2 CASING:
Depth
From D To Ft
From To
/477/ __ Amount
Wall Thickness
Diameter or WeightiFt. Material
eLL:( PVC
From To
13. GROUT: Depth Material Method
From 0 To 21) H. Ctmt rop
From To
t.
14. SCREEN: Depth Diameter Slot Size Material
From To Ftin. in.
From To Ft. in. in.
15. SAND/GRAVF.I. PACK:
Depth Size Material
From To Et
Front To Ft.
16. REMARKS:
Topographic/Land setting
Ridge 0Slope 0Valley it
(check appropriate box)
Latitude/longitude of well Location
Wegreesaninutesiseconds)
Latitude/longitude source:OGPSETopographie map
lebeck box)
DEPTH DRILLING LOG
From To Form Description
yr_
•
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include thc road
numbers and common road names.
74 /1.1.-3
,tn•
c
C")
1
1/40
I DO I II1REBY CF.RTIFY .111AT IIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WEITI 15A NCAC 2C. WELL
CONSTRtiC N STANDARDS, AND TIIAT A COPY OF TILLS RECORD I IAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
e .7 --D
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
33fl33
North Carolina - Department of Environment and N. ural Resources - D.iv/ision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) AL) NAME (print) i (01[�Q,J. el l/JI LUCC.�D //�� ct:wrlFICA}TttoN #3 )4
WELL CONTRACTOR COMPANY NAME (*nue _V(o� 'wed 4- Pimp PHONE # (9 q6Y —312°
lyo2- I
.Sf:TFE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable( (if applicable)
I . WELL USE (Check Applicable Box): Residential R�Municipal/Public 0 industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ileat Pump Water Injection 0 Other 0 If Other, List Use
2- WELL LOCATION: /�
Nearest Town: M a5csl E Y e.q County 0-02-/WeCti
Street Nana, Numbers. Community. tv, Subdivision, Lot No.. Zip Code)
;. OWNER: Tone wadi -tea
E- 44.--
(: ttect or Route No.)
tliCGI_a/ro V /,lid_JC. e_ dL'
c (own State Zip Code
(822)_ 9210—oz
Arca code- ['hone number
4. DATE DRILLED_ %-_%—v L
TOTAL. DEPTH: 1 `35 I _. _ —
-t
Address /0.3_0_5_
I\/\I.0 \\ I:I I UI.UI A/'1. I. V'lll In./. \A 1.11'1 Vio l 1 '-'I i.1'
7. STATIC WATER LEVEL 13clow Top of Casing: Za _FT..
t Use "r" if Above Top of Casing(
K. TOP OF CASING IS / FT. Above Land Surface*
"I'op of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C.0118.
YIELD (gpm): 2-0 METHOD OF)TEST 2- 140ci
10. WATER ZONES (depth): / 65
11. DISINFECTION: Type/-}
1'_ CASING:
Depth Diameter
From 0__Io 510 Ft. 62"
From To _ __ Ft.
From To Ft.
13. FromUT0 To Topth ZO Ft rerial
From To Ft. (� ���
14. SCREEN: Depth Diameter Slot Size
From To Pt. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Amount
Wall Thickness
or Weight/Ft. Material
PUG
From To Ft
Prom To Ft
16. REMARKS:
Topo_grayhic/Land setting
❑Ridge GdSlope ❑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
((D' 5 6 '
_ 2' - l85' L,tan%
LOCATION SKETCII
Show direction and distance in miles from at least
rwo State Roads or County Roads. Include the tGdd
numbers and common road names.
0
c->
lD
No
0
-1
I DO I IER'E,lB�Y CERTIFY TIIAT'I'UIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C'. WELL
('ONSIROfl'ION STANDARDS, AND TI IAT A COPY OF TIIIS RECORD I IAS BEEN PROVIDED TO TI IE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 0712001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Serald CERTIFICATION #32 2
WELL CONTRACTOR COMPANY NAME .tire_ene Ales wea /bine PliONE # f(d26_6 Cig -3. PO
STATE WELL CONSTRUCTION rERmin _ILO 2— ASSOCIATED WQ PERMIT#
(if giplicablel (if applicable)
1. WELL USE (('heck Applicable Box): Residential Et- Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I icat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: _ad -IVA- County ft a4'tiR50/
I Streei Name, Numbers. Comlnunity, Subdivision, lot No.. Zip Lode)
3. OWNER: Ch ade-S tiOCID5
Address _P:s2._/3.0.4 : /Ye /
(Street or Route No.)
2--872-1
Lax or State Zip Code
€3"lair
Ai ea wee- Phone number
4. DATE DRILLED Jo
2 lit)(23
:0. WATER ZONES (depth): _
-30 t 6
5. TOTAL DEPTH:
Ht1' S WELL I11111 5t I: `lc! !s!t: ! YES ! 1
7. STATIC WATER LEVEL Below Top of Casing: 4JD FT.
(t:se if Above Top of Lasing)
S. TOP OE CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith ISA NCAC 2C: .0118.
9. YIELD (gpm): _5'7z_ METHOD OF TEST
33 05#2_,
Topographic/Land setting
ORidge DSlope OValley
(check appropnate box)
1-atitudelongitude of well location
(degrees/Inmates/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
b.51
22& b Oi-71
11. DISINFECTION: Type_ Itrlt Amount
12. CASING: W'alt Thickness
Depth Diameter or Weight/Et. Material
from C.) To b5 Ft. b" eVC
From ! To _ _ EL
from To Et.
13. GROET: Depth Material
From 0! To zo Et. (teal&
from To
Method
7—°/(2
14. SCREEN: Depth Diameter Slot Size Material
1:11.1111 To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Erom To Et.
From To Et.
lb. REMARKS: _ _
6
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
c
rr
i DO I IEREBY CERTIFY TIIAT Tlifti WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, Vv'ELL
CONSTR(' !ION STANDARDS, AND TIIAT A COPY OF TIIIS RECORD I IAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WEL,I. 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

APWELL CONSTRUCTION RECORD 33 O b3
North Carolina - Department of Environment and Natural Resources/u��Division of Water Quality - Groundwater Section //
wT:1.LCONTRACTOR (INDIVIDUAL) NAME (print) �(p�rint) C- 3/(�U'L,�4/-t( �j CERTIFICATION #J T53
WELL CO.NTRACTORCOMPA NV NAME (�J(/eea e ros WCX� i kizip PHONE # { i LC/Q•,j _I%0
NI ATE WEL.l. CONSTRUCTION PERMIT# / T Z ASSOCIATED K—'OPPERMI'1"' _ _
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 12----Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery' ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2 WELL LOCATION: �
Nearest Town: ,/
_`-` IL1tt/.P / County.
Arsetwoceot
(Street Name, Numbers (Community. Subdivision, Int No., Zip Code)
3. OWNER: .-%eu'e_ (IUS
Address 'i7 a 'f huaiv
LdYe--
LS Rtre-tor uie No.)
CUCIA1 lei Utile AFL 2B1&
City or Town State h p Coale
(.' )- qZb - 2: 3L2
Area code- Phone number
4. DATE DRILLED 7 7/-O 6
5 TOTAI. DEPTH: .3r51
( I\l\I.l \1.1.i 1 U1.111 n!-1. 1.\'ll l IF (. \A:111 1'1 .'l,l l l NA)
7. STATIC WATER LEVEL Below Top of Casing: a D FT.
Itise"+'• if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordancpe with 15A NCAC 2C .0118.
9 YIELD (gpm): CO METHOD OF TESTZF—S
10. WATER ZONES {depth): 2- 5
11 _ DISINFECTION: Tvpe p rM Amount
12. CASING, Wall Thickness
Depth Diameter or WeigheTt. Material
From__ To 23- FL br f' {�1G
From To Ft.
From To Ft.
13_ GROUT: Depth �(��enal Method
From D To w Ft. lx/)te/ ToQ
From To Ft. /
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
I'7om To Ft. in. in.
15. SAND/GRAVEL PA('K:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge 12Srlope ❑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' 03' Clay
ZN'- 3 Ds' 6 rrarn{e
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. o
0
a
a
G-7
CD
m
I DO I IERFB ' CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRFION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
8 7/ 0 c
SIGNATURE OF PERSON CONSTRUCTING Ti IE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-I636 Phone No. [phone], within 30 days. GW-1 REV. 07'2001

32 857
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaWral Resources - Division of Water Quality - Groundwater Section
WI1.1. CONTRACTOR (INDIVIDUAL) NAME (print) WELL CONTRACTOR COMPANY NAME:-Gfcen(%_g(o5 wail _4-•Knen/9 -. PHONE # [phone] ?3
STATE WEI.I. CONSTRUCTION PERMIT# _ ( i a Z - _ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
/y Webb CERTIFICATION # 89
I. WELL USE (Check Applicable Box): Residential LrMunicipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: � �J �
Nearest Town: kW/ i,psJ
County
ttO
( Street Name. Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER: Address I9 yJGt s �
Add fan Cr
o %lGudat(
t Ly
/t (Street Or Route tCo-)
eJL
City or Town State hp (ode
285- 51)9- -7 .3 1
.Area code- Phone number
4. DATE DRILLED 5-z y -0 L
5. TO'CAL DEPTH: ,3a5
/�I.l \1. �.,I,I RI -Ill n!'I. 1.\ I\ I Ins(: \A 1.1 V'I.t 1 1 NO rr"
7. STATIC WATER LEVEL Below Top of Casing y 0 ET.
(Use' -- if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (pm): �% METHOD OF TEST 2 go
ID. WATER ZONES (depth): 70S
3oSr
I I. DISINFECTION: Type "pf
12. CASING:
Depth Diameter
Frum_p _ Tor/_ - 7 Ft. 6 u
Prom To
From To
13. GROUT: Depth
From b To 2-0
l•rom To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
Ft.
Ft.
2BSo 3
Amount
Wall Thickness
or Weight/Ft. Maleal
eC—
Material Method
Ft. yll — 7tp
Ft.
Prom To
Ib. REMARKS:
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Size Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley C3tt
(check appropriate box)
Latitude/longitude of well location
(degrees:minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Forpnption Description
(1 1
91_305'
�ataat,lR
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the mg
numbers and common road names.
r—
fV
(n r:
^ G_`'
I DO HEREBY C'.ERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION SDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL. OWNER
z,tu oo s Q)'��✓ 2-2. O _cam
SIGNATURE OF PERSON CONSTRUCTING Ti IE 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

3N9Q56
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naturaln_Resourcesu- Division of Water Quality - Groundwater Section
[/
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_ POyctjl CERTIFICATION#_...3`S?/
W'ELI. CONTRACTOR COMPANY NAME &rt&z t� %o5 I . al 4_ pcfy ie _ _ PHONE # (Q4 6S%8_-3 7
STATE WELT. CONSTRUCTION PERMIT# I /D Z ASSOCIATED WO PERMIT/4
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): ResidentiaPaunicipal/Public 0 Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
WELL LOCATION: II
Nearest Town: IA) Qtl'Aes V IMi_ County i}4J'I OW.,
(Street Name, Numbers, Community. Subdivision, Lot No
3. OWNER: IC
Address yy F0/to. ,/rcLAA
Strcyt or Rome No.)
Nljd ls%G
Zip Code)
Wall403 t_ Z678
City or Town State
Zip Code
L. z _.731 g ob (
Area code- Phone number
4. DATE DRILLED 5-23-- a 6
5. TOTAL DEPTH: 365 �
IW I-e \t;IJ1 UOI A!'1. r.Y�r. Ill.,,U:1.1i '' VI.l 11 NO H--
7. STATICI.WATER LEVEL Below Top of Casing:. y D, ET.
(Use "Jr if Above Top of Casing)
N. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): '60 �" METHOD OF TEST Z H190Q4-5
ID. WATER ZONES (depth): r3 y5'
11. DISINFECTION: Tvpc Amount
12. CASING: Wall Thicknes
Depth Diameter or Weight/Ft
From 0 To /3,3 Ft. 6 t'
From To Ft.
From To Ft.____
13. GROUT: Depth aterial Method
From 0 To 1.0 Ft. int&E I"JO
From To Ft. II
14. SCREEN: Depth Diameter Slot Size Material
From _ _ TO . Ft. in. in.
From To H. in. in.
15. SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
Ft.
Material
pV c-
From To
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley as#ar
(check appropriate box)
Latitude/longitude of well location
lde r-esminutesseeonds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
f
134/1-34 ' <rnranik
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.
CD
I DU I IEREBI' CERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTIOiN JARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TILE WELL OWNER
44.O 2 C1 A--
'9°, 0-C) G
SIGNATURE, OF PERSON CONSTRUCTING TILE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 0712001

329 8 55
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/1Resourries - Division of Water Quality - Groundwater Section `'
WELT. CONTRACTOR COMPANY ) NAME (print) _1a09&[_.`u�.. C%VA I,,.I CERTIFICATION #3357
N'F:LL(ON('RAC'"fOR(INUIYIDUAI. v
NAME Greene. y6rQS (Nett tJ-Parnp _ PHONE # (OS 6va-3/70
STATE WELT. CONSTRUCTION PERMIT() _ _ /``dd b Z ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential EK Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: '` ,,
Nearest Town: Lap - C'uuny/J „ 1Md
(Street Name, Numbers, Community, Subdivision, Ent No., Zip Code)
3. OWNER: 12490-
Address 93 N/ at LI—
iiStreet or Rt,nAlNt-
Way Aeso zs ? S G.
City or Town State Zip Code
81$)- yy 6 5'J3 IQ
Area code- Phone number
4. [LATE DRILLED b
5. TOTAL DLPTFI: f/p,S/
f. I tL U:M.I i RI'!" 4!'I. LA IC( IN(. k t.t YLl I I N. t ��
7. STATIC' WATER LEVEL Below top of Casing: 7.0 ET,
(Use if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
"I np of easing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /7 METHOD OF TEST 2 frodl-1
10. WATER ZONES (depth): Z fj5
3 SS'
1. DISINFECTION: Type Pf/73-
12. CASING:
Depth Diameter
From (2 To S % Ft. brr
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 70 Ft.SOJe6 " Top
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Et. in. • - in.
From _ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Amount
Wall Thickness
or Weieht/Ft. Material
PV
16
From To Et.
From _ To Ft.
REMARKS:
r
I DO HEREBY CERTIFY TIIAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION S A DARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL. OWNER
Q ( e� -�C
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Topographic/Land setting
midge ❑Slope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Fu aeon Description
89' - yo5` (-7i-Ciak -_
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.
O
CPI
•_
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. 0712001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcesur- Division of Water Quality - Groundwater Sectionioy'/
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_ IS_4) � OI'U'Vaj,I —_. CERTIFICATION
WEI.1. CONTRACTOR COMPANY NAME e%e�'/C/iei �%as N ( _ r ten p PHONE # (Zp6 ✓8=3 D% 0
SPATE WELL CONSTRUCTION PERMIT# ' i. 0 Z ASSOCIATED W'Q PERMIT#
Of applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential 43Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Hem Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: _ 01.114lntat- County
042
(Street Name. Numbers, Community. Subdivision. Lot No., Zip Code)
3. OWNER: iliac/ JbAGS el 0 6ai13,i )e
Address / SS 409it, 2.ot
(Mite; or Route Nu.)
Waf�ne�dtbe n1- 2-e786
City or Town State Zip C. ode
12$I-. 954 -573 0
Arca code- Phone number
4. DATE DRILLED .J %5-'0 6
5. TOTAL DEPTH: 24' -'
i„u..°. P/l(I_!. REP! AU!. I.VI.I!Mt. ., rl..c I✓ii Ni;,
7. STATIC WATER LEVEL Below Top of Casing: FT.
( Use "+" if Above Top of C'asine)
S. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / Z METHOD OF TEST Z MVgi
10. WAT ER ZONES (depth): 12-5'
1 I. DISINFECTION: Type
12. CASING:
Depth Diameter
From 0 To .3_, Ft. (. rt
From To Ft.
From To Ft.
13. GROUT: Depth
From iJ To 2-0
From To
14. SCREEN: Depth
From To Ft. in. in.
From To Fl. in. in.
15. S.AND/GR.AVEL. PACK:
Depth Size Material
16
From To Ft.
From To Ft.
REMARKS:
Amount
Wall 'Thickness
or Weight/Ft. Material
aterial Method
Ft. emend- %Di
Ft.
Diameter Slot Size Material
ographic/Land setting
Idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees; minutes! seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
From To Formation Description
qo— 7�ys' 6randfe
LOCATION SKETCH
Show direction and distance in miles from'}casf'
two State Roads or County Roads. Include Rhc road
numbers and common road names. tV
U
Cr.
I DO I IEREt3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTHI STANDARDS. AND THAT A COPY OF PUS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
rr9�19t/----4oG G
SIGNATURE OF PERSON CONSTRUCTING TILE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�9��Resources
-(_Division of Water Quality - Groundwater Section,/
W2:1.I. CONTRACTOR (INDIVIDUAL) NAME/ (print)in. �JIh Vebb CERTIFICATION #_27/8
WF:1.1. CONTRACTOR COMPANY NAME _6 etAe Dias W ctt 4-- ParryPHONE. # &i-8) ttnr317-0
SLATE WELL CONSTRUCTION PERMIT# JZ a 2 .ASSOCIATED WI) PERMIT# _..
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 121 Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOC'ATI•N`:
Nearest Town: 1A) a-tii(ie,LiGil t County
tat
(Street Name, Numbers, Community.
WAS t.,yy.. Subdivision.
�L t No, Zip Code)
3. OWNER: ...te4c( 4-VI"-,
Address {0(f Cfs-Zdvbf,GL %l%C-ram_
(Stre t or Route Nu.)
$1t iaJ1ey Nc- Z117.Yl
City or Toan Slate Zip ('ode
(.gam-Lps-3aL3_
Area code- Phone number •
4. DATE DRILLED 4
5. TOTAL DEPTH: Q 115'_
ttt.0 U't_1 .1 DI.OI A(9. LSIIS 'Si. U 1-1 1 YES t t Sit) ter
7. STATIC WATER LEVEL Below Top of Casing: Z0-300 FT.
tUse"*' if Above lop of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*top of casing terminated at/or below land surface requires a
variance in accordance; with I5A NCAC 2C .0118.
9. YIELD (gpm): r1L METHOD OF TEST
10_ WATER ZONES (depth): S03 if7_
11. DISINFECTION: Type f71<+ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From _ 0 To 4 S Ft. 6 (t _loll t-
From) To Ft.
From To Ft.
13. GROUT: Depth A1aterial Method
From To 2.-0 Ft. I8�1,6 f o p
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From. __ To Ft. in. in. N
From____ To Ft. in. in. o
cm
15. SAND/GRAVEL PACK: -
Depth Size Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley artt
(check appropriate box)
Latitude/longitude of well location
Idegreestminutes/second.)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
DE
(491- 415 scan(
Hodes
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.
From To Ft.
From To Ft.
16. REMARKS:
0
1 DO HEREBY CERTIFY TI IAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CUNSFRUCrDQA.' STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
&M.& 2ci t sar.. 9-to-0&
SIGNATURE OF PERSON C''ONSTRUCIING 'DIE 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

4. DATE DRILLbD -2- -O L
S. TOTAL DEPTH: 6'
._ I)'ILI AUI:I UL111 q!'I. I. Vic IN! V.141 I7 '. C I AJ.rt1�
7. STATIC WATER LEVEL Below Top of Casing: FT.
(use.9- it Above Top of Casing)
K. TOP OF CASING IS I FT. Above Land Surface*
*top op of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. �7
9. YIELD (gpm): 09, METHOD OF TEST 2- #oW¢<S
ID. WATER ZONES (depth): _5b.S
DtS1' s
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na(ura/l_ Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)�j�r�j��//t Al ('*ego CERTIFICATION#29I S
WELL CONTRACTOR COMPANY' NAME _ C(cent £fos we.0 d-P($fl,O PHONE # &la 6Y$'317a
STATE WELL CONSTRUCTION PERMIT#Iv aZ_ ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
WELL USE (Cheek Applicable Box): Residential k M unicipal!Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: ''//
Nearest Town:KlQ,pt ALP.S Lu`(._ County
Woof
(Street Name, Numbers,
Community. Subdivision. lots No., hip Cde)
3. OWNER: N�a44- 4 06 to Isha.&
Address (ai QiwnpOGsi/ rest_ gst•
Topographic/Land setting
❑Ridge :Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
degrees/minutesrseconds)
Latitude/longitude source:❑GPS❑Topographic map
14 �/(Street or Roue No.) (check box)
jilt Y(lu'2QI /J`C 3'75I DEPTH DRILLING LOG
��oocir o Town store zip Code From To F ation Description
(Q rq)- J 4 0 j,.3
Area code- Phone number ,5-41 - Y7rbrsr 3 f'4,.nf
11 DISINFECTION: Tvpc 1.4-17f Amount
I?. CASING: Wall'fhickness
Depth Diameter or Weight/Ft. Material
From 0 To SK Ft. CO` Pir
From To Ft.
From To Ft.
13- ()ROUT: Depth Material Method
From 0 To 2,0 Ft. C
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To 1't. in. in.
From To Et. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To R.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names. O
I DO HEREBY CERTIFY TI TAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCT! N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
4- 7-0-0
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. 07/200I

32 S85
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N• t�ur/a�l'Ress turces-Division of Water Quality - Groundwater Section' Q
WELL CONTRACTOR (INDIVIDUAL) NAME (print)^_ y_4A U .s-memo(e.- CERTIFICATION p328
Wt:1.1. CONTRACTOR COMPANY NAME -C (e�(mrrssre, &co. L ett4--R/a C 2.
SPATE WELL CONSTRUCTION PERMIT,/ _ _``7 V 2- ASSOCIATED WQ PERMIT#
(if applicable) Of applicable)
1 _ WELL. USE (Check Applicable Box): Residential C 'Municipal1Puhlic 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
_ PIIONE#€28 L983120
2. WELL LOCATION: ,
Nearest Town: eesuctt.e County 40�61)CO2,
(Street Nauru, Number. Community. Subdivision, Lot No., Zip Code)
3. OWNER: M tern+oS%
Address r0 j3 pyL S87
I Str•et or Route No.)
14oq edui,CLe_ NC_
Lac
ity or Town tatc Zip Crate
( t/SZ' Z�L(2
Area code- Phone number
4. DATE DRILLED f q/Q (o
5. TOTAL DEPTH: /ys
,. ,v,t.c 9:1., , PI.PI A/,. I. VICI IN./, ).1. , VI.)-: 1 1 !No7. STATIC' WATER LEVEL Below Top of C'.asing: 0 FT.
(Use "-I-- if Above Top of('axing)
S. 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): (D METHOD OF TEST Z Hoard
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 'FT)
(check appropriate box)
Latitude/longitude of well location
(degreesrminutesrseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fo ion Description
1—' 7tCtit
S6 J r
11. DISINFECTION: Type g Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From QTo _ `r Pi'
Ft. __-- G
From To Ft.
From To Ft.
13. GROUT: Depth Material , Method
From 0 To 7-0 Ft. Ceineior ibp
From To Ft. _
14. SCREEN: Depth Diameter Slot Size Material
From 'fo Pt, in. in.
From To Ft. in. in.
15- SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
From To Ft.
I6. REMARKS:
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.
tv
0
1 DU I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
C()NSIRU(110 STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
G % Zo _ a c
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

3?-t"' 329860
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)____Rabh,,. Webb CERTIFICATION I#s21/4p
WF:1.I. CONTRACTOR COMPANY NAME _GreOR) _ I�Co�112/.5 ((Jul `-Anne _ PHONE # R)67B 3/70
STATE WELL CONSTRUCTION PERMIT# _7 OL ASSOCIATED WE) PERMIT#
(if applicable) (if applicable)
I. WELL USE (Cheek 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:kl_f2IQr_ia
eyCounty, t4 ft4 J(XX,
1
(Street Name, Numbers. Community. Subdivision, lot No., Zip Code)
3. OWNER: Gror9e HTarrfsON
Address BO1$ ^( tA)
(Street or Route No.)
alkland FL. Y307c,
City or Town State hip Code
(95q)-3Y0--y3/o
Area code- Phone number
4. DATE DRILLED
5. 'TOTAI. DEPTH:
v11_l A11 L1 UI. UI nr'1. t. VIA' t Ik,l. U I..1 I.? Vt.l 1 I n:0 1-<•
7. STATIC WATER LEVEL Below Top of Casing: / /O FT.
(Use'v' if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): OZ.- METHOD OF TEST .Z 800. $
7 I0. WATER ZONES (depth): OSr
11. DISINFECTION: Tvpe J-J-rN
12. CASING:
Depth Diameter
From 0 To Z42 Ft. b `r
From To Ft.
From To Ft.
13. GROUT: Depth
From___ To 2-0
From To
14. SCREEN: Depth
From To
From To
15. S.AND/GRAA'LI. PA('K:
Depth Size
-! -0 co
gas'
Ft.
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Amount
Wall 'Thickness
or Weight/Ft. Material
PVC
Material Method
Cea2feI- TT_
From To
From To
16. REMARKS:
Ft.
Ft.
Material
Topographic/Land setting
❑Ridge DSlope ❑Valley 12Flat
(check appropriate box)
Latitude/longitude of well Iocatiod
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
To Formation Description
DEPTH
From
Z(v'
Ras' C�rCiri)tte
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the row
numbers and common road names.
L �
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION $ IANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
•
-r j 6 -0(9
SIGNATURE OF PERSON CONSTRUCTING 'f1 IE 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

Bin 328 B 3
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
,,Resources L-`Division of Water Quality - Groundwater Section
po
WELL CONTRACTOR (INDIVIDUAL) NAME (print) I2.bb,IV Webb CERTIFICATIONpR_2q,8
PHONE 11 032s 78_3/7o
WF.LI. CONTRACTOR COMPANY' NAME C reaie_ eroS. We-t 14 Pthr i
STATE. WELT. CONSTRUCTION PERMIT# 190 L .ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
2
3. OWNER:
WELL. USE (Check Applicable Box): Residential 0...--Municipal/Public ❑ Industrial 0 .Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
WELL LOCATIO�N�:
Nearest Torn: iam e3NLtI L County gall Woo-.
(Street Name, Numbers, Community. Subdivision. Lot No., Zip Code)
W IIItainr
Address -/.0. Qsi 372—
(Street or Route No.)
nk
e lot- 287'S
City or Town '• ` hp Code
(L�Z�3-'/
Area code- Phone number
4. DATE DRILLED 4/610 L
5. TOTAL DEPTH: b05'
i),):.c \v:.i : PI.. P!. A('(. (.XI-1, (n.(: \a, I.l i ? v:.v I II xl.(,y�
7. STATIC WATER LEVEL Below Top of Casing: /CO ET.
( Use "+` if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (,pm): 3 0 METHOp OF TEST
10. WATER ZONES (depth): _5---oS
Sb5'
11. DISINFECTION: Type /fT/f Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To Ft. 6 t'
From To Ft.
From To Ft.
2 !fo(.2S
,plc
Topographic/Land setting
❑Ridge i�Slope DValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
ldegrees:minutes'seconds)
Latitude/longitude source:DGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Pt 4.S'Ciati
(4 b' . 6 05' 6, rCtnvl-G
13. GROUT: Depth Material Method
From .0 To 2-0Ft.ce/YleNrL "it p
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
1- rom To Ft.
Et.
From To
16. REMARKS:
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.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE. WITH I5A NCAC 2C', WELL
CONSTRUCTISTANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI IE 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. 07/200I

c1 N864
e^i
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Watcr Quality - Groundwater Section
WELL('oNTRACFOR(INDIVIDUAL) NAME (print) 6eroid 1SIZ2/m,oce_ CERTIFICATION #'3Z.82—
WELL CO:NTRA('TORCOMPANY NAME W - 6fetne 6ra5 C/l `1' [✓j/ / PHONE. # 18�d6g9-300
STATE WELL CONSTRUCTION PERMIT(' [y{t ASSOCIATED WC/ PERMIT# o
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential Kr-MunicipaI/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: Ult.l
[�MiL -e
County UJoC.
(Street Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Str et or Route No.)
eiLla
jS1e ri)lley Joc
Kay or Town State
Area code- Phone number
4. DATE DRILLED 4 v14 •0
Z8`75I
Zip Code
5. TOTAL. DEPTH: 3OS'
/\I.l \l:i.l I.vI ,,k,!_\A.1-11') Vi.l l I n.11 IF
7. STATIC WATER LEVEL Below Top of Casing: ZO FT.
(Csc "+'- if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0I I8.
9. YIELD (gpm): 15 METHOD OF TEST 2-F10t-' .-S
10. WATER ZONES (depth): 6-
/fo5'
I]. DISINFECTION: Tvpc 1-1-114"
12. CASING:
Depth
From To
From To
13. GROUT: Depth
From 0 To 2-0
Prom To
14. SCREEN: Depth
Diameter/
From i� To 5� Ft. J7
Ft.
Ft.
Amount
Wall Thickness
or Weight/Ft. Material
Pi/ L
atcrial
Ft. Centeitir
Et.
Diameter Slot Size
Drum To
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS:
Material
Ft. in. in.
Ft. in. in.
Size Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 8'F'lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fotmmtion Description
D' S1 '
¶-r / « 45f
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
I DO HERE Y CERTIFY TIIAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST CTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
aaia.;47 'I- zo -o C
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. 072001

32 858
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N: tural Resources - Division of Water Quality - Groundwater Section ��/
WELL CONTRACTOR (INDIVIDUAL.) NAM E/(print) _ 49e(_ Ou eta CERTIFICATION #_3p3J /
WELL CONTRACTOR COMPANY NAME _ `?(LCA e.._ 6-0j_._ waa / IA'✓I/�. _... PHONE# (e4 �i (/'O" j D
STATE WELL, CONSTRUCTION PERMIT/4 iy 0_Z ASSOCIATED WO PERM in
(if applicable) (if applicable)
1. WELL USE (Cheek Applicable Box): Residential "❑ Municipal.IPublic ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LO('ATIO%� �
Nearest Town:1ddfL406- County idaywooc(
(Street Name, Numbers. Community. Subdivision. t.ot No., Zip Code)
3. OWNER: I�o05 �,,,(f_(, /I,-1rC/7 bur
.Address ST ,4ho4cf. As ,�
1-
(Street or (tome No.)
Watt AlA jot N (— 2-878
( ny or Town State Zip Code
(64- Y -9031
Area code- Phone number
4. DATE DRILLED 5-31 -O L
5. TOTAL DEPTH: ¢j3 (7—�-
.,/1L1-1 'A' 1.! II I. fN A,/ i. 1.. 11, INJ. U-L.I ' VP". L I n_) i•••<
7. STATIC WATER LEVEL Below Top of Casing: CID FT.
(Use "i'' if Above Top of Casing)
H. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance witl( 15A NCAC 2C .0118.
9. YIELD (gpm): h 0 i METHOD OF TEST
10. WATER ZONES (depth):
p � Z-,oclocf
Dk5 t
Topographic/Land setting
Bf dge ❑Slope DValley ❑Flat
(check appropriate box)
Latitudc/longitude of well location
(degrees/minutes/seconds)
Latitude/ longitude source:❑GPS❑Topographic map
(cheek box}
DEPTH DRILLING LOG
From To or tion Description
2-1'- 83ot
11. DISINFECTION: Type 1117i-
12. CASING:
Depth Diameter
From Q To Z0 Ft. "2$i
From To Ft.
From-_ _ To Ft.
13. GROUT: Depth Material Method
___
From 0 To 20 Ft. Len eA_ j-7) p_
From To Ft.
14. SCREEN. Depth Diameter Slot Size Material
From____ To Ft. in. in.
From__ To Et. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Amount
Wall Thickness
or Weieht/Ft.
Material
PVC
From To Ft.
From_ To PL
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names. r
L
0
Ps)
V _}•
c'
2005
1 DO I IEREBY ('ERTIFY THAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION S !D.ARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Aria Ju44r- 7-Lr7- b
SIGN.AFURL OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Naa�»nlral Resources - Division of Water Quality - Groundwater Section
C( /
WELL CONTRACTOR (INDIVIDUAL) NAMES (print) .Vo � Or.lirta( CERTIFICATION #335
WELL CONTRACTOR COMPANY NAME IJJ fetP(J
e.aa %OS W'�U t/a PHONE # gal'8.3�)b
SI ATE WELL CONSTRUCTION PERMIT# /7 D Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential a.""--Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: f''
Nearest Town: `-'v"L de. County fiat/ (N04
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) e
3. OWNER: �i/CORG
Address tJ 9�t /wnCC-o re— £-oC
(Street or Route No.)
r cte AJC. 21d724
4
5. TOTAL DEPTH: /LO
DOES WEi 1 REPLACE EXISTING WELL? YES Li NO
7. STATIC WATER LEVEL Below Top of Casing: 2-0 FT.
/ (Use "+" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below laud surface requires a
variance in accordance wifils 15A NCAC 2C .0118.
9. YIELD (gpm): b METH99I, 9F TEST 2- M2/R-S
10. WATER ZONES (depth): /w
11. DISINFECTION: Type Hill Amount
12. C'.ASING: Wall Thickness
Depth Di9rr}etter or Weight/Ft. Material
From Q To 9-2 Ft. (b� ,f
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope OValleyt
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
Fro,trtr To Fo on Description
U
9- rj-o' G�ranik
City or Town ��ss Staff Zip Code
( )- 4ta'///S
Area code- Phone number
DATE DRILLED 3 -3/ - 0 it
13. GROUT:
From D
Depth
To 2-O
Material
Ft. ( eft) ent
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.
Method
Top
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 2flisii
CO
0
0
i 6. REMARKS:
1 DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTRUCTIOId'STANDARDS, AND TTI T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Qr2taaa_, L, -- al3/o C
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nj yrral Resources Division of Water Quality - Groundwater Section
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) t\Useir OViat/CERTIFICATION #335y
WELL. CONTRACTOR COMPANY NAME Qn'e.� £�-VUet/y Pf wtp PHONE # (84) H qg ?
STATE WELL CONSTRUCTION PERMIT# / T O 2— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er--Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: /+
Nearest Town: C.-4 de_ County WDCriL
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ) !? /an cc°
Address _309 G/QACC- C6Vt 40C
z,,(Street or Route No.)
d e tit L 2 8 7 Z-
ity or Town StateZip Code
; (e - I-/0o-/-
Area code- Phone number J/
4. DATE DRILLED �r 0 6
5. TOTAL DEPTH: fj ¶t
6. DOES WELL REPLACE EXISTING WELL? YES L NO L-V
7. STATIC WATER LEVEL Below Top of Casing: yO 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 accordai. wjth 15A NCAC 2C .0118.
9. YIELD (gpm): 73 METHOD OF TEST 2 Hoots
I0. WATER ZONES (depth): % IDS
Topographic/Land setting
❑Ridge BSiope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Fo tion Description
35' �S' 6nu] o:t
1 I. DISINFECTION: Type Orl Amount
12. CAS1NCi: Wall Thickness
Depth Diameter or Weight/Ft. MAtefiaVLl
To /W Ft. 6
From 0
From To Ft.
From _ To Ft.
13. GROUT: Depth Material L
From 0 To 2-0 Ft. CeA1 wv7
From To Ft.
Method
Top
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.
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 06 202
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTINN STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
06
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N�ajf}lrral Resources�n
- Division of Water Quality - Groundwater Section_
WELL CONTRACTOR (INDIVIDUAL) NAME (print) (CO er UVY�' I CERTIFICATION 53.+g
WELL CONTRACTOR COMPANY NAME (jfee4C &OS I'V L
STATE WELL CONSTRUCTION PERMIT# / # D 2-
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
PHONE #
1. WELL USE (Check Applicable Box): Residential Er- Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION
Nearest Town: �d.c County 1122.10410Cret
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LSW W1eic-e
�p
p Address ,' a lance
ut-tet.,
(Street or Route No.)
Cbide /1)C- 28?L/
City or Town State Zip Code
(gam 40o —/n$
Area code- Phone number
4. DATE DRILLED y
5. TOTAL DEPTH: 5 r
E. DOES WELL REPLACE : I: V II'1'IN:1 WELL? ? YES I 1 NO L
7. STATIC WATER LEVEL Below Top of Casing: 9 0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance wit ISA NCAC 2C .0118.
9. YIELD (gpm): W MET OD OF TEST 2 4eG443
10. WATER ZONES (depth): /b5 r
11. DISINFECTION: Type %"/'7"/-/' Amount
12_ CASING: Wall Thickness
Depth Diameter or Weight/Ft. ateri 1
From_-_ O To MS-- Ft._kl_
From To Ft.
From To Ft.
13. GROUT: Depth aterial Method
From 0 To 2-0 Ft. te/Y14g2(-- To p
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.
Topographic/Land setting
ORidge 25%pe OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From ( To r
0 05-
/OSt-/y3S r `trafitlf.
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 2025
a
CO
N_
0
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
(ONSTRUC N STANDARDS, AND TIIAT A COPY OF THIS RECORD }IAS BEEN PROVIDED TO THE WELL OWNER
- 0aa 4th-- S3/0G
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natal Resources - Division of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME (print) IC.Uj'er / IOV Vita CERTIFICATION # 33's7�/
WELL CONTRACTOR COMPANY NAME 6(ecn j8xo s.WCU •L Paine
STATE WELL CONSTRUCTION PERMIT# J7 D Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # 1818a .6 V8-30 a
I . WELL USE (Check Applicable Box): Residential 12• 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: 04...$ ter -
County Iiag0004
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: l JAL- d A.".UF'/1ER.VOc` c.t
Address b AG Seto
/ , (Street or Route No.)
wQr/A S✓c/L? L
City r Town State
2-67g4
Zip Code
($ 952 -gSOa
Area code- Phone number
4. DATE DRILLED •L 9- 0 6
5. TOTAL DEPTH: 405
(. DOLS WELL REPLACE ACE I XES'I I!NU WE! I.? YES ICI NO ter
7. STATIC WATER LEVEL Below Top of Casing: 3 0 D 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 .0119.
9. YIELD (gpm): 100 r- METHOD OF TEST
10. WATER ZONES (depth): 135 a
11. DISINFECTION: Type
12. CASING:
Depth
From To
From To
From To
13. GROUT: Depth
From [) To 2-0
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To Ft.
14 -rid
Diarriefer
Ft.
Ft.
Ft.
Amount
Wall Thickness
or Weight/Ft. Material
pvG
Material L Method
Ft. CBM,/.ALT rop
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
From To - Ft.
16. REMARKS:
Topo_graphie/Land setting
❑Ridge QSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From �7To
iss 9051 �i/Qilc�L
2NooS
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 0 6 2053
0
0
c i7
3Cp
ri
CD Erl—
rV or)
e' D0
T
-y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTRUCTION�S,TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4:244,27)40 34 G
SIGNATURE OF PERSON CONSTRUCTING THE WELL ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 2abl, (Ethic,
WELL CONTRACTOR COMPANY NAME C fe ent 4las • (,1)Ptl 4- Panne
STATE WELL CONSTRUCTION PERMIT# /i o 2- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: / G
�r1
County /JJ4WOaci
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: a hit
Address .S9 ✓./ LZ
(Street or Route No.)
Can PO /l
2--c37/'
Zip Code
(gam)- 6(8- 6757
Area code- Phone number
4. DATE DRILLED .3-7 O L
5. TOTAL DEPTH: /2S
,)IX)LS WELL REPLACE E X!STING W ELL? YES iNO Er
7. STATIC WATER LEVEL Below Top of Casing: ((AFT.
/ (Use "+" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
City or Town State
CERTIFICATION # 2118
PHONE # l ) 6 U8 30
Topographic/Land setting
ORidge ❑Slope OValley &f t
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
' 90'
I /2S(
"Top of casing terminated atlor below land surface requires a
variance in accord ce with 15A NCAC 2C .0118.
9. YIELD (gpm):, D METHOD OF TEST Zffotlitf
10. WATER ZONES (depth): / 05
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.
)l. DISINFECTION: Type Nnd
12. CASING:
Depth
From D To 70 Ft.
From To Ft.
From To Ft.
Dirrter
Amount
Wall Thickness
or Weight/Ft. Mteria1
13. GROUT: Depth �M�-atJerial
From Q To 2-0l.'ltj
From To
Ft.
Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
ethod
A
Slot Size Material
in.
in.
-< >,C
I
cor*i'i
15. SAND/GRAVEL PACK: 7...I.c.
Depth Size Material cr,.. >DIti
From To Ft. - rn tt'�0
From To Ft. ti
--1
16. REMARKS:
JUN 06 2GC3
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC ON STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
3/a.c
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

1
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources/�- Division of Water Quality - Groundwater Section pp
WELL CONTRACTOR (INDIVIDUAL) NAMES (print)
P_D &" D('/I(/%�ait / CERTIFICATION # 24/CJ
WELL CONTRACTOR COMPANY NAME lJ1 ree.fe 6to s. 1/rrelt 4- Pimp PRONE #
STATE WELL CONSTRUCTION PERMIT# /7 ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
IB�SI 648-31) o
1. WELL USE (Check Applicable Box): Residentia1C Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIWI^� I p�
Nearest Town: Lard -Or -Lard -Or -County "__��y�
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
L
3. OWNER: JObrag Chi
Address 4%13 £/Qd f Cf rats
'�(Sueet AJCNo.) p2--e7/,‘
City or Town State Zip Code
(3*)- 3-u'1- 8418
Area code- Phone number -�
4. DATE DRILLED 33 30-06
5. TOTAL DEPTH: 2,g
6. DOLS WELL REPLACE EX!S i INU \VEl I, I Yi.S t i NO fT
7. STATIC WATER LEVEL Below Top of Casing: 4/0 1 FT.
(Use "+' if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance ith I5A NCAC 2C .0118.
9. YIELD (gpm): " METHOD OF TEST Zia
10. WATER ZONES (depth): 2.0.5 r-' 221.1'
11. DISINFECTION: Type
12. CASING:
Depth
From n To 1 43 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From D To Ft. tern eiti- ra p
From To Ft.
Diameter
&e.
Amount
Wall Thickness
or Weight/Ft. Material
ptc
14. SCREEN: Depth Diameter
Slot Size Material
Topographic/Land setting
ORidge OSlope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Fo ation Description
?MI a s' 61/iti r
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
From To Ft. in. in.
From To Ft. in. in. Ju'Y l 06 LC J
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C'ONSTRUCTJQN STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
YO L
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL D TE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/�Resources�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) IC.OL96/ D-URya I ( �% CERTIFICATION #333V
WELL CONTRACTOR COMPANY NAME (n (B14A e• _iD/DS• Weil 4- &nit PHONE # (Ba :y83/7a
STATE WELL CONSTRUCTION PERMIT# /-7 a Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential liVMunicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION
Nearest Town: Gild e
County la*woc .
(Street Name, Numbers, Community, Subdivision,��//Lot No., Zip Code)
3. OWNER: � K.-/ AN45
Address 352,0 (1O
(Street or Routeof
cukJeoVC/% Pc- s1_2or
City or Town State
(S )- e1.7- 03(13
Arca code- Phone number
4. DATE DRILLED I'd2'e 6
5. TOTAL DEPTH: (SS
DCES WELL REPLACE EY!SCING Ar(E1_1.? YES U NO le
7. STATIC WATER LEVEL Below Top of Casing: 9 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST Z/I%'O IAA
10. WATER ZONES (depth):
11 DISINFECTION: Type
12. CASING:
Depth
From 0 To 5
From To
From To
Zip Code
�T opographic/Land setting
rdge ❑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 Format on Description
D' . 3/ '
S2' - b B.5' G �a f
Hill
Amount
Wall Thickness
Diameter or Weight/Ft. Material
Ft. b t' ICJ C
Ft.
Ft.
13. GROUT: Depth Material Method
From p To 7.0 Ft. Ctat i- fly
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 It ;C, u' 0 e.,.,"
From To Ft.
From_ To Ft.
LOCATION SKETCH
Show direction and distance in miles from at leaaT-
two State Roads or County Roads. Include the nisi
numbers and common road names. t -n
P3
rn'
0 ill
Co
—
1
CO
0
rn
16. REMARKS:
I DO HEREBY CERTIFY TIiAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCT' STANDARDS, AND TI IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO TIIE WELL OWNER
613
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N;tur/al Resources s-LDivision of Water Quality - Groundwater Section �7
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Y5)1O, A Webb CERTIFICATION 4b
WELT. CONTRACTOR COMPANY NAME f,f s &as luetl 4 Pnnp PHONE#1 bge'3I?
STATE WELL CONSTRUCTION PERMIT# / f 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
l . WELL USE (Check Applicable Box): Residential EY- 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: (ltgde�XJD
County
G(
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: £cc( laid
Address 30ri G[airtC6ret4-
(Street or Route No.)
de pc T143721
Topogr�aphic/Land setting
W ❑Ridge Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
City or Town Stat Zip Code From To Form ton Description
(90e)_ yc�- /,1.f ° - 9g t (j O_1/
Area code- Phone number $!t I /f ii s ° f M td-t
4. DATE DRILLED 4'30 "bS
5. TOTAL DEPTH: g5 t
6. 1X)ES \VLI r REPLACE EX!S !N(1 llnEI i ? YkS i t INC le.
7. STATIC WATER LEVEL Below Top of Casing: 6 b FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordanV 7Ith ISA NCAC 2C .0115.
9. YIELD (gpm): /L METHO9 OF TEST Z .#OJiJ
10. WATER ZONES (depth): 5t6 - 7Y5 °
1I. DISINFECTION: Type «74 Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 9 % Ft. & ° t PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 2.0 Ft. 't emeAL to,
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 Siz.e Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JUN 06 %c,v
1 DO I IEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STmDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
p44Ig4.. Azar, 5 /3/0 L
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - `Division of Water Quality - Groundwater Section
s!p
WELL CONTRACTOR (INDIVIDUAL) NAME" print) PAW& xiCERTIFICATION # Lig
WELT. CONTRACTOR COMPANY NAME f 9 teen a etas . tij e t ( 4-- Anne PHONE # aati bY8 3I7 a
STATE WELL CONSTRUCTION PERMIT# / e o Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1
WELL USE (Check Applicable Box): Residentia1C Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town: Lfy,.Iiv/1 County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: .30 Wad
Address SLr� 0.41 L/ GCIC�
�// (Street or Route No. )
de A)c_ LS7Z!
City or Town State Zip Code
(BLB )-
Area code- Phone number
4. DATE DRILLED ,3 2.O K7 (e
5. TOTAL DEPTH: 3�.
DOLL um, l RE I A(' E I: V IC'�'INU riles l '. ES l n�l1J _P_. ..._ �... 1. _ ... Y.
L
Topographic/Land setting
❑Ridge ❑Slope OValley $Plat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formati n Description
6N'-1�' gm vit.
7. STATIC WATER LEVEL Below Top of Casing: / 0 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a -
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): ' 9 METHOD OF TEST 2..4ottc3
10. WATER ZONES (depth): 22/51
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.
11. DISINFECTION: Type Amount
12_ CASING: Wall Thickness
Depth From_Q_To L 3 Ft. Di getter or Weight/Ft. FNL l
From To Ft.
From To Ft.
13. GROUTh` Depth aterialG Method
From V To Ft. 2M T p
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.
JUlf 06 LLLD
CA
0
0
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
C'ONSTRUCTIONANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
-CJ, 3-1fl L
SIGNATURE OF PEER O 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

60
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tura`l Res/oIu'rce's/- Division of Water Quality - Groundwater Section p
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �b�n W� � CERTIFICATIONA#21 /
WELL. CONTRACTOR COMPANY NAME Gi TCCA &tIJ%�. NCGI I--P inP PHONE # (azl 6 -3I I0
STATE WELL CONSTRUCTION PERMIT# iq OZ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Cd' Municipa1IPublic ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection ❑ Other O If Other, List Use
2
WELL LOCATION:
Nearest Town: 411100/1114,
County gialfUJODGI
Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: gad. S'a e-'6 aJ
Address 2S etP-ChnP •
4
(Sgee q��ute No.)�
City or Town v SStta N Zip Code
(�L�) 42,E-pz75�
Area code- Phone number
DATE DRILLED 9/ZbOs
o TOTAL DEPTH: 4 5 r
vr/S/
X)LS WELL REPLACE EX!S'i!NG y. EL I.? YES LJ NOJ�1
7. STATIC WATER LEVEL Below Top of Casing: 7.00 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordan e with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST Z btooz$
10. WATER ZONES (depth): �5• - ,390'
1 L DISINFECTION: Type
12. CASING:
Depth Diameter
From Q To ail Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0To 20 Ft. (),mom ilia
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.
Topographic/Land setting
ORidge OSIrlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
Q'- 2Y'
25' - Lio5'
i
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. aterial numbers and common road names.
G
16. REMARKS:
JUJ 06 2023
s
1
CO
rU
cn
1 DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
( ONSTRUCT)QN STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
5/3/a 6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nawiral Resources - Division of Water Quality - Groundwater Section
Pat
WELL CONTRACTOR COMPANY NAME 6 e een ,5ro-s. we Pam p PHONE # n'.3 /% 0
STATE WELL CONSTRUCTION PERMIT/4 Pi 0 2— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
V. CONTRACTOR (INDIVIDUAL) NAME (print) K-QfDI A
CERTIFICATION # 2Va
WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: I
Nearest Town: (-I-on County uoczL
(Street Name, Numbers, Community, Subdivision, Lot No., Lip Code)
3. OWNER_z 8ipt/ ��.�lni1%�
Address /JA(/ fit/ tea(
(Streeto note No.)
r(1 nk4 /J 2.537 < L
ty or Town State
(6z8)_ by8- go9y
4
5
F. DOES WE'.'..1. REPLACE EX!S fI!NG WELL? YES 1! NO rt'
7. STATIC WATER LEVEL Below Top of Casing: g is FT.
(Use "+" if Above Top of Casing)
N. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated atlor below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): V 0 METHOD OF TEST 2 F%0 arei
10. WATER ZONES (depth): 205I- 665 r
Zip Code
Topographic/Land setting
ORidge ❑Slope OValley G#flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(cheek box)
DRILLING LOG
Formation Description
DEPTH
From To
l51 i85t
Area code- Phone number
DATE DRILLED 3649, _p 6
TOTAL DEPTH: ,(9 3
11. DISINFECTION: Type E--r#
12. CASING:
Depth Diarypter
Fromm __ To Kb Ft. 6
From To Ft.
From To Ft.
13. GROUT: Depth Material ,
From Q To 2-0 Ft. real $M
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
Amount
Wall Thickness
or Weight/Ft. Material
puC
Method
'p
From To Ft.
From To Ft.
ra
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Includ 4Ie radii
numbers and common road names. vo• .5-en
)s0
.3
cr.
J-!1 itU a
CO
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
('ONSTRUCTISTANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
fan a9a- -oa>ti .g'3/0
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

y9Js
(,. ))OLS \'/LI t REPLACE EX!STINE; WELL? o YES (Li NO Id
7. STATIC WATER LEVEL Below Top of Casing: 2- 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS I FT. Above Land Surface*
' 'Top of casing terminated at/or below land surface requires a
variance in aecordanestwith 15A NCAC 2C .0118.
9. YIELD (gpm): .3 METH2D Of TEST 2 y'DUgj
10. WATER ZONES (depth): 3)6 5
Topo c/Land setting
❑Ridge lope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From r sot Formation Description
may'• <l 5' GranLk
I i. DISINFECTION: Type
12 CASING:
Depth Diameter
From_ To 53 Ft. 6 r t
From To Ft.
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) P,E) etw✓a,U CERTIFICATION # .335*
WELT. CONTRACTOR COMPANY NAME T g n e o-jD3 ([ 4- Pone PHONE # fBZA Vie .3i7 0
STATE WELL CONSTRUCTION PERMIT# it/0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I . WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town:
/123YLLIe County % il/Ces P%
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: HOU/1itQLL I eLd ,dP.%S
Address 339/ pahaood_td
treet or Route No.)
/143 VIA e- Ne- Lg786
(it or Town State
Zip Code
g2-Zr z/03
Area code- Phone number
4. DATE DRILLED L%'/ %'fl
5. TOTAL DEPTH:
To Ft.
13. Depth
To au Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From _ To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To F't.
Amount
Wall Thickness
or Weight/Ft. M teerial
Material
CeneTheitifr
Method
7-0p
From
GROUTFrom
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JC17N
16. REMARKS:
1 DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C'DNSTRUC7 ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
1:14 X lztda-f►"' 53 �G
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N ral Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ~b IA. weh � � CERTIFICATION # 2ilip
WELL CONTRACTOR COMPANY NAME & ear £,-as tti-sQmip
STATE WELL CONSTRUCTION PERMIT# NO2- Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # & 6VS :.317 0
WELL USE (Check Applicable Box): Residential (" Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nearest Town:
(e trail, County dayloaxl
(Street Name. Nuummbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: l}Jebrge ns° y`"
Address 54./6 Pk) /L7re/7-
(Street or- oute No.)
taA,SP11 ,3301E
City or Toth' State Zip Code
(' 1- 95 ?Vo-3/
Area code- Phone number
4. DATE DRILLED y LS (o
5. TOTAL DEPTH: /2135' U%r/
(., DOLS \\I1:1 1 REPLACE E ETI': XIST I1:1 O 1 VIES LJl NO
7. STATIC WATER LEVEL Below Top of Casing: 5 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordansg with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST Z HCCIAS
10. WATER ZONES (depth): HSI "' 90s
Topographic/Land setting
❑Ridge OSlope OValley I3Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From, To Fortty�tionDescription
O z'
y3'-/ s' (j 1- s k
1 1. DISINFECTION: Type /f'n/T Amount
Wall Thickness
Diameter or Weight/Ft. Material
From (�
C/ bet Q(1G
12. CASING:
13
14
15
From
From
GROUT:
From v
Depth
To 'L Ft.
To Ft.
To Ft.
Depth
To 20 Ft.
From To
SCREEN. Depth
From To
From__ To
SAND/GRAVEL PACK:
Depth
From_ To
From To
Material
CBme,I.f-
Ft.
Diameter
Ft. in.
Ft. in.
Method
re
Slot Size Material
in.
in.
Size Material
Ft.
Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the taus(
numbers and common road names.
�U1V l( �u6J
CO
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
COCTION STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
_aziy/1J ea4a
>i
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and ir•ff�v�/)at�tural Resources - Division of Water Quality - Groundwater Section
W ELLCONTRACTOR (INDIVIDUAL) NAME (print)_.ex DJYa LI CERTIFICATIONS/3357
WELL CONTRACTOR COMPANY NAME 6_1 Cen c.s W ,,) 1 / el /.U42, PHONE # ("et) LV `r)i- 5"/ 7 U
ti
STATE WELL CONSTRUCTION PERMIT# ) ( 0 ASSOCIATED WQPERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential E'Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. W EI.I. LOCATION: / p
Nearest Town: Clyde County I,& 1.vocr
( Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: KRtp fit/ A-/StJ
Address L. _Cued/Ay//L.
treet or Route No.)
L-1Vc JUc— Z c7Z 1
(ay or T own State Zip Code
(&11)- 1.117 3'fiy
Area code- Phone number
4. DATE DRILLED 7 -to-C L
5. TOTAL DEPTH: ZZSI
,. ( \''I.0 \VI.II REPLACE I:vll' I I N,(: \A:1:I I'r VI.0 I1 N(1 rI
7. STATIC WATER LEVEL Below Top of Casing: St a FT.
(Use -+" if Above Top of Casing)
8. TOP OF CASING IS i FT. Above Land Surface*
"fop of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 1L&S
10. WATER ZONES (depth): 2
11
12
Depth
From_ (7 To 35 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material �"
From 0To .2.-0Ft. LC',i)je.�ll-
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. . in.
15. SAND/(TRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
DISINFECTION: Type u%/-/ Amount
CASING: Wall Thickness
Diameter or Weight/Ft. Marial
(J` QC
Method
ro p
16. REMARKS:
I DO HEREBY
(aNSIRUC7.
Topogra ic/Land setting
❑Ridge lope OValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0 -_ 5 ' toy .
.=3h'-ZZSt fon.Le
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
t
s
RILEY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STANDARDS,�AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Ll?1 via- �--1. ac il-t \
y-5
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NaturalIn�Resources`�- Division of Water Quality - Groundwater Section �[
WELL CONTRACTOR (INDIVIDUAL) NAME (print) t E'% DU ✓[i. (L CERTIFICATION #�jJ 7
WELT. CONTRACTOR COMPANY NAME 6 ree/l ? b/;,S5, eital (�. �s'rip PHONE # jEt.n [-v8 300
STATE WELL CONSTRUCTION PERMIT# 14 0 ` ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 42' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO :
Nearest Town: ��7 dI e tiagitiatte
County
Area code- Phone number
4. DATE DRILLED 3' /...o
5. TOTAL DEPTH: 4163
I Street Name. Numbers,'�sCommunity, Subdivision, To No:, Zip Code)
3. OWNER: (Idle r9/4r'/•'IL/�T/CUI 'f-12'
Address 7 Z. Seine/ tie /It
(StRoute No.)
reet or
Clyde n;c_ Z97z/
city or 1 own State Zip Code
(g�x3__.,z 7-jy3/
DOES WELL REPLACE I:vlll !NU WELL? _r YES 11 NO IL!
7. STATIC WATER LEVEL Below Top of Casing: ti' 0 FT.
(Use "+" if Above Top of Casing)
8. Top OF CASING IS 1 FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2. 41LS
10. WATER ZONES (depth): U yS r
1 I. DISINFECTION: Type
12. CASING:
G Depth
b O FL DialGe/ r Vita
1
From To t
From To Ft.
T4
From To Ft.
13. GROUT: Depth _Material Method
From (0 To Z.O Ft. (P/77e2/- /op
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft.
16. REMARKS:
Topog9phic/Land setting
❑Ridge 19SIope ❑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 Form ion Description
0 - L 0' 1 _Leal
b1'—v175 bIC/Pc-r -
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBWERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS TRU('TION STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
famine/ C� s
SIGNATURE OF PERSON CONSTRUCTING TILE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tural Resources - Division of Water Quality - Groundwater Section
WELL COti7RACTOR (INDIVIDUAL) NAM/E �(print) L Ito e CERTIFICATIONUe # Z(i/Q
NEI.I, CONTRACTOR COMPANY NAME (,J}r€±jlt. N 0,5 LLt/' u/V)4) PHONE # tie) 6Y17..3/70
SLATE WELL CONSTRUCTION PERMIT# IV 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Cr/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: )"Jrtyii es y L//r
County 4,4ri'Cckx
(Street Name. Numbers, Community, Subdivision, Lot NNoo, Zip Code)
3. OWNER: l'VU[re-X1jj ,-
/
Address LI tL> 9 'Un S: 7 ✓ ���°O°�
(Street or Route N .
i7 A -kit, ,.LJ C 2 b )/
( by or Town State Zip Code
e'e'�)- 1�y -2 3
Arca code- Phone number y
4. DATE DRILLED2�,,,��- 0
5. TOTAL DEPTH: y 077 b .)
n„Ll\'.'I'.I1. P.I'PL- n(1. I:YI4'I INIt:\t;I:ILo Yr.' t1 Nlt) III
7. STATIC WATER LEVEL Below Top of Casing: / O U FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2-
10. WATER ZONES (depth): 3 ;�3
11. DISINFECTION: Type f} T/ f
12. CASING:
Depth
From 0 To /„ /
From _ To
From_ To
13. GROUT: Depth
From To 10
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From_To
16. REMARKS:
I DO HEREBY ('E
('ONSTRUCTI
Diameter
FL 6"
Ft.
Ft.
Amount
Wall Thickness
or Weight/Ft. Material
6feet
Material
Ft. [. e/riN m-
Ft.
Diameter
Ft. in.
Ft. in.
Ft.
Ft.
Size
Method
fop
Slot Size Material
in.
in.
Material
Topographic/Land setting
❑Ridge D'Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Form Description
fir' /SI lionC
IS L' - 4/ 0.'
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.
TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
TANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

3. OWNER:
4
5
7
8
9
10
Address
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural/�Resources - Division of Water Quality - Groundwater Section
I`—
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Clr42( _bS+I/r4.tI CERTIFICATION# 93.J/
amp
WE:l.l. CONTRACTOR COMPANY NAME are ±.IC /3'
STATE WELL CONSTRUCTION PERMIT# Li I— V v
(if applicable) (if applicable)
PHONE # (((il/) G Y H 3/ 7 C'
ASSOCIATED WQ PERMIT#
1. WELL USE (Check Applicable Box): Residential Id" Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other O If Other, List Use
2. WEL.l. LOCATION:rr�
Nearest Town: l �l.(t d. County 11-fu1 taxi I
(Street Name, Numbers, Community, Subdivision, .ot No., Lip Code)
&l]t•r% LJ 1 Sh:cfo>c
I (Street or u No
City or Town State Zip Code
(t)- 73Y-613b'
Area code- Phone number
DATE DRILLED Z -2.3 - C
TOTAL DEPTH: Ham
DOES U'I.I 1_ REPLACE I:VIS.! ING U:C11'1 vi;(1 NO rl
STATIC WATER LEVEL Below Top of Casing: .SG FT.
(Use "+" if Above Top of Casing)
TOP OF CASING IS / FT. Above Land Surface"
"Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
YIELD (gpm): METHOD OF TEST 2 iv 5
WATER ZONES (depth): .3 b=J '
11. DISINFECTION: Type
12. CASING:
^�1 Depth
From L To 11
From To
From_ To
13. GROUT: Depth
From O To 2-0
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To
From To
16. REMARKS:
1/ 77) Amount
Ft.
Ft.
Ft.
Diameter
Wall Thickness
or Weight/Ft. Material
pi
Material
Ft. Leine/it
Ft.
Diameter
Ft. in.
Ft. in.
Size
Ft.
Ft.
Method
Slot Size Material
in.
in.
Material
Topogra,pPhic/Land setting
❑Ridge IJ Iope ❑Valley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
U "7 2' ( lL7(�. ' yo5 �j/4.>(fC
LOCATION SKETCH
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
c')
O
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
( ONSI RUC XRYN STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
fin.&,,02 .LL-74-1. t--- y- 6.1. &
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
wF,LLCONTRAC( OR (INDIVIDUAL) NAMES(prior) t`O.(�){e II-Vali CERTIFICATION #/31TC/
WELT, CONTRACTOR COMPANY NAME/(,)fe eiie4,9JS. Gaee.L'(4 /20117 PHONE # en; ht6,3l%u
STATE WELL CONSTRUCTION PERMIT# / Lis 02— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
7. WELL USE (Check Applicable Box): Residential la- Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEL1. LOCATION: I
Nearest Town: M. � � ii 1 t 11 County -U p* if turd
( Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: eitr('.G,' _Sit cRSL/�
Address P.O 5crf- 1000
(Street or Route No.) _)'SSu) L!,X (�f Nl zU.75_ /
(-ity it own Stag Zip Code
(Si)-1)233i-I05lea
Area code- Phone number
4. DATE DRILLED Z- Z -0 (es
5. TOTAI. DEPTH: / OOS
:.(ua, pr1.7 1 01 PI ACC! 11V1S1 IN,(; WELL? o YES L1 N.0 r i
7. STATIC WATER LEVEL Below Top of Casing: / 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 00
10. WATER ZONES (depth): '�)$
11. DISINFE(''TION: Type N TN Amount
12. CASING: Wall Thickness
Depth
From 0 To Z 3 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From U To GV Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/(;RAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Dian ter or Weight/Ft. Material
tz PJ
l6. REMARKS:
Material
P/1jrrLfi
Method
TOP
Topogrv1-r-ic/Land setting
❑Ridge WLSlope ['Valley ❑Flat
(check appropnate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To t F rmation Description
D — 13 (�
2.41- /oar (>ea/irk
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 TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS IRUCTIO STANDARDS, AND THAT
A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TILE WELL OWNER
y-6 -0
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Napiral Resources - Division of Water Quality - Groundwater Section
W ELI. CONTRACTOR (INDIVIDUAL) NAME (print)
N'ta.l. CONTRACTOR COMPANY NAME C?yfP. rike_
S'I ATE WELL CONSTRUCTION PERMIT# I Ole
(if applicable)
Dltst -1.(.( /1 ✓CERTIFICATIONI3j5/
ttt `b)A,0 PHONE#Oda I74H"317v
ASSOCIATED WQ PERMITS/
(if applicable)
1. WELL USE (Check Applicable Box): Residential le-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEIL. LOCATION'
Nearest Town: Chi/1 Pon County
NU 9' u.'c7Oc{f..
Strcel Name. Numbers, Community, Subdivision, lot No., Zip Code)
3. OWNER: Larry
Address ! &Ss /(Znd1tvec.- ((rc4f
Street or Ro r e Nq.
CUiI )xJ (tl �1i7�
ay or Town State
28'7/L.
Zip ('ode
Area code- Phone number
4. DATE DRILLED `J -0 Co
5. TOTAL DEPTH: LS5
u. LYLES \V I..:., REPLACE EVIS:I INi(i WELL? _' Yrl 1 1 NO r I
7. STATIC WATER LEVEL Below Top of Casing: hiL1 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS I FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD9F TEST % FM-S
I0. WATER ZONES (depth):
1 I . DISINFECTION: Type
12. CASING:
Depth
From D To '7 b Ft.
From To Ft.
From_ To Ft.
13. GROUT: Depth frlaterial
From 0 To 2-0 Ft. (p'2T)e;/7f
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.
Topogray�hic/Land setting
DRidge 0SIope ❑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 Fo ation Description
�LPY
%7'- zt s'
f1 71•f
Diameter
Amount
Wall Thickness
or Weight/Ft. M te,rial
PVC-
1
h. REMARKS:
Method
rof
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 DU HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C WELL
CONS [RUCTION �FANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSrRUC I ING 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
y- k.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natnfal Resoure Division of Water Quality - Groundwater Section
NF:LL CONTRACTOR (INDIVIDUAL) NAME (print) i cc/ f / t/y /1-a CERTIFICATION IILS5y
WELL CONTRACTOR COMPANY NAME Ore el it) /EIS l,U /! 4F/Ac/1p PHONE # fit) (, f/e-.at70
STATE WELL. CONSTRUCTION PERMIT# / 9 13 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential V 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: `(J S 0 County / �(-(<% l.411
(Street Name. Numbers, Community, Subdivision, Lot No.. Zip Code)
3. OWNER: t. , 1 '7 G'/1 e J L/`-
Address Zt/Zn �ll,ff.J/J
Li'i-
(Street or Route No.l(
eJ.�ty ,LI% L,Vi/0
city or Town State Zip Cale
I 2 y0 • 07Cy)
Area code- Phone number
4. DATE DRILLED .J --'3 0 6
5. TOTAL DEPTH: %y5'
1v n. S WELL REPLACE A!'t: I: Y ICI i,, : U: I:I I 't YE S ,l_yI NO I I
.
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surfaces
*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 2 Hi J
10. WATER ZONES (depth): (�
I I . DISINFECTION: Type
12. CASING:
Depth
Frum_ 3 To Ft.
From _ To Et.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 2 0 Ft. (ed') 621- TroD
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.
Diameter
6"
1(). REMARKS:
Amount
Wall Thickness
or Weight/Ft. Material
RIO
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Flat
v , • (check appropriate box) TC?
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fot�tation Description
0'- is' (C
2vl - 715' 6. f4 r7i-T-(
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.
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
( ()NS"IRUCTON STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
-.---�.‘241/2)9cZ.-'CLE{..N
SIGNATURE OF PERSON CONSTRUCTING THE WELL
2-6 O(.
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
//-__/Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME. (print) QLnnh!t (L c � 6 ]J� CERTIFICATION #2ry� / 11
WW ELI. CONTRACTOR COMPANY NAME 6 t'e4.e /?✓.'_1 . Wet/ Y' ann n PHONE # (22(11 i, C,M- �7 0
STATE WELL CONSTRUCTION PERMIT# / I t) . ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential II/Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEI.I. LOCATION:
Nearest Town: GQ'/l�-i;rt
County CLltA. t'
(Street Name, Numbers, /Comm//u'nn�J1iity, Subdivision, Lot No., Zip Code)
3. OWNER: l)�/Ia- P l.m r '-
Address ryD� La to &
(Street or Route No.)
rel oD L 2-Y, 7/
ity or town State Zip Code
In- N33 3zgL-
Area code- Phone number
4. DATE DRILLED 3 -/ , - O (}
5. TOTAL DEPTH: "CS `
,- ,rr,C� \A/LI U1: Dt n/'I: t ILI In✓: t1'L1 o vt .. I n.rt f I
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
"Top of casing terminated at/er below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 I41-S
10. WATER ZONES (depth): YD `.3 r
1 I. DISINFECTION: Type Airti. Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
Prum_ Q To -30 Ft. 11II
From_ _ To Ft.
From To Ft.
13. (iROUT: Depth aterial
From Q To 20 Ft. 'f-/f eki--
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ftin. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From___ To Ft.
®i
16. REMARKS:
Method
Top
Topographic/Land setting -�
❑Ridge ❑Slope ❑Valley BFIat
(check appropriate box)
Latitude/longitude of well location
(degreesiminutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fop't tion Description
0 l - 3 01 (-LCtit
G ra; ; H.
3/ - 7Q ,
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.
I
I DU HEREBY CERTIFY TIIAT TII'S WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(ONSIR(ION STANDARDS, AND THAT A COPY OF THIS RECORD 11AS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
/\ OV
MELT CONTRACTOR (INDIVIDUAL) NAME (rint) I�f' /A( /// n `__ ^
WELL CONTRACTOR COMPANY NAME l.l.rt /I( Arc. - I-14U fNrnp
S IATE WELL CONSTRUCTION PERMIT# / 4r 0 2— ASSOCIATED WQ PVVERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential jd/ Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 - Other 0 If Other, List Use
CERTIFICATIONC# SJY
Ir �c:' PHONE # ) -3/7 C/
2. WEI.1. LOCATIOly^h
Nearest Town: L-LT:)n
County 4I.CEc1i
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: LQUi�--
Address () t / b I
/ (Street or Route No.)
U /) tv /L C--
4
5
7
8
9
10
II
12
Z871b
City or 'I own State Zip Code
(1)'G - 4Y< 3YJ
Area code- Phone number
DATE DRILLED Z - U (r
TOTAL DEPTH: / `j
1X)LS Hrt.,l.l_ ot:pl A(9.: ).YICI )Ail: U: Li 1 : YES 1 1 NO 1
STATIC WATER LEVEL Below Top of Casing: 2 D FT.
(Use "+" if Above Top of Casing)
TOP OF CASING IS / FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
YIELD (gpm): METHOD OF TEST 2 kits
WATER ZONES (depth): 1(e5
DISINFECTION: Type
CASING:
Depth From U To 23
From To
From To
13. GROUT: Depth
From 0 To 2-0
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From- __-_— To
16.
Amount
Wall Thickness
Diameter or Weight/Ft. Material
Ft. h �/G
Ft.
Ft.
aterial
Ft. .edne4r-
Ft.
Method
o
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size
Ft.
Material
Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley PFiat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Foryry�13�tion Description
(11 — L3' 99
241 -n:5' �� ritnl Lr'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
-1
O
RI MARKS:
1 DO IIERERY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
(ON'S I RUCT N STANDARDS, AND TIIAT A COPY OF TIIIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I&VJ& £ Z4L j -L)�i
SIGNATURE OF PERSON CONSTRUCTING THE WELL 6ATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natyral (Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) J/ 1 � L ,, / / `/ L
K t ��40Q4— nn CERTIFICATION #z ] �`i
WEI.I.('ONTRA(:TORCOMPANY NAME Cirf//c 01 OS. kith »041/) PHONE # (' :) 6YS'3/7c%
STATE WELL CONSTRUCTION PERMIT# 17 V Z— ASSOCIATED WQ PERMIT#
(if applicable) — (if applicable)
1. WELL USE (Check Applicable Box): Residential 4Y/ Municipal/Public El Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. W111.1, LOCATION: I �
Nearest Town: (.f /) JD/l)
County »6U,ccco--
I Sven Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER:
Address r,•t7 Cj d /...IJCI %t _
(Street or Route No. )
Cf-LIAPSd.0 4, c LS RSC
IN or own State Zip Code
t 1•12- scot, - c(I-19
.\rea code- Phone number
4. DATE DRILLED .) Q - ✓ io
5. TOTAL DEPTH: Z('S
(s DOES '1I.I1 REPLACE is I:vISL( Nil: WELL? YES 11 NO 11
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 ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 get.)
10. WATER ZONES (depth): / tis 1
I
12
From
From
13. GROUT: Depth
From 0 To 1, Ft.
From _ To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
DISINFECTION: Type ►-%/%< Amount
CASING: Wall Thickness
Depth��j Diameter or Weight/Ft. M erial
From 0 To 7 7 Ft. 16`f f/k
m To Ft.
To Ft.
Material Methody
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting j,
❑Ridge ❑Slope OValley BFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
Fro To r Formation Description
C
'/4'- zcs1
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 TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C WELL
CONS'I(.f(TION STANDARDS, AND TIIAT A COPY OF THIS RECORD I IAS BEEN PROVIDED TO TIIE WELL OWNER
l.._Iiz: c 7 Ket V-5 id
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# /'l ' ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
/
WELL USE (Check Applicable Box): Residential E Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
WELL LOCATION: / n
Nearest Town: ((/,7
WELL CONSTRUCTION RECORD
Nunh Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
W ELL (ONTRACIOR (INDIVIDUAL) NAME (print) D.1 i/Js(L yui2th
6, ee,)e fl:. S. kkd
County
) Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
a
Address / 5
(street or Route No.)
C/UC
City or I t iiw State
t-9 y3 a.(
Area code- Phone number
4. DATE DRILLED 2 ' 3 C--.
ZU7/k
Zip Code
5. TOTAL DEPTH: 31c3 '
!snrc WELL REPLACE I:v !Si ING 91:1 1 ., YI..S r1
[�I NO r
7. STATIC WATER LEVEL Below Top of Casing: 8& FT.
(Use "' " if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2I&S
10. WATER ZONES (depth): 3(/5
11. DISINFECTION: Type 44 T )l
12. CASING:
Depth , 1 Diameter
Frum 0 To 60 Ft. tr
From To Ft.
From_ To Ft.
13. GROUT: Depth
From (7 To 2-0 Ft.
From ._ To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From_ ___ To Ft.
I('. REMARKS:
Amount
Wall Thickness
or Weight/Ft. terial
Material
(0OW/
Method
-pp
Slot Size Material
in.
in.
Size Material
CERTIFICATION # 2Y/8
PHONE # Lea) 6Q C3 30O
Topogr rc/Land setting
❑Ridge lope ❑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
D' • 8o'E" C(ail
Bti 7" - 5ti ' Cs AV.74.
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 DU I LREBX ('ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONS "IRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
-- tutwli' l C�d
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resour s - Division of Water Quality - Groundwater Section?�
WE.LI,CONTRACTOR (INDIVIDUAL) NAME (print) 12(-1�iei Ori Itt 1U nn CERTIFICATION# 335'f
WELL CONTRACTOR COMPANY NAME rte,')Q j�/%ts Wet( '+ pu t� ' }
iiu C,) /ITp PHONE # {I� ��) E (IFi _-3/7C
STATE : WELL CONSTRUCTION PERMIT# / 7 0 a-- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEI.1. LOCATION:
Nearest Town: lt�ch-
County Nc 1-44/04-1
( Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:ILi/Op re r'/O7a git,/r5/L'1
Address
(Street or Route No.)
C Vrie AIL- 2 g7L-
( .ty or rown Stare Zip Code
(irl"r)-_--L. 2 7- 5Y3Y
Area code- Phone number
4. DATE DRILLED 3 //7/c 60
5. TOTAL DEPTH: _S Z 5'
i),)!'WELL IEnt.A('L. L.YI<I !NG WELL? YES 11 NO ILII
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 atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2Hes
10. WATER ZONES (depth): SD5 r
11. DISINFECTION: Type /-/ 77t Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Mazer al
FL (p c' P(/
From To Ft.
Flom Q To 2.2.7
From To Ft.
13. GROUT: Depth aterial
From_Q To 2 13 Ft. C'P/)7ez1 f
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SANDiGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Slot Size
in.
in.
Material
Method
1-o//
Topog�9pphic/Land setting
❑Ridge IIMMSlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formptiionn Description
ta
6 !(t t %C
DEPTH
From To
0 - zz 17 'r
Z 2- 4 „) L
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DU IIEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONS I RUCTION STANDARDS, AND THAT A COPY OF THIS RECORD ILAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N'2(Jural Resources - Division of Water Quality - Groundwater Section
VS ELI. CONTRACTOR (INDIVIDUAL) NAME (print) K t (;,_/ I G
01�
/' q� CERTIFICATION
/#j5Y
W EL.l. CONTRACTOR COMPANY NAME CL they/ F L'S' - "Veit 4- r cm,. PHONE # j-1 ) V to -q[ J b
STATE WELL CONSTRUCTION PERMIT# /V 0 -2-- ASSOCIATED WQ PERMIT#
(if applicable) (ifapplicable)
1. WELL USE (Check Applicable Box): Residential H/ Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELI. LOCATION'
Nearest Town: (� L({dt'
County HartA'i>vrl
1 Street Name. Numbers. Community, Subdivision, Lot No., Zip Code)
3. ()WNLR: P(f.-I /Y"/Ar -)... IcA di6/ paJ
Address 21
(Street or Route No.)
cjydc /11G Z4 yz/
(lty or I ovo State Zip Code
(/ }- h 2. 7 — 3 y 31
Area code- Phone number
4. DATE DRILLED 3 - 23 - .:%L•
5. TOTAL DEPTH: Li05
IW,I. `,\/1._1.1. REPLACE EY!S.! IN(: \A/I.I I.? YES LI N(1 Li
7. STATIC WATER LEVEL Below Top of Casing: 9 0 FT.
(Use "+• if Above Top of Casing)
5. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 /Tits
10. WATER ZONES (depth): 3
11. DISINFECTION: Type Orrli Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From i.� To Z S Ft. 19 e pi g
From To Ft.
From _ To Ft.
I3. (TROUT: Depth Material i Method
From__ Z_ To ZO Ft. a To p
From_ To Ft.
14. S(REEN' 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.
lb. REMARKS:
Topo�gr�3phic/Land setting
❑Ridge IBSlope ❑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 - y'I054 1
<s ' (:taw
�1n
ic
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 DU HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
('ONSTRU(fi1UN STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
-5 -O 6
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tural Resolll��rces - Division of Water Quality - Groundwater Section
%\ ELL CONTRACTOR (INDIVIDUAL) NAME (print) {� E/ VihCot-t CERTIFICATION#.'�35y
WELL CONTRACTOR COMPANY NAME 6j1)69 f- A as wail ¢ juf/. n49 PHONE itr&2 i i'V Yi- 300
STATE WELL CONSTRUCTION PERMIT# I 1 J -. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential CYT Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. Wf:LI. LOCAT.I
Nearest Town:
r
C Ie. Y it44F-!/ County [la y LJ oC'
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: it at ilggSsler
Address ) 4 Crroall S a yf° U .
(Street or Route No.)
Clyde mc.-
City or Town State
(Crstw- Zz4,=7I97
Atea code- ('hone number
4. DATE DRILLED / 2-& "C &
a'67 z 1
Zip Code
5. TOTAL DEPTH:
UO :S !..:.I. REPLACE L:v!c.1 INJ(i \t,;L._!_L? YES Li NO LI
7. STATIC WATER LEVEL Below Top of Casing: rX FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated aVor below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 fLE S
10. WATER ZONES (depth): S
11.
!2. CASING:
DISINFECTION: Type /-{'r��
Depth '/ Diameter
From 0 To 5 S 7 Ft. b t
From To Ft.
From To Ft.
13. GROUT: Depth Cent
From (0 To 2-0 Ft.
l_-P/rie11
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
I5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft.
Material
Ot'C
1
t
16. REMARKS: -.
Topographic/Land setting
❑Ridge dope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
d_ - ss•y Cat/
53 5'— i21,' l,fC(l,T,4
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 DO IIEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONS'I RCA ION STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
_ J !Z }LEWYia.. ciesi
SIGNATURE OF PERSON CONSTRUCTING TITE 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

V}4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
W �/ Q
ELL CONTRACTOR (INDIVIDUAL) NAME rint) 2O�`4-: / . Web �,_ CERTIFICATION Z7
WELLCONTRACIOR COMPANY NAME 1)i_re'4C 6/S G(.'d1 1 i)✓m/O PHONE # (B2d 648-3/ 70
S FATE WELL CONSTRUCTION PERMIT(' / t 0 Z- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential Bet Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WEL1. LOCAT ON:
Nearest Town: &y}t.jt1 EJv(Ik
County_PfaSat
t Street Name. Numbers, Community. Subdivision, Lot No., Zip Code)
•
3. OWNER: F�av d ! Ocati
Address �jJ. 0 d n`" ea 7
( trm or Route No. )
ut NC Z� )Z/
City or own State Zip ('ode
(qIj)-.04 -'7/99
Area code- Phone number
4. DATE DRILLED (i _ —0 (o
5. TOTAL DEPTH: ThOS r
VI,:1 II NO 1 1
'
7. STATIC' WATER LEVEL Below Top of Casing: 7/&, C FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface'
Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST ZS
10. WATER ZONES (depth): '1%in t" LID 5'
11. DISINFECTION: Type /TM
12. CASING:
Depth Diameter
From 0 To5b Ft. "
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
P11
13. GROUT: Depth f aterial Method
From To 71 Ft. L 1'n it i fop
From To Ft.
14. SCREEN: Depth Diameter
From _ To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Site
From To Ft.
From To Ft.
lb. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope OValley y7f lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Foation Description
5S' LLat-'
�`i'- Bo$' (iran Lk
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
3
�a
I DU HEREBY CERTIFY TIiAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
CONSIRU TON STANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCT ING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
3 22914
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section !�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) iS h�jC D(.V ett((
n
WELL CONTRACTOR COMPANY NAME errrcG (CIS Lae (( t F+t+PU� (.-) t -I-n - PHONE # t »i Qt/ 3/Z
STATE WELL CONSTRUCTION PERMIT# /1/0 y ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
CERTIFICATION #2s3J 7
1. WELL USE (Check Applicable Box): Residential tif 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: a✓\ -f-cr. -
95 Pond. V(Cu (Set
County 444.•{tJ0
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
m
3. OWNER: CAn. VTLv(-S
Address 'IC Oil dl
(Street or Route No.)
C-Cfr..G,� NL a..fl
City or Town State Zip Code
( )-
Arca code- Phone number
4. DATE DRILLED /'R�'v'
5. TOTAL DEPTH: 1fOS
6. DOES WFL(. REPLACE EXIS'rtN(i WE! 1? YES U NO k
7. STATIC WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): S'{ METHOD OF TEST ci h1`5
10. WATER ZONES (depth): 34:6- I
1 1. DISINFECTION: Type -HO-1
12. CASING:
Depth
From 3 To 1S-tr Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From O To atO Ft.
Diameter
L.0
Material
Amount 77taGlciS
Wall Thickness
or Weight/Ft. Material
/J✓L
From To Ft.
14. SCREEN: Depth Diameter
From_ To Ft. in.
From_ To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Method
47=4P
Slot Size Material
in.
in.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge OSlope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
5
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
MAR 08 2006
Asheville Regional Office
Aquifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION TANDARDS, AND THAT A COPY OF THIS RECORD IlAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUR OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)��0I0 t en- WelO h CERTIFICATION t�ylY
//
WELL CONTRACTOR COMPANY NAME S-3T zn.-C f ro.1 (}) C (('I- ! (t/k,p WT (' OC_- PHONE # ( SS t rtir 3 n c
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
( Ky 9 f) c r) er L .L
1. WELL USE (Check Applicable Box): Residential B Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO ty`I ta4W0d -
Nearest Town: el f61'�- Coun
Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: rem_
Address //2/4U9'BiroC.pr 7) r
(Street or Route Ro.) at- /(-P
City or Town State Zip Code
( )-
Area code- Phone number �,.,�
4. DATE DRILLED I �31
5. TOTAL DEPTH: / 5?-5
Topographic/Land setting
ORidge ❑Slope OValley—enat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From�/�J�Qj' To Formation Description
5nevi( r
DOES ..L REPLACE EXISTING WELL? t YES LI NO Li'
7. STATIC WATER LEVEL Below Top of Casing: L. C. 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): 2tl METHOD OF TEST a-h r'
10. WATER ZONES (depth): / /or
11. DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From To 7YFt. a �%✓L
From To Ft.
From To Ft.
13. GROUT: Depth Materi Method
From L.)To )6 Ft. er Y°
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.
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
MAR 08 2006
Asheville Regional Office
1 b. REMARKS: Aquifer Protection
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF P SON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourcese- Division/of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Q,0Al cJ W 6 Ls siCERTIFICATION # 2111 e
WELL CONTRACTOR COMPANY NAME 61e_Ne 8 as- Ell gw PIMP PHONE # gzi5) tQ 3/"70
STATE WELL CONSTRUCTION PERMIT# ly b 7s ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential VMunicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELI. LOCATION:
Nearest Town:1IU41/)Ua5V1 L L
(Street Name, lcumbers, Community, Subdivision, Lot No., Zip Code)
Topographic/Land setting
County IA4p1000 ❑Ridge ❑Slope ❑Valley Ubflat
(check appropriate box)
3. OWNER: bz/,i z t54WvE .
Address coS
(Street or Route No.)
CIE (/,NeSfnLg ,jG 2756
City or Tow State Zip Code
( )-
Area code- Phone number /
4. DATE DRILLED / r 6-0 (-
5. TOTAL DEPTH: 290
DOES WELL r U I A!' : l XIS! ;NG WELL? I o YES 1 NO LI
7. STATIC WATER LEVEL Below Top of Casing: 8 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS l FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): M THOD OF TEST 2 f%Q3
icyWATER ZONES (depth): 7o
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.
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
71'— 2.90 &tempTt
1 1 . DISINFECTION: Type ij7/f
12. CASING:
Depth
From (i To 7 ) Ft.
Diameter
From _ To Ft.
Front To Ft.
13. GROUT: Depth Material
From D To 2-0 Ft. _CI--
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
From To Ft. in.
Amount
Wall Thickness
or Weight/Ft. Material
>7JC
Method
-roP
Slot Size Material
in. in.
in.
l5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
RECEIVED
MAR 2 7 200S
Asheville Regional Office
Aquifer Protection
0
0
o'
1 DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STtiNDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/ao2L0d42_ 0/ 7. ,6.4.4Ih
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

F n r
n. 0S- • A
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural�aResources-�- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ty.tM11� ID/ cLs2 n n CERTIFICATION #'� 7/2)
WELL CONTRACTOR COMPANY NAME 6aeree1V6 Btosi. WCcz it' Puue PHONE # 05z3 erni�.3I70
STATE WELL CONSTRUCTION PERMIT'S 1 i0 ASSOCIATED WQ PERMIT/1
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential El Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: LUJ.VPE S "I LLL. County H 4 quO On[)
Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 7S 9 6llrt/A7'1 JZ .4 V
(Street or Route No.)
/2-scgIkLL. 3 c
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED I L3 .O
L
Z(170 3
Zip Code
5. TOTAL DEPTH: ) 0 415 I
(:. DOES \vWEE.i. REPLACE EXISTING Nnn o YES r t NO L I
7. STATIC WATER LEVEL Below Top of Casing: Ci O 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.
9. YIELD (gpm): METHOD OF TEST Z HI
1(1. WATER ZONES (depth): / O 2
11. DISINFECTION: Type }/ T/-/ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From /) To / / S3 Ft 6" 19(1h.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 _._ To ZD Ft. P
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope OValley I3flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From (T[oIl.� Formation Description
I%-
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.
14. SCREEN: Depth Diameter Slot Size Mate ial
From To Ft. in. in.
From _ To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
RECEIVED
MAR 2 7 2025
Asheville Regional Office
Aquifer Protection
16. REMARKS:
0
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCT STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
g- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ely-,eQO✓s__CERTIFICATION # 299
WELL CONTRACTOR COMPANY NAME6/g-6/VC Etas. welt. Y' rn v HP
STATE WELL CONSTRUCTION PERMIT# /2I OZ✓ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # i,'M-3170
WELL USE (Check Applicable Box): Residential RI Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: Cf. US County i-NA-LADco^l)
DN@rtL NW TP_AI c-
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
CAV TU/J /1) C ?,� 71 to
('ity or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED /- -D 6
5. TOTAL DEPTH: / 0 5 '
,.. DOLS WEL:. REPLACE EXISTING WELL? YES rI NO !I
7. STATIC WATER LEVEL Below Top of Casing: 2. D 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 TEST 2 It C5
10. WATER ZONES (depth): e 5
11. DISINFECTION: Type bTM
i2. CASING:
Depth
From b To_Zft Ft.
From To Ft.
Diameter
Amount
Wall Thickness
or Weight/Ft. Material
OJC
From To Ft.
13. GROUT: Depth Material Method
From ri To ZD Ft. Cenaur -oP
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ltlat
(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 Z �O ' CLAY
2_7'- /05(j Ile"
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
MAR 2 7 2C06
Asheville Regional Office
A s utter Protection
16. REMARKS:
CD
CD
G1
1 D() HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTRUCTION S A DARDS, AND THAT/A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
QNi.tw4 d . ( ,04.azta J .3 ig - O (o
SIGNATURE OF PERSON (:ONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N al (c712R,e/ssou es - Division of Water Quality - Groundwater Section L,
WELL CONTRACTOR (INDIVIDUAL) NAMES (print) 1 t'1[S_iOUALC- CERTIFICATION# 3?5]
WELL CONTRACTOR COMPANY NAME eaU_� Q )S I1) p[ j-P01? PHONE # fr+Zrr b4' -3170
STATE WELL CONSTRUCTION PERMIT#
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential I3 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N:
Nearest Town: r166/6: Y(ALG County HAtil+i)00D
E ‘14 -res e—
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:6ALaLli Loa iZ M < L*1 22) N)LLI ps
// Topographic/Land setting
Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Address L/73 AA])VOCI�' .1)Q ' Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
DRILLING LOG
City or Tow State Formation Description
CALIK G
I1Dz-
2&7a/
Zip Code
( )-
Area code- Phone number
4. DATE DRILLED / * 7. a
5. TOTAL DEPTH: 2.0r7
DUES WI'1.i_ REPLACE EX'S"! !N(i 'gtlfi 1 ' YES Li NU (.'(
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): /qj'
DEPTH
From To
0
2y "I0"- 205
11. DISINFECTION: Type NT1a Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From () To24'94 Ft. 6'' fro v`C:.
From To Ft.
From To Ft.
13. GROUT: Depth Material Merh,gd
From O To 20 Ft. Ceilef 7r TDv
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Slot Size Material
in.
in.
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
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
(:ONSIRUCTION STANDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Cr
SIGNATUR OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources r--Di/vi'si'on of Water Quality - Groundwater Section ''1
WELL.CONTRACTOR (INDIVIDUAL) NAME (print) (print) ,etAi1U JA )ELSLL /1 n CERTIFICATION #1+1%//J
WELL CONTRACTOR COMPANY NAME S.,�Q ['/I l� �T IdJ�LC.� �Y"t1FI/' PHONE # j/ 174/ -3/ 70
STATE WELL CONSTRUCTION PERMIT# /I 0 Z— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential li3' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: Nearest Town: C AVID it)County PiNt0015A
Street Name, Numbers, Community, �Srubdivision, Lot No., Zip Code)
3. OWNER: A S Atig LUt S
Address / 90 etiF57por PLA c
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED / -3 -0 (,
5. TOTAL DEPTH: Q& 5
.. Do..,c yr it LI. REPLACE EX IS!!NG WELL? .t YES _i NO Li
7. STATIC WATER LEVEL Below Top of Casing: J 0 C0 FT.
f (Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/er below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 rigs
10. WATER ZONES (depth): 94 5
Topographic/Land setting
❑Ridge ❑Slope ❑Valley CaTI{lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
.. Z.
- 96,5 ` (12FFA17/
(Street or Route No.)
ARDz:70y
11 DISINFECTION: Type Era
12. CASING:
Depth
From 0 To 23 Ft.
From _ To Ft.
From To Ft.
13 GROUT: Depth Material
From C) To 2 D Ft. Cci4
From To
Diameter
Amount
Wall Thickness
or Weight/Ft. Material
PVC,
Ft.
Method
IvP
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Material
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
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
O
0
1 DO IIEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION tNDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural ResourcesWELSH
q-Division of Water Quality - Groundwater Section L't
W ELL CONTRACTOR (INDIVIDUAL) NAME (print) IC TE6 /N tN ELS sit CERTIFICATION # z4/(l
WELL CONTRACTOR COMPANY NAME £ 2FF47< ,�a2.iLS. W flL T- Pl'N P PHONE # ( )
STATE WELL CONSTRUCTION PERMIT# IVO Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: SILL County 6 4p,OD0A
COO C C i
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: JO H&UALy r/ QFFMA{t.)
Address 32157 /UDoL CI /f%•
(Street or Route No.)
Nuflca_3 .nx-e i SC. 2-957C,
City or Town State
( )-
Area code- Phone number
4. DATE DRILLED 2-0 -O &,
5. TOTAL DEPTH: -73 0
DUES 4f':' ' REPLACE. EY.IS I !NG WELL? YES L I NO
7. STATIC WATER LEVEL Below Top of Casing: ) q 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 /DES
10. WATER ZONES (depth):
Zip Code
72-s it'
11. DISINFECTION: Type /7 Tit
12. CASING:
Depth- 7
_S.1
From n To / y
From
From
13. GROUT: Depth
From () To 2 0
From To
14. SCREEN: Depth
From To
From To
15 SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Diameter
Ft. 66''
To Ft.
To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
PI'c
Material Mcth d
Ft. _e /1-1 U r
Ft.
Diameter Slot Size Material
Ft. in. in. _.
Ft. in. in.
Size Material
Topographic/Land setting //
❑Ridge ❑Slope OValley QFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
4�' - 3y0' ITS
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
MAR 2 7 2026
Asheville Regional Office
Aquifer Protection
0
0
Cr
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION $t DARDS, AND THAT COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a41iri
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME' (print) , ti�OB /�I/T hA� ti CERTIFICATION # 2��pp
9/ S
WELL CONTRACTOR COMPANY NAME 6�L1'y&C giskeJ`. we44_1 Am PHONE # t9z b%-5IJt%
STATE WELL CONSTRUCTION PERMIT# Pi Oa. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL. USE (Check Applicable Box): Residential 12 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WEL.I, LOCATIO
Nearest Town: �¢7TbN' Countyjn_y_WDCA
/�'/I 2 /a -
(Street Name, Numbers, CouYtrnnity, Subdivision, Lot No., Zip Code)
3. OWNER: NOOkrTA-w l/00k“ Eh7ia50
Address 73 7 j OUPTO y ILA ,
(Street or Route No.)
CA-Ail64 b'C Z g7) Co
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED /- 3 I - o 6
5. TOTAL DEPTH: 05 '
(.. DVFS \VIt.t. REPLACE FX!S! ENG WELL? YES Li NO ❑
7. STATIC WATER LEVEL Below Top of Casing: ) 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ' FT. Above Land Surface*
*Top otcasing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 / e5
10. WATER ZONES (depth): 99D
11. DISINFECTION: Type MTII Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To- //,) Ft.
From To Ft.
From To Ft.
hat
Material
pvc
I3. (TROUT: Depth Material Method
From 0 To 20 Ft. C6MENl- t12
From To Ft.
14. SCREEN: Depth Diameter Slot Size Matenal
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From /To Formation Description
ot
Ill ' - Ll 5'5' (32AN I Fr -
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
MAR 2 7 2006
Asheville Regional Office
Aquifer Protection
0
0
16. REMARKS:
I DO HEREBY CER Y THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
S C�TURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N tural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print),, K 0�^6i/U 1.t)EL.SH CERTIFICATION a 29/8
WELT. CONTRACTOR COMPANY NAME SM(�6 £ 0.5• LUE).L-4 PIM la PHONE # 62.4 &98 3/70
STATE WELL CONSTRUCTION PERMIT/1 17 d1 ASSOCIATED WO PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential IV Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
WELL, LOCATION:
Nearest Town: 20/¢1.11UeSV"1LLE County PAVI, 10°b
L.b
(Street Name, Numbers, Community,/Subdivision,, Lot No., Zip Code) p �
3. OWNER: �Eff YAi-/YG', (A�!(9L�r TThQGart+
Address 3 i1i,,y 4PPy tit) LL.n0 cc. p 43
.)
CI-Y D (Street or ,%JRoute_ ?- CT'72-1
City or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 2 ' 1 _o
5. TOTAL DEPTH: 2-45
L`OFS WE'.LL. REPLACE IiX!S.r!NO WuE:L Lo YES U NO Li
7. STATIC WATER LEVEL Below Top of Casing: St% 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 TEST 2 µQ S
10. WATER ZONES (depth): 245 '
I I. DISINFECTION: Type f-1 tit
12. CASING:
Depth
R 'D
From 0 To LI Ft.
From To Ft.
From To Ft.
Diameter
b''
Amount
Wall Thickness
or Weight/Ft. Material
PVC.
13. GROUT: Depth �ntM!aterial
From 0 To 20 Ft. C6 NEM I
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
10P
Topographic/Land setting //
❑Ridge ❑Slope OValley <t7PIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From - gTo i Formation Description
0185' - 2.95' tomit 115
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.
Slot Size Material
in.
in.
Material
RECEIVED
MAR 27 2B06
Asheville Regional Office
Aquifer Protection
16. REMARKS:
0
0
cm
I DO HEREBY CERTIFY TBAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('ONSTRUCTION,STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section �/
WELL CONTRACTOR (INDIVIDUAL) NAME (print)'��!K�pbie �.4L-L- CERTIFICATION #325 J
WELL CONTRACTOR COMPANY NAME 3�))&t1J-r ''M05. L" -r PUMP
/I
STATE WELL CONSTRUCTION PERMIT# 0 Z_
(if applicable) (if applicable)
ASSOCIATED WQ PERMIT#
PHONE # C/6 hy8-.3/7O
1. WELL USE (Check Applicable Box): Residential iif Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town: _i L ro/ti County HAL/t.0006
PLENAMx gJ3 (Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: gni/ FaerI{E (�%(/
Address ti3 / I 4L Ln\i Ff -M al)
(Street or Route No.)
CAA-nyu NC Zf37Ily
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED 2 -14 -O
4.0
5. TOTAL DEPTH: 3 05'
(•, DOHS W:'.1.1. REPLACE FXEn EN i WELL? ' YFS LI NO ❑
7. STATIC WATER LEVEL Below Top of Casing: 4i 0 FT.
(Use "+" if Above Top of Casing)
R. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST % /-%/QS
10. WATER ZONES (depth): Zg 5 '
11. DISINFECTION: Type H'(/i
12. CASING:
From 0
From
From
13. GROUT:
From 0
From
14
15
Amount
Wall Thickness
Depth Diameter or Weight/Ft.
To 1I Ft. (v "
To Ft.
To Ft.
Depth Material Method
To 7i0 Ft. (.Pjpp /1A ()
To Ft.
SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Slot Size Material
in.
in.
Material
Topographic/Land setting
Midge ❑Slope [Valley [Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From Tornt Formation Description
0 JInr
119' .B5' ZJfe'uiT r
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
RECEIVED
MAR 27 2005
Asheville Regional Office
Aquifer Protection
0
0
16. REMARKS:
I DO HEREBY
CONSTRUCTI
TIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
TANDARDS, AND THAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Res
WELL CONTRACTOR (INDIVIDUAL) NAME (fff riot) cx�e
WELL CONTRACTOR COMPANY NAME C) rl-E
/y0 7—
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
urces - Division of Water Quality - Groundwater Section
di( ,/t I CERTIFICATION #�t333
�Q ,j �1'LtS• �C'l,N J()7'� PHONE # k�Z€ bl83/7O
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential id Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELI. LOCAT N:
Nearest Town: fla /ej County HalmiDO(j
MAT tar & m
(Street Name, Numbers,__/ Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ne(i#or ehlf1e&
Address ,30/ n .S(,dcibinntie
(Street or Route No.)
Alf Q tut, FL 331 H5-
('ity or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED 2 -11-00
5. TOTAL DEPTH: y 05 •
(, DOES WELL REPLACE C'E l:vic'l tiNG WEI.1» YES LJ INC L
7. STATIC WATER LEVEL Below Top of Casing: 1/ 0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below laud surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 y,2S
10. WATER ZONES (depth): 3135
11 DISINFECTION: Type H rf1
12. CASING:
Depth Diameter
From 0 To /2.0 Ft. (P#
From To Ft.
From To Ft.
13. GROUT: Depth
From 1) To .O Ft.
Amount
Wall Thickness
or Weight/Ft. Material
Steel
Material
(emen+
Method
oa
�/ 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
(ZI ` - gas' (-, LA, !rE
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.
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.
RECEIVED
MAR 27 2006
Asheville Regional Office
A•uifer Protection
0
0
cry
16. REMARKS:
1 DO HEREBY,CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CON Si RON STANDARDS, AND THAT A COPY OF THIS RECORD IiAS BEEN PROVIDED TO THE WELL OWNER
RUC
)- d 3' 8-0 to
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment andNaturalResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMEE��r (print) dNJS A3 t v JT! LAVA / / CERTIFICATION # 3 351r-
WELL CONTRACTOR COMPANY NAME Sec AreS. [N if `f Pee Me i c.. PHONE #(82&64le-3tie
STATE WELL CONSTRUCTION PERMIT# /d"o .Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WEL1. LOCATIO :
Nearest Town: h County !'ta-yW#o�
Shales o-f I )'Marra-y ?.cf
(Street Name, Numbers, Community, Subdivisions, Lot No., Zip Code)
3. OWNER: RD be r -E aActat S
Address 1 C>S 5 Lo_rte s r
/i (Slice) or Rouie No.)
Oc .'I-014 IQ C al 2 7/ to
City or Town State Zip Code
( )-
Area code- Phone number
4 DATE DRILLED - l.2 - b �o
5. TOTAL DEPTH: / $ S
.. D'JFS\\ILIA. REPLACE I:VrST !Nli WELL'? YES r1 NO
7. STATIC WATER LEVEL Below Top of Casing: a0 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.
9. YIELD (gpm): 3b METHOD OF TEST rs
I D. WATER ZONES (depth): Co 5 t - D
- 1 D %pen
11. DISINFECTION: Type HT Fi Amount 13 41444
12. CASING: Wall Thickness
Depth
From 0 To Ft.
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge IISlope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O 241 ' C/ate
-7 (1 r / 95 c 9 0-A-H Ve
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
Diameter or Weight/Ft. Material numbers and common road names.
Lois PVC
13. GROUT: Depth Material Method
From D To 20 Ft. Ce. re. c..-# ______
From _ To Ft.
13. 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:
RECEIVED
MAR 08 2006
Asheville Regional Office
Aquifer Protection
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STAND,�RQS, AND THAT A COPY OF THIS RECORD ISAS BEEN PROVIDED TO THE WELL OWNER
)j /-J/-6 4
SIGNATURE OF PEKSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

e ,j V c)'ff
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources.- Division of Water Quality - Groundwater Section'/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) p.t 6iA,,� �. )V ido,(_ �J/'�, ..____ CERTIFICATION g240 S
WELL CONTRACTOR COMPANY NAME , &r -eae &roS well `i-- gimp _... PHONE # 6V 8-3/O
STATE: WELL('ONSIRU(:TION PERMITS--VoZ__-_. ASSOCIATEDWQ PERMIT,*
I if applicable) (if applicable)
I. WEI.I. USE (Check Applicable Box): Residential erMunicipaUPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ I{eat Pump Water Injection ❑ Other ❑ If Other, List Use
2. W'IU.l, LOCATION
Nearest Town:La/J,412/1 County
Street Name. Numbers. Community, Subdivision, tut No., Zip ( ode)
3. OWNER: jansorki,
t.0
Address ._
(Street or Route No_)
(uc-
Coyor'lown State
(€L$)- JDO^1 o2-
Area care- Phone number
4. DATE DRILLED '2-3--0 6
5. TOTAI. DEPTH: 5t)S t /
n/ l:c WELLU1.1)1 nr I I vl%. I :Ni t t::.t ELL? YI.L, Li n.(.) Itf
7. STATIC WATER LEVEL Below Top of Casing: 3 FT.
(Lse "4- if Above Top of Casing)
R. TOP OF CASING IS I FT. Above Land Surface`
`Top of casing terminated at/or below land surface requires a
variance in accordance )rith 15A NCAC 2C .0118.
9. YIELD (pm): 3 112_ METHOD OF TEST 2 moue
i0. WATER ZONES (depth): 3L25'
Z8721
Zip Code
1 1. DISINFECTION: Type__ kft f _ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From,,d To 33 Fi. b"
Front To _ Ft. _
From To
13. n
_ 0 TopdZ. l-
0 FtGAYIe�1
Fromoni .l
_ P
Erom
14. SCREEN: Depth Diameter Slot Size
Prom To Ft. in. in.
From To _. _ _ Ft. in. in.
15. SAND/GRAVE(. PACK: _.
Depth Size
From To Ft.
From To Ft.
lb. REMARKS:
DUI IliRF
CONSIRI'
Method
lop
Topographic/Land setting
DRidge ❑Slope ❑Valley R FS
)(Muck 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
01
I' - 5bi (yBoni1 E_
LOCATION SKETCI I
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
c
l
r—
Y CERTIFY Ti IAT TI it); WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C. WELL
ION STANDARDS, AND COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
r3 -0.6
SIGNATURE OF PERSON CONSTRUCTING TI{E WELL. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, N('
27699-1636 Phone No. [phone]. within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
g,lr. 1
,l it t+ t< 'rF
North Carolina - Department of Environment and i)Z;atura! Resources - Division of Water Quality - Groundwater Section ��22
NAME
t-- Weil
-(n//� ____ - CERTIFICATION 0ZV/ O
WELL I. CONTRACTOR COMPANY NAME, _(S(Q[2e!nxe etas Wekl.4 Py[tnp _._ PHONE 0 / V) 6 i g 3/7D
STATE WELL CONSTRUCTION PERMIT# -__I 7_-✓Z- —_. _.. ASSOCIATED WQ PERM in -- _
(if applicable) (if applicable)
WELT. CONTRACTOR (INDIVIDUAL.) NAME (print)
bi AV) ebb
1 . WELL USE (Check Applicable Box): Residential C Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Beat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION -
Nearest Tenn:_A +DO _
County
utud-
I Street Name. Numbers. Community. Subd
ion, I.or No., 'Lip Code)
3. OWNER: £_b GrOWei
Address _17 _ L7n` Ot/ er ter�-
(Strec4 or Route No.1
Cafrion -N t 2 B 71 ca
4v p.r. qgtD Zip Code
Srce code- Phone number
4. DATE DRILLED_-- _
5- TOTAL DEPTH: TO-5 ...
I01EN).'III 1 ul.ul *SS. LYiCI In,,: a-bl I vl.3I1 NO le
7. STATIC' WATER LEVEL Below Top of Casing: FT.
it Above Top of (acing) •
8. TOP OF CASING IS FT. Above (.and Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD r TEST Z b(i�
10. WATER ZONES (ed pth'):
Topographic/Land setting
❑Ridge ❑Slope ❑Valleyat
(check appropriate box)
Latitude/longitude of well location
Idegreetcminutesiseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
� v
I I. DISINFECTION: Tvpc__. - ite _ -, Amount
12. CASING: Wall Thickness
Depth, /' Ur m •ter (t or Weight/Ft. M 'rjal
PromQ&
To Ft.
From To Ft.
13
14
15
From To
GROUT: Depth ,Material Method
From _7---- To7.
_Q_Ft
. (f!iti 1 op
From To Ft.
SCREEN: Depth Diameter Slot Size Material
From To Ft.
in. in.
From To Ft. in. in.
SAND/GRAVEI. PACK:
Depth Size Material
From To Ft.
Fnmt To Et.
lb. REMARKS:
LOCATION SKETCI I
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names. O
C
c
G7 --
tfl =�
1 -
1 IX) LIE 3Y CERTIFY TIlAT THIS WELL WAS CONSTRUCTED IN A('C'ORDANCE WAIL I5A NCAC 3C. WELL
Ct )NST U TION STANDARDS, AND TI LAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE WELL OWNER
DACE
SIGNATURE OF PERSON C'ONSIRUC'TING TILE WELL.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, N('
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

v
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural_ Resources - Division of Water Quality - Groundwater Section
CERTIFICATION # 335y
PHONE # (9Z9) 6 «9317c
WELL CONTRACTOR (INDIVIDUAL) NAME` (print)
:/7/
WELL CONRAC OR COMPANY NAME 6reeie_.,�ros WPte l 4-.
STATE WELL CoNs nuc'TION PERSIU# /q C7Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable I3ox): Residential B"---Municipai/Puhlic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 heat Pump Water Injection 0 Other 0 If Other, List Use
2. WIILI, LOCATION: Nearest Town: 19$U ''.t.1-`t
County (4tu1LL)006t.
t Street Name, Numbers. C/'oCommunity, Sulxlivision, Lot No., Zip Code)
3. OWNER: A 0e, S1jpta_ae_ �
Address 36_JoaebUN TL2.L
9 (Strreei ur Route NMI
LabtdeiCail•e State c ZipCod8 7e25-
tB-(or 'rowit y t'/36(0
Area code- ('hone number
4. DATE DRILLED_ 7i j-- 0 6,
5. TOTAL DEPTH:_ k_4•5'
IVU: S tat of-nI 1r1. I.\_Icl In:r. N1.11 a v1.ct1
7. STATIC WATER LEVEL Below Top of Casing: Z. Q __FT.
(Use"+ if Above Top of Casing) •
R. TOP OF CASING IS 1 FT. Above (,and Surface*
"Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C: .0118.
9. YIELD (pm): Z. UMETHOD OF TEST
10. WATER ZONES (depth): -_645I
fio(JGS
11. DISINFECTION: Type _ pf-rg Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft- N aterial
i:rom0 ToJ03 FL.__.b,.--- pVG
From _ _. To _ ___ Ft.
From To Pt,
I3. GROUT: Depth }Material Method
From b To ZipFt. (,.2m�"�, Top
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft- in. in.
From To Ft. _ in. in.
I , SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
lb. REMARKS:
Topogra ie/Land setting
❑Ridge 2glope ❑Valley ❑Flat
(cheek appropriate box)
Latitude/longitude of welt location
(degrees/minutes/.seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Format on Deseription
fP
LOCATION SKETCII
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
cD C
1
1/40
0
Q
11)O IlEREBY CERTIFY THAT 'FIRS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO$"STANDARUS, AND TIIAT A ('.OPY OF THIS RECORD I IAS BEEN PROVIDED TO TIIE WELL. OWNER
a-/ O
SIGNATURE OF PERSON CONSTRUCTING TILE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone]. within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and ral Resources - I ivision of Water Quality - Groundwater Section
Nagob(ti
���
(Ai
WELL CONTRACTOR (INDIVIDUAL) NAME Pint) ,Q f I,,,n��/ QQ'',��t '/ 2
WELT, CONTRACTOR COMPANY NAME-(jJlu nt ,ros V-'ea4-.p✓lY.-J) -. ___-..-PHONE #(61 4Ye 3/7o
SLATE WELL CONSTRUCTION PERMIT# i`C- ASSOCIATED WQfPERMIT#
(if applicable) (if applicable)
CERTIFICATION #
i. WELL. USE (('heck Applicable 13ox): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 heat Pump Water injection 0 Other 0 If Other, List Use
WELL, LOCATION:
Nearest Town:_G'- County
WDOOt
Street Name, Numbers, Community. Subdivision, lot No., Zip Code)
3. OWNER:
Address -y(p-� M
(Street or Route Nol
Qnban NL ZR 11,C.
State Zip Sty or Tumor. ('ode
—9'03R
Area code- Phone number
4. DATE DRILLED_-2*0 & -- -
5. TOTAL. DEPTH: .52_c'
I V,CI U'I:I t Din" 4( I. I,' l i In,r. t l.1 i , vi.0 ( 1 \,n LI'
7. STATIC WATER LEVEL Below Top of Casing: / Oa FT.
I Lse "a" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminals actor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): (�Q_-. METHOD OF TEST t oc -S
l0. WATER ZONES (depth): �s
L 54-e phe s
II. DISINFECTION: Type-- f-fr/T
12. CASIN(i:
Depth
From D _ To 2.0 Et
From To Pt
_ From To-......1[
Diameter
/ Il
Amount
Wall Thickness
or Weight/Ft, Material
L
1 3. (TROUT: Depth Material�"'I.
0 From . ToZQ//
Ft. C einE
From To
4. SCREEN: Depth
From To
From To
5. SAND/GRAVE(, PACK:
Depth
From To
Ft.
Diameter Slit Size
Ft. in. in.
Ft. in. in.
lit.
From To Ft.
16. REMARKS:
I DO IIEREBY CERTIFY 'FIIA' FIBS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSIRL('TIONA$ ANDARDS, AND THAT A COPY OF TEES RECORD I IAS BEEN PROVIDED TO THE WELL OWNER
Method
/ 0P
Material
Size Material
Topographic/Land setting
❑RidgeEaS e ❑Valley ❑Flat
(cheek appmpriate box)
Latitude/longitude of well location
(degreesminutesiseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check hex)
DEPTI I DRILLING LOG
From To Formation Description
0,
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. o
0
c
0
I
r� --
o ! C-
SIGNATURE OF PERSON CONSTRUCTING TILE WELL.
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

o 3 r 4I
WELL CONSTRUCTION RECORD
North Carolina - Depanment of Environment and Naf-
tt�uraalResourc�s - Division of Water Quality - Groundwater Section (/
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 'C� ser J.✓_ .I/� CERTIFICATION # 335
WELL CONTRACroRCOMPANY NAME areff/e. &TDS Dieu c-rJMpPHONE #fRM&y8-3/70
STATE WELL CONSTRUCTION PERMIT# NO -2-- ASSOCIATED WQ PERMIT#
( if applicable) (if applicable)
I. WELL. USE (Check Applicable Box): Residential If--Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Hcat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: chat_
County
l49-tomaod
Streel Name. Numbers, Community. Subdivision, An No.. hip Code)
3. OWNER: ge4 Uth- /'8r,tA��-JSt p
Address �Q�-,__,Q(5/vklw•e _
(Street or Route No.)
M S •3 5&D
State hip Code
(G_ 54 tEL y 9 3 2
Area code- Phone number
4. DATE DRILLED 1'/ � /a
7
TOTAL DEPTH: 2
w)I:C VEIT. ot.m nrr I.cictvi..((sr, rl
STATIC WATER LEVEL Below Top of Casing: 2C7___ FT.
(Use it Above Top of('asingl
h. TOP OF CASING IS / FT. Above Land Surface*
Fop of casing terminated at/or below land surface requires a
Topographic/Land setting
❑Ridge IMpe ❑Valley ❑Flat
tcheck appropriate box)
Latitude/longitude of well location
(degreesiminutesiseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Fojntption Description
o c t
51,
variance in accordannje with 15A NCAC 2C:.0118.
9. YIELD (gpm): ha— METHOD OF TEST 2 /-lo°&5
it). WATER ZONES (depth): 7 yS
I I. DISINFECTION: Type-..
12. CASING:
Depth
From
From._ To
.
Front To
13. GROUT: Depth
From__ _ To. -
From To
14. SCREEN: Depth
-tTH .. Amount
Wall Thickness
Diameter or Weight/Ft. Material
Ft. 6" _1V (✓
Ft.
Material Method
Ft. :Men_
Ft.
Diameter Slot Size Material
Iron: _ To Ft. in. in.
From To Ft. in. in.
I5. SAND/(GRAVEL PACK:
Depth
From To Ft.
Size Material
LOCATION SKETCII
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road names. 0
From To Ft.
16. REMARKS:
i DU I IERF.UY CERTIFY TI IAT'CIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONS9RU('T!Ogt SnANDARDS, AND T!IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI fE WELL DATE
0
r;_
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

‘,-; 3 u ti 4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) I
Vitt!. CONTRACTOR COMPANY NAME 6 re-ent
CERTIFICATION it 355Y.
as 4- nimp _ PHONE ft 41/2 5- 30
STATE WELL CONSTRUCTION PERMIT# pi, 0 2- ASSOCIATED WQ PERM in
i if applicabie) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public D Industrial 0 Agricultural 0
Monitoring 0 Recovery D Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town:
91e iretheit County4990(
(Street Name, Numbers, Community, Subdivision, icit No., Zip ('ode)
0WNFR:jQA 6u, Lit -
Address _. P4 d-
(Stret3eir Route No.YLq)
AO_S 1- C--
City or Town State
S2s$
Zip Code
kren code- Phone number
4. DATE DRILLED 1 70 -I, 0 ‘r.
5. TOTAL DEPTH: 2'85
c- 4,c I NO
7. STATIC WATER LEVEL Below Top of Casing: 2_D
Use "4" if Above Top of caking)
H. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C .0tis.
9. YIELD (gpm): A51METHOD OF TEST 7— /240(-42-3
10. WATER ZONES (depth): . 7.4.5
I DISINFECTION: Type
I 2. CASING:
i
FT.
Depth Diameter
From 0 To
From Ft.
Amount
Wall:thickness
or Weight/Ft. Material
Sted
FromTo Et.
13. GROUT: Depth ).Material Method
From .ro j.-0 Ft. Cern ea.+
To
14. SC R El tlC: Depth Diameter Slot Size Material
From To F1. in. in.
From _ To - Ft. in
15. SAND/GRAVEL PACK:
Depth Size Material
Top
Front To Ft.
From To Et.
16. REMARKS: _
Topographic/Land setting
DRidge DSIope OValley lariat
(check appropriate box)
Latitude/loneitude of welt location
(degreesiminutes/seeonds)
Latitude/longitude sourcer0GPSOTopographic map
(check box)
DEPTH DRILLING 1.06
From To Forma on Description
JLibI251
LOCATION SKETCI I
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1/40
DO i [ER EBY CERTIFY TI EAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE W'ITII 15A NCAC 2C', WELL
CONSTRI1CTION ANDARDS, AND TIIAT A COPY OF THIS RECORD I IAS I3F.EN PROVIDED TO TIIE WELL OWNER
a_
12 -o
SIGNATURE OF PERSON CONSTRUCTING TILE WELI. 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

ti v V V
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat rail l Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) CERTIFICATION#
WELL CONTRACTOR COMPANY NAME 6a-ent &eaS`WO 4- J-/(!M-P __PHONE #i6'2A6 Ye;30J
STATE WELL CONSTRUCTION PERMrr# _ , Q Z.—_ -__ _. _ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WE1.1. USE (Check Applicable Box): Residential P-Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Beat Pump Water Injection 0 Other ❑ If Other, List Use
2. W111.1. LOCATION 'I�
Nearest Town:_—
County. QCXA
{Street Name Numbers. Community, Subdivision, lot No., Zip (ode)
3.OWNER: EddieNe6ee
Address _97&E4(j l
Street or Route c No. I i(�rfle.l3erx.c�� s
4
5
7
S
1(1
use
City orlbwn State Zip Role
(S7$- Ws7-43ss
Area Bode- Phone number
DATE DRILLED_ 1-12. -o 6
TOTAI. DEPTII: Z OS
IVH:C \1'.il REP! ni! I.8I8!i8i. V. i.I I \'I.1, 11 1J1
STATICWATER LEVEL Below Top of Casing: 2-0_ _ FT.
Lse'- if Above Top of (':ssing; •
TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or belon land surface requires a
sariance in accordance .ith ISA NCAC 2C .0118.
YIELD (gpm): Z,2 __. METHOD OF TEST 2-MN-Xi
WATER ZONES (depth): /65-
1 I. DISINFECTION: Type... f('- _ - Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Steel
From J O To q � Ft. 6 G /
From To Ft.
From To I't.
13. GROUT: Depth Material
From QTo Zi? FL Ce/flet
From To PI
Method
Topographic/Land setting
❑Ridge JZSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreesvminutesiseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTI' DRILLING LOG
From To Formation Description
o' y&'
CEP - 2-05T1
LOCATION SKETCII
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
14. SCREEN: Depth Diameter Slot Size Material
Prom Tu Ft.in. in.
From To Ft. in. in.
15. SAND/GRAVEL. PACK:
Depth Size Material
From To Ft.
i
1
j
C-
Gtp
CD
0
From To Ft. t
irs. REMARKS:
! DU I IERE13Y CERTIFY TI IAT'11115 WELL WAS CONSTRUCTED IN ACCORDANCE W'ITII I5A NCAC' 2C. WELL
CUNSTRLL(IyON STANDARDS, ANT) THAT A COPY OF TI ITS RECORD IIAS I3EEN PROVIDED TO TIIE WELL OWNER
:3 -O (o
SIGNATURE OF PERSON CONSTRUCTING TIIE WELL. DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

Area code- Phone number
4. DATE DRILLED 6_ Z I -0
5. TOTAL DEPTH: S
ITS \VT!! U1.111 nt'I-I.VI 111Jt: WTI l'1 ii ,/11 1-�1
7
7. STATIC WATER LEVEL Below Top of Casing: tl _ FT.
I Cse "," if Above Top of Casing)
X. TOP OF CASING 1S /— ET. Above (.and Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpnt): 8 METHOD OF TEST_
10. WATER ZONES (depth): _ _ /4.51
J 3i'v 47,
WELL CONSTRUCTION RECORD
North Carolina- Department of Environment and Nat ral ResourlcI`e`s'- Division of Water Quality- Groundwater Section
+� Nab — q O
WE1.1. CO\"fRAC"tOR (INDIVIDUAL) NAME (print) Q(��)r'S. Wait
_/� 'n CN:RTIPICATIUO�//C`/��t7/0
WELL CONTRACTOR COMPANY NAME _CCeen.e.. R..Yos (N!'.ti6-�-(�tr�/nh_-__- PHONE It QZC.r G 78-3i%(
STATE WELL CONS'IRUC:'r1ON PERMI'IY# _Jw (7 _... ASSOCIATED WQ PERMED*
(if applicable) (if applicable)
I. WELL ESE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Usti
2. WELL LOCATION:
Nearest Town:_ • j vale County
.33.1
(Street Name, Numbers, Community. Subdi visioli I.ut No., Zip Code)
3. OWNER: Qbrr Shirks (degrees/minutesiseconds)
Address Z ,s t_Sf0 .S'-I Latitude/longitude source:❑GPS❑Topographic map
6DU) M n (Street or Row6A 34b24 DEPTH DRILLING LOG
e No.l (check box)
n \ rtow„ State Zip (de Front To For escription
(7°4 zvs-/l79 v /,
on D
_z' — zo51- ED ra4
Topographic/Land setting
❑Ridge ❑Slope ❑Valley tat
(check appropriate box)
Latitude/longitude of well location
11. DISINFECTION: Type_ }-3117J Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To 7,/ Ft. e, ft -PVC
From To Ft.
From _ To
13. GROUT: Depth Material Method
From ©__--To7 .__Ft. /11P rz y
From To Ft. _
14. SCREEN: Depth Diameter Slot Size Material
From To Et. in. in.
Frorn __ _ To _ , Ft. in. in. I
15. SAND./GRAVEL. PACK:
Depth Size Material
From To Ft_
From To Ft.
Ih. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at (cast
two State Roads or ('ounty Roads. Include the road
numbers and common road names.
r
I DO I IERFBY CERTIFY TTIA'f Tins WELL WAS CONSTRUCTED IN ACCORDANCE WITI I I5A NCAC 2C. WELL
CONSTRUCT' j STANDARDS. AND THAT A COPY OF THIS RECORD IIAS I3EEN PROVIDED TO TIFF WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI IE WEL.1.
4?-3-o
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
ri
tiJ J ,i 0
North Carolina - Department of Environment and I • tural (Resources(- Diirii
'n of WatereQuality-pGroundwater Section/�
w'ELL CONTRACTOR (INDIVIDUAL) NAME (print)inpbbl /t/ W�-6b(ben,
Silen1O/�a;RTIFICAATT�ION /#- Z'pp7ip ( 327
WELL CONTRACTOR COMPANY NAME �J%fti/ [l e Biw �"'" a (ben, - .-._ PHONE.. # tn2cy 6Vi3 ".3/i )
STATE WELL CONSTRUCTION PERMIT# _ / Y _ _._ _ . ASSOCIATED WQ PERMff#
l if applicabie) (if applicable)
1. WELL USE (Check Applicable Box): Residential CY Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 (scat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO:'.
Nearest Town: . _ cc - County e
( Street Name, Numbers. Community.
Subdivision, Lot No., Zip Cute)
3. OWNER: MarMti IC-U4,�/_ �
Address _�f-s— ti/earbtJC,t�ICir tt .
StrechL,U s4 j 4.1/ee ._—No4/ C- z7 I O
wax/
city or l'uwn Sate Zip Code
Area cook- Phone number
4. DATE DRILLED jej -2-I -O G
5. TOTAL. DEPTH: 9 DS (
')•u:c; �t�1a( u�: n( nt'i. (. s_i.iin��;\r,I.((', 'vi.'.;II x.:)i��
7. STATIC' WATER LEVEL Below Top of Casing: ,. d FT.
Csc "-` if Above Top of Casing, •
N. TOP OF CASING IS 1 __ FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD Of TEST 2--#0 (La
10. WATER ZONES (depth):
Topographic/Land setting
DRidge ❑Slope ❑Valley IC
I check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTI I DRILLING LOG
From To t For ation Description
11. DISINFECTION: Type._ Amount
12 CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From O To 1j9 Ft. _6
From To Ft.
(t
From To
13 (GROUT: Depth�, Material - al��Method
From 0 To?:[lt Ft.... Cem�l tet010
From To Ft. I
14. SCREEN: Depth Diameter Slot Size Material
From To Pt. in. in.
From To Ft. in. in.
15 SAND/GRAVEL PA('K:
Depth Size Material
From To Ft.
Front--�- To Ft. -
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at lea,�Lr
two State Roads or County Roads. Include the rerad
numbers and common road names.
c,
YD
0
cr.
1 DO I1ER EBY CERTIFY lliAl T111S WELL WAS CONSTRUCTED IN ACCORDANCE WITII IAA NCAC 2C, WELL
C'UNSTRIICTI , STANDARDS, AND TIIAT A COPY OF TINS RECORD I lAS BEEN PROVIDED TO TIIE WELL OWNER
g 3-0c
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. 072001

t) '
WELL CONSTRUCTION RECORD
North Carolina - Department of F:nvirontncnt and N. turat Reso1u'rccs/ Division of Water Quality - Groundwater Section
L/ �t
WELL CONTRACTOR (INDINIDIIAL) NAM/EE -(print) F�W�" t Webb-,,/__.pn/ _ ___ CERTIFICATION #2.11/6
WELL CONTR.AC IOR COMPANY NAMEC7reege_ t��5 ✓uefiCI`—✓rnP .---- PHONE # fY)v{�- 6 I$_3/7 0
spat) WELL CONSTRUCTION PERMITS/ ) ✓ D — _.., ASSOCIATED WC) PERMrr#
(if applicable)
(if applicable)
I. WELL. USE (Check Applicable Bus): Residential ''Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 ([cat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: //
Nearest Town: . // ,o S (-date County
wood
Street Name, Numhem Community, Subdivision, Ln No., Zip Cale)
3. OWNER: HI
itt
Address - i VIA or
(Street or Route Nu. 1
co.
JUL-
City or Town State
(G - 934/-7o2-r
LS7(
hip Code
Area aide- Phone number
4. DATE DRILLED b - 8-3'4.-_ --_
5. TOTAI. DEPTH: y%�f--
i. r)).rtl /,/-1- I.V L Trill_ U i-i I'� Y - 8:n I.e.—
7. STATIC WATER LEVEL Below Top of Casing: YID FT.
lsc "-" it Above Tup of Casing)
8. TOP OF CASING IS 1 FT. Above [.and Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ��w1''��'' ISA NCAC 2C .0118. �/,.y�� (
9. YIELD (gpm): _Z5 _ METHOD OFfTEST2T1w/�J
10. WATER ZONES (depth):
Li us
1 I . DISINFECTION: Type (J— - _ Amount
12_ CASING: Wall Thickness
Depth Diameter or Weight/Et. Material
From D To 92.— Ft. f' PVC -
From. _ To _ Ft.
From To -- Pt.
I - GROU- T: Depth Material , Method
From O_-_- To?s2.__ Ft. Ce/Ir�A� rJ
From To Ft. /
14. SCREE- N: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PA('K: ------
Depth Size Material
From. To
From To
16. REMARKS:
Ft.
Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley tartil
(check appropriate box)
Latitude/longitude of well location
(degrees minutes! seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTII DRILLING LOG
From To Formation Description
a- has, �i ✓1'�t.7!
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.
DU I IERERY CERTIFY 1l iAT'IlIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII ISA NCAC 2C, WELL
CONSTRIJ('TIoyN STANDARDS, AND TIIAT A COPY OF TILIS RECORD I LAS 13EEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI IE WEI.I. DATE
e•3-o
c.
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
34,157!14
North Carolina - Department of Environment and Natu_rJal Resources - Division of Water Quality- Groundwater Section
p
WELL CONTRACTOR (INDIVIDUAL) NAME (print) I I/li WN/CJLJ CERTIFICATION #,-QYO
WELL CONTRACTOR COMPANY NAME PAP . GY o4ent3 �PGI -IOf%Inp PHONE # eta 6 f & 3/7C7
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential OK-Municipal/Public 0 Industrial 0
Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
co
County LVOCC
mbers,
Community,""Subdivision, Lot No., Zip Code)
���,��
3. OWNER: */ Pedr//,
cL.
t 1
Address Z7Z1 AJ•As. yR IA'
(Street or Route No. ) po,i_, 3306
y �5/vfhouSP vf F'�
City or Town State Zip Code
( )- y/s-Obi 5-
Area code- Phone number
4. DATE DRILLED //-30 -o L
5. TOTAL DEPTH: y9S'
6. DOES WELL REPLACE I EXic,"rin;(; WELL? YES Li NO lU-
7. STATIC WATER LEVEL Below Top of Casing: (n 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 300 METHOD OF TEST JithiUrS
10. WATER ZONES (depth): we'
11 DISINFECTION: Type #Th
12. CASING:
Depth
From Q To Z7
From To
From To
Diameter
Ft. 6"
Ft.
Ft.
Amount
Wall Thickness
or Weight/Ft. Material
pvc
13. GROUT: Depth Material Method
From 0 To Z- Ft. LeinB/yf-- %p U
From To Ft. I
14. SCREEN' Depth Diameter Slot Size Ma erill
From To Ft. in. in. 7�I
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
Topographic/Land setting
❑Ridge ❑Slope ❑Valley rlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
FJorrtm/�aattiio{onn'Description
DEPTH
From To
27
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRU9tQON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
eurto,ria rr--- /2=6 L
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

33?O s
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources/��- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) gf G.41 Greed CERTIFIC�AATII,ON#�ZB�
WELL CONTRACTOR COMPANY NAME 6 I/t/&DQ lit -Merl «kf R4 P PHONE # pcpl 69B 3/70
STATE WELL CONSTRUCTION PERMIT# i 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Bunicipal/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: Clyde County f'TQ.(lLQexd
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Kicky r� ✓e
Address 2/8! JdlAd I. -It. La
tree; or Route No.)
M '1 ' Town Ste B,J(eq NC 2875/
re Zip Code
C r
(878)- 9C-4 3?8 f
Area code- Phone number I2
4. DATE DRILLED 8 J 0 -a i.
5. TOTAL DEPTH: .3 r/
6. DOES '4'ELI, REPLACE FX!S.l !NC; vtlr.' i 9 YES n NO V
7. STATIC WATER LEVEL Below Top of Casing: 90 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance is accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): y METHOD OF TEST 2IIIDCWS
10. WATER ZONES (depth): 45
Z(o5'
11. DISINFECTION: Type -Uri, Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. aterial
(o
C
From Q To y(i Ft. f'
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 2.0 Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
Method
Tole
Material
Cem tivF
Fromrop
y5'
Topographic/Land setting
❑Ridgepe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
tude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
To Formation Description
3Nsl %e
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.
0I
1Ir
t3
t
a.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STC ARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

From To
15. SAND/GRAVEL PACK:
WELL CONSTRUCTION RECORD
fi r flAe R.
6 ttf
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ,` 't'y R amp
# 2285(
WELL CONTRACTOR COMPANY NAME Greene gro �/Iees WEIR- PHONE # (or-q 6 V 9 :3/% 0
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
IYo v
ASSOCIATED WQ PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential lel MunicipaUPublic 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/yde—
County /44.41.00c4
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: 4104 tr7/Q,//et
Address 1/43OQ (,lance oue_P-d.
(Street or Route No.)
Clyde. NC. L8724
City or Town State Zip Code
(Sea- 900'/9/S
Area code- Phone number
4. DATE DRILLED g /%-0(e
5. TOTAL DEPTH: 505 '
6. DOES WF.L1. REPLACE: ItKN.! !NU WELL? YES L NO r
7. STATIC WATER LEVEL Below Top of Casing: 4/ 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /5 METHOD OF TEST Z h w i
10. WATER ZONES (depth): 39S '
9 I
11. DISINFECTION: Type /lt»/' Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0To f 0% Ft. P "
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From (i To 2-0 Ft. Ceres % p
From To Ft.
14. SCREEN- Depth Diameter Slot Size Material
From To Ft. in. in.
Ft. in. in.
)01/C
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topogra is/Land setting
❑Ridge ni 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 ' /09'
>08' ,%s' ife
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ST1\NDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
OAWst �p f ae> ./ 9-Z7-0
SI NATURE OE PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na ural Reso aces - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Ise .►J(/ irevil CERTIFICATION # .335Y
WELL CONTRACTOR COMPANY NAME 6 rf.Ene • tosidieis [&ei/4 Arai° PHONE # le2$ 64'8 S/9a
STATE WELL CONSTRUCTION PERMIT# / 7 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ir MunicipaUPublic 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO n:�
Nearest Town: :IJIe. y Ql'ey County fi,IIJW
r
(Street Name, Numbers,�Community, Subdivision, Lot No., Zip Code)
/n
3. OWNER: /"Mt{ I -I ail /
Address //pJ ' ,Jo ay Gate £/t--
(Street e:�Rgyte No.)
jute/al(j 9qi Z
City or Town State Zip Code
(Qi>- 95120414,9
Area code- Phone number
4. DATE DRILLED 012 ,D 6
5. TOTAL DEPTH: OO,y—
6. DOES 1i'ELl. REPLACE Ev !Si !NU \q;El I o Y rl NO
7. STATIC WATER LEVEL Below Top of Casing: / a FT.
( Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface"
*Top of casing terminated at/or below land surface requires a
variance in accords ce with 15A NCAC 2C.0118. dun
9. YIELD (gpm): METHOD OF TEST 2IIwrn
10. WATER ZONES (depth): 6 90
11. DISINFECTION: Type / 17I
12. CASING:
Depth
From 0 To GS Ft.
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 2.1) Ft.
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
,52leel
Diameter
6 it
,Jvlaterial
tmtA
Method
Top
Slot Size Material
in.
in.
Size Material
16. REMARKS:
,Topographic/Land setting
HRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Forma 'on Description
DEPTH
From To
' -705'
pi vie
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIODYSTANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
��ainta
n 1--(1.0 cr3 y-2T-66
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 6,-piA,('re eat n/� CERTIFICATION # 2285
WELL CONTRACTOR COMPANY NAME C (rime 6 o'Ie/S well d /�iorp PHONE # B2S 6V S 3/7o
STATE WELL CONSTRUCTION PERMIT# /V D Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: I I'
Nearest Town: Clyde County 11721/Weal
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: John t3U!9qIit-
Address ZIS Wade aui min 4(.
• (Street or Route No.)
W/upbesinN.e ,IC- 2g2S b
City or Town State Zip Code
(828)- 9sz - /1070
Area code- Phone number
4. DATE DRILLED 9;6-O 4O
5. TOTAL DEPTH: lVi'
l 1. DISINFECTION: Type
12. CASING:
6. DOES \\/ELL. REPLACE EY!S'! !NC: WEL! ? YES n NO kY
7. STATIC WATER LEVEL Below Top of Casing: ZO 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 .8118.
9. YIELD (gpm): .3 0 METHOD OF TEST 2.Hour5
10. WATER ZONES (depth): /00'
!Lo u'
�(rid Amount
Wall Thickness
Depth Diameter or Weight/Ft.t ri Ft. 1
From To 9 7 Ft. !O
From To Ft.
From To Ft.
13. GROUT: Depth Material vlethod
op
From 0 To 20 Ft. GeA1e44
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:
Topograp�hic/Land setting
❑Ridge BSlope OValley ❑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 Fo ation Description
- &r
LOCATION SKETCH
Show direction and distance in miles from at le st
two State Roads or County Roads. Include th ad
numbers and common road names.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOI/LSTANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
C •--) 947-0L
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat�yJ;'alResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) kobll,(/I/ �Q
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT# /y b Z ASSOCIATED WQ PERMIT#
(if applicable)
1
(if applicable)
CERTIFICATION # 29/p
PHONE # (8 6 y8 3/70
WELL USE (Check Applicable Box): Residential CVMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
WELL LOCATION:
Nearest Town: (,(9a.(,nejui//t County HagWaxl
(Street Name, Numbers,ebn (,Q,n
Community, Subdivision, Lot No., Zip Code)
3. OWNER: „.5 ila(le)
Address 3911 Lea(/lsy C;/-.
�r((Street orRouteto No.)
latn fJ- .�38 03
City or Town State Zip Code
( - &48-13s3
Area code- Phone number
4. DATE DRILLED - B .�
5. TOTAL DEPTH:
6. DOES WELL. REPLACE EX!SL !Nv; W EI i ? YES rL3 NO
7. STATIC WATER LEVEL Below Top of Casing: 900 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): (9 METHOD OF TEST 2 i4eu/ S
10. WATER ZONES (depth): 14,5
//95'
11. DISINFECTION: Type /-/TN Amount
12. CASING:
From
From
From
13. GROUT:
From 0
From
14. SCREEN:
From
From To
15. SAND/GRAVEL PACK:
Depth
To
To
b
Depth
To S / Ft.
To Ft.
Ft.
To
Depth
To 2-0
Depth
Wall Thickness
Diameter or Weight/Ft. Material
6" pvc
aterial
Ft. rein '
Ft.
To Ft.
Ft.
Method
Top
Diameter Slot Size Material
in. in.
in. in.
Size
From Ft.
From Ft.
Material
Topographic/Land setting
ORidge ❑Slope OValley fi3Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
n' 5i ' Clay,
5zr 11(•.SI 6rani tt
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STBr1QDARDS, AND THAT
A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATUREPERSON7 1
CONSTRUCTING THE WELL DATE G
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME�'pp'rint),
WELL CONTRACTOR COMPANY NAME L7ree
!Resources - Division of Water Quality - Groundwater Section
CERTIFICATION # 2 y/8
c+':/k�•s w�� d— Oni0 PHONE # &2�) 698:3/9
STATE WELL CONSTRUCTION PERMIT# i7 o 4 ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
I. WELL USE (Check Applicable Box): Residential lY Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest TownfeSU6{lt County,
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: k..cue& p cc /li
Address 145 N Ma,X s7
(Street or Route No.)
butt/4AelOa/le- /uc, Z879.6
City or Town State Zip Code
(828)- 952-D307
Area code- Phone number
4. DATE DRILLED 4 //-o (e
5. TOTAL DEPTH: 305 I
6. DOES WELL RFPLACIr t !NC; W ELL? YES L] NO la"
7. STATIC WATER LEVEL Below Top of Casing: / 00 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /2- METHOD OF TEST 2 ykurs
10. WATER ZONES (depth): ) $5 r
I I. DISINFECTION: Type fin/
12. CASING:
Amount
Wall Thickness
or Weight/Ft. Material
PVC
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.
Depth Diameter
From 0 To /13 Ft b (I
From To . Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 10 Ft. CEA ext. To p
Topographic/Land setting
❑Ridge Qlope ❑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
D' /23'
Izy' - .3us'
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION.SYANDARDS, ANDTIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
// X /di^-)
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

'if
4
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) r((Q,1 (Jrtene- CERTIFICATION#zzett
WELL CONTRACTOR COMPANY NAME ` reeve ratlteyj Lct/L P(/rilro PHONE #g3a698,3/90
STATE WELL CONSTRUCTION PERMIT# NO Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Lr Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other O If Other, List Use
2. WELL LOCATION:
Nearest Town: C.Lutt County HQ!/p�acaL
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: ad 20fMan.
Address /3/ gllorT Oaks+
«Street or Route No.)
WilliaS Wilt nlC Z876
City or Town Statf Zip Codc
(S8- Moir 03 6 /
Area code- Phone number
4. DATE DRILLED B l.5 -0 (o
5. TOTAL DEPTH: 905'
6. DOES WELL REPLACE Lvl l !NU WELL? YES L NO L'
7. STATIC WATER LEVEL Below Top of Casing: ih D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TEST 2 Hours
10. WATER ZONES (depth): 3y-5
11. DISINFECTION: Type /4 TR
12. CASING:
Amount
Wall Thickness
Depth Diameter or Weight/Ft.
From b To /09 Ft. j'
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 To 20 Ft. Cement
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.
'tire
�v ethod
/of
From To Ft.
16. REMARKS:
Topographic/Land setting
❑R dge 2Slope OValley OF1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
D' /o'i'
/ 08' 905' ▪ i▪ nanrt-e,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
£ C r� 9-2.9 vc
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

Depth
To b R
To
To
13. Depth
To
To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na I' I,,e�,, bbIy�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �b/ti wn
WELL CONTRACTOR COMPANY NAME 6 reene g/PN>e/s Wed of Pump
STATE WELL CONSTRUCTION PERMIT# /y O2. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1 Resources - Division of Water Quality- Groundwater Section(
CERTIFICATION #2TI8
PHONE # Oka 6V8-3/2O
1. WELL USE (Check Applicable Box): Residential al/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:JA,2040e..$0 t /1.1.
County I4&. LO0o-
(Street Name, Numbers, Community, Subdivision. Lot No.. Zip Code)
3. OWNER: Le e 260
Address 5-2 fl (/ f]Of>41 cello Are
(4121ity or Town State
)- 4/50- v83 I
(Street or Route No.)
Ot tts %IC '752-O
Zip Code
Area code- Phone number
4. DATE DRILLED e -/9 -0 (o
5. TOTAL DEPTH: 72.5'
6. DOES WELL REPLCEEXISr1NC;PW;r.iiv YES Li NO Y'
7. STATIC WATER LEVEL Below Top of Casing: y 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): f/Z METHOD OF TEST 2 Hours
10. WATER ZONES (depth): 32,5
923'
11. DISINFECTION: Type i %ii Amount
12. CASING:
From Q
From
From
GROUT:
From Q
Wall Thickness
Diameter or Weight/Ft. Material
Ft. (O" pvc
Ft.
Ft.
Material Method
Ft. Cemen7L Top
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in. -
Size Material
Topographic/Land setting
❑Ridge ❑Slope OValley I/7Ffat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
7a5'
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.
tri
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION TANDARDS, AND TIIATT A�COPY OF THIS RECORD HAS BEEN PROVIDED TO THE/HWELL�OWNER
wvta as rsl C4a.4QA'l• > 7 1-2 // -Q it
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

4r
tJ `_.����•
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources /--Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �b//I, Webb CERTIFICATION # 2q/R
WELL CONTRACTOR COMPANY NAME 6 !cede tro#e rs well cl- Ain?PHONE # etas)bt(B 3/70
STATE WELL CONSTRUCTION PERMIT# )'I 01— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential 'Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: t ue ynt-5"1(1-e,
County 11 Gtll1,uaat
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: TaI», �AIO(/4- (on QCS� A--
Address/l Address )4ckkerfy
(Street or Route No.)
W644t5ulilt MC 2878c
„city or Town State Zip Code
(€2- 73 V .59/3
Area code- Phone number
DATE DRILLED // ZZ
4
5
6
7
TOTAL DEPTH: 2 b.5'
1)OLS WELL REN AC')., F.XIS I !Nu: WELL? v Y ES Li. NO re -
STATIC
WATER LEVEL Below Top of Casing: 5 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): z a METHOD OF TEST Z WOO I S
10. WATER ZONES (depth): 2 t/ 15 i
LOCATION SKETCH
Show direction and distance in miles from at leas
two State Roads or County Roads. Include the ro
numbers and common road names. 'C
CI
•
•
1
6I
ID,
Topographic/Land setting
'Midge ❑Slope ❑Valley CdFI'at
(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
6 ' 265' Trani it
11. DISINFECTION: Type !'T 74
12. CASING:
From 0
Depth Diameter
To 6 / Ft. 6 rl
From To
Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft. Material
pve
13. GROUT: Depth Material Wth(hod
From 0 To 10 Ft. Caraitn-r J O?
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO?S/3TjANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
awuaa_a Cato-n--1 9-27-0 c,
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

04
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources
�,-LDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) /2D 6) . (tJ G06 CERTIFICATION # 21//28
WELL CONTRACTOR COMPANY NAME G reenv a o7+ters tAlel/' /29Y4'J PHONE # (AS b4Q 3I7O
STATE WELL CONSTRUCTION PERMIT# /O Z ASSOCIATED WO PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ult Municipal/Public 0 Industrial O Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: W(gne,SD(/bt CountyLartd,
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: {../UIOL NPnOtgFei
Address PO AOX (761
(Street or Route No.)
/-ta.gyle Vdey iut Z0751
City or Town State Zip Code
(2zS- bz1-b90 .
Area code- Phone number
4. DATE DRILLED 7-2.1 -
5. TOTAL DEPTH: g 05
6. DOLS 'VEL!. REPLACE ! _v!N HNCi \Vrt i 9 YES I-1 NO Lr
7. STATIC WATER LEVEL Below Top of Casing: I O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TEST 2 14 U/ S
10. WATER ZONES (depth): y65 '
714,5'
1 I. DISINFECTION: Type 1417/ Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From Q To `D% Ft 1p IIPVC
From To Ft.
From To Ft.
13. GROUT: Depth Material' Method
From 0 To 2-0 Ft. Ceine/y Top
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.
Topographic/Land setting
ORidge ❑Slope OValley Sect
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
0' 106'
/O71- $05'
ta
fie
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.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION ANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTION
_ ct 4.4 9 L7-ore
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso'urce_sI- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ICOQQUI it W('ih'Ib �/yY�p CERTIFICATION # 29/R
WELL CONTRACTOR COMPANY NAME &-e/�ene B164.04,S Cti 4 O4 1 PHONE # (B�) 648 3/0
STATE WELL CONSTRUCTION PERMIT# Igo o 2— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential EY 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:MGty51C volley County I4&IWOQJ
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 121c o-tct
Address *3.3 re
is
739 %
Area code- Phone number
4. DATE DRILLED B-' S5-- 0 le
5. TOTAL DEPTH: 325'
C. DOE.; \k'FL!. REP!..M.' EXIS! !NG \A,Lit? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: b 0 FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /7 METHOD OF TEST 2. ?lours
10. WATER ZONES (depth): 3C.5'
� ! t r Route No.)
ytl 51c- rill,
2675/
C'i or Town State Zip Code
11. DISINFECTION: Type HIE
12. CASING:
Depth
From Q To y 6 Ft.
From To Ft.
From To Ft.
13, GROUT: Depth Material Ivigthod
From 0 To_ (2, Ft. C.ememh iop
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.
Diameter
to
Amount
Wall Thickness
or Weight/Ft. Material
PVG
From To Ft.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 12 at
(check appropriate box)
Latitude/longitude of well location
Latitude/long
DEPTH
From To
I7' 326'
(degrees/minutes/seconds)
tude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
rahIle
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
CONSTRUCTIODi'3TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Rn?A o& ;G�LQLfdf� J
9-27-0 c
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) QobtA, Webb CERTIFICATION#24,1
WELL CONTRACTOR COMPANY NAME 6 reene sern4'hers Wed ci bump PRONE # (Nth 649 3/70
STATE WELL CONSTRUCTION PERMIT# / -I d L ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 12/ MunicipaVPublic 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT N: '/'Q /I
Nearest Town: t & o Y tt e*j County lietipooal
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: a/ ahlt
Address 333 (ails
rd. Coker
(Street or Route No.)
/l a-5i e )(alley A/c 26751
City or Town to Zip Code
(�- 23f1- Qb 9
Area code- Phone number
4. DATE DRILLED g 9/ -a (o
5. TOTAL DEPTH: Jo O5 '
6. HOES WELL. REPLACE 1:v!S'(!NU 'N E' i ., YFS f,_1 NO (y
7. STATIC WATER LEVEL Below Top of Casing: /20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S % FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. 9. YIELD (gpm): .3 METHOD OF TEST 2. yours
10. WATER ZONES (depth): 45'
1 l . DISINFECTION: Type f i 01 Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From fj To 5S Ft. �' aV L
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From D Z To O Ft. Cemen# To p
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.
Topographic/Land setting
ORidge laThope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
Or SS'
59' bo5' aka , 2
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0
l6. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTIOANDARDS, AND TI(AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a,ncaaa J (0.i4e-)SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
9'?-d6
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) QObi A�wp/"pbb CERTIFICATION# 2949
WELL CONTRACTOR COMPANY NAME Li rtene 6/o* e s uiw' Rm-o PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ) -r 0 ASSOCIATED WQ PERMIT#
(ifapplicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential 10/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: 1-
Nearest Town: Can -ion County flay Weal
(Street Name, Numbers,mb�sCommunity, Subdivision.; Lot No., Zip Code)
3. OWNER: Chun lea Lanni05 (degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
-(Street or Rout No.) (check box)
DEPTH
Address /'S5 _6k/t pT Spaik
W Gynes 414e NC- 26 78 6 DRILLING LOG
Topographic/Land setting
❑Ridge ❑Slope DValley 03'rat
(check appropriate box)
Latitude/longitude of well location
City or Town State
($Z8- 5027975
Area code- Phone number
4. DATE DRILLED g :3 .0
5. TOTAL DEPTH: 2 135'
6. : )TOES \V ELL DEDI ICI: EX!Si 1NU \krEL I yES Li NO ti✓ _
7. STATIC WATER LEVEL Below Top of Casing: ti FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): / / METHOD OF TEST 2 Hoofs
10. WATER ZONES (depth): 245
Zip Code
From To
0' Zo,
Z/' zS5' e
Formation Description
11. DISINFECTION: Type N 77-1
12. CASING:
Depth Diameter
From b To ZO Ft. 61 t PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Iyjjhod
From 0To 20 Ft. Ctme'f lop
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.
Amount
Wall Thickness
or Weight/Ft. Material
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
0.
1
W
O '
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCT( TANDARDS, AND Ti IAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
afregacc (s) 11-27- o C.
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

e5 a Ki`t+'
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality- Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) int an 6ree e. CERTIFICATION# 22 &S
WELL CONTRACTOR COMPANY NAME Greene 8 r o+hers low 4 Panp PHONE # (13?$I R 3/9 0
STATE WELL CONSTRUCTION PERMIT# l qOy ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential GY 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: GOO top
County Haywood
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3.OWNER: HoOlatn Pg2 s /John0-4241,e.Flk
Address ZZ51 OMoaUcz,ndap(
(Street or Route No.)
Aesufl/ e Luc. 2878
City or Town State Zip Code
(f32,)- 1152-1/4/(/7
Area code- Phone number
4. DATE DRILLED 9-22 -0 le
5. TOTAL DEPTH: 265r
DOES WELL E I TIN _ W I YES i NO ram✓
F.. >C.:S ..YS_. C. h Y_. L
7. STATIC WATER LEVEL Below Top of Casing: y 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 with 15A NCAC 2C .0118.
9. YIELD (gpm): €/ D METHOD OF TEST 2 Ilows
10. WATER ZONES (depth): /&55 r
is -
I1. DISINFECTION: Type H rFY
Amount
12. CASING: Wall Thickness
Depth D/ia_meter or Weight/Ft. Material
From 0 To // / Ft. (' r PVC -
From To Ft.
From To Ft.
13. GROUT: Depth Material- , Method
From 0 To 2 0 Ft. C etnea Mg
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
Q1Fidge ❑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 Fo ation Description
b' //r •
//2' Zk5' tra ,fe
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
r:r.r
ivC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIO]' TANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/Z41lo.912.. 02 -n-- 9-27.O10
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

9LT., 0 3,
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources, Division of Water Quality - Groundwater Section
Q
W E LI, CONTRACTOR (INDIVIDUAL) NAME (print) Perth', �✓i 2elnO r e, CERTIFICATION # .7W2—
WELL CONTRACTOR COMPANY NAME 6reea a- f;l hers Were 4 Pimp PHONE # (* eye '3170
STATE WELL CONSTRUCTION PERMIT# /V0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
2.
WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
WELL LOCATION: •
I��''/ /� �/J
Nearest Town: Notre it alley County rl/L(,6(49 t%C.
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3 OWNER: Tara Al �m►Struoior'
Address 13 p Naafi rrq ✓L-
w APsv • ISgee or Route C) 257 5
City or Town State ��Zip Code
(8zs) 1.3y. $9/5
Area code- Phone number
4. DATE DRILLED 7-3I -0(0
5. TOTAL DEPTH: 2051
6. DOES WELL REPLACE u.v(c.! !NU WELL_' YES r, I NO
7. STATIC WATER LEVEL Below Top of Casing: 2 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9 YIELD (gpm): 7 fl METHOD OF TEST 2 "huts
10. WATER ZONES (depth): / k35
11. DISINFECTION: Type Fiji} Amount
12. CASING: Wall Thickness
Diameter or Weight/Ft. Material
From 0 5 6 ` Put
From To
Depth
To O Ft.
Ft.
From To Ft.
13. GROUT: Depth
From 0 To ZO Ft.
From To Ft.
14. SCREEN- Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Material
Ceme4f
�cthod
(0
Topographic/Land setting
l kidge 0Slope ['Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreeslminutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
51' Zo5' ("at if°
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. - -
• 1E00
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIONYS�'['ANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
O'vuaa a orj,(,ga>J 2,9 -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

WELL CONSTRUCTION RECORD
o01 u
\onI Carolina - Department of En.monment and Nat(?ral Resources Division of Water Quality - Groundwater Section
I:
...- -
WLI (O\'1'KAC I'OK(1\nI VIDI AL)\AMF, (print) - Qbl /L Wes10. L- --.--- CERTIFICATION
NAEl1.( O\ I RACFOR COMPAN\NAME C(eent 66+ to5 Weil -Amp PHONE #6 e73170
5'GY1F: WELL C:ONS7RLC1'lo\ PERMI'I'k /�0 __._.. _ _ ASSOCIATED WC) PF:RMrfk
(if applicable) (if applicable)
1. WELL USE (('heck Applicable i3ux): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2 \vN1.t. LOCATIONj:
Nearest Town: tWt 19.(4 /145u ase County
Saten Name- Numhers Community, Subdivision, tut No.. lip Cult)
;. OWNLR:J/f'n. p Ie_v ut/dens
Address 335t. W ood
,street or Route No.
.y YSuw'-L AJ_C, z878 rd
( it. o-' i -n State Zip Code
eta,- 924 -7/B@
1ma node I'hncc nmtiber
i. i):ATL DRILLED _e
TOTAI. DEPTH. zz-5
\1. I..I- 1I Pi ( I \_:• In. _ \A 1.1-I .r V I-S 1 I NO
7. STATIC WATER LEVEL Below Top of Casing: _AliFT.
it sc" it Above Top of ('asingl
it TOP ()I: CASING IS l FT. Above land Surface`
*Fop of casing terminated at/or below land surface requires a
variance in accordance with 15A NC AC 2C .0118.
9. YIELD uzpm)c JZ __ METHOD OF TEST
IL`- WATER ZONES (depth): ZDS.
2 Rears
. _ 1)1SINFECTION: Type_ /-E-TH Amount
CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
from 0 To / Z-7 Pt. 6 '' P✓C
iiron To Ft.
From To Ft.
.?_ GROLT' Depth ,,Material Method
i-rom- O To Ft. eenea.+ To p
Front To Et.
_-- S( I2LLN: Depth Diameter Slot Size Material
iron: To 1't- in. in.
iaor.: To Ft- in. in.
SAND GRAVE1. PACK: -----
Depth Sic Material
From To Pt.
Topographic/Land setting
❑Ridge ❑Slope [Valley 19Vat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Form tion Description
2.7
$' G,r
LOCATION SKETCI1
Show direction and distance in milts from at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
N
m
t .
J
CD •
CPI •
ror,1 To Ft.
'.h. REMARKS:
1 DO IIEREBY C'ERIIFY IIlAIlI1IS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C', WELL
( ONS"I RU(YhtION STANDARDS. AND TI lAT A COPY OF THIS RECORD I1AS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE of PERSON consrRucTwG THE wEt.t.
001
0
fl
an
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

ej ':J ii 0 '3 J
2006 WELL CONSTRUCTION RECORD
N(tRRCatrt)iina - Department of Environment and N' ural Resources - Division of Water Quality - Groundwater Section
W EI 1 CONTRACTOR (INDIVIDUAL) NAME (print) fil k, U t/6b CERTIFICATION # 244 g
WELL CONTRACTOR COMPANY NAME _(]re4 ii s la -ALL /Dto.__W !.� ea* PHONE # (`C%$ :3 i70
S TA 1 E WELL CONSTRUCTION PERMIT# /7 0 Z-- ASSOCIATED WQ PERMIT# ---
(if applicable) (if applicable)
WELL. USE (Check Applicable Box): Residential Er-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. Witl ,I, LOCATION: •
Nearest Town: egile.S_Wia." County yo
(Street Name, Numbers Community, Su bdi vission, Iut No., Zip Code)
N 3. OWNER: Ty,. Y/etc. tD(JIiC�,E_CLJ
Address _ at/ L ILA we 0 CL Qd
(Street or Route No.) n 7
(:ity or Town State Zip Code
18- 4Zb-2/43'$
Area code- Phone number
4. DATE DRILLED_ ^g 'D_%_
5. TOTAL DEPTH: 3ZS
vUa'U-1.:l 01:UI r-I. LV(.I I*N. U E! !V l
7. STATIC WATER LEVEL Below Top of Casing:4,0 FT.
Use"-t 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
Topographic/Land setting
❑Ridge ❑Slope ❑Valley 12ffat
(check appropriate box)
I atitude/longitude of well location
(degrees:minuati(seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
variance in accordance with ISA NCAC 2C.0118. ---
9_ YIELD (gpm): JD METHOD OF TEST 9 44ut.S
!0. WATER ZONES (depth): 305
11. DISINFECTION: Type kry
12_ CASING:
Depth Diameter
From To ///40 Ft, %p
Erom To Ft,
From To
GROUT: Depth
From Q To2-t Ft.
From _.. To
SCREEN: Depth
From To Ft.
From To Pt.
13
Ia
15
Amount
Wail Thicknes
or Weight/Ft,
Material
PvG
Material Method
Tp r
Diameter Slot Size Material
in. in.
in. in.
SAND/GRAVEL. PACK:
Depth Sizc Material
i:ronr To Pt.
6'
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
m
O
CT1
Frain To Ft.
Ib. REMARKS:
l DO I IEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
('UNSTR(ES-ION STANDARDS. AND TIIAT A COPY OF THIS RECORD I IAS BEEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
8Zf-o6
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- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ?to
1. WELL CONTRACTOR:
i7ess-:c1K SotA7ets
Well Contractor (Individual) Name
C\�de 3a ecs SGt�
Well aNractor Compdry Name
STREET ADDRESS it-aR 5 Wti aZW
Rot St. ct.tsS77Nc a8'143
City or T&wn „ State - Zip Code
( bag r (o(a5- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#fdapplicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED a— 9-
TIME COMPLETED/7 3O AM Err rMp
3. WELL LOCATION: / ''//
CITY: /IAriV , Udiy COUNTY Arloa et
��
40
(Street Name. Numbers, Community, Subdirision, Lot No., Parcel, Zip Code) -
TlOGRAPHIC/ LAND SETTING:
ope [Valley ❑Flat ()Ridge ❑Other
(Check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: [ GPS °Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form 7not using GPS)
4. WELL OWNER
OWNER'S NAME RO�(O 1l Ci..fi I�cC,at]] �1
STREET ADDRESS f33a5 CL?eov no \'\vci
May be in degas,
minutes, seconds or
in a decimal format
Gtyde ,'ac. Qicla‘
Cigar Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: a O S /
b. DOES WELL REPLACE EXISTING WELL? ❑ NO Iq
c. WATER LEVEL Below Top of Casing: 7C) FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
. 'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD Wpm): 020 METHOD OF TEST .Q
324340
f. DISINFECTION: Type p' i(S Amount /6
g. WATER ZONES (depth):
Rom To From To
From To From To
From - To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From / To\LC FL (r %v pA Y
From To Ft. --raper
Rom To Ft.
7. GROUT: Depth Material Method
From 0 To `„}O Ft. C-tt 13t ?GU. CIS
From To Ft
From To Ft
8. SCREEN: Depth Diu er S of Size Material
From To Ft. in. h.
From To Ft in. m.
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 Fonnatici Description
i/` /)(lee` d, -le on
YG & of 6rrc,,. A
11. REMARKS:
-Regional-6#1ee
I DO HEREBY CERTIFY TWIT THIS WELL WAS COnbTRUCIED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCRON STANDARDS, ANC THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CE IFIEDD 'LL CONTRWTOR DATE
/ /
PRINTED NAME OF PERSON CONSTRU 1?NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7N5

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-
C&,aw4.) & 9Zdr
WELL CONTRACTOR CERTIFICATION #: 2-U3
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residentiallg Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
4. DATE DRILLED a•VatfinL 4 — 1(0 5
5. TOTAL DEPTH q OS I4./ ' 7o S-
6. CUTTINGS COLLECTED YES NOS
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOta
8. STATIC WATER LEVEL Below Top of Casing: .5:O FT.
(Use' . B Above Top o1 Casing)
9. TOP OF CASING IS / FT Above Land Surface'
'Top of casing terminated at/or below land surface requires a variance In accor-
dance with 15A NCAC 2C,Rua
10. YIELD (gpm)• d METHOD OF TEST 13
11. WATER ZONES (depth)-
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: ei A h TWO County: 14 I Lt CCJO ci cL
.. kt\.sayt `7-r ; _
(Road Name and Numbers, Conenun r or Subdivision and Lot No.) DRILLING LOG DEPTH
3. OWNER 7? rn14 t2A Y (Qi %iZ€Lt From To Fonnada Descrip on
Address (l fO l , e 0— `7 O O or P J (Oar.F�+t1
enR�r (StreetorNc o.) Q el1 q j _ / 9Q Mtcts:l 2J
Ail- /Lea _ant i
a17 At,11-L.
G-RAv/ it
City or Town State Zip Code
12. CHLORINATION: Type
13. CASING:
/4-T4-
Amount • v
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
Depth Diarneter or Weight/Ft. Material (Show direction and distance from at least two State
From f% To 76 Ft (oily"' f-21- 9-2-2 PUS Roads, or other map reference points)
From To Ft
From To Ft
14. GROUT:
Depttbvn Material Method
From i7 To Ft C QY^c° rn� 1.44
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:
RECEIVED
APR 1 2006
Asheville Regional Office
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C WELL pry' 'fifer Protection
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WECCOw iWA.
FOR OFFICE USE ONLY
Quad No:
„//are/op
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quality, Groundwater Section within 30 days
Serial No
GW-1 REV. 12/99

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # Z1-1,24n
1. WELL CONTRACTOR:
1��cc.ciA\k. So*JTecs
Well Contractor (Individual) Name
(�' \'de `..sn'.»jecs a' Son
Well ontractor Compahy Name
STREET ADDRESS 1.424R 5 We N aCA
Flo} 6 inetc A3C a 8143
City or Tann State - Zip Code
(8a8» (0(as- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#prapplicable)
DWQ or OTHER PERMIT A{if applicable)
WELL USE (Check Applicable 800z): Residential Water Supply ❑
DATE DRILLED / -jo —cC
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION: '/
CITY: liferyneri 0/4- COUNTY lierwood
(Ja�ch Coo.: Qjr
(Street Name. Numbers, Community, Subdivision, Lcr No., Parcel, Zip Code).. -
TOPOGRAPHIC / LAND SETTING
&grope ()Valley ❑Flat ❑Ridge °Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: °GPS ❑Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form snot using GPS)
4. WELL OWNER
OWNER'S NAME Cac \ 6oW.4 tto LLC
STREET ADDRESS (014%. CILVSCa &CCkC
May be in degrees,
minutes, seconds or
in a decimal format
k-Vn\nev:tte nic aaeraob
City or Tom State Zip Code
(Sae) Yell (E(c8
Area code - Phone number
5. WELL DETAILS: /) b r
a. TOTAL DEPTH: M1 J /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO nr
c. WATER LEVEL Below Top of Casing: SC) FT.
(Use'+- if Above Top of Casing)
d. TOP OF CASING IS �_ FT. Above Land Surface`
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / 3 METHOD OF TEST (t
324349
f. DISINFECTION: Type P` %IS Amount /
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Demeter Wei Mat
From / To 94 Ft. S I fir
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To `. 1O FL C f--Te3Pflt ?DU. Vice
From To Ft
From To Ft
8. SCREEN: Depth Diameter S'ot Size Material
From To Ft. in. M.
From To Ft. in. M.
From To FL in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
Frain To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
q6. cos
11. REMARKS:
Forrnatil Description
a%ef 41,"4 Jt A
irre n V..c
REL;EIVED
F , .',
TS3I 1�. V riLVQ
Aquifer Protection
1 DO HEREBY CERTIFY THATTMS WELL WAS CONSTRUCTED N ACCORDANCE Waal
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. NC THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG TURF OF CERTIFIED WELL C2 ' - •
/ Jo-6
DATE
/OM6` • foie err/A 4 rs
PRINTED NAME O PERSON CONSTRUCT'NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # fit{ fl,
1. WELL CONTRACTOR:
ecc,eve'H. 5aQyecs
Web Contractor (Individual) Name
C\ode &.ajecs Soc\
Well ontractor Corn Name
STREET ADDRESS 11-lfb£', rJ k+-1 Pock
Not <ngs7 A3Q a8"1M3
City or T State - Zip Code
(eat 1- totes- aoaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # if applicable)
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box):Residential Water Supply El
DATE DRILLED " 02 1 - C¢
TIME COMPLETED 3 it 30 AM ❑ PM
3. WELL LOCATION:
CITY: IAi.c.// rtesV WICWICCOUNTY /TWlu sad]
(h-.FIr3 St`-ti-a r. 1> /
(Street Name, Numbers, Cmnmunity, Subdesion, LC. No., Parcel, Zip Code)-
TOJOGRAPHIC / LAND SETTING:
�Clope °Valley ❑Flat ORidge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: °GPS Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form Inot using GPS)
4. WELL OWNER
OWNER'S NAME ii en earselie.vr
STREET ADDRESS f01 («vec ? CAn4 Read
eat\-.-.1 >v r Si i t
City or Town ' State Zip Code
(Re,(04b- o0q�1
Area code - Phone number
5. WELL DETAILS: �f fi
a. TOTAL DEPTH: t!C d c
b. DOS WELL REPLACE EXISTING WELL? YES ° NO
L4'
c. WATER LEVEL Below Top of Casing: 7 ( 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): (26 METHOD OF TEST
324344
f. DISINFECTION: Type PS Amount / V
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weigh Mat
From_, ToFt 6/y .M0)/ 7/G iG
From To Ft.
From To Ft.
7. GROUT: Depth
Material Method
From_D___To•O Ft. C,..-9—Thctitt Otatea
From To FL
From To Ft
8. SCREEN: Depth Diameter Sot Size Material
From To Ft. in. in.
From To Ft in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
F m To Forma&a Description
S 3 no.er () .den
5.3 ag, 6-ren`ie
11. REMARKS:
RECI
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. ANC THAT ACOPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OW R.
SIGNATURE OF CERTI ED 'W%'EELL CONTT�y- CTOR DATE
PRNTED t NAME OF PERSON CONSTRUCT: NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

G
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 43(4
1. WELL CONTRACTOR:
�ecc.eCc 'Ne4.tan `sa ecs
Well Contractor (Individual) Name
C\ yce 6Ctss 1ecs c So C\
Well Contractor Company Na
STREET ADDRESS \'VAR S - 1-\ls'y ao C'1
'Not etc .nc" PC 08'7 43
City or T 1/41 Stele -Zip Code
( 8as)- fobs- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID :6(if applicable)
STATE WELL PERMIT#Ofapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 7 S C
TIME COMPLETED / r t7 n AM ❑ PM (�
3. WELL LOCATION:�/fvi
CITY: 40pV UQ(KY COUNTY //dy,Anmd
S& A C-LL a L; t i ;: c_
(Street Name. Numbers, (community. Subdivision, La No.. Parcel. Zip Code)
TO GRAPHIC f LAND SETTING:
lope ❑Valley ❑Fiat ❑Ridge Maher
(check appropriate box)
LATITUDE '`_
LONGFTUDE
May be in degrees.
miram6 seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of eel must be shown on a USGS topo map and
attached to this form 1 not using GPS)
4, WELL OWNER
/t, . Q -
OWNER'S NAME 11)/ r71�-(
STR rT DRESS I 0- 25�, r red
City or own
r
State
( s2k>9?9— 4199
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: a 65-
o2X'7c2 1
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 50 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 1S I FT. Above Land Surface'
'Top d casing terminated at/or below lend surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): d METHOD OF TEST R.___
f. DISINFECTION: Type 0 v \S Amount l v
g. WATER ZONES (depth):
From To From
From To From
From To From
6. CASING:
To
To
To
Thickness/
Depth Darer Weight M edal
From }\ To ?e Ft t, 4 SnflI S
From To Ft
From 'To Ft
7. GROUT: Depth Material Method
From 0 To go Ft Cel-T1 Bak POLxCt
From To Ft.
From To Ft
8. SCREEN: Depth Diameter SttSize 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
1
.--11.-. REMARKS:
Formaticn Description
ONQC 13 r trio n
(scan ite
Tor
100 HEREBY CERTFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT COPY Or THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL NTR4CTOR DATE
neccsCK '1AQO.t1n6a3A1 C S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # r2t43(Q
1. WELL CONTRACTOR:
l7 eV cw. c '1kec An
Wen Contractor (Individual) Name
C\ y toe 5auziecs 4- So rl
W e8 Contractor Company N
STREET ADDRESS 4\PlP, S , 1-\Lay ao q
14ot t c :nq'.. NC 08'7 43
City or TOin Ste -,Zip Code
( Sea} fobs- a oa a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #fdapplicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT #(if applicable) —/
WELL USE (Check Applicable Box): Residential Water Supply py'
DATE DRILLED 3 —/-5/7:-
TIME COMPLETED / d 0 AM O PM l3-
3. WELL LOCATION:
CITY: Wa>/.rfci((C COUNTY //u,1/rv00d
Cro6 Ter- e%rr,re /ee!
(Street Name. Numbers. Community. Subdivision, Lot No, Parcel. Zip Code)
TO RAPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Otter
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑GPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME JC piC 14
STREET ADDRESS 30y - 14 c-I4 v.%eon L,)o•r
May be in degrees,
minutes, seconds or
in a decimal format
Gy'de_ , PC- Penal
Ci6jr or Tam State Zip Code
( 212$)- (a a'1 - $'l too
Area code - Phone number
5. WELL DETAILS: ^�S
a. TOTAL DEPTH: j
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 11
e. WATER LEVEL Belau Top of Casing: 4 O FT.
(Use'+ if Above Top of Casing)
d. TOP OF CASING IS t FT. Above Land Surface`
'Top of casing terminated afar below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): '- METHOD OF TEST R
)
f. DISINFECTION: Type 4.i\S Amount /.S
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: �amet Thickness/
From Jr-1 Depths
Ft. ea �er Weight
erial
From To Ft
From To Ft
7. GROUT: Depth �r Material Method
From 0 To PO FL Ce.`01 poistetk
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Sot Size Material
From To FL in. in.
From To Ft. in. in.
ROM To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
From To Ft
10. DRIWNG LOG
From To/(
Y
'I(, 3 6S
11. REMARKS:
Formatic n Description
ONES 13,cry�n
Cnar\,te
rV
J
0
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRI CIED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AN, THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
3--/s-G
SIGNATURE OF CE TIFI ELL CONTR ACTOR DATE
i)ecc.tK 'Neo.t' Sa'.s �c s
PRINTED NAME OF PERSON CONSTRUC 1'NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

LONGITUDE
a'
RESIDENTIAL WELL CONSTRUCTION RECOF,D
North Carolina Dewartment of Environment and Natural Resources- Division of Wat :r Quality
WELL CONTRACTOR CERTIFICATION #- ay34.
1. WELL CONTRACTOR:
Pkrrick' /44/1 &Wt., 5
•
Well Contractor (Individual) Name
C &c! c NSGt *PS $
Well tractor Company N
STREET ADDRESS J7 80 ( ij V 02051'
�o Sprrrny IV. Cp 02 87(l3
City or Tvfm J State
Zip Code
( Sa?)- 6 6C- (239_2
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID #(H applicable)
STATE WELL PERMIT/fib( applicable)
DWQ or OTHER PERMIT #('rf applicable)
WELL USE (Check Applicable Box): Residentel Water Supply Fy
DATE DRILLED 3- --CXo
TIME COMPLETED aC.O'O - A5I PMpI
3. WELL LOCATION:
CITY: CQt1koY'1 - COUNTY Ilay6storl
rh Q55 e �QnC
(Sweet Name, Numbers, Community, Subdivision, Ut No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 May be in degrees,
— minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Tographic map
(location of we/ must be shown on a USG Atopo map and
attached to this form IT not using GPS)
0. WELL OWNER
OWNER'S NAME L3 NO'c1 ()DCA& 3
STREET ADDRESS fb tbc,x to
tea- nest/:Ile NL a81'B
City ix Town State Zip Code
(eat >- mow
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:O5
b. DOES WELL REPLACE EXISTING WELL& YES O NO ®<
c WATER LEVEL Below Top of Casing: FT.
(Use "-Er it Above Top of Casing)
d. TOP OF CASING IS FT. Atlbve Land Surface'
'Top d casing terminated atlor below land Surface may require
a variance in accordance with 15A NCAC .0118.
e. YIELD (gpm): B METHOD OF *ST
f. DISINFECTION: Type P.; t t,S Amount e�0
g. WATER ZONES (depth):
From To From
From To From
From To
6. CASING:
From
To
To
To
Thickness/
Depth, tyigmeter lAj t
From l To a' Ft.4,// t
From To Ft.
From To Ft.
7. GROUT: Depth Material
�1
From 1 To 111 Ft. . r mo¢-
From To Ft.
From To FL
Materins
5 ee�
Method
Phu/ t
8. SCREEN: Depth Diam Ater Slot Size Material
From To Ft. in, in.
From To Ft in. in,
From To Ftin. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To F ormation Description
( a~ flier (\arPP
ati
1OS —S wait'. e
11. REMARKS:
rV
J
D1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wmf
15A NCAC 2C, WELL CONSTRUCTION STAND/ RDS. AND THAT A COPY OF THIS
RECORD WAS BEEN PROVIDED TD THE WELL OWNER.
7 ,F CERTIFIED
• a ,Sp 3- D3-
SIGN//A�TTURE OF CERTIFIED WELL C TRACTOR DATE
()err( /1 Ara �4 tw VT,�_r
PRINTED NAME OFF PERSON CONSTRUCT NG THEW ELL
Submit the original to the Division of /Voter Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 21699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

0
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 1-1,3(Q
1. WELL CONTRACTOR:
t e.v etc Mecca\ MCQ\ay et S
Well Contractor (Individual) Name
e\y�e aa1A1'ecs .3/4-Sor
Well Contractor Company Nene
\yQ -\6 .l-\ta7 a0S+
'HO* s :nna. NC 08'7 43
-Zip Code
STREET ADDRESS
City or T Sae
( 8a8} (obs- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Alit applicable)
STATE WELL PERMIT/RR applicable)
DWQ or OTHER PERMIT A(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 3 -� )��- G
- TIME COMPLETED i i D 0 AM ❑ PM (Si —
3. WELL LOCATION:
CITY: C/4A1/0/1
.44 4r•TT P Coot
(Sheet Name, Numbers. Community. Subdivision, Lo: No.. Parcel. Zip Code)
TO RAPHIC / LAND SETTING:
kqe °Valley ❑Fiat ORidge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE
COUNTY ,44ustoo
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this ram anot using GPS)
4. WELL OWNER
OWNER'S NAME (S+I%O'+(\ GCeveb
STREET ADDRESS et) iekTIC
(,�4y Aesv.\‘e NC 2efl9)(o
City of Town State Zip Code
($a.9a » '-\oo 'A%&9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: S6S
b. DOES WELL REPLACE EXISTING WELL? YES O NO 2/
c. WATER LEVEL Below Top of Casing: VC) FT.
(Use -+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
'Top of casing terminated atfa below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ?e, METHOD OF TEST
t. DISINFECTION: Type 4 • \ \S Amount aS-
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight M erial
Fmk' To 7 f Ft.- (o Irk tWR , ee
From To Ft.
From To Ft.
7. GROUT: Depth Material McBwd-
From 0 To Ft e ermenj SDow erk
From To 7 f Ft.
From To Ft
8. SCREEN: Depth Diameter S'ot 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. DRIWNG LOG
From To Formaticn Description
1 rI8 cne.c ( ct(uf
'lot Soy (._rtctatte_
11- REMARKS:
0
LIT
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OFU£RTIFIED WELKCONTR4CTOR DATE
nect.cK 1A\ *' :•sy-2cs
PRINTED NAME OF PERSON C NSTRUCTiNG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mkt,
1517 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-la
Rev. 7/05

324635
WELL CONSTRUCTION RECORD
North C tollna - Department of I ❑vironnient and Natural Reso - es - Divisive, of Water Quality Groundwater Section
/ ��
\\ ELT ('ONI PACT OR(INDIVIDUAL) Si print) J��� lGG v�f/%� CLtrrnacn'n/o/N N'�Q'q'(.'��/
\Vll.I. CON DUCT OI((OVM PANV NAME �f lee (tiL, fr.tr, . _. PHONE /I U)Y39,7-555
SL\I h: \\T:I.I. (' O.SII(tCI ION PF:a AI1'I#
lif aJslnlicahlcl
ASSOCIATED w'Q I'El(;\I I'r#
(it applicable)
I. WELL USE (('heck Applicable Box): Itcsidential 0 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Ntonitoring 0 Recnvcry ❑ lieu( Pump Water Injection 0 Other 0 IFOther. List Use
2. WELL LOCATION:
Ny:yrest „town:: (AL>O .J'ilh County
(Shea Name. Numbers. Community. Suhdi cisun, tat No.. Zip Cade)
3. 0AVNEIt:
Address e
li/ tSi Wind
I(oul
lll� i tuna Slate
tsci
Zip Code
Arcs code- Phone nuul.cr.x - .S -
4. DATE DRILLED (�l�l (%(
-
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL VEL. Below Top of Casing: 072 ET.
(Use' -' if Above -fop of Casing)
8. TOP OF CASING IS �— FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accord: ties t ' h IS,\ NCAC 2C
9. YIELD(gpnt): ®l MTh IODOrTEST /9`r
10. WATER ZONES (depth):
I I. DISINENUTION. Type iriS Amounl
12. ('ASINCi: Wall'fhtckness
Depth Diimiter or
From �0e— To 7S FI. /,./V
From To E).
From To I:I.
13. G ROUT: Depth Material
Front 0 To dO I IO-fin e'v7
Prom 'To
14. SCREEN: Ucpth Diameter
From To R.
From To Fi. in.
15. SAND/GRAVEL PACK:
Depth Size
From To PI.
From To Pt.
16. RI.NIAItKS
opographic/Land setting
Midge ❑Slope Malley Dial
(check appropriate bun)
Latitude/longitude of well location
tdcgrecs/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek box)
DEPTH DRILLING LOG
1-1 ) To Eor nun n I)cscription
C ¢
LOCATION SKETCH
Show direction and disiancs in miles from al leas)
two State Roads or County Roads. Include the rood
ncrial- numbers and common road names.
_ 0113 2�
Method
1 DU I IEREBY CERTIFY TI IAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WI TI I I5A NCAC 2C, WELL
NSTRU 'TION STANDARDS, Al THAT A COrY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGN;A FLEE OF PERSON CONSTRUCTING THE WELL
DATE
S%L4 lit the origi tat to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. G W-1 REV. 07/2001

324634
O'k:1.1. CUN I It.\C'tOlt llNlu tut:AI) \.\\I,�P//(�(-prnll�J�,✓ ry ,�ivoteo(IP rt
\\T:I.I. ('o.1 It \('I Olt (O\I I'%NV N\\IF [/ D'e. i"`e�7/ / ",'Fit
ST,ATF: AAT:I.1. (() s I IOTA ION I'ERdl rrq
i f nppl icahlc)
WELL CONSTRUCTION RECORD
Noah Carolina - llcparmlcm of Environment and,N,.y(pral Reso .ces - Division of Water Quality - Groundwater Section
CERTIFICATION #._r
PHONE # 'i•+yIt"2Z
\SSOCI.VI El) \VQ I'ERE\IITft
(ifapplieablc)
V\TILL USE (Check Applicable Box): Residential Municipal/public 0 Industrial 0 Agricultural ❑
Monitoring ❑ Recovery ❑ Heal Pump Water Injection 0 Other 0 If Other, List Use
2. WELL. LOCVTI0
Nearest Town
Orr
ISlrecl Na
3. OWNI1It:
Address
C County
S
mm�il 1. Suhdlvisiun. Lot No_ Lip Code)
vZ90 • '
V I o it Slat. ' Zip ('ode
Area code- Plume number •
�/'
DA
5. TOT\ . DRILLED dr 4.-
5. "TONAL. UI:I'll l: rs �
6. DOGS WELL REPLACE EXISTING WELL? YES 0 NO Ply
7. STATIC WATER LEVEL Below Top of Casing: /60 FT.
Ilse"+" if Above Top of Casing)
8. TOP OP CASING IS cQ FT. Above Land Surface*
*Tap ur easing terminated at/or below land surface requires a
9. YIELD (gpm):
variance in accord:mcy..,with IS:\ NCAC 2C .II1 I$.
o< METHOD OF TEST Jaime
10. WATER ZONES (depth):
DEI''FFI
n o�mt —'to
V ."X0
tidopographic/Land setting
tgc ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
tdegrees/l aims les/seconds)
linu1 c11ongilu(Ic source:❑GPSCITopographic nap
(cheek box)
DRILLING LOG
lyyl�(aliyn Description
e
LOCATION SKETCI1
I I . DISINI'I{C'TION: Type____ Amount Show direction and distance in miles from al lead
1 2. CASING: Wall Thickness two Stale Roads or County Roads. Include the road
Ucplh
From �,� T„ 3
How 1
hront To
Zi/°rice or Weight/D. Al mr )J numbers and common road names.
frc-
Nt.
13. GROU h: Depth))1dterial
��� 1
From 0 To,X1.7
From To Ft.
14. SCREEN: Depth Diameter Slut Size
in.
From "To FI. in. ill.
15. SAND/GRAVEL PA('K:
IJcplh Size Material
From To PI in
From To Ft
From To Ft
16. REMARKS:
Method
1 DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
Cy7GS�TRUCTION STANjQARDS, ANI) TUAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SI( iNATURE OF PERSON CONSTRUCTING TI Ili WELL DATE
SNbmit the original to the Division of Water Qualify, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 31) days. G W-1 REV. 07/2001

° .4633
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N•dl ural Res° rces - Division of Water Quality - Groundwater Section
riCERTIF'ICATl0N„ayde
whau.(ns-rlt:1(-n It(fUUPANAN,1ME i•LC. ii%g'-Pii-v% PRONE a (FG(1) &&. —S '
s ATE WVEI.l. co\srnt (II0N I'ER.II IH AsSOCIAFFI) WQ rIRAVrq
I it applicable)
WELL CON I It.11-1UI( (ISMVInl'AI.) N:1M print
CS( reA5J,acr_c-
(i r appl iclble)
I. WELL USE (Cheek Applicable lion): Residential (3 lvl unicipal/Public ❑ Industrial 0 Agricultural 0
Monitoring O Recovery O Heat I'unip Water Injection ❑ Other 0 IIOlhcr, List Use
2. WELL LOCATION:
N re,lown:l/xZ)Q. N J-e Couuy 4r I
(Sired! Name. Nwnixrv. Community. Su 'division. Lot No.. Zip Code)
3. OWNER
topographic/Land setting
(ge ❑Slope OVaney ❑Plat
(check appropriate Pox)
Latitude/longitude of well location
( degrecshninmes/s«oods I
tl,NNe �'• � I.aliiudellongilude sourcc:O(il'SOTopographic map
ye(Street or Itiuy,. 7�
Env or Town Slate Zip Code
ram)- G,a; - gos-s-
Area mule- Phone anodic
4. DATE DRILLED .2 —g'-- C 4
5. TOTAL DEPTH:
6. DOES WELL. REPLACE EXISTING WELL? YES 0 NO l9"
7. STATIC' WATER LEVEL mow Top of Casing: 0..? ET.
(IJse "t" if Above Top of Casing)
8. TOP OF CASING IS PT. Above Land Surface*
*Top of sing iernttnalcd al/ur below laud surface requires a
variance in accordance with I5A NCAC 2(:.al111.
9. YIELD(gpnl): %_ME'flIODOFTEST /9.C-
10. WATER ZONES (depth):
I I. DISINFECTION: Type111--- Amount
12. CASING: wail Thickness
From 1404( To
Ucptil„y^ Di.ancicr or \Vc hl/FI. M: crial.
5f°/
From To
From "En
13. GROUT: Depth a h.atecjii'pII Method
ru Fnl ® To O2O FL ej +-f - _CFp
Prom To
14. SC'I(Iil'.N: Depth Diameter Slul Size Material
Prom To fl. in. in.
From To 1'I. in. _ in.
15. SAND/GRAVEL l'ACK:
Depth Size Material
from To Pt.
from To Pt.
16. REMARKS.: •
DEI'Tl l
I roll) To
0 ao
0
S/
5 / /or
(check hu )
DRILLING LOG
Fs alio( Description
LOCATION SKETCI
Show direction and distance in miles from al least
two Slate Roads or County Roads. Include the road
numbers and common road names.
11)O fll'.I(EUY CERTIFY TIIATTI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
(() TIt(ICI- INSTAND.AI(DS.ANDTJ.t{\I'ACOPYOFTI{ISI(RC)RI)IIASI3EENPROVIDEDTOTILEWEILOWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
0
bmit the original to the Division or \Paler Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-16361'1 . No. [phone], within 30 days. GW-1 REV. 07/2001

124632
\VEL E CONSTRUCTION RECORD
North Carolina - I )cparnnun of Environment and N ural Rcso ices Division of Water Quality - Groundwater Section/
„l(1.1. r'ONIIC\('1111t Ilan\l nl',IIN\PI yt ml �� J'�� i�J ree_?5 Y1i'%c - CERTIFICATION gOi6w
NFI.I. CON II( ('TOR ((DII'AN1 NAME ri, cc we/I - Mj/en, I IIONE, N i''t 6927-556W.
ST:CI I: N 4:I.L CONS I RI (TION FERMI! N ASSOCIATED WO I'ERAIIT#
(il applicable) (il aPplicable)
I. AV'LLI. USE (Check Applicable I3ox): Residential Eblunicipal/Public ❑ Industrial 0 Agricultural ❑
Mouitotin1' ❑ !teem ery 0 Heat Pump Water Injection 0 Other I['Other, List Use
2. WELL LOCATION:
Nyt own:
Lit
(Street Name. heis, Community. Subdivision. lot No Zip (Code)
3. OWNER / h'// fiC /J7//7-< 01/
Addrus eur;ggelS-)--vep
('/yae
e County it _G_
i Struet kit ILn9c Nii.i
1v.c: : s7-2l
Coy oi Tosco Slaw Lip Code
($912)- gvSs
Aren cade- Phone 'amine
4. DATE DRILLED 'R —2--C Coy
5. TOTAL DEPTH: fi
6. DOES WELL REPLACE EXISTING; WELL? YES NO LR-
T 7. SA'I12 WA"ftat LEVEL Below Top of Casing: ? FT.
(Ilse"t' it Above Tap of Casing)
8. TOT' OF CASING IS ET. Above I.:md Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with IS,\ NC AC 2C .0118.
9. YIELD (gpm): / MEII IOD OF "PEST /9. r
10. WATER ZONES (depth):
11. DISINFGC'.l.
12. CASING:
From to
From
From
13. GROUT.
From r/
front_
14. SCREEN:
From
Front
ION: I ype
Topographic/Land setting
tidge ❑Slope ❑Valley plat
Ichcck appropriate hurl
Latitude/longitude of well location
plegreeS/ n 1 n W es/secun(1<)
itudellungitude sower❑Cil'S❑topographic map
l cheek hii\I
DEPTH DRILLING Loci
From 'To F' Ft allot Description
0 oZC PCL
0
it,
Depth I)ilyncter
To Ft.
To PI.
Depth b.ucn I
To 020 F.t
To I'I.
Depth Di:uucter Slot Size Material
To rlin. in.
Ta PI. in. in.
Anunun
Wall Thickness
or \Veight/Ft. M: erial.
Sj�Pe
15. SAND/GRAVEL PACK:
Dcpih
Front lb
From To
Size
I1.
Material
LOCATION SKEW!!
Show direction and distance in miles from at (east
two Slate Roads or County Roads. Include the road
numbers and common road names.
4,435-0
MCwed
16. REMARKS:
I DO HEREBY CERTIFY TBAT "[TITS VVILLI. WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CC 1. TR(ICTjON STANDARDS, AND T\T A COI'Y OF l"TITS RECORD IIAS 13LFN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
a-0
DATE
2.11
bmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. (919I 733-3221, within 31) days. G W-I REV. 07/2001
L.'

2466
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Di 'ISI )li of Water Quality - Groundwater Section �%
\yEla, (ON"I IIA('TUN (INDIVIDUAL) NANO- �1r �V-/-'l-' �VC // 1 �c CERTIFICATION # . �6
\\'EL.I. (UN I It:\( -I OR (ll\IPAN1 N.\\IF:
ti Ail I: \\'El.I. CONS'I It l'CIION I't' IZNll'r# ASSI/CIAI'ED \\'Q I'ER\IIT#
if;IpphuIMc)
(i l' appl wattle)
PRONE # (V�"-Tt7a
I. AVI:LI, (JSI: (Check Applicable Eo.v):Residcntial ❑ Industrial ❑ Agricultural ❑
A1oniloring ❑ Recovery ❑ I Teat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest '/ownl43qJV:$Ui//e Count
edie ' ¢cre5
4/OG'ca'
(Street Name.//Numhan. Community. Subdivision, Lot No.. Zip Code)
3. OWNER:,& 'f✓11R " (-J:Cee,
Address Jil /e fir; zed,/
S%i%eel it Rowe No.) 2.
eVecQQ`/
4
5
6
7
t'ur err II n- 3 Lip (alc
Arca ei nits Phone number _ -
DATE DRILLED
TOT.AI.
DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ic
STATIC WATER LEVEL Below Top of Casing: FT.
I Use "+" 1' A6ovc Top of Casing)
S. TOT' OE CASING IS ET. Above Land Surface'
'Top of casing 1ermin a lgid at/or below land surface rug a i res a
variance in accordance nith I5A NCAC 2C .01 ��11
9. YIELD (gpm): /d METI IOD OF TEST iT/f
10. WATER ZONES (depth):
11. DISINFECTION. Type / / 7 -
12. CASING:
Depth Diameter
From To_,5-F1. V•5/
From To Pt.
Topographic/Land setting
idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latiludc/longitude of well location
(degrees/ini macs/seeouds )
Latitude/longitude souree:OGPSOTopoeraphic map
(check box /
DR11.1-INCi LOG
Up I'rll
Eron
To
4)rtuat ionDescription
LOCATION SKETCII
Amount Show direction and distance in miles From al least
Wall Thickness two State Roads or County Roads. Include the road
or Wcicht'PI. h trial numbers and common road names.
From "To
13. GROLJI`//,Depth Maicriul Method
From V To Olt) P1. CPS eN�
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From "To FI. ill. in.
From To FI. in. _ in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To
From To Ft.
16. REMARKS
csi
0
crs
1 DO IIERILIiY C FRT'IPI"HIA-T TI ITS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CC STRLICI')O STANDARDS, ANU "CHAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
(3 - - o
SIGNATURE OF PERSON CONSTRUCTING THE WILL DATE
SWfnnil 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. G W-I REV. 07/2001

3246- 5
WELL CONSTRUCTION RECORD v"
North Carolina - I )cp rtment of Environment and Natural
Resources Divviisiiou ool Water Quality Groundwater Section.
\VI?LI. CIIN I It.\("lGl(UNtll\ IUt AII,) NANO?
T:prlllt)c��' 1 / J✓I! / C' CERTIFICATION a n.�J tC6
\\II. C FOR.CONT RAFOR (O\ll'AN1' \ \\IF - fi C_'?'-(.lt / _ $ ' /A/rt PRONEn S'.tg)la-�7-g5"98
Sl.\'I I l\rasa. Cl/NSI III ("1'I(IN I'ER\III# _..:\SNO(T\T ED WQ I'P:u,\II'1'l/
i ll.applic able) (il applicable)
WFLI. USE (Chock Applicable Box): Residential 2' btunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 ITeat Pump AWater Injection 0 Other 0 If Other, List Use
2. \VFLL. LOCATION:
Nca eat Town:
3. OWNER
Address
hCount)
nanny. Suhdrcisiuu 11,1 No.. Zip Cock)
4ISlreel ur Rome No
v. N.
i •
or loan Stale
)- 92o 3oc.3
Arc.' code- Phone number
S. DATE DRILLED /7`
5. TOTAL DEPTH: YOZ-5-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL 13clow Top of Casing: 3 C FT.
(Use "i" II Above Top or Casing/
8. TOP OF CASING IS 07 F1'. Above Land Surface'
`Top of casing lerrninat¢d at/or below land surface requires a
variance in accordance with 1>,\ NCAC 2C.11118.
9. YIELD Igpin): 7 METHOD OF TESL '/
10. WATER ZONES (depth):
as 78}
Lip Code
I I. DISINFECTION: Type
12. CASING:
topographic/Land setting
urge ❑Slope ❑Valley ❑Flat
(check approprime box)
Latitude/longitude of well location
tdeerecs/m iu W es!secoudsl
Laliludo%Iongitude source:❑GPS❑Topographic map
(check boxl
D I'.PTI-I DRILLING LOG
From To F n alit Description
0 o2U
ao ycf
s %s
A111oun1
I)cplh Uiauicler or A1'ci haft. criul
From 702 To ye
From To
LOCATION SKETCH
Show direction and distance in miles from al least
Wall Thickness two Stale Roads or County Roads. Include the road
numbers and common road names.
Et. 6221 ./ Ow 7‘
FI.
From To P1.
13. GROUT: I)eplh Material Method
From_ -ro :90 Ft. CNMe-1/7
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Pr. in. in.
From To 1=1. in. in.
15. SAND,/GRAVEL PACK:
Depth Size Material
From To FI.
From 'fo FI.
s
16. 12EM/ARKS:
73/
--,0
('
0
1 1)0 HEREBY CERTIFY TIIA'l THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI I I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS A ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO 'HiE WELL OWNER
Itt
SIGNATURE OP PERSON CONSTRUC1lN(i 111E WELL. DATE
Su In it the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636Plume No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
3223-7,5
North Carolina - Department in -Environment and Natural Res
VAI':LI. (ON'I lEXCTOIt (INDIVIDUAL) AI.) NANO' (priugS(
\C F.I.I. (O\) RA('1 OR (YI\II'AN\ \ VxIP:[ ' )Ce tele/
.ST,ATb: w'I':l.I. COSS 1BCCrION I'EI(,AI IT # _ ---
lirapplici heel
rces - Dvi ion or Water Quality - Groundwater Section
Are CER I II ICAA'.FIONN # o?i�dlo
1'/'i PHONE # 1�tste?nt '
ASSOCIATED \VQ 1'ERAIIT#
(ifapplicable)
I. AYELI. USE (Check Applicable Roy): Residential iiunicipaliPublic O Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 I feat Pump Water Injection 0 other 0 If Glher, List Use
2. WELL LOCATION: /
Nc' csl Town:eA1/ ra/V County
re' Ant' Cue lei
(Stri t Nano. Numbers. Community. Solido), Lot No.. hip Code)
3. ovyNLt.frdro&4$i
d870t 1
r.,, t
4
6
7
(Strect or Rome
iv_ Le
Ca) 0 n Slue
(s 6ye- Slate
.Are:: code- Phone nwnher
DATE DRILLED
=P6
TOTAL DEFT fl: �C
DOES WELL REPLACE EXISTING YELL? YES O NO 7�"�
STATIC AVATEIt LEVEL Below Top of Casing:
(Use "I" if / hou: Top of Casing)
R. TOP OF CASING IS Ff. Above Land Surface'
`Tap of casing terminated al/or below land surface I egtures a
variance in accnrdanc • w il6 15 \ NCAC 2C.01 IS.
9. YIELD(gpin): 020 METHOD 0F'VEST Jq'r
Zip ('ode
Topographic/Lund setting
❑Ridge OSlope Ettrzilley ❑slat
(cheek app rupria to box)
L'llitudc/longitude or well location
tlegreesanini es/ecocids)
L.utilude'lou gitude sou ee:OG!'SDTopographic map
(cheek box)
DRILLING LOG
>ur u(ion )escriplion
hunt To
0
10. WATER ZONES (depth):
I I. DISINPEC
12. CASING:,
Prom/yoZ
From
From
13. GROU
elim
From
From
14. SCREEN:
.IION: Type
Depili
fo 8
To
To
Depth
fo020
To
Amount
Wall 7Lickoess
Uia17teter ,r \b II -EL P I: tint
1'1,
El.
iNI:thuiul L Method
I LCc". e-rr
Depth Diameter Slut Size Klateri;d
From To Et. in. in.
From To Il in.
15. SAND;GR:AV'EI. ',Act:
----
Ugnh Size Material
From
Prone To Ft.
16. RIINIARKS:
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY main' in' TI IAT TI IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CON LICITI S"F RDS, AND TI IAT A COPY Of THIS RECORD ILAS BEEN PROVIDED TO TI IL WELL OWNF
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Wader Quality, Groundwater Sceliou, 1636 Mail Service tenter - Raleigh,
27699-I63b )'hour No. [phone], within 311 days. t G W-I REV. O71

�Vl I]J CONSTRUCTION RECORD
O)
North Carolina - Department of Environment and Natural R_ esou ces - Division of Water Qualify - Groundwater Section
WELL ('U\I ItA("TUE (INDIVIDUAL) NAME wino _3CTr i5 G � /\ f 1-e CE1a1FICATIONtjd4S'
VA]:I.1, CON] NA("I711( (I)AI PA NV NAMEt k 4-'//' .^•{�� PHONE N 6,2 S)&7- 5a1 thr
StA It 1\ICI.1CONS" ur ('i ION Pr:ucl l]N ASSOCIATED WQ PERAI ITN
lit;ippl icahlet (i( applicable)
I. AVLI.L USE (('heck Applicable Box): Residential unicipaIPublic ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I !cat Pump Water Injection 0 Other 0 IIOthcr, List Use
2. WELL LOCATION:
Nearest 'I-/�)\YI
X li
-CC /t�t,�> r
(Sued N-.unc Numbeix. Community. Subdivision
[to No.. Zip ('odes
C
i. OWNER: lug l� L tet"r'l/'
Address _37C.cc/Air,(. >;c&Z'
y ,�J (Slr' i if Route No
(it) or _Nun SI.ae
(kg
Area code- Phone number
4. DATE DRII.1.1(D / R 7 _i
5. TOIALDEI'iTI.---
County
/Ip (ilde
6. DOES WELL REPLACE E:NISI ING WELL? YES 0 NO l
7. STA'MCWATERLEVEL Below Top ofCasing. '�6 FT.
}} (use if Above fop ofGsing)
S. TOF OF CASI NCI IS . FT. Above Land Surface*
'Top of casing terminated at/or below land snr6ce requires a
variance in accordance with I5,\ NCAC 2C .0118.
9. 1'1ELD (gpm): / METHOD OETES!. /9, r-
10. WATER ZONES (depth):
I I. DISINI'G("IION, I'YPc- Amount
12. CASINO: Wall Thickness
Depth s�//{{ //Di: iclur or Wei.F}h /FL tcrinl
1-r(n11 To 7W FL ((i iii a / C stet'/
From To Pt.
From _ Ib PI.
13. GROUP: Depth Material Method
From C' To .Qo Pt. C F-'^f,v7
Front To Ft.
14. SCREEN: Depth Dimneter Slol Size Material
From To PI in. in.
From 'To PI. in.
15. SAND/GRAVEL PACK:
Depth Size NialeFial
From To
From fo
16. REMARKS:
opographic/Land soling
(idge ❑Slope ❑Valley ❑Flat
celled:appropriate box)
Lalitudc/longitude of well location
Idegreexininulesisecondsl
ludcrlongiludc sourcc:OGPS❑Topographic map
check box)
DEPTH H DRII.LINCI LOG
From ,[o (ygati)n Description
� w
�/7 v . 11 f.y
7 5- =- f A v, Ye
LOCATION SKETCH
Show direction and distance in miles from al least
two Slate Roads or County Roads. Include the road
numbers and common road names.
I DO HEREBY CERTIFY TIHATTIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
'-"NSTI;U2TION STANDAR,USAND THAT;A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWN
SIGNATURE OF PERSON CONSTRUCTING i IIH WELL
/".27-c
C
DATE W 7
Omni the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, a
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/ )1
8
3
0
00
CO
0
Cr)

VE1,L coNSTRUCTIoN REcoRI*
North Carolina - I)epaitrncnt of Environment and Natural -R esources - Division of Water Quality - Groundwater Section
VA' ra.l. ((1A 1 R.ACI OI2 (INDIA'IIII AI I N A.AI,f(priat).y�LE I'3(tO1 i, jC CERTIFICATII,ON N Q��1�
OVA (RCIR/1 OC\II'AN\ \\\IIr J I''te l'li Cl�y.. !), � y PHONE # {S )76-1?-��JO
S'1:\TIr wr:1.1. ('O\STRI. (AR/ N
I'Elt\Itlk
Ail ;ipplitablet
ASSOCIATED AVQ l'EltVIJTN
(il applicable)
I. WELL USN (Check Applicable Box): Residential LT Municipat/public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I leaf Pump Witter Injection ❑ Other ❑ ItOther, List Use
2. WELL LOCATION:
Neatest i., ,1: ei v7�C;i✓
County WO✓?ct
n
:thee �tse�; : ,��c/
(Sired Nome Vm lbws. Conn unil) St hd,ci.ion. Lot No.. Grp Cade)
3, (WNI72: re- o," fats✓'_
Add less " ,(�� _..5;�_.
GJ L' E-j i �C
(Sied ;;r Rowe No -I
L1 t , 2q 2/C.,
tlh or I own S!mc
Are' axle- Phone number
�
/
4. DATE DRILLED 7 ".5/-Otc7
5. TOTAL DEPTH: ..2
6. DOES WELL REPLACE EXISTING WELL? YES-\❑ NO f9'
7. STATIC WATER LEVEL 13clow Top of Casing: eje, FT.
(Use "+" if Above Top of Casing)
•
8. 'FOP OF CASING IS FT. Above Land Surface*
*Top or casing terminated at/or below laud surface requires a
variance in accordance with 15.\ NCAC 2C .11118.
9. YIELD OAnn1. I METHOD OF TES] 409,r-
I(1. WATER ZONES (depth):
/ip f'odc
�opoglaphic/Land setting
ti lgc ❑Slop ❑Valley OHM
(check appreis late box t
Latitude/longitude of well location
1legrcs'minulc../sec nds)
Lafit ucledongii tide soulcc:DCPS❑ Topographic neap
(check boss
DEPTH DRILLING LOG
Iret To Iiytrynuliyrn Ucscriplinll
1U t
U % f ,-go
�2 I Orn f.
LOCATION SKETCII
1 I. DISINFECTION. Type Amount Show direction and distance in miles from al (cast
12. CASING: Wail Thickness two Slate Roads or County Roads. Include the road
t Dcplh I r n cler or Weight/Ft. MPdcria numbers and common road names.
From To 7C Ft.(/Sf. S,/ Tf'„lW%J/�
Front To
Prom To FI.
13. GROUT: Depth Material Mcthed
From 0 to ,9?(, It. CC/.M'*'i
From To Pl.
14. SCRI,IcN: Depth Diameter Slot Size Material
Fronl 1 PI in. in.
Ivoii To Fi. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Ft-0111 To Ft.
From To Ft.
16. RENIARI:S:
I DO IIEREI3V CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
TRUCTION STANDARDS. i THAT A COPY OF THIS RECORD I IAS I3LEN PROVIDED TO THE WELL 0
rl
2
(,
%Is' T-
9
SIGNATURE OF PERSON CONSTRUCTING THF WELL DATE 3 '5. • co
7
�1v
27699-1636 Phone No. [phone], within 30 days. os
8
t
Su Wait the origiu:d In the Division of Water Qua lily, Groundwater Section, 1636 Mail Service Center- Raleigl

North Carolina • 0epMn.Nd ol Envaorellr t end Mural Rnaean - OMdon 01 Weser away - Groundwater Section
1636 Mi Soma Center. Raleigh. N.C. 27886 teliPlorw (e19) 7615921
WELL CONSTRUCTION RECORD WELL CONTRACTOR' 0.\ con ° f c r
WELL CONTRACTOR aurrricArom F cQ 13
STATE WELL CONSTRUCTION PERMITS.
1. WELL WEAL:hsm$pncat a so* Raelaw,r.( D' Municipal O Industrial 0 Au1loSSar l 0 Mo s a" 0
Flocovey U Hoot Pan, Water h jest. D Dear p Naar. LIN Use
Wl31 LOCATION: Cotdr HOB..{ W
Nona Tenor V`/: lc /ofMelocaaon
(Rood Nome and Nwlbro. Commas, and tat Ns ) DRILLING LOG DEPTH
P:Y`1, 3. OWNER t ` I PTl( 2 slam To FanedonDo
Addrns 1t01 clerceruil p Lansz.
\NQ Tine v t1Te. NF_
ay Eke Zip Code
4. DATE DRILLED 5-15-
5. rout DEPTH ;'+$
e. curry** COLLECTED YES 0 No
7. DOES WELL REPLACE EXISTING WELL? �p NO®'
S. STATIC WATER LEVEL Below Tap of Claim FT.
1j (Um'V' SAW.* Top of Cube
S. TOP OF CASING 1S I FT Above Land Sadao•
'Tap of adobe 1wtabrod INN bNsw bM shoo nqukoo a yobbo In now
dales wit 15A NCAC2Cpto
10. YIELD (ypm): ?S METHOD OF TEST P ( C5
11. WATER ZONES (dsplh).
-te
O
12. CHLORINATION: Type Amount S eddMaltl•
space bneeded tam book ofbnn- x't
13. CASING:
N
7FO TibbsLOCATION SKETCH 0
Depth am ldrtor sr WMyOFt Ferudal. , w d ollon end db4.ea kin at bat two Spb
From ( To g Ft. �y'-Y �Q_"r(G (ShoRoods, or other mop roloreree points)
From To FL
From To FL
14. GROUT:
Depth Motorlol
From I (cc R. C era/n-4 From
To
From To FL
15. SCREEN:
Depth Db.rl.Mr Sbl Ski Ma
From _ To _ F1 _ M. _ In.
Front _ To _ Ft.. In. _ In.
From To FL_ In; In
16. SAND/GRAVEL PACK
Depth Size Mabd.
From To FL
From To FL
17. REMARKS:
1-40ciAn
c-nEL.
-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A 'CAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS RECORD
1(ly SEEN P ONDED TO THE WELL OWNER
FOR OFFICE USE ONLY /V�- /V �ti� 45 �/7 —O
Wad Mix
Soda Na
NONAhaIEasPERSON CONSTRICraipTHE WEIL DATE
Sub,* adyiNl is Man eT absOusety O sldralr Sudan SAND SO days
Ow•1 REV. f21n
LUDO

0 0 0 u Z 1
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (prim[/ 6e. eaCI _cI�,, nniO-/rCp/�), CERTIFICATION tt32
� b z
3cCPP_e V, "s We C.l4—f'cimp PHONE # (v4 is (1 -317 0
WELL CONTRACTOR COMPANY NAME ((
STATE WELL. CONSTRUCTION PERMIT# /i°Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL, USE (Cheek Applicable Box): Residentialtr-Municipal/Puhlic ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: tA) /leitit Ilife (County
' J eu I,s'eo'-1
(Sueei Name, Numbers, Community, Subdivision, l ut No., Zip Code)
3. OWNER: 6a7 Jacks et —
Address 1329__ _ - 6-cony / .
Laid
} rect or fi mte No. t b a FL 01
Cite or'iimb State Zip Code
Esk6 682--bz-
1' c.. coda- Frame number
4. DATE DRILLED- -/ D
5. TOTAL DEPTFI:034 -
.I.at ul.la nt t. t. s,t.'•t.c,1 ii n: ) V-
7. STATIC WATER LEVEL Below Top of Casing: L C7 FT.
I ((Tie .. if Above Top of Casing)
S. TOP OF CASING IS !__ FT. Above Land Surface*
*Top of casing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C .0118. ,I^
9. YIELD (gpm): ,� 0 METHOD OF TEST 2iP0die(
10. WATER ZONES (depth): ZSS
11
to
13
14
15
DISINFECTION: Type_ f- ///f .. Amount
CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From o To_ Et. 6 41
From To Ft.
Eel_
From To Irt.
GROUT: Depth Material Method
To f
m
From __. To _ 2-0 Ft. Onter(.(-
To F!.
SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
SAND/GRAVEL. PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
topographic/Land setting
Widge ❑Slope ❑Valley Mat
(check appropriate box)
Latitudc/longitude of well location
(degrecsnninutesrseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To I For ion Description
�T O5 •
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. rla
Material
i DO I IEREBY CERTIFY.l(IAI TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
C'ONSTRIiC N STANDARDS, AND TIIAT A COPY OF TIIIS RECORD IIAS 13EEN PROVIDED TO TIIE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TILE WELI. 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. 07/20111

WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural Resources -_Division of Water Quality
NEI I. CONTRACTOR (0ND' Vuxl Al) NA NI ' n C rn iii 6iteG'rinl -
WELL(ONI'RACIORCOMPANYNAME /L
SG It: WELL CONSTRUCT ION PERM II'a f 7 `G,- - ASSOCIATED WI) PERMIT#
lit applicable) (if applicable)
3r33385
- Groundwater Section /�
tprin , n CERTIFICATION # * 2-e
"iccef_e_ (ate/4etaW -`"_ l" vi✓tl0__ PHONE IS ('9/8) 640' 30 0
1 WELL USE (('heck Applicable Box): Residential th 1unicipal/Puhlic D Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ ilea[ Pump Water Injection 0 Other 0 If Other, List Use
2. 'KEI I. LOCATION:
Near town:
an-l-hec
(-tree[ Name, Numbers, ('ommunity, Subdivision, I of No., Zip (',ale)
wile County fJa ttuoQC
ow 2A�P floineri _�[ls[11�„b
Address z`f�;�l darcf.
Street or Route tiu.l
( It Or I own State
f32e,
Zip Code
Atea cialc Phone number
4. DATE DRILLED _/2 (9,o67 _..
5. TOTAL DEPTH: // 5
I)rAIa U!I-I I f)Lltl A(Y. i.Y!.ttn.t; ,A,t.i ! '.' y I tt ktl
7. 4l'AI I(` WATER LEVEL Below Top of Casing: 70 a FT.
(1.se "4 if Above lop of Casing)
5, TOP OF CASING 1S __ __.. FT. Above Land Surface*
-lop of casing terminated at/or below land surface requires a
wriance in accordance with 15A N(: A(' 2( .0118.
9. YIELD (gpm): 1/ METI OD OF TEST Z{lours
ID. WAFER ZONES (depth): SC" 9 Do
I I. DISINFECTION: Type__ Amount
13. CASING: Wall Thickness
Depth Uianwtcr or Weight/Ft. Material
Frttm_.._Q_ To. a__ EtL Gi (' PYC
From To Ft
From_- To Ft.
13. ( ;RI A' : Depth fs1 aterial
From Q___ To 2n H. Qm
Prom To
14. SCREEN: Depth Diameter Slot Size
Prom To Ftin. ut.
From To _.__.. FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Method
J QP
atcrial
From To
From To
16. REMARKS:
�lTopographic/Land setting
INKtdgc ❑Slope ❑Valley ❑Flat
lcbeck appropriate box)
Latitude/longitude of well location
(degreesiminutesisecunds)
Latitude/longitude source:❑GPS❑Topographic map
(cheek hex)
DEPTH DRILLING LOG
From To Formation Description
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.
RECEIVED
D v, OF WATER QUALITY
JAN 0 8 zu07
I DO IIFREBY ('ER'IIFY IIIAT TIIIS WELL WAS (ONS'fI(U('I'ED IN ACCORDANCE WITH ISA N('AC' 2C, WEL1.
( ( )Nti I I IION STANDARDS, AND 17 IA'I- A COPY OF TI I1S RECORD IIAS BEEN PROVIDED TO DIE WELL OWNER
40efGt CO c /-,5 -0 7
SI(,NA'I'ERE OF PERSON CONS IRt1CTIN(i I'IIF: WELL DATE
Subrnit 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

333384
WELL CONSTRUCTION RECORD
North ( 'arolina - Department of Environment and Nat ral Resources,,- Division/�of Water Quality - Groundwater Section // p
%NEIA.(.(WI RAC'101t (INDIVIDIIAI.) N'.i Al E; (print) , Iti y�/ebh //)) CERTIFICATION# 21/O
l�iiteene_&o left SUCE(�V(imt ____ PHONE aex, 6wl8&3/7a
KI,i1'T: WE:i,L C'UNSIR(ICI7ON PE:RMI I. /YQ Z--- _ ASSO('IA'IE:D WQ PERMIT#
(if applicable)
\ 1.1.l, (ON TRACTOR COMPANY NAME
(if applicable)
I- WIi .L. USE ((heck Applicable Box): Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 I feat Pump Water injection 0 Other 0 If other, List Use
2. WELL LOCATION:
Nearest Town:-.� des vu-L'e.
County
Woa-4
;Ireet Name, Numbers. Community. Subdic ision, Int Nu., Zip ('ode)
3- OW'NER: 61/CP ri)6 /b!)7 tio/Yes
Address . 0, )<_. /351/
(Street or Ruute No.l
aN� Z$70 ro
( ityor l own State /ip f.'odc
828 )- ._ *f> -9.2-9 9
Ai ea code- Phone number
T. DATE DRILLED_--. /27'!3 0/0
5- TO'(AI. DEPTH:
!".I.l'\\'I.I I pit! .11 1'I
7. 4LA(I(' WATER LEVEL Below Top nl C acing: 4L FT.
(1:w"4 if Above 'lop of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
'top of casing terminated at/or below land surface requires a
sanative in accordance with I5A NCAC 2C .0118.
9- YIELD (;pm): _-— METHOD OF TEST four.
ID. WAII:R ZONES (depth): 125r
II- DISINFECTION: Type Hg1 Amount_
12. CASING: Wall Thickness
Depth/l Diameter or Weight/Ft. Material
From ! To lFt. 6r%YL
From'To
From To
13. GROUT: Depth
From 0 To 2-41_
From To
Id. St RI'.1N: Depth Diameter Slot Size Material
From To Ft. in. in.
From To
15. SAND/ORAVET PACK:
I )epllt Size Material
Ft.
rialr
Ft. &Ind(1.21—
From _ "ro Ft.
From 'l o Ft.
If. REMARKS:
tjlpihod
I.10
Topographic/Land setting
❑Ridge ❑Slope ❑Valley
(check appropriate tom)
latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑CIPSDTopographic map
(check box)
DEPTH DRILLING LOG
From �Tyo Forrm�tioon Description
�b r 20Sr 6,rra.4r-Pe
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.
RECEIVED
DIV. OF WATER QUALITY
JAN 0 8 2UU7
I DO J IEREltl' (IR111Y 11IAI 1111S WELL WAS CONS I RIIC'I'ED IN ACCORDANCE WIH 1 I5A NCAC 2C', WELL
( DNS I IL{I i ION STANDARDS. AND I IA I A COPY OF THIS RECORD I IAS BEEN PROVIDED TO TI IE WELL OWNER
l 10/14.42/7 d ` t°7
SIGNATURE, OF PERSON ('ONSIRIICIING 771E WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD 3 3 j 3 8 3
North Carolina - Department of Environment and Na�M}J{i�tal Resources - (Division of Water Quality - Groundwater Section
W Etc CONYRA( TOR (INDIVIDU L) NAME (prim) Il,obl/1. k/IJ CERTIFICATION #Z//p
WELL CONTRA(C'-OR COMPANY NAME 6CC. _s•J[.0 e_65— wat PIIONE ft ea) via 770
S R IF. w ELt. (ONS fRU(TION-PERM it
(if applicable)
/'/O 2- ASSOCIATED WQ PI RMIT#
(if applicable)
1 . WILL. USE (Check Applicable Box): Residential Municipal/Public O Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ileat Pump Water Injection 0 Other 0 if Other, List Use
2. WELL OCATU)N:
Nearest fawn: Ri& e(7> ✓cLL2.. _ County
wood
anwlt? -e,
I 'street Nnm_ Nurnbus, Community,
, Subdiv uinn, Lot No., Zip (ode)
"3. ()t4NI)R: Ja-00iN a(Address )03 00d 0 i
'_ (Sheet in Route No_)
C-0440Z) Ai C Z8 77 C
tr�� ( its u'I'i,t t State' ` Zip ( 'ode
Area side- phone number 4. DATE DRILLED_ //.2-7
t "0 6
5_ 1 OTAI. DEPI 11: 5- 5
t I)t. pi nr Y�1. \'lllln•( \1.L1 VLl(1 nrr aX
7. S1AF I(' WATId( LEVEL. Below "fop of Casing: __4 Q_FT.
11! se "i- if Abovelop of Casing)
R. FOP OF CASING 1S L FT- Above Land Surface*
*I op of casing terminated at/or helms land surface requires a
sariance in accordance with 15A NC A(' 2C' .0118.
9. YIELD (gpm): '% METi1)(D OF TEST ZHOU(`)
10. WAIIR ZONES (depth): y65 '
Topographic/Land setting
❑Ridge DSlope ❑Valley 11lat
(check appropriate box)
1,atitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑(iPS❑Topographic map
(check box)
DEPTI1 DRILLING LOG
From To Fo t ation Description
r r
!' (
azak
LOCATION SKETCII
II DISINFECTION: Type tT Amount _ Show direction and distance in miles from at (east
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From V To 40 Et. 6 rr PVC —
From '1'o I t.
From To H.
13. GROUT, Depth /Material Method
From nTo 20 Ft. (tMO*
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From 'co Ft. in. in.
From To Pt. in. in.
15. SAND/GRAVE(. PACK:
Depth Size Material
I-ron) To
Fron) To I t.
Ih. REMARKS:
To
RECEIVED
DIV. OF WATER QUALITY
JAN 0 8 Z007
I DU I IP.REBY CERTIFY THAT 1111S WELL WAS CONS! Rt)Ci ED IN ACCORDANCE WITH I SA NCAC 2C, WELL
('( )NS I (ION STANDARDS, AND 'DINE A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIIE? WELL OWNER
evitwa
SICiNAIURP: OF PERSON CONS'IRUC'IING 771E WELL
laudvi
/ 5-07
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Censer- Raleigh, NC'
27699-1636 Phone No. [phone]. within 30 days. G W-1 REV. 07/2001

336524
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality
w ELI. CONTRACTOR (IN DI VI DI'lA NAYIE I print) Reknit,
)
6 �,�^ ti(.4�mf
WELLa.CONTRACTOR C.OYIPANY NANIE woe, ��''`
,CI'E W ELL CONSTRUCTION PERM TO NO2--I T -ASSOCIATED VS() PERMIT#
(ifapplicable) .- (if applicable)
Groundwater Section// CJp
CERTIFICATION # z7/
PHONE # 403I 6q8 cv7°
1. WELL USE (('heck Applicable Box): Residential H CMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ heat Pump Water Injection 0 other 0 If Other, List Use
Topographic/Land setting
❑Ridge giSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
2. WALL LOCATIO _ /
Nearest Mown: _ altkP!)
CountyW
(Strcct Kaule, Numbers. Community. Subdivision, tot No.. Zip Cale)
3.
Address .Or 04.7 _. _-------
(Street or Route No_)
Canon /uG 24:5-7r c
('ItV or Towil State tip Code
At ea code- Phone number
4. DATE DRILLED_ //� C -_
5. T-OTAL DEPTH: CO
I. I)()I.t' 1V1.11 ILIA nI L 1.Y I1l INI. IA,I.I l .r Vl.11l1 M1r) IW
7. SIATI(' WATER LEVEL Below l tip of Casing: _42 Q FT.
( Csc "4" if Abovefop of Casing)
S. TOP OF CASING IS j_ FT. Above Land Surface*
'lop of casing terminated at/or helots land surface requires a
s arianee in accordance with 15A NC AT 2C .0118.
9. YIELD (gpm): 4 METHOD OF,TEST 2
10- WATER ZONES (depth): #05
II. DISINFECTION: Type W/7 _ Amount..
2. CASING: Wall Thickness
Depth Diantyter or Weight/Ft.
From__.0 To._45 H. t/ov
From To Ft.
Fnm) ......-- To----- Ft.
tcrial
JC-
(degrees/minutes/seconds)
Latitude/longitude sours(.:❑(iPS❑Topographic map
(check box)
DEPTII DRILLING LOG
Fr�n "Jo Formation Description
y1&"-30, ranfac
13. (iRUI;'I: Depth Material -M7-eihod
From Q To 3D Ft (era _ 1. 0.---
From To H.
14. S('RI ISN' Depth Diameter Slot Size Material
From 1-o Ft. in. in.
From ToFL in. in._--
15. SAND/G RA VEIL PACK:
Depth Size Material
From To_._.
From To__
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.
RECEIVED
my OF WATER QUALITY
tAN 9 4 2007
16. REMARKS:..
1 I$) I IEREBY CERTIFY fI IAT THIS WELL WAS CONSTRUCT RIUC'I ED IN ACCORDANCE WI fl I I5A NCAC 2C, WEL1.
( ONS FKI..`I ON STANDARDS. ANI) THAT A COPY OF TIIIS RECORD I LAS BEEN PROVIDED TO TI IE W ELL WNER
.a41.12easicry.)) JL as v 6O
��
SIGNA'ITDLF. 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

336523
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N• ural Resources - Division of Water Quality - Groundwater Section
WELT. CONTRACTOR (INDIVIDUAL) NAME (print)
MI I I. ('ON-I'RACTOR COMPANY' NAME
STATE WELL ('ONSTRLIC'I ION PERMI'I #
(if applicable)
0
C N:N'I'IFICA1'ION # 2 V IS
reeve S.e owlie _Well -4 _- PIIONE# Je0o) 69C1 C376
/Yoz
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL. USE (Check Applicable Box): Residential Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Ifeat Pump Water Injection O Other O If Other, I.ist Use
2. WELL LOC'ATl(�N:
Nearest Town: %9e (d6W County_( !
(Street Name, Numbers, ('omen uu ity, Nu bdi vision Lot No.. Zip ('ale)
3. OWNER:
�
cobs o/
Address 'P.Q, A ..._l011
1- >_na�treet vs, nleNNC- g6 79
( lh or'I'owl State Zip ( ode
_y/8' 7/03
AreaCO(le ('hone lumber
4. 1)ATF. DRILLED /2-13 -O
0)E1' 5. '1l'AI.11l1: _2.OJ5l.
1)(ll.l' 1l 1.1 1 11.111 A!'1- 1- \ 1'-1 1'"t ; '/y .1 I l' )
7. STA I IC WA.' ER LEVEL Below lop of Casing: 60 FT.
v'4 f Above lop of Casing)
S. lOP OF CASING IS -__-/ FT. Above Land Surface*
*top of casing terminated at/or below land surface requires a
sariance in accordance with ISA N('A(2(' AD 18.
YIEI D (gprny /Z METHOD OF TEST 2 Ho urS
9
10. WATERZONES (depth): __./ 85'
I. DISINFECTION: Type_ n, Amount,.
I2. EASING: Wall Thickness
Depth Diameter or Weida/Ft. Material
m Erub To 5(0 Ftb•r
flb`ti wSob
From To Ft.
From To Ft.
()VC
13. GROUT: Depth ., IIatteriial L Method
From QTo � Pt. C.G//Le1i _ . Top
From To Pt.
14. SCREEN: Depth Diameter Slot Size Material
From__... To .-__._. Ft.in. in.
From To I't. in. in.
I5. SAND/(iRAVEL PACK:
Depth Size Material
Front_ To Ft
Prom To Pt.
l6, REMARKS:
Topographic/Land setting
❑Ridge CNSlope OValley DPlat
(check appropriate Mix)
I.atitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude .source:OGPSOTopographie map
(check box)
DEPTH (check
LOG
From To Form: tion Description
5?' 0-05r rAnt
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.
DJV OFWATER ociAtITV
JAN 0 4 2007
I DO I IIIREIIY CERTIFY TI IAI' 1I IIS WEII. WAS CONSTRUCTED IN ACCORDANCE Wfll I I5A NCAC 2C, WELL
( )N.ti I RU(711Y)N STANDARDS, ANI) TI IAf A COPY OF Ti IIS RECORD I IAS BEEN PROVIDED To Ti Ili WELL OWNER
SI(iNA"IURE OF PERSON CONSTRUCTING lI1R WELL.
i2-29 -oc
I)A'FE
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

9
10
II
2
Ii
11
15
STATE WELL CONSTRUCTION PERMITS/
336522
WELL CONSTRUCTION RECORD
North ( uolina - Department of Environment and Natural Resources -- Division of Water Quality - Groundwater Section
Q,
w ELI,(ONlRACTOR (INDIVIDUAL) NA,MEE (print)t)�'f.i1�\,,eh2!,)I' ,,,'_%}_ _ CERI'IFICA�TIION/ iWd././`�
WE.I,I, C ONTRACTOR COMPANY NAME. G,�GCM€_ /UW'/.ICI j Lut f�( r.,3 PHONE # 6' 6 6 vs el re
1v9 ?_
ASSOCIATED WO PERMIT#
(i f applicable) (if applicable)
1. WELL. USE (('heck Applicable Box): Residential Er—Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring ❑ Recovery ❑ I Ieat Pump Water Injection 0 Other ❑ If Other, I.ist Use
WELL I,.00ATI() G
k C
Nearest Iown :l.. A 49�Qdounty
f ti reet Name, Numbers, Cun otulnty, Subdivision, Lot No., lip (',de)
i. OWNER: III C7��
Address 35 " over1CP-sf' Pkct
(Street or Route No 1
1 yFL 32707
town State hip ode
925- 95 -- -
Alea teak- Plume number
1. DATE, DRILLED_ _ 2 -/Z-0 6
5 T(I AL DEPTH: /2(}5'
Illll.1/4' 11.t.1 I I)1.111 A!. I1A1-1 1 'I V'I.l I_I V,1 I Ir✓
7. SIATICWATER LEVEL Belowfop ofCasing: b1/0 FT.
l(.xtr 4 it Above lop of Casing)
FOP OF CASING IS _1___ FT. Above Land Surface*
lop of casing terminated at/or below land surface requires a
sariance in accordantq with I5A NCAC 2C .0118.
YIELD (gpm): //2/ METHOD OF TEST 2_1-10 -S
WATER ZONES (depth): 5b5
boS'
I)ISINPIKTION: Type_ _ gig Amount
CASING: Wall Thickness
Depth ���// Diameter ur Weight/ft M ttyyr l
From__. Q To. l!7__- Ft t,r i
From To Ft
Prom To Ft
I.iRU(IT: Depth Material thud
J iom Q.__ To Z- Ft. Ce ne>tk 1 op
It root To 1-Y.
S('REEN: Depth Diameter Slot Size Material
From _ To PLin. in.
From _. Tt___- Ft. in. in. ._._..._-
SAND GRA VLI, PACK:
I)epth Size Material
From_.. _ 1 q Ft.
From To ht.
REMARKS:
TopographiciLand setting
�.�
❑Ridge Slope ❑Valley I�1'lat
(check appropriate box)
Latitude/longitude of well location
degrces/minutes/seconds)
latitude/longitude source:❑GPS❑Topographic map
tcheck box)
DEPTII DRILLING LOG
From To Fon anon Description
25( /2 5'- �
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.
RECEIVED
DIV, OF WATER QUALITY
JAN (I 4 200%
I DO I IEREBY CERTIFY TI (Al THIS WEI.I. WAS CONSTRUCTED IN ACCORDANCE WI111 ISA NCAC 2C, W11_L.
( ( )NS I r TION STANDARDS. AND 'H IA1 A (01'Y OF 11IIS RECORD I IAS BEEN PROVIDED TO THE WELL OWNER
_fie(—. a(o «) J2 U3 -o C
SI(GNAT(JRE, OF PERSON CONSTRUCTING 171E 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. G W-I REV. 07/2001

WELL CONSTRUCTION RECORD
336521
North Carolina - Department of Environment and Natural Resources -1,Division of Water Quality- Groundwater Section
NELL, (ONII1A('TOI( (INDIVIDUAL) NAME (print) 1"o .6 7/As Vv ebb CERTIFICATION N 27/S
WLI (ONikn(-FOR COMPANY NAME Greene_io#he.r We (4-PihY1(�-- PHONE u(i%%&360$•3/70
S Fait: W ELL (ONS'IRUCI'ION PERMIT# HO 2 -
(if applicable)
ASSOCIATED WO PERMIT#
(if applicabic)
1. Will. USE (('heck Applicable Box): Residential 63 Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Ifeat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: •,I
Nearest Town: IAJ ( 'Y( ilt_.. County (7al/w
(Street Name, Numbers, ('unmm uity, Subdivision, Lxit No., Zip ('ode(
3.OWNER: S& CV1&oaG
Address -_.70 jioc e, •
�0 (‘Street or Kurile No.)
Gt9aAa eJvc . NC 2-8784J
City or w State
---- Zip 1'odc
04* 73cf Z7Ct
Amu code- Plume number
4- DATE DRILLED._. /LL%•0 (O
5. TOTAI. DEPTII: 305 r
,l.L, `r,'1.1 i h;.pt nr I. )..,1c.11r_,ri 1t/'-H '.' Y1,5 I ai r.t) ii✓
7. STATIC WATER LEVEL 13c!uw'lop ofCasing: 470 PT.
(I:se'4- if Above Top of Casing)
S. TOP OF CASING IS _ _ ET. Above Land Surface*
'Top of easing terminated at/or below land surface requires a
variance in accordance with ISA N2C.0118.
v. YIELD (gpm): __/ 7 METHC.A('OD OF1 TEST 7i[ jjr,,5___
10. WATER ZONES (depth): 5 f
11- I )ISIN FEC'TION: Type
12. CASING
Topographic/Land setting „-
❑Ridge ❑Slope OValley RFIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude souree:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
r
60 r 305
•
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diameter or Weight/Ft. 'Material numbers and common road names.
From O Tok 7_. Ft.
From 'Co Pt.
From -- To —_ Ft.
13. GROUT: Depth Material
From._...Q To_70 Ft, CxineirA-.
From ._ T'o
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. _ in. in.
From 1'q 1't. in. in.
I . SAND/CiRAVET, PACK:
Depth Size Material
From To Ft.
Prom To Et.
•s
Prc-
I6.REMARKS:
Mrethod
ap
RECEN EpUA1.�
IV,Of WA
IANQ4zo7
I DU I IIikEIG C'ER IIFY TI IA1 THIS WELL. WAS CONS I RUC1'ED IN ACCORDANCE WEI 1115A NCAC 2C, WE),I.
( ()NS'I RI ON STANDARDS,, AND II IAT A COPY OF 'MIS RECORD IIAS I3EEN PROVIDED TO 'HIE WELL OWNER
- LlLC9fbv /2-2-8-o L
SIGNA111RE OF PERSON ('ONS'IR(KIING 771E 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. _ G W-I REV. 07/2001

WELL CONSTRUCTION RECORD 3 3 g 8 3
North (''arulina - Department of Environment and NaturalResources Division of Water Quality - Groundwater Section
7AC TOR(INDIV'IDUAL;NAME (print) �C////`'PG„, 4I zm SfOCC-
W7: Y.1. (ONR
(.'ERI'IFICA I ION # 3z Z
n PHONE # ce24 6 N8-3/70
Wf'.u.c'n��rltncTol((:x),MPnnv NAME L7 woe Piers_- GVCEI-`-�-.rlr� - ---..
StAI'F. WELL CONSTRUCTION PERMIT# �7 0_ " ASSOCIATED W'Q PERMIT#
(if applicable) (if applicable)
1 WELL 11SE (('heck Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 I leat Pump Water Injection 0 other 0 If Other, List Use
2 VVIIEI, LOCATION:
Nearest Mown:
(StreetNumber, community, Subdivision, Lot No., Zip ('ode)
A. OW NEW kambi& Na ham-t/r\--
Address - -NgNO. ,3W 1 TJ cfr
ikte/p0000/
I ` el Street or Rout No
I),l/, , 33/57
( t, of Pease State Zip ( ode
30 -/ 60 --oeeef-
Aiea Little - Plane number
4. DATE DRILLED__
5 7 OTAI. DEPEl1: /2-0 0
2'0'S \A'l.l I IJ1. 111 Al 1-1-\'1<-f In( "-1.11 V'I.Sl l nil t�
7. STATI(' W'ATIR LEVEL Below Top of('acing: g35 FT.
its,: "4' if Above lop of ( asing)
R. FOP OF CASING IS _ — FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
. ariance in accordance with 15A NC A(' 2C' .0118.
9. YIELD (gpm): '�2 - MET/HOD (/F TEST 2440 Or)
I U. WATER ZONES (depth): 4405
11. DISINFECTION: Type Amount.
I2. CASING: Wall Thickness
Depth Diameter or Weight/Pt. Matpnal
From D, To Se Et. 6 NdL
From To Et.
1-inn) - To Ft.
13. (iROIiT'. Depth Material Method
From 0 To 2 0 El C.efiLeziF
From To
I4. Sr 'RI l',N: Depth Diameter Slot Size Material
from to Ft. in. in.
From To Ft. in. in
15. SANINGRAVEI. PACK:
Depth Size Material
1-root_ To
From - To
16. REMARKS:
Tp
opographiefLand setting
tdge ❑Slope OValley ❑Flat
telieck appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:0GPSOTopographic map
(check box )
DEPTH DRILLING LOG
From To Formation Description
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.
RECEIVED
DN. OF WATER QUALITY
JAN 0 8 2007
I DU Ill'RE13Y CERTIFY-IIIATTIIIS WPT.1. WAS CONSTRUCTED IN ACCORDANCE wrili I5A NC'AC 2C, WELT
CONS I KU(n\)N STANDARDS, ANI) 11 IAT A COPY OF IIS RECORD I IAS 13EEN PROVIDED TO TIIE WELL OWNER
��a/14—e . a _ - c = /-5-0 _7
SIGNAI URF; OP PERSON C'ONSIRUCIING 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. (iW-] REV. 07/2001

WELL CONSTRUCTION RECORD Quality Groundwater Section
Division of Water Qu ty' Si Z
CERTIFICATION, D
North Carolina - Department of Environment and Natural Resources - _PRONE >x
56
WELL CONTRACTOR (INDIVIDUAL) NAME p^nt)1i-�2jC s'/� (/yyY1
WELL CONTRACTOR COMPANY NAME _ ��o— —T-� ASSOCIATED WQ PERMIT#
if a licable
STATE WELL CONSTRUCTION PERMITS cultural 0
(if a licable P Industrial 0 Agricultural Applicable Box): Residential B- Munici a Ot btic er If Other, List Use
WELL USE (Check over Heat Pump Water Injection 0 Monitoring 0 Recovery 0 a hic/Land setting
TopograP
pRiTo lope [Walley sett OFlat
2, WELL LOCATION^'� n County (check appropriate box)
Nearest Town: 1 Latitude/longitude of well location
Community, Subdivision, Lot No., Zip Code)
ry' (degrees/minutes/seconds)
(Sneer Name. Numbers, (degre o a hic map
fl^' Latitude/longitude source:OGPSOTop gr P
3. OWNER: /'% '"�t`0SO Kpt, (check box)
Address ' DRILLS
.,.._._.9,.,.,PNi DEPTH Formation Description
Area code- Phone number
4. DATE DRILLED
� 5 5. TOTAL YES ❑ NrJ
!, DOES WFLL REPLACE EXISTING \t ELL? FT.
Er-
7. STATIC WATER LEVEL Below
Use' o f AbovegTop of Casing)
8. TOP OF CASING IS Jam— FT. Above Land Surface*
*Top or casing terminated atlar below land surface requires
variance in accordsoce witil 15A NCAC 2C ,0118. !J ��
METHOD OF TEST
9. YIELD ZONES
�� �'. 10 D
10. WATER ZONES (depth):
Amount_
11. DISINFECTION: Type s� Wall Tht
12. CASING:
tY�
>un r 7•Z�_
ckness
Depth Diameter or Weight/Ft. Material
From To Ft.
To Ft. Method
From Material
13. GROUT: Depth
Fromm ___ To ZD Ft.
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVELPACK:
Depth
Size
To Ft._
To Ft._
From.
From
Ft.
Diameter Slot Size
n.
Ft. in.
Ft.
n. in.
Material
Material
CH
Show dire LOCATIONdistance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
Hoy ` ZOOS
OEc i 2 Zoos
LL
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISANCAC 2C, WE
16. REMARKS:
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCT �Qj� SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Groundwater Section,1636 Mail Service CGV✓rl REVgh, C
Submit the hone No. (o 19) 33-3221n w1 of h nt30 days. er Ty�
27699-1636 Phone No. [phone],
ITV

11
CASING:
.335341i
WELL CONSTRUCTION RECORD
Quality Groundwater Section
North Carolina - Department of Environment and Nat raft l Resources - Division of Water
61 I , I tbb CERTIFICATION # 21118
WELL CONTRACTOR (INDIVIDUAL) NAME (p
WELL CONTRACTOR COMPANY NAME. _ NOSTATE WELL CONSTRUCTION PERMIT#
(ifa licable
1. WELL USE (Check Applicable Box): Residentialt Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
Topographic/Land setting
°Ridge ❑Slope ❑Valle lat
(check appropriate
Latitude/longitude of well location
(degrees/minutes/seconds) p g hie
Latitude/longitude source:OGPSOTo o rap map
(check box)
DEPTH DRILLING LOG
From To F9,r'rlation Description
2. WELL LOCATION'
Nearest Town: ('anon
(print)
Q /, e t / J. PHONE # & 0
P,CnP l�r�d7> f�—WC 4
County
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
(Street or Route No.)
//��,, y�City or Town Zip Code
(s092)- ci [9Y
Area code- Phone number
4. DATE DRILLED ,,
5. TOTAL DEPTH:
6. DOES `NE L. REPI.AC1! EX'`"! USCi u, 11LL'? YES rLl !SO FT.
7. STATIC WATER LEVEL Below Top ofingo—lflCasing)—
(Use" f AboveP o
8. TOP OF CASING IS ._-- FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
9. YIELD (gpm): _f2—
variance in accordance with 15A NCAC 2C .0118. / U(s
10. WATER ZONES (depth):
ASSOCIATED WQ PERMIT#
(if applicable)
LOCATI ON SKETCH
•
DISINFECTION: Type
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
12 Diameter or Weight/Ft. Material numbers and common road names.
Depth
From
0
From To Ft.
From To Ft. —
13. GROUT: Depth �M_aterial
From'). — To 20 Ft._s-r=Z✓l&1t
From To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
To
From
From
Diameter
Ft. in.
Ft. in.
Ft.
To Ft.
Method
Slot Size
in. _�.--;-
in.
Size Material
DEC 1 2 2006
16. REMARKS:
1 DO HEREBY CE IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTIONS ANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE ELLOWNER
5-
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service CGWrI - RREVgh, NC
27699-1636 Phone No. [phone], within 30 days.
DATE

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and . tural Resources - Division of Water Quality - Groundwater Section-��1
WELL CONTRACTOR (INDIVIDUAL) NAME (print) i/ v.r .I -)rrP0 CERTIFICAATIION# 22-85
PHONE # 623)64/8'3/7O
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
rte
lyOZ-
ASSOCIATED WQ PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential C� 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: C4/4v0 County 100004..
(Street Name, Numbers, Community,�Subdivision, Lot No., Zip Code)
3. OWNER: IOU hetetC ()JP
0-141
Address Q C
(Street or Route No.) ��
Ukupitwiiil.a NC.
City or Town State Zip Code
(g)- /13w-900cD
Area code- Phone number
4. DATE DRILLED 10-1 6-0 6
5. TOTAL DEPTH: b SS'
6. DOcc WE !. REPLACE ): FvtS.!!NG NA, Li 19 YES O NE) fa
7. STATIC WATER LEVEL Below Top of Casing: 1 0 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm):gj METHOD OF TEST 2:%r!l f
10. WATER ZONES (depth): y/ S'
bbD'
11. DISINFECTION: Type 14714-
12. CASING:
Depth Diameter
From b To 135 Ft. /of
From To Ft.
From To Ft.
13. GROUT: Depth Material i Method
From 0 To ZO Ft. C tne.di -- Toe
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.
Amount
Wall Thickness
or Weight/Ft. Material
PV
From To Ft.
Topograa hic/Land setting
ORidge NSlope DValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
'
LOCATION SKETCH
Show direction and distance in miles fr m afcast
two State Roads or County Roads. Incl t road
numbers and common road names.
:)7
RECEIVED
1l\/ QF ',r�L !R i L?7ll1T
TOO r 1:. ?0OCa_.
16. REMARKS:
1 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 THE WELL OWNER
i1ww'wa // -16 -0 C
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

3353-2
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N ural Resources
n-�Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL)
NAME (print) 4,bIN 1n. w'-' CERTIFICATION#,7H/S
/* ens $ is 3/7o
�j welt ,- `, ,,/ D,
WELL CONTRACTOR COMPANY NAME Cie ep'C 6roihees wee `✓ Awe
ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential UK-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
STATE WELL CONSTRUCTION PERMIT# / 1 0 Z-
2. WELLLOCATIO
Nearest Town: allne..514/be.
County HaAttOOCCI
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: 3JIM 14/t ��
Address /3%t7( /.v /t%WWT/.bq az
(Street or Route No.)
Ff Pnce 4 39915
City or Town State Zip Code
(816)- 9th-oigz
Area code- Phone number
4. DATE DRILLED / 0 -2 -0 G
5. TOTAL DEPTH: 6135'
6-. DOES WEL!. REPLACE ! X!S !NO WELL? YES L7 NO
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. /
9. YIELD (gpm): 2S METHOD OF TEST 2ldo(in
10. WATER ZONES (depth): l%SS
665
11. DISINFECTION: Type /+27/
12. CASING:
Depth Diameter
From 0 To (03 Ft. (ort
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 2.0
Ft.
Amount
Wall Thickness
or Weight/Ft. Material
Material
&emeN%
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
❑Ridge ❑Slope ❑Valley fitFlat
(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
by' bBS' C ramire
Method
ToP
Material
LOCATION SKETCH 'n
Show direction and distance in miles frouii at least E-"
two State Roads or County Roads. Includethe toad N
numbers and common road names. 1 `± o0
RECEIVED
cm../. OF WATER QUALITY
Y
HDV 2 t 2006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTIOI)f STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
24'leAAet-i £ (--u-QY, //- /6 0 i
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

Area code- Phone number
4. DATE DRILLED 10 _2b —0 4'
5. TOTAL DEPTH: 3a5' �/
6. DOES WELLREPLACE EX'S;t EANG WEl::' YLS LI NO
7. STATIC WATER LEVEL Below Top of Casing: .3 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance w th ISA NCAC 2C .0118. 9. YIELD (gpm): 3 5 METHODOF TEST 2NOCheS
10. WATER ZONES (depth): Z6Jr
290'
11. DISINFECTION: Type nrlf
12. CASING:
Depth
Amount
Wall Thickness
Dianster or Weight/Et. Material
From l°] To 5-3 Ft. b PVC -
From To Ft.
From To Ft.
13. GROUT: Depth Material //
From 0 To 2.0 Ft. eten18/V>"
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.
Method
Tee
16. REMARKS:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 6rc/&,M,L (preen 3e CERTIFICATIION#_2Ss
WELL CONTRACTOR COMPANY NAME 6 reeve- 6 m-Mtrs Iota cl-Pornp PHONE # 41Kl 6V8-3/90
STATE. WELL CONSTRUCTION PERMIT# / t Q !i ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential F3 Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: I 0.'/neS ✓tl/-e
County list y weed
(Street Name, Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER: 2( UG tz1750 Ar- (degrees/minutes/seconds)
Address Z 9 9 kvflsk r&r/YL IA Latitude/longitude source:❑GPS❑Topographic map
(Street or Route No.) (check box)
II �G N c Z 0 � 6� DEPTH DRILLING L
State Zip Code From To Formation Descri lion
LtlCCynesv
City or Town� '
(928)- Li0o-96 / 0' 53
sy' 3 05' b • ' i;i-G
Topogra /Land setting
❑Ridge lope ❑Valley ❑Flat
( check appropriate box)
Latitude/longitude of well location
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
MIOV 2 1 2006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCT N STANDARDS, AND TIiAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0411Im& `'( AmJ
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/f /4 —t
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD � p
North Carolina - Department of Environment and Nat/p/ra�l Resources - Division of Water Quality - Groundwater
Section
#ion
WELL CONTRACTOR (INDIVIDUAL) NAME (print) nLb �tbbl 0l1�0 �ifi
PHONE #----
WELL CONTRACTOR COMPANY NAME . €IlL_�--
/QZ ASSOCIATED WQ PERMIT#
STATE WELL(if
licable) ON PERMIT# �`� if licable
(if a licable
1. WELL USE (Check Applicable Box):
: Residential teaInjection�Oipa Other c 0 OthdusLi l U0 Agricultural 0
Monitoring 0 Recovery Pump
TopographiGland setting
[Ridge [Slope [Valley fdl:lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLS G
From To Fom7ation D4"sc?ritSII
(�-- gS r— LIRE/ i
'14' 403
2. WELL LOCATION: IIII o�
Nearest Town:
Q.g CountyHA—
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
Nts9tWG
treet or Route
l t'aHAl
City or Tawn State
�Jjj;,_ ¥ 52 oo 2
Area code- Phone number
4. DATE DRILLED L a 9 "p
5. TOTAL DEPTH:
6 DOLS WE t ut:PL.nUF 1:YIS 1 ¶NU WELL? YES I NO its
7. STATIC WATER LEVEL Below Top of Casing: /o D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variancein accordance wit ISA �NC ETF1 OF TEST % (JC5
0118.
9. YIELDELD(gpm):—.
10 WATER ZONES (depth)'
Zip Code
r nreTt nN SKETCH
Amount Show direction and distance in miles from at least
11. DISINFECTION: Type Wall Thickness two State Roads or County Roads. Include the for
L. CASING: h DepDiameter or Wei htlFt. g Ma numbers and common road names.
t
From__(__ ToFt._ &___
From To Ft.
From To Ft.
Material Mcthod'�''�'�
13. GROUT: DepthoFt. /�dl Tof—'— -
From�_ To
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
To Ft. in. in.
From n
From To Ft. in.
15. SAND/GRAVEL PACK: Material
Depth Size
From To Ft.
From To Ft.
O
rrl
CC)
O
rn
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC • STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Ceenterl RREVgh, NC
27699-1636 Phone No. [phone], within 30 days.

33 331
WELL CONSTRUCTION RECORD ,Q�
North Carolina - Department of Environment and atural Resources - Division of Water Quality - Groundwater
Section
# ioS n
r PHONE # (d2A. /� $ %d
WELL CONTRACTOR COMPANY NAMF. (print) cult' L
��P
WELL CONTRACTOR COMPANY NAME ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# ifa licable
(if a licable 1.
d 1 PS/
Municipal/Public 0 Industrial 0 Agricultural 0
WELL USE (Check Applicable Box): Rest entta Other 0 If Other, List Use
Monitoring 0 Recovery 0 Heat Pump Water Injection 0
2. WELLLOCATI
Nearest Town:
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
CountyJ'/111flifitad_
State Zip Code
,ity o2.-(„gin , zn��
Area code- Phone number
4. DATE DRILLED
5. TOTAL DEPTH:
7. STATIC WATER LEVEL Below To `ofC il i Yt.L(,l n;O
ES 4 EL - LCS T.
" ` " op of Casing'
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S FT. Above Land Surface*
*Top of casing terminated atior below land surface requires a
variance in accordance with ISA NCAC 2C .0118. METHOD OF TEST
s
9. YIELD (gpm): �.— r
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING: Diameter
Depth Fj
From_ To Ft.
From To Ft.
From To Ft.
13. GROUT: Doth Ft. 'e,Dt �
Material
From_Q_
From To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Diameter
Ft. in.
Ft. in.
Amount
Wall Thickness
or Weight/Ft. Material
Method
Slot Size Material
_ in.
in.
Size Material
Topogra hic/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) h1C map
Latitude/longitude source:❑GPS❑TopogIa p
(check box)
DEPTH DRILLING G
From To Fo ationrT�escrtptton
56k w'
LOCATION H
Show direction and distance in nail Is f rorn attleast o
two State Roads or County t7a
numbers and common road names.
RECE
DIN i..}. `,i`1Xfl
NOV 2 Y. Z006
16. REMARKS:
I DO HEREBYRTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUC. ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELLz,O� ER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
C
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh,Neigh,
27699-1636 Phone No. [phone], within 30 days. GW-1 REV.07/2001

335345
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. r//
Address
North Carolina - Department of Environment )d
WELL CONTRACTOR (INDIVIDUAL) NAME pr t)
WELL
OWNER: -i-�/� LL —�}}
(Streetor Route No.)
State Zip Code
City or To'n 3�6y
Area code- Phone number n �i
4. DATE DRILLED 9 L- -
5. TOTAL DEPTH:
6. DOES
WELL REPLACE AUE Ex!s'!Nr,. WI''' o YES L.1 NO I
7. STATIC WATER LEVEL Below Top of Casing:.iQ--FT'
(Use ••+" if Above Top of Casing)
S. TOP OF CASING I5 J FT. Above Land Surface*
*Top of casing terminated atior below land surface requires {f aXi
METHOD OF TEST variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm):t Sr %�i
10. WATER ZONES (depth): _--�
11DISINFECTION: Type Show direction and distance in miles from at least
Amount �— two State Roads or County Roads. Include the road
.
12. CASING: Wall Thickness Diameter or Weight/Ft. Mato erial numbers and common road names.
Depth a•
From—To-5'—Ft. b
From To Ft.
From To Ft. ethod
Depth Material 0
13. GROUT: P 11n� 'r
From O To Z1� Ft.
Ft
To .
From S
Diameter lot Size Material
]4. SCREEN: Depth Ft. in. in.
From To Ft. in. in.
From To
15. SAND/GRAVEL PACK: Size Material
Depth
From To Ft.
From
To Ft. -----
WELL CONSTRUCTION RECORD
tural Resources - Division of Water Quality - Groundwater Section s
CERTIFICATION
PHONE # (7 9-0
CONTRACTOR COMPANY NAME
WELL CONSTRUCTION PERMIT# r a i )
(ifa licable '{ able
I
�
ASSOCIATED WQ PERMIT#
STATE
Residential Municipal/Public 0 Industrial 0 Agricultural 0
I . WELL USE (Check Applicable Box):
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Topogra hic/Land setting
ORidge ope OValley OFlat
2. WELL LOCATION: County�'n/ ate box)
(check appropri
Nearest Town: Latitude/longitude of well location
(degrees/minutes/seconds) hic map
Latitude/longitude source:O (ch Pk iOTopogra P
)
DRILLS LOG
Formation Description
DEPTH
LOCATION SKETCH
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15ANCAC 2C, WELL
CONSTRUCTIO�i'STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
r -- • SIGNATURE OF PERSON CONSTRU TING THE WELL -
_ DATE
Mye pda2 It iee Center - Raleigh, NC
Submit the original to the Division of Water Quality, Groundwater Section
ULL- d LUUU GW-1 REV.07I2001
27699-1636 Phone No. [phone], within 30 days.

346
WELL CONSTRUCTION RECORD Quality Groundwater Section s
Division of Water Qu ty CERTIFICATION
North Carolina - Department of Environment and Natural Resources - AAT1 648 —6:
r Brd e� CERTIFICATION
#�
WELL CONTRACTOR (INDIVIDUAL) NAME (Prig)
WELL CONTRACTOR COMPANY NAME ASSOCIATED WQ PERMIT#
nD
if a licable
STATF, WELL CONSTRUCTION PERMIT# cultural 0
(if a licable ff./Municipal/Public
/
. WELL USE (Check Applicable Box): Residential p� Municipal/ h r 0 If Other,Industrial
II e Ate'
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0
2. WELL LOCATIO
Nearest Town:
Community, Subdivision, Lot No., Zip Code)
(Street Name, Numbers,
3. OWNER:
Address
County ing U
State Zip Code
rty or Town Q
4 DATE DRILLED 9_ /2 -a 6
Area code- Phone number
t
5. TOTAL DEPTH:
6.DOES WELL REPLACE Lvl i!NG turn 1'r VES L0 NO Wi
(Use "+" if Above Top of Casing)
7. STATIC WATER LEVEL Below Top of Casing: FT.
S. TOP OF CASING IS �—
FT. Above Land Surface*
*Top of casing terminated Orlon below land surface requires a
variance in aceordane) with 1S METHOD OF TEST 2
lleViri
9. YIELD (gprn): (o
10. WATER ZONES (depth): / 0
Amount
11. DISINFECTION: Type Wall Thickness
12. CASING: Depth Diameter or Weight/Ft.
From —To Ft._LI__
To Ft.
From Ft.
From TO
Depth p�Mate�rial�.
13. GROUT. To w Ft. t...e
From Ft.
To
Topographic/Land
setting
°RidgEISiope /Valley /Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) a hIC map
Latitude/longitude source:O(chPk0Topogr P
box)
DEPTH DRILL
Fo ' ', ion Description
From To }
From
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEELPACK
Depth
From To
From To
__.—Material-.__._
Diameter Slot S¢e
Ft. in. in. _
Ft. in.
Size Material
Ft.
Ft.
Sr�al
t '
8
LOCATION SKETCH
Show direction and distancemiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DEC l 2 2005
NOS( 11- ZOOS
16. REMARKS:
AND THAT A COPYNOF THIS RECORD HA BEEN PRO DIED O ATHECWWELELLOWNER
/f7-0 s'
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the hone to (t 9) 2Water Quality, Groundwater Section,1636 Mail Service Ceenteri Raleigh,
NC
of
27699-1636 Phone No. [phone], within 30 days.

335347
WELL CONSTRUCTION RECORD
Quality Groundwater Section
WELL
CERTIFICATION Se
North Carolina - Department of Environment and Natural Resources - Division of Water Q
✓YJ'!•P PHONE # yA .,i
WELLCONTRACTOR(INDIVIDDAL)NAME (print) S tei ��
cede l( PERMIT#
SWELL TATE WELL CO OR COMPANY NAME _ /4 0 Z ASSOCIATED WQ
Y if a licable
STATE WELL CONSTRUCTION PERMIT# Agricultural 0
(if a licable industrial 0 8r
Applicable Box): Residential p�Municipa1 Other If Other,uList Use
WELL USE (Cheek Apr Heat Pump Water Injection ❑
Monitoring 0 Recovery Topographic/Land setting
�at
'/_ pRiTo (]Slope 3 setting
2. WELL LOCATION: `�� County�� check ate box)
Nearest Town: Latitude/longitude of well location
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
(degrees/minutes/seconds) a hiC map
Latitude/longitude sourcource:u(chPS4Top° gr P
3. OWNER: L6Y.G DRILLING OG
Address _� ure No) DEPTH eck box)
Formation Description
WI
(Street or oG Z S To
From m i
"Lip Code �) r
City or.Tovm
State t
Area code- Phone number n / 6
4. DATE DRILLED iiy-
5. TOTAL DEPTH: 's- S: -- �—
r r ACl. lEXIS+ lniG W + o YES ❑ NO t
r.
i I:l...
7. DOES C'WA R..P�, Casing:p of _-t �j—FT. —�
7. STATIC WATER LEVEL BeloWUse - if Above Top of Casing) -�
FT. Above Land Surface`
g. TOP of CASING IS *Top of casing ordancetwi ah /orIS below land .0118.e requires a ' u / -----
variance is accordaaee __ t51MEA THO t OF TEST_LOCATION
9. YIELD ZOO T H
10. W ATER ZONES (depth): Show direction and distant Rofl sI Include the r ad
re-rr1 Amount __._ t o State Roads or Counry
11 . DISINFECTION: Type_Y�-_+r — Wall Thickness numbers and common road names.
12. CASING: Depth Diameter or Weight/Ft. Material
�r
To._2� Ft.�__—
From_ To Ft.
From Ft.
From To ethod
Depth Material v
13. GROUT: P Ft. ��,,,, g _ - _
From_2--To�Q— v +�� —e `RE
To Ft.�--_'
FromCDiameter Stot Size Matenal_ _ ..
_ -........
)006
14. SCREEN: Depth Ft in. in. —�- y,(l�r �`i: n -
rirti
From TO Ft. in. in. yam— - ..
From To
15. SAND/GRAVEL PACK: Si�.e Material DEC 1. 20�6
Depth _ice
To Ft.
From Ft. ---��.
From To
16. REMARKS: WELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C,r/
CONSTRUCTI': . STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THEWELLOWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
TE
Groundwater Section, 1636 Mail Service Center - Raleigh, C
Submit Water
the hone No. (919)) 33-3221n within 30 dayQuality,
Gwa RE
o
27699-t636 Phone [phone],

North Carolina - Department of Environment and Natural Resources
Division of Water Quality - Groundwater Section
WELL CONSTRUCTION RECORD
2VA
CERTIFICATION tW
WELL CONTRACTOR (INDIVIDUAL) NA
TRACTOR COMPANY NAME
WELL CONSTRUCTION
ble Agricultural 0
1 Er Municipal/Public O Industrial 0 Agri
Topographic/Land setting
ORidge OSlope Walley
QFiat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) a hie map
Latitude/longitude source:OheckOTopogrp
box)
DRILLING LOG
Formation Description
PERMIT#
ME (/print)�/,,emu-�-JF'.1,I rLi NA �o't30
CrI Sin U'-- J A �� P PHONE # yt�.a�—
WELL CONTRACTOR (� Q ASSOCIATED WQ PERMIT#
ifa lWQP
STATE
(ifa tea
From To Ft.
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
From To_
From To
16.
Ft.
n A
From. —To z0 Ft. $MS/1—
MatcripL.--- -
Diameter
Ft. in.
Ft. in.
Size
Ft.
Ft.
Area code- Phone number
4 DATE DRILLED
WELL USE (Check Applicable Box): Residential
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATION:
vil1 County `�d°
Nearest Town: h —��--
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address —
(Street or Route No.)
CiheA) i'e IV L Zip code
City or Town State
lei)- 7 s_ L 77 97
-Z�
5. TOTAL DEPTH: i_CV
ar
7.
DOES r, ELL REPLACE EX!S'! !NU W.,, E(,I? YES U NO
STATIC
., i.. 1of
7. SWATER LEVEL
Below
use" "+" ifAbovegTop of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
op of casing terminated atlor below land surface requires a'
variance io accordance with 15A NCAC 2C .0118. Zl7r/
METHOD OF TES U/I-----
9. YIELD -(d�— S 1
10. WATER ZONES (depth): , i , at least
Show direction and distant in miles
ds. Include the road
y T/G Amount --- two State Roads or Counry
11. DISINFECTION: Type Wall Thickness
12. CASING: Diameter or Weight/Ft. M t@ trial, numbers and common road names.
nn Depth
From_12 To�� Ft
DEPTH
From To
*
22
From To Ft.
From To 1 Method
13. GROUT: Depth atcria
C
Slot Size
Material
LOCATION SKETCH
DEC12 2006
REMARK
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC r : - STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURP. OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section,1636 Mail Service Center - Raleigh,NC
, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. h
S:

335334
WELL CONSTRUCTION RECORD Groundwater Section
Division of Water Quality - on
CERTIFICATION #
North Carolina - Department of L) NAME
and Natural Resource - #4 O
�harS _PHONE # 1>r -S�ZJI
WELL CONTRACTOR (INDIVIDUCOMPANY NAME
E (print) ��
WELL CONTRACTOR COMPANY NAME EEC-- ASSOCIATED WQ PERMITS
STATE WELLCONSTRUCTIONa cab e) PERMITS rti 2- if a licable
(if a licable) Agricultural 0
1. WELL USE (Check Applicable Box): Residential
Injection Er--Municipal/Public
pa Other If Other, List U❑se A�
Monitoring 0 Recovery 0 Heat Pump Water
setting
NJltidge ❑Slope °Valley °Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) a hIC map
Latitude/longitude source:°heckbox)bT°Po Sr p
DRILLING GG
Formation Description
2. WE.LLLOCATION:'`.—County
Nearest Town: Ut A
(Street Name, Numbers, Community' Subdivision, Lot No., Zip Code)
3. OWNER:
Address _ (Street or Ro
wn y From,
City or Town
State Zip Code
ilCo '7 --
Area code- Phone number ^ ��r , _�-
4. DATE DRILLED t 4n (D —
5. TOTALDEPTH: YES Li NO �_�_�
6.DOES WELL REPLACE. EX.1St 1NU '.' E11 oFT.
7. STATIC WATER LEVEL Below Top (Us ' ° if Above f gTop of Casing) �—
8. TOP OF CASING IS
FT. Above Land Surface*
*Top of casing terminated IS below land surface requires a V variance in accordance with 1. MA ETHOD OF TEST 2 S r S
AC 2C .0118.
9. YIELD O N CH
10. WATER ZONES (depth):
11. CA
Show direction and distance in miles from at least
DISINFE
Amount two State Roads or County Roads. Include the road
12. CASING.ING: ION: Type Wall Thickness Diameter or Weight/Ft. MatPnal numbers and common road names.
Depth '
From_ To J __ Ft. b r
From To Ft.
From To Ft. h Material Method
Depth 13. GROUT: p (o�P
From�TO � Ft._.. _-�n_--�— __--_
Material
From i °-
14. SCREEN: Depth
From Too —
From To
15. SAND/GRAVEELPPACK: th Size
From To Ft.
From To Ft._
Ft.
Diameter
Ft. in.
Ft. in.
Slot Size
in.
in.
Material
DEPTH
To
NOV 21 Z006
16 REMARK
ACCORDANCE WITH 15A NCAC 2C, WELL DO
S:
OWNER
t O HEREBY CERTIFY THAT THISAWELL WAS CONSTRUCTED THIS
THE IN D HAS E //'/L �
CONSTRUCTIC TANDARDS, A D THAT A COPY OF Tl}IS RECORD HAS BEEN PROVIDED TO THE WELL
n„ DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of hain 30 days.
27699-1636 Phone No. [phone],
litY, Groundwater SEction, 1 36 Mari Service CeOnt�)errl REV. ttg47/2 0l
Pf
t'o
LITY
DEC 12 2006

335335
WELL CONSTRUCTION RECORD
DivisionQualityGroundwater Section S
Groundwater N lion
North CONTR - Depart (INDIVI of L) NA E (p and NaJ,urat Kcsouan h fG.en_e_of Water — 'QTI /,!$ 3/,
tint /1✓� 1 �%U4�.,i(/it'� - PHONE N 1SaY _
WELL CONTRACTOR COMPANY N ME_ (print)
�iit®f r _.-_
atilt
TOR
12(
0'� ASSOCIATF;n WQ PERMITS( _.-
STATE WELLCONSTRUCTION
NSTR CTION PERMiF:_ - (ifa licabie)
I [f __
STAFF; W'F;LLf:a licab QF1ON PF:RMI'1'k __L] ---
(if a licablc) Agricultural ❑
Applicable l3ox): Residential �unicipal/Public 0 Industrial 0 g
I - MonWEitoring
LSEg Recovery
ve
Other 0 If Other, List lJsu_-----
Monitoring 0 Recovery 0 I(cut Pump Water Injection
2. WELT
LOCATION:
Topogra setting
in
Nearest Tuwn:__CAnwn_ County_ °RidSe lope pVallcy❑Flat
check apprt)PItatc box)
latitude/longitude of well location
1 Street Name, Numbers. Comorumty, Subdivision, tia No.. hip Code)
/� �,y �p�� Wegrcudhmnutas/seconds)
�i1___L �-'-`--"_—)&_ Lacieudc/longitude souroe:�GPconds) graphic map
3. UWia:SS . (5...(1 (check box)
-I'J OS Coro /I P�L — DRILLING LOG
Ad(irc.tis _- llBPTIi
•
A et ur te tute'�o.G y ` �/ lip Code To F rmation Description
AI^,., J_Z--- From
city war l L- —
Area code- Phone numberO �
4. DATE DRILLED- 9�i/ ---
5. TOTAL DEPTH:-. 12 aS- Y I. q I I NO ��
” e ry t. i i o f p, � i 1 t I Y, t a i I K : t� I'd L. ! •
_LLD_ I NO 1 T.
7. STATIC'. WATER LEVEL Below tTop of Casing: op of Casing)
--
ET. Above Land Surface`
8. TOP OF of
IS _I_ —
*Top of casing terminated at/or below land surface requires a —
rILLI) ing accordant. with IS NC AC 2C .0118.METHOD OF TEST O(/ -
9.
10. WATER 7ONES (depth) — —
LOCATi( ll
Show direction and distance m miles from at cast
/1:T - -_ Amount __� two State Roads ord County l from the road
ast
I1, DISINFECTION: - �/ Wall eightncss
n o Stat and rnC o road names.
11. CASING: Diameter or Weight/ft. Material,
Depth , eG_
Tot_b _ — __.
Ft. —
Prom_.. p._ -. Ft.
To Pt.___ _.
From.. To
From Material ethod
13.GROUT: Depth7p� +G
Zo Ft. Leine -- 6�
Flom_ . _.'To
Crum. _._— To Slot Size Material :--. _ __ r...__._
Diameter y
(4 t SCREEN: Depth Et n. NO! 2 1 2006
To_ ---
From--- Et. in. . _— m. _
From __.To. - _ 1
15. SANDICiRAVDepth DEC PACK: Size Material !
] 2 2006
To_ Et
from --_ Ft
Prom —To_—
lb. REMARKS: _ . _ __ _ .
STANDARDS, AND TIIAT A COPY OF TIIIS RECORD 11AS BEEN PROVLDED
t DO IIERFBY CERTIFY FIlAY ' GU15 WELL WAS CONSTRUCTED EN ACCORDANCE WWI lSA NCAC 2C, WELL
CUNSTRU�' (>' r� __ - TO 1-I1E WL1. L ER
�--
UA I'f•,
- --- SIGNNBiRP. OP PERSON CONSTRUCTING TILE WELL Raleigh,N(
Groundwater Section, 1636 Mail Service Center
ee'W I V.hNC
Submit the hone No. (919)o 1he 733-3221,D21, wt Water n30 days.
27649-1636 Phone No.
!TV

333336
North Carolina - Department o
WELL CONTRACTOR (IN DIVID
WELL CONTRACTOR COMPAN
STALE WELL. CONSTRUCTION
(if a l'cable)
1
WELL CONSTRUCTION RECORD
f Environment and Naj�trat Resuurcts - )ivision of Water Quality - Groundwater Section
Q
(._.♦Q bI h (, )I^ - CERTIFICATION
(:#%L�7 �V
UAL)
NAME (print)) NAME &Tea& Q eaW Y,,0I�u/� ,,/'///� PHONE # "-6 L96
ASSOCIATE. WO
PERMITN -_.. _. ...
pERMrrq _—_ f Z-� 2— -- "-. (if a licablc)
WELL I USE (Check Applicable 13 x) Residential C� Municipal/Public 0 Industr
Monitoring Recovery ❑ li
2. WELL LOCATION
Nearest Town:
t1n
'
cut Pump Water Injection 0 Other
Topogra "(Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
_�— (degrees/minutes/seconds)
sourcinutes/seconds) +ra hie map
Latitude/longitude source:❑GP(check box) pob P
DEPTH DRII,IING LOG
Formation
Countynt/ 6a
(StreetName, Numbers, Community, Subdivision, n No., Zip Code)
n
3. OWNLR:_- in_ aAddress _- (Jf-.._pi...
City /ty or Town
Stale Zip Code 10
�I\
($ u3,—J��11--- 3
Area code Phone number V // O - _
4. DATE DRILLED D ---
/
5. TOTALDEPTII ___-7 yi.f--
IvIo S vl:l nl alto n("I. E YIls 11F(t ntl ._, bIL 11 -A.
7. STATIC WATER LEVEL 13cluw Top
e"4'\ifAboveTopoo 0 FT.
(usof Casing) --
8. TOP CASING IS —
/__ FT. Above Land Surface*
'f op of of casing termm inated at/or below land surface requires a
a ariamu: e in accordantf with 15A NCAC 2C .0118. � ` — -
�� METHO )O ,TEST_ - L
10. WATER ZONES (depth): ___ . --
(05
-_ Amount
11. DISINFECTION: Tyi._ .Wrir Wall 'thickness
12 CASING: Diameter or Weight/Ft. Material
Depth r. PVC -
From // �r _-.
To .__ Ft. —
...-- - -
Ft'
Front _ _ _ To_ th Method
Material
13. GRMaterial Ft._ C6m_____Tap—_
From
©. -- To
I Tom _ To—.— _Ft. -------
Slot Size Material
Diameter _.._�.-.
l4. SCREEN: P.N: Depth Ft in. in. —
To— - From_ in. in.-T--_'
From _ - -
I . SAND/GRAVEL PACK Site Material
Depth
To— Et- - ----_-----
To Ft.
From_
ial ❑ Agricultural 0
❑ If Other, List
LOC.ATI_ O,'T(-1I.
Show direction and distance in miles from at (east
two State Roads or County Roads. Include the road
numbers and common road natnes.
DEC 1 2 2006
200E
i6. REMARKS
I DO HEREBY CERITFY IItAF THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH C
I5ANCAC 2. WELL
CONSTRt/ ION STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TIk.O OWNER
DATE.
j ryA�LLn�
--w •-- SIGNATURE OF PERSON CONSIRUCTINCi TI IF WEI.I.
Submit the Phone
to 121, of Water Quality, Groundwater Section, 1636 Mail Service Center
C WrI REVgh. C
27699-1636 Pbone No. [phone], within 30 days.

-33-333 i
WELL CONSTRUCTION RECORD
nt of Environment and Na ral Resources - Division of Water Quality - Groundwater Section
)}' , W�6 cFtrruLCA'noNaZ�%/8
North Carolina - Department
f� ,/
well V*P€'2ne _. _PHONE # (.4V19.631.2()
WELL CONTRACTOR (INDIVIDUAL) NAMp, (print) Well c'roRcoMPnNYNAMk(�lGGnP✓
-- (ifa hcable)
L CONSTRUCTION PERMIT# _. _
(ifa flicablel
WELL CONTRA - /l[
STATE WELL C7
WELL. ESE (Check Applicable Box): Residential Fa---Municipal/Public O Industrial O Agricultural
1
-_ - PERMIT'#
`7 2 ASSOCIATED WQ
Monitoring O Recovery O Ileat Pump Water Injection ❑ Other ❑ If Other, List se -
2. W'ELI,LOCATI5
Nearest Town:
County__
of No.. lip Code)
(Street Name, Numbers, Community, Robdrvison,
7
3. OWNER:_ _
Address _-..19K.
(Str!eet or Route No.)
-- - Lip Cute
City or Town Stag
814.9- YL/ �06
Area code- Rhone number
4 DATE DRILLED
5. TO
7. STATIC WATER LEVEL BctowtTop ofCasing:
Aboveig: ,a_o
p of Casing)
R. TOP OFfCASING IS _ 1 __ FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C MIDI. -�� �/�,����
9. YIELD (gpm): /12- METHOD TEST _ 2-Q a-
10. WATER 'ZONES (depth): -_ __'
/y-6
Topographic/Land setting, !ar
ORidge OSlope OValley In(l
(check appropriate box)
Latitude/longitude of well location
— -- (degreevminates/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING I OGOG
hatit-AT
ation Description
TOTAL DEPTH:__--
1 I. DISINFECTION'. Type..
12. CASING: p
Depth __.pr -
O. To 5, Et.---.t!!___._ _ - -
From_ _ _
From - To .... Ft. From__ _ To Ft. -
uteriul ,
13. GROUT: DeTO C _ -
From_P- Tq_- _ Ft. From __. To _ _ Ft..-...
Diameter Slot Size -Maiarlal-_.
l4 SCREEN: Depth Ft. in. in..,._ -
From_ _To_— .__
From.__._. -
Ft. in.
15. SAND/GRAVEL PACK: Size Material
Depth
From_
To__ Ft.
From To -Ft.
Method
Amount
DEPTH
Frotnl
--
To
II i
LOCATION SKETCII
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
\Vali' Weight/Ft. numbers and common road names.
Diam�tcr or Wetght/Ft. Material
V 2,1. Z006
16. REMARKS: _ -- ---- _ WELL
[ DO i IEREB ' CERTIFY TIIA'f THUS WELL WAS CONSTRUCTED IN ACCORDANCE Wall I5A NCAC 2C,
('ONSTRU H N STANDARDS, AND TIIAT A COPY OF THIS RECORD IIAS BEEN PROVIDED TO TI WELL74
ER
SIGNATURE OP PERSON CONSTRUCTING TIIII WELL
DATE.
Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
Submit the hone No. (19) 3i -3221 within Water Q Y�
GW-1 REV. 07/2001
27699-1636 Phone (yl9) 733-3221, 30 days.

-335338
'. ) 2Osr
q A!F
7. STATIC WATER LEVEL 13clowTopUse" cf if AbovCasing: �00 _FT.
pot( a iltgi
ri. TOP OFCASING IS-1—
ET. Above I,and Surface*
°'Ibp of casing terminated atlor below land surface requires a _
variance in accordance with ISA NCAC 2C. .0118. 'L�-
9. YIELD (gpm): y�5---. METHOD OF TEST 14 Jt
tp_ WATER ZONES (depth):.
� 7� Amount ___----
1 t. DISINFECTION: TYPE rI-� r/ - -- Wall Thickness
trial
WELL CONSTRUCTION RECORD
Division QualityGroundwater Sectio�n��'j�
CERTIFICATION Sec o""" a
�Rlan North Carolina -Department of Environment and Natural Resources`�i��� ���qr b �� ��i7
♦ME. print) Nam*' w .PHONE. # 1(�.-
WELL CONTRACTOR COMPANY NAME ircene- p 1' - „
WELL CONTRA("tpR COMPANY - G �'�IG/'ASSOCIATF:U WQ PBRMCI#�---
STATE WELL CONSTRUCTION icable) 10N PF:RMI't'# _._!- 0- — - _ -.. (iT 'cable)
(ita licablel Agricultural 0
Applicable l3ox): Residential CC�Municipal/Public 0 Industrial 0 Ag
l . WELL ri g (Check Apr .. heat PurnpWater Injection 0
Other ❑ if Other, List Use__------
Monitoring 0 RecoveryTopographic/Land setting
❑Ridge l3K6pe ❑Valley ❑Flat
County [�D (check appmprina: bux)
Latitude/longitude of well location
'!. WELL LOCATION: r�
Nearest Town:
—�— Code)----- Subdivision. Alt No.. Zip
(Street Name. Number.. Community.
3. OWNER:
Address -. b(v.Q-- - )-
(Street
�— AR/UC-C No.)
v`�-
CIt, or Town State .tp Code
Area code- Phone number
[ A'EL DRILLED__ ED /0 1'D.fO- ._-_..
---
Nt
l lef 'l I Y W I Ix:e' Ul 11 ,1 V i L 1 1 x;r)
5. TOTAI,DIiPTFL_
(degrees/minutes/seconds) 0 hiC mapLatitude/longitude source:OGPSDTop 6na P
(check box)
DEPTH DRILL INCI LOG
Ton 7/ Formation Description
From
UCp'MythL'- CASING: Diameter or Weight/Et Mat
�,,
I rom-- O- - To_h2�._ Et.
From To
- - To_ —Ft.-_._ __ ---_.
From_ _.__ _._ Method
13 GROUT: Depth Material _
From b ...- To._. Ft. Coble- -P----
I rem _-----To Et.
Slot Size Material
Diameter
SRLE,N: Depth Ft la in. --r
Front To - in.
Material
From To Ft. in. _...
15. SAND/GRAVEL. PACK: Sire
Depth
ProTo Ft..
m-- -- -- - -.
From
To Ft.
ran
Show direction and distance s from at (east
two State Roads or County Roads. Include the road
numbers and common road names.
DEC 12 2M b
(ENE) _
t)Iy/ r r ;, : + l t-,AL f f'(
V 42 1 2006
16. REMARKS: _. - ----- - WELL
t DO I IEREBY CERIIFY'tllAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C,
CUNSTRL'( 'jON STANDARDS, AND THAT A COPY OP TIPS RECORD IIAS I3EEN PROVIDED TO THE WELL LOWNER
__---- DATE- ----j- - - SIGNATURE OF PERSON CONSTRUCTING TILE WELI.
, NC
Submit the original to the Division within 30 days.GW-1 REV. h
Quality,
Groundwater Section, 1636 Mail Service Center -Raleigh,
of Water
27699-1636 Phone No. (919) 733-322h

WELL CONSTRUCTION RECORD Groundwater Section
al Resources - Division of Water Quality -
artment of Environment and N CERTIFICATION #
North Carolina - Department I A PHONE #
WELL CONTRACTOR (INDIVIDUAL) NAME^(P^nt]�oQnL , uK
WELT. CONTRACTOR COMPANY NAME G l tit _ASSOCIATED WQ PERMIT#
STATE WELLCONSTRUCTION
aPPicable PERMIT#02'__-�-- ifa licable Agricultural (ifa licable Industrial 0 Agn
Applicable Box): Residential Municipal/Publicbl0 CI If Other, List Use
1. WELL USE (Check veP Heat Pump Water Injection 0 Monitoring 0 Recovery ❑ Topographic/Land setting
CJRidge ❑Slope 0Vallett fdllat
2. WELL LOCATION: ns Il �� County (cheek appropriate box)
Nearest Town: I /
Latitude/longitude of well location
(Sweet Name, Numbers, Community, Subdivision, Lot No., Zip Code) 3. OWNER: (degrees/minutes/seconds)
Latitude/longitude source:OGPonds)
Address og phic map
DEPTH
/ (check box)
DRILLING
Formation Description
From To ,
D%�Ir 3Z
(Street or Route No.) 2 43 -,.r 2 /
S�ta�tg Zip code
City or Town
5 246
(�>e3'�e 6 Area code- Phone number /O ,/2. 0
4. DATE DRILLED
5. TOTALDEPTH:
6. DthSTATIC
REPLACE EyisW To �i.,n:1 si g Es,-% No FT
7. STATIC WATER LEVEL Below Top of Casing:
(Use p Above Top of Casing) ---�
FTAbove Land Surface'
g TOP OF CASING IS _----- .
*Top of casing terminated at/or below land surface requires a
variance in accordance Nth ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST_c =� --
10. WATER ZONES (depth): Roads. Include the road
Show direction and distance in miles from at least
LOCATION SKETCH
Amount two State Roads or County
11. DISINFECTION: Type Wall Thickness numbers and common road names.
12. CASING: Depth D� rjieter or Weight/Ft. M t�G
From 0 Too — Ft.
From
To Ft.
To Ft. Method
From Matetal
13. GROUT: Depth Ft. c&flPA'%
From To_—
To Ft.�
From Diameter Slot Size
14. SCREEN: Depth in.
To
From Ft. n. Ft in in.
From To
15. SAND/GRAVEL PACK: Material
Depth Size
Ft.
To --�—
From Ft.
From To
DEC 12 29116
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIT16. REMARKS: WELL
DARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
H ISA NCAC 2 ,
CONSTRUCTION S (/ P
-----J"'� SIGNATURE OF PERSON CONSTRUCTING THE WELLDATE
Quality, Water Groundwater Section,1636 Mail Service Center
Raleigh,
C
Submit the original. (the 33 3221 within 30 days.
27699-] 636 Phone No. (919)

WF.L1, CONTRACTOR COMPANY NAME ASSOCIATED WQ PERMIT
T# if livable
STATE WELL flie
i a i
al frY Munici
WELL USE (Check Recovery
ice e
Monitoring 0 Recovery ❑ Heat Pump Water Injection
S CONSTRUCTION
2. WELL LOCATION' CountyFf
Nearest Town:
1 Street Name, Numbers, Community, Subdivision, Lot No., lip Code)
3, OWNER:
Address
City or Town
State Zip Code
18')- v• c
Area code- Phone number D . Z _ 0 %
4. DATE DRILLED
5. TOTAL DEPTH:
DOE WELL REPLACE Evlcr!n,ri WELL? YES Li NO L
7. STATIC WATER LEVEL Below Top of Casing: -_e!i_FT.
(Use "+" if Above Top of Casing)
! FT. Above Land Surface*
8. TOP OF CASING IS !
*Top of casing terminated h below land .01face requires a ��
variance g accordance with ISA/ H D OF TEST 2
118.
9. YIELD (gpm):—� 10. WATER ZONES (depth):
Ic 1 Amount
11. DISINFECTION: Type_. _ .. Wall Thickness
12. CASING Material
From
Depth Diameter or Weight/Ft. Mkt J�
—�— To_ Ft.—� (/
From To Ft.
From To Ft.---- ethod
_--
13. GROUT: Depth
Mate
From 2b Ft. —�_
To Ft
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
335340
tural Resources - Division of Water Quality - Groundwater Section
CERTIFICATION# 21ile
PHONE #
PERMI
(if 1'cable Agricultural Resident pal/Public 0 Industrial 0 Agri
Applicable Box) Other 0 If Other, List Use
1.
Topographic/Land setting
Ridge ❑Slope OValley
(check approPriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) hie map
(check
Latitude/longitude source:OPOTopogra p
DEPTH box)
DRILLS LAG
Formation Description
From
14. SCREEN: Depth
From To
From To
15. SAND/GRAVELDepth
PACK:
To
To__
From
From
'-mot
Diameter Slot Size Mate Tial
Ft._ n.---in.
FL
n. in.
Size
Ft._
Ft
Material
From To
� r A2—
LOCATION SKETCH
Show direction miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DEC 1 2 2006 NO\
l 1 2006
16. REMARKS: WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL
1)OWNER
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2 ,
CONSTRUCTI�I STANDARDS,
(!�Q
----�`— SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the hone to 1) 21, of Water Quality,
Groundwater Section,1636 Mail Service Centeri Raleigh,
C
27699-1636 Phone No. [phone], within 30 days.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NatgralResources �ision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ��11
WELL CONTRACTOR COMPANY NAME ��p ZZ ASSOCIATED WQ PERMIT#
STATE WELL CONSTRUCTION PERMIT# �ifa�licablel
(ifa hcable)
CERTIFICATION # 2 f7
PHONE #
LISO
1. WELL USE (Check Applicable Box): Residential le Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELLLOCATIO d!
Nearest Town:
County_
(Street Name, Nu fibers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
City State Zip Codeap..��t or Town' Z
Area code- Phone number
p �
4. DATE DRILLED 7�u �a_— --
5. TOTAL DEPTH: 26Err
6. DOES WELL. REPLACE EX SLING WE! !! YES U NO FT.
7. STATIC WATER LEVEL Below Top of Casing:
32- (Use "+' if Above Top of Casing)
S. TOP OF CASING IS % FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith 15A NCAC 2C .0118.
9 YIELD (gpm): METHOD OF TEST 2-Adf i
10. WATER ZONES (depth): -ot05
11. DISINFECTION: Type Amount-
12. CASING: Wall Thickness
Depths Diameter or Weight/Ft.
Fromm
From To Ft.
From To_
Depth
13. GROUT:
From 0 To 2.0
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From
To Ft. in. m.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft._
!Serial
C-
Ft.
Material 11 Method
Ft. iLe MOzhy— T O p
Material
Topographic/Land setting /
°Ridge ❑Slope °Valley I/dFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:°GPS°Topographic map
(check box)
DEPTH DRILLING LOG
From To Fomtation Description
LOCATION
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DEC 12 2006 �ar,J _ Ms
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTII,' STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL ER
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh,NC
Raleigh,
27699-1636 Phone No. [phone], within 30 days. GWr1 RSV07/2001

335342
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
/_I rna
WELL CONTRACTOR COMPANY NAME rrrlr�s.ati-�-- _ASSOCIATED WQ PERMIT#_�----
if a licable
STATE WELLCONSTRUCTIONa licable ION PERMIT# (if a licable iculmral ❑
1. WELL USE (Check Applicable Box): Residential lireMunicipal/Public 0 Industrial ❑ Agr
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
l gnu v dgeD Topographic/Land setting lat
��/� ORidge ❑Slope Walley
2. WELL LOCATION: J !!t i County (check appropriate box)
Nearest Town:(UfQ--G Latitude/longitude of well location
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) (degrees/minutes/seconds)
o ra hic map
3, OWNER: Latitude/longitude source:O(chckbox) p g P
Address ante No.) DEPTH
DRILLS G
Formation Description
w
ay Town State
WELL CONSTRUCTION RECORD Groundwater Section
al Resources - Division of Water Quality -
CERTIFICATION 820
/ tD
PHONE y #
(I1�"
��..2�pp,, D% O?/_?
Area code- Phone number ^ / 'D
4. DATE DRILLED t� 3
5. TOTAL DEPTH:6 DOES WELL. REPLACE I'x:!S. N(i \*,n:1.1.YES NO
FT.
IS-
7. STATIC WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
8. TOP OF CASING Iat
FT. Above Land Surface`
*Top of casing terminated
rdai ce with
bat/or
IS below land surface requires Za�(.%�S
variance in accordance with 15AMETHOD OF TEST -----
AC 2C .0118.
9. YIELD (gpm): -�—
10. WATER ZONES (depth):
Zip Code
11. DISINFECTION: Type
12. CASING:
Depth
From_ Ft._"..�Q—
From To Ft
From To
13.
Amount
Wall Thickness
Diameter or Weight/Ft. Mat L
Ft. Method
Material ,v
GROUT: Depth Ft. —� �—
From_dj-_ — �- -
From To Ft. Material MaterialDiameter Slot Size
14. SCREEN: Depth Ft in in
From To in in.
From To Ft.
15. SAND/GRAVEL pPACK: th Size Material
From To Ft. From
To Ft. --_—
From
5
LOCATION SKETCH
Show direction and distancemiles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
DEC 12 2Q06
16. REMARKS:
COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
LL
A THAT 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WE
C'ONSTRUCTIO ANDARDS, AND a
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/2001
1636 Phone No.GWr1 RSV.h,Submit the original NC
27699,(919) 71133 3221, within 30 days.ty, Groundwater Section, 1636 Mail Service Center -Raleigh,

335343
WELL CONSTRUCTION RECORD North Carolina - Department of Environment and Natural Resources - Division of Water Quality -
Groundwater Section
CERTIFICATION ATION #2y�
ATI e�
PHONE # sst
1711)
ASSOCIATED WQ PEAT#
if applicable)
T.
p, - M .cipal/Pubtic 0 Industrial 0 Agricultural 0
Topographic/Land setting
�at
ORidge ❑Slope OValley
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds) O hiC map
Latitude/longitude source:O (chetk OTop g P
box)
DEPTH DRILLING LOG
S--
Formation Description
From To
(if a licable
Applicable Box): Residential UTU
WELL USE (Check over 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
Monitoring Cl Recoveryy�//
County {)�C
WELL CONTRACTOR (lNDIVIDU AL) NAME (print)
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERM1T#
1
2. WELL Town:_ON', _ _,Uil
Nearest Town:—_e)1=�'A' (7i_`!"1"2_S_
(Street Name, Numbers, Community,Subdivision, Lot No., Zip Code)
3. OWNER:
Address
Ci or Town State
(gZ�d5�1=_$32L
Area code- Phone number D �L7 a (p
4. DATE DRILLED t
5. TOTAL DEPTH:�-1. �— y l Li NO ��
6. DOES WELL REPLACE Evict¶NU W I''o
7. STATIC WATER LEVEL BelowTop+of Abo e Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a 0 u/s
variancein accordanceMETHOD OF TEST
CAC 2C .0118.
9. YIELDELD(gpmY ��t�-���-�� 5'
10. WATER ZONES (depth): 11. DISINFECTION: Type_ng
12. CASING: Depth �� Diameter
From�__ T0__57—
_b„
From To Ft.
Ft.
From
13. GROUT:
From
From__
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEELPPACK:
Ft.
th
To .
From Ft.
From To
Zip Code
LOCATION SKETCH
Show direction and distance❑fros m the r at t
Amountc two State Roads or County
Wall ThicknRoads. Id
numbers and common road names.
or Weight/Ft.
t. Material
c+
To Method
Depth ,Mater��ia�l,1.
To Zip
Ft..------
To aterial
Diameter Slot Size
Ft.
n. in.
Ftin. in.
Sizc Material
DEC 1. 2 206b
1006
Y
16. REMARKS:
WELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
�LL OWNER G
CONSTRUCTION STA�`RDS, AND THAT OF THIS RECORD HAS BEEN PROVIDED TO
THE DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Quality, Groundwater Section,1636 Mail Service Center - REV. NC 1
Submit the hone No. (919)1) 733-3221,2wof Water Q tS+
27699-1636 Phone No. within 30 days.

a
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Wtd
Nat al GGResources
s -- Division of Water Quality - Groundwater Section ((
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Nat al
. CERTIFICATTII�ON#%y/pJJ
WELT. CONTRACTOR COMPANY NAME 61'eeiw &iWeis lure 4)Qhfl p „(-T c PHONE # €wf egg 3/70
STATE WELL CONSTRUCTION PERMIT# I 110 Z— ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential B'Municipal/Public O Industrial O Agricultural O
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: it Nearest Town: 11QL_ v"-ile ! County fiCUA)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: J.t
8/y-le_
Address �O.tb)C, I4/75-
ltreet or Route No.)
have. NC
Cityhave
S
(82g)y 6 9,-Do f
28151
Zip Code
Area code- Phone number
4. DATE DRILLED 1/ 4
5. TOTAL DEPTH: 9 5
6. DOES WELL. REPLACE AXIS!!'( WELL? YES LI NO S-
7. STATIC WATER LEVEL Below Top of Casing: 6, 5 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 3 METHOD OF TEST Z f:GYI(s
10. WATER ZONES (depth): 1' Z.,S '
1 1. DISINFECTION: Type Pig Amount
12. CASING: Wall Thickness
�y
Depth , I Diameter or Weight/Ft. aterial
From 0 To P Y Ft. 6"
From To Ft.
From To Ft.
13. GROUT: Depth atcrial Method
From 0 ToZo Ft. Le/ne )--- To
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 y
❑Ridge ❑Slope OValley Drat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
Froopm gqToyy , Fotspat5pn Die ription
85' 9g5' 6+onz,F e
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 WITFTTSATNCAC2C, WELL
CONSTRUCTIONS 7DARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d 04t Lae IF 1. s—a-C
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

335324
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and ur 1 Resources f(- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) �1 /n)� �' (Peet
CERTIFICATION # 27J
WELL CONTRACTOR COMPANY NAME eireon.e 6io`d'MJrs (»ee /L'mp Vic PHONE # (rJ$ b 3/7b
STATE WELL CONSTRUCTION PERMIT# Ho Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Pf Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: a
Nearest Town: &{%£gAis06/1/ e. County f��WoSe_
(Street Name, Numbers, Community,o , Subdivision, Lott
No., Zip Code)
3. OWNER: Ca !1 &/If - tiii 9t' dir011ty A%L't.Sbn—
Topogr ic/Land setting
❑Ridge Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Address 2 7B t/lam i' 1 pet Latitude/longitude source:OGPSOTopographic map
( Street or Route No.) (check box)
/1�SuUlp IC(
4 B78/ DEPTH DRILLING LOG
City or Town State Zip Code Frwnt / To I F ation Description
(- 739- 7065 ,(� z/// // �
Area code- Phone number n 35' - .3-051 6 n d ,Le
4. DATE DRILLED B�7', L�i`O 'c
5. TOTAL DEPTH: .J 6 1 �� �
U. DOES \VE1 1 REPLACE EMMt) 1NC WE!., Y US Li nLfr
NO
7. STATIC WATER LEVEL Below Top of Casing: //00 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordailgr with ISA NCAC 2C .0118. `/
9. YIELD (gpm): ` METHOD OF TEST F /yDOri
10. WATER ZONES (depth): 305
11. DISINFECTION: Type tint
t
12. CASING:
Depth
From Q To I o y Ft.
From To Ft.
Diameter
6"
LOCAT ON SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or Cpunty Rtsg�d,sl thu tea
or Weight/Ft. M enal numbers and common road nilinZ ; t`
VG
From To Ft.
13. GROUT: Depth Material Method
From 0 To ZD Ft. Leal PNi' To p
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.
DEC 12 2006
r4 ::]Fs
R.E.'CE tE.r,_....
Oj\. OF WATER QLI<'+i.-'tT\i
NO» 21 2006
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRU C I(N STANDARDS, AND TIIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
aennae-- ,`� C�CIJ r�--� 1/-
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
31<°?`5
tur l Resourc�e�s((- Division of Water Quality - Groundwater Section
ph(� wtbb CERTIFICATION #.2 /D
WELL CONTRACTOR COMPANY NAME &Irten pt A /vjets &.eLt T fZ'n p (�f'XC-PHONE # (gal 698-/70
STATE WELL CONSTRUCTION PERMIT# / 7 07
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential 8'Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCAT ON1:
Nearest Town: �/i)011 MS U t C'-e", County j P/40001
(Street Name, Numbers, Community. Subdivision, Lot No., Zip Code)
3. OWNER: frie-ha--Ple-S
Address 32-09
(Street or Route No. )
( ampa /%L /13
City o T wn State Zip Code
(g 6)- if01o8-
Area code- Phone number /D 4. DATE DRILLED
/-Y 0 6
5. TOTAL DEPTH: LP/
J r
6. DOES WE: REPLACE (._v'S.' !NU WELL?
Y.,A rl h;f) r.J..•""'
7. STATIC WATER LEVEL Below Top of Casing: Y 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /'' METHOD OF TEST 2lkkurj
10. WATER ZONES (depth): 925 f
11. DISINFECTION: Type kpf
Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To li o Ft b`' a (-
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To Z-0 Ft. Ge/n Tbp
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.
Topographic/Land setting
❑Ridge ❑Slope ❑Valley '9
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To F.tyationDescription
D bor
to ' - yy5'
LOCATION CKFTCT
Show direction and distitnce in reggriofiapipattas D
two State Roads or Coulity Roa igtl
numbers and common road names.
RECEIVED
11R'` OF WATER QUALITY
I'.?ntr 2 1 2006
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTE6 $ STANDARDS, AND TI(AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
044Maa
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
335886
North Carolina - Department of Environment and NaturalResources�)- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Re b1ti 1J Q, 3 CERTIFICATION#2'� �d
WELL CONTRACTOR COMPANY NAME C ,6?m reene 'iers kV 4- airy)
STATE WELL CONSTRUCTION PERMIT# / 0 2- ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
PHONE # ez1 698 317o
1. WELL USE (Check Applicable Box): Residential !Tr—Municipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO
Nearest Town:
(Street Name, Numbers, Commu ity, Subdivision, Lot No., Zip Code)
3. OWNER: deb/1. Trr'U/ /n��
Address !D% pi1.53L7Pnt, 1-e ,C
(Street or Route No.)
n,esv LU'G /uC 2-87S Co
City or Town Slate Zip Code
( )-
Area code- Phone number
4. DATE DRILLED /D'Lq-0 CO
11. DISINFECTION: Type
12. CASING:
in Depth Dia 'tier
From To y7 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth material Method
From 0 To 2-0 Ft. ,Material To /1
From To Ft. 1_
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.
Topogr is/Land setting
❑Ridge Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
18' .rzsr 6 ran /--e
5. TOTAL DEPTH: 5-245'
6. DOSS A*,WELL. REP( ^C?i EX!SFINC:',VH i.7 YES L NO t _.
7. STATIC WATER LEVEL Below Top of Casing: in b FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118. �//���'�
9. YIELD (gpm): .3 METHOD OF TEST .2 Pairs
10. WATER ZONES (depth): 3es •
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.
County WIDOd
Amount
Walt Thickness
or Weight/Ft. Material
P✓ C -
HTlt
From To Ft.
16. REMARKS:
JAN 02 2007
REple
GEI pE,DUR� s
Or 14
tiEL _1t r�" (1$11
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
CONSTRUCT,$TANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/2 -5- _o (-
DATE
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

From V
From
From
13. GROUT: Depth
From 0 To
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Napprral Resources __-IDivision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME f (print) KI.ob� L/L tPth D CERTIFICATION # �/18
WELL CONTRACTOR COMPANY NAME Imo: eerie, [X oMen C( 4- PAT PHONE # Icryl I,V6'-8/7D
STATE WELL CONSTRUCTION PERMIT# 17 0 L ASSOCIATED WQ PEERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
NcarestJTown: v at+�4zZ14A9 rooL_
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: t/9Uh'LGiis bream/t, , S
Address jj/ox /(1z-g
County Artitp,1100C1
,(Street or Route No.)
tA)04/4e1utlle, jtk' 2S7S C
City or Town State Zip Code
- 442/-6538
Area code- Phone number
4. DATE DRILLED /I2-0 -O(p
5. TOTAL DEPTH: j0.5
6. DOES WELL REPLACE EXIS USC WE! ! o YES Li! NO er
7. STATIC WATER LEVEL Below Top of Casing: (s 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): '7 METHOD OF TEST 2 boors
10. WATER ZONES (depth): C3V,5-
11. DISINFECTION: Type W j-71 Amount
12. CASING: Wall Thickness
or Weight/Ft. Material
py C
Depth Diameter
To 4/7 Ft. Err
To Ft.
To Ft.
aterial • _ Method
Ft. ,la- ro n
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size
Ft.
Ft.
Material
16. REMARKS:
33.58S e
Topographic/Land setting
❑Ridge ❑Slope OValley 43Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
Fro i To Forfnation Description
C
q415 ' .5-05 I
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.
^el',
JAN 02 2007
RECENT 1r! lY
cw"�:. @ r00F
I DO HEREBY RTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUC4fON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

335888
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na ral Resources - Division of Water Quality - Groundwater Section �!
WELL CONTRACTOR (INDIVIDUAL) NAME (print) rf( QIA G f/t,e'^7tP, /�/t CERTIFICATION # V
WELL CONTRACTOR COMPANY NAME 6tco come 6tv4etz luatt V--Amp PHONE # 9z 6V6i3/70
STATE WELL CONSTRUCTION PERMIT# Pi 0 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential A' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIO war"
Nearest Town. / County 4 ar"
An-i- - 6ii,t aaru crack £slad-es
(Street Name, Numbers, Community, Subdivision,_
Lot No., Zip Code)
3. OWNER: � tJ Iflt{ Cie vedetit
Address ,O. /u 373
HQ�'Ot t.000C1NC_ L873$
City or Town State Zip Code
C0'S -S/3 9
Area code- Phone number
4. DATE DRILLED /H /S _0 (0
5. TOTAL DEPTH: 5 05'
L)'JE 9.71:LI. REPLACE LXISYriNO Vl. 1 o YES t NO r
7. STATIC WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. -� �"
9 YIELD (gpm): 3 METHOD OF TEST 2/1eor3
10. WATER ZONES (depth): 245
11. DISINFECTION: Type tiig Amount
12. CASING: Wall Thickness
Depth Dia�eiecr or Weight/Ft. Material
From 0 To /3 C� Ft. p
From To Ft.
From To Ft.
13. GROUT: Depth Materi"al,, Method
From 0 To 2-0 Ft. CLmei v7 To
From To Ft. Y
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 HFlat
(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
131 ' Ss' a 4-6
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 02 2007
rRWAEEEIVII.Cr"
700`
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRYyt{I'ION STANDARDS, AND A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/
//t -vze a---G� a- fY 01^� /2- 57"0 (i
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME 1-een e /P>%0
335889
ral Resources - Division of Water Quality - Groundwater Section
CERTIFICATION #21 18
PHONE # (98,3/70
STATE WELL CONSTRUCTION PERMIT# /qo Z
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential ErMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI'O.Nr(•
/
Nearest own: A P�$VL�1 County a.qw
awl est i...as
(Street Name, Numb rs, Community, Subdivision, Lot No., Zip Code)
3. OWNER: J( m' Cry
Address /j�D L _q tidal
P. al ILL
(Street or oute N'A)
LVQ.(/izese[EIrP Mc c 2 9 i 65-
Ci6F or Town State Zip Code
(826)•
-
Area code- Phone number
4. DATE DRILLED JO I -O L
5. TOTAL DEPTH: /e
y DOES W!!!.1. REPLACE ACr EX!S.t'!N(i WELL? L a YES rl NO Le'
7. STATIC WATER LEVEL Below Top of Casing: en FT.
(Use "+" if Above Top of Casing)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance miti 15A NCAC 2C .0118. //
9. YIELD (gpm): 35 METHOD OF TEST 211tg'S
10. WATER ZONES (depth): 165 r
1 I . DISINFECTION: Type /-T/i Amount
12. CASING: Wall Thickness
or Weight/Ft. Material
p✓L
Depth
From b To g 3 Ft.
From To Ft.
From To Ft.
Diameter
In
13. GROUT: Depth Material , Method
From To 2-0 Ft. Ce/neAl ro n
From To Ft. !-
14. SCREEN: Depth
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
Diameter Slot Size Material
in.
in.
Material
Topographic/Land setting
❑Ridge ❑Slope ❑Valley Elf1at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From Ta3o Formation Description
gar /B5' EOS
Pandit -PC
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.
JAM 0 2 2001
ECEIVED
co. O)�WXT R OUA .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI{ 15A NCAC 2C, WELL
CONSTRU ' ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONTRACTOR COMPANY NAME 6f-P. a bop,G/O
STATE WELL CONSTRUCTION PERMIT#HE applicable)
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na al but,
- Division of Water Quality - Groundwater Section�
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ►�C/(%/(L wol b CERTIFICATION 1i2n/
�S
W
e/Id-
��j
z.
ti
PHONE # fls'li. 6981V7V
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential 19 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 Ton I/004/18.1s y I County IICU ji0000(
(%n derwood, ,t
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 6 eor9 e H r6ani el/
Address /07tr4rry �0f3
(Street or Route No.)
Clyde N L 2-872-/
City or Town State Zip Code
(Qt )- 7/2 -/53b
Area code- Phone number
4. DATE DRILLED /0 '/6 "D 6
5. TOTAL DEPTH: INS/
6. DOES WELL REPLACE EXIST!NC fan..!.!.? YES ❑ NO 61-
7. STATIC WATER LEVEL Below Top of Casing: 10 D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS � FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): t METHOD OF t TEST 2 Nt/ grs
10. WATER ZONES (depth): 3 t$ 5
1 1. DISINFECTION: Type H7 #
I . CASING:
Depth
From 0 To (p 3 Ft.
From To Ft.
From To Ft.
Dimeter
/r
Amount
Wall Thickness
or Weight/Ft. Material
pi/C-
13. GROUT: Depth Material Method
From 0 To ZU Ft sin en* Top
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
DRidge ❑Slope DValley gnat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
O—_
6r2TLtfe.
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.
,lAN 02 20I
RECEN ED IH.L1• T
I DO HEREB CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII I5A NCAC 2C, WELL
CONSTR ON STANDARDS, AND
�THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
,A
/Z-S(v(.7
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
91

WELL CONSTRUCTION RECORD
t faa2North Carolina - Department of Environment and I�jatural Resources - Division of Water Quality - Groundwater Secti�on>°j,(� _?
WELL CONTRACTOR (INDIVIDUAL) NAME/(print) (/Jl r, an ()Teen e CERTIFICATIONQ# Z&BS
WELL CONTRACTOR COMPANY NAME 1;Irene tto biers 6u di4— 4-Puny PHONE # j Z 698'3/70
STATE WELL CONSTRUCTION PERMIT# /S' a Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ['Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: (e
H4JlY18.4 w✓ titet. iateJ
(Street Name, Numbers, Community, Subdivision,
CouptyL/(,t1
b
Lot No., Zip Code)
3. OWNER: Nwrt'M,,(L Viehy fUIicle'a
Address .33Q/ ellt,�vo
4-
(Street or Route No.)
tiO OA/46 tat_ N-C 28 28 G
City or Town State Zip Code
Area code- Phone number
4. DATE DRILLED I i --i f.-Q L
5. TOTAL DEPTH: 7 6 S t
(. DOES WELL REPLACE EX1ST!NKi vVI'I±? YES Li Na) L✓
7. STATIC WATER LEVEL Below Top of Casing: go FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. 9. YIELD (gpm): (po ;F METHOD OF TEST 2-WOWS
10. WATER ZONES (depth): 2115 t
11. DISINFECTION: Type
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To / 38 Ft b t t PVC
From To Ft.
From To Ft.
n
Amount
13. GROUT: Depth Material Method
From (7 To 20 Ft. (ern en4 Thp
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
DRidge ['Slope OValley QF at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPSDTopographic map
(check box)
DEPTH DRILLING LOG
From To F rmation Description
/ 9 t 1.31bat fe
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN t> > 2C07
4
Re aErED_tt,. r‘;o
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C:ONSTjtC TION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

335693
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N;rigra` Resources,w,-//�Division of Water Quality - Groundwater Section n
WELL CONTRACTOR (INDIVIDUAL) NAME
(print) n I AA' 1N/'h/) _/ nn CERTIFICATION 02/bg
WELL CONTRACTOR COMPANY NAME � JGQ,to I TS Well Ct-Pe PHONE # OS 948 s/70
STATE WELL CONSTRUCTION PERMIT# NO L ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IY Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2 WELL LOCATIO
Nearest To G,-,,./ County thlyWOd
I Street Name, Numbers; Community, Subdivision, Lot No., Zip Code)
3. OWNER: t4 fe
Address %O `J5 PP�VQ.QL cove
(Street or Route No.)
WSW ec WC /✓C 2E721.
City or Town State Zip Code
$)- 73y 3Sa9
Area code- Phone number
4. DATE DRILLED //-7Z-o &
5. TOTAL DEPTH: ,34/S1
DOES WWELLRi:PL V. E EX!S'rinpCi W E:.l ., YES ❑ NO iX 7
STATIC WATER LEVEL Below Top of Casing: (v 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): Ja METHOD OF TEST ZPodf$
10. WATER ZONES (depth): .3 25
11. DISINFECTION: Type HTal
12. CASING:
Depth Diameter
From 0 To y7 Ft. bf `
From To Ft.
From To Ft.
13. GROUT: Depth Material L Method
From (9 To � Ft. (email- To /3
Amount
Wall Thickness
or Weight/Ft. Material
PVC -
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:
Topogr3pphic/Land setting
❑Ridge 1P1Slope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From 0
09 ' 343.
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.
JAM 0 2 2007
Ca
• • RECEF EWPD )pl mf
)cr "1 °) 200F.,.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTILU�C4'ION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
a itaaa_ ,Q.4e3 /L-S-o
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
335694
North Carolina - Department of Environment and Nap�)1r��al/Resources --�D/ivision of Water Quality - Groundwater Section A
WELL CONTRACTOR (INDIVIDUAL) NAME
/' (print) IC.f) hl/l, Webb /} CERTIFICATION# 240AA
WELL CONTRACTOR COMPANY NAME Cree.fle rn Mns (tipj( &Peer P PHONE # (018)LYB -3/70
STATE WELL CONSTRUCTION PERMIT# Igo Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential E' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION
Nearest Town:
Cain ?z n✓e,
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 64-eve f/L
County WOOL:
Address 2.44o (1,9 D `4l Mat(
(Street or Route No.)
CCyde ft9C 2 S)zl
City or Town State Zip Code
&- ez7'fig 77
Area code- Phone number
4. DATE DRILLED // -t76
5. TOTAL DEPTH: Z$,5-
DOES WELL REPLACE EXISr!!!`l :'ail:] i o YES LI !NO W
7. STATIC WATER LEVEL Below Top of Casing: G D 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 accordaote with 15A NCAC 2C .01I8.
9. YIELD (gpm): /1 METHOD OF TEST 2-flours
10. WATER ZONES (depth): 24S'
1 I. DISINFECTION: Type rr/ i% Amount
12. CASING: Wall Thickness
Depth ,, Diameter or Weight/Ft. Material
//
From 0 To 7L Ft. G 6' P✓ C
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To Za Ft.
From To Ft
aterial
mend
Method
Tbp
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge ['Slope ❑Valley Dclat
(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
r)' y
Liz' - ZUS 6MA
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 0 2 2007
ECEI RED JAI 1TY
tit; [
L ?Dr
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRJdC{CION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/z—s--o
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
335695
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
,Q
WELL CONTRACTOR (INDIVIDUAL) NAME` (print)op Pob�,/,A u_)!b'/6./ CERTIFICATION #2 /U
WELL CONTRACTOR COMPANY NAME _ ,/ ` /2w4/ICA) ((/t Allp PHONE #plc+ )HVB 3`70
STATE WELL CONSTRUCTION PERMIT# Ji 7 o L ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Er Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery O Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest To : U L County 6itnial
/65 4.1 _aaAQ
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 61nnBmr
a. -
Address / OSI towit
(Street or Route No.)
U k4Ael ut//4 Air Z87g 6
City or Town Stale Zip Code
(AZG)- 734/- Dz9t/
Area code- Phone number
4. DATE DRILLED %D /2.'-06
5. TOTAL DEPTH: 21-l5'
/„ DOES WELL REPLACE I X!S!!N,U \Vk1 ? YES r2 NO I —
7. STATIC WATER LEVEL Below Top of Casing: 6 D FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 60 METHOD OF TEST 2{/pc(,5
10. WATER ZONES (depth):
Topographic/Land setting
❑Ridge ❑Slope OValley C•FF'lat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Formation Description
DEPTH
From To
6z' vs'
11. DISINFECTION: Type 1417k- Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 6 To to l Ft. /p" pvc
From To Ft.
From To Ft.
13. GROUT: Depth /. Material , Method
From 0 To 20 Ft. Center%- To p
From To Ft. r
14. SCREEN- Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
I6. 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.
JAN 02 2001
i ED TM fP��
ttiR.
1Q0
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITII 15A NCAC 2C, WELL
CONSTRUC,N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
I
�viceaaa 441496)*)
/z-6-06
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-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
f--c+h
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ,tiWebb
WELLCONTRACTOR COMPANY NAME 6-reen Q AroMei3 (Jet,{ t ,04np
STATE WELL CONSTRUCTION PERMIT# 1yb Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential IW Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATION: I� ,,
Nearest Town: C CLn4os s_ County 600d
(,Qj 111's (put
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Chaf/eS /,H�&a, ..
Address �( WUJIS 63ve-
(Street or Route No.)
C� b^ NC Z8716
City or Town State
('8aa)- 6y&2957
Area code- Phone number
4. DATE DRILLED //-3 19 (o
Zip Code
5. TOTAL DEPTH: 725'
6. ))"ES WELL REPLACE EX,ic r!NG una i v YES Li !NO 4.1/
7. STATIC WATER LEVEL Below Top of Casing: 46 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 1SA NCAC 2C .0118.
9. YIELD (gpm): /0 METHOD OF TEST .Z/s
10. WATER ZONES (depth): / O S
/25'
11. DISINFECTION: Type //%W
12. CASING:
Depth
From b To Z /O Ft.
From To Ft.
From To Ft.
Depth ^ Materi�1
To Zo Ft. C.
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
13. GROUT:
From 0
Amount
Wall Thickness
Diameter or Weight/Ft. Material
6"
pi/G
Method
7-ap
Material
3371396
CERTIFICATION #24/8
PHONE # I+ ) bI/B 3/70
Topographic/Land setting
ORidge ❑Slope OValley E2at
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DRILLING LOG
Fyrmation Description
DEPTH
From To
O' Z6'
Z7' /Zs' Acemle,
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 0 2 2001
'11\I
RECEIVED IJM rCV
F VOASF
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C.ONSTRU N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
anliaag- /LOUD ar-- /L- 6 -o C.
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
WELL CONTRACTOR (INDIVIDUAL) NAME (print) RObi/L Webb
335897
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR COMPANY NAME c rpede agtOi .e u r.vel( y-Pore
STATE WELL CONSTRUCTION PERMIT# J VDZ. ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
CERTIFICATION # 2VI f9
PHONE # &Z) 61/B 3/70
1. WELL USE (Check Applicable Box): Residential IrMunicipal/Public ❑ Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATIO
Nearest Town: QuAPS✓-lit
5/eel
t �
umbers,
County %/trai
(Street Na Community, Subdivision, Lot No., Zip Code)
3. OWNER; /2IL4ont Ia4n
Address p/
(57etorRo o.)
IUalmaa NC
City or Town State
LE786
Zip Code
(274)- </52 -L6 / 6
Area code- Phone number
4. DATE DRILLED // /3 -fl G
5. TOTAL DEPTH: /OOS
6. DOES WELL REPLACE EX S!11 (i WEI I v YES [..t Nlri
7. STATIC WATER LEVEL Below Top of Casing: 8 25 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /AS METHOD OF TEST 2 Hecir,5
10. WATER ZONES (depth): 6205r
11. DISINFECTION: Type WIN
l2. CASING:
Depth
From 0 To ZZ
From To
From To
13. GROUT: Depth
From O To 20
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
16. REMARKS:
Diameter
Ft. (o"
Ft.
Ft.
Ft.
aterial 4A4ethod
/Il P.NJ" l o p
Amount
Wall Thickness
or Weight/Ft. Material
pv
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size
Ft.
Ft.
Material
Topographic/Land setting
ORidge ❑Slope OValley refelat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
7.31 /° 5, gran tic
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 0 2 2007
cCENED
k4t�AhiT`J
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
i000NSTRUC ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
i 14k2Q r tZJ4(0.) /2. -6 -0 C
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N,gtural Resources - Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME "(eta
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
335699
Groundwater Sectionti
CERTIFICATION #a?8
"7ffi Pryi GUP C15
2tt ip PHONE it 60.3/%a
/SFo Z
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential IB Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: County
/0%/0 / tdq rti SUnue
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 24 ?LEi!' j
(Street or Route No.)
4Shauflle Alt z88o3
City or Town State Zip Code
(9a)- z77-7€54
Area code- Phone number
4. DATE DRILLED //- 9-0 (a
5. TOTAL DEPTH: 005
6_ DOEWE; REPLACE EXI T! N(: ar i o YES LI nit r
cot
Diameter
From D T yo Ft. 6 it pvc
From To Ft.
From To Ft.
13. GROUT' Depth Materiall I Method
From 0 To2-C) Ft. GentB!I/T- f /)
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.
7. STATIC WATER LEVEL Below Top of Casing: zf%O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): /3 METHOD OF TEST 2 No £Y S
10. WATER ZONES (depth): Sr
S'
bes'
1 I. DISINFECTION: Type /-l% f Amount
12. CASING: Wall Thickness
Depth or Weight/Ft. Material
0
Topograp�hic/Land setting
❑Ridge B lope OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:IJGPSDTopographic map
(check box)
DEPTH DRILLING LOG
Fronj 0(TToo Ft ation Description
Y/ ' 1051
16. REMARKS:
',rap /
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 02 2007
RECEIVED, ,
sot-!. ')E °'•,IATr_EH i'a!-141 IN
CIEu 1 ' 1000
1 DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS
IT U TION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
/L4i�c76
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

335700
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N. tural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) 1r ��(,,,0��//,,&�'gm� e- CERTIFICATION iK-26S
WELL CONTRACTOR COMPANY NAME ireeAe • /(-hers-f ers k-et4 1-- Afire PHONE # ( 698-3I7 a
STATE WELL CONSTRUCTION PERMIT# /7 °Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential a- Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIO,
Nearest o 'V'f
County """
ow se.
(Street Na(„e,Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: e /M, .4I . �/tf 4J
Address 2 q ,s ftJ r
(Street or Route No.)
As htei ll a Me 20803
n. ity or Town State Zip Code
(-$77-78S2
Area code- Phone number
4. DATE DRILLED // .3 -a 6
5. TOTAL DEPTH: 2V s
6. DOEWELL. REPLACE I:X}ST!NG t'l.,l l o YES ❑ NO For-.
7. STATIC WATER LEVEL Below Top of Casing: ,3 0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordanggee�with ISA NCAC 2C .0118.
9. YIELD (gpm): 2 Q METHOD OF TEST 2/JoUri
W. WATER ZONES (depth): 225
2.4/5 I
11. DISINFECTION: Type /n74-
12. CASING:
Depth Diameter
From 0 To '/Z Ft. b f'
From To Ft.
From To Ft.
13. GROUT: Depth
From 0 To 2.b Ft.
Amount
Wall Thickness
or Weight/Ft. Material
Material
Ceinenl-
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
16. REMARKS:
PVC -
Method
Top
Slot Size Material
in.
in.
Material
Topogr3�pphic/Land setting
❑Ridge RS. lope ❑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 Fo ation Description
0, 112' P
I/3 ' z q s'
C ✓2
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.
NI
RACE �o )��1
OF .N>
JAN 0 2 2007
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C WELL
CONSTR T1ON STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
335701
North Carolina - Department of Environment and N tural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) br9Q,n Greene /� CERTIFICATION #Zzfls
Grua CONTRACTOR COMPANY NAME Gra P B'd�l4 LOPE I fOt/riip PHONE # ($22 6V8-3/76
STATE WELL CONSTRUCTION PERMIT# / 90 Z ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Ir.-Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT
Near c.6t Town
County
cs 40410
e,
axed
I Street ame, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 1 �y�S /vinart D/elopine
Address 2.41 oar •
Asheville (Street Route zeso3
City or Town State Zip Code
(( /?Q)- 2-77-7852-
Area code- Phone number
4. DATE DRILLED //-L •O
5. TOTAL DEPTH: /30,5
6. DOES WELL REPLACE rvirnnup WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: Li-. FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 2 NOCKS
10. WATER ZONES (depth): O
11. DISINFECTION: Type /f]i Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft.
From 0 To 57 Ft. G f
From To Ft.
From To Ft.
13. GROUT: Depth Material Mp(hod
From 0 To 2,0 Ft. Cemeaif Pap
From To Ft.
14. SCREEN
From
Topographic/Land setting
❑Ridge f(ope OValley OFIat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To F rmation Description
0t 59'
53' /a Qs' ✓' ttlf,
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.
Depth Diameter Slot Size Material
To Ft. in. in. IUnD
From To Ft. in. in. RE CEEv nil/WV/-
15. SAND/GRAVEL PACK: ,_)lV Or tf.�:T
Depth Size Material JAN 0 2 2001 J -rj11F;
From To Ft. f" i'
From To Ft.
16. REMARKS:
I DO I IEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST)2•QCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�aA'taaci. t CatDa)ti JL-6 G
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

I . WELL USE (Check Applicable Box): Residential C ' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town
.dS x
(Street Name, Numbers, Compunity, Subdivision,
Lot No., Zip Code)
3. OWNER: [15„i 1MC. e.46 / L) n,4
�rh&VI !/ SorAR�oje No.)/, 7 A d (check box)
P' l�� 3 DRILLING LOG
City or Town State Zip Code To F,ggnation Description
WELL CONSTRUCTION RECORD 3 3 5 7 0 2
North Carolina - Department of Environment and Natural Resources' - Division of Water Quality - Groundwater Section
�p� WELL CONTRACTOR (INDIVIDUAL) NAME (print) A ion rpre e. CERTIFICATION ft 22O17
WELL CONTRACTOR COMPANY NAME LC'n` //b`#&CS QOz/C pf/m� PHONE # �� 6V-8.5/70
STATE WELL CONSTRUCTION PERMIT# /7 d 7 . ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
County Gdbtx`c.
Topographic/Land setting
ORidge 4aSOpe OValley OFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Address Z rbe Latitude/longitude source:OGPSOTopographic map
(Street
(Ba 277 7 $ S 2—
Area code- Phone number
4. DATE DRILLED // ?;-9 �-06
5. TOTAL DEPTH: 3b
6. DOES WELL REPLACE IiYISr!NNCI WELL? YES L i NO
7. STATIC WATER LEVEL Below Top of Casing: 6 t FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface'
*Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 30 METHOD OF TEST Z/ivU/S
10. WATER ZONES (depth): 3tiS1
Amount
12. CASING: Wall Thickness
d Depth �p meter or Weight/Ft. Ma erial
From Y3 Ft 0✓�
From To Ft.
From To Ft.
13. GROUT: Depth „Material Method
/
From 6 To 2-O Ft. (_eMend- Top
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
11. DISINFECTION: Type H7i1
16. REMARKS:
DEPTH
From
y4 t
_
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
.JAIN 0 `.2 2007
EGENEG,iI l\Tv
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRU N STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4.44.14.42 SIGNATURE OF PERSON/2 -6 -o C CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-1 REV. 07/2001

North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)
WELL CONTRACTOR COMPANY NAME areeaLe/ 17
STATE WELL CONSTRUCTION PERMIT# ° 2 ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential lE Municipal/Public 0 Industrial O Agricultural ❑
Monitoring O Recovery O Heat Pump Water Injection O Other O If Other, List Use
2. WELL LOCATI
Nearest To�
(Street Name, �N+umb eers.. Community,
3. OWNER: ly itha
Address 24/ cc'ee -lj2
(Street nRoute No.)
"OCity or Town State Zip Code
qST )- L77-7$SZ
Area code- Phone number
4. DATE DRILLED l` �--£I
5. TOTAL DEPTH: ` SS
berm!!, NC
WELL CONSTRUCTION RECORD
(if applicable)
County #difilit/Oc
Subdivision, Lot No., Zip Code)
9&Sopmeett-
Ci
2 8803
0 (vey 1-
6. DOES WELL REPLACE Ev!S' ! NT1 WELT? YEA:, U NO it
7. STATIC WATER LEVEL Below Top of Casing: 3 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 with 15A NCAC 2C .0118.
9. YIELD (gpm): 3 0 METHOD OF TEST ZDUr,S
10. WATER ZONES (depth): 2.2.05
II DISINFECTION: Type Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From 0 To Ft. 6 /' PVC_
From To Ft.
From To Ft.
13. GROUT: Depth /M,_are�na!
From Q To 2-0 Ft. (. stte
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.
Method
To p
33`i703
CERTIFICATION # GGO()
PHONE # 6 9B 3 I7 0
Topogra»ic/Land setting
❑Ridge OSlope DValley (]Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From �Tor Clay
Description
ay4,an;
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
JAN 0? 2007
16. REMARKS:
`CEI �Egi TY
( ,,. 100e.
l-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONST1,JCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
el a--/24 -o
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 RECO:AD
North Carolina Department of Environment and Natwal Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # • lire
1. WELL CONTRACTOR:
e.oe: c c.
W eA Contractor (Individual) Nane
eNcetrt 6o�Aa erS *'San
Wdl Cr Company N
STREET ADDRESS V-V V S \\t. 1 aoS
iio'r Svc;n0) NC ;.8'►`j3
City or Town -rip Cafe
(Ct(oEr aaaa--
Nee coda- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d epokable)
STATE WELLPERMIT#(Rappli able)
DWQ or OTHER PERMIT #(9 applicable)
WELL USE (Check Applicable Sox): Residential Water Supply L3/
DATE DRILLED 7"a.f
TIME CaiapLE7ED 3 ,/3 d AM 0 PM [Eh--
3. WELL LOCATION:
CRY: W tncl es; /4 . COUNTY %& e./ooe
P2c$59 l; r4c
{Street Nane. Nurobeas,Conanday. Subdivision, Lot No.. Parca, Dp Code)'
TO RAPHICI LAND SETTING:
°Valley ❑Flat 0 Rage ❑Otter
(erect appropriate box)
LATITUDE 3
LONGITUDE
Latitzdenengimde source: Er GPS °Topographic map
(bastion of wet lime be shorn on a USGS topo map and
attached to this form Inot ush9 GPS)
May to in dam, 1
m!ma<s, seconds or
in a decimal comet
4. WELL OWNER
OWNER'S NAME
/ l V
vcist
Cnnycr Town State as Code
<Sa4t )_ a ss-gnty
Area code - Phone number
S. WELL DETAILS: _
a. TOTAL DEPTH: - 5 CD-5—
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO/
c. WATER LEVEL Below Top of Casing _3U Fr.
(fist'+' BAbove Top d casing)
d. TOP OF CASING IS FT. Abdre Land Surface
'Tap d casing terminated air bebw land surfate may require
alaiance F Eccorrda ce with 1SA NCAC 2C .0118. e. YIELD(gprn): 7 METHOD OF TEST R•3
6. CASING:
A. JJIi ! 1 f
t. DISINFECTION: Type4�i tS Amount /-S
g. WATER ZONES (depth):
From To
From To
From To From To
Fran To From To
Thickness/
Depth
From +1 o/V0 Fi.
From To
Ft.
From To FI.
7. GROUT: Depth Material i Method
From 0 Togo R. (esk. n fry ire'
From To R.
From To - FI-. - ...
8. SCREEN: Depth Daneter Slot Ste Material
From To Fl. in. in.
From To R. in. in.
From To P. in. in. i..-
LC,
9. SAND/GRAV0. PACK:
Depth Size Maleriei Cs I
• From To' FL r..a
rs�
From To FL
Rom To Ft.
r )
10. DRILLING LOG
From To Formation DD
/yo ?of
11. REMARKS:
r
J
r
I DO ItEREeY t,en rYTHAT THIS Wf1 L 'PAS CONSIF.LCCFD N ACCORDANCE WM1
15A NCAC 2C, WELL CONS1RUC AN ] TP NDAPAS. MS nNTA COPT OF TMS
RECORD HAS SEEN TO7M: NELL OWNER.
SIGNATURE OF CERTIFIED N ONTRACTOR DATE
" erc.ck LJ,eabt Act,
PRINTED NAME OF PERSON ;ONSTRUCTING l iE WELL
Submit the originaltothe Division of Water Quality within 30 days. 1617 Nall Service Canter —Raleigh, NC 27699-1617 PhoneNo [phone] ext 568.� PA
Fenn GW-Ia
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECO:3D
North Carolina Department of Environment and Natural Resounscs- Division of Via:a Qua1Et
WELL CONTRACTOR CERTIFICATION #• 04 ate
1. WELL CONTRACTOR:
S.' 3'^/2CS
W e l Contractor (Individual) Name
' S 4a.d'1 Cc S '*' E G n
wsi cartrxYa Company Narhe
STREET ADDRESS \`\%ZS \ma y aoS
11ok 5�r;n S) lac "0..81-V43
City or Tam FOI-Se -Zip Code
)_ i. oS- aoaa_
A1ea code- Phase number
2. WELL INFORMATION:
SITE WELL ID Mg epd cab)e)
STATE WELL PERMIT#(aeopecable)
DWQ.or OTHER PERMIT #(d appficable)
WELL USE (Check Applicable Bask Residential Water Suppy{"
DRI DATE LLED 7--02 (' 6
TIME COMPLETED 3 ! DO - AMP PM olf
3. WELL LOCATION: I
CITY: (A) a j�I1P. f L r /7C COUNTY fA�r.,rl'>d
Cotoe- � (la(,1
{St N�rne. Numbers. Carenomty. Euteassort, Lot No.. parcel. DP Code)
TOPOGRAPHIC / LAND SETTING:
DVa*ey ❑Fiat DRidge °Other
(check apropiate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS OTopographic map
(option of we/ must be stow) at a USGS topo map and
Shed forms form snot using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
` WELL OWNER b
OWNER'S NAME
5�7EET ADORES? LDy 154f t
City ot Town State
828 I- WO 1881/47
Area code - Phone number
Z Code
S. WW. DETAILS: r 'Ik4S
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV
c. WATER LEVEL Beim Top of Casing: <Der_.) FT.
(Use ^e' d Aboye Top d Casing)
d. TOP 0F CASING IS ‘ FT. Abve Land Surface"
'Teo d casing terminated atla below lard surface may require
a valance in madame With 15A NCAC 2C .0118. e. YIELD Wpm): 5 METHOD OF TEST e.•3
330 15
f. DISINFECTION: Type4ii XS Amount as
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From To
6. CASING: Thickness/
Depth
Q Disinter Waght Material ,
From .}t ToF/ Ft. totS0,221 nk(�:t,
From To Ft. /
From To Fl.
7. GROUT:tom Depth Materia� Matted
Fran 0 To a0 P. Cef-YpPAt It.Prp4
Fran To Fl. _...... _._...
From To F1.
8. SCREEN: Depth Diameter SPX Sibs Material:
From To P: ^in. in.
From To R. in. _ n. -�
i"
Fran To P. n. irk. : ?
9. SANDIGRAVEL PACK: ,
Depth Sire Maleiai r,.,
• From To - FL
From To Ft.
From To It.
10. DRIWNG LOG
From To Formation
/ 9/ Lir
9 / l 115 6-nr "{*
11. REMARKS:
I DO HERESY I.tn rwY MAT IRS WEL L VSC 1STRI T P4 AC ORDUCE Atm
15A CAC 2C, WELL CONS RUCfDN 1.
RECORD HAS BEEN PROVIDED To TEE n ELL OWIET..
SIGNATURE OF CERTI .tea WEI
OR DATE
c et 0' Wee. ,A)(3 .b ccnS5
PRINTED NAME OF PERSON XNSTRUCTING TliE WELL
Submit the original to the Division of
ater Quality
17 Phone within
{0 d 73. Attn:
Info Information
PA
1617 Nail Semite Center- Raleigh,
NC
Form GYV-la
Rev. 7/85

33Li l36
RESfDENTJAL WELL coNSTRVCTIoN REa):2n
North Cart Depertma t of En' uvhunan and Natural Resources- Division of vk'aer Qaatity
WELL CONTRACTOR CERTIFICATION a- OM ate
1. WELL CONTRACTOR:
\er. h Saa�teSS
well Contractor (Individual) Nane -
��>. a to ' S t3.s.1y e� S 'k'
Wei( aka Company Neale
al
STREET ADDRESS ‘v=v8 S .1'tisS7 aoq
i o-4 5?c. n ) NC a8"l+-' 3
Cityor Twin She -T.ip Code
I�S=� (n(o5o`9- L
Area code- Phone number
2. WELL INFORMATIOt't
SITE WELL ID eleappeable)
STATE WELLPERMMTWEass wane)
DYYQ.or OTHER PERMIT 3(d apparel
WELL USE (Check Applicable Boxy: Residential Water Supply 1
DATE mum 7 a2
TIME COMPLETED 3i30 AMO PM9--
3.WBI LOCATIOtt /J//
C[TY: tO4yitr ebb . COUNTY M/riooC
5./cti1 Cc.) Of' 4/
{sYsatName. Numbers. cannerey. Subdivision. Lot No.. Panel Zb Code)
T9POGRAPHICt LAND SETTING:
PJSb1e ijValley OFldt DRidde t7Other
(check app.dpra box)
LATITUDE
LONGITUDE_ _
LatitudeAongitukk source: ❑GPS 0Topographic map
(location of vree most be shown on a USGS topo map and
attached to this Tam (rid using GPS)
a. WELL OWNER
May be in defiers,
rands seconds or
in a deal come
OWNER'S KANE /44'2ng
ESS
nte
CityTown Stale ripcoae
(8a0{ . ant. -(Loses
Area code- Phase number
A WELL DETAILS:
a. TOTALDEYTit' J 0-5-
b. DOES WELL REPLACE EXISTING WELL? TES IDa WATER LEVEL BeimTop of Casing !X O FT.
osew'aMore Top ofCasing)
d. TOP OF CASING IS FT. Abase Land Surface^'
?op d casing ffitranafed at/or below land mutate may rewire
a variance it aooawith 15A NCAC 2C A_Mte. YIELD(gpn) O di METDDOF TEST 11:•3
NO7
t. DISINFECTION: TyPe4 V \ t -S Amount /S
g. WATER ZONES (depth):
From To From To
From To From To
From To Rom To
6_ CASING: �?� Tficimessf
WWII
Firrn To .3 5 R. se T. /l,044 I
From To Ft.
From To R. .
7. GROUT: Depth Matma! Method
From el To a0 R. Cefiren ek ere 4
From To Fl. r
From To fr.
LL SCREEN: Depth Denote- Sfit Sire Material
From To R ' it.
From To R. in. in.
From To R. it in.
9. SANOtORAVEL PACK:
Ter
t7.
Depth Ste Material
' From To' FL
Frown To Ft.
From To FL
70. DRRIJNG LOG
From / To
35 30S
11. REMARKS:
uh
Formation
fi
f i
c
1
c
100 HEREBY CERWFYTAT Tas WE1LTINS CCOISITSCIED ACCnROWICE WITH
15A rot 2C. WELL CONSratCtEa::7Ara7NPDS. AnDTNT A COI' CFTC
RECORD HAS BEEN PROVIDED TOTla: wf OWNER.
SIGNATURE OF CERTIFIED `B PONTRAC CR DATE
'iece . Ck Nlyea. 6
PRINTED NAME OF PERSON X NSRL G THE WELL
61bmit the original la the *vision of Water Quality within 30 �77 Mali Service Center —Raleigh, NC 27599-16177 Phone No. (919733-7015 ext
Attn: Information les,
Fain GW-la
Rea. MI5

RESJDENTAL WELL CONSTRUCTION RECO:3D
North Carolina Department of Environment and Natural Resources- Division of Water Quetta'
WELL CONTRACTOR CERTIFICATION # 04 36
1. WELL CONTRACTOR:
g--Ct C k \-\er '" SF3 w�t2CS
Well Contracts (Individual) Name
e-.a42. s•s *son.
Well C Company Narhe
STREET ADDRESS \'3\% \�LJ7 oZO<
4-kok 5?c n s) NC - V-8'1'-+3
City or Twin State - -Zip Code
at (DADS- aOaa
Area cede- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d applicable)
STATE WELL PERMIT#Qttapplicabie)
DWQ or OTHER PERMIT ST applicable)
WELL USE (Check Applicable Box): Residential Water Supply p�
DATE DRILLED 7-a•�?o- c�
TIME COMPLETED 3 , O 4 AM D PM fB�
3. WELL LOCATION:
CITY: L✓C.jhP!(_• // COUNTY%V Lhcl1/
�t.SSe// (7 Vie 4/
{Stec+ Name. NumberS. Cam unity. Subdivision, Let. No.. Parcel. Z4 Code)'
TO RAPHIC / LAND SETTING:
etr lopeDValley nflat 0Ridae n Other
(cheek appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude solace: n GPS o Topographic map
(location of wel mustbe shown on a USGS topo map and
ached to this form 1 not usrrg GPS)
4, WELL OWNER
OWNER'S NAME - e-c._ F (Ay;
(E-
RA
May be in degtm
minutes seconds or
in a decimal foment
STREET ADDRESS kC S e C
tu& )CPSV:!I till c-
city a own
(gab )-']3M-ill to
Area code - Phone number
rm Code
5. WELL DETAILS: n
a TOTAL DEPTH: Y 6 -�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW/
c WATER LEVEL BeimTop of Casing /70 FT.
(Use +' if Above Top of Casing)
cL TOP OF CASING tS • k FT. Above Lard SuTfaoe'
'Top of casing terminated at)a below kind surface may require
a variance in accordance with 15A NCAC 2C .0118.
e_ YIELD (gpm): 711 METHOD OF TEST 0.•3
6. CASING:
330714
f. DISINFECTION: Type: 115 Amount
g. WATER ZONES (depth):
From To From To
From To From To
Fran To From To
Thickness/
Depth D"!sn�er cW�enigh�t M r
From 4- Tv 7t' -FL :7'�"k n . f.�/
From To FI. r
From
To Fl.
7. GROUT: Depth 0 To aO
From
Fran To F.
From Ft
Material
P. CP/keit'f'
Method
r /AF 4
8. SCREEN: Depth Dia neter Slat SS Material
From To P. hi. in:
From To Fi. in. in.
From To - FI. in. in. .
9. SANDIGRAVEL PACK:
Depth Ste Malerel Cit.
• From To Ft ha
From To Ft r
From To Ft
10. DRILLING LOG
From To
/ 74'
7( yes
11. REMARKS:
,Formation
fir•
0
C--FT - -k
0
1" I
LJr 73
r_p G.fit
C7
r 00 REVERT ttK rrY THAT ThS WELL VAS CONSTRICTED N ACCCRD NCE WITH
15A NCAC 2C, WELL cortsmr1C ON STANDARDS. AlSTHATA COPY OF INS
RECORD HAS BEEN PROVIDED TO THEM ELL OWIEF.
7-a?o'4
SIGNATURE OF CERTIFIED VT OR DATE
'tectr. tk HtG - Se a
PRINTED NAME OF PERSON SiRUCTING THE X NWELL
Submit the original 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 GIN -la
Rev.7DS

RESIDENTJIL WELL CONSTRUCTION RECCE 2D
North Carolina Deyart�nent of Environment and Natural Resources- Di.i,wnr of Water charity
WELL CONTRACTOR CERTIFICATION /V 2t aka
L DISINFECTION: Type {#,�Le Amount 30
g. WATER ZONES (depth):FromcTo From To
From To From To
nQ Rom. To F-ocn To
STREET ADDRESS \'\%a CI NILtw>j 2q 6. CASING:
�1Depth D�*p� W
From_3,a_To /7 R. _ler�y -
Hoity Sn tl sate
NC- 'code i3 Fran To/ Ft. ail
City a Tam SRT�dee .. _Z.� Cale
1: WELL CONTRACTOR:
^1e cr. tk N.vr.J.ZO. •.ate e t
WO Contracts' (kdtviduat) Name
wd C CompanyNer'te
Area coda Phase number
2-WELL INFORMAT)0tt
SITE WELL ID 1J(dsppiwble)
STATE WEU_PERMTI (►sopacele)
DWG cc OTHER PER* rr{d rppleable) /
WELL USE (CheckAppi!ke
g ng: Resider A Water Supply 12
DATE DRILLED 4S- 9- 4
van caimans, 3 [3 G AMID PM H�-
3.WELLLOCATIOtt
CTfY: (IA jYhP��//P - COUNTY �j/r*/ond
-Max tame.Cmmuray. SttlDpaebct.Lot No.. Paco* DP ColeY
aRAPHIC T LAND SETTING:
a OHaiey DFlat oRidpe t7Other
(check opropnate too
tATTh1DE 3
LONGITUDE
May be n dege .
minium seconds or
in a decimal format
Latitude/longitude soon.: GPS oTopogcaphic InvP
(loc ftn of we/ must be shorn on a USGS two map and
attached loll is form /not usiig GPS)
4. WELLOW
OWNER'S NAME
rt ADDRESS
Area code- Phase numbs-
rt.)il bow
S. WELL DETAILS: /os
a. TOTAL DEPTIL Go
b. DOES WELL REPLACE EXISTING WELL? TES Ncrgyit
c. WATER LEVEL BebeTop of Casing (4, a FT.
(Use 4" If Above Top d Cases) .
d. TOP OF CASING IS . - . FT. Abeam Land Surface*
'Tap of cake temenated afro be ow lad surface may requite
a mama 'vr azadarce WNr ISA NCAC 2C .0118.
a. TEED (gf+Ar 7 METHOD OF TEST R'3
Fran To R.
OdUt13
7. GROUT: Depth Maria!
Ran 0 To_s2a.. frown
.r.y(Psl'�'.
From To R.
Rom To FT.
8. SCREEN: Depth Da natn Sint Stie MeadW...
From To R. kt. n.
From To R. in as CT --
Fran Fran To R. ilt Al- c 2
0.3
R SAND/GRAYS- PACK: ;;-r
Depth Ste MiffibL)
• Fran Ta- Ft
From TO Ft. vi
From To Ft.
IR DRILLING LOG J
From To
//7 ?mrt rna'B�
J �t
11. REMARKS:
100 NER 't CERTIFY THAT WS WELLM•K CONSmLCI® MA ANCE 'Me
15A ,c..0 2G WEIt CONSTROCION r4NOAF.DS. M9 Minn COPY OFT eS
RECORD HAS BEEN PROVIOEDTOTHI:MELL
r
SIGNA OF.- DATE
PRINTED NAME OF PERSON x'NS'-RU WELL
Submit the original l to the Division of Water Quality within 30 days. Attu: intonation PAS,
1617 Nail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] tort 568.
Form GW-la
Rev 7705

RES.JDENTJAL WELL CONSII'RUCTION REco:2D
North Carolina Department of Environment and Natural -Resources- Division of R atrr Quaity
WELL CONTRACTOR CERTIFICATION iF. 0416
330 12
1. WELL CONTRACTOR:
Ohts: Os. -.' ec_ b, E L' vess
W ea Contractor (Individudl Name -
Weil company
yq{S �JQeI
STREET ADDRESS `N�afineQ .`\1a'Y ROq
14Lo'e 5 c:' \° 1 NC. - .0-de'l'a3
City or Tam Slat -Op Cede
oYi3 (n405- aloaa,
2. wEu_INFORMATIOrt
SITE wELI ID Sfaesps sale)
STATE WELLVERMT9grePpFnNe)
DWQ.or OTHER PERMIT Kt appacable)
WELL USE (Cheek Appresble Br.): Residential Water Supply t7
DATE DRIL.t.ED ? -/% - 6
TIME COMPLETED y : ?c> AM O PM 9--
3. WELL LOCATIOtt //
CRY: 11- 4,y/l'JvI//e - COUNTY ?4y tocc>r
/1P Pe'- (v)c
{Sbar ?tiers. 0cn wady Subdivision, Lot No.. Parcel, Zq Code)
TOrGRAPHIC RAND SETTING:
Ovalley ElFlat a Ridge aOther
(check box)
LATITUDE 3
LONGITUDE
May be 1n degas, I
raring seconds or
in a decir al format
Latitude/longitude sane: D GPS °Topographic map
(Wagon dsal mwstbe sham on a USGS typo map and
attached to form r not nsieg GPS)
4. WELL OWNER
OWNERS NAME - tit wv,-
oT CZ r'c b -
(Sty or Tam Shane
(Suaa�a 2.089
Area code- Phone number
bp Code
S. WELL DETAILS:
a. TOTAL DEPTIt` L -7 05
b. DOES waLREPLATE EaSTING WELL? YES n7 NOW
WATER LEVEL Below Tcp d Casing /Gi 0 FT.
(Use"*- EAice Top d Casing)
d TOP OFCASING IS si . FT. Above Land Surface*
'rep d cushy laminated aVa below lard surface may re9nHe
armistice h accoleneevai ISA NCAC ZC .0118.
e- YaD(gjm* 2 mETHODCFTEST (C•3
t. DtSINFELTKOL Typ*4 \ %S Amount �,3s
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth DisinterWeight
Fran _2 ( Ft to Uyfal
From To R.
Rom To FI.
7. GROUT: Depth Material
From_To R. (rote/1 f
From To Fl.
From To ' - Fr: -
8. SCREEN: DepCh Dia Hater Ski Site Material'
Rom To FI. in. in. �___^
From To P. in.. in. "r _
Rom To R. in. R `'
9. SAND/GRAVEL PACK: t:`
Depth She Material r..±
' From To' Ft r
Method
tad
From To FL
From To Ft
10. DRILLING LOG
eFrom To Format�k•F tion'
/ 21
ntr 7°5 _ &,off
11. REMARKS:
r
r
c
I00 Y OERTFYTN*T THIS VIPS TED IN CONDUCE Wmr
'r'SA NCCC ZC. WELL CONSTRuCTON .
RECORDNIS BEEN PROVIDED TOTHE
--. "---
7/Tc
SIGNATURE OF C W CONTRACTOR DATE
bete:0,- V eaitb. 6 L e_
PRINTED NAME OF PERSON �DNSTRU G WEU.
Submit the oral to the Division of Water Quality within 30 days. Attn: Information 143
1617 Nail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fam GW-la
Rte. 7)05

RESIDENTIAL WELL CONSTRUCTION RECO:3D
North Carolina Department of Environment and Natural Resources- Division of Wier Qualm
WELL CONTRACTOR CERTIFICATION # . 0434.4
1. WELL CONTRACTOR:
ece: e k -.Aer-2'tti.
Welt Contractor (Individual) Name
e.-c ' k S o n
Well Contractor Company Nate
Sc�wye.cs
STREET ADDRESS ‘.1/42316 S
%La./ ael
Viol S�C'ionSS) JJC Q.951M1,
City or Town State Zip Code
(Watt} (oios- aoaa.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(e applicable)
DWQ or OTHER PERMIT 4(d.iyp&4
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED - /7- C
TIME COMPLETED / , 0 o
3. WELL LOCATION:
crrv: /4.41/1rsL',//e: COUNTY ,yc noJ
fa20 Cree
(Sine y ne. Numbers. Canmunity. Subdivision, Lot No.. Parcel. Op Code)
RAPHIC / LAND SETTING:
Skye QVelley ❑Flat ORidge ❑Other
(check appropdate bac)
LATITUDE 3
LONGITUDE
Latitude/longitude solace: ❑ GPS D Topographic map
(location of we/ must be shown on a USGS topo map and
attached to this form f not using GPS)
A
AM (SPM D
degrees,
be in degre
minutes, seconds or
in a decimal format
LOWNER
//
OWNER'S NAME a �^�l /� /lp
STT./yg/��jY-�T.�AjDIDRESS (Y o /.J 42' 7 / 0
�t 54-todRE. l Pl 021717
City a Town Zip Code
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 7 O S-
P. DOES WELL REPLACE EXISTING WELL? YES NO(IIi
c. WATER LEVEL Below Top of Casing: 70 FT.
(Use '+' if Above Top d Casing)
d TOP OF CASING IS ' FT. Above Land Surface'
Tap of casing tormented aaor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. C�
e. YIELD Wpm): / METHOD OF TEST R-5
32732G
T..DISINFECTION: Type 1); t \ S
g.. WATER ZONES (depth):
From
From
From
6. CASING:
To
To
To
Amount 3S
From To
From To
From To
Depth Diameter
From 4-X To 7(e Ft _ILL_
From To Ft
From To Ft.
7. GROUT: Depth
From 0 Toj2 C) Ft
From
From
To Ft
Thiclmessi
Weigh Mn�t
Sara f tI/s ,L
Maeda
CP.H r'Lf"
To Ft
Method
/ Ou ref
8. SCREEN: Depth Der nester .Slot Size.__. .3
From To Ft in. 1 in.
From To Ft in. in. 7'
From To FL in.
9. SAND/GRAVEL PACK:
Depth
From To
From
From
Ft.
To Ft.
To R.
10. DRIWNG LOG
From To
/ 7(,
7Ca
Size
I'O if'
Formation De ipdi�
Over.
>of Gez.a . /i _..__.._.
11. REMARKS:
rT
w S'
�'-
r
r
100 HERESY CERTIFY TWT THIS WELL Y'AS CONSWI'C1ED N ACCORDANCE MTH
15A NCAC 2C, WELL CONSTRUCTION Se WARDS. AMTHAT ACOPY OF THIS
RECORD HAS SEEN PROVIDED TO THE NELL OWNER.
SIGNATURE OF CERTIFIED W CI0, DATE
bete.tk \Ate-k , !scan
PRINTED NAME OF PERSON C CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Masi Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7A5

Zip Code
04-17-'06 11:55 FROM-NCDENR ASHEVILLE Ri 82d2SHt04:3
1. WELL CONTRACTOR:
ENLLAL wzt CONSTRUCTION R Cnan
North Carolina Denazttnent vffnvuvn:nent and Natural Reaou rces. Division of Water C
WELL CONTRACTOR CERTIFICATION ii R. r{3 L-e Quality
1.-y12S y n.LL/105 U-
nL1p
Wel /Coot arior ( Satiated NATta
11
�icP
Clyde Sawyers & Son Well Drilling
14885 Hwy 209
Hot Springs NC 28743 �S
Area code. Phone number'
I2. WELL INFORMATION:
SITE WELL ID *Orapraceto*
STATE WELL PERMITIMInmenwe)_
DWQ or OTHER PERMIT/KtapplicableL
WELL USE (Check AppIvable ScrO: Reeidentet War Sup*
DATE DRILLED S%
t TIME COMPLETED AM O PM La—
i 1. WELL LOCATION.
CITY: _ Cfe COUNTY A K Oar f
(Street Nana Numbs nt Community. Subdvaon, Lot No, Pans, La GoM9
POGWAPHIC! LAND SETT'eNG:
OVER'', ❑Flat DRIdge DCttter
tcnearappropaam orw
LATITUDE - —
Coda
LONGITUDE"
norms. seconds
in a admit, Throat
May bs in degrccs,
ce
Laritdefongtudc awn*: ❑OPS .Topographic leap
&caLvn orwelmust bs Mown on a USGS tope map and
attached to lure Vern ?not usng OPS;
4, WELL OWNER
OWNER'S NAME
STP. AD
__s/3_
• Abe code- Phone number
d. WELL DETAILS:
A TOTAL DEP t_ Q C
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO jr
e. WATER LEVEL Below Top cf Casing:
(Use `✓ if Above Top of CaNazi) T.
et. TOP OP CASINO IS � FT. Above Lard Surface 'Teo of early asmarated aWr no bw Lan surface m
a variance in accordance Wlh 14A NCAC 2C .0116����
a YIELD(9PmF. _ METHOD Of TEST. =.
V
Submit the origami to the Division of Water Quality within 30 dam:. Uhl; Information Mgt„
1617 Mail Service Center- Raleigh, NC 2769E4017 Phone No. [phone] ext 562.
1
Fran_ TO FL -_
7. OROUT: Cwtt
Material
F.-.•�.s ,,_ To 'dam
From_ To FL . .
Frp;L To FL`
I. SCREEN: Oapth Damatar Sbt s"
F Tg oz Meteret
From__
Fran_�_FL n.
Tp F��%n
9..$ANDiGRAVEL PACK:
Depth
From____To
It DRILLING rDRIILLING LOG
F
11. REMARKS:
L DISINFECTION: Type r S A
• A WATER ZONES (depth):
From To From
From To � T
Fro To
From To Front
9. CASING: - _ _
Dept) Iii:Mese
Fran__ To Co C2 FL,_ f
F
ram To F'�-..-..-...
FL
M.�MAI MrO
Site Ma trial
FL.
R.
Formation DescYilpDn
— l.sJRr /i
100 NERfl CER Wy ?HATTIM WELL WAS 15A NCAC 2C. WELL CONS CCh9AND r1A A Doty A 7.s WRH
RECORD MS SEEN PROV ED ME WELL DWUERm TINTAC7YOF TNIa
en, ATQRE per t:CK l lt:f:D DATg
NTRACT�DR rAATE
/0Crrrc_ k
PRINTED NAME OF PERSON NSTki1CTIN THE W=LL
327321
nount,U
rb
Form GW.1a
Rev. 7105
r-
-c •
-

327622
RESIDENTIAL WELL CONSTRUCTION RECO'2D
North Carolina Department of Environment and Natural Resources Division of Wu tc Quality
WELL CONTRACTOR CERTIFICATION #. aka
1. WELL CONTRACTOR:
Qacc;c.k '. \Qcah Sa-•a`ieCS
Well Contractor (Individual) Name
•
CA\j 8.42_ S O n
Well Cdriractor Company Nate
STREET ADDRESS t1/4 Cill0 S
letIzy Q04
>\ot Sr;Y.9s) >J ainy",
City or Town State "+Zip Code
caa%} Colas' aon
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 1D #(a applicable)
STATE -WELL PERMIT/Ka applicable)
DWQ or OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Bond: Residential Water Supply.Br
DATE DRILLED S—/S' C l�
TIME COMPLETED 07, m30 AMID PM fir
3.WELL LOCATION: )) '/
CITY: deft Pi t/i L(e COUNTY j/aywocW/
.(S Nam , Numbers. Community, Subdivision, Lot No. Pamce& Zip Code)
T POG HIC / LAND SETTING:
°valley °FM E7 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS °Topographic trap
(location of we/ must be shown on a USGS topo map and
attached to bets form (not rang GPS)
May be m degrees,
minutes, steads or
in a decimal format
4. WELL OWNER /
OWNER'S NAME o/i Ap me /1{/
trr
. 1//
STREET ADDRESS -3if 1J/G(�/� Re 7'Ql-C-
Celle /1 C- r2 8'7oZ I
City or own Sta/tee Zip Code
( ton/)- 7-3Y-7-5n0
Area code - Phone number
S WELL DETAILS:
a. TOTAL DEPTH: Co C
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 10.
e. WATER LEVEL Below Top of Casing. 30 FT.
(Use'+' 8 Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface'
`Top d casing terminated attar beta land surface may require
a variance in acwdance with 15A NCAC 2C .0118.
e. YIELD (gpm): 2 METHOD OF TEST fZ`5
t. DISINFECTION: Type 9 t t$ Amount of.f
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
From To
From To
From
To
Thickness/
Dep
Marial
Fran To m%�i Ft airM .5/tv//
Fran To Ft
From To Ft.
7. GROUT: Depth Materia Method
From 0 To ' U Ft Center/. ph, n 1
From To Ft.
From To Ft
8. SCREEN: Depth Dia teeter Sea Size Material
From To Ft in. in.
From To Ft in. in.
From To Ft. in. vu.
9. SAND/GRAVEL PACK:
Depth Size
From
from
From
To Ft.
To Ft.
To FI.
10. DRIWNG LOG
From To
/ 76
?G C 5
11. REMARKS:
Material
Formation Description
Ouer I,
G/bn, t(e
-TI
J
RECEIVED
AUG P5 2LL3
I DO HEREBY CERTFY THAT WELL Y '�, piy�X
15A NCAC 2C, WELL CONSTR " •:-R: ' I
RECORD HAS BEEN PROVIDED TOTE h ELL OWNEF.
SIGNATURE OF CE
•
tetC.cx 13/4f0.41.1. aJ'ye_43
PRINTED NAME OF PERSON CDNSTRUCTING 713E WELL
OF'so Wm1
ONTRACTOR DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mit.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONTRACTOR CERTIFICATION if
1. WELL CONTRACTOR:
�erc; 0.34- -Aec_ \'. Saw�rets
W ea Contractor (Indwidual) Name
Well Cthbacthr Company Nate
STREET ADDRESS "‘RlSS Iti1/4Z,./ a
ot S�c:�gs, )Jc d,
City or Town State ,-Zip Cade
(8a9» roes- 3aaa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ire applicable)
STATE WELL PERMITIFR applicable)
DWQ or OTHER PERMIT ii(d wlAF•eI�L)
WELL USE (Cheek Applicabley
Box): Residential Water Suppl
DATE DRILLED-St/7 Ce
TIME COMPLETED PAR) AM LT rt"t O
3. WELL LOCATION: AI,/
/
CIT': LIJ ttt..907gt - COUNTY AI,/cvbo
Sant<i./,acy DCtVQ
.(Street Name, Numbers. Community, Subdivision, Lot No.. Pareet. Zip Code)
TOPOGRAPHIC / LAND SETTING:
Skye °Valley °Flat ❑Ridge C Other
(cheek appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: °GPS C Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form 7not usag GPS)
a WELL OWNER
OWNER'S NAME CY\ o cce\ Ter\ bct
STREET ADDRESS 90 «0( 1Cal-kV,
L,JO. YtE`tV:tteT )JC aenC610
City a Town State Zip Code
(9 Wb)- yam - 0-Et9,
May be in degrees,
minutes, seconds or
in a decimal format
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: SOS
b. DOES WELL REPLACE EXISTING WELL? YES D NO a—
t. WATER LEVEL BdowTop of Casing / 515 FT.
(Use •+• if Above Top of Casing)
d. TOP OF CASING IS . \ FT. Above Land Surface'
Top of casing terrtmeted at/or below land surface may require
a variance in aowdance wfh 15A NCAC 2C .0118.
e. YIELD (gpm): 2 METHOD or TEST P.-3
RESIDENTIAL WELL CONSTRUCTION RECO'2D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
0436
327337
f. DISINFECTION: Type �, \ \S
Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To Fran To
6. CASING:
Thickness/
Depth D- er We' M M
From -� To , FL b'� 51)Qtyl Pf S
From To Ft
From To Ft
7. GROUT: Depth
!, 2Material Method
From 0 To �l� Ft CLr^1PY fOr..iwi
From To FI
From To Ft
8. SCREEN: Depth
From To
From To
From To
Di:ratter Slot Size
Ft in. n.
Ft in. in.
Ft n in.
9. SAND/GRAVE. PACK:
Depth
From To
Ororn To
Frorn To
10. DRILLING LOG
From To
6a
60
205-
I1. REMARKS:
Ft.
Ft.
Ft.
T iU
Size Material
Formation Descrtptinh-
0
O
rr
to
N Chr
r
.. HEREBY CERTFY THAT THIS WELL VAS CONSiRL-CVED N ACCORDANCE MTTH
t C 2C, WELL CONSTRUCTC* SPNDARDS. ANC THAT ACOPY OF THIS
RECOR. ._EEN PRODDED TO y t. ELL OWNER.
• TURE OF CERTIAE_IL CONTRACTORS DATE
to C. CU- \AtOK, Soar
PRINTED NAME OF PERSON C CNSTRUCTI G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information IOIt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-Ia
Rev. 7105

4? i;x 2..2 -zi
11. DISINFECTION: Type #7/9Amount
12. CASING: Wall Thickness
From 71-e,. Depth/D' eter or Weight/Ft. }'b�l gnat
To OD Ft. y {/ /('.
From To Ft.
From To Ft.
13. GROUT: Depth Ca
* Method
From 0 To �'D Ft. f a n.r[�N
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:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural
lRResources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAMEAprint) -*Aft 5 rot,_ �h.l re CERTIFICATION
/#�47�
WELL CONTRACTOR COMPANY NAME / r/ re- tve,/�X , ,a PHONE # I$)GvT2:e.S9,
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential 5/Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT
Ne rest Town:
.Q Caf:24:4
ss[reet Name
County wax'
-d
Numbers,
1 Community, Subdivision, Lot No., Zip Code)
3. OWNER: K' rr ` `Nyi'g e -re.- o
Address
d
di4 (Street,ort' ute No.) c2 gs.2
Cit4r Town
State
)-
Zip Code
Area code- Phone number
4. DATE DRILLED S-3 I O
5. TOTAL DEPTH: 705--41+
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO B'
7. STATIC WATER LEVEL Below Top of Casing /8C 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.0119.
9. YIELD (gpm): / METHOD OF TEST /fir
10. WATER ZONES (depth): •
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.
opographic/Land setting.
tdge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
F Daryl d o ryD e s c ri p t i o n
d y
DEPTH
From To
705
1'-% v
AUG 25 211rS
Ashrre lle Re .-?S\ Hee
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COIy6�2UCTIpN TANDARDS, AND TEA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SMSmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-322I, within 30 days. GW-1 REV. 07/2001

r• h rv<
t}r.: l
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section //
CERTIFICATION # �O6
WELL CONTRACTOR (INDIVIDUAL) NAME rint)
WELL CONTRACTOR COMPANY NAME tCam. //I w-griP PHONE #
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential NI'<vunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
N est To
gety,vh%
E Coun
(Street Name. Nutnbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: AJ £[/NA1 /jnv
Address /93�c5t)(e tCc '
re or Route No.)
.,.y or Town State
9A - g6,6-0
Area code- Phone number 4. DATE DRILLED —/7—//�� 06
5. TOTAL DEPTH: 30..5 -
I I. DISINFECTION: Type
12. CASING:
Depth
Frotn To ]a
From To
From To Ft.
13. GROUT: Depth Material
To (90 Ft. Ce B^'
From
ticz
From D To Ft.
Zip Code
Topographic/Land setting
EtRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees minu[esiseconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From
To
o2t)
20
77
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO NV2
7. STATIC WATER LEVEL Below Top of Casing: a 6 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
75'
l
3."
`Top of casing terminated atlor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /0 METHOD OF TEST /5217-
10. WATER ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
T
Amount
Wall Thickness
Diameter or W �j dit. aerial/
•/Sf•
131'S
Ft. •
Fr, .ty'Description
'4
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
Method
Material
CQNSTRUCT)STANDARDS, AND T[J-p�A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
it
4'
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and Natural Resources - D-iivvi -ion of Water Quality - Groundwater Section
\1 ���-F.L1. ('1)\"112.\('11112 (I\III\'IUC\h)\;\,\Ili: inrinik N74/3 The h/re CERTIFICATION I YG"✓e/
\%Fall. CONTRACTOR COW IS\\\'.\AAll•: / //—,« bfre// Y/:44.-1 PRONE a 4677-65.9.5.
S-I .\ I F: \\ 4:t.1. COAST lit CHUN I Ett.\ll'rtt
(ir.Iaplicahle) (i(applicable)
:\ss0CL\TED \\'Q PER.\IITN
I. WELL USE (Check Applicable Box): Residential 19 :Municipal/public 0 Industrial 0 Acricullural 0
Nloiiilurin_ 0 Recovery ❑ 1 teat Pump \Voter Injection 0 Oilier 0 If Other. List Use
2. WIiLI. LOCATION:
Nearest Town: A )e UJ4/,ej/ Count
Fx,..s /to - C
S1ree1 Name. A'umbms. Community. Sulu v ivon. Lul No. Zip Code)
OWNER: .tit!/$
Address/ god T , _J_ eiders"
6yyyyyy rret o t): No.)
/// 9
(
4,00e '7Ridgc ❑Slope ❑Valley ❑Plat
(check appropriate howl
Latitude/longitude of %veil location
(72-.S
,3yd7,.A70
-nv nV 1 Si de Lip Code
1,/r l 0)- 7?3-J%/
Area ode- Phone numhcr
4. DATE DRILLED 5, r--o
5. TOTAL. DEVIL I: e5-6S—F'-1-
6. DOGS WELL. REPLACE EXISTING VVI'.I.L? YES 0 NO
7. STATIC ATIC WATER LEVEL Below Top of Casing: /AO PT.
(Use"✓' i1Above Top of Caemg)
S. TOP OF CASING IS FT. Above Land SurlSce*
'Toy of casing terminated atlor below laud surface requires a
variance in accordance with I i\ NCAC 2C .0118.
9. YIELD (gpm): / METHOD OF TEST 't4'
ID. WATER ZONES (depth):
11 DISINFECTION. Type fir, Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. N leriul
Tu Pt.
Prom *� �4 _6 /
Fnno To Ft.
From To PI.
13, GROUT: Dcplh Vtalcnal ;Method
From 7% To FL :, 2^6.
Prang To 1 1.
la. SCREEN: Depth Diameter Slol Size ,Material
Prmn To PI in. in.
From To Pt in. in.
15. SANLYCiRAVEI. PACK:
Depth
Front To
From To
opographic/Land setting
t decrees; in inwevieeonds
Luliludc-longitude source❑GI'S❑lopographic Amp
check box)
DEPTH DRILLING LOG
From To FA -tuition )cscription
dlic-
Size
.N1ulcrial
16. RENIARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two Slate Roads or County Roads. Include the road
numbers and common road names.
�w/9
'1UUb7 C b
A h`
8
01
I DO III:R LI31' CERTIFY TEAT 1111S WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
C'OTRUCIION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING TI Ili WELL
=06
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 163E Mail Service Center - Raleigh, NC
27699-1636 l'hone Ni,. [phone], o'ithin 31) days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD 0
North Carolina - Department of Environment and IJ
WELL CONTRACTOR (INDIVIDUAL) NAM(pdn
WELL CONTRACTOR COMPANY NAME riteWe/
s - Divisio
✓~7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
ofWater Quality - Groundwater
Section
eCERTIFICATION#7"//
PHONE # efaiaitantV
I. WELL USE (Check Applicable Box): Residential & Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION„ ��
N rest Town: I¢ yive.414 County
K) dervl-eI-LJ �LOr
(Street Name. Numbers, ommunity, Subdivision, Lot No., Zip Code)
3. OWNER:J �y wa)r'
Address ,Y7 it'i✓ervie"v Dr -
reel or Route
A/c�ives�� /u C.No.)
fig) lyior) — St� 7 Zip Code
Area code- Phone number...,
4. DATE DRILLED / 1},—nto
5. TOTAL DEPTH. e)
6. DOES WELL REPLACE EXISTING WELL? YE ❑ 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 accordanceeith 15A NCAC 2C .011E.
9. YIELD (gpm): /q( METHOD OF TESTJG/G--
10. WATER ZONES (depth):
Topograa is/Land setting
❑Ridge BSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/mimes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
• DRILLING LOG
F. ;ti. Description
4
DEPTH
From To
0 '.2a
O2
LOCATION SKETCH
11. DISINFECTION: Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
From 1(9,_ Depth
To 'Y
From To
From To
13. GROUT: Depth
From b Too2D
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth
From To
From To
Ft.
Ft.
Ft.
er or Weight/Ft. M erial, numbers and common road names. CD
0
A
c'D
m'-
wG
ot:
c
r
1-
-<
„aMaterial ,/- Method
Ft. (E�"'pi✓r
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Size Material
Ft.
Ft.
N
0
0
16. REMARKS:
I 1 • HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
C TRU t, try STANDARDS, AN 'r T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
mite original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME n�t� ��/
WELL CONIRACFOR COMPANY NAME l/ r.-l_ V(/(
3.05 2 8
Resource - Divisio of Water Quality - Groundwater Section
�G Oo CERTIFICATION #�c?5/66
�M/ PHONE # {3C�r�tr7 :J 65M13
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
1. WELL USE (Check Applicable Box): Residential Er—Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest
JCChn /Ut Ode —
(Street Name. Numbers, Community, Su�b�division, Lot No., Zip Code)
3. OWNEIZe Af /AA ern S.
Address
Zip Code
Area code- Phone number
4. DATE DRILLED 7— %G —
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO I�
7. STATIC WATER LEVEL Below Top of Casing: /O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordan�y' ith 15A NCAC 2C .0118.
9. YIELD (gpm): __ METHOD OF TESTA' r
10. WATER ZONES (depth):
5. TOTAL DEPTH: / S
11. DISINFECTION: Type
12. CASING:
From 'Ia
(Street or Ro
City 07)It' wn State
Topographic/Land setting
❑Ridge ❑Slope ❑Valley L9Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH • DRILLING LOG
From To Fertjtatio Description
T
Depth,// Diameter
To 7,7 FL 6 w
From To FL
From To Ft.
13. GROUT: Depth Material
From C9 To o?-L) Ft. (,(2i)A.e.rvr
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
]5. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. �f al numbers and common road names.
Method
Slot Size Material
in.
in.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COp9RUCTION STANDARDS, THAT A CORY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
)4.
7 /o-o6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Res
WELL CONTRACTOR (INDIVIDUAL) NAMEc,rtnt
%YELL CONTRACTOR COMPANY NAME/
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
o ry r r. C. 'w
'J 0 i 04 /
es - Di isi9n of Water Quality Groundwater Section
CERTIFICATION # "/
PHONE # (US 61/-g Yp
ASSOCIATED WQ PERMIT#
(if a. Iicable)
I. WELL USE (Check Applicable Box): Residential LN" Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCAT
N re t Town:
(Street Name. Numbers.. Community,,/ySubdivision, Lot No., Zip Code)
3. OWNER: Flit ariYer-
4W6aro (Street(S�treeor Rout. No.) c) 7 � 77`
City or Town State Zip Code
K
Address S.S 61/Pi✓ViWP % /
)-
Area code- Phone numbeL„
4. DATE DRILLED /
-& o6
5. TOTAL DEPTH: 3-OS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: /90 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS O FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordanc9 tith ISA NCAC 2C .0118.
9. YIELD (gpm): � METHOD OF TEST 4/
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
7
Depth�99����t r
From 7a To Ft. 49 %/
From To Ft.
From To Ft.
13. GROUT:, Depth Material L
From (/ To (�h Ft. CFMC�7
14
Amount
opographic/Land setting
EBItrdTge ❑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 Tg F ption.aescription
Q
LOCATION SKETCH
Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. Mnumbers and common road names.
,363
From To Ft.
SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
Method
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH l5A NCAC 2C, WELL
CO RU ION STANDARD ND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7Qyo6
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
bmit t e original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
0
rice 't/e/

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Re
WELL CONTRACTOR (INDIVIDUAL) NAME,. (print)4
mrces -
17 ;re
WELL CONTRACTOR COMPANY NAMk-,o' "tom` // T / (insP
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
• • r-
V J k VAs V
ivision of Water Quality - Groundwater Section
CERTIFICATION rC%
PHONE #
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential 0' Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nw est Town: t4
(Street Name. N . bbers, Community, Subdivision,
LLoyNo., Zii ode
3. OWNER: A7//ee^d r5ML'eAd/ L.,bo/v0��SO.r�
Address ///7 tty/'On+r !`
reel or Rout No.)
%y�r�P N l r a s78�
ny o tJcs 070 Zip Code
Area code- Phone number
4. DATE DRILLED 7jt — b tP
5. TOTAL DEPTH: 3c;,-
Topographic/Land setting
Elite ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
To do Description
From
n Se-
3-0
6. DOES WELL REPLACE EXISTING WELL? YE NO n
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 accordan e with 15A NCAC 2C .0118.
9. YIELD (gpm): __(� METHOD OF TEST'
10. WATER ZONES (depth):
I 1 . DISINFECTION: Type
12. CASING: P
Dep
/�C, Toth Fit° From
From To Ft.
From To Ft.
Amount
Wall Thickness
or Weight/Ft.
13. GROUT: Depth�s7,, Material' /-
From O To (n) Ft.�.�'�.P�T
From To - Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
erial numbers and common road names. o
gib
Method
Slot Size Material
in.
in.
Size Material
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C�R� STANDARDS, AN AT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O �R
7/�`o
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N�turaL, .eso ,a es - Dhcisiop of Water Quality - Groundwater
WELL CONTRACTOR (INDIVIDUAL)
.f{ /It/
NAM
WELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
wr
Section
s , lG CERTIFICATION tt951
a. 've PHONE #
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential ' Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI
Nearest To ..t
Ak VW.
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:ie ✓
i
Addr ss 1 v� � v.
078
(Scree or Route No.) S-7
) ity `rp Zip Code
Area code- Phone numb
4. DATE DRILLED
�9`D
5. TOTAL DEPTH: O2SS /�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 12
7. STATIC WATER LEVEL Below Top of Casing: 3/ FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordan ith 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST//r
10. WATER ZONES (depth):
Topographic/Land setting
EtICIge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
ati+n Description
DEPTH
From To
LOCATION SKETCH
1 1. DISINFECTION: Type Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
^ia Depth,%3yjer of Wet ht/Ft. //�/I�pterial numbers and common road names. o
From To D� Ft�.Y)R-al/ /'� Sf2(-
From To Ft.
From To Ft.
13. GROUT:^Depth aterial Method
From l/ To 02O Ft. (it+e"iT
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
Slot Size Material
in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
/ooV
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C9NSTRUCTION STANDARDI$rr41)ID THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
777-66
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

CI 67' (a, ' ° 14
r � u kJt9
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Reso
WELL CONTRACTOR (INDIVIDUAL) NAME Ant ',/
WELL CONTRACTOR COMPANY NAME / 7'Ce btt / Q-
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ces - D'v'sign of Water Quality - Groundwater Section //
-
A i �' CERTIF:CAATIIONN #Q'�h�yJ
c//PP PHONE # rg{T)(ryv77: -C95
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential Q—Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Usc
2. WELL LOCATIONl: �/
Nearest Town:
//an/7TOit/ County,
4%,,Tr4 Y /u
(Street Name. ➢lumbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: U/O �AN-e
Address /4" -I; YtvCe- ;/'
{St et or Route No.)
//d^AreSVi% We. 02g 7&'
ny ot-Town. 7State Zip Code
Area code- Phone number
4. DATE DRILLED 7�2 - O w
5. TOTAL DEPTH: 77 f'r
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: 73 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): � METHOD OF TEST
`Top of casing terminated at/or below land surface requires a
I
0. WATER ZONES (depth):
Topo�gr�a$hic/Landsetting
❑Ridge 035lope ❑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 Fog to Description
11. DISINFECTION: Type r
12. CASING:
Fromfo?
From
From
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
Depth Diareter or W itift eria1 numbers and common road names.
To / 7` Ft�/� /
To Ft.
To Ft.
13. GROUT: Depth Material Method
From 0 To Ft. Z ---4ev
From To Ft t
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.
1
0
c�
tip
0
rn
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
NSTRU r N STANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PERSON CONSTRUCTING THE WELL
uhmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
- North Carolina - Department of Environment and Neat 1
WELL CONTRACTOR (INDIVIDUAL) NAME j151nt
WELL CONTRACTOR COMPANY NAME / / ACC'
STATE WELL CONSTRUCTION PERMIT#
(if a licablc)
es
�t
e9 t)l) v2
urces - Dt lsiLgn of Water.+Quality - Groundwater Section
�� //� roc j„• f` CERTIFICATION
#�9�7CLG'�yp
%4-,cM� PHONE #YN5S {% 'e
ASSOCIATED WQ PERMIT#
(if a. licablc)
1. WELL USE (Check Applicable Box): Residential I✓T Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
N est own:
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address 3
e County
Q�''--ya��fCity(uojrr Town (�' State' Zip Code
(!?L�i )- l�- /o/ i
Area code- Phone number /��
4. DATE DRILLED — C Cli -
5. TOTAL DEPTH: (aC `pT,--,2kg-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO inl
7. STATIC WATER LEVEL Below Top of Casing: 3 / FT.
(Use "+^ if Above Top of Casing)
8. TOP OF CASING IS en< FT. Above Land Surface*
Topographic/Land setting
Midge ❑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
Fr0
o F. ,Rion a escription
'9-
`Top of casing terminated atior below land surface requires a
variance in accardancf with 15A NCAC 2C .0118.
9. YIELD (gpm): / 0 METHOD OF TEST 1 r
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
De t D' er
P
From To Ft. /y
From To Ft.
From To Ft.
13. GROUT: Depth .1 pterial Method
From 0 To 0(0 Ft.
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. include the road
or Weight/Ft. riaL_ numbers and common road names.
ii5s
16. REMARKS:
AUG 2523S
0
s.0
1 DO HEREBY CERTIFY THAT THI WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CC?tsTRU1 I STANDARDS, D HAT A COPY QF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
77-0(7
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Sd#fmit the r Hgintkl 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

3 3 C
2 2%
- WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and t t$u�Nt�$�u��r� a ces -/,D vii ion of Water Quality - Groundwater Section /
WELL CONTRACTOR (INDIVIDUAL) NAME (pdntr rvoi&2/te CERTIFIC,�ATTIIONttt
WELL CONTRACTOR COMPANY NAME rite Alt°/Pt©M� PHONE # ,col 6/7
STATE WELL CONSTRUCTION PERMIT# _ _ ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Near p To n: �/ County
/ do Ue
(Street Name. N tubers, Community, Subdivision, Lot No., Zip Code)
3. O W N ER.,a-e" C �$��_1 I't/ 6
Address ..56 /72_ en-pve
trees or Route
dU�eSv// /1/il" �f 7
City or Town State Zip Code
(—)-
Area code- Phone numb
4. DATE DRILLED O
5. TOTAL DEPTH: /%OS�
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1�
7. STATIC WATER LEVEL Below Top of Casing: /S FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordancgg fiqlth ISA NCAC 2C .0118.
9. YIELD (gpm): Y0 METHOD OF TEST Al r"
10. WATER ZONES (depth):
II. DISINFECTION: Type 7, Amount
12. CASING: Wall Thickness
From toDepth,-- �,j I)i�rn er or Weight/Ft.
To hFL(
From To Ft.
From To Ft.
13. GROUT: Depth
From I/ To 020 F
From To Ft.
Material
me
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
Topographic/Land setting
❑Ridge Mope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To atjop'Description
0 :aD 4
Method
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
4 066
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COpJ$TRUCTNDA, A�T A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
7-25 06
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
99-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD '
North Carolina - Department of Environment and Natural Resources - Division /. oof Water Quality - Groundwater Section
�f'
WELL CONTRACTOR (INDIVIDUAL) NAM F�(print)
�� /�AVIb 5$t & &4 CERTIFICATIONp�p.p4"(1al
VA'ELL CONTRACTOR COMPANY NAME AO (HAIL WQI1 ).-gait PHONE # ($aw &83- Ha3
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ MIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: «
A,«Ile county kyW
(Street Name. Numbers. Community, Subdivision, Lot No.. Zip Code)
3. OWNER
Address
(4 R no are) CDC (1-)
(Sued ute No
c'yne,sv�ll� �G� 872<(
C it or Town State Zip Code
( )-
Area code- Phone number
4. DATE DRILLED (-0 d -
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO [JV
7. STATIC WATER LEVEL Below Top of Casing,: J OO FT. '
(Use ^+ " if above Top of Casing)
Topog hie/Land setting
❑Ridge lope ❑Valley ❑Flat
(check appropriate box)
ptisdSDdlgd) [ l locV"-J k
(degrees/minutes/secondss))�,G
Latitude/longitude source:UGPSLJTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
8. TOP OF CASING IS ) FT. Above Land Surfaces
*Top of casing terminated at/or below land surface requires a
variance in accordance itb 15A NCAC 2C .0118. n'
9. YIELD (gpm): `J METHOD O(F� TES'IGOT 1• �(..tArici
10. WATER ZONES (depth): I00) j T O
11 DISINFECTION: Type 1 Pt NC4' Amount
12. CASING: Wall Thickness
Depth Diameter or W'eight/Ft. Material
rom t o tt.
to
70
13. Depth Mate al Method
ToTo Ft. __�
14. 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.
From tt.
From Et.
GROUT:
From
From
SCREEN:
P.
0Jii030
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and CQI cacti -@dd.f11DiL@,L
16. REMARKS:
1 DO HEREBY CERTIFY TJHAT THIS WELL WAS CONSTRUE I ED IN ACCORDANCE WITH 15A NCAC 2C, WELL
/
SON RUCTION STANDARDS. AND OPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL D�A7fE��
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources Division
nnpof Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME(print)Da_IU_1D 5`+�','t'I��'akin N r` CERTIFICATION 43if,P.II �j
\\'ELL CONTRACTOR COMPANV NAME Rpp'r;'liaeh\AN ,y<IA ( 1 `�\ `y� PHONE p tA0+d15127. /Ot1#-3
SLATE WELL CONSTRUCTION PERMIT# ASSOCIATED WO PERMIT*/
(if applicable) (if applicable)
1. WELL LSE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural ❑
Monitoring_ 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION: ,��D
0 lyix?Sc.
Nnl_ C G WOo S n
(Street Name, Numbers. Community, Subdivision. Lot No.. Zip Code)
3. OWNER: adLie4D CS15+ cbots
Address 55 Cot*H'q J ok •
z46 iiSatreet orMQNo.) a2fls
C,ry or Town State Zip Code
Area code- Phone number r_
1. DATE DRILLED
5. TOTAL DEPTH: tie
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO q-7
7. STATIC WATER LEVEL Below Top of Casing: DO FT. •
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S / FT. Above Land Surface*
/a
0(0
`Top of casing terminated at/or below land surface requires a
Topogr is/Land setting
❑Ridge lope ❑Valley DFlat
(check appropriate box)
N3SiAD3/g. t` jn r--B*yd9
(degreesiininutes/secondslr�. 2-7 3 I 1
Latitude/loneitude source:LGPSLITopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accordan with ISA NCAC 2C .0118. /'� „�
9. YIELD (gpm): v U HOD L/O' F T$ST p %ai0' 1
0. WATER ZONES (depth): v T � `J ��i� 4
1. DISINFECTION: TypeTR$ IC+ Amount o2
12. CASING: Wall Thickness
Dept 5 Diameter or Weight/Ft. Material
From 10 (,per Ft.
From 10 Ft.
from 10 Ft.
13. GROUT: Depth
From To
From To
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
Material Method
Ft.
Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
Matenat
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.
co
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION. STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL ' DA
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

SOW ONLY
amine
lembO ,r-O.v.b.. ldSSwL....elodN...eIlmo..00-alwfomaw.ros •awdroterSalon
IOW Md Smoke Omer • ROO" N.C. =lWO-1QSHon. pm 73741111
WELL CONSTRUCTION RECORD WELL OONTRAe jRs (&Lru lA,i .f
WELLCONTRAC10R CEN7lIOAT1ON 1-3
STATE WELL OO,a,a crsNPat1ERr.
o,
1. WELL USE_Leremleyeseate— Pie Raaldrsif wa,p.t D babes O
Ramo, Host Pump w+rI1--•DMet p VOther, UMU c
2.
WELLLOCAT10 omat.r i of The balm bars)
N.welTewc1cut MreSvt IIe ccer Hof{ A-t)o ,
Red lioneyer rams..,agonies,/ ernee slat..)
A OWNERtrim(' ; rn
Add"... 81 G. C 1 .
l l (Re romomtw.e
Y"Y,SV IIP A)C lss5
al.rrt... aor. ace
4. DATEORILLEDI A 1-U.0
s. TOTALDEPin 3' C
e. curries COLLECTED YES NOQ-
7. DOES WELL REPLACE EXISTING WELT vas p NDp'
e. STATIC WATER LEVEL Belo. Tap el CIS FT.
It TOP OF CASING IS l pie
Above Lord Sobar
lip et swig Waded Se Winne aim ropiw.%Signsr-
ew..I 'SAWA=wtn
10. YIELD Win* - METHOD OF Taff l
11. WATER LOPES (dapa4
And d al O Masiodng 0
oRiLll1[a wo Cant
E-newswersi
5- "f��`�
--EGG
12. CHLORINATION: Typo Amount
1S. CABBNt
S odlrs.lapro b modal ter book et form
LOCA11ON 1O1O$
NS Tains
DEO al�rr wrjLai Glom . Phew dl.oram.nddM..erkm.ttrrttoeew.
From�_To 51 p, )hC Iteds,aSur map r/.omopokes)
From, To R 1
From To R.
14. GROUT:
Dopes Magid Method
Farm _ To c�f? R eM)42..1l1jMethod"
From To R
13. SCREEN
apes Mine Mot ebi 1l N W ram,
o L7
F1am.�_To_FI_ b. _h o C
From �To_R_ In.In.
ToR_ h M.
10. SANQgRAVEL PACK hi n c C re c'1 E
DopesSic. 1P.tnld
From To R
From To R-tfQVv
17. RElhMARlis:
0
:c
c�PCK. r'•
r.
1 DOHERM CERTIFY TNATTNISwELL WAS 00I411iRUC110M ACCORDA O wnN taA NOM = WELL.
CdeincuDNSTANDARDS.MCTHAT ACOPTO_F/THISR�EOOPsf%f SINNFRONDED TOME WELLOW16L
FOR OFFICE
�7 ��( lGo^^r— -/6J-��i`�-
alolQlulaOr71laor00NOTI ICI1NOrlf Wesel orate
Men erb anrakkrrawr.aer y.-..arras. eh 30 dares
anal IMV. qoa
r

Nos Coes
lfaolloSrtra.Cwdw.Dwdaid M ...OIws w Mike WdwMr_ .
Ir.V.. N.C. Uestmas Taw pm MIMI
WELL CONSTRUCTION RECORD wia.LCONTRACTOlts %t an A fl
Wt LootmeActoNCa twICATIONF. (DI 3
STAT. WILL CONSTRUCTION PetMtr
1. WELL taaLwsetcApplealaas* a.ra asia mot tsa❑ boss El Aitken' 0 mat sing p
Risconry IL Poop Walt Ober p aawr. ut Lar
2. WELL LOCAtIOItPia Wall Rift btMeobags*
lass yaw .1lrc.:51�1r5Vi llr Omar Netts%(;CC'I
plod nw..aasar+y wSMdAL L.MIM!b4 C .LRIQLO6 DEPTTH
A OWNER X Vie ere Finn Ts
Address i1I— 4 tI t v.
1CXi")9.c1 xll7)Y-CiA'J 0� /5 `'1 `i ce.'t
Orel Ts Se SOW,
4. DATE wain Le-Ia-OlD LIM- -17
5. TOTAL DEPTH S"
a curry=CO ECTED vs0 NOQ
7. DOES voin REPLACEEIOe7NG WELL/ YES 0
a STATIC WATER LEVEL aim Tap of Maar Fr.
Noe 'PSAWa.TepelCoil
IL TOP OF CASINO III FT. Atp.oLead Swine
KAtseam I.orr.d.orrYaw k.fseine ape. new b....w
drloaRlf11/KaalaAtte
1. YIELD ISINS: —La_ temp or msr t 5
JJ 11. WATER ZONES (doped:
1Z. CHLORINATE/Pt Typo Amount Ioddball wpm laneeded uwbeak dism
1S. CASINO:
Duper
Wellies WCATION 1 �?... �.
r
. wwyWaYa� fy - no-7- c:ft CO: (1
14.OROUT: Oop�
Flan To c 7l i MNMIY MAW 4n\ c.
0,
r—
� -' hi
ii ram, -•l
ti < cCl - CC
n
A C'LIIV E
Ft= To Ft
1S. SCREW*
Ram
From To
Rent _ To
to SANDIORAIELPACK
Dept
To
Dade Wee Mon
Ram To F!
Rom To
17. RE34Ilme
DIsmilor slat Wei Rhoda
_ Ft _ In. _ In. t_
Ft.__ Yt In.
P. la In. ;r ..,off � s'�_�A
a e aCCQ5
Z-40 hl
I OOHERESY CEIRFY THAT Bit WEIl WAS CClslaUCTED W freemanWITH ISA NCAC SC. WELL
CONSTRUCTION UT NDPADS.ANDTWITAOOP_VOFT'S!RECORDIMeSIM FRONDEDTOTHEWELOWNER,
‘,' / 3
FOR OFFICE WE ONLY
Sad SR
Liu
n3
1 U
MdIiM11111Eesmeow a011R1alaf.ona 1St GATE
earn awIMOrliwtwaer EA-..rrrwdrrwa.70don
laFt MY. NM

Nam Carolina • Departed of Environment and Natural Resources - Olrtelan of WaMr
1435 Ma Soma Cr*Raid" N.C. 27enx-P .iefcne Mt) 7324221 Quay - 0nsa S.eeon
na
WELL CONSTRUCTION RECORD WELL CONTRACTOR; (10a iC
WELL CONTRACTOR CERTIFICATION h I
STATE WELLCONSTRUCTION PERMIT,;
1. WELL USEjsek Applinble Sn RSNdfl0 tQ Murio%al 0 Industrial 0 ApASAWrd ❑ MonbrIng ❑
Recovery LJ Heat Purrp Water Ir{eoSon 0 Other 0 11 Other, list Uus
Z WELL LOCH �(�-r�-�^, Math of 0* loatheSow)
. tErts .�("'Y(.'\LV i I IP cony: {- h 2,3t :, �{-Y"X`,l
(Road Nwn and Nan Cu^^J 'for SrAL41an wd�f r No.) ORILLINO LOO DEPTH
3. OWNER r\r ct& c4 $ C*Th C r- k, Q f \ From Ts Fa DEPTHwagn
Address SC�ilc1 c1 C] 1I
aatm �Mate aadde -. —
4. DATEDISLLW �-a— -+A.0 % r
5. TOTAL DEPTH ZC V
S. curnmas coLLECTED YES 0 NOta
7. DOES WELL REPLACE EXISTING WELL? YES 0 Ndti
S. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 1 FT. Above Land Surface
'Tap or ashy Mrndrrld air Wien tad swan wens a vans* In sewn
dans wlm trA NCAC 2C 4111
10. YIELD (ppm): 5 METHOD OF TEST CA
t 1. WATER ZONES (depth)*
12. CHLORINATION: Type
13. CASING:
Amount Iladdlibnal pees k ended use bads of form
F� wee TMewwas
I LOCATION SKETCH
From Tp i V� a WnldrFt laSLzS �- how dkee9an and dstros from M Mat two We
To FL l\_LLJ C Roads, a�mw Senors��) r
From To FL
14. GROUT: CCU d£lC� =-C
Ram 1o111 n C` LiY Z l4 Method
From To FL
15. SCREEN:
Depth Demeter Slot Skis Material
From To Ft In. In.
From __ To __ P1. _ In. _ In.
Front Te FL In: In.
16. SAND/GRAVEL PACK:
Depth Sire Mefl
From To FL
From To Ft.
17. REMARKS:
Liao
Jonci- i nn
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C. WEI L
CONSTRUCTION STANDARDS. AND THAT A WPX OF THIS RECOROIUS BEEN PRONGED TO THE WELL OWVER.
6-2-0A
FOR OFFICE USE ONLY
Cued Mr
lsdd No.
TUNE OF PERKIN CONSTROCTaf3 TIE WELL DATE
Subtle SOW a Ohba al TAW" s tlasdraa thaw within 30 days
'
OW-1 HET. IOW

•
Note Carolina • De,.a ..id of Enrolment and Nana Reamer - IMdabn el War Curt' • Cboadwaw Saari
1103 Mr Serra Corer • Ralalpb, N.C. 27S90-163SPtons (91Y) 7333221
WELL CONSTRUCTION RECORD WEU. CONTRACTOR: r1 an n
WELL CONTRACTOR CERTIFICATION t rO1 t 3
STATE WELL CONSTRUCTION PEW/TN
1. WELL USE (Chock Applicable Soap Ra)drM61ld Monied C3 Industrial 0 Agdotdlunl ❑ Monitoring 0
Recovery ❑ sat Pur p Water Madan ❑ Other ['] II OOter. List We:
2. WEU. LOCAT)Or (Show WNW' of ale L.S. bibw) Neon* Tort `v ��'"lfl CSV r
1 I V County: 1 `ti�^1t UCrfi
(ReedIlpilcard Noreen. C tvnu y. or &McMill n and let No
3. OWNER (clber� c6'n\— t
Adder r CI kairiwattr Aar R6
OtyrT burn Zip Cede
4. DATEDRILLEDFJ tp
5. TOTAL DEPTH
e. curnmes COLLECTED YES Q NOE2/
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOU/
6. STATIC WATER LEVEL Below Top of Casing: FT.
SAW I Able Top a Caring)
9. TOP OF CASING IS I FT. Above Land Surface•
'Top or miry Iradruted Wet bonne land slam nooks. a werunoe In weep
donee w.b 15A !CAC 2C Atli i
10. YIELD (ppnt): _a_ METHOD OF TEST y
11. WATER ZONES (depth):
GRILLING LOG DEPTH
To
-FLU
dirsl
:TZa .��iia
�10-S
r-�
0
12. CHLORINATION: Type Amount It additional epees b needed ae btdc
13. CASINO:
WWITIOdmin LOCATION SKETCH
Dap61( 1 n RCM(
MEIS , (Slaw dlr ollon and dorms Mum a let too D it c �1
From To — R) p, M(j Pap" C Ara r other map m amok Porch) c ;-• `'
From To FL r
From To FL
14. GROUT:
Depth Malarial Method
From t T r J D FI Cr-r c W1±
From To FL
1 S. SCREEN:
Depth Diameter Slot Sidi Materiel
From _To_FI In in.
From _To_FL_ In. In.
From To FL In to
16. SANWGRAVELPACC:
Da* Size Malarial
From To FL
Fran To FL
17. REMARKS:
P core 4AC eu\ Q ver
DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 16A NCAC 2C. WELL
CONSTRUCTION STANDARDS, NCTHAT ACOPY OFTHIS RECORD
� IT PROVIDED TO THE WELL OWNER
FOR OFFICE USE ONLY
Oust fro
8.WNe.
sgtL)T 3IE OF PERSON CONarrILICIw TIE WELL DATE
Subdt clonal b VMS,. a War Oraltr, Owud.ar asebn within 30 days
GSM IEY. fait

329320
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rmaoaccs- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #- Out 3V
1. WELL CONTRACTOR:
eve: C_K 'Aeo.'th Sa•-rtcCS
Web Contractor (Nd"rv!dual) Name .
\.CnarcS 54n
Well Company Note
STREET ADDRESS \'\%Z .YCi/iY a.OQ
%ko�F g�c:� s) Nc - aien43
City a Tam �Lp Code
(8 %)- (a(oS'apaa.
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(d.ppe:able)
STATE WELL PERWTAINsmokable)
DMZ or OTHER PERMIT «I appfiable)
WELL USE (Cheek A/
ppllceb!e Box): Residential Water Supply
b DATE DRILLED -/S' %h
TAME COMPLETED oc / C' c AM 0 PM S
3. WELL LOCATION: / //''
CITY: W a.NIPJ J / /4 .. COUNTY no Yt-r) O W
L-( Lr f ( %rate J) K c
{Sax !tame, Numbers. Community. SubSNsiati Lot No.. Partin. Zk. Code)
TO/PJGR4PH!C /LAND SETTING:
OSIoPe OVaeyy ❑Flew °Ridge ❑°the
(check aproprtele box)
LATITUDE 3
LONGITUDE
May be m degree,
minutes, seconds or
in a decimal format
Latitude/longitude son: cGPS °Topogapluc map
(location afwet mustbe shown on a USGS topes mep and
attached to 3* form snot using GPS)
4. WELL OWNER _
OWNER'S NAME St 1*% Leai\i) i..
STREET ADDRESS (0(01 Sweetlhctac
OVISena { F\ 34601
City or Town State Zip Code
($13 )- 165- 581
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTtt 8 O 5—
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Br. Top d Casing ea
(Use •+' ff Above Top d Casing)
d. TOP OF CASING IS : Fr. Above Land Surface'
Top d casing terminated at/or below land surface may require
a variance 6n acodda ce with 1SA NCAC 2C .0118.
e. VELD (gpm):. X r) METHOD OF TEST •
t. DISINFECTION: Type4,\\S
Amour*
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
G. CASING: r-
Dep
Fran_ iToth3 % planter _ R-1
From To R.
From To Ft.
Thi !mass
7. GROUT: Depth Maaial
From0Toa Fl. (en\tlst'f'.
Frain To - R.
From To - Ft.
8. SCREEN: Depth Diameter Slot Sze Materiel
From To R. m. R
__. From To R. in- in.
From To R. in. R
9. SAID/GRAVEL PACK:
Depth Size Material
Fran To' FL
From To Ft
From To Ft
10. DR!WNG LOG
From To Commotion
/ S 7 (Zcr L�._
C7
11. REMARKS:
ti
I00 HERBY leanTHAT TtaS WELL Y'A9 GO'SIRLCIED NACL'ORDVQE win.
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. Mir THAT COPT OF MIS
REWRBtygata:NRtO VW TO TR: MW. OWNER.
SIGNATURE OF CERTIFIED WEf1 CONTRACTOR - DATE
' ? cc. CA. \AQO 44 6e6.b
PRINTED NAME OF PERSON xWSTRUCTING T1HE WELL
Submit the original to the Division of Water Quality within 30 days. Amer: information MA,
1617 Mail Service Center— Raleigh, NC Z7699-1617 Phone No. [phone] ext 568.
Fain GW-la
Rev. 7At5

329319
RESIDENTIAL WELL CONSTRUCTION RECO: tD
North Carolina Department of Environment and Natural o[ Retauutta- D�ruitnr of Warr Quality
WELL CONTRACTOR CERTIFICATION # V l aka
1_ WELL CONTRACTOR: „. p �••c
Wet Contractor (ndNidua) Name
t\xj SiiQ 6n_.2iyya-cs0 n
Wet Culrber.M Company Nate
STREET ADDRESS \.1/43‘IVS Cl V<t.•Si aos
Hod s r;hgS) LNG awl '-i3
City or Town SMe -Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID it(e apprrable)
STATE WELL PERMITS((acorceme)
OWQ or OTHER PERMIT #(B applicable)
WELL USE (Chet* AppGable Box)//: ResidsntW li Water Supply
DATE DRILLED 4�I
TIME COMPLETED .J a 'ad AM 0 PM C/
3. WELL LOCATION:
CITY: !Aic yews U../4 -. COUNTY fiat/r ✓6or!
N Clicnr &Peter
{Stec Name Numbers. cananuraty. SubdMaon. Lot No.. Parcel. Zlp Code)
RAPHIC LAND SETTING:
bpe OVatey ❑FIM CIRtdge nether
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
n a decimal forget
Latitude/longitude source: ❑ GPS ❑Topographic map
(location of welmustbe shorn on e USGS topes map end
attached to this form irnot ushg GPS)
4. WELL OWNER \tr L
OWNERS NAMED Y�`� .,Jk fr 4t TI')
STREET ADDRESS 4 </ sties TnC
iA/O-cis. /%llc/ 6.
City cc Todn State Zip Code
1 g as ), tab" a Wei
Area code - Phone number
S. WELL DETAILS:
a TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
e WATER LEVEL BebwTop of Casing: L¢ o FT.
(Use'+" if Above Top of Casing)
d TOP OF CASING IS FT. Above land Surface"
'Top ofeasing terminated at/or belay Lard surface may reqube
a variance in accordance with 15A NCAC 2C .0118.
• YIELD wpm):Ot 0 METHOD OF TEST Plit
f. DtSI FECLTOtt Type41% tS
g. WATER ZONES (depth)
From To From To
From
From
8. CASING:
To
To
m Fro
From
To
To
Diam
Frgrr�� To /4 `F FT. o ^.r�i�{t�
ter t
Depth
From To P. Let_Barr /
From To Ft.
7. GROUT: Depth
From_�_T
From To
To
Maria! Merliod
R. Centel fri tee 4
Ft.
From To
8. SCREEN: Depth
From To
From To
From To Ft.
P.
Derlefer Slot Sire Materiel
P. in. n.
Fl_ n.. n.
9. SAND/GRAVEL PACK:
DepBi
From
From
From
To FL
To Ft
To Ft
Size
Material
te. DRILLING LOG
From To Foration
/ /7 4 OmLaer L�ir.r
(a. G-11Vtitit
11. REMARKS:
Cz-
77
100 HERESY t.eM rtYTMATTea WELLY AS CCn1RUCim N ACCMPNCE WITH
15A NCAC 2C, WELL CONSTRUCT/OIL :TA CARDS. APO THAT COPY OFT M
RECORD HAS BEEN PROVIDED TO ELL OMEN.
SIGNATURE OF CERTIFIED 1 CONTRACTOR DATE
'DeCr.tx Nilto.t•b. : o.sb
PRINTED NAME OF PERSON xNSTRUCFt4G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and N�a tral Res % ces - D'/visssion of Water Quality - Groundwater Section
WELL CO.\"FRAC'I'OR (INDIVIDUAL) NAM�.�Priot ."q�% 7'(JO A, re.CERTIFICATION #.3"
WELL CONTRACFOR COMPANY NAME rifee tQL
l/ • vMP PHONE # (S 7�`a/:J
STATE WELL CONSTRUCTION PERMIT#
(ifan plicable) (if ap Iicable)
1. WELL USE (Check Applicable Box): Residential Iii Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
329751
ASSOCIATED WQ PERMIT#
2. WELL LOCATI►N: J
N
e�wn'ce
(S
treel Nam . Numbers,
Community,
Subdivision, Lot No., Zip Code)
3. OWNER: /j {ve
Pall .
Address 4 'IC/ 7'f.g ,Di),,
(Street or Route
Cala or Town State/
( )-
Area code- Phone number
4. DATE DRILLED (!/ 0 G6
5. TOTAL DEPTH: /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO M
7. STATIC WATER LEVEL Below Top of Casing: jS FT.
(Use"+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 1 METHOD OF TEST n/r
10. WATER ZONES (depth):
Zip Code
11. DISINFECTION: Type 17--
12. CASING:
Depth Diameter
From ^ To 7a. Ft. &4/
From To Ft.
From To Ft.
Depth
13. GROUT:
From
From
14. SCREEN:
From
Topogra is/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 Fr atio description
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. p'] to ' / . numbers and common road names.
'/(J Sn/a/v'
/.Material Method
To oO Ft. ( P-r+e"r
To Ft.
Depth Diameter Slot Size Material
To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
To Ft.
To Ft.
From
From
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
COTRU IOv TANDARDS, THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
ubmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001
0

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na��fryJ so
WELL CONTRACTOR (INDIVIDUAL) NAM�Fj/(print —
WELL CONTRACTOR COMPANY NAME
329750
es - Div' i n of Water Quality - Groundwater Section
fc c 4, re_ CERTIFICATION #C71 1
✓i"t� PHONE #080 Ss`fl
ASSOCIATED WQ PERMIT#
tplicable)
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential P i lunicipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Teen:
r:
(Street Name. Numbers, Community, Subdivision. Lot No., Zip Code)
3. OWNER:
Os✓ AT
Address // lice✓
(Street or Route No.)
N ( •
Area code- Phone number
4. DATE DRILLED 6
5. TOTAL DEPTH: 3p-r 9o5
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO n"---
7. STATIC WATER LEVEL Below Top of Casing: .20 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
Zip Code
Topogra /Land setting
❑Ridge ESlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Fpt/tttigtt Description
f / r_
Fr
DEPTH
To
0
/ 4•A/)4,AI
G City or To n
6S $late
)- C/%- a57
`Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): . 5" METHOD OF TEST
10. WATER ZONES (depth):
11. DISINFECTION: Type ,47 / /
12. CASING:
From ltZ
Depth DialeJ
To %3 Ft. 62
From To Ft.
From To Ft.
13. GROUT: Depth
From O To
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. include the road
or Weight/Ft. k1leerri L numbers and comet n road names.
!// f9w 9 i
', Material 1
Ft. cet" 01//
Method
Slot Size Material
in.
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
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. 072001

3. OWNER
Address
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Na
WELL CONTRACTOR (INDIVIDUAL) NAME
\\'ELL CONTRACTOR COMPANY NAME
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
`.39Pi719
0 Al v
so es - Division of Water Quality - Groundwater Section
rC(-,kc»%,re CERTIFICATIONt/C24164°
L m7 PHONE it I ;' 5 7r
ASSOCIATED WQ PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential Ef Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION: _ 11�,���pa"
Nearest Town: ,� Jae eottnty
'vR/V.s C/ e tier/ '
(Street Name. Numbers, Community. Subdivision, Lot No., Zip Code)
AO v/5 nft,4,5
P P. jam, �1 44 l h,,yna 5 r54
(Street or Route No.)
s4
City gr Town Smte Zip Code
lnildtt
Area code- Phone number,
4. DATE DRILLED
5. TOTAL DEPTH: / ✓
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
7. STATIC WATER LEVEL Below Top of Casing: /Q, 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 tth 15A NCAC 2C .0118.
9. YIELD (gpm): 0 METHOD OF TEST �'
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
FromDepth 2
To :3.,
From To
From To
Amount
Wall Thickness
Diameter or Wei ght/FL Material;
Ft. &P V . /.fO' .SY i
Ft.
Ft.
13. GROUT: Depth Material
. From V To Ft. &"- en/7-
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
opographic/Land setting
Ridge DSlope DValley ❑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 Fo ati9n Description
0 CA/
oG 3�
-3..sOs-
-
Method
Slot Size Material
in.
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.
L
rC
Ch
0
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STRUTII N STANDARDSyh THAT A DOPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Sfrbmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
32p-748
North Carolina - Department of Environment and Natural Resourc - Diviss on of Water Quality - Groundwater Section
/
WELL CONTRACTOR (INDIVIDUAL) NAME rint) '�''`L' �1OO/SJ 4ire CERTIFICATION ti 2966
WELL CONTRACTOR COMPANY NAME fi Ce `S�/ q,✓/H p PHONE # S O
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
_._ (if applicable)
I. WELL USE (Check Applicable Box): Residential li Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION
Nearci9st'Town: / 6 County
t4Ie O.7
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
__Topographic/Land setting
Midge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
3. OWNER: �/% / �-a -it C-lid%� 3Y /�' 4 icihdegrees/minutes/seconds)
Address O 0' r�l}1 , r
/ j Seyl or Roule /No.) 0?6, ^3
y or Town rate Zip Code
Imo)(73 os-z
Area code- Phone number
4. DATE DRILLED �1- �0,6.
5. TOTAL DEPTH: 7O,S 1-Y
6. DOES WELL REPLACE EXISTING WELL? YESefp NO 0
7. STATIC WATER LEVEL Below Top of Casing: c..50 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface`
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. '
9. YIELD (gpm): ) METHOD OF TEST,4t r
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Depth
From "2 To 6 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From (7 To 0 Ft. of ,. edr
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.
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH ' DRILLING LOG
From To Fo ij tion description
z S7
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. M teria1 numbers and common road names.
�tr.4/3yy
16. REMARKS:
-<
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C TRU 1 N STANDARDS D THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
•
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
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-I REV. 07/2001
O

329747
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nat ra so�s - Divisim Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME, rint LfJf00 r CERTIFICATION/t�I/5/46'
WELL CONTRACTOR COMPANY NAME ✓ r1Ge /� i Jr ? PHONE # (SY" EAz7 5.3M
SLATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL USE (Check Applicable Box): Residential U' unicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIO
Ne r_ N I) ill pY County
,e T
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3OWNER:441 /4
.7/ dtuv-2-
AddressPSea
Qiirr
C
Tow State// Zip Code
Area code- Phone �(o " �S$Qi
number.
4. DATE DRILLEDG�
62
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 ..b10 �T /
7. STATIC WATER LEVEL Below Top of Casing: 35 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS arc FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): /fJ METHOD OF TEST/$ ( r
10. \VATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
�
Depth7/3
From 9To
From To
From To
13. GROUT- Depth
From v To:)r>
From To
d5779
7/7
Amount
Wall Thickness
Di et r or Weight/Ft. M enal
/i Ft. ,'/`S
Ft.
Ft.
/' Material
FLS r'
Ft
Method
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
Idge ❑Slope ❑Valley DFlat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:DGPSDTopoeraphic map
(check box)
DRILLING LOG
To . atirn Description
DEPTH
From
O
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.
/301/
N t
r—
o O'
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONS RUCTION STANDARDS, ANAT A COPY OF\ HIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Sub ltD
he original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
o
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and NNaalttt al RR sou s Division of Water Quality - Groundwater Section �/
VAlL l.l. (UA'I R.A("I ou (INDIVIDUAL) A.tAIE Irinlc2 rf 1 /�- 4. r c' CERTIFICATION # Y(�V(y[�7
\\T:I.1. (o\l It.\('FOR ('Ill11'AN\ AlN.: /fee GAL ' /C {rtn� PHONE # O2 �,pi7 p3/a
.tit.\I E \\'llt,l, CONS RUCTION I'EIt\lI'I# ASSOCL\T EI) \\'Q I'ERi\IrfI
I iraphhc:tbH (if applicable)
326387
I. WELL USE (Cheek Applicable 13os): Residential L941unicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 I leaf Pump Water Injection 0 Other ❑ If Other, List Use
2. AVEI-L. LOCATION:
Nealf� si IONS
t tilreel Name. NmnI,c s ('onm
3. OWNER: uleglc s!niuuies/second.)
Address Latitude/longitude sourer:❑GPSD I opographic map
or Root,: No
`t'j,�_ (cheekh xl
�6 e Jj1�5— d 1�e? -3 DFI T71 DRILLING LOG
) (fill Flom To intion))escription
0
/C' County
.h(1icuiwt Int No.. Lip Code)
Topographic/Land setting
❑Ridge ❑Slope ❑Valley ❑Plat
(check appropriate box)
Lalilude/IongilIfle of well location
ells or !own SI.ac
Area code- Phone ne numb.)
! Unl DRILLED —06 -" _ r0 ✓�5y
Me�
, TOTAL DLPTII �0 5 - -
6 DOES WELL RLPLACEIiXISIING WLLL? YES NO qr.--
7 SI A'IIC WATER LEVEL I3clow'Fop of Casing:
(use "+" if Above Top of Casing)
8, TOP OF CASING IS a FT. Above Land Surface*
`Ton of casing terminated at/or below land surface requires a
variance in accordance will, 15A NCAC 2C .0118.
9. YIELD (gpm): /5
- METHOD OE TEST 4,r-
10. WATER VONLS (depth):
y LOCATION SKETCH
11, DISINEECIION. Type »/ 7 Amount Show direction and distance in miles from al (cast
12. CASING: Wall'Ihickness Iwo State Roads or County Roads. Include the road
Depth {, l)i drier or AA'eight/6d NIa IhlI numbers and common m od nm aes.
From 7©� Tot.,
Io/ 19. / !d/�-eJ-,� O
Fro '' ��` m >> To Ft /C�))///�
From In 1:,.
13, GROUT: Depth q�� M;neriol Method
Front e7 T1) C"CC� i:ic ...eiJT
Prone To Pt.
14. SCREEN: Depth Diameter Slul Size Material
From To 1-1 in. in.
From TO I I. in, in.
15. SANI)/GRAVEI. PACK: ,i ii l� �j 7J.,5
Dcplh Size \laterial
From To FL From To Ft.
16.IEN1AILK S:
-c
-t
W
r-. c r i
O
Q y
r
1 DC) I1E12E13Y CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CCkdS'1RUClION STANDARDS, AND TIIAT A (t71'Y OF THIS RECORD I1AS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OE PERSON CONSTRUCITIN(i THE WEI. L DATE
Submit the original to the Division of Water Quality, Crolliulw de - Section, 1636 Mail Service Center - Raleigh, NC
27609-1636 )'hone No. [phone], within 30 days. GW-I R.V. 07/2001

II. DISINFLC
12. CASING::
Prom "to?
vrolll
From
3. OWNFR•
Add/ess
/' IS„ccl or Rmnc No 1
LL'iti
)r Town Slue/ Lip ('udc
4
5
6
1
Area axle- Phone mmml,cr,/
DATE DRILLED 7 V�t�--06
TOTAL DEPTH: �'4'
DOES WELL REPLACE EXISTING WELL? YES 0 NO
WELL CONSTRUCTION RECORD
North C'au,Ina - Department of Environment ironment and N yral Rcsou- cs -
Div'siol of Watcr Quality
\T:I.Lr(1\I It\CIUIt(ODI\IDE\ II\A\IF trint)CJ ' Too (( r�
\\"1!1.1. (o\ I R \CI'OR ((1]I I',\., life/ 9- um
STATE \\ F:I.I. CU\SI RUCTION ION l'ER\I ITN ASSOCIATED \\'O I'E lihl l'1'/
(if applicable)
(ifapplicublol
1
- Groundwater Section
CERTIFICATION Ng5/447
PHONE a (� 6'17-1357'
WELL USE (Check Applicable Box): I{csidanial L7 IYlunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ 1 leat Pump Water Injection 0 Other 0 IfOther, List Use
2. WELLLOCATION:
Neal vl Town Ui /C County
(Street Name. r: u,nhcn (ammo, y_ &,hdi cixnnt Lit No_ CnJrI
�/ LL
CL A n /a
7. STATIC WATER LEVEL Below Top or Casing: (23r..--
tUse '.t'. if Above Top of Casing,
S. TOP OF CASING IS 02 FT. Above Land Surface*
"rp id casing Ivrninated at/or below land surface raprires a
variance in accordance with I5A NCAC 2C .III Itt.
9. YIELD (gpm): /O METHOD OF TEST Ty/ /�
10. WATER ZONES (depth):
TION, Type /0/, Amount
\\'all Thickness
Depth iaetcr or Weight/Ft.tii, rial
13. GROUI':
From
From
la. SCREEN:
From
1r0m
To 57IJ H. �y
To PI.
lb FR
FT.
ec
DI'PII
F n To
0)0
02c,
7 /0S
os 5�'5-
Depth Material ,Method
To vaC Ft.ei �NyL
To Ft.
Depth Ui:meter Slot Sin Maletial
To Ft. in.
To I't in in.
15. SAND/GRAVEL PACK:
Depth
From To PI.
From To Pt
Size \lzterial
16. ILl:IAl,ARKS:
Topographic/Land setting
ETCLIge ❑Slope ❑Valley ❑Flat
(check appropriate box)
t% Latinidc/longitude of well location
(dcgrces'nlinmcs/seconds)
r.alilude.longitude sources❑GPS❑Topographic nap
(check box)
DRILLING LOG
I' m tigl Description
�-r
LOCATION SKETC' I
Show direction and distance in miles from at least
two Stale Roads or County Roads. Include the road
nwnbcrs and common road names.
in 06 2353
-cc
cO
0
I DO HEREBY CERTIFY TIIAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
C NSTR �JU IONS'IANDAR131s,AND 'II IAT A COPY OF TINS RECORD HAS BEILN I'ROVIDFD TO IE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
(Mink the original to the Division of Water Quality, Groundwater Section, 1636 Nlail Service Center- Raleigh, NC
27699-1636I'hone No. [phone], within 30 days. GW-I REV. 07/2001
FE
0
-c rsl
Y0
A<
corn
c=0
r
—=1
-G

.Area code- Phone number
4.
5.
6. DOES WELL REPLACE EXISTING WELL? YES El NO
7. STATIC WATER LEVEL Below Top of Casing: c /
(Use"I"i f Above Top of Casing)
8. TOP OF CASING IS oC ET. Above Land Surface*
*fug of casing terminated at/or below I:old surface requires a
variance in accordance with I5A NCAC 2C ,II118.
9. YIELD (gpm); AI" IMEll IOD OF TEST 41-
10. WATER ZONES (depth):
DATE DRILLED y-/K' L (�-
TOTAL DEPTH: 3 yr
3. OWNER:
Address
283S5..
WELL CONSTRUCTION RECORD
North Carolina - I )cparuncnt of Environment and Natural Resources - Division of Water Quality - Groundwater Section
( l li tllJ
VA'EL1. CON"! ItACI'U It (INDIVIDUAL) NANO: /(primp ✓ �-� (% �J�p� � �'e CEIt'I'IFICATION/ ' 7 ��,./�� \\4:1.1, ('U\T RA(TOR CONII'ANN' NAME f�kr CC Lveli 4 i ri4110 I'IION6 # f /'�376
SI A'IT: \\tail. (Y)\SI it( (-I ION Ph:RNlII #
( if applicable)
ASSOCIATED \\'Q I»IRMI'I'#
(if applicable)
1. W'EI.I. USL (('heck Applicable Box): 12esidenlial li IA9unicipaliPublic 0 Industrial 0 Agricultural 0
Muuiloring 0 Recovery ❑ I leaf Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town:_
ISlrcct Nanm. Nlllllhcl]. ('olnmunlis. subdivision, Lul Fo.. /ip Codcl
/3
41
/Jte^r / /.y�1`y. el or Rook. No. h" e^-�! G
L1.4 p/lie _em c' v2D 2O -sue
'tote Zip Code Front To
)- — %%%% e'- 0
///
Er/1/
s
Lopographie/Land setting
d� c ❑Slope ❑Valley ❑Plat
(check iate box)
I.Ititu Ie/longilu Ic of well location
(dcgrecs.nl inulesiscoodsi
Latitude/Iongilude source:❑GPS❑Topographic (nap
(check hox)
DRILLING LOG
L f�/54D( 1t Description
l�.
moo✓
I I. DISINFECTION: Type // t, Amount
12. CASING: Wall Thickness
Depth Dim t/cicr or 1\'ci iltiP(. h evict
From tcZ To /0_ El, 6L'/ ,/�s
Froltl To
Fnnll To
13. GROW(, Depth /t Material Method
Front Q To a0 Ft.C�o/he4/
From To Pl.
14. SCREEN: Depth Diameter Slot Size Material
prom To Fl in.
Front To PI. in. in.
15. SAND/GR.AVL'L PACK:
Depth Size Material
From T o Ft.
From To
16. REMARKS:
FI.
LOCATION SKETCII
Show direction and distance in miles from at (cast
two State Roads or County Roads. Include the road
numbers and common road names.
S i3o ()
JUN 0 6 2005
A
�-t
CO
tV
0'
1 DO HEREI3Y CERTIFY TITAT TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OE THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OP PERSON CONSTRUCTING 'HIE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Censer- Raleigh, NC
27699-1636 Phone No. [phone], within 31) days. G W-I REV. 07/2001

NN ELI. (U\ I It.\('Toll CONI I'ANN \ NNIE ree
Sr.\TF: U i1.l. CO1S I I I I 1 ION PERM la a ..- __- . _ — _ASSOCIATE!) NNQ pf:Ral via
( il.rplieablel (iripplicable)
WELL CONSTRUCTION RECORD
North Carolina - I )eparuneni or Environment and N- ui- Reso •cgs - Division of Water Quality - Groundwater Section -
Nvel.l. (0N I "CI OR (INunaur N1) NAME priul CTl ( / 2net t re CERTIFICATION a "e;
v,..ty0
rItONE a 0InC)(474
I. WELL USE (Check Applicable I3ox): Residential 0 Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Ilcal Pump Water Injection 0 Other ❑ IhOther, List Use
3. 0yVNER/ f 4 Q �kJ `)
Address 7
2. WELL LOCATION:
N,eAesl I wn:1�✓ ilo e County
ei /.4-u)iE
(SlreeK anc. Nuurbcrr. Conmmo ay. Sub(1ivision. Lul NO.. (Ip Code)
6aacr i,r 1(um: No.l
i« <t 2 %9
nr or Iona SiQlc h p('udc
Arco Cale- phone mmnim- -- 0 4. DATE DRILLED
5. TOTAL DEPTH: ,PC,S
6. DOES \VELL REPLACE EXISTING WELL? YES 0 NO L9�
7. STATIC WATER LEVEL Below Top of Casing: /0 FT.
( Ilse "4- if Above Top oFCasing)
8. TOP OPCASING IS FT. Above Land Surface*
*Top orcasing terminated al/or below laud surface requires a
variance in accordance ailh I5A NCAC 2C .011R.
9. YIELD(gpm): %C METHOD OFTEST nit
10. WATER ZONES (depth):
326384
Topographic/Land setting
idge ❑Slope ❑Valley ❑Ilat
(check appropriate box)
Latitude/longitude of well location
( dcgrccsnrinmcs/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(click box)
DEI'Ti1 DRILLING I.OG
Fn ❑ To F r :111fln Description
I I. DISINFECTION: Typrj2.7`-i/ Amount
12. CASING: Wall Thickness
Depth '/ isp1}ic'r or Weight/Ft.
From �'� To c5%
From To Pt.
From To PI.
13. GROUT: Depth. bfilcrial ,Method
Prom V To 01Ft. �f'^+�i✓�
LOCATION SKETCH
Show direction and distance in miles front at least
two Slate Roads or County Roads. Include the road
.Iriul numbers and common road names. 0
V,C-
#i33i
Prom To
14. SCREEN: Ucpth Diameter Slot Sizc Material
From To in. in.
From 'fo in. in.
15. SAND/GRAVEL PA('K:
Ucplh Size Material
From To FI.
From To PI.
16. RENIARKS:
a
N
0
JUN 06 2096
I DO I IEREIIV CERTIFY TI IAT 11IIS WELL WAS CONSTRUCTED IN ACCORDANCE WITI 1 I5A NCAC 2C, WELL
STRI. 'I(LN STANDARDS, A)eh).-FIIAI.A4'OI'Y Oh IIIIS RECORD IIAS I3EFN PROVIDED TOIL IF WELL OWNER
SI(uNAIURIi or: PERSON CONSTRUCTING T III AVELI.
DATE
aril the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service (.enter - lialeigh, NC
27699-1636 I'hone No. [phone], Nvithin 30 days. GW-1 REV. 07/2001

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
oZ�
WELL CONTRACTOR CERTIFICAT ON # TJ (Q
1. WELL CONTRACTOR:
1tecc,cc 1\eat\n SGWyecS
Wee Contractor (Individual) Name
C\ ycie acts,61ecs Soe
Well Contractor Company Na
STREET ADDRESS VM:11R S . ` -\tYY/ ao Ct
'Not 3 ncS NC Q8'743
City or To yr State -Zip Code
( gas)_ (Olos- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/IV applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Sox): Residential Water Supply 0
DATE DRILLED 3 /3 -
TIME COMPLETED Sr O J AM 0 PM L9�
3. WELL LOCATION:
CITY. ,,//
CITY: C?/f/O/1 COUNTY 4474,Oc✓/
4er4 'ee Oo/n e
(Street Name. Numbers, Community. Sobel sloe, Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope ❑Valley ❑Flat ❑Ridge ❑Outer
(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 MIS town or not using GPS)
4. WELL OWNER
OWNER'S NAME AA.. kC \, Ne-\ keN
STREET ADDRESS LA Coto o \ QST C,4e t$c -)'
Co -+‘ton !JG Q521 tto
City or Town ) State Zip Code
'May be in degrees,
minutes. seconds or
in a decimal format
c 8a2 > (.2\-vB - -73E0
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 30-5—
b. DOES WELL REPLACE EXISTING WELL?YES 0 NO V
c. WATER LEVEL Below Top of Casing: /
Y? 0 FT.
(Use if Above Top of Casing)
d. TOP OF CASING IS \ FT. Above Land Surface'
'Top c( 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 C, v\S Amount iS
g. WATER ZONES (depth):
From To From
From To From
From To From
To
To
To
6. CASING: Thickness/
rial
From -Y� DepthTo g Ft. ea �� SM2I M
6 S
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
Fran 0 To gC Ft. CR.CnenX QOw er\
From
From
To Ft
To Ft.
8. SCREEN: Depth Diameter Sol 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
8l
Formation Description
n &eon-kte_
C E ft D
11. R MA1tiCS:
r.r , ..
-J
Lip
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR CIED N ACCORDANCE WM1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, MEI THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIEbW ELL CONTR'ACTOR DATE
necv.c c MQ.O.er, 5gAy eC 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-1a
Rev. 7105

RESIDENT/AL WELL CONSTRUCTION RECOF D
North Carolina Department of Environment and Natural Resources- Division of Wat a Quality
WELL CONTRACTOR CERTIFICATION # c21'I3(4
1. WELL CONTRACTOR:
�e�c.eu ' 1ec. n "")G‘,..1yes5
Well Contractor (Individual) Name
C� yrte. 3c&x 1QcS Soh
W ell Contractor Company NaThe
STREET ADDRESS V- P1E� S . 7-, 1.�-'y ao q
l-►o-* 'bnc -,}'C. a8'7 43
City or T4m kJ State -Zip Code
(Sally (obs- a oa
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *Cif applicable)
STATE WELL PERMIT#(8 applicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable
Box): Residential Water Supply El
DATE DRILLED 3- o b
TIME COMPLETED yi J,r$ AM ❑ PM g)--
3. WELL LOCATION: ,, //
CITY. WnY0PA COUNTY N4VG1/Cocl
New IC04n1 .d
(Stet Name, Numbers. Canmunity, Subdbesion, Lot No.. Parcel. Zip Code)
TO GRAPHIC / LAND SETTING:
lope ❑Valley ['Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes. seconds or
in a decimal tomcat
Latitude/)ongitude source: ❑GPS ❑Topographic map
(bcafion of weft must be shown on a USGS topo map and
attached to this form T not uscg GPS)
4. WELL OWNER OWNER'S NAME f1O a\V1 COA-NItC
STREET ADDRESS riciL: kJac.c occ S Tcn.A,
('_Cir30r NC. ib
City or Town State Zip Code
(9 %) �3A Og3S
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: aaS /
b. DOES WELL REPLACE EXISTING WELL? YES IDQ NO -
c. WATER LEVEL Below Top d Casing: Sv FT.
(Use if Above Tap af Casing)
d. TOP OF CASING IS FT. Above Land Surface'
-Top af casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
�` e. YIELD (gpm): (3' METHOD OF TEST R,
f. DISINFECTION: Type 1) 1S Amount /d
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth, (/ Diameter Weight Material
From '-Y� To 1 Ft�D�M- 'Vintpiers&
From To Ft.
From •To Ft.
7. GROUT: Depth Material Method
From 0 To g0 FL CI,emer1-k Qow A
From To Ft.
From To FL
8. SCREEN: Depth Diarr Eter S rt Size Material
From To Ft in. in.
From To Ft. in. in.
From To Ft. _in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft
10. DRILLING LOG
From To
1 3$
l:ormaticr Description
(free -n
___C3 .QQf\ i 4 e
R.EE"CER,r - 1
ikAh
1. RE KS'
,7
1 DO HEREBY CERTIFY THAT TMS WELL WA: CONSTRI CTED N ACCORDANCE WAR
ISA NCAC 2C. WELL CONSTRUCTION STANr ARDS. Alf? •HAT A COPY OF TraS
RECORD 11AS BEEN PROVIDED TO THE WEL L OWNER.
-45 tf.<
SIGNATURE OF CERTIFIED,IELL CONTRACTOR DATE
i1Pcc.cK 14Q.Cs rs •(nNA-I S
PRINTED NAME OF PERSON CON 3TRUCT RIG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt ,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fam GW-la
Rev. 7/C6

North Caroline • Dopeorrent or Eminent end Newel Resources - Dtvt.ton a Wslw QRey • Groundwater Swam
103E MS Savkr Cartier- Udell/(, N.C. 27EEE•,S3E•Mons p/E) 733- t21
WELL. CONSTRUCTION RECORD WELL CONTRACTOR: CIOfl.nA ti
nu. CONTRACTOR CERTWICATION h & 11
STATE WELL CONSTRUCTION PERMITS•.
326643
1.
2.
WELL USE_Feeck Applicable est Municipal 0 Man Agdo SnI p Montano 0
Recovery alll Heat Pump Water w4.Otlon`p Oilier p E a»r. UN U.K
WELL LOCAT`IO,N,: ( . sketch of I1tq taaron
N.«eelT eft u Jfl0Q1/tUQ. Cower. Weed
(Rood ► ernes,.�e *abn Cwnn.e7. EiB .... end tot Na)
3. OWNER L`�PI % ie.7. l�t7rY1 In
t7np« «.. u.r
ZipCede
4. DATE DRILLED 4 D- 2-a°
a. TOTAL DEPTH 14S
S. CUTTINGS c0LLECTED YES Q NOE(
7. DOES WELL REPLACE EXISTING WELL? YES NOlEr
S. STATIC WATER LEVEL Below Top of Casing: FT.
Risen else Top et CWgl
E. TOP OF CASING IS. 1 FT Above Lend Surface'
'Top a nobs terselmed seer below lend .nisei ..,aa . mime is weep
d10. wMD( NCini): 1A;.Pt,. METHOD OF TEST 1"L
t 0. YIELD (gpm): 1
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
From To 1 k5 ., CD,`II L
From To FL
From To FL
14. GROUT:
Wall Thermo
«WUJMML Usede
re -re I
Depth MetsdS Method
From ' Tore FI. CD rn.Q.
From To FL
15. SCREEN:
Depth Diameter SIN Stti MENde(
From To F1 In. In.
From To FL In. In.
From To FL_ In. In.
1S. SANWGRAVELPACK:
Depht Sae Mendel
From To F1.
From To FL
DRILUNG LOG DEPTH
T.
\\S" - a` ci C%fC311t t t
Oct - a rc,z
b aS -14�j era IR
r addMonwt specs le needed use bed( a term
LOCATION SKETCH
(Slow *scion end Stenos Mcm si keel two tWa
Rosa or odor mop Morena/
17. REMARKS:
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 1EA NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A CQPY OF THIS RECORD HAS SEEN FROVIDEOTO THE WELL OWNER.
JURE OP PEEK* cancan 1 can THE WELL DATE
Submit edrd r arlu.. of WS,GS ocwd wr.r Suakin NEW 30 days
FOR OFFICE USE ONLY
Ord Re
Eerie IN.
JUN i%�� "J j oW1REY.i

•
•..
Noel Camino • Department dEnvironment and Name Anourae.-Otillonel WSW amity -GrourdwatrS•adon
1113e IASI Sarele. Canter - RS.gh. N.C.27fSIl3l Phone (step 733-3221 3 2 6 6 4
WELL CONSTRUCTION RECORD WELL CONTRACTOR: G tozywatLr
WELL CONTRACTOR CERTE7CATION g a t I
STATE WELL OONRTRUCTION PERMIM
1. WELL USILLowek Appikle a.Stu) Reddening CI Muic*N 0 sums 0 ASdoldturel 0 Mordbrhp 0
Recovery Heat Pump Water Irdeorcn ❑ Oster p R Ol her. Ust Uw
2. WELL LOCA Show Mab of the wagon Sal
Nearest Teat DnV1U.2. Cowdr• Vi(' .1,11.006
(Rood Ntra«.. r AadtMer and tot Nal DRIWNG LOG DEPTH
3. OtnrNEfT 1n\�P? v�_P7 Fin To remeewr Cwwydan
Address
Uri JU na..Ai nu N ' air I,tr o
CerarT Elva Zip Coda S40_ MOOS-
4. DATE DEPTH
DRILLED
5. TOTAL TH Y
S. CUTTINGSCOU.ECTED YES 0 No
7. DOES WELL REPLACE EXISTING WELL? YES 0 Nmei-
a STATIC WATER LEVEL Below Top 01 Casing: FT.
S. TOP OF CASING IS 1 AFT Above Land Surface'
*Top el easing 1.. _ied Wer Wow lend awls rt,.t • wan.. M more
dense .Ni 1SA MAC 20 A to (n1
10. YIELD (()pm): aMETHOD OF TEST Ym10-t
11. WATER ZONES (depth):
•
12. CHLORINATION: Type Amount 3 eddNrrl epees b medal sea bed: d Norm
13. CASING:
WS Mans LOCATION SKETCH SS��
Depth vs.. or WeglaFt n.�at,andy� (Show dYad.n and dame Mom at let two Stale 1
From_To �� Fl. FLMC Roads, arother map Serena* ptnb)
From To FL 73.
1
Rom To FL
14. GROUT:
Depth Materiel Method
From I To .aft n. C.0-MO 1A+
From To FL
15. SCREEN:
Depth Ors Slot Ske MOOS
From To FI In. In.
From To FI h. In.
From To FL In; h.
16. SAND/GRAVEL PACK:
Depth Size MaMtel
From To FL
From To Ft.
17. REMARKS:
1 DO HERESY CERTffy 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.
FOR OFFICE USE ONLY
On Ns
Seal No.
e�
rn
tst-135. p%o4tCrIL.Qid
03.,09
Ppf,
TIME OFPHRSON CONSTFUCTINO THE WELL DATE
Subsa ad.ht b Chinon Weser Cues Oraurdr wr swoon weds 30 days
wen REY. 17M
JUN 06 ZOOS

North Carotins • Depenment d Ennkoramrd and Hound Raoaa.. - Okkkn d Walt Duey • Groundwater Seaton
1.31 MSI Sorvk. Center • Rr.iph, N.C. 27p1f•1e3Sfbru (910) 713•3221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: aaox-wracir
WELL CONTRACTOR CERTMNCATION F. 1 I
STATE WEU. CONSTRUCTION PERMITS
1. WELL USE,,,{�� kApplkabN Pa Resdsn ai Munlc�d p InduuMS 0
Recovery Da Haat Pump Water In jaot.n ❑ Other [l E Olhsi Lbt Lbw
2. WEU. LOCATION: (Slaw skald' of Io:Mkn Sow)
N.a.nTO= hkeu..knesvi Ile. Cyr. (A. rcl
Shed Name end Manna Cennunly, or SubdnMan and La N0.)
3. OWNER AO V ex' i&nstrun-i Din
Address at a,, P+
Cayo Tasn aura Zip Ca
DATE DRILLED 4 14- n1 p
IFOR OFFICE USE ONLY
cad Ns
Bald Ne.
4.
s. TOTALDEPTH I►4r
0. commas COLLECTED YES Npe`I
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO
I. STATIC WATER LEVEI. Below Top of Casing: FT.
S. TOP OF CASING S 111 1 FT. 'Above Land Surface*
i AbeesAeon Tee er Cost
`rep of tang Snaked Wei beam low/ aarh.e nyndra a .rNnoa I moot -
dams ISA NCAC 2Cl Io n
10. YIELD (Rpm): METHOD OF TEST 1r110)
11. WATER ZONES (depth):
Aprladlura ❑ Monliodng ❑
DRUM LOG
J- 4.a Ti
(0'3/4- I
ktoo- 114-W
12. CHLORINATION: Type Amount
13. CASING:
Dthrkin
Fran t To 'rr+
From To
From To
14. GROUT:
E Scathing pat b needed use bads d form
vat wren LOCATION SKETCH
Ste w W.Qa !�.k�Ila1„ Plow an w drd *throe from et Nest Iwo SlobFL l o y�+ ^ r
Road., r other mop rela.roe ponds)
FL
Ft.
Materiel Method
From To�rt1Q Fl. Cement
From To FL
15. SCREEN:
Depth Diameter Ski Ski Mated&
From To_Ft__ In. _in.
Front To FI. In.. In,
From To FT. M. in. l _
1S. SAND/GRAVEL PACK: S ....A �//J
1aPlh Shur Maimed $tri.I'
From TO FL 7 '0
From To Ft n �d 2 erte1
17. REMARKS:
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH NSA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY
//OF THIS RECORD WAS SEEN PROVIDED TO THE WELL OWNER
?cent/
arMTIAIEOFPERSON CCIoMt11YCINOTHE WEIL DATE
Subnteddal N Maas d WaNOwinr mmaadarN Smoke witty 30 days
OW1 NEV. 121111.
JUN 06 2003
Li (2y/aci

talics�sna DI LU. a&mrarn� and wuaR..a.o.s- Milan elW.b.awy.om widw .s.nron
HlSety% N.C. a7No.1e6e.Fbau (/1h 739a221
WELL CONSTRUCTION RECORD WELL CONTRACTOR: (`l onnkniC -
WELL CONTRACTOR CERTNICATION N: a I1
STATE WELL CONSTRUCTION PERMITS:
326635
1. WELL USEOredi Appbs ebb .,p ReddenSe Munk/pal 0 Industrial 0 Agricultural 0 MwNlorIng ❑
Recovery UIII Heat Pump Wain w.ono„ p Olh.r p E OIMr, U.t Use:
2. WELL LOCH• (Show pinch Wagon
el li.agon Sow)
N...lTowrc, ` n pony ► � r
(Reed Herne end Webers. Cannwly, w Weibilkw and Lar NO
3. OWNER L letiflit OWLS
Adingc C ooci Drive
air&Tern Was regal
4. DATE .FELLED 41
5. TOTAL DEPTH tbJ T
6. CUTTINGS COLLECTED YES 0 HOQ- '
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ"
t STATIC WATER LEVEL Below Top of Cuing: FT.
M1aS II Mawr TapN Caolt
9. TOP OF CASINO 1S FT. Above Lad Sedaee
'rep et swine laradnesd seed eslew land soden room a widow In seam,
dame weds 1SA NCAC 96O1.
10. YIELD (gpm): "L.(�-
. METHOD OF TEST f 1104
11. WATER ZONES (depth): 1
12. CHLORINATION: Typo Amount
19. CASINO:
Fran_DTo pIh 1 FL
Fron• To FL
From To FL
14. GROUT:
N.ddMloran S epees b needed use beak al bra
LOCATION SKETCH!
w WelehYFl. Mrn4lC drams bn and San Man.1 Nast two Stab
4 Ra.de,aother nap nlarawepained il--.
it- 1n J I:IP .
Sf- on
Wd Widows
Depth Materiel Method
From I. To ace FE. (Inner*,
From To Ft.
15. SCREEN:
Depth Diameter Slot Ski Materiel
From To Ft In. In.
From To __ FL. _ In. In.
From To FL_
16. SAND/GRAVEL PACK:
Dept
From To Ft.
From To Ft.
17. REMARKS:
Sin Made(
cL•
0
a+
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTAUCrE01N ACCORDANCE WITH ISA NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
yl7/“,
IFOR OFFICE USE ONLY I
Ouad Ka
Sedet Ns.
rt(aatimunE as ransom CO$ mucrepas THE WELL DATE
Sobel edeYa as Geddes al Waist Cl y. bruedaaw Ismw WNdn 30 day.
OWtREV.WM
JUN 06 2095

From To FL
From To Ft.
14. GROUT:
North Carolina • D.p.nm«t of EmY«en«M.nd Hound Remora - Dlvbbn a W.ler Wets . oroudwaw Seauon
103 Mall Sento Conger - ROO" N.C. 27119fe1S3S-Pho o pis) 7334921
WELL CONSTRUCTION RECORD
WELLCONTRACTORh C10ante -Sair 3 2 U 6 3 4
WEU. CONTRACTOR CERTM7CATION h at 1 3
STATE WELL CONSTRUCTION PERMITS;
1. WELL USII_Lasek Apptteta S«rji ReNdeMef{r Muitltel 0 sin ❑
Recovery UMI Haat Pump Water MCn ❑ Oiler p E OStar. Lint Use:
2 WELL sketch or Ete Wagon 4ktt larni
Neared Tonnm�
Agraallufd ❑ Monk*, ❑
meal rimy. mere«.Oa.rre.dt7.« rdLaNs) DRILLING LOG DEPTH
3. OWNER 44e\/QW'�N,`LH}1nr:Mwn..rn1 )fl
1v4re.1«r icA Rem To Co
OyeT-tAddregan m w . aSlao a's c
4. me DRILLED 4-a� een Elp Cede
a�io - SAS
5. TOTAL DEPTH r57 5
6. CUTTINGS COLLECTED YES 0 N0123'
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOD"
S. STATIC WATER LEVEL Show Top of Casing: FT.
'Use ',OEMs, Top et Cote
9. TOP OF CASING IS ' FT. Above Land Suffice•
-Top el suing lerat.t.d oho below lend shun mane . ens to neer.
dr.e SS ISA NCAC 1a
10. YIELD (ppm): 5[) METHOD OF TEST (l`C'
11. WATER ZONES (doplb):
12. CHLORINATION: Type
19. CASING:
Amount S edd2bnd spoor b wooded um beak of form
WA news LOCATION SKETCH
De
pt
h
clay.. orWJFL Wolohan ew.ed . ow drsobn and dbtares from al least trio Stale
From. To �� Ft.y4 pno11C Mow Tleeda,of other mop referent* poems)
Depth n MssdS Mo6ad
From i To ao Fl t_u T 1 2-Va
From To FL
15. SCREEN:
Depth Dlsns sr Sit Ski Material
From To Ft _ In. _ In.
From __ To __ Fl __ In __ In.
From _ To _ FL_._ In: ___ In.
1t SAND/GRAVELPACK:
Dap* Size MaadY
From To FL
From To FL
17. REMARKS:
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 20. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
u(2414,
FOR OFFICE USE ONLY
Dad I/w
S.dr No
WWII edyk* Oaten el Wager OP PIERSON �1IPM THE RIM. DATE
Gus . o..d.rw Seam wilt 30 days
OW.I REV. 12l1N
JJJN 0 6 2035

se oNMaCMw►'11411�1%MQ.2/M�F1NsN�ptg7J1 aWe
�
3266c3F
Ord We
r1 n To FL
From To R.
14. GROUT:
12. CABER;
WELL CONSTRUCTION RECORD WULLcoma* !'kPr1 rI r Yl 1-0 a"
�fh
OOIMTIIYc iER TS: a i 3
1. WELL 1ps_�a.o.a11partDoe an. _
tO & MldvpdD rMw .0 Apby.d0
BTU NwPomp waloM
Yjoolon0 Ober ■orw.LMLboe M'+01�D
2. WM.LCCA (Mlarobb.ofboboMs,w/.,4
Nana J P oyes,: i- Ajtnnrxll.
Ades15'j a�1On k - Care- 9d .
C'Lraa AIN
Kw a
Tau o 20Cot
4. DATEORILLW 4-- Ln 1gC7- GLI
lifts
t TOTAL DEPTH �4.
7. DOES WEIL REPLACE E70STINS WLSLt
& STATIC WATER LEVtfl -TpelC1 FT.
�
S. TOP OF CASINO IS plroy....Tops/ FT. Moto La and Swam*
'Too drow boasts how Y.Inolrorw.or.whnoIs a
doroollilrA/NACINIA1111 n
1t Yea 1W* , Y) METHOD OF TOT 0-Ni S
11. WATER RO1ER Morn*
-C 11G L+Q�. of rrw
Fa To 7w..r.nDan or.
12. CHLORINATION: Typo Amami
rrand moos bwaded wbdidb.,
Oop� arw�.OWTWensok anne r+.-I loowdbadoloM�dlmnooba llagala
mks
Faa1 l To I�-1 .R 0 Yy I�K],'ll i! nos aadormop ens WNW
MobW Mdgd
Rom- Tor Ti R. r r nt
From To FL
15. SCREErt
apM Olnnolor Sbl sbi Mdold
From To , FI M. h
From To __ FL In. • . W.
From To FL Inc 1..
I& SANIVORAVEL PACK
Derr
Front To
From To,
17. r
FL
FL
Boo Mdnld
Q
C>4
s 1
a
-c
0
oa
IDotam court THAT 71rSTIlLLTWISOONSTRUOTEOMACCO O EMRw1M NMsc. WELL
CONSTRUCTION STANDARDS.AND THAT ADOPYOPUS RECORD NMI MIN PROVIDED TOTHE NE L
FOR OFFICE USE ONLY /! -
ages tagli dl�. So TMOs.r oat 30 dors anla
AVM NEV. 1/w
JUNr,d
v v _°Ufis
•

3. WELL LO TION:
CITY: wNv
treet Name Numb-rs, C
n
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depar-vent of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
C
Well Contractor (Individual) Name
AAA GREENE BROS. WELL DRLG. OF SYLVA, INC.
Well Contractor Company Name
STREET ADDRESS 1800 SKYLAND DRIVE
SYLVA
NC 28779
City or Town State
( 828 )_ 586-5550
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMITS/(if applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED ? - li! — (0
TIME COMPLETED AM El Jam'
COUNTY
_
at. Al A .4
nily, bdi ion, Lot No., reel, Zip
TOPOGRAPHIC / LAND SETTING:
zlealope ❑Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(locatron of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME -7 Le.. if) -I
STREET ADDRESS
-e_
orT
Area cod - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: / OCD /
St. e
�G0
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing:
(Use'+• if Above Top of Casing)
d. TOP OF CASING IS ( FT. Above Land Surface*
*Top of casing terminal actor below land surface may require
a variance in acrordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF 7E51L f r
Amount
From To
From To
From To
Thickness/
DepFrom O To Z I FL Diameter Weighcogt2j Material r'
From To Ft. "_' / T"` �
From To Ft.
7. GROUT: � Depth Material Method
From To _3 Ft.
From To 7,61 Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size /'' .Material
From To Ft. in. in.
Fran To Ftin. in.
From To Ft. in. in.
f. DISINFECTION: Type HTI1
g. WATER ZONES (depth):
From To
From •To
From To
6. CASING:
9. SAND/GRAVEL PACK:
Depth
From To Ft
From To Ft.
From To Ft.
Size Material
10. DRILLING LOG
From To Formation Description
11. REMARKS:
ED
v tJr
blur
FEW I A MU/
;III/, flF 16/41tt? of ry,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS�TE i�NN AAppCC 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AA0ATIA ek)P RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
STh -
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mao Service Center— Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
W
IS Em
SIGNATURE OF CERTIFIED W, I,I_ CONTRACTOR (, DATE 6
— I Prt---L,,
PRINTED NAME OF PERSON CONSTRUCT] G THE WELL
Form GW-tor
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3041
1. WELL CONTRACTOR:
PAUL BRYANT BRUCE
Well Contractor (Individual) Name
AAA GREENE BROS. WELL DRLG. OF SYLVA, INC
Well Contractor Company Name
STREET ADDRESS 1800 SKYLAND DRIVE
SYLVA NC 28779
City or Town State Zip Code
( 828 )_ 586-5550
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT *Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 6/20/06
TIME COMPLETED 5:00 AM ❑ PM 21
3. WELL LOCATION:
CITY: WAYNESVILLE
COUNTY HAYWOOD
CAMP BRANCH TO WOLF PEN ROAD TO PRESIDENTIAL DRIVE
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat El Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER
OWNER'S NAME ROSS ADICKMAN
STREET ADDRESS 2400 NE 2ND AVE. STUDIO B
MIAMI, FL 33137
City or Town State Zip Code
( 828 )_ 232-4700
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 800
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 500 FT.
(Use "+" if Above Top of Casing)
tl. TOP OF CASING IS 1 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 1 quart METHOD OF TEST AIR
338O55
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
From 405 To 408 From
From To From
From To From
6. CASING:
Amount 36 OUNCES
Depth piliairter
From 0 To 37 Ft.
From To Ft.
From To Ft.
To
To
To
Thickness/ h
7. GROUT: Depth Material
From 0 To 3 Ft.CEMENT
From 3 To 20 Ft. BENTONITE
From To Ft.
Material
Method
TOP
PUMP WITH TRIM PIPE
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0-32 CLAY
32-405 GRANITE
405-408 CAVITY
408-800 GRANITE
11. REMARKS:
REV. OF'A!ef uAtriY
f'-Fl3 %II(I/
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
r'! 'LsA_ %S i} - 2- r J /
SIGNATURE OF CERTIFIED WELL ONTRACTOR DATE
Ad i ,A c
PRINTED NAME OF ERSON 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 # 3041
1. WELL CONTRACTOR:
PAUL BRYANT BRUCE
Well Contractor (Individual) Name
AAA GREENE BROS. WELL DRLG. OF SYLVA, INC
Well Contractor Company Name
STREET ADDRESS 1800 SKYLAND DRIVE
SYLVA
City or Town
( 828 )- 586-5550
Area code- Phone number
NC
State
28779
Zip Code
2. WELL INFORMATION:
SITE WELL ID #(ilapplicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply EI
DATE DRILLED 6/20/06
TIME COMPLETED 5:00 AM ❑ PM ID
3. WELL LOCATION:
CITY: WAYNESVILLE
COUNTY HAYWOOD
CAMP BRANCH TO WOLF PEN ROAD TO PRESIDENTIAL DRIVE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley ❑Flat 10 Ridge ❑Other
(check apprapdate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME ROSS ADICKMAN
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS 2400 NE 2ND AVE. STUDIO B
MIAMI, FL 33137
City or Town State Zip Code
( 828 )- 232-4700
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 800
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 400 FT.
(Use -+^ if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface`
'Top of casing terminated aVor belay land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 10 METHOD OF TEST AIR
338054
f. DISINFECTION: Type HTH
Amount 36 OUNCES
g. WATER ZONES (depth):
From 430 To 433 From 630 To 633
From To From To
From To From To
6. CASING:
Depth7 Dipmeter
From 0 To Ft. 6 'U4
From To Ft.
From To Ft.
Thickness/Weht
7. GROUT: Depth Material Method
From 0 To 3 Ft. CEMENT TOP
From 3 To 20 Ft. BENTONITE
From To Ft.
PUMP WrrIf TRIM PIPE
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0-42
42-430
430-433
433-630
630-633
633-800
11. REMARKS:
Formation Description.
CLAY
GRANITE
CAVITY
GRANITE
CAVITY
GRANITE
RECEIVED
f r4V, flr \WTER OI IfALITV
t:EH ZUU7
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.
SA -< ;S 07
SIGN RE QF CER IFIED W LL CONTRACTOR DATE
rad d l'✓ C e
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 Nattnal Resources- Division WA Quai:t;
WELL CONTRACTOR CERTIFICATION Ott aka
337523
1. WELL CONTRACTOR:
Q-r; a Sa o-secs
Weft Contractor (Individual) Name
.A, jcL& s k Spn.
Wen Cotinator Company Nolte
STREET ADDRESS iyVC!S "I9 th..'"1 Q.©g
$pp-1����•.�,�a�pyC•�ity a Town e -Zp Code
(8 %)- i.[3(05" a0ga.
Area ccde- Phone number
2. WELL INFORMATION:
SITE WELL ID alfd apgloNe)
STATE WELL PERMRR(dappnoble)
DWQ or OTHER PERMIT;i(d applicable)
WELL USE (Check Applicable Box): Reside -Mal Water Supply G—
DATE DRILLED /&^ —o27 ?-
TIMECOMPLETED o2r2C) AM PM9'
3. WELL LOCATION:
crrv: �i/ rntV �• cOUNnri7e2661
/471"gb-564 ,xi4v/.
{Sty Naha Numbers. Cum. . S br4 Lot No.. Parcel. ZEP Cole)
TOPOGRAPHIC f LAND SETTING:
❑Slope °Valley °FIB °Ridge to other
(cheek -erne hive
L ITTUDE 3
LONGITUDE_
Latitude/longitude source: ° GPS °Topographic map
(location of wed menthe shown on a USGS repo map and
ataaa.vJ to his form I not using GPS)
4. WELL OWNER
OWNER'SNAME C4C4 r tA\tc-'n
STREET ADDRESS 'ISO M<^'Ct. Sea C'.cet rLRya
CA uT7 !l''C• State Zip Code
May be in degrees.
minutes, seem:hot
m a decimal format
tf?a9, tv")f o
Area code - Phone number
5. WELL OFT. AILS: Q �S
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOT/
e. WATER LEVEL BelowTop of Casing 7.6 FT.
(Use W f Abair Top of Casing)
d_ TOP OF CASING IS . FT. Abere Land Surface"
'Tap d casing terminated BM' below land surface may require
a variance in accordance With 16A NCAC 2C .0118.
e. YIELD(gpm): / METHOD OF TEST R•S
f. DISINFECTION: Type4 t1A.S Amount yd
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness:
Fran4_To 7 /
From To Fl.
From To Fi.
DiaP !, Weigh
FL
7. GROUT: Depths .11 Matela[
From 0 To QC n. ie,n(oit
Ram To Fl.
From To Fl.
8. SCREEN:
From
From
F
From
Depth Dianeter Mat Size Material
To P. in in.
To R. ir.. in.
To Ft. ir. in.
9_ SANDIGRAVEL PACK:
Depth
From
From
From
Size Material
To- Ft
ToFt
To Ft
10. DRILLING LOG
From To
7 /
Formation nDn
7 / e --r'ry r•�r`),-¢'
11. REMARKS:
11 AI 'r (9 ?flil/
I DO HEREBY CERr&Y THAT TVS WELLVAS CONSTRICTED Att OF n wWITHUC
ISA NCAC2C, WELL CORSIRrta S V'DS AND NATA
RECORD HAS SEEN PRONDED TO THE N 'NER.
%ate/
SIG TURE OF C Fl NTRACTOR DATE
piece. Wee,. .. lee,1
PRINTED NAME OF PERSON 7-ONSTRUCTd4G TIDE WELL
Submit the originai to the Division of Water Quality within 30 days. Attn: information MS.,
1617 Nail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fan GW-la
Req. 7105

WELL CONSTRUCTION RECORD
North Carolina -DeparmratofBnvim tandNaturalResauces-DivisionofWa6ar
WtU.cormtACTOROND IDuat.)N lusenln r' /�{Iiotit° Y Quality TIONter Section
c�T>Ficanoxa Z 7 h'
WELL CONTRACTOR COMPANY
STATE WELL CONsatocnox PEIIaa1T# A OaA nD WQ Madan
n
Of applicable) // gfspplicable)
1. WELL USE (Check Applicable Boa): Residential Eigbmicipawublic 0 Industrial 0 Agncatmral 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Otter, List Use
2. WELL LOCATION
Nearest Town:YlJt);7 is V I County th loA +I
a 6 Y9'-p 0
(Sew Name,N®beo„ Community. Sob tiviaios, Let Na, Zip Code)
3. OWNER A; i k C \ iankA;
Address 3!D tit M san (-raet Rrj.
W t` tsv�1l tt Al C-
orposNe) a 81$�
atiown soca Scot
2gcode
Ann code- Phone e amber
4. DATE DRILLED 9-3I-(7l7
5. TOTAL DEPTH: 3 S
6. DOES WELL REPLACE EXISTING WELL? YES NO fd'
7. STATIC WATER LEVEL Below Top of Casing:
& TOP OF CASING IS l fi ° � (11se'�t+�ifAbore Tapofcasig)
FT. Alcove Land Surface
'Top of sedan teem eel ado below land motet ratites
variance ha as ardaaen with 15ANCAC 2C A11S.
9. YIELD (gpm) S' METHOD OF TEST l , .w t •�
10. WATER ZONES (depth):
11. DISINFECTION: Type C C H
12. CASING:
J/ Dian® eter
From W To `iD Ft ti lig
FronL._____To Ft.
From To Ft,
13. GROUT- Depth
To �U
Amount l0 o L
Waft Maness
sr Weight/Ft. Mat lal
0it-2l /Vt
Maseru'
Ft. (oxcrytc
From To Ft
14. SDepth Diameter Slot sin MaterialFro To E _____it in,
From To Et.__in, in.
15. SAND/GRAVEL PACK:
From Two Ft Size
From To Ft__
16. REMARKS:
TopographidLand setting
Midge OSlope Malley DPW
week ePRepdmebox)
Latin:de/longit ide of well location
(thareseniouterieseotto
Iatimde/longiwde source:OGPS opographic map
Oiled( box)
mem ARILLINGLOG
From To Formation Description
Method
i.:r f 0,1`x
337444
n 1( = L T: ' I_!TY
LOCATION SKETCH
Show direction and distance in axles from at least
two State Roads or County Roads. Include the road
numbers and common mad names.
I DO HEREBY CERTIFY THAT THIS WAS CO
—t'—ON STANDARD4PIDTACOPY
ci
s TiIREOF
1/L
CTFD IN ACCORDANCE WITH 15A NCAC 2C, WELL
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mali Service Carter -Raleigh, NC
27699-1636 Thone Na [phone], within 30 days.
Gw 1 REV. 07n001

RESIDENTIAL WELL CONSTRUCTION RECO:AD
North Carolina Department of Environment and Natural Resources- Division of Maw Quality
WELL CONTRACTOR CERTIFICATION #•
1. WELL CONTRACTOR:
W eA Contractor (Individual) Name
Well Ca Company Node
STREET ADDRESS Vy2 Q S WA./ aOR
Hc'k• j?c';h , Nc = aTTAL3
City or Town ^ -Zip Code
�j.�p
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID A(d applicable)
STATE WELL PERMITegr am:Scable)
DWQ or OTHER PERMIT #(If applcable)
WELL USE (Check Applicable Sac): Residential Water Supply el
DATE DRILLED /a � r
TIME COMPLETED /I vd AM
3. WELL LOCATION:
COY: 14/71/6el�u/1I. COUNTY "lye/ ri 0
Gene - r5 In "C
4S4seNaFe_ Numbers. Camrnunny. Subdivision, Lot No.. Parcel, Zip Cede)
RAPHIC f LAND SETTING:
0Vailey °Flat ORidge ❑Other
(chedc-rr box)
LATITUDE 3
LONGITUDE
Iatitude/longitudesaace_ DGPS OTopog -Rhicmap_.
(bcatbn ofwet mustbe shorn, on a USGS topes map and
attached to this farm (not using GPS)
A WELL OWNER
OWNER'S NAME Ken z C'-o-Tye&ref-
STREET ADDRESS 7 D'7 - Raver t 0%. R.a
May be in degrees,
minutes, seconds or
in a decimal format
Can}oY. NC art le
City or Town State Zip Code
( C318 T 11 oo- a4Y'1
Area code - Phone number
5. WELL DETAILS: P
a. TOTAL DEPTH: J
b. DOES WELL REPLACE EXISTING WELL? YES 0
NOIV
c. WATER LEVEL Below Top of Casing �(J Fr.
(Use'+' 1Above Top et Casing)
d. TOP OF CASING 13 / FT. Above land Surface'
'Top of casing terminated alfot below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpnt): /CC METHOD OF Itas ev:+tv
7. GROUT: Depth
36
"n`-'r69
e c c
t_ DISINFECT1Ott Type 911$ Amount %
g. WATER ZONES (depth):
From To From
From To Frorn
From To From
To
To
To
6. CASING: Thickness/
From -�� To (C LFI. tp Ter
From To R.
From To Fl.
�7 Material
Method
From 0To oCo Fl. (en1ani' 'X / IP d
From To Fl.
From To Fl.
8. SCREEN: Depth Diapeter SIot Size Material
From To R ir.. in.
From To Fl in.. in.
From To R. U. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To' Ft.
From To Ft
From To Ft
10. DRILLING LOG
From To aronnation Description
et Aviv -teal
11. REMARKS:
G"t@
RECEIVED
env FWorleGnJtLITV
MAN 1,113 zoo/
100 HEREBY CERTIFY THAT 1US WELL V 'AS CONSTRUCTED N ACCORDAN'E. wmr'
15A NCAC 2C. WELL CONSTRUCT/ON STANDARDS. AKI1HATA COPY OF THIS
RECORD HAS BEEN PROVIDED TOTS: OWNER.
SIGNATURE OF
ONTRgCTOR DATE
bec . 0- was. it y 4,,C.irb
PRINTED NAME OF PERSON X 4STRUCTII'iG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information M1t.,
1617 Maii Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 558.
Faro GW-la
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- I )hasten or Water Quality
WELL CONTRACTOR CERTIFICATION #
z vi8
337807
1. WELL CONTRACTOR:
j0 ti1 t RkW
II Conn actor (Individual) Name
teen_ 13i0s lieu 4- puny
Null Guaractor Company Nei°°
STREJ.T ADDRESS Pio• Ass. 72 V
44 D& Nt 2-87 /
City or Town State Zip Code
I(32�). bye ;3/70
Area code Phone number
'WELL INFORMATION:
SITE 'WELL ID #pl applicable)_
S fAl LC WELL PERMIT/Mt applicable)
DWG or 01 HER PERMIT #(if applicable)
WELL USE (Check Aue Applicable Box): Residential Water Supply <
DATE DRILLED JQ;3/-0
i IVIE COMPLETED AM ❑ PM
:NELL LOCATION:
onesvU.L-e COUNTY etywocet
et Narne. Numbers, Community, Suodmsion, LGI No-, Parcel, Zip Code)
I OPCCRAFI IIC / LAND SETTING'
1Iope Walley tJ Flat (1 Ridge IOther
(check appropriate box)
Mzt IN in decrees,
I P,7 iTl1DF 3 minutes. seconds or
LONGITUDE In a decimal tnmtat
ati!udc:Ttmeitude source: [ ItiPS I ldbpugraphic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GpS)
6. WELL OWNER
OWNER'S NAME _keg
AdsS!RFEi ADDRESS _{2et 5L./2ndcea-k$ ad
Watin sd6G/'e nlC_ a678G
city o I own State Zip Code
ae 5}-793 S`
Pi ea code - I'hone nu nber
WELL DETAILS: /-
a. TOTAL DEPTH: .r
5&5
b. DOES WELL REPLACE EXISTING WELL? YES i] NO 1,
c. WATER LEVEL Below Top of Casing: Y D FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS i FT. Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 45- METHOD OF TEST 2 /70i r.,
f. DISINFECTION: Type
g. WATE ZCQNES' (depth):
From 30✓To From To
From 513 To From To
From To From To
Amount
6. CASING: Thickness/
Depth �" Diameter Weight aterial
From 0 To 7ity Ft. toil I/L
From To Ft.
From To Ft.
7. GROUT: Depth /`Material
Frorn 0 To Zo Ft. (C€Me/VIL
From To Ft.
From To Ft.
Method
Toe
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
2 • .5151 pat 1-,
11. REMARKS:
,.r t.t N S:4J
t,)I,ikl,!
? UU7
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 Tp THE WELL OWNER.
/18-07
SIGNATU E OF CERTIFIED WELL C• ` - ' CTOR DATE
,ervan ;ICB()e-
PRIN FED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-ta
Rev. 7/05

WELL CONSTRUCTION RECORD
328675
North Carolina -Department of Environment and Naajur ll Reso rces - Ia'vision of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME riot h're CERTIFICATION #�W6
WELL CON'TR,\C"TOR COMPANY NAME rl kW /Ja'r'P fy PHONE # eo1 4C<"p/ eiea'7
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential �unicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO
Nee Best Town:
// ere
( heel Name, Numbers, Community, Subdivision, Lot Na, Zip Code)
3. 0WNER: t. lhD///
Address W/S Rr, ✓, /2( /
oyyzie (Street or pure No.) �g2
1/2
Ai(
City
or Town llig Zip Code
Area code- Phone number
4. DATE DRILLED A�%3-D 6
5.TOTAL DEPTH: 3f'3 &
6. DOES WELL REPLACE EXISTING WELL? YES 1 NO 0
7. STATIC WATER LEVEL Below Top of Casing: f@a) FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS ( FT. Above Land Surface*
`Tup of casing terminated actor below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpm): 7,,5— METHOD OF TEST.4'f
10. WATER ZONES (depth):
DLL
I I. DISINFECTION: Type
12. CASING:
Count
Topogra is/Land setting
❑Ridge lope .❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
DEPTH
From
CS
5
Depth ameter
Fromi� To 1'0 Ftep Y
From To Ft.
From To Ft.
13. GROUTS., Depth „ �jvlaterial y Method
From 16.) To Ft.(G�%'r/✓7
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.
Amount
Wall Thickness
or Weight/Ft. lM4ter
F+rynatir Description
ND
LOCATION SKETCH
Show direction and distance in miles from at lea
two State Roads or County Roads. Include the meal
numbers and common road names. ^�
RECEIVED
DIV. OF WATER QUALITY
JAN 0 8 2007
16. REMARKS:
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STRU TI•N STANDARDS ND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
/0' /3—e
Y
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
mitthe 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

t3B874
WELL CONSTRUCTION RECORD
North Carolina -"Department of Environment and jNaj�.�1traal(l�'Resources - DD/iv/ii$,sion of Water Quality - Groundwater Section WELL CONTRACTOR (INDIVIDUAL) NAME In in IO / UG�/ GI/le CERTIFICATION #a//"['//
�
WELL CON'i'I \CfOR COMPANY NAME / nee tie// 9' , ,rffl
PHONE # (C A` 7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I.
2.
WELL USE (Check Applicable Box): Residential Nf Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
WELL LOCATION:
Nearest Tor: bye tveS0 / e County
//M be/ / n/e Dr:
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNERUO���
Address
ayr�/(Street /�or a�-) ( 7 IO
eige76 ZIp Code
Area code- Phone number-7
4. DATE DRILLED /i�t —$t i�fCJ
5.TOTAL DEPTH: .c
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 2-7
7
STATIC WATER LEVEL Below Top of Casing: 3 FT.
^^�� (Use "+" if Above Top of Casing)
8, TOP OF CASING IS oL FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance w th 15A NCAC 2C .0119. •
9. YIELD(gpm): 1� METHOD OF TEST /Q//
10. WATER ZONES (depth):
/�-_.�,�_/ LOCATION SKETCH
11. DISINFECTION: Type le J Amount Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. rial - numbers and common road names.
tier
opographic/Land setting
tdge ❑Slope ,❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees(n inures/seconds)
Latitude/longitude source:❑GPSOTopographic map
(check box)
DEPTH DRILLING LOG
From ,To F. atiot .Description
•
r9-
Aar
-
TO eve
Depth
From fa? To/Cr
From To Ft.
From To Ft.
13. GROUT: Depth. Material JJ Method
From 0 To O2O Ft.(.e/le^/J
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:
RECEIVED
DIV. OF WATER QUALITY
JAN 0 8 2007
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
STRUC/ ON j ANDARDS, AND T COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
ubmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699.1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001
a/

North Carolina • Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
1636 Mail Service Center -Raleigh. N.C. 27699.163&
Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: k /i91 %livi
WELL CONTRACTOR CERTIFICATION #:& I Pi
STATE WELL. CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Sox): Residential Er Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection
❑ Other If Other, List Use:
2. WELL LOCATI N: (Show sketch of the location below)
Nearest Town:
County: st(1�1�_Xi��
4.
5.
6.
7.
8.
Address t Formation Desedpson
d i D� .'.tort ,',' t5e snvv, i -2O sAna 1- -
City or Toxin nv� Milo �! l ninnt
s� Zip Code NCI -) () DATE DRILLED )qD. - 3
TOTAL DEPTH
(Road Na . Numbers, - ty. or Su
OWNER r ` ;bdivision and Lot No.) DRILLING LOG DEPTH
From To F
9. TOP OF CASING IS
'Top of easing terminated Wor
dance with 1SA NCAC 911e
10. YIELD (gpm):
11. WATER ZONES (depth)
2. CHLORINATION: Typ
3. CASING:
CUTTINGS COLLECTED YES NOr
DOES WELL REPLACE EXISTING WELLS S CD NO0
STATIC WATER LEVEL Below Top of Casing: FT
(use . i Above Top of Casing)
FT. Above Land Surface'
below land surface requires a variance In actor -
METHOD OF TEST
e
Dept .,..o'ir titer
From --1._ To ,�6) . Ft. d yy
From To Ft.
From _ To Ft.
14. GROUT:
Depth Material
From ___L__ To >: Ft. CS, (i Y 1I
From To Ft
15. SCREEN:
From
From
From
From _
From
17. REMARKS:
Depth
To
To
To
16. SAND/GRAVEL PACK:
Depth
To
To
Ft
Ft.
Ft.
Diameter Slot Size
in. in.
in. In.
In. in
Ft
Ft
Amount
r to
G7'J
t
le&
If additional space is needed use back of form
Wall Thickness
Or WelgtwFt. Material.
pfloac
Method
Size Material
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
t
vEI
tql
A fl
au}L IN ,6o1
i.a
O
us q
RECEIVED
O1V. OF WATER CURL
IAN) 5 2007
C/i1Q164) itt 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.
FOR OFFICE USE ONLY
Quad No:
Serial No.
J/—z l'6 C
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Ou&ity, Groundwater Section within 30 days
DATE
GWI 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 (919) T33-3221
WELL CONSTRUCTION RECORD
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #•
STATE WELL CONSTRUCTION PERMIT#:
ta
1. WELL SE (Check Applicable Bosh Residential" Municipal 0 Industrial ❑ q
Recovery 0 Heat Pump Water Injection 0 Other 9ricuttural ❑ Monitoring ❑
[� If Other, List Use:
From
From
17. REMARKS:
13. CASING:
From
From
From
14. GROUT:
2. WELL LOCATI N: Show sketch of the location below)
Nearest Town:
County: C1I•j\1c-1
(Road Name arcs Numbers
Th. OWNER
Address ;r
Criy or Tovm State
4. DATE DRILLEDL ! XD
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ED NO�
7. DOES WELL REPLACE EXISTING WELL? YES NO�i
6. STATIC WATER LEVEL. Below Top Of Casing: FT.
9. 70P OF CASING IS I (Use •.• 9 Above Top of Casing)
'Top or t. FT. Above Land Surface'
donee with 9 terminated aver below land surface requires a variance in accor-
15A NCAC 2C.01111
10. YIELD (gpm): _L_ METHOD OF TEST _L✓]tt
11. WATER ZONES (depth):
12. CHLORINATION: Type ----- —_ Amount
Depth . Diameter
_ To � Ft. Q J
To Ft,
To Ft.
Depth Material Method
From —� To -AO FL �'O�"ilYt"i }
From To F1. -
15. SCREEN:
From
From
Depth
To
To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
DRILLING LOG
DEPTH
Fonnaupn Desalption
f .,+rt
If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at least two State,,4
d O r tC. Roads, or other map a crane points)
RECEIV�ir
OW. OF WATER oUALITY
IAN 0 5 2007
Diameter Slot Size Material
Ft _ In. in.
Ft. in. In.
Ft. __ in. in
Size
Ft
Ft.
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
•
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD H BEEN PROVIDED THE WELL OWNER.
°uad No.
FOR OFFICE USE ONLY TO 4,i.,�y'lssv� 11_21 -66
SIG TURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water °utility, Groundwater San within 30 days DATE
ed
Serial No.
It1v
lc co% F-Tc nF C(»!on !�K
GW-1 REV. t299

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
2. WELL LOCATI
Nearest Town:
WELL CONTRACTOR: _
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT/I:
fl
1
1. WELL USE (Check Applicable sox): Residential Municipal 0 Industrial 0
Recovery 0 Heat Pump Water Injection
❑ Other If Other, List Use:
(Sh w sketch f the location below)
�PS� Cony:
(Road Numbers. Commwy. or Subdivl
3. OWNER i y' ] sron end Lot No
Address ac;nl f1n,ItilDia't
4.
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO�
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NQI' 8. STATIC WATER LEVEL Below Top of Casing: FT
9, TOP OF CASING IS--- }f--� (� •'• 11 Above Toped Casing)
FT. Above Land Surface'
'Top of easing tarminatad at/oror below lend surface requires a nee In accor-
dance with 1SA NCAC 2C.011a
10. YIELD (gpm): _ METHOD OF TEST C
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
Depth
From-__.L,_— To
From To
From To-
14. GROUT:
j Dept
From I To
From To Ft.
15. SCREEN:
Ft.
Ft.
Ft..
From
From
From
FOR OFFICE USE ONLY
Quad No:
Sinai No.
Depth
To
To
To
16. SAND/GRAVEL PACK:
Depth
From To
From To�_
17. REMARKS:
D Wall Thickness
iwnetar a Weight/Ft.
Ft Mate aI Method
Diameter Slot Size Material
Ft In. -__ in.
Ft..in. In.
Ft.in. In
Ft.
Ft.
Size Material
1,^I I y (Otfeel 0f a 0.
City Toe; Stale 1-r/��
DATE DRILLED Zip Code -�J_'1—dSrn
DRILLING LOG
- from Td
Agricultural ❑ Monitoring 0
rca
It additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at feast two State
Roads, or other map reference points)
(CAC
�t.l
RECEIVED
0IV OF WATFR OUALITY
AN ?, h 200/n Lit
V
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.
S$O 'RJR OF PERSON CONSTRUCTING THE wEU. DATE
Submit original to Division of Water Qualify. Oroundwater Section within 30 days
GW-t REV. 12/99

Nat Conte •www.adsttS..e.a.eeNSW Noommo.-MAW olWet SI-oantanor don
ICS w S_J_ Calor • Ntdl/I.. tc. itnos SP s MN 7E4121
WELL CONSTRUCTION RECORD ww•COKTRACT01b «a O'rtI fun r I-
wEiL CONTRACTOR CENT IPICATION sea 1 I;
STATE WELL CONSTRUCTION .-..a S1
1. WELL USE_psna spas* ape IlstidenlolCr IMMO0 bld/fr0 Apb lbsed Malrottne0
Raa ramp al .S Fu u War kjserwt ❑ Oast [] EOr, or, LIN k e
2. wBLLOCATIOttWhoa?Wok* ofMbeMaebibs)
lasing IA fl°S d, IIP, ant ri/324)'LDDDd
V
end Nana Nan rwwri►rrfdrinwftat Ns) OIRLSOLOO
t OWNER *en'i-c'Z}iD-n.A./O N+wr t.
Addr_O »F I �fl(�feMneJ . ) - 31
AifJ 10„rliIY 0 N.Y &SSiStP 7Z�� 7Li;
DATEORILLED C/'s Mar moSae1 1 r '.D o44- U �yt7S
TOTAL DEPTH cw
CUTTINGS COLLECTED maO HOLY
DOES WEIL REPLACE METRO WIN17 YES ❑ NOD'
STATIC WATER LEVEL Robin Top older FT.
Icy MemTeel ORM.
E. TCP OF CASINO IS T _ FT Alms land War
nip sNsoft Isnew ledsNrbsdwItofsuds lapin .slips bswr•
10.YIELD bps* `� METHOD OF TEST
dame WAIN= IC AP
11. WATER ZONES (d/, -
4.
r.
7.
A
12. CHLORINATION: Typo Amount
13. CASINO:
r sdEkrdrps b wad wb.etot bon
LL1C-ATIDN SKETCH
OOPS 2i Olin* sr �r,brr�tr� . . pldrdbe/onOn/dbdiwiomstdstrsrMtu
From ) TO R. O ‘,1-1 4 F� Wall IVAN.
Rwd.,aohsnaprolwwwpers.)
Flue -To FL I EP js
Fr
an To R. l i-- Co ie. ftv.
14. GROUT:
n� Met*
From i_Tt R. u/M r'0��
From To FL
15. SCRIM
D.pllt DMnsfr SIMIS Mstsdl
From To _ R _ In. h
Fran To __ FL In. M.
From To _ FL at In.
1S. SANDIORAVEL PACK:
Dept Ilbs MY.As
To FL
From
From To FL
17. REMARKS:
1,,t RECEIVED
tf�OF WATER OIJALU rV
IAN (PI 5 2007
�r-it nan BLit,
I 00 RENEW CORTIFYTHAT THIS VOW. WAS CONSTRUCTED At CO IDANCIIWINIILA NGICIC. MU.
CONSTRUCTER STANDARDS. AND THAT A TES IMO, HAS MINPROVIDED TONE WELLOWNER.
�v✓ 11— a.3-d(a
1lssOgles ootrotlrrttUlrttlssat DUE
sf.s.frtsadThIsrliallitS..irrrskewWitOdays
Rim la OS
FOR OFFICE USE ONLY
as; nu
MY tin
FED 21 2",.1

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Not Coots • O•p.rbrwr.al Ssa.r.rrsrd and Nome Ilmoura.- Mien a W.w CMwily • Or.ardaslw''slow
Ian IbrSS.. L,Oar•R• MSNC.*7SUSSFla.mAq)7834121
WELL CONSTRUCTION RECORD nu.. CONTRACTOR: flail rik l'o t? x
TAU. CONTRACTOR CERTIPICAT10NF. dll'2,
STATE Val OONINIII »1ON PEIINTis
1. WILL USitewrb AppSssitaplRooldoellol I lahmtlplD IndLhs Apbri..lEl Us
Rams ID HS Pump Wow Wools El OW 1101hsc
2 WELL LOCATI t plow Se alp* boMwr b low)
pass at lr Yi#r .10�Q 1 I0it Ds&* In
Nswuj�
Mal Darfqr Nwabaw.. 1. .orili LL.nldNal
x Owve Lflui CfllAt
4.
t
7.
Ci rrttr (Dr•
<;;,ci-110
DATEoIRU.wj I-)7-{O
TOTAL OLNRH 4+ 5"
CurnmosoOLLECTED vas CI NDb
DOES WELL REPLACE EXISTING WELL? YES p ND fj
DRILLMD 1D0
Pau T.
I ;r?�
scut
S. STATIC WATER LEVEi.'slow Top d Quilt FT.
I w asps Teo OS*
S. TOP OF CASINO Ni FFT. Above land'urbwJ
•Tpa ossiou luratherlMM below Md_--w*iw.w.Yno Msums&
dos via wANDA4lCJ111t 1o.YNLO( * ES
-I METHOD OF TT n �cf
11. WATER ZONES (dope*
C Ci -?()
'4 (C
12. CHLORINATION: Typo
it CABMM
minims
From . Drib pL Mr, orWill sear. �,pa r`r,c
Fran To Pt
From
14. GROUT:
To Ft
Dito3
�✓/,,�0
From 7i , rtCVk"-rf
From
15. SCRIM
Copt
From To
From To
From To
To FL
DIaINMr Not Ski Mabry
FL br In.
-FL br. ._-__In.
DEPIH
stirIc
` (Y xJ pt
r oddbrdspa b rwsdsd use budr d Ann
LOCATSTII su IUI
iMosbsudm Nod dldwsrs ban SS.dwo Nosho
Reads, W
to
,\cc h Loco? LaykJ •
It sANo,onAVEL.PACK IJ
Dept shoo Mill."1
From To Ft RECEIVED r eYa-l-U-
From To FL ,a. CF WATER gUAllIt
17. REMARK& I-40w)
'
.CCORC100FRRESYCERTWYTHATTMSWSLWSCONATRUCTWMAow-ammo. W1N /0A
NDAC PA aMIL
l.
CONSTRUCTION STANDA D& AND THAT ACOPY OFTHIS=IW@N tel MIMEO TOTHE WELL OWNER.
00FF= uss ONLY !' / `r /1-z et `No
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an
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11

North Carolina • Department of Environment and Natural Resources • Division of Water Quality • Groundwater Section
1636 Mail Service Canter - Raleigh, N.C. 7
2 699.1636 Phone [phone]
WELL CONSTRUCTION RECORD
c>,
ca
G7a
tie
00
WELL CONTRACTOR: p.QArkAto
WELL CONTRACTOR CERTIFICATION
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable sox): Residentia)fa' Municipal
M' I r ❑
Recovery ❑ Heat Pump Water Injection �f OtheraCI If Other, List Use:
2. WELL LOCAT N: (Show sketch of the location below)
Nearest Town:
County:
®. (Road Name
3. OWNER
Address
Numbers Cormmn/ or Subs:Wsion and tot No)
City own _ Stake
5. TOTA DEPTHRILLED -OW
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES 0 NOZr
7. DOES WELL REPLACE EXISTING WELL? YES 0 NO(f 6. STATIC WATER LEVEL Below Top of Casing: FT.
l (UN •'• a Above Top of Casing)
9. TOP OF CASING IS
and Surface'
'Top of casing terminated at/or below land s rfbsurface requires oVO a valiance In accor-
dance with 1SA NCAC 2CAIIS
10. YIELD (gpm): W METHOD OF TEST
tCT
11. WATER ZONES (depth):
•
12. CHLORINATION: Type
13. CASING:
From
From.
From
14. GROUT:
Depth ateri Method
From To �i Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft __ In. in.
From To .__ Ft _ In. .___ In.
From To _ Ft. __ in. __ in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft.
17. REMARKS:
Dept n
To Ft.
To Ft.
-To Ft.
er
Amount
Wall Thickness
or Weight/F. Materi.
Agricultural ❑ Monitoring ❑
DEPTH
If additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
*31
RECEIVED
DIV, OF WATER QUALITY
JAN 0 5 2007
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
//-3-4
SIG TURE OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water Quality, Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
Serve No.
i
DATE
GW-I REV. 12/99

RESIDENTIAL WELL CONSTRUCTION REco:2n
North Carolina Department of Environment and Natural Resources- Division of Water Qual:t;
WELL CONTRACTOR CERTIFICATION # • Ott list
1. WELL CONTRACTOR:
QAT c k Gov*_;tn 'FI.•r,ecs
Well Contractor (Individual) Name
eeNq�de ' bo+. ije cfs $Son
WellCdibactor Company Narita
STREET ADDRESS `‘"V3 e1 S.1 wt,N a.CiR
4\0"r 3ernc4 N :', C = f 'OH -,Ha
.•��ppCity or Town �^ e , .. -Zip Code
( �j]
% - (n(ora..
Area code- Phone numbe
2. WELL INFORMATION:
SITE WELL ID #(R apple able)
STATE WELL PERMIT*? applicable)
DWQ or OTHER PERMIT 3(YF
WELL USE (Check Applicable Box): Residential Water Supply O/
DATE DRLLED /42—°21:—Ca
TIME COMPLETED 2 r06
3. WEU. LOCATION:�'
CI
TY: Lrl4('A - C' l ..
/Lfet^ eel
.(St'N Name. Numbers. Canmunay. Subdivision, Lot No.. Parcel, ZW Code)
TOPOGRAPHIC / LAND SETTING:
Qtlope °Valley ❑Flat °Ridge oOther
(cheek .v,nwash. ben
IATIIUDE 3
)
AM o PM y�
COUNTY /YGYCdLb c/
LONGITUDE
May be and
minutes, seconds or
in a decimal format
Latitude/longitude source_ °CPS °Topographic map
(cation of wed must be shown on a USGS tope map and
attached to -this Term Plot using GPS)
4_ WELL OWNER
OWNER'S NAME
STREET ADDRESS
Se
CCityor rTown
7 C 0,4A crams
n1c as 7a (
State Zip Code
(ON )- 13+- g8aa
Area code - Phone number
5. WELL DETAILS: <�W
TOTAL DEPTH:
a.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV-
c. WATER LEVEL Below Top of Casing: 1 O FT.
(Use'+' if Above Top of casing)
el. . TOP OF CASING IS 1 FT. Abeve Land Sur
'Top of casing terminated aVor below land surface may require
a variance in OtAada,k.., with 15A NCAC 2C .0118.
e. YIELD (gpm): 41 METHOD OF TEST R.s
33',
1. DISINFECTION: Type4 t %$ Amount /p
g. WATER ZONES (depth):
From To From
From - To From To
To
From To From To
6. CASING: Thitlmess/
Depth Drair' Weight
From �- To Q FL �'Ca_ ..�
From
Rom
To Ft.
To R.
7. GROUT: Depth ��l1 Materat Method
//
Rom © To odd R. (end-/iti• Yte`Fd
From To Ft.
From To - FI.
8. SCREEN: Depth Da naer Slot Sire Material
From To F_ in. in.
From To R. it . in.
From To R. _ir. in.
9- SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From
From
To Ft
To Ft
10- DR!WNG LOG
From To
f
Formation Descrivtion
Our,-
(C D c2S C—nvi-}e
McCEIVED
Cori-0- WAT R al IA t %p''
-- a) 2007
It REMARKS: FEB 21 2007
100 HEREBY CERTFY THAT THIS WELL V'AS CONStPLCim N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTOR MA .-. ANC THAT A COPY OF THIS
RECORD HAS BEEN PROVIDEDTO7HE w E y 'HER
SI `' TORE OF CERTIFIED N - 1CRACTOOsR� DATE
PRINTED NAME OF PERSON X'NSTRUCTi G UNE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Matt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fonn GW-la
Rev. 7t05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Rater Quality
WELL CONTRACTOR CERTIFICATION # - o[ 136
1. WELL CONTRACTOR:
Q.cc; C' C Nraaecr_jh F WrJe.cS
Well Contractor(badrvdual) Name
s1+L S 4t,.112-C S k S 0 n
Wed Ct Company Nathe
STREET ADDRESS \`h1%$ `a Vcd..17 24ci
14104 5 cs5) Nc - a8nt-13
City or Town Siege -Zip Code
(8A\o_ cobs- a oaa,
Area code- Phone number
2. WELL INFORMATIOtt
SITE WELL ID A('dapplicable)
STATE WELL FERMI-IN/applicable)
DWQ or OTHER PERMIT A(I applicable)
WELL USE (Check Appfiable Box): Residential Water Supply yi
DATE DRILLED .ft. 7—
TMfit .
TE COMPLETED Y.'Uv AMID PM V '
3. WELL LOCA//TIOtt
CIes/cid
CITY: Ld4i7C./aV- COUNTY es/citi'
Al 7 D6, 4-
{Sheet Name, Numbem, Community. owommun, Lot No.. Parcel, Zp Code)
T POGRAPHIC / LAND SETTING:
Slope Ovafey ❑Flat ❑Ridge neither
(church eppropdate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: O GPS O Topographic trap
(bcebon of wed moat be shown on a USGS topo map and
attached to this form I not usag GPS)
4, WELL OWNER
Si3.-t . \ TA:AVI S
Maybe in degrees,
minutes, seconds or
in a decimal format
OWNER'S NAME
STREET ADDRESS 4't 19 f.'k:,)e Octk R.
LJwyne tv; f/e , NC_ 2819,5
City or Town State Tip Code
( $t9 )• ie a' - col to'3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: �D S
b. DOES WELL REPLACE EXISTING WELL? YES D NOS,
c. WATER LEVEL Below ley et Caving /p FT.
(Use '+' it Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface`
`Top of casing tertdnated abor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 3 METHOD OF TEST (C •'S
335296
f. DISINFECTION: Type4;1 Amount / 0
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Thickness/
DepthWeight
From�_Th�i_Ft. tp .
From To
F1.
From To F1.
7. GROUT: Depth Material Method
From 0 To at% R. (riataI'. fdata
From To F1.
From To Ft.
8. SCREEN: Depth Dianeter Slot Size Material
From To R. in. in.
From To R. in. in.
From To P1. in. lit
rn
9. SAND/GRAVEL PACK: CD
Depth Size F-4
From To- Ft. - iV
From To Ft
From To Ft
10. DRILLING LOG
Fro/m T9
Formation Desipption
0 (le'
95 c2e) erta a /i.
11. REMARKS:
itH
7Mh
100 HEREBY CERTFY THAT THIS WELL Y'AS Ct tfMIXTED N ACCORDANCEWITH
'15A NCAC 2C, WELL CONS1RUCTON: TP NDARDS. MIT THAT A COT' °ems
RECORD HAS BEEN Ptt .t THE N ELL OW9.
SIGNATURE OF CERTIFI RACTOR DATE
'bete. Ck Het 4j 6ce rps5
PRINTED NAME OF PERSON ZICHSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mit.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7105

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department or Environment and Natural Resources- Division of V1'ater Qua)ity
WELL CONTRACTOR CERTIFICATION 8. «, 3k
t. DISINFECTION: Type4:\ 1$ Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To _ From To
1. WEU-CONTRACTOR: ,
Race: c%L 1Ae }i", Se a-jecs
Well Contractor (Individual) Name
Well Coltaetor Company We
STREET ADDRESS `y% Q V 2 \kcal 2oS
434 5vc;n4 , NC - asnuk3
City or Town -Zip Code
($a421} totes- ac$a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Me apprcaae)
STATE WELL PERMIT/Reappdrable)
DWQ or OTHER PERMIT tFR(applcable) f
WELL USE (Check Applicable Box): Residential Water Supply (J
DATEDRILLEP 9-1-C
TIME COMPLETED lea i_)
3. WELL LOCATOR:
CITY: eStti��L .. coutr!
v ` r Lot No_ Parcel, is code)
Lassen Name. Ntaneera. community.
TOPOGRAPHIC r LAND SETTING:
ttktpe [Valley ❑Flea ❑Rage natter
(cheek appropb bt°0
LATITUDE 3
LONGITUDE
AM ❑ PM®/
May be in degev,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑OPS [Topographic neap
(Towhee of wet must be shown on a USGS tope map and
ached to this tram (not using GPS)
9. WELL OWNER
OWNER'S NAME L0.C, Fu1toc
STREET ADDRESS tei ),,(act•It s Csee." Rr%
akAde AZC own Stale aA7airm Code
(Rai >• '779- 61 B9
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 20-5-
b. DOES WELL REPLACE EXISTING WELL? YES D NOV
G WATER LEVEL Bela* Top d Casktg: go FT.
(Use -+" IAbove Top of Casing)
a. TOP OF CASING IS 1 . FT. Abate Land Surface"
-Top d casing terminated error bebw lad surface may MOMS
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpnt): S METHOD OF TEST �•�
335295
6. CASING: //rt�� .t �e� !1 i
From # 1 1j% n... io •�a_ .,d(+a:+C-1
Ram To Ft.
From To R.
Thickness(
7. GROUT: Depth Mate'
From 0 ToQ FL. (entenf
From To P1.
From To F1.
8. SCREEN: Depth Diaenter Sbt Size Materiel
From To R. in. _ in.
From To R. in.. n.
From To Ft. in. it.
9. SAND/GRAVEL PACK:
Depot Size Material
Rom To- FL G
From To Ft m •
Fom
—
To FL
N
10. DRIWNG LOG Iv
From To Formation
1 3G _ fit)r1' ..mer
i
11. REMARKS:
tin;!
t OD HEREBY CERTIFY THAT TM WELL V 'AS COISIRLCIED N ACC0RWI CE WITH
15A NCAC 2G WELL COmsenucEN u1 ROAMS_ AKDIHATA COPY OF Tess
RECORD HAS BEEN PROVIDED 10 mi! w "• •_.......ec
SIGNATURE OF CERTI"
9-8-�
CONTRACTOR DATE
belt , GX Tr%Q0. Se y 543.413
PRINTED NAME OF PERSON ONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: ktfonttation
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568-
Form GW-la
Rev. 7/05

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION
North Carolina Department of Environment and Natural Resources -ion oof WORD
WELL CONTRACTOR Quality
CERTIFICATION
Well lontraclwCompany Name
STREET ADDRESS
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(t( applicable)
STATE WELL PERMIT#(ir applicable)
D WQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box
DATE DRILLED // - 3 ti�M/
TIME COMPLETED Z
3. WELL LOCATION:
CITY: �s_ite.. .cz/
(Street NNumbers, Community. Subdivision, Lot No., Parcel, Zip Coda)
TOPOGRAPHIC / LAND SETTING:
oSlope ❑Valley ❑Flat ID Ridge p Other
(check appropriate box) �—�—
LATITUDE 3 j "T" 7 May be in degrees,
minut
LONGITUDE r aivy ., j �secondsor
� in a decimal format
Latitude/longitude sourc!
(bcat%on of well must be shown on a U GS map
anddp
attached to this room snot us' topo map
4. WELL OWNER //JJ mg GPS)
OWNERS NAME (Jp y
e!,�/✓ mom '/, �7ra 1
STREET ADDRESS
CI ty or Town State
Zip Code
Area code} Phone
number
5. WELL DETAILS:
a. TOTAL DEPTH; 2 __
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing
(Use'+"of
if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land
_ -
. 'Top of casing terminated aUor below land gwrsurface maySurequir
a variance in accordance with 15A NCAC 2C .0118. e
e. YIELD (gprn): _12.__ METHOD OF TEST * ; It
1 - g r
Submit the original to the Division of Water Quality within
1617 Mail Service Center —
Phone No. [phone] ext 568.
Raleigh, NC 27699-1617 30 days. Attn: Information Mgt.,
3351$5
f. DISINFECTION: Type , r.r.
Amount a ..Z
9. WATER ZONES (depth):
From /VD To
From J .70 To
To
From To To
6. CASING:
Depth
m_
FroTo
From To
From To
Ft.
7, GROUT: Depth
Fro_ ToQ FL
From To FL_
From To
FL
8. SCREEN: Depth
From To F, ameTer Slot Size Material
From To
From To
9. SAND/GRAVEL PACK:
Depth
From Size Material
From
From
To Ft.
To Ft.
To Ft.
From
From
From
10. DRILLING LOG
From To
0„ . it Formation Description
=.s�L✓J�Asti
G. .t,•L
I1. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND MA AT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE-^r OR .!-c7 �%i
ERTIFIED WELL CONTRACTDATE
a
RINTED NAME OF PERSON CONSTRUCTING THE WELL
F0°m GW-1a
Rev. 7/05
CD
0

1. W CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION ti 3351.60
evenntractor Company Name
STREET ADDRESSa 7 1
City or Town State
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#01 applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED
TIME COMPLETE_
._ AM ❑ PM
3. WELL LOCATION:
CITY:
jiarl.%0Q� COUNTY jririzgad
(Street Name, Numbers, Community, Subdivision,
Lot No., Parcel, Zip Code)
TOP PHIC /LAND SETTING:
lope ❑ Valley 0 Flat ❑ Ridge ❑ Other
(check appropriate box) �----
LATITUDE 3
N S_ 9=iL May be in deg ees,
LONGITUDE '(� r (� minutes, seconds or
/ in a decimal format
Latitude/longitude source: S
❑ Topographic
(location of wed must be shown on a USGS topo map
ndp
attached to this form if not using GPS) map and
4. WELL OWNER
OWNER'S NAME �,f•L./YA
STT ADDRESS
City or Town
tate
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:_ �/Jr c' _
b. DOES WELL REPLACE EXISTING WELL?WEYES ❑ NO
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing) '---�'
d. TOP OF CASING IS -___L_____
FT. Above Land *
*Top of casing terminatedat/or below land surfaceam y re
a variance in accordance with 15A NCAC 2C .0118.require
e. YIELD (gpm): 3a_____ METHOD OF TEST �
' r
Zip Code
f. DISINFECTION: Type
g• WATER ZONES (depth):
From TDB
From To GG/I
From To
6. CASING:
Depth Thickness/
From�To 1» Diameter Weight Material
To Ft.
From Ft.inil`
,dS i0
�"Ci1iLt2/
From To Ft.
7. GROUT: Depth
From_ ToQ Ft.
��11 nnMaterial
From To
From To Ft.
8. SCREEN: Depth
From To
From To
From To
SAND/GRAVEL PACK:
Depth
From To
From To
From To
From
From
From
Amount /Q
Method
Diameter Slot Size Material
Ft. -__in. in.
Ft in.
Ft. in.
in.
Size Material
10. DRILLING LOG
From To Formation Description
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WM1
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEL • WNER.
SIGNA
UR F C •-TIFIED CONTRACTOR
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-1a
Rev. 7/05

North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
249
f. DISINFECTION: Type jatiti
Amount�2�
g. WATER ZONES (depth):
From To
From To
City or Town
State Zip Code
(SE>-
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: 3 e. AM ❑
CITY: L /
rT Y---__ COUNTY bal.)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
CISlope O Valley emt ❑ Ridge ❑ Other
(check appropriate box) —�
LATITUDEI g I f2_ r May he in degrees,
LONGITUDE&)O/LA f• minutes,secondsor
r� Yin a decimal format
Latitude/longitude source:
(location of well must be shown a USES t po m is and
attached to this form d not using GpS) p° map and
4. WELL OWNER
OWNER'S NAME
STR€ET ADDRESS
City or Town v - y
spa it State Zip Code
)- a a.Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:_ a
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c, WATER LEVEL Below Top of Casing: t�
(Use `+" if Above Top of Casing)
d. TOP OF CASING IS
'Top of casing terminated at/or FT.w lansurd surf Land Surface*
a variance in accordance with be face may require
SA NNCAC 2C .Ot 18.
e. YIELD (gpm): yfj
METHOD OF TEST
I
RESIDENTIAL WELL CONSTRUCTION RECORD
ti$
? eD 1. 3 0
7. GROUT: Depth
Material
Thickness/
Diameter Wei ht
Material
0 r _-CCU, s
From To Ft.
From To
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO THEW WELL OWNER.
PRINTED NAME eF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality
1617 Mail Service Center — Raleigh, NC 27699_1617 h within 30 d
(919)a
Phone No.7s. Adn. Information Mgt.,
33_
7015 ext 568.
Form GW-la
Rev. 7/05
IF

1. W CONTRACTOR:
RESIDENTIAL WELL c
North Carolina Department of Environment and Naturale cuurcesTDiivvision of WaRD
ter WELL CONTRACTOR Quality
CERTIFICATIONq���
1I
Well mlractor Company Name rv�
STREET ADDRESS, 7
etc �sfE �t
City or Town State
LYM
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
DATE DRILLED a
TIME COMPLETED r
AM
3. WELL LOCATION:`/
s rnit d
CITY: ey
—�_ COUNTY
Zip Code
Water Supply .
PM
Nad
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code
TOPC PHIC / LAND SETTING: )
pe 0 Valley ❑Flat 0 Ridge 0 Other
(check appropriate box)
----�—
LATITUDV61 3$_ Sift_
LONGITUDEL'
Latitude/longitude source:
(location of well must be shown on a ['Topographic
topo
ni is ndp
attached to this form if not using GPS) map and
4. WELL OWNER
OWNER'S NAME
S - ET ADDRESS
City or Town
2)__chs
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE
WELL? YES NO 0
c. WATER LEVEL Below Top of Casing: ____[%� /
(Use'+' if Above Top of Casing) `-'�--FT'
d. TOP OF CASING IS __L._ FT. Above Land
`Top of casing terminated at/or below land quirsurface maySurequir
a variance in accprdance with 15A NCAC 2C .0118, e
e. YIELD (gpm): 1 6��j
METHOD OF TESjayailihji
iJ
May be in degrees,
minutes, seconds or
in a decimal format
Zip Code
T. DISINFECTION: Type p n r
g. WATER ZONES (depth):
From To
From To
From To
6. CASING:
Depth Thickness/
From To /,�` Diameter Weight Material
From To Ft/ia. /.25✓C S
FromFt.
To Ft.
7. GROUT: Depth
From _ �j aLa/Al
,I Material
ToFt._
From To
From To Ft
8. SCREEN: Depth
From TO
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
11. REMARKS:
From
From
From
Amount
Method
J
I
Diameter Slot Size Material
Ft in.
in.
Ft in. in.
Ft. in.
in.
To FL.
To Ft.
To Ft.
Size Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCT/ON STANDARDS. AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
CONTRACTOR ATE
ib
PRI TED NAME •F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1a
Rev. 7/05
CD
(m7
I—+
TV:
sti

'WELL CONTRACTOR (INDIVIDUAL) CONTRACTOR COMPANY
/�
WELCONTRACTOR COMPANY NAME 7 r r CE /<4
STATE WELL CONSTRUCTION PERMIT*/
(_fapplicable)
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and.Nat I Reso
(
ces - I'vis)on of Water Quality - Groundwater Section
'///
CERTIFICATION NaYfr�
PHONE f
L'/y/
ASSOCIATED WQ PERMIT#
(if applicable)
1. WELL USE (Check Applicable Box): Residential C9 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use
t iZ i#S7S/7
2. WELL LOCATIO
Nealrst Tcgwn _
(Streea N:une, Numbers, Community, Subdivision, Lot No., Zip Code)
1
3. OWNER:�g1)i, (YA6-
Address (7 ay i2c
(reel or Route No.)
In nn tare • 786a
ity or Town State Zip Code
Area code. Phone number 4. DATE DRILLEDJ- / —06
5. TOTAL DEPTH: o% (5-
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IV
7. STATIC WATER LEVEL Below Top of Casing: 3) 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.01 I8.
9. YIELD (gpm): /U METHOD OF TEST /4-. ,
10. WATER ZONES (depth):
11. DISINFECTION: Type
12. CASING:
Amount
Wall Thickness
Depth // D' meter
From12 Tot Ft. or/set/Ft. Materia
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To Ft(LI..n&.tJ *
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
edge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreeshninwes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH ' DRILLING LOG
To For atio. Description
D
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,
Dv OF \NNTFE tQ1;Al_ITY
NOV 9e 9 Z006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
t1STRjJT10N STAND DS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
9'1 489
North Carolina -. Department of Environment and ttlairural Reso ces - w/`
sp n of Water Quality - Groundwater Section
L 'WEL 'T CONRAC'1'OR(INDI VIDUAL) NAM (print) `�'� ion N/�. CERTIFICATION #
WELL cON'IRACTOR COMPANY NAME r%.CE 14Ve//4' --rM/
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
aye/
PHONE # g'5-)6271aticle9 / 7
ASSOCIATED WQ PERMIT#
(if applicable)
WELL USE (Check Applicable Box): Residential Er Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCAT ,N•
Nneera�rrrre_sttt^ T wn: / v
County
(Street ame. a hers, C munity, Sub vision, Lot No.. Zip Code)
Address )(raJ66
0/Sae (Street RouteAtor - 190a
emCts)-7�rty or l' n449 Zip Code
Area code- Phone number •
4. DATE DRILLED/C:1/22r O 6
5. TOTAL DEPTH: n—r-
7. STATIC WATER LEVEL Below Top of Casing: A90 FT.
(Use "+" if Above Top of Cuing)
8. TOP OF CASING IS (7L FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .01IS.
9. YIELD (gpm): / METHOD OF TESTV4/(
10. WATER ZONES (depth):
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
6. DOES WELL REP ACE EXISTING
Topographic/Land setting
TTe ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
• DRILLING LOG
atien Description
DEPTH
From [o
WEL
L? YES ❑ NO ❑
11. DISINFECTION: Type }irk Amount
12. CASING: Wall Thickness
Depth t c er or Weight/Ft pMMMtt e
From'a� To 7/ Ft .
From To Ft.
From To Ft.
13. GROUT: Depth ...a Material Method
From 0 To p?0 Ft( ce,A4e'v�
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.
/851
REGEE EaDoNiTY
oW QFWP
Mpu
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C TRUCTION STANDARDS, AND yHiIT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
4
/0-.75 =0
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Su Kmit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nail Reso ces
'WELL CONTRACTOR (INDIVIDUAL) NAM Fn(print) "C
WELL CONTRACTOR COMPANY NAME / I CC W'
STATE WELL CONSTRUCTION PERMIT#
(inapplicable)
334490
vision of Water Quality - Groundwater Section
J CERTIFICATION��y#eP`/e
p- PHONE # r��u) 60-7Oo?c) / r%
ASSOCIATED WO PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residential QMunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATI'O/N:
Inc arcs t /7'o w n •_
v
M
(Street Name. Numbe
3. OWNER:2j
Address 1j
14/501 c 51 r,
;Type;
ti
Area code- Phone number
4. DATE DRILLED/P{_-" 1-0
County
ommunity, Subdivision, Lot No., Zip Code)
kier
5. TOTAL DEPTH:
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: �2 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 I5A NCAC 2C .0118.
9. YIELD (gpm): a_.METHOD OF TEST da-I
10. WATER ZONES (depth):
el or R/qule No.) 7f/
State
00?
6
Zip Code
11. DISINFECTION: Type
12. CASING:
Depth } ia ter
From-� To 3�7 Ft. %'i
From To Ft.
From To Ft.
13. GROUT: Depth Material
From 0 Top2O Ft(vac,v7
From To Ft.
J
Amount
Wall Thickness
or Weight/Ft. Mpteriaj
Method
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16.REMARKS:
opographic/Land setting
idge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrceshninules/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH • DRILLING LOG
From l^ g atiu Description
rJ`CJ
o 355 „i� '7S
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
GENED
>yN � IREl� Oi;.
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C STRUC I STANDARDS, pD THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
At
SIGNATURE OF PERSON CONSTRUCTING THE WELL
0—
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days.
GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina = Department of Environment and Nail Reso ces
'WELL CONTRACTOR (INDIVIDUAL) NAM Fi,(print)1
'CC 14-'e'/ Q
WELL CONTRACTOR COMPANY NAME
3344121
vis n of Water Quality - Groundwater Section
CERTIFICATION#C21/W
PHONE #
4/7 /67
algr1s/%
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable)
(if applicable)
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. LOCATIO '
pre Town:C. //Pe County
1C.5 Cr K1 e
t
et Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER
Address
m�E al
3rrco g ,
ree or atecNo.) l<v 7l 9
Zip Code
6ff6)- 71C
n OSe
Arca code- Fhone number
4. DATE DRILLED s—a 0 G
5. TOTAL DEPTH:
6. DOES WELL REPLA E EXISTING WELL? YES 0 NO iX
7. STATIC WATER LEVEL Below Top of Casing: —7 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S FT. Above Land Surface*
•Tup of casing terminated at/or below land surface requires a
variance In accordai e with 15A NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST4 a/I.--
10. WATER ZONES (depth):
•
1 I. DISINFECTION: Type 77 %77
12. CASING:
DePt 7 L/ a�i"a r
From 2 ToFL1D
From To Ft.
From To Ft.
I3. GROUT: Depth
From To ‘720
From To
14. SCREEN:
From
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Topographic/Land setting
IdRidge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Foil -nation escription
DEPTH
From To
O
Amount
Wall Thickness
or Weight/Ft. M terial
04
Material L Method
Ft. Ce-4C' v
Ft.
Depth Diameter Slot Size Material
To Ft. in. in.
Ft. in. 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.
4/362.7
RECENED AIM?
p)v OE WA ER OU•
NOV e 9 Zoos
16.REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
NSTP UCTION STANDA3.QiS AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
4-C27'o
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Maii Service Center- Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-I REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nail Reso ces - �'vi/sµln of Water Quality - Groundwater Section /
'WELL CONTRACTOR (INDIVIDUAL) NAM E,(print) —C. •.'a o % CERTIFICATION#'-
WELL CONTRACTOR COMPANY NAN1E
STATE.WELL CONSTRUCTION PERMIT#
(i f appl icable)
�47N, PHONE # W5)6271s' 9 / /
ASSOCIATED WQ PERMIT#
(if applicable)
I. WELL USE (Check Applicable Box): Residenlial'9' Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIQN:
Ne cst Town: County
Si,r9ar/.
I Snec auto, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: /0 rSk SC �r�ti?VS
Address ; 4O s'(j, 410 `"�£.-E✓LI�re4-
r \`�- Z11 �1'iw—of-lt.) �/ li .X 6 I- 1
iiy orT w� t/J7 Stale i Zip Code
(Svc r Route No.)
( )- 4 G_ /0795
Arca code- Phone number?p
4. DATE DRILLED i9O"04112
5. TOTAL DEPTH: 370
6. DOES WELL REPLACE EXISTING WELL? YES❑ NO IS-
7. STATIC WATER LEVEL Below Top of Casing: 6 O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in uccorda ce with ISA NCAC 2C .0118. `
9. YIELD (gpm):1 METHOD OF TESTA/
10 WATER ZONES (depth):
I I. DISINFECTION: Type
12. CASING:
,y-1 Depth
From 1 a To 00 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth n.. Matcgal
From 0 To a0 Ft.S AW0.vf
From To Ft.
14. SCREEN: Depth Diameter
From To Ft. in.
From To Ft, in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
10-1
/-opographic/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)
• DRILLING LOG
atf9n Description
DEPTH
From To
LOCATION SKETCH
Amount Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or Weight/Ft. serial numbers and common road names. jvl
,44hc J� 0070
Method DIV ocIn,/ctic•CFI ypp
Slot Size Material Nov 0 9 2006
in.
in.
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
C(1J"fSTRUCTInN STANDARDS /(Ary THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
theD'v"
9-f -®6
IGNATURE OF PERSON CONSTRUCTING THE WELL DATE
bmit the original toDivision of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC
27699-1636 Phone No. (919) 733-322I, within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
334414
North Carolina - Department of Environment and li I Reso ces - vts/{On of Water Quality - Groundwater Section
"WELL CO:N'I'RACrOI4 (INDIVIDUAL) NAM (print) �y�/-r�%( a/,
WELL CONTRACTOR COMPANY NAME J jr tE 'tf
STATE WELL CONSTRUCTION PERMIT#
(ifaptJlicablc)
J CERTIFICATION
N# r�
PHONE # j )c str?.a) / %
6/y/
ASSOCIATED WQ PERMIT#
(ifa. licable)
I. WELL USE (Check Applicable Box): Residential to Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Ncr • st Town:
11101107
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address
County
y rU et Dr -
7 8S
Zip Code
f 3) 7.7b—,a23
Area code- Phone numb
DATE DRILLED
trees or Route No.)
ny or Town State
4. n-O6
5. TOTAL DEPTH: o9OrC
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO'Ler
7. STATIC WATER LEVEL Below Top of Casing: ,.._ FT.
^� (Use "+" if Above Top of Casing)
8. TOP OF CASING IS o< FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance w ISA NCAC 2C .0118.
9. YIELD (gpm): /5 METHOD OF TESTA 2
10. WATER ZONES (depth):
11. DISINFECTION: Type fa7, Amount
12. CASING:
Dep
Froml—c2 To
From To Ft.
From To Ft.
13. GROUT: Depth Materjal Method
From c2 ToC
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/Lan �,.sseetting
❑Ridge ❑Slope galley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreeshninutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Je nlatiiyn Description
'4-
LOCATION SKETCH
Show direction and distance in miles from at least
Wall Thickness two State Roads or County Roads. Include the road
or WeightFt. M terial numbers and common road names.
1 �4- 002V
RECEIVED
DIV OF WATER 01.JALITY
Nov ,>, 9 ?006
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
C STRUC 10 STANDARDS, ¢IyD THAT A -COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
Sa'hmit 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
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE

WELL CONSTRUCTION RECORD '. :z4 4 9 2
ces - 'vision of Water Quality - Groundwater Section 7/
J CERTIFICATION #a
North Carolina -. Department of Environment and NaN�I Reso
'WELL CONTRACTOR (INDIVIDUAL) NAM (print) —.
p
WELL CONTRACTOR CONIPANY NAME rf CE VVQ
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
ASSOCIATED WQ PERMIT#
(if applicable)
PHONE # .O'$5 7Soc / /
1. WELL USE (Check Applicable Box): Residential ♦a' Municipal/Public ❑ Industrial ❑ Agricultural 0
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Neargst Town:
(Street Name. /N/umbers, Community, Subdivision,
Lot No., Zip Code)
3. OWNER: /, i- !/UOni�it7 C
Address / �q-,wP :
J _ /_' (Str I or Route No.)
fo!/� 'tC: 0
2875b
City or own St a Zip Code
( (L640- }}S6-.SB4,6o
Area code. Phone numb
4. DATE DRILLED tj— u 6
5. TOTAL DEPTH:
County 4170J
Amount
12. CASING: Wall Thickness
Depth From To . Ft. Di ter or Weight/Ft. M erial
'S/ f' Sfr C
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 20 Ft. y1_
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To FL in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
6. DOES WELL REPLACE EXISTING WELL? YES qi NO & -
7. STATIC WATER LEVEL Below Top of Casing: / FT.
(Use"+" if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .0118. _
9. YIELD (gpm): 3 METHOD OF TESTA; r�
10. WATER ZONES (depth): L
11. DISINFECTION: Type /747/7
opographic/Land setting
Pidge DSlope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPS❑Topographic map
(check box)
• DRILLING LOG
Fo tion escription
DEPTH
From To
okt
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.
FF,CEIVED
ouALITY
Nov B 7006
16. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
TRUC TLON STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
SYlbmit 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

oJQ'y VIC JNC. PHONE # ('V`/.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring O Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATI N11: � 1 u
Nearest Town: 1C�W County I 'KgraiTh
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
y
3. OWNER: 11 71 C th'
Address �4,4 KL4, Pb C
City o1/4;lown State
C 1 _ (Street or ZitC
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAM, pri t) L{3�a 4 v1YV/011lCERTIFICATIONg�
#a14+0ot
WELL CONTRACTOR COMPANY NAME
Zip Code
Area code- Phone number
4. DATE DRILLED 11
5. TOTAL DEPTH: t T c /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO @•
7. STATIC WATER LEVEL Below Top of Casing: 11'Q FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING I5 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
Topographic/Land setting
ORidge Wope OValley OFlat
(check appropriatetud
e.bbox) ,��tj ty...�
Na35c 3'.AiUwVKJ°7bC8�0•O0,
(degrees/minutes/seconds) EIcr , v e1 Latitude/longitude souree:OGPSOTopographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
variance in accordance with ISA NCAC 2C .0118.
9. YIELD (gpm): 50 METHOD F TEST
10. WATER ZONES (depth): /10, r
I L DISINFECTION: Type 7Adet- Amount 2
12. CASING: Wall Thickness
FromDepth Diameter or Weight/Ft.
To /0e) Ft.
From To Ft.
From To Ft.
13. GROUT: Depth Material
�
From To . Ij/ C
From To / 7
14. SCREEN:
From
From
Ft
F
Depth Diameter
To Ft. in.
To FL in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Slot Size
in.
in.
Material
Material
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include the road
numbers and common road names.
E Fry
1 D0 HEREBY CERTIFY THAT
CONSTRUCTION STAN 'ARDS
v �
HIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
is
SIGNA URE OF PERSON CONSTRUCTING THE WELL // /6
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
OC
CC:

RESIDENTIAL WELL CONSTRUCTION RECO3D
North Carolina DLymnnent of Environment and Natural Resources- Division of St a:v QuaJiiy
WELL CONTRACTOR CERTIFICATION 8 • att aka
1. WELL CONTRACTOR .
V Q-if: t ' Aec.;i t 'y0.W'ye.
WeR Cmtractor. (indh duaq Name
Q-.'J&Q ' 6csa yyQ�S * E n
Well Contractor Compmry Narhe
•
STREET ADDRESS V"\� 1H TS ..Wu -f p2 j9�
%\04 5 c;naS7 NC a8 -43
City or Town • -Zip Code
( o%). (etos— Oat-
Area code- Phorre number
2 WELL INFORMATION:
SITE WELL ID PMappkable)
STATE WELL PERMIT*?applicable)
DWQ or OTHER PERMITS(1f applicable) /
WELL USE (Check Applicable Bccq: Residential Water Supply riv
DATEDRILLED/�-'22-lP
TIME COMPLETED / & AMP PMp/
3. WEU. LOCATION:
CITY: 4/4/ fi: tO COUNTY / - 4/eo i
/{ //V// CI 16/n 1RI KK aectuk cS+tLEe
-(StreetNumber. Community. Subdh ior4 Lot No.. Parcel, Zip�• )' .
TTOO 3RAPHIC / LAND SETTING:
t� Pe °Valley ❑F,* ❑Ridge ❑Other
(cheek appopriate box)
LATTR)DE 3
LONGITUDE
May be m degrees,
minute, seconds or
in a decimal format
Latitude/longitude source: (7GPS °Topographic map
Vocation of wen mwstte shown on a USGS topo map and
attached to this form lnot using GPS)
A WELL OWNER
OWNER'S NAME Rainy et PAle; cm.
STREET ADDRESS tiyvir' L�endacv p - ve
beet;n P.! e. 3a54%
City or Town ' State Zip Code
(R5o - 2% 1- ss93
Area code - Phone number
8. WELL DETAILS:
a. TOTAL DEPTH: /OS—
b. DOES WELL REPLACE EXISTING WELL? YES in Novi
c WATER LEVEL Beim Tap c( Casing: /Q FT.
(Use •+- IAbove Top of Casing)
tL TOP OF CASING IS ± . FT. Abore Lard Surface`
Top of casing terminated aver below lard surface may require
a variance in accordance vfih 15A NCAC 2C .0118.
e. YIELD Wpm)*`/0 METHOD OF TEST rt•3
335290
1. DISINFECTION: Type4a1 1$ Amount
g. WATER ZONES (depth):
From To From
From To Fron
From To _ Fron
6. CASING:
__To
To
To
Thickness/
Frnm�_ToToth0( � Fl. Damper W
eight
From To Ft. -C
From To Ft.
7. GROUT: Depth Material
From_ Toa Fl. Cerriraitt.
From To P.
From To Ft.
8. SCREEN: Depth
From To
From To
From To
Method
inteeci
Dianeter SWt Slav Material
R. M. in.
P. in. in.
rt. P. C4
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
s From To Ft.
10. DRIUJNG LOG
From To
l 2'
c1 / /n S Grvio, 'C'e
Formation
1 t)rf A
11. REMARKS:
DEC 12 200G
1 DC HEREBY CERTIFY MAT THIS WELL WAS CONSTRUCTED NACCORwl.CE went
tSA NCAC ZC. WELL CONSTRUC ION:TPNDARQ3. AM4D1HATA coprOF1te5
RECORD HAS SEEN PROVIDED TOT r_ OWNER.
e
/lr--d-c.
SIGNATURE OF « - N =-' CONTRACTOR DATE
C.'- a• l• Swart
PRINTED NAME OF PERSON aNSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: information Mot,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GW-ta
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nail Reso ces
'WELL CONTRACTOR (INDIVIDUAL) NAM (print) ' - C.
\VEIT. CONTRACTOR COMPANY NAME rice Lr,D
SfATt: WELL CONSTRUCTION PERMIT#
(ifal)plicablc)
ASSOCIATED WQ PERMIT#
(if applicable)
335485
vi n of Water Quality - Groundwater Section
i
CERTIFICATION #&%GaC"
PHONE #
i l-Ael9S17
I. WELL USE (Check Applicable Box): Residential 2 Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATISN
Nc.94cst�T9vn: -N
IS Veil Name
3. OWNEI
Address
ove
bers, Community, Subdivision, Lot No., Zip Code)
4.
reef or Rowe ..)
A>4 e.<0/79 /1/' , 7AG,
Ciy s Smte 3Zip Code
Area code- Phone number
4. DATE DRILLED�7 / '-0eetc'
5. TOTAL DEPTH: -A:5
6. DOES WELL REPLACE EXISTING WELL? YES 0 O ❑
7. STATIC WATER LEVEL Below Top of Casing: 3
FT.
(Use "+'• if Above Top of Casing)
8. TOP OF CASING 1S FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance ISA NCAC 2C .0118.
9. YIELD (gpm): METHOD OF TEST 4092,—
10. WATER ZONES (depth):
11. DISINFECTION: Type /y-7' }}- Amount
12. CASING: Wall Thickness
ToDep
Ft. tit �r or WeighUFtJJJ. M eria�
From /�
From To Ft.
From To Ft.
13. GROUT: Depth Material J/ Method
From 0 Tora"j Ft. Cement--
From To Ft.
14. SCREEN: Depth Diameter Slot Size
Material
From
To Ft. in. in.
From To Ft. in.
15. SAND/GRAVEL PACK: in.
Depth
From To Ft.
From To Ft.
16. REMARKS:
Size Material
jlopographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degreeshninwes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
From To F rr}a(io Description
O
DEPTH
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.
REC.EILLJ
DIV OF 'NATER DUALITY
DEC 0 6 Z006
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
• STRUCTION STANDARDS, A ! THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
GNATURE OF PERSON CONSTRUCTING THE WELL
e 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
DATE

335486
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and N al Res ces - vision of Water Qual
1 1
/ y
WELL CONTRACTOR (INDIVIDUAL) NAME rint)) J m/TC
WELL CONT RACTOR CO
MPANY NAME
fy
WELL1(P �i /il
- Groundwater Section
CERTIFICATION # •205‘✓
PHONE #
STATE WELL, CONSTRUCTION PERM IT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
I. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATI
NNAa rest Town:
//e(
R1'f�C) ifinr f
(Street Name, Nunmers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:
Address _
-4(4" County
O. j3 nit .i55`_
Street •nr tF�i N, ,1
4\sc.16.\\.e.. vaW To7
r low g1.,P 457 i
Area code- Future. numbe '' ^^�� //
4. DATE DRILLED 1'o? "Gj (Ev
5. TOTAL DEPTH: 5-c /
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO Er
7. STATIC WATER LEVEL Below Top of Casing: g9 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 accords with 15A NCAC 2C .0118. \
9. YIELD (gpm):._ _ METHOD OF TEST A- r
10. WATER ZONES (depth):
I I. DISINFECTION: Type Amount
12. CASING: Wall Thickness
From
Depth
Tob 2 FtMeter or Weight/Ft. M"teri L
. s y
From To Ft.
From To Ft.
13. GROUT: Depth
__aterial 4_From 0 To 0CC) Ft. 0v,
From To Ft.
14. SCREEN: Depth Diameter
From To Ft.
From To
15. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
16. REMARKS':
Method
Slot Size Material
in. in.
Ft. in. in,
Size Material
4topographic/Land setting
,eIdge ❑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 .r atjyfi Description
LOCATION SKETCH O
Show direction and distance in miles froin at least Z`
two State Roads or County Roads. Include the road")
numbers and common road names.
RECEIVED
ntv OF WATER QUALITY
)EC 0 6 2006
I DO HEREBY CERTIFY THAT THI
STRU TION STANDARDS
WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
b 'it t e original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Nail Reso
WELL CONTRACTOR (INDIVIDUAL) NAM�(print) ,�, /�
WELL CON'I'It:\CrOlt CONIPANY NAME ] / / cE 144
STATE WELL CONSTRUCTION PERMIT#
(If applicable)
ces
3•35'487
visjon of Water Quality - Groundwater Section CERTIFICATION #6i)Ke"�j/
PHONE #
ASSOCIATED WQ PERMIT#
(if appl icablc)
F 7-m10,ocP / 7
I. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O If Other, List Use
2. WELL LOCATION
Nest Town: !4 _
r S k7 r ✓a-'C.
(Sired Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: 4 7f
r
Address 7 S 3 Iv/J
1,444400.6,
City
Feet or R to No.)
yTowq State
Z(P GPO S
Area code- Phone number /
4. DATE DRILLED /1"5 0e
5. TOTAL DEPTH: _ €2,5-
07571-s-
Zip Code
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO'ir
7. STATIC WATER LEVEL Below Top of Casing: ate FT.
8. TOP OF CASING IS Q(Use "+" if Above Top of Casing)
8. TOP OF CASING IS t FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .011g.
9. YIELD (gpm): (5-- METHOD OF TEST ,* r
10. WATER ZONES (depth): '/
II. DISINFECTION: Type j/�
12. CASING.
From �� Depth Diameter
To_� Ft. f/ /5/
From To Ft.
From To Ft.
13. GROUTS') Depth
From tTo Q
c/ o Ft
�blaterial
Amount
Wall Thickness
•ort ej5hUFt . 2t �/
t� 72
Method
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.
Topogra;�hic/Land setting
❑Ridge slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:OGPSOTopographic map
(check box)
DEPTH - DRILLING LOG
From fro F. r atir I Description
6)
LOCATION SKETCH O
Show direction and distance in miles from at least FO
two State Roads or County Roads. Include the road
numbers and common road names. v
RECEIVEUAIl,
r.
)ff' „(j 7.06
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CO t/S'R 2UCTI0y STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
!l
SIGNATURE OF PERSON CONSTRUCTING THE WELL //'—DATErl—o ;
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

11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
From
From
From ._
14. GROUT:
From
From
15. SCREEN:
Depth
To
To
To
Ft.
Ft.
Ft.
Wow lend surface requires a variance In atcor-
danee Minna NCAC to .oils
10. YIELD (gpm): �' , METHOD OF TEST C't
Walt Thicanoss
Diameter or Weight/Ft.
North Carolina • Department of Environment and Natural Resources • Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636•Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: i I, t , I ; r
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
334243
1. WELL
USE (Check Applicable Box): Residential❑ Municipal 0 Industrial ❑ Agricultural Recovery 0 Heat Pump Water Injectiong cultural 0 Monitoring ❑
0 Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: A `l \ t �)' -1 ,� \ -_.
_ .. County:
(1
3. OWNERR and Numbers, Con nunity_ or Subdivision and Lot No.)
Address
\
Ctly or Town State Zip Code
4. DATE DRILLED _ - _ pi])
5. TOTAL DEPTH a
6. CUTTINGS COLLECTED YES❑ NOQ
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NOQ _ 8, STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (Use •.• If Above Toper Casing)
--L FT. Above Land Surface' 1*.()- a
'Top or casing terminated aVor C-
nF ��,
DRILLING LOG
From To
DEPTH
Formation Description
kw
\TV
It additionalapace is needed use back of form
LOCATION SKETCH
Material (Show direction and distance from at toast two State
Roads, or other map reference points)
Depth Material Method
To emi Ft.
To Ft
Depth Diameter Slot Size Material
From To Ft In _ in
From To Ft. __ in. In.
From To __ Ft. _ in. in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
t
Submit original to Division of Water Molly, SectTING ion within 30 days DATE
GW-I REV. t2199
FOR OFFICE USE ONLY 1
Quad No:
Serial No.

From
From
17. REMARKS:
1 FOR OFFICE USE ONLY
Quad No:
Depth
To
To
To
North Carolina - Department of Environment and Natural Resources - Division or Water Quality . Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27999-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: U,,f2, "C.t.7 � rr
WELL CONTRACTOR CERTIFICATION ,:5fI R
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Appltubts awn: Residentialar Municipal ❑ Industrial 0
Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use: Agricultural 0 Monitoring 0
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: )Lis ae,,�\i1\\P
County:
(Road Warne and; ube?Cornor Subdivision 3. OWNER t1t� rtWNry' and tot No.)
Address rr t�
City o�J own Stale
4. DATE DRILLED Cj Zip CoOi
5. TOTAL DEPTH
6.
S COLLECTED YES
7. DNOET
O SIWELLREPLA EEXISTING❑WELL? YES c3 Noei
8. STATIC WATER LEVEL Below Top of Casing: FT
9. TOP OF CASING IS_L___ (Use '4' a Above Top of Casing)
'Top of casing terminated at/or below land � surface requiresAbove a varianceinaccor-
donee with 16A NCAC 2C 0113
10. YIELD (gpm): 1l 1� METHOD OF TEST t_�_
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Amount
Thickne
_ WallFrom_.L_01 Ft. (p t/r t or w as
From To Ft. `�-�—
From To Ft.
14. GROUT:
Depth Material
From _L,__ To a Ft. Q'QI'Y VEn
From To Ft.
15. SCREEN:
From
From
From
16. SAND/GRAVEL PACK:
Depth
To
To__
Diameter Slot Size
Ft in.
Ft. .__ In. ___
Ft. _._ In.
Ft.
Ft.
ORILLI NG LOG
To
334239
DEPTH
�+ Formation Deecsfpaon
(.�anCi t O. In -
It additional space is needed use back of form
_LOCATION SKETrq.t
�etteriall (Show direction and distance from at least two State
�=5 C Roads, or other map refereneo Points)
Method
Material
in.
in.
in.
Size Material
Rime scree L+-i
F ncs CrecL
)44
�t7W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCA2C, WELL
CONSTRUCTION STANDARDS, AND THAT A
Serial No.
i
i`izz"✓ j0-6.-a�
.++.nrcre_e L Eck.
�ictine rSLcu.c,
Rcsi- cn 2_,
COPY OTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIG OF PERSON CONSTRUCTING THE WELL
Submit original to Division of Water COW, . Groundwater Section within 30 days GATE
GW-1 REV. t2/99

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
1. WELL USE (duck Applicable am): Residential
From
From
17. REMARKS:
WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATIONS: cm)) l
STATE WELL CONSTRUCTION PERMITS:
Recovery ❑ Heat Pump Water Injection Municipal 0 Industrial CI Agricultural ❑
❑ Other ❑ If Other, List Use:
2. WELL LOCH ON. (Show sketch of the ocation below)
Nearest Town: ) flP S\' 1 I
County: t�^
"(Road Name and Numbers, l �K' or Subdivision and Lot No.)
�3. OWNER
Address %—"`: <
City Town Stan DO Cues
4. DATE DRILLED 1/4-1-
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ED NOU
7. DOES WELL REPLACE EXISTING WELL? YES NO
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (a'4.' a Above Top of Casing)
FT. Above
Land
'Top of casing terminated atror be land surface requires a variance n accor-
dance with 16A NCAC .010
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
11 Depth
From __.L— To _
From To
From To
14. GROUT:
Ft.._____
FI.
Ft.
Diameter Wag Thickness ,t..,
or WeIOt+VR. M, at1 1
Depth Material Method
From To .&C FL . _
From To Ft.
15. SCREEN:
Depth
From To
From To
From _ To
16. SAND/GRAVEL PACK:
Depth
To
To__
Diameter Slot Size
Ft in. in.
Ft. .___ In. .. In.
FL In. in
Size
Ft. __
Ft.
Material
Material
DRILLING LOG
To
334238
Monitoring ❑
)V
Gt.1\J5Ck.)�t 1tipc
•ie
U additional space is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
Fines Crec
1
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY/pF THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY �NL/Alm ////i J' ` t
Quad No: SIG TURE OF PERSON CONSTRUCTING THE WELL (/ "L
Submit anginal to Division of Water Outlay, Groundwater Section within 30 days DATE
GW-1 REV. 12/99
Sena No
pn"Fher C.r. Rci .

From
From
17. REMARKS:
North Carolina • Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.163&Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: Cl 'Vt f ►-e
WELL CONTRACTOR CERTIFICATION STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE (Check Applicable Box): Residential Municipal ❑ Industrial ❑
Recovery [� Heat Pump Water Injection 0 Other r-, If Other, Agricultural❑
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:\n1CAtlMo otl��o
--�-----_� county:
-(Road Na Numbers. po
�3. OWNER ry.orSubcfvisionand Lot No.)
Address
City or Town State
4. DATE DRILLED - zipCode
5. TOTAL DEPTH-=
6. NGS COLLECTED YES N
7. DOS WELL REPLACE EXISTING WELL77 YES N0 '
8. STATIC WATER LEVEL Below Top of Casing: FT.b°
�_ (Use6• 9 Above Top of Caging)
9. TOP OF CASING 1S
'Top or casing terminated at/or below land s rfaccs requires aAbove Land arSance I
dance with 15A NCAC 2C.p11e 9tdrea(avar4np In accor-
dance YIELD (gpm): j Y. METHOD OF TEST �11�
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount 13. CASING:
From ._L To
From To
From To
14. GROUT:
Ft.
R.
Ft..
OR)LLI�OG
From To
334237
Monitoring ❑
DEPTH
Formation Description
anCLi.c
It additional space is needed use back of form
Wag Thickness _ LOCAT! N SKETCH
or WeighVFL Mena( C (Show direction
and distance from at least two State
II Depth Material Method
From _t___ To FL
From To Ft.
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
Diameter Slot Size
Ft In.
Ft. ._—_ in.
Ft. ____ in.
Size
Ft. ___
Ft.
Material
in.
In.
in.
Material
Roads, or other map reference points)
+venot
141.011Frver*texvr
FtneSCr-eFLOel
,
rnKreek Eicik
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RECORD BEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY ZiY n Ds
Quad No: SIG l YTURE OF PERSON/ So
Submit original to Division of Water Maly, Groundwater Section within 30 days
Serial No.
DATE
or h. it
taaar
6-11f
rofTh
Laurel Pd,
GW-I REV. /7199

From
From
17. REMARKS:
North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Canter - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION *: v
STATE WELL CONSTRUCTION PERMIT*:
3G4229
1. WELL USE (Cheek Applicable Box): ResidentialMunicipal ❑ Industrial ❑ Agricultural
❑
Recovery ❑ Heat Pump Water Injection
1❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: 1 rC"`;•.(: i',"
County:
Monitoring ❑
(Road Name and Numbers. Convnuntty, or SubthWon and tot No.) 3. OWNER D titer
cn Co o t p DRILLING LOG
Address r From To
LLL7ntor - - o 4 —
City or Town Stake _
4. DATE DRILLEDD Cone
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES NO'
7. DOES WELL REPLACE EXISTING WELL? YES 0 NOQ 6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I (Use *•a 9 Above Top of Casing)
FT Above Land Surface'
`repot casing terminated at/or below lend surface requires ■ variance In accor-
dance with 15A NCAC 2C 41T1$
10. YIELD (gpm): c' METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type Amount
13. CASING:
From
From_.
From
14. GROUT:
Depth Diameter
To ' - Ft \ 0 /�l
To Ft.
To Ft.
DEPTH
Formation Description
„I
9EcrC` l 2,)Fk �y
�tvr,F�IP`
to 11n 7%5
If additional apace is needed use back of form
Wall ThicknessLOCATION SKETCH
or Wetgmv... Material (Show direction and distance from at least two State
Roads, or other map reference points)
Depth Material Method
From To aLJ Ft. (1 Gf , ,,
From To Ft.
15. SCREEN:
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To__
Diameter Slot Size Material
Ft in in
Ft._ in. in.
FL _ _ in. in
Size Material
Ft
Ft
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECH ORD
BEEN PROVIDED TO THE WELL OWNER.
z"?� 9-2-0 0
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Quallty, Groundwater Section within 30 days
FOR OFFICE USE ONLY
Quad No:
Serial No.
GW1 REV. 12199

FOR OFFICE USE ONLY
Quad No:
Serial No.
North Carolina • Department of Environment and Natural Resources • Division of Water Quality •Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR: C 11/4k(�i'IfR f c ;-
WELL. CONTRACTOR CERTIFICATION a:�1)z 1
STATE WELL CONSTRUCTION PERMIT#: —�
334222
1. WELL USE (ChsckApplicable Sox): Residenual[K Municipal 0 Industrial ❑ Agricultural 0 Monitoring ❑
RecOYery 0 Heat Pump Water Injection
0 Other ❑ If Other, List Use:
2- WELL LOCATION: Sho sk c the location below)
Nearest Town: 1 I(!
County:11 i �(
(Road Nang. and Numbers. Cwnryyty. or Subdivision
- 3. OWNER and Lot No,)
(' e t DRILLING LOG DEPTH
Address ��,� 1-i,�i-. C From To
City o. Town State
4. DATEDRILLED� (l I'(i(L Zip Code
5. TOTAL DEPTH - 6. NOE-y
7. DOES I WELL REPLACE EXISTINNGS COLLECTED YESG ELL?? YES ❑ 8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (� 9 Above Top M Casing)
FT. Above
'Top of casing terminated attarar below land surface requires a valance In accor-
dance with 15A NCAC 2C,.91141
10. YIELD (gpm): METHOD OF TEST 11 C
11. WATER ZONES (depth): t---
12. CHLORINATION: Type
13. CASING: Amount
From
From`.
From
14. GROUT:
Lan/'F�orm�atioonn Description .
i c)( (JY
rr wtevEa-
r,Tap ni 1ALITY
FIB`J i- �OQFi
ff additional space is needed use back of term
Depttg Diarreter all ThicknessCATION CKF LOTC!
To Ft. it ya Weight/M.�M�aatterial (Shpw direction and distance from at WE two State
pall
To Ft- Roads, or other map reference points)
To Ft,
e at ri I Method
From To Ft. I.
From T� _ Ft.
15. SCREEN:
Depth Diameter Slot SIze Material
From To Ft in.
From --- in. Ft. in. --__ In.
From To _ Ft _ In.
16. SAND/GRAVEL PACK: in.
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
-1 r
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COP OF THIS RECORD H BEEN PROVIDED TO THE WELL OWNER.
SIGNATQREOF PERSON THE 2 ^6A
Submit original to Division of Water CONSTRUCTING WELL
ty, Groundwater Section within 30 days
DATE
GW-i REV. 12n99

From
From
17. REMARKS:
North Carolina • Department of Environment and Natural Resources • Division of Water
Quality -Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699-1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#. ))
1 WELL USE (Chuck Applicable Boa): ResidentialEl Municipal
Recovery ❑ Heat Pump Water Injection 0 Other
2. WELL LOCATION: (Show sketgh of the location below)
Nearest Town; r.) t IYIry1
County:
(Road Nang and Numbers, ComNnW
3. OWNER h. or Su06wsion and Lot No.)
Address
Olt.
City or Town 'tea
4. DATE DRILLED Q Star zip Code
S. TOTAL DEPTH
6. CUTTINGS COLLECTED YES Ej NO
CI
7. DOES WELL REPLACE EXISTING WELL? YES ED NOga
8, STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS ` (UN if AboveTop of Cas'
---tom FT. Above Land Surface'
dance with 15A NCAC 2C .011e
'Top of casing terminated attor below land surface requires a variance In accor-
10. YIELD (gpm): METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING: Amount
From
From,
From
14. GROUT:
Dept
To.
To
To
Ft
Ft,
Depth Material
From . L To" Ft. LC%D
From To
15. SCREEN: Ft. �--
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To__
Waa TNebrysa
Ft. ,Diameter or Weight/FL Material
YG)
Method
Diameter Slot Size Material
Ft In. in.
Ft. in. In.
FL In. in.
Size Material
Ft.
_ Ft.
t DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY , THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
)R OFFICE I icc nen .. L/✓T A r _ /'
SIGfrATURE OF PERSON CONSTRUCTING THE /6 '�V
Submit original to Division of Water Duality, Groundwater Section within 30 days DATE
❑ Industrial ❑
1f Other, List Use:
DRILLING LOG
(C From
To
e?e} F. w 1
Agricultural ❑ Monitoring ❑
niv'
If additional apace is needed
P ceded use back of form
LOCATION clrerru
(Show direction and distance from at least two State
Roads, or other map reference points)
GW1 REV. 12/99

WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION p) )>j
STATE WELL CONSTRUCTION PERMIT,:
1. WELL USE (Check Applicable Sox) R 'd
Agrioulturai
WELL LOCATION* ❑
2. CATION (Show sketch f th
North Carolina - Department of Environment and Natural Resources • Division of Water Quality - Groundwater Section
1636 Mail Service Center . Raleigh, N.C. 27699.1638-Phone [phone]
WELL CONSTRUCTION RECORD
Recovery ❑ Pump Water Injection 0 Other Heat esi ential Municipal a! ❑ Iindustrialial ❑
� If Other, List Use:
Nearest Town: 1 Q L ° e location below)
County: ..a L i 'yy.y{'
From
From
17. REMARKS:
I3. CASING:
11. WATER ZONES (depth):
(Road Nam}.and
3. OWNER eirccn.
Address )
City. •wn
4. DATE DRILLED -- L(: by Code
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES0 NOE-
7. DOES WELL REPLACE EXISTING WELL? S 0 NOU
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS I ( use ••Ramond a
'Top of easing terminated at/or below land suit requires
varSuiance
In1
dance with 16A NCAC 2C .0,) 9ulraa a rarlanoe accor-
dance YIELD (gpm): a METHOD OF TEST 1 4
12. CHLORINATION: Type
Amount
Dept Diameter or eght/Thickness
From�_To al Ft. t NphyR
From To
Ft.
FromFt.Ft.
14. GROUT:
From
From
15. SCREEN:
Depth _ Material
Method
�1 i To FL
To FL
Depth
From To
From To
From To
16. SAND/GRAVEL PACK:
Depth
To
To
Diameter Slot Size Material
Ft In. in.
Ft. in. In.
FL--__ In. in.
Size Material
Ft.
_ Ft.
I DO HEREBY CERTIFY THAT THIS WELL W L
CONSTRUCTION STANDARDS,CONSTRUCTED RE IN ACCORDANCE WITHPROVIDED
1 E NCAC EC, WELL
AND THAT A CO OF THIS RECORD H S BEEN PROM
'' �" �-r/!� DEO TO,1THE WELL OWNER.
TORE OF PERSON CONSTRUCTING THEE . �� a
Submit o 1 fl to Divlalo11of Water °vylh., oroimowster DATE
Secion within 30 days
GW I REV. 12/99
s Y,
_
414
—n
Monitoring ❑
DRILLING LOG DEPTH
From To Formation Descdption
_Rerappy7cedg._
nv of -An
If additional apace is needed use
back of form
LOCATION ctccrrt.i
(Show direction and distance from at least two Stat
Roads, or other map reference pants)

Department Carolina • Depaent of Environment
Division of Water Quality •Groundwater Section
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION,:
STATE WELL CONSTRUCTION PERMIT,:
Municipal ❑ Industrial 0 r�r
Other If Other, List Use: Agriculture/ ❑ Ahdhitoting
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
From
From
17. REMARKS:
1. WELL USE (Chock Applicable sox): Residentia121
Recovery ❑ Heat Pump Water Injection
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: �,`� ,
County:
(Road Name and Nunn CormwNty. or Sutxavision and lot Nal 3. OWNER t DRILLING LOG DEPT,
s
Address lc -
From To Fomuuon
on D u
L.1dset or
City or Town State
4. DATE DRILLED
5. TOTAL DEPTH6.
7. D�INGS COLLECTED YES El
WELL REPLACE EXISTING WELL? YESYEED NOCI
6. STATIC WATER LEVEL Below Top of Casing: FT
9. TOP OF CASING IS j (use *4' a Above lap of Casuq) �a..:'�?- �'.l' )R4_s ;
FT. Above Land Surfaces F \l` -Top of casing t.rminat d at/or blow land surface requires a variance In actor- ,
dance with 15A NCAC 2C4a1111
10. YIELD (gpm): - l: METHOD OF TEST !'
11. WATER ZONES (depth): F�
12. CHLORINATION: Type
13. CASING:
From
From
From
14. GROUT:
From
From
15. SCREEN:
From
From
From
0
Amount
Depth Diameter Wag Thickness
or WelghVFL Material
To Ft.
To Ft.
To Ft.
Depth Material Method
To f ' Ft. 5_
To Ft.
Depth
To
To
To
16. SAND/GRAVEL PACK:
Depth
To
To__
Ft
Ft.
Ft.
Diameter Slot Size
In.
In.
In.
Size
Ft
Ft.
Material
in.
In.
in.
Material
If additional apace is needed use back of form
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
IFOR OFFICE USE ONLY
Quad No:
Serial No.
7-7 rTJ
SiL t&ATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit original to Division of Water Duality, Groundwater Section within 30 days
GW1 REV. 12/99

North Carolina - Department of Environment and Natural Resources • Division of Water Ouality - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION I:
STATE WELL CONSTRUCTION PERMIT#:
1. WELL USE #deck Applicable Boa): Residential Municipal 0 Industrial 0
Recovery 0 Heat Pump Water Injection 0 Other
If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town - i ' -
County:
(Road Name and Numbers, or Subdivision and
ra, Co i•, �`�
`• 3. OWNER Lot No .) DRILLING LOG DEPT
G From Address / To Formation Description
1 At NUM orHOW. No.)
•City or Town Stab
Z!p Code
334249
Agricultural ❑ MOtlitoiing
rn
4. DATE DRILLED
5. TOTAL. DEPTH -'k-I
6. CUTTINGS COLLECTED YES ❑ NO
CY
7. DOES WELL REPLACE EXISTING WELL? YES ED NOLJ
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (use•�• R Above Top of Casing)
d
Top of casing terminated aVor below land surface requiFT Above res a Surface'
elanceIn accor-
dance with 154 NCAC 3C .011a
10. YIELD (gpm): ti METHOD OF TEST
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
Depth - Diameter
From To - Ft
From To Ft,
From To Ft.
14. GROUT:
,) hQr1
9. .
Amount If additional space is needed use back of form
Wall Thickness LOCATION SKETCH
or Weketta Material (Show direction and distance from at least two State
r f Roads, or other map reference points)
Depth -, Material Method
From Tor-- ( Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To _ Ft _ in _` in.
From To Ft In In.
From To FL in In
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft
17. REMARKS:
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS
RECORD
L HfryS
BEEN PROVIDED TO THE WELL OWNER.
If —7-.6
TURE OF PERSON CONSTRUCTING THE WELL DATE
Submii original to Division of Water Ouauty. Groundwater Sedan within 30 days
FOR OFFICE USE ONLY
Quad No:
Soda No.
i
GW-1 REV. t2199

North Carolina • Department of Environment and Natural Resources • Division of Water Ouality • Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR:
WELL CONTRACTOR CERTIFICATION #:
STATE WELL CONSTRUCTION PERMIT#:
ci` 342A8
t} d
1. WELL USE (Check Applicable Sox):Residential ❑ Municipal Industrial❑
Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town:
County:
(Road Name and Numbers. Co
3. OWNER nYnrnth•orsubdvsonandLotNo,) DRILLING LOG
Address j From To
4. DATE DRILLED
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES ❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES NOC
8. STATIC WATER LEVEL Below Top of Casing: FT.
City or Town Stale Zip Code
Agricultural ❑ t+TOn(tring
O
DEPT4 co
FormationD supdon
9. TOP OF CASING IS (Use •A. a Above Top of g) CtNO `-r(
Top or casing FT. Above Land Surface' RE nUA
g tarminatsd aVor below lend surface require# a variance In floor- �-,F `-N 1- ( C
dance with 15A NCAC 2C .0113 D `
10. YIELD (gpm): 9 i METHOD OF
11. WATER ZONES (depth):
12. CHLORINATION: Typo
13. CASING:
Amount If additional space is needed use back of form
Depth py�1ef i Than.. LOCATION SKETCH
From To Ft. or efgfVFc. Material (Show direction and distance from \\att least two State
From To Ft_ Roads, or other map reference potpts)
From To Ft,
14. GROUT:
Depth Material Method
From To_ Ft.
From To Ft
15. SCREEN:
Depth Diameter Slot Size Material
From To Ft in. in
From To Ft. in. In.
From _ To _ FL _ In. ____ in.
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft
From To Ft,
17. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD H SEEN PROVIDED TO THE WELL OWNER.
SIG TORE OF PERSON CONSTRUCTING THE WELL DATE
Submit onglnal to Division of Water Quality, Groundwater Section within 30 days
GW I REV. 12121
FOR OFFICE USE ONLY I
Quad No:
Serial No.

.R�y
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTOR:
en Contractor (Individual) Name
MA GREENE BROS. WELL DRLG. OF SYLVA, INC.
Well Contractor Company Name
STREET ADDRESS 1800 SKYLAND DRIVE
BACLEA-
LEA -
SYLVA
NC 28779
City or Town
( 828 )_ 586-5550
Area code- Phone number
State
2. WELL INFORMATION:
SITE WELL ID Air applicable)
Zip Code
STATE WELL PERMITAif applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Applicable Box): Residential Water Supply c/
TIME COMPLETED
3. WELL LOCATION:
CITYW W n950. //•e
DATE DRILLED-y
COUNTY
OPOGRAPHIC / LAND SETTING:
ijoitve
❑Valley ❑Flat O Ridge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: ❑ GPS ❑Topographic map 02 Sv
(location of wel must be shown on a USGS topo map and /
attached to this to snot using GPS) �e Ufl lop
lj
4. l�
f. DISINFECTION: Type HIM
g. WATERnZONESn(depth):
From / DO To / 0 3
From &.57) To
From y 33 To—c/33
0..a c;.
0 a
AMOURS
OUNCES
From / a "Fo / %•
From To
From To
6. CASING: Thiclmess/ Wed?' Q DeO Jamete Weight 2/ ,-& c ,
From To Ft.
Frmt
Frorn
To Ft.,
To Ft.
7. GROUT: Depth Material _ Meth
From O To 3 FL�3�1�.�.
From To GO 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.
AM O PMf c 9. SANDIGRAVEL PACK:
Depth
From
Fran
fg> From
LJUPX
(Street Name, Numbers, Community, Subdosi. , Ler No., Pam. , Zip Code) / 1 /
10. DRILLING LOG
From To
t
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: `/ (JU,�(/! Z)
a. TOTAL DEPTH: 8 U�
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO/
c. WATER LEVEL Below Tog of Casing: 210 FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface
?op of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .011$., _
e. YIELD (gpm): Al )/ METHOD OF TEST //'71 l
WELLOWNER )i\I ^ ,,!�
OWNER'S NAME 05 5 � C ([,k
STREET ADDRESS °I �V 4/J/ t11 IV C 3 3 7 FJ
P1 r Lcnd-- 3-e Zip Code
City or Town ) State P
Area code- Phone number
To Ft.
To Ft.
To — Ft.
U- 7✓
7U /V U
_JQ
D = t
11. REMARKS:
Size Material
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDN.YIE Want
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE •RD... - N PROVIDED TO THE W. NER.
SIGNATURE % CERTIFIED WELL CONTRA
s
ED NAME OF PERSO
PRI
OR DATE
r vt.. v Lt w
CONSTRUCTING THE WELL
116 Submit Mai Servi original Center- Re aleigh, NC 2 699 16117 ivision of Water al(Phonewithin
No (9 9) 733.7Attn: ext 68.Uon Mgt,
Fond GW-13
Rev. 7/05

.ellell Contractor al) Name
AAA GREENE BROS. WELL DRLG. OF SYLVA. INC.
Well Contractor Company Name
1800 SKYLAND DRIVE
STREET ADDRESS
SYLVA
City or Town
82( 8 )_ 586-5550
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ a OTHER PERMIT #(if applicable)
WELL WELL USE (Check Applicable: G'denbbl Water Supply l/
DATE DRILLED—(f
TIME COMPLETED,
3. WELL LOCATION:
CITY AJ KLr G ❑ I I COUNTY
NC
State
1} L
28779
Zip Code
Le-/,f(ctX-
AM ❑ PMft
(Sued Name, Numbers, Community. $ulx5wvo • Lot No.. Parc
TOPOGRAPHIC / LAND SETTING:
frfiltape ❑Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE
LONGITUDE__
Latitudefongitude source: ❑GPS ❑Topographic map
(location of wet must be shown on a USGS topo map and
attached to this lo f not using GPS)
4. WELL OWNER DA I1
OWNER'S NAME O. 5
STREET ADDRESS.?
City or Town
Area code- Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 1
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOX
c. WATER LEVEL Below Top of Casing:
(Use'+' if Above Top of Casing)
d. TOP OF CASING I5 y FT. Ab0Ve ('and Surface'
'Top of casing terminated at/a blow land surface may require
a variance in accordance with 15A NCAC 2C .011
e. YIELD (gpm): METHOD OF TEST / !
Submit the original to the Division of Water Quality within
1617 Mail Service Center— Raleigh, NC 27699.1617 Phone No
Zip Code)
May be in degrees,
minutes, seconds a
in a decimal format
Pe(,le by
D L
' RESIDENTIAL WELL CONSTRUCTION RECORD
North CarolinaDepartment of Environment and Natural Resources-Divisionisof Water Quality
WELL CONTRACTOR CERTIFICATION # ��—
f. DISINFECTION: Type,
g. WATER ZONES (depth):
From 1 QQ To1,Er— From
From ._ To 5 1'm
Fro.
From q_3 To V3J Fran,
6. CASING:Dep iar to
Fran To Ft.
Fran,
From
}, ,:,rA fir;
c., v � 6
Amount
7
From
8. SCREEN:
From
From _
From
To
To
Ft.
Ft.
To
To
Thickness/ '
Weight IILIerial
ad
n
GROUT: Depth Materi
FraTo 3 Ft.
Fran To co FL
F
To
Depth
To
_To _Ft
To
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
(_LUI•al 2--)
al eth
Diameter Slot Size
Ft. in. in.
in.
Ft In.
FL
FL
Ft.
—�Z
11. REMARKS:
Size
In.
in.
Material
Material -
Formation Description
-0 w
PO
T THIS WELL WAS CONSTRUCTED IN ACCCR
ISAA NCAC 2C. WELLL CONSTRUCTION STANDARDS. AND THAT A COPY OFFTT E
S
R. ORD HAS BEEN PROVIDED TO THE WELL OWE
SIGNATURE • CERTIFIED WELL CONT
PRI ED NAME OF PERSO CONSTRUCTING THE WELL
30 days. Attn: Information Mgt,
. [phone] ext 568.
OR
Form GW-la
Rev. 7/05

From_8To _Ft. 4 %t5 2j4,/%t5 fvCS /
From To Ft.
From To Ft.
13. GROUT: Depth /i Material
From D To S n Ft. ('DIlCPE#t
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From To Ft. in. in.
From To Ft. in. in.
15. SANDiGRAVELPACK:
Depth Size Material
From To Ft.
From To Ft.
Method
Rriq
Material
16. REMARKS:
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and rat Resources - Divisi
WELL CONTRACTOR (INDIVIDUAL) NAME (print)_
WELL CONTRACTOR COMPANY NAME 1 GtSO
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
MP/
ASSOCIATED WQ PERMIT#
(if applicable)
3 9 < S01
of Water Quality - Groundwater Section
CERTIFICATION #e2h'a_ _
PHONE 4=52- 2446_
1. WELL USE (Check Applicable Box): Residential C3 Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION: )
Nearest Town:4h m& fU///L County
(Suet[ Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:J'‘/�A7_ e"ts. C 4AGa-_,
Address % t1{s9n4
fart Diu
Sveet or Rout o.)
;no (o
�
abed7t
City or Town State
Zip Code
(923)- a5a- 1to99
Area code- Phone number
4. DATE DRILLED //Q/6
5. TOTAL DEPTH: //OS
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO L3
7. STATIC WATER LEVEL Below Top of Casing: 4,0 FT.
(Use +•" if Above Top of Casing)
3. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordane with I5A NCAC 2C .0118. r//
j
9. YIELD (gpm): 1 METHOD 0 TEST 101.1:rier i
10. WATER ZONES (depth): 26(/3� I
// LOCATION SKETCH
11. DISINFECTION: Type ('�jj4 24/C. Amount /241— Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
rrl
Depth Diameter or Weight/Ft. Material numbers and common road names. =Z
:v
pographic/Land setting
Ridge ❑Slope ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of wel ocation
4/ c s r,c v,9 .37
(degrees/minu s/secc ds)
Latitude/longitude source: f3C'PS❑Topographic map
(check box)
DEPTH - DRILLING LOG
From To Formation Description
.V
ca _ * serer r�'l et.
S9 by
v — yos Cia,,, f�
cen
1462,
O
1 DO HEREBY CERTIFY THAT THIS WEL / AS CONSTRUL fbD IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AD TH / A COPY OF THIS REC)t IJta.S BEEN PROVIDED TO THE WELL OWNER
1 'A
ftE F PERSON CON
/6
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 of Water Quality
WELL CONTRACTOR CERTIFICATION # 200,3 g
33 .7 44
1. IN CONTRACTOR:
I
W abh 9
fERQ&l oNs GuEIt aid
Well clntractor Company Name
STREET ADDRESS Gy 771 Xc _
i1Fi('esi g 14C a87w
City or Town / State Zip Code
51 -VI 4_
Area code- Phone number
s
%m p, LLC-
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(k applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Li --
DATE DRILLED 6
TIME COMPLETED
3. WELL LOCATION:
l CITY: 4117q/
AM ❑ PM'Lzj
COUNTY tiCrt)OQI/
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP ZPHIC / LAND SETTING:
lope °Valley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3$ r 12.7r .2 fJ/ r
LONGITUDE
444
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitudesounce: PS ❑T opographic 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
STRE ADDRESS '/., FLr fi d�
City or Town .Q Stale k R
( %As>- a.4-a-(0o99
Area code - Phone number
5. WELL DETAILS: 2
a. TOTAL DEPTH: 30-5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p�
c. WATER LEVEL Below Top of Casing: Li) FT.
(Use -+- if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface'
'Top of casing terminated aVor Below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
I
e. YIELD (gpm): S METHOD OF TESTBid/Ne 4 —?1,
f. DISINFECTION: Type WO rind f Amount /Q ny
g. WATER ZONES (depth):
Fran To /97) From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From (J To`/J3 Ft. 6, 25 Z//r/Af cY )
From To Ft.
From To Ft.
7. GROAT: t-� Depth Material
From D To � Ft. &table"
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.
FromTo Ft.
From To Ft.
10. DRILLING LOG
From To
GO —77 sack..<
7f — SJ .0
g.3 3O5 6.w.v.54
11. REMARKS:
Formation Description
cn
J
g
I DO HEREBY CERTIFY THAT THLS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WE OWNER
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-1a
Rev. 7/05

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 410
1. �WELL CONTRACTOR: t. life /
l�kL1t)N'FS
1 Contractor (Individual) Name
.Ejum
oceAb /i IE/1 a.rd p 1LC.
Well ontractor Company Name
STREET ADDRESS r ,E&
b
City or Town / State Zip Code
(iaR8 5 2- 84912-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(a applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box): Residential Water Supply CV
DATE DRILLED 6 00
TIME COMPLETED 2 ,CD AM PM Er
3. WELL LOCATION:`
CITY: CJyefc- COUNTY .✓49.1'
/t c.E,,ez A
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING:
75lope °Valley ❑Flat ❑Ridge ❑Other
(check appropnale box)
LATITUDE 3 r 32, -7J417
LONGITUDE r L 51.? JVZ
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: a'CPS °Topographic map
(location of wen must be shown on a USGS topo map and
attached to this form not using GPS)
4. WELL OWNER n
OWNER'S NAME Mt/)7 ej A/77e%
/)C4.
BEET ADDRESS (7 6/6 4 .arr /do jJw_
rALLersodvYlle /aC t g79/
City or Town State Zip Cade
(Sag)-(e y417y
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 1Dr"
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p*---
c. WATER LEVEL Below Top of Casing: 410 FT.
(Use `+' if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface•
'Top of casing terminated aUorbelow land surface may require
a variance in accordance with 15A NCAC 2C .0j118.
e. YIELD (gem): Z G METHOD OF TESTJt)pj/)rrr15-Rq
R
u
51
f. DISINFECTION: Type !./Oe.....
Amount rr ki1
g. WATER ZONES (depth):
From iirO To From To
From /fit To From To
From To From To
6. CASING:
Depth Diameter
From o To
From To
From To
Ft.
Ft.
Ft.
Thickness/
Weight Material
7. GROUT: Depth Depth Material Method
° To gO Ft. CO/IC re . ?e?l/fr/V3
To Ft.
From
From
From
8. SCREEN:
From
From
From
To Ft.
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From
From
From
Size Material
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
0-
- ,f-L
Jb Zor'
11. REMARKS:
Formation Description
C /<y
14,
8
O
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE oFkRTIFIED WELL CONTRACTOR
vi A-N [ Ale S
HINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

RESIDENTIAL, WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-rcDivision of Water Quality
WELL CONTRACTOR CERTIFICAT ON # J
1. WELL CONTRACTOR:
E/Z/4111 & i N ES
,yye�ll Contractor Individual) Name ")�
1 Et4 SONS /c fell aw J unlpt TLC,
Well ontractor Company Name
STREET ADDRESS r�y3/ LL; LPt(PiE-c y,
• .?79g
City or Town / State Zip Code
SCR )- a' 849Lz
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Of applicable)
STATE WELL PERMIT#(ir applicable)
DWQ or OTHER PERMIT #(if applicable) /
WELL USE (Check Applicable Box): Residential Water Supply g�
DATE DRILLED 6 - /i - 06
TIME COMPLETED 2: 7s' AM ❑ PM Q-
3. WELL LOCATION: CITY: C/ �/ COUNTY /Y� &nod
fo{f C #42(
(Street flame, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TO GRAPHIC / LAND SETTING
Slope DValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3 s 2Z.G
LONGITUDE Jr- L xi. /at'
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: EtG`PS ❑Topogaphic 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
n?4^rns [, Go. 5/7rii
STR T ADDRESS P 19 r!70 9�/o"t
C I{ i Ci e_ /? ( / arff %S%/
City or/rown State Zip Cale
( Si; 4)_ 976-6853
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 2Cer
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Q'
c. WATER LEVEL Below Top of Casing: 4,0 Fr.
(Use `+• if Above Top of Casing)
d. TOP OF CASING 15 / FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)' /r METHOD OF TEST jJp(Lrl'r1Cj- r 1
23.1 '52
f. DISINFECTION: Type
Amount /2 >46
g. WATER ZONES (depth):
From ? " To From To
From /fro To From To
From ?7O To From
6. CASING:
Depth Diameter
From 0 Toy¢' Ft. C,.,—
From To Ft.
From To Ft.
To
Thickness/
Weight
-r/ah/
Material
7. GROUT:Depth Material Method
n
From f/ To G`O Ft. Co/IC rGfc ?to athiii
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
4s/
in.
in.
in.
Material
Material
Formation Description
c% s�
4•7-- 21/2r G �.
—D
SEP ; {> [CO
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
D,4-nl TL LUr lye 5
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - //Di "'°a of Water Quality - Groundwater Section
WELL CONTRACTOR fi flD)DAI4 NAMtptist /i//eyI C �h o�(B5' :z cnernacA7tav w 2 71
WELL CONTRACTOR COMPANY NAM&LV ee wr4 d r.�e// /�u � non Liman -or
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ MRtrte
(ifappliable) Of walkable)
1. WELL USE (Check Applicable Box): Residential Er blScipal/Public ❑ Industrial ❑ Agriadorai ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: Nearest Town: ✓E i /e / u can
7/7 Ail v R 780
(Street Nam, Nerlin Cam, Sobdiviem, lest No., T4 Cods)
3. OWNER /eC 5,/m,no/rc
Address 2/ 7 BiirDei' ntcherni K i
Rome No.)
WAyiL)e:vi'l e /t'Z 7V0
Ow or Town Sue Zip Cede
_ -
Aracede- Phone nab. r __.
4. DATE DRILLED /0 —Z3 —O
5. TOTAL DEPTH: !Oti
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Cuing: 70 FT.
/.(Use'W' WAbas Top atCa i
8. TOP OF CASING 1S /011 FT. Above Land Surfaces
flap Nelda tesaSaM Wit below Ind ssssa metro •
mimic* a.c•►dase with ISA NCAC 2C MIS.
9. YIELD (gpm): z- MBTHOD OF TEST Tnt eel
10. WATER ZONES (depth):
11. DISINFECTION: Type CC,/ Amowu Je) o Z
12. CASING: Wall Thicmen
Farm_ To tnO Ft :in
4UR red,
From_,__ To Ft
Fto�_ To Ft
13. GROUT: ar Depth Moat
Fmr� To 2{LFt,( BFi(-i ete t° to
From_ To Ft
14. SCREEN: Depth Diameter Slot Size Maouibi
F To Ft _io. in.
From__ To Ft_in. in.
15. SAND/GRAVEL PACK:
Depth Size Maeuial
FroTo Ft
Ftnw_To Ft
Topograjtbfctand setting
ORidge I7abpe Malley Flat
(rdetapp,aptiNe bcc)
Latitude/longitude of well location
(dapsmlmimadmeaob)
Latitude/longitude souuce:l7GPSDTopographic map
(etch boa)
r)RU.T.TP,!p T rtr
Formation Description
DEU R
From To
Cam? 19
a
Show direction and distance in miles Rom at least
two State Roads or County Roads. Include the road
'rumbas and coon road tames.
16. REMARKS:
I DO HEREBY CERTIFY MCAT TIES WELL W
CONSTRUCTED 1N ACCORDANCE WITH ISA NCAC 2C, WELL
CONSTRC� rSTANDARDSS. AND . T COY OF RECORD HAS BEEN PROVIDED TO THE WELL OWNER
C
6-z3-64
CONSTRUCTING THE V/ELL DATE
Submit the origlaal to tbe Divides of Water Quality, Groundwater Section,1b36 Mail Service Center -Raleigh, NC
2?H9-1tt36Monallo.019)%33:3221,within 30.dan, .GW.I REV..OTCl001.

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources -/Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME �l��i°c4 /C /` p n CA > Zt" cnnnanoN s 2 7 G G '/
wan NTS coAcron COMPANY NAME 9cV ee (.u4Q4r w e(f ? / r nom f OA b P?- 0 fl c
STATE WELL CONSTRUCTION PEEMiri ASSOCIATED WQ PEnwm
(ifs pliable) (Ifdppliable)
1. WELL USE (Chock Applicable Box): Residential Li MmicipaUPublic ❑ Industrial ❑ Agricultural o
Monitoring O Recovery O Heat Pump Water Injection O Other O If Otbar, List Use
2 WELL LOCATION: /
Nest To j t7P r�
/$ C/Q`�i i/9j /� Brook 0 buy
— 7E7
(Street Noma, Numbers, Cam. 8etbdiviaim, tat No. Zip Cue)
3. OWNER / � / 4'- r
Address /8 oQ » /,9
(Sawa w EameNo.)
Sim Zip C.oda
L�
Area cede- Moe camber,
4. DATE DRILLED 7% S--0 6-
5. TOTAL DEPTH• SG Q
6. DOES WELL REPLACE E)OSTINO WELL? YES O NO 0
7. STATIC WATER LEVEL
cBelow Top ofCaalog: 7 20 FT.
8. TOP OF CASINO IS /O NFT. Above Land Surface'
(/ dr
Caw or Ton
'Top of a rlag tensioned valor Mew Sad sedate require' a
vorhae'bswd.aea MS ISANCAC2C Ar1L /
9. YIELD (gpm): y METHOD OF TEST ri ei
10. WATER ZONES (depth):
T d setting
°Ridge Stipp* Malloy DFlat
(eMetappopdae bat)
Latitude/longitude of well location
Mane etierwha000b)
Latitude/longihde sun e:DOPSOTopographic map
(d *boa)
t�J.ryt3 Ten
Formation Description
p�
From To
11. DISINFECTION: Type l' C # Amount Z OZ
12. CASING: Dym Wall Thanes
Depth or Weightift Material
F� To be Ft nit SDR
From_ To FL
From_ To Ft
13. GROUT: Depth /
From 1 To � Ft O/ ncrc fC
Front_ To Ft
14. SCREEN: Depth Diameter Slot Size Matmiai
From 0 To Ft�is in.
From_ To Ft m. in.
15. SAND/GRAVEL PACK:
Depth Size Material
Front_ �To Ft
Farrar_ —___To Ft. /
16. REMARKS. NO 5Ole c
e
•
LOCATION SKETCH
Show direction and distance in miles from at )east
two State Roads or Cowry Roads. Include the road
numbers and common road rmmes.
z ---fn ft/ beer /
1 DO HTOtEBYCERTIFY THAT THIS WELL WAS CONSTRUCTED 1NACCORDANCE WITH 1SA NCAC 2C, WELL
CdNSIR�,�^nL�C710NSTANDARDS, AND A OF THIS na r HAS BEEN PROVIDED TO THE WELL OWNER
(� e
7-5"-06
G THE WE1L DATE
-el
t�
Sabmk the original to the Division of Water Quality, Groundwater Section, 16 6 Men Service Center - Raleigh, NC
27699-16367beee Ne..(919) 7333231, wkkln 30 days 11W-1 REV. -07/2001

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resduryes - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) J R--4-RTt
WELT. CONTRACTOR COMPANY NAME RppW 4 CYI /AN
STATE WELL CONSTRUCTION PERMIT# A RMIT#
(if applicable) (if applicable)
et
3-
e? CJ2
t /(I�IQ
SSOCLATED \V
41 61Tr1q
el r3 1 .3 i I
CERTIFICATION # APO
PHONE # (9R8)683"92223
1. WELL USE (Check Applicable Box): Residential I Municipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring; U Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town:14a)CSUi its County A k/
(Street Name. Numbers. Community, Subdivision, Lot No., Zip Code)
3. OWN ER:J4Pet G r;SHNO
Address a6r5 Eaq /65 Nce .
7 (Street neRoute No.)
Lei/Ahfa.Stfi((c !VC 018NC>
City or Town State Zip Code
)-
Area code- Phone number
4. DATE DRILLED '-�(/3f Oco
5. TOTAL DEPTH- -2 f3S"
6. DOES WELL REPLACE EXISTING WELL? YES O NO
7. STATIC WATER LEVEL Below Top of Casing: a O FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING 1S / FT. Above Land Surface*
'Top of casing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C .011&
Topog icfLand setting
❑Ridge IB'Slope ❑Valley ❑Flat
(check appropriate box)
location N35°3b3SW083'A5G
(degreesiminutes/seconds)Cpr- 1 Wy
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
9. YIELD (gpm): ego METHOD OF TEST (*AL. CO CCAPZ-JZ
10. WATER ZONES (depth): ?C
11. DISINFECTION: Type--%7t3h t Amount ot.
12. CASING: Wall Thickness
or Weight/Ft. Material
Depth Diameter
From C J To 76 Ft.
From To Ft.
From To Ft.
13. GROUT: Depth 22 Material ,/ Method
From To V FtR®fCggcle �yProu
From To 1 4 Ft:EV-Mai TVtt I1
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16.REMARKS:
LOCATION SKETCH
Show direction and distance in miles from at lea
two State Roads or County Roads. Include the ro
numbers and common road names. M
b Q
t
cit
O
471
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE • F PERSON CONSTRUCTING THE WELL
A
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

at r q
O % Y rl'
• WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resourc s - Division of Water Quality - Groundwater Sectionl
w ELL CONTRACTOR (INDIVIDUAL) NAME (print) LAK .L y Q. £ I CERTIFICATION akri Z.
tt ELL cuNnt,icroR COMPANYNAME� �► • Ach��Pu � f (
4�M.% PHONE # VS 03.9aa3
Si ATE WELL CONSTRUCTION PERMIT#
(It applicable)
.ASSOCIATED %VQ P:Gt' ITn
01 aPehcable)
I. WELL USE (Check Applicable Box): Residential lYMunicipaliPublic ❑ industrial 0 .Agricultural ❑
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCAT.IO.N:
Nearest Town:41/I06ViEQ/ County CiKiff
i✓OoD
(S«cet Nome. Numbers. Community. Subdivision, Lot ;,o.. Zip Code)
3 OWNER: I/1E-M/ 5 KCAf{7 /ava-Ac L"
Address i5 X !6o /
(St et or Route No.) (22 it
City or Town State Zip Code
Ara code- Phone number e
4- DATE DRILLED T ///C%%
5. TOTAL DEPTH: 6 ,5-'I
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: oat, Ff.
(Use "4" if Above Top of Casing)
S. TOP OE CASING IS i FT. Above Land Surface'
*Top of casing terminated at/or below land surface requires a
variance in accordance with I5A NCAC 2C AI18.
Topogra Ic/Land setting
❑Ridge lope ❑Valley OFlat
(check appropriate boa)
Latitydn,3id of ve t Ig� o im 5
(degreesiminutes)seconds) cic( r1 g1c-2 Latitudcf!on gitude source:DGPSOTopo graphic mapD6
(meek box)
DEPTH DRILLING LOG
From To Formation Description
9. YIELD (gpm)tel METHOD OFTESIC #PJC
10. WATER ZONE (�. @O
depth): 200
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.
11. DISINFECTION: Type—Tra6 C/
12. CASING:
From
From
From
13. GROUT:
From
Amount t�
Wall Thickness
Depth // Diameter or Weight/FL Material
To 5 CP Ft.
To Ft.
To Ft.
Depth /� iVlateria_i 1
To EtCOnce
From
To j q Ft tAkiieCi
14. SCREEN: Depth
From To
From To
15. SAND/GRAVEL PACK
Depth
Prom To Pt.
Diameter
Ft. in.
Ft. in.
Slot Size
in.
in.
Size Material
Material
i:rom To Ft.
16. REMARKS
SE
I DO HEREBY CERTIF ' THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STA,-IARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
ATE
b
Sub r t 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

w 2 33`1
��
WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and //N^atural Resourcesur- Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) L .AzR (N&( CERTIFICATION ='A100
w EL.t. CON'I RACFOR COMPANY NAME �ippflRQhf'9N `e l/ "DK; IN PHONE # MSI CE 3'7,a 3,
SI ATE WELL CONSTRUCTION PER ,IFr2 ( ASSOCIATED w'Q PE MIT-
lit applicable) Inapplicable)
1. WELL USE (Check Applicable Box): Residential 0.---"Kunicipal/Public ❑ Industrial Cl Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other O if Other, List Use.
2. WELL LOCATION: J !/ ,, t� Topogra is/Land setting
Nearest Town: Ma i it VdteL] County cry, ❑Ride ope ❑Valley DFlat
(check appropriate box)
( Strcel Name. Numbers. Community. Subdivision, Lot No.. Zip Code) Latitude/ onoitude of we l location
..� ( yyy��� NS35 3 533 &3 ao.41?
3. OWNER: --t� J_y TcGc tU (degreesiminutes/seconds) e€/. 2Cf37
Address I'5 Q+X35 i DR. • Latitude/longitude source:OGPS❑Topographic map
[ irceet or )(eye No.) �11 (check box)
Mcot�usv1Il.c NC. A S« IDEPTH DRILLING LOG
City or Town Sate Zip Code From To Formation Description
l )-
Area cede- Phone number �7
4. DATE DRILLED 7'49 /000
S. TOTAL DEPTH: 0.76,`
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (ice
7. STATIC WATER LEVEL Below Top of Casing: OD FT.
(ise"+ if Above Top of Casino)
S. TOP OF CASING IS / FT. Above Land Surface*
*Top or casing terminated atlor below land surfacerequires a
variance in accordance with 15A NCAC 2C_nl tt.
9. YIELD (gpm): /a METHOD OFTESTCA
t0. WATER ZONES (depth): i aPl g?O pZ 11'5
I . DISINFECTION: Type Az let Amount o2,.
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft Material
From To (IC Ft.
From To Ft.
From To Ft.
13. GROUT: Depth 2
From To 3. Ft.
From To i Ft.
4. SCREEN: Depth Diameter Slot Size Material
From To Ft. inin.
in.
5. SAND/GRAVEL PACK:
Depth Size .Material
Pront To FL
From To Ft. in.
trom 10 Pt.
LOCATION SKETCH
Show direction and distance in miles from al least
two State Roads or County Roads. Include thud
numbers and common road names.
SEF t 9 L3:3
O
1 '
{
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C. WELL
CONSTRUCTION STANDAR) . AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d �o
SIGNATURE OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001

North Carolina - Department of Environment and Natural Resources - Division of Water Quality • Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699-1636Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: l X Pan 0 17“--
WELL CONTRACTOR CERTIFICATION it: c& 113
STATE WELL CONSTRUCTION PERMIT#:
r: t) n c,,
tl
1 WELL USE (Check Applicable cos): Residential Municipal 0 Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery 0 Heat Pump Water Injection
❑ Other El If Other, List Use:
2. WELL LOCATION. (Show sketch of the location below) Nearest Town:1(�t G�ASl'12.5VJ e County: A.A) God
J
�3.
4. DATE DRILLED 1-10 - S
5. TOTAL DEPTH
6. CUTTINGS COLLECTED YES [Li NOL�!
7. DOES WELL REPLACE EXISTING WELL? YES (❑ NO id
6. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS 1 (Use if Above Top of Casale)
FT. Above Land Surface'
'Top of using terminated ator Slow land surface requires a variance in accor-
dance with 1SA NCAC 2C .ells
10. YIELD (gpm): (0 METHOD OF TEST V 11 G
11. WATER ZONES (depth):
12. CHLORINATION: Type
13. CASING:
(Road Name and Numbs Community. or Subdivision and Lot No,) DRILLING LOG DEPTH
OWNER r�C1-- n� On ab / F � To Former De
Add�ressJ��,(c O U)iri `ph(1,0 �� b
Nal i it5V t I n°t °r RgaNy.Ro.Tii 1 3 S 1 S-�
Oh Town star 4I coo. LaG - 1-7 O ro ► 7 i C
Amount
If additional apace is needed use back of form
Wall Thickness LOCATION SKETCH
From I th or Weight/R.Weight/R.iS itinet
(ShowMaterial direction and distance from at least two State
From1 I L Ft r jn Roads, or other map reference points)
To Ft.
From To Ft
14. GROUT:
44
From �,•,Dept !r`` _ To dU Ft (�T�
From To F1
15. SCREEN:
1.
Method f�
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 Sire Material
From To Ft
From To Ft
17. REMARKS:
rrci
z
O '
rna+-rrAn C X \-
- urn \N
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY F THIS RE C RD HAS EEN PROVIDED TO THE WELL OWNER.'
p
FOR OFFICE USE ONLY —r! 7-QC
Quad No: SKi E OF PERSON CONSTRUCTING THE WELL DATE
Submit original to of Water Duality, Groundwater Section within 30 days
GW-1 REV. 12199
Serial No.

99n 4
i •ice
Noes Cabe -Otp.nraa5lva...dand NSW Rea -OktbiraVAS Oa- ow.ikalwsrwr
ROINWSato Ora.- PISS NZ. MI►wsr . Mal ��
WELL CONSTRUCTION RECORD WELL COMPACTOR: C Dfl L fltsr
WILL COIRRACTOR CO TIPICATION l: r \ y
•TAT!WELL CONSTRUCTION FS U is
1. WILL waibmit DabRo_O.isdC1 IsbobbolD UPSON Aplwira❑ M.iasgD
pang PIS Pomp Wally-: 0 me [] bit tki We
2.
WELL IDCAllOtt (Mow ONO a Iva baM M - 6ib
NarorTaarc \ .r�.t�; ,e �,v� �t 'min .�.i-. A: cod
SYdNrr.�r/Mom..r.es aa.aaralm.dLaaaa
Ate y Cacj IeY'T) X
�rV)C JV The J'J\ 11 'arwl\17.4. E I���
calrseTs se >b
t oATECRM.LED '«'"
5. Tararens 4ti S
S. wrumSCOLLECTED PESO
DIRLSLO LDo DEPTH
na To For.r..o...v-
--,U%- SLc,L) l)'
7. DOES MILL REPLACE SOOTING WELL? YES ❑ NDO'
1. STATIC WATER LEVEL Mow Top SSolOrint FT.
FTW II Non Top ot Oalre
5. TOP OF CASINO IS I FT Pieria Land Swine
lop ameg lualedaart lawYrd_rttrweiratararrw Yrrt.
/awa�r1M51SACl6
10.YIELD (Wrr* METH0DOFTEST
11. WATER ZONES: WWI*
12. CHLORINATION: Typo Amoad
11. CASIKt
ROM 1 Dopes
Fres
1 1 R t4�
F,rll To R
Fwm To Ft.
1t. sum
Root i 1
Frra
13. Sprat
Faro
From
Fwm
1t SANWORAME.PACK:
Dopes
To
_ To_
To
Flom
Flow
17. TSSIIM11/12
5di-__ qua brrsad a»Mdcaken
_rSTMrrrw LDC:ATIDN MCETKSK
.Mnn NSW pea i_Sla eta Ws SY_l losOS
(knit I_ k Mabod
R
Depth OkmaOr SollY
To Ft In. In.
To _ R_ In. In.
_To_R_ lit In.
100 HOW C url THAT MIS MULL WAS CONSTRUCTED
CONSTRUCTION STANEWICS. AND TRW ACOPY OFTNS
FOR OFFLCE USE ONLY
owns
SSW.
gamma MSm 15A a SC. WELL
NITS SIEII FRONCED TO THE MELL OIMER
OPPIIIIIIONCONIMMUCIIIIIITIE11S1 MTt
Sae at S0 don
014 Nt ta.
OCT0221

North Carolina - Department of Environment end Natural Resources • Division of Water Quality - Groundwater Section
1636 Mal Service Center - Raleigh, N.C. 27699.1636-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR• �a GcnY1 Cl/4c-r-
WELL CONTRACTOR CERTIFICATION a: ry 1 Z
STATE WELL CONSTRUCTION PERMITI:
9 0..M1 r
1 WELL
USE (Check Applicable Boa): Residential Municipal❑ Industrial ❑ Agricultural CI Monitoring Elry ❑ Heat Pump Water Injection Other If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below)
Nearest Town: V\itttl-Y'4:z:\f1F�F County.(-^.1�:
(Road Nair, and Numbers. COmnuruty, or SubaMyon and tot No,)
OWNER iFp .fl *C y
Address(Wait or Haute NO.I
City or -Town r Stay 2k Code
DRILLING LOG
From To
DEPTH
Fomutlon Description
J/JFY t ` (Li i
I1
4. DATE DRILLED=.-1'-I_iJ ' I('4(-t- ii;j� 1,--i,i
\ is L
5. TOTAL DEPTH 1 C J
6. CUTTINGS COLLECTED YES❑ NO
7. DOES WELL REPLACE EXISTING WELL? YES O Nog/
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING IS (Use •• V Above Top ofCasing)
FT. Above Land Surface'
'Top of easing terminated ator below land solace requires a variance in accor-
dance wait 15.4 NCAC 2C.2.1111 C
10. YIELD (gpm): 1 t METHOD OF TEST 1'-�. �'
11. WATER ZONES (depth)*
12. CHLORINATION: Type Amount
13. CASING:
Depth
From To Ft
From To Ft
From To Ft
14. GROUT:
Diameter
It additional space is needed use back of form
Wau Thidmeas LOCATION SKETCH
or Weight/Ft. Material (Show direction and distance from at toast two State
j-=== Roads, or other map reference points)
Depth Material Method
From To r't V Ft _ .', .i ; >_
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:
QCla5 (1
IG- i5
5
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A CO OF THIS RE ORD HAS EEN PROVIDED TO THE WELL OWNER.
Quad No: TORE OF PERSON CONSTRUCTING THE WELL DATE
FOR OFFICE USE ONLY
Serial No.
Summit original to Division o1 avatar Duality, Grousudwater Section within 30 days
6W-1 REV. 12199

• .
lirwCombs -Om/mrrmMr•a nApor rdmndllrmalburwmm-01kkoae/arOne-OnwolnerSea
1QrNS*mks Omr.r-RS^N.QvasirR4Uartpn 71ai
WELL CONSTRUCTION RECORD WELL OONIRrCIaa IN A ofl n .k t 4e r
WILL CONIRAOTORCONTEWATr7Nr:
'TAW WELL OONWIN CIION 1SIL.n
1. Win ina_Parnek ATlretbrrR R..e.sfl Sionlo .l D bdo.bld D d D ra.w%D
Reseseryci Hoof Purim WOW bloom . D 0r1.r n It OINK tit Us
2. WELL toranOrtProw MOM eltobosonboa)
Noose Ton InJi Id V\P '.)Cy ,C
s
4.
r.
A
7.
t
PBS Nino oul Ornallyanilokkaldon mono Ns)
orrNER HCr1 H(-lDVV)or' r,iT
OaRLINu Los
Ts
1-Uc
D�rN
Fam.lomrmmrb.a
wow 1 G S- Lk 3 rx r"CLs' ,
My ease 11111!) SODA
OATS MILES fit - I0 �', , - 1 %;
TOTALOEPTN 11 Serm
wrings amino YEs0 NoQ
DOES WELL REPLACE SOOTING WELL/ Y!s O NOB
STATIC WATER LEVEL Sobs Top IA Choker FT.
I. TOP OF CASINO ISM_ FT. Pialad S1.keoo'
'Toeaallow barmrd ofie lodes Irtow- wmarlanMmnmw
dos sit 1rAEaaarrSSW
10.VIEW kW* .A_METHOD OF Tar l)-'.IG
11. WATER ZONES *par
tabs r.2.) - \ o0V- Or
12. CHLORINATION. Typo
1t. CABSIt
Airman,
r_-- ..2mom bnomad o..toe ofbs
MS Mans LOtflflllKE7CN
Dept, Clads mow Mom. Abmr+.mreMarRow loom albotl.mrlrr
Fmm To.tC FL Si -SA— t �trl,,r C Arra or Wm mop ewe ptt)
From To FL
Frorl To FL
14. GROUT:
From T ,U a,'LA III)(A
From To FL
13. SCRIM
Rom
From To
Rom To
16. SANDIDRAVELPACK
D.prr
Rom To
From To
17. REMAWI t
Ds*
_To -
MAW
OIr..M sbl Ski l6lrad
Fl_ I. M.
R. b1 k
n._ lit In.
a .
FL
FL
ll.bdd
17.
en VS=
rn
IS -5 91 Vafltc
c
Q+ Tie
q- S
10OHEW COMP/ THAT TMOSWELL WAS OONOTRUC1®NACO 11WI CE%WH OA ICC t.WELL
OOr1ETMJCTnISTA/oA noTH TACCP}CpFTIMIWOpW! ISIFf10YE1®TO1WWELLOINIB.
� '/' -04
FOR OFNCE WE ONLY
as ow
OS No
lS UflOFrW1•erCenWrmIO1.IbTIN VIIIIL Orlr
rw..drbarrbYrmtwoorb,bm.rU.rmtm11 tSDdin
i1 Mt. I.b1

North Carolina - Department of Environment and Natural Resources • Division of Water Oualhy - Groundwater Section
1636 Mail Service Center - Raleigh, N.C. 27699.1638-Phone [phone]
WELL CONSTRUCTION RECORD WELL CONTRACTOR• Ci 9 an A. OWQX—
WELL CONTRACTOR CERTIFICATION,: p711
STATE WELL CONSTRUCTION PERMIT,:
9 q1•2)
1. WELL USE (Cheek Applicable Box): Residential Municipal ❑ Industrial ❑ Agricultural ❑ Recovery ❑ Heat Pump Water Injection
❑ Other ❑ If Other, List Use:
2. WELL LOCATION: (Show sketch of the location below) 11�
County: t'I k lju)OOC/
Nearest Town: Win i .\I1eSU (UQ
--. (RawlNumDars. mw6vi
Caruty, or Subsion and Lot No.) DRILLING LOG
3. OWNER
N 11i4..r7 1— eS
'Rita` 1 A Y700 K-Ci . \ — m To
City _\ 1eio'N�ou_o.) n�^ �-7—Imo}
4. DATE ED�—L3I-� sass Zip Code Iq0 - , (1"tS
5. TOTAL DEPTH • - `
6. CUTTINGS COLLECTED YES NO'
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO[_
8. STATIC WATER LEVEL Below Top of Casing: FT.
9. TOP OF CASING !S l (� •. 11Above Top of Casing)
FT. Above Land Surface'
Top of using terminated aVor below land surface regulres a variance In accor-
dance whh 15A NCAC 2C 1111
10. YIELD (gpm): D METHOD OF TEST i C',t
11. WATER ZONES (depth): 1
12. CHLORINATION: Type Amount
13, CASING:
Address
Dept
From 1 To
From To
From To
14. GROUT:
From
From
15. SCREEN:
1.
Diameter
tf { o W (i Material
ia 1-j jS� direction and distance from at least two State
Ft
l 1 t_-_
Roads, or other reap reference points)
Ft.
Monitoring ❑
DEPTH
Formation Desenption
It additional space is needed use back of form
Ft
Was Thickness LOCATION SKETCH
Depth Material Method
TOao Ft. C'DXYIeV'i'i-
To Ft
Depth Diameter Slot Size Material
From To Ft in in
From To Ft In In.
From _ To _ FL _ in _ in
16. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
17. REMARKS:
erryyti t l
TUr
m
tD
O •
Cr. .71
JDY.n CL.0 ,tr
I q D �" V
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY THIS RECO
RD
HASS EN PROVIDED TO THE WELL OWNER.
FOR OFFICE USE ONLY i �`� /!%y(i�/r�)� �'
Quad No:
Serial No.
TURE OF PERSON CONSTRUCTING THE WELL GATE
Writ original to Division of Water Ouasty, Groundwater Section within 30 days
G -1 REV. 12/99

se 0 0
}72
Hoe Orem • Dear or Ilrelemmet al Head llommen Ohtirmellear n s,.ow.r..rrs.arm
trrr IAd►w.rter Owe -Rrrlli. NZ.nJO.Fxssrbre. pun Mal
WELL CONSTRUCTION RECORD waLooaAClae �(LftC0
TIRL CONIRACIOR CrIT.ICATION F: r-::
STATE nu. OOI<s11RICICN remant
1. WttLL USE_LaerbA/Mre-. R_M.iMILd/ ____ ❑ SSW ❑ Apkei d ❑ M.i.Yq ❑
BYO Heel rs*WSbjrrs..❑ Oesw0 NOtMr.thtlWW
2 t▪ r- 1TL a (Wow MIMdIdMlOrw.e Oa* r.rl,ji AJ'(,6 CI
end NsindMoen Canoiser Idideldre.rtrMy ORLS1IOIE6 0 IM
i Oa N\ crnmc&zm vvcc Ci, S liar To hadwOwyla
Addis ,tea NC+` F YYTLYjr-\ \r-1 1 i �Lr�r
cligi.c.Ar a k•-r d i4Ci - 7�� it eP ( r
are Tam Edo Bee
4. DATmmam S-'\--.ptf r- - =-.ET (I'CXS,I','•7,.
5. TOTAL DEPTH .z 0 V
s. curntios OOLLECTED rasp Ndcf
7. DOES WELL REPLACE EMEND WELT TES p N
S. STATIC WATER LEVEL srtr.Tap elCedar FT.
s. TOP OFCAMS ls FT. An tad:
lop elwerr Iaoiarrorb 1Sthed apt. • glare Ile nap
dnaMD1rA/VACX
10. YIELD lip* METHOD OF TEST C,
11 WATER ZONES (Spar
12. CHLORINATION: Typo
12. CAISIE
Amami redrtedspew bowed wobeebdlern
MAMona LOCAT1dl EtONRCM
Duple oenr- Mrs r. Mode- IMmriwwnmiddYEwobrarlro.aoats
Fran i To 1 I_l FL l S vLi p tcAori C Rasa or Ms asp Sauna point X
Fenn To FL
From Te FL
14. GROUT:
Dopb
From To - (; FL
Fran To Tl.
1e. SCR@1t
Dees Ol.nrhr srt she IItUe S
Front _To_ F1_ b. M.
From To FL In. bt
Rent _To_R._ k In.
111. SANDeoRAVB. PACK
Dopes BB
From To FL
Ron To FL
17. IIRIAAIt
MSS
Ccf
0
COW
t DO HERBY COMFY THAT MS WELL INAS CONIRRUCI®IN AocatI11R:s W H 1N1 MAC SC. WSL
CONSTRUCRORRANDAR 1O, 1HATA OFTi111RECORD IMsWSW P11011CWDTOT)E%EU.OWNER
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SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION A `1 to
1. WELL CONTRACTOR:
Oerc.cx NQe,'ch 4^.0.s..11¢tS
Well Contractor (Individual) Name
CA1ae �Sn,aryecS Z Sow WE\\s T4t;nc�
Well Contractor Company Name c)
STREET ADDRESS \*Mb '? aOcy
\'tot SpC .t4S y NC - a3't'°i:3
City or To31n \State - -Zip Code
(aa%y tobS- ao zz,
Area code- Phone number
2 WELL INFORMATION:
SITE WELL ID Alit applicable)
STATE WELL PERMITA(Rapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED %,2
TIME COMPLETED .1 (J b AM ❑ PM
3. WELL LOCATION: ,+
CITY: %%i�5 e L)4/ram/ COUNTY / :7/1,r.-,nri
Stogy T3C1Q opt 11
(Street Name, N rs, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Qs!hpe OValley ❑Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: OGPS ❑Topographic map
(bcatbn of we/ must be shown on a USGS topo map and
attached to this form if not uses) GPS)
4. WELL OWNER /�
OWNER'S NAME 4P1X1'2s:e o.n '-14 e tage kc31-1 tvl
STREET ADDRESS Pr)` loa at b �.)
Mnnp' e-la\‘e-,tJc. atria
Cityor Zip Cade
(eaa r 3L-l\,
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: .� S
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing: , S d 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): .3 METHOD OF TEST
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From
From
6. CASING:
To
To
Amount /4
From To
From_ To
From To
Thickness/
Depth , Diameter Weight
From_ To 69 FL (o -.a kk L\
From To Ft.
From To Ft
7. GROUT: Depth Material
From 0 To_a_Q_ Ft
From To Ft
From To Ft
8- SCREEN:
From
From
F
From
Material
Method
IOUCQd
Depth Diameter SIX Size
To Ft, in. in.
To Ft in. in.
To Ft, in. in,
9- SAND/GRAVEL PACK:
Depth
From To Ft,
From To Ft
From To Ft.
Material
Size Material
10. DRILLING LOG
From To Formatioi Description
1 L % Ov%c- i3ucdon
.?caf CTC 0.'r1 t 1?
11. REMARKS:
1
_cn
3 03_
1 DO HEREBY CERTSY THAT THIS WELL WAS CONSTRIXTED N ACCORDANCE WITH
1SA NCAC 2C, WELL CONSTRUCT/ON STANDARDS, AND MATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF RT LED ' LL 1CTOR /DATE
Dtcc:cK 1\r,ath Sa(aye.iS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submft the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05

WELL CONSTRUCTION RECORD
North Carolina - Department or Environment and N- ural Res irces irces -'/Division or Water Quality - Groundwater Section
CON'( WI'lt(INDIVIDUAL) NAM('. (> inn EJAe7k6A'Y2 CERTIFICATION ,//�
�
\\ ELT COST R.\CIOR COMPANY NAME1/2r" it/e/7 PIIONE # ("7Go)- 796/5
St .err: \\ ELT. c--ONSIRCC I It)N PER)(I I # ASSOCIATED WQ PEltdl IT#
( iLtpliclble)
(ir applicable)
I. WELL USE (Check Applicable i3o.c): Residential �Vlunieipal/Public ❑- Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Ilcut Pump Water Injection 0 Other ❑ I1.0ther, List Use
2. WELL LOCATIO�NN: //
Nca r'sl T )wn: [1'KJ NeS '; /t ( 'ounly
(Street Name. Numberr.., Community, Suhdisisiou, Lot Nu.. Zip Codcl
3. OWNI'RU/
Address .7 3Y.Soei0"-
cc r home No i
l s Fowl' Slum
I ssa5)- %a' — %-5-12
Arco curie- Phone numher q -I. DATE DRILIIi ./— 0O
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATlilt LEVE1. Below lop olCasim': 7f/ FT.
(Use "+" i f Above Tnp of Casing)
3. 'FOP OF CASING IS PT. Above Land Surface'
*Tut of casing terminated at/or below laud surface requires a
variance in accordance with 15,\ NCAC 2C MI IF.
9. YIELD(gpl„): MHTHODOI'TEST #9./
I0. AVATER ZONES (depth):
5. TOTAL. DEPTH: 3t'45—
Ts-/
Zip code From
•
1 L DISINFECTION: Type 771T
12. CASING:
P74-
rom
Amount
Wall Thickness
Depth Diundcr or A1'cinhtiFt. N- teri l
To /06 Ft. (c/v_ ,/g
From To Ft. From To FL
13, GROUT: Depth NT:aerial Nlethod
(
From 0 To Ft. Le,µe,.f
From .1t rt.
(4. SCRLIiN: Depth Diameter Slot Size (viaterial
Front To II. in. in.
From To Pt. in. in.
15. SANI),/(iRAVHI. PACK:
Dcplli Sizc Material
From To Ft
lion In
16. 131)8I;\I(KS.
_�TopographiciLand setting
Bliidgc ❑Slope ❑Valley ❑Flat
(check appropriate box/
Latitude/longitude of well location
t Ieurccs niumcs. seconds(
i_aliludciluueiludc source:❑GPS❑Topographic map
I<li �cf: Nix)
DEPTH DRILLING LOG
1 n9rlion dscripliun
/a -
LOCATION SKETCH
Show direction and distance in nodes front at least
two State Roads or County Roads. Include the road
numbers and common road names.
AUG
I DO !ILIUM' CERTIFY IIIA'I TIIIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD I1AS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit IIle original to the Division of Water Qualify, Groundwater Section, 1636 Mail ServiceCenter-Raleigh, NC
27699-1636 Phone Ni,. [phone], within 30 days. GW-I REV. 07/2001
Z

WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WETL CONrRACroa (INDIVIDUAL) maw (plat) BRIAN THOMAS
nay COMRAc ORcoMPANY NAME GEOLOGIC EXPLORATION, INC.
STATE WELL CONSTRUCTION PERMIT ASSOCIATED WQ PERM IW
(if applicable) (if applicable)
CERTIFICATION a2581
PnoNE a [phone]
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public 13 Industrial ❑ Agricultural 13
Monitoring El Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: CANTON County HAYWOOD
24 TRAMMELL AVENUE (ANDERSON RESIDENCE)
(Street Name, Nlmbas, Commmity, Subdivision, La No., Zip Code)
3. OWNER JAMES ANDERSON
Address 24 TRAMMELL AVENUE
(Street or Rome No.)
CANTON NC 28716
City or Tosco State Zip Code
l-)
Area axle- Place mutl6a
4. DATE DRILLED 05/19/06
5. TOTAL DEPTH: so.0 FEET
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
7. STATIC WATER LEVEL Below Top of Casing:20.0 FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS o.o FT. Above Land Surface*
`Tap of easing tatkatd atior below Sad surface requires a
variance V arotdrecwab 1SA NCAC 2C .l11&
9. YIELD (gpm): N/A METHOD OF TEST N/A
10. WATER ZONES (depth): N/A
11. DISINFECTION: Type N/A Amount
12. CASING: Wall Thickness
Depth Diameter or Weight/FL Material
From 0.0 To2o.o pt. 2 INCH SCH 40 PVC
From To Ft
From To Ft
13. GROUT: Depth Material Method
From 0.0 To 14.0 Ft. Portland Bentonite Slurry
From To Ft
14. SCREEN: Depth Diameter Slot Size Material
From 200 To 50.0 Ft.2.0 in. .010 in. PVC
From To Ft in. in.
15. SAND/GRAVEL PACK:
Depth Sire Material
From 18.0 To 50.0 Ft. 20-40 FINE SILICA SAND
From To Ft
16. REMARKS: MW-1 BENTONITE SEAL FROM 14.0 TO 18.0 FEET
Topographic/Land setting
❑Ridge ❑Slope Malley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degraa/mmrtdseomdr)
Latitude/longitude source:❑GPS❑Topographic mar
(duck box)
pKILLING LOG
From To Formation Description
0.0 14.0 RED SILTY CLAY
14.0 30.0 TAN SILTY CLAY
PARTIALLY WEATHERED ROCK
30.0 50.0
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 IN ACCORDANCE W1TH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS A COPS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
, 141 O CO
• SIGNATURE OF PERSON CONSTRUCTING THE WELL DA
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.

11. DISINFECTION: Type
12. CASING:
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Brendan M. Brodie
WELL CONTRACTOR COMPANY NAME EarthCon, Inc.
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#
(if applicable) (if applicable)
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality n r3 r
C%+. (-'
CERTIFICATION # 3297
PHONE # [phone]
1. WELL USE (Check Applicable Box): Residential 0 Municipal/Public 0 Industrial ❑ Agricultural 0
Monitoring I19 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: CarltOrl County Haywood
26 Trammel Avenue, 28716
(Street Name, Numbers, Conanunity, Subdivision, Lot No., Zip Code)
3. OWNER: Singleton & Jordan Environmental
Address 70 Woodfn Place
(Street or Route No.)
Asheville NC 28801
City or Town State Zip Code
(864 )- 225-8959
Area code- Phone number
4. DATE DRILLED 6-6-06
5. TOTAL DEPTH: 39 feet
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO IN
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 TEST
10. WATER ZONES (depth):
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.
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
0-39 ft. Saprolitic Grey
Silty Sand
Depth Diameter
From 0 To 29 Ft. 2-inches
From To Ft.
From To Ft.
13. GROUT:
From 0
From
14. SCREEN:
From 29
From
Depth Material
To 27 Ft. Portland
Amount
Wall Thickness
or Weight/Ft. Material
PVC
To Ft.
Depth Diameter
To 39 Ft. 2 in
To Ft. in
Method
Slot Size Material
0.010 in. PVC
in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 27 To 29 Ft. F x 50 Silica Sand
From To Ft.
16. REMARKS: Monitoring Well MW-1
C—
O
0
0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH 15A NCAC 2C WELL
CONSTRUCT STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
,,� ,,,,eri 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

1. WELL CONTRACTOR:
Q:CV : c)c Ttkec- 1,
Wd Contractor (Individual) Name
ex\))dt ' n.
Wee Contactor Company Nate
STREET ADDRESS \%&%%% QOS
tto! Sr;hgSl NC- 3-8'1+43
CM or Tarn sure -Zip Code
40f8a%} (acos- &oan_
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID Red applicable)
STATE WELL. PERMIT/Mr applicable)
DWQ.a OTHER PERMIT #(d applicable)
WELL USE (Check Applicable Box): Residential Water Supply d
DATE DRILLED 7 3/-4.
TIME COMPLETED /, 'CO AM D PM la--
3. WELL LOCATION:
art': otItfvh county Sao cl
Shire Cade Ld
{Seed Name. Numben. Community. Subdivision, Lck No.. Parcel, Zip Code)
T9POGRAPHIC / LAND SETTING:
gSbpe OValey ❑Fka t7 Ridge
(meek swoPiate bnx)
LATITUDE 3
LONGITUDE
❑Other
May be in degrees,
minutia, seconds or
in a decimal format
Latitude/longitude source: ❑ CPS OTopographic map
(location &set must be shown on a USGS topo map and
ached tothisben 7n�t using GPS)
WET_L OWNER
OWNER'S NAME IAil— J.+ C_k--
STR DRESS Lai1.
City or Town Seate Zip Code
(82.a )- t."1/446' (e533
Area code - Phone number
S.WELLDETAILS: "'�7
a TOTAL DEPTH: NOV DOES WELL REPLACE EXISTING WELL.? YES IDSj�
e. WATER LEVEL SeimTopofCasing 3C Fr.
(use rd Abate Top of Casing)
d. TOP OF CASING IS ' FT. Abase Land Surface'
'Top d easing teminated aver below land surface may require
a variance in aocardencewith t5A NCAC 2C .0118.
e. YIELD(gpmr V METHOD OF TEST R•3
RESIDENTIAL WELL CONSTRUCTION RECO3D 3 3 0! 2 0
North Carolina Department of Environment and Natural Resources- Division of Water ?jetty
WELL CONTRACTOR CERTIFICATION # Ott 36
f, DISINFECTION: Type4> % 1$ Amount /
g. WATER ZONES (depth):
Ram To From To
From To From To
From To From To
6. CASING: Thickness/
Depth_ D' WOO ,
SFt. Uleas21 L.
From To Ft.
From To R.
7. GROUT: Depth Mama Method
From 0 To ol© Fl. (entan�-_ i] tee 4
From To P.
From To Ft
8. SCREEN: Depth Dia nelc Sbt S' ,. MaterUl
From To Fl. in.
From To R. m. _ in.
From To F1- in. in. z ,
C--:
9. SAND/GRAVEL PACK: - G
Depth Size Modal Fv
From To' Ft. - C.1
From To Ft t'`s
._t
From To Ft r '
Ls
t4. DR!WNG LOG
From To
I Sc
r( -rys
11. REMARKS:
Formation
Ort
&nj
c` -
I DO HEREBY CERTIFY THAT THUS WELL WAS CONSTRLCtm N ACCCASANCE WITH
1SA NCAC 2C. WELL CONSTRUCTOR: TANWRDS. Ater' THAT A COPY OF TNS
RECORD HAS SEEN PROV1DEDTO TM: N
7—.F/':
SIGNATURE OF DATE
bare. tx VOW-4yt the,A.bzers
PRINTED NAME OF PERSON XtftISTRUCTI TRE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Wilt+
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Fan GW-la
Rev. 7)15